Allergic Rhinitis and Allergic Rhinitis and SinusitisSinusitis

for Primary Care Providersfor Primary Care ProvidersSteve Meixel, MDSteve Meixel, MD

Waccamaw Waccamaw

Community CareCommunity Care

ReferenceReference

www.uptodate.com 2014 UpToDate 2014 UpToDate

Pharmacology of allergic rhinitisPharmacology of allergic rhinitis Acute sinusitis and rhinosinusitis in Acute sinusitis and rhinosinusitis in

adultsadults

Why talk about Why talk about Hay Fever and Sinusitis?Hay Fever and Sinusitis?

Very common: affects 10-30% of pop. Very common: affects 10-30% of pop. Our environment:Our environment:

Lots of allergensLots of allergens Long allergy seasonsLong allergy seasons

People are not getting the treatment People are not getting the treatment they need.they need.

Ineffective treatment = MORE Ineffective treatment = MORE problems.problems.

Types and Causes of Allergic ReactionsTypes and Causes of Allergic Reactions

Symptoms of Allergic RhinitisSymptoms of Allergic Rhinitis(Hay Fever):(Hay Fever):

Runny noseRunny nose SneezingSneezing Itchy eyesItchy eyes

How does pollen cause a How does pollen cause a problem?problem?

Treatments:Treatments:

Allergen avoidance: Allergen avoidance: Keep a symptom diaryKeep a symptom diary

Pharmacotherapy Pharmacotherapy (nasal (nasal steroids are first line)steroids are first line)

Allergen immunotherapy Allergen immunotherapy (“allergy shots”)(“allergy shots”)

Decongestants open the Decongestants open the airwayairway

Sudafed (e.g. Claritin D)Sudafed (e.g. Claritin D) Phenylephrine (e.g. Dimetapp, lots of Phenylephrine (e.g. Dimetapp, lots of

others)others)

Afrin Nasal Spray Afrin Nasal Spray BEWARE: Use only 5 days! BEWARE: Use only 5 days!

(or rhinitis medicamentosa can develop)(or rhinitis medicamentosa can develop)

CautionCaution: can cause problems with : can cause problems with urination in MEN (prostatic obstruction)urination in MEN (prostatic obstruction)

Prostate GlandProstate Gland

How to Evaluate a Drug:How to Evaluate a Drug:STEPSTEP

The things that the The things that the patientspatients care care about.about.

SSafetyafety

TTolerabilityolerability

EEfficacyfficacy

PPricerice

Nasal SteroidsNasal Steroids(Flonase, Nasonex, (Flonase, Nasonex,

Rhinocort……)Rhinocort……)

Most effective single therapyMost effective single therapy More effective than antihistamines or More effective than antihistamines or

antihistamine spraysantihistamine sprays Non-sedatingNon-sedating Often also helps with eye itchingOften also helps with eye itching Can work in 3 – 12 hrs.Can work in 3 – 12 hrs. May take 7-10 days to reach full May take 7-10 days to reach full

benefitbenefit

Nasal Steroids Nasal Steroids (Flonase, Nasonex, (Flonase, Nasonex,

Rhinocort……)Rhinocort……) Start at maximal dose and taper lower Start at maximal dose and taper lower

once controlledonce controlled More expensive than antihistaminesMore expensive than antihistamines Caution with glaucomaCaution with glaucoma

Theme: EFFECTIVE! Theme: EFFECTIVE! Start early, may need to use all season, Start early, may need to use all season,

$$$$

Different generations: same Different generations: same effect, but different effect, but different

bioavailability.bioavailability.

11stst generation: Higher bioavailabilty generation: Higher bioavailabilty Beclomethasone (Beconase AQ $196, Qnasl Beclomethasone (Beconase AQ $196, Qnasl

$159) $159) Flunisolide (Nasarel $69)Flunisolide (Nasarel $69) Budesonide (Rhinocort Aqua $135)Budesonide (Rhinocort Aqua $135)

22ndnd generation: lower risk of systemic effects generation: lower risk of systemic effects Fluticasone proprionate (Flonase $106)Fluticasone proprionate (Flonase $106) Fluticasone furoate (Veramyst $137)Fluticasone furoate (Veramyst $137) Mometasone furoate (Nasonex $158)Mometasone furoate (Nasonex $158)

Nasal Steroids: Side EffectsNasal Steroids: Side Effects

Local irritation (2-10%): Local irritation (2-10%): drying, burning, smell, tastedrying, burning, smell, taste

