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HEENOT 2 > Pharm - Nose/Oroph. > Flashcards

Pharm - Nose/Oroph. Flashcards

1
Q

List the 6 medications to treat AR

A
  1. Intranasal glucocorticoids (INGC)
  2. Antihistamines
  3. Decongestants
  4. Ipratropium bromide (Atrovent)
  5. Montelukast (Singulair)
  6. Cromolyn Sodium (Nasalcrom)
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2
Q

what is the most effective, single therapy for pt with persistent nasal sx associated with AR?

A

INGC

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3
Q

INGC MoA

A
  • Inhibit allergic inflammation in the nose at many levels - Downregulate inflammatory response by binding to intracellular glucocorticoid receptors in the cell’s cytoplasm - Enter the cell’s nucleus, bind with genes, make mRNA for anti-inflammatory proteins AND suppress transcription of most cytokine and chemokine genes (produce inflammation)
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4
Q

INGC indication

A
  • Moderate to severe intermittent and persistent AR - AR preferred agent, more effective than the other classes of medications
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5
Q

INGC contraindication

A

hypersensitivity to the drug

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6
Q

INGC ADE

A
  • Nasal burning, stinging, dryness (related to alcohol or propylene glycol) - Nose bleeds:
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7
Q

INGC nose bleeds - two types

A
  1. Frank epistaxis: mechanical trauma from repeat sprays 2. Scant blood in nasal mucous: pause treatment for a few days, ensure pt using correct technique
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8
Q

INGC expected clinical effects

A

Decrease in nasal congestion, rhinorrhea, itching, sneezing

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9
Q

Two major types of INGC

A

First and second generations

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10
Q

What are two first generation INGC - generic - brand - dose

A
  1. Triamcinolone (Nasacrod Allergy 24) 2 sprays daily
  2. Budesonide nasal spray (Rhinocort) 1 spray daily
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11
Q

List 5 second generation INGC - generic - brand - dose

A
  • Mometasone (Nasonex) 1 spray daily
  • Ciclesonide (Omnaris) aqueous suspension pump spray 2 sprays daily
  • Ciclesonide (Zetonna) pressurized aerosol spray 1 spray daily
  • Fluticasone (Flonase Allergy relief, GoodSense Nasoflow) adult 2 sprays daily children 1 spray daily
  • Fluticasone furoate (Flonase Sensimist): adults 2 sprays daily children 1 spray daily
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12
Q

Antihistamine MoA

A
  • Bind to and activate histamine H1 and H2 (in the gut) receptors
  • Compete with histamine for H1 receptors on cells (competitive antagonist) and inhibit the effects of histamine
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13
Q

how should antihistamines be used for best effect

A

regular use before/during allergen exposure to ensure med reaches all cell receptors before histamine does

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14
Q

What do histamines cause

A

vasodilation muscle constriction endothelial permeability

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15
Q

What are hx of histamine allergy sx

A
  • sneezing - rhinitis - rhinorrhea - erythema - pruritus - urticaria
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16
Q

Antihistamine indication

A
  • Most effective for treating nasal itching, conjunctival itching, tearing, sneezing, rhinorrhea in the nose. - Do not relieve nasal congestion
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17
Q

Antihistamine contraindication

A
  • Doses should be reduced in renal and hepatic function impairment - Loratidine: use every other day in kidney or liver impairment
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18
Q

Antihistamine ADE 1st Gen

A
  • CNS symptoms (sedation and impaired thinking)
  • impaired driving
  • HA, drowsiness, dry mouth, fatigue
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19
Q

Antihistamine 1st Gen ADE children

A
  • Impaired school performance
  • Paradoxical agitation <2 (can cause death)
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20
Q

Antihistamine 1st Gen ADE Elderly

A
  • Anticholinergic properties: Dry mouth constipation urinary hesitance dry eyes
  • Confusion: dementia-like symptoms
  • Sedation
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21
Q

Antihistamine ADE nasal sprays

A

bitter taste HA sleepiness nasal burning pharyngitis

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22
Q

Antihistamine dosing diff between 1st and 2nd gen

A

1st - short half life so multiple daily doses 2nd

  • longer half life so dose 1-2 daily
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23
Q

Antihistamine 2nd gen ADE

A

less sedating than 1st gen

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24
Q

Two 2nd gen oral antihistamines generic and brand

A
  • Loratadine (Claritin)
  • Cetirizine (Zyrtec)
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25
Q

Two 2nd gen nasal spray antihistamines generic and brand

A
  • Azelastine
  • Olopatadine (Patanase)
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26
Q

