[ATI] Medications for Lower Respiratory Airflow Disorders

Bronchodilators + Anti-inflammatories (2)

Glucocorticoids: Beclomethasone, prednisone

Leukotriene modifiers: Montelukast & Zileuton

Pure Bronchodilators (5)

Beta2‑adrenergic agonists: Albuterol (B-2 Agonists)

Inhaled anticholinergics: Ipratropium (Muscarinic Antagonists)

Methylxanthines: Theophylline

Bronchodilator Side Effects (General) (4)

Tachycardia

Hypertension

Hypotension

Chest pain

Beta2-Adrenergic Agonists Use (3)

Manages chronic asthma (LABA)

Prevention of exercise-induced bronchospasm

Treats acute asthma (SABA)

Manages COPD

Beta2-Adrenergic Agonists Mechanism

Activate B2 receptor in lungs bronchodilate and vasodilator

Inhaled Anticholinergics Use (2)

Relief of bronchoconstriction in clients who have COPD

Decreases secretions in clients with COPD

Manages allergen-induced and exercise-induced bronchospasm

Methylxanthines Use

Manages chronic asthma in p/t that metabolize meds slowly

Manages COPD (not first line)

Glucocorticoid Use/Actions

Action: Prevents inflammation, suppresses airway mucus production, reduces airway mucosa edema

Long-term manages chronic asthma

Short-term manages post-attack acute asthma (oral)

Analogy: Fire extinguishers—they cool down the inflammation and prevent it from spreading, but overusing them can make the body a little too cool

Leukotriene Modifiers Use

Adjunctive therapy in the treatment of allergic rhinitis, CHRONIC asthma, and exercise-induced bronchospasm

Inhaled Anticholinergics Mechanism/Action

aka Muscarinic Antagonists

Inhibits the acetylcholine acting on muscarine receptors of the parasympathetic nervous system (causes bronchoconstriction)

• Increases Bronchodilation

Methylxanthines Mechanism/Action

Inhibits phosphodiesterase (contracts bronchi smooth muscles)

• Bronchodilation (relaxes smooth muscles of bronchi/oles)

Glucorticoid Mechanism/Action

Inhibits the release of leukotrienes, prostaglandins, and histamine (causes inflammation)

• Suppresses inflammation

Inhibits action of WBCs (causes inflammation and protects immune system)

• Suppresses immune system

• Decreases edema in airways

Leukotriene Modifiers Mechanism/Action

Inhibits the action of Leukotrienes (causes allergic reactions: airway inflammation and mucus production)

• Suppresses inflammation via receptor antagonists (Montelukast, Zafirlukast)

• Suppresses inflammation via elimination (Zileuton)

Beta2-Adrenergic Agonists Adverse/Side Effects

Chest pain, palpitations

Nervousness, restlessness, tremors

Inhaled Anticholinergics Adverse/Side Effects

Dry mouth, irritation of the pharynx

Increased intraocular pressure

Urinary retention

Methylxanthines Adverse/Side Effects

(Stimulatory)

Restlessness, insomnia

Nausea, vomiting, diarrhea

Toxicity: Seizures

Dysrhythmias

GI distress, intestinal bleeding

Hyperreflexia

Hyperglycemia

Hypokalemia

Metabolic Disturbances

Tachycardia/Palpitations

Primary hypertension

Secondary hypotension (Tachycardia)

Methylxanthines Pharmacological Effects (image)

Glucocorticoid Adverse/Side Effects

Bone demineralization, muscle wasting

Hyperglycemia (blocks glucokinase receptors on pancreas: insulin resistance)

Peptic ulcer disease

Infection

Fluid and electrolyte imbalances

Headache

Inhaled: Oral candidiasis (rinse mouth)

Oral: Suppression of adrenal function

Nasal: Dry mucous membranes, epistaxis, sore throat

Oral Glucocorticoid Adverse/Side Effects

Suppression of adrenal function

Hyperglycemia (blocks glucokinase receptors on pancreas)

Inhaled Glucocorticoid Adverse/Side Effects

Oral candidiasis (rinse mouth)

Hoarseness

Osteoporosis

Bleeding

Nasal Glucocorticoid Adverse/Side Effects

Dry mucous membranes, epistaxis, sore throat

Leukotriene Modifiers Adverse/Side Effects

Liver damage (Zileuton/Zafirlukast)

Neuropsychiatric effects such as suicidal ideations

Potentiates warfarin and theophylline

Infection

Beta2-Adrenergic Agonists Interventions/Considerations/Administrations/Instructions

Monitor and report dizziness, heart palpitations, chest pain, and shortness of breath

Monitor and report tremors

• Notify provider if tremors interfere with activities of daily living.

