NR507 Week 1: Case Study

NR507 Week 1: Case Study

Pathophysiology & Clinical Findings of the Disease

1. Identify the correct hypersensitivity reaction:

The hypersensitivity response seen in this case study is specifically allergic rhinitis, which is classified as a Type 1 hypersensitivity reaction. The patient had signs of rhinorrhea, sneezing, and enduring nasal congestion. Allergic rhinitis is diagnosed by a thorough evaluation of the patient’s health history and a detailed physical examination. Confirming the diagnosis may be possible if there is a positive response to empirical treatment with a nasal glucocorticoid. Sensitivity testing to allergens in the serum or allergy skin testing may provide a conclusive diagnosis. Serum testing is only performed on individuals who do not respond to first therapy or who need to identify particular allergens. Skin testing exhibits somewhat higher sensitivity and is more economically efficient. Contraindications for this treatment include unmanaged asthma, unstable cardiovascular illness, pregnancy, and simultaneous use of beta-blockers (Zhang et al., 2022). The anti-IgE monoclonal antibody omalizumab, H2-receptor antagonists, and tricyclic antidepressants may interfere with allergy skin test findings. Regular use of radiographic imaging is not often advised for diagnosing allergic rhinitis.

2. Explain the pathophysiology associated with the chosen hypersensitivity reaction:

Allergic rhinitis refers to the inflammation of various mucous membranes in the body, including the sinuses, throat, middle ear, eustachian tubes, nose, and eyes. This inflammation is caused by a specific immune response involving immunoglobulin E and is triggered by exposure to an external protein. Allergic reactions to extrinsic allergens have a substantial genetic influence. When specific IgE antibodies against foreign proteins are produced, it indicates that the person has become allergically sensitized to those proteins. Heparin, kinins, chymase, histamine, and tryptase are among the mediators that are released when mast cells in the nasal mucosa with IgE on them are present (Liu & Liu, 2022). Leukotrienes, prostaglandin D2, and mediators are involved in a number of rhinorrhea symptoms, such as postnasal drip, edema, redness, sneezing, nasal congestion, and irritation. In the initial stage of the reaction, there is an elevation in secretions, vascular permeability, congestion, pressure, and activation of sensory nerves. In 4 to 8 hours, these mediators attract additional inflammatory cells to the mucosa, leading to the late-phase response (Linton et al., 2021). The manifestations of the late-phase reaction have a resemblance to those of the initial stage, which is characterized by a reduction in sneezing and itching and an elevation in congestion along with mucus production. The terminal stage may last for a prolonged duration, ranging from several hours to even multiple days. The inflammatory response might result in systemic manifestations, such as weariness, drowsiness, and malaise, which can have a detrimental influence on an individual’s quality of life.

3. Identify at least three subjective findings from the case:

According to the provided case, the patient is a 35-year-old female who has been suffering from worsening nasal congestion and repeated sinus infections. She was under the impression that she was in excellent health until about a year ago when she began to experience symptoms such as runny nose, sneezing, and congestion that have continued. She observed a significant improvement in her rhinorrhea symptoms during her two-week Caribbean cruise for a family reunion. However, upon returning home, the symptoms resurfaced after a few days. She resides with her spouse and their five-year-old kid. They own a dog that has been a part of their household for the past four years and a cat that became a member of their family one year ago.

4. Identify at least three objective findings from the case:

During the examination, the nurse practitioner noted several objective findings in the patient’s case. These included inflammation of the nares, venous edema on the lower lids, redness and swelling of the eyelids, conjunctiva, and nasal crease.

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

1. Identify two strongly recommended medication classes for the treatment of the condition and provide an example (drug name) for each:

Allergic rhinitis usually improves with medication, and occasional symptoms can be managed with oral antihistamines, decongestants, or a combination of both. According to Meng et al. (2020), second-generation antihistamines, also referred to as nonsedating antihistamines, effectively manage symptoms but have limited impact on nasal congestion. They are commonly favored as the initial treatment option, particularly for symptoms that occur seasonally or episodically. In the US market, there are many second-generation oral antihistamines available, including Desloratadine, fexofenadine, loratadine, levocetirizine, and cetirizine. Research findings indicate that there are no significant variations in effectiveness between cetirizine and placebo, although cetirizine may lead to drowsiness more often (Linton et al., 2021).

Intranasal steroids are highly suggested for the management of allergic rhinitis. Nasal corticosteroids are a group of intranasal steroids that can be categorized into three generations according to their bioavailability. The bioavailability and systemic adverse effects of first-generation corticosteroids, such as beclomethasone, are higher compared to second- and third-generation categories, which have lower bioavailability and fewer systemic adverse effects (Lourenço et al., 2020). Nasal steroid sprays are known for their effectiveness in treating allergic rhinitis by effectively managing the four primary symptoms: sneezing, itching, rhinorrhea, and congestion. The FDA has approved several medications for nasal allergy symptoms, such as triamcinolone acetonide, Flonase, and Rhinocort (Terada & Kawata, 2022). The local adverse effects of this treatment are minimal, usually resulting in only minor irritation or nasal bleeding. However, it is essential to note that the safety of this treatment during pregnancy has not been established. Regular use of nasal steroids is recommended for ongoing treatment, as they are effective in managing vasomotor rhinitis or mixed rhinitis, as well as controlling nasal polyps.

