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Allergies
Rhinitis – Conjunctivitis – Dermatitis



    Over-The-Counter Treatment Options,
   Information & Counsel for t...
Overview of Presentation

 Present scope, objectives and brief intro
 Discuss topics including:
    Allergic rhinitis
    ...
Topics Not Covered

This talk WILL NOT focus on mold, food, animal/insect
or chemical (e.g. latex) allergies, especially t...
Objectives

 Outline criteria for self-treatment and
when it is advisable to refer a patient to a
physician for further ca...
Introduction
 Up to 50 million
Americans suffer
from seasonal and
chronic allergies
 Roughly $4 billion
in direct healthca...
Allergic Rhinitis
Etiology & Symptoms

 Outdoor aeroallergens: pollen, mold spores and
pollutants (e.g. ozone & exhaust particles)
 Indoor a...
Self-Treatment or Refer?

 Exclusions for self-treatment
    Symptoms of sinusitis, otitis media (w/ effusion) and/or a
  ...
Treatment Options
Antihistamines (AH)        Nonpharmacologic
  Systemic                   Allergen avoidance
  1st and 2n...
AH & Dosages
Systemic AH Products

   Chlorpheniramine   Cetirizine
   1st generation     2nd generation




   Clemastine         Lora...
Nasal DC & Dosages
Nasal DC Products

             Saline          Nephazoline




 Rx only
             Ephedrine       Xylometazoline
in th...
Systemic DC & Dosages
Select OTC Products
Cromolyn Sodium
Unique MOA
  Mast cell stabilizer
  Ideal for prophylaxis

Strengths
  Well tolerated
  Low systemic absor...
Tx Approach - AH & DC

                             Decongestants
Antihistamines
                               2nd line a...
Duration of Treatment

 Algorithms point to short-term
treatment intervals of 3-4 days per step
   NMT 3 days if using lon...
Key Counseling Points
  Encourage pt to assess allergen exposure and
remove if possible – best method for “cure”
 Stress c...
Allergic
Conjunctivitis
Etiology & Symptoms

 Multiple allergens can cause conjunctivitis –
1o are pollen, animal dander and topical eye
products ...
Self-Treatment or Refer?

 Majority of cases seen in community
pharmacy are self-treatment
   Commonly associated with all...
Treatment Options
Decongestants (DC)       Nonpharmacologic
  Nephazoline              Allergen avoidance
  Phenylephrine ...
DC and AH + Dosages




1st line is artificial tears
   HNPD 15th Ed. p. 580-81 Table 28.1

2nd line is DC/AH combo
3rd li...
Select DC
Products
Ocular Combo Products

    Pheniramine 0.3%      Naphazoline 0.012%
    Naphazoline 0.025%    Zinc Sulfate 0.25%




    P...
Duration of Treatment

 Decongestants (e.g. phenylephrine)
should be limited to NMT 3 days of use
   Rebound conjunctival ...
Key Counseling Points

 Stress adherence to regimen and 72 hr
duration to avoid SEs and rebound problem
 DC CI in pregnant...
Allergic Contact
   Dermatitis
Etiology & Symptoms

 Hypersensitivity reaction type 4 (cell mediated
response – delayed = 24-72 hours for sxs)
Main causa...
Self-Treatment or Refer?

 Exclusions for self-            Exclusions for self-
treatment                      treatment (...
Treatment Options
Hydrocortisone (1%)     Nonpharmacologic
  1st line treatment
                          Cold showers
Ane...
Hydrocortisone Options
Select OTC Products
Duration of Treatment

 Resolution of symptoms is key driver for how
long tx should last – limited to 1 week w/ tx
 Some t...
Key Counseling Points

 Avoidance of allergens and locations that
harbor them is the BEST strategy
 If contact is made, ta...
Summary
Treatment Toolbox

Drug categories covered
  Antihistamines (systemic, topical, nasal & ocular)
  Decongestants (systemic,...
Take Home Points
#1 – Know your exclusion          #3 – Discuss how to use
 criteria & when to refer          med and for ...
References
 American Academy of Allergy Asthma and Immunology website
www.aaaai.org/patients/resources/medication_guide.as...
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OTC Allergies

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Consider this deck OTC treatments 101 for allergic conditions such as rhinitis, conjunctivitis and dermatitis.

