Pharmaceutical guidelines of patients with pathology of breathing organs. Symptomatic treatment of RHINITIS

Rhinitis inflammation of the mucous lining of the nose Rhinitis is a nonspecific term that covers infections, allergies, and other disorders whose common feature is the location of their symptoms. In rhinitis, the mucous membranes become infected or irritated, producing a discharge, congestion, and swelling of the tissues. The most widespread form of infectious rhinitis, is the common cold.

Related symptomatic terms Rhinorrhea (secretions discharged from the nose) Nasal congestion is manifested by obstructed nasal passages (“stuffy nose”) and nasal drainage (“runny nose”).

Persistent rhinitis This means that rhinitis symptoms continue long-term (symptoms that last for an hour or more on most days of the year). In many cases the symptoms are present for some part of the day on most days. In some cases the symptoms come and go. The severity can vary. Some people have mild nose irritation which comes and goes, and causes little trouble. On the other hand, some people become distressed by their regular, daily symptoms. Severe symptoms can affect work, school, home and social life.

Persistent allergic rhinitis The most common cause of persistent rhinitis is an allergy to the house dust mite, allergy to pets or other animals Hay fever (caused by an allergy to pollen) is another type of allergic rhinitis. Hay fever tends to be seasonal and not persistent because it occurs during a particular period each year (the grass pollen season during late spring and early summer) Symptoms of allergy in the nose are due to the immune system reacting to the allergen. Cells in the lining of the nose release histamine and other chemicals when they come into contact with the allergen. This causes inflammation in the nose (rhinitis) and the typical symptoms.

Persistent non-allergic rhinitis Triggers for persistent rhinitis (can cause a rhinitis in their own right, but they can also make symptoms worse if a person already have an allergic rhinitis) Irritation of the nose by smoke, strong smells, fumes, chemicals, changes in temperature or humidity. Hormonal changes during pregnancy and puberty, which can sometimes cause nose symptoms. If a person has an overactive thyroid gland, this can also sometimes lead to rhinitis. Food and drink - mainly hot, spicy food, or alcohol. Sensitivity to certain food colourings or preservatives may be a cause. Emotion such as stress or sexual arousal can sometimes affect the nose.

Persistent non-allergic rhinitis Medication - a side-effect from certain medicines is a rare cause. These include: betablocker medicines, aspirin and other anti-inflammatory medicines, angiotensin converting enzyme (ACE) inhibitors, the contraceptive pill and chlorpromazine. Rhinitis medicamentosa - rhinitis that can occur due to the overuse of nasal decongestant sprays. These sprays are used to help a blocked nose and they reduce swelling of blood vessels in the nose. If they are used for more than 5-7 days, the swelling can recur again. The temptation is to use yet more decongestant and a vicious circle can be set up. A similar problem can occur in people who abuse cocaine.

Persistent non-allergic rhinitis In some people, no specific trigger for their persistent rhinitis may be found. This is called idiopathic rhinitis.

Persistent rhinitis Persistent rhinitis is common. It can affect anyone of any age although it affects adults more commonly than children. It is becoming increasingly common in older people. Colds are due to viral infections, and normally only last a week or so. Persistent rhinitis is not due to an infection. -Allergic rhinitis (be it hay fever or persistent rhinitis) tends to run in families. A person is also more likely to develop allergic rhinitis if he already has asthma or eczema. Equally, if a person has allergic rhinitis, he is more likely to develop eczema or asthma. The conditions asthma, eczema and allergic rhinitis are known together as atopic conditions or atopy. A tendency to atopy can run in families.

Causes Comon cold Allergic rhinitis May be treated with OTC agents Nasal polyps Foreign bodies in nasal passage Sinusitis Consultation of a doctor is needed

The common cold The common cold is the most frequent viral infection in the general population, are self-limited, lasting about 3-10 days, although they are sometimes followed by a bacterial infection. Children are more susceptible than adults; teenage boys more susceptible than teenage girls; and adult women more susceptible than adult men.

TREATNING SYMPTOMS Rhinitis accompanied by hyperthermia above 38-38,5 °C An unpleasent smell from a nose Hemorrhagic nasal discharge Purulent nasal discharge Rhinitis accompanied by cough (longer then a week) Rhinitis accompanied by long steading (weeks) hyperthermia

Nasal decongestants are used to relieve nasal obstruction and discharge Adrenergic (sympathomimetic) drugs are most often used for this purpose: relieve nasal congestion and swelling by constricting arterioles and reducing blood flow to nasal mucosa.

