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RRCCPA Pharmacotherapeutics > Pulm Case Wrap-Up (Jaynstein) (Midterm) > Flashcards

Pulm Case Wrap-Up (Jaynstein) (Midterm) Flashcards

1
Q

Medications used for symptom control in a URI?

A
  • Decongestants
  • Pain and fever relievers
  • Cough suppressants
  • Cough expectorants
  • Vitamins and supplements
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2
Q

Medications used for allergic rhinitis

A
  • Antihistamines
  • Intranasal corticosteroids
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3
Q

MOA for decongestants

A
  • Directly stimulate alpha-adrenergic receptors of the respiratory mucosa causing vasoconstriction which reduces mucosal swelling and improves ventilation
  • Directly stimulate beta-adrenergic receptors causing bronchial relaxation
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4
Q

S/E of decongestants

A
  • Vasoconstriction and tachycardia can result in angina
  • HTN
  • Worsening of CV disease
  • Increase in glycogenolysis and gluconeogenesis
  • CNS stimulation
    • Nervousness
    • Insomnia
    • Dizziness
    • Drowsiness
  • Urinary retention
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5
Q

Who should avoid taking decongestants

A
  • Pts with HTN
  • <6 YO
  • During first trimester of pregnancy
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6
Q

Examples of decongestant medications and their duration of action

A
  • Pseudoephedrine (Sudafed)
    • Duration 4-6 hours
    • 100% absorbed
  • Phenylephrine (Sudafed PE)
    • Duration 2-4 hours
    • 30% absorbed
    • Garbage medication that does not help most people
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7
Q

MOA cough suppressants/Antitussives

A
  • Act at one of two sites
    • Centrally on the medullary cough center
    • Locally at the site of irritation
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8
Q

WHich cough suppressants act Centrally on the medullary cough center

A
  • Dextromethorphan
  • Opiates
  • Benzonate (Tessalon)
    • Does not cause drowsiness
    • Many Pts report these do not help
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9
Q

Which cough suppressants act locally at the sight of irritation?

A
  • Lozenges
  • Viscous preparations
    • Such as viscous lidocaine
  • Menthol
  • Camphor
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10
Q

What is dextromethorphan?

A
  • A centrally acting D-isomer of codeine
    • Lower addiction profile
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11
Q

S/E of dextromethorphan

A
  • Serotonin syndrome
  • Nausea
  • Dizziness
  • Drowsiness
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12
Q

Is dextromethorphan safe in pregnancy?

A

Yes

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13
Q

Who should avoid taking dextromethorphan?

A
  • Pts on MAOIs
  • Caution in Pts taking SSRIs but not contraindicated
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14
Q

Describe codeine

A
  • Centrally acting
  • High abuse potential
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15
Q

S/E of codeine

A
  • CNS depression
  • Respiratory depression
  • Common allergen
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16
Q

Is codeine safe in pregnancy?

A
  • Use with caution in pregnancy
    • Category C
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17
Q

Benzonate (Tessalon) is?

A
  • Centrally acting
  • No addictive properties
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18
Q

S/E of Benzonate (Tessalon)

A
  • Headache
  • Dizziness
  • Rarely causes drowsiness
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19
Q

Is Benzonate (Tessalon) safe in pregnancy?

A

Caution advised no data on safety profile

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20
Q

MOA of expectorants (mucolytics)

A
  • Dissolve thick mucus
  • Enhance airway clearing
  • Promote cough
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21
Q

S/E of expectorants (mucolytics)

A
  • Nausea
  • Vomiting
  • Rash
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22
Q

Are expectorants (mucolytics) safe in pregnancy?

A

Yes

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23
Q

Common expectorants (mucolytics)

A
  • Mucinex
  • Guaifenesin (Robitussin)
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24
Q

Who should avoid taking expectorants (mucolytics)?

A
  • Children < 6 YO
  • Guaifenesin may exacerbate nephrolithiasis
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25
Q

Robitussin DM is a mix of which two medications?

A

Dextromethorphan and guaifenesin

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26
Q

Common vitamins and supplements used in the treatment of URIs. Do they work?

