CTMA 2 - Canadian Pharmacists Association

CTMA 2

Canada’s Trusted Reference forMinor Ailments

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Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.

Table of ContentsEditorial Advisory Committee ................................................................................................vii

Authors ........................................................................................................................... viii

Reviewers ........................................................................................................................ ix

Editor's Message ................................................................................................................ x

Editorial Policy, Description and Limitations of Information........................................................... xi

How to Use Compendium of Therapeutics for Minor Ailments ......................................................xii

Patient Assessments ......................................................................................................... xiii

Communicating With Patients1 Effective Pharmacist-patient Interactions, Barbara J. Farrell ...................................................12 Facilitating Behaviour Change, Lisa Dolovich .................................................................... 123 Pharmacist Assessment of the Self-treating Patient, Nardine Nakhla ...................................... 21

Psychiatric Conditions4 Depression, Ric M. Procyshyn and Alasdair M. Barr............................................................ 275 Insomnia, Ric M. Procyshyn and Alasdair M. Barr............................................................... 386 Smoking Cessation, Kristine Petrasko and Manjit Bains....................................................... 52

Central Nervous System Conditions7 Fever, Yvonne M. Shevchuk .......................................................................................... 828 Headache, Irene Worthington ........................................................................................ 999 Heat-related Disorders, Dorothy Tscheng ........................................................................11710 Tinnitus, Yvonne M. Shevchuk ..................................................................................... 12811 Vertigo and Dizziness, Yvonne M. Shevchuk ................................................................... 132

Eye Care12 Assessment of Patients with Eye Conditions, Anne M. Friesen ............................................ 13913 Conjunctivitis, Anne M. Friesen .................................................................................... 14014 Contact Lens Care, David S. Wing and Ken Gellatly ......................................................... 14815 Dry Eye, Anne M. Friesen ........................................................................................... 16216 Eyelid Conditions: Hordeolum, Chalazion and Blepharitis, Anne M. Friesen ........................... 169

Ear Conditions17 Assessment of Patients with Hearing Loss, Ear Pain and Ear Drainage, Yvonne M.

Shevchuk ................................................................................................................ 18718 Complications Affecting the Ear: Ear Piercing, Foreign Bodies and Barotrauma, Yvonne M.

Shevchuk ................................................................................................................ 19319 Impacted Earwax, Yvonne M. Shevchuk......................................................................... 198

iii


Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments

20 Otitis Media and Otitis Externa, Yvonne M. Shevchuk ....................................................... 206

Respiratory Conditions21 Acute Cough, Daniel J.G. Thirion .................................................................................. 21722 Allergic Rhinitis, Jennifer Kendrick ................................................................................ 22623 Assessment of Patients with Upper Respiratory Tract Symptoms, Daniel J.G. Thirion .............. 24924 Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis, Daniel J.G. Thirion ........................... 254

Metabolic and Cardiovascular Conditions25 Diabetes Care, Lori MacCallum .................................................................................... 27326 Diabetes Care Devices, Ronald Silver ........................................................................... 29327 Lifestyle Management and Disease Prevention, L. Maria Gutschi ........................................ 302

Gastrointestinal Conditions28 Assessment of Patients with Abdominal Pain, Peter Thomson ............................................ 32329 Constipation, Jane Bowles-Jordan ................................................................................ 32730 Diarrhea, Antonietta Forrester ...................................................................................... 35331 Dyspepsia and GERD, Co Q. D. Pham .......................................................................... 37832 Gastrointestinal Gas, Co Q. D. Pham............................................................................. 39033 Hemorrhoids, Joyce Chan ........................................................................................... 39834 Infant Colic, Shelita Dattani ......................................................................................... 40735 Irritable Bowel Syndrome, Lynette Kosar ........................................................................ 42036 Nausea and Vomiting, Christine Hughes ........................................................................ 42937 Ostomy Care, Marie Berry........................................................................................... 44838 Perianal Symptom Assessment, Joyce Chan .................................................................. 46339 Pinworms, Joyce Chan ............................................................................................... 465

Nutrition40 Infant Nutrition, Joan Brennan-Donnan .......................................................................... 47241 Special Diets, Shirley Heschuk..................................................................................... 49142 Sports Nutrition, Shirley Heschuk.................................................................................. 50643 Weight Management, Shirley Heschuk........................................................................... 519

Musculoskeletal Conditions44 Drug Use and Abuse in Sports, Lily Lum......................................................................... 54745 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 55446 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 56947 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 59048 Sports Injuries, Lily Lum.............................................................................................. 608

Foot Conditions

iv



49 Assessment of Foot Symptoms, Anne Mallin ................................................................... 62150 Athlete's Foot, Anne Mallin .......................................................................................... 62351 Corns, Calluses, Bunions and Ingrown Toenails, Anne Mallin.............................................. 63152 Plantar Warts, Anne Mallin .......................................................................................... 641

Dermatologic Conditions53 A Summary of Common Skin Conditions, Penny F. Miller ................................................... 64854 Acne, Debra Sibbald .................................................................................................. 65355 Atopic, Contact, and Stasis Dermatitis, Debra Sibbald ....................................................... 68256 Bacterial Skin Infections: Impetigo, Furuncles and Carbuncles, Penny F. Miller ....................... 71657 Burns, Nancy Kleiman ................................................................................................ 73058 Dandruff and Seborrheic Dermatitis, Debra Sibbald .......................................................... 74059 Diaper Dermatitis, Debra Sibbald.................................................................................. 76060 Dressings, Marie Berry ............................................................................................... 77961 Drug-induced Skin Reactions, Sandra Knowles ............................................................... 78662 Dry Skin, Nancy Kleiman ............................................................................................ 80263 Frostbite, Nancy Kleiman ............................................................................................ 80964 Fungal Nail Infections (Onychomycosis), Penny F. Miller.................................................... 81865 Fungal Skin Infections, Penny F. Miller ........................................................................... 82766 Hair Care and Hair Growth, Nancy Kleiman .................................................................... 84267 Insect Bites and Stings, Nancy Kleiman ......................................................................... 86168 Minor Cuts and Wounds, Nancy Kleiman ........................................................................ 87769 Parasitic Skin Infections: Lice and Scabies, Penny F. Miller ................................................ 88670 Perspiration and Body Odour, Nancy Kleiman ................................................................. 90471 Psoriasis, Debra Sibbald............................................................................................. 91572 Prevention and Treatment of Sun-Induced Skin Damage, Nancy Kleiman.............................. 93973 Viral Skin Infections: Common and Flat Warts, Penny F. Miller ............................................ 95674 Viral Skin Rashes, Sandra Knowles............................................................................... 968

Reproductive, Gynecologic and Genitourinary Health75 Benign Prostatic Hyperplasia and Associated Lower Urinary Tract Symptoms, Cheryl A.

Sadowski ................................................................................................................ 98576 Contraception, Anne Marie Whelan ............................................................................... 99977 Dysmenorrhea, Thomas E.R. Brown ............................................................................103178 Male Sexual Dysfunction, Tom Smiley ..........................................................................104179 Menopause and Perimenopause, Thomas E.R. Brown .....................................................105480 Pregnancy and Fertility Testing, Marie Berry...................................................................106781 Premenstrual Syndrome, Thomas E.R. Brown ................................................................107482 Prenatal and Postpartum Care, Carla Dillon ...................................................................109083 Urinary Incontinence, Cheryl A. Sadowski ..................................................................... 113284 Vaginal Symptoms, Hygiene and Infections, Laura-Lynn Pollock......................................... 1145

v


20 Otitis Media and Otitis Externa, Yvonne M. Shevchuk ....................................................... 206

Respiratory Conditions21 Acute Cough, Daniel J.G. Thirion .................................................................................. 21722 Allergic Rhinitis, Jennifer Kendrick ................................................................................ 22623 Assessment of Patients with Upper Respiratory Tract Symptoms, Daniel J.G. Thirion .............. 24924 Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis, Daniel J.G. Thirion ........................... 254

Metabolic and Cardiovascular Conditions25 Diabetes Care, Lori MacCallum .................................................................................... 27326 Diabetes Care Devices, Ronald Silver ........................................................................... 29327 Lifestyle Management and Disease Prevention, L. Maria Gutschi ........................................ 302

Gastrointestinal Conditions28 Assessment of Patients with Abdominal Pain, Peter Thomson ............................................ 32329 Constipation, Jane Bowles-Jordan ................................................................................ 32730 Diarrhea, Antonietta Forrester ...................................................................................... 35331 Dyspepsia and GERD, Co Q. D. Pham .......................................................................... 37832 Gastrointestinal Gas, Co Q. D. Pham............................................................................. 39033 Hemorrhoids, Joyce Chan ........................................................................................... 39834 Infant Colic, Shelita Dattani ......................................................................................... 40735 Irritable Bowel Syndrome, Lynette Kosar ........................................................................ 42036 Nausea and Vomiting, Christine Hughes ........................................................................ 42937 Ostomy Care, Marie Berry........................................................................................... 44838 Perianal Symptom Assessment, Joyce Chan .................................................................. 46339 Pinworms, Joyce Chan ............................................................................................... 465

Nutrition40 Infant Nutrition, Joan Brennan-Donnan .......................................................................... 47241 Special Diets, Shirley Heschuk..................................................................................... 49142 Sports Nutrition, Shirley Heschuk.................................................................................. 50643 Weight Management, Shirley Heschuk........................................................................... 519

Musculoskeletal Conditions44 Drug Use and Abuse in Sports, Lily Lum......................................................................... 54745 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 55446 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 56947 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 59048 Sports Injuries, Lily Lum.............................................................................................. 608

Foot Conditions

iv



Dental Health85 Dental Conditions, Michelle Bourassa........................................................................... 116786 Oral Hygiene, Dental Plaque and Caries, Michelle Bourassa ............................................. 117687 Periodontal Conditions: Gingivitis and Periodontitis, Michelle Bourassa ............................... 118888 Teething, Michelle Bourassa .......................................................................................1201

Mouth Conditions89 Aphthous Ulcers (Canker Sores), Adeline T. Chau Markarian.............................................120990 Cold Sores (Herpes Labialis), James S. Conklin .............................................................122091 Dry Mouth, Victoria Kletas ..........................................................................................123292 Halitosis, Shirin Abadi ...............................................................................................124293 Oral Candidiasis, Karen Wlock ....................................................................................1249

General AppendicesI Complementary and Alternative Therapies, Cynthia Richard and Paul A. Spagnuolo ..............1258II Home Testing, Marie Berry .........................................................................................1278III Information for the Traveller, Mark Kearney ....................................................................1289IV Medical Devices and Aids to Daily Living, Marie Berry ......................................................1304V Pregnancy and Breastfeeding: Self-care Therapy for Common Conditions, Myla E.

