Transcript Chapter X

Chapter 9
Respiratory Drugs
© Paradigm Publishing, Inc.
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Learning Objectives
• Differentiate the pulmonary diseases.
• Learn the pathophysiology and treatment
of asthma.
• Define the goals of asthma treatment.
• Discuss the pathophysiology and
treatment of emphysema and chronic
bronchitis.
• Describe other diseases related to the
lungs.
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Learning Objectives
• Be aware of the reemergence of tuberculosis
and of treatment for this disease.
• Understand how the antitussives, expectorants,
decongestants, and antihistamines differ, and
be able to describe their uses.
• Know why some drugs are prescribed for their
side effects.
• Outline smoking cessation plans and supportive
therapy.
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Asthma
• Inflammatory disease in which
inflammation causes the airways to tighten
• Reversible condition
• Intermittent attacks are precipitated by
specific triggering events
• Causes a decrease in the amount of
oxygen and carbon dioxide exchanged
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Three Classes of Asthma
• Allergic
– Present in 35% to 55% of patients
• Exercise Induced
• Nonallergic
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Upper and Lower Respiratory Tracts
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Oxygen and Carbon Dioxide Exchange
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Asthma
• An asthmatic lung compared to a
normal lung
– More sensitive
– Responds to lower doses of allergens
• Studies strongly support genetic
predisposition to developing asthma
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Characteristics of Asthma
1. Reversible small airway obstruction
2. Progressive airway inflammation
3. Increased airway responsiveness to
variety of stimuli
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Characteristics of Asthma
• These 3 characteristics translate into
– Wheezing
– Dyspnea
– Acute and chronic cough
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Asthma Attack: First
Response
• Triggered by an antigen-antibody
reaction
• Causes degranulation of mast cells
which release histamine
• Result: bronchospasm and increased
mucus production that plugs the
small airways
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Asthma Attack: Second
Response
• Bronchoconstriction with delayed,
sustained reactions
• Causes self-sustaining inflammation
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Asthmatic Response
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Peak Flow Meter
• Expiratory peak flow rate (PEFR) is
the most useful measure to assess
– Severity
– Course of asthma
• Patient blows into peak flow meter,
PEFR recorded in liters/minute
• Aids in determining course of therapy
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Six Goals of Asthma Care
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•
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Sleep well every night
Be able to go to work or school every day
Be free from wheezing all day
Have good control of coughing
Be able to continue with activities and
exercise
• Tolerate medicines well
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Asthma Management for
Patients
• Know triggers and limit them
• Accurately use a Peak Flow Meter
regularly
• Be aware of status asthmaticus, a
medical emergency
– Requires prompt attention
– May require emergency room
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Asthma Drug Therapy
• Drug therapy mainstay of asthma
management
• Drug therapy depends on persistence
of asthma attacks
• Asthma begins with intermittent
attacks. May progress to mild-tosevere, persistent symptoms
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Devices Used in Asthma
Therapy
• Metered dose inhaler (MDI)
– Contains medication and compressed air
– Delivers specific amount of medication with
each puff
• Spacer
– Used with MDIs to get medication into lungs
instead of depositing on back of throat
• Nebulizer
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Nebulizers
• Uses stream of air that
flows through liquid
medication to make a
fine mist for inhalation
• Very effective
• Must be cleaned and
taken care of to reduce
risk of contamination
• Used for young children
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HFA Inhalers
• CFCs were propellants of MDIs
– Depleted Earth’s ozone layer
– Banned in late 1980s
• In 2008 FDA required MDIs to be
converted to hydrofluroalkane (HFA),
known as HFA MDI inhalers
• HFA inhalers produce finer mist with better
lung deposit of drug
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Dry Powder Inhalers
• Alternative to CFC-propelled inhalers,
no gases used
• Many manufacturers incorporating
drugs into dry-powder inhalers
• To use
– Pellet placed in inhaler and crushed
– When user inhales, inhaler activates
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Priming MDIs
• Prime MDIs before first use, if
dropped, or not used for several
weeks
• To prime, shake inhaler for 5
seconds. Release spray.
• Also, shake MDIs well before each
use
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Six Steps to Use HFA MDIs
1.
2.
3.
4.
Remove cap and shake inhaler.
Breathe out all the way.
Place mouthpiece between lips.
Press down on inhaler, hold for a few
seconds, then breathe in slowly.
5. Hold breath and count to 10.
6. Breathe out slowly.
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Five Steps to Use
Dry-Powder MDIs
1. Activate the inhaler, insert disk, etc.
2. Breathe out all the way.
3. Place mouthpiece to your lips and
breathe in quickly.
