CTMA 2

Canada’s Trusted Reference for

Minor Ailments

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 Created by Canadian experts for
Canadian healthcare practitioners
treating Canadian patients

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 iii
Table of Contents
Editorial Advisory Committee ................................................................................................vii
Authors ........................................................................................................................... viii
Reviewers ........................................................................................................................ ix
Editor's Message ................................................................................................................ x
Editorial Policy, Description and Limitations of Information........................................................... xi
How to Use Compendium of Therapeutics for Minor Ailments ......................................................xii
Patient Assessments ......................................................................................................... xiii

Communicating With Patients

1 Effective Pharmacist-patient Interactions, Barbara J. Farrell ................................................... 1
2 Facilitating Behaviour Change, Lisa Dolovich .................................................................... 12
3 Pharmacist Assessment of the Self-treating Patient, Nardine Nakhla ...................................... 21

Psychiatric Conditions
4 Depression, Ric M. Procyshyn and Alasdair M. Barr............................................................ 27
5 Insomnia, Ric M. Procyshyn and Alasdair M. Barr............................................................... 38
6 Smoking Cessation, Kristine Petrasko and Manjit Bains....................................................... 52

Central Nervous System Conditions

7 Fever, Yvonne M. Shevchuk .......................................................................................... 82
8 Headache, Irene Worthington ........................................................................................ 99
9 Heat-related Disorders, Dorothy Tscheng ........................................................................117
10 Tinnitus, Yvonne M. Shevchuk ..................................................................................... 128
11 Vertigo and Dizziness, Yvonne M. Shevchuk ................................................................... 132

Eye Care
12 Assessment of Patients with Eye Conditions, Anne M. Friesen............................................ 139
13 Conjunctivitis, Anne M. Friesen .................................................................................... 140
14 Contact Lens Care, David S. Wing and Ken Gellatly ......................................................... 148
15 Dry Eye, Anne M. Friesen ........................................................................................... 162
16 Eyelid Conditions: Hordeolum, Chalazion and Blepharitis, Anne M. Friesen ........................... 169

Ear Conditions
17 Assessment of Patients with Hearing Loss, Ear Pain and Ear Drainage, Yvonne M.
Shevchuk ................................................................................................................ 187
18 Complications Affecting the Ear: Ear Piercing, Foreign Bodies and Barotrauma, Yvonne M.
Shevchuk ................................................................................................................ 193
19 Impacted Earwax, Yvonne M. Shevchuk......................................................................... 198

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 iv
20 Otitis Media and Otitis Externa, Yvonne M. Shevchuk ....................................................... 206

Respiratory Conditions
21 Acute Cough, Daniel J.G. Thirion.................................................................................. 217
22 Allergic Rhinitis, Jennifer Kendrick ................................................................................ 226
23 Assessment of Patients with Upper Respiratory Tract Symptoms, Daniel J.G. Thirion .............. 249
24 Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis, Daniel J.G. Thirion ........................... 254

Metabolic and Cardiovascular Conditions

25 Diabetes Care, Lori MacCallum .................................................................................... 273
26 Diabetes Care Devices, Ronald Silver ........................................................................... 293
27 Lifestyle Management and Disease Prevention, L. Maria Gutschi ........................................ 302

Gastrointestinal Conditions
28 Assessment of Patients with Abdominal Pain, Peter Thomson ............................................ 323
29 Constipation, Jane Bowles-Jordan ................................................................................ 327
30 Diarrhea, Antonietta Forrester ...................................................................................... 353
31 Dyspepsia and GERD, Co Q. D. Pham .......................................................................... 378
32 Gastrointestinal Gas, Co Q. D. Pham............................................................................. 390
33 Hemorrhoids, Joyce Chan ........................................................................................... 398
34 Infant Colic, Shelita Dattani ......................................................................................... 407
35 Irritable Bowel Syndrome, Lynette Kosar ........................................................................ 420
36 Nausea and Vomiting, Christine Hughes ........................................................................ 429
37 Ostomy Care, Marie Berry........................................................................................... 448
38 Perianal Symptom Assessment, Joyce Chan .................................................................. 463
39 Pinworms, Joyce Chan ............................................................................................... 465

Nutrition
40 Infant Nutrition, Joan Brennan-Donnan .......................................................................... 472
41 Special Diets, Shirley Heschuk..................................................................................... 491
42 Sports Nutrition, Shirley Heschuk.................................................................................. 506
43 Weight Management, Shirley Heschuk........................................................................... 519

Musculoskeletal Conditions
44 Drug Use and Abuse in Sports, Lily Lum......................................................................... 547
45 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 554
46 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 569
47 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 590
48 Sports Injuries, Lily Lum.............................................................................................. 608

Foot Conditions

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 45 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 554
46 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 569
47 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 590
48 Sports Injuries, Lily Lum.............................................................................................. 608

Foot Conditions
v
49 Assessment of Foot Symptoms, Anne Mallin ................................................................... 621
50 Athlete's Foot, Anne Mallin .......................................................................................... 623
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
51 Corns, Calluses, Bunions and Ingrown Toenails, Anne Mallin.............................................. 631
52 Plantar Warts, Anne Mallin .......................................................................................... 641

Dermatologic Conditions
53 A Summary of Common Skin Conditions, Penny F. Miller ................................................... 648
54 Acne, Debra Sibbald .................................................................................................. 653
55 Atopic, Contact, and Stasis Dermatitis, Debra Sibbald ....................................................... 682
56 Bacterial Skin Infections: Impetigo, Furuncles and Carbuncles, Penny F. Miller ....................... 716
57 Burns, Nancy Kleiman ................................................................................................ 730
58 Dandruff and Seborrheic Dermatitis, Debra Sibbald .......................................................... 740
59 Diaper Dermatitis, Debra Sibbald.................................................................................. 760
60 Dressings, Marie Berry ............................................................................................... 779
61 Drug-induced Skin Reactions, Sandra Knowles ............................................................... 786
62 Dry Skin, Nancy Kleiman ............................................................................................ 802
63 Frostbite, Nancy Kleiman ............................................................................................ 809
64 Fungal Nail Infections (Onychomycosis), Penny F. Miller.................................................... 818
65 Fungal Skin Infections, Penny F. Miller ........................................................................... 827
66 Hair Care and Hair Growth, Nancy Kleiman .................................................................... 842
67 Insect Bites and Stings, Nancy Kleiman ......................................................................... 861
68 Minor Cuts and Wounds, Nancy Kleiman........................................................................ 877
69 Parasitic Skin Infections: Lice and Scabies, Penny F. Miller ................................................ 886
70 Perspiration and Body Odour, Nancy Kleiman ................................................................. 904
71 Psoriasis, Debra Sibbald............................................................................................. 915
72 Prevention and Treatment of Sun-Induced Skin Damage, Nancy Kleiman.............................. 939
73 Viral Skin Infections: Common and Flat Warts, Penny F. Miller ............................................ 956
74 Viral Skin Rashes, Sandra Knowles............................................................................... 968

Reproductive, Gynecologic and Genitourinary Health

75 Benign Prostatic Hyperplasia and Associated Lower Urinary Tract Symptoms, Cheryl A.
Sadowski ................................................................................................................ 985
76 Contraception, Anne Marie Whelan ............................................................................... 999
77 Dysmenorrhea, Thomas E.R. Brown ............................................................................ 1031
78 Male Sexual Dysfunction, Tom Smiley .......................................................................... 1041
79 Menopause and Perimenopause, Thomas E.R. Brown ..................................................... 1054
80 Pregnancy and Fertility Testing, Marie Berry................................................................... 1067
81 Premenstrual Syndrome, Thomas E.R. Brown ................................................................ 1074
82 Prenatal and Postpartum Care, Carla Dillon ................................................................... 1090
83 Urinary Incontinence, Cheryl A. Sadowski ..................................................................... 1132
84 Vaginal Symptoms, Hygiene and Infections, Laura-Lynn Pollock......................................... 1145

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 vi
Dental Health
85 Dental Conditions, Michelle Bourassa........................................................................... 1167
86 Oral Hygiene, Dental Plaque and Caries, Michelle Bourassa ............................................. 1176
87 Periodontal Conditions: Gingivitis and Periodontitis, Michelle Bourassa ............................... 1188
88 Teething, Michelle Bourassa ....................................................................................... 1201

Mouth Conditions
89 Aphthous Ulcers (Canker Sores), Adeline T. Chau Markarian............................................. 1209
90 Cold Sores (Herpes Labialis), James S. Conklin ............................................................. 1220
91 Dry Mouth, Victoria Kletas .......................................................................................... 1232
92 Halitosis, Shirin Abadi ............................................................................................... 1242
93 Oral Candidiasis, Karen Wlock .................................................................................... 1249

General Appendices
I Complementary and Alternative Therapies, Cynthia Richard and Paul A. Spagnuolo .............. 1258
II Home Testing, Marie Berry ......................................................................................... 1278
III Information for the Traveller, Mark Kearney .................................................................... 1289
IV Medical Devices and Aids to Daily Living, Marie Berry ...................................................... 1304
V Pregnancy and Breastfeeding: Self-care Therapy for Common Conditions, Myla E.
Moretti ................................................................................................................... 1320
VI Nutritional Supplements, L. Maria Gutschi ..................................................................... 1329

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 206 Ear Conditions

Ear Conditions

Chapter 20
Otitis Media and Otitis Externa
Chapter 20

Yvonne M. Shevchuk, BSP, PharmD, FCSHP

Otitis Media
Pathophysiology
Acute otitis media (AOM) is an infection of the middle ear cavity and is one of the most common
bacterial infections in childhood.1 Seventy-five percent of children experience at least 1 episode prior
to entering school.2 To diagnose AOM, 3 criteria need to be met: 1) signs and symptoms of middle ear
inflammation 2) the presence of middle ear effusion and 3) acute onset (often abrupt) of signs and
symptoms of middle ear inflammation and effusion.1 Symptoms include acute ear pain (often
unilateral and developing over a few hours), fever and reduced hearing.1 Tugging or pulling on the ears
is often described, but this is a very nonspecific sign.1 Children too young to complain of pain or
pressure in the ears may display irritability, excessive fussiness, poor feeding and disrupted sleep
patterns. Acute otitis media is more common in the winter months. A recent history of viral upper
respiratory tract infection is often present.2 The microorganisms most commonly associated with AOM
are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.1,2
AOM has a high spontaneous recovery rate; 80% of children experience spontaneous symptomatic
relief with placebo or no drug therapy.3,4 For this reason, the concept of “watchful waiting” is
advocated after appropriate healthcare practitioner assessment and diagnosis of AOM. Rather than
immediate initiation of antibiotic therapy, appropriately selected children are managed with analgesic
therapy for the first 24–48 hours. This includes children >6 months of age with no craniofacial
abnormalities who have uncomplicated AOM (normal host, no otorrhea, no history of chronic or
recurrent AOM) without severe pain or systemic illness, and whose caregivers are able to recognize
severe illness, take the child for immediate assessment, and provide access to follow-up care.1,2

Goals of Therapy
■ Relieve symptoms of fever, pain and irritability
■ Eliminate bacteria from the middle ear
■ Ensure appropriate therapy to reduce the risk of resistant pathogens and drug-related adverse effects
such as antibiotic-associated diarrhea
■ Prevent complications, e.g., mastoiditis, intracranial infection, facial paralysis

Nonpharmacologic Therapy
Comfort measures, such as warmed oils, warm or cold compresses and heating pads have been used by
parents and caregivers for years, although there are no studies evaluating their effectiveness. If tried,
heat therapy should be used cautiously and with close supervision in children, to avoid burns. A young
child should never sleep with a hot water bottle or heating pad. Question the caregiver about whether
there has been any drainage from the ear prior to recommending any topical therapy. Warmed oil
should not be used if there is a chance of perforation or any suspicion of drainage. Warming of drops
or oil should be done by rolling the bottle between the palms; other methods such as placing the bottle

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 Ear Conditions
Chapter 20: Otitis Media and Otitis Externa 207
in a glass of warm water or using the microwave oven should be avoided as serious burns have been
reported.

