CME INFORMATION. December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 55S

Transcription

1 CME SECTION Sponsored by the University of Medicine & Dentistry of New Jersey (UMDNJ), UMDNJ New Jersey Medical School, Department of Medicine, Division of Allergy and Immunology, and the UMDNJ Center for Continuing and Outreach Education Release date: December 16, 2002 Expiration date: June 30, 2004

2 CME INFORMATION Introduction The incidence of atopic disorders appears to be rising in industrialized nations worldwide. It is essential that primary care physicians be aware of this fact and take steps to administer appropriate treatment. Target Audience This continuing medical education (CME) activity is intended for primary care physicians. Learning Objectives After completing this supplement, participants will be able to: 1. Discuss the rationale for the use of H 1 antagonists in treating: a. allergic rhinitis b. urticaria and other pruritic dermatoses c. ocular allergy 2. Describe the role of histamine in the pathophysiology of asthma 3. Discuss the immunomodulatory and anti-inflammatory effects of H 1 antagonists 4. Discuss the role of H 1 -antagonist therapy in the allergic rhinitis asthma syndrome 5. Be aware of the effects of alternative herbal medications in atopic disorders 6. Recognize the clinical and pharmacologic differences among H 1 antagonists Method of Instruction Participants should read the Learning Objectives and read the text in its entirety. After reviewing the text, participants should complete the post-test consisting of a series of multiple-choice questions. Upon completion of this activity, including submission of the post-test, registration, and evaluation materials, and achieving a passing score of 70% on the post-test, participants will receive a CME credit letter awarding AMA/PRA Category 1 credit and the test answer key. This material will be mailed 4 weeks after receipt of the required post-test, registration, and evaluation materials. Estimated time required to complete this activity as designed is 7 hours. Accreditation UMDNJ Center for Continuing and Outreach Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. UMDNJ Center for Continuing and Outreach Education designates this educational activity for a maximum of 7.0 hours in Category 1 credit toward the AMA Physician s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. The activity was prepared in accordance with the ACCME Essentials. This activity was reviewed for relevance, accuracy of content, balance of presentation, and time required for participation by CME Activity Director, Leonard Bielory, MD, with review by Loren Rosenberg, MD, Gary B. Zuckerman, MD, Richard Luka, MD, Peter Benincasa, MD, and Alan Wolff, MD. December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 55S

3 CME ASSESSMENT TEST Optimal Use of H 1 -Receptor Antagonists for Allergic Disorders Questions are grouped according to each of the 7 articles in which the points are discussed. Please circle the correct answer for each question on the Answer Sheet provided at the end of this section. Immunomodulatory and Antiinflammatory Activities of H 1 -Receptor Antagonists: Role of Histamine in the Pathophysiology of Asthma 1. Which of the following symptoms can be triggered by histamine release? a. Rhinitis b. Abdominal cramps c. Wheal and flare reactions d. Eczema e. a, b, and c only f. All of the above 2. Histamine can elicit which of the following during an immediate allergic reaction? a. Smooth muscle contraction b. Mucus hypersecretion c. Vasodilation d. Edema e. All of the above 3. Histamine can induce which of the following? a. Adhesion molecule expression b. Chemokine release c. Cytokine release d. Accessory molecule expression e. T-cell proliferation f. a, b, c, and d 4. Which of the following antihistamines has been shown to increase forced expiratory volume in 1 second (FEV 1 )? a. Cetirizine b. Astemizole c. Terfenadine d. Chlorpheniramine e. a, b, and c f. All of the above 5. Histamine modulates allergic inflammatory responses via a. H 1 receptors b. H 2 receptors c. a and b 6. Histamine-induced gastric secretion is mediated via a. H 1 receptors b. H 2 receptors c. H 3 receptors d. H 4 receptors 7. Antihistamines have shown bronchoprotective effects on a. asthma b. exercise-induced bronchospasm c. allergen-challenge induced early and late responses d. a, b, and c e. none of the above 8. H 1 receptors have been detected on a. brain b. airway smooth muscle c. genitourinary system d. lymphocytes 9. H 4 receptors may have anti-inflammatory effects as they are expressed on a. neutrophils b. eosinophils c. mast cells d. CD 4 T cells 10. Which of the following statements about histamine is true? a. It may be secreted into the airways of patients with asthma. b. It may be released from activated T cells. c. Its levels correlate with asthma severity. d. a and c e. All of the above Treatment of Allergic Asthma 11. Which of the following are risk factors for the development of asthma? a. Family history of allergies or asthma b. Personal history of allergies and atopic dermatitis c. Maternal cigarette smoking d. All of the above 12. -Blockers should be avoided in all patients with asthma. December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 57S

