advanced pharmacology respiratory pharmacology handout samples/advanced... · 1 unit 5 ©2014...

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©2014 Barkley & AssociatesUnit 5

Advanced PharmacologyRespiratory Pharmacology

Thomas W. Barkley, Jr., PhD, ACNP‐BC, FAANPPresident, Barkley & Associates

www.NPcourses.comand

Professor of NursingDirector of Nurse Practitioner ProgramsCalifornia State University, Los Angeles

Robert Fellin, PharmD, BCPSFaculty, Barkley & Associates

Pharmacist, Cedars‐Sinai Medical CenterLos Angeles, CA


Allergic Rhinitis Allergic rhinitis (hay fever) – resembles the

common cold:

Tearing

Sneezing

Nasal congestion

Postnasal drip

Itchy throat

Due to antigen (allergen) exposure

Pollen, mold spores, dust mites, certain foods, animal dander

Genetic predisposition

http://www.theage.com.au

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Allergic Rhinitis Seasonal vs. perennial allergic rhinitis

Pathophysiology: Inflammation of the mucous membranes in the nose, throat and airways

Normal nasal mucosa has many mast cells and basophils (try to recognize environmental agents as the enter the body)

Allergic rhinitis patients have more mast cells

Histamine (chemical mediator of inflammation): responsible for many of the symptoms of allergic rhinitis

H1-receptors: Responsible for allergic symptoms


H1-receptor Antagonists/AntihistaminesFIRST Generation Agents:

brompheniramine (Dimetapp), chlorpheniramine (Chlor-Trimeton), clemastine (Tavist), cyproheptadine (Periactin), dexchlorpheniramine (Polaramine), dimenhydrinate (Dramamine), diphenhydramine (Benadryl), hydroxyzine (Atarax, Vistaril), promethazine (Phenergan)

Adverse Effects: sedation, dry mouth, headache, dizziness, urinary retention, thickening of bronchial secretions, nausea, vomiting, hypotension, tachycardia, QT prolongation

Comments: All equally effectiveOften combined with decongestant/antitussiveMost effective when taken prophylactically to prevent allergic symptomsAbility to reverse acute allergic symptoms is limitedCaution with alcohol and other CNS depressantsSome patients experience paradoxical excitation

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H1-receptor Antagonists/AntihistaminesSECOND Generation Agents:

azelastine (Astelin), cetirizine (Zyrtec), desloratadine (Clarinex), fexofenadine (Allegra), levocetirizine (Xyzal), loratadine (Claritin), olopatadine (Patanase, Patanol)

Adverse Effects: dry mouth, headache, dizziness, drowsiness, bitter taste (olopatadine), nausea, hypotension, sedation (less than 1st

generation)

Comments: Azelastine: intranasal formulationMost effective when taken prophylactically to prevent allergic symptomsAbility to reverse acute allergic symptoms is limitedAll equally effectiveCaution with alcohol and other CNS depressantsSome patients experience CNS stimulation (nervousness, insomnia, tremor, etc.)Considered less effective than 1st generation agents


Nasal DecongestantsAgents: naphazoline (Privine), oxymetazoline (Afrin), phenylephrine (Neo-

Synephrine), pseudoephedrine (Sudafed)

MOA: sympathomimetic, alpha-adrenergic activity

Adverse Effects: Intranasal: transient nasal irritation, burning, sneezing, nasal dryness, rebound congestionAll: headache, nervousness, insomnia, headache, dry mouth, CNS excitation, tremors, dysrhythmias, tachycardia, difficulty in voiding

Comments: Provide immediate relief for acute allergy symptomsIntranasal: duration should not exceed 3 to 5 days as tolerance developsTolerance: gradually switch to intranasal corticosteroidsOral products do not produce rebound congestionProlonged use: hypersecretion of mucus, worsening nasal congestionOnset of action: intranasal much faster than oral agentsDo not relive sneezing, tearing

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Intranasal GlucocorticoidsAgents: beclomethasone (Beconase AQ), budesonide (Rhinocort

Aqua), ciclesonide (Omnaris), flunisolide (Nasalide), fluticasone (Flonase), mometasone (Nasonex), triamcinolone acetonide (Nasacort AQ)

MOA: reduce inflammation, edema; cause vasoconstriction

Adverse Effects:

transient nasal irritation, burning, sneezing, nasal dryness, epistaxis

Comments: DOC for allergic rhinitisMinimal adverse effectsAll administered by metered-spray deviceAll equally effectiveMay take 3-4 weeks to achieve peak responseMost effective when taken in advance of expected allergen exposure


