PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
DRUGS FOR LOWER RESPIRATORY DISORDERS
LOWER RESPIRATORY SYTEM


Lower Respiratory (Trachea, bronchi, bronchioles, alveoli, and alveolar-capillary membrane)Gas exchange
Gas-exchange airways- composed of acinus (bronchi, bronchioles, alveoli)
o Any problem in tissues interfere with oxygenation.
Any distensible organ has compliance.
LUNG COMPLIANCE/ EXPANSIBILITY/ DISTENSIBILITY




Lung compliance (Expand)- lung volume based on the unit of the pressure in the alveoli
o Lung volume is determined by lung’s ability to stretch
o Ability of your lungs to expand
o Opposite of surface tension (collapse)
o Opposite to elasticity (recoil)
o Directly proportional to lung volume and inversely proportional to the pressure
Factors that affect the lung compliance:
o Connective tissues (collagen and elastin)
o Surface tension in the alveoli
High lung compliance for those who have COPD; Low lung compliance for restrictive diseases
2 Major Categories of Lower Respiratory Tract Disorder
o COPD- caused by airway obstruction with increased airway resistance of airflow to lung
tissues because it has stretched so much
 Emphysema, chronic bronchitis, bronchiectasis, frequent and chronic asthma
causes irreversible tissue lung damage
 CAL (Chronic Airflow Limitation)- Emphysema, chronic bronchitis,
bronchiectasis, and asthma
o
1|Page
Restrictive Pulmonary Disease- decrease of total lung capacity due to fluid accumulation
or loss of elasticity of the lungs
 Pulmonary edema
 Pulmonary fibrosis
 Pneumonitis
 Lung tumors
 Thoracic deformities (i.e., scoliosis)
 Disorders affecting thoracic muscular wall such as myasthenia gravis
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
COPD (i.e., Emphysema)
Restrictive disorders (Cystic Fibrosis)
Lung expand
Compliance
Expansibility
Lung Collapse
Recoil
Elasticity (either or loss)
Distensibility
Surfactant
Elastase
Emphysema
I can get the air in but I cannot get the air out.
Elastic recoil
Surface tension
Elastin
Fibrosis
I cannot get the air in but I can get the air out.
Obstructed from exhaling
Restricted from filling
CHRONIC OBSTUCTIVE PULMONARY DISORDER





Cigarette smoking accounts as the common risk factor for COPD. According to World Health
Organization, Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of
death worldwide, causing 3.23 million deaths in 2019. And, over 80% of these deaths occurred in
low- and middle-income countries.
Asthma- either reversible or irreversible depending on the case; it occurs in two ways;
o Inflammation- it obstructs lumen in the inside
o Airway hyperresponsiveness that leads to bronchoconstriction
Chronic bronchitis
o Progressive lung disease caused by smoking or lung infection
o Inflammation and excessive mucous secretion
o When alveolar sac is damaged, this may lead to hypercapnia and hypoxemia that will
eventually become respiratory acidosis if not treated
o Rhonchi may be heard
Bronchiectasis
o Abnormal dilation of the bronchi and bronchioles secondary to frequent infection and
inflammation
Emphysema
o Progressive lung disease caused by
 Atmospheric contaminants
 Cigarette smoking
 Lack of alpha1-antitrypsin- it inhibits the proteolytic enzymes (released by the
bacteria pr phagocytic cells) that causes destruction of the alveoli.
 When the terminal bronchioles were plugged with mucus it decreases the fibers
and elastin which is used for the recoil. Alveolar just expands along with other
alveoli until it become destroyed. The overexpanded alveoli have trapped air that
causes inadequate gas exchange.
2|Page
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Bronchodilator drugs







Sympathomimetics agents or adrenoreceptor agents
Methylxanthines
Leukotriene antagonists
Glucocorticoids
Cromolyn
Anticholinergic
Mucolytics
SYMPATHOMIMETIC DRUGS
Sympathomimetics agents or adrenoreceptor agents are best delivered by inhalation because it causes
greatest local effect on airway smooth muscle with least systemic toxicity.

Drugs that mimic actions of epinephrine and norepinephrine
o Different modes;
DIRECT
INDIRECT
Epinephrine
Actions are dependent to the release of endogenous
catecholamines
Norepinephrine
Both causes activation of adrenoreceptors
o Two principal receptors
Alpha
Beta
Smooth muscle contraction
Smooth muscle relaxation
Alpha
Beta
Alpha 1
Alpha 2
Equal affinity Equal
affinity
for
epinephrine
epinephrine
norepinephrine
and
norepinephrine
 Indirect mode, two mechanisms
Beta 1
Beta 2
for Equal affinity for Higher affinity for epinephrine
and epinephrine and and norepinephrine
norepinephrine
Displacement of stored catecholamines from the adrenergic nerve ending




 Amphetamine and tyramine
o Inhibition reuptake of catecholamines already released
 Cocaine and Tricyclic antidepressants
Relaxes airway smooth muscle and inhibits the release of broncho constricting mediators from mast
cells
Prevents mast cell degranulation
Inhibit microvascular leakage and increase mucociliary transport by increasing ciliary activity
Beta agonists stimulate the adenylyl cyclase that increases intracellular cAMP that induces
bronchodilation
3|Page
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA




Directly relax airway smooth muscle
When beta2 receptors stimulated, relaxation of airway smooth muscles, inhibition of mediator
release, tachycardia and skeletal tremor may follow as its side effects
It includes
o Epinephrine
o Ephedrine
o Isoproterenol
o Albuterol
o Beta2-selective agents
 Isoproterenol
 Isoetharine
 Metaproterenol
 Terbutaline
 Albuterol (salbutamol)
 Salmeterol
Epinephrine and isoproterenol cause increase of rate and force in cardiac contraction (B1 receptors)
and they are reserved for special situations
DRUGS INCLUDED



Epinephrine
o Effective and rapidly acting bronchodilator
o Injected or inhaled as a micro aerosol from a pressurized cannister.
o Bronchodilation achieved after 15 minutes and lasts for 60-90 minutes
o Stimulates Alpha and Beta1 and 2 receptors
o Administered during emergency situations to restore circulation and increase the patency
of airway
o Adverse effects
 Tachycardia
 Arrhythmia
 Worsening angina pectoris
o used in treating the acute vasodilation, shock, bronchospasms of anaphylaxis
Ephedrine
o It has a longer duration compared to epinephrine
o Lower potency
Isopterenol
o Potent bronchodilator
o It effects after 5 minutes when inhaled as a micro aerosol from a pressurized canister and
lasts for 60-90 minutes.
o Adverse effect is cardiac arrythmias that is why it is now rarely used in asthma
Beta2 Selective Drugs
4|Page
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA






Contains larger substitution on the amino group and in the position amino group and in the position
of the hydroxyl groups on the aromatic ring
o Albuterol
o Terbutaline
o Metaproterenol
o Pirbuterol
metered-dose inhalers
Bronchodilation is achieved 15-30 minutes and lasts 3-4 hours
Albuterol and terbutaline are available in tablet form. The PO administration has no advantage over
the inhaled treatment of its effect
only terbutaline is available in subcutaneous injection (0.25mg)
Salmeterol and formoterol- new generations of long-acting B2 selective agonists; both drugs are
potent and have longer duration of 12 hours due to its high lipid solubility; interacts with inhaled
corticosteroids to improve asthma control; Not recommended as the sole therapy
PROTOTYPE DRUG: METAPROTERENOL


Some beta1 agent are affected but primarily used as beta2 agent.
PO or Inhalation
Drug class
Pharmacokinetics
Pharmacodynamics
Bronchodilator
A:
PO;
absorbed
PO
Adrenergic
beta2 and some
beta1
well
Onset: 15-30 mins
D: Unknown
Peak: 1h
Therapeutic
effects
The drug treats
bronchospasm,
asthma;
Promotes
bronchodilation
Dosage
Contraindication
Interactions
A/C: >9 y: PO:
20 mg q6-8h
Hypersensitivity
Cardiac
dysrhythmias
Narrow-angle
glaucoma
Cardiac disease
Hypertension
Increased action
with
other
sympathomimetic
drugs
Decrease action
with beta blockers
Decreased sodium
potassium
Older adults 10
mg q6-8h
M: Unknown
Alupent
Duration: 4h
E: Urine
Category C
C: 6-9 y; 10 mg
q6-8h
SubQ
Onset: 1-5 mins
Peak: 1h
Duration: 3-4 hrs
5|Page
A/C: >12y: MDI
2-3 inhal as
single dose; wait
2 mins before
second dose, if
necessary; use
only q3-4h to
max: 12 inhal/d
Side effects
Nervousness
Tremors
Restlessness
Insomnia
Headache
Nausea
Vomiting
Hyperglycemia
Muscle cramping in
extremities
Adverse Reactions
Tachycardia
Palpitation
hypertension
Cardiac
dysrhythmias
Cardiac
arrest
Paradoxical
bronchoconstriction
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Mechanism of Action:

Relaxation of smooth muscle of bronchi due to increase of cAMP
Nursing Considerations:


Assess lung sounds, pulse, and blood pressure before administration and during peak of medication;
observe patient for wheezing after administration, if this occurs, call physician; monitor heart rate,
respiratory rate, blood pressure, and arterial or capillary blood gases if applicable
Do not use solutions for nebulization if they are brown or contain a precipitate; before using, the
inhaler must be shaken well
PARASYMPATHOLYTICS DRUGS
Anticholinergics


Also known as muscarinic antagonists
blocks muscarinic actions, thus, causing inhibition of muscarinic functions.
Muscarinic Receptors



These receptors are activated by the ligand acetylcholine
Differs in function as ionotropic ligand-gated and G-protein coupled receptors
Functions within both the central and peripheral nervous system, as well as the neuromuscular
junction.
Muscarinic Receptor
Location
Effect
M1, M4, M5
Primarily found in the cerebral cortex,
gastric, and salivary glands
Affects cognitive process as
well as dry mouth
M2
Located in the smooth muscle and
cardiac tissues
Increases heart rate
6|Page
Blocked SA and AV nodes
affects heart rate (may lead to
tachyarrhythmia)
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
M3
Also present in the smooth muscles,
GI Tract
Gastric motility, Prolonged
gastric emptying, and
lengthen intestinal transit
time.
Urinary tract
Decrease in bladder
contraction
Airway
Bronchodilation
Decrease bronchial secretions
Eye
Mydriasis- narrowing of the
iridocorneal angle
Impaired accommodation
(abnormalities of the pupil)
Blood Pressure
minimal effect on vascular
tone and BP.
Exocrine glands (gastric, and salivary
glands)
7|Page
Decreases secretions.
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
fig. 1.1,
fig. 1.2
Figures 1.1 and 1.2 illustrate how the drug takes effect in producing bronchodilation in our smooth
muscles. For the figure 1.1, it indicates a picture of the axon terminals (nerve ending) connected
to our smooth muscles. Normally, these axon terminals produce acetylcholine (ACh) that then
attaches/binds to our sodium-ion channels. The binding of the ACh and the ligand-gated channels,
shown in figure 1.2, results in its opening allowing sodium ions to pass through triggering a
muscular action potential. This action potential caused by the sodium ions first travels through the
surface of the sarcolemma. After the sarcolemma, it travels along the T Tubules that penetrate in
the fiber allowing the release of calcium from the sarcoplasmic reticulum that results in muscle
constriction.
8|Page
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Action Potential > Release of ACh > ACh binding > Sodium ion passess through > Triggers
Action Potential > Penetrate the fiber > Release of Calcium ions > Muscle Constriction
How does the “Anti” work?
First, is the Nondepolarizing Agents
● Basically, these nondepolarizing agents replace the function of the Ach.
○ So, it binds to the receptors but does not induce ion channel opening.
○ As a result, it inhibits sodium ions to enter that essentially leads to an effective
prevention for muscle contraction
● These agents are not absorbed very well in the GI tract (IV route is essential)
Second, is the Depolarizing Agents
● ACh antagonist that mimics the action of the ACh
○ first, the depolarizing agents attach to the channels that allows sodium to pass
through the channel
○ But these agents are acetylcholinesterase inhibitors.
In short, they block the sodium-ion channels or the muscarinic receptors.
ANTICHOLINERGIC DRUGS
Chemical characteristics
Drug
Quaternary ammonium
Ipratropium
derivatives (hydrophilic, poor
bioavailability and CNS
penetration)
Brand names:
- Atrovent
- Combivent
- Ipravent
Dosage
Bronchodilator for
COPD:
Short-acting muscarinic
antagonist. (SAMA)
via Inhalation:
2 inhalations 4 times/day Used for treating COPD
is required. If necessary, grade 1 and higher
12 inhalations per day
would be the maximum.
Acute management for
asthma exacerbations
and refraction
Nebulization:
500mg 3-4 times a day.
Doses should have a 6-8
9|Page
Indication
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
hours gap in between.
Asthma Exacerbation
via Inhalation:
8 inhalations q20min for
up to 3 hours is needed.
Nebulization:
500mg q20min for 3
doses
Rhinorrhea (Perennial
Allergy)
via Intranasal:
2 sprays per nostril 2-3
times/day
Rhinorrhea (Common
Allergy)
via Intranasal:
2 sprays per nostril 2-3
times/day for up to 4
days
Rhinorrhea (Seasonal
Allergy)
via Intranasal:
2 sprays per nostril 2-3
times/day for up to 3
weeks
Tiotropium
10 | P a g e
COPD (maintenance
treatment)
Longer acting
muscarinic antagonists
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Brand name:
- Spiriva
Handihalers,
Respimat
- Stiolto
via Inhalation:
(LAMAs)
18mcg (1 capsule)/day
via HandiHaler device
(Spiriva). While 2
inhalations of 2.5 mg
once daily is required
for Spiriva Respimat
Long-term treatment for
COPD (grade 2 and
above)
Inspiolto Respimat
Asthma
via Inhalation:
2 inhalations of 1.25
mcg once daily.
Maximum benefit may
take 4-8 weeks of
continuous inhalation of
Spiriva Respimat.
Aclidinium
Brand name:
- Tudorza Pressair
inhalation powder (400
mcg/inh)
For maintenance
treatment of COPD:
●
●
Umeclidinium
11 | P a g e
Adults—One
puff 2 times a
day, in the
morning and
evening, about
12 hours apart.
Each puff
contains 400
micrograms
(mcg) of
aclidinium
bromide.
Children—Use
and dose must
be determined
by your doctor.
inhalation powder (62.5
mcg (0.0625 mg)/inh)
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Brand name:
For maintenance
treatment of COPD:
- Incruse Ellipta
●
●
Adults—One
inhalation once a
day. Do not take
more than one
inhalation every
24 hours.
Children—Use
is
not
recommended.
PROTOTYPE DRUG: IPRATROPIUM
DRUG CLASS
BRAND NAME/S
DOSAGE
●
●
Pharmacotherapeutic
- Anticholinergics
Clinical
- Bronchodilator
●
●
Atrovent
Combivent Respimat (albuterol/ipratropium combination)
Bronchodilator for COPD:
via Inhalation:
2 inhalations 4 times/day is required. If necessary, 12 inhalations per day
would be the maximum.
Nebulization:
500mg 3-4 times a day. Doses should have a 6-8 hours gap in between.
Asthma Exacerbation
via Inhalation:
8 inhalations q20min for up to 3 hours is needed.
Nebulization:
12 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
500mg q20min for 3 doses
Rhinorrhea (Perennial Allergy)
via Intranasal:
2 sprays per nostril 2-3 times/day
Rhinorrhea (Common Allergy)
via Intranasal:
2 sprays per nostril 2-3 times/day for up to 4 days
Rhinorrhea (Seasonal Allergy)
via Intranasal:
2 sprays per nostril 2-3 times/day for up to 3 weeks
INDICATIONS
●
●
●
●
CONTRAINDICATIO
NS & CAUTIONS
●
●
●
13 | P a g e
Therapeutic actions are bronchodilation
Indication for this drug is that anticholinergics like the ipratropium
and tiotropium are used for treating asthma exacerbations, COPD,
rhinorrhea, and sialorrhea. That also provides prevention of nausea,
vomiting, and dizziness from motion sickness.
- Children are more sensitive to its adverse effects; while
- Adults should be cautioned about the adverse effects from
this drug.
Also, pregnant women are not allowed to take these type of drug as
it can penetrate through the placenta making the fetus susceptible to
any adverse effects.
Susceptibility to adverse effects also takes place in different age
groups. Hence, adjustment in dosage is needed to prevent the side
effects.
For the contraindication and cautions in using or taking
anticholinergic drugs;
First, we must be knowledgeable if we are ALLERGIC to any
components of the drug.
Second, these drugs are contraindicated in patients with glaucoma,
especially angle-closure glaucoma
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
●
●
Third, because these drugs are slow gastric emptying, they may
increase symptoms of patients with gastric ulcers. Nonselective
antimuscarinic agents should NEVER be used to treat patients with
acid-peptic disease,
Fourth, pregnant women are prohibited in taking these meds as its
components goes in the breast milk.
PHARMACOKINETIC
S
Route
Onset
Peak
Duration
Inhalation
1-3 minutes
1.5-2 hours
Up to 4 hours
Nasal
5 minutes
1-4 hours
4-8 hours
●
●
●
●
●
●
MECHANISM OF
ACTIONS
Absorption: minimal systemic absorption after inhalation due to
lack of absorption potential in the mucosal surfaces.
Volume of Distribution: Highly distributed in the tissues with 4.6
L/kg
Protein Binding: Low
Metabolism: Systemic absorption=Metabolised in the liver
Elimination: urine elimination of the drug says that it remains
unchanged; if orally administered, it is primarily excreted in feces.
Half Life: 1.5-4 hours (Nasal)
“ I can’t S-S-P-P”
I can’t SEE
I can’t SPIT
I can’t PEE
I can’t POOP
ADVERSE EFFECTS
“ABCDs.”
A- agitation
B- blurred vision
C- constipation
14 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
D- dry mouth
S- stasis of urine and sweating.
Side effects includes the “ABCDs” and:
drowsiness
sedation
hallucinations
memory problems
nausea
headache
DRUG TO DRUG
INTERACTIONS
●
●
●
Antihistamines, antiparkinsonisms, MAOIs, TCAs have
cholinergic effects so the incidence of anticholinergic effects
increases.
Phenothiazines, a psychotic drug, decreases the effectiveness of
the anticholinergic effect of the drug.
Burdock, rosemary, and turmeric
Nursing Considerations







