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92 Cards in this Set
- Front
- Back
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What is asthma?
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Chronic inflammatory disease
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What are the s/s of asthma?
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1. recurrent, episodic bouts of coughing
2. wheezing 3. shortness of breath |
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What is the pathophysiology behind asthma?
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1. narrowing of the trachea and bronchioles
2. contraction of airway smooth muscles, mucosal thickening from edema and cellular infiltration |
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What happens when mast cells are activated?
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Mast cells secrete inflammatory cells and inflammatory mediators
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What do inflammatory cells cause?
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Inflammation
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What do inflammatory mediators cause?
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Bronchoconstriction
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If asthma is untreated, what are the consequences?
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Airway remodeling (chronic effect) -- irreversible
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Which drug types function as bronchodilators?
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1. Beta-adrenergic receptor agonists
2. Methylxanthines 3. Anticholinergic agents |
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Which drug types function as anti-inflammatory agents?
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1. Corticosteroids
2. Leukotriene modifiers |
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What is the MOA for beta-adrenergic receptor agonists?
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Act on beta receptors in the lungs, causing an increase in cAMP. cAMP --> increased relaxation in lungs => BRONCHODILATION
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Which beta receptor is responsible for chronotropy in the heart?
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Beta 1
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Which beta receptor is responsible for inotropy in the heart?
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Beta 2
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What are the therapeutic effects of beta agonists?
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1. Bronchodilation
2. Inhibit the release of bronchoconstricting mediators 3. Increase mucus clearance |
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What are some examples of non-selective beta agonists?
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epinephrine, terbutaline, isoproterenol, metaproterenol
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What are some examples of selective beta agonists?
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albuterol, levalbuterol, salmeterol, etc.
(-terol endings) |
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How quickly do short-acting beta agonists (SABA) work?
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5 minutes
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What are some examples of SABAs?
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epinephrine, terbutaline, albuterol, levalbuterol
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How quickly do long-acting beta agonists (LABA) work?
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30 minutes
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What are some examples of LABAs?
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salmeterol, formeterol
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How does the duration of action compare between LABAs and SABAs?
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LABAs work 2-3x longer than SABAs
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Which medications are available as MDIs?
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albuterol, levalbuterol
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Which medications are available as DPIs?
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salmeterol, formoterol
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Which medication can be administered orally?
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albuterol -- increased risk of side effects
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Which medications can be administered subQ?
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epinephrine, terbutaline -- increased risk of side effects (tachycardia especially)
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What is the relationship between albuterol and electrolyte effects?
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Albuterol causes potassium to shift intracellularly, resulting in low serum potassium levels. When albuterol use is ceased, potassium shifts back to the extracellular space.
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What is the cause of tremors with beta agonists?
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Direct stimulation of beta 2 receptors in skeletal muscle
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What causes tachycardia with beta agonist med use?
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Direct stimulation of beta 1 and beta 2 receptors on heart
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How does tolerance develop with beta agonist med use?
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Over time there is a down-regulation of beta 2 receptors in the lung and decreased binding affinity for the remaining receptors
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What are some significant drug-drug interactions with beta agonists?
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1. Adrenergic meds -- additive side effects
2. Beta blockers -- therapeutic effects of beta 2 agonists may be lost |
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What are the clinical uses for beta agonists?
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1. Acute attacks
2. Maintenance therapy 3. Prophylaxis (before exercise or allergen exposure) |
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What are the indications for LABA therapy?
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LABA therapy must be paired with corticosteroids for long-term asthma control
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Under what circumstances should LABAs not be used?
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Asthma controlled with low or medium doses of inhaled corticosteroids
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What is the MOA of methylxanthines?
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Inhibit PDE, the enzyme responsible for cAMP breakdown --> relaxation of airway smooth muscles = BRONCHODILATION
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Besides bronchodilation, what do methylxanthines promote?
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Increased mucus clearance
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What are the methylxanthines?
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theophylline, aminophylline
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What is important about dosing of theophylline?
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Oral dosage forms are not interchangeable on a mg-to-mg basis
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In what circumstances is theophylline used?
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Rarely used or initiated; one of the last options for tx
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With which population is aminophylline okay to use?
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Pediatric patients
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Why is clinical use limited for methylxanthines?
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They have a narrow therapeutic index, requiring serum concentration monitoring
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Are methylxanthines effective for acute relief of asthma symptoms?
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No, but their use reduces the need for SABAs
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What is the metabolism/excretion pattern for methylxanthines?
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Metabolism: 90% hepatic (CYP 1A2, CYP 3A4)
Excretion: 10% renal |
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What are the significant CNS side effects of methylxanthines?
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1. Increased alertness
2. Seizures |
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What cardiac side effects are associated with methylxanthines?
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Arrythmias
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How does the effectiveness of methylxanthines compare to LABAs?
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Methylxanthines are less effective as add-on therapy
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What is the MOA of anticholinergic agents?
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Compete with ACh at the muscarinic receptor causing decreased vagal tone to the airway => BRONCHODILATION
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What are the names of anticholinergic agents?
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ipratroprium, tiotroprium
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Which of the anticholinergic agents works for 24 hours?
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tiotroprium
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In what formulation is ipratroprium available?
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MDI, solution for nebulization
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In what formulation is tiotroprium available?
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DPI only
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What are the possible side effects of anticholinergic agents?
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Blurred vision, headache, flushed skin, tachycardia, urinary retention
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What are the clinical uses for anticholinergic agents?
