Comprehensive Study Guide on Medications and Therapeutics

CH 38

Diabetes

• rapid/short first then the intermediate (same syringe)* (within 10-15 min max life) Always draw up clear before cloudy, or RN (regular then NPH)

• Long acting can NEVER BE mixed

• ONLY ONE insulin we CAN give intraveniously regular insulin

• No insulin pumps in imaging

Type I (have to use insulin - Sub Q)

Type II ─ for those unresponsive to diet, exercise, oral agents

Glucose elevating medications INCREASE BG

• For use in hypoglycemic events

• Assess blood sugar before acting/ medicating

• Conscious patient:

  • glucose tablet or gel ─ absorbed rapidly

• Unconscious patient:

  • D50% given IVP (dexterose = 50% sugar)

  • Glucagon SQ ─ may induce vomiting, turn patient on side!

Types of Insulin

• Rapid acting ─ insulin lispro (Humalog) (clear in color) (nutritional, sliding scale)

• Short acting ─ regular (clear color) (sliding scale)

• Intermediate acting ─ NPH (Humulin N) (cloudy) (basal)

• Long acting ─ glargine (Lantus) (clear) (basal)

Insulin 

AE - hypoglycemia

Conrta - none 

Caution - assess BG, preg/lac.(they will only use insulin)

Drug interaction - steroids, diuretics, niacin, thyroid hormone = elevated BS// Etho, sulfa drug, ASA = lowers BS

Sulfonylureas - glyburide: stimulated insulin release (type 2 ONLY)

AE - hypoglycemia, GI effects, heart burn

Contra/caution - allergies, if need for tight control on BG, Type 1, preg/lac., 

Drug-drug - beta blockers (hypoglycemic effect), acidified urine med(decrease excreation)

Biguanides - metformin: decrease glucose production in liver, increasing uptake of glucose in cells, Does not stimulate insulin secretion

Indication - Type 2, obesity diabetes

AE - GI, lactic acidosis (n/v, cramp, irregular rapid breathing)

Contras - renal dz, acute cardiac events, sepsis (risk of lactic acidosis)

Drug-drug - Iodine dyes (stop med day of exam, held for 48 hrs.)

Glucagonlike Polypeptide Receptor Agonists (GLP-1 Agonists) - semaglutide: increase insulin release, decrease glucagon release (lowers BS), slows GI emptying

Indication - type 2, weight loss, reduce risk or CV events

Pharmacokinetic - SQ, oral

AE - pancreatitis, GI

Contras - Boxed warning (risk of thyroid cancer), not for type 1, preg/lac.

Drug-drug - oral meds, other antidiabetic agents (monitor)

(36) endocrine - steroids 

Glucocorticoids - prednisone: Anti-inflammatory and immunosuppressive effects,  stimulation of glucose for energy

AE - MANY! … Labile emotions(meh), Mental status changes,  psychosis, anxiety, insomnia, **Masking of signs, symptoms of infection, Altered fat distribution, Delayed growth in children, Long term use: “Cushing’s Syndrome ” → Moon face/Buffalo hump, Thin extremities (protein wasting), Skin changes, purple striae, thin skin (prednisone skin), Water retention, edema,, hypertension, K+ loss, Osteoporosis, Delayed wound healing, Bruising, Weight gain, Diabetes Mellitus (^ high glucose)

Contras/cautions - Hold for infection process, Caution in diabetes, Caution with stomach ulcers, Endocrine disorders, Pregnancy/lactation, Adrenal suppression → causing body’s own production to stop (Use short courses, taper and off whenever possible)

Scheduling Guidelines: Alternate-day therapy (ADT) - double dose taken every other AM

Pt teaching - Do not stop abruptly, Medical alert bracelet, Avoid exposure to infection, Vaccines – no live virus, Notify PCP for fever >100, Monitor blood sugars, Weights-fluid retention, Diet – salt restriction (retaining sodium), Take oral preps with meals in the morning (2am - 8am), Inhalation teaching (education!)

