pharmacology test 3 Flashcards
drugs that mimic the effects of SNS neurotransmitters
Norepinephrine (NE), Epinephrine (EPI), Dopamine
Alpha1-adrenergic receptors
Located on postsynaptic effector cells (the cell, muscle, or organ that the nerve stimulates)
Alpha2-adrenergic receptors
Located on presynaptic nerve terminals (the nerve that stimulates the effector cells)
Control the release of neurotransmitters
Alpha-Adrenergic Agonist Responses
vasoconstriction and CNS stimulation
Beta1-adrenergic receptors
located primarily in the heart
Beta2-adrenergic receptors
located in smooth muscle of the bronchioles, arterioles, and visceral organs
Catecholamines
produces a sympathetic response
Endogenous: epinephrine, norepinephrine, dopamine
Synthetic: dobutamine, phenylephrine
Catecholamines are metabolized by
Monoamine oxidase (MAO) - wow you know like MAOI’s
Catechol ortho-methyltransferase (COMT)
Adrenergic Drugs Effect
Vasoconstriction of blood vessels, relaxation of GI smooth muscles (decreased motility), constriction of bladder sphincter, contraction of uterus, male ejaculation, contraction of pupillary muscles of the eye (dilated pupils)
Increased force of contraction (positive inotropic effect)
Increased heart rate (positive chronotropic effect)
Increased conduction through AV node (positive dromotropic effect)
Adrenergic Indications: Respiratory
Bronchodilators: drugs that stimulate beta2-adrenergic receptors of bronchial smooth muscles, causing relaxation, resulting in bronchodilation
Examples: albuterol, ephedrine, epinephrine, formoterol, levalbuterol, metaproterenol, pirbuterol, and salmeterol
Adrenergic Indications: Nasal Congestion
Intranasal (topical) application causes constriction of dilated arterioles and reduction of nasal blood flow, thus decreasing congestion.
Examples: ephedrine, naphazoline, oxymetazoline, phenylephrine, and tetrahydrozoline
Adrenergic Indications: Ophthalmic
Temporary relief of conjunctival congestion (eyes)
Alpha-adrenergic receptors
Examples: epinephrine, naphazoline, phenylephrine, tetrahydrozoline
Reduction of intraocular pressure and dilation of pupils: treatment of open-angle glaucoma
Alpha-adrenergic receptors
Examples: epinephrine and dipivefrin
Adrenergic Indications: Overactive Bladder
Relaxes the detrusor muscle during the storage phase of the bladder fill cycle
Increases bladder storage capacity
mirabegron (Myrbetriq)
Cardiovascular Indications Vasoactive Adrenergics (Pressors, Inotropes)
Also called cardioselective sympathomimetics
Used to support the heart during cardiac failure or shock; various alpha and beta receptors affected
Vasoactive Sympathomimetics (Pressors, Inotropes): Examples
Dobutamine, ephedrine, fenoldopam, midodrine
Dopamine, epinephrine, phenylephrine, norepinephrine
Contraindications for Pressors
known allergy and severe hypertension
Adverse Effects of Alpha-adrenergic Drugs
Headache, restlessness, excitement, insomnia, euphoria
Chest pain, vasoconstriction, reflexive bradycardia, palpitations, dysrhythmias
Anorexia, dry mouth, nausea, vomiting, taste changes
Adverse Effects of Beta-Adrenergic Drugs
Mild tremors, headache, nervousness, dizziness
Increased heart rate, palpitations, fluctuations of blood pressure
Sweating, nausea, vomiting, muscle cramps
Adrenergic Drugs Overdose and Toxicity
From excessive CNS stimulation: seizures
Intracranial bleeding due to extreme elevation of blood pressure
Effective treatment: rapid acting sympatholytic drug. They have short half-lives, thus effects are short-lived
Symptom management and support the respiratory and cardiac systems
Adrenergic Drugs Interactions
Adrenergic antagonists
Anesthetic drugs
MAOIs
Antihistamines
Thyroid preparations
usually has a decreased effect of the meds
Dobutamine
similar to dopamine
Stimulates beta1 receptors on heart muscle (myocardium); increases cardiac output by increasing contractility (positive inotropy), which increases the stroke volume, especially in patients with heart failure.
