ENT Flashcards
What are the otic conditions that can be self treated and those that requires a referral?
Self treated:
- cerumen impaction
- water-clogged ears
Referral:
- otitis externa (swimmers ear)
- ear pain (otalgia)
- objects in the ear
- perforated eardrum
-ear drainage
- tinnitus
- hearing loss
What is cerumen and its characteristics?
Mixture of secretions from the ceruminous gland (modified apocrine sweat glands) and sebaceous glands combined with the desquamated sheets of the stratum corneum and hair
Characteristics:
- Present in a varied color and consistency
- Possesses antibacterial and antifungal properties
- Water repellant nature serves as an oily, mechanical barrier
- Sticky nature serves to protect the tympanic membrane
- Lubricating property prevents pruritis to the external ear canal
- Self cleaning mechanism known as ceruminokinesis
Definition of cerumen impaction
An accumulation of cerumen that causes symptoms or prevents a needed assessment of the ear canal, tympanic membrane, or audiovestibular system or both.
Epidemiology of cerumen impaction
- ~10% of children
- ~5% of healthy adults
- Up to 57% of older persons in nursing home
- ~30% of cognitively impaired patients
Etiology of cerumen impaction
- Genetic factors eg stenotic canals, more hair
- Elderly
- Conditions that causes increased scaling in the ear canal
- Mechanical blockage
- Inadequate body hygiene
Clinical Presentation of cerumen impaction
- Feeling of pressure or fullness
- Ear discomfort
- May cause vertigo, tinnitis, puritis
- May cause a chronic cough
- Can result in gradual hearing loss
- Pain is not normally present and impaction may be unilateral or bilateral
When to refer for cerumen impaction?
- Signs of infection
- Pain associated with ear discharge
- Recent ear surgery in prior 6 weeks
- Bleeding or signs of trauma
- Presence of ruptured tympanic membrane or tympanostomy tubes
- Incapable of following proper instructions for use of otic drops
- Hypersensitivity to recommended agents
- No improvement after 4 days of self care
What to take note of for assessing cerumen impaction
Assess for signs and symptoms
- Course of symptoms
- Any associated symptoms
Gather medical and medication history - History of surgery and medical conditions
- Prescription and OTC products used
Any situation for urgent referral?
- History of trauma
What should not be used for cerumen impaction?
Q tips, metal ear picks, ear candle
Treatment types of cerumen impaction
Pharmacologicals/Cerumenolytic Agents (water based, oil based, non water or oil based) , irrigation, manual removal (by specialist)
What are the water based cerumenolytic agents available? (explain MOA + SE)
Docusate sodium (GSL)
- MOA: Mild emulsifier which penetrates and helps disperse ear wax
- SE: Allergic reaction such redness of the skin area and/or a rash.
Hydrogen peroxide 3% (not available in community pharmacy)
- MOA: Releases nascent oxygen when exposed to moisture, hence mechanically loosens debris and helps to remove ear wax
- Precaution: Avoid over use (causes tissue maceration -> infection)
What are the oil based cerumenolytic agents available? (explain MOA + SE)
Almond oil, arachis/peanut oil, mineral oil
- MOA: Lubricate and soft cerumen to facilitate movement out of ear but does not disintegrate cerumen
- Precaution: Avoid arachis oil containing preparations for patients w peanut allergy
What are the non water or oil based cerumenolytic agents available? (explain MOA + SE)
Carbamide peroxide (Urea-hydrogen peroxide) (GSL):
- Approved by FDA
- MOA: Reacts with catalase in tissue
→ release of oxygen. Weak antibacterial effect
- SE: May cause bubbling or crackling
sound in the ear
Glycerin (GSL):
- MOA: Emollient property and acts as a humectant
Available ear cleaning products
Isotonic seawater (Audiclean/Audisol) (GSL)
How to administer ear drops?
- Wash hands with soap and warm water; then dry them the thoroughly.
- Carefully wash and dry the outside of the ear with a damp washcloth, taking care not to get water in the ear canal.
- Warm eardrops to body temperature by holding the container in the palm for a few minutes.
- Tilt head to the side opposite the affected ear. Pull the ear backward and upward to open the ear canal. For children <3 years old , pull the ear backward and downward.
- Open the container carefully. Position the dropper tip near, but not inside, the ear canal opening. Do not allow the dropper to touch the ear.
- Place the proper dose or number of drops into ear canal. Replace the cap on the container.
- Keep the head in the same position for a few minutes after instillation.
- Regain normal position, gently wipe excess medication off the outside of the ear using a clean tissue. Do not clean inside of ear canal!
- Wash your hands to remove any medication.
Monitoring and Patient education for cerumen impaction
Evaluate response in 2days. Refer if no resolution after 4days or for patients experiencing symptoms after impaction removal.
Do not overclean ears or use Qtips/ear candles
What is water clogged ears?
- It is the retention of water in the external ear canal, thereby causing discomfort and a sensation of fullness,
accompanied by gradual hearing loss. - Trapped moisture can compromise the natural defenses of the external auditory canal, causing tissue maceration and making the person more susceptible to infection
- Common in people with high water exposure such as swimmers and divers
When to refer for water clogged ears?
- Signs of infection
- Pain associated with ear discharge
- Recent ear surgery in prior 6 weeks
- Bleeding or signs of trauma
- Presence of ruptured tympanic membrane or tympanostomy tubes
- Incapable of following proper instructions for use of otic drops
- Hypersensitivity to recommended agents
- No improvement after 4 days of self care
What to asses for in water clogged ears?
Assess for signs and symptoms
- Course of symptoms
- Any associated symptoms
Gather medical and medication history - History of surgery and medical conditions
- Prescription and OTC products used
Any situation for urgent referral?
- History of trauma
Pharmacological treatment for water clogged ears
Instilling ear drops containing isopropyl alcohol (95%) and glycerin (Audisol- GSL)
Non-pharmacological treatment for water clogged ears
- Reducing water exposure:
Wearing shower/swimming cap
or ear plug while bathing or swimming - Tilt affected ear downwards and gently shaking excess water from the ears
What is otitis externa and its causes?
- Also known as “Swimmer’s ear”
- It is a diffuse inflammation of the external ear canal secondary to infection.