Moretti ...................................................................................................................1320VI Nutritional Supplements, L. Maria Gutschi .....................................................................1329

vi



Ear Conditions

Chapter 20Chapter 20Otitis Media and Otitis ExternaYvonne M. Shevchuk, BSP, PharmD, FCSHP

Otitis MediaPathophysiologyAcute otitis media (AOM) is an infection of the middle ear cavity and is one of the most commonbacterial infections in childhood.1 Seventy-five percent of children experience at least 1 episode priorto entering school.2 To diagnose AOM, 3 criteria need to be met: 1) signs and symptoms of middle earinflammation 2) the presence of middle ear effusion and 3) acute onset (often abrupt) of signs andsymptoms of middle ear inflammation and effusion.1 Symptoms include acute ear pain (oftenunilateral and developing over a few hours), fever and reduced hearing.1 Tugging or pulling on the earsis often described, but this is a very nonspecific sign.1 Children too young to complain of pain orpressure in the ears may display irritability, excessive fussiness, poor feeding and disrupted sleeppatterns. Acute otitis media is more common in the winter months. A recent history of viral upperrespiratory tract infection is often present.2 The microorganisms most commonly associated with AOMare Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.1,2

AOM has a high spontaneous recovery rate; 80% of children experience spontaneous symptomaticrelief with placebo or no drug therapy.3,4 For this reason, the concept of “watchful waiting” isadvocated after appropriate healthcare practitioner assessment and diagnosis of AOM. Rather thanimmediate initiation of antibiotic therapy, appropriately selected children are managed with analgesictherapy for the first 24–48 hours. This includes children >6 months of age with no craniofacialabnormalities who have uncomplicated AOM (normal host, no otorrhea, no history of chronic orrecurrent AOM) without severe pain or systemic illness, and whose caregivers are able to recognizesevere illness, take the child for immediate assessment, and provide access to follow-up care.1,2

Goals of Therapy■ Relieve symptoms of fever, pain and irritability■ Eliminate bacteria from the middle ear■ Ensure appropriate therapy to reduce the risk of resistant pathogens and drug-related adverse effects

such as antibiotic-associated diarrhea■ Prevent complications, e.g., mastoiditis, intracranial infection, facial paralysis

Nonpharmacologic TherapyComfort measures, such as warmed oils, warm or cold compresses and heating pads have been used byparents and caregivers for years, although there are no studies evaluating their effectiveness. If tried,heat therapy should be used cautiously and with close supervision in children, to avoid burns. A youngchild should never sleep with a hot water bottle or heating pad. Question the caregiver about whetherthere has been any drainage from the ear prior to recommending any topical therapy. Warmed oilshould not be used if there is a chance of perforation or any suspicion of drainage. Warming of dropsor oil should be done by rolling the bottle between the palms; other methods such as placing the bottle

206 Ear Conditions


Ear Conditions


in a glass of warm water or using the microwave oven should be avoided as serious burns have beenreported.

Pharmacologic TherapyFor more information on management of acute otitis media, consult the Compendium of TherapeuticChoices: Acute Otitis Media in Childhood.■ If antibiotics are used, systemic therapy is required; topical agents are not used in AOM.■ Adequate analgesia with usual doses of acetaminophen or ibuprofen is important (see Chapter 7:

Fever, Table 5).■ Topical analgesics may provide short-term analgesia in children with AOM, but should not replace

oral analgesics.5,6 Topical analgesics may cause local hypersensitivity reactions.■ Decongestants and antihistamines, which were recommended in the past, do not speed the

resolution of effusion and can have significant adverse effects in children and therefore should notbe used.7,8

For a more complete discussion of acute otitis media, see Suggested Readings.

Otitis ExternaPathophysiologyOtitis externa is defined as inflammation of the external auditory canal (EAC) and may also involvethe pinna or tympanic membrane (TM). Otitis externa is often due to infection.9,10,11,12 The EAC iswarm, dark and prone to becoming moist. This provides an excellent environment for bacteria or fungito proliferate, particularly if the EAC is traumatized. Otitis externa can be categorized as acute diffuse,acute localized, chronic, eczematous or necrotizing.12 The main focus of this chapter is acute diffuseotitis externa.

Acute Diffuse Otitis ExternaPredisposing factors for acute diffuse otitis externa include:9,10,11,13■ Too little cerumen—cerumen provides antibacterial action by physically protecting the canal and

maintaining a low pH■ Too much cerumen, which can lead to occlusion and maceration■ Moisture (swimming, bathing, water sports, perspiration, increased humidity)—macerates

underlying skin and raises pH■ Trauma to EAC (fingernails, cotton-tipped swabs, other foreign objects, overzealous wax removal)

—abrasion and laceration allowing inoculation of organisms■ Chronic dermatologic disorders■ Hearing aids■ Narrow, hairy ear canal.

The most common etiology of acute otitis externa is bacterial infection. Fungal overgrowth occursrarely, and primarily in patients who have received prior antibiotic therapy. The 2 most commonmicroorganisms causing acute otitis externa are Pseudomonas aeruginosa (20–60%) andStaphylococcus aureus (10–70%).10,11

Bacterial otitis externa produces ear pain or discomfort (otalgia), otorrhea, pruritus and tenderness,especially on manipulation of the ear.10,11 These symptoms may be more intense than those seen withfungal otitis externa. Cellulitis of the pinna and regional lymphadenopathy may be present.10 Fungal

Chapter 20: Otitis Media and Otitis Externa 207


Chapter 20: Otitis Media and Otitis Externa


otitis externa may be asymptomatic or may produce pruritus and fullness in the ear. It classicallyoccurs after prolonged treatment of bacterial otitis externa with antibiotics which alter the bacterialflora of the EAC. The EAC may contain black, grey, bluish green, yellow or white fungal elements anddebris.

Acute Localized Otitis Externa (Furunculosis)This is an acute localized “boil” (infected hair follicle) in the ear canal usually due to S. aureus. Itproduces localized pain, itching, edema, erythema and possibly a fluctuance or abscess. The painsubsides when the boil comes to a head and bursts. Topical mupirocin or fusidic acid can be used formild cases.14 Incision and drainage may be required for some patients. Patients appearing to needincision and drainage should be seen by a healthcare practitioner with appropriate training. In moresevere cases, systemic antibiotics active against S. aureus should be considered.10

Chronic Otitis ExternaChronic otitis externa is characterized as a thickening of the EAC skin secondary to low-gradeinfection and inflammation. There is usually unrelenting pruritus, mild discomfort and dry, flaky skinin the EAC with lack of cerumen. This is often due to nonbacterial causes including allergic contactdermatitis.9

Eczematous Otitis ExternaEczematous otitis externa may be due to a variety of skin conditions, including atopic, seborrheic orcontact dermatitis, psoriasis, lupus erythematosus, neurodermatitis and infantile eczema. Lesionstypically occur elsewhere on the body, especially the head and neck, as well as the auricle and EAC.Appearance may range from mild erythema and scaling with atopic dermatitis to the typical adherentscales of psoriasis (see Chapter 55: Atopic, Contact, and Stasis Dermatitis; Chapter 58: Dandruff andSeborrheic Dermatitis; and Chapter 71: Psoriasis for a more complete description of the lesions). Themost common symptom is pruritus, although erythema, edema, crusting and oozing may be present.The lesions may become secondarily infected with bacteria or fungi. Treatment is primarilymanagement of the underlying condition.15

Necrotizing (Malignant) Otitis ExternaThis is an infection that extends to the mastoid or temporal bone and is usually seen inimmunocompromised patients or those with diabetes. Urgent referral and systemic antimicrobialtherapy are required.10,11

This chapter focuses on the management of acute diffuse otitis externa.

Goals of Therapy■ Eliminate pathogenic microorganisms■ Control pain■ Restore the canal to normal health so it resists infection—return to normal acidic pH and adequate

cerumen

Patient AssessmentAcute otitis externa is characterized by otalgia (70% of cases), itching (60%) or fullness (22%) with orwithout hearing loss (32%) and discharge in or coming from the ear (otorrhea).10,16 Incidence peaks inchildren age 7–12 years and declines after the age of 50.16 It is unilateral in 90% of cases.16 Thediscomfort can range from pruritus to severe pain. The pain is often worse with motion of the ear

208 Ear Conditions


Ear Conditions


(pushing the tragus or pulling the pinna),10 including movement caused by chewing.11 Determining thetype of otitis externa (infectious vs. noninfectious) can be assisted by the description of the signs andsymptoms above and the presence of contributing factors (e.g., history of swimming or trauma to theEAC), or the presence of dermatologic conditions on areas of the body other than the EAC.

The drug must be delivered to the infected tissue if topical therapy is to be successful.10,16 Cleansingmust be done by a healthcare practitioner with appropriate training. Therefore, if there is significantedema or debris in the EAC, the patient may need to be referred so that aural toilet can be performedor for a wick to be placed.10 In mild cases, a topical product may be initiated without cleansing;recommendations for pain management are important.

Nonpharmacologic TherapyAdequate cleansing of the ear canal with removal of debris may be required frequently so that topicaltherapy can be effective.9,10 If the canal is not patent, ear wicks may be inserted by a healthcarepractitioner to reduce edema and swelling and provide a mechanism for drug delivery to the canal.10,11These may remain in place for 2–5 days.

Pharmacologic TherapyFor comparative ingredients of nonprescription products, consult the Compendium of Products forMinor Ailments—Analgesic Products: Internal Analgesics and Antipyretics; Otic Products.

Topical treatment is the mainstay of therapy, although in more severe cases, when infection has spreadbeyond the EAC, when otitis media coexists, or if the patient has a condition such as diabetes orimmunodeficiency, systemic antibiotics may be required.10 In uncomplicated cases, systemic therapydoes not improve outcomes compared with topical therapy and increases the risk of adverse effects andantibiotic resistance and time to clinical cure.17 Topical therapy options include acidifying agents,antibiotics alone or antibiotic/corticosteroid combinations (see Table 1). Comparative trials showsimilar outcomes among approaches; therefore, the choice is determined by healthcare practitioner andpatient preference, the side effect profile of the agents and cost.10,11,12,18,19 One trial demonstrated thatcorticosteroid drops (with either acetic acid or antibiotic) are more effective than acetic acid alone andrecommended that acetic acid alone not be used in adult patients.20 In patients whose symptoms lastlonger than a week, acetic acid may be less effective than an antibiotic/corticosteroid combination;efficacy at 1 week is similar.18 Advantages and disadvantages of the various products are outlined inTable 1.

Antibiotic drops are available as both otic and ophthalmic preparations. Both nonprescription andprescription products are available. Otic products are more acidic than ophthalmic preparations andmay cause burning on instillation. If a patient cannot tolerate otic preparations, ophthalmicpreparations may be more comfortable.21 Preparations for treatment of otitis externa may containcorticosteroids, which reduce inflammation and edema and may resolve symptoms more quickly;however, this has not been shown in all studies and corticosteroids may occasionally be topicalsensitizers.18

One particular concern with topical therapy of acute otitis externa is the potential ototoxicity ofaminoglycosides.22 This is a documented adverse effect of systemically administeredaminoglycosides. If the tympanic membrane is intact, the risk with topical administration is extremelysmall. Risk factors for ototoxicity include ruptured tympanic membrane, use of the product for morethan 1 week and continued use after otorrhea has subsided. Topical fluoroquinolones have not beenassociated with ototoxicity.

Enough liquid to fill the canal (3–4 drops) should be instilled 3–4 times daily (most products exceptfluoroquinolones). Symptoms will last for approximately 6 days after treatment begins; however,





improvement in symptoms should occur within 48–72 hours.10 Patients should be treated for 1 week. Ifsymptoms are not completely gone, therapy can be continued until symptoms resolve plus a few daysbeyond (up to 2 weeks).18 In 65–90% of patients, clinical resolution occurs in 7–10 days.10 Forinformation on correct instillation of eardrops, see Eardrops—What You Need to Know.

Fungal otitis externa often responds to cleansing and acidification alone, although topical antifungalagents (clioquinol, clotrimazole, tolnaftate) may also be used.16 Some preparations may need to becompounded.

Otitis externa can be very painful. Usual doses of acetaminophen, ibuprofen or naproxen sodiumcan be used for analgesia (ASA can be used in adults).10,11 Although some otic preparations containtopical anesthetics, the efficacy of these agents has not been determined in acute otitis externa, andtopical hypersensitivity reactions can occur.10 If topical anesthetic agents are used in addition to othertopical therapy, this will dilute the acidifier or antibiotic present in the canal. Avoid their use in otitisexterna. Systemic analgesia is the preferred recommendation.

Eczematous Otitis ExternaEczematous otitis externa is managed by treating the underlying dermatologic disease (e.g., seborrhea,psoriasis, acne).9,15 Contact dermatitis commonly occurs on or in the ears, and grooming products(e.g., shampoos, hair sprays and hair dyes) are common allergens.10 Hearing aids and earplugs mayalso cause dermatitis of the EAC. Neomycin is one of the topical medications that most commonlycauses allergic contact dermatitis.10 Patients sensitive to neomycin may also react to tobramycin. Otheragents commonly placed in the ear that are reported to cause contact dermatitis include benzalkoniumchloride, benzocaine and propylene glycol.23

Management includes avoiding the offending agent, applying acetic acid solution to dry oozinglesions and re-acidify the canal, or symptomatic therapy with a topical corticosteroid.

