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815 > Chapter 11 - Cold & Allergies > Flashcards

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
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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
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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
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4
Q

Cold Complications

A
  • Sinusitis
  • Middle ear infections
  • Bronchitis
  • Pneumonia
  • Exacerbation of asthma or COPD
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5
Q

Cold Treatment Goals

A
  • Reduce bothersome symptoms

- Prevent transmission of cold virus to others

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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
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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
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8
Q

Cold Pharmacologic Categories

A
  • Decongestants
  • Antihistamines
  • Local anesthetics
  • Systemic analgesics
  • Antitussives and protussives
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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
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10
Q

Direct Acting Decongestants

A
  • Bind directly to adrenergic receptors

- Ex: Phenylephrine, oxymetazolone, tetrahydrozoline

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11
Q

Indirect Acting Decongestants

A
  • Displace NE to cause reactions
  • Prone to tachyphylaxis
  • Ex: Ephedrine
  • Not recommended for children < 6 y.o.
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12
Q

Systemic Non-Rx Decongestants

A
  • Sudafed
  • Phenylephrine
  • Metabolized by COMT and MAO
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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
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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
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15
Q

Antihistamines - Cold

A
  • Not effective alone in reducing rhinorrhea and sneezing from colds
  • Beneficial with decongestants
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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)

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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

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18
Q

Antitussives & Protussives - Cold

A
  • Usually nonproductive coughs with colds
  • Expectorants - not effective
  • Antitussives - may be effective but not recommended
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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
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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
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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
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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
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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
Q

Cold Evaluation Outcomes

A
  • 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
Q

Allergic Rhinitis

A
  • 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
Q

Allergic Rhinitis Pathophysiology

A
  • 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
Q

Four Allergic Rhinitis Phases

A
  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
Q

Allergic Rhinitis Clinical Presentations

A
  • 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
Q

Allergic Rhinitis Complications

A
  • Sinusitis
  • Otitis media
  • Nasal polyps
  • Sleep apnea
  • Hyposmia
31
Q

Allergic Rhinitis Treatment Goals

A

NOT CURE

  • Reduce symptoms
  • Improve patient’s functional status and well-being
32
Q

Allergic Rhinitis Treatment Steps

A

3 Steps

  1. Allergen avoidance
  2. Pharmacotherapy
  3. Immunotherapy
33
Q

Allergic Rhinitis Nonpharmacologic

A
  • 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
Q

Allergic Rhinitis Pharmacologic

A
  • 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
Q

INCS - Allergic Rhinitis

A
  • 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
Q

Antihistmines - Allergic Rhinitis

A
  • 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
Q

Combination Products - Antihistamines

A
  • Combined with decongestants and analgesics

- Use with caution since increased risk of adverse effects like insomnia

38
Q

Decongestants - Allergic Rhinitis

A
  • Used to treat congestion common with allergic rhinitis

- Systemic or short-term topicals

39
Q

Cromolyn Sodium - Allergic Rhinitis

A
  • 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
Q

Pharmacotherapeutic Comparison - Allergic Rhinitis

A
  • 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
Q

Special Populations - Allergic Rhinitis

A
  • 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
Q

Complementary Therapies - Allergic Rhinitis

A
  • 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
Q

Counseling - Allergic Rhinitis

A
  • 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
Q

Evaluation Outcomes - Allergic Rhinitis

A
  • 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
Q

Group A beta-hemolytic steptococci

A

Rare cause of viral and bacterial co-infection with cold

46
Q

Cold Modes of Transmisison

A
  • Self-inoculation

- Aerosol transmission

47
Q

Cold Exclusions for Self-Treatment

A
  • 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
Q

Phenylephrine

A

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
Q

Oxymetazoline

A
  • Afrin
  • Nasal
  • Long acting, ~ 12 hours
  • Not recommended for children < 6 y.o.
50
Q

Pseudoephedrine

A
  • 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
Q

Intermittent Allergic Rhinits

A
  • 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
Q

Persistent Allergic Rhinitis

A
  • 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
Q

Episodic Allergic Rhinitis

A
  • 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
Q

Allergic Rhinitis Exclusions

A
  • 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
Q

First Generation Antihistamine Examples

A
  • Chlorpheniramine
  • Diphenhydramine
  • Doxylamine
56
Q

Second Generation Antihistamine Examples

A
  • Cetirizine
  • Fexofenadine (don’t take with fruit juice, approved for pilots)
  • Levocetirizine
  • Loratidine
57
Q

Cetirizine

A
  • Most potent 2nd generation antihistamine
  • Some sedative properties in 10% of the population
  • Aka Zyrtec

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