allergic rhinitis

allergic rhinitis: IgE, inflammatory, post-allergens exposure
*mast cell are in the nasal mucosa – degranulate when histamine shows up
-more likely to have if: FH of AR, atopic dermatitis, asthma; exposed to allergens, eczema, secondhand smoke
-symptoms: sneezing, clear rhinorrhea, nasal congestion, fatigue, post nasal drip, itchy nose/eyes
-classification:

  • intermittent: <4 days/week OR <4 weeks/year
  • persistent: >4 days/week AND >4 weeks/year
  • mild: not interfering with QOL
  • moderate or severe: does interfere with QOL

drugs
intranasal corticosteroids – reduce inflammation; #1 for congestion or moderate/severe symptoms
“instill 1-2 sprays in each nostil once to twice daily” – continuous use
good for sneezing, itching, rhinorrhea, congestion, ocular symptoms
a/e: HA, dry, burn, sting, nosebleeds
[beclomethasone, budesonide, flunisolide, fluticasone propionate, fluticasone furoate, mometasone, triamcinolone, ciclesonide]
antihistamines – antagonize H1 receptors
oral: good for sneezing, rhinorrhea, itching eyes -continuous use best but FAST onset time; #1 for intermittent/mild symptoms
a/e: sedation, anticholinergic, stomach probs, narrow-angle glaucoma, urinary retention issues/BPH
[chlorpheniramine, diphenhydramine, cetirizine, levocetirizine, loratadine, desloratadine, fexofenadine]
intranasal: good for sneezing, rhinorrhea, nasal pruritus – more targeted delivery than oral – better for congestion
a/e: taste, HA, nasal burning, somnolence, BID
[azelastine, olopatadine, dymista]
ophthalmic: good for conjunctivitis
a/e: HA, blurry vision, burning/stinging, taste
[ketotifen, azelastine, olopatadine, alcaftadine, emedastine, epinastine]
decongestants – sympathomimetic; target adrenergic receptors in nose = vasoconstriction
topical: PRN xx,3-5 – otherwise rhinitis medicamentosa
a/e: sneezing, burn/sting, drying
[phenylephrine, tetrahydrozoline, naphazoline, oxymetazoline]
oral: careful b/c can increase BP; alt for nasal congestion
[pseudoephedrine, phenylephrine]

others:
cromolyn: mast cell stabilizer w/ slow onset
ipratropium: anticholinergic for rhinorrhea
LTRA: montelukast – can cause nasal congestion, extremely slow onset
mAb – omalizumab: binds circulating IgE

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