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Flashcards in EENT Pharm Deck (232):
1

Rx options for Otitis Externa

Anti-infectives w/ or w/out steroids
Acid-alcohol solutions

2

Best Rx for Otitis Externa w/ tubes or perforated TM

Ofloxacin

3

Rx for Otitis Externa to avoid with tubes or perforated TM

Neomyacin, acid-alcohol solutions

4

Route of administration for anti-infective for Otitis externa

Topical

5

Most common Rx for Otitis Externa

Ones w/ steroids:
Ciprofloxacin/hydrocortisone
Ciprofloxacin/dexamethasone
Hydrocortisone/neomycin/polymycin (not w/tubes)

6

Rx for Otitis Externa w/ pseudomonas

Ciprofloxacin or Ofloxacin

7

What do Otitis Externa Anti-infectives end in?

-acin

8

5 acid-alcohol solutions

acetic acid/aluminum acetate
acetic acid/propylene glycol
acetic acid/propylene glycol/hydrocortisone
isopropyl alcohol/glycerine
isopropyl alcohol/propylene glycol

9

Side effects of anti-infectives

ear pain, contact dermatitis, ototoxicity

10

Side effects of acid-alcohol solutions

Stinging, burning, local irritation

11

Benefits of acid-alcohol solutions for otitis externa

Induces drying, supplements natural environment of ears

12

What should you do if Otitis Externa hasn't responded after 1 wk of treatment?

Culture

13

OTC treatment options for water clogged ears

-Isopropyl alcohol (95%) in anhydrous glycerine (5%)
-50:50 acetic acid + isopropyl alcohol **

14

Antibiotic therapy treatment guidelines for AOM in 6 mo+ old

Bilateral or unilateral AOM + severe signs/symptoms

15

Antibiotic therapy treatment guidelines for AOM in 6-24 mos old

Bilateral AOM

16

Watch and wait treatment guidelines for AOM in 6 mo-23 mo old

Non severe unilateral AOM

17

Watch and wait treatment guidelines for AOM in 24 mo+ old

Nonsevere AOM

18

Rx of choice for AOM

Amoxicillin

19

Do you give any meds for watch and wait AOM? What?

Yes, ibuprofen/acetaminophen

20

If pt with AOM had recent treatment with Amoxicillin, what should you add to current treatment

B-lactamase coverage (clavulanate)

21

Amoxicillin resistance with AOM, med?

Amoxicillin/clavulanate

22

Best Rx choice to treat AOM in pt with tubes?

Ofloxacin

23

Options for cerumen impaction

-Carbamide peroxide
-Triethanolamine polypeptide oleate
-Hydrogen peroxide/warm water
-Olive/sweet oil
-Glycerin

24

If you need to also dry the ear canal when removing cerumen impaction, what treatment would you avoid?

Hydrogen peroxide/ warm water

25

Which cerumen softener is an emollient?

Glycerine

26

Contraindications for cerumen impaction treatment

-Tubes or perforated TM
-history of adverse rxn

27

Possible side effects of cerumen treatment

• Mild itching
• Burning
• Ear pain
• Erythema of the ear canal
• Allergic ReacAons (hives, difficulty breathing, swelling of face, lips, tongue, throat) EMERGENCY

28

Do's of cerumen impaction treatment

-Do instill med, and once wax is softened follow with warm water irrigation via syringe
-Do make sure to completely remove drops
-Do understand that periodic prophylactic removal may be appropriate

29

Do not's of cerumen impaction treatment

-Don't use carbamide peroxide longer than 4 days (damage to TM possible)
-Don't use Q-tip to clean out wax
-Don't leave drops in ears longer than 30 minutes

30

Things to remember regarding Otic meds

-Think twice and avoid neomycin use with tubes or perforated TM
-Ofloxacin is good choice for AOM w/ tubes

31

Ophthalmic Anesthetic options

Amino Esters:
-proparacaine
-tetracaine

Amino-amides:
-lidocaine

32

Improper use of ophthalmic anesthetic can lead to:

Deep corneal infiltrates, ulceration, and perforation

33

When would you use an ophthalmic anesthetic?