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1. Maintenance therapy for patients with COPD
2. Combination therapy with SABA for acute attack |
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What is the MOA of corticosteroids?
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1. Cause a reduction in the markers of airway inflammation
2. Decrease vascular congestion and cellular infiltration 3. Improve beta 2 receptor agonists sensitivity to the beta 2 receptor in acute setting |
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In what forms are corticosteroids available for use?
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Inhaled, parenteral
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How quickly do corticosteroids work?
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Inhaled: ~2 weeks
Parenteral: 6-8 hours |
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How is the dosing for corticosteroids determined?
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Individually, based on the severity of the patient's asthma
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What special consideration should be paid to the cessation of corticosteroids?
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Patient should be weaned over period of 1-2 weeks when discontinuation is desired
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What patient teaching is necessary for inhaled corticosteroids?
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Rinse mouth after inhalation to prevent fungal infection
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What are the immediate adverse effects of corticosteroid use?
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Hyperglycemia; psychiatric disturbances (e.g., delirium)
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What are the long-term adverse effects of corticosteroid use?
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1. Osteoporosis/fracture
2. HTN 3. Thinning of the skin/impaired wound healing 4. Adrenal axis suppression 5. Myopathy 6. Immunosuppression 7. Glaucoma |
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What are significant drug-drug interactions with corticosteroid use?
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Inhaled corticosteroids + potent CYP 3A4 inhibitors:
clinically significant Cushing's syndrome and adrenal insufficiency |
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What are the clinical uses of corticosteroids?
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1. Acute exacerbations -- blunt late phase asthma; first dose IV then oral therapy
2. Prevention of attacks -- inhalation preferred with dosing based on severity |
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What is the action of leukotrienes?
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Potent constrictors of bronchial smooth muscles
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What is the MOA of leukotriene modifiers?
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1. Exert anti-inflammatory effects by either preventing leukotriene formation
OR 2. Act as a receptor antagonist |
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Which leukotriene modifier prevents leukotriene formation?
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zileuton (Zyflo)
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Which leukotriene modifier acts as a receptor antagonist?
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zafirlukast, montelukast
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What are the adverse effects of leukotriene modifiers?
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1. Hepatotoxicity (zileuton)
2. Headache 3. GI upset |
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Which leukotriene modifiers have drug-drug interactions?
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zafirlukast and zileuton (warfarin and theophylline)
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What are the clinical uses of leukotriene modifiers?
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1. Maintenance therapy (alternative to corticosteroids)
2. Prophylaxis for exercise or allergen-induced asthma 3. Aspirin-induced asthma |
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What is the final class of medications used to treat asthma?
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Monoclonal antibody -- omalizumab (Xolair)
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What is the MOA of omalizumab?
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Inhibits IgE binding receptors on mast cells
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What adverse effects are a/w omalizumab?
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Injection site reactions: bruising, redness, burning, pain
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What is the clinical use for omalizumab?
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Helpful in moderate to severe persistent allergy-related asthma.
Very expensive and rarely prescribed (all other therapies exhausted first) |
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What is COPD?
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Syndrome of chronic limitation of expiratory airflow obstruction (includes emphysema and chronic bronchitis)
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What is the greatest risk factor for COPD?
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Smoking
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Can medications for COPD reverse damage?
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No -- medications can slow the decline in lung function and treat symptoms, but damage is irreversible
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How is stable COPD managed long-term?
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1. Supplemental O2
2. Regular tx with one or more bronchodilators (esp. anticholinergics) 3. Inhaled corticosteroids |
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How is stable COPD managed when there is an acute exacerbation?
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1. SABA
2. Antibiotics in patients with increased secretions |
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What are the indications for corticosteroid therapy for COPD?
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Regular tx should only be prescribed to patients who remain sympomatic or have recurrent exacerbations
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What is the risk a/w inhaled corticosteroid-only therapy for COPD?
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Increased rate of pneumonia
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What is the best management therapy for COPD?
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Corticosteroid + LABA
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How does nicotine act on the brain?
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Stimulates dopamine release, causing excitation
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What is the goal of nicotine replacement therapy (NRT)?
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Aims to control nictoine levels in teh bloodstream so that withdrawal does not occur?
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What are the benefits of nicotine gum, lozenges, and inhaler?
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Patients can titrate therapy to manage withdrawal symptoms
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What is the benefit of nicotine patch?
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Better compliance
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What is the disadvantage of nicotine patch?
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Patient cannot titrate to manage symptoms
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In which patients are nicotine inhalers contraindicated?
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Patients with an underlying bronchospastic condition (e.g., patients using asthma inhaler)
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In which patient populations should NRT be used with caution?
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1. Immediate (past 2 wks) post-myocardial infarction
2. Serious arrhythmias 3. Serious or worsening angina |
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How does Bupriopion work (MOA)?
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Blocks the reuptake of dopamine
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What are the benefits of bupriopion?
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1. Can be used in combo with NRT
2. First choice for depressed smokers (bupriopion is an antidepressant) 3. Well-tolerated in patients with CV disease 4. May delay weight gain 5. Can begin med 1-2 wks before quit date |
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With which patients should caution be used when prescribing bupriopion?
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Seizure disorder
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What is the MOA for varenicline (Chantix)?
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1. Acts as partial agonist at nicotine receptors
2. Prevents full agonist activity of nicotine at the receptors |
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What is a major warning for prescribing Chantix?
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Serious neuropsychiatric symptoms have occurred -- changes in behavior, agitation, depressed mood, suicidal ideation, and vivid dreams
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