PHARM I: EXAM #3 (Pulm Questions)

What medications do you want to avoid giving to a pt with bronchitis?

- antihistamines
- sympathomimetics

Routine antibiotics are not recommended for bronchitis but in what case would we want to consider giving them and which would we prescribe?

- if symptoms last for more than five days
- doxy
- macrolides
- FQ but avoid unless pt has recent abx exposure

What factors increase the risk for PCN-resistant S. pneumoniae CAP? (6)

- older than 65
- alcoholism
- B-lactam use in past 3 months
- immunosuppressed
- comorbidities
- exposure to child in daycare

What factors increase the risk for enteric gram negative CAP? (4)

- nursing home pt
- underlying cardiopulmonary dz
- comorbidities
- recent abx therapy

What factors increase the risk for P. aeruginosa CAP? (4)

- structural lung dz
- corticosteroid use
- broad spectrum abx therapy for more than seven days in the past month
- malnutrition

What are the 1st line and 2nd line outpatient treatments for CAP?

- 1st-> macrolide
- 2nd-> doxy

For treatment of CAP outpatient in a patient with risk factors for resistant S. pneumoniae, what should be prescribed?

- beta-lactam + macrolide
OR
- if allergic to beta-lactam, respiratory FQ i.e. levofloxacin or moxifloxacin

What is inpatient treatment for CAP for a patient who is not in the ICU?

- an IV beta-lactam:
3rd generation cephalosporin or high-dose ampicillin PLUS macrolide
OR
doxycycline
OR
respiratory FQ

What is inpatient treatment for CAP for an ICU patient?

- same as non-ICU, but all meds given IV
- if MRSA CAP, add vancomycin

How would you treat nosocomial PNA in a patient with NO risk factors for MDR pathogens?

- 3rd gen cephalosporins
OR
- respiratory FQ
OR
- ampicillin/sulbactam
OR
- ertapenem

How would you treat nosocomial PNA in a patient who has risk factors for MDR pathogens?

- gram negative combo therapy:
antipseudomonal cephalopsorin, carbapenem, or PCN
PLUS
antipseudomonal FQ or aminoglycoside
- PLUS gram positive coverage
vancomycin

What are the antipseudomonal cephalosporins?

- Ceftazidime
- Cefipime (4th gen)

What are the antipseudomonal carbapenems?

- Imipenem (caution in those with sz history)
- Meropenem

What is the antipseudomonal PCN?

- piperacillin/tazobactam

What are the antipseudomonal FQ and what are their benefits?

- ciprofloxacin, levofloxacin
- good activity against atypicals and good lung tissue penetration

What are the aminoglycosides?

- gentamicin
- tobramycin
- amikacin

What two things cover MRSA and which requires renal adjustment/causes ototoxicity and nephrotoxicity?

- vancomycin and linezolid
- vancomycin requires renal adjustment

What is the combo therapy for tuberculosis?

- 2 months of INH, Rifampin, Ethambutol, and Pyrazinamide
FOLLOWED BY
- 4 months of INH and Rifampin

What are the characteristics of INH? (3)

- bacteriostatic for latent
- bacteriocidal for active
- inhibits production of waxy cell coat

What are the adverse effects of INH? (4)

- Lupus like syndrome (metabolized by acetylation)
- hepatitis-> increased in alcoholics and the elderly
- peripheral neuritis-> pyridoxine deficiency (give B6)
- sz due to decreased pyridoxine, cannot convert glutamate to GABA

Rifampin is a broad spectrum drug used for TB, what is its mechanism?

- inhibits RNA polymerase

What are the adverse effects of Rifampin? (5)

- CYP enzyme inducer (3A4, 1A2, 2C9)
- hepatitis
- orange secretions
- flu-like syndromes
- GI disturbances

Why is Ethambutol useful in TB treatment?

it helps weaken the cell wall to allow other agents better access

Ethambutol needs what?

renal dose adjustment

What are the adverse effects of Ethambutol?

- visual disturbances-> decreases red-green discrimination and VA

What is the mechanism of pyrazinamide?

it gets converted to pyrazinic acid which lowers pH so bacteria can't grow, enters macrophages, and gets destroyed

What is the advantage of pyrazinamide?

decreases duration of combo therapy

Why do we give pyrazinamide for only two months?

to avoid liver toxicity

What are the adverse effects of pyrazinamide? (3)

- increases LFTs
- inhibits uric acid secretion
- avoid in pregnancy

During anaphylaxis, what is given to aid in volume expansion?

