Term
When treating a patient with an acute asthma exacerbation, which medications
would you consider and how would you dose them? |
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Definition
| short acting beta 2 agonist. Examples Albuterol and Xopenex. every 4-6 hours until the xacerbation resolves, then they can return to PRN use. oral steroids dosed for 3-5 days depending on the severity |
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Term
| According to the NHLBI guidelines, which medications are appropriate for the preventive treatment of persistent asthma? |
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Definition
0-4yo-inhaled corticosteroids Flovent or Budesonide nebulized with possible addition montelukast and/cromolyn. Corticosteroid dose depends on step, always start with higher
5-11yr old-inhaled corticosteroids and long acting inhaled beta 2 agonists,consider montelukast, cromolyn. Salmeterol is indicated for those children 4 years and up. Formoterol isindicted in those 5 yrs and up.
12 and up-inhaled corticosteroid (dose depends on severity), long acting beta 2 agonist, leukotriene modifier, consider omalizumab if pts have allergies and severe symptoms with referral to allergist. |
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Term
| Where are the beta 1 receptors located? What adverse effects does stimulation of the beta 1 receptors cause? |
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Definition
Beta 1 receptors are located in the heart. If stimulated, as with an agonist,
you may to see hypertension, tachycardia, palpitations, tremors and irritability. |
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Term
According to the clinical guidelines, where do the leukotriene modifiers fit into
the treatment plan of asthma? |
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Definition
| They can be used as an alternative treatment in persistent asthma. Montelukast can also be used inpatients that have an allergic component to their asthma as well and can be used in children. |
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Term
List the potential drug interactions that can occur with the leukotriene
modifiers. |
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Definition
Zafirlukast inhibits CYP450 enzymes therefore can increase levels of
drugs that are metabolized by the CYP450 enzyme system |
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Term
Theophylline is metabolized by CYP1A2 enzyme system. What would you
expect to see regarding the drug levels if theophylline is given with an
inducer? Inhibitor? |
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Definition
If theophylline is given with a CYP1A2 inducer, you will see a decrease in
the plasma drug levels of theophylline. There will be an increase in the
metabolism of theophylline, decreasing blood levels. If theophylline is
given with an inhibitor, this will slow the metabolism of theophylline and
you will see a rise in drug levels of theophylline. |
|
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Term
| What adverse effects would you expect to see with theophylline? |
|
Definition
Because it is chemically similar to caffeine, similar adverse effects may be
seen. Those are restlessness, anxiety, dizziness, headaches, tachycardia,
palpitations, diuresis. |
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Term
When would you consider the Anti-IgE Monoclonal Antibody Omalizumab
(Xolair®) in treating asthma? |
|
Definition
This is a new class of asthma agents. It is indicated for the treatment of
moderate to severe persistent asthma in those patients with a positive skin
test to an allergen and in those whose symptoms are uncontrolled by inhaled
steroids. This class of medications works by inhibiting the binding of IgE on
the surface of mast cells and basophils. It inhibits the release of mediators of
the allergic response. This drug is indicated for those patients >12 yrs old
and is not indicated for an acute attack. Not highly recommended unless
there is collaboration with an allergy specialist. It is very expensive. |
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Term
| What is the mechanism of action of the inhaled and intranasal steroids? |
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Definition
Inhaled-inhibit the IgE and mast cell mediated migration of inflammatory
cells to tissues-decreasing inflammation in the airways.
Intranasal work at this site of the nasal mucosa doing the same therefore
decreasing the inflammation in the nasal mucosa. Both formulations of steroids are not indicated for prn or acute attacks. They are used in managing symptoms and prevention of flare ups of allergic rhinitis and asthma |
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Term
When treating allergic rhinitis with intranasal steroids, what would you need
to tell your patient regarding the effects of the medication? |
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Definition
The effects of the medications may take several days to a week to show
effectiveness. Do not use as a PRN medication. |
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Term
What are the advantages and disadvantages of the mast cell stabilizers?
