DH206: Pharmacology CH 19:Respiratory Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Respiratory Drugs Diseases treated with respiratory drugs 1. Asthma 2. COPD: emphysema, bronchitis 3. Upper respiratory infections Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 2 http://www.ispot.tv/ad/7F8P/anoro-air-filled-world Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 3 Class of Resp. Diseases Clinic III Location Upper Resp Lower Resp Acute Rhinitis Sinusitis Pharyngitis/Tonsillitis Flu Acute bronchitis Pneumonia Chronic Allergic rhinitis TB Asthma COPD Cystic bronchitis Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 4 Respiratory Drugs Asthma • Considered an inflammatory disease • Chronic lung disease • Drug therapy aimed at relieving broncho-spasm & inflammation Airway Obstruction Caused By: Notations Bronchoconstriction Loss lung elasticity Mediated through ß-2 receptors Inflammation Results from mucous production Mediators are histamine, prostaglandins, leukotrienes, cytokines Loss lung elasticity Results from air sac enlargement Tx is difficult (long-term, high dose meds) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 5 2007 Guidelines for Management of Asthma USE THIS INSTEAD P.221, TABLE 19-1 EASIER TO UNDERSTAND THIS WAY ASTHMA TYPE THERAPY 1st LINE DRUGS 2nd LINE DRUGS Intermittent No meds Albuterol prn (B2-agonist) ------------ Mild Daily meds Inhaled corticosteroid Leukotriene modifier Methylxanthine Mast cell stabilizer Moderate Daily meds Inhaled corticosteroid OR LABA Leukotriene modifier Methylxanthine Severe Daily meds Inhaled corticosteroid + LABA Leukotriene modifier Methylxanthine Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 6 Respiratory Drugs 2007 Guidelines for Diagnosis & Management of Asthma • Number & frequency of meds ↑ as severity of asthma worsens • Beginning therapy: start with highest recommendations & stair- step down as patient needs • Inhaled meds preferred agents • High concentrations of drug delivered to airways with few systemic side effects • Severe asthma attacks 1) ß-2 agonist preferred agent (EPI) 2) Corticosteroid tablets to relieve inflammation 3) Oxygen Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 7 Respiratory Drugs Drug Delivery 1. Systemic: oral, parental 2. Inhaled: shorter onset, fewer side effects 1) Nebulizer 2) Dry powder inhaler 3) Metered-dose inhalers (most common delivery system) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 8 Respiratory Drugs Asthma Medications: 2 classes of medications 1. Quick-relief medications •Reliever/Acute rescue drugs 2. Long-term medications •Control, Maintenance meds •Taken daily •Most have anti-inflammatory effects Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 9 Respiratory Drugs Asthma Medications • 2 classes of medications 1. Quick-relief medications •Reliever/Acute rescue drugs 2. Long-term medications (mild, moderate, severe asthma & COPD) •Control, Maintenance meds •Taken daily •Most have anti-inflammatory effects Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 10 Quick-Relief Meds Produce bronchodilation Protype: albuterol(Ventolin, Proventil) Tx acute symptoms Not used for daily prevention Patients need to rinse after use (NBQ) DRUG CATEGORIES MECHANISM OF ACTION USES Beta-Adrenergic Agents (Sympathomimetic Agents) Stimulate beta-2 adrenergic receptors prn Anticholinergics Block cholinergic (muscarinic) receptors COPD Systemic corticosteroids Emergencies Asthma or COPD Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 11 Quick-Relief Meds p. 224 1. Beta-Adrenergic Agents (Sympathomimetic Agents) ß-2 Adrenergic Drugs Albuterol(Proventil, Ventolin) Metaproterenol(Alupent) Levalbuterol(Xopenex) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 12 Quick-Relief Meds 1. Beta-Adrenergic Agents (Sympathomimetic Agents) • NON-SELECTIVE (stimulate β-1 & β-2) o2 drugs: Epi & isopreterenol(Isuprel) oWhen used to tx asthma – will also ↑ heart rate • SELECTIVE oSelective beta-2 drugs are BEST: bronchodilators oFewer effects on beta-1 Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 13 Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 14 β-agonist stimulates enzyme AC to ↑ cAMP levels – results in dilation Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 15 Can be difficult for kids to use: use a separate connector – can decrease amt of drug administered Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 16 NBQ After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth? a. b. c. d. Ipratropium Cromlyn sodium Metaproterenol Theophylline Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 17 NBQ After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth? a. b. c. d. Ipratropium Cromlyn sodium Metaproterenol Theophylline Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 18 NBQ Which of the following drugs is the drug of choice for the quick relief of bronchospasm? a. b. c. d. Albuterol Ipratropium Hydrocortisone