Intravenous drug; given by continuous infusion
Short term treatment of heart failure. Beta1 selective vasoactive drug. Similar to dopamine but this is synthetic. Can give the patient chest pain, if the patient already has a heart problem it will make it worse.
Dopamine
Naturally occurring catecholamine neurotransmitter
Potent dopaminergic as well as beta1- and alpha1-adrenergic receptor activity
Low dosages: can dilate blood vessels in the brain, heart, kidneys, and mesentery, which increases blood flow to these areas (dopaminergic receptor activity)
Higher infusion rates: improve cardiac contractility and output (beta1-adrenergic receptor activity)
Highest doses: vasoconstriction (alpha1-adrenergic receptor activity)
preferred drug for patients in shock, IV on a titrated line
Epinephrine
Administered in emergency situations – epipen given subQ
One of the primary vasoactive drugs used in many advanced cardiac life support protocols
Can be given to dead people when trying to pull a Frankenstein
“ACLS think epi” -we can give it as long as we need to, there is no stopping point
Norepinephrine (Levophed)
Causes vasoconstriction
Direct-stimulating beta-adrenergic effects on the heart (beta1-adrenergic receptors)
No stimulation to beta2-adrenergic receptors of the lung
Treatment of hypotension and shock
Administered by continuous infusion titrated drip
Phenylephrine (Neo-Synephrine)
Used primarily for short-term treatment to raise blood pressure in patients in shock
Control of supraventricular tachycardias
Vasoconstriction in regional anesthesia
Topical ophthalmic drug: nasal decongestant
Adrenergic Drugs Nursing Implications
logical things also:
lung disease: Encourage fluid intake (up to 3000 mL/day) if permitted.
2 adrenergic drugs together increase effects so watch out for tachycardia and hypertension
Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations.
using multiple adrenergic drugs can cause tachycardia and hypertension
adrenergic therapeutic effects: cardiac
Decreased edema
Increased urinary output
Return to normal vital signs
Improved skin color and temperature
Increased LOC
adrenergic therapeutic effects: respiratory
Return to normal respiratory rate
Improved breath sounds, fewer crackles
Increased air exchange
Decreased cough
Less dyspnea
Improved blood gases
Increased activity tolerance
Adrenergic Blockers
Adrenergic antagonists, sympatholytics
Alpha blockers, beta blockers, or alpha-beta blockers
Alpha 1 – heart
Beta 2 – lungs
Alpha blockers drug effects
Arterial and venous dilation (reduces blood pressure)
Prostate gland and bladder relaxes, decreasing urinary obstruction and BPH
Alpha blockers Indications
Hypertension (especially for those with pheochromocytoma), BPH, Raynaud’s disease, acrocyanosis, and frostbite
Alpha blockers adverse effects
Teach patients about how they’re likely to experience hypotension, orthostatic hypotension, and especially first dose hypotension
Palpitations, orthostatichypotension, tachycardia, edema, chest pain
Dizziness, headache, anxiety, depression, weakness, numbness, fatigue
Nausea, vomiting, diarrhea, constipation, abdominal pain
Incontinence, dry mouth, pharyngitis
Alpha blockers contraindications
Known allergies
Peripheral vascular disease
Hepatic/renal disease
Coronary artery disease
Peptic ulcer
Sepsis
Common Alpha Blockers
Phenoxybenzamine HCl (Dibenzyline)
Phentolamine (Generic)
Prazosin (Minipress)
Terazosin (Hytrin)
Alfuzosin (Uroxatral)
Tamsulosin (Flomax)
Doxazosin (Cardura)
Phentolamine (Regitine)
Alpha Blocker
for hypertension, to establish a diagnosis of pheochromocytoma, and if a vasoconstricting drug has been extraverted it can be used to reverse the effects
contraindicated in MI and coronary artery disease
Tamsulosin (Flomax)
for treatment of BPH and off-label for female patients with kidney stones
contraindicated in patients using drugs for limp dick disease such as sildenafil
causes severe hypotension in those cases
