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Pharm 130 > Viral rhinitis > Flashcards

Viral rhinitis Flashcards

1
Q

rates in adults and children

A

children 6-8 colds/year

adults (over60) 2-4 colds/year

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2
Q

viral rhinitis is the leading cause of work and school absenteeism

A

true

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3
Q

When can infection occur and how many infecting agents

A

can occur any time of year

-over 200 different VIRUSES

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4
Q

Rhinoviruses

  • how many ID’d serotypes
  • when prevalence high
A

most common in all age groups (30-50%)

  • over 100 serotypes
  • higher prevalence in early fall, late spring
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5
Q

Coronaviruses

  • percent cases
  • prevalence
A

10-20%

high prevalence during mid winter early spring

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6
Q

other common viruses

A

RSV - respiratory syncytial virus

adenovirus

parainfluenza

enterovirus

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7
Q

Modes of inoculation

A

1) self inoculation - of nasal mucosa or conjunctiva following hand contact with virus laden secretions
+directly from an infected person (animate objects, hands)
+indirectly from environmental surfaces (inanimate objects, dorrknobs, phones)

2) prolonged contact with airbourne droplets produced by coughing, sneezing, talking
- small particle aerosols lingering in air
- direct hit by large particle aerosols from infected person

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8
Q

order of responses in flare response to infection

A

viral infection of nasal epithelium –> immune response –> mediators –> symptoms

immune response

  • killer T cells activated
  • antibody production begins

Mediators

  • bradykinin,
  • PG’s,
  • Histamine,
  • other cytokines

symptoms

  • sore throat
  • cough
  • nasal congestion
  • rhinorhhea
  • sneezing
  • fever/chills
  • cough
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9
Q

incubation period

A

24-72 hours

-symptoms largely due to immune response to infection rather than direct viral damage to respiratory tract

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10
Q

VR is self limiting t/f

A

true

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11
Q

how long do symptoms of VR last

A

7-14 days

1-2 weeks

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12
Q

what is the first symptom

A

throat discomfort

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13
Q

symptoms/time

A

day 1
-throat discomfort

day2/3

  • nasal congestion and rhinorrhea
  • nasal discharge is CLEAR and WATERY at beginning and becomes MUCOPURULENT

day 4-5

  • cough may be present; may persist for 1-2 weeks
  • dry at beginning then often becomes productive
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14
Q

Physical assessment

A
  • slightly red pharynz w/ evidence of postnasal drainage
  • nasal obstruction
  • mildly to moderate tender sinuses on palpation

-low-grade fever possible
+rarely >37.8
+children more often than adults

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15
Q

complications

A

may cause exacerbations of asthma or COPD

AND OR

predispose indivs to bacterial complications:
-sinusitis, pneumonia, bronchitis, ostitis media (kids)

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16
Q

Acute cough

A

less than 3 weeks

-caused by VR

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17
Q

subacute cough

A

3-8 weeks

-cause: infection, bacterial sinusitis, asthma

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18
Q

chronic cough

A

greater than 8 weeks

  • GERD why 8 weeks
  • over 12 weeks attributable to smoking
cause:
post nasal drip syndrome
asthma
GERD
some meds
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19
Q

productive cough

A
  • wet or chesty
  • expells secretions from LRT
  • if retained impair ventilation and lungs and ability rss infection
-secretions may be:
\+clear (bronchitis)
\+purulent (bacterial infection)
\+discoloured (yellow w/ inflammatory disorders)
\+maloderous 9anaerobic infection
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20
Q

non productive cough

A

dry or hacking

  • no useful physiologic purpose
  • assocaited w/ viral RTI, GERD, cardiac disease, some meds, atypical bac infections
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21
Q

URTI prevention measures

A
  • avoid touching nasal mucosa/conjunctiva
  • routine handwashing (20s)

-alcohol based hand rub
+not supplement HW
+not effective if hands visibly soiled
+efficacious ABHR=62-95%

  • antiviral/disinfectant commercial products
  • sneeze and cough etiquette

children avoid sharing bevs or food

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22
Q

Cough treatment

A

dry - antitussive

productive - protussive

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23
Q

sore throat treatment

A

anesthetic or antiseptic

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24
Q

fever and pain treatment

A

analgesic/antipyretic

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25
Q

nasal treatment

A

systemic decongestant
topical decongestant
1st generation antihistamine

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26
Q

CCMs are generally safe

A

true

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27
Q

in what population are CCMs being re-evaluated

A

pediatric

  • no strong evidence of efficacy
  • toxicities and death
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28
Q

