Chapter 11 - Cold & Allergies Flashcards
1
Q
Cold
A
- AKA common cold
- Viral infection of upper respiratory tract (URT)
- Kids: 6-10 colds/year
- Adults < 60 y.o.: 2-4 colds/year
- Adults > 60 y.o.: 1 cold/year
2
Q
Pathophysiology of Colds
A
- Limited to URT
- Host-defense system usually protects body from infectious and foreign particles
- Nose has cholinergic, sympathetic, ad sensory nerves (drug targets)
- Cause symptoms when stimulated
- Sensory - stimulated by histamine/bradykinin to cause sneezing
- Cholinergic/Sympathetic - stimulated causing congestion (responds to many mediators) by constricting or dilating blood flow
- 200+ viruses cause colds, most common is rhinoviruses
3
Q
Clinical Presentation of Colds
A
- Predictable symptoms: 1-3 days post infection get a sore throat, nasal symtoms 2-3 days later, then cough (infrequent) appears on day 4 or 5
- May see slightly red pharynx, postnasal drainage, nasal obstruction, and mild to moderately tender sinuses
- Secretion starts thin, clear, and watery and may go to thick yellow/green, then back to clear
4
Q
Cold Complications
A
- Sinusitis
- Middle ear infections
- Bronchitis
- Pneumonia
- Exacerbation of asthma or COPD
5
Q
Cold Treatment Goals
A
- Reduce bothersome symptoms
- Prevent transmission of cold virus to others
6
Q
General Cold Treatment Approach
A
- Mainstay is nonpharmacologics
- Use single-entity products to treat specific symptoms over combination products
- Due to symptoms appearing and peaking at different times
7
Q
Cold Nonpharmacologics
A
- Evidence of efficacy is lacking
- Popular therapies - fluids, rest, nutritious diet, vaporizers, humidifiers
- Salt gargles for sore throat
- Saline nasal spray to moisten irritated mucous membranes
- Tea with lemon/honey, chicken soup, and hot broths are soothing
- Breate Right strips can give temporary relief from congestion/stuffiness
- Aromatic oils/rubs - soothing and improve sleep, supervise their use in children
- Infants: sit upright and use bulb syringes as needed
- Wash hands properly, use alcohol based hand sanitizers, use antiviral disinfectants, and antiviral tissues to reduce its spread
8
Q
Cold Pharmacologic Categories
A
- Decongestants
- Antihistamines
- Local anesthetics
- Systemic analgesics
- Antitussives and protussives
9
Q
Decongestants - Cold
A
- Treat sinus and nasal congestion
- Adrenergic agonists (sympathomimetics)
- Stimulate alpha receptors to cause vasoconstriction
- 3 Types: Direct acting, indirect acting, and mixed
- Acute overdose - life threatening, especially in kids, and can cause coma, CNS stimulation/depression, CV collapse
- Adverse Rxns: CV stimulation, CNS stimulation (more common in kids/elderly and with systemic decongestants)
- React with MANY medications and can’t use with MAOIs
- Exacerbate hypertension, DM, increases IOP, heart disease
- Can be used to make meth
10
Q
Direct Acting Decongestants
A
- Bind directly to adrenergic receptors
- Ex: Phenylephrine, oxymetazolone, tetrahydrozoline
11
Q
Indirect Acting Decongestants
A
- Displace NE to cause reactions
- Prone to tachyphylaxis
- Ex: Ephedrine
- Not recommended for children < 6 y.o.
12
Q
Systemic Non-Rx Decongestants
A
- Sudafed
- Phenylephrine
- Metabolized by COMT and MAO
13
Q
Intranasal Non-Rx Short-acting Decongestants
A
- Ephedrine
- Levmetamfetamine
- Naphazoline
- Phenylephrine
- Provide temporary relief from nasal congestion and cough from postnasal drip
- NOT for sinusitis
14
Q
Intranasal Non-Rx Long-acting Decongestants
A
- Xylometazoline
- Oxymetazoline (Afrin)
- Provide temporary relief from nasal congestion and cough from postnasal drip
- NOT for sinusitis
15
Q
Antihistamines - Cold
A
- Not effective alone in reducing rhinorrhea and sneezing from colds
- Beneficial with decongestants
16
Q
Local Anesthetics - Cold
A
-Temporary relief of sore throats
-Use every 2-4 hours
-Avoid benzocaine in those with allergies and < 2 y.o.
