Asthma = chronic, reactive inflammatory airway disease.
Triggers (allergen, GERD, stress, exercise) → 3 simultaneous events:
Narrowing/bronchoconstriction
Smooth-muscle tightening
Mucus production + edema (via inflammatory mediators: histamine, leukotrienes)
Grasping this cascade dictates drug selection: open airway (bronchodilate), dry mucus (anticholinergic), suppress inflammation (steroids & modifiers).
Bronchodilators
Short-acting (SABA)- beta 2 agonist, rescue inhalers,
Examples: Albuterol, Levalbuterol,albuterol (ProAir HFA, Ventolin HFA), levalbuterol (Xopenex HFA), and ipratropium (Atrovent HFA).
Mechanism: Quickly relaxes bronchial smooth muscle, providing rapid relief from acute bronchospasm.
Long-acting (LABA)- treats COPD and emphysema, used 2x day q12 hr. Never treats sudden asthma sxs !!!! examples are salmeterol (Serevent), formoterol (Foradil, Perforomist), and indacaterol (Arcapta). These medications are not intended for immediate relief and should only be used on a regular schedule to help control symptoms.
Anticholinergic bronchodilators
Methylxanthines (e.g., theophylline)
Anti-inflammatory agents
Inhaled, PO, IV corticosteroids
Leukotriene modifiers (LTRA)-trigger inflamatory reaction.
Mast-cell stabilizers
Immunomodulators (IgE monoclonal antibodies)
Ancillary respiratory drugs
Expectorants, antitussives, decongestants, antihistamines
MOA: stimulate pulmonary β₂-receptors → rapid bronchodilation.
Examples / brand aliases
Albuterol (ProAir, Proventil, Ventolin) – gold-standard rescue.
Levalbuterol (Xopenex)
Pirbuterol (Maxair)
Clinical pearls
Use PRN; ideally ≤2×/week.
Pre-exercise prophylaxis if exercise-induced asthma.
Over-use = red flag → reassess control plan.
Dosing: BID, q12 h; never for acute symptoms.
COPD/emphysema pts need continuous bronchodilation.
Agents: Formoterol (Foradil), Salmeterol (Serevent), Indacaterol (Arcapta), Olodaterol (Striverdi).
MOA: block muscarinic receptors → ↓secretions + bronchodilation.
Short-acting: Ipratropium bromide (Atrovent) — mixes well with albuterol in ED/EMS “Duoneb”.
Long-acting: Tiotropium (Spiriva), Umeclidinium/Vilanterol (Anoro), Aclidinium (Tudorza).
Adverse/Teaching
Anticholinergic SE: dry mouth/eyes, ↑BP, urinary retention.
Avoid ocular contact (can precipitate glaucoma).
Beclomethasone (Qvar), Budesonide (Pulmicort), Fluticasone (Flovent), Mometasone (Asmanex).
Treat root inflammation: block prostaglandins, cytokines.
Rinse mouth post-use → prevent oral candidiasis (thrush).
PO: Prednisone, Prednisolone
IV/IM: Dexamethasone, Methylprednisolone
Taper if >5 days to avoid adrenal suppression. only used for short course
SE: fluid retention, weight gain, insomnia, ↑BP, ↑appetite, mood swings, hyperglycemia.
Leukotriene Modifiers = potent mediators of bronchoconstriction + mucus. Act on MAST cells.
Agents/doses
Montelukast (Singulair) – 10 \text{ mg} nightly; >1 y o
Zafirlukast (Accolate) – >7 y o
Monitor LFTs.
Indication: maintenance, aspirin-sensitive asthma, allergic rhinitis.
Theophylline – reserve for refractory cases. Short acting
Class: methyxanthines (terbutaline mentioned as related).
Narrow therapeutic window; check serum levels.
SE: headache, tremor, insomnia, palpitations, restlessness.
Advair Diskus = Fluticasone(steroid) + Salmeterol
Symbicort = Budesonide + Formoterol
Dulera = Mometasone + Formoterol
Brio Ellipta, Anoro Ellipta (various combos)
Still rinse mouth immediatelyThis helps prevent oral thrush and reduces the risk of side effects associated with steroid inhalers. !
Mnemonics:
SABA = Short-Acting β₂ Agonist
LABA = Long-Acting β₂ Agonist
Omalizumab (Xolair) – anti-IgE monoclonal; for severe allergic asthma under pulmonologist/allergist care.
Cromolyn sodium, Nedocromil
Prophylaxis: inhibit histamine release from mast cells.
Useful before predictable environmental exposure (pollen, exercise).
SE: bitter taste, throat irritation.
