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Do a Power point presentation about Cough Cold Flu and Allergic Rhinitis.
Cough,
Cold, Flu
JIMMY NGUYEN, PHARMD
ASSISTANT PROFESSOR, CLINICAL SCIENCES
AMERICAN UNIVERSITY OF HEALTH SCIENCES
LEARNING OBJECTIVES
Differentiate between signs and symptoms of cold and flu
Describe the mechanism of action of drugs used for treatment of symptoms
associated with the common cold
Assess the patient to determine if the cause of his/her symptoms are due to cold,
influenza or other cause.
Identify the patients that require referral or can be self-treated with nonpharmacological or OTC medications
Describe the pharmacology of decongestants, antitussives, protussives, local
anesthetics, and complementary medicines used for the treatment of signs
and symptoms.
Recommend OTC medication for self-treatment based on individual patient
specific information.
Counsel patients on how to optimally treat sign and
symptoms with OTC medication
Common Cold: Background
A viral infection of the upper respiratory tract.
1 billion cases per year
Children usually have 6-10 colds per year.
Adults younger than 60 years typically have 2-4 colds per
year, whereas adults older than 60 years usually have 1 cold per
year.
Colds are usually self-limiting; however, because symptoms
are bothersome, patients frequently self-medicate and spend
an estimated $3 billion annually on nonprescription cold and
cough products.
Pathophysiology of Colds
Colds are limited to the upper respiratory tract and primarily affect the
following respiratory structures: pharynx, nasopharynx, nose, cavernous
sinusoids, and paranasal sinuses.
Over 200 viruses cause colds. The majority of colds in children and adults
are caused by rhinoviruses.
Other viruses known to cause colds include coronaviruses, parainfluenza,
adenoviruses, echoviruses
Peak viral concentration occur 2-4 days after initial inoculation. Virus
present for 16-18 days
Infected cells release chemokine “distress signals” cascade of active
inflammatory mediators and neurogenic reflexes
Pathophysiology of Colds
Etiology
The most efficient mode of viral transmission is self- inoculation of the
nasal mucosa or conjunctiva after contact with viral-laden secretions
on animate or inanimate objects.
Aerosol transmission is also common.
Hand shake, door knobs, telephones
Coughing or sneezing
Increased susceptibility to colds has been linked to:
Higher exposure rates (e.g., increased population density in classrooms or
day care centers)
Allergic disorders affecting the nose or pharynx; less diverse social networks;
Weakened immune system due to smoking, a sedentary lifestyle, chronic
psychological stress, or sleep deprivation.
Common Cold: Clinical
Presentation
Symptoms appears 1-3 days after infection.
Sore throat is the first symptom to appear, followed by nasal symptoms,
which dominate 2-3 days later.
Nasal symptoms include: congestion, rhinorrhea, sneezing
Cough, although an infrequent symptom ( 3 months of age with rectal temperature ≥104 F or equivalent
< 3 months of age with rectal temperature ≥100.1 F or equivalent
Non-pharmacologic Treatment
Rest
Maintain adequate fluid intake, good nutrition
Humidification
Upright position for nasal drainage
Saline gargles or nasal irrigation
Bulb syringe for infants and toddlers
Cough: Background
Cough is the most common symptom for which patients
seek medical care.
Cough is also a common reason for emergency department visits.
In 2010, cough was the second most common reason for children
younger than 15 years to visit emergency departments and the seventh
most common reason for adults.
Americans spend more than $4 billion
annually on nonprescription cough/cold and related medications, more
than any other nonprescription sales category.
In most cases, cough is protective - facilitates removal of
inhaled foreign particles and excessive secretions
Coughs: Clinical Presentation
Cough is a symptom of diverse infectious
and noninfectious disorders, classified as :
acute (duration of less than 3 weeks),
• subacute (duration of 3-8 weeks), or
• chronic (duration of more than 8 weeks)
•
• Productive cough (wet cough): expels secretions from the lower
respiratory
lungs
ability
tract;
could
impair
ventilation
and
the
to resist infection (e.g., bacterial infections)
• Non-productive cough (dry cough) e.g., GERD, drug induced cough,
viral respiratory tract infection
Cough: Pathophysiology
Defense mechanism to rid the airway of mucus, foreign bodies,
and cellular debris
The “cough control center” is located in the medulla, but separate from
the respiratory control center, coordinate the complex cough response.
Cough is initiated by stimulation of chemically and
mechanically sensitive, vagally mediated sensory
pathways in pharyngeal, laryngeal, esophageal, and
tracheobronchial airway epithelium.
The number of afferent nerves activated and the intensity
of activation may influence the cough threshold.
Coughs: Exclusions to Self-Treat
Treatment Options
Pharmacological
Antitussives & Protussives
Decongestants
Antihistamines
Local Anesthetics
Systemic Analgesics
Non-pharmacological
Fluid intake, adequate rest, a nutritious diet as
tolerated, and increased humidification with steamy showers, vaporizers,
or humidifiers
Interventions to promote nasal drainage
Proper hand hygiene
Antitussives and Protussives
FDA-approved nonprescription oral antitussives include:
codeine (Schedule C-V available by Rx in CA only)
dextromethorphan,
diphenhydramine
Protussives (expectorants)
Guaifenesin
Codeine (Schedule V)
Indication: the suppression
of nonproductive cough caused by chemical or mechanical
respiratory tract irritation.