Inhale before inhaling glucocorticoids

Avoid caffeine/stimulants

Report chest pain and heart palpitations.

Notify provider if tremors interfere with activities of daily living.

SABA for acute asthma

LABA for chronic asthma (maintenance)

Inhaled Anticholinergic Interventions/Considerations/Administrations/Instructions

Provide water and hard candy to client (frequently)

Schedule routine testing for glaucoma.

Monitor urinary elimination patterns, especially in older adults (report changes)

Delay use of other inhalants for 5 minutes

Do not use as an emergency rescue medication

• NOT FOR ACUTE ASTHMA (RESCUE) - COPD ONLY

Rinse the mouth after use to reduce unpleasant taste

Do not swallow

Inhalation via HandiHaler device (dry-powder capsule in haler)

Methylxanthines Interventions/Considerations/Administrations/Instructions

Monitor plasma medication levels

• Discontinue if toxic levels found

• Give activated charcoal to decrease absorption.

Prepare to initiate anticonvulsant therapy and seizure precautions.

Monitor heart rate and rhythm.

• Give antidysrhythmics to restore heart rate and rhythm.

Chew chewables thoroughly

Do not crush or chew sustained-release/enteric-coat

Strict schedule between doses

• Do not double if dose missed

Reduce or eliminate caffeine intake

Glucocorticoid Interventions

Provide/prescribe a spacer.

Monitor potassium levels

Initiate antifungal therapy as needed.

Observe for suppression of adrenal function.

Monitor plasma medication levels.

Recommend alternate-day dosing.

Monitor for signs of bone demineralization, muscle wasting.

Recommend the lowest possible effective dose and alternate-day dosing.

Monitor blood glucose levels, especially for clients who have diabetes mellitus.

Recommend adjustment of dosages of insulin/hypoglycemic medications accordingly.

Observe for gastrointestinal bleeding (bloody vomitus; black, tarry stools).

Implement gastric protective measures.

Give drug with food or meals.

Recommend analgesic substitute if NSAID is prescribed.

Observe for signs of infection that may not include fever or inflammation (sore throat, fatigue, tachycardia, and discharge from a wound).

Recommend initiation of appropriate antimicrobial therapy.

Monitor for weight gain or edema (hypernatremia).

Monitor for generalized weakness (hypokalemia).

Recommend initiation of appropriate fluid and electrolyte replacement therapy.

Provide client with water and hard candy or throat lozenges to suck on.

Provide humidified air for epistaxis and sore throat.

Administer non-NSAID analgesic such as acetaminophen

Glucocorticoid Interventions (Inhaled)

Use on a regular schedule rather than PRN.

• Do not use these drugs for an acute attack.

• When using concurrently with a beta2 adrenergic agonist inhaler, use the beta2 agonist first to dilate the airway before using the glucocorticoid.

Glucocorticoid Interventions (Oral)

Use twice daily for 5 to 10 days.

• For long-term use (10 days or more), take once daily using alternate-day dosing.

• Taper the dose slowly when symptoms are controlled to establish the lowest possible oral dose.

• Take supplemental doses as needed in times of stress (illness, surgery).

Glucocorticoid Interventions (Nasal)

WEAN: Use a metered-dose device

• Use the full dose initially and taper to the lowest effective dose. Expect the full therapeutic effect to take 2 to 3 weeks.

• Use a nasal decongestant (sympathomimetic) first if the nares are completely blocked.

Aim away from septum

Glucocorticoid Instructions

Use a spacer (on most glucocorticoid metered-dose inhalers) to deposit less medication in the oropharynx.

Rinse the mouth and/or gargle after using the glucocorticoid inhaler to prevent candidiasis.

Explain the schedule of alternate-day therapy.

Taper the dose before discontinuing it. NEVER stop abruptly.

Take the medication on alternate days.

