A 37-year-old woman comes to the physician complaining of persistent rhinorrhea. Her symptoms peak on arising from sleep and can be accompanied by 8-12 sneezes in rapid sequence. She has occasional postnasal drip. Her symptoms started about 5 years ago and have become progressively worse. There is no seasonal component to her symptoms, and she does not have itchy eyes. She has tried over-the-counter loratadine, which did not help. She has never had sinusitis, asthma, or eczema. The patient does not regularly use aspirin or over-the-counter nonsteroidal anti-inflammatory agents and has never used nasal sprays. She has no pets in the home. She takes amlodipine for hypertension.
Her blood pressure is 146/92 mm Hg and pulse 72/min. Her oropharynx is normal, and there are no nasal polyps. The turbinates are pale and boggy. Her chest is clear to auscultation.
Which of the following is the most appropriate treatment for her symptoms?

Question

A 37-year-old woman comes to the physician complaining of persistent rhinorrhea.  Her symptoms peak on arising from sleep and can be accompanied by 8-12 sneezes in rapid sequence.  She has occasional postnasal drip.  Her symptoms started about 5 years ago and have become progressively worse.  There is no seasonal component to her symptoms, and she does not have itchy eyes.  She has tried over-the-counter loratadine, which did not help.  She has never had sinusitis, asthma, or eczema.  The patient does not regularly use aspirin or over-the-counter nonsteroidal anti-inflammatory agents and has never used nasal sprays.  She has no pets in the home.  She takes amlodipine for hypertension.
Her blood pressure is 146/92 mm Hg and pulse 72/min.  Her oropharynx is normal, and there are no nasal polyps.  The turbinates are pale and boggy.  Her chest is clear to auscultation.
Which of the following is the most appropriate treatment for her symptoms?

Quizplus · Accepted Answer

11ec193a_979c_4065_853d_c931a925680c_MD0002_00 This patient has sneezing, nasal congestion starting in her 30s, and no atopic symptoms, findings characteristic of vasomotor rhinitis. Distinguishing features of vasomotor rhinitis include onset in women age 20-45, perennial symptoms, and lack of itchy eyes and nose. Allergic rhinitis usually has a strong seasonal component, is often associated with eye/nasal itching, and has onset before age 20. Regular use of inhaled nasal corticosteroids provides the most consistent relief for vasomotor rhinitis (similar to allergic rhinitis). In more severe cases, a combination of nasal corticosteroids and nasal antihistamine is needed for efficacy. Nasal saline irrigation is recommended prior to use of nasal preparations to cleanse the mucosa so that the steroids will be better absorbed. (Choice A) Intranasal ipratropium is useful when rhinorrhea is the only or predominant symptom and is provoked by smells or other environmental triggers such as cold. While no head-to-head trial results are available, nasal corticosteroids are recommended in guidelines as first-line agents due to better symptom relief. (Choice C) Oral and nasal decongestants should be used with caution in individuals with hypertension. Nasal decongestants should not be used for more than 3 days to avoid rhinitis medicamentosa. (Choice D) Intranasal corticosteroids and intranasal antihistamines are more efficacious than oral anti-histamines for vasomotor rhinitis. (Choice E) Leukotriene antagonists (eg, montelukast) have been shown to have efficacy similar to oral antihistamines in allergic rhinitis. Leukotriene antagonists play a role in allergic rhinitis with asthma but have not been shown to be of benefit in vasomotor rhinitis. Educational objective: Vasomotor rhinitis occurs commonly in women after age 20, with perennial symptoms and lack of atopic symptoms (eg, no nasal or eye itching). Intranasal corticosteroids are the preferred treatment. In severe cases, combined nasal corticosteroids and nasal antihistamines are effective in providing symptom relief. __________ References: Intranasal fluticasone propionate is effective for perennial nonallergic rhinitis with or without nasal eosinophilia. (http://www.ncbi.nlm.nih.gov/pubmed/11995670)

A 37-Year-Old Woman Comes to the Physician Complaining of Persistent