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Pharmacology for advance practice nursing 712 > Week 4- HEENT > Flashcards

Week 4- HEENT Flashcards

1
Q

Describe the eye overview

  • Anterior section
  • Posterior section
  • Ciliary body
A
  1. The eye is separated into two segments by the lens (anterior and posterior sections)
    1. Anterior section (comprised of anterior and posterior chambers) filled with aqueous humor (AH)
    2. Posterior section filled with vitreous humor
  2. Ciliary body: ring-like structure that surrounds and supports lens
    1. Secretes AH
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2
Q

Eye Overview

  • What does the aqueous humor provide?
  • Where does aqueous humor drain/exit?
A
  1. AH provides oxygen and nutrients
    1. 80% drains through trabecular meshwork in the anterior chamber
    2. 20% exits anterior chamber through iris root and spaces in ciliary muscle – uveoscleral outflow
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3
Q

Describe glaucoma.

A
  1. Glaucoma
    1. Progressive optic neuropathy cause by elevated intraocular pressure (IOP) > 21 mmHg leading to optic nerve damage
      1. Normal IOP 10-21 mm Hg
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4
Q

Differentiate between the two different types of glaucoma.

  • Open-angle
  • Angle-closure
A
  1. Open-angle glaucoma
    1. Silent disease
    2. Obstruction in aqueous humor outflow by obstruction of the trabecular meshwork
    3. Peripheral vision loss
  2. Angle-closure glaucoma
    1. Medical emergency
    2. Obstruction of anterior chamber angle resulting in intermittent or acutely elevate IOP with optic nerve damage
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5
Q

What are the treatment goals of glaucoma?

A
  1. Prevent further loss of vision
  2. Minimize adverse effects of therapy and impact on vision, general health, and quality of life
  3. Maintain IOP at or below a pressure which further optic nerve damage could occur
    1. Goal at least 25% lower than the patient’s baseline IOP
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6
Q

What is the role of the PCP in glaucoma management?

A
  1. Role of primary care provider:
    1. Refer to ophthalmologist for suspicion of glaucoma
    2. Be aware of medications that are prescribed, drug interactions, and adverse effects from these medications
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7
Q

Discuss the 4 differenet non-pharmacological treatment options for glaucoma.

A
  1. Laser trabeculoplasty
    1. Laser energy aimed at trabecular meshwork
  2. Trabeculectomy
    1. Surgical removal of a portion of the trabecular meshwork
  3. Cyclodestructive surgery
    1. Trans-scleral laser reduces rate of aqueous humor production
  4. Aqueous shunts
    1. Drainage device that redirects the outflow of aqueous humor through a small tube into an outlet chamber placed underneath the conjunctiva
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8
Q

Glaucoma: Prostaglandin analogs

-Mechanism of action

A
  1. Mechanism of action (MOA): reduce IOP by binding to the FP receptor (subtype of prostaglandin receptor) to increase the outflow of aqueous humor through uveoscleral outflow
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9
Q

Glaucoma: Prostaglandin analogs

-Agents

A
  1. Latanoprost (Xaltan®) 0.005% solution
  2. Bimatoprost (Lumigan®) 0.01% and 0.03% solution
  3. Travoprost (Travatan Z®) 0.004% solution
  4. Tafluprost (Zioptan®) 0.0015% solution
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10
Q

Glaucoma: Prostaglandin analogs

-Adverse effects

A
  1. Adverse effects:
    1. Ocular hyperemia (eye redness)
    2. Increased number and length of eyelashes
    3. Changes in eye color (may be permanent)
    4. Rare: uveitis or cystoid macular edema
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11
Q

Glaucoma: Prostaglandin analogs

-Warning/Precautions

A
  1. Permanent pigmentation of the iris and/or eyelids, and increase number/length of eyelashes
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12
Q

Glaucoma: Alpha-adrenergic

-Agents

A
  1. Agents:
    1. Brimonidine (Alphagan P® ) 0.15% 0.15%, 0.2% solution
    2. Brimonidine (Lumify®[OTC]) 0.025% solution
    3. Apraclonidine (Iopidine®) 0.5%, 1% solution
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13
Q

Glaucoma: Alpha-adrenergic

-MOA

A
  1. MOA: decrease intraocular pressure by reducing aqueous humor production and increasing uveoscleral outflow
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14
Q

Glaucoma: Alpha-adrenergic

-Adverse effects

A
  1. Adverse effects:
    1. Sensation of foreign body in eye
    2. Ocular pain
    3. Drowsiness
    4. Dry eyes
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15
Q

Glaucoma: Alpha-adrenergic

-Contraindications/Warnings & Precautions

A
  1. Contraindications:
    1. Concomitant MAO inhibitor therapy
  2. Warnings/Precautions:
    1. <6 years old (risk of respiratory depression)
    2. Caution in patients with CVD, depression, orthostatic hypotension
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16
Q

Glaucoma: Beta Blockers

-Agents

A
  1. Timolol (Timoptic®, Betimol®) 0.25%, 0.5% solution
  2. Betaxolol (Betoptic-S®)0.5% solution (generic) 0.25% suspension (brand)
  3. Levobunol (Betagan®) 0.25%, 0.5% solution
  4. Metipranolol (OptiPranolol®) 0.3% solution
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17
Q

