37. Allergic Rhinitis, Cough + Cold Flashcards
How to tell difference between cold vs allergic rhinitis
Cold: sneezing, runny nose, thick+dark mucus, sore throat, body aches // symptoms take about 3 days to appear, and usually last about a week
Allergy: sneezing, runny nose, thin+clear mucus, wheezing, red/watery eyes // symptoms can last for days or months
____ are first line for chronic, moderate-to-severe symptoms of allergic rhinitis
Intranasal steroids
____ can be used for milder, intermittent symptoms of allergic rhinitis
Oral antihistamines
MOA of intranasal steroids
Decrease inflammation
Common side effect of intranasal steroids
Epistaxis (nose bleeds)
Others: HA, dry nose, unpleasant taste, localized infection
It can take up to ____ to get full relief with intranasal steroid use
One week
___ and ___ are preferred nasal steroid in pregnancy
Budesonide and beclomethasone
Common intranasal steroid examples
Budesonide (Rhinocort)
Fluticasone (Flonase)
Trimacinolone (Nasacort)
Oral antihistamines are effective in reducing symptoms of itching, sneezing, rhinorrhea, and other types of immediate hypersensitivity reactions but have little effect on ____
nasal congestion
Antihistamines MOA
Block H1 receptor site
1st gen Antihistamines examples
Diphenhydramine (Benadryl)
Chlorpheniramine (Aller-Chlor)
Doxylamine (Unisom)
Diphenhydramine (Benadryl) adult dosing
25mg PO Q4-6H or 50mg PO Q6-8H (max 300mg/day)
Diphenhydramine (Benadryl) age <6yo dosing
Do NOT use OTC unless directed by HCP
Warnings for 1st gen oral antihistamines
Avoid in elderly - strong anticholinergic effects, Beer’s criteria
Use caution in CVD, prostate enlargement, glaucoma, asthma, pyloduodenal obstruction and thyroid disease
Do NOT use with MAOi (especially celmastine or carbinoxamine)
Side effects for 1st gen oral antihistamines
Somnolence, cognitive impairment, strong anticholingeric effects (dry mouth, blurred vision, urinary retention, constipation) and seizures/arrhythmias at higher doses
2nd gen oral antihistamine examples
Cetirizine (Zyrtec)
Levocetirizine (Xyzal)
Fexofenadine (Allegra)
Loratadine (Claritin)
More sedating vs less sedating 2nd gen oral antihistamines
More = cetirizine, levocetirizine
Less = fexofenadine, loratadine
If using in pregnancy, which 2nd gen oral antihistamines are preferred?
Loratadine and cetirizine
Which 2nd gen oral antihistamine should pts take with water (not fruit juice d/t less absorption)
Fexofenadine
Which 2nd gen oral antihistamines have fast onset and may work best for some patients?
Cetirizine and levocetirizine
Some allergy products come as a combination product with _____, indicated with “-D” in the name
Pseudoephedrine or phenylephrine
What are some examples of intranasal antihistamines?
Azelastine (Astepro)
Olopatadine (Patanase)
Note: can be combined with intranasal steroid (increases cost and risk for side effects)
T/F: intranasal antihistamines should not use with intranasal steroids
False - can be combined with intranasal steroid (but increases cost and risk for side effects)
MOA decongestants
Alpha-adrenergic agonists (sympathomimetics), cause vasoconstriction reducing sinus and nasal congestion
Under federal law, max amount allowed to purchase pseudoephedrine, phenylpropanolamine and ephedrine is ____ per day and ____ in a 30-day period
3.6g per day
9g in 30 day period
To combat the methamphetamine epidemic, there are restricted sales of OCT products containing _____ since these can all be converted easily to methamphetamine
Pseudoephedrine, phenylpropanolamine, ephedrine
Which decongestants should not be used within 14 days of MAOi?
