Immunology & Allergy Pharmacotherapy II Past Paper PDF 2025

Pharmacotherapy II: Immunology & Allergy Augsburg PA Program, 2025 Clinton Billhorn, PA-C, CAQ-HM [email protected]  Learning Objectives Chapter 54 1. Outline the physiology of natural, cell-mediated and antibody-mediated...

Pharmacotherapy II: Immunology & Allergy Augsburg PA Program, 2025 Clinton Billhorn, PA-C, CAQ-HM [email protected]  Learning Objectives Chapter 54 1. Outline the physiology of natural, cell-mediated and antibody-mediated immunity. Chapter 56 2. Describe the physiologic effects of histamine-1 and histamine-2 stimulation. 3. Given a patient scenario, select the best medication considering the pharmacologic effects and patient-care concerns across the lifespan. 4. Summarize the key prescribing considerations of antihistamines. Chapter 58 5. Review the physiologic synthesis, secretion and effects of glucocorticoids. 6. Explain the 2 differences in molecular mechanism of action between glucocorticoids and most other drugs. 7. Given a patient scenario, select the best medication considering the pharmacologic effects and patient-care concerns across the lifespan. 8. Provide patient education and an appropriate taper schedule for a patient receiving glucocorticoids. 9. Summarize the key prescribing considerations of glucocorticoids. UpToDate article posted to Moodle: “Anaphylaxis: Emergency treatment” 10. Know the pathophysiology and characteristics of anaphylaxis. 11. Outline the acute management of anaphylaxis in adults and children. 12. Explain how the mechanism of action and pharmacokinetics of epinephrine make it effective in the acute management of anaphylaxis. Chapter 63 13. Apply the pharmacologic management of allergic rhinitis to determine the appropriate clinical interventions for a patient with allergy symptoms. 14. Describe the adverse effects and oral and topical administration of sympathomimetic medications. 15. Given a patient scenario, select the best medication considering the pharmacologic effects and patient-care concerns across the lifespan for allergic rhinitis. 16. Provide patient education for managing the common cold in a pediatric patient. For the following representative medications (included on the Unit Representative Medication List), know the medication class, mechanism of action, indications, adverse effects, contraindications, interactions (common), monitoring (if needed), and patient education. Chlorpheniramine Methyl-prednisolone Diphenhydramine Dexamethasone Promethazine Beclomethasone Hydroxyzine Fluticasone proprionate Loratidine Montelukast Epinephrine Omalizumab Hydrocortisone Phenylephrine Prednisone Oxymetazoline Pseudoephedrine Codeine Dextromethorphan Guaifenesin  Chlorpheniramine - Antihistamine (1 st Gen) Brand Name: Aller-Chlor MOA: Competitive inhibitor of histamine Indication: Temporary relief of allergy symptoms Adverse effects: Constipation, Xerostomia, Drowsiness Contraindications: Do not use as a sleep-aid Major interactions: Do not combine with other antihistamines Patient Education/Clinical Pearls: Avoid alcohol/driving  Promethazine Antihistamine (1 st Gen) Brand Name: Phenergan MOA: Competitive inhibitor of histamine, blocks dopamine receptors, blocks alpha-adrenergics depressing certain hormones Indication: *Rarely used for allergies Adverse effects: Arrhythmia, Respiratory depression (Children), Neuroleptic malignant syndrome, akathisia, dystonia, elevated BP Contraindications: Parkinson’s, Myasthenia Gravis Major interactions: Do not combine w/other antihistamines, opioids, Patient Education/Clinical Pearls: Very sedating, many side effects  Loratadine - Antihistamine (2 nd Brand Name: Claritin Gen) MOA: Selective peripheral histamine antagonist Indication: Allergy symptoms, urticaria Adverse effects: Headache, Xerostomia, Dry eyes Contraindications: None, QTc prolongation Major interactions: Don’t combine w/other antihistamines Patient Education/Clinical Pearls: Well tolerated  Phenylephrine - Alpha Adrenergic Agonist Brand Name: Sudafed PE MOA: Alpha agonist Indication: Nasal congestion Adverse effects: Hypertension, headache, blurred vision Contraindications: Heart disease, hypertension, Parkinson’s Major interactions: Avoid other sympathomimetics Patient Education/Clinical Pearls: Don’t take if you have HTN, Parkinson’s, don’t take >3 days  Oxymetazoline - Alpha Adrenergic Agonist Brand Name: Afrin MOA: Alpha adrenergic, vasoconstriction Indication: Nasal congestion, nose bleeds Adverse effects: Dry nose, rebound congestion Contraindications: No major contradictions Major interactions: No major interactions Patient Education/Clinical Pearls: Do not use >3 days  Pseudoephedrine - Alpha Beta Agonist Brand Name: Sudafed MOA: Stimulates alpha receptors, stimulates beta-receptors Indication: Nasal congestion Adverse effects: Tachycardia, HTN Contraindications: Heart disease, MAOI inhibitors Major interactions: Alpha/Beta Agonist Patient Education/Clinical Pearls: Do not use >3 days or if you have heart disease  Codeine - Opioid, ‘Antitussive’ Brand Name: Codeine MOA: Direct action in the medulla Indication: Cough Adverse effects: Respiratory depression, circulatory depression Contraindications: Airway compromise, OSA Major interactions: Amphetamines, MAOI, other CNS depressants Patient Education/Clinical Pearls: Respiratory depression needs to be discussed  Relevant medications from prior units Diphenhydramine Hydroxyzine Epinephrine Hydrocortisone Prednisone Methyl-prednisolone Dexamethasone Beclomethasone Fluticasone propionate Montelukast Omalizumab Dextromethorphan Guaifenesin Natural, Cell Mediated, and Antibody-Mediated Immunity Cell Type Action B-Cell (lymphocyte) Antibody production Cytotoxic T-Cells (CD8) Lyse target cells Helper T-Cells (CD4) Promote B and CD8-cells proliferation, Delayed hypersensitivity reactions Macrophages Promote B and CD8-cells as Antigen-presenting cells; Phagocytosis of cells tagged with antibodies and those in effector stage of delayed hypersensitivity reactions; Promote CD8-cell proliferation Mast Cells Immediate hypersensitivity reactions Basophils Immediate hypersensitivity reactions Neutrophils (PMNs) Phagocytosis of bacteria, especially those tagged with IgG; Mediate inflammation Eosinophils Attack helminths and foreign particles tagged with IgE (allergy, asthma, anaphylaxis); Contribute to immediate hypersensitivity reactions Natural, Cell Mediated, and Antibody-Mediated Immunity Natural, Cell Mediated, and Antibody-Mediated Immunity 1. All these pathways lead to the same thing → inflammation 2. When this pathway doesn’t work, or works too well, new problems develop a. Common Variable Immunodeficiency b. Autoimmune disorders c. Cancer d. Anaphylaxis  Histamine I vs Histamine II Histamine I Histamine II Vasodilation Capillary permeability Gastric acid secretion Bronchoconstriction CNS (cognition, sleep) Sensory (itching, mucous)  Histamine I Histamine I Antihistamines Common drugs 1st and 2nd generation Cetirizine (Zyrtec) 1st generation more sedating Loratadine (Claritin) Hydroxyzine (Atarax/Vistaril) Does not impact mast cells Diphenhydramine (Benadryl) Reduces flushing, edema, itching, Chlorpheniramine pain, mucous Promethazine Treats mild/moderate allergies, motion sickness, insomnia  Histamine II Histamine I Histamine II Antihistamines Common drugs Famotidine (Pepcid, Zantac) Cimetidine (Tagamet) Vasodilation Used more for treatment of Capillary permeability anaphylaxis Bronchoconstriction CNS (cognition, sleep) Sensory (itching, mucous)  Case 1: Infants Parents bring their 3 month old baby to urgent care complaining of a runny What would you recommend? nose. They are requesting a medication to help reduce nasal congestion/rhinorrhea.  Case 2: Children/Adolescents A 12 year old is seen in clinic with five days of runny nose, cough, and What would you recommend? is having a hard time sleeping. They’ve tried humidified air and vapor rub without improvement. Mom has a prescription for Codeine when she’s sick and is wondering if they can get that.  Case 3: Pregnancy A 26 year old G1P0 24 weeks presenting with watery eyes, nasal What would you recommend? congestion, and sore throat. She is wondering what is safe to take to help with her symptoms?  