Pharmacologic Therapy
For more information on management of acute otitis media, consult the Compendium of Therapeutic
Choices: Acute Otitis Media in Childhood.
■ If antibiotics are used, systemic therapy is required; topical agents are not used in AOM.
■ Adequate analgesia with usual doses of acetaminophen or ibuprofen is important (see Chapter 7:
Fever, Table 5).
■ Topical analgesics may provide short-term analgesia in children with AOM, but should not replace
oral analgesics.5,6 Topical analgesics may cause local hypersensitivity reactions.
■ Decongestants and antihistamines, which were recommended in the past, do not speed the
resolution of effusion and can have significant adverse effects in children and therefore should not
be used.7,8
For a more complete discussion of acute otitis media, see Suggested Readings.

Otitis Externa
Pathophysiology
Otitis externa is defined as inflammation of the external auditory canal (EAC) and may also involve
the pinna or tympanic membrane (TM). Otitis externa is often due to infection.9,10,11,12 The EAC is
warm, dark and prone to becoming moist. This provides an excellent environment for bacteria or fungi
to proliferate, particularly if the EAC is traumatized. Otitis externa can be categorized as acute diffuse,
acute localized, chronic, eczematous or necrotizing.12 The main focus of this chapter is acute diffuse
otitis externa.

Acute Diffuse Otitis Externa

Predisposing factors for acute diffuse otitis externa include:9,10,11,13
■ Too little cerumen—cerumen provides antibacterial action by physically protecting the canal and
maintaining a low pH
■ Too much cerumen, which can lead to occlusion and maceration
■ Moisture (swimming, bathing, water sports, perspiration, increased humidity)—macerates
underlying skin and raises pH
■ Trauma to EAC (fingernails, cotton-tipped swabs, other foreign objects, overzealous wax removal)
—abrasion and laceration allowing inoculation of organisms
■ Chronic dermatologic disorders
■ Hearing aids
■ Narrow, hairy ear canal.

The most common etiology of acute otitis externa is bacterial infection. Fungal overgrowth occurs
rarely, and primarily in patients who have received prior antibiotic therapy. The 2 most common
microorganisms causing acute otitis externa are Pseudomonas aeruginosa (20–60%) and
Staphylococcus aureus (10–70%).10,11
Bacterial otitis externa produces ear pain or discomfort (otalgia), otorrhea, pruritus and tenderness,
especially on manipulation of the ear.10,11 These symptoms may be more intense than those seen with
fungal otitis externa. Cellulitis of the pinna and regional lymphadenopathy may be present.10 Fungal

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 Chapter 20: Otitis Media and Otitis Externa
208 Ear Conditions
otitis externa may be asymptomatic or may produce pruritus and fullness in the ear. It classically
occurs after prolonged treatment of bacterial otitis externa with antibiotics which alter the bacterial
flora of the EAC. The EAC may contain black, grey, bluish green, yellow or white fungal elements and
debris.

Acute Localized Otitis Externa (Furunculosis)

This is an acute localized “boil” (infected hair follicle) in the ear canal usually due to S. aureus. It
produces localized pain, itching, edema, erythema and possibly a fluctuance or abscess. The pain
subsides when the boil comes to a head and bursts. Topical mupirocin or fusidic acid can be used for
mild cases.14 Incision and drainage may be required for some patients. Patients appearing to need
incision and drainage should be seen by a healthcare practitioner with appropriate training. In more
severe cases, systemic antibiotics active against S. aureus should be considered.10

Chronic Otitis Externa

Chronic otitis externa is characterized as a thickening of the EAC skin secondary to low-grade
infection and inflammation. There is usually unrelenting pruritus, mild discomfort and dry, flaky skin
in the EAC with lack of cerumen. This is often due to nonbacterial causes including allergic contact
dermatitis.9

Eczematous Otitis Externa

Eczematous otitis externa may be due to a variety of skin conditions, including atopic, seborrheic or
contact dermatitis, psoriasis, lupus erythematosus, neurodermatitis and infantile eczema. Lesions
typically occur elsewhere on the body, especially the head and neck, as well as the auricle and EAC.
Appearance may range from mild erythema and scaling with atopic dermatitis to the typical adherent
scales of psoriasis (see Chapter 55: Atopic, Contact, and Stasis Dermatitis; Chapter 58: Dandruff and
Seborrheic Dermatitis; and Chapter 71: Psoriasis for a more complete description of the lesions). The
most common symptom is pruritus, although erythema, edema, crusting and oozing may be present.
The lesions may become secondarily infected with bacteria or fungi. Treatment is primarily
management of the underlying condition.15

Necrotizing (Malignant) Otitis Externa

This is an infection that extends to the mastoid or temporal bone and is usually seen in
immunocompromised patients or those with diabetes. Urgent referral and systemic antimicrobial
therapy are required.10,11
This chapter focuses on the management of acute diffuse otitis externa.

Goals of Therapy
■ Eliminate pathogenic microorganisms
■ Control pain
■ Restore the canal to normal health so it resists infection—return to normal acidic pH and adequate
cerumen

Patient Assessment
Acute otitis externa is characterized by otalgia (70% of cases), itching (60%) or fullness (22%) with or
without hearing loss (32%) and discharge in or coming from the ear (otorrhea).10,16 Incidence peaks in
children age 7–12 years and declines after the age of 50.16 It is unilateral in 90% of cases.16 The
discomfort can range from pruritus to severe pain. The pain is often worse with motion of the ear

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 Ear Conditions
Chapter 20: Otitis Media and Otitis Externa 209
(pushing the tragus or pulling the pinna),10 including movement caused by chewing.11 Determining the
type of otitis externa (infectious vs. noninfectious) can be assisted by the description of the signs and
symptoms above and the presence of contributing factors (e.g., history of swimming or trauma to the
EAC), or the presence of dermatologic conditions on areas of the body other than the EAC.
The drug must be delivered to the infected tissue if topical therapy is to be successful.10,16 Cleansing
must be done by a healthcare practitioner with appropriate training. Therefore, if there is significant
edema or debris in the EAC, the patient may need to be referred so that aural toilet can be performed
or for a wick to be placed.10 In mild cases, a topical product may be initiated without cleansing;
recommendations for pain management are important.

Nonpharmacologic Therapy
Adequate cleansing of the ear canal with removal of debris may be required frequently so that topical
therapy can be effective.9,10 If the canal is not patent, ear wicks may be inserted by a healthcare
practitioner to reduce edema and swelling and provide a mechanism for drug delivery to the canal.10,11
These may remain in place for 2–5 days.

Pharmacologic Therapy
For comparative ingredients of nonprescription products, consult the Compendium of Products for
Minor Ailments—Analgesic Products: Internal Analgesics and Antipyretics; Otic Products.
Topical treatment is the mainstay of therapy, although in more severe cases, when infection has spread
beyond the EAC, when otitis media coexists, or if the patient has a condition such as diabetes or
immunodeficiency, systemic antibiotics may be required.10 In uncomplicated cases, systemic therapy
does not improve outcomes compared with topical therapy and increases the risk of adverse effects and
antibiotic resistance and time to clinical cure.17 Topical therapy options include acidifying agents,
antibiotics alone or antibiotic/corticosteroid combinations (see Table 1). Comparative trials show
similar outcomes among approaches; therefore, the choice is determined by healthcare practitioner and
patient preference, the side effect profile of the agents and cost.10,11,12,18,19 One trial demonstrated that
corticosteroid drops (with either acetic acid or antibiotic) are more effective than acetic acid alone and
recommended that acetic acid alone not be used in adult patients.20 In patients whose symptoms last
longer than a week, acetic acid may be less effective than an antibiotic/corticosteroid combination;
efficacy at 1 week is similar.18 Advantages and disadvantages of the various products are outlined in
Table 1.
Antibiotic drops are available as both otic and ophthalmic preparations. Both nonprescription and
prescription products are available. Otic products are more acidic than ophthalmic preparations and
may cause burning on instillation. If a patient cannot tolerate otic preparations, ophthalmic
preparations may be more comfortable.21 Preparations for treatment of otitis externa may contain
corticosteroids, which reduce inflammation and edema and may resolve symptoms more quickly;
however, this has not been shown in all studies and corticosteroids may occasionally be topical
sensitizers.18
One particular concern with topical therapy of acute otitis externa is the potential ototoxicity of
aminoglycosides.22 This is a documented adverse effect of systemically administered
aminoglycosides. If the tympanic membrane is intact, the risk with topical administration is extremely
small. Risk factors for ototoxicity include ruptured tympanic membrane, use of the product for more
than 1 week and continued use after otorrhea has subsided. Topical fluoroquinolones have not been
associated with ototoxicity.
Enough liquid to fill the canal (3–4 drops) should be instilled 3–4 times daily (most products except
fluoroquinolones). Symptoms will last for approximately 6 days after treatment begins; however,

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 Chapter 20: Otitis Media and Otitis Externa
210 Ear Conditions
improvement in symptoms should occur within 48–72 hours.10 Patients should be treated for 1 week. If
symptoms are not completely gone, therapy can be continued until symptoms resolve plus a few days
beyond (up to 2 weeks).18 In 65–90% of patients, clinical resolution occurs in 7–10 days.10 For
information on correct instillation of eardrops, see Eardrops—What You Need to Know.
Fungal otitis externa often responds to cleansing and acidification alone, although topical antifungal
agents (clioquinol, clotrimazole, tolnaftate) may also be used.16 Some preparations may need to be
compounded.
Otitis externa can be very painful. Usual doses of acetaminophen, ibuprofen or naproxen sodium
can be used for analgesia (ASA can be used in adults).10,11 Although some otic preparations contain
topical anesthetics, the efficacy of these agents has not been determined in acute otitis externa, and
topical hypersensitivity reactions can occur.10 If topical anesthetic agents are used in addition to other
topical therapy, this will dilute the acidifier or antibiotic present in the canal. Avoid their use in otitis
externa. Systemic analgesia is the preferred recommendation.

Eczematous Otitis Externa

Eczematous otitis externa is managed by treating the underlying dermatologic disease (e.g., seborrhea,
psoriasis, acne).9,15 Contact dermatitis commonly occurs on or in the ears, and grooming products
(e.g., shampoos, hair sprays and hair dyes) are common allergens.10 Hearing aids and earplugs may
also cause dermatitis of the EAC. Neomycin is one of the topical medications that most commonly
causes allergic contact dermatitis.10 Patients sensitive to neomycin may also react to tobramycin. Other
agents commonly placed in the ear that are reported to cause contact dermatitis include benzalkonium
chloride, benzocaine and propylene glycol.23
Management includes avoiding the offending agent, applying acetic acid solution to dry oozing
lesions and re-acidify the canal, or symptomatic therapy with a topical corticosteroid.

Prevention of Recurrence
Provide information on how to prevent a recurrence to individuals who develop acute otitis externa:
■ After swimming or bathing, dry the external canal with a blow dryer on low setting or by
instillation of acidifying or alcohol drops.10,11,16
■ Avoid overzealous cleansing and scratching (trauma) of the ear canal.10
■ Avoid cotton-tipped swabs.11,16,24
■ Avoid water sports for at least 7–10 days during treatment.10
■ Ear plugs and bathing caps may be used to keep the ears dry; however, there is little evidence to
guide recommendations.10 Frequent use of ear plugs may also act as a local irritant and promote
infection.

Monitoring of Therapy
Symptoms should be significantly reduced by day 3 of therapy,10,11 and for most patients symptoms
should have completely resolved in a week. Occasionally up to 14 days of treatment is needed.18
Follow up with the patient in 3–5 days to ensure symptoms are improving and at the end of treatment
to ensure resolution. If symptoms worsen or do not resolve, consider the following: the patient may be
reacting to the medication (contact dermatitis); a superinfection may have developed; the diagnosis
may be incorrect; improper or infrequent use of eardrops; inadequate penetration of topical agents due
to debris or narrowing of the canal; immunosuppression or malignant otitis externa; or the organism is
not susceptible to the topical agent selected.9,10 Assessment for further treatment will be required.

