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112 Cards in this Set
- Front
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Allergic Rhinitis
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inflammation of the nasal mucous membranes due to Type 1 hypersensitivity reactions mediated by IgE antibodies produced after exposure to allergens
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Early phase of allergy
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*occurs within minutes
*results in rapid release of mediators *lasts up to 90 minutes |
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Late phase of allergic reaction
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*occurs within 4-8 hours of initial exposure
*inflammatory response *causes persistent chronic symptoms *priming response *lasts for hours, even days |
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Clinical presentation of allergic rhinitis
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1) clear rhinorrhea
2) watery eyes 3) sneezing 4) pruritis of nose, eyes, palate 5) nasal congestion 6) postnasal drip, cough, irratibility **allergic salute (nasal crease) **allergic shiners |
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Types of Allergic Rhinitis
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1) Seasonal - repetitive, different seasons (spring and fall), triggers (tree and grass pollen)
2) Perennial - no cyclic pattern, all year, triggers (pets, dust mites, animal dander, cig smoke) |
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Pharmacological treatment options
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1) oral antihistamines
2) Topical antihistamines (intranasal) 3) Oral Decongestants 4) Topical/intranasal decongestants 5) Intranasal Corticosteroids 6) Cromolyn (nasalcrom) 7) Ophthalmic agents 8) Montelukast (singulair) |
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First generation oral antihistamines for allergies
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1) Brompheniramine (Dimetane) 4mg q6h
2) Chlorpheniramine (Chlor-Trimeton) 4mg q6h 3) Clemastine (Tavist) 1.34mg q8h 4) Diphenhydramine (Benadryl) 12.5-50mg q8h |
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Second generation oral antihistamines for allergies1
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1) Loratidine (Claritin, Alavert) 10mg qd
2) Cetirizine (Zyrtec) 5-10mg qd 3) Desloratidine (Clarinex) 10mg qd 4) Fexofenadine (Allegra) 60mg BID or 180mg qd 5) levocetirizine (Xyzal) 5mg qd |
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Intranasal Antihistamines for allergies
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1) Azelastine (Astelin, Astepro) 1-2 sprays (137mcg) EN bid
2) Olopatadine (Patanase) 2 sprays (665mcg) EN bid |
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Oral antihistamines
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*1st line treatment ; help prevent symptoms
Perennial - take regularly Seasonal - take 1-2 hours prior to exposure to triggers |
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Intranasal antihistamines
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ADRs: drowsiness, bitter taste
Use: gently blow nose, tilt head forward and breath out, close 1 nostril and hold spray bottle vertical, spray |
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Oral Decongestants
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relieves nasal congestion and not for long time use
ADRs: CNS stimulation, HTN C/I: severe uncontrolled HTN, severe diabetes |
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Topical/Intranasal decongestants
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*little-no systemic absorption
ADRs: burning, stinging, rebound congestion if used more than 3 days |
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Topical/Intranasal decongestants for allergies
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1) phenylephrine 0.25%, 0.5%, 0.01% (Neo-synephrine) 1-3 drops or sprays per nostril q4-6h
2) Oxymetazoline 0.05% (Afrin) 2-3 sprays or drops per nostril q12h |
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Oral Decongestants used for allergies
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1) phenylephrine (Sudafed PE) 120mg q12h
2) pseudoephedrine (Sudafed) 30-60mg q4-6h |
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Intranasal corticosteroids for allergies
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*Most Effective*
1st line treatment for moderate-severe symptoms Perennial - take all year Season - take 2-4 weeks prior to allergy season then continue 2-4 weeks after season |
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MOA and ADRs of intranasal corticosteroids
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MOA: decrease formation & release of inflammatory mediators
ADRs: nosebleeds, nasal irritation, burning, stinging Onset: relief in 24-48hrs, optimal effect in 2-3 weeks |
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Intranasal corticosteroids
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1) Beclomethasone dipropionate (Qnasl) 2 sprays each nostril (80mcg) qd
2) Ciclesonide (Omnaris) 2 sprays each nostril (50mcg) qd 3) Fluticasone furoate (Veramyst) 1-2 sprays EN qd 4) Fluticasone propionate (Flonase) 2 sprays EN BID 5) Mometasone (Nasonex) 2 sprays EN qd then decrease to 1 spray EN |
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Cromolyn (NasalCrom) nasal Spray (OTC)
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*less effective; use up to 1 week prior to exposure*
MOA: anti-inflammatory agent ADRs: good safety profile; nasal burning, nosebleed, DOSE: 1 spray each nostril 3-4x daily |
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Counseling for cromolyn (NasalCrom)