- Usually seen in warm climates, areas with increased humility and in patients with increased water exposure
Causes:
- Excessive moisture causes maceration of the skin and cerumen breakdown
- Change in pH of the local ear
environment leading to
overgrowth of pathogenic
organisms such as Pseudomonas
aeruginosa
- Regular, aggressive cleaning of the ear causes local trauma
- Allow entry of organisms into the
ear
- Use of devices that occlude the ear canal eg hearing aids
- Chronic dermatologic disease eg eczema, psoriasis, seborrheic dermatitis
Clinical Manifestation of Otitis Externa
- Itching, irritation, erythema
- Acute pain
- Drainage of foul smelling watery discharge
- Fullness with or without jaw pain
- Impaired hearing due to occlusion of external auditory canal
Treatment of Otitis Externa and patient education
Treatment:
- Topical antimicrobials with acidifying agent (Prescription only)
- Topical antimicrobials with or without steroids (Prescription only)
- Need referral to physician
- Painkillers (Paracetamol, NSAIDs)
Patient Education:
- Counsel on proper use of eardrops
- Caution patient not to manipulate or insert anything into the ear
- Avoid water activities for 7-10 days while undergoing treatment
- Earplugs can be used during showering, bathing or hair washing
- Symptoms shld improve within 2-3days but may take 2wks to resolve
What is Tinnitus?
- It is the perception of sound in proximity to the head in the absence of an external source
- It can be perceived as being within one or both ears, within or around the head, or as an outside distant noise (usually “ringing” sound)
- Not a disease but a condition that can result from a wide range of underlying causes
Common causes of tinnitus
cerumen impaction, ototoxic medications (eg. aminoglycoside, immunosuppressants, antivirals for hep c treatment)
Clinical Manifestation of Acute Otitis Media
- Ear popping and ear fullness
- Ear pulling/tugging
- Ear pain
- Drainage of mucopurulent discharge (if tympanic membrane is ruptured)
- Hearing loss
- Dizziness, anorexia, irritatability
- Systemic symptoms eg fever
- Bulging tympanic membrane
Difference btw otitis externa and otitis media
OE:
- caused by trauma/water
- itchy
- pain on movement of tragus
- ear canal narrow
- ear drum is normal or red
- discharge is present (thin)
- no fever
OM:
- caused by preceding URTI
- no itch
- no pain on movement of tragus
- normal ear canal
- eardrum is red, bulging or perforated
- discharge is mucoid (only if perforated)
- fever is present
Common respiratory conditions seen in community pharmacy
cough, viral sore throat, cold
Define cough
- A forceful expulsion of air from the lungs, either voluntary or involuntary, to aid in clearing of irritants, secretions or foreign particles
- It is one of the most common symptoms for patients to seek medical care particular in young children
- Acute (< 3wks), subacute (3-8wks) or chronic (>8wks)
Pathophysiology of cough
Stimulation of receptors in pharynx, larynx, trachea and bifurcation of the large bronchi –> Signal relayed to the cough centre in the medulla –> Activation of the muscle in the diaphragm, chest wall and abdomen –> Contraction of muscles with sudden opening of the glottis with rapid expulsion of air
Etiology of cough
Acute:
* Viral upper respiratory tract infection (URTI)
* Acute bronchitis
* Exacerbation of underlying diseases (asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF)
* Pneumonia
* Foreign body aspiration
Subacute:
* Post infectious cough
* Exacerbation of underlying diseases (asthma)
Chronic:
* Upper airway cough syndrome (UACS) (Post nasal drip)
* Asthma
* COPD (Chronic bronchitis)
* Gastroesophageal reflux disease (GERD)
* Angiotensin converting enzymes inhibitors (ACEIs)
* Intrapulmonary malignancies
* Tuberculosis
Clinical Presentation of Cough
Productive:
* “Wet” or chesty
* Caused by infection, chronic bronchitis, pneumonia, tuberculosis, irritants
* Helps to expel secretions from the lower respiratory tract
* Can be clear, purulent, malodourous
Non-productive (no sputum)
* Dry, tight, trickly
* Caused by viral infection, GERD, cardiac disease and medications
* No useful physiological purpose
When to refer for cough?
- Concurrent cardiopulmonary chronic diseases (eg asthma, COPD, congestive heart failure) or GERD
- Shortness of breath
- Chest pain
- Hemoptysis
- Unintentional weight loss
- Drenching night sweats
- Cough with thick yellow or green sputum or pus like secretions
- Fever > 37.5 degree celsius*
- Cough > 7 days
- Suspected drug induced cough (eg ACEI)
- Inhalation of foreign particles
- Cough that worsen during self-treatment or develop new
symptoms - Barking cough (croup) in children
What to assess for when patient presents with cough?
- Assess for signs and symptoms:
- Course of symptoms eg onset, duration, periodicity
- Characteristics of the cough eg sputum colour, nature of sputum
- Any associated symptoms such as fever, headache, sore throat, nasal congestion, SOB, dyspnea, hemoptysis, unintentional weight loss, chest pain - Gather age of patient, medical, medication and social history
- History of medical conditions and social history such as smoking, allergen, irritant exposure
- Prescription and OTC products used (To rule out drug-related causes of cough) - Any situations requiring urgent referral?
- Drenching night sweats
- Shortness of breath
- Chest pain
- Hemoptysis
- Unintentional weight loss
- Inhalation of foreign particles
- Fever
Conditions to eliminate if patient presents with cough
- Upper airway cough syndrome (post nasal drip)
- Acute bronchitis
- Croup
- Chronic bronchitis
- Asthma
- Community acquired pneumonia
- Drug-induced cough
- Other less likely causes such as heart failure, tuberculosis, lung tumor, GERD
Non pharmacologic tx for cough
- Humidification
- Hydration with oral liquid
- Avoidance of irritants eg smoke, dust, pollutants
- Honey
Pharmacologic Tx groups for cough
Cough suppressants (Antitussives) for nonproductive cough.
Expectorants and Mucolytics for productive cough
Examples of cough suppressants for non productive cough
Centrally acting (1st line):
- Codeine
- Dextromethorphan
- Pholcodine
H1 Antihistamine (1st Generation):
- Diphenhydramine
Explain the MOA of codeine + dosing + onset of action
- Pro-drug of morphine, metabolised by CYP2D6
- MOA: Suppress cough reflex by direct central action
- Dosing: Adult and children >12 yo: 10-20mg q4-6 hr Max: 120mg daily. Children <12 yo: Not recommended for use
- Onset: 30-60 mins via oral route
HSA drug safety advisory for codeine
Deaths and respiratory depression in children aged 2-5y/o following tonsillectomy and/or adenoidectomy for obstructive sleep apnoea syndrome.