MOA: Codeine acts centrally on the medulla to increase the
cough threshold (suppress the central cough control center).
Codeine is methylmorphine; morphine may be the active antitussive.
Codeine is well absorbed orally with a 15- to 30-minute onset of
action and a 4- to 6-hour duration of effect. The elimination half-life is 2.53 hours.
FDA 2018: Cough and cold medicines containing codeine or
hydrocodone should not be used in those under 18 years
of age because the risks of these medicines outweigh their benefits.
Codeine: ADRs
Usual antitussive codeine dosages have low toxicity and little risk
of addiction.
The lethal dose of codeine in adults is 0.5-
1 gram, with death from marked respiratory
depression and cardiopulmonary collapse.
Codeine-containing Schedule CV products must contain one or more noncodeine active ingredients and no
more than 200 mg of codeine per 100 milliliters.
The most common side effects associated with antitussive codeine
dosages are nausea, vomiting, sedation, dizziness, and constipation.
Codeine: Warnings/Precautions/Pr
egnancy/DDI
Pregnancy category: C
CI: Codeine is contraindicated in patients with known codeine
(or codeine derivatives) hypersensitivity and during labor when
a premature birth is anticipated.
DDI: concomitant use of codeine and central nervous system
(CNS) depressants (e.g., barbiturates, sedatives, or alcohol)
causes additive CNS depression.
Patients with impaired respiratory reserve (e.g., asthma or
COPD) or preexisting respiratory depression, drug addicts, and
individuals who take other respiratory depressants or sedatives, including
alcohol, should use codeine with caution.
Dextromethorphan (DXM) –
Robitussin DM, Delsym
Indication:
suppression of nonproductive cough caused by chemical or mecha
nical respiratory tract irritation.
MOA: acts centrally in the medulla to increase the
cough threshold
It is well absorbed orally with a 15- to 30-minute onset of action and a 3to 6-hour duration of effect.
Dextromethorphan exhibits polymorphic metabolism, with a usual
elimination half-life of 1.2-2.2 hours. However, the half-life may be as long
as 45 hours in people with a poor metabolism phenotype.
Public Health Advisory: FDA Recommends that Over-the-Counter
(OTC) Cough and Cold Products not be used for Infants and Children
under 2 Years of Age.
Currently, FDA does not recommend nonprescription cold medications for
children younger than 2 years because of the lack of efficacy and risk of
misuse or overuse leading to adverse events and death.
Manufacturers have voluntarily updated product labeling to
statement “Do not use in children under four years of age.
include the
DXM: ADRs
Side effects with usual doses are uncommon but may include
drowsiness, nausea or vomiting, stomach discomfort,
or constipation.
Dextromethorphan overdoses & abuse can cause confusion, excitation,
nervousness, irritability, restlessness, drowsiness, as well as severe
nausea and vomiting; respiratory depression may occur with very
high doses.
CI: Patients who have known hypersensitivity to dextromethorphan
or who have a prior history of dextromethorphan dependence should not
take it.
DDI:
Additive CNS depression occurs with alcohol,
antihistamines, and psychotropic medications.
Dextromethorphan should not be taken for at least 14 days after
the MAOI is discontinued.
CA Law requires purchasers of DXM ≥18 yo – verify with proper ID
(no recording keeping required)
Guaifenesin –
Robitussin, Tussin, Mucinex
Indication: only FDA-approved expectorant, is indicated for the symptomatic
relief of acute, ineffective productive cough.
MOA: increases the effective hydration of the respiratory tract,
loosens and thins lower respiratory tract secretions, facilitating its removal
by natural clearance processes.
Few data support its efficacy, especially at nonprescription dosages.
Although the pharmacokinetics of guaifenesin is not well described,
guaifenesin appears to be well absorbed after oral administration,
with a half-life of about 1 hour.
Do not use extended-release tablets in children 12 years:
Formulation
Immediate Release
Extended Release
Dose
200-400mg
600 mg
Frequency
Q4hrs
Q12hrs
Max/day
2400 mg
2400 mg
Counseling point
Take with plenty of
water
• Do NOT
crush/chew
• Take with plenty
of water
Knowledge Check
What is the max daily dose of guaifenesin for adults?
2400 mg
600 mg
1200 mg
3200 mg
4200 mg
Knowledge Check
What is the max daily dose of guaifenesin for adults?
2400 mg
600 mg
1200 mg
3200 mg
4200 mg
Cough: Product Selection
Targeted towards productive or non-productive cough
Combinations of antitussives and protussives
are potentially counterproductive.
Antitussives should not be used to treat productive cough unless the potential
benefit outweighs the risk (e.g., significant nocturnal cough).
What kind of cough are they experiencing?
Phlegmy, chest congestion, productive
Tight, dry and hacking, non-productive
Cough: Non-pharmacological
Non-medicated lozenges may reduce cough
by decreasing throat irritation.
Babies and young children up to about 2 years of age cannot blow
their noses; a rubber bulb nasal syringe may be used to clear
the nasal passages and reduce cough if postnasal drip causes cough.
Propping infants upright when they sleep and raising the head of the bed at
night promotes drainage of nasal secretions.
