Respiratory - Exam 4 Flashcards
Anticholinergics inhibit what type of nerve impulse?
parasympathetic
Anticholinergics work by ?
selectively blocking the binding of the neurotransmitter acetylcholine (ACH)
pneumonic for effects of anticholinergics?
hot as a car (increased body temp), blind as a bat (Mydriasis - dilated pupils), dry as a bone (dry eyes, mouth, decreased sweat), red as a beet (flushed face), mad as a hatter (delirium)
anticholinergics are divided into three categories in accordance with their ?
specific targets in the central and/or peripheral nervous system
anticholinergic three catergoies
antimuscarinic ACH agents ganglionic blockers (pre and post ganglionic of ANS) neuromuscular blockers ( cause paralysis)
Anticholinergics cause and inhibit what
bronchodilation and inhibit nasal secretions
prevent acute bronchospasm in bronchitis, emphysema, rhinorrhea and COPD
Common inhaled Anticholinergics?
Ipratropium (Atrovent)
Tiotropium (Spiriva)
Ipratropium and albuterol combination ( Combivent)
what Anticholinergic do you have to watch for potential additive Anticholinergic effects
?
Tiotropium (Spiriva)
Ipratropium (Atrovent) dosage for COPD maintenance and an asthma exacerbation )mod-severe)
COPD - 2 puffs inhaled lid
asthma - 8 puffs inhaled q20 min prn
Combivent subclass?
Anticholinergics, Inhaled; Beta-2 Agonists : short acting inhaled
Three main respiratory disorders that are responsive to treatment?
allergic rhinitis
Asthma
Cough
Two main respiratory disorders that are less responsive to treatment?
COPD
Chronic bronchitis
Bronchodilators beta receptors
class of sympathomimetic agents which act upon the beta adrenoceptors
Beta adrenoreceptor agonist mimic the action of ?
epi and norepinephrine
Activation of _____ receptors induces ______ _________ )force of contraction of the heart), ____________ ______ (rate) of the cardiac mucle - leading to increased heart rate and blood pressure
Beta 1
Inotropic
Chronotropic output
secretion of _______ from the stomach (hunger hormone) - drives hunger response
ghrelin
_____ released from the kidneys (renal perfusion, increased BP)
Renin
Activation of _____ receptors causes ______ muscle relaxation in _____ __ and blood vessels and it also _________ heart rate and heart ______ ___________
Beta 2
smooth
lungs, GI
increased heart rate and heart muscle contraction
where are beta 3 receptors mainly located ? when they are activated what does it induce?
adipose tissue
it induces metabolism of lipids
what are bronchodilators also know as?
beta-2 receptor agonists or beta agonists
where are bronchodilators used?
they are used to treat the reversible bronchoconstriction seen in asthma
bronchodilators stimulate both _____ & _____ adrenergic receptors
beta 1 and beta 2
beta 2 stimulates can induce ______________ if given parenterally like inhaled or injection
adverse effects
tachycardia and palpitations
Some adverse effects of beta 2 agonists
tremor tachycardia sweats agitation severe: pulmonary edema, myocardial ischemia and cardiac arrhythmia
ventricular arrhythmias may occur if the heart rate is greater than ___ beats/min
130
Prolonged administration or excessive dosing may result in _________ ________ due to increased serum lactic acid concentrations
metabolic acidosis (Tussmaul BS)
Why do we get increased lactic acid
increased glycolysis and pyruvate production
Patients using ___ formulations should wait - minutes between inhalations and shake the inhaler before use
MDI
3-5
Using a spacer allows for ?
better administration - especially in children
SABA’s stimulate _____ adrenergic receptors in the lung giving rise to a relaxation of bronchial smooth muscle
beta 2
clinical uses of SABA’s?
