Improving Quality of Life in Patients with Allergic Rhinitis: The Pharmacist's Role

Brought to you through an educational grant from Aventis, a member of Sanofi-Aventis Group

Behavioral Objectives

After completing this continuing education article, the pharmacist should be able to:

• Define the impact of allergic rhinitis, including prevalence, afflicted populations, and direct and indirect costs of care.
• Understand factors that contribute to the prevalence of allergic rhinitis.
• Describe the clinical presentation and diagnostic considerations in allergic rhinitis.
• Give an overview of the prescription and over-the-counter treatment options, including first-and-second generation antihistamines, corticosteroids, leukotriene modifiers, and decongestants used for allergic rhinitis, with a focus on efficacies and side-effect profiles.
• Discuss the pharmacist's role in improving the quality of life in patients with allergic rhinitis, including optimizing treatment regimens and practical suggestions to communicate to patients to help them avoid allergens.

Rhinitis is inflammation of themucous membranes that linethe nasal passages and is characterizedby rhinorrhea and nasal congestion.Factors contributing to rhinitisinclude allergies, infection, hormones,and occupational exposures.

Impact of Allergic Rhinitis

Allergic rhinitis affects 40 millionAmericans-10% to 30% of adults andup to 40% of children and youngadults. Allergic rhinitis affects malesand females in equal proportion butgenerally occurs in individuals youngerthan 45 years, peaking in prevalencebetween the ages of 21 and 30 years.¹Ranging in severity from mild to debilitating,it is not a life-threatening condition,although it is a significantcause of morbidity. In addition to inflammationof the mucous membranes,rhinorrhea, and nasal congestion,it may also cause fatigue,cognitive impairment, and/or headache.The economic burden of allergicrhinitis is also significant, includingsubstantial medical treatment costs,reduced productivity in the workplace,and missed school days. According tothe US Department of Health andHuman Services, direct costs for prescriptionmedications and office visitsare nearing $1.8 billion and indirectcosts related to loss of workplace productivityare approximately $3.8 billionannually.²

Complications of allergic rhinitis arealso burdensome and may affect theparanasal sinuses, eustachian tubes,sense of smell, and even the lower airways.Allergic rhinitis is also associatedwith numerous comorbidities, includingsinusitis, otitis, and sleep disturbances.In fact, patients with allergicrhinitis are up to 3 times more likely todevelop asthma.³

Causes of Allergic Rhinitis

Several factors increase risk for allergicrhinitis, including family history ofallergic rhinitis and family or personalhistory of atopic dermatitis or asthma,as well as exposure to allergens.⁴ Forallergic rhinitis to develop, the individualmust first be exposed to an allergen,which is a protein that elicits anallergic response in a particular individual.Allergic rhinitis can be classifiedas seasonal or perennial, depending onwhether it occurs only in specific seasonsor continuously throughout theyear.⁴ Seasonal allergens often includeairborne pollen from trees, weeds, andgrasses and mold spores on decayedvegetation.⁴ Pollen allergies may bereferred to as rose fever when occurringin the spring and hay fever in late summerand fall. Indoor allergens, includingdust mites, pet dander, some typesof mold, and cockroaches, are generallyresponsible for perennial allergicrhinitis.⁴

There are 2 phases in allergic response.In the early phase, mastcell-bound immunoglobulin E (IgE)antibodies react to the allergen withinminutes (Figures 1 and 2). This triggersformation and immediate release ofhistamine, leukotrienes, bradykinin,and other chemical mediators andcauses nasal itching, rhinorrhea, sneezing,and/or congestion.⁵ Over the nextseveral hours, the lining of the nosebecomes infiltrated with white bloodcells (eosinophils, basophils, monocytes,and lymphocytes) and the chemicalmediators, histamine andleukotrienes, resulting in a "primed"and hyperresponsive nasal mucosa.Subsequent exposure to the offendingallergen, even very small amounts,often results in significant allergicresponse and nasal symptoms in aprimed airway.⁵

The inflammatory response may persistfor several weeks after allergenexposure due to the lingering inflammatoryinfiltrate. Therefore, nasal inflammationmay persist for severalweeks and may even be continuous inpatients with perennial allergic rhinitis.

