‘ CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 2
CLIN PHARM 2 - Ivory Diane Amancio
ALLERGIC RHINITIS
Allergic Rhinitis
- Involves inflammation of the nasal mucous
membrane.
- Two types:
1. Seasonal Allergic Rhinitis (Hay fever)
- Hay because it primarily comes from
hay, mga pollen
⊳ Occurs in response to allergens usually
present at predictable times of the year;
during plant pollination (Spring or fall)
- Walay spring or fall ang philippines, pero
naay time nga tig pulak na sa mga
mangga so kasagaran mo react ang
mga tao ana, like iingon tigpulak naman
gud sa mga mangga, thus this is not
only for season countries, but it is
associated with ting pulak sa mga plant
2. Persistent Allergic Rhinitis (Perennial Allergic
Rhinitis)
⊳ Year-round (di mag agad sa pollination)
disease caused by non-seasonal
disease.(house dust mites, animal dander,
and molds)
⊳ Patients may have a combination of the two-
with year-round symptoms and seasonal
Exacerbation (ma grabehan pud at certain
time sa year). (possible pud na perennial +
seasonal ang allergic rhinitis sa px)
ETIOLOGY OF ALLERGIC RHINITIS
Determined by 3 Factors:
1. Genetic
2. Allergen Exposure
3. Presence of Other Risk Factors
Genetic:
✓ Family history of Allergic Rhinitis
✓ Atopic Dermatitis
✓ Asthma
❖ Suggests that rhinitis is allergic. (kay naa na sa
iyang blood or genetic makeup)
❖ Increased risk if one parent is atopic (tendency/
possible nga allergy) and further increases if two are
allergic.
2. Allergen Exposure (pollen, dust mites and animal
dander)
- Individuals must be exposed over time to a
protein that elicits the allergic response in that
individual.
TERM
02
- Microbial exposure in the first years of life could
help prevent Allergic disease by stimulating a
nonatopic immune response.
Farm Children: (Suburban)
✓ High exposure of endotoxin in barns and dust
around the farmhouse.
✓ Consumption of no pasteurized farm milk.
✓ Proactive exposure to harmless bacteria in early
Life.
- During covid, di kaayo affected ang people in
the streets compared to children nga very
contained
- Before, asthma was considered sakit sa datoon
Children from High Socioeconomic Class:
✓ Frequently has more positive skin tests allergen
sensitization than children in the suburban area
3. Presence of Other Risk Factors
✓ Elevated Serum IgE (>100 IU/mL) before the
age of 6 years
✓ Eczema
✓ Heavy exposure to secondhand cigarette
smoke
NASAL PHYSIOLOGY AND
PATHOPHYSIOLOGY
Nasal PHYSIOLOGY
● The air passes to through the nose, turbulence
throws particulate matter against a mucus blanket.
● Mucus blanket - pertains to vascular area of the
nose kanang naay mga blood vessels
● The rhythmic movements of the nasal cilia cause the
mucous blanket to move posteriorly where it is
eventually swallowed; thus trapped foreign particles
are removed via the GI tract and do not reach the
lungs
● Thus, dele maka acquire ug foreign body ang lungs,
ditso ra ang foreign body sa GI tract
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PATHOPHYSIOLOGY
● It also concentrates foreign protein material into the
posterior nasopharynx, where lymph tissues identify
them and produce most of the allergic antibody that
drives allergic rhinitis
clear secretions. Tearing and periorbital (muscles
surrounding the eyes) swelling may be present.
➢ Adenoidal breathing - ping ot ang ilong, sa ba ba mo
ginhawa, matulog mag nga nga

Laboratory and Diagnostic Tests

Laboratory:
➢ Microscopic examination of the nasal smear will
show numerous eosinophils. Blood eosinophil
count (immune cells) may be elevated in allergic
rhinitis, but it is nonspecific.

