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Consider this deck OTC treatments 101 for allergic conditions such as rhinitis, conjunctivitis and dermatitis.
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AllergiesAllergiesRhinitis Rhinitis –– Conjunctivitis Conjunctivitis –– DermatitisDermatitis
OverOver--TheThe--Counter Treatment Options, Counter Treatment Options,
Information & Counsel for the ConsumerInformation & Counsel for the Consumer
John W. Probst, MPHJohn W. Probst, MPHUSC School of PharmacyUSC School of PharmacyCommunity RotationCommunity RotationApril 14, 2009April 14, 2009
Overview of PresentationOverview of Presentation
Present scope, objectives and brief introPresent scope, objectives and brief intro
Discuss topics including:Discuss topics including:
Allergic rhinitisAllergic rhinitis
Allergic conjunctivitisAllergic conjunctivitis
Allergic contact dermatitisAllergic contact dermatitis
Key talking points include:Key talking points include: 1)1) when to treat (i.e. when to treat (i.e. when to use OTC product vs. refer pt to see MD); when to use OTC product vs. refer pt to see MD); 2) 2) how to treat/tx options; and how to treat/tx options; and 3) 3) duration of txduration of tx
Summary and Q & ASummary and Q & A
Topics Not CoveredTopics Not Covered
This talk This talk WILL NOTWILL NOT focus on mold, food, animal/insect focus on mold, food, animal/insect or chemical (e.g. latex) allergies, especially those causing or chemical (e.g. latex) allergies, especially those causing anaphylaxis, and their treatments. Commercially anaphylaxis, and their treatments. Commercially available OTC products focus primarily on the three available OTC products focus primarily on the three conditions to be covered in this presentation.conditions to be covered in this presentation.
ObjectivesObjectives
Outline criteria for selfOutline criteria for self--treatment and treatment and when it is advisable to refer a patient to a when it is advisable to refer a patient to a physician for further care and treatmentphysician for further care and treatment
Describe conditionDescribe condition--centric OTC treatment centric OTC treatment options/regimens for those suffering from options/regimens for those suffering from common seasonal or chronic allergiescommon seasonal or chronic allergies
Provide useful counseling points that aid Provide useful counseling points that aid in the safe and effective use of the OTC in the safe and effective use of the OTC products that are available to treat allergiesproducts that are available to treat allergies
IntroductionIntroduction
Up to Up to 5050 million million Americans suffer Americans suffer from seasonal and from seasonal and chronic allergieschronic allergies
Roughly $Roughly $44 billion billion in direct healthcare in direct healthcare costs annually due to costs annually due to allergy related illnessallergy related illness
OTC allergy drugs OTC allergy drugs account for account for 5858% of % of nonnon--rx purchasesrx purchases
Allergic RhinitisAllergic Rhinitis
Etiology & SymptomsEtiology & Symptoms
Outdoor aeroallergens: Outdoor aeroallergens: pollen, mold spores and pollen, mold spores and pollutants (e.g. ozone & exhaust particles)pollutants (e.g. ozone & exhaust particles)
Indoor aeroallergens: Indoor aeroallergens: dust mites, cockroaches, dust mites, cockroaches, mold spores, cigarette smoke and pet dandermold spores, cigarette smoke and pet dander
Primary symptoms: Primary symptoms: ““more than a runny nosemore than a runny nose””
Watery eyesWatery eyes
Itchy eyes, nose and/or throatItchy eyes, nose and/or throat
Nasal congestionNasal congestion
Watery rhinorrheaWatery rhinorrhea
Red, irritated eyes w/ conjunctival injectionRed, irritated eyes w/ conjunctival injection
SelfSelf--Treatment or Refer?Treatment or Refer?
Exclusions for selfExclusions for self--treatmenttreatment
Symptoms of sinusitis, otitis media (w/ effusion) and/or a Symptoms of sinusitis, otitis media (w/ effusion) and/or a lower respiratory infection (e.g. pneumonia, bronchitis, etc)lower respiratory infection (e.g. pneumonia, bronchitis, etc)
Exacerbation or recentExacerbation or recent--onset of asthmaonset of asthma
History of History of nonnon--allergicallergic rhinitisrhinitis
Seasonal vs. Perennial Seasonal vs. Perennial –– slightly different slightly different algorithms, but same objective = algorithms, but same objective = ↑↑ QOL!QOL!
