inflammation of the nasal mucous membrane with one or more of the following: nasal congestion, rhinorrhea (runny nose), sneezing, and itching.
There are several types of _____ including nonallergic ____ and occupational _____, and allergic ____.
Rhinitis caused by a mucous membrane exposure to inhaled allergenic materials that elicit a specific response mediated by IgE
Seasonal allergic rhinitis
allergic rhinitis that occurs in response to specific allergens present at predictable times of the year
Perennial allergic rhinitis
allergic rhinitis that occurs year round
Episodic allergic rhinitis
allergic rhinitis that occurs by sporadic exposures to allergens that are not usually en- countered in the patient's indoor or outdoor environment (e.g., visiting a home with pets when the patient has no pet exposure in their own home or work environment)
inflammation of the conjunctiva that is medicated by IgE and is associated with itching, erythema (i.e., redness), and tearing
i. The outer layer of the eye (which is a thin epithelium)
ii. A thin, transparent mucous membrane that lines the eyelids and covers the visible part of the eye
iii. Functions to lubricate the eye by secreting oils and mucus
A protein that elicits an allergic response
Seasonal Allergic Rhinitis Allergens include:
i. Tree pollens (spring)
ii. Grass pollens (late spring-early summer)
iii. Weed pollens (late summer-early fall)
Perennial Allergic Rhinitis Allergens
i. Mold spores
ii. House dust mite fecal proteins
iii. Animal dander
Tree pollen allergen (season)
Grass pollen allergen (season)
(Season): Late Spring - Early Summer
Weed pollen allergen (season)
(Season): Late Summer - Early Fall
Risk factors for allergic rhinitis
a. Family history of atopy
b. Higher Socioeconomic classes
c. Higher serum IgE levels (>100 IU/mL) before age six
d. Positive allergy skin prick test
state of hypersensitivity to an allergen
Antibody present on the surface of basophils.
Results in release of histamine and heparin during allergic and inflammatory reactions.
Most Common Causes of Drug-Induced Rhinitis
a. Ace inhibitors
b. ?-receptor antagonists
c. Phosphodiesterase-5 selective inhibitors
i. Provides airway for respiration
ii. Moistens and warms entering air
iii. Filters and cleans inspired air
iv. Serves as a resonating chamber for speech
v. Houses the olfactory (smell receptors)
i. Lies posterior to the external nose
ii. Comprises large surface area lined by an epithelial mucous membrane
i. Consists of an epithelium (sheet of cells)
ii. Supported by an underlying layer of connective tissue
iii. Coated with viscous fluid (mucus) secreted by either goblet cells strewn throughout the epithelium and/or underlying mucous glands
i. Resident to the nasal cavity
ii. Release watery fluid containing lysosome (chemically destroys bacteria)
i. Continuous with pharynx, larynx
a. Air filled spaces located within the bones of the face
Continuous with the nasal cavity and produce mucus and fluids that drain into the nasal cavity.
(also called nasal conchae) extend the length of the nasal cavity and can increase the mucosal surface area when they become engorged with blood.
As a consequence of increased blood flow, ___________ swell and reduce the airflow through the nose causing nasal congestion.
the conchae (turbinates)
hypersensitivity reaction (general definition)
An immune response in itself, if excessive or aberrant, that can also cause tissue injury and disease
Hypersensitivity reaction (mechanism
Upon subsequent exposure to allergen, the allergen binds to and cross-links the IgE molecules. This event causes mast cells and basophils, to rapidly release the contents of their secretory vesicles, a process called degranulation, as well as to synthesiz
(function): causes vasodilation, increased vascular permeability (edema), and the transient contraction of smooth muscle;
(function): causes damage to local tissues
(function): arachidonic acid metabolite that causes
(function): arachidonic acid metabolite that stimulates prolonged smooth muscle contraction; and
(function): induce local inflammation, and stimulate the recruitment of immune cells (eosinophils, neutrophils, and TH2 cells).
Histamine often causes the following symptoms associated with allergic rhinitis:
-itching & sneezing
-nasal congestion, redness, heat
rhinorrhea results from:
reflexive stimulation of the parasympathetic nervous system leading to secretion of mucus from mucous glands,
itching and sneezing result from:
histamine stimulation of H1 receptors on sensory nerve endings, and
nasal congestion, redness, heat result from:
submucosal edema and engorgement of the nasal turbinates as a result of vasodilation and increased vascular permeability of the blood vessels in the nasal cavity.
Conjunctivitis is associated with
redness of the eyes due to vasodilation of the peripheral small blood vessels.
In patients with allergic rhinitis, an abnormally large number of helper _______ differentiate into ______,
T cells, TH2 Cells
IgE-mediated WBC present in increased numbers during an allergic reaction
Release chemical mediators that promote the migration of additional immune cells to the site, as well as chemicals that are destructive to epithelial tissues.
TH2 cell role
stimulate mast cell- and eosinophil-mediated immunity, as well as the secretion of mucus
____is central to allergic rhinitis by binding to and activating histamine-1 (H1) receptors.
IgE allergen tests are indicated in patients to:
-provide an allergic basis for the patient's symptoms
-to confirm suspected causes of the patient's symptoms
-to assess the sensitivity to a specific allergen for avoidance measures and/or allergen immunotherapy
Epicutaneous skin test
[Diagnostic Tes]: (aka scratch or prick test)
? Performed by making a superficial wound in the outermost layer of the skin. Then a drop of antigen is placed in the wound and allowed to diffuse into the underlying skin.
