Drug Topics- August 11, 2008

52 DRUG TOPICS AUGUST 11, 2008 www.drugtopics.com CONTINUING EDUCATION Treatment of GAS with antibiotics has been associated with a reduction in symptoms if therapy begins during the first 48 hours of onset. After 48 hours, there is a good likelihood for selfimprovement without medical intervention. When weighing the risk of complications with the potential for self-improvement, it is important to note that therapy may be safely postponed in adults up to nine days after the onset of symptoms without the risk of complications. However, those who are treated within the first 48 hours also have a great DT CAPSULE frequency of recurrence, as it is Recent guidelines from believed that the the American College of immune response offers some fuChest Physicians state ture protection. that using dextrometho- Should treatment rphan and guaifenesin for be prescribed, penicillin (250mg coughing is not effective. four times a day or 500mg twice to four times a day) remains the drug of choice for treatment of GAS pharyngitis. Antibiotic treatment offers the potential benefit of prevention of rheumatic fever, further infectious complications, and reducing the symptomatic duration and risk of transmission to others. The exception is acute glomerulonephritis, which is unaffected by therapy as it is associated with the patient’s immune response to the bacterial infection itself. Amoxicillin may be utilized as an alternative for children or others to improve tolerability. Cefdinir (600mg daily or 300mg twice daily), macrolides (azithromycin or clarithromycin), and clindamycin all remain effective alternatives for patients with a non-anaphylactic penicillin allergy. When recommending a treatment alternative for GAS, it is important to keep in mind that erythromycin resistance has been reported in sections of the United States. The standard duration of therapy remains 10 days with the exception of azithromycin, which follows a fiveday dosing course. purulent nasal discharge, congestion of one or both nasal passages, and facial tenderness or pain over the affected sinus cavity, especially upon bending down. Other symptoms associated with sinusitis are unpleasant taste or smell, jaw or tooth pain, and headache. The gold-standard diagnostic test for bacterial sinusitis is sinus aspiration and culture. However, this is an invasive procedure and is rarely done in primary care settings. There are no other diagnostic tests to differentiate between viral and bacterial sinusitis. Viral sinusitis will usually resolve in seven to 10 days. In contrast, bacterial sinusitis usually lasts longer and may require treatment. However, 75% of bacterial sinusitis cases resolve without antibiotics in one month. Treatment of sinusitis usually is supportive. Analgesics are used to treat facial, jaw, or tooth pain associated with the infection. Topical decongestants are sometimes more effective than systemic decongestants when treating sinusitis. However, patients with sinusitis, especially bacterial, have poor response to decongestants, and the risk of rebound congestion when using topical decongestants for more than three to five days is a concern. Systemic steroids have not been shown to be effective when treating sinusitis, and a recent study of 207 patients showed that nasal steroids were not effective in severe cases of acute sinusitis. The same study showed a modest benefit of nasal steroids when used early in mild cases of acute sinusitis. Antihistamines and nasal irrigation with saline have been used to treat some cases of sinusitis, but the effectiveness of these treatments is unknown. Using antibiotics to treat bacterial sinusitis is controversial. Recent reviews of the literature suggest that antibiotics are minimally to not effective in treating sinusitis. The poor effectiveness has been attributed to the poor penetration of antibiotics into closed cavities like the paranasal sinuses. The decision to use antibiotics should be based on the severity and duration of the infection and risk for complications, such as intracranial or orbital infections of suspected bacterial sinusitis. If antibiotics are deemed necessary, amoxicillin is considered first line. Acceptable alternatives include trimethoprim/sulfamethoxazole and macrolides. Antibiotics should be prescribed for 10 to 14 days. Currently there is no evidence that longer courses of antibiotics are more effective. If the patient’s symptoms worsen after seven days of antibiotic treatment, the antibiotic should be changed. Sinusitis This upper respiratory infection, also known as rhinosinusitis, is defined as inflammation of one or more of the paranasal sinuses, which is caused by viral or bacterial pathogens. Sinusitis can be further delineated into categories as acute ( eight weeks). It affects over 30 million people annually and is the fifth-most common reason for antibiotic treatment. Viral pathogens include rhinovirus, parainfluenza, influenza, and coronaviruses. The most common bacterial pathogens involved in sinusitis include Streptococcus pneumoniae and Haemophilus influenzae. Moraxella catarrhalis and Staphylococcus aureus infections are also possible. Symptoms of sinusitis can be nonspecific but usually include Bronchiolitis This infectious process is characterized by a fever, nasal discharge, and a dry wheezy cough that is usually “high pitched.” Neutrophilic inflammation of the lung tissue is also a predominant diagnostic sign. Eighty percent of cases are caused by respiratory syncytial virus (RSV). Other viral pathogens include human metapneumovirus, rhinovirus, adenovirus, influenza, parainfluenza viruses, and enteroviruses. RSV can be further classified as group A or B and is routinely associated with young children (<two years). Children less than one and pre-term infants are at the greatest risk for severe complications, such as pneumonia and respiratory failure. Infection with RSV does http://www.drugtopics.com

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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