Drugs affecting the Respiratory System
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Transcript Drugs affecting the Respiratory System
By Linda Self
Key Terms
1.
2.
3.
4.
5.
6.
Ventilation
Perfusion
Diffusion
Pulmonary Circulation
Surfactant
pneumocytes
Asthma—inflammation, hyperreactivity,
and
bronchoconstriction
GERD may cause
microaspiration/resultant nighttime
cough
Antiasthma medications can also
exacerbate GERD
May
be triggered by viruses
Irritants
Allergens
Can develop at any age
Seen more often in children who are
exposed to airway irritants during
infancy
Bronchoconstriction
Inflammation
Mucosal
edema
Excessive mucous
Mast
cells
Chemical mediators such as histamine,
prostaglandins, acetylcholine, cGMP,
interleukins, leukotrienes are released
when triggered. Mobilization of
eosinophils. All cause movement of fluid
and proteins into tissues.
Bronchoconstrictive substances
antagonized by cAMP
Combination
of chronic bronchitis and
emphysema
Bronchoconstriction and inflammation
are more constant, less reversibility
Anatomic and physiologic changes occur
over years
Leads to increasing dyspnea and activity
intolerance
Bronchodilators
and anti-inflammatories
Step
1-Mild Intermittent—symptoms 2
days/week or less or 2 nights/month or
less. No daily medication needed; treat
with inhaled beta2 agonist
Step 2-Mild persistent—symptoms
>2/week but <1x/day or >2
nights/month. In those >5 years old, use
inhaled corticosteroid, leukotriene
modifier, Intal (cromolyn), or sustained
release theophylline
Step
2—Mild persistent
Children 5 years and younger—inhaled
corticosteroid by nebulizer of MDI with a
holding chamber. Can also use leukotriene
modifier or Intal by nebulizer
Step 3—Moderate persistent. Symptoms
daily and > one night per week.
Older than 5yo—low to med. Dose
corticosteroid and long acting beta 2
agonist. Alternatives p. 714
Step 3—
Children
< 5 yo: low dose inhaled
corticosteroid and a long acting beta 2
agonist or medium dose inhaled
corticosteroid
Step 4—Severe persistent—symptoms
continual during daytime and frequently at
night.
>5yo—high dose inhaled corticosteroid,
long acting beta 2 agonist; intermittent
admin. of oral corticosteroids
Step
4—
Children less than 5 yo—same as for
adults and older children
Adrenergics—stimulate
beta 2 receptors
in smooth muscle of bronchi and
bronchioles
Receptors stimulate cAMP
=bronchodilation
Cardiac stimulation is an adverse effect
of these medications
Cautious
use in hypertension and cardiac
disease
Selective beta 2 agonists by inhalation
are drugs of choice
Epinephrine sc in acute
bronchoconstriction
Proventil
(albuterol)
Xopenex (levalbuterol)
Treatment
of first choice to relieve acute
asthma
Aerosol or nebulization
May be given by MDI
Overuse will diminish their
bronchodilating effects>>>>tolerance
Foradil
(formoterol) and Serevent
(salmeterol) are long acting beta 2
adrenergic agonists used only for
prophylaxis. Black box warning on
Serevent—use in deteriorating asthma
can be life-threatening
Alupent (metaproterenol)—intermediate
acting. Useful in exercise induced
asthma, tx acute bronchospasm.
