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45 Cards in this Set

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ANTHISTAMINES
(H1 RECEPTOR BLOCKER)
-1st generation: highly sedating
-2nd generation: rarely sedative
-MOA: binding to H1 receptor and preventing activation by histamine
-Effects on periphery: decrease flushing, edema, itching, pain, suppress mucus secretion
-Effects on central: therapeutic dose causes CNS depression (drowsiness, slowed reaction time, etc.); overdose causes CNS stimulation and convulsions
-Use: 1. mild allergic syndromes allergic rhinitis best used prophylactically, acute urticaria, allergic conjunctivitis, mild transfusion reactions; 2. adjuvant therapy for severe allergic syndromes like anaphylaxis; 3. motion sickness-dipenhydramine, meclizine, promethazine; 4. insomnia-dipenhydramine, pyrilamine; 5. not effective for common cold, may be used for anticholinergic properties
-ADRs: 1. sedation most common, develop tolerance; 2. other CNS effects (dizziness, confusion, fatigue, coordination issues), paradoxical excitation (insomnia, nervousness, tremors; most common in children and may be seen in elderly); 3. GI disturbances (N/V, loss of appetite, diarrhea, constipation); 4. Anticholinergic effects: dry mouth, urinary hesitancy, constipation, palpitations; 5. cardiac dysrhythmias-rare and seen w/drugs no longer on market; 6. azelastine-bitter taste and somnolence
-Acute Toxicity: sx-dilated pupils, flushing, hyperpyrexia, tachycardia, dry mouth, urinary retention; children may experience hallucinations, ataxia, convulsions, and coordination issues. Can lead to coma, cv collapse, and death. tx by enhancing drug removal w/charcoal then cathartic and sx mgmt.
-Drug Interx: CNS depressants (benzos, opioids, alcohol), can cause additive effect
-Pregnancy and lactation: only use when benefits clearly outweigh the risks, need to look at individual agents since some are faster, can excrete through breast milk
ANTIHISTAMINE PRODUCTS
-ROUTE
-DOSE (ADULT)
-SEDATION
-ANTICHOLINERGIC EFX
ALKYLAMINES
-brompherniramine: oral, 4mg q4-6h, low, moderate
-chlorpheniramine: oral, 4mg q4-6h, low, moderate
ETHANOLAMINES
-clemastine: oral, 1.34mg q12h, moderate, high
-diphenhydramine: oral/IV/IM, 25-50mg q6-8h, high, high
PHENOTHIAZINES
-promethazine: oral/IV/IM/rectal, 12.5-25mg q6-24h, high, high
2ND GENERATION AGENTS: low-none sedation and anticholinergic effects
-azelastine: nasal/eye, 2sprays bid
-cetirizine: oral, 5-10mg qd
-fexofenadine: oral, 60mg bid/180mg qd
-loratadine: oral, 10mg qd
-desloratadine: oral, 5mg qd
SELECTING APPROPRIATE ANTIHISTAMINE
-indication: motion sickness, allergic rhinitis, etc.
-sedative vs non sedative
-route of admin and dosing options
-anticholinergic effects
-cost
INTRANASAL GLUCOCORTICOIDS
-best for prevention and tx of seasonal and perennial rhinitis
-first line agent
-suppress/prevent congestion, rhinorrhea, sneezing, nasal itching, erythema
-agents: beclomethasone, budesonide, flunisolide, mometasone, triamcinolone
-ADR: dry nasal mucosa, burning/itching sensation, sore throat, epistaxis, headache; systemic rare
-dosage and admin.: 1 week(seasonal) to 2-3 weeks(perennial) to see maximal response; sprayed 1-2 in each nostril qd/bid
INTRANASAL CROMOLYN SODIUM
(NASALCROM)
-less effective than IN-GC
-MOA: decreases release of histamine and other mediators from mast cells
