Pharm module 1C

Albuterol - Short-acting Beta2 Agonists (SABA)

• SABAs selectively activate beta2 receptors in bronchial smooth muscle through the sympathetic nervous system, causing bronchodilation.
• Bronchospasm is relieved, histamine release is inhibited, and ciliary motility is increased.
• Inhaled SABAs are for short-acting prevention of asthma episodes (exercise-induced) and treatment of bronchospasm and asthma.
• Oral SABAs are for long-acting, long-term control of asthma.
• Complications of SABAs include tachycardia and tremors, as well as heart palpitations.
  • Oral agents can cause tachycardia and angina due to activation of alpha1 receptors in the heart and dosage may need to be reduced.
  • Tremors are caused by activation of beta2 receptors in skeletal muscle, as well as heart palpitations.
• Pregnancy/lactation safety has not been established.
• Contraindicated in clients who have tachydysrhythmia.
• Use cautiously in clients who have diabetes mellitus, hyperthyroidism, heart disease, hypertension, and angina.
• Beta-adrenergic blockers should not be used concurrently as they can negate the effects of SABAs.
• MAOIs and tricyclic antidepressants can increase the risk of tachycardia and angina; report any increase in symptoms.
• Nursing administration can be inhaled and oral.
• If prescribed both, use the inhaled beta2 agonist before the inhaled glucocorticoid to promote bronchodilation and enhance glucocorticoid absorption.
• SABAs are used to treat an acute episode.
• Effectiveness is evaluated by the long-term control of asthma, prevention of exercise-induced asthma, and resolution of asthma exacerbations, evidenced by the absence of shortness of breath, clear breath sounds, absence of wheezing, and return of respiratory rate to baseline.
• Short-acting SABA Levalbuterol.
• Long-acting beta2 adrenergic agonists include formoterol, salmeterol, terbutaline, vilanterol, and olodaterol.
• Short-acting beta2 agonists treat acute episodes.
• Formoterol and salmeterol are long-acting beta2 agonist inhalers and used every 12 hours for long-term control, not to abort asthma attacks or exacerbations.
• Long-acting agents are not used alone but in combination with an inhaled glucocorticoid and are used for long-term control of asthma.
• Client education includes the use of a metered-dose inhaler with or without a spacer.
• Follow the manufacturer's instructions and don't exceed prescribed doses.
• Know the dosage schedule (either fixed or as-needed).
• Observe for indications of an impending asthma episode and keep a log of the frequency and intensity of exacerbations.
• Notify the provider if there is an increase in the frequency and intensity of asthma exacerbations.
• Avoid caffeine, and let the provider know if tremors interfere with ADLs.
• For metered-dose inhaler: hold the inhaler 1-2 inches away from their open mouth.
• Take a deep breath, exhale completely, then inhale slowly and deeply as you depress the inhaler, continuing to breathe in for 3-5 seconds.
• Hold your breath for approximately 10 seconds.
• A spacer is used to hold the medication in suspension for a longer amount of time.
• With the spacer attached, exhale slowly and deeply through the mouth for 3-5 seconds and hold your breath again for 10 seconds.

Theophylline - Methylxanthine

• Theophylline relaxes bronchial smooth muscle by blocking phosphodiesterase, resulting in bronchodilation.
• Previously first-line asthma medication, now used infrequently due to safer and more effective medications.
• Oral theophylline is used for long-term control of chronic asthma; previously used for COPD, but evidence-based practice no longer recommends methylxanthines for COPD.
• Mild toxicity reactions include GI distress and restlessness, as well as insomnia.
• More severe reactions can happen with higher therapeutic doses and can include dysrhythmias and seizures.
• The therapeutic range is 5 to 15 mcg/mL, and adverse reactions are unlikely at doses less than 20 mcg/mL.
• Pregnancy safety not established but safe for use when lactating.
• Use caution in clients who have heart disease, hypertension, liver and kidney dysfunction, and diabetes mellitus, children and older adults.
• Caffeine increases CNS and cardiac adverse effects of theophylline.
  • Caffeine can increase theophylline levels, so clients should avoid caffeine.
• Phenobarbital, phenytoin, and rifampin decrease theophylline levels, requiring increased dosage.
• Cimetidine, ciprofloxacin, and other fluoroquinolone antibiotics increase theophylline levels, requiring decreased dosage.
• Nursing administration is oral, or IV for emergency only.
• Take as prescribed; if a dose is missed, the following dose should not be doubled.
• Sustained-release preparations should not be chewed or crushed and should be swallowed whole.
• Initial dose is based on age, weight, and other factors.
• Evaluate for long-term control of asthma
• Take as prescribed and do not double in the event of a missed dose.
• Do not chew or crush sustained-release preparations and swallow whole.
• Reduce or eliminate caffeine intake and encourage periodic lab tests of med levels.

