Allergic Rhinitis

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robinlhx
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188076
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Allergic Rhinitis
Updated:
2012-12-08 22:46:28
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Allergic Rhinitis
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Allergic Rhinitis, cold and cough
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  1. Allergic Rhinitis facts
    • One of the most common medical disordersfound in humans.
    • Approximately 20 to 30% of US Populationaffected.
    • – 40% of children
    • Sixth most prevalent chronic illness.
  2. Nasal Anatomy/Physiology
    • Function = olfaction and air preparation
    • Three nasal preparatory functions:   heat, humidity, cleaning*
    • Mucosa covered by a double layer of fluid:
    • ------outer layer: thick, sticky trapping layer
    • ------inner layer: thinner, aqueous layer with mediators
    • -if your nose keep runny, get sinys infection (b/c it's wam, dark,wet)
    • Highly vascular
    • -people jus take OTC antihistamine instead of Rx anticholinergics to treat congestion, b/c it has anticholingergic as side effect.
  3. Nasal Immune Response Mechanisms
    • IgE bound to mast cells/basophils-----release histamine
    • histamine is most important for symptoms of AR
    • Two reactions (similar to asthma):
    • -----immediate: occurs within minutes of exposure due torelease of pre-formed mediators and newly generated mediators from arachidonic acid cascade
    • ----late-phase: occurs several hours after exposure due to influxof inflammatory cells (eosinophils, monocytes,macrophages, basophils), lymphocytes.
  4. Clinical Presentation / Symptoms
    • clear rhinorrhea,
    • sneezing,
    • nasal congestion,
    • post-nasal drip,
    • pruritis of eyes, ears, nose and palate,
    • allergic conjunctivitis.
  5. Two types of allegic Rhinitis
    • Seasonal Allergic Rhinitis
    • Perennial Allergic Rhinitis
  6. Seasonal Allergic Rhinitis
    • Cyclical, predictable, correlated with pollen counts
    • Pollen size important: 10-100 μm
    • – Spring →Trees
    • – Summer →grasses
    • – Late summer →Weeds
    • – NOT flowering plants pollenated via insects
    • -Geographical regionality
    • -Susceptibility typically in childhood, better later
  7. Perennial Allergic Rhinitis
    • Unpredictable, more continuous
    • Potential allergen sources:
    • -------– dust mites, pet dander, mold, food, drugs, insects
    • Symptoms may be more subtle:
    • --------itchy eyes, itchy throat,stuffy nose, headaches, eczema, fullnessin the ears, fatigue, irritability,difficulty concentrating
    • -maybe frustrating because can't find the triggers
  8. Complications with Allergic Rhinitis
    • Inability to sleep,
    • chronic malaise,fatigue,
    • poor work and school efficiency.
    • Loss of smell or taste,
    • sinusitis,
    • nasal polyps,post-nasal drip,
    • cough.
    • Acute otitis media
    • chronic middle ear effusion - obstruction of eustachian tube
    • -delay development of language learning in kids b/c of hearing problem
    • Structural facial and dental problems
    • orthodontic problems
    • ,nasal crease,
    • “shiners”
  9. Diagnosis of Allergy
    • History
    • • Physical exam findings
    • • Nasal scrapings - eosinophils
    • • Allergen Skin testing
    • • RAST (Radioallergosorbent test)
  10. Allergic Rhinitis - Therapy
    • • Avoidance of the allergen
    • • Mast cell stabilizers
    • • Topical Anticholinergic
    • • Immunotherapy
    • • Mechanical drainage
    •      – Sinus Irrigation
    •         • Neti Pot
  11. Mechanical Therapy--Allergic Rhinitis
    • • Sinus surgery
    • • Ear tubes– Tympanostomy Tube Surgery
    • -You can put ear tube to reduce the pressure inside the inner ear, so that fluid in Eustachian tube wil drain away. Tube usually falls off by itself, if not, ask Dr. to do so.
    • -Make sure use Ear Plug when swimming
    • -Pseudo can help to open the Eustachian tube also,  can be used to treat motion sickess-----airplane
  12. Allergic Rhinitis - Pharmacologic Therapy
    • Antihistamines ----Anticholinergics  (SE: Dry mouth, Drowsiness, Dizziness)
    • Decongestants-- S.E: mimic sympahetic Activity
    • Combinations--- Not Recommended
    • Nasal Steroid-----Reduce inflmammation
  13. Antihistamines--info
    • Most effective as preventative medications -with seasonal allergy start therapy prior toseason.
