Key concepts:
o Atrovent
Anticholinergic nasal spray, Local application of anticholinergic agents to the nasal
mucosa inhibits vagally mediated reflexes by antagonizing the action of acetylcholine at the
cholinergic receptor. Inhibits secretions.
Pregnancy category B* - good for pregnant women with rhinorrhea
Common S/E’s
Bad taste
Nasal dryness
Epistaxis
Indications: Allergic Rhinitis, rhinorrhea associated with common cold
Precautions: hypersensitivity to atropine, caution in pt’s with narrow angle glaucoma,
prostatic hyperplasia, bladder neck obstruction.
Adverse Rx: HA, epistaxis, pharyngitis, and nasal dryness
Astelin/ Azelastine
Topical antihistamine, histamine receptor antagonist
S/E’s: Bitter taste, HA, nasal burning, somnolence
Decrease in somnolence with Patanase
Somnolence
HA’s
Nasal burning
o Decrease in somnolence w. Patanase
,o Indication
Allergic rhinitis: treatment algorithm:
-suspect allergic rhinitis – do nasal smears, skin testing RAST testing
- if diagnosis confirmed, begin non-pharm management (avoidance of irritants, A/C)
-if symptoms persist: start antihistamine either alone or in combination with nasal
decongestant or intranasal corticosteroids.
-if symptoms persist, immunotherapy.
o NasalCrom
Mast cell stabilizer
Useful as prophylaxis
Safe in pregnancy
Indicated for allergic rhinitis
o Topical Steroids – Intranasal (Flonase)
Act directly to block the effects of inflammation on the nasal mucus membrane
May take up to 1 week to become fully effective
Typically considered safe in pregnancy
For children, there is a risk of impacting growth
Best for established seasonal or perennial rhinitis*
First line therapy for allergies: intranasal steroids (+ 2nd gen antihistamine)
2nd line: antihistamines + nasal decongestants
3rd: intranasal cromolyn
Children age 2 and up can have mometasone and fluticasone, children age 4
and up can have fluticasone propionate, and children age 6 and older can have
, ciclesonide, budesonide, and flunisolide
Ocular Antihistamine
o Patanol and Pataday
o H1 receptor antagonist and mast cell inhibitor for eyes
o Pregnancy C*
o Indications
Allergic conjunctivitis
Allergic rhinitis
◦ Decongestants -oral and nasal
Cause vasoconstriction, assist in clearance of nasal mucous, not for use if < 4
years old. Sympathomimetics that stimulate alpha & beta adrenergic receptors. Stimulant
CNS effects.
Topical: Oxymetazoline, Phenlephrine, neo-synephrinem Afrin
Oral: Pseudoephedrine, Phenylephrine, Sudafed
◦ C/I’s
◦ Narrow angle glaucoma
◦ Severe uncontrolled HTN
◦ CAD
◦ p/ts treated w. MAOI w/in 14 days
◦ Caution
◦ HTN
◦ Cardiac disease
◦ Renal impairment
◦ Hyperthyroidism
◦ Diabetes
, ◦ Prostatic hypertrophy
◦ Urinary incontinence
◦ Adverse Drug Effects
◦ Increased BP and HR
◦ Palpitations
◦ HA, dizziness
◦ GI distress
◦ Insomnia
◦ Tremor
◦ P/t’s w. controlled HTN
◦ Can take for a short course w. monitoring
◦ Interactions
◦ Appetite suppressants
◦ MAOI’s (Hypertensive crisis)
◦ Beta-adrenergic agents (brady & HTN)
Kids need to be at least 6, do not exceed 2 doses of afrin in 24 hrs
◦ Give at least 2 hrs before bedtime for oral
Use for 3-4 days max to avoid rebound congestion.
◦ When would you use oral? When would you recommend nasal
Nasal to avoid systemic effects, use oral after 3-4 days to avoid rebound
congestion.
◦ Rhinitis medicamentosa: rebound rhinitis caused by nasal congestion that is
triggered by overuse of topical decongestants.
