Pharm Pulmonary Exam 1 Flashcards
LABA
Long acting beta agonist
SABA
Short acting Beta agonist
Most effective medication for relief of acute bronchospasm.
More than one canister per month suggests inadequate asthma control
Regularly scheduled use is not generally recommended
May lower effectiveness
May increase airway hyperresponsiveness
LAMA
Long acting Muscarinic Antagonists
Bronchodilators MOA
Activate Beta 2 receptors in smooth muscles of lung, promoting bronchodilation and thereby relieving bronchospasm.
Also suppress histamine release in the lung and increase ciliary motility
Open up bronchial tubes so that more air can move through.
Helps clear mucus from lungs.
As airway opens the mucus moves more freely and can be coughed out.
Short acting Bronchodilators
Quick acting, Rescue
Relieve asthma symptoms very quickly by opening airways
Action starts within minutes after inhalation and last for 2 to 4 hours
Used 15- 20 minutes before exercise to prevent exercise induced asthma
Long acting Bronchodilators
Used to provide control -
not quick relief of asthma
Lasts for at least 12 hours
Those containing formoterol begin their action within a few minutes, while those containing salmeterol take up to 45 minutes to begin their action
Regularly scheduled of use of SABA is not generally recommended due to:
May lower effectiveness
May increase airway hyperresponsiveness
Albuterol HFA
Ventolin (beta 2 agonist)
Indications
Bronchospasm
Exercise induced bronchospasm (2 puffs 15 minutes before exercise)
(Nebules, Syrup, Inhal soln 0.5%)
Interactions:
Avoid MAOI, tricyclics within 14 days (increased cardiovascular effects)
Adverse:
Hypokalemia,
Tremor, nervousness, headache, dizziness, hyperactivity, insomnia, weakness, tachycardia
Bronchodilators Adverse effects
Inhaled:
(tachycardia, angina, tremors)
Oral:
Systemic exposure is much larger
adverse effects are more likely
Excessive dosage can lead to angina pectoris, tachydysrhythmia, tremor
Ipratropium Bromide
Atrovent 17mcg
(Anti-cholinergic / Anti-muscarinic)
Bronchospasm associated with chronic bronchitis and emphysema Asthma exacerbation (mod-severe)
Contra:
Allergy to atropine or its derivatives
Warning:
Narrow angle glaucoma
Interactions:
Other anti-cholinergics
Adverse:
Anti-cholinergic effects
Ipratropium Bromide 20mcg
+
Albuterol 100mcg
Combivent
Contraindications:
Atropine allergy
Extreme caution within 2 weeks of MAOI’s or tricyclics (increased cardiovascular effect)
Muscarinic antagonist MOA
Ipratropium
Tiotropium (longer acting)
Given by aerosol
Competitively blocks muscarinic receptors in the airways and effectively prevent the bronchoconstriction caused by vagal discharge. it has no effect on the inflammatory aspect of asthma
MDI vs DPI
MDI
Metered Dose inhaler
Advantages -Non breath activated
Disadvantages - Patient coordination
DPI
Dry Powder Inhaler
Advantages - Breath activated, propellent not required
Inhaled corticoid steroids
Mometasone Fluticasone Flunisolide Ciclesonide Budesonide
LABA Adverse / Contras
Formoterol, Salmeterol
For: Bronchospasm
Adverse:
HA, pain, HTN, Dizzy, Nasal/throat irritation
Interactions
Alpha blocker, azoles, BB, Clarithromycin, Loops, MAOI’s, TCA’s, Quinidine, Nelfinavir/ritonavir
Precautions:
CVD, DM, COPD, Thyroid, glaucoma, seizure, hypokalemia, pregnancy, lactation,
Contra:
Acute asthma attack
LABA Medications
Pure LABA’s
Salmeterol
Formoterol
LABA’s
Indacaterol
Oldaterol
Vilanterol
Salmeterol
Adjunct to inhaled corticosteroids for the treatment of asthma in prevention of bronchospasm in reversible airway obstruction disease
Not for acute relief of bronchospasm
Contra:
***Treatment of asthma without use of inhaled corticosteroids
Primary treatment of status asthmaticus
Acute asthma, COPD
Warning
***Asthma related death
Using LABA alone to treat asthma:
When using LABA alone to treat asthma without inhaled corticosteroids can lead to lung inflammation and an increased risk of asthma related death.