- IV crystalloids aka any fluid that is salt containing

What endogenous catecholamine is given during anaphylaxis?

epinephrine

What are the alpha effects of epinephrine?

vasoconstriction, decreased vascular permeability

What are the beta effects of epinephrine?

bronchial smooth muscle relaxation

What are the adverse effects of epinephrine? (5)

- anxiety
- HTN
- tachycardia
- N/V
- diaphoresis

OD of epinephrine can lead to what?

- cerebrovascular hemorrhage
- MI
- pulmonary edema

What are the H1 histamine blockers and what do they do?

- diphenhydramine, hydroxyzine
- relieve rash, pruritus, hives

What is the H2 histamine blocker?

famotidine

What bronchodilator might be used in anaphylaxis? What does it do and what are its adverse effects?

- Albuterol (B2 agonist)
- relaxes bronchial smooth muscle
- anxiousness, tremor, tachycardia

What medications take time to work and should not be made a priority to give first during anaphylaxis?

corticosteroids i.e. methylprednisolone, prednisone

What are the quick relief meds for asthma? (3)

- SABAs
- anticholinergics
- systemic corticosteroids

What are the long term controller meds for asthma? (6)

- LABAs
- inhaled corticosteroids
- leukotriene modifiers
- mast cell stabilizers
- anti-IgE antibody
- methylxanthines

What is the mechanism of beta 2 agonists? (2)

- increases cAMP
- relaxes airway smooth muscle

What are the SABAs?

- Albuterol
- Levalbuterol

What are the LABAs?

- Formoterol
- Salmeterol

What are the adverse effects of the beta 2 agonists? (7)

- tachycardia
- hypotension
- HA
- dizziness
- tremors
- hyperglycemia
- transient hypokalemia

What are the inhaled corticosteroids? (BBFFMT)

- Beclomethasone
- Budesonide
- Flunisolide
- Fluticasone
- Mometasone
- Triamcinolone

What do the ICS's do and how long does it take for them to work best?

- control inflammation
- up to 8 weeks

What are the adverse effects of an ICS? (3)

- oral candidiasis
- suppress growth in children
- inhibit immune system

What are the long-term combo meds? (LABA + ICS) (/BMF)

- formoterol/budesonide (Symbicort)
- formoterol/mometasone (Dulera)
- salmeterol/fluticosone (Advair)

What leukotriene modifier is used in asthma treatment?

- Montelukast (leukotriene receptor antagonist)

What is Montelukast effective in treating and in what pts is it thought to be useful in?

- ASA induced asthma
- those pts with night-time awakenings

What injectable leukotriene modifier is used in asthma treatment and what are its adverse effects?

- Zileuton
- flu-like syndrome, inhibits CYP enzymes

What medications are given to remove the trigger or antigen in asthma patients?

- mast cell stabilizers
- Cromolyn, Nedocromil

What mab might be given to an asthma patient to control inflammation?

- Omalizumab

How does Omalizumab work?

binds circulating IgE

What are the adverse effects of Omalizumab? (2)

- anaphylaxis
- secondary malignancies

What asthma medication given to control inflammation is generally used more in COPD patients because of its ability to inhibit PDE, increase cGMP, and cause bronchial smooth muscle relaxation?

- Methylxanthines-> Theophylline

What are the side effects of theophylline? (3)

- increased gastric acid secretions
- diuretic effect
- sz, arrhythmias

What is the mechanism of anticholinergics used in asthma treatment?

- block Ach effect on muscarinic receptors, leading to bronchodilation

What is the short-acting anticholinergic and how long does it last?

Ipratropium, up to 8 hours

What is the long-acting anticholinergic and how long does it last?

Tiotropium, 24 hours

Oral systemic corticosteroids are good for what?

acute exacerbations

What side effect is seen with long term use of oral systemic corticosteroids?

- adrenal suppression

What is the algorithm for status asthmaticus? (5)

- continuous albuterol nebulizer
- IV steroids
- magnesium
- ketamine if intubated b/c it provides bronchodilation
- aminophylline if nothing else works

What is the mechanism of bupropion SR?

- nicotine indirectly activates epinephrine and dopamine in the CNS, this medication mimics these effects b/c it inhibits the uptake of norepi and dopamine

Bupropion should be avoided in pts with? (3)

- sz hx
- MAOI use
- caution in those taking noradrenergic antidepressants

What do nicotine replacement agents help with?

physical withdrawal symptoms

What is the partial nicotine receptor agonist used in smoking cessation?

Varenicline (Chantix)

What is a side effect of varenicline?

sleep disturbances-> really vivid dreams

What is the black box warning for varenicline?

neuropsychiatric events