Combo product - 2nd gen antihistamine generic and brand

A

Azelastine & Fluticasone (Dymista)

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27
Q

Loratadine dose

A

10 mg daily =>2 yo

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28
Q

Decongestant MoA

A
  • Sympathomimetics (similar to NE and epinephrine)
  • Directly stimulate alpha-adrenergic receptors
  • Cause vasoconstriction
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29
Q

Decongestant Indication

A

Nasal congestion

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30
Q

Decongestant Contraindication

A
  • Don’t take pseudoephedrine while taking MAO inhibitor therapy or for 2 weeks after stopping MAOI
  • Do not administer ER pseudoephedrine to <12
  • Avoid in pts with uncontrolled HTN
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31
Q

Decongestants not indicated as what?

A
  • mono-therapy for chronic AR
  • most commonly used in combo with antihistamines
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32
Q

Oral Decongestant ADE

A
  • CNS stimulation (nervousness, restlessness, insomnia, termor, dizziness, headache, anorexia)
  • Can counteract drowsiness caused by antihistamines, tachycardia, palpitations
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33
Q

Nasal Decongestant ADE

A
  • Burning
  • Stinging
  • Dryness
  • Tolerance and rebound congestion (rhinitis medicamentosa) if used for > 1 week
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34
Q

Expected clinical effect decongestants

A

Relief of nasal congestion:

  • Decreased tissue hyperemia,
  • Decreased tissue edema,
  • Decreased nasal congestion
  • Increased nasal airway patency
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35
Q

One oral decongestants generic brand

A

Pseudoephedrine (Sudafed)

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36
Q

What is often being used instead of pseudoephedrine?

A

phenylephrine - but not as effective in the treatment of allergic rhinitis symptoms

Due to pseudoephedrine use in meth labs

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37
Q

One nasal spray decongestant example

A

Oxymetazoline (Afrin)

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38
Q

Ipratropium bromide (Atrovent) MoA

A
  • Antimuscarinic agent
  • Inhibits parasympathetic neurons that control secretion
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39
Q

Ipratropium bromide (Atrovent) Indication

A

Decreases rhinorrhea associated with persistent AR

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40
Q

Ipratropium bromide (Atrovent) Contraindication

A

Hypersensitivity to the drug

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41
Q

Ipratropium bromide (Atrovent) ADE

A

Dryness nose bleeds nasal irritation

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42
Q

Ipratropium bromide (Atrovent) Expected Clinical Effet

A
  • Decrease rhinorrhea
  • Less effective than INGC for sneezing, pruritis, nasal obstruction due to AR
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43
Q

Montelukast (Singulair) MoA

A

Blocks leukotriene 1 receptor (competitive antagonist) to decrease inflammation

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44
Q

Montelukast (Singulair) Indication

A
  • Seasonal and persistent AR
  • Not a first line option
  • Pts who don’t tolerate or who refuse nasal sprays
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45
Q

Montelukast (Singulair) Contraindication

A

Hypersensitivity to drug

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46
Q

Montelukast (Singulair) ADE

A
  • HA, abdom pain, cough, flu-like sx
  • DO NOT RX to people with active, preexisting anxiety, depression or symptoms of a psych disorder
  • Abnormal dreams, insomnia, anxiety, worsening depression, suicidal thinking, rare cases of suicide
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47
Q

Montelukast (Singulair) Expected clinical effect

A
  • Similar efficiacy to antihistamines
  • Less effective than INGC
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48
Q

Cromolyn Sodium (Nasalcrom) MoA

A

Mast cell stabilizer

– inhibits release of histamine and other inflammatory mediators

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49
Q

Cromolyn Sodium (Nasalcrom) Indication

A
  • Seasonal and persistent AR
  • Good for episodic symptoms to allergens (animal dander)
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50
Q

Cromolyn Sodium (Nasalcrom) Contraindicatino

A

hypersensitivity to drug

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51
Q

Cromolyn Sodium (Nasalcrom) ADE

A
  • Sneezing
  • nasal irritation
  • unpleasant taste Very safe
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52
Q

Cromolyn Sodium (Nasalcrom) Expected clinical effect

A
  • Nasal: prevent symptoms even when used within 30 min of allergic exposure
  • Less effective than INGC or 2nd gen antihistamines
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53
Q

Non pharmaceutic way to control allergic rhinitis

A

nasal saline irrigation

  • use alone or with other topical meds
  • can be used before other topicals to clear nasal mucosa
  • always use “safe” water to avoid amoebas :(
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54
Q

How often can nasal irrigation be used?