Check inhaler technique
Assess the presence of contraindications and cautions above to avoid adverse effects.
o Auscultate lung sounds
Question history of glaucoma, urinary retention, myasthenia gravis
Establish physical assessment to monitor for potential risk susceptibility for adverse effect.
Monitor laboratory test results to determine any considerations like dosage adjustment for
preventing potential toxicity.
Monitor rate, depth, rhythm, type of respiration
Quality rate of pulse
Patient education, teaching






Advise patients not to exceed the prescribed dose.
Rinse mouth after each use of the inhaler.
Frequent drinks and the use of sugar-free gum can help with dry mouth.
Seek medical attention if more than the usual dosage is required.
Keep delivery devices clean and dry.
Take a missed dose as soon as remembered unless it is almost time for the next dose. Do not take
a double dose.
15 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA

Avoid getting in the eyes.
METHYLXANTHINES
Methylxanthines are derived from purine base xanthine. That is produced by both plants and animals.
These are alkaloids that can be found in high concentrations in tea, coffee, and chocolate. Theophylline,
theobromine, and caffeine are the most popular. They can be found in different concentrations in coffee,
chocolate, and tea.
Mechanism of Action
When Beta-2 receptor is being activated, activation of GS coupled protein (receptors) makes our
adenylyl cyclase (AC). These AC are the one that converts the ATP into cyclic adenosine
monophosphate or the cAMP.
Why is cAMP important?