Adverse effects: headache, abnormal ejaculation, rhinitis, and others
Beta1 Receptors are located
primarily in the heart, they’re called cardioselective for this
Beta2 Receptors are located
Located primarily on smooth muscle of bronchioles and blood vessels
beta1 blockers (cardioselective) mechanism of action
Reduce SNS stimulation of the heart
Decrease heart rate
Prolong sinoatrial (SA) node recovery
Slow conduction rate through the AV node
Decrease myocardial contractility, thus reducing myocardial oxygen demand
nonselective beta blockers action
Nonselective beta blockers (beta1 and beta2)
Cause same effects on heart as cardioselective beta blockers
Constrict bronchioles, resulting in narrowing of airways and shortness of breath
Produce vasoconstriction of blood vessels
Other effects
Indications for Beta Blockers
angina, cardioprotective properties, dysrhythmias, migraine headache, hypertension, heart failure, glaucoma (topical)
beta blockers contraindications
Known drug allergy
Uncompensated heart failure
Cardiogenic shock
Heart block, bradycardia
Pregnancy
Severe pulmonary disease
Raynaud’s disease – makes it worse
beta blockers adverse effects
can be given for and cause heart failure
bradycardia, depression, constipation, impotence, fatigue
may interfere with normal signs of hypoglycemia
beta blockers overdose management
Symptomatic and supportive care
Atropine for bradycardia
Cardiac pacing
Vasopressors for severe hypotension
Hemodialysis to enhance elimination in severe overdoses
beta blocker interaction with antacids
decreased absorption, reduced beta blocker activity
beta blocker interaction with antimuscarinics
antagonism, reduced beta blocker effects
beta blocker interaction with digoxin, diuretics and neuromuscular blocking drugs
additive effects, increases bradycardia (dig), hypotension (diuretics), and prolonged neuromuscular blockade
beta blockers and diabetes mellitus
can mask the signs and symptoms of hypoglycemia
Atenolol (Tenormin)
cardioselective beta blocker - oral
Commonly used to prevent future heart attacks in patients who have had one
Hypertension and angina
Management of thyrotoxicosis to help block the symptoms of excessive thyroid activity
Carvedilol (Coreg)
Nonselective beta blocker, an alpha1-blocker, a calcium channel blocker, and possibly an antioxidant
Slows progression of heart failure and to decrease the frequency of hospitalization
Most commonly added to digoxin, furosemide, and angiotensin-converting enzyme inhibitors when used to treat heart failure
Esmolol (Brevibloc)
Very strong short-acting beta1-blocker - IV only
acute situations to provide rapid temporary control of the ventricular rate in patients with supraventricular tachydysrhythmias
Metoprolol (Lopressor)
beta1 blocker
Oral and injectable
Monitoring required when giving IV – must be on tele monitor
Has been shown to increase survival in patients who have had an MI
Propranolol (Inderal)
Prototypical nonselective beta1 and beta2-blocking drug
Tachydysrhythmias, subaortic stenosis, migraine headaches, essential tremor, hypertension, cardioprotective after MI
Oral and injectable form
Sotalol (Betapace)
Nonselective beta blocker - oral
Potent antidysrhythmic properties
Indicated for management of difficult-to-treat dysrhythmias
non selective beta blockers
Carvedilol (Coreg, Coreg CR)
Labetalol (Normodyne, Trandate)
Nadolol (Corgard)
Penbutolol (Levatol)
Pindolol (Visken)
Propranolol (Inderal)
Sotalol (Betapace)
Timolol (Blocadren, Timoptic)
cardioselective beta blockers
Acebutolol (Sectral)
Atenolol (Tenormin)
Betaxolol (Kerlone)
Esmolol (Brevibloc)
Nebivolol (Bystolic)
Metoprolol (Lopressor, Toprol-XL)
beta blockers nursing implications
Assess for allergies and history of COPD, hypotension, cardiac dysrhythmias, bradycardia, heart failure, and other cardiovascular problems.
Any pre-existing condition that might be exacerbated by the use of these drugs might be a contraindication to their use.