A

PRN Daily BID

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55
Q

Intermittent allergic rhinitis

A
  • symptoms are present <4 days/week
  • Persist for less than four weeks
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56
Q

Persistent allergic rhinitis

A
  • Present >4 days/week
  • Persist for more than four weeks
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57
Q

Mild allergic rhinitis

A

NO

  • Sleep disturbance
  • Impairment of daily activities
  • Impairment of school/work
  • Troublesome sx
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58
Q

moderate-severe allergic rhinitis

A

One or more of the following:

  • Sleep disturbance
  • Impairment of daily activities
  • Impairment of school/work
  • Troublesome sx
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59
Q

What is (maybe) the most important way to control allergic rhinitis?

A

environmental trigger control

60
Q

what is the goal of medical treatment of AR

A

control symptoms while allowing usual daily activities, min ADE

61
Q

Treatment of mild AR - generally start with what?

A

start local, move systemic

62
Q

Treatment of mild AR - best option for adults - best option for children

A
  • adult: nasal spray steroid
  • child: antihistamine
63
Q

Treatment of mild AR best way to use therapies?

A

All therapies work best when taken regularly but for very mild symptoms or intermittent exposure to known allergen, PRN use is ok

64
Q

Treatment of mild AR - most effective treatment

A

INGC ≥ 2 years

65
Q

Treatment of mild AR - how can INGC be dosed?

A

regularly or PRN

66
Q

Treatment of mild AR - three examples of INGC to use

A
  • mometasone - fluticasone - triamcinolone
67
Q

Treatment of mild AR - when to use 2nd gen oral antihistamine

A
  • allergen exposure can be predicted - use 2-5 hours prior to exposure
68
Q

Treatment of mild AR - two 2nd gen oral antihistamines that can be easily used by children

A
  • cetirizine - loratadine come in syrups
69
Q

Treatment of mild AR - what med is best used 4-7 days prior to allergen exposure

A

Intranasal Cromolyn - often preferred for young children due to safety profile

70
Q

Treatment of moderate-severe AR - most effective & best initial therapy

A

INGC - 2nd gen, low bioavailability options

71
Q

Treatment of moderate-severe AR - two INGC to use

A
  • Mometasone furcate - fluticasone furoate
72
Q

Treatment of moderate-severe AR - what do if INGC fails to adequately control sx?

A

add a second therapy in conjunction with INGC

73
Q

Treatment of moderate-severe AR - if already using INGC but still have breakthrough sx

A

antihistamine intranasal spray ex: azelastine + fluticasone (Dymista) for >12

74
Q

Treatment of moderate-severe AR - if already using INGC but still have nasal congestion

A

decongestant nasal sprays (oxymetazoline) + 2nd gen oral antihistamine

75
Q

Treatment of moderate-severe AR - if already using INGC but still have itching, sneezing, rhinorrhea

A

2nd gen oral antihistamine - cetirizine or loratadine

76
Q

Treatment of moderate-severe AR - if already using INGC but still have rhinorrhea

A

ipratropium

77
Q

Treatment of moderate-severe AR - if already using INGC but have asthma

A

montelukast

78
Q

Treatment of moderate-severe AR - if already using INGC but still have allergic rhinitis and allergic conjunctivitis

A

antihistamine eyedrops

79
Q

Treatment of AR in pregnant women

A
  • Allergen avoidance - Cromolyn 2nd gen INGC (lowest effective dose) - Oral 2nd gen antihistamines: Loratadine and certirizine
80
Q

what should pregnant women avoid using for AR

A

Oral decongestants

81
Q

Treatment of AR in breastfeeding

A
  • Allergen avoidance - Nasal saline - INGC (budesonide) or cromolyn plus cetirizine or loratadine
82
Q

What are the four classes used to treat mild/intermittent AR for people >2

A
  1. oral 2nd gen antihistamines 2. Antihistamine nasal spray 3. INGC 4. Mast cell stabilizer
83
Q

Oral 2nd gen antihistamine example and age it is appropriate for

A

Cetirizine ≥6 months

84
Q

Antihistamine nasal spray example and age it is appropriate for

A

Aselastine (Aster) ≥5 years

85
Q

INGC examples (2) and age

A

Mometasone furoate (Nasonex) ≥ 2 years Fluticasone furoate (Flonase) no age specified

86
Q

Mast cell stabilizer and age appropriate for

A

Cromolyn (NasalCrom) ≥ 2 years

87
Q

Most common orgs cause acute sinusitis

A

Gram pos: Strep pneumoniae Gram neg: H. influenza M. Catarrhalis The cat hangs out in the box again with the flu and strep

