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Course Number: GRANDROUND 2006, Fall 2009

College/University: Utah

Word Count: 2046


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Allergic Disorders in the Primary Care Setting Scott Taylor MD, ABIM, ABP Asthma & Allergy Clinic of Utah September 20, 2006 History John is 25-year-old computer programmer who presents in mid-September with acute complaints of nasal discharge, congestion, repetitive sneezing and itching of the eyes. In addition he complains of fatigue and difficulty concentrating although he denies headache or fever. He...

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Disorders Allergic in the Primary Care Setting Scott Taylor MD, ABIM, ABP Asthma & Allergy Clinic of Utah September 20, 2006 History John is 25-year-old computer programmer who presents in mid-September with acute complaints of nasal discharge, congestion, repetitive sneezing and itching of the eyes. In addition he complains of fatigue and difficulty concentrating although he denies headache or fever. He also complains of increased shortness of breath for the last few weeks when he begins to exercise and reports waking up several times in the middle of the night coughing. The only medications he has tried are over the counter allergy combination preparations with mild benefit. Based on the History so far the most likely diagnosis is A) Acute on Chronic Rhinosinusitis with allergic post nasal drip B) Allergic Rhinitis with Exercise Induced Bronchoconstriction C) Allergic Rhinosinusitis with poorly controlled asthma D) Infectious Enterovirus with resulting bronchitis Physical Exam Gen: Fatigued appearing man using a nasal voice with faint allergic shiners Heent: Increased conjunctiva erythema with markedly swollen pale turbinates with no noted polyps. Clear discharge noted with no sinus tenderness on palpation. Oropharynx exam reveals no cobblestoning. The rest of the exam including auscultation of the chest is essentially within normal limits Based on the History and Physical the next most appropriate step would be A) Trial of non sedating antihistamines and/or nasal steroids with close follow up B) Rast (IgE) testing to ascertain allergen sensitization to recommend avoidance measures C) Referral to an Allergist for appropriate skin testing to recommend avoidance measures D) Spirometry E) CT scan of the paranasal sinuses Objectives Allergic Rhinitis pathophysiology/treatment What is Immunotherapy/How does it work? Asthma pathophysiology and treatment (allergic and non allergic) What does an Allergist really do anyway? Allergic Rhinitis Affects an estimated 60 million people (20% of the population) Prevalence in industrialized world is increasing Often associated with other co morbidities; Sinusitis (60%) Allergic Conjunctivitis Asthma (50%) Oral Allergy Syndrome Eczema (30%) Recurrent Otitis Media Significant cost to health care ($7 billion) and significant lost school and work days. Busse W, Lemanske RF Jr. N Engl J Med 2001;344:350-62 http://www.ipm.ucdavis.edu/PMG/WEEDS/russian_thistle.html http://www.pbase.com/kleb7842/image/45489381 Busse WW, Lemanske RF Jr. N Engl J Med 2001;344:350-62 Rhinitis Classification Eosinophilic Rhinitis Allergic rhinitis NARES Noneosinophilic rhinitis Infectious (URI) Vasomotor Rhinitis (Gustatory/skier's nose) Atrophic Rhinitis Rhintis Medicamentosa (Common!) Hormonal Rhinitis (Pregnancy, Hypothyroidism) Other Conditions Blockage (structural, foreign body, choanal atresia, angiofibroma) CSF Rhinorrhea Psychiatric Conditions Other Associations with Rhinitis Systemic Disease DM, Sarcoidosis, Wegener's, Relapsing Polychondritis, Uremia Infectious Disease TB, Syphilis, leishmaniasis, coccidiomycosis, blastomycosis Medications Ace-inhibitors, B-blockers, OCP, Reserpine Allergic Rhinitis Diagnosis History- Sneezing, rhinorrhea, nasal obstruction, itching of the eyes, nose and palate as well as postnasal drip, cough, irritability and fatigue. Seasonal Sxs alone (11%) Perennial Sxs (56%) Perennial with seasonal exacerbations (33%) PE- Allergic salute with