Rhinology Allergy Management

Question 1

What are the three main strategies used to

manage allergy?

Answer 1

● Environmental modification
● Pharmacotherapy
● Immunotherapy

Question 2

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?

Answer 2

Antihistamines

Question 3

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

Answer 3

They are highly lipophilic and cross the blood brain barrier.

Question 4

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

Answer 4

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

Question 5

Why are second-generation antihistamines

currently preferred?

Answer 5

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

Question 6

Provide examples of systemic first-generation

antihistamines.

Answer 6

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

Question 7

Provide examples of systemic second-generation

antihistamines.

Answer 7

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

Question 8

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

Answer 8

● Azelastine

● Olopatadine

Question 9

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

Answer 9

Decongestants

Question 10

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

Answer 10

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

Question 11

Name four medications that function as topical

decongestants.

Answer 11

● Tetrahydrozoline
● Naphazoline
● Oxymetazoline
● Phenylephrine

Question 12

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

Answer 12

Rhinitis medicamentosa

Question 13

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?

Answer 13

● Prednisone
● Methylpredisolone
● Dexamethasone

Question 14

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

Answer 14

Budesonide (Rhinocort Aqua)

Question 15

What intranasal topical corticosteroids are

commonly used?

Answer 15

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

Question 16

Which intranasal corticosteroids are approved for

patients as young as 2 years of age?

Answer 16

Mometasone furoate and fluticasone furoate

Question 17

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?

Answer 17

Epistaxis

Question 18

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)?

Answer 18

Cromolyn sodium

Question 19

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

Answer 19

Montelukast

Question 20

What conditions have been shown to benefit from

immunotherapy?

Answer 20

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.

Question 21

For a patient to be considered for immunotherapy,

what conditions must be met?

Answer 21

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.

Question 22

What are the contraindications for

immunotherapy?

Answer 22

● 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

Question 23

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

Answer 23

● 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)

Question 24

What is the length of time normally required for

immunotherapy to achieve good effect?

Answer 24

3 to 5 years

Question 25

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?

Answer 25

Subcutaneous immunotherapy (SCIT)

Question 26

When choosing a starting dose for SCIT, what

two goals should be achieved?

Answer 26

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

Question 27

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

Answer 27

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

Question 28

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

Answer 28

● 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.

Question 29

What might result in an unexpected systemic or

significant local reaction during immunotherapy?

Answer 29

● 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

Question 30

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

Answer 30

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

Question 31

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

Answer 31

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.

Question 32

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?

Answer 32

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.

Question 33

True or False. Sublingual immunotherapy has pre-

dominantly been used for single antigen therapy.

Answer 33

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.