Transcript Over-The-Counter (OTC) Management for Geriatric Patients: A

Kathleen A. Lusk, PharmD, BCPS
G. Blair Sarbacker, PharmD, BCACP
Christine Whong, PharmD, BCPS
Christine Whong, PharmD, BCPS
Assistant Professor of Pharmacy Practice
University of the Incarnate Word, Feik School of Pharmacy
After this session, attendees should be able to:
Compare new contraceptive agents.
2. Educate a patient on the use of the new contraceptive
agents.
1.
~6.6 million pregnancies occurred (N = 6583*)
51%
49%
Intended (n = 3216*)
Unintended (n = 3367*)
*Number of pregnancies (thousands)
Am J Public Health. 2014 Feb;104 Suppl 1:S43-8.
WOMEN AGED 18 – 19 YEARS
WOMEN AGED 20 – 24 YEARS
2001: 79%
2008: 64%
2001: 59%
2008: 77%
Am J Public Health. 2014 Feb;104 Suppl 1:S43-8.
80%
70%
60%
50%
40%
30%
20%
10%
0%
72% 71%
23% 23%
16%
2%
2002
N/A
8%
2% 5%
2006 - 2010
*IUD = intrauterine device
Welti K, Wildsmith E, Manlove, J. Trends and Recent Estimates: Contraceptive Use Among U.S. Teens and Young Adults. Washington (DC):
Child Trends; 2011 Dec. Publication No.: 2011-239-1-7.
Combined Oral Contraceptives
• Ethinyl estradiol/levonorgestrel
(Quartette™)
• Ethinyl
estradiol/norethindrone/ferrous
fumarate (Lo Minastrin™ Fe)
• Ethinyl
estradiol/norethindrone/ferrous
fumarate (Minastrin™ Fe)
• Extended-cycle regimen
• Biphasic regimen, placebo: ferrous
fumarate, chewable tablets
• Monophasic regimen, placebo: ferrous
fumarate, chewable tablets
Long-Acting Reversible Contraceptive (LARC)
• Levonorgestrel-releasing
intrauterine system (Skyla®)
• Indicated for prevention of pregnancy for
up to 3 years
Hormonal Emergency Contraception
• Levonorgestrel (Plan B One-Step®)
• Approved for OTC use in 2013

Extended-cycle regimen
 Active pills for 84 days
▪ Ethinyl estradiol dose varies
▪ 20 mcg x 42 days
▪ 25 mcg x 21 days
▪ 30 mcg x 21 days
 Low dose estrogen for 7 days
▪ Ethinyl estradiol 10 mcg
Extended-Cycle Tablet Dispenser
Quartette™ [package insert]. Sellersville, PA: Teva Women’s Health, Inc; 2013.
http://www.herquartette.com/VirtualPillPack.aspx

Breakthrough bleeding
 Highest risk during 1st 3 months
 Varying estrogen dose designed to ↓ risk
▪ No studies to support claim
 Does not constitute ineffectiveness
▪ If breakthrough bleeding persists > 3 months
▪ Increase estrogen dose if current dose < 30 mcg

Cost
 Quartette™ > generic LoSeasonique
Quartette™ [package insert]. Sellersville, PA: Teva Women’s Health, Inc; 2013.

Biphasic regimen
 Day 1 – 24 (active)
▪ Ethinyl estradiol 10 mcg/norethindrone acetate 1 mg
▪ Mint-flavored, chewable tablets
 Day 24 – 26 (active)
▪ Ethinyl estradiol 10 mcg
 Day 27 – 28 (placebo)
▪ Ferrous fumarate 75 mg
Lo Minastrin™ Fe [package insert]. Rockaway, NJ: Warner Chilcott, LLC; 2013.

