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CASE STUDY 6:  Allergic Rhinitis

Peter Davies is a 50 year old business man. He has allergic rhinitis and is hypersensitive to pollen. Peter has had this condition for several years and is currently treating it himself. His symptoms include sneezing, rhinorrhoea and nasal blockage. His eyes, nose and palate are itchy and he is feeling dizzy and drowsy.

Questions

1. Allergic rhinitis produces a local inflammatory response. A number of substances play an important role in this response. These include:

1. Prostaglandins

2. Histamine

3. Leukotrienes

4. Bradykinin

5. Cytokines
   
   Describe the roles of each of these substances in inflammation.
    

(Check answers to question 1)

2. What crucial questions would you ask of this patient when taking a history?

(Check answers to question 2)

3. What could be causing the drowsiness and dizziness?

(Check answers to question 3)

4. What medication might you prescribe for Peter?

(Check answers to question 4)

5. What advice would you offer him?

(Check answers to question 5)



 

Answers

1.

a. Prostaglandins
Prostaglandins are extremely powerful, both released and responded to by practically all body tissues. Tissue damage, for example, that caused by infection or trauma, leads to the release of large amounts of prostaglandins at the site of inflammation. They have a number of actions including:

• The increased action of histamine (see below).

• Direct action on pain receptors (nociceptors) and the relay of pain messages to the brain.

• A pyrogenic effect, resetting the hypothalamus or temperature-regulating centre of the brain at a higher level.

b. Histamine
Mast cells and basophils contain histamine. During inflammation histamine is released. This substance acts on specific receptors and effects include:

• Vasodilation.

• Increased vascular permeability.

• Spasm of smooth muscle.

c. Leukotrienes
Leukotrienes are released by activated white blood cells (leukocytes) and are found in inflammatory exudate and tissues in a number of inflammatory conditions. The action of leukotrienes include:

• Chemotaxis

• Contraction of bronchial muscle.

• Vasodilation.

d. Bradykinin
The increased vascular permeability which occurs during inflammation leads to the leakage of plasma and other substances from blood vessels. Hageman factor (factor XII of the blood clotting sequence) is one of these substances. The leakage of this factor leads to the generation of bradykinin. Bradykinin has a number of effects including:

• Vasodilation.

• Increased vascular permeability.

• Transmission of pain messages to the brain.

e. Cytokines
Cytokines are released from, and regulate, the actions of both inflammatory and immune system cells.

2) & 3) Although allergic rhinitis can cause lethargy, by taking a number of over-the-counter (OTC) products Peter could have inadvertently overdosed himself. This might be why he is feeling dizzy and drowsy. It is therefore important to identify which medicines he has been taking.

4) Treatment is dependent upon symptoms and whether clients prefer topical or oral preparations. The following regime is recommended by the International Rhinitis Management Working Group [1] and can be used as a guide to inform prescribing decisions.

Mild disease with occasional symptoms: If symptomatic administer a rapid onset oral antihistamine or, a topical antihistamine or cromoglycate to eyes and nose.

Moderate disease with prominent nasal symptoms: Intranasal corticosteroid and topical antihistamines or cromoglycate to the eyes if necessary.

Moderate disease and prominent eye symptoms: Oral antihistamines or intranasal steroid and topical cromoglycate to the eyes.

Watery rhinorrhoea: The addition of intranasal ipratropium to existing therapy.

The choice of antihistamine should also be based on response and patient preference. A short acting preparation to relieve intermittent symptoms may be preferred over a product which provides longer term relief.

5) Peter should avoid exposure to pollen by spending time indoors when the pollen count is high and ensure windows and doors are closed. It is important that he understands how to use nasal sprays correctly i.e. as outlined in the product literature and that he adheres to the treatment regimen. It is also important that Peter appreciates that although products may not produce an immediate effect, they should be used regularly. As Peter has previously experienced allergic rhinitis, it might be helpful to commence treatment before the symptoms of the condition appear.

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