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© Paradigm Publishing, Inc. 1
Chapter 9
Respiratory Drugs
© Paradigm Publishing, Inc. 2
Learning Objectives
• Differentiate the pulmonary diseases.• Learn the pathophysiology and treatment of
asthma.• Define the goals of asthma treatment.• Discuss the pathophysiology and treatment
of emphysema and chronic bronchitis.• Describe other diseases related to the
lungs.
© Paradigm Publishing, Inc. 3
Learning Objectives
• Be aware of the reemergence of tuberculosis and of treatment for this disease.
• Understand how the antitussives, expectorants, decongestants, and antihistamines differ, and be able to describe their uses.
• Know why some drugs are prescribed for their side effects.
• Outline smoking cessation plans and supportive therapy.
4© Paradigm Publishing, Inc.
Asthma
• Inflammatory disease in which inflammation causes the airways to tighten
• Reversible condition
• Intermittent attacks are precipitated by specific triggering events
• Causes a decrease in the amount of oxygen and carbon dioxide exchanged
5© Paradigm Publishing, Inc.
Three Classes of Asthma
• Allergic– Present in 35% to 55% of patients
• Exercise Induced
• Nonallergic
6© Paradigm Publishing, Inc.
Upper and Lower Respiratory Tracts
7© Paradigm Publishing, Inc.
Oxygen and Carbon Dioxide Exchange
8© Paradigm Publishing, Inc.
Asthma
• An asthmatic lung compared to a normal lung– More sensitive
– Responds to lower doses of allergens
• Studies strongly support genetic predisposition to developing asthma
9© Paradigm Publishing, Inc.
Characteristics of Asthma
1. Reversible small airway obstruction
2. Progressive airway inflammation
3. Increased airway responsiveness to variety of stimuli
10© Paradigm Publishing, Inc.
Characteristics of Asthma
• These 3 characteristics translate into– Wheezing– Dyspnea– Acute and chronic cough
11© Paradigm Publishing, Inc.
Asthma Attack: First Response
• Triggered by an antigen-antibody reaction
• Causes degranulation of mast cells which release histamine
• Result: bronchospasm and increased mucus production that plugs the small airways
12© Paradigm Publishing, Inc.
Asthma Attack: Second Response
• Bronchoconstriction with delayed, sustained reactions
• Causes self-sustaining inflammation
13© Paradigm Publishing, Inc.
Asthmatic Response
14© Paradigm Publishing, Inc.
Peak Flow Meter
• Expiratory peak flow rate (PEFR) is the most useful measure to assess– Severity– Course of asthma
• Patient blows into peak flow meter, PEFR recorded in liters/minute
• Aids in determining course of therapy
15© Paradigm Publishing, Inc.
Six Goals of Asthma Care
• Sleep well every night• Be able to go to work or school every day• Be free from wheezing all day• Have good control of coughing• Be able to continue with activities and
exercise• Tolerate medicines well
16© Paradigm Publishing, Inc.
Asthma Management for Patients
• Know triggers and limit them
• Accurately use a Peak Flow Meter regularly
• Be aware of status asthmaticus, a medical emergency– Requires prompt attention– May require emergency room
17© Paradigm Publishing, Inc.
Asthma Drug Therapy
• Drug therapy mainstay of asthma management
• Drug therapy depends on persistence of asthma attacks
• Asthma begins with intermittent attacks. May progress to mild-to-severe, persistent symptoms
18© Paradigm Publishing, Inc.
Devices Used in Asthma Therapy
• Metered dose inhaler (MDI)– Contains medication and compressed air– Delivers specific amount of medication with
each puff
• Spacer– Used with MDIs to get medication into lungs
instead of depositing on back of throat
• Nebulizer
19© Paradigm Publishing, Inc.
Nebulizers
• Uses stream of air that flows through liquid medication to make a fine mist for inhalation
• Very effective
• Must be cleaned and taken care of to reduce risk of contamination
• Used for young children
20© Paradigm Publishing, Inc.
HFA Inhalers
• CFCs were propellants of MDIs– Depleted Earth’s ozone layer
– Banned in late 1980s
• In 2008 FDA required MDIs to be converted to hydrofluroalkane (HFA), known as HFA MDI inhalers
• HFA inhalers produce finer mist with better lung deposit of drug
21© Paradigm Publishing, Inc.
Dry Powder Inhalers
• Alternative to CFC-propelled inhalers, no gases used
• Many manufacturers incorporating drugs into dry-powder inhalers
• To use– Pellet placed in inhaler and crushed– When user inhales, inhaler activates
22© Paradigm Publishing, Inc.
Priming MDIs
• Prime MDIs before first use, if dropped, or not used for several weeks
• To prime, shake inhaler for 5 seconds. Release spray.
• Also, shake MDIs well before each use
23© Paradigm Publishing, Inc.
