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Clinical Pharmacology > HEENT > Flashcards

HEENT Flashcards

1
Q

What is histamine?

A

chemical messengers that mediate allergic and inflammatory reactions, gastric acid secretion, and neurotransmission

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2
Q

Where is histamine located?

A

In mast cell granules. A lot in nose, mouth, skin, internal body surfaces, blood vessels (non-mast cell in stomach and brain)

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3
Q

How is histamine released?

A

immune-mediated, degranulate quickly when exposed to appropriate antigen chemical or mechanical release

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4
Q

What are the histamine receptors?

A

H1 and H2

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5
Q

What does H1 do?

A

Stimulates sensory nerve endings, cause bronchoconstriction and increase nasal and bronchial mucus
Increase **capillary permeability (swollen stuffy nose)–> edema–>vasodilation**–> decreasing BP

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6
Q

What does H2 do?

A

Stimulates gastric acid secretion, increases capillary permeability and vasodilation, also increase heart rate and contractility

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7
Q

What are the oral antihistamines’ MOA?

A

Block H1 receptor-mediated response to histamine
Competitive binding

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8
Q

How do first gen oral antihistamines work?

A

Penetrate the CNS, cause sedation (cross blood brain barrier), interact with other receptors…anti-cholinergic properties (urinary retention/constipation)

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9
Q

How do second gen oral antihistamines work?

A

Minimal to none distrubution into CNS, specific for H1 receptors only. Do not cross blood brain barrier

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10
Q

What is the indication for medication regarding allergic rhinitis and uticaria?

A

Second gen preferred due to less sedation (loratadine (claritin), desloratadine (Clarinex), fexofenadine (Allegra)), possible mild sedation with cetrizine (zyrtec)
Reduces sneezing, itching, rhinorrea

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11
Q

What are the indications for oral antihistamines pregnancy induced N/V?

A

Doxylamine (Unisom) + B6

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12
Q

What are the options of oral antihistamines for motion sickness prevention?

A

Diphenhydramine (Benadryl, Unisom), hydroxyzine (Visatril, Atarax), meclizine (Antivert)

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13
Q

What are the indications of oral antihistamines for insomnia?

A

Diphenhydramine (Benadryl, Unisom) and doxylamine (Unisom) (common in OTC sleep aids and night time cold and cough meds….) only for short term use

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14
Q

What are the indications of oral antihistamines for antiparkinsonism effects?

A

diphenhydramine (benadryl) is most effective –> suppresses extrapyramidal symptoms of certain antipsychotics

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15
Q

What oral antihistamines are most associated with sedation as a side effect?

A

Common with first gen –> most with diphenhydramine (benadryl), hydroxyzine (vistaril, atarax)
Slight with chlorpheniramine (chlor-trimeton) and meclizine (Antivert)
Can see opposite effect in children

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16
Q

What oral antihistamines are most associated with anticholinergic effects as a side effect?

A

more common with first generation (worse with diphenhydramine)

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17
Q

What are some risks of DDI with oral antihistamines?

A

Potentiate CNS depressants (alcohol), anticholinergic effects, worsen urinary retention in BPH, decrease effectiveness of cholinesterase inhibitors used in alzhiemers, many are CYP2D6, 3A4 substrates/inhibitors

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18
Q

What are ex. of intranasal antihistamines?

A

Azelastine nasal (astelin), olopatdine nasal (patanase)

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19
Q

What are indications of intranasal antihistamines?

A

More effective than oral agents (try those first!), particularly more effective against nasal congestion less effective than intranasal corticosteroids

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20
Q

What are potential side effects of intranasal antihistamines?

A

bitter taste, nasal irritation, epistaxis, rare sedation/anticholinergic effects

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21
Q

What are examples of intranasal corticosteroids?

A

beclomethasone nasal (Beconase AQ), Budesonide nasal (Rhinocort Aqua), Fluticasone propionate nasal (flonase), Mometasone nasal (nasonex), Triacmcinolone nasal (nasacort AQ)

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22
Q

What is the mechanism of action for intranasal corticosteroids?

A

Reduces proinflammatory mediators -> PGs, LTRs, cytokines (prostaglandins, leukotrienes, cytokines)
Vasoconstriction of nasal passages –> decreases sneezing, itching, rhinorrea, nasal congestion

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23
Q

What are associated symptoms of intranasal corticosteroid use?

A

Local irritation, burning/stinging, epistaxis

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24
Q

What are examples of mast cell stabilizers?

A

Cromolyn inhaled (Intal)

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25
Q

What is the MOA of mast cell stabilizers?

A

Stabilizes mast cell and eosinophil plasma membrane –> prevents degranlation of mast cell, stopping release of histamines, leukotrienes, etc

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26
Q

What are the indications for mast cell stabilizers?

