NUR 3031-002 Basic Concepts of Pharm: Respiratory Medications Part 1 (Asthma and COPD) Part 2: (Cough and Cold)

Treatment for Asthma and COPD: Bronchodilators NTN

Beta-2 Adrenergic Agonists

Methylxanthines

Anticholinergics

Treatment for Asthma and COPD: Anti-inflammatory Drugs NTN

Glucocorticoids (Steroids)

Leukotriene

Cromolyn

Asthma:

A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.

COPD:

Chronic Obstructive Pulmonary Disease, a lung disease commonly seen in smokers

- Worsens over time

- Irreversible

Bronchodilators: Beta-2 Adrenergic Agonists MOA

Activates Beta-2 receptors in the lung, causing bronchoDILATION

Bronchodilators: Beta-2 Adrenergic Agonists: Possible Systemic Effects

Systemic effects of Beta-2 Agonists:

Tachycardia (most common)

Dysrythmias

Angina

Tremor (Rare)

Seizures (Rare)

Short-Acting Beta-2 Agonists (SABA)

Albuterol (ProAir)

Levalbuterol (Xopenex)

Short-Acting Beta-2 Agonists (SABA) Therapeutic effects

Inhaled with quick onset of action

- Used PRN to abort an acute asthma attack

- Goal: use twice a week or less

- Higher use = asthma not well controlled = additional medications

Short-Acting Beta-2 Agonists (SABA) Dosage

Metered-Dose Inhaler (MDI)

Dry Powder Inhaler

Nebulizer

Short-Acting Beta-2 Agonists (SABA) Administration Technique

2 Breaths: wait 1 minute between each breath.

- Bronchodilation occurs and allows the second inhalation to penetrate deeply

Short-Acting Beta-2 Agonists (SABA) Administration Technique (MDI)

Use a spacer to increase medication delivery and prevent most of the dose from landing on the tongue

Short-Acting Beta-2 Agonists (SABA) Dosage Implications

Administer first when using other inhalers to allow maximum bronchodilation and absorption of all medications

Long-Acting Beta2-Agonist (LABAs)

Formoterol - Inhaler

Salmeterol (Serverent Diskus)- Inhaler

Terbutaline (oral)

Long-Acting Beta2-Agonist (LABAs) Administration

Taken on a fixed schedule or for long-term control

(q12h for inhalers)

- Used for Maintenance

Long-Acting Beta2-Agonist (LABAs): COPD

LABAs are preferred for patients with stable COPD

Long-Acting Beta2-Agonist (LABAs): Asthma

LABAs are always combined with glucocorticoids for patients with asthma

- Increased risk of DEATH when used alone

- FDA recommends combined inhalers

Bronchodilators: Methylxanthines

Theophyline

Bronchodilators: Methylxanthines (Theophylline) MOA

Relaxes bronchial smooth muscle

Bronchodilators: Methylxanthines (Theophylline) Therapeutic Effects

Maintenance of stable asthma

Long duration of action: good for patients with nocturnal asthma attacks

Bronchodilators: Methylxanthines (Theophylline) Toxicity S/S

N/V/D

Restlessness, Insomnia

Dysrythmias

Convulsions

Bronchodilators: Methylxanthines (Theophylline) Contraindications

DO NOT CONSUME CAFFEINE

Both are methylxanthines and can increase the risk of toxicity

Bronchodilators: Anticholinergics

Ipratropium (Atrovent) = Atropine Derivative

Tiotropoium (Spiriva)

Bronchodilators: Anticholinergics MOA

Blocks muscarinic receptors in the bronchi, reducing bronchoconstriction

Bronchodilators: Anticholinergics Pharmacokinetics

Only Available in Inhalants:

Long-acting and short-acting

Bronchodilators: Anticholinergics Adverse Effects

Few systemic effects, but clients may

develop anticholinergic effects

• Most common: Xerostomia (Dry mouth)

Glucocorticoids MOA

Decreases inflammatory mediators and infiltration with inflammatory cells

• Reduces mucus production and edema of airway mucosa

Inhaled Glucocorticoids:

Beclomethasone

Fluticasone (Flovent)

Oral/IV Glucocorticoids:

Prednisone,

Methylprednisolone

Cortisone

Inhaled Glucocorticoids: Pharmacokinetics

Take daily on a fixed schedule for long-term (chronic) management of COPD/Asthma

Inhaled Glucocorticoids: Adverse Effects

Growth suppression in children

Candidiasis (thrush) on the tongue, hoarseness; must rinse mouth/throat after use

Inhaled Glucocorticoids vs PO/IV

Acts locally with fewer systemic effects than PO/IV glucocorticoids: lower risk of hyperglycemia, immunosuppression, GI Bleed, or adrenal insufficiency

Leukotriene Modifiers

Montelukast (Singulair)

Leukotriene Modifiers: Montelukast (Singulair) MOA

Leukotriene receptor blocker- blocks activation of inflammatory leukotrienes

Leukotriene Modifiers: Montelukast (Singulair) Therapeutic Effects

Used to prevent exercise-induced bronchospasm (EIB)

- Administered on a fixed schedule

Leukotriene Modifiers: Montelukast (Singulair) Adverse Effects

Associated with neuropsychiatric events such as mood changes and suicidality (rare)

Cromolyn MOA

• Reduces inflammation by stabilizing the cell membrane of mast cells,

• reducing histamine and other inflammatory mediators

• inhibiting eosinophils and other inflammatory cells

Cromolyn Implications

Less effective than other medications like glucocorticoids

- Third-Line Therapy

Cromolyn Pharmacokinetics

Administered via nebulizer

• Safest asthma medication

Medications used for Cough, Cold, Allergy:

