Updated Drug Therapies for Nasal Congestion, Cough, and to Decrease Histamine Effects and Allergic Responses

Antitussives prototype

Dextromethorphan - non-opioid, codeine - opioid

Dextromethorphan Tx

Treatment of nonproductive cough

Dextromethorphan MOA:

Work in the CNS to directly suppress the cough reflex in the medullary cough center, will also cause drying of mucus membranes

Dextromethorphan CI/C:

• Pregnancy or breastfeeding

• Don't use if head injury or CNS depression (concussion or sedated etc.) since they work directly on the CNS

• Don't use with children under 4 years old - risk of CNS effects

• In men with BPH this drug can cause urinary retention

Dextromethorphan AE:

• Oversedation, drowsiness, confusion, dizziness (CNS effects)

• drying effect (nausea, dry mouth, nasal irritation, constipation) - will need to drink water

• Tachycardia, HTN, restlessness

Dextromethorphan Teaching points:

•Don't mix with alcohol

•Do not drive or operate heavy machinery while on medication

Dextromethorphan DI

Codeine and Hydrocodone are opiates so abuse potential exists along with rest of side effects - avoid ETOH!, MAOIs (can cause hypotension, fever, coma)

A way to remember Anticholernergic side effects

Can’t see, can't pee, can't spit, can't shit

Nebulizer

-Uses compressed air to change liquid drug into fine mist for inhalation

-If using hand-held device or mask sit upright or in a Semi-Fowler position

-Breathe slowly and deeply during treatment

-Rinse out mouth and clean device when treatment is over

Inhalers

-Wait at least 1 minute between inhalations of the same medications

-If 2 inhaled medications are prescribed, wait at least 5 minutes between medications

-spacer is used to hold the dose of the drug while the patient inhales

Mast Cell Stabilizers Prototype

Cromolyn

Cromolyn MOA

suppresses inflammation, does not cause bronchodilation. Effects less than steroids so not preferred drug for asthma but can be useful if issues tolerating steroids.

Cromolyn Therapeutic Use

used for prophylaxis in mild persistent asthma, exercise induced bronchospasm (EIB), intranasal can relieve allergic rhinitis

Cromolyn Teaching

Used for prevention of asthma exacerbation. May take several weeks to see therapeutic effects. Not to be used for emergent situations!

Rescue and maintenance inhalers

Inhale the short-acting beta2 agonist (SABA) before inhaling the glucocorticoid. The beta2 agonist promotes bronchodilation and enhances the absorption of the glucocorticoid

Topical Nasal Decongestants-Nasal Sympathomimetic Prototype

Oxymetazoline (Afrin)

Oxymetazoline (Afrin), Pseudoephedrine/phenylephrine AND Fluticasone (Flonase) MOA:

Treatment of nasal/sinus congestion due to overproduction of mucus secretions - rhinitis, sinusitis, otitis

Oxymetazoline (Afrin) MOA

Causes vasoconstriction (activating the SNS receptors) in the nasal passages and sinuses - shrinks swollen mucous membranes and opens clogged passages. This works FAST (within minutes)

Oxymetazoline (Afrin) CI/C and AE

CI/C: Must check nares to make sure no lesions or erosions exist before administering (CI)

AE: Nose bleeds, irritation of the membranes, erosions (take a long time)

Oxymetazoline AE

Nose bleeds, irritation of the membranes, erosions (take a long time)

Oxymetazoline (Afrin) Teaching Points

• Proper technique needed to deliver medication - sit upright, hold down the opposite nostril when spraying medication

• may be aerosol (shake well) or spray

• Mimics the sympathetic nervous activity

  • So increased HR, BP, Resp, Agitation, CAUTION when underlying conditions are related to this activity (HTN, Anxiety, Arrythmia, Insomnia etc.)

• Should only use for 3-5 days before risking rebound congestion

Oxymetazoline DI

Oral Decongestants-Oral Sympathomimetics Prototype

P - Pseudoephedrine, phenylephrine

You should only use Oxymetazoline (Afrin) for how long?