Clinical Presentation

The chief complaints of patientswith allergic rhinitis are usually clearrhinorrhea, sneezing episodes, nasalcongestion, nasal and/or eye itching,and postnasal drip. Patients may complainof a cough or an impaired senseof smell and taste.⁶ Patients may twitchtheir nose due to itchy mucous membranes.In children, repeated rubbingto relieve itchy symptoms may resultin a crease across the bridge of thenose. Chronic mouth breathing maybe evident in patients with substantialnasal congestion. A high arched palatemay indicate a history of long-termmouth breathing. Patients may alsopresent with red conjunctiva andincreased lacrimation.⁷ Dark ringsunder the eyes, termed "allergic shiners,"are thought to result from lymphaticbackflow due to chronic nasalcongestion.

Diagnosing Allergic Rhinitis

The differential diagnosis of allergicrhinitis is straightforward.⁴ A thoroughhistory and physical examinationare performed, and diagnostictests are used in some cases. The historyincludes description of symptoms,including type and duration,allergen exposures, response to anyprevious therapies or medications,previous nasal injuries or surgeries,family history, and presence of othermedical problems.⁴ To establish theoffending allergens in seasonal allergicrhinitis, it is important to determinethe month(s) in which symptomsare most severe. Tree pollenseason is generally in early spring,with grass pollen season following inlate spring and early summer. Weedpollen season usually starts in mid-August and lasts until early October.Often, it is difficult to identify thespecific contributing allergen(s), particularlyin perennial rhinitis. If thesymptoms are most severe upon wakening,however, dust mites are thelikely offenders.⁸

The physical examination shouldevaluate the ears, eyes, nose, throat,and lungs. Nasal examination shouldfocus on appearance of the mucousmembranes, patency of the airway,and the nasal discharge. The nasal liningin allergic rhinitis is generally paleand edematous. The examination ofthe nares, nasopharynx, and oral cavitycan be made with a light and nasalspeculum, but nasal endoscopy issometimes employed.⁹

Allergen testing is particularly usefulin establishing the diagnosis ofseasonal and perennial allergic rhinitis.It aids in identification of thepatient's specific offending allergen(s),allowing the patient and health careprovider to establish targeted allergenavoidance, immunotherapy, and/orother treatment options. Skin testingis the most widely used and cost-effectivemethod of allergen testing.⁴ Skintesting confirms the presence of IgEantibodies to allergens. For patientswho have perennial symptoms, testinggenerally includes agents such asdust mites, animal dander, and moldspores. In those with seasonal symptoms,testing will include agents suchas weed, grass, and tree pollens. Inchildren, some foods may cause allergicreactions but generally not rhinitis.These are less common in adultsbut should be investigated if patientscomplain of itching, hives, or gastrointestinalsymptoms after eating.⁴

The 2 types of skin tests are prickpuncture tests and intradermal tests.Prick puncture tests are more commonlyused because they are generallysafe, cause little discomfort, andare 80% to 85% sensitive. Intradermaltests are used less frequently, becausethey are overly sensitive to the pointof causing nonspecific irritation.They are indicated when absolute(100%) specificity is required or whenallergens are likely to have producednegative results via the prick puncturemethod.¹⁰ The patient's allergist,pharmacist, or other health careprovider should counsel the patientthat antihistamines can interfere withallergy testing and, therefore, shouldnot be used for at least 48 hours priorto testing.¹⁰

Skin testing may not be possible inpatients with severe dermatologic diseasedue to lack of normal skin. Inthese patients, the radioallergosorbenttest (RAST), which is an in vitro serumIgE immunoassay, can be used.Because the RAST is more expensive, itshould be reserved for those patientsunable to tolerate traditional skin testingmethods.¹⁰

Additional tests are available forestablishing the diagnosis of allergicrhinitis. Nasal cytology, an examinationof nasal secretions, helps in theidentification of inflammatory cells.Elevated eosinophil levels may indicateallergic rhinitis. Some tests usedprimarily in research are nasal challengetesting and measurement ofnasal airway resistance.⁹

Classification of AllergicRhinitis

The World Health Organization(WHO) brought together physicianexperts in December 1999, with anobjective of reporting on whether anassociation exists between allergicrhinitis and asthma. The documentthey produced was entitled "AllergicRhinitis and Its Impact on Asthma"(ARIA), and it serves several purposes.First, ARIA emphasizes the impact ofallergic rhinitis on asthma. It also providesrecommendations with supportiveevidence for diagnosis, classification,and a stepwise treatmentapproach for allergic rhinitis.¹¹ TheARIA document originated the newclassification system of allergic rhinitis,which is very similar to that usedfor asthma.

