DH206: Pharmacology
CH 19:Respiratory
Lisa Mayo, RDH, BSDH
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Respiratory Drugs
Diseases treated with respiratory drugs
1. Asthma
2. COPD: emphysema, bronchitis
3. Upper respiratory infections
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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
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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)
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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
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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
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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)
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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
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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
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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
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Quick-Relief Meds
p. 224
1. Beta-Adrenergic Agents (Sympathomimetic Agents)
ß-2 Adrenergic Drugs
Albuterol(Proventil, Ventolin)
Metaproterenol(Alupent)
Levalbuterol(Xopenex)
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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
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β-agonist stimulates enzyme
AC to ↑ cAMP levels – results
in dilation
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Can be difficult for
kids to use: use a
separate connector –
can decrease amt of
drug administered
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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
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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
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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
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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
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NBQ
Which of the following drugs is classified as a β2-agonist
bronchodilator?
a.
b.
c.
d.
Albuterol
Ipratropium
Hydrocortisone
Montelukast
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NBQ
Which of the following drugs is classified as a β2-agonist
bronchodilator?
a.
b.
c.
d.
Albuterol
Ipratropium
Hydrocortisone
Montelukast
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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
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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)
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Muscarinic antagonists
block effects of ACH &
PANS – leads to
bronchodilation
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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
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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
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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
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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
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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)
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Long-Term Meds
Inhaled corticosteroids
Inhaled Corticosteroids
Beclomethasone dipropionate(Beclovent, Vanceril)
Budesonide(Pulmicort)
Flumisolide(Aerobid)
Fluticasone(Flovent, Advair)
Mometasone(Asmanex)
Triamcinolone(Azmacort)
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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
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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)
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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
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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)
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Theophylline inhibits enzyme PDE,
slows inactivation of cAMP, leads
to dilation
Theophylline
antagonizes
adenosine
(bronchoconstrictior)
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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
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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)
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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
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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)
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zafirlukast
(Accolate),
Zileutron
(Zoflo)
montelukast
(Singular)
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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
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Long-Term Meds
Immunomodulators
• Prevent IgE from binding to mast cells
Immunomodulators
Omalizumab(Xolair)
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omalizumab(Xolair)
Binds to receptors so allergen
cannot
omalizumab(Xolair)
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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
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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
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NBQ
Which of the following drugs is used to control mild persistent
asthma?
a.
b.
c.
d.
Albuterol
Ipratropium
Inhaled beclomethasone
Salmeterol
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NBQ
Which of the following drugs is used to control mild persistent
asthma?
a.
b.
c.
d.
Albuterol
Ipratropium
Inhaled beclomethasone
Salmeterol
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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
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Agents used to manage upper
respiratory tract infections
Agents used to manage upper respiratory tract infections
1) Nasal Decongestants
2) Expectorants & Mucolytics
3) Antitussives
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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
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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
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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
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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
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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
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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
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NBQ
Which of the following terms defines “suppressing a cough?”
a.
b.
c.
d.
Expectorant
Antitussive
Antihistamine
Antiasthma
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NBQ
Which of the following terms defines “suppressing a cough?”
a.
b.
c.
d.
Expectorant
Antitussive
Antihistamine
Antiasthma
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NBQ
Which of the following drugs MAY be contraindicated in
asthmatics?
a.
b.
c.
d.
Aspirin
Acetaminophen
Vitamin C
Folic acid
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NBQ
Which of the following drugs MAY be contraindicated in
asthmatics?
a.
b.
c.
d.
Aspirin
Acetaminophen
Vitamin C
Folic acid
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