Seasonal Seasonal –– Six (6) different tx approaches based on s/sxsSix (6) different tx approaches based on s/sxs
Perennial Perennial –– Three (3) different tx approaches based on s/sxsThree (3) different tx approaches based on s/sxs
FYIFYI……algorithms are found on p. 218algorithms are found on p. 218--220 of HNPD 15220 of HNPD 15thth Ed.Ed.
Treatment OptionsTreatment Options
Antihistamines Antihistamines (AH)(AH)
SystemicSystemic
11stst and 2and 2ndnd generationgeneration
Decongestants Decongestants (DC)(DC)
PhenylephrinePhenylephrine
PseudoephedrinePseudoephedrine
Nasal sprays/dropsNasal sprays/drops
Combo productsCombo products
Cromolyn SodiumCromolyn Sodium
NonpharmacologicNonpharmacologic
Allergen avoidanceAllergen avoidance
HEPA filtersHEPA filters
AllergenAllergen--free productsfree products
Nasal rinses (e.g. saline)Nasal rinses (e.g. saline)
Alternative therapyAlternative therapy
ImmunotherapyImmunotherapy
Herbal treatmentsHerbal treatments
Ephedra & FeverfewEphedra & Feverfew
AH & DosagesAH & Dosages
Systemic AH ProductsSystemic AH Products
ChlorpheniramineChlorpheniramine11stst generationgeneration
ClemastineClemastine11stst generationgeneration
DiphenhydramineDiphenhydramine11stst generationgeneration
CetirizineCetirizine22ndnd generationgeneration
LoratadineLoratadine22ndnd generationgeneration
Loratadine ODTLoratadine ODT22ndnd generationgeneration
Nasal DC & DosagesNasal DC & Dosages
Nasal DC ProductsNasal DC Products
SalineSaline
EphedrineEphedrine
PhenylephrinePhenylephrine
NephazolineNephazoline
XylometazolineXylometazoline
OxymetazolineOxymetazoline
Rx only Rx only
in the USAin the USA
Systemic DC & DosagesSystemic DC & Dosages
Select OTC ProductsSelect OTC Products
Cromolyn SodiumCromolyn Sodium
Unique MOAUnique MOAMast cell stabilizerMast cell stabilizer
Ideal for prophylaxisIdeal for prophylaxis
StrengthsStrengthsWell toleratedWell tolerated
Low systemic absorptionLow systemic absorption
WeaknessesWeaknessesApprox. 3Approx. 3--7 days for results7 days for results
22--4 weeks = max benefit4 weeks = max benefit
CI for kids CI for kids ≤≤5 years old5 years old
Tx Approach Tx Approach -- AH & DCAH & DC
AntihistaminesAntihistamines
11stst lineline
22ndnd gen. preferredgen. preferred
NonNon--drowsydrowsy
Peripherally selectivePeripherally selective
No anticholinergic SENo anticholinergic SE
No photosensitivityNo photosensitivity
Well toleratedWell tolerated
DecongestantsDecongestants
22ndnd line after AHline after AH
Systemic preferredSystemic preferred
Nasal products Nasal products tend to be overusedtend to be overused
Combo products Combo products are popular, but are popular, but avoid ones w/ pain avoid ones w/ pain relievers if possiblerelievers if possible
Duration of TreatmentDuration of Treatment
Algorithms point to shortAlgorithms point to short--term term treatment intervals of 3treatment intervals of 3--4 days per step 4 days per step
NMT 3 days if using longNMT 3 days if using long--acting nonacting non--saline nasal sprayssaline nasal sprays
Max for DC use is 5 days (risk for rhinitis medicamentosa)Max for DC use is 5 days (risk for rhinitis medicamentosa)
Assessment should occur after each 3Assessment should occur after each 3--4 day period4 day period
Dependent upon severity of symptoms Dependent upon severity of symptoms and medicationand medication--related side effectsrelated side effects
Other factors include exposure to Other factors include exposure to allergen, need for prophylaxis and QOLallergen, need for prophylaxis and QOL
Key Counseling PointsKey Counseling Points
Encourage pt to assess allergen exposure and Encourage pt to assess allergen exposure and remove if possible remove if possible –– best method for best method for ““curecure””
Stress compliance and proper administration Stress compliance and proper administration strategies (i.e. prophylaxis & multiple meds)strategies (i.e. prophylaxis & multiple meds)
Confirm that pt is able to take AH and/or DCConfirm that pt is able to take AH and/or DC
CI in newborns and premature infantsCI in newborns and premature infants
