Flashcards in HENT Deck (124):
What are decongestants?
alpha agonists that produce vasoconstriction
What does the vasoconstriction of decongestants result in?
-shrinkage of swollen nasal mucous membranes
-reduces nasal congestion and increases drainage of sinus secretions
-makes it easier to breathe
-help nasal stuffiness
How can decongestants be applied?
-systemic (oral) OTC & Rx
What do decongestants stimulate (MOA)?
-stimulate alpha 1 adrenergic receptors in the nasal mucosa, constricting BVs
How does the vasoconstriction of decongestants decrease congestion?
-decrease blood flow to nasal mucosa
-less blood flow means less edema of mucosal passages
-less edema means less congestions
=more air passage through airways
Rate of absorption/onset of topical nasal decongestants
-rapid onset of action
topical vs. oral decongestants:
-which one is more effective?
topical application of decongestants tend to be more effective compared to PO
topical vs. oral decongestants:
-which one has a longer effect?
-topical effect generally lasts longer than oral
topical vs. oral decongestants:
-which one is more effective and
-what are the benefits
-the topical route allows more of the drug to get where you want it
-with less systemic absorption
-and fewer side effects
How are topical nasal decongestants used? (dose and where)
1 to 2 sprays in each nostril every 12 hours
patient education about topical nasal decongestants
-keep applicator CLEAN
-spray & breath in
-don't let it drip down back of throat
Why don't you want nasal decongestants to drip down the back of the throat?
-can get systemic absorption and ADRs
It's difficult to prevent topical nasal decongestants from dripping down the back of the throat.
-What do you have to do because of this?
-If there is a contraindication to using PO decongestants, then nasal decongestants are contraindicated as well
Local ADRs of topical decongestants
-stinging, burning, dryness of mucous membranes in the nose
What is rhinitis medicamentosa
-special ADR for topical decongestants
-happens >3-5 days use then you try to stop
-when you stop you get rebound congestion, often worse
tx of rhinitis medicamentosa
oral decongestans & nasal corticosteroids
Systemic ADRs of topical decongestants
-increased blood sugar
-increased intraocular pressure
What causes the systemic ADRs of topical decongestants
-activation of adrenergic alpha receptors
Contraindications for topical decongestants
-narrow angle glaucoma
Why is CAD (coronary artery disease) a contraindication for topical decongestants?
can increase rate & work of heart, increasing anemia
Why is HTN a contraindication for topical decongestants?
can increase BP
Why is Hyperthyroid a contraindication for topical decongestants?
can increase sx of hyperthyroidism
Why is DM (diabetes) a contraindication for topical decongestants?
metabolic effects can increase blood sugar
Why is narrow angle glaucoma a contraindication for topical decongestants?
can acutely close the angle in the eye causing acute angle closure glaucoma
Why is BPH (benign prostatic hypertrophy) a contraindication for topical decongestants?
cause urinary retention
Oral decongestants are less effective than topical, but what is their benefit?
benefit: can use for longer period of time because don't get rebound effect
downside: more side effects
What receptor effects do oral decongestants have?
alpha (and maybe some beta)
-going for alpha 1 receptor effect
Which oral decongestant has more beta effects?
What side effects do you see with PSE because of its beta receptor effect
-insomnia due to CNS stimulation
examples of decongestants
Why is PSE sold behind the counter?
Jonas making meth
ADRs of oral decongestants
CNS stim keeps you awake so don't take within 4-6h before bed
HTN-risk of stroke, (hx of stroke then don't give)
Palpitations - symp stim increases HR
_______ of nasal passages occurs frequently with many ENT diseases (what type of drug does this relate to?)
inflammation of nasal passages (where steroids come into play)
MOA of nasal corticosteroids
-nasal steroids suppress inflammation in the nasal passages
-decreases intracellular edema & nasal discharge produced by irritation
-making it easier to breath
-and reducing a runny nose
How long do you need to use nasal corticosteroids to see peak effect?
-hormones take longer to work
-use 2-3 weeks for peak effect
-don't work fast but work VERY well/ very effective
OTC topical decongestant nasal sprays (list)
Rx only topical decongestant nasal spray (list)
List common topical nasal steroids
-Fluticasone (Flonase & Veramyst)
-Beclomethasone (Vancenase, Beconase)
-Triamcinolone (Nasacort, Nasacort AQ)
Dose of topical nasal steroids
-1 to 2 sprays in each nostril twice per day
Make sure the patient can ______ before giving nasal steroids.
-Make sure patient can inhale before giving nasal steroids
-if no air going through nose, meds can't get far either
If pt. has poor nasal patency, what do you give them and why?