Salmeterol Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 19 NBQ Which of the following drugs is the drug of choice for the quick relief of bronchospasm? a. b. c. d. Albuterol Ipratropium Hydrocortisone Salmeterol Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 20 NBQ Which of the following drugs is classified as a β2-agonist bronchodilator? a. b. c. d. Albuterol Ipratropium Hydrocortisone Montelukast Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 21 NBQ Which of the following drugs is classified as a β2-agonist bronchodilator? a. b. c. d. Albuterol Ipratropium Hydrocortisone Montelukast Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 22 Quick-Relief Drugs p.226 2. Anticholinergic Agents: used for tx COPD, not asthma DRUG NOTATIONS Ipratropium bromideHFA(Atrovent) PROTYPE Nasal spray: useful for rhinitis Ipratropium bromide + albuterol sulfate(Combivent) Tiotropium bromide(Spiriva) LONG-TERM, NOT SHORT ACTING FOR TX COPD Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 23 Quick-Relief Drugs 2. Anticholinergic Agents • Action: Inhibit ACH receptors on smooth muscle= bronchodilation • Protype: ipratropium bromide(Atrovent) • Adverse effects • Xerostomia • Taste alteration • Instruct pt to rinse mouth after each inhalation (NBQ) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 24 Muscarinic antagonists block effects of ACH & PANS – leads to bronchodilation Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 25 Quick-Relief Drugs 3. Systemic corticosteroids • Used when asthma cannot be controlled by bronchodilators alone • Short-term • Decrease inflammation • Systemic delivery = acute attacks Inhaled delivery = chronic, long-term therapy Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 26 Respiratory Drugs Asthma Medications • 2 classes of medications 1. Quick-relief medications •Reliever/Acute rescue drugs 2. Long-term medications •Control, Maintenance meds •Taken daily •Most have anti-inflammatory effects Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 27 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists Asthma or COPD (LABA) (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 28 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 29 Long-Term Meds Inhaled corticosteroids • • • • • Drug of choice for persistent asthma 1st line long-term therapy Potent & effective anti-inflammatory agents Decrease airway hyper-reactivity & swelling Rinse mouth after inhaler use (NBQ) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 30 Long-Term Meds Inhaled corticosteroids Inhaled Corticosteroids Beclomethasone dipropionate(Beclovent, Vanceril) Budesonide(Pulmicort) Flumisolide(Aerobid) Fluticasone(Flovent, Advair) Mometasone(Asmanex) Triamcinolone(Azmacort) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 31 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 32 Long-Term Meds Selective long-acting ß-2 Agonists (LABA) • Bronchodilators • Not used alone – usually in combo w/corticosteroids • Black box: NOT to be used as stand alone tx – increase risk of asthma-related deaths Selective long-acting ß-2 Agonists Salmeterol(Serevent) Formoterol(Foradil) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 33 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 34 Long-Term Meds Methylxanthines • Bronchodilators that relax the airway smooth muscle • COPD • Many drug interactions • Erythromycin • Clarithromycin • Caffeine: can cause mild bronchodilation in patients with asthma (100mg which is in a cup of coffee) Methylxanthines Theophylline(Slo-Phyllin),TheoDur, Theo-24) Aminophylline(norphyl) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 35 Theophylline inhibits enzyme PDE, slows inactivation of cAMP, leads to dilation Theophylline antagonizes adenosine (bronchoconstrictior) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 36 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 37 Long-Term Meds Mast cell stabilizers p.225, books calls this category cromolyn • Inhibit release of histamine (decrease inflammation) Mast Cell Stabilizers Cromolyn sodium(Intal) Nedocromil(Tilade) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 38 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 39 Long-Term Meds Leukotrienes Modifiers • Block activity of arachidonic acid derivatives = decrease inflammation • P-450 enzyme induction • Drug interactions • Aspirin • Erythromycin • Increase effect Warfarin Leukotriene Modifiers Zafirukast(Accolate) Montelukast(Singular) Zileutron(Zyflo) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 40 zafirlukast (Accolate), Zileutron (Zoflo) montelukast (Singular) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 41 Long-Term Meds Inhaled corticosteroids Asthma Selective long-acting ß-2 Agonists (LABA) Asthma or COPD (never used as stand-along therapy, always in combo) Methylxanthines COPD IV for status asthmaticus Mast cell stabilizers Asthma Leukotrienes Modifiers Asthma Immunomodulators Asthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 42 Long-Term Meds Immunomodulators • Prevent IgE from binding to mast cells Immunomodulators Omalizumab(Xolair) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 43 omalizumab(Xolair) Binds to receptors so allergen cannot omalizumab(Xolair) Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 44 NBQ Which of the following drugs is preferred for long-term control of asthma? a. b. c. d. B-1 agonist B-2 agonist Inhaled corticosteroid Oral corticosteroids Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 45 NBQ Which of the following drugs is preferred for long-term control of asthma? a. b. c. d. B-1 agonist B-2 agonist Inhaled corticosteroid Oral corticosteroids Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 46 NBQ Which of the following drugs is used to control mild persistent asthma? a. b. c. d. Albuterol Ipratropium Inhaled beclomethasone Salmeterol Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 47 NBQ Which of the following drugs is used to control mild persistent asthma? a. b. c. d. Albuterol Ipratropium Inhaled beclomethasone Salmeterol Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 48 Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 49 DH Considerations • Aspirin & NSAIDs contraindicated in asthmatic patients (can lead • • • • • to bronchospasm) Anticholinergic side effects Consult MD in SEVERE asthma cases Inhalers brought to appts Systemic corticosteroids – pt may need increase dose morning of apt Inhalers: advise pt to rinse after to avoid dry mouth & oral candidiasis Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 50 Agents used to manage upper respiratory tract infections Agents used to manage upper respiratory tract infections 1) Nasal Decongestants 2) Expectorants & Mucolytics 3) Antitussives Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 51 Agents used to manage upper respiratory tract infections 1) Nasal Decongestants • Constrict blood vessels in nasal mucous membranes • Chronic use may result in rebound swelling and congestion • Book correction: not all nasal decongestants are α-agonists (p.226) • Remember: Patanase is a nasal antihistamine, not a decongestant Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 52 Agents used to manage upper respiratory tract infections Nasal Decongestants phenylephrine (Neo-Synephrine, Sinex, Allerest) α-agonist pseudoephedrine(Sudafed, Sucrets, Actifed) α-agonist Beclomethasone(Beconase,Vancenase) Corticosteroid Nasal spray Mometasone(Nasonex) Corticosteroid Nasal spray Fluticasone(Flonase) Corticosteroid Nasal spray Budesonide(Rhinocort) Corticosteroid Nasal spray Flunisolide(Nasalide) Corticosteroid Nasal spray Cromolyn(Nasalcrom) OTC nasal spray Nedocromil(Tiladle) Nasal spray for asthma & rhinitis Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 53 NBQ Which of the following types of agents are nasal decongestants? a. b. c. d. B-1 agonist B-2 blockers Alpha-1 agonist Alpha-2 blockers Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 54 NBQ Which of the following types of agents are nasal decongestants? a. b. c. d. B-1 agonist B-2 blockers Alpha-1 agonist Alpha-2 blockers Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 55 Agents used to manage upper respiratory tract infections 2) Expectorants & Mucolytics • Mucolytics • Promote removal of exudate or mucus from respiratory passages • Liquefying & decrease viscosity of mucus • Acetylcysteine(Mucosil): Useful in cystic fibrosis • Expectorants • Drugs that facilitate the removal of thickened mucus secretions from the lungs • Action: ↑ bronchial = liquefy mucus • Guaifenesin(Mucinex) most popular Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 56 Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 57 Agents used to manage upper respiratory tract infections 3) Antitussives: agents used to suppress cough Drugs Notations Opioids: (Codeine, Hydrocodone, Hydromorphone) Narcotic opioid Avoid in asthmatic (cause respiratory depression) Dextromethorphan(Robitussin, Vicks) Non-narcotic Many OTC products contain Benzonatate(Tessalon) Non-narcotic Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 58 NBQ Which of the following terms defines “suppressing a cough?” a. b. c. d. Expectorant Antitussive Antihistamine Antiasthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 59 NBQ Which of the following terms defines “suppressing a cough?” a. b. c. d. Expectorant Antitussive Antihistamine Antiasthma Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 60 NBQ Which of the following drugs MAY be contraindicated in asthmatics? a. b. c. d. Aspirin Acetaminophen Vitamin C Folic acid Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 61 NBQ Which of the following drugs MAY be contraindicated in asthmatics? a. b. c. d. Aspirin Acetaminophen Vitamin C Folic acid Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 62 Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 63