Glaucoma: Beta Blockers

-MOA

A
  1. MOA: interfering with the production of aqueous humor induced by cyclic adenosine monophosphate (cAMP)
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18
Q

Glaucoma: Beta Blockers

-Adverse effects

A
  1. Adverse effects:
    1. Local: eye irritation/stinging
    2. Systemic: headaches, dizziness, bradycardia, masking hypoglycemic
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19
Q

Glaucoma: Beta Blockers

  • Contraindications
  • Warnings/Precautions
A
  • Contraindications:
    • Bronchial asthma, severe COPD
    • Sinus bradycardia, 2nd or 3rd degree AV block, heart failure, cardiogenic shock
  • Warnings/Precautions:
    • Caution in patients with cardiovascular disease, diabetes, heart failure, myasthenia gravis, respiratory diseases, and thyroid disease
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20
Q

Glaucoma: Carbonic anhydrase inhibitors

-Agents

A
  1. Agents:
    1. Brinzolamide (Azopt®) 1% suspension
    2. Dorzolamide (Trusopt®) 2% solution
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21
Q

Glaucoma: Carbonic anhydrase inhibitors

-MOA

A
  • MOA: slows the formation of bicarbonate ions, which reduces sodium and fluid transport and leads to decreased production of aqueous humor
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22
Q

Glaucoma: Carbonic anhydrase inhibitors

-Adverse Effects

A
  • Adverse effects:
    • Dysgeusia (bitter taste) ~25%
    • Eye discomfort/burning sensation
    • Blurred vision
    • Eyelid irritation/eye redness
    • Photophobia/headache
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23
Q

Glaucoma: Carbonic anhydrase inhibitors

-Warnings/Precautions

A
  • Warnings/Precautions:
    • Sulfonamide – caution with sulfa allergies, but most patients can tolerate
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24
Q

Glaucoma: Miotics, cholinesterase inhibitors

-Agents

A
  1. Carbachol (Carboptioc®) 1.5%, 3% solution
  2. Pilocarpine (Isopto Carpine®, Diocarpine®) 0.25-10% solution
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25
Q

Glaucoma: Miotics, cholinesterase inhibitors

-MOA

A
  1. Mechanism of action (MOA): stimulates cholinergic receptors in the eye causing decreased resistance to aqueous humor outflow leading to a decrease in intraocular pressure
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26
Q

Glaucoma: Miotics, cholinesterase inhibitors

-Adverse Effects

A
  1. Adverse effects:
    1. Hyperemia
    2. Myopia (pupil constriction)
    3. Eye discomfort/burning sensation
    4. Blurred vision
    5. Eyelid irritation/eye redness
    6. Photophobia/headache
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27
Q

Glaucoma: Miotics, cholinesterase inhibitors

-Contraindications

A
  1. Contraindications:
    1. Active inflammation of the eye
    2. Iritis, uveitis, secondary glaucoma
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28
Q

Glaucoma: Rho Kinase inhibitors

-Agents

A
  1. Agents:
    1. Netarsudil (Rhopressa®) 0.02% solution
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29
Q

Glaucoma: Rho Kinase inhibitors

-MOA

A
  1. Mechanism of action (MOA): decreases resistance in the trabecular network to increase aqueous humor outflow
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30
Q

Glaucoma: Rho Kinase inhibitors

-Adverse Effects

A
  1. Adverse effects:
    1. Conjunctival hyperemia
    2. Corneal verticillata (corneal deposits froming a golden brown or gray whorl patter in the inferior cornea; most resolved when treatment was discontinued)
    3. Eye pain, corneal staining, blurred vision, increased lacrimation, eyelid erythema, reduced visual acuity
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31
Q

What is the typical/first-line therapy for glaucoma? What is an alternative therapy if drugs are not effective?

-

A
  1. Typical treatment
    1. First-line therapy: topical drugs that lower intraocular pressure (IOP)
      1. Prostaglandin analog monotherapy is preferred for initial treatment
      2. A topical beta blocker, carbonic anhydrase inhibitor, selective alpha2-agonist, or netarsudil could be added or substituted if IOP fails to reach the target range (8-22 mm Hg).
    2. Alternatives: laser trabeculoplasty and surgery
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32
Q

Define Conjunctivitis

A

Inflammation of conjunctiva

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33
Q

Types of Conjunctivitis

  • Non-infections
  • Infections
A
  1. Noninfections:
    1. Allergic
    2. Mechanical/irritative/toxic
    3. Immune-mediated
    4. Neoplastic
  2. Infections:
    1. Viral
    2. Bacterial
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34
Q

Allergic Conjunctivitis

  • Description
  • Causes
  • Treatment
  • Goal of treatment
A
  • Bilateral red eyes and itching
  • Environmental allergens (pollen, animal dander)
  • remove and avoid allergen; FIRST LINE: artificial tears, topical antihistamines, systemic antihistamines
  • Provide symptomatic relief
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35
Q

Allergic Conjunctivitis

  • Description
  • Causes
  • Treatment
  • Goal of treatment
A
  • “Pink eye”, unilateral or bilateral, red eyes, itchy, watery discharge
  • Adenovirus, most common pathogen
  • Cold compress, proper hygiene, artificial tears
  • Usual self-limiting and resolves within 2 weeks
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36
Q

Bacterial Conjunctivitis

  • Description
  • Causes
  • Treatment
  • Goal of treatment
A
  • Unilateral or bilateral purulent discharge
  • S. pneumonia, H. influenza, S. aureus
  • ophthalmic antibiotics
  • Mild form: usual self-limiting in adults
  • Severe form: may persist without treatment
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37
Q

What is the Allergic Conjunctivitis first line therapy?