Should only use for 3-5 days

Pseudoephedrine, phenylephrine TX

Treatment of nasal/sinus congestion due to overproduction of mucus secretions - rhinitis, sinusitis, otitis

Pseudoephedrine, phenylephrine MOA

: SNS mimic (sympathomimetic) - causes vasoconstriction (activating the SNS receptors) in the nasal passages and sinuses - shrinks swollen mucous membranes and opens clogged passages

Pseudoephedrine, phenylephrine AE and CI/C:

AE: HTN, Anxiety, Insomnia, arrythmias

Caution with conditions that don't play well with the SNS - glaucoma, HTN, diabetes, thyroid disease, prostate problems, coronary artery disease (CAD)

Caution in pregnancy - not really studied in pregnancy so risk vs reward here

Pseudoephedrine, phenylephrine

This is a systemic medicine (whole body affected) so SNS effects are more likely and more annoying - tremor, anxiety, agitation, pallor, sweating, racing heart

Pseudoephedrine, phenylephrine Teaching Points:

Teaching Points:

Should only use for up to 7 days before risking rebound congestion (rebound vasodilation called rhinitis medicamentosa) - not for chronic rhinitis

Topical Nasal Steroid Prototype

Fluticasone (Flonase)

Fluticasone (Flonase) MOA

We are not sure but know that steroids have an anti-inflammatory effect - therapeutic effect is not immediate and may take up to **2-3 weeks to develop full therapeutic effect

Fluticasone (Flonase) AE

Very few- over-drying of the mucosa, headache. We like this medicine because it has very few systemic effects compared to oral steroids or antihistamines - great for pregnant/lactating women

Fluticasone (Flonase) Teaching Points

Spray out towards nasal mucosa - not directly up nose

Must use consistently to be effective and must have patience since effectiveness is delayed

May cause local burning, irrigation, stinging, headache

May put you at risk for infection

Steroids lower immune response - so cannot give in the presence of an acute infection and must avoid airborne infections - notify provider if signs of infection

Client can take non-NSAID analgesic like Tylenol if they experience headache

**More effective than oral antihistamines for nasal and eye allergy symptoms

Expectorants Prototype

P - Guaifenesin (Mucinex)

Guaifenesin (Mucinex) TX

Tx: To help cough up thickened secretions in the respiratory tract - bronchitis, pneumonia, etc.

Guaifenesin (Mucinex) MOA

Thin out lower respiratory tract secretions by reducing surface tension making it easier to have a productive cough and clear airways. Increase production of respiratory secretions, which in turn decrease viscosity of mucous

Guaifenesin (Mucinex) CI and AE

CI: Clients with diabetes (sugar content)

AE: GI symptoms - n/v/loss of appetite (anorexia)

Guaifenesin (Mucinex) Teaching Points

Teaching Points:

Need to find the origin of the cough/thickened secretions as this med may mask symptoms - ****do not use longer than one week!

Increase fluid intake to help expectorant liquify secretions

This is the only expectorant on the market, so it shows up in many combination OTC meds to treat cold and flu symptoms - make sure to check what is in each so you don't take excessive doses

Short Acting Beta2 Agonists (SABAs)

-Albuterol, levalbuterol

-Used as needed in bronchospasm. 2 puffs inhaled q4h PRN. Used more frequently in acute bronchospasm. For exercise-induced bronchospasm 2 puffs inhaled x1 5-30 minutes before exercise.

Long Acting Beta2 Agonists (LABAs)

-Formoterol, salmeterol

-Used every 12 hours for long-term control and are not used to abort an asthma attack or exacerbation. Not used alone but are prescribed in combination with an inhaled glucocorticoid

Key points about Long-Acting Beta₂ Agonists (LABAs)

Can increase risk of asthma-related death when used alone so typically paired with inhaled glucocorticoid or anticholinergic

Only used when inhaled glucocorticoid has been inadequate by itself

best used for long term control

Mucolytics Prototype

P - Acetylcysteine (Mucomyst)

Acetylcysteine (Mucomyst) Tx:

Tx: Increase or liquefy respiratory secretions to aid the clearing of the airways in high-risk respiratory patients who are coughing up thick, tenacious secretions. Patients may be suffering from conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumonia, or tuberculosis. Also used to treat Tylenol overdose

Acetylcysteine (Mucomyst) MOA:

Liquify lower respiratory tract secretions (break up the protein bonds in the mucous) making it easier to have a productive cough and clear airways

Acetylcysteine (Mucomyst) AE:

GI upset, rash, bronchospasm (because it is inhaled), rotten egg smell can induce nausea

Acetylcysteine (Mucomyst) Teaching Points:

Caution with acute bronchospasm, peptic ulcer, or esophageal varices (or active bleeding in the GI) - could make these things worse

For high-risk respiratory patients, this medication is administered with a nebulizer (inhaled aerosol)

Monitor respiratory status frequently (auscultation of lungs).

