Patient Encounter Part 1

AW is a 26-year-old woman who presents to your clinic or store. She moved to this part of the country with her husband and 2-year-old son about 3 months ago. She complains of sneezing and runny nose, which began for the first time as an adult about 2 months ago. Her symptoms are worse when she is outdoors, especially if the weather is windy. She has symptoms almost every day, and the symptoms interfere with her sleep. She awakens tired and feels that way most of the day. She indicates that she has no other medical problems and is taking no chronic medications. She asks your recommendation for OTC treatment.

What symptoms are consistent with AR?

How would you categorize this patient's condition?

What would you suggest for initial management?

Table 62-7 Single-Agent Second-Generation Antihistamine Products (Oral and Intranasal)

Oral

SwgjiJtBn^ljmt formulation_Usual Adult Dosage_Usual Pediatric Dosag-r

CMiiaW^tZyiHK,

5. id mg latMAhow

s-io ooco -diiy

&-1! m425 mgonctdiity

generi}

i rvtyml lyiup

li-Jl mg once or twice daily

2-5 yet 2.S-5 mgonte da*ly or 2.5rrej

IWMdUty

6 yo or more, adult dosage

Deflor ¿iodine' (QarmaO

inic) rstxiCi mn/ml iyrgp

$ mcjoiXidjiy

6-11 mn; l mg onwclslly

J.5, S mg dlsinlKjralingtabs

1-5 yoc l-Ji mg once daily

6-11 ym 2.5 intone? diily

fexofenadine* (All«5rat

50, M), HO mo

¿0 mg iwioe dally or

6-J.3 mc* IS mg twice daily

30 mg>5 mL yj4f»nyu(i

180 «nj onci1 tidily

Ml pi 30 mg twice ddity

tevoceNiump iXyjal)

5 mcj tain

5 mg once daly

6-H yw 2.5 m<j once daily

nkJ/5 ml «Anion

& rno-S yar US ring oftediily

laratidine ' Itlarilin:

10 mj ta(>t, 1 mgAnL syrup/susp,

IQmgonce daily

2-5 m 5 mg once daily

WJveit.gwwiO

5, li rnydilHVlL'lirjfliiKI (¿tjs

& yo or moro; aduU doisge

Intrjiniiil Spray

Uiual Adult Qoiagf lEifh

Generic (brand) (fame

mcgyjpfay

Nostril)

Usual Pediatric dosage [iach Wostnl)

Aztkurlnt (AstOiii)

137

1-2 SpUyi twite daily

5-H yO( 1 Sjjuylwktdiiilr1

Otopatddine iPntanjwf

(OS

2 sprays twice dally

ftol approwd for c hll(*en lew (han 12 yo

MoT?. acrivasline is avafeble only with pseurtoeptiednneandso ¡snot included in this Cable

MoT?. acrivasline is avafeble only with pseurtoeptiednneandso ¡snot included in this Cable moi months -ofcH yo, yemi aid. ■AvffldbteOm.

"AvjitjhA1 irt COrrtWrtjIid with (iy>nJfJii:tiCdrin(.'fc(jrtSirl| IdWifiy fai pi.'dijflrk dOwr*1}. only i|)|»«l for kSCfVSth* urlkjiij. not AR. figm HfK i, jq-Mi. J3.

Adjunctive or Secondary Choice Agents Decongestants

Decongestant drugs are useful to relieve the nasal congestion component of 1-3 10 13

AR. ' This is due to their a1 adrenergic agonist activity, which results in constriction of the vasculature in the nasal mucosa. They do not prevent release of any of the mediators involved in AR. Thus, they do not provide any benefit for the sneezing, itching, rhinorrhea, or the ocular manifestations. Decongestants can be given alone, either by the oral or by the intranasal route. Also, numerous combination products, consisting of a decongestant with an antihistamine (and sometimes other ingredients), are available as oral medications. There are some special considerations for use of de-congestants in pediatric and pregnant patients (see the Special Populations section later).

