Pharm pulm Flashcards
what are the four drug types under anti-inflammatory agents?
- glucocorticoids
- mast cell membrane stablizers
- leukotriene receptor antagonists
- phosphodiesterase-4 inhibitor
what are the two drugs that fall under glucocorticoids?
- inhalents: fluticasone, budesonide
2. oral-prednisone
what is the name of the drug that was a mast cell membrane stabilizer?
cromolyn
what is the name of the drug that is a leukotriene receptor antagoinst?
zafirlukast
what is the name of the drug that is a phosphodiesterase-4 inhibitor?
roflumilast
what are the three drug classes that fall under short acting bronchodilators?
- adrenergic antagonists (SABA)
- PDE inhibitor or methylxanthine
- anticholingeric
what is the one oral and two inhalant meds tat are adrenergic agonists, SHORT acting bronchodilators?
oral: terbutaline
inhalant: albuterol, levabuterol
Short acting bronchodilators: what ar ethe two drugs that are PDE inhibitors?
- theophylline
2. roflumilast
short acting broncodilators: what is the anticholinergic drug that is an inhalant?
ipratropium
what are the two drug classes within the LONG acting bronchodilators?
adrenergic agonists (LABA) ("controller med") ("steroid sparing")
anticholingergicwhat are the two long acting bronchodilators inhalant adrenergic agonist?
salmetrerol, formoterol
what is the name of the long acting anticholingeric bronchodilators?
tiotropium
what is the name of the IgE antibody agent? how is it administered?
SQ administration-omalizumab
what is advair MDI a combinationr of? which two drug classes?
fluticasone and salmeterol
inhaled glucocorticoid/LABA
what is symbicort MDI a comhination of? which two drug classes?
budesinide/formoterol
inhaled corticosteroid/LABA
what is combivent a combination of? which two drug classes?
ipratropium/albuterol
inhaled SA anticholinergic and SABA
what is anoro ellipta a combination of? which two drug classes?
umeclidimium and vilanterol
inhaled LA anticholingergic/LABA
what are the three drug classes of nicotine agents?
- nicotine replacement
- antidepressant
- partial nicotine agonist
what methods are for nicotein replacement? (4)
nicorette gum, nicoderm patch, nicotrol inhaler, nictrol nasap spray
what antidepressent can be used as a nicotein agent?
atypical Dopmine reuptake inhibitor-bupropion
what is a partial nicotine agonist?
varenicline
what are the two groups of bronchodilators?
short and long term
medications used to treat asthma are increased in what type of manner?
stepwise, depending on the severity of the asthma the person has and their response to treatment of those medications
what are three risks associated with the risk of asthma?
genetics, atopy (allergy), and obesity
when is a person’s symptoms worse for asthma?
worse at night and early morning
what is prolonged in a person with asthma?
inspiratory and expiratory phases
is the bronchospasms experience by an asthma patient reversible,
why yes, yes it is
what are two symptoms you see with a patient with asthma?
episodic wheezing and cough
what are the two risk factors associated with COPD?
tobacco smoking and occupation exsposure
what are some signs of COPD?
excessive cough, sputum production, continous
what happens to the air flow in COPD? what is this caused by? what does this cause for the phases?
airflow obstruction secondary to airway destruction, causes longer expiratory phase
what are the two types of COPD?
chronic bronchitis, emphysema, OR BOTH!
is COPD reversible
marginally
what are COPD exacerbations usually caused by?
VIRAL INFECTION
explain the four stages of GOLD rating for COPD?
gold 1: mild, FEV > 80 percent predicted
gold 2: moderate 50-80 percent predicted
gold 3: severe 30-50 percent predicted
gold 4: very severe
what are the two main approaches to bronchspastic disorders?
- directly decrease bronchospasm
2. decrease bronchial responsiveness to stimulation
how can you directly decrease bronchospasm? (2)
acutely: stimulate B2 agonist receptors
long term: increase cAMP levels in smooth muscle cells
what are the four ways you can decrease bronchial responsiveness to STIMULATION?
