Allergic rhinitis Flashcards by Kelsey Con

risk factors of allergic rhinitis

age - adolescents and young adults
family history
repeated exposure to multiple offending allergen
presence of other allergic conditions (asthma and atopic dermatitis)

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pathophysiology

IgE produces after first contact and binds to mast cells and basophils
second exposure IgE recognizes allergen causing degranulation and release of preformed mediators, lasts 30-90 min
4-8 hours later get migration of inflammatory mediators, eosinophils etc and congestion predominated

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nasal symptoms

paroxysmal sneezing
itching
watery rhinorrhea
nasal congestion

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what happens after persistant inflammation

decrease threshold of allergen needed to produce a response

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ocular symptoms

red irritated eyes 
itching or burning 
tearing 
stringy watery discharge 
puff eyelid in the morning

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facial symptoms

openmouth breathing
allergic salute
darkeningunder eyes due to venous congestion
wrinklens beneath the lower lid

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systemic symptoms

cognitive impairment
fatigue
irritability
malaise

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3 characteristic exposure time to allergens

seasonal
perennial (all year)
episodic

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2 characterizations of symptom frequency

intermittent is = 4 days per week OR = 4 weeks per year

persistent is >4days per week AND >4 weeks per year

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mild symptom severity

doesnt interfere with quality of life

no troublesome symptoms

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moderate to severe symptom severity

symptoms interfere with the quality of life

abnormal sleep, impairment of activites, troublesome symptoms

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differential diagnosis of allergic rhinitis

infectious rhinitis (cold)
idiopathic or inflammatory non allergic rhinitis 
vasomotor rhinitis (non inflammatory) 
hormonal - pregnancy, mensus
nasal polyps 
drug induced rhinitis
occupational rhinitis

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describe vasomotor rhinitis

non allergic
occurs later in life
nasal congestion, rhinorrhea, postnasla drip usually in women 40-60
many different triggers

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medications that can cause non allergic drug induced rhinitis

antihypertensive agents 
oral contraceptives
NSAIDS
topical decongestants overuse
older antipsychotics

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red flags

under 2 (asthma?)
wheezing shortness of breath
tightness in chest
painful ears/sinuses (infection?) 
fever
purulent nasal/ocular discharge
allergen not identifiable 
no response to OTC after 2 weeks

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how does normal saline help with allergic rhinitis

reduce concentration of inflammatory mediators
flush out mucus and allergens
improve nasal airflow

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how might nasal breathing strips help

mechanical means to improve nasal airflow

relieve symptoms?

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goals of therapy

avoid or minimize the exposure to the allergen
alleviate symptoms
minimize adverse effects of the medication

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antihistamine mechanism of action

reversible antagonist at H1 receptor preventing binding and action at the receptor site

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which symptoms do antihistamines help with

reduce sneezing, runny nose, and itching but not congestion or stuffiness (except desloratadine, cetirizine, fexofenadine)

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2 examples of first generation antihistamines

chlorpheniramine

diphenhydramine

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examples of second generation AH

loratadine
cetirizine
fexofenadine

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side effects of first gen

dry mouth and eyes 
constipation 
urinary retention 
sedation 
fatigue 
dizziness
sedation 
mucus secretion thickened

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drug interactions with first gen

alcohol
hypnotics
sedatives
CNS depressants

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average dosing and onset for 2nd gen

about an hour | dose once daily

side effects of second gen

headache | cetirizine may cause drowsiness

how should AH be taken for chronic allergic rhinitis

start 2 weeks before season and continue throughout the season and 2 weeks after taken on a daily basis

how should AH be taken for infrequent exposure

2-4 hours before exposure

how to take AH if already experiencing symptoms

wont work right away because no effect on the histamine already released can start but will only see the benefit in 2-3 days

what may be some causes of ineffectiveness of AH

``` non adherence increased antigen exposure worsening of condition severe diseae similar symptoms to unrelated disease switch to another class of AH ```

contraindications for 1st gen