Acute asthma
COPD
exercise induced brochospasm
Examples of SABA’s
Albuterol (Ventolin, Proventil) Metaproterenol (Alupent) Pirbuterol (Maxair) Terbutaline (Brethren) Levabuterol (Xopenex)
When are SABA’s contraindicated?
with preexisting arrhythmias, angina, palpitations, narrow angle glaucoma (increased IOP), or sensitivity to any component in the formulation
Pharmacokinetics of SABA’s?
gradually absorbed from bronchi in 15 min if inhaled
Rapidly absorbed from GI if ingested
Metabolized in liver and excreted in urine
HF - 2 to 3 hrs
Considerations when using SABA’s?
use of one MDI every 2 months increased risk of exacerbation
frequency of used is related to disease severity
Use more than twice a week means asthma is not controlled
EVERY PATIENT SHOULD USE A SPACE DEVICE
Can use in children under 6
If you are pregnant SABA’s should be used with caution because there is a risk of ?
fetal harm
interference w/ uterine contractility (drugs MOA)
Are SABA’s lactation safe?
YES
Albuterol special note - strength clarification.
1 spray = 108 mpg albuterol sulfate equivalent to 90 mpg albuterol base
Bronchospasm SABA dosage
2 puffs inhaled q4-6h prn
Bronchospasm (exercise induced) SABA dosage?
2 puffs inhaled x1
start: 5-30 min before exercise
Levalbuterol (Xopenex) subclass:
Beta-2 Agonists 1: (L-isomer)
Short acting Inhaled
Levalbuterol (Xopenex) MOA?
selectively stimulates beta-2 adrenergic receptors, relaxing airway smooth muscle
Levalbuterol (Xopenex) Metabolism?
GI tract, CYP450
Levalbuterol (Xopenex) excretion?
urine 80-100%
feces <20%
HF: 3.3-4 hrs
Levalbuterol (Xopenex) pregnancy and lactation?
preg - C
and lactation UKN
(24 vial, 3mL = 245.99$)
Generic 2013 controversy! b/c Xopenex went generic
“I like opened b/c it does not make the heart beat fast”
LABA’s cause relaxation of bronchial, uterine and vascular ____________
smooth muscle
Clinical uses of LABA’s?
control of reversible airway obstruction
Prevention of exercise-induced asthma
Prevention of bronchospasm in COPD
Emphysema
LABA’s example?
Salmeterol (servant Diskus)
Bitolterol (Tornalate)
Formoterol (Foradil)
Fluticasone furcate ( Breo) - new combo
When do you not use LABA’s?
LABA’s should not be used in an acute asthma attack
When are LABA’s contraindicated?
preexisting arrhythmias, angina, palpitations, chest pain, narrow angle glaucoma or sensitivity to any component in the formulation
you want to inhale salmeterol __ - __ min before exercise to prevent bronchospams
30-60 min
Max: 1 puff inhaled q12
Salmeterol subclass:
beta 2 agonists
Long acting inhaled
MOA - activates beta 2 adrenoreceptors relaxing airway smooth muscle
HF 5.5 hrs
preg - C
UKN lactation
Salmeterol meds usage?
> 4 y.o.
make sure to rise your mouth after using inhaled medications cause you want to prevent_______________
fungal infection
Salmeterol adverse reactions
CV - palpitations, tachycardia GI - nausea, heart burn META - hypoglycemia Neuro - tremor PUL - cough, dry throat
Salmeterol ( Servant Diskus) Conscientious considerations?
excessive use leads to tolerance, so evaluate risk benefit
do not consider as mono therapy - not a primary drug for asthma (make sure to add a ICS?)
Dosing is critical in children
Xanthine derivatives ( methylated xanthines family) - affect what?
affect the airways but stimulate heart rate and force of contraction and cardiac arrhythmias at high concentrations
When are Methylated xanthines used commonly?
treatment of in-patient COPD exacerbations when all other options have been exhausted
Xanthine derivatives what do they do?
they directly relax smooth muscle in the bronchial airways and by relaxing pulmonary blood vessels
THEY ASLO INCREASE FORCE OF CONTRACTION OF DIAPHRAGMATIC MUSCLES
Positive Inotropic and Chronotropic activity ( increased heart contractility and increased rate)
Examples of Xanthine derivatives?