A

Topical (ophthalmic) options

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38
Q

OTC options for Allergic Conjunctivitis- Artifical tears (ocular lubricants)

  • MOA
  • Usual dosing
A
  1. Available as gel, solution, ointment
  2. Usual directions:
    1. Apply 1-2 drops into eyes as needed (gel, solution)
    2. Apply ~1/4 inch into inside of eyelid 1-2 times daily as needed (ointment)
  3. MOA: offer a tear-like lubrication for relief of dry eyes and eye irritation
    1. Multiple different types (e.g. dextran, hydroxypropyl methylcellulose, mineral oil, sodium chloride, etc.)
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39
Q

OTC options for Allergic Conjunctivitis- Ophthalmic vasoconstrictors

  • Agents
  • Directions
  • MOA
  • Adverse effects/warnings
A
  1. Example products (OTC):
    1. Naphazoline (e.g. Clear Eyes®)
    2. Oxymetazoline (e.g. OcuClear®)
    3. Tetrahydrozoline (e.g. Visine®)
  2. Usual dosing: 1-2 drops in each eye four times a day
  3. MOA: cause vasoconstriction in conjunctival blood vessels leading to decreased conjunctival edema
    1. Used to relieve eye redness
  4. Adverse effects: temporary blurring of vision, mydriasis (dilation of pupil), transient stinging/burning
  5. Warnings/precautions: If symptoms worsen or persist for more than 72 hours, patient should be seen by an ophthalmologist
    1. Rebound congestion or redness can develop with frequent or extended use of ophthalmic vasoconstrictors
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40
Q

Options for Allergic Conjunctivitis- Antihistamines

  • OTC Products
  • Prescription Products
  • MOA
  • Adverse Effects
A
  1. Example products (OTC):
    1. Antazoline/naphazoline (e.g. Vasocon-A®)
    2. Ketotifen (e.g. Alaway®), Zaditor®)
    3. Pheniramine/naphazoline (e.g. Naphazoline Plus®, Opcon-A®)
  2. Example prescription products:
    1. Olopatadine (Pataday®, Patanol®, Pazeo®)
    2. Azelastine (Optivar®)
  3. Mechanism of action: block H1 histamine receptors to inhibit release of histamine from mast cells, leading to decreased ocular pruritus
  4. Adverse effects:
    1. Headache
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41
Q

Prescription options for Allergic Conjunctivitis-Mast Cell Stabilizers

  • Agents
  • MOA
  • Adverse Effects/Warnings
A
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42
Q

Prescription options for Allergic Conjunctivitis- NSAIDs

  • Agents
  • MOA
  • Adverse Effects/Warnings
A
  1. Example products (prescription only):
    1. Diclofenac (Voltaren®)
    2. Flurbiprofen(Ocufen®)
    3. Ketorolac(Acular®)
  2. Mechanism of action: block the action of cyclooxygenase (COX) and inhibit the conversion of arachidonic acid to prostaglandins which reduces pain/inflammation
  3. Adverse effects:
    1. Minor ocular irritation
  4. Warnings/precautions:
    1. Caution in patients with aspirin/NSAID sensitivity
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43
Q

Prescription options for Allergic Conjunctivitis- Corticosteroids

  • Agents
  • MOA
  • Adverse Effects/Warnings
A
  1. Example products (prescription only):
    1. Loteprednol (Lotemax®)
    2. Prednisolone (Pred Mild®)
    3. Fluorometholone (FML Forte®)
  2. Mechanism of action: suppress the late-phase reaction of allergic inflammation
  3. Adverse effects:
    1. Potential severe: glaucoma; cataracts
    2. Systemic side effects may develop with extensive use
  4. Warnings/precautions:
    1. NOT recommended for typical management of acute conjunctivitis due to adverse effects and risk of sight-threatening complications (e.g. corneal scarring, melting, and perforation)
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44
Q

Viral Conjunctivitis Treatment

A
  1. Majority of cases of acute, infections conjunctivitis are viral and self-limited
  2. Do NOT require antimicrobial treatment
  3. Medications used to mitigate symptoms:
    1. Artificial tears
    2. Topical antihistamines
    3. Topical steroids
    4. Oral analgesics
    5. Cold compresses
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45
Q

Bacterial Conjunctivitis

-Common pathogens for infants, children, and older adults

A
  1. Common pathogens:
    1. Infants <1 month (ophthalmia neonatorum): chlamydia most common, gonococcal most serious
    2. Children 3 months through 8 years: staphylococcal, strepto­coccal, or Haemophilus conjunctivitis.
    3. Older adults: Staphylococcus aureus and Pseudomonas aeruginosa
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46
Q