Miscellaneous AgentsAgents: cromolyn (NasalCrom), ipratropium (Atrovent), montelukast

(Singulair)

MOA: mast cell stabilizer, anti-inflammatory (cromolyn)anticholinergic agent (ipratropium)leukotriene receptor antagonist (montelukast)

Adverse Effects: nasal burning, irritation (cromolyn)nasal irritation, burning, sneezing, nasal dryness, cough, HA (ipratropium)HA, nausea, diarrhea (montelukast)

Comments: Reserved for patients unresponsive to other therapiesMay take 4 weeks to achieve peak responseMost effective when taken in advance of expected allergen exposureLimited effectiveness/less effective than other agentsRole of montelukast remains to be defined

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Antitussives: OpioidsAgents: codeine, (Robitussin-AC), dextromethorphan (Benylin,

Delsym), hydrocodone (Hycodan)

MOA: suppress the cough reflex via CNS

Adverse Effects:

lightheadedness, sedation, nausea, headache and dizziness

Comments: Most effective agents available for cough suppressionSuppression of cough obtained at doses lower than those needed for analgesiaDextromethorphan max dose: 120 mg/dayDextromethorphan: most frequently used antitussive (OTC cough & cold products)Use of codeine/hydrocodone has diminishedCodeine/hydrocodone: controlled substances


Antitussives: Non-OpioidsAgents: benzonatate (Tessalon Perles)

MOA: anesthetizes the stretch receptors in the lungs, thus suppressing cough

Adverse Effects:

nausea, dizziness, headache, sedated, somnolence

Comments: Benzonatate requires prescriptionWell tolerated with minimal adverse effectsDo not crush/chew benzonatate = numbing of the mouth and pharynxChemically related to local anesthetics

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ExpectorantsAgents: guaifenesin (Robitussin)

MOA: increases the volume and reduces the viscosity of secretions in the trachea and bronchi

Adverse Effects:

nausea, vomiting

Comments: Most effective OTC expectorant (?)

Common ingredient in many OTC cough and cold preparationsMaximum dose: 2400 mg/24 hours


FDA Statements: OTC Cold Products Not appropriate to take data from adults

and apply it to children under 12 years of age

Products containing decongestants, antihistamines and antitussives are NOT effective in children < 6 years of age – and may cause serious side effects

FDA: strongly recommend NOT using such OTC products in children < 2 years of age

More studies about how these medicines affect children are needed

www.sharp.com

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Mucolytics


N-Acetylcysteine (Mucomyst)Indications: Adjuvant therapy in patients with abnormal or viscid

mucous secretions in acute and chronic broncho-pulmonary disease

MOA: exerts mucolytic action through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity

Dose: 1 mL of 20% solution or 2 mL of 10% solution via nebulizer 4 times/day

AdverseEffects:

Nausea, vomiting, bronchospasm

Comments: Patients should receive a bronchodilator prior to administration

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Dornase Alfa (Pulmozyme)Indications: Adjunct management of CF to reduce the frequency

of respiratory infections, and to improve pulmonary function

MOA: recombinant Human Deoxyribonuclease (rHDNase); selectively cleaves DNA of neutrophils thereby decreasing mucous viscosity

Dose: 2.5mg nebulized inhalation daily

AdverseEffects:

chest pain, pharyngitis, cough dyspnea, hemoptysis, wheezing, rash, conjunctivitis

Comments: Should not be used routinely as a mucolytic outside cystic fibrosis patients


Drugs for Lower Pulmonary Disorders

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Pulmonary Drugs via Inhalation Aerosol – suspension of minute liquid droplets or fine sold

particles suspended in gas Major Advantage: Delivers drugs to the immediate site of

action (reducing systemic effects) An oral drug would have to be given in a higher dose to

have an equivalent therapeutic dose All inhalation agents have the potential to produce

systemic effects (e.g., anesthetics, paint thinners, etc.)


