Medications Flashcards
- older H1 antagonists, work well for most allergic rhinitis sxs.
- with prolonged use, patient tolerance to side effects improves
- usually taken QHS
- class is more lipid soluable and cross the blood brain barrier
1st generation antihistamines
what are the usual side effects of 1st generation anithistamines? what medications are 1st generation?
side effects: Drowsiness, cognitive impairment, driving skills affected , anticholinergic effects
meds: chloropheniramine, diphenhydramine (benedryl)
- one of the safest during pregnancy
- competes with histamine on H1 receptor sites of blood vessels and respiratory tract
- for >2y/o dose by age and weight in peds
Chlorpheniramine
- also safe in pregnancy
- competes with histamine on H1 receptor sites of blood vessels and respiratory tract
- for >3y/o, dose by age and weight in peds
Diphenhydramine
- newer antihistamines, aka nonsedating antihistamines
- compete with histamine on H1 receptor sites of blood vessels, GI tract and respiratory tract inhibiting the effect that histamine would have on the cell
- lower rate of sedation and anticholinergic effects
- help with allergic rhinitis sxs, but not nasal congestion (combination)
2nd generation antihistamines
which medications are 2nd generation antihistamines?
fexofenadine (allegra)
loratadine (claritin)
certirizine (Zyrtec)- can be used >6months , dose by weight for peds, >6 y/o dose as adult
- highly efficacious for allergic rhinitis, more effective than monotherapy with antihistamines
- controls the 4 major sxs of allergic rhinitis (sneezing, itiching, rhinorrhea, congestion)
- poor control of ocular symptoms
- not associated with significant systemic effects in adults (preg. Category B)
- can cause nasal dryness and epistaxis
- works better when used daily instead of PRN
- tolerance with prolonged use
corticosteroid nasal spray
prevention and pain control for otitis media
Prevention
* vaccines (pneumococcal, influenza, HIB…)
* environmental factors (pets/allergies, tobacco exposure)
* bottle feeding in bed
Pain management
* ibuprofen 10mg/kgs po TID prn pain best per studies
* acetaminophen 10-15mg/kg q 4-6 hrs prn for pain
* auralgan (topical benzacaine)- rapid improvement in pain
acetaminophen helps with pain, but not inflammation
what does not improve or have any benefits for otitis media
- antihistamines & decongestants do not improve healing or minimize the complications
- corticosteroids (PO) have shown no benefit in treating AOM
who are antibiotics recommended for in AOM treatment?
- all children <6m/o with findings consistent with AOM
- children <2 y/o with bilateral AOM
- children with AOM with Otorrhea
- children 6 m/o to 2 y/o when the diagnosis is certain
- children > 2y/o with severe infection/illness (Moderate otalgia of tem >39 degrees)
what is the 1st line antibiotics selection for AOM?
high-dose amoxicillin 80-90mg/kg PO BID x 10 days
* children 2-6 y/o can be treated for 5-7 days
* amoxicillin is safe, effective, inexpensive and has a narrow spectrum of activity
what is 2nd line for treatment of AOM?
- amoxicillin/Clavulanate (augmentin) 80-90mg/kg/d x10d
- cefuroxime axetil (Ceftin) 30mg/kg/day BID x 10d
- ceftriaxone (rocephin) 50mg/kg IM daily x 3 days
Treatment for persistent AOM treatment
* if already on antibiotic therapy and not improved
Azithromyin (3 dosing patterns)
* 30mg/kg one-dose, 20mg/kg/D x3D, 5-10mg/kg/d x 5D
* Augmentin (amox+clavulanic acid) high dose @ 90mg/kg/day BID x 10D
* clindamycin (cleocin) 30-40mg/kg/day TID/QID x 10D
* If allergic to PCN (cephalosporins, TMP sulfa, or macrolides
treatment of tympanostomy tube ottorhea in kids?