Treatment for infants bacterial conjunctivitis

  • Gonococcal
  • Chlamydial
A

Gonococcal conjunctivitis: requires intramuscular ceftriaxone

Prevention: erythromycin ointment within 1 hour of birth

Chlamydial conjunctivitis: requires treatment with systemic erythromycin

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47
Q

Treatment for mild bacterial conjunctivitis

A
  1. Mild bacterial conjunctivitis is usually self-limiting, but topical antibiotic therapy may speed clinical improvement (especially if given before day 6)
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48
Q

Typical first line options for bacterial conjunctivitis

A
  1. Typical first line options:
    1. Polymyxin B/trimethoprim solution 1 drop every 6 hours x 5-7 days
    2. Erythromycin ointment 1 cm ribbon up to 6 times daily
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49
Q

Second line treatment options for bacterial conjunctivitis

A
  1. 2nd line:
    1. Polymyxin B with bacitracin ointment
    2. Azithromycin solution
    3. Tobramycin or gentamycin solution
    4. Ciprofloxacin, moxifloxacin, levofloxacin solution
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50
Q

What should be obtained if gonococcal infection is a possibility in sexually active individuals?

A
  1. Obtain culture for Gram staining if gonococcal infection is a possibility in sexually active individuals
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51
Q

Ophthalmic anti-infectives

-General adverse effects

A
  1. General adverse effects:
    1. Local irritation
    2. Superinfection with prolonged use
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52
Q

Ophthalmic anti-infectives

-General precautions

A
  1. Hypersensitivity to any component of the preparation
    1. Chance for cross-sensitivity between individual agents of same class
  2. May retard corneal healing after ocular trauma or ocular surgery
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53
Q

Dry eye treatment goals

A
  1. Goals: relief of symptoms, maintain or improve visual acuity, prevent long-term adverse effects from dry eye
54
Q

Dry eye treatment- nonpharmacological

A

Nonpharmacologic: warm compresses, humidifier, remove medications that cause dry

55
Q

Dry eye treatment- Pharmacologic

A
  1. 1st line: artificial tears
  2. Cyclosporine (Restasis®) 0.05% solution 1 drop twice daily
    1. Adverse effects: burning sensation in eye
  3. Lifitegrast (Xiidra®)5% solution 1 drop twice daily
    1. Adverse effects: eye irritation/discomfort, bad taste
56
Q

Ophthalmic Preparation Administration

-General Patient Reminders

A
  1. Remove contacts before using eye medicines and do not reinsert for 15 minutes
  2. Do not touch the tip of eye dropper or ointment tube on the eye or any other surface.
  3. Suspension eye drops need to be shaken before use.
  4. Vision may be blurry in the moments following use of eye medicines.
  5. If multiple medications are indicated, wait at least 5 minutes between drops.
  6. Order of administration if using multiple formulations:
      1. eye drop solution
      1. eye drop suspension
      1. eye ointment
57
Q

What is the order for eye drop administration if using multiple formulas?

A
  1. Eye drop solution
  2. Eye drop Suspension
  3. Eye drop ointment
58
Q

What is the best eye drop formula for children?

A

Ointment preferred in children (easier to administer, stays on the lid better)

59
Q

General Eye Drop Patient Instructions

A
  1. Wash hands thoroughly with soap and water.
  2. Check the solution for color, particles and the dropper tip to make sure that it is not chipped or cracked. Avoid touching the dropper tip against the eye or anything else.
  3. Tilt head back
  4. With both eyes open, gently pull down the lower lid of eye to form a “pocket”
  5. Gently squeeze the dropper so that the drop falls into the pocket of the lower eyelid.
  6. May brace hand holding the dropper against face if needed
  7. Close eye. Do not rub. Try not to blink
  8. May place one finger at the corner of the eye near the nose and apply gentle pressure for up to 1 minute to prevent the medication from draining out of the eye.
  9. Replace and tighten the cap right away. Do not wipe or rinse the dropper tip.
60
Q

General Eye Ointment Patient Instructions.

A
  1. Wash hands thoroughly with soap and water.
  2. Hold the tube in hand for 1-2 minutes to warm it
  3. With first use of a new tube, squeeze out and discard the first 0.25 in. of medication.
  4. Holding the tube between thumb and forefinger, place it as near to eyelid as possible without touching it.
    1. Brace the remaining fingers of that hand against your face if necessary
  5. With your index finger, pull the lower eyelid down to form a pocket and squeeze a thin ribbon of ointment (~0.25-0.5 in.) into the pocket.
  6. Blink eye gently; then close eye for 1 to 2 minutes to rotate and distribute. Do not rub.
  7. With a tissue, wipe any excess ointment or gel from the eyelids and lashes. With another clean tissue, wipe the tip of the tube clean.
  8. Replace and tighten the cap right away.
  9. Wash hands to remove any medication.
61
Q

Describe otitis media.

A
  1. Inflammation of the middle ear
    1. Acute otitis media (AOM) – rapid, symptomatic infection with effusion (fluid) in the middle ear
    2. Otitis media with effusion (OME) – NOT an acute illness, but is characterized by middle ear effusion (NO inflammation of middle ear).
      1. Develops from a mechanical/obstructive phenomenon
62
Q

What are the common pathogens for otitis media?