Less viscous and thus easier-to-expel secretions are formed when
a person is well hydrated. Maintain adequate fluid intake– water!
Cautious hydration is recommended for patients with lower respiratory tract
infections, heart failure, renal failure, or other conditions
potentially exacerbated by over-hydration.
Cough: Non-Pharm - humidifiers
Humidifiers (ultrasonic, impeller, and evaporative)
increase the amount of moisture in inspired air, which may soothe
irritated airways.
High humidity may increase environmental mold, dust mites,
minerals, and microorganisms.
Vaporizers (humidifiers with a medication well or cup for volatile
inhalants) produce a medicated vapor.
Cool-mist humidifiers and vaporizers are preferred because fewer bacteria grow
at the cooler temperatures and there is less risk of scalding if they
are tipped over.
Humidifiers and vaporizers must be cleaned daily and disinfected weekly.
Knowledge Check
John Smith comes into your pharmacy complaining of a hacking
sound cough that has lasted for 2 weeks. He reports no other
symptoms. Patient was exposed to COVID positive patient last
month and suspect it may be "late COVID". He has repeated test
and all have been negative. Smith read online that delysrum is a
good medicaiton to use to suppress his cough and wanted
recommendation.
Is this patient a good candidate for self-treatment?
Knowledge Check
You are a pharmacist working in a busy retail pharmacy. Doctor
sends in a prescription for Mucinex 1200 mg every 4 hours. Your
technicians types up:
Dextromethorphan 400 mg tablet: Take 3 tablet by mouth every 4
hours
What is wrong with this prescription?
Knowledge Check
You are a pharmacist working in a busy retail pharmacy. Doctor
sends in a prescription for Mucinex 1200 mg every 4 hours. Your
technicians types up:
Dextromethorphan 400 mg tablet: Take 3 tablet by mouth every 4
hours
What is wrong with this prescription?
Generic for Mucinex is guaifenesin
Max daily dose of guaifenesin is 2400 mg per day
Oral H1-Antihistamines
Indication: Allergy, rhinorrhea (runny nose), nausea / vomiting (N/V),
and insomnia
Two generations: 1st generation and 2nd generation
Oral H1-Antihistamines
1st Generation Antihistatmine
Selective for H1-receptors and cross blood brain barrier
Cross BBB: reason for sedation effect
Sedative and anticholinergic
Anticholinergic: blurred vision, constipation, dry mouth, tachycardia, urine retention
Diphenhydramine - Benadryl
MOA: Nonselective (first-generation) antihistamine with
significant sedating and anticholinergic properties, acts centrally in
the medulla to increase the cough threshold.
Indication: Diphenhydramine is indicated for the
suppression of nonproductive cough caused by chemical
or mechanical respiratory tract irritation.
Diphenhydramine is well absorbed following oral
administration, with a bioavailability of 40%-70%, an onset of action
of about 15 minutes, and a duration of action of about 4-6 hours.
Use in those ≥ 6 years of age
Diphenhydramine: ADRs
Side effects of diphenhydramine include drowsiness, disturbed
coordination, respiratory depression, blurred vision,
urinary retention, dry mouth, and dry respiratory secretions.
Diphenhydramine may cause excitability, especially in children.
Pregnancy: B
Warnings: Diphenhydramine should be used with caution in patients
with diseases potentially exacerbated by drugs with
anticholinergic activity, including:
narrow-angle glaucoma, stenosing peptic ulcer, pyloroduodenal obstruction,
symptomatic prostatic hypertrophy, bladder-neck
obstruction, asthma and
other lower respiratory tract disease, elevated
intraocular pressure, hyperthyroidism, cardiovascular
disease, or hypertension.
Chlorpheniramine (Chlor-Trimeton)
1st generation antihistamine
Indication: relieve symptoms of allergy, hay fever, and the common
cold
Temporarily relieve sneezing, runny nose, itchy/watery eyes, itching
of nose or throat
Chlorpheniramine (Chlor-Trimeton)
Dosing: 12 mg BID
ADR: drowsniess, dizziness, blurred
vision, dry mouth/nose/throat,
constipation, some memory or
concentration problems
Oral H1-Antihistamines
2nd Generation:
Selective for peripheral H1 receptors
Decrease side effect of sedation
Sedation can still occur
Less CYP450 drug interaction
2nd Generation Drugs:
Cetirizine (Zyrtec)
Fexofenadine (Allegra)
Loratadine (Claritin)
Loratadine (Claritin)
Dosing: 10 mg once daily
Least sedative - along with Fexofenadine (Allegra) of the 2nd
generations
Onset of action 3 hours
Cetirizine (Zyrtec)
Dosing: 10 mg once daily
Most sedative of the 2nd generation antihistamine
NO CYP450 substrate
Onset of action 1 hour (works faster)
Oral H1-Antihistamines
QUESTIONS??
Allergic Rhinitis
CS 713
“Do everything without
complaining or arguing, so that
you may become blameless and
pure, children of God without
fault in a crooked and depraved
generation, in which you shine
like stars in the universe.”
Philippians 2:14-15
2
Objectives
1.
Describe the pathophysiology of allergic rhinitis
2.
Identify common triggers and risk factors of allergic rhinitis
3.
Differentiate between the common cold, non-allergic rhinitis, and allergic rhinitis based
on patient presentation
4.