decreases release of inflammatory mediators
decreases bronchial secretions
causes relaxation in smooth muscles ~ bronchodilation
16 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Normally, cAMP is converted into AMP (adenosine monophosphate) due to the presence of the
enzyme called phosphodiesterase (PDE).
So, what the methylxanthine does is it inhibits the PDE that causes its degradation, resulting in
more/ increasing levels of cAMP that leads to bronchodilation.
ADDITIONAL INFO OR GENERATION OF DRUG
PROTORYPE DRUG: THEOPHYLLINE
DRUG CLASS
BRAND NAME/S
DOSAGE
●
●
Pharmacotherapeutic
- Methylxanthine
Clinical
- Bronchodilator, COPD exacerbation
●
●
●
Elixophyllin
Uniphyl
Theo-24
Intravenous (IV):
●
●
for patients with acute bronchospasm
5-7 mg/kg intravenously, followed by a maintenance dose of 0.40.6 mg/kg per hour to maintain serum concentrations at 10-15 mg/L
Oral (PO):
●
Should be taken consistently with or without food
○
○
INDICATIONS
●
●
17 | P a g e
The 12-hour formulation (twice daily)
■ initiated at the end of every 12-hour dosing
The 24-hour formulation (once daily)
■ Taking each morning at a strictly same time frame
and avoiding taing at night.
■ Patients that require a higher dose should take the
medication less than an hour before a high-fat meal.
Therapeutic action
- Slightly relax the airways in the lungs ( bronchodilator ).
- Improve breathing by increasing the strength of the
diaphragm (if it is weakened) and by stimulating the
breathing control centers in the brain.
- Make it easier to get mucus out of the lungs.
Indication
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
-
CONTRAINDICATIO
NS & CAUTIONS
●
●
Treats symptoms and reversible airflow obstruction.
Inhibition of proinflammatory mediators
Deceleration of fibrotic changes in the lung
Relaxation of the bronchial musculature results to
bronchodilation
Damaged cardiac muscle (e.g., following myocardial infarction)
Significant risk of drug interactions (e.g., ciprofloxacin, cimetidine)
PHARMACOKINETIC
S
Route
Onset
Peak
Duration
Oral
1-3 minutes
1.5-2 hours
N/A
IV
15 minutes
15-30 minutes
N/A
●
●
●
●
●
●
Absorption: rapid and complete absorption after oral administration.
Volume of Distribution: 0.3 to 0.7L/kg
Protein Binding:40%, primarily to albumin
Metabolism: metabolized in the liver and levels are sensitive to
stimulation or inhibition of the P450 enzyme system and levels are
increased by many drugs such as cimetidine, corticosteroids,
macrolide and quinolone antibiotics, and interferon.
Elimination: does not undergo any appreciable presystemic
elimination, distributes freely into fat-free tissues and is extensively
metabolized in the liver.
Half Life:
○ 8 hours in adults;
○ 4-5 hours in smokers
MECHANISM OF
ACTIONS
ADVERSE EFFECTS
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●
●
●
●
●
●
●
●
nausea/vomiting,
stomach/abdominal pain,
headache,
trouble sleeping,
diarrhea,
irritability,
restlessness,
nervousness,
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
DRUG TO DRUG
INTERACTIONS
●
●
shaking; or
increased urination
●
Riociguat (a drug that treats pulmonary hypertension) may react
with theophylline.
Cigarette/mariuana smoking decreases blood levels of this
medication.
Caffeine and alcohol intake can increase the medication’s side
effects.
Do not take medications containing aminophylline or oxtriphylline
while using theophylline
This medication may interfere with certain lab tests possibly causing
false test results.
●
●
●
●
Nursing Considerations
Theophylline has a low therapeutic index.
●
Dosage is determined by monitoring response, tolerance, pulmonary function, and serum
theophylline levels. Target range is 10 to 20 mcg/ml.
● Use cautiously in young children, infants, neonates, and elderly patients.
● Depending on assay used, theophylline levels may be falsely elevated in the presence of
furosemide, phenylbutazone, probenecid, theobromine, caffeine, tea, chocolate, cola beverages,
and acetaminophen. Falsely elevated serum uric acid as measured by the Bittner or calorimetric
method.
● Monitor vital signs and watch for signs and symptoms of toxicity.
● Obtain serum theophylline measurements in patients receiving long-term therapy. Ideal levels are
between 10 and 20 mcg/ml, although some patients may respond adequately with lower serum
levels. Check every 6 months. If levels are less than 10 mcg/ml, increase dose by about 25% each
day. If levels are 20 to 25 mcg/ml, decrease dose by about 10% each day. If levels are 25 to 30
mcg/ml, skip the next dose and decrease by 25% each day. If levels are more than 30 mcg/ml, skip
the next two doses and decrease by 50% each day. Repeat serum level determination.
Breast-feeding patients
●
Drug appears in breast milk and may cause irritability, insomnia, or fretfulness in the breast-fed
infant. A decision must be made to stop either breast-feeding or drug.
Pediatric patients
●
Use cautiously in neonates. Children usually require higher doses (on a mg/kg basis) than adults.
Maximum recommended daily doses are 24 mg/kg in children younger than age 9; 20 mg/kg in
children age 9 to 12; 18 mg/kg in adolescents ages 12 to 16; 13 mg/kg or 900 mg (whichever is
less) in adolescents and adults age 16 and older.
Patient education
●
●
Tell patients to take drugs with food if GI upset occurs with liquid preparations or non-sustainedrelease forms.
Instruct patients to continue to use the same brand of theophylline.
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
●
If a patient smokes, tell him to call if he quits because theophylline dose may need to be reduced
to avoid toxicity.
○ Advise patients to take drug at regular intervals as instructed, around-the-clock.
○ If a patient misses a dose, tell him to take it as soon as possible but not to double the dose.
○ Inform patients of adverse effects and possible signs of toxicity.
INTRANASAL CORTICOSTEROIDS
Intranasal Glucocorticoids
●
●
●
Intranasal glucocorticoids or steroids are used for treatment of allergic rhinitis.
Anti-inflammatory action for allergic rhinitis symptoms of rhinorrhea, sneezing, and congestion.
These drugs may be used alone or in combination with an H1 antihistamine.
INTRANASAL GLUCOCORTICOIDS
GENERIC
(BRAND)
ROUTE AND DOSAGE
USES AND CONSIDERATIONS
beclomethasone
(Beconase AQ,
Qnasl)
A: 1-2 puffs/sprays b.i.d
budesonide
(Pulmicort,
Rhinocort)
A/C: >6 y: 1-2 sprays
b.i.d. or 4 sprays in the
morning
For seasonal rhinitis in adults and children.
Maintenance therapy for asthma. Pregnancy
category: C; PB: 90%; t 1 2 : 2.5-3 h
dexamethasone
(Decadron)
A/C: 6-12 y: 1-2 sprays
b.i.d.
For allergic and inflammatory conditions.
Administered orally, intravenously,
ophthalmically, topically, and intranasally.
A potent steroid used for short-term
therapy. May have a systemic effect.
Pregnancy category: C; PB: UK; t 1 2 : 23.5 h
flunisolide
A: 2 sprays b.i.d./t.i.d.
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C: 6-12 y: 1 spray b.i.d.
For seasonal or perennial allergic and
nonallergic rhinitis. Pregnancy category: C;
PB: 87%; t 1 2 : 15 h
For seasonal rhinitis in adults and children.
May be used for steroid-dependent asthma.
C: 6-14 y: 1 spray t.i.d. or
Pregnancy category: C; PB: UK; t 1 2 : 1-2
2 sprays b.i.d.
h
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
fluticasone (Flonase, A: 2 sprays once daily or
Flovent)
1 spray b.i.d.
C: >6 y: 1 spray/d
mometasone furoate
(Nasonex)
A: 2 sprays once daily
triamcinolone
(Nasacort AQ)
A/C: 1-2 sprays once
daily
C: 1 spray once daily
For seasonal allergic rhinitis. When
symptoms decrease, reduce dose to 1 spray
daily. Pregnancy category: C: PB: 91%; t 1
2:8h
For seasonal allergic rhinitis. Pregnancy
category: C; PB: UK; t 1 2 : UK Note:
Direct spray away from nasal septum;
gently sniff.
For allergic rhinitis. Has many uses, such as
an immunosuppressant. Pregnancy
category: C; PB: UK; t 1 2 : 2-5 h
PROTOTYPE DRUG: BECLOMETHASONE
●
●
●
●
●
●
●
●
Brand name
○ Beconase AQ
○ Qnasl
Classification
○ adrenocorticosteroid
○ anti-inflammatory, immunosuppressant
Mode of action
○ controls or prevents inflammation by altering rate of protein synthesis; depresses migration
of polymorphonuclear leukocytes, fibroblasts; reverses capillary permeability.
Therapeutic outcome
○ inhalation: inhibits bronchoconstriction, produces smooth muscle relaxation, decreases
mucus secretion.
○ intranasal: decreases response to seasonal, perennial rhinitis.
Uses
○ Seasonal, perennial allergic/vasomotor rhinitis, nasal polyps, chronic steroid dependent
asthma
Contraindications
○ Hypersensitivity, status asthmaticus (primary treatment)
Precautions
○ Pregnancy C, breastfeeding, child ,12, nasal disease/surgery, nonasthmatic bronchial
disease, bacterial, fungal, viral infections of mouth, throat, lungs, HPA suppression,
osteoporosis, Cushing’s syndrome, diabetes mellitus, measles, cataracts, corticosteroid
hypersensitivity, glaucoma, herpes infection
Dosage and routes
○ Adult and child .12 yr:
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
■
●
●
●
●
●
Oral inh 48-80 mcg bid (alone) or 40-160 mcg bid (with inhaled corticosteroids),
max 320 bid
○ Child 5-12 yr.:
■ Oral inh 40 mcg bid, max 80 mcg bid
○ Available forms:
■ Inhalation, Oral: 40 mcg/inhalation, 80 mcg/inhalation.
■ Nasal Inhalation:
● (Beconase AQ): 42 mcg/inhalation.
● (QNASL): 40 mcg/actuation, 80 mcg/ actuation.
Implementation
○ Oral route
■ give PO, using a spacer device for proper dose
■ shake oral aerosol well, use spacer
■ use after cleaning aerosol top daily with warm water; dry thoroughly
■ store in a cool environment; do not puncture or incinerate container
○ Nasal route
■ Shake inhaler, invert, tilt head backward, insert nozzle into nostril, away from
septum; hold other nostril closed and depress activator, inhale through nose, exhale
through mouth
Adverse effects
○ CNS
■ Headache; psychiatric/behavioral changes (child)
○ EENT
■ Candidal infection of oral cavity, hoarseness, sore throat, dysgeusia, loss of taste/
smell
○ ENDO
■ Hypothalamic-pituitary (HPA) suppression
○ GI
■ Dry mouth, dyspepsia
○ MISC
■ Angioedema, adrenal insufficiency, facial edema, Churg-Strauss syndrome (rare)
○ RESP
■ Bronchospasm, wheezing, cough
Pharmacokinetics
○ absorption: locally only
○ distribution: not distributed
○ metabolism: lungs, liver (by CYP3A)
○ excretion: feces, urine
○ half-life: 2.8 hr
Pharmacodynamics
○ onset: [inh 1-4 wk] [Nasal 10 min]
○ peak: [inh unknown] [nasal unknown]
○ duration [inh unknown] [nasal unknown]
Nursing Considerations
○ Assessment
■ Assess adrenal suppression: 17-KS, plasma cortisol for decreased levels, adrenal
function periodically for HPA axis suppression during prolonged therapy; monitor
growth and development
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
■
○
○
Assess blood studies, neutrophils, decreased platelets; WBC with diff at baseline
and q3mo; if neutrophils are ,1000/mm3 , discontinue treatment
■ Check nasal passages during long-term treatment for changes in mucus; check for
burning, stinging; assess for glucocorticoid withdrawal: dizziness, hypotension,
fatigue, muscle/joint pain; notify prescriber immediately
■ Assess respiratory status: rest, rhythm, characteristics; auscultate lung bilaterally
before and throughout treatment
■ Assess for fungal infections in mucous membranes
Patient/family education
■ Teach patient to gargle/rinse mouth after each use to prevent oral fungal infections
■ Teach patient that in times of stress, systemic corticosteroids may be needed to
prevent adrenal insufficiency; do not discontinue oral product abruptly, taper
slowly
■ Teach patient to continue using product even if mild nasal bleeding occurs; is
usually transient
■ Teach patient method of administration after providing written instructions from
manufacturer
■ Clean inhaler by wiping with dry cloth
■ Teach patient the symptoms of adrenal insufficiency: nausea, anorexia, fatigue,
dizziness, dyspnea, weakness, joint pain, depression
Evaluate
■ Positive therapeutic outcome: Decrease in runny nose, improved symptoms of
bronchial asthma.
·
CORTICOSTEROIDS
●
●
●
Glucocorticoids, members of the corticosteroid family, are used to treat respiratory disorders
particularly asthma.
These drugs have an anti-inflammatory action and are indicated if asthma is unresponsive to
bronchodilator therapy or if the patient has an asthmatic attack while on maximum doses of
theophylline or an adrenergic drug.
It is thought that glucocorticoids have a synergistic effect when given with agonist.