Encourage to cough up secretions instead of swallowing them

Have suction equipment available and help the client suction as needed

Leukotriene Receptor Antagonists - drugs that affect inflammation Prototype

P: montelukast, zafirlukast

montelukast, zafirlukast MOA:

either block or antagonize receptors for the production of leukotrienes D4 and E4 - which are components of asthma

montelukast, zafirlukast CI/C:

caution in pts with hepatic or renal impairment; fetal toxicity has been reported in animal studies, so use in pregnancy and lactation should benefit the mother more than it risks the fetus; are not to be used for an emergency asthma attack - this is a maintenance drug

montelukast, zafirlukast AE:

AE: HA, dizziness, N, diarrhea, ABD pain, elevated liver enzymes (P-450 system) with zafirlukast, neuropsychiatric symptoms and suicidal ideation

montelukast, zafirlukast DI:

phenobarbital, rifampin, and phenytoin may need higher doses of montelukast. Zafirlukast can increase levels of warfarin which could cause?

Oral steroids - drugs that affect INFLAMMATION Prototype

Prednisone

Prednisone MOA

suppress inflammation (prevent release of leukotrienes, prostaglandins, and histamine)

decrease infiltration of inflammatory cells (eosinophils, leukocytes), decreased edema of airways

Prednisone CI/C

peptic ulcer disease, diabetes, HTN, renal dysfunction, or regular NSAID use. If client has systemic fungal infection or recently received a live virus vaccine avoid giving steroid

Prednisone AE

suppression of adrenal function, muscle wasting/bone demineralization, hyperglycemia, PUD, immunosuppression (will have increased risk for infection if on long term therapy), hypernatremia, hypokalemia

Prednisone Teaching

-Monitor plasma drug levels to determine the amount of adrenal function suppression.

-Observe for signs of infection that may not include fever or inflammation because these body responses are suppressed by steroids (sore throat, fatigue, tachycardia, wound discharge). Notify provider immediately

-For long term use (10 or more days) dose will need to be tapered due to potential for adrenal crisis

-Take gastric-protective measures to prevent ulcers (take PPI, avoid NSAIDs).

Predinisone DI:

Furosemide (increased risk of hypokalemia), NSAIDS (increased risk of GIB), insulin and oral hypoglycemics effectiveness reduced while on steroids

Inhaled steroids - drugs that affect inflammation Prototype

P: Beclomethasone

Beclomethasone MOA:

suppress inflammation (prevent release of leukotrienes, prostaglandins, and histamine) decrease infiltration of inflammatory cells (eosinophils, leukocytes), decreased edema of airways, used for long-term management of asthma or COPD

Beclomethasone CI/C

CI/C: these medications should not ever be used for the treatment of an acute asthma attack or status asthmaticus; use with caution in active respiratory infection

Beclomethasone Adverse Effects

due to the route of administration; sore throat, hoarseness, coughing, dry mouth, and pharyngeal/laryngeal fungal infections, oral thrush (use spacer to decrease drug contact with mouth and oral pharynx)

Inhaled steroids are beneficial because they have fewer systemic effects than oral steroids

Beclomethasone Teaching

Teaching:

contact the MD if there are S/S of respiratory infection

May take 2-3 weeks to reach effective levels

To prevent thrush patient needs to wash out mouth well after use

Anticholinergics - another bronchodilator Prototype

ipratropium

ipratropium MOA

MOA: inhibits the action of acetylcholine at vagal-mediated receptor sites and relaxes smooth muscle leading to bronchodilation

ipratropium CI/C

caution in any condition that could be aggravated by anticholinergic effects (narrow angle glaucoma, bladder neck obstruction, or prostate hypertrophy)

ipratropium AE

dizziness, HA, fatigue, nervousness, dry mouth, sore throat, palpitations, and urinary retention

ipratropium DI

DI: don't combine with any other anticholinergics

ipratropium teaching points

Teaching Points: Fewer systemic effects than SABAS - not as effective so do not use in acute asthma exacerbation as a rescue drug

