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Pharm exam 2 > Allergy Rhinitis > Flashcards

Allergy Rhinitis Flashcards

1
Q

What is rhinitis?

A
  • Inflammation of the lining of the nose and other parts of the upper respiratory tract
  • Most common: Allergic rhinitis
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2
Q

What is allergic rhinitis

A

An allergen-induced and immunoglobulin E (IgE)- mediated type of rhinitis.
Leads to inflammatory markers

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3
Q

Symptoms of rhinitis

A
  • Watery rhinorrhea
  • Sneezing
  • Itching (nasal, throat, eye, ear)
  • Nasal congestion
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4
Q

Seasonal allergic rhinitis (hay fever) characteristics

A
  • Specific seasonal allergies
  • Predictable times of year
  • Pollen from trees, grasses, and weeds
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5
Q

Persistent allergic rhinitis (perennial) characteristics

A
  • Non-seasonal allergens
  • Year-round
  • Dust mites, animal dander, molds
  • Less variable, chronic symptoms
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6
Q

Background & epidemiology of rhinintis

A
  • Extremely common

- 40-50% of patients who have skin or serum tests are allergic to aeroallergens measured by allergen-specific IgE.

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7
Q

Rhinitis CNS issues

A
  • Inability to complete activities of daily living
  • Anxiety
  • Depression
  • learning difficulties
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8
Q

Rhinitis associated with other conditions

A
  • Asthma
  • Chronic rhinosinusitis
  • Otitis media
  • Nasal plyps
  • Resp. infections
  • Orthodontic misalignment
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9
Q

Rhinitis risk factors

A
  • Genetics/family hx
  • Exposure to allergens
  • Increased IgE levels before age 6
  • Eczema
  • Heavy secondhand smoke exposure
  • Higher socioeconomic status
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10
Q

Rhinitis protective factors

A

-Exposure to harmless microbes in the first years of life.

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11
Q

Allergens

A

Pollen grains- trees, grasses, weeds, year round and seasonal
Mold spores- Present year round
Indoor allergens- year round
Flowering of plants and its pollen does not actually cause rhinitis.

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12
Q

What does activation of cAMP do?

A

Stimulates bronchial relaxation, which results in AMP.

Increase cAMP or reduce breakdown of cAMP with PDE (enzyme) by blocking PDE

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13
Q

Muscarinic antagonist

A

Prevents constriction

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14
Q

Leukotriene antagonists

A

Decrease bronchial constriction

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15
Q

Which drug is used as the parent for corticosteroids?

A

Hydrocortisone..If drug is less than 1, it is less potent.

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16
Q

How do corticosteroids work?

A
  • Work on inflammatory mediators and structural cells

- Help decrease inflammation to any process.

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17
Q

3 basic nasal functions

A
  1. heating
  2. humidification
  3. filtration
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18
Q

Cleansing process

A

Air moves through the nose, particulate matter sticks to the mucous membrane.
cilia moves mucous towards the throat–> trapped particles are swallowed–> removed via GI tract
-Concentrates foreign proteins in nasopharynx–> identification via lymph tissue–> produces allergic antibodies–> allergic rhinitis.

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19
Q

Immediate phase

A
  • Occurs within minutes of allergen exposure
  • Degrannulation of mast cells
  • Release of pro-inflammatory mediators (histamine & cytokines) and inflammatory mediators (leukotrienes, prostaglandins, and bradykinin)
  • Nerve stimulation–> nasal itching and sneezing
  • Histamine–> nasal drainage and obstruction
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20
Q

Late phase

A
  • Begins 4-8 hrs after allergen exposure.
  • Cytokines release by mast cels and t lymphocytes migrate to site of allergen exposure
  • Nasal congestion is the primary characteristic of the late phase and can be persistent and chronic.
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21
Q

Symptoms of rhinitis

A
  • Rhinorrhea
  • Post-nasal drip
  • Sneezing
  • Itching eyes, ears, nose
  • Red, watery eyes
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22
Q

Signs of rhinitis

A
  • Allergic salute (nasal crease)
  • Allergic shiners (bags under eyes)
  • Mouth breathing
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23
Q

Rhinitis complications

A

Acute otitis media
Sinusitis
^both occur due to nasal obstruction

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24
Q

Seasonal classification

A

Symptoms present only during specific portions of the year

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25
Q

Perennial classification

A

Symptoms present throughout the year

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26
Q

Episodic classification

A

Symptoms present only during intermittent exposure to allergen trigger

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27
Q

Intermittent mild

A

Symptoms occur less than 4 days a week, or less than 4 consecutive weeks.
Symptoms do not impair sleep, activities or school/work
No troublesome symptoms

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28
Q

Intermittent moderate-severe

A

Symptoms occur less than 4 days a week, or less than 4 consecutive weeks.
One or more of the following occurs:
Impairment of sleep
Impairment of daily actuates or school/work
Troublesome symptoms

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29
Q

Persistent mild

A

Symptoms occur more than 4 days a week and greater than 4 consecutive weeks
Symptoms do not impair sleep, activities, or school/work

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30
Q

Persistent moderate-severe

A

Symptoms occur more than 4 days a week and greater than 4 consecutive weeks
One or more of the following occurs:
-Impairment of sleep
-Impairment of daily activities or school/work
-Troublesome symptoms.

