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PDC > OTC Allergic Rhinitis > Flashcards

OTC Allergic Rhinitis Flashcards

1
Q

Classification of “Seasonal” Allergic Rhinitis (SAR)?

Classification depends on timing and duration of symptoms

A

Intermittent

Specific allergens responsible

Predictable occurrence

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2
Q

Classification of “Perennial” Allergic Rhinitis (PER)?

Classification depends on timing and duration of symptoms

A

Persistent

Non-seasonal allergens responsible

Year round occurrence (pet, cats, mold,)

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3
Q

Causes of Non-Allergic Rhinitis?

A

*Overuse of topical decongestants – Only can use for 3 days, after will cause rebound congestions

Drug-Induced
B-Blockers
ACEIs
Chlorpromazine
Clonidine
Hydralazine
Oral Contraceptives
ASA
NSAIDS
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4
Q

Immune Response: Immediate

A

Immediate reaction - within minutes of exposure

Rapid release of histamine, chemotactic factors, kinins, leukotrienes

Causes vasodilation, nasal congestion, and secretion of mucous – Use Nasal Congest-ant to constrict.

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5
Q

Immune Response: Late phase

A

Late phase reaction - several hours later

Renewed allergic symptoms due to influx of inflammatory cells & hyperresponsive mucosa (nasal congestion, rhinorrhea)

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6
Q

Signs and Symptoms of Allergic Rhinitis - Important Slide

A 
Rhinorrhea 
Nasal congestion
Pruritus (eyes, nose)
Ocular discharge (lacrimation)
Sneezing
Postnasal drip
Conjunctivitis

“Allergic shiners” —Black Eyes

“Allergic salute”—tip of nose

“Allergic gape”—sleep with mouth open

Decreased sense of smell (hyposmia)

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7
Q

Physician Referral for Allergic Rhinitis

A

Children < 12 years of age*

Pregnant or lactating women*

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8
Q

Goals of Therapy: Allergic Rhinitis

A

Goals of Therapy

Reduce symptoms

Provide optimal symptomatic relief and control of symptoms
Improve the patient’s functional status and sense of well being

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9
Q

Non-Pharmacologic Therapy: Avoidance

A

Avoidance of allergens is the most important and safest method in preventing symptoms of allergic reactions

Indoor Allergens:
Encasing mattress, box springs, and pillows with dust-mite impermeable materials

Outdoor Allergens:

Avoiding outdoor activities when pollen counts are high and closing house and car windows

Avoiding activities that disturb decaying plant material

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10
Q

Non-Pharmacologic Therapy Examples?

A

HEPA filter
(High Efficiency Particulate) : Helpful with dust mites

Nasal Passage Strips

Nasal Wetting Agents

Neti-Pots:

MUST USE SALT PACKETS—SODUIM CHOLRINE PACKETS IN NASAL SPRAY

DON’T USED Table SALT

DO NOT USE TAP WATER, USE DISTILLED WATER

GREAT FOR PREGNANT PATIENTS

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11
Q

Non-Pharmacologic Therapy : Nasal Wetting Agents

A

May relieve nasal irritation and dryness therefore decreasing stuffiness, rhinorrhea, and sneezing

Saline (i.e. Ocean Nasal Spray ®), propylene, polyethylene glycol sprays

Neti-pots, saline nasal irrigation systems

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12
Q

Non-Pharmacologic Therapy : HEPA filters

A

Removes pollen, mold spores, and cat allergens

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13
Q

Non-Pharmacologic Therapy:

Nasal Passage Strips

A

Vicks ® Breathe Right Strips

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14
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

Regularly or As needed

A

must use REGULARLY

i.e. antihistamines and mast cell stabilizers

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15
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

SAR (Seasonal Allergic Rhinitis)

A

Start medications at least 1 week before symptoms usually appear

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16
Q

Initiation of Pharmacotherapy: Allergic Rhinitis

PER (Perennial Allergic Rhinitis)

