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Define: rhinitis

Inflammation of membranes lining nose

Define: allergic rhinitis

Immunologically mediated rhinitis, initiated by an antigen-antibody reactions
Characterized by:
• Nasal congestion
• Rhinorrhea
• Sneezing
• Itchy nose
• Postnasal discharge
• Severity range from mild to debilitating

Classification of allergic rhinitis:

- Seasonal


- Perennial


- Perennial with seasonal exacerbation


- Episodic

Classification of non-allergic rhinitis:

- Vasomotor rhinitis
- Non-allergic rhinitis with Eosinophilia (NARES)

Characteristics of vasomotor rhinitis:

Sx: sneezing and watery rhinorrhea with or without nasal congestion or allergic basis can be found
Triggers: cold dry air, odors, emotions
- Cholinergic hyper-responsiveness may be the cause
- Anticholinergic tx (ipratroprium bromide intranasal spray) is effective

Characteristics of non-allergic rhinitis with eosinophilia (NARES):

- Similar Sx to allergic rhinitis but no
evidence of IgE-mediated hypersensitivity
- Eosinophils are abundant in nasal secretions
- Unknown cause
- Responds to intranasal CS

Epidemiology or allergic rhinitis:

- 10-30% of population


- 40% of children


- Usually before 20 y/o


- Decreased quality of life: decreased sleep, productivity, work and school attendance, concentration and mental functioning

Predisposing factors to allergic rhinitis?

- Family history of atopy (asthma, allergic rhinits, atopic dermatitis; increased risk if both parents affected)


- High socioeconomic class


- Allergen exposure

Define: priming response

With repeated exposure to allergens, the amount of allergen to induce an immediate response decreases

Drugs associated with rhinitis:

- ACE inhibitors
- Phosphodiesterase-5-selective inhibitors (Sildenafil- Erectile dysfunction)
- A- blockers (Prazosin, terazosin)
- ASA, NSAIDS
- Beta blockers
- Methyldopa
- OCs
- Overuse of topical decongestants (sympathomimetics)

Allergens (and time period) for seasonal allergic rhinitis?

- Seasonal exacerbation
- Tree pollens in spring (March, April)
- Grass pollens in summer (May, June, July)
- Weed pollens in summer and fall (Aug, Sept, Oct)
- Mold spores (Feb – Nov)

Allergens for perennial allergic rhinitis?

Environmental allergens such as :


- dust mites


- molds


- animal danders


- occupational allergens


- some perennial pollens

Sx presentation patterns in patients?

- Develop within 2- 3 years after sensitizing exposure
- Often escalate in severity then plateau or diminish
- May diminish with age

Symptoms of allergic rhinitis?

- Nasal congestion


- Clear rhinorrhea


- Sneezing and itching (nasal and palatia)


- Conjunctivitis (red, itchy eyes)


- Periorbital swelling


- Postnasal drip can cause coughing


- Systemic: fatigue, irritability, depression

Physical examination findings?

General: facial pallor, allergic shiners, mouth breathing, transverse crease on nose bridge (allergic salute)
- Dennie-Morgan lines and conjunctivitis
- Nasal mucosal swelling (bluish)
- Fluid in middle ear

General: facial pallor, allergic shiners, mouth breathing, transverse crease on nose bridge (allergic salute)


- Dennie-Morgan lines and conjunctivitis


- Nasal mucosal swelling (bluish)


- Fluid in middle ear

Diagnostic tests for allergic rhinitis?

- Skin Tests
- Nasal cytology (for eosinophils & neutrophils)
- Serology (serum IgE increase 2 – 6 x normal in 30% – 40% patients)

Advantages of skin tests?

- Most sensitive, cost effective, and fast


- Identifies relevant allergens


- Only used in persistent or severe cases

Disadvantages of skin tests?

