Chapter 65 Flashcards
Which symptom is least typical of allergic rhinitis?
A. Nasal and/or ocular itching
B. Sleep disturbance
C. Sneezing
D. Rhinorrhea
Answer B
Typical symptoms of allergic rhinitis include rhinorrhea [Answer D], sneezing [Answer
B], itching (mostly nasal but also palate, throat, eyes, ears) [Answer A], and nasal
congestion. Sleep disturbance [Answer B] is a possible symptom, but not typical in
allergic rhinitis.
JR a 25-year-old man, reports that his allergic rhinitis symptoms occur less than 4 days
per week, without sleep disturbance, impairment of daily activity, or troublesome
symptoms. Which term most appropriately describes JR’s allergic rhinitis?
A. Intermittent and mild
B. Persistent and mild
C. Intermittent and moderate/severe
D. Persistent and moderate/severe
Answer A
Based on the ARIA 2016 update, symptoms of note include sleep disturbance,
interference with daily activities (including leisure or sport), impairment of school/work,
and troublesome symptoms. It also defines mild as having none of the noted symptoms
present [Answer A], whereas moderate-severe as presence of any one of the noted
symptoms [Answers C and D]. Intermittent is defined as symptoms present for less than 4
days/week or for less than 4 consecutive weeks [Answer A], whereas persistent is defined
as symptoms present for 4 or more days/week and for more than 4 consecutive weeks
[Answers B and D].Answer B
Typical symptoms of allergic rhinitis include rhinorrhea [Answer D], sneezing [Answer
B], itching (mostly nasal but also palate, throat, eyes, ears) [Answer A], and nasal
congestion. Sleep disturbance [Answer B] is a possible symptom, but not typical in
allergic rhinitis.
WW is a 35-year-old woman seen at the family medicine clinic for allergic rhinitis with
rhinorrhea, nasal itching and congestion, sneezing, and ocular itching every day of the
week and for more than 4 consecutive weeks. She reports that her symptoms cause her
difficulty sleeping and being able to do daily activities like running and working in her
garden. She does not have any medication allergies and no other past medical history.
She is not currently on any medications except a multivitamin. She says she needs to stay
alert for her work so does not want to take anything that would make her sleepy or tired,
if all possible. Which is the most appropriate treatment for WW at this time?
A. Diphenhydramine tablet
B. Cromolyn intranasal spray
C. Loratadine tablet
D. Triamcinolone nasal spray
Answer D
Diphenhydramine [Answer A] is a first-generation antihistamine and is more sedating
which may interfere with her daily activities such as her work, running and working in
her garden. Cromolyn intranasal spray [Answer B], is moderately effective however is
less effective than INCs and oral or intranasal antihistamines and requires frequent dosing
of four times a day. Loratadine [Answer C] is a second-generation antihistamine and less
sedating that first-generation antihistamines but can still potentially have some sedating
effects. Oral second-generation antihistamines are effective for the sneezing, itching, and
rhinorrhea of AR but less effective for the nasal congestion. They also improve ocular
symptoms. Since the patient has congestion in addition to rhinorrhea, nasal itching
sneezing, and ocular itching every day of the week and for more than 4 consecutive
weeks, the use of loratadine may not be the most appropriate first choice. Triamcinolone
nasal spray [Answer D], as an intranasal corticosteroid, is a first line agent and is
effective for sneezing, itching, rhinorrhea, and especially effective for nasal congestion.
PT is a 28-year-old man who presents to the clinic with rhinitis medicamentosa or
rebound congestion. Which of his current medications is most likely the cause?
A. Saline nasal spray
B. Phenylephrine nasal spray
C. Fluticasone propionate nasal spray
D. Azelastine nasal spray
Answer B
The continuous use of intranasal decongestants such as phenylephrine nasal spray
[Answer B] often causes a paradoxical rebound phenomenon of persistent nasal
congestion, called rhinitis medicamentosa. Saline nasal spray [Answer A], intranasal
corticosteroids such as fluticasone propionate [Answer C], and intranasal antihistamines
such as azelastine nasal spray [Answer D] do not cause rhinitis medicamentosa.
JJ is a 45-year-old man who is currently on fluticasone nasal spray for allergic rhinitis;
however, his symptoms are not well controlled on this treatment alone. The physician
would like to add on an oral antihistamine. JJ works with heavy machinery as a part of
construction firm and states “I cannot be sleepy or tired while at work.” Which oral
antihistamine is the most appropriate for JJ?