LABA + ICS Meds
Advair
Fluticasone + Salmeterol
Airduo
Fluticasone + Salmeterol
Breo Ellipta
Fluticasone + vilanterol
Dulera
Mometasone + formoterol
Symbicort
Budesonide + Formoterol
LTRA
Leukotriene receptor antagonist
Montelukast
Zileuton
Anti-leukotriene agents inhibit the action of leukotrienes by blocking the CysLT1 receptor or by interrupting production by 5-lipoxygenase
LTRA
Leukotriene receptor antagonist
Anti-leukotriene agents inhibit the action of leukotrienes by blocking the CysLT1 receptor
What meds?
Montelukast
Zafirlukast
Pranlukast
MZP
Generally well tolerated
Be aware of possible psych , behavior, neurogenic issues
LTRA
Leukotriene receptor antagonist
by interrupting production by 5-lipoxygenase
Zileutron
Generally has more adverse effects than the others
Montelukast
Singulair (leukotriene receptor antagonist)
> 15 years old : One 10mg tablet
For seasonal allergic rhinitis. Reserve use for those who have an adequate response or intolerance to alternate therapies
Warning:
Serious neuropsychiatric events
Adverse:
URI, Fever, HA, Pharyngitis, cough, abdominal pain, diarrhea, otitis media, influenza, rhinorrhea, sinusitis
Zileuton
Zyflo (5-lipooxygenase inhibitor)
Prophylaxis and chronic treatment of asthma
Not recommended for Children
Contra:
Active liver disease, ALT elevated 3x normal limit
Warnings:
Not for primary treatment of acute attacks
Monitor liver function
History of liver disease, Monitor liver function 1st 3 months, every 2-3 months for remainder of the year
Alcohol consumption, neuropsych events
Interactions Potentiates theophylline (reduce dose of theophylline)
Acute bronchiolitis
is broadly defined as a clinical syndrome of respiratory distress that occurs in children <2 years of age and is characterized by upper respiratory symptoms leading to lower respiratory infection with inflammation, which results in wheezing and or crackles. It typically occurs with primary infection or reinfection with a viral pathogen.
Acute bronchiolitis
management of severe bronchiolitis
Supportive care
(hydration, O2, Resp support)
and anticipatory guidance are the mainstays of management of severe bronchiolitis
Acute bronchiolitis
Children with first episode of bronchiolitis
Don’t administer inhaled bronchodilators
(albuterol, Epi) to infants and children with first episode of bronchiolitis.