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31
Q

Rhinitis treatment goals

A
  • Minimize frequency & severity of symptoms
  • Prevent complications
  • Improve quality of life
  • Improve attendance and productivity/performance at school/work
  • Minimize adverse effects of therapy
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32
Q

Rhinitis: approaches to treatment

A
  1. allergen avoidance
  2. pharmacotherapy (prevent and treat symptoms)
  3. Immunotherapy
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33
Q

Non-pharmacologic measures

A
  • breastfeed infants exclusively for 3 months
  • Avoid tobacco smoke
  • Avoid allergens
  • Nasal saline
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34
Q

MOA nasal saline

A

moisten nasal cavity and promote mucocilliary clearance

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35
Q

Nasal saline indication & delivery

A

Alternative or adjunct treatment for AR

-Irrigation, spray, drops, nebulizer

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36
Q

Nasal saline symptom relief /Adverse effects

A

sneezing, nasal congestion

side effects- nasal irrigation, infection

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37
Q

Perennial allergen control strategies

A

-Reduce mold growth: Keep humidity <50% & remove obvious growth with bleach or disinfectant
-Remove pets from the home, if feasible
-Reduce exposure to dust mites:
Encase bedding w/ impermeable covers, wash linens in hot water, use HEPA filters

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38
Q

Seasonal allergen control strategies

A
  • Keep windows closed & minimize time spent outdoors during pollen seasons
  • Filter masks can be worn while gardening or mowing the lawn
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39
Q

List all pharmacologic options

A
  • Anti-histamines
  • Decongestants
  • Intranasal corticosteroids
  • Mast cell stabilizers
  • Intranasal anti-cholinergices
  • Leukotriene receptor antagonists
40
Q

What are the mainstays of treatment?

What is 1st line therapy?

A

Antihistamines and nasal steroids are mainstays of treatment

-No particular agent used first, best to tailor therapy to symptoms

41
Q

Antihistamine MOA

A
  • Histamine receptor antagonist- competitive antagonists to histamine
  • Binds to H1 receptors without activating them–> prevents histamine from binding and causing downstream effects
42
Q

Anticholinergics with histamine

A

If histamine is already bound, hard for medications to take effect.
Anticholinergics help reverse symptoms if histamine is already bound- help with drying nose, & overproduction of mucous.

43
Q

Antihistamines relieve what symptoms?

A

Sneezing, itching, rhinorrhea, and ocular symptoms

44
Q

2nd generation antihistamines

A
  • preferred
  • peripherally selective
  • non sedating
45
Q

1st generation antihistamines

A
  • non-selective (CNS effects)

- sedating

46
Q

Perennial allergic rhinitis tx

A

Systemic antihistamine & Intranasal steroid.

47
Q

OTC 2nd generation antihistamines

A

Cetirizine, fexofenadine, loratadine

48
Q

OTC 1st generation antihistamines

A

Chlorpheniramine, clemastine, diphenhydramine

49
Q

1st generation adverse effects

A

Sedation, dry mouth, dry eyes, urinary retention.

50
Q

Bepotastine (Bepreve)

A

Ophthalmic antihistamine

51
Q

Azelastine (Optivar)

A

Ophthalmic antihistamine

52
Q

Ketotifen (Alway/Zatidor)

A

Ophthalmic antihistamine

53
Q

Olopatadine (Pataday/Patanol)

A

Ophthalmic antihistamine

54
Q

Antihistamines: Intranasal Adverse Effects

A

Drowsiness, drying effects, headache, diminished efficacy over time

55
Q

Azelastine (astellin/Astepro)

A

intranasal prescription drug

56
Q

Olopatadine (pantanase)

A

intranasal prescription drug

-less drowsiness, it is a selective drug.

57
Q

decongestants MOA

A

Alpha adrenergic receptor agonists on nasal mucosa–> vasoconstriction
Shrink swollen mucosa–> improved ventilation

58
Q

Phenylephrine receptor specificity

A

Alpha 1

59
Q

Oxymetazoline and naphazoline receptor specificity

A

Alpha 2

60
Q

Pseudo ephedrine receptor selectivity

A

Alpha & norepinephrine

61
Q

Topical decongestants caution

A

Max duration: 3-5 days

Rebound congestion

62
Q

Topical decongestants counseling points

A
  • Use smallest dose
  • Use infrequently
  • Use only when necessary
63
Q

Topical decongestants adverse effects

A
  • Burning, stinging, dryness, sneezing

- Minimal systemic side effects

64
Q

Short-acting topical decongestant

A

Phenylephrine (neo-synephrine) up to 4 hours

65
Q

Long acting topical decongestant

A

Oxymetazoline (Afrin)- up to 12 hours.

