Ch. 37

Question 1

Non Drug Tx for Allergic Rhinitis

Answer 1

nasal irrigation & wetting agents

safe for children & pregnancy
irrigation contains isotonic or hypertonic saline
& can be administered via syringe or Neti pot

Question 2

Drug Tx for Allergic Rhinitis

Answer 2

chronic, mod-sev: intranasal steroids
intermittent, mild: oral antihistamines
if congestion: decongestants

Question 3

Intranasal Steroids:
MOA
Warnings
SEs
Monitoring
Notes

Answer 3

MOA: decrease inflammation & first line for moderate-severe allergic rhinitis

Warnings: avoid if nasal septal ulcers/surgery/trauma; high doses for long periods can cause adreanl suppression, poor growth in children, immunosuppression; caution w cataracts and/or glaucoma due to ^ in IOP and ^ risk of developing cataract/glaucoma

SEs: Epistaxis, headache, dry nose, unpleasant taste, localized infection

Monitoring: growth (pediatric), vision changes, eye exams if long-term use, sxs of oral thrush and/or adrenal suppression

Notes:
* take up to 1 week to get full relief
* budesonide and beclomethasone are preferred in pregnancy
* shake bottle before each use

IOP: intraocular pressure
Epistaxis: nose bleeds

Question 4

Budesonide brand
OTC or RX
Dosing

Intranasal Steroid

Answer 4

Rhinocort Allergy
OTC
Adult: 1 spray/nostril/day [max 4/n/d]
age <6: max 2/n/day

Question 5

Fluticasone brand (4)
Fluticasone + azelastine brand
OTC or RX
Dosing

Intranasal Steroid

Answer 5

Flonase Allergy Relief/Flonase Sensimat/Children’s Flonase/Xhance
Dymista
OTC & RX
Age 12+: 1-2 sprays/n/d
age: 2-11: 1 s/n/d

Question 6

Triamcinolone brand
OTC or RX
Dosing

Intranasal Steroid

Answer 6

Nasacort Allergy 24hr
OTC
Age 6+: 1-2 s/n/d
age 2-5: 1 s/n/d

Question 7

Beclomethasone brand
OTC or RX
Dosing

Intranasal Steroid

Answer 7

Beconase/Qnasl
Rx
adult: 1-2 s/n BID (beconase)
2 s/n BID (Qnasl)

Question 8

Ciclesonide brand
OTC or RX
Dosing

Intranasal Steroid

Answer 8

Omnaris/Zetonna
RX
adult: 2 s/n/d (omnaris)
1 s/n/d (zetonna)

Question 9

Flunisolide
OTC or RX
Dosing

Intranasal Steroid

Answer 9

no brand
RX
adult: 2 s/n BID or TID

Question 10

Mometasone brand
OTC or RX
Dosing

nasal implant brand name
mometasone + olopatadine brand name

Intranasal Steroid

Answer 10

Nasonex 24HR Allergy
RX and OTC
adult: 2 s/n QD

nasal implant: Sinuva
Ryaltris

Question 11

1st gen Antihistamines:
MOA
CIs
Warnings
SEs
Notes

Answer 11

MOA: H1 receptor antagonist; for mild-mod symptoms
1st gen: more sedation
CIs: neonates or premature infants, breastfeeding
Warnings: Avoid in elderly [anticholinergic/BEERS] & children <2; CNS depression/sedation; caution if CVD, prostate enlargement, glaucoma, asthma, thyroid disease
SEs: somnolence, cognitive impairement, anticholinergic effects, seizures/arrhythmias (high doses)
Notes: 2nd gen preferred in pregnancy; no 1st gen if lactating; can cause photosensitivity; d/c 72 hrs before allergy testing

somnolence: sleepiness
anticholinergic effects: dry mouth, blurred vision, urinary retention, constipation {can’t see, can’t spit, can’t pee & can’t shit]

Question 12

Diphenhydramine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing
Indications

STUDY TIP GAL
antihistamine

Answer 12

Benadryl
1st gen
C, T, chew, elixir, strip, syrup, injection, cream, gel, solution, spray
RX & OTC
Dosing:
* adult: 25 mg PO Q4-6H or 50 mg PO Q6-8H [max 200 mg/day]
* 6-11: 12.5-15 mg PO Q4-6H [max 150 mg/day]
* <6: do NOT use OTC w/o provider instruction

