OTC drugs for respiratory system Medical Presentation

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OTC Presented by: Dr sherehan adel
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A-respiratory disorders
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Common cold
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Etiology: 1. There are about 200 identified viral strains that invade the nasal and bronchial epithelial cells to cause common cold. 2. The virus most commonly responsible for the common cold are the rhinoviruses followed by the coronaviruses. 3. To produce infection, a rhinovirus must penetrate the protective mucous that covers the nasal epithelium.
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4. Mucus in the nasal passage traps and removes most contaminants, but the rhinovirus remains attached to the nasal mucous membranes via a specific receptor. 5. Rhinovirus infection leads to the release of various inflammatory mediators. 6. Histamine is not involved in the inflammation associated with rhinovirus infection, but it is associated with the immediate phase of allergic response (sneezing and itching).
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(a) Humidity is low. (b) Cold weather dries the lining of the nasal passage. c) Kids in school spend more time indoors and thus are exposed to more viruses. . Several factors affecting susceptibility & transmission of Virus. Poor nutritional state, fatigue, and emotional stress Colds are more common in winter because:
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. There are five symptoms where a pharmacist can recommend treatment: stuffy or runny nose, sore or scratchy throat, cough, headache, and a general feeling of malaise.
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E. Treatment Decongestants. Nasal decongestants are sympatomimetic amine. They stimulate the α-adrenergic receptors of vascular smooth muscle, which constrict dilated arterioles. This decreases edema and, thus, increases nasal ventilation and drainage.
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A-Intranasal decongestants The major disadvantage is the potential to develop rebound congestion. Some of these products may not be used in young children Eg: naphzoline : Cause CNS depression In children less than 12y
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Topical saline nasal products : are recommended for children less than age 2 years and pregnant women (because of concern of possible harm to the fetus by sympathomimetic agents. could cause rebound congestion and apnea in these patients.
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These are the intranasal decongestant approved by FDA:
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b. Oral decongestants An oral decongestant may be useful in reaching deep into the nasopharyngeal and sinus passage where topical solutions may not be accessible. Because oral agents induce less intense vasoconstriction locally, they have not been associated with rebound congestion.
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Oral decongestants should be avoided or used cautiously in patients with problems such as: Heart disease Hyperthyroidism Benign prostatic hypertrophy Narrow angle glaucoma, HT, D.
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FDA-approved oral decongestants include:
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C. Nasal strips. This is an adhesive bandage device that pulls open the nostrils and might relieve nasal congestion and decrease snoring. This device might be useful in persons who need to avoid the sympathomimetic agents (e.g., pregnant women).
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2. Antihistamines: Kinins cause inflammation in the lining of the nose. This inflammation results in sneezing, runny nose, and stuffiness Use: The use of antihistamines may show no effect, whereas others have shown a decrease in sneezing and nasal secretions (runny nose).
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C. Classes of first-generation antihistamines: Alkylamines : celmastin – chlorpheniramin . (lower incidence of drowsiness) ethanolamine: most sedative
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d. Side effects: 1- Because of their anticholinergic properties, it may cause dry mouth, blurred vision, difficulty in urination, Constipation, irritability, and dizziness. 2- Patients with narrow angle glaucoma, benign prostatic hypertrophy, and asthma should avoid first-generation antihistamines because the anticholinergic activities may exacerbate their condition.
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5- second- generation antihistamines which are currently available by Prescription (with the exception of loratadine) have difficulty crossing the BBB.
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No sedation , no anticholinergic SE Others, available by Prescription eg: Cetrizine – fexofenadine:
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3. Expectorants and Antitussives Coughing from the common cold usually is caused by stimulation of cough receptors located within the epithelial lining of the tracheobronchial tree.
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OTC analgesic and antipyretics relieve mild to moderate pain and reduce inflammation and fever Salicylates and NSAIDs reduce pain, inflammation, and fever, but acetaminophen generally is effective for only pain and fever.
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Salicylates Salicylates are used to relieve mild to moderate pain and reduce inflammation and fever. Antiplatelet.
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For analgesia or antipyretic in adult: 325-650 mg every 4 hours. The maximum daily dose is 4000 mg for no longer, than 10 days for pain or 3 days for fever, without consulting a physician. Child dosage depends on age. Salicylates should be given for no longer than 5 days for pain, 3 days for fever, without consulting a physician.
