Allergic rhinitis

results of immunotherapy

1/3 no sx; 1/3 less sx; 1/3 relapse

brand name for fexofenadine

Allegra

what is atopy

Atopy (atopic syndrome) is a syndrome characterized by a tendency to be "hyperallergic". A person with atopy typically presents with one or more of the following: eczema (atopic dermatitis), allergic rhinitis (hay fever), allergic conjunctivitis, or allergic asthma. Patients with atopy also have a tendency to have food allergies.

treatment for allergic rhinitis

Benadryl q4-6h; chlorpheniramine (not as strong as Benadryl and can also cause drowsiness); nasal irrigation; environmental controls; nasal corticosteroid spray; nasal antihistamine spray; ipratropium bromide nasal spray (Atrovent); nasal cromolyn; nasal decongestant spray; oral antihistamines; oral decongestants; leukotriene antagonists; allergy shots (immunotherapy)

brand name for desloratadine

Clarinex

cromolyn: drug class

anti-inflammatory nasal spray; specific allergen blocker

what are treatments for itchy eyes

antihistamine eye drops provide faster relief than oral, or use a combination eye + PO antihistamines; use Visine A first or olopatadine

what conditions can be exacerbated by chronic uncontrolled allergic rhinitis

asthma and eczema

what are people with allergic rhinitis more prone to develop?

asthma, other allergies, sinusitis, sleep disorders (snoring, sleep apnea), nasal polyps, ear infections

what is the diagnostic criteria for allergic rhinitis?

at least 2 of the 4 for an hour or more on most days: rhinorrhea, nasal congestion, sneezing, nasal itching. Other common symptoms: itchy throat or roof of mouth, itchy watery eyes

what is the allergic response called

atopy

are antihistamines best used for symptom relief or prophylactically in allergy season

best used before an allergy attack happens

what are three common sources of indoor animal dander

cats, house mice, dogs

what are triggers for irritative rhinitis and what happens as a result?

cigarette smoke, air pollution, strong odors, EtOH, cold air; passages become red and engorged

causes of rhinitis

colds, allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise. List is not comprehensive.

Visine A: drug class

combination decongestant + antihistamine for use in the eye

newer blood test for IgE

enzyme-based assay using IgE antibodies; detect increased levels of allergen-specific IgE in response to particular allergens; may be less accurate than skin testing; performed only when skin testing is contraindicated or results are uncertain

most common indoor allergen

enzymes on dust mite feces

when do allergies typically appear, if they are going to appear at all?

in childhood but can develop at any age

what is one detrimental effect of asthma on the lungs

irreversible remodeling

what do antihistamines treat?

itching, sneezing and runny nose; hives, some rash

when does tree pollen cause symptoms

late March - early April

when do grasses cause symptoms

late afternoon; May-June.

zafirlukast: drug class. What does it treat?

leukotriene antagonist; asthma

montelukast: drug class. What does it treat?

leukotriene antagonist; asthma, seasonal/indoor allergies

what is nasal cromolyn used to treat

moderate to severe allergic rhinitis

name a leukotriene antagonist

montelukast

cetirizine: drug class, 2 qualities

most potent and sedating antihistamine

flunisolide: drug class and age range

nasal corticosteroid 6+

treatment of rhinitis medicamentosa

nasal corticosteroids

what anti-inflammatory drugs are used in moderate to severe allergic rhinitis

nasal corticosteroids, either alone or in combination with 2nd gen antihistamines; in chronic cases these drugs may be used daily

drug-related causes of rhinitis

nasal decongestants, oral contraceptives, HRT, anxiolytics, antidepressants, ED drugs, beta blockers, vasodilators, cocaine

cycle of rebound and dependency occurs with? What happens?