Before the ARIA guidelines, allergicrhinitis was classified as seasonal,perennial, or occupational.⁴ This classificationmade it difficult to distinguishthe types of allergic rhinitis,because seasonal allergens often causesymptoms that look like perennialallergic rhinitis, and perennial allergensmay be present only during certainparts of the year. Additionally,some patients develop an allergicresponse to seasonal and perennialallergens, having symptoms of varyingseverity throughout the year. The ARIAguidelines system has reclassified allergicrhinitis to "intermittent" or "persistent"based on symptom timing andfrequency. This system also classifiessymptom severity as "mild" or "moderateto severe," taking into accounthow the symptoms affect the patient'squality of life.¹¹

Comorbid Conditions

Poorly controlled allergic rhinitismay lead to comorbid conditions. Theincidence of sinusitis and otitis mediaare clearly more common in patientswith allergic rhinitis. This probablyresults from nasal mucosal hypertrophyinfringing on the ostea, which arethe draining sites of the paranasalsinuses, and on the eustachian tubeleading to the middle ear.

A significant association is evidentbetween allergic rhinitis and asthma.⁴More than 80% of patients with asthmaalso have allergic rhinitis. Allergic rhinitisappears to be a predisposing factor tothe development of asthma and alsocontributes to asthma severity. Appropriatetherapy of allergic rhinitis hasbeen shown to impact asthma morbidityfavorably. The ARIA guidelines highlightthe need to evaluate patients withpersistent allergic rhinitis for asthmaand to evaluate patients with asthmafor allergic rhinitis.¹¹

Treatment Options

The goal of treating allergic rhinitisis symptom reduction or prevention,while minimizing side effects and costof therapy (Table 1). The current managementoptions for allergic rhinitisare organized into a stepwiseapproach, which includes allergenavoidance, pharmacotherapy to preventor treat symptoms, and allergenspecificimmunotherapy.⁴

Allergen Avoidance

Allergen avoidance is essential tosuccessful treatment of allergic rhinitis,but while it can be very effective,it is often the most difficult treatmentapproach to achieve. Complete allergenavoidance is usually not possible,but exposure to common allergenssuch as dust mites, pet dander,pollen, and mold spores can bereduced with relatively simple measures(Table 2).

Avoiding outdoor activities duringhigh pollen season and between 5:00and 10:00 AM, when the pollen countsare highest, can minimize pollen exposure.When outdoor activities are necessary,filter masks can be worn to providea barrier against the offendingallergens. The use of home and autoair-conditioning instead of open windowsmarkedly reduces pollen andmold exposure during allergy-specificseasons.

Dust mites are microscopic insectsthat most often reside in warm, humidenvironments, such as bedding, carpets,and upholstered furniture. Dust miteexposure can be lessened with theuse of impermeable bedding coversand weekly washing in very hot(> 130°F) water, which destroys mitesand their allergenic feces.⁸ Maintaininghousehold humidity levels at or below50% via use of a dehumidifier may alsoreduce the level of dust-mite allergens.Carpet should be replaced with tile orwood floors and curtains with blinds ornonfabric shades. Stuffed animals maybe washed or placed in the freezerovernight weekly to remove mites.

Pet-dander allergens can best beavoided by finding a new home for thepet. However, pet owners are oftenreluctant to comply with this recommendation,and they should beadvised, at minimum, not to allow thepet in the bedroom of the allergicpatient. Pet dander resides in soft fabrics,including bedding and carpet.High-efficiency particulate air (HEPA)filters are most effective in removinglighter-weight airborne allergens,including pet dander, pollen, andmold spores.⁴ Frequent vacuumingwith a HEPA vacuum and pet bathingshould be recommended.

Pharmacotherapy

Medications for allergic rhinitis fallinto 2 main categories: those that primarilyrelieve symptoms and thosethat target the inflammation and treatthe underlying disease. Patients mayseek symptom relief with over-the-countermedications before everaddressing the condition with theirphysicians, because over-the-counterproducts are more accessible andaffordable, particularly for patientswithout medical or prescription insurance.The pharmacist is the appropriatehealth care provider to providethorough education about these productsand their role in the treatment ofallergic rhinitis. In selecting over-the-counteror prescription treatments, avariety of factors may influence thedecision, including type and durationof symptoms, previous therapy success,patient comorbidities, side effects, cost,and patient preference.