Prevention of RecurrenceProvide information on how to prevent a recurrence to individuals who develop acute otitis externa:■ After swimming or bathing, dry the external canal with a blow dryer on low setting or by

instillation of acidifying or alcohol drops.10,11,16■ Avoid overzealous cleansing and scratching (trauma) of the ear canal.10■ Avoid cotton-tipped swabs.11,16,24■ Avoid water sports for at least 7–10 days during treatment.10■ Ear plugs and bathing caps may be used to keep the ears dry; however, there is little evidence to

guide recommendations.10 Frequent use of ear plugs may also act as a local irritant and promoteinfection.

Monitoring of TherapySymptoms should be significantly reduced by day 3 of therapy,10,11 and for most patients symptomsshould have completely resolved in a week. Occasionally up to 14 days of treatment is needed.18Follow up with the patient in 3–5 days to ensure symptoms are improving and at the end of treatmentto ensure resolution. If symptoms worsen or do not resolve, consider the following: the patient may bereacting to the medication (contact dermatitis); a superinfection may have developed; the diagnosismay be incorrect; improper or infrequent use of eardrops; inadequate penetration of topical agents dueto debris or narrowing of the canal; immunosuppression or malignant otitis externa; or the organism isnot susceptible to the topical agent selected.9,10 Assessment for further treatment will be required.

210 Ear Conditions


Ear Conditions


Advice for the PatientAdvise patients on:■ Prevention of recurrences■ Methods of pain control■ Correct use of eardrops■ Possible side effects of treatment and their management (see Table 1)■ When to see a healthcare practitioner.





Table1:

Drugs

forO

titisEx

terna

Class

Drug

Indicatio

nsAdverse

Effects

Com

ments

Costa

AcidifyingAgents

aceticacid2%

25Preventionand

treatmentofm

ildAOE

Can

beirritatingto

inflamed

canal.

Possiblyototoxic.

Broad-spectrumantibacterial.

Restoresacidity

tocanal.

Lowercostthan

antibiotics.

Nocommercialproductavailable.May

beprepared

bydilutingwhitevinegarw

ithequalpartsisopropyl

alcoholorw

ater.10

$

Antibiotics

ciprofloxacin

Ciloxan,generics

TreatmentofA

OE

Welltolerated.

Notassociated

with

ototoxicity.

Activeagainstm

anygram

-negativeorganism

sincludingP.aeruginosa

andsomegram

-positive

(S.

aureus).

Twice-daily

dosing.

Topicalquinolonesprovidesimilarclinicalcurerates

asothertopicalantibiotics.19

Ophthalmicsolutions

canbe

used

intheears.

$

gram

icidin/polym

yxinB

OptimyxinEarDrops,

Polysporin

Eye/Ear

Drops

TreatmentofA

OE

Potentially

ototoxic.

Gramicidin—activeagainstgram-positive

organism

s.Polym

yxinB—activeagainstgram-negative

organism

s.

$$

moxifloxacin

Vigam

oxTreatmentofA

OE

See

ciprofloxacin.

See

ciprofloxacin.

Ophthalmicsolutions

canbe

used

intheears.

$$

ofloxacin

Ocuflox,generics

TreatmentofA

OE

See

ciprofloxacin.

See

ciprofloxacin.

Ophthalmicsolutions

canbe

used

intheears.

$

tobram

ycin

Tobrex,generics

TreatmentofA

OE

Potentially

ototoxic,

particularly

with

perforatedtympanic

mem

brane,

tympanostom

ytubesor

use>1

wk.

Aminoglycosidesactiveagainstgram-negative

organism

s(e.g.,Pseudom

onas)and

S.aureus.

Ophthalmicsolutions

canbe

used

intheears.

$

Corticosteroids

dexamethasone

Maxidex

Dermatologiccauses

ofAOE

May

cause

hypersensitivity

reactions.

Anti-inflammatorypropertiesreduce

swellingand

edem

a.Ifbacterialetiology

combine

with

acidifieror

antibiotic.

Ophthalmicsolutions

canbe

used

intheears.

$

(cont'd)

212 Ear Conditions


Ear Conditions


Class

Drug

Indicatio

nsAdverse

Effects

Com

ments

Costa

Antibiotic/

Corticosteroid

Com

binatio

ns

ciprofloxacin/

dexamethasone

Ciprodex

TreatmentofA

OE

See

ciprofloxacin.

See

dexamethasone.

See

ciprofloxacin.

See

dexamethasone.

$$$

clioquinol/flum

ethasone

pivalate

LocacortenVioform

Eardrops

TreatmentofA

OE

Negligiblegram

-negativeactivity.

Bacteriostatic.

See

dexamethasone.

Clioquinolactiveagainstfungiandgram

-positive

bacteria.

See

dexamethasone.

$$

framycetin/gramicidin/

dexamethasone

Sofracort

TreatmentofA

OE

See

tobram

ycin.

See

dexamethasone.

Fram

ycetinactiveagainstgram-negativeorganism

s(butnotP

seudom

onas)and

S.aureus.


organism

s.See

dexamethasone.

$$

Miscellaneou

santipyrine/benzocaine

Auralgan

Topicalanalgesia

Benzocainemay

producetopical

hypersensitivity

reactions.

Antipyrine—

mild

anesthetic;can

cause

burninganditching.

May

masksymptom

sof

worsening

AOE.

Donotuse

with

ruptured

tympanicmem

brane.

Oralanalgesicspreferred.

$

isopropylalcohol95%

glycerin5%

Auro-DriEarWater

PreventionofAOE

Painfulwhenused

inacuteotitisexterna.

Usefuldryingagent.

$

aCostofsmallestavailablepack

size;includesdrug

costonly.

Abb

reviations:

AOE=acuteotitisexterna

Legend:

$<$10

$$$10–20

$$$$20–30





Suggested Readings

Otitis ExternaHui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis

externa. Paediatr Child Health 2013;18:96-101.Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa.Otolaryngol Head Neck Surg 2014;150:S1-S24.

Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.Otitis MediaLe Saux N, Robinson J. Management of acute otitis media in children six months of age and older.Paediatr Child Health 2016;21(1):39–44.

Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media.Pediatrics 2013:131:e964-99.

Vergison A, Dagan R, Arguedas A et al. Otitis media and its consequences: beyond the earache.Lancet Infect Dis 2010;10:195-203.

References1. Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.2. Le Saux N, Robinson J. Management of acute otitis media in children six months of age and older. Paediatr Child Health 2016;21(1):39–44.3. Rosenfeld RM, Vertrees JE, Carr J et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from

thirty-three randomized trials. J Pediatr 1994;124:355-67.4. Venekamp RP, Sanders SL, Glasziou PP et al. Antibiotics for acute otitis media in children. Cochrane Database of Syst Rev

2015;1:CD000219.5. Carley SD. Best evidence topic reports. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary.Emerg Med J 2008;25:103.

6. Foxlee R, Johansson A, Wejfalk J et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev 2006;3:CD005657.7. Mandel EM, Rockette HE, Bluestone CD et al. Efficacy of amoxicillin with and without decongestant-antihistamine for otitis media with

effusion in children. Results of a double-blind, randomized trial. N Engl J Med 1987;316:432-7.8. Cantekin EI, Mandel EM, Bluestone CD et al. Lack of efficacy of a decongestant-antihistamine combination for otitis media with effusion

(“secretory” otitis media) in children. Results of a double-blind, randomized trial. N Engl J Med 1983;308:297-301.9. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.10. Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2014;150:S1-

S24.11. Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Paediatr Child Health

2013;18:96-101.12. Hajioff D, Mackeith S. Otitis externa. Clin Evid (Online) 2008;pii:0510.13. Klein JO. Otitis externa, otitis media and mastoiditis. In: Mandell GL, Bennett JE, Dolin R, eds.Mandell, Douglas and Bennett's principles

and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingston/Elsevier; 2010. p. 831-8.14. Blondel-Hill E, Fryters S. Bugs & Drugs app. Edmonton (AB): Alberta Health Services; 2015.15. Shea CR. Dermatologic diseases of the external auditory canal. Otolaryngol Clin North Am 1996;29:783-94.16. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician 2006:74:1510-6.17. Pabla L, Jindal M, Latif K. The management of otitis externa in UK general practice. Eur Arch Otorhinolaryngol 2012;269:753-6.18. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev 2010;1:CD004740.19. Rosenfeld RM, Singer M, Wasserman JM et al. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head

Neck Surg 2006;134:S24-48.20. van Balen FA, Smit WM, Zuithoff NP et al. Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised

controlled trial. BMJ 2003;327:1201-5.21. Ong YK, Chee G. Infections of the external ear. Ann Acad Med Singapore 2005;34:330-4.22. Haynes DS, Rutka J, Hawke M et al. Ototoxicity of ototopical drops–an update. Otolaryngol Clin North Am 2007;40:669-83.23. Fraki JE, Kalimo K, Tuohimaa P et al. Contact allergy to various components of topical preparations for treatment of external otitis. Acta

Otolaryngol 1985;100:414-8.24. Nussinovitch M, Rimon A, Volovitz B et al. Cotton-tipped applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol

2004;68:433-5.25. Thorp MA, Kruger J, Oliver S et al. The antibacterial activity of acetic acid and Burow's solution as topical otological preparations. J Laryngol

Otol 1998;112:925-8.

214 Ear Conditions


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Ear Conditions


Acute Otitis Externa (Swimmer's Ear)—What You Need toKnow

What is acute otitis externa?Acute otitis externa, or “swimmer's ear,” is an infection of the ear canal. The symptoms are itching orpain in the ear and liquid draining from it. The ear may become plugged. Your hearing may beaffected.

What causes acute otitis externa?The skin in your ears may become infected because of:■ Too much water in the ear (from bathing, swimming or water sports)■ Removing the natural earwax that protects the ear canal■ Skin conditions in the ear canal (such as eczema)■ Using cotton-tipped swabs, fingernails or other sharp objects in the ear canal■ Wax buildup due to hearing aids or other ear devices

What is the treatment for acute otitis externa?■ The usual treatment is prescription eardrops. A healthcare provider may have to clean the ear canal

for the drops to work.■ Most drops need to be used 3 or 4 times a day.■ Use the drops until 3 days after all symptoms are gone.■ Symptoms are usually much better in 3 days and should be gone in 10 days.■ While you are using eardrops:

– Keep your ears as dry as possible. Take a bath instead of a shower. Avoid swimming and watersports until the treatment is done.

– Don't poke your fingers or other objects into your ears.

What can you do to prevent acute otitis externa?■ Keep the ear canal as dry as possible:

– Dry ears with a towel after swimming or bathing. Use a blow dryer set on low to dry the earcanal. You can also use diluted vinegar or alcohol drops in the ear.

– Try using a bathing cap or ear plugs when swimming. If this makes it worse, stop using.■ Do not clean earwax out of your ears:

– Earwax protects against infection. The ears generally clean themselves. If you have pain in yourears from earwax, see your healthcare provider.

■ Do not put anything in the ear canal except eardrops. Fingernails, cotton-tipped swabs and otherobjects irritate and damage the skin. If the skin is damaged you are more likely to get an infection.





Eardrops—What You Need to Know

Hints to help you use eardrops safely:If possible, get someone to put the drops in your ear for you.■ Warm the eardrops to body temperature by holding the bottle in your hands for a few minutes. Do

not heat the drops in hot water or the microwave because this could cause pain and dizziness orserious burns.

■ Always wash your hands with soap and water before administering the eardrops.■ The eardrops must be kept clean. Do not let the dropper touch the ear or anything else that could

have germs on it and let germs get into your eardrops.■ Shake the bottle before using if there is a “Shake Well” label on the bottle. Lie on your side so that

the ear you are treating is facing up.■ The ear canal must be straight so that the eardrops can reach the affected tissue. The direction that

you pull the top of the ear depends on the person's age.– For adults and children over 3 years, gently pull the top of the ear up and back.– For children under 3 years, gently pull the top of the ear down and back

■ Hold the dropper above the ear. Place the prescribed number of drops into the ear. Do not put thedropper into the ear canal. It could injure the ear.