A

Start medications before known exposure

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17
Q

Length of Therapy: Pharmacotherapy therapy

A

Duration and severity of symptoms

Pattern of allergen exposure (i.e. episodic vs. continuous)

Geographical location -WORSENS symptoms (could be in the amazon forest)

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18
Q

Pharmacotherapy for Allergic Rhinitis

A

Intranasal Corticosteroids

Antihistamines
(Systemic): First generation (sedating, nonselective)

Second generation (non-sedating, peripherally selective)

Topical Ophthalmic Antihistamines

Cromolyn Sodium Nasal Spray

Decongestants:
Systemic Decongestants
Topical Nasal Decongestants

Combination Products – ALLEGRA D

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19
Q

Intranasal Corticosteroids

A

Nasacort ® Allergy 24 HR
Triamcinolone acetonide

Flonase ® Allergy Relief
Fluticasone propionate

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20
Q

Intranasal Corticosteroids: Adverse Effects

A

sore throat

DO NOT AIM TOWARDS NASAL SEPTUM??? TILT HEAD DOWN A BIT TOWARDS THE NASAL SPRAY.

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21
Q

Administration of FLONASE

A

GOLD STANDARD

Do NOT blow nose for 15 minutes after use

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22
Q

Intranasal Corticosteroids: Ages

Which gets put to 2 sprays?

Focus on AGE, Dose is just there for completion

A

Nasacort ® Allergy 24 HR
6 to < 12 years

Want the lowest effective dose: 1 spray in each nostril once daily may increase to 2 sprays in each nostril once daily if uncontrolled symptoms (wiggle room)

Fluticasone propionate

4 to < 12 years

Dose: 1 spray in each nostril once daily

23
Q

List the Antihistamines

A

Benadryl ® Allergy
Diphenhydramine

Chlor-Trimeton ® Allergy
Chlorpheniramine

Zyrtec ®
Cetirizine

Allegra ® Allergy
Fexofenadine

Claritin ®
Loratadine

24
Q

Antihistamines Indications

A

temporary relief of hay fever or upper respiratory allergies:

Sneezing
Runny nose
Itchy watery eyes
Itching of the nose and throat

25
Q

What’s the difference between 1st generation antihistamines and 2nd generation antihistamines?

A

1st generation NON-selective “sedating antihistamines”

2nd generation peripherally SELECTIVE “non-sedation antihistamines”

26
Q

Systemic OTC Antihistamines: 1st generation specifics

A

Class: Alkylamine and Ethanolamine

Sedation :
Ethanolamine (more sedative)

“Diphenhydramine HCL/citrate
Doxylamine succinate
Clemastine fumarate”

> Alkylamine

(less sedative than Ethanolamine)

(Brompheniramine maleate
Chlorpheniramine maleate)

Strong Anticholinergic Effects

Very Lipophilic molecules

Nonselective
“Sedating Antihistamine”

27
Q

Systemic OTC Antihistamines: 2nd generation specifics

A

Piperazines -(more sedating)
Cetirizine-non sedating cause 10%, active metabolite hydrazine (sleep)

Piperidines
Fexofenadine
Loratadine

Sedation:
Piperazines > Piperidines

28
Q

1st Generation Sedating Antihistamines

A

Benadryl ® Allergy
Diphenhydramine

Chlor-Trimeton ®
Chlorpheniramine

Tavist ® Allergy
Clemastine

Children’s Dimetapp
Brompheniramine** 1 mg/ 5 mL + Phenylephrine

Vicks ® NyQuil
Doxylamine** 12.5 mg/ 30 mL + Dextromethorphan 30 mg/ 30 mL + APAP

29
Q

1st Generation Warnings

A

Should NOT use more than 7 days

Adverse effects: (not used for AR)

Anticholinergic:
Dryness (eyes, mouth, nose), blurred vision, urinary retention, constipation, nausea/vomiting, loss of appetite

