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Advanced Pharmacology > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Asthma Background

  • _______ disease of the lungs
    • Characterized by ______ episodes of acute bronchoconstriction
  • Secondary to noxious ____ and ____ -reactive pulmonary airways
  • Severity/progression _____ among patients
  • Poorly controlled and/or untreated leads to permanent _____ damage and remodeling which can progress to?
A
  • Inflammatory
    • reversible
  • stimuli, hyper-reactive
  • variable
  • structural -> COPD
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2
Q

Patho of Asthma

A
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3
Q

Medications Used to Treat Asthma

  1. ________ Agents (3)
  2. ________ Agents (2)
  3. (1)
A
  1. Bronchodilating
    • Sympathomimetic Agents (Beta 2 Agonists)
    • Methylxanthines (Theophylline)
    • Antimuscarinic Agents
  2. Anti-inflammatory
    • Corticosteroids
    • Leukotrine Pathway Inhibitors
  3. IgE Monoclonal Antibody
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4
Q

B-2 Agonists MOA

Bind to B-2 receptors (_____ selective, may also bind to __ receptors) on smooth muscle in the ____ and activates adenylyl cyclase (AC) to yield ____ (intracellular mediator) ultimately ______ bonchial and trachial smooth muscles

A

moderately, B1, lung, cAMP, relaxing

cAMP -> promotes bronchodilation

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5
Q

+Sympathomimetic Agents

  • Routinely admistered via _____
    • Provides maximum concentrations to the ____
    • Minimizes ______ absorption/toxicity
  • Short-acting B-2 agonists used for ______ therapy
    • Indicated for m___, i______ asthma
  • Long-acting B-2 agonists (LABAs) used for ______ therapy
A
  • inhalation
    • lungs
    • systemic
  • rescue
    • mild, intermittent
  • maintenance
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6
Q

+Short Acting B-2 Agonists

(2)

A

Albuterol (Proair, Ventolin)

Levalbuteral (Xopenex)

Levalbuterol more selective than albuterol

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7
Q

+Long Acting B-2 Agonists (LABAs)

(4)

A

Salmeterol​/fluticasone (Advair)

Formoterol/budesonide (Symbicort)

Vilanterol/fluticasone (Breo Ellipta)

Olodaterol/tiotropium (Stiolto Respimat)

The long acting B2 differs on which steroid combined with and how long they act

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8
Q

+Albuterol, Levalbuterol

  • Maximum bronchodilation achieved ___ minutes after inhalation
  • Duration of action ~__ hrs (Dosed q__-__ hrs prn)
  • _____ is a purer form (____ selective for B-2, potential for less _______, sometimes more ____ for the pt)
  • For those who cannot use an inhaler?
  • _____ also available in an oral tablet
    • Associated with ____ SE and no clinical advantage
A
  • 15
  • ~4 (Q4-6 prn)
  • Levalbuterol (more, tachycardia, expensive)
  • Nebulized
  • Albuterol
    • increased
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9
Q

+Salmeterol, Formoterol

  • ______ duration of action (~__ hrs) - ____ daily dosing
  • Always used in ______ with a ________
A
  • Long, ~12, twice
  • combination, corticosteroid
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10
Q
A
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11
Q

Antimuscarinic Agents

MOA

Works by blocking ___ receptors on ______ smooth muscle released from the _____ nerve pathways secondary to a ______ stimuli (_____ reactivity)

A

Blocks Ach, airway, vagal, noxious, hyper

Some ppl have excessive Ach

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12
Q

+Antimuscarinic Agents

(3)

A

Ipatropium bromide (Atrovent) - Short acting

Tiotropium (Spiriva) - Long acting

Umeclidinium (Incruse Ellipta) - Long acting

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13
Q

+Ipatropium (Atrovent) PK

  • ____ acting
    • Dose: ____ times a day
    • Potent _____ analog (anti_____)
    • _____ systemic absorption (Does not enter ____)
    • Given via ______ route for?
    • Enhanced bronchodilation when given with _____ (____)*
      • Indication for COPD:
      • Indication for Asthma:
    • Muscarinic involvement is both (2)
A
  • Short
    • Multiple
    • Atropine (anticholinergic)
    • Minimal, X CNS
    • Inhalation - Acute episodes in asthma
    • Albuterol (Combivent)
      • maintenance therapy
      • acute management in asthma (ER) or in pts intolerant to beta-agonists
    • stimuli and patient dependent
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14
Q