Oral Antihistamines. Oral antihistaminesare a common pharmacotherapychoice for treatment of allergicrhinitis. These medications work bycompetitively blocking histamine atthe H₁ receptor site, thereby reducingmany of the classic, histamine-mediatedsymptoms of allergic rhinitis,including itching, sneezing, rhinorrhea,and allergic conjunctivitis. Theyare less useful in relieving nasal congestion,however. Many oral antihistaminesare available, both with andwithout a prescription, and they areclassified by their selectivity for the H₁receptor as well as their ability to crossthe blood-brain barrier.

First-generation antihistamines, suchas chlorpheniramine and diphenhydramine,are available without a prescriptionbut cause significant sedationand anticholinergic effects, becausethey cross the blood-brain barrier easily.It is important to advise patientsthat these medications can have a considerableeffect on coordination, workperformance, ability to drive, andinformation processing.

Second-generation antihistaminesare less likely to cause sedation becausethey do not cross the blood-brain barrieras easily, but they may still be associatedwith sedation. An expert consensusstatement reported that allergicrhinitis should be treated with thenewer, second-generation antihistaminesbecause of these significantlyimpairing side effects.^12,13

Patients should be counseled thatthe sedating antihistamines may augmentthe sedating effects of other medicationsand alcohol. First-generationantihistamines are contraindicated inpatients with hypersensitivity to any ofthe medication ingredients, narrowangleglaucoma, stenosing peptic ulcer,symptomatic prostatic hypertrophy,bladder neck obstruction, pyloroduodenalobstruction, and monoamineoxidase inhibitor use.

ARIA guidelines recommend oralantihistamines for mild intermittent,mild persistent, and moderate-to-severeintermittent allergic rhinitis. They arenot recommended, however, as first-linetreatment in moderate-to-severe persistentcases, where intranasal corticosteroidsare considered more useful.¹⁰

Decongestants. Both topical (intranasal)and oral decongestants are effectivein providing short-term symptomcontrol in that they decrease rhinorrheaand congestion associated with allergicrhinitis. Nasal decongestants causesmooth muscle vasoconstriction viaactivation of alpha-adrenergic receptorsin the nasal mucosa. They can be usedalone for symptom relief or in conjunctionwith antihistamine therapy.¹⁴Although oral systemic decongestantsare effective, they are associated withsignificant side effects, including insomnia,nervousness, tachycardia, elevationof blood pressure and/or blood glucose,and urinary retention. Pseudoephedrineis the most widely used oral decongestant.Topical decongestants act morelocally but should only be used for a 3-day period, because prolonged useresults in rhinitis medicamentosa, orrebound congestion.

Intranasal Corticosteroids.Intranasal corticosteroids are widely regardedas the most effective treatmentfor allergic rhinitis. They alleviate allthe major symptoms, including sneezing,rhinorrhea, itching, and nasal congestion.Intranasal corticosteroids arerecommended for all stages of allergicrhinitis in the ARIA guidelines.¹⁰

In a meta-analysis of 16 randomizedcontrolled trials involving more than2000 patients, researchers evaluatedefficacy of intranasal corticosteroids ascompared with oral antihistamines inrelieving total nasal symptoms, includingsneezing, rhinorrhea, itching, andpostnasal drip. They found that intranasalcorticosteroids produced significantlygreater relief of total nasal symptomsthan oral antihistamines. Themeta-analysis revealed no significantdifference between the 2 classes of medicationson relief of eye symptoms.¹⁵ Inan evidence-based evaluation of 13 randomizedblinded studies, researchersfound that total allergic rhinitis-associatednasal symptoms and nasal obstructionwere better relieved with intranasalcorticosteroids than with nonsedatingantihistamines.¹⁶

Intranasal corticosteroids have alsobeen found to be more effective thantopical antihistamines in the treatmentof allergic rhinitis. Researchers performeda meta-analysis of randomizedcontrolled trials and concluded thatintranasal steroids more effectivelyreduced nasal symptoms (sneezing,rhinorrhea, itching, and nasal blockage)than topical antihistamines.¹⁷

A variety of intranasalcorticosteroids are on themarket and all have beenshown to be safe andeffective in the treatmentof allergic rhinitis. Therefore,patient factors, suchas taste and smell, cost,frequency of dosing,and/or previous therapeuticsuccess, should be consideredwhen selecting anintranasal corticosteroidproduct. Aqueous productsare particularly usefulin patients who havenasal dryness and significantnasal congestion,whereas nonaqueouspreparations work well inpatients who have significantrhinorrhea.

