Patients should not use INCS / TAC if:
Intranasal corticosteroids
- First talk to your provider if:
- recent nasal ulcers / surgery / unhealed nasal injuries
- asthma meds
- prescription steroid medications
- currently have eye infection
- glaucoma or cataracts
Types of Allergens
-
Outdoor = Seasonal
- Tree pollen / Grass / Ragweed
- Pollen.com to check pollen counts
-
Indoor = Perennial = HARDEST TO AVOID AND MANAGE
- Dust mites / Animal Dander
- Mold / Cockroach droppings
-
Airborn
- Smoke / perfume / fues
Budesonide Nasal Spray
Rhinocort
-
LOWER VOLUME OF SPRAY
- vs fluticasone / TAC
- Scent / Alcohol free
- No Drug interactions! (like nasacort)
- Only indicated for Ages 6+
- still potential for slow growth rate
- see md if >2 mo use in a year
- Dose:
- 1-2 sprays en qd
- May take Up to 2 weeks for full symptom relief
Dextromethophan Dose
Dayquil / Robitussin / Delsym
10-20mg q 4 hr
or
30mg q6-8
Max = 120mg/day
Allergy Drugs with NO SEDATION
Loratadiine
Fexofenadine
Guaifenesin Dose
only FDA approved expectorant
>12 years old
200-400mg Q4
take with a full glass of water
used for non-productive congested cough
Aka ineffective productive cough
FDA Public Health Advisory for
OTC cold/cough medications
-
Should NOT be used to treat i_nfants & children <2 years old_
- mainly due to IMPROPER USAGE
-
For children 2-11 yrs old:
- understand that OTC drugs do NOT shorten duration of cold
- check drug facts, beware of overlap active ingredients
- Only use measuring spoons / cups
- do not use for sedation
Short Acting Topical Decongestants
4-6 hours
Phenylephrine
0.25-1% Neo-Synephrine
Levmetamfetamine
Vapor Inhalor
Propylhexedrine
Benzedrex inhaler
Intranasal Corticosteroids
INCS
Treatment for Allergic Rhinitis
Only for ALLERGIES
not for COLDS
even if symptoms are indicated, ONLY ALLERGIES
Triamcinalone (TAC) / Fluticasone Propionate
Budesonide / Fluticasone Furoate
Cold Symptoms
-
Limited to Upper Respiratory Tract
- 1-3 days after infection
- 1st symptom = Sore Throat
- Days 2-3 = Nasal symptoms
- Days 4-5 = Cough (only 20% of patients)
- Typically does not cause soreness or fever
Triamcinolone Nasal Counseling
- TAC use QD w/o missing a dose
- may take up to 1 week to provide full relief/benefit
- most will see improvement on FIRST DAY
- may take up to 1 week to provide full relief/benefit
- Pregnancy: talk to PCP before use
- Can be used in children 2+:
- but potential for slowed growth rate
- try not to use for >2 months in a year
When to see Doctor for SORE THROAT
- If you have been in contact with someone w/ STREP THROAT
-
Sudden Onset
- w/ fever and/or Swollen glands
- or a RASH
- w/ fever and/or Swollen glands
- Trouble Swallowing liquids
- Sore throat for >1 week
- FRONT OF NECK = sore / stiff
Which allergy medications are okay for children
2y/o and older?