Monophasic regimen
 Day 1 – 24 (active)
▪ Ethinyl estradiol 10 mcg/norethindrone acetate 1 mg
▪ Mint-flavored, chewable tablets
 Day 24 – 28 (placebo)
▪ Ferrous fumarate 75 mg
Minastrin™ 24 Fe [package insert]. Rockaway, NJ: Warner Chilcott, LLC; 2013.
http://www.minastrin24.com/

Replacing Loestrin® 24 Fe
 Same drugs and dosing regimen
 Cannot be automatically substituted due to difference in
dosage forms

Generic Loestrin® 24 Fe will be available this year

Cost
 Minastrin™ brands ≈ Loestrin® brands
Adverse Effect(s)
Content
Nausea, breast tenderness, hypertension, headache
Excessive estrogen
Early or mid-cycle breakthrough bleeding, increased
spotting, hypomenorrhea
Insufficient estrogen
Breast tenderness, headache, fatigue, mood changes
Excessive progestin
Late breakthrough bleeding
Insufficient progestin
Polyphagia, weight gain, acne, oily skin, hirsutism
Excessive androgen
O’Mara NB. Hormonal Contraception. Pharmacist’s Letter; 2013 Mar. Publication No.: 2903059-1-7.

Most frequently cited reason for failure to initiate or
discontinue use

No evidence of causal relationship between
combined oral contraceptives and weight gain has
been established
 No significant differences among agents
▪ Extended-cycle regimens do not cause more weight changes than
standard regimens
Cochrane Database Syst Rev. 2014 Jan 29;1:CD003987.
THE AMERICAN COLLEGE OF OBSTETRICIANS AND
GYNECOLOGISTS (ACOG)

Does not affect oral
contraceptive steroid
levels:
 Ampicillin
 Doxycycline
 Fluconazole
 Metronidazole
 Quinolones (ciprofloxacin,
levofloxacin, moxifloxacin)
 Tetracycline
Obstet Gynecol. 2006 Jun;107(6):1453-72.

Decreases oral
contraceptive steroid
levels:
 Rifampin
CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) – U.S.
MEDICAL ELIGIBILITY CRITERIA FOR CONTRACEPTIVE USE

Category 1 (no restriction
for use):
 Broad-spectrum antibiotics
Category 3 (theoretical or
proven risks outweigh
advantages of use):
 Antifungals
 Rifampin
 Antiparasitics
 Rifabutin

Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010.
http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf. Published May 28, 2010. Accessed May 11, 2014.

Assess patient-specific risk factors for reduced oral
contraceptive efficacy
 Noncompliance
 Vomiting
 Diarrhea
 Menstrual irregularities

Inform all patients of possible interaction
Obstet Gynecol. 2001;98(5 pt 1):853-60.

Long-acting reversible contraceptive
 Levonorgestrel 14 mcg/day after 24 days
▪ Decreases to 5 mcg/day after 3 years
 Must be removed or replaced after 3 years

Patient should be re-examined 4 – 6 weeks postinsertion
Skyla ® [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceutical Inc; 2013.
http://www.skyla-us.com/what-is-skyla.php#HowItWorks

Irregular bleeding & spotting (1st 6 months following
insertion)
 Unacceptable bleeding  common reason for
discontinuation
 Oligomenorrhea or amenorrhea likely to occur by the end
of 1st year use

Pain
 Decreases over time
Curr Opin Obstet Gynecol. 2013;25(Suppl 1):S1-10.

Pelvic inflammatory
disease

Osteoporosis

IUD size
 1.6 cases/1,000 woman-
years used




Infertility
Ectopic pregnancy
Weight gain
Acne
Eur J Contracept Reprod Health Care. 2012 Oct;17(5):340-50.
Curr Opin Obstet Gynecol. 2013;25(Suppl 1):S1-10.
 Expulsion

Perforation

Cancer

Cost

Parental consent
required
J Adolesc Health. 2013 Apr;52(4 Suppl):S14-21.







Benefits
Risks
Alternatives
Inquiries about the contraceptive option
Decisions to withdraw from use
Explanation of method
Documentation
J Adolesc Health. 2013 Apr;52(4 Suppl):S40-6.

Approved for OTC use in June 2013
Plan B One-Step® [package insert]. Sellersvile, PA: Teva Women’s Health, Inc; 2011.
http://www.planbonestep.com/index.aspx

Irregular bleeding

Fatigue (13.3%)

Headache (13.3%)
 Heavier menstrual
bleeding (30.9%)

Nausea (13.7%)

Dizziness (9.6%)

Lower abdominal pain
(13.3%)

Breast tenderness
(8.2%)
Plan B One-Step® [package insert]. Sellersvile, PA: Teva Women’s Health, Inc; 2011.
Obstet Gynecol. 2010 May;115(5):1100-9.

