Multimodality treatment of allergic rhinitis

‡ Allergic rhinitis affects approximately 50 million people in the U.S., and the prevalence is rising.
‡ Allergies represent the 2nd leading cause of chronic disease in the U.S., costing the healthcare system $18 billion annually.
‡ 3.4 million days lost from work annually and 2 ‡ The head and neck region is the “shock organ” ‡ Sneezing – 84%‡ Anterior rhinorrhea – 76%‡ Itchy eyes – 71% ‡ Nasal congestion – 70%‡ Itchy nose – 56% ‡ Sinus pressure – 52%‡ Headache – 49%‡ Watery eyes – 49% Sneezing
Rhinorrhea
Congestion
Symptoms
„ Competitive H1 binding„ Lipophilic (crosses the BBB) „ Anticholinergic effect (urinary retention, xerostomia) „ Diphenhydramine, chlorpheniramine, hydroxyzine „ Non-competitive H1 binding„ Lipophobic (less sedation, improved performance) „ Terfenadine, fexofenadine, loratadine (des), azelastine, „ Cardiac effects (macrolides, systemic antifungals) Itchiness, airway smooth muscle contraction „ Binds to alpha-1 and alpha-2 receptors „ Displaced norepinephrine from receptors Cetirizine = fexofenadine > loratadine Effects on the task of driving: diphen.>EtOH>fex=placebo Response time: EtOH>diphen>fex=placebo Testing scores in children (10-12): non-atopic>loratadine>diphen ‡ Levels peak - 2 hours (½ life 3-4 hours) ‡ Local potency greater than with systemic ‡ Risks – rhinitis medicamentosa (>7 days) ‡ May produce urinary retention or insomnia „ Phenylephrine (Neo-synephrine®)„ Oxymetazoline (Afrin, Dristan®) ‡ Use with caution in patients with a history of: HTN, CAD, glaucoma, hyperthyroidism, „ Naphazoline (Privine®)„ Epinephrine (Primatene®) MAO inhibitor use, urinary retention, CVA ‡ Pseudoephendrine is only available choice ‡ Binds to intracellular receptors (mRNA, ‡ Prevents initiation of the allergic cascade ‡ Major side effects include HA, nosebleeds „ Decreased recruitment and migration of ‡ Posterior subcapsular cataracts not proven ‡ Use when congestion is a major symptom ‡ Chronic use leads to growth suppression in „ Decreased activity of basophils and mast cells „ Decreased migration of APC, T-cells, B-cells ‡ Initially identified in the 1930’s – called ‡ Combination with antihistamine has been ‡ Effects of cysteinyl leukotrienes (C4,D4,E4) ‡ Low side effect profile - Isolated cases of liver toxicity and Churg-Strauss syndrome „ LTE4 attracts neutro, eos in asthmatic patients ‡ Useful in nasal polyposis +/- ASA triad? ‡ Topical ipratropium bromide (Atrovent®) ‡ Useful before anticipated antigen exposure ‡ Cromolyn sodium (Nasalcrom®, Intal®) ‡ Begin with AM loading dose, repeat in 6 ‡ Use with caution in elderly patients, „ Late phase inhibition of eos and neutrophils „ Try a non-sedating AH ± decongestant or a leukotriene „ Consider intranasal steroid alone or combined „ Inadequate response to initial therapy „ Significant impact on the quality of life„ Co-morbidities are occurring „ Combined therapy ± oral corticosteroids, antibiotics ‡ In general, the lowest effective dose of a ‡ You must be aware of side effects, safety ‡ Medication strategies must be tailored to ‡ You may have to follow a moving target!

Pathways of Allergic Inflammation

Leukotriene Receptor Antagonists

Topical Nasal Sprays & Montelukast

Pharmacotherapy – Other Modalities

Source: http://www.entnyc.com/allergy_pharm.pdf