Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Drug design wikipedia , lookup
Psychopharmacology wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Drug interaction wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Drug discovery wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Neuropharmacology wikipedia , lookup
Chapter 9 Respiratory Drugs © Paradigm Publishing, Inc. 1 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. 2 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. © Paradigm Publishing, Inc. 3 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 © Paradigm Publishing, Inc. 4 Three Classes of Asthma • Allergic – Present in 35% to 55% of patients • Exercise Induced • Nonallergic © Paradigm Publishing, Inc. 5 Upper and Lower Respiratory Tracts © Paradigm Publishing, Inc. 6 Oxygen and Carbon Dioxide Exchange © Paradigm Publishing, Inc. 7 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 © Paradigm Publishing, Inc. 8 Characteristics of Asthma 1. Reversible small airway obstruction 2. Progressive airway inflammation 3. Increased airway responsiveness to variety of stimuli © Paradigm Publishing, Inc. 9 Characteristics of Asthma • These 3 characteristics translate into – Wheezing – Dyspnea – Acute and chronic cough © Paradigm Publishing, Inc. 10 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 © Paradigm Publishing, Inc. 11 Asthma Attack: Second Response • Bronchoconstriction with delayed, sustained reactions • Causes self-sustaining inflammation © Paradigm Publishing, Inc. 12 Asthmatic Response © Paradigm Publishing, Inc. 13 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 © Paradigm Publishing, Inc. 14 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 © Paradigm Publishing, Inc. 15 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 © Paradigm Publishing, Inc. 16 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-tosevere, persistent symptoms © Paradigm Publishing, Inc. 17 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 © Paradigm Publishing, Inc. 18 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 © Paradigm Publishing, Inc. 19 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 © Paradigm Publishing, Inc. 20 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 © Paradigm Publishing, Inc. 21 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 © Paradigm Publishing, Inc. 22 Six Steps to Use HFA MDIs 1. 2. 3. 4. Remove cap and shake inhaler. Breathe out all the way. Place mouthpiece between lips. Press down on inhaler, hold for a few seconds, then breathe in slowly. 5. Hold breath and count to 10. 6. Breathe out slowly. © Paradigm Publishing, Inc. 23 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. © Paradigm Publishing, Inc. 24 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 © Paradigm Publishing, Inc. 25 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 © Paradigm Publishing, Inc. 26 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. 27 Drug List Asthma Agents Bronchodilators – albuterol (Proventil, Proventil HFA, Ventolin HFA, ProAir HFA) – epinephrine (EpiPen) – formoterol (Foradil, Perforomist) – ipratropium (Atrovent) – isoproterenol (Isuprel) © Paradigm Publishing, Inc. 28 Drug List Asthma Agents Bronchodilators – levalbuterol (Xopenex) – metaproterenol (Alupent) – pirbuterol (Maxair) – salmeterol (Serevent) – terbutaline (Brethine) – tiotropium (Spiriva) © Paradigm Publishing, Inc. 29 epinephrine (EpiPen) • Drug of choice for acute attack of asthma • Many patients with asthma carry an EpiPen © Paradigm Publishing, Inc. 30 Dispensing Issues of epinephrine Warning! • Look-alike and sound-alike – Epinephrine – Ephedrine © Paradigm Publishing, Inc. 31 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 © Paradigm Publishing, Inc. 32 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 © Paradigm Publishing, Inc. 33 Dispensing Issues of albuterol Warning! • Proventil HFA and ProAir HFA cannot be interchanged • If Rx for an albuterol inhaler, any of the 3 brands can be used © Paradigm Publishing, Inc. 34 levalbuterol (Xopenex) • Isomer of albuterol • Can be prescribed at lower doses than albuterol • Has fewer side effects than albuterol © Paradigm Publishing, Inc. 35 ipratropium (Atrovent) • Blocks ACh in bronchial smooth muscle causing bronchodilation • Used for prevention of attacks, not rescue situations • Short-acting, does not cause arrhythmias © Paradigm Publishing, Inc. 36 Dispensing Issues of ipratropium (Atrovent) Warning! • 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 © Paradigm Publishing, Inc. 37 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 © Paradigm Publishing, Inc. 38 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 © Paradigm Publishing, Inc. 39 Dispensing Issues of Formoterol (Foradil) Warning! • 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) © Paradigm Publishing, Inc. 40 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. 