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
2
Q
What is allergic rhinitis
A
An allergen-induced and immunoglobulin E (IgE)- mediated type of rhinitis.
Leads to inflammatory markers
3
Q
Symptoms of rhinitis
A
- Watery rhinorrhea
- Sneezing
- Itching (nasal, throat, eye, ear)
- Nasal congestion
4
Q
Seasonal allergic rhinitis (hay fever) characteristics
A
- Specific seasonal allergies
- Predictable times of year
- Pollen from trees, grasses, and weeds
5
Q
Persistent allergic rhinitis (perennial) characteristics
A
- Non-seasonal allergens
- Year-round
- Dust mites, animal dander, molds
- Less variable, chronic symptoms
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.
7
Q
Rhinitis CNS issues
A
- Inability to complete activities of daily living
- Anxiety
- Depression
- learning difficulties
8
Q
Rhinitis associated with other conditions
A
- Asthma
- Chronic rhinosinusitis
- Otitis media
- Nasal plyps
- Resp. infections
- Orthodontic misalignment
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
10
Q
Rhinitis protective factors
A
-Exposure to harmless microbes in the first years of life.
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.
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
13
Q
Muscarinic antagonist
A
Prevents constriction
14
Q
Leukotriene antagonists
A
Decrease bronchial constriction
15
Q
Which drug is used as the parent for corticosteroids?
A
Hydrocortisone..If drug is less than 1, it is less potent.
16
Q
How do corticosteroids work?
A
- Work on inflammatory mediators and structural cells
- Help decrease inflammation to any process.
17
Q
3 basic nasal functions
A
- heating
- humidification
- filtration
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.
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
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.
21
Q
Symptoms of rhinitis
A
- Rhinorrhea
- Post-nasal drip
- Sneezing
- Itching eyes, ears, nose
- Red, watery eyes
22
Q
Signs of rhinitis
A
- Allergic salute (nasal crease)
- Allergic shiners (bags under eyes)
- Mouth breathing
23
Q
Rhinitis complications
A
Acute otitis media
Sinusitis
^both occur due to nasal obstruction
24
Q
Seasonal classification
A
Symptoms present only during specific portions of the year
25
Perennial classification
Symptoms present throughout the year
26
Episodic classification
Symptoms present only during intermittent exposure to allergen trigger
27
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
28
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
29
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
30
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.
31
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
32
Rhinitis: approaches to treatment
1. allergen avoidance
2. pharmacotherapy (prevent and treat symptoms)
3. Immunotherapy
33
Non-pharmacologic measures
- breastfeed infants exclusively for 3 months
- Avoid tobacco smoke
- Avoid allergens
- Nasal saline
34
MOA nasal saline
moisten nasal cavity and promote mucocilliary clearance
35
Nasal saline indication & delivery
Alternative or adjunct treatment for AR
| -Irrigation, spray, drops, nebulizer
36
Nasal saline symptom relief /Adverse effects
sneezing, nasal congestion
| side effects- nasal irrigation, infection
37
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
38
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
39
List all pharmacologic options
- Anti-histamines
- Decongestants
- Intranasal corticosteroids
- Mast cell stabilizers
- Intranasal anti-cholinergices
- Leukotriene receptor antagonists
40
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
41
Antihistamine MOA
- Histamine receptor antagonist- competitive antagonists to histamine
- Binds to H1 receptors without activating them--> prevents histamine from binding and causing downstream effects
42
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.
43
Antihistamines relieve what symptoms?
Sneezing, itching, rhinorrhea, and ocular symptoms
44
2nd generation antihistamines
- preferred
- peripherally selective
- non sedating
45
1st generation antihistamines
- non-selective (CNS effects)
| - sedating
46
Perennial allergic rhinitis tx
Systemic antihistamine & Intranasal steroid.
47
OTC 2nd generation antihistamines
Cetirizine, fexofenadine, loratadine
48
OTC 1st generation antihistamines
Chlorpheniramine, clemastine, diphenhydramine
49
1st generation adverse effects
Sedation, dry mouth, dry eyes, urinary retention.
50
Bepotastine (Bepreve)
Ophthalmic antihistamine
51
Azelastine (Optivar)
Ophthalmic antihistamine
52
Ketotifen (Alway/Zatidor)
Ophthalmic antihistamine
53
Olopatadine (Pataday/Patanol)
Ophthalmic antihistamine
54
Antihistamines: Intranasal Adverse Effects
Drowsiness, drying effects, headache, diminished efficacy over time
55
Azelastine (astellin/Astepro)
intranasal prescription drug
56
Olopatadine (pantanase)
intranasal prescription drug
| -less drowsiness, it is a selective drug.