A
  • Vitamin C
    • Anecdotal evidence only
  • Echinacea
    • EBM reveals benefit
      • Appears most effective in Pts with compromised immune systems
  • Zinc
    • EBM shows contradictory evidence
    • S/E are common but not life-threatening
      • Nausea
      • Mouth irritation
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27
Q

Abx options for Mild to moderate bacterial sinusitis

A
  • Amoxicillin/clavulanate 875mg PO BID X 7 days
  • Doxycycline 100mg BID X 7 days
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28
Q

In cases of bacterial sinusitis where there is a concern for resistance of prior Abx failure which Abx may be used?

A
  • Amoxicillin/clavulanate 2000mg BID X 10-14 days
  • Levofloxacin 500mg QD X 5 days
  • Moxifloxacin 400mg QD X 10 days
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29
Q

In cases of severe bacterial sinusitis where the Pt is hospitalized which Abx may be used?

A
  • Ampicillin/Sulbactam 3gm IV QID
  • Levofloxacin 500mg IV QD
  • Ceftriaxone (Rocephin) 1gm IV BID
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30
Q

Why are macrolides (clarithromycin or azithromycin), trimethoprim-sulfamethoxazole, and second or third-generation cephalosporins NOT recommended for empiric therapy of bacterial sinusitis?

A

High rates of resistance of S. pneumoniae

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31
Q

Define well-controlled asthma

A
  • Symptoms: < / = 2 days/week
  • Nighttime awakenings: = 2x/month
  • Interference with normal activity: None
  • Short-acting beta2-agonist use for symptom control: = 2 days/week
  • FEV1 or peak flow: > 80% predicted/personal best
  • Exacerbations requiring oral systemic corticosteroids: 0-1/year
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32
Q

Recommended action for the treatment of well-controlled asthma?

A
  • Maintain current step
  • Regular follow-up at every 1-6 months to maintain control
  • Consider step down if well controlled for at least 3 months
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33
Q

Define not well-controlled asthma

A
  • Symptoms: > 2 days/week
  • Nighttime awakenings: 1-3x/week
  • Interference with normal activity: Some limitation
  • Short-acting beta2-agonist use for symptom control: > 2 days/week
  • FEV1 or peak flow: 60-80% predicted/personal best
  • Exacerbations requiring oral systemic corticosteroids: >/= 2/year
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34
Q

Define very poorly controlled asthma

A
  • Symptoms: Throughout the day
  • Nighttime awakenings: >/= 4x/week
  • Interference with normal activity: Extremely limited
  • Short-acting beta2-agonist use for symptom control: Several times per day
  • FEV1 or peak flow: > 60% predicted/personal best
  • Exacerbations requiring oral systemic corticosteroids: >/= 2/year
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35
Q

Recommended action for the treatment of well-controlled asthma

A
  • Maintain current step
  • Regular follow-up every 1-6 months to maintain control
  • Consider step down if well controlled for at least 3 months
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36
Q

Recommended action for the treatment of not well controlled asthma

A
  • Step up 1 step
  • Reevaluate in 2-6 weeks
  • For side effects consider alternative treatment options
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37
Q

Recommended action for the treatment of very poorly controlled asthma

A
  • Consider short course of oral systemic corticosteroids
  • Step up 1-2 steps
  • Reevaluate in 2 weeks
  • For side effects, consider alternative treatment options
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38
Q

In the stepwise approach to the treatment of asthma, how many steps are there?

A

6

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39
Q

What does step 1 in the treatment of asthma consist of?

A
  • Recommended for intermittent asthma
  • SABA PRN
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40
Q

What does step 2 in the treatment of asthma consist of?

A
  • Recommended starting point for persistent asthma
  • SABA PRN
  • Low-dose ICS

For all of these step questions I omitted the alternative treatment options

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41
Q

What does step 3 in the treatment of asthma consist of?

A
  • SABA PRN
  • Low-dose ICS + LABA
    • OR medium-dose ICS
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42
Q

What does step 4 in the treatment of asthma consist of?

A
  • SABA PRN
  • Medium-dose ICS + LABA
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43
Q

What does step 5 in the treatment of asthma consist of?

A
  • SABA PRN
  • High-dose ICS + LABA
  • And consider omalizumab for Pts with allergies
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44
Q

What does step 6 in the treatment of asthma consist of?

