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KEY CONCEPTS

KEY CONCEPTS

  • image Allergic rhinitis is a common disease. Prevention measures and treatment are justified in most cases because of the potential for complications.

  • image Because an immune response to allergens results in release of inflammatory mediators that cause allergic rhinitis symptoms, patients must understand the rationale for proper timing and administration of prophylactic regimens.

  • image Avoidance of allergens is difficult and it may be impractical to expect full success.

  • image Antihistamines offer an effective option for treating both seasonal and persistent allergic rhinitis.

  • image Intranasal steroids are highly effective in patients who use them properly.

  • image While immunotherapy is the only disease-modifying treatment of allergic rhinitis, expense, potential risks, and the major time commitment required make patient selection critical.

PATIENT CARE PROCESS

Patient Care Process* for Management of Allergic Rhinitis

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Collect

  • Primary complaint(s) (sneezing, clear rhinorrhea, postnasal drip, nasal congestion, ocular or otic symptoms, pruritic nose or palate)

  • Patient characteristics (eg, age, race, sex, pregnant)

  • Past medical history, allergy testing, medications

  • Patient family, social history—dietary habits; presence of pets, mold, or wall-to-wall carpeting; times of year, situations, or locations (indoor or outdoor) when symptoms are worse

  • Current over-the-counter (OTC) products, prescription medications, dietary supplements; past medications or interventions used for treating rhinitis symptoms

  • Past or current use of environmental controls of potential allergens (eg, removal of carpeting or pets, air-filtration systems)

  • Objective data

    • Presence of allergic “shiners” (dark circles under eyes) or “salute” (crease across nose caused by constant rubbing)

    • Labs when available (eg, IgE, serum eosinophil count)

    • Other diagnostic tests when available (eg, allergy testing)

Assess

  • Presence of concomitant atopic disorders (eg, asthma, atopic dermatitis)

  • Presence of complications of allergic rhinitis (eg, acute otitis media, middle ear effusion, sinusitis, epistaxis)

  • Timing of symptoms—seasonal or persistent (see Table e13-2)

  • Usefulness for environmental controls of allergens (primarily for persistent cases)

  • Which symptoms to control (eg, nasal congestion, clear rhinorrhea, sneezing, pruritus, ocular conjunctivitis)

  • Current or past medications and patient response to those

  • Appropriateness and effectiveness of current regimen

Plan*

  • Nonpharmacologic interventions (eg, allergen avoidance, nasal rinses, nasal strips; see Table e13-3)

  • Drug therapy regimen including specific agent(s), dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Table e13-2 and Fig. e13-2)

  • Patient education (eg, purpose of treatment, allergen avoidance, nonpharmacologic interventions, drug therapy, and the potential need for referral to physician or allergist for prescription or immunologic treatment).

  • Self-monitoring of symptoms and adverse effects—where and how to record results

  • Referrals to other providers when appropriate (eg, physician, allergist)

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up if needed

Follow-up: Monitor and Evaluate

  • Monitoring parameters including efficacy (eg, bothersome symptoms), safety (eg, drowsiness, anticholinergic effects, effects on blood pressure; medication-specific adverse effects  [see Table e13-8])

  • Patient perception of control of bothersome symptoms

  • Presence of adverse effects

  • Continued presence of physical signs of nasal and ocular pruritus

  • Patient adherence to treatment plan using multiple sources of information

  • Referrals to other ...

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