4. Hold breath and count to 10.
5. Breathe out slowly.
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More MDI Use Instructions
• For a second puff, wait about 1 minute,
then return to Step 1.
• If another inhaler is prescribed, wait 5
minutes before use.
• Clean mouthpiece after every use
• Rinse mouthpiece if corticosteroid is used
• Treatment should be reviewed every
3 to 6 months
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Bronchodilators
• Agents that relax smooth-muscle
cells of the bronchioles
– Airway diameter increases
– Gases moving in and out of lungs
improve
• When using different medications,
bronchodilators always used first
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Medications Needed By
Patients with Asthma
• Both a long-term medication and a
rescue medication to treat asthma
and control attacks
• Inhaled corticosteroids are the most
effective medications
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Drug List
Asthma Agents
Bronchodilators
– albuterol (Proventil, Proventil HFA,
Ventolin HFA, ProAir HFA)
– epinephrine (EpiPen)
– formoterol (Foradil, Perforomist)
– ipratropium (Atrovent)
– isoproterenol (Isuprel)
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Drug List
Asthma Agents
Bronchodilators
– levalbuterol (Xopenex)
– metaproterenol (Alupent)
– pirbuterol (Maxair)
– salmeterol (Serevent)
– terbutaline (Brethine)
– tiotropium (Spiriva)
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epinephrine (EpiPen)
• Drug of choice for acute attack of
asthma
• Many patients with asthma carry an
EpiPen
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Dispensing Issues of
epinephrine
Warning!
• Look-alike and sound-alike
– Epinephrine
– Ephedrine
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Short-Acting Inhaled
Bronchodilators
• albuterol
– Relaxes bronchial smooth muscle with
little effect on heart rate, duration of 3 to
6 hours
• isoproterenol
– Relaxes bronchial smooth muscle, use
up to 5x/day, maximum of 6
inhalations/hour
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Short-Acting Inhaled
Bronchodilators
• metaproterenol
– Onset of action within minutes, duration
of action 4 hours, little effect on heart
rate
• pirbuterol
– Prevent and treat bronchospasm,
duration of action 4 to 6 hours, use up to
12x/day
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Dispensing Issues of
albuterol
Warning!
• Proventil HFA and ProAir HFA
cannot be interchanged
• If Rx for an albuterol inhaler, any of
the 3 brands can be used
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levalbuterol (Xopenex)
• Isomer of albuterol
• Can be prescribed at lower doses
than albuterol
• Has fewer side effects than albuterol
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ipratropium (Atrovent)
• Blocks ACh in bronchial smooth
muscle causing bronchodilation
• Used for prevention of attacks, not
rescue situations
• Short-acting, does not cause
arrhythmias
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Dispensing Issues of
ipratropium (Atrovent)
Warning!
• Patient with peanut allergy may be allergic
to suspending agent in the inhaler
• Warning about possible allergy problem
may not appear in computer when drug is
dispensed
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Long-Acting Inhaled
Bronchodilators
• salmeterol
– For maintenance therapy, use exactly
as directed, not for acute situations,
long duration useful during night
• terbutaline
– For reversible airway obstruction and
bronchial asthma
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Long-Acting Inhaled
Bronchodilators
• Formoterol (Foradil)
– Onset of action within minutes (faster
than salmeterol), acts locally in lungs to
relax smooth muscle and inhibit release
of mast cells
– Refrigerate until dispensed
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Dispensing Issues of
Formoterol (Foradil)
Warning!
