Week 7: Allergies Flashcards
What is intermittent allergies?
Symptoms occur ≤ 4 days per week or ≤ weeks
What is persistent allergies?
Symptoms occur >4days per week and >4 weeks
What is episodic allergies?
Symptoms occur on exposure to or contact with potential allergens that is not normally a part of the person’s environment
What are the risk factors of allergies?
- Family hisotry
- Elevated IgE
- Higher socioeconomic level
- Eczema
- Diet
- Positive reactions to allergy skin tests
How many allergy zones are in the US?
8
What is the purpose of allergy zones?
Better way to identify the triggers of individuals seasonal allergies
What are the common outdoor triggers?
- Pollen
- Mold spores
- Pollutants
What are the common indoor triggers?
- Pet dander
- Dust mites
- Cockroaches
- Mold spores
What are the common occupational triggers?
- Wool dust
- Latex
- Resins
- Organic dust
- Various chemicals
Describe sensitization of allergen exposure?
- IgE specific to allergen are created
- Mast cell produces histamine, prostaglandins, and leukotrienes and is now primed
What are the steps of early phase?
- Returning allergen
- Allergen binding to IgE antibodies
- Histamine, prostaglandin, leukotriene and IL5 are released
- Mediators released leading to signs and symptoms of AC
What are the steps of late phase?
Leukotriene and IL5 recruit eosinophils and other mediators
What are the clinical presentation of allergies?
- Sneezing
- Rhinorrhea
- Pruritus eyes, nose, and mouth
- Nasal obstruction
- Pain in sinus or throat
What are the complications of allergies?
- Sinusitis
- Nasal polyp formation
- Sleep apnea
- Diminished sense of smell
- Exacerbations of preexisting asthma
- Depression
- Anxiety
- Sexual dysfunction
- Delayed speech development
- Facial or dental abnormalities
What are the treatment goals for allergies?
- Reduce symptoms
- Improve the patients functional status
- Improve the patients’s sense of well being
- Treatment is individualized to provide optimal symptomatic relief and/or control
What are the non pharm of allergy meds?
Nasal wetting agents or irrigation with warm saline
What is the caution using saline rinses?
Only use distilled, sterile, or boiled water
What are the pharm treatments for allergies?
- intranasal CS
- Antihistamine (ocular and oral)
- Decongestants (topical and oral)
- Mast cell stabilizers
What is the most effective pharm treatment for allergies?
INCS
What is INCS mechanism?
- 1st line treatment for moderate-severe rhinitis
- GC
- Complex mechanism of action work by decreasing inflammation by inhibiting multiple cell types and mediators
What does INCS treat (symptoms)?
Itching, rhinitis, sneezing, congestion
What is the age restriction of Budesonide?
<6 YO
What is the age restriction of fluticasone furoate?
<2 YO
What is the age restriction of fluticasone propionate?
<4 YO
What is the age restriction of triamcinolone acetonide?
<2 YO
What are OTC INCS?
- Nasacort (triacinlone acetonide)
- Rhinocort (Budesonide)
- Flonase (Fluticasone)
What are the exclusions of allergy self care?
- <12 YO unless diagnosed with rhinitis and approved by PCP
- Pregnant or lactating unless diagnosed with rhinitis and approved by PCP
- Nonallergic rhinitis
- Infection
- Undiagnosed or uncontrolled asthma
- Severe side effects of treatment
What are the counseling points of INCS?
- Shake well
- Administer at regular intervals
- 1 week for full relief
- Few drug interactions
What are the adverse effects of INCS?
- Nasal discomfort
- Sneezing
- Cough
- Pharyngitis
What are things to consider with INCS?
Long term use is linked to changes in vision, glaucoma, Caracas, increased risk of infection, and growth inhibition in children
What are the categories of antihistamines?
- Sedating (s1st gen)
- Non sedating (2nd gen)
What are 1st gen antihistamines?
- Chlorpheniramine (Chlor-Trimeton®, Aller-Chlor®)
- Diphenhydramine (Benadryl®)
- Clemastine (Dayhist®)
What are the 2nd gen antihistamines?
