Allergic Rhinitis

Allergic Rhinitis (Hay Fever) MOA

IgE-mediated inflammatory response of the nasal mucosa after exposure to inhaled allergen

Allergic Rhinitis (Hay Fever) Symptoms

Often accompanied by symptoms involving the eyes, ears, and throat

* Nasal congestions
* Rhinorrhea (anterior or posterior)
* Sneezing
* Itching

Allergic Rhinitis (Hay Faver) Onset

* Onset in childhood, adolescence, and early adulthood
* Often wane, but can persist

Allergic Rhinitis (Hay Fever) Predisposing Factors

* Genetic susceptibility
* Atopy: the inherited tendency to develop IgE-mediated immune responses

Allergic Rhinitis (Hay Fever) Pathophysiology

* Step 1: Sensitization
* Allergen-specific IgE produced by B-lymphocytes
* Step 2: Early phase reaction
* Occurs within minutes
* Upon re-exposure to allergen
* Mast cell degranulation and mediator release
* Step 3: Late phase reaction
* Occurs hours to days after exposure
* Influx of inflammatory cells

Seasonal Allergic Rhinitis

* Episodic/intermittent
* Caused by:
* Pollen
* Molds
* Occasional animal exposures

Seasonal Allergic Rhinitis Symptoms

* Sneezing
* Rhinorrhea
* Itching
* Watery eyes
* Conjunctivitis

Perennial Allergic Rhinitis

* Persistent
* Common causes:
* Dust mites
* Animal dander
* Cockroaches
* Molds

Perennial Allergic Rhinitis Symptoms

* Congestion
* Post-nasal drip
* Cough
* Malaise
* Fatigue

Perennial Allergic Rhinitis: Physical Findings

* Allergic shiners
* Allergic salute
* Nasal crease
* Mouth breathing

Allergic Rhinitis Diagnostic Testing

* Skin Tests
* Blood Tests

When to Recommend Allergic Rhinitis Diagnostic Testing

* Clinical diagnosis, but inadequate response to empiric therapy
* Diagnosis is uncertain
* Allergen knowledge to aid in avoidance or treatment

Allergic Rhinitis Skin Tests

* Skin prick or intradermal
* More sensitive and less expensive than blood
* Can rarely trigger severe reactions
* Medications can interfere

Allergic Rhinitis Blood Tests (IgE Assays)

* Less sensitive, but more convenient than skin test
* No need to discontinue medications
* No risk anaphylaxis

Therapeutic Goals

* Reduce or prevent symptoms and their impact
* Prevent complications

How to Achieve Allergic Rhinitis Goals

* Accomplished by:
* Allergen avoidance
* Pharmacotherapy
* Immunotherapy

Pharmacotherapy

* Corticosteroids
* Leukotriene antagonists
* Antihistamines
* Mast cell stabilizers
* Decongestants
* Anticholinergics

Most Effective Class to Treat Allergic Rhinitis

Nasal Corticosteroids

Nasal Corticosteroids Treatment: Indications, Guidelines

* __**First line**__
* Treat congestion, sneezing, rhinorrhea, pruritus, cough, conjunctivitis
* Guidelines highly recommend if symptoms affect quality of life

Nasal Corticosteroids Drugs

* Beclomethasone dipropionate (Rx)


* Budesonide (OTC)
* Ciclesonide (Rx)
* Flunisolide (Rx)
* Fluticasone furoate (OTC)
* Fluticasone propionate (Rx/OTC)
* Mometasone furoate monohydrate (Rx/OTC)
* Triamcinolone acetonide (OTC)

What Cells Do Nasal Corticosteroid Act On?