■ Stay in the same position for 3–5 minutes after using the drops. This will allow the eardrops to rundown into the ear canal.

■ A gentle to-and-fro movement of the ear will sometimes help in getting the drops to their intendeddestination. You can also press with an in/out movement on the small piece of cartilage in front ofthe ear.

■ Dry the earlobe if there are any eardrops on it.■ If you have had a wick placed in your ear, do not remove it. It may fall out on its own as the

swelling and infection in the ear improves.

If you have to put drops in both ears:Wait about 5–10 minutes before putting drops in the second ear. You want to be sure that the medicinestays in the ear canal of the first ear long enough to reach the eardrum before you tilt your head to putdrops in the other ear.

These instructions may be changed by your healthcare provider depending on your medical conditionor the type of medicine in the eardrops.© 2016 Consumer Health Information Corporation (www.consumer-health.com). All rights reserved. This information is adapted from UnderstandingCanadian Prescription Drugs by Dorothy L. Smith, Pharm.D. published by Key Porter Books 1992.

216 Ear Conditions



Respiratory Conditions

Chapter 22Chapter 22Allergic RhinitisJennifer Kendrick, BScPharm, ACPR, PharmD

PathophysiologyAllergic rhinitis affects 10–30% of the population, and the prevalence is increasing.1,2,3 It is estimatedthat more than 500 million people worldwide are affected.3 The prevalence of allergic rhinitis isthought to be highest in school-age children; 80% of people with allergic rhinitis are diagnosed before20 years of age.1,4 Allergic rhinitis is associated with a genetic predisposition; children have a 30%chance of developing allergic rhinitis if one parent is affected and a 50% chance if both are affected.5,6

Allergic rhinitis is characterized by inflammation of the nasal mucosa following inhalation of anallergen.1,4,6,7 The allergic reaction is mediated by antigen-antibody responses and takes place in 3phases. The first phase, sensitization, occurs on first contact with the allergen. IgE is produced andbinds to receptors on the surface of mast cells and basophils. The second and third phases occur on re-exposure to an allergen in a sensitized individual. The second phase, immediate reaction, occurs withinminutes of re-exposure and lasts up to 30–90 minutes. In this phase the allergen binds to allergen-specific IgE and the mast cells release preformed mediators, histamine and tumor necrosis factor alpha(TNF-α), and newly generated mediators, leukotrienes LTC4, LTD4, LTE4, prostaglandin D2 andkinins. The third phase, late reaction, occurs 4–8 hours after exposure. It is characterized by migrationof inflammatory cells, eosinophils, monocytes, macrophages and basophils.

Allergic rhinitis was previously classified as seasonal or perennial; however, this classification wasdetermined to be inadequate for a number of reasons. For example, outdoor pollens and moulds maybe perennial in some regions and symptoms of perennial allergy may not be present year-round. TheAllergic Rhinitis and its Impact on Asthma (ARIA) guideline proposed the classifications ofintermittent allergic rhinitis (IAR) and persistent allergic rhinitis (PAR) in 2008.3 IAR is defined assymptoms of allergic rhinitis occurring <4 days/week or for <4 weeks at a time. PAR is defined assymptoms of allergic rhinitis occurring ≥4 days/week and for ≥4 weeks at a time. Allergic rhinitis isfurther classified based on severity. In mild allergic rhinitis, symptoms are present but not troublesomeand there is no impairment in daily activities, school or work and no sleep disturbance. In moderate/severe allergic rhinitis, one or more is present: troublesome symptoms, impairment in daily activities,school or work, or sleep disturbance.3,7 The ARIA classification has been validated in both adults andchildren.

Rhinitis may also be nonallergic. Conditions associated with nonallergic rhinitis are listed in Table 1.Drugs associated with rhinitis are listed in Table 2.

Goals of Therapy■ Prevent symptoms by avoiding exposure to allergen(s)■ Alleviate signs and symptoms produced by the allergic response■ Improve quality of life

226 Respiratory Conditions




Table 1: Possible Nonallergic Causes of Acute and Chronic Rhinitis3,4,6,7

■ Drug-induced (see )■ Hormones

– pregnancy, menstruation, hypothyroidism■ Infection

– viral, bacterial, fungal, other■ Nonallergic rhinitis with eosinophilia syndrome (NARES)■ Other

– emotions, e.g., stress, sexual arousal– vasomotor rhinitis, e.g., exercise, cold air– anatomic abnormalities, e.g., nasal septal deviation, enlarged adenoids and tonsils, nasal tumors, choanal atresiaa

– food and alcohol– nasal polyps– atrophy– foreign body

a A congenital defect where the posterior nares do not communicate with the nasopharynx.

Table 2: Drugs Associated with Rhinitis6,8

■ ACE inhibitors■ ASA and other NSAIDs■ Cocaine■ Diuretics, e.g., amiloride, hydrochlorothiazide■ Gabapentin■ Hydralazine

■ Oral contraceptives■ Phosphodiesterase-5 inhibitors, e.g., sildenafil■ Psychotropics, e.g., chlorpromazine, risperidone■ Sympatholytics, e.g., clonidine, doxazosin, methyldopa,

phentolamine, prazosin■ Topical decongestants (prolonged use)

Patient AssessmentThe sensitization phase of allergic rhinitis is asymptomatic. Symptoms of the second or immediatephase include sneezing, nasal and palatal pruritus, congestion and clear rhinorrhea.9 Symptoms of thedelayed phase are similar but nasal congestion predominates.4 Patients may also have itchy, red,watery eyes (allergic conjunctivitis), itchy throat, ear fullness and popping, and a feeling of pressureover the cheeks and forehead.4 Facial signs of allergic rhinitis are illustrated in Figure 1. The allergicsalute is a sign more commonly seen in children, where the patient wipes the nose with the palm of thehand in an upward motion.

Some patients present primarily with symptoms of sneezing and rhinorrhea, whereas others are mostlybothered by nasal blockage and have little or no itching or sneezing.6 Eye symptoms are morecommonly associated with outdoor allergens.3,7

Allergic rhinitis can have a significant impact on a patient's quality of life. Patients may haveheadache, difficulty concentrating, fatigue or sleep disturbance.6 Malaise or fatigue may be presentingcomplaints in children.9 Complications of allergic rhinitis include sinusitis, otitis media, asthma, andsleep apnea. In children, there may be dental overbite and a high-arched palate due to chronic mouthbreathing.3,6

An assessment plan for patients suffering from allergic rhinitis is illustrated in Figure 2. During theassessment, also identify precipitating factors/allergens and assess occupational exposure and responseto previous therapy.

Chapter 22: Allergic Rhinitis 227


Chapter 22: Allergic Rhinitis


Figure 1: Facial Signs of Allergic Rhinitis

Morgan's Lines or Dennie's sign or folds are extra creases at the lower eyelids due to edema. Allergic shiners describe discoloured infraorbital areas due tovenous stasis resulting from nasal swelling. The transverse nasal crease is a crease seen at the junction of the bulbous portion of the nose and thenosebridge and is caused by recurrent nose rubbing (allergic salute). Conjunctival injection refers to conjunctival redness fading toward the edges.

Consider the need for prescription therapy or referral for allergy testing if the patient has already triedappropriate nonprescription therapy for 2 weeks without an adequate response, or if the allergenresponsible for symptoms cannot be readily identified.3 Also refer patients for further assessment ifthey have signs or symptoms that are unilateral or are not usually associated with allergic rhinitis (e.g.,fever, pain, loss of smell or taste, recurrent epistaxis, purulent nasal or ocular secretions, postnasal dripwith or without rhinorrhea) or symptoms suggesting complications such as asthma.3

PreventionPrevention is the first step in the management of allergic rhinitis. Although consensus is thatimprovement in symptoms should occur with allergen avoidance, little evidence supports individualmeasures.3 While some measures such as washing pets, impermeable covers for bedding, and airfiltration have been shown to reduce the allergen level, a corresponding reduction in allergic symptomshas not been shown.9 The benefits of environmental control may take weeks or months to fullymanifest. Avoidance measures for common allergens are presented below.1,3,6,7

Pollen■ Keep windows and doors closed when at home or in the car.■ If using air conditioning, keep the unit on recirculate or the indoor cycle, if the choice is available.■ Do not use window or attic fans.■ Monitor weather reports on pollen counts, if available. Decrease outdoor exposure during periods

of high pollen counts. Pollen counts tend to be highest on sunny, windy days.■ Do not dry clothing outdoors.■ Shower or bathe and wash hair after outdoor activity to remove pollen from hair and skin and

prevent contamination of bedding.





Outdoor Moulds■ Remain in a closed environment as much as possible.■ If using air conditioning, keep the unit on the indoor cycle, if the choice is available; note, however,

that units can be heavily contaminated with mould.■ Use of face masks for activities such as raking leaves or working with compost or dry soil may

have limited value because air seeps around the edges of the mask and the mask does not protectthe eyes.

Indoor Moulds■ Use fungicide on sinks, shower stalls, nonrefrigerated vegetable storage areas and garbage pails. A

solution of equal parts household bleach and water effectively kills mould.■ Avoid console humidifiers and cool mist vaporizers; if these must be used, keep them scrupulously

clean.■ If the home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep

foundation vents open.■ If the basement is damp or tends to flood, avoid carpeting or furnishing the basement. Use a

dehumidifier at all times and empty the extracted water from the air frequently; remove anystanding water as soon as possible.

■ Remove houseplants, which are a common source of mould. Alternatively, keep soil surface dryand clean of debris to reduce mould.

House Dust Mites■ Avoid carpeting the bedroom and main living areas.■ Plastic, leather or wood furniture is best.■ Some acaricides (e.g., benzyl benzoate, tannic acid) appear to reduce the mite population if used

regularly. However, their clinical effect is not established and they are not routinely recommended.3■ If possible, clean while the allergic individual is not at home.■ Mite-sensitive persons should avoid vacuuming or making beds. Those who must do their own

cleaning should wear a facemask during cleaning and for 10–15 minutes afterward.■ Use a vacuum cleaner with an efficient double filtration system.■ Keep indoor humidity between 40% and 45%.■ Minimize use of humidifiers as excess humidity promotes mite growth.■ Encase all mattresses, box springs and pillows in the allergic individual's bedroom in zippered,

allergen-proof casings.■ Consider replacing old mattresses.■ Wash bedding in hot (>55°C) water at least every 2 weeks. Cooler water temperatures will not kill

dust mites, nor will detergents.■ Avoid stuffed toys that cannot be washed. Alternatively, put stuffed toys or pillows in a hot dryer or

in plastic bags and freeze every 2 weeks to kill dust mites.■ Do not store items under the bed.■ Use window shades instead of venetian blinds.■ Evidence suggests the best strategy is a combination of the above interventions.10





Animal Allergens■ Permanent removal of pets from the home is the best way to control animal allergens. This should

be followed by thorough cleaning of the house, including washing carpets. “Trial” removal of petsis not helpful; it can take 20 weeks or longer for cat allergen levels to drop to levels comparable tohomes without cats.

■ If the family is unable to remove the animal from the home then:– remove carpets and replace with hard flooring– keep the animal away from the allergic individual's bedroom and other living areas where the

allergic individual spends time– a high-efficiency particulate air (HEPA) filter or electrostatic air purifier may be helpful– washing cats weekly and dogs once or twice weekly may help but evidence to support this

approach is lacking– eliminate litter boxes if possible; otherwise place them in an area unconnected to the air supply

for the rest of the house.

Occupational Allergens■ For individuals affected by occupational rhinitis, recommend minimizing or eliminating exposure.■ Common causes of occupational rhinitis include animal or vegetable proteins (e.g., mouse, rat,

wheat, grains, latex), enzymes, pharmaceuticals (e.g., antibiotics) and chemicals (e.g., resins).

