Asthma and COPD Pharmacology

asissons
Flashcards by asissons, updated more than 1 year ago
asissons
Created by asissons over 5 years ago
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Flashcards on Asthma and COPD Pharmacology, created by asissons on 03/19/2015.

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Question Answer
Name one type of Asthma Medication Classification Relievers (for intermittent symptoms): e.g short acting beta2-agonists
Name one type of Asthma Medication Classification Controllers (Maintenance therapy) : Two types: 1. Anti-inflammatory medications: steroidal - inhaled or oral corticosteroids Non steroidal LTRAs, anti allergic agents. 2. Bronhcodilators: Long acting beta2 agonists, ethophyline, antcholinergics
Name the three major characteristics of Asthma - pathophysiology 1. airway hyper responsiveness 2. chronic airway inflammation 3. reversible airway obstruction (either spontaneously or with treatment) other features: nocturnal worsening, recurrent attacks, multiple triggers.
Asthma symptomology wheezing, cough, dyspnea, chest tightness, sputum production
name three main types of inhalation devices metered dose inhaler dry powder inhalers nebulizer
List some advantages for administering drugs via inhalation 1. drug delivered directly to site of action 2. minimal systemic effects 3. rapid relief of acute attacks 4. most devices are portable Disadvantages: 1. technique may be difficult for some pts. 2. decreased efficacy with poor technique.
How much drugs reaches the lungs with a Metered Dose Inhaler? 10-20% shake prior to use
Is there more or less efficacy if the a MDI is cold? Less. It is difficult to estimate how much is left in the canister
List the important steps of MDI technique: 1. Stand or sit up straight 2. shake the inhaler 3. TAKE A SLOW DEEP BREATH IN. 4. as you start to inhale slowly, press on the inhaler. keep breathing until your lungs are full. 5. hold your breath for as long as you can. BETWEEN 5-10 SECS.
What should you remember to do after using an inhaler and why? rinse your mouth to prevent thrush and sore throat (for ICS only)
List the difference in the amount of drug that reaches the lungs using a spacer vs. not using a space: spacer:21% no spacer: 9%
What is a DPI (Dry powder inhaler)? breath activated,easier to use than an MDI deliver more to the lungs (20%) Biggest problem: bad inspiratory flow rate additive may cause cough and irritation. Have dose coutners.
List the steps involved in use an DPI Turbuhaler: 1. turn the coloured wheel one way and back the other way until it clikcs. 2. breathe out normally 3. tilt head back slightly 4. breathe in deeply and forcefully 5. hold breath for 10 seconds or as long as you can. rinse and gargle after.
What is a nebulizer? a nebulizer converts drug solution into a mist which is inhaled via face mask or mouthpiece.
what are some of the disadvantages of a Nebulizer? 1. less dose delivered to lower airways ( 10%) 2. takes longer to deliver drug. 3. there is an increased dose compared to MDI or DPI therefore increased side effects 4. care/maintenance required 5. not portable
What are some of the advantages of a Nebulizer? 1. good for an acute attack 2. good for pts who are unable to use another device 3. good for anxious pts.
What is a steroid? general name for compounds that have 4 rings of carbon atoms many different types with very different effects : cholesterol sex hormones anabolic steroids corticosteroids
What do Corticosteroids do? They have anti inflam effects: 1. Dec. synthesis and release of mediators (histamine, leukotrines, interleukins, prostoglandins) 2.Dec. infiltration and activity of inflammatory cells 3. Dec. edema of airway mucose 4. Dec. broncial hyperreactivity, lo
What do Corticosteroids increase? Increase number of bronchial beta 2 receptors and responsiveness to beta agonists.
Will Corticosteroids relieve an acute attack? Use for prophylaxis on a fixed schedule to reduce severity of acute attacks Will NOT relieve an acute attack.
What systems do corticosteroids affect? E.g cortisol, put the body in stress mode so the body is burning more glucose. Catabolic hormone. 1. increase salt and water retnetion by kidney 2. dysreg. of mood 3. incres. gastric acid prod. 4. dec. calcium absorption and increase excretion. 5.
