Rhinology Allergy Management Flashcards by Evan Cumpston

What are the three main strategies used to

manage allergy?

● Environmental modification
● Pharmacotherapy
● Immunotherapy

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What drug class works on H1 receptors as antago-
nists, is most effective in treating early phase
allergic response related symptoms and can cause
sedation as a major side effect?

Antihistamines

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Why do first-generation antihistamines result in
sedation, psychomotor impairment, and central
nervous system suppression?

They are highly lipophilic and cross the blood brain barrier.

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In addition to sedation, what two side effects
should be considered when prescribing first
generation antihistamines?

● Anticholinergic side effects (i.e., urinary retention, dry
mucous membranes, constipation, etc.)
● Tachyphylaxis

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Why are second-generation antihistamines

currently preferred?

● Lipophobic → Do not cross the blood-brain barrier
● Fewer or no anticholinergic side effects
● Less or no tachyphylaxis

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Provide examples of systemic first-generation

antihistamines.

● Diphenhydramine
● Chlorpheniramine
● Azatadine
● Hydroxyzine
● Tiprolidine
● Brompheniramine.
● Clemastine (Tavist)

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Provide examples of systemic second-generation

antihistamines.

● Desloratidine* (Clarinex)
● Loratidine (Claritin)
● Fexofenadine* (Allegra)
● Cetirizine (Zyrtec)
● Levocetirizine* (Xyzal)
* Can be considered third-generation antihistamines.

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Name two second-generation topical
antihistamines that have relatively rapid onset
and effectiveness in treating congestion.

● Azelastine

● Olopatadine

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What drug class works primarily as α1-receptor
agonists resulting in vasoconstriction?

Decongestants

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What are the primary side effects associated with
systemic decongestants such as phenylephrine
and pseudoephedrine?

● α-Adrenergic side effects: Hypertension, increased ap-
petite, tachycardia, arrhythmia
● Tachyphylaxis (rebound rhinitis)

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Name four medications that function as topical

decongestants.

● Tetrahydrozoline
● Naphazoline
● Oxymetazoline
● Phenylephrine

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What condition can occur as a result of
tachyphylaxis associated with topical
decongestants when used for as little as 3 days?

Rhinitis medicamentosa

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What are the three most commonly used oral
corticosteroids for allergic rhinitis, which function
to decrease the inflammatory reaction in as little
as 12 to 24 hours?

● Prednisone
● Methylpredisolone
● Dexamethasone

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What is the only topical corticosteroid nasal spray
that is pregnancy class B?

Budesonide (Rhinocort Aqua)

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What intranasal topical corticosteroids are

commonly used?

● Budesonide (Rhinocort Aqua)
● Triamcinolone acetate (Nasacort)
● Fluticasone propionate/furoate (Flonase/Veramyst)*
● Mometasone furoate (Nasonex)*
● Ciclesonide (Omnaris)
● Flunisolide (Nasarel)
*Onset of action within 12 hours

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Which intranasal corticosteroids are approved for

patients as young as 2 years of age?

Mometasone furoate and fluticasone furoate

What side effect of intranasal corticosteroids has
been related to drying and thinning of the nasal
mucosa and can be related to improper intranasal
application?

Epistaxis

What intranasal topical medication can be used
prophylactically to stabilize mast cell degranulation,
is well tolerated due to low systemic absorption
(lipophobic), but must be redosed multiple times
per day (short half-life)?

Cromolyn sodium

Name the leukotriene receptor antagonist that is
approved for allergic rhinitis and can be used in
children as young as 6 months.

Montelukast

What conditions have been shown to benefit from

immunotherapy?

Allergic rhinitis, allergic conjunctivitis, allergic asthma, and

stinging insect hypersensitivity. Potential uses include preven-
tion of asthma in patients with allergic rhinitis and manage-
ment of atopic dermatitis and aeroallergen sensitization.

For a patient to be considered for immunotherapy,

what conditions must be met?

The allergen must cause clinically significant symptoms,
and allergen-specific IgE must be demonstrated through in
vivo or in vitro testing. Environmental avoidance and
medical management should have been optimized.

What are the contraindications for

immunotherapy?

● Non-IgE mediated symptoms
● Symptoms controlled with maximal medical treatment
and environmental avoidance
● Atopic dermatitis (small studies suggest some benefit if
induced by aeroallergens)
● Food allergy
● Allergies related to very short seasonal allergen exposure
● Poorly controlled asthma
● Use of β-blockers

Describe the major impact(s) immunotherapy
has on the immune system resulting in allergic
tolerance and decreased associated symptoms
over time.

