51 years old female has perennial allergic rhinitis and takes 5 mg Cetirizine PO once daily (Due to NAFLD..as shown in the screenshot), and her symptoms are well controlled with this dosage regimen. But, when she takes a bath, this triggers episodes of shortness of breath. So my question how she can manage theses shortness of breath episodes knowing that she won't be able to exceed 5 mg daily of Cetirizine as mentioned by drug monograph (Hepatic impairment takes 5 mg only per day), and also she didn't tolerate intranasal glucocorticoid like fluticasone because she suffered shortness of breath as a side effect of Fluticasone.
Medical History:
Atrial Fibrillation : Takes bisoprolol 2.5 mg once per day
Hemorrhoids : Takes Daflon 500 mg once per day
Cutaneous vasculitis.
Non-alcoholic fatty liver disease.
she needs to undergo spirometry to see airflow reversibility and treat accordingly
alternatively mast cell stqbiliser may help
Dear Mostafa!
The therapy is a one thing. I agree with Shan. But: does the shortness of breath the Fluticasone or the preservative of the nasal spray? And what is in the bath or in the bathroom? Allergens, parfums, or mycetes (Aspergillus, Alternaria, etc)?- she has perennial rhinitis. She needs a rescue inhaler(SABA) and vs ICS.
Dr.Paula, How can I know whether it is the preservative or the active ingredient that is causing the shortness of breath ? Also, based on what evidence, she would use rescue inhaler ? Because I couldn't find this in the guidelines.
Dear Mostafa! You wrote that the patient has sometimes dyspnoe.
I think this patient has asthma bronchiale, too. I recommend spirometry pre and postbroncodilatator (with SABA), find out that in enviroment exist moulds (Aspergillus?) and try other nasal steroid with other preservative for example beclomethasone on rhinitis allergica.
Dear Mustafa,
I agree with both opinions mentioned here by Dr Paula Herke and Dr Krishnan.
I think this patient needs an extensive allergic asthma screening with spirometry pre and post bronchodilators. Is the shortness of breath only on taking baths?! What does she use in the bath?! Check that and check for moulds?! Have you identified what is causing / aggrevating her perennial allergy frome previous work up?.
She needs a SABA first and if there's no response you can add a steriod inhaler in other types than fluticasone e.g. beclomethasone or Budesonide and a LABA (e.g. Symbicort) or an intra nasal spray such as Rhinocort.
Identifying whether or not she's asthmatic pending a spirometry result is key, and most importantly identifying what is causing these episodes in the bath only is mandatory.
I think her shortness of breath is not related to any type of allergic disorders and is mainly related to a type of phobia for example claustrophobia and she need thorough psuchologic evaluation and support and even some mild sedative as needed. It is certainely indicated to have a cardiac assessment and spirometric evaluation before any psychosomatic consideration.
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