2013, EMA: Use of codeine for postoperative pain management in children and adolescents <18y/o is contraindicated due to increased risk of respiratory depression.
2015, EMA: Use of codeine containing products for relief of cough and cold in children is contraindicated in children <12y/o.
HSA: for treatment of unproductive cough and acute moderate pain not relieved by analgesics, codeine remains indicated for those >=12y/o. Lowest dose + lowest duration.
Codeine (SEs, precautions, contraindications)
- SEs: Drowsiness, sedation, N/V, constipation, urinary retention, respiratory depression
- Precautions:
- CNS depressants eg alcohol, sedatives - Serotonin modulator eg citalopram, fluoxetine
- Concurrent use with CYP2D6 inhibitors eg diphenhydramine (inhibit conversion to active metabolite)
- Elderly
- Contraindications:
- Concurrent or within 2 weeks of MAO inhibitors (MAOIs) eg seligiline, isocarboxazid, phenelzine, tranylcypromine, consumption
Examples of Codeine containing cough suppressants
P-only item:
- Dhasedyl: Codeine Phosphate 9mg, Promethazine HCL 3.6mg per 5mL
- Procodin: Codeine Phosphate 9mg, Ephedrine HCL 6mg, Promethazine HCL 3.6mg per 5mL
- Cophadyl: Codeine Phosphate 9mg, Promethazine HCL 3.6mg per 5mL
Regulations on codeine containing cough preparations - Health Product Regulation 2016
- Limited to 240mL (ie two 120mL bottles) per customer
- Must not supply to the same individual more than once within a period of 4 days
- Number of purchases per day must be recorded
- No public display of products
- Compulsory patient counselling by pharmacist
Dextromethorphan (MOA, Dosing)
- Non-opioid with no analgesic, sedative, respiratory
depressant or addictive property at usual doses - MOA: Act centrally in the medulla to increase the cough threshold
- Dosing:
- Adult, adolescent and children >12 yo: 10-20mg q4 hr or 20-30mg q6-8 hr. Max: 120mg daily
- Children (6-<12 yo): 10mg q4 hr: Max 60mg daily
- Children (2-<6 yo): 5mg q4 hr Max: 30mg daily
Dextromethorphan (Onset of action, SEs, Precautions, CIs)
- Onset:
- 15-30 mins via oral route
- SEs:
- Drowsiness, sedation, N/V, stomach discomfort, constipation
- Precautions:
- CNS depressants eg alcohol, anxiolytic, hypnotics and antidepressants
- Increase risk of serotonin syndrome with concomitant proserotonergic drugs eg citalopram, fluoxetine
- Concurrent use of potent CYP2D6 inhibitors eg fluoxetine, paroxetine
- Contraindications:
- Concurrent or within 2 weeks of MAOIs consumption
Examples of dextromethorphan containing cough suppressants
P-only items:
- Tussidex Forte: Dextromethorphan HBr 15mg per 5mL
- Tussils 5: Dextromethorphan HBr 5mg per lozenge
- Sedilix DM: Dextromethorphan HBr 15 mg, Promethazine HCL 3.125mg, Pseudoepherine HCL 30mg per 5mL
Pholcodine (MOA, Dosing)
- Derivative of codeine
- Mild sedative effect, little or no analgesic or euphoric effect
- MOA: Suppress cough reflex by direct central action
- Dosing:
- Adult, adolescents and children > 12 yo: 5-15mg q6-8 hr. Max: 60 mg daily
- Children (6-12 yo): 5-7.5mg q8-12 hr. Max 40 mg daily
Pholcodine (SEs, precautions, CIs)
SEs:
- N/V, gastric disturbances, dizziness, constipation
Precautions:
- CNS depressants eg alcohol, sedatives
Contraindications:
- Concurrent or within 2 weeks of stopping MAOIs
Examples of pholcodine containing cough suppressants
P-only item:
* Durotuss Regular: Pholcodine 5mg per 5mL
* Durotuss Forte: Pholcodine 15mg per 5mL
* Durotuss Dry cough lozenges: Pholcodine 5.5mg, Cetylpyridinium Chloride 1.33mg per lozenge
Diphenhydramine (MOA, Dosing)
- First generation H1 receptor antagonist with significant sedating and anticholinergic properties
- MOA: Act centrally in the medulla to increase the cough threshold
- Dosing:
- Adult, adolescents and children > 12 yo: 25-50mg q4-6 hr. Max: 300mg daily
- Children (6-<12yo): 12.5-25mg q4-6 hr. Max: 150mg daily
Diphenhydramine (Onset, SEs, Precautions)
Onset:
- 15 mins via oral route
SEs:
- Drowsiness, nausea, constipation, urinary retention, dry mouth, blurred vision
Precautions:
- CNS depressants eg alcohol, benzodiazepines, hypnotics, antidepressants
- Use with caution or avoid concurrent administration with anticholinergic agents and sedatives
- Use with caution in patients with closed angle glaucoma, elevated ocular pressure, stenosing peptic ulcer, prostate hypertrophy, bladder neck obstruction, hyperthyroidism, hypertension and heart disease
- Elderly
Examples of diphenhydramine containing cough suppressants
P-only item:
- Benocten Tablet: Diphenhydramine HCl 50mg per tablet
- Diphen 10: Diphenhydramine HCl 10mg, ammonium chloride 125mg per 5ml
HSA advisory of cough and cold medicine in children
<2y/o: use of antihistamines, cough suppressants, cold and flu prdts generally not recommended (weight R vs B)
Other products for cough
GSL:
- Menthol lozenges (Vapo drops)
- Camphor, Menthol & Eucalyptus Oil (Mentholatum)
Guaifenesin (MOA, Dosing, Onset, SE)
- Natural product derived from the guaiac tree
- MOA: Stimulate secretion of respiratory tract fluid, increasing sputum volume and decreasing viscosity –> assisting in the removal of sputum
- Dosing:
- Adult, adolescent and children > 12 yo: 200-400mg q4 hr Max: 2400mg daily
- Children (4-<12 yo): 100-200mg q4 hr Max: 1200mg daily
- Children (2-<4 yo): 50-100mg q4 hr. Max: 600mg daily
- Onset: 30 mins
- SEs: N/V, diarrhea, stomachache, dizziness, drowsiness, headache, rash
Examples of Guaifenesin containing expectorant
GSL:
- Breacol Cough Syrup: Guaifenesin 100mg, per 5mL
- Cofen 50 Cough Syrup: Guaifenesin 100mg, per 5mL
- Mucinex tablet: Guaifenesin 600mg per tablet
- Robitussin EX Syrup: Guaifenesin 100mg per 5mL
Expectorant containing Ammonium Chloride
P-only item:
- Bena Expectorant: Ammonium chloride 102mg, Diphenhydramine HCL 10mg per 5mL.
