Pharm exam 4

• SABA


  Short acting beta2 agonists, bronchodilators such as Albuterol, Levalbuterol, and Pirbuterol, used in treating acute bronchoconstriction
• SABA mechanism of action

  • They work by stimulating beta 2 receptors in the lungs, which results in bronchodilation
  • Even though they are inhaled, some systemic effects occur
• Systemic effects of SABA

  • Cardiovascular: tachycardia, palpitations
  • CNS: excitation, nervousness, irritability
  • Skeletomuscular: Tremors
• SABA indication


  Indicated for both children and adults, albuterol is first-line therapy for acute asthma attacks
• Montelukast


  Leukotriene inhibitor, used in long-term treatment of disorders causing bronchoconstriction
• Montelukast contains phenylalanine and so are contraindicated in patients with PKU
• Adverse effects of montelukast

  • GI upset
  • Myalgia
  • Fever
  • CNS excitation including sleep disorders, restlessness, and irritability
• Montelukast indication


  The only leukotriene inhibitor that is indicated for children older than 1 year
• Patient teaching for montelukast

  • Take as prescribed even if symptom free
  • Emphasis should be made that it is not for acute attacks
  • Zafirlukast is taken on an empty stomach
  • Made aware of CNS events such as agitation, anxiousness, insomnia
  • Self-monitor respiratory system, avoid or quick smoking, avoid triggers
• Patient teaching for inhaled corticosteroids

  • Rinse mouth to prevent oral candidiasis
  • Tachycardia can occur
  • Bronchospasm can occur
  • Teach how to use, spacers can be used to get the most effect especially in children
  • Don't take the capsules by mouth they must be broken in the mechanism and inhaled
  • Not for use in acute asthma attack
• Albuterol mechanism of action

  Albuterol is a short acting beta 2 agonist, triggers beta 2 adrenergic receptors which results in direct bronchodilation
• Inhaled corticosteroids mechanism of action

  Corticosteroids suppress IgE immunoglobulins which are the main trigger for release of mast cells and other inflammatory factors
• Adverse effects of inhaled corticosteroids are related to localized immunosuppression. Oral candidiasis can occur if the patient does not rinse after each use
• When to use a short acting beta agonist

  In the event of acute asthma attack. Albuterol is the first-line therapy and is indicated in children and adults
• Inhaled muscarinic receptor antagonists mechanism of action

  Muscarinic receptor antagonists are anticholinergics that work by competitively inhibiting cholinergic receptors, relieving bronchoconstriction by relaxing smooth muscle of the respiratory tract, and decreasing secretions
• Anticholinergics, even inhaled can cause systemic effects
• Inhaled anticholinergics


  • Ipatropium, tiotropium
• Adverse effects of inhaled corticosteroids

  • Immunosuppression which can increase risk of oral candidiasis
  • Intranasal can cause nasal dryness, bloody nose, or itching
• LABA


  Long acting beta 2 adrenergic agonists used in the treatment of long-term COPD or other bronchoconstricting disease process
• LABA/LAMA combination


  Used as a first-line therapy in the treatment of COPD
• LABA/LAMA combination


  • Salmeterol/ipratropium
• Omalizumab mechanism of action and indication


  Omalizumab is a monoclonal antibody that works by binding to free IgE which downregulates mast cells and basophils
• Populations that should not be prescribed pseudoephedrine


  • Concurrent MAOI therapy
  • Severe HTN or coronary artery disease
  • Infants
• Drug for nasal congestion with hypertension

  Fluticasone OTC should be used. Pseudoephedrine can exacerbate HTN
• Adverse effects of antihistamines

  • Drowsiness and dizziness related to antihistamine effect
  • 1st gen can cause some anticholinergic effects such as dry mouth, and urinary retention
• Conditions that should cause a patient to avoid antihistamines

  • Lower respiratory tract diseases due to thickened secretions
  • Narrow-angle glaucoma
  • Urinary constriction diseases
• Antitussives and their mechanisms of action

  • Dextromethorphan: Elevates the threshold of coughing in the CNS
  • Codeine: Blocks cough receptors in the CNS
  • Benzonatate: Anesthetizes stretch receptors that cause coughing in the respiratory tract
• Treatment of upper respiratory infections

  • Viral URI: Symptom management, decongestants
  • Sudafed contraindicated in children under 4
  • Tylenol, ibuprofen for general malaise
  • Bacterial URI: Add antibiotics to therapy regimen
• Factors to consider when choosing a diuretic for hypertension

  • Set an appropriate goal
  • Thiazide diuretic is first-line for essential hypertension, hydrochlorothiazide is treatment of choice in uncomplicated patients
  • Loop diuretics may be appropriate in patients with altered kidney function
  • Thiazide diuretics do not work effectively in patients with kidney impairment
  • If a loop diuretic is prescribed then potassium must also be prescribed
• Mechanisms of action of diuretic classes

  • Loop diuretics: Decrease sodium reabsorption in the ascending loop, increase sodium in the ascending loop results in water being pulled from the interstitial fluid and excreted through the urine, potassium is also excreted
  • Thiazide diuretics: Decrease sodium reabsorption in the descending loop
  • Potassium-sparing diuretics: Spare potassium by adding aldosterone
• Patient education for taking antacids

  • Only take as prescribed, take 1-3 hours after a meal for best effect
  • If taking OTC only take as instructed
  • Separate antacids with other drugs by at least 1 hour
  • Constipation with Al and Ca based antacids
  • Diarrhea with Mg based antacids
  • Use low sodium preparations for those with HTN or other disease that requires low sodium
  • Take half glass of water after
• Loperamide mechanism of action

  Binds to opiate receptors in the intestinal wall to decrease peristalsis and secretions, an antidiarrheal
• Lab values to monitor with long-term PPI administration

  • Vitamin B-12 deficiency
  • Fe deficiency
  • Ca deficiency
• PPIs can cause vitamin B-12 deficiency in long-term use. Ca and Fe deficiency are not of clinical significance
• Reason for osteoporosis risk with omeprazole

  PPIs increase gastric pH which may reduce absorption of certain nutrients that are generally absorbed in the stomach
• Most rapid acting laxative

  Stimulants such as bisacodyl directly stimulate peristalsis causing the intestines to move fecal matter out. Osmotic laxatives like PEG 3350 are also very fast
• How metoclopramide improves GERD

  Metoclopramide is a prokinetic that increases gastric motility and tone, improving symptoms of GERD by increasing gastric motility and esophageal sphincter tone
• Limitations of metoclopramide use for GERD

  • Only used for GERD that is not able to be treated by PPI or H2RA
  • Has significant side effects, EPS, depression
  • Only indicated in patients who have delayed gastric emptying that do not respond to other treatments
• Symptoms of GERD are associated with gastric acid getting into the esophagus due to a weak esophageal sphincter and decreased gastric pH
• Step Down Approach with GERD

  • Start with high dose PPI and antacids and slowly work down to a dose that decreases symptoms
  • Usual duration of therapy is 8 weeks before tapering starts
  • If it does not work then increase to 2 times a day for 8 weeks
  • Step-down is indicated in patients who have moderate to severe symptoms and will provide quick relief
  • PPIs, short-term, have minimal adverse effects so a step-down approach is not necessarily more risky than a step-up