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 Ear Conditions
Chapter 20: Otitis Media and Otitis Externa 211
Advice for the Patient
Advise patients on:
■ Prevention of recurrences
■ Methods of pain control
■ Correct use of eardrops

■ Possible side effects of treatment and their management (see Table 1)

■ When to see a healthcare practitioner.

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 Table 1: Drugs for Otitis Externa
212
Class Drug Indications Adverse Effects Comments Costa

Acidifying Agents acetic acid 2%25 Prevention and Can be irritating to Broad-spectrum antibacterial. $
treatment of mild AOE inflamed canal. Restores acidity to canal.
Possibly ototoxic. Lower cost than antibiotics.
No commercial product available. May be prepared

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by diluting white vinegar with equal parts isopropyl
alcohol or water.10

Antibiotics ciprofloxacin Treatment of AOE Well tolerated. Active against many gram-negative organisms $
Ciloxan, generics Not associated with including P. aeruginosa and some gram-positive (S.
Ear Conditions

ototoxicity. aureus).
Twice-daily dosing.
Topical quinolones provide similar clinical cure rates
as other topical antibiotics.19
Ophthalmic solutions can be used in the ears.

gramicidin/polymyxin B Treatment of AOE Potentially ototoxic. Gramicidin—active against gram-positive $$

Optimyxin Ear Drops, organisms.
Polysporin Eye/Ear Polymyxin B—active against gram-negative

Copyright © Canadian Pharmacists Association. All rights reserved.

Drops organisms.

moxifloxacin Treatment of AOE See ciprofloxacin. See ciprofloxacin. $$

Vigamox Ophthalmic solutions can be used in the ears.

ofloxacin Treatment of AOE See ciprofloxacin. See ciprofloxacin. $

Ocuflox, generics Ophthalmic solutions can be used in the ears.

tobramycin Treatment of AOE Potentially ototoxic, Aminoglycosides active against gram-negative $

Tobrex, generics particularly with organisms (e.g., Pseudomonas) and S. aureus.
perforated tympanic Ophthalmic solutions can be used in the ears.
membrane,
tympanostomy tubes or
use >1 wk.

Corticosteroids dexamethasone Dermatologic causes of May cause Anti-inflammatory properties reduce swelling and $
Maxidex AOE hypersensitivity edema.
reactions. If bacterial etiology combine with acidifier or
antibiotic.
Ophthalmic solutions can be used in the ears.

(cont'd)
Chapter 20: Otitis Media and Otitis Externa

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 Class Drug Indications Adverse Effects Comments Costa

Antibiotic/ ciprofloxacin/ Treatment of AOE See ciprofloxacin. See ciprofloxacin. $$$

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Corticosteroid dexamethasone See dexamethasone. See dexamethasone.
Ear Conditions

Ciprodex

14
Combinations

clioquinol/flumethasone Treatment of AOE Negligible gram- Clioquinol active against fungi and gram-positive $$
pivalate negative activity. bacteria.

Compendium of Therapeutics
Locacorten Vioform Bacteriostatic. See dexamethasone.
Eardrops See dexamethasone.

framycetin/gramicidin/ Treatment of AOE See tobramycin. Framycetin active against gram-negative organisms $$
dexamethasone See dexamethasone. (but not Pseudomonas) and S. aureus.
Sofracort Gramicidin—active against gram-positive
organisms.

for Minor Ailments

See dexamethasone.

Miscellaneous antipyrine/benzocaine Topical analgesia Benzocaine may Do not use with ruptured tympanic membrane. $
Auralgan produce topical Oral analgesics preferred.
hypersensitivity
reactions.
Antipyrine—mild
anesthetic; can cause
burning and itching.
May mask symptoms of
worsening AOE.

isopropyl alcohol 95% Prevention of AOE Painful when used in Useful drying agent. $
glycerin 5% acute otitis externa.
Auro-Dri Ear Water
a Cost of smallest available pack size; includes drug cost only.
Abbreviations: AOE = acute otitis externa
Legend: $ < $10 $$ $10–20 $$$ $20–30
Chapter 20: Otitis Media and Otitis Externa

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 Chapter 20: Otitis Media and Otitis Externa
214 Ear Conditions
Suggested Readings
Otitis Externa
3 Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis
externa. Paediatr Child Health 2013;18:96-101.
Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa.
Otolaryngol Head Neck Surg 2014;150:S1-S24.
Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.
Otitis Media
Le Saux N, Robinson J. Management of acute otitis media in children six months of age and older.
Paediatr Child Health 2016;21(1):39–44.
Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media.
Pediatrics 2013:131:e964-99.
Vergison A, Dagan R, Arguedas A et al. Otitis media and its consequences: beyond the earache.
Lancet Infect Dis 2010;10:195-203.

References
1. Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.
2. Le Saux N, Robinson J. Management of acute otitis media in children six months of age and older. Paediatr Child Health 2016;21(1):39–44.
3. Rosenfeld RM, Vertrees JE, Carr J et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from
thirty-three randomized trials. J Pediatr 1994;124:355-67.
4. Venekamp RP, Sanders SL, Glasziou PP et al. Antibiotics for acute otitis media in children. Cochrane Database of Syst Rev
2015;1:CD000219.
5. Carley SD. Best evidence topic reports. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary.
Emerg Med J 2008;25:103.
6. Foxlee R, Johansson A, Wejfalk J et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev 2006;3:CD005657.
7. Mandel EM, Rockette HE, Bluestone CD et al. Efficacy of amoxicillin with and without decongestant-antihistamine for otitis media with
effusion in children. Results of a double-blind, randomized trial. N Engl J Med 1987;316:432-7.
8. Cantekin EI, Mandel EM, Bluestone CD et al. Lack of efficacy of a decongestant-antihistamine combination for otitis media with effusion
(“secretory” otitis media) in children. Results of a double-blind, randomized trial. N Engl J Med 1983;308:297-301.
9. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.
10. Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2014;150:S1-
S24.
11. Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Paediatr Child Health
2013;18:96-101.
12. Hajioff D, Mackeith S. Otitis externa. Clin Evid (Online) 2008;pii:0510.
13. Klein JO. Otitis externa, otitis media and mastoiditis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's principles
and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingston/Elsevier; 2010. p. 831-8.
14. Blondel-Hill E, Fryters S. Bugs & Drugs app. Edmonton (AB): Alberta Health Services; 2015.
15. Shea CR. Dermatologic diseases of the external auditory canal. Otolaryngol Clin North Am 1996;29:783-94.
16. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician 2006:74:1510-6.
17. Pabla L, Jindal M, Latif K. The management of otitis externa in UK general practice. Eur Arch Otorhinolaryngol 2012;269:753-6.
18. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev 2010;1:CD004740.
19. Rosenfeld RM, Singer M, Wasserman JM et al. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head
Neck Surg 2006;134:S24-48.
20. van Balen FA, Smit WM, Zuithoff NP et al. Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised
controlled trial. BMJ 2003;327:1201-5.
21. Ong YK, Chee G. Infections of the external ear. Ann Acad Med Singapore 2005;34:330-4.
22. Haynes DS, Rutka J, Hawke M et al. Ototoxicity of ototopical drops–an update. Otolaryngol Clin North Am 2007;40:669-83.
23. Fraki JE, Kalimo K, Tuohimaa P et al. Contact allergy to various components of topical preparations for treatment of external otitis. Acta
Otolaryngol 1985;100:414-8.
24. Nussinovitch M, Rimon A, Volovitz B et al. Cotton-tipped applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol
2004;68:433-5.
25. Thorp MA, Kruger J, Oliver S et al. The antibacterial activity of acetic acid and Burow's solution as topical otological preparations. J Laryngol
Otol 1998;112:925-8.

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 Ear Conditions
Chapter 20: Otitis Media and Otitis Externa 215

Acute Otitis Externa (Swimmer's Ear)—What You Need to

Know
What is acute otitis externa?
Acute otitis externa, or “swimmer's ear,” is an infection of the ear canal. The symptoms are itching or
pain in the ear and liquid draining from it. The ear may become plugged. Your hearing may be
affected.

What causes acute otitis externa?

The skin in your ears may become infected because of:
■ Too much water in the ear (from bathing, swimming or water sports)
■ Removing the natural earwax that protects the ear canal
■ Skin conditions in the ear canal (such as eczema)
■ Using cotton-tipped swabs, fingernails or other sharp objects in the ear canal
■ Wax buildup due to hearing aids or other ear devices

What is the treatment for acute otitis externa?

■ The usual treatment is prescription eardrops. A healthcare provider may have to clean the ear canal
for the drops to work.
■ Most drops need to be used 3 or 4 times a day.
■ Use the drops until 3 days after all symptoms are gone.
■ Symptoms are usually much better in 3 days and should be gone in 10 days.
■ While you are using eardrops:
– Keep your ears as dry as possible. Take a bath instead of a shower. Avoid swimming and water
sports until the treatment is done.
– Don't poke your fingers or other objects into your ears.

What can you do to prevent acute otitis externa?

■ Keep the ear canal as dry as possible:
– Dry ears with a towel after swimming or bathing. Use a blow dryer set on low to dry the ear
canal. You can also use diluted vinegar or alcohol drops in the ear.
– Try using a bathing cap or ear plugs when swimming. If this makes it worse, stop using.
■ Do not clean earwax out of your ears:
– Earwax protects against infection. The ears generally clean themselves. If you have pain in your
ears from earwax, see your healthcare provider.
■ Do not put anything in the ear canal except eardrops. Fingernails, cotton-tipped swabs and other
objects irritate and damage the skin. If the skin is damaged you are more likely to get an infection.

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 Chapter 20: Otitis Media and Otitis Externa
216 Ear Conditions

Eardrops—What You Need to Know

Hints to help you use eardrops safely:
If possible, get someone to put the drops in your ear for you.
■ Warm the eardrops to body temperature by holding the bottle in your hands for a few minutes. Do
not heat the drops in hot water or the microwave because this could cause pain and dizziness or
serious burns.
■ Always wash your hands with soap and water before administering the eardrops.

■ The eardrops must be kept clean. Do not let the dropper touch the ear or anything else that could
have germs on it and let germs get into your eardrops.
■ Shake the bottle before using if there is a “Shake Well” label on the bottle. Lie on your side so that
the ear you are treating is facing up.
■ The ear canal must be straight so that the eardrops can reach the affected tissue. The direction that
you pull the top of the ear depends on the person's age.
– For adults and children over 3 years, gently pull the top of the ear up and back.
– For children under 3 years, gently pull the top of the ear down and back
■ Hold the dropper above the ear. Place the prescribed number of drops into the ear. Do not put the
dropper into the ear canal. It could injure the ear.
■ Stay in the same position for 3–5 minutes after using the drops. This will allow the eardrops to run
down into the ear canal.
■ A gentle to-and-fro movement of the ear will sometimes help in getting the drops to their intended
destination. You can also press with an in/out movement on the small piece of cartilage in front of
the ear.
■ Dry the earlobe if there are any eardrops on it.
■ If you have had a wick placed in your ear, do not remove it. It may fall out on its own as the
swelling and infection in the ear improves.

If you have to put drops in both ears:

Wait about 5–10 minutes before putting drops in the second ear. You want to be sure that the medicine
stays in the ear canal of the first ear long enough to reach the eardrum before you tilt your head to put
drops in the other ear.
These instructions may be changed by your healthcare provider depending on your medical condition
or the type of medicine in the eardrops.
© 2016 Consumer Health Information Corporation (www.consumer-health.com). All rights reserved. This information is adapted from Understanding
Canadian Prescription Drugs by Dorothy L. Smith, Pharm.D. published by Key Porter Books 1992.