Perform weight-bearing exercise daily.

Consume adequate calcium and vitamin D.

Avoid taking NSAIDs.

Take the medication with food or meals.

Use a humidifier during sleep.

Increase fluid intake.

Suck on hard candy or lozenges.

Take over-the-counter, non-NSAID analgesics as needed.

Report any of the following conditions immediately:

• Polyphagia, polydipsia, and polyuria

• Indigestion or bloody vomitus as well as black, tarry stools

• Manifestations of infection, such as a sore throat, that may not be accompanied by fever or inflammation

• Painful mucous membranes with white patches

• Weight gain or edema

• Weakness

Leukotriene Modifiers Interventions/Considerations/Administrations/Instructions

Periodic LFT (risk of liver damage)

• Report abdominal tenderness, nausea, or anorexia.

Observe/report behavioral changes (such as such as agitation, insomnia, anxiety, or irritability)

Mix oral granules with applesauce, carrots, rice, or ice cream or place directly on the tongue.

Take 2 hours before exercise to prevent exercise-induced bronchospasm (EIB)

• Do not repeat dose for 24 hours

Take on an empty stomach once daily (Montekulast)

Beta2-Adrenergic Agonists Contraindications

Allergy to albuterol or levalbuterol

Inhaled Anticholinergic Contraindications

Hypersensitivity to ipratropium, atropine, belladonna alkaloids, or bromide

Methylxanthines Contraindications

Impaired metabolism

Tobacco or marijuana use (boosts metabolism)

Caffeine (boosts metabolism)

Glucocorticoid Contraindications

Recent live virus immunization

Systemic fungal infection

Oral candidiasis

Leukotriene Modifiers Contraindications

Liver dysfunction (zileuton and zafirlukast), not montelukast

Acute asthma exacerbations

Status asthmaticus

Beta2-Adrenergic Agonists Safety Alerts

Note various inhalation devices and measurements

Clients must notify of chest pain, heart palpations, or increased pulse rate

• History of CV, HTN, or taking digitalis-type meds

Inhaled Anticholinergic Safety Alerts

NOT FOR ACUTE ASTHMA (RESCUE) - COPD ONLY

Methylxanthines Safety Alerts

Use antidysrhythmic if life-threatening cardiac dysrhythmias occur

Use anticonvulsant therapy and seizure precautions if a seizure occurs

Metabolic rates are affected by age, medications, and disease, as well as smoking either tobacco or marijuana

Monitor plasma levels to prevent toxicity

Taking the OTC med cimetidine for indigestion or gastroesophageal reflux disease (GERD) increases the risk for toxicity.

Glucocorticoid Safety Alerts

Oral

• Gastric-protective measures to prevent gastric ulcers

• Avoid in oral candidiasis, systemic fungal infection or live virus immunization (lowers immune system)

Avoid NSAIDs (use acetaminophen)

Take with snack or meal

Immediately report black, tarry stools and blood vomit

Immediately report infection signs (lowers immune system)

• Sore throat (fever not guranteed)

• Inflammation, fatigue, tachycardia, drainage

• White patches on mucous membranes (oral candidiasis)

Leukotriene Modifiers Safety Alerts

Periodic LFT (risk of liver damage)

• Report abdominal tenderness, nausea, or anorexia.

Observe/report behavioral changes (such as such as agitation, insomnia, anxiety, or irritability)

Clients should alert provide if taking Zileuton or Zafirlukast

• Increases anticoagulant effects of warfarin (bleeding, hemorrhage)

• Hepatotoxic

Beta2-Adrenergic Agonists Precautions

Diabetes mellitus

Hyperthyroidism

Cardiovascular disease

Hypertension

Angina pectoris

Tachydysrhythmias

Tachycardia due to digitalis toxicity

Anticholinergic Precautions

Glaucoma

Prostatic hypertrophy

Bladder neck obstruction

Methylxanthines Precautions

Heart disease

Liver dysfunction (linked to injury, Hep C, elevated ALT)

Acute pulmonary edema

Glucocorticoid Precautions

Peptic ulcer disease

Diabetes mellitus

Hypertension

Renal dysfunction

Use of NSAIDs

Leukotriene Modifiers Precautions

Severe asthma

Beta2-Adrenergic Agonists Interactions

Blockers reduce the effectiveness

Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants increase the risk of hypertension, tachycardia, and angina.

