chapter 17: drugs for respiratory disorders and allergic rhinitis

what are the 2 major respiratory diseases?

1. asthma

2. status asthmaticus

what is asthma?

reversible airway obstruction with inflammation

what triggers asthma?

1. allergens

2. exercise

3. stress

4. upper respiratory tract infection

5. environmental pollution

6. medication

what are signs and symptoms of asthma?

1. shortness of breath

2. wheezing

what is treatment for asthma?

fast acting B2 agonist inhalers

what should patients with asthma do at dental visits?

bring inhaler with them

what is status asthmaticus?

persistent, life-threatening bronchospasm

how is status asthmaticus treated?

unresponsive to treatment

what does COPD stand for?

chronic obstructive pulmonary disease

what is COPD?

irreversible airway obstruction

what is COPD commonly associated with?

smoking

what are the 2 types of COPD?

1. chronic bronchitis

2. emphysema

what is chronic bronchitis?

chronic inflammation of airways

what is emphysema?

alveolar destruction

what does alveolar mean?

relating to cavities/air sacs

what happens during emphysema?

airspace enlargement and airway collapse

what are treatments for COPD?

1. anti-muscarinics

2. B2-adrenergic agonist

3. anti-histamines

what does muscarinic mean?

an agent relating to actions of acetylcholine on PANS

what does adrenergic mean?

relating to adrenaline (epi/norepi), related to SANS

what does MDI stand for?

metered dose inhalers

what are advantages of MDIs?

1. medication directly delivered to bronchioles

2. reduces total dose and systemic adverse effects

3. better bronchodilator than oral dose

4. inhaled dose can be accurately measured

what does HFA stand for?

hydrofluoroalkane propellants

what did MDIs replace?

chlorofluorocarbons

what can MDIs deliver?

1. B adrenergic agonist

2. corticosteroids

3. cromolyn

4. anti-muscarinics

what are b adrenergic agonists?

medications that mimic stress hormones (epi - adrenaline, and norepi)

where are b-1 receptors found?

heart

where are b-2 receptors found?

lungs

where are b-3 receptors found?

bladder and fat tissue

what are adrenergic agents AKA?

sympathomimetic agents

what do adrenergic agents do?

produces bronchodilation by stimulating B-receptors in the lungs

what do B2 agonists block release of?

release of inflammatory mediators from mast cells

what does SABA mean?

short acting B2 agonists

what is the onset of SABA?

5-15 minutes

what is the duration of SABA?

3-6 hours

what are SABAs known as?

rescue medications

what are uses of SABA?

1. asthma

2. COPD with mild obstruction

3. emergency asthma attacks

4. prevention of exercise-induced asthma

5. acute intermittent COPD relief

what are examples of SABA?

1. albuterol

2. metaproterenol

3. levalbuterol

what are side effects of SABA?

1. xerostomia

2. tremors

3. tachycardia

4. QT prolongation

5. insomnia

6. hyperglycemia

7. hypokalemia

8. hypomagnesemia

9. nervousness

what is tolerance to SABA?

receptor down regulation

what is an SABA + anti-cholinergic combination example?

albuterol + ipratropium

what are LABAs?

long acting B2 agonists

what is the onset for LABA?

45 minutes

what is the duration of LABA?

12 hours

what are examples of LABA?

1. salmeterol

2. indacaterol

what are uses of LABA?

1. persistent asthma

2. COPD with moderate to severe obstruction

3. prophylaxis

what are side effects of LABA?

1. tremor

2. tachycardia

3. QT prolongation

4. insomnia

5. hyperglycemia

6. hypokalemia

what is hypokalemia?

low potassium level in blood

what are black box warnings for SABA?

none

what are black box warnings for LABA?

children 4-11 have higher risk of death

when should LABAs for asthma be used?

only combined with an inhaled corticosteroids

what are some examples of LABA + inhaled corticosteroids?

1. fluticasone + salmeterol

2. budesonide + formoterol

what is the difference between SABA and LABA?

• SABA: short, quick rescue

• LABA: long term control/prevention

what does LABA for asthma require?

NEEDS an inhaled corticosteroid

what are muscarinic antagonists?

anti-cholinergics

what are anti-cholinergics?

a medication that blocks acetylcholine action

what does acetylcholine do?

helps nerves communicate for PANS (rest and digest)

what is the mechanism of action of muscarinic antagonists?

1. inhibits acetylcholine

2. produces bronchodilation

what are examples of muscarinic antagonists?

