Thrp: Pulmonary Flashcards
Cortisone
Endogenous Prodrug Glucocorticoid: Short acting (25)
Avoid in liver dz
Hydrocortisone
Glucocorticoid: Short acting (20)
Prednisone
Prodrug Glucocorticoid: Intermediate acting (5)
Avoid in liver dz
CF Tx: Not used chronically
CF Dose:1-2mg/kg on alternating days
Prednisolone
Glucocorticoid: Intermediate acting (5)
Methylprednisolone
Glucocorticoid: Intermediate acting (4)
No mineral-retaining potency
Triamcinolone
Glucocorticoid: Intermediate acting (4)
No mineral-retaining potency
Nasal Steroid AQ
Betamethasone
Glucocorticoid: Long Acting (0.6)
No mineral-retaining potency
6mg = 3.25 days HPA-axis suppression
Dexamethasone
Glucocorticoid: Long acting (0.75)
No mineral-retaining potency
5mg = 2.75 days HPA-axis suppression
Fludrocortisone
Glucocorticoid: Aldosterone mimetic (125X mineralocorticoid)
Tx: primary/secondary adrenal replacement
Steroid Dosing: Low Dose
5-15mg/day
Maintenance therapy
Steroid Dosing: Moderate Dose
0.5mg/kg/day
Non-Sx manifestations of mild to mod disease/Maintenance therapy
Steroid Dosing: High Dose
1-3mg/kg/day
Control active disease (two edge sword)
Colchicine
Anti-Gout: Steroid sparing therapy
Methotrexate
Chemo: Steroid sparing therapy
Albuterol
SAβA
Tx: Asthma & COPD & CF (neb)
MDI Dose: 2-4puff q4-6hr prn
Neb: 0.63-5mg udv q6-8hr prn
Proventil, Ventolin, ProAir HFA
Accuneb, Proventil Neb
Provental Tab/Syrup
Levalbuterol
SAβA: 0.63mg Levalbuterol = 1.25 Albuterol
MDI Dose: 2-4puff q4-6hr prn
Neb: 0.31-1.25mg udv q6-8hr prn
Xopenex MDI/Neb
Pirbuterol
SAβA
2 pffs q4-6h (max 12pffs/day)
Maxair autoinhaler
Epinephrine
SAβA: Systemic is an issue both alpha and beta
Dose: (>4hr: 0.5ml (11.25mg) via EZ breathe atomizer 1-3 inhalations q3hr prn (Max 12 inh/24hrs)
Asthamnefrine
Terbutaline
SAβA: only one formulated for parenteral use RARE
PO and SubQ dosing
Tx: Asthma also delay labor
Albuterol/Ipratropium
SAβA + AntiACH
Combivent MDI (off market 2013)
Combivent Respimat : 1 inh QID
Duoneb: 3ml neb QID
Arformoterol
LAβA
15mg/2ml neb bid
*Tx: ONLY COPD indication
(Brovana)
Formoterol
LAβA
(Foradil aerolizer) DPI: 1cap via inhaler BID
Tx: COPD indication only
(Perforomist) 12mcg puff bid OR 20mcg neb BID
Tx: COPD indication only
Salmeterol
LAβA
DPI: 1 puff BID
Tx: asthma, exercise induced bronchospasm, COPD
(Serevent Diskus)
Indacaterol
LAβA: Ultra-long
DPI 75mcg QD*
Tx: COPD indication only
(Arcapta Neohaler)
Ipratropium
SAMA
Asthma:
2-3pffs q6hr with SAβA
COPD:
2-6 inhalations QID (max 12/day)
Rhinitis:
primary tx if rhinorrhea is prominent Sx
1-2 sprays each nostril BID-TID
*Taper up to avoid Bloody Nose
AE: dry mouth, dryness
(Atrovent)
Beclomethasone
Inhaled Corticosteroid (Qvar)
Nasal Steroid AQ/mdi
Budesonide
Inhaled Corticosteroid
(Pulmicort Flexhaler)
or Neb = Pulmicort respules (0.25mg/2ml or 0.5mg/2ml)
0.5-1mg QD
Nasal Steroid AQ
(Rhinocort)
Ciclesonide
Inhaled Corticosteroid: “Soft Steroid” On Site activated (still SE)
(Alvesco)
Nasal Steroid AQ/mdi
Fluticasone
Inhaled Corticosteroid
(Flovent)
Nasal Steroid (prop and fur) AQ
Mometasone
Inhaled Corticosteroid
(Asmanex Twisthaler)
Nasal Steroid AQ (Nasonex)
Fluticasone/Salmeterol
Combo: Inhaled Corticosteroid + LAβA
DPI: (Advair Discus) 250/500mcg or 500/500mcg puff BID
MDI (Advair HFA) 115/21 or 230/21mcg 2 puffs BID
Budesonide/Formoterol
Combo: Inhaled Corticosteroid + LAβA
