Self Care Exam 2 - Allergy

Allergic Rhinitis - Murray Lecture Objectives: 1. List common presenting symptoms of allergic rhinitis. a. Allergies = inflammatory IgE-mediated disease characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, or nasal itching i. Inflammation caused by allergen b. Classifying i. Intermittent + ii. Mild + persistent moderate-severe 1. Symptoms 1. Symptoms >4days/week <4days/week or >4 weeks or <4 weeks 2. Normal sleep 2. Abnormal 3. No impairment sleep of daily 3. Impairment of activities daily activities 4. Normal 4. Problems at work/school work/school 5. No 5. Bothersome bothersome symptoms symptoms c. Risk factors i. Family history ii. Asthma iii. Atopic dermatitis/eczema iv. Higher socioeconomic status d. Protective Factors i. Multiple older siblings ii. Growing up in farming environment e. Symptoms i. ii. iii. f. cough/clearing throat v. Runny nose Sore throat vi. Red eye/lacrimation Hearing,smell,taste vii. Sneezing alterations viii. rash/itching iv. Mood changes ix. Fatigue Consequences → leading to impaired quality of life and even surgery i. Acute 1. Sinusitis → sinus infection 2. Otitis media with effusion → ear infection ii. Chronic 1. Nasal polyps → skin bumps 2. Sleep apnea → trouble sleeping 3. Hyposmia → loss of smell 2. Recommend appropriate pharmacotherapy for allergic rhinitis. a. NONPHARM tx OPTIONS i. Allergen avoidance 1. Indoor a. Cover pillows and mattress with plastic/dust shield b. Use animal products instead of synthetic products c. Remove items that collect dust → wicker, drapes, carpets d. Washbedding twice weekly, floors daily, empty dust filters 2. Outdoor a. Avoid activities that disturb decaying material → raking leaves, compost b. Watch the air quality index c. Plan outdoor activities when there is a low pollen count d. Close windows during high pollen count b. PHARMACOLOGIC i. Flow chart 1. If mild OR mod-severe → intranasal corticosteroid = starting point 2. If moderate severe and intranasal corticosteroid alone doesn't work → intranasal corticosteroid + intranasal antihistamine → then allergy testing or immunotherapy. 3. If congested → intranasal or oral decongestant ii. Intranasal corticosteroids 1. MOA = reduction in inflammatory mediators and cytokine release within nasal cavity 2. TX = nasal congestion, sneezing, itching 3. ADR = local effects of burning, dryness, bloody nose headache, nasal drip, bad aftertaste. 4. Generics a. Beclomethasone - Rx b. Budesonide - OTC c. Ciclesonide - Rx → oldest tx >12yo d. Fluticasone propionate - OTC e. Fluticasone furoate - OTC f. Mometasone furoate - Rx g. Triamcinolone acetonide - OTC → youngest tx >2yo iii. Antihistamines → nasal or oral 1. MOA = block the action of histamine at H1 receptor 2. TX = sneezing or itching iv. v. vi. 3. ADR = anticholinergic (dry eyes, dry mouth, urinary retention, constipation, decreased gastric emptying), CNS confusion and drowsy 4. Generics a. 1st gen i. Diphenhydramine - OTC ii. Chlorpheniramine - OTC b. 2nd gen i. Cetirizine - OTC ii. Desloratadine - RX iii. Fexofenadine - OTC iv. Levocetirizine - OTC v. Loratadine - RX c. Intranasal i. Azelastine - RX ii. Olopatadine - EX Leukotriene receptor antagonist 1. MOA = inhibit cysteinyl leukotriene receptors → decrease mucus secretion, bronchodilation, no plasma exudation, no eosinophil recruitment 2. TX = beneficial in allergic rhinitis + asthma patients 3. ADR = headache, neuropsychiatric events 4. Generic i. Montelukast >6mo - RX Decongestants 1. MOA= vasoconstriction of respirator mucosa and bronchial relaxation 2. TX = nasal congestion 3. ADR = insomnia, headache, dry mouth, nervousness, increased BP, elevated HR 4. Generics a. Pseudoephedrine >4yo - OTC behind counter - need ID b. Phenylephrine >2/>4yo - OTC c. Oxymetazoline >6yo - OTC Immunotherapy 1. MOA = down-regulates allergic response in an allergen specific manner 2. ADR = anaphylaxis, injection rite reaction, oral itching and discomfort 3. CONTRA = uncontrolled asthma and Beta blocker use 4. Generics - both SQ and SL options a. Oralair - grass pollen b. Grastek - grass pollen c. Rageiwek - ragweed d. Odactra - house dust mites 3. Recall Clinical PEARLS a. Intranasal corticosteroid i. Tilt head forward, shake and prime ii. Up to 36h to see effect iii. Better efficacy if used more often iv. Better than oral antihistamines and leukotriene v. Begin 7 days before pollen season vi. Systemic- growth suppression in children b. Antihistamines i. Tolerance can develop ii. Maximal benefit when taken continuously iii. Quick onset of action iv. Oral antihistamines < intranasal corticosteroids c. Leukotriene Receptor antagonist i. Beneficial in patient with allergic rhinitis and asthma ii. Limited benefit as monotherapy iii. Most expensive option iv. Inferior to nasal steroids d. Decongestants i. Nasal spray is associated with rebound congestion after 3 days ii. Only in combinations e. Immunotherapy i. Therapy is tailored based on a patient specific allergen ii. Benefit lasts up to 3 years after discontinuation 4. Recognize contraindications, and drug-drug interactions for antihistamines, intranasal corticosteroids, leukotriene receptor antagonists, and decongestants. a. Antihistamine i. NO fexofenadine with fruit juice b. Immunotherapy i. NO uncontrolled asthma patients ii. NO beta blocker patients 5. Self-care Treatment PEARLS a. NO OTC self-care i. Children <12yo unless diagnosed ii. pregnant/lactating women iii. Symptoms of infection iv. Uncontrolled asthma or COPD v. Uncontrolled symptoms after 2-4weeks of therapy b. COMBOS i. Combination of oral antihistamines with intranasal steroid are NOT recommended ii. Oral antihistamines preferred for EPISODIC environmental episodes or intermittent mild symptoms