A

NOT FIRST LINE…
alternative daily therapy for mild asthma
Prevention of bronchoconstriction caused by unavoidable allergen, cold weather, exercise (before exercise/unavoidable allergen)
NOT rescue therapy…slow acting

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27
Q

What are the side effects of mast cell stabilizers?

A

Throat irritation, dry throat, dysgeusia (bad taste in mouth), cough

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28
Q

What is a leukotriene receptor antagonist?

A

Montelukast (singulair)

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29
Q

What is Montelukast (Singulair)?

A

Leukotriene receptor antagonist
- decreases inflammation in airway
- 2nd line for mild intermittent disease esp with comorbid mild, persistent asthma
- can be used in children as young as 6 months + older
- only for asthma & allergies
- does not work on nose, only airway

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30
Q

When should you consider antibiotics for bacterial sinusitis?

A

Greater than 10 days, facial/dental pain, fever, maxillary edema/puffiness…double hump sign

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31
Q

How do you treat acute bacterial sinusitis?

A

Augmentin
PCN allergy: clindamycin, cefdinir, doxycycline (no <8yo)
Macrolides no…high resistance
Sulfa no…high resistance
Fluoroquinolones no…avoid when possible (do not use in pediatrics)
**Levaquin, Moxifloxacin **

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32
Q

What are examples of oral nasal decongestants?

A

pseudophedrine (sudafed), pseudoephedrine/loratidine (claritin-d), phenylephrine (OTC usually a combo)

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33
Q

What are the MOA of oral nasal decongestants?

A

stimulates both alpha and beta adrenergic receptors, induce release of norepinephrine from nerve endings, similar actions to epinephrine VASOCONSTRICTION (less potent)

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34
Q

What’s the clinical use of oral nasal decongestants?

A

for allergic rhinitis, common cold, sinusitis, etc. Phenyelphrine NOT LESS EFFECTIVE nasal dec. than pseudophedrine (equal in efficacy)

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35
Q

What was the Combat Methamphetamine Epidemic Act of 2005?

A

pseudophedrine is a methamphetamine precursor –> used for illegal meth production, requires customer ID, behind the counter,

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36
Q

What are the adverse effects of oral nasal decongestants?

A

elevated BP, urinary retention

insomnia, headache, tachycardia, palpitations, anxiety, tremor, nausea

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37
Q

Who should you not prescribe oral nasal decongestants to?

A

hypertensive and BPH patients

Use Coricidin HBP in HTN

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38
Q

What are examples of topical decongestants?

A

phenylphrine (neo-synephrine)
oxymetazoline nasal (afrin)

39
Q

What is the MOA of topical decongestants?

A

immediate response
alpha agonists – vasoconstriction in nasal mucosa and reduce airway resistance
rapid onset of action, few systemic effects with aerosol – increased systemic adverse effects if PO

40
Q

What is the clinical use for topical nasal decongestants?

A

allergic rhinitis, common cold, etc…SHORT TERM..3-5d course
epistaxis

41
Q

What are adverse effects of topical nasal decongestants?

A

rebound congestion, used more than recommended days
Elevated BP, urinary retention avoid in HTN and BPH
insomnia, headache, tachycardia, palpitations, anxiety, tremor, nausea

42
Q

What category is dextromethorphan?

A

antitussive

43
Q

What do antitussives do?

A

cough suppressant

44
Q

How is dextromethorphan OTC?

A

formulated alone or in combo with guaifenesin (Mucinex-DM) OR phenylephrine, pseudophedrine, acetaminophen

45
Q

What is dextromethorphan?

A

structurally related to codeine, depresses medullary cough center…relatively no analgesic action or addiction potential at recommended dose

46
Q

What are other properties of dextromethorphan?

A

serotonin reuptake inhibitor (serotonin syndrome), NMDA receptor blocker (dissociative hallucinogen and euphoria at much higher doses than recommended)

47
Q

What category is benzonatate?

A

antitussive

48
Q

What is benzonatate?

A

Tessalon Perles anti tussive, local anesthetic (decreases sensitivity of airway stretch receptors and reduces drive to cough)
for cough >10yo, very minimal side effects

49
Q

What category is codeine?

A

antitussive

50
Q

What is the clinical use of codeine?

A

Moderate opioid agonist with antitussive effects, suppresses response of CNS cough center at doses that do not cause analgesia

51
Q

What are side effects of codeine?

A

N/V, constipation, sedation, addictive potential
Prodrug: analgesia effect needs conversion to morphine by CYP2D6

52
Q

What is an expectorant?

A

Med that thins airway mucus

53
Q

What category is guaifenesin?

A

expectorant

54
Q

How is guaifenesin OTC?

A

combo with dextromethorphan, phenylephrine, pseudoephedrine (Mucinex-D), acetaminophen
alone = mucinex

55
Q

What are the side effects of guaifenesin?

A

no antitussive effects, may cause N/V at doses higher than recommended (elderly), rarely causes uric acid nephrolithiasis
so with kidney stone history do not prescribe!

56
Q

What types of glaucoma are there?