Case 4: Breastfeeding A 26 year old G1P1 6 weeks postpartum currently breastfeeding What would you recommend? presenting with watery eyes, nasal congestion, and sore throat. She is wondering what is safe to take to help with her symptoms?  Case 5: Older adults 82 year old patient with paroxysmal atrial fibrillation, hypertension, What would you recommend? dementia, hyperlipidemia, and COPD who presents to clinic with recent viral illness and ongoing cough. He has a lot of chest pain and family is concerned he’s going to break a rib from all the coughing. He isn’t sleeping well and is getting a little more confused than normal. Glucocorticoids: Synthesis, Secretion, Effects Synthesis Secretion Effects Adrenal cortex Hypothalamic-Pituitary Axis Body temp Blood Pressure Metabolism Inflammation Lung maturation Glucocorticoids: Molecular Mechanism 1. Binds to glucocorticoid receptors in the cytoplasm 2. Directly impacts gene expression → gene modulation Glucocorticoids: Patient Education Children Pregnant Women Long-term use can cause Cleft palate and neonatal inhibition of bone growth hypoadrenalism risk, when and decreased stature; systemic use is needed, Increases the risk for hydrocortisone is lifetime osteoporosis. preferred. Breast Feeding Elderly Low dose okay Osteoporosis Adrenal insufficiency Gastrointestinal upset/ulcer Glucocorticoids: Key Prescribing Considerations Baseline Data Monitoring Infection Bone Density CBC Lipids Consider Tb (long-term) Weight Glucose/A1c Height (peds) High risk patients Therapeutic Goals Immunocompromised Reduce inflammation Elderly Improve respiratory symptoms Diabetes Control inappropriate immune Digoxin response NSAIDs GI issues Glucocorticoids: Minimize Adverse Effects Osteoporosis Vit D/Calcium if long-term or recurrent use Steroid induced hyperglycemia Depends on context Gastric ulcers Use ppx, especially if other risk factors Growth restriction Alternate days, may need growth hormone if chronic use  Case 1: Glucocorticoids 55 year old patient with COPD, hypertension, hyperlipidemia, rheumatoid arthritis complicated by adrenal What other management is insufficiency who presented with a HR of indicated? 120, BP 85/60, Temp 101.4, and RR 16 with left lower lobe infiltrate on imaging. Patient takes 15 mg hydrocortisone daily with 0.1 mg fludrocortisone daily. You start routine sepsis management with fluids and antibiotics.  Case 2: Glucocorticoids 20 year old patient with tobacco use disorder and mild persistent asthma who presents with increased shortness of breath. He was found to What are next steps? have significant wheezing with increased work of breathing. He has been using his albuterol inhaler more frequently. You give back to back albuterol nebulizers x 3 with improvement in symptoms. Anaphylaxis: Pathophysiology and Characteristics Pathophysiology Characteristics Adults Children 1. Release of mast cells/basophil derived mediators 1. Skin/Mucosa → 90% 2. IgE/IgG mediated 2. Respiratory → 85% 3. Cytokines, Eosinophils 3. GI → 45% 4. Chain Reaction 4. CV → 45%  Anaphylaxis: Acute Management Adults Children 1. Epinephrine (0.3-0.5mg IM q 5-10min) 1. Epinephrine (0.01mg/kg IM, Max 0.5mg IM q 5-10min) 2. Oxygen 2. Oxygen 3. Normal saline 3. Normal saline (20mL/kg) 4. Albuterol 4. Albuterol 5. H1 - Benadryl 5. H1 - Benadryl (1mg/kg) 6. H2 - Famotidine 6. H2 - Famotidine (0.25mg/kg) 7. Glucocorticoid - Methylprednisolone 7. Glucocorticoid - Methylprednisolone (1mg/kg) Anaphylaxis: Why does epinephrine work? Kemp, S.F., Lockey, R.F., Simons, F.E.R. et al. Epinephrine: The Drug of Choice for Anaphylaxis--A Statement of the World Allergy Organization. World Allergy Organ J 1 (Suppl 2), S18 (2008). https://doi.org/10.1186/1939-4551-1-S2-S18 Allergic Rhinitis Management Cases Children (12 mo) Pregnant Women Breast Feeding Elderly Common Cold Management: Pediatrics 1. Spoonful of honey (only if 12 mo or greater) 2. Warm fluids 3. Nose frida if unable to blow their nose 4. Steamy showers 5. Humidified air 6. Cough medicines are NOT recommended for kids