32 YO White male here for eval of evaluation of allergic rhinitis
Owns vinyl repair business (boats, recreational vehicles, automobiles); reports exposure to chemicals related to work that cause worsening of allergic rhinitis.
122/74, P 76, R 18
Patient has received multiple steroid shots over the last decade.
Flonase & Zyrtec
Allergic Rhinitis, nonallergic rhinitis, acute sinusitis, infectious rhinosinusitis
Plan: Allergic rhinitis (AR) is an immunoglobulin E (IgE)-mediated inflammatory disease of the nasal mucous membranes caused by inhaled allergens, which provoke nasal symptoms including nasal congestion, rhinorrhea, sneezing, and nasal itching (Yang et al., 2022). Assess the patient for worsening signs and symptoms, time of year these seem to be improved or less bothersome, and known triggers. Goals of drug therapy would be to alleviate said symptoms and have no adverse reaction to the medications. There are several treatment options that can be used in combination with each other: intranasal antihistamines, nasal decongestants, intranasal decongestants, and intranasal corticosteroids.
- Intranasal steroids are first-line drugs of choice for allergic rhinitis and are more effective than antihistamines, especially for patients with diminished quality of life due to significant symptom improvement (Shirley et al., 2020). This class of medications can take several days to have full effect, so concurrent use with an oral antihistamine can be used also. The patient already takes an antihistamine and an intranasal corticosteroid. The patient can swap from Flonase to budesonide and from Zyrtec to Allegra for trial of improvement. Prescribing an intranasal antihistamine, for nasal symptoms, such as Azelastine 1-2 sprays in each nostril 1-2 times daily. If symptoms are severe oral prednisone may be given in the interim while the patient waits for immunotherapy.
- The key to treatment is prevention. Encourage the patient to avoid the irritant or limit exposure time if possible. If using a first-generation antihistamine, you may become drowsy, so this may not be the best option to use before work or other activities requiring alertness. Educate patient on complications that may occur with AR and when to follow up with physician.
- Collaboration / Consults:
- Refer patient allergen specialist for skin-prick testing. Immunotherapy can be iniated once allergen(s) are identified.