Mineralocorticoids - {fluid retention*}Affect electrolyte and homeostasis, Increase sodium and water retention and potassium excretion

fludrocortisone: Used for adrenal insufficiency in combination with glucocorticoid (Off label → hypotension)

AE -  r/t increased fluid volume (Na/ water retention); possible hypokalemia (monitor arrhythmias)

Contras - Severe cardiac disease and HTN (^ BP from meds)

Cautions - Preg/ Lac., Presence of infection → will alter adrenal response, High sodium intake

NC - Allergies, asses VS, baseline electrolytes, weights (fluid overload), taper

(37) Thyroid 

Hypothyroid (depressed - low T4, elevated TSH//Lack of sufficient thyroid hormone → lack iodine, tumor, surgery/radiation): Lethargy, Sleepiness, Slowed speech, Hypoactive reflexes, Bradycardia, Hypotension, Oliguria, Decreased appetite, Weight gain

Hashimoto disease ─ autoimmune; Myxedema - gradual

(1)Tx: levothyroxine: treats hypothyroidism

Contras - Thyrotoxicosis(hyperthyroidism), acute MI(could exacerbate MI)

Caution/AE - Lactation, monitor for hyperthyroidism

NC - Assess cardiovascular status (med adjust), overdose(hyperthyroidism), take regularly in AM, empty stomach, Oral anticoagulant effect increased, Decrease effectiveness of digitalis (for heat failure), Periodic blood tests, Pregnancy ─ levothroixine drug of choice, caution with lactation

Hyperthyroid (stimulated - low TSH and high T4//Excessive amounts of thyroid hormone): Insomnia, Anxiety, Tachycardia, Hypertension, Increased appetite, Weight loss

Graves disease (autoimmune dz), Goiter

(2)Tx: 

Thioamides - prophylthiouricil(preg.), methimazole: prevent synthesis of thyroid hormone (T4) in thyroid cells

Contras - preg/lac.

caution/AE - over suppression of thyroid(lethargy, bradycardia, n/v/d), Changes serum levels (metabolism slows — anticoagulants, beta blockers)

Iodine products(solutions): iodine needed to produce thyroid hormone, large doses block this function (oversaturation/drowning)

Contras - preg (DO NOT GIVE)

Caution - monitor for hypothyroidism/serum levels, GI distress, teeth staining, 

(37) parathyroid - regulates calcium levels

Antihypocalcemic Agents - Deficient levels of PTH → hypocalcemia

calcitriol: →Vit. D,  Stimulates calcium = increase calcium

AE - GI: metallic taste, N/V/C, dry mouth, anorexia//CNS: weakness, HA, somnolence, irritability

Contras - renal stones

NC - monitor calcium levels, nutritional consult

Antihypercalcemic Agents - Drugs act on serum levels of calcium not on PTH

indication - Paget’s disease; post-menopausal osteoporosis; osteoporosis in males (alendronate)

Bisphosphonates - alendronate: Slows bone resorption(breakdown) → lower serum calcium levels, does not prevent bone formation

AE - Abdominal pain, constipation, diarrhea, nausea, Musculoskeletal pain, Esophageal erosion (educate! → sit up right full 30 min after taking meds., AM, FULL GLASS OF WATER W/FOOD), Long term(5YRS.) → increased risk femoral shaft fractures

Contras - preg, hypocalcemia (makes is worse)

Calcitonins - calcitonin salmon: Inhibit bone resorption(prevent old bone from being broken down), lower calcium, promote excretion (kidneys)

AE - Flushing, skin rash, N/V, Local inflammation at inj site

Contras - allergy to salmon/fish, hypocalcemia, preg/lac (outweight)

Caution - renal dz

• Encourage fluids!

(29-33) ANS

Look at notes on ipad too

Autonomic Nervous System

• sympathetic Nervous system

  • AKA Fight or Flight

  •  Speeds things up for action!

  • Adrenergic receptors = norepinephrine, epinephrine

• Parasympathetic Nervous System

  • AKA Rest/Repair (Grill and Chill)

  •  Controls homeostasis

Alpha

Alpha 1: Found in blood vessels, iris, bladder

• Stimulation → Cause vasoconstriction → increased BP(Dilates pupil)

• increased closure of internal sphincter (urethra) (urinary retention = decreased urine output)

Alpha 2* My own rules!: Located on nerve membranes

• control/release of NE, Decrease in SNS activity → leads to decrease BP and HR

Beta

Beta 1: in heart

• Stimulation → increased myocardial activity and HR (pump more efficiently)

Beta 2 : Lungs

• Stimulation → dilate airways (allow more o2 in)

Parasympathetic Receptors - opposition to SNS

• Cholinergic receptors → Neurotransmitter ACh 

• Simulation = increased motility, decreased heart rate, constriction of the bronchi, Pupillary constriction