False negatives occur with anthihistamines, TCAs, Oral or TCS (must D/C before test)

Seasonal, perennial, and common cold:


DURATION

Seasonal: weeks - months


Perennial: continuous


Common cold: 1 week

Seasonal, perennial, and common cold:


DISCHARGE

Seasonal: watery


Perennial: not so copious


Common cold: mucopurulent

Seasonal, perennial, and common cold:


SORE THROAT

Seasonal: rare


Perennial: uncommon (irritated)


Common cold: sore throat + cough

Seasonal, perennial, and common cold:


Itch/ sneeze

Seasonal: itchy, sneezing


Perennial: less common


Common cold: mild sneeze, rarely itchy

Allergic rhinitis complications?

- Recurrent upper resp. infection (colds)


- Nasal polyps (sac-like growths of inflamed nasal mucosa)


- Loss of smell/ taste


- Facial and dental abnormalities


- Epistasis (nose bleeds)


- Sleep disorder

Complications/ comorbidities of allergic rhinitis?

- Asthma


- Sinusitis


- Otitis media with effusion (OME)

Allergen avoidance methods for house dust mites?

- Wash bedding and toys Q1-2 weeks in HOT water (>130F)


- Impermeable mattress and pillow covers are ineffective


- Reduce indoor humidity to 40-45%


- Minimize clutter; dust/ vacuum weekly


- Polished/ wipeable furniture and flooring

Allergen avoidance methods for pets?

- Keep out of bedroom/ home if possible


- Run HEPA air cleaner if indoor pet


- Bathe pet 2x/week


- Wash pet bedding weekly

Allergen avoidance methods for pollen?

- Close home and car windows and filter air (AC)


- Rinse of skin and hair before bed


- Dry laundry in dryer


- Plan outdoor activities in low pollen times

Allergen avoidance methods for fungi/ molds?

- Reduce indoor humidity (40 – 45% relative humidity)
- Repair any structural leaks for moisture
- Discard moldy furnishings
- Clean with fungicide (10% Cl bleach)

Use and efficacy of nasal irrigation?

Neti pot - administer saline solution/ flush nasal passageways


- Infection risk if naegleria fowleri (ameba) in tap water


- Evidence showing relief of symptoms, help as adjunct therapy, and tolerated by most patients

MOA of oral antihistamines?

Competitive blockers of H1 receptors. They do not prevent the release of histamine.

Use and efficacy of oral antihistamines?

Nasal response usually caused by histamine release; therefore need to take before exposure or continuously


- effective as PRN by maintenance is better


- Not responsive with chronic symptoms, high allergen exposure, or prolonged exposure


- Not very effective decongestant


- Can decrease non-nasal symptoms

Why are first generation oral antihistamines (chlorphenarimine, diphenhydramine) often not used for allergic rhinitis?

- sedation and anticholinergic effects


- GI disturbances


- Impair children's learning/ academic performance


- Cause fatal car accidents

Characteristics of second generation (loratidine, desloratidine, fexofenadine (cetirizine)) antihistamines?

- Large and lipophobic (doesn't cross BBB)


- Non-sedating (except cetirizine) at regular doses


- Not CNS depressant at regular doses


- Long acting (QD-BID dosing)


- Cost/day: $1.08-2.98

Dosing regimen for cetirizine (Reactine)?

5-10mg QD

Dosing regimen for fexofenadine (Allegra)?

60mg BID

Dosing regimen for loratidine (Claritin)?

10mg QD

Dosing regimen for desloratidine (Aerius)?

5mg qd

Which second generation oral histamines have pregnancy category B, and C?


1. Cetirizine


2. Fexofenadine


3. Loratidine


4. Desloratidine

B: 1 and 3


C: 2 and 4

Use and efficacy for topical antihistamines?

Levocabastine (Livostin 0.5%), BID


For nasal or ocular symptoms (eye drops or nasal spray)


- Equal or superior efficacy to oral antihistamines, faster onset


- Clinically significant effect on nasal congestion


Side effect for topical antihistamines?

Bad taste

MOA of decongestants?

Act on alpha -adrenergic receptors to cause vasoconstriction to reduce nasal congestion


- Effective to reduce severe obstructive congestion impairing absorption of intranasal steroids
- Can increase BP, stimulate CNS, interact with MAO inhibitors

Name 4 topical decongestants.

- Phenylephrine


- Oxymetazoline


- Xylometazoline


- Naphazoline (immidazolines = longer acting)

Name 2 oral decongestants.

- Phenylephrine


- Pseudophedrine

Efficacy of combination products?

Antihistamine (dries nasal secretion) + decongestant (reduce congestion)


- more effective in combo than alone


- convenient for short periods of time

Disadvantages of combination products?

Antihistamines + decongestant


- more insomnia and nervousness (even with sedating antihistamine)


- difficult to titrate dose when in combo

Efficacy of topical corticosteroids vs. antihistamines?

- More effective than antihistamines


- decrease all Sx (congestion, itching, sneezing, rhinorrhea, and similar effect on ocular symptoms compared to oral antihistamines)


- Use prophylactically and PRN


- Slow onset (3 days; max effect at 2 weeks)

Which topical corticosteroids are used for allergic rhinitis?
Budesonide, flunisolide, fluticasone, mometasone, triamcinolone

Which hand is used during administration of topical intranasal steroid?

If using on left nostril, use right hand to administer


- this directs spray away from septum to decrease risk of epistasis

Which oral corticosteroids are used for allergic rhinitis?

Prednisone 20-40 mg/d for 5 to 7 days
for very severe or intractable nasal symptoms or nasal polyposis.

MOA and use of cromolyn?

MOA: stabilizes mast cell membranes to prevent release of inflammatory mediator



Use: mild to moderate conditions (and prior to allergen exposure in episodic cases)


- steroids are superior in efficacy and compliance

Dosing regimen of cromolyn?

1 spray each nostril 6 times daily until adequate response obtained then decrease to bid or tid.


- delayed effect 4-7 days (or 2 weeks if severe or perennial cases)


- Cost: $15/4 weeks

SEs of cromolyn?

Safe with very few SEs: sneezing, stinging, nasal burning

MOA and use of Ipratropium (Atrovent)?

MOA: Blocks cholinergic receptors to decrease watery nasal secretions


Use: 1 spay per nostril TID-QID


- Lacking evidence for use in allergic rhinitis

Use and efficacy of leukotriene receptor antagonists (Montelukast/ Zafirlukast)?
- Similar efficacy to anithistamines (loratadine)
- Less effective than nasal CS
- Combined antihistamine + LTRA superior to either alone
- Weak as monotherapy to allergic rhinitis

MOA and use of immunotherapy?

Production of IgG blocking antibodies (block IgE from binding to antigen thereby inhibiting mast cell rupture)


- Use if non-responsive to pharmacotherapy or unable to tolerate SEs or avoid allergens


- Requires frequent injections

Disadvantages of immunotherapy?

- Requires frequent injections


- Risk of anaphylaxis (5% with high-potency extracts)

Define: intermittent allergic rhinitis

<4 days/week or <4 week in duration

Define: persistent allergic rhinitis

>4 days/week or >4 week duration

Define: mild allergic rhinitis

Normal sleep, daily activities, no troublesome symptoms

Define: moderate/ severe allergic rhinitis

One or more: decreased sleep, impaired daily activities, troublesome symptoms

Treatment options for mild seasonal allergic rhinitis?

- Treat with oral or nasal antihistamine


- For eye: topical antihistamine or cromones

Treatment options for moderate seasonal allergic rhinitis?

- Nasal CS


- For eye: topical antihistamine or cromones

Treatment options for severe seasonal allergic rhinitis?

- Nasal CS plus oral/ nasal antihistamine



Inadequate control: add further Sx treatment, or short-course oral CS, or consider immunotherapy

For resistant cases of perennial allergic rhinitis, how is nasal blockage treated?

- Short course topical decongestant or oral decongestant, or short course oral CS


- if resistant, surgical turbinate reduction

For resistant cases of perennial allergic rhinitis, how is resistant rhinorrhoea treated?

Nasal ipratropium bromide