ALLERGIC

RHINITIS
 Pharmacotherapy of
respiratory tract disease
Clinical pharmacy level 5
 Allergic rhinitis is a type of inflammation in the nose that occurs when

the immune system overreacts to allergens in the air.

 • Signs and symptoms include: a runny or stuffy nose, sneezing, red,

itchy, and watery eyes, and swelling around the eyes.

 • Allergic rhinitis is triggered by breathing in tiny particles of

allergens.

 • The most common airborne allergens that cause rhinitis are dust

mites, pollen and spores, and animal skin, urine and saliva
• Chief Complaint
• “I can’t breathe! I feel congested around the clock and am constantly
sneezing.”
• HPI
• James Patrick is a 19-year-old African-American man presenting to his
family medicine clinic with complaints of severe congestion and
persistent sneezing. He states that symptoms are at their worst
immediately upon returning to his apartment every evening and that
they started last August when he moved to his new apartment. Prior to
this move, he noticed symptoms like these on a much more sporadic
basis; since the move they have been bothering him every day, and he
is having trouble sleeping. He hasn’t noticed a fever or a sore throat,
but the symptoms are becoming unbearable. He is seeking advice on
• PMH
• Mild-persistent asthma (diagnosed when he was age 13)
• FH
• Father, age 44, with a history of asthma and allergic rhinitis. Mother, age 38, with a
history of migraines.
• SH
• Lives in an apartment close to his university and place of work; (–) tobacco, (–) illicit
drugs, (+) alcohol, has two cats that he adopted when he moved into his new
apartment.
• Meds
• Diphenhydramine 25 mg PO Q HS (centrally acting histamine-1 (H1) receptor
antagonists)
• Albuterol MDI (A metered dose inhaler (MDI) is a small device that delivers
a measured amount of medication to your lungs) two puffs Q 6 H PRN
• All
• Penicillin (hives)
• ROS
• Denies headaches; no shortness of breath, wheezing, chest pain, or abdominal
discomfort
• Physical Examination
• Gen
• Young African-American male who appears tired and sounds congested. Although
sneezing is a main complaint, he has not sneezed at all during this visit.
• VS
• BP 112/74 mm Hg, P 68 bpm, RR 18, T 36.9°C; Wt 175 lb, Ht 5′10″
• Skin
• HEENT
• NC/AT (Normocephalic, Atraumatic); PERRLA (pupils are equal, round and reactive
to light and accommodation); EOMI (extra-ocular motion intact); (–) periorbital edema
or discoloration; TMs are intact (tympanic membrane); (+) swollen nasal mucous
membranes and nasal turbinates (play an important physiological role by warming
and humidifying inspired air and by regulating nasal airflowbut they also contribute
substantially to nasal airway obstruction, particularly in cases of allergy and viral
upper respiratory infections) with a pale, bluish hue and discharge down the posterior
pharynx; (–) tenderness over frontal and maxillary sinuses; (–) oropharyngeal
lesions; throat is non-erythematous
• Neck/Lymph Nodes
• No lymphadenopathy or thyromegaly
• Chest
• CTA bilaterally; no noticeable wheezing
• CV
• RRR without murmur or rub
• Abd
• Soft, nontender, (+) BS
• Genit/Rect
• Deferred
• Ext
• No erythema, pain, or edema; pulses 2+
• Neuro
• A & O × 3; CN: visual fields and hearing intact; 5/5 strength throughout
 LABS

• Other
• Peak expiratory flow (PEF) (a quick test to measure air flowing out of the lungs):
Patient states that readings are always >80% of personal best (If your score is 80%
of your personal best score and you don't have symptoms, this is usually normal and
nothing to worry about)
• Assessment
• This is a 19-year-old man complaining of signs and symptoms consistent with
moderate–severe persistent perennial allergic rhinitis
 Problem identification
1.A. Create a list of the patient’s drug therapy
problems.
•Uncontrolled moderate-to-severe
persistent perennial allergic rhinitis.
• Seasonal: Symptoms can occur in spring,
summer, and early fall. They are usually caused
by sensitivity to airborne mold spores or to
pollens from trees, grasses, or weeds.
• Perennial: Symptoms occur year-round and
are generally caused by sensitivity to dust mites,
pet hair or mold

• Well-controlled mild persistent asthma.

•Potentially inappropriate use of diphenhydramine.
(First-generation antihistamines are not recommended
for managing persistent allergic rhinitis primarily due to
their adverse effect profiles, including the propensity to
cause sedation).
1.B. What information (signs, symptoms, laboratory
values) indicates the presence or severity of allergic
rhinitis?

Signs and symptoms?

