Allergic Rhinitis, Cough and Cold Flashcards
How long do the symptoms of a common cold usually last?
Symptoms take about three days to appear and usually last for about a week
What are some symptoms of a common cold?
Sneezing, runny nose, thick and dark mucus, sore throat, body ache
What are some symptoms of allergies?
Sneezing, runny nose, thin and clear mucus, wheezing, red and watery eyes
How long do allergies symptoms last?
Symptoms can last for days or months after contact with allergens
What causes colds?
Viruses
What causes allergic rhinitis?
Exposure to allergen
What are some complications of allergic rhinitis?
Chronic sinusitis, otitis media (in children) and asthma exacerbatons
What can be utilized to determine patient-specific allergens?
IgE-mediated skin prick test or blood test
What are some common allergens?
Pollens, molds, dust mites, animal dander
What are some non-drug treatments of allergic rhinitis?
Avoiding exposure to known or suspected allergens, vacuuming carpets, drapes and upholstery with a HEPA vacuum cleaner, removing carpets and upholstered furniture, encasing pillows, mattresses and washing bedding in hot water quickly
What is AQI?
AQI is the air quality index which rates the local air as good to hazardous
How can pollen counts be useful in allergic rhinitis?
When pollen count is high. it is best to have patients stay indoors, with the windows closed and with the air conditioner
What is a disadvantage to raising children in an overly-clean environment?
Children lose the chance to build a healthy immune system
What are some agents that can provide symptom relief of allergic rhinitis?
Nasal irrigation and wetting agents provide symptom relief by reducing nasal stuffiness, runny nose and sneezing
How do nasal gels work?
Nasal gels with petrolatum can be applied around the nostrils to physically block pollens and allergens from entering the nose
*Considered safe for most populations, including children and pregnant women
How do wetting agents work?
Wetting agents contain saline, propylene or polyethylene glycol, which provide moisture and reduce irritation to the nasal passages
How does nasal irrigation work?
Nasal irrigation uses an isotonic or hypertonic saline solution to rinse out allergens and mucus, improve ciliary function and reduce swelling
How do you prepare a nasal irrigation?
- Premixed saline packets are commercially available or a salt solution can be prepared at home
- Homemade or store-bought saline solution must be combined with distilled, sterile or previously boiled and cooled water
- Tap water should not be used because it contains organisms that are safe to ingest orally but can cause infections when used for nasal irrigation
How do you administer nasal irrigations?
- Nasal irrigations can be administered using a syringe or neti pot
- Prepared saline solution is placed in the neti pot, then poured into one nostril and drained out of the other nostril
- After each use, the neti pot should be rinsed out with distilled, sterile or previously boiled water and allowed to air dry
What are some common side effects of nasal irrigations?
Mild nasal stinging or burning which are increased at higher concentrations of saline
What is the first line drug treatment in chronic, moderate-to-severe symptoms in allergic rhinitis?
Intranasal steroids
How can you treat milder, intermittent symptoms of allergic rhinitis?
Oral antihistamines
*Decongestants can be used if congestion is present
How do intranasal steroids work?
Intranasal steroids work by decreasing inflammation
What are some examples of intranasal steroids?
Budesonide (Rhinocort), Fluticasone (Flonase) Triamcinolone (Nasacort), Beclomethasone, Ciclesonide, Flunisolide, Mometasone
What are some warnings associated with intranasal steroids?
- Avoid use if recent nasal septal ulcers, nasal surgery, or recent nasal trauma due to delayed wound healing
- High doses for prolonged periods can cause: adrenal suppression, decreased growth velocity (pediatrics) and immunosuppression
- Use caution in patients with cataracts and/or glaucoma (increased intraocular pressure, open-angle glaucoma and cataracts have occurred with prolonged use)
What are some major side effects of intranasal steroids?
Epistaxis (nose bleeds), headache, dry nose, unpleasant taste, localized infection
What are some monitoring parameters of intranasal steroids?
