Treatment of Coughs and Colds Flashcards
What is rhinitis?
Inflammation of the nasal mucous membranes
What are some of the common symptoms of rhinitis?
- nasal congestion
- rhinorrhoea
- sneezing
- itching
- and / or post nasal drainage
What can the causes of rhinitis be classified as?
Causes of rhinitis may be either
1. Infectious
or
2. Non-infectious
What are some of the infectious causes of rhinitis?
- viral (colds and flu)
- bacterial (sinusitis)
What are some of the non-infectious causes of rhinitis?
- allergic (IgE-mediated)
- non-allergic (vasomotor = chronic)
What are some of the treatment options for rhinitis associated with the common cold?
- Steam inhalations
- Mesna
- Antihistamines
- Systemic decongestants
- Local decongestants
What is the purpose of steam inhalations in the management of rhinitis associated with the common cold?
Steam inhalations liquefy nasal secretions used with volatile compounds
- Friar’s Balsam, Menthol, Eucalyptus
= Symptomatic relief in coryza conditions
RELIEVES CONGESTION
What is the purpose of Mesna in the management of rhinitis associated with the common cold?
Mesna is a mucolytic agent
- nasal spray
= Relieves nasal obstruction
What is the purpose of antihistamines in the management of rhinitis associated with the common cold and what are some of the common adverse effects of these agents?
Polycomponent Cold Medications!
- increase tenacity of secretions
- interfere with normal ciliary function
- cause drowsiness
(These are usually 1st generation antihistamines)
What is the purpose of systemic decongestants in the management of rhinitis associated with the common cold?
Symptomatic relief of congestion
What is an example of a systemic decongestant used in the management of the common cold?
Pseudoephedrine
What are examples of local decongestants used in the management of the common cold?
Local decongestants usually contain sympathomimetic agents e.g:
- Xylometazoline
- Oxymetazoline
- Phenylephrine
What is the purpose of local decongestants in the management of rhinitis associated with the common cold?
Cause vasoconstriction of mucosal blood vessels = decreased oedema
Why should local decongestants not be used for longer than 5 days continuously?
Cause rebound congestion a.k.a. Rhinitis Medicamentosa
- Secondary vasodilation
- Temporary increased nasal congestion
How should purulent rhinitis be managed?
This condition is usually associated with sinusitis and therefore antibiotic treatment is advised.
In addition, symptomatic management is also advised.
Which antibiotics are commonly used to treat purulent rhinitis?
- Amoxiclav
- Levofloxacin
- Moxifloxacin
What is commonly used for the symptomatic management of purulent rhinitis?
- Nasal decongestants = symptomatic relief (either oral or topical)
- Nasal irrigation with saline = removes thick mucous secretions
What agents are used in the management of allergic rhinitis?
- Systemic antihistamines
- Systemic corticosteroids
- Local decongestants
- Topical preparations
- Hyposensitization
When is hyposensitization useful in the management of allergic rhinitis?
Useful when specific antigen is identified and symptoms induced by exposure may be dangerous.
When should systemic antihistamines be used in the management of allergic rhinitis?
In mild cases with / without systemic nasal decongestants
- 2nd, 3rd generation = less sedation
What is an example of a systemic nasal decongestant?
Pseudoephedrine
What are some examples of 2nd / 3rd generation antihistamines that may be used in the management of allergic rhinitis?
- Cetirizine
- Loratidine
- Desloratidine
- Ebastine
- Levocetirizine
Why are systemic corticosteroids used in the management of allergic rhinitis?
Used for short periods to relieve severe mucosal oedema
What are local decongestants?
Vasoconstrictor nose drops
What are local decongestants used for in the management of allergic rhinitis?
Only for relief during acute attack until systemic antihistamine and / or decongestant or topical preparation takes effect.
What topical preparations are used in the management of allergic rhinitis?
- IN (intranasal) corticosteroids
2. Antihistamines intranasally
What are examples of intranasal corticosteroids used in the management of allergic rhinitis?
- Beclomethasone
- Fluticasone
- Budesonide
- Ciclesonide
What are intranasal corticosteroids used for in the management of allergic rhinitis?
Most effective for seasonal and perennial allergic rhinitis
- these drugs have a localized effect and are poorly absorbed thus very little reaches the systemic circulation intact = very little systemic effect
What are examples of intranasal antihistamines used in the management of allergic rhinitis?
- Levocabastine
- Azelastine
What are intranasal antihistamines used for in the management of allergic rhinitis?
Seasonal allergic rhinitis
What is another use of the topical preparations used in the management of allergic rhinitis?
These drugs can also be used as prophylactic treatment - before onset of allergy season and continued until it is over
Perennial rhinitis: dose slowly decreases until symptoms disappear = maintenance dose
What is vasomotor rhinitis?
A type of non-allergic rhinitis
= An exaggerated physiological reaction to stimuli
e.g. heat, smoke, cold, dust etc.
- Mediated through PSNS stimulation
What can be done to manage vasomotor rhinitis?
If possible avoid precipitating factors or situations
- short term topical decongestants = symptomatic relief
- anti-inflammatory action of topical steroids
What is the mechanism of action of decongestants?
Sympathomimetic drugs
- decrease blood slow through oedematous tissue
- opens up nasal passages
What is the mechanism of action of direct effect decongestants?
Direct effect on alpha-adrenoceptors (agonist)
What is the mechanism of action of indirect effect decongestants?
Presynaptic release of NA
What is the mechanism of action of non-selective decongestants?
Mixed action
- act on alpha and beta adrenoceptors
What is the mechanism of action of selective decongestants?