Inhaled Corticosteroids (ICS) first line therapy fro all patients except pts with mild asthma benefits seen in days, max effect in 3 months
short term Side effects of ICS S/F due to local deposition: orophanyngeal candidiasis (thrush) dysphonia gargle after each puff.
long term side fx of ICS in high doses 1. bone loss in women 2. adrenal insufficiency with long term high doses 3. exacerbation of glaucoma
ICS in children shown to slow growth in short term studies; long term show no effect. still recommended as first line therapy for children
Side effects of Oral corticosteroids: short term: 1. GI intolerance - n/v, diarrhea, cramps 2. glucose intolerance - can lead to diabetes 3. HTN 4. edema 5. psych. disturbances 6. insomnia (dose in the AM)
Long term SFX of OCS: 1. Adrenal insufficiency (most supplement with steroids in times of stress) 2. osteoporosis, avascular necrosis 3. glaucoma, catracts 4. body fat redistribution - moon face, buffalo hump, truncal obesity 5. derma: skin atrophy, purpura, telangectiasis
What is Adrenal insufficiency? It is when the adrenal glands stop the production of endogenous glucocorticosteroids. Adrenal glands atrophy and cannot make steroids they do not recover immediately after stoping steroids, can take days or a year.
Control of Cortisol hypothalamus: release CRH: Pituitary gland- ACTH - adrenal cortex - glucocorticoids (Cortisol)
Stress and adrenal insufficiency: stress = infection, exercise, surgery BP and blood glucose content maintained vis increase in cortisol secretion from adrenal cortex. with adrenal insuff. must receive suppl steroid when stressed. anyone on long term glucocorticoids after d/cd need supp. stress doses until adrenals recov
A. Insuff. patients should wear a Medic alter bracelet and carry emergency supply of corticosteroid.
Corticosteroid withdrawal: withdraw slowly, schedule determined by degree of adrenal suppression taper doses withdrawal symptoms: HYPOtension, HYPOglycemia, myalgia, arthralgia, fatigue. Tapering not required for acute dosing : less than 14 days.
Other common uses of corticosteroids Rheumatic diseases( arthritis) Derma disorders inflammatory bowel disease cerebral edema cancer organ transplantation allergic diseases and reactions
Beta 2 agonists: Inhaled Long acting or short acting ORAL Most effect drugs for : relieving actue bronchospasm preventing exercise induced bronchospasm Activate beta 2 adrengeric recepetors in lung smooth muscle causing BRONCHODILATION
Inhaled short acting Beta 2 agonists: SABA E.g Salbutamol: blue coloured MDI Drug of choice for RELIEF of ACUTE attacks (onset = mins, duration = 3-5 hours) Drug of choice for preventing of exercise induced symptoms (use immed. prior) Use on PRN basis not regularly
Inhaled long acting Beta 2 agonists: LABA Salmeterol: long term control for sever asthma, use REGULARLY not PRN must use with ICS NOT for acute attacks delayed onset, lasts up to 12 hours sustained relaxation of airway smooth muscle good for nocturnal symptoms
Combo ICS and LABA Advair: fluicasone and salmeterol maintenance therapy for patients with moderate to sever disease who need both drugs use regularly q 12 h MDI or DPI
Oral beta 2 agonists Salbutamol slow and erratic absorption long acting more side effects than inhaled agents REGULAR use not PRN NOT FOR ACUTE attacks
Parental Beta 2 Agonists For asthmatic emergencies unable to use inhaled therapy, coughing excessively, poor response to nebulization, life threatening cases Salbutamol or epinephrine (NON SELECTIVE BETA AGONIST) -i
Side effects of Parental Beta 2 Agonists increased sfx (HA, angina, dysrhythmias, incre. BP, Inc. blood glucose decreased potassium may be given SC, IM, or IV
Salbutamol dosing Dosing depends on route of administration MDI inhalation: 100-200 mcg Nebulization: 2.5 mg Oral tablet : 2 mg injection: 4-8 mcg/kg
