1. Allergic Rhinitis and Sinusitis for Primary Care Providers
Steve Meixel, MD
Waccamaw
Community Care

2. Reference www.uptodate.com 2014 UpToDate
Pharmacology of allergic rhinitis
Acute sinusitis and rhinosinusitis in adults

3. Why talk about Hay Fever and Sinusitis?
Very common: affects 10-30% of pop.
Our environment:
Lots of allergens
Long allergy seasons
People are not getting the treatment they need.
Ineffective treatment = MORE problems.

4. Types and Causes of Allergic Reactions

5. Symptoms of Allergic Rhinitis (Hay Fever):
Runny nose
Sneezing
Itchy eyes

6. How does pollen cause a problem?

8. Treatments: Allergen avoidance: Keep a symptom diary
Pharmacotherapy (nasal steroids are first line)
Allergen immunotherapy (“allergy shots”)

9. Decongestants open the airway
Sudafed (e.g. Claritin D)
Phenylephrine (e.g. Dimetapp, lots of others)
Afrin Nasal Spray
BEWARE: Use only 5 days! (or rhinitis medicamentosa can develop)
Caution: can cause problems with urination in MEN (prostatic obstruction)

10. Prostate Gland

11. How to Evaluate a Drug: STEP
The things that the patients care about.
Safety
Tolerability
Efficacy
Price

12. Nasal Steroids (Flonase, Nasonex, Rhinocort……)
Most effective single therapy
More effective than antihistamines or antihistamine sprays
Non-sedating
Often also helps with eye itching
Can work in 3 – 12 hrs.
May take 7-10 days to reach full benefit

13. Nasal Steroids (Flonase, Nasonex, Rhinocort……)
Start at maximal dose and taper lower once controlled
More expensive than antihistamines
Caution with glaucoma
Theme: EFFECTIVE!
Start early, may need to use all season, $$

14. Different generations: same effect, but different bioavailability.
1st generation: Higher bioavailabilty
Beclomethasone (Beconase AQ $196, Qnasl $159)
Flunisolide (Nasarel $69)
Budesonide (Rhinocort Aqua $135)
2nd generation: lower risk of systemic effects
Fluticasone proprionate (Flonase $106)
Fluticasone furoate (Veramyst $137)
Mometasone furoate (Nasonex $158)

15. Nasal Steroids: Side Effects
Local irritation (2-10%):
drying, burning, smell, taste
Nosebleeds (2-12%):
Scant blood: stop few days on side of bleed
Frank epistaxis: may need to change type (I have had luck with aqueous)…or stop.
Direct spray away from septum.
Possible concerns: Glaucoma, Cataracts

16. Aqueous vs Dry Powder Aqueous: Dry Powder (Qnasl $159, Zetonna $227)
Tilt head forward (to avoid drainage to throat)
Dry Powder (Qnasl $159, Zetonna $227)
For pts who don’t like wet, run-off
Tilt head back, hold breath, exhale thru mouth

17. Other Nasal Sprays Antihistamine: Combination (antihistamine/steroid):
Azelastine (bitter taste)
Astelin ($194)
Astepro ($171)
Olopatadine
Patanase ($194)
Combination (antihistamine/steroid):
Dymista (azelastine/fluticasone) ($182)

18. Oral Antihistamines
1St Generation: (diphenhydramine, chlorpheniramine, hydroxyzine, brompheniramine)– OTC
Sedating, cross blood-brain barrier
Implicated in fatal MVAs
Geriatric problems: confusion, urinary hesitancy
Problems in children:
Impaired school performance
Paradoxical agitation
OTC cold Rx– linked to deaths in <2yo

19. Oral Antihistamines
2nd Generation: e.g. Loratadine, cetirizine, fexofenadine
Avoid unwanted CNS effects
Have anti-inflammatory properties
No evidence that tolerance develops
No evidence to support H1 & H2 (e.g. ranitidine)
As effective as cromolyn

20. Cromolyn sodium (NasalCrom)
Inhibits mast cell release of antihistamine
Safe, even for children >2yo
Dosing: 3-4x/day
Works if used shortly before exposure
E.g. visiting a home with a cat
For allergic rhinitis:
More effective if used just prior to allergy season.
$9-13

22. Montelukast (Singulair)
Approved for allergic rhinitis & asthma
Leukotriene receptor antagonist
Good if cannot tolerate nasal sprays
Rare side effects: depression, suicide
$170/month

23. Ipratropium (Atrovent) Nasal
Controls profuse nasal discharge
Not as effective as nasal steroids for sneezing, itching, nasal obstruction
$130/ bottle

24. Therapies requiring caution
Nasal decongestants: rhinitis medicamentosa
OK for <3-5d:
At onset of treatment
Before air travel
Systemic steroids
OK at start of treatment if symptoms severe
Avoid steroid shots

25. Pregnant Women Allergen avoidance Nasal saline
Intermittent congestion:
Nasal decongestant (for <5d)
Persistent symptoms:
Nasal budesonide (Rhinocort Aqua)
Cromolyn
Loratidine or cetirizine

26. Important other things:
Avoid the allergens (pollen, mold)
Keep windows closed
Set car AC on “inside circulation”
Cat out of the bedroom
Saline (salt water) nose spray (or showers)
Wash out the allergens
Change air filters
Keep diary of symptoms & be a detective

28. Don’ts Don’t use nasal decongestant sprays for longer than 5 days.
Don’t use oral steroids frequently or longer than 2 wks.
However, I frequently use a short course of steroids to arrest the allergies in a severely affected patient.

