Allergic Rhinitis Treatment

Question 1

what is allergic rhinitis?

Answer 1

an inflammatory, IgE- mediated disease characterized by nasal congestion, rhinorrhea, sneezing, and/or itching

Question 2

how common is allergic rhinitis?

Answer 2

most common chronic disease in children
–> allergic triad (atopic dermatitis, allergic rhinitis, asthma)
- but also adults

Question 3

what are the most common precipitating allergens?

Answer 3

1. seasonal
   – grasses, trees, weeds, molds
2. perennial
   – molds, house dust
3. episodic
   – animal dander
4. mixed

Question 4

what are some signs and symptoms of AR?

Answer 4

1. bilateral presentation
2. sneezing/ congestion
3. rhinorrhea (runny nose)
4. nasal creases ( allergic salute)
5. allergic conjunctivitis
6. fatique, depression, irritability

Question 5

what percent of people with AR have allergic conjunctivitis?

Answer 5

50-70%

Question 6

what is non-allergic rhinitis?

Answer 6

CAUSE: exposure to airborne irritants (pollution, chemicals)
PT. POP: adults
Symptoms: chronic rhinorrhea (sneezing is uncommon)

Question 7

what are intermittent symptoms?

Answer 7

• <4 days/week or <4 weeks at a time

Question 8

what are persistent symptoms?

Answer 8

• > 4 days/week or > 4 weeks at a time

Question 9

what are mild symptoms?

Answer 9

• normal
• no troublesome symptoms

Question 10

what are moderate to severe symptoms?

Answer 10

• abnormal sleep
• difficulties at work/ activities/ school/ sports
• troublesome symptoms

Question 11

what are some goals of therapy?

Answer 11

1. minimize symptoms
2. minimize side effects from treatment
3. maintain quality of life

Question 12

what does saline nasal spray do?

Answer 12

1. helps to clear passages of pollen
2. can be used PRN

Question 13

when do you refer patients?

Answer 13

1. unilateral symptoms and purulent discharge
2. dont respond to meds

Question 14

what are the clinical pearls for antihistamines?

Answer 14

1. 1st and 2nd gen
   – no difference in efficacy
   – risk of SEs vary
   – best when taken prior to exposure

Question 15

what are the clinical pearls for ICS?

Answer 15

1. most effective at relieving nasal symptoms
2. choice for mod to severe AR
3. max benefit is 1-2 weeks

Question 16

what are the clinical pearls for decongestants?

Answer 16

1. pseudoephedrine vs. phenylephrine
   – used in combo with other agents
   – max relief of nasal congestion

Question 17

what are the clinical pearls for montelukast?

Answer 17

1. limited role in pts. with AR
   - RX only- $$$
   - less effective than corticosteroids

Question 18

what are the clinical pearls for intranasal antihistamines/ ocular drops?

Answer 18

1. intranasal antihistamines
   - azestaline
   - olopatadine
2. ocular drops
   - olopatadine
   - ketotifen
   - azestaline
   - ketorolac

Question 19

what are some clinical pearls for non-allergic rhinitis?

Answer 19

1. ipratropium bromide
   - 0.03%
   – non-AR
   - 0.06%
   – rhinorrhea with common cold
2. intranasal corticosteroids

Question 20

when do you follow up with AR patient?

Answer 20

1. symptomatic relief
   – others

Question 21

what meds would you give someone with mild intermittent classification? is there a preferred order?

Answer 21

1. OAH +/- decongestant or INA
2. no preferred order

Question 22

what meds would you give someone with mod to severe intermittent classification? is there a preferred order?

Answer 22

1. OAH +/- decongestant; or INA; or LTRA; or INCS
2. no preferred order

Question 23

what meds would you give someone with mild persistent classification? is there a preferred order?

Answer 23

1. OAH +/- decongestant; or INA; or INCS
2. no preferred order

Question 24

what meds would you give someone with mod to severe persistent classification? is there a preferred order?

Answer 24

1. INCS, OAH +/- decongestant or LTRA
2. preferred order
   - combo therapy if symptoms not controlled with single agent

Question 25

if you had symptoms controlled but ADRs are problematic what would you give the patient?

Answer 25

switch to alternative agent to minimize ADRs

Question 26

if you had any AR type with severe congestion what would you give the patient?

Answer 26

consider routine use of antihistamine decongestant combo

Question 27

if you had any AR type with persistent rhinorrhea what would you give the patient?

Answer 27

consider adding iprotropium NS

Question 28

if you had severe AR w/o good symptom control what would you give the patient?

Answer 28

consider skin testing and immunotherapy (shots)

Question 29

if you had AR symptoms not well controlled and pt has mod to severe asthma or atopic dermatitis (rare) what would you give the patient?

Answer 29

consider tx with biologics

Question 30

what are the disadvantages and advantages of oral antihistamines (only 2nd gen)?

Answer 30

1. QD dosing (adv)
2. only impacts histamine receptors (disadv)

Question 31

what are the disadvantages and advantages of intranasal antihistamines?

Answer 31

1. excellent for rhinorrhea (adv)
2. expensive; risk of drowsiness (disadv)

Question 32

what are the disadvantages and advantages of intranasal cromolyn?

Answer 32

1. safe for pregnancy (adv)
2. required TID-QID dosing (disadv)

Question 33

what are the disadvantages and advantages of ICS?

Answer 33

1. QD dosing and most complete symptomatic relief (adv)
2. max benefit is 1-2 weeks (disadv)

Question 34

what are the disadvantages and advantages of montelukast?

Answer 34

1. QD dosing (adv)
2. rx only; and more expensive than OTC meds (disadv)

Question 35

what are the disadvantages and advantages of oral or intranasal decongestant?

Answer 35

1. superior for relieving congestion (adv)
2. use of nasal sprays should be limited to 3 days (disadv)

Question 36

what are the disadvantages and advantages of immunotherapy?

Answer 36

1. specific antigens (adv)
2. expensive (disadv)

Question 37

what are the disadvantages and advantages of biologics?

Answer 37

1. very severe symptoms (adv)
2. expensive (disadv)