Patients should beadvised to use these medications priorto allergen exposure on a scheduledbasis. Also, the onset of action ofintranasal corticosteroids is approximately12 hours, and maximal benefitmay not be seen for 3 to 14 days.Because these medications act locallyand have very low systemic absorption,side effects are generally minimal andmay include nasal irritation, burning,or dryness. Premedication with salinenasal sprays should be recommendedto alleviate these side effects.Researchers showed that mometasoneand fluticasone have lower systemicbioavailability, which may reduce therisk of systemic side effects.¹⁸ Finally, itis important to counsel patients on theappropriate use/administration ofthese products (Table 3).

Intranasal Antihistamines.Intranasal antihistamines are effectivein controlling sneezing, rhinorrhea,and nasal itching associated with allergicrhinitis and have been shown to bemore effective than oral antihistaminesand less effective than intranasal corticosteroidsin the treatment of congestion.¹⁹ ARIA guidelines recommendintranasal antihistamines as an appropriatefirst-line treatment for mildintermittent, mild persistent, and moderate-to-severe intermittent allergicrhinitis and as an adjunct to intranasalcorticosteroids for moderate-to-severepersistent cases.¹⁰ Sedation or drowsinessand bitter taste are the most commonlyreported side effects.²⁰

Leukotriene Modifiers.Leukotrienes contribute to airwayinflammation via bronchial smoothmuscle constriction. Additionally,leukotrienes increase nasal blood flowand airway resistance much more drasticallythan histamine. Althoughplacebo-controlled studies haveproven efficacy of leukotriene modifiers,there is little conclusive evidencethat they are more effective than oralantihistamines. Additionally, smallstudies suggest that combination therapy with a leukotriene modifier and anoral antihistamine is no more effectivethan with the antihistamine alone. Ina review of literature to determine therole of leukotriene modifiers in thetreatment of allergic rhinitis, researchersconcluded that the data donot support widespread use of leukotrienemodifiers instead of an intranasalcorticosteroid alone or in combinationwith an antihistamine.²¹

Mast-Cell Stabilizers. After exposureto a specific antigen, mast-celldegranulation occurs, resulting in therelease of multiple inflammatorymediators. Cromolyn, a mast-cell stabilizer,prevents the inflammatoryprocess by inhibiting entry of calciumions. There are no direct anti-inflammatoryor antihistaminic effects.

Cromolyn should be administeredintranasally up to 7 days prior to exposureto a known allergen, and maximalbenefit is generally seen after 2 to 4weeks'continuous use. Cromolyn hasan excellent safety profile, includingsafety in pregnancy, and it is availablewithout a prescription. It needs to betaken 4 times daily, however, andpatients may have difficulty adheringto this frequent dosing regimen.²⁰

Stepwise Approach toTreatment

The Joint Task Force on Practice Parametersin Allergy, Asthma, andImmunology guidelines endorses antihistaminesas first-line pharmacotherapyfor patients with mild-to-moderateallergic rhinitis and intranasal corticosteroidsas first-line treatment forpatients with more severe forms of thedisease.²² The conclusions of a metaanalysis,however, provided a compellingargument for intranasal corticosteroidsto be used first in allclassifications of allergic rhinitis.²³ Ifsufficient response is not realized withone or the other, a combination of oralantihistamine and intranasal corticosteroidshould be tried next, then otheragents added 1 by 1 until the desiredresponse is achieved. If no combinationof medications produces adequateresponse, allergen-specific immunotherapyshould then be considered.Immunotherapy is a medical procedurethat uses controlled exposure toknown allergens to reduce the severityof allergic disease. As increasing quantitiesof allergen are injected subcutaneouslyinto the patient, there is a correspondinggradual increase in theallergen-specific IgG antibodies and agradual decrease in allergen-specific IgEantibodies.