Local anesthesia for procedures: foreign bodies, sutures, scrapings for Dx

34

MOA for ophthalmic anesthetic

Penetrate to sensory nerve endings in corneal tissue, bind to receptors within sodium channels ->blocks sodium, no depolarization, nerve cannot transmit pain impulses

35

ophthalmic anesthetic:
A
D
M
E

A: Rapid @ conjunctival capillaries, local action
D: protein binding high
M: unknown in eye/skin, some metabolism
may occur if systemically absorbed
E: Lidocaine? Tetracaine, proparacaine->bile

36

T1/2 for Ophthalmic anesthetics

proparacaine -shorter
lidocaine - medium
tetracaine -longer

37

Possible adverse rxn to ophthalmic anesthetics

Burning or stinging on application

Extended use: Severe keratitis, opacification, scarring of cornea and loss of vision possible (rare)

38

Possible side effects or adverse rxn to ophthalmic anti-infectives

Blurry vision, local irritation, super-infections possible with long term use

39

Bacteriostatic

Prevents growth of bacteria

40

Bactericidal

Kills bacteria

41

Bacteriostatic ophthalmic anti-infectives

-Sulfacetamide
-Bacitracin
-Erythromycin
-Fluoroquinolone: ciprofloxin, moxifloxin, etc

42

Bactericidal ophthalmic anti-infectives

-Tobramycin/gentamicin
-Polymixin B

43

Possible causes of conjunctivitis

Allergic
Infective (bacterial, viral, fungal(rare))

44

Contraindications for ophthalmic anti-infectives

Sulfa allergy (Sulfacetamide)

45

Good choice of ophthalmic anti-infective for contact wearers

Fluoroquinolone: ciprofloxin, moxifloxin, etc
(broader spectrum)

46

Good choice of ophthalmic anti-infective for infants and children

Erythromycin ointment has good coverage and is easier to administer than drops.
– Well tolerated

47

Which ophthalmic anti-infectives can cause irritation that look like failed treatment?

Sulfacetamide and gentamicin

48

MOA for Ophthalmic Mast Cell Stabilizers

Inhibits degranulation of mast cells after exposure to antigen. Reduces histamine release

49

Ophthalmic Mast Cell Stabilizers options
(-crom-)

-Nedocromil 2%
-Cromolyn Sodium 4%
-Iodoxamide 0.1%

50

What would you use an Ophthalmic Mast Cell Stabilizer for?

Allergic conjunctivitis & keratitis

51

Adverse rxns to Ophthalmic Mast Cell Stabilizers?

Transient stinging or burning, blurry vision, photophobia, mydriasis, rhinitis, sinusitis, headache

52

Adverse rxns to Ophthalmic Antihistamines

Transient stinging or burning, blurry vision, photophobia, mydriasis, rhinitis, headache

53

Ophthalmic Antihistimine options (-astine)

-Azelastine
-Epinastine
-Emedastine
-Ketotifen
-Levocabastine
-Olopatadine

54

What Rx blocks the effects of histamine and blunts symptoms of allergic conjunctivitis. H1 blocker, and good at relieving the itching.

Ophthalmic antihistamines

55

Best to use to treat redness associated with allergic conjunctivitis

Ophthalmic vasoconstrictors/decongestant

56

MOA of Ophthalmic vasoconstrictors/decongestant

Constricts the blood vessels in the conjunctiva. Weak sympathomimetic

57

What can happen with overuse of Ophthalmic vasoconstrictors/decongestant?

Rebound congestion/redness

58

Use of Ophthalmic vasoconstrictors/decongestants should be avoided if...

-Hx of heart disease, high BP, enlarged prostate, narrow angle glaucoma.
-Wears contacts
-Takes MAOI's or tricyclics

59

Adverse effects of Ophthalmic vasoconstrictors/decongestants if absorbed systemically?

