PHAR3330 Respiratory Disorders: Allergic Rhinitis & Sore Throat PDF

PHAR3330 Respiratory Disorders: Allergic Rhinitis & Sore Throat Dr. Bilvick Tai Lecturer, School of Pharmacy Date: Sep 27, 2024 Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 1  Learning objectives To i...

PHAR3330 Respiratory Disorders: Allergic Rhinitis & Sore Throat Dr. Bilvick Tai Lecturer, School of Pharmacy Date: Sep 27, 2024 Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 1  Learning objectives To identify the causes/ risk factors for and signs/symptoms of allergic rhinitis and sore throat To evaluate whether a specific patient is eligible for self-treatment To discuss the clinical particulars of medications, including both prescription-only, pharmacy-only, and OTC medications, used for allergic rhinitis and sore throat To recommend appropriate pharmacological and non-pharmacological management in a given patient scenario To provide appropriate patient counselling in a given patient scenario Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 2  Rhinitis Presence of one or more of the following nasal symptoms: o Sneezing, rhinorrhea, nasal congestion, nasal itching, cough Most common forms of rhinitis: o Allergic rhinitis o Non-allergic rhinitis ▪ Compared with allergic rhinitis: ❖ Onset at a later age ❖ Absence of nasal and ocular itching and prominent sneezing ❖ Nasal congestion and postnasal drainage are prominent symptoms ❖ Symptoms are perennial Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 3  Rhinitis Most common forms of rhinitis: o Pregnancy rhinitis ▪ Nasal congestion in the last 1 to 2 months of pregnancy ▪ Symptoms disappear completely within 2 weeks after delivery o Occupational rhinitis ▪ Caused by airborne allergens or irritants in the patient's workplace ▪ Patients often report that symptoms are more prominent at work and improve on days off ▪ Examples of triggers: ❖ Proteins from the urine and fur of laboratory animals ❖ Food proteins in food processing ❖ Organic dusts in woodworking Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 4  Allergic rhinitis – Introduction 2 types: seasonal allergic rhinitis and perennial allergic rhinitis Can be diagnosed at any age o Rare in children less than 2 years old o Number of cases decreases after age of 65 years Risk factors for allergic rhinitis: o Family history of atopy o Filaggrin gene mutation o Elevated serum IgE >100 IU/mL before age of 6 years o Higher socioeconomic level o Eczema o Positive reactions to allergy skin tests Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 5  Allergic rhinitis – Introduction Diet may be a risk factor in children and adolescents o Individuals who consume ≥3 fast-food meals per week show an increased incidence of allergic disorders Triggered by indoor and outdoor environmental allergens o E.g. pollen, mold spores o E.g. ozone, tobacco smoke, diesel exhaust particles o E.g. house-dust mites and cockroaches, mold spores, pet dander Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 6  Allergic rhinitis – Pathogenesis Consists of 4 phases: 1. Sensitization phase o Occurs following the initial allergen exposure, during which the allergen stimulates IgE production 2. Early phase o Occurs within minutes of subsequent allergen exposure o Rapid release of mast cell mediators (e.g. histamine), as well as the production of additional mediators 3. Cellular recruitment o Circulating leukocytes are attracted to the nasal mucosa and release more inflammatory mediators Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 7  Allergic rhinitis – Pathogenesis Consists of 4 phases: 4. Late phase o Begins 2–4 hours after allergen exposure Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 8  Allergic rhinitis – Clinical Presentation Duration Severity Mild Intermittent (None of the symptoms in “Moderate-Severe” is present) (Symptoms occur ≤4 days Moderate–Severe per week or ≤4 (One or more occurs: sleep disturbance; impairment of weeks) school or work performance; impairment of daily activities, leisure, and/or sport activities; troublesome symptoms) Mild Persistent (None of the symptoms in “Moderate-Severe” is present) (Symptoms occur >4 days Moderate–Severe per week and >4 (One or more occurs: sleep disturbance; impairment of weeks) school or work performance; impairment of daily activities, leisure, and/or sport activities; troublesome symptoms) Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 9  Allergic rhinitis – Clinical Presentation Episodic allergic rhinitis: o Symptoms occur on exposure to or contact with potential allergen that is not normally a part of the person’s environment Signs and symptoms of allergic rhinitis: o Bilateral symptoms o Frequent paroxysmal sneezing o Anterior watery rhinorrhea o Variable degree of nasal obstruction o Frequent pruritus of eyes, nose, and/or palate o Frequent conjunctivitis o Sinus pain and throat pain may be present Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 10  Allergic rhinitis – Clinical Presentation “Allergic shiners” o Infraorbital edema and darkening due to subcutaneous venodilation “Dennie-Morgan lines” o Accentuated lines or folds below the lower eyelids “Allergic salute” o Upward “swipe” of tip of the nose with palm of the hand “Allergic gape” o Open-mouth breathing secondary to nasal