Eyes, Ears, Nose and Skin Conditions

Symptoms of allergies:

sneezing

runny nose

thin, clear mucus

wheezing

red, watery eyes

symptoms can last for days or months after contact with allergies

Symptoms of cold:

sneezing

runny nose

thick, dark mucus

sore throat

body aches

symptoms take about three days to appear and usually last for about a week

Non drug treatment of allergic rhinitis:

avoiding exposure to known or suspected allergen

vacuuming carpets, drapes, and upholstery with HEPA vacuum cleaner

What are common allergens?

pollens

molds

dust mites

animal dander

Nasal irrigation

combined with distilled, sterile or previously boiled and cooled water.

tap water should not be used.

can be administered using a syringe or neti pot, then pour into one nostril and drained out of the other nostril while breathing through the mouth

What are 1st line medications for chronic, moderate to severe symptoms?

intranasal steroids

1st line treatment for milder, intermittent symptoms:

oral antihistamines

MOA of intranasal steroids:

work by decreasing inflammation.

Intranasal steroid medications:

budesonide (Rhinocort allergy)

fluticasone (Flonase allergy relief, Flonase sensimist, children’s Flonase)

triamcinolone ( nasacort allergy 24 HR, nasacort allergy 24 HR children)

beclomethasone (Becconase AQ)

Side effects of intranasal steroids:

epistaxis

What is the preferred nasal steroid during pregnancy?

budesonide and beclomethasone

How long can it take to see relief from intranasal steroids?

up to 1 week to get full relief

1st generation oral antihistmaines:

diphenhydramine (benadryl)

chlorpheniramine (Aller-chlor)

doxylamine (unisom)

dosing of benadryl:

adult: 25 mg by mouth every 4-6 hours or 50 mg by mouth every 6-8 hours

do not use OTC in children < 6 years old unless directed by healthcare provider

Warnings in 1st generation oral antihistamines:

avoid in elderly patients and children < 2 years old

prostate enlargement

use with caution in patients with glaucoma

Side effects of 1st generation antihistamines:

somnolence

cognitive impairment

strong anticholinergic side effects

Second generation oral antihistamines:

cetirizine (Zyrtec allergy, Zyrtec children’s allergy) + pseudoephedrine ( Zyrtec-D)

levocetirizine (Xyzal allergy 24 HR, Xyzall ALLergy 24 HR children)

fexofenadine (allegra allergy, allegra allergy childrens) + pseudoephedrine (Allegra-D)

loratadine (Claritin, claritin children’s) + pseudoephedrine (Claritin-D)

Most sedating 2nd generation antihistamines:

cetirizine

levocetirizine

Less sedating 2nd generation antihistmine:

fexofenadine

loratadine

MOA of decongestants:

alpha adrenergic gonists that causes vasoconstriction.

Systemic oral decongestants:

phenylephrine (Sudafed PE)

Pseudoephedrine (Sudafed, Nexafed, Zephrex-D

Contraindication to systemic oral decongestant:

do not use within 14 days of MAO inhibitors

Warnings for systemic oral decongestants:

avoid in children <2 years (FDA) and <4 years (package labeling)

use with caution in patients ith CV disease and uncontrolled hypertension

can increase the IOP ( caution in glaucoma patients)

avoid during the 1st trimester of pregnancy

Side effects of systemic oral decongestants:

cardiovascular stimulation: tachycardia, palpitations, increased BP

CNS stimulation: anxiety, tremors, insomnia

decreased appetite

Intranasal decongestants:

oxymetazoline (Afrin)

Side effects of intranasal decongestants:

rhinitis

medicamentosa( rebound congestion if used longer than 3 days)

What is the maximum pseudoephedrine allowed for purchase?

3.6 grams per day

9 gram in a 30 day period

Intranasal cromolyn: NasalCrom

mast cell stabilizer used for treatment and prophylaxis of allergic rhinitis

used regularly not PRN

Medication commonly used in children for allergic rhinitis and asthma:

montelukast: singulair

What is a preventative treatment for allergies?

immunotherapy

Common cold:

a viral infection of upper respiratory tract.

transmitted by mucus secretions or by the air

Natural drug treatment for colds:

zinc

vitamin C: ascorbic acid

echinacea

airborne

emergen-C

BY how long does vitamin C decrease the duration of a cold?

it decreases it by 1-1.5 days at doses of 1-3 grams per day

Expectorants:

guaifenesin ( mucinex, robiitussin mucus + chest congestion, robafen) + dextromethorphan ( robafen DM, robitussin DM)

When are expectorants used?

for productive cough to help thin the mucus

Cough seppressants:

dextromethorphan (Delsym, robafen cough, robitussin cough) + guaifenesin ( robafen DM, robitussin DM)

codeine

benzonatate (tessalon perles)

diphenhydramine (benadryl)

Contraindications to dextromethorphan:

do not use within 14 days of an MAO inhibitor

Warnings of dextromethorphan:

serotonin syndrome

Boxed warning for codeine products used for cough suppressants:

respiratory depression and death have occurred in children who received codeine following tonsillectomy and/or adenoidectomy and had evidence of ultra rapid metabolizers.

Contraindications to codeine products:

do not use in children < 12 years of age or in children < 18 years of age after tonsillectomy and/or adenoidectomy

FDA recommends avoiding codeine cough and cold products:

patients <18 years of age

cough and cold combination products:

dextromethorphan/promethazine

brompheniramine/pseudoephedrine/dextromethorphan (bromfed DM)

promethazine/codeine: C-V

chlorpheniramine/hydrocodone (tussicaps): C-II

Children < 4 years old avoid:

OTC cough and cold products

Children < 2 years avoid:

OTC cough and cold products

promethazine

topical menthol and camphor

Children < 18 years old avoid:

codeine and hydrocodone contianing cough and cold products