nasal decongestants: more then 3 days use results in lessening effectiveness, swelling in nasal passages; pt increases dose to clear congestion and the cycle worsens;

decongestants: mechanism of action

nasal vasoconstriction

treating mild seasonal allergy attacks

nasal wash; intermittent use of 2nd gen non-nonsedating antihistamines; decongestants;

late phase symptoms of allergic rhinitis

occurs 4-8 h after exposure; nasal congestion, plugged ears; fatigue; slower mentation; dark circles under the eye; puffy/creased lower eyelid; crease across the bridge of the nose from the "allergic salute" hand pushing the nose upward to clear drainage

active ingredients in oral decongestants

pseudoephedrine (Sudafed), phenylephrine

causes of nasal polyps

sinus infections that cause mucus membrane overgrowth; may multiply

what are the effects of histamine release on the respiratory system

sneezing, coughing, wheezing

benefits of immunotherapy

specific allergen can be targeted, reduces lung and upper airway sensitivity to allergens; prevent new allergies in kids; reduce asthma symptoms and drug dosing; may actually prevent asthma in kids with allergies at risk

how to reduce ragweed allergy symptoms

take meds 1-2 weeks before ragweed season (September-October); wear sunglasses for eye protection from pollen;

what happens to antibody-antigen molecules on the surface of target cells?

they bind to Fc receptors causing IgE cross-linking and receptor clustering on the target cell membrane

common complaints of nasal allergy sufferers besides nasal symptoms

tired, miserable, irritable

what are leukotriene antagonists used for

tx of moderate to severe allergic rhinitis and asthma

how long does cromolyn take to work?

up to 3 weeks

controlling allergens in bedding/curtains

use blinds instead; wash with the hottest water possible; use dust mite proof covers? Sleep high off the floor; wash stuffed animals also

can pregnancy worsen or relieve nasal congestion

worsen; may be due to elevated estrogen levels; usually clears up after delivery

brand name for loratadine

Claritin

leukotriene: physiologic effect; involvement in ______ disease(s)

One of their roles (specifically, leukotriene D4) is to trigger contractions in the smooth muscles lining the bronchioles; their overproduction is a major cause of inflammation in asthma and allergic rhinitis.[3] Leukotriene antagonists are used to treat these disorders by inhibiting the production or activity of leukotrienes.

Why do some people react to pollen? Does it cause disease?

Reasons are not completely understood why the body mounts a hypersensitive response to a non-disease-causing agent

what effects do leukotrienes have on allergy-related asthma

airway constriction, mucus production

dymista: what does it treat? What is the route of entry?

allergic rhinitis 12+ yo; nasal spray

azelastine: drug class

antihistamine

olopatadine: drug class

antihistamine eye drops

what is a common pet allergen besides dander

cat saliva

causes of vasomotor rhinitis

causes: oversensitive blood vessels and nerve cells in the nose; smoke, toxins, temperature/humidity changes, stress, sexual arousal

what is the most potent and most sedating antihistamine PO

cetirizine

2nd gen non-sedating antihistamines

cetirizine, loratadine, fexofenadine, desloratadine

what is a major trigger of asthma

cockroaches; may reduce lung function even in patients without asthma

what may be the root of symptoms of sleep disorders and daytime fatigue in allergic rhinitis, particularly the perennial type, with snoring in severe cases

congestion

what is the first line treatment for mild allergic rhinitis in pregnancy

cromolyn

what drugs are safe to use in allergic rhinitis with pregnancy

cromolyn, nasal steroids

what is needed for the diagnosis of allergic rhinitis

based on pt symptoms; in most cases no testing is needed; allergy testing may be used to confirm an allergic trigger

what is the risk of continued use of nasal decongestants

dependency and rebound

disconcerting side effects of leukotriene antagonists

depression, insomnia, irritability, suicidal ideations, aggression, hallucinations, agitation, shall I continue?

