ACC Final Pharmacology Exam Review

CH 7

Key terms:

• Anticholingergic bronchodilator • Antimuscarinic bronchodilator • Cholingergic • Muscarinic • Parasympatholytic • Parasympathomimic

Ch. 7

• 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

• Key terms: • Xanthine • Methlyxanthines • Phosphodiesterase

Ch. 8

• 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

• 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 N-acetylcysteine

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 pseudo-plastic 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

– 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• 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

• 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

• 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– 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)