Allergic Rhinitis, Cough, & Cold

What are symptoms of an allergy?

sneezing

runny nose

thin, clear mucus

wheezing

red, watery eyes

symptoms can last for days or months

What are symptoms of a cold?

sneezing

runny nose

thick, dark mucus

sore throat

body aches

symptoms take 3 days to appear, last for a week

Non-drug treatment for allergies

- avoid exposure to known or suspected allergens

- nasal irrigation and wetting agents

What are common allergens?

- pollens from trees, grass, weed

- molds

- dust mites in bedding, carpet (vacuum and wash in hot water weekly)

- animal dander

Wetting agent brand names

Ocean

Little Remedies

Nasal irrigation ingredients

isotonic or hypertonic saline solutions

What type of water should be used for nasal irrigation to avoid infections?

saline mixture + distilled, sterile, or previously boiled and cooled water

(tap water should not be used; this includes bottled water)

How can nasal irrigations be administered?

with a syringe or neti pot

(poured into one nostril and drained out of the other)

drug treatment for allergies (which drug classes can be used?)

1. nasal steroids

2. antihistamines

3. decongestants

- intralnasal Cromolyn (NasalCrom)

- oral leukotriene receptor antagnoist (Montelukast; Singulair)

- intranasal Ipratropium

- immunotherapy

What is first line for chronic, moderate-to-severe symptoms of allergies? (drug class)

intranasal steroids

budesonide brand name

Rhinocort Allergy

fluticasone brand name

Flonase

triamcinolone brand name

Nasacort

mometasone brand name

Nasonex

Ryaltris generic name

mometasone + olopatadine

ciclesonide brand name

Omnaris, Zetonna

intranasal steroids side effects

epistasxis (nose bleed), unpleasant taste

How long does it take to get full relief from intranasal steroids?

one week

What are the preferred nasal steroids for pregnancy?

budesonide (Rhinocort) and beclomethasone

What can be used to treat milder, intermittent symptoms of allergy? (drug class)

antihistamines (reduces immediate hypersensitivity reactions, but little effect on nasal congestion)

Why are second-generation antihistamines preferred over first-generation?

they cause less sedation and cognitive impairment

What is diphenhydramine and what is it used for?

first generation antihistamine

- treat acute allergic reactions

- prevent allergic reactions (premedication regimens)

- allergic rhinitis

- cough

- sleeping (sedation)

- dystonic reactions (anticholinergic properties)

- motion sickness

can worsen some disease states (BPH, constipation, dementia, glaucoma)

diphenhydramine brand name

Benadryl

chlorpheniramine brand name

Aller-Chlor

doxylamine brand name

Unisom (for sleep)

carbinoxamine brand name

Karbinal ER, RyVent

diphenhydramine adult dosing

25 mg PO Q4-6 hours or 50mg PO Q6-8 hours (max 300mg/day)

diphenhydramine dosing for children <6 years

do not use OTC unless directed by healthcare provider

first generation oral antihistamine warnings

- avoid in elderly

- caution in patients with CV disease, prostate enlargement, glaucoma

first generation oral antihistamine side effects

somnolence (sleepy)

cognitive impairment

strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation)

cetirizine brand name

Zyrtec

Zyrtec-D generic name

cetirizine + pseudoephedrine

levocetirizine brand name

Xyzal

fexofenadine brand name

Allegra

Allegra-D generic name

fexofenadine + peudoephedrine

loratadine brand name

Claritin

Claritin-D generic name

loratadine + pseudophedrine

desloratadine brand name

Clarinex

azelastine brand name

Astepro

Dymista generic name

azelastine + fluticasone

olopatadine brand name

Patanase

Which second generation oral antihistamine is more sedating?

cetirizine (Zyrtec) and levocetirizine (Xyzal)

Which second generation oral antihistamine is less sedating?

fexofenadine (Allegra) and loratadine (Claritin)

What drug class can be combined with intranasal steroids but will increase cost and side effects?

intranasal antihistamines

How do decongestants work? (drug class and MOA)

alpha-adrenergic agonists (symapthomimetics)

cause vasoconstriction -> reduces sinus and nasal congestion

What is the federal maximum amount allowed for purchase of pseudoephedrine, phenylpropanolamine, ephedrine?