Recognize exclusion/inclusion criteria to self-care for allergic rhinitis and identify cases
that warrant referral
5.
Recommend an appropriate patient-specific treatment to manage allergic rhinitis,
including pharmacologic and non-pharmacologic therapies
6.
Provide accurate counseling on pharmacologic and non-pharmacologic treatments for
allergic rhinitis
3
Background
❖
Allergic rhinitis:
➢
Also commonly known as “Hay Fever”
➢
A systemic disease with prominent nasal symptoms due to inflammation of
the nasal mucous membranes caused by inhaled allergenic materials
➢
❖
Elicits a specific response mediated by immunoglobulin E (IgE)
Affects adults and children
➢
Symptoms usually begin after the second year of life
➢
Highest prevalence in adults 18-64 years old
➢
After age 65 number of cases decrease
4
Epidemiology
❖ 8% of adults and 11% of children are newly diagnosed each year
❖ Affects up to 30% of adults and up to 40% of children in industrialized
countries worldwide
❖ About $2.4 billion spent on prescription and over-the-counter
medications
5
Pathophysiology
https://www.youtube.com/watch?v=y3bOgdvV-_M
6
Pathophysiology
Figure 1. Adapted by Eilidh Clark from Naish J, Revest P, Court DS 2009 Saunders Elsevier’s Medical Sciences, Edinburgh.
7
Guidelines
❖
Allergic Rhinitis and its Impact on Asthma (ARIA)
❖
Joint Council of Allergy, Asthma & Immunology (JCAAI)
❖
American Academy of Otolaryngology – Head and Neck Surgery
(AAO-HNS)
8
Classifications
❖ Seasonal allergic rhinitis
➢
Intermittent Allergic Rhinitis (IAR)
❖ Perennial allergic rhinitis
➢
Persistent Allergic Rhinitis (PER)
❖ Depends on the timing and
duration of symptoms
❖
Symptoms also classified as
moderate or moderate-severe
Allergic Rhinitis and its impact on Asthma (ARIA) 2019
9
Common Triggers
❖
❖
Indoor Allergens
❖
Occupational Allergens
➢
House dust mites
➢
Wool dust
➢
Cockroaches
➢
Latex
➢
Mold spores
➢
Resins
➢
Cigarette smoke
➢
Biologic enzymes
➢
Pet dander
➢
Organic dusts (flour)
➢
Various chemicals
Outdoor Allergens
➢
Pollen
➢
Mold spores
➢
Pollutants (ozone and diesel exhaust)
10
What Are Some Signs & Symptoms of AR?
11
Signs & Symptoms
Coughing
Blocked or Runny Nose
Ear Discomfort
Watery or Itchy Eyes
with redness
Dry Itchy Skin
Sneezing
Avoid Allergies 2019. www.allergistatlanta.info
Breathing Problem
12
Facial, Nasal, and Throat Features
1.
“Allergic shiners”
2.
“Dennie-Morgan lines”
3.
“Allergic salute”
4.
“Allergic crease”
5.
“Allergic gape”
6.
Nonexudative cobblestone appearance of posterior oropharynx
1
2
3
4
6
13
Allergic Rhinitis vs. Non-Allergic Rhinitis
Symptoms/Findings
Non-Allergic Rhinitis
Allergic Rhinitis
Symptom presentation
Bilateral symptoms, worse upon
Unilateral symptoms common but can
awakening, improve during the day,
be bilateral; constant day and night
then worsen at night
Sneezing
Little or none
Common, paroxysmal
Runny nose
Posterior, thick, cloudy, green or
yellow discharge (infection)
Anterior, watery
Itchy eyes
Not present
Common
Congestion
Usually present and often severe
Variable
Red eyes
Not present
Common
Aches and pains
Variable depending on cause
Sinus pain may be present; throat
pain due to post nasal drip possible
Anosmia
Common
Rare
Epistaxis
Recurrent
Rare
14
Allergic Rhinitis vs. Common Cold
Symptom
Common Cold
Allergic Rhinitis
Sneezing
Usual
Usual
Congestion
Common
Common
Runny nose
Common
Common
Sore throat
Common
Sometimes
Cough
Common
Sometimes
Fatigue, weakness
Sometimes
Sometimes
Body aches and pains
Slight
Never
Fever
Rare
Never
Itchy eyes
Rare – never
Common
Duration
New, recent, 3-14 days
Recurrent, prior diagnosis, weeks
15
Exclusions to Self-Treatment
❖
Children < 12 years old
❖
Pregnant or lactating women
❖
Symptoms of nonallergic rhinitis
❖
Symptoms of otitis media, sinusitis, bronchitis, or other infection
❖
Symptoms of undiagnosed or uncontrolled asthma (wheezing, shortness of
breath), COPD, or other respiratory disorders
❖
Moderate-to-severe persistent allergic rhinitis or symptoms unresponsive to
treatment
❖
Severe or unacceptable side effects of treatment
Unless already diagnosed with AR and approved for self-treatment by a PCP
16
Case Vignette 1
AC is a 22-year-old female presented to pharmacy for OTC
recommendation with a cough, congestion, thick yellow nasal
discharge and a slight loss of sense of smell that started 4 days ago.
1.
What condition does she has?