Growth (pediatrics), vision changes, eye exams in long-term use, s/s of oral thrush and/or adrenal suppression
*If using regularly for several months, recommend periodic nasal exams to evaluation for nasal septal perforation or ulcers
What are some important notes about intranasal steroids?
- Can take up to one week to get full relief
- Budesonide and beclomethasone are the preferred nasal steroids in pregnancy
- Shake well before each use
- Discard device after total number of labeled doses, even if bottle does not feel completely empty
What are antihistamines effective for?
Antihistamines are effective in reducing symptoms of itching, sneezing, rhinorrhea and other types of immediate hypersensitivity reactions but have little effect on nasal congestion
How do antihistamines work?
Antihistamines work by blocking histamine at the histamine-1 (H1) receptor site
What are some examples of first generation antihistamines?
Examples include hydroxyzine, meclizine and diphenhydramine, chlorpheniramine, doxylamine, clemastine, carbinoxamine
What are some indications of diphenhydramine?
Treatment of acute allergic reactions (+/- epinephrine, depending on severity), prevention of allergic reactions (included in most premedication regimens for high-risk drugs), allergic rhinitis, cough (has antitussive properties), sleep (sedating), dystonic reactions (anticholinergic properties), motion sickness
What are some examples of disease states that can be worsened by diphenhydramine?
BPH, constipation, dementia, glaucoma
What are contraindications of first generation antihistamines?
Neonates or premature infants, breastfeeding
What are some warnings about first generation antihistamines?
- Avoid in elderly (strong anticholinergic effects) and in children < 2 years
- Can cause CNS depression/sedation
- Use with caution in patients with cardiovascular disease, prostate enlargement, glaucoma, asthma, pyloroduodenal obstruction and thyroid disease
- Do not use with MAO inhibitors
- Do not use diphenhydramine in children < 6 years or doxylamine in children < 12 years
What are some side effects of first generation antihistamines?
Somnolence, cognitive impairment, strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation) and seizures/arrhythmias at higher doses
What are some important counseling points of first generation antihistamines?
- Second generation agents are preferred for lactating women
- Should be discontinued > 72 hours prior to allergy skin testing
- Can cause photosensitivity (use sunscreens and wear protective clothing while taking)
- FDA issued a Safety Alert regarding reports of abuse/misuse of diphenhydramine by teenagers leading to serious heart problems, seizures, coma or death
Why are second-generation oral antihistamines preferred for treatment of allergic rhinitis?
They cause less sedation and cognitive impairment
What are some examples of second generation oral antihistamines?
Cetirizine, Levocetirizine, Fexofenadine, Loratadine, Desloratadine
What are some contraindications to Levocetirizine?
End-stage renal disease (CrCl < 10 ml/min), hemodialysis, infants and children 6 months to 11 years of age with renal impairment
What are some warnings associated with second-generation oral antihistamines?
- Can cause CNS depression/sedation, especially when used with other sedating drugs
- Use with caution in the elderly and in renal or hepatic impairment
What are some notable side effects of second generation oral antihistamines?
Somnolence can still be seen (more with cetirizine and levocetirizine), headache
What are some counseling points of second generation oral antihistamines?
- Fexofenadine: take with water (not fruit juice) and avoid administration with aluminum or magnesium-containing products
- Should be d/c’ed > 72 hours prior to allergy skin testing
- If using in pregnancy, loratidine and cetirizine are preferred
- Cetirizine and levocetirizine have a fast onset
- More sedating: cetirizine and levocetirizine
- Less sedating: fexofenadine and loratidine
- Some formulations of fexofenadine, loratadine and desloratadine contain phenylalanine (avoid with PKU)
What are some examples of intranasal antihistamines?
Azelastine, Olopatadine
What are some common side effects of intranasal antihistamines?
Bitter taste, headache, somnolence, nasal irritation, epistaxis, sinus pain
What is something to note with intranasal antihistamines?
