nsc 830 drugs that affect the respiratory...
TRANSCRIPT
![Page 1: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/1.jpg)
8/13/2015
1
Drugs that Affect the
Respiratory SystemBROOKE BENTLEY, PHD, APRN
Goals of Therapy
Asthma� Prevent symptoms
� Decrease use of SABAs
� Maintain normal pulm function & prevent loss of lung function
� Maintain QOL including attendance at school, work and physical activities
� Prevent exacerbations & minimize ED visits and/or hospitalizations
� Provide optimal pharmacotherapy with minimal or no AEs
COPD� Reduce COPD symptoms
� Reduce the frequency & severity of
exacerbations and reduce hospitalizations
� Improve health status
� Improve exercise tolerance
� Minimize the impact of the medications on
other potential co-morbid conditions
![Page 2: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/2.jpg)
8/13/2015
2
Goals of Drug Therapy
�1. dilate the airways
�2. reduce inflammation
�3. stabilize mast cells
Delivery Methods
� Correct use of Metered Dose Inhaler (MDI) inhaler:
![Page 3: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/3.jpg)
8/13/2015
3
Delivery Methods
� Dry-Powder Inhaler (DPI)
� Dry, micronized powder delivered directly
to the lung
� Breathe in quickly & deeply
� Dose lost if patient exhales through the
device
� Avoid moister in the device
![Page 4: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/4.jpg)
8/13/2015
4
Delivery Methods
� DPI: Spiriva: Single-dose capsules must be inserted into the inhaler prior to use
![Page 5: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/5.jpg)
8/13/2015
5
Delivery Route
� Nebulizer
� Converts a drug solution to a mist
� Mist is inhaled through a face mask or mouthpiece
� Face mask must have snug fit
� Good for children or patients unable to coordinate use of MDIs or DPIs
� Good for home setting
� Less portable when leaving home
Adrenergics (Sympathomimetics)
� MOA: Stimulates beta 2 receptors causing the formation of cAMP (cyclic
adenosine monophosphate) in the airway tissue which results in bronchodilation
� AE: (incidence & severity will depend on the receptor selectivity (beta 2 in
bronchial smooth muscle = bronchodilation; beta 1 in heart = increased HR &
contractility) of the drug as well as the mode of administration (oral vs. inhaled)
� Cardiac:
�Tachycardia/arrhythmias/palpitations
�Worsening of angina symptoms
� CNS:
�Nervousness/anxiety/insomnia
�Tremor
![Page 6: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/6.jpg)
8/13/2015
6
Adrenergics (Sympathomimetics)
� Special Considerations:
� Use beta 2 selective agents whenever possible to minimize side
effects
� Use inhaled drug if possible to avoid systemic effects
� Avoid excessive use to avoid tolerance and possible increases in
mortality rate
� Use with caution in patients with angina, hypertension, diabetes
mellitus, or hyperthyroidism
Adrenergics (Sympathomimetics)
� Short-Acting Beta Agonist (SABA)
� “Rescue” inhalers
� SABA agents should always be available for episodes of shortness of
breath
� Not generally meant for regularly scheduled use:
�May increase AEs
�Decrease effectiveness
�Increase airway hyper-responsiveness
![Page 7: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/7.jpg)
8/13/2015
7
Adrenergics (Sympathomimetics)
� Short-Acting Beta Agonist (SABA)
� Asthma: if using more than 2 days/wk for symptom relief (excluding exercise-induced bronchospasm), then poor asthma control and change in therapy is needed
� Using more than 2 canisters/month is dangerous (risk for death in asthma pts)
� Exercise-induced asthma:
� School age child: Rx - dispense 2?; school form (triggers, self-administer, nurse-administer, S/S distress)
� COPD: SABA agents may help decrease symptoms, but long acting therapy is more beneficial
Adrenergics (Sympathomimetics)
� Common Drugs:
� Short-Acting Beta Agonist (SABA)
�albuterol
� Brand names:
� Proventil HFA, Ventolin HFA, ProAir HFA
�onset 5 min & duration 4 hrs
�PRN use for acute attacks
�Available forms: MDI, nebulizer
�Writing for refills?
