Pulmonary HTN & Tobacco Cessation Flashcards
What is Pulmonary Arterial Hypertension?
Pack-Year Smoking History
Pack-Year = Packs per day x Years smoked
What are the 5 A’s to Treat Tobacco Use and Dependence?
1- Ask
2- Advise
3- Assess
4- Assist
5- Arrange for follow-up
What are the treatment options for Tobacco Cessation?
NRT: patch, gum, lozenge, inhaler, nasal spray
Drugs: Bupropion, Varenicline
Who are the exceptions to drug treatment?
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.
Smoking and CYP1A2
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
What vaccines are recommended for Smokers?
1- Pneumococcal
2- Influenza
First-line NRT
Combination of long-acting (patch) with short acting (gum, lozenge)
How many cigarettes is in a pack?
20
Nicotine Patch Dosing
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
Nicotine Gum and Lozenge Dosing
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
Warnings of Nicotine Replacement Therapy
Avoid in:
-Post-MI
-Arrhythmias
-Angina
-Pregnancy
Avoid Inhalers and Nasal sprays in COPD and Asthma
Side Effects of NRT
Insomnia, headache, dizziness
Patch: Vivid dreams, skin irritation
Bupropion
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
Varenicline
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
Nicotine Patch Administration
-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
Nicotine Gum Administration
-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
What is Pulmonary Hypertension?
Continuous high blood pressure in the Pulmonary Arteries (mPAP >= 25 mmHg)
Pathophysiology of PAH
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
Symptoms of PAH
-Fatigue
-Dyspnea
-Chest Pain
-Syncope
-Edema
-Raynaud’s Phenomenon
Non-Drug treatment of PAH
1) Sodium Restriction (<2.4 g/day)
-This helps manage volume status
2) Avoid the use of NSAIDs
3) Immunizations (Flu and Pneumonia)
Diagnostic Test for PAH
Right Heart Catheterization
“Responder” treatment in PAH
Calcium Channel Blockers
-Nifedipine LA
-Diltiazem
-Amlopdipine
*Verapamil is not recommended
“Non-Responder” treatment in PAH
-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
Supportive Therapy in PAH
1) Loop Diuretics (Volume overload)
2) Digoxin (To improve cardiac output)
3) Warfarin (INR goal: 1.5-2.5)
Prostacyclin Analogues (Prostanoids) and Receptor Agaonists
-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
Endothelin Receptor Antagonists (ERA) MOA
MOA: Blocks Endothelin, a vasoconstrictor with proliferative effects
Drugs:
-Bosantan
-Ambrisentan
-Macitentan
Boxed Warning for ERAs
1) Restricted Access REMS: Embryo-fetal toxicity
2) Bosentan (Tracleer): Hepatotoxicity
Phosphodiesterase-5 Inhibitors (PDE-5)
MOA: Causes pulmonary vasculature relaxation and vasodilation
CI: Nitrates
DRUGS:
-Sildenafil (Brand: Revatio)
-Tadalafil (Brand: Adcirca)
Soluble Guanylate Cyclase (sGC) Stimulator
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