nasal crease, allergic shiners, Denie Morgan Lines, Boggy turbinates with a pale bluish hue, clear rhinorrhea anteriorly and/or cobble stoning (lymphoid hyerplasia) from post nasal drip secondary to nasal obstruction Allergic Rhinitis Diagnosis Continued Nasal Cytology- Eosinophils vs Neutrophils Skin Testing- In-vivo prick testing of the back or forearm with common allergens and to observe for wheal and flare after 15 minutes. Intradermals can be done on select negative pricks with a high index of suspicion. Immediate results, less expensive risk of systemic reaction small RAST Testing- In-vitro blood work (Immunocap) to check specific IgE levels of suspected allergens. Delayed results, expensive, painful for children, no risk of systemic reaction. Decreased Sensitivity as compared to skin testing Allergen Avoidance Pet allergen is found primarily in the dander (skin flakes) and saliva NOT the hair Cat allergen in up to 90% of homes (even if no cat) After removal of cat the allergen level stays significantly elevated for several months (short avoidance trails not effective) Washing cat regularly and HEPA filter +/ Dust Mite and Mold rarely an issue in Utah as there is low humidity THERAPY FOR ALLERGIC RHINIITIS THERAPY COST/YR MECHANISM SIDE EFFECTS Lifestyle Limitation? Sedation HA Dry Mouth Pharyngitis Epistaxis HA HA Flu Sxs Abdom pain Local Rxn Anaphlaxis (Rare) DURATION Allergic Avoidance Antihistimine Free $-$$$ N/A Block Histamine (Not help congestion) Lifetime Lifetime Nasal Steroids $$-$$$ AntiInflammation LTRA/LT Syn-Inhib Long termImmunomodulation Lifetime LT Modifiers $$$ Lifetime *Immuno-Therapy *If symptoms refractory to avoidance and medications and/or medications not tolerated or desired, consider immunotherapy. $$$$ (1st Year) 3-5 years $$-$$$ (2nd3rd yr) (5-20 yr) (Also effective in Allergic Asthma) McKay IR, Rosen FS. N Engl J Med 2001;109-113. Oral Allergy Syndrome Oral Pruritis, rapid onset, IgE-mediated, rarely progressive with various fresh fruits/vegetables Found in up to 50% of patients with Birch and/or Ragweed allergy Cross reactive proteins (food/pollen) Birch- apple, cherry, apricot, carrot, kiwi, plum Ragweed- watermelon, cantaloupe, banana, cucumber Caution with Decongestants HTN DM CAD BPH Hyperthyroidism Raynauds, APLAS Asthma Continues to be a Major Problem in the United States Affects 12-15 million Americans,10-12% of children under 18 More than 5,500 people die from asthma every year Economic impact of asthma is estimated to be close to $3 billion annually The third leading cause of preventable hospitalization in the US "Hence it may be concluded every inveterate Asthma to be a mixt affection, stir'd up by the default partly of the Lungs ill-formed and partly of the Nerves and nervous Fibers pertaining to the breathing parts" Thomas E.Willis 1684 Current definition of Asthma "Chronic Inflammatory disorder of the airways in which many cells play a role...In Susceptible individuals, this inflammation causes recurrent wheezing, breathlessness, chest tightness and cough, particularly at night and /or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible...The inflammation also causes as associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli." Lemanske/Busse JACI Feb 2003 Pathophysiology Genetics (complex genetic disorder) Airway obstruction (smooth muscle spasm, mucosal edema, mucus hyper secretion, inflammation and remodeling) Airway Hyper responsiveness (methacholine, cold air, exercise hyperventilation) Other Precipitating Factors of Asthma Infections Exercise NSAID/ASA GERD Psychosocial Isocyanates Mold proteases Many others Exercise Induced Bronchoconstriction (EIB) One of the most common precipitants of airway obstruction in asthmatic patients Wheezing, coughing, shortness of breath, and, children, in chest pain or discomfort Symptoms are most intense 5-10 minutes AFTER the cessation of exercise secondary to progressive bronchospasm Spontaneous remission usually follows within 30-60 minutes Albuterol 2-4 puffs 10-15 minutes prior to exertion and/or use of montelukast. Cromolyn