Adrenergic-Blocking Drugs: Nursing Implications
change positions slowly
avoid caffeine (excessive irritability)
avoid alcohol ingestion and hazardous activities until blood levels become stable
Instruct patients to notify their physicians if palpitations, dyspnea, nausea, or vomiting occurs.
adrenergic blocking drugs therapeutic effects
Decreased chest pain in patients with angina
Return to normal BP and heart rate
Other specific effects, depending on the use
beta blockers nursing implications
Rebound hypertension if meds stopped abruptly
call doctor if you’re too sick to take the meds
might be a decrease in activity tolerance (bitches get dizzy)
hot tubs and saunas may increase hypotension
call doc if
Weight gain of more than 2 lb in 1 day or 5 lb in 1 week
Edema of the feet or ankles
SOB, fatigue, weakness, syncope, dizziness
Pulse less than 60
Cholinergic Drugs Overview
aka cholinergic agonists or parasympathomimetics
mimick acetylcholine (ACh)
In the CNS functions as an inhibitory neurotransmitter affecting learning, memory, attention
In the peripheral nervous system functions as an excitatory neurotransmitter inducing muscle contraction
parasympathetic response
eyes: constricted pupil
lungs: constricts bronchioles and increase secretions
heart: decreased heart rate
blood vessels: dilate
GI: Increase peristalsis and digestion
mechanism of action: direct-acting cholinergic agonists
binds directly to cholinergic receptors
mechanism of action: indirect-acting cholinergic agonists
Inhibit the enzyme acetylcholinesterase, which breaks down ACh
Results in more ACh available at the receptors
indirect-acting cholinergic agonists reversible vs irreversible
Reversible: bind to cholinesterase for a short period of time
Irreversible: binds to cholinesterase for a long period of time
or binds to cholinesterase and form a permanent covalent bond. The body must make new cholinesterase to break these bonds.
indications for direct acting cholinergic agonists
Reduce intraocular pressure
Useful for glaucoma and intraocular surgery (Acetylcholine, Carbachol)
Pilocarpine – for glaucoma. Given topically.
Depress inner canthus to minimize general absorption
SLUDGE acronym
Cholinergic crisis symptoms:
Salivation
Lacrimation
Urinary incontinence
Diarrhea
Gastrointestinal cramps
Emesis
cholinergic crisis symptoms
Circulatory collapse, hypotension, bloody diarrhea, shock, and cardiac arrest. SLUDGE acronym
early signs: Abdominal cramps, salivation, flushing of the skin, nausea, and vomiting, transient syncope, transient complete heart block, dyspnea, and orthostatic hypotension
cholinergic crisis how to fix
early phase: atropine a cholinergic antagonist
severe cardiovascular reactions or bronchoconstriction: epinephrine an adrenergic agonist
most common precipitants of cholinergic crisis
Drug overdose
Certain poisonous mushrooms
Nerve Gas exposure (Sarin)
Organophosphate pesticide exposure
cholinergic drug interactions
wow surprise anticholinergics cancel it out. Also antihistamines, sympathomimetics
most other interactions have an additive effect
** Bethanechol (Urecholine) **
Uses: treatment of urinary retention - they should pee within an hour
direct acting
Contraindications: known drug allergy, hyperthyroidism, peptic ulcer, active bronchial asthma, cardiac disease or coronary artery disease, epilepsy, and parkinsonism
Adverse effects: syncope, hypotension with reflex tachycardia, headache, seizure, GI upset, and asthma attacks
Interactions: acetylcholinesterase inhibitors (i.e., indirect-acting cholinergics)
Donepezil (Aricept)
increases levels of ACh by inhibiting acetylcholinesterase
for: mild to moderate Alzheimer’s disease
Adverse effects: GI upset (including ulcer risk caused by increased gastric secretions), drowsiness, dizziness, insomnia, and muscle cramps. The effects on the cardiovascular system are complex and may include bradycardia, syncope, hypotension with reflex tachycardia, or hypertension.
Interacting drugs: anticholinergics (counteract donepezil effects) and nonsteroidal antiinflammatory drugs (NSAIDs)
Memantine (Namenda)
not a cholinergic drug
NMDA receptor agonist
Used for treatment of Alzheimer’s disease
Improves cognitive function and quality of life
Adverse effects: Hypotension, Headache, GI upset, Muscle pain, Fatigue, Ataxia
Pyridostigmine (Mestinon)
Indirect-acting cholinergic drugs that work to increase ACh by inhibiting acetylcholinesterase
Use: myasthenia gravis
Edrophonium (Tensilon)
indirect-acting cholinergic
used to diagnose myasthenia gravis
It can also be used to differentiate between myasthenia gravis and cholinergic crisis.