41 Drug List Asthma Agents Xanthine Derivatives – aminophylline (Truphylline) – theophylline (Theo 24, TheoAir) © Paradigm Publishing, Inc. 42 theophylline (Theo 24, TheoAir) • Use only in lung diseases unresponsive to other drugs because it has many interactions • Blood levels can become elevated quickly © Paradigm Publishing, Inc. 43 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. 44 Drug List Asthma Agents Leukotriene Inhibitors – montelukast (Singulair) – zafirlukast (Accolate) – zileuton (Zyflo) © Paradigm Publishing, Inc. 45 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 © Paradigm Publishing, Inc. 46 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 © Paradigm Publishing, Inc. 47 zileuton (Zyflo) • • • • Reduces production of leukotrienes Strong warnings about liver toxicity Can double theophylline levels Approved for patients 12 years or older © Paradigm Publishing, Inc. 48 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 © Paradigm Publishing, Inc. 49 Primary Side Effects of Corticosteroids • • • • Oral candidiasis Irritation and burning of nasal mucosa Hoarseness Dry mouth © Paradigm Publishing, Inc. 50 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 © Paradigm Publishing, Inc. 51 Corticosteroids • Always use lowest effective dose • Add salmeterol to inhaled corticosteroids if needed to decrease the dose of corticosteroid needed for control © Paradigm Publishing, Inc. 52 Dispensing Issues of Corticosteroids Warning! • Patient should rinse mouth with water after using inhalers to prevent oral candidiasis • Patient should be taught how to correctly use these medications © Paradigm Publishing, Inc. 53 Drug List Asthma 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. 54 Drug List Asthma Agents: Corticosteroids – hydrocortisone (Solu-Cortef) – methylprednisolone (Medrol Dose-Pack, Solu-Medrol) – mometasone furoate (Asmanex) – prednisolone (Orapred, Pediapred) – prednisone (Deltasone) – triamcinolone (Azmacort, Nasacort AQ) © Paradigm Publishing, Inc. 55 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 © Paradigm Publishing, Inc. 56 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 © Paradigm Publishing, Inc. 57 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. 58 Drug List Asthma Agents Mast Cell Stabilizers – cromolyn sodium (Crolom, Gastrocrom, Intal, Opticrom, Nasalcrom) – nedocromil (Tilade) © Paradigm Publishing, Inc. 59 Drug List Asthma Agents Monoclonoal Antibody – omalizumab (Xolair) Combination Drugs – fluticasone-salmeterol (Advair Diskus) © Paradigm Publishing, Inc. 60 fluticasone-salmeterol (Advair Diskus) • Combines corticosteroid (antiinflammatory) 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. 61 Terms to Remember asthma bronchospasm peak flow meter peak expiratory flow rate (PEFR) status asthmaticus metered dose inhaler (MDI) © Paradigm Publishing, Inc. 62 Terms to Remember spacer nebulizer bronchodilator xanthine derivative leukotriene inhibitor corticosteroid © Paradigm Publishing, Inc. 63 Terms to Remember mast cell stabilizer monoclonal antibody © Paradigm Publishing, Inc. 64 Chronic Obstructive Pulmonary Disease (COPD) • Emphysema and chronic bronchitis • COPD is irreversible © Paradigm Publishing, Inc. 65 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 © Paradigm Publishing, Inc. 66 Major Risk Factors For Emphysema • Cigarette smoking – Destroys walls of lungs • Occupational exposure • Air pollution • Genetic factors © Paradigm Publishing, Inc. 67 Bronchitis • Lining of the bronchial airways becomes inflamed • Causes patient to have difficulty breathing out © Paradigm Publishing, Inc. 68 Two Types of Bronchitis • Acute – Caused by infection, usually viral – Runs a brief course • Chronic – Longer lasting condition © Paradigm Publishing, Inc. 69 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 © Paradigm Publishing, Inc. 70 Natural Defense System of the Lungs • In properly functioning system – Provides good protection against pathogens – Removes potentially infectious agents from the lungs © Paradigm Publishing, Inc. 71 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 © Paradigm Publishing, Inc. 72 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 © Paradigm Publishing, Inc. 73 Cellular Makeup of an Alveolus and Capillary Supply © Paradigm Publishing, Inc. 74 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. 