ALL 2ndgen Antihistamines
Cromylyn Sodium
TAC
Fluticasone Furoate (sensimist
Fluticasone Propionate is 4+ y/o
Pregnancy & Nursing
for Cough Supressants
Diphenhydramine is generall PREFERRED
DM is not a teratogen, and is generally safe during pregnancy
DM products w/o ethanol are SAFE for nursing mothers
Sore Throat Treatment Options
-
Stay Hydrated / Warm Liquids = Tea/honey
- painful swallowing can lead to DEHYDRATION
- avoid citrus drinks
- painful swallowing can lead to DEHYDRATION
- Salt Water Gargling = 1-1.5ts of salt in 1 cup warm water
- salt water pulls liquid OUT of swollen membranes
-
Popsicles / Ice Chips
- cold has NUMBING EFFECT
-
Hard Candies
- reduce dryness / soothe pain
- Vaporizer / Humidifyer
- OTC PAIN MEDICATIONS for pain = Tylenol
Avoiding Allergens
Treatment for Allergic Rhinitis
- Highest pollen conditions occur on DRY & Windy days
- Pollen.com
-
Stay indoors:
- highest pollen count is between 5am - 10am
- Keep windows closed / change filters
Fluticasone FUROATE
flonase SENSIMIST
-
LOW VOLUME SPRAY
- vs fluticasone propionate / TAC
- Alcohol & Scent Free
- vs fluticasone propionate
- Approved for Ages 2+
- vs 4+ for fluticasone propionate
-
Same indicaitions & drug interactions as fluticasone propionate
- still indicate for watery EYES
- 1 week for full effect
Productive Cough
Wet Cough
Expels secretions from LOWER respiratory tract
Can Be Effective if secretions are EASILY EXPELLED
ineffective if secretions are DIFFICULT to expel
Cromylyn Sodium Dose
NasalCrom
Mast Cell Stabilizer, okay for 2+ & pregnancy & elderly
1 spray (5.2mg) EN 3TID/4-QID
USE BEFORE SYMPTOMS
max 6 times / day
takes up to 7days for effect
Pregnancy / Nursing Use
of Antihistamines
-
Nursing: AVOID
- excreted in breast milk
- can inhibit lactation
-
Pregnancy: AVOID
- unless CLEARLY NEEDED
- benefits > risks
- unless CLEARLY NEEDED
Age Considerations
for Antihistamines
-
Diphenhydramine = 1st gen OTC histamine
-
on BEER’s LIST
- Do not use in patients 65> age
- Risk of sedation & AC effects INCREASED
-
on BEER’s LIST
-
Most antihistamines have NO DOSING for <6yrs old
-
except for Loratadine / Fexofenadine / Cetirizine/levocet
- >2yrs old
-
except for Loratadine / Fexofenadine / Cetirizine/levocet
Topical Decongestants for Pregnancy or Children?
DNU IN PREGNANCY
reduced uterine blood flow
All okay, including menthol for 2+ y/o
saline can be used for <2y/o
Cetirizine Dose
5-10mg QD
Drowsiness warning
Side Effects of
Topical Decongestants
Phenylephrine Spray / Vapor Inhalor / Benzedrex
oxymetazoline
-
Rebound Effect –> Vicious Cycle
- overuse of the topical products
- only use SHORT TERM
- for COLDS not allergies
- only use SHORT TERM
- can cause nasal membranes to be MORE congestion
- overuse of the topical products
- To treat Rebound effect:
- D/C offending drug -> use oral Decongestants or saline
- Takes 1-2 weeks for nasal membranes to return to normal.
Diphenhydramine Dose
as a Cough Supressant
25mg Q4 hours
okay for children 6+, but FDA PH advisory 2-11 years
Acts centrallin in medulla to increase cough threshhold
Side effects:
Drowsiness / Blurred Vision
Dry Mouth
Urinary Retention
Difference between ALLERGY vs Cold/URI
-
Allergies:
- sometimes cough, less often than cold
-
NEVER ACHES / PAINS / FEVER
- sometimes fatigue / sore throat
-
ITCHY eyes
- eyes can be watery in both cold and allergy
- sneezing is more common
-
Duration of Symptoms very depending on TRIGGER
- days-months
Counseling for Dextromethorphan
-
DM:
-
Do not use if currently taking or 2 weeks after stopping
- MAO INHIBITOR
- or SSRIs
-
Do not use if currently taking or 2 weeks after stopping
-
Diphenhydramine products:
- may cause drowsiness / avoid alcohol
- Stop Use & see MD if:
- cough >7 days or returns or w/ fever/rash/headache
- cough w/ too much phlegm
- cough that is chronic, or occurs w/ smoking / asthma
Considerations for
Guaifenesin (expectorant)
No association w/ developmental toxicity
Pregnancy / Nursing SAFE
Drink w/ FULL GLASS OF WATER
- Ask doctor if:
- too much phlegm beforehand or chronic cough
-
cough > 7 days
- or comes back / fever / rash / headache
Exclusions for Self-Treatment
for Allergic Rhinitis
-
SYMPTOMS OF INFECTION
- otitis media = ear inflammation
- fever / wheezing / bronchitis / chest congestion
- Thick respiratory secretions, NOT CLEAR
- Symptoms of undiagnosed / uncontrolled ASTHMA:
- wheezing / SOB / COPD
-
Pregnant:
- common cause of nonallergic rhinitis
- Patients who DO NOT respond or symptoms worsen
- after taking OTC options
Topical Rub Products
Include Camphor / Menthol
VICKS VAPORUB
ONLY FOR EXTERNAL USE
Apply on Chest / Throat
may cover w/ loose dry cloth
allow vapors to hit nose / mouth
DO NOT APPLY TO IRRITATED SKIN
Nasal Strips
Breathe Right
Mechanically opens nasal passages
Choose the RIGHT SIZE
Lavendar scent available
Indicated for 5years and older
& PREGNANT WOMEN!