Children with RSV bronchiolitis
Treated the same as children with bronchiolitis caused by other pathogens
Supportive care is mainstay
Pharmacotherapy is not routinely recommended
Adults and Older Children with RSV bronchiolitis
Glucocorticoids and bronchodilators may be beneficial
Interventions that have shown a reduced rate of progression and decreased mortality in observational studies include
Single agent combination therapy with ribavirin
intravenous immune globulin
palivizumab
and/or glucocorticoids
Ribavirin
Virazole (Nucleoside analogue)
indications
Sever lower respiratory infections due to RSV in hospitalized infants and young children
Children;
Treat within first 3 days of infection
Contra:
Pregnancy Cat X
palivizumab
Synagis
Class:
Antiviral monoclonal antibody (IgG1K)
Acute epiglottitis
Describes inflammation of the epiglottitis and adjacent supraglottic structures
Airway is first priority
Sniffing, tripod posture
Swelling is generally improved after 2-3 days after ABX when caused by H. Flu
Acute epiglottitis Tx
Combination of
3rd gen ceph
and anti-staph agent (vanc)
Ceph and vanc
Croup (mild)
Single dose Dexamethasone or prednisolone
Children with moderate croup
Stridor at rest with mild to moderate retractions should be evaluated in the office or the ED
Tx: Nebulized Epi
and
Single dose of dexamethasone
0.6mg/kg (max 16mg) least invasive route
Children with severe croup
Stridor at rest with marked retractions and significant distress or agitation should be seen in the ED
Approach these children cautiously as anxiety may increase and worsen the airway obstruction
Tx: Nebulized Epi
and
Single dose of dexamethasone
0.6mg/kg (max 16mg) least invasive route
Why dexamethasone for moderate to severe croup
Most extensively studied inexpensive easy to administer longer duration of action compared with other agents 0.6mg/kg (max 16mg) least invasive route
Hospital management of croup
Supportive care IV fluids, Fever reduction Repeated doses of nebulized EPI Humidified O2 (no repeated dosages of steroids) Monitor for worsening respiratory distress
Pertussis in infants and children
Supportive care is mainstay
Pay attention to fluid and nutritional status
Avoid known triggers for paroxysmal coughing fits
(Exercise, cold, nasopharyngeal suctioning)
Symptomatic treatments with Bronchodilators, corticosteroids, antihistamines, antitussives haven’t been proven to improve cough in pertussis
Pertussis in infants and children
Treatment
Macrolides (Azithromycin, erythromycin)
Bactrim may be used as alternative
For incompletely immunized children with well documented pertussis infection:
Treatment
Complete immunization with an acellular pertussis containing vaccine
DTAP or TDAP vaccine rather than just diphtheria toxoid/tetanus toxoid vaccine
Children may return to school after they have completed 5 days of ABX or if untreated, 21 days after symptoms begin
Pertussis in adults
Azithromycin or clarithromycin
Bactrim is alternative
TDaP is recommended at age11-12
Patients with B. Pertussis infections:
Should avoid contact with young children and infants until they have completed at least 5 days of ABX.
Should not return to work/school etc until after 5 days of ABX
Pertussis prevention
Tetanus and diphtheria toxoids and acellular pertussis (TDaP) vaccination
Routine vaccination:
Previously did not receive Tdap at or after age 11:
1 dose Tdap, then Td or Tdap every 10 years
Cystic fibrosis
For patients under 6 there is no evidence of best treatment
Therapies focus on:
Clearance of airway secretions Reversal of bronchoconstriction Treatment of respiratory infections Replacement of pancreatic enzymes Nutritional and psychosocial support
Cystic fibrosis for under 6 years old
For patients under 6 there is no evidence of best treatment
Therapies focus on:
Clearance of airway secretions Reversal of bronchoconstriction Treatment of respiratory infections Replacement of pancreatic enzymes Nutritional and psychosocial support
Cystic fibrosis managment
CFTR modulators - depends on age and genotype
Airway clearance therapies - inhaled Dnase, inhaled hypertonic saline, chest physiotherapy
Prevention/management of infections - vaccinations, infection control