• Do not need to refrigerate after dispensing
and good for 4 months
• Technician must write on box the date
after which the drug should be discarded
(expiration date or 4 months after
dispensing)
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Asthma Agents: Xanthine
Derivatives
• Drugs structurally similar to caffeine
• Causes relaxation of airway smooth
muscle
• Result: Airway dilution and better air
movement
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Drug List
Asthma Agents
Xanthine Derivatives
– aminophylline (Truphylline)
– theophylline (Theo 24, TheoAir)
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theophylline (Theo 24,
TheoAir)
• Use only in lung diseases
unresponsive to other drugs because
it has many interactions
• Blood levels can become elevated
quickly
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Asthma Agents:
Leukotriene Inhibitors
• Increase edema, mucus, and vascular
permeability
– Substances can pass through blood vessels
• 100 to 1,000 times more potent than
histamine
• Block synthesis of, or the body’s
inflammatory responses to, leukotrienes
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Drug List
Asthma Agents
Leukotriene Inhibitors
– montelukast (Singulair)
– zafirlukast (Accolate)
– zileuton (Zyflo)
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montelukast (Singulair)
• Indicated for prophylaxis and chronic
treatment of asthma
• Do not use to treat acute attacks
• Approved for use in adults and children 12
months and older
• Once-daily dosage
• Also used to treat seasonal allergiesa
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zafirlukast (Accolate)
• Indicated for prophylaxis and long-term
treatment in children 5 years and older
• Antagonizes leukotriene receptors which
reduces edema, mucus, and vascular
permeability
• Good results reported with few side effects
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zileuton (Zyflo)
•
•
•
•
Reduces production of leukotrienes
Strong warnings about liver toxicity
Can double theophylline levels
Approved for patients 12 years or older
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Asthma Agents:
Corticosteroids
• Anti-inflammatory agents that suppress the
immune response
• Used for more difficult cases of asthma
• Usually prescribed on alternate-day basis
or as tapering doses when short-term
therapy is indicated
• Many patients with asthma still not using
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Primary Side Effects of
Corticosteroids
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Oral candidiasis
Irritation and burning of nasal mucosa
Hoarseness
Dry mouth
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Side Effects of Long-Time
Use of Oral Corticosteroids
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•
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Growth of facial hair in females
Breast development in males
“Buffalo hump,” “moon face”
Edema
Weight gain
Easy bruising
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Corticosteroids
• Always use lowest effective dose
• Add salmeterol to inhaled
corticosteroids if needed to decrease
the dose of corticosteroid needed for
control
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Dispensing Issues of
Corticosteroids
Warning!
• Patient should rinse mouth with water
after using inhalers to prevent oral
candidiasis
• Patient should be taught how to
correctly use these medications
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Drug List
Asthma Agents: Corticosteroids
– beclomethasone (Beconase AQ, QVAR,
Vanceril)
– budesonide (Entocort EC, Pulmicort
Respules, Pulmicort Turbuhaler,
Rhinocort)
– dexamethasone (Decadron)
– flunisolide (AeroBid)
– fluticasone (Flonase, Flovent)
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Drug List
Asthma Agents: Corticosteroids
– hydrocortisone (Solu-Cortef)
– methylprednisolone (Medrol Dose-Pack,
Solu-Medrol)
– mometasone furoate (Asmanex)
– prednisolone (Orapred, Pediapred)
– prednisone (Deltasone)
– triamcinolone (Azmacort, Nasacort AQ)
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fluticasone (Flonase,
Flovent)
• Flonase (Flovent) is same drug in nasal
spray Flonase
• Flovent comes in 3 strengths
– Lowest for mild asthma
– Highest to wean patients off oral
corticosteroids
• 1 to 2 weeks to reach maximum benefit
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budesonide (Entocort EC,
Pulmicort Respules, Pulmicort
Turbuhaler, Rhinocort)
• Pulmicort Turbuhaler
– Dry powder inhaler, breath activated,
primed only prior to initial use
– Easier to use
• Pulmicort Respules for home
nebulizers, age 12 months or older
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mometasone furoate
(Asmanex)
• Dry powder for inhalation
• Twisthaler dispenser with dose
counter
• Used for prophylactic therapy,
maximum benefit can take 2+ weeks
• Major side effect: headache
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Drug List
Asthma Agents
Mast Cell Stabilizers
– cromolyn sodium (Crolom,
Gastrocrom, Intal, Opticrom,
Nasalcrom)
– nedocromil (Tilade)
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Drug List
Asthma Agents
Monoclonoal Antibody
– omalizumab (Xolair)
Combination Drugs
– fluticasone-salmeterol (Advair
Diskus)
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fluticasone-salmeterol
(Advair Diskus)
• Combines corticosteroid (antiinflammatory) and a beta-2 agonist
• Indicated for maintenance therapy in
patients 12 years and older
• Available in powder for inhalation
• Should not be used with a spacer
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Terms to Remember
asthma
bronchospasm
peak flow meter
peak expiratory flow rate (PEFR)
status asthmaticus
metered dose inhaler (MDI)
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Terms to Remember
spacer
nebulizer
bronchodilator
xanthine derivative
leukotriene inhibitor
corticosteroid
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Terms to Remember
mast cell stabilizer
monoclonal antibody
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Chronic Obstructive
Pulmonary Disease (COPD)
• Emphysema and chronic bronchitis
• COPD is irreversible
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Emphysema
• Characterized by destruction of air sacs
which lose ability to exchange oxygen and
carbon dioxide
• Early stages: shortness of breath after
heavy exercise
• As disease progresses
– Patient gasps for air after short walk
– Causes tachypnea, patient looks flushed
© Paradigm Publishing, Inc.
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Major Risk Factors For
Emphysema
• Cigarette smoking
– Destroys walls of lungs
• Occupational exposure
• Air pollution
• Genetic factors
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Bronchitis
• Lining of the bronchial airways
becomes inflamed
• Causes patient to have difficulty
breathing out
© Paradigm Publishing, Inc.