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1) use continuously for effectiveness
2) slow onset 3) preferred in pregnancy 4) safe for 2 years and up |
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Ophthalmic agents for allergies
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Place: acute allergic conjunctivitis; seasonal/perennial allergies
ADRs: headache, eye irritation, dry eyes, visual disturbances USE: keep eye open, pull down lower lid, play drop |
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Ophthalmic agents
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1) Naphazoline/Pheniramine (Naphcon A, Opcon A, Ocuhist, Privine) 1-2 drops in affected eye up to 4x daily
2) Ketotifen (Zaditor, Alaway) 1 drop, bid q8-12h 3) Olopatadine (Patanol, Pataday) 1-2 drops BID q6-8h up to 6 weeks 4) Emedastine (Emadine) 1 drop up to 4x daily 5) Azelastine (Optivar) 1 drop BID |
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Montelukast (Singulair)
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*1st leukotriene receptor antagonist
USE: effective alone or in combo with antihistamine DOSING: 10mg qd |
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Omalizumab (Xolair)
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*Recombinant humanized anti-IgE monoclonal antibody*
USE: injectable Subq treatment, every expensive |
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Best product for Sneezing and itching in allergies
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1) oral antihistamines
2) Nasal antihistamines 3) intranasal corticosteroids |
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Best products for congestion
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1) intranasal corticosteroids
2) Oral decongestants 3) Intranasal decongestant |
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Best product for rhinorrhea
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1) topical anticholinergics
2) intranasal corticosteroids 3) oral anithistamines |
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Body's defenses against irritants
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1) vasodilation
2) inflammation 3) mucus production |
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Mucus problems
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1) drains into lungs (bronchitis, pneumonia)
2) Rhinorrhea (runny nose) 3) Drains into sinuses(sinus headache, sinus infection) 4) Post nasal drip (cough, sore throat, laryngitis) 5) Drains into eustachian tube (ear infection) |
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Causes of the common cold
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1) Rhinovirus
2) Other viruses (over 200 kinds) 3) transmission (self-inoculation) 4) aerosol transmission |
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Risk factors for the common cold
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1) smoking
2) poor nutrition 3) fatigue 4) decreased defense mechanisms 5) sick contacts |
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Signs/Symptoms of the common cold
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*appear 1-3 days after infection*
*Duration: 7-10 days 1) pharyngitis 2) nasal congestion 3) rhinorrhea 4) cough 5) sneezing 6) maybe headache, chills |
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Signs of complications with a cold
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1) fever occuring 3-5 days after a cold
2) green/yellow thick mucus in phlegm |
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When to refer a patient with a cold to a doctor
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1) fever >101.5
2) chest pain, SOB 3) symptoms worsen 4) children <2years or elderly 5) symptoms last >7 days 6) thick colored sputum |
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Prevention of common cold
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1) wash hands and keep away from nose/eyes
2) drink plenty of fluids 3) avoid sick contacts 4) cover nose when sneeze, mouth when cough |
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Non-Pharm treatment of common cold
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1) increased fluids and rest
2) proper nutrition 3) increase humidity 4) saline gargles, nasal sprays, breath right, bulb syringe |
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Classes of drugs used for Common Cold
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1) sore throat remedies
2) decongestants 3) antihistamines 4) cough suppressants and expectorants 5) antipyretics/analgesics |
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Treatment for pharyngitis (sore throat)
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LOCAL ANESTHETICS (sucrets, cepacol, halls)
1) soothing effect: coats irritated mucus membranes 2) use q3-4 hours |
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MOA of decongestants for common cold
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*treat nasal congestion*
stimulate alpha receptors ---constriction of blood vessels ---- decrease sinus vessel engorgement and mucosal edema |
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Oral Decongestants for congestion
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1) phenylephrine (Sudafed PE)
2) Pseudoephedrine (Sudafed) |
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Meth Precursor Control Act
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must be 18yo with photo ID, sign a log
no more than 2 packages at once or more than 7500mg PSE in any 30 day period |
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Topical decongestants for congestion (NASAL SPRAYS)