Other Diagnostic Tests

✓ Percutaneous skin tests with diluted allergen,
positive control (histamine), and negative control are
used to identify to what the patient has sensitivities.
Allergen Sensitization and the Allergic Response: ✓ Radioallergosorbent test can detect IgE
⊳ Exposure to antigen stimulates IgE production and antibodies
sensitization of mast cells with antigen-specific IgE in the blood that are specific for a given allergen.
antibodies.
TREATMENT
⊳ Subsequent exposure to the same antigen produces
an allergic reaction when mast cell mediators are Pharmacotherapeutic Option
Released.
- There is a subsequent exposure in allergic Medication Symptoms Comments
rhinitis Class Controlled

Antihistamines
⊳ Systemic Sneezing, For seasonal
(oral) rhinorrhea, allergic rhinitis,
itching, begin treatment
conjunctivitis before allergen
exposure.
Nonsedating
agents should be
tried first. If
ineffective or too
expensive for the
patient, the older
agents may be
used. (use oral for
seasonal) For
If curious pa mo sa pathophysiology, watch osmosis
perennial allergic
video
rhinitis, use an
intranasal steroid
CLINICAL PRESENTATION
as an alternative to
Signs and Symptoms of Allergic Rhinitis or in combination
Symptoms: with systemic
➢ The patient typically complains of clear rhinorrhea, antihistamines.
paroxysms of sneezing, nasal congestion,
⊳ Ophthalmic Conjunctivitis Logical addition to
postnasal drip, and pruritic eyes (itchy), ears, nose,
or palate. Late-phase reaction consists of primarily nasal steroids if
nasal congestion. ocular symptoms
are present.
Signs:
➢ For children, physical exam may reveal allergic ⊳ Intranasal Sneezing, Option for seasonal
shiners, a transverse nasal crease caused by rhinorrhea, allergic rhinitis.
repeated rubbing of the nose, and adenoidal nasal pruritus Warn patients of
breathing. Nasal turbinate's are coated with thin,
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 potential rhinitis
drowsiness.
Intranasal Rhinorrhea Reserve for use
Decongestants anticholinergic when above
⊳ Systemic Nasal Only needed when s therapies fail or
congestion nasal congestion is cannot be
present. tolerated.

