ACC Final Pharmacology Exam Review

CH 7

Key terms: • • • • • • Anticholingergic bronchodilator Antimuscarinic bronchodilator Cholingergic Muscarinic Parasympatholytic Parasympathomimic

Ch. 7

• • • • • • • • Indication for Atrovent Specific anticholinergics TABLE 7-1 Basic difference between Tertiary and Quaternary compounds Mode of action- may use power point description Muscarinic receptor subtypes 1-3 only (in lungs) Adverse effects Use in COPD

Ch. 7

• Anticholinergics: only two used for the inhalation route: – Atrovent (Ipatropium Bromide), 0.5 mg SVN, MDI dose – Spiriva (Tiotropium Bromide), handihaler dry powder – Both have little systemic side effects – Use one or the other. Used for COPD and also during asthmatic attacks

Ch. 7

• • • • Combivent: Combo of Atrovent and Albuterol in a MDI; know dosage Duoneb : Combo of Albuterol and Atrovent in a SVN, know dosage Give combos for synergetic effect Atropine: No longer aerosolized, used to increase HR, dry mouth. Tertiary compound, means it crosses BBB has systemic effects

Ch. 7

• • Spiriva – DPI, 18 ug/inhalation, given QD – Onset 30 min, peak 3hr, duration 24 hrs Atrovent: – MDI (HFA)17 ug/puff x 2 puffs, QID – Onset 15 min, peak 1-2 hr, duration 4-6 hrs – SVN 0.02% solution, 0.5 mg TID

Ch. 7

• • • • •

Mode of action of anticholinergics cGMP inhibits constriction and mucus production cGMP acts as a secondary messenger much like cAMP but instead of converting ATP, cGMP prevents neurotransmitters from entering the bronchial smooth muscle cell Unlike sympathometic bronchodilators, Atrovent/Spiriva do not cross the blood brain barrier and thus have essentially no systemic side effects (both are derivatives of Atropine, but are quaternary amines) Slower bronchodilator effects and less intense than adrenergics

Ch. 7

• • • • • • Atrovent is non selective M blocker Quaternary compund, does not cross the BBB Spiriva: dissociates more slowly from M1 and M3 receptors. More selective than Atrovent M2: inhibits further AcH release Cholinergic effects: decrease HR, miosis, contraction of lens, salivation, urination, secretion of mucus, bronchoconstriction AcH destroyed by cholinesterase

Ch. 7

• • Anticholinergic effects: increased HR, pupil dilation, flattened lens (USE CAUTION WITH ATROVENT WITH patients with Glaucoma), drying of upper airway, urinary retention, antidiarrheal, mucociliary slowing Adverse effects: dry mouth, cough, avoid spraying in eye

• • • • Key terms: Xanthine Methlyxanthines Phosphodiesterase

Ch. 8

Ch. 8

• • • • • • • Clinical indications and use Asthma COPD Apnea of prematurity Increases diaphragmatic strength Inhibition of phosphodiesterase Theophylline toxicity and side effects

Ch. 8

• • • Methylxanthines : derived from Xanthines, consist of Caffeine, theophylline, and theobromine Phosphodiesterase : enzyme that inhibits cAMP. Xanthine believed to inhibit this enzyme, thus increasing bronchodilation Uses: Apnea/bradycardias; most common use of Xanthine, in form of Caffiene for neonates

Ch. 8

• Uses: COPD as a weak bronchodilator, increasing respiratory muscle strength, increases contractility for patients on long term mechanical ventilation (helps with diaphragm wasting); respiratory muscle endurance, central ventilatory drive, cardiovascular effects by increasing CO, and antiinflammatory effects

Ch. 8

• Theophylline : lots of side effects, must keep in narrow therapeutic range, headache, anxiety, restlessness, nausea, anorexia, vomiting, abdomial pain, hematemesis, tachypnea, palpitations, SVT, ventricular arrhythmias, hypotension, diruresis

• • • • • • • • • Key terms: Abhesives Expectorant Glycoprotein Mucin Mucoactive agent Mucokenetic agent Mucolytric agent Mucis Sputum

CH. 9

CH. 9

• • • • • • • • • Clinical indication for use Source of airway secretions TABLE 9-1 Mucus in disease states Chronic bronchitis Asthma Cystic fibrosis Mode of action and indications for use of N acetylcysteine page 175 Mode of action and indication for Dornase alfa page 176

Ch. 9

• • • • Abhesives: coating of film that preventsor reduces adhesion Elasticity: modulus G rheologic property characteristic of solids it is represented by the storage of Expectorant : medication meant to increase the volume or hydration of airway secretions Gel: macromolecular description of pseudo plastic material viscosity and elasticity

Ch. 9

• • • • • Mucin : principle airway gel forming mucins Mucoactive agent : effect on mucus secretion Mucokinetic agent: increases ciliary clearance or respiratory mucus Mucolytic agent: degrades polymers in secretions Mucoregulatory agent : reduces volume of airway mucus secretion and appears to be especially effective in hypersecretory states