basis of immunotherapy "allergy shots"

desensitization to a specific allergen such as house dust, cat dander, grass pollen, mold

name 2 prescription antihistamines PO

desloratadine, levocetirizine

what happens when treating a viral infection with an antihistamine

does not help

how is cromolyn used

does not treat symptoms; only as a prophylaxis

what allergens are stirred up by vacuuming instead of reduced

dust mite and cat allergens; remove carpets/rugs in these cases

what are indoor allergens causing allergic rhinitis

dust mites and especially their frass (feces); cockroaches, pet dander, molds on wallpaper/plants/carpet/furniture

how can parents reduce risk of pet allergies, seasonal allergies, and asthma in their kids

early exposure to multiple pets in the first year

compare effects of leukotriene antagonists vs. antihistamines and nasal corticosteroids

equal to antihistamines; not as effective as nasal corticosteroids

side effects of immunotherapy

general itching, swelling, red eyes, hives, soreness at injection site, worsening of asthma and dyspnea are less common (anaphylaxis)

what can be done to treat a patient at the peak of the allergy season and nothing works for them?

glucocorticoids: use dexamethasone or depo medrol shot; can increase blood glucose levels in diabetes

definition of rhinitis

inflammation of the nasal passages

who can receive immunotherapy?

kids and pregnant women already started on therapy prior to pregnancy; dosing is cut in half during pregnancy; generally anyone who tests positive for a specific allergen and who is unresponsive to conventional meds

interesting paradox about onset and duration of seasonal allergic rhinitis

kids who develop allergies early tend not to carry them into adulthood; adults who develop allergies tend to hang on to them until at least middle age; in both age groups, allergies tend to diminish eventually

do kids in day care have more or less asthma

less

side effects of nasal corticosteroids

less than systemic corticosteroids: dry/burning/stinging nasal passages; sneezing; HA, nosebleed

name 3 OTC antihistamines PO

loratadine, cetirizine, fexofenadine

what happens when treating a bacterial infection with an antihistamine

makes it worse

what cells release histamine and by what method

mast cells and basophils; cells may rupture

what cells does IgE attach to and where are they found

mast cells found in the nose, eyes, lungs, and digestive tract; also basophils

when does ragweed cause the worst symptoms

morning; August until the first frost

breakdown of allergic rhinitis in kids

most common chronic condition; 20% seasonal; 40% perennial; 40% mixed

what processes occur in the elderly that make them more prone to chronic rhinitis

mucous membranes dry with age; cartilage weakens causing airflow changes

compare effectiveness of multiple-allergen SLIT vs. single allergen treatment.

multiple allergen SLIT provides better relief

consider this combined treatment for allergic rhinitis

nasal corticosteroid + 2nd gen antihistamines

ciclesonide: drug class and age range

nasal corticosteroid 12+

fluticasone: drug class and age range

nasal corticosteroid 2+

triamcinolone: drug class and age range

nasal corticosteroid 2+

mometasone furoate: drug class and age range

nasal corticosteroid 3+

beclomethasone: drug class and age range

nasal corticosteroid 6+

budesonide: drug class and age range

nasal corticosteroid 6+

2nd gen antihistamines are more effective in what form to treat seasonal allergic rhinitis

nasal form; can cause drowsiness; not as effective as nasal corticosteroids

normal pattern of nasal air flow with congestion

nasal passages alternate from being wide open (decongested) to partly or completely blocked (congested)

azelastine: drug class

nasal spray antihistamine, prescription only

oloptadine: drug class

nasal spray antihistamine, prescription only

which is more effective for allergies: cromolyn or nasal steroids

nasal steroids

do antihistamines treat nasal congestion

no unless combined with a decongestant

what is another name for 2nd gen antihistamines; does this name mask side effects?

