Cough+Cold/Pharyngitis/Sinusitis/Acute Otitis Media/Mastoiditis Pharmacology

Common Cold

PP: viral infection of upper respiratory tract
contagious period→until sx persist

RF: smoking
very young
very old
recent exposure to infected contacts

E: m/c→rhinovirus
preschool-aged (average: 3-8 times/year)
elementary school-aged (average: 3-8 times/year)

CM: rhinorrhea
nasal obstruction
sneezing
cough

TX: no antibiotics
self limiting
sx relief

Cough+Etiology

PP: mechanical/chemical stimuli→forceful expulsion of air→removes irritant in airway
mechanism poorly understood

E: asthma
COPD
smoking infection
lung cancer
GERD/GI dysfxn
allergic rhinitis
bacterial sinusitis
ACE inhibitors→lisinopril
cough hypersensitivity syndrome

Cough Tx Considerations

identify+treat cause:

palliative tx→used until source problem resolved

postnasal drip:

• PO antihistamines

• nasal decongestants

• intranasal steroids

ACE inhibitor:

• change to ARBs

acid reflux associated cough:

• H2 receptor antagonist (rantidine)

• PPI (omeprazole)

• URI

• don’t suppress cough→clears mucus from lungs+improves breathing

assesment

• acute vs chronic cough

• dry vs productive (mucus) cough

Cough/Cold Tx Goals

1st line→NP

• rest

• increased fluid intake

• reduce severity of sx

• observe course of infection

Cough/Cold Nonpharmacologic/NP Tx

maintain cleanliness+hygiene→reduce transmission

• disinfect environment

• wash hands regularly

rest

hydration

position mattress at 45° angle

maintain comfortable temperature+humidity

stop smoking+alcohol

Pharmacologic/Mx Tx List

alleviate severity of sxs

topical/PO/nasal decongestants ±antihistamines

intranasal anticholinergic

non-steroidal anti-inflammatories (NSAIDS)
-ibuprofen

pain/fever reducers
-acetaminophen

antitussives
dry:
-dextromethorphan
-codeine
-benzonatate

mucolytics

Pseudoephedrine

MX: decongestants

MOA: direct alpha+beta agonist→vasoconstriction+bronchiole relaxation (respectively)

I: reduce pain
fever

ROA: IR
ER tablets
behind the counter+prescription restrictions
acute cough→add antihistamine

AE: increased BP
increased HR
CNS sx: restlessness
insomnia
anxiety
stimulation
headaches

CI: uncontrolled HTN
narrow angle glaucoma

Phenylephrine+Nasal Oxymetolazine

MX: decongestants

MOA: direct alpha antagonist→vasoconstriction

I: reduce pain
fever

ROA:
PE: nasal spray
PO tablets

O: nasal

over the counter
acute cough→add antihistamine

AE: PE less effective than pseudoephedrine

topical/nasal: little systemic absorption
palpitations
headaches

prolonged use (over 3+ days)→rebound congestion

1st Generation Antihistamines

MX: diphenhydramine
chlorpheniramine

MOA: non-selective competitive antagonist of histamine H1 receptor

I: reduce pain
fever

ROA: Q 4-6 hours

AE: more anticholinergic sx than 2nd gen AH
CNS effects→increased fall risk
kids→paradoxical stimulation

CI: elderly
bladder obstruction
benign prostatic hyperplasia (BPH)
narrow-angle glaucoma

2nd Gen Antihistamines

MX: cetirizine
loratidine
levocetirizine
desloratadine
fexofenadine

MOA: selective competitive antagonist of histamine H1 receptor

I: reduce pain
fever

AE: fewer anticholinergic effects
don’t act centrally: larger protein→difficulty crossing BBB
don’t work as quickly as 1st gen→last longer

Intranasal Anticholinergic

MX: ipratropium 0.06%
Rx nasal spray

I: reduce pain
fever

MOA: inhibits serous+seromucous gland secretions→dries up runny nose→improves rhinorrhea (doesn’t improve nasal congestion)

AE: nasal dryness
epistaxis (nose bleeding)
headache

CI: don’t use more than 4+ days
narrow angle glaucoma
benign prostatic hypertrophy (BPH)
pregnancy
lactation

Ibuprofen

MX: NSAIDs

MOA: inhibits COX-2 enzyme→reduces prostaglandin synthesis→reduces inflammation

I: reduce pain
fever

ROA: PO
onset→30-60 min
half life→4 hours→take q4-6h

AE:
abdominal cramps
nausea
indigestion

CI:
peptic ulcers
GI hemorrhage
prolonged bleeding time
mild liver enzyme elevations
acute kidney injury (AKI)
CV concerns

CI MX:

antiplatelet property mxs:

• P2Y12 inihibitors

• other NSAIDS

• SSRIs

anticoagulants
alcohol
aminoglycosides
ARBs
ACEs

Black Box:
cardiovascular effects: increased BP→increased stroke risk
GI effects
renal impairment
pregnancy
lactation
babies under 6 months

Prostaglandins vs NSAIDs Effects On Kidney

prostaglandins:

• increased arteriole vasodilation

• increased blood flow

NSAIDS:

• decreased prostaglandin concentration

• decreased bloodflow to kidney→can cause damage

NSAIDS Effects On Gut

take with food:

• protects GI lining

• gets rid of stomach defenses→ulcers→mucosal injury+bleeding+more ulcers

Acetaminophen

MOA: activates descending serotonergic inhibitory pathways in CNS→decreases pain

inhibitors hypothalamic heat-regulating centers

overdose→depletes glutathione

overdose tx:

• activated charcoal

• n-acetylcysteine

I: fever
reduce pain

ROA:
PO
PR
IV
q 4-6 hrs
onset→30-60 min
half life→4 hrs
do not exceed 4+ grams/day→unintentional overdose

CI: acute hepatic failure
hepatotoxicity
heavy alcohol use
alcoholic liver disease

CI MX: several CYP enzymes (interactions infrequent/rare)
warfarin
phenytoin

Black Box: max dose→liver toxicity
prophx→pt education

Expectorants

MX: guaifenesin

MOA: increases hydration of respiratory tract→decreases mucus viscosity→improved mucous clearance

I: productive cough

ROA: IR
ER
liquid solution
syrup
over the counter
can combine with codeine
recommended increase in water intake→increases mucous viscosity

AE: nausea
vomiting
upper respiratory infection (URI)→decreases cough reflex

sxs not improving in 7 days→reach out to provider

Antitussives

MX: dextromethorphan
codeine

MOA: decreases sensitivity of cough receptors+depresses medullary cough center

I: dry cough

AE: nausea
vomiting
constipation
upset stomach

CI:

Dextro:

• structurally related to morphine

• low doses→does not contain addictive/analgesic qualities

• high doses→addictive quality (“robo-tripping”)

Codeine:

• combination with 1+ non-codeine ingredient

• analgesic properties→addictive

• impaired respiratory reserve

• substance abuse hx

• other respiratory depressants

NMDA Receptor Antagonist

MX: benzonatate

MOA: anesthetic action→suppresses respiratory stretch receptor action

I: dry cough

AE: dizziness
dysphagia
seizures
generally ineffective

Honey

MOA: kids (1-18 y/o)→can be used as an antitussive+improves sleep
same as dextromethorphan

I: dry cough
kids (1-18 y/o)

AE: nervousness
insomnia
hyperactivity

Cough/Cold Combination Txs

dayquil:

• phenylephrine (decongestant)

• dextromethorphan (cough suppressant)

• acetainophen (pain reliever)

nyquil:

• phenylephrine (decongestant)

• dextromethorphan (cough suppressant)

• acetaminophen (pain reliever)

• doxylamine (antihistamine)

mucinex DM:

• guaifenesin (expectorant)

• dextromethorphan (cough suppressant)

claritin D:

• loratadine (antihistamine)

• pseudoephedrine (decongestant)

caution of acetaminophen content in combination products

Rhinosinusitis Causative Organisms

m/c→viruses (90-98%)
-following a viral URI/common cold

bx (70%)

• s pneumoniae

• h influenzae

• peds→m catarrhalis

bx indications

• persistent sx
  -last over days+don’t improve

• severe sx
  -high fever 102°F+
  -purulent nasal discharge x 3-4 days at beginning of illness

• double sickening
  -appear to improve→sudden worsening after 5 days

Rhinosinusitis Clinical Presentation

nasal discharge

nasal congestion

scratchy throat

cough

fever

hyposmia

anosmia

halitosis

pain
-facial
-ear
-dental
-head

Bacterial Rhinosinusitis Adult Tx

NP:
3-5 days post-tx→watchful waiting

MX:

american academy of otolaryngology
1st line:

• amoxicillin BID x 5-7 days

• amoxicillin TID x 5-7 days

high resistance risk

• augmentin PO BID x 5-7 days

beta lactam allergy

• doxycycline PO BID

• levofloxacin PO q24h

• moxifloxacin PO q24h

Bacterial Rhinosinusitis Tx Fail+Severe Infections

Tx fail

• augmentin PO q12h

• levofloxacin PO daily

• moxifloxacin PO daily

severe infection (requiring hospitalization)

• unasyn IV q6h

• levofloxacin PO/IV daily

• moxifloxacin PO/IV daily

• ceftriaxone IV q12-24h

• cefotaxime IV q4-6h

Bacterial Rhinosinusitis Tx: Antibiotics to Avoid

macrolides+bactrim

• high resistance
  -s pneumoniae
  -h influenzae

• not recommended for empiric tx

fluoroquinolones
-moxifloxacin
-levofloxacin

• adverse drug reaction risk outweighs benefit

• not recommended for empiric tx

Bacterial Rhinosinusitis Tx: Duration

3-5 days→improvement
-no improvement/worsens→reassess

adults→5-7 days recommended

peds→10-14 days recommended

Rhinosinusitis NP Tx

pain management

hydration

steamy showers

warm facial packs

avoid cold/dry air

intranasal saline irrigations/sprays
-netipot
-ocean nasal spray

• may improve sx in adults

• avoid in babies

• ensure preparation with sterile water→risk of ofamebic encepharalitis in tap water

intranasal corticosteroids

• after 15 days of use→may decrease mucosal swelling+promote drainage

antihistamines+PO steroids

• not routinely recommended

Intranasal Corticosteroids

MX:

