Module 8.9 - Allergic Rhinitis

Question 1

What is allergic rhinitis?

Answer 1

An immunoglobulin (Ig) E-mediated reaction to an antigen (allergen) that occurs after previous exposure to the same substance; may be seasonal or perennial.

Question 2

What causes allergic rhinitis?

Answer 2

1. Seasonal – occurs at the same time every year, pollens are dependent on geographic region with the most common offenders: trees, grasses and ragweed.
2. Perennial – occurs year round and is commonly associated with indoor inhalants, such as dust mites, mold spores and animal dander.
3. Misc – cigarette smoke, chemical irritants (perfumes, candles, chemicals), air pollutants and food
4. History of asthma, atopic dermatitis associated with allergic rhinitis

Question 3

What are the subjective/physical examination findings associated with allergic rhinitis?

Answer 3

A. Clear nasal discharge

B. Nasal congestion and pressure.

C. Sneezing

D. Excessive postnasal drainage causing sore throat and cough

E. Facial swelling/puffiness

F. Itching of eyes and nose

G. Headache

H. Pale, edematous mucous membranes

I. Enlarged and boggy turbinates

J. Mouth breathing

K. ‘Allergic shiners’ – dark circles under the eyes

L. ‘Allergic salute’ – rubbing of the nose upward, causing a horizontal crease

M. Allergic conjunctivitis

NOTE * Sinus tenderness should NOT be present.

Question 4

What laboratory/diagnostic tests are used to diagnose allergic rhinitis?

Answer 4

• Consider referring for antigen testing
• Patient Education: Immunotherapy requires the identifications of specific antigens by dermal or serum testing.

Question 5

Describe the medical management for a patient with allergic rhinitis

Answer 5

1. Avoid Allergens

2. Non-sedating antihistamines, or 2nd and 3rd generation antihistamines (all PRN) - 1st line therapy:

• Cetirizine (Zyrtec) 10mg po daily
• Desloratadine (clarinex) 5mg po daily
• Fexofenadine (Allegra) 60mg po bid or 180mg po daily
• Levocetirizine (Xyzal) 2.5-5 mg po daily
• Loratadine (Claritin) 10mg po daily
  
  • Most are effective when taken prophylactically to prevent allergy symptoms with limited ability to reverse acute allergic symptoms
  • Considered less effective than 1st generation medications.

3. Topical corticosteroid nasal sprays – 2nd line therapy

• Fluticasone (Flonase) 2 sprays daily for exacerbations.
• Budesonide (Nasacort, Rhinocort) 1 spray per nostril q day, max 4 sprays per nostril daily
• Beclomethasone (Beconase AQ) 1-2 sprays in each nostril bid
  
  • All equally effective, may take 3-4 weeks to achieve peak response and are most effective when taken in advance of expected allergen exposure

4. May use a corticosteroid (dexamethasone long acting [Decadron-LA] 8 mg IM, or Medrol dosepak, for acute episodes which don’t respond to other medications.

Question 6

What are some 1st generation antihistamines used in allergic rhinitis?

Answer 6

1. Diphenhydramine (Benadryl) 25-50mg po q 4-6 hours; max 300mg/day

2. Brompheniramine (Dimetapp) 4mg po q 4 -6 hours
3. Chlorpheniramine (Chlor-Trimeton) 4mg po q 4 -6 hours, max 24mg/day
4. All equally effective with limited ability to reverse acute allergic symptoms
   * Patient Education: avoid with alcohol and other CNS depressants, some patient experience paradoxical excitement*

Question 7

What are some miscellaneous agents used to treat allergic rhinitis?

Answer 7

1. Cromolyn (NasalCrom nasal spray), 1 spray per nostril 3-6 times daily- utilized for mild cases, less potent than intranasal steroids
2. Ipratropium (Atrovent nasal spray) 2 sprays per nostril 2-3 times daily
3. Motelukast (Singulair) 10mg po daily – used for cases resistance to 1st and 2nd line therapy

Limited effectiveness and less efficacy than other agents and may take 4 weeks to achieve peak response.