Devices for Inhalation Metered Dose Inhalers (MDIs) – use a propellant to deliver

a measured dose of drug to the lungs during each breath of drug emitted from the MDI

Dry Powder Inhalers (DPIs) – small device that is activated by inhalation to deliver a fine powder directly to the bronchial tree

Nebulizers – small machines that vaporize a liquid medication into a fine mist that can be inhaled, using a face mask of handheld device

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Methods of Aerosol DeliveryPopulation Optimal technique Therapeutic issues

MDI Age > 5 years

old

Actuation during slow deep inhalation followed by 10 second breath holding

Open mouth technique

Close mouth technique

Deposition of 50~80% of actuated dose in oral-pharynx

Spacer and

Valve holding chamber

Age > 4 years old Actuation during slow deep inhalation followed by 10 second breath holding

Bulky to carry

Decrease oral-pharyngeal deposition & decrease risk of thrush

Nebulizer For patient who cannot use MDI or a face mask

Slow tidal breathing with occasional deep breaths

Using a “blow-by”technique is not appropriate

Output is dependent on device and operating parameters

Use of face mask decreases delivery to lungs by 50%

Expert Panel Report: NHLBI Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm


Disadvantages of Aerosols Precise dose received by the patient is difficult to measure Optimally, only 10-50% actually reaches the lower

respiratory tract Swallowing medication may cause systemic SE Rinse mouth thoroughly after use

http://www.myrespiratorysupply.com http://www.aafa.org www.parknicollet.com

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Which Method of Drug Delivery is Superior?

Metered-Dose Inhaler

Dry Powder Inhaler

Nebulizer

Pharmacology for Nurses: A Pathophysiologic Approach (4th Edition)


Asthma“Chronic inflammatory disorder of the airways… causing recurrent episodes of wheezing, breathlessness, chest tightness and coughing…that is reversible either spontaneously or with treatment.” 22.9 million people in the US have asthma One of the most common chronic diseases of childhood Variability in response to medications requires

individualization of therapy

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Asthma Increased responsiveness of the trachea and bronchi to stimuliNarrowing of airways

http://www.lincoln.ne.gov/city/health/environ/pollu/dirtair.htm


Asthma: Pathophysiological Characteristics

Hypertrophy of smooth muscle Mucosal edema and hyperemia Thickening of epithelial

basement membrane Hypertrophy of mucus gland Acute inflammation Plugging of airways by thick,

viscous mucus

http://www.asthmainschools.com/index.php?option=com_content&view=article&id=59&Itemid=51

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Asthma

Most important allergens are encountered indoors!

Dust, pets, roaches, molds, cigarette smoke, exercise, etc.

Labs/Diagnostics

Signs and symptoms (intermittent dyspnea, cough & wheezing)

Physical exam & Patient history

PFT values (spirometry)

Chest x-ray findings: hyperinflation

2007 Asthma Guidelines: National Heart, Lung and Blood Institute


Classification of Asthma Severity

Components of Severity

Asthma Severity

Intermittent

Persistent

Mild Moderate Severe

Symptoms < 2 days/week >2 days/week Daily Throughout the day

Nighttime awakening < 2 x/month 3-4 x/month > 1 x/week, not nightly Often 7 x/week

Short acting β agonist for symptom control < 2 day/week > 2 days/week Daily Several times a day

Interference with normal activities none Minor Some Extreme

Lung functionFEV1 > 80% > 80 % 60-80 % < 60%

FEV1/ FVC normal normal Reduced < 5% Reduced > 5%

Risk Exacerbation requiring oral systemic corticosteroids 0-1 / year > 2 / year

Recommended Step for Initiating therapy

Step 1 Step 2

Step 3 Step 4 or 5

Consider short course of oral systemic corticosteroids

Expert Panel Report: NHLBI Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

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©2014 Barkley & AssociatesUnit 5Expert Panel Report: NHLBI Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Management of Asthma


Beta-Agonists/SympathomimeticsIndications: DOC for acute bronchoconstriction;

Intermittent symptoms;Exercise-Induced Bronchospasm (EIB)

Agents: Short acting agents (SABA’s):albuterol (Proventil), levalbuterol (Xopenex), metaproterenol(Alupent), pirbuterol (Maxair), terbutaline (oral; Brethine)

MOA: cause bronchial smooth muscle relaxationAdverseEffects:

dose-related tachycardia, tremor, palpitations, nausea, headache, hypokalemia

Comments: Scheduled daily use not recommendedQuick onset of actionDuration of action: 5-6 hoursLevalbuterol is NOT superior to other agentsDPI’s not indicated for acute severe exacerbations

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Inhaled Corticosteroids (ICS)Indications: Preferred therapy for long-term control of persistent

asthma in all patientsAgents: beclomethasone (Beclovent), budesonide (Pulmicort),

ciclesonide (Alvesco), flunisolide (Aerospan), fluticasone (Flovent), mometasone (Asmanex)

