OTC: Allergic Rhinitis

Allergic Rhinitis Patho

IgE mediated immune response

• allergen exposure early phase rhinorrhea

• late stage congestion, post-nasal drop

lowers threshold for allergic mediated triggers in future

Allergic Rhinitis Signs

• bilateral symptoms

• sneezing

• runny nose - thin, watery mucus

• conjunctivitis

• sinus pain

• allergic shiners/dennie’s lines

Nonallergic Rhinitis Signs

cold, flu, infection, etc

• unilateral

• severe nasal obstruction

• thick nasal drip

Exclusions to Self Care

• < 12 years* unless PCP recommends

• Pregnant/Lactation* unless PCP recommends

• symptoms of nonallergic rhinitis

• infection symptoms (fever, etc)

• respiratory symptoms (COPD, asthma)

Classification of Allergic Rhinitis

1. Intermittent: < 4 days OR week < 4 weeks symptoms

2. Persistent: > 4 days AND > 4 weeks

Allergic Rhinitis Treatment Algorithm

begin ahead of allergen exposure

Non-pharm approaches to AR

• Nasal irrigation

  • isotonic/hypertonic saline

  • neti pots, bulb syringes

• Allergy Testing

Intranasal Corticoids

first line for allergic rhinitis treatment

• Triamcinolone, Fluticasone, Budesonide

moa: decreases mediators of inflammation

intranasal corticosteroid counsel points

• proper nasal spray administration needed

• potential to slow children growth rates with continued use

• drug interactions: CYP3A4 inhibitors

  • systemic azole antifungals

  • protease inhibitors (HIV)

Triamcinolone Dosing

• Nasacort

Adults and Children > 12 years of age

• 2 sprays in each nostril

Children 6 - 12 years

• 1 or 2 spray

Children 2 - 5 years (can use with very young children)

• 1 spray

Children < 2 years → do not use

Fluticasone Dosing

• Flonase

Adults and Children > 12 years of age

• 2 sprays in each nostril

Children 4 - 11 years of age

• 1 spray

Children < 4 years of age

Budesonide Dosing

• Rhinocort

Adults and Children > 12 years of age

• 2 sprays in each nostril

Children 6 - 12 years

• 1 spray can be 2 spray in each

Children < 6 years of age: do not use

Oral Antihistamines

2nd Generation: non-sedating antihistamines for allergic rhinitis

• Fexofenadine (allegra)

• Loratadine (claritin)

• Cetirizine (Zyrtec)* drowsy effect

less lipophilic = less CNS penetration = less sedation

→ anti-cholinergic effects

Ocular Antihistamines

use for eyes that are: itching, redness, and watery

• Ketotifen (Alaway, Zaditor)

Olopatadine (Pataday)

H1- antihistamine ocular drops

• relief of itchy eyes caused by allergic rhinitis

• remove contact lenses prior and wait >10 minutes

Astepro azelastine hydrocholoride

novel antihistamine nasal spray

Cromolyn

intranasal mast-cell stabilizer

• long onset

• multiple times a day dosing

very safe for special populations for treating allergic rhinitis

Children < 12 years of age Population

once approved by PCP

• loratadine drug of choice for pediatrics

• limit use of intranasal corticosteroids (growth limiting)

Elderly Population

loratadine drug of choice

• avoid first-generation antihistamines

  • BEER’s sedation and anticholinergic criteria

Pregnancy Population

must be approved by PCP first

• chlorpheniramine and diphenhydramine are first line

  • first generations

• do not use fexofenadine, budesonide, and triamcinolone

Lactation Population

antihistamines are contraindicated

• if needed: short acting

• chlorpheniramine, fexofenadine, and loratadine (short acting)

Complimentary Therapies for Allergies

• whey protein

• local honey

• bromelain

• butterbur

• feverfew (?)

• antigen containing products