Allergic Rhinitis: patient assessment Flashcards
what are the 3 types of rhinitis
allergic
infectious
nonallergic non infectious
can also gen a combo (mixed rhinitis)
what causes non allergic non infectious rhinitis
reactive rhinitis (rhinopathy) - hyper responsiveness to non allergic, physical or chemical stimuli
- gustatory rhinitis
drug indued rhinitis
endocrine disorders
hormonal rhinitis
non allergic rhinitis with eosinophilia syndrome
atrophic rhinitis
rhinitis of elderly
idopathic rhinitis
distingusihing between allergic rhinitis and non allergic
symptom presentation
sneezing
rhinorrhea
pruritus of eyes/nose and/or palate
nasal obstruction
conjunctivities
- symptom presentation
- AR: Bilateral, worst upon waking, subtile during day, worse at night
- NARunilateral symptoms common but can be bilateral. constant day and night
- sneezing
- AR: frequest, paroxysmal
- NAR little to none
- rhinorrhea
- AR: anterior watery
- NAR posterior, wateror/thick or mucopurulent (often ass w/ ifnection)
- pruritus of eyes/nose and/or palate
- AR: Frequest
- NAR: not present
- nasal obstruction
- AR variable
- NAR: usually present and often severe
- conjunctivities
- AR frequent
- NAR: not present
distingusihing between allergic rhinitis and non allergic
Pain
anosmia
Epistaxis
facial,nasal or throat featues
age/onset of smp
pattern of symptoms
- Pain
- AR: Sinus pain due to congestion
- NAR: Variable depending on cause
- anosmia
- AR: Rate
- NAR: Frequest
- Epistaxis
- AR: Rare
- NAR: recurrent
- facial,nasal or throat features
- AR: allergic shinners, facies, salute
- NAR: nasal polyps, spetal deviation, enlarged tonsils and/or adenoids
- age/onset of smp
- AR: Earlier
- NAR: Later
- pattern of symptoms
- AR: seasonal or perennial
- NAR: almost always perennial
how can you distingish AR from structural/mechanical Abnormalities
look for
Deviated septum
Enlarged adenoids
Hypertrophic turbinates
Foreign bodies/nasal trauma
Choanal atresia
Nasal polyps
Nasal tumors (benign or malignant)
Nasal valve problems
how can you distingish AR from Autoimmune disorders
Sjogren’s syndrome
Systemic lupus erythematous (SLE)
Relapsing polychondritis
Eosinophilic Granulomatosis with polyangiitis (formerly Churg-Straus syndrome)
Granulomatous diseases (sarcodosis, granulomatosis with polyanglitis)
what else could be mistaken for AR
Cystic fibrosis
Cilia dyskinesia syndromes (e.g., primary ciliary dyskinesia)
Immunodeficiency
Amyloidosis
Chronic fatigue syndrome
Disorders of acid reflux: GERD or Laryngopharyndeal erflux (LPR)
nasal symptoms that are red flags for AR
Unilateral nasal symptoms
Recurrent epistaxis
Mucopurulent nasal discharge
Post-nasal drip with thick mucous
Anterior rhinorrhea with pain
ocular red flags for AR
Unilateral eye symptoms
Eye pain (infection? Iritis?)
Photophobia
other red flags for AR
Fever
Muscle pain
Persistent cough
Loss of taste or smell
Symptoms suggestive of anaphylaxis
Wheezing, shortness of breath (asthma?)
Persistent headache, facial pain (sinusitis?)