    • Primarily for symptomatic improvement
    • “drying” effects  b/c anticholingerics property
  14. Antihistamines- Precaution
    • – Urinary retention especially in men
    • – Narrow angle glaucoma,
    • – Hperthyroidism,
    • – Cardiovascular disease
    • Constipation - Elderly
    • Dry eyes
    • • Avoid machinery (driving) , alcohol
  15. Antihistamines - Classes
    • Ethanolamines: (Mod-High sedation, Highanticholinergic effects)
    • – carbinoxamine (Palgic)
    • – clemastine (Tavist, Tavist 1)
    • – dimenhydrate (Dramamine) -----for motion sickness: airplane
    • – diphenhydramine (Benadryl)
    • – doxylamine (Unisom), phenyltolaxime
  16. Antihistamines - Classes Cont`
    • • Piperazines: (Mod sedation, Modanticholinergic)
    • – Cyclizine (Marezine) OTC
    • – Hydroxyzine (Atarax, Vistaril)
    • –Meclizine (Antivert)
    • -Bonine OTC
    • -Dramamine -----Less Drowsy Formular OTC
  17. Misc 1st and 2nd Generation Antihistamines
    • First generation:
    • Phenothiazines: (Mod-high sedation, highanticholinergic)
    • ----Cyproheptadine (Periactin) :Seasonal allergies
    • Second generation: (Low sedation,low to no anticholinergic)
    • ----Astemizole (Hismanal DC’d in US)
    • ----Terfendadine (Seldane DC’d in US)
  18. Antihistamine Classes Cont'
    • • Loratadine (Claritin)
    • ----10 mg QD
    • • Desloratadine (Clarinex)
    • ---- 5 mg QD
    • • Fexofenadine (allegra)
    • ---- 30-60mg BID (or 180 QD)
    • • Acrivastine (Semprex-D)
    • -----8mg/60mg PSE
    • -All of Above don't treat Skin Rash
    • • Cetirizine (Zyretc)
    • -----5-10mg QD
    • Zyretc Treats Skin Rash!!!
    • • Levocetirizine (Xyzal)
    • -----5mg QD
    • it maybe slightly more effective than Singulair in reducing nasal or nonnasal symptoms
  19. “Second Generation” anihistamine Agents (Not Recommend)
    • Less sedation and anticholinergic effects
    • more expensive.
    • Risk of prolonged QTc interval and proarrhythmiceffect (terfenadine, astemizole)
    • Many patients tolerate older agents very well
  20. Antihistamines - AlternativeRoutes: Intranasal
    • Intranasal – Azelastine:
    •  Astelin® and Optivar®
    • • Comparable to oral antihistamines
    • – More rapid relief of symptoms
    • – Can cause drowsiness (F = ~40%)
    • – 2 sprays BID
  21. Antihistamines - AlternativeRoutes : Ophthalmic
    • • Ophthalmic
    • – Levocabastine (Livostin®)
    • – Olopatadine (Patanol®)
    • –Bepotastine (Bepreve®)
    • – Epinastine (Elestat®)
    • – Ketotifen (Zadiotr®)
  22. Decongestants
    info
    S.E.
    • Topical:
    • – Rapid acting
    • – Risk of “Rhinitis Medicamentosa”
    • - limit to 3-5 days of use maximum.
    • – Local AEs:  burning, stinging, sneezing,mucosal dryness
  23. Topical Decongestants:
    Short-Acting (< 4 hours)
    Intermediate-Acting (4-6 hours)
    Long-Acting (up to 12 hours)
    • Short-Acting (< 4 hours)
    • – Phenylephrine Neosynephrine
    • – Intermediate-Acting (4-6 hours):
    • – Naphazoline
    • – Tetrahydrozoline (Tyzine)
    • – Long-Acting (up to 12 hours):
    • – Oxymetazoline (Afrin or Visine LR)
    • –Xylometazoline (Otrivin)
  24. Systemic Decongestants
    info and S.E. / DI
    • – Slower in onset, longer acting (?)
    • – Risk of systemic AEs - CNS stimulation,tachycardia, hypertension
    • – Avoid in CV diseases, hypertension
    • – Drug interactions - e.g. MAOIs
  25. Systemic Decongestants
    Drugs
    • Pseudoephedrine ---Pt needs to sign to buy  OTC
    • – 30-60mg every 4 to 6 hours
    • -- Least likely systemic S.E.
    • • Phenylephrine
    • – 10-20mg every 4-6 hours
    • •Phenylpropanolamine (pulled from market)
    • • Ephedrine (not good)
  26. Nasal Steroids
    • • Excellent choice for Perennial rhinitis
    • • Helpful for seasonal rhinitis if started before their season
    • • Minimal side effects at usual doses. (overdose:bloody nose)
    • First line agent
    • •Onset of effects delayed (usually need 7-10 days to relieve symptom)
    • “preventer”
  27. Nasal Steroids
    AEs, Dosing
    • • Clear blocked nasal passages beforeinitiating therapy - decongestant
    • Initially BID to TID, decrese frenquency once get response
    • AEs:
    • Sneezing, stinging, HA,
    • fungal infection (rare)
    • DO NOT USE with Nasal Ulcers, Recent nasal surgey, or Trauma
  28. Nasal Steroids
    Drugs
    • • Beclomethasone (Beconase, Vancenase,AQ’s)
    • • Budesonide (Rhinocort, Rhiocort Aqua)
    • • Ciclesonide (OmnarisTM )
    • • Flunisolide (Nasalide, Nasarel)
    • • Fluticasone (Flonase)
    • • Mometasone (Nasonex)
    • • Triamcinolone(Nasacort)
  29. Nasal Cromolyn OTC
    • Mast cell stabilizer
    • For seasonal rhinitis, must start therapy prior to start of season.
