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Analgesics NAPLEX PG 132. Treatment Algorithm for Pain Patient in pain Rating Scale 0-10 Mild Pain (0-3) NSAID, aspirin, APAP Moderate Pain (4-6) Weak.

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Presentation on theme: "Analgesics NAPLEX PG 132. Treatment Algorithm for Pain Patient in pain Rating Scale 0-10 Mild Pain (0-3) NSAID, aspirin, APAP Moderate Pain (4-6) Weak."— Presentation transcript:

1 Analgesics NAPLEX PG 132

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3 Treatment Algorithm for Pain Patient in pain Rating Scale 0-10 Mild Pain (0-3) NSAID, aspirin, APAP Moderate Pain (4-6) Weak opioid: codeine, hydrocodone Severe Pain (7-10) Strong opioid: morphine, oxycodone, hydromorphone

4 Treating Specific Types of Cancer Pain Bone pain NSAIDs, bisphosphonates, corticosteroids, opiates Visceral pain NSAIDs, opiates Neuropathic pain TCAs, gabapentin, carbamazepine, corticosteroids Muscle spasms Benzodiazepines, baclofen Bone pain NSAIDs, bisphosphonates, corticosteroids, opiates Visceral pain NSAIDs, opiates Neuropathic pain TCAs, gabapentin, carbamazepine, corticosteroids Muscle spasms Benzodiazepines, baclofen

5 Non Opioid Analgesics DrugDoseIntervalRenal AdjustmentHepatic Adjustment Acetaminophen500-1000 mg Max: 4 g 4-6 hoursGFR: >50 ml/min q4h, 10-50 ml/min q6h, <10 ml/min q8h 1/2 life is increased, Can be given safely Aspirin500- 1000 mg Max: 4 g 4-6 hoursAvoid Celecoxib100-200 mg Max: 800 mg 12 hoursAvoidDecrease dose by 50 % Rofecoxib (off market) 12.5 mg-25 mg Max: 50 mg DailyAvoid Valdecoxib (off market) 10-20 mg Max: 40 mg DailyAvoid PG 134

6 Non Opioid Analgesics cont DrugDoseIntervalRenal AdjustmentHepatic Adjustment Ibuprofen200-800 mg Max: 3.2 g/day 4-6 hoursUse with caution Contraindicated in renal failure No dose alterations, Kinetics minimally effected Naproxen550 mg initial, 250 subsequent Max: 1.5g/day 6-8 hoursUse with cautionReduce dose 50% Indomethacin25 mg Max: 200mg/day 8-12 hoursUse with cautionAvoid Ketoralac30 mg or 60 mg IM Max: 5 days of combine treatment (IM & PO) 6 hoursAvoid

7 Oxicams Carboxylic Acids Fenamates Naphthylalkanone Acetic Acids oxaprozin naproxen ibuprofen ketoprofen fenoprofen flurbiprofen Propionic Acids meclofenamate mefenamic acid piroxicam meloxicam sulindac etodolac indomethacin tolmetin diclofenac ketorolac nabumetone GI Sparing Agents diclofenac/misoprostol Salicylates ASA Nonacetylated Salicylates salsalate diflunisal choline

8 Weak Opioid Analgesics DrugDoseIntervalRenal AdjustmentHepatic Adjustment Codeine15-60 mg Max: 120 mg 4-6 hoursCrCl: 10-50 ml/min=75% of dose, <10 ml/min=50% of dose A dosage adjustment decrease Oxycodone w/ -acetaminophen -aspirin 5 mg Max: 4 g*4-6 hours Be conservative, drug levels increase by 50% 1/3 to 1/2 of usual dose, Elimination 1/2 life increase by 2.3 hours Hydrocodone w/ -ibuprofen (7.5/200) -acetaminophen (5/500) -aspirin (5/500) 1-2 tabs Max: 5 tabs 1-2 tabs Max: 4 g* 1-2 tabs Max: 4 g* 4-6 hours Use cautiously in mild to moderate renal failure, avoid in severe renal failure Avoid Tramadol -acetaminophen (37.5/325) 50-100 mg Max: 400mg 2 tabs Max: 8 tabs 4-6 hours CrCl < 30 ml/min increase dosing interval to q12h with a max of 200 mg per day Cirrhosis 50 mg q12h Avoid

9 Weak Opioid Analgesics cont DrugDoseIntervalRenal AdjustmentHepatic Adjustment Propoxyphene -acetaminophen -aspirin 1-2 tabs Max: 4 g* 1-2 tabs 4 hours Dont give in severe renal failure, use cautiously in mild and moderate renal failure Avoid