Indications: acute allergic rxns, allergic rxn prophylaxis, allergic rhinitis, cough (antitussive properties), sleep, dystonic rxns (anticholinergic properties), motion sickness
* can worsen some disease states: BPH, constipation, dementia, glaucoma

Question 13

Chlorpheniramine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

antihistamine

Answer 13

Aller-Chlor
1st
T, syrup
OTC
adult only
IR: 4 mg Q4-6H [max 24 mg/d]
ER: 12 mg Q12H [max 24 mg/d]

Question 14

Doxylamine
1st or 2nd gen
dosage form
RX or OTC
Dosing

antihistamine

Answer 14

no brand for allergy, but for sleep: Unisom
1st
tablet
OTC
adult: 12.5-25mg Q4-6H (max 75 mg/d)

Question 15

Clemastine
1st or 2nd gen
dosage form
RX or OTC
Dosing

antihistamine

Answer 15

1st
t, syrup
RX
adult: 1.34-2.68 mg Q8-12H [max 8.04 mg/d]

No brand

Question 16

Carbinoxamine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

antihistamine

Answer 16

Karbinal ER, RyVent
1st
t, liquid
adult IR: 4-8 mg Q6-8H
adult ER: 6-16 mg Q12H

Question 17

2nd gen Antihistamines:
MOA
CIs
Warnings
SEs
Notes

Answer 17

MOA: H1 receptor antagonist
CIs: ESRD CrCL < 10, HD, ages 6 mo-11 yrs w renal impairment (levocetirizine)
warnings: somnolence (cetirizine, levocetirizine >), headache
notes:
* fexofenadine: take w water (not fruit juice due to decrease absorption); do not administer w Al or Mg containing products
* d/c 72 hrs before allergy testing
* pregnancy: cetirizine + levocetirizine preferred
* less sedating: fexofenadine + loratadine
* rebound pruritus possible with d/c of cetirizine
* if PKU: avoid some formulations of fexofenadine, loratadine & desloratadine that contain phenlalaline
* all 2nd gens okay for children, except desloratadine

ESRD: end stage renal disease
CrCl: Creatinine Clearance
HD: hemodialysis
somnolence: sleepiness
pruritus: severe itching
PKU: phenylketonuria; cannot breakdown the amino acid phenylalanine; build up can cause brain damage & other health issues

Question 18

Cetirizine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

Answer 18

Zyrtec Allergy
[+pseudoephedrine: Zyrtec-D]
2nd
c, t, solution, syrup, chew, ODT, inj.
RX & OTC
age 6+: 5-10 mg QD [max 5 mg QD for elderly]
age 2-5: 2.5-5 mg QD

Question 19

Levocetirizine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

Answer 19

Xyzal
2nd
t, solution
RX and OTC
12+: 5 mg QHS
6-11: 2.5 QHS
6 mos-5yrs: 1.25 QHS

youngest age approval of antihistamines

Question 20

Fexofenadine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

Answer 20

Allegra (+pseudoephedrine: Allegra D)
2nd
t, suspension, ODT
OTC
12+: 60 mg BID or 160 QD
2-11: 30 mg BID

Question 21

Loratadine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

Answer 21

Claritin (+pseudoephedrine: Claritin-D)
2nd
t, c, chew, solution, syrup, ODT
OTC
age 6+: 10 QD or 5 BID [Reditabs]
age 2-5: 5 mg QD

Question 22

Desloratadine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

Answer 22

Clarinex (+pseudoephedrine: Clarinex-D)
2nd
t, ODT
RX
adult: 5 mg QD

Question 23

Intranasal Antihistamines:
SEs
Notes

Answer 23

SEs: bitter taste, headache, somnolence, nasal irritation, epistaxis, sinus pain
Notes: help with nasal congestion; CAN be combined with intranasal steroid

epistaxis: nose bleeds

Question 24

Azelastine brand
1st or 2nd gen
dosage form
RX or OTC
Dosing

azelastine + fluticasone brand

intranasal antihistamine

Answer 24

Astepro
2nd
intranasal
OTC and RX
adult: 1-2 s/n BID
Dymista

Question 25

Olopatadine brand 1st or 2nd gen dosage form RX or OTC Dosing ## Footnote intranasal antihistamine

