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146 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Name 4 things that affect coumadin dosing:
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Genetics (CYP, VK oxioreductase),
food, age (older - lower dose), weight |
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Which factors does cumidin inhibit?
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II, VII, IX, X, as well as proteins C & S
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How would you dose a liver pt cumidin?
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Less - they make less factors, are very sensitive
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What are the 2 ways an Abx can affect cumidin in a pt?
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CYP, and by killing VK producing bacteria in the GI tract
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To what extent do genetics (CYP & VK OR) affect cumidin dosing?
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40%
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What drugs can cumidin be susceptible to interations with?
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Just about anything. To be safe - always lower an inr 2 days later.
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Majority of Abx raises inr, one lowers it. Why?
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Rif lowers inr in pt on cumidin - is a CYP inducer. It induces metabolism of cumidin, lowing S.C.
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How do oral nasal decongestants (pseudoephedrme, pseudaphed PE, phemlephrone) work?
what is their MOA?) |
They are pressors. They bind to alpha 1 (alpha adreneigic vasocanstoctron) receptors in the vasculature and stimulate them.
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What happens to nasal - Sinus SM vasculature when you have a cold?
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There is vasodialation sec to inflamatory mediaters. This process is antagonized by nasal decongestants.
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How do nasal decongestants help the plumbing of the nose and sinuses?
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They promote drainage
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Why do we sign for sudafed?
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It is 1 reduction step away from being converted to meth.
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Why are nasal decongestants and antihistenmines a good mix?
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Antihistenmines help dry the airways to lower the drainage. They also help eye sx.
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What would an antihistamine alone probably do?
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Probably make congestion worse.
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What are some SE's of oral nasal decongestants?
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Higher HR, irritability, insomnia, ancretea, higher BP
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Why is pseudafed PE only effective in higher doses?
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1st pass
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What is the most troublesome SE of nasal decongestants?
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Higher HR
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Since phenylephone does not work well PO, how does it work well?
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Topically
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How long can you use phenylephone topically?
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Only a few days. Any longer and you will get medicamentosa (rebound effect)
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Why was ephidrine removed from market?
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As a wt. Loss supplement it caused strokes
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With bladder/urinary tract disorders, who will benefit from an alpha agonist?
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People with difficulty controlling their bladder. Alpha agonist will improve their ability to control flow because it causes constriction
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Who will be hurt by use of an alpha adrenergic agonist?
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Male population with difficulty urinating. Will probably make it worse
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What is the effracy of topical phenylephrine?
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Very good
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What are the systemic SE's of top phen?
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none
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When looking at nasal decong, what caution do we use when evaluating label?
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Cannot just go by label. Must pay attention to ingredients
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What is Afrin and what is dose?
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Long acting, 2-3 sprays twice daily
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What is dose for topical phenylephrine?
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2-3 sprays Q 4 hours
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Do antihistemines provide nasal decongestion?
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No. Only drying.
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What are the cautions on the box of PO nasal decongestants?
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Ask MD if you have: H Dis, higher BP, thyroid dis, DM, trouble urinating, sec to enl. Prostate. Also separate from MAOI's by 2 weeks
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Why worry about DM w/ nasal dec?
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Alpha agonists promote glucose release from liver
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Why worry about nas dec with thyroid diz?
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Worry for HR (alpha ag will higher HR)
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Do oral nasal decongestants cause medicamentosa?
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No. They do have some potentially severe systemic SE's though, most troublesome which are CV
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Why do drug companies market PE when it does not work?
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It can be sold anywhere (gas stat, convenience st.). It does not have to be signed for.
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What can happen when an oral nasal decongestant is given with an MAOI?
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BP can go through the roof
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There is a risk for giving a nasal degongestant to someone on an MAOI. Why? (MAO knocks over IV pole, break bag)
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Monomine oxiolase is an enzyme that breaks down neurotransmitters in the brain (Dopamine, Norephephone, Epinephrine) MAOI's inhibit their break down. If you then stimulate these receptors, BP goes up, up, up. (Crisis)
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what does MAO do in the body?
what do MAOI's do in the body? |
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With oral antihistamines, what is the difference between 1st and 2nd generation?
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1st gen crosses blood/brain barrier
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Name some 1st generation oral antihistemines:
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Brompheniramine, Chlorpheniramine, Doxylamine, Diphenhydramine, Triprolidine
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Name the 3 legal 2nd generation oral antihistemines:
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Cetirizine (Zyrtec), Fenfexadine, Loraterdine
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What does the antihistemine warning label say?
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Do not take unsupervised (MD) if you have COPD or chronic bronchitis, or difficulty urinating 20 enlarged prostate
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Whydoes a-histamine label say what is says?
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Drying effects irritate Lunger's (chron bronchitis and COPD) and,
anticholerergics relax the detrusor muscle, decreasing the ability to empty the bladder |
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What disease are we really worried about with antihistemines?
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Closed angle glaucona. Drainage of vitrous humor is already impaired. An anticholorergic will dialate the pupil (contstricting the iris), making the already narrow drain close off.
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What 2 2nd generation oral antihistemines were taken off the market? Why?
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Astemizole and Seldane. They are substrates for CYP. Higher in SC = QT prolong, torsades. Too hard to keep track of
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What system innervates the Detrusor muscle?
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Parasympathetic (Cholenergic)
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What do anticholerergic antihistemines do to this muscle?
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Relax it, lowering ability to empty bladder
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How do topical steroids work in the sinuses?
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They inhibit migration and activity of inflamatory mediators
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What are prec/SE's with topical steroids?
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Mucosal irritators, epistaxsis
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Is there systemic SE's or rebound w nasal steroids?
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None of the above
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Name 2 topical steroids for the sinuses?
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Flonase, Rhinacort
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What is the difference between Flonase and Veramyst? (dingy)
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Veramyst is scent free
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How do nasal steroids compare in efficacy to other nasal decongestants?
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Almost as good, even better
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Do nasal steroids work for eye st?
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Not as good as antihistemines
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What is Atrovent?
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An anticholerergic that promotes brochodialation
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What do cholenergics do to the bronchral tree?
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Constrict it
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How does albuterol work in pure asthma?
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It reverses it
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In reality, what lung issues do most pt's we see have?
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A mix - COPD - Asthma
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Is Asthma a restrictive process or an inflamatory one?
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An inflamatory one
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Is COPD a restrictive process or an inflamatory one?
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Restrictive, destructive
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56 year old, no change in FEV with albuterol, which inhaled agent do you go to next?
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V slide
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How is asthma triggered?
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Allergens, wide variety
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What is the major factor in asthma? (Pathophys)
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Airway inflamation, but also small airways too
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In asthma RX, what is important? (Delivery wise)
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Delivery to lower airways. Technique of pt is important for this
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What 2 bad things happen with in the bronchial tree with asthma?
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Inflamation, and the elastic-looking bands of muscle constrict the tract
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How do you RX bronchoconstriction acutely?
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Give a drug that will stimulate B2 receptors (Albuterol, B2 agonist)
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What will the B2 agonist do?
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Promote smooth muscle relaxation
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What is more effective than albuterol?
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Epi-but? Risk vs benefit?
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What is a key factor in asthma on the patient's end?
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Motivation and concordance. It takes vigilance to stay on top of this disease.
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What are the 4 key factors in asthma mgt?
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Routine monitoring (St, FEV), control triggers,
Drug RX, Pt education |
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What are some asthma triggers?
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Dust, animal dander, airborn irritants, seasonal pollens (tree, grass, weed), mold
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What drugs are best for long term asthma control?
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Corticosteroids
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What are second best drugs for asthma?
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Leukotrien modifiers (singular)
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Name the 7 catagories of drugs available for asthma today: (think of the pneumonic)
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Beta agonists, Antichorenergics, Corticosteroids, Mast cell stabilizers, Mononoclanal antibodies, Lleukotriene modifiers
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How do beta agonists work at the beta 2 receptor?
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They enhance conversion of ATP to CAMP by stimulating adenalyde cyclase. This results in smooth musle relatation
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What are some SE's of B agonists?
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Tachycardia, palpitations, tremor, lower K
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Through what route do most systemic SE's of inhaled b agonists get absorbed?
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Swallowed. It is impossible not to. Also, at this level of absorption, you overome B1 B2 selectivity
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Name 3 Beta agonists
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Albuterol (also in tabs), salmeterol (serevent) and Levalbuterol (topenet)
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What was the FDA warning on long acting beta agonists?
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Regular use will increase chance of a severe asthma episode. Also, avoid 1st tine use
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Name 2 long acting Beta agonists (that the warning pertains to)
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Sulmeterol (serevent) and Fomoterol (foradil)
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What is the most common combination including long acting B agonists?
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Combination with an inhaled steroid
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Name a short acting inhaled anticholerergic
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Atrovent
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Name a long acting anti-cholerergic
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Spiriva
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What is in aduir diskus?
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Servevent and Flonase
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Which is easier to control, MDI or diskus?
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Diskus
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Is Aduir for acute Rx?
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No
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What do corticosteroids inhibit in the body?
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Arichdonic acid, thus Leukotrienes and Prostaglands
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What do leukotrienes and prostaglands do?
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They are inflamatory
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Where do leukotrienes hang out?
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In the lungs
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Why do steroids produce a higher WBC with no left shift?
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Because there (the hanging ones are mature) are WBC's attached to bv walls just clinging there. Steroids destroy that linkage, now they are mobile and canted
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What are some SE's of steroids?
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Higher BP, osteoporosis, musle weakness, skin weak
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Name the acute SE's of steroids: (Rapper pheumonic for acute steroids)
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GCE HAH!
G- GI: ulcer/bleed, C-CNS (mania, dep), E-Electrolyte imbalances, H-Hypertension, A-anasareca (fluid ret), H-hyperglycemia |
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What are some chronic adverse effects of steroids? (Guitar player pneumonic for fad, sad people)
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APGIOO.
A-adrenal supression, P-proximal muscle weakness, G-growth supression, I-Immunosupression, O-ostioporosis, O-occular toxiciy |
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Between Azmacort, QVAR, Polmicort and Flovent, which is more potent?
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Flovent. @220 ng can only take 3 puffs a day max
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In terms of potency, what does 3 puffs of Flovent = in Azmacort? (Per day)
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>20 puffs/day
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What happens if you use flovent in pts on HIV drugs?
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Higher Sc. Cyp pathway
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On adult Asthma management chart, describe Sx and SABA needs: (1-4/5)
(this is broken down on the lacture 4 addemdum.) |
1 (intermit) <2D wk (SABA need) <2D/wk, 2 (mild persist) >2D wk (SABA need)72 d/wk, 3 (most persist) daily (SABA need) daily, 4/5 (severe persist) continuous (SABA need) several x day
(this is broken down on pharm lecture 4 addendum.) |
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What do leukotrienes do in the body?
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They are potent contractile agents. They mediate bronchospasm, muscus, edema, eosm recruitment, smooth muscle profection. They hang out in the lungs
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What does singular do?
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It specifically blocks the leukotriene receptors
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What is the difference between Zylro and singular?
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Zyflo blocks synthesis of leukotrienes by inhibiting 5-lipooxygenase. Singular selectively blocks leukotriene receptors
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Why is Zyflo not as good a choice as the selective leukotriene recepter blockers like singular and accolate?
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It causes liver toxicity
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What do leukotriene receptor blockers have in common with antihistemines?
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They do the same thing. Leukotriene receptor blockers are almost like giving an expensive antihistemine
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Why would you give a leukotriene receptor blocker instead of an antihistamine for that purpose?
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You could use it if you were one of a small few who got systemic SE's from inhaled steroids
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What is Zileuton?
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A leukotriene antagonist (not receptor blocker)
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Why do we not use Zileuton much?
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It is a CYP450 inhibitor. It is also hepatoxotic and requires LFT monitoring.
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What do Leukotriene antagonists interact with?
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Theo, cumodin
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Name 3 Leukotriene Antagonists?
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Zileuton, Zafirlukast, Montelukast
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What is Chung-Strauss syndrome?
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Seen with Leukotriene modifiers, it is a vasculitis. Is it the asthma or the drug?
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What do mast cell stabilizers do?
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They block the release of histamine from mast cells
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Name 2 mast cell stabilizers
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Cromolyn Sodium (interl) and Nedocromil sodium (Tilade)
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Do we use mast cell stabilizers in an acute event?
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No-chronic
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Why do parents want their kids on mast cell stabilizers?
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Because there are no SE's. But in reality, inhaled steroids are better and will thwart a cycle of PO steroids, which has more SE's than anything
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How is Atrovent like the opposite of albuterol?
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Albuterol promotes increase in CAMP, Atrovent blocks muscurinic receptors and prevents conversion of GTP to cGMP. (cGMP promotes Broncho constriction)
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Albut and CAMP?
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Higher CAMP (more bronchodilation)
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Atrovent and cGMP?
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Lower cGMP (less Broncho constriction)
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Who might get Atrovent instead of albuterol?
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Someone who has too many SE's with Albuterol, or combo with COPD pts
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What is the antithesis of CAMP?
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cGMP. It broncho constricts, while CAMP broncho dialates. They are opposite one another in action on the bronchial tree
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Which is quicker at opening the airways, Albuterol or Atrovent?
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Albuterol. Atrovent takes longer
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What do ammophylline and Theophyline do? (action on airways)
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They relax smooth muscle
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What is a theraputic theo level?
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10-20 mcg/ml (think < INR X10)
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What are SE's of theo? (think caffine)
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G1 irritation, CNS (agitat, SZ) tachy/arryth.
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What is theo just like?
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Caffine
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Why do we not use theo as much anymore?
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It has a narrow TI.
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When in what diseases do we caution for potentially high blood levels with theophylline?
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Age, heart failure, LN. DIZ, drug interactions
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What drugs interact with theo?
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Cimetidine, Emycin, CIPRO
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What would lower blood levels of theo?
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Age, smoking, drug interactions
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What drugs lower blood levels?
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Phenobarb, Dilantin, Rifampin (inducers)
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Name the drug that is a monoclonal antibody
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Omalizumab (xolair)
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When would we use omalizumab (xolair?)
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Allergic asthma that is refractory. Costs 10k/year
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What type of pts would use Omalizumab (xolair)?
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Peanut allergies - parents will pay cash
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How do you dose Omalizumab (Xolair)?
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SQ every 1-2 weeks. Animal source, pot. for reaction (s.c.)
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What is Albuterol HFA?
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Ozone friendly, company branded it after regulation passed and doubled the price
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Example: theodor + cipro. What happens?
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CYP inhibition. Higher SC. Deaths reported.
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So in closing, the 7 drugs for asthma are:
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BACMML.
B-beta agonists (Alb), A-anti-cholenergics (Atrov), C-corticosteroids (pred), M-mast cell stab (cromolyn sodium), M-monoclonal antibodies (xolair), L-leukotriene modifiers (singular, Accolate) |
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COPD office visits/year?
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15-20 mil
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COPD medical expense/year?
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714 mil
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Where is COPD on leading causes of death?
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4th
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How many die from COPD annually?
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126,382
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Basically, what is the pathophys of COPD? (Draw)
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Inflamation -> -small airway diz, -remodeling ->Airflow limitation; Inflamation -> -parenchymal dest, alveo loss, -lower elastic recoil -> Airflow limitation
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Is COPD reversible?
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No
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What are goals of COPD?
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Assess and monitor PFT's, quit moking, education, drug Rx
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What would happen in an asthma attack (to FEV) as opposed to COPD when treated witha B agonist?
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FEV would improve with a beta agonist in asthma. In COPD, it would not
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How do available COPD drugs impact long term decline in lung function?
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They have little effect
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Of the 4 (B agonist, Anticholenergic, theo, combinations) which is best for COPD?
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Anticholenergics
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What about inhaled steroids with COPD?
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? efficacy
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What is the long acting anticholenergic?
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Spiriva
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How does spiriva work?
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Blocks aceytlcholine at the muscarinic receptors in the parasympathetic nervous system, preventing increase in cGMP
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How do we dose spiriva?
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18 mg daily via handihaler
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When would we use inhaled steroids in COPD?
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Only when some reversibility is demonstrated, or if repeated exacerbations require other Rx (Abx, po steroids)
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In case study, 25 y.o. female with hx intermittant asthma, noted to be asking for INH refills too soon. She is really a 3 or 4 on asthma mgt. scale. If she refuses inhaled steroids, how could you Rx her?
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You could try singular, but she needs to know that steroids have the greatest efficacy.
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