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PHRM 504 > Lecture 9: Allergies > Flashcards

Lecture 9: Allergies Flashcards

1
Q

Allergy Rhinitis

A

Sneezing, itchy nose, eyes and roof of mouth, runny or stuffy nose: watery, red, swollen eyes
- Also called Hay fever

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2
Q

Allergic rhinitis pathophysiology

A

Systemic upper respiratory disease with primarily nasal symptoms

  • 4 phases
  • acute complications: sinusitis, otitis media
  • chronic complications: nasal polyps, sleep apnea, sinusitis, hyposmia
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3
Q

Four phases of allergic rhinitis

A
  1. Sensitization
  2. Early phase
  3. Cellular recruitment
  4. Late phase
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3
Q

Sensitization

A

initial allergen exposure stimulates beta-lymphocytic IgE (immunoglobin E) production

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4
Q

Early phase

A

release of preformed mast cell mediators (histamine, proteases) and production of additional mediators (prostaglandins, leukotrienes, etc.)

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5
Q

Cellular Recruitment

A

circulating leukocytes are attracted to nasal mucosa and release more inflammatory mediators

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6
Q

Late Phase

A

mucus hypersecretion - begins 2-4 hours after allergen

excess mucus secretion

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7
Q

Allergic rhinitis clinical presentation

A
  • May be intermittent (≤4 days per week or ≤4 weeks) or persistent (≥4 days per week or ≥4 weeks)
    • Frequent sneezing
    • Watery rhinorrhea (Nasal discharge)
    • Itchy eyes, nose, palate
    • Conjunctivitis
    • Allergic shiners, Dennie’s lines, allergic salute and crease
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8
Q

Allergic Rhinitis - Exclusions for self care

A
  • Children <12 years old
  • Pregnant or lactating women
  • Symptoms of non-allergic rhinitis
  • Symptoms of otitis media, sinusitis, bronchitis, or other infection
  • Symptoms of undiagnosed or uncontrolled asthma, COPD, or other respiratory disorder
  • Moderate to severe persistent allergic rhinitis or symptoms unresponsive to treatment
  • Severe or unacceptable side effects of treatment
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9
Q

Allergic Rhinits-Treatment Goals

A
  • Reduce symptoms
  • Improve functional status and sense of well-being
  • 3 steps:
    1. Avoid allergen
    2. Pharmacotherapy(OTC of Rx)
    3. Immunotherapy (Rx)
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10
Q

Allergic Rhinitis - Non-pharmacologic options

A

avoidance or removal of allergens
- Dust mites: Wash bedding weekly, limit carpets/upholstered furniture/ stuffed animals Cats: Weekly baths
Mold Spores: Lower household humidity, avoid raking
Nasal wetting agents: Saline, propylene, polethylene glycol nasal sprays or gels, neti pot

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11
Q

Non-pharmacologic options: Nasal wetting agent

A
  • Saline, propylene, polethylene glycol nasal sprays or gels, neti pot
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12
Q

Non-pharmacologic options: Avoiding or removing allergens

A

Dust mites: Wash bedding weekly, limit carpets/upholstered furniture/ stuffed animals Cats: Weekly baths
Mold Spores: Lower household humidity, avoid raking

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14
Q

Allergic Rhinitis - Pharmacologic Treatment

A
  • Intranasal corticosteroid, - Antihistamine (1st and 2nd Generation)
  • Mast cell stabilizer
  • Decongestant
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15
Q

Intranasal Corticosteroid Characteristics MOA

A

MOA: Inhibit multiple cell types and mediators (including histamine) in order to stop the allergic cascade

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15
Q

Intranasal Corticosteroids Drugs

A
  • Triamcinolone acetonide (55mcg/spray)
  • Fluticasone propionate (50mcg/spray)
  • Budesonide (32mcg/spray)
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16
Q

Intranasal Corticosteroid Characteristics Indication

A
  • Indication: treatment of nasal allergy symptoms (allergic rhinitis)
  • Use regularly for best results
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18
Q

Triamcinolone acetonide adult dosing

A
  • 55mcg/spray
  • 2 sprays in each nostril daily
  • may titrate down to 1 spray in each nostril
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19
Q

Fluticasone Propionate Adult dosing

A
  • 50mcg/spray
  • 2 sprays in each nostril for 1 week
  • may titrate down to 1 spray in each nostril
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20
Q

