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Allergic RhinitisBROOKE BENTLEY, PHD, APRN

Allergic Rhinitis (AR)

� Goals of therapy are to prevent or minimize the symptoms of:

� Rhinorrhea

� Congestion

� Nasal pruritis

� Sneezing

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AR: Intranasal Corticosteroids

� fluticasone (Flonase)

� MOA: Inhibits the influx of inflammatory cells

� Symptoms treated: nasal congestion & pruritis, rhinorrhea, sneezing

� AE:

� Bitter aftertaste

� Burning/nasal dryness/epistaxis

� Potential risk of systemic absorption

� *** can use aqueous base to help decrease AE

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Steps for using a pump bottle/nasal spray

� Gently blow your nose to clear it of mucus before using the medication.

� Remove the cap. ...

� Tilt your head forward slightly. ...

� Hold the pump bottle with your thumb at the bottom and your index and middle fingers on top. ...

� Use right hand for left nostril (and vice versa), put tip just inside nose and aim toward outside wall…

� Squeeze the pump as you begin to breathe in slowly through your nose.

� Try not to sneeze or blow your nose just after using the spray.

� Remember, it may take up to 2 weeks of using a nasal steroid spray before you notice the full effects.

AR: Oral Antihistamines

� Histamine is an important chemical mediator in immune & inflammation responses

� Histamine is found in most body tissues with high concentration in tissues exposed to environmental substances (skin, mucosal surface of nose, lungs & GI tract)

� Histamine is synthesized & stored in secretory granules of mast cells and basophils. It is released from these cells during immediate hypersensitivity reactions & cellular injury. Once released, histamine interacts with 3 types of histamine receptors:

� H1

� H2 (associated with increased gastric acid & pepsin) (H2 blockers: Zantac for PUD)

� H3 (being developed)

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Oral Antihistamines

� When H1 receptors are stimulated, major effects are:

� 1. increased permeability of capillaries (edema – nasal congestion)

� 2. contraction of bronchial & other smooth muscle

� 3. stimulation of sensory peripheral nerve endings (cause pruritis)

� 4. stimulation of vagus nerve endings to produce reflex bronchoconstriction & cough

Oral Antihistamines

� MOA: compete for H1 receptor sites (thus, decreasing allergic response)

� ***More effective if taken PRIOR to exposure to allergens b/c the drugs can occupy receptor sites before histamine is released

� Uses:

� 1. allergic rhinitis (symptoms treated: nasal, ocular & pharyngeal pruritis; sneezing, rhinorrhea, lacrimation)

� 2. dermatologic conditions (acute urticarial, contact dermatitis)

� 3. vascular (angioedema)

� 4. Miscellaneous:

� N/V

� Sleep

� Motion sickness

� Pre-procedure

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Oral Antihistamines

� AE: (more with first generation)

� 1. sedation/drowsiness (Take at HS; caution with ambulation esp in elderly, driving, operating machinery)

� 2. anticholinergic side-effects: dilated pupils, urinary retention, dry mouth, constipation

� Common Drugs:

� First Generation:

� diphenhydramine (Benadryl)

� chlorpheniramine (Chlor-Trimeton)

� promethazine (Phenergan)

� hydroxyzine (Vistaril)

� dimenhydrinate (Dramamine)

� Second Generation: (preferred with AR due to non-sedating)

� fexofenadine (Allegra)

� loratadine (Claritin)

AR: Intranasal Antihistamines

� Ex:

� azelastine (Astelin)

� Minimum age: 5 years

� olopatadine (Patanase)

� Minimum age: 6 years

� AE:

� Bitter aftertaste

� Epistaxis

� Headache

� Nasal irritation

� Sedation

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AR: Ophthalmic Antihistamine Drops

� olopatadine ophthalmic (Patanol) – Rx (very expensive -$107 - if no insurance)

� azelastine ophthalmic (Optivar) - Rx (very expensive - $232 – if no insurance)

� ketotifen ophthalmic (Zaditor) – OTC ($13)

� pheniramine/naphazoline (Visine A) – OTC ($7)

� AE:

� Burning

� Dry eyes

� Headache

AR: Oral/Nasal Decongestants

� Ex:

� pseudoephedrine (Sudafed) – PO (restrictions on OTC sales)

� phenylephrine (Sudafed PE) – PO (NO restrictions on OTC sales)

� oxymetazoline (Afrin) – nasal spray

� MOA:

� stimulates smooth muscle alpha adrenergic (arteries) receptors, producing vasoconstriction & reducing nasal congestion

� AE:

� Increased BP (***caution in patients with high BP)

� Tachycardia, palpitations

� Tremor, nervousness

� Nasal irritation/dryness (Nasal spray)

� Rebound congestion (Nasal spray: Do NOT use >3-5 days)

� Caution/contraindications: hypertension, CAD, glaucoma (narrow angle), MAO inhibitors

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AR: Mast Cell Stabilizers

� Ex:

� Nasal cromolyn (Nasalcrom)

� Minimum age: 2 years

� MOA:

� stabilizes mast cells & prevents the release of inflammatory substances (histamine) when mast cells are confronted with allergens

� Symptoms relieved: nasal pruritis & congestion; sneezing, rhinorrhea

� results typically noted in one week, but may take two to four weeks for full effect (best to initiate 2 weeks before allergies start)

� AE:

� Epistaxis

� Nasal irritation/burning

� Sneezing

� Bad taste

AR: Intranasal Anticholinergics

� Ex:

� ipratropium bromide nasal (Atrovent Nasal)

� Minimum age: 6 years (perennial allergic or nonallergicrhinitis); 5 years (seasonal allergic rhinitis)

� MOA: Blocks acetylcholine receptors, inhibiting nasal seromucousgland secretions

� Symptoms relieved: rhinorrhea

� AE:

� Epistaxis

� Headache

� Nasal dryness/irritation

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AR: Leukotriene Receptor Antagonist

� Leukotrienes = strong chemical mediators of bronchoconstriction & inflammation; leukotrienes also increase mucous secretion & mucosal edema

� Ex: montelukast (Singulair)

� Combo patient (AR & asthma)

� May be on antihistamines & LRA on tougher cases

� Minimum age: 6 months

� Tablets, chewable, granule pkt

� MOA: Blocks leukotriene receptors

� Symptoms treated: nasal pruritis & congestion; sneezing, rhinorrhea

� AE:

� Headache

� Nausea

� Elevated levels of alanine transaminase, aspartate transaminase, and bilirubin