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Pharm > Allergic Rhinitis > Flashcards

Allergic Rhinitis Flashcards

1
Q

Allergic Rhinitis leads to increased risk of (9)

A

Asthma
Chronic rhinosinusitis
Otitis media
Nasal polyposis
Atopic dermatitis
Sleep disordered breathing
Conjunctivitis
Resp Infections
Orthodontic malocclusions

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2
Q

4 defining sx of allergic rhinitis

A

Sneezing
Runny nose
Nasal congestion
Nasal itching

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3
Q

Patients with seasonal allergic conjunctivitis appear with

A

Red, itchy watery eyes

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4
Q

Allergic salute

A

Rubbing hand up against nose to quell itching

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5
Q

Patients may also have a bruised appearance under eyes known as

A

Allergic shiner

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6
Q

Non-Pharm treatment of allergic rhinitis

A

AVOIDANCE of known allergens
DECREASING BODY RESPONSE
NASAL RINSES AND STRIPS

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7
Q

How do we decrease the body response to allergens?

A

Hyposensitization via subcutaneous immunotherapy

Exposing a patient to increasing amounts of the causative allergen to build an immune tolerance

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8
Q

Irrigation of the nasal passages with __________ is useful for what?

A

Saline;
Useful for removing allergens and preparing the membranes for admin of intranasal meds

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9
Q

Pharmacotherapy options for allergic rhinitis (8)

A

Intranasal corticosteroids
Oral antihistamines
Intranasal antihistamines
Oral decongestants
Intranasal decongestants
Intranasal anticholinergics
Intranasal cromolyn
Oral antileukotrienes

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10
Q

Therapeutic effects of intranasal corticosteroids are due to the ________________

A

Topical effects

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11
Q

Intranasal corticosteroids MOA

A

Potent ANTI-INFLAMMATORY effects mast cells, eosinophils, and lymphocytes

AFFECT MEDIATORS of these cells that are involved in inflammation (histamine, leukotrienes, cytokines)

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12
Q

1st line treatment of allergic antihistamines

A

Intranasal corticosteroids

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13
Q

Onset of action for intranasal corticoids

A

7 hours after first dose

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14
Q

When should a patient expect to start feeling better after taking an intranasal corticosteroid?

A

Sx reduce in sever days
Max improvement in 2 weeks

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15
Q

All intranasal corticosteroids seem to work equally in reducing _________, __________, and ___________

A

Sneezing, itching, or rhinorrhea

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16
Q

What is the MOST effective treatment for nasal sx of seasonal and perennial allergic rhinitis?

A

Intranasal corticosteroids

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17
Q

Side effects of nasal corticosteroids

A

Epistaxis
Dry nose
Bad taste
Headache

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18
Q

Contraindications/precautions of intranasal corticosteroids

A

Avoid use with nasal trauma/recent nasal injury

Do periodic nasal checks for nasal perforations and ulcerations every few months

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19
Q

Names of the 1st gen Intranasal corticosteroids

A

Budesinide
Flunisolide
Beclomethasone
Triamcinolone

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20
Q

2nd gen intranasal corticosteroids

A

Fluticasone
Mometasone

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21
Q

Intranasal Decongestant MOA

A

Stimulates 𝛼 adrenergic receptors in arterioles—> vasoconstriction—> decrease sinus vessel engorgement and mucosa edema

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22
Q

Dosing of intranasal decongestants

A

2-3 days

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23
Q

Prolonged used of intranasal decongestants can cause what?

A

Rebound congestion—> RHINITIS MEDICAMENTOSA

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24
Q

Intranasal decongestants provide effective, short term __________

A

Relief of nasal congestion

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25
Q

What sx do intranasal decongestants NOT COVER?

A

Itching
Sneezing
Nasal secretion

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26
Q

Indication of use for Intranasal decongestants

A

Provide prompt relief of nasal congestion
Short term relief

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27
Q

Onset of action of intranasal decongestants

A

5-10min

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28
Q

Rhinitis medicamentosa

A

Caused by many days of regular use of OTC nasal decongestant sprays

Physical exam= SWOLLEN, RED NASAL MUCOSA

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29
Q

Decreasing risk of rhinitis medicamentosa

A

Limited use of otc nasal sprays to max of 5 days with as few doses as possible during those days

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30
Q

Tx of Rhinitis medicamentosa

A

Withdrawal of causative medication
Use of intranasal corticosteroids to help with sx
Counsel patients that rhinitis will get worse temporarily