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Two Types of Bronchitis
• Acute
– Caused by infection, usually viral
– Runs a brief course
• Chronic
– Longer lasting condition
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Chronic Bronchitis
• Difficult to breathe out
• Characterized by cough that produces
purulent, green, or blood-streaked sputum
• Major risk factors
– Cigarette smoking
– Exposure to occupational dusts, fumes, and
environmental pollution
– Bacterial infection
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Natural Defense System of
the Lungs
• In properly functioning system
– Provides good protection against
pathogens
– Removes potentially infectious agents
from the lungs
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Six Types of Body Defense
Cells
• Ciliary carpet rhythmically moves
fluid or mucus up and out of lungs
• Goblet cells secrete mucus
• Clara cells secrete enzymes that
break down airborne toxins
• Epithelial cells produce protein-rich
exudate
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Six Types of Body Defense
Cells
• Type I pneumocytes in alveolar
membranes act as phagocytes by
clearing trash and organisms from
the lung
• Type II pneumocytes synthesize and
secrete surfactant
© Paradigm Publishing, Inc.
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Cellular Makeup of an
Alveolus and Capillary Supply
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Drug Management of
Emphysema and Bronchitis
• Largely empirical
• Methylxanthines, corticosteroids, beta
agonists, and ipratropium form the
foundation of therapy
• One of the best expectorants is water
© Paradigm Publishing, Inc.
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Drug List
Agents for COPD
Mucolytics
– acetylcysteine (Acetadote,
Mucomyst)
– dornase alfa (Pulmozyme)
Anticholinergic
– tiotropium (Spiriva)
© Paradigm Publishing, Inc.
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Drug List
Agents for COPD
Beta Agonists
– arformoterol (Brovana)
– formoterol (Perforomist)
– isoproterenol (Isuprel)
– metaproterenol (Alupent)
© Paradigm Publishing, Inc.
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Drug List
Agents for COPD
Combinations
– ipratropium-albuterol (Combivent,
DuoNeb)
– fluticasone-salmeterol (Advair
Diskus)
© Paradigm Publishing, Inc.
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Drugs Indicated Only for
Treatment of COPD
• tiotropium (Spiriva)
– Similar to ipratropium (Atrovent), but is
dosed 1x/daily
• Combivent, DuoNeb, Brovana, and
Perforomist
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Terms to Remember
emphysema
an irreversible lung disease
characterized by destruction of the
alveoli in the lungs, which allows air to
accumulate in tissues and organs
tachypnea
very rapid respiration causing a flushed
appearance; a characteristic of
emphysema
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Terms to Remember
bronchitis
a condition in which the inner lining
of the bronchial airways becomes
inflamed, causing the expiration of
air from the lungs to be obstructed
mucolytic
an agent that destroys or dissolves
mucus
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Other Lung Diseases
• Most respiratory infections
transmitted through hand contact
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Prevention of Lung Diseases
•
•
•
•
Do not smoke
Avoid secondhand smoke
Avoid air pollution
Get vaccinations for influenza and
pneumonia
• Wash hands
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Pneumonia
• Common lung disease, affects all ages
• Can become infected by microorganisms
that cause pneumonia by
– Inhalation of aerosolized particles
– Entrance through the bloodstream
– Aspiration (inhalation of fluids from the mouth
and throat), commonly occurs during sleep
© Paradigm Publishing, Inc.
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X-Ray of Pneumonic Lung
X-ray of a
patient with
pneumonia that
shows fluid in
the right lung
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Discussion
Why is cigarette smoke implicated in
many diseases that affect the lungs?
The chemicals in cigarette smoke destroy
the walls of the lungs, including the
protective mechanisms.
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Cystic Fibrosis
• Hereditary disease that affects the GI
and respiratory systems
• Fatal disease; death is associated with
the pulmonary system
• GI involvement
– Increase in production and viscosity of
mucus
– Decreased pancreatic digestive enzymes
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Cystic Fibrosis Therapy
• Percussion
– Tapping movement to induce cough and
expectoration of sputum from lungs
• Nebulizer therapy
• Antibiotic therapy
• Annual flu vaccine due to high risk
from complications of influenza
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Respiratory Distress
Syndrome (RDS)
• Occurs in newborns during first few
hours
• Characterized by inadequate
production of pulmonary surfactant
– Fluid lowers surface tension between
alveoli, causing their collapse
• RDS treated with surfactants
© Paradigm Publishing, Inc.