ACOG Emergency Contraception Practice Bulletin
(2010)
 “May be used more than once, even within same
menstrual cycle”
 Should not be used as long-term contraceptive
▪ Less effective
▪ Higher total hormone exposure side effects

Pericoital oral levonorgestrel
 Previous reviews suggest efficacious & safe to use
 Recent study confirmed safety, but was not found to be
more effective than typical use of barrier methods
Obstet Gynecol. 2010 May;115(5):1100-9.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007595.
Contraception. 2014 Mar;89(3):215-21.
1.
Minastrin™ 24 Fe is a chewable tablet formulation
oral contraceptive.
a. True
b.False
2.
If breakthrough bleeding persists with ethinyl
estradiol/levonorgestrel (Quartette™) use beyond
3 months, a decrease in estrogen dose ≥ 30 mcg
should be considered.
a. True
b.False
Kathleen A. Lusk, PharmD, BCPS
Assistant Professor of Pharmacy Practice
University of the Incarnate Word, Feik School of Pharmacy
After this session, attendees should be able to:
Determine an optimal sexually transmitted infection
treatment plan.
2. Apply results of over-the-counter sexually transmitted
infection diagnostic tools.
1.

Etiology: C. trachmoatis
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
MMWR Morb Mortal Wkly Rep 2011; 60(12):370-3.
CDC – National Center of Health Statistics – Chlamydia. /http://www.cdc.gov/std/stats12/chlamydia.htm/. May 9, 2014.

Treatment options
1st line
2nd line
Treatment
Azithromycin 1 g PO
Duration
1 dose
Doxycycline 100 mg PO BID
Erythromycin ethylsuccinate 800 mg PO QID
Levofloxacin 500 mg PO daily
Ofloxacin 300 mg PO BID
7 days
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
7 days

Etiology: N. gonorrhoeae
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
CDC – National Center of Health Statistics – Gonorrhea. /http://www.cdc.gov/std/stats12/gonorrhea.htm/. May 9, 2014.

Treatment options
Treatment
Ceftriaxone 250 mg IM x 1
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Duration
1 dose
MMWR Recomm Rep 2012; 61 (31): 590-4.

Ceftriaxone susceptibility
CDC – National Center of Health Statistics – 2012 Sexually Transmitted Diseases Surveillance. /http://www.cdc.gov/std/stats12/figures/24.htm/.
May 9, 2014.

Commonly infected with C. trachmoatis and N.
gonorrhoeae

Dual therapy required
Treatment
Ceftriaxone 250 mg IM x 1
plus
Duration
1 dose
Azithromycin 1 g PO
Doxycycline 100 mg PO BID
1 dose
7 days
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
MMWR Recomm Rep 2012; 61 (31): 590-4.


Ceftriaxone not available or allergy present
Treatment
Cefixime 400 mg PO x 1
+
Azithromycin 1 g PO x 1
Cefixime 400 mg PO x 1
+
Doxycycline 100 mg PO BID x 7 days
Duration
Azithromycin 2 g PO x 1
1 dose
1 dose
7 days
Alternate regimen chosen  test-of-cure in 1 week
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
MMWR Recomm Rep 2012; 61 (31): 590-4.

Abstain from sexual intercourse for 7 days after
treatment completion

Refer partners for evaluation if sexual contact ≤ 60
days of symptom onset or diagnosis

Patient delivered medication
 Partner evaluation/treatment cannot be ensured
 Reserved for heterosexual patients
MMWR Recomm Rep 2010; 59 (RR-12):1-110.

Etiology: T. pallidum
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
CDC – National Center of Health Statistics – 2012 Sexually Transmitted Diseases Surveillance. /http://www.cdc.gov/std/stats12/figures/33.htm/.
May 9, 2014.

Treatment options
Type
Treatment
Duration
Benzathine penicillin G 2.4 million units IM
1 dose
Benzathine penicillin G 2.4 million units
IM q7 days
3 doses
(21 days)
Aqueous crystalline penicillin 3-4 million units IV
q4 hours (or continuous infusion)
or
Procaine penicillin 2.4 million units IM daily +
probenacid 500 mg PO QID
10-14 days
Primary
Secondary
Early latent
Late latent
Tertiary
Neurosyphilis
MMWR Recomm Rep 2010; 59 (RR-12):1-110.


