Respiratory Flashcards
Short acting Beta 2 agonists
Albuterol
Indications & Pharmacodynamics
Indications: asthma, COPD
Pharmacodynamics: acts on smooth muscle of bronchi to reverse bronchospasm, which decreases airway resistance and residual volume and increases vital capacity and airflow
Short Acting Beta 2 agonists
Albuterol
Caution/contraindications: when to avoid, caution, pregnancy, peds & adverse fx (6)
- Caution/contraindications
- Avoid: arrythmias that cause tachycardia and pheochromocytoma
- Caution: CVD, DM, glaucoma and hyperthyroidism
- Pregnancy: benefits outweigh the risks; Lactation: OK with infant monitoring
- Peds: approved
- Adverse drug effects: tachycardia, dizziness, palpitations, tremors, nervousness, headaches
Long acting beta 2 receptor agonists
Salmeterol
Indications & Pharmacodynamics
Indications: adjunctive therapy for asthma, COPD
Pharmacodynamics: relaxes bronchial smooth muscle by selective action on beta 2 receptors; onset is 30-45 minutes, not for rescue
Long acting beta 2 receptor agonists
Salmeterol
Caution/contraindications: other considerations, caution, pregnancy, peds & adverse fx (6)
- Caution and contraindications
- Other considerations: Use is contraindicated without the use of an asthma controller medication such as inhaled steroid
- Caution:CVD, DM, hyperthyroidism
- Pregnancy: benefits outweigh the risks; Lactation: OK with infant monitoring
- Peds: 4+
- Adverse drug effects: tachycardia, dizziness, palpitations, tremors, nervousness, headache
Which beta 2 agonist is preferred if needed during pregnancy?
Terbutaline
Xanthine derivatives
Theophylline
Indications & Pharmacodynamics
- Indications: asthma, COPD (not first line)
- Pharmacodynamics: inhibits specific phosphodiesterases which in turn increase cAMP, which leads to relaxation of bronchial smooth muscle and pulmonary vessel relaxation; increases force of contraction of diaphragmatic muscles; similar fx as caffeine d/t similar chemical structures
Xanthine derivatives
Theophylline
Caution/contraindications: avoid, pregnancy, peds, caution, monitoring, other considerations
- Avoid: hypersensitivity to xanthine, PUD, seizure disorder
- Pregnancy: Assess with OB risks vs. benefits
- Peds: approved
- Caution: Closely monitor in pts with HTN, ischemic heart disease, coronary insufficiency, CHF or hx of stroke and cardiac arrythmias
- Monitoring: Narrow TI - routine monitoring needed when first starting, adding or removing any other medication
- Other considerations
- Elimination is influenced by diet
- Smoking increases excretion
- Volume of distribution altered in premature neonates, older patients, cirrhosis, pregnant women, critically ill patients
Xanthine derivatives
Theophylline
Adverse fx (including what happens with toxic levels) (16)
- Adverse fx: tachycardia, palpitations, irritability, gastric irritation, HA
- Toxicity (levels greater than 20mcg/mL): nausea, vomiting, diarrhea, headache, insomnia, irritability
- Toxicity (greater than 35): hypotension, cardiac arrythmias, seizures, brain damage, death
Short acting anticholinergics
Ipratropium bromide (atrovent)
Indications & Pharmacodynamics
- Indications: asthma exacerbation (with albuterol), COPD
- Pharmacodynamics: blocks action of acetylcholine at the muscarinic cholinergic receptors in bronchial smooth muscle causing bronchodilation; onset within 15 min
- Reduces the volume of sputum without changing the viscosity
Short acting anticholinergics
Ipratropium bromide (atrovent)
Caution/contraindications: avoid, pregnancy, peds & adverse fx (6)
- Avoid: urinary retention, BPH, closed-angle glaucoma
- Pregnancy: use if only clearly indicated; lactation: compatible
- Peds: Approved
- Adverse fx: cough, dry mouth, mouth and throat irritation, dyspepsia, nausea, vomiting
Long-acting anticholinergics
Tiotropium bromide (Spiriva)
Indications & Pharmacodynamics
Indications: asthma, COPD
Pharmacodynamics: inhibits muscarinic M3 receptors in the lungs leading to smooth muscle bronchodilation
Long-acting anticholinergics
Tiotropium bromide (Spiriva)
Caution/contraindications avoid, other considerations, pregnancy, peds & adverse fx (5)
- Avoid: urinary retention, BPH, closed-angle glaucoma
- Other considerations: Not for asthma exacerbation
- Pregnancy: only if clearly indicated; lactation: approved
- Peds: 6+
- Adverse fx: dry mouth, pharyngitis, URI, HA, mouth irritation
Leukotriene modifiers
Montelukast
Indications & Pharmacodynamics
Indications: chronic asthma, allergic rhinitis
Pharmacodynamics: inhibits cysteinyl leukotriene receptor which is correlated with the patho of asthma, including airway edema and smooth muscle contraction
Leukotriene modifiers
