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(Zocor)
Lovastatin -- 29% 31% 48%
(Mevacor,
generic)
Cerivastatin 0.2-mg 0.3-mg 0.4-mg 0.8-mg
(Baycol) dosage: dosage: dosage: dosage:
25% 30% 36% 44%
Pravastatin 19% 24% 34% 40%
(Pravachol)
Fluvastatin -- 17% 23% 33%
(Lescol)
3.Fibrates (gemfibrozil, clofibrate, fenofibrate)
primarily lower plasma triglyceride and raise HDL
levels. They are effective for the treatment of
hypertriglyceridemia and combined hyperlipidemia.
4.Bile acid sequestrants are effective in patients
with mild to moderate elevations of LDL cholesterol.
Bile acid sequestrants are also effective when used
with a statin or nicotinic acid. Use is often limited by
side effects.
5.Nicotinic acid is effective in patients with hyper-
cholesterolemia and in combined hyperlipidemia
associated with normal and low levels of HDL
cholesterol. Use is often limited by poor tolerability.
6.Probucol modestly lowers LDL cholesterol, but
more prominently reduces HDL cholesterol.
Probucol should be limited to refractory hypercho-
lesterolemia or familial hypercholesterolemia and
xanthomas.
References: See page 255.
Pulmonary Disorders
Allergic Rhinitis
Allergic rhinitis is characterized by paroxysms of sneezing,
rhinorrhea, nasal obstruction, and itching of the eyes, nose,
and palate. It is also frequently associated with postnasal drip,
cough, irritability, and fatigue. Allergic rhinitis is classified as
seasonal if symptoms occur at a particular time of the year,
or perennial if symptoms occur year round.
I.Pathophysiology
A.Common allergens causing seasonal allergic rhinitis are
tree, grass, and weed pollens, and fungi. Dust mites,
cockroaches, animal proteins, and fungi are frequently
associated with perennial rhinitis.
B.Perennial allergic rhinitis is associated with nasal
symptoms, which occur for more than nine months of the
year. Perennial allergic rhinitis usually reflects allergy to
indoor allergens like dust mites, cockroaches, or animal
dander.
C.Nine to 40 percent of the population may have some
form of allergic rhinitis. The prevalence of allergic rhinitis
has a bimodal peak in the early school and early adult
years, and declines thereafter.
II.Clinical manifestations
A.The intense nasal itching that occurs in allergic rhinitis
is associated with nose rubbing, pushing the tip of the nose
up with the hand (the  allergic salute ), and a transverse
nasal crease.
B.Adults and older children frequently have clear mucus.
Young children have persistent rhinorrhea and often snort,
sniff, cough, and clear their throats. Mouth breathing is
common. Allergic rhinitis occurs in association with
sinusitis, asthma, eczema and allergic conjunctivitis.
III.Evaluation
A.Nasal examination. The nasal mucosa frequently
displays a pale bluish hue or pallor along with turbinate
edema. In nonallergic or vasomotor rhinitis, the nasal
turbinates are erythematous and boggy.
B.Identification of allergens. For patients in whom
symptoms are not well controlled with medications and in
whom the cause of rhinitis is not evident from the history,
skin testing may provide an in vivo assessment of IgE
antibodies.
C.Skin tests. Immediate hypersensitivity skin testing is a
quick, inexpensive, and safe way to identify the presence
of allergen specific IgE.
IV.Management of allergic rhinitis (rhinosinusitis)
A.Allergen identification and avoidance. The history
frequently identifies involvement of pollens, molds, house
dust mites and insects, such as fleas and cockroaches, or
animal allergens
B.Allergen avoidance measures:
1.Maintaining the relative humidity at 50 percent or less
to limit house dust mite and mold growth and avoiding
exposure to irritants, such as cigarette smoke.
2.Air conditioners decrease concentrations of pollen,
mold, and dust mite allergens in indoor air.
3.Avoiding exposure to the feces of the house dust mite
is facilitated by removing carpets and furry pets, and
washing bedding in hot water once weekly.
4.HEPA filters may help reduce animal allergens.
Ordinary vacuuming and dusting have little effect.
C.Pharmacologic treatment
1.Nasal decongestant sprays are not recommended in
the treatment of allergic rhinitis. Tachyphylaxis develops
after three to seven days, rebound nasal congestion
results, and continued use causes rhinitis
medicamentosa.
2.Intranasal corticosteroids. Topical intranasal steroid
therapy is presently the most effective single mainte-
nance therapy for allergic rhinitis and causes few side
effects. Topical nasal steroids are more effective than
cromolyn and second generation antihistamines. Most
studies show no effect on growth at recommended
doses.
a.The addition of antihistamine or antihistamine-
decongestant combination to nasal corticosteroids
offers little additional clinical benefit.
b.Topical nasal steroids are available in both aqueous
and freon-propelled preparations. The aqueous
preparations may be particularly useful in patients in
whom freon preparations cause mucosal drying,
crusting, or epistaxis. Rarely, nasal steroids are
associated with nasal septal perforation.
c.As needed use appears to be almost as effective as
daily use in patients with episodic symptoms.
d.The preparations requiring once-daily dosing are
preferred. These include triamcinolone, budesonide,
fluticasone, or mometasone. Mometasone is approved
for use in children older than two years. For children,
mometasone (Nasonex) is the preferred as first-line
therapy. Budesonide and fluticasone propionate are
approved for use in children older than six years.
Drugs for Allergic Rhinitis
Drug Trade Dose
name
Corticosteroid Nasal Sprays
Triamcinolone Nasacort Two sprays qd
Budesonide Rhinocort Two sprays qd
AQ
Fluticasone Flonase Two sprays qd
Mometasone Nasonex Two sprays qd
Beclomethasone Beconase One spray two to qid
Vancenase One spray bid-qid
Beconase One to two sprays bid
AQ One to two sprays bid
Vancenase
AQ
Flunisolide Nasalide Two sprays bid [ Pobierz całość w formacie PDF ]

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