Six Steps to Use HFA MDIs
1. Remove cap and shake inhaler.
2. Breathe out all the way.
3. Place mouthpiece between lips.
4. Press down on inhaler, hold for a few seconds, then breathe in slowly.
5. Hold breath and count to 10.
6. Breathe out slowly.
24© Paradigm Publishing, Inc.
Five Steps to Use Dry-Powder MDIs
1. Activate the inhaler, insert disk, etc.
2. Breathe out all the way.
3. Place mouthpiece to your lips and breathe in quickly.
4. Hold breath and count to 10.
5. Breathe out slowly.
25© Paradigm Publishing, Inc.
More MDI Use Instructions
• For a second puff, wait about 1 minute, then return to Step 1.
• If another inhaler is prescribed, wait 5 minutes before use.
• Clean mouthpiece after every use
• Rinse mouthpiece if corticosteroid is used
• Treatment should be reviewed every 3 to 6 months
26© Paradigm Publishing, Inc.
Bronchodilators
• Agents that relax smooth-muscle cells of the bronchioles– Airway diameter increases
– Gases moving in and out of lungs improve
• When using different medications, bronchodilators always used first
27© Paradigm Publishing, Inc.
Medications Needed By Patients with Asthma
• Both a long-term medication and a rescue medication to treat asthma and control attacks
• Inhaled corticosteroids are the most effective medications
© Paradigm Publishing, Inc. 28
Drug ListAsthma Agents
Bronchodilators– albuterol (Proventil, Proventil HFA,
Ventolin HFA, ProAir HFA)– epinephrine (EpiPen)– formoterol (Foradil, Perforomist)– ipratropium (Atrovent)– isoproterenol (Isuprel)
© Paradigm Publishing, Inc. 29
Drug ListAsthma Agents
Bronchodilators– levalbuterol (Xopenex)– metaproterenol (Alupent)– pirbuterol (Maxair)– salmeterol (Serevent)– terbutaline (Brethine)– tiotropium (Spiriva)
30© Paradigm Publishing, Inc.
epinephrine (EpiPen)
• Drug of choice for acute attack of asthma
• Many patients with asthma carry an EpiPen
31© Paradigm Publishing, Inc.
Dispensing Issues of epinephrine
• Look-alike and sound-alike– Epinephrine
– Ephedrine
Warning!
32© Paradigm Publishing, Inc.
Short-Acting Inhaled Bronchodilators
• albuterol– Relaxes bronchial smooth muscle with
little effect on heart rate, duration of 3 to 6 hours
• isoproterenol– Relaxes bronchial smooth muscle, use
up to 5x/day, maximum of 6 inhalations/hour
33© Paradigm Publishing, Inc.
Short-Acting Inhaled Bronchodilators
• metaproterenol– Onset of action within minutes, duration
of action 4 hours, little effect on heart rate
• pirbuterol– Prevent and treat bronchospasm,
duration of action 4 to 6 hours, use up to 12x/day
34© Paradigm Publishing, Inc.
Dispensing Issues of albuterol
• Proventil HFA and ProAir HFA cannot be interchanged
• If Rx for an albuterol inhaler, any of the 3 brands can be used
Warning!
35© Paradigm Publishing, Inc.
levalbuterol (Xopenex)
• Isomer of albuterol
• Can be prescribed at lower doses than albuterol
• Has fewer side effects than albuterol
36© Paradigm Publishing, Inc.
ipratropium (Atrovent)
• Blocks ACh in bronchial smooth muscle causing bronchodilation
• Used for prevention of attacks, not rescue situations
• Short-acting, does not cause arrhythmias
37© Paradigm Publishing, Inc.
Dispensing Issues of ipratropium (Atrovent)
• Patient with peanut allergy may be allergic to suspending agent in the inhaler
• Warning about possible allergy problem may not appear in computer when drug is dispensed
Warning!
38© Paradigm Publishing, Inc.
Long-Acting Inhaled Bronchodilators
• salmeterol– For maintenance therapy, use exactly as
directed, not for acute situations, long duration useful during night
• terbutaline– For reversible airway obstruction and
bronchial asthma
39© Paradigm Publishing, Inc.
Long-Acting Inhaled Bronchodilators
• Formoterol (Foradil)– Onset of action within minutes (faster
than salmeterol), acts locally in lungs to relax smooth muscle and inhibit release of mast cells
– Refrigerate until dispensed
40© Paradigm Publishing, Inc.
Dispensing Issues of Formoterol (Foradil)
• Do not need to refrigerate after dispensing and good for 4 months
• Technician must write on box the date after which the drug should be discarded (expiration date or 4 months after dispensing)
Warning!
41© Paradigm Publishing, Inc.
Asthma Agents: Xanthine Derivatives
• Drugs structurally similar to caffeine
• Causes relaxation of airway smooth muscle
• Result: Airway dilution and better air movement
© Paradigm Publishing, Inc. 42
Drug ListAsthma AgentsXanthine Derivatives
– aminophylline (Truphylline)– theophylline (Theo 24, TheoAir)
43© Paradigm Publishing, Inc.
theophylline (Theo 24, TheoAir)
• Use only in lung diseases unresponsive to other drugs because it has many interactions
• Blood levels can become elevated quickly
44© Paradigm Publishing, Inc.