Nonpharmacologic TherapyIntranasal saline spray and irrigation has been shown to reduce nasal symptoms and the need forpharmacologic therapy in children and nonpregnant adults.11 The effect of intranasal saline irrigationin pregnant women is less clear.12 Isotonic saline is preferred to hypertonic saline, as it improvesmucociliary clearance; however, the optimal dose, frequency and delivery have not been established.11

Tobacco smoke can aggravate symptoms and should be avoided by all patients with allergic rhinitis.3Other irritants that should be avoided include insect sprays, air pollution and fresh tar or paint.3

Pharmacologic TherapyWhen avoidance of allergens is ineffective or impractical, consider pharmacologic options. If it ispossible to predict the onset of symptoms (e.g., intermittent exposure), prophylactic medication shouldbe started before exposure.

For comparative ingredients of nonprescription products, consult the Compendium of Products forMinor Ailments—Cough, Cold and Allergy Products.

Table 3 summarizes the pharmacologic activity of different therapies for the treatment of allergicrhinitis.

Medications for treatment of allergic rhinitis are described in Table 5 and Table 6.

Several guidelines for the treatment of allergic rhinitis are available and each provides similartreatment recommendations.3,6,7,9 For mild symptoms, second-generation antihistamines are thedrugs of choice, although they produce only a modest improvement in nasal congestion. First-generation antihistamines are no longer recommended first-line due to their adverse effect profile.6For moderate to severe allergic rhinitis, regularly administered intranasal corticosteroids arerecommended as first-line therapy.14





Table 3: Comparative Symptom Relief of Allergic Rhinitis Therapies7,13

Medication Rhinorrhea Congestion Sneezing Nasal ItchEye

Symptomsa

Oral antihistamines + +/- + + +/-

Intranasal mast cell stabilizers +/- +/- +/- +/- -

Decongestants (oral and topical) - + - - -

Intranasal corticosteroids ++ ++ ++ ++ +/-

Leukotriene receptor antagonists + + +/- +/- +/-

Intranasal anticholinergics ++ - - - -

Intranasal antihistamines ++ ++ ++ ++ +/-

a See Chapter 13: Conjunctivitis.Abbreviations: (+/-) = modest or variable effect

AntihistaminesIntroduced in the 1940s, antihistamines were the first medications used for the treatment of allergicrhinitis. They act as competitive antagonists for the histamine-1 (H1) receptor found on the surface oftarget cells in the nose, lung, conjunctiva and skin.15 They also act as a reverse agonist, meaning thatthey change the three-dimensional configuration of the receptor, decreasing its affinity for histamineand down-regulating histamine-driven symptoms.15 Antihistamines decrease nasal itching, sneezing,rhinorrhea, conjunctival itching and lacrimation but generally do not relieve nasal congestion.Desloratadine, fexofenadine and cetirizine have modest effects on nasal congestion.16Antihistamines are first-line treatment in mild cases of allergic rhinitis.3,6,9

Antihistamines are divided into 2 major classes: first- and second-generation. All are similarlyeffective; however, adverse effect profiles and pharmacology differ.15,17,18,19,20,21

First-generation antihistamines have a rapid onset but relatively short duration of action due to theirshort half-life.22,23 They are poorly selective for the H1 receptor and also exert effects on cholinergicreceptors. The anticholinergic effect manifests as dry mouth and nasal passages, difficulty voidingurine, constipation and tachycardia. They are also highly lipophilic and therefore cross the blood-brainbarrier and interact with central H1 receptors. This results in CNS effects such as sedation andpsychomotor and cognitive impairment. In children, paradoxical excitation may occur.24 Performanceimpairment has been documented using various measures (e.g., reaction time, visual-motorcoordination, arithmetical exercises and memory, learning and driving tests) although more recent datasuggest that the magnitude of these effects has been overstated.25,26 CNS depression and impairmentcan be independent of any subjective complaints by the patient.27 First-generation antihistamines alsoimpair learning and academic performance in children.27 Workers taking first-generationantihistamines have lower work performance and are more likely to be involved in workplaceaccidents. Daytime performance effects are noted even when the antihistamine is taken only atbedtime.6,27

First-generation antihistamines can decrease rhinorrhea, but mucus secretion may be thickened and canbe more bothersome for some patients.15

The first-generation antihistamines should be used with caution in patients with narrow-angleglaucoma, stenosing peptic ulcer, pyloroduodenal obstruction, symptomatic prostatic hypertrophy orbladder-neck obstruction, cardiovascular disease and chronic lung disease.





Second-generation antihistamines are more selective for H1 receptors and less lipophilic.Consequently, they do not have significant anticholinergic adverse effects and do not cross the blood-brain barrier.20 Use of cetirizine in standard doses is associated with more sedation compared withplacebo, but less than first-generation antihistamines.6 Administration of standard doses of loratadineand desloratadine results in an incidence of sedation equivalent to placebo; however, drowsiness hasbeen reported at higher than recommended doses, or rarely in susceptible individuals at recommendeddoses.6 Fexofenadine appears to be nonsedating, even at increased doses. Due to their improvedadverse effect profile, especially with regard to sedation and psychomotor performance, second-generation antihistamines represent a better choice than first-generation agents for the treatment ofallergic rhinitis.6,14 Clinical trials comparing various second-generation antihistamines demonstratesimilar reduction of symptoms.2,19,21,28 They are less effective than intranasal corticosteroids for mostsymptoms of allergic rhinitis.6 Two meta-analyses demonstrated intranasal corticosteroids were moreeffective than antihistamines for relieving congestion and sneezing; for ocular symptoms, nodifference was found.29,30

The intranasal antihistamine levocabastine is effective for sneezing, nasal pruritus and rhinorrhea. Ithas a rapid onset of action (<15 minutes), but must be used 2–4 times daily.22 The intranasalantihistamine azelastine (available only in combination with fluticasone in Canada) is clinicallysimilar to oral second-generation antihistamines for the relief of nasal symptoms.30

Antihistamines are more effective when taken before allergen exposure. The best results are obtainedwith chronic dosing compared with intermittent dosing; therefore, patients should take theantihistamine for as long as they are in contact with the allergen.14 If one antihistamine is not effective,switching to another antihistamine may be beneficial.31

Mast Cell StabilizersSodium cromoglycate (also called cromolyn sodium) modestly reduces itching, sneezing andrhinorrhea but is not effective for nasal congestion.3 Treatment should begin before exposure to theallergen and continue for the entire allergen season.22 If treatment begins after allergen exposure, reliefmay be delayed up to 4 weeks. Sodium cromoglycate is less effective than corticosteroids for allergicrhinitis and has not been adequately compared with leukotriene receptor antagonists andantihistamines.6,30

DecongestantsDecongestants are available in oral and topical formulations. Oral decongestants generally have aweaker effect on nasal obstruction than the topical formulations.22 When given orally, decongestantscan cause systemic adverse effects (see Table 5). Most available agents do not cause blood pressureelevations in normotensive persons unless the recommended dose is significantly exceeded.32Elevation of blood pressure may occur at standard doses in hypertensive patients.33

Systemic absorption from topical formulations is low, resulting in mainly local adverse effects (seeTable 6). Rhinitis medicamentosa (rebound vasodilation) can occur if topical decongestants are usedfor more than 3–5 days.34 In one study, 49% of patients reported using an intranasal decongestant dailyfor at least one year, even though 80% reported having received education about limiting the durationof use. Intranasal decongestant overuse was less common in patients who were using intranasalcorticosteroid or oral antihistamine.35 Overuse can lead to nasal congestion when the topical agent isstopped, and to permanent overgrowth of nasal tissue with chronic overuse. This condition is morelikely to occur with shorter-acting agents (phenylephrine) than with longer-acting agents(oxymetazoline and xylometazoline). Many solutions to this problem have been proposed, includingslow tapering of the decongestant, adding or switching to intranasal corticosteroids, or abruptdiscontinuation of the topical decongestant. Abrupt cessation is effective but may be uncomfortable forthe patient as nasal congestion may persist for several days or weeks.34





CorticosteroidsIntranasal corticosteroids are more effective against the nasal symptoms of allergic rhinitis than oraland intranasal antihistamines, nasal cromoglycate and leukotriene receptor antagonists.29,30 Intranasalcorticosteroids are the drugs of choice for moderate to severe or persistent allergic rhinitis, and formild allergic rhinitis that does not respond to antihistamines.3,6,9 Some intranasal corticosteroids(mometasone furoate and fluticasone furoate) have a modest benefit on allergic conjunctivitissymptoms.6,10,36,37,38 A meta-analysis suggests that intranasal corticosteroids as a class are effective forocular symptoms of allergic rhinitis; however the magnitude of effect has not been quantified.39 Onsetof action of intranasal corticosteroids is within 6–8 hours of first dose, although maximum effect maytake a few weeks. Short courses of oral corticosteroids may be required for severe cases of allergicrhinitis that is unresponsive to other treatment.6 Patients may prefer intranasal corticosteroids inaerosol form compared with spray form; therefore, switching to another intranasal corticosteroidformulation may be recommended if patient tolerability is affecting therapy.40 Regular use ofintranasal steroids is more effective than intermittent use.14

Leukotriene Receptor Antagonists (LTRA)Montelukast is superior to placebo but less effective than intranasal corticosteroids for nasalsymptoms of allergic rhinitis.30 Montelukast is similar in efficacy to loratadine, but patient response ismore variable than with antihistamines.30 There may be additive effects when it is used concomitantlywith antihistamines. Montelukast is more effective than oral antihistamines and comparable tointranasal corticosteroids for reduction of asthma symptoms and use of rescue asthma medication.30 Asa result, montelukast may be a reasonable option for allergic rhinitis coexisting with asthma.6,7,9Otherwise, montelukast is not recommended as first-line therapy for allergic rhinitis.9

ImmunotherapyAccording to clinical practice guidelines, allergen immunotherapy should be considered for patientswho continue to have moderate to severe symptoms despite treatment or those who require systemiccorticosteroids.2,9 Immunotherapy may be indicated when the exposure to allergens is significant andunavoidable (e.g., grass pollen), and when the symptom complex is severe enough to warrant the time,expense and small risk of anaphylaxis.6 Allergen immunotherapy is the only treatment that can modifythe natural history of allergic rhinitis and potentially induce long-term disease remission after cessationof treatment. It may also prevent the development of new allergies and reduce the risk of developmentof asthma in children. Therefore, allergen immunotherapy may be considered even in milder cases ofallergic rhinitis. Immunotherapy is administered by subcutaneous injection, although sublingualimmunotherapy seems to be somewhat effective as well.6,41,42

AnticholinergicsIntranasal ipratropium bromide is effective for rhinorrhea secondary to allergic rhinitis but not forother symptoms.22

Combination TherapiesCombination therapy is recommended by some guidelines when patients have inadequate response tomonotherapy.9 Some combinations have been shown to be more effective than monotherapy whileothers have not.

First- and Second-generation AntihistaminesSome experts suggest a second-generation antihistamine during the day and a first-generationantihistamine at bedtime to promote sleep. Evidence to support this practice is lacking and next-day





sedation is possible.2 If sleep is disturbed due to allergies, symptom relief itself can be expected toimprove sleep.

Antihistamine plus DecongestantBecause antihistamines may have only a modest effect on nasal congestion, antihistamines anddecongestants are often combined. Some patients may respond to this combination whencorticosteroids have failed or when either medication alone does not provide adequate relief of nasalsymptoms.2,30

Antihistamine plus CorticosteroidIntranasal corticosteroids are often combined with oral antihistamines to treat severe or resistant casesof allergic rhinitis.6 This strategy seems logical because the 2 drugs have different mechanisms ofaction. Evidence is insufficient to support the combination of intranasal corticosteroids and oralantihistamines, as it has not been consistently shown to be superior to either medication alone.2,30However, intranasal corticosteroid in combination with intranasal antihistamine (fluticasone/azelastine) is more effective for the nasal symptoms of allergic rhinitis than either medication alone.30

Antihistamine or Intranasal Corticosteroid plus LTRAAn additive effect has been shown when LTRAs and either oral antihistamines or intranasalcorticosteroids are used concomitantly.30 The efficacy of oral antihistamines in combination with aLTRA is less than that of intranasal corticosteroids alone.6 However, antihistamine-LTRA combinationtherapy may provide an alternative for patients who are unresponsive or nonadherent to intranasalcorticosteroid therapy.