Stimulate alpha-adrenoceptors
= vasoconstriction of arterioles in nasal mucosa
What are the sympathomimetics used systemically as nasal decongestants?
- Ephedrine
- Pseudoephedrine
- Methylephedrine
- Phenylpropanolamine
- Phenylephrine
What are the sympathomimetics used topically as nasal decongestants?
- Phenylephrine
- Imidazolines (long-acting)
- Oxymetazoline
- Xylometazoline
What do systemic sympathomimetic preparations often contain?
Many preparations contain an antihistamine (usually a first generation antihistamine in the case of a cold and flu preparation or a second generation antihistamine in the case of a preparation for allergic rhinitis)
- usually a first generation anti-histamine, as it dries up nasal secretions
What is the onset of action of systemic sympathomimetic preparations?
Slower onset of action
When are systemic sympathomimetic preparations useful?
When the patient already suffers from rebound congestion
What are some of the SE associated with systemic sympathomimetic agents?
Many CI and SE
What are some of the uses of short term systemic sympathomimetic agents?
Short term:
- Acute coryza associated with nasal congestion
- Severe nasal congestion (both of an allergic or viral nature)
What form of topical sympathomimetic agent is preferred?
Sprays are preferred over drops
What are the pharmacokinetics of topical sympathomimetic agents?
Decreased systemic effects
Rapid onset of action
Which is the short acting topical sympathomimetic agent?
Phenylephedrine
What is the duration of action of the short acting topical sympathomimetic agents, and what is significant about their SE?
Approx. 4 hours
- more likely to cause rebound congestion
Which are the long acting topical sympathomimetic agents?
- Oxymetazoline
- Xylometazoline
What is the duration of action of the long acting topical sympathomimetic agents?
Approx. 6 hours
- 2-3 x daily
What are the topical sympathomimetic agents used for?
Short-term relief of nasal congestion
What are some of the drug interactions of systemic sympathomimetic agents?
- MAOI
- Non-selective beta-adrenoreceptor blockers e.g. propranolol
- TCA
- Other sympathomimetic agents
- Digoxin
- Quinidine
- Halogenated volatile anesthetics
In which age-group are both topical and systemic sympathomimetic nasal decongestants contraindicated?
Infants < 6 months old
What are some of the SE of systemic sympathomimetic agents?
- Mild CNS stimulation with anxiety, nervousness, insomnia
- Headache, tremors, tachycardia, palpitations, cardiac arrhythmia and drowsiness
- Fixed skin eruptions
- Hypertension, cerebral haemorrhage, pulmonary oedema
What do systemic sympathomimetic agents cause in high doses?
Dizziness and nausea
What is a dangerous SE of Phenylpropanolamine when used in high doses?
Hemorrhagic stroke in high doses
What is important about systemic sympathomimetic agents and athletes?
In sport ephedrine is banned
- others are considered “specific substances” and are monitored
What is important about topical sympathomimetic agents and athletes?
Can be used in sport
What are some of the SE of topical sympathomimetic agents?
- Direct toxic effect on cilia
- Cause rebound congestion (rhinitis medicamentosa) if used for more than 5 days consecutively
- Systemic effects possible in small children
- Transient burning or dryness of mucosa
- May become reservoirs for bacteria and fungi
DRUG INTERACTIONS present
What are contraindications of topical sympathomimetics?
Careful observation in certain high risk patients:
- hyperthyroidism
- ischaemic heart disease
- hypertension
- DM
What are absolute contraindications of systemic sympathomimetics?
- Severe hypertension or ischaemic heart disease
- MAOI therapy
What are relative contraindications of systemic sympathomimetics?
- Hyperthyroidism
- DM
- Coronary Artery Disease
- Raised intraocular pressure
- Prostatic hypertrophy
- Severe renal & hepatic impairment
What are the topical corticosteroids?
- . Beclomethasone
- Fluticasone
- Budesonide
- Momethasone
- Triamcinolone
What are topical corticosteroids used for?
Most effective maintenance therapy (prophylaxis) for seasonal and perennial allergic rhinitis
- also useful in non-allergic rhinitis
What are the systemic effects of the topical corticosteroids?
Poorly absorbed
= little systemic effect
When are topical corticosteroids contraindicated?
CI in rhinitis associated with influenza or the common cold
- caution in patients with infection of the nasal cavity
What are some adverse effects of the topical corticosteroids?
- transient burning or stinging
- headache
- dry nose
- sneezing
- nasal bleeding
- stuffy nose
- irritation of the throat
What can occur with excessive use of topical corticosteroids?
Adrenal suppression
- takes some time to take effect
- useful for weaning patients with rebound congestion off topical decongestants
What can the other topical agents be used for?
Less effective for maintenance therapy.
May be useful in allergic rhinitis
What is Cromoglicic Acid used for in SA?
Not used in nasal preparations in SA
Used topically for allergic conjunctivitis but only of use when taken prophylactically
- in SA used to prevent eye involvement in patients with allergy (eye drops)
What are the pharmacokinetics of Cromoglicic Acid?
Safe, but has weak anti-inflammatory effects
- short duration of action
What is the mechanism of action of Cromoglicic Acid?
- mast cell stabilizer
- prevent histamine release from mast cells
- decreases exaggerated neuronal reflexes
- may decrease release of T-cell cytokines
- various other effects
What are the two topical antihistamines?
- Azelastine
2. Levocabastine
What is Azelastine used for?
- allergic rhinitis
- blocks H-1 receptors
- inhibits the release of inflammatory mediators from mast cells
What is Levocabastine used for?
- long acting
- for the short-term symptomatic treatment of seasonal allergic rhinitis