4 13. Which of the following is a differential diagnosis of asthma in adults? a. Pulmonary hypertension b. Congestive heart failure c. Gastroesophageal reflux disease d. All of the above 14. A 36-year-old patient with symptoms of asthma once every 2 weeks, nighttime symptoms once a month, and an FEV 1 of 90% of predicted presents to your office. Which of the following is the most appropriate treatment? a. Low-dose inhaled corticosteroids b. Montelukast 10 mg c. Theophylline d. Albuterol inhaler on an as-needed basis 15. A 29-year-old patient comes to your office complaining of shortness of breath, wheezing, and cough twice a week in the daytime and 3 times at night for the last month ( 1 time per week). Spirometry done at your office showed an FEV 1 of 85% of predicted and a 14% improvement after use of a bronchodilator. How would you classify this patient? a. Intermittent asthma b. Mild persistent asthma c. Moderate persistent asthma d. This patient does not have asthma 16. What is the most appropriate treatment for the patient described in question 15? a. Low-dose inhaled corticosteroids b. Leukotriene modifier c. H 1 antihistamine d. Prednisone 20 mg qd for 5 days 17. A patient presents to your office with moderate persistent asthma not adequately controlled on low-dose inhaled corticosteroid. Which of the following interventions has shown the greatest therapeutic benefits? a. Doubling the dose of inhaled corticosteroid b. Adding a leukotriene modifier c. Adding a long-acting 2 -agonist d. Adding inhaled cromolyn 18. Which of the following classifications of asthma may be treated by monotherapy with a leukotriene modifier? a. intermittent asthma b. Mild persistent asthma c. Moderate persistent asthma d. Severe persistent asthma 19. Which of the following inhaled corticosteroids is the most potent? a. Beclomethasone b. Fluticasone c. Flunisolide d. Budesonide 20. An acute exacerbation of asthma is best treated with which of the following agents? a. Leukotriene modifier b. Long-acting 2 -agonist c. Intravenous theophylline d. Short-acting 2 -agonist Treatment of Allergic Rhinitis 21. Which of the following phrases does not accurately describe a characteristic of allergic rhinitis?: a. A trivial disorder that spontaneously remits over time b. A disorder that is often associated with asthma exacerbations, sinusitis, otitis media, and other complications c. Associated with a decreased quality of life d. Common in both children and adults e. Shows an increased prevalence worldwide 22. Approximately what proportion of patients with allergic rhinitis have concomitant asthma or bronchial hyperreactivity? a. 26% b. 56% c. 66% d. 76% 23. Antihistamines have generally not been considered effective for which symptom in patients with allergic rhinitis? a. Rhinorrhea b. Sneezing c. Itchy eye d. Itchy nose e. Nasal congestion 24. Which of the following treatments is administered only with particular caution and prudence to children with allergic rhinitis because of possible effects on linear bone growth? a. Intranasal corticosteroid b. Intranasal decongestant c. First-generation sedating antihistamine d. Newer nonsedating antihistamine e. Immunotherapy 25. Which of the following is not a complication of allergic rhinitis in children? 58S December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A)