A
  • SABA PRN
  • High-dose ICS + LABA + oral corticosteroid
  • Consider omalizumab for Pts with allergies
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45
Q

Before stepping up the treatment of asthma what should you first check?

A
  • Adherence
  • Environmental control
  • Comorbid conditions
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46
Q

At what step in the treatment of asthma should you consult an asthma specialist?

A

When Pts require step 4 or higher

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47
Q

Typed of inhalation devices used in the treatment of asthma

A
  • Metered-Dose Inhalers (MDI)
  • Dry Powder Inhalers (DPI)
  • Nebulizers
  • HFA - Diskus
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48
Q

Classes of drugs used in the treatment of asthma

A
  • Inhaled Beta-2-Agonists
    • Short and long-actingLeuko
  • Inhaled Corticosteroids (ICS)
  • Leukotriene Modifiers
  • Mast Cell Stabilizers
  • Anticholinergics
  • Anti-IgE Antibodies
  • Theophylline
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49
Q

Describe the MOA, Onset, Peak, and Duration for inhaled Short-Acting Beta-2-agonists (SABA)

A
  • MOA: Beta-2 agonist
  • Onset: 5 minutes
  • Peak: 30-60 minutes
  • Duration: 4-6 hours
50
Q

S/E of inhaled Short-Acting Beta-2-agonists (SABA)

A
  • Tachycardia
  • QTc prolongation
  • Tremor
  • Anxiety
  • Hyperglycemia
  • Hypokalemia
  • Hypomagnesemia

The higher the does the more likely the S/E

51
Q

Are Long-Acting Beta-2-agonists (LABA) recommended as monotherapy for the treatment of asthma?

A
  • NO!!
    • Black box warning
      • LABA use was associated with an increased risk of asthma-related hospitalizations, intubation, and death.
        • The greatest risk was in children 4-11 YO
52
Q

If a LABA is required for the treatment of asthma what should it be used in combination with?

A
  • An ICS
    • Preferably in the same inhaler
53
Q

MOA for inhaled corticosteroids (ICS)

A
  • Inhibits inflammatory cytokines via the glucocorticoid receptor
54
Q

S/E of ICS

A
  • Oral candidiasis (Thrush)
  • Dysphonia
  • Reflex cough
  • Reflex bronchospasm
55
Q

Of all the medications used in the treatment of asthma which is the most effective for long-term control of symptoms?

A

ICS

56
Q

Common ICS medications

A
  • Qvar
  • Pulmicort
  • Flovent
57
Q

Updated asthma guidelines now recommend what?

A

PRN ICS at initial asthma Dx

58
Q

S/E of LABA+ICS combos

A
  • Tremor
  • Muscle cramps
  • Tachycardia
  • Other cardiac effects

These S/E are more likely if the LABA+ICS combo is used in higher-than-recommended doses

59
Q

Common LABA+ICS medications

A
  • Salmeterol/fluticasone (Advair)
  • Formoterol/budesonide (Symbicort)
  • Formoterol/mometasone (Dulera)
60
Q

Are leukotriene modifiers ever used as first-line treatment of asthma?

A

No

61
Q

MOA of leukotriene modifiers

A
  • Inhibits physiologic actions of LTD4 at the CysLTI receptor without any agonist activity
    • AKA block the actions of leukotrienes
      • Leukotrienes cause constriction and mucus production
62
Q

S/E of leukotriene modifiers

A
  • Abdominal pain
  • Nausea
  • JAundice
  • Itching
  • Lethargy
63
Q

When are leukotriene modifiers used?

A
  • Alternative to low-dose ICS when Pts are unable or unwilling to use an ICS
    • Less effective than ICS
  • Used as an alternative therapy instead of LABA for Pts not well controlled on an ICS alone
    • Less effective than LABA
64
Q

What medication is a leukotriene modifier?

A

Singular

65
Q

MOA of Mast Cell Stabilizers

A
  • Alters function of delayed Cl- channels and inhibits cell activation
    • Inhibition of cough
    • Inhibition of early response to antigens (mast cells)
    • Inhibition of late response to antigens (eosinophils)
66
Q

S/E of Mast Cell Stabilizers

A
  • Throat irritation
  • Cough
  • Dry mouth
  • Wheezing
  • Chest tightness
67
Q

Common Mast Cell Stabilizer medication

A

Cromolyn

68
Q

Failure of pharmacologic treatment in asthma can usually be attributed to?

