WBR1086

Author	PageAuthor::Chetan Lokhande
Exam Type	ExamType::USMLE Step 2 CK
Main Category
Sub Category	SubCategory::Endocrine
Prompt	[[Prompt::A 26-year-old male who works in a college library comes to you with a complaint of running nose. He says that this is not the first time he had this symptoms. He sometimes also presents with a cough, nasal congestion and sneezing. He claims that his jobs requires cleaning the library shelf which usually has a lost of dust on it. On enquiry he said that the physician last time prescribed him with a medication, which after a few days made his running nose worse. What could the physician have suggested to prevent this side effect?]]
Answer A	AnswerA::Drug free week
Answer A Explanation	AnswerAExp::Drug free week is not helpful for preventing rhinitis medicamentosa as it usually occurs on the 5-7 th day.
Answer B	AnswerB::Stop the medication
Answer B Explanation	AnswerBExp::Stopping the medication altogether is not indicated as it would not help the patient.
Answer C	AnswerC::Not use the drug for more than 5 consecutive days
Answer C Explanation	AnswerCExp::Rhinitis medicamentosa usually occurs on the 5th-7th day. Hence, stopping the drug on the 5 th day would not prevent this condition
Answer D	AnswerD::Not use the drug for more than 3 consecutive days
Answer D Explanation	AnswerDExp::This is the correct technique to prevent the most common side effect of topical decongestants. Ask the patient to stop the drug for a day or two and start again on the 5 th day.
Answer E	AnswerE::Switch over to oral forms
Answer E Explanation	AnswerEExp::There are no indications to start oral decongestants for allergic rhinitis.
Right Answer	RightAnswer::D
Explanation	[[Explanation::This is a clear case of 'Rhinitis medicamentosa'. The patient classically presents with a running nose, which first improves after using topical decongestants but worsens after few days due to rebound congestion. This is a very common side-effect of topical decongestants. The best way to prevent this is not using the drug for more than 3 days. Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g. oxymetazoline, phenylephrine, and xylometazoline nasal sprays) that work by constricting blood vessels in the lining of the nose. This condition typically occurs after 5 to 7 days of use of such medications. Patients often try increasing both the dose and the frequency of nasal sprays upon the onset of RM, worsening the condition. The swelling of the nasal passages caused by rebound congestion may eventually result in polyps that block nasal breathing until surgically removed. Topical nasal sprays act as an agonist to sympathetic α1 receptors in the blood vessels of the nose, signaling those vessels to contract. By decreasing blood flow to the lining of the nose, the tissue becomes less congested and mucous production is slowed. However, after several days use of these products these receptors become downregulated requiring more frequent and higher doses to prevent the rebound congestion that results when the medicine wears off. The treatment of RM involves withdrawal of the offending nasal spray. Both a "cold turkey" and a "weaning" approach can be used. Symptoms of congestion and runny nose can often be temporized by using prescription nasal steroid sprays 1 to 2 times daily for a few weeks. For very severe cases oral steroids may be necessary. Oral decongestant medications like pseudoephedrine can also help with the transition. Other commercially available products such as Rhinostat may help ease withdrawal from physiological tolerance to the nasal decongestant by providing an easy means to dilute the spray gradually. A study has shown that the anti-infective agent benzalkonium chloride, which is frequently added to topical nasal sprays, aggravates the condition by further increasing the rebound swelling. Common issues that lead to overuse of topical decongestants: 1.Deviated septum 2.Upper respiratory tract infection 3.Vasomotor rhinitis 4.Cocaine abuse 5.Pregnancy (these products are not considered safe for pregnancy, however) 6.Chronic rhinosinusitis 7.Hypertrophy of the Inferior Turbinates Educational Objective Rhinitis medicamentosa (or RM) is a condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g. oxymetazoline, phenylephrine, and xylometazoline nasal sprays) that work by constricting blood vessels in the lining of the nose. This condition typically occurs after 5 to 7 days of use of such medications. Prevention is by stopping the drug after 3 days. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Decongestants, WBRKeyword::Rhinitis medicamentosa, WBRKeyword::Rebound congestion
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