What is the best course of action for a patient with allergic rhinitis taking Claritin (Loratadine) D every 12 hours, who complains of insomnia, restlessness, and anxiety, with tachycardia and mild hypertension, potentially due to pseudoephedrine?

From the Guidelines

The nurse should contact the provider to discuss using an intranasal glucocorticoid and Claritin (option A). The patient's symptoms of insomnia, restlessness, anxiety, elevated heart rate (90 bpm), and borderline blood pressure (130/85) are consistent with pseudoephedrine toxicity, which is a component of Claritin D 1. According to the 2017 Joint Task Force on Practice Parameters, intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis 1. The combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment of moderate to severe seasonal allergic rhinitis 1. Switching to regular Claritin (loratadine only) without pseudoephedrine and adding an intranasal glucocorticoid may help alleviate the patient's symptoms while minimizing the risk of pseudoephedrine toxicity.

Some key points to consider:

• Intranasal corticosteroids are effective in controlling the 4 major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion 1.
• The combination of an intranasal corticosteroid and an intranasal antihistamine may provide greater symptom reduction than monotherapy with either agent 1.
• Pseudoephedrine can cause central nervous system stimulation and cardiovascular effects, especially when taken every 12 hours 1.
• The patient's symptoms are consistent with pseudoephedrine toxicity, and adjusting the medication regimen may help alleviate these symptoms.

Overall, discussing the use of an intranasal glucocorticoid and Claritin with the provider is the best course of action to ensure the patient receives effective treatment for their allergic rhinitis while minimizing the risk of pseudoephedrine toxicity.

From the FDA Drug Label

STOP USE AND ASK A DOCTOR IF an allergic reaction to this product occurs. Seek medical help right away. The patient is experiencing insomnia, restlessness, and anxiety while taking Claritin D, which contains pseudoephedrine, a sympathomimetic drug. The patient's heart rate is 90 bpm and blood pressure is 130/85.

• The nurse will contact the provider to report potential adverse effects of pseudoephedrine, such as anxiety and insomnia, which may be related to its sympathomimetic properties.
• The nurse may suggest alternative treatments, such as an intranasal glucocorticoid and loratadine (Claritin), as mentioned in option A, to manage the patient's allergic rhinitis symptoms while minimizing potential adverse effects 2. The most appropriate course of action is option A, as it addresses the patient's symptoms and potential adverse effects of pseudoephedrine 3.

From the Research

Patient's Condition

The patient has allergic rhinitis and is taking Claritin D every 12 hours. They complain of insomnia, restlessness, and anxiety, with a heart rate of 90 bpm and blood pressure of 130/85.

Treatment Options

• The nurse will contact the provider to discuss alternative treatment options, considering the patient's symptoms and current medication.
• One possible option is to discuss using an intranasal glucocorticoid and Claritin, as studies have shown that intranasal glucocorticoids are effective in controlling inflammation and symptoms of allergic rhinitis 4, 5, 6.
• Another option is to report acute toxicity due to pseudoephedrine, a component of Claritin D, which can cause insomnia, restlessness, and anxiety as side effects.
• However, suggesting using an agent with a sympathomimetic drug only may not be the best option, as sympathomimetic drugs can exacerbate anxiety and insomnia.

Evidence-Based Recommendations

• Studies have shown that intranasal glucocorticoids are more effective than antihistamines or leukotriene receptor antagonists in reducing nasal symptoms and inflammation in patients with allergic rhinitis 4, 5, 6.
• Combination therapy with an intranasal glucocorticoid and an antihistamine may be more effective in controlling symptoms than monotherapy 7, 8.
• The choice of treatment should be based on the patient's individual needs and symptoms, and the nurse should consult with the provider to determine the best course of action.