CNS Depression:
Sedation/ drowsiness, psychosis***
Avoid other CNS depressants
Use caution/ avoid in geriatric or older patients
Increased fall risk (avoid in geriatrics) **

 Contraindicated
Acute asthma (uncontrolled), narrow-angle glaucoma, benign prostate hypertrophy (BPH), bladder obstruction

Drug Interactions: CNS Depressants, Anticholinergics, Monoamine Oxidase Inhibitors (MAOIs)
MAOIs- phenelzine (Nardil ®), tranylcypromine (Parnate ®), isocarboxazide (Marplan ®

30
Q

2nd Generation Antihistamines

A

Claritin D:
Loratadine* + Pseudoephedrine

Zyrtec: Cetirizine

Allegra: Fexofenadine

31
Q

Benifts of 2nd Generation Antihistamines

A 
Non-sedating antihistamines are the nonprescription antihistamine therapy of choice for allergic rhinitis:
Efficacy
Safety
Quick onset of action
Long duration
32
Q

Comparison of label information for Allergic Rhinitis OTC Antihistamines

A

First Generation: (q4-6q)
Chlorpheniramine, Brompheniramine, Diphenhydramine

–Anticholinergic warnings (i.e. caution in BPH, Glaucoma

–NOT FOR elderly, causes Drowsiness

2nd Generation:
Once or twice daily

Cetirizine: (highest Drowsiness in 2nd generation)

Loratadine: No Drowsiness

33
Q

Counseling points:

OTC Antihistamines

A

Fexofenadine:

Do not take at the same time as Aluminum or Magnesium antacids

Do not take with fruit juices (i.e. grapefruit, apple, orange juice)- separate by at least 2 hours

34
Q

OTC Antihistamines:
Product availability

What formulation are available?

A

Immediate and sustained release tablets and capsules, chewable tablets, oral disintegrating tablets and strips, solutions, and syrups (alcohol-free, dye-free, and sucrose-free)

35
Q

Ophthalmic Products; (Antihistamines??) List

A

Naphcon- A ®
Pheniramine** maleate 0.3% + Naphazoline

Opcon- A ®
Pheniramine** maleate 0.3% + Naphazoline

36
Q

Cromolyn Sodium Nasal Spray : The details

A

PREFERRED INITIAL DRUG OF CHOICE DURING PREGNANCY AND LACTATION-DOC IN PREGNACY

Use: Prevention and treatment symptoms of allergic rhinitis
Most effective if used PRIOR to exposure (3-7 days)
i.e. SAR (Seasonal Allergic Rhinitis)

37
Q

Nasal Spray: Cromolyn sodium

A

NasalCrom ® Nasal Spray
Cromolyn sodium

Cromolyn sodium must cover the entire nasal lining; therefore patients should be instructed to clear nasal passages prior to administration and inhale gently through the nose

38
Q

OTC Decongestants

A

Sudafed®
Pseudoephedrine

Sudafed PE ®
Phenylephrine

Little Noses ® Decongestant Drops : Phenylephrine

Afrin ® Nasal Spray
Oxymetazoline

4-Way Fast Acting ® Nasal Spray : Phenylephrine

Neo-Synephrine ® Nasal Spray
Phenylephrine

39
Q

OTC Decongestants: DETAILS

MOA AND FDA APPROVAL

A

NOT approved for OTC self-treatment of congestion associated with sinusitis

MOA:
Produces vasoconstriction**, resulting in decreased blood flow and shrinkage of tissue in the nasal passage by acting on adrenergic receptors in the blood vessels of the nasal mucosa

40
Q

OTC Decongestants:

ADRs

Warnings

Drug interactions

Adverse Events

A 
Adverse Effects (Systemic):
Cardiovascular stimulation: increased blood pressure, tachycardia, palpitations, arrhythmias

CNS stimulation: restlessness, insomnia, anxiety, tremors, hallucinations

Warnings:
Hypertension, heart disease, diabetes, hyperthyroid, benign prostate hypertrophy (BPH)- very sensitive to ALPHA adrenergic stimulation. (just concentrate at cardiovascular disease.