Brethine
(terbutaline)—selective beta 2
adrenergic agonist that is a long-acting
bronchodilator
When given subq, loses selectivity
Also used to decrease premature uterine
contractions during pregnancy
Block
the action of acetylcholine in
bronchial smooth muscle when given by
inhalation
Action reduces intracellular guanosine
monophosphate (GMP) which is a
bronchoconstrictive substance
Atrovent (ipratropium)—caution in BPH,
narrow-angle glaucoma
Spiriva (tiotropium)
Theophylline
Mechanism
of action unclear
Bronchodilate, inhibit pulmonary edema,
increase action of cilia, strengthen
diaphragmatic contractions, over-all antiinflammatory action
Increases CO, causes peripheral
vasodilation, mild diuresis, stimulates
CNS
Contraindicated
in acute gastritis and
PUD
Second line
Narrow therapeutic window—therapeutic
range is 5-15 mcg/mLh
Multiple drug interactions
Suppress
inflammation by inhibiting
movement of fluid and protein into
tissues; migration and function of
neutrophils and eosinophils, synthesis of
histamine in mast cells, and production of
proinflammatory substances
Benefits: decreased mucous secretion,
decreased edema and reduced reactivity
Second
action is to increase the number
and sensitivity of beta 2 adrenergic
receptors
Can be given PO or IV
Pulmonary function usually improves
within 6-8 hours
Continue drugs for 7-10 days
Fewer
long term side effects if inhaled
End-stage COPD may become steroid
dependent
In asthma, systemic steroids generally
are used only temporarily
Taper high dose oral steroids to avoid
hypothalamic-pituitary axis suppression
For
inhalation:
Beclovent—beclomethasone
Pulmicor—budesonide
Aerobid—flunisolide
Flovent—fluticasone
Azmacort—triamcinolone
Most inhaled steroids are being
reformulated with HFA
Systemic
use: prednisone,
methylprednisolone, and hydrocortisone
In acute, severe asthma—a systemic
corticosteroid may be indicated when
inhaled beta 2 agonists are ineffective
Leukotrienes
are strong chemical
mediators of bronchoconstriction and
inflammation
Increase mucous secretion and mucosal
edema
Formed by the lipoxygenase pathway of
arachidonic acid metabolism in response
to cellular injury
Are release more slowly than histamine
Developed
to counteract the effects of
leukotrienes
Indicated for long term treatment of
asthma in adults and children
Prevent attacks induced by some
allergens, exercise, cold air,
hyperventilation, irritants and
ASA/NSAIDs
Not useful in acute attacks
Injured
cell
Arachidonic acid
XXXX
Lipooxygenase
Leukotrienes
XXXX
Bronchi, WBCs
Bronchoconstriction
Singulair
(montelukast) and Accolate
(zafirlukast) are leukotriene receptor
antagonists
Can be used in combination with
bronchodilators and corticosteroids
Less effective than low doses of inhaled
steroids
Should not be used during lactation
Can cause HA, nausea, diarrhea, other
Intal
(cromolyn)
Tilade (nedocromil)
Prevent release of bronchoconstrictive
and inflammatory substances when mast
cells are confronted with allergens and
other stimuli
Prophylaxis only
Inhalation, nebulizer or MDI, nasal spray
as well
Xolair
(omalizumab) works by binding to
IgE, blocking receptors on surfaces of
mast cells and basophils
Prevents release of chemical mediators of
allergic reactions
Adjunctive therapy
Can cause life-threatening anaphylaxis
Histamine
is the first chemical mediator
released in immune and inflammatory
responses
Concentrated in skin, mucosal surfaces of
eyes, nose, lungs, CNS and GI tract
Located in mast cells and basophils
Interacts with histamine receptors on
target organs called H1 and H2
H1
receptors are located mainly on
smooth muscle cells in blood vessels and
the respiratory and GI tracts
H1 binding causes: pruritus, flushing,
increased mucous production, increased
permeability of veins—edema,
contraction of smooth muscle in
bronchi>>bronchoconstriction and
cough
With
H2 receptor stimulation, main
effects are increased secretion of gastric
acid and pepsin, decreased immunologic
and proinflammatory reactions,
increased rate and force of myocardial
contraction
Are
exaggerated responses by the
immune sysem that produce tissue injury
and possible serious disease
Allergic reactions may result from
specific antibodies, sensitized T
lymphocytes, or both, formed durng
exposure to an antigen.
Type
I—immediate hypersensitivity, IgE
induced response triggered by the
interaction of antigen with antigenspecific IgE bound on mast cells
Anaphylaxis is an example
Does not occur on first exposure to an
antigen
Can develop profound vasodilation
resulting in hypotension, laryngeal
edema, bronchoconstriction
Type
II—IgG or IgM mediated which
generate direct damage to cell surfaces.