Ipratropium – Inhaled anticholinergics (muscarinic antagonists)

• Blocks muscarinic receptors of bronchi, resulting in bronchodilation; works on the parasympathetic system.
• Relieve bronchospasms associated with COPD and allergen-induced and exercise-induced bronchospasm.
• Ipratropium is FDA-approved only for bronchospasms associated with COPD, though it is often used off-label for asthma and is part of evidence-based guidelines for asthma management.
• Complications include local anticholinergic effects like dry mouth and hoarseness; sip fluids or suck on sugar-free hard candies if these occur.
• Pregnancy/lactation safety has not been established.
• The ipratropium/albuterol combo is contraindicated in clients who have an allergy to soy or peanuts because the medication preparations can contain soy lecithin.
• Use cautiously in clients who have narrow-angle glaucoma and benign prostatic hyperplasia due to anticholinergic effects.
• The usual adult dosage is 2 puffs via inhaler or nebulizer.
• Maintain the prescribed time between puffs.
• Beta2 adrenergic agonists enhance the bronchodilation effects of inhaled anticholinergics; talk to the provider about adjusting the dosage of one med if taken concurrently.
• Effectiveness is evaluated by the control of bronchospasm in clients who have COPD and prevention of allergen-induced and exercise-induced bronchospasm.
• Client education includes sucking on hard candy or sipping water to avoid side effects.
• Wait at least 5 minutes between other inhaler meds.

Beclomethasone (inhaled), Prednisone (oral) - Glucocorticoids

• Prevent inflammations, suppress airway mucus production, and promote the responsiveness of beta2 receptors in the bronchial tree.
• Reduction in airway mucosa edema and does not provide immediate effects but rather promotes decreased frequency and severity of exacerbations and asthma attacks.
• Short-term IV agents are used for status asthmaticus.
• Inhaled agents (beclomethasone) are used for long-term prophylaxis of asthma.
• Beclomethasone decreases inflammation.
• Short-term oral therapy is used to treat manifestations following an acute asthma episode.
• Long-term oral therapy (prednisone) is used to treat chronic, severe asthma.
• Promote lung maturity and decrease respiratory distress in fetuses at risk for preterm birth.
• Beclomethasone can cause difficulty speaking, hoarseness, and candidiasis, so gargle with mouthwash or water after use.
• Prednisone, when used for >10 days, can cause the suppression of adrenal gland function and should monitor glucose levels and administer oral glucocorticoid on an alternate-day dosing schedule.
• Oral meds can cause bone loss, hyperglycemia and glycosuria, myopathy, peptic ulcer disease, infection, disturbances of fluid and electrolytes and increased appetite and trouble sleeping/insomnia.
  • Decrease oral if myopathy
  • administer with food if Peptic Ulcer
  • Report infections
  • fluid retention and edema from hypokalemia
• Pregnancy safety not established, and avoid chronic use when lactating.
• Contraindicated in clients who receive live virus vaccine and those who have systemic fungal infection, children, diabetes, hypertension, heart failure, peptic ulcer disease, osteoporosis, and/or kidney dysfunction.
• Concurrent use of potassium-depleting diuretics increases the risk of hypokalemia.
• Concurrent use of NSAIDs increases the risk of GI ulceration
• Concurrent use of glucocorticoids and hypoglycemic agents counteract the effects.
• Administer using an MDI device, DPI, or nebulizer.
• Glucocorticoid MDIs using chlorofluorocarbons as a propellant are being withdrawn from the market.
• The new devices using hydrofluoroalkane no longer require a spacer to increase drug delivery.
• Oral glucocorticoids are used short-term, for 3 to 10 days, following an acute asthma exacerbation.
• If the client is on long-term oral therapy, additional dosages of oral glucocorticoids are required in times of stress.
• Clients who discontinue oral glucocorticoid meds or switch from oral to inhaled agents require additional doses of oral or IV glucocorticoids during periods of stress.
• Evaluation for long-term control of asthma and resolution of acute exacerbation as demonstrated by the absence of shortness of breath, clear breath sounds, absence of wheezing, and return of respiratory rate to baseline.
• Inhaled glucocorticoids include budesonide, fluticasone, formoterol, and mometasone.
• IV glucocorticoids include hydrocortisone and methylprednisolone
• To prevent candidiasis, inhaled: use a spacer so less of the medication is deposited in the mouth and oropharynx. Rinse mouth and gargle after using the inhaler
• Oral medications can never be stopped abruptly to minimize the effects of impaired adrenal gland function; taper doses off.
• Increase diet of calcium and vitamin D and perform weight-bearing exercises daily to combat muscle and bone loss.
• Report weight gain, edema, and generalized weakness because it may indicate electrolyte imbalance that can be life-threatening.

Methylprednisolone

• Administered IV, and is used in emergent situations.

Montelukast – Leukotriene modifiers

• Leukotriene modifiers suppress the effects of leukotrienes, thereby reducing inflammation, bronchoconstriction, airway edema, and mucus production.
• It is used for long-term therapy of asthma in adults and children and to prevent exercise-induced bronchospasm and is used in children as young as 12 months of age.
• Complications include depression and suicidal ideation.
• Use cautiously in clients with liver dysfunction
• Montelukast used concurrently with phenytoin can inhibit the effects of montelukast.
• Give oral or chewable tablets and oral granules once daily in the evening (do not take again for another 24 hours) and take at least two hours before exercising
• Pregnancy decently safe but not safe when lactating.
• Evaluate for long term control of asthma.
• Educate clients and family to be aware of behavioral changes such as anxiety, agitation, insomnia, or irritability, which could be indicative of neuropsychiatric adverse effects.