Nosebleeds (2-12%):Nosebleeds (2-12%): Scant blood: stop few days on side of bleed Scant blood: stop few days on side of bleed Frank epistaxis: may need to change type Frank epistaxis: may need to change type

(I have had luck with aqueous)…or stop. (I have had luck with aqueous)…or stop. Direct spray away from septum.Direct spray away from septum. Possible concerns: Glaucoma, CataractsPossible concerns: Glaucoma, Cataracts

Aqueous vs Dry PowderAqueous vs Dry Powder

Aqueous: Aqueous: Tilt head forward Tilt head forward

(to avoid drainage to throat) (to avoid drainage to throat) Dry Powder (Qnasl $159, Zetonna Dry Powder (Qnasl $159, Zetonna

$227)$227) For pts who don’t like wet, run-offFor pts who don’t like wet, run-off Tilt head back, hold breath, Tilt head back, hold breath,

exhale thru mouthexhale thru mouth

Other Nasal SpraysOther Nasal Sprays

Antihistamine:Antihistamine: Azelastine (bitter taste)Azelastine (bitter taste)

Astelin ($194)Astelin ($194) Astepro ($171)Astepro ($171)

OlopatadineOlopatadine Patanase ($194)Patanase ($194)

Combination (antihistamine/steroid): Combination (antihistamine/steroid): Dymista (azelastine/fluticasone) ($182) Dymista (azelastine/fluticasone) ($182)

Oral AntihistaminesOral Antihistamines

11StSt Generation Generation: : (diphenhydramine, (diphenhydramine, chlorpheniramine, hydroxyzine, brompheniramine)– chlorpheniramine, hydroxyzine, brompheniramine)– OTCOTC Sedating, cross blood-brain barrierSedating, cross blood-brain barrier Implicated in fatal MVAsImplicated in fatal MVAs Geriatric problems: confusion, urinary hesitancyGeriatric problems: confusion, urinary hesitancy Problems in children:Problems in children:

Impaired school performanceImpaired school performance Paradoxical agitationParadoxical agitation OTC cold Rx– linked to deaths in <2yoOTC cold Rx– linked to deaths in <2yo

Oral AntihistaminesOral Antihistamines

22ndnd Generation: Generation: e.g. Loratadine, cetirizine, e.g. Loratadine, cetirizine, fexofenadinefexofenadine Avoid unwanted CNS effectsAvoid unwanted CNS effects Have anti-inflammatory propertiesHave anti-inflammatory properties No evidence that tolerance developsNo evidence that tolerance develops No evidence to support H1 & H2 (e.g. No evidence to support H1 & H2 (e.g.

ranitidine)ranitidine) As effective as cromolynAs effective as cromolyn

Cromolyn sodium Cromolyn sodium (NasalCrom)(NasalCrom)

Inhibits mast cell release of antihistamineInhibits mast cell release of antihistamine Safe, even for children >2yoSafe, even for children >2yo Dosing: 3-4x/dayDosing: 3-4x/day Works if used shortly before exposureWorks if used shortly before exposure

E.g. visiting a home with a catE.g. visiting a home with a cat For allergic rhinitis:For allergic rhinitis:

More effective if used just prior to allergy More effective if used just prior to allergy season.season.

$9-13$9-13

Montelukast (Singulair)Montelukast (Singulair)

Approved for allergic rhinitis Approved for allergic rhinitis & & asthmaasthma

Leukotriene receptor antagonistLeukotriene receptor antagonist Good if cannot tolerate nasal spraysGood if cannot tolerate nasal sprays Rare side effects: depression, suicideRare side effects: depression, suicide $170/month $170/month

Ipratropium (Atrovent) Ipratropium (Atrovent) NasalNasal

Controls profuse nasal dischargeControls profuse nasal discharge Not as effective as nasal steroids for Not as effective as nasal steroids for

sneezing, itching, nasal obstructionsneezing, itching, nasal obstruction $130/ bottle$130/ bottle

Therapies requiring Therapies requiring cautioncaution

Nasal decongestants: Nasal decongestants: rhinitis medicamentosarhinitis medicamentosa

OK for <3-5d: OK for <3-5d: At onset of treatmentAt onset of treatment Before air travelBefore air travel

Systemic steroidsSystemic steroids OK at start of treatment if symptoms OK at start of treatment if symptoms

severesevere Avoid steroid shotsAvoid steroid shots

Pregnant WomenPregnant Women

Allergen avoidanceAllergen avoidance Nasal salineNasal saline Intermittent congestion: Intermittent congestion:

Nasal decongestant (for <5d)Nasal decongestant (for <5d) Persistent symptoms:Persistent symptoms:

Nasal budesonide (Rhinocort Aqua)Nasal budesonide (Rhinocort Aqua) CromolynCromolyn Loratidine or cetirizine Loratidine or cetirizine

Important other things: Important other things:

Avoid the allergens (pollen, mold)Avoid the allergens (pollen, mold) Keep windows closedKeep windows closed Set car AC on “inside circulation”Set car AC on “inside circulation” Cat out of the bedroomCat out of the bedroom

Saline (salt water) nose spray (or Saline (salt water) nose spray (or showers)showers) Wash out the allergensWash out the allergens

Change air filters Change air filters Keep diary of symptoms & be a detectiveKeep diary of symptoms & be a detective

Don’tsDon’ts

Don’t use nasal decongestant sprays Don’t use nasal decongestant sprays for longer than 5 days.for longer than 5 days.

Don’t use oral steroids frequently or Don’t use oral steroids frequently or longer than 2 wks.longer than 2 wks. However, I frequently use a short course However, I frequently use a short course

of steroids to arrest the allergies in a of steroids to arrest the allergies in a severely affected patient.severely affected patient.

If nasal steroids are not If nasal steroids are not effective alone…effective alone…

Add a 2Add a 2ndnd generation antihistamine or generation antihistamine or an antihistamine/decongestantan antihistamine/decongestant

Add a topical antihistamine nasal sprayAdd a topical antihistamine nasal spray Antihistamine eye drops Antihistamine eye drops

(for allergic conjunctivitis)(for allergic conjunctivitis) Montelukast (Singulair) – Montelukast (Singulair) –

especially if asthma alsoespecially if asthma also Atrovent NasalAtrovent Nasal

Complications:Complications:

Asthma gets worse.Asthma gets worse.

Sinus infectionsSinus infections Ear infectionsEar infections

Principle: Principle: Body cavities that get blocked get Body cavities that get blocked get infected!infected!

Referral:Referral:

Children with persistent symptoms– Children with persistent symptoms– for consideration of immunotherapyfor consideration of immunotherapy

Patients who fail maximal therapyPatients who fail maximal therapy Coexisting asthma or nasal polypsCoexisting asthma or nasal polyps Recurrent complications (e.g. otitis Recurrent complications (e.g. otitis

media)media) Intolerable side effects from treatmentsIntolerable side effects from treatments Pts. interested in immunotherapyPts. interested in immunotherapy Pts. requiring recurrent systemic steroidsPts. requiring recurrent systemic steroids

SinusitisSinusitis

Acute Rhinosinusitis Acute Rhinosinusitis (lasts < 4weeks) (lasts < 4weeks)

Acute Viral Rhinosinusitis (AAcute Viral Rhinosinusitis (AVVRS):RS): e.g. Cold: usually resolves in 7-10 de.g. Cold: usually resolves in 7-10 d

Acute Bacterial Rhinosinusitis Acute Bacterial Rhinosinusitis (A(ABBRS):RS): Complicates AComplicates AVVRS in 0.5-2%RS in 0.5-2% 40-69% of A40-69% of ABBRS clears spontaneouslyRS clears spontaneously

Clinical Problems:Clinical Problems:

Antibiotics are not needed for AAntibiotics are not needed for AVVRSRS But 85-98% treat with antibiotics (1990)But 85-98% treat with antibiotics (1990)

Problem: Cannot distinguish AProblem: Cannot distinguish ABBRS vs RS vs AAVVRS in first 10 days.RS in first 10 days. How can we limit antibiotic use?How can we limit antibiotic use?

Suspect ASuspect ABBRSRS

AARRS lasts S lasts >> 10d with no improvement 10d with no improvement Severe symptoms: Severe symptoms:

T>102, purulent discharge, facial pain T>102, purulent discharge, facial pain (x3d)(x3d)

Worse symptoms (“double sickening”)Worse symptoms (“double sickening”) Pt was improving.Pt was improving. Then worse symptoms after 5-6d.Then worse symptoms after 5-6d.

Treatment of ATreatment of AVVRS <10d =RS <10d =Supportive CareSupportive Care

1. Acetaminophen (< 3-4g/d) or NSAID1. Acetaminophen (< 3-4g/d) or NSAID

2. Nasal saline2. Nasal saline

3. +/- Nasal steroids: (NNT 15 = $$)3. +/- Nasal steroids: (NNT 15 = $$)

Best in patients with h/o allergic rhinitisBest in patients with h/o allergic rhinitis

4. Nasal decongestants <3-5d (or rebound)4. Nasal decongestants <3-5d (or rebound)

Not helpful in ANot helpful in ABBRSRS

(continued)(continued)

Treatment of ATreatment of AVVRSRS

5. Oral decongestants:5. Oral decongestants:

Not helpful for ANot helpful for ABBRSRS

6. Antihistamines: Not recommended.6. Antihistamines: Not recommended.

No evidence of benefit, + side No evidence of benefit, + side effects effects

7. Mucolytics (e.g. Guaifenesin):7. Mucolytics (e.g. Guaifenesin):

No data to show benefit.No data to show benefit.