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Contraindications: Aspirin is contraindicated in patients with bleeding disorders or peptic ulcers. Also aspirin should not given to children or teenagers with a viral illness, because Reye’s syndrome (i.e. fatty liver degeneration accompanied by encephalopathy) may occur.
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C. Acetaminophen For analgesia or antipyretic in adults, the dosage is 500-1000 mg three times daily as needed.
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NSAIDs Currently, Ibuprofen (Brufen®), Naproxen (Naprosyn®), and Ketoprofen (ketofan®), are the only NSAIDs available without a prescription. NSAIDs are used to relieve mild-to-moderate pain and reduce inflammation and fever.
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cough
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Cough is a physiological protective reflex that assists in clearing the respiratory tract of mucus, inhaled irritants, and other foreign debris. The cough center in the medulla coordinates a series of events that leads to the cough response.
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Cough may be :
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a. Antitussives If coughs is persistent, bothersome, or sleep disrupting, may be suppressed with an antitussive. Antitussives inhibit or suppress coughing. Most act centrally to depress the medullary cough center and thus elevate the threshold for incoming cough impulses. Examples include narcotics, such as codeine, and the nonnarcotic antitussive dextromethorphan.
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(3) Antitussive may act peripherally on sensory nerve receptors within the respiratory tract. These agents are exemplified by the volatile agents such as camphor and menthol.
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(4) Demulcents, such as hard candy or cough drops, soothe an irritated throat and bronchial passageway and may produce an antitussive action.
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(5) FDA-approved OTC antitussives include: Codeine and its salts : Has addictive property Has analgesic activity In Egypt :
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Adverse effects include: Drowsiness , constipation , abdominal discomfort . Respiratory depression usually occurs with prescription analgesic doses of this drug.
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b) Dextromethorphan: Is a synthetic nonnarcotic agent, having no analgesic or addictive properties. As a cough suppressant, it is as effective as codeine. Pharmacists should be aware of reports of high-dose recreational abuse of this agent.
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(c) Diphenhydramine : Is an antihistamine and antitussive agent. Its antitussive effects are due to its central-acting mechanism through the medullary cough center. Diphenhydramine acts centrally on the cough center similarly to codeine, rather than by generalized depression of the CNS.
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Part of diphenhydramine’s antitussive action may be mediated through anticholinergic activity. As an ethanolamine antihistamine, this agent may produce sedation and symptoms of anticholinergic action.
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(d) Camphor and menthol: These agents produce a sensation of coolness on the respiratory tract by stimulating cold sensory receptors. This engenders a local anesthetic effect on respiratory passageways, which produces an antitussive effect.
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b. Expectorants (1) It facilitate removal of mucus and other irritants from the respiratory tract. This produces less tenacious secretions and/or decreases the viscosity of thickened secretions. (2) Their major pharmacological action is to irritate receptors in the gastric mucosa. This promotes increased output from secretory glands of the GI system and reflexively increases flow of fluids from glands lining the respiratory tract. The outcome is increased volume and decreased viscosity of bronchial secretions.
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(3) Guafenesin is the only expectorant that has demonstrated safety and efficacy for self-administration per the FDA. It causes gastric disturbance, N, and V. Taking it with a full glass of water may reduce gastric irritation.
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4. Demulcents Are used to relieve dry or sore throat. Sucking on hard candy works by promoting salivary flow, which is soothing.
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5-mucolytic Alter mucous structure so decrease viscosity Eg: bromohexine and its active metabolite (ambroxol). acetylcystien
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6. Combination products. a. There are a large number of combination cough and cold products on the market. (1) “Nighttime” or “PM” usually signifies that the product contains diphenhydramine. (2) “Sinus” usually signifies a decongestant (pseudoephedrine) and/or an analgesic (acetaminophen). (3) “Cough” usually signifies that the product contains dextromthorphan.
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(4) “No drowsiness” or “daytime” on the label usually indicates that the product contains a decongestant (pseudoephedrine) and does not contain an antihistamine. (5)”Allergy” signifies that it contains an antihistamine. (6) “AM” indicates that it contains a decongestant (i.e., no antihistamine). (7) “Cold” or “flu” usually signifies that it contains a decongestant or decongestant and antihistamine.
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ALLERGIC RHINITIS
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ALLERGIC RHINITIS ALLERGIC RHINITIS may be seasonal or perennial. Seasonal are associated with pollination patterns of offending allergens. It is commonly called “hay fever”. Perennial rhinitis is chronic and is caused by antigens, such as house dust or animal protein.