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1) easy to use, inexpensive, quick onset
2) imprecise dosing, high risk of contamination Ex. phenylephrine (Neo-Synephrine), oxymetazoline (Afrin) |
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Topical decongestants for congestion (Drops)
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1) small children
2) awkward, pass into larynx, high risk of contamination Ex. xylometazoline (Otrivin) |
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Topical decongestants for congestion (Inhalers)
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1) small, unobtrusive
2) lose efficacy after few months Ex. Vicks Vapor Inhaler |
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Major counseling point for topical decongestants
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Rebound Congestion if used for more than 3 days
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ADRs of topical decongestants
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1) burning, stinging, dryness, irritation
2) rebound congestion |
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How to prevent rebound congestion (rhinitis medicamentosa)
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1) take only as needed
2) do not use longer than 3 days 3) switch to different decongestant |
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Adverse effects of antihistamines
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1) photosensitivity
2) anticholinergic (dry eyes, nose, mouth, blurry vision, urinary retention, constipation) 3) sedation (1st gen) 4) CNS stimulation |
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1st generation antihistamines help with rhinorrhea and not 2nd generation
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they block cholinergic receptors to a much great extent
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Post Nasal Drip
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*upper airway cough syndrome (UACS)*
1) can cause coughing and/or throat irritation |
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Causes of cough
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1) asthma/COPD
2) GERD 3) post nasal drip 4) bronchitis 5) CHF 6) smoking 7) ACEIs |
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Classification and types of cough
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non-productive OR productive
Class: acute: <3weeks subacute >3 weeks chronic |
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Cough Suppressants (antitussives)
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*for non-productive cough*
MOA: direct effect on cough center in medulla, increases cough threshold ADRs: nausea, vomiting, sedation, constipation, headache |
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Gold standard cough suppressant
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Codeine
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Cough Expectorants (Protussives)
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*for productive cough*
MOA: thins out and loosens mucus ADRs: NVD, dizziness, HA, drowsiness |
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Antipyretics/Analgesics
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*for fever and pain*
MOA: inhibition of prostaglandin synthesis |
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Complementary and Alternative Therapies (CAM) for the common cold
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1) echinacea - immune stimulant which may decrease duration and severity
2) Zinc (cold-eeze, Zicam) - maybe block adhesion of the rhinovirus to nasal epithelium which may decrease duration and/or severity of symptoms 3) Vitamin C - may decrease duration/severity |
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Dosing a) Phenylephrine (Sudafed PE) and b) pseudoephedrine (Sudafed) for the common cold
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a) 10mg PO q4 h
b) 60mg po q4-6h |
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Dosing of a) diphenhydramine (Benadryl) and b) chlorpheniramine (Chlor-Trimeton) for the common cold
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a) 25-50mg po q4-6h
b) 4mg po q4-6h |
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Dosing of a) dextromethorphan (Delsym) and b) benzonatate (Tessalon Perles) for common cold
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a) 10-20mg po q4h OR 30mg po q6-8h
b) 100-200mg po TID |
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Dosing of guaifenesin (Mucinex) for the common cold
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200-400mg po q4h
ER: 600-1200mg po q12h |
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Dosing of a) APAP (Tylenol) and b) Ibuprofen (Motrin, Advil) for the common cold
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a) ADULT: 325-1000mg po q6h CHILDREN: 10-15mg/kg/dose
b) 200-400mg po q4-6h |
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3 tissues of prostate
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1) Glandular (Epithelial) - produces secretions
2) Smooth muscle (Stromal) - alpha receptors - contracts to empty bladder 3) Capsule (outer) - alpha receptors - contraction to empty bladder |
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Symptoms of BPH
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1) Obstructive voiding
2) Irritative voiding 3) Silent prostatism |
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Obstructive voiding symptoms of BPH
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*due to failure of bladder emptying* ***BOO***
1) decreased force of stream 2) hesitancy 3) straining to void 4) incomplete emptying |
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Irritative voiding symptoms of BPH