88
Q

Adult abx of choice for acute sinusitis - standard dose - high dose

A

Standard: Augmentin due to high prevalence of beta-lactamase production by common bacteria High: Higher dose augmentin

89
Q

Adult abx of choice for acute sinusitis - allergy to pen

A

Doxycycline levofloxacin moxifloxacin

90
Q

Child abx of choice for acute sinusitis - standard

A

Standard: Amoxicillin

91
Q

Child abx of choice for acute sinusitis - High dose (2)

A

2 X dose amox if high rate of s. pneumonia resistance

2X dose Augmentin if

  • severe illness
  • Purulent nasal discharge
  • <2 yo
  • Daycare attendee
  • Has had abx in last 30 days
92
Q

Abx of choice for acute sinusitis and NPO

A

IM ceftriaxone

93
Q

Abx of choice for acute sinusitis with type 1 pen allergy

A
  • Clindamycin + cefixime
  • Linezolid + cefixime
  • Levofloxacin
94
Q

Abx of choice for acute sinusitis with non type 1 pen allergy

A

cephalosporins

95
Q

Adjunct therapy for acute sinusitis

A
  • Pain or fever: acetaminophen or NSAID
  • INGC to reduce inflammation in nose and sinus (Risk of oral candidiasis)
96
Q

what is not recommended as an adjunct therapy for acute sinusitis

A

Antihistamines and decongestants due to SA

97
Q

Child with acute sinusitis, run through changes if unresponsive to given therapy

A
  • 3 day observation period is ok if otherwise healthy, mild, not worsening
  • 72 hours no improvement: amox +/- clavulanate
  • 72 hours no improvement: high dose augmenting
  • 72 hours no improvement: Clindamycin + cefixime, linezolid + cefixime, levofloxacin
98
Q

What kind of observation period is considered for adults with acute sinusitis?

99
Q

First line treatment for adults acute sinusitis

100
Q

when consider high dose abx for adult

A
  • recent abx
  • recent hospitalization
  • >65
  • immunocompromised
101
Q

Tx goals in chronic sinusitis

A
  • control of mucosal inflammation and edema
  • maintenance of adequate sinus ventilation and drainage
  • tx of colonizing or infecting microorganisms, if present
  • reduction in the number of acute exacerbations
102
Q

Most common organisms in chronic sinusitis

A

-aerobic:

*gram +: strep pneumoniae

*gram -: H. flu and M. cat

-anaerobic:

*if risk for MRSA, coverage for this should be included

103
Q

When selecting abx therapy for adults with CRS without nasal polyposis, empirical therapy is used based on what?

A
  • likelihood of pathogens
  • hx of drug allergies
  • risk factors for beta-lactamase producing organisms and MRSA
  • cost
104
Q

Example regimen in CRS without nasal polyposis

A
  1. amoxicillin-clavulanate for 3-4 weeks
  2. if penicillin allergy and MRSA suspected: clindamycin
105
Q

What is the main side effect of clavulanate?

106
Q

Abx treatment in adult with CRS with nasal polyposis

A

-if bacterial infection is suspected or confirmed, same abx strategy as CRS without NP

107
Q

What is the most appropriate glucocorticoid tx regiment for adults w/ CRS with AND without NP?

A

-oral prednisone - 10 days

108
Q

Maintenance therapy of CRS without NP

A
  1. intranasal glucocorticoid spray for inflam. 2. intranasal saline spray 3. tx underlying allergic rhinitis if present -allergen avoidance/immunotherapy -oral/topical antihistamine 3. antileukotriene agents in pts w/ refractory nasal congestion and PND 4. avoid chronic use of oral decongestants
109
Q

Maintenance of therapy of CRS with NP

A
  1. use of topical glucocorticoids (intranasal) 2. antileukotrienes may be beneficial as adjunct 3. antihistamines can be tried in pts w/ persistent nasal symptoms despite steroid use
110
Q

MoA of nystatin

A

binds to sterols in fungal cell membrane, changing the cell wall permeability which allows the intracellular contents to leak out. It is not absorbed through the mucous membranes or intact skin

111
Q

MoA of Azole derivatives (clotrimazole, miconazole, fluconazole)

A

interferes w/ fungal cytochrome P450 activity, decreasing ergosterol synthesis (principal sterol in fungal cell membrane) and inhibiting cell membrane formation

112
Q

Azole drug adverse effects

A

-GI upset -prolonged administration can cause hepatotoxicity -periodic monitoring of aminotransferases is prudent w/ chronic administration

