Self Care - Allergic Rhinitis

Allergic rhinitis risk factors

upper respiratory system disorder; family history; elevated serum IgE > 100 IU/mL prior to age 6; high socioeconomic levels; eczema; positive allergy skin tests; diet (> fast food meals/week)

Allergic rhinitis allergy triggers

outdoor aeroallergens (pollen, mold spores); pollutants (ozone, tobacco smoke, diesel exhaust); indoor aeroallergens (dust mites, cockroaches, mold spores, pet dander); occupational allergens (wool dust, latex, resins, biologic enzymes, organic dusts (flour), various chemicals)

Four phases of allergic rhinitis

sensitization, early, cellular recruitment, late

sensitization phase

initial exposure; simulations of beta-lymphocyte-mediated IgE production

early phase

within minutes; rapid release of preformed mast cell mediators, production of new mediators

cellular recruitment phase

over time; eosinophils attracted to nasal mucosa and release more inflammatory mediators

late phase

2-4 hours past exposure; mucus hypersecretion secondary to submucosal gland hypertrophy and congestion

intermittent duration

symptoms occur < 4 days/week OR < 4 weeks

persistent duration

symptoms occur > 4 days per week AND > 4 weeks

episodic duration

symptoms occur if an individual is in contact with an exposure that is not normally a part of the individual’s environment

mild severity

symptoms do not impair sleep or daily activities, no troublesome symptoms

moderate/severe severity

one or more of the following occurs: impairment of sleep; impairment of daily activities; troublesome symptoms

Nonallergic rhinitis causes

hormonal (pregnancy, puberty); septal deviation; drug-induced (cocaine, beta-blockers, ACE-Is, clonidine, hydralazine, oral contraceptives, ASA, NSAIDs, topical decongestant OVERUSE); eosinophilic nonallergic rhinitis (NARES); nasal polyps; facial or head trauma; autonomics (age, physical or chemical agent)

Nonallergic rhinitis differences from allergic rhinitis

not always bilateral symptom; little to no sneezing; no pruritis of eyes, nose and/or palate; nasal obstruction is usually present; no conjunctivitis; variable; recurrent epistaxis (nose bleed)

Allergic rhinitis symptoms

bilateral symptoms, worse upon waking; frequent sneezing; anterior, watery rhinorrhea; frequent pruritus of eyes, nose, and palate; frequent conjunctivitis; sinus or throat pain; allergic shiners (darkness under eyes); Dennie’s lines (wrinkles below lower eyelids); allergic crease; allergic salute; allergic gape

Allergic rhinitis treatment goals

reduce symptoms; improve patient’s functional status; improve patient’s sense of well being; individualize treatment to provide optimal symptomatic control

allergic rhinitis steps for treatment

allergen avoidance; pharmacotherapy; immunotherapy

Non-pharm therapy for allergic rhinitis

avoid irritants (dust mites, mold spores, pet dander, cockroaches, pollutants, pollen); ventilation systems with high-efficiency particular air (HEPA) filters (change filters regularly); weekly vacuuming of carpets, drapes, etc.; nasal wetting agents and nasal irrigation

Nasal Wetting Agents and Nasal Irrigation

decreases stuffiness, rhinorrhea, and sneezing; only use distilled, sterile, or boiled tap water in nasal irrigation to avoid serious infection

Exclusions for self care for allergic rhinitis

children less than 12 years; pregnant or lactating women; symptoms of nonallergic rhinitis; symptoms of otitis media, sinusitis, bronchitis, or other infections; symptoms of undiagnosed or uncontrolled asthma or other lower respiratory disorder (wheezing, SOB); severe or unacceptable side effects of treatment

Pharmacologic therapy for allergic rhinitis

intranasal corticosteroids; antihistamine; decongestants; cromolyn sodium

Intranasal Corticosteroid examples

fluticasone (Flonase); triamcinolone (Nasacort); budesonide (Rhinocort)

