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Please include a written OSCE script for these scenarios. Scenario 1: Mrs. Ned visited your pharmacy with the following symptoms: sneezing, itching of the nose, mouth and eyes; watery eyes, a stuffy nose, a runny nose, a sore throat, and wheezing. As a pharmacist, you must explain to Ms. Ned why she is suffering from the following symptoms.
Scenario 2: Discuss the COPD management strategy to your provider, and when is the optimal time to provide antibiotics to your patient?
Scenario 3: Mrs. Betty called you to pick up her prescription. Her Physician prescribed the following medications for Allergic Rhinitis: Levocetirizine 10 mg OD, Nafarin A 5 tabs every 6 hours as needed for nasal congestions with Body Malaise. Since last month, she has been taking Betamethasone 5 mg tablets. For her maintenance medications, she requests a prescription from Dr. Dave for metformin 500 mg and lisinopril 10mg. For Drug-Interactions, may you please assist Ms. Martha with her medication administration?
Scenario 1: Mrs. Ned visited your pharmacy with the following symptoms: sneezing, itching of the nose, mouth and eyes; watery eyes, a stuffy nose, a runny nose, a sore throat, and wheezing. As a pharmacist, you must explain to Ms. Ned why she is suffering from the following symptoms.
Ms. Ned is suffering from the following symptoms because of Allergic Rhinitis (Allergies)
Allergic rhinitis is the medical term for hay fever or allergies. You have an allergy when your body overreacts to things that don't cause problems for most people. These things are called allergens. Your body's overreaction to the allergens is what causes symptoms.
There are 2 forms of allergic rhinitis:
Symptoms of allergic rhinitis
Your symptoms can vary, depending on the severity of your allergies. Symptoms can include:
Allergic rhinitis can last several weeks, longer than a cold or the flu. It does not cause fever. The nasal discharge from hay fever is thin, watery, and clear. Nasal discharge from a cold or the flu tends to be thicker. Itching (mostly in the eyes, nose, mouth, throat, and skin) is common with hay fever but not with a cold or the flu. Sneezing occurs more with hay fever. You may even have severe sneeze attacks.
Causes allergic rhinitis
You have an allergy when your body overreacts to things that don't cause problems for most people. These things are called allergens. If you have allergies, your body releases chemicals when you are exposed to an allergen. One such chemical is called histamine. Histamine is your body's defense against the allergen. The release of histamine causes your symptoms.
Hay fever is an allergic reaction to pollen. Pollen comes from flowering trees, grass, and weeds. If you are allergic to pollen, you will notice your symptoms are worse on hot, dry days when wind carries the pollen. On rainy days, pollen often is washed to the ground, which means you are less likely to breathe it.
Allergens that can cause perennial allergic rhinitis include:
Allergic rhinitis cannot be prevented. You can help your symptoms by avoiding the things that cause your symptoms, including:
Allergic rhinitis treatment
Several medicines can be used to treat allergies. Your doctor will help you determine what medicine is best for you depending on your symptoms, age, and overall health. These medicines help prevent symptoms if you use them regularly, before you're exposed to allergens.
Scenario 2: Discuss the COPD management strategy to your provider, and when is the optimal time to provide antibiotics to your patient?
COPD is commonly misdiagnosed. Many people who have COPD may not be diagnosed until the disease is advanced.
To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, and discuss any exposure you've had to lung irritants especially cigarette smoke. Your doctor may order several tests to diagnose your condition.
Tests may include:
Treatment
Many people with COPD have mild forms of the disease for which little therapy is needed other than smoking cessation. Even for more advanced stages of disease, effective therapy is available that can control symptoms, slow progression, reduce your risk of complications and exacerbations, and improve your ability to lead an active life.
Quitting smoking
The most essential step in any treatment plan for COPD is to quit all smoking. Stopping smoking can keep COPD from getting worse and reducing your ability to breathe. But quitting smoking isn't easy. And this task may seem particularly daunting if you've tried to quit and have been unsuccessful.
Talk to your doctor about nicotine replacement products and medications that might help, as well as how to handle relapses. Your doctor may also recommend a support group for people who want to quit smoking. Also, avoid secondhand smoke exposure whenever possible.
Medications
Several kinds of medications are used to treat the symptoms and complications of COPD. You may take some medications on a regular basis and others as needed.