Helps with nasal congestion and can be combined with an intranasal steroid (increases cost and risk for side effects)
What are decongestants and how do they work?
Decongestants are alpha-adrenergic agonists (sympathomimetics) that cause vasoconstriction, which decreases sinus vessel engorgement and mucosal edema and makes them effective at reducing sinus and nasal congestion
What are some facts about phenylephrine?
- Phenylephrine has poor oral absorption
- Comes as a nasal spray but lasts for a shorter time and causes more side effects than oxymetazoline spray
What are some facts about pseudoephedrine?
- Pseudoephedrine is an effective systemic decongestant
- Precursor. to methamphetamine and has restricted distribution
What was the purpose of the Combat Methamphetamine Epidemic Act of 2005?
Restricted sales of nonprescription products containing pseudoephedrine, phenylpropanolamine and ephedrine, since these can be easily converted to methamphetamine
Describe the features Combat Methamphetamine Epidemic Act of 2005.
- Products must be kept behind the counter or in a locked cabinet, usually located in the pharmacy
- A logbook of any sale more than a single-dose package (minimum of 60 mg) is kept
- For any sale above this amount, the customer must show a government issued photo
- Customers record their name, date and time of sale and signature while staff has to verify and record customer address and what the person received as well as the quantity purchased
- Under federal law, the maximum amount allowed for purchase is 3.6 grams per day and 9 grams in a 30 day period
- Logbook must be kept secured for a minimum of 2 years and be readily available upon request by board inspectors or law enforcement
What are the oral decongestants?
Phenylephrine and Pseudoephedrine
What is a contraindication of oral decongestants?
Do not use within 14 days of MAO inhibitors
What are some warnings or oral decongestants?
- Avoid in children <2 years (FDA), < 4 years (package labeling)
- Use with caution in patients with CV disease and uncontrolled hypertension, hyperthyroidism, diabetes, bowel obstruction, glaucoma, BPH, renal impairment, seizure disorder, elderly
What are some notable side effects of oral decongestants?
CV stimulation (tachycardia, palpitations, increased BP), CNS stimulation, decreased appetite, dizziness, headache
What are some counseling points of oral decongestants?
- Phenylephrine has low bioavailability (<38%); pseudoephedrine is more effective
- Onset of 15-60 minutes
What is an example of an intranasal decongestant?
Oxymetazoline
What are some contraindications and warnings with intranasal decongestants?
- Do not use for more than 3 days
- Do not use with MAO inhibitors
- Use with caution in patients with CV disease and uncontrolled hypertension, thyroid disease, diabetes and BPH
- Fast onset
What are some notable side effects of intranasal decongestants?
Rhinitis medicamentosa (rebound congestion) if used longer than 3 days, nasal stinging, burning and dryness, sneezing, trauma from the tip of the device
What are some additional allergy medications?
Intranasal cromolyn, oral leukotriene receptor antagonist, intranasal ipratropium, immunotherapy
How is intranasal cromolyn used?
Intranasal cromolyn is an OTC mast cell stabilizer used for treatment and prophylaxis of allergic rhinitis
What are some important counseling points of intranasal cromolyn?
- Must be started at the onset of allergy season and used regularly not PRN to be effective
- Symptoms will start to improve in 3-7 days, but maximal effect can take > 2-4 weeks of continued use
- Not as effective as other agents but it is safe to use in children > 2 years old and in pregnancy
What is Montelukast indicated for?
Montelukast is the only leukotriene modifying agent indicated for the treatment of both allergic rhinitis and asthma
*Commonly used in children
What is the FDA issued box warning for Montelukast?
Serious neuropsychiatric side effects
What is an important counseling point of Montelukast?
Reserved for those who are unable to be treated effectively with other medications
What is intranasal ipratropium effective for?
This drug is effective for decreasing rhinorrhea by causing nasal dryness (it is not effective for other nasal symptoms)
What is the use of immunotherapy in allergic rhinitis?