Paradoxical excitation

A

when child gets very energetic instead of calming down with use of diphenhydramine

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29
Q

Problems with CCMs in children

A
  • completely contraindicated in kids younger than 2
  • used to sedate children
  • use in a daycare setting - trust idiot not mess up dose
  • combining 2 or more meds with same API
  • misidentification of product
  • use nonRx for adults on kids (buckleys)
  • failure use measuring device
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30
Q

SEs of children using OTC CCMs

A

convulsions, inc HR, dec conciousness, abnorm heart rhythms, hallucinations

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31
Q

CCMs in children

A

current treatment only target symptom reduction

lack evidence for vast majority of interventions for management of VR

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32
Q

changes in CCM labeling

A

ages 6-11 - limited evidence but dose provided on packaging

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33
Q

4 banned therapeutic catagories for CC in children under 6

A

antihistamines IN CCMs

antitussives

expectorants

decongestants

NO MORE EFFECTIVE THAN PLACEBO IN VIRAL INDUCED COUGH

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34
Q

antitussives

  • MoA
  • OTC evidence
  • OTC antitussives
  • hydrocodone
  • where avoid
A
  • MoA, act centrally on the medulla to inc cough threshold
  • evidence of OTC cough prods is limited and conflicting

-OTC antitussives
+codeine - only available with 2 other ingredients, adult dose (12+) 10-20mg q4-6, max 120mg/d
+dextromethorphan - adult dose 30mg q6-8h _____ age 6-11 5-10mg q4h OR 15mg q6-8 (ER) max 60mg/day

hydrocodone available by prescription

avoid use in productive cough

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35
Q

does diphenhydramine have antitussive action?

A

yes

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36
Q

precautions antitussives: codeine

A

AE: drowsiness/sedation, nausea, constipation

significant abuse potential

contraindication: MAOI

DI: CYP2D6 inhibitors; CNS depressants

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37
Q

precautions antitussives: dextromethorphan

A

AE: well tolerated; occaisonal dizziness, drowsiness, nausea

abuse potential: present if used in high dose

contraindications: MAOIs

DI: CYP2D6 inhibitors

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38
Q

why codeine and dextromethorphan DI with CYP2D6 inhibitors

A

DM/C blocks seretonin reuptake ——-> serotonin syndrome

AVOID OTHER SEROTONERGIC MODULATING DRUGS (SSRIs)

codeine less risk than DM

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39
Q

antitussives in children

A

no more effective than placebo for cough

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40
Q

Expectorants

  • evidence for URTI
  • action
  • what congestion
  • guaifenesin
  • SE?
  • abuse potential?
  • DI?
  • any reports of guaifenesin poisoning?
A

-limited evidence for acute cough in URTI for ALL AGES

-acts peripherally
+MAY reduce viscosity and aid in expectoration of sputum

-may be used for chest congestion

guaifenesin
-NOT INDICATED FOR KIDS UNDER 6

  • side effects are rare
  • no abuse potential
  • no DIs
  • no specific or individual reports of guaifenesin poisoning
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41
Q

guaifenesin dose

A

Adult: 200-400mg q4-6 max 2.4g/day

6-11: 100-200mg q4-6h (~12mg/kg/day) max 1.2g/day

42
Q

Topical antitussives: menthol and camphor

A

Menthol and camphor

  • present in lozenges and topical ointments
  • increases perception of nasal breathing
  • no improvement in objective measures
43
Q

topical antitussives: vapor rub doses

A

2-5: 5mL once daily

6-11: 10mL once daily

44
Q

how do topical antitussives work/do they work

-problems

A

work by distracting brain
-increase perception of nasal breathing

work for kids but not adults
-improve cough severity and quality of sleep

PROBLEMS

  • strong smell children may not tolerate (start low and build up)
  • MAY be effective in common cold in children
  • NOT SAFE BY NOSTRILS -> child aspirates
45
Q

Oral decongestants evidence

A

moderately effective for cold symptoms

-nasal congestion, sinus pain

46
Q

oral decongestant MoA

A

alpha-adrenergic agonist; vasoconstriction of nasal BVs, reducing vessel engorgement and mucosal edema

47
Q

what casues stuffiness

A

vasodilation of nasal BVs

48
Q

Oral decongestants onset of action

A

~30 minutes

49
Q

what are the 3 types of oral decongestants

A

pseudophedrine, phenylephrine, and phenylpropanolamine

50
Q

what oral decongestant was removed from the market

A

phenylpropanolamine removed from market in 2000 due to risk of hemorrhagic stroke in women