- Loratadine (Claritin®)
- Cetirizine (Zyrtec®)
- Levocetirizine (Xyzal®)
- Fexofenadine (Allegra®)
What is the use for antihistamines?
- Mild and moderate rhinitis
- Faster onset than 1st line treatment for episodic allergies
- Useful except for congestion
What is the MAO of antihistamine?
- Block histamine at the histamine 1 receptor site
- 2nd gen also inhibit release of mast cell mediators
What antihistamine is preferred?
2nd gen due to less sedation, cognitive impairment, and anticholinergic side effects
What are the contraindications with 1st gen antihistamine?
- Newborns and premature infants
- Lactation
- Acute asthma
- MAO inhibitors
- Narrow angle glaucoma
What is the caution with 1st gen antihistamines?
- Elderly due to anticholingeric effects (BEERs list)
- Patients with CVD, prostate enlargement, glaucoma, asthma
What are the side effects of 1st gen antihistamines?
- Somnolence
- Cognitive impairment
- Anticholinergic effect
- Photosensitivity
What is the counseling point of 2nd gen antihistamine?
- Less sedating but can still cause CNS depression or sedation
What are the side effects of 2nd gen antihistamines?
Somnolence and headache
What 2nd gen antihistamine are the least sedating?
Fecofenadine and loratadine
What is the counseling point for fexofenadine?
Not be take with juice
What are decongestants?
Effective in reducing sinus and nasal congestion
What is the MOA of decongestants?
A-adrenergic agonists that cause vasoconstriction decreasing sinus engorgement and mucosal edema
What is the product that has D listed contain?
Pseudoephedrine
What can control congestion?
Systemic decongestants or short term topical nasal decongestants
What is the caution with topical decongestants?
Use for 3 or less days to reduce the risk of rebound effect
What are mast cell stabilizers?
Indication preventing and treating symptoms of allergic rhinitis
What is the OTC mast cell stabilizer?
Cromolyn sodium (NasalCrom®)
What is the MAO of mast cell stabilizer?
Blocks influx of calcium into mast cells preventing mediator release
No drug interactions
How should you take mast cell stabilizers?
- Treatment is more effective before symptoms
- Must be scheduled dosing, not effective with prn
- 3-7days for initial improvement but 2-4 weeks for maximal therapeutic benefit
What are the side effects of mast cell stabilizers?
No drug interactions
What is the preferred INCS for pregnancy?
Budesonide
When can pregnancy use self treatment?
referred to provider initially
What are the recommendations for pregnancy?
- Intranasal cromolyn is 1st line recommendation due to safety profile
- Intranasal cromolyn is 1st line recommendation due to safety profile
- Loratadine and cetirizine are considered low risk for 2nd gen antihistamines
- Budesonide: INCS
What are the recommendations for lactation?
- Intranasal cromolyn
- INCS is probably compatible
- Could recommend 2nd gen loratadine, cetirizine, or fexofenadine if antihistamine is needed-should be used with caution and under supervision of PCP
What should not be used in lactation?
- Long acting and recommend taking dose at night after lactation
- 1st gen antih are contraindicated
What are the recommendation of geriatrics?
- Loratidine and intranasal cromolyn
- Need to consider renal/hepatic impairment
- Loratadine, cetirizine, and fexofenadine require adjustments
What should be avoided with geriatrics?
- Sedating antihistamines
- Caution with 1st gen antihistamines due to anticholinergic side effects
What are cautions with pediatrics?
Due to concern for asthma, children less than 12 years of age must be referred to PCP
What are the recommendations of pediatrics?
- Loratadine is antihistamine of choice, then fexofenadine, levocetirizine, and cetirizine
- Different INCSs can be conspired but review package insert as they are based on different ages
What should be avoided with pediatrics?
Avoid 1st gen antihistamines due to paradoxical excitation
DA is a 30 y/o female who presents to you requesting help on selecting an allergy medication. No PMH and is not on any medications currently. She is a student during the day and wants to make sure whatever she takes is not sedating. What can you recommend that would be the least sedating?
Laratadine