Hypoglycemic (antidiabetic) drugs require increased dosing because of hyperglycemic effects.

Inhaled Anticholinergic Interactions

Beta2-adrenergic agonists enhance bronchodilation

Methylxanthines Interactions

Cimetidine, some fluoroquinolones, and caffeine increase the risk of toxicity.

Phenobarbital, phenytoin, and nicotine increase metabolism of theophylline.

Glucocorticoid Interactions

Potassium-depleting diuretics, such as furosemide increase risk of hypokalemia.

NSAIDs increase the risk of gastrointestinal bleeding.

Effects of insulin and oral hypoglycemics are decreased.

Leukotriene Modifiers Interactions

Concurrent use with phenobarbital, rifampin, and phenytoin may necessitate higher dosages.

Potentiates warfarin and theophylline

Short Acting Beta2-Adrenergic Agonists (SABA) Medications (Inhaled) (6)

Albuterol (Proventil HFA / Ventolin HFA)

Ephedrine

Epinephrine (like Sympathomimetics)

Levalbuterol

Metaproterenol

Terbutaline (Generic only)

Long Acting Beta2-Adrenergic Agonists (LABA) Medications (Oral)

Formoterol (Foradil Aerolizer)

Salmeterol (Severent)

Aformoterol

Idacaterol

Short Acting Muscarinic Antagonists (SAMA) Inhaled Anticholinergics Medications

Ipratropium

Long Acting Muscarinic Antagonists (LAMA) Inhaled Anticholinergics Medications

Umeclidinium

Tiotropium

Aclidinium

Revefenacin

Methylxanthines Medications

Theophylline

Aminophylline (generic only) (IV)

Glucocorticoid Medications (nasal)

Fluticasone

Budesonide

Glucocorticoid Medications (4)

Beclomethasone dipropionate (inhalant)

Prednisone (oral)

Fluticasone (intranasal or inhaled)

Budesonide (nasally or inhaled , also for allergic rhinitis)

Methylprednisone (IV)

Glucocorticoid Medications (oral)

Prednisone

Glucocorticoid Medications (inhaled)

Budesonide

Beclomethasone dipropionate

Fluticasone

Beclomethasone dipropionate (inhalant)

Classification: Glucocorticoids

Therapeutic use: Used for long-term management of chronic asthma and short-term management of post-exacerbation manifestations.

Prednisone (oral)

Classification: Glucocorticoids

Therapeutic use: Used for long-term management of chronic asthma and short-term management of post-exacerbation manifestations.

Fluticasone (intranasal or inhaled)

Classification: Glucocorticoids

Therapeutic use: Used for long-term management of chronic asthma and short-term management of post-exacerbation manifestations.

Budesonide (nasally or inhaled - allergic rhinitis)

Classification: Glucocorticoids

Therapeutic use: Used for long-term management of chronic asthma and short-term management of post-exacerbation manifestations.

Albuterol

Classification: Short-Acting Beta2-Adrenergic Agonists (SABA)

Therapeutic use: Manages asthma, prevents exercise-induced bronchospams, treats ongoing asthma exacerbations.

Ipratropium

Classification: Short-Acting Anticholinergic (SAMA)

Therapeutic use: Relieves bronchoconstriction and decreases secretions in clients who have COPD.

Tiotropium

Classification: Long-Acting Anticholinergic (LAMA)

Therapeutic use: Relieves bronchoconstriction and decreases secretions in clients who have COPD.

SAMA

Short-Acting Muscarinic Antagonist

Theophylline

Classification: Methylxanthines

Therapeutic use: Manages chronic asthma.

Montelukast

Classification: Leukotriene Modifiers (Antagonist)

Therapeutic use: Treats rhinitis, asthma, and exercise-induced bronchospasm.

Zileutron

Classification: Leukotriene Modifiers (Eliminates)

Therapeutic use: Treats rhinitis, asthma, and exercise-induced bronchospasm.

(Hepatotoxic & Amplifies Warfarin)

Zafirkukast

Classification: Leukotriene Modifiers (Antagonist)

Therapeutic use: Treats rhinitis, asthma, and exercise-induced bronchospasm.