-used for prophylaxis not tx and response may take 1-2 weeks to develop
-Dose: 1 spray/nostril 4-6/day
DECONGESTANTS
-available products: phenylephrine, pseudoephedrine, oxymetazoline
-MOA: decrease nasal congestion by activating alpha1-adrenergic receptors on blood vessels in nose
-only relieves stuffiness and congestion not rhinorrhea, sneezing, or itching
-ADR: rebound congestion w/topical agents, CNS stimulation w/oral (restlessness, irritability, anxiety, insomnia), CV events (avoid in those with HTN and CAD), hemorrhagic stroke (seen w/phenylpropanolamine which was removed from market), abuse (effects similar to amphetamines)
-topical admin: shouldnt be used more than 3 days (2 for oxymetazoline), drops preferred for kids, sprays less effective than equal volume drops
-oral v. topical: topical works faster, oral acts longer, systemic effects seen w/oral, rebound congestion w/topical
ANTIHISTAMINE-DECONGESTANT COMBO
-good for patients w/nasal congestion
-loratadine+pseudoephedrine>claritin D, fexofenadine+pseudoephedrine>allegra D
-can be given seperate: 2 seperate oral dosages or oral antihistamine w/nasal decongestant
IPRATROPIUM
(ATROVENT)
-for allergic rhinitis, asthma, and common cold
MONTELUKAST
(SINGULAIR)
(leukotriene antagonist)
-seasonal and perennial allergic rhinitis to reduce nasal congestion
-less effective than nasal glucocorticoids
OMALIZUMAB
(XOLAIR)
monoclonal antibody of IgE
PRODUCTIVE COUGH
-wet
-sputum produced (clear, purulent, colored, malodorous)
-expels secretion from lower RT
NONPRODUCTIVE COUGH
-dry, hacking
-no sputum production
-serves no useful medical purpose
COUGH
-complications: insomnia, m/s pain, hoarseness, urinary incontinense, syncope (rare), rib fractures (rare)
-tx goals: reduce number and severity of episodes, prevent complications, tx underlying causes
ANTITUSSIVES
-OPIOID
(CODEINE AND HYDROCODONE)
-codeine most effective
-generally found in combo
-classified in schedules of Controlled Substances Act
-dose of codeine: 10-20mg q4-6h
ANTITUSSIVES
ANTITUSSIVES
-NONOPIOID
(DEXTROMETHORPHAN, DYPHENHYDRAMINE, AND BENZONATATE)
DEXTROMETHORPHAN
-similar in efficacy to codeine
-potential for abuse; not on schedule
-dose: 10-30mg q4-8h
-may enhance analgesic effects of opioids
DYPENHYDRAMINE
-25mg q4h
BENZONATATE (TESSALON)
-MOA: decrease sensitivity to stretch receptors in resp. tract
-ADR: sedation, dizziness, constipation
-**capsules should not be chewed, crushed, or sucke on b/c can cause paralysis of mouth and pharynx
-dose: 100mg tid
PROTUSSIVES
(EXPECTORANTS)
-for productive coughs, makes them more productive
GUAIFENASIN (MUSINEX)
-higher doses may be needed
-efficacy not clearly demonstrated
-ADR: N/V, drowsiness, stomach pain
-shouldnt be used in patient w/chronic lower resp tract diseases like asthma and COPD
OTHER AGENTS
(MUCOLYTICS)
-makes mucus more watery and cough more productive
-hypertonic saline and acetylcysteine (Mucomyst) admin by inhalation
-ADR: bronchospasm
-acetylcysteine has rotten egg odor
COMMON COLD
-etiology: rhinovirus, adenovirus, resp. syncytial virus (RSV), parainfluenza virus
-sx: rhinorrhea, nasal congestion, cough, sneezing, sore throat, hoarseness, headache, malaise, myalgia, fever in children rare in adults, self limiting
-goal of tx: reduce sx
-combo cold remedies: reserved for patients w/multiple sx.