MOA: anti-inflammatory; inhibits inflammatory cells and release of inflammatory mediators

Adverse Effects: headache, pharyngitis, dysphonia, oral candidiasis

Comments: Administer on scheduled basis, not “prn”NOT used to treat an acute asthma attackRinse mouth thoroughly after inhalationBudesonide is preferred in pregnancySystemic adverse effects can occur with any ICS


Beta-Agonists/SympathomimeticsIndications: Treatment and prevention of bronchospasm only as

concomitant therapy inhaled corticosteroid;Exercise-Induced Bronchospasm (EIB)

Agents: Long acting (LABA’s): arformoterol (Brovana)*, formoterol (Foradil), indacaterol (Arcapta)*, salmeterol(Serevent)

MOA: cause bronchial smooth muscle relaxationAdverse Effects: tachycardia, tremor, palpitations, nausea, headache,

hypokalemiaComments: DO NOT act quickly

NOT for acute symptom managementDuration of action: 12 hoursShould not be used as monotherapy *FDA labeled only for COPD

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MethylxanthinesIndications: Alternative, not preferred, therapy for mild persistent

asthma or as adjunct therapy with ICSAgents: aminophylline (IV),

theophylline (oral; Theo-Dur)MOA: bronchodilation through smooth muscle relaxation

Adverse Effects:

nausea, vomiting, headache, insomnia, tremor,

irritability, restlessness, tachycardia, seizures

Comments: Clinical utility limited by low therapeutic indexMany drug-drug interactionsMetabolism/clearance is age dependentMonitor dug levels


Mast Cell StabilizersIndications: Alternative, but not preferred for mild persistent

asthma; Exercise induced bronchospasm (EIB)

Agents: cromolyn (Intal)

MOA: anti-inflammatory; prevents bronchoconstriction; blocks the release of histamine

AdverseEffects:

Relatively non-toxic; taste disturbances, cough

Comments: Not a substitute for ICSNot as effective as beta-agonist for EIBAs effective as theophylline or leukotriene antagonistsMay take up to 4 weeks to achieve benefit

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Leukotriene ModifiersIndications: Alternative, but not preferred for mild persistent asthma;

Exercise induced bronchospasm (EIB)Agents: montelukast (Singulair), zafirlukast (Accolate), zileuton

(Zyflo)MOA: inhibit bronchoconstriction; may prevent airway edema

and smooth muscle contractionAdverse Effects: abdominal pain, dizziness, rash, dyspepsia,

hepatotoxicityComments: Not all patients report a benefit with treatment

Difficult to predict who will respondSeveral drug interactionsZileuton: hepatotoxicity; monitor LFT’sLess effective than low dose ICSNot as effective as LABA’s when added to ICS


AnticholinergicsIndications: Adjunct therapy in acute asthma exacerbation not

completely responsive to beta agonistAgents: ipratropium bromide (Atrovent)MOA: blocks acetylcholine at parasympathetic sites in

bronchial smooth muscle causing bronchodilationAdverse Effects: Rare: mydriasis, dry mouth, taste disturbances

Comments: ipratropium + beta agonists = greater and prolonged bronchodilation than using either agent separatelyAdditional long-term studies are needed to determine its role in asthma*Not FDA labeled for asthma

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Systemic CorticosteroidsIndications: Acute severe exacerbations not responding completely to

initial inhaled beta-agonist therapyAgents: prednisone (Deltasone), methylprednisolone (Solu-

Medrol), prednisolone (Millipred)MOA: anti-inflammatory; inhibits inflammatory cells and release

of inflammatory mediatorsAdverse Effects: nausea, hyperglycemia, psychosis, weight gain,

osteoporosisComments: IV therapy offers no therapeutic advantage over oral

administrationDuration of therapy: 5-10 daysHigh-dose regimens do not enhance outcomes and are associated with higher rate of side effectsShould not be used as chronic maintenance therapy


Recombinant Anti-IgE AntibodyIndications: Treatment of allergic asthma not well controlled on oral

corticosteroids or ICSAgent: omalizumab (Xolair)

MOA: binds to the mast cells limiting the of release of mediators in response to allergen exposure

Dose: Based on baseline total serum IgE level & weightAdverseEffects:

injection site reaction, headache, pharyngitis, sinusitis, thrombocytopenia, anaphylaxis