A
  • Lack of adherence to prescribed medications
    • Most common cause of treatment failure
  • Continued exposure to tobacco smoke and other airborne pollutants, allergens, or irritants
    • Smoking and exposure to second-hand smoke can cause airway hyperresponsiveness and decrease the effectiveness of ICS
  • Some Pts with asthma may be concurrently be taking aspirin or other NSAIDs, or other medications that can cause asthma symptoms
    • Samter’s triad
  • Oral nonselective beta-adrenergic blockers, such as propranolol, timolol, etc, can precipitate bronchospasm in Pts with asthma and decrease the broncho-dilating effect of Beta-2agonists
69
Q

Oh shit, your Pt with asthma also suffers from migraines, what are some migraine prophylaxis options that will not interfere with their asthma medications?

A
  • Non-dihydropyridine CCB
    • Verapamil
  • Beta-1-selective Beta-blocker
    • Metoprolol
    • Atenolol
  • Anticonvulsant
    • Valproic acid
    • Topiramate
    • If Pt is on an OCP anticonvulsants can decrease their efficacy
  • TCA
    • Amitriptyline
    • Nortriptyline
70
Q

How can Pts who use ICS reduce the risk of developing thrush?

A
  • Rinse mouth after using ICS
  • Use a spacer
71
Q

Will thrush related to ICS use go away without treatment?

A

No, it must be treated

72
Q

Recommended treatment for oral thrush associated with ICS use

A

Nystatin 5 mL whish and swallow QID X 7-14 days

73
Q

Define COPD

A

A preventable and treatable disease state characterized by airflow obstruction that is not fully reversible

74
Q

Primary cause of COPD

A

Cigarette smoking

75
Q

The airflow obstruction in COPD is defined as?

A
  • FEV1 < 80% predicted and FEV1/FVC < 0.7
76
Q

Using the GOLD criteria define mild COPD

A
  • In Pts with FEV1/FVC < 0.70
  • GOLD1
    • FEV1 > 80% predicted
77
Q

Using the GOLD criteria define moderate COPD

A
  • In Pts with FEV1/FVC < 0.70
  • GOLD2
    • 50% < FEV1 < 80% predicted
78
Q

Using the GOLD criteria define severe COPD

A
  • In Pts with FEV1/FVC < 0.70
  • GOLD3
    • 30% < FEV1 < 50% predicted
79
Q

Using the GOLD criteria define very severe COPD

A
  • In Pts with FEV1/FVC < 0.70
  • GOLD4
    • FEV1 < 30% predicted
80
Q

There are 4 stages of COPD for all stages what is the recommended treatment?

A
  • Avoidance of risk factors
  • Influenza/Pneumococcal vaccination
81
Q

There are 4 stages of COPD for stage I what are the characteristics and the recommended treatment?

A
  • Characteristics
    • FEV1/FVC < 70%
    • FEV1 > 80% predicted
    • With or without symptoms
  • Recommended treatment
    • Short-acting bronchodilator PRN
82
Q

There are 4 stages of COPD for stage II what are the characteristics and the recommended treatment?

A
  • Characteristics
    • FEV1/FVC < 70%
    • 50% < FEV1 < 80% predicted
    • DOE
    • With or without cough and sputum production
  • Recommended treatment
    • Short-acting bronchodilator PRN
    • Regular treatment with one or more long-acting bronchodilators
    • Rehabilitation
83
Q

There are 4 stages of COPD for stage III what are the characteristics and the recommended treatment?

A
  • Characteristics
    • FEV1/FVC < 70%
    • 30% < FEV1 < 50% predicted
    • Increased dyspnea
    • Reduced exercise capacity
    • Fatigue
    • Repeated exacerbations
  • Recommended treatment
    • Short-acting bronchodilator PRN
    • Regular treatment with one or more long-acting bronchodilators
    • Rehabilitation
    • Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations
84
Q

There are 4 stages of COPD for stage IV what are the characteristics and the recommended treatment?