Special PopulationsChildrenThe guidelines for treatment of allergic rhinitis in children are similar to those for adults.6 Healthcarepractitioners must ensure they select the correct dosage, ensure proper administration and minimizeadverse effects.3,7,24 Most second-generation antihistamines are now available in pediatricformulations for children >6 months and are generally preferred over first-generation agents due toimproved adverse effect profiles. Table 5 and Table 6 provide dosage guidelines and age limits for oraland intranasal agents. Intranasal corticosteroids are also effective and are considered safe in children>2 years of age, depending on the formulation.24 Intranasal budesonide and mometasone furoatehave not shown growth suppression with prolonged use at recommended doses.6,43,44 Intranasalbeclomethasone dipropionate, fluticasone propionate and triamcinolone acetonide have beenshown to reduce growth velocity by 0.2–0.9 cm per year within the first year of treatment.45,46,47Longer term studies have not been conducted. If intranasal corticosteroids are used, use the lowestpossible dose, monitor growth and use other therapies (e.g., antihistamines) to minimize the dose ofcorticosteroid required for symptom control.6 Decongestants are not recommended for use in childrenunder 6 years.48,49 In those children, intranasal saline drops or spray may be used to clear nasalpassages before eating or sleeping.

PregnancyIntranasal cromoglycate and intranasal corticosteroids are both considered safe during pregnancyalthough beclomethasone, budesonide and fluticasone propionate have accumulated more safetydata than other intranasal corticosteroids.6 Neither first- nor second-generation antihistamines havebeen associated with teratogenic effects in pregnancy.50,51 First-generation antihistamines werepreviously favoured because of substantially greater experience; however, safety data for cetirizineand loratadine now indicate these are acceptable options. Chlorpheniramine has a good safety





record in pregnancy. Although diphenhydramine has good safety data and is still recommended andfrequently used in pregnancy, there have been isolated reports of cleft palate.51 Sedation and impairedperformance may limit the use of first-generation antihistamines. Oral decongestants should beavoided in the first trimester.51 A topical decongestant may be used; at usual doses, they do notpresent a risk to the fetus. Immunotherapy generally should not be started during pregnancy. Coursesof immunotherapy started prior to conception may be continued if beneficial and not causing systemicreactions; doses should not be increased during pregnancy.52 See Appendix V: Pregnancy andBreastfeeding: Self-care Therapy for Common Conditions.

BreastfeedingRecommendations for breastfeeding are similar to those during pregnancy. Both first- and second-generation antihistamines are considered safe while breastfeeding.53 First-generation antihistaminesmay in theory diminish milk production via their anticholinergic effect; however, this has not beenreported in practice. Infant somnolence should be monitored when a first-generation antihistamine orcetirizine is used.

The systemic absorption of topical decongestants is low and transfer into breast milk is unknown.Consequently, these agents are expected to be reasonably safe during breastfeeding.

The American Academy of Pediatrics considers pseudoephedrine to be compatible withbreastfeeding.51 Information on the use of other oral decongestants during breastfeeding is limited.

Information on the use of topical sodium cromoglycate during breastfeeding is not available, althoughthe manufacturer recommends caution.

Monitoring of TherapyTable 4 provides a monitoring plan framework that should be individualized.

Table 4: Monitoring of Therapy for Allergic Rhinitis

Symptoms Monitoring Endpoint of Therapy Actions

Allergic symptoms(sneezing, runny nose,itchy and watery eyes,congestion, rhinorrhea)

Patients: DailyHealthcare practitioner:Next visit or by telephone 1wk later

Patient able to performdaily activities.Patient able to sleep.

If nonprescription therapy is ineffectiveafter 1 wk, optimize allergen avoidanceand medication dose (if applicable). Ifsymptoms not controlled after a furtherwk of therapy, consider another agent.Refer as necessary.3

Drowsiness(antihistamine)

Patient: DailyHealthcare practitioner:Next visit or by telephonewhen checking for efficacy

Patient not drowsy duringthe day.

Switch to a less sedating antihistamine.If using cetirizine, could give dose atbedtime.

Insomnia(oral decongestant)

Patient: DailyHealthcare practitioner: 1wk

No insomnia. Change medication schedule so lastdose taken 4–6 h before bedtime ordiscontinue medication.

Elevated blood pressurein hypertensive patients(oral decongestant)

Patient: DailyHealthcare practitioner:Monitor blood pressure ofhypertensive patients twicein the first wk

No elevation in bloodpressure above baseline.

Stop decongestant if blood pressureelevated above baseline.





Advice for the PatientAdvise all patients about allergen avoidance. In addition, patients who require drug therapy shouldreceive counselling regarding proper use of the medication, expected results and management ofadverse effects (see Table 4).

Figure 2: Assessment and Initial Treatment of Patients with Allergic Rhinitis3,4,6,7





Table5:

OralA

gentsforA

llergicRhinitis

Class

Drug

Dosage

Adverse

Effects

DrugInteractions

Com

ments

Costa

Antihistamines,

First-g

eneration

chlorpheniramine

Chlor-Tripolon,

generics

Adu

lts:4

mgQ4–6H

po;

maximum

24mg/day

Children:0.35

mg/kg/day

dividedQ4–6H

poor 2–5y:1mgQ4–6H

po;

maximum

6mg/day

6–11

y:2mgQ4–6H

po;

maximum

12mg/day

CNS:S

edation,fatigue,

dizziness,impairm

ent

ofcognition

and

performance.

Anticholinergic:Dry

mouthandeyes,

constipation,urinary

retention.

IncreasedCNSdepression

whencombined:Alcohol,

sedatives,tranquilizers,

barbiturates.

Increasedanticholinergic

side

effectswhencombined

with:TCAs,scopolam

ine.

Increase

chlorpheniramine

levelsresulting

inincreased

adverseeffectswhen

combinedwith

moderate

CYP2D

6inhibitors,e.g.,

amiodarone,celecoxib.

Avoidcombinationwith

strong

CYP2D

6inhibitors,

e.g.,bupropion,paroxetine.

$

diphenhydram

ine

Benadryl

Preparations,

generics

Adu

lts:25–50

mgQ6–8H

po;m

aximum

300mg/day

Children:5mg/kg/day

given

in3or4divideddosespo

2–5y:Maximum

37.5mg/day

6–11

y:Maximum

150mg/day

See

chlorpheniramine.

IncreasedCNSdepression:

Alcohol,sedatives,

tranquilizers,barbiturates.


side

effectswhencombined

with:TCAs,scopolam

ine.

May

increase

levelsof

CYP2D

6substrates,e.g.,

metoprolol,venlafaxine.

Availableinpediatric

liquid

formulation.

$

Antihistamines,

Second

-generatio

n

cetirizine

Reactine,generics

Adu

lts:5–10mgQ24Hpo;

maximum

20mgQ24Hpo

Children:

6–12

months:2.5mgQ24H

po 12–23months:2.5mgQ24H

po;m

aximum

2.5mgQ12H

2–5y:2.5mgQ24Hpo;

maximum

5mg/dayin1or2

doses

≥6y:Adultdosage

Minimaltono

anticholinergiceffects.

May

causedrow

siness

insomeindividuals

especiallyathigher

doses.

Headache.

IncreasedCNSdepression:

Alcohol,sedatives,

tranquilizers,barbiturates.


side

effects:TC

As,

scopolam

ine.

Activemetabolite

ofhydroxyzine.


5mg

rapid-dissolve

tablet.

Availableas

5mg/5mL

syrup.

$





Class

Drug

Dosage

Adverse

Effects

DrugInteractions

Com

ments

Costa

desloratadine

Aerius,generics

Adu

lts:5

mgQ24Hpo

Children:

6–11

months:1mgQ24Hpo

1–5y:1.25

mgQ24Hpo

6–11

y:2.5mgQ24Hpo

Minimaltono

anticholinergiceffects.

Headache.

P-gpinhibitors(e.g.,

erythrom

ycin,ketoconazole)

may

increase

loratadine

levelswhileP-gpinducers

(e.g.,carbam

azepine,

dexamethasone)m

aydecrease

loratadine

levels;

clinicaleffectprobably

minimal.

Activemetabolite

ofloratadine.


liquid

formulation.

$

fexofenadine

Allegra

Adu

lts:60mgQ12Hpo

Sustained-release:120

mg

Q24Hpo

Children:

2–11

y:30

mgQ12Hpo

See

desloratadine.

Decreased

fexofenadine

level:Aluminum

-and

magnesium

-containing

antacids.

Ingestionoffruitjuices

such

asapple,grapefruitor

orange

may

decrease

bioavailability.

Activemetabolite

ofterfenadine.O

nly5%

ofa

dose

ismetabolized.

$

loratadine

Claritin,C

laritin

LiquidCapsules,

generics

Adu

lts:10mgQ24Hpo

Children:

2–5y:5mgQ24Hpo

≥5y:10

mgQ24Hpo

See

desloratadine.

QT cprolongationreported

with

concom

itantuseof

loratadine

andam

iodarone.

Cautionisadvised.

P-gpinhibitors(e.g.,

erythrom

ycin,ketoconazole)

may

increase

loratadine

levelswhileP-gpinducers

(e.g.,carbam

azepine,

dexamethasone)m

aydecrease

loratadine

levels;

clinicaleffectprobably

minimal.


liquid

formulationandrapid-

dissolve

tablets.

$ (cont'd)

Table5:

OralA

gentsforA

llergicRhinitis

(cont'd)





Class

Drug

Dosage

Adverse

Effects

DrugInteractions

Com

ments

Costa

Decon

gestants

pseudoephedrine

Eltor120,

Sudafed,generics

Adu

lts:60mgQ4–6H

po;

maximum

240mg/day

Sustained-release:120

mg

Q12Hpo;m

aximum

240mg/

day

Children:

6–11

y:30

mgQ4–6H

poMaximum

120mg/day

≥12y:adultdose

Mild

CNSstimulation

(nervousness,

excitability,

restlessness,dizziness,

weakness,insomnia).

Peripheral

vasoconstriction.

Tachycardiaor

palpitationmay

occur.

Blood

pressuremay

beincreasedin

hypertensivesubjects.

May

adverselyaffect

bloodsugarcontrolin

diabetics.

Beta-blockers:

Antihypertensiveeffectsmay

bereduced.

Contraindicatedwith

MAOIs

andergotderivatives.

Avoidusewith

phenothiazines

andselective

serotoninreuptake

inhibitors.

Cautioninpatientswith

heartdisease,highblood

pressure,hyperthyroidism

,diabetes,angleclosure

glaucomaandprostatic

enlargem

ent.

Concurrentuse

with

oruse

within2weeks

ofMAOIs

may

causehypertensive

crisis.

$$

Antihistamine,

Second

-generatio

n/Decon

gestant

Com

binatio

ns

cetirizine/

pseudoephedrine

Reactine

Com

plete

Adu

lts:1

tab(5mg/120mg)

Q12Hpo

Children:

≥12y:Giveadultdose

See

cetirizine.

See

pseudoephedrine.

See

cetirizine.

See

pseudoephedrine.

See

cetirizine.

See

pseudoephedrine.

$$

desloratadine/

pseudoephedrine

AeriusDualAction

12Hour

Adu

lts:1

tab(2.5

mg/120mg)Q12Hpo

Children:


See

desloratadine.

See

pseudoephedrine.

See

desloratadine.

See

pseudoephedrine.

See

desloratadine.

See

pseudoephedrine.

$$

fexofenadine/

pseudoephedrine

Allegra-D

Adu

lts:1

tab(60mg/

120mg)Q12Hpo

Children:


See

desloratadine.

See

pseudoephedrine.

See

fexofenadine.

See

pseudoephedrine.

See

fexofenadine.