Immunotherapy is a preventative treatment allergies, either through SC injections or SL treatments
How does immunotherapy work in allergic rhinitis?
- They work by slowly increasing exposure to the allergen, making the immune system less sensitive to the substance
- Long term immunotherapy can improve the underlying allergic disease and relieve symptoms even after stopping treatment
- It is recommended to treat for a minimum of three years
What is the common cold?
A viral infection of the upper respiratory tract
What is the common cold caused by?
It is caused by over 200 viruses , including rhinoviruses and coronaviruses
How is a common cold transmitted?
It is transmitted by mucus secretions (via patient’s hands) or by the air (from coughing or sneezing)
What are some ways transmission can be prevented?
- Coughing or sneezing into the elbow or into a tissue is rather than coughing into a hand, which can then touch surfaces and spread illness
- Frequent handwashing with soap or soap substitutes (e.g. hand sanitizer)
What is the goal of treatment of cough and cold?
The goal of treatment is to reduce duration and frequency of symptoms to allow the patient to feel better and return to normal activities
What are some examples of natural products that can be used for cough and cold?
Zinc and vitamin C (ascorbic acid)
How is zinc useful for cough and cold?
- Can be used for cold prevention and treatment
- Zinc lozenges or syrup might decrease cold duration if used correctly and at first signs of symptoms
How is zinc supposed to be taken?
Taken every two hours while awake, starting 24-48 hours of symptoms onset
What is zinc rated as in the Natural Medicines Database?
Possibly effective
What are some side effects of zinc?
Mouth irritation, metallic taste and nausea
What is an important counseling point about zinc?
They should not be used for more than 5 to 7 days, as long term use can cause copper deficiency
What has data shown about taking vitamin C?
- Some data has shown a decrease in the duration of he cold by 1-1.5 days at doses of 1-3 grams/day
- Might also be a dose dependent response (doses of at least 2 grams/day appear to work better than 1 gram/day)
What is Vitamin C rated as in the Natural Medicines Database?
Possibly effective
What can occur with high doses of Vitamin C?
High doses of Vitamin C (4 g/day or greater) can cause diarrhea and possibly kidney stones
What is another product that is rated as “possibly effective” for cold treatment?
Echinacea
What are some examples of reputable manufacturers of cold treatments?
Airborne and Emergen-C, Immune+ are popular products that contain a variety of ingredients, including vitamin C, vitamin E, zinc and echinacea
What kind of cough is typically associated with colds?
Nonproductive
What do you use for productive coughs?
If productive cough is present, expectorants can be used to thin mucus and move secretions up and out of the respiratory tract
What are some examples of expectorants?
Guaifenesin (Mucinex, Robitussin Mucus + Chest Congestion, Robafen)
*+dextromethorphan (Robafen DM, Robitussin DM)
What are some side effects of expectorants?
Nausea (dose-related), vomiting, dizziness, headache, rash, diarrhea, stomach pain
What are some important counseling points of expectorants?
- OTC: do not use ER tablets in children <12 years at age
- Some formulations contain phenylalanine (avoid with PKU)
What are cough suppressants used for?
Cough suppressants are used for dry, nonproductive cough or to suppress productive cough at night to allow for restful sleep
How does Dextromethorphan and opioids (such as codeine and hydrocodone) work as a cough suppressant?
Dextromethorphan and opioids, such as codeine and hydrocodone, have a high affinity for several regions of the brain, including the medullary cough center, suppressing the cough reflex
*Dextromethorphan acts as a serotonin reuptake inhibitor
How does Benzonatate suppress coughs?
Benzonatate suppresses cough by a topical anesthetic action on the respiratory stretch receptors
How does Benzonatate suppress coughs?
Benzonatate suppresses cough by a topical anesthetic action on the respiratory stretch receptors
Why do opioid and dextromethorphan have abuse potential?
At high doses, it acts as an NMDA-receptor blocker leading to euphoria and hallucinations, similar to PCP, termed “robo-tripping”
How do states combat the abuse potential of dextromethorphan?