Bronchodilators
Bronchodilators are medications that usually come in inhalers — they relax the muscles around your airways. This can help relieve coughing and shortness of breath and make breathing easier. Depending on the severity of your disease, you may need a short-acting bronchodilator before activities, a long-acting bronchodilator that you use every day or both.
Examples of short-acting bronchodilators include:
Examples of long-acting bronchodilators include:
Inhaled steroids
Inhaled corticosteroid medications can reduce airway inflammation and help prevent exacerbations. Side effects may include bruising, oral infections and hoarseness. These medications are useful for people with frequent exacerbations of COPD. Examples of inhaled steroids include:
Combination inhalers
Some medications combine bronchodilators and inhaled steroids. Examples of these combination inhalers include:
Combination inhalers that include more than one type of bronchodilator also are available. Examples of these include:
Oral steroids
For people who experience periods when their COPD becomes more severe, called moderate or severe acute exacerbation, short courses (for example, five days) of oral corticosteroids may prevent further worsening of COPD. However, long-term use of these medications can have serious side effects, such as weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection.
Phosphodiesterase-4 inhibitors
A medication approved for people with severe COPD and symptoms of chronic bronchitis is roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug decreases airway inflammation and relaxes the airways. Common side effects include diarrhea and weight loss.
Theophylline
When other treatment has been ineffective or if cost is a factor, theophylline (Elixophyllin, Theo-24, Theochron), a less expensive medication, may help improve breathing and prevent episodes of worsening COPD. Side effects are dose related and may include nausea, headache, fast heartbeat and tremor, so tests are used to monitor blood levels of the medication.
Antibiotics
Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate COPD symptoms. Antibiotics help treat episodes of worsening COPD, but they aren't generally recommended for prevention. Some studies show that certain antibiotics, such as azithromycin (Zithromax), prevent episodes of worsening COPD, but side effects and antibiotic resistance may limit their use.
Lung therapies
Doctors often use these additional therapies for people with moderate or severe COPD:
Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There are several devices that deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town.
Some people with COPD use oxygen only during activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy proved to extend life. Talk to your doctor about your needs and options.
Pulmonary rehabilitation program. These programs generally combine education, exercise training, nutrition advice and counseling. You'll work with a variety of specialists, who can tailor your rehabilitation program to meet your needs.
Pulmonary rehabilitation after episodes of worsening COPD may reduce readmission to the hospital, increase your ability to participate in everyday activities and improve your quality of life. Talk to your doctor about referral to a program.
Surgery
Surgery is an option for some people with some forms of severe emphysema who aren't helped sufficiently by medications alone. Surgical options include:
Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung tissue from the upper lungs. This creates extra space in your chest cavity so that the remaining healthier lung tissue can expand and the diaphragm can work more efficiently. In some people, this surgery can improve quality of life and prolong survival.
Endoscopic lung volume reduction a minimally invasive procedure has recently been approved by the U.S. Food and Drug Administration to treat people with COPD. A tiny one-way endobronchial valve is placed in the lung, allowing the most damaged lobe to shrink so that the healthier part of the lung has more space to expand and function.
Scenario 3: Mrs. Betty called you to pick up her prescription. Her Physician prescribed the following medications for Allergic Rhinitis: Levocetirizine 10 mg OD, Nafarin A 5 tabs every 6 hours as needed for nasal congestions with Body Malaise. Since last month, she has been taking Betamethasone 5 mg tablets. For her maintenance medications, she requests a prescription from Dr. Dave for metformin 500 mg and lisinopril 10mg. For Drug-Interactions, may you please assist Ms. Martha with her medication administration?
Allergic rhinitis
- is a common chronic respiratory illness that affects quality of life, productivity, and other comorbid conditions, including asthma. Treatment should be based on the patient's age and severity of symptoms. Patients should be advised to avoid known allergens and be educated about their condition. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation). With the exception of cetirizine, second-generation antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less than adequate response to usual treatments. Evidence does not support the use of mite-proof impermeable covers, air filtration systems, or delayed exposure to solid foods in infancy.
Pharmacotherapy
Pharmacologic options for the treatment of allergic rhinitis include intranasal corticosteroids, oral and topical antihistamines, decongestants, intranasal cromolyn (Nasalcrom), intranasal anticholinergics, and leukotriene receptor antagonists. The International Primary Care Respiratory Group, British Society for Allergy and Clinical Immunology, and American Academy of Allergy Asthma and Immunology recommend initiating therapy with an intranasal corticosteroid alone for mild to moderate disease and using second-line therapies for moderate to severe disease.