Montelukast & Zafirlukast
Caution/contraindications (Zafirlukast: avoid, caution, peds; Montelukast: avoid, peds); both pregnancy & adverse fx (4)
- Zafirlukast
- avoid: active liver disease
- caution: dose reduction in hepatic dysfunction
- Peds 5+ ok
- Montelukast
- avoid: severe liver disease
- peds: persistent asthma 12+ months, exercise-induced asthma 15+ years
- Pregnancy: approved; lactation: caution
- Adverse fx: headache, GI upset, myalgias, increase in respiratory infections
Leukotriene Modifiers
Zileuton
Indications & Pharmacodynamics
Indications: chronic asthma
Pharmacodynamics: inhibits 5-lipoxygenase from arachidonic acid - results in reduction of inflammation, edema, mucous secretion and bronchoconstriction
Leukotriene modifiers
Zileuton
Caution/contraindications: avoid, pregnancy, peds & Adverse fx (6)
- Avoid: active liver disease
- Pregnancy/lactation: avoid
- Peds: persistent asthma 12+ years
- Adverse fx: HA, dyspepsia, increased serum ALT, myalgia, URI
- Reported in post-marketing studies: Neuropsychiatric events (hallucination, agitation, aggression, SI, insomnia, depression)
Corticosteroids
Fluticasone
Indications & Pharmacodynamics (inhaled vs. intranasal)
- Indications: asthma, COPD, allergic rhinitis
- Pharmacodynamics: extremely potent vasoconstrictive and anti-inflammatory activity
- Inhaled corticosteroids: inhibit IgE in mast cell migration of inflammatory cells into the bronchial
- Intranasal: focuses on inflammation in the nasal mucosa alone
Corticosteroids
Fluticasone
Caution/contraindications: other considerations, caution, pregnancy, peds
- Other considerations: Not for asthma exacerbation
- Caution in active infection
- Pregnancy/lactation: OK
- Peds: determine by age
Corticosteroids
Fluticasone
Adverse fx (8) (includes intranasal specific sx [4])
- Adverse fx: xerostomia, hoarseness, mouth and throat irritation, flushing, bad taste, oral candidiasis, rash, urticaria
- Intranasal: nasal irritation, itching, sneezing, dryness
Corticosteroids
Fluticasone
Patient education for inhaled (2) vs. intranasal (3)
- Patient education: inhaled corticosteroids
- Rinse mouth out after use to reduce risk of hoarseness and oral candida
- Bronchodilator first then inhaled corticosteroid
- Patient education: intranasal
- Blow nose prior to application
- Fx can take 3-7 days
- Rinse out mouth to reduce risk of oral candida
Inhaled anti-inflammatory agent
Cromolyn sodium
Indications & Pharmacodynamics
- Indications: asthma, bronchospasm, prophylaxis, allergic rhinitis
- Pharmacodynamics: mast cell stabilizer - inhibits antigen-induced bronchospasm and blocks the release of histamine by inhibiting mast cell degranulation
- Prevents release of leukotrienes
- Reduces bronchi hyper-reactivity to stimuli with sustained use
Inhaled anti-inflammatory agent
Cromolyn sodium
Caution/contraindications: other considerations, pregnancy, peds & adverse fx (4) (include intranasal [2])
- other considerations: Not for acute exacerbation
- Pregnancy/lactation
- Other inhaled agents preferred in pregnancy/lactation
- Intranasal compatible with pregnancy/lactation
- Peds: 2+
- Adverse fx: throat irritation, cough, drowsiness, bronchospasm
- Intranasal: nasal irritation, burning sensation in the nose
Inhaled anti-inflammatory agent
Cromolyn sodium
Patient education
Intranasal cromolyn may take up to 4 weeks to show improvement if used for allergic rhinitis - start prior to onset of exposure
First-generation antihistamines
Diphenhydramine
Indications & Pharmacodynamics
indications: allergic rhinitis, hypersensitivity reactions, urticaria and angioedema, insomnia, motion sickness antiemetic
Pharmacodynamics: competitively antagonizes the effects of histamine at the peripheral H1 receptor sites at the GI tract, blood vessels and respiratory tract - prevents responses mediated by histamine
First-generation antihistamines
Diphenhydramine
Caution/contraindications: avoid, caution, pregnancy & adverse fx (9)
- Caution/contra
- Avoid: with CNS depressants, narrow-angle glaucoma, BPH, thickened respiratory secretions, premature infants and newborns
- Caution: elderly patients and young children (risk for paradoxical reaction)
- Alternative agents recommended in pregnancy; avoid in lactation
- Adverse fx: drowsiness, sedation, confusion, ataxia, urinary retention, paradoxical excitation, dry mouth, tremor, blurred vision
Second-generation antihistamines
Cetirizine, loratadine, fexofenadine
Indications & Pharmacodynamics
Indications: respiratory allergies, urticaria
Pharmacodynamics: competitively antagonizes the effects of histamine at the peripheral H1 receptor sites at the GI tract, blood vessels and respiratory tract