CI in pregnant and nursing CI in pregnant and nursing ♀♀CI in pts w/ HTN, DM, LRT disease, narrow angle glaucoma, CI in pts w/ HTN, DM, LRT disease, narrow angle glaucoma, stenosing peptic ulcer, BPH, bladderstenosing peptic ulcer, BPH, bladder--neck obstruction, neck obstruction, esophogeal narrowing, abnormal esophogeal peristalsis and esophogeal narrowing, abnormal esophogeal peristalsis and pylorduodenalpylorduodenal
Ask pt about other meds Ask pt about other meds –– screen for DDIscreen for DDI
EtOH, sedatives, MAOI and CNS depressants are CIEtOH, sedatives, MAOI and CNS depressants are CI
Allergic Allergic ConjunctivitisConjunctivitis
Etiology & SymptomsEtiology & Symptoms
Multiple allergens can cause conjunctivitis Multiple allergens can cause conjunctivitis ––11oo are pollen, animal dander and topical eye are pollen, animal dander and topical eye products (i.e. makeup)products (i.e. makeup)
Very common comorbid condition Very common comorbid condition with seasonal allergic rhinitiswith seasonal allergic rhinitis
Primary symptoms: Primary symptoms: ““II’’m not cryingm not crying…”…”
Itching and irritationItching and irritation
Excessive tearing (can cause blurring of vision)Excessive tearing (can cause blurring of vision)
Watery discharge from the eyeWatery discharge from the eye
SelfSelf--Treatment or Refer?Treatment or Refer?
Majority of cases seen in community Majority of cases seen in community pharmacy are selfpharmacy are self--treatmenttreatment
Commonly associated with allergic rhinitisCommonly associated with allergic rhinitis
Serious eye conditions usually prompt MD visitSerious eye conditions usually prompt MD visit
Pain is usually tolerable Pain is usually tolerable –– pt seeks pt seeks sxsx controlcontrol
If pharmacist suspects damage to eyeIf pharmacist suspects damage to eye’’s s surface surface refer to MD immediately!refer to MD immediately!
When in doubt, and if sxs become worse When in doubt, and if sxs become worse or donor don’’t resolvet resolve……refer to MDrefer to MD
Treatment OptionsTreatment Options
Decongestants Decongestants (DC)(DC)
NephazolineNephazoline
PhenylephrinePhenylephrine
TetrahydrozolineTetrahydrozoline
OxymetazolineOxymetazoline
Antihistamines Antihistamines (AH)(AH)
Pheniramine maleatePheniramine maleate
Antazoline phosphateAntazoline phosphate
Combo productsCombo products
NonpharmacologicNonpharmacologic
Allergen avoidanceAllergen avoidance
HEPA filtersHEPA filters
AllergenAllergen--free productsfree products
Eye lubricants/tearsEye lubricants/tears
Cold compressCold compress
Alternative therapyAlternative therapy
Homeopathic productHomeopathic product
Similasan Eye Drops #2Similasan Eye Drops #2
DC and AH + DosagesDC and AH + Dosages
11stst line is artificial tearsline is artificial tears
HNPD 15HNPD 15thth Ed. p. 580Ed. p. 580--81 Table 28.181 Table 28.1
22ndnd line is DC/AH comboline is DC/AH combo
33rdrd line is DC/AH + oral AHline is DC/AH + oral AH
Select DC Select DC ProductsProducts
Ocular Combo ProductsOcular Combo Products
Pheniramine 0.3%Pheniramine 0.3%
Naphazoline 0.025%Naphazoline 0.025%
Pheniramine 0.3%Pheniramine 0.3%
Naphazoline 0.0267%Naphazoline 0.0267%
Antazoline 0.5%Antazoline 0.5%
Naphazoline 0.05%Naphazoline 0.05%
Naphazoline 0.012%Naphazoline 0.012%
Zinc Sulfate 0.25%Zinc Sulfate 0.25%
Tetrahydrozoline 0.05%Tetrahydrozoline 0.05%
Zinc Sulfate 0.25%Zinc Sulfate 0.25%
Phenylephrine 0.12%Phenylephrine 0.12%
Zinc Sulfate 0.25%Zinc Sulfate 0.25%
Duration of TreatmentDuration of Treatment
Decongestants (e.g. phenylephrine) Decongestants (e.g. phenylephrine) should be limited to NMT 3 days of useshould be limited to NMT 3 days of use
Rebound conjunctival hyperemia, allergic Rebound conjunctival hyperemia, allergic conjunctivitis and allergic blepharitis can result if conjunctivitis and allergic blepharitis can result if ocular decongestants are abused or used longocular decongestants are abused or used long--termterm
Antihistamines are shown to aid in Antihistamines are shown to aid in rapid relief of sxs rapid relief of sxs DC+AH = shorter txDC+AH = shorter tx
