LECTURE 32 - treatment of allergic rhinitis Flashcards
List the symptoms of allergic rhinitis
Sneezing
Runny nose (nasal crease in children)
Nasal congestion
Red & watery eyes
Itchy nose & eyes
What is the cause of allergic rhinitis?
IgE-mediated disease
What is the cause of NON-allergic rhinitis?
Exposure to airborne irritants: pollution, chemicals, smoke
What patient population is most affected by allergic rhinitis?
Common in adults & children
What patient population is most affected by NON-allergic rhinitis?
Primarily seen in adults
List characteristic symptom(s) of allergic rhinitis
Sneezing very common plus congestion & rhinorrhea
List characteristic symptom(s) of NON-allergic rhinitis
Chronic rhinorrhea
Sneezing is uncommon
List common allergens that can cause allergic rhinitis
Pollens: grasses, trees
Molds
Dust – dust mite feces
Animal dander – cats (more common), dogs
Describe MILD allergic rhinitis
No interference with daily activities, work, school, sleep
Describe MODERATE-SEVERE allergic rhinitis
Interferes with daily activities, work, school, sleep
Describe intermittent vs. persistent allergic rhinitis
Describe seasonal vs. perennial allergic rhinitis
What is a non-pharmacological “treatment” for allergic rhinitis?
avoidance
List some pharmacological treatment options for allergic rhinitis
decongestants (inhaled, oral)
corticosteroids (intranasal, oral)
antihistamines (intranasal, oral)
intranasal cromolyn
leukotriene receptor antagonists
What are the possible treatment(s) for a patient with “mild intermittent” allergic rhinitis?
- Oral antihistamine (OAH) +/- decongestant
- Intranasal antihistamine (INA)
(NO Leukotriene receptor antagonist (LTRA) for mild AR)
What are the possible treatment(s) for a patient with “moderate-severe intermittent” allergic rhinitis?
- OAH +/- decongestant
- Intranasal antihistamine (INA)
- Leukotriene receptor antagonist (LTRA)
- Intranasal corticosteroid (INCS)
What are the possible treatment(s) for a patient with “mild persistant” allergic rhinitis?
- OAH +/- decongestant
- Intranasal antihistamine (INA)
- Intranasal corticosteroid (INCS)
What are the possible treatment(s) for a patient with “moderate-severe persistent” allergic rhinitis?
- Intranasal corticosteroid (INCS)
- OAH +/- decongestant
- Leukotriene receptor antagonist (LTRA)
** there is a preferred order for tx of moderate-severe persistent AR & combination therapy can be used if sx are not controlled with a single agent **
What is the next step if symptoms are controlled, but there are adverse drug reactions (ADRs)?
switch to an alternative agent to minimize ADRs
What is the next step if the patient experiencing allergic rhinitis is also experiencing severe congestion?
consider routine use of antihistamine / decongestant combo
What is the next step if the patient experiencing allergic rhinitis is also experiencing persistent rhinorrhea?
Consider adding ipratropium nasal spray
What is the next step if patient is experiencing severe allergic rhinitis without good symptom control?
Consider skin testing & immunotherapy (allergy shots)
In the RARE case that a patient has allergic rhinitis without good symptom control AND has moderate - severe asthma or atopic dermatitis, what is the next step?
consider treatment with biologics:
Omalizumab
Dupilumab
List the advantages of 2nd generation oral antihistamines as treatment for allergic rhinitis
Effective for mild to moderate AR
Once daily dosing
OTC – low cost
Well tolerated
List the advantages of intranasal antihistamines as treatment for allergic rhinitis
Localized therapy
Excellent for rhinorrhea
List the advantages of intranasal corticosteroids as treatment for allergic rhinitis
Very effective for most pts with moderate to severe AR
One daily dosing
Most complete symptomatic relief
Activity against multiple mediators
OTC – well tolerated
List the advantages of intranasal cromolyn as treatment for allergic rhinitis
Safe to use in pregnancy
No risk of ADRs or toxicity
List the advantages of montelukast as treatment for allergic rhinitis
Similar efficacy to antihistamines
Oral, once daily dosing
Also indicated for children with mild asthma
List the advantages of oral/intranasal decongestant as treatment for allergic rhinitis
Superior for relieving congestion
Enhances efficacy of antihistamines when used in combination
OTC – low cost
List the advantages of immunotherapy / desensitization as treatment for allergic rhinitis
Targeted to specific antigens
Very effective for some patients
List the advantages of biologics as treatment for allergic rhinitis
Role in treatment of pts with AR limited to those with very severe sx and those with asthma or atopic dermatitis
List the disadvantages of 2nd generation oral antihistamines as a treatment for allergic rhinitis
Less effective for nasal congestion
Only impacts histamine receptors
List the disadvantages of intranasal antihistamines as a treatment for allergic rhinitis
EXPENSIVE
BID dosing
Bitter taste
Risk of drowsiness
List the disadvantages of intranasal corticosteroids as a treatment for allergic rhinitis
Risk of nose bleeds (if used incorrectly)
Mild nasal symptoms
Must be used routinely for best results
Max benefit in 1-2 weeks
List the disadvantages of intranasal cromolyn as a treatment for allergic rhinitis
Only effective for mild AR
Requires TID-QID dosing
List the disadvantages of montelukast as a treatment for allergic rhinitis
Rx only
More expensive than OTC medications
List the disadvantages of oral/intranasal decongestants as a treatment for allergic rhinitis
Restrictions on dispensing
Use of nasal sprays should be limited to 3 days
Use with caution in pts with poorly controlled HTN or IHD
List the disadvantages of immunotherapy / desensitization as a treatment for allergic rhinitis
EXPENSIVE
Weekly to monthly injections
Requires frequent MD visits
List the disadvantages of biologics as a treatment for allergic rhinitis
VERY EXPENSIVE
Access only through specialty prescription
What symptom(s) of AR are oral antihistamines most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
moderately effective at relieving: rhinorrhea, sneezing, nasal itching (2/3 efficacy)
What symptom(s) of AR are oral antihistamines least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
only mild relief of congestion (1/3 efficacy)
What symptom(s) of AR are intranasal corticosteroids least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
none! it relieves all symptoms, just takes a long time to work
What symptom(s) of AR are intranasal corticosteroids most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
all of them! just takes a long time to work
What symptom(s) of AR are intranasal antihistamines most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it moderately relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (works faster than INCS)
What symptom(s) of AR are intranasal antihistamines least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it moderately relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (works faster than INCS)
What symptom(s) of AR is intranasal cromolyn least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)
What symptom(s) of AR is intranasal cromolyn most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)
What symptom(s) of AR are leukotriene receptor antagonists most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)
What symptom(s) of AR are leukotriene receptor antagonists least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)
What symptom(s) of AR are oral & inhaled decongestants most effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
oral and inhaled decongestants relieve congestion VERY WELL, and mildly relieve rhinorrhea (1/3 efficacy)
What symptom(s) of AR are oral & inhaled decongestants least effective at relieving?
(Congestion, Rhinorrhea, Sneezing, Nasal Itching)
oral and inhaled decongestants DO NOT relieve sneezing or nasal itching
