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CDM Exam 3 > Respiratory PCOL > Flashcards

Respiratory PCOL Flashcards

1
Q

Organs the effect sympathetic action: contraction

A 
Radial Muscle (a1)
skeletal muscle (a)
sphincters (a1)
uterus (a)
Pilomotor smooth muscle (a)
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2
Q

Organs the effect sympathetic action: relaxing

A 
ciliary muscle (B)
skeletal muscle (M)
bronchiolar smooth muscle (B2)
smooth muscle walls (A2, B2)
bladder wall (B2)
uterus (b2)
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3
Q

Short Acting B2 Agonists MOA

A

Act on the β2 receptors, which activate cytoplasmic G proteins, which activate adenylyl cyclase to produce cyclic adenosine monophosphate (cAMP) which decreases unbound intracellular calcium, producing smooth muscle relaxation and mast cell membrane stabilization.

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4
Q

SABA meds

A

Epinephrine
Isoproterenol
Albuterol

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5
Q

SABA: Albuterol brand names

A

ProAir
Proventil
Ventolin

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6
Q

SABA: Albuterol supplied as

A

DPI, MDI, Nebs, Syrup, Tab

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7
Q

SABA: Albuterol onset

A

5-10 min

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8
Q

SABA: Albuterol duration

A

4-6 hr

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9
Q

SABA: Albuterol dosing

A

DPI (≥4 yoa):

  • -> 2 inhalations every 4 to 6 hours. In some patients, 1 inhalation every 4 hours may be sufficient
  • -> 2 inhalations 15 to 30 minutes before exercise for Exercise Induced Bronchospasm (EIB) prevention

MDI (≥4 yoa):

  • -> 1-2 puffs Q4-6h prn SOB
  • -> 2 inhalations 15-30 minutes prior to exercise for Exercise Induced Bronchospasm (EIB)

Neb: 2.5mg neb over 5-15 minutes 3-4 times daily prn

Tablet: 2-4mg PO 3-4 times daily; max 32mg/day in divided doses (IR syrup/tablets)

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10
Q

Tissue type: airways

Receptor: beta 2

A

Response: Smooth muscle relaxation (bronchodilation), increased ciliary beat, increased serous secretion, and inhibition of mast cell degranulation

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11
Q

Tissue type: airways

Receptor: alpha

A

Response:Smooth muscle contraction (bronchoconstriction?)

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12
Q

Tissue type: Heart

Receptor: B1

A

Response: Inotropic and chronotropic

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13
Q

Tissue type: Heart

Receptor: B2

A

Response: chronotropic (change HR)

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14
Q

Tissue type: Vasculature

Receptor: B2

A

Response: Vasodilation, decreased microvascular leakage

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15
Q

Tissue Type: Vasculature

Receptor: a

A

Response: Vasoconstriciton

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16
Q

Tissue Type: Skeletal

Receptor Type: B2

A

Response: Increased neuromuscular transmission (tremor and increased strength of contraction)

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17
Q

Tissue Type: Uterus

Receptor Type: B2

A

Response: Relaxation

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18
Q

Tissue Type: Metabolic

Receptor Type: a, B1

A

Response: Glycogenolysis, lipolysis

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19
Q

Tissue Type: Metabolic

Receptor Type: B2

A

Gluconeogenesis, hypokalemia, increased lactate production

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20
Q

SABA ADR

A 
Tremor
Anxiety
Tachycardia
Hypokalemia
Hypomagnesemia
Hyperglycemia
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21
Q

SABA drug interactions

A

Beta-blockers, diuretics, sympathomimetics

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22
Q

SABA monitor

A

Symptoms, HR, K

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23
Q

SABA pt education

A

Place in therapy, inhalation device technique

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24
Q

Short acting muscarinic antagonists (SAMA)

A

Competitive inhibition of muscarinic receptors in airways thereby preventing bronchoconstriction mediated by vagal nerve