Bronchodilators - inhaled beta 2 adrenergic receptor agonist
Anti-inflammatory therapy - azithromycin, ibuprofen, inhaled glucocorticoids
Prevention of acute exacerbations - routine surveillance of sputum cultures or throat swabs
CFTR
Cystic fibrosis transmembrane conductance regulator
All patients with CF should undergo CFTR genotyping to determine if they carry one of the variants approved for CFTR modulator therapy
Selection depends on variant and child’s age
Elexacaftor, Tezacaftor, Ivacaftor
Trikafta
Indications
Tx of CF in patients 12 and older who have at least one “F508del” mutation in the CFTR gene
Foreign body aspiration in children
FB aspiration should be suspected in children who have sudden onset of lower respiratory symptoms,
or those who do not respond to standard management of other suspected etiologies such as pneumonia, asthma, or croup
Highest risk is children ages 1-3
Hyaline membrane disease
Now known as
Respiratory distress syndrome (RDS)
It is caused by surfactant deficiency that leads to alveolar collapse and diffuse atelectasis
Tx:
Synchronized intermittent mandatory ventilation
Administration of exogenous surfactants can be used in the delivery room as prophylaxis or as rescue
poractant alfa
Curosurf (lung surfactant)
indications
Treatment (rescue) of respiratory distress syndrome (RDS) in premature infants
Childhood asthma
Treatment for acute exacerbation
Treatment for acute exacerbation
Goal: relieve the bronchoconstriction
SABA - albuterol, levobuterol
SAMA - Ipratropium Bromide
Systemic glucocorticoids - Prednisone, prednisolone
Childhood Asthma
Treatment for asthma management
Treatment for asthma management
Patient education - Optimizing control of asthma symptoms and prevention
Control of asthma triggers
Monitoring for changes in symptoms or lung function
Pharmacological therapy
Childhood asthma
Treatment of asthma - control and prevention
Treatment of asthma - control and prevention
inhaled glucocorticoids - Budesonide, fluticasone propionate, Beclomethasone
Leukotriene modifiers - Montelukast
Long acting beta agonist bronchodilator and inhaled steroid combo
Carcinoid tumors
Carcinoid syndrome is relatively uncommon
But it can appear in both parents with locoregional or disseminated disease.
Surgical resection represents the preferred strategy for patients with locoregional lung NET’s producing carcinoid syndrome.
For unresectable disease, we recommend initiation of long acting somatostatin analog (SSA) therapy with octreotide
Carcinoid syndrome symptoms
Skin flushing Hives NVD Cramps Bronchoconstriction Cough, wheezing, Dyspnea Hepatomegaly Pelvic fibrosis Cardiac valve lesions
Carcinoid tumors with progressive or disseminated disease that is SSA resistant (somatostatin analog)
Everolimus
Somatostatin analogs (SSA)
Injections of SSA’a can be used to lessen symptoms of carcinoid syndrome including diarrhea and flushing
Octreotide (Sandostatin Depot)
can be long or short acting
They help block serotonin which helps with diarrhea and flushing
Octreotide
Sandostatin (SSA)
Warnings:
DM, Hypothyroidism, CVD
Adverse:
Gallbladder abnormalities, GI Upset, Bradycardia, conduction abnormalities, arrhythmias, hyperglycemia, hypoglycemia, hypothyroidism
Everolimus
Afinitor (mTOR Kinase inhibitor)
Indications:
In adults with progressive neuroendocrine tumors of pancreatic origin (PNET)
or
progressive, well differentiated, non functional endocrine Tumors (NET) of GI or lung origin with unresectable locally advanced or metastatic disease
Not for treating functional carcinoid tumors
Contraindications
Allergy to other rapamycin derivatives
Adverse:
Stomatitis, infections, rash, fatigue, diarrhea, edema
telotristat
Xermelo (tryptophan hydroxylase inhibitor)
Indications:
In combination with somatostatin analog therapy
to treat carcinoid syndrome diarrhea in adults inadequately controlled by SSA therapy
Adverse:
Nausea, HA, Increased GGT, Depression, flatulence, decreased appetite
Recently approved in the US for Diarrhea from carcinoid syndrome
It targets overproduction of serotonin within neuroendocrine tumor cells and is taken in combo with a somatostatin analog when the SSA alone is not effective.