Ammonium salt is traditionally used to induce vomiting, and it was believed that at sub-emetic doses, they would cause gastric irritation, triggering reflex expectoration
Mucolytics (examples, MOA)
- Examples: N-Acetylcysteine, carbocisteine, bromhexine and ambroxol
- MOA:
- N-acetylcysteine + carbocisteine: Depolarises mucopolysaccharides by hydrolysing the disulphide bonds in the mucoproteins
- Bromhexine + ambroxol: Depolarises mucopolysaccharides by liberating lysosomal enzymes. Promote mucus clearance and reduces sputum surface tension
N-acetylcysteine (Dosing, SEs)
Adult and children > 6yo: 600mg daily Children 2-6 yo: 100mg BD-QDS
SE: N/V, GI discomfort, headache, diarrhoea
Caution in pts w Hx of peptic ulcer
Examples of mucolytic preparations
GSL:
- N- Acetylcysteine Tablet: Acetylcysteine 600mg per tablet
- Rhinathiol Syrup: Carbocisteine 250mg per 5ml
- Mucolix Elixir: Bromhexine 4mg per 5ml
- Mucosolvan Liquid: Ambroxol HCL 30mg per 5mL
Herbal products for cough
Prospan, Nin jiom pei pa kao
What cough medications are suitable for pregnant and lactating women?
- Antitussive of choice: Dextromethorphan (alcohol free formulation)
- Expectorant of choice: Guaifenesin (alcohol free formulation)
- All medicines should be used at the lowest effective dose for the shortest duration for pregnant women.
Monitoring for cough
- Optimise non-pharmacological measures
- Monitor for: Improvement/resolution of symptoms + Side effects
- Refer if no improvement of symptoms after 7 days or if symptoms worsen or any situations necessitating urgent referral are present
Definition and Etiology of Cold
- A cold also known as the common cold is a viral infection of the respiratory tract
- Typically limited to the upper respiratory tract and primarily affects the nose, throat, sinuses and trachea
- Produced by over 200 viruses:
Rhinoviruses, Coronaviruses, Parainfluenza viruses, Respiratory syncytial viruses (RSV), Adenoviruses
How does cold get transmitted?
Transmitted person to person through 3 main modes:
- Hand contact
- Large particles droplets from close
contact with infected person
- Small particle droplets from airborne particles
Epidemiology of cold
- Adults experience on average 2-4 colds per year
- Children experience on average 5-6 colds per year, although it can be as high as 12 colds per year
- Susceptibility to cold not affected by cold and wet weather
Pathophysiology of cold
- Penetration of the mucous blanket of the nasal or bronchial mucociliary epithelium by the virus through attachment to intracellular adhesion molecule-1-receptor.
- Damage to ciliated cells resulting in release of mediators such as bradykinins and cytokines
- Inflammation of tissues lining the nose, increase capillary permeability of cell walls, thereby causing edema which is experienced by the patient as nasal congestion and sneezing. Fluid also drip to back of throat, spreading virus to the throat and upper chest, thereby causing cough and sore throat
Risk factors for cold
- exposure of children to day care setting
- crowded spaces
- chronic physiological stress
- sleep deprivation
- underlying chronic disease
- smoking
Clinical Presentation of cold
- The symptoms that appear after 1-3 days of incubation include:
- Sore, scratch throat
- Sneezing
- Nasal discharge (rhinorrhea) and
congestion
- Malaise
- Mild fever
- Muscle aches and pains - On day 3-4, a non-productive cough begins which becomes loose and productive before fading
- Peak of symptoms: 2-4 days after onset
- Symptoms and severity vary with viral agent
- Medium duration 7-14 days for rhinovirus - Can also involve other mucous membranes including paranasal sinus, eustachian tubes and middle ear
- Sleep can be disrupted
Complications of cold
- Acute rhinosinusitis
- Acute otitis media
- Lower respiratory tract infections
- Asthma & COPD exacerbation
When to refer for cold
- Fever > 37.5oC
- Concurrent cardiopulmonary chronic diseases (eg asthma, COPD, congestive heart failure)
- Shortness of breath
- Chest pain
- AIDS or chronic immunosuppressant therapy
- Frail patients of advanced age
- Children < 2 years of age
- Worsen of symptoms or development of additional symptoms during self-treatment
- Hypersensitivity to non-prescription
pharmacologicals
What to assess for in cold
- Assess for signs and symptoms:
- Ask about onset of symptoms, nature of symptoms, aggravating factors
- Pay attention to severity of symptoms for some patients - Gather age, medical, medication, social history .
- Hx of medical conditions + general state of health
- Prescription + OTC prdts used. Allergies?