INTRANASAL CORTICOSTEROIDS
Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. They act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa.3 Their onset of action is 30 minutes, although peak effect may take several hours to days, with maximum effectiveness usually noted after two to four weeks of use.
ORAL ANTIHISTAMINES
Histamine is the most studied mediator in early allergic response. It causes smooth muscle constriction, mucus secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis. The first-generation antihistamines include brompheniramine, chlorpheniramine, clemastine, and diphenhydramine (Benadryl). They may cause substantial adverse effects, including sedation, fatigue, and impaired mental status. These adverse effects occur because the older antihistamines are more lipid soluble and more readily cross the blood-brain barrier than second-generation antihistamines. The use of first-generation antihistamines has been associated with poor school performance, impaired driving, and an increase in automobile collisions and work injuries. Although one RCT of 63 children eight to 10 years of age did not show that the short-term use of first- or second-generation antihistamines caused drowsiness or impaired school performance, the children in this study were only treated for three days, and the sample size was small.
INTRANASAL ANTIHISTAMINES
Compared with oral antihistamines, intranasal antihistamines offer the advantage of delivering a higher concentration of medication to a specific targeted area, resulting in fewer adverse effects. Currently, azelastine (Astelin; approved for ages five years and older) and olopatadine (Patanase; approved for ages six years and older) are the two FDA-approved intranasal antihistamine preparations for the treatment of allergic rhinitis. As a class, their onset of action occurs within 15 minutes and lasts up to four hours. Adverse effects include a bitter aftertaste, headache, nasal irritation, epistaxis, and sedation. Although intranasal antihistamines are an option in patients whose symptoms did not improve with second-generation oral antihistamines, their use as first- or second-line therapy is limited by their adverse effects and cost compared with second-generation oral antihistamines, and by their decreased effectiveness compared with intranasal corticosteroids.
DECONGESTANTS
Oral and topical decongestants improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. Although the most commonly available decongestants are phenylephrine, oxymetazoline (Afrin), and pseudoephedrine, the abuse potential for pseudoephedrine should be weighed against its benefits.
Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness. Duration of use for more than three to five days is usually not recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. However, a study of 35 patients found no rebound when oxymetazoline was used for 10 days. Because oral decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia, patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism should only use these medications with close monitoring. A study of 25 patients with controlled hypertension provides some reassurance about the use of oral decongestants; compared with placebo, this randomized crossover study found minimal effect on blood pressure with pseudoephedrine use.
INTRANASAL CROMOLYN
Intranasal cromolyn is available over the counter and is thought to act by inhibiting the degranulation of mast cells. Although safe for general use, it is not considered first-line therapy for allergic rhinitis because of its decreased effectiveness at relieving symptoms compared with antihistamines or intranasal corticosteroids, and its inconvenient dosing schedule of three or four times daily.
INTRANASAL ANTICHOLINERGICS
Ipratropium (Atrovent) has been shown to provide relief only for excessive rhinorrhea. Advantages include that it does not cross the blood-brain barrier and is not systemically absorbed. Adverse effects include dryness of the nasal mucosa, epistaxis, and headache. Compliance is also an issue because it needs to be administered two or three times daily.
LEUKOTRIENE RECEPTOR ANTAGONISTS
Although the leukotriene LTD receptor antagonist montelukast (Singulair) is FDA approved for the treatment of allergic rhinitis, a systematic review of 20 trials involving adults treated with montelukast for allergic rhinitis showed only minimal improvement (which was not clinically relevant) in the symptom of nasal congestion. Another RCT involving 58 adults comparing montelukast with pseudoephedrine for two weeks showed no difference between the two therapies. In addition, two large, independent meta-analyses concluded that although montelukast is better than placebo, it is not as effective as intranasal corticosteroids or antihistamines and should only be considered as second- or third-line therapy.
COMBINATION THERAPY
Although many studies have looked at the combination of an intranasal corticosteroid with an antihistamine or leukotriene receptor antagonist, most have concluded that combination therapy is no more effective than monotherapy with intranasal corticosteroids. However, one study looking at the combination of fluticasone and azelastine found this treatment combination to be superior to either treatment alone in patients with moderate to severe allergic rhinitis. Therefore, although patients should not have therapy initiated with more than one agent, combination therapy is an option for patients with severe or persistent symptoms.