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**due to failure of the bladder detrusor muscle to store urine**
1) urgency 2) clothes wetting 3) frequency |
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Silent Prostatism for BPH
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**patient adapts to other symptoms**
1) palpable enlarged gland 2) urodynamic evidence of obstruction 3) no complaints |
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Diagnostic Testing for BPH
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1) Abnormal rectal exam - prostate enlarged
2) Post void residual (PVR) urine volume >/= 50ml 3) Peak/mean urine flow rates </=10-12 ml/sec 4) urinalysis 5) serum creatnine |
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Mild BPH
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1) Asymptomatic/mild symptoms
2) AUA score </= 7 3) enlarged prostate 4) urine flow rate < 10mlsec |
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Moderate BPH
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1) bothersome symptoms
2) AUA score 8-19 3) enlarged prostate 4) urine flow rate < 10ml/sec 5) obstructive/irritative voiding symptoms |
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Severe BPH
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1) bothersome symptoms
2) AUA score >/=20 3) enlarged prostate 4) urine flow rate < 10ml/sec 5) obstructive/irritative voiding symptoms 6) 1+ complications |
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Medications to avoid in BPH
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1) Testosterone - stimulate BPH tissue growth
2) Diuretics - increase urinary output 3) Decongestants - stimulate alpha receptors 4) Anticholinergics - acute urinary retention |
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Treatment options for BPH
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1) Watchful waiting
2) Medical Therapy 3) Surgical Therapy |
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Treatment for BPH with mild symptoms
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watchful waiting
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Treatment for BPH with Severe symptoms and complications
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Surgery
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Treatment of BPH with Moderate Symptoms & small prostate and low PSA
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alpha antagonist
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Treatment of BPH with Moderate symptoms & large prostate and increase PSA
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5alpha reductase inhibitor OR 5a reductase inhibitor + alpha antagonist
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Treatment of BPH with moderate symptoms and irritative voiding symptoms
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alpha antagonist + anticholinergic
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Treatment of BPH with moderate symptoms and ED
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alpha antagonist or PDE inhibitor or both
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Which medication treatment decreases the size of the prostate
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5-alpha reductase inhibitors
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Peak onset of alpha antagonists for BPH
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1-6 weeks
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Alpha Antagonists used for BPH
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1) Terazosin (Hytrin)
2) Doxazosin (Cardura) 3) Alfuzosin (Uroxatral) 4) Tamsulosin (Flomax) 5) Silodosin (Rapaflo) |
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Drug of choice for moderate/severe symptoms who cannot tolerate hypotension
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Tamsulosin (Flomax)
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ADRs of alpha antagonist
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1) first dose syncope
2) orthostatic hypotension 3) Anejaculation 4) Floppy iris (small pupil syndrome) |
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5 alpha reductase inhibitors
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1) Finasteride (Proscar)
2) Dutasteride (Avodart) |
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Drug of choice for moderate/severe symptoms with enlarged prostate
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5-alpha reductase inhibitors (finasteride)
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ADRs of 5-alpha reductase inhibitors
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1) pregnancy cat X
2) erectile dysfunction 3) decreased libido 4) ejaculatory disorders |
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PDE's for BPH
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tadalafil (Cialis)
onset: ~4 weeks |
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Anticholinergic agents used for BPH
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1) tolterodine (Detrol)
2) Oxybutynin (Ditropan) 3) Trospium (Sanctura) 4) Solifenacin (Vesicare) 5) Darifenacin (Enablex) 6) Fesoterodine (Toviaz) |
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Indications for Surgical treatment in BPH
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1) Severe BOO symptoms (more than 1 episode of acute urinary retention)
2) complications of BPH |
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4 components for normal male sexual function
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1) libido
2) penile erection 3) ejaculation 4) fertility |
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4 essential components to having a normal penile erection