Oxymetazoline is a commonly used nasal spray; pseudoephedrine is taken orally. Rebound nasal swelling can occur with excessive or extended use of nasal sprays (eg, >7 days, perhaps sooner).

Sympathomimetic alpha-sympathomimetics (naphazoline, tetrahydrozoline,xylometazoline) Initially, vasoconstriction reduces mucosal blood flow and, hence, capillary pressure. Fluid exuded into the interstitial space is drained through the veins, thus shrinking the nasal mucosa. Due to the reduced supply of fluid, secretion of nasal mucus decreases. In coryza, nasal patency is restored. After vasoconstriction subsides, reactive hyperemia causes renewed exudation of plasma fluid into the interstitial space, the nose is “stuffy” again, and the patient feels a need to reapply decongestant. In this way, a vicious cycle threatens. Besides rebound congestion, persistent use of a decongestant entails the risk of atrophic damage caused by prolonged hypoxia of the nasal mucosa

Menthol Ointment Days of wiping and blowing the nose can leave the skin around nostrils sore and irritated. A simple remedy is to dab a menthol-infused ointment under, but not in, the nose. Menthol has mild numbing agents that can relieve the pain of raw skin. As an added benefit, breathing in the medicated vapors that contain menthol or camphor may help open clogged passages and relieve symptoms of congestion. Use only in children over 2 years of age.

Nasal Strips Another strategy for relieving nighttime congestion is to try over-the-counter nasal strips. These are strips of tape worn on the bridge of the nose to open the nasal passages. While they can't unclog the nose, they do create more space for airflow.

Allergic rhinitis treatment avoiding the cause of the allergy(if a person can avoid the cause of an allergy, symptoms should reduce and stop - this is not as easy as it sounds), antihistamine nose sprays, antihistamine tablets, steroid nose sprays.

Antihistamines Antihistamines relieve allergy symptoms by blocking histamine, the chemical “culprit” that causes many symptoms. Antihistamines are classified as H1 blockers and H2 blockers, depending on the type of receptors (on the surface of cells) that they act on. H1 receptors are associated with human tissue involving capillaries, and H2 receptors predominate in the lining of the stomach.

Antihistamine nasal sprays A dose from an antihistamine nasal spray can rapidly ease itching, sneezing and watering (within 15 minutes or so). It may not be so good at easing congestion. A spray can be used as required if a patient have mild symptoms. It can also be taken regularly to keep symptoms away.

Antihistamine tablets (or liquid medicines) Antihistamines taken by mouth (tablets or liquids) are an alternative. They ease most of the symptoms but may not be so good at relieving nasal congestion (blocked nose). Antihistamines taken by mouth are good if the patient has eye symptoms as well as nose symptoms. They are also usually given to small children instead of a nasal spray. A dose usually works within an hour. Therefore, one can be taken as required if symptoms are mild, or come and go. One can also be taken regularly if symptoms occur each day.

Antihistamines First generation antihistamines Benadryl (diphenhydramine) Chlor-Trimeton (chlorpheniramine)

Antihistamines First generation antihistamines have drawbacks that include being short-acting, making it difficult to concentrate, and drowsiness. The major side effect of this allergy medication is drowsiness. Histamine is actually a neurotransmitter which helps nerve cells communicate, thus allowing brains to work properly. An “antihistamine,” therefore, would block the normal way brains function. The drug manufacturers warn patients who take this medicine to avoid activities in which they need to remain alert, such as: driving, operating machinery, and performing physically dangerous tasks. People who can not avoid these activities are advised to take this medication only at night.

Antihistamines 1st generation other side effects include: increased anxiety, nausea, loss of libido, depression, fatigue, loss of appetite, difficulty with urination, tremors, dry mouth, gastritis, and dizziness.

Antihistamines 2nd generation antihistamines zyrtec (cetirizine) allegra (fexofenadine) clarinex (desloratadine) claritin (loratadine) They are less likely to cause the drowsiness associated with the older medications, so they are often referred to as “nonsedating.” Although claritin has been recently made available over-the-counter, most of the nonsedating antihistamines require a prescription. In general, if these newer antihistamines do not work well for a patient, doctors will then resort to the original, first generation antihistamines.