``` glaucoma (increases pressure) bladder obstruction peptic ulcer hyperthyroidism (increase cardiac effects) cardiac disease prostate disease chronic lung disease (thickened mucus) ```

oral decongestants

phenyephrine | pseudoephedrine

intranasal decongestants

oxymetazoline xylometazoline phenylephrine

decongestants mechanism of action and what it treats

vasoconstriction on the alpha receptors in nasal mucosa and decreased inflammation only useful in late stage to help with congestion

onset of action for oral decongestants

15-30 min

age for oral decongestants

over 6

adverse effects of aroal decongestants

``` dizzy headache tremor difficulty sleeping peripheral vasoconstriction tachycardia palpitation blood sugar ```

contraindications of oral decongestants

``` heart disease gluacima diabetes hyperthyroidism porstate enlargment severe hypertension ```

onset for intranasal decongestants

5-10min

side effects of intranasal decongestants side effects

nasal burning stinging dryness | nucosal ulceration

what is rhinitis medicamentosa in intranasal decongestants

rebound congestion that occurs from prolonged use (3-5days) that causes down regulation of alpha receptors rebound swelling of nasal mucosa

what age can use intranasal decongestants

over 12

which decongestant is best to use

topical because less systemic effects

what are some alternates to decongestants

desloratidine cetirizine fexofenadine normal saline

opthalmic decongestant mechanism of action

vasoconstriction decreases eye redness

contraindications of opthalmic decongestant

glaucoma

side ffects of opthalmic decongestants

burning, stinging | rebound redness and swelling if used more than 10 days

example of mast cell stabolizer

sodium cromoglycate

mast cell stabilizer mechanism of action

inhibits degranulation of mast cells to alleviate runny nose itching and sneezing

disadvantages to mast cell stabilizers

delayed onset may take 4-7 days for any improvement and full benefit 3-4 weeks requires 3-4 times a day dosing so lack of adherence not very effective

intranasal corticosteroids mechanism of action

decrease influx of inflammatory cells and inhibit release of cytokine which leads to the reduction of inflammation

onset of intranasal corticosteroids

30 min max effect takes 7-14 days

side effects of intranasal corticosteroids

``` burning stinging bosebleeds headache throat irritation nos sytemic effects because quickly metabolized ```

age you can use intranasal corticosteroids

triamcinolone over 12 | fluticasone over 18

what can pharmacists prescribe for vasomotor and allergic rhinitis

corticosteroid nasal preparations for topical use

why is it better to use 2nd gen AH than intranasal AH

have similar efficacy but lots of side effects and twice daily dosing

what prescription combo is available and when do you use it

intranasal corticosteroid and antihistamine | only when no resolution with INS alone

example of prescription intranasal anticholinergic and how does it work

ipratropium solution prevents secretions of the nasal mucosa

when to use IN anticholinergics

excessive rhinorrhea | somet ypes of vasomotor rhinitis

why is there no drug interactions with IN anticholinergic

no systemic absorption and doesnt cross BB

when can you use oral steroids

for short time in patients with severe symptoms, in combo with INS

what do you use for persistant symptoms that affect the quality of life

intranasal corticosteroids

what do you use for mild intermittent symptoms

oral second gen antihistamine

what is immunotherapy

giving the patient some of the allergen so the immune system would not respond when exposed to the allergen

two types of immunotherapy

subcutaneous injection - regular intervals at doctors office sublingual - first at office then at home

best option for children?

INS can be prescribed for children over 4 but likely use 2nd gen antihistamine because 1st cause hyperactivity nasal saline before eating and sleeping

treatment of allergic rhinitis in pregnant women (if first time experiencing symptoms prob vasomotor not allergic!!)

loratidine and cetirizine

what reduces effectiveness of fexofenadine

juices

monitoring of allergic rhinitis

symptom relief within 3-4 days complete relief may take 2 weeks of not refer pharmacist follow up in a week