- Any contact with someone with cold? - Any situations for urgent referral?:
- Fever
- Shortness of breath
- Chest pain
- AIDS or chronic immunosuppressant therapy
- Severe exacerbation of cardiopulmonary conditions Frail elderly
Conditions to eliminate for cold
- Influenza
- Covid-19
- Allergic and nonallergic rhinitis
- Rhinosinusitis
- Pharyngitis
Differences btw cold, influenza, allergic rhinitis
Onset:
cold- starts gradually w sore, scratchy throat
influenza- abrupt onset of fever w nasal smx
AR- sudden onset of smx
Fever:
cold- non or mild fever
influenza- high fever lasting 3-4days
AR- no fever
Malaise:
cold- slight malaise, occasional myalgia + feeling of fatigue
influenza- feeling of fatigue w myalgia, malaise is common
AR- occasional feeling of fatigue
Sneezing:
cold- common
influenza- occasional sneezing
AR- paroxysmal sneezing
Nasal pruritis:
cold- usually absent
influenza- usually absent
AR- present
Non pharmacologic strategies for cold
Reduction of bothersome symptoms:
- Increase fluid intake, adequate rest and nutritious diet
- Humidification
Prevention of transmission:
- Respiratory hygiene
- Proper hand hygiene
- Frequent hand cleansing with soap,
use of hand sanitizers eg alcohol
based (60-80%) sanitizers,
chlorhexidine or antiviral
disinfectants eg Lysol
Pharmacological treatment grps for nasal smx
Decongestants, H1 antihistamine
Decongestants MOA + examples
- Useful for sinus and nasal congestion
- Can be systemic (oral) or topical (nasal spray or drops):
- Examples of systemic decongestants include pseudoephedrine, phenylephrine
- Examples of topical decongestants include oxymetazoline, xylometazoline and naphazoline
- MOA: Stimulate alpha-adrenergic receptors in nasal blood vessels as adrenergic agonist -> constriction of blood vessels -> decrease in sinusoid vessel engorgement and mucosal edema
Oral decongestants dosing
Pseudoephedrine (F=90-100%):
- Adult, adolescents, children (12 yo): 60mg q4- 6hr Max: 240mg daily
- Children (6-<12 yo):30mg q4-6 hr Max: 120mg daily
- Children (4-<6 yo):15 mg q4-6 hr Max: 60mg daily
- Examples: Zyrtec-D, Clarityn-D
Phenylephrine (F=38%):
- Adult, adolescents, children (>=12 yo): 10mg q4 hr Max: 60mg daily
- Children (6-11 yo): 5mg q4 hr Max: 30mg daily
- Children (4-5 yo):2.5 mg q4 hr Max: 15mg daily
- Examples: Panadol cold relief PE caplet
SE of oral decongestant
Side Effects:
- CVS: elevated BP, tachycardia, palpitations
- CNS: Insomnia, anxiety, restlessness, tremors, headache, excitability
- Others: constipation, anorexia, urinary retention, blurred vision
Precautions + CI of oral decongestant
Precautions: Caution in patients with CVS disease including hypertension and ischemic heart disease, diabetes, glaucoma, increase ocular pressure, benign prostatic hyperplasia, hyperthyroidism
Contraindication: Concomitant use of monoamine oxidase inhibitors (MAOIs) such as selegiline, isocarboxazid or within 2 weeks of discontinuation of MAOIs
Examples + Dosing of topical decongestant
Oxymetazoline (iliadin):
- Adult, children (>6 yo): 0.05% q8-12hr
- Children (1-6 yo): 0.025% q8-12 hr
- Infant (4 weeks – 1 yo): 0.01%
q8-12 hr
Xylometazoline (otrivin):
- Adult, children (>12 yo), adolescence: 0.1% q8-12hr
- Children (2-11 yo): 0.05% q8-12 hr
Naphazoline:
- Adult: 0.05% not more than q3hr
SE + Important note for topical decongestant
Side Effects:
- Propellent and vehicle related: Burning, stinging, sneezing, local dryness
- Trauma from tip of device
Important note:
- Rhinitis Medicamentosa (RM)
- Rebound congestion -> inflammation of the nasal mucosa caused by the prolonged use of topical nasal decongestants (> 7 to 10 days)
- Treatment of RM involves the discontinuation of the topical decongestant slowly, replacing with topical normal saline, intranasal steroids or systemic decongestant
Patient education on use of topical decongestant
- Topical decongestants can cause temporary discomfort such as burning, stinging, sneezing or an increase in nasal discharge
- Product should not be shared with others
- Do not exceed the recommended dose
- Do not use more than 3-5 days
- Discard if contaminated or if product is discoloured
How to administer topical decongestant nasal spray?
- Blow your nose gently.
- Wash your hands well with soap and water.
- Remove the packaging from the nasal spray pump.
- Some nasal sprays need to be primed before use. As well, some nasal sprays need to be shaken. If your spray needs to be primed before using, squeeze it a few times into the air as directed until a fine mist appears.
- Gently blow your nose to clear your nostrils
- Tilt your head forward, depress one nostril, insert the tip into other nostril. Aim the nozzle away from the nasal septum and gently squeeze the nozzle. Inhale gently and breathe out through the mouth after each spray
- If more than 1 spray is required per nostril, alternate the spray between nostrils one by one to prevent medication wastage.
- Put the cap back onto the nasal spray container.
- Try not to blow your nose for several minutes after using the spray.
- Do not use for more than 5 consecutive days to prevent rebound congestion
How to administer topical decongestant nasal drops?
- Before using, practice using the dropper to good dosage control.
- Gentle blow your nose to clear your nostrils
- Lie down on the edge of the bed and tilt the head back.
- Administer the drops into one nostril without touching the dropper to the nose
- After administering, remain in position for 2minutes.
- Repeat with the other nostril
- Do not use for more than 5 consecutive days to prevent rebound congestion
Oral vs topical decongestant
Onset:
oral- 15-30min
top- faster onset, few min - 5 min
Decongestant effect:
oral- “lesser”
top- “greater”
Rebound congestion?:
oral- no
top- yes
Local irritation:
oral- no
top- yes
Alternative products for nasal congestion
- Nasal saline available as isotonic, hypertonic, seawater, buffered solutions
- Available in various volumes and different frequency of use
- MOA: Remove mucus and inflammatory mediators
- No serious adverse effects
- Usually minor local irritation and discomfort
- Safe for young children and pregnant women
Other examples:
- Menthol or camphor containing products (vapex, vaporub)
- Nasal strips (breathe right)
- Nasal bulb
H1 antihistamine Examples + MOA
- Useful for rhinorrhea, sneezing and nasal itch (allergic rhinitis)
- Two generations
First generation: sedating + nonselective
Second generation: non-selective + peripherally selective
General MOAs:
- Release of mast cell mediators and decrease in cellular recruitment (second generation agents)
- First generation agents possess high anticholinergic activity via interaction with neuronal muscarinic receptors
H1 Antihistamine SEs
Central nervous system:
- Sedation (esp with 1st Gen as they crosses BBB)
- Dizziness, lack of coordination, confusion
- Paradoxical: insomnia, excitation, tremors
Anticholinergic: (esp with 1st Gen)
- Dry mouth, urinary retention, palpitations
Gastrointestinal:
- Nausea, vomiting, loss of appetite, diarrhoea, constipation
Orthostatic hypotension (esp phenothiazine group)
Cardiac:
- Increase QT prolongation, cardiac arrhythmia (selected 1st Gen)
H1 antihistamine precautions + DDI + drug-food interactions
Precautions: Elderly, BPH, glaucoma
Note:
- Drug-drug interactions (ethanol, opioids, antidepressants)
- Drug-food interactions (Fruit juice - fexofenadine)
First generation H1 antihistamine examples + dosing
Chlorpheniramine:
- Adult, adolescents, children (12 yo): 4mg q4-6hr Max:24mg daily
- Children (6-<12 yo):2mg q4-6 hr Max:12mg daily
- Children (2-<6 yo):1 mg q4-6 hr Max:6mg daily
Dexchlorpheniramine:
- Adult, adolescents, children (>12 yo): 2mg q4-6hr Max: 12mg daily
- Children (6-<12 yo):1mg q4-6 hr Max: 6mg daily
Promethazine:
- Adult: 12.5-25mg q8-12 hr
- Children (10-17yo): 10-20mg q8-12hr
- Children (5-9 yo): 5-10mg q12hr
- Children (2-4yo): 5mg q12hr
Diphenhydramine:
- Adult, adolescents and children > 12 yo: 25-50mg q4-6 hr Max: 300mg daily
- Children (6-<12yo): 12.5-25mg q4-6 hr Max: 150mg daily
Second generation H1 antihistamine examples + dosing
Loratadine:
- Adult, adolescent, children >=6 yo and > 30kg: 10mg daily Max: 10mg daily
- Children (>=2-<6 yo) and <30kg: 5mg daily Max: 5mg daily
Cetirizine (Zyrtec):
- Adult: 10mg daily Max: 10mg daily
- Adolescent and children >= 6yo: 5-10mg daily Max: 10mg daily
- Children (2-<6yo): 5mg daily Max: 5mg daily
Fexofenadine (Telfast):
- Adult, adolescents and children (12 yo): 120-180mg daily Max: 120 or 180mg daily
- Children (2-<12yo):30mg BD Max: 60mg daily
What cold medications are safe for pregnant women?