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 226 Respiratory Conditions

Respiratory Conditions

Chapter 22
Allergic Rhinitis
Chapter 22

Jennifer Kendrick, BScPharm, ACPR, PharmD

Pathophysiology
Allergic rhinitis affects 10–30% of the population, and the prevalence is increasing.1,2,3 It is estimated
that more than 500 million people worldwide are affected.3 The prevalence of allergic rhinitis is
thought to be highest in school-age children; 80% of people with allergic rhinitis are diagnosed before
20 years of age.1,4 Allergic rhinitis is associated with a genetic predisposition; children have a 30%
chance of developing allergic rhinitis if one parent is affected and a 50% chance if both are affected.5,6
Allergic rhinitis is characterized by inflammation of the nasal mucosa following inhalation of an
allergen.1,4,6,7 The allergic reaction is mediated by antigen-antibody responses and takes place in 3
phases. The first phase, sensitization, occurs on first contact with the allergen. IgE is produced and
binds to receptors on the surface of mast cells and basophils. The second and third phases occur on re-
exposure to an allergen in a sensitized individual. The second phase, immediate reaction, occurs within
minutes of re-exposure and lasts up to 30–90 minutes. In this phase the allergen binds to allergen-
specific IgE and the mast cells release preformed mediators, histamine and tumor necrosis factor alpha
(TNF-α), and newly generated mediators, leukotrienes LTC4, LTD4, LTE4, prostaglandin D2 and
kinins. The third phase, late reaction, occurs 4–8 hours after exposure. It is characterized by migration
of inflammatory cells, eosinophils, monocytes, macrophages and basophils.
Allergic rhinitis was previously classified as seasonal or perennial; however, this classification was
determined to be inadequate for a number of reasons. For example, outdoor pollens and moulds may
be perennial in some regions and symptoms of perennial allergy may not be present year-round. The
Allergic Rhinitis and its Impact on Asthma (ARIA) guideline proposed the classifications of
intermittent allergic rhinitis (IAR) and persistent allergic rhinitis (PAR) in 2008.3 IAR is defined as
symptoms of allergic rhinitis occurring <4 days/week or for <4 weeks at a time. PAR is defined as
symptoms of allergic rhinitis occurring ≥4 days/week and for ≥4 weeks at a time. Allergic rhinitis is
further classified based on severity. In mild allergic rhinitis, symptoms are present but not troublesome
and there is no impairment in daily activities, school or work and no sleep disturbance. In moderate/
severe allergic rhinitis, one or more is present: troublesome symptoms, impairment in daily activities,
school or work, or sleep disturbance.3,7 The ARIA classification has been validated in both adults and
children.
Rhinitis may also be nonallergic. Conditions associated with nonallergic rhinitis are listed in Table 1.
Drugs associated with rhinitis are listed in Table 2.

Goals of Therapy
■ Prevent symptoms by avoiding exposure to allergen(s)
■ Alleviate signs and symptoms produced by the allergic response
■ Improve quality of life

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 Respiratory Conditions
Chapter 22: Allergic Rhinitis 227
Table 1: Possible Nonallergic Causes of Acute and Chronic Rhinitis3,4,6,7

■ Drug-induced (see )
■ Hormones
– pregnancy, menstruation, hypothyroidism
■ Infection
– viral, bacterial, fungal, other
■ Nonallergic rhinitis with eosinophilia syndrome (NARES)
■ Other
– emotions, e.g., stress, sexual arousal
– vasomotor rhinitis, e.g., exercise, cold air
– anatomic abnormalities, e.g., nasal septal deviation, enlarged adenoids and tonsils, nasal tumors, choanal atresiaa
– food and alcohol
– nasal polyps
– atrophy
– foreign body

a A congenital defect where the posterior nares do not communicate with the nasopharynx.

Table 2: Drugs Associated with Rhinitis6,8

■ ACE inhibitors ■ Oral contraceptives

■ ASA and other NSAIDs ■ Phosphodiesterase-5 inhibitors, e.g., sildenafil
■ Cocaine ■ Psychotropics, e.g., chlorpromazine, risperidone
■ Diuretics, e.g., amiloride, hydrochlorothiazide ■ Sympatholytics, e.g., clonidine, doxazosin, methyldopa,
■ Gabapentin phentolamine, prazosin
■ Hydralazine
■ Topical decongestants (prolonged use)

Patient Assessment
The sensitization phase of allergic rhinitis is asymptomatic. Symptoms of the second or immediate
phase include sneezing, nasal and palatal pruritus, congestion and clear rhinorrhea.9 Symptoms of the
delayed phase are similar but nasal congestion predominates.4 Patients may also have itchy, red,
watery eyes (allergic conjunctivitis), itchy throat, ear fullness and popping, and a feeling of pressure
over the cheeks and forehead.4 Facial signs of allergic rhinitis are illustrated in Figure 1. The allergic
salute is a sign more commonly seen in children, where the patient wipes the nose with the palm of the
hand in an upward motion.
Some patients present primarily with symptoms of sneezing and rhinorrhea, whereas others are mostly
bothered by nasal blockage and have little or no itching or sneezing.6 Eye symptoms are more
commonly associated with outdoor allergens.3,7
Allergic rhinitis can have a significant impact on a patient's quality of life. Patients may have
headache, difficulty concentrating, fatigue or sleep disturbance.6 Malaise or fatigue may be presenting
complaints in children.9 Complications of allergic rhinitis include sinusitis, otitis media, asthma, and
sleep apnea. In children, there may be dental overbite and a high-arched palate due to chronic mouth
breathing.3,6
An assessment plan for patients suffering from allergic rhinitis is illustrated in Figure 2. During the
assessment, also identify precipitating factors/allergens and assess occupational exposure and response
to previous therapy.

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 Chapter 22: Allergic Rhinitis
228 Respiratory Conditions
Figure 1: Facial Signs of Allergic Rhinitis

Morgan's Lines or Dennie's sign or folds are extra creases at the lower eyelids due to edema. Allergic shiners describe discoloured infraorbital areas due to
venous stasis resulting from nasal swelling. The transverse nasal crease is a crease seen at the junction of the bulbous portion of the nose and the
nosebridge and is caused by recurrent nose rubbing (allergic salute). Conjunctival injection refers to conjunctival redness fading toward the edges.

Consider the need for prescription therapy or referral for allergy testing if the patient has already tried
appropriate nonprescription therapy for 2 weeks without an adequate response, or if the allergen
responsible for symptoms cannot be readily identified.3 Also refer patients for further assessment if
they have signs or symptoms that are unilateral or are not usually associated with allergic rhinitis (e.g.,
fever, pain, loss of smell or taste, recurrent epistaxis, purulent nasal or ocular secretions, postnasal drip
with or without rhinorrhea) or symptoms suggesting complications such as asthma.3

Prevention
Prevention is the first step in the management of allergic rhinitis. Although consensus is that
improvement in symptoms should occur with allergen avoidance, little evidence supports individual
measures.3 While some measures such as washing pets, impermeable covers for bedding, and air
filtration have been shown to reduce the allergen level, a corresponding reduction in allergic symptoms
has not been shown.9 The benefits of environmental control may take weeks or months to fully
manifest. Avoidance measures for common allergens are presented below.1,3,6,7

Pollen
■ Keep windows and doors closed when at home or in the car.
■ If using air conditioning, keep the unit on recirculate or the indoor cycle, if the choice is available.
■ Do not use window or attic fans.
■ Monitor weather reports on pollen counts, if available. Decrease outdoor exposure during periods
of high pollen counts. Pollen counts tend to be highest on sunny, windy days.
■ Do not dry clothing outdoors.
■ Shower or bathe and wash hair after outdoor activity to remove pollen from hair and skin and
prevent contamination of bedding.

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 Respiratory Conditions
Chapter 22: Allergic Rhinitis 229
Outdoor Moulds
■ Remain in a closed environment as much as possible.
■ If using air conditioning, keep the unit on the indoor cycle, if the choice is available; note, however,
that units can be heavily contaminated with mould.
■ Use of face masks for activities such as raking leaves or working with compost or dry soil may
have limited value because air seeps around the edges of the mask and the mask does not protect
the eyes.

Indoor Moulds
■ Use fungicide on sinks, shower stalls, nonrefrigerated vegetable storage areas and garbage pails. A
solution of equal parts household bleach and water effectively kills mould.
■ Avoid console humidifiers and cool mist vaporizers; if these must be used, keep them scrupulously
clean.
■ If the home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep
foundation vents open.
■ If the basement is damp or tends to flood, avoid carpeting or furnishing the basement. Use a
dehumidifier at all times and empty the extracted water from the air frequently; remove any
standing water as soon as possible.
■ Remove houseplants, which are a common source of mould. Alternatively, keep soil surface dry
and clean of debris to reduce mould.

House Dust Mites

■ Avoid carpeting the bedroom and main living areas.
■ Plastic, leather or wood furniture is best.
■ Some acaricides (e.g., benzyl benzoate, tannic acid) appear to reduce the mite population if used
regularly. However, their clinical effect is not established and they are not routinely recommended.3
■ If possible, clean while the allergic individual is not at home.
■ Mite-sensitive persons should avoid vacuuming or making beds. Those who must do their own
cleaning should wear a facemask during cleaning and for 10–15 minutes afterward.
■ Use a vacuum cleaner with an efficient double filtration system.
■ Keep indoor humidity between 40% and 45%.
■ Minimize use of humidifiers as excess humidity promotes mite growth.
■ Encase all mattresses, box springs and pillows in the allergic individual's bedroom in zippered,
allergen-proof casings.
■ Consider replacing old mattresses.
■ Wash bedding in hot (>55°C) water at least every 2 weeks. Cooler water temperatures will not kill
dust mites, nor will detergents.
■ Avoid stuffed toys that cannot be washed. Alternatively, put stuffed toys or pillows in a hot dryer or
in plastic bags and freeze every 2 weeks to kill dust mites.
■ Do not store items under the bed.
■ Use window shades instead of venetian blinds.
■ Evidence suggests the best strategy is a combination of the above interventions.10

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 Chapter 22: Allergic Rhinitis
230 Respiratory Conditions
Animal Allergens
■ Permanent removal of pets from the home is the best way to control animal allergens. This should
be followed by thorough cleaning of the house, including washing carpets. “Trial” removal of pets
is not helpful; it can take 20 weeks or longer for cat allergen levels to drop to levels comparable to
homes without cats.
■ If the family is unable to remove the animal from the home then:
– remove carpets and replace with hard flooring
– keep the animal away from the allergic individual's bedroom and other living areas where the
allergic individual spends time
– a high-efficiency particulate air (HEPA) filter or electrostatic air purifier may be helpful
– washing cats weekly and dogs once or twice weekly may help but evidence to support this
approach is lacking
– eliminate litter boxes if possible; otherwise place them in an area unconnected to the air supply
for the rest of the house.

Occupational Allergens
■ For individuals affected by occupational rhinitis, recommend minimizing or eliminating exposure.
■ Common causes of occupational rhinitis include animal or vegetable proteins (e.g., mouse, rat,
wheat, grains, latex), enzymes, pharmaceuticals (e.g., antibiotics) and chemicals (e.g., resins).