- tx w/ topical abx ear drops, with or without corticosteroids
- oxfloxacin 5 drops BID x 5-7 days
- if granulation tissue, add topical steroid (cipro/dexamethasone)
- topical failures, switch to PO antibiotics (amox, clavulanate)
what is the dosing for ibuprofen?
10mg/kg PO TID PRN
what is dosing of acetaminophen?
10-15mg/kg Q 4-6 hours PRN
treatment of bacterial otitis externa
- 2% acetic acid drops to restore normal flora, or:
- cortisporin Otic
- polymyxin B
- ofloxacin 0.3% (for use with TM rupture)
Dosing for high dose amoxicillin?
80-90mg/kg PO BID x 10 D
Dosing for amoxillin/cavulanate (augmentin)
80-90mg/kg/d x 10d
What treatment should be used for patients with otitis externa in toxic state or unresponsive to treatments
- dicloxacillin
- if severe pain & granulation - Parenteral
treatment of fungal otitis externa
- cleanse canal, acidifying drops
- if not resolved- OTC 1% clotrimazole
- if TM perforated- tolnaftate
- all tx above 3-4 drops BID x 7 days
Treatment of the common cold?
decongestants +/- 1st generation antihistamines
*Relieve nasal symptoms, cough
*antihistamines alone not recommended
*rest and hydration
*intranasal steroids not recommended
MOA: sympathomimetic alpha adrenergic agonist; vasoconstricts blood vessles to decrease swelling and discharge
* absorbed in the gut/urine excreted
* much better absorbed than phenylephrine
* routes: Oral
Pseudophedrine
what are adverse effects of pseudophedrine? what are contraindactions?
AE: tachycardia, decreased appetite, elevated BP &HR, insomnia
contraindication: cardiac disease, HTN, glaucoma, during/within 14 days of MAOI use
MOA:sympathomimetic alpha adrenergic agonist; vasoconstrict blood vessels to decrease swelling and discharge
- absorbed in the gut (only 38% bioavailable)
- routes: oral, intranasal, IV/injectable
phenylephrine
MOA: sympathomimetic alpha adrenergic vasoconstriction; decreases mucosal edema
- absorbed through the mucous membranes, onset in 10 minutes
- route: intranasal
- same adverse effects as pseduophedrine but also rhinitis medicamentoa
oxymetazoline
what medications are decongestants?
pseudophedrine
phenylephrine
oxymetazoline
which medications are expectorants?
Guaifenesin
which medications are antitussives?
dextromethorphan
codeine
hydrocodone
MOA: increases the effective hydration of the respiratory tract; reduces viscosity of mucus, facilitating its removal by natural clearance processes
Route: PO (liquid and tablet)
pharmacokinetics: Well absorbed, excreted in urine
guaifenesin
adverse effects of gauifenesin? Contraindications?
- AE: N/V, dizziness, drowsiness, headache, rash, nephrolithiasis
- cautions: hypersensitivity to drug/class/component, nephrolithiasis, patients < 6
- MOA: central depression of the cough center (medulla oblongata) uncompetitive NMDA receptor antagonist and sigma-1 receptor agonist
- absorbed in the gut, processed in the liver
- route: oral (liquid and pill/capsule)
- adverse effects: N/V, diarrhea, drowsiness, nervousness, restlessness
dextromethorphan
contraindications of dextromethorphan?
children <4 y/o
do not use if using MAO inhibitor
MOA: central depression of the medulla oblongta
* commonly combined with promethazine (an antihistamine) in cough syrup; one of the most commonly prescribed antitussives, but some research shows not effective at reducing cough in acute URI
* absorbed in gut, processed in liver, exreted by kidney
* Route: Oral
Codeine
- Not effective as monotherapy in treating the common
- studies show that combined with a decongestant, more effective than either drug
- diphenhydramine may offer some relief of rhinorrhea and sneezing but side effects make it impractical
antihistamines
treatment for pediatric patients with URI or sinusitis?
