What is the diagnosis and treatment plan for a patient with a chronic dry cough, scratchy itchy eyes, occasional scratchy throat, and ear popping, who will try daily allergy medication (e.g. diphenhydramine) before considering further testing for asthma or reactive airway disease?

From the Guidelines

Leona should start with a daily over-the-counter antihistamine like cetirizine (Zyrtec) 10mg, loratadine (Claritin) 10mg, or fexofenadine (Allegra) 180mg once daily for at least 2-4 weeks to address her chronic dry cough and associated symptoms. These non-drowsy options are preferable for daytime use, though diphenhydramine (Benadryl) 25-50mg can be used at night if needed. If the antihistamine alone doesn't provide sufficient relief, adding a nasal steroid spray like fluticasone (Flonase) or triamcinolone (Nasacort) once daily may help, especially if post-nasal drip is contributing to her cough. Her symptoms of chronic dry cough, itchy eyes, scratchy throat, and ear popping suggest allergic rhinitis as a likely cause, which often triggers upper airway irritation leading to chronic cough, as supported by the guidelines for the diagnosis and management of rhinitis 1.

Some key points to consider in her management include:

• The importance of individualizing her treatment plan based on the spectrum, duration, and severity of her symptoms, as well as her preferences and comorbidities 1.
• The potential need for a step-up or step-down approach in her treatment, depending on her response to initial therapy 1.
• The consideration of environmental modifications, such as using air purifiers and reducing allergen exposure, to help alleviate her symptoms 1.
• The possibility of underlying asthma or reactive airway disease, which may require further evaluation and treatment if her symptoms do not improve with initial therapy 1.

If these allergy medications don't improve her symptoms after 4 weeks of consistent use, she should return for further evaluation, possibly including pulmonary function testing to assess for asthma or reactive airway disease. Environmental modifications like using air purifiers, washing bedding in hot water weekly, and keeping windows closed during high pollen seasons may also help reduce allergen exposure. The most recent guidelines for managing chronic cough due to asthma and non-asthmatic eosinophilic bronchitis support the use of inhaled corticosteroids as first-line treatment for these conditions 1.

From the FDA Drug Label

These trials evaluated the total nasal symptom scores (TNSS) that included rhinorrhea, nasal obstruction, sneezing, and nasal itching in known allergic patients who were treated for 2 to 24 weeks. Subjects treated with Fluticasone Propionate Nasal Spray, USP exhibited significantly greater decreases in TNSS than vehicle placebo-treated patients Nasal mucosal basophils and eosinophils were also reduced at the end of treatment in adult studies; however, the clinical significance of this decrease is not known The studies demonstrated significantly greater reduction in TNSS (sum of nasal congestion, rhinorrhea, sneezing, and nasal itching) with Fluticasone Propionate Nasal Spray, USP, 200 mcg compared to placebo.

The patient's symptoms of cough, scratchy itchy eyes, scratchy throat, and popping of the ears may be related to allergic rhinitis. The use of Fluticasone Propionate Nasal Spray, USP may help alleviate these symptoms.

• The medication has been shown to decrease TNSS in patients with allergic rhinitis.
• It is recommended to start with a daily dose of 200 mcg (two 50-mcg sprays in each nostril once daily) and adjust as needed.
• Patients should use the medication at regular intervals for optimal effect.
• If symptoms do not improve, further testing for asthma or other conditions may be necessary 2.
• Common adverse reactions include headache, pharyngitis, epistaxis, and cough 2.

From the Research

Symptoms and Potential Causes

• Leona's symptoms include a dry hacky cough, scratchy itchy eyes, occasional scratchy throat, and occasional popping of the ears, which may be indicative of allergic rhinitis or asthma 3, 4.
• The presence of a daily cough with no other complaints or concerns suggests that Leona's symptoms may be related to an allergic reaction or airway hyperresponsiveness.

Diagnostic Testing and Treatment

• Leona was instructed to take a daily allergy medication to see if it improves her symptoms, which is a common approach for treating allergic rhinitis 4.
• If the allergy medication does not improve her symptoms, further testing such as spirometry or impulse oscillometry may be necessary to diagnose airway hyperresponsiveness or asthma 3.
• The study by 3 suggests that impulse oscillometry may be a more sensitive and effective method for detecting airway hyperresponsiveness compared to spirometry.

Comparison of Treatment Options

• The study by 4 compared the effectiveness of levocetirizine and loratadine in treating allergic rhinitis, and found that levocetirizine was significantly more effective in improving total symptom score.
• This suggests that levocetirizine may be a more effective treatment option for Leona's symptoms, although it is unclear which medication she was prescribed.