Adrenergic Agonists(for shock or bronchospasm)

• Increased heart rate(cardiovascular), Vasoconstriction, Reduce nasal congestion, pupil dilation, sweating

Alpha 1 Adrenergic Agonists - phenylephrine: produces vasoconstriction (alpha 1 only) = ^ BP

TA - Nasal decongestant, Contraction of GU sphincters (urinary incontinence), Dilate pupils – due to constriction of eye muscles

Indication - treat shock, cold & allergy products

Contras - Severe HTN or tachycardia, narrow angle glaucoma (risk of exacerbation/made worse)

Cautions - (stimulating Sympathetic nervous system), Thyroid, glucose stimulation, Renal/hepatic dz

Drug-drug - Decrease effectiveness of HTN meds, beta-blockers, Dilating pupil causes sensitivity to light/blurred vision

NC - Do not stop abruptly → taper!, Monitor for IV extravasations (med leaks into surrounding tissue → necrosis/cell death)

Alpha 2 Adrenergic Agonists (own rules) - clonidine: stimulation decreases sympathetic outflow from CNS, Inhibits release of norepinephrine

Indication - HTN

AE - CNS effects → sedation, drowsiness, HA, Hypotension, bradycardia

Caution - PVD, renal/hepatic dz

NC - Do not stop abruptly → taper dose

Beta 2 Adrenergic Agonists (lungs) - albuterol: quickly dilates bronchi and increases rate and depth of respirations

Indication - Used during acute phase of asthmatic attacks

Pharmacokinetics - inhalants

contra/caution - HTN, Tachycardia, diabetes

Beta 1 & 2 Adrenergic Agonists (stimulates both beta 1(heart) and beta 2(lung) receptors) - isoproterenol: increased heart rate, positive inotropic effect, BP, treatment of shock, bronchospasm during surgery

contras/caution - See alpha adrenergic info

Alpha and Beta Adrenergic Agonists 

- dopamine: Stimulates alpha 1 and beta 1 receptor activity,  Stimulates heart and BP, increases BF to kidney

Indication - shock

Contras - Pheochromocytoma  (tumor secretion tumor, ^ hormone = fatal), Tachy, arrhythmias or vfib, Hypovolemia (need to replace fluid = treat differently)

Caution - PVD

Drug-drug - TCAs & MAOIs, (antidepressants), and HTN meds 

NC - Monitor for IV extravasation, Not a treatment for Parkinsons!! (does not cross the blood brain barrier)

- epinephrine: drug of choice for anaphylaxis treatment (beta blockers minimize affect)

TA - Stimulates alpha 1 and beta 1 & 2 receptors

Indication - Cardiac arrest, Drug of choice for bronchospasm, laryngeal edema, allergic reaction

NC - assess Vs/neuro, medical hx, labs, hx meds and OTC, Wean meds over 2-4 days (*alpha agonists) to prevent rebound HTN, arrhythmias

Educate - Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations, use of inhaler

Adrenergic Antagonists (blockers) - opposite effect of adrenergic agonists (block stimulation of SNS)

Non-Selective Adrenergic Antagonists - labetalol: Block NE at alpha and beta receptor sites, Results in ↓ BP, ↓ HR, ↑ renal perfusion

Indication - HTN without reflex tachycardia (low BP = body trying to compensate)

Contras - Bradycardia, heart block, asthma(already have bronchial constriction), heart failure (could be made worse

Caution - Diabetes(mask s/s of hypo and hyper glycemia), bronchospasm, pregnancy

Alpha 1 Selective Adrenergic Antagonists - tamsulosin: Blocks alpha 1 receptors ONLY, BPH(benign prostatic hyperplasia) – produces smooth muscle relaxation prostate and bladder → improved urine flow

Indication - BPH (tamsulosin) → cause relaxation = urine flows, Some used for HTN

AE - r/t SNS blockage, CNS effects → orthostatic hypotension, dizziness, Vasodilation → Tachycardia/ flushing, “first dose syncope” → 30 -90 min after dose; start low, wean up, give at night (sudden, severe in BP → thats why take at nigh to decrease risk of falls)

contras/caution - Allergy and pregnancy, Heart, renal and hepatic failure

Drug-drug - Monitor effect with other pressure lower meds

Non-Selective Beta-Adrenergic Antagonists - treat wide variety of cardiovascular problems, Block both beta 1 and beta 2 receptors in SNS 

