Pulmonology Flashcards
guaifenesin MOA
expectorant - increases volume of resp tract secretions to loosen phlegm/bronchial secretions
increases the efficacy of cough reflex
guaifenesin max dosage
maximum dose 2400 mg/day
guaifenesin AEs/drug interactions
generally well tolerated
N/V, dizziness, HA, rash
risk of kidney stone formation in high quantities –> hydration!
dextromethorphan (robitussin) MOA
antitussive - relieves throat irritation by cough suppression in medulla
most commonly used non-opioid agent for cough
dextromethorphan maximum dosage
adults and children >12 - 120 mg/day
children 6-12- 60 mg/day
children 4-5- 30 mg/day
dextromethorphan AEs/interactions
N, drowsiness, euphoric effect (robotripping)
avoid in asthma/COPD, hyperglc, bradypnea, pregnancy
interactions w/ MAOI - serotonin syndrome, quinidine
can cause + urine tox - PCP, opioids, heroin
benzonatate (Tessalon) MOA
peripherally anesthetizes stretch receptors in airways to reduce cough reflex
benzonatate AEs
sedation, HA, confusion, visual hallucinations, pruritis, N
*must be taken whole
benzonatate dosing
100-200mg TID
codeine dosing for cough
10-20 mg q4-6h
max dose 120 mg/day
codeine/hydrocodone AEs
constipation, sedation, N/V, dizziness
many drug interactions w CYP2D6
hydrocodone dosage for cough
5 mg q4-6h
max dose 30 mg/day
antihistamines MOA for cough
anticholinergic activity helps reduce post-nasal drip
AEs of antihistamines
dry mouth, dry eyes, blurred vision, constipation, bladder outlet obstruction, CNS impairment
what children should use OTC cough and cold products?
> 2 years
gabapentin MOA for cough
inhibits neutrotransmitter release to help reduce chronic refractory cough
gabapentin dosing
300 mg QD, increase as needed
max 600 mg TID
gabapentin AEs/precautions
CNS depression
adjust dose to renal function
intransal corticosteroids MOA for allergic rhinitis
most effective prevention and treatment of allergic rhinitis!
anti-inflammatory
reduces ocular symptoms (itching, tearing, redness)
intransasal corticosteroids AEs
dryness, irritation, burning, bleeding of nasal mucosa, sore throat, loss of smell
> 12 month use can stunt growth in children
most common OTC intransal corticosteroid
fluiticasone propionate
OTC and prescription
what generation is fluticasone propionate?
second generation intranasal corticosteroid
fluticasone propionate dosage
50 mcg/spray
4-6 years - one spray per nostril QD
>12 years - 2 sprays per nostril QD for 7d, than 1-2 sprays QD
first generation oral antihistamines examples
diphenhydramine (benadryl)
chlorpheniramine (chlor-trimeton)
antihistamines AEs
sedation, CNS impairment
anticholinergic
hangovereffect
second generation oral antihistamines examples
fexofenadine (allegra)
cetirizine (zyrtec)
levocetirizine (xyzal)
loratidine (claritin)
first vs second generation oral antihistamines
second generation - less sedating d/t limited bbb penetration
preferred first line for allergic rhinitis
less effective for nasal congestion
cetirizine may cause sedation
most used second generation antihistamine
loratidine
loratidine dosing
10 mg QD - adults
5 mg QD - peds
- intransasal antihistamines example
azelastine
0.15% available OTC for ages 6 and older
pseudophedrine dosing
30-60 mg Q6h
max dose 240 mg in 24 h
pseudoephedrine MOA
oral decongestant
vasoconstriction in nasal mucosa
stimulation of alpha 1 in venus sinusoids
pseudoephedrine use
relief of nasal congesion and itching, NOT sneezing
tolerance
sales restrictions
pseudoephedrine AEs/precautions
tachycardia, insomnia, excitability/palpitations
use w caution in patients with HTN, cardiovascular disease, DM, hyperthyroid, glaucoma, bladder neck obstruction
oxymetazoline (Afrin) MOA
intransasal decongestant - stimulates A receptors in arterioles of the nasal mucosa to produce vasoconstriction
OTC
- oxymetazoline AEs
stinging, burning, dryness of mouth
less likely than PO to have systemic effects
do not use as monotherapy >3 d - risk of rebound nasal decongestant
cromolyn sodium (nasalcrom) MOA
mast cell stabilizer
intranasal cromolyn inhibits mast cell degranulation and mediator release
less effective than intranasal corticosteroids and second generation antihistamines
mast cell stabilizer AEs
nasal stinging and sneezing
may take 1-2 weeks to achieve maximum effect
alpha1-proteinase inhibitors MOA/use
congenital antitrypsin (AAT) deficiency leads to increase elastic damage in lungs causing emphysema
these drugs render proteolytic enzymes seen in inflammation inactive
alpha1-proteinase inhibitors dosage
60 mg/kg IV infusion weekly
lung surfactants MOA
reduce surface tension in alveoli during ventilation in premature infants
reduces mortality and pneumothoraces associated with respiratory distress syndrome
lung surfactant AEs
hypotension, bradycardia, decreased O2 saturation
corticosteroid AEs
adrenal insufficiency (cushings), osteoporosis, immunosuppression, fluid/electrolyte imbalance (d/t fluid retention), hyperglycemia, GI effects, CNS effects (psychosis), dermatologic effects
betamethasone (celestone soluspan) use
glucocorticoid used in preterm mothers to reduce the incidence of RDS
used w surfactantI
SABA precautions
regularly scheduled use is not recommended - may lower effectiveness and increase airway hyperresponsiveness
more than one canister per month suggests inadequate asthma control
albuterol MOA
SABA
stimulates b-adrenergic receptors
do not decrease airway inflammation
SABA/LABA AEs
tachycardia, skeletal muscle tremors, HA, palpitations, QT prolongation, insomnia, hypokalemia, hyperglc
may develop tolerance
ipratropium MOA
SAMA
SAMA/LAMA AEs
dry mouth, urinary retention, blurred vision, tachycardia, increased intraocular pressure
use w caution w glaucoma, BPH
when is a SAMA used?