Budesonide Adult dosing

A
  • 32mcg/spray

- 2 sprays in each nostril daily

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21
Q

Triamcinolone acetonide pediatric dosing 6-11 years old

A

6-11 years old: 1 spray in each nostril daily

- may increase to 2 sprays in each nostril

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21
Q

Fluticasone Propionate pediatric dosing

A

4-11 years old: 1 spray in each nostril daily

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23
Q

Budesonide Pediatric dosing

A

6-11 years old- 1 spray in each nostril daily

- 2-5 years old- N/A

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24
Q

Antihistamines MOA

A

MOA: compete with histamine at central and peripheral H1 receptor sites to prevent histamine-receptor interaction and resulting mediator release

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25
Q

Antihistamines Indication

A

Relief of symptoms of allergic rhinitis and other types of immediate hypersensitivity reactions

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26
Q

First Generation Antihistamine Characteristics

A

Sedating / nonselective

  • Lipophilic- able to cross blood brain barrier
  • Peak effect in 1.5- 3 hours
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27
Q

First Generation antihistamine special populations

A
  • Avoid in children unless under direction of a primary care doctor (PCP) due to paradoxical excitation
  • Avoid in elderly patients due to increased risk of drug interactions and CNS depression
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28
Q

First Generation anti-histamine drugs

A

Diphenhydramine

Chlorpheniramine

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29
Q

Diphenhydramine adult dosing 12 and older:

A

25-50mg every 4-6 hours

MDD: 300mg

30
Q

Diphenhydramine dosing 6-11 years old

A

12.5-25mg every 4-6 hours

MDD: 150mg

31
Q

Diphenhydramine dosing 2-5 years old

A

6.25mg every 4-6 hours

MDD: 37.5 mg

32
Q

Chlorpheniramine dosing adults 12 and over

A

4 mg every 4-6 hours

MDD: 24 mg

33
Q

Chlorpheniramine dosing 6-11 years old

A

2mg every 4-6 hours

MDD: 12mg

34
Q

Chlorpheniramine 2-5 years old

A

N/A

35
Q

1st generation antihistamine adverse effects

A
  • CNS depression - sedation, poor performance,
    incoordination, reduced motor skills (more common in adults)
  • CNS stimulation - anxiety, hallucinations, appetite
    stimulation, muscle dyskinesias (more common in children)
  • Anticholinergic - dry eyes and mucous membranes,
    blurred vision, urinary hesitancy and retention, constipation, reflex tachycardia
36
Q

First Generation Antihistamines Contraindications

A
  • newborn/premature infant
  • lactating women
  • narrow angle glaucoma
  • use of MAOI medication ( drugs that treat depression)
37
Q

First Generation Antihistamines Drug interactions

A
  • Anticholinergic medications ( drugs that block action of acetylcholine- neurotransmitter)
  • alcohol
  • sedative medications
38
Q

High doses of Benadryl cause

A

seizures, hallucinations, agitation, confusion, hyperthermia, arrhythmias

39
Q

Second Generation Antihistamines Characteristics

A
  • Nonsedating/selective
  • Protein bound lipophobic molecules - do not readily cross blood brain barrier
  • Peak effect in 1 - 3 hours,
40
Q

Second Generation Antihistamines Drugs

A

Loratadine (nonsedating)
Fexofenadine (nonsedating)
Cetirizine ( moderate sedation)
Levocetirizine (moderate)

41
Q

Loratadine adult dosing

nonsedating

A

10mg every 24 hours

42
Q

Fexofenadine adult dosing

nonsedating

A

60mg every 12 hours or 180mg every 24 hours

43
Q

Cetirizine adult dosing

moderate sedation

A

10mg every 24 hours *avoid in adults older than 65 years unless recommended by PCP

44
Q

Levocetirizine adult dosing

moderate sedation

A

5mg every 24 hours *avoid in adults older than 65 years unless recommended by PCP

45
Q

Loratadine pediatric dosing

A

For 6-11 yrs old: 5-10mg every 24 hours
For 2-5 yrs old: 2.5mg every 12 hours
For less than 2: N/A

46
Q

Fexofenadine pediatric dosing

A

For 2-11 yrs old: 30mg every 12 hours

For less than 2: N/A

47
Q

Cetirizine pediatric dosing

A

For 6-11 yrs old: 10mg every 24 hours
For 2-5 yrs old: 2.5mg once or twice daily OR 5mg every 24 hours
For 6-12 months: 2.5mg daily (ask doctor)
12-24 month: 2.5mg once to twice daily (ask doctor)

48
Q

Levocetirizine pediatric dosing

A

For 6-11 yrs old: 2.5mg every 24 hours
For 2-5 years old: 1.25mg every 24 hours
For less than 2: N/A

