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197 Cards in this Set
- Front
- Back
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Chylomicrons
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-ratio defines particle
-job is to deliver fatty acids all over the body -cholesterol, phospholipid, and protein alls particle to move |
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VLDL
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about half triglycerides, 1/4 cholesterol and the rest phospholipids and proteins
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LDL
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causes hypercholesterolemia
-lots of cholesterol and not much triglycerides Best predictor for heart disease |
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HDL
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mostly proteins- high density
good cholesterol |
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Positive risk factors other than LDL cholesterol for CHD
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-men >45, women >55
-family history of premature CHD, <55 for men, <65 for women -smoking -hypertension -low HDL cholesterol ,40 mg/dl -negative risk factor- HDL >60 mg/dl |
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Treatment decisions based on LDL cholesterol
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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 |
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Bile Acid Sequestrants
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cholestyramine
colestipol colesevelam |
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Bile Acid Sequestrants MOA
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bind bile acids in the intestine and prevents absorption
liver uses LDL to make more cholesterol for bile acids |
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Sequestrants Adverse Effects
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belching, bloating, constipation, unpleasant taste and texture
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Sequestrants Effects on Cholesterol
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increase in triglycerides
slight increase in HDL moderate decrease in LDL |
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Niacin MOA
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reduction in hepatic production of VLDL
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Niacin Common Adverse Drug Reactions
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flushing, pruritis, rash, urticaria
prophylaxis -take with food -use SR product -start with low dose and titrate up -aspirin before dose -don't take with hot fluids or alcohol |
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Niacin Serious Adverse Drug Reactions
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-hepatotoxicity
-gastritis -hyperglycemia -gout -myalgias contraindications: -diabetes -active gout -peptic ulcer disease -severe gastritis |
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Niacin Effects on Cholesterol
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lowers triglycerides
*best drug to increase HDL moderately decreases LDL |
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Statins
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lovastatin
pravastatin simvastatin fluastatin atorvastatin |
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Statins MOA
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inhibition of intracellular synthesis of cholesterol in the liver
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Serious Adverse Drug Reaction of Statins
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hepatotoxicity
myopathy (aches, weakness, soreness) |
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Statins Effect on Cholesterol
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decrease in triglycerides
slight increase in HDL *biggest reduction of LDL 25-60% |
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Fibric Acid Derivatives
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gemfibrozil
fenobirate |
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Fibric Acids Derivatives MOA
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catabolism of VLDL
used for lowering triglycerides Targeted towards diabetics |
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Common ADRs of Fibric Acid Derivatives
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dyspepsia
abdominal pain |
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Serious ADRs of Fibric Acid Derivatives
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cholilithiasis- gall stones
myopathy hepatitis |
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Ezetimibe
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Inhibits absorption of cholesterol across intestinal wall
-used with statins to reduce LDLs |
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Criteria for CHD risk equivalents
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any condition that increases risk so much that we pretend they already have the disease, such as diabetes
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Compare and contrast acute and chronic pain
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Types of Pain
• Acute – Nociceptive – Transient (< 3 months) – Occurs after direct nerve stimulation (injury or trauma) – Supportive physical findings – Relieved with conventional analgesic therapy • Chronic – Neuropathic – Persistant (> 3 months) – Occurs in the absence of detectable, ongoing tissue-damaging process – Delay in onset/persists after precipitating injury – Not easily treated with conventional analgesics |
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Two major types of pain: Nociceptive
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direct stimulation of pain receptors, either somatic or visceral
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Two major types of pain: Neuropathic
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Caused by peripheral nerve injury rather than stimulation of pain receptors
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Compare and contrast pain management between acute and chronic pain
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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 Dependence/ Tolerance to medication Psychological Usually not present Often a major problem component Relief of pain Highly desirable Highly desirable Characteristic Acute Chronic |
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Non Opioid Analgesics
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Acetaminophen (APAP)
Aspirin (ASA) NSAIDs |
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Acetaminophen
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Tylenol
Use: mild to moderate pain -analgesic and antipyretic -NOT anti-inflammatory caution in hepatic impairment or heavy alcohol users |
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Aspirin
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-Salicylate
use: inflammation, fever, anti-platlet Caution: -allergy -bleeding disorders or in combination with other anti-platlets -young children for viral infection (Reye's syndrome) -pregnancy -history of GI disease -renal dysfunction |
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NSAIDs
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uses: analgesic, anti-pyretic, anti-inflammatory
Caution: -allergy -history of GI disease -in combination with anticoagulants -decreased renal or hepatic function -pregnancy |
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NSAIDs: drugs
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-ibuprofen
-naproxen -ketorolac -diclofenac -etodolac -ketoprofen -sulindac -indomethacin -celecoxib |
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Weak Opioids
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generally used with non opioid medications
oral formulations only -codeine (morphine like) -hydrocodone (morphine like) -propoxyphene (methadone like) |
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Weak Opioid combination products
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codeine/acetaminophen(tylenol #3, 4)
hydrocodone/acetaminophen (lortab, lorcet, vicoden, norco) hydrocodone/ibuprofen(vicoprofen) hydrocodone/aspirin(Damascon-P) propoxyphene/acetaminophen(Darvocet) |
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Central Opioid like Analgesics
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Tramadol:
lower abuse potential than opioid agonists -increased risk of seizure -oral formulation only -dose reduction in renal and hepatic function -tramadol/acetaminophen (Ultracet) |
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Strong Opioids
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-Morphine like:
morphine oxycodone hydromorphone -Meperidine like: meperidine fentanyl -methadone |
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Morphine
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IV, IM, SQ, PO, PR formulations available (1:3 IV/PO dosing ratio)
-imediate release and sustained release |
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Oxycodone
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oral formulations only
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Hydromorphone
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more potent than morphine
IV, IM, SQ, PO formulations available (1:5 IV/PO doing ratio) |
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Meperidine (Demerol)
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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 |
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Fentanyl
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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 |
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Methadone
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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 |
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Opioid Side Effects
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-sedation
-constipation -respiratory depression -nausea -itching, pruritis -tolerance or dependence |
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Patial Agonist
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Advantages: lower abuse potential than morphine
Disadvantages: may initate withdrawal in opioid dependent populations |
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Adjuctive Medications
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Laxatives
Antihistamines Antiemetics -used to alleviate some of the ADRs associated with opioids |
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Mechanisms of Contraception
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-prevent sperm from entering the vagina
-immobilization or inactivation of sperm -fertility awareness -prevention of ovulation/implantation -sterilization |
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Estrogen Contraceptive effects
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inhibition of ovulation
inhibit implantation accelerate ovum transport -luteolysis |
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Progestin contracetive effects
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increase cervical mucus
capacitation inhibited slow ovum transport inhibit implanation inhibit ovulation |
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Difference between monophasic, biphasic, and triphasic COC
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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 |
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Dose of ethinly estrodoil that constitutes a low dose
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30-35 micrograms
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Pharmacological effects of progestins in COC
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progestinal, estrogenic, antiestrogenic, andogenic
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signs and symptoms of estrogen excess
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nausea
breast tenderness headaches weight gain irritability |
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signs and symptoms of estrogen deficiency
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amenorrhea
depression hot flashes irritability decreased libido atrophic vaginitis |
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Non contraceptive advantages of COC
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protect against ovarian and endometrial cancer
decreased benign breast disease decreased rate of eptopic pregnancy PMS reduction/cramping less menstral flow |
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signs and symptoms of progestin excess
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noncyclic weight gain
tiredness acne oily skin nausea/vomiting edema breast tenderness |
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signs and symptoms of progestin deficiency
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late BTB days 8-21
heavy menstral flow delayed withdrawal bleeding weight loss |
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Absolute contraindications for COC
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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 |
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Relative contraindications for COC
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-migraine headache
-hypertension -diabetes -elective surgery -gallbladder disease - >35 years old and heavy smoker - >40 years old and cardiovascular risk factors |
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How and when to start oral contraceptives
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1st tablet on 1st day of menses or 1st tablet on the 1st Sunday after begining menstration
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Missed dose of oral contraceptives
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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 |
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Signs and symptoms of medical emergencies of women on COC
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loss of vision
unilateral numbness, weakness, tingling severe pain in chest, left arm, neck hemoptysis severe pains, tenderness, swelling sluring of speech hepatic mass or tenderness |
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Combined injectible contraceptive
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cyclofem
-injected once a month |
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Mini pill
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Uses: appropriate for nursing mothers or women with estrogen related ADRs
-less effective and more likely to produce more side effects |
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Implanon
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uses: inserted in the upper arm and lasts for 3 years
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Depo-Prevera
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deep IM injection
-administered every 3 months |
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Difference between Yaz/Yasmin and other COCs
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claims less weight gain because it acts like a diuretic
-approved for treatment of PMDD |
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Difference between Seasonale and other COCs
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4 periods a year
monophasic, so doesn't decrease acne |
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Difference between Seasonique and other COCs
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same as Seasonale but uses low dose estrogen instead of placebo during the 4 menstral periods/year which reduces breakthrough bleeding
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Differences between Lybrel and other COCs
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no menstral periods
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How to use the Nuvaring
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insert into vagina and begin the same way you would for oral contraceptives
3 weeks in, 1 week out, insert new one |
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How to Use and special risks associated with Ortho-Evra patch
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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 |
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Patient instructions for use of minipill
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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 |
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Advantages and disadvantages of condoms
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advantages: available over the counter, 12% effectiveness
disadvantages: can break, slip off |
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Advantages and disadvantages of female condoms
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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 cumbersome |
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advantages and disadvantages of spermacides
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advantages:
readily available OTC effective immediately can be lubricating no systemic side effects easy to use may aid the protection against some STDs Disadvantages: failure to use consistently sex too early, sex too late using too little running out not keeping available |
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Diaphram and cervial cap
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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 |
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Efficacy of discussed contraceptives
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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 |
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Mirena
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active ingredients: levonorgestrel-releeasing intrauterine system
effective duration: 5 years ADRs: pelvic inflammatory disease increased menstral blood loss uterine perforation septic abortion ectopic pregnancy + progestin ADRs |
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Emergency contraception
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Preven and Plan B
ADRs: nausea and vomiting |
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Type 1 and Type 2 Diabetes
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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 |
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Diagnosis of Diabetes
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Diagnosis
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) OR Symptoms of diabetes and random blood glucose > 200 mg/dL OR Must confirm on a subsequent day unless unequivocal hyperglycemia symptoms |
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Hyperglycemia signs and symptoms
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exteme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea
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Hypogylecemia signs and symptoms
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shaking, sweating, anxious, dizziness, hunger, fast heartbeat, impaired vision, weakness/fatigue, headache, irritable
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Management of Diabetes and A1c
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Summary of recommendations
for adults with diabetes (ADA) Lipids 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%) |
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Sulfonylureas: Medications
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Sulfonylureas: insulin secretagogues
First generation Acetohexamide (Dymelor®) Chlorpropamide (Diabinese®) Tolazamide (Tolinase®) Tolbutamide (Orinase®) Second generation Glyburide (Micronase®, Diabeta®) Glyburide micronized (Glynase®) Glipizide (Glucotrol XL®) Glimepiride (Amaryl®) |
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Sulfonylureas: MOA
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Stimulate pancreatic beta cells to increase secretion of insulin
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Sulfonylureas: Adverse effects
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Hypoglycemia
mild weight gain pregnancy category C |
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Sulfonylureas: Advantages and Disadvantages
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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 |
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Sulfonylureas: Place in therapy
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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 hyperglycemia Most useful within first 5 years of therapy in patients with no history of insulin use |
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Meglitinides: Medications
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Non-sulfonylurea secretagogues
Repaglindide Nateglindide |
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Meglitinides: MOA
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stimulate insulin release from the pancreatic beta cells to reduce postprandial hyperglycemia
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Meglitinides: Adverse effects
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hypoglycemia
weight gain pregnancy category C |
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Meglitinides: Advantages and Disadvantages
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Advantages:
Do not cause continuous insulin secretion More closely reproduces normal pancreatic response Causes less hypoglycemia / weight gain than sulfonylureas Disadvantages: More costly than sulfonylureas CYP3A4 metabolism drug interactions |
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Meglitinides: Place in therapy
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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 hypoglycemia |
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Biguanides: Medications
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insulin sensitizer
metformin |
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Biguanides: MOA
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lowers both basal and postprandial blood glucose
decreases hepatic glucose output increases peripheral muscle glucose improves insulin sensitivity |
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Biguanides: Adverse effects
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gastrointestinal
lactic acidosis |
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Biguanides: Advantages and Disadvantages
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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 hypoglycemia |
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Biguanides: place in therapy
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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 |
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Thiazolidinediones: Medications
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insulin sensitizer
pioglitazone rosiglitazone |
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Thiazolidinediones: Adverse effects
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weight gain
edema/fluid retention possible hepatotoxicity |
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Thiazolidinediones: MOA
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Enhancement of insulin sensitivity in adipose tissue, skeletal muscle, and the liver
decreases hepatic output lowers the free fatty acid concentrations |
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Thiazolidinediones: Advantages and Disadvantages
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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 |
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Thiazolidenediones: Contraindications/ precautions
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Contraindications /
precautions: Congestive heart failure Elevated liver enzymes Liver disease Edema Pregnancy / breast feeding |
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Thiazolidinediones: Place in therapy
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Place in therapy:
Good combination agent or replacement agent for metformin Second line after metformin and sulfonylureas due to adverse effects and cost Should be taken with a meal Do not cause hypoglycemia in monotherapy |
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Alpha-glucosidase inhibitors: Medications
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Acarbbose
Miglitol |
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Alpha-glucosidase inhibitors: MOA
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blocks gut absorption of complex sugars
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Alpha-glucosidase inhibitors: Adverse effects
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flatulence
GI distress Diarrhea |
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Alpha-glucosidase inhibitors: Contraindications
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hypersensitivity
liver disease renal disease pregnancy/ breast feeding Avoid in patients with: liver cirrhosis severe kidney disease inflammatory bowel disease |
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Alpha-glucosidase inhibitors: Place in therapy
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may be used to prolong time to insulin
use in patients not candidates for insulin |
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Alpha-glucosidase inhibitors: Advantages and Disadvantages
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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 |
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Dipeptidyl peptidase IV inhibitor (DPP-4): Medication
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Sitagliptin- Januvia
Hormone modifiers |
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DDP-4 inhibitor: Adverse Effects and Medication interactions
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diarrhea
joint pain runny nose/sore throat headache interactions: alcohol digoxin exenatide |
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DPP-4 inhibitor: MOA
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prevents breakdown of GLP-1
improves insulin production suppresses glucagon secretion |
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DPP-4 inhibitor: Advantages and Disadvantages
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Advantages
Once daily oral agent Targets postprandial blood glucose No hypoglycemia as monotherapy Weight neutral Disadvantages: Best if A1c <8.5% |
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DPP-4 inhibitor: Contraindications/precautions and place in therapy
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Contraindications /
precautions: Diabetic ketoacidosis (DKA) Renal Place in therapy: Patients with type 2 diabetes Monotherapy or in combination |
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Incretin mimetic: Medication
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exenatide- Byetta
Hormone modifier |
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Incretin mimetic: MOA
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Mechanism of action:
Stimulates the glucagonlike peptide-1 (GLP-1) receptor Suppresses glucagon secretion Augments glucose dependent insulin release Slows gastric emptying Reduces food intake Promotes beta cell proliferation |
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Incretin mimetic: adverse effects
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hypoglycemia
nausea/ vomiting weight loss accute pancreatis |
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Incretin mimetic: Advantages and Disadvantages
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Advantages:
Promotes beta cell function Weight loss Disadvantages: Nausea / vomiting |
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Incretin mimetic: place in therapy and contraindications
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Place in therapy:
Adjunct therapy for type 2 diabetes Injectable dosing twice daily one hour prior to meals Contraindications / precautions: Severe GI disease / bleeding End stage renal disease (ESRD) Gastroparesis |
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Amylinomimetic: medication
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pramlintide- Symlin
Hormone modifier |
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Amylinomimetic: MOA
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Mechanism of action:
Slows gastric emptying Reduces postprandial glucagon secretion Causes satiety leading to decreased caloric intake and potential |
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Amylinomimetic: Adverse effects and contraindications
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Adverse effects:
Hypoglyceima Nausea / vomiting Lipodystrophy Contraindications: Gastroparesis Hypoglycemia unawareness |
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Amylinomimetic: Advantages and Disadvantages
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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 |
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Amylinomimetic: Place in therapy
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Place in therapy:
Patients with type 1 or 2 diabetes on mealtime insulin Patients with postprandial hyperglycemia |
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Treatment plan for Type 1 Diabetes
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diet, exercise, and insulin
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Treatment plan for Type 2 Diabetes
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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 |
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Basal insulin
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Lowers glucose between meals and overnight
Decreases fasting blood glucose Nearly constant levels Approximately 50% of daily insulin |
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Bolus insulin
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Lowers glucose during and after meals
Approximately 50% of daily insulin 10-20% at each meal |
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Rapid Acting insulins
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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 |
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Short acting insulin
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Regular onset: 30-60 min peak: 1-5 hours duration: 6-10 hrs
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Intermediate acting insulin
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NPh onset: 1-3 hours peak: 4-6 hrs duration: 12-16 hours
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Long Acting insulin
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Detemir (Levemir®) onset: 1-2 hours duration: 12-24 hours
No significant peak Glargine (Lantus®) onset: 1-2 hours duration: 24 hours |
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Calculating total daily dose of insulin
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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 |
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Calculating split-mixed regimen
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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 |
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Calculating insulin- switching regimens
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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 conversion NPh (twice daily injection) to Glargine decrease by 20% NPh to Detemir 1:1 |
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Characteristics of asthma
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Inflammation
Both acute and chronic Airway remodeling Reversible airway obstruction Bronchospasm Edema Hypersecretion Hyperresponsiveness |
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Signs and Symptoms of asthma
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wheezing
cough chest tightness shortness of breath difficulty breathing worse at night, in early morning, with exercise or exposure to triggers |
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Concurrent illness that may worsen asthma
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allergic rhinitis
sinusitis viral infections GERD pyschological factors premenstral |
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Pulmonary Function tests that are used to diagnose asthma
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spirometry
peak flow meters |
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Steps in using a peak flow meter
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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 |
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Cutoffs for green, yellow, and red zones
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less than 50%= red zone
50-79%= yellow zone 80% or higher= green zone |
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Classifying asthma severity: Step 1
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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 |
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Classifying asthma severity: Step 2
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Mild Persistent:
Low dose inhaled corticosteroids Alternatives to ICS Cromolyn or Nedocromil or Theophylline SR Leukotriene modifier may also be added in some patients |
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Classifying asthma severity: Step 3
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Moderate Persistent:
Medium dose inhaled corticosteroids -- AND -- Long-acting β2 agonist OR alternative Medium dose inhaled corticosteroids -- AND -- Theophylline SR |
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Classifying asthma severity: Step 4
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Severe Persistent:
High dose inhaled corticosteroids -- AND -- Long-acting β2 agonist AND if needed Oral corticosteroids Theophylline SR |
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Common triggers of asthma
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respiratory infection
allergens environment emotions exercise drugs/preservatives occupational stimuli |
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Classifications of Asthma severity
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Step 1
Mild inermittent 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 Moderate persistent FEV1 or PEF > 60% to < 80% Daily symptoms Daily use of inhaled, short-acting B2-agonist Exacerbations affect activity Nocturnal > 1 time/wk Step 4: Severe persistent FEV1 or PEF ≤ 60% Continual symptoms Limited physical activity Frequent exacerbations & nocturnal symptoms |
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Short acting beta-2 agonists: medications
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albuterol
levalbuterol pirbuterol metaproterenol bitolterol |
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short acting beta-2 agonists: MOA and ADRs
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MOA: bronchodilation by smooth muscle
relaxation Mostly as inhaler or nebulized solution but some available orally* Used for immediate, short term relief (rescue medication) Continued scheduled use (or overuse) results in reduced efficacy ADRs: tachycardia, arrhythmias, muscle tremor, headache, hypokalemia, hyperglycemia |
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long acting beta-2 agonists: medications
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salmeterol
formoterol arformoterol |
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long acting beta-2 agonists: MOA and ADRs
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MOA: long-lasting bronchodilation through
smooth muscle relaxation Active for ≥12 hours Used for maintenance therapy NOT for immediate (rescue) relief |
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Inhaled corticosteroids
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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 |
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Systemic Corticosteroids
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MOA: anti-inflammatory
Uses Acute severe asthma exacerbations Short-term use Severe persistent asthma uncontrolled with inhaler therapy Disadvantages Numerous side effects Impaired wound healing Increased risk of infection Central redistribution of fat/weight gain Increased blood glucose Increased blood pressure Osteoporosis/fractures Glaucoma/cataracts IV and oral agents |
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Leukotrine modifier: Medications and use
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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 |
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Mast cell stabilizers: Medications and use
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cromolyn
nedocromil used for prevention (prophylaxis) |
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Theophylline
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oral, sustained-release formulation prefered for chronic used
ADRs: toxic in overdose, many drug interactions |
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Anticholinergics
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Ipratropium
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 |
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Management Strategies of Asthma: Step up
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If control not maintained, REVIEW medication
use (adherence and technique) and environmental factors Consider moving a step up (adding medications or increasing doses) |
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Management Strategies of Asthma: Step down
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Therapy should be reviewed every 6 months
for possible step down in intensity of therapy Adequate control with less medication |
