Module 6 Respiratory Study Guide Fall 2024 PDF

Module 6: Respiratory Study Guide Module 6 Unit A Guiding Questions © What is the difference between H1RAs and H2RAs? o H1RAs: bind selectively to H1 receptor and therefore block the actions of histamines at these sites Low receptor specificity and interact with...

Module 6: Respiratory Study Guide Module 6 Unit A Guiding Questions © What is the difference between H1RAs and H2RAs? o H1RAs: bind selectively to H1 receptor and therefore block the actions of histamines at these sites Low receptor specificity and interact with both peripheral and central histamine receptors and readily cross the blood brain barrier o H2RAs: selectively block H2 receptor sites to effectively reduce the secretion of gastric acid Useful for the tx of gastric ulcers and GERD (ex: cimetidine, famotidine, nizatidine, and ranitidine) © Which histamine receptor antagonist has generations? What is the difference between the generations? o H1 receptor antagonists o 1st Generation: crosses the blood brain barrier causing sedative effects o 2nd Generation: do not cross the blood brain barrier (if it does it is in negligible amounts) so do not cause sedative effects § exception: Cetirizine/Zyrtec (long half-life and causes sedation) © What are anticholinergic side effects? Who should avoid drugs with anticholinergic side effects? o sinus tachycardia, dry skin, dry mucous membranes, dilated pupils, constipation, ileus, urinary retention, and agitated delirium o AVOID: elderly, glaucoma, BPH © Which drugs in this unit have anticholinergic side effects? o 1st generation antihistamines: diphenhydramine (Benadryl) o Oral decongestants: pseudoephedrine (Sudafed) o 2nd generation antihistamines: cetirizine (Zyrtec), fexofenadine (Allegra) © What is the recommendation about combining cough and cold medicine products? Why? o choose single agent products lessens the risk of overdose because each ingredient can be dosed by age and weight avoids unnecessary meds much easier to determine allergen © What is the potential side effect of nasal decongestants? What patient teaching is indicated with these products? o sneezing, nasal dryness, and rebound nasal congestion (rhinitis medicamentosa) o not recommended for more than 3 days in a row for risk of rebound nasal congestion © Which patients should avoid oral decongestants? o hypertension, arrythmias, and patients who sleeping problems © When is drug therapy indicated for cough? When should it be avoided? Why? o cough suppression should be used only when the pt has a nonproductive cough or for rest at night o avoid opioids in pts with a hx of substance abuse or COPD; OTC CCMs should not be used in those under 2 © What is the difference between antitussive and expectorants? When should each be used? o antitussive: cough suppressant for a nonproductive cough o expectorant: thins secretions to make it easier to clear a productive cough © Which drugs in this unit are controllers and relievers? o controllers: keep them “at bay”; prevent symptoms by decreasing inflammatory mediators intranasal corticosteroids: fluticasone propionate (Flonase) leukotriene modifiers: Montelukast (Singulair) o relievers: relieves acute symptoms by blocking the action of histamine 2nd generation oral antihistamines: loratadine (Claritin) intranasal antihistamines: azelastine (Astelin) ocular antihistamines: olopatadine (Patanol) © What are the benefits and potential side effects of nasal antihistamines? o benefits: rapid onset, reduce hyperreactivity of the airways o side effects: sedation (less than oral), bitter taste © How and why are Leukotriene modifiers used in the treatment of allergies? o work by decreasing the smooth muscle contraction of the vessels, decreasing blood vessel permeability, and decreasing the inflammatory response caused by leukotrienes released from the mast cells and eosinophils o most effective when taken at bedtime © What is the Black Box Warning for Leukotriene modifiers? o Montelukast (Singulair) has a BBW for the potential risk of agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal ideation and behavior (including suicide), and tremor. © What treatment options are available for cough, cold, or allergies during pregnancy or lactation? o 1st line: rest, hydration, a diet high in fruits and vegetables, and saline nasal spray or washes o intranasal corticosteroids: the most effective agent for allergic rhinitis and 1st line med tx for pregnancy Budesonide (Rhinocort): the only corticosteroid that is category B Beclomethasone, Flonase, Nasonex: category C, safety in lactation is unknown § poor oral bioavailability and rapid first-pass hepatic uptake will likely result in low to insignificant