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Question 3#

A 25-year-old woman complains of watery rhinorrhea and pruritus of the eyes and nose. She had mild asthma as an adolescent, but her lower respiratory symptoms have resolved. The nasal symptoms occur throughout the year but are worse in spring and fall. She has no pets in the home and avoids exposure to pollens and grass as much as possible. She has had inadequate symptom relief with month-long trials of daily oral loratadine and cetirizine. She does not use OTC decongestants. On physical examination, VS are normal. Nasal mucosa is pale and boggy, and she has an “allergic crease” on her nose. There is no sinus tenderness or lymphadenopathy.

What is the best next step in management of her symptoms? 

A. Referral to allergist for immunotherapy
B. Addition of montelukast 10 mg daily to the oral antihistamine
C. Addition of prednisone 10 mg daily until symptoms are controlled, then taper to lowest dose that controls her symptoms
D. Addition of daily intranasal glucocorticoid
E. Addition of daily intranasal cromolyn

Correct Answer is D


Allergic rhinitis is caused by allergens that trigger a local hypersensitivity reaction. Specific IgE antibodies attach to mast cells or basophils. Mast cell degranulation leads to a cascade of inflammatory mediators. This woman’s other atopic symptoms, seasonal exacerbations and negative medication history suggest that other causes of rhinitis (vasomotor rhinitis, rhinitis medicamentosa) are unlikely. Itching and sneezing are more common in allergic rhinitis than in vasomotor rhinitis, where nasal discharge and congestion are the dominant complaints. In allergic rhinitis, nasal turbinates appear pale and boggy (rather than red and inflamed as in infectious rhinitis).

Avoidance measures alone are often ineffective. Oral nonsedating anti-histamines are useful in mild cases (although they are ineffective at relieving nasal congestion). The most effective treatment is daily use of a potent nasal corticosteroid, which provides symptom relief in 70% of patients. Side effects are uncommon, although with prolonged use the risks of osteopenia and hypothalamic-pituitary-adrenal (HPA) axis suppression are increased. The leukotriene antagonist montelukast and immunotherapy are reserved for patients who fail to respond to nasal steroids. Long-term use of systemic steroids should be avoided because of the high risk of serious side effects. Intranasal cromolyn can be tried in mild cases but is less effective than a potent intranasal corticosteroid.