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1) psychogenic factor - stimulation
2) testosterone - maintains a libido 3) Good vascular flow to penis 4) Neurologic control of erectile tissue |
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Erectile Dysfunction
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persistent failure (typically over 3 months) to achieve an erection suitable for satisfactory sexual intercourse
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Risk factors for ED
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1) over 50 years old
2) concurrent disorder associated w/ decreased CNS perception of sexual stimulation (stroke, mental disorder) 3) concurrent medical illnesses - mpaired vascular supply to penis 4) drugs that cause ED |
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Drugs that can cause ED
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1) anticholinergic agents (antihistamines, TCAs)
2) Estrogens (leuprolide, spironolactone, digoxin) 3) CNS depressants (barbiturates, narcotics, benzos) 4) Dopamine Antagonists (metoclopramide) |
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Diagnostic Evaluation for ED
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1) patient medical history
2) physical exam 3) Medication profile review 4) serum testosterone levels 5) Patient self assessment of erectile function |
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Treatment algorithm to select appropriate treatement for ED
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1) quit smoking, drugs, alcohol
2) quit drugs that can cause ED 3) control underlying diseases 4) start psychosocial counseling 5) stratification for CV risk |
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Low risk on CV risk stratification for ED
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can be prescribed a PDE inhibitor with any special precautions
reassess every 6-12 months *asymptomatic CAD, less than 3 risk factors for CAD, controlled HTN |
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High Risk on CV risk stratification for ED
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Should not receive a PDE inhibitor and should abstain from all sexual activity
*unstable/refractory angina, uncontrolled HTN, CHF |
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Intermediate Risk on CV risk stratification for ED
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Should undergo cardiac evals to dermine if they are low or high risk
*3+ risk factors for CAD, mild-moderate stable angina, recent MI or CVA, history of stroke/TIA |
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Vacuum Erection device (VED)
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MOA: cylindrical chamber that fits over penis, suction pressure draws blood into corporal bodies
ONSET: 15-30 minutes DURATION: 1 hour Preferred for older men with steady sexual partners |
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Indications and ADRs of vacuum erection device
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1) stable sexual relationship
ADRs: penile pain, discoloration, cold penile shaft, failure to ejaculate |
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Drug of choice for ED
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phosphodiesterase inhibitors (PDEs)
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PDE for ED
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MOA: competitively inhibits isoenzyme type 5 in corporal tissue, increase cGMP, vasodilation
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Dosing for PDEs
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On-demand = 1 hour before intercourse(sildenafil/vardenafil) or 2 hours before (tadalafil)
once daily, low dose |
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PDE's used for ED
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1) sildenafil (Viagra)
2) Vardenafil (Levitra, Staxyn) 3) Tadalafil (Cialis) 4) Avanafil (Stendra) |
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Reasons PDE's don't work
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1) sexual foreplay is absent
2) not up-titrated to a larger, more effective dose 3) not coordinating time of drug admin with meals or sex |
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ADRs of PDEs
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1) cyanopsia - difficulty adapting to light, blurry vision, blue-green color discrimination
2) headache 3) flushing 4) hypotension 5) nasal congestion |
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Drug Interactions with PDEs
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1) Nitrates (BLACK BOX WARNING) - severe hypotension
2) CYP3A4 inhibitors (cimetidine, erythromycin) - increase levels of sildenafil 3) alpha antagonists (terazosin, doxazosin) - hypotension |
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Intracavernosal injection treatment with Alprostadil (Caverject, Edex)
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MOA: stimulate adenylate cyclase, enhances production of cyclic AMP(vasodilator), increase blood flow
ONSET: 5-15 minutes DURATION: 1 hour or less |
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Instruction for use of alprostadil for ED
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1) initial dosage titration done under dr's supervision
2) no more than 1 injection/day and no more than 3/week 3) inject at 90 degree angle on side of penis shaft 4) inject only 1 side, massage the drug |
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ADRs of alprostadil
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1) penile pain (burning near injection site)
2) hematoma (poor injection technique) 3) priapism/prolonged erection |
