Pulmonary Pharm Flashcards
What are the two main drug types for pulmonary?
Bronchodilators and Anti-inflammatories
What classes are in bronchodilators?
Beta2 Agonists, Anticholinergics, Xanthine derivatives
What classes are in Anti-inflammatories?
Leukotriene receptor antagonists (LTRAs), Inhaled glucocorticoids, Mast cell stabilizers
What drug classes are used to treat COPD?
Beta2 Adrenergic and Glucocorticoids
What do bronchodilators do?
Dilate the bronchioles. Give before giving an inhaled glucocorticoid to open airways and improve efficacy of steroid.
What do Glucocorticoids do?
Decrease inflammation of the bronchioles
How do bronchodilators works?
Relaxes the smooth muscle in the bronchial –> dilates bronchi and bronchioles
What meds are short acting Beta-adrenergic agonists?
Albuterol (PO or inhaled) and Levalbuterol (Inhaled)
What meds are long acting Beta-adrenergic agonists?
Salmeterol and Formoterol
What should be used in an asthma attack?
Short acting Beta-Adrenergic agonists. Albuterol or Levalbuterol.
Suffix for Beta-Adrenergic Agonists
-erol
What is a rescue drug?
Short acting beta-adrenergic agonists (SABA)
What is the duration for SABA?
Q4-6 hrs
What is the duration for LABA?
Q12-14 hrs. THIS IS GIVEN FOR PREVENTION
Beta-Adrenergic Agonists MOA
Mimics the action of the SNS to stimulate the fight or flight response. Relaxes and dilates the airway by stimulating the Beta2-adrenergic receptors in the LUNGS.
Non-selective adrenergic drugs
stimulate both beta 1 and beta 2 and alpha receptors. EPINEPHERINE
Non-selective beta-adrenergic drugs
stimulates both beta 1 and beta 3 receptors METAPROTERENOL.
Selective beta-2 receptors
stimulates only beta 2 in the lungs. ALBUTEROL.
Epinephrine MOA
Stimulates the alpha receptors, beta 1 in the heart and beta 2 in the lungs. Decreases edema and swelling in mucous membranes by vasoconstriction, has cardiovascular effects (Increases HR and BP) and stimulates CNS.
Where is the beta 1 receptor?
Heart
Where is the beta 2 receptor?
Lungs
Indication for Beta-adrenergic agonists
prevention or relief of bronchospasm related to asthma, bronchitis, or other pulmonary conditions
Contraindications for Beta-adrenergic agonists
uncontrolled HTN, cardiac dysrhythmias, high risk for TIA
What do you need to avoid while on Beta-adrenergics?
MAOIs and sympathomimetics (ephedrine/Sudafed) bc it increases risk for HTN
Effect of Beta-adrenergic agonists on DM pt?
May increase blood sugar. Need higher doses of the med and insulin to compensate.
Adverse effects of Beta-adrenergic agonists
Insomnia, restlessness, anorexia, cardiac stimulation, hyperglycemia, tremor, vascular headache, HTN or hypotension
What do you do if too many beta-adrenergic agonists are given? (Overdose)
Beta blocker
MDI
metered dose inhaler. Non-breath activated. Pt. must be coordinated. (Evohaler)
DPI
dry powder inhaler. Breath-activated and propellant not required. (Accuhaler and Terbuhaler)
Types of inhalers
MDI, DPI and nebulizer. Can give higher doses and doesn’t required pt coordination.
Albuterol delivery method
MDI or nebulizer
Albuterol indications
Asthma, bronchitis, and emphysema. ACUTE episodes of wheezing, chest tightness and SOA
Onset of Albuterol
minutes
What is the first line of defense for an asthma attack?
Albuterol
What indicates inadequate control of asthma?
If pt. is using more than one cannister of Albuterol per month. Need to be transitioned to anti-inflammatory therapy with possible PO med.
How many actuations are in a canister?
200
Indications for Salmeterol
Worsening of COPD, moderate to severe asthma - typically given twice daily
Do you give salmeterol alone?