Phenylephrine (Sudafed PE) and pseudoephedrine (Sudafed, Nexafed, Zephrex-D)
Phenylephrine and pseudoephedrine should be avoided in children ___ (FDA) and ___ (package labeling)
<2 yo (FDA), <4 yo (package labeling)
Warnings with phenylephrine and pseudoephedrine
Use with caution in pts with CV disease and uncontrolled HTN (can increase BP), BPH (can cause urinary retention, DM (can increase BG)
Others: hyperthyroidism (can worsen), bowel obstruction, glaucoma (can increase IOP), renal impairment, seizure disorder, the elderly
Side effects with phenylephrine and pseudoephedrine
CV stimulation (tachycardia, palpitations, increased BP), CNS stimulation (anxiety, tremors, insomnia, nervousness, restlessness, fear, hallucinations), decreased appetite, dizziness, HA
Oral decongestants should be avoided in ___ trimester of pregnancy
first
Intranasal decongestant examples
Oxymetazoline (Afrin), phenylephrine (has more side effects than Afrin)
Warnings for intranasal decongestants
Use caution in pts with BPH, CVD, uncontrolled HTN, thyroid disease, DM
Side effects of Intranasal decongestants
Rhinitis medicamentosa (rebound congestion if used longer than 3 days)
Others: nasal stinging, burning, and dryness, sneezing, trauma from tip of the device
If Afrin (oxymetazoline) is used longer than 3 days, what may occur?
Rebound congestion
____ is an OTC mast cell stabilizer sued for treatment and ppx of allergic rhinitis. How is it used to be effective?
Intranasl cromolyn (NasalCrom)
Must be started at the onset of allergy season and used regularly (not PRN) to be effective
NasalCrom is not as effective as other agents but it is safe in which patient populations?
Children ≥2yo and pregnancy
___ is the only leukotriene modifying agent indicated for the treatment of both allergic rhinitis and asthma. It is commonly used in children
Montelukast (Singulair)
SL Immunotherapy Oralair contains ____
5 different grass pollen extracts
SL Immunotherapy Grastek contains ____
Timothy grass pollen extract
SL Immunotherapy Ragwitek contains ____
Ragweed pollen extract
SL Immunotherapy Odactra contains ____
House dust mite allergen extract
Natural products sued for colds
Zinc - “possibly effective”
Vitamin C (ascorbic acid) - may decrease duration of cold by 1-1.5 days at doses of 1-3 g/day
Echinacea - “possibly effective”
If productive cough is present, ___ can be used to thin mucus and move secretions up and out of respiratory tract
Expectorants
Expectorants examples
Guaifenesin (Mucinex, Robitussin, Robafen)
Cough suppressant examples
Dextromethorphan (Delsym, Robafen, Robitussin)
Codeine
Benzonatate (Tessalon Perles)
Diphenhydramine (Benadryl)
How do dextromethorphan and opioids such as codeine and hydrocodone work as cough suppressants?
They have high affinity for several regions of the brain, including the medullary cough center, suppressing the cough reflex
___ acts as a serotonin reuptake inhibitor. At usual antitussive doses, it does not have addictive properties. At high doses, it acts as an NMDA-receptor blocker leading to euphoria and hallucinations similar to the illicit substance PCP
Dextromethorphan
D/t its abuse potential, many states ban the sale of dextromethorphan to people < ___yo
18
Which cough suppressants should not be used within 14 days of MAOi
Dextromethorphan
Warnings with dextromethorphan
Serotonin syndrome (if co-admin with other serotonergic drugs), use caution in pts who are CYP2D6 poor metabolizers or with CYP2D6i
If the product name has DM at the end, such as Robitussin DM, it contains ___
dextromethorphan
Boxed warning for codeine
Respiratory depression + death have occurred in children who received codeine following tonsillectomy and/or adenoidectomy and had evidence of being ultra-rapid metabolizers d/t CYP4D6 polymorphism
Deaths have also occurred in nursing infants after being exposed to high conc of morphine from mothers who were ultra-rapid metabolizers
Codeine age restriction
Do NOT use in children <12yo or <18yo after tonsillectomy and/or adenoidectomy
If the product name has AC at the end, such as G Tussin AC, it contains ___
Codeine
Codeine combination products are C-___
C-V
Chlorpheniramine/hydrocodone (TussiCaps) is considered C-___
C-II
In children <18yo, what cough+cold products should be avoided?
Codeine and hydrocodone-containing cough and products
In children <4yo, what cough+cold products should be avoided?
OTC cough and cold products (package labeling)
In children <2yo, what cough+cold products should be avoided?
OTC cough and cold products (FDA)
Promethazine (FDA)
Avoid topical menthol (Vicks VaporRub) and camphor (package labeling)
T/F: Topical products containing menthol (e.g. Vicks VapoRub) work best when applied under the nose to clear the airways
False - apply to chest and neck (never directly to the nose)
Which drugs are contraindicated within 14 days of MAOi
Phenylephrine, pseudoephedrine, and extromethorphan