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Appropriate Technique for MDIs
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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 |
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Advantages for using a spacer
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decreased oropharyngeal deposition
enhanced lung delivery removes need for good hand-lung coordination |
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Advantages and disadvantages for MDIs
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Advantages
Small & convenient Disadvantages Appropriate technique required Requires inspiratory force Large pharyngeal deposition (10% to lungs |
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Advantages and disadvantages for DPIs
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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 |
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Advantages and disadvantages for nebulizers
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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 oxygen) Longer duration of treatment (10-15 mins) |
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Generalized Seizures
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-tonic-clonic
-myoclonic -absence |
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Partial Seizures
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-simple
-complex |
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Tonic-Clonic Seizures
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• Also called “grand mal” seizures
• Full body motor convulsions with loss of consciousness • Tonic convulsive spasms with muscular contractions • Clonic convulsive spasms with rapidly alternating rigidity and relaxation • May lose bowel and bladder control |
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Myoclonic Seizures
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• Brief motor convulsions
• Often confined to one part of the body • May spread and become generalized |
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Absense Seizures
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• 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 convulsions • Generally occur in young children |
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Simple Partial Seizures
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• 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 consciousness |
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Complex Partial Seizures
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• 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 |
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Adverse Effects of Barbiturates
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sedation, hypotension,
depression, decreased cognitive function, rash – Not usually first line therapy due to adverse effects |
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Adverse Effects of Hydantoins
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drowsiness, gingival
hyperplasia, hirsutism, rash – At too high doses, nystagmus and ataxia |
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Adverse Effects of Carbamazepine
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Nausea, blurred vision,
dizziness, rash • More serious: hyponatremia, bone marrow suppression, liver disturbances – Less CNS effects than many other antiepileptics |
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Adverse Effects of Oxcarbazepine
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dizziness, nausea, rash
– Fewer effects reported than for phenytoin, valproic acid, carbamazepine More serious: hyponatremia |
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Adverse Effects of Valproic Acid
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• Adverse Effects: GI effects - nausea,
vomiting, diarrhea; weight gain, drowsiness – Most common effects are usually mild • More serious: pancreatitis, liver toxicity, thrombocytopenia |
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Adverse Effects of Gabapentin
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Fatigue, dizziness,
drowsiness – Less CNS effects than traditional antiepileptics |
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Adverse Effects of Lamotrigine
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Rash
– requires initial low doses with SLOW titration upward – risk of more serious rash increased with concomitant use of VPA |
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Adverse Effects of Levetiracetam
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sedation, fatigue,
coordination difficulties |
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Adverse Effects of Tiagabine
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dizziness, mild to
moderate transient effects - diarrhea, drowsiness, nervousness; no serious adverse effects reported |
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Adverse Effects of Zonisamide
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CNS effects - dizziness,
drowsiness, headache; hypersensitivity reactions, kidney stones • Contraindicated in sulfonamide allergy |
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Adverse Effects of Ethosuximide
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nausea and vomiting
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Adverse Effects of Benzodiazepines
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– Sedation, confusion, nausea and constipation
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Phenytoin
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A hydantoin that can only be administered orally
-an enzyme inducer |
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Fosphenytoin
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A pro drug that is administered via IV or IM
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Antiepileptic drugs that are inducers
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*Carbamazepine is an autoinducer
-barbiturates: phenobarbital and primidone -hydantoins: phenytoin - |
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Antiepileptic drugs that are inhibitors
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-Valproic acid
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Indication for Ethosuximide
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Absense Seizures
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Use of Benzodiazepines
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used to stop seizures that are already in progress
may be used in absense seizures if ethosuximide isn't working |
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Uses of Gabapentin
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partial seizures and treatment of neuropathic pain
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First Line drug of choice for Tonic-clonic seizures
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phenytoin, carbamezapine, valproic acid
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First line drug of choice for generalized myoclonic seizures
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valproic acid, clonazepam
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First line drug of choice for generalized absense seizures
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ethosuximide, valproic acid
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First line drug of choice for partial seizures
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carbamazepine, phenytoin, lamotrigine, valproic acid, oxcarbazepine
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