Immunotherapy
Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments. Targeted immunotherapy is the only treatment that changes the natural course of allergic rhinitis, preventing exacerbation. It consists of a small amount of allergen extract given sublingually or subcutaneously over the course of a few years, with maintenance periods typically lasting between three to five years. The greatest risk associated with immunotherapy is anaphylaxis. Although the usefulness of sublingual immunotherapy in adults with allergic rhinitis has been supported by several large trials, studies in children have met with mixed results, and the FDA has yet to approve a commercial product for sublingual use.
Nonpharmacologic Therapies ACUPUNCTURE
Although the precise mechanism by which acupuncture works is unclear, proponents suggest that it releases neurochemicals such as beta-endorphins, enkephalins, and serotonin, which in turn mediate the inflammatory pathways involved in allergic rhinitis. Based on RCTs looking at acupuncture as a treatment for allergic rhinitis in adults and children, there is insufficient evidence to support or refute its use.
Diagnosis and Treatment of Allergic Rhinitis
Diagnosis of Allergic Rhinitis
A doctor usually diagnoses allergic rhinitis based on symptoms. You should be asked questions about what your symptoms are, when your symptoms occur, and if you've noticed anything that makes your symptoms worse. Your doctor may recommend skin and blood tests to identify what you're having an allergic reaction to. A skin test involves your doctor pricking your skin with common allergens, and watching for swelling and redness. The blood tests can show compounds related to an allergic response.
At Home Treatments for Allergic Rhinitis
If your allergic rhinitis symptoms are mild to moderate, you may be able to treat them yourself using over the counter products. A nasal spray or neti pot can help wash the mucus out of your nose, and make breathing a little easier. Make sure you use a saline solution from a pharmacy, and to follow the directions. Avoid using saline sprays that contain benzalkonium chloride, though, as they may make your symptoms worse.
Some over the counter medications may prove useful, as well. Antihistimines such as Claritin, Zyrtec, and Allegra can help reduce the symptoms of your allergic reaction. There are also antihistimine nasal sprays available. Depending on your symptoms, you may want to try decongestants to reduce nasal congestion, but for no more than three days.
Prescription Treatments for Allergic Rhinitis
If your allergic rhinitis is severe, or is not responding to at home treatments, your doctor may prescribe a corticosteroid spray. A corticosteroid works to directly reduce the inflammation.
Another option your doctor may explore is a leukotriene modifier. Leukotriene is produced by your immune system, and is the cause of the inflammation. Leukotriene modifiers block these compounds, preventing the allergic reaction.
Step-by-step explanation
Scenario 1: Mrs. Ned visited your pharmacy with the following symptoms: sneezing, itching of the nose, mouth and eyes; watery eyes, a stuffy nose, a runny nose, a sore throat, and wheezing. As a pharmacist, you must explain to Ms. Ned why she is suffering from the following symptoms.
Ms. Ned is suffering from the following symptoms because of Allergic Rhinitis (Allergies)
Allergic rhinitis is the medical term for hay fever or allergies. You have an allergy when your body overreacts to things that don't cause problems for most people. These things are called allergens. Your body's overreaction to the allergens is what causes symptoms.
There are 2 forms of allergic rhinitis:
Symptoms of allergic rhinitis
Your symptoms can vary, depending on the severity of your allergies. Symptoms can include:
Allergic rhinitis can last several weeks, longer than a cold or the flu. It does not cause fever. The nasal discharge from hay fever is thin, watery, and clear. Nasal discharge from a cold or the flu tends to be thicker. Itching (mostly in the eyes, nose, mouth, throat, and skin) is common with hay fever but not with a cold or the flu. Sneezing occurs more with hay fever. You may even have severe sneeze attacks.
Causes allergic rhinitis
You have an allergy when your body overreacts to things that don't cause problems for most people. These things are called allergens. If you have allergies, your body releases chemicals when you are exposed to an allergen. One such chemical is called histamine. Histamine is your body's defense against the allergen. The release of histamine causes your symptoms.
Hay fever is an allergic reaction to pollen. Pollen comes from flowering trees, grass, and weeds. If you are allergic to pollen, you will notice your symptoms are worse on hot, dry days when wind carries the pollen. On rainy days, pollen often is washed to the ground, which means you are less likely to breathe it.