Tachycardia, aggravation of arrhythmias

60

Local adverse effects of Ophthalmic vasoconstrictors/decongestants?

mydriasis (pupil dilation), burning/stinging, blurry vision

61

OTC options for Ophthalmic vasoconstrictors/decongestants? (-zoline)

-Naphazoline -best option (Clear Eyes)
-Tetrahydrozoline (Visine)
-Oxymetazoline -fewer side fx (Vision LR)
-Phenylephrine (glaucoma risk)

62

OTC combination products to treat Allergic Conjunctivitis

-Naphazoline + pheniramine
-Naphazoline + antazoline

63

Contraindications for OTC combination products to treat allergic conjunctivitis

Heart disease, high BP, enlarged prostate, narrow angle glaucoma (due to vasoconstrictors)

64

Sx of Dry Eye

Ocular burning, redness, blurred vision, discomfort, desire to rub eye

65

Options for Dry Eye

-Artificial Tears
-Ocular Emollients
-Cyclosporine

66

Artificial tear options

-Cellulose derivatives: longer lasting, but can leave a crust on the eyes
-Polyvinyl alcohol: shorter acting, but no crust
-Povidone and dextran 70: transient stinging and burning

67

Ocular emollient options

Lanolin, mineral oil, white ointment, yellow wax, white wax, petroleum
(ointment or liquid)

68

Rx for keratoconjunctivitis sick (suppressed tear production due to ocular inflammation)

Cyclosporine (Restasis)

69

MOA for Cyclosporine

Inhibits interleukin 2 that is needed for T cell action

70

Adverse effects of cyclosporine

burning, eye discomfort

71

Sx of corneal edema

Foggy vision, haloes around lights, photophobia, irritation, foreign body sensation, extreme eye pain

72

Etiology of corneal edema

Prolonged contact lens wearing, infection, glaucoma, iritis

73

Tx of corneal edema

Sodium chloride (2-5%), ointment if drops ineffective

74

MOA of pupillary dilation agents

Muscarinic agents - block parasympathetic receptors (that would normally cause pupils to constrict if stimulated)

75

Parasympathetic action of the eye:

Constriction (miosis) inner circular muscle constricts

76

Sympathetic action of the eye:

Dilation (mydriasis) outer radial muscle constricts

77

Pupillary Dilation agents:

-Tropicamide- peaks @ 20-30 min, lasts 2-7 hours
-Cyclopentolate- peaks @ 25-75 min, lasts 6-24 hrs
-Homatropine -lasts 24-72 hours

78

Possible adverse rxn of pupillary dilation agents

Tachycardia, flushing, blurry vision, photophobia, dry mouth, slurred speech, drowsiness, hallucinations, congestion, irritated eyes

79

Contraindications for pupillary dilation agent use

Closed angle glaucoma- dilation can occlude outflow of aqueous humor, raise IOP which further occludes outflow

80

Used to detect corneal defects and abrasions

Fluorescein- fluoresces under ultraviolet spectrum. Will stain epithelial damage, but does not stain cornea

81

What is fluorescein?

Yellow, water-soluble dibasic-acid xanthine dye

82

Beclomethasone

Intranasal Corticosteroid

83

Nudesonide

Intranasal Corticosteroid

84

Ciclesonide

Intranasal Corticosteroid

85

Flunisolid

Intranasal Corticosteroid

86

Fluticasone furoate

Intranasal Corticosteroid

87

Fluticasone proprionate

Intranasal Corticosteroid

88

Mometasone

Intranasal Corticosteroid

89

Triamcinolone acetonide

Intranasal Corticosteroid

90

What is the MOA for intranasal corticosteroids?

Decrease influx of inflammatory cells, inhibits release of cytokines which reduces inflammation of nasal mucosa.

91

What is the MOA for oral antihistamines?

H1 receptor antagonist.

92

What is an H1 antagonist?

Blocks the action of the histamine at the H1 receptor, which helps relieve allergic reactions. Antihistamine.

93

What are examples of first generation oral antihistamines?

Chlorpheniramine. Brompheniramine. Diphenhydramine. Clemastine.

94

What are the key points of 1st generation antihistamines?

Nonselective. Sedating. More frequent dosing.

95

What are the key points of 2nd generation antihistamines?