2.
Can she get OTC meds?
17
Case Vignette 2
JN is a 12-year-old male who has been experiencing coughing at night,
congestion, and shortness of breath when he plays sports or exercises.
His mom comes into the pharmacy asking for over the counter
medication for allergy.
Is he a candidate for self-care? Why or why not?
18
Treatment
❖
No cure
❖
Goals of therapy
➢
Reduce symptoms
➢
Improve patient’s functional status
and sense of well being
➢
❖
Quality of life
Individualized treatment to provide
optimal symptomatic relief
19
Approach to Treatment
❖
❖
Three steps of treatment:
1.
Allergen Avoidance
2.
Non-Pharmacotherapy & Pharmacotherapy
3.
Immunotherapy
Maximize each step before moving to the next
➢
Allergen avoidance usually not sufficient alone; targeted therapy with
single drug is usually indicated
20
Allergen Avoidance - Indoor
House dust mites
■
■
■
■
Lower household humidity to less than 40%, use acaricides
Remove carpets, upholstered furniture, stuffed animals, and bookshelves
Encase mattress, box springs, and pillows in mite-impermeable materials
Wash un-encased bedding weekly in HOT (130F) water
Cockroaches
■
■
■
Keep kitchen areas clean
Keep food stored tightly
Treat with baits or pesticides
Mold spores
■
■
■
■
Prevalent in late summer and fall
Lower household humidity
Remove houseplants
Vent food preparation areas and bathroom
21
Allergen Avoidance - Indoor
❖
Cigarette smoke
❖
Pet dander
➢
❖
Weekly cat baths (unproven)
HEPA Filters
➢
Ventilation systems with high-efficiency particulate
air (HEPA) filters
➢
Remove pollen, mold spores, and cat allergens from
household air
➢
Do not remove fecal particles from house-dust
mites, which settle to the floor too quickly to be
filtered
22
Allergen Avoidance - Outdoor
❖
Pollen
➢
Pollen Counts - https://weather.com/forecast/allergy/l/USCA0412:1:US
➢
Trees pollinate in spring, grasses in early summer
➢
Ragweed pollinates from mid-August to the first fall frost
Pollen counts highest early in the morning and lowest after a rainstorm
➢
❖
Mold spores
➢
➢
❖
Prevalent in late summer and fall
Avoid activities that disturb decaying plant material (e.g., raking leaves)
Pollutants (ozone and diesel exhaust)
➢
Be aware of the air quality index (AQI; a measure of five major air pollutants per 24
hours) and plan outdoor activities when the AQI is low
➢
https://airnow.gov/index.cfm?action=airnow.local_city&zipcode=92840&submit=Go
23
Non-Pharmacologic Agents
Nasal wetting agents
➢
Saline, polyethylene glycol sprays or gels
➢
Nasal irrigation with warm saline
■
Isotonic or hypertonic
■
Syringe or Neti-Pot
■
Use only distilled, sterile, or boiled tap water
➢
Relieve nasal mucosal irritation and dryness
➢
Decrease nasal stuffiness, rhinorrhea, sneezing
➢
Adverse effects: mild stinging or burning
24
http://www.neilmed.com/knowledgebase/article/58/how-come-the-saline-solution-does-not-drain-out-the-opposite-nostril-when-i-try-to-do-irrigation
25
How To Use Nasal Irrigation System
https://www.youtube.com/watch?v=GR9bC_wVuVg
26
Pharmacologic Therapy
❖
Intranasal Corticosteroid
❖
Antihistamines: Oral and Ophthalmic
❖
Decongestants: Oral and Intranasal
❖
Mast cell stabilizer (cromolyn)
27
Intranasal Corticosteroids (INCS)
❖
Mechanism of action
➢
Inhibit multiple cell types and mediators stopping the “allergic cascade”
❖
Most effective treatment for moderate-severe IAR and both types of PER
❖
1st line treatment for Allergic Rhinitis
❖
Common side effects:
➢
❖
❖
Nasal discomfort, bleeding, sneezing
Rare but serious side effects:
➢
Changes in vision, glaucoma, cataracts
➢
Increased risk of infection, growth inhibition in children
If no relief of symptoms after 2 weeks of use refer to PCP or allergist
28
Intranasal Corticosteroids (INCS)
Triamcinolone
Fluticasone
Budesonide
29
INCS Comparison
Brand
Nasacort
Flonase
Rhinocort
Generic
Triamcinolone
Fluticasone
Budesonide
Time to relief
7-8 hrs
2-12 hrs
10 hrs
Max efficacy
up to 2 weeks
up to 3-4 days
up to 2 weeks
Direction
2 sprays in each
nostril/day
2 sprays in each
nostril/day
2 sprays in each
nostril/day
Age recommendations
> 2 years old
> 4 years old
> 6 years old
https://www.flonase.com/about/
http://www.rhinocort.com/
http://nasacort.com/otc-nasal-spray.aspx
30
Intranasal Spray Administration
https://www.pharmacytimes.com/publications/issue/2015/july2015/rd362_july2015 31
Antihistamines
❖
Mechanism of action
➢
Compete with histamine at central and peripheral histamine receptor sites
➢
Prevent histamine from binding and subsequent mediator release
➢
Second generation antihistamines: inhibit release of mast cell mediators and may
decrease cellular recruitment
➢
Highly selective for H1 receptors but have little effect on H2, H3, or H4 receptors
32
First Generation Antihistamines
❖
Commonly called sedating antihistamines