    • • Effects delayed - 2 to 4 weeks.
    • • Clear nasal passages before treatment
    • • AEs - sneezing and nasal stinging
  30. Nasal Ipratroprium
    • Anticholinergic effects may improve symptomsby decreasing nasal secretions and decongestingthe nasal passages.
    • Side effects are mild - headache, nose bleeds,and nasal dryness.
    • NOT a First Line Drug
  31. Leukotriene Antagonists
    • • Rapid onset
    • • Additive effects with antihistamines.
    • • May be particularly useful for patients with asthma and allergic rhinitis

    • • Montelukast (Singulair)
    • – Adults 10mg qd
    • – Adolescents/child 6-14 5mg qd
    • – Children 2-5 = 4mg qd
  32. Immunotherapy
    • • Injection of offending allergen
    • • Increases tolerance to allergen exposure.
    • -expensive, risky, for seletive population
  33. Common Cold
    Five common viruses
    • • Five common viruses:
    • – rhinovirus (2, 9, 14) ----Most Common, and develop rapidly
    • – coronovirus (229E)
    • – respiratory syncytial virus (RSV)---Develop slowly
  34. Common Cold -- Clinical Presentation
    • • Sequence:
    • -------sore throat→nasal S/S→watery eyes,sneezing→cough
    • • cough occurs in <20% (60% in RSV)
  35. Bacterial vs. Viral Pharyngitis ( sore throat)
    • • Bacterial:– rapid onset, marked soreness, marked constitutional symptoms, respiratory S/S +/-,large and tender nodes
    • • Viral:– slower onset, less severe soreness, mild onstitutional symptoms, frequent respiratoryS/S, slight enlargement of nodes, but non tender
  36. Common Cold vs. Influenza
    • Common cold:
    • High fever is rare;   minimal headache  
    • cough is less common,
    • 5-10 day duration, occur any time of theyear
    • • Influenza:
    • fever is sudden, > 102°F;( dignostic) prominent headache,
    • cough common, photophobia,
    • 1 week duration; only during the Influenza Season (Late Fall andWinter)
  37. Basics of Management of cold
    • • Self-limiting: resolves in 5-10 days.
    • • Antibiotics are ineffective for viral illness
    • • Prevention: it is none proven
  38. Antihistamine for Common Cold
    • it doesn't play a important role in Cold
    • Don't Recommond anything make drowsiness (Ex.Antihistamine) in Elderly, because they might fall and break hips then die.
  39. Single Component Products for Cold
    • Decongestants:
    • – Pseudoephedrine --- good shit
    • --Systemic DOC
    • Topical agents - 3-5 days maximum
    • • Antitussives:
    • – Dextromethorphan - DOC
    • • Expectorants
    • • Analgesic/Antipyretic
    • – Acetaminophen - DOC
    • – Aspirin
    • – NSAIDs
  40. • Types of cough:
    • non-productive: no chest congestion, nophlegm
    • congested/non-productive
    • productive of phlegm
  41. Cough Reflex
    • • It's Important Defense Mechanism
    • • Physician referral if persistent cough for greaterthan 1 week.
  42. Antitussives
    • -abusive , Addictive
    • • Indicated only  for dry, hacking, non-productivecough
  43. Antitussives - Systemic
    • • Codeine: “Gold Standard
    • lower dose (10-20 mg)
    • low-dependency potential, but caution with chronic use
    • Controlled Substance
    • side effects: nausea, drowsiness, constipation
    • CI to COPD
    • Not Recommond in Elderly
  44. Antitussives - Systemic Cont`
    • • Dextromethorphan:
    • – no analgesia
    • –rare respiratory depression
    • contraindicated for patients on MAOI’s
    • • Diphenhydramine
    • Not recommended!!
  45. Antitussives - Topical
    • Camphor/menthol are only two onmonograph
    • • Ointments rubbed on throat or chest
    • • Do not allow ingestion (seizures withcamphor)
    • NOT Recommond!!
  46. Expectorants
    Info and drug
    • -no proven value in treatment of the common cold.
    • -Water is still the most effective expectorant!!!!!
    • • Guaifenesin
    • -harmful but taste terrible
    • -questionanl eficacy
    • -NOT recommend !
  47. Summary of Cold
    • Encourage the use of single component medicationswhen indicated.
    • Not every symptom needs treatment
    • OTC Cough andCold Medications Should Not Be Used inInfants and Children <2 Years of Age

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