Respiratory

Question 1

Atopic triad

Answer 1

Asthma

Allergic rhinitis

Atopic ezcema

Question 2

Pharmacological agents used for Asthma

Answer 2

Beta 2 agonists (LABA and SABA)

Muscarinic antagonists (LAMA and SAMA)

Xanthines

Corticosteroids

Leukotriene Modifiers

Question 3

Step wise approach to asthma management

Answer 3

Question 4

Beta 1 vs Beta 2 receptors

Answer 4

Question 5

Beta 2 Agonists Mechanism of Action

Answer 5

Activates beta receptors causing smooth muscle relaxation

SABA vs LABA

Question 6

SABA examples and indications

Answer 6

Albuterol, levalbuterol (Xopenex), pirbuterol (Maxair), metaproterenol (Alupent), and terbutaline (Brethine, Brethaire)

Used for acute bronchospasm

Asthma is considered poorly controlled if using inhaler more than 2x a week or if going through more than one inhaler/month; consider step up

Question 7

Albuterol (SABAs) Pharmacodynamics

Answer 7

• acts on the smooth muscle of the bronchi to reverse bronchospasm by activating beta 2 receptors in the lungs increasing vital capacity and airflow
• also has some effect on beta 1 receptors in the heart - causes side effects tachycardia, nervousness, etc.

Question 8

Albuterol cautions/contraindications

Answer 8

• avoid in arrhythmias that cause tachycardia and pheochromocytoma (adrenal tumor- increased sympathetic response)
• can cause HTN
• caution in pts with CV disease (CHF, HTN), diabetes, glaucoma, and hyperthyroidism

Question 9

Albuterol/SABA Adverse Drug Reactions (usually transient)

Answer 9

tachycardia, dizziness, palpitations, tremors, nervousness, headache - ** due to effect on beta 1 receptors in the heart**

Question 10

LABA examples and indications

Answer 10

• Salmeterol
• Formoterol
• vilanterol (Breo Ellipta) - Ultra long acting - taken QD “Very easy to take”

Used in management of asthma and COPD. Do NOT use as monotherapy in asthma patients (usually paired with ICS).

Not for acute symptom management.

Question 11

Salmeterol (Serevent) [LABA] Mechanism of Action

Answer 11

• relaxes bronchial smooth muscle by selective action on beta 2 receptors

3 advantanges:

• Quick onset of action
• Long MOA- last longer
• More selective to Beta-2 receptors which decreases the prevalence of side effects

Question 12

LABA cautions/contraindications

Answer 12

• NOT to be used as mono-therapy in patients with asthma (Serevent and Foradil) - causes downregulation of beta-2 receptors if used alone so in emergencies, short-acting beta-2 receptor antagonist medications (Albuterol) will not work - leads to increase in asthma intubations and death
• caution in pts with cardiovascular dz, diabetes, hyperthyroidism, glaucoma

Question 13

Inhaled Corticosteroids Examples and Mechanism of Action

Answer 13

Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone

• potent anti-inflammatory and vasoconstriction action
• inhaled: inhibit IgE in mast cell migration of inflammatory cells into the bronchioles

Question 14

ICSs indications

Answer 14

• Primarily used in asthma (2nd line if pt is using SABAs more than 2x/week)
• can also be used in COPD to reduce exacerbations - keep pts out of the hospital

Question 15

ICSs cautions/ contraindications

Answer 15

• NOT for asthma exacerbation
• use caution in active infection
• watch potassium levels, glucose, bone density, growth (high doses for a long time)

Avoid in: Cushing syndrome, herpes, tuberculosis, nasal trauma or ulcers, untreated respiratory infection

Question 16

ICSs ADRs

Answer 16

-dry mouth (xerostomia), hoarseness, mouth and throat irriation, flushing, bad taste, oral candidiasis, rash, urticaria (rare)

Question 17

ICS Patient education

Answer 17

• rinse mouth and spit after use
• keep taking as directed - the only way you know this is working is by less use of SABAs
• if using the a bronchodilator - use the bronchodilator 1st and then after a few minutes use the ICS inhaler
• nasal: blow nose prior to application
• effects are not immediate - takes 3-7 days to see full effect

Question 18

Leukotriene modifier example and mechaism of action

Answer 18

Montelukast (Singulair)

block bronchconstriction by preventing leukotrienes from binding to receptor sites

Question 19

Leukotriene modifiers contraindication

Answer 19

acute bronchospasm, lactation, liver impairment

Question 20

Leukotriene modifiers adverse drug reactions

Answer 20

Fatigue, fever, abdominal pain, h/a

Question 21

Leukotriene modifier indication

Answer 21

maintenance therapy for asthma >1 year, prevention of EIA>15 years old, allergic rhinitis

Question 22

Pharmacological agents used for COPD

Answer 22

Antimuscarinics (LAMAs and SAMAs)

Beta 2 agonists (LABAs and SABAs)

Question 23

Anti-muscarinic mechanism of action and indication

Answer 23

Blocks activation of muscarinic receptors which cause bronchocontriction.

LAMA vs SAMA

More commonly used in COPD than asthma

Question 24

LAMA example

Answer 24

Tiotropium (Spiriva)

Question 25

SAMA example

Answer 25

Ipratropium

Question 26

Management for COPD

Answer 26

Start with LAMA/SAMA then add LABA/SABA

ICS 3rd line

Question 27

Pharmacological options for smoking cessation

Answer 27

Bupropion

Varenicline (Chantix)

Nicotine replacement therapy

Question 28

Nicotine replacement therapy patient education

Answer 28

Avoid using multiple forms of nicotine to avoid overdosing (ie. cannot continue to smoke while using)

Question 29

Varenicline (Chantix) adverse drug reactions

Answer 29

CNS depression, hypersensitivity, nausea, cardiac events, nightmares, insomnia

**Can cause depression and SI, use caution**

Question 30

Bupropion (Wellbutrin, Zyban) adverse drug reactions

Answer 30

Weightloss (good options for patients concerned about weight gain, caution in underweight), insomnia

Contraindicated with seizure disorder