OTC Allergic Rhinitis Flashcards
Classification of “Seasonal” Allergic Rhinitis (SAR)?
Classification depends on timing and duration of symptoms
Intermittent
Specific allergens responsible
Predictable occurrence
Classification of “Perennial” Allergic Rhinitis (PER)?
Classification depends on timing and duration of symptoms
Persistent
Non-seasonal allergens responsible
Year round occurrence (pet, cats, mold,)
Causes of Non-Allergic Rhinitis?
*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
Immune Response: Immediate
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.
Immune Response: Late phase
Late phase reaction - several hours later
Renewed allergic symptoms due to influx of inflammatory cells & hyperresponsive mucosa (nasal congestion, rhinorrhea)
Signs and Symptoms of Allergic Rhinitis - Important Slide
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)
Physician Referral for Allergic Rhinitis
Children < 12 years of age*
Pregnant or lactating women*
Goals of Therapy: Allergic Rhinitis
Goals of Therapy
Reduce symptoms
Provide optimal symptomatic relief and control of symptoms
Improve the patient’s functional status and sense of well being
Non-Pharmacologic Therapy: Avoidance
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
Non-Pharmacologic Therapy Examples?
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
Non-Pharmacologic Therapy : Nasal Wetting Agents
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
Non-Pharmacologic Therapy : HEPA filters
Removes pollen, mold spores, and cat allergens
Non-Pharmacologic Therapy:
Nasal Passage Strips
Vicks ® Breathe Right Strips
Initiation of Pharmacotherapy: Allergic Rhinitis
Regularly or As needed
must use REGULARLY
i.e. antihistamines and mast cell stabilizers
Initiation of Pharmacotherapy: Allergic Rhinitis
SAR (Seasonal Allergic Rhinitis)
Start medications at least 1 week before symptoms usually appear
Initiation of Pharmacotherapy: Allergic Rhinitis
PER (Perennial Allergic Rhinitis)
Start medications before known exposure
Length of Therapy: Pharmacotherapy therapy
Duration and severity of symptoms
Pattern of allergen exposure (i.e. episodic vs. continuous)
Geographical location -WORSENS symptoms (could be in the amazon forest)
Pharmacotherapy for Allergic Rhinitis
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
Intranasal Corticosteroids
Nasacort ® Allergy 24 HR
Triamcinolone acetonide
Flonase ® Allergy Relief
Fluticasone propionate
Intranasal Corticosteroids: Adverse Effects
sore throat
DO NOT AIM TOWARDS NASAL SEPTUM??? TILT HEAD DOWN A BIT TOWARDS THE NASAL SPRAY.
Administration of FLONASE
GOLD STANDARD
Do NOT blow nose for 15 minutes after use
Intranasal Corticosteroids: Ages
Which gets put to 2 sprays?
Focus on AGE, Dose is just there for completion
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
List the Antihistamines
Benadryl ® Allergy
Diphenhydramine
Chlor-Trimeton ® Allergy
Chlorpheniramine
Zyrtec ®
Cetirizine
Allegra ® Allergy
Fexofenadine
Claritin ®
Loratadine
Antihistamines Indications
temporary relief of hay fever or upper respiratory allergies:
Sneezing
Runny nose
Itchy watery eyes
Itching of the nose and throat
What’s the difference between 1st generation antihistamines and 2nd generation antihistamines?
1st generation NON-selective “sedating antihistamines”
2nd generation peripherally SELECTIVE “non-sedation antihistamines”
Systemic OTC Antihistamines: 1st generation specifics
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”
Systemic OTC Antihistamines: 2nd generation specifics
Piperazines -(more sedating)
Cetirizine-non sedating cause 10%, active metabolite hydrazine (sleep)
Piperidines
Fexofenadine
Loratadine
Sedation:
Piperazines > Piperidines
1st Generation Sedating Antihistamines
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
1st Generation Warnings
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 ®
2nd Generation Antihistamines
Claritin D:
Loratadine* + Pseudoephedrine
Zyrtec: Cetirizine
Allegra: Fexofenadine
Benifts of 2nd Generation Antihistamines
Non-sedating antihistamines are the nonprescription antihistamine therapy of choice for allergic rhinitis: Efficacy Safety Quick onset of action Long duration
Comparison of label information for Allergic Rhinitis OTC Antihistamines
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
Counseling points:
OTC Antihistamines
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
OTC Antihistamines:
Product availability
What formulation are available?
Immediate and sustained release tablets and capsules, chewable tablets, oral disintegrating tablets and strips, solutions, and syrups (alcohol-free, dye-free, and sucrose-free)
Ophthalmic Products; (Antihistamines??) List
Naphcon- A ®
Pheniramine** maleate 0.3% + Naphazoline
Opcon- A ®
Pheniramine** maleate 0.3% + Naphazoline
Cromolyn Sodium Nasal Spray : The details
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)
Nasal Spray: Cromolyn sodium
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
OTC Decongestants
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
OTC Decongestants: DETAILS
MOA AND FDA APPROVAL
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
OTC Decongestants:
ADRs
Warnings
Drug interactions
Adverse Events
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
Sudefed with deterrent technology.
Zephrex-D TM and Nexafed TM have methamphetamine deterring technology, has sudefed in it!!!!** Same price as Sudefed**
bioavailability: Sudefed vs Sudafed PE
Systemic Decongestants
Phenylephrine
Sudafed PE® – LOW bioavailability
Pseudoephedrine
Sudafed –Higher BioAvailble
Maximum of 7 days
2005 Combat Methamphetamine Epidemic Act changed the classification of pseudoephedrine “scheduled listed chemical products
Pseudoephedrine
Behind pharmacy counter
Limited Quantity 3.6 grams/ day and 9 grams/ month
Topical Nasal Decongestants
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),”
Topical Nasal Decongestants: Nasal Spray (NS)**
Counseling Points
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
Topical Nasal Decongestants:
Nasal Inhaler**
Counseling Points
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*
Combination Products: Know the contents
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
Zyrtec- D® 12 hour
Cetirizine 5 mg
Pseudoephedrine 120 mg
Benadryl Allergy and Sinus
APAP 325
Dipenhydramine 12.5 mg
Phenylepherine 5mg
Advil Allergy Sinus
Chlorpheniramine maleate 2 mg Antihistamine
Ibuprofen 200 mg (NSAID)* Pain reliever/fever reducer
Pseudoephedrine HCl 30 mg Nasal decongestant
Phenylephrine
Frequency??
4-Way Fast Acting® Nasal Spray (NS)
Vicks® Sinex NS
Neo-Synephrine®
Little Noses® Decongestant Nose Drops
4 hours
Oxymetazoline – Last longer
Frequency?
Afrin® Original NS Mucinex® NS Zicam® Sinus Relief NS Zicam® Congestion Relief Vicks® Sinex 12 hour
10 - 12 hours
Levmetamfetamine
(l-desoxyephedrine)
Propylhexedrine
Concentration Data??
Vicks® Vapor Inhaler
Benzedrex® Inhaler
(inactive after 2 -3 months)