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1-NAPLEX (Review Daily) > Pulmonary HTN & Tobacco Cessation > Flashcards

Pulmonary HTN & Tobacco Cessation Flashcards

1
Q

What is Pulmonary Arterial Hypertension?

A
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2
Q

Pack-Year Smoking History

A

Pack-Year = Packs per day x Years smoked

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3
Q

What are the 5 A’s to Treat Tobacco Use and Dependence?

A

1- Ask
2- Advise
3- Assess
4- Assist
5- Arrange for follow-up

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4
Q

What are the treatment options for Tobacco Cessation?

A

NRT: patch, gum, lozenge, inhaler, nasal spray
Drugs: Bupropion, Varenicline

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5
Q

Who are the exceptions to drug treatment?

A

1- Pregnant women
2- Adolescents
3- Smokeless tobacco users (e.g. chewing tobacco)
4- ‘Light’ Smokers (< 10 cigarettes/day)

*Behavioral Counseling is recommended as first-line treatment.

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6
Q

Smoking and CYP1A2

A

The non-nicotine chemicals in tobacco smoke induce CYP1A2. When smoking stops, it can cause supra-therapeutic levels of
-Caffeine
-Theophylline
-Fluvoxamine
-Olanzapine
-Clozapine
-Warfarin

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7
Q

What vaccines are recommended for Smokers?

A

1- Pneumococcal
2- Influenza

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8
Q

First-line NRT

A

Combination of long-acting (patch) with short acting (gum, lozenge)

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9
Q

How many cigarettes is in a pack?

A

20

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10
Q

Nicotine Patch Dosing

A

Brand: NicoDerm

Dosing:
10-WEEK SCHEDULE
- If > 10 cigarettes/day
START 21 mg x 6 weeks
THEN 14 mg x 2 weeks
THEN 7 mg x 2 weeks

8-WEEK SCHEDULE
-If ≤ 10 cigarettes/day
START 14 mg x 6 weeks
THEN 7 mg x 2 weeks

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11
Q

Nicotine Gum and Lozenge Dosing

A

Brand: Nicorette

*Based on the timing of 1st cigarette after waking

12-WEEK SCHEDULE

≤ 30 minutes after waking?
START 4 mg q1-2h x 6 weeks
THEN 4 mg q2-4h x 3 weeks
THEN 4 mg q4-8h x 3 weeks

> 30 minutes after waking?
START 2 mg q1-2h x 6 weeks
THEN 2 mg q2-4h x 3 weeks
THEN 2 mg q4-6h x 3 weeks

*Do not eat/drink 15 minutes before/during use

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12
Q

Warnings of Nicotine Replacement Therapy

A

Avoid in:
-Post-MI
-Arrhythmias
-Angina
-Pregnancy

Avoid Inhalers and Nasal sprays in COPD and Asthma

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13
Q

Side Effects of NRT

A

Insomnia, headache, dizziness

Patch: Vivid dreams, skin irritation

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14
Q

Bupropion

A

MOA: Blocks the neuronal Reuptake of dopamine and/or norepinephrine, resulting in reduced cravings and other withdrawal symptoms

Start: 1 week before quitting date

Dose: 150 mg qAM x 3 days, THEN 150 mg BID
MAX: 300 mg/day

Duration: 6 months

Boxed Warning: Suicidal thinking and behavior in children, adolescent and young adults.

Contraindications: Seizure disorder, hx of anorexia/bulimia

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15
Q

Varenicline

A

Brand: Chantix

MOA: Partial neuronal alpha-4 beta-2 nicotinic receptor agonist.

