respiratory medications

Short-acting beta agonists (SABA) medication

Albuterol (ProAir, Ventolin, Proventil)

used 2x max

used as a rescue inhaler

Long-acting beta agonists (LABA) medication

Salmeterol (Serevent)

Formoterol (Foradil)

vilanterol

Anticholinergics

Ipratropium

Tiotropium

Leukotriene Modifiers

Montelukast (singulair)

prevent histamine and bronchospasm for people with asthma

Albuterol

Selective beta2 agonist with minor beta1 activity

Relaxes bronchial smooth muscle and decrease the obstruction

“Rescue inhaler” for bronchospasm

Used in addition to other medication to maintain bronchodilation

Beta Agonist Side Effects

tachycardia

palpations

CNS excitation effects (tremors, dizziness, skakiness, nervousness, and restlessness)

headache

increase blood sugar

can developer tolerance

be careful with HTN and CAD

Long-Acting Beta Agonists

Typically 12 hour half-life

Very effective in COPD in reducing exacerbations

Often in combination with an inhaled steroid

Localized

LABA and Asthma

LABA must be used with steroid in asthmatic patients

Used in asthma when symptoms are not responding to steroids alone

Should not be used in children under age 4 and caution in children under 16

Muscarinic Receptors in healthy lungs

control smooth muscle tone, mucus secretion, vasodilation, and inflammation.

Muscarinic Receptors in COPD and asthma

cholinergic (parasympathetic) mechanisms contribute to increased bronchoconstriction and mucus secretion that limit airflow

Inhaled Anticholinergics

Promotes bronchodilation by blocking muscarinic cholinergic receptors by antagonizing acetylcholine → anticholinergic

Decreases amount of cellular energy which leads to decreased contractility of smooth muscle in the airway**.**

Effective only in mouth-airways

Inhaled Anticholinergics short acting medication

Ipratropium bromide (Atrovent)

Blocks the muscarinic cholinergic receptors

Inhaled Anticholinergics long acting medication

Tiotropium bromide (Spiriva)

Inhibits the muscarinic M3 receptors in the lungs

Ipratropium (SABA)

Blocks the muscarinic cholinergic receptors

Poorly absorbed so minimal systemic exposure (1-2%)

Watch for anticholinergic side effects: mainly dry mouth

May cause cough

NOT FOR ACUTE BRONCHOSPASM

Can not use if allergic to SOY

Tiotropium (LAMA)

Muscarinic Blocker

Dry powder inhaler:About 20% bioavailability- potential more side effects (urine retention, increased IOP)

Anticholinergic Side effects

• skin

  • skin flushing

  • unable to sweat

  • overheating

• Brain

  • drowsiness

  • dizziness

  • confusion

  • hallucinations

• eyes

  • blurred vision

  • dry eyes

• mouth

  • dry mouth

• heart

  • rapid heart rate (Tachycardia)

• bowel

  • constipation

• bladder

  • urine retention

Bronchodilators

• Beta Agonists (B2) work to dilate the airways to decrease resistance in improve airflow

• Can be short acting for rescue or long acting for maintenance

• Given as inhaler or in nebulized form

• Rescue meds-should not be used more than 2x week; Use an indicator of therapy efficacy/failure

• Exercise induced asthma

Anti-inflammatory medications can…

Block the inflammatory process which leads to the swelling, mucus and narrowing of the airway

Corticosteroids (SONE/NIDE)

Foundation of asthma care

Used in advanced COPD

Blocks components of the inflammatory process in the arachidonic pathway

Used when rapid decrease in inflammation is needed

Usually begin at a higher dose then taper

Coricosteriods Long term effects or overdose

• Osteoporosis will develop in up to 20% of those treated with steroids for a year with decreased density in 3 months

• Hyperglycemia

• CNS

  • Delirium, agitation, panic and anxiety, mania

• HTN

• Thin skin

• Bruising, purpura

• Poor wound healing

• Gastric ulceration

• Sweating

• Anxiety, insomnia, weakness, mood swings

Cushingoid Syndrome

• Sensitizes blood vessels and heart to epinephrine and norepinephrine → increased BP and myocardial contractility

• Increases glucose production in liver and increases free fatty acid formation for increased insulin production.

• Blocks insulin effect in muscles to shunt glucose to brain

• Bone is broken down to release calcium for muscle contraction and nerve conduction

• Depressed T-Cell function, TNF, Ils and Interferons thus depressing inflammation to divert energy

Cushingoid Syndrome Symptoms

• CNS irritability and emotional disturbances

• red and round face

• hypertension

• cardiac hypertrophy

• hyperplasia, tumor

• purple striae

• obesity (fat deposition on abdomen and back of neck)

• osteoporosis

• muscle wasting

• skin ulcers

• Females: amenorrhea, hirsutism

• males: erectile dysfunction

Montelukast (Singulair)

Leukotriene receptor antagonist

Inhibits leukotriene receptor And blocks the actions of the leukotriene

Stops the allergic response which decreases the asthma and inflammatory response

Not used in primary treatment

Headache, GI symptoms. Generally well tolerated

Used in those age 2 and over

Taken at night

Actions of leukotriene

bronchospasm

bronchial edema

Montelukast (Singulair) Black box warning

psychiatric side effects such as aggression, depression, agitation, sleep disturbances, suicidal thoughts, and suicide.

Inhaled Steroids

• Includes all three types of Medications: ICS, LAMA, LABA

• Only 10-30% of the medication makes it to the lung

• If not used with spacer up to 92% stays in the mouth.

• Bioavailability depends on the medication

• Fluticasone- has 30% of dose is absorbed

• Not for relief of acute bronchospasm

• More expensive as there are few generics

Intra nasal Steroid Allergic Rhinitis

• Steroids work by inhibiting IgE and the mast cells into the tissues

• Nasal sprays have local effect

Coricosteriod suffix

-sone

-lone

-ide

Antihistamines First generation

diphenhydramine

very effective

Often not tolerated because of side effects

Anticholinergic

Onset 15 minutes

Antihistamines Second generation

Loratidine, Cetirizine , Fexofenadine

Less effective

Less side effects

Half life 7 and 30 hours.

Onset in about an 1-2 hours

Decongestants

Pseudoephedrine (Sudafed)

Oxymetazoline

Pseudoephedrine (Sudafed)

a sympathomimetic with a mixed mechanism of action, direct and indirect.

It indirectly stimulates alpha-adrenergic receptors, causing the release of endogenous norepinephrine (NE) while it directly stimulates beta-adrenergic

OTC but must come from the pharmacist

Side Effects can be a problem

Phenylephrine: not as effective

Oxymetazoline

An alpha-1A adrenoceptor agonist used to treat nasal congestion

Afrin nose spray

Works great but can cause rhinitis medicamentosa

Antitussives medications

Dextromethorphan (DM)

Guaifenesin

Antitussives

• Cough medicines

• Very few are effective

• Treat the cause of the cough

• Nonopioid

• Opioid

• Combination

Dextromethorphan (DM):

• complex mechanism of action.

• Suppresses cough center in brain, blocks NMDA and agonist of Sigma-1 receptors.

• A lot of side effects

Guaifenesin:

expectorant loosens secretions to eliminate by coughing by decreasing viscosity