ent prob - jamesvu

[ArchivalUser]

A 22-year-old man comes to the office for management of his allergic rhinitis. He has been told by various physicians over the years that he suffers from this disorder, but that he has never had any medications prescribed. Rather, he has been instructed to avoid certain environmental exposures. He reports that each spring and early summer he routinely suffers from sneezing, nasal discharge, and pruritus as well as eye itching and watering. The symptoms often abate in the fall and winter, although he occasionally has symptoms during this time. A survey of his environmental exposures reveals no toxic irritants in the workplace, perfumes, or colognes that seem to trigger the symptoms. However, cat hair exacerbates his symptoms. He works approximately an hour from his home and that he commutes by car. The most appropriate next step in management is to

A. advise him to have his home cleaned weekly to decrease the number of triggers
B. initiate over-the counter antihistamine therapy
C. prescribe an intranasal antihistamine
D. prescribe an intranasal steroid
E. prescribe an oral antihistamine

[ArchivalUser]

c

[ArchivalUser]

DDD

[ArchivalUser]

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The correct answer is D. This patient has allergic rhinitis (AR). AR may be seasonal or perennial with significant overlap. For seasonal rhinitis there are well identified triggers in spring and summer. Perennial is characterized by more chronic symptoms with occasional flares. The diagnosis is solely based upon the history and physical examination. For this patient who appears to have a significant overlap between the two and has no clear allergen identified, medical treatment is indicated. Medical therapy has been shown to improve symptoms and is associated with an overall improved quality of life. Topical intranasal steroids are superior to prescription non-sedating antihistamines for overall symptom control and for fewer side effects. For this reason, they are now considered first-line pharmacotherapy for allergic rhinitis.

Since the patient has no clear allergen identifiable, it will likely not benefit him to have weekly home cleaning (choice A). For patients with such triggers identified, this maneuver often dramatically improves symptoms.

Over-the-counter antihistamine therapy (choice B) are so-called "sedating" or "traditional" antihistamines. These are not good agents for this patient because of his necessity to drive each day. In fact, studies have documented the driving performance of patients on these drugs are similar to those with alcohol intoxication.

Prescription strength intranasal (choice E) or oral (choice C) antihistamines are so called "non-drowsy" formulations. These are superior to the standard first generation agents but are not first-line therapy any longer. Steroids are now considered more efficacious and should be tried first. The intranasal formulations offer no added benefit when compared to oral formulations and are therefore not recommended.

[ArchivalUser]

thanks for posting Qs with detailed explanation.