See

pseudoephedrine.

$$

loratadine/

pseudoephedrine

ClaritinAllergy+

Sinus,C

laritin

Allergy+Sinus

ExtraStrength

Adu

lts:1

tab(5mg/120mg)

Q12Hpo

or 1tab(10mg/240mg)Q24H

po Children:


See

desloratadine.

See

pseudoephedrine.

See

loratadine.

See

pseudoephedrine.

See

loratadine.

See

pseudoephedrine.

$$ (cont'd)



Class

Drug

Dosage

Adverse

Effects

DrugInteractions

Com

ments

Costa

Leukotrie

neReceptor

Antagon

ists

montelukast

Singulair,

Montelukast,other

generics

Adu

ltsandchildren≥15y:

10mgQHS

Children:

6–14

y:5mgQHS

2–5y:4mgQHS

Headache,abdominal

pain,flu-like

symptom

s.Strong

CYP2C

9and3A

4inducers(e.g.,

carbam

azepine,

phenobarbital,phenytoin,

rifam

pin)may

decrease

montelukastlevelswhereas,

strong

CYP2C

9inhibitors

(e.g.,sulfadiazine)may

increase

montelukastlevels;

clinicalsignificanceis

uncertain;how

ever,m

onitor

forreduced

efficacyor

adverseeffects.

Strong

CYP2C

9and3A

4inducers(e.g.,

carbam

azepine,


rifam

pin)may

decrease

montelukastlevels

whereas,strong

CYP2C

9inhibitors(e.g.,fluconazole)

may

increase

montelukast

levels;clinicalsignificance

isuncertain;how

ever,

monitorforreduced

efficacyoradverseeffects

$$

aCostof10daysupply;includesdrug

costonly

Dosageadjustmentm

aybe

requiredinrenalimpairm

ent.

Abb

reviations:

CNS=centralnervous

system

;MAOI=

monoamineoxidaseinhibitor;SR=sustainedrelease

Legend:

$<$10

$$$10–20

Table5:

OralA

gentsforA

llergicRhinitis

(cont'd)




Copyright © . All rights reserved. Compendium of Therapeutics for Minor Ailments

Class

Drug

Dosage

Adverse

Effects

DrugInteractions

Com

ments

Costa

Leukotrie

neReceptor

Antagon

ists

montelukast

Singulair,

Montelukast,other

generics

Adu

ltsandchildren≥15y:

10mgQHS

Children:

6–14

y:5mgQHS

2–5y:4mgQHS

Headache,abdominal

pain,flu-like

symptom

s.Strong

CYP2C

9and3A

4inducers(e.g.,

carbam

azepine,


rifam

pin)may

decrease

montelukastlevelswhereas,

strong

CYP2C

9inhibitors

(e.g.,sulfadiazine)may

increase

montelukastlevels;

clinicalsignificanceis

uncertain;how

ever,m

onitor

forreduced

efficacyor

adverseeffects.

Strong

CYP2C

9and3A

4inducers(e.g.,

carbam

azepine,


rifam

pin)may

decrease

montelukastlevels

whereas,strong

CYP2C

9inhibitors(e.g.,fluconazole)

may

increase

montelukast

levels;clinicalsignificance

isuncertain;how

ever,

monitorforreduced

efficacyoradverseeffects

$$

aCostof10-daysupply;includesdrug

costonly

Dosageadjustmentm

aybe

requiredinrenalimpairm

ent.

Abb

reviations:

CNS=centralnervous

system

;MAOI=

monoamineoxidaseinhibitor;SR=sustainedrelease

Legend:

$<$10

$$$10–20

Table5:

OralA

gentsforA

llergicRhinitis

(cont'd)




Compendium of Therapeutics for Minor Ailments Copyright © . All rights reserved.

Table6:

IntranasalAgentsforA

llergicRhinitis

Class

Drug

Dosage

Adverse

Effects

Com

ments

Costa

Antihistamines

levocabastine

LivostinNasalSpray

Adu

ltsandChildren(≥12–65y):2

sprays

(50µg/spray)pernostrilBID;m

ayincrease

to2sprays

TID–Q

ID

Nasalirritation.

Shake

wellbeforeuse.

Initialprimingrequired.

Discontinue

ifno

improvem

entseen

within3days.

$$$

Antihistamine/

Corticosteroid

Com

binatio

ns

azelastine/fluticasone

Dym

ista

Adu

ltsandchildren≥12y:1spray

(137

µg/50µg)ineach

nostrilBID

Burning

orstinging,

nosebleeds.

Dysgeusiamay

occurif

patienttiltshead

back

too

farduringadministration.

Avoidusewith

ritonavirdueto

potentialforsystem

iccorticosteroid

effects.

Rarelycauses

drow

siness.

$100

Corticosteroids

beclom

ethasone

generics

Adu

ltsandchildren≥6

y:2sprays

(50µg/spray)ineach

nostrilBID

Adults:M

aximum

12sprays/day

Children:Maximum

8sprays/day

Use

lowesteffectivedose

form

aintenance

therapy

Burning

orstinging,

nosebleed.

May

causemild

grow

thsuppressionwith

prolongeduse.

45,46,47

Use

atregularintervals.S

lowonset

(7–14days

form

aximaleffect).

Drugmay

failtoreachthesiteof

actionifexcessivenasalm

ucus

secretionoredem

aofthenasal

mucosaispresent.May

usea

vasoconstrictor(intranasal

decongestant)2–3

days

priortothe

suspension.

Aim

sprayup

towards

turbinates

and

away

fromseptum

.Liquidformsmay

bemoreeffectivethan

metered-dose

inhalers.

$$





Class

Drug

Dosage

Adverse

Effects

Com

ments

Costa

budesonide

RhinocortAqua,

RhinocortTurbuhaler

Nasalsuspension

:Adu

ltsandchildren≥6

y(64µg

/metered

dose):Initialdose

2sprays

ineach

nostril

daily

or 1sprayineach

nostrilBID;m

aydecrease

maintenance

dose

to1sprayineach

nostril

daily

Nasalpo

wder:

Adu

ltsandchildren≥6

y(100

µg/dose):

Initialdose

2applications

ineach

nostrilin

themorning

or 1applicationineach

nostrilBID;m

aydecrease

maintenance

dose

to1sprayin

each

nostrildaily

Maximum

400µg/day

See

beclom

ethasone.

See

beclom

ethasone.

Forthe

nasalsuspension,initial

primingneeded.R

e-primeifnotused

≥4days.

$$-$$$

ciclesonide

Omnaris

Adu

ltsandchildren≥12y:2sprays

(50µg/spray)ineach

nostrildaily;

maximum

200µg/day

Burning

orstinging,

nosebleeds.

See

beclom

ethasone.

Initialprimingneeded.

$$$

flunisolide

generics

Adu

lts:2

sprays

(25µg/metered

spray)in

each

nostrilBID,m

ayincrease

toTIDif

needed;m

aximum

300µg/day

Children6–14

y:1sprayineach

nostril

TID;m

aximum

150µg/day

See

ciclesonide.

See

beclom

ethasone.

$$

Table6:


llergicRhinitis

(cont'd)




Compendium of Therapeutics for Minor Ailments Copyright © . All rights reserved.

Class

Drug

Dosage

Adverse

Effects

Com

ments

Costa

fluticasonepropionate

Flonase,generics

Adu


(50µg/spray)ineach

nostrildaily,m

ayincrease

toBID

inseveresituations;

maximum

400µg/day

Children4–11

y:1–2sprays

ineach

nostril

daily;m

aximum

200µg/day

See

beclom

ethasone.

See

beclom

ethasone.

$$$

fluticasonefuroate

Avamys

Adu


(27.5µg/spray)ineach

nostrilonce

daily;

maximum

110µg/day

Children≥2

yto

<12y:1sprayineach

nostrilonce

daily,m

ayincrease

to2sprays

ineach

nostrilonce

daily

ifneeded.

Decreaseto1sprayineach

nostrildaily

for

maintenance;m

aximum

110µg/day

See

ciclesonide.

See

beclom

ethasone.

Initialprimingneeded.R

e-primeif

notused≥30days

orifcapleftofffor

≥5days.

$$$

mom

etasone

Nasonex

Adu


(50μg/spray)ineach

nostrildaily,m

aydecrease

to1sprayineach

nostrildaily

for

maintenance;m

ayincrease

toBID

inseveresituations.

Children3–11

y:1sprayineach

nostril

daily

See

ciclesonide.

See

beclom

ethasone.

$$$

triam

cinolone

NasacortA

QAdu


(55µg/spray)ineach

nostrilonce

daily,m

aydecrease

to1sprayineach

nostrilonce

daily

Children4–11

y:1spray(55µg/spray)in

each

nostrilonce

daily,m

ayincrease

to2

sprays

ineach

nostrilonce

daily

ifneeded.

Decreaseto1sprayineach

nostrildaily

for

maintenance;m

aximum

110µg/day

See

ciclesonide.

See

beclom

ethasone.

$$$ (cont'd)





Class

Drug

Dosage

Adverse

Effects

Com

ments

Costa

Decon

gestants

oxym

etazoline

ClaritinAllergy

Decongestant,Dristan

Long

LastingNasal

Mist,DristanLong

LastingMentholated

NasalSpray

Adu

ltsandchildren≥6

y:0.05%solution

2–3dropsorsprays/nostrilQ

12H

Burning,stinging,

sneezing,dryness

ofthe

nasalm

ucosa.

Bradycardia,tachycardia,

hypotensionand

hypertensionhave

been

reported.

Onsetofaction:5–10

min.

Long

durationofactionlastingup

to12

h.Donotuse

longerthan

3–5days.

$

phenylephrine

DristanNasalMist

Adu

ltsandchildren≥6

y:0.25%or0.5%

solution2–3dropsorsprays/nostrilQ

4HSee

oxym

etazoline.

See

oxym

etazoline.

$

xylometazoline

Otrivin,BalminilNasal

Decongestant

Adu

ltsandchildren≥6

y:0.05%or0.1%

solution2–3dropsor1–2sprays/nostril

Q8-10H

See

oxym

etazoline.

See

oxym

etazoline.

$

MastC

ell

Stabilizers

sodium

crom

oglycate

Rhinaris

CSAnti-

allergic

Adu

ltsandchildren>2

y:1spray/nostril

3–6tim

esdaily

Local:Sneezing,nasal

stinging

orirritation,bad

tasteinthemouth,

epistaxis.

Less

effectivethan

otheragents.

Onsetofactiondelayedup

to4wk.

$$

aCostof1

unit(spray

pump);includesdrug

costonly.

Legend:

$<$10

$$$10–20

$$-$$$

$10–30

$$$$20–30

Table6:


llergicRhinitis

(cont'd)





Suggested Readings

Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA)guidelines: 2010 revision. J Allergy Clin Immunol 2010;126:466-76.

Seidman MD, Gurgel RK, Lin SYet al. Clinical practice guideline: Allergic rhinitis. Otolaryngol HeadNeck Surg 2015;152:S1-43.

Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updatedpractice parameter. J Allergy Clin Immunol 2008;122:S1-84.

Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med 2015;372:456-63.

References1. Mucci T, Govindaraj S, Tversky J. Allergic rhinitis.Mt Sinai J Med 2011;78:634-44.2. Plaut M, Valentine MD. Clinical practice. Allergic rhinitis. N Engl J Med 2005;353:1934-44.3. Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy ClinImmunol 2010;126:466-76.

4. Greiner A, Hellings PW, Rotiroti G et al. Allergic rhinitis. Lancet 2011;378:2112-22.5. Kay AB. Allergy and allergic diseases. First of two parts. N Engl J Med 2001;344:30-7.6. Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updated practice parameter.J Allergy Clin Immunol 2008;122:S1-84.

7. Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy2008;38:19-42.