Asthma Agents:Leukotriene Inhibitors
• Increase edema, mucus, and vascular permeability– Substances can pass through blood vessels
• 100 to 1,000 times more potent than histamine
• Block synthesis of, or the body’s inflammatory responses to, leukotrienes
© Paradigm Publishing, Inc. 45
Drug ListAsthma AgentsLeukotriene Inhibitors
– montelukast (Singulair)– zafirlukast (Accolate)– zileuton (Zyflo)
46© Paradigm Publishing, Inc.
montelukast (Singulair)
• Indicated for prophylaxis and chronic treatment of asthma
• Do not use to treat acute attacks• Approved for use in adults and children 12
months and older• Once-daily dosage• Also used to treat seasonal allergiesa
47© Paradigm Publishing, Inc.
zafirlukast (Accolate)
• Indicated for prophylaxis and long-term treatment in children 5 years and older
• Antagonizes leukotriene receptors which reduces edema, mucus, and vascular permeability
• Good results reported with few side effects
48© Paradigm Publishing, Inc.
zileuton (Zyflo)
• Reduces production of leukotrienes• Strong warnings about liver toxicity• Can double theophylline levels• Approved for patients 12 years or older
49© Paradigm Publishing, Inc.
Asthma Agents:Corticosteroids
• Anti-inflammatory agents that suppress the immune response
• Used for more difficult cases of asthma• Usually prescribed on alternate-day basis
or as tapering doses when short-term therapy is indicated
• Many patients with asthma still not using
50© Paradigm Publishing, Inc.
Primary Side Effects of Corticosteroids
• Oral candidiasis
• Irritation and burning of nasal mucosa
• Hoarseness
• Dry mouth
51© Paradigm Publishing, Inc.
Side Effects of Long-Time Use of Oral Corticosteroids
• Growth of facial hair in females
• Breast development in males
• “Buffalo hump,” “moon face”
• Edema
• Weight gain
• Easy bruising
52© Paradigm Publishing, Inc.
Corticosteroids
• Always use lowest effective dose
• Add salmeterol to inhaled corticosteroids if needed to decrease the dose of corticosteroid needed for control
53© Paradigm Publishing, Inc.
Dispensing Issues of Corticosteroids
• Patient should rinse mouth with water after using inhalers to prevent oral candidiasis
• Patient should be taught how to correctly use these medications
Warning!
© Paradigm Publishing, Inc. 54
Drug ListAsthma Agents: Corticosteroids
– beclomethasone (Beconase AQ, QVAR, Vanceril)
– budesonide (Entocort EC, Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort)
– dexamethasone (Decadron)
– flunisolide (AeroBid)
– fluticasone (Flonase, Flovent)
© Paradigm Publishing, Inc. 55
Drug ListAsthma Agents: Corticosteroids
– hydrocortisone (Solu-Cortef)
– methylprednisolone (Medrol Dose-Pack, Solu-Medrol)
– mometasone furoate (Asmanex)
– prednisolone (Orapred, Pediapred)
– prednisone (Deltasone)
– triamcinolone (Azmacort, Nasacort AQ)
56© Paradigm Publishing, Inc.
fluticasone (Flonase, Flovent)
• Flonase (Flovent) is same drug in nasal spray Flonase
• Flovent comes in 3 strengths– Lowest for mild asthma– Highest to wean patients off oral
corticosteroids
• 1 to 2 weeks to reach maximum benefit
57© Paradigm Publishing, Inc.
budesonide (Entocort EC, Pulmicort Respules, Pulmicort
Turbuhaler, Rhinocort)• Pulmicort Turbuhaler
– Dry powder inhaler, breath activated, primed only prior to initial use
– Easier to use
• Pulmicort Respules for home nebulizers, age 12 months or older
58© Paradigm Publishing, Inc.
mometasone furoate (Asmanex)
• Dry powder for inhalation
• Twisthaler dispenser with dose counter
• Used for prophylactic therapy, maximum benefit can take 2+ weeks
• Major side effect: headache
© Paradigm Publishing, Inc. 59
Drug ListAsthma Agents
Mast Cell Stabilizers– cromolyn sodium (Crolom,
Gastrocrom, Intal, Opticrom, Nasalcrom)
– nedocromil (Tilade)
© Paradigm Publishing, Inc. 60
Drug ListAsthma AgentsMonoclonoal Antibody
– omalizumab (Xolair)
Combination Drugs– fluticasone-salmeterol (Advair
Diskus)
61© Paradigm Publishing, Inc.
fluticasone-salmeterol (Advair Diskus)
• Combines corticosteroid (anti-inflammatory) and a beta-2 agonist
• Indicated for maintenance therapy in patients 12 years and older
• Available in powder for inhalation
• Should not be used with a spacer
© Paradigm Publishing, Inc. 62
Terms to Remember
asthma
bronchospasm
peak flow meter
peak expiratory flow rate (PEFR)
status asthmaticus
metered dose inhaler (MDI)
© Paradigm Publishing, Inc. 63
Terms to Remember
spacer
nebulizer
bronchodilator
xanthine derivative
leukotriene inhibitor
corticosteroid
© Paradigm Publishing, Inc. 64
Terms to Remember
mast cell stabilizer
monoclonal antibody
65© Paradigm Publishing, Inc.