Most common types of lung cancer
Most common
Non small cell lung cancer = 85% (NSCL)
Subtype of NSCL
Most common
Adenocarcinoma 40%
NSCLC
Non Small Cell lung Cancer
Medication
Pembrolizumab monotherapy
Patients with NSCLC
Non Small Cell lung Cancer
Initial management is largely determined by the stage of disease
Early stages: surgical resection
If extensive intrathoracic disease use concurrent chemoradiation
Patients with advanced disease are managed palliatively with systemic therapy or local palliative modalities
Patients with SCLC
Small cell lung cancer
Systemic Chemo
because SCLC is spread throughout body
For those with limited stage disease, thoracic radiation in combo with chemo is best
Prophylactic cranial irradiation is often used to decrease brain metastases and prolong survival
Both may be beneficial in those with a complete or partial response to initial systemic chemo
pembrolizumab
Keytruda (human programmed death receptor (PD-1) blocking antibody)
Indications
First line single agent for stage 3 NSCLC for those who are not eligible for surgery or chemo
Adverse:
Fatigue, MSK pain, decreased appetite, pruritus, diarrhea, nausea
Elimination:
Half life 22 days
Cisplatin
Platinum coordination complex
Warning:
Nephrotoxicity, peripheral neuropathy, NV, myelosuppression
Adverse:
Nephrotoxicity, peripheral neuropathy, NV, myelosuppression, ototoxicity
Cisplatin MOA
Cytotoxicity results from selective inhibition of tumor DNA synthesis by formation of intra and interstrand crosslinks in the DNA molecule
etoposide
Topoisomerase inhibitor
Adverse:
GI, mucositis, myelosuppression (neutropenia and thrombocytopenia may be fatal)
Sphere of lung cancer complications
SPHERE S - Superior vena cava syndrome P - pancoast tumor H - Horner syndrome E - Pleural effusion R - Recurrent laryngeal symptoms (hoarseness) E - Endocrine
Horner syndrome
SAMPLE S - Sympathetic nerve fiber injury A - Anhidrosis M - Miosis P - Ptosis L - Loss of ciliospinal reflex E - Enopthalmos
Etiologies of Pulmonary nodules
Benign = Infectious granuloma
mycobacteria, coccidiomycosis, histoplasmosis, TB
Malignant = adenocarcinoma
Paraneoplastic syndrome
Small cell carcinoma
SIADH → Hyponatremia
Increased ACTH → Cushings syndrome
Carcinoid → Flushing & diarrhea
Eaton lambert syndrome
SVC syndrome
Paraneoplastic syndrome
Squamous cell carcinoma
PTHrp → Hypercalcemia
Horner syndrome → Ptosis, miosis, anhidrosis
Pancoast tumor → 1st, 2nd, thoracic nerve → Shoulder pain → Ulnar nerve pain
Paraneoplastic syndrome SIADH
SCLC accounts for 75% of all malignancy related to SIADH
Lambert Eaton Myasthenic Syndrome (LEMS)
50% are Autoimmune disorder
diagnosed after age 40
can occur in children under age 10
50% also associated with small cell lung cancer
Diagnosed after age 50
Neurotransmitter associated with LEMS
ACH
Treatment for LEMS in patients with weakness
Amifampridine
amifampridine
Firdapse (potassium channel blocker)
Indication:
LEMS
Contra:
History of seizures
amifampridine (Firdapse) MOA
Potassium channel blocker
Blocks potassium channels allowing calcium channels to stay open longer
this increases ACH release
Increased ACH binding to muscle ACH receptors restores lost muscle strength
Paraneoplastic syndrome
Hematologic
Anemia Leukocytosis Thrombocytosis Eosinophilia Hypercoagulable disorders
ARDS
Typical regime
Methylprednisolone 1mg/kg for 21-28 days
or
Dexamethasone 20mg IV QD for 5 days
followed by 10mg QD for 5 days
Which antibiotic is given for patients with CF and positive for Pseudomonas aeruginosa?
penicillin levofloxacin azithromycin vancomycin metronidazole
azithromycin
Which of the following medications is a SABA?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
albuterol (Ventolin)**
Which of the following medications is a LABA?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
salmeterol (Serevent)**
Which of the following medications is a IgE antagonist?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
omalizumab (Xolair)**
Which of the following medications is a LTRA?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
montelukast (Singulair)**
Which of the following medications is a SAMA?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
ipratropium bromide (Atrovent)**
Which antibiotics is usually the mainstay of therapy for patients with acute epiglottitis?