- decrease IgE levels via allergy meds
- decrease IgE binding to mast cell membrane
- stabalize mast cells to prevent degranulation
- decrease smooth muscle parasympathetic nerve receptor response to stimulation
what are the three adrenal steroids drug classes and their drug names? (these are glucocorticoids that are made in the body naturally)
- glucocorticoids- CORTISOL
- mineralcorticoids: aldosterone
- androgen/estrogen steroids: DHEAS
cortisol (glucocorticoid) has a large impact on (2)
This is made in the body
metabolism and immune function
aldosterone (mineralcorticoid) has a impact on…
electrolyte balanace and salt retention
DHEAS (androgen and estrogen steroids) have a large impact on…
estrogen and testosterone
DUH
what are bronchioles composed of?
smooth muscle and elastic fibers without cartilage support
what is the bronchiolar muscle innervated by? what type of tone does it have?
innverated by sympathetic and parasympathetic nerves
vagus nerves (parasym) maintains a slightly contricted tonic tone (whatever that means)
what type of neurons are stimulated that cause bronchospams? what stimulates them?
secondary to cholinergic motor neurons that respond to acetylcholine stimulation
what do catecholamines do?
sympathetic stimulation increase cAMP causing bronchial smooth muscle relaxation
Beta 2–what nerve receptors does it stimulate and where?
what three things happen when the beta-2 receptor is stimulated?
selectively stimulate sympathetic nerve receptors in bronchial smooth muscle to reduce bronchospasm, increase vasoconstriction, decrease glandular secretion
what do anti-cholingeric inhibit?
the action of acetylcholine on smooth muscle receptors thus reducing bronchospasm
PDE inhibitors do what?
decrease the rate of cAMP degredation there by promoting bronchodilation
what is asthma often seen with ?
eczema
Case: in a 23 yr old patient with bilateral wheezing, eczema, who ran out of his meds and O2 is 84…what do you give him?
- albuterol MDI (SABA)
- fluticasone
- O2
what is interesting about the length of use and albuterol?
effectiveness decreases the longer your use it, esp when people get anxious about their breathing they tend to use more, become slightly dependent on it
how often can you give albuterol in the ED?
every 20 mins
what is interesting about beta2 agonists (SABAs) and the length of time yo use them?
SABAs= albuterol and levalbuterol
the longer you use them the less effective they are, you build up a tolerance for them
what happens if O2 below 88%?
this is real bad and a lot of damage can occur here
medicare will cover if O2 is
what do you need to do for patients who have asthma?
come up with a asthma action plan, especially for when they are about to run out of medication so they don’t have exacerbation and don’t end up in the emergency room
Case: 15 year old athlete with wheezing during and after basketball practice. what type of asthma is this and what do you give him?
exercise induced asthma; sometimes this is the only manifestation but can develop into long term asthma issues
give him albuterol!!! two puffs before practice, two puffs after as needed
Case: 25 year old with 1 year hx of wheezing on daily basis, dyspnea keeps him from playing tennis, and awakens at night with SOB 2-3 times a week. what do we give him?
albuterol MDI and fluticasone
what should you do for a patient if they are having a hard time with MDI dosing?
give them a diskus, might make it easier but keep in mind it is more expensive
what is a common side effect of fluticasone?
thrush, oral candidiasis…..so you need to rinse your mouth out everytime so that way it helps to prevent against this
what pregnancy category are the glucocorticoids, both prednisone and fluticasone?
C, so you need to weigh the benefits and the risks
what is the DOC glucocorticoid inhaler for a pregant lady? why?
budesonide (pulmocort inhaler) because it has less systemic effects!
what is important to do if a patient has asthma/COPD/respiratory issues?
have them get the flu vaccine!! want to prevent issues later on or down the road
Case: 35 year old worker with nighttime wheezing, who gained 50 pounds. he has progressively worse wheezing during the day now. He is already taking albuterol, so what else can we get him and need to make sure he doesn’t have?
add fluticasone so he gets both albuterol and fluticasone
want to check to make sure he doesn’t have sleep apnea that is contributing to the problem, esp since increased body mass
Case: what is the DOC for a 45 year old woman with a 50 pack year history and COPD. She would like to stop smoking and hasn’t tried before. Whats her DOC?
nicotine replacement for first time attempt
nicoderm, inhaler, nicorette, or nasal spray
who should you avoid using nicorette gum in?
people who wear dentures
what is the drug class for varenicline?
partial nictotine agonist (oral)
what is the drug class for bupropion?
atypical antidepressant, oral dopamine reuptake inhibitor
what is the MOA for bupropion?
