Case Studies

Case: Allergic Rhinitis and Allergic Conjunctivitis, Part 1

AJ is a 57-year-old man with a history of hypertension for 10 years (well-controlled on hydrochlorothiazide 25 mg daily and amlodipine 10 mg daily) and intermittent allergic rhinitis a young age. Today, LB presents to your pharmacy with complaints of nasal itching, sneezing, clear rhinorrhea, and stuffiness. Although he usually experiences similar symptoms with added ocular itching every spring, he has noticed his symptoms have become persistent since he moved into an older home in the historic district of town, specifically his nasal congestion. In the past, AJ has successfully treated his symptoms with OTC diphenhydramine 50 mg and pseudoephedrine 60 mg 2 to 4 times daily as needed for symptoms with minimal daytime sedation, although he notes, “Nothing seems to be helping with my itchy eyes.” AJ asks your opinion regarding whether this is the best treatment option for his current allergic symptoms.

How would you respond?

Case: Part 2

AJ visits his primary care physician. He comes back to the pharmacy a few days later with a prescription for fluticasone intranasal spray. You take the time to review the therapy with AJ and he goes home. Two months later, AJ comes by the pharmacy counter. His eyes are both very red and irritated. He is scratching them profusely and there is a clear watery discharge dripping down his cheek. He claims he has been adherent to his fluticasone therapy with good effect and it even took care of his ocular symptoms, until today. AJ reports today he mowed his lawn and then helped his neighbor mow his lawn, and shortly after his eyes started itching until they progressed to this current state.

What do you believe is the best option for AJ’s current ocular symptoms?

ANSWERS

Case 1: Continuing the same regimen is not optimal for AJ because his symptoms have worsened upon his move (now mild, persistent), perhaps because of a new allergen source (mold or dust from the old house). Moreover, AJ stated that his last regimen never helped his ocular symptoms. The pharmacist could consider an intranasal antihistamine or corticosteroid, as both are considered options in mild persistent allergic rhinitis and exhibit superior efficacy for nasal congestion compared with oral antihistamines. Use of either is also likely to eliminate the need for pseudoephedrine. However, intranasal antihistamines will likely be no better than his prior regimen in controlling ocular symptoms, whereas an intranasal corticosteroid would be. Consequently, the pharmacist could recommend AJ seek a prescription for an intranasal corticosteroid such as fluticasone.

Case 2: It is likely that because AJ’s ocular symptoms were previously well controlled with the intranasal steroid, this is just an exacerbation due to allergen exposure from mowing the grass. The pharmacist could recommend naphazoline plus pheneramine (Visine-A) for up to 72 hours to manage AJ’s allergic conjunctivitis. If he starts using naphazoline plus pheneramine and does not begin to feel relief by tomorrow, the pharmacist should then recommend he call his doctor to get a different agent, such as the nonsteroidal agent ketorolac ophthalmic (Acular LS) for a week or so to relieve these severe symptoms.

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Dr. Sobieraj is assistant professor of pharmacy practice and Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy