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197 Cards in this Set

  • Front
  • Back
-ratio defines particle
-job is to deliver fatty acids all over the body
-cholesterol, phospholipid, and protein alls particle to move
about half triglycerides, 1/4 cholesterol and the rest phospholipids and proteins
causes hypercholesterolemia
-lots of cholesterol and not much triglycerides
Best predictor for heart disease
mostly proteins- high density
good cholesterol
Positive risk factors other than LDL cholesterol for CHD
-men >45, women >55
-family history of premature CHD, <55 for men, <65 for women
-low HDL cholesterol ,40 mg/dl
-negative risk factor- HDL >60 mg/dl
Treatment decisions based on LDL cholesterol
w/o CHD, <2 risk factors <160 ml/dl
w/o CHD, >2 risk factors <130 mg/dl
with CHD or risk equivalents <100 mg/dl
Bile Acid Sequestrants
Bile Acid Sequestrants MOA
bind bile acids in the intestine and prevents absorption
liver uses LDL to make more cholesterol for bile acids
Sequestrants Adverse Effects
belching, bloating, constipation, unpleasant taste and texture
Sequestrants Effects on Cholesterol
increase in triglycerides
slight increase in HDL
moderate decrease in LDL
Niacin MOA
reduction in hepatic production of VLDL
Niacin Common Adverse Drug Reactions
flushing, pruritis, rash, urticaria
-take with food
-use SR product
-start with low dose and titrate up
-aspirin before dose
-don't take with hot fluids or alcohol
Niacin Serious Adverse Drug Reactions
-active gout
-peptic ulcer disease
-severe gastritis
Niacin Effects on Cholesterol
lowers triglycerides
*best drug to increase HDL
moderately decreases LDL
Statins MOA
inhibition of intracellular synthesis of cholesterol in the liver
Serious Adverse Drug Reaction of Statins
myopathy (aches, weakness, soreness)
Statins Effect on Cholesterol
decrease in triglycerides
slight increase in HDL
*biggest reduction of LDL 25-60%
Fibric Acid Derivatives
Fibric Acids Derivatives MOA
catabolism of VLDL
used for lowering triglycerides
Targeted towards diabetics
Common ADRs of Fibric Acid Derivatives
abdominal pain
Serious ADRs of Fibric Acid Derivatives
cholilithiasis- gall stones
Inhibits absorption of cholesterol across intestinal wall
-used with statins to reduce LDLs
Criteria for CHD risk equivalents
any condition that increases risk so much that we pretend they already have the disease, such as diabetes
Compare and contrast acute and chronic pain
Types of Pain
• Acute
– Nociceptive
– Transient (< 3 months)
– Occurs after direct
nerve stimulation (injury
or trauma)
– Supportive physical
– Relieved with
conventional analgesic
• Chronic
– Neuropathic
– Persistant (> 3 months)
– Occurs in the absence
of detectable, ongoing
– Delay in onset/persists
after precipitating injury
– Not easily treated with
Two major types of pain: Nociceptive
direct stimulation of pain receptors, either somatic or visceral
Two major types of pain: Neuropathic
Caused by peripheral nerve injury rather than stimulation of pain receptors
Compare and contrast pain management between acute and chronic pain
Acute vs. Chronic Pain
Scheduled (around
Regimen Scheduled or PRN the clock) and PRN
Organic cause Common Often not present
Treatment goal Cure Functionality
Unusual Common
Tolerance to
Psychological Usually not present Often a major problem
Relief of pain Highly desirable Highly desirable
Characteristic Acute Chronic
Non Opioid Analgesics
Acetaminophen (APAP)
Aspirin (ASA)
Use: mild to moderate pain
-analgesic and antipyretic
-NOT anti-inflammatory
caution in hepatic impairment or heavy alcohol users
use: inflammation, fever, anti-platlet
-bleeding disorders or in combination with other anti-platlets
-young children for viral infection (Reye's syndrome)
-history of GI disease
-renal dysfunction
uses: analgesic, anti-pyretic, anti-inflammatory
-history of GI disease
-in combination with anticoagulants
-decreased renal or hepatic function
NSAIDs: drugs
Weak Opioids
generally used with non opioid medications
oral formulations only
-codeine (morphine like)
-hydrocodone (morphine like)
-propoxyphene (methadone like)
Weak Opioid combination products
codeine/acetaminophen(tylenol #3, 4)
hydrocodone/acetaminophen (lortab, lorcet, vicoden, norco)
Central Opioid like Analgesics
lower abuse potential than opioid agonists
-increased risk of seizure
-oral formulation only
-dose reduction in renal and hepatic function
-tramadol/acetaminophen (Ultracet)
Strong Opioids
-Morphine like:
-Meperidine like:
IV, IM, SQ, PO, PR formulations available (1:3 IV/PO dosing ratio)
-imediate release and sustained release
oral formulations only
more potent than morphine
IV, IM, SQ, PO formulations available
(1:5 IV/PO doing ratio)
Meperidine (Demerol)
less potent and shorter duration of action than morphine
-IV, IM, SQ, PO formulations available (1:1 dosing conversion)
-can cause tremor, muscle twithing, and seizures
rarely used in medical practice
much more potent and shorter acting than morphine
-used as adjuct to general anesthesia during surgery
-patch form for chronic pain
-no oral formulation available
more potent than morphine
-available in PO, IV, IM or SQ
Used for:
chronic pain
narcotic treatment programs
-delayed onset and long duration of action
Opioid Side Effects
-respiratory depression
-itching, pruritis
-tolerance or dependence
Patial Agonist
Advantages: lower abuse potential than morphine
Disadvantages: may initate withdrawal in opioid dependent populations
Adjuctive Medications
-used to alleviate some of the ADRs associated with opioids
Mechanisms of Contraception
-prevent sperm from entering the vagina
-immobilization or inactivation of sperm
-fertility awareness
-prevention of ovulation/implantation
Estrogen Contraceptive effects
inhibition of ovulation
inhibit implantation
accelerate ovum transport
Progestin contracetive effects
increase cervical mucus
capacitation inhibited
slow ovum transport
inhibit implanation
inhibit ovulation
Difference between monophasic, biphasic, and triphasic COC
monophasic: all pills in pack have same amount of estrogen/progesterone
biphasic: first 10 days have certain amount of esterogen/progestin, then the last 11 days have an increase in progestin
triphasic: gradual increase of progestin with every week in the pack
Dose of ethinly estrodoil that constitutes a low dose
30-35 micrograms
Pharmacological effects of progestins in COC
progestinal, estrogenic, antiestrogenic, andogenic
signs and symptoms of estrogen excess
breast tenderness
weight gain
signs and symptoms of estrogen deficiency
hot flashes
decreased libido
atrophic vaginitis
Non contraceptive advantages of COC
protect against ovarian and endometrial cancer
decreased benign breast disease
decreased rate of eptopic pregnancy
PMS reduction/cramping
less menstral flow
signs and symptoms of progestin excess
noncyclic weight gain
oily skin
breast tenderness
signs and symptoms of progestin deficiency
late BTB days 8-21
heavy menstral flow
delayed withdrawal bleeding
weight loss
Absolute contraindications for COC
present/past thrombophlebitis, thromboembolic disorders, cerebral vascular disease, coronary occlusion
-markedly impaired liver function
-known or suspected breast cancer
-undiagnosed vaginal bleeding
-known or suspected pregnancy
Relative contraindications for COC
-migraine headache
-elective surgery
-gallbladder disease
- >35 years old and heavy smoker
- >40 years old and cardiovascular risk factors
How and when to start oral contraceptives
1st tablet on 1st day of menses or 1st tablet on the 1st Sunday after begining menstration
Missed dose of oral contraceptives
forget 1: take as soon as remembered
forget 2 in a row during week 1 or 2, take 2 on each of the next 2 days
forget 2 in a row during week 3 or 3 in a row during week 1 or 2, discard the rest of the pack and start a new pack some day
Signs and symptoms of medical emergencies of women on COC
loss of vision
unilateral numbness, weakness, tingling
severe pain in chest, left arm, neck
severe pains, tenderness, swelling
sluring of speech
hepatic mass or tenderness
Combined injectible contraceptive
-injected once a month
Mini pill
Uses: appropriate for nursing mothers or women with estrogen related ADRs
-less effective and more likely to produce more side effects
uses: inserted in the upper arm and lasts for 3 years
deep IM injection
-administered every 3 months
Difference between Yaz/Yasmin and other COCs
claims less weight gain because it acts like a diuretic
-approved for treatment of PMDD
Difference between Seasonale and other COCs
4 periods a year
monophasic, so doesn't decrease acne
Difference between Seasonique and other COCs
same as Seasonale but uses low dose estrogen instead of placebo during the 4 menstral periods/year which reduces breakthrough bleeding
Differences between Lybrel and other COCs
no menstral periods
How to use the Nuvaring
insert into vagina and begin the same way you would for oral contraceptives
3 weeks in, 1 week out, insert new one
How to Use and special risks associated with Ortho-Evra patch
apply patch to abdomen, buttocks, upper torso, or upper outer arm
-patch is changed once a week on the same day and worn for 3 weeks
-increase risk of blood clots due to 60% higher blood estrogen levels than COCs
Patient instructions for use of minipill
begin on the 1st day of menstral bleeding
take exactly the same time every day
usee 2nd method of contraception the first 2 months
use back up method of contraception for 2 days if more than 3 hours late taking the pill
Advantages and disadvantages of condoms
advantages: available over the counter, 12% effectiveness
disadvantages: can break, slip off
Advantages and disadvantages of female condoms
advantages: stronger than latex
STD protection
protects outside vagina
not affected by oil base lubricants
not MD visit needee
con be inserted up to 8 hours before sex
disadvantages: dislike ring hanging outside vagina
advantages and disadvantages of spermacides
readily available OTC
effective immediately
can be lubricating
no systemic side effects
easy to use
may aid the protection against some STDs
failure to use consistently
sex too early, sex too late
using too little
running out
not keeping available
Diaphram and cervial cap
should not be left in more than 48 hours or taken it out before 6 hours after intercourse
should not be used in women that have had children
Efficacy of discussed contraceptives
COCs: 0% perfect, 3% typical
minipill: 1.1% perfect, 3% typical
depo-prevera: 0% perfect, 0.3% typical
spermacides: 0-3% perfect, 21% typical
diaphram: 2.1% perfect, 18% typical
nulliparous cervical cap: 8% perfect, 18% typical
parous cerival cap: 26% perfect, 36% typical
condoms: 4.2% perfect, 12% typical
IUDs: 0.5% perfect, 3% typical
active ingredients: levonorgestrel-releeasing intrauterine system
effective duration: 5 years
pelvic inflammatory disease
increased menstral blood loss
uterine perforation
septic abortion
ectopic pregnancy
+ progestin ADRs
Emergency contraception
Preven and Plan B
nausea and vomiting
Type 1 and Type 2 Diabetes
Type 1 is usually seen in children and is caused by autoimmune destruction of the insulin-secreting beta cells of the pancreas
-complete insulin deficiency
Type 2:
risk increases with age, weight, ethnicity, family history, and lack of physical activity
Caused by a progessive insulin secretory deficit inthe background of insulin resistance
-the beta cells produce insulin, but the body is unable to use it effectively
Diagnosis of Diabetes
2 hour blood glucose > 200 mg/dL during an Oral
Glucose Tolerance Test (OGTT) using 75 grams of
anhydrous glucose dissolved in water
Fasting blood glucose > 126 mg/dL
(no caloric intake for at least 8 hours)
Symptoms of diabetes and
random blood glucose > 200 mg/dL
 Must confirm on a subsequent day unless
unequivocal hyperglycemia symptoms
Hyperglycemia signs and symptoms
exteme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea
Hypogylecemia signs and symptoms
shaking, sweating, anxious, dizziness, hunger, fast heartbeat, impaired vision, weakness/fatigue, headache, irritable
Management of Diabetes and A1c
Summary of recommendations
for adults with diabetes (ADA)
HDL > 40 mg/dL
TG < 150 mg/dL
LDL <100 mg/dL (<70 mg/dL)
Blood pressure
<130/80 mmHg
Glycemic control
Postprandial BG <180 mg/dL
Preprandial BG 90-130 mg/dL
A1c <7% (<6%)
Sulfonylureas: Medications
Sulfonylureas: insulin secretagogues
 First generation
 Acetohexamide
 Chlorpropamide
 Tolazamide (Tolinase®)
 Tolbutamide (Orinase®)
 Second generation
 Glyburide (Micronase®,
 Glyburide micronized
 Glipizide (Glucotrol XL®)
 Glimepiride (Amaryl®)
Sulfonylureas: MOA
Stimulate pancreatic beta cells to increase secretion of insulin
Sulfonylureas: Adverse effects
mild weight gain
pregnancy category C
Sulfonylureas: Advantages and Disadvantages
 Advantages:
 Low cost, generically available
 Much data to support use
 1-2% reduction in A1c
 Second generation has fewer side effects
 Disadvantages:
 Hypoglycemia
 Become less effective over time as beta cell
number and function decreases
Sulfonylureas: Place in therapy
 Place in therapy:
 First line in newly diagnosed type 2 diabetes
 Monotherapy or combination therapy
 Patients that are thin or normal body weight
 Patients with mild to moderate fasting
 Most useful within first 5 years of therapy in
patients with no history of insulin use
Meglitinides: Medications
Non-sulfonylurea secretagogues
Meglitinides: MOA
stimulate insulin release from the pancreatic beta cells to reduce postprandial hyperglycemia
Meglitinides: Adverse effects
weight gain
pregnancy category C
Meglitinides: Advantages and Disadvantages
 Advantages:
 Do not cause continuous insulin secretion
 More closely reproduces normal pancreatic response
 Causes less hypoglycemia / weight gain than
 Disadvantages:
 More costly than sulfonylureas
 CYP3A4 metabolism  drug interactions
Meglitinides: Place in therapy
Place in therapy:
 Monotherapy or combination therapy
 Repaglinide may be useful alternative to
sulfonylurea in renal impairment
 Useful if patient eats sporadically
 Must be taken 15 minutes before each meal and
skipped if meal is skipped
 Alternative to sulfonylureas in patients at risk for
Biguanides: Medications
insulin sensitizer
Biguanides: MOA
lowers both basal and postprandial blood glucose
decreases hepatic glucose output
increases peripheral muscle glucose
improves insulin sensitivity
Biguanides: Adverse effects
lactic acidosis
Biguanides: Advantages and Disadvantages
Place in therapy:
 Monotherapy or combination therapy
 Repaglinide may be useful alternative to
sulfonylurea in renal impairment
 Useful if patient eats sporadically
 Must be taken 15 minutes before each meal and
skipped if meal is skipped
 Alternative to sulfonylureas in patients at risk for
Biguanides: place in therapy
 Place in therapy:
 First line in patients with type 2 diabetes without
renal impairment
 Monotherapy or combination therapy
 Overweight patients
 Minimize GI side effects by taking with meals,
starting at a low dose and slowly icreasing; GI
irritation will decrease over time
Thiazolidinediones: Medications
insulin sensitizer
Thiazolidinediones: Adverse effects
weight gain
edema/fluid retention
possible hepatotoxicity
Thiazolidinediones: MOA
Enhancement of insulin sensitivity in adipose tissue, skeletal muscle, and the liver
decreases hepatic output
lowers the free fatty acid concentrations
Thiazolidinediones: Advantages and Disadvantages
 Advantages:
 May help improve beta cell function
 Lower A1c by 1-2%
 Improves lipid profiles
 Disadvantages:
 Insulin dependent action
 Fluid retention
 Expensive
 Drug interactions with pioglitazone
 Liver function test (LFT) monitoring
 May take up to 12 weeks to see full effect
Thiazolidenediones: Contraindications/ precautions
Contraindications /
 Congestive heart failure
 Elevated liver enzymes
 Liver disease
 Edema
 Pregnancy / breast feeding
Thiazolidinediones: Place in therapy
Place in therapy:
 Good combination agent
or replacement agent for
 Second line after
metformin and
sulfonylureas due to
adverse effects and cost
 Should be taken with a
 Do not cause
hypoglycemia in monotherapy
Alpha-glucosidase inhibitors: Medications
Alpha-glucosidase inhibitors: MOA
blocks gut absorption of complex sugars
Alpha-glucosidase inhibitors: Adverse effects
GI distress
Alpha-glucosidase inhibitors: Contraindications
liver disease
renal disease
pregnancy/ breast feeding
Avoid in patients with:
liver cirrhosis
severe kidney disease
inflammatory bowel disease
Alpha-glucosidase inhibitors: Place in therapy
may be used to prolong time to insulin
use in patients not candidates for insulin
Alpha-glucosidase inhibitors: Advantages and Disadvantages
 Advantages
 Improves postprandial hyperglycemia
 No weight gain
 Limited systemic absorption = fewer drug interactions
 Reduce A1c by 0.5-1%
 Disadvantages:
 Minimal effect on fasting glucose levels
 Poor compliance due to GI effects
 Must be taken 30 minutes prior to meals
 Hypoglycemia MUST be treated with GLUCOSE TABLETS
Dipeptidyl peptidase IV inhibitor (DPP-4): Medication
Sitagliptin- Januvia
Hormone modifiers
DDP-4 inhibitor: Adverse Effects and Medication interactions
joint pain
runny nose/sore throat

DPP-4 inhibitor: MOA
prevents breakdown of GLP-1
improves insulin production
suppresses glucagon secretion
DPP-4 inhibitor: Advantages and Disadvantages
 Advantages
 Once daily oral agent
 Targets postprandial
blood glucose
 No hypoglycemia as
 Weight neutral
 Disadvantages:
 Best if A1c <8.5%
DPP-4 inhibitor: Contraindications/precautions and place in therapy
 Contraindications /
 Diabetic ketoacidosis
 Renal
 Place in therapy:
 Patients with type 2
 Monotherapy or in
Incretin mimetic: Medication
exenatide- Byetta
Hormone modifier
Incretin mimetic: MOA
 Mechanism of action:
 Stimulates the glucagonlike
peptide-1 (GLP-1)
 Suppresses glucagon
 Augments glucose
dependent insulin release
 Slows gastric emptying
 Reduces food intake
 Promotes beta cell
Incretin mimetic: adverse effects
nausea/ vomiting
weight loss
accute pancreatis
Incretin mimetic: Advantages and Disadvantages
 Advantages:
 Promotes beta cell
 Weight loss
 Disadvantages:
 Nausea / vomiting
Incretin mimetic: place in therapy and contraindications
Place in therapy:
 Adjunct therapy for type
2 diabetes
 Injectable dosing twice
daily one hour prior to
 Contraindications /
 Severe GI disease /
 End stage renal disease
 Gastroparesis
Amylinomimetic: medication
pramlintide- Symlin
Hormone modifier
Amylinomimetic: MOA
Mechanism of action:
 Slows gastric emptying
 Reduces postprandial
glucagon secretion
 Causes satiety leading
to decreased caloric
intake and potential
Amylinomimetic: Adverse effects and contraindications
Adverse effects:
 Hypoglyceima
 Nausea / vomiting
 Lipodystrophy
 Contraindications:
 Gastroparesis
 Hypoglycemia
Amylinomimetic: Advantages and Disadvantages
 Advantages:
 Decreases mealtime insulin requirements
 Disadvantages:
 Nausea may be pronounced at first – slow titration
 Additional injections
 Hypoglycemia - must decrease mealtime insulin dose by
50% initially
Amylinomimetic: Place in therapy
 Place in therapy:
 Patients with type 1 or 2 diabetes on mealtime insulin
 Patients with postprandial hyperglycemia
Treatment plan for Type 1 Diabetes
diet, exercise, and insulin
Treatment plan for Type 2 Diabetes
 Diet and exercise
 Monotherapy (sulfonylurea or metformin)
 Combination therapy (additional oral or insulin)
 Oral combination therapy plus:
 Third agent
 Insulin
 May switch to insulin monotherapy
Basal insulin
Lowers glucose between meals and overnight
 Decreases fasting blood glucose
 Nearly constant levels
 Approximately 50% of daily insulin
Bolus insulin
 Lowers glucose during and after meals
 Approximately 50% of daily insulin
 10-20% at each meal
Rapid Acting insulins
Glulisine (Apidra®) onset: 10-15 min peak: 60-90 duration: min 3-5 hours
Lispro (Humalog®) onset: 5-15 min peak: 40-60 duration: min 3-4 hours
Aspart (Novolog®) onset: 10-20 min peak: 60-90 duration: min 3-5 hours
Short acting insulin
Regular onset: 30-60 min peak: 1-5 hours duration: 6-10 hrs
Intermediate acting insulin
NPh onset: 1-3 hours peak: 4-6 hrs duration: 12-16 hours
Long Acting insulin
Detemir (Levemir®) onset: 1-2 hours duration: 12-24 hours
No significant peak
Glargine (Lantus®) onset: 1-2 hours duration: 24 hours
Calculating total daily dose of insulin
Total daily dose (TDD)
 Type 1
 Initially 0.3-0.5 units/kg/day
 Honeymoon phase 0.1-0.4 units/kg/day
 Type 2
 Initially 0.3-0.5 units/kg/day
 Insulin resistance 2.5-3 units/kg/day
Calculating split-mixed regimen
Initially approximately 0.5 units/kg/day
 Method 1:
 Morning dose
 2/3 of TDD in 2:1 ratio of NPh to short/rapid acting
 Evening dose
 1/3 of TDD in 1:1 ratio of NPh to short/rapid acting
 Method 2:
 TDD x 0.4 = AM NPh
 TDD x 0.2 = AM short/rapid acting
 TDD x 0.2 = PM NPh
 TDD x 0.2 = PM short/rapid acting
Calculating insulin- switching regimens
 Short acting to rapid acting  1:1 conversion
 Humulin/Novolin/Novolog 70/30 mix to
Humalog mix 75:25  1:1 conversion
 NPh (one daily injection) to Glargine  1:1
 NPh (twice daily injection) to Glargine 
decrease by 20%
 NPh to Detemir  1:1
Characteristics of asthma
 Both acute and chronic
 Airway remodeling
Reversible airway obstruction
 Bronchospasm
 Edema
 Hypersecretion
Signs and Symptoms of asthma
chest tightness
shortness of breath
difficulty breathing
worse at night, in early morning, with exercise or exposure to triggers
Concurrent illness that may worsen asthma
allergic rhinitis
viral infections
pyschological factors
Pulmonary Function tests that are used to diagnose asthma
peak flow meters
Steps in using a peak flow meter
stand while uses
position indicator at bottom/lowest reading
take a deep breath in and blow out as hard as you can into the meter
repeat process 2-5 times after resting
Cutoffs for green, yellow, and red zones
less than 50%= red zone
50-79%= yellow zone
80% or higher= green zone
Classifying asthma severity: Step 1
Mild intermittent:
No daily medication needed
 B2-agonist rescue inhaler PRN
 A short course of systemic (oral)
corticosteroids may be indicated after an
acute exacerbation
Classifying asthma severity: Step 2
Mild Persistent:
Low dose inhaled corticosteroids
 Alternatives to ICS
 Cromolyn or
 Nedocromil or
 Theophylline SR
 Leukotriene modifier may also be added in
some patients
Classifying asthma severity: Step 3
Moderate Persistent:
 Medium dose inhaled corticosteroids
-- AND --
Long-acting β2 agonist
 OR alternative
 Medium dose inhaled corticosteroids
-- AND --
 Theophylline SR
Classifying asthma severity: Step 4
Severe Persistent:
 High dose inhaled corticosteroids
-- AND --
Long-acting β2 agonist
 AND if needed
 Oral corticosteroids
 Theophylline SR
Common triggers of asthma
respiratory infection
occupational stimuli
Classifications of Asthma severity
Step 1
FEV1 or
PEF ≥ 80%
Daytime ≤ 2 times/wk
Asymptomatic between exacerbations
Nighttime ≤ 2 times/mo

Step 2
mild persistent
FEV1 or
PEF ≥ 80%
Daytime > 2 times/wk but < 1x/day
Exacerbations may affect activity
Nocturnal > 2 times/mo

Step 3

> 60% to < 80%
Daily symptoms
Daily use of inhaled, short-acting B2-agonist
Exacerbations affect activity
Nocturnal > 1 time/wk

Step 4:
FEV1 or
PEF ≤ 60%
Continual symptoms
Limited physical activity
Frequent exacerbations & nocturnal symptoms
Short acting beta-2 agonists: medications
short acting beta-2 agonists: MOA and ADRs
 MOA: bronchodilation by smooth muscle
 Mostly as inhaler or nebulized solution but some
available orally*
 Used for immediate, short term relief (rescue
 Continued scheduled use (or overuse) results in
reduced efficacy
 ADRs: tachycardia, arrhythmias, muscle tremor,
headache, hypokalemia, hyperglycemia
long acting beta-2 agonists: medications
long acting beta-2 agonists: MOA and ADRs
 MOA: long-lasting bronchodilation through
smooth muscle relaxation
 Active for ≥12 hours
 Used for maintenance therapy
 NOT for immediate (rescue) relief
Inhaled corticosteroids
 MOA: anti-inflammatory
 Cornerstone of maintenance therapy
 Reduces BHR and airway remodeling
 Minimize late inflammatory response
 NOT used for rescue
 Less side effects than oral steroids
 ADRs: thrush, throat irritation, bad taste,
dysphonia, cataracts
 Closed mouth technique preferred
 Wash mouth after each use
Systemic Corticosteroids
 MOA: anti-inflammatory
 Uses
 Acute severe asthma
 Short-term use
 Severe persistent
asthma uncontrolled
with inhaler therapy
 Disadvantages
 Numerous side effects
 Impaired wound healing
 Increased risk of
 Central redistribution of
fat/weight gain
 Increased blood
 Increased blood
 Osteoporosis/fractures
 Glaucoma/cataracts
IV and oral agents
Leukotrine modifier: Medications and use
 Montelukast (Singulair®)
 Chewable tablets available
 Approved in children ≥ 2 yrs
 Once daily dosing
 Zafirlukast (Accolate®)
 Approved in children ≥ 5 yrs
 Twice daily dosing
 Zileuton (Zyflo®)
 Can cause liver dysfunction
 Approved in children ≥ 12 yrs
 Four times daily dosing

Used for: prophylaxis and chronic treatment of asthma and allergies
Mast cell stabilizers: Medications and use
used for prevention (prophylaxis)
oral, sustained-release formulation prefered for chronic used
ADRs: toxic in overdose, many drug interactions

 MOA: inhibit cholinergic-mediated
bronchoconstriction and secretions
 Used commonly as nebulized solution in
hospitalized patients
 In combination with albuterol
 NOT used in chronic maintenance therapy
(for asthma)
 Used mostly for COPD
Management Strategies of Asthma: Step up
 If control not maintained, REVIEW medication
use (adherence and technique) and
environmental factors
 Consider moving a step up (adding
medications or increasing doses)
Management Strategies of Asthma: Step down
 Therapy should be reviewed every 6 months
for possible step down in intensity of therapy
 Adequate control with less medication
Appropriate Technique for MDIs
 Remove cap and hold inhaler upright
 Shake inhaler (3-4 shakes)
 Prime inhaler
 Breathe out slowly
 Position inhaler 1-2 inches away from open mouth
 Press down on inhaler to release medication while
starting to breathe in slowly
 Continue to breathe in slowly over 3 to 5 seconds
(while pressing down on inhaler)
 Hold breath for 10 seconds (or as long as possible)
to allow medication to reach deep into lungs
 Repeat as directed; wait 1 minute between puffs
Advantages for using a spacer
decreased oropharyngeal deposition
enhanced lung delivery
removes need for good hand-lung coordination
Advantages and disadvantages for MDIs
 Advantages
 Small & convenient
 Disadvantages
 Appropriate technique
 Requires inspiratory force
 Large pharyngeal
deposition (10% to lungs
Advantages and disadvantages for DPIs
 Advantages
 Require minimal hand-lung coordination
 Disadvantages
 Require higher inspiratory flows than MDIs
 Forceful inhalation may be problematic in acute distress
 Cannot be used for intubated patients
 Cannot be used with spacer devices
 Use in children?
 Powder may irritate throat and cause cough
Advantages and disadvantages for nebulizers
 Advantages
 Patients who cannot manage the technical
aspects of using an MDI or DPI
 e.g. Small children
 Patients with substantially decreased tidal
volumes who cannot deliver MDI or DPI drugs to
deep lung tissue
 Disadvantages
 Require electricity to run compressors (air or
 Longer duration of treatment (10-15 mins)
Generalized Seizures
Partial Seizures
Tonic-Clonic Seizures
• Also called “grand mal” seizures
• Full body motor convulsions with loss of
• Tonic convulsive spasms with muscular
• Clonic convulsive spasms with rapidly
alternating rigidity and relaxation
• May lose bowel and bladder control
Myoclonic Seizures
• Brief motor convulsions
• Often confined to one part of the body
• May spread and become generalized
Absense Seizures
• Also called “petit mal” seizures
• Brief impairment of consciousness with
sudden onset
• May involve staring or rapid eye blinking
• Lasts from 10 seconds to 2 minutes
• Do not usually fall or experience motor
• Generally occur in young children
Simple Partial Seizures
• May be sensory or motor
• Involve a limited area of the brain
• Can be manifested as a sensory change
(numbness) or muscle twitches
• Usually confined to one body part
• Brief in duration with no loss of
Complex Partial Seizures
• Sometimes called “psychomotor”
• Involve loss of consciousness usually less
than 2 minutes
• Some type of characteristic movement,
usually “purposeless” (lip smacking)
• May spread to other parts of the body or
become tonic-clonic
Adverse Effects of Barbiturates
sedation, hypotension,
depression, decreased cognitive function,
– Not usually first line therapy due to adverse
Adverse Effects of Hydantoins
drowsiness, gingival
hyperplasia, hirsutism, rash
– At too high doses, nystagmus and ataxia
Adverse Effects of Carbamazepine
Nausea, blurred vision,
dizziness, rash
• More serious: hyponatremia, bone marrow
suppression, liver disturbances
– Less CNS effects than many other
Adverse Effects of Oxcarbazepine
dizziness, nausea, rash
– Fewer effects reported than for phenytoin,
valproic acid, carbamazepine
More serious: hyponatremia
Adverse Effects of Valproic Acid
• Adverse Effects: GI effects - nausea,
vomiting, diarrhea; weight gain, drowsiness
– Most common effects are usually mild
• More serious: pancreatitis, liver toxicity,
Adverse Effects of Gabapentin
Fatigue, dizziness,
– Less CNS effects than traditional antiepileptics
Adverse Effects of Lamotrigine
– requires initial low doses with SLOW titration
– risk of more serious rash increased with
concomitant use of VPA
Adverse Effects of Levetiracetam
sedation, fatigue,
coordination difficulties
Adverse Effects of Tiagabine
dizziness, mild to
moderate transient effects - diarrhea,
drowsiness, nervousness; no serious adverse
effects reported
Adverse Effects of Zonisamide
CNS effects - dizziness,
drowsiness, headache; hypersensitivity
reactions, kidney stones
• Contraindicated in sulfonamide allergy
Adverse Effects of Ethosuximide
nausea and vomiting
Adverse Effects of Benzodiazepines
– Sedation, confusion, nausea and constipation
A hydantoin that can only be administered orally
-an enzyme inducer
A pro drug that is administered via IV or IM
Antiepileptic drugs that are inducers
*Carbamazepine is an autoinducer
-barbiturates: phenobarbital and primidone
-hydantoins: phenytoin

Antiepileptic drugs that are inhibitors
-Valproic acid
Indication for Ethosuximide
Absense Seizures
Use of Benzodiazepines
used to stop seizures that are already in progress
may be used in absense seizures if ethosuximide isn't working
Uses of Gabapentin
partial seizures and treatment of neuropathic pain
First Line drug of choice for Tonic-clonic seizures
phenytoin, carbamezapine, valproic acid
First line drug of choice for generalized myoclonic seizures
valproic acid, clonazepam
First line drug of choice for generalized absense seizures
ethosuximide, valproic acid
First line drug of choice for partial seizures
carbamazepine, phenytoin, lamotrigine, valproic acid, oxcarbazepine