Combo products should be limited to Combo products should be limited to NMT 3 days of regular use (1NMT 3 days of regular use (1--2 gtts QID)2 gtts QID)
Key Counseling PointsKey Counseling Points
Stress adherence to regimen and 72 hr Stress adherence to regimen and 72 hr duration to avoid SEs and rebound problemduration to avoid SEs and rebound problem
DC CI in pregnant DC CI in pregnant ♀♀ and pts w/ angleand pts w/ angle--closure glaucoma, HTN, arteriosclerosis, closure glaucoma, HTN, arteriosclerosis, CV disease and DMCV disease and DM (CI (CI ↑↑thyroid w/ CV dx)thyroid w/ CV dx)
Suggest pts try the DC naphazoline or Suggest pts try the DC naphazoline or tetrahydrozoline tetrahydrozoline less rebound congestionless rebound congestion
Avoid if taking TCA, MAOI, & atropineAvoid if taking TCA, MAOI, & atropine
Store meds at proper temperatures (i.e. Store meds at proper temperatures (i.e. avoid heat)avoid heat)
Allergic Contact Allergic Contact DermatitisDermatitis
Etiology & SymptomsEtiology & Symptoms
Hypersensitivity reaction type 4 (cell mediated Hypersensitivity reaction type 4 (cell mediated response response –– delayed = 24delayed = 24--72 hours for sxs)72 hours for sxs)
Main causative agentsMain causative agents
Chemical allergens: latex, neomycin, rubber, fragrances etc.Chemical allergens: latex, neomycin, rubber, fragrances etc.
Environmental allergens: toxicodendron plantsEnvironmental allergens: toxicodendron plants
Poison ivy Poison ivy –– T. radicans T. radicans and and T. rydbergiiT. rydbergii
Poison sumac Poison sumac –– T. vernixT. vernix
Poison oak Poison oak –– West (West (T. diversilobumT. diversilobum); East (); East (T. toxicarium)T. toxicarium)
Easy Dx? Easy Dx? –– main s/sxs include red rash, blisters or main s/sxs include red rash, blisters or wheals, itching and/or burning skinwheals, itching and/or burning skin
SelfSelf--Treatment or Refer?Treatment or Refer?
Exclusions for selfExclusions for self--
treatmenttreatment
<2 years old<2 years old
ACD > 2 weeksACD > 2 weeks
>25% of body surface>25% of body surface
Presence of Presence of ↑↑ # of bullae# of bullae
Extreme s/sxsExtreme s/sxs
Swelling of body/extremSwelling of body/extrem
Exclusions for selfExclusions for self--treatment treatment (cont(cont’’))
Swollen eyes/eyelidsSwollen eyes/eyelids
Genitalia involvementGenitalia involvement
Itching of mouth, eyes, Itching of mouth, eyes, nose or anusnose or anus
Low tolerance of pain Low tolerance of pain and associated itchingand associated itching
Impairment of ADLImpairment of ADL
Treatment OptionsTreatment Options
Hydrocortisone Hydrocortisone (1%)(1%)
11stst line treatmentline treatment
AnestheticsAnesthetics
AntihistaminesAntihistamines
DiphenhydramineDiphenhydramine
Benzocaine (20%)Benzocaine (20%)
Pramoxine (1%)Pramoxine (1%)
AntipruriticsAntipruritics
Phenol, camphor and Phenol, camphor and mentholmenthol
NonpharmacologicNonpharmacologic
Cold showersCold showers
Avoidance of further Avoidance of further
exposureexposure
Wash or dispose of Wash or dispose of
contaminated clothingcontaminated clothing
Alternative therapyAlternative therapy
Jewel weedJewel weed
Hydrocortisone OptionsHydrocortisone Options
Select OTC ProductsSelect OTC Products
Duration of TreatmentDuration of Treatment
Resolution of symptoms is key driver for how Resolution of symptoms is key driver for how long tx should last long tx should last –– limited to 1 week w/ txlimited to 1 week w/ tx
Some treatments have NMT limitsSome treatments have NMT limits
Hydrocortisone, TIDHydrocortisone, TID--QID/day, should not be used >7 days QID/day, should not be used >7 days or if symptoms clear then reor if symptoms clear then re--appear after a few days appear after a few days ––ointment is preferred formulationointment is preferred formulation
Astringents, used for oozing and wet sores, can be used for 5 Astringents, used for oozing and wet sores, can be used for 5 to 7 days to 7 days –– dondon’’t used anything too harsh on skint used anything too harsh on skin
