Chapter 37 Respiratory Drugs PDF

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NUR 3415 Pharmacology exam reviews (4 exams)...

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Respiratory Drugs (Chapter 37) Recording: (23:28 minutes) https://fiu.zoom.us/rec/share/3LBfONLxyG6mITSs60uO5yzHjEhKAbx7uXao81CafPSCccN8JWiFZEgvbUf8s jWJ.Zz1MDU5vn7rMVm06  

Upper respiratory tract (URT) Lower respiratory tract (LRT) o Chronic obstructive pulmonary disease (COPD)  Asthma (persistent and present most of the time despite treatment)  Intrinsic (occurring in patients with no history of allergies)  Extrinsic (occurring in patients exposed to a known allergen)  Exercise induced  Drug induced  Status asthmaticus o Prolonged asthma attack that does not respond to typical drug therapy o May last several minutes to hours o Medical emergency  Emphysema  No longer used as a term but is included into COPD  Leukocytes release proteolytic enzymes in response to alveolar inflammation o Air spaces enlarge as a result of the destruction of alveolar walls. o Alveoli surface area is reduced  Alveoli: point of gas exchange  Effective respiration is impaired  Chronic bronchitis  Continuous inflammation and low-grade infection of the bronchi  Excessive secretion of mucus and certain pathologic changes in the bronchial structure  Often occurs as a result of prolonged exposure to bronchial irritants

Bronchodilators Beta-adrenergic agonists (SABA or LABA) -Nonselective adrenergic -Nonselective beta-adrenergic

Nonbronchodilators Leukotriene receptor antagonists (LTRAs) Corticosteroids -Inhaled

-Selective beta2 drugs Anticholinergics Xanthine derivatives

-Systemic -IV Mast cell stabilizers Phosphodiesterase-4 Inhibitor Monoclonal Antibody Antiasthmatic

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Teaching: o Health promotion

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 Avoid exposure  Fluid intake Medication education  Inhalers (with or without spacer – spacers are useful when patient unable to coordinate inhaler with breathing)  Wait 1-2 minutes between puffs  Wait 2-5 minutes between different inhaled drugs  Bronchodilators administered first  MDIs  Nebulizers  Peak flow meter Vaccinations  Pneumonia and/or flu

Bronchodilators: o Bronchodilators: relax bronchial smooth muscle → causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process Beta-adrenergic agonists o Indication: used in acute phase o MOA: Reduces airway constriction and restore normal airflow  Activation of beta2 receptors relaxes smooth muscle in the airway and results in bronchial dilation and increased airflow  Stimulate adrenergic receptors in sympathetic nervous system  Sympathomimetics o Indication:  Bronchospasms related to asthma, bronchitis and pulmonary disease  Acute attacks  Used in hypotension and shock o CI: drug allergy, uncontrolled hypertension, cardiac dysrhythmias, high risk of stroke (vasoconstrictive) o DI: nonselective beta blockers, MAOIs, sympathomimetics  Caution: DM → hyperglycemia o Three types  Nonselective adrenergics  Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors  Example: epinephrine (EpiPen)  AE: insomnia, restlessness, anorexia, vascular headache, hyperglycemia, tremor, cardiac stimulation  Nonselective beta-adrenergics  Stimulate both beta1 and beta2 receptors  Example: metaproterenol  AE: cardiac stimulation, tremor, angina pain, vascular headache, hypotension  Selective beta2 drugs

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 Stimulate only beta2 receptors  Example: albuterol  AE: hypo/hypertension, vascular headache, tremor o Short-acting beta agonist (SABA) inhalers  Albuterol (Ventolin, ProAir)  Most commonly used SABA  Beta2-specific  Limit use – loses its beta2-specific actions at larger doses o → beta1 receptors stimulated: nausea, increased anxiety, palpitations, tremors, tachycardia  Oral and inhalation  Levalbuterol (Xopenex)  Pirbuterol (Maxair)  Terbutaline (Brethine)  Metaproterenol (Alupent) o Long-acting beta agonist (LABA) inhalers  Older LABA  Arformoterol (Brovana)  Formoterol (Foradil, Perforomist)  Salmeterol (Serevent) o Beta2 o Maintenance of asthma and COPD (with inhaled corticosteroid)  Not for acute treatment (longer onset of action) o Never more than twice daily  Newest LABA  Indacaterol (Arcapta Neohaler)  Vilanterol + fluticasone (Breo Ellipta)  Vilanterol + umeclidinium (anticholinergic) (Anoro Ellipta) o Ellipta refers to a new delivery system Anticholinergics o MOA: Binds to ACh receptors  Acetylcholine → bronchial constriction and narrowing of airways  Indirectly cause airway relaxation and dilation o Indications: prevention of the bronchospasm associated with chronic bronchitis or emphysema; not for the management of acute symptoms  Help reduce secretions in COPD patients o AE: dry mouth or throat, nasal congestion, heart palpitations, GI distress, headache, coughing, anxiety o Drugs:  Ipratropium (Atrovent)  Oldest and most common  Liquid or inhalation  BID  tiotropium (Spiriva)