10 Strong Opioid Analgesics DrugDoseIntervalRenal AdjustmentHepatic Adjustment Meperidine - Binds opiate receptors 50 - 150 mg Metabolite accumulation (normeperidine) Anxiety, agitation, tremor &/or seizures 3-4 hoursGFR >50 ml/min No adjustment 10-50 ml/min 75% of dose <10 ml/min 50% of dose Decrease dose, 1/2 life is increased Morphine (gold standard) -immediate release -IV, IM, SQ, continuous infusion -epidural -intrathecal -rectal 10-30 mg 2.5-20 mg 0.8 to 10 mg/hr Max: 80 mg/hr 5mg bolus, redose 1 hr 1 to 2 mg Max: 10 mg/24 hr 0.2 to 1 mg 10-20 mg Titrate to response 2-6 hours No repeat dose 4 hours GFR >50 ml/min No adjustment 10-50 ml/min 75% of dose <10 ml/min 50% of dose (morphine-6-glucuronide) accumulates in renal failure 1/2 life prolonged increase interval by 1.5 to 2 times

11 Strong Opioid Analgesics cont DrugDoseIntervalRenal AdjustmentHepatic Adjustment Hydromorphone -PO, IM, IV, SQ -rectal 1-4 mg 3 mg 4-6 hours 6-8 hours Decrease dose Oxycodone - percocet (APAP) - percodan (ASA) 5 mg May titrate to response – no maximum dose 6 hours –Be conservative, drug levels increase by 50% 1/3 to 1/2 of usual dose, Elimination 1/2 life increase by 2.3 hours Methadone -PO, IM, SQ -IV 2.5-10 mg Max:1000 mg 0.1mg/kg 3-8 hours 4 hrs x 3 doses then 6-12 hours GFR >50ml/min q6h 10-50 ml/min q8h <10 ml/min q12h CrCl <10 ml/min 50-75% dose No Change in dose mild to moderate disease, Avoid in severe liver disease

12 Strong Opioid Analgesics cont DrugDoseIntervalRenal AdjustmentHepatic Adjustment Fentanyl -transdermal -transmucosal - Parenteral Initial 25 mcg/hr Initial 200 mcg 72 hours 30 min CrCl 10-50 ml/min 75% of dose <10 ml/min 50% of dose Unaffected by cirrhosis, effected by hepatic blood flow Remind patients that heat can increase fentanyl absorption. Warn against extended exposure of the patch to heating pads, hot tubs, sunbathing, high fever, etc.

13 Opioid Equianalgesic Dosing DrugOral (mg)Parenteral (mg) Morphine3010 Hydromorphone7.51.5 Oxycodone20-3010-15 Methadone10-20 acute? 2-4 chronic 10 acute? 2-4 chronic Levorphanol4 acute 1 chronic 2 acute 1 chronic Fentanylx0.1-0.2 Oxymorphonex1 Meperidine30075

14 Morphine Analogs---table 2-28, pg.132 General properties CNS depression Respiratory depression Reduce propulsive activity of the gut Urinary retention Toxicity causes pinpoint pupils No maximum dose

15 Meperidine Analogs---See Table 2-28, pg.132 General properties Good analgesic (parenteral) Less CNS depression or constipation than opiates Spasmolytic action - may be useful for pain related to uterus, GI, bronchi, etc. Combination with hydroxyzine or promethazine permits 25–50% dosage reduction Principal drugs Meperidine (Demerol)---accumulates in renal disease, metabolite can cause siezures Diphenoxylate + atropine (Lomotil) – C-V - antidiarrhea - subtherapeutic dose of atropine to prevent abuse

16 PG 133 Central Analgesics Tramadol (Ultram) – oral - binds to u-opiate receptors in the CNS - inhibits reuptake of NE & 5HT in ascending pain pathway - CYP 450 2D6 - renal adjusted Clonidine (Duraclon) epidural, PO or patch for HTN For neuropathic pain-----See other sections

17 PG 133 Drugs for Migraine Headache Types - Tension, Cluster, Migraine - Tension, Cluster, Migraine - Migraine is unilateral, pulsating, throbbing, with or w/o aura, - Migraine is unilateral, pulsating, throbbing, with or w/o aura, nausea, photophobia, sonophobia nausea, photophobia, sonophobia Treatments – Prophylactic and Abortive Abortive Aspirin - analgesic, antipyretic, anti-inflammatory, anti-platelet Acetaminophenanalgesic, antipyretic NSAIDs - analgesic, antipyretic, anti-inflammatory (See Table pg. 133) Mechanism of action Mechanism of action Common adverse effects: GI toxicity, hypersensitivity, renal effects Common adverse effects: GI toxicity, hypersensitivity, renal effects

18 Contraindications to the use of Imitrex include which of the following: I. uncontrolled HTN II. use of and MAOI within the past 2 weeks III. ischemic heart disease a. I only b. III only c. I and II only d. II and III only e. I, II, and III Contraindications to the use of Imitrex include which of the following: I. uncontrolled HTN II. use of and MAOI within the past 2 weeks III. ischemic heart disease a. I only b. III only c. I and II only d. II and III only e. I, II, and III