Allergens that can cause perennial allergic rhinitis include:
Allergic rhinitis cannot be prevented. You can help your symptoms by avoiding the things that cause your symptoms, including:
Allergic rhinitis treatment
Several medicines can be used to treat allergies. Your doctor will help you determine what medicine is best for you depending on your symptoms, age, and overall health. These medicines help prevent symptoms if you use them regularly, before you're exposed to allergens.
Scenario 2: Discuss the COPD management strategy to your provider, and when is the optimal time to provide antibiotics to your patient?
COPD is commonly misdiagnosed. Many people who have COPD may not be diagnosed until the disease is advanced.
To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, and discuss any exposure you've had to lung irritants especially cigarette smoke. Your doctor may order several tests to diagnose your condition.
Tests may include:
Treatment
Many people with COPD have mild forms of the disease for which little therapy is needed other than smoking cessation. Even for more advanced stages of disease, effective therapy is available that can control symptoms, slow progression, reduce your risk of complications and exacerbations, and improve your ability to lead an active life.
Quitting smoking
The most essential step in any treatment plan for COPD is to quit all smoking. Stopping smoking can keep COPD from getting worse and reducing your ability to breathe. But quitting smoking isn't easy. And this task may seem particularly daunting if you've tried to quit and have been unsuccessful.
Talk to your doctor about nicotine replacement products and medications that might help, as well as how to handle relapses. Your doctor may also recommend a support group for people who want to quit smoking. Also, avoid secondhand smoke exposure whenever possible.
Medications
Several kinds of medications are used to treat the symptoms and complications of COPD. You may take some medications on a regular basis and others as needed.
Bronchodilators
Bronchodilators are medications that usually come in inhalers — they relax the muscles around your airways. This can help relieve coughing and shortness of breath and make breathing easier. Depending on the severity of your disease, you may need a short-acting bronchodilator before activities, a long-acting bronchodilator that you use every day or both.
Examples of short-acting bronchodilators include:
Examples of long-acting bronchodilators include:
Inhaled steroids
Inhaled corticosteroid medications can reduce airway inflammation and help prevent exacerbations. Side effects may include bruising, oral infections and hoarseness. These medications are useful for people with frequent exacerbations of COPD. Examples of inhaled steroids include:
Combination inhalers
Some medications combine bronchodilators and inhaled steroids. Examples of these combination inhalers include:
Combination inhalers that include more than one type of bronchodilator also are available. Examples of these include:
Oral steroids
For people who experience periods when their COPD becomes more severe, called moderate or severe acute exacerbation, short courses (for example, five days) of oral corticosteroids may prevent further worsening of COPD. However, long-term use of these medications can have serious side effects, such as weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection.
Phosphodiesterase-4 inhibitors
A medication approved for people with severe COPD and symptoms of chronic bronchitis is roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug decreases airway inflammation and relaxes the airways. Common side effects include diarrhea and weight loss.
Theophylline
When other treatment has been ineffective or if cost is a factor, theophylline (Elixophyllin, Theo-24, Theochron), a less expensive medication, may help improve breathing and prevent episodes of worsening COPD. Side effects are dose related and may include nausea, headache, fast heartbeat and tremor, so tests are used to monitor blood levels of the medication.
Antibiotics
Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate COPD symptoms. Antibiotics help treat episodes of worsening COPD, but they aren't generally recommended for prevention. Some studies show that certain antibiotics, such as azithromycin (Zithromax), prevent episodes of worsening COPD, but side effects and antibiotic resistance may limit their use.
Lung therapies
Doctors often use these additional therapies for people with moderate or severe COPD:
Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There are several devices that deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town.
Some people with COPD use oxygen only during activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy proved to extend life. Talk to your doctor about your needs and options.
Pulmonary rehabilitation program. These programs generally combine education, exercise training, nutrition advice and counseling. You'll work with a variety of specialists, who can tailor your rehabilitation program to meet your needs.
Pulmonary rehabilitation after episodes of worsening COPD may reduce readmission to the hospital, increase your ability to participate in everyday activities and improve your quality of life. Talk to your doctor about referral to a program.
Surgery
Surgery is an option for some people with some forms of severe emphysema who aren't helped sufficiently by medications alone. Surgical options include:
Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung tissue from the upper lungs. This creates extra space in your chest cavity so that the remaining healthier lung tissue can expand and the diaphragm can work more efficiently. In some people, this surgery can improve quality of life and prolong survival.