pts unable to tolerate SABA and in combo w SABA for acute bronchoconstriction
longer duration than albuterol
what is the most effective long-term control therapy for persistent asthma?
inhaled corticosteroids
ICS AEs
oral candidiasis, dysphonia
*rinse mouth and use spacer!
may increase risk for pneumonia with COPD
what is a LABA used?
ASTHMA - mainly ICS/LABA combinations
not monotherapy, not for acute
COPD - can be monotherapy to reduce frequency of severe exacerbations
LABA examplaes
salmeterol - asthma/COPD
formoterol - asthma/COPD
aformoterol - COPD
olodaterol - COPD
formoterol dosing
nebulizer
20 mcg BID
tiotropium MOA
LAMA
when is a LAMA used?
added to ICS/LABA in poorly controled severe asthma
COPD - helps s/s but does not improve lung function
tiotropium ISI dosing for asthma and COPD
asthma - 2 inhalations (2.5 mcg) QD
COPD - 2 inhalations (5mcg) QD
ihlalation spray
what is trelegy?
fluticosone furoate/umeclidinium/vilanterol
ICS/LAMA/LABA
when are leukotriene modifiers used?
alternative to low-dose ICS
not for acute
leukotriene modifiers AEs
hepatotoxicity w/ zafirlukast and zilueton requires monitoring
black box warning w montelukast
commonly used leukotriene modifier & dosage
montelukast (singulair) 10 mg QD in evening
theophylline use & precautions
limited use
bronchodilator w lots of AEs
add on therapy for asthma and COPD
hepatic monitoring required, drug monitoring, significant AEs, interactions w many drugs
concerning AEs w theophylline
convulsions and cardiac arrhythmias at high concentrations
what is the most effective agent for asthma exacerbation not responding to bronchodilators?
oral corticosteroids
prednisone dosing for asthma exacerbation
40 mg/day PO x 5-7 days
may have 6-8 hour delay so should be considered early in treatment
omalizumab (xolair) use and MOA
patients >6 years not well controlled on ICS w/ documented sensitization to airborne allergens
monoclonal antibody that prevents IgE from binding to mast cells and basophils
- omalizumab (xolair) AEs
injection site pain, bruising, black box anaphylaxis warning –>monitor!
Benralizumab (fasenra) MOA and use
IL-5 antagonist
add on therapy for patients >12 w eosinophilic phenotype asthma not controlled w corticosteroids
IL - 5 antagonists
benralizumab (fasenra)
reslizumab (cinqair) - IV
Mepolizumab (nucala)
benralizumab (fasenra) AEs
HA, pyrexia, pharyngitis, hypersensitivity reaction
dupilumab (dupixent) MOA and use
IL-4 agonists
add on therapy for patients >12 w moderate to severe eosinophilic phenotype
emergency astma mgmt
- SaO2 > 90%
- albuterol/levalbuterol nebs continuous
- inhaled ipratropium in ED if needed
- systemic corticosteroids - PO prednisone
albuterol dosing for acute asthma exacerbation
nebulizer - 2.5-5mg q20 minutes, then 2.5-10 mg q 1-4h PRN
MDI - 90 mcg/puff. 4-8 puffs q 20 mins, then ever 1-4h PRN
injections for asthma exacerbations
epinephrine 0.3-0.5 mg q 20 minutes SQ
terbutatline .25 mg q 20 minutes SQ x 3 doses
ipratropium dosing for asthma exacerbation
0.5 mg q 20 minutes x3, then PRN
MDI - 17 mcg/puff. 8 puffs q 20 m PRN
emphysema patho
permanent and destructive enlargement of airspaces distal to the terminal bronchioles without obvious fibrosis and with loss of normal architecture
always involves clinically significant airflow
“pink puffer”
chronic bronchitis patho
presence of a cough productive of sputum not attributable to other causes on most days for at least 3 months over 2 consecutive years
may be present in the absence of airflow limitation
“blue bloater”
duoneb dosing
2.5 mg albuterol/0.5 mg ipratropium QID PRN
- roflumilast (daliresp) use and MOA
oral phosphodisterase-4 inhibitor
used for severe COPD associated w chronic bronchitis and hx of exacerbations
tx can reduce hospitalizations
roflumilast (daliresp) AEs
changes in mood and behavior, weight loss
azithromycin MOA and use
macrolide antibiotic
can decrease rate of COPD exacerbations 250 mg QD
azithromycin AEs
hearing loss, antimicrobial resistance, drug interactions
what COPD LAMA is available as a nebulizer?
revefenacin
what preparations is albuterol available?
MDI, nebulizer, DPI
LAMA examples
tiotropium
umeclidinium
revefenacin
which ICS is available as a neb?
budesonide
what formulation is trelegy?
DPI