Phenyephrine
PE
Dose: 10mg q4 (adults)
- Half life is much shorter 2-3 hours*
- vs 6 hours for PSE*
- Poor stability & shorter shelf-life*
Questionable efficacy vs PSE
Exhibits large individual variability in Bioavailability
Beware of HIGH Fever or no improvement in symptoms
Triamcinolone Nasal
TAC
Nasacort Allergy
-
Corticosteroid for Allergic Rhinitis, relieves symptoms of:
- RUNNY NOSE + CONGESTION (due to allergies)
-
sneezing / nasal itching / stuffy nose
- no indication for EYES and UNSCENTED
-
1st Line therapy for Allergic Rhinitis
- MOST EFFECTIVE TREATMENT
- not indicated for patients with colds
- No risk of sedation and no _drug interactions_
- Takes about a week for results, use QD
- Approved for use in Children 2+
Saline Topical Products
Ocean
Restore Moisture
Relieve Dry/Inflamed Nasal Membranes
caused by:
Colds / low humidity
Nasal decongestant OVERUSE
Nose bleeds / allergies
Airborne
No Date to show efficacy
more to PREVENT not to treat/decrease symptoms
High doses of Vit C –> may lead to kidney stones
Sore Throat vs STREP Throat
- Most SORE throats are due to:
- Viruses / Bacteria / Allergies
- Smoking / Dry air / YELLING
- Breathing through mouth often
-
Strep Throat = Most common Bacterial infection of THROAT
- 5-10% of adult and 15-30% of children
- associated w/
- Fever / Swollen Glands / White patches
- Headache / Nausea / Chills
- Difficulty swollowing.
Anesthetic Agents for Sore throat
Cepacol
Chloraseptic
Sucrets
Chloraseptic SPRAY
Anesthetic Agents
for Sore Throat
Sore Throat Pain
Benzocaine / Phenol / Dyclonine
Look for higher concentrations of active ingredients
Dissolve SLOWLY in mouth
for spray: keep in place for >15 seconds then spit
if numbing, avoid eating/drinking esp HOT items
Cromolyn Sodium Spray
NasalCrom
Mast Cell Stabilizer
–> itching / sneezing / rhinorrhea
USE BEFORE ONSET OF SYMPTOMS
Can use for >2 yrs old & Pregnant & elderly
1 Spray EN TID/QID (max 6x/day)
takes up to 7 days for initial effect
4 weeks for MAX benifit
can cause sneezing / nasal stinging
Side Effects / Considerations
for Antihistamines
- Paradoxical Excitation
- Insomnia / Irritability
- Nervousness / Nightmares
-
Anticholinergic effects:
- Dry mouth / constipation
- Urinary retention / Blurry Vision
-
GI Effects:
- Anorexia / Diarrhea / Abdominal pain
- Avoid in narrow angle glaucoma / asthma
- Do not diphenhydramine w/ others (even TOPICAL)
Oral Decongestants
Only indication is Relief of Nasal Congestion
Pseudophedrine / Phenylephrine
- Adv:
- Longer duration of action vs topical agents
- NOT ASSOCIATED W/ REBOUND CONGESTION
-
Disadvantages:
- less intense vasoconstriction vs topical
- DELAYED ONSET
Pediatric considerations
for Topical Decongestants
Never Use for Children <2 years old
except for SALINE
mentholated products** should NOT be used in **<2 years old
Non-drug measures:
Humidity / fluids / Propping head up
Fluticasone Propionate Dose
Flonase
2 sprays (50mcg) EN QD
for 1 week then -> 1-2 sprays
Age 4+
Also treats ITCHY/WATERY EYES
has a floral scent, use less than <6 months
HIV infection / Ketoconazole / Asthma / Steroids
Budesonide Dose
Rhinocort
1-2 Sprays (32mcg) EN QD
Age 6+ only!