* Effects on multiple mediators
* Prostaglandins
* Leukotrienes
* Mast cells
* T-lymphocytes

Nasal Corticosteroid Effects

* Treat inflammatory component
* ↓ inflammatory cell infiltration
* ↓ epithelial permeability
* ↓ response to cholinergic stimulation
* ↑ vascular sympathetic tone
* ↓ nasal hyperreactivity

Nasal Corticosteroids Initial Relief and Maximum Benefit

* Initial Relief: 4-12 hours
* Maximum Benefit: 2 weeks
* Can use with topical decongestant initially

Nasal Corticosteroids: Differences Between Agents

* Frequency of administration
* Formulations
* Bioavailability
* Cost

Nasal Corticosteroids: Differences Between Formulations

* Propellants, propylene glycol
* Influence tolerability
* Stinging, taste

Nasal Corticosteroids: Differences Between Bioavailability

* Fluticasone and mometasone lower systemic bioavailability
* More lipophilic
* Faster absorption
* Lower potential for systemic adverse effects

Nasal Corticosteroids Differences: Cost, Frequency, Age, Formulation

Nasal Corticosteroids Local Adverse Effects

* Stinging
* Burning
* Dryness
* Sneezing
* Epistaxis
* Nasal septum perforation

Nasal Corticosteroids Systemic Adverse Effects

RARE

* Growth velocity
* Immune suppression
* Adrenal suppression
* Hypersensitivity reactions

Leukotriene Antagonists Drugs

Montelukast (Singulair)

Leukotriene Antagonists Indications

Seasonal allergic rhinitis in patients 2 years of age and older

Leukotriene Antagonists Treatment

Treatment of:

* Nasal congestion
* Rhinorrhea
* Sneezing
* May reduce ocular symptoms

Leukotriene Antagonists Guideline Recommendations

* Guidelines recommend nasal corticosteroid over montelukast for allergic rhinitis
* As monotherapy
* comparable to or inferior to oral antihistamines
* inferior to nasal corticosteroids
* In combination with antihistamine inferior to nasal corticosteroid

Leukotriene Antagonist Precautions

* Psychiatric
* Suicidal thoughts and actions
* Hallucinations
* Insomnia
* Irritability
* Aggression
* Agitation

Leukotriene Antagonist Adverse Reactions

* Headache
* Upper respiratory infections

Systemic Antihistamines

* Histamine-1 receptor antagonists
* Historically the mainstay of therapy
* Rapid onset, but best results when taken continuously

Systemic Antihistamines Indications

* Sneezing
* Rhinorrhea
* Itching
* Conjunctivitis

Systemic Antihistamines Guidelines

Non/Low-sedating systemic antihistamines are recommended in guidelines if primary complaint is sneezing and itching

Sedating Systemic Antihistamines

* Clemastine (Rx/OTC)
* Chlorpheniramine (OTC)
* Brompheniramine (Rx/OTC)
* Diphenhydramine (Rx/OTC)

Non-Sedating Systemic Antihistamines

* Fexofenadine (OTC)
* Desloratadine (Rx)

Low Sedating Systemic Antihistamines

* Cetirizine (Rx/OTC)
* Levocetirizine (Rx/OTC

Systemic Antihistamines Adverse Effects: Sedating Antihistamines

* Sedation
* Cognitive impairment
* Anticholinergic
* Dry mouth
* Urinary retention

Systemic Antihistamines Adverse Effects: Low/Non-Sedating Antihistamines

* Fewer ADRs
* Lack anticholinergic effects

Intranasal Antihistamines Drugs

* Azelastine (Rx/OTC) & Olopatadine (Rx)
* Azelastine HCl/Fluticasone propionate (Rx)
* Olopatadine HCl/Mometasone furoate (Rx)

Intranasal Antihistamines Indications

* Sneezing, rhinorrhea, itching
* May also reduce congestion (due to mast cell stabilizing activity)
* Can be used first line in combination with nasal corticosteroids

Intranasal Antihistamines Adverse Effects

* Sedation
* Bitter taste
* Stinging
* Headache

Systemic Decongestants

* Sympathomimetics
* Alpha adrenergic agents produce nasal vasoconstriction

Systemic Decongestants Drugs

Pseudoephedrine & phenylephrine

Systemic Decongestants Indications

Nasal congestion

Systemic Decongestants Adverse Reactions

* Hypertension
* Restlessness
* Tremor
* Insomnia
* Headache
* Urinary retention
* Palpitations