***HFA = hydrofluroalkane (propellant)
(chloroflurocarbon (CFC) propellant removed from market by FDA in 2008)
![Page 8: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/8.jpg)
8/13/2015
8
Adrenergics (Sympathomimetics)
� Common Drugs:
� Short-Acting Beta Agonist (SABA)
� levoalbuterol (Xopenex)
� Less cardiac side effects
� Longer duration = 8 hrs
� More expensive
� Available forms:
� Nebulizer
� Metered Dose Inhaler (MDI)
Adrenergics (Sympathomimetics)
� Long-Acting Beta Agonist (LABA)
� “Maintenance” inhalers (maintain symptom relief)
�Help decrease exacerbations and related hospitalizations
�NEVER used as monotherapy with asthma patients
�If patient on inhaled LABA & corticosteroid, then use combo
product to increase adherence
![Page 9: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/9.jpg)
8/13/2015
9
Adrenergics (Sympathomimetics)
� Common Drugs:
� Long-Acting Beta Agonist (LABA)
� salmeterol (Serevent Diskus)
� formoterol (Foradil Aerolizer)
� Inhaled: onset 20 min & duration 12 hrs
� Maintenance inhaler
�NOT for acute attacks
� BLACK BOX WARNING:
� LABA increase risk of asthma-related deaths
Anticholinergics
� MOA: Inhibits the effect of acetylcholine in bronchial smooth muscle when given by inhalation which results in bronchodilation
� NOT indicated for “rescue” treatment
� “Maintenance” therapy = SCHEDULED medication
� Primary use = COPD
� AEs: (systemic effects rare)
� Dry mouth/bad taste in mouth
� Blurred vision/exacerbation of narrow-angle glaucoma
� Urinary hesitancy/retention
� Cough
� Dizziness
� Sinusitis
![Page 10: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/10.jpg)
8/13/2015
10
Anticholinergics
� Common Drugs:
� ipratropium (Atrovent)
�Maintenance medication
�NOT for “rescue”
�Onset = 5-15 min Duration = 4-6 hrs
�Available forms: inhaler & nebulizer
� Combo:
�albuterol/ipratropium (Combivent Respimat) – inhaler
�DuoNeb – nebulizer
�NOT for PRN use
Anticholinergics
� Common Drugs:
� tiotropium (Spiriva HandiHaler)
� Maintenance medication
�Onset = 30 min Peak = 1.5-3 hrs Duration = 24 hrs
� Available forms: dry-powder inhaler
� QD dosing
� aclindinium (Tudorza Pressair)
� Maintenance medication
� Slightly faster onset of action
� Available forms: dry-powder inhaler
� BID dosing
�Advantage: may have less dry mouth & urinary retention; more efficacy at night
![Page 11: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/11.jpg)
8/13/2015
11
Mast Cell Stabilizers
� MOA: stabilize mast cells & prevent the release of bronchoconstrictive & inflammatory substances when mast cells are confronted with allergens & other stimuli
� Primary use: Prophylaxis tx for asthma (may take 3 wks to see full clinical effect)
� AEs:
� Hoarseness, coughing
� Unpleasant taste
� Common drugs:
� cromolyn inhaled nebulizer
� Use for asthma: QID
� Use for exercise induced asthma: give 10-60 min prior to exercise
Leukotriene Inhibitor
� Leukotrienes = strong chemical mediators of bronchoconstriction & inflammation;
increase mucous secretion & mucosal edema
� MOA: selectively binds to leukotriene receptors
� Primary use: asthma
� AEs:
� Nausea
� Headache
� CNS: may cause aggressive behavior, hallucinations, depression, suicidality
� Common drugs:
� montelukast (Singulair) – peds: may use at 6 mo of age (granule pkt)
� zileutin (Zyflo) – common drug interactions
� zafirlukast (Accolate) – common drug interactions
![Page 12: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/12.jpg)
8/13/2015
12
Corticosteroids� MOA: anti-inflammatory effect; decreases airway edema &
hyperreactivity
� Primary use: Asthma & COPD
� Available forms: MDI, DPI, nebulizer, PO (tablet & liquid), IM, IV
� Must be scheduled administration; NOT for PRN use
� Inhaled route often preferred (safe, effective, less systemic effects)
� Inhaled route: rinse mouth after use with water to minimize oral candidiasis
Corticosteroids
� Available forms: MDI, DPI, nebulizer, PO, IM, parenteral
� PO:
� short-term use:
�burst therapy = same dose every day for a few days (ie, Prednisone 60 mg QD X 5 days)
�dose pack = start high dose & taper every day to lower doses
�Medrol dose pack (methylprednisolone)(24 mg day 1 then taper by 4 mg qd over 6 days)
�Dex pack (dexamethasone) (6 day, 10 day or 13 day taper)
� longer, individualized wean/taper (Prednisone 2-4 wks)
�WHY TAPER?
![Page 13: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/13.jpg)
8/13/2015
13
HPA Axis(hypothalamus, anterior pituitary, adrenal gland)
� Based on Diurnal Rhythm:
� Evening: Hypothalamus detects low levels of corticosteroids; releases corticotropin releasing hormone (CRH)
� Increased CRH triggers anterior pituitary to release adrenocorticotropin hormone (ACTH)
� Increased ACTH stimulates adrenal gland to synthesize & release corticosteroids (peak release in early morning)
� This is a negative feedback system
� If take exogenous hormones (ie, prednisone) then suppress the release of CRH & ACTH and thus, the adrenal gland is no longer stimulated to produce & secrete hormones and the gland begins to atrophy
� Must slowly taper exogenous hormones (ie, prednisone), so HPA axis “kicks back in”
� Stopping oral corticosteroids abruptly can lead to adrenal insufficiency or adrenal crisis and death
Corticosteroids
� Available forms: MDI, DPI, nebulizer, PO, IM, parenteral
� PO:
�Pediatrics?