(Hepatotoxic & Amplifies Warfarin)

Monitor Liver (3)

Zafirkukast (Leukotriene Modifiers) - Toxic

Zileutron (Leukotriene Modifiers) - Toxic

Theophylline (Methylxanthines) - Injury

Potentiates Anticoagulant Effect of Warfarin (2)

Zafirkukast (Leukotriene Modifiers)

Zileutron (Leukotriene Modifiers)

Monitor Heart (2)

Theophylline (Methylxanthines) - Precaution (Arrythmias, myocardial infarction)

Albuterol, Formoterol, Salmeterol, Terbutaline (Beta2-Adrenergic Agonists) - Safety Alert (chest pain, heart palpations, increased pulse rate)

Avoid caffeine (2)

SABA Albuterol, LABA Formoterol/Salmeterol/Terbutaline (Beta2-Adrenergic Agonists)

Theophylline (Methylxanthines) - Contraindication (increases toxicity risk)

MANAGES COPD (3)

SAMA Ipratropium, LAMA Tiotropium (Inhaled Anticholinergics)

Benzonatate (Nonopioid Antitussives)

Theophylline (Oral Methylxanthines)

DO NOT USE FOR ACUTE ASTHMA (EMERGENCY) (3)

SAMA Ipratropium, LAMA Tiotropium (Inhaled Anticholinergics)

Montekulast, Zafirkulast, Zileuton (Leukotriene Modifiers)

(Inhaled Glucocorticoids)

Nosebleed (Epistaxis) (1)

Budesonide, Beclomethasone dipropionate, Fluticasone (Inhaled Glucocorticoids)

Suppression of adrenal fx (1)

Prednisone (Oral Glucocorticoids)

LONG-TERM (Chronic) Asthma Management (4)

Theophylline (Methylxanthines)

(Glucocorticoids)

Formoterol/Salmeterol/Terbutalin (LABA Beta2-Adrenergic Agonists)

Montekulast, Zafirkulast, Zileuton (Leukotriene Modifiers) - Adjunctive

ACUTE Asthma Management (Emergency)

Albuterol (SABA Beta2-Adrenergic Agonists) (wheezing)

Delay other inhalants for 5 mins

SAMA Ipratropium, LAMA Tiotropium (Inhaled Anticholinergics)

Manages exercised-induced bronchospasms (EIB) (3)

SABA Albuterol, LABA Formoterol/Salmeterol/Terbutaline (Beta2-Adrenergic Agonists)

SAMA Ipratropium, LAMA Tiotropium (Inhaled Anticholinergics)

Montekulast, Zafirkulast, Zileuton (Leukotriene Modifiers) - Adjunctive

Post-Attack Acute Asthma Management (1)

Prednisone (Oral Glucocorticoids)

Hyperglycemia (1)

(Glucocorticoids)

Taper doses (1)

Fluticasone/Budesonide, Prednisone (Nasal/Oral Glucocorticoids)

Bone demineralization (use Vit. D + Calcium) (1)

(Glucocorticoids)

Avoid if urinary retention (1)

SAMA Ipratropium, LAMA Tiotropium (Inhaled Anticholinergics)

Seizures

Theophylline (Methylxanthines)

Diabetes (2)

SABA Albuterol, LABA Formoterol/Salmeterol/Terbutaline (Beta2-Adrenergic Agonists)

(Glucocorticoids)

Hypertension (2)

(Beta2-Adrenergic Agonists)

(Glucocorticoids)

Avoid NSAIDs (GI bleed)

(Glucocorticoids)

ALWAYS TAKEN WITH/AFTER LABAs

(Glucocorticoids)

Take with food

(Glucocorticoids)

Engage weight-bearing exercise (reduces osteoporosis side effect)

(Glucocorticoids)

Candidiasis risk

Prednisone, Budesonide/Beclomethasone dipropionate/ Fluticasone (Oral/Inhaled Glucocorticoids)

Monitor potassium w/ potassium-wasting diuretics

(Glucocorticoids)

Infection Risk (2)

Prednisone, Budesonide/Beclomethasone dipropionate/ Fluticasone (Oral/Inhaled Glucocorticoids)

(Leukotriene Modifiers)

Take on empty stomach

(Leukotriene Modifiers)