Bacterial Sinusitis (ABacterial Sinusitis (ABBRS)RS)

AABBRS is more likely if:RS is more likely if: >> 10 days of symptoms 10 days of symptoms Purulent D/C, Purulent D/C,

facial pressure, facial pressure, nasal congestionnasal congestion

Treatment of ATreatment of ABBRSRS

May observe 3-7d if mild symptoms:May observe 3-7d if mild symptoms: T< 101 (38.3) and mild painT< 101 (38.3) and mild pain Treat if no improvement or if worsensTreat if no improvement or if worsens

Start antibiotics if:Start antibiotics if: Moderate symptoms with clinical AModerate symptoms with clinical ABBRSRS Severe symptomsSevere symptoms

T>102, purulent discharge, facial pain x3dT>102, purulent discharge, facial pain x3d

Recommendation for Recommendation for penicillin non-allergic penicillin non-allergic

patientspatients Amoxicillin-clavulanate for Amoxicillin-clavulanate for 55-7d -7d

500/125mg TID ($46 for 5d) or 500/125mg TID ($46 for 5d) or 875/125mg BID ($33 for 5d)875/125mg BID ($33 for 5d)

2000/125mg BID ($76 for 5d) if 2000/125mg BID ($76 for 5d) if >65yo>65yo recently hospitalizedrecently hospitalized Treated with antibiotic in last monthTreated with antibiotic in last month immunocompromisedimmunocompromised

Penicillin-allergic patientsPenicillin-allergic patients

Doxycycline: 100mg bid x Doxycycline: 100mg bid x 55-7 d-7 d ($6-13 for 5d)($6-13 for 5d)

Respiratory fluoroquinolone Respiratory fluoroquinolone Levofloxacin: 500mg daily x Levofloxacin: 500mg daily x 55-10 d-10 d

($107 for 5d)($107 for 5d) Moxifloxacin: 400mg daily x Moxifloxacin: 400mg daily x 55-10d-10d

($141 for 5d)($141 for 5d)

Not recommended due to Not recommended due to increased bacterial increased bacterial

resistanceresistance

AzithromycinAzithromycin ClarithromycinClarithromycin Trimethoprim-SulfaTrimethoprim-Sulfa CephalosporinsCephalosporins

Pregnant PatientsPregnant Patients

Amoxicillin-clavulanate (class B)Amoxicillin-clavulanate (class B) Azithromycin for pen-allergic (class Azithromycin for pen-allergic (class

B)B)

Don’t useDon’t use

Doxycycline (class D)Doxycycline (class D)

Fluoroquinolones (class C)Fluoroquinolones (class C)

Duration of TreatmentDuration of Treatment

55-7 days is recommended-7 days is recommended

Meta-analysis of 12 trials showed no Meta-analysis of 12 trials showed no difference in cure rates betweendifference in cure rates between 3-6 days vs 6-10 days of treatment3-6 days vs 6-10 days of treatment

22ndnd Line Treatment Line Treatment

Amoxicillin-clavulanate 2000mg/125mg Amoxicillin-clavulanate 2000mg/125mg bidbid

Levofloxacin 500mg dailyLevofloxacin 500mg daily Moxifloxacin 400mg dailyMoxifloxacin 400mg daily

Recommended course is Recommended course is 77 – – 1010 days days

CT scan of sinuses if failure to improve.CT scan of sinuses if failure to improve.

ReferralReferral Early referral:Early referral:

High persistent feverHigh persistent fever Severe headacheSevere headache Meningeal signsMeningeal signs Orbital edema/visual disturbanceOrbital edema/visual disturbance

Less urgent referral: Less urgent referral: Failure to respond to 1Failure to respond to 1stst & 2 & 2ndnd line Rx line Rx 3-4 episodes / year3-4 episodes / year Chronic symptomsChronic symptoms Pts w/ allergic rhinitis who may need immunotherapyPts w/ allergic rhinitis who may need immunotherapy

Hay Fever and SinusitisHay Fever and Sinusitis

Any Questions????Any Questions????