Non-Rx

Lecture 2 - Allergic Rhinitis

Allergic Rhinitis - Non-Pharmacological Therapy

• House dust mites

  • keep home humidity </= 40%

  • remove carpets, stuffed animals, bookshelves from bedroom

  • Encase mattress, box springs, pillows

  • wash bedding in hot water

• Mold spores

  • avoid leaves raking

  • remove house plants

  • repair damp spaces

  • regular vacuuming carpets, drapes

• Pollen from trees, grasses

  • avoid/minimize outdoor activities when high pollen (highest in

    morning, lowest after rainstorms)

  • Close doors/windows during high pollen time

• Pollutants (ozone, exhaust fumes)

  • Ventilation system – HEPA to remove pollen

  • Nasal wetting agents or nasal irrigation w/warm saline

Allergic Rhinitis - Pharmacotherapy

• Intranasal corticosteroids (INCS) - often first line of AR (esp. in severe AR); 4 OTC agents

• Antihistamines - 1st and 2nd generation

• Mast cell stabilizers - cromolyn

• Decongestants - systemic and topical (nasal spray)

Which drug class contains a medication that can be used to make crystal methamphetamine?

Decongestants

Intranasal Corticosteroids

• most effective treatment in AR

• Inhibit different cell types and mediators, stopping the allergic cascade

• Help with nasal symptoms, including itchiness, rhinitis, sneezing, nasal congestion

• Pros: effective, esp. with nasal symptoms; localized adverse effects

  • Cons: does not work on as needed basis, needs routine use; nasal discomfort

INCS - Adverse Effects

• nasal discomfort, nosebleed, cough, pharyngitis

• Headache, dizziness, N/V

  • sensitive to INCS or high dose INCS

INCS - Why caution with long term use

Can cause glaucoma, cataracts, increase risk of fungal infection, growth inhibition in children

OTC INCS Availability and Products

OTC INCS Products

Budesonide Rhinocort Allergy Spray

Triamcinolone acetonide Nasacort Allergy 24 hours (children’s)

Fluticasone furoate Flonase Sensimist (Children’s Flonase)

Fluticasone Propionate Flonase Allery Relief (Children’s)

Antihistamines - MOA

Compete with histamine at central and peripheral H1 receptors, preventing the histamine-receptor interaction, inhibiting mediator release

Antihistamines - 1st Gen - Properties

• lipophilic, easily crosses BBB - sedating

• Quick onset, shorter duration

• High anticholinergic effects

  • constipation

  • dry mouth/eyes

  • urinary retention

Antihistamines - 1st Gen - Caution, avoid if possible in…

• Caution, avoid if possible

  • elderly, require mental alertness

  • Pts w/ prostate enlargement

  • glaucoma

  • CVD

Antihistamines - 1st Gen - Contraindicated in…

• newborns

• Children < 2 y/o

Antihistamine - 1st Gen - OTC Availability

• Diphenhydramine (Benadryl)

• Chlorpheniramine (Chlor-Trimeton)

Antihistamines - 2nd Gen - Properties

• lipophobic, do not easily cross BBB, non-sedating

• Loratidine & fexofenadine: non-sedating

• Cetirizine & levoceterizine: mild sedation

• Separate Fexofenadine and juice or antacids by hours

• Avoid fexofenadine w/ erythromycin, ketoconazole

• Oral - most indicated for children > 2

Antihistamines - 2nd Gen - OTC Availability

• Diphenhydramine (Benadryl)

• Cetirizine (Zyrtec)

• Fexofenadine (Allegra)

• Loratidine (Claritin, Alavert ODT)

• Azelastine (Astelin, Asteopro)

Diphenhydramine (Benadryl) Dose Strength and Dose for Adults > 12 (Daily max)

• dose strength

  • 25 mg, 12.5mg/5mL

• Dose for Adults > 12

  • 25 - 50 mg Q 4-6 hrs (300mg)

Cetirizine (Zyrtec) Dose Strength and Dose for Adults > 12 (Daily max)

• Dose strength

  • 10 mg, 5mg/5mL

• > 12 y/o

  • 10 mg Q24H (10 mg)

Fexofenadine (Allegra) Dose Strength and Dose for Adults > 12 (Daily max)

• dose strength

  • 30 mg, 180 mg, 30mg/5mL

• > 12 y/o

  • 60 mg Q12 H or 180 mg Q24H (180 mg)

Loratidine (Claritin, Alavert ODT) Dose Strength and Dose for Adults > 12 (Daily max)

• dose strength

  • 10 mg, 5mg/5mL

• > 12 y/o

  • 10 mg Q24H (10 mg)

Azelastine (Astelin, Asteopro) Dose Strength and Dose for Adults > 12 (Daily max)

• dose strength

  • 205.5 mcg per spray (60 metered sprays)

• > 12 y/o

  • 1 - spray per nostril BID

Mast Cell Stabilizer - Properties

• cromolyn sodium

• blocks Ca2+ influx into mast cells, preventing mediator release

• Effective if started before symptoms begin

• No drug-drug interaction noted

Mast Cell Stabilizer - Indicated for…

• >/= 2 y/o

• Not 1st line therapy except in

  • Pregnant women and lactating women

Mast Cell Stabilizer - Adverse Effects

• sneezing

• Nasal stinging, burning