A

Closed-angle: treated in hospital, medical emergency
Open-angle: chronic disease state, treated with eye drops

57
Q

What are drugs to avoid in glaucoma?

A

antihistamines, anticholinergics, beta-agonists, corticosteroid eye drops

58
Q

What are glaucoma treatments?

A

Prostaglandins
Non-selective beta blockers
Carbonic anhydrase inhibitors
Cholinergic agonists

59
Q

What are prostaglandins and their MOA?

A

1st line treatment of glaucomas
MOA: increases aqueous outflow

60
Q

What are the prostaglandins clinical pearls?

A

take at night, cannot be administered with contact lenses

61
Q

What are the side effects of prostaglandins?

A

changes in iris pigmentation (skin around eyes may darken too)
eyelash growth
eye redness, tearing, eye pain, lid crusting

62
Q

What are examples of prostaglandins?

A

travoprost (Travatan Z), bimatoprost (Lumigan), Latanoprost (Xaltan)

63
Q

What is the non-selective beta blockers’ MOA?

A

reduce aqueous humor production

64
Q

What are the beta blockers clinical pearls?

A

exacerbation of resp conditions no asthmatics prescribed this, one form is a gel, requires shaking

65
Q

What are some side effects of non-selective beta blockers?

A

burning, stinging, itching of eyes/eyelids
changes in vision
photosensitivity

66
Q

What is the carbonic anhydrase inhibitors MOA?

A

reduces aqueous humor production

67
Q

What are examples of carbonic anhydrase inhibitors?

A

Brinzolamide (azopt), dorzolamide (trusopt)

68
Q

What are cholinergic agonists?

A

glaucoma treatment, also called “miotics”

69
Q

What is the MOA of cholinergic agonists?

A

lowers intraocular pressure by increasing aqueous outflow

70
Q

What are some clinical pearls for cholinergic agonists?

A

Glaucoma should be used 4x daily
also used in acute angle closure to prevent post-op elevation of IOP and counteract mydriasis from sympathomimetics,

use with caution of history of retinal detachment or corneal abrasion

71
Q

What are allergic conjunctivitis antihistamine/decongestant treatments?

A

Naphazoline/pheniramine

72
Q

What are allergic conjunctivitis antihistamine treatments?

A

ketotifen (OTC, zaditor), levocetrizine, emedastine

72
Q

What to use instead of artificial tears?

A

BLINK

73
Q

What NSAID can be used for allergic conjunctivitis?

A

ketorolac

74
Q

What are allergic conjunctivits mast cell stabilizer treatments?

A

Nedocromil, cromolyn

75
Q

What are allergic conjunctivitis antihistamine/mast cell stabilizer treatments?

A

azelastine (optivar), epinastine, olopatadine (pataday, patanase)

76
Q

What are allergic conjunctivitis steroid treatments?

A

dexamethasone, prednisolone (too dangerous if viral, leave steroids for eye specialist)

77
Q

What is the order of treatments for allergic conjuncivitis?

A

antihistamines –> mast cells –> combo of both –> steroids

78
Q

What is the order of treatments for allergic rhinitis?

A

oral antihistamines –> intranasal antihistamines –> intranasal corticosteroids –> mast cell stabilizer –> leukotriene receptor agonist

79
Q

What’s the order of treatments for bacterial conjunctivitis?

A

Polytrim (trimethoprim/Polymyxin B)–> Fluoroquinolones–> aminoglycosides (gentamicin, tobramycin)–> Macrolides (azithromycin, erythromycin)

80
Q

What else are macrolides used for?

A

Shortly after birth for prevention of opthalmic neonatorum due to gonococcal infection

81
Q

If topical otitis externa treatment doesn’t work, what’s next?

A

augmentin

82
Q

What do you use for removal of cerumen?

A

Carbamide peroxide (OTC), helps soften cerumen..but potential for 2nd infection, local irritation, redness

83
Q

Can you put eye drops in the ear?

A

Yes

84
Q

Can you put ear drops in the eye?

A

NO

85
Q

What is BPH?

A

benign prostate hyperplasia…there are a lof of things we have learned about where you should not give people some meds in this list!!

86
Q

What is the MOA of dextromethorphan?

A

depresses medullary cough center, SSRI, NMDA receptor blocker

87
Q

What is the MOA of benzoatate?

A

decreases sensitivity of airway stretch receptors

88
Q

What is the MOA of codeine?

A

suppresses response of CNS cough center

89
Q

What are examples of beta blockers?

A

x: timolol*, betaxolol, levobunolol, carteolol

90
Q

Why aren’t carbonic anhydrase inhibitors used very often in practice?

A

must be used 3x daily..hard to remember..not often seen in practice

91
Q

What are side effects of carbonic anhydrase inhibitors?

A

bitter and unusual taste

92
Q

What are examples of cholinergic agonists?

A

pilocarpine, carbachol

Clinical Pharmacology (9 decks)

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