8. Varghese M, Glaum MC, Lockey RF. Drug-induced rhinitis. Clin Exp Allergy 2010;40:381-4.9. Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152:S1-43.10. Nurmatov U, van Schayck CP, Hurwitz B et al. House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane

systematic review. Allergy 2012;67:158-65.11. Hermelingmeier KE, Weber RK, Hellmich M et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and

meta-analysis. Am J Rhinol Allergy 2012;26:e119-25.12. Garavello W, Somigliana E, Acaia B et al. Nasal lavage in pregnant women with seasonal allergic rhinitis: a randomized study. Int Arch

Allergy Immunol 2010;151:137-41.13. Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am

J Med 2004;116:338-44.14. Laekeman G, Simoens S, Buffels J et al. Continuous versus on-demand pharmacotherapy of allergic rhinitis: evidence and practice. Respir

Med 2010;104:615-25.15. Krouse JH. Allergic rhinitis–current pharmacotherapy. Otolaryngol Clin North Am 2008;41:347-58.16. Bachert C. A review of the efficacy of desloratadine, fexofenadine, and levocetirizine in the treatment of nasal congestion in patients with

allergic rhinitis. Clin Ther 2009;31:921-44.17. Lehman JM, Blaiss MS. Selecting the optimal oral antihistamine for patients with allergic rhinitis. Drugs 2006;66:2309-19.18. Simons FE. Advances in H1-antihistamines N Engl J Med 2004;351:2203-17.19. Slater JW, Zechnich AD, Haxby DG. Second-generation antihistamines: a comparative review. Drugs 1999;57:31-47.20. Horak F, Stubner UP. Comparative tolerability of second generation antihistamines. Drug Saf 1999;20:385-401.21. Simons FE. H1-receptor antagonists. Comparative tolerability and safety. Drug Saf 1994;10:350-80.22. Melvin TA, Patel AA. Pharmacotherapy for allergic rhinitis. Otolaryngol Clin North Am 2011;44:727-39.23. Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician 2010;81:1440-6.24. Turner PJ, Kemp AS. Allergic rhinitis in children. J Paediatr Child Health 2012;48:302-10.25. Bender BG, Berning S, Dudden R et al. Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a

meta-analysis. J Allergy Clin Immunol 2003;111:770-6.26. Weiler JM, Bloomfield JR, Woodworth GG et al. Effects of fexofenadine, diphenhydramine and alcohol on driving performance. A

randomized, placebo-controlled trial in the Iowa driving simulator. Ann Intern Med 2000;132:354-63.27. Church MK, Maurer M, Simons FE et al. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy 2010;65:459-66.28. Walsh GM, Annunziato L, Frossard N et al. New insights into the second generation antihistamines. Drugs 2001;61:207-36.29. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of

randomised controlled trials. BMJ 1998;317:1624-9.30. Glacy J, Putnam K, Godfrey S et al. Treatments for seasonal allergic rhinitis. Rockville: Agency for Healthcare Research and Quality; 2013.

(Comparative Effectiveness Reviews, No. 120.) Available from: www.ncbi.nlm.nih.gov/books/NBK153714.31. Golightly LK, Greos LS. Second-generation antihistamines: actions and efficacy in the management of allergic disorders. Drugs 2005;65:341-

84.32. Johnson DA, Hricik JG. The pharmacology of alpha-adrenergic decongestants. Pharmacotherapy 1993;13:110S-15S.33. Chua SS, Benrimoj SI, Gordon RD et al. A controlled clinical trial on the cardiovascular effects of single doses of pseudoephedrine in

hypertensive patients. Br J Clin Pharmacol 1989;28:369-72.34. Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy 1997;52:28-34.35. Mehuys E, Gevaert P, Brusselle G et al. Self-medication in persistent rhinitis: overuse of decongestants in half of the patients. J Allergy Clin

Immunol Pract 2014;2:313-9.36. Ratner P, Van Bavel JV, Mohar D et al. Efficacy of daily intranasal fluticasone propionate on ocular symptoms associated with seasonal

allergic rhinitis. Ann Allergy Asthma Immunol 2015;114:141-7.37. van Drunen C, Meltzer EO, Bachert C et al. Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of

mometasone furoate. Allergy 2005;60:5-19.





38. Kaiser HB, Naclerio RM, Given J et al. Fluticasone furoate nasal spray: a single treatment option for the symptoms of seasonal allergicrhinitis. J Allergy Clin Immunol 2007;119:1430-7.

39. Hong J, Bielory B, Rosenberg JL. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: a systematic review.Allergy Asthma Proc 2011;32:22-35.

40. Berger WE, Prenner B, Turner R et al. A patient preference and satisfaction study of ciclesonide nasal aerosol and mometasone furoateaqueous nasal spray in patients with perennial allergic rhinitis. Allergy Asthma Proc 2013;34:542-50.

41. Kowalski ML. Systemic and specific treatment for a global disease: allergen immunotherapy revisited. Allergy 2006;61:791-5.42. Jacobsen L, Niggemann B, Dreborg S et al. Specific immunotherapy has long term preventive effect of seasonal and perennial asthma: 10-year

follow-up on the PAT study. Allergy 2007;62:943-8.43. Allen DB. Systemic effects of intranasal steroids: an endocrinologist's perspective. J Allergy Clin Immunol 2000;106:S179-90.44. Skoner DP, Gentile DA, Doyle WJ. Effect on growth of long-term treatment with intranasal triamcinolone acetonide aqueous in children with

allergic rhinitis. Ann Allergy Asthma Immunol 2008;101:431-6.45. Skoner DP, Rachelefsky GS, Meltzer EO et al. Detection of growth suppression in children during treatment with intranasal beclomethasone

dipropionate. Pediatrics 2000;105:E23.46. Lee LA, Sterling R, Maspero J et al. Growth velocity reduced with once-daily fluticasone furoate nasal spray in prepubescent children with

perennial allergic rhinitits. J Allergy Clin Immunol Pract 2014;2:421-7.47. Skoner DP, Berger WE, Gawchik SM et al. Intranasal triamcinolone and growth velocity. Pediatrics 2015;135:e348-56.48. Healthy Canadians. Health Canada releases decision on the labelling of cough and cold products for children. Available from:

www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php. Accessed November 30, 2009.49. Peterson RG, Cran B, Knoppert D et al. Scientific Advisory Panel on Nonprescription Paediatric Cough and Cold Medications (SAP-

NPCCM). Record of proceedings. Ottawa: Health Canada; March 20, 2008.50. Mazzotta P, Loebstein R, Koren G. Treating allergic rhinitis in pregnancy. Safety considerations. Drug Saf 1999;20:361-75.51. Briggs GG, Freeman RK. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 10th ed. Baltimore: Lippincott

Williams & Wilkins; 2015.52. Oykhman P, Kim HL, Ellis AK. Allergen immunotherapy in pregnancy. Allergy Asthma Clin Immunol 2015;11:31.53. Hale TW. Medications and mothers' milk: a manual of lactational pharmacology. 15th ed. Amarillo: Hale Publishing; 2012.





Allergic Rhinitis—What You Need to Know

Allergic rhinitis is a condition caused by allergens in the air. Allergens are things that cause allergies.Some of the symptoms of allergic rhinitis are sneezing, coughing, runny nose, and itchy or wateryeyes. The most important thing you can do to feel better is to avoid the things that cause your allergies.Also avoid exposure to cigarette smoke and strong smells. If you do not know what causes yourallergies, see your doctor.

Helpful Hints for People Who Have AllergiesIf you are allergic to pollen:■ Keep the windows and doors of your house closed.■ If you need to use air conditioning, set the unit to the indoor cycle.■ Do not use window or attic fans.■ Check the weather report to find out about the pollen count. The pollen count tells you what kind of

pollen is in the air and how much. Avoid spending time outdoors when the pollen count is high. Thepollen count is highest on sunny, windy days and in the morning.

■ Do not dry your clothing outdoors.■ Shower or take a bath and wash your hair after outdoor activity. This will remove pollen from your

hair and skin. You want to avoid getting pollen into your bedding.

If you are allergic to outdoor moulds:■ Stay indoors as much as possible.■ If you need to use air conditioning, set the unit to the indoor cycle. Have your air conditioner

cleaned regularly. Air conditioners can be heavily contaminated with mould.■ Use a facemask if you rake leaves or work with compost or dry soil.

If you are allergic to indoor moulds:■ Kill mould with a solution of equal parts household bleach and water. Wash sinks, shower stalls,

nonrefrigerated vegetable storage areas and garbage pails with this solution.■ Avoid using a humidifier or cool mist vaporizer. Moulds grow easily where it is damp. If you must

use a humidifier or vaporizer, clean it often with a solution of equal parts bleach and water.■ If your home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep

the foundation vents open.■ If your basement is damp or tends to flood, do not put carpet or furniture there. For a damp

basement, run a dehumidifier at all times. Empty water from the machine often and clean itregularly. For a flooded basement, drain the water as quickly as possible.

■ Fix any leaky faucets or pipes promptly.■ Do not keep houseplants.

If you are allergic to dust mites:■ Do not put carpet in your bedroom or main living areas.■ Plastic, leather or wood furniture is best.■ If possible, have someone else clean the house while you are not at home.■ If you must do your own cleaning, wear a facemask while you clean and for 10–15 minutes

afterward.





■ Use a vacuum cleaner with an efficient double-filtration system.■ Keep indoor humidity between 40% and 45%. You can buy a hygrometer to measure the humidity

in your house at a hardware store or home centre.■ Avoid using a humidifier or cool mist vaporizer.■ Use zippered, allergen-proof casings on all mattresses, box springs and pillows.■ Consider replacing old mattresses.■ Wash your bedding in hot (>55°C) water at least every 2 weeks. Cooler water will not kill dust

mites.■ Do not keep stuffed toys that cannot be washed.■ Do not store items under your bed.■ Use window shades instead of venetian blinds.

If you are allergic to a pet:■ The best choice is to find another home for the animal. It can take several months before the

allergen levels return to normal.■ If you are not able to give up your pet, then:

– You may find it helps to install a HEPA or electrostatic air purifier in your home.– Keep animals out of your bedroom at all times.– Keep animals out of rooms that have carpets.– Try to keep animals off furniture.– Washing cats weekly and dogs twice weekly may help, though this has not been proven.– Get rid of litter boxes if possible. If not, put them in an area that is not connected to the air

supply for the rest of your home.– If the animal lives in a cage, keep it in a room without carpet, far away from your bedroom.

Medication to Help with Allergy SymptomsYou may want to try medication if:■ You don't feel better even when you avoid the things that cause your allergies.■ Your allergies are interfering with your sleep or your daily activities.

Your pharmacist can help you pick the best medication for you and show you how to use it. SeeTable 1. You can choose between pills or a nasal spray.

Table 1: How to Use a Nasal Spray or Drops

Nasal Spray (Adults only)

1. Gently blow your nose.2. Gently shake bottle and remove cap or lid.3. With your head upright but not tilted backward, press your finger against one side of your nose to close the nostril. Spray the

medication into the open nostril, with the tip directed away from the middle of the nose and back towards the nasal cavity.Squeeze the bottle quickly and breathe in slowly through the nose.

4. Remove tip of nasal spray from your nostril and breathe out through your mouth.5. Do the same thing on the other side.6. Blow your nose in 3–5 minutes.

(cont'd)





Table 1: How to Use a Nasal Spray or Drops (cont'd)

7. Rinse the tip of the spray bottle with hot water, but try not to get water in the bottle. Replace lid.8. Do not use more nose spray than the recommended amount.

Nose Drops (Adult or child)

1. Gently blow your nose.2. Lie on your back on a bed with your head hanging slightly over the side.3. Gently shake bottle. Fill the dropper with the recommended amount of medication. Put the dropper just inside one nostril

(about 0.8 cm or one-third inch). If possible, don't let the dropper touch the skin.4. Apply the recommended number of drops. Apply the medication to the other nostril in the same way.5. Stay in the same position for about 5 minutes. Tilt head from side to side.6. Blow the nose 3–5 minutes later.7. You can also take nose drops by tilting your head back (instead of lying down). Use the recommended number of drops for

each nostril. Then bend over at the waist and hold that position for a few seconds before coming up straight again.8. Rinse the dropper with hot water and return it to the bottle.9. Do not use nose drops more than is recommended on the package.



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