Where in the treatment of asthma would you consider this class of
medications? |
|
Definition
They are anti-inflammatory agents that block the release of histamine and
prevent the release of leukotrienes. They inhibit the antigen induced
broncospasm. Work well for exercise or allergen induced asthma and
treatment of allergic rhinitis. They are available OTC. Cromolyn approved
for use in children.
Disadvantages-require frequent dosing, inhaled formulation has a poor
taste. |
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Term
With which condition are the anticholinergics considered a first line agent?
What are your medication options with this condition? |
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Definition
COPD-the anticholinergics cause a decrease in the contractility of the
smooth muscle in the lungs causing vasodilation. May also be used in
combination with the beta 2 agonists in an exacerbation state. Also
available is the long acting anticholinergics, Spiriva. IT only requires a
once a day dosing schedule. |
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Term
Decongestants are sympathomimetics. What adverse reactions may occur
because of this mechanism of action? With what conditions are these
medications contraindicated for? |
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Definition
Also called adrenergic agonists, sympathomimetics directly and indirectly
stimulate the sympathetic nervous system. Exerts effect on alpha 1 and
alpha 2 receptors. This causes an increase in norepinephrine release
causing restlessness, insomnia, jitteriness, hypertension, and tachycardia.
Because of its mechanism of action, it is contraindicated for use in
patients with hypertension, CAD, pts with arrhythmias, closed angle
glaucoma. |
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Term
| What precautions will you tell patients regarding use of decongestants and antihistamines? Summarize prescribing recommendations for children and those patients with HTN. |
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Definition
| Antitussives (Dextromethorphan), nasal decongestants (pseudoephedrine, Phenylephrine), antihistamines (diphenhydramine, chlorpheniramine, brompheniramine) and the combination of the above have been removed from the market for children under the age of 2. Depending on the medication, these are used with caution in children ages 4 and up. Educate parents on viral infections and the use of nonpharmacological measures such as nasal saline drops, humidifiers. For those patients with HTN, oral decongestants are not recommended. Intranasal formulations can be used for max of 3 days. This seems to have less of an effect on cardiac. Antihistamines can be used. |
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Term
List the advantages and disadvantages of the first and second-generation
antihistamines. |
|
Definition
First generation
Advantages-most available OTC, inexpensive, because they penetrate CNS may induce sedation, helps with those with difficulty sleeping (during times of illness or allergy symptoms)
Disadvantages-more anticholinergic activity causing increased side effects; cause sedation-many cannot take during the day.
Second generation-
Advantages-do not readily penetrate CNS causing less sedation, less anticholinergic effect causing less side effects
Disadvantages-expensive, not available OTC (except Claritin® and Zyrtec®) |
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Term
| A 55 year old female with history of asthma having an asthma exacerbation |
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Definition
| The drug of choice for this patient with asthma having an exacerbation is a short acting beta 2 agonist such as albuterol or xopenex. Also, a short burst of oral corticosteroids would be needed. If she is otherwise healthy, prednisone 40mg daily x 5 days with the albuterol every 4 hours would be appropriate. |
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Term
| 13 year old boy with recurrent asthma exacerbations (currently stable), needs maintenance therapy. |
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Definition
| If he is only using a short acting beta 2 agonist currently, add an inhaled corticosteroid daily. Flovent would be an appropriate choice here. If this is not effective alone, can use long acting beta 2 agonist such as salmeterol. |
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Term
| A 67 year old smoker with Stage II COPD not responding to use of short acting beta 2 agonist and ipratropium (Combivent) use 4 times per day. |
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Definition
| He would need an addition of an inhaled corticosteroid first. If not effective would possibly add a long acting beta 2 agonist such as salmeterol or formoterol. |
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Term
| A 26 year old female with allergic rhinitis with symptoms of nasal congestion and clear nasal discharge. |
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Definition
| Appropriate therapy would be the addition of an intranasal corticosteroid such as fluticisone or Flonase. This would alleviate nasal congestion and discharge. If this is not effective alone, can add the inhaled agent Astelin. |
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