Systemic Decongestants: Phenylephrine

* Phenylephrine ineffective orally
* No better than placebo when studied as prompt and extended-release forms at doses up to 40 mg every 4 hours

Systemic Decongestants: Phenylephrine Alternatives

* Pseudoephedrine
* Topical nasal decongestants

Systemic Decongestants Cautions

* Glaucoma (closed-angle
* Hypertension
* Cardiovascular disease
* Urinary retention, BPH
* Antidepressants __**(MAOI-contraindicated)**__
* Hyperthyroidism
* Diabetes

Antihistamine/Decongestant: Sedating Drugs

* Acrivastine/pseudoephedrine – Rx
* Brompheniramine/pseudoephedrine – OTC
* Chlorpheniramine/phenylephrine – OTC
* Promethazine/phenylephrine - Rx

Antihistamine/Decongestant: Non-Sedating Drugs

* Cetirizine/pseudoephedrine – OTC
* Desloratadine/pseudoephedrine - Rx
* Fexofenadine/pseudoephedrine – OTC
* Loratadine/pseudoephedrine – OTC

Topical Nasal Decongestants Drugs

* Oxymetazoline
* Phenylephrine
* Tetrahydrozoline
* Xylometazoline

Topical Nasal Decongestants Compared to Systemic Decongestants

* More rapid
* More effective
* Fewer systemic side effects

Rhinitis Medicamentosa

* Rebound congestion
* Occurs after 5-10 days of therapy
* Down regulation of alpha receptors
* Limit use to 3-5 days

Rhinitis Medicamentosa Treatment

* DC topical decongestants (can taper)
* Nasal corticosteroids
* Oral corticosteroids

Nasal Mast Cell Stabilizers Drugs

Cromolyn (Nasalcrom, generic) OTC

Mast Cell Stabilizer

* Blocks early & late phase reaction
* Inhibits mast cell degranulation
* Prevents mediator release
* Effects persist 4-8 hours after administration

Mast Cell Stabilizer Indications

* Prevents / relieves sneezing


* Rhinorrhea
* Congestion
* Pruritus

Nasal Cromolyn Adverse Effects

* Sneezing
* Burning

Nasal Cromolyn Dosing

* 4-6 times per day
* Use before exposure to allergen

Allergic Rhinitis Treatment: Other Therapies

* Oral corticosteroids (5-7 days)
* Anticholinergics
* Saline nasal spray/solution

Saline Nasal Spray/Solution

* 1 qt water, 1-1½ tsp kosher or pickling salt, 1 tsp baking soda
* NeilMed sinus rinse kit
* Use distilled, sterilized or previously boiled water

Ocular Allergy Symptoms: Systemic Therapies

* Antihistamines
* Nasal corticosteroids
* Leukotriene antagonists

Ocular Allergy Symptoms: Ophthalmic Agents

* Mast cell stabilizers
* Antihistamines
* Mast cell stabilizers/Antihistamines


* Decongestants
* Decongestants/Antihistamines
* NSAIDs
* Corticosteroids

Ophthalmic Agents Administration

* Allow 5 - 10 minutes between drops
* Nasolacrimal occlusion

Ophthalmic Agents: Contact Lenses

* Benzalkonium chloride
* Discolors leneses
* Allow 15 minutes before insert contacts

Ophthalmic Mast Cell Stabilizer Drugs

* Bepotastine (Bepreve)
* Cromolyn
* Lodoxamide (Alomide)
* Nedocromil (Alocril)

Ophthalmic Mast Cell Stabilizer Indication

Most effective as prophylaxis

Ophthalmic Mast Cell Stabilizer Adverse Effects

* Burning and stinging on instillation
* Headache

Ophthalmic Antihistamines Drugs

* Emedastine (dc’d)
* Cetirizine (Zerviate)