Intranasal Corticosteroids

aka glucocorticoids; effective for itching, rhinitis, sneezing, congestion

intranasal corticosteroid MOA

inhibit multiple mediators including histamine; stop allergic cascade

Intranasal corticosteroids dose

1-2 sprays in each nostril once daily

intranasal corticosteroid adverse effects

generally well tolerated; nasal discomfort, bleeding, sneezing, cough; possibly dizziness, nausea, vomiting

Antihistamines MOA

compete with histamine at central and peripheral histamine (H1) receptor sites, preventing mediator release

Two types of antihistamines

first generation (nonselective) and second generation (partially selective)

First generation antihistamines

sedating; risk of anticholinergic side effects

Second generation antihistamines

non-sedating; also inhibit release of mast cell mediators and may decrease cellular recruitment

First generation antihistamine examples

diphenhydramine (Benadryl) and chlorpheniramine

Diphenhydramine (Benadryl) dosing

25-50 mg every 4-6 hours; 300 mg maximum daily dose

Chlorpheniramine dosing

4 mg every 4-6 hours; 24 mg maximum daily dose

Second generation antihistamine examples

loratadine (Claritin); cetirizine (Zyrtec); fexofenadine (Allegra); levocetirizine (Xyzal)

Loratadine (Claritin) dosing

10 mg every 24 hours

Cetirizine (Zyrtec) dosing

10 mg every 24 hours

fexofenadine (Allegra) dosing

180 mg every 24 hours OR 60 mg every 12 hours

levocetirizine (Xyzal) dosing

5 mg every 24 hours

Intranasal antihistamines

newer OTC class; one product available

intransal atihistamine dosing

1-2 spray in each nostril twice daily OR 2 sprays in each nostril daily

intranasal antihistamine adverse effects

bitter taste, runny nose, headache, sedation possible (use daily at night time if this occurs)

Intranasal antihistamine example

azelastine (Astepro)

First generation antihistamine adverse effects

anticholinergic side effects (dryness of mucous membranes, blurred vision, urinary hesitancy and retention, constipation, reflex tachycardia); overdose may result in cardiac symptoms; sedating; agitating in children; contraindicated in newborns, lactating women, narrow-angle glaucoma, acute asthma, or COPD

second generation antihistamine adverse effects

typically well tolerated; may cause sedation (especially cetirizine); dryness

Antihistamine Combination products

marketed with decongestants and analgesics; more convenient dosing; may cause more adverse effects or unnecessary drug administration

Decongestant

systemic decongestants; topical nasal decongestant (short term only)

Cromolyn Sodium

mast cell stabilizer; less than 7% is absorbed systemically (no systemic activity); no drug interactions

Cromolyn Sodium indication

prevention and treatment of allergic rhinitis symptoms

cromolyn sodium MOA

blocks influx of calcium into mast cells, preventing mediator release

cromolyn sodium dosing

1 spray in nostril 3-6 times daily; more effective if started before symptoms begin

cromolyn sodium adverse effects

sneezing (most common), nasal stinging, burning

Pregnancy

causes nonallergic rhinitis; if allergic rhinitis is present: intranasal cromolyn 1st line (low absorption); Benadryl and chlorpheniramine compatible; Xyzal, Claritin, and Zyrtec have low risk of fetal adverse effects; Allegra is moderate risk

Lactating women

intranasal cromolyn 1st line; antihistamines contraindicated

Children less than 12 years old

refer due to risk of undiagnosed asthma; if approved by physician many products available for children

Products available for approved children

cromolyn, fluticasone furoate, triamcinolone > 2 years; fluticasone propionate > 4 years; budesonide > 6 years; Loratadine is first choice, then fexofenadine, levocetirizine, and cetirizine; avoid 1st generation antihistamines

Older adults

avoid 1st generation antihistamines (fall risk, confusion, hypotension); cromolyn and loratadine are drugs of choice; fexofenadine and levocetirizine need renal dose adjusted; loratadine and cetirizine need renal and hepatic dose adjusted