A. Fexofenadine
B. Diphenhydramine
C. Chlorpheniramine
D. Cetirizine
Answer A
Fexofenadine [Answer A], a second-generation antihistamine, has virtually no sedative
effects which is helpful given his work with heavy machinery.
QB is a 6-year-old boy with allergic rhinitis requiring treatment with an intranasal
steroid. His also has concurrent moderate persistent asthma and eczema of which he is
prescribed fluticasone propionate 110 mcg HFA MDI 2 puff twice a day and triamcinolone cream. Mom is concerned about how QB’s overall steroid exposure and asks the team to prescribe a nasal steroid that minimize additional exposure, if possible.
Which intranasal corticosteroid is most appropriate for QB?
A. Beclomethasone
B. Budesonide
C. Flunisolide
D. Mometasone
Answer D
Older INCSs such as beclomethasone [Answer A], budesonide [Answer B], and
flunisolide [Answer C]) have significant absorption, whereas, among the newer products,
including fluticasone, ciclesonide, and mometasone [Answer D] have bioavailability of
less than 1% to 2%.
BN is a 14-year-old girl who is prescribed azelastine nasal spray. Her Dad asks you, what
are the common side effects she may experience. Which is the most appropriate response
to his question?
A. Insomnia
B. Bitter taste
C. Rash
D. Nausea
Answer B
For both intranasal antihistamine products, azelastine and olopatadine, are second-
generation agents of which the most common side effect is a bitter taste. For some
patients, it may also cause sedation. Insomnia [Answer A], rash [Answer C], and nausea
[Answer D] are not likely with these agents compared to bitter taste [Answer B]
SS is a 30-year-old man who comes to clinic with ongoing AR symptoms despite treatment with fluticasone nasal spray daily. After further assessment it is found that his AR is of mixed etiology. Which is the most appropriate medication to help treat SS’s
symptoms?
A. Azelastine nasal spray
B. Ipratropium nasal spray
C. Mometasone nasal spray
D. Oral fexofenadine
Answer B
Intranasal antihistamines such as azelastine [Answer A] are less effective for nasal
congestion than intranasal corticosteroids (INCs). Ipratropium nasal spray [Answer B], as
an antimuscarinic, is useful for those who rhinorrhea has not been controlled on other
therapy such as an intranasal corticosteroid as well as those with allergic rhinitis with
mixed etiology. Mometasone nasal spray [Answer C] is an INC, and this patient appears
to not have had successful treatment with current intranasal corticosteroid, fluticasone;
thus, changing INCs. Oral fexofenadine [Answer D], is a second-generation antihistamine, of which are not notable effective for mixed etiology AR.Answer B
AZ is a 24-year-old woman who presents to allergy clinic as a possible candidate for
SLIT for her house dust mite allergy. Which SLIT product is most appropriate for this
patient?
A. Grastek
B. Oralair
C. Odactra
D. Ragwitek
Answer C
Grastek [Answer A] is a SLIT for Timothy grass pollen. Oralair [Answer B] is SLIT for a mixture of pollens from Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass. Odactra [Answer C] is SLIT for house dust mites. Radwitek [Answer D] is SLIT for ragweed pollen.
Which medication is mostly likely to cause paradoxical CNS stimulation in young
children?
A. Cetirizine
B. Diphenhydramine
C. Fluticasone
D. Montelukast
Answer B
First-generation antihistamines, such as diphenhydramine [Answer B] may cause
paradoxical CNS stimulation in very young children (e.g., < 2 years old). Second-
generation antihistamines such as cetirizine [Answer A] , intranasal corticosteroid such as
fluticasone [Answer C] are not known to cause paradoxical CNS stimulation. Montelukast [Answer D], a leukotriene receptor antagonist has a boxed warning issued for possible behavioral changes such as sleep disturbances, depression, and suicidal ideation, but not paradoxical CNS stimulation.Answer B
LM is a 19-year-old woman with asthma and diabetes. Her asthma is well-controlled but
notes she has rhinorrhea, nasal and ocular itching when around dogs and cats. Despite
this, she is animal lover and is volunteering at a local pet shelter once to twice a month.
Which is the most appropriate recommendation for LM for use prior to her volunteering
sessions?