Beta 1 Selective Adrenergic Antagonists - metoprolol: Treats HTN, MI, angina, Post MI (decrease cardiac workload and prevent re-infarction)

TA - Cardio-selective → Block cardiac beta 1 receptors, Does not usually block beta 2 receptors in lungs 

Indication - Lowers heart rate/ contractility/cardiac workload, Post MI, Ophthalmic – reduces IOP (timolol)

AE - CNS → fatigue, dizziness/CV → bradycardia, hypotension/GI → N/V/D/Induce CHF → SOB, edema, wt gain

Contras - Diabetes(masking s/s), thyroid dz, pregnancy(passing down effects to fetus), renal/hepatic (metabolism & excretion)

NC - assess VS/Neuro/physical/medical hx/labs(BG), s/s of worsening HF, safety precautions, taper over 2weeks, adequate hydration

Cholinergic Effects (PNS) (wet affect = lots of fluid being used) Adverse affects

• “SLUDGE” 

  • Salivation

  • Lacrimation

  • Urinary incontinence

  • Diarrhea

  • Gastrointestinal cramps

  • Emesis

• “DUMBBELLS”

  • Diarrhea

  • Urination

  • Miosis (pupil constriction)

  • Bronchoconstriction 

  • Bradycardia

  • Emesis

  • Lacrimation

  • Lethargy

  • Salivation/ Sweating

Direct Acting Cholinergic Agonists - bethanechol: Post-op, post partum urinary retention, Atony(flaccid) of bladder

TA - Mimic ACh stimulation

Indication - Increase bladder tone, Increase GI secretions, Increase urinary excretion, Ophthalmic (induce miosis to relieve IOP)

Contras - Bradycardia, hypotension, CAD, Parkinson(make tremors worse), Peptic ulcers, Urinary retention r/t (obstructive) [kidney stone,tumor]

Cautions - Pregnancy (potential affects)

Indirect Acting Cholinergic Agonists (Prevents breakdown of ACh, allowing more stimulation of receptors), used for: Agents used for Myasthenia Gravis and Alzheimer disease

Myasthenia Gravis → pyridostigmine:Improves muscle strength by allowing ACH accumulation

Contras - Bradycardia, obstructions, pregnancy

Cautions - Any clinical picture that could be worsened by PSNS stimulation

Drug-drug - anti-cholinergic, aminoglycosides, steroids

Alzheimer Disease → donepezil: (NOT a cure → slows down progression of Alzheimer)

Works centrally in brain to increase ACh and slows neuronal degradation

Contrast - Same as with pyridostigmine (Mestinon)

Cautions - As above with addition of caution with liver/renal dz

Monitor for too much sludge-effect’

Toxic Effects of Cholinergics: over stimulation of PSNS

• CV – bradycardia, hypotension, conduction abnormalities (AV block & cardiac arrest)

•  CNS – headache, dizziness, & convulsions

•  GI – abdominal cramps, increased GI secretions, N&V

•  RESP – increased bronchial secretions & bronchospasms

• Can go into Cholinergic Crisis(Overdose of cholinergic medication)

  •  Symptoms: Circulatory collapse, Hypotension, Bloody diarrhea, Shock, Cardiac arrest

  • Treatment: Hold drug, Atropine, Epi to reverse bronchoconstriction

  •  Main antidote for overdose and excessive cholinergic stimulation:

  •  **atropine → occupies ACh receptor sites; blocks cholinergic activity

    • Must always be available

Anticholinergics (cholinergic antagonists) - Allows unopposed action of SNS “Dry affect”

Atropine: Tx sinus node dysfunction, Tx of sinus bradycardia, dry secretions pre-op

Contras - Glaucoma (pupil dilation), GI obstruction, urinary obstruction, myasthenia gravis(already have very few ACH), tachy

Caution - preg/lac., HTN, spasticity

AE - 

CNS – restless, delirium, weakness, excitement 

 Eye – dilation, decreased visual acuity, IOP

 GI – decrease salivation, decrease gastric motility, constipation

 GU – urinary retention

 Glandular – decreased sweating (heat regulation → cant lower body temp → heat stroke)

Careful for exercise, hot weather

 Respiratory – decreased bronchial secretions

(23-24) 

Seizure meds

• Effect CNS, (risk of preg/lac., CNS depression, do NOT stop abruptly)

Drugs for generalized seizures:

Hydantoins - phenytoin

TA - Inhibit movement of sodium → action potential cannot continue, Stabilize nerve membranes, sedating

Indications - generalized seizures

Pharmacokinetics - Therapeutic serum levels: 10-20mcg/mL(therapeutically dosed)

• If too low at risk for seizure

• If to high at risk for toxic affects

AE - CNS depression* (esp when starting med), Ataxia(involuntary muscle movement)-seen with overdose/dose regulation, Liver toxicity, Bone marrow suppression, Skin reactions, Gingival hyperplasia (enlargement of the gums) → edu. Proper mouth care, going to dentist

Contras - preg/lac. (outweigh)

Drug-drug - ETOH(no alc), CNS depressants(amplifying = no bueno)

Administer - Do not stop abruptly!* (can induce seizure or status epilepticus = pt. Has a seizure over and over w/ no rest period → cog. Issues, death)

 IV → sloooow, mixed w/ NS only, pain with IVP(excavation → necrosis,tissue death) (cardiac issue w/ IVP)

Shake the bottle well!! (mix → liquid separate = not full active ingredients [salad dressing])

Barbiturates - phenobarbital

TA - Used for seizure, Inhibits impulse conduction in cerebellum, cerebral cortex, lower brainstem, Decreases CNS excitation, motor response

Indication - generalized seizures

AE - CNS depression*, Sedation, hypnosis, anesthesia,**Addiction/ withdrawal (schedule 4 drug)

contars/caution - renal/hepatic dysfunction

Drug-drug - ETOH, CNS depressants

Benzodiazepines - diazepam

TA - Potentiate the effects of GABA-stabilizing nerve endings, decreasing nerve excitability

Indication - generalized seizures

AE - CNS depression, Physical dependence and withdrawal, Watch for paradoxical effects (seeing the opposite we intend to see)

contars/caution - renal/hepatic dysfunction

Drug-drug - ETOH, CNS depressants

Drugs for Absence Seizures - valproic acid

TA - May increase GABA activity, reduces electrical activity

Indication - Absence seizures, Mania (off label), Migraine prevention (off label)

AE - CNS depression, Liver toxicity( Follow liver functions (LFTs), esp. first 6 months)

contras/caution - Severe liver/renal disease, Preg/lac. (weigh risk)

Drug-drug - May potentiate(increase affect) diazepam, barbiturates, anticoagulant meds

Additional Drugs for Seizures - carbamazepine

TA - Stabilizes nerve endings by altering sodium and calcium channels, Increasing activity of GABA

Pharmacokinetics - Oral, Long half-life (25-65 hrs)

AE - CNS effects; CNS depression, GI effects (N/V, anorexia), BBW: serious dermatological reactions (carbamazepine) - skin breakdown, Depression; Suicidal ideation, taper off

Contras - Existing bone marrow suppression, preg/lac.

Drug-drug - MANY

Look at Ipad for more notes!!!!!

(24) Anti-Parkinson

Parkinson’s Disease (LOW dopamine)

• Hallmarks of the disease:

  • Tremor: pill-rolling**

  • Rigidity: cog-wheeling** torque wrench arms you feel every tooth (gear)

  • Akinesia/ Bradykinesia: shuffled gait** (no arm swinging, mask facial expression)

  • Loss of Postural Stability (^ risk of falling, cant do 180)

Medications: (Combo meds are often given to reduce dosage and achieve better control of symptoms)

• Dopaminergic agents:Increase effects of dopamine at receptors

• Anti-cholinergic agents:Oppose effects of ACh at receptor sites

Dopaminergic Agents (2)

-levodopa/carbidopa

TA - Levodopa crosses blood brain barrier, is metabolized into dopamine, short duration, then stimulates dopamine receptors(s/s: improve rapid mins)

Carbidopa prevents breakdown of levodopa in GI and periphery-allows more to get to brain

Prevents levodopa from being digested in stomach so more can cross the bbb, Carbidopa does nothing on its own just stops absorption**Less levodopa is used, adverse effects reduced***

Pharmacokinetics - oral, short duration → dose 2-3 times a day (multiple times)

-amantadine

TA - increase release and inhibits re-uptake(cant go back home) of dopamine in the brain →  increasing dopamine levels for receptors = berry good, Doesn't convert just allows more dopamine in , s/s take longer to see improvement 1-5 days

