Community pharmacy lecture no.5 respiratory system rhinitis

Rhinitis inflammation of the nasal lining. characterized by rhinorrhoea, nasal congestion, sneezing and itching. The majority of cases will be viral infection, colds or allergic rhinitis (AR).

Types of allergic rhinitis (AR)  seasonal or perennial AR was based on Timing of the symptoms and is divided into intermittent (occurring on less than 4 days per week and less than 4 weeks at a time). persistent (occurring on more than 4 days per week and more than 4 weeks at a time).

epidemiology Seasonal intermittent allergic rhinitis (hay fever) It is believed that improved living standards and reduced risk of childhood infections might increase susceptibility to hay fever. Allergic rhinitis is a recognized risk factor for the development of asthma and usually precedes it.

differential diagnosis Within the community pharmacy setting the majority of patients who present with rhinitis will be suffering from a cold or intermittent AR. Diagnosis is largely dependent upon the patient having a family history of atopy, clinical symptoms and worsening symptoms at a particular time of year.

Conditions to eliminate Likely causes 1-Persistent AR Persistent AR is much less common than intermittent AR. The problem tends to be persistent and does not exhibit seasonality.

Conditions to eliminate Likely causes (continued) 2-Infective rhinitis This is normally viral in origin and associated with the common cold. Nasal discharge tends to be more mucopurulent than AR and nasal itching is uncommon.

1- Rhinitis of pregnancy Due to hormonal changes. Conditions to eliminate unLikely causes 1- Rhinitis of pregnancy Due to hormonal changes. It usually starts after the second month of the pregnancy, and resolves spontaneously after childbirth. Nasal congestion is the prominent feature.

Conditions to eliminate unLikely causes (continued) 2- Vasomotor rhinitis (intrinsic rhinitis) Vasomotor rhinitis is thought to be due to either an overactive parasympathetic nervous system response, or hypoactive sympathetic nervous system response to irritants such as dry air, pollutants, or strong odours. The symptoms can be similar to AR yet an allergy test will be negative. Itching and sneezing are less common and patients might experience worsening nasal symptoms in response to climatic factors, such as a sudden change in temperature.

Conditions to eliminate unLikely causes (continued) 3- Rhinitis medicamentosa and Medicine-induced rhinitis Prolonged use of topical decongestants (more than 5 to 7 days), which causes rebound vasodilalalion of the nasal arterioles leading to further nasal congestion.  it is thought to be due to de-sensitisation of the alpha adrenoceptors as a result of constant stimulation.

Conditions to eliminate unLikely causes (continued) 4- Nasal blockage  It is possible that the problem is mechanical or anatomical. 5- Nasal foreign body: A trapped foreign body in a nostril commonly occurs in young children, Within a matter of days of the foreign body being lodged the patient experiences an offensive nasal discharge. Any unilateral discharge, particularly in a child should be referred for nasal examination, as it is highly likely that a foreign body is responsible.

Management Allergen avoidance Avoidance of pollen Stay indoors when pollen counts are high Windows should be closed Sunglasses worn. Pollen filter Be away from exhaust fumes and cigarette smoke. The two main causative agents of persistent ar- house dust mite and animal dander

Medication Management of AR falls broadly into two categories; Systemic. Topical.

Systemic therapy 1. Antihistamines Selectively inhibit histamine H1 receptors and suppress many of the vascular effects of histamine. First generation, sedating antihistamines are the preferred antihistamines in pregnancy as the risk of foetal toxicity appears low, data available does not indicate an increased risk of teratogenicity

Systemic therapy (Continued) Antihistamine Non-sedating antihistamines (not truly non-sedating) Acrivastine Cetirizine Loratadine.( lowest in sedation) Sedating antihistamines Chlorphenamine

Topical therapy Antihistamines, corticosteroids, mast cell stabilisers and decongestants. All can be administered intranasally but corticosteroids cannot be administered intraocularly.

A- Intranasal medication 1) Corticosteroids Recommended by the WHO as first-line therapy because they have demonstrate superiority to antihistamines, decongestant and mast cell stabilizer. They have a slow onset of action and patients should be advised that it will take 2 weeks before maximum clinical efficacy is observed.

A- Intranasal medication (Continued) 1) Corticosteroids Patients who regularly suffer from nasal congestion associated with allergic rhinitis should be advised to commence therapy before exposure to the allergen to ensure symptom control.

A- Intranasal medication (Continued) 2) Antihistamines Azelastine is currently the only nasally administered antihistamine marketed for OTC sale. 3) Mast cell stabilisers sodium cromoglicate is a prophylactic agent. The effect of sodium cromoglicate is only partial - it is less effective than corticosteroids. A further drawback with nasal cromoglicate is the frequency of administration;

A- Intranasal medication (Continued) 4) Decongestants Topical decongestants are effective in the treatment of nasal congestion but are of limited value in treating AR as prolonged use is associated with rebound congestion. Their place in therapy is probably best reserved for when nasal congestion needs to be treated quickly and can provide symptom relief whilst corticosteroid therapy is initiated and has time to begin to exert its action.

B- Intraocular medication 1) mast cell stabilisers Sodium cromoglicate 2) antihistamines The only ocular antihistamine available OTC is antazoline. It is available in combination with xylometazoline. It should be used short-term to avoid possible rebound conjunctivitis caused by xylometazoline

B- Intraocular medication (Continued) 3) sympathomimetics Commonly used to control ocular redness and discomfort. Should be restricted to shortterm (less than 5 days) use to avoid rebound effects.

Summary Loratadine should be recommended as first-line therapy if the patient suffers from mild intermittent general symptoms such as nasal itching, sneezing, rhinorrhoea and associated ocular symptoms. If this fails to control all symptoms then sodium cromoglicate eye drops or a corticosteroid nasal spray should be added to the regimen. If a patient has moderate to severe intermittent symptoms, or persistent AR then regular topical nasal corticosteroids are recommended as first-line treatment,