Allergy Rhinitis Flashcards
What is rhinitis?
- Inflammation of the lining of the nose and other parts of the upper respiratory tract
- Most common: Allergic rhinitis
What is allergic rhinitis
An allergen-induced and immunoglobulin E (IgE)- mediated type of rhinitis.
Leads to inflammatory markers
Symptoms of rhinitis
- Watery rhinorrhea
- Sneezing
- Itching (nasal, throat, eye, ear)
- Nasal congestion
Seasonal allergic rhinitis (hay fever) characteristics
- Specific seasonal allergies
- Predictable times of year
- Pollen from trees, grasses, and weeds
Persistent allergic rhinitis (perennial) characteristics
- Non-seasonal allergens
- Year-round
- Dust mites, animal dander, molds
- Less variable, chronic symptoms
Background & epidemiology of rhinintis
- Extremely common
- 40-50% of patients who have skin or serum tests are allergic to aeroallergens measured by allergen-specific IgE.
Rhinitis CNS issues
- Inability to complete activities of daily living
- Anxiety
- Depression
- learning difficulties
Rhinitis associated with other conditions
- Asthma
- Chronic rhinosinusitis
- Otitis media
- Nasal plyps
- Resp. infections
- Orthodontic misalignment
Rhinitis risk factors
- Genetics/family hx
- Exposure to allergens
- Increased IgE levels before age 6
- Eczema
- Heavy secondhand smoke exposure
- Higher socioeconomic status
Rhinitis protective factors
-Exposure to harmless microbes in the first years of life.
Allergens
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.
What does activation of cAMP do?
Stimulates bronchial relaxation, which results in AMP.
Increase cAMP or reduce breakdown of cAMP with PDE (enzyme) by blocking PDE
Muscarinic antagonist
Prevents constriction
Leukotriene antagonists
Decrease bronchial constriction
Which drug is used as the parent for corticosteroids?
Hydrocortisone..If drug is less than 1, it is less potent.
How do corticosteroids work?
- Work on inflammatory mediators and structural cells
- Help decrease inflammation to any process.
3 basic nasal functions
- heating
- humidification
- filtration
Cleansing process
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.
Immediate phase
- 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
Late phase
- 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.
Symptoms of rhinitis
- Rhinorrhea
- Post-nasal drip
- Sneezing
- Itching eyes, ears, nose
- Red, watery eyes
Signs of rhinitis
- Allergic salute (nasal crease)
- Allergic shiners (bags under eyes)
- Mouth breathing
Rhinitis complications
Acute otitis media
Sinusitis
^both occur due to nasal obstruction
Seasonal classification
Symptoms present only during specific portions of the year
Perennial classification
Symptoms present throughout the year
Episodic classification
Symptoms present only during intermittent exposure to allergen trigger
Intermittent mild
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
Intermittent moderate-severe
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
Persistent mild
Symptoms occur more than 4 days a week and greater than 4 consecutive weeks
Symptoms do not impair sleep, activities, or school/work
Persistent moderate-severe
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.
Rhinitis treatment goals
- Minimize frequency & severity of symptoms
- Prevent complications
- Improve quality of life
- Improve attendance and productivity/performance at school/work
- Minimize adverse effects of therapy
Rhinitis: approaches to treatment
- allergen avoidance
- pharmacotherapy (prevent and treat symptoms)
- Immunotherapy
Non-pharmacologic measures
- breastfeed infants exclusively for 3 months
- Avoid tobacco smoke
- Avoid allergens
- Nasal saline
MOA nasal saline
moisten nasal cavity and promote mucocilliary clearance
Nasal saline indication & delivery
Alternative or adjunct treatment for AR
-Irrigation, spray, drops, nebulizer
Nasal saline symptom relief /Adverse effects
sneezing, nasal congestion
side effects- nasal irrigation, infection
Perennial allergen control strategies
-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
Seasonal allergen control strategies
- Keep windows closed & minimize time spent outdoors during pollen seasons
- Filter masks can be worn while gardening or mowing the lawn
List all pharmacologic options
- Anti-histamines
- Decongestants
- Intranasal corticosteroids
- Mast cell stabilizers
- Intranasal anti-cholinergices
- Leukotriene receptor antagonists
What are the mainstays of treatment?
What is 1st line therapy?
Antihistamines and nasal steroids are mainstays of treatment
-No particular agent used first, best to tailor therapy to symptoms
Antihistamine MOA
- Histamine receptor antagonist- competitive antagonists to histamine
- Binds to H1 receptors without activating them–> prevents histamine from binding and causing downstream effects
Anticholinergics with histamine
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.
Antihistamines relieve what symptoms?
Sneezing, itching, rhinorrhea, and ocular symptoms
2nd generation antihistamines
- preferred
- peripherally selective
- non sedating
1st generation antihistamines
- non-selective (CNS effects)
- sedating
Perennial allergic rhinitis tx
Systemic antihistamine & Intranasal steroid.