Beta 2 agonists : SFX stimulation of beta 1 receptors in heart: inc. HR, inc. Contractility, angina Tremor, anxiety, restlessness (stimulation of b2 recepetors in skeletal muscle) Hypokalemia IV: Oral: Nebulized: MDI/DPI Reports of mortality with overuse
Beta 2 agonists overuse freq. of use is a marker for disease control pt needing SABA more than 3 times per week must receive anti-inflammatory meds. pts receiving SABA several times daily require urgent reassessment (need increase in anti inflamm. therapy)
Leukotriene Receptor Antagonists (LTRAs) Montelukast (singular) Leukotriens lead to bronchoconstriction, eosinophil infiltration, mucous production, airway edema. work by blocking leukotriene receptors. CONTROLLER: no reliever meds. Add on therapy for asthma not controlled with ICS/LABA or
LTRAS decrease exercise induced asthma have minimal side effects dosed orally OD - BID on an empty stomach
Cromolyn (Sodium Cromoglycate) - LTRA suppresses inflammation: prevents release of histamine from mast cells Controller: NOT reliever med Exercise induced bronchospasm (inhale 15 mins prior) alternative to ICS in mild asthma where pt is unable or unwilling to take Safe
Cromolyn (Sodium Cromoglycate) route LTRA Inhalation via nebulization only usually QID
Theophylline LTRA Bronchodilator for maintenance therapy of chronic asthma esp. pts with nighttime attacks Oral admin relaxes bronchial smooth muscle via inhibition of phosphodiesterase and increase in cAMP. third line agent due to safety and toxicity issues
Theophylline LTRA Red flag drug narrow therapeutic range, many drug interactions dose by body weight; titrate according to drug levels (Therapeutic drug monitoring)
Theophylline LTRA side effects side effects increase if levels are above therapeutic range. nausea, vomitting, diarrhea, insomnia, increase heart rate, restlessness, arrhythmia, convulsions.
Theophylline LTRA drug interactions caffeine (avoid) increase effects on CNS/heart, increases theophylline levels -CYP450 inducers: esp smoking decrease theophyline -CYP450 inhibitors increase theophyline Dose OD-BID with food to increase absorption
Muscarinic Antagonists: Anticholinergics - inhaled atropine derivatives causing bronchodilation slower onset than beta agonists approved only for COPD but off label asthma use few side effects: dry mouth, oropharyngeal irritation, metallic taste, avoid getting spray in eyes)
Short acting Muscarinic Antagonists (SAMA) - MDI, Nebulizers Ipratropium bromide (Atrovent) used for allergen or exercise induced asthma, ACUTE attack (Emerg. management), pts intolerant of SABA less effective than SABA slower onset than SABA inhaled q6h usually PRN
Long acting Muscarinic Antagonisits (LAMA) - DPI Tiotropium bromide for COPD No clear role in Asthma onset - 30 MINS NOT for acute tx DPI only Inhaled OD
Measuring lung function FEV1 Forced expiratory volume in one second. gold standard test for determining reversibility of airway disease and bronchodilator efficacy 20% improvement in FEV1 produces noticable subjective relief in most pts.
Limitations to FEV1 Limitations: test depends on pt effort and co-operation spirometer required - expensive and cumbersome
Measuring Lung Function PEFR Peak Expiratory Flow Rate: maximal rate of airflow during expiration exhalation as forcefully as possible into a peak flowmeter pts should measure PEFR every morning.
Zone System for self monitoring PEFR Green Zone: PEFR greater than 80% of pb no symptoms, good control Yellow zone PEFR = 50-80% of pb some symp. suboptimal control may need inhalation of SABA, a short course of OCS Red Zone: PEFR=less then 50% of PB - medical alert requires im
Key principles of Asthma Care Achieve an acceptable level of disease control control environment asthma education/self management ICS is first line therapy for ALL ages additional therapy (e.g LABAs or LTRAs) are added to ICS if control not achieved.
