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Is Your Patient Drugged?Common Meds Used In ENT

Alan Freint, MD

Polling Question

Polling Question

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Intent of This LectureTo familiarize the audiologist with the

most commonly encountered medications

To understands the effects and possible side-effects of medications; good health care is predicated on knowing this information

To provide the audiologist with a basic understanding, not to be exhaustive or lead to prescribing

OverviewAntihistaminesAnti-infectives• Antibiotics• Anti-virals

Anti-inflammatories• Salicylates• NSAIDS• Steroids

Topicals (Ear drops, creams, ointments)Chemotherapy Drugs

Antihistamines

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Antihistamines: Function

Drugs that reduce or eliminate the effects mediated

by histamine, a chemical released during

allergic reactions

Antihistamines block the histamine H-1 receptor

effect on smooth muscles of the respiratory

and gastrointestinal tracts and reduce vascular

permeability

Histamine EffectsHistamine causes:• Congestion• Itching• Vasodilation / flushing• Headache• Bronchoconstriction• Increased vascular permeability• Hypotension / tachycardia

Antihistamines: Indications

Treatment of allergic symptoms

Suppress motion sickness

Available as oral or topical products

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Antihistamines: Types

First-generation

Ethanolamines: Benadryl, Dramamine

Phenothiazines: Phenergan

Piperazines: Meclizine, Bonine

Second-generation – Fewer side effects

Claritin, Clarinex, Allegra, Alavert, etc.

Antihistamines:When Taken Orally…

Onset of action is rapid (about 15-30 minutes)

First-generation meds are generally effective for 6-8 hours, but some benefit may be seen for 12-24 hours

Metabolized mainly in the liver

Antihistamine-like: Anticholinergic -- ScopolaminePrevention of motion sickness

• Rapid onset of action (1 hour)

• Available as a patch (Transderm Scōp)

• Commonly used for cruises

• Lasts for three days

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Antihistamine / DecongestantCombinations

Purpose: Address complaints of allergy,

congestion, and rhinorrhea

Examples: ◊ Actifed ◊ Dimetapp ◊ Claritin D

◊ Coricidin D ◊ Tylenol Sinus

Preparations contain stimulants such as, or similar to, Sudafed or caffeine to counteract potential

depressive effects and “dry” the nose

Antihistamines: How Drugged Is the Patient?

First-generation:• Ethanolamines and Phenothiazines -

Strong possibility of sedative side effects

• Piperazines and Scopolamine –Moderate sedative side effects

• Combination antihistamine / decongestants –Minor sedative side-effects

Second-generation: almost no side effects

Antihistamines: Possible Side Effects

MOST COMMON:• CNS depression / sedation (drowsiness)

• Dry mouth

LESS COMMON:Blurred vision Diplopia Euphoria

Difficulty urinating Impotence Tinnitus

Constipation or diarrhea Gastric distress

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Polling Question

Antibiotics

Antibiotics: Function

Destroy or inhibit the growth of microogranisms

Widely used to treat infectious diseases

Three major indications:• Treatment of infection• Treatment of suspected infection• Treatment to prevent infection (prophylaxis)

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Antibiotics: Methods of Action

Bactericidal – an agent that kills bacteriaBacteriostatic – an agent that inhibits the

growth of bacteria by interfering with • Protein production• DNA production• Cellular metabolism

Bacteriostatic agents must work with the immune system to eradicate the infection

Antibiotics: Methods of Action

Bactericidal

• Penicillins

• Cephalosporins

• Fluoroquinolones

• Vancomycin

• Aminoglycosides

Bacteriostatic• Tetracyclines

• Sulfonamides

• Trimethoprim

• Macrolides

• Chloramphenicol

• Aminoglycosides

Beta-Lactamase

An enzyme produced by certain bacteria that

inactivates penicillin and certain other

antibiotics and results in resistance to those

medicines

Beta-lactamase antibiotics act by inhibiting cell

wall synthesis, thereby interrupting

replication of the bacteria; they are

bactericidal

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Antibiotics: Characteristics of Traditional

Oral AntibioticsPenicillin “G”:• Spectrum – Group A beta-hemolytic

Streptococcus (GABHS), penicillin-susceptible Pneumococcus, Menigococcus

• Advantages – inexpensive, few adverse effects

• Disadvantages – low bio-availability, bitter taste, QID, not stable to beta-lactamase

Traditional Oral Antibiotics (cont’d)

Ampicillin:• Spectrum – same as penicillin but with Gram-

negative organisms (e.g. Haemophilus influenza)

• Advantages – inexpensive therapy for respiratory infections

• Disadvantages – diarrhea (10 -25%), poor absorption in GI tract, TID dosing, increasing penicillin resistance among pneumoccocus, not stable to beta-lactamase