Other symptoms consistent with uncontrolled asthma, COPD, recurrent sinusitis, otitis media, or thyroid disorder
populations that should be referred for AR
- patients who have severe symptms or if trigger for symptom cant be identified
- pregnant atients -> could be hormonal rhinitis
- children wtih moderate/severe AR
Ar Assessment questionaire
symptoms in section 1 are NOT found in AR
- presence of ANY ONE of the suggests an alternative diagnoses shoudl be investiagted -> consider referral to specialist
(Purulent discharge, postnasal drip, facial pain, and loss of smell are common symptoms of sinusitis - sinusitis usually comes with rhinitisso still evualtue with possibilty of AR
* if have watery/runny nose + one or more symptoms in section 2 it suggests AR
* if have has sneezing, nasal itching, and/or conjunctivitis, but NOT watery runny nose, consider alternative diagnoses and/or referral to a specialist.
what are the goals of therapy for treatment of AR
- prevent symptoms by avoiding expsoure to alelrgens
- alleviate signs and symptoms produced by allergic response
- minimize adverse effects of treatment
- improve QOL (swool/work performance, sllep, social functioning)
what are the non pharmacologic adjunct therapies for AR
prevention
saline ansal irrigation
libricant eye drops
cold compress
sunglasses
describe prevention as a non pharmacologic adjunct therapy for AR
- avoidance of allergens is first step in management and will reduce medication use
- Pollen:
- change clothes and bathe/shower after going outdoors
- do not dry clothes outdoors, stay indoors
- Moulds
- remove houseplants
- keep indoor humidity between 40-45+
- use fungicide on sinks, showers, garbage pails
- Dust mites:
- wash bedding once/week with hot water
- encase mattresses, pillows
- repelace carppet with hardwood flooring
- Animal Dander
- keep pets outside of bedroom and main living areas
- brush pets outside, wash cats weekly and dogs biweekly
- install HEPA filter
- Tobacco smoke
- avoid smoking in car or inside home
- use of air conditioning may be helpful
Saline Nasal Irrigation (SNI) as a non pharmacologic adjunct therapy for AR
- rinse nasal cavity with salt water solution
safe and cheap alternative or adjuct to pharm therapy
- shown to improva nasal symptoms, reduce patietn-reported disease severity, decrease use of medicines and impove QOL
- likley works by moisturizing dty nasal passages, thinning mucus (snot) and flushign out some irritating allergens from nose
first line option for AR in pregnancy
saline nasal irigation
what other non pharm treatments for AR exist
- Lubricant eye drops
- help dilute and flush out allergens and inflammatory cells from tear film
- can treat comorbid dry eye
- cold compress
- can alleviate occular itching by causing conjunctival vasoconstriction
- reduced hyperemia and edema
- Sunglasses
- large wraparound sunglasses may be useful to reduce contact with aeroallergens and improve photophobia
how to assess for control in untreated symptopatic patient
assess for control in treated symptomatic patients
describe the step up approach for treating AR
- For mild symptoms, use non sedating H1 antihistamines (oral, intranasal or ocualr)
- For moderate-to-severe symptoms and/or persistent AR, use INCS
- For patients with uncontrolled symptoms at step 2, use combo of INCS and INAH (intranasal corticosteroids and intranasal antihistamines)
- Additional short course of oral sterioids may help establish and continue control yb step 3
- Intraocular cromones or H1-antihistamines can be added to improve the control of ocular symptoms.