Chronic Obstructive Pulmonary Disease (COPD)
• Emphysema and chronic bronchitis
• COPD is irreversible
66© Paradigm Publishing, Inc.
Emphysema
• Characterized by destruction of air sacs which lose ability to exchange oxygen and carbon dioxide
• Early stages: shortness of breath after heavy exercise
• As disease progresses– Patient gasps for air after short walk– Causes tachypnea, patient looks flushed
67© Paradigm Publishing, Inc.
Major Risk Factors For Emphysema
• Cigarette smoking– Destroys walls of lungs
• Occupational exposure
• Air pollution
• Genetic factors
68© Paradigm Publishing, Inc.
Bronchitis
• Lining of the bronchial airways becomes inflamed
• Causes patient to have difficulty breathing out
69© Paradigm Publishing, Inc.
Two Types of Bronchitis
• Acute– Caused by infection, usually viral– Runs a brief course
• Chronic – Longer lasting condition
70© Paradigm Publishing, Inc.
Chronic Bronchitis
• Difficult to breathe out• Characterized by cough that produces
purulent, green, or blood-streaked sputum • Major risk factors
– Cigarette smoking– Exposure to occupational dusts, fumes, and
environmental pollution– Bacterial infection
71© Paradigm Publishing, Inc.
Natural Defense System of the Lungs
• In properly functioning system– Provides good protection against
pathogens– Removes potentially infectious agents
from the lungs
72© Paradigm Publishing, Inc.
Six Types of Body Defense Cells
• Ciliary carpet rhythmically moves fluid or mucus up and out of lungs
• Goblet cells secrete mucus
• Clara cells secrete enzymes that break down airborne toxins
• Epithelial cells produce protein-rich exudate
73© Paradigm Publishing, Inc.
Six Types of Body Defense Cells
• Type I pneumocytes in alveolar membranes act as phagocytes by clearing trash and organisms from the lung
• Type II pneumocytes synthesize and secrete surfactant
74© Paradigm Publishing, Inc.
Cellular Makeup of an Alveolus and Capillary Supply
75© Paradigm Publishing, Inc.
Drug Management of Emphysema and Bronchitis
• Largely empirical
• Methylxanthines, corticosteroids, beta agonists, and ipratropium form the foundation of therapy
• One of the best expectorants is water
© Paradigm Publishing, Inc. 76
Drug ListAgents for COPDMucolytics
– acetylcysteine (Acetadote, Mucomyst)
– dornase alfa (Pulmozyme)
Anticholinergic– tiotropium (Spiriva)
© Paradigm Publishing, Inc. 77
Drug List
Agents for COPDBeta Agonists
– arformoterol (Brovana)– formoterol (Perforomist)– isoproterenol (Isuprel)– metaproterenol (Alupent)
© Paradigm Publishing, Inc. 78
Drug List
Agents for COPDCombinations
– ipratropium-albuterol (Combivent, DuoNeb)
– fluticasone-salmeterol (Advair Diskus)
79© Paradigm Publishing, Inc.
Drugs Indicated Only for Treatment of COPD
• tiotropium (Spiriva) – Similar to ipratropium (Atrovent), but is
dosed 1x/daily
• Combivent, DuoNeb, Brovana, and Perforomist
© Paradigm Publishing, Inc. 80
Terms to Remember
emphysemaan irreversible lung disease
characterized by destruction of the alveoli in the lungs, which allows air to accumulate in tissues and organs
tachypneavery rapid respiration causing a flushed appearance; a characteristic of
emphysema
© Paradigm Publishing, Inc. 81
Terms to Remember
bronchitisa condition in which the inner lining of the bronchial airways becomes inflamed, causing the expiration of air from the lungs to be obstructed
mucolytican agent that destroys or dissolves mucus
82© Paradigm Publishing, Inc.
Other Lung Diseases
• Most respiratory infections transmitted through hand contact
83© Paradigm Publishing, Inc.
Prevention of Lung Diseases
• Do not smoke
• Avoid secondhand smoke
• Avoid air pollution
• Get vaccinations for influenza and pneumonia
• Wash hands
84© Paradigm Publishing, Inc.
Pneumonia
• Common lung disease, affects all ages• Can become infected by microorganisms
that cause pneumonia by– Inhalation of aerosolized particles– Entrance through the bloodstream– Aspiration (inhalation of fluids from the mouth
and throat), commonly occurs during sleep
85© Paradigm Publishing, Inc.