A
  • Characteristics
    • FEV1/FVC < 70%
    • FEV1 < 30% predicted OR < 50% plus respiratory failure
  • Recommended treatment
    • Short-acting bronchodilator PRN
    • Regular treatment with one or more long-acting bronchodilators
    • Rehabilitation
    • Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations
    • Treatment of complications
    • Long-term O2 therapy if chronic failure
    • Consider surgical treatment
85
Q

Using the ABCD classification of COPD what does A indicate and what are the recommended treatments?

A
  • A
    • Low risk
    • Less symptoms
  • Treatment
    • SABA or SAMA

For these I’m omitting the alternative treatments, they can be found in the power point.

86
Q

Using the ABCD classification of COPD what does B indicate and what are the recommended treatments?

A
  • B
    • Low risk
    • More symptoms
  • Treatment
    • LABA or LAMA
87
Q

Using the ABCD classification of COPD what does C indicate and what are the recommended treatments?

A
  • C
    • High risk
    • Less symptoms
  • Treatment
    • ICS + LABA or LAMA
88
Q

Using the ABCD classification of COPD what does D indicate and what are the recommended treatments?

A
  • D
    • High risk
    • More symptoms
  • Treatment
    • ICS + LABA plus/or LAMA
89
Q

Goals of treatment for COPD

A
  • Reduce symptoms
  • Control dyspnea
  • Improve exercise tolerance and quality of life
  • Decrease complications of the disease such as acute exacerbations
90
Q

Which COPD Pts get a SABA?

A
  • All of them
91
Q

A SABA can be combined with what to have an additive effect?

A
  • Ipratropium
    • The combination of ipratropium/albuterol has been found to be more effective than either drug alone and is available in a single inhaler; Combivent
92
Q

For Pts with evidence of significant airflow obstruction and chronic symptoms of COPD, regular treatment with what is recommended?

A
  • A long-acting inhaled bronchodilator
  • Either
    • Long-acting Beta-2-agonist (LABA)
    • Or a Long-acting muscarinic antagonist (LAMA)
93
Q

Commonly used LABAs

A
  • Formoterol (Foradil)
  • Salmeterol (Serevent)
94
Q

Commonly used LAMA

A
  • Tiotropium (Spiriva)
    • Jaynsein’s reccomendation
95
Q

Which COPD Pts are ICS recommended for?

A
  • Pts with severe COPD (FEV < 50%) who experience frequent exacerbations while receiving one or more long-acting bronchodilators
    • Addition of an ICS is recommended to reduce the number of exacerbations
96
Q

Name some LABA/ICS combo medications

A
  • Formoterol/Budesonide (Symbicort)
  • Salmeterol/Fluticasone (Advair)
  • Vilanterol/Fluticasone (Breo Ellipta)
  • Memetasone/Formoterol (Dulera)
97
Q

Name some LAMA/ICS combo medications

A
  • Vilanterol/Umeclidinium (Anoro Ellipta)
  • Olodaterol/Tiotropium (Stiolto Respimat)
98
Q

Is long-term treatment with oral corticosteroids recommended for COPD Pts?

A
  • No the treatment can lead to:
    • Myopathy
    • Glucose intolerance
    • Weight gain
    • Immunosuppression
99
Q

When should oral corticosteroids be used in COPD Pts?

A

During severe exacerbations

100
Q

For COPD Pts with severe hypoxemia what medication has been shown to both increase survival and quality of life?

A

Long-term supplemental O2

101
Q

In COPD Pts with mild or moderate hypoxemia what might O2 therapy help with?

A
  • Increase exercise capacity
  • Effects of long-term benefits in this population are unclear
102
Q

Which COPD Pts should you consider home O2 therapy for?

A
  • Resting O2 < 88% on RA
  • Evidence of pulmonary HTN, CHF or polycythemia
103
Q

What is the hardest thing you will ever do has a PA?

A

Get a Pt approved for home O2

104
Q

The benefits of pulmonary rehab for COPD Pts are well established, what are the benefits?