5 a. Otitis media b. Abnormalities of facial bone development c. Dental malocclusion d. Chronic open-mouth breathing e. Eczema 26. Nasal congestion is a typical symptom of chronic allergic rhinitis. 27. A common contributor to perennial symptoms of allergic rhinitis is: a. animal dander b. mold c. dust mite allergen d. cockroach allergen 28. Which of the following is considered first-line therapy for mild-to-moderate intermittent symptoms of allergic rhinitis? a. First-generation antihistamine available over the counter (OTC) b. Decongestant remedy available OTC c. Newer nonsedating oral antihistamine d. An intranasal corticosteroid e. Immunotherapy 29. The major approaches to management of allergic rhinitis may include all but which of the following: a. avoidance of causal or triggering factors b. pharmacotherapy c. psychotherapy d. immunotherapy 30. Which of the following antihistamines produces sedation at recommended doses? a. Loratadine b. Desloratadine c. Diphenhydramine d. Fexofenadine e. Chlorpheniramine f. Both c and e Pruritic Dermatoses: Overview of Etiology with Therapeutic Measures 31. The primary mediator for most forms of urticaria is a. immunoglobulin (Ig) G b. IgE c. histamine d. an autoantibody 32. Allergic forms of pruritus include which of the following disorders? a. Atopic dermatitis b. Cutaneous mastocytosis c. Cholestasis d. Urticaria e. a, b, and d 33. Pruritus having a nonallergic basis may occur in patients with which of the following disorders? a. Chronic renal failure b. Leukemia c. Diabetes mellitus d. Cholestasis e. All of the above 34. Which of the following chemical mediators is held responsible for the itching associated with acute urticaria related to a seafood allergy? a. Serotonin b. Prostaglandins c. Histamine 35. Rhinorrhea and itching in a patient with acute allergic rhinitis and hives is most likely to respond to which of the following therapies? a. Oral decongestant b. Oral nonsedating H 1 antagonist c. Topical corticosteroid d. Intranasal corticosteroid 36. Relief of allergic, moderately pruritic dermatitis that awakens the patient at night should focus on a. identification/elimination of the cause as feasible b. symptomatic relief with an H 1 inhibitor c. topical relief measures with wait-and-see attitude d. initiation of immunotherapy e. a and b 37. Which of the following therapies may relieve the itching associated with cholestasis? a. Topical corticosteroid b. Oral nonsedating antihistamine c. Opioid antagonist d. Leukotriene modifier 38. Which of the following pruritic skin disorders involves tactile sensitivity to wool and other irritating fibers, a family history of allergy, as well as a psychogenic component? a. Cutaneous mastocytosis b. Urticaria c. Atopic dermatitis d. Dermatitis herpetiformis 39. The pruritus caused by histamine release occurs primarily through activation of which of the following receptors? December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 59S

6 a. H 1 receptor b. H 2 receptor c. Neither 40. Provide the numbers for all appropriate choices of therapy indicated for the itching disorder listed below. Disorder Therapy a. Atopic dermatitis b. Urticaria c. Pruritus with renal failure d. Pruritus with cholestasis Therapies: 1. topical corticosteroid; 2. frequent lubrication; 3. oral antihistamine; 4. cholestyramine; 5. avoidance measures Antihistamine Treatment of Ocular Allergy 41. Local challenge study models for topical drug development provide which type of information? a. Optimal dose b. Onset of action c. Duration of effect d. Comparisons with placebo and reference compounds e. All of the above 42. Which of the following statements regarding the effects of oral antihistamines on ocular allergies is true? a. Terfenadine has been shown to be superior to astemizole for the treatment of ocular erythema and pruritus. b. Chlorpheniramine exhibited no beneficial effects on ocular allergies. c. Oral antihistamines have traditionally been considered superior to intranasal corticosteroids for the control of ocular tearing. d. a and c e. None of the above 43. Topical olopatadine given as adjunctive therapy with oral loratadine provided greater relief of ocular itching and redness than loratadine alone. 44. Topical application of levocabastine appears to be as effective or more effective than oral antihistamines for relieving ocular itching. 45. Topical application of cromolyn (2%) appears to be more effective than oral antihistamines in reducing excessive lacrimation. 46. Intranasal corticosteroids have exhibited a beneficial effect on symptoms of allergic conjunctivitis. 47. In a study by Juniper et al assessing the need for add-on therapy with either an oral antihistamine or an intranasal steroid, most patients required combination therapy. 48. Topical preparations of antihistamines for ophthalmic use appear to have a slower onset of clinical effect than the oral second-generation antihistamines. 49. Oral antihistamines have been shown to a. dampen or block allergic pruritus b. dampen or block allergic erythema c. increase the threshold dose of allergen needed to induce symptoms in allergen conjunctival provocation models d. a and c 50. Laboratory pollen-chamber challenge studies, which are used to evaluate H 1 - antihistaminic activity, have primarily focused on the effects of oral antihistamines on the symptoms of allergic rhinitis. Clinical Pharmacokinetics of H 1 Antihistamines 51. Pharmacokinetic studies of H 1 antihistamines provide information about drug a. absorption b. metabolism c. elimination half-life d. all of the above e. none of the above 52. Population pharmacokinetic studies of H 1 antihistamines are performed in which of the following groups of patients? 60S December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A)