Endoscopic lung volume reduction a minimally invasive procedure has recently been approved by the U.S. Food and Drug Administration to treat people with COPD. A tiny one-way endobronchial valve is placed in the lung, allowing the most damaged lobe to shrink so that the healthier part of the lung has more space to expand and function.
Scenario 3: Mrs. Betty called you to pick up her prescription. Her Physician prescribed the following medications for Allergic Rhinitis: Levocetirizine 10 mg OD, Nafarin A 5 tabs every 6 hours as needed for nasal congestions with Body Malaise. Since last month, she has been taking Betamethasone 5 mg tablets. For her maintenance medications, she requests a prescription from Dr. Dave for metformin 500 mg and lisinopril 10mg. For Drug-Interactions, may you please assist Ms. Martha with her medication administration?
Allergic rhinitis
- is a common chronic respiratory illness that affects quality of life, productivity, and other comorbid conditions, including asthma. Treatment should be based on the patient's age and severity of symptoms. Patients should be advised to avoid known allergens and be educated about their condition. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation). With the exception of cetirizine, second-generation antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less than adequate response to usual treatments. Evidence does not support the use of mite-proof impermeable covers, air filtration systems, or delayed exposure to solid foods in infancy.
Pharmacotherapy
Pharmacologic options for the treatment of allergic rhinitis include intranasal corticosteroids, oral and topical antihistamines, decongestants, intranasal cromolyn (Nasalcrom), intranasal anticholinergics, and leukotriene receptor antagonists. The International Primary Care Respiratory Group, British Society for Allergy and Clinical Immunology, and American Academy of Allergy Asthma and Immunology recommend initiating therapy with an intranasal corticosteroid alone for mild to moderate disease and using second-line therapies for moderate to severe disease.
INTRANASAL CORTICOSTEROIDS
Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. They act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa.3 Their onset of action is 30 minutes, although peak effect may take several hours to days, with maximum effectiveness usually noted after two to four weeks of use.
ORAL ANTIHISTAMINES
Histamine is the most studied mediator in early allergic response. It causes smooth muscle constriction, mucus secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis. The first-generation antihistamines include brompheniramine, chlorpheniramine, clemastine, and diphenhydramine (Benadryl). They may cause substantial adverse effects, including sedation, fatigue, and impaired mental status. These adverse effects occur because the older antihistamines are more lipid soluble and more readily cross the blood-brain barrier than second-generation antihistamines. The use of first-generation antihistamines has been associated with poor school performance, impaired driving, and an increase in automobile collisions and work injuries. Although one RCT of 63 children eight to 10 years of age did not show that the short-term use of first- or second-generation antihistamines caused drowsiness or impaired school performance, the children in this study were only treated for three days, and the sample size was small.
INTRANASAL ANTIHISTAMINES
Compared with oral antihistamines, intranasal antihistamines offer the advantage of delivering a higher concentration of medication to a specific targeted area, resulting in fewer adverse effects. Currently, azelastine (Astelin; approved for ages five years and older) and olopatadine (Patanase; approved for ages six years and older) are the two FDA-approved intranasal antihistamine preparations for the treatment of allergic rhinitis. As a class, their onset of action occurs within 15 minutes and lasts up to four hours. Adverse effects include a bitter aftertaste, headache, nasal irritation, epistaxis, and sedation. Although intranasal antihistamines are an option in patients whose symptoms did not improve with second-generation oral antihistamines, their use as first- or second-line therapy is limited by their adverse effects and cost compared with second-generation oral antihistamines, and by their decreased effectiveness compared with intranasal corticosteroids.
DECONGESTANTS
Oral and topical decongestants improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. Although the most commonly available decongestants are phenylephrine, oxymetazoline (Afrin), and pseudoephedrine, the abuse potential for pseudoephedrine should be weighed against its benefits.
Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness. Duration of use for more than three to five days is usually not recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. However, a study of 35 patients found no rebound when oxymetazoline was used for 10 days. Because oral decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia, patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism should only use these medications with close monitoring. A study of 25 patients with controlled hypertension provides some reassurance about the use of oral decongestants; compared with placebo, this randomized crossover study found minimal effect on blood pressure with pseudoephedrine use.