➢
❖
❖
Highly lipophilic molecules that readily cross the blood brain barrier
Non-Selective
➢
Excessive H1 receptor and cholinergic receptor blockade
➢
Alpha adrenergic and serotonergic activity
Side effects
➢
Anticholinergic
➢
Anti-serotonin
➢
Anti-alpha-adrenergic
33
Second Generation Antihistamines
❖
Commonly called non-sedating antihistamines
➢
Large protein bound molecules with charged side chains, do not readily cross the
blood brain barrier
❖
1st generation may be more effective for allergic rhinitis however side
effect profile causes 2nd generation to be drugs of choice
➢
Cetirizine causes sedation in 10% of patients; most potent second generation
antihistamine
34
Antihistamines
Generic
Product
Drowsiness
Anticholinergic
Alkylamine class, 1st generation
Bronpheniramine
Chlorpheniramine
Dimetane
Chlor-Trimeton
+
++
Ethanolamine class, 1st generation
Clemastine
Tavist
++
+++
Diphenhydramine
Benadryl
+++
+++
+
+/-
Piperazine class, 2nd generation
Cetirizine
Zyrtec
Piperidine class, 2nd generation
Loratadine
Claritin/Alavert
+/-
+/-
Fexofenadine
Allegra
+/-
+/35
Ophthalmic Antihistamines
Loratadine
Ketotifen
Cetirizine
36
Ophthalmics Administration
http://www.safemedication.com/safemed/docs/Eye-Drop-Flyer.pdf
37
Ophthalmics Administration (Cont.)
http://www.safemedication.com/safemed/docs/Eye-Drop-Flyer.pdf
38
Decongestants
❖
Mechanism of action:
➢
❖
Adrenergic agonists: causing blood vessel constriction
Indicated for temporary relief of sinus and nasal congestion and for cough
associated with post-nasal drip
❖
Types of decongestants:
➢
Systemic decongestant
■
➢
➢
Pseudoephedrine and phenylephrine
Intranasal short-acting:
■
Ephedrine, epinephrine, levmetamfetamine, naphazoline
■
Phenylephrine, propylhexedrine, tetrahydrozoline
Intranasal long-acting:
■
Xylometazoline and oxymetazoline
39
Combat Methamphetamine Epidemic Act (2005)
❖
All pseudoephedrine products must now be kept in secure areas (e.g., behind a
pharmacy counter or in a locked cabinet)
❖
The following information from each sale must be entered into a written or
electronic logbook: product name, quantity sold, patient’s name and address,
and time and date of sale.
➢
❖
Patients must show valid identification to purchase pseudoephedrine and then sign
the logbook.
Allowed limits to be placed on sales of pseudoephedrine
➢
➢
Daily: 3.6 grams
Monthly: 9 grams
40
Decongestant Adverse Effects
❖
Cardiovascular stimulation (e.g., elevated blood pressure, tachycardia,
palpitation, or arrhythmias)
❖
CNS stimulation (e.g., restlessness, insomnia, anxiety, tremors, fear, or
hallucinations)
❖
Topical (intranasal) decongestants do not generally cause these ADRs because
they are minimally absorbed
➢
➢
➢
ADRs include propellant – or vehicle-associated effects (e.g., burning, stinging,
sneezing, or local dryness) and trauma from the tip of the device.
Rhinitis medicamentosa (i.e., rebound congestion) has been associated with
topical decongestants.
Therapy should only be for 3 -5 days with these products.
41
Decongestants Warnings & Contraindications
❖
Decongestants are contraindicated in patients receiving concomitant MAO
inhibitors (MAOIs).
❖
Decongestants may exacerbate diseases sensitive to adrenergic stimulation,
such as hypertension, coronary heart disease, ischemic heart disease, diabetes
mellitus, hyperthyroidism, elevated intraocular pressure, and prostatic
hypertrophy.
❖
Patients with hypertension should use decongestants only with medical advice.
➢
No clear evidence exists that any one agent is safer than other agents in patients
with hypertension.
42
Combination Products
Brand Name
Ingredients
Actifed Allergy Nighttime Caplets
Diphenhydramine HCl 25mg
Pseudoephedrine HCl 30mg
Advil Allergy Sinus Tablets
Chlorpheniramine 2mg
Pseudoephedrine HCl 30mg
Ibuprofen 200mg
Allerest Maximum Strength Tablets
Chlorpheniramine 2mg
Pseudoephedrine HCl 30mg
Claritin-D 24 Hour Tablets
Loratadine 10mg
Pseudoephedrine sulfate 240mg
Tylenol Severe Allergy Tablet
Diphenhydramine HCl 12.5mg
Acetaminophen 500mg
43
Intranasal Cromolyn Sodium
❖
Mechanism of action:
➢
Mast cell stabilizer- prevents release of mediators
❖
Approved for age >2 years old
❖
Treatment needs to be started before symptoms begin
❖
Requires 3-7 days for initial treatment to become effective
and 2-4 weeks of continued therapy to get maximal benefit
❖
Side effects
➢
Sneezing, nasal stinging, burning
44
Pregnancy & Lactation
❖ Pregnancy is a common cause of allergic rhinitis – refer for dx
❖ Lactation – refer for dx
❖ Antihistamines:
■
Chlorpheniramine – Drug of choice due to long history of safety
■
Loratadine – low risk
■
Cetirizine – low risk
■
Fexofenadine – moderate risk
■
Take at bedtime after the last feeding
45
Pregnancy & Lactation (Cont.)