Second-generation antihistamines
Cetirizine, loratadine, fexofenadine
1. How are these medications different from diphenhydramine?
2. Which one has the fastest onset and why?
3. What might cause higher peak plasma concentration when taking loratadine?
4. Which of these has more drug-drug interactions?
- Avoid crossing the BBB which is why they do not cause the CNS fx of benadryl
- Cetirizine has fastest onset, least metabolized by CYP450
- Chronic liver disease will have higher peak plasma concentration of loratadine
- Loratadine and fexofenadine have more drug-drug interactions
Second-generation antihistamines
Cetirizine, loratadine, fexofenadine
Caution/contraindications: other considerations, pregnancy, peds & adverse fx (3)
- Caution/contra
- Other considerations: Additive drowsiness when combined with CNS depressants; Loratadine has lowest risk of CNS depression
- Caution in pregnancy and lactation (loratadine is the best)
- Children 6 months+ may take cetirizine; 2 years + may take loratadine, 6 years + fexofenadine
- Adverse fx: headache, drowsiness, nervousness (children)
Decongestants
Pseudophedrine, phenylephrine (oral), oxymetazoline (intranasal)
Indications & Pharmacodynamics
- Indications: nasal congestion related to the common cold, allergic rhinitis
- Pharmacodynamics: mimic the endogenous catecholamines of the SNS; alpha-adrenergic agonists that produce vasoconstriction by stimulating alpha receptors in the mucosa of the respiratory tract; temporarily reduces swelling and inflammation of the mucous membranes
- Intranasal: vasoconstriction when applied to swollen mucous membranes in the nasal passage; shrinks membranes and provides immediate relief but shorter duration
Decongestants
Pseudophedrine, phenylephrine (oral), oxymetazoline (intranasal)
Caution/contraindications: avoid, peds, pregnancy, interactions & adverse fx (8)
- Avoid: severe hypertension and CAD (oral)
- Peds: oral not recommended for children less than 4 (oral)
- Pregnancy/lactation: avoid
- interactions: beta-blockers
- Adverse fx: anxiety, restlessness, HA, insomnia, psychological disturbances, tremors, HTN, tachycardia
- Intranasal: nasal irritation, rebound congestion
Antitussives
Dextromethorphan, codeine, benzonatate
Pharmacodynamics of each
- Dextromethorphan: acts centrally in the medulla to elevate the threshold for coughing; structurally related to codeine
- Codeine: direct fx on cough receptors in the medulla; metabolized by the CYP450
- Benzonatate: related to anesthetic tetracaine and thought to anesthetize the stretch receptors in the respiratory passages, calming the cough
Antitussives
Dextromethorphan, codeine, benzonatate
Caution/contraindications: general avoid; risks of combining codeine & dextromethorphan; Pedatric and pregnancy considerations for each
- Avoid: persistent or chronic cough caused by smoking, asthma or emphysema; allergies to tetracaine or related compounds
- Codeine and dextromethorphan combination
- Risk of abuse with codeine and dextromethorphan (combination is a Schedule V medication)
- CNS depressants when combined with codeine and dextromethorphan can cause additive CNS depression
- Pregnancy/lactation
- codeine: avoid
- Dextromethorphan: Pregnancy ok
- Bezonatate: avoid
- Pediatrics
- Codeine: 12+, but safest to wait until age 18
- Dextromethorphan: 4+ ok
- Benzonatate: 10+ ok
Antitussives
Dextromethorphan, codeine, benzonatate
Adverse fx (Dextro, codeine 3; benzonatate 5)
Dextromethorphan, codeine: drowsiness, dizziness, GI upset
Benzonatate: chest numbness, dizziness, GI upset, HA, chilly sensation
Expectorant
Guaifenesin
Indications & Pharmacodynamics
Indications: cough due to common cold or URI
Pharmacodynamics: increases output of respiratory tract, makes mucus more thin and loose
Expectorant
Guaifenesin
Caution/contraindications: peds, pregnancy & adverse fx (5)
- Caution/contra
- Not for children under 4
- Safe in pregnancy, not studied in lactation
- Adverse fx: GI upset, nausea, vomiting, drowsiness and dizziness