51
Q

pseudophedrine

A
  • oral decongestant
  • widely used
  • 60mg q4-6h OR 120mg q12h (long -acting preparations) max 240mg/day
  • 6-11 years: 30mg 1 4-6hr max 120mg/day
  • MOST EFFICACIOUS
  • makes crystal meth
52
Q

phenylephrine

A

oral decongestant
-more readily available OTC because less risk diversion

10mg q4h max 60mg/day

6-11 years: 5mg q4h, max 30mg/day

53
Q

what are the only 2 medications that can manage congestion

A

psueophedrine and phenylephrine

54
Q

Oral decongestants ADR and precausions

A

ADR - INSOMNIA, tremor, irritability, nervousness, restlessness, diziness, headache, tachycardia, palpitatio, Inc BP in hypertensive patients

precautions

  • avoid oralD in hypertension
  • heart disease
  • beta blockers
  • uncontrolled hyperthyroidism
  • diabetes

ON EXAM contraindications

  • narrow angle glaucoma
  • prostatic hypertrophy
  • avoid w/ MAOIs -> hypertensive crisis
  • uncontrolled hypertension
55
Q

why should you not take an oralD 24H release unless in morning

A

oralDs cause insomnia as ADR

56
Q

nasal decongestants

  • MoA
  • onset
  • long acting
  • short acting
A

MoA
-constrict BVs in nose

Onset of action
- less than 10 minutes

Long acting nasal decongestants
-zylometazoline
-oxymetazoline
DOSE 2-3 sprays ea nostril q10-12h UP TO BID

Short acting
-phenylephrine
DOSE 2-3 spreays ea nostril q4h

57
Q

advantage of nasal decongestants

A

less systemic absorption

-less AEs

58
Q

avoid what when using nasal decongestants

A

avoid with MAOIs

  • hypertensive crisis
  • wait at least one week after
59
Q

Disadvantage of nasal decongestants

A

can cause rebound congestion (medicamentosa) especially with short acting agents

60
Q

Rhinitis medicamentosa

  • prevention
  • treatment
  • how long until mucous membrane returns to normal
A

prevention
-only use topical decongestants for max of 3-5 days

treatment

  • slowly withdraw the nasal decongestant (1 nostril at a time)
  • replace with topical nasal saline
  • abrupt works but difficult (patient congested days-week)

MORE SEVERE
-use systemic decongestant and topical corticosteroid

MM return to normal
- 1-2 wks

61
Q

nasal decongestants APIs (3)

A

oxymetazoline HCl

xylometazoline HCl

phenylephrine HCl

62
Q

Antihistamines

  • indication
  • CC use?
  • why used in night prods
  • precautions
A

Indicated for

  • runny nose
  • may also have antitussive action

Questional benefit in CC
-drying effect with anticolinergic activity (exagerated in 1st generation)
+second generation limited value

Used in nightime products
-sedative effect to outweight decongestant stimulation

precautions

  • sedation, anticholinergic side effects (dry mouth, constipation, increased heart rate)
  • caution with narrow angle glaucoma, heart disease, hyperthyroidism, rpostatic hypertrophy
63
Q

why avoid use of 1st generation AH in elderly

A

sedation

-fall risk

64
Q

Antihistamines in children

A

no more effective than placebo for COUGH

65
Q

first generation antihistamines

A

diphenhydramine HCL

Chlorpheniramine maleate

cyproheptadine HCL

triprolidine HCL

brompheniramine maleate

pheniramine maleate

doxylamine succinate

66
Q

what 1st generation antihistamine is only in combo products

A

triprolidine HCL

67
Q

antihistamine + decongestant in children

A

no more effective than placebo for cough

68
Q

what does DM indicate on a pkg

A

dextromethorphan (antitussive)

69
Q

what does D indicate on pkg

A

Decongestant

70
Q

what does E indicate on pkg

A

expectorant (guaifenesin)

71
Q

daytime

A

contains decongestant

72
Q

nighttime

A

includes antihistamine

73
Q

sinus on pkg

A

analgesic + decongestant

74
Q

Single vs combo drugs

A

WHENEVER POSSIBLE
-try give patients single entity product
+mixed products often extras that are uneeded

75
Q

Pros and cons of combo

A

PRO
-practical, inc patient compliance (less pills)

