DH206: Pharmacology CH 19:Respiratory Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Respiratory Drugs Diseases treated with respiratory drugs Asthma COPD: emphysema, bronchitis Upper respiratory infections

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Class of Resp. Diseases Clinic III Location Acute Chronic Upper Resp Rhinitis Sinusitis Pharyngitis/Tonsillitis Flu Allergic rhinitis Lower Resp Acute bronchitis Pneumonia TB Asthma COPD Cystic bronchitis

Respiratory Drugs Asthma Considered an inflammatory disease Chronic lung disease Drug therapy aimed at relieving broncho-spasm & inflammation Airway Obstruction Caused By: Notations Bronchoconstriction Loss lung elasticity Mediated through ß-2 receptors Inflammation Results from mucous production Mediators are histamine, prostaglandins, leukotrienes, cytokines Results from air sac enlargement Tx is difficult (long-term, high dose meds)

2007 Guidelines for Management of Asthma USE THIS INSTEAD P.221, TABLE 19-1 EASIER TO UNDERSTAND THIS WAY ASTHMA TYPE THERAPY 1st LINE DRUGS 2nd LINE DRUGS Intermittent No meds Albuterol prn (B2-agonist) ------------ Mild Daily meds Inhaled corticosteroid Leukotriene modifier Methylxanthine Mast cell stabilizer Moderate Inhaled corticosteroid OR LABA Severe Inhaled corticosteroid + LABA

2007 Guidelines for Diagnosis & Management of Asthma Respiratory Drugs 2007 Guidelines for Diagnosis & Management of Asthma Number & frequency of meds ↑ as severity of asthma worsens Beginning therapy: start with highest recommendations & stair-step down as patient needs Inhaled meds preferred agents High concentrations of drug delivered to airways with few systemic side effects Severe asthma attacks ß-2 agonist preferred agent (EPI) Corticosteroid tablets to relieve inflammation Oxygen

Respiratory Drugs Drug Delivery Systemic: oral, parental Inhaled: shorter onset, fewer side effects Nebulizer Dry powder inhaler Metered-dose inhalers (most common delivery system)

Respiratory Drugs Asthma Medications: 2 classes of medications Quick-relief medications Reliever/Acute rescue drugs Long-term medications Control, Maintenance meds Taken daily Most have anti-inflammatory effects

Respiratory Drugs Asthma Medications 2 classes of medications Quick-relief medications Reliever/Acute rescue drugs Long-term medications (mild, moderate, severe asthma & COPD) Control, Maintenance meds Taken daily Most have anti-inflammatory effects

Quick-Relief Meds Produce bronchodilation Protype: albuterol(Ventolin, Proventil) Tx acute symptoms Not used for daily prevention Patients need to rinse after use (NBQ) DRUG CATEGORIES MECHANISM OF ACTION USES Beta-Adrenergic Agents (Sympathomimetic Agents) Stimulate beta-2 adrenergic receptors prn Anticholinergics Block cholinergic (muscarinic) receptors COPD Systemic corticosteroids Emergencies Asthma or COPD

Quick-Relief Meds ß-2 Adrenergic Drugs p. 224 Beta-Adrenergic Agents (Sympathomimetic Agents) ß-2 Adrenergic Drugs Albuterol(Proventil, Ventolin) Metaproterenol(Alupent) Levalbuterol(Xopenex)

Quick-Relief Meds Beta-Adrenergic Agents (Sympathomimetic Agents) NON-SELECTIVE (stimulate β-1 & β-2) 2 drugs: Epi & isopreterenol(Isuprel) When used to tx asthma – will also ↑ heart rate SELECTIVE Selective beta-2 drugs are BEST: bronchodilators Fewer effects on beta-1

β-agonist stimulates enzyme AC to ↑ cAMP levels – results in dilation

Can be difficult for kids to use: use a separate connector – can decrease amt of drug administered

NBQ After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth? Ipratropium Cromlyn sodium Metaproterenol Theophylline

NBQ After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth? Ipratropium Cromlyn sodium Metaproterenol Theophylline

NBQ Which of the following drugs is the drug of choice for the quick relief of bronchospasm? Albuterol Ipratropium Hydrocortisone Salmeterol

NBQ Which of the following drugs is the drug of choice for the quick relief of bronchospasm? Albuterol Ipratropium Hydrocortisone Salmeterol

NBQ Which of the following drugs is classified as a β2-agonist bronchodilator? Albuterol Ipratropium Hydrocortisone Montelukast

NBQ Which of the following drugs is classified as a β2-agonist bronchodilator? Albuterol Ipratropium Hydrocortisone Montelukast

Quick-Relief Drugs p.226 Anticholinergic Agents: used for tx COPD, not asthma DRUG NOTATIONS Ipratropium bromideHFA(Atrovent) PROTYPE Nasal spray: useful for rhinitis Ipratropium bromide + albuterol sulfate(Combivent) Tiotropium bromide(Spiriva) LONG-TERM, NOT SHORT ACTING FOR TX COPD

Quick-Relief Drugs Anticholinergic Agents Action: Inhibit ACH receptors on smooth muscle= bronchodilation Protype: ipratropium bromide(Atrovent) Adverse effects Xerostomia Taste alteration Instruct pt to rinse mouth after each inhalation (NBQ)

Muscarinic antagonists block effects of ACH & PANS – leads to bronchodilation

Quick-Relief Drugs Systemic corticosteroids Used when asthma cannot be controlled by bronchodilators alone Short-term Decrease inflammation Systemic delivery = acute attacks Inhaled delivery = chronic, long-term therapy

Respiratory Drugs Asthma Medications 2 classes of medications Quick-relief medications Reliever/Acute rescue drugs Long-term medications Control, Maintenance meds Taken daily Most have anti-inflammatory effects