Anesthetics (CI if open sores) & antipruritics Anesthetics (CI if open sores) & antipruritics should be limited to 3 to 4 applications/day should be limited to 3 to 4 applications/day
Key Counseling PointsKey Counseling Points
Avoidance of allergens and locations that Avoidance of allergens and locations that harbor them is the BEST strategyharbor them is the BEST strategy
If contact is made, take cold shower but donIf contact is made, take cold shower but don’’t t scrub too hard scrub too hard –– avoid woundsavoid wounds
SelfSelf--limiting (NMT 21 days), but tx options limiting (NMT 21 days), but tx options should be used to avoid infection and limit should be used to avoid infection and limit duration of sxs to 7 days duration of sxs to 7 days –– discuss optionsdiscuss options
See MD if sxs become worse, last >2 wks, See MD if sxs become worse, last >2 wks, involve genitalia, face, eyes, or cover large areainvolve genitalia, face, eyes, or cover large area
SummarySummary
Treatment ToolboxTreatment Toolbox
Drug categories coveredDrug categories covered
Antihistamines (systemic, topical, nasal & ocular)Antihistamines (systemic, topical, nasal & ocular)
Decongestants (systemic, topical, nasal & ocular)Decongestants (systemic, topical, nasal & ocular)
Cromolyn sodium and saline (nasal)Cromolyn sodium and saline (nasal)
Artificial tears, lubricants, and astringents (ocular)Artificial tears, lubricants, and astringents (ocular)
Hydrocortisone (topical)Hydrocortisone (topical)
Antipruritics and anesthetics (topical)Antipruritics and anesthetics (topical)
Immunotherapy (systemic)Immunotherapy (systemic)
Alternative/Homeopathic and herbal Alternative/Homeopathic and herbal
Take Home PointsTake Home Points
#1 #1 –– Know your exclusion Know your exclusion criteria & when to refercriteria & when to refer
Should/can not treat all Should/can not treat all pts seeking carepts seeking care
Dictates whether or not a Dictates whether or not a nonnon--rx suggestion is rx suggestion is appropriate and safeappropriate and safe
#2 #2 –– Know all your firstKnow all your first--line nonline non--rx tx optionsrx tx options
Most pts want YOU to Most pts want YOU to make the choice for themmake the choice for them
Fast recall of BEST option Fast recall of BEST option adds to your credibilityadds to your credibility
#3 #3 –– Discuss how to use Discuss how to use med and for how longmed and for how long
Frequency and duration Frequency and duration are important to state and are important to state and repeat repeat –– pt safety issue!!pt safety issue!!
Acute vs. chronic use needs Acute vs. chronic use needs to be stressed due to to be stressed due to potential rebound issuespotential rebound issues
#4 #4 –– If possible, followIf possible, follow--up up and answer pt questionsand answer pt questions
PCP usually isnPCP usually isn’’t involvedt involved
Try to finish the treatment Try to finish the treatment that you started for the ptthat you started for the pt
ReferencesReferences
American Academy of Allergy Asthma and Immunology website American Academy of Allergy Asthma and Immunology website www.aaaai.org/patients/resources/medication_guide.aspwww.aaaai.org/patients/resources/medication_guide.asp
Epocrates RxEpocrates Rx
Fiscella RG, Jensen MK. Fiscella RG, Jensen MK. ““Allergic ConjunctivitisAllergic Conjunctivitis”” Handbook of Handbook of Nonprescription Drugs: An Interactive Approach to SelfNonprescription Drugs: An Interactive Approach to Self--Care, Care, 1515thth ed.ed. 2006:5852006:585--588.588.
Keefner KR. Keefner KR. ““Contact DermatitisContact Dermatitis”” Handbook of Nonprescription Handbook of Nonprescription Drugs: An Interactive Approach to SelfDrugs: An Interactive Approach to Self--CareCare, , 1515thth ed.ed. 2006:7462006:746--758.758.
Scolaro KL. Scolaro KL. ““Allergic RhinitisAllergic Rhinitis”” Handbook of Nonprescription Handbook of Nonprescription Drugs: An Interactive Approach to SelfDrugs: An Interactive Approach to Self--Care, 15Care, 15thth ed.ed. 2006:2132006:213--227.227.
Product photos Product photos –– www.walgreens.comwww.walgreens.com