Allergic Rhinitis & Conjunctivitis Flashcards
What types of drugs can be associated with causing acute rhinitis symptoms
Vasodilators
This group of drugs inhibits prostaglandins
NSAIDs
Two older classifications of allergies:
Seasonal vs perennial (year round)
Intermittent symptoms = how many days a week or how many weeks?
Same for persistent…
Intermittent is <4 days/wk or <4 weeks
Persistent is > or = 4 days/wk and > or = 4 weeks
Allergic rhinitis gets to the moderate/severe range when:
- sleep disorder
- disturb daily life, sport, leisure
- symptoms occur at work or school
- troublesome symptoms
Are intranasal CS used with intermittent mild AR symptoms?
No
When do intranasal CS become the preferred agent?
With persistent symptoms classification
Treatment steps for mild intermittent symptoms
Oral antihistamine or
IN antihistamine +/- decongestant or
LTRA (leukotriene receptor antagonist)
Treatment for moderate/severe intermittent symptoms
Oral antihistamine or
IN antihistamine +/- decongestant, or
LTRA, or
INS (intranasal steroid)
These are all allergen specific and combo INS and IN antihistamine were more effective than monotherapy
Treatment steps for mild persistent symptoms
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Treatment for moderate/severe persistent symptoms…
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Competitive H1 antagonist, or an inverse agonist, of the early response
Antihistamines
AEs for 1st generation antihistamines
Sedation, anticholinergic effects, hypotension (a-block), paradoxical excitement in children
AEs for 2nd generation AHs
HA
Intranasal AHs tend to improve congestion more than oral, but come with what AE?
Bitter taste
Preferred by ACOG in pregnancy, but maybe not the one that does get used
Chlorpheniramine
Pregnancy cat B; used as OTC sleep aid?
Diphenhydramine (Benadryl)
Good 2nd gen AHs that he says get used mostly in pregnancy
Loratadine and Cetirizine
2nd gen AHs are generally preferred why?
Less sedation, performance impairment, and/or anti-cholinergic SEs
What are the two IN AHs?
Azelastine and Olopatadine
Better than oral AHs
MoA of decongestants?
Direct and indirect a1 agonists that produce vasoconstriction of resp mucosa
Need to be careful with these meds and people who already have arrhythmias, HTN, hyperthyroidism b/c they cause increased BP and HR and stroke risk
Decongestants
Other SEs of decongestants besides the CV stuff…
CNS stimulation, urinary retention (careful in BPH), increased BG (careful in DM), rebound congestion, increased ICP, nasal irritation
His favorite decongestant
Oxymetazoline IN
Synthetic a1-agonist used mainly for relief of eye redness, hemorrhoids, and nasal congestion
Phenylephrine
can cause extravasation/tissue necrosis when used IV
Direct-acting a1-a2 agonist used for ocular and nasal vasoconstriction
Oxymetazoline (Afrin; Visine LR)
Direct-acting a and B agonist (a>b) while also displacing NE from storage sites, used for nasal congestion
Pseudoephedrine
PSE is limited daily to 3.6g of PSE base and 30-day purchase limit to 9g PSE base, what’s PSE?
Pseudoephedrine
Decongestant DOC in pregnancy 2nd trimester or later (oral)
Pseudoephedrine (PSE)
Decongestant alternative marketed for people who are unable to take decongestants b/c HBP
Coricidin HBP
Dextromethorphan and Chlorpheniramine…aka AHs, but fail to target obstruction of nasal passages
Inhibits cysteinyl leukotriene, inflammatory mediator released by mast cells, on target cells…comparable efficacy to AHs, but less than IN steroids
Leukotriene Antagonist
Montelukast (Singulair)
Care with this type of med in people with suicidal thoughts
Leukotriene antagonists like singulair
Anti-infl agents that inhibits the mediators of both the early and late phase reaction…MOST EFFECTIVE DRUGS FOR AR RELIEVING ALL FOUR SYMPTOMS
Intranasal Steroids
INSs are effective but how long do they tend to take to work?
Onset is just 1-2 days but max effects occur in 1-2 weeks
AEs of INSs are mild: drying, stinging, epistaxis, after taste, except one bigger concern in peds, which is?
Also tell pts to spray away from nasal septum
Growth suppression
The three most important INSs to know are:
Fluticasone Propionate (Flonase)
Fluticasone Furoate (Veramyst)
Mometasone (Nasonex)
B/c they are all the least lipophilic
Dymista
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Muscarinic antagonist resulting in decreased nasal mucous secretion, and preg cat B…
Ipratropium nasal (Atrovent)
Initial DOC during pregnancy for rhinorrhea and sneezing are?
Mast cell stabilizers like Cromolyn Sodium (Nasalcrom)
Chart from slide 52
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The most effective class of meds across the board for AR symptoms are?
INSs
Triad of symptoms in allergic conjunctivitis (pinkeye not from virus/bacteria)
Itching, conjunctival injection (redness), chemosis (conjunctiva swelling w/ or w/o watery discharge
Treatment steps for mild allergic conjunctivitis…
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Treatment steps for moderate allergic conjunctivitis…
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Treatment steps for severe allergic conjunctivitis…
…
Nonselective ocular AHs (H1 antagonists) that decrease itching and vasodilation
Azelastine (optivar) and Levocabastine (Livostin)
2nd gen ocular AHs
Ketotifen (Zaditor) and Olopatadine (Patanol)
Ocular decongestants include:
Naphazoline (Vasocon) is most potent
Oxymetazoline (Visine LR)
Tetrahydrozoline (Visine original)
Ocular mast cell stabilizers include
Cromolyn, lodoxamide, nedocromil (best b/c can do twice per day which is the least frequent dosing)
Ocular NSAID
Ketoralac (ASA so not for kids)
Ocular steroids, for more severe/chronic allergic conjunctivitis (specialist), ONLY ONE APPROVED FOR USE IN SEASONAL ALLERGIC CONJUNCTIVITIS:
Loteprednol
AEs include cataracts, increase IOP, increase risk for ocular infection
Eye drop administration steps:
Wash hands -> tilt head black and pull lower lid down -> hold dropper close to eye, brace with hand -> squeeze dropper so single drop falls into pocket made by lower eyelid -> close eye for 2-3 min, tip head down, don’t blink/squeeze eyelid, place finger on tear duct and apply pressure, wipe excess, wait 5 min
