ACC Final Pharmacology Exam
Review
CH 7
Key terms:
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Anticholingergic bronchodilator
Antimuscarinic bronchodilator
Cholingergic
Muscarinic
Parasympatholytic
Parasympathomimic
Ch. 7
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Indication for Atrovent
Specific anticholinergics
TABLE 7-1
Basic difference between Tertiary and Quaternary
compounds
Mode of action- may use power point description
Muscarinic receptor subtypes 1-3 only (in lungs)
Adverse effects
Use in COPD
Ch. 7
• Anticholinergics: only two used for the
inhalation route:
– Atrovent (Ipatropium Bromide), 0.5 mg SVN, MDI
dose
– Spiriva (Tiotropium Bromide), handihaler dry
powder
– Both have little systemic side effects
– Use one or the other. Used for COPD and also
during asthmatic attacks
Ch. 7
• Combivent: Combo of Atrovent and Albuterol
in a MDI; know dosage
• Duoneb: Combo of Albuterol and Atrovent in a
SVN, know dosage
• Give combos for synergetic effect
• Atropine: No longer aerosolized, used to
increase HR, dry mouth. Tertiary compound,
means it crosses BBB has systemic effects
Ch. 7
• Spiriva
– DPI, 18 ug/inhalation, given QD
– Onset 30 min, peak 3hr, duration 24 hrs
• Atrovent:
– MDI (HFA)17 ug/puff x 2 puffs, QID
– Onset 15 min, peak 1-2 hr, duration 4-6 hrs
– SVN 0.02% solution, 0.5 mg TID
Ch. 7
• Mode of action of anticholinergics
• cGMP inhibits constriction and mucus production
• cGMP acts as a secondary messenger much like cAMP but
instead of converting ATP, cGMP prevents
neurotransmitters from entering the bronchial smooth
muscle cell
• Unlike sympathometic bronchodilators, Atrovent/Spiriva
do not cross the blood brain barrier and thus have
essentially no systemic side effects (both are derivatives
of Atropine, but are quaternary amines)
• Slower bronchodilator effects and less intense than
adrenergics
Ch. 7
• Atrovent is non selective M blocker
• Quaternary compund, does not cross the BBB
• Spiriva: dissociates more slowly from M1 and M3
receptors. More selective than Atrovent
• M2: inhibits further AcH release
• Cholinergic effects: decrease HR, miosis,
contraction of lens, salivation, urination,
secretion of mucus, bronchoconstriction
• AcH destroyed by cholinesterase
Ch. 7
• Anticholinergic effects: increased HR, pupil
dilation, flattened lens (USE CAUTION WITH
ATROVENT WITH patients with Glaucoma),
drying of upper airway, urinary retention,
antidiarrheal, mucociliary slowing
• Adverse effects: dry mouth, cough, avoid
spraying in eye
Ch. 8
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Key terms:
Xanthine
Methlyxanthines
Phosphodiesterase
Ch. 8
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Clinical indications and use
Asthma
COPD
Apnea of prematurity
Increases diaphragmatic strength
Inhibition of phosphodiesterase
Theophylline toxicity and side effects
Ch. 8
• Methylxanthines: derived from Xanthines,
consist of Caffeine, theophylline, and
theobromine
• Phosphodiesterase: enzyme that inhibits
cAMP. Xanthine believed to inhibit this
enzyme, thus increasing bronchodilation
• Uses: Apnea/bradycardias; most common use
of Xanthine, in form of Caffiene for neonates
Ch. 8
• Uses: COPD as a weak bronchodilator,
increasing respiratory muscle strength,
increases contractility for patients on long
term mechanical ventilation (helps with