Ceftriaxone plus azithromycin Ceftriaxone plus clarithromycin Ceftriaxone plus metronidazole Ceftriaxone plus vancomycin Ceftriaxone plus amoxicillin
Ceftriaxone plus vancomycin
What is the usual first-line agent (no allergies) for patients with pertussis?
Azithromycin metronidazole TMP-SMX vancomycin amoxicillin
Azithromycin**
What is the usual alternative agent for patients with pertussis?
azithromycin metronidazole TMP-SMX vancomycin amoxicillin
TMP-SMX
Which of the following medications has anticholinergic adverse effects?
albuterol (Ventolin) ipratropium bromide (Atrovent) salmeterol (Serevent) montelukast (Singulair) omalizumab (Xolair)
ipratropium bromide (Atrovent)**
Which medication blocks the production of hormones such asserotonin, reducing theflushingand diarrhea associated with carcinoid syndrome?
octreotide (Sandostatin)
everolimus (Afinitor)
telotristat ethyl (Xermelo)
pembrolizumab (Keytruda)
octreotide (Sandostatin)
Which medication is a mTor inhibitor?
octreotide (Sandostatin)
everolimus (Afinitor)
telotristat ethyl (Xermelo)
pembrolizumab (Keytruda)
everolimus (Afinitor)
Which medication was recently approved in the U.S. for the treatment of diarrhea caused by carcinoid syndrome?
octreotide (Sandostatin)
everolimus (Afinitor)
telotristat ethyl (Xermelo)
pembrolizumab (Keytruda
telotristat ethyl (Xermelo)
Which medication shows good promise as a first-line treatment of Stage III non-small cell lung cancer (NSCLC) in patients who are not candidates for surgical resection or definitive chemoradiation, or metastatic NSCLC?
octreotide (Sandostatin)
everolimus (Afinitor)
telotristat ethyl (Xermelo)
pembrolizumab (Keytruda)
pembrolizumab (Keytruda)
Which is not considered a feature of Horner’s syndrome?
Mydriasis
Anhidrosis
Enophthalmos
Ptosis
Mydriasis
Which medication is considered a human programmed death receptor-1 (PD-1)-blocking antibody?
octreotide (Sandostatin)
everolimus (Afinitor)
telotristat ethyl (Xermelo)
pembrolizumab (Keytruda)
pembrolizumab (Keytruda)
Which of the following does not belong in the lung cancer complications mnemonic “Sphere?”
Pancoast tumor
Horner Syndrome
Spherocytosis
Pleural effusion
Spherocytosis
Which of the below is a contraindication for the medication, amifampridine (Firdapse)?
History of MI
History of liver failure
History of seizures
History of atrial fibrillation
History of seizures
Which neurotransmitter is most associated with the medication, amifampridine (Firdapse)?
Dopamine
Norepinephrine
Serotonin
Acetylcholine
Acetylcholine
Which below drug is usually the mainstay drug for acute respiratory distress syndrome?
ASA
Clopidogrel (Plavix)
Enoxaparin (Lovenox)
methylprednisolone
methylprednisolone
Immunomodulators
For patients whose asthma is inadequately controlled on high-dose inhaled glucocorticoids and LABAs, the anti-IgE therapyomalizumab(Xolair)may be considered if there is objective evidence of sensitivity to a perennial allergen (by allergy skin tests or in vitro measurements of allergen-specific IgE) and if the serum IgE level is within the established target range.
Omalizumab
Not for relief of acute bronchospasm or status asthmaticus. Not indicated for treatment of other allergic conditions.
Boxed Warning:
Anaphylaxis.
Antiasthmatic (IgE blocker).
