PHRM 504 > Lecture 9: Allergies > Flashcards

Lecture 9: Allergies Flashcards

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1
Q

Allergy Rhinitis

A

Sneezing, itchy nose, eyes and roof of mouth, runny or stuffy nose: watery, red, swollen eyes
- Also called Hay fever

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2
Q

Allergic rhinitis pathophysiology

A

Systemic upper respiratory disease with primarily nasal symptoms

  • 4 phases
  • acute complications: sinusitis, otitis media
  • chronic complications: nasal polyps, sleep apnea, sinusitis, hyposmia
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3
Q

Four phases of allergic rhinitis

A
  1. Sensitization
  2. Early phase
  3. Cellular recruitment
  4. Late phase
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3
Q

Sensitization

A

initial allergen exposure stimulates beta-lymphocytic IgE (immunoglobin E) production

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4
Q

Early phase

A

release of preformed mast cell mediators (histamine, proteases) and production of additional mediators (prostaglandins, leukotrienes, etc.)

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5
Q

Cellular Recruitment

A

circulating leukocytes are attracted to nasal mucosa and release more inflammatory mediators

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6
Q

Late Phase

A

mucus hypersecretion - begins 2-4 hours after allergen

excess mucus secretion

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7
Q

Allergic rhinitis clinical presentation

A
  • May be intermittent (≤4 days per week or ≤4 weeks) or persistent (≥4 days per week or ≥4 weeks)
    • Frequent sneezing
    • Watery rhinorrhea (Nasal discharge)
    • Itchy eyes, nose, palate
    • Conjunctivitis
    • Allergic shiners, Dennie’s lines, allergic salute and crease
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8
Q

Allergic Rhinitis - Exclusions for self care

A
  • Children <12 years old
  • Pregnant or lactating women
  • Symptoms of non-allergic rhinitis
  • Symptoms of otitis media, sinusitis, bronchitis, or other infection
  • Symptoms of undiagnosed or uncontrolled asthma, COPD, or other respiratory disorder
  • Moderate to severe persistent allergic rhinitis or symptoms unresponsive to treatment
  • Severe or unacceptable side effects of treatment
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9
Q

Allergic Rhinits-Treatment Goals

A
  • Reduce symptoms
  • Improve functional status and sense of well-being
  • 3 steps:
    1. Avoid allergen
    2. Pharmacotherapy(OTC of Rx)
    3. Immunotherapy (Rx)
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10
Q

Allergic Rhinitis - Non-pharmacologic options

A

avoidance or removal of allergens
- Dust mites: Wash bedding weekly, limit carpets/upholstered furniture/ stuffed animals Cats: Weekly baths
Mold Spores: Lower household humidity, avoid raking
Nasal wetting agents: Saline, propylene, polethylene glycol nasal sprays or gels, neti pot

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11
Q

Non-pharmacologic options: Nasal wetting agent

A
  • Saline, propylene, polethylene glycol nasal sprays or gels, neti pot
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12
Q

Non-pharmacologic options: Avoiding or removing allergens

A

Dust mites: Wash bedding weekly, limit carpets/upholstered furniture/ stuffed animals Cats: Weekly baths
Mold Spores: Lower household humidity, avoid raking

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14
Q

Allergic Rhinitis - Pharmacologic Treatment

A
  • Intranasal corticosteroid, - Antihistamine (1st and 2nd Generation)
  • Mast cell stabilizer
  • Decongestant
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15
Q

Intranasal Corticosteroid Characteristics MOA

A

MOA: Inhibit multiple cell types and mediators (including histamine) in order to stop the allergic cascade

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15
Q

Intranasal Corticosteroids Drugs

A
  • Triamcinolone acetonide (55mcg/spray)
  • Fluticasone propionate (50mcg/spray)
  • Budesonide (32mcg/spray)
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16
Q

Intranasal Corticosteroid Characteristics Indication

A
  • Indication: treatment of nasal allergy symptoms (allergic rhinitis)
  • Use regularly for best results
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18
Q

Triamcinolone acetonide adult dosing

A
  • 55mcg/spray
  • 2 sprays in each nostril daily
  • may titrate down to 1 spray in each nostril
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19
Q

Fluticasone Propionate Adult dosing

A
  • 50mcg/spray
  • 2 sprays in each nostril for 1 week
  • may titrate down to 1 spray in each nostril
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20
Q