Traditional Oral Antibiotics (cont’d)

Amoxicillin:

• Spectrum – same as ampicillin

• Advantages – TID dosing, great bubble-gum

taste, less diarrhea (9%)

• Disadvantages – unstable to beta-lactamase

Example: Amoxil

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“Updated” Antibiotic

Augmentin (amoxicillin / clavulanate):• Spectrum – very broad, including:

Beta-lactamase producing H Influenza (H flu)Moraxella catarrhalis (M cat)Pathogens previously susceptible to

amoxicillin• Advantages – high potency• Disadvantages – higher incidence of

diarrhea

Traditional Oral Antibiotics (cont’d)

Macrolides:• Includes – erythromycin, azithromycin,

clarithromycin

• Spectrum – GABHS, M catarrhalis, etc.

• Advantages – inexpensive, alternative for penicillin-allergic patients

• Disadvantages – no activity against H influenza, may be ototoxic

Examples: Zithromax, Biaxin, Dynabac

“Updated” AntibioticKetolides:

• Spectrum – similar to the macrolides

• Advantages –alternative for macrolide-resistant bacteria

• Disadvantages – high liver toxicity, cardiac arrhythmia

Example: Ketek

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Traditional Oral Antibiotics (cont’d)

Tetracycline / Doxycycline:• Spectrum – respiratory pathogens, especially• Advantages – increased spectrum, use in

penicillin or sulfa-allergic patient• Disadvantages – stains developing teeth,

photosensitivity, milk and other foods interfere with absorption, GI upset, esophageal ulceration

Example: Minocin

Traditional Oral Antibiotics (cont’d)

Sulfonamides (Sulfa Drugs):• Spectrum – mostly Gram-negative, some

activity against penicillin-susceptible Pneumococcus

• Advantages – increasing Gram-negativespectrum, penetrates well into sinuses and middle ear space

• Disadvantages – frequent skin reactions, not effective for H influenzaExamples: Bactrim, TMP-SMX

Traditional Oral Antibiotics (cont’d)

Cephalosporins • Spectrum – same as penicillin but added

stability to beta-lactamase, added activity against M catarrhalis

• Advantages – pleasant taste, once or twice-daily dosing, stable to beta-lactamase

• Disadvantages – Newer generations are expensive; cross-reactivity with allergy to penicillin is about 8%

Examples: Ceclor, Ceftin, Omnicef, Cefzil

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Aminoglycosides

Aminoglycosides:• Spectrum – Gram-negative bacteria like

Pseudomonas and Enterobacter• Advantages – Good control of sepsis• Disadvantages – Must be given

intravenously; high risk of hearing loss, vestibular injury, or kidney damage

Examples: Gentamicin, streptomycin, tobramycin, amikacin, neomycin, etc.

Aminoglycosides (cont’d)

5-10% of all patients experience a side effect

Young children and the elderly are at the greatest risk

Excessive dosage or poor excretion of the drug may be injurious at any age

Aminoglycosides (cont’d)

◙◙Amikacin Kanamycin

◙◙Neomycin

◙Tobramycin

◙◙Gentamycin

◙Streptomycin

Kidney damage

VertigoHearing loss

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Fluoroquinolones

Bactericidal action• Spectrum – Very wide range of gram-negative

and gram positive bacteria (along with others)• Advantages – Once daily dosing for newer

generations, resistance is rare• Disadvantages – Photosensitivity, risk of

tendon rupture (worse with steroids), joint pain, peripheral neuropathy, elevated glucose

Examples: Cipro, Floxin, Levaquin, Avelox

Antibiotics:How Drugged Is the Patient?

Resistance –

In some cases, bacteria are resistant to, or

become resistant to, antibiotics that

would normally kill them

Arises from a mutation that alters the

bacteria’s susceptibility to the drug

Polling Question

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Antivirals

Antivirals

Used specifically for treating viral infectionsLike antibiotics, specific antivirals are used for

specific viruses

Viruses cannot reproduce on their own, so they propagate by “hijacking” cells to do the job for them

Antiviral drugs de-activate viral proteins, parts of proteins, or enzymes to disable DNA or RNA replication

Antivirals (cont’d)

Target: herpesviruses, HIV, hepatitis B and CExamples:• Acyclovir (Zovirax) – Herpesviruses and cold

sores• Zidovudine (AZT) -- HIV• Zanamivir (Relenza) -- Influenza• Oseltamivir (Tamiflu) --Influenza• Valacyclovir (Valtrex) – Genital herpes and

cold sores• Famciclovir (Famvir) – Genital herpes

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Antivirals and Antibiotics:Side Effects

Lightheadedness / dizziness

Tinnitus

Nervousness and anxiety

Rash, hives, itching, swelling

Decreased appetite, cramps

Bronchospasm

Q&A

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Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