Peripherally selective. Low incidence of sedation. Once/daily. No anticholinergic effect.

96

What is the most effective 2nd generation antihistamine?

Cetirizine.

97

What are 4 2nd generation antihistamines?

Loratidine. Cetirizine. Fexofenadine. Desloratadine.

98

Which type of antihistamine crosses the blood-brain barrier?

1st generation.

99

Which type of antihistamine has less side effects?

2nd generation.

100

What are some contraindications for antihistamines?

Don’t drive or operate heavy machinery. Narrow-angle glaucoma possible. Avoid alcohol.

101

What are 2 Intranasal antihistamines?

Azelastine. Olopatadine

102

What is the MOA of oral decongestants?

Alpha-adreneric agonist>vasoconstriction. Reduces blood supply to nasal mucosa. Decreases mucosal edema. NO EFFECT ON HISTAMINE.

103

What are contraindications for nasal decongestant?

AVOID if uncontrolled heart disease. Can increase IOP and BP.

104

What are some side effects of Intranasal Corticosteroids?

Headache. Elevated BP. IOP. Tremor. Dizziness. Tachycardia. Insomnia.

105

What are two examples of nasal decongestants?

Phenylephrine. Pseudoephedrine.

106

What is the MOA for topical decongestants?

Alpha agonist that act locally as vasoconstrictors. Decrease blood supply to nose by constricting blood vessels.

107

What are examples of topical decongestants

Phenylephrine. Oxymetazoline.

108

What are contraindications for topical decongestants?

Rhinitis medicamentosa!

109

What are the key points for Intranasal Cromolyn?

Prevents and treats SYMPTOMS of Allergic Rhinitis.

110

What does a mast cell stabilizer do?

Prevents mast cells from releasing histamine. (Intranasal cromolyn).

111

How do intranasal anticholinergics work?

They block acetylcholine receptors.

112

What is an example of an intranasal anticholinergic?

Ipratropium

113

What would you consider using to reduce ocular symptoms in Allergic Rhinitis?

Leukotriene Receptor Antagonists.

114

What is an option for patients with asthma who have allergic rhinitis?

Leukotriene receptor antagonists (montelukast). Reduces bronchospasm.

115

How long does it usually take for immunotherapy to work? How long can it last?

5-7 yrs. 12.

116

2nd generation antihistamines
(-adine)

-Fexofenadine
-Desloratadine
-Loratadine
-Cetirizine **(most effective)

117

1st generation antihistamines
(-amine)

Diphenhydramine
Chlorpheniramine
Brompheniramine
Clemastine

118

What works well to REDUCE RHINORRHEA?

Ipratropium (many other answers).

119

What is a major anticholinergic side effect?

DRYNESS

120

Is the common cold usually viral or bacterial?

Viral

121

Is the onset for a cold gradual or rapid?

Gradual, 1-2 weeks.

122

Meds to treat anaphylaxis

*Epinephrine -life saving
*Antihistamine- symptom relief
*Corticosteroid -suppress biphasic or rebound run

Don't forget to stop the offending drug or whatever caused the rxn to begin with

123

Medical term for pupil constriction

Miotic

124

Main goal of Glaucoma Tx

Reduce IOP either by slowing production or increase drainage of aqueous humor to prevent optic nerve damage and visual field loss

125

Drug classes to treat Glaucoma

-Prostaglandin Analogues
-Beta blockers
-Alpha-adrenergic agonists
-Carbonic anhydrase inhibitors
-Cholinergics
-Mannitol

126

How does systemic absorption occur with topical anti-glaucoma meds?