Penicillin allergy
Skin Test Result
Recommendation
Negative
Conventional penicillin therapy
Positive
Desensitize
Not available
Desensitize
Transmission risk
Syphilis Type
Duration of risk
Primary
3 months + duration of symptoms
Secondary
6 months + duration of symptoms
Early Latent
1 year + duration of symptoms
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Partner Diagnosis and Type
Recommendation
Primary/secondary/early latent
≤ 90 days
May be infected if seronegative
Treat presumptively
Primary/secondary/early latent
> 90 days
Latent
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Treat presumptively if serologic
test not available or if follow up
uncertain
Evaluate clinically and
serologically

Systemic antiviral medications control the signs and
symptoms

Medications do not eradicate virus

Treatment options
 Treatment of 1st clinical episode
 Treatment of recurrent episodes
 Suppressive therapy
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Type
First episode
Suppressive
therapy
Treatment
Acyclovir 400 mg PO TID
Acyclovir 200 mg PO 5x/day
Famciclovir 250 mg PO TID
Valacyclovir 1 g PO BID
Acyclovir 400 mg PO BID
Famciclovir 250 mg PO BID
Valacyclovir 500 mg PO daily
Valacyclovir 1 g PO daily
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
N Engl J Med 2004;350:11–20.
JAMA 1998;280:887–92.
Genitourin Med 1997;73:110–6.
Arch Intern Med 1997;157:343–49.
Duration
7-10 days
Indefinitely
Sex Transm Dis 1997;24:481–6.
Sex Transm Dis 2006;33:529–33.
Type
Episodic
therapy
Treatment
1000 mg PO BID
500 mg x 1,
Famciclovir
then 250 mg PO BID
125 mg PO BID
800 mg PO TID
Acyclovir
800 mg PO BID
400 mg PO TID
500 mg PO BID
Valacyclovir
1 g PO daily
MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Duration
1 day
2 days
5 days
2 days
5 days
5 days
3 days
3 days

Symptomatic
 Evaluated and treated in same manner as patient

Asymptomatic
 Questioned about history of genital lesions
 Offered type-specific serologic testing
MMWR Recomm Rep 2010; 59 (RR-12):1-110.

Etiology: T. vaginalis
1st
Treatment
Duration
Metronidazole 2 g PO x 1
1 dose
Tinidazole 2 g PO x 1
1 dose
Metronidazole 500 mg PO BID
7 days
line
2nd line
Metronidazole gel < oral preparations
 Rescreening at 3 months can be considered
 Refrain from sexual intercourse until treatment
completed and partner cured

MMWR Recomm Rep 2010; 59 (RR-12):1-110.
Ann Intern Med 2006; 145:564-72.
Cochrane Database Syst Rev 2003;(2):CD000218.

Monistat Complete Care Vaginal Health Test®
 Generics also available

Advertisement
 “May be helpful if your symptoms are caused by an
infection that may require follow-up by your healthcare
provider”
 Yeast infection vs. infection requiring treatment by
healthcare professional

Cost: $17.99
http://www.monistat.com/monistat-complete-care
http://www.drugstore.com/monistat-complete-care-vaginal-health-test-itch-relief/qxp522496?catid=184078

Recommended for use if vaginal symptoms present
 Unpleasant odor
 Abnormal, excessive discharge
 Vaginal itching, burning