Indication - Parkinson’s → may be given early onset of dz

• Relieves symptoms 1-5 day

• Often given with levodopa → can reduce dyskinesia seen with levodopa

AE - GI upset (up to 6 months) [cant be protein stops absorption]

• CNS effects → confusion, anxiety, fatigue

• Dyskinesia (involuntary movements)

• Hypotension

• Urinary retention

• On-Off Syndrome: wears off, ‘freezing’ (levodopa) 

  • **Extended release helps reduce this

Contras - Angle closure glaucoma, Suspicious skin lesions → melanoma risk (levodopa)

Cautions - CAD, HTN, asthma, urinary obstruction, Renal and hepatic disease

Drug-drug - Avoid vitamin B-6: promotes breakdown of levodopa → less effective

Anticholinergic Therapy - benztropine

TA - Help to restore chemical balance, Block effects of acetylcholine at receptor sites reducing tremors, rigidity

Indication - Useful when levodopa no longer effective

AE - r/t block PSNS

Contras - Narrow angle glaucoma, GI & GU obstruction, Myasthenia gravis

Caution - Hx of tachy, arrhythmias, HTN, Hepatic dysfunction, Hot environments  reduces sweat response

Can look on IPAD for more notes too !!!!

(54) upper respiratory system

Antitussives - dextromethorphan: Suppress cough reflex by direct action on medullary cough center of the brain

Indications - Cough suppressant

AE - increase viscosity of secretions(thicker/sticky),CNS depression

Contras - Head injury → due to CNS effects, Cough needed to ensure airway,Pregnancy/lactation → CNS effects

Caution - Asthma, emphysema (bronchoconstriction/inflammation → already producing mucous = causing tighter airway), Need for alertness (can cause sleepiness)

Decongestants(3) - Decrease overproduction of secretions by vasoconstriction, Vasoconstriction shrinks swollen membranes, opens passages///Three varieties:Topical nasal sprays, Oral, Topical-Nasal steroids

Topical Nasal Decongestants - phenylphrine

TA - Vasoconstriction → decrease edema/ inflammation nasal membranes

Indication - nasal congestion

Pharmacokinetics - Nasal sprays, immediate onset, not generally systemic (stay in nose)

AE - Localized stinging and burning, Rebound congestion - don't take for more than 3-5 days (over active receptors causing ^)

Contras - Allergy, nasal lesions → (becomes systemic bc direct route to blood stream = systemic affect → we don't want)

Caution - Caution with cardiac, HTN, diabetes 

drug -drug - Sympathomimetic drugs or sympathomimetic-blocking drugs

Oral Decongestants - pseudoephedrine

TA - Shrink nasal mucous membrane → promoting drainage of sinuses/ improving airflow  

Indication - Nasal congestion, Pain associated with otitis media (ear infection)

AE - Rebound congestion, Systemic effects r/t stimulating sympathetic nervous system

contras/caution - See topical decongestants

Drug-drug - Caution with OTC cold and flu medications (contain decongestion)

Nasal STEROID Decongestants - fluticasone

TA - Anti-inflammatory effect

Indication - Allergic rhinitis

Pharm - Not immediate onset → takes time (weeks) to see full effect

AE - Local burning, dryness of mucosa, irritation(throat)///Generally no systemic effects

Contras - acute infection

Caution - Monitor for candida albicans (yeast infection = need good mouth care)//Avoid airborne illness 

Antihistamines - diphenhydramine

TA - Directly compete with histamine for specific receptor sites

Indication - Nasal allergies

• Seasonal or perennial allergic rhinitis (hay fever)

• Allergic reactions (itching)

• Motion sickness

• Parkinson’s disease

• Sleep disorders

  • First generation → greater anticholinergic effects and drowsiness

AE - Drowsiness, sedatio///Anti-cholinergic effects (DRYING)  GI: nausea, arrhythmias, urinary retention

Contras - prg/lac.