❖ Nasal Sprays
➢
Cromolyn (use if patient is breastfeeding)
➢
Triamcinolone (category C)
➢
Fluticasone (category C)
➢
Budesonide (category B)
❖ Decongestants
➢
AVOID phenylephrine
➢
Pseudoephedrine AFTER 1st trimester if no HTN or preeclampsia risk
46
Geriatrics
❖
Beer’s List
➢
➢
❖
Oral Antihistamines
➢
➢
❖
List of medication that should be used with caution or avoided in elderly (>65 years old)
Increased risk of CNS-depressive adverse effects including sedation and hypotension
■
Increased risk of falls
Avoid sedating 1st generation antihistamines
Also assess for additive sedative effects from other medications
Decongestants
➢
Do not recommend pseudoephedrine if patient has uncontrolled HTN
■
Also assess for drug-drug interactions with pseudoephedrine
➢
Combination products with NSAIDs should be avoided in possible due to increase
cardiovascular and GI bleed risk.
❖
Drugs of choice:
➢
Antihistamine: Loratadine
➢
Nasal spray: Intranasal cromolyn
47
Pharmacotherapy Chart Summary
Therapy
Sneezing
Rhinorrhea
Itching
Congestion
ADRs
Intranasal
Corticosteroid
+++
+++
+++
+++
+
Intranasal
Antihistamine
+++
++
+++
+
– to +
1st generation
Antihistamine
+++
+++
+++
+
+++
2nd generation
Antihistamine
+++
++
+++
+
– to +
2nd generation
Antihistamine +
Decongestant
+++
+++
+++
+++
+++
Cromolyn
++
+
+
+
–
Decongestant
–
+
–
+++
+++
48
Summary
Allergic Rhinitis and its impact on Asthma (ARIA) 2019.
49
References
❖
Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th
Edition. 2020.
❖
European Academy of Allergy and Clinical Immunology. Global atlas of allergic
rhinitis and chronic rhinosinusitis. Zurich, Switzerland: EAACI; 2015.
❖
Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection,
and diagnosis. J Allergy Clin Immunol. 2001;108(1 Suppl):S2-8.
❖
Brożek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma
(ARIA) guidelines-2019 revision. J Allergy Clin Immunol. 2019.
❖
Naish J, Revest P, Court DS 2009 Saunders Elsevier’s Medical Sciences, Edinburgh.
50
Allergic Rhinitis
Part Two – Version 20231004
Dr. Transon Nguyen
Please read through Part 1’s slides from the first hour of today’s lecture.
https://docs.google.com/presentation/d/1rugRmjXPn_srV_jEW5bxeAJfQgnxOLbk2agVErbd4bw/edit?usp=sharing
1
2
Allergic Rhinitis
(Endorsed 2014) (Reaffirmed, April 2020)
The guideline, Allergic Rhinitis, was developed by the American
Academy of Otolaryngology-Head and Neck Surgery and was
endorsed by the American Academy of Family Physicians.
https://journals.sagepub.com/doi/full/10.1177/0194599814561600
https://emedicine.medscape.com/article/134825-guidelines
3
Allergic Rhinitis
(Endorsed 2014) (Reaffirmed, April 2020)
The guideline, Allergic Rhinitis, was developed by the American Academy of Otolaryngology-Head and Neck Surgery and
was endorsed by the American Academy of Family Physicians.
https://journals.sagepub.com/doi/full/10.1177/0194599814561600
https://emedicine.medscape.com/article/134825-guidelines
This … is a “Self-Care” course … is “self-care” equivalent to “OTC” ?
Why do we have to learn the prescriptions in these lecture …
Because we are ALWAYS learning … https://youtu.be/8mhadN-8oZE
4
●
●
●
●
●
●
The diagnosis of allergic rhinitis (AR) should be made when history and physical findings are
consistent with an allergic cause (e.g., clear rhinorrhea, pale discoloration of nasal mucosa, and red and watery
eyes) and one or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing .
Individuals with AR should be assessed for the presence of associated conditions such as
asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media.
Specific IgE testing (blood or skin) should be performed for patients with a clinical diagnosis of
AR who do not respond to empiric treatment, or when diagnosis is uncertain, or when
determination of specific target allergen is needed.
Sinonasal imaging should not routinely be performed in patients presenting with symptoms
consistent with allergic rhinitis.
Intranasal steroids should be prescribed for patients with AR whose symptoms affect quality of
life.
Oral second-generation/less sedating antihistamines should be prescribed for patients with
AR and primary complaints of sneezing and itching.
5
●
●
●
●
●
●
Intranasal antihistamines may be prescribed for patients with seasonal, perennial, or episodic AR.
Oral leukotriene receptor antagonists should not be prescribed as primary therapy for patients with AR.