--common ingredients: nsal decongestant to reduce congestion, antitussive to decrease cough, analgesic to reduce pain/possible fever, antihistamine for anticholinergic effects of decreasing mucus secretion, sedation effects often useful in pm forms, and caffeine to offset sedative effects
--disadvantages: fixed doses, may not need all products in the combo, reformulation without changing brand name
ASTHMA
-PATHOPHYSIOLOGY
-chronic inflammatory disorder
-allergen binds to IgE on mast cells causing release of mediators (histamine, leukotireins, prostaglandins, and interleukins)
-mediators bronchoconstriction and promote inflammatory cell (eosinophils, leukocytes, macrophages) infiltration
-inflammatory cells release additional mediators(cytokines, leukotrienes, and interleukins among others)
-result of pathway is airway inflammation-edema, mucus plugging, smooth muscle hypertrophy
ASTHMA
-MONITORING
LUNG FUNCTION TESTING
-forced expiratory volume (FEV)
--most important, most difficult and expensive
--spirometer measure the amount of air expelled from lungs
--results compared to predicted normal value
-peak expiratory flow rate (PEFR)
--normal rate of airflow during expiration
--peak flow meter measures amount of air expelled during forced expiration
--should be measured every morning
-patient needs monitor of sx on routine basis
-zone system
--green zone: no sx, PEFR>80% of personal best, controlled
--yellow zone: some sx, PEFR 50-80% of personal best, control is insufficient
--red zone: sx at rest or interfere w/ADL's, PEFR<50% of personal best, raise medical alert flag, seek medical attention
ASTHMA
-CLASSIFICATION
MILD INTERMITTENT
-sx <2/week
-asx and normal PEFR between exacerbations that last few hours to few days
-nighttime sx <2x/month
-no daily med needed
MILD PERSISTENT
-sx >2/wk, <1/day
-exacerbations may affect ADL
-nighttime sx >2x/month
-tx:use low dose inhaled GC's,
-alternative tx: cromolyn, leukotriene receptor antagonists
MODERATE PERSISTENT
-daily sx, daily use of inhaled short acting beta2 agonists, exacerbations affect ADLs and >2/wk and may last days
-nighttime sx >1/wk
-tx: low dose inhaled GC and long acting beta2 agonist, medium dose inhaled GC +- long acting beta2 agonist
-alternative tx: low dose inhaled GC and leukotirene receptor antagonist or theophylline, medium dose inhaled GC and leukotriene receptor antagonist or theophylline
SEVERE PERSISTENT
-continual sx, limited physical activity, frequent exacerbations
-frequent nighttime sx
-tx: high dose inhaled GC and long acting beta2 agonist +- oral GC
-no alternative tx
--pt shoudld be placed into category in which most severe sx occur
ASTHMA
-TX
-goals: prevent chronic sx (cough, wheezing), maintain normal/near-normal pulmonary fx and ADL, prevent exacerbations and need for ER visits and hospitalizations
-non pharmacological mgmt: reduce/eliminate exposure to allergens like dust mites, pets, cockroaches, molds, smoke, household sprays; measures to reduce allergens are hypoallergenic sheets and blankets, wash bedding and stuffed animals weekly in hot water, remove carpet/rugs, decrease humidity
-drug therapy: stepwise approach, step down patients once controlled
-exacerbations: may require hospitalization, goal of tx is decrease airway obstruction and hypoxemia and normalize lung fx, initial therapy starts with beta2 agonists given q20min up to 3 doses in first hour for severe, patient often receives epi, short course oral GC's, and O2
-exercise induced: inhaled short acting beta2 agonists are mainstay 10-15min or immediately prior to exertion, inhaled cromolyn may also be used 15 min prior to exertion
BETA-ADRENERGIC AGONISTS
-short acting: good for relieving acute attacks, long acting: can lead to increased risk fo asthma related deaths when used incorrectly
-MOA: activate beta2 adrenergic receptors causing bronchodilation
BETA ADRENERGIC AGONISTS
(SHORT ACTING: ALBUTEROL, LEVALBUTEROL)
-used by majority of patients w/asthma to treat acute attack, prn, can be taken before exercise to prevent
-ADR: rarely cause tachycardia, angina, tremor