X-Ray of Pneumonic Lung
X-ray of a patient with pneumonia that shows fluid in the right lung
© Paradigm Publishing, Inc. 86
Discussion
Why is cigarette smoke implicated in many diseases that affect the lungs?
The chemicals in cigarette smoke destroy the walls of the lungs, including the
protective mechanisms.
87© Paradigm Publishing, Inc.
Cystic Fibrosis
• Hereditary disease that affects the GI and respiratory systems
• Fatal disease; death is associated with the pulmonary system
• GI involvement– Increase in production and viscosity of
mucus – Decreased pancreatic digestive enzymes
88© Paradigm Publishing, Inc.
Cystic Fibrosis Therapy
• Percussion– Tapping movement to induce cough and
expectoration of sputum from lungs
• Nebulizer therapy
• Antibiotic therapy
• Annual flu vaccine due to high risk from complications of influenza
89© Paradigm Publishing, Inc.
Respiratory Distress Syndrome (RDS)
• Occurs in newborns during first few hours
• Characterized by inadequate production of pulmonary surfactant– Fluid lowers surface tension between
alveoli, causing their collapse
• RDS treated with surfactants
90© Paradigm Publishing, Inc.
Respiratory Distress Syndrome (RDS)
• Two causes of RDS– Prematurity– Maternal diabetes
• If RDS occurs, replacement surfactant administered
© Paradigm Publishing, Inc. 91
Drug ListSurfactants for Respiratory Distress Syndrome
– beractant (Survanta)– calfactant (Infasurf)– colfosceril palimate (Exosurf
Neonatal)– poractant alfa (Curosurf)
92© Paradigm Publishing, Inc.
beractant (Survanta)
• Drug of choice for RDS• Extracted from cattle lung• Lowers surface tension between the
alveoli to keep them from collapsing• Therapy
– Prophylactic for high risk infants– Rescue within 8 hours of birth
93© Paradigm Publishing, Inc.
Tuberculosis
• Caused by bacterium mycobacterium tuberculosis
• Primarily affects the lungs, may also affect other body tissues and organs
• Transmission through inhaled droplets from an infected person– Droplets descend 1 to 2 inches per hour
94© Paradigm Publishing, Inc.
Tuberculosis (TB)
• Seen primarily in– Alcoholics– Prison population– Immunocompromised– Elderly
95© Paradigm Publishing, Inc.
Two Classes of Tuberculosis
• Exposed, but showing no disease– Test positive on TB test, may not have active
disease
• Exposed and have active organisms– May or may not produce antibodies– Signs and symptoms: weight loss, spitting
blood, night sweats and night fever, chest pain, malaise
96© Paradigm Publishing, Inc.
TB Test
• Protein derivative from killed bacteria injected intradermally
• If patient has been exposed to or has disease, test will be positive
• If positive, patient must have x-rays to look for signs of active disease
97© Paradigm Publishing, Inc.
Four Goals of TB Therapy
• Initiate treatment promptly
• Convert sputum culture to negative as soon as possible
• Achieve cure without relapse
• Prevent emergence of drug-resistant strains
© Paradigm Publishing, Inc. 98
Drug ListAgents for Tuberculosis
– capreomycin (Capastat)– ciprofloxacin (Cipro)– cycloserine (Seromycin)– ethambutol (Myambutol)– ethionamide (Trecator-SC)
© Paradigm Publishing, Inc. 99
Drug ListAgents for Tuberculosis
– isoniazid (INH) (Laniazid, Nydrazid)– isoniazid-pyrazinamide-rifampin
(Rifater)– isoniazid-rifampin (Rifamate)– ofloxacin (Floxin)– pyrazinamide (none)
© Paradigm Publishing, Inc. 100
Drug ListAgents for Tuberculosis
– rifampin (Rifadin, Rimactane)– rifapentine (Priftin)– streptomycin (none)
101© Paradigm Publishing, Inc.
TB Treatment Regimens
• Patients with no symptoms, but positive x-ray– Single agent, usually INH 300 mg QD X
12 months
• Patients with clinical disease– At least 2 agents at a time to prevent
development of drug-resistance bacteria
102© Paradigm Publishing, Inc.
Multidrug Resistant Tuberculosis (MDR-TB)
• MDR-TB, a new strain, has emerged and is resistant to commonly used drugs
• Risk factors for acquiring MDR-TB– Being exposed to MDR-TB
– Not completing TB therapy
– Being prescribed inappropriate agents
– Having immune deficiencies
– Having recurrence of TB
103© Paradigm Publishing, Inc.
Side Effects of Rifampin (Rifadin, Rimactane)
• Reddish-orange discoloration of urine, tears, sweat, other body fluids
• Can permanently stain soft contact lenses
© Paradigm Publishing, Inc. 104
Discussion
Why is patient compliance such an issue with tuberculosis patients?
Patient noncompliance is due to severe side effects, length of time for therapy, and the number of medications. Patients being treated for active TB should avoid alcohol, which is a problem for some populations.
