The Respiratory System

Front 1

3 Reasons to use resp meds

Back 1

Bronchoconstriction
inflammation
mucous production

Front 2

Beta II Selective Agonist: Mechanism of Action

Back 2

Stimulate B2 adrenergic receptors producing smooth muscle relaxants, mast cell stabilization, and skeletal muscle stimulation

Front 3

Beta II Selective Agonist: Rescuer or Long acting?

Back 3

Rescuer

Front 4

Beta II Selective Agonist: Adverse Effects

Back 4

Tachycardia due to baroreceptor reflex because of drop in BP from smooth muscle relaxation and direct stimulation of cardiac B2 receptors.
(increased heart rate)

Increased heart rate may increase myocardial o2 demand

Use with caution in heart disease, use b2 sel ago, no reason to use non-sel agents

Hyopkalemia may result from B2 stim in liver (glyconeogensis) which increase insulin secretion and drives K+ intra cellularly

cough due to bronchospasms not mucus production (hence antitussive won't stop coughing)

Front 5

Short Acting B2 Agonist: Uses

Back 5

Mostly used as inhaler but can be used as nebulizer

Front 6

Short Acting B2 Agonist: I.E.

Back 6

albuterol (Ventolin, proventil)
most common: levoalbuterol (Xopenex)

Front 7

Short Acting B2 Agonist: Action

Back 7

Provides quick relief of intermittent episodes of bronchospasm but should only be used as needed.

Used in acute severe asthma

Max 2 puffs QID

Exercise induced asthma onset 10-15 minutes and provides protection for approx 2 hrs.

Front 8

New Long acting b2 Agonists

Back 8

arformoterol (Brovana)
formoterol (Performomist)
Solutions for nebulizer use, used for those who can't use inhalers

Front 9

Long Acting B2 Agonist: Uses

Back 9

Maint therapy
Controller
Ineffective for acute severe asthma - onset of action is 20 min and may take 1-4 hours for max bronchodilation

Exercise induced asthma provides protection for 8-12 hours.

Must be taken on scheduled basis Q12H

Front 10

Long Acting B2 Agonist: I.E.

Back 10

salmeterol (Serevent) inhaler most common; 2 puffs QID hours

Advair diskus 100/50, 250/50, 500/50 is fluticasone proprionate (steroid) + salmeterol (dry powder) for inhaler daily

Front 11

FDA 2006 LABA Black Box Warning

Back 11

salmeterol xinafoate inhalation powder (Serevent)

fluticasone propionate and salmeterol inhalation powder (Advair)

formoterol fumarate inhalation powder (Foradil Aerolizer)

LABA may increase the chance of severe asthma episodes and death when they occur

Front 12

FDA 2006 LABA Black Box Warning: Guidelines

Back 12

Not first line treatment of asthma

Do not stop without consulting HCP

Do not use if wheezing gets worse

LABA does not relieve sudden wheezing

Always having a short acting bronchodilator avail (rescuer)

Front 13

Steroid effects

Back 13

Inflammation r/t steriods

Front 14

inhale or oral

Back 14

inhale > oral due to systemic effects

Front 15

Symbicort:

Back 15

Combination of corticosteroid (Pulmicort) and long-acting beta-agonist formoterol (Foradil)

Front 16

Symbicort: Indications

Back 16

Maintenance therapy of asthma not adequately controlled with corticosteroid alone

2 puffs BID

Front 17

Anticholinergic Agents: Uses

Back 17

May provide additive benefit to inhaled B2 agonists in acute exacerbations but are not first line drugs.

Alternative for those who cannot use B2 Agonists

Front 18

Anticholinergic Agents: I.E.

Back 18

ipratropium bromide (Atrovent)

tiotropium bromide inhalation powder (SPIRIVA Handihaler)

Front 19

Anticholinergic Agents: Contraindication

Back 19

allergy to atropine, soya lecithin peanut or related food

Front 20

Anticholinergic Agents: Adverse Effects

Back 20

Nervousness
dizziness
palpitations
cough

Front 21

Inhaled Corticosteroids: Routes

Back 21

Inhaled rather than oral because less systemic effects

Nasal acts on nasal mucosa

Front 22

Inhaled Corticosteroids: Mechanisms of Action

Back 22

Interference with arachidonic acid metabolism and synthesis of leukotrienes and prostaglandins; reduce vascular permeability which decrease edema; prevent migration of inflammatory cells.

Front 23

Inhaled Corticosteroids: Uses

Back 23

Most effective anti-inflammatory agents for the treatment of asthma

Anti-inflam agent of first choice in persistent asthma

Use lowest effective dose to avoid side effects

Use with spacer device to decrease side effects and increase lung deposition

Rinse mouth to decrease topical side effects

Front 24

Inhaled Corticosteroids: Adverse Effects

Back 24

Topical -- oral candidiasis, hoarseness

Systemic -- the inhaled dose where systemic absorption is unknown
suppression of serum cortisol occurs at dosages

possibly stunts growth

Front 25

Inhaled Corticosteroids: Dosages

Back 25

>1500 mcg in adults

>800mcg in children

Front 26

Inhaled Corticosteroids: Selection

Back 26

Depends on asthma classification and severity
potency
compliance and number of puffs per dose

cost

Front 27

Inhaled Corticosteroids: I.E.

