Allergic Rhinitis/Cold

Question 1

Intranasal Steroids

Answer 1

• 1st line; used for chronic, moderate-severe sxs
• Budesonide (Rhinocort)
• Fluticasone (Flonase)
• Triamcinolone (Nasacort)
• SE: Epitaxis (nose bleeds)
• Can take up to one week to get full relief
• Budesonide and beclomethasone = preferred for pregnancy

Question 2

Benadryl

Answer 2

• Diphenhydramine
• First-generation oral antihistamine
• Adult: 25 mg PO Q4-6H or 50 mg PO Q6-8H
• DON’T use OTC in kids <6yo

Question 3

Other First-Generation Antihistamines

Answer 3

• Chlorpheniramine (Aller-Chor)

- Doxylamine (Unisom)

Question 4

First-Gen Antihistamines Information

Answer 4

• Warning: Avoid in elderly (antichol. SE), can cause prostate enlargement and glaucoma
• SE: Somnolence, cog. impairment, anticholinergic effect
• Avoid in kids <2 yo
• ALL antihistamines are for mild-moderate sxs

Question 5

Zyrtec

Answer 5

• Cetirizine
• pseudoephedrine option (-D)
• 2nd Gen Antihistamine

Question 6

Xyzal

Answer 6

Levocetirizine

• 2nd Gen Antihistamine
• Okay to use in 6 mo+

Question 7

Allegra

Answer 7

• Fexofenadine
• pseudoephedrine option (-D)
• 2nd Gen Antihistamine
• Separate from fruit juice and antacids (decreased absorption)

Question 8

Claritin

Answer 8

• Loratidine
• pseudoephedrine option (-D)
• 2nd Gen Antihistamine

Question 9

2nd Gen Antihistamine Information

Answer 9

• AVOID fruit juice with fexofenadine (decreased absorption)
• Loratadine and cetirizine preferred in preggo
• Cetirizine and Levocetirizine have the fastest onsets (work best for some people); therefore are also more sedating than the other two
• Generally preferred over 1st gen due to less somnolence
• Most okay in 2 yo+ unless otherwise mentioned

Question 10

Intranasal Antihistamines

Answer 10

• Azelastine (Astelin)
• Olopatadine (Patanase)
• Helps with nasal congestion, can combine with INS
• Not recommended as often

Question 11

Systemic Decongestants

Answer 11

• Phenylephrine (Sudafed PE) - OTC, poor oral absorption

- Pseudoephedrine (Sudafed, Nexafed) - Rx and OTC (BEHIND COUNTER), abuse potential!

Question 12

Topical Decongestants

Answer 12

• AKA Intranasal

- Oxymetazoline (Afrin)

Question 13

Systemic Decongestant Information

Answer 13

• CI: use within 14 days of MAOI
• Avoid in children <2yo (FDA) or <4 yo (packaging)
• Caution in patients with CV disease/BPH (increases BP and can cause urinary retention)
• SE: tachycardia, palpitations, increased BP, insomnia, decreased appetite

Question 14

Topical Decongestant Information

Answer 14

• Caution in use with BPH patients

- SE: Rhinitis medicamentosa (rebound congestion when used >3 days)

Question 15

NasalCrom

Answer 15

• Cromolyn
• OTC mast cell stabilizer
• Used regularly, not PRN
• Start at onset of allergy season and throughout
• Safe in children =<2 yo and pregnancy
• Dosed QD multiple times a day

Question 16

Singulair

Answer 16

• Montelukast
• Leukotriene modifying agent
• Used for allergic rhinitis and asthma
• Box Warning: Serious neuropsychiatric SE

Question 17

Immunotherapies

Answer 17

• Preventative treatment for allergies, either SQ or SL
• Work by slowly increasing exposure to allergen
• SQ shots must be given in medical office, SL must be given in medical office FIRST time then continue at home
• Must have an EpiPen at home if using immunotherapy SL option

Question 18

Oralair

Answer 18

• 1 of 4 approved FDA SL treatments for allergic rhinitis

- Five different grass pollen extracts

Question 19

Grastek

Answer 19

• 1 of 4 approved FDA SL treatments for allergic rhinitis

- Timothy grass pollen extract

Question 20

Ragwitek

Answer 20

• 1 of 4 approved FDA SL treatments for allergic rhinitis

- Ragweed pollen extract

Question 21

Odactra

Answer 21

• 1 of 4 approved FDA SL treatments for allergic rhinitis

- House dust mite allergen extract

Question 22

Natural Medicines for Cold

Answer 22

• Zinc: may decrease duration of cold or be used as a preventative “possibly effective” (start immediately w/ sxs)
• Vitamin C (Ascorbic Acid): decrease duration of cold, “possibly effective”
• Echinacea: “possibly effective”
• Airborne and Emergen-C are popularand contain the above products plus additional vitamins/supplements like vit. E

Question 23

Expectorants

Answer 23

• Guaifenesin (Mucinex, Robitussin Mucus + Chest, Robafen)
• Plus Dextromethorphan = DM
• Thins mucus and used when productive coughs are present

Question 24

Cough Suppressant Options

Answer 24

• Dextromethorphan (Delsym, Robafen Cough, Robitussin Cough)
• Codeine - CII as single entity for pain, CV in combination products for cough/cold
• Benzonatate (Tessalon Perles)
• Diphenhydramine (Benadryl)

Question 25

Dextromethorphan MOA

Answer 25

- Serotonin reuptake inhibitor that acts as a NMDA-receptor blocker at high doses => euphoria and hallucinations (robo-tripping) - Banned to sale to minor <18 yo - For dry, unproductive cough

Question 26

Dextromethorphan Information

Answer 26

- CI: Use within 14 days of a MAOI - Warning: 5HT syndrome - DM = dextromethorphan contained in product

Question 27

Codeine Information

Answer 27

- Box Warning: respiratory depression and death in kids receiving tonsillectomy and/or adenoidectomy (ultra-rapid metabolizers); also death in nursing infants - CI: Use in kids <12 yo, or children < 18 yo receiving tonsillectomy and/or adenoidectomy - FDA recommends avoiding these cough/cold products in patients < 18 yo - CII monotherapy, CV when combined

Question 28

Bromfed DM

Answer 28

- Brompheniramine/pseudoephedrine/DM | - Rx and OTC

Question 29

TussiCaps or Tussionex

Answer 29

- Chlorpheniramine + Hydrocodone | - CII

Question 30

Avoid in <18 yo...

Answer 30

- Codeine containing cough/cold products (FDA) | - Hydrocodone containing cough/cold products (FDA)

Question 31

Avoid in <4 yo...

Answer 31

-OTC cough/cold products (per package labeling)

Question 32

Avoid in <2 yo...

Answer 32

- OTC cough/cold products (FDA) - Promethazine (FDA) - Topical menthol/camphor (package labeling) - Decongestants (FDA)

Question 33

APAP/Ibu Child Dosing

Answer 33

- APAP: 10-15 mg/kg Q4-6H; 160 mg/5 mL - Ibu: 5-10 mg/kg Q6-8H; don't exceed 40 mg/kg/d; dosing varies based on product used - NEVER ASA: Reyes syndrome risk