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Respiratory Distress
Syndrome (RDS)
• Two causes of RDS
– Prematurity
– Maternal diabetes
• If RDS occurs, replacement
surfactant administered
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Drug List
Surfactants for Respiratory Distress
Syndrome
– beractant (Survanta)
– calfactant (Infasurf)
– colfosceril palimate (Exosurf
Neonatal)
– poractant alfa (Curosurf)
© Paradigm Publishing, Inc.
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beractant (Survanta)
• Drug of choice for RDS
• Extracted from cattle lung
• Lowers surface tension between the
alveoli to keep them from collapsing
• Therapy
– Prophylactic for high risk infants
– Rescue within 8 hours of birth
© Paradigm Publishing, Inc.
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Tuberculosis
• Caused by bacterium mycobacterium
tuberculosis
• Primarily affects the lungs, may also
affect other body tissues and organs
• Transmission through inhaled
droplets from an infected person
– Droplets descend 1 to 2 inches per hour
© Paradigm Publishing, Inc.
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Tuberculosis (TB)
• Seen primarily in
– Alcoholics
– Prison population
– Immunocompromised
– Elderly
© Paradigm Publishing, Inc.
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Two Classes of Tuberculosis
• Exposed, but showing no disease
– Test positive on TB test, may not have active
disease
• Exposed and have active organisms
– May or may not produce antibodies
– Signs and symptoms: weight loss, spitting
blood, night sweats and night fever, chest pain,
malaise
© Paradigm Publishing, Inc.
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TB Test
• Protein derivative from killed bacteria
injected intradermally
• If patient has been exposed to or has
disease, test will be positive
• If positive, patient must have x-rays
to look for signs of active disease
© Paradigm Publishing, Inc.
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Four Goals of TB Therapy
• Initiate treatment promptly
• Convert sputum culture to negative
as soon as possible
• Achieve cure without relapse
• Prevent emergence of drug-resistant
strains
© Paradigm Publishing, Inc.
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Drug List
Agents for Tuberculosis
– capreomycin (Capastat)
– ciprofloxacin (Cipro)
– cycloserine (Seromycin)
– ethambutol (Myambutol)
– ethionamide (Trecator-SC)
© Paradigm Publishing, Inc.
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Drug List
Agents for Tuberculosis
– isoniazid (INH) (Laniazid, Nydrazid)
– isoniazid-pyrazinamide-rifampin
(Rifater)
– isoniazid-rifampin (Rifamate)
– ofloxacin (Floxin)
– pyrazinamide (none)
© Paradigm Publishing, Inc.
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Drug List
Agents for Tuberculosis
– rifampin (Rifadin, Rimactane)
– rifapentine (Priftin)
– streptomycin (none)
© Paradigm Publishing, Inc.
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TB Treatment Regimens
• Patients with no symptoms, but
positive x-ray
– Single agent, usually INH 300 mg QD X
12 months
• Patients with clinical disease
– At least 2 agents at a time to prevent
development of drug-resistance bacteria
© Paradigm Publishing, Inc.
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Multidrug Resistant
Tuberculosis (MDR-TB)
• MDR-TB, a new strain, has emerged and
is resistant to commonly used drugs
• Risk factors for acquiring MDR-TB
–
–
–
–
–
Being exposed to MDR-TB
Not completing TB therapy
Being prescribed inappropriate agents
Having immune deficiencies
Having recurrence of TB
© Paradigm Publishing, Inc.
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Side Effects of Rifampin
(Rifadin, Rimactane)
• Reddish-orange discoloration of
urine, tears, sweat, other body fluids
• Can permanently stain soft contact
lenses
© Paradigm Publishing, Inc.
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Discussion
Why is patient compliance such an
issue with tuberculosis patients?
Patient noncompliance is due to severe
side effects, length of time for therapy, and
the number of medications. Patients being
treated for active TB should avoid alcohol,
which is a problem for some populations.
© Paradigm Publishing, Inc.
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Histoplasmosis
• Fungal pulmonary disease
• Caused by breathing in spores from
droppings of chickens, pigeons, starlings,
other birds, and bats
• Called the summer flu due to flu-like
symptoms
• Treatment: Amphotericin B and
itraconazole
© Paradigm Publishing, Inc.
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Terms to Remember
pneumonia
aspiration
cystic fibrosis (CF)
percussion
respiratory distress syndrome
surfactant
© Paradigm Publishing, Inc.
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Terms to Remember
tuberculosis (TB)
histoplasmosis
© Paradigm Publishing, Inc.
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Cough, Cold, and Allergy
• Common cold most prevalent respiratory
tract infections; viral infection
• Symptoms
–
–
–
–
–
Mild malaise
Rhinorrhea (runny nose)
Sneezing
Scratchy throat
Fever
© Paradigm Publishing, Inc.
