Allergy Meds: Glucocorticoids, Afrin, Omalizumab

Intranasal Glucocorticoids (NGCs)

• NGCs effectively prevent and treat seasonal and perennial rhinitis
• Take daily for effectiveness
• Start 2 weeks before allergy season, continue until environmental allergy index declines or first frost
• Adverse effects include drying of the nasal mucosa and local burning/itching
• Systemic effects like adrenal suppression and growth deceleration in children are a lower risk

Rebound Congestion and Afrin Use

• Prevent rebound congestion by avoiding use for more than 3–5 days
• Using every other naris can prevent overuse effects.
• If rebound congestion occurs, gradually taper the dose
• Supplement the weaning process with intranasal glucocorticoids (NGCs).

Omalizumab (Xolair)

• Used for allergy-related asthma only if an allergen causes the asthma
• Administer subcutaneously (SQ) every 2–4 weeks
• Dosage is 150–300 mg every 4 weeks or 225–375 mg every 2 weeks
• Doses exceeding 150 mg need to be split into two sites
• A 75 mg dose is available for children or lower body weight patients
• Black box warning indicates a risk of anaphylaxis.

Guaifenesin for Viral Infections

• Guaifenesin (Mucinex) is an expectorant that thins mucus and increases coughing to help clear trapped sputum
• Patients should increase fluid intake to improve effectiveness
• Often included in OTC combination products
• Labels should be read to avoid accidental overdose
• Should not be used for more than one week
• Medical care is needed if the cough persists
• Can cause drowsiness

AAP Best Practices for Viral Infections in Young Children

• Nasal bulb suctioning and nasal saline drops are appropriate
• Use a cool-mist humidifier
• If the child is over 1 year old, honey can be used to soothe a cough
• If the child is over 2 years old, mentholated chest rubs can be used
• Weight-based acetaminophen and ibuprofen can be used for fever reduction and comfort

Age Restrictions based on AAP guidelines

• Cough and cold products should be avoided in children under 6 years old
• Manufacturer labels state they should not be used in children under 4 years old
• Antihistamine-containing products should not be used to sedate sick or well children

Spacers

• Recommended for inhaled medications, like inhaled glucocorticoids
• Improves drug delivery

Spacer Benifits

• Reduces oropharyngeal deposition of medication
• Decreases side effects, such as oral thrush with inhaled steroids
• Helps patients who have difficulty coordinating inhalation with device activation

Montelukast

• The safest LTRA because it is an oral medication that blocks leukotriene binding
• Reduces nasal congestion and inflammation
• Reserved for patients who have failed other therapies due to neuropsychiatric side effects risk

Roflumilast Treats

• Used prophylactically in patients with COPD with a chronic bronchitis component

Roflumilast MOA

• Selectively inhibits PDE-4
• Leads to increased cAMP
• Reduces inflammation and pulmonary neutrophil infiltration

Roflumilast Contraindications

• Avoid in pregnant and lactating patients
• Common adverse effects: GI distress, headaches, back pain, insomnia

Short-acting beta-2 agonists (SABAs)

• Most effective treatment for acute (emergent) bronchospasm
• Example: Albuterol (rapid onset)

Theophylline

• Normal drug levels: 5–15 mg/dL
• Toxicity signs/symptoms when greater than 20 mg/dL: GI distress, ventricular fibrillation, seizures

Treatment for Theophylline Toxicity

• Discontinue theophylline
• Lidocaine for dysrhythmias
• Benzodiazepines for seizures
• Avoid caffeine and drugs that alter metabolism, such as tobacco and marijuana