2. Describe the mechanism of action for each of the medication classes identified above:

Histamine is a naturally occurring chemical messenger that causes an increase in vascular permeability. This results in swelling and dilation of blood vessels. Antihistamines, by acting as antagonists on the H-1 receptors, reduce this impact and relieve symptoms of allergies. First-generation antihistamines can cross the blood-brain barrier and bind to H-1 receptors in the CNS. On the other hand, second-generation antihistamines mainly focus on peripheral histamine receptors. First-generation antihistamines have a pharmacological duration of around 4 to 6 hours, while second-generation antihistamines give relief for a more extended period of 12 to 24 hours. Meng et al. (2020) reported that the liver metabolizes both drugs via the P450 cytochrome system. Enterochromaffin-like cells produce histamine, which then attaches to H-2 receptors located on parietal cells. This results in an elevation in cAMP concentrations and the subsequent stimulation of protein kinase A. As a result, proteins involved in hydrogen ion transport are phosphorylated. Antihistamines that target the H-2 receptor effectively inhibit this process, resulting in a decrease in the production of stomach acid.

Intranasal corticosteroids (INCS) exhibit a multifaceted mechanism of action, as their minimal systemic effects indicate a primarily localized impact on the nasal mucosa. The local effect has the potential to impact a range of inflammatory cells and their mediators, including Langerhans cells, basophils, mast cells, lymphocytes, and epithelial cells. One potential mechanism, although not yet confirmed, involves the suppression of histamine release that is dependent on immunoglobulin E by corticosteroids. Epithelial cells play a vital role in the effectiveness of INCS, as they are highly concentrated at the epithelial surface. According to Okano et al. (2023), it has been observed that INCS can bind with corticosteroid receptors in epithelial cells. These cells, along with dead or migrating inflammatory cells, are then released into the airway lumen. The INCS therapy efficiently decreases the occurrence of early-phase sneeze and rhinorrhea that happens after exposure to an allergen outside of the pollen season. The precise mechanism via which INCS therapy relieves itching, wheezing, and rhinorrhea remains unclear and requires more research. Further investigation is needed to fully comprehend the diverse processes by which INCS offers therapeutic advantages in instances of allergic rhinitis.

3. Identify two treatment options that are NOT recommended (I.e., recommended against):

The American Academy of Otolaryngology-Head & Neck Surgery Foundation (AAO-HNS) released recommendations in 2015 for the management of allergic rhinitis in patients aged two and older (Zhang et al., 2022). Patients who have symptoms including nasal congestion, changes in the color of the nasal canal, and red and watery eyes are recommended to avoid getting sinus imaging and instead consider particular immunoglobulin E screening as an alternative. Patients may be exposed to unnecessary radiation during sinus imaging. Oral leukotriene receptor antagonist usage is not recommended, according to Terada and Kawata (2022).

It is not advisable to use oral leukotriene receptor antagonists as the initial treatment for allergic rhinitis, as they are not as effective as intranasal corticosteroids and antihistamines. Research studies have indicated that these treatments are typically less effective in managing symptoms compared to intranasal corticosteroids and antihistamines (Siddiqui et al., 2022). Oral leukotriene receptor antagonists are commonly used as an alternative or additional treatment option, particularly for patients with asthma. Nevertheless, there are concerns regarding the occurrence of neuropsychiatric events linked to the use of montelukast, as well as possible side effects, including headaches, gastrointestinal disturbances, and abnormalities in liver enzymes.

References

Linton, S., Burrows, A. G., Hossenbaccus, L., & Ellis, A. K. (2021). Future of allergic rhinitis management. Annals of Allergy Asthma & Immunology, 127(2), 183–190. https://doi.org/10.1016/j.anai.2021.04.029

Liu, Y., & Liu, Z. (2022). Epidemiology, Prevention and Clinical Treatment of Allergic rhinitis: More understanding, Better Patient care. Journal of Clinical Medicine, 11(20), 6062. https://doi.org/10.3390/jcm11206062

Lourenço, O., Bosnic-Anticevich, S., Costa, E., Fonseca, J. A., Menditto, E., Cvetkovski, B., Kritikos, V., Tan, R., Bedbrook, A., Scheire, S., Bachert, C., Białek, S., Briedis, V., Boussery, K., Canonica, G. W. W., Haahtela, T., Kuna, P., Novellino, E., Samoliński, B., . . . Bousquet, J. (2020). Managing Allergic Rhinitis in the Pharmacy: An ARIA Guide for Implementation in Practice. Pharmacy, 8(2), 85. https://doi.org/10.3390/pharmacy8020085

Meng, Y., Wang, C., & Zhang, L. (2020). Advances and novel developments in allergic rhinitis. Allergy, 75(12), 3069–3076. https://doi.org/10.1111/all.14586

Okano, M., Fujieda, S., Gotoh, M., Kurono, Y., Matsubara, A., Ohta, N., Kamijo, A., Yamada, T., Nakamaru, Y., Asako, M., Sakurai, D., Terada, T., Yonekura, S., Sakashita, M., & Okubo, K. (2023). Executive summary: Japanese guidelines for allergic rhinitis 2020. Allergology International, 72(1), 41–53. https://doi.org/10.1016/j.alit.2022.11.003

Siddiqui, Z., Walker, A., Pirwani, M., Tahiri, M., & Syed, I. (2022). Allergic rhinitis: diagnosis and management. British Journal of Hospital Medicine, 83(2), 1–9. https://doi.org/10.12968/hmed.2021.0570

Terada, T., & Kawata, R. (2022). Diagnosis and treatment of local allergic rhinitis. Pathogens, 11(1), 80. https://doi.org/10.3390/pathogens11010080

Zhang, Y., Lan, F., & Zhang, L. (2022). Update on pathomechanisms and treatments in allergic rhinitis. Allergy, 77(11), 3309–3319. https://doi.org/10.1111/all.15454

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