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TREATMENT ALGORITHM - what do all people get?
All: avoidance of allergen and patient education
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Treatment alrgorithm - Mild intermittent symptoms:
2nd generation oral or intranasal antihistamine PRN
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Treatment algorithm - Mild to moderate persistent symptoms:
- Intranasal corticosteroids alone as 1st line treatment
- Consider nasal irrigation or decongestants if nasal congestion
- Consider atrovent or intranasal antihistamines for rhinorrhea
- Consider oral or intranasal antihistamine for persistent nasal ocular symptoms
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Treatment algorithm - Severe persistent symptoms:
- Intranasal corticosteroids + oral/intranasal antihistamines, oral LKTA or Intranasal cromolyn
- If symptoms persist: consider immunotherapy referral or alternative treatments (allergen avoidance, nasal irrigation, acupunture, probiotics, herbals)
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1st line medical therapy for mild to moderate disease?
- Intranasal corticosteroids (work the best)
- All other treatments are 2ne line and should be reserved for failure of intranasal corticosteroids or moderate to severe disease not responding to them.
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What are 2nd line therapies for allergic rhinitis?
- Antihistamines - oral and intranasal
- Decongestants
- Cromolyn
- Leukotriene receptor antagonists
- Non-pharmacologic therapies (nasal irrigation)
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Which class of anti-histamines are better for treating allegic rhinitis?
2nd generation, except for cetirizine, are less likely to cuase sedation and impair performance
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What would you consider in patients with moderate to severe disease not responding to any first or second line treatments?
Immunotherapy - refer them to an immunologist.
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What is the evidence for each of the following:
- Mite-proof impermeable covers
- Air filtration systems
- Delayed exposure to solid food in infancy
- Breastfeeding
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Typical symptoms of allergic rhinitis?
- Rhinorrhea
- Nasal congestion
- Nasal Obstruction
- Nasal pruritis
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How do intranasal corticosteroids work in allergic rhinitis?
- Reduce inflammation of the nasal mucosa (via decreased inflammatory cells and cytokine release)
- Onset of action - 30 min
- Peak effect - several hours to days
- Maximum effectiveness - usually noted after 2-4 weeks of use
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Possible side effects of intranasal corticosteroids?
- Headache
- Throat irritation
- Epistaxis
- Stinging
- Burning
- Nasal dryness
- Rhinitis medicamentoas
- *May reduce growth in children with long term use
- *No proven effect on HPA axis
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Only intranasal corticosteroid with Category B (vs. C) rating in pregnancy?
- Beclomethasone (Beconase)
- All others are C
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Method of action of oral antihistamines?
- Block H1 receptor. Onset 15-30 minutes.
- Intranasal - same MOA, onset 15 min.
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Side effects of antihistamines?
- Oral - dry mouth, sedation at higher than recommended doses
- Intranasal - bitter aftertaste, epistaxis, headache, nasal irritation, sedation
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Method of action of oral decongestants?
- Vasoconstriction
- Onset 15-30 minutes
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Side effects of oral decongestants?
- Arrhythmias (tachycardia), dizziness, headache, hypertension, insomnia, tremor, nervousness, urinary retention
- *Not recommended in Pts with CV disease, glaucoma or hyperthyroidism
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How does intranasal cromolyn work?
- Inhibits histamine release by stabilizing mast cells
- Usually need 1 week to work, often 2-4 weeks for full effect
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Side effects of intranasal cromolyn?
- Epistaxis, nasal irritation, sneezing
- TID or QID dosing is inconvenient
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What are intranasal anticholinergics MOA and which drug in particular? Minimum age?
Ipratropium (Atrovent), blocks Ach Rc, takes 15 min to work, minimum age of 6 years
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Side effects of intranasal ipratroprium?
Epistaxis, headache, nasal dryness
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What is the name of a LKRA? Onset of action?
- Singular, 2 hours onset, minimum age of 6 months
- *Only minimal improvement in nasal congestion, less effective than intranasal corticosteroids or antihistamines
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Possible side effects of LKRA?
Elevated levels of ALT, AST, bilirubin
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Effectiveness of anti-histamines for allergic rhinitis?
- Effective for sneezing, pruritis, rhinorrhea and ocular symptoms
- BUT less effective than intranasal corticosteroids at treating nasal congestion
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How long should decongestants be used for?
Not recommended to exceed 3 to 5 days of use, because get rhinitis medicamentoas or rebound congestion.
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Is combination therapy better?
- NO!
- Combination therapy is no more effective than monotherapy with intranasal corticosteroids. But remains an option if severe or persistent symtpoms.
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What is the only therapy that changes the natural course of allergic rhinitis?
- Targeted immunotherapy is the only treatment that chagnes the natural course of allergic rhinitis, preventing exacerabtions.
- Takes several years and effect lasts for 3-5 years
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Non-pharmacologic treatments and their evidence?
- Acupuncture - no evidence to support or refute use
- Probiotics - no evidence currently
- Herbals - no evidence currently
- Avoidance/Environmental control - avoid cigarette smoke, pets, allergens
- Nasal irrigation for chronic rhinorrhea
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