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OTC Allergic Rhinitis Flashcards

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1
Q

Classification of “Seasonal” Allergic Rhinitis (SAR)?

Classification depends on timing and duration of symptoms

A

Intermittent

Specific allergens responsible

Predictable occurrence

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2
Q

Classification of “Perennial” Allergic Rhinitis (PER)?

Classification depends on timing and duration of symptoms

A

Persistent

Non-seasonal allergens responsible

Year round occurrence (pet, cats, mold,)

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3
Q

Causes of Non-Allergic Rhinitis?

A

*Overuse of topical decongestants – Only can use for 3 days, after will cause rebound congestions

Drug-Induced
B-Blockers
ACEIs
Chlorpromazine
Clonidine
Hydralazine
Oral Contraceptives
ASA
NSAIDS
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4
Q

Immune Response: Immediate

A

Immediate reaction - within minutes of exposure

Rapid release of histamine, chemotactic factors, kinins, leukotrienes

Causes vasodilation, nasal congestion, and secretion of mucous – Use Nasal Congest-ant to constrict.

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5
Q

Immune Response: Late phase

A

Late phase reaction - several hours later

Renewed allergic symptoms due to influx of inflammatory cells & hyperresponsive mucosa (nasal congestion, rhinorrhea)

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6
Q

Signs and Symptoms of Allergic Rhinitis - Important Slide

A 
Rhinorrhea 
Nasal congestion
Pruritus (eyes, nose)
Ocular discharge (lacrimation)
Sneezing
Postnasal drip
Conjunctivitis

“Allergic shiners” —Black Eyes

“Allergic salute”—tip of nose

“Allergic gape”—sleep with mouth open

Decreased sense of smell (hyposmia)

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7
Q

Physician Referral for Allergic Rhinitis

A

Children < 12 years of age*

Pregnant or lactating women*

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8
Q

Goals of Therapy: Allergic Rhinitis

A

Goals of Therapy

Reduce symptoms

Provide optimal symptomatic relief and control of symptoms
Improve the patient’s functional status and sense of well being

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9
Q

Non-Pharmacologic Therapy: Avoidance

A

Avoidance of allergens is the most important and safest method in preventing symptoms of allergic reactions

Indoor Allergens:
Encasing mattress, box springs, and pillows with dust-mite impermeable materials

Outdoor Allergens:

Avoiding outdoor activities when pollen counts are high and closing house and car windows

Avoiding activities that disturb decaying plant material

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10
Q

Non-Pharmacologic Therapy Examples?

A

HEPA filter
(High Efficiency Particulate) : Helpful with dust mites

Nasal Passage Strips

Nasal Wetting Agents

Neti-Pots:

MUST USE SALT PACKETS—SODUIM CHOLRINE PACKETS IN NASAL SPRAY

DON’T USED Table SALT

DO NOT USE TAP WATER, USE DISTILLED WATER

GREAT FOR PREGNANT PATIENTS

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11
Q

Non-Pharmacologic Therapy : Nasal Wetting Agents

A

May relieve nasal irritation and dryness therefore decreasing stuffiness, rhinorrhea, and sneezing

Saline (i.e. Ocean Nasal Spray ®), propylene, polyethylene glycol sprays

Neti-pots, saline nasal irrigation systems

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12
Q

Non-Pharmacologic Therapy : HEPA filters

A

Removes pollen, mold spores, and cat allergens

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13
Q

Non-Pharmacologic Therapy:

Nasal Passage Strips

A

Vicks ® Breathe Right Strips

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14
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

Regularly or As needed

A

must use REGULARLY

i.e. antihistamines and mast cell stabilizers

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15
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

SAR (Seasonal Allergic Rhinitis)

A

Start medications at least 1 week before symptoms usually appear

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16
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

PER (Perennial Allergic Rhinitis)

A

Start medications before known exposure

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17
Q

Length of Therapy: Pharmacotherapy therapy

A

Duration and severity of symptoms

Pattern of allergen exposure (i.e. episodic vs. continuous)

Geographical location -WORSENS symptoms (could be in the amazon forest)

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18
Q

Pharmacotherapy for Allergic Rhinitis

A

Intranasal Corticosteroids

Antihistamines
(Systemic): First generation (sedating, nonselective)

Second generation (non-sedating, peripherally selective)

Topical Ophthalmic Antihistamines

Cromolyn Sodium Nasal Spray

Decongestants:
Systemic Decongestants
Topical Nasal Decongestants

Combination Products – ALLEGRA D

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19
Q

Intranasal Corticosteroids

A

Nasacort ® Allergy 24 HR
Triamcinolone acetonide

Flonase ® Allergy Relief
Fluticasone propionate

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20
Q

Intranasal Corticosteroids: Adverse Effects

A

sore throat

DO NOT AIM TOWARDS NASAL SEPTUM??? TILT HEAD DOWN A BIT TOWARDS THE NASAL SPRAY.