Back 27

fluticasone (Flovent)

triamcinolone (Azmacort)

budesonide (Pulmocort)

flunisolide (Aerobid)

beclomethasone dipropionate (Vanceril, Beclovent)

Dosages vary from daily to QID

Front 28

Mast Cell Stabilizer: Mechanism of Action

Back 28

Mast cell stabalization

INhibit in vitro activation of human neutrophils, macrophages, and eosinophils

Inhibit neurally mediated bronchoconstriction do not have bronchodilatory effects

Front 29

Mast Cell Stabilizer: I.E.

Back 29

cromolyn sodium (Intal)
nedocromil sodium (Tilade)

Front 30

Mast Cell Stabilizer: Uses

Back 30

Maintenance therapy early in mild persistent asthma, particularly for allergy component

Prophylaxis of chronic asthma

May be used in conjunction with B2 agonists for prevention of exercise induced asthma

Due to efficacy and safety may be used in children

Efficacy r/t lung deposition

May take up to 1-2 weeks to achieve effects and max benefit

Start with inhalations QID until symptoms stabilized and reduced to BID or TID

Front 31

Mast Cell Stabilizer: Adverse Effects

Back 31

Side Effects minimal due to no systemic absorption

Cough / wheeze reported with dry powder inhalation of cromolyn

Bad taste and headache reported with inhalation of nedocromil

Front 32

Theophyllines and Derivatives: Mechanism of Action

Back 32

Thought to have bronchodilator effects due to inhibition of release of intracellular calcium

competitive antagonist of the bronchoconstrictor adenoside.

Inhibits pulmonary edema by decreasing vascular permeability

Enhances mucociliary clearance

Strengthen contraction of the diaphragm

stims adrenergic system

Front 33

Theophyllines and Derivatives: Classification

Back 33

Methylxanthine Drugs

Front 34

Theophyllines and Derivatives: Adverse Effects

Back 34

Chronotropic and inotropic cardiac effects

Stimulates CNS and produces cerebral vasoconstriction

Decreases lower esophageal sphincter pressure and increases gastric acid secretion

Must monitor serum concentrations!

Front 35

Theophyllines and Derivatives: Uses

Back 35

Limited use due to side effects and safer more effective B2 Agonists and anti-inflammatories but 2006 making a come back

Used to be given by drip IV under close supervision in acute care settings for control of asthmatic episodes, may still be used if severe (aminophylline)

Front 36

Theophyllines and Derivatives: I.E.

Back 36

theophylline (Theo-24, theo-dur, Uniphyl)

Front 37

Leukotriene Modifiers: Actions

Back 37

Increase vasular permeability leading to edema formation

Cause bronchoconstriction

Recruit inflam mediators (eosinophils) to airway tissues

Decrease mucociliary transport

Front 38

Leukotriene Modifiers: Accolate

Back 38

zafirlukast
Leukotriene receptor antagonist inhibits the early and late phase response after allergen challenge; long term control or prevention of episodes of bronchospasm. Third line drugs

Rapidly absorbed after oral administration (max 3 hrs)

Food decreases bioavailability by 40%

Half life 8-10 hrs (given PO bid)

Front 39

Leukotriene Modifiers: Singulair

Back 39

montelukast (most common)

leukotriene receptor antagonist similar to zafirlukast but once per day oral dosing, also chewable. Not for primary treatment of acute attack

Front 40

Leukotriene Modifiers: Singulair Adverse Effects

Back 40

headache
gastritis
pharyngitis
rhinitis
GI upset
myalgias
fever

Front 41

Leukotriene Modifiers: Singulair Drug interactions

Back 41

zafirlukast potentiates warfarin (Coumadin) drugs that induce CYP450

Front 42

Leukotriene Modifiers: Singulair I.E.

Back 42

erythromycin, rifampin, asparin (decrease concentration)

Front 43

Leukotriene Modifiers: Ziflo

Back 43

zileuton
5-lipoxygenase inhibitor, inhibits early and late phase response after allergen challenge

Rapidly absorbed food does not affect bioavailability

Metabolized via CYP450 isoenzymes 1A2, 2C9, 3A4

Not for acute exacerbations

Front 44

Leukotriene Modifiers: Adverse Effects

Back 44

headache, dyspepsia

Increases alanine aminotransferase (ALT) need to monitor liver enzymes at baseline & Q3 Months

Front 45

Leukotriene Modifiers: Drug interactions

Back 45

warfarin (increase INR)
propanolol (increase beta blocker activity)

theophylline (increase concentrations)

Front 46

Asthma and GERD

Back 46

GERD may worsen with asthma symptoms in some

If asthma symptoms increase after meals and are non responsive to tradition treatment, then GERD may be driving asthma

May need to add PPI
I.E. Protonix, prolosec, prevadic

GERD + Astham = Worse Asthma