A
  1. Common pathogens:
    1. Streptococcus pneumoniae
    2. Haemophilus influenzae
    3. Moraxella catarrhalis
63
Q

What are the risk factors for otitis media?

A
  1. Risk factors
    1. Allergies
    2. Anatomic defects (e.g. cleft palate)
    3. Daycare attendance
    4. Siblings
    5. Tobacco smoke exposure
64
Q

What are the symptoms of otitis media?

A
  1. Symptoms:
    1. Ear pain (often unilateral)
    2. Hearing loss
    3. Fever
    4. Tinnitus
65
Q

What are the treatment goals of otitis media?

A
  1. Treatment Goals:
    1. alleviate ear pain and fever, eradicate infection, prevent complications, and avoid unnecessary antibiotic use
66
Q

Non-pharmacologic therapy for otitis media

A
  1. Majority of uncomplicated infections resolve spontaneously
  2. Nonpharmacologic therapy:
    1. Watch and wait in patients with non-severe illness for 48-72 hours after diagnosis to see if self-resolves.
    2. Heat to affected ear for comfort
67
Q

Symptomatic treatment plan for otitis media.

A
  1. Antipyretics
    1. Acetaminophen – usual dosing 325-650 mg by mouth every 4-6 hours as needed (Maximum 4,000 mg/day)
      1. Children: 10-15 mg/kg every 4-6 hours as needed
    2. Ibuprofen 200-400 mg by mouth every 4-6 hours as needed
      1. Children 5-10 mg/kg every 6-8 hours as needed
68
Q

Pharmacological Treatment for Otitis Media

A
  1. 1st line:
    1. Amoxicillin
    2. Amoxicillin/clavulanate
  2. Mild allergy to penicillins: cephalosporins
    1. E.g. cefdinir, cefuroxime; ceftriaxone
  3. Severe allergy to beta-lactams:
    1. Azithromycin, clarithromycin
  4. Duration: 5-7 days for mild infections, 10 days for severe infections
69
Q

Describe Otitis Externa.

A
  1. Painful, inflammatory condition of external auditory canal
    1. AKA swimmer’s ear
70
Q

What are the common pathogens that cause Otitis Externa?

A
  1. Most common pathogens:
    1. P. aeruginosa
    2. S. aureus
71
Q

Treatment for Otitis Externa.

A
  1. Treatment: topical agents recommended as initial therapy
    1. Treating inflammation and infection:
      1. Otic anti-infectives
      2. Otic acidifying agent
      3. Otic antibiotics/glucocorticoid combination product.
    2. Pain control
      1. Otic analgesics: topical benzocaine may mask disease progression and cause contact dermatitis which can worsen or prolong otitis. Topical benzocaine products are not FDA approved and have been removed from the market.
      2. Oral analgesics
72
Q

Otic anti-infectives

-Adverse Effects/Precautions

A
  1. Adverse effects: itching/application site pain, headache
  2. Precautions:
    1. Exposure following otic administration is typically substantially lower than with systemic exposure
73
Q

Otic anti-infectives

-Place in therapy

A
74
Q

Otic anti-infectives

-MOA

A
75
Q

Otic anti-infectives

-Agents

A

(i) Ciprofloxacin 0.2% otic solution – 1 single use container in affected ear(s) every 12 hours for 7 days
(ii) Ofloxacin 0.3% otic solution 10 drops once daily for 10 days (5 drops daily for children <12 years)
(iii) Ophthalmic preparations may also be used (e.g. gentamicin 3 mg/mL solution)

76
Q

Otic acidifying agent

-Agent

A
  1. Acetic acid 2% otic solution - instill 4 to 6 drops into the external auditory canal. Maintain administration position for 5 minutes. Repeat the procedure every 2 to 3 hours.
77
Q

Otic Acidifying Agent

-MOA

A
  1. Mechanism of action: reduce inflammation, and antibacterial and antifungal properties (exact MOA unknown)
78
Q

Otic Acidifying Agent

-Place in therapy

A
  1. Place in therapy: may consider for mild external otitis
79
Q

Otic Acidifying Agent

-Adverse Effect/Precautions

A
  1. Adverse effects: localized burning, stinging
  2. Precautions:
    1. Avoid use of acidifying agents if tympanic membrane is known or suspected to be non-intact
80
Q

Otic antibiotics/glucocoticoid combination products

-Agents

A
  1. Ciprofloxacin/hydrocortisone (e.g. Cipro HC®)
  2. Ciprofloxacin/dexamethasone (e.g. Ciprodex® otic)
  3. Neomycin/polymyxinB/hydrocortisone (E.g. Cortisporin® otic)
81
Q

Otic antibiotics/glucocoticoid combination products

-Place in therapy

A
  1. Place in therapy:
    1. Topical antibiotic/steroid combinations decrease symptoms (e.g., pain, inflammation, itch) faster than antibiotics alone but do not improve the overall cure rate.
82
Q

Otic antibiotics/glucocoticoid combination products

-Adverse effects/Precautions

A
  1. Adverse effects: Fairly well tolerated, mostly topical adverse effects
  2. Precautions:
    1. Ciprofloxacin/hydrocortisone (Cipro HC®), a non-sterile otic suspension, and aminoglycoside (e.g. neomycin) combination products should not be used in patients with a tympanic membrane perforation.
83
Q