Sodium inhaler 2-4 puffs can be used prior to exertion as well Careful not just incontrolled Asthma (PFT) Diagnosis Asthma can be difficult to diagnose Careful history (coughing, wheezing, shortness of breath, chest tightness, symptoms worse at night, precipitants, family history) Thorough physical exam (wheezing, allergic rhinitis, eczema , pulsus paradoxus (Korotkoff's sound) Pulmonary function tests (Spirometry) Risk of developing Asthma by age 6 in children with recurrent wheezing in the first 3 years Castro- Rodriguez JA et al. AJRCCM 162: 1403, 2000 1 Major Criteria Eczema Parental Asthma + Allergy Skin Test OR 2 Minor Criteria Wheezing w/o URI Eosinophilia (>4%) + Food skin test + 65% chance of developing asthma by 6 - 95% chance of no asthma by age 6 Spirometry in Asthma FEV1 N or FVC (increased RV in severe obstr) FEV1/FVC FEF 25-75 (small airway obstruction) PEF FEV1 (>12%) in response to bronchodilator Mueller GA, Eigen H. Pediatrics in Review 1994; 404-410 Diagnosis continued Bronchoprovocation Methacholine challenge test (increased sensitivity) CXR CBC Allergy skin testing History/Physical 19 year-old college student presents with 2-3 month history of cough that is worse at night and sometimes associated with wheezing. He has no known history of asthma but does state that he has had exercise induced symptoms in the past. He describes significant allergic symptoms to cats (they have a cat) but states that Zyrtec seems to help. He says that the cough has worsened since he came home from school and he has mild pain on inspiration. He describes fatigue since he has been on a special diet and lost over 20 pounds. PE reveals mild erythema of the nasal turbinates with lungs clear to auscultation bilaterally. The rest of the exam was noted to be WNL. PFT was performed which showed FEV1 4.39L (96%) with normal FVC and FEF 25-75% Current Asthma medications 2-Adrenergic agonists Theophylline Cromolyn/Nedocromil Leukotriene Antagonists Glucocorticosteroids Anticholinergics Anti-IgE Antibody 2-Adrenergic agonists Most potent and rapidly acting bronchodilators Available in multiple forms Relaxes smooth muscle Side effects include tremor, tachycardia and increased anxiety Long acting -agonists salmeterol and formeterol are effective for the treatment of moderate to severe persistent asthma but should not be used as monotherapy. Regular use of 2-agonists results in down-regulation of 2-adrenoceptor function Theophylline Methylxanthine with bronchodilator effects that may also have mild antiinflammatory properties. Cheap and can be used as an add-on to inhaled corticosteroids as a controller medication (not as effective as long acting 2-agonists) Requires serum monitoring (5-15 mcg/ml) Side effects include GI symptoms, seizures and adversely affect school performance. Anticholinergics Provide bronchodilation Not considered first line drugs in the treatment of acute asthma but are reserved as adjunctive therapy to inhaled 2-agonists. Provide benefit in acute asthma (severe over mild cases) Side effects include anxiety, dizziness, headache and use with caution in narrow-angle glaucoma or bladder neck obstruction. Leukotriene Antagonists Cysteinyl leukotrienes (LTC4, LTD4 and LTE4) are generated by eosinophils and other cells. These leukotrienes interact with the CysLt1 receptor which can lead to airway smooth muscle contraction and other effects. 5-lipoxygenase inhibitors (Zileuton) inhibits cysteinyl leukotriene synthesis but requires monitoring of liver enzymes regularly as well as 4x/day of dosing. Leukotriene Antagonists Cysteinyl leukotriene receptor antagonists (Zafirlukast and Montelukast) have wider appeal. Can be used in EIB, inhaled allergens and chronic asthma Side effects include headache, abdominal pain and dyspepsia Glucocorticosteroids Most potent anti-inflammatory agents available for the treatment of asthma Decrease in inflammatory cell function, stabilization of vascular leakage, decrease in mucus production and an increase adrenergic response. Steroids suppress multiple inflammatory genes by reversing histon...