2nd line treatment after nicotine replacement, mechanism is unknown….werid
what is the MOA for varencline?
3rd line for smoking cessation, prevents nicotine stimulation of the mesolimbic dopamine system
what is the MOA of nicotine replacement methods? (gum, inhaler, patch, or nasal spray)
biphasic CNS and ANS nicotine receptor stimulant
low dose stimulation: stimulation ANS ganglia
High dose stimulation: stimulation followed by blockade of transmission
If you have a history of seizures which smoking drug should you avoid?
bupropion (zyban/wellbutrin)…..it will make them worse!!! also don’t use this drug if you are bipolar
what is important to include as part of a treatment plan is someone is trying to quit smoking?
counseling!! makes them more successful
Case: in a 65 year old man with 50 pack year history of smoking and COPD, with progressively more short of breath for the last 6 months. he is now limited to 1 mile walk per day from breathing. what is his DOC?
albuterol or levalbuterol ($$) [SABA]
PLUS
budesonide/formoterol [combo corticosteroid/LABA]
what is important to do if patient has COPD and 65+?
get them the pneumonia vax!!
in a healthy person, what is the general combination of asthma drugs you see?
fluticasone + albuterol
SABA and corticosteroid
in COPD patient, what have LABAs been shown to help with? what about anticholingerics?
LABAs=daytime
anticholingergics=nighttime
this is why they take combinations to cover more grounds
which drug do you not want to use if the patient has a history of arrythmia?
theophylline, increases the risk of arrythmia
this drug isn’t used as 1st line, PDE is only used as a last chance really, but should know this!
Case: in a 65 year old man with 50 pack year history of smoking and COPD, with progressively more short of breath for the last 6 months. he is now limited to 1 mile walk per day from breathing. He also has prostatic hypertrophy. what is his DOC?
(this case was given before with different drug choice, this is what white said to do..)
initial treatment could be:
albuterol MDI
levalbuterol MDI
combivent MDI (albuterol ad ipratropium) need to be cautious of this because of prostatic hypertropy, so this wouldn’t be used first
which drug class should you avoid if you have urinary tract flow obstruction or urinary hyperplasia? which specific drugs?
anticholingerics!!
- ipratropium
- tiotropium
- umeclidinium and vilanterol
Case: a 55 year old woman with acute bacterial sinusitis of 2 weeks duration with increases congestion, bilateral maxillary sinus pain for the last 3 days. She has a penicillin allergy, so what is the DOC? what would be the normal ranking if she wasn’t allergic?
DOC: doxycycline since penicillin allergy
Top 3:
- augmentin
- doxycycline
- levaquin (not with heart though since QT elongation)
if a patient has RA and takes methotrexate, what is important to keep in mind if you think they have COPD?
methotrexate can cause pulmonary fibrosis, need to make sure that it is actually COPD instead of looking like that way from a medication side effect
case: a 60 year old woman with COPD who has had increased dyspnea over 3 weeks, takes albuterol BID. hx of COPD, HTZ, H+H 9/27, anemic. what do you do?
- duoneb combivent in office
- prednisone
- umeclidium (anticholinergic) and vilanterol ( LABA)
* continue the albuterol*
also need to figure out the source of the anemia (nuitrition vs bleeding)
what do you do if someone is anemic and they come into your office for COPD?
appropriate to start them on a multivitamin and work them up to find the reason why
explain the “ol” drugs?