Low volume of spray
may take up to 2 weeks for full symptom relief
no drug interactions / scent free / alcohol free
Antihistamine Indications
- Rhinorrhea (runny nose) / Nasal Pruritus (scratchy nose)
- Sneezing
- Allergic Conjunctivitis / Lacrimation / Ocular Pruritis
-
Not indicated for:
-
Colds
- no good date to support indication for pts w/ cold
-
NASAL CONGESTION
- only decongestants are indicated for this
-
Colds
Long Acting Topical Decongestants
12 hours
Oxymetazoline
( Afrin / Sinex )
Topical Zinc Info
Proposed Anti-Viral Agent
may reduce severity / length of symptoms
Start within 24 hours of onset of symptoms
some positive results in studies
Infection Transmission
- Self-inoculation of nasal mucosa / conjuctiva
- touching bacteria then touching self on eyes / nose / mouth
- hand-to-hand contact
- High exposure = Density of classrooms or daycare
- Less common routes:
- aerosoled particles / kissing / contact w/ inanimate obj.
-
Does not increase susceptability to colds by ITSELF
-
cold weather / chills / walking barefoot
- only makes symptoms WORSE if already sick
-
cold weather / chills / walking barefoot
Fluticasone Furoate Dose
Flonase Sensimist
Same as Flonase, but 32mcg/spray
less volume of spray
and approved for Ages 2+
compared to 4+ for flonase
still indicated for itchy & watery eyes
Fluticasone Propionate DOSING
2 Sprays EN QD
for 1 week then -> 1-2 sprays en qd for symptoms
Ask Doctor if >6 months of daily use
May take 1 week to provide full benefit / relief
most people have improvement on FIRST DAY
Questions to ask regarding ailment
Symptoms / Duration / Fever?
Thick or Discolored discharge?
H/O Allergy / Asthma / Bronchitis / Smoker?
What medicines are you taking?
Has anything worked for these symptoms?
Are you pregnant/breastfeeding?
Are you participating in athletic events?
If child, how old and weight?
Fluticasone Propionate
Flonase / ClariSpray
- Compared to TAC/Budesonide, also approved for:
- Itchy / watery EYES due to allergy
-
No indication for PROPIONATE for children:
-
<4 years
- also potential for slowed growth rate
- talk to Dr if >2mo in a year of use
-
<4 years
- Has a light floral scent, some patients find offensive
Topical Antitussives
Camphor & Menthol
Lozenge or Ointment dosage forms
only FDA approved topical antitussives
little efficacy evidence
Side Effects
of Oral Decongestants
- Increased BP
-
Cardiac Stimulation
- typically only after prolonged use
-
May worsten symptoms of underlying diseases
- Hyperthyroidism
- CAD / Ischemid Heart disease
- Prostatic Hypertrophy
- Intraocular Pressure
Pseudophedrine Dose
Sudafed
60mg Q6
120mg Q12 for SR
not for pregnancy nor children <6y/o
okay for breast feeding
consider stocking PSE in cabinet so you can have on hand
Pseudoephedrine is still the same safe and effective product it always was; you will just find it in a different place
Loratadine
Claritin
Non-Sedating
2nd-gen-AH
Only non-drowsy 24 hour product indicated for:
Children 2 +
fexofenadine is non-drowsy BUT is BID dosing for kids
TAC Dosing
Nasacort
2 sprays (55mcg) EN QD
after symptoms controlled -> 1 spray EN QD
may take up to 1 week for relief, do not miss doses
Okay for 2+, watch out for slowed growth rate <2mo
only spray that treats CONGESTION
no sedation / no drug interactions / no scent
Differences between COMMON COLD vs Flu
-
Cold has:
- headache / pain / fatigue is mild or absent
-
Common: Rhinorrhea / Nasal congestion / sneezing
- both flu and cold have sore throat
- cough is less common and is usually non-productive
- Watery eyes
- 5-10 day duration
- complications:
- sinus congestion / earache
Pregnancy, cough medication
DPH vs DM?
