HEENT 07: Allergic Rhinitis

Question 1

What is allergic rhinitis?

Answer 1

• nasal mucosa becomes sensitized to allergens
• IgE mediated
• type I hypersensitivity response
• associated with asthma, atopic dermatitis, allergic conjunctivitis, sinusitis, sleep apnea
• genetic predisposition

Question 2

What are the signs and symptoms of allergic rhinitis?

Answer 2

• sneezing, nasal congestion, rhinorrhea – triggered by exposure to allergens
• enlarged nasal mucosa, nasal polyps, allergic shiners
• chronic cough

Question 3

What are the signs and symptoms of early phase allergic rhinitis?

Answer 3

• clear nasal discharge (rhinorrhea)
• sneezing
• itchy nose, eyes, and throat – nasal itchiness is distinctive to allergic rhinitis
• some congestion

Question 4

What are the signs and symptoms of late phase allergic rhinitis?

Answer 4

major congestion

Question 5

What are some complications of allergic rhinitis? (3)

Answer 5

• ear conditions – related to eustachian tube defects
• sinusitis and URTI
• eosinophilic esophagitis – dysphagia, heartburn, vomiting

Question 6

What are the differential diagnoses of allergic rhinitis?

Answer 6

• infective rhinitis – purulent nasal discharge, swollen glands, short-term, associated with URTI
• irritant rhinitis
• drug-induced rhinitis
• occupational rhinitis

Question 7

How are symptoms of allergic rhinitis classified?

Answer 7

based on frequency and duration:

• intermittent: up to 4 days/week for < 4 consecutive weeks
• persistent: 4 or more days/week for > 4 consecutive weeks

based on severity:

• mild: do not interfere with daily activities
• moderate-severe: very bothersome and interferes with daily activities and disturb sleep

Question 8

What are red flags for referral of allergic rhinitis?

Answer 8

• age < 2 years
• pregnancy
• new medication
• SOB, wheezing
• persistent headache, facial pain
• unilateral nasal symptoms
• worsening or no improvement in symptoms
• mucopurulent nasal discharge

Question 9

What is the first-line treatment for allergic rhinitis?

Answer 9

• oral antihistamines
• intranasal corticosteroids

Question 10

What is the treatment for mild, intermittent allergic rhinitis?

Answer 10

• 2nd generational oral antihistamine
• step-up: INC

note: oral antihistamines can be used as add-on when needed

Question 11

What is the treatment for mild, persistent allergic rhinitis?

Answer 11

INC

note: oral antihistamines can be used as add-on when needed

Question 12

What is the treatment for moderate to severe allergic rhinitis?

Answer 12

(intermittent or persistent)

• first-line: INC
• step-up: INC/INAH

note: oral antihistamines can be used as add-on when needed

Question 13

Intranasal Corticosteroids (INC)

Beclomethasone

Answer 13

• high bioavailability
• 1-2 sprays each nostril BID

Question 14

Intranasal Corticosteroids (INC)

Budesonide

Answer 14

• moderate bioavailability
• 1-2 sprays each nostril daily

Question 15

Intranasal Corticosteroids (INC)

Ciclesonide

Answer 15

• very low bioavailability
• 2 sprays each nostril daily

Question 16

Intranasal Corticosteroids (INC)

Fluticasone Furoate

Answer 16

• very low bioavailability
• 2 sprays each nostril daily

Question 17

Intranasal Corticosteroids (INC)

Fluticasone Propionate

Answer 17

• very low bioavailability
• 1-2 sprays each nostril daily

Question 18

Intranasal Corticosteroids (INC)

Mometasone

Answer 18

• very low bioavailability
• 1-2 sprays each nostril daily

Question 19

Intranasal Corticosteroids (INC)

Triamcinolone

Answer 19

• moderate bioavailability
• 1-2 sprays each nostril daily

Question 20

Describe the efficacy of intranasal corticosteroids.

Answer 20

• maximum effect in 3-14 days – takes longer to work than nasal decongestants
• most can be given up to BID
• works best if used continuously
• more effective than oral antihistamines

Question 21

Describe the adverse effects of intranasal corticosteroids.