- good hydration, humidifier
- rest, elevate head of bed
- nasal saline with suction
- warm liquids, honey
OTC medications:
Children 0-12: antipyretics/analgesics
children >12: as above + decongestants
- First line treatment in bacterial sinusitis?
- Amoxicillin
*augmentin for tx failures
which antibiotics can be used to treat bacterial rhinosinusitis?
- amoxicillin/augmentin
- erythromycin/azithromycin
- levofloxacin
- TMP-sulf
- doxycycline
- clindamycin
- these drugs have potent glucocorticoid and weak mineralcorticoid activity
- have multiple mechanisms of action, including anti-inflammatory activity, immunosuppressive properties, and antiproliferative actions
- anti-inflammatory result from decreased formation release and mediators of inflammation
Nasal steroid
which medications are steroids?
Mometasone
fluticasone
budesonide
MOA: Anti-inflammatory glucocorticosteroid for the once daily treatment of non-infectious rhinitis, and treatment and prevention of nasal polypsis
* May decrease the # and activity of inflammatory cells
* reduces intraepithelial eosinophilia & inflammatory cell infiltration
* no mineralcorticoid or androgenic effects
* can be used in as young as 2 years old
memetasone
- MOA: Anti-inflammatory glucocorticosteroid for the once daily treatment of non-infectious rhinitis, and treatment and prevention of nasal polypsis
- may decrease the # and activity of inflammatory cells
- for use as an adult in 4 >y/o
fluticasone
MOA: Anti-inflammatory glucocorticosteroid for the once daily treatment of non-infectious rhinitis, and treatment and prevention of nasal polypsis
*may decrease the number of activity of inflammatory cells
*has an H2O component, which decreases drying, irritating effect. Better tolerated
budesonide
benefits of intranasal antihistamines vs. PO
- Delivers higher concentration directly to tissue
- less ADR than oral (only has bitter taste, epistaxis, sedation, irritation)
- onset of action within 15 minutes and lasts up to 4 hours
Still 2nd line therapy due to cost, ADRs, efficacy compared to steroid
which medications are intranasal antihistamines?
azelastine, oloptadine
- MOA: inhibits degranulation of mast cells
- OTC and safe but decreased efficacy and compliance (QID)
cromolyn
- MOA: antagonizes acetylcholine receptors, inhibiting nasal mucous gland secretions
- not systemically absorbed
- great for excessive rhinorhhea
- ADR: mucosal dryness, epistaxis, HA
- ipratropium is an example
Intranasal anticholinergics
- MOA: Works as a leukotriene receptor antagonist, preventing their release from mast cells and eosinophils
- An oral antihistamine alternative
- for seasonal and perennial, also used for long-term asthma control and exercisie induced bronchospasms
- ADR: URI, fever, HA, pharyngitis, cough, abdominal pain and neuropsychiatric and suicidality ADR
Montelukast (singulair)
first line alterantive to PCN in URI and sinusitis
Doxycyline
when should you treat acute otitis media in children?
most children will improve with watchful waiting
* if still symptomatic in 48-72 hours–> treat
* minimize risk factors: tobacco exposure, pacifier use, bottle feeding, daycare attendance
* follow-up in 8-12 weeks
what are some UNPROVEN therapies in AOM?
- decongestants & antihistamines- increased ADRs, without improved healing
- if child has AOM as a result of allergic rhinitis nasal steroid is better option
how should you treat OM with effusion?
- persistent middle ear effusion after resolution of AOM is not treatment failure (requires Q3-6m monitoring and reassurance)
- tympanostomy (PE tubes) is preferred therapy for prolong effusion and advere sequelae (hearing, language delay)
- oral or nasal steroids may help with short term resolution but does not decrease long term recurrences
Bacterial etiology of tympanostomy tube ottorhea in kids
- Children < 2yo
s.pneumonia, M. cattarhalis, H. influenzae - Children > 2yo
Pseduomonas aeruginosa and staph. aureus