3.6 grams per day

9 grams in a 30 day period

phenylephrine brand name

Sudafed PE

pseduoephedrine brand name

Sudafed, Nexafed, Zephrex-D

Sudafed dosing for adults

60mg PO q4-6 hours prn

(max 240 mg/day)

systemic decongestant contraindications

do not use within 14 days of MAO inhibitors

systemic decongestant warning

- avoid in children <2 years (FDA), <4 years (package)

- caution in patients with CV disease, BPH (can cause urinary retention)

systemic decongestant side effects

tachycardia, palpitations, increased BP

insomnia

decreased appetite

Can oral decongestants be used during pregnancy?

should be avoided in the first trimester of pregnancy

oxymetazoline brand name

Afrin

oxymetazoline contraindication

do not use for more than 3 days

How long can Afrin be used?

max 3 days (contraindication)

intranasal decongestant warnings

BPH

intranasal decongestant side effects

rhinitis medicamentosa (rebound congestion if used longer than 3 days)

Why can Afrin only be used for MAX 3 days?

due to possible rebound congestion (rhinitis medicamentosa)

NasalCrom generic name

intranasal cromolyn

NasalCrom drug class

OTC mast cell stabilizer used for treatment and prophylaxis of allergic rhinitis

Administration of NasalCrom

started at onset of allergy season and used regularly (not prn)

max effect can take 2-4 weeks of continued use

Is NasalCrom safe in pregnancy?

safe to use in children >2 years old and in pregnancy

Singulair generic name

Montelukast

Can montelukast be used in children?

yes, indicated for both allergic rhinitis and asthma

How is immunotherapy used for allergy?

preventative treatment

work by slowly increasing exposure to the allergen

FDA approved SL immunotherapy treatments for allergic rhinitis

pt should have epinephrine auto-injector while on SL immunotherapy

- Oralair = five different grass pollen extracts

- Grastek = Timothy grass pollen extract

- Ragwitek = ragweed pollen

- Odactra = house dust mite allergen

natural products used for cold

- zinc (do not use for more than 5-7 days)

- vitamin C (ascorbic acid) = decreases the duration of cold by 1-1.5 days

- echinacea = possibly effective

Why are expectorants used?

to thin mucus

guaifenesin brand name

Mucinex, Robitussin Congestion, Robafen

Robafen DM, Robitussin DM generic name

guaifenesin + dextromethorphan (cough suppressant)

dextromethorphan brand name

Delsym, Robafen, Robitussin cough

benzonatate brand name

Tessalon Perles

dextromethorphan contraindication

do not use within 14 days of MAO inhibitor

dextromethorphan warnings

serotonin syndrome

Can dextromethorphan be used in children?

OTC do not use in children < 4 years

codeine boxed warnings

- respiratory depression and death in children who received codeine after tonsillectomy/adenoidectomy = ultra-rapid metabolizers of codeine due to CYP450 2D6 polymorphism

- death in nursing infants, mothers who were ultra-rapid metabolizers

(ultra-rapid metabolizers get too high of concentration)

codeine drug schedule for combo cough and cold products

C-V

Which CYP450 enzyme is codeine associated with?

CYP 2D6

(boxed warning for ultra-rapid metabolizers)

codeine contraindication

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

What is the FDA age recommendation for codeine-containing products?

avoid in < 18 years old

benzonatate warning

do not use in children <10 years

benzonatate side effects

somnolence, confusion, hallucinations

Bromfed DM generic name

brompheniramine + pseudoephedrine + dextromethorphan

TussiCaps generic name and control schedule

chlorpheniramine + hydrocodone (C-II)

pediatric cough and cold treatment - caution

children < 18

- avoid codeine and hydrocodone -containing products (FDA)

children < 4

- avoid OTC cough and cold products (package)

children < 2 years

- avoid OTC cough and cold

- avoid promethazine

- avoid topical menthol and camphor

Can topical products containing menthol (Vicks) be used in children?

should not be used in children <2

Tylenol pediatric dosing

10-15 mg/kg q4-6 hours

no more than 5 doses in 24 h

drops/children's liquid = 160mg/5mL

Motrin pediatric dosing

5-10 mg/kg q6-8 hours

no more than 40 mg/kg/d

drops = 50 mg/1.25mL

liquid = 100mg/5mL

Can aspirin be given to children?

No, due to risk of Reye's Syndrome