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OTC Allergies

  1. 1. Allergies Rhinitis – Conjunctivitis – Dermatitis Over-The-Counter Treatment Options, Information & Counsel for the Consumer John W. Probst, MPH USC School of Pharmacy Community Rotation April 14, 2009
  2. 2. Overview of Presentation Present scope, objectives and brief intro Discuss topics including: Allergic rhinitis Allergic conjunctivitis Allergic contact dermatitis Key talking points include: 1) when to treat (i.e. when to use OTC product vs. refer pt to see MD); 2) how to treat/tx options; and 3) duration of tx Summary and Q & A
  3. 3. Topics Not Covered This talk WILL NOT focus on mold, food, animal/insect or chemical (e.g. latex) allergies, especially those causing anaphylaxis, and their treatments. Commercially available OTC products focus primarily on the three conditions to be covered in this presentation.
  4. 4. Objectives Outline criteria for self-treatment and when it is advisable to refer a patient to a physician for further care and treatment Describe condition-centric OTC treatment options/regimens for those suffering from common seasonal or chronic allergies Provide useful counseling points that aid in the safe and effective use of the OTC products that are available to treat allergies
  5. 5. Introduction Up to 50 million Americans suffer from seasonal and chronic allergies Roughly $4 billion in direct healthcare costs annually due to allergy related illness OTC allergy drugs account for 58% of non-rx purchases
  6. 6. Allergic Rhinitis
  7. 7. Etiology & Symptoms Outdoor aeroallergens: pollen, mold spores and pollutants (e.g. ozone & exhaust particles) Indoor aeroallergens: dust mites, cockroaches, mold spores, cigarette smoke and pet dander Primary symptoms: “more than a runny nose” Watery eyes Itchy eyes, nose and/or throat Nasal congestion Watery rhinorrhea Red, irritated eyes w/ conjunctival injection
  8. 8. Self-Treatment or Refer? Exclusions for self-treatment Symptoms of sinusitis, otitis media (w/ effusion) and/or a lower respiratory infection (e.g. pneumonia, bronchitis, etc) Exacerbation or recent-onset of asthma History of non-allergic rhinitis Seasonal vs. Perennial – slightly different algorithms, but same objective = ↑ QOL! Seasonal – Six (6) different tx approaches based on s/sxs Perennial – Three (3) different tx approaches based on s/sxs FYI…algorithms are found on p. 218-220 of HNPD 15th Ed.
  9. 9. Treatment Options Antihistamines (AH) Nonpharmacologic Systemic Allergen avoidance 1st and 2nd generation HEPA filters Decongestants (DC) Allergen-free products Phenylephrine Nasal rinses (e.g. saline) Pseudoephedrine Alternative therapy Nasal sprays/drops Immunotherapy Combo products Herbal treatments Cromolyn Sodium Ephedra & Feverfew
  10. 10. AH & Dosages
  11. 11. Systemic AH Products Chlorpheniramine Cetirizine 1st generation 2nd generation Clemastine Loratadine 1st generation 2nd generation Diphenhydramine Loratadine ODT 1st generation 2nd generation
  12. 12. Nasal DC & Dosages
  13. 13. Nasal DC Products Saline Nephazoline Rx only Ephedrine Xylometazoline in the USA Phenylephrine Oxymetazoline
  14. 14. Systemic DC & Dosages
  15. 15. Select OTC Products
  16. 16. Cromolyn Sodium Unique MOA Mast cell stabilizer Ideal for prophylaxis Strengths Well tolerated Low systemic absorption Weaknesses Approx. 3-7 days for results 2-4 weeks = max benefit CI for kids ≤5 years old
  17. 17. Tx Approach - AH & DC Decongestants Antihistamines 2nd line after AH 1st line Systemic preferred 2nd gen. preferred Non-drowsy Nasal products tend to be overused Peripherally selective No anticholinergic SE Combo products are popular, but No photosensitivity avoid ones w/ pain Well tolerated relievers if possible