OTC 2nd generation antihistamines
Cetirizine, fexofenadine, loratadine
OTC 1st generation antihistamines
Chlorpheniramine, clemastine, diphenhydramine
1st generation adverse effects
Sedation, dry mouth, dry eyes, urinary retention.
Bepotastine (Bepreve)
Ophthalmic antihistamine
Azelastine (Optivar)
Ophthalmic antihistamine
Ketotifen (Alway/Zatidor)
Ophthalmic antihistamine
Olopatadine (Pataday/Patanol)
Ophthalmic antihistamine
Antihistamines: Intranasal Adverse Effects
Drowsiness, drying effects, headache, diminished efficacy over time
Azelastine (astellin/Astepro)
intranasal prescription drug
Olopatadine (pantanase)
intranasal prescription drug
-less drowsiness, it is a selective drug.
decongestants MOA
Alpha adrenergic receptor agonists on nasal mucosa–> vasoconstriction
Shrink swollen mucosa–> improved ventilation
Phenylephrine receptor specificity
Alpha 1
Oxymetazoline and naphazoline receptor specificity
Alpha 2
Pseudo ephedrine receptor selectivity
Alpha & norepinephrine
Topical decongestants caution
Max duration: 3-5 days
Rebound congestion
Topical decongestants counseling points
- Use smallest dose
- Use infrequently
- Use only when necessary
Topical decongestants adverse effects
- Burning, stinging, dryness, sneezing
- Minimal systemic side effects
Short-acting topical decongestant
Phenylephrine (neo-synephrine) up to 4 hours
Long acting topical decongestant
Oxymetazoline (Afrin)- up to 12 hours.
Systemic decongestants onset and duration
Onset and duration slightly longer than topical decongestants
no risk of rebound congestion
Systemic decongestants contraindications
-Use with MAOIs, uncontrolled hen, severe CAD, BPH
Systemic adverse effects
Increased hen, tachy, decrease appetite, CNS stimulation, tremor, difficulty sleeping.
Systemic decongestant drugs
Pseudoephedrine (sedated)
Intranasal steroid MOA
Reduce inflammation mediator release–> decrease inflammation
Decrease intracellular edema, vasoconstriction
Inhibit mast cell-mediated late phase reactions
Intranasal steroid adverse effects
Headache, stinging, sneezing, epistaxis
Intranasal steroid onset of action
Improvement may occur within days
Peak: 2-3 weeks.
Beclomethasone
Intranasal steroid
need prescription
Budesonide (Rhinocort Aqua)
Intranasal steroid
OTC
no alcohol
Mometasone (Nasonex)
Intranasal steroid
need prescription
Fluticasone (flonase)
Intranasal steroid
OTC
contains alcohol
Flunisolide
Intranasal steroid
Need prescription
Triamcinolone (Nasacort)
OTC
No alcohol
Mast Cell Stabilizers MOA
Stabilize mast cells and interfere with chloride channel function
Weak anti-inflammatory effects
Mast Cell Stabilizers Indications
Seasonal allergic rhinitis (use prior to allergy season)
Perennial rhinitis
Mast Cell Stabilizers Adverse effects
Sneezing, nasal stinging
Cromolyn (NasalcCrom)
Mast Cell Stabilizers OTC Prevents & treats sx Requires 2-4 weeks to notice symptom relief -Dosed q6
Intranasal anticholinergic MOA
Inhibits nasal serous and seromucous gland secretions
Intranasal anticholinergic indication
Anti-secretory effects when applied locally relief from rhinorrhea
Use only when patients fail or cannot tolerate other therapies
Intranasal anticholinergic Adverse effects
Epistaxis, nasal dryness, headache
Ipratropium bromide (Atrovent)
Intranasal anticholinergic
really just relieves rhinorrhea
Leukotriene Receptor Antagonists MOA
Inhibit cysteinyl leukotriene receptor block leukotriene release interfere with pathway of inflammatory mediators released from mast cells
Leukotriene Receptor Antagonists Symptom relief
Sneezing, rhinorrhea, congestion , itching
Leukotriene Receptor Antagonists indicaiton
Mono therapy in patients with asthma and coexisting allergic rhinitis
considered 3rd line agent
Leukotriene Receptor Antagonists adverse effects
Headache, GI upset, heapatotoxicity (rare)
Montelukast (Singulair)
Leukotriene Receptor Antagonists
Indicated for allergic rhinitis
Zafirlukast (Accolate)
Leukotriene Receptor Antagonists
Not approved for allergic rhinitis
Only indicated for asthma
What is immunotherapy?
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.
Immunotherapy proposed mechanism
Induction of IgG blocking antibodies
Reduction of IgE
Immunotherapy Drawbacks
Costly, requires years time commitment, risks
Safe drugs for pregnancy
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
When to refer to a specialist?
Intolerance ot, contraindication of, or failure of medical management
Associated comorbidities
Severe allergic reactions
Consideration of immunotherapy
