Rhinitis

Symptoms of seasonal allergies:

→Common: Sneezing, nasal symptoms

Sometimes: sore throat, headaches, feeling tires or weak

Rare: Cough, loss of taste/smell

Rhinosinusitis

→Chronic, persists 12 or more weeks

2 or more of swallowing symptoms:

•Nasal obstruction/discharge→ Discolored, thick, foul smell/taste

•Facial pressure/pain/fullness

•Impaired sense of smell

•Fatigue

What drugs induce rhinosinusitis

Alpha Blockers→ Doxazosin, terazosin, Prazosin

Topical decongestants→ Oxymetazoline

PDE5 Inhibitors→ Sildenafil, Verdenafil, Tadalafil, Avanafil

Aspirin & Exacerbated Rhinosinusitis

→Increased severity & worsening with exposure to ASA/NSAID

Rhinitis in the elderly

→Be cautious with antihistamine use

→Diphenhydramine can worsen dementia

Allergic rhinitis symtpoms and types

→Symptoms: nasal congestion, rhinorrhea, sneezing, itching

→Seasonal, Perennial, Episodic

Tree pollen peak time

May

Grass Pollen peak time

June

Ragweed Pollen peak time

August-October

Alternaria mold peak time

Intermittent: june, august, sept, november

What is the preferred and most effective treatment for allergic rhinitis?

→Intranasal Corticosteroids 

→More effective than nasal and ophthalmic antihistamines for all symptoms

Onset of action for INCS

3-5 hours to 36 hours, may take up to 1 week for full efficacy

Which INCS have the least systemic bioavailability

Second gens-

Ciclesonide

Mometasone

Fluticasone

What to use before INCS if nasal crusting?

Liquid Saline

INCS adverse effects

Local- Dryness, burning, sneezing, cough, headache

Systemic- Ocular changes, slower growth rate

Oral antihistamines

No tolerance for symptom relief

Fast onset

SECOND GENS ARE PREFERRED: Cetirizine(Zyrtec), desloratadine(Calrinex), Fexofenadaine(Allegra)

Topical antihistamines

Azelastine, Olopatadine,

For immediate relief

Symptom relief → Rhinorrhea, sneezing, nasal itching

Topical antihistamine/INCS

Dymystia→ Azelastine/Fluticasone

Oral Decongestants

Sudafed, Phenylephrine

Topical decongestants

Oxymetazoline, Phenylephrine, Propylhexedrine (stimulant high-can be abused)

Decongestants max time and AEs

3-5 days max to prevent rebound congestion

AEs: Insomnia, increased BP, irritability, headaches

Anticholinergics

Not first line

Ipratropium nasal spray→ Releives rhinorrhea

AEs: headaches, nasal dryness, nosebleed

Mast Cell Stabilizers

Cromolyn nasal spray

Limited efficacy, well tolerated

All immunotherapy must have ________________________

auto-injectable epinephrine

Immunotherapy contraindications

Beta-blockers and ACE inhibitors

SLIT vs SCIT

→SLIT is safer, comfier and convenient!

→SCIT ensures adherence and is more effective

Treatment alogrithm for allergic rhinitis