Respiratory

Question 1

Decongestants - Sympathomimetics
Prototypes
ADRs

Answer 1

Alpha 1 Agonists:
Phenylephrine
Oxymetazoline
Pseudophedrine

ADRs:
topical/intranasal: rebound congestion
oral dosing:
- CV - generalized vasoconstriction - caution for pts with HTN, CAD, arrhythmias, cerebrovascular disease
- CNS - restlessness, irritability, insomina
- high abuse potential r/t CNS stimulation

Question 2

1st gen antihistamines
drug names
ADRs

Answer 2

diphenhydramine, chlorpheniramine - “amine”

ADRs: mild
- sedation
- anticholinergic effects - dry mouth, eyes, urinary retention, tachy
- use with caution: pts with glaucoma, hyperthyroidism, HTN, BPH

-interactions:
- increased CNS effects w/ ETOH, hypnotics, antipsychotics,
anxiolytics, narcotics
- increased anticholinergic effects w/: antipsychotics, TCAs

Question 3

second gen antihistamines

Answer 3

non-sedating
loratidine, cetirizine, fexofenadine, desloratadine, levocetirizine
intranasal - azelastine, olipatadine

histamine 1 receptor antagonists
ADRs: epistaxis, HA, bad taste, somnolence (r/t rare absorption into
systemic circulation)

do not treat the common cold - do not relieve congestion

Question 4

nonopiod antitussives
drug names
ADRs

Answer 4

Dextromethorphan - most effective nonopioid
ADRs:
-potential for abuse at high doses r/t euphoria at high doses
-rare at therapeutic doses - light inebriation, nausea, dizziness, drowsiness

Question 5

Opioid Antitussives
drug names
ADRs

Answer 5

Codeine and Hydrocodone
- 1/10th of dose for pain relief
- schedule V drug (codeine for pain is sch. II)
ADRs: CNS depression - sedation, OD can result in resp. depression

Question 6

expectorant - prototype and education

Answer 6

guaifenesin (robitussin)
hydration is best expectorant

Question 7

mucolytic - prototype, MOA, and ADRs

Answer 7

Acetylcysteine - breaks down mucus (liquefies)
via nebulizer
ADRs: foul odor, bronchospasm, n/v, runny nose, throat/lung irritation, sore mouth, stomatitis, hemoptysis

indic Chronic bronchitis, Cystic fibrosis

Question 8

intranasal glucocorticoids

Answer 8

beclomethasone, budesonide, fluticasone, mometasone, triamcinolone

ADRs dry mucosa, burning/itching, epistaxis, sore throat & HA

Question 9

2 main drug types for both asthma and COPD

Answer 9

Glucocorticoids - beclomethasone, prednisone
Bronchodilators - beta 2 agonists albuterol, salmeterol

Question 10

other anti-inflammatory:
mast cell stabilizer

Answer 10

CroMolyn
prophylaxis, not quick relief - for mild, persistent asthma or exercise induced bronchospasm, + seasonal rhinitis
decreases the release of inflammatory mediators
use 15 minutes before exercise
ADRs - safest anti-asthma med
cough, bronchospasm

Question 11

Leukotriene antagonist

Answer 11

Montelukast, Zafirlukast, zileuton (all PO)
- reduce bronchoconstriction, inflammatory response - prophylactic, not for ongoing attacks
- used in asthma maintenance
- 2nd line - when IGC cannot be used or is inadequate
- less effective than glucocorticoids

ADRs - neuropsych - depression, SI

Question 12

Monoclonal Antibodies

Answer 12

Omalizumab
- pts >12 years with allergy related asthma, uncontrolled by GCs
- binds to igE so less can release histamine, leukotrienes
ADRs
injection site rxn - mild to anaphylaxis

Question 13

For COPD only

Answer 13

Phosphodiesterase-4 inhibitors
Roflumilast
used in severe, chronic COPD
reduces exacerbations
inhibits PDE4 -> increases accum. of cAMP
anti-inflammatory - decrease in cytokines & inflammatory cells
maintenance - taken daily for severe/chronic COPD
no bronchodilation
ADRs: mood changes, depression, SI, weight loss, appetite loss, GI upset, diarrhea, HA, dizziness

Question 14

Anticholinergic Bronchodilators

Answer 14

ipotropium, tiotropium - approved for COPD, very commonly used offlabel for asthma
ADRs: anticholinergic - dry mouth, pharynx irritation, x glaucoma, constipation, blurred vision, dec sweating CV events

Ipotropium
onset: 30 seconds duration: up to 6 hrs
indicated for allergy induced and EIB
*combined with Albuterol - combivent - PNS/SNS

tiotropium - LAMA - maintenance therapy for bronchospasm r/t COPD

Question 15

MDI considerations

Answer 15

2 doses - wait 1 minute
2 different drugs? - SABA, 5 minutes, then glucocorticoid (better delivery)
spacer recommended - 21% -> lungs vs 9%

Question 16

DPI considerations

Answer 16

dry powder inhaler
- don’t require hand-breath coordination (breath activated)
- do require hand-eye coordination
- deliver more drug to lungs ~20%
-spacers not necessary

