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54 Cards in this Set
- Front
- Back
Pathophysiology |
Three phases Sensitization Early (immediate)-phase reaction Late-phase reaction |
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Sensitization |
Patients with genetic capacity to respondwith IgE production will develop allergicresponseAllergen inhaled - antigen-specific IgEproduced, binds to IgE receptors on mastcells/ basophils - re-exposure to allergen - IgE bound to mast cells interacts withallergen - triggers release of inflammatorymediators |
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Early Phase Reactions |
Early-phase -Happens within seconds to minutes -Approximately 1 hour durationRapid release of mediators - Histamine, tryptase, chymase, kinins,heparin - Formation of leukotrienes, prostaglandins -Sneezing, itching, redness, tearing,swelling, ear pressure, post nasal drip |
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Late Phase Reactions |
Late-phase -3-6 hours after exposure -Subsides in 12-24 hours -Patient experiences renewed symptomswithout re-exposure -Cytokine, chemokine release -Sneezing and itching, morecongestion/mucus production comparedwith early-phase |
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Allergic RhinitisClassification by frequency |
Intermittent - Symptoms < 4 days/week or < 4 weeks/yearPersistent - Symptoms > 4 days/week and >4 weeks/yearEpisodic - Symptoms occur if patient is in contact withexposure that is not normally part of thepatient’s environment |
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Allergic Rhinitis Classification by Severity |
Mild -Symptoms are presentbut don’t interfere withquality of life Moderate to Severe -Symptoms interfere withquality of life - Exacerbation of coexistingasthma - Sleep disturbance - Impairment of dailyactivities, leisure and/orsport - Impairment of school orwork performance |
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Diagnosis |
Thorough history Physical examination Diagnostic tests |
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History |
Symptoms -Timing, types Environmental factors and exposures -Wall to wall carpeting, pets, heating, airconditioning Results of previous therapy -What medications have been tried, results Nasal injuries/surgeries Family history -Strong genetic predisposition |
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Skin Testing |
Determinessensitivity to specificallergenSome medicationsmay suppressresponsePositive test giveswheal and flareresponse15 minutes forresults |
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Blood Testing |
Measures IgE tospecific antigen Not as sensitive asskin testing Requires blooddraw Not affected bypatient’smedications |
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Allergic RhinitisComplications |
Disturbed sleep Fatigue Poor work/school performance Loss of smell or taste Facial/dental problems |
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Pharmacotherapy Classes for AR |
Antihistamines Decongestants Corticosteroids Mast cell stabilizers Anticholinergics Leukotriene receptor antagonist |
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Systemic Antihistamines |
Better at preventing than reversingactions of histamine Continuous treatment more effectivecompared to intermittent treatment Control sneezing, rhinorrhea, itching,conjunctivitis Minimal effect on nasal congestion Not as effective as nasal steroids May be adequate for people with mildto moderate disease Lower cost compared to intranasalsteroids |
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First GenerationAntihistamines |
May produce performance impairment inschool, work, and driving Avoid in the following populations: -Heavy machinery/extensive driving/ pilots -Pre-existing intellectual impairment -Benign prostatic hypertrophy (BPH) -Elevated intraocular pressure Limited role in treatment of allergic rhinitis |
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Second GenerationAntihistamines |
Rapid effect (<1 hour) for nasal andocular symptoms Patients who fail to improve with oneagent may respond to an alternativeagent |
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Anithistamine Drug Interactions |
CNS depressants MAOIs Phenytoin Ketoconazole Erythromycin Cimetidine St. John’s wort |
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Intranasal Antihistamine |
Controls sneezing, rhinorrhea, nasalpruritus, eye symptoms, nasalcongestion Fast onset of action (<30 minutes): canuse PRNEffectiveness: equal or superior to 2ndgeneration po antihistamines Less effective than nasalcorticosteroids for nasal symptoms |