  18. 18. Duration of Treatment Algorithms point to short-term treatment intervals of 3-4 days per step NMT 3 days if using long-acting non-saline nasal sprays Max for DC use is 5 days (risk for rhinitis medicamentosa) Assessment should occur after each 3-4 day period Dependent upon severity of symptoms and medication-related side effects Other factors include exposure to allergen, need for prophylaxis and QOL
  19. 19. Key Counseling Points Encourage pt to assess allergen exposure and remove if possible – best method for “cure” Stress compliance and proper administration strategies (i.e. prophylaxis & multiple meds) Confirm that pt is able to take AH and/or DC CI in newborns and premature infants CI in pregnant and nursing ♀ CI in pts w/ HTN, DM, LRT disease, narrow angle glaucoma, stenosing peptic ulcer, BPH, bladder-neck obstruction, esophogeal narrowing, abnormal esophogeal peristalsis and pylorduodenal Ask pt about other meds – screen for DDI EtOH, sedatives, MAOI and CNS depressants are CI
  20. 20. Allergic Conjunctivitis
  21. 21. Etiology & Symptoms Multiple allergens can cause conjunctivitis – 1o are pollen, animal dander and topical eye products (i.e. makeup) Very common comorbid condition with seasonal allergic rhinitis Primary symptoms: “I’m not crying…” Itching and irritation Excessive tearing (can cause blurring of vision) Watery discharge from the eye
  22. 22. Self-Treatment or Refer? Majority of cases seen in community pharmacy are self-treatment Commonly associated with allergic rhinitis Serious eye conditions usually prompt MD visit Pain is usually tolerable – pt seeks sx control If pharmacist suspects damage to eye’s surface refer to MD immediately! When in doubt, and if sxs become worse or don’t resolve…refer to MD
  23. 23. Treatment Options Decongestants (DC) Nonpharmacologic Nephazoline Allergen avoidance Phenylephrine HEPA filters Tetrahydrozoline Allergen-free products Oxymetazoline Eye lubricants/tears Antihistamines (AH) Cold compress Pheniramine maleate Alternative therapy Antazoline phosphate Homeopathic product Combo products Similasan Eye Drops #2
  24. 24. DC and AH + Dosages 1st line is artificial tears HNPD 15th Ed. p. 580-81 Table 28.1 2nd line is DC/AH combo 3rd line is DC/AH + oral AH
  25. 25. Select DC Products
  26. 26. Ocular Combo Products Pheniramine 0.3% Naphazoline 0.012% Naphazoline 0.025% Zinc Sulfate 0.25% Pheniramine 0.3% Tetrahydrozoline 0.05% Naphazoline 0.0267% Zinc Sulfate 0.25% Antazoline 0.5% Phenylephrine 0.12% Naphazoline 0.05% Zinc Sulfate 0.25%
  27. 27. Duration of Treatment Decongestants (e.g. phenylephrine) should be limited to NMT 3 days of use Rebound conjunctival hyperemia, allergic conjunctivitis and allergic blepharitis can result if ocular decongestants are abused or used long-term Antihistamines are shown to aid in rapid relief of sxs DC+AH = shorter tx Combo products should be limited to NMT 3 days of regular use (1-2 gtts QID)
  28. 28. Key Counseling Points Stress adherence to regimen and 72 hr duration to avoid SEs and rebound problem DC CI in pregnant ♀ and pts w/ angle- closure glaucoma, HTN, arteriosclerosis, CV disease and DM (CI ↑thyroid w/ CV dx) Suggest pts try the DC naphazoline or tetrahydrozoline less rebound congestion Avoid if taking TCA, MAOI, & atropine Store meds at proper temperatures (i.e. avoid heat)
  29. 29. Allergic Contact Dermatitis