Nonpharmacologic Therapy
Intranasal saline spray and irrigation has been shown to reduce nasal symptoms and the need for
pharmacologic therapy in children and nonpregnant adults.11 The effect of intranasal saline irrigation
in pregnant women is less clear.12 Isotonic saline is preferred to hypertonic saline, as it improves
mucociliary clearance; however, the optimal dose, frequency and delivery have not been established.11
Tobacco smoke can aggravate symptoms and should be avoided by all patients with allergic rhinitis.3
Other irritants that should be avoided include insect sprays, air pollution and fresh tar or paint.3

Pharmacologic Therapy
When avoidance of allergens is ineffective or impractical, consider pharmacologic options. If it is
possible to predict the onset of symptoms (e.g., intermittent exposure), prophylactic medication should
be started before exposure.
For comparative ingredients of nonprescription products, consult the Compendium of Products for
Minor Ailments—Cough, Cold and Allergy Products.
Table 3 summarizes the pharmacologic activity of different therapies for the treatment of allergic
rhinitis.
Medications for treatment of allergic rhinitis are described in Table 5 and Table 6.
Several guidelines for the treatment of allergic rhinitis are available and each provides similar
treatment recommendations.3,6,7,9 For mild symptoms, second-generation antihistamines are the
drugs of choice, although they produce only a modest improvement in nasal congestion. First-
generation antihistamines are no longer recommended first-line due to their adverse effect profile.6
For moderate to severe allergic rhinitis, regularly administered intranasal corticosteroids are
recommended as first-line therapy.14

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 Respiratory Conditions
Chapter 22: Allergic Rhinitis 231
Table 3: Comparative Symptom Relief of Allergic Rhinitis Therapies7,13

Eye
Medication Rhinorrhea Congestion Sneezing Nasal Itch Symptomsa

Oral antihistamines + +/- + + +/-

Intranasal mast cell stabilizers +/- +/- +/- +/- -

Decongestants (oral and topical) - + - - -

Intranasal corticosteroids ++ ++ ++ ++ +/-

Leukotriene receptor antagonists + + +/- +/- +/-

Intranasal anticholinergics ++ - - - -

Intranasal antihistamines ++ ++ ++ ++ +/-

a See Chapter 13: Conjunctivitis.
Abbreviations: (+/-) = modest or variable effect

Antihistamines
Introduced in the 1940s, antihistamines were the first medications used for the treatment of allergic
rhinitis. They act as competitive antagonists for the histamine-1 (H1) receptor found on the surface of
target cells in the nose, lung, conjunctiva and skin.15 They also act as a reverse agonist, meaning that
they change the three-dimensional configuration of the receptor, decreasing its affinity for histamine
and down-regulating histamine-driven symptoms.15 Antihistamines decrease nasal itching, sneezing,
rhinorrhea, conjunctival itching and lacrimation but generally do not relieve nasal congestion.
Desloratadine, fexofenadine and cetirizine have modest effects on nasal congestion.16
Antihistamines are first-line treatment in mild cases of allergic rhinitis.3,6,9
Antihistamines are divided into 2 major classes: first- and second-generation. All are similarly
effective; however, adverse effect profiles and pharmacology differ.15,17,18,19,20,21
First-generation antihistamines have a rapid onset but relatively short duration of action due to their
short half-life.22,23 They are poorly selective for the H1 receptor and also exert effects on cholinergic
receptors. The anticholinergic effect manifests as dry mouth and nasal passages, difficulty voiding
urine, constipation and tachycardia. They are also highly lipophilic and therefore cross the blood-brain
barrier and interact with central H1 receptors. This results in CNS effects such as sedation and
psychomotor and cognitive impairment. In children, paradoxical excitation may occur.24 Performance
impairment has been documented using various measures (e.g., reaction time, visual-motor
coordination, arithmetical exercises and memory, learning and driving tests) although more recent data
suggest that the magnitude of these effects has been overstated.25,26 CNS depression and impairment
can be independent of any subjective complaints by the patient.27 First-generation antihistamines also
impair learning and academic performance in children.27 Workers taking first-generation
antihistamines have lower work performance and are more likely to be involved in workplace
accidents. Daytime performance effects are noted even when the antihistamine is taken only at
bedtime.6,27
First-generation antihistamines can decrease rhinorrhea, but mucus secretion may be thickened and can
be more bothersome for some patients.15
The first-generation antihistamines should be used with caution in patients with narrow-angle
glaucoma, stenosing peptic ulcer, pyloroduodenal obstruction, symptomatic prostatic hypertrophy or
bladder-neck obstruction, cardiovascular disease and chronic lung disease.

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 Chapter 22: Allergic Rhinitis
232 Respiratory Conditions
Second-generation antihistamines are more selective for H1 receptors and less lipophilic.
Consequently, they do not have significant anticholinergic adverse effects and do not cross the blood-
brain barrier.20 Use of cetirizine in standard doses is associated with more sedation compared with
placebo, but less than first-generation antihistamines.6 Administration of standard doses of loratadine
and desloratadine results in an incidence of sedation equivalent to placebo; however, drowsiness has
been reported at higher than recommended doses, or rarely in susceptible individuals at recommended
doses.6 Fexofenadine appears to be nonsedating, even at increased doses. Due to their improved
adverse effect profile, especially with regard to sedation and psychomotor performance, second-
generation antihistamines represent a better choice than first-generation agents for the treatment of
allergic rhinitis.6,14 Clinical trials comparing various second-generation antihistamines demonstrate
similar reduction of symptoms.2,19,21,28 They are less effective than intranasal corticosteroids for most
symptoms of allergic rhinitis.6 Two meta-analyses demonstrated intranasal corticosteroids were more
effective than antihistamines for relieving congestion and sneezing; for ocular symptoms, no
difference was found.29,30
The intranasal antihistamine levocabastine is effective for sneezing, nasal pruritus and rhinorrhea. It
has a rapid onset of action (<15 minutes), but must be used 2–4 times daily.22 The intranasal
antihistamine azelastine (available only in combination with fluticasone in Canada) is clinically
similar to oral second-generation antihistamines for the relief of nasal symptoms.30
Antihistamines are more effective when taken before allergen exposure. The best results are obtained
with chronic dosing compared with intermittent dosing; therefore, patients should take the
antihistamine for as long as they are in contact with the allergen.14 If one antihistamine is not effective,
switching to another antihistamine may be beneficial.31

Mast Cell Stabilizers

Sodium cromoglycate (also called cromolyn sodium) modestly reduces itching, sneezing and
rhinorrhea but is not effective for nasal congestion.3 Treatment should begin before exposure to the
allergen and continue for the entire allergen season.22 If treatment begins after allergen exposure, relief
may be delayed up to 4 weeks. Sodium cromoglycate is less effective than corticosteroids for allergic
rhinitis and has not been adequately compared with leukotriene receptor antagonists and
antihistamines.6,30

Decongestants
Decongestants are available in oral and topical formulations. Oral decongestants generally have a
weaker effect on nasal obstruction than the topical formulations.22 When given orally, decongestants
can cause systemic adverse effects (see Table 5). Most available agents do not cause blood pressure
elevations in normotensive persons unless the recommended dose is significantly exceeded.32
Elevation of blood pressure may occur at standard doses in hypertensive patients.33
Systemic absorption from topical formulations is low, resulting in mainly local adverse effects (see
Table 6). Rhinitis medicamentosa (rebound vasodilation) can occur if topical decongestants are used
for more than 3–5 days.34 In one study, 49% of patients reported using an intranasal decongestant daily
for at least one year, even though 80% reported having received education about limiting the duration
of use. Intranasal decongestant overuse was less common in patients who were using intranasal
corticosteroid or oral antihistamine.35 Overuse can lead to nasal congestion when the topical agent is
stopped, and to permanent overgrowth of nasal tissue with chronic overuse. This condition is more
likely to occur with shorter-acting agents (phenylephrine) than with longer-acting agents
(oxymetazoline and xylometazoline). Many solutions to this problem have been proposed, including
slow tapering of the decongestant, adding or switching to intranasal corticosteroids, or abrupt
discontinuation of the topical decongestant. Abrupt cessation is effective but may be uncomfortable for
the patient as nasal congestion may persist for several days or weeks.34

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 Respiratory Conditions
Chapter 22: Allergic Rhinitis 233
Corticosteroids
Intranasal corticosteroids are more effective against the nasal symptoms of allergic rhinitis than oral
and intranasal antihistamines, nasal cromoglycate and leukotriene receptor antagonists.29,30 Intranasal
corticosteroids are the drugs of choice for moderate to severe or persistent allergic rhinitis, and for
mild allergic rhinitis that does not respond to antihistamines.3,6,9 Some intranasal corticosteroids
(mometasone furoate and fluticasone furoate) have a modest benefit on allergic conjunctivitis
symptoms.6,10,36,37,38 A meta-analysis suggests that intranasal corticosteroids as a class are effective for
ocular symptoms of allergic rhinitis; however the magnitude of effect has not been quantified.39 Onset
of action of intranasal corticosteroids is within 6–8 hours of first dose, although maximum effect may
take a few weeks. Short courses of oral corticosteroids may be required for severe cases of allergic
rhinitis that is unresponsive to other treatment.6 Patients may prefer intranasal corticosteroids in
aerosol form compared with spray form; therefore, switching to another intranasal corticosteroid
formulation may be recommended if patient tolerability is affecting therapy.40 Regular use of
intranasal steroids is more effective than intermittent use.14

Leukotriene Receptor Antagonists (LTRA)

Montelukast is superior to placebo but less effective than intranasal corticosteroids for nasal
symptoms of allergic rhinitis.30 Montelukast is similar in efficacy to loratadine, but patient response is
more variable than with antihistamines.30 There may be additive effects when it is used concomitantly
with antihistamines. Montelukast is more effective than oral antihistamines and comparable to
intranasal corticosteroids for reduction of asthma symptoms and use of rescue asthma medication.30 As
a result, montelukast may be a reasonable option for allergic rhinitis coexisting with asthma.6,7,9
Otherwise, montelukast is not recommended as first-line therapy for allergic rhinitis.9

Immunotherapy
According to clinical practice guidelines, allergen immunotherapy should be considered for patients
who continue to have moderate to severe symptoms despite treatment or those who require systemic
corticosteroids.2,9 Immunotherapy may be indicated when the exposure to allergens is significant and
unavoidable (e.g., grass pollen), and when the symptom complex is severe enough to warrant the time,
expense and small risk of anaphylaxis.6 Allergen immunotherapy is the only treatment that can modify
the natural history of allergic rhinitis and potentially induce long-term disease remission after cessation
of treatment. It may also prevent the development of new allergies and reduce the risk of development
of asthma in children. Therefore, allergen immunotherapy may be considered even in milder cases of
allergic rhinitis. Immunotherapy is administered by subcutaneous injection, although sublingual
immunotherapy seems to be somewhat effective as well.6,41,42

Anticholinergics
Intranasal ipratropium bromide is effective for rhinorrhea secondary to allergic rhinitis but not for
other symptoms.22

Combination Therapies
Combination therapy is recommended by some guidelines when patients have inadequate response to
monotherapy.9 Some combinations have been shown to be more effective than monotherapy while
others have not.

First- and Second-generation Antihistamines

Some experts suggest a second-generation antihistamine during the day and a first-generation
antihistamine at bedtime to promote sleep. Evidence to support this practice is lacking and next-day

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Sample Chapters for Conference_J.indd 26 6/17/2016 2:35:22 PM

 Chapter 22: Allergic Rhinitis
234 Respiratory Conditions
sedation is possible.2 If sleep is disturbed due to allergies, symptom relief itself can be expected to
improve sleep.

Antihistamine plus Decongestant

Because antihistamines may have only a modest effect on nasal congestion, antihistamines and
decongestants are often combined. Some patients may respond to this combination when
corticosteroids have failed or when either medication alone does not provide adequate relief of nasal
symptoms.2,30

Antihistamine plus Corticosteroid

Intranasal corticosteroids are often combined with oral antihistamines to treat severe or resistant cases
of allergic rhinitis.6 This strategy seems logical because the 2 drugs have different mechanisms of
action. Evidence is insufficient to support the combination of intranasal corticosteroids and oral
antihistamines, as it has not been consistently shown to be superior to either medication alone.2,30
However, intranasal corticosteroid in combination with intranasal antihistamine (fluticasone/
azelastine) is more effective for the nasal symptoms of allergic rhinitis than either medication alone.30

Antihistamine or Intranasal Corticosteroid plus LTRA

An additive effect has been shown when LTRAs and either oral antihistamines or intranasal
corticosteroids are used concomitantly.30 The efficacy of oral antihistamines in combination with a
LTRA is less than that of intranasal corticosteroids alone.6 However, antihistamine-LTRA combination
therapy may provide an alternative for patients who are unresponsive or nonadherent to intranasal
corticosteroid therapy.

