Pharm: GI and rest of Pulm

acute bronchitis

Lower respiratory tract infection of small airways -> peripheral airway narrowing and variable obstruction (infants, <2 y/o)

severe acute bronchitis medications

B agonists (SABA) or neb racemic epinephrine (if albuterol not effective)

caution for acute bronchitis

• Do NOT use corticosteroids unless h/o underlying reactive air disease

• NO antibiotics unless concomitant bacterial infection (otitis, UTI, CXR infiltrate)

what causes acute epiglottis?

Caused by H. flu, strep, group A strep, staph aureus (incl. MRSA)

acute epiglottis drug treatment

DUAL therapy

3rd gen cephalosporin (Ceftriaxone or Cefotaxine) PLUS vancomycin OR clindamycin OR oxacillin OR nafcillin OR cefazolin

what should you consider when treating acute epiglottis?

• Check for PCN allergy

• If predominant  MRSA = vanco

• Empiric therapy

• Renal function = vanco

  • Watch out for red man syndrome!

    • Happens if you infuse too quickly

• Clindamycin = watch out for C. diff

dosing of pediatric med for acute epiglottis

weight based

Pertussis (Whooping Cough)

Contagious infection d/t bordetella pertussis (gram -)

what is your go-to for pertussis?

macrolides (azithromycin)

pertussis 1st and 2nd choice

• First choice: Azithromycin x 5 days

• Second Choice: Clarithromycin x 10 days WITH Trimethoprim-Sulfa (bactrim) x 14 days

what happens if you want to give macrolides to a pertussis pt but they’re allergic?

BACTRIM!

what is a contraindication of bactrim (for pertussis?)

Contraindication: bactrim for anyone under <2 months d/t lack of fully developed BBB and bilirubin will enter the brain

what drugs have no proven effect for pertussis tx?

beta agonists (SABA/LABA), glucocorticoids, and cough suppressants

what is the PEP for pertussis?

Provide to all household contacts, exposure to patient at high risk including infants, women in 3rd sem of pregnancy, renal insufficiency/severe illness, within 21 days

what do you do to prevent pertussis?

Dtap and Tdap

dtap - when do you administer it? how many doses?

• 5 doses - administered at 2, 4, 6, 15-18 month, and 4-6 years

  • D comes before T so give that one first

tdap - when do you give? when is it recommended?

• booster between 11-18 years/10 years, lower dosing from initial dose

  • ACIP recommends Tdap for >65 y/o who have not gotten Tdap and a single booster dose for adolescents

what are preventative medications for flu?

neuraminidase inhibitors

what are antivirals good for flu A, B, and H1N1?

Oseltamivir (Tamiflu) [oral]

Zanamivir (Relenza) [diskhaler]

Baloxavir (Xofluza) [oral] (not a go-to)

Peramivir (rapivab) [IV]

which antiviral that is good for flu a, b, and h1n1 is your go to?

Go to: Oseltamivir (Tamiflu) [oral]

when should you give treatment for flu?

within 48 hours, otherwise little benefit

if hospitalized though, you can start antiviral if >48 hrs

treatment dose for tamiflu

• 75 mg PO BID x 5 days (renal dosing req)

  • Lower dosing parameters if CrCl > 15 or 30

prophylaxis dose for tamiflu

• 75 mg PO QD x 7 days (renal dosing required)

  • Must be >1 year old

SE of tamiflu

GI issues (take with food → improve tolerability), HA

when is tamiflu preferred?

pregnant women, children, hospitalized pts, outpatients w/ severe/complicated/progressive illnesses (diabetics, heart disease, etc)

what if you want to give a kid tamiflu but they don’t can’t take it orally?

oral solution available

what is Zanamivir (Relenza) [diskhaler]?

Inhaled powder, 2 puffs, same frequency as Tamiflu, only the form is different

what is the SE of Zanamivir (Relenza)?

HA, bronchitis, nasal sx, cough

what is the MOA of tamiflu and relenza?

Neuraminidase Inhibitor -> prevents release of virus from host cell

what is a caution for both tamiflu and relenza?

use them with caution if pt has asthma or COPD → bronchospasms

what do you want to avoid with Baloxavir (Xofluza) [oral] ?

Avoid coadministration with dairy products (calcium/magnesium/poly valent minerals inhibits absorption of Xofluza)

what is the MOA of Baloxavir (Xofluza)?

prodrug, blocks replication of RNA -> no new viral cells

what is the tx and prophylaxis dose of Baloxavir (Xofluza)?

• Tx and prophylaxis: 80 mg PO QD

  • WEIGHT BASED

    • >80 kg = 80 mg, typical dose

    • 20-79 kg = 40 mg

what do i have to avoid with Baloxavir (Xofluza)?

