Patient Encounter Part 4

The Big Asthma Lie

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AW returns about 1 year later (she is now 27 years old), and asks what you can recommend for her (now 3-year-old) son, who seems to have developed the same AR that she has. Junior is fussy during the day, constantly rubs his nose, sniffles, and sneezes. He does not sleep through the night because of runny nose and congestion. He even snores because his nose is so stuffed up that he has to breathe through his mouth. She notices dark circles and some lines under his eyes. A neighbor gave her some Benadryl-D Children's Allergy and Sinus and her mother-in-law gave her some Allerfrim. Junior is otherwise healthy, up to date on immunizations and weighs about 16 kg (35 lb). According to the medication labels, the dosage for Junior would be V teaspoonful up to four times a day. So, mom has been giving that dose of both medications for the last 2 days. It helps some, but Junior is even more fussy.

What information suggests that Junior also has AR?

What more information do you need?

What would you recommend at this time?


Omalizumab is a monoclonal antibody that binds to IgE. The product is approved for asthma, but not for AR. It is administered by subcutaneous injection. Dosage is determined by the patient's circulating IgE levels. The cost is high compared to other commonly used modes of therapy for both asthma and AR. Investigational use has demonstrated efficacy in AR, although relative efficacy compared to other modes of therapy for AR is unknown. Its use is best limited to those with concurrent asthma and AR, pending specific approval for AR.

Complementary and Alternative Medicine Therapy

While some would consider saline in the category of complementary and alternative agents, this monograph considers it as an adjunctive mode. Complementary and al-

ternative therapy for AR has been reviewed. Consistent evidence for efficacy has not been established and there are some safety concerns.

Special Populations

Children Generally speaking, the treatment of AR in children is the same as it is for adults. There are, however, limitations in terms of FDA-approved products for different age groups. Also, depending on the age of the patient, there may be administration issues with some products. Most children affected by AR are more than 2 years old, although the disease may begin in children as young as 6 months of age.1

There has been concern about use of combination cough and cold products (many contain an antihistamine and a decongestant) in children. In October 2007, the Nonprescription Drug Advisory Committee of the FDA recommended that OTC combination cough and cold products be limited to children 6 years of age and older. This was based on reports of over 100 deaths in association with these combination products.1 Most of these bad outcomes seem to have resulted from inadvertent overdosage, often by giving doses of the same medication from different combination products. In October 2008, the FDA notified consumers and health care providers that the Consumer Health Protection Agency (CHPA) decided to voluntarily modify the labeling of combination cough and cold products to indicate that they should not be used in children less than 4 years old.43 The CHPA is an association comprised of most of the manufacturers of these products. The announcement indicated that the FDA supports this decision.

First-generation H1 antihistamines are discouraged for children as they are for adults, due to the possible detrimental effects on school performance and learning. Second-generation (less sedating) H1 antihistamines (primarily for mild or intermittent symptoms) or intranasal corticosteroids (for moderate-severe or persistent manifestations) are first-line modes of therapy. Antihistamines may need to be used even for more severe and/or persistent symptoms in those children who have difficulty with use of intranasal products. If necessary, these two classes can be combined.

See Table 62-7 for dosages of second-generation antihistamines by age groups for which they are indicated. If first-generation antihistamines are used, the health care practitioner should guarantee that the family members or caretakers are carefully and thoroughly educated to read and use the dosage recommendations appropriate for age or weight of the patient, as indicated on the product labeling. They should also be warned about the possibility of a paradoxical CNS stimulant side effect. Special care should be given to avoid administration of the same medication from different (especially combination) products. The most common side effects of second-generation antihistamines in children are similar to those for adults.

See Table 62-5 for dosages of intranasal corticosteroids by age groups for which they are indicated. The consensus of opinion about intranasal corticosteroids and systemic side effects, especially delay in growth, is that most products are safe. The greatest potential for problems may exist with beclomethasone.1 Several products have been studied in children and have not been shown to delay growth. However, not every product has been studied carefully in all age groups. Some of the conclusions about safety are extrapolated from data with inhaled corticosteroids, used for asthma. The local side effects of intranasal corticosteroids are the same in children as for adults.

Other therapy options may be worth consideration for some pediatric patients. Montelukast provides an oral alternative, especially for those who are too young to cooperate with intranasal administration of corticosteroids. It may be used in combination with an oral antihistamine in hopes of providing some additional efficacy. Another advantage of montelukast is that it is indicated for children as young as 6 months. Another option for mild or intermittent symptoms is intranasal cromolyn, primarily due to its excellent safety. This OTC product is labeled for use in children 2 years of age and older. Intranasal ipratropium is indicated for patients 6 years of age or older and may benefit unresponsive rhinorrhea.

Table 62-8 Intraocular Medication


GtnfrlC (BrArtd) Nimi1




Maptwullra?' iNaphccm,

OJOIJ% t 0.025*

Foui llrmi dally



Piivint, Oill^il


Nap(iamlirn? f plKniMmlnc1'


Four lirntt ddily

6 yo or mon.L



an( Jit tjmlrn?



F(*|l lirtlttdilly

J yc or mono

Mji( c<HI StdfciiliiW

Cromotyn wnitl

Every-f-6 houis

^ yoor more

Lodojum ido lAbmide)


Four limn, dally

1 yo or mofo

Nedeeiwrill (Atoaf)


Twice dJlly

1 ytiflr frtOit

Pemiiolail (Alamait>


Foui 1im<?s- djily

i yoor more

Antihistamine + mKt

Ajelasilne (Optr^r)


Twif e iHily


cell lUUtfifi

teiiMine itlOilJO


Tvriot daily

J yoor rntme

fetotifen' (Zadito<, Ataway,


Everyfl-I2 hcun

i yoor mtxe

CiiriiiaZvrr«. geneifc}

OkuMUJp (f^IarWl/PaiaiJiy)


Twite d jllji'bfTie djily

3 yOor mmc



T^ioe dally

J or more


Ketorolac lAtuliirl-


Foui limetddily

i yocH mow


lohepjpdrwl lAii^O


Four limes, dally


nSaiD, norKt«ctdal jnhififlanhrulioiy lSlkj. ya. yeare old

'AvgiatJeOTC. Fiofn heft. 1,14, JS, ift.

nSaiD, norKt«ctdal jnhififlanhrulioiy lSlkj. ya. yeare old

'AvgiatJeOTC. Fiofn heft. 1,14, JS, ift.

Table 62-9 Routine Approach to Therapy of AR

All patients should practice avoidance of identified allergens to the extent possible Mild intermittent (including many patients with what some would call seasonal AR) First line :

Oral antihistamine (OTC, initially; preferably second generation) Adjunctive/secondary (may use more than one):

Add OTC oral decongestant for nasal congestion

Add short-term OTC intranasal decongestant for refractory nasal congestion

Add nasal irrigation

Consider prescription therapy for inadequate response (see below) Possibly consider referral for immunotherapy Persistent or moderate-severe First line:

Intranasal corticosteroid

Add oral antihistamine for possible additional benefit if necessary Adjunctive/secondary (may use more than one):

Add short-term intranasal decongestant for refractory nasal congestion

Add nasal irrigation

Add ipratropium for inadequately controlled rhinorrhea

Consider replacement of one first-line agent, if poorly tolerated, with montelukast Consider referral for immunotherapy Episodic (no order of preference intended)

Intranasal cromolyn (OTC) Intranasal antihistamine Intranasal corticosteroid Special situations (children, pregnant women, elderly, athletes, ocular symptoms) See Special Populations section of text

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