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Seasonal Allergies

Matthieu DeClerck, MD, Mizuho Morrison, DO, and Andy Barnett, MD
00:00
36:31

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Andy Barnett does an in-depth review of how to treat seasonal allergies including how to add /adjust meds for patients who are experiencing severe allergic symptoms despite their current medication regimen.

Pearls:

  • Allergic rhinitis/sinusitis/conjunctivitis symptoms are usually indolent, recurring, and ITCHY.

  • First-line treatment of seasonal allergies is a glucocorticoid nasal spray.

  • An antihistamine nasal spray can be a nice bridge for symptomatic patients since the glucocorticoid spray can take days to a week to have an effect.

  • Oral antihistamines are infrequently prescribed since nasal antihistamines are as effective with no systemic anticholinergic effects.



  • Pathophysiology of allergic rhinitis/conjunctivitis

    • Allergens bind to receptors on mast cells which cause the mast cells to degranulate.  Mast cells are heavily concentrated in the nasal mucosa, posterior pharynx, and conjunctiva.

    • Mast cells release histamine and other inflammatory mediators, resulting in itching, congestion, swelling, and leakage (rhinorrhea and tearing).

    • This cascade is best treated by stabilizing the mast cells.

  • Differential diagnosis

    • Viral rhinitis/sinusitis/conjunctivitis

    • Bacterial infections

    • Fungal infections

  • Historical factors suggesting seasonal allergies:

    • Absence of fever

    • Usually, there are typical triggers and a history of similar reactions 

    • If no prior allergic history, ask if new to the area, new pets, etc.

    • Commonly occurs in early fall or late spring

    • Indolent onset -- many present with symptoms >10 days.

    • Tends to be bilateral and symmetric

    • Everyone complains of ITCHING (throat, eyes, nose, ears)

  • Physical exam findings

    • Allergic shiners -- chronic puffiness of the eyelids

    • Nasal crease -- caused by constant itching of the nose

    • Pale, edematous nasal mucosa (vs. beefy red with viral causes)

    • Clear/thin rhinorrhea

    • Cobblestone pharynx and underside of the eyelid (due to swelling of lymph tissue)

    • Chemosis in more severe/acute cases

    • TM retraction or serous fluid accumulation

  • Treatment:

    • Avoid triggers when possible

    • First line: glucocorticoid nasal spray (ie. fluticasone)

      • Most effective single therapy for allergic rhinitis. 

      • 2nd generation glucocorticoids have <1% bioavailability

      • Directly treats the problem without systemic side effects

      • Dose:  1 spray per nostril daily if 2-12 years old, 2 sprays if >12

      • Technique matters  

        • use a contralateral hand to spray each nostril 

        • gently breathe in through the nose after spraying to get most of the medicine on the turbinates and not the back of the throat

      • May take days to weeks to be maximally effective.

      • Usually prescribed for a month as most seasonal allergic triggers last that long.

    • Antihistamine nasal spray (ie. azelastine, olopatadine)

      • Relieves congestion and sneezing

      • Works within minutes.

      • Common approach to add on top of nasal steroid in children >12

      • Combo spray is available (azelastine + fluticasone) 

      • Can be discontinued in a week once the nasal glucocorticoid has had an effect

    • Oral antihistamine (ie. loratadine, fexofenadine, levocetirizine)

      • Helps relieve itching/sneezing/runny nose, but don’t relieve nasal congestion. 

      • Prescribed less frequently since nasal antihistamines are as effective with no systemic anticholinergic effects.

      • Can be sedating, so not recommended for >1 week.

      • Consider combo pseudoephedrine with 2nd gen antihistamine

    • Montelukast oral

      • Effective addition in patients who also have asthma.

      • Not typically considered for patients who have no underlying reactive airway component to their allergies. 

    • Oral steroids 

      • Very short term if severe symptoms

      • Consider a single 10 mg dose of dexamethasone or 3-5 day course of prednisone.

      • Caution in comorbidities

    • Ipratropium bromide 

      • Rarely used, though beneficial for gustatory rhinitis

    • Nasal decongestants (ie. oxymetazoline) 

      • Effective for severe rhinorrhea, but can only be used for 48 hours due to the risk of rebound nasal congestion.

    • Depot steroids

      • Very effective, but not recommended due to risk profile and side effects.

 

References:

  1. Dykewicz M, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. PMID: 32707227

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