ALBUTEROL (PROVENTIL)
-MDI: 2 puffs q4-6h prn
-Nebulizer: 2.5mg q4-6h prn
LEVALBUTEROL (XOPENEX)
-nebulizer: 0.63mg q6-8h prn
BETA ADRENERGIC AGONISTS
(LONG ACTING: FORMOTEROL, SALMETEROL)
FORMOTEROL(FORADIL)
SALMETEROL(SEREVENT)
-fixed based dosing not prn
-long term control not acute attack
-not first line for long term control
-ADR: increased risk of asthma related deaths when used incorrectly
-DPIs 1 puff q12h
BETA ADRENERGIC AGONISTS
(ORAL: ALBUTEROL, TERBUTALINE)
-long acting and long term control
-not first line for long term control
-ADR: angina pectoris, tachydysrhythmias, tremor
ALBUTEROL(PROVENTIL)
-syrup/tablets-2 or 4mg tid-qid
-ER tab-8mg q12h
TERBUTALINE (BRETHINE)
-5mg tid
GLUCOCORTICOIDS
-MOA: suppress inflammation to decrease asthma sx, decrease synthesis and release of inflammatory mediators, decrease activity of inflammatory cells, decrease edema and mucus production, increase number of beta2 receptors and responsiveness to beta2 agonists
-used for prophylaxis/maintenace and tx of severe attacks
GLUCOCORTICOIDS
(INHALATION AGENTS: BECLOMETHASONE, BUDESONIDE, FLUNISOLIDE, FLUTICASONE, MOMETASONE, TRIAMCINOLONE)
-1st line therapy for pt w/mod-severe asthma
-ADR: oropharyngeal candidiasis and dystonia (gargle after each admin), rarely cause adrenal suppression, bone loss, and growth retardation in children
-MDI and DPI, fixed schedule not prn, may need spacers, closed mouth technique
-budesonide also in nebulizer form
GLUCOCORTICOIDS
(ORAL: PREDNISONE, PREDNISOLONE)
-only if severe asthma when sx cant be controlled
-should be used as short a course as possible
-ADR: adrenal suppression, O/P, hyperglycemia, PUD, suppression of growth in children
-acute therapy: 30-40mg bid for 5-7 days
-long term: initial-40-60mg every other morning, reduce by 5-10mg every 2wks to establish lowest effective dose
GLUCOCORTICOID/BETA2 AGONIST COMBO
-for prophylaxis/mtnce therapy
-fluticasone+salmeterol>advair: 1 inhalation bid
-budesonide+formoterol>symbicort: 2 inhalations bid
CROMOLYN
(NEDOCROMIL SIMILAR TO CROMOLYN)
-for prophylaxis/mtnce therapy not acute attack
-MOA: suppress inflammation by stabilizing mast cells and inhibiting inflammatory cells
-use: chronic asthma, exercise induced astma, allergic rhinitis (intranasal)
-ADR: occasional cough and bronchospasm
-nebulizer: 20mg qid
-MDI: 2-4puffs qid then lowest effective dose for maintenance on fixed schedule
THEOPHYLLINE
(METHYLXANTHINE COMPOUND)
-MOA: relaxes smooth muscle in bronchi to cause bronchodilation
-rapid absorption erratic and w/extended form is slower but more stable, metabolized in liver affected by many factors, plasma levels should be between 5 and 15mcg/ml
-toxicity: dysrhythmias, convulsions, cardiorespiratory collapse leading to death
-drug interx:
--caffeine: similar to pharmacologic properties of theophylline
--phenobarbital, phenytoin, rifampin: can decrease levels
--cimetidine, fluroquinolones-can increase levels
-oral: individualized dose to get plasma levels between 5 and 15mcg/ml
-IV: rserved for ER, admin slowly
ANTICHOLINERGIC MEDS FOR ASTHMA
IPRATROPIUM
TIOTROPIUM
LEUKOTRIENE MODIFIERS
(ZILEUTON-ZYFLO)
-for prophylaxis/mntce of asthma
-MOA: inhibits 5-lipoxygenase thus decreasing leukotriene production
-sx improvement 1-2hrs
-ADR: hepatic injury (hepatitis)
-drug intx: CYP450 metabolism, increase levels of theophylline, warfarin, and propanolol
-600mg qid
LEUKOTRIENE MODIFIERS
(ZAFIRLUKAST-ACCOLATE)
-mntce of chronic asthma
-MOA: leukotriene receptor antagonist
-ADR: headache, GI disturbances, arthralgia, myalgia, rare (liver injury and churg-strauss syndx)
-Drug intx: CYP450 inhibitor, increase levels of theophylline and warfarin
-20mg bid, not with food
LEUKOTRIENE MODIFIERS
(MONTELUKAST-SINGULAIR)
-mntce of asthma and allergic rhinitis
-MOA: leukotriene receptor antagonist
-less effective than GC but can enhance sx improvement in combo
-ADR: doesnt appear to cause liver injury, churg strauss syndx
-Drug intx: fewer than zileuton and zafirlukas, phenytoin decreases levels
-10mg qd in the evening, granules that can be put in applesauce, etc.