Results
Color
Result
Recommendation
Yellow
Blue or green
Normal acidity
Abnormal acidity
Consider yeast infection
See healthcare practitioner
Infect Dis Obstet Gynecol 2003;11:209–16.
http://www.drugstore.com/monistat-complete-care-vaginal-health-test-itch-relief/qxp522496?catid=184078
Home Access HIV-1
Test System
Home Access
Express HIV-1 Test
System
OraQuick In-Home
HIV Test
Accuracy
99.9%
99.9%
1 in 12 false (-)
Sample
Blood
Blood
Oral swab
Results (time)
1 week
1 day
20 minutes
Results (availability)
Via phone
Via phone
At home
Counseling
Via phone
Via phone
---
Postage/lab cost
Traditional postage
and lab costs
included in price
Overnight postage
and lab costs
included in price
---
Cost
$37.99
$59.99
$39.99
http://www.drugstore.com/home-access-express-hiv-1-test-system--next-day-results/qxp38331?catid=185976
http://www.drugstore.com/oraquick-in-home-hiv-test/qxp454553?catid=185976
http://www.drugstore.com/home-access-hiv--1-test-system/qxp38330?catid=185976
Ann Intern Med 1997; 157:309-14.
1.
A 55 year old male with a history of a penicillin allergy is diagnosed with neurosyphilis. It is decided
to complete a skin test. The skin test is positive. Which of the following recommendations is most
appropriate for this patient’s treatment?
a. Immediately begin benzathine penicillin G 2.4 million units IM q7 days x 3 doses
b. Begin desensitization protocol. After completion, begin benzathine penicillin G 2.4 million
units IM q7 days x 3 doses
c. Immediately begin aqueous crystalline penicillin 3-4 million units IV q4 hours x 14 days
d. Begin desensitization protocol. After completion, begin aqueous crystalline penicillin 3-4
million units IV q4 hours x 14 days
2.
A 19 year old female presents to your clinic for a check-up. When taking her HPI and PMH, she
states that she has had multiple new sexual partners. When asked, she says she “does her best to
use protection”. She shows you the results of a diagnostic test she purchased at the local pharmacy.
The test was the OraQuick In-Home HIV Test. The results were negative. In addition to counseling
the patient on safe sex practices, what is the most appropriate next step?
a. No additional steps required
b. Have the patient use Home Access HIV-1 Test System test immediately
c. Perform the enzyme-linked immunosorbent assay (ELISA) immediately
d. Counsel the patient to use the OraQuick In-Home HIV test monthly at home
G. Blair Sarbacker, PharmD, BCACP
Assistant Professor of Pharmacy Practice
University of the Incarnate Word, Feik School of Pharmacy
After this session, attendees should be able to:
1.
Choose optimal allergy therapies.

Epidemiology
 Affects 20-30% of
adults, 40% of children
 Typically during
childhood, adolescence
and early adulthood

Symptoms
 Sneezing, nasal
obstruction, nasal
discharge +/- itching
Allergy 2008;63:8–160.

Triggers:

Allergic Rhinitis and its Impact on
Asthma (ARIA)
 World Health Organization, 2008 & 2010
Update

The diagnosis and management of
rhinitis: an updated practice
parameter
 The American Academy of Allergy,
Asthma, and Immunology (AAAAI),
2008

Preferred Practice Pattern
Guidelines. Conjunctivitis.
 American Academy of Ophthalmology
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Allergic salute/
Nasal crease
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.
Duration
Severity
Intermittent
Mild
Symptoms occur < 4
days per week OR <
4 weeks
Moderate-to-Severe
Persistent
Mild
Symptoms occur > 4
days per week AND
> 4 weeks
Allergy 2008;63:8–160.
Moderate-to-Severe
No impairment in sleep or daily
activities; no troublesome symptoms
1 or more of:
 Impairment of sleep
 Impairment of daily activities
 Troublesome symptoms
No impairment in sleep or daily
activities; no troublesome symptoms
1 or more of:
 Impairment of sleep
 Impairment of daily activities
 Troublesome symptoms
J Allergy Clin Immunol 2010;126(3):466–476.
ALLERGIC RHINITIS



Minimize or prevent
symptoms
Ability to undertake ADLs
without limitation
Minimize drug adverse
reactions
ALLERGIC CONJUNCTIVITIS


Provide symptomatic relief
Protect the ocular surface
Allergic “shiners”
Ocular Conjunctivitis
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.