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31
Q

SE of intranasal decongestants

A

Rhinitis medicamentosa
Nasal stinging/burning

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32
Q

Precautions in intranasal decongestant use

A

CV disease
Uncontrolled HTN
Thyroid disease
Diabetes
BPH

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33
Q

What medication is contraindicated for concurrent use with intranasal decongestants

A

MAOIs

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34
Q

What are the 2 commonly used intranasal decongestants

A

Phenylephrine
Oxymetazoline

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35
Q

MOA of intranasal antihistamines

A

Competes with histamine for H1 receptor sites—> inhibition of release of histamine—> decrease of allergic response

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36
Q

Indication of use for Intranasal Antihistamines

A

Seasonal and persistent allergic rhinitis

Situations where known exposure to allergens can be predicted

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37
Q

What do the guidelines suggest use of intranasal antihistamines? Or intranasal glucocorticoids?

A

Intranasal glucocorticoids

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38
Q

Onset of action of Intranasal glucocorticoids

A

<15 min

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39
Q

Dosing of Intranasal antihistamines

A

Can be administered ON DEMAND

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40
Q

Side effects of intranasal antihistamines

A

Bitter taste
Epistaxis
Drowsiness
Headache

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41
Q

What are the 2 intranasal antihistamines?

A

Olopatadine
Azelastine

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42
Q

What 2 agents may be helpful in concurrent use of patients that dont find relief with one agent?

A

Topical antihistamine + topical corticosteroid

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43
Q

MOA Of intranasal anticholinergics

A

Inhibits serous and sernomucous gland secretions—> decreases Rhinorrhea via nasal dryness

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44
Q

What sx do intranasal anticholinergics treat?

A

RHINORRHEA ONLY
(No antihistamine or antiinflammatory effect_

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45
Q

What is the available Intranasal anticholinergic?

A

Ipratropium Bromide

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46
Q

Indications for use of Intranasal anticholinergics

A

Useful for sx relief only

Used in patients with Rhinorrhea that is in sufficiently managed with other agents

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47
Q

Side effects of intranasal anticholinergics

A

Headache
Epistaxis
PHARYNGITIS
Dry nose
Nasal mucosa irritation

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48
Q

Intranasal Cromolyn MOA

A

Mast cell stabilizer

Inhibits the degranulation of sensitized mast cells—> prevention of release of mediators of allergic response and inflammation

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49
Q

Intranasal cromolyn works by…..

A

PREVENTING THE ALLERGIC RXN rather than alleviating sx

50
Q

Cromolyn is useful for what population

A

Individuals who experience episodic sx to allergens

51
Q

When can Cromolyn be taken for EPISODIC allergens?

A

30 min prior to exposure

52
Q

When should cromolyn be started for seasonal allergy relief?

A

Most effective when initiated PRIOR TO POLLEN SEASON

53
Q

When do we prescribe these?

A

Episodic relief
Patients whose response to inhaled corticosteroids and antihistamines are INSUFFICIENT

54
Q

What line agent is cromolyn?

A

3rd line
( frequent dosing with lower efficacy)

55
Q

Antileukotriene MOA

A

Montelukast= leukotriene receptor antagonist—> inhibition of action of leukotrienes—>decrease sx associated with allergic rhinitis

56
Q

What is the ONLY antileukotriene that is approved for the treatment of allergic rhinitis?

A

Montelukast

57
Q

What USED TO BE the indication for use of montelukast? s

A

Patients who couldn’t tolerate or refused nasal sprays

Patients with concomitant asthma and allergic rhinitis

58
Q

Why did the FDA put a BBW on montelukast

A

Due to its neuropsychiatriac changes, fda recommended avoidance of montelukast in favor of other treatments

59
Q

Examples of the Neuropsychiatric changes associated with use of Motelukast?

A

Dream abnormalities
Insomnia
Anxiety
Depression
Suicidal thinking (and possibly suicide)

60
Q

Oral decongestant MOA

A

Directly stimulate 𝛼-adrenergic receptors in respiratory mucosa—> vasoconstriction—> decrease of venous engorgement and mucosal edema—> REDUCE SWELLING AND NASAL CONGESTION

Directly stimulate β-adrenergic receptors—> bronchial relaxation, increased HR and contractility

61
Q

Who are oral decongestants most effective in?

A

Those with nasal congestion as primary sx

Those with congestion unbelievable by ICS or antihistamine products

62
Q

Pseudoephedrine

A

OTC oral decongestant

Placed BEHING THE COUNTER due to the Combat Methamphetamine Epidemic act (CMEA)

63
Q

What is a requirement of the CMEA act?