Neostigmine, Pyridostigmine, and Physostigmine
Uses: reversing the effects of nondepolarizing neuromuscular blocking drugs; treating severe overdoses of tricyclic antidepressants; and antidote after toxic exposure to nondrug anticholinergic agents, including those used in chemical warfare
Organophosphates Antidote
Pyridostigmine, and Physostigmine
Gingko
Common uses
Organic brain syndrome
Vertigo
Tinnitus
May cause GI upset, headache, bleeding, allergic skin reactions
Gingko Interactions
Aspirin – increased risk for bleeding
NSAIDs – increased risk for bleeding
Anticoagulants
Anticonvulsants
Others
Atropine - the Big Thing
the antidote for cholinergics, and it should be available for immediate use if needed
Patients should notify their physician if they experience muscle weakness, abdominal cramps, diarrhea, or difficulty breathing
Natural Anticholinergics
atropine, belladonna, hyoscyamine, scopolamine
synthetic/semisynthetic anticholinergics
benztropine (cogentin)
dicyclomine (bentyl/IBS)
homatropine (mydriatic)
scopolamine (↓secretions) - idk why its on both lists
ipratropium (atrovent)
oxybutynin (ditropan)
tolterodine (detrol)
** anticholinergic effects **
cardiovascular
Small doses: decrease heart rate
Large doses: increase heart rate
CNS
Small doses: decrease muscle rigidity and tremors
Large doses: drowsiness, disorientation, hallucinations
Atropine Indications
to increase heart rate
Diagnosis of sinus node dysfunction
Symptomatic second-degree heart block
Severe sinus bradycardia with hemodynamic compromise (advanced life support)
Pre-op: ↓ oral/GI secretions
Antidote to organophosphate toxicity
Antidote to atropine overdose is physostigmine
Antidote to Atropine
physostigmine
Anticholinergic Indications: respiratory
Blocking the cholinergic stimulation of the PSNS allows unopposed action of the SNS
Results: allergies, URI: ↓secretions from upper airway
(benedryl, vistaril, Phenergan)
COPD, Chronic Bronchitis, Asthma: Relax smooth muscles in bronchi and bronchioles
(Atrovent (ipratroprium) Spiriva (tiotropium): non-steroid controllers)
↓ airway resistance = ↑bronchodilation
Anticholinergics: GI
Oxybutynin (for overactive bladder, neurogenic bladder and incontinence. Contraindicated in glaucoma)
Tolterodine (overactive bladder)
Solifenacin, darifenacin, trospium (same, but less dry mouth)
adverse effects of anticholinergics
Cardiovascular: ↑heart rate, arrhythmias
CNS: irritability, delirium
Eye: mydriasis, blurry vision, ↑IOP
GI: ↓ motility
GU: urinary retention
Resp: ↓ secretions
anticholinergics nursing implications
avoid excess heat; refrain from ETOH, cigs
Assess for cardiac findings
I & O
monitor for confusion (atropine)
Oral hygiene
Blurry vision may affect driving
Therapeutic effects of anticholinergics
Parkinson’s disease: ↓tremors ,salivation, drooling
Urologic problems: improved urinary patterns, less hypermotility, increased time between voiding
Asthma: non-steroid controller, fewer acute events
URI: decreased secretions
Motion Sickness: decreased N & V - topalamine
Pre-op: ↓ secretions = ↓ aspiration
Muscarinic Cholinergic Drugs
stimulate smooth muscle; slow HR
Nicotinic Cholinergic Drugs
Act on skeletal muscle
Direct Cholinergic Drugs Are Used For
GI, Alzheimers
Indirect Cholinergic Drugs Are Used For
decrease IOP (glaucoma)
Anticholinergic Do What
Inhibit Ach by occupying receptor sites - slows things down
Systems affected:
Cardiac
Respiratory
GI & Bladder
Eyes
Cholinergic Agonists side effects
Caution in patient with low BP, bradycardia
Contraindicated in patient with poorly controlled or severe hypotension, bradycardia, asthma, GI/Urinary obstruction
Cholinergic Blockers side effects