DPH is preferred
DM is NOT considered a major teratogen
and is considered safe though.
Nursing / Pregnant Considerations
for Oral Decongestants
-
Nursing Mothers:
- only a little data, small amounts can –> breast milk and cause irritability
- AAP considers pseudophedrine safe during breast feeding
-
Pregnancy:
- risk in FIRST trimester
- *BANNED FOR USE IN ATHLETIC EVENTS*
Topical Decongestants Indications
Relief of Nasal Congestion
systemic absorption is typically minimal w/ TOPICAL dosage forms
Cetirizine
Zyrtec
Drowsiness Warning
~10% of patients SEDATED
2nd-gen-antihistamine
dosing for children 2+
Zinc Products & Dosage
Cold Eeze / Zicam
1 Lozenge Q2-4 hours while awake
(Max 6 lozenges per day)
HAS TO BE LOCAL = can not be taken orally
Start within 24 hrs of symptoms
long term admin can be hazardous
DO NOT USE IF PREGNANT
Side Effects of Guaifenesin
NAUSEA / Vomitting
Dizziness / Headache
Rash / Diarrhea
Sedation
USUALLY MINOR
Differences Between INFLUENZA vs Cold
-
Flu has:
- sudden onset fever > 102-104
- headache / myalgia / fatigue / weakness / exhaution
- non-productive / persistant cough
- eye-pain / burning
- 1 week duration
- complications of:
- bronchitis / pneumonia
- both flu and cold have sore throat
Triamcinolone Acetonide Nasal Dosing
TAC
Nasacort
Approved for use in Children 2+
For adults / age 12+
2 Sprays EN QD
once symptoms are controlled -> 1 Spray EN/day
Use continiuously for at least a weak
UNSCENTED
Fexofenadine Patient Counseling
Fruit Juices = Grapefruit / Orange / Apple
- Do not take with Aluminum / Magnesium Antiacids*
- may REDUCE Bioavailability*
Renal Dysfunction –> decrease dose
For Meltable Tablets:
Take on an EMPTY STOMACH
do not chew / remove from pkg before hand
Fexofenadine
Allegra
Non-Sedating
Once daily (180mg) 24 hour dose for adults
For children 2-11: 30mg BID
(has a meltable tablet dosage form)
also has special counseling points
What allergy medications are okay for PREGNANCY?
Cromylyn Sodium Nasal Spray
also okay for children 2+, need to use BEFORE symptoms
Diphenhydramine is also okay for pregnancy for COUGH
but PREGNANCY is technically contraindicated because ALLERGY is common with pregnancy
Prevention of Infections
-
HANDWASHING can decrease transmission
- virus can survive on hands for hours
-
Not all hand sanitizers are shown to eradicate RHINOVIRUS
-
prefer 60-80% ethanol / isopropanol
- chlorhexidine / povidone-iodine / 4-ammonium
- LYSOL kills >99% of rhinovirus after 1 MINUTE
- Anti-viral tissues are 10% more effective.
-
prefer 60-80% ethanol / isopropanol
Nonproductive Cough
Dry / Hacking Cough
No congestion / phlegm production
Occurs in <20% of patients with a COLD
Irrigation
Neti Pot / Saline Nose Sprays
- Can help with Allergy Symptoms
- Flushes out allergen / irritant (pollen
- Aids in removal of dried/encrusted mucus from nasal passages
- Tips for netipot:
- Use bottled/boiled/distilled water, no tap water
- Saline Packs or 1ts salt-> 16oz water
NON-Pharmacologic Options
for COLDS
- Fluid intake
- Rest
-
Nutrition:
- chicken soup ~anti-inflammatory
-
Increased HUMIDIFICATION of air
- steamy showers / humidifyers / vaporizers
- for YOUNG CHILDREN:
- Nasal aspiration / upright positioning
Guaifenesin
Mucinex / Robitussin
- Only FDA Approved Expectorant
-
Indicated for: Non-Productive Congested Cough
- ineffective productive cough
-
Indicated for: Non-Productive Congested Cough
- Efficacy:
- lack of evidence showing that these decrease sputum viscosity / ease expectoration
-
Important to have adequate Fluid Intake & Humidity
- for expectoration
Fluticasone Propionate DI / Considerations
flonase / clarispray
- If you are taking medication for:
-
HIV (ritonavir / teleprevir / tiprnavir)
- may INCREASE conc. of fluticasone
-
Ketoconazole
- also may INCREASE conc of flutic
- Asthma Medication
- Prescription Steroid Medicine
-
HIV (ritonavir / teleprevir / tiprnavir)
-
PREGNANCY
- talk to dr before use
Allergic Rhinitis
- Can develop at ANY AGE
- can SUDDENLY get allergies,
- allergy history does not matter much
-
Heredity plays a role
- 1 parent w/ allergies -> 48%
- 2 parents -> 70%
- can SUDDENLY get allergies,
- ASTHMA Present in 20% of patients
Exclusions for Self-Treatment
for COLDS
- Do not use if:
- Fever > 100.4 (oral)
-
Chest Pain / SOB
- or underlying pulmonary disease (COPD/asthma)
-
Worsening of symptoms
- during self-treatment
- AIDS / Chronic immunosuppresant therapy
- Elderly / infants <3 months of age
Diphenhydramine
Pregnancy / Contraindications
okay with pregnancy, preferred over DM
AVOID ALCOHOL!