75 Drug List Agents for COPD Mucolytics – acetylcysteine (Acetadote, Mucomyst) – dornase alfa (Pulmozyme) Anticholinergic – tiotropium (Spiriva) © Paradigm Publishing, Inc. 76 Drug List Agents for COPD Beta Agonists – arformoterol (Brovana) – formoterol (Perforomist) – isoproterenol (Isuprel) – metaproterenol (Alupent) © Paradigm Publishing, Inc. 77 Drug List Agents for COPD Combinations – ipratropium-albuterol (Combivent, DuoNeb) – fluticasone-salmeterol (Advair Diskus) © Paradigm Publishing, Inc. 78 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. 79 Terms to Remember emphysema an irreversible lung disease characterized by destruction of the alveoli in the lungs, which allows air to accumulate in tissues and organs tachypnea very rapid respiration causing a flushed appearance; a characteristic of emphysema © Paradigm Publishing, Inc. 80 Terms to Remember bronchitis a condition in which the inner lining of the bronchial airways becomes inflamed, causing the expiration of air from the lungs to be obstructed mucolytic an agent that destroys or dissolves mucus © Paradigm Publishing, Inc. 81 Other Lung Diseases • Most respiratory infections transmitted through hand contact © Paradigm Publishing, Inc. 82 Prevention of Lung Diseases • • • • Do not smoke Avoid secondhand smoke Avoid air pollution Get vaccinations for influenza and pneumonia • Wash hands © Paradigm Publishing, Inc. 83 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 © Paradigm Publishing, Inc. 84 X-Ray of Pneumonic Lung X-ray of a patient with pneumonia that shows fluid in the right lung © Paradigm Publishing, Inc. 85 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. © Paradigm Publishing, Inc. 86 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 © Paradigm Publishing, Inc. 87 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 © Paradigm Publishing, Inc. 88 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 © Paradigm Publishing, Inc. 89 Respiratory Distress Syndrome (RDS) • Two causes of RDS – Prematurity – Maternal diabetes • If RDS occurs, replacement surfactant administered © Paradigm Publishing, Inc. 90 Drug List Surfactants for Respiratory Distress Syndrome – beractant (Survanta) – calfactant (Infasurf) – colfosceril palimate (Exosurf Neonatal) – poractant alfa (Curosurf) © Paradigm Publishing, Inc. 91 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 © Paradigm Publishing, Inc. 92 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 © Paradigm Publishing, Inc. 93 Tuberculosis (TB) • Seen primarily in – Alcoholics – Prison population – Immunocompromised – Elderly © Paradigm Publishing, Inc. 94 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 © Paradigm Publishing, Inc. 95 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 © Paradigm Publishing, Inc. 96 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. 97 Drug List Agents for Tuberculosis – capreomycin (Capastat) – ciprofloxacin (Cipro) – cycloserine (Seromycin) – ethambutol (Myambutol) – ethionamide (Trecator-SC) © Paradigm Publishing, Inc. 98 Drug List Agents for Tuberculosis – isoniazid (INH) (Laniazid, Nydrazid) – isoniazid-pyrazinamide-rifampin (Rifater) – isoniazid-rifampin (Rifamate) – ofloxacin (Floxin) – pyrazinamide (none) © Paradigm Publishing, Inc. 99 Drug List Agents for Tuberculosis – rifampin (Rifadin, Rimactane) – rifapentine (Priftin) – streptomycin (none) © Paradigm Publishing, Inc. 100 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 © Paradigm Publishing, Inc. 101 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 © Paradigm Publishing, Inc. 102 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. 103 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. © Paradigm Publishing, Inc. 104 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. 