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25
SAMA treatment ipratropium brand name
Atrovent
26
Ipratropium: how it is supplied
MDI, Nebs
27
Ipratropium: Onset of action
15-30 min
28
Ipratropium: Duration of action
4-8 h
29
Ipratropium: Dose
2 puff four times daily 0.5 mg neb Q6-8h
30
SAMA precautions and ADR
Narrow-angle glaucoma, prostatic hyperplasia, bladder-neck obstruction Dry mouth, abnormal taste
31
SAMA drug interactions
Anticholinergic medications
32
SAMA monitoring
Symptoms, urinary retention in older men
33
SAMA pt education
Place in therapy, inhalation device technique
34
SABA/SAMA Combination: Ipratropium/ Albuterol
Combivent, Respimat, Duoneb
35
Ipratropium/ Albuterol supplied
SMI, Nebs
36
Ipratropium/ Albuterol onset of action
15-30 min
37
Ipratropium/ Albuterol duration of action
4-8 h
38
Ipratropium/ Albuterol dose
1 puff four times daily in COPD 3mL neb Q6h
39
Long acting B2 agonists (LABA) MOA
Act on the β2 receptors, which activate cytoplasmic G proteins, which activate adenylyl cyclase to produce cyclic adenosine monophosphate (cAMP) which decreases unbound intracellular calcium, producing smooth muscle relaxation and mast cell membrane stabilization
40
LABA treatment options
albuterol, arfomoterol, formoterol, indacaterol, olodaterol, salmeterol
41
LABA Formoterol
Foradil Aerolizer, Perforomist
42
LABA Formoterol supplied
12 mcg Dry Powder Inhaler (DPI), Neb (20mcg/2mL)
43
LABA Formoterol onset on action
less than 5 min
44
LABA Formoterol duration of action
12 hr
45
LABA Formoterol dose
12mcg inhalation BID in kids ≥5 yoa in asthma 12mcg inhalation at least 15 minutes prior to exercise for EIB 12mcg inhalation BID in COPD 20mcg neb BID for COPD
46
LABA Olodaterol brand names
Striverdi, Respimat
47
LABA Olodaterol supply
2.5 mcg SMI
48
LABA Olodaterol onset of action
10-20 minutes
49
LABA Olodaterol duration of action
24 hr
50
LABA Salmeterol supplied
50 mcg DPI
51
LABA Olodaterol onset of action
less than 20 min
52
LABA Olodaterol duration of action
12 hr
53
LABA black box warning
increase risk of asthma related death
54
LABA ADR
Tremor, anxiety, tachycardia, hypokalemia, hypomagnesemia, hyperglycemia, cough (indacaterol)
55
LABA drug interactions
Other QTc prolonging medications
56
LABA monitoring
Symptoms, ADR
57
LABA pt education
Inhalation device training, rationale for use (controller therapy) and not for acute shortness of breath (potential exception with formoterol in the beclomethasone/formoterol combination which may be used as a maintenance and reliever treatment in asthma)
58
Long Acting Muscarinic Antagonist (LAMA) MOA
Inhibition of M1-5 receptors, bronchodilation due to M3 activity in lungs
59
LAMA Tiotropium brand names
Spiriva HandiHaler, Spiriva Respimat
60
LAMA Tiotropium supplied
18 mcg DPI 2. 5 mcg SMI 1. .25 mcg SMI
61
LAMA precautions and ADR
``` Dryness of mouth Bitter, metallic taste Constipation Urinary retention Worsened narrow-angle glaucoma ```
62
LAMA drug interaction
Anti-cholinergic medications
63
LAMA monitoring
Symptoms, ADR
64
LAMA pt education
Role in therapy, inhalation device training
65
LAMA/LABA combination treatment: Tiotropium/Olodaterol
Stiolto Respimat
66
Methylxanthine MOA
Smooth muscle relaxation/ bronchodilation via inhibition of phosphodiesterase (PDE) thereby decreasing the degradation of cAMP to AMP; potentially also mild anti-inflammatory activity via PDE4 inhibition; inhibition of adenosine receptors
67
Methylxanthine: Theophylline
Theo-24, Theo-Dur
68
Methylxanthine ADR
Headache, insomnia, nausea, heartburn, arrhythmias, grand mal convulsions
69
Methylxanthine drug interactions
CYP 3A3/1A2
70
Methylxanthine monitoring