 Desired outcome
2. What are the treatment goals for allergic rhinitis in this
case?
•Eliminate or reduce the severe nasal congestion and sneezing the patient is
experiencing.
If symptoms cannot be eliminated, their frequency and severity should be
minimized as much as possible.
•Prevent future symptoms and comorbidities associated with allergic rhinitis.
• Provide optimal pharmacotherapy with minimal or no adverse effects.
• Maintain the patient’s quality of life.
•Eliminate use of diphenhydramine; there are more effective options with fewer side
effects for treating allergic rhinitis.
 THERAPEUTIC ALTERNATIVES
3.A. WHAT NONDRUG THERAPIES MIGHT BE USEFUL FOR
THIS PATIENT?
• Patients with allergic rhinitis should avoid exposure to cigarette
smoke, pets, and allergens to which they have a known sensitivity.

• Nasal irrigation is beneficial in the treatment of chronic rhinorrhea

and may be used alone or as adjuvant therapy.
 What feasible pharmacoheraputic alternatives are available for treating this
patient’s allergic rhinitis?

 A . Corticosteroids

Intranasal corticosteroids (beclomethasone, fluticasone) are the most effective

medications for treatment of allergic rhinitis.

They improve sneezing, itching, rhinorrhea, and nasal congestion. With an onset of action
that ranges from 3 to 36 hours after first dose. For patients with chronic rhinitis,
improvement may not be seen until 1 to 2 weeks after starting therapy.

Systemic absorption is minimal, and adverse effects of treatment are localized (nasal
irritation, nosebleed, sore throat, and, rarely, candidiasis).

To minimize systemic absorption, patients should be instructed to avoid deep inhalation

during administration into the nose, because the target tissue is the nose, not the lungs or
the throat.
 B. Antihistamines

Oral antihistamines (H1 receptor antagonists) are useful for the management of
symptoms of allergic rhinitis caused by histamine release, such as sneezing, watery
rhinorrhea, and itchy eyes/nose.

First-generation antihistamines (diphenhydramine and chlorpheniramine) are

usually not preferred due to adverse effects, such as sedation, performance
impairment, and other anticholinergic effects. The second-generation
antihistamines (loratadine, cetirizine) are generally better tolerated.

Intranasal antihistamines (olopatadine and azelastine) provide increased delivery of

the drug with fewer adverse effects.

Combinations of antihistamines with decongestants are effective when congestion is a

 C . α-Adrergic agonists

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.

Short-acting α-adrenergic agonists (phenylephrine) and longer-acting

(oxymetazoline) (nasal decongestants) when administered intranasally show few
systemic effects.

Intranasal formulations of α-adrenergic agonists should be used for no longer than

3 days due to the risk of rebound nasal congestion (rhinitis medicamentosa).

For this reason, the α adrenergic agents are not used in the long-term treatment of
allergic rhinitis.
 Administration of oral α-adrenergic agonists
(phenylephrine and pseudoephedrine) results in a longer
duration of action but also increased systemic effects
(increased blood pressure and heart rate). Also, regular
use of them alone or in combination with antihistamines is
not recommended.
 D . Other agents

 Intranasal cromolyn may be useful in allergic rhinitis. Cromolyn is a

prophylactic anti-inflammatory agent that inhibits mast cell degranulation and
release of histamine. To optimize the therapeutic effect, dosing should begin at
least 1 to 2 weeks prior to allergen exposure.

 Some leukotriene receptor antagonists (montelukast) are effective for allergic

rhinitis as monotherapy or in combination with other agents.

 An intranasal formulation of ipratropium is available to treat rhinorrhea

associated with allergic rhinitis or the common cold. The anticholinergic agents
block vagally mediated contraction of airway smooth muscle and mucus
secretion.
 OPTIMAL PLAN
4. What drug, dosage form, dose, schedule, and duration of
therapy are best for this patient?
•Mr. Patrick appears to have persistent perennial allergic rhinitis. While the specific
allergen that is triggering his symptoms is unknown, it appears to be encountered
indoors, so all nonpharmacologic measures suggested in answer (3.a.) above would
be appropriate.
•If he is amenable to an intranasal preparation, either an intranasal corticosteroid or
intranasal antihistamine with intranasal corticosteroid would treat sneezing,
itching, rhinorrea, and conjuncitivis.
•Due to the patient’s congestion, a an intranasal decongestant may be
appropriate to help alleviate congestion.
An example of an acceptable intranasal decongestant is:
`✓ Oxymetazoline 0.05% two to three sprays in each nostril twice daily for 3–5 days.

✓ If little or no response to intranasal decongestant, use intranasal corticosteroids.