◦ Oral antihistamines
Describe different mech of action between first and second generation
of antihistamines
Beer’s Criteria
o Atrovent
Anticholinergic nasal spray, Local application of anticholinergic agents to the nasal
mucosa inhibits vagally mediated reflexes by antagonizing the action of acetylcholine at the
cholinergic receptor. Inhibits secretions.
Pregnancy category B* - good for pregnant women with rhinorrhea
Common S/E’s
Bad taste
Nasal dryness
Epistaxis
Indications: Allergic Rhinitis, rhinorrhea associated with common cold
Precautions: hypersensitivity to atropine, caution in pt’s with narrow angle glaucoma,
prostatic hyperplasia, bladder neck obstruction.
Adverse Rx: HA, epistaxis, pharyngitis, and nasal dryness
Astelin/ Azelastine
Topical antihistamine, histamine receptor antagonist
S/E’s: Bitter taste, HA, nasal burning, somnolence
Decrease in somnolence with Patanase
Somnolence
HA’s
Nasal burning
o Decrease in somnolence w. Patanase
,o Indication
Allergic rhinitis: treatment algorithm:
-suspect allergic rhinitis – do nasal smears, skin testing RAST testing
- if diagnosis confirmed, begin non-pharm management (avoidance of irritants, A/C)
-if symptoms persist: start antihistamine either alone or in combination with nasal
decongestant or intranasal corticosteroids.
-if symptoms persist, immunotherapy.
o NasalCrom
Mast cell stabilizer
Useful as prophylaxis
Safe in pregnancy
Indicated for allergic rhinitis
o Topical Steroids – Intranasal (Flonase)
Act directly to block the effects of inflammation on the nasal mucus membrane
May take up to 1 week to become fully effective
Typically considered safe in pregnancy
For children, there is a risk of impacting growth
Best for established seasonal or perennial rhinitis*
First line therapy for allergies: intranasal steroids (+ 2nd gen antihistamine)
2nd line: antihistamines + nasal decongestants
3rd: intranasal cromolyn
Children age 2 and up can have mometasone and fluticasone, children age 4
and up can have fluticasone propionate, and children age 6 and older can have
, ciclesonide, budesonide, and flunisolide
Ocular Antihistamine
o Patanol and Pataday
o H1 receptor antagonist and mast cell inhibitor for eyes
o Pregnancy C*
o Indications
Allergic conjunctivitis
Allergic rhinitis
◦ Decongestants -oral and nasal
Cause vasoconstriction, assist in clearance of nasal mucous, not for use if < 4
years old. Sympathomimetics that stimulate alpha & beta adrenergic receptors. Stimulant
CNS effects.
Topical: Oxymetazoline, Phenlephrine, neo-synephrinem Afrin
Oral: Pseudoephedrine, Phenylephrine, Sudafed
◦ C/I’s
◦ Narrow angle glaucoma
◦ Severe uncontrolled HTN
◦ CAD
◦ p/ts treated w. MAOI w/in 14 days
◦ Caution
◦ HTN
◦ Cardiac disease
◦ Renal impairment
◦ Hyperthyroidism
◦ Diabetes
, ◦ Prostatic hypertrophy
◦ Urinary incontinence
◦ Adverse Drug Effects
◦ Increased BP and HR
◦ Palpitations
◦ HA, dizziness
◦ GI distress
◦ Insomnia
◦ Tremor
◦ P/t’s w. controlled HTN
◦ Can take for a short course w. monitoring
◦ Interactions
◦ Appetite suppressants
◦ MAOI’s (Hypertensive crisis)
◦ Beta-adrenergic agents (brady & HTN)
Kids need to be at least 6, do not exceed 2 doses of afrin in 24 hrs
◦ Give at least 2 hrs before bedtime for oral
Use for 3-4 days max to avoid rebound congestion.
◦ When would you use oral? When would you recommend nasal
Nasal to avoid systemic effects, use oral after 3-4 days to avoid rebound
congestion.
◦ Rhinitis medicamentosa: rebound rhinitis caused by nasal congestion that is
triggered by overuse of topical decongestants.
◦ Oral antihistamines
Describe different mech of action between first and second generation
of antihistamines
Beer’s Criteria