amounts of infant exposure Oxymetazoline (Afrin)- may reduce milk supply, Xylometazoline (Novorin, Sinutab), and Naphazoline are category C and likely unsafe in lactation. Should be avoided. o antihistamines: chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), and doxylamine (Unisom) do not have teratogenic effects begin with chlorpheniramine: high safety profile and been on the market the longest in small doses, chlorpheniramine and diphenhydramine are safe for breastfeeding § large doses or prolonged use may cause infant sedation and a reduction in milk supply (especially when combined with Sudafed) start with 2nd generation antihistamines in breastfeeding because they are non-sedating § The British Society for Allergy and Clinical Immunology recommends cetirizine (Zyrtec) at the lowest dose for the shortest period of time as the 1st line antihistamine with lactation Doxylamine is known for its safety in pregnancy § use with breastfeeding is possible unsafe § likely passes through the breast milk and can cause sedation and paradoxical CNS stimulation § use with caution especially for infants with respiratory disorders o antitussives: codeine, guaifenesin, dextromethorphan are all category C Codeine has mixed information about fetal effects § time dosages and feedings for the least amount of exposure possible § monitor weight gain and warning signs of sedation: drowsiness, breathing difficulties, and decreased interest in feeding § AAP considers this to compatible with breastfeeding Guaifenesin in the first trimester may be associated with birth defects § infant exposure from the maternal intake is likely much smaller than when given directly  § effectiveness is questionable so it’s best to avoid the medication and any possible risks Dextromethorphan doesn’t have any studies available on its presence in milk or its effects on infants § can be given to infants at 1 month § infant exposure from the maternal intake is likely much smaller than when given directly § effectiveness is questionable so it’s best to avoid the medication and any possible risks o decongestants: Pseudoephedrine (Sudafed), Oxymetazoline (Afrin), Phenylephrine (Neo-Synephrine, Sudafed PE, AH-CHEW D, Rhinall) not considered 1st line for rhinitis in pregnancy may be used for acute congestive episodes if non-pharm methods are ineffective start with nasal instead of oral route Pseudoephedrine (Sudafed) is a category C drug and although it hasn’t been confirmed, is associated with an increased risk of gastroschisis with 1st trimester use but safe in 2nd and 3rd § likely reaches the breast milk and causes occasional irritability and decr production Oxymetazoline (Afrin) is a category C drug and should not be used more than 3 days § risk for rebound congestion Phenylephrine has mixed reviews on safety § some say it may cause fetal hypoxia § in healthy pregnancy with a normal uteroplacental sufficiency short term use in likely safe consider the use of nasal before oral decongestants Afrin and Sudafed use during lactation is unknown Module 6 Unit B Guiding Questions © What are the three methods of inhaled medication delivery? What are the pros and cons of each? o MDIs: small hand-held device that delivers a measured dose of the drug with each actuation Requires hand breath coordination Even with optimal use, only ~10% of the drug reaches the lungs o DPIs: used to deliver drugs in the form of a dry, micronized powder, directly to the lungs Do not require hand breath coordination Deliver more drugs to the lungs, ~20% o Nebulizers: small machine used to convert a drug solution into a mist that is much finer than those produced by inhalers Less drug deposition on the oropharynx and increased delivery to the lungs Hand breath coordination is not a concern © Classify drugs in the module into either asthma controllers or asthma relievers. o Controllers: prevent and control symptoms by decreasing airway inflammation controlling symptoms, and reducing future risks ICS, leukotriene modifiers, and or the inhaled corticosteroids combined with the LABAs o Relievers: provided to all patients with asthma for “as needed relief” from the acute, breakthrough symptoms of asthma or from the symptoms of an asthma exacerbation SABAs, SAMAs, and oral corticosteroids © Why and how are steroids used in the treatment of asthma? o Oral: typically given in short “bursts” in exacerbations Gives coverage until the inhaled corticosteroid can kick-in o Inhaled: mainstay of maintenance therapy o Decrease inflammation, provide bronchodilation, and decrease airway mucus production © Why are the long-acting beta2 agonists used only in combination with an inhaled corticosteroid, not as monotherapy? o Use as