Allergic Rhinitis Flashcards
What is Rhinitis? What are common causes to consider?
Inflammation of the nose and upper respiratory tract
- Allergic
- Non-allergic (Vasomotor, Infectious)
- Occupational (Irritants)
- Hormonally-related (Pregnancy)
- Drug-related
- Inflammatory/Immunologic Diseases
What are common complications associated with Allergic Rhinitis?
- Asthma
- Sinusitis
- Obstructive sleep apnea
- Otitis media
- Nasal polyposis
Describe the etiology and pathophysiology of the early-phase allergic rhinitis?
[occurs within minutes]
- Trigger allergen becomes bound to IgE fixed to mast cells in nasal mucosa
¦
- Mast cells degranulate (release of histamine, macophages, WBCs, cysteine leukotrienes, and prostaglandins)
¦
- Vasodilation, mucosa edema, hypertrophy (resulting nasal congestion)
T or F: Rhinorrhea, sneezing, itching are all sumptoms associated with the early response.
T
Describe etiology and pathphysiology of the late-phase allergic rhinitis?
Affects up to 50% of patients (begins as early as 2 hours lasting up to 12 hours)
- Release of mediators
- Characterized by inflammation and severe long lasting nasal congestion (main symptom)
What is the priming response associated with allergic rhinitis?
Patients usuall prolonged/repeasted exposure to allergic rhinitis
Streamlines process (lower threshold) resulting in mediator release
Late phase inflammation thought to contribute
What are the different types of Allergic Rhinitis?
- Seasonal (only during certain times of the year)
- Perennial (presents throughout the year)
- Episodic (triggered by intermittent exposure)
What are available medications for treatment of allergic rhinitis? What is a 1st LINE TX for mild and servere allergic rhinitis?
- Corticosteriods (Internasal) [1st LINE TX, severe]
- Antihistamines (Oral) [1st LINE TX, mild]
- Antihistamines (Intranasal)
- Decongestants
- Mast Cell Stabilizers
- Leukotrienes receptor anatagonists
- Antimuscarinic agents
What intranasal corticosteriods are available for treatment of allergic rhinitis?
- Beclomethasone dipropionate
- Budesonide
- Ciclesonide
- Flunisolide
- Fluticasone furoate
- Fluticasone propionate
- Mometasone
- Triamcinolone acetonide
T or F: When administering intranasal medications, remember to clear nose shake to prime and tip head backwards.
F; DO NOT TIP HEAD BACKWARDS
What oral antihistamines are available for treatment of allergic rhinitis?
- Desloratadine
- Loratadine
- Fexofenadine
- Cetririzine
What intranasal antihistamines are available for treatment of allergic rhinitis?
- Azalastine
- Olopatadine
Why are intranasal antihistamines a useful treating allergic rhinitis? Pitfalls?
- Helpful with congestion
- Less effective with ocular symptoms
What decongestants are available for treatment of allergic rhinitis? Are these oral or intranasal medications?
- Pseudophedrine (oral)
- Phenylephrine (oral, intranasal)
- Oxymetazoline (intranasal)
- Naphazoline (intranasal)
Why are decongestants useful in treatment of allergic rhinitis? Pitfalls?
Helpful with nasal congestion; No benefit for sneezing, itching, rinorrhea, ocular symptoms
T or F: Intranasal decongestants can not be used more than 3 days due to possible rhinitis medicamentosa.
T; considered paradoxial rebound congestion
What are ADRs associated with intranasal decongestants?
- Stinging
- Burning
- Dryness
- Sneezing
Generally mild (not often any systemic effects)
What are ADRs associated with oral decongestants?
Generally well-tolerated; Caution with cardiac disease, cerebrovascular disease, glaucoma, hyperthyroidism, diabetes
What mast cell stabilizers are available for treatment of allergic rhinitis? What forms are available?
Cromolyn sodium (OTC interanasal prep)
What is the MOA of Cromolyn sodium? Duration of treatment?
Stabilize mast cells preventing release of inflammatory mediators; May take up to 2 weeks (moderately effective but not as good as intranasal steriod/antihistamines)
What are indications for using Cromolyn sodium?
Patients with mild/intermittent symptoms (esp. pedatrics and pregnancy)
What are ADRs of Cromolyn sodium?
- Generally well-tolerated
- Mild local stinging
- Sneezing
- Unpleasant taste
- Epistaxis
What leukotriene receptor antagonists are available for treatment of allergic rhinitis?
Montelukast (Singulair)
What is the MOA of Montelukast?
Competitively anatgonizes leukotriene receptors
T or F: Combination treatment of montelukast with antihistamines provides better coverage than either alone, however not better than intranasal steriods.
T
What are ADRs of Montelukast?
Well-tolerated
FDA WARNING: suicidal ideation
What general demographics are treated with Montelukast?
- Children over 6 months of age
- Pregnancy
What antimuscarinic agents are available for treatment of allergic rhinitis? What delivery systems are available?
Ipatroprium (intranasal spray)
What dose-related changes in treatment with Ipatroprium?
- 0.03%: children 6+ Y/O
- 0.06%: Rinorrhea associated with colds in children 5+ Y/O
When is Ipatroprium indicated for a patient with allergic rhinitis?
Limited use for patients with uncontrolled rhinorrhea (antihistamines/intranasal steroids uneffective)
What ADRs are associated with Ipatroprium?
- Mild epistaxis
- Nasal dryness
What immunomodulators are available for treatment of allergic rhinitis?
Omalizumab (Xolair)
T or F: Omalizumab is approved for asthma (not allergies) with displayed benefit for allergic rhinitis treatment.
T
What is the BLACK BOX warning for Omalizumab?
Anaphylaxis
Why is Saline indicated for allergic rhinitis?
Helpful with sneezing and congestion but less effective than intranasal steriods?
What ADRs are associated with Saline treatment?
- Some nausea
- Mild irritation
Why are intraocular preparation useful for treatment of allergic rhinitis?
Good for treatment of patients with predominantly eye-related symptoms
What intraocular preparations are available for treatment of allergic rhinitis? What type of drug is the intraocular prep?
- Naphazoline (Decongestant/Vasoconstrictor)
- Naphazoline/Pheniramine (Decongestant/Antihistamine)
- Emedastine (Antihistamine)
- Alcaftadine (Antihistamine)
- Cromolyn (Mast cell stabilizer)
- Nedocromil (Mast cell stabilizer)
- Lodoxamide (Mast cell stabilizer)
- Acelastine (Mast cell stabilizer/antihistamine)
- Epinastine (Mast cell stabilizer/antihistamine)
- Olopatadine (Mast cell stabilizer/antihistamine)
- Ketorlac (NSAID)
- Loteprednol (Corticosteroid)
How do you treat/prevent allergic rhinitis? (Silly question)
Avoidance!!
What medications may be used as adjunct TX for mild allergic rhinitis?
- Decongestants (OTC)
- Intranasal decongestants (OTC, short-term)
- Saline (intranasal)
- Intraocular preps (as needed)
What medications may beused as 1st LINE TX for mild allergic rhinitis?
- Antihistamines (Oral)
What medications may be used as 1st LINE TX for moderate to severe (persistent) allergic rhinitis?
-
Steriods (intranasal)
- Add oral antihistamine
What medications may be used as adjunctive TX for moderate to severe (persistent) allergic rhinitis?
- Decongestant (intranasal, short-term)
- Saline (intranasal)
- Ipratroprium (esp. for uncontrolled rhinorrhea
[should consider replace 1 1st LINE TX with montelukast]