Glucocorticoids can be given using the following methods:
● MDI inhaler
● Tablet
● Intravenous
● Inhaled glucocorticoids are not helpful in treating a severe asthmatic attack, because it may take 1
to 4 weeks for an inhaled steroid to reach its full effect.
● Patients with acute asthma exacerbations are usually given systemic glucocorticoids (i.e., IV) for
rapid effectiveness in large doses (20 to 40 mg prednisone for 5 days; 1 to 2 mg/kg/day for children
for 3 to 5 days).
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
● When severe asthma requires prolonged glucocorticoid therapy, weaning or tapering of the dose
may be necessary to prevent an exacerbation of asthma symptoms and suppression of adrenal
function.
● Side effects associated with orally inhaled glucocorticoids are generally local (e.g., throat irritation,
hoarseness, dry mouth, coughing) rather than systemic.
● Oral and injectable glucocorticoids have many side effects when used long-term, but short-term use
usually causes no significant side effects
PROTOTYPE DRUG: BUDENOSINE
DRUG CLASS
●
●
Pharmacotherapeutic
- Glucocorticoid
Clinical
- Anti-inflammatory, anti-allergy
BRAND NAME
●
●
Pulmicort
Rhinicort Aqua
DOSAGE
●
Adult and pediatric (>6 y): 200–400
mcg b.i.d. (two inhalations), maximum
dose 800 mcg b.i.d.
INDICATIONS
●
Prevention and treatment of asthma;
treatment of chronic steroid-dependent
bronchial asthma; used as adjunctive
therapy for asthma patients who do not
respond to traditional bronchodilators
CONTRAINDICATIONS & CAUTIONS
●
Hypersensitivity
to
budesonide
(nebulization/inhalation)
Primary treatment of status asthmaticus,
acute episodes of asthma. Not for relief of
acute bronchospasms.
●
PHARMACOKINETICS
●
These drugs are rapidly absorbed from the
respiratory tract, but they take from 2 to 3
weeks to reach effective levels, and so
patients must be encouraged to take them
to reach and then maintain the effective
levels. They are metabolized by natural
systems, mostly within the liver, and are
excreted in urine.
PHARMACODYNAMICS
●
Onset
- Slow
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
●
●
●
●
MODE OF ACTION
●
●
ADVERSE EFFECTS
Peak
- Rapid
Duration
- 8-12 hours
Half-life
- 2 to 3 hours; metabolized in the
liver and excreted in urine.
Decreases the inflammatory response in
the airway
This action will increase airflow and
facilitate respiration in an airway
narrowed by inflammation.
Irritability, headache, rebound congestion,
epistaxis, local infection.
Nursing Considerations
ASSESSMENT
●
●
●
●
DIAGNOSIS
Assess for possible contraindications or cautions: acute
asthmatic attacks and allergy to the drugs, which are
contraindications, and systemic infections, pregnancy, or
lactation, which require cautious use.
Perform a physical examination to establish baseline data for
assessing the effectiveness of the drug and the occurrence of
any adverse effects associated with drug therapy.
Monitor blood pressure, pulse, and auscultation to evaluate
cardiovascular response.
Assess respirations and adventitious sounds to monitor drug
effectiveness.
Nursing diagnoses related to drug therapy might include
the following:
IMPLEMENTATION
●
●
●
Risk for Injury related to immunosuppression
Acute Pain related to local effects of the drug
Deficient knowledge regarding drug therapy
●
Do not administer the drug to treat an acute asthma attack or
status asthmaticus because these drugs are not intended for
treatment of acute attack and will not provide the immediate
relief that is needed.
Taper systemic steroids carefully during the transfer to inhaled
steroids; deaths have occurred from adrenal insufficiency with
sudden withdrawal.
Have the patient use decongestant drops before using the
●
●
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
inhaled steroid to facilitate penetration of the drug if nasal
congestion is a problem.
EVALUATION
●
●
●
●
Monitor patient response to the drug (improved breathing).
Monitor for adverse effects (nasal irritation, fever, GI upset).
Evaluate the effectiveness of the teaching plan (patient can
name drug, dosage, adverse effects to watch for, specific
measures to avoid them, and measures to take to increase the
effectiveness of the drug).
Monitor the effectiveness of other measures to ease breathing.
MUCOLYTICS
Increase or liquefy respiratory secretions to aid the clearing of the airways in high-risk respiratory patients
who are coughing up thick, tenacious secretions. Patients may be suffering from conditions such as chronic
obstructive pulmonary disease (COPD), cystic fibrosis, pneumonia, or tuberculosis.
PROTOTYPE DRUG: ACETYLCYSTEINE
DRUG CLASS
●
●
Pharmacotherapeutic
- Respiratory inhalant
Clinical
- Mucolytic
BRAND NAME
●
●
N-acetylcysteine
Mucomyst
DOSAGE
●
PO: ADULTS, ELDERLY, CHILDREN
- Loading dose of 140 mg/kg,
followed in 4 hrs by maintenance
dose of 70 mg/kg q4h for 17
additional
doses
(or
until
acetaminophen assay reveals nontoxic level). Repeat dose if emesis
occurs
within
1
hr
of
administration.
IV: ADULTS, ELDERLY, CHILDREN
- Consists of 3 doses. Total Dose:
300 mg/kg.) 150 mg/kg infused
●
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
over 60 min, then 50 mg/kg
infused over 4 hrs, then 100 mg/kg
infused over 16 hrs
INDICATIONS
●
Mucolytic
adjunctive
therapy
for
abnormal, viscid, or inspissated mucous
secretions in acute and chronic
bronchopulmonary disorders; to lessen
hepatic injury in cases of acetaminophen
toxicity.
CONTRAINDICATIONS & CAUTIONS
●
Caution should be used in cases of acute
bronchospasm,
peptic
ulcer,
and
esophageal varices because the increased
secretions could aggravate the problem.
There are no data on the effects of the drugs
in pregnancy or lactation.
PHARMACOKINETICS
●
The medication may be administered by
nebulization or by direct instillation into
the trachea via an endotracheal tube or
tracheostomy.
Acetylcysteine is metabolized in the liver
and excreted somewhat in urine. It is not
known whether it crosses the placenta or
enters breast milk.
●
PHARMACODYNAMICS
Instillation Inhilation
●
●
●
Onset
- 1 min
Peak
- 5-10 min
Duration
- 2-3 hours
Oral
●
●
●
●
-
27 | P a g e
Onset
- 30-60 min
Peak
- 1-2 hours
Duration
- Unknown
Half-life
2 to 3 hours; metabolized in the liver and
excreted in urine.
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
MODE OF ACTION
●
Splits links in the mucoproteins contained
in the respiratory mucus secretions,
decreasing the viscosity of the secretions;
protects liver cells from acetaminophen
effects.
ADVERSE EFFECTS
●
Adverse effects most commonly associated
with mucolytic drugs include GI upset,
stomatitis, rhinorrhea, bronchospasm, and
occasionally a rash.
Nursing Considerations
ASSESSMENT
●
●
●
●
●
DIAGNOSIS
Assess for possible contraindications or cautions: any history
of allergy to the drugs and the presence of acute bronchospasm,
which are contraindications to the use of these drugs; and peptic
ulcer and esophageal varices, which would require careful
monitoring and cautious use.
Perform a physical examination to establish baseline data for
assessing the effectiveness of the drug and the occurrence of
any adverse effects associated with drug therapy.
Assess skin color and lesions to monitor for adverse reactions.
Monitor blood pressure and pulse to evaluate cardiac response
to drug treatment.
Evaluate respirations and adventitious sounds to monitor drug
effectiveness.
Nursing diagnoses related to drug therapy might include
the following:
●
●
●
●
IMPLEMENTATION
●
●
●
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Acute Pain related to GI, CNS, or skin effects of the drug
Disturbed Sensory Perception (Kinesthetic) related to CNS
effects
Ineffective Airway Clearance related to bronchospasm
Deficient Knowledge regarding drug therapy
Avoid combining with other drugs in the nebulizer to avoid the
formation of precipitates and potential loss of effectiveness of
either drug.
Dilute concentrate with sterile water for injection if buildup
becomes a problem that could impede drug delivery.
Note that patients receiving acetylcysteine by face mask should
have the residue wiped off the facemask and off their face with
plain water to prevent skin breakdown.
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
EVALUATION
●
●
●
●
Monitor patient response to the drug (improvement of
respiratory symptoms, loosening of secretions).
Monitor for adverse effects (CNS effects, skin rash,
bronchospasm, GI upset).
Evaluate the effectiveness of the teaching plan (patient can
name drug, dosage, adverse effects to watch for, specific
measures to avoid them, and measures to take to increase the
effectiveness of the drug).
Monitor the effectiveness of comfort and safety measures and
compliance with the regimen.
ANTIHISMATICS DRUGS
LEUKOTRIENE RECEPTOR ANTAGONISTS AND SYNTHESIS INHIBITORS
Leukotrienes
● The eicosanoid family includes a group of inflammatory mediators known as leukotrienes
(LTs).
● Antigens, immune complexes, complement, cytokines, osmotic challenges, and pollutants
are among the immunologic and nonimmunologic stimuli that stimulate their production,
which is largely carried out by leukocytes. These substances work together to promote the
inflammatory cascade by altering vascular permeability, affecting leukocytes, and
constricting smooth muscle.
● Most notably, the bronchoconstriction caused by leukotriene activity plays an important
part in the pathophysiology of asthma, which opens the door to the use of targeted
pharmacotherapy to treat asthma and comparable disorders.
● Leukotrienes are largely synthesized in leukocytes. Different leukocytes generate mostly
leukotriene B (LTB) or the cysteinyl class of leukotrienes. Neutrophils are the principal
producers of LTB and only a little quantity of cysteinyl leukotrienes. The cysteinyl
leukotrienes are mostly produced by eosinophils, basophils, and mast cells. They have a
negligible capability for LTB production. Macrophages and monocytes act as
intermediaries because they are sufficiently capable of producing both LTB and cysteinyl
leukotrienes.
● cysLT1 is involved in airway changes including bronchoconstriction, edema, and mucus
formation. cysLT2 causes increased vascular permeability and tissue fibrosis, but has no
effect on the airways.
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PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
● As stated, Leukotrienes are crucial in asthma because they promote inflammation,
bronchoconstriction, and mucus development. LTC 4, LTD 4, and LTE 4 are the most
potent bronchoconstrictors in humans.
● Leukotrienes have the potential to draw white blood cells to the lungs, causing thickening
and swelling of the lining of the lung. They also have the additional effect of increasing
mucus formation and making it easier for fluids to collect (an important part of
inflammation).
● Due to its severe bronchoconstrictive impact (which is at least 200 times greater than
histamine), LTD4 is considered to be the most significant cysteinyl leukotriene in the
pathophysiology of asthma. This is due to the fact that LTD4 causes the muscles around
the airways to tighten.
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Figure 1. Overview of the leukotriene pathway demonstrating the key enzymes encoded by genes with variants
associated with asthma, aspirin-exacerbated respiratory disease (AERD), or the pharmacologic response to leukotriene
modifier therapy. Red boxes demonstrate known genetic associations. BLT, Leukotriene B; PG, pharmacogenetic
association; CysLT, cysteinyl leukotriene. Modified with permission from N Engl J Med. 1999;340:197-206.
Retrieved from https://pubmed.ncbi.nlm.nih.gov/19665766/
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PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Leukotriene Receptor Antagonists and Synthesis Inhibitors
● also called leukotriene modifiers
● These medications are beneficial in decreasing the inflammatory symptoms of asthma
brought on by allergy and environmental triggers.
● utilized for exercise-induced asthma but not approved for use in the treatment of acute
asthmatic attacks
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
Leukotriene Receptor Antagonists
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
zafirlukast (Accolate)
Pharmacotherapeutic:
Leukotriene receptor
antagonist; Bronchodilator
 Clinical: Antiasthma
 Trade name: Accolate
 Pregnancy Category: B
Drug Classification