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2. Symptoms : - Symptoms are similar and overlap with those of the common cold. “Summer cold”. These symptoms include : Sneezing episodes, Nasal pruritus with congestion, Conjunctival erythema and itching, - The symptoms associated with allergic rhinitis are due to an immunoglobulin E (IgE)-mediated immunological reaction
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3. Pathophysiology The allergic response is divided into several phases: 1.Sensitization, 2.Early phase, 3.Cellular recruitment, 4.Late phase. Inhaled allergens interact with T- and B- cell lymphocytes to produce IgE antibodies, which become attached to mast cells and basophils (sensitization).
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On subsequent reexposure to the allergen, degranulation of the mast cells and basophils occurs, causing the release of histamine, LT, PG, and BK. Rhinorrhea, sneezing, itching, and discomfort occur within minutes as part of the early-phase response. A late-phase inflammatory response occurs 4-24 hrs later, with migration and activation of eosinophils, neutrophils, basophils, macrophages, and monocytes in the nasal mucosa (Cellular recruitment).
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Renewed allergic symptoms of increasing nasal secretions and nasal congestion occur without additional allergen exposure.
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4. OTC Treatment. The best treatment is to avoid the allergens that trigger the allergic symptoms. . Antihistamines: - first generation (sedating, nonselective) -second generation (nonsedating, selective) agents.
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Antihistamines are useful for treating the sneezing, rhinorrhea, pruritus, lacrimation, and irritated itchy eyes (early-phase symptoms). They do not work to correct nasal congestion (late-phase symptoms).
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. If possible antihistamine therapy should be started 1-2 weeks before a known allergy season or several hrs before exposure to a known allergen. Antihistamines should be taken uninterrupted throughout the pollen season. . The first and second-generation antihistamines are roughly of equal efficacy
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II. Decongestants . Decongestants counter congestion and help reverse drowsiness associated with first-generation antihistamines. Systemic decongestants are preferred when a decongestant action is required for longer than 3-5 days. If the patient does not respond fully to antihistamines alone (i.e., continues to have nasal congestion) the next step would be to add an oral decongestant.
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. Decongestants
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III. Cromolyn sodium (Cholichrom ®, Epichrom®) The proposed mechanism of action is stabilization of mast cells, interfering with calcium transport and induction of degranulation. This agent is more effective in treating seasonal versus perennial allergic rhinitis. To be maximally effective, it must be started 2-4 weeks before the exposure of the offending allergens and continued throughout the contact period.
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4. Prescription treatment Corticosteroids : Intranasal steroids have emerged as the most effective treatment of allergic rhinitis, relieving sneezing, nasal pruritus, congestion, and rhinorrhea associated with the inflammation. (2) Intranasal steroids are ineffective in the treatment of ocular tearing or ocular pruritus.
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Symptom relief is though to be related to the ability of steroids to inhibit the activity of multiple cell types (e.g., mast cells, basophils, eosinophils, neutrophils, macrophages, lymphocytes) and mediators of inflammatory response. Decreased capillary permeability and decreased nasal mucous secretion . Treatment with these medications should start at the first signs of clinical symptoms and is usually continued throughout the allergen season.
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The more recently developed formulations of beclomethasone, fluticasone and triamcinolone avoid the adrenal suppression at recommended doses.
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Azelastine : antihistamine nasal spray is approved for the treatment of seasonal allergic rhinitis symptoms. Same efficacy as oral Antihistaminic but more tolerable side effect.
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montelukast the leukotriene inhibitor that has been used for asthma has now been approved for the relief of symptoms of seasonal allergic rhinitis in patients over the age of 2.
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. Patients with the following signs or symptoms should be referred for medical follow-up : because theses may indicate the presence of strep throat, bacterial pneumonia, or other more serious infections. A fever greater than 38.3ºC accompanied by shaking chills, and coughing up thick phlegm (especially if greenish or foul smelling). 2. Sharp chest pain when taking a deep breath
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3. Cold-like symptoms that do not improve after 7 days 4. Any fever greater than 39.4ºC 5. Coughing up blood 6. Any significant throat pain in a child 7. A painful throat in addition to any of the following: a. Pus (yellowish-white spots) on the tonsils or throat b. Fever greater than 38.3 ºC
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