Oral decongestant products are currently limited to pseudoephedrine and phenylephrine (phenylpropanolamine was removed from the market in 2000).i0 Pseudoephedrine has been changed from truly OTC to a more controlled status because it is an ingredient in the illicit manufacture of methamphetamine. The new, so-called behind-the-counter (BTC) status, established by the federal Combat Methaphetamine Act of 2005, requires special storage; photo identification of purchasers; a log book of sales, which must be signed by purchasers; and specific lim-

31,32

itations on daily and monthly quantities. ' Subsequent to this change in status of pseudoephedrine, some manufacturers changed the ingredients of their products by replacing psuedoephedrine with phenylephrine. This was probably to maintain shelf presence in the OTC sales area. However, much controversy surrounds the efficacy of oral phenylephrine. At the time of this writing, the clinical literature suggests that the currently recommended adult dose is minimally effective as a nasal decongest-

33-35 ant.33 35

The side effects of orally administered decongestants most often affect cardiovascular function or the CNS. The side effects are primarily due to sympathetic stimulation, and are usually dose-related. Some elevation of blood pressure may occur, but in normotensive and well-controlled hypertensive patients, the elevation is usually small. It is not of clinical significance in most situations, especially considering that these drugs are most appropriately used only briefly or intermittently. Insomnia, nervousness, irritability, and anxiety are relatively common CNS side effects. Some patients may have decreased appetite, tremors, headache, and even hallucinations. Men with benign prostatic hyperplasia (BPH) and other patients with disorders causing bladder outlet obstruction may have increased urinary retention due to a1 stimulation of the urethral sphincter. Theoretically, there may be some differences in the side effects between pseudoephedrine and phenylephrine. This is due to their effects on sympathetic nervous system receptors. Pseudoephedrine stimulates both a and ft receptors, whereas the effects of recommended oral doses of phenylephrine are essentially limited to stimulation of a receptors. Comparative studies are not available to confirm these differences in the clinical setting.

The intranasal agents currently available include the OTC products phenylephrine, oxymetazoline, and naphazoline, and the prescription product tetrahydrozoline. Product labeling should be followed for dosage, but it is noteworthy that oxymetazoline is the longest acting of these agents, and is usually given only twice daily. Intranasal application of decongestants provides rapid and effective relief of nasal congestion. This therapy may provide relief for nasal congestion, even for those patients already on intranasal corticosteroids.36 However, the continuous use of intranasal decongestants often causes a paradoxical rebound phenomenon of persistent

1 10 37

nasal congestion, called rhinitis medicamentosa. ' ' While some patients do not develop rhinitis medicamentosa even after several weeks of continuous use of intranasal decongestants, the usual recommendation is to use them for no more than three consecutive days.1 Intranasal decongestants can cause local side effects, including stinging, burning, dryness, and even sneezing. These are usually mild and well tolerated. Due to very limited absorption, the intranasal route rarely causes systemic side effects.1,8,10 Administration technique should be optimized as described in Table 62-6. Should rhinitis medicamentosa occur, the best management is first to discontinue the decongestant, possibly with a taper to minimize worsening the situation. However, the response to withdrawal is often delayed for days. Therefore, it may be necessary to start intranasal corticosteroids, and/or (especially if intranasal corticosteroids are already part of the patient's regimen) begin a short course of oral corticost-

eroid.

Despite the usual good tolerance of recommended doses of oral decongestants, caution is warranted when they are used in patients with cardiac disease (dysrhythmi-as, angina pectoris, heart failure), hypertension, cerebrovascular disease, bladder outlet obstruction (including BPH), glaucoma (especially closed angle), hyperthyroid-

1 10 13

ism, and possibly diabetes. ' ' The best application of decongestants in AR

is short-term to overcome severe nasal congestion, especially to facilitate improved efficacy of (other) intranasal agents (e.g., corticosteroids and antihistamines). The choice between the two routes of administration is based on several considerations, including cost, convenience, patient preference, speed of onset (within 30 minutes orally, within 5-10 minutes for intranasal), and side effects.1,8,38

Mast Cell Stabilizer/Cromone1'10'21'22'38

Cromolyn is the only agent in the cromone class that is approved in the United States for treatment of AR. It is available as an OTC intranasal product. The mechanism of action in AR is mast cell stabilization. The drug binds to mast cells, and prevents release of the mediators of AR that would otherwise result from allergen exposure. The drug is moderately effective, but less so than both intranasal corticosteroids and oral or intranasal antihistamines. It does have effects on both early and late phases of AR. Its effects begin within 4 to 7 days of use, but may not be maximal for up to 2 weeks.1 However, it can be used effectively on an as needed basis for episodic exposures to allergen.1 As with all intranasal products, if there is severe nasal congestion, exposure will be limited. Short-term use of a decongestant or an intranasal antihistamine may solve this problem. Cromolyn is very well-tolerated. The most common side effects are mild local stinging and/or burning, sneezing, unpleasant taste, and possibly nose bleed. A disadvantage is the frequency of administration. At least initially, it should be used four times daily. Some patients may need only two or three daily doses when used continuously after the first few weeks at four times daily. It is most useful for patients with mild or intermittent symptoms, in the pediatric population and in pregnant women.

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