113
Q

Tx of oral candidiasis in immunocompetent infants

A

nystatin susp

114
Q

Tx of oral candidiasis in neonates

A

nystatin susp

115
Q

Tx of oral candidiasis in infants 30 days or older

A

Nystatin susp 100,000 units to each cheek (200,000 units per dose) 4 times daily for 7-14 days

116
Q

Tx of oral candidiasis in children

A

Nystatin suspension 400,000 – 600,000 units “swish and swallow” 4 times per day for 7-14 days

117
Q

Alternative tx of oral candidiasis in children

A

-nystatin lozenges -clotrimazole lozenges

118
Q

Tx of oral candidiasis in adults that are HIV seronegative

A

-clotrimazole troches (low adherence d/t dose) -miconazole - effective but more expensive -nystatin - not always palatable

119
Q

If there is no response to the local tx of oral candidiasis in adults, what tx is recommended?

A

-oral fluconazole

120
Q

drug to treat oral candidiasis refractory to nystatin or other first line therapy in infants

A

oral fluconazole and appropriate decontamination measures of pacifiers and bottle nipples

121
Q

drug to treat oral candidiasis refractory to nystatin or other first line therapy in children

A

oral fluconazole

122
Q

Describe the role of docosanol in the treatment of mild oral herpes simplex (OHS)

A

-10% cream available OTC -may decrease healing time and reduce severity of symptoms when applied at the first sign of recurrence -applied 5 times per day until the lesion is healed, but for no more than 10 days

123
Q

possible adverse effects of docosanol

A

rash and itching at site of application

124
Q

role of oral and IV antiviral medications in more serious OHS infections

A

-may stop viral replications in the skin, but does not eliminate HSV form the body to prevent later outbreaks -Ex: valacyclovir, famciclovir, acyclovir

125
Q

role of antiviral creams in more serious OHS infections

A

-may shorten attacks of recurrent HSV-1 if applied early, usually before lesions develop -ex: acyclovir and penciclovir cream

126
Q

What is the cause of the majority of pharyngeal infections?

127
Q

Common viruses that cause pharyngitis

A

-Adenovirus -Influenza -Parainfluenza -Rhinovirus -RSV

128
Q

Most common bacterial cause of pharyngitis

A

group A strep (GAS)

129
Q

What are some rare organisms to cause pharyngitis?

A

-corynebacterium diphtheriae -neisseria gonorrhoeae

130
Q

Abx for pharyngitis are only indicated for what?

A

GAS pharyngitis

131
Q

Abx of choice for GAS pharyngitis

A

-penicillin and amoxicillin (narrow spectrum, low incidence of ADE, low cost) Ex: penicillin VK tabs

132
Q

What abx for GAS pharyngitis is preferred in pts unlikely to comply w/ 10 day course of tx?

A

benzathine penicillin G

133
Q

What is significant about amoxicillin as tx for GAS pharyngitis?

A

it is the only indication for which once daily amoxicillin is acceptable

134
Q

second line abx of choice for GAS pharyngitis in non type 1 penicillin allergy

A

1st generation cephalosporins -Cephalexin -Cefadroxil

135
Q

second line abx of choice for GAS pharyngitis in type 1 penicillin allergy

A

-Clindamycin -Clarithromycin -Azithromycin

136
Q

reason for not using aspirin in people =< 21 years old

A

Risk of Reye’s syndrome - a neuro complication d/t viral infection

137
Q

What INGC preferred in children

A

second generation INGC due to low bioavailability and once daily dosing

138
Q

Optimal dosing for INGC

A

Start with max dose for age

once symptoms are controlled, decrease dose to lowest effective dose

** diff than most drugs

139
Q

How to administer INGC

A

Shake

Prime

Blow

Aim

Breathe and Spray

140
Q

what are third generation antihistamines

A

active metabolites of second-gen drugs

improved clinical efficacy and min side effects

141
Q

what is a good “bridge” option to use while INGC take effect

A

Antihistamine nasal sprays

  • rapid onset (<15 min)
  • can be used on demand
142
Q

How to administer oral antihistamines

A

regularly or PRN 2-5 hours before exposure

143
Q

Dosing variations for INGC

A
  • PRN or regularly
  • if can predict exposure, use 2 days before, through, and 2 days after exposure
144
Q

Dosing Dosing variations for Mast cell stabilizer

A
  • PRN or regularly
  • Less effective than INGC or 2nd gen antihistamines
  • QID dosing
  • can use 30 min prior to brief exposure (pet dander)
  • can be started 4-7 days prior to prolonged exposure

HEENOT 2 (7 decks)

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