Primarily through the nasolacrimal duct

127

MOA of Prostaglandin Analogues (1st line Tx)

Synthetic analogues of prostaglandin act on RF (prostaglandin receptor), increase outflow of intraoccular aqueous humor through uveoscleral pathway, which lowers IOP 23-35%

128

Helpful med to prevent biphasic rxn in anaphylaxis

Corticosteroids
-first dose IV
-typically multi-day course. Short term! (3-5 days)

129

MOA of corticosteroids

Decreases influx of inflammatory cells, inhibits release of cytokines -> reduce inflammation
-prednisone
-prednisolone
-Methylprednisolone
-Dexamethasone
-many more

130

Corticosteroids:
A
D
M
E
T1/2

A: GI tract, highly bioavailable
D: 70-90% protein bound
M: Liver
E: Renal
T1/2: 2-4 hours

131

Adverse rxns of corticosteroids

Hypertension, body fluid retention, impaired glucose tolerance, increased appetite, weight gain, osteoporosis, disturbance in mood, delirium

132

Adverse rxns of beta blockers

Bradycardia, bronchospasm, depression, fatigue, ocular dryness

133

MOA of Alpha-Adrenergic Agonists (a2)

Decreases aqueous humor production by causing vasoconstriction (maybe increases outflow)

134

Options for Glaucoma Alpha-Adrenergic Agonist Rx (-idine)

-Brimonidine
-Apraclonidine

135

What are CYP450s?

Drug metabolizing enzymes

136

MOA of Carbonic Anhydrase Inhibitors

Slows action of carbonic anhydrase to decrease aqueous humor volume -> decreases IOP

137

Glaucoma Carbonic Anhydrase Inhibitor Rx options (-zolamide)

-Acetazolamide*
-Dorzolamide
-Brinzolamide
-Methazolamide*
-Dichlorphenamide

* oral tablets used less often

138

Adverse rxns of Carbonic Anhydrase Inhibitors

Ocular irritation, sour taste

139

Contraindications for use of Carbonic Anhydrase Inhibitors

Sulfa Allergy

140

MOA of Cholinergics

Has similar effects as acetylcholine -> parasympathetic response of miosis (essentially it contracts the iris sphincter muscle, which opens the canal of Schlemm, which increase the outflow of aqueous humor through trabecular meshwork, which decreases IOP =>miosis)

Direct- directly stimulates ocular cholinergic receptors

Indirect- bind to and activate cholinesterases (that break down acetylcholine-> keep acetylcholine around)

141

Direct-Acting Cholinergics (Miotics)

-Pilocarpine
-Carbachol

142

Indirect Acting Cholinnergics (Miotics)

Echothiophate
(very long half life, irreversible)

143

Adverse rxns of Cholinergics (Miotics)

Blurred vision, poor night vision, eye pain, headache

144

Combination drops to treat Glaucoma

Timolol + dorzolamide

145

Glaucoma drug interactions

Acetazolamide interacts with
- aspirin
- Cyclosporine
- Lithium
- Phenytoin

146

Glaucoma drug classes that slow production of aqueous humor:

Beta blockers
Alpha 2 agonists
Carbonic anhydrase inhibitors

147

Glaucoma drug classes that increase drainage of aqueous humor

Prostaglandins
Cholinergics/muscarinics

148

Drug used to treat acute attack of closed angle glaucoma

Mannitol, Glycerin

149

Pharmacologic Tx for Mild Allergic Rhinitis

antihistamines prn

150

MOA of Mannitol, Glycerin

Causes blood to be hypertonic compared to intraocular and spinal fluids, which causes osmotic gradient (pulls water from intraocular and spinal areas out to bloodstream), and excess fluid is secreted in the urine

151

Pharmacologic Tx for Severe Allergic Rhinitis

Refer to specialty/immunotherapy

152

Humoral immunity (antibodies & B cells) + cellular immunity =(no antibodies & T cells)

Acquired immunity

153

Hypersensitivity Rxn Types :(resulting from interaction between antigen and immune system)

Type I: IgE-mediated -antigen complex binds to mast cells causing release of histamine and inflammatory mediators (anaphylaxis/allergy)
(Also Types II- IV)

Pseudoallergic (anaphylactoid)

154

Spectrum of Effects of IgE mediated rxns

-Mild = allergic rhinitis
-Moderate (!!) = urticaria (hives), angioedema (swelling)
-Severe (!!!!!) = anaphylaxis

155

Benefits of intranasal corticosteroids

Reduces ocular symptoms, nasopharyngeal itching, sneezing, rhinorrhea.
More effective than antihistamines in severe cases

156

2nd generation antihistamines (-adine)

-Fexofenadine
-Desloratadine
-Loratadine
-Cetirizine

157

1st generation antihistamines

Diphenhydramine

158

Follow up Rx for moderate hypersensitivity rxn

Oral corticosteroids -short course (e.g. prednisone for 3-5 days)

159

Further Rx care following moderate hypersensitivity rxn

Epinephrine auto injector

160

What type of rxn is anaphylaxis?