diaphragm wasting); respiratory muscle
endurance, central ventilatory drive,
cardiovascular effects by increasing CO, and
antiinflammatory effects
Ch. 8
• Theophylline: lots of side effects, must keep in
narrow therapeutic range, headache, anxiety,
restlessness, nausea, anorexia, vomiting,
abdomial pain, hematemesis, tachypnea,
palpitations, SVT, ventricular arrhythmias,
hypotension, diruresis
CH. 9
Key terms:
• Abhesives
• Expectorant
• Glycoprotein
• Mucin
• Mucoactive agent
• Mucokenetic agent
• Mucolytric agent
• Mucis
• Sputum
CH. 9
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Clinical indication for use
Source of airway secretions
TABLE 9-1
Mucus in disease states
Chronic bronchitis
Asthma
Cystic fibrosis
Mode of action and indications for use of Nacetylcysteine page 175
• Mode of action and indication for Dornase alfa page
176
Ch. 9
• Abhesives: coating of film that preventsor
reduces adhesion
• Elasticity: rheologic property characteristic of
solids it is represented by the storage of
modulus G
• Expectorant: medication meant to increase
the volume or hydration of airway secretions
• Gel: macromolecular description of pseudoplastic material viscosity and elasticity
Ch. 9
• Mucin: principle airway gel forming mucins
• Mucoactive agent: effect on mucus secretion
• Mucokinetic agent: increases ciliary clearance
or respiratory mucus
• Mucolytic agent: degrades polymers in
secretions
• Mucoregulatory agent: reduces volume of
airway mucus secretion and appears to be
especially effective in hypersecretory states
Ch. 9
• Know layers of mucosa (gel, sol layer, epithelial cells, cilia,
goblet cells, bronchial glands- produce most mucus)
• Produce 100 ml of mucus daily
• Acetylcysteine (NAC): Mucomyst, 10%/20%, SVN 3-5 ml
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Causes bronchospasm, give with bronchodilator
Rotten egg smell, nausea
Directly instilled, or aerosolized
Breaks down sulfhydryl groups for disulfide bonds of mucus
Given to COPD, pneumonia, congestion, acetaminophen
overdose
– Incompatible with anti-biotics (do not mix mucomyst)
Ch. 9
• Factors affecting mucus transport:
– COPD/CF
– Airway drying
– Narcotics
– Artificial airways/suctioning
– Cigarette smoke
– Pollution
– Hyperoxia/hypoxia
Ch. 9
• Food intake (milk) in particular does not increase
mucus
• Adrenergics: increase cilia beat and mucus
production
• Cholinergics: increase ciliary beat and mucus
• Anticholinergics: decrease cilia beat and decrease
mucus production
• Xanthines: increase cilia beat and production
• Steroids: no effects on cilia, decrease mucus
production
Ch. 9
• Sputum: mucus plus oral secretions
• Bronchorrhea: watery sputum
• Asthma: inflammation/increased mucus
production
• CF: impaired proteins, get frequent infections
such as pseudomonas, require Dornase Alfa.
Most congestion is not mucin, instead puss
from neutrophil degradation
Ch. 9
• Physical properties of mucus include viscosity,
elasticity, cohesion, and adhesity.
• Dornase Alfa:
– Pulmozyme dose 2.5 mg
– Given during infections with CF
– Reduces extracellular DNA and F-actin polymers,
reduces viscosity and adhesiveness of mucus
– Does not cause bronchospasm, may cause pharyngitis,
laryngitis, rash, chest pain, conjunctivitis
Ch. 9
• Expectorants:
– Sodium Bicarb: increases pH of mucus weakening