Short-Acting Beta₂ Agonists Prototype

P: albuterol, levalbuterol

Albuterol: MOA

mimic the effects of the SNS; relaxes smooth muscle and dilates the bronchi, decreases wheezing, helps airways stay open!

Albuterol CI/C

CI/C: "these drugs are contraindicated or should be used with caution, depending on the severity of the underlying condition" including valvular disease, vascular disease, arrhythmias, diabetes, and hyperthyroidism - need to be monitored closely because of increase in SNS stimulation; used in pregnancy and lactation only if the benefits to the mother outweigh the risks to the fetus/infant

Albuterol AE

attributed to sympathomimetic stimulation (increased BP, tachycardia, decreased renal and GI blood flow, sweating, pallor, flushing, tremors), increased blood glucose, hypokalemia

Albuterol Teaching

proper delivery of inhaled medication, avoid caffeine

Albuterol DI

DI: avoid the use of other stimulants - especially if the client finds the adverse effects of the medication uncomfortable

Albuterol can or cannot be used in emergent situations?

Can be used in emergent situations to open the airway!

Methylxanthines Prototype

P: Theophylline

Theophylline MOA

relaxes smooth muscles of the bronchi resulting in bronchodilation

Theophylline CI/C

CI/C: caution with a history of GI, coronary, respiratory, renal, or hepatic disease, caution with alcoholism and hyperthyroid; no studies on effects of xanthines in pregnancy, but has been associated with fetal abnormalities and breathing problems

Theophylline AE

associated with level of theophylline in the blood; narrow therapeutic range 10 - 20 mcg/dl; restlessness, insomnia, GI upset, N, V, irritability, tachycardia, seizures, brain damage and death

Theophylline Teaching

Teaching: take with food, avoid other stimulants (caffeine!), drug-drug interactions; does the patient smoke?

Antihistamines: 1st Generation Prototype

P - Diphenhydramine (Benadryl)

Diphenhydramine Treatment

Seasonal allergies, acute allergy attacks, narrowed airways due to allergic response, runny nose (rhinorrhea), urticaria

Diphenhydramine MOA

Selectively block histamine receptor sites to blunt the allergic response (mild: runny nose, watery eyes, sneezing, itchy skin, itchy ears, or major: anaphylaxis), also has anticholinergic properties

Diphenhydramine CI/C

CI/C:

-Can't give to anyone with narrow angle glaucoma

-Caution/Be careful if you have renal or liver problems (closely monitor)

-Do not mix with alcohol - may cause life threatening CNS depression

-May cause QT elongation

Diphenhydramine AE

Major sedation, balance problems, confusion, urinary retention, constipation

(not the best drug for elderly or those at risk for falls)

Will likely cause sedation and some urinary retention

Antihistamines: 2nd Generation Prototype

P - cetirizine (Zyrtec)

cetirizine tx:

Seasonal allergies, runny nose (rhinitis), chronic idiopathic urticaria

cetirizine CI/C

Don't give to infants under 6 months. Caution in breastfeeding women

Caution/Be careful with them if you have renal or liver problems (closely monitor)

cetirizine AE

Over drying, sedation, confusion, urinary retention

Which generation of histamines is better for elderly patients?

2nd Generation antihistamines are non-sedating (better option for elderly and those at risk for falls),

though cetirizine can still be moderately sedating

cetirizine Teaching Points

Drink those 8 glasses of water with these

cetirizine DI

CI/C:

Don't give to infants under 6 months.

Caution in breastfeeding women

Caution/Be careful with them if you have renal or liver problems (closely monitor)

Cetirizine MOA:

MOA: Selectively block histamine receptor sites to blunt the allergic response (mild: runny nose, watery eyes, sneezing, itchy skin, itchy ears, or major: anaphylaxis)