OMALIZUMAB
(XOLAIR)
-monoclonal antibody
-MOA: IgE antagonist by binding to IgE to make it unavailable to bind with mast cells
-2nd or last line agent for those w/allergy related asthma when preferred options fail
-only useful when specific allergen is cause of attack
-ADR: injection site reaction, viral infection, URTI, sinusitis headache, pharyngitis, rare (malignancy, anaphylaxis)
-single use vial for SQ
-once reconstituted should be room temp for no longer than 4h or fridge no longer than 8h
-dose based on body wt and serium IgE level at baseline
-typical: 150-300mg q4wks to 225-375mg q2wks
-doses >150mg should be split and at 2 or more sites
COPD
-airflow is limited and the limitation is not fully reversible
-sx: cough, sputum production, dyspnea on exertion
-risk factors: tobacco smoke, occupational exposure, indoor air pollutants, outdoor air pollutants
-tx: prevent disease progression, relieve sx, decrease mortality, improve exercise tolerance and health status, prvent and tx exacerbations and complications
-reduce risk factors: smoking cessation, protective gear and avoidance of occupational exposure, for pollution, proper indoor ventilation, monitor public air quality announcements
-exercise to reduce dyspnea and fatigue
-non mechanical ventilation:exacerbations
-immunizations: flu, pneumococcal
-O2 therapy good for those w/chronic hypoxia
-education on how to avoid factors and monitoring
ASTHMA VS COPD
ASTHMA
-onset early in life
-sx vary day to day
-sx present at night/early morning
-allergy, rhinitis, and/or eczema present
-family history of asthma
-reversible airflow limitation
COPD
-onset midlife
-sx slowly progress
-long smoking hx
-dyspnea during exercise
-irreversible airflow limitation
CLASSIFICATION AND TX OF COPD
-CLASSIFICATION
-LUNG FX
-SX
-TX
STAGE 0
-normal lung fx
-chronic cough, sputum production
-avoid risk factors, flu and pneumococcal vaccine
STAGE 1: MILD
-FEV>=80% predicted, mild airflow limits
-chronic cough, sputum production
-add short acting bronchodilator prn
STAGE 2: MODERATE
-80%>FEV>=50% predicted, worsening airflow limits
-progression of cough and sputum prodx, SOB upon exertion
-add regular tx w/>=long acting bronchodilators and rehab
STAGE 3: SEVERE
-50%>FEV>=30% predicted, further worsening aiflow limits
-increased SOB, repeated exacerbations that impact QOL
-add inhaled GC if having repeated exacerbations
STAGE 4: VERY SEVERE
-FEV<30% predicted or <50% and chronic resp. failure, severe airflow limits
-QOL very impaired, exacerbations may be life threatening
-add long term O2 therapy, consider surgical tx
BRONCHODILATORS
(BETA2 AGONISTS)
-inhaled preferred, po and parenteral use discouraged
-not as effective in COPD as asthma
-Agents: ALBUTEROL, FORMOTEROL, SALMETEROL
-albuterol can be prn or scheduled to prevent sx
-salmeterol and formoterol can be given q12h in those w/frequent and persistent sx
BRONCHODILATORS
(ANTICHOLINERGICS-IPATROPIUM, TIOTROPIUM)
-MOA: inhibit cholinergic receptors in lungs which reduces cGMP causing bronchodilation
IPATROPIUM (ATROVENT)
-for COPD or asthma
-can be in combo w/beta2 agonists
-ADR: dry mouth, irritation of pharynx, metallic taste
-avoid atrovent and combivent in those w/peanut allergy
-MDI: 2-4 puffs qid
-Nebulizer: 3ml qid
TIOTROPIUM (SPIRIVA)
-long acting
-COPD or asthma when other tx not effective
-ADR: dry mouth
-capsules crushed for inhalation
-18mcg qd
-handi-haler device
COMBO BRONCHODILATORS
ANTICHOLINERGICS + BETA2 AGONISTS
METHYLXANTHINES+THEOPHYLLINES
-sustained release form
-added if not well controlled on ipratropium and beta2 agonist
-initial 200mg bid, usual 400-900mg qd, therapeutic 10-20mcg/ml
CORTICOSTEROIDS
-should be avoided if possible
-consider for short term exacerbations and inhalation for chronic stable COPD
-combo bronchodilators and corticosteroids
--salmeterol+fluticasone>advair
--formoterol+budesonide>symbicort
EXACERBATIONS
-goal of therapy: prevent/reduce hospital stay, prevent resp. failure and death, resolve sx and return to baseline
-bronchodilators: short acting preferred, may need nebulization'
-corticosteroids: prefer short course 9-14 days
-antimicrobial therapy
--candidates for therapy: have 2/3 of sx: increased dyspnea, increased sputum volume, increased sputum purulence
--common pathogens: hemophilus influenzae, moraxella catarrhalis, streptococcus pneumoniae, hemophilus parainfluenza
--therapy lasts 7-10days
-should be limited to acute exacerbations