Start: 1 week before quitting date

*Most effective monotherapy and a first-line therapy

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16
Q

Nicotine Patch Administration

A

-Apply a new patch at the start of a new day
-Press onto skin for ~10 seconds
-Wear for 24 hours. If vivid dreams or trouble sleeping occurs, remove the patch prior to bedtime and apply a new one in the morning
-Rotate the application site
-Do not cut the patch or wear more than one at a time

17
Q

Nicotine Gum Administration

A

-Chew slowly until there is a tingly or peppery flavor in the mouth
-Park it between the cheek and gum
-When the tingle goes away, begin chewing slowly again until it returns, then park the gum again
-Repeat until most of the flavor or tingle is gone (~30 mins)
-Do not eat or drink 15 mins before or during chewing

18
Q

What is Pulmonary Hypertension?

A

Continuous high blood pressure in the Pulmonary Arteries (mPAP >= 25 mmHg)

19
Q

Pathophysiology of PAH

A

1) Imbalance of vasoconstrictor/vasodilators
-Increase in vasoconstrictors (Endothelin-1 and thromboxane A2)
-Decrease in vasodilators (prostacyclins)
Result: Increase pressure in pulmonary vasculature

2) Imbalance of proliferation/apoptosis
-Arteries thicken and scar tissue form

3) Leads to enlarged right ventricle and right heart failure

20
Q

Symptoms of PAH

A

-Fatigue
-Dyspnea
-Chest Pain
-Syncope
-Edema
-Raynaud’s Phenomenon

21
Q

Non-Drug treatment of PAH

A

1) Sodium Restriction (<2.4 g/day)
-This helps manage volume status

2) Avoid the use of NSAIDs

3) Immunizations (Flu and Pneumonia)

22
Q

Diagnostic Test for PAH

A

Right Heart Catheterization

23
Q

“Responder” treatment in PAH

A

Calcium Channel Blockers
-Nifedipine LA
-Diltiazem
-Amlopdipine

*Verapamil is not recommended

24
Q

“Non-Responder” treatment in PAH

A

-This also applies to “Responder” patients who fail CCB treatment

Treatment:
1) Prostacyclin analogs and Receptor agonists
2) Endothelin Receptor Antagonist (ERA)
3) Phosphodiesterase-5 (PDE-5) Inhibitor
4) Soluble Guanylate Cyclase (sGC) Stimulator

25
Q

Supportive Therapy in PAH

A

1) Loop Diuretics (Volume overload)

2) Digoxin (To improve cardiac output)

3) Warfarin (INR goal: 1.5-2.5)

26
Q

Prostacyclin Analogues (Prostanoids) and Receptor Agaonists

A

-These are potent vasodilators (Pulmonary and Systemic) and platelet inhibitors

DRUGS:
1) Epoprostenol (Brand: Flolan & Veletri)
-Given continuous IV
-Half life: ~5 min
-Patients MUST be on this all the time - life threatening if stopped suddenly
-PROTECT FROM LIGHT (including tubing too)
-Starting Dose: 2 ng/kg/min

2) Treprostinil
3) IIoprost
4) Selexipag

27
Q

Endothelin Receptor Antagonists (ERA) MOA

A

MOA: Blocks Endothelin, a vasoconstrictor with proliferative effects

Drugs:
-Bosantan
-Ambrisentan
-Macitentan

28
Q

Boxed Warning for ERAs

A

1) Restricted Access REMS: Embryo-fetal toxicity

2) Bosentan (Tracleer): Hepatotoxicity

29
Q

Phosphodiesterase-5 Inhibitors (PDE-5)

A

MOA: Causes pulmonary vasculature relaxation and vasodilation
CI: Nitrates

DRUGS:
-Sildenafil (Brand: Revatio)
-Tadalafil (Brand: Adcirca)

30
Q

Soluble Guanylate Cyclase (sGC) Stimulator

A

DRUG: Riociguat

MOA: sensitizes sGC to endogenous NO and directly stimulates the receptor at a different binding site. This increases cGMP, leading to relaxation and antiproliferative effects in the pulmonary artery smooth muslce cells.

CI: Pregnancy and use with PDE-5i or nitrates

1-NAPLEX (Review Daily) (32 decks)

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