on Beer’s list
DNU in pts 65+, due to AC / sedation
Fexofenadine Dose
60mg q12
180mg q24
Non-Sedating
but 30mg BID CHEW dosing for kids 2-11
avoid fruit juice / kidney fxn
Al / Mg antacids
Allergic Rhinitis TREATMENT
- Avoid Allergens!
- Immunotherapy
- Pharmacotherapy:
- Nasal Steroids
- Antihistamines (2nd gen preferred)
- Mast Cell Stabilizers
- Decongestants
Age for Self-Treatment to be Excluded
for COUGH
children <4 y/o
Pregnancy / Nursing
for Topical Decongestants
Pregnancy - Potential for
Reducing Uterine Blood flow
Briggs - No human data for breat feeding
can be compatable
Counseling for Topical Decongestants
Phenylephrine Spray / Vapor Inhalor / Benzedrex
oxymetazoline
Notify MD if: Insomnia / Tremor
Weakness / Irregular Heart beat
Do NOT exceed recommended dosage or duration
<3 days
Stinging / Burning / Drying
of NASAL MUCOSA may occur
Loratadine Dose
10mg Qd
non drowsy
good for 2+
Levocetirizine
Xyzal
Taken in the EVENING
Drowsiness warning
dosing for children 2+
2nd-gen-antihistamine
- Not recommended for >65 yrs old*
- or kidney disease*
Issues with Robitussin DM
Has both DM & Guaifenesin
Guaifenesin = INCREASES secretions of Lower respiratory
DM = decreases the cough threshhold
together may cause retention of secretions
can lead to INFECTION / AIRWAY OBSTRUCTION
Antitussives
for COUGH
- Supress cough reflex by acting on cough center @ medulla
- Indicated to decrease frequency of cough:
- for Dry / Non-productive cough
- Examples of FDA approvedd ingredients:
- Dextromethorphan
- Diphenhydramine
- Codeine
- Chlophendianol
Primatine Mist / Tablets
- Tablets = Ephedrine
- Mist = Epinephrine (not available)
-
NOT RECOMMENDED IN ANY PATIENT
- for temporary relief of SOB due to asthma
-
RX Bronchodialators are MORE EFFECTIVE
- asthma patients are not good candidates for self-care
Levocetirizine Dosing
Xyzal
5mg QD
TAKEN IN THE EVENING
drowsiness warning
not recommended in >65 y/o
or kidney disease
Exclusions to Self-Treamtment
of COUGH
- Cough w/ thick yellow or green sputum/phlegm
- likely the cold can be treated (T_REAT UNDERLYING DISORDER TO STOP THE COUGH FIRST!)_
- CHILDREN < 4 y/o
- __Cough w/:
- Chest Pain / SOB / tight-feeling throat
- Swollen Legs/ankles
- Rash / hemoptysis
- Fever / Night Sweats
- Chronic Cough > 7 days, or if worsens w/ treatment
- H/O COPD / Asthma / Bronchitis / CHF
- Suspected drug-associated cough
TAC IS ALSO APPROVED FOR CONGESTION
TAC IS ALSO APPROVED FOR CONGESTION