Question 17

Inhaled Glucocorticoids

Answer 17

-most effective asthma drug
-beclomethasone, fluticasone, budesonide
-improved efficacy when used w/ beta 2 agonist
-low risk for toxicity
-gargle/rinse after - reduces candidiasis
other ADRs:
- prolonged therapy –> systemic symptoms
- adrenal suppression - osteoporosis, hyperglycemia, hypernatremia, hypokalemia, immunosuppression, fluid retention, growth suppression (children)
- MUST TAPER - acute adrenal insufficiency due to lack of endogenous glucocorticoids
- with prolonged use, must take stress doses in times of severe stress - failure to do so can be fatal

Question 18

oral glucocorticoids

Answer 18

used for more severe cases
<10 days usually no significant ADRs
oral prolonged therapy –> adrenal suppression
- osteoporosis
- hyperglycemia
- peptic ulcer disease
- growth suppression (children)
- psych disturbances
cushing’s syndrome
Menstrual disorders
Obesity (Central distribution of fat)
Neurosis (depression or psychosis)
Face (moon, hirsutism, acne)
Altered muscle physiology (proximal muscle weakness)
Supra-Clavicular and Dorso-Cervical fat pads.
Infection (immunosuppression)
Elevated blood pressure
Skin (Easy bruisability)

Question 19

bronchodilators

Answer 19

beta 2 agonists - most effective dilator

methylxanthines, anticholinergics

Question 20

SABA

Answer 20

prototype - albuterol
rescue, prevention of EIB (short acting)
safety - dose-dependent selectivity, beta 1 agonist
- tachydysrhythmias, angina, seizures, arrest and death may occur
no anti-inflammatory capabilities
use beta 2 agonists (SABA and LABA) with CAUTION in pts with diabetes, hyperthyroidism, heart disease, hypertension, angina

Question 21

LABA

Answer 21

Salmeterol - prolonged prophylaxis
- fixed schedule
- same loss of selectivity like SABA in high doses, can increase risk of asthma related death so always use with IGC
- use with IGC - preferably in same device (advair- indicated for longterm maintenance), if not use bronchodilator first
- not useful as rescue/prevent EIB

Question 22

Methylxanthines

Answer 22

Theophylline PO, Aminophyline IV
Caffeine citrate
MOA: relaxes smooth muscle
NARROW therapeutic window - 5 -15 mcg check theophylline serum levels
ADRs - CNS excitation, cardiac stimulation -
indications of toxicity - vomiting, restless, dizzy, diarrhea, insomnia, dysrhythmias, convulsions
safety - avoid activities requiring alertness
many drug interactions - CYP450 system
caffeine can intensify, smoking/THC decreases 1/2 life
no longer routinely used

Question 23

Acute Severe Asthma Exacerbation

Answer 23

Initial therapy consists of:
Oxygen to relieve hypoxemia
Inhaled high-dose SAβA to relieve airflow obstruction
Possibly a nebulizer with a bronchodilator
Systemic glucocorticoid to reduce airway inflammation
Nebulized ipratropium to further reduce airflow obstruction.
IV fluid should also be considered

Question 24

asthma management

Answer 24

4 classes of severity based on impairment and risk
reduce exposure to irritants
measure and track Peak expiratory flow (PEF)
if less than 80% of personal best, monitor more frequently (60-80 yellow zone, >60 danger zone)
stepwise approach PRN SABA -> Low dose IGC, -> +LABA -> medium to high dose IGC + LABA -> + oral corticosteroid and mab for allergy triggered
- seek care, f/u if rescue more than twice a week

Question 25

COPD mgmt

Answer 25

same as asthma
-bronchodilators - LABA, SABA for exacerbation
-GCs - always administered with LABA
-anticholinergics
- PDE4 inhibitor - roflumilast

exacerbations
- supplement O2 88%-92%
- SABA, in combo with inhaled anticholinergic
- systemic GCs
- antibiotics if s/s infection

support, education, quitline

Question 26

Primary TB med “I” - active/latent

Answer 26

Isoniazid (INH)
must be given with at least 1 other med - active
ADRs:
Drug-induced B6 defCNS seizure, dizziness, ataxia
peripheral neuropathy
GI distress (related to hepatoxicity -monitor liver enzymes), dry mouth
contraindicated for liver disease
avoid acetominophen, ETOH
educate sx of liver impairment: stomach pain, nausea anorexia, fatigue, dark urine, clay stools, jaundice
CYP450 inhibitor - drug toxicity seizure meds, sedation meds

Question 27

Primary TB med “R”

Answer 27

Rifampin
same ADRs as isoniazid
special: discoloration of body fluids - urine, sweat, saliva, tears

Rifapentine - long-acting analog of Rifampin (same ADRs + CYP450 inducer - dec levels of other drugs)

Question 28

primary TB med “P”

Answer 28

Pyrazinamide
Special ADRs: non-gouty arthralgia - pain in joints
manage with NSAIDs - aspirin, ibuprofen
N/V, rash, photosensitivity

Question 29

primary TB med “E”

Answer 29

Ethambutol
Special ADRs: optic neuritis (dose related) - constricted visual fields, ability to see red and green
- GI distress, Anorexia, Nausea
Education: report vision changes, assessment before and during Rx, admin w/ food