LECTURE 32 - treatment of allergic rhinitis

Question 1

List the symptoms of allergic rhinitis

Answer 1

Sneezing
Runny nose (nasal crease in children)
Nasal congestion
Red & watery eyes
Itchy nose & eyes

Question 2

What is the cause of allergic rhinitis?

Answer 2

IgE-mediated disease

Question 3

What is the cause of NON-allergic rhinitis?

Answer 3

Exposure to airborne irritants: pollution, chemicals, smoke

Question 4

What patient population is most affected by allergic rhinitis?

Answer 4

Common in adults & children

Question 5

What patient population is most affected by NON-allergic rhinitis?

Answer 5

Primarily seen in adults

Question 6

List characteristic symptom(s) of allergic rhinitis

Answer 6

Sneezing very common plus congestion & rhinorrhea

Question 7

List characteristic symptom(s) of NON-allergic rhinitis

Answer 7

Chronic rhinorrhea
Sneezing is uncommon

Question 8

List common allergens that can cause allergic rhinitis

Answer 8

Pollens: grasses, trees
Molds
Dust – dust mite feces
Animal dander – cats (more common), dogs

Question 9

Describe MILD allergic rhinitis

Answer 9

No interference with daily activities, work, school, sleep

Question 10

Describe MODERATE-SEVERE allergic rhinitis

Answer 10

Interferes with daily activities, work, school, sleep

Question 11

Describe intermittent vs. persistent allergic rhinitis

Question 12

Describe seasonal vs. perennial allergic rhinitis

Question 13

What is a non-pharmacological “treatment” for allergic rhinitis?

Answer 13

avoidance

Question 14

List some pharmacological treatment options for allergic rhinitis

Answer 14

decongestants (inhaled, oral)
corticosteroids (intranasal, oral)
antihistamines (intranasal, oral)
intranasal cromolyn
leukotriene receptor antagonists

Question 15

What are the possible treatment(s) for a patient with “mild intermittent” allergic rhinitis?

Answer 15

• Oral antihistamine (OAH) +/- decongestant
• Intranasal antihistamine (INA)

(NO Leukotriene receptor antagonist (LTRA) for mild AR)

Question 16

What are the possible treatment(s) for a patient with “moderate-severe intermittent” allergic rhinitis?

Answer 16

• OAH +/- decongestant
• Intranasal antihistamine (INA)
• Leukotriene receptor antagonist (LTRA)
• Intranasal corticosteroid (INCS)

Question 17

What are the possible treatment(s) for a patient with “mild persistant” allergic rhinitis?

Answer 17

• OAH +/- decongestant
• Intranasal antihistamine (INA)
• Intranasal corticosteroid (INCS)

Question 18

What are the possible treatment(s) for a patient with “moderate-severe persistent” allergic rhinitis?

Answer 18

• Intranasal corticosteroid (INCS)
• OAH +/- decongestant
• Leukotriene receptor antagonist (LTRA)

** there is a preferred order for tx of moderate-severe persistent AR & combination therapy can be used if sx are not controlled with a single agent **

Question 19

What is the next step if symptoms are controlled, but there are adverse drug reactions (ADRs)?

Answer 19

switch to an alternative agent to minimize ADRs

Question 20

What is the next step if the patient experiencing allergic rhinitis is also experiencing severe congestion?

Answer 20

consider routine use of antihistamine / decongestant combo

Question 21

What is the next step if the patient experiencing allergic rhinitis is also experiencing persistent rhinorrhea?

Answer 21

Consider adding ipratropium nasal spray

Question 22

What is the next step if patient is experiencing severe allergic rhinitis without good symptom control?

Answer 22

Consider skin testing & immunotherapy (allergy shots)

Question 23

In the RARE case that a patient has allergic rhinitis without good symptom control AND has moderate - severe asthma or atopic dermatitis, what is the next step?