Ch. 9

• • • Know layers of mucosa (gel, sol layer, epithelial cells, cilia, goblet cells, bronchial glands- produce most mucus) Produce 100 ml of mucus daily Acetylcysteine (NAC): Mucomyst, 10%/20%, SVN 3-5 ml – Causes bronchospasm, give with bronchodilator – Rotten egg smell, nausea – – Directly instilled, or aerosolized Breaks down sulfhydryl groups for disulfide bonds of mucus – Given to COPD, pneumonia, congestion, acetaminophen overdose – Incompatible with anti-biotics (do not mix mucomyst)

Ch. 9

• Factors affecting mucus transport: – COPD/CF – Airway drying – Narcotics – Artificial airways/suctioning – Cigarette smoke – Pollution – Hyperoxia/hypoxia

Ch. 9

• • • • • • Food intake (milk) in particular does not increase mucus Adrenergics : increase cilia beat and mucus production Cholinergics: increase ciliary beat and mucus Anticholinergics: decrease cilia beat and decrease mucus production Xanthines: increase cilia beat and production Steroids: no effects on cilia, decrease mucus production

Ch. 9

• • • • Sputum: mucus plus oral secretions Bronchorrhea: watery sputum Asthma: inflammation/increased mucus production CF: impaired proteins, get frequent infections such as pseudomonas, require Dornase Alfa. Most congestion is not mucin, instead puss from neutrophil degradation

Ch. 9

• • Physical properties of mucus include viscosity, elasticity, cohesion, and adhesity. Dornase Alfa: – Pulmozyme dose 2.5 mg – Given during infections with CF – Reduces extracellular DNA and F-actin polymers, reduces viscosity and adhesiveness of mucus – Does not cause bronchospasm, may cause pharyngitis, laryngitis, rash, chest pain, conjunctivitis

Ch. 9

• Expectorants: – Sodium Bicarb: increases pH of mucus weakening bonds lowering viscosity and elasticity, used directly or aerosolized. Weak – Guaifesnsin: cilitoxic when applied directly – Hypertonic Saline : >0.9%, for induction of cough – Use adjunct therapy for mucus control • PEP, CPT, IPPB, Heated humidity, postural drainage, Bronchodilators, Vest • Bland aerosols (without medications)

CH 10

• • • • • • • • Key terms: Prophylactic and rescue treatment Physical principles of surfactant and surface tension Application to lung BOX 10-1 composition of surfactant Table 10-1 (only need to know drug/brand names) Survanta page 198 Infasurf and curosurf Mode of action page 199-200

Ch. 10

• • • Surfactant agents regulate surface tension in films at gas-liquid interfaces, described by LaPlace’s Law Surfactants are used are prophylactic or rescue treatment for RDS Used exogenous surfactants include: – Beractant (Survanta), Calfactant (infasurf), Poractant alfa (Curosurf)

Ch. 10

• • • Surfactant is directly instilled into the airway via endotracheal tube and adaptor, must closely monitor patient for compliance changes in order to prevent pneumothorax Surfactants used are all natural based Surfactant is composed of: – 85-90% lipids and 10% Proteins – Exogenous surfactant enter into the alveolar pool and replace deficient natural surfactant

CH 11

• • • • • • • • • • • • • • • • Key terms: Adrenal cortical hormones Endogenous Exogenous IgE Prostglandin Steroids Steroid Diabetes Clinical indications: Asthma /COPD Adrenal cortical hormones TABLE 11-1 (only need to know dosages for adults, for Qvar, Flovent, Pulmicort, and Advair) Review the hypothalamic pituritary adrenal axis, diurnal steroid cycle Inflammation response (review) Mode of action of corticoid steroids page 215 Effects on WBC and Beta receptors Know side effects of systemic BOX 11-3 and inhaled BOX 11-4

Ch. 11

• • • • • • Adrenal cortical hormone: chemicals secreted by the adrenal cortex (steroids) Endogenous : made within body Exogenous : outside body IgE : immune antibody, increased with allergen Prostglandin : hormone type substances circulating in body Steroids: Glucocorticoids or corticosteroids, antiinflammatory effect

Ch. 11

• • Adrenal cortical hormones: adrenal cortex secretes natural antiinflammatories. Secreted at the hypothlamic pituritary adrenal (HPA) axis portion of the adrenal gland Indications: – COPD – Asthma (moderate/severe persistent); must also give a LABA with steroid. Commonly Advair or Symbicort

Ch. 11

• • Corticosteroids secreted by the adrenal cortex include glucocorticoids (cortisol), minaerlocorticoids (aldosterone), and the androgen estrogen hormones Beclomethasone: – QVAR, MDI 40 or 80, 160 ug/puff, BID – Rinse mouth after all steroids to prevent thrush

Ch. 11

• • • • Fluticasone (Flovent); MDI 44, 110 and 220 ug/puff, BID; DPI 50, 100, 250; combined with Serevent to make Advair, doses 500/50, 250/50, 100/50 Budesonide (Pulmicort); only nebulized steroid, respules SVN 0.25-0.5 mg; tubahaler DPI 200 ug/actuation BID; mixed with foradil to make Symbicort, MDI doses 80/4.5, 160/4.5 BID Mometasone (Asmanex); Twisthaler DPI, 220 ug; BID Flunisolide (Aerospan); – MDI 80 ug/puff, BID