Pain control for Otitis Externa

A
  1. Otic analgesics: topical benzocaine may mask disease progression and cause contact dermatitis which can worsen or prolong otitis. Topical benzocaine products are not FDA approved and have been removed from the market.
    1. Benzocaine/antipyrine/glycerin otic solution
    2. Benzocaine/antipyrine/propylene glycol otic solution
  2. Oral analgesics
    1. E.g. acetaminophen, ibuprofen
84
Q

Otitis Externa Treatment Pearls

A
  1. Ophthalmic formulations may also be used in ears (e.g. due to cost or availability)
    1. Eye drops can be used in ears, but ear drops can NOT be used eyes due to sterility
    2. Examples:
      1. Ciprofloxacin ophthalmic plus dexamethasone ophthalmic may be a lower cost option for patients when ciprofloxacin/dexamethasone (Ciprodex®) otic is too expensive
      2. Ciprofloxacin or ofloxacin ophthalmic agents may be used in the ear if less expensive for the patient
    3. Referral to ENT in patients with a tympanic membrane perforation
      1. Also if initial presentation is severe, poor response to treatment, recurrent problems, unable to determine if tympanic membrane is perforated or patient is immunocompromised (e.g., diabetes mellitus, on chemotherapy).
85
Q

How to use ear drops

A
  1. Wash hands.
  2. Hold the bottle of ear drops in hands for a few minutes to warm them up.
  3. Shake the bottle gently for about ten seconds.
  4. Open the bottle; avoid touching the dropper to any surface
  5. Lie on side, or tilt head, so ear is facing up.
  6. Place drops into ear.
    1. Gently pull the ear up and back before placing the drops
    2. In young children, the earlobe should be pulled downward to fill the ear canal
  7. Remain lying on side, or tilting head, for three to five minutes
    1. May also place a cotton ball in ear canal for 20 minutes to maximize medicine exposure
  8. Repeat on other side if needed, then wash hands
86
Q

Describe Sinusitits.

A
  1. Inflammation of the nasal cavity and paranasal sinuses
87
Q

What are the causes of sinusitits?

A
  1. Etiology
    1. Most common: respiratory viruses
    2. Allergies
    3. Environmental irritants
    4. Secondary bacterial infection in 0.2-2% of adults and 5-13% of children
      1. <7 days likely viral, >7 days or more severe is likely bacteria
88
Q

What is the pathophysiology of sinusitits?

A
  1. Pathophysiology
    1. Mucosal inflammation and mucociliary dysfunction from viral infection or allergy leading to blocked sinuses
    2. Causative organisms: S. pneumoniae, H. influenzae most common.
89
Q

What is the goal of sinusitis treatment?

A
  1. Goals: relieve symptoms, promote sinus drainage, prevent complications
90
Q

What are nonpharmacologic treatments for sinusitis?

A
  1. Nonpharmacologic:
    1. Humidifiers
    2. Saline nasal sprays
    3. Nasal irrigations
91
Q

What are the pharmacologic treatments for sinusitis?

A
  1. Pharmacologic:
    1. Monitor with supportive care for 7-10 days before starting antibiotics
    2. If viral, likely to improve/resolve within 10 days
    3. Analgesics
    4. Decongestants
    5. Antibiotics
92
Q

What are the antibiotics for sinusitis?

A
  1. 1st line:
    1. Amoxicillin 500 mg PO TID or 875 mg PO BID
    2. Amoxicillin-clavulanate 500 mg/125 mg PO TID or 875 mg/125 mg PO BID
  2. Risk factors for pneumococcal resistance:
    1. Age >65, hospitalization in last 5 days, antibiotics in past month, immunocompromised, multiple comorbidities, severe infection
    2. High-dose amoxicillin-clavulanate 2 g/125 mg ER tab PO BID
  3. Penicillin allergy:
    1. Doxycycline 100 mg PO BID or 200 mg PO daily
      1. NOT in children
    2. Third-generation cephalosporin (cefixime, cefpodoxime) ± clindamycin
    3. Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
  4. Duration: 5-7 days
93
Q

Describe pharyngitis.

A
  1. Inflammation of the throat (often from infection)
    1. Generally self-limited
94
Q

What are the causes of pharyngitis?

A
  1. Etiology
    1. Common manifestation of viral upper respiratory tract infections (URIs)
    2. Bacterial causes: Streptococcus pyogenes (Group A streptococci) most common
      1. Others: corynebacterium diptheriae, Group C and G strep, Chlamydia pneumonia, Mycoplasma pneumonia, and Neisseria gonorrheae
    3. Viral causes: rhinovirus, coronavirus, adenovirus, influenza, Epstein-Barr virus
  2. Important to distinguish between viral and bacterial to avoid unnecessary antibiotic therapy and untreated streptococcal infection
95
Q

What are the signs and symptoms of streptococcal pharyngitis?

A
  1. Signs/Symptoms:
    1. Sore throat w/ severe pain while swallowing
    2. Fever
    3. Headache, abdominal pain, nausea, vomiting
    4. Tender, anterior cervical lymphadenitis
    5. Swollen red uvula
    6. Halitosis
    7. Soft palate petechiae
96
Q

What are diagnosis tests for streptococcal pharyngitis? Which is the gold standard?