Theophylline levels (5-15mcg/mL in adults; 5-10mcg/mL in children), symptoms
71
Methylxanthine Pt Education
Place in therapy, side effects (signs and symptoms of toxicities)
72
Systemic Corticosteroids moa
Modifies gene expression of cells leading to gene activation or suppression Block late reaction to allergen and reduce airway hyperresponsiveness Inhibit cytokine production, adhesion protein activation, and inflammatory cell migration and activation Reverse β2 receptor down-regulation
73
Systemic Corticosteroids treatments
Prednisone
74
Systemic Corticosteroids ADR
``` Adrenal suppression (HPA Axis) Growth suppression Osteoporosis Cataracts Myopathy Increased appetite Weight gain Hyperglycemia CNS side effects (psychosis, insomnia, emotional liability) HTN GI side effects (PUD, gastritis) Cushingoid appearance ```
75
Systemic Corticosteroids: Fluoroquinolones, oral-antidiabetics, CYP3A4 inhibitors
Fluoroquinolones, oral-antidiabetics, CYP3A4 inhibitors…
76
Systemic Corticosteroids Monitoring
Clinical improvement, side effects (BP, blood glucose, mental status, electrolyte panels), growth, etc.
77
Systemic Corticosteroids Pt Education
Side effects
78
Inhaled Corticosteroids (ICS) ADR
``` Cough Dysphonia Thrush Delayed childhood growth Osteoporosis Skin thinning Bruising Cataracts and glaucoma Hyperglycemia Pneumonia (we will discuss this in COPD specifically) ```
79
ICS ADR interventions Spacers or valved holding chambers
``` Spacers or valved holding chambers Rinse mouth after inhalation Monitor growth in children Use lowest dose ICS possible For adults, consider supplementing calcium + vitamin D ```
80
ICS: Drug interactions
CYP450-CYP3A4 Protease inhibitors Ketoconazole
81
ICS monitoring
Growth | Disease outcomes
82
ICS pt education
use spacer/holding chamber | Rinse mouth after inhalation
83
ICS/LABA brand names Budesonide/Formoterol Fluticasone/Salmeterol
symbicort Advair Diskus, HFA, Airduo, Respliclick, Wixela
84
ICS/LABA/LAMA combination | Fluticasone furoate/Umeclidium/Vilsnterol
Trelegy Ellipta
85
Macrolide Antibiotics MOA
Macrolide antibiotics bind to the 50s ribosomal subunit preventing protein synthesis, also has anti- inflammatory effects
86
Macrolide Antibiotics treatment options
``` Asthma: Azithromycin 500mg po TIW for prevention of asthma exacerbations in the GINA guidelines COPD: • Azithromycin 500mg PO x1, then 250mg PO daily x 4 days for COPD exacerbations (AECOPD) • Azithromycin x 52 weeks for prevention of COPD exacerbations ```
87
Macrolide Antibiotics ADR
N/V/D, QTc prolongation, increased LFTs, may worsen MG, may cause antibiotic resistance
88
Macrolide Antibiotics DDIs
CYP3A4 and QTc | prolonging agents
89
Macrolide Antibiotics monitoring and pt education
QTc, hearing, exacerbation rate Educate on purpose, adverse effects
90
Phosphodiesterase-4 Inhibitors
Roflumilast (Daliresp)
91
Phosphodiesterase-4 Inhibitors MOA
``` Roflumilast and active metabolite (roflumilast N-oxide) both inhibit phosphodiesterase- 4 (PDE-4) causing an increase in cAMP. ```
92
Roflumilast: Warnings
``` Acute bronchospasm Psychiatric events Weight decrease Use with strong CYP inducers is not recommended ```
93
Roflumilast contraindications
Child-Pugh | B/C liver impairment
94
Roflumilast ADR
``` Gastrointestinal disorders: abdominal pain, dyspepsia, gastritis, vomiting Infections: rhinitis, sinusitis, urinary tract infection Musculoskeletal: muscle spasm Nervous System: tremors Psychiatric: anxiety, depression, suicidality, sleep disturbances ```
95
Roflumilast DDIs
``` Extensive metabolism via CYP3A4 and 1A2 • CYP3A4 • Inducer: Rifampin, carbamazepine, phenytoin • Inhibitor: Erythromycin, clarithromycin, azole antifungals, amiodarone, ketoconazole • CYP1A2 • Inducer: Phenytoin • Inhibitor: Ciprofloxacin ```
