dh206: pharmacology ch 19:respiratory lisa mayo, rdh, bsdh copyright © 2011, 2007 mosby, inc., an...
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DH206: PharmacologyCH 19:RespiratoryLisa Mayo, RDH, BSDH
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
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Respiratory Drugs
Diseases treated with respiratory drugs
1. Asthma
2. COPD: emphysema, bronchitis
3. Upper respiratory infections
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Class of Resp. DiseasesClinic III
Location Acute Chronic
Upper Resp RhinitisSinusitisPharyngitis/TonsillitisFlu
Allergic rhinitis
Lower Resp Acute bronchitisPneumonia
TBAsthmaCOPD Cystic bronchitis
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Respiratory DrugsAsthma
• Considered an inflammatory disease• Chronic lung disease• Drug therapy aimed at relieving broncho-spasm & inflammation
Airway ObstructionCaused By:
Notations
Bronchoconstriction Loss lung elasticityMediated through ß-2 receptors
Inflammation Results from mucous productionMediators are histamine, prostaglandins, leukotrienes, cytokines
Loss lung elasticity Results from air sac enlargementTx is difficult (long-term, high dose meds)
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2007 Guidelines for Management of Asthma
ASTHMA TYPE
THERAPY 1st LINE DRUGS 2nd LINE DRUGS
Intermittent No meds Albuterol prn (B2-agonist) ------------
Mild Daily meds Inhaled corticosteroid Leukotriene modifierMethylxanthineMast cell stabilizer
Moderate Daily meds Inhaled corticosteroid OR LABA Leukotriene modifierMethylxanthine
Severe Daily meds Inhaled corticosteroid + LABA Leukotriene modifierMethylxanthine
USE THIS INSTEAD P.221, TABLE 19-1EASIER TO UNDERSTAND THIS WAY
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Respiratory Drugs2007 Guidelines for Diagnosis & Management of Asthma• Number & frequency of meds ↑ as severity of asthma worsens• Beginning therapy: start with highest recommendations & stair-
step down as patient needs• Inhaled meds preferred agents
• High concentrations of drug delivered to airways with few systemic side effects
• Severe asthma attacks
1) ß-2 agonist preferred agent (EPI)
2) Corticosteroid tablets to relieve inflammation
3) Oxygen
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Respiratory Drugs
Drug Delivery
1. Systemic: oral, parental
2. Inhaled: shorter onset, fewer side effects
1) Nebulizer
2) Dry powder inhaler
3) Metered-dose inhalers (most common delivery system)
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Respiratory Drugs
Asthma Medications: 2 classes of medications
1. Quick-relief medications•Reliever/Acute rescue drugs
2. Long-term medications•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects
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Respiratory DrugsAsthma Medications
• 2 classes of medications
1. Quick-relief medications•Reliever/Acute rescue drugs
2. Long-term medications (mild, moderate, severe asthma & COPD)•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects
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Quick-Relief MedsProduce bronchodilationProtype: albuterol(Ventolin, Proventil)Tx acute symptomsNot used for daily preventionPatients need to rinse after use (NBQ)
DRUG CATEGORIES
MECHANISM OF ACTION USES
Beta-Adrenergic Agents (Sympathomimetic Agents)
Stimulate beta-2 adrenergic receptors prn
Anticholinergics Block cholinergic (muscarinic) receptors COPD
Systemic corticosteroids
Emergencies Asthma or COPD
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Quick-Relief Meds
1. Beta-Adrenergic Agents (Sympathomimetic Agents)
ß-2 Adrenergic DrugsAlbuterol(Proventil, Ventolin)
Metaproterenol(Alupent)
Levalbuterol(Xopenex)
p. 224
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Quick-Relief Meds
1. Beta-Adrenergic Agents (Sympathomimetic Agents)• NON-SELECTIVE (stimulate β-1 & β-2)o2 drugs: Epi & isopreterenol(Isuprel)oWhen used to tx asthma – will also ↑ heart rate
• SELECTIVEoSelective beta-2 drugs are BEST: bronchodilatorsoFewer effects on beta-1
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β-agonist stimulates enzyme AC to ↑ cAMP levels – results in dilation
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Can be difficult for kids to use: use a separate connector – can decrease amt of drug administered
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NBQ
After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?
a. Ipratropiumb. Cromlyn sodiumc. Metaproterenold. Theophylline
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NBQ
After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?