Examples include: blood transfusion
reactions, hemolytic disease of
newborns, hypersensitivity reactions to
drugs such as heparin or penicillin
Type
III is an IgG or IgM mediated
reaction characterized by formation of
antigen-antibody complexes that induce
inflammatory reaction in tissues.
Prototype is Serum Sickness.
Immune response can occur following
antitoxin administration, pcn or sulfa
drugs
Delayed
hypersensitivity
Cell mediated response where sensitized
T lymphocytes react with an antigen to
cause inflammation, release of
lymphokines , direct cytotoxicity or both
Classic examples are tuberculin test,
contact dermatitis and some graft
rejections
IgE
mediated
Inflammation of nasal mucosa caused by
a hypersensitivity reaction to inhaled
allergens
Presents with itching of throat, eyes and
ears
Seasonal and perennial
Can lead to chronic fatigue, difficulty
sleeping, sinus infections, postnasal drip,
cough and headache
Atrovent
nasal spray
Beconase (beclomethasone)
Rhinocort (budesonide)
Flonase (fluticasone)
Nasonex (mometasone)
Nasalcrom (a mast cell stabilizer)
Type
IV hypersensitivity reaction
Poison ivy an example
Usually occurs >24h after re-exposure
Allergic
food reactions—result from
ingestion of a protein
Most common food allergy is shellfish,
others include milk, eggs, peanuts
Allergic drug reactions—unpredictable,
may occur 7-10 days after initial
exposure
Pseudoallergic drug reactions—
resemble immune responses but do not
produce antibodies, i.e. anaphylactoid
Inhibit
smooth muscle constriction in
blood vessels and the respiratory and GI
tracts
Decrease capillary permeability
Decrease salivation and tear formation
Act by binding with the histamine
receptor
Allergic
rhinitis
Anaphylaxis
Allergic conjunctivitis
Drug allergies
Transfusions of blood products
Dermatologic conditions
Nonallergic such as motion sickness,
nausea and vomiting, sleep
Caution
in pregnancy
BPH
Bladder
neck obstruction
Narrow angle glaucoma
Bind
to central and peripheral receptors
Can cause CNS depression or stimulation
Have substantial anticholinergic effects
Examples:
Chlor-Trimeton (chlorpheniramine)
Benadryl (diphenhydramine)
Vistaril (hydroxyzine)
Phenergan (promethazine)
Selective
or nonsedating
Do not cross blood brain barrier
Examples:
Astelin (azelastine)
Allegra (fexofenadine)
Claritin (loratadine)
Clarinex (desloratadine)
Zyrtec
Xyzal
Relieve
nasal obstruction and discharge
Adrenergic
Rebound nasal swelling called “rhinitis
medicamentosa”
Afrin
Sudafed (pseudoephedrine)
Contraindicated in severe hypertension,
CAD, narrow angle glaucoma, TCAs or
MAOIs
Suppress
cough by depressing cough
center in medulla or by increasing flow of
saliva
For dry, hacking, non-productive cough
Not recommended in children and
adolescents
Codeine, hydrocodone
dextromethorphan
Liquefy
respiratory secretions
Guiafenesin
By
inhalation to liquefy mucous
Mucomyst (acetylcysteine)
May be used in treating acetaminophen
overdose
Contain
antihistamine, decongestant and
an analgesic
Chlorpheniramine, pseudoephedrine,
acetaminophen, dextromethorphan and
guiafenesin
Decongestants can cause stasis of
secretions
PM contains antihistamine
Tamiflu can be used to limit spread of
virus in respiratory tract
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2.
3.
4.
5.
6.
7.
8.
Name two beta adrenergic bronchodilators
Name an inhaled steroid
Give an example of a leukotriene modifier
Name a mast cell stabilizer
Name a common infection after frequent
use of an inhaled steroid
Name a first generation H1 receptor
antagonist
Name a second generation H1 receptor
antagonist.
Name an H2 receptor antagonist.