IgE mediated (Type I Rxn)

161

What is the time frame for an anaphylactic response? 2nd Rxn? (Biphasic Rxn)

-W/in 1 hour (5-30 min)
- 8-72 hours later

162

Meds to treat anaphylaxis

Epinephrine -life saving
Antihistamine- symptom relief
Corticosteroid -suppress biphasic or rebound run

Don't forget to stop the offending drug or whatever caused the rxn to begin with

163

MOA of epinephrine

Alpha & beta adrenergic agonist (sympathomimetic)

- causes rapid vasoconstriction and rapid relaxation of bronchial smooth muscle

164

MOA of oral/topical decongestants

-Alpha-adreneric agonists → vasoconstriction
-Constriction of blood vessels to decrease blood supply to nasal mucosa, decrease mucosal edema
-> no effect on histamine

165

Adverse effects of epinephrine

agitation, anxiety, tremulousness, headache, dizziness, pallor, palpitations, arrhythmias

166

2nd line Tx for anaphylaxis

Antihistamines
-helps erythema & pruritus, but doesn't help with airway obstruction or high BP
-given IV, IM or po
-couple with epinephrine

167

MOA of antihistamines

H1 receptor antagonists
1st gen: sedating, nonselective (diphenhydramine)
2nd gen: selective, low sedation, no anticholinergic fx

168

Helpful med to prevent biphasic rxn in anaphylaxis

Corticosteroids
-first dose IV
-typically multi-day course (3-5 days)

169

MOA of corticosteroids

Decreases influx of inflammatory cells, inhibits release of cytokines -> reduce inflammation
-prednisone
-prednisolone
-Methylprednisolone
-Dexamethasone
-many more

170

Corticosteroids:
A
D
M
E
T1/2

A: GI tract, highly bioavailable
D: 70-90% protein bound
M: Liver
E: Renal
T1/2: 2-4 hours

171

Alternative to Topical Decongestants

Saline nasal drops, spray, rinse: no interactions, very safe, use if unsure cold vs allergies

172

What are the 4 types of hypersensitivity reactions?

Type I: IgE-mediated- release of histamine and inflammatory mediators (minutes to hours) (anaphylaxis/allergy)

Type II: Cytotoxic reaction (variable timing)- IgM or IgG antibodies attack drug coated cell

Type III: immune complex (1-3 wks)- drug antibody complexes deposit on tissues

Type IV: delayed, cell-mediated (2-7 days) - presentation of drug molecules to sensitized T cells ->cytokine and inflammatory mediator release

173

What is pseudo allergic?

Results from direct mast cell activation, degranulation
-looks like Type I
- Anaphylactoid = mimics anaphylaxis
- e.g. anaphylactoid rxn after radiocontrast media

174

Importance of Distribution (of drug)

How much is free in the blood affects dosing. Drug in tissue must get back to blood in order to be excreted; too much drug in tissue can cause lethal toxicity

Amount of drug in the body divided by the concentration in the blood = distribution

175

What are CYP450s?

Drug metabolizing enzymes

176

Montelukast -> leukotriene receptor antagonist to treat allergic rhinitis

-Reduce ocular symptoms, sneezing, rhinorrhea
-May be particularly useful for patients with asthma

177

What is half-life?

how long does it take for half of the drug to leave the body. Good for dosing intervals, determining how long it takes to reach a steady state, or when drug is finally cleared from the body. Usually takes 5-6 half-lives to completely leave the body (some adverse effects take longer or are irreversible)

178

How often do you give a drug if you are trying to build up the level in the body?

Give every half of a half life

179

What is Glomerular filtration rate (GFR)?