Drug Interactions:
Monoamine oxidase inhibitors (MAOI)
MAOIs- phenelzine (Nardil ®), tranylcypromine (Parnate ®), isocarboxazide (Marplan ®) - Can get hypertesnive crisis in Patients abover

41
Q

Sudefed with deterrent technology.

A

Zephrex-D TM and Nexafed TM have methamphetamine deterring technology, has sudefed in it!!!!** Same price as Sudefed**

42
Q

bioavailability: Sudefed vs Sudafed PE

Systemic Decongestants

A

Phenylephrine
Sudafed PE® – LOW bioavailability

Pseudoephedrine
Sudafed –Higher BioAvailble

Maximum of 7 days

43
Q

2005 Combat Methamphetamine Epidemic Act changed the classification of pseudoephedrine “scheduled listed chemical products

A

Pseudoephedrine
Behind pharmacy counter
Limited Quantity 3.6 grams/ day and 9 grams/ month

44
Q

Topical Nasal Decongestants

A

Rhinitis medicamentosa:
–What to do!!!!

(Rebound congestion)
Treatment of rebound congestion:

SLOW WITHDRAWAL

Replace with normal saline

Systemic decongestants

Not to exceed 3 days to prevent rebound congestion – “how quick It works, Diluent (Benechromilchloride),”

45
Q 
Topical Nasal Decongestants: 
Nasal Spray (NS)**

Counseling Points

A

Prime the pump before using it the first time

Hold the bottle with the nozzle placed between the first two fingers and the thumb placed on the bottom of the bottle

Tilt the head forward

Gently insert the nozzle tip into one nostril.

Sniff deeply while depressing the pump once

46
Q

Topical Nasal Decongestants:
Nasal Inhaler**

Counseling Points

A

Warm the inhaler in hand just before use

Gently insert the inhaler tip into one nostril and sniff deeply while inhaling

Wipe the inhaler after each use

Discard after 2-3 months even if the inhaler still smells medicinal*

47
Q

Combination Products: Know the contents

A

Advil Allergy Sinus ® Ibuprofen 200 mg —HA
Pseudoephedrine 30 mg - Allergy
Chlorphenirmine 2mg

Benadryl Allergy and Sinus
APAP 325
Dipenhydramine 12.5 mg
Phenylepherine 5mg

Zyrtec- D® 12 hour
Cetirizine 5 mg
Pseudoephedrine 120 mg

Advil Allergy Sinus®
Chlorpheniramine maleate 2 mg Antihistamine
Ibuprofen 200 mg (NSAID)* Pain reliever/fever reducer
Pseudoephedrine HCl 30 mg Nasal decongestant

48
Q

Zyrtec- D® 12 hour

A

Cetirizine 5 mg

Pseudoephedrine 120 mg

49
Q

Benadryl Allergy and Sinus

A

APAP 325
Dipenhydramine 12.5 mg
Phenylepherine 5mg

50
Q

Advil Allergy Sinus

A

Chlorpheniramine maleate 2 mg Antihistamine
Ibuprofen 200 mg (NSAID)* Pain reliever/fever reducer
Pseudoephedrine HCl 30 mg Nasal decongestant

51
Q

Phenylephrine

Frequency??

4-Way Fast Acting® Nasal Spray (NS)

Vicks® Sinex NS

Neo-Synephrine®

Little Noses® Decongestant Nose Drops

A

4 hours

52
Q

Oxymetazoline – Last longer

Frequency?

Afrin® Original NS
Mucinex® NS
Zicam® Sinus Relief NS
Zicam® Congestion Relief
Vicks® Sinex 12 hour
A

10 - 12 hours

53
Q

Levmetamfetamine

(l-desoxyephedrine)
Propylhexedrine

Concentration Data??

Vicks® Vapor Inhaler
Benzedrex® Inhaler

A

(inactive after 2 -3 months)

PDC (6 decks)

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