Combination pharmacologic therapy may be prescribed for patients with AR who have
inadequate response to monotherapy. The most effective combination therapy is an intranasal
steroid and an intranasal antihistamine.
Immunotherapy should be prescribed for patients with AR who have inadequate response to
pharmacologic therapy.
Avoidance of known allergens or environmental control may be considered in patients with AR
who have identified allergens that correlate with their clinical symptoms.
Inferior turbinate reduction may be considered for patients with AR with nasal airway obstruction
and enlarged inferior turbinates who have failed medical management.
6
Term
Definition
Allergic rhinitis
(AR)
Disease caused by an IgE-mediated inflammatory response of the nasal mucous membranes after exposure to
inhaled allergens. Symptoms include rhinorrhea (anterior or posterior nasal drainage), nasal congestion, nasal
itching, and sneezing.
Seasonal allergic
rhinitis (SAR)
Disease caused by an IgE-mediated inflammatory response to seasonal aeroallergens. The length of seasonal
exposure to these allergens is dependent on geographic location and climatic conditions.
Perennial allergic
rhinitis (PAR)
Disease caused by an IgE-mediated inflammatory response to year-round environmental aeroallergens. These
may include dust mites, mold, animal allergens, or certain occupational allergens.
Intermittent allergic
rhinitis
Disease caused by an IgE-mediated inflammatory response and characterized by frequency of exposure or
symptoms (4 weeks per year).
Episodic allergic
rhinitis
Disease caused by an IgE-mediated inflammatory response that can occur if an individual is in contact with an
exposure that is not normally a part of the individual’s environment. (ie, a cat at a friend’s house).
7
8
9
10
11
12
13
Intranasal Steroids and Oral Antihistamines
When patients have no response to INS or incomplete control of nasal symptoms with an INS, oral antihistamines
should not be routinely used as additive therapy. The largest trials have shown no benefit of taking an INS plus oral
antihistamine compared with INS plus placebo in adults.259,260
A Cochrane review including only one study of adequate quality found no evidence to support this combination in children. 261
Oral Antihistamines and Oral Decongestants
Oral antihistamines and oral decongestant combinations control AR symptoms better than either oral
antihistamine or oral decongestant alone. This benefit has been consistently demonstrated in multiple randomized,
placebo-controlled trials, each with more than 500 subjects enrolled.262-270 Adding an oral decongestant to a
second-generation antihistamine increases side effects of insomnia, headache, dry mouth, and nervousness.263,264,267
Additionally, the potential for tolerance from chronic use of oral decongestants may be seen.
In one study, 24-hour extended-release pseudoephedrine (240 mg) caused less insomnia than 12-hour extended-release
pseudoephedrine (120 mg) taken twice daily (4% vs 15%, P < .01).271 A 2005 meta-analysis concluded that “pseudoephedrine
caused a small but significant increase in systolic blood pressure (0.99 mm Hg; 95% CI, 0.08 to 1.90) and heart rate (2.83
beats/min; 95% CI, 2.0 to 3.6), with no effect on diastolic blood pressure (0.63 mm Hg, 95% CI, –0.10 to 1.35).” 272 Oral
decongestant use is not recommended for patients under 4 years of age, and the extended-release, 120-mg, 12-hour dose is
not recommended for patients under 12 years of age.
14
15
Oral Antihistamines and Leukotriene Receptor Antagonists
There is conflicting evidence as to whether combined treatment with oral antihistamine and LTRA is superior to either as
single treatment, and therefore routine use of combined therapy is not recommended. Combinations of oral antihistamines
and LTRAs were equivalent to oral antihistamine alone within arms of several studies.273-277 Alternatively, some trials showed
that oral antihistamine plus LTRA was superior to oral antihistamine alone278-280 or LTRA alone278,279 for AR symptoms. Other
studies showed a benefit when combining oral antihistamine and LTRA compared with oral antihistamine or LTRA in
preventing symptoms,281 in patients who had poor control with LTRA monotherapy,282 and specifically in nighttime
symptoms.276 Combination of oral antihistamine and LTRA is either inferior to273,283-285 or less likely equivalent to277 INS
monotherapy in control of AR symptoms.
Intranasal Steroids and Leukotriene Receptor Antagonists
LTRAs should not routinely be used as additive therapy for patients benefiting from INS for AR. 283,286,287 Three studies with
arms that compared INS to INS + LTRA did not show a significant benefit to adding LTRA for their primary outcome. The
largest trial enrolled 102 patients.287
Intranasal Steroids and Intranasal Antihistamines
The combination of INS and intranasal antihistamine is more effective than INS or intranasal antihistamine monotherapy for
AR.243,288-290 This benefit has been demonstrated across multiple symptoms of AR and in patients with moderate to severe
symptoms.290 In patients who tolerate INS or intranasal antihistamine spray and have inadequate control of AR symptoms
with a single agent, combined INS + intranasal antihistamine is an effective option.243,288-290
16
Intranasal Steroids and Intranasal Oxymetazoline
The combination of INS and intranasal oxymetazoline is more effective in controlling AR symptoms than either
monotherapy.291-294 The development of rhinitis medicamentosa (rebound nasal congestion from overuse of
intranasal oxymetazoline) is a concern. The sizes and lengths of the currently available studies are insufficient to draw
conclusions about the risk of rhinitis medicamentosa. Short-term use (
