ch 63 Flashcards
allergic rhinitis symptoms
sneezing
rhinorrhea
pruritis
nasal congestion due to dilation and increased permeability of nasal blood vessels
some have associated
conjunctivitis
sinusitis
asthma
Allergic rhinitis has 2 major forms
seasonal
perennial
seasonal rhinitis is AKA
occurs in the ___ and ___
in reaction to
Hay fever
spring and fall
outdoor allergens such as fungi and pollens from weeds, grasses and trees
Perennial (nonseasonal rhinitis)is triggered by
indoor allergens such as house dust mite and pet dander
drug classes for allergic rhinitis
intranasal glucocorticoids
antihistamines (oral and intranasal)
sympathomimetics (oral and intranasal)
the most effective drugs for prevention and treatment of seasonal and perennial rhinitis
intranasal glucocorticoids
Budesonide (Rhinocort Aqua)
Fluticasone Propionate (Flonase)
Triamcinolone (Nasocort Allergy 24 hours)
Budesonide (Rhinocort Aqua)
Fluticasone Propionate (Flonase)
Triamcinolone (Nasocort Allergy 24 hours)
intranasal glucocorticoids
Adverse effects intranasal glucocorticoids
drying of the nasal mucosa burning or itching sensation sore throat epistaxis headache
systemic effects rare at recommended dosing
adrenal suppression
slowing of linear growth in children
Benefits of intranasal glucocorticoids are greatest when
dosing is done daily rather than irregularly
After symptoms are controlled, dosage reduced to lowest effective
For patients with seasonal allergic rhinitis max effects of intranasal glucocorticoids may require
For perennial rhinitis max responses may take
a week or more to develop
2-3 weeks to develop
If you have congestion and you are administering intranasal glucocorticoids, how can you improve absorption
apply a topical decongestant first
first line drugs for mild to moderate allergic rhinitis
oral antihistamines
Oral antihistamines are most effective when taking
prophylactically and less helpful when taken after symptoms appear
Oral antihistamines relieve
sneezing, rhinorrhea, nasal itching but do not reduce nasal congestion
why are glucocorticoids more effective than antihistamines
Histamine is only one of several mediators of allergic rhinitis
why are antihistamines not effective with symptom control in the common cold
histamine does not contribute to symptoms of infectious rhinitis
Some patients take first generation antihistamines for their drying effect during a common cold but why could this complicate it
increasing the viscosity of their secretions
Adverse effects of first gen antihistamines (diphenhydramine)
sedation anticholinergic effects such as drying of nasal secretions dry mouth constipation urinary hesitancy
When generation of antihistamines has sedation and anticholinergic adverse effects
first gen which are rare in second gen
if nasal congestion is the dominant complaint
what meds?
if that doesnt work?
Intranasal glucocorticoids
Oral decongestant
combination therapy allergy testing reassess for anatomic nasal obstruction reassess for nonallergic inflammation immunotherapy
if intermittent sneezing, nasal itching and rhinorrhea are the main complaints, what meds?
if that doesnt work?
oral antihistamine
intranasal antihistamines
allergy testing
avoidance
immunotherapy
If mild rhinitis symptoms
if that doesnt work
oral antihistamine
intranasal glucocorticoids
intranasal antihistamine
moderate/severe rhinitis symptoms
if that doesnt work
intranasal glucocorticoids
intranasal antihistamine
combination therapy
allergy testing
aggressive environmental control
immunotherapy
2 intranasal histamines used for allergic rhinitis
Azelastine (Astelin and Astepro)
olopatadine (Patanase)
Azelastine (Astelin and Astepro)
olopatadine (Patanase)
for adults and children older than
12 years old
adverse effects
Azelastine (Astelin and Astepro)
olopatadine (Patanase)
somnolence
nosebleeds
headaches
Azelastine (Astelin and Astepro)
olopatadine (Patanase)
what generation
second generation
intranasal antihistamines
Chlorpheniramine
Diphenhydramine (Benadryl)
first generation oral antihistamines
sedating
Cromolyn reduces symptoms by
suppressing the release of histamine and other inflammatory mediators from mast cells
used for prophylaxis
may take a week or 2 to develop
If congestion is present ______ should be used before Cromolyn
topical decongestant
Sympathomimetics (Decongestants) work by
shrinking swollen membranes followed by nasal drainage
topical vs oral Sympathomimetics (Decongestants)
topical - vasoconstriction is rapid and intense
oral - responses are delayed, moderate and prolonged
In pt with allergic rhinitis Sympathomimetics (Decongestants) only relieve
congestion
They do not reduce rhinorrhea, sneezing or itching
Adverse effects of topical Sympathomimetics (Decongestants)
Rebound congestion
how to prevent rebound congestion
limit topical administration to 3-5 days
how to break rebound congestion
abrupt discontinuation (very uncomfortable)
stop one nostril at a time
or
use intranasal glucocorticoid (in both nostrils) for 2-6 weeks starting 1 week before d/c decongestant
topical Sympathomimetics (Decongestants) are not appropriate for
chronic rhinitis
Adverse effects of oral Sympathomimetics (Decongestants)
CNS excitation includes restlessness
irritability
anxiety
insomnia
widespread vasoconstriction - if used in excess this can happen in the topicals as well. This can be dangerous for those with HTN, CAD, Cardiac dysrhythmias, Cerebrovascular disease
Sympathomimetics (Decongestants) that is associated with abuse
Pseudoephedrine - similar to amphetamine
what is the combat methamphetamine epidemic act of 2005
all products that contain pseudoephedrine be kept behind the counter even though you dont need a prescription. It is tracked and you can purchase no more than 9g per month and 3.6g on any given day
what Sympathomimetics (Decongestants) is not very effective
phenylephrine
how should you administer drops?