Answer 21

• common: epistaxis, nasal irritation, headache
• rare: ulceration of mucosa, pharyngeal candidiasis, rash, septum perforation

Question 22

Oral Antihistamines

Bilastine

Answer 22

20 mg daily

• somewhat sedating
• Rx
• take on empty stomach

Question 23

Oral Antihistamines

Cetirizine

Answer 23

10 mg daily

• most sedating
• dose adjust renal impairment
• quickest acting (20 min)

Question 24

Oral Antihistamines

Desloratadine

Answer 24

5 mg daily

• diarrhea in children
• dose adjust renal impairment

Question 25

Oral Antihistamines Fexofenadine

Answer 25

60 mg BID or 120 mg daily - dose adjust renal impairment

Question 26

Oral Antihistamines Loratadine

Answer 26

10 mg daily - xerostomia - dose adjust renal impairment

Question 27

Oral Antihistamines Rupatadine

Answer 27

10 mg daily - somewhat sedating - Rx

Question 28

Combination Oral Antihistamines and Intranasal Corticosteroids

Answer 28

- unclear evidence - not wrong to use together, may increase ADRs - switch to INCS is reasonable transition if oral AH not working

Question 29

Intranasal Antihistamines (INAH)

Answer 29

- better than oral for nasal congestion– may work even if oral AH failed - only available in Canada combined with INC – Dymista (fluticasone/azelastine), Ryaltris (mometasone/olopatadine) - ADR: bitter taste, epistaxis

Question 30

What is the main role of decongestants in management of allergic rhinitis?

Answer 30

symptomatic relief while other medications (INC) are taking time to work (3-14 days) - short-term use only is what is recommended - generally NOT recommended for use in children

Question 31

What are the concerns of using decongestants in management of allergic rhinitis?

Answer 31

- use in people with uncontrolled HTN, CAD – can increase BP - do not use with MAOIs (ie. mocobemide) - rebound congestion with intranasal products after 3-5 days of use

Question 32

What does intranasal ipratropium do?

Answer 32

decreases rhinorrhea, but minimal effect on congestion

Question 33

What does montelukast (oral leukotriene receptor antagonist) do?

Answer 33

- modest effect – varied response - add on when other therapies are ineffective

Question 34

When is immunotherapy indicated?

Answer 34

- if coexisting allergies and asthma - if using maximum pharmacotherapy

Question 35

Actions of Different Classes INC - rhinorrhea - sneezing - congestion - sinusitis - allergic conjunctivitis

Answer 35

- rhinorrhea: YES - sneezing: YES - congestion: YES - sinusitis: YES - allergic conjunctivitis: YES

Question 36

Actions of Different Classes Oral AH - rhinorrhea - sneezing - congestion - sinusitis - allergic conjunctivitis

Answer 36

- rhinorrhea: YES - sneezing: YES - congestion: ? - sinusitis: NO - allergic conjunctivitis: YES

Question 37

Actions of Different Classes INAH (with INC) - rhinorrhea - sneezing - congestion - sinusitis - allergic conjunctivitis

Answer 37

- rhinorrhea: YES - sneezing: YES - congestion: YES - sinusitis: NO - allergic conjunctivitis: ?

Question 38

Actions of Different Classes Decongestant - rhinorrhea - sneezing - congestion - sinusitis - allergic conjunctivitis

Answer 38

- rhinorrhea: NO - sneezing: NO - congestion: YES - sinusitis: NO - allergic conjunctivitis: NO

Question 39

What is used for treatment of ocular symptoms? (2)

Answer 39

- ophthalmic antihistamine (antazoline, olopatadine, pheniramine (all OTC)) – often combined with decongestant - ophthalmic mast cell stabilizer – Cromolyn (OTC)

Question 40

Are INCs safe in pregnancy?

Answer 40

yes - exception: triamcinolone - most data for cetirizine and loratadine

Question 41

What are the efficacy monitoring points for allergic rhinitis?

Answer 41

- symptoms should start to be relieved within first day or 2 - minimal improvement or no improvement – step-up treatment, refer - visual analog scale (VAS) to determine efficacy – assess in 3-7 days to determine if working (step-up/down, continue)

Question 42

What can pharmacists in BC prescribe for allergic rhinitis?

Answer 42

- intransal drugs - ophthalmic drugs - oral antihistamines