Codeine

• Antitussive, suppress (chronic) nonproductive cough through depression of the CNS to increase cough threshold.
• Only take when needed on a short-term basis.

Dextromethorphan – Antitussive non-opioid

• Suppresses cough through its action on the CNS, although not an opioid, it is derived from opioids.
• Used for cough suppression and can reduce pain when combined with an opioid.
• Few adverse effects include mild nausea, dizziness, some potential for abuse, and sedation can occur.
• Safe to use when pregnant but use with caution when lactating.
• Can cause high fever when used within 2 weeks of MAOI antidepressants.
• Some formulations contain alcohol and/or sucrose and are available in capsules, lozenges (12 yrs +), liquids, and syrups.
• Evaluate for absence or decreased episodes of coughing

Guaifenesin – Expectorants

• Guaifenesin promotes increased cough production by increasing and thinning mucous secretions, reducing surface tension.
• Used in treating manifestations of colds, allergic or nonallergic rhinitis, or for cough caused by lower respiratory disorders.
• Complications include GI upset and drowsiness/dizziness, as well as allergic reactions or rashes.
• Safety not established when pregnant or lactating.
• Caution in clients who have asthma because guaifenesin can cause bronchospasm
• Advise clients who are breastfeeding to talk to their provider before taking.
• Depending on the formulation and med combinations, preparations containing guaifenesin might be contraindicated for children.
• Expectorants are contraindicated in clients who have a cough lasting more than one week, diabetes (sugar content), or clients receiving disulfiram (alcohol content).
• Available in tablets (should not be crushed) and capsules and report cough lasting longer than one week to the provider.
• Increase the client's fluid intake to help expectorant liquefy secretions and evaluated when cough is more productive.
• Chest congestion is decreased.
• Client education includes taking guaifenesin with a full glass of water and continue optimal fluid intake throughout therapy.
• Read OTC labels carefully to discover what meds have been combined in the preparation used.
• Guaifenesin is combined with other meds (antitussives, decongestants) as a liquid or syrup.

Acetylcysteine

• Mucolytic.
• It thins and enhances the flow of secretions in the respiratory passages.
• Used in clients who have acute and chronic pulmonary disorders exacerbated by large amounts of secretions and pts with cystic fibrosis.

Phenylephrine - Decongestant

• Sympathomimetic decongestants stimulate alpha1-adrenergic receptors, reducing inflammation of the nasal membranes.
• Treat allergic or nonallergic rhinitis by relieving nasal stuffiness and acts as a decongestant for clients who have sinusitis and the common cold
• Complications include Rebound congestion, CNS stimulation, Vasoconstriction -> hypertension
• Safety not established when pregnant or lactating.
• Contraindicated in clients who have closed-angle glaucoma.
• Use caution in pts with coronary artery disease, hypertension, cerebrovascular disease, and dysrhythmias
• Administer nasal drops in the lateral, head-low position and teach clients about proper use.
• Drops are preferred for children because they can be administered precisely, and toxicity can be prevented.
• Effective, it improves manifestations (relief of congestion, increased ease of breathing).
• Awareness of differences between topical and oral agents.
  • Topical agents are more effective, work faster, have shorter duration, and should not be used for longer than 3 to 5 days to avoid rebound congestion.
  • Oral agents are avoided in people with Vasoconstriction and CNS stimulation and Do not lead to rebound congestion
• Do not exceed the recommended doses

Diphenhydramine (1st gen), Loratadine (2nd Gen) - Antihistamines

• Antihistamine action is on the H1 receptors, which blocks histamine release in small blood vessels, capillaries, and nerves during allergic reactions.
• They relieve itching, sneezing, and rhinorrhea but do not relieve nasal congestion and first-generation antihistamines produce anticholinergic effects and drowsiness.
• Used for mild allergic reactions(seasonal allergic rhinitis, urticaria, mild transfusion reaction) , anaphylaxis , motion sickness, and insomnia
• Often used in combination with sympatholytic to provide a nasal decongestant effect.
• Complications include sedation and Anti-cholinergic effects, and respiratory depression
• In CNS depressants/alcohol cause additive CNS depression.
• Pregnancy: Loratadine safety not established
• Lactating: Loratadine is considered safe
• Use caution in children and adults
• Use caution in clients with asthma, seizure disorder, cardiac arrest, renal disease, urinary retention, open-angle glaucoma, hypertension, and prostate hypertrophy
• IF taking a 1st gen, be aware of side effects and evaluate for Improvement of allergic reaction (absence of rhinitis, urticaria)
• Improvement of allergic reaction (absence of rhinitis, urticaria)
• Relief of motion sickness (decreased nausea and vomiting)