Avoidance of allergens
 For outdoor symptoms:
▪ Check pollen counts and air quality index
▪ Keep house doors and windows closed
▪ Avoid outdoor exposures as much as possible
 For indoor symptoms:
▪ Remove symptom triggers (i.e. pets, smoke)
▪ Lower the humidity in the home to reduce molds
▪ Wash bedding in hot water weekly & encase mattresses
dust mite resistant coverings

& pillows in
Nasal saline
 Reduce irritation and dryness
 Remove mucus & allergens from the nose


Ocular lubricants
Cold compresses to eyes 3-4 times per day
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.
Fig 1 Recommendations of the ARIA update (from Bousquet et al<ce:cross-ref refid="bib8"> 8 </ce:cross-ref> ). CS , Corticosteroid; LTRA , leukotriene receptor
antagonist.
J Allergy Clin Immunol 2012;130(5):1049-62

If not responding to treatment of allergic rhinitis,
consider adding:
 Ophthalmic lubricant
 Ophthalmic antihistamine/mast cell stabilizer
 Ophthalmic antihistamine
 Ophthalmic antihistamine/decongestant
▪ Decreased tolerability

Efficacy is comparable between all except lubricants
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Oral
+++
+++
0 to +
+++
++
Intranasal
++
+++
+
++
0
Intraocular
0
0
0
0
+++
+++
+++
++
++
+
Intranasal
+
+
+
+
0
Intraocular
0
0
0
0
++
Intranasal
0
0
++
0
0
Oral
0
0
+
0
0
ANTICHOLINERGICS
0
+++
0
0
0
LRTA
+
++
++
?
++
ARIA
ANTIHISTAMINES
CORTICOSTEROIDS
CROMONES
DECONGESTANTS
Adapted from Allergy. 2008;63:8–160.

Most effective single agent: all symptoms are targeted

Very effective in nasal congestion
 No agent within the class considered superior
▪ Mometasone (Nasonex®) and fluticasone (Veramyst®)approved for ocular sx
▪ Triamcinolone (Nasacort®) is now OTC
▪ Budesonide (Rhinocort Aqua®) – pregnancy category B
 Compared in clinical trials to antihistamines, montelukast and steroids shown to be
more effective

Maximal benefit seen after 2 weeks of use

Some patients will see symptoms reduce in few days
 Can start with a higher dose and reduce after 2 weeks
 Intermittent use - initiate 2 weeks prior to expected exposure to allergen and continue
for 2-3 weeks after the season
ARIA
Sneezing
Rhinorrhea
Nasal Obstruction
Nasal Itching
Ocular
Corticosteroids
+++
+++
++
++
+
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.

Adverse effects
 Nasal crusting, dryness, epistaxis, burning
 No clinically significant effect on HPA axis/ growth in children

Requires correct administration technique to minimize
chance for adverse effects
 Do not direct the spray toward the septum
 Head pointed slightly downward when
administering spray to avoid throat drainage
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2008;122:S1-84.
J Allergy Clin Immunol 2010;126(3):466–476.
Rhinocort Aqua[package insert]. Wilmington, DE: AstraZeneca; 2010.

First generation oral agents associated with sedation,
anticholinergic effects, confusion
 ADEs more frequent in the elderly
 Precautions/contraindications include BPH, glaucoma
 If postnasal drip occurs, 1st generation may be warranted

Second generation oral products preferred due to an improved
tolerability profile
 AAAAI oral preferred agents are fexofenadine, loratadine, desloratadine due
to no sedation at recommended doses
 Cetirizine, levocetirizine might have drowsiness at recommended doses
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal
Itching
Ocular
Oral Antihistamines
+++
+++
0 to +
+++
++
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.

Oral targets most symptoms
 Less impact on nasal congestion and polyps
 1st line in mild disease

Usually effective within one day in treating the targeted
symptoms
2nd Generation (Nonsedating) Antihistamines
Dose
RX/OTC/Both
Cetirizine (Zyrtec®) – Category B
Levocetirizine (Xyzal®)
Loratadine (Alavert® & Claritin®) – Category B
Desloratadine (Clarinex®)
Fexofenadine (Allegra®)
10 mg daily
5 mg daily
10 mg daily
5 mg daily
180 mg daily
Both
RX
OTC*
RX
OTC*
*can still get via RX
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.