* step down approach can be used in patietns with prev treatment failure or resistance to monotherapy -> step 3 as the frist option, then after few days of imporve conider treatemnt reduction
first line therapy for mild, intermitted AR
Rx and Non Rx
second generation oral anti histamines
- only procue modest imporvement in nasal congestion but 1st gen no longer recommneded bc of adverse effects
Non Rx: Cetirizine, Desloratadine, Fexofenadine, Loratadine
Rx: Cetirizine (20mg), Bilastine, Rupatadine
first lien therapy for treatment for mild persistent AR
regularly administered intranasal corticosteroids
Non Rx: Triamcinolone acetonide, Fluticasone propionate
Rx: Beclomethasone dipropionate, Budesonide, Ciclesonide, flunisolide, fluticasone furonate, mometasone furoate
first line treatment for moderate severe AR
regularly administered intranasal corticosteroids
Non Rx: Triamcinolone acetonide, Fluticasone propionate
Rx: Beclomethasone dipropionate, Budesonide, Ciclesonide, flunisolide, fluticasone furonate, mometasone furoate
why not use first gen antihistamines for AR
give exmaples of them
diphenhydramine, chlorpheniramine
- not selective for H1 reecptor, also have antimuscarinic, anti-alpha, adrenergic and anti-serotonin effect
- easily cross BBB
- associated with sedation, psychomotor retardation, reduced academic performact
use fo 2nd generation antihistamines for treatmetn of AR
ex: fexofenadine, bilastine
more specific for peripheral H1 receptors, limited penetration in BBB (reduced sedation)
- effectively reduce sneezing, itching and rhinorrhea when taken regularly at the time of maximal symptoms or prior to allergen exposure
- best results when obtained w/ chronic dosing rather than intermitent
what antihisatmine would you not use in children
Bilastine (Blexten)
fexogenadine (allegra) not indicated in children under 6
drawbacks of antihistamines
- less potent then INCS, but many patients prefer oral drugs
- intranasal AH less effective than INCS, but work in minutes
- second gen OAH generally well tolerated but can cause occasiaonal sedation, dry mouth and headache
- first generation OAH are no logner recommended for AR bc of high risk of significant AE
treatment of AR with INCS
- mainstay therapy for moderate-severe AR or mild persistent AR
- combo of OAH and INCS not found more effective than monotherapy with INCS*
- can experience benefit in first day of therapy, but most comes 2-4 weeks in
- potential side effects are nasal irritation and nose bleeds, but less common in newer formulations
Rx INCS
- Beclomethasone dipropionate (Beconase Aq®) 50mcg
- Budesonide (Rhinocort Aqua®)
- Ciclesonide (Omnaris®)
- Fluticasone furoate (Avamys®)
- Fluticasone propionate (Flonase®)
- Mometasone (Nasonex®)
- Triamcinolone acetonide (Nasacort Aq®)
Non Rx INCS
Triamcinolone acetonide (Nasacort Allergy 24HR®)
Fluticasone propionate (Flonase® Allergy Relief) 50mcg
frist line therapy for mild, persistent AR or moderate-to-severe AR in patients over 12 years of age
Intranasal Corticosteroids (INCS) + Intranasal Antihistamine (INAH)
- Fluticasone/azelastine (Dymista®) 50mcg/137mcg
- also reduced ocular symptoms
- works in min but peak in several days/weeks
- shoudl be used regularly
- consider in patients who dont respond to INCS alone
Leukotriene Receptor Antagonists (LTRA) for AR treatment
ex: montelukast and zafirlukast
- mostest effiacy similar to OAH, not as effective as INCS
- can be used as monotherapy or in combo with INCS or OAH in patients with concomitant asthma
- can use if patients dont improve or cant tolerate first line
Intranasal anticholinergics for treatment of AR
- Intranasal ipratropium
- considered in AR when rhinorrhea is the primary symptom or is refractory to INCS and/or antihistamines
- effective in cases of vasomotor rhinitis, like “skier’s nose”
Intranasal Mast cell stabilizers for treatment fo AR
sodium cromoglycate
less effective than INCS but have excellent safety profiles
-
decongestants for AR
- may be used temporarily to relieve nasal obstruction symptoms.
ex: pseudoephedrine, phenylephrine (efficacy for phenyl not well establihed) - stimulatrory side effects
immunotherapy for AR treatment
- used to desensitize patients with IgE-dependent sensitivities to specific antigens when they cannot effectively avoid the allergen
- Clinical benefits associated with immunotherapy have been shown to persist for at least three years following administration.
duration of treatment for intermitent vvs persistent AR
intermmittent: treatment should be contrinued daily for 2 weeks or dor duration of pollen season or other allergen exposure
Persistent; longer course treatment needed
the combination of OAH with INCS was found to be ____ than INCS alone
the combination of OAH with INCS was not found to be more effective than INCS alone
The combination of INAH with INCS was found to be ___ than INCS alone
The combination of INAH with INCS was found to be more effective than INCS alone
INAH-containing medications are effective within ___
minutes