49
Q

2nd generation antihistamine adverse effects

A

rare compared to first generation antihistamines

50
Q

2nd generation antihistamine Drug interactions

A

• Fexofenadine + fruit juice (apple, grape, orange): Juices inhibit intestinal organic anion transporting polypeptides (OATPs)
- Separate juice and drug by 2 hours
• Fexofenadine + ketoconazole = increased fexofenadine concentration
• Fexofenadine + erythromycin = increased fexofenadine concentration
• Loratadine + amiodarone = increased risk of QT prolongation

51
Q

First vs Second Generation Antihistamines

A
  • both have similar efficacy, second gen have less adverse reactions/ effects
  • first gen may be used for the anticholinergic effects (somnolence, drying)
52
Q

Mast Cell Stabilizer Characteristics

A

MOA: blocks influx of calcium into mast cells to block mediator release

Indication: prevent and treat symptoms of allergic rhinitis

Limited system absorption - good in pregnancy and lactation

  • May take 3-7 days for any effect and 2-4 weeks for maximal effect
  • Cromolyn sodium
53
Q

Mast Cell Stabilizer Adverse effects

A

sneezing, nasal stinging, burning

54
Q

Mast Cell stabilizer drug interactions

A

None

55
Q

Cromolyn sodium dosing

A

For 2 and older- 1 spray in each nostril 3-6 times daily

56
Q

Decongestant Characteristics

A

MOA: adrenergic agonist (sympathomimetics) - stimulate alpha-adrenergic receptors to constrict blood vessels which decreases sinusoid vessel engorgement and mucosal edema

Indication: temporary relief of nasal and eustachian tube (passage from the pharynx to the middle ear cavitiy) congestion and for cough associated with postnasal drip
- there are Topical and oral options

57
Q

Oral Decongestant Characteristics and drugs you can use

A

• Peak 0.5 - 2 hours after administration

  • Phenylephrine
  • Pseudoephedrine
58
Q

Oral decongestant adverse effects

A

Adverse Effects:
- Cardiovascular stimulation: elevated blood pressure (BP), tachycardia, palpitation, arrhythmia
• CNS stimulation: restlessness, insomnia, anxiety, tremors

59
Q

Oral decongestant Caution

A
  • hypertension
  • hyperthyroidism
  • heart disease
  • elevated intraocular pressure (fluid pressure in eye)
  • prostatic hypertrophy enlarge prostate glands
60
Q

Oral decongestant Drug interactions

A

Drug Interactions: Antacids, MAOIs, TCAs ( antidepressants)

61
Q

Phenylephrine adult dosing

A

10mg every 4 hours

MDD: 60mg

62
Q

Pseudoephedrine adult dosing

A

60 mg every 4-6 hours

MDD: 240mg

63
Q

Phenylephrine pediatric dosing

A

For 6-11 years old: 5mg every 4 hours
MDD: 30mg

For 4-5 years old: 2.5mg every 4 hours
MDD: 15mg

64
Q

Pseudoephedrine pediatric dosing

A

For 6-11 years old: 30mg every 4-6 hours
MDD: 120mg

For 4-5 years old: 15mg every 4-6 hours
MDD: 60mg

65
Q

Combat Methamphetamine Epidemic Act of 2005

A
  • intended to decrease availability of pseudoephedrine
  • Bans OTC sale of pseudoephedrine
  • Limit the amount purchased by individuals each month
  • Max 3.6g per day
  • Max 9g per month
  • Pharmacies must check photo ID and maintain a logbook
66
Q

Topical decongestants drug

A

Oxymetazoline

67
Q

Topical decongestants drug 6 and older dosing

A

For 6 years and older: 2-3 drops/sprays not more than every 10-12 hours
( MDD: 2 doses/ 24 hours)

68
Q

Topical decongestants dosing for 2-5 years old

A

For 2-5 years old: Not recommended in children less than 6 years except under advice/ dosing of PCP

69
Q

Topical decongestants drug adverse effects

A

Rare due to poor systemic absorption
- May include nasal burning, stinging, sneezing, dryness

Rebound congestion: Generally recommended using for a maximum of 3-5 days

70
Q

Allergy case- You must use the PPCP

A

Collect: SCHOLARMAC
Assess: Exclusions? Interacting medicatiosn? Contraindications?
Plan: What is the best treatment option
Implement: Explain choice to patient and provide medication counseling
Follow up: How soon should the patient feel better? Next steps?

71
Q

Clinical pearls

A
  1. intranasal steroids may be more effective than antihistamines at relieving congestion
  2. antihistamines may be more effective at relieving histamine mediated symptoms (sneezing, runny nose, ocular symptoms)
  3. Intranasal steroids and antihistamines work best when taken regularly, not as needed

PHRM 504 (22 decks)

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