66
Q

Systemic decongestants onset and duration

A

Onset and duration slightly longer than topical decongestants
no risk of rebound congestion

67
Q

Systemic decongestants contraindications

A

-Use with MAOIs, uncontrolled hen, severe CAD, BPH

68
Q

Systemic adverse effects

A

Increased hen, tachy, decrease appetite, CNS stimulation, tremor, difficulty sleeping.

69
Q

Systemic decongestant drugs

A

Pseudoephedrine (sedated)

70
Q

Intranasal steroid MOA

A

Reduce inflammation mediator release–> decrease inflammation
Decrease intracellular edema, vasoconstriction
Inhibit mast cell-mediated late phase reactions

71
Q

Intranasal steroid adverse effects

A

Headache, stinging, sneezing, epistaxis

72
Q

Intranasal steroid onset of action

A

Improvement may occur within days

Peak: 2-3 weeks.

73
Q

Beclomethasone

A

Intranasal steroid

need prescription

74
Q

Budesonide (Rhinocort Aqua)

A

Intranasal steroid
OTC
no alcohol

75
Q

Mometasone (Nasonex)

A

Intranasal steroid

need prescription

76
Q

Fluticasone (flonase)

A

Intranasal steroid
OTC
contains alcohol

77
Q

Flunisolide

A

Intranasal steroid

Need prescription

78
Q

Triamcinolone (Nasacort)

A

OTC

No alcohol

79
Q

Mast Cell Stabilizers MOA

A

Stabilize mast cells and interfere with chloride channel function
Weak anti-inflammatory effects

80
Q

Mast Cell Stabilizers Indications

A

Seasonal allergic rhinitis (use prior to allergy season)

Perennial rhinitis

81
Q

Mast Cell Stabilizers Adverse effects

A

Sneezing, nasal stinging

82
Q

Cromolyn (NasalcCrom)

A 
Mast Cell Stabilizers
OTC
Prevents &amp; treats sx
Requires 2-4 weeks to notice symptom relief
-Dosed q6
83
Q

Intranasal anticholinergic MOA

A

Inhibits nasal serous and seromucous gland secretions

84
Q

Intranasal anticholinergic indication

A

Anti-secretory effects when applied locally  relief from rhinorrhea
Use only when patients fail or cannot tolerate other therapies

85
Q

Intranasal anticholinergic Adverse effects

A

Epistaxis, nasal dryness, headache

86
Q

Ipratropium bromide (Atrovent)

A

Intranasal anticholinergic

really just relieves rhinorrhea

87
Q

Leukotriene Receptor Antagonists MOA

A

Inhibit cysteinyl leukotriene receptor  block leukotriene release  interfere with pathway of inflammatory mediators released from mast cells

88
Q

Leukotriene Receptor Antagonists Symptom relief

A

Sneezing, rhinorrhea, congestion , itching

89
Q

Leukotriene Receptor Antagonists indicaiton

A

Mono therapy in patients with asthma and coexisting allergic rhinitis
considered 3rd line agent

90
Q

Leukotriene Receptor Antagonists adverse effects

A

Headache, GI upset, heapatotoxicity (rare)

91
Q

Montelukast (Singulair)

A

Leukotriene Receptor Antagonists

Indicated for allergic rhinitis

92
Q

Zafirlukast (Accolate)

A

Leukotriene Receptor Antagonists
Not approved for allergic rhinitis
Only indicated for asthma

93
Q

What is immunotherapy?

A

Slow, gradual process of injecting or taking increasing doses of antigens that cause allergic symptoms in to the body
Goal: develop tolerance to normal exposure of the antigen
More beneficial with seasonal allergic rhinitis
Some oral agents are available, usually a shot.

94
Q

Immunotherapy proposed mechanism

A

Induction of IgG blocking antibodies

Reduction of IgE

95
Q

Immunotherapy Drawbacks

A

Costly, requires years time commitment, risks

96
Q

Safe drugs for pregnancy

A

Nasal saline is 1st line treatment for mild-moderate nasal symptoms
Intranasal budesonide is recommended for severe or persistent symptoms
Intranasal cromolyn is not as effective
Oral antihistamines-
1st generation- chlorpheniramine
2nd generation- loratadine or cetirizine

97
Q

When to refer to a specialist?

A

Intolerance ot, contraindication of, or failure of medical management
Associated comorbidities
Severe allergic reactions
Consideration of immunotherapy

Pharm exam 2 (6 decks)

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