What is the diagnosis and treatment for an 11-year-old with seasonal allergies, allergy-induced asthma, and symptoms of clear nasal drainage, cough, sporadic wheezing, ear pain, and itchy eyes?

From the Guidelines

I strongly recommend starting the 11-year-old on a comprehensive allergy treatment regimen that includes a second-generation antihistamine like cetirizine (Zyrtec) 10mg once daily or loratadine (Claritin) 10mg once daily, along with a nasal corticosteroid spray such as fluticasone propionate (Flonase) 1-2 sprays per nostril daily, as supported by the 2017 Joint Task Force on Practice Parameters 1.

Allergy Treatment Regimen

The patient's symptoms of increasing nasal drainage, cough, sporadic wheezing, and itchy eyes are consistent with allergic rhinitis, and the history of seasonal allergy-induced asthma suggests that treatment should also address asthma symptoms.

• A second-generation antihistamine will help reduce itching and drainage.
• A nasal corticosteroid spray will decrease nasal inflammation.
• For the asthma symptoms, an albuterol inhaler 2 puffs every 4-6 hours as needed for wheezing is recommended.
• Given the history of seasonal allergy-induced asthma, consider a daily inhaled corticosteroid like fluticasone (Flovent) 44mcg, 2 puffs twice daily to prevent asthma exacerbations.

Additional Recommendations

• The patient can continue using eye drops for itchy eyes, preferably an antihistamine eye drop like ketotifen (Zaditor) 1 drop in each eye twice daily.
• For the ear pain, monitor for signs of infection, but this may resolve with allergy treatment.
• The Tylenol cold and cough should be discontinued as targeted allergy and asthma medications are more effective.

Follow-up

A follow-up appointment in 2-4 weeks is recommended to assess treatment effectiveness, as suggested by the clinical practice guideline for allergic rhinitis 1.

This comprehensive approach addresses all symptoms by targeting the underlying allergic inflammation, and is supported by the most recent and highest quality studies, including those from the 2017 Joint Task Force on Practice Parameters 1.

From the FDA Drug Label

Pediatric patients (4 years of age and older) should be started with 100 mcg (1 spray in each nostril once daily). Treatment with 200 mcg (2 sprays in each nostril once daily or 1 spray in each nostril twice daily) should be reserved for pediatric patients not adequately responding to 100 mcg daily Once adequate control is achieved, the dosage should be decreased to 100 mcg (1 spray in each nostril) daily. Maximum total daily doses should not exceed 2 sprays in each nostril (total dose, 200 mcg/day). There is no evidence that exceeding the recommended dose is more effective.

The patient is 11 years old and has a history of seasonal allergy-induced asthma. The recommended starting dose for pediatric patients 4 years of age and older is 100 mcg (1 spray in each nostril once daily). If adequate control is not achieved, the dose can be increased to 200 mcg (2 sprays in each nostril once daily or 1 spray in each nostril twice daily). The maximum total daily dose should not exceed 2 sprays in each nostril (total dose, 200 mcg/day) 2.

From the Research

Patient Presentation

The 11-year-old patient presents with symptoms of increasing nasal drainage, cough, sporadic wheezing, intermittent right ear pain, and itchy eyes. The patient has a history of seasonal allergy-induced asthma and has been given Tylenol cold and cough.

Relevant Studies

• The patient's symptoms are consistent with allergic rhinitis, which affects an estimated 15% of the US population and is associated with the presence of asthma, eczema, and other conditions 3.
• The study suggests that patients with allergic rhinitis should avoid inciting allergens and may be treated with second-generation H1 antihistamines, intranasal antihistamines, or intranasal corticosteroids, depending on the severity and frequency of symptoms 3.
• A study on the efficacy and safety of loratadine plus pseudoephedrine in patients with seasonal allergic rhinitis and mild asthma found that the combination significantly reduced total rhinitis and asthma symptom severity scores and improved peak expiratory flow rates and quality of life 4.
• Another study highlights the importance of selecting nonimpairing second-generation antihistamines to manage allergic rhinitis, as they produce less sedation and impairment compared to older agents 5.
• A review of the evidence-based use of antihistamines for treatment of allergic conditions supports the use of second-generation H1 antihistamines in oral and intranasal formulations, including in combination with intranasal corticosteroids, for the treatment of allergic rhinitis and other related conditions 6.

Treatment Options

• Based on the patient's symptoms and history, treatment options may include:
  • Second-generation H1 antihistamines, such as loratadine or cetirizine
  • Intranasal antihistamines, such as azelastine or olopatadine
  • Intranasal corticosteroids, such as fluticasone or triamcinolone
  • Combination therapy with an antihistamine and a decongestant, such as pseudoephedrine
• The patient's mother has been using eyedrops for the itchy eyes, but antihistamines or nasal sprays have not been used as of yet. A refill of the current medication may not be sufficient to manage the patient's symptoms, and alternative treatment options should be considered.