Antihistamines 3rd generation antihistamines First generation antihistamines can potentially cause problems because of their tendency to cause sedation. Second generation antihistamines such as loratadine and cetirizine were developed in the early 1980s, and they provided a distinct benefit in that they did not cause the side-effect of sedation for patients. A problem developed, however, when some of these newer drugs were found to cause cardiac problems. Third generation antihistamines may soon be the best antihistamines for many patients. They are now being developed in order to eliminate the possibility of cardiac toxicity. One of the first of these, fexofenadine, was approved in July of 1996, and more third generation antihistamines are under development.

Steroid nasal sprays and drops A steroid nasal spray usually works well to clear all the nasal symptoms (itch, sneezing, watering and congestion). It works by reducing inflammation in the nose. A steroid nasal spray also tends to ease eye symptoms. It is not clear how it helps the eye symptoms - but it often does! Steroid nasal drops are also sometimes used. It takes several days for a steroid spray to build up to its full effect. In some people it can take up to three weeks or longer to be fully effective. A steroid nasal spray tends to be the most effective treatment when symptoms are more severe. It can also be used in addition to antihistamines if symptoms are not fully controlled by either alone.

Steroid nasal sprays and drops It is needed to use the spray each day to keep symptoms away. However, once symptoms have gone, the dose of a steroid spray can often be reduced to a low maintenance dose each day to keep symptoms away. Side-effects or problems with steroid nasal sprays are rare

Other nasal sprays They tend to be used if there are problems with any of the above treatments. Sometimes one is used as an add-on treatment in addition to one or more of the above treatments if symptoms are not fully controlled: Sodium cromoglicate nasal spray. Like steroid sprays, it takes a while to build up its effect, and needs to be taken regularly. One disadvantage is that it needs to be taken 4-5 times a day (steroid sprays are taken 1-2 times a day).

Other nasal sprays Ipratropium bromide nasal spray may be worth a try if one have a lot of watery discharge. It has no effect on sneezing or congestion. Decongestant nasal sprays are not usually advised for more than a few days. They have an immediate effect to clear a blocked nose. However, if a person uses one for more than 5-7 days, a rebound, more severe congestion of the nose often develops. One may be useful for a few days to clear a blocked nose when the patient first uses a steroid nasal spray. The steroid can then get to the lining of the nose to work. Don't use decongestant nasal sprays for more than seven days. You should also not use a decongestant nasal spray if you are taking an antidepressant called a monoamine oxidase inhibitor (MAOI).

EYE DROPS in addition to other treatments: Antihistamine eye drops work quickly, using as required to ease a flare-up of eye symptoms or regularly if needed. 'Mast cell stabilisers' are another type of eye drop. They are thought to work by stopping the release of histamine from mast cells. It is needed to use them regularly to prevent symptoms.

Treatment for severe symptoms Rarely, a short course of steroid tablets is prescribed (for students sitting exams, who have severe symptoms which are not eased by other treatments). Steroids usually work well to reduce inflammation. A short course is usually safe.

Duration of treatment Persistent rhinitis is an ongoing (chronic) condition that usually needs regular treatment to prevent symptoms. However, over time the condition may ease, and even go completely in some cases. It may be worth stopping treatment every six months or so to see if symptoms come back without the treatment. The treatment can be started again if symptoms return

Pharmaceutical guidelines RHINITIS All decongestants are not recommended to apply more than 2 weeks Preparations, containing a pseudoephedrine and phenilpropanolamin, can cause sense of anxiety, insomnia, tremor, there is a risk of development of stroke at their application, violations of cerebral circulation of blood (even for young people) and cardiac arrhythmias, delay of urination for patients with the hypertrophy of the prostate gland (pseudoephedrine)

Pharmaceutical guidelines RHINITIS Preparations, containing a pseudoephedrine and phenylpropanolamin, are not combined with an alcohol, are contraindicated the drivers of motor transport Sympathomymetics can cause the increase of blood pressure, therefore it is necessary to appoint them patients with arterial hypertension and hyperthyroidism with a carefulness

Pharmaceutical guidelines RHINITIS Sympathomymetics can cause the increase of ophthalmotonus, therefore it is necessary to appoint them patients with glaucoma with a carefulness Drugs, containing sympathomymetics, can strengthen an action and side effects of antidepressants, monoaminooxidase inhibitors, psychostimulators (increasing of arterial pressure).

Pharmaceutical guidelines RHINITIS Preparations, containing sympathomymetics, can weaken the action of antihypertensives and beta-blockers, that shows up in the increase of pressure and, at combined application with beta-blockers, possibilities of development of heart arrhythmias