NO. It’s given with an inhaled corticosteroid.
What is the warning for Salmeterol?
It has been associated with an increase in asthma-related deaths (more common in black/african americans)
Anticholinergic MOA
Blocks action of acetylcholine –> creates bronchodilation by preventing bronchoconstriction
KEY POINT for anticholinergic meds
By blocking the effect of acetylcholine, we inhibit the normal physiological response of bronchoconstriction and mucus production.
Indications for anticholinergics
prophylaxis and maintenance therapy
Type of anticholinergic
Ipratropium
What do we normally give with anticholinergics?
Albuterol
Anticholinergic adverse effects
dry as a bone (dry throat, dry mouth, constipation, dry eyes, urinary retention), hot as a hare (feeling hot and decreased sweating), blind as a bat (blurred vision), red as a beet (redness), mad as a hatter (sedation, dizziness, confusion, hallucinations), tachycardia
Xanthine Derivatives (Methylxanthines) MOA
Increases levels of the cAMP enzyme by inhibiting phosphodiesterase –> stimulates CNS and CVD systems
What are the meds for Xanthine derivatives
Theophylline and aminophylline
Suffix for Xanthine derivatives
-phylline
What are xanthine derivatives used for?
second-line treatment
Why are xanthine derivatives used as a second treatment?
High risk of toxicity and drug-drug interactions
Indications for xanthine derivatives
preventative treatment for asthma attacks and COPD exacerbations
What do high levels of cAMP do?
induce smooth muscle relaxation and inhibit IgE induced release of chemical mediators of an allergic reaction
SE of xanthine derivatives
Toxicity –> N/V/D, Headache, tachycardia, dysrhythmias, seizure disorders, hyperthyroid, and peptic ulcers
Interactions with xanthine derivatives
Caffeine may increase SE because the body processes it similarly to caffeine. Smoking can decrease absorption.
Therapeutic index for xanthine derivatives
NARROW. Monitor the serum levels to watch for toxicity
drug interactions of xanthine derivatives
macrolide antibiotics, allopurinol, cimetidine, quinolones, flu vaccine, and oral contraceptives
What is the antidote for xanthine derivatives?
activated charcoal
Leukotriene receptor agonists (LTRA) MOA
prevent leukotrienes from attaching to receptors located on immune cells and within the lungs –> prevent inflammation
Normal function of leukotrienes
They are released by mast cells during the inflammatory response –> induce inflammation, bronchoconstriction and mucus production
Route for leukotriene receptor antagonists
PO
Meds for LTRAs
montelukast and zafirlukast
suffix for LTRAs
-kast
What LTRA can’t be given to children under 5?
Zafirlukast
What LTRA is used for child over 12 months?
Montelukast
Indication for LTRAs
Prophylaxis and chronic treatment of asthma in adults and children. Also used for allergies.
AE of LTRAs
Headache, nausea, dizziness, insomnia, diarrhea
When are corticosteroids given PO rather than inhaled?
Temporarily during a COPD exacerbation until switch to inhaled
Inhaled corticosteroids MOA
Reduces inflammation and enhances activity of beta agonists, also helps with bronchodilation
What are the meds for inhaled coritcosteroids?
beclomethasone diproprionate, budesonide, and fluticasone
Downside of inhaled corticosteroids
Can take several weeks of continuous therapy before seeing full effect of steroids. May be started on PO med to bridge over.
Inhale corticosteroid route
MDI or nebulizer
What do you teach to asthma pts about inhaled corticosteroids?
This is not a PRN medication, you need to take it on a regular schedule. When you take it, take the bronchodilator first to increase absorption of the corticosteroid. Commonly given with beta-adrenergic med.
AE of inhaled corticosteroid
Pharyngeal irritation, coughing, dry mouth, and oral fungal infections
What do you do to prevent oral fungal infections with inhaled corticosteroids?
Rinse mouth after use
What would you give to a pt with an oral fungal infection?