INTRANASAL CROMOLYN
Intranasal cromolyn is available over the counter and is thought to act by inhibiting the degranulation of mast cells. Although safe for general use, it is not considered first-line therapy for allergic rhinitis because of its decreased effectiveness at relieving symptoms compared with antihistamines or intranasal corticosteroids, and its inconvenient dosing schedule of three or four times daily.
INTRANASAL ANTICHOLINERGICS
Ipratropium (Atrovent) has been shown to provide relief only for excessive rhinorrhea. Advantages include that it does not cross the blood-brain barrier and is not systemically absorbed. Adverse effects include dryness of the nasal mucosa, epistaxis, and headache. Compliance is also an issue because it needs to be administered two or three times daily.
LEUKOTRIENE RECEPTOR ANTAGONISTS
Although the leukotriene LTD receptor antagonist montelukast (Singulair) is FDA approved for the treatment of allergic rhinitis, a systematic review of 20 trials involving adults treated with montelukast for allergic rhinitis showed only minimal improvement (which was not clinically relevant) in the symptom of nasal congestion. Another RCT involving 58 adults comparing montelukast with pseudoephedrine for two weeks showed no difference between the two therapies. In addition, two large, independent meta-analyses concluded that although montelukast is better than placebo, it is not as effective as intranasal corticosteroids or antihistamines and should only be considered as second- or third-line therapy.
COMBINATION THERAPY
Although many studies have looked at the combination of an intranasal corticosteroid with an antihistamine or leukotriene receptor antagonist, most have concluded that combination therapy is no more effective than monotherapy with intranasal corticosteroids. However, one study looking at the combination of fluticasone and azelastine found this treatment combination to be superior to either treatment alone in patients with moderate to severe allergic rhinitis. Therefore, although patients should not have therapy initiated with more than one agent, combination therapy is an option for patients with severe or persistent symptoms.
Immunotherapy
Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments. Targeted immunotherapy is the only treatment that changes the natural course of allergic rhinitis, preventing exacerbation. It consists of a small amount of allergen extract given sublingually or subcutaneously over the course of a few years, with maintenance periods typically lasting between three to five years. The greatest risk associated with immunotherapy is anaphylaxis. Although the usefulness of sublingual immunotherapy in adults with allergic rhinitis has been supported by several large trials, studies in children have met with mixed results, and the FDA has yet to approve a commercial product for sublingual use.
Nonpharmacologic Therapies ACUPUNCTURE
Although the precise mechanism by which acupuncture works is unclear, proponents suggest that it releases neurochemicals such as beta-endorphins, enkephalins, and serotonin, which in turn mediate the inflammatory pathways involved in allergic rhinitis. Based on RCTs looking at acupuncture as a treatment for allergic rhinitis in adults and children, there is insufficient evidence to support or refute its use.
Diagnosis and Treatment of Allergic Rhinitis
Diagnosis of Allergic Rhinitis
A doctor usually diagnoses allergic rhinitis based on symptoms. You should be asked questions about what your symptoms are, when your symptoms occur, and if you've noticed anything that makes your symptoms worse. Your doctor may recommend skin and blood tests to identify what you're having an allergic reaction to. A skin test involves your doctor pricking your skin with common allergens, and watching for swelling and redness. The blood tests can show compounds related to an allergic response.
At Home Treatments for Allergic Rhinitis
If your allergic rhinitis symptoms are mild to moderate, you may be able to treat them yourself using over the counter products. A nasal spray or neti pot can help wash the mucus out of your nose, and make breathing a little easier. Make sure you use a saline solution from a pharmacy, and to follow the directions. Avoid using saline sprays that contain benzalkonium chloride, though, as they may make your symptoms worse.
Some over the counter medications may prove useful, as well. Antihistimines such as Claritin, Zyrtec, and Allegra can help reduce the symptoms of your allergic reaction. There are also antihistimine nasal sprays available. Depending on your symptoms, you may want to try decongestants to reduce nasal congestion, but for no more than three days.
Prescription Treatments for Allergic Rhinitis
If your allergic rhinitis is severe, or is not responding to at home treatments, your doctor may prescribe a corticosteroid spray. A corticosteroid works to directly reduce the inflammation.
Another option your doctor may explore is a leukotriene modifier. Leukotriene is produced by your immune system, and is the cause of the inflammation. Leukotriene modifiers block these compounds, preventing the allergic reaction.