Dry secretions: mouth, eyes, mucosa, sweat
Hyper or hypotension
Decrease urine output
Constipation
Cholinergic drugs nursing implications
take as prescribed. Noncompliance may have serious consequence
Assess for cardiac findings
Assess for GI/GU obstruction
Best given 1-2 hours before meal
Labs: amylase, lipase, AST, bili which may increase
anticholinergics memory aid
Can’t see can’t spit can’t sweat can’t shit
no glaucoma
adrenergic agonists drugs memory aid
fight or flight
adrenergic antagonist/blocker memory aid
feed, breed, pee, poo
cholinergics memory aid
SLUDGE:
salivation, lactation, urination, diarrhea, GI distress, emesis
“turn on” SNS
adrenergic agonist
“turn off” SNS
adrenergic blocker/antagonist
“turn on” PNS
cholinergic agonist, SLUDGE/wet
“turn off” PSN
anticholinergic, DRY
Hematopoietic Drugs Overview
promote the synthesis of major blood components by promoting the growth, or differentiation, and function of their precursor cells in the bone marrow
Hematopoietic drug indications
bone marrow destruction (from chemo)
low neutrophils
enhances the killing features of mature immune system cells
increases RBC and platelet production
helps patients tolerate higher doses of chemo
DO NOT GIVE IF HEMOGLOBIN IS OVER 10
Erythropoietic drugs
Epoetin alfa (Epogen, Procrit)
Darbepoetin alfa (Aransep)
Colony-stimulating factors (CSFs)
stimulates precursor cells
Filgrastim (Neupogen)
Pegfilgrastim (Neulasta)
Sargramostim (Leukine)
Platelet-promoting drugs
Oprelvekin (Neumega)
Romiplostim (Nplate)
Filgrastim (Neupogen)
granulocyte colony-stimulating factors (G-CSF)
Stimulates precursor cells for granulocytes (WBC - including basophils, eosinophils, and neutrophils)
Administered before patient develops infection
Filgrastim (Neupogen) and Pegfilgrastim (Neulasta)
granulocyte colony-stimulating factors (G-CSF)
Stimulates precursor cells for granulocytes (WBC - including basophils, eosinophils, and neutrophils)
Administered before patient develops infection - wait 24 hours after chemo
Pegfilgrastim is just a longer lasting version
Oprelvekin (Neumega)
platelet promoting - ALSO a interleukin
prevention of chemotherapy-induced severe thrombocytopenia - helps avoid platelet infusions
Stimulates megakaryocytes
Romiplostim
platelet promoter
Hematopoietic Drugs: adverse effects
Fever
Muscle aches
Bone pain
Flushing
Interferons
Proteins with three basic properties
Antiviral, Antitumor, Immunomodulating
Used to treat certain viral infections and cancer
Interferons Indications
Viral infections: genital warts, hepatitis
Cancers: Chronic myelogenous leukemia, follicular lymphoma, hairy-cell leukemia, Kaposi’s sarcoma, malignant melanoma
Autoimmune disorders: MS
Interferons Adverse Effects
Flulike effects
fever, chills, headache, myalgia
dose-limiting adverse effect is fatigue
anorexia, dizziness, nausea, vomiting, diarrhea
Monoclonal Antibodies
Treatment of cancer, rheumatoid arthritis (RA), MS, and organ transplantation
Specifically target cancer cells and have minimal effect on healthy cells
Fewer adverse effects than traditional antineoplastic medications
Monoclonal antibodies naming convention
end in -mab
Adalimumab
Alemtuzumab
Bevacizumab
Cetuximab
Golimumab
Ibritumomab tiuxetan
Infliximab
Natalizumab
Rituximab
Trastuzumab
monoclonal antibodies side effects and contraindications
very few contraindications,
side effects are flu like
Interleukins
Natural part of the immune system
Beneficial antitumor action
Capillary Leak Syndrome
Severe toxicity of aldesleukin therapy
Capillaries lose ability to retain vital colloids in the blood; these substances are “leaked” into the surrounding tissues.