+Tiotropium (Spiriva)

  • _____ acting
    • ​Dose frequency
    • Route, what form does it come in?
    • Indication
A
  • Long
    • ​Once daily
    • Inhalation, powder
    • Maintenance therapy for COPD
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15
Q

+Umeclidinium (Incruse Ellipta)

  • ____ acting
    • Dose frequency
    • Route, what form does it come in?
A
  • Long
    • Once daily
    • Powder for inhalation
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16
Q
A
17
Q

+Antiflammatory Agents Used to Treat Asthma

(2)

A

Corticosteroids

Leukotriene Pathway Inibitors

18
Q

+Corticosteroids

MOA

  • Inhibit production of _______
  • Reduces _____ reactivity
  • NOT a ________
A
  • cytokines
  • hyper
  • NOT a bronchodilator
19
Q

+Corticosteroids

Routes

A

Inhalation

Oral

20
Q

+Corticosteroids Indications

When given via Inhalation

When given via Oral

A

Maintenance therapy in moderate to severe asthma

Severe, acute episodes AND refractory disease (many SE when given orally eg. prednisone)

21
Q

+Corticosteroids

Common SE

A

Hoarseness

Oral Candidiasis (Thrush) -> rinse mouth after each use to prevent

22
Q

+Inhaled Corticosteroids

(2)

Combination with _____ – reserved for _____ disease

(2)

A

Budesonide (Pulmicort)

Fluticasone (Flovent)

LABAs – Severe

Fluticasone + Salmeterol (Advair)

Budesonide + Formoterol (Symbicort)

23
Q

Treatment Algorithm

  • Always assess a_______, c______, e______ control
  • The use of a SABA > __ days per week should prompt re-evaluation
  • Reassess pt __-__ wks after medication ______
A
  • administration, compliance, environmental
  • > 2 days/week -> re-evaluate
  • 2-6 wks after adjustment
24
Q

+Treatment Algorithm

All patients need a _____ for ____ therapy

Chronic Treatment (if needed)​

  1. (2)
  2. Then if that doesn’t work can (3)
  3. (2) for more severe/refractory disease (why?)
A

SABA for rescue

  1. Low dose inhaled steroid (fluticasone) or Leukotriene inhibitor (Singulair)
  2. Increase dose of inh steroid, add leukotriene inh, or escalate LABA (but LABA should not be the first drug prescribed)
  3. Oral steroids (prednisone) or IgE antibody - bc alot more SE
25
Q

Poll 3

A
26
Q

COPD

  • Progressive, chronic _____ obstruction of airflow secondary to ______ damage
    • ______ smoke, occupational ____, p_______, a__
  • Associated with chronic ______ response to noxious particles/gases within airways and the lungs
A
  • irreversible, structural
    • tobaccor, dust, pollution age
  • inflammatory
27
Q

COPD Patho

2 types

1) I_____ and _____ can cause bronchiolles to _____, ______ air within the _____ leading to over _____ and r_____
2) ______ is damaged -> inability to transfer __ and ___ -> Lungs cannot supply adequate oxgen to the _____

A

Chronic Bronchitis

1) Inflammation, fibrosis, collapse, trapping, alveoli, expansion, rupture

Emphysema

2) Elasticity, O2 and CO2, blood

28
Q

+COPD Treatment

  • ______ pharmacological approach to asthma
    • Which drug is more commonly seen in COPD vs. asthma (reduces frequency of ______)
  • ____ not used in COPD
  • ________ usually dosed signficantly higher in COPD
  • ________ may be used if infection is present
    • _______ ______ may be what causes the pts COPD exacerbation (NOT ALWAYS!)
  • Severe disease may require chronic ______ supplementation
A
  • Similar
    • Long-acting antimuscarinics, reduces exacerbations
  • IgE
  • Corticosteroids
  • Antibiotics
    • Bacterial Pneumonia
  • oxygen
  • Main diff: COPD’s more so seen with long acting muscarinics (so those drugs usually reserved for severe asthma is used more commonly in COPD)*
  • And a lot more steroid use*
29
Q

Poll 4

Which of the following agents is used routinely as maintenance therapy for COPD, but NOT for asthma

  • Salmeterol
  • Fluticasone
  • IgE
  • Tiotropium
A

Tiotropium

30
Q

+Hydroxychloroquine Recommendations

Recommended?