A

Customer identify must be verified

Fed law limited the quantities of pseudoephedrine that patient can buy at once and within a specific time period

64
Q

CMEA led to the introduction of the less-effective agent known as

A

Phenylephrine

65
Q

Issues with Phenylephrine

A

Effectiveness=questionable

When taken orally, it is not likely to be significantly effective due to extensive gut metabolization

4x FDA approved dose still would not cause significant effects on congestion

Poor oral absorption

66
Q

SE of Oral decongestants

A

Insomnia
Loss of appetitie
Elevated BP
Palpitations
Restlessness

67
Q

Precautions of pseudoephedrine

A

Use cautiously
- controlled HTN
- arrythmias
- CHD
- uncontrolled hyperthyroid
- narrow angle glaucoma
- BPH

68
Q

What population is pseudoephedrine NOT RECOMMENDED IN?

A

Patients taking stimulants for ADHD (together can increase BP and HR—> increase CV risk)

Patients on MAOIs

69
Q

2 oral decongestants available

A

Pseudoephedrine
Phenylephrine

70
Q

1st gen oral antihistamines

A

Target central and peripheral H1 receptors
Lipophilic—> cross BBB—> SEDATING

Bind to cholingergic, 𝛼-adrenergic, and sertonergic receptors—> anticholinergic effects

71
Q

What are the anticholinergic SE that 1st gen antihistamines can cause?

A

Dry mouth
Dry eyes
Difficulty urinating
Constipation
Increased HR

72
Q

2nd gen antihistamines

A

Lipophilic—> do not cross BBB
More specific to peripheral H1 receptors
Minimally sedating and less cognitive effects

73
Q

What sx do oral antihistamines combat?

A

Itching
Sneezing
Runny nose
Itchy, red eyes—> allergic conjunctivits

74
Q

What sx is not covered by oral antihistamines

A

Nasal congestion

75
Q

______________________ provide greater relief for allergic rhinitis sx than oral antihistamines, without sedation and other anticholinergic effects

A

Intranasal glucocorticoids

76
Q

1st gen SE

A

Sedation
Decreased cognitive and motor skills
ANTICHOLINERGIC SX

Some patients (esp. children may notice stimulating effects
Insomnia
Anxiety
Hallucinations

77
Q

2nd gen antihistamine SE

A

Sedation (less so than 1st gen)

78
Q

Precautions of 1st gen oral antihistamines

A

No use in patients with NARROW ANGLE GLAUCOMA—> pupillary dilation—> worsen narrow angle

ELDERLY- increased risk of falls and dry mouth—> avoid

79
Q

For best sx relief, antihistamines should be taken when?

A

Prophylactically (2-5 hours prior to exposure)
OR
Regular basis if needed chronically

80
Q

What are the 1st gen antihistamines?

A

Chlorpheniramine
Diphenhydramine
Clemastine
Hydroxyzine

81
Q

What are the 2nd gen antihistamines?

A

Cetirizine
Levocetirizine
Fexofenadine
Loratadine
Desloratadine

82
Q

Diphenhydramine roles

A

Treatment of acute allergic reactions
Prevention of allergic reaction as premedications
Allergic rhinitis
Cough (antitussive properties)
Insomnia
Dystonias
Motion sickness

83
Q

Mechanism of saline on sx reduction of allergic rhinitis

A

Depends on washing away allergens and inflammatory mediators induced by allergic reactions

84
Q

What type of saline seems to decrease edema of the nasal mucosa?

A

Hypertonic solutions

85
Q

What type of saline doesn’t seem to have an anti-allergy affect?

A

NaCl

86
Q

SE of saline

A

Minor burning or stinging in the nose

87
Q

Use of hypertonic saline irrigation TID reduces what after 3–6 weeks of tx

A

Reduces allergy sx and use of oral antihistamines

88
Q

What is the MOST EFFECTIVE single-agent maintenance therapy that has few side effects?

A

Glucocorticoids

89
Q

What is the preferred antihistamines if antihistamine therapy is desired?

A

2nd gen antihistamines

90
Q

For patients with mild or intermittent sx, what is the suggested treatment?

A

Glucocorticoids

91
Q

For a patients with persistent/ moderate-severe sx, what is the suggested treatment?

A

Glucocorticoid nasal spray

92
Q

If glucocorticoid monotherapy is not adequately relieving sx, what is the recommendation

A

Add antihistamine nasal spray
OR
Start oral antihistamine/decongestant combo

93
Q

For patients with mild sx who prefer other agents bc oral admin or desire to avoid ICS, what are some options they can use?

A

Antihistamine nasal spray
2nd gen antihistamines
Cromolyn Nasal Spray

94
Q

What is the main complaint of patients with allergic conjunctivitis?