Antihistamine of choice: Chlorpheniramine,
dexchlorpheniramine.
Saline nasal rinses are safest option to clear a blocked nose
All medicines should be used at the lowest effective dose for the shortest duration for pregnant women
What cold medications are safe for lactating women?
- Antihistamine of choice: Chlorpheniramine, dexchlorpheniramine
- Antihistamine can decrease maternal serum prolactin concentrations when administered prior to the establishment of nursing
- Use first generation H1 antihistamine with caution when breastfeeding
- Avoid oral and topical decongestants as they can limit breast milk secretion
- Saline nasal rinses is safest option for nasal congestion
Supplements for cold
Vitamin C, Zinc, Echinacea
Where does Sore-throat associated with cold affect?
Sore throats are often associated with the common cold.
Can affect any part of the respiratory mucosa of the throat including the pharynx and tonsils
Pharmacologicals for sore-throat assoc w cold
Local anesthetic: benzocaine, lidocaine
Anti-inflammatories: benzydamine (difflam), lysozyme (leftose)
Systemi analgesics: paracetamol, NSAIDs eg. ibuprofen, naproxen
What should be educated to patient and monitored for cold?
Educate on:
- Non pharmacological measures
- Drug use eg administration of nasal spray,
precautions, adverse effects
Monitor for:
- Improvement of symptoms in 7 days.
Refer to Dr if symptoms worsen, fever develop or if symptoms last longer than 7-14 days.
Definition of rhinitis
Symptomatic inflammation of the inner lining of the nose, leading to:
- Rhinorrhea
- Sneezing
- Nasal obstruction
- Nasal itch
with two nasal symptoms should be present for 2 or more consecutive days for more than 1 hour on most days
Causes of infectious and nonallergic rhinitis
- Infectious: Bacterial, viral and other infectious agents
- Nonallergic rhinitis:
- Drug-induced: Aspirin/NSAIDs, antihypertensive (ACEIs, beta blockers, CCBs), OCs, prolonged use of topical decongestants, antidepressants, sedatives, phosphodiesterase 5 inhibitors
- Hormonal eg pregnancy, menstrual cycle
- Idiopathic or vasomotor
- Structural eg septal deviation, polyps
- Traumatic
Definition of allergic rhinitis and its triggers
Allergic rhinitis (AR) is a symptomatic disorder of the nose, induced after allergen exposure by an IgE mediated inflammation of the membranes lining the nose. Its often associated with ocular symptoms
It is triggered by allergens:
- Outdoor allergens (SAR): Pollen (from trees, grasses and ragweeds), mould spores
- Indoor allergens (PAR): Dust mites, animal dander, cockroaches, mould spores, cigarette smoke
- Occupational allergens (PAR): Wood dust, latex, resins, chemical (isocyanate, glutaraldehyde)
- Ingested allergens (PAR): Wheat, eggs, milk and nuts
In Singapore, the most common allergen is the house dust mite.