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Inhaled corticosteroids Drug of choice for persistent asthma 1st line long-term therapy Potent & effective anti-inflammatory agents Decrease airway hyper-reactivity & swelling Rinse mouth after inhaler use (NBQ)

Long-Term Meds Inhaled Corticosteroids Inhaled corticosteroids Beclomethasone dipropionate(Beclovent, Vanceril) Budesonide(Pulmicort) Flumisolide(Aerobid) Fluticasone(Flovent, Advair) Mometasone(Asmanex) Triamcinolone(Azmacort)

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Selective long-acting ß-2 Agonists (LABA) Bronchodilators Not used alone – usually in combo w/corticosteroids Black box: NOT to be used as stand alone tx – increase risk of asthma-related deaths Selective long-acting ß-2 Agonists Salmeterol(Serevent) Formoterol(Foradil)

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Methylxanthines Methylxanthines Bronchodilators that relax the airway smooth muscle COPD Many drug interactions Erythromycin Clarithromycin Caffeine: can cause mild bronchodilation in patients with asthma (100mg which is in a cup of coffee) Methylxanthines Theophylline(Slo-Phyllin),TheoDur, Theo-24) Aminophylline(norphyl)

Theophylline inhibits enzyme PDE, slows inactivation of cAMP, leads to dilation Theophylline antagonizes adenosine (bronchoconstrictior)

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Mast cell stabilizers p.225, books calls this category cromolyn Inhibit release of histamine (decrease inflammation) Mast Cell Stabilizers Cromolyn sodium(Intal) Nedocromil(Tilade)

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Leukotrienes Modifiers Block activity of arachidonic acid derivatives = decrease inflammation P-450 enzyme induction Drug interactions Aspirin Erythromycin Increase effect Warfarin Leukotriene Modifiers Zafirukast(Accolate) Montelukast(Singular) Zileutron(Zyflo)

zafirlukast (Accolate), montelukast (Singular) Zileutron (Zoflo)

Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Leukotrienes Modifiers Immunomodulators

Long-Term Meds Immunomodulators Immunomodulators Omalizumab(Xolair) Prevent IgE from binding to mast cells Immunomodulators Omalizumab(Xolair)

Binds to receptors so allergen cannot omalizumab(Xolair) Binds to receptors so allergen cannot omalizumab(Xolair)

NBQ Which of the following drugs is preferred for long-term control of asthma? B-1 agonist B-2 agonist Inhaled corticosteroid Oral corticosteroids

NBQ Which of the following drugs is preferred for long-term control of asthma? B-1 agonist B-2 agonist Inhaled corticosteroid Oral corticosteroids

NBQ Which of the following drugs is used to control mild persistent asthma? Albuterol Ipratropium Inhaled beclomethasone Salmeterol

NBQ Which of the following drugs is used to control mild persistent asthma? Albuterol Ipratropium Inhaled beclomethasone Salmeterol

DH Considerations Aspirin & NSAIDs contraindicated in asthmatic patients (can lead to bronchospasm) Anticholinergic side effects Consult MD in SEVERE asthma cases Inhalers brought to appts Systemic corticosteroids – pt may need increase dose morning of apt Inhalers: advise pt to rinse after to avoid dry mouth & oral candidiasis

Agents used to manage upper respiratory tract infections Nasal Decongestants Expectorants & Mucolytics Antitussives

Agents used to manage upper respiratory tract infections Nasal Decongestants Constrict blood vessels in nasal mucous membranes Chronic use may result in rebound swelling and congestion Book correction: not all nasal decongestants are α-agonists (p.226) Remember: Patanase is a nasal antihistamine, not a decongestant

Agents used to manage upper respiratory tract infections Nasal Decongestants phenylephrine (Neo-Synephrine, Sinex, Allerest) α-agonist pseudoephedrine(Sudafed, Sucrets, Actifed) Beclomethasone(Beconase,Vancenase) Corticosteroid Nasal spray Mometasone(Nasonex) Fluticasone(Flonase) Budesonide(Rhinocort) Flunisolide(Nasalide) Cromolyn(Nasalcrom) OTC nasal spray Nedocromil(Tiladle) Nasal spray for asthma & rhinitis

NBQ Which of the following types of agents are nasal decongestants? B-1 agonist B-2 blockers Alpha-1 agonist Alpha-2 blockers

NBQ Which of the following types of agents are nasal decongestants? B-1 agonist B-2 blockers Alpha-1 agonist Alpha-2 blockers

Agents used to manage upper respiratory tract infections Expectorants & Mucolytics Mucolytics Promote removal of exudate or mucus from respiratory passages Liquefying & decrease viscosity of mucus Acetylcysteine(Mucosil): Useful in cystic fibrosis Expectorants Drugs that facilitate the removal of thickened mucus secretions from the lungs Action: ↑ bronchial = liquefy mucus Guaifenesin(Mucinex) most popular

Agents used to manage upper respiratory tract infections Antitussives: agents used to suppress cough Drugs Notations Opioids: (Codeine, Hydrocodone, Hydromorphone) Narcotic opioid Avoid in asthmatic (cause respiratory depression) Dextromethorphan(Robitussin, Vicks) Non-narcotic Many OTC products contain Benzonatate(Tessalon)

NBQ Which of the following terms defines “suppressing a cough?” Expectorant Antitussive Antihistamine Antiasthma

NBQ Which of the following terms defines “suppressing a cough?” Expectorant Antitussive Antihistamine Antiasthma

NBQ Which of the following drugs MAY be contraindicated in asthmatics? Aspirin Acetaminophen Vitamin C Folic acid

NBQ Which of the following drugs MAY be contraindicated in asthmatics? Aspirin Acetaminophen Vitamin C Folic acid