Beta 1 (heart): atenolol
Beta 2 (lungs): someterol, formoterol, albuterol, levalbuterol
all “ol” drugs are beta drugs
case: 30 year old with progressive wheezing for 3 years despite ICS and albuterol. No DVT and hasn’t been to te clinic in the last two years. fluticasone 44 mg and albuterol. what would you do for this patient?
moderate persistent asthma
you increase the doses of the fluticasone, maybe try introducing a spacer to make the delivery more effective
may consider prednisone
what does a space eliminate?
the issue of timing the dose with the breathing
does a better job getting the drug to the lung tissue
what is a risk of using fluticasone?
can retard growth in children ,stop using it and then no more issues
what is the FEV1 associated with COPD?
what can’t you do with combo inhalers?
increase the dose like you can with fluticasone because if you do you increase the amount of BOTH drugs and then you might give the patient too much of one of them
case: a 40 year old patient with hx of asthma and inhalent allergies with new nasal polyps. he has shortness of breath that wakes him up at night. uses rescue inhaler once a day. fluticasone BID, albuterol PRN. what do you want to do for him?
omalizumab sq injections every 2-4 weeks since allergies aren’t controlled with inhalers
OR prednisone
OR increase dose of fluticasone
should consider SAMTRAs triad and as about asprin sensitivity
what is the drug class for omalizumab?
antibody agent: anti-IGE antibody, immunomodulator
what is the MOA of omalizumab?
binds to IgE antibody receptors on mast cells and blocks attachment of IgE antibody preventing degranulation and release of histamines and leukotrienes
what is SAMTRAs triad?
reactive airway disease
nasal polyps
asprin allergy
so want to know if a patient has asprin allergies because it can present like regular allergies
what is one major caution when using omalizumab?
it can cause anaphylaxis on the first dose so want to always give it in the doctors office and have epi ready to go!
case: you have a 16 y/o hs student who wont take their albuterol at school because they’re embaressed. she keeps waking up at night and FEV1 is 70%. what do you do about it? (2 options)
- fluticasone, won’t see results for two weeks but can take it to help manage long term symptoms rinse mouth
- fluticasone/salmeterol (LABA), increases compliance
what is the benefit of using a combination inhaler?
increases compliance and you get more bang for you buck
what shoul you always do when a patient is on a corticosteroid?
look at the dose of it to see if you can increase the dose of the med
what is a major effect of zafirlukast?
liver disease, so don’t take this lightly
sometimes this drug is used in samtras triad
who uses cromolyn and what does it do?
children
mast cell stablizer
what is feofolin? what does it cause?
PP4 inhibitor, causes cardiac arrythmia?
what are two effects that neoplastic drugs have?
decrease immune response
decrease neutrophil count
should people with asthma take a LABA without a inhaled corticosteroid? what about people with COPD?
NO!!! people with asthma can only take a LABA if they are ALSO taking a inhaled corticosteroid!
Pt with COPD can use a LABA without a inhaled corticosteroid, this is encouraged
explain how come a LABA monotherapy has increased risk of death in a asthma patient, whereas the combination LABA/ICS doesn’t? who do you used a LABA in?
LABA monotherapy has increased risk of death in asthma patients, whereas when combined with a ICS, this risk decreases
this is why asthma patients on a LABA should always have a ICS
since there is a risk regardless, you only use this in pts with MODERATE/SEVERE, persistent asthma that is NOT controled with ICS and PRN SABA
If you put a asthma patient on a LABA, what must you make sure they are also on?
ICS—–otherwise it increases their risk for death!
Case: you have a patient with uncontolled COPD and GLAUCOMA. He already takes albuterol but it is now uncontrolled. what do you need to consider for this patient? involved case
trade off here is: do we give the patient a drug that can make the glaucoma itself worse, or do we give a drug that interferes with the glaucoma meds.
NEED TO CONSIDER LENGTH OF TREATMENT
- SHORT TERM: if in office give COMBIVENT NEB, but both ipratropium and albuterol are contraindicated for glaucoma. since this is a one time thing you can do it, its unlikely to effect glaucoma.