Epidemiology of AR
- A common allergic disorder worldwide affecting 25% of children and 40% of adults
- In Singapore, the estimated prevalence is 5.5-13%
- Affect all ages with peaks in the teens
- Can impact quality of life, sleep, concentration, learning and daily function
Clinically symptoms of AR
The classic cardinal symptoms of allergic rhinitis includes:
- Rhinorrhea (usually clear and watery)
- Nasal congestion
- Sneezing that is paroxysmal
- Pruritis of ear, eyes and nose
Other manifestations
- Ophthalmic symptoms (itch, irritation,
conjunctivitis)
- Headache
- Pain
Clinical signs of AR
Allergic shiners & Dennie-Morgan folds
Allergic salute
Allergic crease
AR vs nonallergic rhinitis
AR:
- Bilateral symptoms worsen on awakening, improve during the day, then may be worse at night
- Frequent, paroxysmal sneezing
- Anterior, watery discharge
- Frequent pruritis of eyes, nose and/or palate
- Sinus pain due to congestion may be present; Throat pain due to postnasal drip irritation may be present
- Frequent conjunctivitis
- Rare anosmia, epistaxis
- Presence of Allergic shiners, Dennie-morgan folds, allergic salute and crease
Non-allergic rhinitis:
- Unilateral symptoms common but can be bilateral, constant day and night
- Little or none sneezing
- Posterior, watery or thick and/or mucopurulent discharge (associated with infection)
- Absence of Pruritis of eyes, nose and/or palate
- Conjunctivitis not present
- Pain variable depending on cause
- Frequent anosmia and recurrent epistaxis
- Presence of Nasal polyps, nasal septa deviation, enlarged tonsils and/or adenoids
Risk Factors for AR
- Genetics and familial history
- Family history of atopy in one or both parents
- Filaggrin gene mutation - Environmental factors
- Pollution
- Irritants - Exposure to allergens
Conditions associated with AR
- Asthma:
- Over 80% of asthmatic have AR
- 10-40% of patients with AR have asthma
- Atopic dermatitis
- Sinusitis
- Eustachian tube dysfunction
- Otitis media
- Sleep apneoa
- Dentofacial abnormalities
Define mild intermittent AR
< 4 days per week OR < 4 weeks per stretch
All of the following:
* Normal sleep
* No impairment of daily
activities, sport, leisure
* Normal work & school
* No troublesome symptoms
Define moderate to severe intermittent AR
< 4 days per week OR < 4 weeks per stretch
One or more items:
* Abnormal sleep
* Impairment of daily activities,
sport, leisure
* Impacts work & school
* Troublesome symptoms
Define mild persistent AR
> 4 days per week AND >4 weeks per stretch
All of the following:
* Normal sleep
* No impairment of daily activities, sport, leisure
* Normal work & school
* No troublesome symptoms
Define moderate to severe persistent AR
> 4 days per week AND >4 weeks per stretch
One or more items:
* Abnormal sleep
* Impairment of daily activities,
sport, leisure
* Impacts work & school
* Troublesome symptoms
Diagnosis of AR
- History
- Presentation of classical symptoms of AR
- Presence of temporal patterns
- Allergen history and family history - Examination
- General observation, ENT and eyes,
chest examination - Allergy testing
- Skin prick test
- Radioallergoabsorbent tests for specific IgE (RAST)
- Nasal allergen challenge
Symptoms that are suggestive of AR
2 or more of the following symptoms for >1hour on most days:
- Watery rhinorrhea
- Sneezing, especially paroxysmal
- Nasal obstruction
- Nasal pruritus
- ± Conjunctivitis
Differential diagnosis of AR
- Upper respiratory tract infections
- Non-allergic rhinitis:
- Medication-induced rhinitis
- Vasomotor rhinitis
- Hormonal – pregnancy
- Nasal polys
- Deviated nasal septum
- Presence of foreign body
When to refer for AR
- Children < 12 years, pregnant women (unless diagnosed by doctor and non-prescription therapy approved by doctor)
- Symptoms of non-allergic rhinitis (mucopurlent discharge, unbearable facial pain, anosmia, fever > 38 degree celsius, epistaxis)
- Symptoms of otitis media, sinusitis, bronchitis or other infections
- Undiagnosed or uncontrolled asthma, COPD or other lower respiratory diseases
- Moderate or severe persistent allergic rhinitis
- Not responding to treatment
- Treatment failure or persistent symptoms
- Severe or unacceptable side effects of treatment
- Medication induced rhinitis
What to assess for in AR
- Assess for signs and symptoms
- Ask about nature and duration of symptoms, location of symptoms, aggravating or remitting factors
- Ask about presence of other associated symptoms - Gather age of onset, history of allergen exposure, family history of atopy, medical and medication history
- Check for pregnancy or breastfeeding if applicable?
- Any situations for urgent referral
- Shortness of breath or difficulty breathing
- Uncontrolled asthma
- High fever
- Severe headache or eye pain
Allergen avoidance and environmental control for house dust mites
- Remove dust
- Remove carpets
- Remove dust accumulating objects - Protect patient
- Encase bedding with impermeable covers - Control mites
- Wash bedding with hot cycle
- Use vacuum with HEPA filter
- Acaricides
- Maintain humidity between 35%- 50%
Allergen avoidance and environmental control for cockroaches
- Careful food preparation and clean up
- Put away food, wash dishes, wipe up spills, store garbage in tightly sealed containers
- Use cockroach trap
- Seek professional help for bad infestation
Allergen avoidance and environmental control for Pets
- Remove cat/dog from home if possible
- If not, use a combination of the following measures:
- Keep pet out of the house
- If in the house, keep animal out of the bedroom and in an uncarpeted room with HEPA air filter
- Bath the pet frequently
- Wash hand after handling animal
Allergen avoidance and environmental control for moulds
- Remove potted plants
- Remove visible mould
- Dry or remove wet carpets
- Fix any leaks
- Ensure adequate ventilation
- Control humidity
Available pharmacotherapy for AF
Topical:
* Intranasal H1 antihistamine#
* Intranasal corticosteroids (INCs)
* Intranasal decongestants
* Intranasal cromones*
* Intranasal anticholinergic^
- Not available in Singapore #Available as combination product in Singapore
^ Exemption item – only available upon special request
Oral:
* Oral H1 antihistamines
* Oral corticosteroids
* Oral decongestants
* Leukotriene antagonist
First gen vs Sec gen oral H1 antihsitamine
Useful for rhinorrhoea, sneezing, nasal itch, ocular symptoms but limited effect for nasal congestion
First gen:
* Examples: chlorpheniramine, dexchlorpheniramine
* Lipophilic and readily crossed BBB
- Significant sedation & anticholinergic effects
* Dosed multiple times daily
* Not preferred for allergic rhinitis
Second gen:
* Examples: loratidine, fexofenadine
* Minimal passage through BBB
- Less sedation & anticholinergic effects
* Dosed once or twice daily
* Preferred for allergic rhinitis
Intranasal H1 antihistamine example, MOA, onset, dosing
Azelastine (Azelastine + Fluticasone proprionate, POM item)
- Newer antihistamine available as
intranasal dosage form
- FDA approved for treatment of allergic rhinitis
- MOA:
- Selective H1 antagonist
- Possesses mast cell stabilizing and
anti- inflammatory properties
- Onset: 15 mins (intranasal)
- Dosing (Dymista): Adult, adolescent and children > 6yo: 1 spray in each nostril BD
Azelastine PK, SEs, precautions
Pharmacokinetics:
- Duration of action: 12 hrs
- Bioavailability: 40%
- Metabolism: Hepatic via CYP; active metabolite, desmethylazelastine
SEs:
- Somnolence , bitter taste, headache, nasal burning, epistaxis,
dizziness, fatigue
Precaution:
- CNS depressants eg alcohol
Intranasal Corticosteroid Onset, SEs, precautions
- Useful for rhinorrhoea, sneezing, nasal itch, nasal congestion and ocular symptoms
- Most effective medication for treating allergic rhinitis
- Onset:~12hrs (Maximal effect: 2weeks)
- SEs:
- Minimal systemic side effects
- Local: dryness, nasal irritation, occasional epistaxis
- Precautions:
- Patients with cataract, glaucoma
First gen intranasal CS example, dosing
First generation: Systemic bioavailability 10-50%
Triamcinolone acetate: Adults >= 18 yo: 2 sprays into each nostril once daily
Second gen intranasal CS examples, dosing
Second generation: Systemic bioavailability <1% or undetectable
Mometasone furoate (Nasonex): Adults and >= 18 yo: 2 sprays into each nostril once daily
Fluticasone furoate (Avamys): Adults >= 18 yo: 2 sprays into each nostril once daily
Fluticasone propionate (Flixonase): Adults ≥ 18 yo: 2 sprays into each nostril once daily
Dymista 36.5mcg combined with azelastine 100mcg+: Children >= 6 yo: 1 spray into each nostril BD
*P only item; **P+ item, minimum age >=18 yo and and maximum supply: up to 3 months duration; +POM item
How to administer intranasal steroid sprays
- Wash your hands well with soap and water.