105© Paradigm Publishing, Inc.
Histoplasmosis
• Fungal pulmonary disease• Caused by breathing in spores from
droppings of chickens, pigeons, starlings, other birds, and bats
• Called the summer flu due to flu-like symptoms
• Treatment: Amphotericin B and itraconazole
© Paradigm Publishing, Inc. 106
Terms to Remember
pneumonia
aspiration
cystic fibrosis (CF)
percussion
respiratory distress syndrome
surfactant
© Paradigm Publishing, Inc. 107
Terms to Remember
tuberculosis (TB)
histoplasmosis
108© Paradigm Publishing, Inc.
Cough, Cold, and Allergy
• Common cold most prevalent respiratory tract infections; viral infection
• Symptoms– Mild malaise– Rhinorrhea (runny nose)– Sneezing– Scratchy throat– Fever
109© Paradigm Publishing, Inc.
Colds
• Bacterial sinusitis and otitis media are frequent complications warranting antibiotic therapy
110© Paradigm Publishing, Inc.
Allergies
• Symptoms of some allergies same as colds, like runny nose and itchy eyes
• Allergy is state of hypersensitivity induced by exposure to particular antigen
• Colds and many allergies treated with same medications
111© Paradigm Publishing, Inc.
OTC Products for Colds and Coughs
• People self-treat colds and coughs to relieve symptoms and prevent complications
• 4 groups of drugs, alone or combinations: antitussives, expectorants, decongestants, antihistamines. Most are OTCs– Each has different mechanism of action and
purpose
112© Paradigm Publishing, Inc.
OTC Products for Colds and Coughs
• Pharmacy technicians cannot make OTC remedy recommendations
• Technicians can– Direct patient to OTC remedies– Make patient aware of proper uses and side
effects
• Tavist (clemastine) only drug approved by FDA to treat colds
113© Paradigm Publishing, Inc.
Transmitting Colds
• Colds transmitted person to person– Directly when infected person sneezes
or coughs– Indirectly by surfaces such as
telephones, doorknobs, toys
• To cough, turn head and cough into shoulder, not the hand
114© Paradigm Publishing, Inc.
Preventing Colds
• Often contract cold by rubbing eyes or nose after touching contaminated surface or people with cold
• Best prevention is to wash hands
• In pharmacy, wipe phones with alcohol regularly
115© Paradigm Publishing, Inc.
Antitussives
• Coughing clears airways of excess secretions and foreign materials
• Reduce the frequency of a cough, especially if dry and nonproductive– CNS depression of cough center (reflex)
116© Paradigm Publishing, Inc.
Cough Reflex and Antitussives
• Cough reflex stimulated by stretch receptors and irritant receptors in lungs and airway
• Antitussive products – Correct or block irritation of receptors– Block transmission to brain– Increase cough center threshold– Block action of expiratory muscles
© Paradigm Publishing, Inc. 117
Drug List
Antitussives– benzonatate (Tessalon)– codeine (various combinations)– dextromethorphan (Delsym)– diphenhydramine (Benadryl)– hydrocodone-chlorpheniramine
(Tussionex)
© Paradigm Publishing, Inc. 118
Drug List
Antitussives– promethazine-codeine (Phenegran
with codeine
© Paradigm Publishing, Inc. 119
Drug List
AntitussivesDextromethorphan Combinations
– dextromethorphan-pseudoephedrine-brompheniramine (Bromfed-
DM, Myphetane DX)– guaifenesin-dextromethorphan
(Mucinex DM)– promethazine-dextromethorphan
(none)
120© Paradigm Publishing, Inc.
Codeine
• The “Gold Standard,” against which all other antitussives are compared
• Drying effect on respiratory mucosa
• C-V, but can be purchased without a prescription in some states – Dispensing must be done by the pharmacist
who writes initials by patient’s signature
121© Paradigm Publishing, Inc.
Side Effects of Codeine
• Nausea
• Drowsiness
• Light-headedness
• Constipation
• Take with food to decrease stomach upset
122© Paradigm Publishing, Inc.
hydrocodone-chlorpheniramine (Tussionex)
• Often drug of abuse, high street value
• Hydrocodone derivative of codeine, very addictive
• Schedule III, but pharmacies store under lock and key
• Pharmacy technicians should check to make sure prescription is legal
123© Paradigm Publishing, Inc.
benzonatate (Tessalon)
• Locally anesthetizes stretch receptors in the airway, lungs, and pleura
• Do not chew capsule
• Side effects: sedation, headache, dizziness
124© Paradigm Publishing, Inc.
dextromethorphan (Delsym)
• Works as well as codeine without analgesic properties
• Does not depress respiration or have abuse potential
• Often combined with other cough and cold preparations
125© Paradigm Publishing, Inc.
Dispensing Issues of dextromethorphan (Delsym)
• Consuming large quantities can produce hallucinations, called robo-tripping
• Popular with teens as recreational drug
• Purchaser must show proof of age and be over 18 years
Warning!
