Module 6: Allergy and URI Flashcards by Lindy Kirk

1st Generation antihistamines example

Benadryl, promethazine (phenergen)

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Indication for Bendryl

Flu, cold, and allergy symptoms
Insomnia
Anaphylaxis
Motion sickness
Parkinsonism
Pruritus
Anxiety

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MOA benedryl

Acts as an antihistamine by competing with histamine for receptor sites on effector cells.

Block both histaminic and muscarinic receptors as well as passing the blood-brain barrier

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Safety Benedryl

SEDATION

Anticholinergic effects

Use with or within 14 days of MAO inhibitor therapy

To sedate a child

Do not use: Newborns, premature infants, nursing mothers

Caution about sedative effects and use caution in using in the elderly

D2D: CYP2D6 inhibitor, weak, anticholinergic effects, CNS depression, decrease central histamine effects

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BBW Promethazine (phenergan)

in children less than two years old: serious behavioral and other adverse effects

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Education with benedryl

Avoid concomitant use of MAO inhibitors or CNS depressants.
No alcohol

Avoid applying occlusive dressings, cosmetics, or other skin products over areas treated with topical formulation.
Patient should not use topical form on eyes or eyelid.

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Pediatric considerations Benedryl

Cr at baseline (peds)

Young children may experience a paradoxical excitation effect.

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2nd Generation antihistamines example

*cetirizine (Zyrtec)

**Fexofenadine (Allegra)

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Indication Zyrtec and Allegra

Allergic rhinitis
Sneezing
Itchy/watery eyes
Itchy nose/throat
Chronic idiopathic urticaria

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MOA zyrtec and allegra

Acts as an antihistamine by competing with histamine for receptor sites on effector cells.

Blocks histaminic receptors and does not pass the blood-brain barrier

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Caution with zyrtec and allegra

Caution in patients 65 yo and older
*Caution if concurrent CNS depressant use
Cr at baseline, then in elderly pts consider periodically

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D2d with allegra and zyrtec

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Zyrtec safety

Sedating, CNS depression, decreases central histamine effects

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Safety allegra

prolonged Qt, OATP1A2 substrate, OATP2B1 substrate, P-gp substrate, binds to polyvalent cations

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Nasal Decongestants example

Oxymetazoline (Afrin)

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Afrin indication

Nasal congestion, sinus congestion/pressure

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MOA afrin

Stimulates smooth muscle alpha adrenergic receptors, producing vasoconstriction and reducing nasal congestion

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Safety afrin

MAO inhibitor use within 14 days
Caution in individuals with glaucoma, angle-closure, HTN, cardiovascular disease, diabetes, hyperthyroidism
D2D: hypertensive effects, interferes with radiolabeled norepinephrine analog effect

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Special considerations/education afrin

No routine tests recommended
Rebound congestion
Use for 3 days or less

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Oral decongestants example

Sudafed

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Indication Sudafed

Nasal congestion due to common cold, hay fever, or upper respiratory allergies

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MOA sudafed

Enhance norepinephrine and epinephrine or adrenergic activity by stimulating the alpha1-adrenergic receptor which induces vasoconstriction.

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Caution and D2D Sudafed

Anticholenergic
Caution: pregnancy
Caution in individuals with glaucoma, angle-closure, HTN, cardiovascular disease, diabetes, hyperthyroidism
D2D: (alpha-1 agonist; beta-2 agonist) hyperglycemic effects, hypertensive effects, interferes with radiolabeled norepinephrine analog effect, urine pH sensitivity.

Sudafed in children

Use in pediatric patients <4 years of age has limited efficacy, the AAP warns against the use in young children.