- Remove the packaging from the nasal spray pump.
- Some nasal sprays need to be primed before use. As well, some nasal sprays need to be shaken. If your spray needs to be primed before using, squeeze it a few times into the air as directed until a fine mist appears.
- Gently blow your nose to clear your nostrils
- Tilt you head forward, depress one nostril, insert the tip into other nostril. Aim the nozzle away from the nasal septum and gently squeeze the nozzle. Inhale gently and breathe out through the mouth after each spray
- If more than 1 spray is required per nostril, alternate the spray between nostrils one by one to prevent medication wastage.
- If taste of medicament is present, rinse mouth before use.
- Put the cap back onto the nasal spray container.
- Try not to blow your nose for several minutes after using the spray.
Leukotriene Antagonist use in AR
- Used in children and adolescent with asthma and allergic rhinitis
- Better effect than placebo
- Usually considered less than
antihistamine - Less effective than intranasal steroids
- Example: Montelukast (Singular)
HSA Advisory on montelukast
BBW: serious behaviour and mood-related changes with montelukast + neuropsychiatric safety concern.
Recommended against the use of LTRAs, including montelukast, as primary treatment therapy for allergic rhinitis, except in asthmatic patients.
To advise their patients and/or caregivers to be alert to changes in behaviour or new neuropsychiatric symptoms when taking montelukast
Intranasal cromones use in AR (MOA, SEs)
- Better effect than placebo butl ess effective compared to intranasal steroids
- Short healf life –requiring 3-6 doses per day
- MOA: Prevent degranulation of mast cells
- SEs: Nasal irritation, sneezing, epistaxis, bad taste
- Example: Sodium cromoglycate
Intranasal anticholinergic use in AR (MOA, SE)
- Effective for rhinorrhea but no effect on other nasal symptoms
- Adjunct treatment
- MOA: Antagonises the action of acetylcholine
- SEs: Dryness of nasal membrane, epistaxis
- Example: Ipratropium bromide
Decongestants use in AR
- Oral or nasal decongestants can be used short term to reduce nasal congestion
- Chronic use of nasal decongestants results in rhinitis medicamentosa
Systemic steroids use in AR
- Brief short course is rarely indicated
- May be considered if severe nasal obstruction is present or severe symptoms despite conventional therapy
Saline nasal irrigation use in AR
- Clears inflammatory mucous and allergens
- Well tolerated and effective in reducing symptoms
- Not a replacement for pharmacotherapy
- Good for children and pregnant women
Use of Visual Analogue Scale to grade severity of AR
- VAS is used by patient to grade the severity of his AR symptoms where patient point to a point that best corresponds to the severity of symptoms or current status of disease control
- VAS has been shown to correlate well with the ARIA classification of symptom severity, as well as other symptom and quality of life measuring instruments
- A score of 50mm correlates to moderate to severe AR
- Scores and grade of AR control:
- > 50mm: uncontrolled AR
- 20–50mm: partially controlled AR
- < 20mm: well controlled AR
General pharmacotherapy for mild to severe AR - Uptodate
Mild or episodic symptoms:
- Second generation oral H1 antihistamine
- Antihistamine nasal spray
- Glucocorticoid nasal spray
- Cromolyn nasal spray
Persistent or moderate-to-severe symptoms:
- Glucocorticoid nasal spray
- Second agent can be added for patient who fail to respond adequately with initial therapy
- Intranasal antihistamine
- Minimally sedating oral H1 antihistamine
- Minimally sedation oral H1 antihistamine/decongestant combination
General first line pharmacotherapy for mild to severe AR in community pharmacy
- Treatment of mild, intermittent allergic rhinitis: Second generation oral H1 antihistamine, administered
regularly or as needed - Treatment of moderate to severe, intermittent or mild persistent allergic rhinitis: INC is the most effective single therapy
What medications are safe for pregnant women with AR?
- Saline nasal rinse are the safest option to clear
block nose - Budesonide is the preferred intranasal
corticosteroids - Loratadine or cetirizine can be considered preferably after 1st trimester upon discussion with obstetrician
- Oral and nasal decongestants not recommended
What medications are safe for lactating women with AR?
- Saline nasal rinses is safest option for nasal congestion
- Avoid oral and topical decongestants as they can limit breast milk secretion
- All intranasal steroids are probably safe in lactation
What should be educated to patient w AR and monitored?
Educate patients on:
- Environmental control measures
- Appropriate use of medications including correct device techniques
- Common adverse effects
- When to seek medical assistance
Monitor for:
- Response to therapy after a 2-4 week trial and recommend treatment modification as needed or refer to physician when necessary.
When is immunotherapy used in AR
- Involves exposing patient sequentially increasing amounts of allergen to which he/she is sensitive to induce immune tolerance
- Only disease modifying treatment available for allergic rhinitis
- Suitable for patients with moderate to severe allergic rhinitis:
- Who are not adequately controlled with medications
- Who have experienced unacceptable adverse events
- Who want an option to reduce long term use of medications Who are able to comply with protocol
- Who have allergic asthma
- Not for patients with uncontrolled asthma and those taking beta-blockers
Types of immunotherapy available
- Subcutaneous injection (SCIT):
- Administered at physician office due to potential for anaphylaxis
- Build up phase – 1-3 injections per week
- Maintenance phase – once every 2-4 weeks for 3-5 years - Sublingual (SLIT):
- First dose administered in physician office. If no anaphylaxis, subsequent doses can be administered at home
- Minor ADRs: pruritis and edema of mouth, lips and throat
- Patients should be educated on signs and symptoms of
severe allergic reaction
- Patients should have injectable epinephrine and be trained
on how to use it