29. If nasal steroids are not effective alone…
Add a 2nd generation antihistamine or an antihistamine/decongestant
Add a topical antihistamine nasal spray
Antihistamine eye drops (for allergic conjunctivitis)
Montelukast (Singulair) – especially if asthma also
Atrovent Nasal

30. Complications: Asthma gets worse. Sinus infections Ear infections
Principle: Body cavities that get blocked get infected!

34. Referral:
Children with persistent symptoms– for consideration of immunotherapy
Patients who fail maximal therapy
Coexisting asthma or nasal polyps
Recurrent complications (e.g. otitis media)
Intolerable side effects from treatments
Pts. interested in immunotherapy
Pts. requiring recurrent systemic steroids

35. Sinusitis

36. Acute Rhinosinusitis (lasts < 4weeks)
Acute Viral Rhinosinusitis (AVRS):
e.g. Cold: usually resolves in 7-10 d
Acute Bacterial Rhinosinusitis (ABRS):
Complicates AVRS in 0.5-2%
40-69% of ABRS clears spontaneously

37. Clinical Problems: Antibiotics are not needed for AVRS
But 85-98% treat with antibiotics (1990)
Problem: Cannot distinguish ABRS vs AVRS in first 10 days.
How can we limit antibiotic use?

38. Suspect ABRS ARS lasts > 10d with no improvement Severe symptoms:
T>102, purulent discharge, facial pain (x3d)
Worse symptoms (“double sickening”)
Pt was improving.
Then worse symptoms after 5-6d.

39. Treatment of AVRS <10d = Supportive Care
1. Acetaminophen (< 3-4g/d) or NSAID 2. Nasal saline 3. +/- Nasal steroids: (NNT 15 = $$) Best in patients with h/o allergic rhinitis 4. Nasal decongestants <3-5d (or rebound) Not helpful in ABRS (continued)

40. Treatment of AVRS
5. Oral decongestants: Not helpful for ABRS 6. Antihistamines: Not recommended. No evidence of benefit, + side effects 7. Mucolytics (e.g. Guaifenesin): No data to show benefit.

41. Bacterial Sinusitis (ABRS)
ABRS is more likely if:
> 10 days of symptoms
Purulent D/C, facial pressure, nasal congestion

43. Treatment of ABRS May observe 3-7d if mild symptoms:
T< 101 (38.3) and mild pain
Treat if no improvement or if worsens
Start antibiotics if:
Moderate symptoms with clinical ABRS
Severe symptoms
T>102, purulent discharge, facial pain x3d

44. Recommendation for penicillin non-allergic patients
Amoxicillin-clavulanate for 5-7d
500/125mg TID ($46 for 5d) or 875/125mg BID ($33 for 5d)
2000/125mg BID ($76 for 5d) if
>65yo
recently hospitalized
Treated with antibiotic in last month
immunocompromised

45. Penicillin-allergic patients
Doxycycline: 100mg bid x 5-7 d
($6-13 for 5d)
Respiratory fluoroquinolone
Levofloxacin: 500mg daily x 5-10 d
($107 for 5d)
Moxifloxacin: 400mg daily x 5-10d
($141 for 5d)

46. Not recommended due to increased bacterial resistance
Azithromycin
Clarithromycin
Trimethoprim-Sulfa
Cephalosporins

47. Pregnant Patients Amoxicillin-clavulanate (class B)
Azithromycin for pen-allergic (class B)
Don’t use
Doxycycline (class D)
Fluoroquinolones (class C)

48. Duration of Treatment 5-7 days is recommended
Meta-analysis of 12 trials showed no difference in cure rates between
3-6 days vs 6-10 days of treatment

49. 2nd Line Treatment Amoxicillin-clavulanate 2000mg/125mg bid
Levofloxacin 500mg daily
Moxifloxacin 400mg daily
Recommended course is 7 – 10 days
CT scan of sinuses if failure to improve.

50. Referral Early referral: Less urgent referral: High persistent fever
Severe headache
Meningeal signs
Orbital edema/visual disturbance
Less urgent referral:
Failure to respond to 1st & 2nd line Rx
3-4 episodes / year
Chronic symptoms
Pts w/ allergic rhinitis who may need immunotherapy

52. Hay Fever and Sinusitis
Any Questions????