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Pharmacology > Common Illnesses and Treatments > Flashcards

Common Illnesses and Treatments Flashcards

1
Q

Allergic rhinitis

A

2nd most common atopic disorder (asthma is
first)

Can be seasonal, perennial or episodic

Genetic and environmental factors

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2
Q

Allergic Rhinitis: Physiology

A

Inhaled allergens bind to a specific IgE
antibody

Superficial mucosal mast cells and basophils
degranulate and release chemical mediators

Early phase reaction: edema, cellular
recruitment, increased vascular permeability
leads to hyperemia, increased secretions

Late phase response: additional chemical
mediators released , nasal obstruction

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3
Q

Treatment of allergic rhinitis

A

Nonpharmacologic

Pharmacologic:

Nasal atrovent

Nasal antihistamines

Nasal cromolyn

Intranasal corticosteroids

Decongestants

Oral antihistamines

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4
Q

Nasal atrovent

A

Ipratropium bromide

Anticholinergic

Antagonizes action of acetylcholine at the
cholinergic receptor

Inhibits vagally mediated reflexes

Inhibits secretions from serous and
seromucous glands in nasal passages

Minimally crosses the nasal membrane, GI
mucosa and blood brain barrier

Poor (2-3%) absorption into systemic
circulation

Nasal atrovent

Use: allergic perennial rhinitis, and
nonallergic perennial rhinitis

Works well to alleviate rhinorrhea

Minimal effect on nasal congestion, and
sneezing

Contraindication: hypersensitivity to atropine

Precautions: narrow angle glaucoma,
prostatic hypertrophy, or bladder neck
obstruction

Pregnancy category B

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5
Q

Side effects - atrovent

A

Can cause rare cases of urticaria,
angioedema, bronchospasm after
administration

Bad taste!!

Nasal dryness

Epistaxis

Rare – dry mouth, blurred vision, eye pain
(don’t get in eyes!), dizziness, hoarseness,
cough

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6
Q

Nasal antihistamines

A

Only current available is Astelin/Astepro
(azelastine) and Patanase (olaptadine)

Others still in testing with FDA

Advantage is local effect and lack of steroids

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7
Q

Astelin/Astepro (Azelastine)

A

Histamine H1- receptor antagonist

Metabolized by the P450 system

Indicated for seasonal allergic rhinitis and
vasomotor rhinitis (rhinorrhea, post nasal
drip, nasal congestion)

Precautions: care should be taken when
performing activities that require mental
alertness

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8
Q

Astelin: side effects

A

Bitter taste!

Somnolence

Headaches

Nasal burning

Pharyngitis

Paroxysmal sneezing

Weight gain

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9
Q

Patanase

A

2nd generation H1 Antagonist

Age 6 -11 – 1 spray each nostril twice daily

Age 12 through elders – 2 sprays each nostril
twice daily

Pregnancy category C

Also may cause drowsiness and caution
should be exercised if driving or operating
machinery. CNS depression.

Licensed for seasonal rhinitis only

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10
Q

Side effects Patanase

A

Nasal ulcers

Drowsiness

Epistaxis

Dry mouth

Bitter taste (13%)

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11
Q

Nasal cromolyn

A

Mast cell stabilizer

Acts on mast cells to prevent antigen
triggered degranulation & release of
histamine and other allergic mediators

Use: allergic rhinitis – seasonal or chronic

Takes 2-4 weeks to see an effect

Use if other medications are not successful

Precautions: liver disease, kidney disease,
nasal polyps

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12
Q

Cromolyn side effects

A

Burning

Epistaxis

Flushing

Sneezing

Cough

Headache

Unpleasant taste

Urticaria

Angioedema

Bronchospasm

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13
Q

Intranasal corticosteroids

A

First line therapy for allergic rhinitis!

Most effective at reducing inflammation and
related nasal obstruction

Inhibits release of mediators from basophils

Inhibits influx of other inflammatory cells

Active against early and late phase allergic
response

Can be used alone or in combination with
antihistamines

May take one week or more to see an effect
Clinically indicated in sinusitis, rhinitis

Clinically indicated in Obstructive
sleep apnea (2012) when surgery in
contraindicated, or when symptoms persist
post-op.

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14
Q

Intranasal steroids

A

Beclomethasone (Beconase)

Age 6 and up

Budesonide (Rhinocort)

Age 6 and up

Flunisolide (no brand name available)

Age 6 and up

Fluticasone (Flonase, Veramyst)

Age 2 and up

Preferred by most insurances

Mometasone (Nasonex)

Age 2 and up

Triamcinalone (Nasacort)

Age 2 and up

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15
Q

Intranasal Corticosteroids: SEs

A

Nasal burning, irritation

Epistaxis

Headache

Growth velocity delay? Monitor height!