Nasal targets most symptoms except ocular
 More effective at nasal congestion
 Systemically absorbed up to 40%
 Systemic AEs: drowsiness and headache




Local AEs: dryness
Onset of action <15 mins
Olopatadine (Patanase®)
Azelastine
 Astelin® - bitter taste, HA, somnolence
 Astepro® different base solution – improved taste

RX only
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Intranasal Antihistamines
++
+++
+
++
0
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.
OTC: ketotifen (Alaway®; Zatiador®)
RX: azelastine (Optivar®), epinastine (Elestat®),
olopatadine (Pataday®; Patanol®)
 Adverse Events:


 Burning, stinging, and discomfort upon instillation

Contraindications:
 Closed-angle glaucoma
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Intraocular
Antihistamines
0
0
0
0
+++
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.




OTC: pheniramine & antazoline
RX: alcaftadine (Lastacaft®) & emedastine (Emadine®)
OTC products are available in combination
with ophthalmic decongestants
Contraindications:
 Closed-angle glaucoma
 Sensitivity to active ingredient
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Intraocular
Antihistamines
0
0
0
0
+++
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.




Targets nasal congestion
Can alleviate sinus
pressure/headaches & ear
congestion
Useful in a short course to
reduce congestion as other
medications are initiated
Pseudoephedrine >
phenylephrine

Consider contraindications/
precautions for oral:

CVD, HTN
 Hyperthyroidism
 MAO inhibitors

Oral Adverse Reactions

Insomnia
 Agitation

Nexafed® - tamper-resistant
 Sudafed®
 Sudafed PE®
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Oral Decongestants
0
0
+
0
0
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.
NASAL


OPHTHALMIC
Targets nasal congestion
Rhinitis medicamentosa



Use for 3-5 days
Targets ocular redness
Adverse Events:

Nasal Dryness
Oxymetazoline (Afrin®)
Phenylephrine (Neo-Synephrine®)
 OTC only
 Caution in HTN





Dryness
Rebound congestion
▪ Do not use for more than 72 hours
▪ Less common with naphazoline and
tetrahydrozoline
▪ If rebound congestion occurs, refer to
eye care provider
Contraindications:

Open-angle or closed-angle glaucoma
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Topical Decongestants
0
0
++
0
0
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.

Available as nasal (Nasalcrom OTC), ocular
 Nasal formulation targets all symptoms except ocular
 Less effective than intranasal corticosteroids and oral antihistamines


Most effective when used prior to allergen exposure
Nasal and ocular may require dosing 4-6 times per day
 Can decrease frequency after 2-3 weeks


Few side effects
1st line in pregnancy
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal Itching
Ocular
Intranasal
+
+
+
+
0
Intraocular
0
0
0
0
++
ARIA
Cromones
Allergy 2008;63:8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
Preferred Practice Pattern Guidelines. Conjunctivitis. AAAO. 2013.
J Allergy Clin Immunol. 2008;122:S1-84.

Ipratropium available as intranasal formulation
 Atrovent Nasal Spray
 2 sprays per nostril BID or TID

Only symptom that it treats is rhinorrhea
 Less effect than nasal steroids


Consider precautions in BPH and glaucoma
ADEs minimal; dryness of nasal membranes
ARIA
Anticholinergics
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal
Itching
Ocular
0
+++
0
0
0
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.







Montelukast (Singulair®) only LTRA with FDA approval (adults and
children 6 months and older)
Studies resulted in relief of sneezing, congestion, rhinorrhea, and nasal
itching
Similar efficacy to oral antihistamines, less effective than intranasal
corticosteroids
Can be used in combination with antihistamines; has better evidence for
treating nasal obstruction
Same dosing as asthma
Pregnancy category B
Just denied OTC designation
ARIA
Sneezing
Rhinorrhea
Nasal
Obstruction
Nasal
Itching
Ocular
LRTA
+
++
++
?
++
Allergy 2008;63: 8–160.
J Allergy Clin Immunol 2010;126(3):466–476.
J Allergy Clin Immunol 2008;122:S1-84.

What symptoms does the patient complain of?
 Itchy, running nose
 Daily, does not impair sleep or daily activities
 Nose

What have they tried and was it successful?
When comparing the treatments for allergic rhinitis,
which of the following is the most efficacious for relief
of all symptoms?
a. Intranasal corticosteroids
b. Oral antihistamines
c. Intranasal cromones
d. Oral decongestants
e. Intranasal antihistamines