HEENT 07: Allergic Rhinitis Flashcards
What is allergic rhinitis?
- nasal mucosa becomes sensitized to allergens
- IgE mediated
- type I hypersensitivity response
- associated with asthma, atopic dermatitis, allergic conjunctivitis, sinusitis, sleep apnea
- genetic predisposition
What are the signs and symptoms of allergic rhinitis?
- sneezing, nasal congestion, rhinorrhea – triggered by exposure to allergens
- enlarged nasal mucosa, nasal polyps, allergic shiners
- chronic cough
What are the signs and symptoms of early phase allergic rhinitis?
- clear nasal discharge (rhinorrhea)
- sneezing
- itchy nose, eyes, and throat – nasal itchiness is distinctive to allergic rhinitis
- some congestion
What are the signs and symptoms of late phase allergic rhinitis?
major congestion
What are some complications of allergic rhinitis? (3)
- ear conditions – related to eustachian tube defects
- sinusitis and URTI
- eosinophilic esophagitis – dysphagia, heartburn, vomiting
What are the differential diagnoses of allergic rhinitis?
- infective rhinitis – purulent nasal discharge, swollen glands, short-term, associated with URTI
- irritant rhinitis
- drug-induced rhinitis
- occupational rhinitis
How are symptoms of allergic rhinitis classified?
based on frequency and duration:
- intermittent: up to 4 days/week for < 4 consecutive weeks
- persistent: 4 or more days/week for > 4 consecutive weeks
based on severity:
- mild: do not interfere with daily activities
- moderate-severe: very bothersome and interferes with daily activities and disturb sleep
What are red flags for referral of allergic rhinitis?
- age < 2 years
- pregnancy
- new medication
- SOB, wheezing
- persistent headache, facial pain
- unilateral nasal symptoms
- worsening or no improvement in symptoms
- mucopurulent nasal discharge
What is the first-line treatment for allergic rhinitis?
- oral antihistamines
- intranasal corticosteroids
What is the treatment for mild, intermittent allergic rhinitis?
- 2nd generational oral antihistamine
- step-up: INC
note: oral antihistamines can be used as add-on when needed
What is the treatment for mild, persistent allergic rhinitis?
INC
note: oral antihistamines can be used as add-on when needed
What is the treatment for moderate to severe allergic rhinitis?
(intermittent or persistent)
- first-line: INC
- step-up: INC/INAH
note: oral antihistamines can be used as add-on when needed
Intranasal Corticosteroids (INC)
Beclomethasone
- high bioavailability
- 1-2 sprays each nostril BID
Intranasal Corticosteroids (INC)
Budesonide
- moderate bioavailability
- 1-2 sprays each nostril daily
Intranasal Corticosteroids (INC)
Ciclesonide
- very low bioavailability
- 2 sprays each nostril daily
Intranasal Corticosteroids (INC)
Fluticasone Furoate
- very low bioavailability
- 2 sprays each nostril daily
Intranasal Corticosteroids (INC)
Fluticasone Propionate
- very low bioavailability
- 1-2 sprays each nostril daily
Intranasal Corticosteroids (INC)
Mometasone
- very low bioavailability
- 1-2 sprays each nostril daily
Intranasal Corticosteroids (INC)
Triamcinolone
- moderate bioavailability
- 1-2 sprays each nostril daily
Describe the efficacy of intranasal corticosteroids.
- maximum effect in 3-14 days – takes longer to work than nasal decongestants
- most can be given up to BID
- works best if used continuously
- more effective than oral antihistamines
Describe the adverse effects of intranasal corticosteroids.
- common: epistaxis, nasal irritation, headache
- rare: ulceration of mucosa, pharyngeal candidiasis, rash, septum perforation
Oral Antihistamines
Bilastine
20 mg daily
- somewhat sedating
- Rx
- take on empty stomach
Oral Antihistamines
Cetirizine
10 mg daily
- most sedating
- dose adjust renal impairment
- quickest acting (20 min)
Oral Antihistamines
Desloratadine
5 mg daily
- diarrhea in children
- dose adjust renal impairment
Oral Antihistamines
Fexofenadine
60 mg BID or 120 mg daily
- dose adjust renal impairment
Oral Antihistamines
Loratadine
10 mg daily
- xerostomia
- dose adjust renal impairment
Oral Antihistamines
Rupatadine
10 mg daily
- somewhat sedating
- Rx
Combination Oral Antihistamines and Intranasal Corticosteroids
- unclear evidence
- not wrong to use together, may increase ADRs
- switch to INCS is reasonable transition if oral AH not working
Intranasal Antihistamines (INAH)
- better than oral for nasal congestion– may work even if oral AH failed
- only available in Canada combined with INC – Dymista (fluticasone/azelastine), Ryaltris (mometasone/olopatadine)
- ADR: bitter taste, epistaxis
What is the main role of decongestants in management of allergic rhinitis?
symptomatic relief while other medications (INC) are taking time to work (3-14 days)
- short-term use only is what is recommended
- generally NOT recommended for use in children
What are the concerns of using decongestants in management of allergic rhinitis?
- use in people with uncontrolled HTN, CAD – can increase BP
- do not use with MAOIs (ie. mocobemide)
- rebound congestion with intranasal products after 3-5 days of use
What does intranasal ipratropium do?
decreases rhinorrhea, but minimal effect on congestion
What does montelukast (oral leukotriene receptor antagonist) do?
- modest effect – varied response
- add on when other therapies are ineffective
When is immunotherapy indicated?
- if coexisting allergies and asthma
- if using maximum pharmacotherapy
Actions of Different Classes
INC
- rhinorrhea
- sneezing
- congestion
- sinusitis
- allergic conjunctivitis
- rhinorrhea: YES
- sneezing: YES
- congestion: YES
- sinusitis: YES
- allergic conjunctivitis: YES
Actions of Different Classes
Oral AH
- rhinorrhea
- sneezing
- congestion
- sinusitis
- allergic conjunctivitis
- rhinorrhea: YES
- sneezing: YES
- congestion: ?
- sinusitis: NO
- allergic conjunctivitis: YES
Actions of Different Classes
INAH (with INC)
- rhinorrhea
- sneezing
- congestion
- sinusitis
- allergic conjunctivitis
- rhinorrhea: YES
- sneezing: YES
- congestion: YES
- sinusitis: NO
- allergic conjunctivitis: ?
Actions of Different Classes
Decongestant
- rhinorrhea
- sneezing
- congestion
- sinusitis
- allergic conjunctivitis
- rhinorrhea: NO
- sneezing: NO
- congestion: YES
- sinusitis: NO
- allergic conjunctivitis: NO
What is used for treatment of ocular symptoms? (2)
- ophthalmic antihistamine (antazoline, olopatadine, pheniramine (all OTC)) – often combined with decongestant
- ophthalmic mast cell stabilizer – Cromolyn (OTC)
Are INCs safe in pregnancy?
yes
- exception: triamcinolone
- most data for cetirizine and loratadine
What are the efficacy monitoring points for allergic rhinitis?
- symptoms should start to be relieved within first day or 2
- minimal improvement or no improvement – step-up treatment, refer
- visual analog scale (VAS) to determine efficacy – assess in 3-7 days to determine if working (step-up/down, continue)
What can pharmacists in BC prescribe for allergic rhinitis?
- intransal drugs
- ophthalmic drugs
- oral antihistamines