A
  1. Rapid antigen detection test (RADT): 70-90% sensitivity, results available within minutes
  2. Throat culture – “gold standard” – results within 24-48 hours
  3. Only perform tests when signs/symptoms indicate potential infection
    1. ~20% of children are colonized
97
Q

What are the treatment goals for pharyngitis?

A
  1. Goals: shorten disease course, reduce spread, prevent complications
98
Q

What are the nonpharmacologic treatments for pharyngitis?

A
  1. Nonpharmacologic:
    1. Salt water gargle
99
Q

What are the pharmacologic treatments for pharyngitis?

A
  1. Symptom management:
    1. Allergy causes: antihistamines (e.g. loratadine)
    2. GERD causes: H2 antagonists (e.g. ranitidine) or PPIs (e.g. omeprazole)
    3. Pain: acetaminophen or ibuprofen
  2. Antibiotics – only when confirmed by lab and clinical symptoms
100
Q

What is the treatment for bacterial pharyngitis?

A
  1. Only treat with antibiotics if signs/symptoms of severe infection, ruled out viral infection, and positive RADT/throat culture
  2. 1st line:
    1. Penicillin V 500 mg PO 2-3 times daily x 10 days
    2. Amoxicillin 500 mg PO BID x 10 days
  3. Mild penicillin allergy: cephalosporins
    1. Cephalexin 500 mg PO BID x 10 days
    2. Cefdinir 300 mg PO BID x 5-10 days
    3. Others
  4. Severe penicillin allergy
    1. Azithromycin 500 mg PO day 1, then 250 mg PO days 2-5
  5. Penicillin allergy and macrolide resistance:

Clindamycin 300 mg PO TID x 10 days

101
Q

Describe the common cold.

A
  1. Self-limiting viral URI
102
Q

What are the causes of the common cold?

A
  1. Etiology
    1. Common viruses: rhinoviruses, coronaviruses, parainfluenza viruses, respiratory syncytial virus, and adenoviruses
    2. Can become complicated by bacterial superinfections
103
Q

What is the pathophysiology of the common cold?

A
  1. Pathophysiology
    1. Symptoms arise from epithelial damage, inflammation, vasodilation, local tissue edema, increased mucus production, and impaired mucociliary clearance
104
Q

What is the goal of treatment for the common cold?

A
  1. Goals: minimize discomfort from symptoms
105
Q

What is the nonpharmacologic treatment for the common cold?

A
  1. Nonpharmacologic
    1. Air humidifiers
    2. Intranasal saline drops/sprays
  2. Increased fluid intake
  3. Saline gargles
  4. Rest
  5. Nasal strips
  6. Common Cold Treatment
106
Q

What is the pharmacologic treatment for the common cold?

A
  1. AVOID antibiotics!
  2. Medications for symptom relief as needed:
  3. Fever/pain: antipyretics and analgesics
  4. Throat pain: local anesthetics (lozenges and sprays) – benzocaine,
  5. Congestion: decongestants
    1. Limit use to 3 days to avoid rebound congestion
  6. Cough:
    1. Suppressant: dextromethorphan
    2. Expectorant: guaifenesin
  7. Avoid antihistamines (impair mucociliary clearance of thick mucus)
107
Q

Decongestants

-Agents

A
  1. Examples:
    1. Pseudoephedrine 60 mg by mouth every 4-6 hours OR 120 mg extended release every 12 hours OR 240 mg extended release every 24 hours
    2. Phenylephrine
      1. Oral: 10 mg by mouth every 4 hours as needed for up to 7 days
      2. Nasal
        1. 0.25%-1% solution – instill 2-3 sprays in each nostril no more than every 4 hours for up to 3 days
108
Q

Decongestants

-MOA

A
  1. Mechanism of action: alpha-adrenergic agonist activity which produces systemic arterial vasoconstriction
109
Q

Decongestants

-Adverse Effects/Precautions

A
  1. Adverse Effects
    1. Nasal: Burning, stinging, sneezing
    2. Oral: Anxiety, dizziness, insomnia
  2. Warnings/Precautions
    1. Frequent or prolonged use of nasal decongestants may cause rebound nasal congestion
    2. Use with caution in patients with hypertension or heart disease
      1. May cause hypertension
110
Q

Cough Suppressant

-Agents

A
  1. Dextromethorphan 20 mg every 4 hours as needed (max of 6 doses in 24 hours)
    1. Children 4-6 years: 5 mg every 4 hours as needed
    2. Children 6-12 years: 10 mg every 4 hours as needed
111
Q

Cough Suppressant

-MOA

A
  1. Mechanism of action: decreases the sensitivity of cough receptors and interrupts cough impulse transmission
112
Q

Cough Suppressant

-Place in therapy

A
113
Q

Cough Suppressant

-Adverse Effects/Precautions

A
  1. Adverse Effects:
    1. Dizziness
    2. Drowsiness
    3. Nervousness/restlessness
    4. GI distress/nausea
  2. Warnings/Precautions
    1. Increased risk of serotonin syndrome with other serotonergic drugs
    2. Potential for abuse/misuse
114
Q

Expectorants

-Agents

A

Guaifenesin 200-400 mg every 4 hours as needed OR 600 mg extended release every 12 hours as needed

115
Q

Expectorants

-MOA

A
  1. Mechanism of action: increases the effective hydration of the respiratory tract, facilitating reduced viscosity of respiratory mucus
116
Q

Expectorants

-Place in therapy

A
  1. Place in therapy
    1. Limited efficacy of benefit
117
Q

Expectorants

-Adverse Effects

A
  1. Adverse effects:
    1. Dizziness
    2. Drowsiness
    3. Headache
    4. Skin rash
118
Q

Describe Allergic rhinitis.