Mode of Action

montelukast (Singulair)
Pharmacotherapeutic:
Leukotriene receptor
inhibitor; Bronchodilator
 Clinical: Antiasthma
 Trade name: Singulair
 Pregnancy Category: B

Selective and competitive
receptor antagonist of
leukotriene D4 and E4
(LTD4 and LTE4),
components of slowreacting substance of
anaphylaxis (SRSA).


Selective receptor antagonist
of leukotriene D4, thus
inhibiting
bronchoconstriction.
Binds with leukotriene
receptors to inhibit smooth
muscle contraction and
bronchoconstriction
Therapeutic Effects

helps to prevent the signs
and symptoms of asthma
o airway edema,
o smooth muscle
constriction, and
o altered cellular
activity due to
inflammation

Controls asthmatic attacks by
inhibiting leukotriene release
as well as inflammatory
action associated with the
attack.
Uses and
Indications

Prophylaxis and chronic
treatment of asthma in
adults and children >5 y
(not for acute
bronchospasm).
Reduces inflammation
within bronchial tubes and
airways.
Off label: Urticaria

Prophylaxis and chronic
treatment of asthma or
allergic rhinitis.
Prophylaxis, chronic
treatment of asthma.
Prevention of exerciseinduced bronchoconstriction.
Off label: Urticaria


33 | P a g e



PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Dosage
A: PO: 20 mg b.i.d. 1 h
before or 2 h after meals;
max: 40 mg/d
C: >5 y: PO: 10 mg b.i.d.;
max: 20 mg/d






Hypersensitivity to
zafirlukast;
acute asthma attacks,
including status
asthmaticus,
acute bronchospasm;
children <5 years.
Hypersensitivity to
montelukast;
severe asthmatic attack,
status asthmaticus or acute
bronchospasm




Hepatic impairment,
hepatic disease;
patients 65 years older
status asthmaticus




Severe liver disease,
suicidal ideation,
breastfeeding,
corticosteroid withdrawal

LAB VALUES: Abnormal
liver function tests (ALT,
AST)
DRUG Interactions to:
o Dasabuvir
o Leflunomide
o Pixantrone
o Teriflunomide


Contraindications


Cautions

DRUG: Erythromycin,
theophylline may decrease
concentration/effect. May
increase effects of warfarin
(increases INR).
 HERBAL: None
significant.
 FOOD: Food decreases
bioavailability by 40%.
 LAB VALUES: None
significant.
 Absorption: PO, rapidly
Pharmacokinetics
absorbed
 Bioavailability: Reduced
40% with food
 Distribution: 99% proteinbound
 Metabolism: t½: 10hrs,
metabolized in liver
 Excretion: 90% excreted in
feces, 10% in urine
Pharmacodynamics PER OREM
Interactions
34 | P a g e






A: PO: 10 mg/d at least 2 h
before exercise
C: 6-15 y: PO: 5 mg/d at
least 2 h before exercise
Absorption: Well absorbed
Distribution: 99% proteinbound
Metabolism: t½: : 2.7-5.5 h
Elimination: Feces, bile
PER OREM
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA



Side Effects



Adverse Effects
Onset: UK
Peak: 3 hours
Duration: 12 hours
Frequent (13%):
Headache.
Occasional (3%): Nausea,
diarrhea.
Rare (less than 3%):
Generalized pain, asthenia,
myalgia, fever, dyspepsia,
vomiting, dizziness.




Onset: UK
Peak: 3–4 h for oral tablet,
2–2.5 h for chewable tablet.
Duration: 24 h
Fever, headache, drowsiness,
dizziness, fatigue,
restlessness, insomnia,
confusion, depression, nasal
congestion, cough, sore
throat, dental pain, influenza,
dyspepsia, nausea, vomiting,
abdominal pain, weight loss,
rash

Concurrent administration
of inhaled corticosteroids
increases risk of upper
respiratory tract infection

Angioedema, bleeding,
vasculitis, seizures, edema
Life-threatening: anaphylaxis,
suicidal ideation, StevensJohnson syndrome

Regularly assess respiratory
and airway condition.
Lab tests: Periodic liver
function tests.
Monitor closely PT and INR
with concurrent warfarin
therapy.
Monitor closely phenytoin
level with concurrent
phenytoin therapy.

Monitor effectiveness
carefully when used in
combination with
phenobarbital or other potent
cytochrome P450 enzyme
inducers.
Lab test: Periodic liver
function tests.
Taking medication
regularly, even during
symptom-free periods.
Note: Drug is not intended
to treat acute episodes of
asthma.
Report S&S of hepatic
toxicity (see Appendix F) or

Nursing Implications
Assessment and
Drug Effects




Patient and Family
Education


35 | P a g e


Do not use for reversal of an
acute asthmatic attack.
Inform physician if shortacting inhaled bronchodilators
are needed more often than
usual with montelukast.
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA


36 | P a g e
flu-like symptoms to
physician. Follow-up lab
work is very important.
Notify physician
immediately if condition
worsens while using
prescribed doses of all
antiasthmatic medications.
Do not breastfeed while
taking this drug.


