CASE STUDY: Allergic Rhinitis

Peter Davies is a 50 year old business man. He has allergic rhinitis and
is hypersensitive to pollen. Peter has had this condition for several
years and is currently treating it himself. His symptoms include
sneezing, rhinorrhoea and nasal blockage. His eyes, nose and palate
are itchy and he is feeling dizzy and drowsy.

Allergic rhinitis produces a local inflammatory response. A number of

substances play an important role in this response. These include:

a. Prostaglandins
Prostaglandins are extremely powerful, both released and responded to by practically
all body tissues. Tissue damage, for example, that caused by infection or trauma,
leads to the release of large amounts of prostaglandins at the site of inflammation.
They have a number of actions including:

• The increased action of histamine (see below).

• Direct action on pain receptors (nociceptors) and the relay of pain messages
to the brain.
• A pyrogenic effect, resetting the hypothalamus or temperature-regulating
centre of the brain at a higher level.

b. Histamine
Mast cells and basophils contain histamine. During inflammation histamine is
released. This substance acts on specific receptors and effects include:

• Vasodilation.
• Increased vascular permeability.
• Spasm of smooth muscle.

c. Leukotrienes
Leukotrienes are released by activated white blood cells (leukocytes) and are found
in inflammatory exudate and tissues in a number of inflammatory conditions. The
action of leukotrienes include:

• Chemotaxis
• Contraction of bronchial muscle.
• Vasodilation.

d. Bradykinin
The increased vascular permeability which occurs during inflammation leads to the
leakage of plasma and other substances from blood vessels. Hageman factor (factor
XII of the blood clotting sequence) is one of these substances. The leakage of this
factor leads to the generation of bradykinin. Bradykinin has a number of effects
including:

• Vasodilation.
 • Increased vascular permeability.
• Transmission of pain messages to the brain.

e. Cytokines
Cytokines are released from, and regulate, the actions of both inflammatory and
immune system cells.

Although allergic rhinitis can cause lethargy, by taking a number of over-the-counter

(OTC) products Peter could have inadvertently overdosed himself. This might be why
he is feeling dizzy and drowsy. It is therefore important to identify which medicines
he has been taking.
Treatment is dependent upon symptoms and whether clients prefer topical or oral
preparations.
Mild disease with occasional symptoms: If symptomatic administer a rapid onset
oral antihistamine or, a topical antihistamine or cromoglycate to eyes and nose.

Moderate disease with prominent nasal symptoms: Intranasal corticosteroid

and topical antihistamines or cromoglycate to the eyes if necessary.

Moderate disease and prominent eye symptoms: Oral antihistamines or

intranasal steroid and topical cromoglycate to the eyes.

Watery rhinorrhoea: The addition of intranasal ipratropium to existing therapy.

The choice of antihistamine should also be based on response and patient

preference. A short acting preparation to relieve intermittent symptoms may be
preferred over a product which provides longer term relief.

The most commonly prescribed medications for allergic rhinitis are H1 antihistamines.
These drugs antagonize the action of histamine by blocking receptor sites on target
cells.

Examples of H1 antihistamines:

Chlorepheniramine maleate: Allergyl®, Anallerge®, Pirafene®

Clemastine: Tavegyl®

Ciproheptadine: Triactin®, Phenergan®

Dimethindene: Fenistil®

Doxylamine succinate: Adwisomn®, Donormyl®

Chlorphenoxamine: Allergex®, Avil®

Although conventional or first-generation antihistamines are efficacious, they can be
associated with drowsiness and performance impairment. Impaired driving
performance has been documented with use of conventional antihistamines, even in
persons with no subjective awareness of drowsiness. Older adults may be more
sensitive to the psychomotor impairment promoted by antihistamines and are at
increased risk for complications such as fractures and subdural hematomas caused
by falls. Prominent anticholinergic effects, including dryness of the mouth and eyes,
constipation, inhibition of micturition, and potential provocation of narrow-angle
glaucoma, can occur. Because of concomitant comorbid conditions (e.g., increased
intraocular pressure, benign prostatic hypertrophy, preexisting cognitive impairment)
that can increase the potential risk associated with regular or even intermittent use,
first-generation antihistamines should be prescribed or recommended cautiously in
older adults.