-give normal saline
-will quickly & temporarily decrease edema to allow increased air flow so medication can get in
No ________ or _________ for 10 mins after inhalation of nasal steroids
no sneezing or blowing
-may blow med out
Local ADRs of topical nasal steroids
-stinging, HA, nose bleeds
Why do nose bleeds sometimes occur in topical nasal steroids
systemic ADRs of topical nasal steroids
-not many systemic effects because giving topically
-concern is mild growth suppression in children
Contraindications for topical nasal steroids
-ulceration of nasal septum
-recent nose surgery
All because steroids cause poor wound healing
Functions of histamine
1. immediate allergic & inflammatory rxns
2. Gastric acid secretion
3. CNS - stim nerve endings that case pain & itch
-make sleepy and stimulate some cholinergic receptors
Which receptors in skin and mucous membranes are involved with histamine?
-cause vasodilation leading to heat, redness, inflammation
_____ receptors are in gastric mucosa
And what do the blockers do
H2-blockers reduce gastric acid secretion
Where are H1 receptors located?
smooth muscle, endothelium & brain
H1 blockers are used in...
allergic conditions to decrease itch & inflammatory response to allergic conditions
Effects of 1st generation H1 receptor antagonists
-strong sedative effect & more anticholinergic effects
-because they get into the CNS (where there are H1 receptors)
2nd generation H1 antagonists don't get into the _____ as well
-so how are effects different from 1st gen
don't get into CNS as well
than 1st generation
1st Generation Anti Histamines are also called
List of 1st Gen AntiHistamines
-Azaelastine (Astelin Nasal Spray)
2nd Generation AntiHistamines are also called
peripherally selective (periphery, not CNS)
non sedating antihistamines
List 2nd Gen AntiHistamines
What speed/absorption are antihistamines
-both 1st and 2nd gen rapidly and well absorbed orally
How are antihistamines distributed throughout body?
-widely distributed throughout body
-except 2nd gen b/c don't get into CNS & don't cause sleepiness
How long do antihistamines work?
1st gen- 4-6h
2nd gen- 12-24h
-bind receptor & block effect of native histamine
What receptors do histamine have primary effect on?
Why do they have effects on other receptors?
-primary effect on H1 receptors
-structurally similar to drugs that block other receptors so have effects on other receptors (muscarinic, alpha, serotonin)
Effects common to anti-histamines (three effects that may be desired or side effects)
-anti nausea and anti emetic
Sedative Effect of Anti Histamine
-mostly which generation?
-1st gen because penetrate CNS
-sometimes with 2nd gen, but less since less gets into CNS
Sedative effect of anti histamine can be ____ or not _____
desired or not desired
-OTC sleep aids are non addicting antihistamines
Example of not getting desired effect of sedative anti histamine
-sometimes children get excited with 1st gen antihistamines instead of getting sedated
Which generation of antihistamines can decrease nausea, vomitting, & dizziness
-1st gen better than 2nd gen
-work well for nausea/vom from vestibular dysfxn (motion sickness)
What drug is especially good for dizziness/disequilibrium
What drug is good for nausea
ADRs of Antihistamines related to muscarinic effects
-can block muscarinic receptor so cause:
-dryng effect (decrease nasal, salivary & lacrimal secretions)
Clinical uses of H1 Antagonists
Why are antihistamines good drugs for allergic rhinitis?
-Allergic rhinitis is hypersensitivity rxn (histamine released locally in nasal passages)
-histamine is primary mediator of many allergic rhinitis sx
-so antihistamines are drug of choice
Why are antihistamines given in pruritic conditions
-decrease itch (histamine is major cause of pruritis)
-may decrease awareness of itch by causing sedation
-Why are h1 antagonists good for vertigo/motion sickness
-histamine has blocking effect in inner ear or CNS
-sedation, hallucinatins, ataxia (occur more with better penetration into CNS, more in elderly; avoid taking antihistamines when driving/operating heavy machinery or with other sedating drugs)
-anticholinergic (dry mouth, constipation, difficulty voiding)- use carefully/not at all if already glaucoma, hyperthyroid, BPH
-excitation in children
Special Anti-Histamine: topical nasal antihistamine
-first generation antihistamine given as topical in nasal passages
-2 sprays in each nostril BID, gives rapid improvement of sx
-less effective over time
side effects of azelastine
-(topical nasal antihistamine)
Topical Ophthalmic Antihistamines
Ketotifen (zatidor, Claritin)
-1 gtt OU BID
Anti tussives are used to...
decrease cough, generally do this by suppressing cough reflext
When would you not want to suppress a cough?
and when WOULD you consider using?