Caution - Renal/hepatic disease, Long QT syndrome (px in HR rhythm → arrhythmia and or CA), Respiratory disease due to thickening of bronchial secretions

Expectorants - guaifenesin

TA - Increase productive cough, decrease viscosity(thin), reduces adhesiveness(less sticky)

AE - GI: N/V, anorexia

Contras - Allergy

Cautions - preg., Assess persistent coughs for underlying disease

Mucolytics - acetylcysteine

TA.indication - increase or liquefy respiratory secretions in high risk respiratory patients → and cough them up

Pharm - Administration: nebulization, Separate nebulizer – precipitates (cant mix)

AE - GI upset, Stomatitis (need mouth care)

Contas/caution - Acute bronchospasm, PUD(peptic ulcer dz), esoph. Varices (exasturbates disease)

(55) lower respiratory tract

diseases : Asthma, COPD – chronic obstruction of airways(Emphysema – damage to alveoli

Chronic bronchitis – inflammation/mucus airway)

Bronchodilators/Antiasthmatics (3)

• Long-term control

• Quick relief (rescue)

• Three drugs classes:Xanthines,Beta-agonists,Anti-cholinergics

Xanthines - theophylline

TA - Direct effect on smooth muscles of bronchi causing relaxation/dilation and decreasing swelling

Indication - Asthma; Bronchospasms

Pharma - Therapeutic levels: 10-20 mcg/mL

AE - GI upset/ nausea, Irritability/ restlessness (because it's a stimulant), Tachycardia

Contras - Allergy, pregnancy/lactation

Caution - Cardiac disease, hyperthyroidism due to increase stimulation(exasturbation)

Drug-drug - MANY!!///Nicotine (increase metabolism or xanthines) P450 → speeds up = if they smoke they have to increase dosage

Sympathomimetics/
Beta Agonists - albuterol

TA - Stimulate sympathetic nervous system → quickly dilates bronchi and increases rate and depth of respirations

Indication - Used during acute phase of asthmatic attacks → often called “rescue drugs”

Pharma - Inhalants  (some in oral, parenteral forms), Inhaled → rapidly absorbed; duration of action varies

AE - r/t stimulation of sympathetic nervous system

• Insomnia

• Restlessness (tremor, shaking, adrenalin feeling)

• Anorexia 

• Vascular headache

• Hyperglycemia

• Tremor

• Cardiac stimulation (tachy)

Contras/caution - allergy, HTN, tachycardia, hyperthyroidism

Assess/kimplementation - Assess lungs sounds pre/post, VS pre/post, teach use of inhaler(Compress inhaler WHILE inhaling (over 3-5 secs), hold for 10 sec)

Anticholinergics - ipratropium

TA - BLOCKS action of acetylcholine (ACh) → block PSN

Result: bronchoconstriction is prevented, airways dilate

Indication - Prevention (NOT rescue!!) → too long onset, Useful for patients unable to tolerate beta-agonists (but not as effective)

Pharm - Inhalants, Ipratropium → rapid onset (15 min); 1-2hr hour peak

Can be combined with albuterol → combivent → dosed less frequently

AE - Anticholinergic effects → dizziness, headache, fatigue, dry mouth, palpitations, urinary retention 

Contras/caution - r/t  Anticholinergic effects, Allergy to soy products or peanuts!!!

Drug-drug - Increase in anticholinergic effects when combined with other anticholinergics

Drugs affecting inflammation

Inhaled steroids - budesonide

TA - Reduces inflammation, muscle relaxation

Indication - Treatment of bronchospastic disorders that are not controlled by conventional bronchodilation, Used early in disease process with bronchodilator, In acute episodes corticosteroid is given IV (then orally for several days)

AE - Limited due to inhalation, Dry mouth, sore throat, hoarseness, Oral fungal infections (**oral care!!)

Contra - Not for acute attack, Pregnancy/lactation

Caution - Active respiratory infection

• ***Bronchodilate first…. then steroid (ex. albuterone first then budsinate)

Leukotriene Receptor Antagonists 

Leukotrienes cause inflammation, bronchoconstriction, and mucus production

• Result: coughing, wheezing, shortness of breath

Leukotriene Receptor Antagonists - montelukast

TA - Decreases vascular permeability, Decreases mucus production, Inflammation in the lungs is blocked, and asthma symptoms are relieved, and seasonal allergies

Indication - Prophylaxis and chronic treatment of asthma in adults and children (NOT meant for management of acute asthmatic attacks), Tx of allergic rhinitis

AE - HA, N/V/D, Elevated LFTs, Generalized myalgia, Long term effects not fully studied –? Neuro and psych effects

Contra/caution - Allergy, Metabolized extensively in the liver/renal, Preg/lac. – fetal toxicity in animal studies

Drug-drug - coumadin, ASA, CCBs, cyclosporine

• If inhalants used for exercise asthma use 30 to 60 minutes prior to exercise