Avoid giving Xofluza if they got live attenuated IV in last 17 days

what is a slight benefit of Baloxavir (Xofluza)?

Can give if pt has poor renal function (since Tamiflu is stricter w/ renal function)

what is the dose for Peramivir (rapivab) [IV]?

Treatment: one IV dose over 30 mins, no prophylaxis

what are antivirals that are only good for flu A?

• Amantadine (Symmetrel)

• Rimantadine (Flumadine)

  • Not as effective, SE is bad

what is the approach to starting outpatient antiviral tx?

• Does pt have progressive illness?

• Do they have risk of flu? 

• Do they have exposure to others?

  • If yes to any of these -> antiviral treatment

who has inc risk of flu complications?

• Children < 5 y/o, esp <2 y/o

• Pt <19 y/o receiving long term ASA or salicylate containing drugs

• >65 y/o

• Obesity (BMI > 40 kg/m2)

• Pregnancy or </2 weeks postpartum

• Non-hispanic black, hispanic or latino, american indian or alaskan native heritage persons

• Residents of nursing homes/long term care facilities

• Immunosuppressed

• Chronic medical conditions

Adjuvanted vaccines

an ingredient that helps create a stronger immune response

recombinant vaccines

produced w/o flu virus or chicken eggs, 3x the amount of antigen of standard dose (stronger)

trivalent vaccines

more common, 2 A and 1 B

quadrivalent vaccines

2 A and 2 B

Live-attenuated vaccine

uses weakened (attenuated) form of germ that causes disease

inactivated vaccine

used the “killed” version of germ that caused disease

who can get Tri or quadrivalent indicated flu vaccine IM?

anyone > 6 mos

who shouldn’t get Quadrivalent live attenuated flu vaccine nasal spray for ages 2-49 y/o?

NOT for people with asthma or underlying diseases

what should you do if Children aged 6 mos-8 yrs receiving flu vaccine for the first time?

should receive 2 doses 4 weeks apart

for flu vaccine, can you get it if you have an egg allergy?

yes.

what are antihistamines?

dec histamine-mediated contraction of smooth muscle of bronchi

when would you use a antihistamine?

prevents allergic responses by histamine

what are the first gen antihistamines for rhinitis?

• Diphenhydramine (Benadryl)

• Meclizine (Dramamine)

• Hydroxyzine

• Dimenhydrinate

• Promethazine

when do you take Meclizine (Dramamine)?

For motion sickness

what is hydroxyzine good for?

for chronic itching (keratitis), anxiolytic

what can you use Dimenhydrinate for?*

motion sickness*

why is promethazine not really great?

bad SE

H1 first generation have what SE?

All of these crosses CNS barrier -> causes sedation, drowsiness

what is H1 second gen drugs?

Certirizine (Zyrtec)

Loratadine (Claritin)

Fexofenadine (Allegra)

Desloratadine

Levocetirizine

which H1 second gen drug has biggest risk for drowsiness, even though most 2nd gen doesn’t cause drowsiness?

Certirizine (Zyrtec)

H1 antihistamines:

• how well are they absorbed?

• max serum levels?

Well absorbed after oral administration

Max serum levels in 1-2 hours

what is the half life of H1 first gen?

short half life, take is 2-3x a day (except meclizine)

what is the half life for H1 antihistamines 2nd gen?

longer half life (12-24 hours), 1x a day dosing

(includes meclizine, 1st gen)

what are the SE of H1 antihistamines?

• Sedation (less common with 2nd gen)*

• CNS effects: fatigue, dizziness, lack of coordination, tremors

• Anticholinergic: dry mouth, blurred vision, urinary retention

• Tachycardia

• Hypotension

• HA: more common SE of 2nd gen

  • Elderly and kids more likely to experience SE

what are some interactions with H1 antihistamines?

CNS depressants

MAO inhibitors

Cholinesterase inhibitors

what happens if you block cholinergic receptor?

INC dry mouth, urinary retention, and sinus tachy

what happens if you block a-adrenergic?

INC hypotension, dizziness, and reflex tachy

what happens if you block serotonin?

INC appetite

what happens if you Block histamine H1?

DEC allergic inflammation, neurotransmission in CNS, and cognitive performance. INC sedation and appetite

if you add what to antihistamines will there be a decrease in absorption?

calcium and magnesium

what do you do to avoid antihistamine tolerance?

switching out your medication for other ones or take med PRN instead of routinely

what do antitussives do? what will happen if you add benzocaine?

Acts on cough center in medulla by elevating its threshold for cough reflux, dec sensitivity of cough centers → cough suppression

can block pain w/ benzocaine

what is the go-to for antitussive medication? what is the dosing?

Dextromethorphan (Delsym): derivative of morphine, OTC, effective, one ingredient, BID dosing - go to!

what are the drug examples for antitussives?

• Dextromethorphan (Delsym): derivative of morphine

• Guaifenesin/hydrocodone (Hycotuss): antitussive/expectorant

• Diphenhydramine/Dextromethorphan (Duratuss DM): antihistamine/antitussive

  • Diph: 1st gen H1 antihistamine

• Promethazine w/ Codeine: antihistamine/antitussive

  • Use lower dose of codeine

what is the MOA of Benzonatate (Tessalon)?

MOA: anesthetizes stretch receptors in lungs

what is the dose for Benzonatate (Tessalon)?

PRN dosing ONLY, do NOT chew -> numbs tongue

what are the interactions for Benzonatate (Tessalon)? [antitussive]

Interactions: CNS depressants, antihistamines

treatment of pHTN groups

• group 1: vasodilators

• group 2: diuretics

• group 3: oxygen therapy

• group 4: anticoag

group 1: vasodilators for pHTN treatment FIRST LINE

calcium channel blockers

• Nifedipine, diltiazem, amlodipine ALL ARE EXTENDED RELEASE (better compliance and less risk of SE)

side effects of CCBs

SE: peripheral edema with all (esp amlodipine), orthostatic HTN

what are some other vasodilators you can use for pHTN?

• Phosphodiesterase-5 inhibitors (tadalafil, sildenafil AKA viagra)

  • Tadalafil is preferred > sildenafil

• Prostacyclins (Epoprosternol, Ioloprost)

• Endothelin receptor antagonists (Ambrosentan, Bosentan)

  • Ambrosentan: preferred

prescribing for pHTN vasodilation

• Dual therapy is preferred as long as it’s not in the same group/have the same MOA: ambrisentan and tadalafil is the most commonly prescribed. You should start with CCB, if that doesn’t work, then do dual therapy.

  • d/t side effect profile and dosing (For the 2 drugs)

group 2: diuretics for pHTN go-to

• treating HF and volume overload

  • Loop diuretics are go-to

  • If they already are on a thiazide diuretic, try to get the fluid under control first -> add loop diuretics

group 3: oxygen therapy for pHTN

if hypoxia at rest of w/ physical activity

group 4: anticoag for pHTN

•  long term anticoag is recommended, use oral like Xarelto, Eliquis

treatment for cor pulmonale

• dobutamine (IV)

• Milrinone (IV)

dobutamine MOA

direct acting catecholamine, stimulates B1 agonist. INC HR and cardiac output

dobutamine SE

cardiac arrhythmias, tension, anxiety, tremor

milrinone MOA

phosphodiesterase-3 inhibitor. Increases intracellular cAMP -> myocardial relaxation

milrinone SE

hypotension, arrhythmia 

what are medication induced causes of esophagitis?

NSAIDS, biphosphonates, potassium chloride, iron supplements, antibiotics (tetracycline, doxycycline, clindamycin), vitamin C (helps absorb iron -> more GI upset so take it with food), CCB, BB

Space these 2 - give iron first (needs acid), and then give famotidine (antacid/reduces acid)

what happens if you change med from pill → liquid?

changing to a liquid form reduces contact time = less SE

management of Medication-Induced Esophagitis

• Discontinue causative agent

• Change dosage formulation

  • Changing to a liquid form reduces contact time

• Short term use of antacids or cytoprotective agents

  • Antacid: H2 antagonist, mylanta, tums

• Patients with severe odynophagia may need parenteral nutrition

GERD non-pharm treatment

• Modify diet (no spicy food, hot food, too much food)

• Body positioning

• Increase fluid intake

• Smoking cessation (inc gastric secretion)

pharm treatment for GERD

• Antacids

• H2 receptor antagonists

• Proton pump inhibitors (PPIs)

• Cholinergic agents

antacid drugs

• magnesium trisilicate or hydroxide, Aluminum hydroxide, Calcium carbonate (Tums)

antacid MOA

neutralizes hydrochloric acid -> reduces pepsin absorption

SE of antacids

•  are dosed dependent: 

  • Magnesium: diarrhea and hypermagnesemia

  • Aluminum: neurotoxicity, anemia, constipation

  • Calcium: constipation, hypercalcemia, alkalosis, acute/chronic renal injury

PPIs reduce what?

reduce the amount of magnesium in the system

H-2 receptor antagonist (H2RA) drugs

Famotidine (Pepcid), Nizatidine (Axis), Cimeditidine (Tagamet)

cimeditine SE

SE profile is bad. CYP inhibitor. INC lvls of warfarin, phenytoin, quinidine (anti-arrhythmic), benzodiazepines (valium/xanax/adavan), procainamide. Can cause confusion in elderly. Gynecomastia and galactorrhea.