bonds lowering viscosity and elasticity, used
directly or aerosolized. Weak
– Guaifesnsin: cilitoxic when applied directly
– Hypertonic Saline: >0.9%, for induction of cough
– Use adjunct therapy for mucus control
• PEP, CPT, IPPB, Heated humidity, postural drainage,
Bronchodilators, Vest
• Bland aerosols (without medications)
CH 10
Key terms:
• Prophylactic and rescue treatment
• Physical principles of surfactant and surface tension
• Application to lung
• BOX 10-1 composition of surfactant
• Table 10-1 (only need to know drug/brand names)
• Survanta page 198
• Infasurf and curosurf
• Mode of action page 199-200
Ch. 10
• Surfactant agents regulate surface tension in
films at gas-liquid interfaces, described by
LaPlace’s Law
• Surfactants are used are prophylactic or
rescue treatment for RDS
• Used exogenous surfactants include:
– Beractant (Survanta), Calfactant (infasurf),
Poractant alfa (Curosurf)
Ch. 10
• Surfactant is directly instilled into the airway
via endotracheal tube and adaptor, must
closely monitor patient for compliance
changes in order to prevent pneumothorax
• Surfactants used are all natural based
• Surfactant is composed of:
– 85-90% lipids and 10% Proteins
– Exogenous surfactant enter into the alveolar pool
and replace deficient natural surfactant
CH 11
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Key terms:
Adrenal cortical hormones
Endogenous
Exogenous
IgE
Prostglandin
Steroids
Steroid Diabetes
Clinical indications: Asthma /COPD
Adrenal cortical hormones
TABLE 11-1 (only need to know dosages for adults, for Qvar, Flovent, Pulmicort,
and Advair)
Review the hypothalamic pituritary adrenal axis, diurnal steroid cycle
Inflammation response (review)
Mode of action of corticoid steroids page 215
Effects on WBC and Beta receptors
Know side effects of systemic BOX 11-3 and inhaled BOX 11-4
Ch. 11
• Adrenal cortical hormone: chemicals secreted by
the adrenal cortex (steroids)
• Endogenous: made within body
• Exogenous: outside body
• IgE: immune antibody, increased with allergen
• Prostglandin: hormone type substances
circulating in body
• Steroids: Glucocorticoids or corticosteroids,
antiinflammatory effect
Ch. 11
• Adrenal cortical hormones: adrenal cortex
secretes natural antiinflammatories. Secreted
at the hypothlamic pituritary adrenal (HPA)
axis portion of the adrenal gland
• Indications:
– COPD
– Asthma (moderate/severe persistent); must also
give a LABA with steroid. Commonly Advair or
Symbicort
Ch. 11
• Corticosteroids secreted by the adrenal cortex
include glucocorticoids (cortisol),
minaerlocorticoids (aldosterone), and the
androgen estrogen hormones
• Beclomethasone:
– QVAR, MDI 40 or 80, 160 ug/puff, BID
– Rinse mouth after all steroids to prevent thrush
Ch. 11
• Fluticasone (Flovent); MDI 44, 110 and 220 ug/puff,
BID; DPI 50, 100, 250; combined with Serevent to make
Advair, doses 500/50, 250/50, 100/50
• Budesonide (Pulmicort); only nebulized steroid,
respules SVN 0.25-0.5 mg; tubahaler DPI 200
ug/actuation BID; mixed with foradil to make
Symbicort, MDI doses 80/4.5, 160/4.5 BID
• Mometasone (Asmanex); Twisthaler DPI, 220 ug; BID
• Flunisolide (Aerospan);
– MDI 80 ug/puff, BID
Ch. 11
• Hypothalamic Pituitary Adrenal Axis (HPA):
controls endogenous steroids, may be
suppressed/affected with exogenous steroid use.