7 a. Patients in large clinical efficacy/safety trials b. Patients in pharmacodynamic studies c. Patients in hospitals d. All of the above e. None of the above 53. Which of the following H 1 antihistamine has been associated with diminished effect to same dose (tolerance) during regular administration? a. Cetirizine b. Desloratadine c. Fexofenadine d. Levocetirizine e. None of the above 54. Pharmacodynamic studies are useful for determining which of the following about H 1 antihistamines? a. Onset of activity b. Duration of activity c. Residual activity after stopping d. All of the above e. None of the above 55. Elimination half-life values of orally administered H 1 antihistamines in current use vary from a. 3 to 6 hours b. 6 to 12 hours c. 3 to 12 hours d. 6 to 24 hours e. 2 to 27 hours 56. Which of the following H 1 antihistamines are eliminated mostly unchanged (i.e., are not metabolized extensively)? a. Cetirizine, desloratadine, and loratadine b. Desloratadine, loratadine, and levocetirizine c. Cetirizine, desloratadine, and fexofenadine d. Cetirizine, fexofenadine, and levocetirizine Complementary and Alternative Medicine Herbal Therapies for Atopic Disorders 57. The second most common group of chronic conditions for which patients seek out complementary and alternative medicine (CAM) therapies is a. back pain b. arthritis c. atopic disorders d. heart disease e. hypertension 58. Which statement is true regarding atopic disorders and CAM therapies? a. More than 20% of adults in the United States have atopic disorders, and 42% have used some form of CAM therapy. b. More than 50% of adults in the United States have atopic disorders, and 10% have used some form of CAM therapy. c. Five percent of adults in the United States have atopic disorders, and 3% have used some form of CAM therapy. d. More than 20% of adults in the United States have atopic disorders, and 10% have used some form of CAM therapy. e. More than 30% of adults in the United States have atopic disorders, and approximately 3% have used some form of CAM therapy. 59. Which of the following statements is true? a. Ma huang is a form of acupuncture used for asthma. b. Ma huang is a harmless herbal therapy used for asthma. c. Ma huang is derived from carrot roots. d. Ma huang is derived from wild mushrooms. e. Ma huang contains ephedrine. 60. Ma huang has been associated with a. sudden death b. nephrolithiasis c. acute hepatitis d. potent sympathetic activity 61. Ling-gan-jiang-wei-xin-xia-ren tang, a variant of minor blue dragon, has been reported to inhibit degranulation and histamine release of mast cells stimulated with either antigen or compound 48/80 in vitro. 62. Which of the following statements is true regarding saiboku-to, the Japanese kampo formulation? a. Saiboku-to has been reported to decrease epoprostenol production. b. Saiboku-to has been reported to inhibit eotaxin production. c. Pneumonitis and pneumonia have been associated with saiboku-tu. d. Specific flavonoid components of Scutellaria are believed to be responsible for some of the antiallergic effects of saiboku-to. e. All of the above 63. Poncirus trifoliata extract, found in the Korean formulation jisil, has been shown to a. stabilize mast cell membranes b. have potent sympathetic activity c. inhibit cyclic adenosine monophosphate phosphodiesterase December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 61S

8 d. a and c e. none of the above 64. Which of the following statements is true regarding echinacea? a. Echinacea may be effective in treating and preventing symptoms of upper respiratory inflammatory reactions. b. Echinacea is related to ragweed. c. Echinacea has been associated with anaphylaxis, urticaria, and angioedema. d. All of the above e. None of the above 65. Indian ayurvedic medicine consists of a. yoga b. meditation c. homeopathy d. herbal therapy 66. Which of the following statements is true regarding CAM herbal therapies? a. CAM herbal therapies are natural and therefore harmless. b. Well-controlled scientific studies have been performed on many of the Asian herbal therapies. c. CAM herbal therapies are only used in Asia for the treatment of atopic disorders. d. Well-controlled scientific studies have been performed on many of the Western herbal therapies. e. No scientific evidence exists that supports the antiallergic effects of CAM herbal therapies. 62S December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A)