Ongoing studies investigating ______

A

NOT recommended

prophylaxis

Was politicized, but maybe can work early on? With azithro has SE bc they prolong QT

31
Q

+Remdesivir

MOA

  • In vitro data (4)
  • _____ data from Ebola studies (n~500)
  • First treatment used in a patient case in the ___ for Covid-19
  • Clinical Trials with ______
A

Inhibits viral replication

  • Eboa, SARS-Cov-1, MERS-CoV, SARS-CoV-2
  • Safety
  • US
  • RESULTS!
32
Q

+Remdesivir: 5 v. 10 days

  • ______ supplementation evaluated on day ___
  • Receiving (1), 14 day mortality _____ in __ day arm
    • 5-day 40% mortality vs 10 day 17% mortality
A
  • Oxygen, day 5
  • Mechanical Ventilation, higher in 5 day arm
  • What we found was no difference in 5 vs 10 days of tx*
  • The only diff was with ventilated pts on day 5 of remdesivir -> mortality increased if only given 5 days - so these pts are the only ones given 10 days of tx*
33
Q

+Remdesivir Recommendations

  • ______ Use ______ granted by ___ (May 1, 2020)
  • Criteria
    • SpO2 < __% on ___ or req ___
    • ____ < ____
      • Duration of __ days (__ days in intubated)
  • _____ disease = weight benefit v. risk
  • Monitoring: ___ (must stop if ALT > ____), ____ (can cause transient ____ during infusion)
A
  • Emergency Authorization, FDA
    • 94% on RA or req O2
    • ALT < 200
      • 5, 10 if intubated
  • Renal
  • LFTs (ALT > 200), BP (hypotension)
  • On step of right before FDA approval*
  • WE SEE HYPOTENSION, TRANSAMINITIS > monitor ALT daily*
34
Q

+Remdesivir Recommendations

Conclusion

A

First line for symptomatic COVID-19

Not a cure, impact better if given early (viral phase)
Inhaled and SQ formulation under investigation

Recommended to give EARLIER in disease

35
Q

+Steroid Recommendations

Which drug?

What did the studies show?

A

Dexamethasone

6mg/day showed decreased mortality in COVID pts requiring O2 supplementation

Benefit was NOT seen in pts who did not require O2

36
Q

+Steroid Recommendations for COVID

  • Guidelines suggest using ______ ( or _____/_____ equivalent) at __ mg/day for up to __ days
  • Monitoring (4)
A
  • Dexamethasone, (pred/methlypred), 6 mg/day for 10 days
  • Hyperglycemia, Bacterial infections, Insomnia, Agitation

Since dex is commonly on shortage

37
Q

+COVID 19 Conclusion

  • ____ agents proposed
  • Current guideline recommendations
    • Remdesivir (____ the better - think ____ phase)
    • Steroids (ideally after __-__ days after _____ onset)
    • Convalescent plasma (____ in clinical ___ setting)
    • The rest either not recommended or insufficient data to recommend for or against
A
  • Many
  • Currently
    • earlier, viral
    • 5-8 days after symptom onset
    • only in trial
38
Q

Poll 5

  • 43F no PMH with an 8 day history of fever, cough, and worsening SOB. In the ED, tested positive for SARS-CoV-2
  • When you see the pt you notice she is on 2L NC with a SpO2 94%
  • WHich of the following agents would best treat this pt?
    • Remdesivir
    • Hydroxychloroquine
    • Azithromycin
    • Dexamethasone
A

Remdesivir

Dexamethasone

Both but if she wasn’t on oxygen wouldn’t get dex

Advanced Pharmacology (14 decks)

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