OTC:

• fluticasone

• budesonide

Rx:

• beclomethasone

• ciclesonide

• flunisolide

• mometasone

• triamcinolone

MOA: reduces mast cell degranulation→decreased cytokine secretion→decreased inflammation
-interferes with antibody-antigen reaction

I: runny nose
cogestion
itching
sneezing

ROA:

• intranasal spray→need to prep spray before use
  -continuously
  -PRN

• onset: 3-12 hours

• max effects: 1-2 weeks

• nasal blockage→can combine with decongestant spray x 2-3 days

AE: irritation
bleeding

C: AE→rare
no significant systemic absorption

Viral Pharyngitis E+CM

E:
rhinovirus
coronavirus
adenovirus
influenza A
influenza B
parainfluenza
epstein-barr virus

CM:
cough
coryza
conjunctivitis
diarrhea
hoarseness

Viral Pharyngitis Tx

goal→supportive care

NP:

• salt water gargles

MX:

• methol lozenges→cepacol

• pain relief throat sprays→chloraseptic spray

adults

• acetaminophen PO q4-6h

• ibuprofen q4-6h

peds

• acetaminophen q4-6h

• ibuprofen q6-8h

Bacterial Pharyngitis E+CM

E: group A beta-hemolytic streptococcus (GABHS)
-adults→5-15%
-peds→20-30%

CM:

• sudden onset

• sore throat

• fever

• HA

• inflamed tonsils/pharynx

• patchy discrete exudates

• tender+enlarged anterior cervical lymph nodes

Bacterial Pharyngitis Tx

adults

• penicillin V PO q6-8h x 10 days

• penicillin V PO q12h x 10 days

• amoxicillin PO TID x 10 days

• penicillin G benzathine IM

peds

• penicillin V PO BID x 10 days

• penicillin V PO TID x 10 days

• amoxicillin PO BID x 10 days

• penicillin G benzathine IM

penicillin allergy

• cephalexin x 10 days

• cefadroxil x 10 days

• clindamycin x 10 days

• azithromycin x 10 days

Penicillin-Cephalosporin Cross Allergies

true cross allergy→very low (10%)
-1st gen cephalosporins→1%
-1st gen cephalosporins→increased cross-reactivity

important to know manifestation of allergy

type 1: IgE-mediated (severe)

• anaphylaxis

• bronchospasm

• urticaria

• angioedema

type 4: idiopathic (not “true” allergy)

• occurs 72+hrs post-mx

• rash

• pruritis

• recurrence→unpredictable

Acute Otitis Media Etiology+Resistance Rates

m/c E in adults

• s pneumoniae

• h influenzae

• s pyogenes

• m catarrhalis

m/c E in peds

• anatomy of the ear

• daycare exposure

• viruses

resistance rates

• bactrim→63%

• macrolides→32%

• high-dose amoxicillin→2% (low)
  -inhibits 98% of pneumococcus

• highest resistance cephalosporins
  -cefixime
  -cefaclor

Acute Otitis Media Mx Tx

1st line

• high-dose amoxicillin

• high-dose augmentin
  only if
  -pt got amoxicillin in past 30 days
  -pt CM→conjunctivitis

penicillin allergy

• cefdinir

• cefuroxime

• cefpodoxime

• ceftriaxone IV/IM

2nd line/Tx fail

• high-dose augmentin

• ceftriaxone IM/IV

penicillin allergy

• clindamycin ±3rd gen cephalosporin

• tympanocentesis

• ENT specialist referral

Otic Drops

MX: ciprofloxacin+dexamethasone
ciprofloxacin+hydrocortisone

I: chronic otitis media

ROA:
BID x 7 days
warm bottle→avoid dizziness from cold suspension
shake well
pt lays down x 60 seconds

AE:
rare
ear irritation
ear discomfort
dizziness
tachycardia
allergic reaction

Otitis Externa

PP: cellulitis of ear canal

RF: swimming
trauma

E: 98%→bx
s aureus
pseudomonas

CM/DX:

need all 3

1. -ear canal inflammation
   -itching
   -fullness

2. ear canal inflammation sx
   -ex→tenderness

3. erythematous ear canal+occasional otorrhea

Otitis Externa Mx Tx Initiation

goals

• decrease pain

• eradicate causative organisms

decrease pain
mild-moderate pain:

• PO acetaminophen

• NSAIDS±opioid

eradicate causative organisms

1. clear debris from ear canal

2. topical abx ear drops
   -high abx concentration at site
   -reduces inflammation
   -duration→7-10 days

3. recurrent episodes/necrotizing OE/immunocompromised→systemic abx

Otitis External Abx Tx

1st line

• fluoroquinolone drops

• u 6m/o→not recommended

2nd line

• neomycin-polymyxin B drops

• viral/fungal→avoid

3rd line

• antifungals→clotrimazole

I:
-ear canal obstruction can’t be relieved
-infxn spreads beyond ear canal