Due to its abuse potential, many states ban the sale of dextromethorphan to minors < 18 years of age
What is the schedule of codeine products containing one or more non-codeine active ingredients?
C-V drugs
What is the maximum amount of codeine a codeine product can have?
No more than 200 mg of codeine/100 mL
What product is codeine typically abused with and what are the street names?
Codeine is abused, particularly in combination with promethazine, known by the street names “purple drank” and “lean”
What are some examples of cough suppressants?
Dextromethorphan (Delsym, Robafen Cough, Robitussin Cough), + guaifenesin (Robafen DM, Robitussin DM), Codeine, Benzonatate (Tessalon Perles), Diphenhydramine (Benadryl)
What is a contraindication of dextromethorphan?
Do not use within 14 days of a MAO inhibitor
What is a warning of dextromethorphan?
Serotonin syndrome (if co-administered with other serotonergic drugs) - Use with cuation in patients who are CYP2D6 poor metabolizers or with CYP2D^ inhibitors, debilitated (e.g. sedated, confined to a supine position)
What are some side effects of dextromethorphan?
N/V, drowsiness, CNS depression (especially when used with other sedating drugs)
What are some counseling points about Dextromethorphan?
- If the product name has DM at the end, such as Robitussin DM, it contains dextromethorphan
- OTC: do not use in children < 4 years
What is the boxed warning associated with codeine?
Respiratory depression and death have occurred in children who received codeine following tonsillectomy and/or adenoidectomy and had evidence of being ultra-rapid metabolizers of codeine due to CYP2D6 polymorphism
*Deaths have also occurred in nursing infants after being exposed to high concentrations of morphine from mothers who were ultra-rapid metabolizers
What is a contraindication of the use of codeine?
Do not use in children < 12 years of age (any indication) or in children < 18 years of age after tonsillectomy and/or adenoidectomy
What is a counseling point about codeine?
The FDA recommends to avoid codeine-containing cough and cold products for patients < 18 years of age
What is a warning about Benzonatate?
Do not use in children < 10 years of age (accidental ingestion and fatal overdose has been reported)
What are some side effects of benzonatate?
Somnolence, confusion, hallucinations
What is the role of analgesics/antipyretics in cough?
Analgesics and antipyretics such as acetaminophen and ibuprofen are used to relieve sore throat, body malaise and fever
*Use caution not to exceed the maximum daily dosing for acetaminophen or ibuprofen if multiple medications are being used
What are some examples of cough and cold combinations?
Dextromethorphan/promethazine, brompheniramine/pseudoephedrine/dextromethorphan (Bromfed DM), Promethazine/codeine, promethazine/phenylephrine/codeine, guaifenesin/codeine, guaifenesin/codeine/pseudoephedrine, chlorpheniramine/hydrocodone, chlorpheniramine/codeine
What are some commonly used abbreviations for cough medications?
D = decongestant PE = phenylephrine DM = dextromethorphan AC = codeine
What are the steps to take when a young child has a cold?
If young child has a cold, it is safe and useful to recommend proper hydration, nasal bulbs for gentle suctioning, saline drops/sprays and vaporizers/humidifiers
*Ibuprofen and acetaminophen can be used, if needed, for fever or pain
Which medications should be avoided in children < 18 years?
Avoid codeine and hydrocodone-containing cough and cold products
Which medications should be avoided with children < 4 years?
Avoid OTC cough and cold products (package labeling)
Which medications should be avoided in children < 2 years?
Avoid OTC cough and cold products, promethazine, topical menthol and camphor
Why do you not use promethazine in children < 2 years?
Because of the risk of fatal respiratory depression
How can topical products containing menthol be used for colds?
Topical products containing menthol can be applied to the chest and neck (never directly to the nose) to help open the airways and suppress cough
What can happen if if menthol-containing products are ingested?
In children < 2 years of age, menthol should not be ingested because it can cause cardiac and CNS toxicity
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