non-sedating antihistamines; cetirizine and nasal sprays can cause drowsiness at normal doses; loratidine and desloratadine can cause drowsiness at more than normal doses; take at bed time

caution in use of decongestant sprays

not for use more than 3 days in a row

what risks are increased with exposure to 2nd hand smoke to kids

risk of asthma and asthma-related ER visits in kids

early phase symptoms of allergic rhinitis

runny nose, sneezing, itchy eyes/nose/throat/palate; occur within minutes of exposure

what are home remedies for allergic rhinitis

saline nasal lavage (neti pot)

how does sublingual immunotherapy compare to subcutaneous immunotherapy in terms of results

similar results in placebo-controlled trials;

when do mold spores cause symptoms

spring, summer, fall; peaking on dry windy afternoons or damp/rainy mornings

side effects of eye drops

stinging, HA, nasal congestion

how to treat nasal bleeding when taking antihistamines

stop for 1 week, line nose with vaseline using a qtip, restart meds

long term complications of nasal steroid use

suppression of stress hormones mainly in oral forms; do not combine nasal steroids and inhaled corticosteroids for asthma because of risk of growth retardation; do not administer nasal steroids in patients with active injury or infection of the nose

what can happen to the turbinates in chronic rhinitis

swelling in the turbinates as a result of either allergic or non-allergic causes can become persistent --> turbinate hypertrophy --> persistent nasal congestion --> frontal/maxillary sinus pressure/HA --> surgical intervention

definition of chronic rhinitis

symptoms lasting more than 6 weeks. Can be caused by allergies, structural problems, or infection

what are side effects of antihistamines

thicken mucus secretions --> worsen bacterial rhinitis or sinusitis; can lose effectiveness over time

who is at increased risk for complications from decongestants

those at risk of pathologic vasoconstriction (heart disease, HTN, thyroid dz, diabetes, BPH, migraine, Raynaud's, cold sensitivity, COPD)

how to reduce exposure to people with pet allergies

use dry pet shampoo once a week, especially on cats; cats harbor more allergens than dogs; keep pets off carpets and out of bedrooms or better yet out of the house

time frame of side effects from allergy shots

usually occur within 20 minutes; some may delay up to 2 hours

two types of non-allergic rhinitis

vasomotor and irritative

what are some ways to reduce allergens in the home

washing pets weekly, HEPA filters, washing bedding/curtains, reducing humidity, cleaning up mold

when should allergy shots be used to treat moderate to severe allergic rhinitis

when other treatments are not effective; shorts are expensive; can reduce asthma symptoms

nasal steroids ok in pregnancy?

yes but as always, with caution

name 2 leukotriene antagonists and what they treat

zafirlukast, montelukast: both treat asthma; montelukast treats seasonal and indoor allergies

brand name for cetirizine

Zyrtec

name 2 nasal spray antihistamines, prescription only

azelastine, oloptadine

what is the earliest age to develop allergic rhinitis

2 or 3

what antihistamines are used in moderate to severe allergic rhinitis

2nd gen non-sedating antihistamines used in combination with nasal corticosteroids; nasal antihistamine sprays;

what is the duration of SLIT? Duration of SCIT?

3-5 years for both once at maintenance dose to provide full benefits

target humidity levels indoors

30-50%

what is a life-threatening form of atopy

Atopic syndrome can be fatal for those who experience serious allergic reactions, such as anaphylaxis, brought on by reactions to food or environment.

what are other names for antihistamine

H1-blocker, H1 antagonist, H1 inverse agonist

side effects of antihistamines

HA, dry mouth, dry nose; cease when stopping med

which immunoglobulin is a key player in allergic reactions?

IgE

what is the role of mast cells

IgE receptor site; release histamine; stimulate production of more IgE

leukotriene: family, formation, location

Leukotrienes are a family of eicosanoid inflammatory mediators produced in leukocytes by the oxidation of arachidonic acid by the enzyme arachidonate 5-lipoxygenase.[1][2] As their name implies, leukotrienes were first discovered in leukocytes, but have since been found in other immune cells.

leukotriene: function and associated molecules

Leukotrienes use lipid signaling to convey information to either the cell producing them (autocrine signaling) or neighboring cells (paracrine signaling) in order to regulate immune responses. Leukotriene production is usually accompanied by the production of histamine and prostaglandins, which also act as inflammatory mediators.

what is the allergic triad?