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Azelastine (Astelin®, Astepro®) |
1-2 sprays bid- Indication ≥ 6 yrs AE: drowsiness, bitter taste, epistaxis, nasaldiscomfort Astepro® has different base solution - Decrease bitter taste and nasal discomfort (but stillpresent) |
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Olopatadine (Patanase®) |
1-2 sprays each nostril BID (≥ 6 yrs) AE: bitter taste, drowsiness, epistaxis |
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Azelastine (Optivar®) |
1 drop each eye BID (≥ 3 years) Wait at least 10 minutes before insertingcontacts Dual action: mast cell stabilizer |
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Olopatadine (Patanol 0.1%®, Pataday0.2%®) |
1 drop affected eye bid (≥3 yrs old) 1 drop each eye daily (≥3 yrs old) Replace contact 10 minutes after use Dual action: mast cell stabilizer |
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Alcaftadine (Lastacaft®) |
1 drop each eye once daily Replace contact 10 minutes after use |
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Emedastine (Emadine®) |
1 drop each eye up to QID (> 3 years) Wait 10 minutes before using contacts |
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Naphazoline/pheniramine Naphcon-A®, Opcon-A®, Visine-A® |
1-2 drops each eye up to QIDCan cause rebound |
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Decongestants |
Sympathomimetic agents that act onadrenergic receptors in nasal mucosacausing vasoconstriction Available in topical and systemicformulationsReduce nasal congestion, some rhinorrheaMinimal effect on sneezing, itching or ocularsymptoms |
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Oral Decongestants |
Pseudoephedrine and Phenylephrine CNS adverse effects -Nervousness, insomnia, irritability, headacheCardiovascular adverse effects -Palpitations, tachycardia, increase bloodpressure Increase intraocular pressure Aggravate urinary obstruction |
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Oral Decongestants Cautions |
Use with caution: -Cardiovascular disease -Hyperthyroidism -Glaucoma -Any bladder neck obstruction -Do not use within 14 days of MAOI |
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Phenylephrine hydrochloride -Neo-Synephrine® |
Duration up to 4 hours Minimal systemic absorption -AEs: burning, stinging, sneezing, drynessRhinitis medicamentosa -α-adrenoceptor mediated down-regulation anddesensitization of response Effective for nasal congestion |
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Oxymetazoline HCL Afrin® |
Duration up to 12 hours Minimal systemic absorption -AEs: burning, stinging, sneezing, dryness Rhinitis medicamentosa -α-adrenoceptor mediated down-regulation and desensitization of response Effective for nasal congestion |
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OphthalmicDecongestants |
Naphazoline -Vasocon®, Albalon®, many genericsPhenylephrine -Neo-Synephrine Ophthalmic® Relieve ocular redness Prolonged use can lead toconjunctivitis medicamentosa -Use limited to 10 days does not appear toinduce |
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Intranasal Corticosteroids(INCS) |
Most effective medication class forcontrolling symptoms of allergic rhinitis Onset of action: 3-36 hours Effective for sneezing, rhinorrhea,itching, nasal congestion, ocularsymptoms PRN use not as effective ascontinuous usePRN use better than placebo |
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INCS AE’s |
INCS side effects -Nasal irritation -Epistaxis -Nasal crusting/dryness -Nasal septum perforation -Minimal systemic side effects with recommendeddoses Drug interactions -Fluticasone and strong inhibitors of CYP3A4(ritonavir, itraconazole, nefazodone) casereports |
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Dymista™ |
Azelastine hydrochloride and fluticasonepropionate Approved for 6 years and older 1 spray each nostril twice daily AEs -Drowsiness, change in taste, nosebleeds,headache |
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Loteprednol (Alrex® 0.2%, Lotemax® 0.5%) |
0.2%: temporary relief of seasonalallergic conjunctivitis -1 drop each eye up to QID -If using > 14 days need eye exam - Reduced risk of increasing intraocularpressure compared with other ocularcorticosteroids 0.5%: ocular inflammation; use underclose supervision |
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Oral Corticosteroids |
Short course (5-7 days) for verysevere allergic rhinitis Single administration of parenteralcorticosteroids is discouraged |
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Cromolyn sodium (Nasalcrom®) Nasal Spray |