126© Paradigm Publishing, Inc.
Expectorants
• Help rid lungs and airway of mucus when coughing
• Decrease thickness and viscosity (stickiness) of mucus so cough will eject mucus
• Used for dry and productive coughs
127© Paradigm Publishing, Inc.
Water
• Can work as well as, if not better than, medication expectorants
• Staying well-hydrated thins mucus and allows for easier expectoration
• 6 to 8 glasses of water a day
© Paradigm Publishing, Inc. 128
Drug ListExpectorants
– guaifenesin (Mucinex)– potassium iodide (Iossat, Lugol
solution)
Combinations– guaifenesin-codeine (Robitussin A-C)– guaifenesin-pseudoephedrine
(Mucinex D)
129© Paradigm Publishing, Inc.
guaifenesin (Mucinex)
• Most-used expectorant, many forms
• Loosens phlegm and thins bronchial secretions
• Often combined with other drugs
• Indicated for patients with smoking, asthma, or emphysema
130© Paradigm Publishing, Inc.
Decongestants
• Swelling and stuffiness caused by vasodilation and leakage of fluids into nasal mucosa
• Decongestants cause constriction– Promotes drainage, improves nasal
ventilation, and relieves stuffiness– Allows sinus cavities to drain
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Decongestants
• Increase heart rate and blood pressure
• Stimulates the CNS
• Patients sometimes take decongestants to overcome drowsiness
• Should not be taken by those who cannot tolerate sympathetic stimulation
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Decongestants
• Prolonged use of topical decongestants can cause rebound rhinitis medicamentosa
• Therapy should not exceed 3 to 5 days
• Available in topical and oral forms
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Drug ListDecongestants
– pseudoephedrine (Sudafed)– phenylephrine (Sudafed PE, Neo-
Synephrine, others)– phenylephrine, IV (none)
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Drug ListDecongestants
Pseudoephedrine Combinations
– cetirizine-pseudoephedrine (Zytrec-D)
– fexofenadine-pseudoephedrine (Allegra-D)
– guaifenesin-pseudoephrine (Mucinex D)
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Drug ListDecongestantsPseudoephedrine Combinations
– ibuprofen-pseudoephedrine (Advil Cold and Sinus)
– ibuprofen-pseudoephedrine chlorpheniramine (Advil Allergy and Sinus)
– loratadine-pseudoephedrine (Claritin D)
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Drug ListDecongestants
Pseudoephedrine Combinations – naproxen-pseudoephedrine (Aleve
Cold and Sinus)– triprolidine-pseudeophedrine (Actifed
Cold and Allergy)
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Dispensing Issues of Decongestants
– Diabetes– Heart disease– Uncontrolled
hypertension– Hyperthyroidism– Prostatic hypertrophy– Tourette syndrome
Warning!
Should be avoided in patients with
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Oral Side Effects of Decongestants
• Anxiety• CNS stimulation • Dizziness• Hallucinations• Headache
• Increased blood pressure
• Increased heart rate
• Insomnia• Tremor
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Side Effects of Topical Decongestants
• Burning sensation
• Contact dermatitis
• Dry mouth
• Rhinitis medicamentosa
• Sneezing
• Stinging sensation
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pseudoephedrine (Sudafed)
• Most-used and most effective decongestant; in many combinations
• If hypertension is well controlled, patients can take pseudoephedrine for short time
• Strong abuse potential, can be made into methamphetamine
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Dispensing Issues of Pseudoephedrine
• Amount purchased at one time is limited• Products containing pseudoephedrine are
kept behind the counter• Consumer must specifically ask for them
and show ID
Warning!