-Antiseptics are not effective for viral infections
EX: Cepacol, Chloraseptic (not recommended in kids < 2 y.o.), contain benzocaine
-Also menthol and camphor (Vicks)
17
Q
Systemic Analgesics - Cold
A
- Effective for aches or fevers associated with colds
- Don’t use aspirin in kids with viral illnesses or younger than 15 y.o. in general, risk of Reye’s syndrome
18
Q
Antitussives & Protussives - Cold
A
- Usually nonproductive coughs with colds
- Expectorants - not effective
- Antitussives - may be effective but not recommended
19
Q
Pharmacotherapeutic Comparison
A
- Local anesthetics and systemic analgesics have good evidence for pain, fever, and sore throat
- Topical decongestants limited to 3-5 day use due to risk of RM (rebound rhinitis)
- Pseudoephedrine more efficacious than phenylephrine
20
Q
Special Populations - Cold
A
- Pregnant and breastfeeding (BF) - use nondrug therapy and only use drugs when necessary and that have long standing safety records
- Don’t use combination products, maximum strength products, long acting products, etc. in pregnany or BF
- Avoid systemic decongestants while preggo
- Pseudoephedrine - preferred in BF
- Drink more fluids if milk production decreases
- No non-Rx medications for kids < 2 y.o.
- Emphasize nondrug measures in kids and only use drugs when necessary - follow directions carefully and avoid combination products
- Can consider decongestants in CONTROLLED hypertensive patients
21
Q
Patient Factors - Cold
A
- If symptoms last longer than 7-14 days or a chronic condition is suspected - don’t self-treat
- Patients with conditions exacerbated by sympathetic stimulation should avoid decongestants (CV, DM, etc.)
- Oral decongestants are considered “doping” agents
- Use dosage forms that correlate with patient abilities
22
Q
Complementary Therapies - Cold
A
- Zinc and vitamin C are popular choices
- High zinc concentrations can block the adhesion of rhinovirus to nasal epithelial cells which may reduce/prevent colds
- Oral zinc formulations cause GI upset side effects
- Vitamin C may lower the duration of a cold and can also cause GI side effects
- Both are better for prophylaxis than treatment
- Other probiotics and vitamin supplements MAY help but aren’t proven to help
23
Q
Cold Assessments
A
- Case-based approach
- If not excluded, give recommendations for most bothersome symptoms
24
Q
Cold Counseling
A
- Nondrug measures may be effective in relieving discomfort of cold symptoms
- Recommend therapies for specific symptoms
- Describe the purpose and directions of each non-Rx medication for their target symptom(s)
- Tell them when to seek medical attention
25
Cold Evaluation Outcomes
- Monitor for worsening symptoms, temperature increases, nasal secretions, respirations, and face/neck pain
- If complications are suspected, seek medical attention
- Should clear up or improve in 7-14 days
26
Allergic Rhinitis
- 20% of adults and 40% of kids affected in the US
- $3.4 billion in direct costs and $11 billion in indirect
- More prevalent in the south and in young to middle aged population
27
Allergic Rhinitis Pathophysiology
- Affected upper respiratory system (URS)
- Risk factors: family history, filaggrin gene mutation, increased IgE, socioeconomic class, eczema, diet
- Triggered by indoor or outdoor allergens
- Common indoor allergens: house dust mites, cockroaches, mold spores, cigarette smoke, pet dander, wool dust, latex, resins, dust based on work
- Common outdoor allergens: pollen, mold spores, pollutants
28
Four Allergic Rhinitis Phases
1. Sensitization: initial exposure stimulating IgE production
2. Early Phase - minutes after subsequent exposure, rapid release of mast cell mediators - symptoms
3. Cellular Recruitment - leukocytes, eosinophils, mast cells release more inflammatory mediators
4. Late Phase - begins 2-4 hours after exposure and causes hypersecretion secondary to gland hypertrophy and congestion, priming tissues to decrease the threshold for triggers