1. ipratropium bromide

2. tiptropium bromide

what is the first choice to treat COPD?

ipratropium

what is used for long term COPD treatment?

tiotropium

what is more effective for COPD than asthma?

muscarinic antagonists

what are side effects of muscarinic antagonists?

1. dry mouth

2. pharyngeal irritation

3. bad taste

4. glaucoma

what are dental concerns with muscarinic antagonists?

xerostomia and increased concerns for patients with glaucoma

what do corticosteroids block?

inflammation

what do corticosteroids decrease?

airway inflammation

what are examples of inhaled corticosteroids?

1. beclomethasone

2. fluticasone

3. budesonide

4. flunisolide

what are the effects of inhaled corticosteroids?

1. improved pulmonary function

2. prevents symptoms

3. decreases wheezing, tightness, and cough

4. decreases airway inflammation

5. reduces edema

6. lowers airway hyper-responsiveness

what is the most effective long term treatment for mild, moderate, and severe persistent asthma?

inhaled corticosteroids

can inhaled corticosteroids be used alone to treat COPD?

no

what must inhaled corticosteroids be combined with to treat COPD?

LABAs

what are examples of oral corticosteroids?

prednisone

what is prednisone used for?

patients with severe asthma

what are adverse effects of oral corticosteroids with chronic inhaled corticosteroids use?

1. candidiasis

2. adrenal suppression

3. poor wound healing

4. xerostomia

5. hoarseness/dysphonia

6. unpleasant taste

7. osteoporosis

8. cataracts

9. slow growth rate in children

what dental implication should patients watch out for with inhaled corticosteroid use?

rinse and gargle after use to avoid oral candidiasis

what are leukotrienes?

inflammatory lipid mediators produced by immune cells

what are leukotrienes synthesized from?

arachidonic acid by enzyme 5-lipoxygenase

what do leukotrienes cause during inflammation?

1. bronchoconstriction

2. increased mucus secretion

3. mucosal edema

4. eosinophil recruitment

what is the mechanism of action for leukotrienes?

leukotrienes modifiers block the effects/release of leukotrienes

what are uses of leukotriene modifiers?

1. asthma not controlled by B2 agonists/corticosteroids

2. prophylaxis

3. adjunctive treatment with inhaled corticosteroids

what is prophylaxis?

any measure taken to prevent a disease/condition from developing/spreading

what are examples of leukotriene drugs?

1. zileuton

2. zafirlukast

3. montelukast

what is the mechanism of zileutron?

prevents synthesis of leukotrienes

what are adverse effects of zileutron?

life threatening hepatic injury

what is the mechanism of montelukast?

leukotriene receptor antagonist

what are adverse effects of montelukast?

1. agitation

2. aggression

3. anxiousness

4. abnormal dreams/hallucinations

5. depression

6. insomnia

7. irritability

8. suicidal thoughts/behaviors

what is the mechanism of zafirlukast?

leukotriene receptor antagonist

what are adverse effects of zafirlukast?

drug interactions and liver injury

what does zafirlukast interact with?

1. erythromycin

2. aspirin

3. increases warfarin effect

4. life threatening hepatic injury

what is cromolyn sodium?

mast cell degranulation inhibitor/mass cell stabilizer

what is the mechanism of action for cromolyn sodium?

prevents mast cells from releasing

1. histamine

2. proteases

3. cytokines

4. leukotrienes

5. prostaglandins

what are uses of cromolyn sodium?

1. prophylaxis of asthma

2. chronic asthma prevention

3. taken before exercise induced asthma

what is cromolyn sodium not used for?

acute asthma attacks

what is the least toxic of asthma medications?

cromolyn sodium

what is the non-steroidal treatment of choice for asthma?

cromolyn sodium

what are examples of xanthines and methylxanthines?

1. theophylline

2. caffeine

3. theobromine

what are examples of xanthines/methylxanthines?

1. theophylline

2. aminophylline

what is the mechanism of action of xanthines/methylxanthines?

1. blocks adenosine receptors

2. decreases production/release of histamine from mast cells

3. decreases inflammation

4. inhibits phosphodiesterase

5. increases cAMP levels

6. produces bronchodilation

7. kills inflammatory cells

what are uses of xanthines/methylxanthines?

1. mild persistent asthma

2. bronchospasm with COPD

3. IV aminophylline may be used for acute asthma attacks/status asthmaticus if inhaled drugs cannot be used

why is theophylline not preferred for treatment?

narrow therapeutic index

what are adverse effects of xanthines/methylxanthines?

1. nausea, vomiting

2. increases gastric secretions

3. insomnia

4. diuresis

5. severe cardiovascular arrhythmias