allergic rhinitis and cough and cold

Allergy testing is an Ig__ mediated skin test

IgE

Cold

A. Thick, dark mucus

B. Thin, clear mucus

A. Thick, dark mucus

Allergies

A. Thick, dark mucus

B. Thin, clear mucus

B. Thin, clear mucus

Is neti pot safe in children?

Yes

Is neti pot safe in pregnancy?

Yes

Examples of comerically available wetting agents? (2)

• Ocean

• Little Remedies

What type of water should NOT be used for nasal irrigation?

Tap water

Should use isotonic (0.9%) or hypertonic (2-3.5%) saline or distilled water or boiling water

Allergies Drug TX options (3)

• Intranasal steroids (first line for mod-severe)

• Oral antihistamines

• Decongestants

Intranasal steroids options

• Budesonide (Rhinocort allergy) OTC

• Fluticasone (Flonase Allergy Relief, Flonase Sensimist, Childrens Flonase) RX & OTC

• Triamcinoline (Nasacort Allergy 24HR): OTC

With IN steroids it can take up to ___ week to get full relief

1

What are the preferred IN steroids in pregnancy? (2)

• Budesonide

• Beclomethasone

Antihistamines block what recpetor?

H-1

First gen antihistamines (5)

• Diphenhydramien (Benadryl)

• Chlorpheniramine

• Doxylamine

Diphenhydramine dosing

• Adult 25 mg PO q4-6hr or 50 mg q6-8hr

• Age <6 yo don't use OTC

What patients should First gen antihistamines be cautioned in? (3)

• Elderly

• Prostate enlargement

• Glaucoma

What antihistamines are preferred in pregnancy (2)

• Loratadine

• Cetirizine

Second gen antihistamines options (4)

• Cetirizine (Zyrtec Allergy, + Childrens): RX & OTC

• Levocetirizine (Xyzal Allergry 24HR, + Childrens): RX & OTC

• Fexofenadine (Allegry Allergy, + Childrens): OTC

• Loratadine (Claritin, + Childrens): OTC

What are the least sedating SGA? (2)

• Fexofenadine (Allegra)

• Loratadine (Claritin)

What should fexofenadine be taken with?

Water, not fruit juice

Intranasal antihistamines (2)

• Azelastine (Astepro Allergy)

• Olopatadine

Decongestants MOA

Alpha-adrenergic agonists (sympathomimetics) that cause vasoconstriction

Decongestants examples (2)

• Phenylephrine (Sudafed PE)

• Psudeoephedrine (Sudafed, Nexafed, Zephrex-D)

What is the age cutoff for decongestants?

Avoid <2 yo (FDA)

Avoid <4 yo (package labeling)

Decongestants warnings (3) and CI

• Avoid with <2 yo (FDA), <4 yo (labeling)

• Caution in CV disease

• Caution in BPH (can cause urinary retention)

CI do not use within 14 days of MAO inhibitors

Decongestants AE (4)

• Tachycardia

• HTN

• Insomnia

• Decreased appetite

Can decongestants be used during pregnancy?

Avoid during first trimester

Max pseudoephedrine, phenylpropanolamine, or ephedrine that can be purchased in 1 day and max that can be purchased in 30 day period

Max amount allowed for purchase is 3.6 g/day and 9 g in a 30 day period

Why is psuedofed kept behind the counter?

Due to the combat methamphetamine epidemic act 2005

What is pseudoephrine a precursor to?

Methamphetamine

Intranasal decongestants (2)

• Oxymetazoline (Afrin)

• Phenylephrine

Oxymetazoline should not be used for more than __ days

3 due to rebound congestion (rhinitis medicaentosa)

Decongestants main DDI

Do not use within 14 days of MAOI

Intranasal cromolyn

• NasalCrom OTC mast cell stabilizer

• Must be started at the onset of allergy season & used regularly (not PTN)

• Safe in ≥2 YO and pregnancy

What is the allergy tx that works by slowly increasing exposure to the allergen?

SC immunotherapy allergy shots

What should you know about SL immunotherapy TX?

Must be monitored for 30 min after for any sxs of allergic rxns

What must a pt have at all times if on SL immunotherapy TX?

Epi pen

Natural products for colds (3)

• Zinc

• Vitamin C (ascorbic acid)

• Echinacea

TX for productive coughs (expectorants) (1)

• Guaifenesin (Mucinex, Robitussin Mucus + Chest Congestion)

Cough suppressants options (4)

• Dextromethorphan (Delsym, Robafen Cough)

• Codeine (C-II alone, C-IV if in combo product)

• Benzonatate (Tessalon Perles)

• Diphenhydramine (Benadryl)

Dextromethorphan MOA

acts as a serotonin reuptake inhibitor

• At high doses it acts as an NMDA receptor blocker leading to euphoria and hallucinations

Dextromethorphan main DDI (1)

Do not use within 14 days of MAOI

Dextromethorphan warning (1)

Serotonin syndrome

FDA recommends not using codeine in kids < ___ yo

<18

Pediatric cough/cold age cutoffs (studygal) (4)

• <18 yo avoid codeine & hydrocodone products per FDA

• <4 yo avoid OTC products per package label

• <2 yo avoid OTC products & promethazine per FDA

• <2 yo avoid topical menthol & camphor per package labeling

If you see AC think ______

If you see DM think ______

If you see D think _______

If you see PE think _______

codeine

dextromethorphan

decongestant

phenylephrine

side effects of intranasal steroids

epistaxis (nose bleeds)

First gen antihistamines side effects

Somnolence

cognitive impairment

anticholinergic effects