Special Populations
Children
The guidelines for treatment of allergic rhinitis in children are similar to those for adults.6 Healthcare
practitioners must ensure they select the correct dosage, ensure proper administration and minimize
adverse effects.3,7,24 Most second-generation antihistamines are now available in pediatric
formulations for children >6 months and are generally preferred over first-generation agents due to
improved adverse effect profiles. Table 5 and Table 6 provide dosage guidelines and age limits for oral
and intranasal agents. Intranasal corticosteroids are also effective and are considered safe in children
>2 years of age, depending on the formulation.24 Intranasal budesonide and mometasone furoate
have not shown growth suppression with prolonged use at recommended doses.6,43,44 Intranasal
beclomethasone dipropionate, fluticasone propionate and triamcinolone acetonide have been
shown to reduce growth velocity by 0.2–0.9 cm per year within the first year of treatment.45,46,47
Longer term studies have not been conducted. If intranasal corticosteroids are used, use the lowest
possible dose, monitor growth and use other therapies (e.g., antihistamines) to minimize the dose of
corticosteroid required for symptom control.6 Decongestants are not recommended for use in children
under 6 years.48,49 In those children, intranasal saline drops or spray may be used to clear nasal
passages before eating or sleeping.

Pregnancy
Intranasal cromoglycate and intranasal corticosteroids are both considered safe during pregnancy
although beclomethasone, budesonide and fluticasone propionate have accumulated more safety
data than other intranasal corticosteroids.6 Neither first- nor second-generation antihistamines have
been associated with teratogenic effects in pregnancy.50,51 First-generation antihistamines were
previously favoured because of substantially greater experience; however, safety data for cetirizine
and loratadine now indicate these are acceptable options. Chlorpheniramine has a good safety

Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments

Sample Chapters for Conference_J.indd 27 6/17/2016 2:35:22 PM

 Respiratory Conditions
Chapter 22: Allergic Rhinitis 235
record in pregnancy. Although diphenhydramine has good safety data and is still recommended and
frequently used in pregnancy, there have been isolated reports of cleft palate.51 Sedation and impaired
performance may limit the use of first-generation antihistamines. Oral decongestants should be
avoided in the first trimester.51 A topical decongestant may be used; at usual doses, they do not
present a risk to the fetus. Immunotherapy generally should not be started during pregnancy. Courses
of immunotherapy started prior to conception may be continued if beneficial and not causing systemic
reactions; doses should not be increased during pregnancy.52 See Appendix V: Pregnancy and
Breastfeeding: Self-care Therapy for Common Conditions.

Breastfeeding
Recommendations for breastfeeding are similar to those during pregnancy. Both first- and second-
generation antihistamines are considered safe while breastfeeding.53 First-generation antihistamines
may in theory diminish milk production via their anticholinergic effect; however, this has not been
reported in practice. Infant somnolence should be monitored when a first-generation antihistamine or
cetirizine is used.
The systemic absorption of topical decongestants is low and transfer into breast milk is unknown.
Consequently, these agents are expected to be reasonably safe during breastfeeding.
The American Academy of Pediatrics considers pseudoephedrine to be compatible with
breastfeeding.51 Information on the use of other oral decongestants during breastfeeding is limited.
Information on the use of topical sodium cromoglycate during breastfeeding is not available, although
the manufacturer recommends caution.

Monitoring of Therapy
Table 4 provides a monitoring plan framework that should be individualized.
Table 4: Monitoring of Therapy for Allergic Rhinitis

Symptoms Monitoring Endpoint of Therapy Actions

Allergic symptoms Patients: Daily Patient able to perform If nonprescription therapy is ineffective
(sneezing, runny nose, Healthcare practitioner: daily activities. after 1 wk, optimize allergen avoidance
itchy and watery eyes, Next visit or by telephone 1 Patient able to sleep. and medication dose (if applicable). If
congestion, rhinorrhea) wk later symptoms not controlled after a further
wk of therapy, consider another agent.
Refer as necessary.3

Drowsiness Patient: Daily Patient not drowsy during Switch to a less sedating antihistamine.
(antihistamine) Healthcare practitioner: the day. If using cetirizine, could give dose at
Next visit or by telephone bedtime.
when checking for efficacy

Insomnia Patient: Daily No insomnia. Change medication schedule so last

(oral decongestant) Healthcare practitioner: 1 dose taken 4–6 h before bedtime or
wk discontinue medication.

Elevated blood pressure Patient: Daily No elevation in blood Stop decongestant if blood pressure
in hypertensive patients Healthcare practitioner: pressure above baseline. elevated above baseline.
(oral decongestant) Monitor blood pressure of
hypertensive patients twice
in the first wk

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 Chapter 22: Allergic Rhinitis
236 Respiratory Conditions
Advice for the Patient
Advise all patients about allergen avoidance. In addition, patients who require drug therapy should
receive counselling regarding proper use of the medication, expected results and management of
adverse effects (see Table 4).

Figure 2: Assessment and Initial Treatment of Patients with Allergic Rhinitis3,4,6,7

Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments

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 Table 5: Oral Agents for Allergic Rhinitis
Class Drug Dosage Adverse Effects Drug Interactions Comments Costa

Antihistamines, chlorpheniramine Adults: 4 mg Q4–6H po; CNS: Sedation, fatigue, Increased CNS depression $
First-generation Chlor-Tripolon, maximum 24 mg/day dizziness, impairment when combined: Alcohol,
generics Children: 0.35 mg/kg/day of cognition and sedatives, tranquilizers,
divided Q4–6H po performance. barbiturates.
Anticholinergic: Dry Increased anticholinergic
or

Sample Chapters for Conference_J.indd 30

mouth and eyes, side effects when combined
2–5 y: 1 mg Q4–6H po; constipation, urinary with: TCAs, scopolamine.
maximum 6 mg/day retention. Increase chlorpheniramine
6–11 y: 2 mg Q4–6H po; levels resulting in increased
adverse effects when
Respiratory Conditions

maximum 12 mg/day
combined with moderate
CYP2D6 inhibitors, e.g.,

Compendium of Therapeutics for Minor Ailments

amiodarone, celecoxib.
Avoid combination with
strong CYP2D6 inhibitors,
e.g., bupropion, paroxetine.

diphenhydramine Adults: 25–50 mg Q6–8H See chlorpheniramine. Increased CNS depression: Available in pediatric liquid $
Benadryl po; maximum 300 mg/day Alcohol, sedatives, formulation.
Preparations, Children: 5 mg/kg/day given tranquilizers, barbiturates.
generics in 3 or 4 divided doses po Increased anticholinergic
side effects when combined
2–5 y: Maximum 37.5 mg/day with: TCAs, scopolamine.
6–11 y: Maximum150 mg/day May increase levels of
CYP2D6 substrates, e.g.,
metoprolol, venlafaxine.

Antihistamines, cetirizine Adults: 5–10 mg Q24H po; Minimal to no Increased CNS depression: Active metabolite of $
Second- Reactine, generics maximum 20 mg Q24H po anticholinergic effects. Alcohol, sedatives, hydroxyzine.
generation Children: May cause drowsiness tranquilizers, barbiturates. Available in pediatric 5 mg
in some individuals Increased anticholinergic rapid-dissolve tablet.
6–12 months: 2.5 mg Q24H
especially at higher side effects: TCAs,
po Available as 5 mg/5 mL
doses. scopolamine.
12–23 months: 2.5 mg Q24H syrup.
Headache.
po; maximum 2.5 mg Q12H
2–5 y: 2.5 mg Q24H po;
maximum 5 mg/day in 1 or 2
doses
≥6 y: Adult dosage
Chapter 22: Allergic Rhinitis
237

Copyright © Canadian Pharmacists Association. All rights reserved.

6/17/2016 2:35:24 PM
 Table 5: Oral Agents for Allergic Rhinitis (cont'd) 238
Class Drug Dosage Adverse Effects Drug Interactions Comments Costa

desloratadine Adults: 5 mg Q24H po Minimal to no P-gp inhibitors (e.g., Active metabolite of $

Aerius, generics Children: anticholinergic effects. erythromycin, ketoconazole) loratadine.
Headache. may increase loratadine Available in pediatric liquid
6–11 months: 1 mg Q24H po
levels while P-gp inducers formulation.
1–5 y: 1.25 mg Q24H po (e.g., carbamazepine,

Sample Chapters for Conference_J.indd 31

6–11 y: 2.5 mg Q24H po dexamethasone) may
decrease loratadine levels;
clinical effect probably
minimal.

fexofenadine Adults: 60 mg Q12H po See desloratadine. Decreased fexofenadine Active metabolite of $

Allegra Sustained-release: 120 mg level: Aluminum- and terfenadine. Only 5% of a
Q24H po magnesium-containing dose is metabolized.
antacids.
Children: Ingestion of fruit juices such
Respiratory Conditions

2–11 y: 30 mg Q12H po as apple, grapefruit or

orange may decrease
bioavailability.

Adults: 10 mg Q24H po See desloratadine. QTc prolongation reported Available in pediatric liquid $

Copyright © Canadian Pharmacists Association. All rights reserved.

loratadine
Claritin, Claritin Children: with concomitant use of formulation and rapid-
Liquid Capsules, loratadine and amiodarone. dissolve tablets.
2–5 y: 5 mg Q24H po
generics Caution is advised.
≥5 y: 10 mg Q24H po P-gp inhibitors (e.g.,
erythromycin, ketoconazole)
may increase loratadine
levels while P-gp inducers
(e.g., carbamazepine,
dexamethasone) may
decrease loratadine levels;
clinical effect probably
minimal.

(cont'd)
Chapter 22: Allergic Rhinitis

Compendium of Therapeutics for Minor Ailments

6/17/2016 2:35:24 PM
 Table 5: Oral Agents for Allergic Rhinitis (cont'd) 240
Class Drug Dosage Adverse Effects Drug Interactions Comments Costaa
Class Drug Dosage Adverse Effects Drug Interactions Comments Cost

Copyright
Leukotriene montelukast Adults and children ≥15 y: Headache, abdominal Strong CYP2C9 and 3A4 Strong CYP2C9 and 3A4 $$

Compendium
Decongestants pseudoephedrine Adults: 60 mg Q4–6H po; Mild CNS stimulation Beta-blockers: Caution in patients with $$
Receptor Singulair, 10 mg QHS pain, flu-like symptoms. inducers (e.g., inducers (e.g.,
maximum 240 mg/day (nervousness, Antihypertensive effects may heart disease, high blood
Antagonists Montelukast, other Children: carbamazepine, carbamazepine,
Eltor 120, Sustained-release: 120 mg excitability, be reduced. pressure, hyperthyroidism,
generics phenobarbital, phenytoin, phenobarbital, phenytoin,

© Canadian
Sudafed, generics 6–14 y: 5 mg QHS restlessness, dizziness, Contraindicated with MAOIs diabetes, angle closure
Q12H po; maximum 240 mg/ rifampin) may decrease rifampin) may decrease
weakness, insomnia). and ergot derivatives. glaucoma and prostatic

Sample Chapters for Conference_J.indd 32

2–5
day y: 4 mg QHS montelukast levels whereas, montelukast levels
Peripheral Avoid use with enlargement.
strong CYP2C9 inhibitors whereas, strong CYP2C9

of Therapeutics
Children: vasoconstriction. phenothiazines and selective
(e.g., sulfadiazine) may Concurrent
inhibitors (e.g., with or use
usefluconazole)
6–11 y: 30 mg Q4–6H po Tachycardia or serotonin reuptake inhibitors. of MAOIs

Pharmacists
increase montelukast levels; may
withinincrease
2 weeksmontelukast
Maximum 120 mg/day palpitation may occur. may cause hypertensive
Respiratory Conditions

clinical significance is levels; clinical significance

Blood pressure may be

for Minor
uncertain; however, monitor crisis.
is uncertain; however,
≥12 y: adult dose increased in
for reduced efficacy or monitor for reduced
hypertensive subjects.
adverse effects. efficacy or adverse effects

Association.
May adversely affect
a Cost of 10 day supply; includes drug cost only
blood sugar control in
Respiratory Conditions

diabetics.
Dosage adjustment may be required in renal impairment.
Antihistamine,
Abbreviations: cetirizine/
CNS = central = monoamine
nervous system; MAOIAdults: (5 mg/120
1 taboxidase inhibitor;
mg)SR = See cetirizine.
sustained release See cetirizine. See cetirizine. $$
Second-
Legend: pseudoephedrine
$ < $10 $$ $10–20 Q12H po See pseudoephedrine. See pseudoephedrine. See pseudoephedrine.
generation/ Children:

AilmentsAll rights reserved.