a. Ipratropiumb. Cromlyn sodiumc. Metaproterenold. Theophylline
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NBQ
Which of the following drugs is the drug of choice for the quick relief of bronchospasm?
a. Albuterolb. Ipratropiumc. Hydrocortisoned. Salmeterol
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NBQ
Which of the following drugs is the drug of choice for the quick relief of bronchospasm?
a. Albuterolb. Ipratropiumc. Hydrocortisoned. Salmeterol
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NBQ
Which of the following drugs is classified as a β2-agonist bronchodilator?
a. Albuterolb. Ipratropiumc. Hydrocortisoned. Montelukast
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NBQ
Which of the following drugs is classified as a β2-agonist bronchodilator?
a. Albuterolb. Ipratropiumc. Hydrocortisoned. Montelukast
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Quick-Relief Drugs
2. Anticholinergic Agents: used for tx COPD, not asthma
DRUG NOTATIONS
Ipratropium bromideHFA(Atrovent) PROTYPENasal spray: useful for rhinitis
Ipratropium bromide + albuterol sulfate(Combivent)
Tiotropium bromide(Spiriva) LONG-TERM, NOT SHORT ACTING FOR TX COPD
p.226
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Quick-Relief Drugs2. Anticholinergic Agents
• Action: Inhibit ACH receptors on smooth muscle= bronchodilation
• Protype: ipratropium bromide(Atrovent)• Adverse effects
• Xerostomia• Taste alteration• Instruct pt to rinse mouth after each inhalation (NBQ)
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Muscarinic antagonists block effects of ACH & PANS – leads to bronchodilation
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Quick-Relief Drugs
3. Systemic corticosteroids• Used when asthma cannot be controlled by bronchodilators alone
• Short-term• Decrease inflammation• Systemic delivery = acute attacks
Inhaled delivery = chronic, long-term therapy
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Respiratory DrugsAsthma Medications
• 2 classes of medications
1. Quick-relief medications•Reliever/Acute rescue drugs
2. Long-term medications•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Inhaled corticosteroids• Drug of choice for persistent asthma• 1st line long-term therapy• Potent & effective anti-inflammatory agents• Decrease airway hyper-reactivity & swelling• Rinse mouth after inhaler use (NBQ)
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Long-Term Meds
Inhaled corticosteroids
Inhaled CorticosteroidsBeclomethasone dipropionate(Beclovent, Vanceril)
Budesonide(Pulmicort)
Flumisolide(Aerobid)
Fluticasone(Flovent, Advair)
Mometasone(Asmanex)
Triamcinolone(Azmacort)
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Selective long-acting ß-2 Agonists (LABA)• Bronchodilators• Not used alone – usually in combo w/corticosteroids• Black box: NOT to be used as stand alone tx – increase risk
of asthma-related deaths
Selective long-acting ß-2 Agonists
Salmeterol(Serevent)
Formoterol(Foradil)
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term MedsMethylxanthines
• Bronchodilators that relax the airway smooth muscle• COPD• Many drug interactions
• Erythromycin• Clarithromycin• Caffeine: can cause mild bronchodilation in patients with asthma
(100mg which is in a cup of coffee)
Methylxanthines
Theophylline(Slo-Phyllin),TheoDur, Theo-24)
Aminophylline(norphyl)
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Theophylline inhibits enzyme PDE, slows inactivation of cAMP, leads to dilation
Theophylline antagonizes adenosine (bronchoconstrictior)
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Mast cell stabilizers p.225, books calls this category cromolyn
• Inhibit release of histamine (decrease inflammation)
Mast Cell Stabilizers
Cromolyn sodium(Intal)
Nedocromil(Tilade)
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Leukotrienes Modifiers• Block activity of arachidonic acid derivatives = decrease
inflammation • P-450 enzyme induction • Drug interactions
• Aspirin• Erythromycin• Increase effect Warfarin
Leukotriene Modifiers
Zafirukast(Accolate)
Montelukast(Singular)
Zileutron(Zyflo)
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Zileutron(Zoflo)
zafirlukast(Accolate),
montelukast(Singular)
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Long-Term Meds
Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD(never used as stand-along therapy, always in combo)
Methylxanthines COPDIV for status asthmaticus
Mast cell stabilizers Asthma
Leukotrienes Modifiers Asthma
Immunomodulators Asthma
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Long-Term Meds
Immunomodulators• Prevent IgE from binding to mast cells
Immunomodulators
Omalizumab(Xolair)
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omalizumab(Xolair)
omalizumab(Xolair)Binds to receptors so allergen cannot
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NBQ
Which of the following drugs is preferred for long-term control of asthma?