Use chewable tablets (contain
phenylalanine) with caution
with PKU.
Do not breastfeed while
taking this drug.
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
Leukotriene Synthesis Inhibitor
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Drug Classification




zileuton (Zyflo CR)
Pharmacotherapeutic: Leukotriene synthesis inhibitor;
Bronchodilator
Clinical: Antiasthma
Trade name: Zyflo CR
Pregnancy Category: C
Mode of Action

Therapeutic Effects

Uses and
Indications


Dosage

A: PO: 1200 mg b.i.d. within 1 hr after morning and evening meal
Contraindications



Hypersensitivity to zileuton or zafirlukast,
active liver disease,
lactation
Cautions


Hepatic insufficiency.
Safety and effectiveness in children >12 y are not established.
Interactions

DRUG: May double theophylline levels and increase toxicity.
Increases hypoprothrombinemic effects of warfarin. May increase
levels of BETA BLOCKERS (especially propranolol), leading to
hypotension and bradycardia.
FOOD: Improved absorption when administered w/ food
(controlled-release). Alcohol may increase CNS depression and risk
of hepatotoxicity.

Pharmacokinetics




Inhibits 5-lipoxygenase, the enzyme needed to start the conversion
of arachidonic acid to leukotrienes.
Zileuton helps to prevent the signs and symptoms of asthma
including airway edema, smooth muscle constriction, and altered
cellular activity due to inflammation.
For prophylaxis and maintenance therapy for chronic asthma.
Reduces inflammation in airways and decreases
bronchoconstriction
Absorption: Rapidly absorbed from GI tract
Distribution: 93% protein-bound
Metabolism: t½: 2.5 hrs, metabolized in liver
Excretion: Excreted primarily in urine (94%)
Pharmacodynamics PER OREM

37 | P a g e
Onset of Action: UK
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Side and Adverse
Effects


Peak: 1.7 hours
Duration: 5-8 hours

Headache, dizziness, pain including pharyngolaryngeal pain, GI
disturbances, myalgia, arthralgia, sinusitis, conjunctivitis, fever,
hypertonia, lymphadenopathy, malaise, neuropsychiatric events
(e.g. sleep disorders, behaviour changes), UTI, vaginitis,
hypersensitivity, urticaria, rash, leucopenia, jaundice,
hyperbilirubinaemia and elevated liver enzymes.
Potentially Fatal: Severe hepatic injury.

Nursing Implications
Assessment and
Drug Effects



Patient and Family
Education





Assess respiratory status and airway function regularly.
Lab tests: Periodic CBC and routine blood chemistry; monthly liver
function tests for 3 mo, then every 2–3 mo for rest of first year,
then periodically.
Instructions for CONCURRENT THERAPIES: Reduce
theophylline dose and closely monitor theophylline levels; closely
monitor PT and INR with warfarin therapy; closely monitor
phenytoin level with phenytoin therapy; closely monitor HR and
BP for excessive beta blockade with propranolol therapy.
Take medication regularly even during symptom-free periods.
Drug is not intended to treat acute episodes of asthma.
Report to physician promptly S&S of hepatic toxicity (see
Appendix F) or flu-like symptoms. Follow-up lab work is very
important.
Notify physician if condition worsens while using prescribed doses
of all antiasthmatic medications.
Do not breastfeed while taking this drug.
Nursing Process
Assessment
 Record medical, drug, and herbal histories; note any drug-drug or drug-herb interactions.
 Record baseline vital signs for identifying abnormalities and for future comparisons.
 Assess for wheezing, decreased breath sounds, cough, and sputum production.
 Assess sensorium for confusion and restlessness caused by hypoxia and hypercapnia.
 Assess for a history of phenylketonuria when montelukast is prescribed, because children’s
chewable tablets contain phenylalanine.
 Determine hydration; diuresis may result in dehydration in children and older adults.
38 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Nursing Diagnosis
 Ineffective airway clearance related to retained secretions in bronchi
 Activity intolerance related to imbalance between oxygen supply and demand
 Deficient knowledge of OTC drug interaction related to lack of exposure to information
Planning
 Patient will be free from wheezing, or wheezing has significantly improved.
 Patient’s lung fields will be clear within 2 to 5 days.
 Patient will take medications as prescribed.
Interventions
 Monitor respirations for rate, depth, rhythm, and type.
 Monitor lung sounds for rhonchi, wheezing, or rales.
 Observe lips and fingernails for cyanosis.
 Monitor drug therapy for effectiveness.
 Observe for side effects.
 Provide adequate hydration; fluids aid in loosening secretions.
 Monitor liver function tests; AST and ALT may be elevated with zafirlukast and
montelukast.
 Provide pulmonary therapy by chest clapping and postural drainage, as appropriate.
Patient Teaching
General
 Advise patient that if allergic reaction occurs (i.e., rash, urticaria), drug should be
discontinued and health care provider should be notified.
 Monitor periodic liver function tests.
 Direct patient not to take St. John’s wort without first checking with health care provider,
because this herb may decrease montelukast concentration.
 Warn patient that black or green tea and guarana with montelukast and zafirlukast may
cause increased stimulation.
 Encourage patient to stop smoking.
 Discuss ways to alleviate anxiety (relaxation techniques, music).
 Advise patient having frequent or severe asthmatic attacks to wear an ID bracelet or
MedicAlert tag.
 Encourage patient contemplating pregnancy to seek medical advice before taking
montelukast.
 Caution patient or significant other not to open oral granule packets until ready for use.
After opening packet, dose must be administered within 15 minutes. If mixed with baby
formula or approved food (applesauce, carrots,rice, or ice cream), do not store for future
use.

Advise patient with known aspirin sensitivity to avoid a bronchoconstrictor response by
avoiding aspirin and NSAIDs while taking montelukast.
Self-Administration
 Teach patient not to use montelukast for reversal of an acute asthmatic attack, because it is
only recommended for prevention of acute attacks and treatment of chronic asthma.
 Advise patient to continue to use the usual regimen of inhaled prophylaxis and short-acting
rescue medication for exercise-induced bronchospasm.
39 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA



Encourage patient to inform health care provider if short-acting inhaled bronchodilators are
needed more often than usual with montelukast.
Tell patient to comply with medication regimen even during symptom-free periods.
Advise patient (especially children) that chewable tablets are to be chewed thoroughly
because swallowing whole may alter absorption.
Diet