Decongestant Reactine ≥12 y: Give adult dose
Combinations Complete

desloratadine/ Adults: 1 tab (2.5 See desloratadine. See desloratadine. See desloratadine. $$
pseudoephedrine mg/120 mg) Q12H po See pseudoephedrine. See pseudoephedrine. See pseudoephedrine.
Children:
Aerius Dual Action ≥12 y: Give adult dose
12 Hour

fexofenadine/ Adults: 1 tab (60 mg/ See desloratadine. See fexofenadine. See fexofenadine. $$
pseudoephedrine 120 mg) Q12H po See pseudoephedrine. See pseudoephedrine. See pseudoephedrine.
Children:
Allegra-D ≥12 y: Give adult dose

Copyright © Canadian
loratadine/ Adults: 1 tab (5 mg/120 mg) See desloratadine. See loratadine. See loratadine. $$
pseudoephedrine Q12H po See pseudoephedrine. See pseudoephedrine. See pseudoephedrine.

Compendium
or
Claritin Allergy +
1 tab (10 mg/240 mg) Q24H

Pharmacists
Sinus, Claritin
po
Allergy + Sinus
Extra Strength Children:
≥12 y: Give adult dose

of Therapeutics
Chapter 22: Allergic Rhinitis

Association.for
(cont'd)

AllMinor
rightsAilments
239

reserved.

6/17/2016 2:35:25 PM
 Table 5: Oral Agents for Allergic Rhinitis (cont'd) 24
Class Drug Dosage Adverse Effects Drug Interactions Comments Costa

Leukotriene montelukast Adults and children ≥15 y: Headache, abdominal Strong CYP2C9 and 3A4 Strong CYP2C9 and 3A4 $$
Receptor Singulair, 10 mg QHS pain, flu-like symptoms. inducers (e.g., inducers (e.g.,
Antagonists Montelukast, other Children: carbamazepine, carbamazepine,
generics phenobarbital, phenytoin, phenobarbital, phenytoin,
6–14 y: 5 mg QHS
rifampin) may decrease rifampin) may decrease

Sample Chapters for Conference_J.indd 33

2–5 y: 4 mg QHS montelukast levels whereas, montelukast levels
strong CYP2C9 inhibitors whereas, strong CYP2C9

Copyright © . All rights reserved.

(e.g., sulfadiazine) may inhibitors (e.g., fluconazole)
increase montelukast levels; may increase montelukast
clinical significance is levels; clinical significance
uncertain; however, monitor is uncertain; however,
for reduced efficacy or monitor for reduced
adverse effects. efficacy or adverse effects

a Cost of 10-day supply; includes drug cost only

Respiratory Conditions

Dosage adjustment may be required in renal impairment.

Abbreviations: CNS = central nervous system; MAOI = monoamine oxidase inhibitor; SR = sustained release
Legend: $ < $10 $$ $10–20
Chapter 22: Allergic Rhinitis

Compendium of Therapeutics for Minor Ailments

6/17/2016 2:35:25 PM
 Table 6: Intranasal Agents for Allergic Rhinitis
Class Drug Dosage Adverse Effects Comments Costa

Antihistamines levocabastine Adults and Children (≥12–65 y): 2 sprays Nasal irritation. Shake well before use. $$$
Livostin Nasal Spray (50 µg/spray) per nostril BID; may increase Initial priming required.
to 2 sprays TID–QID
Discontinue if no improvement seen
within 3 days.

Sample Chapters for Conference_J.indd 34

Antihistamine/ azelastine/fluticasone Adults and children ≥12 y: 1 spray Burning or stinging, Avoid use with ritonavir due to $100
Corticosteroid Dymista (137 µg/50 µg) in each nostril BID nosebleeds. potential for systemic corticosteroid
Combinations Dysgeusia may occur if effects.
patient tilts head back too Rarely causes drowsiness.
Respiratory Conditions

far during administration.

Compendium of Therapeutics for Minor Ailments

Corticosteroids beclomethasone Adults and children ≥6 y: 2 sprays Burning or stinging, Use at regular intervals. Slow onset $$
generics (50 µg/spray) in each nostril BID nosebleed. (7–14 days for maximal effect).
Adults: Maximum 12 sprays/day May cause mild growth Drug may fail to reach the site of
suppression with action if excessive nasal mucus
Children: Maximum 8 sprays/day prolonged use.45,46,47 secretion or edema of the nasal
Use lowest effective dose for maintenance mucosa is present. May use a
therapy vasoconstrictor (intranasal
decongestant) 2–3 days prior to the
suspension.
Aim spray up towards turbinates and
away from septum. Liquid forms may
be more effective than metered-dose
inhalers.
Chapter 22: Allergic Rhinitis
25

Copyright © . All rights reserved.

6/17/2016 2:35:25 PM
 Table 6: Intranasal Agents for Allergic Rhinitis (cont'd) 26
Class Drug Dosage Adverse Effects Comments Costa

budesonide Nasal suspension: See beclomethasone. See beclomethasone. $$-$$$

Rhinocort Aqua, Adults and children ≥6 y (64 µg/metered For the nasal suspension, initial
Rhinocort Turbuhaler dose): Initial dose 2 sprays in each nostril priming needed. Re-prime if not used
daily ≥4 days.

Sample Chapters for Conference_J.indd 35

or
1 spray in each nostril BID; may decrease

Copyright © . All rights reserved.

maintenance dose to 1 spray in each nostril
daily
Nasal powder:
Adults and children ≥6 y (100 µg/dose):
Initial dose 2 applications in each nostril in
the morning
Respiratory Conditions

or
1 application in each nostril BID; may
decrease maintenance dose to 1 spray in
each nostril daily
Maximum 400 µg/day

ciclesonide Adults and children ≥12 y: 2 sprays Burning or stinging, See beclomethasone. $$$
Omnaris (50 µg/spray) in each nostril daily; nosebleeds. Initial priming needed.
maximum 200 µg/day

flunisolide Adults: 2 sprays (25 µg/metered spray) in See ciclesonide. See beclomethasone. $$
generics each nostril BID, may increase to TID if
needed; maximum 300 µg/day
Children 6–14 y: 1 spray in each nostril
TID; maximum 150 µg/day
Chapter 22: Allergic Rhinitis

Compendium of Therapeutics for Minor Ailments

6/17/2016 2:35:25 PM
 Class Drug Dosage Adverse Effects Comments Costa

fluticasone propionate Adults and children ≥12 y: 2 sprays See beclomethasone. See beclomethasone. $$$
Flonase, generics (50 µg/spray) in each nostril daily, may
increase to BID in severe situations;
maximum 400 µg/day
Children 4–11 y: 1–2 sprays in each nostril
daily; maximum 200 µg/day

Sample Chapters for Conference_J.indd 36

fluticasone furoate Adults and children ≥12 y: 2 sprays See ciclesonide. See beclomethasone. $$$
Avamys (27.5 µg/spray) in each nostril once daily; Initial priming needed. Re-prime if
maximum 110 µg/day not used ≥30 days or if cap left off for
Respiratory Conditions

Children ≥2 y to <12 y: 1 spray in each ≥5 days.

nostril once daily, may increase to 2 sprays

Compendium of Therapeutics for Minor Ailments

in each nostril once daily if needed.
Decrease to 1 spray in each nostril daily for
maintenance; maximum 110 µg/day

mometasone Adults and children ≥12 y: 2 sprays See ciclesonide. See beclomethasone. $$$
Nasonex (50 μg/spray) in each nostril daily, may
decrease to 1 spray in each nostril daily for
maintenance; may increase to BID in
severe situations.
Children 3–11 y: 1 spray in each nostril
daily

triamcinolone Adults and children ≥12 y: 2 sprays See ciclesonide. See beclomethasone. $$$
Nasacort AQ (55 µg/spray) in each nostril once daily, may
decrease to 1 spray in each nostril once
daily
Children 4–11 y: 1 spray (55 µg/spray) in
each nostril once daily, may increase to 2
sprays in each nostril once daily if needed.
Decrease to 1 spray in each nostril daily for
maintenance; maximum 110 µg/day

(cont'd)
Chapter 22: Allergic Rhinitis
27

Copyright © . All rights reserved.

6/17/2016 2:35:25 PM
 Table 6: Intranasal Agents for Allergic Rhinitis (cont'd) 28
Class Drug Dosage Adverse Effects Comments Costa

Decongestants oxymetazoline Adults and children ≥6 y: 0.05% solution Burning, stinging, Onset of action: 5–10 min. $
Claritin Allergy 2–3 drops or sprays/nostril Q12H sneezing, dryness of the Long duration of action lasting up to
Decongestant, Dristan nasal mucosa. 12 h.
Long Lasting Nasal Bradycardia, tachycardia,
Do not use longer than 3–5 days.
Mist, Dristan Long hypotension and

Sample Chapters for Conference_J.indd 37

Lasting Mentholated hypertension have been
Nasal Spray reported.

Copyright © . All rights reserved.

phenylephrine Adults and children ≥6 y: 0.25% or 0.5% See oxymetazoline. See oxymetazoline. $
Dristan Nasal Mist solution 2–3 drops or sprays/nostril Q4H

xylometazoline Adults and children ≥6 y: 0.05% or 0.1% See oxymetazoline. See oxymetazoline. $
Otrivin, Balminil Nasal solution 2–3 drops or 1–2 sprays/nostril
Decongestant Q8-10H
Respiratory Conditions

Mast Cell sodium cromoglycate Adults and children >2 y: 1 spray/nostril Local: Sneezing, nasal Less effective than other agents. $$
Stabilizers Rhinaris CS Anti- 3–6 times daily stinging or irritation, bad Onset of action delayed up to 4 wk.
allergic taste in the mouth,
epistaxis.

a Cost of 1 unit (spray pump); includes drug cost only.

Legend: $ < $10 $$ $10–20 $$-$$$ $10–30 $$$ $20–30
Chapter 22: Allergic Rhinitis

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6/17/2016 2:35:25 PM
 Respiratory Conditions
244 Respiratory Conditions
Suggested Readings
Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA)
guidelines: 2010 revision. J Allergy Clin Immunol 2010;126:466-76.
Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head
Neck Surg 2015;152:S1-43.
Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updated
practice parameter. J Allergy Clin Immunol 2008;122:S1-84.
Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med 2015;372:456-63.