Ophthalmic Antihistamines

* Rapid onset
* Itching relief

Ophthalmic Antihistamines Adverse Effects

* Burning and stinging on instillation
* Fatigue
* Dry mouth
* Headache

Ophthalmic Mast Cell Stabilizers/Antihistamines Drugs

* Alcaftadine (Lastacaft)
* Azelastine (Optivar, generic)
* Epinastine (generic)
* Ketotifen
* Olopatadine (Pataday, Patanol)

Ophthalmic Mast Cell Stabilizers/Antihistamines Onset

Rapid onset

Ophthalmic Mast Cell Stabilizers/Antihistamines ADE

* Stinging and burning on instillation
* Bitter taste
* Headache

Ophthalmic Decongestants Drugs

* Naphazoline
* Oxymetazoline
* Phenylephrine
* Tetrahydrozoline

Ophthalmic Decongestants Onset

Rapid Onset

Ophthalmic Decongestants Indications

Decrease itching and redness

Ophthalmic Decongestants Adverse Effects

* Stinging/burning
* Decreased accommodation
* Blurred vision
* Pupil dilation
* Rebound vasodilation

Ophthalmic Decongestants Cautions

* __**Short term use only!!**__
* Hypertension
* Heart disease
* Narrow-angle (angle-closure) glaucoma

Ophthalmic Decongestant/Antihistamines

__**SHORT-TERM USE**__

* Naphazoline/pheniramine maleate

Ophthalmic Decongestant/Antihistamines Onset

Rapid onset

Ophthalmic Decongestant/Antihistamines Effectiveness

* More effective than decongestant
* Less effective than Rx antihistamine

Ophthalmic Decongestant/Antihistamines Adverse Effects

* Stinging/burning
* Decreased accommodation
* Blurred vision
* Pupil dilation
* Rebound vasodilation

Ophthalmic Decongestant/Antihistamines Cautions

* __**Short term use only!!**__
* Hypertension
* Heart disease
* Narrow-angle (angle-closure) glaucoma

Ophthalmic NSAIDs Drug

Ketorolac (Acular)

Ophthalmic NSAIDs Indication

Relieves ocular itching

Ophthalmic NSAIDs Adverse Effects

* Stinging/burning (20-40%)
* Allergic reactions
* Ocular irritation/inflammation

Ophthalmic NSAIDs Cautions

* Cross-sensitivity aspirin/NSAIDs
* Bleeding

Immunotherapy (“Allergy Shots”)

* Administration of specific allergens extract
* Relieves symptoms 3+ years after discontinue injections
* Effective in allergic rhinitis caused by tree pollens, grass pollens, weed pollens, mold spores, dust mites, and animal dander

Immunotherapy (“Allergy Shots”) Are Considered When

* Allergen exposure is unavoidable
* Allergic response all year or most of the year
* Difficulty treating pharmacologically
* Significant potential benefit (children and young adults)

Immunotherapy (“Allergy Shots”) Guidelines

Guidelines recommend referring for potential immunotherapy if inadequate response to pharmacologic therapy

Immunotherapy (“Allergy Shots”) Process

1-2 injections weekly (dose-building), then tapered to once monthly

Immunotherapy (“Allergy Shots”) Cautions

* Major risk: anaphylaxis
* Beta-blocker therapy – reduce epinephrine response
* Chronic medical conditions that reduce ability to survive a reaction

Sublingual Immunotherapy vs Injection

* Timothy grass pollen allergen extract sublingual tablet (Grastek, Merck)
* Sweet vernal, orchard, perennial rye, Timothy, and Kentucky blue grass mixed pollens allergen extract sublingual tablet (Oralair, Stallergenes)
* Short ragweed pollen allergen extract (Ragwitek, Merck)
* House dust mite allergen extract sublingual tablet (Odactra, ALK)

Immunotherapy: Injection vs Sublingual

Sublingual safer