Cortisol release causes breakdown of
carbohydrates, fats, and proteins to make glucose
for energy. Side effect of systemic steroid is
steroid diabetes
• Diurnal Steroid Cycle: levels of natural steroids
follow a daily or diurnal rhythm. Give exogenous
steroids following normal cycle of release
Ch. 11
• Inflammatory response: Redness, flare, wheal,
increased vascular permeability, leukocytic
infiltration, phagocytosis, mediator cascade
• Mode of action: upregulation of
antiinflammatory proteins and downregulation of
proinflammatory proteins
• Systemic Steroids (Prednisone/Salmederol), are
potent, given following or during COPD or asthma
exacerbation and several days after, continued
use leads to many side effects
Ch. 11
• Systemic side effects:
– HPA suppression
– Immunosuppressant, WBC affected
– Psychiatric reactions
– Myopathy of skeletal muscle
– Fluid retention
– Moon face, osteoporosis
– Increased WBC
– Increased glucose levels
Ch. 11
• Minimize oral side effects with use of holding
chamber, rinsing mouth after use
• Inhaled steroids may cause oral candidiasis
(thrush), hoarseness, cough,
bronchoconstriction
CH 12
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Key terms:
Antileukotrienes
Ige
Leukotrienes
Mast Cells
Mast cell stabilizers
Clinical indications
Table 12-1 (only need to know names)
Review allergic response in asthma
Cromolyn sodium page 230-231
Ch. 12
• Antiluekotrienes: agents that block
inflammatory mediators, do not prevent mast
cell degranulation
• Mast cell inhibitors: prevent degranulation, do
not stop mediators once release
• Both used in extrinsic asthma as a
prophylactic treatment; typically mild or
moderate persistent asthma
Ch. 12
• Allergic response in airway caused by IgE
mediated mast cell release of mediators
• Cromolyn sodium (Intal); MDI 800 ug/actuation,
SVN 20 mg QID
• Nedocromil sodium (Tilade); MDI 1.75
mg/actuation QID
• Leukotrienes: Zafirkulast (accolate), Montelukast
(Sinuglair), Zileuton (Zyflo); ALL tablets
• Omalizumab (Xolair): allergy shot, Q- every 4
weeks
Ch. 12
• MOA of Intal: inhibits mediator release by
preventing calcium influx necessary for extrusion
of mast cell
• Intal has no antagonist effect on chemical
mediators themselves
• Does not operate through cAMP system, no
bronchodilation
• Does not prevent Ige antibody formation on Mast
cell
• Do not replace inhaled steroids with mast cell
inhibitors suddenly as the HPA will be affected
Ch. 12
• Tilade: prevents mast cell release but also
esionphil, histamine, trypase and others
• Can inhibit esionphil chemotaxis and adhesion
CH. 13
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Key terms:
Virostatic
Virucidal
Virus
Penatmidine: Indications, mode of action and
aerosolize use
• TABLE 13-1 (don’t worry about dosages)
• Ribavirin: Indications, mode of action, aerosolize
use and side effects
• Tobramycin: indications, and mode of action of us
Ch. 13
• PCP: interstitial plasma cell pneumonia
affecting immunocompromised, particularly
HIV/AIDS.
• Pentamindine (Nebupent)indicated as a
prophylactic for patients susceptible to PCP.
Should be given once a month in a scavenger
nebulizer, 300 mg in 6ml water
• Know side effects of each antiinfective
Ch. 13
• Ribavirn (Virazole): for treatment of RSV/Hep
C, given with SPAG, multiple side effects
• Tobramycin (Tobi), 300 mg, for CF patients, or
anyone with pseudomonas. Strict dosing and
frequency requirments
• Zanamivir (relenza): influenza
• Amphotericin B: antifungal drugs is indicated
after a lung transplant
General Pharm-NMB
• Depolarizing vs Non-depolarizing Paralytic
– Mode of action
– Names in power point
• Indications
• Hazards
General Pharm-Narcotics
• Action – not completely understood, but affect neurotransmission
at specific sites in the CNS, affect autonomic nervous system
transmission
• Indications/hazards
• Know names of Opioid analgesics – high potency
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Morphine
Oxymorphone
Fentanyl
Methadone (Heroin wean)
Dilaudid
General Pharm-Narcotics
• Indications/hazards
• Know names of Opioid analgesics – high
potency
– Demerol
– Percocet/Oxycodone/Oxycontin
General Pharm-Narcotics
• Low Potency
– Codeine- found in cough meds
Side effects and hazards
• Hypotension
• Transient hyperglycemia
• Depression of respiratory system
• Cough reflex decreased
• Nausea and vomiting
Narcotic Antagonists
• Competitive replacement of narcotic from receptor site
• Pure antagonists
– Naloxone - (proprietary name – Narcan
Sedatives
• Benzodiazepines (anti-anxiety/muscle
relaxants)
– Ativan
– Versed
– Haldol
– Deprivan
Sedatives
• Hypnotics
– Valium
– Quaaludes
• Barbituates
– Phenobarbital (anti convulsant)