A
  • Reduce dyspnea
  • Improve functional capacity
  • Improve the quality of life
  • Reduce number of hospitalizations
105
Q
  • An ABG comes back with the following:
    • pH: 7.38
    • PaCO2: 29
    • HCO3: 15 mEq/L

This indicates?

A

Something probably, but for the exam it’s unimportant. Won’t be any ABG questions.

106
Q

Which organisms make up 60% of community acquired pneumonia (CAP)?

A

Streptococcus pneumoniae and Mycoplasma pneumoniae

107
Q

Which Abx are no longer considered first line in the treatment of S. pneumoniae PNA due to high levels of resistance?

A
  • Penicillins
    • Pen VK
    • Amox
    • Augmentin
  • First and second-generation cephalosporins
108
Q

Which ABx are good choices for the treatment of CAP caused by S. pneumoniae

A
  • Third-generation cephalosporins
    • Ceftriaxone
    • Ceftazidime
  • Macrolides
    • Azithromycin
    • Clarithromycin
  • Fluoroquinolones
    • Levofloxacin
    • Moxifloxacin
  • Tetracycline
    • Doxycycline
      • Jaynstein’s go-to for CAP monotherapy
109
Q

ABx options for treatment of CAP caused by Mycoplasma

A
  • Tetracyclines
    • Doxycycline
  • Macrolides
    • Erythromycin
  • Fluoroquinolones
    • Levofloxacin
110
Q

ABx options for CAP caused by H. flu

A
  • Macrolides
    • Clarithromycin
    • Azithromycin
  • Fluoroquinolones
    • Levofloxacin
    • Moxifloxacin
111
Q

ABx options for CAP caused by Chlamydohilia pneumonia

A
  • Macrolides
    • Clarithromycin
    • Azithromycin
  • Fluoroquinolones
    • Levofloxacin
112
Q

ABx options for CAP caused by Legionella

A
  • Macrolides
    • Clarithromycin
    • Azithromycin
  • Fluoroquinolones
    • Levofloxacin
  • Tetracyclines
    • Doxycycline
113
Q

When determining whether to give an Abx IV or PO what should you consider?

A
  • Bioavailability of the drug
    • Fluoroquinolones have good bioavailability so there is no difference in their efficacy between IV and PO
  • ICU Pts are usually on antimicrobials that only come in IV form
114
Q

When should you switch a Pt from IV Abx to PO?

A

As soon as it is safe to do so

115
Q

Which criteria determine whether a Pt is stable enough to switch from IV ABx to PO?

A
  • Normal VS for 24 hours
    • Afebrile
    • RR < / = 24 breaths/minute
    • HR < / = 100 bpm
    • Systolic BP >/= 90 mmHg
    • O2 sat > 90% on RA
  • No respiratory distress
116
Q

Early transition from IV Abx to PO decreases what?

A
  • Length of hospital stay
  • Cost
117
Q

40-50% of Pts admitted for IV ABx can be switched to PO within what time frame?

A

2-3 days

118
Q

Just because a Pt is hospitalized for CAP does not mean they need IV ABx, what other reasons might they be hospitalized for?

A
  • Hypoxia/respiratory distress
  • Monitoring for improvment
  • Moderate to high risk of decompensating
119
Q

What are the criteria of the CURB-65 score?

A
  • Each is worth 1 point (max 5 points)
    • Confusion
    • Urea (>7 mmol/L)
    • Respiratory rate (>/=30/min)
    • BP (SBP <90 mmHg or DBP <60 mmHg)
    • Age (=65 years)
120
Q

Which CURB-65 scores indicate outpatient treatment of CAP may be appropriate?

A
  • 0-1
    • Score of 0 indicates a 0.7% mortality rate
    • Score of 1 indicates a 2.1% mortality rate
121
Q

A CURB-65 score of 2 indicates?

A
  • A short hospital stay or supervised outpatient treatment
  • Score of 2 indicates a 9.2% mortality rate
122
Q

Which CURB-65 scores indicate the need for hospital admission and possible admission to the ICU?

A
  • CURB-65 scores of 3-5
    • Score of 3 indicates a 14.5% mortality
    • Score of 4 indicates a 40% mortality
    • Score of 5 indicates a 57% mortality

RRCCPA Pharmacotherapeutics (11 decks)

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