Patients who are eligible for immunotherapyare those who have moderate-to-severe allergy symptoms occurringthroughout most of the year, haveidentified allergens via skin test orRAST, have failed pharmacotherapy,cannot avoid allergens, and/or childrenwho do not have chronic irreversibleupper airway changes. Immunotherapyusually consists of weekly subcutaneousallergen solution injections in increasingdoses until maintenance dose isobtained. The maintenance dose is continuedabout once every 2 to 4 weeksfor 4 or more years.

Durham et al showed that allergen-specificimmunotherapy alters thecourse of allergic rhinitis disease, resultingin long-term efficacy and possiblyhalting disease progression and preventingthe development of comorbidconditions.²⁴ Immunotherapy works tolessen symptoms of allergic rhinitis byreducing the number of mast cells andinflammatory mediators. In theDurham study, 1 group received 3 yearsof immunotherapy, then 3 years ofplacebo treatment; another groupreceived 6 years of immunotherapy;and a third group was not treated withimmunotherapy. After the 6-yearperiod, a 75% reduction in diseaseseverity was noted in both immunotherapygroups, as comparedwith the nonimmunotherapy group.²⁴

An important consideration wheninitiating immunotherapy is the significanttime commitment on the part ofthe patient.

The most serious potential sideeffect of immunotherapy is anaphylaxisto the injection, so patientsshould be monitored for 20 to 30 minutesafter each injection. Anaphylacticreactions may include sneezing, rhinorrhea,itchy eyes, swelling of the airway,cough, wheezing, shortness ofbreath, chest tightness, and/or dizziness.These reactions must be treatedimmediately. Local reactions mayinclude redness and swelling, forwhich ice packs may be helpful.

The Preventive Allergy TreatmentStudy, a randomized placebo-controlledtrial, evaluated whether use ofimmunotherapy to treat allergic rhinitiswould delay onset of asthma.Researchers studied more than 200children in Europe and found that,after 3 years, the children whoreceived immunotherapy for allergicrhinitis had significantly fewerasthma symptoms than the placebo-treatedgroup.²⁵

Conclusion

Allergic rhinitis is an extremely common condition that extracts a significant price, both in terms of dollarsspent and quality of life. Complications include sinusitis, otitis, andasthma. A careful history, physical examination, and skin testing will notonly make the diagnosis but also pinpoint the offending allergens. This canallow the first therapeutic approach, environmental control, to be moreeffective. The second approach-pharmacologic-includes oral nonsedating antihistamines, decongestants, andtopical agents such as corticosteroids and antihistamines. In patients not respondingto these measures, immunotherapy (allergy shots) can be used.Patients no longer have to "live with" their allergies. Making an accuratediagnosis and instituting appropriate therapy should result in significantimprovement in the vast majority of allergic rhinitis patients.

Lori C. Brown, PharmD: Clinical Assistant Professor, University of North Carolina at Chapel Hill; Clinical Coordinator, Kerr Health Care Center. Raymond G. Slavin, MD, MS: Professor of Internal Medicine and Microbiology, Saint Louis University School of Medicine.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.

MWC Office of Continuing Professional Education is accredited by the Accreditation Council for PharmacyEducation as a provider of continuing pharmacy education. This program is approved for 2 contact hours (0.2 CEU) under the ACPE universal program number of 290-999-05-009-H01. The program is available for CE credit through June 30, 2008.

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CE REVIEW QUESTIONS

(Based on the article starting on page 84) Choose the 1 most correct answer.

1. Allergic rhinitis affects what percentageof American children?

• 0%-10%
• 10%-20%
• 20%-30%
• Up to 40%

2. Which of the following comorbiditiesis (are) associated with allergic rhinitis?

• Asthma
• Otitis media
• Sinusitis
• All of the above

3. The "early phase" of the nasal allergicresponse occurs when:

• Mast-cell-bound immunoglobulinE antibodies react to the allergen.
• The nasal lining becomes infiltratedwith white blood cells.
• Subsequent exposure to the offendingallergen, even very smallamounts, often results in significantallergic response and nasalsymptoms.
• There is a lingering inflammatoryinfiltrate.

4. Which of the following is not a typicalcomponent of the clinical presentation ofallergic rhinitis?

• Postnasal drip
• Colored rhinorrhea
• "Allergic shiners"
• Increased lacrimation

5. RJ is an 8-year-old boy who presents tothe physician with sneezing episodes, redand teary eyes, and a crease across thebridge of his nose. In order to establish adiagnosis of rhinitis, which is the mostcost-effective method of allergen testing?