? Fastest and least expensive screen
Intradermal skin test
? Performed by injecting diluted allergen between the layers of the skin
? Useful in patients who have negative epicutaneous tests, but who are suspected of having an allergic etiology for their symptoms
? A positive test produces a whe
Radioallergosorbent test (RAST)
? In vitro assay that is more expensive and less sensitive than skin tests
? Useful when skin test extracts are not available, when negative controls produce a reaction, when antihistamine therapy cannot be discontinued, or in the prese
Allergic Rhinitis Complications Include:
-inability to sleep
-poor work or school efficiency
-post nasal drip with cough
-loss of smell or taste
-high arched, V-shaped palate due to chronic edema and venous stasis (blood pooling in veins)
-permanent transverse crease across the lower pa
Goals of therapy for allergic rhinitis
Minimize or prevent symptoms.
Minimize side effects of medications.
Maintain a normal lifestyle, including participating in outdoor activities, yard work, and playing with pets as desired.
Nonpharmacologic therapy typically consists of: (summary)
identifying triggers and avoiding triggers when practical
Nonpharmacologic patient counseling includes the following:
Identify triggers and avoid triggers when practical
Mold growth can be reduced by maintaining household humidity below 50% and removing obvious growth with bleach or disinfectant.
Exposure to dust mites can be reduced by encasing mattresses and pillows wi
Why is intranasal drug delivery advantageous?
Nasal tissue is the site of allergic rhinitis
Intranasal drug delivery minimizes systemic drug exposure. >Drug does not distribute into and affect the rest of the body nearly to the same extent as oral delivery (often translates into fewer adverse effects
Counseling points for intranasal drug delivery:
Nasal passages should be cleared prior to administration (i.e., blow your nose before using this drug).
Avoid clearing nasal passage for about 10 minutes after administration (i.e., don't blow your nose right away after using this drug).
Direct the spray
Slow, gradual process of injecting increasing doses of antigens responsible for eliciting allergic symptoms in a patient with the hope of increasing tolerance to the allergen when natural exposure occurs.
Immunotherapy diminishes ______ production, increases _____ production, changes T-lymphocytes, reduces inflammatory mediator release from sensitized cells, and diminishes tissue responsiveness.
In general, very dilute solutions are given _____ times per week. The concentration is increased until the maximum tolerated dose is achieved. This maintenance dose is continued every ______ weeks, depending on clinical response.
Adverse effects of immunotherapy include:
Mild local reactions (e.g., induration and swelling at the site of the injection), generalized urticaria, bronchospasm, laryngospasm, vascular collapse, and anaphylactic reactions.
When patients use the term "antihistamine" they are nearly always referring to ____ receptor antagonists
histamine receptors responsible for allergic symptoms
Located in stomach
Stimulation results in secretion of hydrochloric acid
Antihistamines block histamine from activating H1 receptors, and preventmost of the effects of histamine on _______.
H1 receptor antagonists also block muscarinic acetylcholine receptors, producing:
anticholinergic" effects (i.e., dry mouth and eyes, blurry vision, urinary retention, constipation
Second Generation Oral Antihistamines
Acrivastine/Pseudoephedrine (Semprex-D�) (Rx)
Cetirizine (Zyrtec�) (OTC)
Levocetirizine (Xyzal�) (Rx)
Fexofenadine (Allegra�) (OTC)
Loratadine (Claritin�) (OTC)
Desloratadine (Clarinex�) (Rx)
First Generation Oral Antihistamines
Brompheniramine (Dimetapp�) (OTC)
Chlorpheniramine (Chlor-Trimeton�) (OTC)
Carbinoxamine (Arbinoxa�, Palgic�) (Rx)
Clemastine (Tavist�) (Rx, OTC)
Cyproheptadine (Periactin�) (Rx)
Diphenhydramine (Benadryl�) (Rx, OTC)
Promethazine (Phenergan�) (Rx)
Azelastine (Astelin�, Astepro�) (Rx)
Azelastine/Fluticasone (Dymista�) (Rx)
Olopatidine (Patanase�) (Rx)
Alcaftadine (Lastacaft�) (Rx)
Azelastine (Optivar�) (Rx)
Bepotastine (Bepreve�) (Rx)
Emedastine (Emadine�) (Rx)
Epinastine (Elestat�) (Rx)
Ketotifen (Zaditor�) (OTC)
Olopatidine (Patanol�, Pataday�) (Rx)
Oral second generation agents are listed before oral first generation agents to indicate that
There is a preference of second generation antihistamines over first generation histamines
Second generation agents have little to no __________and do not cause significant ______________ effects
M ACh receptor blockade, anticholinergic
Second generation agents have _________ distribution into CNS and cause ______ CNS-related adverse effects than 1st generation agents
First generation agents have __________ distribution into CNS and cause ________ CNS-related adverse effects
refers to a drug that mimics the neurotransmitters released at the terminus of sympathetic nerves (norepinephrine and epinephrine). Some of these drugs are chemical mimics of epinephrine and norepinephrine, while others are close chemical analogs
?1-Adrenergic Agonist Decongestants (Sympathomimetics)
______ and _____ are close chemical mimics of norepinephrine and epinephrine,