A
  1. Allergic Rhinitis
    1. IgE-mediated inflammation of the upper respiratory tract due to allergy
    2. Initial contact sensitizes patient, and those with inherited tendency to allergic disorders produce IgE antibodies
    3. Subsequent exposures trigger allergic responses:
      1. Early-phase: allergen binds to IgE on mast cells w/in minutes of exposure
        1. Mast cells release mediators (histamine) which stimulates production of other mediators (e.g. cysteine leukotrienes and prostaglandin D2)
        2. Mediators bind to receptors in the nose and cause vasodilation, mucosal edema and hypertrophy  nasal congestion
      2. Late-phase
        1. Occurs in ~50% of AR sufferers; begins 2 hrs after early phase; peak at 6-12 hrs
        2. Second release of mediators + an inflammatory component leading to severe and long-lasting nasal congestion
119
Q

What are nonpharmacologic treatments for allergic rhinitis?

A
  1. Outdoor plant pollen triggers:
    1. Limit outdoor exposure during high pollen conditions
    2. Wear a face mask during activities that would have many allergens in the air
    3. Keeps windows and doors closed
    4. Use air conditioning
  2. Indoor allergens (dust mites, mold/fungi, cockroaches, pets)
    1. Air conditioning
    2. Humidity below 50%
    3. Clean frequently
    4. Vacuum frequently
    5. Minimize carpeting, fabric-covered furniture
    6. Launder bed frequently
  3. Irritants
    1. Avoid smoke, chlorine fumes, and other substances identified as irritant triggers
120
Q

What are pharmacologic treatment options for allergic rhinitis?

A
  1. Glucocorticoid nasal spray
  2. 2nd generation antihistamines
  3. Antihistamine nasal spray (azelastine, olopatadine)
  4. Cromolyn nasal spray
  5. Montelukast (with concomitant asthma)
121
Q

Glucocorticoid nasal spray

-Agents

A
  1. Examples:
    1. Mometasone (e.g. Nasonex®) 50 mcg/act
    2. Fluticasone (e.g. Flonase®) 50 mcg/act
    3. Triamcinolone (e.g. Nasacort®) 55 mcg/act
122
Q

Glucocorticoid nasal spray

-Typical dosing

A
  1. Typical dosing: 1-2 sprays in each nostril once or twice daily
123
Q

Glucocorticoid nasal spray

-MOA

A
  1. MOA: inhibit allergic inflammation by downregulating inflammatory responses
124
Q

Glucocorticoid nasal spray

-Place in therapy for allergic rhinitis

A
  1. Place in therapy:
    1. 1st line
    2. Works best if used daily, also can be used as needed
125
Q

Glucocorticoid nasal spray

-Warnings/Adverse Effects

A
  1. Warnings/precautions:
    1. May cause hypercortisolism or suppression of the hypothalamic-pituitary-adrenal axis leading to adrenal crisis
    2. Delayed wound healing
    3. Immunosuppression
  2. Adverse effects:
    1. Headache
    2. Nausea/vomiting
    3. Local irritation
126
Q

2nd generation antihistamines

-Agents

A
  1. Examples:
    1. Cetirizine (Zyrtec®)
    2. Loratadine (Claritin®)
    3. Fexofenadine (Allegra®)
    4. Desloratadine (Clarinex®)
    5. Levocetirizine (Xyzal®)
127
Q

2nd generation antihistamines

-MOA

A
  1. MOA: competitively inhibits histamine from binding to H1-receptors, thereby reducing allergy symptoms such as itching
128
Q

2nd generation antihistamines

-Warnings/Adverse Effects

A
  1. Warnings/precautions:
    1. May cause CNS depression/sedation (less sedation and anticholinergic effects with 2nd and 3rd generation antihistamines compared to 1st generation (e.g. diphenhydramine)
  2. Adverse effects
    1. Headache
    2. Drowsiness
    3. xerostomia
129
Q

Antihistamine nasal spray

-Agents

A
  1. Examples:
    1. Azelastine (Astepro®)
    2. Olopatadine (Patanase®)
130
Q

Antihistamine nasal spray

-MOA

A
  1. MOA: competitively inhibits histamine binding to H1 receptors, reduces hyper-reactivity of airways, and improves mucociliary transport
131
Q

Antihistamine nasal spray

-Warnings/Adverse Effects

A
  1. Warnings/precautions:
    1. May cause CNS depression
    2. Risk of nasal ulcerations (olopatadine)
  2. Adverse effects
    1. Bitter taste
    2. Headache
    3. Drowsiness
    4. Cough

Pharmacology for advance practice nursing 712 (24 decks)

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