Nasal Only needed when Leukotriene See When combined

⊳ Topical
congestion nasal congestion is receptor comments with antihistamines,
present. Do not antagonists more effective than
exceed 3-5 days. (Montelukast) antihistamines
- Symptoms alone. May be used
there will as monotherapy in
be a children with
rebound for asthma and
rhinorrhea coexisting allergic
after taking rhinitis.
3-5 days With combination of
- Bisan orally antihistamines
or systemic Co-Aleva (Ebastine
na siya, + Betamethasone)
there can If di na ma igo ang
be a patient sa
significant antihistamines,
effect on then agto nas
patients Leukotriene
antagonist +
Intranasal Sneezing, For seasonal Antihistamine
corticosteroids rhinorrhea, allergic rhinitis,
itching, nasal an option when
congestion congestion is
CASE STUDY
present. Must
begin therapy Chief Complaint (CC)
before allergen
“My nose is stopped up and I can’t sleep at night. I wake
exposure.
up with a dry mouth, and it stays dry all day. Sometimes
Excellent choice for
I start sneezing and can’t stop. When I do stop sneezing,
perennial rhinitis.
my nose starts running and then plugs up again. I am
having trouble in school because I am always tired, and
Mast cell See Prevents
now my eyes are itchy and watery all the time.”
stabilizers comments symptoms;
(Cromolyn therefore, for
History of Present Illness (HPI)
Sodium) seasonal allergic
rhinitis, use before AB is a 19-year-old woman who presents to her
offending allergen’s physician with complaints of upper respiratory
season starts. For symptoms. The symptoms have occurred off and on
perennial rhinitis, since she was a child, worsening in the fall and
improvement may lessening in the spring; however, they have been
not be seen for up continuous for the last 7 months. Additionally, she has
to 1 month. developed itchy, watery eyes that did not occur with the
- If nag rhinitis symptoms she had in the past. She has not run a
cromolyn fever and does not have throat pain, but she does have
sodium, an occasional nonproductive cough that gets worse at
advise the night.
patient di
makita Past Medical History (PMH)
ditso ang
improveme ➔ Allergic rhinitis × 14 years
nt sa ➔ Tonsillectomy(usa pud sa risk factor) and
adenoidectomy at age 8
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➔ Anterior cruciate ligament reconstruction at age 16
➔ Sinusitis 5 months ago
Sinusitis, ni inflare or ni hubag sa sinuses, orbital
sinuses, maxillary; Rhinitis, kay nasal mucosa ang ni
hubag dele ang sinus
Importance of tonsils: helps in filtering with foreign
body
Family History (FH)
Father age 43, with a history of HTN and hyperlipidemia.
Mother age 39, with a history of major depressive
disorder. Brother age 17, with moderate persistent
asthma, and sister age 14, with allergic rhinitis
Social History (SH)
● Lives in a 3-bedroom house built on a concrete slab
with two roommates. She has been living there for
approximately 9 months. One roommate smokes
cigarettes, but not in the house.
● AB smokes occasionally when she drinks
alcohol. She drinks 5 or 6 drinks once or twice a
week when she goes out (risk factor, nag
maintain man gud siyag alcohol, acute
alcoholism so enzyme inhibitor). One of her
roommates has a cat that lives indoors.
● Last August (about 8 months ago) AB started
attending the State University where she is a nursing
major. AB plays intramural flag football and
basketball at the University and competes locally
and regionally in triathlons.
MEDS
➔ Clemastine (Tavist) 1 tablet po BID
➔ Oxymetazoline nasal spray PRN at night (once or
twice a week)
❖ Butterbur Extract 1 capsule po BID ➢ Butterbur
or Petasites hybridus is an herbal remedy that
exhibits antihistamine and anti-leukotriene
activity and has been shown to attenuate the
response to adenosine monophosphate
challenge in patients with allergic rhinitis and
asthma
ALLERGY
Codeine (itching) - for dry cough; antitussive
Review of Systems (ROS)
Admits to occasional headaches but denies shortness of
breath, wheezing, chest pain, or abdominal discomfort
Physical Examination (PE)
GEN
⊳ The patient is a young woman who looks her stated
age. She appears tired with darkened areas under her
eyes. She sounds congested and is continually
rubbing her nose and eye.
Vital Signs
⊳ BP 102/62 - low
⊳ P 64
⊳ RR 14
⊳ T 36.9°C
⊳ Wt 114 lb & Ht 5'4''
HEENT
⊳ NC/AT; PERRLA; EOMI.
⊳ Chemosis (swelling of the conjunctive of the eyes or
periorbital region) and conjunctival injection.
⊳ Periorbital edema and discoloration.
⊳ TMs are intact.
⊳ Nasal mucous membranes and turbinates are swollen
and pale with no epistaxis. There is no tenderness
over the frontal and maxillary sinuses. There are no
oropharyngeal lesions, and the throat is
non-erythematous (wala ray redness sa throat)
⊳ Neck No lymphadenopathy or thyromegaly
⊳ Chest CRX bilaterally; no wheezes
⊳ Breast Deferred
⊳ Heart RRR without murmur or rub
⊳ Abdomen Soft, non-tender, (+) BS
⊳ Genit/Rect Deferred
⊳ Extremities No CCE (Clubbing, Cyanosis, Edema),
pulses 2+ throughout
⊳ Neuro A & O × 3; DTRs 2+ throughout; 5/5 strength;
CN I–XII intact
ASSESSMENT
This is a 19-year-old woman with nasal congestion,
chemosis, and conjunctival injection most likely due to
seasonal and perennial allergies
PLAN
Perennial rhinitis with seasonal exacerbations:
Discontinue butterbur. Continue Tavist; start Singulair
10 mg 1 tablet po at bedtime. (Tavist and Singulair will
enhance the effect together, synergistic ang effect)
- If nasal congestion, we need to use topical
congestant, we need to clean the nose first, if
wala na nasal congestion, go to steroids
- Seasonal, dx of choice is systemic
antihistamine, orally taken drug, that is for
exacerbation, take antihistamine before season
maabot
PROBLEM IDENTIFICATION
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 Part 1
⊳ Create a list of the patient’s drug therapy problems.
- Gitagaan siya ug singulair, kay sige siyag take
antihistamine pero wa na ni effect sa iyaa
⊳ What information (signs, symptoms, laboratory values)
indicates the presence or severity of allergic rhinitis?
⊳ What additional information from the patient history is
needed to satisfactorily assess this patient?

OPTIMAL PLAN
Part 2
⊳ What drug, dosage form, dose, schedule, and duration
of therapy are best for this patient?
⊳ What alternatives would be appropriate if the initial
therapy fails?

OUTCOME EVALUATION
Part 3
⊳ What clinical and laboratory parameters are necessary
to evaluate the therapy for achievement of the desired
therapeutic outcome and to detect or prevent adverse
effects?

PATIENT EDUCATION
Part 4
⊳ What information should be provided to a patient
receiving an intranasal corticosteroid to enhance
compliance, ensure successful therapy, and
minimize adverse effects?
⊳ What information should be provided to a patient
receiving an ophthalmic antihistamine?