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Colds
• Bacterial sinusitis and otitis media
are frequent complications warranting
antibiotic therapy
© Paradigm Publishing, Inc.
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Allergies
• Symptoms of some allergies same as
colds, like runny nose and itchy eyes
• Allergy is state of hypersensitivity
induced by exposure to particular
antigen
• Colds and many allergies treated with
same medications
© Paradigm Publishing, Inc.
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OTC Products for Colds and
Coughs
• People self-treat colds and coughs to
relieve symptoms and prevent
complications
• 4 groups of drugs, alone or combinations:
antitussives, expectorants, decongestants,
antihistamines. Most are OTCs
– Each has different mechanism of action and
purpose
© Paradigm Publishing, Inc.
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OTC Products for Colds and
Coughs
• Pharmacy technicians cannot make OTC
remedy recommendations
• Technicians can
– Direct patient to OTC remedies
– Make patient aware of proper uses and side
effects
• Tavist (clemastine) only drug approved by
FDA to treat colds
© Paradigm Publishing, Inc.
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Transmitting Colds
• Colds transmitted person to person
– Directly when infected person sneezes
or coughs
– Indirectly by surfaces such as
telephones, doorknobs, toys
• To cough, turn head and cough into
shoulder, not the hand
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Preventing Colds
• Often contract cold by rubbing eyes
or nose after touching contaminated
surface or people with cold
• Best prevention is to wash hands
• In pharmacy, wipe phones with
alcohol regularly
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Antitussives
• Coughing clears airways of excess
secretions and foreign materials
• Reduce the frequency of a cough,
especially if dry and nonproductive
– CNS depression of cough center (reflex)
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Cough Reflex and
Antitussives
• Cough reflex stimulated by stretch
receptors and irritant receptors in lungs
and airway
• Antitussive products
–
–
–
–
Correct or block irritation of receptors
Block transmission to brain
Increase cough center threshold
Block action of expiratory muscles
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Drug List
Antitussives
– benzonatate (Tessalon)
– codeine (various combinations)
– dextromethorphan (Delsym)
– diphenhydramine (Benadryl)
– hydrocodone-chlorpheniramine
(Tussionex)
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Drug List
Antitussives
– promethazine-codeine (Phenegran
with codeine
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Drug List
Antitussives
Dextromethorphan Combinations
– dextromethorphan-pseudoephedrinebrompheniramine (Bromfed-DM,
Myphetane DX)
– guaifenesin-dextromethorphan
(Mucinex DM)
– promethazine-dextromethorphan
(none)
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Codeine
• The “Gold Standard,” against which all
other antitussives are compared
• Drying effect on respiratory mucosa
• C-V, but can be purchased without a
prescription in some states
– Dispensing must be done by the pharmacist
who writes initials by patient’s signature
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Side Effects of Codeine
•
•
•
•
•
Nausea
Drowsiness
Light-headedness
Constipation
Take with food to decrease stomach
upset
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hydrocodone-chlorpheniramine
(Tussionex)
• Often drug of abuse, high street value
• Hydrocodone derivative of codeine, very
addictive
• Schedule III, but pharmacies store under
lock and key
• Pharmacy technicians should check to
make sure prescription is legal
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benzonatate (Tessalon)
• Locally anesthetizes stretch receptors
in the airway, lungs, and pleura
• Do not chew capsule
• Side effects: sedation, headache,
dizziness
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dextromethorphan (Delsym)
• Works as well as codeine without
analgesic properties
• Does not depress respiration or have
abuse potential
• Often combined with other cough and
cold preparations
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Dispensing Issues of
dextromethorphan (Delsym)
Warning!