Budesonide Adult dosing

A
  • 32mcg/spray

- 2 sprays in each nostril daily

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21
Q

Triamcinolone acetonide pediatric dosing 6-11 years old

A

6-11 years old: 1 spray in each nostril daily

- may increase to 2 sprays in each nostril

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21
Q

Fluticasone Propionate pediatric dosing

A

4-11 years old: 1 spray in each nostril daily

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23
Q

Budesonide Pediatric dosing

A

6-11 years old- 1 spray in each nostril daily

- 2-5 years old- N/A

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24
Q

Antihistamines MOA

A

MOA: compete with histamine at central and peripheral H1 receptor sites to prevent histamine-receptor interaction and resulting mediator release

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25
Antihistamines Indication
Relief of symptoms of allergic rhinitis and other types of immediate hypersensitivity reactions
26
First Generation Antihistamine Characteristics
Sedating / nonselective - Lipophilic- able to cross blood brain barrier - Peak effect in 1.5- 3 hours
27
First Generation antihistamine special populations
- Avoid in children unless under direction of a primary care doctor (PCP) due to paradoxical excitation - Avoid in elderly patients due to increased risk of drug interactions and CNS depression
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First Generation anti-histamine drugs
Diphenhydramine | Chlorpheniramine
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Diphenhydramine adult dosing 12 and older:
25-50mg every 4-6 hours | MDD: 300mg
30
Diphenhydramine dosing 6-11 years old
12.5-25mg every 4-6 hours | MDD: 150mg
31
Diphenhydramine dosing 2-5 years old
6.25mg every 4-6 hours | MDD: 37.5 mg
32
Chlorpheniramine dosing adults 12 and over
4 mg every 4-6 hours | MDD: 24 mg
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Chlorpheniramine dosing 6-11 years old
2mg every 4-6 hours | MDD: 12mg
34
Chlorpheniramine 2-5 years old
N/A
35
1st generation antihistamine adverse effects
- CNS depression - sedation, poor performance, incoordination, reduced motor skills (more common in adults) - CNS stimulation - anxiety, hallucinations, appetite stimulation, muscle dyskinesias (more common in children) - Anticholinergic - dry eyes and mucous membranes, blurred vision, urinary hesitancy and retention, constipation, reflex tachycardia
36
First Generation Antihistamines Contraindications
- newborn/premature infant - lactating women - narrow angle glaucoma - use of MAOI medication ( drugs that treat depression)
37
First Generation Antihistamines Drug interactions
- Anticholinergic medications ( drugs that block action of acetylcholine- neurotransmitter) - alcohol - sedative medications
38
High doses of Benadryl cause
seizures, hallucinations, agitation, confusion, hyperthermia, arrhythmias
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Second Generation Antihistamines Characteristics
- Nonsedating/selective - Protein bound lipophobic molecules - do not readily cross blood brain barrier - Peak effect in 1 - 3 hours,
40
Second Generation Antihistamines Drugs
Loratadine (nonsedating) Fexofenadine (nonsedating) Cetirizine ( moderate sedation) Levocetirizine (moderate)
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Loratadine adult dosing | nonsedating
10mg every 24 hours
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Fexofenadine adult dosing | nonsedating
60mg every 12 hours or 180mg every 24 hours
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Cetirizine adult dosing | moderate sedation
10mg every 24 hours *avoid in adults older than 65 years unless recommended by PCP
44
Levocetirizine adult dosing | moderate sedation
5mg every 24 hours *avoid in adults older than 65 years unless recommended by PCP
45
Loratadine pediatric dosing
For 6-11 yrs old: 5-10mg every 24 hours For 2-5 yrs old: 2.5mg every 12 hours For less than 2: N/A
46
Fexofenadine pediatric dosing
For 2-11 yrs old: 30mg every 12 hours | For less than 2: N/A
47
Cetirizine pediatric dosing
For 6-11 yrs old: 10mg every 24 hours For 2-5 yrs old: 2.5mg once or twice daily OR 5mg every 24 hours For 6-12 months: 2.5mg daily (ask doctor) 12-24 month: 2.5mg once to twice daily (ask doctor)
48
Levocetirizine pediatric dosing
For 6-11 yrs old: 2.5mg every 24 hours For 2-5 years old: 1.25mg every 24 hours For less than 2: N/A
49
2nd generation antihistamine adverse effects
rare compared to first generation antihistamines
50
2nd generation antihistamine Drug interactions