  30. 30. Etiology & Symptoms Hypersensitivity reaction type 4 (cell mediated response – delayed = 24-72 hours for sxs) Main causative agents Chemical allergens: latex, neomycin, rubber, fragrances etc. Environmental allergens: toxicodendron plants Poison ivy – T. radicans and T. rydbergii Poison sumac – T. vernix Poison oak – West (T. diversilobum); East (T. toxicarium) Easy Dx? – main s/sxs include red rash, blisters or wheals, itching and/or burning skin
  31. 31. Self-Treatment or Refer? Exclusions for self- Exclusions for self- treatment treatment (cont’) Swollen eyes/eyelids <2 years old Genitalia involvement ACD > 2 weeks Itching of mouth, eyes, >25% of body surface nose or anus Presence of ↑ # of bullae Low tolerance of pain Extreme s/sxs and associated itching Swelling of body/extrem Impairment of ADL
  32. 32. Treatment Options Hydrocortisone (1%) Nonpharmacologic 1st line treatment Cold showers Anesthetics Avoidance of further Antihistamines exposure Diphenhydramine Wash or dispose of Benzocaine (20%) contaminated clothing Pramoxine (1%) Alternative therapy Antipruritics Jewel weed Phenol, camphor and menthol
  33. 33. Hydrocortisone Options
  34. 34. Select OTC Products
  35. 35. Duration of Treatment Resolution of symptoms is key driver for how long tx should last – limited to 1 week w/ tx Some treatments have NMT limits Hydrocortisone, TID-QID/day, should not be used >7 days or if symptoms clear then re-appear after a few days – ointment is preferred formulation Astringents, used for oozing and wet sores, can be used for 5 to 7 days – don’t used anything too harsh on skin Anesthetics (CI if open sores) & antipruritics should be limited to 3 to 4 applications/day
  36. 36. Key Counseling Points Avoidance of allergens and locations that harbor them is the BEST strategy If contact is made, take cold shower but don’t scrub too hard – avoid wounds Self-limiting (NMT 21 days), but tx options should be used to avoid infection and limit duration of sxs to 7 days – discuss options See MD if sxs become worse, last >2 wks, involve genitalia, face, eyes, or cover large area
  37. 37. Summary
  38. 38. Treatment Toolbox Drug categories covered Antihistamines (systemic, topical, nasal & ocular) Decongestants (systemic, topical, nasal & ocular) Cromolyn sodium and saline (nasal) Artificial tears, lubricants, and astringents (ocular) Hydrocortisone (topical) Antipruritics and anesthetics (topical) Immunotherapy (systemic) Alternative/Homeopathic and herbal
  39. 39. Take Home Points #1 – Know your exclusion #3 – Discuss how to use criteria & when to refer med and for how long Should/can not treat all Frequency and duration pts seeking care are important to state and repeat – pt safety issue!! Dictates whether or not a non-rx suggestion is Acute vs. chronic use needs appropriate and safe to be stressed due to potential rebound issues #2 – Know all your first- #4 – If possible, follow-up line non-rx tx options and answer pt questions Most pts want YOU to make the choice for them PCP usually isn’t involved Fast recall of BEST option Try to finish the treatment adds to your credibility that you started for the pt
  40. 40. References American Academy of Allergy Asthma and Immunology website www.aaaai.org/patients/resources/medication_guide.asp Epocrates Rx Fiscella RG, Jensen MK. “Allergic Conjunctivitis” Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 15th ed. 2006:585-588. Keefner KR. “Contact Dermatitis” Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 15th ed. 2006:746- 758. Scolaro KL. “Allergic Rhinitis” Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 15th ed. 2006:213- 227. Product photos – www.walgreens.com

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