a. B-1 agonistb. B-2 agonistc. Inhaled corticosteroidd. Oral corticosteroids
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NBQ
Which of the following drugs is preferred for long-term control of asthma?
a. B-1 agonistb. B-2 agonistc. Inhaled corticosteroidd. Oral corticosteroids
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NBQ
Which of the following drugs is used to control mild persistent asthma?
a. Albuterolb. Ipratropiumc. Inhaled beclomethasoned. Salmeterol
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NBQ
Which of the following drugs is used to control mild persistent asthma?
a. Albuterolb. Ipratropiumc. Inhaled beclomethasoned. Salmeterol
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DH Considerations
• Aspirin & NSAIDs contraindicated in asthmatic patients (can lead to bronchospasm)
• Anticholinergic side effects• Consult MD in SEVERE asthma cases• Inhalers brought to appts• Systemic corticosteroids – pt may need increase dose morning of
apt• Inhalers: advise pt to rinse after to avoid dry mouth & oral
candidiasis
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Agents used to manage upper respiratory tract infections
Agents used to manage upper respiratory tract infections1) Nasal Decongestants2) Expectorants & Mucolytics3) Antitussives
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Agents used to manage upper respiratory tract infections
1) Nasal Decongestants• Constrict blood vessels in nasal mucous membranes• Chronic use may result in rebound swelling and congestion• Book correction: not all nasal decongestants are α-agonists
(p.226)• Remember: Patanase is a nasal antihistamine, not a
decongestant
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Agents used to manage upper respiratory tract infections
Nasal Decongestants
phenylephrine (Neo-Synephrine, Sinex, Allerest) α-agonist
pseudoephedrine(Sudafed, Sucrets, Actifed) α-agonist
Beclomethasone(Beconase,Vancenase) Corticosteroid Nasal spray
Mometasone(Nasonex) Corticosteroid Nasal spray
Fluticasone(Flonase) Corticosteroid Nasal spray
Budesonide(Rhinocort) Corticosteroid Nasal spray
Flunisolide(Nasalide) Corticosteroid Nasal spray
Cromolyn(Nasalcrom) OTC nasal spray
Nedocromil(Tiladle) Nasal spray for asthma & rhinitis
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NBQ
Which of the following types of agents are nasal decongestants?
a. B-1 agonistb. B-2 blockersc. Alpha-1 agonistd. Alpha-2 blockers
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NBQ
Which of the following types of agents are nasal decongestants?
a. B-1 agonistb. B-2 blockersc. Alpha-1 agonistd. Alpha-2 blockers
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Agents used to manage upper respiratory tract infections
2) Expectorants & Mucolytics• Mucolytics
• Promote removal of exudate or mucus from respiratory passages• Liquefying & decrease viscosity of mucus• Acetylcysteine(Mucosil): Useful in cystic fibrosis
• Expectorants• Drugs that facilitate the removal of thickened mucus secretions from
the lungs• Action: ↑ bronchial = liquefy mucus• Guaifenesin(Mucinex) most popular
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Agents used to manage upper respiratory tract infections
3) Antitussives: agents used to suppress coughDrugs Notations
Opioids: (Codeine, Hydrocodone, Hydromorphone)
Narcotic opioidAvoid in asthmatic (cause respiratory depression)
Dextromethorphan(Robitussin, Vicks)
Non-narcoticMany OTC products contain
Benzonatate(Tessalon) Non-narcotic
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NBQ
Which of the following terms defines “suppressing a cough?”a. Expectorantb. Antitussivec. Antihistamined. Antiasthma
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NBQ
Which of the following terms defines “suppressing a cough?”a. Expectorantb. Antitussivec. Antihistamined. Antiasthma
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NBQ
Which of the following drugs MAY be contraindicated in asthmatics?
a. Aspirinb. Acetaminophenc. Vitamin Cd. Folic acid
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NBQ
Which of the following drugs MAY be contraindicated in asthmatics?
a. Aspirinb. Acetaminophenc. Vitamin Cd. Folic acid
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