Allergic Rhinitis Flashcards
When does allergic rhinitis develop?
usually after 2nd year of life; it is prevalent in children and adults
types of allergic rhinitis
- seasonal (hay fever)
- perennial
- intermittent (sxs 4 days a week or less OR lasts 4 weeks or less)
- persistent (sxs more than 4 days a week or more OR lasts greater than 4 weeks)
- mild (sxs do not interfere with daily activities)
- moderate-severe (impairment of sleep, daily activities, or bad symptoms)
risk factors of allergic rhinitis
family hx of allergic disorders (atopy), filaggrin gene mutation, elevated serum IgE under 6 years of age, higher socioeconomic class, eczema, positive reaction to allergy skin tests, children eating three or more fast food meals per week
allergic rhinitis mediated response
IgE; involves release of mast cell mediators
4 phases
sensitization, early phase, cellular recruitment, late phase
AR symptoms and findings
bilateral symptoms, worse when awakening and at night, frequent or paroxysmal sneezing, anterior watery rhinorrhea, pruritis of eyes/nose, conjunctivitis, allergic shiners, wrinkles below lower eyelids, allergic crease, allergic salute, allergic gape
AR causes and triggers
pollen, mold. pollutants, dust mites, cockroaches, smoke, pet dander, wool dust, latex, resins, biologic enzymes, organic dusts, chemicals
non-AR symptoms and findings
unilateral symptoms, constant day and night, little or no sneezing, posterior watery or thick rhinorrhea, nasal obstruction, anosmia, epistaxis, nasal polyps, enlarged tonsils, nasal septal deviation
non-AR causes and triggers
puberty, pregnancy, thyroid, septal deviation, cocaine, BB, ACEI, chlorpromazine, clonidine, NSAIDS, aspirin, overuse of topical decongestants, systemic inflammatory, lesions/polyps, facial or head trauma
symptoms of AR
itching nose, palate, sneezing, watery rhinorrhea, postnasal drip, nasal congestion
complications of AR
- acute: sinusitis, otitis media with effusion
- chronic: nasal polyps, seep apnea, sinusitis, hyposmia
treatment approach
- allergen avoidance
- pharmacotherapy
- immunotherapy
goals of treatment
- reduce symptoms
- improve functional status and sense of well-being
- individualize to provide optimal symptomatic relief/control
exclusions to self-care
- undiagnosed
- children under 12 and pregnant/lactating women
- signs and symptoms of non-AR
- signs and symptoms of infection
- signs and symptoms of undiagnosed or uncontrolled asthma or other lower respiratory disorders
- unacceptable/severe treatment SE
non-pharmacologic management
- allergen avoidance
- lower household humidity
- limit exposure to pets
- vacuum frequently (avoid carpeting and upholstered furniture)
- HEPA filters
- saline nasal spray
- Neti pot
for initial treatment of seasonal AR in persons aged 12 years or older
routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine
for initial treatment of seasonal AR in persons aged 15 years or older
recommend an intranasal corticosteroid over a leukotriene receptor antagonist
for treatment of moderate to severe seasonal AR in persons aged 12 or older
the clinician may recommend the combo of an intranasal corticosteroid and an intranasal antihistamine for initial treatment
triamcinolone
Nasacort allergy 24 hr and children’s Nasacort allergy
2 years and older
examples of intranasal glucocorticoids
- triamcinolone
- fluticasone propionate
- budesonide
- fluticasone furoate
fluticasone propionate
Flonase allergy relief and children’s Flonase allergy relief
4 years and older
fluticasone furoate
Flonase sensimist allergy relief
2 years and older
budesonide
rhinocort allergy spray
6 years and older
intranasal glucocorticoids are effective for nasal symptoms and congestion because
they inhibit multiple cell types and mediators and also effectively stops the allergic cascade
are IG’s sedating?
no
how often do you use IGs
once daily administration (shake well before use)
FDA warnings on IG
increased risk of growth inhibition in children and should be limited to less than two months per year without the supervision of a health care provider
moa of antihistamines
compete with histamine at central and peripheral histamine receptor sites and prevents the histamine-receptor interaction which prevents the subsequent mediator release
first generation antihistamines usage for AR
controversial due to the risks of sedation and anticholinergic effects
classes of first generation antihistamines
alkylamines and ethanolamines
alkylamines
most potent antihistamines, moderately sedating, higher risk of paradoxical CNS stimulation than other classes
examples of alkylamines
chlorpheniramine
brompheniramine
dexbrompheniramine
ethanolamines
highly sedating, strong anticholinergic effects, large doses can cause seizures and arrhythmias
examples of ethanolamines
diphenhydramine
doxylamine
clemastine
second generations usage in AR
effective with little to no sedation; effective in reducing itching, sneezing and rhinorrhea but has little effect on nasal congestion
classes of second generation antihistamines
piperidines and piperazines
piperidines examples
fexofenadine, loratadine
non-sedating
piperazines examples
cetirizine, levocetirizine, and meclizine
minimally to moderate sedating
DOC in pregnancy
chlorpheniramine
loratadine, cetirizine and diphenhydramine are also acceptable
DOC in breastfeeding
no antihistamines
DOC in children
loratadine followed by fexofenadine and cetirizine (sedating AH avoided due to excitation and risk of AE with misuse
DOC in elderly
loratadine, intranasal cromolyn
Narrow angle glaucoma
sedating AH should be avoided
when to discontinue AH before allergy skin test
at least 4 days
what AH shouldn’t be taken with fruit juice
fexofenadine (separate with at least two hours)
which AH’s are photosensitizing
all sedating AH
what AH should be used cautiously in those requiring mental alertness
sedating AH and cetirizine/levocetirizine
decongestants are appropriate for use in patients with
AR accompanied by congestion
antihistamine + systemic decongestants
- useful in patients with nasal congestion + allergies
- should only use short term unless MD says
mast cell stabilizers
cromolyn sodium (treats and prevents)
moa of CS
works on the surface of mast cells to inhibit degranulation
onset of action for CS
3-7 days, full efficacy seen in 2-4 weeks
counseling on when patients should start taking CS
approximately 4 weeks prior to expected allergy season
is CS used for relief of acute symptoms?
no, efficacy is generally considered to be somewhat less than oral antihistamines
CS administration
nasal spray; one spray each nostril 3-6 times daily at regular intervals
CS approved in
patients older than 5 and preferred in pregnancy/lactation