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5. Kay AB. Allergy and allergic diseases. First of two parts. N Engl J Med 2001;344:30-7.
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8. Varghese M, Glaum MC, Lockey RF. Drug-induced rhinitis. Clin Exp Allergy 2010;40:381-4.
9. Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152:S1-43.
10. Nurmatov U, van Schayck CP, Hurwitz B et al. House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane
systematic review. Allergy 2012;67:158-65.
11. Hermelingmeier KE, Weber RK, Hellmich M et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and
meta-analysis. Am J Rhinol Allergy 2012;26:e119-25.
12. Garavello W, Somigliana E, Acaia B et al. Nasal lavage in pregnant women with seasonal allergic rhinitis: a randomized study. Int Arch
Allergy Immunol 2010;151:137-41.
13. Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am
J Med 2004;116:338-44.
14. Laekeman G, Simoens S, Buffels J et al. Continuous versus on-demand pharmacotherapy of allergic rhinitis: evidence and practice. Respir
Med 2010;104:615-25.
15. Krouse JH. Allergic rhinitis–current pharmacotherapy. Otolaryngol Clin North Am 2008;41:347-58.
16. Bachert C. A review of the efficacy of desloratadine, fexofenadine, and levocetirizine in the treatment of nasal congestion in patients with
allergic rhinitis. Clin Ther 2009;31:921-44.
17. Lehman JM, Blaiss MS. Selecting the optimal oral antihistamine for patients with allergic rhinitis. Drugs 2006;66:2309-19.
18. Simons FE. Advances in H1-antihistamines N Engl J Med 2004;351:2203-17.
19. Slater JW, Zechnich AD, Haxby DG. Second-generation antihistamines: a comparative review. Drugs 1999;57:31-47.
20. Horak F, Stubner UP. Comparative tolerability of second generation antihistamines. Drug Saf 1999;20:385-401.
21. Simons FE. H1-receptor antagonists. Comparative tolerability and safety. Drug Saf 1994;10:350-80.
22. Melvin TA, Patel AA. Pharmacotherapy for allergic rhinitis. Otolaryngol Clin North Am 2011;44:727-39.
23. Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician 2010;81:1440-6.
24. Turner PJ, Kemp AS. Allergic rhinitis in children. J Paediatr Child Health 2012;48:302-10.
25. Bender BG, Berning S, Dudden R et al. Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a
meta-analysis. J Allergy Clin Immunol 2003;111:770-6.
26. Weiler JM, Bloomfield JR, Woodworth GG et al. Effects of fexofenadine, diphenhydramine and alcohol on driving performance. A
randomized, placebo-controlled trial in the Iowa driving simulator. Ann Intern Med 2000;132:354-63.
27. Church MK, Maurer M, Simons FE et al. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy 2010;65:459-66.
28. Walsh GM, Annunziato L, Frossard N et al. New insights into the second generation antihistamines. Drugs 2001;61:207-36.
29. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of
randomised controlled trials. BMJ 1998;317:1624-9.
30. Glacy J, Putnam K, Godfrey S et al. Treatments for seasonal allergic rhinitis. Rockville: Agency for Healthcare Research and Quality; 2013.
(Comparative Effectiveness Reviews, No. 120.) Available from: www.ncbi.nlm.nih.gov/books/NBK153714.
31. Golightly LK, Greos LS. Second-generation antihistamines: actions and efficacy in the management of allergic disorders. Drugs 2005;65:341-
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32. Johnson DA, Hricik JG. The pharmacology of alpha-adrenergic decongestants. Pharmacotherapy 1993;13:110S-15S.
33. Chua SS, Benrimoj SI, Gordon RD et al. A controlled clinical trial on the cardiovascular effects of single doses of pseudoephedrine in
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34. Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy 1997;52:28-34.
35. Mehuys E, Gevaert P, Brusselle G et al. Self-medication in persistent rhinitis: overuse of decongestants in half of the patients. J Allergy Clin
Immunol Pract 2014;2:313-9.
36. Ratner P, Van Bavel JV, Mohar D et al. Efficacy of daily intranasal fluticasone propionate on ocular symptoms associated with seasonal
allergic rhinitis. Ann Allergy Asthma Immunol 2015;114:141-7.
37. van Drunen C, Meltzer EO, Bachert C et al. Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of
mometasone furoate. Allergy 2005;60:5-19.

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 Chapter 22: Allergic Rhinitis
Chapter 22: Allergic Rhinitis 245
38. Kaiser HB, Naclerio RM, Given J et al. Fluticasone furoate nasal spray: a single treatment option for the symptoms of seasonal allergic
rhinitis. J Allergy Clin Immunol 2007;119:1430-7.
39. Hong J, Bielory B, Rosenberg JL. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: a systematic review.
Allergy Asthma Proc 2011;32:22-35.
40. Berger WE, Prenner B, Turner R et al. A patient preference and satisfaction study of ciclesonide nasal aerosol and mometasone furoate
aqueous nasal spray in patients with perennial allergic rhinitis. Allergy Asthma Proc 2013;34:542-50.
41. Kowalski ML. Systemic and specific treatment for a global disease: allergen immunotherapy revisited. Allergy 2006;61:791-5.
42. Jacobsen L, Niggemann B, Dreborg S et al. Specific immunotherapy has long term preventive effect of seasonal and perennial asthma: 10-year
follow-up on the PAT study. Allergy 2007;62:943-8.
43. Allen DB. Systemic effects of intranasal steroids: an endocrinologist's perspective. J Allergy Clin Immunol 2000;106:S179-90.
44. Skoner DP, Gentile DA, Doyle WJ. Effect on growth of long-term treatment with intranasal triamcinolone acetonide aqueous in children with
allergic rhinitis. Ann Allergy Asthma Immunol 2008;101:431-6.
45. Skoner DP, Rachelefsky GS, Meltzer EO et al. Detection of growth suppression in children during treatment with intranasal beclomethasone
dipropionate. Pediatrics 2000;105:E23.
46. Lee LA, Sterling R, Maspero J et al. Growth velocity reduced with once-daily fluticasone furoate nasal spray in prepubescent children with
perennial allergic rhinitits. J Allergy Clin Immunol Pract 2014;2:421-7.
47. Skoner DP, Berger WE, Gawchik SM et al. Intranasal triamcinolone and growth velocity. Pediatrics 2015;135:e348-56.
48. Healthy Canadians. Health Canada releases decision on the labelling of cough and cold products for children. Available from:
www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php. Accessed November 30, 2009.
49. Peterson RG, Cran B, Knoppert D et al. Scientific Advisory Panel on Nonprescription Paediatric Cough and Cold Medications (SAP-
NPCCM). Record of proceedings. Ottawa: Health Canada; March 20, 2008.
50. Mazzotta P, Loebstein R, Koren G. Treating allergic rhinitis in pregnancy. Safety considerations. Drug Saf 1999;20:361-75.
51. Briggs GG, Freeman RK. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 10th ed. Baltimore: Lippincott
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52. Oykhman P, Kim HL, Ellis AK. Allergen immunotherapy in pregnancy. Allergy Asthma Clin Immunol 2015;11:31.
53. Hale TW. Medications and mothers' milk: a manual of lactational pharmacology. 15th ed. Amarillo: Hale Publishing; 2012.

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 Respiratory Conditions
246 Respiratory Conditions

Allergic Rhinitis—What You Need to Know

Allergic rhinitis is a condition caused by allergens in the air. Allergens are things that cause allergies.
Some of the symptoms of allergic rhinitis are sneezing, coughing, runny nose, and itchy or watery
eyes. The most important thing you can do to feel better is to avoid the things that cause your allergies.
Also avoid exposure to cigarette smoke and strong smells. If you do not know what causes your
allergies, see your doctor.

Helpful Hints for People Who Have Allergies

If you are allergic to pollen:
■ Keep the windows and doors of your house closed.
■ If you need to use air conditioning, set the unit to the indoor cycle.
■ Do not use window or attic fans.
■ Check the weather report to find out about the pollen count. The pollen count tells you what kind of
pollen is in the air and how much. Avoid spending time outdoors when the pollen count is high. The
pollen count is highest on sunny, windy days and in the morning.
■ Do not dry your clothing outdoors.
■ Shower or take a bath and wash your hair after outdoor activity. This will remove pollen from your
hair and skin. You want to avoid getting pollen into your bedding.

If you are allergic to outdoor moulds:

■ Stay indoors as much as possible.

■ If you need to use air conditioning, set the unit to the indoor cycle. Have your air conditioner
cleaned regularly. Air conditioners can be heavily contaminated with mould.
■ Use a facemask if you rake leaves or work with compost or dry soil.

If you are allergic to indoor moulds:

■ Kill mould with a solution of equal parts household bleach and water. Wash sinks, shower stalls,
nonrefrigerated vegetable storage areas and garbage pails with this solution.
■ Avoid using a humidifier or cool mist vaporizer. Moulds grow easily where it is damp. If you must
use a humidifier or vaporizer, clean it often with a solution of equal parts bleach and water.
■ If your home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep
the foundation vents open.
■ If your basement is damp or tends to flood, do not put carpet or furniture there. For a damp
basement, run a dehumidifier at all times. Empty water from the machine often and clean it
regularly. For a flooded basement, drain the water as quickly as possible.
■ Fix any leaky faucets or pipes promptly.
■ Do not keep houseplants.

If you are allergic to dust mites:

■ Do not put carpet in your bedroom or main living areas.
■ Plastic, leather or wood furniture is best.
■ If possible, have someone else clean the house while you are not at home.
■ If you must do your own cleaning, wear a facemask while you clean and for 10–15 minutes
afterward.

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 Chapter 22: Allergic Rhinitis
Chapter 22: Allergic Rhinitis 247
■ Use a vacuum cleaner with an efficient double-filtration system.
■ Keep indoor humidity between 40% and 45%. You can buy a hygrometer to measure the humidity
in your house at a hardware store or home centre.
■ Avoid using a humidifier or cool mist vaporizer.
■ Use zippered, allergen-proof casings on all mattresses, box springs and pillows.
■ Consider replacing old mattresses.
■ Wash your bedding in hot (>55°C) water at least every 2 weeks. Cooler water will not kill dust
mites.
■ Do not keep stuffed toys that cannot be washed.
■ Do not store items under your bed.
■ Use window shades instead of venetian blinds.

If you are allergic to a pet:

■ The best choice is to find another home for the animal. It can take several months before the
allergen levels return to normal.
■ If you are not able to give up your pet, then:

– You may find it helps to install a HEPA or electrostatic air purifier in your home.
– Keep animals out of your bedroom at all times.
– Keep animals out of rooms that have carpets.
– Try to keep animals off furniture.
– Washing cats weekly and dogs twice weekly may help, though this has not been proven.
– Get rid of litter boxes if possible. If not, put them in an area that is not connected to the air
supply for the rest of your home.
– If the animal lives in a cage, keep it in a room without carpet, far away from your bedroom.

Medication to Help with Allergy Symptoms

You may want to try medication if:
■ You don't feel better even when you avoid the things that cause your allergies.
■ Your allergies are interfering with your sleep or your daily activities.

Your pharmacist can help you pick the best medication for you and show you how to use it. See
Table 1. You can choose between pills or a nasal spray.
Table 1: How to Use a Nasal Spray or Drops

Nasal Spray (Adults only)

1. Gently blow your nose.

2. Gently shake bottle and remove cap or lid.
3. With your head upright but not tilted backward, press your finger against one side of your nose to close the nostril. Spray the
medication into the open nostril, with the tip directed away from the middle of the nose and back towards the nasal cavity.
Squeeze the bottle quickly and breathe in slowly through the nose.
4. Remove tip of nasal spray from your nostril and breathe out through your mouth.
5. Do the same thing on the other side.
6. Blow your nose in 3–5 minutes.

(cont'd)

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 Respiratory Conditions
248 Respiratory Conditions
Table 1: How to Use a Nasal Spray or Drops (cont'd)
7. Rinse the tip of the spray bottle with hot water, but try not to get water in the bottle. Replace lid.
8. Do not use more nose spray than the recommended amount.

Nose Drops (Adult or child)

1. Gently blow your nose.

2. Lie on your back on a bed with your head hanging slightly over the side.
3. Gently shake bottle. Fill the dropper with the recommended amount of medication. Put the dropper just inside one nostril
(about 0.8 cm or one-third inch). If possible, don't let the dropper touch the skin.
4. Apply the recommended number of drops. Apply the medication to the other nostril in the same way.
5. Stay in the same position for about 5 minutes. Tilt head from side to side.
6. Blow the nose 3–5 minutes later.
7. You can also take nose drops by tilting your head back (instead of lying down). Use the recommended number of drops for
each nostril. Then bend over at the waist and hold that position for a few seconds before coming up straight again.
8. Rinse the dropper with hot water and return it to the bottle.
9. Do not use nose drops more than is recommended on the package.

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