otc allergies

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


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


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


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


Decongestants Decongestants (DC)(DC)

NephazolineNephazoline


TetrahydrozolineTetrahydrozoline

OxymetazolineOxymetazoline

Antihistamines Antihistamines (AH)(AH)

Pheniramine maleatePheniramine maleate

Antazoline phosphateAntazoline phosphate

Combo productsCombo products


Allergen avoidanceAllergen avoidance

HEPA filtersHEPA filters

AllergenAllergen--free productsfree products

Eye lubricants/tearsEye lubricants/tears

Cold compressCold compress


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%


Antazoline 0.5%Antazoline 0.5%



Zinc Sulfate 0.25%Zinc Sulfate 0.25%

Tetrahydrozoline 0.05%Tetrahydrozoline 0.05%


Phenylephrine 0.12%Phenylephrine 0.12%



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)


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


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


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


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


Cold showersCold showers

Avoidance of further Avoidance of further

exposureexposure

Wash or dispose of Wash or dispose of

contaminated clothingcontaminated clothing


Jewel weedJewel weed

Hydrocortisone OptionsHydrocortisone Options

Select OTC ProductsSelect OTC Products


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


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

otc allergies

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