• Fexofenadine + fruit juice (apple, grape, orange): Juices inhibit intestinal organic anion transporting polypeptides (OATPs) - Separate juice and drug by 2 hours • Fexofenadine + ketoconazole = increased fexofenadine concentration • Fexofenadine + erythromycin = increased fexofenadine concentration • Loratadine + amiodarone = increased risk of QT prolongation
51
First vs Second Generation Antihistamines
- both have similar efficacy, second gen have less adverse reactions/ effects - first gen may be used for the anticholinergic effects (somnolence, drying)
52
Mast Cell Stabilizer Characteristics
MOA: blocks influx of calcium into mast cells to block mediator release Indication: prevent and treat symptoms of allergic rhinitis Limited system absorption - good in pregnancy and lactation - May take 3-7 days for any effect and 2-4 weeks for maximal effect - Cromolyn sodium
53
Mast Cell Stabilizer Adverse effects
sneezing, nasal stinging, burning
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Mast Cell stabilizer drug interactions
None
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Cromolyn sodium dosing
For 2 and older- 1 spray in each nostril 3-6 times daily
56
Decongestant Characteristics
MOA: adrenergic agonist (sympathomimetics) - stimulate alpha-adrenergic receptors to constrict blood vessels which decreases sinusoid vessel engorgement and mucosal edema Indication: temporary relief of nasal and eustachian tube (passage from the pharynx to the middle ear cavitiy) congestion and for cough associated with postnasal drip - there are Topical and oral options
57
Oral Decongestant Characteristics and drugs you can use
• Peak 0.5 - 2 hours after administration - Phenylephrine - Pseudoephedrine
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Oral decongestant adverse effects
Adverse Effects: - Cardiovascular stimulation: elevated blood pressure (BP), tachycardia, palpitation, arrhythmia • CNS stimulation: restlessness, insomnia, anxiety, tremors
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Oral decongestant Caution
- hypertension - hyperthyroidism - heart disease - elevated intraocular pressure (fluid pressure in eye) - prostatic hypertrophy enlarge prostate glands
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Oral decongestant Drug interactions
Drug Interactions: Antacids, MAOIs, TCAs ( antidepressants)
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Phenylephrine adult dosing
10mg every 4 hours | MDD: 60mg
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Pseudoephedrine adult dosing
60 mg every 4-6 hours | MDD: 240mg
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Phenylephrine pediatric dosing
For 6-11 years old: 5mg every 4 hours MDD: 30mg For 4-5 years old: 2.5mg every 4 hours MDD: 15mg
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Pseudoephedrine pediatric dosing
For 6-11 years old: 30mg every 4-6 hours MDD: 120mg For 4-5 years old: 15mg every 4-6 hours MDD: 60mg
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Combat Methamphetamine Epidemic Act of 2005
- intended to decrease availability of pseudoephedrine - Bans OTC sale of pseudoephedrine - Limit the amount purchased by individuals each month - Max 3.6g per day - Max 9g per month - Pharmacies must check photo ID and maintain a logbook
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Topical decongestants drug
Oxymetazoline
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Topical decongestants drug 6 and older dosing
For 6 years and older: 2-3 drops/sprays not more than every 10-12 hours ( MDD: 2 doses/ 24 hours)
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Topical decongestants dosing for 2-5 years old
For 2-5 years old: Not recommended in children less than 6 years except under advice/ dosing of PCP
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Topical decongestants drug adverse effects
Rare due to poor systemic absorption - May include nasal burning, stinging, sneezing, dryness Rebound congestion: Generally recommended using for a maximum of 3-5 days
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Allergy case- You must use the PPCP
Collect: SCHOLARMAC Assess: Exclusions? Interacting medicatiosn? Contraindications? Plan: What is the best treatment option Implement: Explain choice to patient and provide medication counseling Follow up: How soon should the patient feel better? Next steps?
71
Clinical pearls
1. intranasal steroids may be more effective than antihistamines at relieving congestion 2. antihistamines may be more effective at relieving histamine mediated symptoms (sneezing, runny nose, ocular symptoms) 3. Intranasal steroids and antihistamines work best when taken regularly, not as needed
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