monotherapy in asthma leads to greater risk of asthma-related deaths They are used to achieve sustained bronchodilation and are classified as maintenance drugs and do not provide “quick” relief from an acute attack © Can albuterol prolong QT? o Yes © Why must Beta 2 agonist be used with caution in patients with diabetes mellitus? o May increase serum glucose levels and aggravate preexisting diabetes and ketoacidosis © What are the potential side effects of oral glucocorticoids? o Headaches, dizziness, trouble sleeping, inappropriate happiness, severe mood swings, hyperglycemia, and bone loss © What is hypothalamic-pituitary-adrenal axis suppression, and how is it avoided? o Leads to an adrenal crisis o Withdrawal or discontinuation should be done slowly and carefully to avoid this reaction © Do inhaled corticosteroids pose the same risk as oral steroids? o Yes, but at a much lower rate. © What patient teaching is required for inhaled corticosteroids? o Bone loss is a risk with prolonged high dose inhaled steroids Fight potential loss with calcium and vit D supplementation, weight-bearing exercise, and not smoking o Can cause increased intraocular patients so should be used with caution in pts with cataracts or glaucoma Consider routine eye exams o Gradually taper off medication to avoid withdrawal symptoms o Rinse mouth with water after each use to help prevent local oropharyngeal Candida infections © What concerns does the use of glucocorticoids in the treatment of asthma pose to children? o Reduction in growth velocity in the first year of using ICS Returns to normal and this delay in the first year does not impact height as an adult © What is the role of mast cell stabilizers in the treatment of asthma? o Anti-inflammatory agents that prevent bronchoconstriction They block the release of histamine and SRS-A (the slow-reacting substance of anaphylaxis) from sensitized mast cells © Identify the differences and roles of SABAs, LABAs, SAMAs, and LAMAs in asthma treatment? o SABAs: “quick” reliever medication o LABAs: used to achieve sustained bronchodilation and are classified as maintenance drugs o SAMAs: “quick” acting; blocks the binding of acetylcholine to the muscarinic receptors, causing bronchodilation, decreased mucus, and less airway inflammation o LAMAs: long acting; blocks the binding of acetylcholine to the muscarinic receptors, causing bronchodilation, decreased mucus, and less airway inflammation © What does a narrow therapeutic index mean? o Higher risk for toxicity because the therapeutic range is very narrow © How are Monoclonal Antibodies used in the treatment of asthma? What are the risks associated with monoclonal antibodies? o Anti-IgE antibody: works by limiting the ability of allergens to trigger the release of histamine, leukotrienes, and other inflammatory mediators BBW: Omalizumab- anaphylaxis has occurred as early as after the first dose but also beyond 1 year after being administered regularly o Interleukin-5 receptor antagonists: works by decreasing the production of eosinophils Can lead to immunogenicity, anaphylaxis, malignancy, and neoplasms  BBW: anaphylaxis o Interleukin-4 receptor alpha antagonists: inhibits IL4 cytokine-induced inflammatory responses while also reducing other inflammatory mediators such as IL-13 Hypersensitivity reactions including urticaria and rash can occur In rare cases patients have serious systemic eosinophilia § conjunctivitis and keratitis have been reported o Risk for immune-type reactions Vasculitis, eosinophilia, and hypersensitive reactions such as urticaria and conjunctivitis © What drugs may be used to treat asthma in pregnancy and lactation? o Albuterol is the preferred SABA when asthma tx is needed during pregnancy o For those with mild, intermittent asthma, no controller therapy is indicated Budesonide is the preferred inhaled corticosteroid for use during pregnancy o Most asthma medications are considered safe during lactation Albuterol and budesonide are considered safe due to low bioavailability and maternal serum levels Theophylline may cause hyperstimulation and disrupted sleep § May be breastfeed before medication admin and abstain for 2-4 hours after © What vaccines are recommended for patients with COPD? o Flu, pneumococcal pneumonia, Tdap, Zoster © Do you know the differences and roles of SABAs, LABAs, SAMAs, and LAMAs in COPD treatment? o SABAs & SAMAs: should not be used regularly but rather to relieve acute symptoms More effective together than taking them alone o LABAs & LAMAs: regular treatment with a long-acting bronchodilator is recommended in those with moderate to severe symptoms © What is the role of oral and inhaled corticosteroids in the treatment of