Allergic Rhinitis

Allergic Rhinitis four phases

Sensitization phase

Early phase

Cellular Recruitment phase

Late phase

Sensitization phase

Follows initial exposure

ONLY HAPPENS ONCE

IgE production

No symptoms

Early phase

The second reaction and any subsequent reactions begin at phase 2

Occurs within minutes

Mast cell mediators - histamine and proteases

Inflammatory mediators - prostaglandins and leukotrienes

Cellular Recruitment phase

Eosinophils are attracted to the nasal mucosa

More inflammatory mediators are released

Late Phase

Begins 2-4 hours after allergen exposure

Mucus hypersecretion

Three classifications of allergic rhinitis

Intermittent

Persistent

Episodic

Intermittent Allergic Rhinitis (IAR)

Symptoms occur 4 or less days per week OR for less than four weeks

Persistent Allergic Rhinitis (PER)

Symptoms occur over 4 days per week AND for longer than four weeks

Episodic Allergic Rhinitis

Occurs upon exposure or contact with potential allergen

Therapy of allergic rhinitis is directed at this mediator produced in the early stage

Histamine

Allergic Rhinitis symptoms

Bilateral

Paroxysmal sneezing (several times in a row)

Watery rhinorreah (runny nose)

Itchy eyes, nose, and/or palate

Nasal obstruction

Conjunctivitis

Hallmark symptom of allergic rhinitis that allows for differentiation of symptoms from a common cold

Itching of the eyes, nose, and/or palate

Systemic symptoms of allergic rhinitis

Fatigue

Irritability

Cognitive impairment

Exclusions to self treatment of allergic rhinitis

Children under twelve years old

Symptoms of otitis media, sinusitis, or bronchitis

Symptoms of undiagnosed or uncontrolled asthma

Three types of treatment for allergic rhinitis

Avoidance of triggers

Pharmacotherapy

Immunotherapy

Nonpharm treatments of allergic rhinitis

Nasal saline sprays

Nasal irrigation

Nasal irrigation uses

Relieve nasal mucosal irritation and dryness

Neti pot - distilled, sterile, or boiled water

Pharmacologic treatments of allergic rhinitis

Intranasal corticosteroids

Antihistamines

Decongestants

Cromolyn Sodium

Saline nasal spray uses

Moistens irritated mucosal membranes

Loosens encrusted mucus

Can be sprayed upwards or dropped when held downwards

Ocean Premium Saline Nasal Spray API

NaCl 0.65%

Intranasal corticosteroids API

Budesonide, fluticasone, mometrasone, triamcinolone

Intranasal corticosteroids MOA

Inhibits multiple types of chemical mediators

Stops the allergic cascade

Intranasal corticosteroids uses

Itchy nose, sneezing, runny nose, congestion

To treat itchy and watery eyes this specific Intranasal corticosteroid is used

Fluticasone

These nasal corticosteroid APIs are the only treatments that should be used in children 2-4 years

Fluticasone furoate, mometasone furoate, and triamcinolone acetate

This nasal corticosteroid is approved for children over 4 years

Fluticasone proportionate

This nasal corticosteroid is approved for children over 6 years

Budesonide

Oral first generation antihistamine API

Brompheniramine, chlorpheniramine, diphenhydramine

Oral second generation antihistamine API

Fexofenadine, loratidine, cetirizine, levocetirizine

Topical antihistamine API

Azalastine

Cetirizine, levocetirizine

Antihistamine MOA

Competes with histamine at central and peripheral histamine type 1 receptor sites

Prevents histamine-receptor interaction and subsequent mediator release

Second generation antihistamines inhibit the release of mast cell mediators

Antihistamine uses

Itching, sneezing, runny nose

Has no effect on nasal congestion

Antihistamine anticholinergic effects

Dry eyes and mucus membranes

Constipation

Urinary retention

Blurred vision

These two second generation antihistamines have a 10% change of sedation

Cetirizine and levocetirizine

This drug class must be stopped 14 days prior to antihistamine use

MAOIs

Fexofenadine food interaction

Fruit juice

Separate by 2 hours

This antihistamine API is first line in pediatric and geriatric patients

Loratidine

This antihistamine is first line in pregnant patients

Diphenhydramine / chlorpheniramine

Max benefit of Cromolyn is achieved after this duration

2-4 weeks

Cromolyn Sodium MOA

Prevents and treats symptoms of allergic rhinitis

Cromolyn should only be used in patients this age or older

2 years

Cromolyn Sodium dosing

1 spray in each nostril 3-6x daily at regular intervals

Cromolyn Sodium onset of action

3-7 days

No immediate relief

When patients should be referred

Symptoms do not decrease after 1-2 weeks of treatment

Signs and symptoms of a bacterial infection develop