Quiz 3
I think there is matching on that quiz. Mast cell stabilizer. Give me some examples. How would it work?
Examples include cromolyn sodium and nedocromil. These medications work by preventing the release of inflammatory mediators from mast cells, thereby reducing airway hyperresponsiveness and inflammation associated with asthma.
Immune immunomodulators. Give me some examples. What are they used for? Combination drugs, combination therapy, inhaled corticosteroids, and LABA. What are some common names?
What are some LABAs? Theophylline, what you should monitor for. What are some side effects of Theophylline, Steroids, what you should do, some teachings.
Salmeterol: Used as a long-acting bronchodilator to prevent asthma symptoms and improve lung function.
Formoterol: Works similarly to Salmeterol, often used in conjunction with inhaled corticosteroids to control chronic symptoms.
Monitoring for potential side effects includes checking heart rate, blood pressure, and signs of increased asthma symptoms or exacerbation. Common side effects of Theophylline may include headaches, palpitations, and muscle tremors, and patients should be advised to report any unusual symptoms immediately.
Give me some examples of, ICS. What are some inhaled corticosteroids? What are some PO corticosteroids? What are some IV corticosteroids? What are some side effects of steroids?
Bronchodilators, short acting versus long acting. Which ones are rescue? Which ones are not rescue? Right.
Inhaled Corticosteroids (ICS):
Fluticasone
Budesonide
Beclomethasone
Oral Corticosteroids (PO):
Prednisone
Methylprednisolone
Dexamethasone
Intravenous Corticosteroids (IV):
Hydrocortisone
Methylprednisolone (Solu-Medrol)
Dexamethasone
Side Effects of Steroids:
Weight gain
Mood changes
Increased blood sugar
Osteoporosis
Increased risk of infections
Bronchodilators:
Short-acting (Rescue):
Albuterol
Levalbuterol
Long-acting (Not Rescue):
Salmeterol
Formoterol
Indicated for long-term management of asthma and COPD; helps open airways and improve breathing.
Guaifenesin (Mucinex, Robitussin) – thins mucus; ↑fluid intake.
Benzonatate (Tessalon Perles) – Teach swallow whole (chewing → laryngeal anesthesia/aspiration).
Dextromethorphan, Codeine, Hydrocodone combinations.
Pseudoephedrine, Phenylephrine, Epinephrine – α-agonists; stimulate SNS.
SE: palpitations, ↑BP, insomnia, nervousness, urinary retention.
Regulated sales (meth precursor).
monitor blood pressure and heart rate
1st-gen: Diphenhydramine (Benadryl) – sedation.
2nd-gen: Loratadine (Claritin), Cetirizine (Zyrtec) – less sedation.
Rescue only: Albuterol (SABA) ± Ipratropium (Duoneb).
LABA contraindicated in acute attack.
Rinse mouth after any ICS-containing product.
Theophylline: monitor serum level + watch for toxicity.
use theophylline for status epilepticus in patients who do not respond to conventional treatments, but be cautious as it may lead to increased heart rate and potential complications.
LTRA & Mast-cell stabilizers = prophylaxis; monitor LFTs (LTRA).
Anticholinergics → avoid in BPH, glaucoma; caution ↑BP.
SABA over-use (>2×/wk) signals poor control → step-up therapy.
AHA: \ge 140/90\ \text{mmHg} is elevated.
Thiazide: Hydrochlorothiazide (HCTZ) – K⁺ wasting; monitor electrolytes; Teach: eat banana , spinach or potassium supplement
Loop: Furosemide (Lasix) – powerful K⁺ wasting, okay in low GFR.
K⁺-sparing: Spironolactone, Amiloride, Triamterene – avoid high-K diet.
check kidney function, creatinine clearance
beta 1 in heart, beta 2 receptors in lung
Non-selective (β₁+β₂): Propranolol, Nadolol , Carvedilol/Coreg→ avoid in asthma/COPD (blocks lung β₂). Do not give to ppl with asthma and COPD!!!! example- no Propranolol should be prescribed, as it can lead to bronchospasm and respiratory complications.
Selective (β₁ only): Metoprolol, Atenolol → safer options for patients with asthma or COPD, as they primarily affect heart rate without impacting lung function.
Cardio-selective (β₁ only): Atenolol, Metoprolol, Bisoprolol, Acebutolol – safer in airway disease.
Do not stop abruptly (rebound HTN, angina, MI).
Teach avoid certain foods like parsley/ potentiate hypertension, do not abruptly stop beta blocker- MI can occur
Clonidine, Methyldopa, Guanfacine – rapid vasodilation; taper to avoid rebound crisis.
Prazosin, Terazosin, Doxazosin – dual use: HTN + BPH (urethral dilation).