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 aclidinium (Tudorza)  Umeclidinium (Incruse Ellipta) Xanthine Derivatives o MOA: increase levels of energy-producing cAMP (by inhibiting its breakdown) results in relaxation of smooth muscle, bronchodilation, and increased airflow  Also causes CNS stimulation  + chronotropic and + inotropic drugs o ↑ cardiac output and ↑ blood flow to kidneys (diuretic effect) o Indications: asthma (mild or moderate), chronic bronchitis, emphysema, adjunct in COPD management  NOT for acute asthma attack  Not used often due to drug interactions and drug levels in blood o CI: history of PUD or GI disease, caution in cardia dz o DI: cimetidine, oral contraceptives, allopurinol, certain antibiotics, influenza vaccine, and others  Cigarettes enhance xanthine metabolism  Charcoal-broiled, high-protein, low-carb food reduce xanthines o AE: n/v, anorexia, GERD, cardiac, diuresis, hyperglycemia  Epigastric pain should be reported to prescriber o Plant alkaloids:  Caffeine  CNS stimulatnt  Indications: bradycardia, bradypnea in infants  Theobromine  Theophylline (Theo-Dur)  Most commonly used xanthine derivative  Various forms o aminophylline – injectable  Indication: status asthmaticus who have not responded to fast-acting beta agonists (e.g. epinephrine)  Only theophylline is used as a bronchodilator o Slow onset – do not use for acute asthma attack  Levels: 5-15 mcg/mL o Synthetic xanthines: aminophylline and dyphylline Nonbronchodilating o Leukotriene receptor antagonists (LTRAs)  MOA: inhibitors leukotrienes from attaching to receptor in lungs and in circulation thus blocking inflammation in lungs  Leukotrienes cause inflammation, bronchoconstriction, vascular permeability, and mucus production  Indication:  Prophylaxis and long-term treatment and prevention of asthma in adults and children 12 years of age and older  Not meant for management of acute asthmatic attacks

 Improvement seen in about 1 week CI: Allergy to povidone, lactose, titanium dioxide, or cellulose derivatives  These are are inactive ingredients in these drugs  Teaching: liver function, take every night as prescribed  Newer class of asthma medications  Montelukast (Singulair) o also approved for treatment of allergic rhinitis o AE: Headache, n/d  Zafirlukast (Accolate) o AE: Headache, n/d  Zileuton (Zyflo) o AE: headache, nausea, dizziness, insomnia Corticosteroids  MOA: anti-inflammatory properties  Prevent release of leukocytes  Increase responsiveness of smooth muscles to beta-adrenergic drugs (beta2)  Various forms  Inhaled forms - reduce systemic effects o Indication: chronic asthma (does not relieve symptoms of acute asthma attack), bronchospastic disorders o CI: drug allergy, candida +, systemic fungal infections o AE: pharyngeal irritation, coughing, dry mouth, oral fungal infections o DI: dose adjustment of antidiabetic drugs (due to hyperglycemia), Cyclosporine and tacrolimus, Itraconazole, Phenytoin, phenobarbital, and rifampin o Teaching: gargle and rinse after use  Bronchodilator before corticosteroid  Systemic used to treat acute exacerbations or severe asthma o AE: Addisonian crisis  IV: acute exacerbations of asthma or other COPD  May take several weeks to see effects  Beclomethasone dipropionate (Beclovent)  Budesonide (Pulmicort Turbuhaler)  Ciclesonide (Omnaris)  Flunisolide (AeroBid)  Fluticasone (Flovent)  Mometasone (Asmanex)  Triamcinolone acetonide (Azmacort)  methylprednisolone (Medrol)  Dexamethasone Mast cell stabilizers  rarely used cromolyn and nedocromil, which are sometimes used for exerciseinduced asthma Phosphodiesterase-4 Inhibitor 

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Roflumilast (Daliresp)  Indicated to prevent coughing and excess mucus from worsening and to decrease the frequency of life-threatening COPD exacerbations  AE: nausea, diarrhea, headache, insomnia, dizziness, weight loss, and psychiatric symptoms. Monoclonal Antibody Antiasthmatic  Omalizumab (Xolair), mepolizumab (Nucala), reslizumab (Cinqair)  Selectively binds to the immunoglobulin E, which in turn limits the release of mediators of the allergic response  Given by injection  Potential for producing anaphylaxis  Monitor closely for hypersensitivity reactions  Indication: moderate to severe asthma 

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