Second-generation antihistamines, which lack the prominent central nervous system

or anticholinergic properties of conventional antihistamines, are generally preferred.
Second-generation antihistamines include oral fexofenadine, oral levocetirizine, oral
loratidine (available without a prescription), oral desloratidine, oral cetirizine
(available without a prescription), and intranasal azelastine.

Second-Generation Antihistamines

Medication (Trade name) Daily Dose

Azelastine (Azelast®, Zalastin®) 2 sprays in each nostril bid

Cetirizine (Zyrtec®, Histazine®, 5 or 10 mg qd

Cetritin®)

Fexofenadine (Allerfen®, Rapido®, 180 mg qd or 60 mg bid

Telfast®)

Levocetirizine (Levcet®, Allear®) 2.5 or 5 mg qd

Loratidine (Claritine®) 10 mg qd

Desloratidine (Aerius®, Delarex®, 5 mg qd

Desa®)

Other drugs used in case of allergic rhinitis:

Decongestants
Oral decongestants primarily reduce nasal congestion and can attenuate drainage,
but they do not affect sneezing or itching. They are often helpful taken in
combination with an antihistamine.

Intranasal Corticosteroids

Intranasal corticosteroids are the most efficacious agents for managing allergic
rhinitis given that symptoms of allergic rhinitis reflect an inflammatory response
promoted by aeroallergen exposure.

Recommendation:

Peter should avoid exposure to pollen by spending time indoors when the pollen
count is high and ensure windows and doors are closed. It is important that he
understands how to use nasal sprays correctly i.e. as outlined in the product
literature and that he adheres to the treatment regimen. It is also important that
Peter appreciates that although products may not produce an immediate effect, they
should be used regularly. As Peter has previously experienced allergic rhinitis, it
might be helpful to commence treatment before the symptoms of the condition
appear.

Drugs contraindicated in case of Treatment with

Antihistamines:

Contraindications/Precautions:

First-generation antihistamines: Hypersensitivity to specific or structurally related

antihistamines; newborn or premature infants; nursing mothers; narrow-angle
glaucoma; stenosing peptic ulcer; symptomatic prostatic hypertrophy; bladder neck
obstruction; pyloroduodenal obstruction; lower respiratory tract symptoms (including
asthma); monoamine oxidase inhibitor (MAOI) use; elderly, debilitated patients
(cyproheptadine).

Second- and third-generation antihistamines: Hypersensitivity to specific or

structurally related antihistamines. Desloratadine is contraindicated in those with
loratadine hypersensitivity, and cetirizine is contraindicated in those with a known
hypersensitivity to hydroxyzine.

Antihistamines Drug Interactions

Precipitant Drug Object Drug Effect
Antihistamines alcohol, CNS Additive CNS depressant
depressants effects; may be less likely with
second- or third-generation
agents
Azole Antifungals: loratadine, Increase object drug plasma
fluconazole, itraconazole, desloratadine level
keoconazole, miconazole
Cimetadine
Levodopa
Macrolide Antibiotics:
azithromycin, clarithromycin, desloratadine
erythromycin
MAOIs:
phenelzine, isocarboxazid,
tranylcypromine
Protease Inhibitors:
ritonavir, indinavir,
saquinavir, nelfinavir
Serotonin Reuptatke
Inhibitors (SSRIs):
fluoxetine, fluvoxamine,
nefazodone, paroxetine,
sertraline
loratadine Increase object drug plasma
level
promethazine Decrease effect of levodopa
loratadine, Increase object drug plasma
level
first-generation May prolong and intensify
antihistamines anticholingergic and sedative
effects of antihistamines; may
result in hypotension and
extrapyramidal side effects
first-generation Increase object drug plasma
antihistamines, level
loratadine
first-generation Increase object drug plasma
antihistamines level

References:

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/aller
gy/allergic-rhinitis/#bib2

http://www.nurse-prescriber.co.uk/education/Cases/Case%20study%206%20-
%20Allergic%20Rhinitis.htm#ans4

http://pharmacy.oregonstate.edu/drug_policy/pages/dur_board/reviews/article
s/antihistamine-lit.html

Done By: Dr. Rowan Mohamed Ahmed