Blurred vision

Tinnitus

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16
Q

Decongestants

A

Systemic (oral) or intranasal

Alpha adrenergic receptor agonists

Have vasoconstrictive effect, shrinks swollen
mucosa and helps breathing

Can be taken orally or topically (nasal
sprays)

  • pseudophedrine is safest*
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17
Q

Ephedrine

A

Alpha and beta adrenergic agonist

Used to be available as oral decongestant

Has large CNS stimulation effects

Stimulates heart rate and cardiac output

Causes bronchodilation

Hypertension and insomnia common side
effects

No longer available, was also in herbal
remedies (Ephedra, Ma Huang) – which the
FDA also banned

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18
Q

Phenylephrine

A

Selective alpha 1 receptor agonist

Very similar chemically to epinephrine

Available commonly now “Children’s Sudafed
PE”

Has replaced phenylpropanolamine and
pseudophedrine in most OTC products

Can be dosed down to age 4 yo (for nasal
congestion)

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19
Q

Phenylpropanolamine

A

Commonly used in OTC cold mixtures until
recently

Similar to ephedrine but less CNS stimulation

An association found between PPA and
hemorrhagic stroke

Found by the FDA to be “not safe for over
the counter use”

Advise patients to check labels for PPA as all
products may not yet be reformulated

20
Q

Sudafed: Caution-

A

Do not use under 4 years old ??

Great caution with the elderly given
greater sensitivity to side effects and more
comorbidities

21
Q

Pseudophedrine (Sudafed)

A

Stereoisomer of ephedrine

Less effects of tachycardia, hypertension,
and CNS stimulation than ephedrine

Should be used with GREAT caution in people
w/ hypertension, cardiac disease, and
prostatic enlargement

CONTRAINDICATED within 14 days of use of a
MAO inhibitors

Great risk of abuse, so while still considered
the safest, Sudafed is hard to get – need to
sign a book at the pharmacy and show ID

22
Q

Nasal decongestants

A

Useful in acute rhinitis

People tend to overuse  “rhinitis
medicamentosa” – rebound effect –
hyperemia and increased congestion

Occurs with use >3-5 days

Examples:

oxymetazoline (AFRIN)

Neosynephrine (phenylephrine)

23
Q

Oral antihistamines

A

Bind to H1 receptors to prevent histamine

binding and release, decreases secretions

24
Q

First generation OA’s

A

Diphenhydramine, hydroxyzine, chlorpheniramine,
brompheniramine, promethazine, cyproheptadine,
others

Sedating

Inhibits CYP2D6 or substrate

25
Q

Second generation OA’s

A

Peripheral histamine blockers

Little or no CNS effect

Cetirizine, loratidine, fexofenadine

Induce CYP P450 system

26
Q

First Generation OA’s: Caution-

A

All first generation antihistamines are on
the BEERS list  should not be used in the
elderly due to the anticholinergic effects

May also be associated with a higher SIDS
rate in the premature or term neonate

Not for OTC use under the age of 2 yo

27
Q

Diphenhydramine

A

Benadryl

1st generation H1 blocker

Used for allergies, sleep, prevention
of motion sickness, dystonic reactions,
Parkinson’s

Side effects:

Hypotension, palpitations, tachycardia, sedation,
dizziness, paradoxical excitement, xerostomia,
thickened bronchial secretions

Dosing: 5 mg/kg/day, not to exceed 300
mg/24 hrs

28
Q

Hydroxyzine

A

Atarax, Vistaril

1st generation H1 blocker

Syrup may contain sodium benzoate

Uses: anxiety, antihistamine, antiemetic

s/e drowsiness, dizziness, xerostomia,
anticholinergic effects

Dose: 2 mg/kg/day divided q 6-8 hrs

29
Q

Chlorpheniramine

A

Chlor-Trimeton

1st generation H1-blocker

Use: perennial & seasonal allergic rhinitis,
urticaria

In many OTC cold preparations

s/e: drowsiness, excitability, thickening of
bronchial secretions

Cytochrome P450 substrate

Can be dosed down to age 2 – dose by form
(maleate vs dexclorpheniramine maleate)

30
Q

Cetirizine

A

Zyrtec

2nd generation H1 blocker

Use: allergic rhinitis, urticaria

s/e: BP changes, headache, GI s/s,
drowsiness, photosensitivity

Cytochrome P450 , CYP3A4 substrate

Dosing: down to 6 months

6 mo-23 months 2.5 mg daily

2-5 yo 2.5-5 mg daily

6 yo + 5-10 mg daily

31
Q

Loratidine

A

Alavert, Claritin, Tavist ND, Triaminic
Allerchews

2nd generation H1 blocker

Use: allergic rhinitis, urticaria

Less sedating than other antihistamines

Cytochrome P450 isoenzyme CYP 2D6 &
CYP3A3/4

s/e: Xerostomia, drowsiness,
photosensitivity

Dose: 2-5 yo 5 mg daily

6 yo + 10 mg once daily

32
Q

Fexofenadine

A

Allegra

2nd generation H1 blocker

Use: allergic rhinitis, urticaria

s/e: GI s/s, drowsiness, fatigue

Cytochrome P450 isoenzyme CYP2D6
inhibitor and CYP3A4 substrate

Dose:

Age 6 months – for urticaria – 15 mg BID

Age 2-11 30 mgs BID

Age 12+ 60 mg BID OR 180 mg QD

fruit juices interfere with absorption

33
Q

Fexofenadine in elders

A

Plasma levels in the elderly are generally
higher than those observed in other age
groups.

