Patient Name
DOB
Phone number
Pharmacy Phone number
Physician Name
Address
Phone number
Rhinitis
Medication Action Plan
[Sample 10/08]
[Not scientifically studied]
Signature MD/Physician Extender
Date completed: ___________
These are Your Rhinitis and Allergic Conjunctivitis Medications
Antihistamines
 Allegra (fexofenadine)  D ____mg tab  Syrup
 Claritin (loratadine)
 D____ mg tab  Syrup
 Clarinex (desloratadine)  D ___ mg tab  Syrup
 Xyzal (levocetirizinzz)  D____mg tab  Syrup
 Zyrtec (cetirizine)
 D ____ mg tab
 Benadryl (diphenhydramine)  D __ mg tab Syrup

_________________
 D ___ mg tab  Syrup
Nasal Antihistamines
 Astelin (azelastine)
___ sp./nostril
 Patanase (olopatidine)
___ sp./nostril
Other Meds/Treatments
 Orapred (prednisolone)  ___ mg ODT  Syrup (15mg/5 ml)
 Pediapred (prednisolone)
 Syrup (5mg/5 ml)
 Prednisone
 _____mg tab
 Medrol (methylprednisolone)
 _____mg tab
 Allergy injections  Prescribed  Not prescribed at this time
 Implement environmental control for ______________________
Nasal Corticosteroids
 Flonase (fluticasone propionate)
 Nasacort AQ (triamcinolone
acetonide)
 Nasonex (mometasone)
 Rhinocort (budesonide)
 Veramyst (fluticasone furoate)
 Omnaris (ciclesonide)
Leukotriene Modifiers
 Singulair_mg tab  Granules
Mast Cell Inhibitors
 NasalCrom (cromolyn)
Anticholinergics
 Atrovent Nasal (ipratropium)
 0.03% 0.06%
 Nasal saline/moisturizer
_____________________
Rhinitis Steps


Oral Decongestants
Pseudoephedrine (Sudafed PSE)
Phenylephrine (Sudafed PE)
 ____ mg tab  Syrup
Nasal Decongestants



Oxymetazoline (Afrin, Equate, …)
Phenylephrine
Use________ before nasal spray
Eye Drops
 Alamast (pemirolast)
 Alocril (nedocromil)
 Crolom (cromolyn)
 Elestat (epinastine)
 Emadine (emedastine)
 Optivar (azelastine)
 Pataday  Patanol (olopatadine)
 ________________________
What to do

____________________
to be started as directed below _____ hours or ____ days before exposure
Step 1: Infrequent symptoms
Symptoms are not daily & there is no
interference with activity most days
•Medications needed only occasionally






Step 2: Mild but frequent symptoms
before Tx
Mild nasal symptoms on a regular basis &
mild interference with activities
•Take noted medication daily





Decongestant  Nasal  Oral
Antihistamine  Oral  Nasal
Eye Drops
NasalCrom  Atrovent
Nasal Corticosteroid
___________________
Nasal Corticosteroid
Oral antihistamine  D
Nasal antihistamine
Singulair
NasalCrom  Atrovent

___________________
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
_____ times a day as needed
_____ times a day as needed
_____ times a day as needed
_____ times a day as needed
_____ times a day regularly
_____ times a day as needed
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 AM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
 PM
Step 3: Moderate symptoms before Tx
OR not controlled with Step 2 meds
Moderate nasal symptoms on a regular basis
& moderate interference with activities
• Take noted medications (e.g., nasal
corticosteroids if not used in Step 2, or
take 2 medications)
Step 4: Moderate to Severe symptoms
before Tx OR not controlled with Step
3 meds
Daily symptoms & severe interference
with activities
• Take noted 2-3 medications and/or change
of 1 or more medications)
Step 5: Severe & not controlled with
Step 4 meds.
Cannot function in usual activities





Nasal Corticosteroid
Oral antihistamine  D
Nasal antihistamine
Singulair
NasalCrom  Atrovent

___________________
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
 AM
 AM
 AM
 AM
 AM
 AM
 PM
 PM
 PM
 PM
 PM
 PM





Nasal Corticosteroid
Oral antihistamine  D
Nasal antihistamine
Singulair
NasalCrom  Atrovent

___________________
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
______ dose(s)
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
_____ times a day regularly
 AM
 AM
 AM
 AM
 AM
 AM
 PM
 PM
 PM
 PM
 PM
 PM



Oral Steroid
______ dose(s)
Call health care provider to discuss symptoms
____________________________________
Step 0: Episodic Symptoms , e.g. to
prevent onset of symptoms
_____ times a day regularly for 3-5 days
 To schedule office visit
What to do for Increased Nasal Symptoms
It is your allergy season OR you are exposed to your triggers: First, take your usual medications and then follow Action A, B, C below




Mild Episode : Action A
Incomplete response to usual medication(s)
Increased nasal or eye symptoms
Move up one Step (to Step 2-4)
Call physician if you reach Step 5



Controlled
No interference with activities
< 2 days per week of nasal or eye symptoms



Moderate Episode: Action B
Incomplete response to Action A added
medications after 24 hours
Move up one more Step (to Step 2-4)
Call physician if you reach Step 5



Severe Episode: Action C
Incomplete response to Action B added
medications after 24 hours
Move up one more Step (to Step 2-4)
Call physician if you reach Step 5
Long-Term Management of Nasal Symptoms



Fair Control
Mild interference with activities
2 – 6 days per week nasal or eye symptoms



Not controlled
Moderate to severe interference with activities
Daily mod to severe nasal or eye symptoms
Adapted from: Wallace, D.V., et al., Rhinitis Action Plan, revised. J Allergy Clin Immunol, 2008. 122(6): p. 1237


Stay at the same step or move down if directed
Adapted from: Wallace, D.V., et al., Rhinitis Action Plan, revised. J Allergy Clin Immunol, 2008. 122(6): p. 1237