Rhinitis and Rhinosinusitis Dr. Burchette EXAM I Flashcards
Typical patient presentation of Allergic Rhinitis
-Watery nose
-sneezing
-itching
Which immunoglobulin is most likely to be involved in allergic responses?
-IgE
-causes Histamine release
What does “atopic” mean?
-predisposition (more likely) to have an allergic response to something - when a first-degree relative has allergic tendencies
Which respiratory condition can be triggered by allergic responses?
-asthma, eczema (dermatitis, inflammation of the skin)
-people with tendencies to allergic reactions may be more likely to have asthma
Other medical conditions that are associated with Allergic Rhinitis?
-asthma
-chronic sinusitis
-nasal polyps
-otitis media
Physical findings indicating allergic rhinitis
-The “allergic salute”: wiping away the discharge due to runny nose
-allergic crease: line on the nose from lifting the nose
-allergic shiners: dark rings around the eyes
Clinical patient presentation of Allergic Rhinitis
-Watery nose: clear discharge
-sneezing
-Itchy eyes, ears, nose, soft palate
-Nasal congestion
-Postnasal drip
-Mouth breathing, especially at night
First-line pharmacotherapy for Allergic Rhinitis
-Oral antihistamines - PREFERRED
-Intranasal antihistamines - not preferred bc of taste and dripping into the throat
What are the symptoms that are appropriate to treat with Antihistamines?
!!!!
-sneezing, itching, and watery nose
-caused by Histamines
Antihistamines are good for prevention and not as effective once the action has occurred
T or F
True
What are the anticholinergic side effects of Antihistamines?
Drying effects: dry the runny nose
-dry mouth
-dry nose -> nose bleeding
-urinary retention
-eyes dry, pupils dilated
-constipation
-tachycardia, increased BP (caution older patients)
-stimulates appetite
Which agents are most likely to have Anticholinergic side effects?
-(also common with Intranasal steroids: Flonase)
Ethanolamines:
Clemastine
Diphenhydramine
-Promethazine
-they also have sedative side effects
Which ‘nasal’ Antihistamine has low sedative and low anticholinergic side effects?
Azelastine
(nasal is less preferred)
Which Antihistamines are associated with low sedative and anticholinergic side effects?
-Azelastine (nasal)
-Cetirizine (Levo) (Zyrtec)* associated with drowsiness
-Loratadine (Claritine)
-Desloratadine (Clarinex)
-Fexofenadine (Allegra)
What are the directions for Antihistamines?
-Avoid with other CNS depressants, like alcohol
-take with a glass of water, and food (helps with N/V)
-Caution with other OTC preps that may have antihistamines
included
-Most effective if taken 1 – 2 hours prior to allergen exposure
Patients may take Antihistamines every day, which is fine.
T or F
True
How do Decongestants work?
-Vasoconstriction of blood vessels in the nasal cavity to reduce the swelling
-works best with antihistamines when decongestion is present
-Long-term use causes rebound vasodilation
Side effects for topical Decongestants
-Topical AEs include burning, stinging, sneezing and dryness
-rebound congestion
Side effects for oral (systemic) Decongestants
-HTN, cardiovascular diseases
-Caution with those at risk for strokes
What are common Decongestant agents?
-oxymetazoline (Afrin) !! - higher risk for rebound congestion
-phenylephrine
-naphazoline
What is the maximum duration for topical decongestion?
3-5 days
-less is better
-caution for oxymetazoline (Afrin)
What to look out for in Combo products?
-ask patients if they take combi products
-they contain acetaminophen, phenylephrine, antihistamine
-overmedication of decongestants (they should be taken for short-term treatment)
What is Intranasal steroids appropriate for?
Allergic rhinitis
-best for yearly allergies
-MOA: change gene transcription in immune cells
Side effects of Intranasal steroids
-sneezing
-burning
-stinging
-headache
-nosebleeds
What to counsel on patients who might need fast relief
-it gets better after 1-2 days
-may take weeks to get full effect (2 – 3 weeks) -> works on the transcriptional level
-take it constantly - it takes time to see the full effect
-consider antihistamines instead
Counseling points
-May take weeks to get full effect (2 – 3 weeks)
-Avoid blowing nose or sneezing for 10 min post admin
-Avoid with nasal ulcers or nasal trauma
-Clear blocked nasal passages prior to admin to ensure adequate penetration into the nasal mucosa
EXAM QUESTION
How to take Flonase
When are Leukotrienes appropriate?
-not appropriate for allergic rhinitis alone
-only with concomitant asthma!
-patients with allergies and asthma may take leukotriene agents (leukotriene antagonists) to help with asthma attacks triggered by allergens
-Example: Montelukast (Singulair)
What is Rhinosinusitis?
-Infected and inflamed membranes of the sinuses
-need antibiotics
-often secondary to a VIRAL rhinosinusitis (feeling worse than before - double sickening)
What are signs that point to bacterial versus viral infection?
-Persistent symptoms for 10 or more days without
signs of improvement
-Onset with severe symptoms (high fever, purulent nasal discharge, or facial pain) for 3-4 consecutive days
-double-sickening: feeling better, than worse than before -> the virus caused inflammation -> warm environment for bacteria to grow
What are the most common bacterial pathogens associated with Rhinosinusitis?
-Strep. pneumoniae
-Haemophilus influenzae
-Moraxella catarrhalis
Signs and Symptoms
-purulent discharge
-Nasal congestion or obstruction
-Facial pain or pressure, dental pain
-Fever, fatigue
-Headache
-Ear pain/pressure/fullness
-Cough
First-line treatment for Rhinosinusitis
Amox/Clav (Augmentin)
-children or adults
Why might Augmentin be a good choice to treat Rhinosinusitis?
-the target pathogens are Strep. pneumo. H. flu, M. cat
-Amoxicillin covers Strep. pneumo
(Strep -> ß-lactam)
-Clavulanic acid covers H. flu and M. cat which produces a ß-lactamase
How to treat Rhinosinusitis in case of Beta-lactam allergy
-Adults: Doxycycline and resp. Quinolone (Levofloxacin, Moxifloxacin) -> not for children (tendon rupture, impairs growth)
-Children: Clinda + Cephalosporin (3rd GEN: Omnicef (Cefdinir)
What to think about when treating children with Clindamycin liquid?
Very bad taste
What is the duration of treatment for Rhinosinusitis?
Adults: 5-7 days
Children: 10-14 days (we don’t have evidence for kids that shorter treatment works=
Why are antihistamines and decongestants avoided in Rhinosinusitis?
-It dries up the infected material in the nasal cavity
-it causes it to get stuck in the sinuses
-consider nasal saline, blowing out the infected material in the nose