Once daily dosing is recommended when
starting therapy in elderly patients or
patients with decreased renal function (Lexi-
comp, 2014)

34
Q

Cardiotoxicity and OA’s

A

Seldane or terfenadine was widely used in
the US prior to the 1990s for allergies

Fexofenadine is a metabolite of terfenadine

Terfenadine was pulled from the market
by the FDA when they found that it
interacted with other medications and foods
(erythromycin, grapefruit) and caused QT
prolongation and Torsade de Pointes

Fexofenadine levels increase with other CYP
450 medications but no QT prolongation has
been seen

35
Q

Desloratine

A

Clarinex

Marketed as “purified” Loratidine

Metabolite of loratidine

Peripheral H1 blocker

Some people are slow metabolizers

Can be used in Seasonal or perennial allergic
rhinitis and chronic urticaria

Desloratadine

Dose down to 6 mo of age: 1 mg daily

1-5 yo: 1.25 mg daily

6-11 yo: 2.5 mg once daily

12 yo + 5 mg daily

No reductions in dose for the elderly in
general but MUST reduce dose in Hepatic
disease and/or Renal disease

Pregnancy category C

Not recommended in breastfeeding women

36
Q

Levocetirizine (xyzal)

A

Purified H1 antagonist

Licensed for urticaria and allergic rhinitis

Dosing: Usual

Children 6 months to 5 years: 1.25 mg once daily

Children 6-11 years: 2.5 mg once daily

Children ≥12 years and Adults: 5 mg once daily

Pregnancy category B

In Elders – start at lowest dose and go up if
needed

Also need to reduce dose for altered renal
function

37
Q

Upper respiratory infections

Viral – leading pathogens:

A

Rhinoviruses

Parainfluenza

Respiratory syncytial virus

Coronaviruses

Adenoviruses

Enteroviruses

Influenza

Mycoplasma pneumonia

Reoviruses

38
Q

Cough suppressants

A

Dextromethorphan

Tessalon perles

Codeine

Hydrocodone

39
Q

Dextromethorphan

A

Acts on cough center in medulla to suppress
cough

Pharmacologically related to morphine

Efficacy????

s/e: nausea, dizziness, drowsiness

Cytochrome P450 isoenzyme CYP2D6,
CYP2E1, CYP3A3/4 substrate

Dosing: available down to 1 mo of age, most
recommend NO meds prior to 4 years of age.

40
Q

Benzonatate

A

Tessalon Perles

Chemically similar to Tetracaine

Local anesthetic effect of lung passages to
calm cough

Can be used for common cold, bronchitis,
pneumonia, asthma

Adult dosing only! 100-200 mg TID

Must be swallowed whole!

41
Q

Codeine & Hydrocodone

A

Act directly on medulla to suppress cough

Good for night time cough relief

Hydrocodone: various cough suspensions
available – best is Tussionex – hydrocodone +
Chlorpheniramine maleate – available down
to age 6 yo.

All can cause drowsiness, dizziness, pruritis,
dependence

Pregnancy category C  addiction in neonate
with chronic use

42
Q

Codeine in children

A

Many preparations with codeine available for
children – used to be mainstay of postop pain
for T&A’s and for cough

Codeine is metabolized into morphine

Many fatalities occurred after codeine
administration (after T&A) and noted to
be ultrarapid metabolizers due to CYP2D6
polymorphism  toxic levels of morphine in
serum – resp depression and death

Black Box Warnings

43
Q

Codeine

A

No codeine under the age of 12

No codeine in breastfeeding mothers

If codeine must be used: Codeine
should be prescribed in all patients in
the lowest effective dose and for the
shortest period of time; patients and
caregivers should be informed about
risks and signs of morphine overdose

(FDA.gov, Lexi-comp, 2014)

44
Q

Guaifenesin

A

Guiatuss, Mucinex, Robitussin

Expectorant

Thought to act by stimulating respiratory
tract secretions, increasing fluid volume and
decreasing viscosity of sputum

Efficacy????

Good safety profile

s/e: headache, dizziness, nausea, vomiting,
stomach pain, rash

Can dose down to age 2

45
Q

FDA Warning re: cough/ cold med preps in peds

A

2007

Public health advisory that advised NO
over the counter cough or cold medicine in
children under the age of 2

In 2008 recommendation was updated to
recommend no cough and cold meds under
the age of 6

No ban as of fall 2008

Deaths have occurred, but most are due to
giving too much or giving too often.

FDA recommendations (2007)

No cough or cold products under 2 yo unless
directed by health care provider

Never use adult medicines for children

Pay attention to different dosage strengths

Be aware of drug interactions

Read the warnings on the package

Do not exceed recommended dose

Use measuring device that comes with
medicine OR one that is provided by
pharmacy

Cough and cold medicine do not “cure” colds

Pharmacology (17 decks)

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