Inhibits mast cell degranulation Adverse effects: sneezing and nasalstingingMust be taken 3-6 times/day Initiate therapy before allergen season (atleast 1 week) Less effective than INCS |
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Mast Cell StabilizersEye Drops |
Slow onset of action Several days for optimal symptomrelief -More appropriate for prophylactic vsacute |
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Cromolyn (Crolom®, Opticrom®) |
Mast Cell StabilizersEye Drops 1 drop each eye 4-6 times/day No contacts during treatment |
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Nedocromil (Alocril®) |
Mast Cell StabilizersEye Drops 1-2 drops each eye BID Avoid contacts if signs/symptoms of allergicconjunctivitis |
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Pemirolast (Alamast®) |
Mast Cell StabilizersEye Drops 1-2 drops each eye QID At least 10 minutes prior to contact lens insertion |
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Ketotifen (Zaditor®, Alaway®) |
Mast Cell/AntihistamineEye Drops 1 drop each eye q 8-12 hours At least 10 minutes prior to contact lensinsertion |
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IntranasalAnticholinergics |
Ipratropium bromide (Atrovent®) -0.03%, 0.06% Relief of rhinorrhea -Concomitant use with INCS has additiveeffectAdverse effects headache, nosebleeds and nasal dryness |
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Montelukast Singulair® |
Efficacy: equally or less effective than poantihistamines, less effective than INCSApproved for allergic rhinitis in patients ≥ 6months Dosing -4 mg daily (6 months-5 years old) -5 mg daily (6-14 years old) -10 mg daily (> 14 years old) |
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Nasal Saline |
Chronic rhinorrhea and rhinosinusitisReports of brain infections caused byamoeba Naegleria fowleri found in sometap water -Use distilled or sterile water |
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Immunotherapy |
Slow, gradual process of injectingincreasing doses of antigens Clinical benefits may be sustained foryearsExpensive, risks, time consuming Sublingual immunotherapy |
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Sublingual ImmunotherapyProducts Oralair® |
Activity -Sweet vernal,orchard, perennialrye, timothy, Kentuckyblue grass Comment -First dose in physician office • Severe allergic reaction box warning • Initiate 4 months prior to symptom onset • Dose strength is Index of Reactivity (IR) |
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Sublingual ImmunotherapyProducts Grastek® |
Activity - Timothy grass Comment • First dose in physician office • Severe allergic reaction box warning • Initiate ≥12 weeks prior to symptom onset • Dose strength is Bioequivalent AllergyUnits (BAU) |
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Sublingual ImmunotherapyProducts Ragwitek® |
Activity - Ragweed Comment • First dose in physician office • Severe allergic reaction box warning • Initiate ≥12 weeks prior to symptom onset • Dose strength is Amb a 1-Unit |
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Drug-Induced Rhinitis |
ACE inhibitors β-blockers α-blockers Phosphodiesterase-5-inhibitors (ED) ASA NSAID Chlorpormazine, thioridazine, perphenazine,chlordiazepoxide, amitriptyline, alprazolamCylclosporine, mycophenolic acid Oral contraceptives |
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Elderly |
Decongestants -May cause urinary retention in BPH -Cardiac and CNS stimulation Sedating antihistamines -Bladder disturbances -Problems with visual accommodation -Sedation may contribute to falls/fractures |
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Alternative Therapy |
No definitive proof of efficacy Echinacea purpurea -Avoid in patients with weed pollenallergies -Implicated in anaphylaxis |
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Combination Therapy |
INCS + po antihistamine -No benefit if antihistamine added toregular INCS therapy. -PRN INCS added to regularantihistamine may provide benefit PO antihistamine + po decongestant -Better control than either agent alone PO antihistamine + montelukast -Not recommended, conflicting results |
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Combination Therapy |
INCS + montelukast -No added benefit INCS + intranasal antihistamine -More effective than either agent asmonotherapy INCS + intranasal oxymetazoline -More effective then either agent asmonotherapy |
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Management |
Consider -Age -Frequency, severity and spectrum ofsymptoms -Allergen exposure pattern -Comorbidities -Response to previous treatment -Cost -Patient preference |