How well kidneys are filtering. Another way is CrCl, which is how well body is clearing creatinine (good indicator of how well the kidneys are working)

180

What is the Therapeutic Index (TI)?

level between too much that will be toxic and too little when it won't work.

181

What is a loading dose?

Large first dose - some gets bound up in the tissues and the rest can go around and attack what it needs

182

What is the fastest rate of onset of a drug? Slowest?

-(fastest) IV or inhalation -> 30 sec-1min
-(fast) IM ->5 min
-(Mid) Subcutaneous, oral -> 30 min
-(Slower) transdermal, oral-> 2 hours

183

What is the best way to administer a drug that is degraded in the digestive tract?

Subcutaneous or IV

184

What is the preferred route of administration?

Oral

185

Codeine w/guaifenesin

-narcotic, helps pt sleep
-Prodrug
-some people can be poor metabolizers or ultra rapid metabolizers

Avoid in children <12
Avoid alcohol

186

What is the abbreviation:
od
ad

Right eye
Right ear

187

Hydrocodone

-Narcotic, helps pt sleep

Avoid in children <12
Avoid alcohol

188

What is the abbreviation:
ou
au

Both eyes
both ears

189

Pharmacologic Tx for Mild Allergic Rhinitis

antihistamines pen

190

Pharmacologic Tx for Moderate Allergic Rhinitis

intranasal steroid +/- antihistamine +/- decongestant for nose +/- ophthalmic antihistamine for eyes

191

Pharmacologic Tx for Severe Allergic Rhinitis

Refer to specialty/immunotherapy

192

Sore Throat/cough remedies

-Saline gargle
-Sprays, lozenges (numb locally)
Benzocaine
Dyclonine
Phenol
Menthol
-Honey (Buckwheat)
-Lots of water

193

MOA of intranasal corticosteroids

Decrease influx of inflammatory cells, inhibit release of cytokines -> reduce nasal mucosal inflammation

194

How long does it take intranasal corticosteroids to work? Peak?

Less than 30 min, peaks hours-days

195

Benefits of intranasal corticosteroids

Reduces ocular symptoms, nasopharyngeal itching, sneezing, rhinorrhea.
More effective than antihistamines in severe cases

196

Intranasal corticosteroid options (-onide)

-Beclomethasone
-Budesonide
-Ciclesonide
-Flunisolid
-Fluticasone furoate (no alcohol)
-Fluticasone propionate (no alcohol)
-Mometasone
-Triamcinolone acetonide (no alcohol)

197

Adverse effects of Intranasal corticosteroids

Bitter aftertaste,
burning, epistaxis, headache, nasal dryness, possible systemic absorption, stinging, throat irritation

198

Antihistamines
A
D
M
E
T1/2

A: Rapid
D: 60-70% protein bound
M: minimal; desloratadine is a prodrug (first pass metabolism)
E: fexofenadine, desloratadine, loratadine→feces and urine; others → urine
T1/2: variable

199

Side fx of 1st gen antihistamines

-Cross blood-brain barrier ->sedation, fatigue, impaired mental status.
-Paradoxical stimulation in some children, elderly

200

Side fx of 2nd get antihistamines

Don't cross blood-brain barrier-> less sedative (except for cetirizine 1/10)

201

Precautions/contraindications for antihistamines

-Do not drive, operate heavy machinery
-Avoid alcohol
-Prostatic hyperplasia can occur
-Narrow-angle glaucoma possible

202

Intranasal antihistamine options

Azelastine
Olopatadine
Azelastine/fluticasone combo ($$$)

203

Adverse rxn of intranasal antihistamine

bitter aftertaste, headache, nasal irritation, sedation, epistaxis

204

MOA of oral decongestants

-Alpha-adreneric agonists → vasoconstriction
-Constriction of blood vessels to decrease blood supply to nasal mucosa, decrease mucosal edema

205

Oral decongestant options

Phenylephrine (low bioavailability)
Pseudoephedrine

206

Side fx of oral decongestants

-Headache
-Elevated blood pressure
-IOP
-Tremor
-Urinary retention
-Dizziness
-Tachycardia
-Insomnia