105 Terms to Remember pneumonia aspiration cystic fibrosis (CF) percussion respiratory distress syndrome surfactant © Paradigm Publishing, Inc. 106 Terms to Remember tuberculosis (TB) histoplasmosis © Paradigm Publishing, Inc. 107 Cough, Cold, and Allergy • Common cold most prevalent respiratory tract infections; viral infection • Symptoms – – – – – Mild malaise Rhinorrhea (runny nose) Sneezing Scratchy throat Fever © Paradigm Publishing, Inc. 108 Colds • Bacterial sinusitis and otitis media are frequent complications warranting antibiotic therapy © Paradigm Publishing, Inc. 109 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 © Paradigm Publishing, Inc. 110 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 © Paradigm Publishing, Inc. 111 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 © Paradigm Publishing, Inc. 112 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 © Paradigm Publishing, Inc. 113 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 © Paradigm Publishing, Inc. 114 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) © Paradigm Publishing, Inc. 115 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. 116 Drug List Antitussives – benzonatate (Tessalon) – codeine (various combinations) – dextromethorphan (Delsym) – diphenhydramine (Benadryl) – hydrocodone-chlorpheniramine (Tussionex) © Paradigm Publishing, Inc. 117 Drug List Antitussives – promethazine-codeine (Phenegran with codeine © Paradigm Publishing, Inc. 118 Drug List Antitussives Dextromethorphan Combinations – dextromethorphan-pseudoephedrinebrompheniramine (Bromfed-DM, Myphetane DX) – guaifenesin-dextromethorphan (Mucinex DM) – promethazine-dextromethorphan (none) © Paradigm Publishing, Inc. 119 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 © Paradigm Publishing, Inc. 120 Side Effects of Codeine • • • • • Nausea Drowsiness Light-headedness Constipation Take with food to decrease stomach upset © Paradigm Publishing, Inc. 121 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 © Paradigm Publishing, Inc. 122 benzonatate (Tessalon) • Locally anesthetizes stretch receptors in the airway, lungs, and pleura • Do not chew capsule • Side effects: sedation, headache, dizziness © Paradigm Publishing, Inc. 123 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 © Paradigm Publishing, Inc. 124 Dispensing Issues of dextromethorphan (Delsym) Warning! • 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 © Paradigm Publishing, Inc. 125 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 © Paradigm Publishing, Inc. 126 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. 127 Drug List Expectorants – guaifenesin (Mucinex) – potassium iodide (Iossat, Lugol solution) Combinations – guaifenesin-codeine (Robitussin A-C) – guaifenesin-pseudoephedrine (Mucinex D) © Paradigm Publishing, Inc. 128 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 © Paradigm Publishing, Inc. 129 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 © Paradigm Publishing, Inc. 130 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 © Paradigm Publishing, Inc. 131 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 © Paradigm Publishing, Inc. 132 Drug List Decongestants – pseudoephedrine (Sudafed) – phenylephrine (Sudafed PE, NeoSynephrine, others) – phenylephrine, IV (none) © Paradigm Publishing, Inc. 133 Drug List Decongestants Pseudoephedrine Combinations – cetirizine-pseudoephedrine (Zytrec-D) – fexofenadine-pseudoephedrine (Allegra-D) – guaifenesin-pseudoephrine (Mucinex D) © Paradigm Publishing, Inc. 134 Drug List Decongestants Pseudoephedrine Combinations – ibuprofen-pseudoephedrine (Advil Cold and Sinus) – ibuprofen-pseudoephedrine chlorpheniramine (Advil Allergy and Sinus) – loratadine-pseudoephedrine (Claritin D) © Paradigm Publishing, Inc. 135 Drug List Decongestants Pseudoephedrine Combinations – naproxen-pseudoephedrine (Aleve Cold and Sinus) – triprolidine-pseudeophedrine (Actifed Cold and Allergy) © Paradigm Publishing, Inc. 136 Dispensing Issues of Decongestants Warning! Should be avoided in patients with – Diabetes – Heart disease – Uncontrolled hypertension – Hyperthyroidism – Prostatic hypertrophy – Tourette syndrome © Paradigm Publishing, Inc. 137 Oral Side Effects of Decongestants • • • • • Anxiety CNS stimulation Dizziness Hallucinations Headache • Increased blood pressure • Increased heart rate • Insomnia • Tremor © Paradigm Publishing, Inc. 138 Side Effects of Topical Decongestants • • • • • • Burning sensation Contact dermatitis Dry mouth Rhinitis medicamentosa Sneezing Stinging sensation © Paradigm Publishing, Inc. 139 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 © Paradigm Publishing, Inc. 140 Dispensing Issues of Pseudoephedrine Warning! • Amount purchased at one time is limited • Products containing pseudoephedrine are kept behind the counter • Consumer must specifically ask for them and show ID © Paradigm Publishing, Inc. 141 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 © Paradigm Publishing, Inc. 142 Antihistamines • Well absorbed in tissues • Widely distributed across blood-brain barrier