Allergic Rhinitis: Comprehensive Overview PDF

Allergic Rhinitis A Comprehensive Overview for Clinical Pharmacy Students OTC Course 1445 Introduction to Allergic Rhinitis (AR) • Allergic rhinitis (AR) is an atopic disease characterized by symptoms of nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis. Classifi...

Allergic Rhinitis A Comprehensive Overview for Clinical Pharmacy Students OTC Course 1445 Introduction to Allergic Rhinitis (AR) • Allergic rhinitis (AR) is an atopic disease characterized by symptoms of nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis. Classification of AR Based on Duration: • Intermittent AR: Symptoms occur for less than four days per week or less than four weeks per year. • Persistent AR: Symptoms occur for more than four days per week and for more than four weeks per year. Based on Triggers: • Seasonal Allergic Rhinitis (SAR): Symptoms occur during specific seasons when certain allergens, such as pollen, are prevalent. • Perennial Allergic Rhinitis (PAR): Symptoms persist throughout the year, often due to indoor allergens like dust mites, pet dander, or mold. Risk factors • • • • Family history of atopy Male sex Presence of allergen-specific IgE, a serum IgE greater than 100 IU/mL before age 6 years Higher socioeconomic status Studies in young children have shown a higher risk of AR in those with an early introduction to foods or formula and/or heavy exposure to cigarette smoking in the first year of life Factors identified that may have a protective effect on the development of AR: • Breastfeeding: the role in the development of AR is often debated • Farm effect: It is hypothesized that early pet exposure may induce immune tolerance There is a growing interest in the development of allergies, and a meta-analysis of 8 studies showed a 40% lower risk in subjects who had lived on a farm during their first year of life Diagnosis and Assessment • Importance of patient history and physical examination • Allergy testing methods Differential diagnosis Non-allergic Rhinitis: • Vasomotor rhinitis • Hormonal rhinitis (e.g., pregnancy, hypothyroidism) • Occupational rhinitis (exposure to irritants at work) Infectious Rhinitis: • Common cold (viral rhinitis) • Bacterial sinusitis • Influenza • Other upper respiratory tract infections Structural Abnormalities: • Deviated septum • Nasal polyps • Foreign body in the nasal cavity Drug-Induced Rhinitis: • Rhinitis medicamentosa (rebound nasal congestion due to overuse of decongestant nasal sprays) • Side effects of medications (e.g., antihypertensives, oral contraceptives) Differential diagnosis Atrophic Rhinitis: • Characterized by dryness and crusting of the nasal mucosa • Can result from previous nasal surgery, certain medical conditions, or prolonged use of nasal decongestant sprays Autoimmune Conditions: • Granulomatosis with polyangiitis (formerly Wegener's granulomatosis) • Sarcoidosis Gastroesophageal Reflux Disease (GERD): • Laryngopharyngeal reflux can cause nasal symptoms due to the backflow of stomach acid Endocrine Disorders: • Hypothyroidism can sometimes present with nasal congestion and rhinorrhea Non-Pharmacological Management • Allergen avoidance strategies • Environmental controls Pharmacotherapy for Allergic Rhinitis • Antihistamines (1st and 2nd generation) • Intranasal corticosteroids • Decongestants • Leukotriene receptor antagonists • Immunotherapy Intranasal corticosteroid • Monotherapy or in combination with oral antihistamines in patients with mild, moderate, or severe symptoms Studies have shown intranasal corticosteroids are superior to antihistamines in effectively reducing nasal inflammation and improving mucosal pathology • Topical intranasal steroid should be the first-line treatment for AR • Patients should always receive counsel on the appropriate use of devices They should be used regularly, as their peak effect may take multiple days to develop. The spray bottle's tip should be placed just inside the naris and aimed laterally towards the ipsilateral eye to minimize contact of the product with the nasal septum • The most common side effect reported is nasal irritation, followed by epistaxis, both of which can be prevented by spraying away from the nasal septum • Oral and injectable steroids have been shown to alleviate symptoms of AR but are not recommended for routine use due to their significant systemic side-effect profile Antihistamines First-generation (diphenhydramine, chlorpheniramine, and hydroxyzine) • Can be quite sedating due to their ability to cross the blood-brain barrier • Side effects are due to effect on muscarinic receptors, causing of dry mouth, urinary retention, constipation, and/or tachycardia Second-generation (fexofenadine, loratadine, desloratadine, and