CON

  • no flexibility
  • symps peak and resolve at var times
76
Q

Expectorant + antitussive

A

irrational combo

77
Q

analgesic + decongestant

A

sinus headache/pain

78
Q

decongestant + antihistamine

A

some benefit in acute cough due to PND

-may be helpful at bedtime due to insomnia with decongestants

79
Q

Combination products why not recommended

A

less flexibility in dosing

unnecessary drugs

more AEs

possible OD (mult prods w/ acetaminophen)

80
Q

why combination products used

A

more convenient for multiple symptoms

-increase compliance and reduce cost

81
Q

Pasteurized Honey

  • what ages
  • effects
  • efficacy
A

safe in children above 1 yeah
-under 1 risk of botulism

demulcent, antioxidant, antimicrobial effects

EFFICACY

  • parents rated honey highest for symptomatic relief of nocturnal cough and sleep difficulty due to URTI
  • no strong evidence for or against use
82
Q

what type of pasturized honey usually used

A

buckweed honey

-thicker, darker, less sweet

83
Q

why does honey work for children

A

likely due to coating area

-rather than antiviral

84
Q

Nonpharm measures for children with URI (6)

A
  • rest
  • nasal bulb syringe
  • upright positioning - helps with airway and breathing
  • adequate fluid intake (avoid dehydration)
  • increase air humidity
  • normal saline (as decongestant, kids prefer drops over spray)
85
Q

what should parents/caregivers rely on for children younger than 6 in URI

A

nonpharmacologic measures

86
Q

Nasal irrigation with saline

A
  • alleviates sore throat
  • thins nasal secretions
  • can reduce need for nasal decongestants and mucolytics
87
Q

nasal irrigation with saline in children

A

may be effective for common cold in children

88
Q

analgesics/antipyretics

A

headache, pain, fever

acetaminophen
- 10-15mg/kg/dose

Ibuprofen

  • 5-10mg/kg/dose
  • beneficial for discomfort or pain cuased by the viral illness
  • do not significantly reduce total symptom score or duration of cold
89
Q

Implement

  • what tell (2)
  • nonpharm
  • screen
A

tell patient few interventions have evidence that support use

provide strong messages on

  • self limited nature of common cold
  • importance of preventative measures
  • treatments which are safe and effective, which are not
  • nonpharm measures may be effective in relieving some of discomfort of cold symptoms
  • screen self-treating pateitns thoroughly for signs and symptoms of more serious condition that warrants referal
90
Q

Follow up

A

2-14 days assess efficacy and safety of therapy
-if someone with risk factor go with 2

7 or less days of nonRx drug therapy should relieve most symptoms

91
Q

symptoms improve but persist

A

re-evaluate

-if cough persists but has improved at follow-up, patient should continue therapy until cough resolved

92
Q

development of S/S of possible complications

-how monitor

A 
REFER
-monitor by measuring:
\+T
\+assess nasal secretions
\+respirations
\+facial/neck pain
93
Q

when does change of mucous colour indicate secondary bacterial sinus infection

A

clear to yellow/green colour occurs normally in course of common cold

indicates 2ndary bac sinus infec when fails to resolve after 10-14 days

94
Q

Monitoring: cold symptoms

A

able perform daily activities

  • patient: monitor daily
  • RPh: next visit or phone in 2-3days
  • optimize nonpharm measures/change treatment
95
Q

Monitoring: insomnia (oral decongestant)

A

able to sleep?

  • patient: daily
  • RPh: one week
  • change med schedule or D/C
96
Q

Monitoring: High BP (patients with hypertension):

A

elevation in BP above baseline?

  • patients daily
  • RPh: BP 2x in week one
  • stop med if BP elevate above baseline
97
Q

Monitoring: Drowsiness (antihistamine)

A

Drowsiness?

  • patients: daily
  • RPh: next visit or phone when checking efficacy
  • d/c treatment if still causing drowsiness
98
Q

Monitoring: drowsiness (certain antitussives)

A

drowsiness?
Patient: daily
RPh: next visit or phone when checking efficacy
change medication schedule or treatment

99
Q

symptoms dont improve or worsen after 14 days

A

refer

100
Q

examples of worsening symptoms

A

-T>40.5degC for one day or fever longer 72hrs

cough lasting>3wks

thick green nasal discharge for more than two weeks

yellow eye discharge

ear or sinus pain

CHILD APPEARS DEHYDRATED

Pharm 130 (13 decks)

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