causing sedation • Can cross the placenta and adversely affect fetus © Paradigm Publishing, Inc. 143 Drug List Antihistamines – azatadine (Optimine) – azelastine (Astelin, Optivar) – cetirizine (Zyrtec) – chlorpheniramine (Chlortrimeton) – clemastine (Tavist Allergy) – cyproheptadine (Periactin) – desloratadine (Clarinex) © Paradigm Publishing, Inc. 144 Drug List Antihistamines – diphenhydramine (Benadryl) – fexofenadine (Allegra) – hydroxyzine (Atarax, Vistaril) – levoctirizine (Xyzal) – loratadine (Claritin) – meclizine (Antivert) – promethazine (Phenergan) © Paradigm Publishing, Inc. 145 Therapeutic Uses of Antihistamines • Allergies • Control venom reactions • Insomnia • Rash, edema, and hay fever • Cough • Vertigo • Lessens extrapyramidal side effects of antipsychotics • Nausea and vomiting • Prevent certain drug reactions and allergies • Serum sickness • Hypersensitivity © Paradigm Publishing, Inc. 146 Hypersensitivity Reactions • Excessive immune response to a foreign agent • Can range from a slight rash to a serious response such as serum sickness © Paradigm Publishing, Inc. 147 Side Effects of Antihistamines • Anticholinergic responses – – – – – Dry mouth Drying of URT mucosa Blurred vision Constipation Urinary retention • Hyperactivity in some children • Sedation most common © Paradigm Publishing, Inc. 148 diphenhydramine (Benadryl) • Major ingredient in OTC sleep medications • Synergistic with alcohol use • Dizziness common side effect • New drugs have fewer side effects © Paradigm Publishing, Inc. 149 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 © Paradigm Publishing, Inc. 150 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 © Paradigm Publishing, Inc. 151 Drug List Nasal Corticosteroids – beclomethasone (Beconase AQ) – budesonide (Rhinocort Aqua) – ciclesonide (Omnaris) – flunisolide (Nasarel) © Paradigm Publishing, Inc. 152 Drug List Nasal Corticosteroids – fluticasone (Veramyst), furoate – fluticasone (Flonase), propionate – mometasone (Nasonex) – triamcinolone (Nasacort AQ) © Paradigm Publishing, Inc. 153 fluticasone (Veramyst, Flonase) • Used in two different forms • Veramyst has stronger binding affinity • Flonase easier to use © Paradigm Publishing, Inc. 154 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 © Paradigm Publishing, Inc. 155 Terms to Remember antitussive cough reflex stretch receptor irritant receptor expectorant decongestant © Paradigm Publishing, Inc. 156 Terms to Remember rhinitis medicamentosa antihistamine © Paradigm Publishing, Inc. 157 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 © Paradigm Publishing, Inc. 158 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 © Paradigm Publishing, Inc. 159 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 © Paradigm Publishing, Inc. 160 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 © Paradigm Publishing, Inc. 161 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 © Paradigm Publishing, Inc. 162 5 Step Quit Plan 1. 2. 3. 4. Set a date Inform family, friends, coworkers Remove cigarettes from daily life Review previous attempts and analyze what caused relapse 5. Anticipate challenges © Paradigm Publishing, Inc. 163 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 © Paradigm Publishing, Inc. 164 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 © Paradigm Publishing, Inc. 165 Drug List Smoking Cessation Agents – bupropion (Wellbutrin SR, Zyban) – nicotine (Commit, Habitrol, Nicoderm CQ, Nicorette, ProStep, Nicotrol) – varenicline (Chantix) © Paradigm Publishing, Inc. 166 Dispensing Issues of Smoking Cessation Agents Warning! • 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 © Paradigm Publishing, Inc. 167 Symptoms of Nicotine Excess • • • • • • Abdominal pain Confusion Diarrhea Dizziness Headache Hearing loss • • • • Hypersalivation Nausea Perspiration Visual disturbances • Vomiting • Weakness © Paradigm Publishing, Inc. 168 Dispensing Issues of Smoking Cessation Agents Warning! • Smoking while on nicotine replacement therapy could cause signs of nicotine excess © Paradigm Publishing, Inc. 169 Discussion You are trying to get a friend to stop smoking. Name five reasons why your friend should quit. © Paradigm Publishing, Inc. 170 Terms to Remember nicotine the addictive component of tobacco cotinine a major metabolite of nicotine © Paradigm Publishing, Inc. 171 Assignments • Complete Chapter Review activities • Answer questions in Study Notes document • Study Partner – Quiz in review mode – Matching activities – Drug tables © Paradigm Publishing, Inc. 172