• Radioallergosorbent test (RAST)
• Nasal cytology
• Skin testing
• Nasal challenge test

6. The pharmacist should advise RJ thatwhich of the following medications caninterfere with his allergy test and shouldtherefore be discontinued for 48 hoursbefore the testing procedure?

• Nasal decongestants
• Topical decongestants
• First-generation antihistamines
• Intranasal corticosteroids

7. ARIA [Allergic Rhinitis and Its Impacton Asthma] guidelines suggest coevaluationfor which comorbid condition in allpatients who present with allergicrhinitis?

• Otitis media
• Asthma
• Sinusitis
• All of the above

8. After allergen testing and symptomevaluation, it is determined that RJ hassevere persistent allergic rhinitis secondaryto dust-mite exposure. Which of thefollowing treatments is not recommendedas first-line therapy?

• Impermeable bedding covers,washed weekly in very hot water
• Maintaining household humidityat or below 50%
• Intranasal corticosteroid
• Oral antihistamine

9. Weiner et al showed in their metaanalysisthat:

• Intranasal corticosteroids are moreeffective than oral antihistaminesin relieving total nasal symptoms.
• Oral antihistamines are more effectivethan intranasal corticosteroidsin relieving total nasal symptoms.
• Intranasal corticosteroids are moreeffective than oral antihistaminesin relieving eye symptoms.
• Oral antihistamines are more effectivethan intranasal corticosteroidsin relieving eye symptoms.

10. When selecting an intranasal corticosteroidproduct, which of the followingshould be considered?

• Patient's sense of taste
• Patient's sense of smell
• Frequency of dosing
• All of the above

11. Intranasal antihistamines have beenshown to be _______________ in the treatmentof nasal congestion.

• More effective than oral antihistaminesand less effective thanintranasal corticosteroids
• More effective than intranasalcorticosteroids and less effectivethan oral antihistamines
• Equally effective as intranasal corticosteroidsand oral antihistamines
• None of the above

12. Leukotrienes contribute to theallergic response by all the followingmethods except:

• Increasing airway inflammation.
• Constricting bronchial smoothmuscle.
• Decreasing airway resistance.
• Increasing nasal blood flow.

13. Which of the following is not true ofthe mast-cell stabilizer cromolyn?

• It is safe for use in pregnancy.
• It should be dosed 4 times daily, aregimen to which some patientshave difficulty adhering.
• It is available without a prescription.
• It has direct anti-inflammatoryeffects.

14. Which of the following is not trueabout immunotherapy?

• It works by reducing the number ofmast cells and inflammatory mediatorsin allergic rhinitis.
• It alters the course of allergicrhinitis disease.
• It has no effect on developingasthma symptoms.
• Patients should be monitored for20 to 30 minutes after eachinjection.

15. Which of the following intranasalcorticosteroids has a recommended doseof 1 to 4 sprays in each nostril oncedaily?

• Triamcinolone (Nasacort AQ)
• Fluticasone (Flonase)
• Budesonide (Rhinocort AQ)
• A and C

16. Patients who are eligible for immunotherapyinclude all of the followinggroups except:

• Those who have moderate-to-severeallergy symptoms occurringthroughout most of the year.
• Those children who have chronicirreversible upper airway changes.
• Those who have identified allergensvia skin testing or RAST.
• Those who have failed pharmacotherapyand cannot avoidallergens.

17. Intranasal corticosteroid side effectsgenerally include which of the following?

• Nasal irritation
• Stunted growth
• Considerable hypothalamic-pituitary-adrenal axis suppression
• All of the above

18. Rhinitis medicamentosa is thescientific term for a side effect associatedwith the use of which of the followingtypes of medication?

• Topical decongestants
• Intranasal antihistamines
• Intranasal corticosteroids
• A and B

19. Casale et al showed that second-generationantihistamines have:

• Significantly more sedating effectsthan first-generation antihistamines.
• Significantly fewer sedating effectsthan first-generation antihistamines.
• The same level of sedating effects asfirst-generation antihistamines.
• None of the above

20. Hay fever is another term for allergicrhinitis associated with:

• Pollen in the spring.
• Pollen in the fall.
• Perennial dust mites.
• Pet dander.