MDI : 2 puffs BID (80/4.5 or 160/4.5mcg)
(Symbicort HFA()
Mometasone/Formoterol
Combo: Inhaled Corticosteroid + LAβA
MDI: 2puffs BID (100/5 or 200/5mcg)
(Dulera)
Theophylline
Me-Xanthine: ~PDE-III/IV inhibitor
2nd/3rd line for chronic asthma: COPD use is controversial (added if pt fails other rx or is non-compliant)
Many SE/DDI
Zafirlukast
Leukotriene Modifier Leukotriene Receptor Antagonist (LTRA)
Tx: Asthma
20mg BID AC
Many DDI
Zileuton
Leukotriene Modifier
1200mg BID
Many DDI
Montelukast
Leukotriene Modifier Tx: Astma 10mg qpm or ≥ 2hrs before exercise Allergic Rhinitis (only proven to be better than Px here) 10mg qpm
Less DDI
Omalizumab
MAb inhibits binding of IgE to Receptor (IgE highest on cascade)
Tx: Asthma
AE: *Anaphylaxis,
(Xolair$$$10,000/yr)
Asthma Tx: Step 1
SAβA PRN
Asthma Tx: Step 2
Low-dose ICS
Asthma Tx: Step 3
Low-dose ICS + LAβA
OR
Med-dose ICS (if CI to β-Ag)
Asthma Tx: Step 4
Med-Dose ICS + LAβA
Asthma Tx: Step 5
High-dose ICS + LAβA
AND
Consider Omalizumab for pts who have allergies
Asthma Tx: Step 6
High-dose ICS + LAβA + Oral corticosteroid
AND
Consider Omalizumab for pts who have allergies
Nicotine gum
2mg for 25mg/day
Chew 1 piece q1-2hr (max 30 (2mg) piece/day; 20 (4mg)/day)
**Technique: Chew and park for 30 min then discard; “peppery” “park”
Avoid acidic beverages for 15 min before and after gum (impairs absorption)
Nicotine patch
7,14,21mg: Step down therapy (Dose= 1mg/cig; max one 21mg patch)
1 patch/day
Technique: place on hairless location between the neck and waist. Rotate sites daily)
AE: Skin irritation: tx rotate sites or apply hydrocortisone crm
Nicotine inhaler
10mg/cartridge (delivers 4mg nicotine)
puff like cig continuously for 20min
AE: Sore throat, cough
Electronic cig NOT healthy: an unregulated product
Nicotine nasal spray
Rx: 0.5mg/spray
Use 1 spray each nostril per hr prn: max 5doses/hr; 40doses/day
AE: irritation Addictive
Nicotine lozenge
2,4mg step therapy
sig:1 lozenge only q1-2hr wk 1-6; q2-4hr wk 7-9; q4-8hr wk 10-12
Taste bad
Bupropion SR
150mg qd x 3d TH 150mg bid x 7-12 wks
Set quit date 1wk after starting the med
enroll in program
May be used with nicotine patch
AE: insomnia, dry mouth, tremor;
safe in pts with stable or acute CV dz
Varenicline
sig: 0.5mg qd x 1-3 days th bid for 4-7 days th 1mg bid for 2-12 wks
Set quit date 1 wk from starting med
AE: n/v unusual dreams
STOP taking med if depressed mood suicidal thoughts or behavior
Safe in pts with stable CV w/o Hx of depression or psych Dz
Nicotine Replacent CI’s
Tx: Heavier smokers (15 cig/day)
RELATIVE CI: Pregnancy, CV dz (recent MI, angina, arrhythmia)
DO NOT smoke while on replacement
Tiotropium bromide
LAMA (m3 antagonist)
Handihaler: 1 puff qd
AE: dry mouth
(Spiriva)
Aclidinium
LAMA (m3 antagonist)
1 puff BID
AE: dry mouth
(Spiriva)
Roflumilast
PDE-4 inhibitor
500mg QDay
TX: COPD (limited efficacy and $$$)
AE: GI, HA, Dizziness, insomnia
MANY DDI: CYP 3A4
Oxygen
COPD Tx: ONLY tx shown to red. mortality
on for 15hrs/day to be beneficial
COPD pts Vaccinations
Annual seasonal
Pneumococcal
Tdap
COPD: Group A Tx
SAMA prn OR SAβA
Essential: Smoking Cessation;
Physical exercise; flu and pneumococcal vaccine
COPD: Group B Tx
LAMA or LAβA
Essential: Smoking Cessation; Pulmonary Rehab
Physical exercise; flu and pneumococcal vaccine
COPD: Group C Tx
ICS + LAβA or LAMA
Essential: Smoking Cessation; Pulmonary Rehab