Symbicort as single inhaler therapy budesonide (ICS) and formoterol Formoterol - both a rapid acting and long lasting beta 2 agonist can be used a reliever and controller at the same ICS dose in pts greater or equal to 12 yrs. with asthma uncontrolled on fixed dose ICS/LABA can be used as a controller alone (with SABA as a reliver when needed)
Emergency management of Asthma Goals: relieve airway obstruction, hypoxemia, normalize lung function primary therapy: repetitive inhalation of SABA (MDI or Neb) ER: short course corticoster. (IV or PO) and or hihg dose ICS if no response to first dose of SABA Oxygen=95 +
Non Pharmacologic options Avoid precipitating factors (allergens) smoking cessation vaccination: pneumococcal vaccine, and annual flu vaccine avoid meds that may trigger attacks e.g ASA, non steroidal anti inflam, NSAIDs
COPD - Major features 1. chronic airflow limitation 2. chronic cough, increase sputum, dyspnea, impaired gas exchange
Clinical manifestations Asthma age of onset less than 40 not causal with smoking no sputum often allergies stable with exacerbations spirometry often normalizes clinical symptoms are intermittent and variable
Acute exacerbations of COPD (AECOPD) 1. increase respiratory sym (dyspnes, sputum volume, purulence) 2. non-specific symp - malaise, sleep disturbance, fatigue, depression, confusion. Triggers - inhaled irritants (smoke, allergens, GERD, CHF, drug reactions
How many AE per year 50% due to infection (Viral, bacterial) Most pts 2-3 AE per year.
Goal of COPD therapy slow disease progression, control symptoms, improve exercise tolerance, reduce mortality.
Goal of AE-COPD therapy Relief of acute symptoms (dyspnea, sputum production, and purulence) cure infection prevent mortality
Management of COPD SMOKING CESSATION avoid occupational and air pollutants Pulmonary rehabilitation/exercise Immunization to prevent respiratory infection or related complication (flu, pneumo)
Pharma of COPD if asymotomatic, normal spirometry - no meds symptomatic : less symtoms - SAMAor SABA PRN More symps: LAMA or LABA standing If greater or equal to 2 AE per year add ICS
if you have greater or equal to two AE a year what is your pharma? LAMA OR LABA and ICS
Role of ICS in COPD Fewer pts benefit from maintenance corticosteroid only add in selected cases
Theophylline in COPD:" weak bronchodilator and modest improvement in pulmonary function, dyspnea, and exercise performance may add if continued symptoms despite the use of LAMA/LABA or uncontroled nocturnal symptoms. Monitoring of blood levels, sfx and DIs
Roflumilast in COPD phosphodiesterase 4 PDE4 inhibitor increases level of cAMP in lung cells - reduced inflammation, cough, mucus used in pts with freq. AE who are already on LAMA/LABA and maybe ICS
SFX of Roflumilast GI: nausea, disrrhea, weight loss CNS: insomnia, dizziness, hA, anxiety, depression Orally, OD
Management of AECOPD Chest xray to rule out pneumonia or CHF O2 sat. 88-92% bronchodilators systemic corticosteroid antibiotics supportive care
Pharmacotherapy of AECOPD: Bronchodilators inhaled bronchodilators for increasing dyspnea SABA with or without SAMA (combo usually used) Nebulizer or MDI wiht space same efficacy.
Pharm AECOPD : corticosteroids systemic steroids show benefit for AE improve FEV1 and shorten recovery time, reduce treatment failure and length of hospital stay. Rec: prednisone 40 mg daily * 5 days in most moderate to sever cases. NO ICS
Pharma AECOPD: Antibiotics used if increased dyspnea, sputum volume and purulence or mechanical ventilation. there is Increased infection risk in pts on chronic OCS most common pathogens H. Influenca, Haemophilus specif, M. Catarrhalis, Strep. pneumoniae
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