Antitussives example

Tessalon Perles | Benzonatate

Indication tessalon pearls and Benzontate

Cough suppressant

MOA Tessalon pearls and benzonatate

Anesthetizes respiratory passage, lung, and pleural stretch receptors, reducing cough reflex

Safety antitussives

Hypersensitivity can cause bronchospasm and laryngospasm May cause bizarre behavior (confusion, visual hallucinations) May cause sedation

Expectorants example

Mucinex | guaifenesin

Indication Mucinex and guaifenesin

Help loosen mucus and thin bronchial secretions

MOA mucinex and guaifenesin

Increases volume and decreases viscosity of respiratory tract secretions

Safety Mucinex and guaifenesin

Caution in nephrolithiasis Caution in patients <6 yo D2D: None

Intranasal Antihistamines examples

Astelin (azelastine) | Olopatadine

Astelin (azelastine) Olopatadine Indication

Perennial allergic rhinitis Seasonal allergic rhinitis Vasomotor rhinitis

MOA Astelin (azelastine) and Olopatadine

Antagonizes central and peripheral histamine H1 receptors | Inhibits histamine release from mast cells

Safety Astelin (azelastine) and Olopatadine

``` Caution if concurrent CNS depressant use Caution if depression history must be >6 yo D2D: None May cause nasal septal perforation, nasal ulcer, hyposmia, anosmia, depression in long-term use ```

Leukotriene Modifiers/Blockers

Montelukast (Singular) zafirlukast (Accolate)

Indication Montelukast (Singular) and zafirlukast (Accolate)

Allergic rhinitis Asthma Bronchoconstriction

MOA Montelukast (Singular) and zafirlukast (Accolate)

Selectively binds to cysteinyl leukotriene receptors

Safety Montelukast (Singular) and zafirlukast (Accolate)

Caution severe asthma Caution if PKU D2D: CYP2C8 substrate, CYP2C9 substrate, CYP3A4 substrate Monitor s/sx neuropsychiatric events incl. depression, behavior changes, sleep disturbances, suicidality Can cause suicidality, aggressive behavior, hallucinations, depression Can cause pulmonary eosinophilia Can cause hepatic failure Can cause Churg-Strauss syndrome

BBW Montelukast (Singular) and zafirlukast (Accolate)

Neuropsychiatric events

Nasal Corticosteroids example

Flonase (fluticasone)

Flonase indication

``` Allergic rhinitis Asthma Bronchoconstriction Allergic rhinitis Nasal polyps Nonallergic rhinitis ```

MOA flonase

Exact mechanism unknown; inhibits multiple inflammatory cytokines; produces multiple glucocorticoid and mineralocorticoid effects

Safety and D2D flonase

Unhealed nasal septal ulcer or wound Caution if hepatic impairment, recent long-term systemic corticosteroid, glaucoma, cataracts D2D: CYP3A4 substrate, immunosuppressive effects

What can be suppressed with long term use of Flonase

``` Can cause growth suppression (long-term use in peds patients) Adrenal suppression (long-term use) ```

Intranasal Cromolyn example

NasalCrom

Indication NasalCrom

Allergic rhinitis

MOA NasalCrom

Inhibits mast cell degranulation (mast cell stabilizer)

Safety NasalCrom

Can cause bronchospasm, nasal burning, sneezing

Optic decongestant/antihistamine example

Naphazoline/pheniramine (Naphcon-A, Opcon-A)

Naphazoline/pheniramine (Naphcon-A, Opcon-A) Indication

Decrease eye redness

Naphazoline/pheniramine (Naphcon-A, Opcon-A) MOA

Binds to histamine 1 receptors, thereby inhibiting phospholipase A2 and production of endothelium-derived relaxing factor

Caution and D2D Naphazoline/pheniramine (Naphcon-A, Opcon-A)

Caution: individuals with diabetes, glaucoma, heart problems, HTN, hyperthyroidism, eye infection/injury D2D: Hypertensive effects, interferes with radiolabeled norephinephrine analog effect

Side effects Naphazoline/pheniramine (Naphcon-A, Opcon-A)

Can cause dilated pupils, blurred vision | Can cause worsening eye redness, itching swelling, eye pain