cetirizine) • Improved H1 selectivity, so less sedating, and have longer half-lives (12 to 24 hrs) • Fexofenadine has no sedating effects, but loratadine and desloratadine may be sedating at higher doses • Cetirizine has the most potential sedating effect • Both first- and second-generation antihistamines are effective at controlling symptoms of AR • There is no one agent recommended over others, as all have shown similar efficacy and safety profiles in terms of symptom relief • Intranasal antihistamines, have a rapid onset and are more efficacious than oral antihistamines in relieving nasal symptoms • Can be used in conjunction with topical nasal steroid sprays with a synergistic effect Oral Decongestants (Pseudoephedrine) • Useful in relieving symptoms • Not recommended for extended daily use due to their side-effect profile • Intranasal decongestants (such as xylometazoline) are alpha-agonists that are delivered directly to nasal tissue to produce vasoconstriction • Prolonged use of intranasal decongestants has a risk of causing rebound nasal congestion (rhinitis medicamentosa) and, therefore, should not be used for more than a week Leukotriene receptor antagonists and Immunotherapy Leukotriene receptor antagonists (LTRAs) (montelukast and zafirlukast) • Can be beneficial in patients with AR, but they are not as efficacious as intranasal corticosteroids • Their use is often in combination therapy with other agents for severe or refractory symptoms • For patients in whom avoidance measures and combination pharmacotherapy are not effective Allergen immunotherapy • Subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) are commonly used therapies • Weekly incremental doses are given for 6 to 8 months, followed by maintenance doses for 3 to 5 years. Typically, patients experience a prolonged, protective effect, and therapy can be ceased Random ➢ Sodium cromoglycate (Cromolyn) effectively reduces sneezing, rhinorrhea, and nasal pruritis, so it is a reasonable option. ➢ Surgical treatment is reserved for patients with nasal polyposis, inferior turbinate hypertrophy causing intractable nasal obstruction, or chronic sinus disease refractory to medical treatment ➢ Budesonide is the only FDA-approved agent for pregnant patients experiencing symptoms of allergic rhinitis ➢ Omalizumab a monoclonal antibody, is beneficial in patients with AR, although the cost associated with therapy is a limiting factor in its use ➢ Nasal saline can be another option in conjunction with other treatment modalities ➢ Isotonic solutions are more beneficial in adults, whereas hypertonic solutions may be more effective in children Patient Counseling and Education • Proper use of medications • Adherence and potential side effects When to seek medical attention (Red flags) Worsening Symptoms: • Persistent or worsening nasal congestion, sneezing, itching, or rhinorrhea despite appropriate treatment. Severe Fatigue or Malaise: • Unexplained and severe fatigue or malaise that is not relieved by rest. Symptoms Affecting Quality of Life: • Marked impairment in daily activities, work, or sleep due to allergic rhinitis symptoms. Eye Symptoms: • Such as persistent redness, itching, swelling, or discharge. • Headache or Facial Pain: Unexplained headaches or facial pain, especially if associated with sinus pressure. • Symptoms Beyond the Nose and Eyes: Such as persistent coughing or wheezing. • Ear Symptoms: Such as persistent ear pain, fullness, or hearing loss. When to seek medical attention (Red flags) • Recurrent Sinus Infections: Recurrent or persistent sinus infections despite appropriate treatment for allergic rhinitis. • Exacerbation of Asthma: Such as increased shortness of breath or wheezing. • New-Onset Symptoms: Especially in individuals who have not been previously diagnosed with allergic rhinitis. • Symptoms Not Responding to Medication: Lack of response to over-the-counter or prescribed allergy medications. • Systemic Symptoms: Development of systemic symptoms such as fever, chills, or body aches. • Nasal Bleeding: Unexplained or recurrent nasal bleeding. • Development of Skin Rashes or hives. • Pregnancy or Lactation: Any concerns about the safety of medications or the impact of allergic rhinitis on maternal and fetal health. General Recommendations Ask About Symptom Duration and Triggers: Inquire about the duration of symptoms and any specific triggers or patterns the patient has noticed. Provide Symptom Relief: Recommend appropriate OTC products based on predominant symptoms (antihistamines for itching, decongestants for congestion). Educate on Proper Medication Use: Provide instructions on the correct use of nasal sprays, especially if intranasal corticosteroids are recommended. Refer for Further Evaluation: Encourage patients