Rhinitis and Sinusitis Pharm Flashcards by Bree Henry

What is the treatment plan for moderate to severe rhinosinusitis

Symptomatic:
Analgesics
Antihistamine/decongestant combinations
Saline nasal spray
Zinc
Dextromethorphan
Expectorants
Intranasal ipratropium
Intranasal cromolyn sodium
Humidifiers

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Use of Zinc

May decrease sold symptoms severity and duration
Adverse side effects:
Loss of smell (nasal solutions)
Taste disturbances
Nausea

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Use of saline nasal spray

Ocean nasal spray
Symptomatic relief of nasal symptoms
Sodium chloride 0.65% - active ingredient
Squeeze twice in each nostril as needed

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Use of decongestants

Mild relief as monotherapy
Oral: pseudoephedrine and phenylephrine
Linked to manufacturing amphetamines

Topical: oxymetolazine - Afrin
Limit to 2-3 days to avoid rebound rhinitis
Side effects: Nosebleeds, Agitation, insomnia, HTN

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Medicated nasal spray use - intranasal cromolyn sodium

Well tolerated
Reduces duration of rhinitis symptoms
Mast cell stabilizer - inhibits mast cell degranulation

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Medicated nasal sprays - Ipratropium bromide (Atrovent)

improved rhinorrhea and sneezing
Does NOT help with congestion
Common cold - 0.06%; 2 in each nostril 3-4 times a day
Adverse effects: Nasal dryness, blood tinged mucus, epistaxis

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Humidifier use

May reduce nasal congestion
cool mist humidifier
drain and clean daily to prevent bacteria
Several feet away from bed

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Allergic rhinitis nonpharm treatment

Avoid irritant

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Treatment options allergic rhinitis

Antihistamines
Corticosteroids
Leukotriene inhibitors
Decongestants

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Antihistamine MOA

block action of histamine at histamine receptors - topical and systemic

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Corticosteroids MOA

Inhibit production of inflammatory cytokines and chemokines - topical and systemic

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Leukotriene inhibitor MOA

Blocks action of leukotriene to reduce inflammation - systemic

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Decongestants MOA

stimulate smooth muscle alpha adrenergic receptors to produce vasoconstriction and reduce nasal congestion - topical and systemic

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Intranasal antihistamine clinical pearls

First line agent for mild allergic rhinitis
Best if patients prefer non-corticosteroid treatment or that have irritation/epistaxis with them - less effective

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Intranasal antihistamine dosing

Azelastine nasal spray 0.1%, 0.15%
Seasonal: either dose, 1-2 sprays in each nostril BID
Perennial: 0.15%, 2 sprays in each nostril twice daily

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Intranasal corticosteroid options

Beclomethasone
Budesonide
Ciclesonide
Fluticasone
Mometasone
Triamcinolone

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Intranasal corticosteroid info

Treatment of choice for mod-severe allergic rhinitis
Efficacy best when on scheduled basis rather than PRN
Epistaxis risk
Only use mometasone and fluticasone if <6
Superior even to other options combined
Once or twice daily dosing

first generation oral antihistamine info

Diphenhydramine
Relieves allergic rhinitis symptoms
prevents motion sickness
Anticholinergic, antiemetic and sedative effects
Crosses BBB
Interacts with other sedatives
Some children may have reverse effect of hyperactivity

Second generation oral antihistamine options

Cetirizine (zyrtec)
Levocetirizine (Xyzal)
Fexofenadine (Allegra)
Loratadine (Claritin)
Desloratadine (Clarinex)

Second generation oral antihistamine clinical pearls

First line agent, but ineffective for nasal congestion alone
preferred over first gen
Desloratadine not as effective as others
Avoid combining first and second gen

Second generation oral antihistamine extra info

Adverse effects:
Dry mouth, HA, somnolence
Safety:
Loratadine and cetirizine are preg catB
Efficacy:
Effective for treatment of seasonal or perennial
Dosing is once or twice daily
Good to be used in combo with decongestants

Oral decongestants info

Phenylephrine and pseudoephedrine*
Can cause insomnia or palpitations
Caution with patients with CVD, DM, or hyperthyroidism
Most effective when used with oral antihistamine

What are the leukotriene receptor inhibitors

Montelukast
Zafirlukast
Zileuton

Leukotriene inhibitor pearls

For patients who do not have adequate symptom control with oral antihistamine, intranasal corticosteroids, or combination
Montelukast used most frequently
May be used in combo with oral antihistamine

Leukotriene inhibitor adverse effects and efficacy

Adverse effects: HA, Abd. pain, Nasal congestion/cold like symptoms Efficacy: Less effective than intranasal corticosteroids, same as oral antihistamines *neuropsychiatric disorders have been reported

What are some of the regulators that are not working properly and cause vasomotor rhinitis?

1. Acetylcholine PNS neurotransmitter 2. Norepinephrine and neuropeptide Y 3. Neuropeptides and nociceptive type C fibers of the trigeminal nerve

What is the treatment for vasomotor rhinitis?

1. Avoid triggers 2. topical nasal corticosteroids (first line) 3. Topical anticholinergic agents (first line if rhinorrhea predominant) 4. Oral antihistamines 5. Topical antihistamines 6. Topical decongestants

Use of topical nasal corticosteroids for vasomotor rhinitis

Fluticasone Propionate (Flonase) 1-2 puffs in each nostril daily decreases neutrophil and eosinophil chemotaxis on the nasal mucosa, decreases mast cell and basophil mediator release, decreases edema and inflammation

Use of Anticholinergic agents in vasomotor rhinitis

Ipratropium bromide 0.03% 21 mcg per puff, 2 puffs in each nostril BID - TIB Blocks parasympathetic input to the nasal mucosa

Use of oral antihistamines in vasomotor rhinitis

limited role No approved agents May help with sneezing/itching

Topical antihistamine use in vasomotor rhinitis

Azelastine 0.1% 2 puffs in each nostril twice daily H1 receptor antagonist Combine with topical intranasal corticosteroid and topical antihistamine for chronic vasomotor rhinitis tx

Topical decongestant use in vasomotor rhinitis

oxymetazoline, phenylephrine Primarily for nasal congestion Short term relief Rhinitis medicamentosa - limit 5 days

What covers which symptoms for vasomotor rhinitis?

IN corticosteroids and IN antihistamines cover all 4 symptoms and can be combined Intranasal cholinergics - rhinorrhea only Decongestants - congestion only

Treatment of rhinitis medicamentosa

Stop decongestant Sx worsen before improving intranasal corticosteroids Oral prednisone 0.5mg/kg for 5 days

When should acute sinusitis be treated with antibiotics?

Symptoms progress beyond a viral infection (5-7 days) Worsening symptoms Sinus discharge purulent and discolored

AB treatment for sinusitis

First line - Amoxacillin/Clavulanate PCN allergy - Doxycycline or Fluoroquinolone

AB treatment for sinusitis if initial treatment failure

High dose Amoxicillin/clavulanate Doxycycline Levofloxacin or moxifloxacin

AB treatment for sinusitis if resistant strep pneumoniae

High dose Amoxicillin/clavulanate Levofloxacin, moxifloxacin

Treatment duration for sinusitis ABs

5-7 days longer if increased resistance risk

Dosing of Augmentin for sinusitis

Amoxicillin/clavulanate - 500mg/125mg 3x daily or 875/125mg twice daily High dose: 2000mg/125mg twice daily

Doxycycline, Levaquin and Moxifloxacin dosing for sinusitis

Doxy - 100mg BID or 200mg daily Levaquin - 500mg daily Moxifloxacin - 400mg daily