lecture 34 (allergic rhinitis)

Question 1

what is allergic rhinitis?

Answer 1

• an inflammatory, IgE-mediated disease
• sensitization
• runny nose, nasal congestion, sneezing, red/watery eyes, itchy eyes and nose, nasal creases (nasal salute common in children)
• triad of atopic dermatitis, allergic rhinitis, and asthma very common

Question 2

allergic vs non-allergic rhinitis

Answer 2

allergic:
- IgE-mediated disease
- common in adults and children
- sneezing very common plus congestion and rhinorrhea

non-allergic:
- exposure to airborne irritants (pollution, chemicals, smoke)
- primarily seen in adults
- chronic rhinorrhea
- sneezing uncommon

Question 3

sensitization

Answer 3

allergen –> uptake and processing of allergen –> presentation of allergen fragments –> naive CD4+ –> (IL-4) TH2 cell –> (IL-4/13) B cell –> allergen-specific IgE –> binding of IgE sensitizes mast cell

Question 4

re-exposure to allergen

Answer 4

sensitized mast cell –> histamine, leukotrienes, prostaglandins, tryptase, kinins –> early phase symptoms

TH2 cell –> cytokines/chemokines –> eosinophils and TH2 cells (infiltration of activated effector cells) –> late phase symptoms

Question 5

early phase symptoms

Answer 5

sneezing
nasal itching
rhinorrhea
nasal congestion

Question 6

late phase reactions

Answer 6

nasal congestion/obstruction
nasal hyperreactivity

Question 7

most common allergens

Answer 7

grasses
trees
molds
dust/mites
animals

Question 8

questions to ask patients

Answer 8

what symptoms are you having?
do you have any symptoms like fever, chills, or cough?
is your nasal discharge clear or colored?
how long have you had these symptoms?
do you notice a change in symptoms with the change of seasons?
does the severity of your symptoms change when you move indoors to outdoors or vice versa?

Question 9

early phase reaction site of drug action

Answer 9

• antileukotrienes and antihistamines
• prevents vasodilation, vascular leakage, smooth muscle spasm
• prevents symptoms of sneezing, rhinorrhea, lacrimation, etc.

Question 10

late phase reaction site of drug action

Answer 10

• corticosteroids
• inhibit release of cytokines, eosinophil activation/recruitment
• prevents eosinophil peroxidase, monobasic protein, eosinophil cationic protein, cytokines
• prevents mucosal edema, epithelial damage, leukocyte infiltration

Question 11

mild intermittent treatment

Answer 11

oral antihistamine +/- decongestant OR intranasal antihistamine
- no preferred order
- LTRA not used for mild AR

Question 12

moderate to severe intermittent treatment

Answer 12

OAH +/- decongestant OR INA OR INCS
- no preferred order

Question 13

mild persistent treatment

Answer 13

OAH +/- decongestant OR INA OR INCS
- no preferred order
- LTRA not used for mild AR

Question 14

moderate to severe persistent treatment

Answer 14

1. INCS OR OAH +/- decongestant
2. LTRA
   - preferred order
   - combo therapy if symptoms not controlled with single agent

Question 15

stepwise treatment

Answer 15

Sx controlled but ADR are problematic –> switch to alternative agent

any AR type with severe congestion –> consider routine use of AH decongestant combo

any AR type with persistent rhinorrhea –> consider adding ipratropium NS

severe AR w/o good Sx control –> skin testing and allergy shots

AR Sx not well controlled and pt has mod/sev asthma or atopic dermatitis (rare) –> consider biologics (omalizumab/xolair, dupilumab/dupixent)