obstruction Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 11  Allergic rhinitis – Clinical Presentation “Nasal crease” o Horizontal crease just above bulbar portion of the nose Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 12  Allergic rhinitis – Complications Acute complications: o Sinusitis o Otitis media with effusion Chronic complications: o Sinusitis o Nasal polyp formation o Sleep apnea o Hyposmia Allergic rhinitis has been implicated in the development of asthma and in exacerbation of preexisting asthma in children and adults Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 13  Allergic rhinitis – Treatment Treatment goals: o Reduce symptoms o Improve patient’s functional status and sense of well-being 3 treatment components: 1. Pharmacotherapy 2. Allergen avoidance 3. Immunotherapy o Indications: ▪ Severe symptoms that are only partially controlled with medications ▪ Patient’s preference to minimize the use or cost of medications ▪ Prevention of progression to asthma Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 14  Allergic rhinitis – Treatment Allergen avoidance o Dust mites (Dermatophagoides spp.) ▪ Colonize bedding, sofas, carpets, or any woven material ▪ Neither the dust mites nor their debris can be seen under normal circumstances ▪ Thrive in warm, humid environments ▪ Absorb humidity from the atmosphere and feed on organic matter (e.g. shed skin particles) ▪ Effective measure: ❖ Cover for pillow / mattress with zipped covers ❖ Use of vacuum cleaner ❖ Control humidity ❖ Reduce areas that can harbor dust mite colonies Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 15  Allergic rhinitis – Treatment Allergen avoidance o Mold spores ▪ Outdoor molds ❖ E.g. Alternaria, Cladosporium ❖ Measure to minimize exposure: ✓ Do not disturb decaying plant material ▪ Indoor molds: ❖ E.g. Penicillium, Aspergillus ❖ Measure to minimize exposure: ✓ Lower household humidity ✓ Remove houseplants ✓ Apply fungicide to obviously moldy areas Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 16  Allergic rhinitis – Treatment Allergen avoidance o Pet-derived allergens ▪ Majority of pet-allergic patients are reactive to cats and/or dogs ▪ Most people with cat allergy are sensitized to the protein Fel d 1 ▪ Measure to minimize exposure: ❖ Keep animals outside the house ❖ Use air filter / cleaner ❖ Regular house cleaning and use of vacuum cleaner ❖ Reduce reservoirs (e.g. carpets) ❖ Regularly wash the pet Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 17  Allergic rhinitis – Treatment Allergen avoidance o Pollens ▪ Produced by trees in spring, grasses in early summer, and ragweed in autumn ▪ Pollen counts ❖ Can help patients plan outdoor activities at appropriate times ❖ Highest early in the morning and lowest after rain clears the air ▪ Measures to minimize exposure (during peak seasons): ❖ Close windows at home and in the car ❖ Use air conditioners / filter / cleaner ❖ Stay indoor as much as possible ❖ Shower before bed to remove pollens from hair and skin Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 18  Allergic rhinitis – Treatment Exclusion for Self-Treatment Symptoms of non-allergic rhinitis Symptoms of otitis media, sinusitis, bronchitis, or other infection Symptoms of undiagnosed or uncontrolled asthma (e.g. wheezing, SOB); COPD, or lower respiratory disorder Severe or unacceptable side effects of treatment The following patients are highly recommended to be diagnosed with allergic rhinitis by doctor first before receiving self-treatment: o Children < 12 years o Pregnant or lactating women Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 19  Allergic rhinitis – Pharmacotherapy Older children (>2 years of age) and adults: o Treatment options for mild or episodic symptoms: ▪ Minimally sedating oral antihistamine ▪ Antihistamine nasal spray ▪ Glucocorticoid nasal spray o Treatment options for persistent or moderate-to-severe symptoms: ▪ Glucocorticoid nasal spray ▪ A second agent can be added: o Antihistamine nasal spray o Minimally sedating oral antihistamine o Minimally sedating oral antihistamine/decongestant combination Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 20  Allergic rhinitis – Pharmacotherapy Older children (>2 years of age) and adults: o Treatment options for concurrent allergic conjunctivitis: ▪ Glucocorticoid nasal spray + antihistamine eye drop ❖ Oral instead of ophthalmic antihistamine drop can be more practical in children Older adults: o Treatment options: ▪ Glucocorticoid nasal spray ▪ Minimally sedating antihistamine ▪ Antihistamine nasal spray Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 21  Glucocorticoid nasal spray Examples: o Beclomethasone, budesonide, triamcinolone o Fluticasone furoate / propionate, ciclesonide, mometasone MOA: inhibit allergic inflammation in the nose The most effective single maintenance therapy for allergic rhinitis o More effective than oral antihistamines for relief of: ▪ Nasal congestion, nasal discharge, sneezing, nasal itch, postnasal drip o Also more effective than antihistamine nasal spray Copyright © 2020. All Rights Reserved. Faculty of Medicine, The Chinese University of Hong Kong 22  Glucocorticoid nasal spray 1st-generation agents: systemic bioavailability of 10 - 50% 2nd-generation agents: systemic bioavailability