COPD? o Inhaled: decrease inflammation; especially in those with high eosinophilia counts or in those that have an asthma component o Oral: used for treating acute exacerbations in hospitalized patients or during emergent situations, as they have been shown to reduce treatment failure, the rate of relapse, and they can improve lung function and breathlessness © Which patients with COPD should receive Phosphodiesterase-4 (PDE4) enzyme inhibitors? Are there any special concerns? o Can be added in patients with chronic bronchitis or those on maximal inhaled therapy  o Adverse effects: diarrhea, nausea, reduced appetite, weight loss, abdominal pain, sleep disturbances, hepatotoxicity and headaches o Neuropsychiatric effects (anxiety, depression, insomnia) Rarely: suicidal behavior/ideation and completed suicide reported © What is the role of antibiotics and mucolytics in the treatment of COPD? o Antibiotics: more recent studies have shown that regular use may reduce exacerbation rates (likely because some antibiotics act as anti-inflammatory agents as well) o Mucolytics: in patients not receiving ICS, regular treatment can reduce exacerbations and improve health status Module 6 Unit C Guiding questions © What are the risks and benefits of the different forms of NRT? o Gum: OTC Adverse effects: hypersalivation, hiccups, dyspepsia, and mouth and jaw soreness Advantages: serves as oral substitute for tobacco, it can delay/lessen weight gain, it has an easy titration, and it can be used with other agents Disadvantages: needs to be dosed frequently, it might be problematic for patients with significant dental work or jar issues, and it might not be acceptable or desirable to chew gum in social situations o Lozenge: OTC Adverse effects: nausea, hiccups, cough, and insomnia Advantages: serves as oral substitute for tobacco, it can delay/lessen weight gain, it has an easy titration, and it can be used with other agents Disadvantages: the need for frequent dosing which can compromise its adherence § Can lead to stomach upset, nausea, and loose stools o Transdermal patch: OTC Adverse effects: local skin reactions (erythema, pruritic, burning), headaches, and sleep disturbances (if the patch is on at night) Advantages: once-daily dosing, can be used in combination with other agents as it delivers consistent nicotine levels over 24 hours; works well with bupropion (Zyban) Disadvantages: when used as monotherapy, it cannot be titrated to acutely manage withdrawal symptoms o Nasal Spray: requires a prescription Adverse effects: nasal and/or throat irritation (hot, peppery, or burning), rhinitis, tearing, sneezing, cough, and headache  Advantages: it can be titrated to rapidly manage withdrawal symptoms and it can be used combination with other agents Disadvantages: the need for frequents dosing can compromise adherence, nasal administration might not be acceptable or desirable for some patients, it can cause nasal irritation, and it is not recommended for use by patients with chronic nasal disorders or severe reactive airway disease © How does varenicline work in the treatment of smoking cessation? o Prevents nicotine stimulation of the dopaminergic system associated with nicotine addiction Binds to the 5-HT3 receptor (significance not determined) with moderate affinity § Decrease in craving and withdrawal symptoms © What are the potential serious side effects/adverse effects of Varenicline? o May enhance the adverse or even toxic effects of alcohol Alcohol tolerance may be decreased o Increased risk for neuropsychiatric adverse effects Hostility, agitation, anger, depression, and suicidal feelings o May enhance the adverse effects of nicotine o May cause CNS depression May impair physical or mental abilities Lowers seizure threshold o Potential increased risk of CV events (MI) Due to effects on nicotine acetylcholine receptors which may impact CV function © How does Bupropion SR (Zyban) work in treating smoking cessation? o the primary mechanism of action is thought to be dopaminergic and/or noradrenergic inhibits neuronal uptake of norepinephrine and dopamine (aminoketone) © What are the potential serious side effects/Adverse effects of Bupropion SR (Zyban)? o Suicidal thoughts, mood changes, hallucinations, panic, depression, restlessness, insomnia, anxiety, and cognitive impairment BBW: suicidal thoughts and behavior in children, adolescents, and young adults © What are the options for smoking cessation during pregnancy? o Bupropion and its metabolites cross the placenta o Data specific to CV malformations is inconsistent Additional information is needed to show that bupropion is effective for treating smoking cessation in pregnancy (weigh risk vs. benefits)