Ch. 11

• • Hypothalamic Pituitary Adrenal Axis (HPA): controls endogenous steroids, may be suppressed/affected with exogenous steroid use. Cortisol release causes breakdown of carbohydrates, fats, and proteins to make glucose for energy. Side effect of systemic steroid is steroid diabetes Diurnal Steroid Cycle : levels of natural steroids follow a daily or diurnal rhythm. Give exogenous steroids following normal cycle of release

Ch. 11

• • • Inflammatory response: Redness, flare, wheal, increased vascular permeability, leukocytic infiltration, phagocytosis, mediator cascade Mode of action: upregulation of antiinflammatory proteins and downregulation of proinflammatory proteins Systemic Steroids (Prednisone/Salmederol), are potent, given following or during COPD or asthma exacerbation and several days after, continued use leads to many side effects

Ch. 11

• Systemic side effects: – HPA suppression – Immunosuppressant, WBC affected – Psychiatric reactions – Myopathy of skeletal muscle – Fluid retention – Moon face, osteoporosis – Increased WBC – Increased glucose levels

Ch. 11

• • Minimize oral side effects with use of holding chamber, rinsing mouth after use Inhaled steroids may cause oral candidiasis (thrush), hoarseness, cough, bronchoconstriction

CH 12

• • • • • • • • • • Key terms: Antileukotrienes Ige Leukotrienes Mast Cells Mast cell stabilizers Clinical indications Table 12-1 (only need to know names) Review allergic response in asthma Cromolyn sodium page 230-231

Ch. 12

• • • Antiluekotrienes: agents that block inflammatory mediators, do not prevent mast cell degranulation Mast cell inhibitors : prevent degranulation, do not stop mediators once release Both used in extrinsic asthma as a prophylactic treatment; typically mild or moderate persistent asthma

Ch. 12

• • • • • Allergic response in airway caused by IgE mediated mast cell release of mediators Cromolyn sodium (Intal); MDI 800 ug/actuation, SVN 20 mg QID Nedocromil sodium (Tilade); MDI 1.75 mg/actuation QID Leukotrienes : Zafirkulast (accolate), Montelukast (Sinuglair), Zileuton (Zyflo); ALL tablets Omalizumab (Xolair): allergy shot, Q- every 4 weeks

Ch. 12

• • • • • MOA of Intal: inhibits mediator release by preventing calcium influx necessary for extrusion of mast cell Intal has no antagonist effect on chemical mediators themselves Does not operate through cAMP system, no bronchodilation Does not prevent Ige antibody formation on Mast cell Do not replace inhaled steroids with mast cell inhibitors suddenly as the HPA will be affected

Ch. 12

• • Tilade: prevents mast cell release but also esionphil, histamine, trypase and others Can inhibit esionphil chemotaxis and adhesion

CH. 13

• • • • • • • • Key terms: Virostatic Virucidal Virus Penatmidine: Indications, mode of action and aerosolize use TABLE 13-1 (don’t worry about dosages) Ribavirin: Indications, mode of action, aerosolize use and side effects Tobramycin: indications, and mode of action of us

Ch. 13

• • • PCP: interstitial plasma cell pneumonia affecting immunocompromised, particularly HIV/AIDS. Pentamindine (Nebupent) indicated as a prophylactic for patients susceptible to PCP. Should be given once a month in a scavenger nebulizer, 300 mg in 6ml water Know side effects of each antiinfective

Ch. 13

• • • • Ribavirn (Virazole): for treatment of RSV/Hep C, given with SPAG, multiple side effects Tobramycin (Tobi), 300 mg, for CF patients, or anyone with pseudomonas. Strict dosing and frequency requirments Zanamivir (relenza): influenza Amphotericin B: antifungal drugs is indicated after a lung transplant

General Pharm-NMB

• • • Depolarizing vs Non-depolarizing Paralytic – Mode of action – Names in power point Indications Hazards

General Pharm-Narcotics

• • • Action – not completely understood, but affect neurotransmission at specific sites in the CNS, affect autonomic nervous system transmission Indications/hazards Know names of Opioid analgesics – high potency – Morphine – – Oxymorphone Fentanyl – – Methadone (Heroin wean) Dilaudid

General Pharm-Narcotics

• • Indications/hazards Know names of Opioid analgesics – high potency – Demerol – Percocet/Oxycodone/Oxycontin

General Pharm-Narcotics

• Low Potency – Codeine- found in cough meds Side effects and hazards • Hypotension • Transient hyperglycemia • Depression of respiratory system • Cough reflex decreased • Nausea and vomiting

Narcotic Antagonists

• Competitive replacement of narcotic from receptor site • Pure antagonists – Naloxone - (proprietary name – Narcan

Sedatives

• Benzodiazepines (anti-anxiety/muscle relaxants) – Ativan – Versed – Haldol – Deprivan

Sedatives

• • Hypnotics – Valium – Quaaludes Barbituates – Phenobarbital (anti convulsant)