Glucocorticoids: intranasal

Antihistamines

Sympathomimetics

Antitussives

Expectorants and Mucolytics

Histamine: Role in the Body

- Stored in secretory vesicles

- Release is triggered by activated antibodies or other substances

Histamine: Role of Antibodies

- Antibodies are activated by reexposure to allergens

-- First exposure creates antibodies; subsequent exposure activates the antibodies

- Other triggering substances require no prior exposure

Histamine: H1 Physiologic Response

Vasodilation: warmth, flushing, decreased blood

Increased capillary permeability: edema, decreased blood pressure

Bronchoconstriction

Mucus Production

Pain. ithcing

CNS effects: regulation of processes such as sleep-wake cycle, seizure suppression, cognition, and neurotransmitter release

Histamine: H2 Receptors Physiologic Response

Gastric Acid Secretion

Antihistamines: First-Generation H1 Antagonists MOA

Block histamine receptors and some block muscarinic receptors

Antihistamines: First-Generation H1 Antagonists

Diphenhydramine (Benadryl)

Hydroxyzine (Vistaril)

Promethazine (Phenergan)

Antihistamines: First-Generation H1 Pharmacodynamics

Lipid soluble with affinity for CNS histamine receptors = crosses BBB

Antihistamines: First-Generation H1 Antagonists Contraindications

Do NOT consume:

- Alcohol

- Additional anticholinergic drugs

Do NOT Operate:

- Heavy machinery/ or driving

Antihistamines: First-Generation H1 Antagonists Adverse Effects

Sedation

Anticholinergic Effects:

• Dry mucous membranes

• Urinary retention

• Constipation

Antihistamines: First-Generation H1 Antagonists Side Effects

Reduced:

• flushing

• Edema

• Itching

• Mucus production

Antihistamines: First-Generation H1 Antagonists Therapeutic vs Toxic Dose

CNS depression/drowsiness at therapeutic doses

CNS excitation at toxic doses; PARADOXICAL EFFECT in children and older adults

Antihistamines: First-Generation H1 Antagonists Adverse Effects (Promethazine (Phenergan) Extravasation

Extensive tissue damage

• IM preferred route

• IV: dilute to 25mg/mL over 1 minute

Antihistamines: Second Generation

Cetirizine (Zyrtec)

Fexofenadine (Allegra)

Loratadine (Claritin)

Antihistamines: Second Generation vs First Generation

Low lipid solubility and low affinity for CNS H1 receptors = does not easily cross the BBB

- Not sedating

- Antihistamine effects treat allergy symptoms without CNS or anticholinergic effects

Decongestants

Pseudoephedrine (Sudafed), Phenylephrine

Decongestants MOA

Activation of Alpha-1 receptors in the nose causes vasoconstriction, relieving congestion

Decongestants Adverse Effects

Rebound congestion when wears off

CNS stimulation (insomnia, irritability, anxiety)

Decongestants Adverse Effects Contraindications

Systemic vasoconstriction: hypertension (contraindications)

Decongestants Adverse Effects: Abuse potential

Abuse: pseudoephedrine can be made into methamphetamine

Antitussives: Opioid Cough Suppressants

Codiene

Antitussives: Non-Opioid Cough Suppressants (Dextromethorphan):

Dextromethorphan = Suppresses the cough reflex in the CNS

Antitussives: Non-Opioid Cough Suppressants (Benzonatate):

Benzonatate = Decreases sensitivity of

respiratory stretch receptors

Expectorants and Mucolytics: Expectorants MOA

Increase flow of respiratory secretions to allow for easier expulsion

Expectorants and Mucolytics: Expectorants

• Guaifenesin (Mucinex)

Expectorants and Mucolytics: Mucolytics MOA

Thin mucus

Expectorants and Mucolytics: Mucolytics

• Hypertonic saline

• Acetylcysteine (inhaled)

Which information should the nurse include when

teaching a patient about inhaled glucocorticoids?

A. Inhaled glucocorticoids have many significant adverse effects.

B. The principal side effects of inhaled

glucocorticoids include hypertension and weight gain.

C. Use of a spacer can minimize side effects.

D. Patients should rinse the mouth and gargle before administering inhaled glucocorticoids.

C. Use of a spacer can minimize side effects.

A patient is prescribed codeine as

an antitussive. Which symptom

will the nurse observe for as an

adverse effect of this medication?

A. Respiratory depression

B. Increased heart rate

C. Productive cough

D. Restlessness

A. Respiratory depression

Rationale: Codeine is an opioid, and its main adverse effect is RR Depression

A patient asks what medication would

be most effective in the treatment of

seasonal hay fever. The nurse will teach

the patient about the use of which

drug?

A. Azelastine [Astelin]

B. Chlorpheniramine [Chlor-Trimeton]

C. Fluticasone [Flonase]

D. Pseudoephedrine [Sudafed]

C. Fluticasone [Flonase]

Rationale: Steroid

A patient with asthma is prescribed albuterol [Proventil], 2 puffs 3 times a day. What should the nurse teach the patient to do?

A. Rinse the mouth after taking the prescribed dose.

B. Take an extra dose if breathing is

compromised.

C. Wait 1 minute between puffs from the

inhaler.

D. Take adequate amounts of calcium and vitamin D.

C. Wait 1 minute between puffs from the

inhaler.

Rationale: Leaving time between breaths allows for bronchodilation to occur and leads to better absorption of the drug