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OTC Allergies

1. Allergies Rhinitis – Conjunctivitis – Dermatitis Over-The-Counter Treatment Options, Information & Counsel for the Consumer John W. Probst, MPH USC School of…
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  • 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. 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. 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. 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. 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. Allergic Rhinitis
  • 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. 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. 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. AH & Dosages
  • 11. Systemic AH Products Chlorpheniramine Cetirizine 1st generation 2nd generation Clemastine Loratadine 1st generation 2nd generation Diphenhydramine Loratadine ODT 1st generation 2nd generation
  • 12. Nasal DC & Dosages
  • 13. Nasal DC Products Saline Nephazoline Rx only Ephedrine Xylometazoline in the USA Phenylephrine Oxymetazoline
  • 14. Systemic DC & Dosages
  • 15. Select OTC Products
  • 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. 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. 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. 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. Allergic Conjunctivitis
  • 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. 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. 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. 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. Select DC Products
  • 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. 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. 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. Allergic Contact Dermatitis
  • 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. 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. 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. Hydrocortisone Options
  • 34. Select OTC Products
  • 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. 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. Summary
  • 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. 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. References American Academy of Allergy Asthma and Immunology website 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 –
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