with pt in a lateral, head-low position, causes to spread slowly over the nasal mucosa
drops are preferred in young children bc
they are particularly susceptible to toxicity
Sprays are ____ effective than drops
less
Diff in oral and topical agents
1) topical act faster than oral and are usually more effective
2) oral agents act longer than topical preparations
3) systemic effects (vasoconstriction and CNS stim) occur primarily with oral agents; topical agents usually elicit these responses only when dosage is higher than recommended
4) rebound congestion is common with prolonged use of topicals but its rare in oral
route for phenylephrine that is effective and route that is not
oral - not due to first pass metabolism
topical - fast and effective
Pseudoephedrine oral
compared with oral phenylephrine, it is better absorbed, longer half life and much more effective
Atrovent for allergic rhinitis treats
decreases rhinorrhea
does not decrease sneezing, nasal congestion or postnasal drip
most common side effects for Atrovent used for allergic rhinitis
nasal drying and irritation
no systemic effects
Montelukast (Singulair) for seasonal and perennial allergic rhinitis works to relieve
nasal congestion
little effect on sneezing or itching
less effective than intranasal glucocorticoids
Montelukast (Singulair) adverse effects
Neurophsychiatric effects including agitation, aggression, hallucinations, depression, insomnia, restlessness, SI
Best to reserve Montelukast for
patients who do not respond to or cannot tolerate intranasal glucocorticoids, antihistamines or both
Opioid antitussives used most often for cough suppression work by?
examples
act in CNS to elevate cough threshold
Codeine - most effective
Hydrocodone - more potent - greater liability for abuse
opioid antagonist
naloxone (narcan)
What schedule when codeine is dispensed alone vs with antitussive mixtures
Schedule II
Schedule V
most common OTC nonopioid cough medicine
Dextromethorphan
At therapeutic doses, dextromethorphan does not
depress respiration
antihistamine with the ability to suppress cough
Diphenhydramine
Diphenhydramine adverse
sedative
anticholinergic
Benzonatate (Tessalon) combo of
tetracaine and procaine
Adverse effects of Benzonatate (Tessalon)
sedation
dizziness
constipation
pt ed for Benzonatate (Tessalon)
in children younger than 2 - ingestion of just 1-2 caps can be fatal
swallow whole. Do not suck or chew
-can cause laryngospasm, bronchospasm, and circulatory collapse
overdose of Benzonatate (Tessalon)
seizures
dysrhythmias
death
smaller doses of Benzonatate (Tessalon) can cause
confusion
chest numbness
visual hallucinations
burning sensation in eyes
Benzonatate (Tessalon) for children and adults
10 and older
a drug that renders cough more productive by stimulating flow of resp tract secretions
Expectorant (guaifenesin - Mucinex)
a drug that reacts directly with mucus to make it more watery
mucolytic
(hypertonic saline and acetylcysteine)
can trigger bronchospasm
drug that smells like rotten egg bc of sulfur content
Mucolytics
most URIs are caused by
rhinovirus
URI symptoms
rhinorrhea nasal congestion cough sneezing sore throat hoarseness headache malaise myalgia fever for children
Vit c and zinc for colds
no evidence that it will prevent or cure
combination cold remedies contain 2 or more of
nasal decongestant an antitussive analgesic antihistamine caffeine
Why are antihistamines used in cold remedies
because of anticholinergic properties, used to suppress mucus secretion but it can worsen URI bc it can thicken secretions -> may lead to sinusitis
why is caffeine used in cold remedies
to offset sedative effects of antihistamines may also help with associated headaches
OTC combo formulations
it can be reformulated and then sold under the same name
Young children and OTC cold remedies
no proof of safety but is proof of potential for serious harm
children treated for convulsions, tachycardia, hallucinations, impaired consciousness
FDA says no OTC cold remedies for children younger than 2yrs….reviewing safety for 2-11
American Academy of pediatrics says older than 6 years
only use pediatric approved products
ask a professional first
read all product safety info first
use measuring device provided with product
d/c and seek professional care if condition worsens or fails to improve
avoid using antihistamine containing products to sedate
managing colds in children
bulb syringe to remove nasal secretions in ages less than 6 mos
saline nose drops to decrease stuffiness
cool mist humidifier to thin secretions
older than 1 yr , honey for cough
older than 2 yrs, mentholated chest rubs
acetaminophen or ibuprofen for discomfort or fever
LTRA that that does not cause liver injury
Montelukast (Singulair)
What LTRA does not have neuropsychiatric side effects
they all do
Zileuton (Zyflo)
Zafirlukast (Accolate)
Montelukast (Singulair)
what 2 LTRAs have the risk of Churg Strauss syndrome
Zafirlukast (Accolate)
Montelukast (Singulair)
weight loss
flulike
pulmonary vasculitis
Churg Strauss syndrome
usually when glucocorticoids are being withdrawn
alternative to inhaled glucocorticoid for prophylactic therapy of asthma, administered on a fixed schedule to reduce frequency and intensity of attacks. Max effects take several weeks to develop
given 4 times per day!
