Respiratory: Allergic Rhinitis

Question 1

What is Allergic rhinitis

Answer 1

IgE mediated hypersensitivity triggered by allergens

localized to nose

Question 2

Biggest risk factor for Allergic rhinitis

Answer 2

Personal or FH of asthma/eczema

Question 3

Episodic Allergic Rhinitis symptoms

Answer 3

occur when exposed to allergen outside of normal routine

Question 4

Intermittent Allergic rhinitis symptoms

Answer 4

over <4 days/week or <4 weeks

Question 5

Persistent Allergic rhinitis symptoms

Answer 5

occur >4 days/week or >4 weeks

also known as perennial

Question 6

Signs and Symptoms of Allergic Rhinitis (most common)

Answer 6

Itchy eyes, nose, palate
Watery Rhinorrhea
Repetitive sneezing
nasal congestion

Question 7

Self treatment exclusions for Allergic Rhinitis

Answer 7

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

Question 8

Treatment of Allergic Rhinitis

Answer 8

Avoid allergens

washings stuff, using HEPA filters, avoid outdoor activities when pollen high

Question 9

Possible non-pharmacologic options for Allergic Rhinitis

Answer 9

Sodium Chloride nasal spray, irrigation or drops

don’t share bottles
can be used in children and young babies

Question 10

When taking pharmacotherapy for allergies, start them….

Answer 10

about 1 week prior to anticipated allergen exposure if you get them every year

make sure to use meds regularly rather than episodically

Question 11

1st line for allergic rhinitis

Answer 11

Intranasal steroids

Question 12

Add on therapy w/ allergic rhinitis of itching and sneezing

Answer 12

2nd gen antihistamines

Question 13

When should you consider intranasal antihistamines

Answer 13

if don’t benefit from intranasal steroids or oral antihistamines

Question 14

Leukotriene Receptor Antagonists not recommended in patients without….

Answer 14

asthma

Question 15

Intranasal Corticosteroids

Answer 15

1st line

broad anti-inflame properties that reduce inflammation

Well tolerated..possible nose bleeds or itching/sneezing

oral used for severe cases

Question 16

Intranasal Corticosteroids counseling

Answer 16

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

Question 17

RX only Intranasal Corticosteroids

Answer 17

Beclomethasone (QNASL, Beconase AQ)

Question 18

RX/OTC Intranasal Corticosteroids

Answer 18

Fluticasone (Flonase)(also approved ophthalmic symptoms)
Triamcinolone (Nasacort)
Budesonide (Rhinocort)
Mometasone (Nasonex)

Question 19

Pharmacotherapy: Antihistamines

Answer 19

good for early phase, not so much for late phase stuff

often used in combo with decongestants

Question 20

2nd Gen antihistamines

Answer 20

Cetirizine (Zyrtec)
Fexofenadine (Allegra)
Loratadine (Claritin)

Question 21

Most drowsy 2nd gen

Answer 21

Zyrtec

avoid in pts who need to be alert

Question 22

2nd gen preferred in pregnancy and pediatrics

Answer 22

Claritin

Question 23

2nd gen w/ juice interactions

Answer 23

Allegra

Question 24

Intranasal Antihistamine

Answer 24

Azelastine (RX) and Olopatadine (RX)

less effective than oral
might cause sedation

Question 25

Ophthalmic Antihistamines

Answer 25

Ketotifen (OTC),Olopatadine (OTC)
Azelastine (RX)

useful for allergic conjunctivitis

Question 26

1st gen Antihistamine precautions

Answer 26

Infants/Breast feeding
caution in elderly
Narrow-angle glaucoma
BPH
GI/GU obstruction

Question 27

Mast cell Stabilizer

Answer 27

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

Question 28

Oral Decongestants

Answer 28

Pseudoephedrine (BTC) - more effective
DDI - MAOIs/TCAs in combo/2 weeks following

Phenylephrine (OTC)

Question 29

Intranasal Decongestants

Answer 29

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

Question 30

Decongestant warnings

Answer 30

Avoid pts taking MAOIs and TCAs

Uncontrolled diabetes, thyroid, HTN, CHD, etc

Question 31

Intranasal Anticholinergic Spray

Answer 31

Ipratropium 0.03%/0.06% (RX)

dry secretions and decrease runny nose

Question 32

Leukotriene Receptor Antagonist

Answer 32

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

Question 33

For Rhinorrhea add on

Answer 33

antihistamine or ipratropium nasal

Question 34

For itching/sneezing add

Answer 34

antihistamine

Question 35

For nasal congestion add

Answer 35

intranasal (limit 3 days) or oral decongestant

Question 36

For ocular symptoms add

Answer 36

INCS fluticasone furoate/propionate or ocular antihistamine

Question 37

For minimal systemic effects use

Answer 37

intranasa cromolyn

Question 38

Pregnant women w/ Allergic Rhinitis

Answer 38

1st line = intranasal cromolyn

INCS are safe
2nd gen loratadine preferred
Oxymetazoline preferred decongestant

Similar for breastfeeding

Question 39

Treating Allergic Rhinitis for children

Answer 39

<12 = doctor to see if asthma

if self care ok, loratadine is the choice

Question 40

Treating Allergic Rhinitis for elderly

Answer 40

avoid 1st gen

Intranasal cromolyn, Loratodine/ fexofenadine drugs of choice