Physical exercise; flu and pneumococcal vaccine
COPD: Group D Tx
ICS + LAβA or LAMA
Essential: Smoking Cessation; Pulmonary Rehab
Physical exercise; flu and pneumococcal vaccine
Diphenhydramine
1st gen antihistamine
High Anti - H/ACH/Sedation
Brompheniramine
First Gen Antihistamine
Slightly safer profile: Dec Sedation
Chlorpheniramine
First Gen Antihistamine
Slightly safer profile: Dec Sedation
Fexofenadine
2nd Gen antihistamine (OTC)
Allegra
Loratadine
2nd Gen antihistamine (OTC)
Claritin
Desloratadine
2nd Gen antihistamine
Clarinex
Cetirizine
2nd Gen antihistamine (OTC)
Caution metabolized to Hydoxyzine (1st gen anti-H)
(Zyrtec)
Levocetirizine
2nd Gen antihistamine
Xyzal
Levocabastine
Ocular Antihistamine
1-2 gtt QID
Emedastine
Ocular Antihistamine
1 gtt QID
Bepostastine
Ocular Antihistamine
1 gtt BID*
Azelastine
Ocular Anti-Histamine/Mast Cell Stabilizer
1 gtt BID
OR Nasal Anti-histamine
2 spray BID
*Taste Terrible
(Astelin, Astepro)
Olopatidine
Ocular Anti-Histamine/Mast Cell Stabilizer
1 gtt BID
Minimal mast cell activity
OR Nasal Anti-histamine
2 spray BID
(Patanase)
Ketotifen
Ocular Anti-Histamine/Mast Cell Stabilizer
1 gtt TID - QID
Ketorolac
NSAID approved for eye (Acular)
1-2 gtt QID
Systemic Toxicity SE’s
Phenylephrine
Oral and Topical Decongestant:
4 hr prep
Naphazoline
Topical Decongestant:
4-6 hr prep
Oxymetazoline
Topical Decongestant:
12 hr prep
Xylometazoline
Topical Decongestant:
12 hr prep
Pseudoephedrine
Oral decongestant
Cromolyn
Mast Cell Stabilizer: Ocular and Nasal Preps
Fluticasone prop/Azelastine
Combo Nasal Steroid/Antihistamine
1spray BID
Alone fluticasone takes 2wks to work, azelastine works immediately but bad taste
(Dymista)
Tobramycin
Chronic CF ABx
IV or Nebulized
28 Days on 28 days off
Aztreonam
Mono-lactam for Chronic CF ABx for pts w/ pseudomonas
Azithromycin
CF Abx used chronically: has more of a anti-inflamatory MOA
Dornase Alfa
(Pulmozyme) Cleaves DNA: loosens mucus
2.5mg Neb QD-BID
Protect from light
AE: Hoarseness and sore throat
Hypertonic Saline
MOA: Replete sodium/water content w/in lung
7% neb BID
AE: Can cz bronchospasm: *Admin Albuterol prior to hypertonic saline
Ivacaftor
MOA: Chloride channel potentiator
*Tx specific g551d mutation (squeaky gate)
150mg PO BID (daily in hepatic impairment)
Must monitor LFT quarterly 1st yr
DDI: 3A4 (monitor pts meds)
($294,000/yr)
CF Tx Regim
- Albuterol
- Pulmozyme
- Hypertonic saline (can switch 2,3)
- Airway clearance technique
- Inhaled tobramycin/aztreonam
- Inhaled steroid
Pancrealipase
Pancreatic enzyme:
Do Not Substitute no AB ratings
individual agents dosed based on LIPASE Enz
*DOSE:
500 U /kg/meal
250 U /kg/snack
Adjust: ±125-250 U /kg/meal until stool is normal
MONITOR: Stool freq, vol, appearance (normal 1-2 stools/day)
DNE: 2500 U/kg/meal => fibrosing colonapathy (>6000U/kg/meal=colonic stricture)
Ranitadine
H2 Antagonist: Adjunct CF therapy
2-4mg/kg/dose to ic pH and allow for enzyme activity
Also to tx CF-GERD
Preferred over omeprazole
ADEK
Vitamin A,D,E,K for CF pts
2T qDay
GoLytely
To Tx CF DIOS
Polyethylene Glycol 3350 NF
Prevent CF DIOS
17gm/day
Ursodeoxycholic acid
“Liver Diuretic”
15-30mg/kg/day (NTE 900mg/day)
CF Vaccinations
Annual seasonal Pneumococcal Tdap Hep A/B HPV
CF Ibuprofen Dosing
Typ: 25mg.kg BID
To tx asthma component
Test 20-30mg/kg and obtain blood leves 1,2,3 hrs later
Goal [ ] = 50-100mg/L