Nystatin rinse
Combination inhaled glucocorticoid and bronchodilator meds
budesonide with formoterol and fluticasone with salmeterol
KEY POINT for combination inhalers
Not for acute attacks
Indications for combination inhalers
Moderate to severe asthma
Mast cell stabilizer MOA
Stabilizes membranes of mast cells to prevent release of broncho-constrictive inflammatory substances
Mast cell stabilizer med
Cromolyn
Indication for Mast cell stabilizer
Prevention of acute asthma attacks. Given 15-20 minutes prior to known triggers.
Monoclonal antibody anti-asthmatic MOA
monoclonal antibody which selectively binds to immunoglobulin IgE –> limits the release of mediators of allergic response (decreases hyperresponsiveness)
Monoclonal antibody Anti-asthmatic med
omalizumab
Route for monoclonal antibody therapy
injection – must be monitored for hypersensitivity reactions
When is monoclonal antibody therapy used?
As an add-on therapy for asthma
Selective PDE-4 Inhibitor MOA
Selectively inhibits PDE4 enzyme in the lung cells –> anti-inflammatory effects
Indication for Selective PDE4 inhibitors
Prevention of COPD exacerbations. Works best for chronic bronchitis with hx of alot of exacerbations.
Route for Selective PDE4 inhibitors
PO
SE of Selective PDE4 inhibitors
N/V/D, headache, muscle spasm, decreased appetite, uncontrollable tremors
What med is a selective PDE4 inhibitor?
roflumilast
What is the PDE4 enzyme?
inflammation trigger
What are the long-term control medications?
anticholinergics, xanthine derivatives, inhaled corticosteroids, leukotriene modifiers, mast cell stabilizers and LABA
What are the short-term or quick relief medications?
SABA and albuterol
Antitubercular drug categories
First-line, used to treat first; and second-line, used for more complicated cases that are resistant to primary meds
Typical treatment for TB
Started on a 4 drug regimen and then tested to see what the pt is susceptible to and adjust from there. Treatment for rest of life.
Most common medication for TB
Isoniazid or INH
Isoniazid (INH) MOA
Disrupts the cell wall synthesis essential to the function of mycobacteria
Route for INH
Oral
SE of INH
Peripheral neuropathy, hepatoxicity, optic neuritis, visual disturbances, hyperglycemia
What do you need to avoid while on INH?
Antacids. They can reduce the absorption.
Black box warning for INH
Increased risk of hepatitis
What do we monitor with INH?
Liver enzymes –> metabolized in the liver
Rifampin MOA
Inhibits protein synthesis via attacking the hydrocarbon ring structure of mycobacteria
What is Rifampin used for in addition to TB?
meningitis, HIV, and leprosy mycobacterium
Why does rifampin decrease the effect of certain drugs?
It’s a CYP450 inhibitor
SE of rifampin
hepatitis, hematologic disorders, red-brown discoloration of urine and other body fluids
Route of rifampin
PO and IV
Teaching point for rifampin
May change the color of body fluids, need to tell a pharmacist or HCP if taking because of the drug interactions
Ethambutol MOA
Diffusing into the mycobacteria and suppresses RNA synthesis, which inhibits protein synthesis
SE of ethambutol
retrobulbar neuritis (nerve neuritis in eye), blindness
Route of ethambutol
PO
Pyrazinamide (PZA) MOA
unknown - thought to inhibit lipid and nucleic acid synthesis necessary for DNA replication
SE of PZA
hepatotoxicity and hyperuricemia
Contraindication for PZA
people with severe hepatic disease or acute gout because gout is already high uric acid levels
What TB drug is not safe for pregnant women in US but used in other countries?
PZA
Streptomycin MOA
aminoglycoside –> interferes with the normal synthesis, causing production of faulty proteins within the bacteria
SE of streptomycin
ototoxicity, nephrotoxicity, blood dyscrasias
Streptomycin Route
IM injection only - given daily
Antitubercular meds
Streptomycin, Pyrazinamide (PZA), Ethambutol, Rifampin, and Isoniazid (INH)