Answer 23

consider treatment with biologics:
Omalizumab
Dupilumab

Question 24

List the advantages of 2nd generation oral antihistamines as treatment for allergic rhinitis

Answer 24

Effective for mild to moderate AR
Once daily dosing
OTC – low cost
Well tolerated

Question 25

List the advantages of intranasal antihistamines as treatment for allergic rhinitis

Answer 25

Localized therapy Excellent for rhinorrhea

Question 26

List the advantages of intranasal corticosteroids as treatment for allergic rhinitis

Answer 26

Very effective for most pts with moderate to severe AR One daily dosing Most complete symptomatic relief Activity against multiple mediators OTC – well tolerated

Question 27

List the advantages of intranasal cromolyn as treatment for allergic rhinitis

Answer 27

Safe to use in pregnancy No risk of ADRs or toxicity

Question 28

List the advantages of montelukast as treatment for allergic rhinitis

Answer 28

Similar efficacy to antihistamines Oral, once daily dosing Also indicated for children with mild asthma

Question 29

List the advantages of oral/intranasal decongestant as treatment for allergic rhinitis

Answer 29

Superior for relieving congestion Enhances efficacy of antihistamines when used in combination OTC – low cost

Question 30

List the advantages of immunotherapy / desensitization as treatment for allergic rhinitis

Answer 30

Targeted to specific antigens Very effective for some patients

Question 31

List the advantages of biologics as treatment for allergic rhinitis

Answer 31

Role in treatment of pts with AR limited to those with very severe sx and those with asthma or atopic dermatitis

Question 32

List the disadvantages of 2nd generation oral antihistamines as a treatment for allergic rhinitis

Answer 32

Less effective for nasal congestion Only impacts histamine receptors

Question 33

List the disadvantages of intranasal antihistamines as a treatment for allergic rhinitis

Answer 33

EXPENSIVE BID dosing Bitter taste Risk of drowsiness

Question 34

List the disadvantages of intranasal corticosteroids as a treatment for allergic rhinitis

Answer 34

Risk of nose bleeds (if used incorrectly) Mild nasal symptoms Must be used routinely for best results Max benefit in 1-2 weeks

Question 35

List the disadvantages of intranasal cromolyn as a treatment for allergic rhinitis

Answer 35

Only effective for mild AR Requires TID-QID dosing

Question 36

List the disadvantages of montelukast as a treatment for allergic rhinitis

Answer 36

Rx only More expensive than OTC medications

Question 37

List the disadvantages of oral/intranasal decongestants as a treatment for allergic rhinitis

Answer 37

Restrictions on dispensing Use of nasal sprays should be limited to 3 days Use with caution in pts with poorly controlled HTN or IHD

Question 38

List the disadvantages of immunotherapy / desensitization as a treatment for allergic rhinitis

Answer 38

EXPENSIVE Weekly to monthly injections Requires frequent MD visits

Question 39

List the disadvantages of biologics as a treatment for allergic rhinitis

Answer 39

VERY EXPENSIVE Access only through specialty prescription

Question 40

What symptom(s) of AR are oral antihistamines most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 40

moderately effective at relieving: rhinorrhea, sneezing, nasal itching (2/3 efficacy)

Question 41

What symptom(s) of AR are oral antihistamines least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 41

only mild relief of congestion (1/3 efficacy)

Question 42

What symptom(s) of AR are intranasal corticosteroids least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 42

none! it relieves all symptoms, just takes a long time to work

Question 43

What symptom(s) of AR are intranasal corticosteroids most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 43

all of them! just takes a long time to work

Question 44

What symptom(s) of AR are intranasal antihistamines most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 44

it moderately relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (works faster than INCS)

Question 45

What symptom(s) of AR are intranasal antihistamines least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 45

it moderately relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (works faster than INCS)

Question 46

What symptom(s) of AR is intranasal cromolyn least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 46

it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)

Question 47

What symptom(s) of AR is intranasal cromolyn most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 47

it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)

Question 48

What symptom(s) of AR are leukotriene receptor antagonists most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 48

it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)

Question 49

What symptom(s) of AR are leukotriene receptor antagonists least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 49

it mildly relieves all symptoms - congestion, rhinorrhea, sneezing, nasal Itching (1/3 efficacy)

Question 50

What symptom(s) of AR are oral & inhaled decongestants most effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 50

oral and inhaled decongestants relieve congestion VERY WELL, and mildly relieve rhinorrhea (1/3 efficacy)

Question 51

What symptom(s) of AR are oral & inhaled decongestants least effective at relieving? (Congestion, Rhinorrhea, Sneezing, Nasal Itching)

Answer 51

oral and inhaled decongestants DO NOT relieve sneezing or nasal itching