Respiratory: Allergic Rhinitis Flashcards
What is Allergic rhinitis
IgE mediated hypersensitivity triggered by allergens
localized to nose
Biggest risk factor for Allergic rhinitis
Personal or FH of asthma/eczema
Episodic Allergic Rhinitis symptoms
occur when exposed to allergen outside of normal routine
Intermittent Allergic rhinitis symptoms
over <4 days/week or <4 weeks
Persistent Allergic rhinitis symptoms
occur >4 days/week or >4 weeks
also known as perennial
Signs and Symptoms of Allergic Rhinitis (most common)
Itchy eyes, nose, palate
Watery Rhinorrhea
Repetitive sneezing
nasal congestion
Self treatment exclusions for Allergic Rhinitis
Child <12 (make sure not asthma) Preg/ Lactating history of non-allergic rhinitis Symptoms of upper respiratory Tract infection unresponsive to OTC treatment unacceptable adverse effects
Treatment of Allergic Rhinitis
Avoid allergens
washings stuff, using HEPA filters, avoid outdoor activities when pollen high
Possible non-pharmacologic options for Allergic Rhinitis
Sodium Chloride nasal spray, irrigation or drops
don’t share bottles
can be used in children and young babies
When taking pharmacotherapy for allergies, start them….
about 1 week prior to anticipated allergen exposure if you get them every year
make sure to use meds regularly rather than episodically
1st line for allergic rhinitis
Intranasal steroids
Add on therapy w/ allergic rhinitis of itching and sneezing
2nd gen antihistamines
When should you consider intranasal antihistamines
if don’t benefit from intranasal steroids or oral antihistamines
Leukotriene Receptor Antagonists not recommended in patients without….
asthma
Intranasal Corticosteroids
1st line
broad anti-inflame properties that reduce inflammation
Well tolerated..possible nose bleeds or itching/sneezing
oral used for severe cases
Intranasal Corticosteroids counseling
shake before use, prime 1st use and if not used for >1 week
Benefits not immediate
Peak response in a few days to 2 weeks
RX only Intranasal Corticosteroids
Beclomethasone (QNASL, Beconase AQ)
RX/OTC Intranasal Corticosteroids
Fluticasone (Flonase)(also approved ophthalmic symptoms)
Triamcinolone (Nasacort)
Budesonide (Rhinocort)
Mometasone (Nasonex)
Pharmacotherapy: Antihistamines
good for early phase, not so much for late phase stuff
often used in combo with decongestants
2nd Gen antihistamines
Cetirizine (Zyrtec)
Fexofenadine (Allegra)
Loratadine (Claritin)
Most drowsy 2nd gen
Zyrtec
avoid in pts who need to be alert
2nd gen preferred in pregnancy and pediatrics
Claritin
2nd gen w/ juice interactions
Allegra
Intranasal Antihistamine
Azelastine (RX) and Olopatadine (RX)
less effective than oral
might cause sedation
Ophthalmic Antihistamines
Ketotifen (OTC),Olopatadine (OTC)
Azelastine (RX)
useful for allergic conjunctivitis
1st gen Antihistamine precautions
Infants/Breast feeding caution in elderly Narrow-angle glaucoma BPH GI/GU obstruction
Mast cell Stabilizer
Cromolyn Sodium (OTC)
most effective if started prior to symptoms onset,dont useful after. Take take up to 7 days to see improvement, and 2-3weeks for full effect
very safe and well tolerated (Pregnancy, 2yr+, elderly) if taken correctly
Oral Decongestants
Pseudoephedrine (BTC) - more effective
DDI - MAOIs/TCAs in combo/2 weeks following
Phenylephrine (OTC)
Intranasal Decongestants
Oxymetazoline 0.05% (OTC)
Phenylephrine 0.25%/0.5% (OTC)
can cause rebound congestion if used for longer than 3-5 days. takes 1-2 weeks to resolve
DDIs- MAOIs and TCAs
Decongestant warnings
Avoid pts taking MAOIs and TCAs
Uncontrolled diabetes, thyroid, HTN, CHD, etc
Intranasal Anticholinergic Spray
Ipratropium 0.03%/0.06% (RX)
dry secretions and decrease runny nose
Leukotriene Receptor Antagonist
Montelukast (RX) only one approved for Allergic rhinitis
as effective as 2nd gen antihistamines, less intranasal corticosteroids
Black box warning psychiatric events
Don’t recommend for Allergic Rhinitis due to this
For Rhinorrhea add on
antihistamine or ipratropium nasal
For itching/sneezing add
antihistamine
For nasal congestion add
intranasal (limit 3 days) or oral decongestant
For ocular symptoms add
INCS fluticasone furoate/propionate or ocular antihistamine
For minimal systemic effects use
intranasa cromolyn
Pregnant women w/ Allergic Rhinitis
1st line = intranasal cromolyn
INCS are safe
2nd gen loratadine preferred
Oxymetazoline preferred decongestant
Similar for breastfeeding
Treating Allergic Rhinitis for children
<12 = doctor to see if asthma
if self care ok, loratadine is the choice
Treating Allergic Rhinitis for elderly
avoid 1st gen
Intranasal cromolyn, Loratodine/ fexofenadine drugs of choice