- LONG TERM: on the other hand the DOC for long term COPD, a LAAC, would have increased risk of worsening his glaucoma. so next step is SALMETEROL LABA and need to monitor glaucoma closely because it may interact with their glucoma med Timolol.
what is cortisol?
the glucocorticoid that the body produces naturally
Case: a 60 year old lady with COPD and RA who gets SOB over 6 months, concerned COPD is getting worse. He has a dry cough. Advair diskus. methotrexate.
What do you worry about?
since on methotrexate he can get pulmonary fibrosis and you worry about this.
want to get a CT to see if methotrexate is causing this and it wrongly presents as COPD exacerbation.
Case: 45 year old wants to stop smoking. he has used nicorette gum last months and it hasn’t worked. he wants to try something else. No mental health history. DOC?
DOC: bupropion, second line drug after nicotine replacement.
Can use this because patient doesn’t have mental health history. This drug can cause suicide ideation, so don’t want to give it to those patients!
what two smoking drugs have black box warnings? what are they for??
bupropion: black box for psychiatric events, depression, and SUICIDE
varencline: black box for psychiatric events, depression and SUICIDE
THEYRE THE SAME!
what do you NOT use bupropion in?
what do you caution patients about in varencline?
DON’T USE EITHER IN DEPRESSION/MENTAL HEALTH OR AT LEAST BE CAUTIOUS WHEN PRESCRIBING
bupropion: don’t use in seizures!
varencline: caution for VIVID dreams!
case: man with COPD (chronic bronchitis) exacerbation lasts 3 days with productive cough and purluent sputum last two days. Albuterol and symbicort. consolidation in posterior lower lung. CXR: infiltrate. Increase WBC. FEV1 55%. whats the DOC? whats the order of drugs?
suspect pneumonia
short burst of prednisone with antibiotic
- beta lactam
- macrolide
- fluoroquinolone
in COPD patients, if they have increased sputum, SOB, and cough….AND THE CXR IS NEG FOR INFILTRATE…..what do you need to consider?
always consider abx if they have exacerbation with these symptoms because COPD patients have increased risk of infection
do oral steroids have a place in COPD exacerbation?
YES THEY DO!!
oral steroids play an important role in COPD exacerbations but NOT in chronic use
what are the three meds Blessington said you should consider if a patient has a acute exacerbation of COPD?
- antibiotics
- oral steroids
- what type of inhaler?
case: 75 year COPD old man with hx of drinking and smoking, 6 month cough with copious sputum with blood. hes lost 15 lbs. MDI TID. rhonchi and wheeze. CT reveals dilated thickened bronchi. SaO2 86%.
DOC? Drive indicates two diagnosis and two concerns here.
what do you worry about in this patient? (2)
DOC: long acting anticholingeric; tiotropium
DOC if you think infection (copious sputum): azithromycin
with dilated thickened bronchi you worry about bronchiectasis and the weight loss and hemoptosis you worry about cancer
what is bronciectasis? what can it be associated with? how do you find it?
suggested by CT showing dilated thickened bronchi
this often occurs with chronic infection like COPD, the airways become dilated, airway size increases, mucous production increases and risk for infection increases.
all of these combinations make it harder to COPD patient to clear the infection
case: 30 year old woman with CF on azithromycin for 3 days for control of pulmonary infection but has gotten worse and developed exacerbation with SOB and purlulent sputum. what is DOC?
suspect CF in this patient
choose new DOC that covers pseudomonas because CF patients are particularly susceptible to pseudomonas infections
what are CF patients put on pancreatic enzymes?
CF increases mucous production and plugs ducts, the pancreas can’t release enzymes.
these enzymes increase absorption in the intestine so CF patients need these as supplements!
what percent of CF patients are on pancreatic enzymes?
90%
case: a 78 year old man, smoker, was brought in with rapid confusion over last 24 hours, stage 4 CKD, COPD. Tritropium, symbicort, albuterol. BP: 160/90. absent breath sounds lower right. H+H 10/30.
DOC? what do you suspect?
suspect pneumonia, low H+H can be from anemia of chronic disease
You know the drugs!!
exacerbation of COPD can be caused by…..? (random)
anemia
so this might be a problem, because anemia of chronic disease can go along with COPD.
what two things can cause confusion in elderly?