Result: massive fluid retention, respiratory distress, heart failure, myocardial infarction, dysrhythmias, reversible after IL therapy is discontinued
Aldesleukin (Proleukin)
Interleukin.
can lead to capillary leak syndrome
Treatment of metastatic renal cell carcinoma and metastatic melanoma
Off-label uses include HIV infection and AIDS and non-Hodgkin’s lymphoma
Rheumatoid Arthritis
Autoimmune disorder causing inflammation and tissue damage in joints
Diagnosis primarily symptomatic
Treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and DMARDs.
Osteoarthritis
Another type of arthritis
Age-related degeneration of joint tissues
Pain and reduced function
Disease-Modifying Antirheumatic Drugs (DMARDs)
DMARDS
Modify the disease of RA
Exhibit antiinflammatory, antiarthritic, and immunomodulating effects
Inhibit the movement of various cells into an inflamed, damaged area, such as a joint
Slow onset of action of several weeks versus minutes to hours for NSAIDs
Also referred to as slow-acting antirheumatic drugs
-make sure patient is up to date on vaccinations and is not currently sick
Abatacept (Orencia)
DMARD
Used to treat RA
Caution if the patient has a history of recurrent infections or COPD
Patients must be up to date on immunizations before starting therapy
May increase risk of infections associated with live vaccines
May decrease response to vaccines
Etanercept (Enbrel)
Used to treat RA (including juvenile) and psoriasis
Patients must be screened for latex allergy (some dosage forms may contain latex).
Onset of action: 1 to 2 weeks
Contraindicated in presence of active infections
Reactivation of hepatitis and tuberculosis has been reported.
Leflunomide (Arava)
Treatment of active RA
Contraindicated in women who are or may become pregnant
Methotrexate
Anticancer drug commonly used to treat RA in much lower doses
Weekly dosing
Adverse effects: bone marrow suppression
Advise to take folic acid supplement to lessen likelihood of adverse effects
Takes 3 to 6 weeks for onset of antirheumatic action
DMARDs Nursing Implications
Assess for allergies, specifically allergies to egg proteins, IgG, or neomycin.
Assess for conditions that may be contraindications (TB, hep. etc)
Assess baseline blood counts; perform cardiac, renal, and liver studies.
Assess, monitor and teach to watch for presence of infection.
Follow specific guidelines for preparation and administration of drugs.
therapeutic responses for DMARDs
Decrease in growth of lesion or mass
Improved blood counts
Absence of infection, anemia, and hemorrhage
Status asthmaticus
Prolonged asthma attack that does not respond to typical drug therapy
May last several minutes to hours
Medical emergency
Bronchodilators
Beta-Adrenergic Agonists
Anticholinergics
Xanthine derivatives
Nonbronchodilating Respiratory Drugs
Leukotriene Receptor Antagonist
Corticosteroids
Beta-Adrenergic Agonists overview
Used during acute phase of asthmatic attacks
Quickly reduce airway constriction and restore normal airflow
Short-acting beta agonist (SABA) inhalers
Albuterol (Ventolin, ProAir)
*Levalbuterol (Xopenex)
Pirbuterol (Maxair)
Terbutaline (Brethine)
Metaproterenol (Alupent)
Long-acting beta agonist (LABA) inhalers
Arformoterol (Brovana)
Formoterol (Foradil, Perforomist)
Salmeterol (Serevent)
Beta-Adrenergic Agonists Indications
Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases
Used in treatment and prevention of acute attacks
Used in hypotension and shock
Beta-Adrenergic Agonists Contraindications
Known drug allergy
Uncontrolled HTN
High risk of stroke
Cardiac dysrhythmias
Epinephrine (alpha and beta) Adverse Reactions
Insomnia, restlessness, anorexia , vascular headache, hyperglycemia, tremor, cardiac stimulation
Metaproterenol (beta1 and beta 2) Adverse Reactions
Cardiac stimulation, tremor, anginal pain, vascular headache, hypotension
Albuterol (beta 2) Adverse Reactions
Hypotension or hypertension, vascular headache, tremor, anxiety/nervousness
Beta-Adrenergic Agonists Interactions
beta blockers don’t like beta agonists wow
Monoamine oxidase inhibitors (MAOI inhibitors)
Sympathomimetics
hyperglycemia can occur, monitor with diabetes
Albuterol (Proventil)
Short-acting beta2-specific bronchodilation beta agonist
Most commonly used drug in this class
Must not be used too frequently – patients will be less sensitive to it if used too much
Oral and inhalational use
Inhalational dosage forms include metered-dose inhalers (MDIs) as well as solutions for inhalation.