Tell patient to take leukotriene receptor antagonists in the evening for maximum
effectiveness.
Cultural Considerations
 Use both hands to show respect when offering a prescription, instructions, or pamphlets to
Asians and Pacific Islanders.
Evaluation
 Evaluate the effectiveness of the bronchodilators.Patient is breathing without wheezing and
without side effects of the drug.
 Evaluate tolerance to activity.
MAST CELL STABILIZERS
Mast cells
●
Mast cells or mastocytes are connective tissue cells that are responsible for the inflammatory
response of the body, or its reaction to injury or infection.
● Mastocytes produce different substances such as histamine and leukotrienes, in response to
inflammation or irritation, which causes the dilation of small blood vessels and kills bacteria.
Mast Cell Stabilizer
●
●
●
A mast cell stabilizer is a drug that focuses mainly on the inhibition of histamine and slow-reacting
substance of anaphylaxis (SRSA) production at the cellular level.
It prevents the mast cells from releasing substances that cause inflammation and
bronchoconstriction during situations wherein mast cells are stimulated due to irritation or the
presence of an antigen.
Currently, there is only one drug still available under this drug class, Cromolyn.
○ It is an FDA-approved medication with the purpose revolving around the prophylaxis of
bronchial asthma and treatment of allergic rhinitis and mastocytosis (the excessive
gathering of mast cells in the body’s tissues) in pediatric and adult patients. Hence, it is the
prototype drug of this class.
40 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
CROMOLYN
Drug Name
●
●
●
Drug Classification
●
●
●
Dosage
Generic Name: Cromolyn
Chemical Name: Sodium Cromoglycate, Sodium
Cromolyn
Brand/Trade Name: NasalCrom, Gastrocrom, Intal
Therapeutic: antiasthmatics, allergy, cold, and cough
remedies
Pharmacologic mast cell stabilizers
Pregnancy Category B
Adult Dose:
●
●
Nasalcrom
○ 1 spray each nostril
○ 3 to 4 times a day
Gastrocrom
○ Adults and Adolescents (13 years and above): 2
ampules 4 times a day, 30 minutes before meals
and at bedtime
Pediatric Dose:
●
●
●
Indications
●
●
●
●
41 | P a g e
Nasalcrom
○ 2 to 11 years old: 1 spray in each nostril
○ 3 to 4 times a day
Intal
○ 5 years and above: 4 times at regular intervals
(should not be exceeded)
Gastrocrom
○ Children (2 to 12 years old): 1 ampule 4 times a
day, 30 minutes before meals and at bedtime
○ Not recommended for pediatric patients under 2
years old
Prophylaxis of severe bronchial asthma (it is not used for
acute asthmatic attacks)
Prevention of exercise-induced asthma
Intranasal route: Prevention and treatment of seasonal and
perennial allergic rhinitis.
PO: Mastocytosis, treatment of food allergy, treatment of
inflammatory bowel disease (IBD)
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Therapeutic Actions
● Cromolyn inhibits the release of histamine and SRSA.
● It is able to prevent allergic asthmatic response when a person’s respiratory tract is exposed
to the foreign substance through blocking the calcium ions from entering mast cells, which
are needed for mast cell degranulation, thereby stopping the release of the stimulated
chemical mediators.
● Cromolyn is not absorbed from the site of administration, therefore it only has a local
effect. Since there are numerous drugs available for inflammation that are far more
effective and have fewer side effects, cromolyn is not as frequently used compared in the
past.
● There are several formulations of the drug:
○ ophthalmic solution for eye-related allergic symptoms,
○ nasal for allergic rhinitis,
○ inhaled form for allergies and;
○ capsule or oral form may prevent food allergy.
○ The nasal and eye drop forms of cromolyn are used for hay fever and the oral
formulation is available for food allergy.
Pharmacokinetics
Pharmacokinetics
Absorption
●
●
●
●
Oral: 0.5 to 2 %
Nasal: 8%
Affects local areas only
Small amounts may reach systemic circulation after
inhalation
Distribution
●
Since only small amounts are absorbed, its
distribution is unknown and does not have enough
studies.
Metabolism and Excretion
●
●
Metabolized in the liver
Small amounts absorbed are excreted unchanged in
urine and feces
Majority of the drug, about 98%, is excreted in the
feces and the rest in the urine; others via exhalation
●
Half-life
42 | P a g e
80 to 90 minutes
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Route
Onset
Peak
Duration
Inhalation
1 to 2 weeks
2 to 4 weeks
6 to 8 hours
Nasal
1 to 2 weeks
2 to 4 weeks
6 to 8 hours
Oral
2 to 6 weeks
15 minutes
6 to 8 hours
Contraindications and Cautions
● Cromolyn is contraindicated in patients who have shown hypersensitivity.
● It cannot also be used during acute attacks of asthma because it does not take action
immediately and has no direct bronchodilator effects.
● The drug is not recommended for the usage of children 2 years old and below, due to the
limited studies of its safety and efficacy.
● Furthermore, there is insufficient adequate and well-controlled studies when used in
pregnant women and human response is different with regards to animal reproduction
studies, therefore the risk is not yet defined. It must only be administered if needed and the
benefit to the mother clearly outweighs potential risk to the fetus.
● There is no established studies if the drug can be excreted in breast milk, thus lactating
women should use the drug with caution.
Adverse Effects and Side Effects
● Its most common side effects include postnasal drip, irritation of the nose and airway, and
cough--especially when administered through aerosol spray. Also, drug allergy cases are
rare. These side effects may be decreased by drinking water before and after the
administration of the drug.
● A serious side effect of cromolyn that may occur when the therapy is discontinued abruptly,
rebound bronchospasm.
● Despite it having a low incidence of side effects, it is only moderately effective,
accordingly, there are more and newer drugs produced that replaced the use of cromolyn.
43 | P a g e
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Area of the body
Adverse Effects/Side Effects
Central Nervous System
dizziness, headache
Skin
rash, urticaria, angioedema
Ears, eyes, nose, throat
(EENT)
intranasal— nasal irritation, nasal congestion, sneezing
Respiratory
inhalation— irritation of the throat and trachea, cough,
wheezing, bronchospasm
Gastrointestinal
nausea, unpleasant taste, diarrhea
Others
allergic reactions including ANAPHYLAXIS or worsening of
conditions being treated
Drug to Drug Interactions
● Currently, it is said that there are no existing drug to drug interactions.
Nursing Considerations
● Assessment
○ Perform a physical examination to have a baseline data of the client and to serve as a basis
for the assessment of the effectiveness of the drug and drug therapy, including the
occurrence of adverse effects.
○ Assess for possible contraindications or cautions before administering the drug or
beginning the drug therapy, keeping in mind the adverse effects and if there is any
presence of impaired renal or hepatic function.
■ Impaired renal or hepatic function may affect the metabolization or
excretion of the drug.
○ Assess lung sounds and respiratory function to evaluate the effectiveness of the
drug before and routinely during the drug therapy.
● Diagnoses
○
○
○
○
44 | P a g e
Ineffective airway clearance
Acute Pain related to local effects, headache, or GI effects
Risk for Injury related to CNS effects
Deficient Knowledge regarding drug therapy
PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
● Implementation
○
○
○
○
Review the proper administration procedure and delivery with the patient periodically to
ensure the effectiveness of the drug.
Instruct the patient of cautions, especially avoiding the abruptly discontinuation use of the
drug to prevent adverse effects.
Provide patient teaching of the needed information namely the drug name, dosage,
cautions, warning signs that may indicate potential problems to avoid any adverse effects
such as the usage of the drug during acute asthmatic attacks and to enhance patient
knowledge of the drug therapy and it promotes cooperation.
Ensure to offer support and encouragement to guide and aid the patient throughout the drug
therapy and cope with it.
● Evaluation
○
○
○
○
Monitor the patient’s response to the drug and drug therapy, to know the effectiveness such
as the improvement of breathing, relief of signs of allergic disorders.
Monitor for any adverse effects for early detection and to avoid further complications.
Evaluate the effectiveness of the patient teaching to ensure patient knowledge.
The therapeutic effects are usually observable within 2 to 4 weeks after the beginning of
therapy.
Patient Education
● Instruct patient and/or guardian on the correct use of medication and all the needed information.
●
●
●
●
●
The medication must be administered routinely and should not exceed the prescribed dose. Missed
doses must be taken as soon as remembered, but still with regular intervals with other doses. Double
doses are not allowed. The therapy must not be discontinued abruptly without the physician’s
instructions or adverse effects may occur.
Throat irritation, cough, and hoarseness may be minimized by the following actions: gargling
water, drinking a few amounts of water, or by taking a lozenge after each treatment.
Know the correct procedure or proper actions when an acute asthma attack occurs. Cromolyn is not
applicable for acute asthma.
Cromolyn does not entirely eliminate the continued need for therapy with bronchodilators,
expectorants, antibiotics, or corticosteroids, but they may be reduced in terms of their amount and
usage frequency.
Note and immediately contact your physician for any unusual signs or symptoms, such as adverse
effects (e.g., hypersensitivity reactions) for these can be severe or life-threatening. Physicians may
advise the patient to discontinue the use of drug when an allergic reaction is detected.
Remember the contraindications and cautions of the drug to avoid complications.
REFERENCES
Comerford, K. C., & Durkin, M. T. (2021). Nursing 2021 drug handbook. 41st edition. Philadelphia:
Wolters Kluwer.
Hodgson, B. B., & Kizior, R. J. (2020). Saunders nursing drug handbook. Philadelphia: Saunders.
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PAMANTASAN NG LUNGSOD NG MAYNILA | COLLEGE OF NURSING| BLOCK 2
PHARMACOLOGY
PROFESSOR MARY CRIS T. ROMBAOA
ANIEVAS| BAUTISTA| COSING| DAYAO| DEL PILAR| DOMASIN| ECHANO| PRILLA
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer.
Katzung, B. G. (2004). Basic & clinical pharmacology. New York: Lange Medical Books/McGraw Hill.
Katzung, B. G., Kruidering-Hall, M., & Trevor, A. J. (2019). Katzung & Trevor's pharmacology:
Examination & board review (Twelth edition.). New York: McGraw-Hill Education.
LeFever Kee, J., Hayes, E. R., & McCuistion, L. E. (2015). Pharmacology: A patient-centered nursing
process approach. St. Louis, MO: Elsevier/Saunders. 8.
Tortora, G. J. (2006). Principles of anatomy and physiology. 11th ed. Hoboken, NJ: J. Wiley.
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