Allergic Rhinitis

Front 1

Pathophysiology

Back 1

Three phases

Sensitization

Early (immediate)-phase reaction

Late-phase reaction

Front 2

Sensitization

Back 2

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

Front 3

Early Phase Reactions

Back 3

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

Front 4

Late Phase Reactions

Back 4

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

Front 5

Allergic RhinitisClassification by frequency

Back 5

Intermittent

- Symptoms < 4 days/week or < 4 weeks/yearPersistent

- Symptoms > 4 days/week and >4 weeks/yearEpisodic

- Symptoms occur if patient is in contact withexposure that is not normally part of thepatient’s environment

Front 6

Allergic Rhinitis Classification by Severity

Back 6

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

Front 7

Diagnosis

Back 7

Thorough history

Physical examination

Diagnostic tests

Front 8

History

Back 8

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

Front 9

Skin Testing

Back 9

Determinessensitivity to specificallergenSome medicationsmay suppressresponsePositive test giveswheal and flareresponse15 minutes forresults

Front 10

Blood Testing

Back 10

Measures IgE tospecific antigen

Not as sensitive asskin testing

Requires blooddraw

Not affected bypatient’smedications

Front 11

Allergic RhinitisComplications

Back 11

Disturbed sleep

Fatigue

Poor work/school performance

Loss of smell or taste

Facial/dental problems

Front 12

Pharmacotherapy Classes for AR

Back 12

Antihistamines

Decongestants

Corticosteroids

Mast cell stabilizers

Anticholinergics

Leukotriene receptor antagonist

Front 13

Systemic Antihistamines

Back 13

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

Front 14

First GenerationAntihistamines

Back 14

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

Front 15

Second GenerationAntihistamines

Back 15

Rapid effect (<1 hour) for nasal andocular symptoms

Patients who fail to improve with oneagent may respond to an alternativeagent

Front 16

Anithistamine Drug Interactions

Back 16

CNS depressants

MAOIs

Phenytoin

Ketoconazole

Erythromycin

Cimetidine

St. John’s wort

Front 17

Intranasal Antihistamine

Back 17

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

Front 18

Azelastine (Astelin®, Astepro®)

Back 18

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)

Front 19

Olopatadine (Patanase®)

Back 19

1-2 sprays each nostril BID (≥ 6 yrs)

AE: bitter taste, drowsiness, epistaxis

Front 20

Azelastine (Optivar®)

Back 20

1 drop each eye BID (≥ 3 years)

Wait at least 10 minutes before insertingcontacts

Dual action: mast cell stabilizer

Front 21

Olopatadine (Patanol 0.1%®, Pataday0.2%®)

Back 21

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

Front 22

Alcaftadine (Lastacaft®)

Back 22

1 drop each eye once daily

Replace contact 10 minutes after use

Front 23

Emedastine (Emadine®)

Back 23

1 drop each eye up to QID (> 3 years)

Wait 10 minutes before using contacts

Front 24

Naphazoline/pheniramine

Naphcon-A®, Opcon-A®, Visine-A®

Back 24

1-2 drops each eye up to QIDCan cause rebound

Front 25

Decongestants

Back 25

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

Front 26

Oral Decongestants

Back 26

Pseudoephedrine and Phenylephrine

CNS adverse effects

-Nervousness, insomnia, irritability, headacheCardiovascular adverse effects

-Palpitations, tachycardia, increase bloodpressure

Increase intraocular pressure

Aggravate urinary obstruction

Front 27

Oral Decongestants Cautions

Back 27

Use with caution:

-Cardiovascular disease

-Hyperthyroidism

-Glaucoma

-Any bladder neck obstruction

-Do not use within 14 days of MAOI

Front 28

Phenylephrine hydrochloride

-Neo-Synephrine®

Back 28

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

Front 29

Oxymetazoline HCL

Afrin®

Back 29

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

Front 30

OphthalmicDecongestants

Back 30

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

Front 31

Intranasal Corticosteroids(INCS)

Back 31

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

Front 32

INCS AE’s

Back 32

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

Front 33

Dymista™

Back 33

Azelastine hydrochloride and fluticasonepropionate

Approved for 6 years and older

1 spray each nostril twice daily

AEs

-Drowsiness, change in taste, nosebleeds,headache

Front 34

Loteprednol (Alrex® 0.2%, Lotemax® 0.5%)

Back 34

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

Front 35

Oral Corticosteroids

Back 35

Short course (5-7 days) for verysevere allergic rhinitis

Single administration of parenteralcorticosteroids is discouraged

Front 36

Cromolyn sodium (Nasalcrom®) Nasal Spray

Back 36

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

Front 37

Mast Cell StabilizersEye Drops

Back 37

Slow onset of action

Several days for optimal symptomrelief

-More appropriate for prophylactic vsacute

Front 38

Cromolyn (Crolom®, Opticrom®)

Back 38

Mast Cell StabilizersEye Drops

1 drop each eye 4-6 times/day

No contacts during treatment

Front 39

Nedocromil (Alocril®)

Back 39

Mast Cell StabilizersEye Drops

1-2 drops each eye BID

Avoid contacts if signs/symptoms of allergicconjunctivitis

Front 40

Pemirolast (Alamast®)

Back 40

Mast Cell StabilizersEye Drops

1-2 drops each eye QID

At least 10 minutes prior to contact lens insertion

Front 41

Ketotifen (Zaditor®, Alaway®)

Back 41

Mast Cell/AntihistamineEye Drops

1 drop each eye q 8-12 hours

At least 10 minutes prior to contact lensinsertion

Front 42

IntranasalAnticholinergics

Back 42

Ipratropium bromide (Atrovent®)

-0.03%, 0.06%

Relief of rhinorrhea

-Concomitant use with INCS has additiveeffectAdverse effects headache, nosebleeds and nasal dryness

Front 43

Montelukast Singulair®

Back 43

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)

Front 44

Nasal Saline

Back 44

Chronic rhinorrhea and rhinosinusitisReports of brain infections caused byamoeba Naegleria fowleri found in sometap water

-Use distilled or sterile water

Front 45

Immunotherapy

Back 45

Slow, gradual process of injectingincreasing doses of antigens

Clinical benefits may be sustained foryearsExpensive, risks, time consuming

Sublingual immunotherapy

Front 46

Sublingual ImmunotherapyProducts

Oralair®

Back 46

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)

Front 47

Sublingual ImmunotherapyProducts

Grastek®

Back 47

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)

Front 48

Sublingual ImmunotherapyProducts

Ragwitek®

Back 48

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

Front 49

Drug-Induced Rhinitis

Back 49

ACE inhibitors

β-blockers

α-blockers

Phosphodiesterase-5-inhibitors (ED)

ASA

NSAID

Chlorpormazine, thioridazine, perphenazine,chlordiazepoxide, amitriptyline, alprazolamCylclosporine, mycophenolic acid

Oral contraceptives

Front 50

Elderly

Back 50

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

Front 51

Alternative Therapy

Back 51

No definitive proof of efficacy

Echinacea purpurea

-Avoid in patients with weed pollenallergies

-Implicated in anaphylaxis

Front 52

Combination Therapy

Back 52

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

Front 53

Combination Therapy

Back 53

INCS + montelukast

-No added benefit

INCS + intranasal antihistamine

-More effective than either agent asmonotherapy

INCS + intranasal oxymetazoline

-More effective then either agent asmonotherapy

Front 54

Management

Back 54

Consider

-Age

-Frequency, severity and spectrum ofsymptoms

-Allergen exposure pattern

-Comorbidities

-Response to previous treatment

-Cost

-Patient preference