57
decongestants MOA
Alpha adrenergic receptor agonists on nasal mucosa--> vasoconstriction
Shrink swollen mucosa--> improved ventilation
58
Phenylephrine receptor specificity
Alpha 1
59
Oxymetazoline and naphazoline receptor specificity
Alpha 2
60
Pseudo ephedrine receptor selectivity
Alpha & norepinephrine
61
Topical decongestants caution
Max duration: 3-5 days
| Rebound congestion
62
Topical decongestants counseling points
- Use smallest dose
- Use infrequently
- Use only when necessary
63
Topical decongestants adverse effects
- Burning, stinging, dryness, sneezing
| - Minimal systemic side effects
64
Short-acting topical decongestant
Phenylephrine (neo-synephrine) up to 4 hours
65
Long acting topical decongestant
Oxymetazoline (Afrin)- up to 12 hours.
66
Systemic decongestants onset and duration
Onset and duration slightly longer than topical decongestants
no risk of rebound congestion
67
Systemic decongestants contraindications
-Use with MAOIs, uncontrolled hen, severe CAD, BPH
68
Systemic adverse effects
Increased hen, tachy, decrease appetite, CNS stimulation, tremor, difficulty sleeping.
69
Systemic decongestant drugs
Pseudoephedrine (sedated)
70
Intranasal steroid MOA
Reduce inflammation mediator release--> decrease inflammation
Decrease intracellular edema, vasoconstriction
Inhibit mast cell-mediated late phase reactions
71
Intranasal steroid adverse effects
Headache, stinging, sneezing, epistaxis
72
Intranasal steroid onset of action
Improvement may occur within days
| Peak: 2-3 weeks.
73
Beclomethasone
Intranasal steroid
| need prescription
74
Budesonide (Rhinocort Aqua)
Intranasal steroid
OTC
no alcohol
75
Mometasone (Nasonex)
Intranasal steroid
| need prescription
76
Fluticasone (flonase)
Intranasal steroid
OTC
contains alcohol
77
Flunisolide
Intranasal steroid
| Need prescription
78
Triamcinolone (Nasacort)
OTC
| No alcohol
79
Mast Cell Stabilizers MOA
Stabilize mast cells and interfere with chloride channel function
Weak anti-inflammatory effects
80
Mast Cell Stabilizers Indications
Seasonal allergic rhinitis (use prior to allergy season)
| Perennial rhinitis
81
Mast Cell Stabilizers Adverse effects
Sneezing, nasal stinging
82
Cromolyn (NasalcCrom)
```
Mast Cell Stabilizers
OTC
Prevents & treats sx
Requires 2-4 weeks to notice symptom relief
-Dosed q6
```
83
Intranasal anticholinergic MOA
Inhibits nasal serous and seromucous gland secretions
84
Intranasal anticholinergic indication
Anti-secretory effects when applied locally relief from rhinorrhea
Use only when patients fail or cannot tolerate other therapies
85
Intranasal anticholinergic Adverse effects
Epistaxis, nasal dryness, headache
86
Ipratropium bromide (Atrovent)
Intranasal anticholinergic
| really just relieves rhinorrhea
87
Leukotriene Receptor Antagonists MOA
Inhibit cysteinyl leukotriene receptor block leukotriene release interfere with pathway of inflammatory mediators released from mast cells
88
Leukotriene Receptor Antagonists Symptom relief
Sneezing, rhinorrhea, congestion , itching
89
Leukotriene Receptor Antagonists indicaiton
Mono therapy in patients with asthma and coexisting allergic rhinitis
considered 3rd line agent
90
Leukotriene Receptor Antagonists adverse effects
Headache, GI upset, heapatotoxicity (rare)
91
Montelukast (Singulair)
Leukotriene Receptor Antagonists
| Indicated for allergic rhinitis
92
Zafirlukast (Accolate)
Leukotriene Receptor Antagonists
Not approved for allergic rhinitis
Only indicated for asthma
93
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.
94
Immunotherapy proposed mechanism
Induction of IgG blocking antibodies
| Reduction of IgE
95
Immunotherapy Drawbacks
Costly, requires years time commitment, risks
96
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
97
When to refer to a specialist?
Intolerance ot, contraindication of, or failure of medical management
Associated comorbidities
Severe allergic reactions
Consideration of immunotherapy