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Antihistamines
• Used primarily to combat allergic reactions, nausea, vertigo, and insomnia
• Most common side effects are sedation, dry mouth, constipation, urinary retention
• Prevent binding of histamine to receptor sites
• Many are sold OTC
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Antihistamines
• Well absorbed in tissues
• Widely distributed across blood-brain barrier causing sedation
• Can cross the placenta and adversely affect fetus
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Drug ListAntihistamines
– azatadine (Optimine)– azelastine (Astelin, Optivar)– cetirizine (Zyrtec)– chlorpheniramine (Chlortrimeton)– clemastine (Tavist Allergy)– cyproheptadine (Periactin)– desloratadine (Clarinex)
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Drug ListAntihistamines
– diphenhydramine (Benadryl)– fexofenadine (Allegra)– hydroxyzine (Atarax, Vistaril)– levoctirizine (Xyzal)– loratadine (Claritin)– meclizine (Antivert)– promethazine (Phenergan)
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Therapeutic Uses of Antihistamines
• Allergies
• Insomnia
• Rash, edema, and hay fever
• Cough
• Vertigo
• Nausea and vomiting
• Serum sickness
• Control venom reactions
• Lessens extrapyramidal side effects of antipsychotics
• Prevent certain drug reactions and allergies
• Hypersensitivity
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Hypersensitivity Reactions
• Excessive immune response to a foreign agent
• Can range from a slight rash to a serious response such as serum sickness
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Side Effects of Antihistamines
• Anticholinergic responses– Dry mouth– Drying of URT mucosa– Blurred vision– Constipation– Urinary retention
• Hyperactivity in some children• Sedation most common
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diphenhydramine (Benadryl)
• Major ingredient in OTC sleep medications
• Synergistic with alcohol use
• Dizziness common side effect
• New drugs have fewer side effects
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fexofenadine and clemastine
• fexofenadine (Allegra)– Less sedating than most other
antihistaimines
• clemastine (Travist Allergy)– Least-sedating OTC antihistamine– Approved by FDA for treatment of
symptoms of cold
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Nasal Corticosteroids
• Most effective monotherapy for allergic rhinitis
• Must be used daily
• Can cause nasal irritation and bleeding; direct spray away from septum
• Local infections of Candida albicans may occur in nose with long term use
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Drug ListNasal Corticosteroids
– beclomethasone (Beconase AQ)– budesonide (Rhinocort Aqua)– ciclesonide (Omnaris)– flunisolide (Nasarel)
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Drug ListNasal Corticosteroids
– fluticasone (Veramyst), furoate– fluticasone (Flonase), propionate– mometasone (Nasonex)– triamcinolone (Nasacort AQ)
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fluticasone (Veramyst, Flonase)
• Used in two different forms
• Veramyst has stronger binding affinity
• Flonase easier to use
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mometasone furoate (Nasonex)
• Depresses release of endogenous chemical mediators of inflammation
• Reverses dilation and permeability of vessels in area, decreases cell access to injury site
• Children over 12 can use to prevent symptoms of allergic rhinitis
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Terms to Remember
antitussive
cough reflex
stretch receptor
irritant receptor
expectorant
decongestant
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Terms to Remember
rhinitis medicamentosa
antihistamine
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Smoking Cessation
• On average, cigarette smokers lose about 15 years of life
• Cigarette smoke contains 4,000+ chemical compounds including at least 43 carcinogens
• Secondhand smoke contains all 43 carcinogens and toxins
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Smoking
• Can lead to– Leukemia– Cancer: lung, mouth, pharynx, larynx,
esophagus, pancreas, cervix, kidney, bladder, ovaries, uterus, and prostate
• Increases risk of heart disease, COPD, stroke
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Smoking
• Related to birth defects of mothers who smoke during pregnancy
• Secondhand smoke puts children at risk of developing asthma, respiratory infection, and middle-ear infection
• Nicotine is addictive component of tobacco. Can interact with some medications
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Effects of Nicotine
• CNS and PNS stimulation and depression
• Respiratory stimulation
• Skeletal muscle relaxation
• Increase in blood pressure, heart rate, cardiac output, oxygen consumption
• Physical and psychological dependence
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Personal Benefits to Smoking Cessation
• Improved performance in sports and sex
• Better-smelling home, car, clothing, breath
• Economic savings• Addiction freedom
• Healthier babies• Improved health
and self-esteem• Improved sense of
taste and smell• No exposing
others to smoke• Set good example
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5 Step Quit Plan
1. Set a date
2. Inform family, friends, coworkers
3. Remove cigarettes from daily life
4. Review previous attempts and analyze what caused relapse
5. Anticipate challenges
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Smoking Cessation
• Key is abstinence
• Some fears that keep people from quitting: weight gain, nicotine withdrawal
• Most nicotine cessation drugs OTC– varenicline (Chantix) most successful
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Symptoms of Nicotine Withdrawal
• Anxiety• Craving tobacco• Decreased blood
pressure and heart rate
• Depression• Difficulty
concentrating
• Drowsiness• Frustration,
irritability, hostility• GI disturbances• Headache• Increased appetite,
skin temperature• Insomnia
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Drug ListSmoking Cessation Agents
– bupropion (Wellbutrin SR, Zyban)– nicotine (Commit, Habitrol, Nicoderm
CQ, Nicorette, ProStep, Nicotrol)– varenicline (Chantix)
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Dispensing Issues of Smoking Cessation Agents
• Lozenges should not be chewed
• Patch application site should be rotated to prevent skin reactions
• Smoking during nicotine replacement therapy could show signs of nicotine excess
Warning!
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Symptoms of Nicotine Excess
• Abdominal pain• Confusion• Diarrhea• Dizziness• Headache• Hearing loss
• Hypersalivation• Nausea• Perspiration• Visual
disturbances• Vomiting• Weakness
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Dispensing Issues of Smoking Cessation Agents
• Smoking while on nicotine replacement therapy could cause signs of nicotine excess
Warning!
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Discussion
You are trying to get a friend to stop smoking. Name five reasons why your friend should quit.
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Terms to Remember
nicotine
the addictive component of tobacco
cotinine
a major metabolite of nicotine
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Assignments
• Complete Chapter Review activities• Answer questions in Study Notes
document• Study Partner
– Quiz in review mode– Matching activities– Drug tables