Orthostatic hypotension; rise slowly.
Hydralazine – relaxes arterial smooth muscle; monitor tachycardia/edema.
Block conversion of angiotensin I → II.
examples are
Enalapril
Lisinopril
Ramipril
SE: dry cough, angio-edema, hyper-kalemia, peripheral edema/hands and feet.
Contra-pregnancy (↓placental flow). hypersensitivity reaction in African americans
Block angiotensin II receptor → no aldosterone release; less cough/angio-edema vs ACE.
Dihydropyridines: Amlodipine, Nifedipine, Nicardipine
Non-DHP: Verapamil, Diltiazem
Avoid grapefruit juice (CYP450 inhibitor ↑drug level, esp. Verapamil).
Grape fruit can initiate can cause increased verapamil level.
So there will be questions and examples, matching questions. First of all, know your classes, calcium channel blockers.
So you should be able to talk about how the calcium channel channel work, what are some examples, and what are some patient teachings, and what are some lab monitorings. ACE, ARBs, the prills, the beta blockers, direct acting or the central acting of agonist, and the diuretics. They are on your tests.
Total, LDL, Triglycerides = atherogenic; HDL = protective.
Cholestyramine (Questran), Colestipol (Colestid), Colesevelam (Welchol).
Stay in GI tract; bind bile/fats for fecal excretion.
Indication: familial hypercholesterolemia.
Issues: severe constipation/fecal impaction → push fluids + fiber; malabsorption of fat-soluble vitamins A,D,E,K – monitor levels.
Gemfibrozil (Lopid), Fenofibrate (Tricor).
Primary action: ↓Triglycerides, modest ↑HDL.
Derived from fungi – caution allergy to mushrooms.
SE: dyspepsia, blurred vision, myalgia (monitor muscles).
Give 30 min before meals.
check for mushroom allergy
Atorvastatin, Rosuvastatin (Crestor), Simvastatin (Zocor), Pravastatin, Lovastatin.
Block rate-limiting enzyme of cholesterol synthesis (great ↓LDL & Total; mild ↑HDL).
Dose at bedtime (nocturnal cholesterol synthesis peak).
Major risk: myopathy → rhabdomyolysis (↑CK, muscle pain) – stop immediately.
Monitor LFTs q4 wks.
↓Triglycerides, ↑HDL.
SE: intense flushing/vasodilation; pre-medicate with Aspirin 325\,\text{mg} 30 min prior- helps to avoid sudden vasodilation/seems like heart attack
Additional side effects include gastrointestinal disturbances and hepatotoxicity; monitoring liver function is essential during treatment.
Contraindications: liver disease, active peptic ulcer disease, and caution in patients with diabetes due to potential impact on glucose levels.
Avoid in diabetes (raises glucose).
Ezetimibe (Zetia).
Blocks intestinal brush-border absorption of dietary & biliary cholesterol.
SE: arthralgia, myalgia, back pain; monitor CK/creatinine kinase for rhabdo.
Test question. A patient with familiar hypercholesterolemia will need one of these drugs, Buntofinal.
study smart. So what you will see on the test for these, one, two, three, four, five, each all the classes, you're gonna need to do an example of each. Right?
There's a matching. Then you're gonna need to know specific teachings for each. Bowel sequester and drugs cause constipation, severe fecal impaction. Therefore, people with familial hypercholesterolemia, you wanna make sure you give them enough water. Monitor for vitamins, alright, because of the constipation.
Long-acting inhaler frequency: q12 h.
Creatinine clearance cutoff for thiazide: <30 → prefer loop.
High BP definition: \ge140/90 (AHA).
LABA/ICS combo names: Advair, Symbicort, Dulera – always rinse.
Theophylline & Statins: both demand serum level or CK monitoring.
Grapefruit rule: universally avoid with cardio meds; critically elevates Verapamil.
Diuretics mnemonic:
“Loops Force out water & K⁺, Thiazides deplete K⁺, Spironolactone Spares K⁺.”
Niacin flush counter-measure \rightarrow Aspirin pre-dose.
ACE vs ARB: same pathway, diff step; ARB eliminates cough.
Asthma step-care: ↑symptom frequency \rightarrow add controller, not more SABA.
Matching questions likely:
Drug class ⇄ Example
Rescue vs maintenance
Inhaled steroid names, PO vs IV steroids
Laboratory monitoring flags:
LTRA & Statins – LFTs
Theophylline – serum level
Statins & Ezetimibe – CK for rhabdo
Beta-agonists – heart rate and potassium levels
Inhaled corticosteroids – potential effects on growth velocity in pediatrics