Cromolyn
very safe
inconvenient
Pt ed for cromolyn
instruct pt on proper use and care of nebs
administer 15 min before exercise and exposure to other precipitating factors such as cold and environment
long term - regular schedule
monitor and record peak expiratory flow, symptom frequency, symptom intensity, nighttime awakenings, effect on normal activity, SABA use
Bronchodilators are used in
COPD
asthma
SABA kids
2yr and older
anticholinergics should not be used in kids younger than
11 years old
Methylxanthines kids
children of all ages including neonates
Pregnant women and bronchodilators
B2 agonists may cause uterine relaxation.
Benefits greater than risk
inhaled anticholinergics are among the safer
no methylxanthines
B2 agonists and breastfeeding
fine use caution
anticholinergics
dry up milk
older adults bronchodilators
anticholinergics on BEERS
B agonists benefit vs risk
LABAs and asthma
important note
long term control, not first line
MUST be combined with a glucocorticoid
LAMA that contains lactose
Umeclidinium
Ipratropium (Atrovent)
Short Acting Anticholinergic
Aclidinium (Tudorza)
Tiotropium (Spiriva)
Umeclidinium (Incruse Elliptal)
Long Acting Muscarinic Antagonist
med for asthma warned to avoid caffeine
Theophylline
caffeine can intensify adverse effects while decreasing theophylline breakdown
med for asthma that warn against smoking tobacco or marijuana
Theophylline
increase clearance of Theophylline
signs of theophylline tox
nausea vomiting abd discomfort diarrhea insomnia restlessness palpitations
decreased FEV1 means
obstruction on exhalation
FEV1/FVC (pulmonary function test) is used to
distinguish obstructive from restrictive
FEV1/FVC decreased
obstructive
pulmonary fibrosis
conditions of decreased intercostal or diaphragmatic strength such as myasthenia gravis, obesity, pectus excavatum
restrictive
FEV1/FVC increased or normal
restrictive
what is used to monitor asthma
PEF (does not diagnose)
maximal rate of airflow during expiration using a peak flowmeter
PEF
when Use of SABAs increase, physical activity limited what does your pulmonary function test do
FEV1 decreases which means FEV1/FVC number drops
Saba goal for control
less than 2 days a week
to diagnose COPD requires what
pulmonary function test FEV1/FVC less than 0.7
Treatment goal COPD
reduce symptoms
improve pt health status
increase exercise tolerance
reduce risks and mortality
COPD few symptoms low risk is what category and what treatment
Cat A
SABA and consider LAMA or LABA
COPD increased symptoms, low risk
cat and treatment?
Cat B
Symptom control - SABA
Add in LAMA or LABA or combo LAMA/LABA
antiinflammatory asthma long term
glucocorticoids
LTRA
Cromolyn
Bronchodilators asthma - long term control
LABA inhaled or oral
Theophyline
Quick relief Bronchodilator
SABA
Anticholinergics
Quick relief Antiinflammatory
Glucocorticoids systemic
COPD few symptoms, high risk
Cat C
SABA
first choice - LAMA
persistent symptoms - Combo LAMA/LABA or LABA/IGC
COPD increased symptoms, high risk
Cat D
SABA
first choice - LAMA or LAMA/LABA or IGC/LABA
Persistent - Combo LAMA/LABA/IGC
still persistent consider
Roflumilast
Azithromycin
what drug class will you avoid in COPD in pt with a tachydysrhythmia or heart issue
LABA
taking a glucocorticoid and blood sugar
in adrenal suppression - how does it change
Hyperglycemia
hypoglycemia
glucocorticoid must be combined with what for COPD
LABA
FEV1 > = 80 copd
mild COPD
FEV1 50-79%copd
Moderate
FeV1 30-49%copd
Severe
FEV1 <30%copd
Very Severe