Theophylline
Aminophylline
What are the clinical uses of xanthine derivatives?
weak bronchodilators held in reserve for patients who are on maximal therapy with safer medications
IV and PO
IV = trouble but good treatment range but you get into early toxic levels faster and have side effects
Theophylline subclass, MOA metabolism and excretion?
Subclass: other asthma
MOA: UKN, but increase cAMP; antagonizes adenosine receptors
Metabolism: liver, CYP450
Excretion: urine, HF - 8.2 hrs (HF altered by many concurrent illnesses)
Theophylline MOA
antagonizes adenosine receptors and increases cAMP
Theophylline Metabolism
aminophylline converted to theophylline active metabolites
Theophylline asthma / COPD maintenance tx dosage?
300-600 mg/day PO divided qd-bid
Xanthine derivatives toxicities are ____ related and occur near usual therapeutic dose.
dose
Xanthine derivatives serious side effects can occur w/o any preceding signs of less _______ ________
serious toxicity
what is required with giving Xanthine derivatives ?
monitoring of serum conc.
ICS clinical uses?
prophylactic treatment of asthma
allergic rhinitis
steroid are adjunct treatment to asthma
ICS examples?
Budesonide (Pulmicort)
Flunisolide (Aerobid)
Triamcinalone (Azmacort)
Dosing considerations with ICS?
use the lowest possible dose of ICS that maintains asthma control
most effective for long term control - down regulation of receptors
“start low and go slow”
Steroids Subclass?
corticosteroids, Inhaled
Steroids MOA?
exact anti-inflammatory action is UKN; produces multiple glucocorticoid and mineralocorticoid effects
Steroids metabolism?
liver extensively
HF 2-3 hrs
Steroids Pregnancy and lactation?
B and probably safe
wow its a B! its because it promotes lung growth of the fetus so it is actually considered beneficial in pregnancy
Intranasal steroids treatment?
acute allergic rhinitis and chronic rhinitis
43% allergic
23% non-allergic
34% mixed
Examples for allergic rhinitis?
Triamcinalone (Nasacort)
Fluticasone (Flonase)
Beclomethasone (Beconase)
Ciclesonide (Omnaris)
Allergic rhinitis treatment options?
Antihistamine - have no decongestant effects
Intranasal products
decongestants - pseudophedrine
Clinical uses for ORAL corticosteroids?
Asthma - short term burst therapy
COPD
replacement therapy in adrenal insufficiency
Crohn’s disease (anti- inflammatory.)
Oral Steroid examples?
Hydrocortisone (Solu-Cortef)
Prednisone ( Deltasone)
Methylprednisolone (solu-medrol)
Oral Steroids contraindications?
contraindicated with serious fungal infections, viral or tubercle skin infection, hyperglycemia or DM (drives sugar through the roof with DM) 100-400 in a sec
Hydrocortisone (solu-cortef) status asthmatics dosage?
300-400 mg/day IV divided q6h
Beclomethasone dipropionate inhaled (Qvar) MOA?
selectively binds to cysteine leukotriene receptors (leukotriene inhibitor)
anti-inflammatory action is UKN, but it inhibits multiple inflammatory cytokines; produces multiple glucocorticoid and mineralocorticoid effects
Beclomethasone dipropionate inhaled (Qvar) class?
inhaled corticosteroid
Beclomethasone dipropionate inhaled (Qvar) clinical uses?
asthma maintenance Tx
pre dosing based on age (chewable tablet)
Pregnancy (risk vs. benefit)
Is a leukotriene inhibitor a steroid?
yes
Montelukast (Singulair) clinical uses?
asthma maintenance tx
bronchospasm, exercise induced
Allergic rhinitis
Examples of Leukotriene inhibitors ?
Montelukast (Singulair)
Zafirlukast (Accolate)
Examples of Mast Cell Stabilizers?
Cromolyn Inhaled (Intal) Nedocromil (Tilade)
Mast Cell Stabilizer MOA?
inhibits mast cell degranulation
Mast Cell Stabilizers clinical uses?
Asthma maint. tx
Asthma, exercise induced
Mast Cell Stabilizers are pregnancy and lactation safe.
T or F?
True