A. Intranasal cromolyn
B. Oral diphenhydramine
C. Oral loratadine
D. Intranasal triamcinolone
Answer A
Given the need for more immediate onset of action, the use of oral loratadine (second
generation antihistamine, [Answer C]) or intranasal triamcinolone (INC, [Answer D])
may not be ideal as they are not as effective for as-needed basis for episodic exposures to
allergens. Oral diphenhydramine [Answer B], a first-generation antihistamine, may have
a relatively quicker onset, however its sedative effects may hinder ability to do activities
such as volunteering at the local pet shelter. Given the need for immediate onset and as
needed use for episodic allergen exposure, intranasal cromolyn [Answer A] would be the
most appropriate.
RD is a 58-year-old male patient with poorly controlled hypertension, diabetes, and
persistent rhinorrhea and nasal itch due to allergic rhinitis. He admits he is not great with
medication adherence, especially if he has to take medications multiple times a day. He
has not had good response to oral fexofenadine and intranasal fluticasone propionate.
Which is the most appropriate added treatment for him at this time?
A. Intranasal azelastine
B. Oral cetirizine
C. Intranasal cromolyn
D. Oral pseudoephedrine
Answer A
Given RD is already on an oral second-generation antihistamine (fexofenadine), adding
another medication of the same class (cetirizine [Answer B] is not going to add benefit,
however, may increase risk for side effects such as sedation. RD is not great with medication adherence, so use of a medication needing dosing four times a day, such as intranasal cromolyn [Answer C] is not appropriate. The patient should also avoid oral pseudoephedrine [Answer D] because he has concurrent poorly controlled hypertension, adding this medication may increase his blood pressure further. Intranasal azelastine
[Answer A] provides a different and local route of administration for an antihistamine and can be dosed twice a day and does not interfere with his concurrent conditions of hypertension and diabetes.
JD is a 15-year-old boy with concurrent moderate persistent asthma and allergic rhinitis.
His medications include fluticasone propionate/salmeterol 230 mcg/21 mcg 2 puff
inhaled twice a day, montelukast 10 mg daily, fluticasone nasal spray, and azelastine
nasal spray. Which additional tests would be needed to evaluate if omalizumab is
appropriate for his asthma and AR?
A. Complete blood count (CBC) with differential assessing total eosinophils
B. Serum creatine (SCr) and blood urea nitrogen (BUN)
C. Serum immunoglobulin (IgE)
D. Hepatic function panel (HFP)
Answer C
Complete blood count (CBC) with differential assessing total eosinophils [Answer A]
would be assessed if considering an anti-interleukin agent such as dupilumab. Renal
[Answer B] and hepatic function [Answer D] labs is not usually assessed to determine eligibility for biologic therapy. Since dosing is based on weight and serum IgE, serum IgE [Answer C] would be the most appropriate test of those listed to help assess if omalizumab is appropriate for this patient.
A 32-year-old woman, who is known to be 12 weeks pregnant, has been on saline nasal
rinses and oral loratadine for her allergic rhinitis. Her symptoms of nasal congestion,
rhinorrhea, sneezing, and ocular itching are still poorly controlled, despite good
adherence. Which is the most appropriate to recommend as possible added therapy?
A. Beclomethasone nasal spray
B. Capsaicin nasal spray
C. Cromolyn nasal spray
D. Oral phenylephrine
Answer C
Data on cromolyn [Answer C] demonstrate no perinatal mortality or prematurity and thus
is a safe option for this patient. There is somewhat lacking data on fetal harm regarding
various INCs (e.g., beclomethasone nasal spray, [Answer A]) and thus would not be first
line for this patient. There is lack of safety and effectiveness data regarding capsaicin
nasal spray [Answer B] overall, and thus would not be an appropriate choice for a pregnant patient. Oral decongestants such as phenylephrine [Answer D] are best avoided,
especially in the first trimester.
JS is a 10-year-old girl treated for her AR with the following: fexofenadine, mometasone
nasal spray, azelastine nasal spray, and montelukast. Her mother comes to you with a
question about drug-related issues and change in behavior. JS appears more withdrawn,
sleeping more, and has stopped participating in activities she used to love such as sports.
Which medication is most likely associated with these new symptoms?
A. Montelukast
B. Fexofenadine
C. Mometasone
D. Azelastine
Answer A
Montelukast [Answer A], a leukotriene receptor antagonist has a boxed warning issued
for possible behavioral changes such as sleep disturbances, depression, and suicidal
ideation. Second-generation antihistamines (e.g., fexofenadine [Answer B]), intranasal
corticosteroids (e.g., mometasone, [Answer C]), and intranasal antihistamine (e.g., azelastine [Answer A]) are not commonly associated with such symptoms related to behavioral changes such as sleep disturbances, depression, and suicidal ideation.