• Consuming large quantities can produce
hallucinations, called robo-tripping
• Popular with teens as recreational drug
• Purchaser must show proof of age and be
over 18 years
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Expectorants
• Help rid lungs and airway of mucus
when coughing
• Decrease thickness and viscosity
(stickiness) of mucus so cough will
eject mucus
• Used for dry and productive coughs
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Water
• Can work as well as, if not better
than, medication expectorants
• Staying well-hydrated thins mucus
and allows for easier expectoration
• 6 to 8 glasses of water a day
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Drug List
Expectorants
– guaifenesin (Mucinex)
– potassium iodide (Iossat, Lugol
solution)
Combinations
– guaifenesin-codeine (Robitussin A-C)
– guaifenesin-pseudoephedrine
(Mucinex D)
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guaifenesin (Mucinex)
• Most-used expectorant, many forms
• Loosens phlegm and thins bronchial
secretions
• Often combined with other drugs
• Indicated for patients with smoking,
asthma, or emphysema
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Decongestants
• Swelling and stuffiness caused by
vasodilation and leakage of fluids into
nasal mucosa
• Decongestants cause constriction
– Promotes drainage, improves nasal
ventilation, and relieves stuffiness
– Allows sinus cavities to drain
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Decongestants
• Increase heart rate and blood pressure
• Stimulates the CNS
• Patients sometimes take decongestants to
overcome drowsiness
• Should not be taken by those who cannot
tolerate sympathetic stimulation
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Decongestants
• Prolonged use of topical
decongestants can cause rebound
rhinitis medicamentosa
• Therapy should not exceed 3 to 5
days
• Available in topical and oral forms
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Drug List
Decongestants
– pseudoephedrine (Sudafed)
– phenylephrine (Sudafed PE, NeoSynephrine, others)
– phenylephrine, IV (none)
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Drug List
Decongestants
Pseudoephedrine Combinations
– cetirizine-pseudoephedrine
(Zytrec-D)
– fexofenadine-pseudoephedrine
(Allegra-D)
– guaifenesin-pseudoephrine
(Mucinex D)
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Drug List
Decongestants
Pseudoephedrine Combinations
– ibuprofen-pseudoephedrine (Advil
Cold and Sinus)
– ibuprofen-pseudoephedrine
chlorpheniramine (Advil Allergy and
Sinus)
– loratadine-pseudoephedrine
(Claritin D)
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Drug List
Decongestants
Pseudoephedrine Combinations
– naproxen-pseudoephedrine (Aleve
Cold and Sinus)
– triprolidine-pseudeophedrine (Actifed
Cold and Allergy)
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Dispensing Issues of
Decongestants
Warning!
Should be
avoided in
patients with
– Diabetes
– Heart disease
– Uncontrolled
hypertension
– Hyperthyroidism
– Prostatic hypertrophy
– Tourette syndrome
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Oral Side Effects of
Decongestants
•
•
•
•
•
Anxiety
CNS stimulation
Dizziness
Hallucinations
Headache
• Increased blood
pressure
• Increased heart
rate
• Insomnia
• Tremor
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Side Effects of Topical
Decongestants
•
•
•
•
•
•
Burning sensation
Contact dermatitis
Dry mouth
Rhinitis medicamentosa
Sneezing
Stinging sensation
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pseudoephedrine (Sudafed)
• Most-used and most effective
decongestant; in many combinations
• If hypertension is well controlled,
patients can take pseudoephedrine
for short time
• Strong abuse potential, can be made
into methamphetamine
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Dispensing Issues of
Pseudoephedrine
Warning!
• Amount purchased at one time is limited
• Products containing pseudoephedrine are
kept behind the counter
• Consumer must specifically ask for them
and show ID
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Antihistamines
• Used primarily to combat allergic
reactions, nausea, vertigo, and insomnia
• Most common side effects are sedation,
dry mouth, constipation, urinary retention
• Prevent binding of histamine to receptor
sites
• Many are sold OTC
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Antihistamines
• Well absorbed in tissues
• Widely distributed across blood-brain
barrier causing sedation
• Can cross the placenta and adversely
affect fetus
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Drug List
Antihistamines
– azatadine (Optimine)
– azelastine (Astelin, Optivar)
– cetirizine (Zyrtec)
– chlorpheniramine (Chlortrimeton)
– clemastine (Tavist Allergy)
– cyproheptadine (Periactin)
– desloratadine (Clarinex)
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Drug List
Antihistamines
– diphenhydramine (Benadryl)
– fexofenadine (Allegra)
– hydroxyzine (Atarax, Vistaril)
– levoctirizine (Xyzal)
– loratadine (Claritin)
– meclizine (Antivert)
– promethazine (Phenergan)
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Therapeutic Uses of
Antihistamines
• Allergies
• Control venom
reactions
• Insomnia
• Rash, edema, and
hay fever
• Cough
• Vertigo
• Lessens
extrapyramidal side
effects of
antipsychotics
• Nausea and vomiting
• Prevent certain drug
reactions and allergies
• Serum sickness
• Hypersensitivity
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Hypersensitivity Reactions
• Excessive immune response to a
foreign agent
• Can range from a slight rash to a
serious response such as serum
sickness
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Side Effects of
Antihistamines
• Anticholinergic responses
–
–
–
–
–
Dry mouth
Drying of URT mucosa
Blurred vision
Constipation
Urinary retention