96
Roflumilast monitoring
Weight, FEV1, COPD | exacerbations, depression
97
Roflumilast pt education
Place in therapy, side effects (weight loss, insomnia, depression)
98
Biologic agents
Mepolizumab (Nucala®) Tezepelumab-ekko (Tezspire) Dupilumab (Dupixent®) Omalizumab (Xolair®)
99
Biologics pathway IgE
Omalizumab (Xolair®)
100
Biologics pathway IL-4/IL-13
Dupilumab (Dupixent®)
101
Biologics pathway IL-5
Mepolizumab (Nucala®)
102
Biologics pathway TLSP
Tezepelumab-ekko (Tezspire)
103
Omalizumab (xolair) moa
A monoclonal antibody that binds to circulating IgE, preventing it from binding to high affinity receptors on basophils and mast cells
104
Omalizumab precautions
Anaphylaxis (0.1% of patients, blackbox warning) Malignancy (0.5% of patients) Acute asthma symptoms Eosinophilic conditions Rare cases of systemic eosinophilic conditions Churg-Strauss syndrome possible Corticosteroid reduction Fever, arthralgia, and rash Similar constellation of symptoms to serum sickness Discontinue if develops Parasitic infection
105
Omalizumab ADR
Pain and bruising at injection sites (5-20%) Anaphylaxis (0.1%, blackbox warning) Malignant neoplasm (0.5%)
106
Omalizumab Monitoring
IgE levels (baseline), reduction in exacerbations and symptoms, improvements in FEV1, side effects (anaphylaxis)
107
Omalizumab pt education
Recognition and treatment of anaphylaxis
108
Mepolizumab (Nucala®) MOA
Humanized IgG1 monoclonal antibody against IL-5 preventing it from binding to its receptor on eosinophils thereby reducing blood, tissue, and sputum eosinophils
109
Mepolizumab (Nucala®) ADR
Headache, nasopharyngitis, upper respiratory tract infections, sinusitis, injection site reactions
110
Mepolizumab (Nucala®) monitoring
Improvements in symptoms
111
Mepolizumab (Nucala®) pt education
Side effects (hypersensitivity)
112
Dupilumab (Dupixent) MOA
Humanized monoclonal antibody against IL-4 and IL-1
113
Dupilumab (Dupixent) ADR
Injection site reactions, conjunctivitis, herpes simplex infection
114
Dupilumab (Dupixent) monitoring
Improvement in symptoms, exacerbations, FEV1, side effects
115
Dupilumab (Dupixent) pt education
Store in the fridge, SQ injection training, sharps disposal, advise patients to discontinue and seek treatment if hypersensitivity symptoms
116
Tezepelumab-ekko (Tezspire) MOA
TSLP signals the presence of danger and can trigger immune response
117
Tezepelumab-ekko (Tezspire) ADR
Arthralgia, pharyngitis, hypersensitivity, back pain, helminth infection
118
Tezepelumab-ekko (Tezspire) precaution
Avoid use of live attenuated vaccines, may put patients at risk of (parasite) infection
119
Tezepelumab-ekko (Tezspire) monitoring
Asthma control
120
Tezepelumab-ekko (Tezspire) pt education
Role in therapy, side effects, avoiding live vaccinations
121
Asthma recuse meds
SABA SAMA ICS/Fomoterol Systemic Corticosteroids
122
COPD rescue meds
SABA SAMA Systemic Corticosteroids
123
Asthma controller meds
``` Bronchodilators -->LABA -->LAMA (tiotropium) -->Theophylline ICS Mast Cell Stabilizers Leukotriene Modifiers Macrolide antibiotics Biologics Combination Therapies ```
124
COPD controller meds
``` LA Bronchodilators -->LABA -->LAMA -->Theophylline Anti-Inflammatory -->Inhaled Corticosteroids -->Phosphodiesterase 4 Inhibitors -->Macrolide antibiotics Combination Therapies ```
124
COPD controller meds
``` LA Bronchodilators -->LABA -->LAMA -->Theophylline Anti-Inflammatory -->Inhaled Corticosteroids -->Phosphodiesterase 4 Inhibitors -->Macrolide antibiotics Combination Therapies ```

CDM Exam 3 (8 decks)

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