A

Itchy red watery eyes

95
Q

What type of reaction is allergic conjunctivits?

A

IgE mediated type I hypersensitivity reaction

96
Q

MOA of Ophthalmic Anthistamines/ Vasoconstrictors

A

Antihistamine component—> works by competitively and reversibly blocking histamine receptors to prevent the actions of histamine

Vasoconstrictor component—> activates 𝛼-adrenergic receptors of the blood vessels to vasoconstriction and decrease edema

97
Q

Dosage information for opthalmic antihistamines/vasoconstrictors

A

Can be used 4x/day for up to 1-2 weeks during acute reactions

98
Q

Why is suggested to only use Ophthalmic antihistamines and vasoconstrictors for up to 2 weeks?

A

Risk of rebound reactions from the vasoconstrictor

99
Q

What is the name of the ophthalmic antihistamine/vasoconstrictor?

A

Pheniramine

100
Q

MOA of Ophthalmic antihistamine w/o vasoconstrictor

A

Same as above
Works by competitively and reversibly blocking histamine receptors to prevent actions of histamine

101
Q

Names of the Ophthalamic antihistamines

A

Olopatadine
Azelastine
Epinastine
Cetitizine

102
Q

MOA of antihistamine/mast stabilizer ophthalmic solutions

A

ANTIHISTAMINE PROPERTIES: decrease late phase allergic response by decreasing inflam cells from being released

MAST CELL PROPERTIES: stabilize mast cells—> release fewer inital proinflammatory mast cell mediators

REDUCE inflammation by inhibiting leukocytes and decreases the release of other inflammatory mediators (i.e basophils)

103
Q

Which are more effective:
Antihistamine/Mast Cell stabilizers
Antihistamine/ Vasoconstrictors

A

Antihistamine/ Mast Cell Stabalizers

104
Q

Side effects of Ophthalmic antihistamines/mast cell stabalizers

A

Burning
Stinging
Headaches
Dry eyes

105
Q

What are the 2 antihistamine/mast cell stabilizer ophthalmic solutions?

A

Ketoifen
Alcaftadine

106
Q

Indications of use for Ophthalmic mast cell stabalizers

A

For seasonal allergic conjunctivits IF:
- pt can predict onset of sx
- pt cant tolerate other drops
- frequent recurrent or persistent sx

107
Q

When should ophthalmic mast cell stabilizers be started?

A

2-4 weeks before exposure to allergens

108
Q

How long does it take for Ophthalmic mast cell stabilizers to take effect?

A

5–14 days

109
Q

T/F: Mast cell stabalizers are effective for ACUTE relief of sx

A

False

110
Q

T/F: antihistamines with mast cell stabilizing properties are usually more effective and preferred over mast cell stabilizers alone

A

True

111
Q

What are the 3 Ophthalmic mast cell stabalizers?

A

CLN
Cromolyn sodium
Lodoxamide
Nedocromil

112
Q

__________ ophthalmic drops have more efficacy compared to placebo but are far less effective than an antihistamine with mast cell stabilizing effects

A

Ophthalmic NSAIDs

113
Q

What is the Ophthalmic NSAID approved for treatment of allergic conjunctivits?

A

Keterolac Ophthalmic

114
Q

What drops are prescribed for refractory cases of allergic conjunctivitis?

A

Ophtahalmic corticosteroids

115
Q

MOA OF Ophthalmic Glucocorticoids

A

Glucocorticoids suppress the late phase reaction of allergic inflammation

116
Q

How are Ophthamic corticosteroids dosed?

A

Pulse therapy with max of 2 weeks duration for those who antihistamine/mast cell stabilizing drops dont work

117
Q

SE of ophthalmic glucocorticoids

A

Cataract formation
Elevated IOP
Glaucoma
2ndary infection

118
Q

What do ophthalmic corticosteroids do so that mast cell stabilizers and antihistamines have a greater chance to work?

A

They help to SLOW THE IMMUNE RESPONSE

119
Q

What are SOFT STEROIDS?

A

Group of topical glucocorticoids that have reduced risk of increasing IOP bc formulated to undergo RAPID INACTIVATION upon corneal penetration

120
Q

What are the Opthalmic glucocorticoids that are considered “SOFT”?

A

Loteprednol .2% solution
Prednisolone .12% suspension
Fluorometholone .1% solution

121
Q

What are the 2 ophthalmic corticosteroids that can increase IOP?

A

Prednisolone 1% suspension
Dexamethasone .1% solution

Pharm (4 decks)

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