29
Allergic Rhinitis Clinical Presentations
- Seasonal and perennial allergic rhinitis - "hay fever"
- Intermittent (IAR) and persistent allergic rhinitis (PAR) - more accepted medical terminology
- Classifications depends on timing and duration of symptoms
- Symptoms can also vary from mild to severe
- Systemic symptoms: fatigue, irritability, malaise, and cognitive impairment
30
Allergic Rhinitis Complications
- Sinusitis
- Otitis media
- Nasal polyps
- Sleep apnea
- Hyposmia
31
Allergic Rhinitis Treatment Goals
NOT CURE
- Reduce symptoms
- Improve patient's functional status and well-being
32
Allergic Rhinitis Treatment Steps
3 Steps
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
33
Allergic Rhinitis Nonpharmacologic
- Allergen avoidance is usually not enough and single entity drugs are initiated, but is the primary recommendation
- Nasal wetting agents or nasal irrigation may relieve mucosal irritation and dryness
- Reduces stuffiness, rhinorrhea, and sneezing
34
Allergic Rhinitis Pharmacologic
- Intranasal corticosteroids (INCS) are most effective and only recently went OTC
- Before that oral and ocular antihistamines were used, topical and oral decongestants and mast cell stabilizers were also utilized
- Use regularly rather than episodically for most effective treatment
35
INCS - Allergic Rhinitis
- Aka glucocorticoids
- Very effective
- Treat itching, rhinitis, sneezing, and congestion
- Stop the "allergic cascade"
- Triamcinolone and Fluticasone are the only non-Rx approved for use
- Triamcinolone: use in 2 y.o. +
- Fluticasone: use in 4 y.o. +
- Complete symptom control may not occur for at least a week, so use regularly rather than episodically
- SE: nasal discomfort, bleeding, sneezing, glaucoma, cataracts, increased infection risk, growth inhibition in children
- Budesonide is preferred during pregnancy now
36
Antihistmines - Allergic Rhinitis
- One of the most frequently prescribed drug classes
- Sedating = 1st generation (crosses CNS, lipophilic), Nonsedation = 2nd generation (doesn't cross CNS)
- Sedating antihistamines have a risk of anticholinergic effects, controversial to use
- Compete with antihistamines at receptors to block their effects, highly selective for H1 receptors
- 2nd generation also inhibit mast cell release and decrease cellular recruitment
- Sedating overdoses: cardiac symptoms, CNS symptoms, drowsiness, restlessness, hyperactivity, tachycardia
- Adverse Effects: CNS, anticholinergic in 1st generation
- Don't use sedating histamines in newborns, premature infants, BF, and narrow-angle glaucoma patients
- Don't use if patients are asthmatic, have peptic ulcers, prostatic hypertrophy, or use MAOIs
37
Combination Products - Antihistamines
- Combined with decongestants and analgesics
| - Use with caution since increased risk of adverse effects like insomnia
38
Decongestants - Allergic Rhinitis
- Used to treat congestion common with allergic rhinitis
| - Systemic or short-term topicals
39
Cromolyn Sodium - Allergic Rhinitis
- Mast cell stabilizer
- No systemic effects
- Use in 2 y.o. +
- Better to use before symptoms start if possible
- SE: sneezing, nasal stinging, burning
40
Pharmacotherapeutic Comparison - Allergic Rhinitis
- INCS - most effective for moderate to severe IAR and all types of PER, 1st line monotherapy
- Combine with antihistamines, decongestants, and mast cell stabilizers if additional control is needed
- Sedating antihistamines are effective, possible more than nonsedating, but have risks of sedation and cognitive impairment making the nonsedating the preferred recommendation
41
Special Populations - Allergic Rhinitis
- Pregnant women and children < 12 y.o. need differential diagnosing to ensure nonallergic rhinitis, asthma, or other conditions are the cause
- Intranasal cromolyn, diphenhydramine, and chlorpheniramine are first recommendations for preggo