207

Precautions/contraindications for oral decongestants

-Avoid in uncontrolled HTN, heart disease, DM, Hyperthyroidism, enlarged prostate, narrow angle glaucoma, high BP

208

Side fx of topical decongestants

-Minimal systemic absorption, few side effects
-Local burning
-Nasal irritation, dryness
-Sneezing

209

Precautions/contraindications of topical decongestants

Rebound congestion (rhinitis medicamentosa) may occur if use > 3-5 days

210

Options for topical decongestants

Phenylephrine
Oxymetazoline

211

Alternative to Topical Decongestants

Saline nasal drops, spray, rinse: no interactions, very safe, use if unsure cold vs allergies

212

Intranasal mast cell stabalizer

Cromolyn ->Prevent and treat allergic symptoms: nasopharyngeal itching, sneezing, rhinorrhea
- only works if taken regularly, and must take 4-6 times daily, 2-3 wks for max effect

213

Side fx of Intranasal Cromolyn

nasal irritation, nasal burning, stinging, sneezing, cough, unpleasant taste, epistaxis

214

Intranasal anticholinergics option

Ipratropium ->reduces rhinorrhea

215

MOA of Intranasal anticholinergics

Block acetylcholine receptors -> less mucus

216

Montelukast ->leukotriene receptor antagonist

-Reduce ocular symptoms, sneezing, rhinorrhea
-May be particularly useful for patients with asthma

217

Immunotherapy for allergic rhinitis best for pts who...

-are unresponsive to usual treatment
-who cannot tolerate usual treatment
-who want to avoid long term med use
-with allergic asthma

218

Nonpharmacologic Tx for common cold

humidifiers, increase fluids, rest

219

Pharmacologic Tx of common cold

-Decongestants +/- antihistamines
-analgesics
-local anesthetic (lozenges, spray)
-cough meds??

220

Meds to treat fever, pain, headaches

Acetaminophen
NSAIDS: ibuprofen, naproxen

221

Who should not take cough meds at all

Children <6 yo

222

Cough/cold meds are mostly ineffective, what might be helpful?

-High-dose inhaled corticosteroids
-Buckwheat honey (not <1yo)
-nasal irrigation with saline
-vapor rub
-Zinc sulfate?

223

Cough med options

Antitussives
Expectorants
Sore throat remedies

224

Antitussive options

Codeine (w/guaifenesin)
Hydrocodone
Dextromethorphan
Benzonatate

225

Codeine w/guaifenesin

-narcotic, helps pt sleep
-Prodrug
-some people can be poor metabolizers or ultra rapid metabolizers

Avoid in children <12
Avoid alcohol

226

Codeine w/guaifenesin
A
D
M
E
T1/2

A: absorbed orally
D: crosses blood brain barrier
M: primarily in liver; prodrug, variable metabolism
E: urine
T1/2: 2.5-4 hours

227

Hydrocodone

-Narcotic, helps pt sleep
-

228

Dextromethorphan

-For non-productive cough
-interacts with MAO inhibitors
-MOA- centrally mediated
-maybe has some benefit

229

Dextromethorphan
A
D
M
E
T1/2

A: Absorbed from GI
D: crosses blood brain barrier
M: prodrug, liver CYP2D6 → active drug
E: urine
T1/2: variable (2-24 hours)

230

Benzonatate

MOA: anesthetizes respiratory passage, lung, pleural stretch receptors (reduces cough reflex)

Adverse Reactions: hypersensitivity, GI upset, sedation

Maybe has benefit

M: Liver, unknown CYP450
E: urine
T1/2: ?

231

Expectorant

Guaifenesin

MOA: thinning of mucus to enhance clearance
For productive cough
Side effects: GI discomfort
Counseling point: increase fluid intake

Maybe has benefit

232

Sore Throat/cough remedies

-Saline gargle
-Sprays, lozenges (numb locally)
Benzocaine
Dyclonine
Phenol
Menthol
-Honey (Buckwheat)
-Lots of water