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21
Q

Administration of FLONASE

A

GOLD STANDARD

Do NOT blow nose for 15 minutes after use

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22
Q

Intranasal Corticosteroids: Ages

Which gets put to 2 sprays?

Focus on AGE, Dose is just there for completion

Study These Flashcards
A

Nasacort ® Allergy 24 HR
6 to < 12 years

Want the lowest effective dose: 1 spray in each nostril once daily may increase to 2 sprays in each nostril once daily if uncontrolled symptoms (wiggle room)

Fluticasone propionate

4 to < 12 years

Dose: 1 spray in each nostril once daily

23
Q

List the Antihistamines

Study These Flashcards
A

Benadryl ® Allergy
Diphenhydramine

Chlor-Trimeton ® Allergy
Chlorpheniramine

Zyrtec ®
Cetirizine

Allegra ® Allergy
Fexofenadine

Claritin ®
Loratadine

24
Q

Antihistamines Indications

Study These Flashcards
A

temporary relief of hay fever or upper respiratory allergies:

Sneezing
Runny nose
Itchy watery eyes
Itching of the nose and throat

25
What's the difference between 1st generation antihistamines and 2nd generation antihistamines?
1st generation NON-selective “sedating antihistamines" 2nd generation peripherally SELECTIVE “non-sedation antihistamines”
26
*Systemic OTC Antihistamines*: 1st generation specifics
Class: Alkylamine and Ethanolamine **Sedation** : Ethanolamine (more sedative) "Diphenhydramine HCL/citrate Doxylamine succinate Clemastine fumarate" > Alkylamine (less sedative than Ethanolamine) (Brompheniramine maleate Chlorpheniramine maleate) Strong Anticholinergic Effects Very Lipophilic molecules Nonselective “Sedating Antihistamine"
27
*Systemic OTC Antihistamines*: 2nd generation specifics
Piperazines -(more sedating) Cetirizine-non sedating cause 10%, active metabolite hydrazine (sleep) Piperidines Fexofenadine Loratadine Sedation: Piperazines > Piperidines
28
1st Generation Sedating Antihistamines
Benadryl ® Allergy Diphenhydramine Chlor-Trimeton ® Chlorpheniramine Tavist ® Allergy Clemastine Children’s Dimetapp Brompheniramine** 1 mg/ 5 mL + Phenylephrine Vicks ® NyQuil Doxylamine** 12.5 mg/ 30 mL + Dextromethorphan 30 mg/ 30 mL + APAP
29
1st Generation Warnings
Should NOT use more than 7 days Adverse effects: (not used for AR) Anticholinergic: Dryness (eyes, mouth, nose), blurred vision, urinary retention, constipation, nausea/vomiting, loss of appetite CNS Depression: Sedation/ drowsiness, psychosis*** Avoid other CNS depressants Use caution/ avoid in geriatric or older patients Increased fall risk (avoid in geriatrics) ** ``` Contraindicated Acute asthma (uncontrolled), narrow-angle glaucoma, benign prostate hypertrophy (BPH), bladder obstruction ``` Drug Interactions: CNS Depressants, Anticholinergics, Monoamine Oxidase Inhibitors (MAOIs) MAOIs- phenelzine (Nardil ®), tranylcypromine (Parnate ®), isocarboxazide (Marplan ®
30
2nd Generation Antihistamines
Claritin D: Loratadine* + Pseudoephedrine Zyrtec: Cetirizine Allegra: Fexofenadine
31
Benifts of 2nd Generation Antihistamines
``` Non-sedating antihistamines are the nonprescription antihistamine therapy of choice for allergic rhinitis: Efficacy Safety Quick onset of action Long duration ```
32
Comparison of label information for Allergic Rhinitis OTC Antihistamines
First Generation: (q4-6q) *Chlorpheniramine, Brompheniramine, Diphenhydramine* --Anticholinergic warnings (i.e. caution in BPH, Glaucoma --NOT FOR elderly, causes Drowsiness 2nd Generation: Once or twice daily Cetirizine: (highest Drowsiness in 2nd generation) Loratadine: No Drowsiness
33
Counseling points: OTC Antihistamines
Fexofenadine: Do not take at the same time as Aluminum or Magnesium antacids Do not take with fruit juices (i.e. grapefruit, apple, orange juice)- separate by at least 2 hours
34
OTC Antihistamines: Product availability What formulation are available?
Immediate and sustained release tablets and capsules, chewable tablets, oral disintegrating tablets and strips, solutions, and syrups (alcohol-free, dye-free, and sucrose-free)
35
Ophthalmic Products; (Antihistamines??) List
Naphcon- A ® Pheniramine** maleate 0.3% + Naphazoline Opcon- A ® Pheniramine** maleate 0.3% + Naphazoline
36
Cromolyn Sodium Nasal Spray : The details