• Hyperactivity in some children
• Sedation most common
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diphenhydramine (Benadryl)
• Major ingredient in OTC sleep
medications
• Synergistic with alcohol use
• Dizziness common side effect
• New drugs have fewer side effects
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fexofenadine and
clemastine
• fexofenadine (Allegra)
– Less sedating than most other
antihistaimines
• clemastine (Travist Allergy)
– Least-sedating OTC antihistamine
– Approved by FDA for treatment of
symptoms of cold
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Nasal Corticosteroids
• Most effective monotherapy for allergic
rhinitis
• Must be used daily
• Can cause nasal irritation and bleeding;
direct spray away from septum
• Local infections of Candida albicans may
occur in nose with long term use
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Drug List
Nasal Corticosteroids
– beclomethasone (Beconase AQ)
– budesonide (Rhinocort Aqua)
– ciclesonide (Omnaris)
– flunisolide (Nasarel)
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Drug List
Nasal Corticosteroids
– fluticasone (Veramyst), furoate
– fluticasone (Flonase), propionate
– mometasone (Nasonex)
– triamcinolone (Nasacort AQ)
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fluticasone (Veramyst,
Flonase)
• Used in two different forms
• Veramyst has stronger binding affinity
• Flonase easier to use
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mometasone furoate
(Nasonex)
• Depresses release of endogenous
chemical mediators of inflammation
• Reverses dilation and permeability of
vessels in area, decreases cell
access to injury site
• Children over 12 can use to prevent
symptoms of allergic rhinitis
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Terms to Remember
antitussive
cough reflex
stretch receptor
irritant receptor
expectorant
decongestant
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Terms to Remember
rhinitis medicamentosa
antihistamine
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Smoking Cessation
• On average, cigarette smokers lose
about 15 years of life
• Cigarette smoke contains 4,000+
chemical compounds including at
least 43 carcinogens
• Secondhand smoke contains all 43
carcinogens and toxins
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Smoking
• Can lead to
– Leukemia
– Cancer: lung, mouth, pharynx, larynx,
esophagus, pancreas, cervix, kidney,
bladder, ovaries, uterus, and prostate
• Increases risk of heart disease,
COPD, stroke
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Smoking
• Related to birth defects of mothers who
smoke during pregnancy
• Secondhand smoke puts children at risk of
developing asthma, respiratory infection,
and middle-ear infection
• Nicotine is addictive component of
tobacco. Can interact with some
medications
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Effects of Nicotine
• CNS and PNS
stimulation and
depression
• Respiratory
stimulation
• Skeletal muscle
relaxation
• Increase in blood
pressure, heart
rate, cardiac
output, oxygen
consumption
• Physical and
psychological
dependence
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Personal Benefits to
Smoking Cessation
• Improved
performance in
sports and sex
• Better-smelling
home, car,
clothing, breath
• Economic savings
• Addiction freedom
• Healthier babies
• Improved health
and self-esteem
• Improved sense of
taste and smell
• No exposing
others to smoke
• Set good example
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5 Step Quit Plan
1.
2.
3.
4.
Set a date
Inform family, friends, coworkers
Remove cigarettes from daily life
Review previous attempts and
analyze what caused relapse
5. Anticipate challenges
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Smoking Cessation
• Key is abstinence
• Some fears that keep people from
quitting: weight gain, nicotine
withdrawal
• Most nicotine cessation drugs OTC
– varenicline (Chantix) most successful
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Symptoms of Nicotine
Withdrawal
• Anxiety
• Craving tobacco
• Decreased blood
pressure and heart
rate
• Depression
• Difficulty
concentrating
• Drowsiness
• Frustration,
irritability, hostility
• GI disturbances
• Headache
• Increased appetite,
skin temperature
• Insomnia
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Drug List
Smoking Cessation Agents
– bupropion (Wellbutrin SR, Zyban)
– nicotine (Commit, Habitrol, Nicoderm
CQ, Nicorette, ProStep, Nicotrol)
– varenicline (Chantix)
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Dispensing Issues of
Smoking Cessation Agents
Warning!
• Lozenges should not be chewed
• Patch application site should be rotated to
prevent skin reactions
• Smoking during nicotine replacement
therapy could show signs of nicotine
excess
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Symptoms of Nicotine
Excess
•
•
•
•
•
•
Abdominal pain
Confusion
Diarrhea
Dizziness
Headache
Hearing loss
•
•
•
•
Hypersalivation
Nausea
Perspiration
Visual
disturbances
• Vomiting
• Weakness
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Dispensing Issues of
Smoking Cessation Agents
Warning!
• Smoking while on nicotine
replacement therapy could cause
signs of nicotine excess
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Discussion
You are trying to get a friend to stop
smoking. Name five reasons why your
friend should quit.
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Terms to Remember
nicotine
the addictive component of tobacco
cotinine
a major metabolite of nicotine
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Assignments
• Complete Chapter Review activities
• Answer questions in Study Notes
document
• Study Partner
– Quiz in review mode
– Matching activities
– Drug tables
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