Comments: Do not abruptly stop systemic or ICS upon initiation of therapySubcutaneous injectionCost of therapy is significantDue to the potential for anaphylaxis, patients should be observed for 2 hours after injection

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Asthma Action Plan

http://www.pedipress.com/dap_using4zone_actionplan.html

Individualize for each patient

Allows for self-management

Teaches patients to recognize triggers/ early signs of deterioration

Allows early institution of therapy for acute exacerbations

Improves outcomes


COPDChronic Bronchitis:Excessive secretion of

bronchial mucus – Present 3 months or more in each of 2 consecutive years

Emphysema:Abnormal permanentenlargement of air spaces

distal to the terminal bronchiole

– Destruction of the alveoli

http://my.clevelandclinic.org/disorders/chronic_obstructive_pulmonary_disease/hic_understanding_copd.aspx

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COPD Diagnostics Symptoms (dyspnea at rest or on exertion, cough with or

without sputum production, progressive limitation of activity)

Spirometry showing airflow limitation that is incompletely reversible with inhaled bronchodilator

FEV1 and all other measurements of expiratory airflow reduced

TLC, FRC and RV may be increased

Absence of an alternative explanation for the symptoms and airflow limitation

2014 GOLD Guidelines for COPD: Global Strategy for Diagnosis, Management and Prevention of COPD


Classification of COPDClassification of Severity of Airflow Limitation in COPD

(Based on Post-Bronchodilator FEV1)

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 ≥ 80% predicted

GOLD 2: Moderate 50% ≤ FEV1 < 80% predicted

GOLD 3: Severe 30% ≤ FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

http://www.goldcopd.org/uploads/users/files/GOLD_Report_2014_Jan23.pdf

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Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

Risk

(GOLD

Classification of Airflow Lim

itation)

Risk

(Exacerbation history)

≥ 2or > 1 leadingto hospitaladmission

1 (not leadingto hospitaladmission)

0

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10

BreathlessnessmMRC 0–1 mMRC > 2



Management of COPD Smoking cessation Avoid irritants and allergens Pulmonary rehabilitation Immunizations Influenza vaccine Pneumococcal vaccine

Pharmacotherapy Bronchodilators Theophylline Corticosteroids Antibiotics Oxygen

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Beta-Agonists/SympathomimeticsIndications: DOC for intermittent symptoms of COPD

Beta-agonist = anticholinergicAgents: Short acting agents (SABA’s):

albuterol (Proventil), levalbuterol (Xopenex), pirbuterol (Maxair)

MOA: cause bronchial smooth muscle relaxationAdverseEffects:

dose-related tachycardia, tremor, palpitations, nausea, headache, hypokalemia

Comments: Improve symptoms; do not slow decline of COPDScheduled daily use may be requiredQuick onset of actionLevalbuterol is NOT superior to other agentsFrequently used in combination with anticholinergic (Combivent)


AnticholinergicsIndications: DOC for COPD; use tiotropium for frequent and persistent

symptomsNOT used as monotherapy for acute exacerbations

Agents: Short acting: ipratropium bromide (Atrovent)Long acting: tiotropium (Spiriva), aclidinium (Tudorza)

MOA: blocks acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation

Adverse Effects: Rare: mydriasis, dry mouth, taste disturbances

Comments: Improve symptoms; do not slow decline of COPDSlower onset and more prolonged effect compared with beta-agonistConsider tiotropium when patients require short acting agents on a scheduled basisFrequently used in combination with beta-agonist

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Beta-Agonists/SympathomimeticsIndications: Frequent and persistent symptoms of COPD; utilized when

patients require short acting agents on a scheduled basisAgents: Long acting (LABA’s): arformoterol (Brovana)*, formoterol

(Foradil), indacaterol (Arcapta)*, salmeterol (Serevent)MOA: Cause bronchial smooth muscle relaxationAdverse Effects:

Tachycardia, tremor, palpitations, nausea, headache, hypokalemia

Comments: NOT for acute symptom managementMore convenient: 12 hour durationUseful for nocturnal symptomsNo dose titration; standard dosage for all agentsImprove symptoms and reduce exacerbations*FDA labeled for COPD


MethylxanthinesIndications: Adjunct therapy for patients who have not achieved

optimal response to ipratropium/beta-agonist

Agents: theophylline (oral; Theo-Dur)MOA: bronchodilation through smooth muscle relaxation;

respiratory stimulant; reduces diaphragmatic fatigue

AdverseEffects:

nausea, vomiting, headache, insomnia, tremor, irritability, restlessness, tachycardia, seizures