9 CUT HERE CME ASSESSMENT TEST ANSWER SHEET Release Date: December 16, 2002 Expiration Date: June 30, 2004 INSTRUCTIONS: 1) Read the learning objectives, review the activity, and complete the post-test. 2) Complete this registration form and the activity evaluation form on page 64S. Record your test answers on the Answer Sheet below. 3) Send the registration and evaluation forms, along with your credit card information or a check/money order for $15.00 made out to UMDNJ- CCOE to: UMDNJ Center for Continuing and Outreach Education Via mail: PO Box 1709, Newark, NJ Fax: (973) Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% is achieved, a CME credit letter awarding AMA/PRA Category 1 credit and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to complete the activity again. ANSWER SHEET (circle the best answer) 1. a b c d e f 23. a b c d e 45. a b 2. a b c d e 24. a b c d e 46. a b 3. a b c d e f 25. a b c d e 47. a b 4. a b c d e f 26. a b 48. a b 5. a b c 27. a b c d e 49. a b c d e 6. a b c d 28. a b c d e 50. a b 7. a b c d e 29. a b c d 51. a b c d e 8. a b c d e 30. a b c d e f 52. a b c d e 9. a b c d e 31. a b c d 53. a b c d e 10. a b c d e 32. a b c d e 54. a b c d e 11. a b c d 33. a b c d e 55. a b c d e 12. a b 34. a b c 56. a b c d 13. a b c d 35. a b c d 57. a b c d e 14. a b c d 36. a b c d e 58. a b c d e 15. a b c d 37. a b c d 59. a b c d e 16. a b c d 38. a b c d 60. a b c d e 17. a b c d 39. a b c 61. a b 18. a b c d 40. a: a b c d e 19. a b c d b: a b c d e 20. a b c d c: a b c d e 21. a b c d e d: a b c d e 22. a b c d 41. a b c d e 66. a b c d e 42. a b c d e 43. a b 44. a b REGISTRATION FORM I have read the articles on Optimal Use of H 1 -Receptor Antagonists for Allergic Disorders, published as a supplement to The American Journal of Medicine, and have answered the CME test questions and completed the Evaluation Form for this educational activity. Signature Date Last name First name MI Degree Specialty Address City Postal Code Country Phone Fax Social Security No. (US residents only; for CME recording purposes) Affiliation Time (in hours) to complete this activity Enclosed is my check for $15 made payable to UMDNJ-CCOE (7 hours maximum) Credit card: MasterCard Visa American Express Card number: Exp. date: Signature: December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A) 63S State

10 CME EVALUATION FORM The planning and execution of useful and educationally sound continuing education activities are guided in large part by input from participants. To assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please take a few moments to complete this Evaluation Form. Your response will help to ensure that future programs are informative and meet the educational needs of the participants. Please note: a letter for CME credit with information on long-term credit retention will be issued only upon receipt of this completed Evaluation Form. Thank you for your cooperation! PROGRAM OBJECTIVES Having completed this activity, are you better able to accomplish the following? Strongly Agree Strongly Disagree 1. Discuss the rationale for the use of H 1 antagonists in treating: a. allergic rhinitis b. urticaria and other pruritic dermatoses c. ocular allergy Describe the role of histamine in the pathophysiology of asthma Discuss the immunomodulatory and anti-inflammatory effects of H 1 antagonists 4. Discuss the role of H 1 -antagonist therapy in the allergic rhinitis asthma syndrome 5. Discuss the effects of alternative herbal medications in atopic disorders 6. Recognize the clinical and pharmacologic differences among H 1 antagonists OVERALL EVALUATION Strongly Agree Strongly Disagree The information presented increased my awareness/understanding of the subject The information presented will influence how I practice The information presented will help me in improving patient care The faculty demonstrated current knowledge of the subject The program was educationally sound and scientifically balanced The program avoided commercial bias or influence Overall, the program met my expectations I would recommend this program to my colleagues If you anticipate changing 1 aspect of your practice as a result of your participation in this activity, please provide a brief description of how you plan to do so: Please provide any additional comments (positive and negative) pertaining to this activity with suggestions for improvement: Please list any topics that you would like to see addressed in future educational activities: CE Activity Code: 03MN17 64S December 16, 2002 THE AMERICAN JOURNAL OF MEDICINE Volume 113 (9A)