PREFERRED INITIAL DRUG OF CHOICE DURING PREGNANCY AND LACTATION-DOC IN PREGNACY Use: Prevention and treatment symptoms of allergic rhinitis Most effective if used PRIOR to exposure (3-7 days) i.e. SAR (Seasonal Allergic Rhinitis)
37
Nasal Spray: Cromolyn sodium
NasalCrom ® Nasal Spray Cromolyn sodium Cromolyn sodium must cover the entire nasal lining; therefore patients should be instructed to clear nasal passages prior to administration and inhale gently through the nose
38
OTC Decongestants
Sudafed® Pseudoephedrine Sudafed PE ® Phenylephrine Little Noses ® Decongestant Drops : Phenylephrine Afrin ® Nasal Spray Oxymetazoline 4-Way Fast Acting ® Nasal Spray : Phenylephrine Neo-Synephrine ® Nasal Spray Phenylephrine
39
OTC Decongestants: DETAILS MOA AND FDA APPROVAL
NOT approved for OTC self-treatment of congestion associated with sinusitis MOA: Produces vasoconstriction**, resulting in decreased blood flow and shrinkage of tissue in the nasal passage by acting on adrenergic receptors in the blood vessels of the nasal mucosa
40
OTC Decongestants: ADRs Warnings Drug interactions Adverse Events
``` Adverse Effects (Systemic): Cardiovascular stimulation: increased blood pressure, tachycardia, palpitations, arrhythmias ``` CNS stimulation: restlessness, insomnia, anxiety, tremors, hallucinations Warnings: Hypertension, heart disease, diabetes, hyperthyroid, benign prostate hypertrophy (BPH)- very sensitive to ALPHA adrenergic stimulation. (just concentrate at cardiovascular disease. Drug Interactions: Monoamine oxidase inhibitors (MAOI) MAOIs- phenelzine (Nardil ®), tranylcypromine (Parnate ®), isocarboxazide (Marplan ®) - Can get hypertesnive crisis in Patients abover
41
Sudefed with deterrent technology.
Zephrex-D TM and Nexafed TM have methamphetamine deterring technology, has sudefed in it!!!!**** Same price as Sudefed****
42
bioavailability: Sudefed vs Sudafed PE Systemic Decongestants
Phenylephrine Sudafed PE® -- LOW bioavailability Pseudoephedrine Sudafed --Higher BioAvailble Maximum of 7 days
43
2005 Combat Methamphetamine Epidemic Act changed the classification of pseudoephedrine “scheduled listed chemical products
Pseudoephedrine Behind pharmacy counter Limited Quantity 3.6 grams/ day and 9 grams/ month
44
Topical Nasal Decongestants
Rhinitis medicamentosa: --What to do!!!! (Rebound congestion) Treatment of rebound congestion: SLOW WITHDRAWAL Replace with normal saline Systemic decongestants Not to exceed 3 days to prevent rebound congestion – “how quick It works, Diluent (Benechromilchloride),”
45
``` Topical Nasal Decongestants: Nasal Spray (NS)** ``` Counseling Points
Prime the pump before using it the first time Hold the bottle with the nozzle placed between the first two fingers and the thumb placed on the bottom of the bottle Tilt the head forward Gently insert the nozzle tip into one nostril. Sniff deeply while depressing the pump once
46
Topical Nasal Decongestants: Nasal Inhaler** Counseling Points
Warm the inhaler in hand just before use Gently insert the inhaler tip into one nostril and sniff deeply while inhaling Wipe the inhaler after each use ***Discard after 2-3 months even if the inhaler still smells medicinal****
47
Combination Products: Know the contents
Advil Allergy Sinus ® Ibuprofen 200 mg ---HA Pseudoephedrine 30 mg - Allergy Chlorphenirmine 2mg Benadryl Allergy and Sinus APAP 325 Dipenhydramine 12.5 mg Phenylepherine 5mg Zyrtec- D® 12 hour Cetirizine 5 mg Pseudoephedrine 120 mg Advil Allergy Sinus® Chlorpheniramine maleate 2 mg Antihistamine Ibuprofen 200 mg (NSAID)* Pain reliever/fever reducer Pseudoephedrine HCl 30 mg Nasal decongestant
48
Zyrtec- D® 12 hour
Cetirizine 5 mg | Pseudoephedrine 120 mg
49
Benadryl Allergy and Sinus
APAP 325 Dipenhydramine 12.5 mg Phenylepherine 5mg
50
Advil Allergy Sinus
Chlorpheniramine maleate 2 mg Antihistamine Ibuprofen 200 mg (NSAID)* Pain reliever/fever reducer Pseudoephedrine HCl 30 mg Nasal decongestant
51
Phenylephrine Frequency?? 4-Way Fast Acting® Nasal Spray (NS) Vicks® Sinex NS Neo-Synephrine® Little Noses® Decongestant Nose Drops
4 hours
52
Oxymetazoline – Last longer Frequency? ``` Afrin® Original NS Mucinex® NS Zicam® Sinus Relief NS Zicam® Congestion Relief Vicks® Sinex 12 hour ```
10 - 12 hours
53
Levmetamfetamine (l-desoxyephedrine) Propylhexedrine Concentration Data?? Vicks® Vapor Inhaler Benzedrex® Inhaler
(inactive after 2 -3 months)

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