� prednisolone (Orapred, Prelone) – oral liquid
� long-term use: alternate day dosing to reduce adrenal suppression & AEs
� Parenteral route for emergency situations:
� Considering admission to hospital: oxygenation low, tachypneic, tri-pod position,
accessory muscles
� Hospital IV steroids or IM Solumedrol
� Nebs, pulse ox, oxygen in office for a few hours
� Emergent hump?
![Page 14: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/14.jpg)
8/13/2015
14
Corticosteroids
Inhaled
� Candidiasis
� Hoarseness
� Cough
� Headache
� Long-term use: increased pneumonia in COPD patients
Oral
� Adrenal suppression
� Immunosuppressant effect
� Osteoporosis
� Hyperglycemia
� Muscle wasting
� Hypertension
� Possible PUD
� Integument – thinned skin
� Hypokalemia & hypernatremia
Inhaled Corticosteroids
� Common drugs:
� budesonide (Pulmicort) – flexhaler DPI, respulesfor nebulizer
�Flexhaler – minimum age of 6 yo
�Respules – minimum age of 1 yo
� fluticasone (Flovent) – MDI, DPI
� Minimum age of 4 yo
� beclomethasone (Qvar) – MDI
� Minimum age of 5 yo
![Page 15: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/15.jpg)
8/13/2015
15
Combination Products
� LABA and Corticosteroid products:
� salmeterol/fluticasone (Advair)
� Minimum age 4 yo
� formoterol/budesonide (Symbicort)
� Age >12 yo
� formoterol/mometasone (Dulera)
� Age >12 yo
�NEVER for acute attack
�Remember adverse effects from both components
Phosphodiesterase 4 (PDE4) Inhibitor
� MOA: selectively inhibits phosphodiesterase type 4 (PDE4), leading to increased intracellular cAMP (cyclic adenosine monophosphate) levels; thus reducing inflammation
� PDE4 inhibitors are NOT direct bronchodilators
� Primary use:
� Not a first line therapy; usually with COPD not well controlled on LABAs & anticholinergics
� AEs:
� GI: nausea, diarrhea, weight loss
� CNS: insomnia, anxiety, depression
� Metabolized by CYP 3A4 substrate (careful with CYP 3A4 inhibitors – e-mycin, cimetidine, fluconazole)
� Common drug: roflumilast (Daliresp)
![Page 16: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/16.jpg)
8/13/2015
16
Methylxanthines
� MOA: exact MOA unknown; increases cAMP and leads to bronchodilation; mild anti-inflammatory & diuretic effects
� NOT a first line therapy
� AEs:
� CNS: nervousness, insomnia, tremors
� Cardiac: tachycardia
� GI: N/V, anorexia
� Narrow therapeutic index: 5-20 mcg/ml; frequent serum levels needed
� Numerous drug-drug interactions (CYP 1A2 substrate)
� Higher doses needed with cigarette smokers (b/c tobacco is CYP 1A2 inducer)
� Common drug: theophylline (Theo-24)
Monoclonal Antibody
� MOA: inhibits IgE binding to mast cells & basophils; thus, decreasing the release of mediators of the allergic response
� Primary use: uncontrolled, severe, persistent asthma in pts over 12 yo (allergic component)
� Maxed out on high dose ICS & LABA
� Available form: SQ every 2-4 wks; (very expensive)
� AEs:
� Injection site rxns
� Headache
� Viral URI
� Common drug: omalizumab (Xolair)
� BLACK BOX WARNING: anaphylaxis can occur up to 24 hrs after any dose
![Page 17: NSC 830 Drugs that Affect the Respiratory Systemcourses.hs.eku.edu/nsc830/week4/pdf/respiratorymeds.pdf8/13/2015 1 Drugs that Affect the Respiratory System BROOKE BENTLEY, PHD, APRN](https://reader034.vdocuments.mx/reader034/viewer/2022051723/5ab8893f7f8b9ad13d8ca365/html5/thumbnails/17.jpg)
8/13/2015
17
Home Oxygen
� Guidelines for insurance/Medicare/Medicaid to pay for home oxygen
� DME (Durable Medical Equipment)
� Home concentrator (pull oxygen out of the air & concentrating it)
� Portable method depending on mobility
� May need conserving device: makes the tank last longer; breath actuated or gives pulses of oxygen
� Continuous flow or just HS
� Liters per minute/nasal cannula
� Humidification
� No smoking