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TREATMENT ALGORITHM - what do all people get?
All: avoidance of allergen and patient education
Treatment alrgorithm - Mild intermittent symptoms:
2nd generation oral or intranasal antihistamine PRN
Treatment algorithm - Mild to moderate persistent symptoms:
- Intranasal corticosteroids alone as 1st line treatment
- Consider nasal irrigation or decongestants if nasal congestion
- Consider atrovent or intranasal antihistamines for rhinorrhea
- Consider oral or intranasal antihistamine for persistent nasal ocular symptoms
Treatment algorithm - Severe persistent symptoms:
- Intranasal corticosteroids + oral/intranasal antihistamines, oral LKTA or Intranasal cromolyn
- If symptoms persist: consider immunotherapy referral or alternative treatments (allergen avoidance, nasal irrigation, acupunture, probiotics, herbals)
1st line medical therapy for mild to moderate disease?
- Intranasal corticosteroids (work the best)
- All other treatments are 2ne line and should be reserved for failure of intranasal corticosteroids or moderate to severe disease not responding to them.
What are 2nd line therapies for allergic rhinitis?
- Antihistamines - oral and intranasal
- Leukotriene receptor antagonists
- Non-pharmacologic therapies (nasal irrigation)
Which class of anti-histamines are better for treating allegic rhinitis?
2nd generation, except for cetirizine, are less likely to cuase sedation and impair performance
What would you consider in patients with moderate to severe disease not responding to any first or second line treatments?
Immunotherapy - refer them to an immunologist.
What is the evidence for each of the following:
- Mite-proof impermeable covers
- Air filtration systems
- Delayed exposure to solid food in infancy
Typical symptoms of allergic rhinitis?
- Nasal congestion
- Nasal Obstruction
- Nasal pruritis
How do intranasal corticosteroids work in allergic rhinitis?
- Reduce inflammation of the nasal mucosa (via decreased inflammatory cells and cytokine release)
- Onset of action - 30 min
- Peak effect - several hours to days
- Maximum effectiveness - usually noted after 2-4 weeks of use
Possible side effects of intranasal corticosteroids?
- Throat irritation
- Nasal dryness
- Rhinitis medicamentoas
- *May reduce growth in children with long term use
- *No proven effect on HPA axis
Only intranasal corticosteroid with Category B (vs. C) rating in pregnancy?
- Beclomethasone (Beconase)
- All others are C
Method of action of oral antihistamines?
- Block H1 receptor. Onset 15-30 minutes.
- Intranasal - same MOA, onset 15 min.
Side effects of antihistamines?
- Oral - dry mouth, sedation at higher than recommended doses
- Intranasal - bitter aftertaste, epistaxis, headache, nasal irritation, sedation
Method of action of oral decongestants?
- Onset 15-30 minutes
Side effects of oral decongestants?
- Arrhythmias (tachycardia), dizziness, headache, hypertension, insomnia, tremor, nervousness, urinary retention
- *Not recommended in Pts with CV disease, glaucoma or hyperthyroidism
How does intranasal cromolyn work?
- Inhibits histamine release by stabilizing mast cells
- Usually need 1 week to work, often 2-4 weeks for full effect
Side effects of intranasal cromolyn?
- Epistaxis, nasal irritation, sneezing
- TID or QID dosing is inconvenient
What are intranasal anticholinergics MOA and which drug in particular? Minimum age?
Ipratropium (Atrovent), blocks Ach Rc, takes 15 min to work, minimum age of 6 years
Side effects of intranasal ipratroprium?
Epistaxis, headache, nasal dryness
What is the name of a LKRA? Onset of action?
- Singular, 2 hours onset, minimum age of 6 months
- *Only minimal improvement in nasal congestion, less effective than intranasal corticosteroids or antihistamines
Possible side effects of LKRA?
Elevated levels of ALT, AST, bilirubin
Effectiveness of anti-histamines for allergic rhinitis?
- Effective for sneezing, pruritis, rhinorrhea and ocular symptoms
- BUT less effective than intranasal corticosteroids at treating nasal congestion
How long should decongestants be used for?
Not recommended to exceed 3 to 5 days of use, because get rhinitis medicamentoas or rebound congestion.
Is combination therapy better?
- Combination therapy is no more effective than monotherapy with intranasal corticosteroids. But remains an option if severe or persistent symtpoms.
What is the only therapy that changes the natural course of allergic rhinitis?
- Targeted immunotherapy is the only treatment that chagnes the natural course of allergic rhinitis, preventing exacerabtions.
- Takes several years and effect lasts for 3-5 years
Non-pharmacologic treatments and their evidence?
- Acupuncture - no evidence to support or refute use
- Probiotics - no evidence currently
- Herbals - no evidence currently
- Avoidance/Environmental control - avoid cigarette smoke, pets, allergens
- Nasal irrigation for chronic rhinorrhea