Patients with atopy usually develop what is referred to as the "allergic triad" of symptoms, i.e., eczema (atopic dermatitis), hay fever (allergic rhinitis), and allergy-induced asthma (allergic asthma). They also have a tendency to have food allergies, and other symptoms characterized by their hyperallergic state. For example, eosinophilic esophagitis is found associated with atopic allergies.

older blood test for IgE

RAST (radioallergosorbent test)

what is Samter's triad

Samter's triad is a medical condition consisting of asthma, aspirin and NSAID sensitivity, and nasal/ethmoidal polyposis. It usually begins in young adulthood (twenties and thirties are the most common onset times) and may not include any other allergies.

mechanism of Samter's triad

The disorder is caused by an anomaly in the arachidonic acid cascade which leads to increased production of cysteinyl leukotrienes, a series of chemicals involved in the body's inflammatory response. When medications like NSAIDs or aspirin block the COX-1 enzyme, production of thromboxane and some prostaglandins is decreased, and in patients with aspirin-induced asthma this results in the overproduction of leukotrienes and produces the severe asthma and allergy-like effects. The underlying cause of the disorder is not fully understood

what drugs are included in the combo drug Dymista? Age range?

azelastine, fluticasone; use in 12+ yo

what can moms do to help prevent or delay wheezing and atopic dermatitis in high-risk infants?

breastfeed for first 4 months; wait to introduce solid food until 4-6 months; some evidence that the gut vasculature is permeable to ingested proteins which can allow proteins access to the blood until those fenestrations close off

contraindications for immunotherapy

extreme skin response test, wheezing, uncontrolled severe asthma or lung disease, beta blocker use

what is one common rhinitis symptom that does not occur in the vasomotor rhinitis

eye irritation

what can itch with allergic rhinitis?

eyes, nose, throat, roof of the mouth

potential contraindications for use of eye drops

heart disease, HTN, enlarged prostate, glaucoma

nasal smear testing results

high eosinophil counts confirm an allergy; low counts do not rule out allergy

when would you order a CT in chronic rhinitis

if chronic sinusitis or sinus polyps is suspected to be causing chronic nasal obstruction or HA; consider nasal endoscopy if rhinitis is unresponsive to treatment

what are prescription treatments for allergic rhinitis

oral and nasal antihistamines, corticosteroid nasal sprays, cromolyn, leukotriene antagonists, decongestants, allergy shots

alternative to immunotherapy shots

oral meds: pill/sublingual/drops; cheaper than shots; SL forms not approved in the US

what is the cause of rhinitis medicamentosa

overuse of decongestant sprays (3-5 days); causes inflammation

nasal decongestants: active ingredients

oxymetazoline, xylometazoline, phenylephrine

most common trigger of allergic rhinitis

pollen

possible causes of nasal blockage

polyps, deviated septum

contraindications for use of decongestants

pregnancy, under age 4; caution under age 14; children appear to metabolize decongestants differently than adults; CNS effects include convulsions, LOC, tachycardia, death

what can be done to lessen the side effects of immunotherapy

premedicate with antihistamines/corticosteroids; down side of this is masking of early signs of anaphylaxis

general description of immunotherapy shot administration

prolonged course of weekly/biweekly injections of dilute extracts of specific allergens with increasing strength of dose to reach a maintenance dose; may take months or up to 3 years; dosing frequency is decreased to 2-4 weeks at maintenance dose; tx is continued for 3-5 years; benefit should be seen 3-6 months; if no benefit for 12-18 months, discontinue

side effects from allergy shots are more common for what allergens

ragweed and dust mites

what is the most common cause of allergic rhinitis in the US

ragweed, affects 75% of sufferers

effects of corticosteroids in treating allergies

reduce inflammation and mucus production; improve sleep and daytime alertness; reduce nasal polyps