- Can also use fluticasone, loratidine, or cetirizine if medications aren't well tolerated in the pregnant woman
- BF - intranasal cromolyn is primary recommendation, triamcinolone and fluticasone are PROBABLY okay too
- Antihistamines = contraindication in BF, can pass into milk
- Cromolyn sodium, triamcinolone and fluticasone are also recommended in kids (as long as they meet age requirements)
- Consult doctor if you are using a nasal spray on a child for 2 or more months out of the year
- Avoid sedating antihistmaines in kids (paradoxical effects) and elderly (increased CNS depression effects)
- Loratidine and cromolyn are the best choices for elderly
42
Complementary Therapies - Allergic Rhinitis
- Ephedra and feverfew - common herbals
- Ephedra has serious adverse effects like stroke and is banned by the FDA
- Feverfew's active ingredient is proven for safety and efficacy
- All other options aren't proven for safety and efficacy
43
Counseling - Allergic Rhinitis
- Avoid allergens - best method
- Advise about proper use of allergy medications and SE/interactions, as well as warnings
- Let them know when to seek medical attention
44
Evaluation Outcomes - Allergic Rhinitis
- Relief may take up to 2-4 weeks
- After this, follow up should be done if symptoms aren't controlled or SE are occuring
- If not controlled, increasing the dosage, changing medications, or changing formulations may help
- If not responding to non-Rx methods, go to doctor for Rx option and other methods (immunotherapy)
- Anyone with warnings or serious reactions, see PCP
- If STILL not treated, reconsider diagnosis
45
Group A beta-hemolytic steptococci
Rare cause of viral and bacterial co-infection with cold
46
Cold Modes of Transmisison
- Self-inoculation
| - Aerosol transmission
47
Cold Exclusions for Self-Treatment
- Fever > 100.4 F
- Chest pain
- SOB
- Worsening/development of symptoms
- Cardiopulmonary diseases
- AIDS or immunosuppressant therapy
- Frail patients or advanced age
- Infants < 3 mo.
- Hypersensitivities
48
Phenylephrine
Systemic
- Low bioavailability
- Half life: 2.5 hours
- Peak concentraionts: 1/2 - 2 hours
Nasal
- Short acting
- Not recommended for children < 6 y.o.
49
Oxymetazoline
- Afrin
- Nasal
- Long acting, ~ 12 hours
- Not recommended for children < 6 y.o.
50
Pseudoephedrine
- Well absorbed after oral admin.
- Half life ~ 6 hours
- Peak concentrations: 1/2 - 2 hours
- Not recommended for children < 2 y.o. (FDA) or < 4 y.o. (manufacturers)
- More bioavailable and effective than phenylephrine
51
Intermittent Allergic Rhinits
- Symptoms occurs < 4 days a week OR for < 4 weeks
- Mild - doesn't impair sleep and daily activity
- Moderate - severe - Imapirment of sleep/daily activities with troublesome symptoms
52
Persistent Allergic Rhinitis
- Symptoms occur > 4 days per week AND for > 4 weeks
- -Mild - doesn't impair sleep and daily activity
- Moderate - severe - Imapirment of sleep/daily activities with troublesome symptoms
53
Episodic Allergic Rhinitis
- Occur when individual is in contact with trigger that is not normally part of their environment
- Can have mild, moderate, or severe reaction
- First line is antihistamines due to their quick onset of action
54
Allergic Rhinitis Exclusions
- Children < 12 y.o.
- Pregnant or lactating women
- Symptoms of nonallergic rhinitis
- Symptoms of otitis media, sinusitis, bronchitis, or other infections
- Symptoms of asthma, COPD, or other respiratory disorders
- Severe or unacceptable SE
55
First Generation Antihistamine Examples
- Chlorpheniramine
- Diphenhydramine
- Doxylamine
56
Second Generation Antihistamine Examples
- Cetirizine
- Fexofenadine (don't take with fruit juice, approved for pilots)
- Levocetirizine
- Loratidine
57
Cetirizine
- Most potent 2nd generation antihistamine
- Some sedative properties in 10% of the population
- Aka Zyrtec