Answer 25

Patanase 2nd intranasal spray RX adult: 2 s/n BID

Question 26

Decongestants: **MOA** **CIs** **Warnings** **SEs** **Notes**

Answer 26

MOA: alpha adrenergic agonists (sympathomimetics), cause vasoconstriction which decreases sinus vessel engorgement & mucosal edema CIs: do not use within 14 days of MAO inhibitors (HTN crisis) Warnings: avoid in age < 2 (FDA), < 4 (Package insert); caution in CVD (^ BP), hyperthyroidism (can worsen), DM (^ BG), bowel obstruction, glaucoma (^ IOP), BPH (urinary retention); elderly; seizure disorder SEs: CV stimulation (^ BP, palpitations, ^HR), CNS stimulation (anxiety, tremors, **insomnia**, restlessness, fear, hallucination), **decrease appetite**, dizziness, headache Notes: * phenylephrine: poor oral absorption; also comes as nasal spray but lasts shorter time & more SEs than oxymetazoline * **avoid in 1st trimester of pregnancy** * pseudoephedrine more effective; phenylephrine low bioavailability (<38%) * onset: 15-60 minutes ## Footnote Effects of Sympathomimetics: ^ heart rate/cardiac output/blood pressure; Bronchodilation; Pupil dilation, Sweating, Anxiety, Agitation MAO: monoamine oxidase inhibitors [Selegiline (Emsam), Isocarboxazid (Marplan), Phenelzine (Nardil), and Tranylcypromine (Parnate)] CVD: cardiovascular disease DM: diabetes mellitus IOP: intraocular pressure

Question 27

**Phenylephrine** brand dosage form RX or OTC Dosing

Answer 27

Sudafed PE t, liq, solution, injection (acute/critical care) OTC adult: 10 mg Q4H PRN [max 60 mg/d] 6-11: 5 mg Q4H PRN [max 30 mg/d] age 4-5: 2.5 mg Q4H PRN [max 15 mg/d] ## Footnote decongestant

Question 28

**Pseudoephedrine** brand dosage form RX or OTC Dosing

Answer 28

Sudafed, Nexafed, Zephrex-D t, liquid, syrup RX and non-Rx behind the counter adult: 60 mg Q4-6H PRN or 120 mg ER Q12H or 240 mg ER QD [max 240 mg/d] 6-11: 30 mg Q4-6H PRN [max 120 mg/d] age 4-5: 15 mg Q4-6H PRN [max 60 mg/d] ## Footnote Decongestant

Question 29

Intranasal Decongestants: **CIs** **Warnings** **SEs** **Notes**

Answer 29

CIs: oxymetazoline- do not use more than 3 days Warnings: do not use with MAOi SEs: **rhinitis medicamentosa**, nasal stinging, burning, dryness Notes: * Fast onset: 5-10 minutes ## Footnote MAOi: monoamine oxidase inhibitors rhinitis medicamentosa: rebound congestion if used more than 3 days

Question 30

**Oxymetazoline** brand dosage form RX or OTC Dosing

Answer 30

**Afrin**, Vicks Sinex, Zicam nasal spray OTC Age 6+: 2-3 s/nQ12H PRN ## Footnote intranasal decongestant

Question 31

Phenylephrine brand dosage form RX or OTC Dosing

Answer 31

Little Remedies nasal spray OTC Adult: 2-3 s or 0.25% to 1% per nostril Q4H PRN ## Footnote Intranasal decongestant

Question 32

Other Allergy Meds: **Intranasal Cromolyn** **Montelukast** Intranasal Ipratropium Immunotherapy

Answer 32

Intranasal Cromolyn * **NasalCrom** * OTC mast cell stabilizer * **used regularly** at onset of allergy season * safe in children + pregnancy * tx and prophylaxis of allergic rhinitis Montelukast * Singulair * Oral Leukotriene Receptor Antagonist * tx of allergic rhinitis & asthma * common use in children * BBW: risk of neuropsychiatric SEs Intranasal Ipratropium * helps decrease rhinorrhea by causing nasal dryness Immunotherapy * preventative tx via SubQ or sublingual * slowly ^ exposure to allergen (~3 yr tx) * Sublingual > Oralair (5 grass pollen), Grastek (Timothy grass pollen), Ragwitek (ragweed pollen), Odactra (house dust mite allergen) ## Footnote BBW: black box warning rhinorrhea: runny nose