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Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Drugs with analgesic, antipyretic, and anti-inflammatory effects

• They reduce pain and fever at low doses and inflammation at high doses

They are non-narcotic, not steroidsMost prominent members:• Ibuprofen (Advil, Motrin, etc.)• Aspirin (ASA)

Tylenol (acetaminophen) is not an NSAID

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (cont’d)

70 million prescriptions annually and 30 billion OTC doses sold

Advantages – Relatively safe; no sedation, respiratory depression, or addiction potential

Disadvantages – Often cause heart burn, perforated ulcer, gastrointestinal bleeding and possibly death

Dose-dependent: higher doses for longer periods increase the risk of ulceration

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (cont’d)

Mode of Action• Non-selective inhibitors of

cyclooxygenase-1 or -2 (known as COX-1 or COX-2 inhibitors), enzymes that initiate the cascade of chemical changes that cause inflammation

Vioxx, a COX-2 inhibitor, was one of several NSAIDs implicated in causing heart disease

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NSAIDs:How Drugged Is the Patient?

May cause tinnitus, possibly irreversibleRelatively high incidence of renal

impairmentRepresent 43% of drug-related ER visits

16,500 deaths annually!

Not “innocent” drugs even though available over-the-counter

Salicylates

Collectively, a group of analgesics (pain-killing drugs) derived from salicylic acid, an NSAID

They work by inhibiting varioustransaminases & dehydrogenases

Most common is aspirin (acetylsalicylic acid or ASA)

Aspirin:How Drugged Is the Patient?

• The greater the dose, the greater the symptoms

• May cause reversible hearing loss and tinnitus

• 6-8 g/day can lead to toxicity • Upon discontinuation, salicylate levels

fall rapidly as the drug is excreted• Hearing may return within 24-72 hours

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Salicylates (cont’d)

Aspirin is found in the following medications (among many others):

¤ Bufferin ¤ Alka Seltzer

¤ Percodan ¤ Fiorinal ¤ Coricidin

¤ Anacin ¤ Norgesic ¤ Equagesic

¤ Ecotrin ¤ Bayer Aspirin ¤ Percodan

¤ Empirin Compound ¤ Aspergum

SteroidsCorticosteroids• Glucocorticoids –

Regulate many aspects of metabolism and immune function via cortisol (hydrocortisone)

• Mineralocorticoids –maintain blood volume and regulate kidney excretion of electrolytes

Anabolic steroids –interact with androgen, the “body-building” steroid, to increase muscle and bone

Glucocorticoids

Possess potent anti-inflammatory and immunosuppressive properties

Used to treat:• Arthritis• Allergic reactions, • Dermatitis, and • As adjunctive therapy for autoimmune

diseasesExcellent absorption through intestines or skin

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Glucocorticoids: Common Drugs

Hydrocortisone (Cortisol)PrednisonePrednisoloneMethylprednisoloneDexamethasoneBetamethasoneTriamcinoloneBeclomethasone

Glucocorticoids: How Drugged Is the Patient?

Increase blood glucose levelsIncrease blood pressure levelsCause an excitatory effect on the central

nervous system (for example: insomnia, euphoria, mania)

Cause immunosuppressionCause appetite stimulation and weight gainAffect ovulation and menstrual periodsCause muscle breakdown and weakness

Steroids given to treat SNHL, vertigo, or tinnitus may cause muscles to develop?

a)True

b)False

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Topicals

Topical Preparations

Hydrocortisone cream or ointment• ½ or 1 % strength

Antibiotic cream or ointment• Bacitracin• Triple Antibiotic (neomycin, polymyxin,

bacitracin)

Antifungal cream or lotion• Lotrimin (clotrimazole) solution

Ear DropsSafe:• Fluoroquinolones (Ciprodex or Floxin)• Tobramycin (Tobradex)• Clotrimazole or Miconazole (Lotrimin)

Ototoxic: (if medication gets into the middle ear):• Neomycin / polymyxin B (Cortisporin)• Gentamicin• Vosol• Gentian Violet

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Chemotherapy

Chemotherapy

Cisplatin• Primarily affects the outer hair cells

• May cause tinnitus

• Associated with a high frequency hearing loss

Carboplatin• Preferentially destroys the inner hair cells

• OAEs remain normal

• Low (lower) incidence of hearing loss

Hello, Betty Ford…

Audiologists should be familiar with the most common medications

Research online or consult with a “friendly” pharmacist or physician when a patient presents with unusual complaints

Call the prescribing physician to question side effects your patient develops

Be comfortable with your knowledge base

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Q&A

To ask a question, please type your question into the chat box in the lower left corner of the screen and click on the “Send” button located right below the box.

Alan Freint, MDafreint@aol.com