Rhinitis and Sinusitis Pharm Flashcards
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
Use of Zinc
May decrease sold symptoms severity and duration
Adverse side effects:
Loss of smell (nasal solutions)
Taste disturbances
Nausea
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
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
Medicated nasal spray use - intranasal cromolyn sodium
Well tolerated
Reduces duration of rhinitis symptoms
Mast cell stabilizer - inhibits mast cell degranulation
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
Humidifier use
May reduce nasal congestion
cool mist humidifier
drain and clean daily to prevent bacteria
Several feet away from bed
Allergic rhinitis nonpharm treatment
Avoid irritant
Treatment options allergic rhinitis
Antihistamines
Corticosteroids
Leukotriene inhibitors
Decongestants
Antihistamine MOA
block action of histamine at histamine receptors - topical and systemic
Corticosteroids MOA
Inhibit production of inflammatory cytokines and chemokines - topical and systemic
Leukotriene inhibitor MOA
Blocks action of leukotriene to reduce inflammation - systemic
Decongestants MOA
stimulate smooth muscle alpha adrenergic receptors to produce vasoconstriction and reduce nasal congestion - topical and systemic
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
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
Intranasal corticosteroid options
Beclomethasone
Budesonide
Ciclesonide
Fluticasone
Mometasone
Triamcinolone
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?
- Acetylcholine PNS neurotransmitter
- Norepinephrine and neuropeptide Y
- Neuropeptides and nociceptive type C fibers of the trigeminal nerve
What is the treatment for vasomotor rhinitis?
- Avoid triggers
- topical nasal corticosteroids (first line)
- Topical anticholinergic agents (first line if rhinorrhea predominant)
- Oral antihistamines
- Topical antihistamines
- 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