with persistent or severe symptoms, or those with uncertain diagnoses, to seek further evaluation from a healthcare provider. Consider Coexisting Conditions: Be aware of the potential for coexisting conditions (e.g., asthma, GERD) that may require additional management. Complications • Impaired Quality of Life: Chronic AR can significantly impair quality of life, affecting daily activities, work, and social interactions. • Impaired Cognitive Function: Sleep disturbances associated with AR may lead to impaired cognitive function, decreased concentration, and reduced productivity. • Chronic Fatigue: Persistent symptoms and sleep disturbances can contribute to chronic fatigue and a sense of general malaise. • Exacerbation of Asthma: Uncontrolled AR can worsen asthma symptoms and lead to more frequent exacerbations in individuals with both conditions. • Chronic Sinusitis: Persistent allergic inflammation in the nasal passages may contribute to chronic sinusitis, requiring ongoing management. • Nasal Septum Deviation: Chronic nasal congestion may lead to changes in the structure of the nasal passages, such as a deviated septum. • Social Isolation: Severe AR symptoms may lead to social isolation and withdrawal from activities, impacting the overall well-being of individuals. • Medication Side Effects: Long-term use of certain medications for AR, such as nasal corticosteroids, may have side effects, and healthcare providers need to monitor for these. Special Populations • Pediatric considerations • Pregnancy and lactation • Geriatric considerations Pediatric Considerations Diagnosis and Assessment: AR symptoms may manifest differently in children. Recognition may be challenging, requiring careful consideration of age-appropriate signs and symptoms. Treatment Selection: • Choose medications with safety profiles suitable for children. • Nasal corticosteroids are often considered safe for long-term use in children with moderate to severe symptoms. Dosage Adjustments: • Adjust medication dosages based on the child's age and weight. • Use age-appropriate formulations (e.g., pediatric liquid formulations). Monitoring Growth: Monitor growth parameters, as long-term use of corticosteroids may affect growth in some children. Education for Parents/Caregivers: • Provide thorough education on proper medication administration. • Address concerns related to potential side effects. Pregnancy and Lactation Considerations Risk-Benefit Assessment: • Conduct a thorough risk-benefit assessment before initiating any pharmacotherapy during pregnancy. • Consider the potential impact of untreated AR on the mother and fetus. Medication Selection: • Prefer intranasal corticosteroids as first-line treatment due to their favorable safety profile. • Antihistamines may be considered based on individual circumstances and after consultation with a healthcare provider. Avoidance of Decongestants: Decongestants should be used with caution and only under the guidance of a healthcare provider due to potential effects on blood pressure. Lactation: • Many medications used for AR are considered safe during lactation, but consultation with a healthcare provider is essential. • Encourage breastfeeding mothers to maintain adequate hydration. Geriatric Considerations Coexisting Conditions: Consider the presence of comorbidities common in the elderly, such as cardiovascular disease, when selecting medications. Polypharmacy: Be mindful of polypharmacy and potential drug interactions with medications used to manage other chronic conditions. Cognitive Function: Consider the potential impact of AR symptoms, medications, and sleep disturbances on cognitive function in the elderly. Renal and Hepatic Function: Assess renal and hepatic function when selecting medications, as age-related changes may affect drug metabolism. Adherence and Education: • Ensure clear communication and education to enhance medication adherence. • Be aware of potential barriers to adherence, such as difficulty using nasal spray devices. Regular Follow-up: Schedule regular follow-up appointments to monitor treatment efficacy and assess for any adverse effects. Overall Considerations Individualized Treatment Plans: Recognize that treatment plans need to be individualized based on the patient's age, medical history, and overall health. Monitoring and Adjustments: Regularly monitor treatment efficacy and make adjustments as needed, considering changes in health status. Communication and Shared Decision-Making: Engage in open communication and shared decision-making with patients in special populations, involving them in their care. Consultation with Specialists: In complex cases, consider consulting specialists such as allergists, pediatricians, or obstetricians to optimize care.