Salmeterol (Serevent)
Long-acting beta2 agonist bronchodilator
Never to be used for acute treatment
Used for the maintenance treatment of asthma and COPD and is with an inhaled corticosteroid
Salmeterol should never be given more than twice daily
Anticholinergics: Mechanism of Action
Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways, anticholinergics fuck up that plan
Result: bronchoconstriction is prevented, airways dilate
Indirectly cause airway relaxation and dilation
Anticholinergics: Adverse Effects
Dry mouth or throat, nasal congestion, heart palpitations, gastrointestinal (GI) distress, headache, coughing, anxiety
- Push oral care, fluids, hard candy
Ipratropium (Atrovent)
anticholinergic and bronchodilator
Available both as a liquid aerosol for inhalation and as a multidose inhaler
Usually dosed twice daily
Xanthine Derivatives
plant alkaloid related to caffeine
Increase levels of cAMP by stopping it from breaking down
Result: increased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow
increased force of contraction, heart rate, cardiac output. Has a diuretic effect.
Xanthine Derivatives: Adverse Effects
smoking enhances metabolism of the drug
Nausea, vomiting, anorexia, gastroesophageal reflux during sleep – careful with patients with a history of gastric ulcers
Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias – be careful with patients who have a cardiac history
Transient increased urination
Hyperglycemia
Theophylline
Xanthine derivative
Oral, rectal, injectable (as aminophylline), and topical dosage forms
Aminophylline: intravenous (IV) treatment of patients with status asthmaticus who have not responded to fast-acting beta agonists such as epinephrine
Therapeutic range for theophylline blood level is 5 to 20 mcg/mL
Leukotriene Receptor Antagonists (LTRAs)
Nonbronchodilating, great for allergy induced asthma
Montelukast (Singulair) – most common
Zafirlukast (Accolate)
Zileuton (Zyflo)
Leukotriene Receptor Antagonists Indications
Prophylaxis and long-term treatment and prevention of asthma in adults and children (1 year+)
Not meant for management of acute asthmatic attacks
Improvement with their use is typically seen in about 1 week
Keep taking even if you feel better
Leukotriene Receptor Antagonists Contraindications
Known drug allergy
Previous adverse drug reaction
Allergy to povidone, lactose, titanium dioxide, or cellulose derivatives is also important to note because these are inactive ingredients in these drugs.
Inhaled Corticosteroids
Beclomethasone dipropionate (Beclovent)
Budesonide (Pulmicort Turbuhaler)
Flunisolide (AeroBid)
Fluticasone (Flovent)
Triamcinolone acetonide (Azmacort)
Fluticasone/salmeterol (Advair)
Systemic Corticosteroids
Methylprednisolone
Prednisone
Corticosteroids: Indications
treatment of bronchospastic disorders to control the inflammatory response
Persistent asthma
generally used only to treat acute exacerbations or severe asthma
IV corticosteroids: acute exacerbation of asthma or other COPD
Corticosteroids: Contraindications
Drug allergy and hypersensitivity to glucocorticoids
Not to be sole therapy for acute asthma attacks
sputum tests positive for Candida organisms and systemic fungal infection
Corticosteroids: Adverse Effects
Inhaled
Pharyngeal irritation, coughing, dry mouth, oral fungal infections
Systemic
Susceptibility to infection, CNS effects, Osteroporosis
also moon face, nervousness, insomnia and psychosis
Monoclonal Antibody Antiasthmatic
Omalizumab (Xolair), mepolizumab (Nucala), reslizumab (Cinqair)
Selectively binds to the immunoglobulin E, which in turn limits the release of mediators of the allergic response
Given by injection
Respiratory Drugs Therapeutic Responses
Decreased dyspnea
Decreased wheezing, restlessness, and anxiety
Improved respiratory patterns with return to normal rate and quality
Improved activity tolerance
Decreased symptoms and increased ease of breathing
