Drug induced Pulmonary Disorders/Toxicities

How is drug induced pulmonary toxicity diagnosed?

How is drug induced pulmonary toxicity diagnosed?

It is diagnosed by exclusion. Other disease processes must be ruled out before diagnosing drug-induced pulmonary toxicity.

What are the 9 defined set of criteria for diagnosing drug reactions ( also known as the Naranjo Assessment)?

1.       Correct identification of the drug, its dose, and its duration of administration

2.       Exclusion of other primary or secondary lung diseases

3.       Temporal eligibility: Appropriate latent period (exposure to toxicity)

4.       Recurrence with rechallenge (not commonly performed)

5.       Singularity of drug (i.e., other drugs the patient is taking)

6.       Remission of symptoms with removal of the drug

7.       Characteristic pattern of reaction to a specific drug (perhaps previously documented)

8.       Quantification of drug levels that confirm abnormal levels (especially for overdoses)

9.       Degree of certainty of drug reaction (i.e., causative, probable, or possible)

What test is most sensitive for defining /seeing pulmonary abnormalities that involve the parenchyma and interstitial infiltrates?

1.       High-resolution computed tomography (CT) scanning is more sensitive than chest X-ray for determining radiographic abnormalities.

Describe some patient related and drug related risk factors for developing drug induced pulmonary disorders:

Patient-Related	Drug-Related
Young/advanced age	Dose or administration rate
Gender	Cumulative dose
Occupational factors	Treatment duration
Underlying disease 1.       Lung 2.       Immune-mediated 3.       Renal/hepatic	Simultaneous oxygen
Ethnicity	Radiation
	Combination therapy

Explain the clinical presentation of Apnea:

Exaggerated respiratory depressant response

What is the clinical presentation of bronchospasm?

Wheezing, SOB, sneezing, cough, may develop nasal polyps

Describe the clinical presentation of aspirin induced bronchospasm:

Rhinorrhea, nasal congestion followed by nasal polyps, aspirin intolerance

What is the clincal presentation of Non-cardiogenic Pulmonary Edema?

Persistent cough, tachypnea, dyspnea, tachycardia, rales on auscultation, hypoxemia

What is the clincal presentation of pulmonary eosinophilia?

Fever, nonproductive cough, dyspnea,

cyanosis, bilateral

pulmonary

infiltrates, eosinophilia in the blood, and pleuritic chest pain

What is the clinical presentation of pneumonitis and fibrosis?

Dyspnea, hypoxemia, nonproductive cough, diffuse alveolar damage,

and interstitial pneumonitis in the absence of lower respiratory infection

What are risk factors of apnea?

COPD, alveolar hypoventilation, and chronic CO2 retainers, elderly

What are risk factors of bronchospams?

COPD, asthma, preexisting bronchial hyperreactivity 

What is the risk factors of aspirin induced bronchospasm?

Asthma, Incidence ↑ w/ age, Women > men

What is the risk factors of non-cardiogenic pulmonary edema?

IVDU, moderate to high narcotic doses, chemotherapy

What is the risk factors for pneumonitis and fibrosis?

Chemo: cumulative dose, ↑age, concurrent or previous radiotherapy, Amiodarone:  >400mg amiodarone for ≥2months or ≥2yrs of therapy

What are the top 3 drugs that incite apnea?

BZDs, NMBAs, aminoglycosides

What are the top 3 drugs that incite bronchospams?

ASA/NSAIDS, ßblockers, ACEIs

What are the top drugs that incite aspirin induced bronchospasm?

-aspirin

What are the top 3 drugs that incite non-cardiogenic pulmonary edema?

Chemo agents,

Narcotic analgesics,

Heroin/Cocaine

Corticosteroids

What are the top 3 drugs that incite pulmonary eosinophilia?

Nitrofurantoin, methotrexate, sulfonamides

What are the top 3 drugs that incite pneumonitis and fibrosis?

Chemo, amiodarone, cocaine, sulfonamides, SSRIs

A patient is asthmatic and is taking nadolol for the treatment of portal hypertension what pulmonary induced condition are they at risk of?

-Bronchospams

A 64 year old is an intravenous drug user is now experiencing an acute onset of dyspnea with tachypnea, tachycardia hypoxemia, and diffuse crackles upon physical examination. The patient has fluffy infiltrates present on the chest radiograph. What type of pulmonary condition does this patient present with?

-non-cardiogenic pulmonary edema

A patient is 35 year old women with asthma and nasal polyps, what pulmonary condition do they have?

-aspirin induced bronchospasms

A patient has been inhaling cocaine for about 10 years, and they present to the ED with fever. cough, and dyspnea and pleuritic chest pain. What pulmonary condition do they have?

-pulmonary eosinophilia

A 46 yr. old CF taking Amiodarone 300 mg tid for the treatment of ventricular arrhythmias began experiencing cough, dyspnea, and hypoxemia. What pulmonary condition do they have?

-pneumonitis and fibrosis

A 34 yr. old AAM with PMH of COPD and seizures. Came to the ED via EMS and recieved diazepam and phenobarbital for treatment of partial seizures and began experiencing decreased oxygen saturation. What pulmonary condition do they have?

-Apnea

What is the first line treatment for management of drug induced pulmonary toxicities?

1.       The treatment of drug-induced lung disease consists of immediately discontinuing the offending drug and appropriately managing the pulmonary symptoms.

What is the role of the pharmacist in treating and preventing drug induced pulmonary disorders?

a. Complete a detailed medication history (prescriptions, OTCs, herbal products, tobacco, alcohol and illicit drug use)

 b. Actively identify patients with risk factors

c.        Before starting any medication, patients should be educated about the potential adverse effects 

d.       Every patient at each pharmacy visit should be asked if he or she smokes and is interested in quitting. 

e.       Reporting suspected ADR to FDA (MedWatch program) www.fda.gov/safety/medwatch/default.htm

f.         Patients who develop drug toxicity should be advised to avoid the drug in the future