-if cough is productive, don't suppress it--get the phlegm out
-if cough is dry and nonproductive, then suppress it OR if productive cough is keeping up at night, etc
List Anti tussives
Oral/systemic: dextromethorphan, narcotics (codeine)
OTC oral cough suppressant
-chemical isomer of the narcotic methorphan
-suppresses cough without pain relief or addiction
What are the primary group used when giving prescription antitussives?
Why/how narcotics as cough suppressants
-have effect on cough reflex in throat & brain (work centrally & peripherally)
-often available in liquid (cough syrup)
Common narcotic as cough suppressant
Codeine usually 10mg at a time
Ex: phenergan with codeine, robitussin AC, Tussionex
-Camphor & menthol
-rubbed on throat/chest & inhaled (vicks)
-also available as lozenge & throat sprays
MOA of topical antitussives
-stimulate cold sensory receptors and give sensation of cooling and local anesthetic effect that decreases cough
What do expectorants do?
help bring up secretions
**guaifenesin is only one
-Mucinex, Mucinex DM, Mucinex D
Uses & side effects of Guaifenesin
-used for productive cough to bring up phlegm more easily
-OTC, drink 8 oz water with it
-well tolerated w/few & mild side effects
Mast Cell Stabilizers
Cromolyn sodium (Nasalcrom)
Indications for mast cell stabilizers
When do mast cell stabilizers work best?
BEFORE symptoms, work best at preventing allergic rhinitis symptoms
-(once the mast cell degranulates & histamine is released, the drug really has no effect)
MOA of mast cell stabilizers
-stabilizes mast cells so there is no degranulation & release of histamine
how are mast cell stabilizers given? and how long until they start to work
topically (spray up nose)
-takes 1-2 weeks to start to work and have to take 3-4 times per day
-not very convenient or poplular
ADRs of mast cell stabilizers
-few, some nasal stinging & sneezing
What is the drug of choice for sneezing and rhinorrhea from pregnancy?
mast cell stabilizers because not absorbed so there's no risk to fetus
Ipratropium nasal spray (atrovent)
MOA of cholinergic blockers
and mode of delivery
antagonize cholinergic receptors in nasal passages
-inhibits secretions from serous and seromucous glands lining the nasal mucosa
indications for cholinergic blockers
dries up rhinorrhea
ADRs of cholinergic blockers
HA, dry nose, nose bleeds
MOA & delivery of leukotriene inhibitors
-MOA: leukotrienes released in response to allergic rxns
-these drugs inhibit leukotrienes and decrease response in allergic/hypersensitivity rxns
indications for leukotriene inhibitors
-in ear, nose, & throat disease only use for allergic or seasonal rhinitis
-more of role in asthma
What class would you use for vertigo/motion sickness?
What do H1 drugs suppress to treat vertigo/motion sickness?
And which drug is best?
-dizziness/vertigo are sx seen with vestibular dysfxn
-1st gen H1 blockers work best, Meclizine
Which drug effective for motion sickness?
-also a vestibular problem
-dimenhydrinate (dramamine) a sedating H1 blocker
What is Allergic Rhinitis
a hypersensitivity reaction up the nose and in the throat to an antigen in the air
Primary drugs used for allergic rhinitis
-Antihistamines (help sx of sneezing, rhinorrhea, itching, & conjuncivitis
-Decongestants for nasal congestion
-Nasal corticosteroids (treat all, but take time)
Second line drugs for allergic rhinitis
-Anti tussive if dry cough
-expectorant if productive
How to pick H1 blocker for allergic rhinitis
-1st & 2nd gen work equally well
-1st gen cause drowsiness (good @ bedtime if trouble sleeping)
-2nd gen cause less sedation
-try one, if doesn't work, try the other
If using one H1 blocker for allergic rhinitis but effect wears off, what do you do?
Works but effects wear off then try a new h1 blocker
-switching groups often helps restore effectiveness
What do you combine for allergic rhinitis
-pros & cons of combining drugs?
-decongestant, antihistamine, antitussive together
-cons: may get exposure to drugs you don't need
May combine drugs for allergic rhinitis but what is better?
to just use what controls the symptoms. Look at effect of one drug and add another group if necessary
URI or viral rhinitis
Note about allergic rhinitis vs viral rhinitis (sx? drugs?)
-similar sx to allergic rhinitis but different pathology so
-meds work differently
What meds proven beneficial in colds?
decongestants and antipyretics
what medications might help a little for viral rhinitis/cold
antitussives, nasal steroids, ipratropium
Which medications don't help colds at all and may slow down improvement
Meds in sinusitis are similar to
When should antihistamines be used for sinusitis?
ONLY if patient has allergic rhinitis TOO.
-if you think there is bacterial involvement, antihistamines may slow down improvement
Medications and sinusitis
-antihistamines only if allergic TOO
-nasal steroids help only a little
-abx only if bacterial
-don't know effect of decongestants