UTI, pneumonia
case: in a patient with COPD, CKD, and anemia…..which would you think is the cause for an exacerbation?
CKD because it causes systemic effects and effects so many other parts of the body and health.
anemia plays a role but CKD is more severe.
when you have a patient with both of these, you want to check eGFR and BUN/creatine to check the progression of kidney disease because it could be causing exacerbation
case: 50 year old man who came in can’t sleep from snoring continously and irregular breathing. he is extremely tired during the day. BMI 41. O2 84. BP 170/110.
DOC? what do you suspect?
obstructive sleep apnea
DOC: neb in office, do sleep study so they can hopefully get CPAP, decrease weight because this causes increase risk for sleep apnea
high BP…wanna look into that. they were on BP meds for the case, buttt it is still really high!
case: 65 year old COPD fell at home and has been taking his friends narcotics with oxycodone. his family checked on him today and he is semi responsive and scent of alcohol.
DOC?
COPD complicated by narcotic use
narcotics are sedating esp with alcohol. cause RESP DISTRESS and can exacerbate COPD and decrease persons ability to breath!!
stop narcotics, monitor closely, get them on O2
Case: patient with COPD with glaucoma? what is the DOC?
usually would be long term anticholingeric
but since glaucoma the new DOC becomes LABA!!!!!!
what is the DOC for patients with COPD without any complicating factors?
- long term anticholingergics: tiotropium
2. LABA-salmoteral, fermoterol, vilanterol
what is the MOA of methotrexate?
Inhibits dihydrofolate reductase and DNA production, inhibits production of cytokines
what is the drug class for methotrexate?
Antimetabolites:
Antifolate
what is the indication for methotrexate?
Recent RA less than 6 months, Low Disease Activity, No poor prognostic features. Cancer Remission.
what are the side effects for methotrexate? (6)
Arachnoiditis, Subacture Toxicity reaction (CN Palsy, Seizure, Coma) Pulmonary Fibrosis, Hepatotoxicity, Bone Marrow Suppression, ARF, SJS
what is the DOC for CAP?
cephalosporin +macrolide OR fluoroquinolone
(ceftriaxone) + (azithromycin) (levaquin)
this isn’t what we learned in CM, but this was from one of the cases
what is the criteria for admitting to the hospital called?
Curb65
what is one negative effect of albuterol?
increased HR
In obstructive sleep apnea, what does CPAP do?
continuous positive pressure, pushes air into the alveoli and forces the airways to stay open
what is alcohol and narcotics bad?
alcohol ruins the liver
narcotics are CYP340, so if the liver is shot, it can’t clear the narcotics from the blood and they stay in the person longer. this means they can cause greater respiratory depression
if the patient is 65+ and has COPD what are the two important things to get?
pneumonia vax + prevnar
get prevnar 6-12 months later
what don’t you want to do with bupropion?
stop abruptly, want to taper the patient off
what abx tx would you use for a patient with bronchiectasis?
broad spectrum because it could be caused by a lot of things
if a patient uses the SABA >2 a week, what type of asmtha do they have? what should you start them on?
what about if they use the SABA daily?
> 2 week=mild persistent…get them on a ICS too
SABA daily=mod persistent
can an ICS slow the progression of asthma?
YES…..this is why it is reccomended to get them on a ICS early
what is the caution about using albuterol in a patient with high BP? what might be a better option?
abuterol increases BP….therefore if you have a patient with high BP it might be a better idea to put them on levalbuterol because it has less SE and won’t effect BP as much
its more expensive, so hopefully the pt can deal
explain the nebulizer treatment options?
YOU CAN NEB ALBUTEROL!!!! or IPRATROPIUM/ALBUTEROL (combivent)
typically use just albuterol, unless the patient has a neb at home with albuterol and it isn’t strong enough and not helping them enough then you hit them with the combo drug neb!! :)
explain the treatment depending on the classification of asthma?
- intermittent