● Increase in the number of TH2 cells and increased
numbers of Treg cells.
● Increase in IL-10 and IL-12, decrease in IL-4 and IL-5
● Decreased release of early and late phase inflammatory
mediators.
● Decreased migration of inflammatory cells
● Suppression of antigen-specific IgE over time following
initial rise
● Increased levels of IgG4 (blocking antibody vs. T-helper
regulatory cell)

What is the length of time normally required for

immunotherapy to achieve good effect?

3 to 5 years

What technique is used to administer gradually increasing concentrations of allergy-provoking antigen over time to the patient in an effort to modulate allergen-specific immune reactions and symptoms via subcutaneous injection?

Subcutaneous immunotherapy (SCIT)

When choosing a starting dose for SCIT, what | two goals should be achieved?

● Strong enough concentration to induce rapidly an antigen-specific response ● Not strong enough to induce a significant local or systemic reaction

What dose is considered the maximum dose that can be delivered without inducing significant local or systemic effects?

Maintenance dose (delivers a goal cumulative amount of antigen over 3 to 5 years; should control symptoms for 1 week)

``` Describe the process of dose escalation from a starting dose (generally chosen based on modified quantitative testing) to a maintenance dose. ```

● Increase antigen load by 0.05 to 0.10 mL weekly (safe). ● Increase antigen load by 0.05 to 0.10 mL twice weekly in healthy patients (no significant asthma or history of anaphylaxis). ● Once maintenance dose is achieved, space injections from weekly or biweekly to every 2 to 3 weeks, then every 6 to 12 months (assuming symptoms are con- trolled) for 3 to 5 years. ● Treatment can be discontinued after 3 to 5 years, with careful observation for recurrent symptoms.

What might result in an unexpected systemic or | significant local reaction during immunotherapy?

● Wrong patient ● Wrong concentration ● Administering the immunotherapy during a time of year with increased environmental allergen load ● Upper or lower respiratory tract infection ● Asthma, poorly controlled ● Drug allergy

True or False. Successful immunotherapy will elimi- nate the need for any adjuvant medical therapy and should stop any breakthrough symptoms.

False. Some breakthrough symptoms are expected, and medications may be necessary to augment the immuno- therapy effect even when successful.

Describe the grading system used by the World Allergy Organization for systemic complications related to SCIT.

``` World Allergy Organization Grade I: One organ system ● Cutaneous ○ General pruritis, urticaria, flushing, sensation of heat or warmth ○ Angioedema (not laryngeal, tongue, or uvular) ● Upper respiratory ○ Rhinitis (sneezing, rhinorrhea, nasal pruritis, and/or congestion) ○ Throat clearing (itchy throat) ○ Cough (not lower airway) ● Conjunctival ○ Erythema ○ Pruritis ○ Tearing ● Other ○ Nausea ○ Metallic taste ○ Headache Grade II: More than one organ system ● Lower respiratory ○ Asthma (cough, wheeze, shortness of breath) ○ A drop of < 40% in peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) ○ Responsive to bronchodilators ● Gastrointestinal ○ Abdominal cramps, vomiting, diarrhea ● Other ○ Uterine cramps Grade III: More than one organ system ● Lower respiratory ○ Asthma ○ A drop of 40% or more in PEF or FEV1 ○ Not responsive to bronchodilators ● Upper respiratory ○ Laryngeal, uvular, or tongue edema with or without stridor Grade IV: More than one organ system ● Lower or upper respiratory ○ Respiratory failure with or without loss of conscious- ness ● Cardiovascular ○ Hypotension with or without loss of consciousness Grade V: Death Note: Many patients report a sense of impending doom with worsening complications. ```

What form of immunotherapy relies on fixed or escalating-dose schedules for antigen administered sublingually or orally with the goal of decreasing allergic symptoms, modulating the immune system, and providing a safe and easy method for immunotherapy?

``` Sublingual immunotherapy (SLIT). Used in Europe. Cur- rently, SLIT is used off-label in the United States as a ``` physician-prepared serum (similar to that given subcuta- neously) and is not covered by third-party payers.

True or False. Sublingual immunotherapy has pre- | dominantly been used for single antigen therapy.