Comments: Clinical utility limited by low therapeutic indexMany drug-drug interactionsMonitor dug levelsConsidered only for those who are intolerant or unable to use an inhaled bronchodilator

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Inhaled Corticosteroids (ICS)Indications: Symptomatic patients with a FEV1 < 50% & repeated

exacerbations (Stage III and IV)Agents: beclomethasone (Beclovent), budesonide (Pulmicort),

ciclesonide (Alvesco), flunisolide (Aerospan), fluticasone (Flovent), mometasone (Asmanex)


Adverse Effects: headache, pharyngitis, dysphonia, oral candidiasis

Comments: Does not modify long-term decline of FEV1 in COPDReduces frequency of exacerbations Combination therapy with LABA > either agent aloneNot all patients will benefit from ICSRinse mouth thoroughly after inhalationSystemic adverse effects can occur with any ICS


Systemic CorticosteroidsIndications: Acute exacerbation;

Chronic therapy should be avoided if possible

Agents: prednisone (Deltasone), methylprednisolone (Solu-Medrol), prednisolone (Millipred)


AdverseEffects:

nausea, hyperglycemia, psychosis, weight gain, osteoporosis

Comments: Clinical benefit in chronic management not evident and risk of toxicity is extensiveNOT considered as routine maintenance therapyIf required, use lowest effective dose

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Phosphodiesterase 4 InhibitorsIndications: severe COPD associated with chronic bronchitisAgents: roflumilast (Daliresp)MOA: not well defined; increased levels of intracellular

cyclic AMP in lung cells, and reduced neutrophil and eosinophil cell counts in the lungs

Adverse Effects:

weight loss, decrease in appetite, diarrhea, nausea, dizziness, headache, insomnia, anxiety, depression, suicidal ideation, completed suicide

Comments: NOT for acute symptom managementContraindicated in liver impairmentMore studies are required to further define roflumilast’s role in therapy


Patient Group Recommended First Choice Alternative Choice Other Possible Treatments**

AShort-acting anticholinergic prn

or Short-acting beta2-agonist prn

Long-acting anticholinergic or

Long-acting beta2-agonist or

Short-acting beta2-agonist andshort-acting anticholinergic

Theophylline

BLong-acting anticholinergic

or Long-acting beta2-agonist

Long-acting anticholinergicand long-acting beta2 -agonist

Short-acting beta2-agonist and/or

Short-acting anticholinergic

Theophylline

C

Inhaled corticosteroid +long-acting beta2-agonist

or Long-acting anticholinergic

Long-acting anticholinergicand long-acting beta2 -agonist

orLong-acting anticholinergic

and phosphodiesterase-4 inhibitor or

Long-acting beta2-agonistand phosphodiesterase-4

Inhibitor



Theophylline

D

Inhaled corticosteroid +long-acting beta2-agonist

and/orLong-acting anticholinergic

Inhaled corticosteroid +long-acting beta2-agonist and long-acting anticholinergic

orInhaled corticosteroid +

long-acting beta2-agonist and phosphodiesterase-4 inhibitoror

Long-acting anticholinergic andlong-acting beta2-agonist

orLong-acting anticholinergic andphosphodiesterase-4 inhibitor

Carbocysteine



Theophylline

*Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference**Medications in this column can be used alone or in combination with other options in the Recommended First Choice and Alternative Choice columns


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Pneumonia


Pneumonia: Signs/Symptoms Fever Shaking chills Purulent sputum Lung consolidation on physical exam Malaise Increased fremitus

www.med-ed.virginia.edu

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Management of Pneumonia Strep. pneumoniae: most common etiological agent for community

acquired pneumonia (CAP)

Outpatient Management of CAP:

Healthy patients (< 60 years old with NO comorbidities)

Macrolide (azithromycin, clarithromycin, erythromycin)

Doxycycline

Patients with other health problems (e.g., COPD, diabetes, heart failure, cancer or > 65 years old)

Respiratory fluoroquinolone (moxifloxacin, gemifloxacin or levofloxacin

Beta-lactam (amoxicillin-clavulanate, cefuroxime) plus a macrolide or doxycycline


The End

advanced pharmacology respiratory pharmacology handout samples/advanced... · 1 unit 5 ©2014...

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