19 Contraindications to the use of Imitrex include which of the following: I. uncontrolled HTN II. use of and MAOI within the past 2 weeks III. ischemic heart disease a. I only b. III only c. I and II only d. II and III only e. I, II, and III Contraindications to the use of Imitrex include which of the following: I. uncontrolled HTN II. use of and MAOI within the past 2 weeks III. ischemic heart disease a. I only b. III only c. I and II only d. II and III only e. I, II, and III

20 PG 132 Drugs for Migraine Abortive - (cont.) Dihydroergotamine (Migranal) nasal spray; dose may be repeated after 15 min – MOA – blocks alpha adrenergic causing vasoconstrition 5-HT1 D Receptor Agonists avoid in patients with cardiovascular disease Almotriptan (Axert) Almotriptan (Axert) Eletriptan (Relpax) – tablets; newest agent on the market – another me-too Eletriptan (Relpax) – tablets; newest agent on the market – another me-too Frovatriptan (Frova) – tablets; longest half life among agents Naratriptan (Amerge) - tablets Naratriptan (Amerge) - tablets Rizatriptan (Maxalt) - tablets; also Maxalt MLT (oral disintegrating tab) Rizatriptan (Maxalt) - tablets; also Maxalt MLT (oral disintegrating tab) Sumatriptan (Imitrex) - injection, tablet, nasal spray Sumatriptan (Imitrex) - injection, tablet, nasal spray Zolmitriptan (Zomig) - tablets; also Zomig ZMT (oral disintegrating tab) Zolmitriptan (Zomig) - tablets; also Zomig ZMT (oral disintegrating tab)

21 PG 133 Drugs for Migraine Prophylactic Therapy - Given to patients with >2-3 HA/month, severe HA, ineffective treatment Drugs of Choice: - propranolol (Inderal) – use if patient also has HTN - amitriptyline (Elavil) – concomitant depression - valproate (Depakote) - concomitant seizures Other agents: - verapamil, topiramate

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23 Pathophysiology

24 Complications Source: www.arava.com

25 Rheumatoid Arthritis Corticosteroids – early, acute, not long-term - also NSAIDs / COX-2 Inhibitors Disease Modifying Antirheumatic Drugs (DMARDs) – liver, heme Auranofin (Ridaura) Aurothioglucose (Solganol) Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Cyclosporine (Neoral, Sandimmune) Gold sodium thiomalate (Myochrysine) Hydroxychloroquine (Plaquenil) – retinal toxicity – Q 6 months Methotrexate (Rheumatrex) Leflunomide (Arava)---Preg Cat X, long half-life, hepatotoxic Penicillamine (Cuprimine, Depen) Sulfasalazine (Azulfindine) – orange-yellow urine Corticosteroids – early, acute, not long-term - also NSAIDs / COX-2 Inhibitors Disease Modifying Antirheumatic Drugs (DMARDs) – liver, heme Auranofin (Ridaura) Aurothioglucose (Solganol) Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Cyclosporine (Neoral, Sandimmune) Gold sodium thiomalate (Myochrysine) Hydroxychloroquine (Plaquenil) – retinal toxicity – Q 6 months Methotrexate (Rheumatrex) Leflunomide (Arava)---Preg Cat X, long half-life, hepatotoxic Penicillamine (Cuprimine, Depen) Sulfasalazine (Azulfindine) – orange-yellow urine PG 134 Gold

26 Biologic Response Modifiers Etanercept (Enbrel) – avoid with live vaccine (soluble receptor TNF inhibitor) Anakinra (Kineret) – monitor for pulmonary problems (IL-1 receptor antagonist) Infliximab (Remicade) – monitor for infection (monoclonal antibody for TNF) Adalimumab (Humira) – monitor for infection (monoclonal antibody for TNF receptor) Abatacept (Orencia®) – monitor for infection (Inhibits T-Cell (T- lymphocytes activation by binding to CD80 and CD86 on antigen presenting cells) Osteoarthritis (OA) - acetaminophen & NSAIDs - surgery – knee/hip replacement - glucosamine/chondrotin – NIH study (GAIT) Biologic Response Modifiers Etanercept (Enbrel) – avoid with live vaccine (soluble receptor TNF inhibitor) Anakinra (Kineret) – monitor for pulmonary problems (IL-1 receptor antagonist) Infliximab (Remicade) – monitor for infection (monoclonal antibody for TNF) Adalimumab (Humira) – monitor for infection (monoclonal antibody for TNF receptor) Abatacept (Orencia®) – monitor for infection (Inhibits T-Cell (T- lymphocytes activation by binding to CD80 and CD86 on antigen presenting cells) Osteoarthritis (OA) - acetaminophen & NSAIDs - surgery – knee/hip replacement - glucosamine/chondrotin – NIH study (GAIT) PG 134

27 Joint Distribution: RA Compared to OA Rheumatoid Arthritis Osteoarthritis

28 SLE (systemic lupus erythematosus) occurs more frequently in: a. male African Americans b. Asians c. post-menopausal women d. people of Mediterranean origin e. young women SLE (systemic lupus erythematosus) occurs more frequently in: a. male African Americans b. Asians c. post-menopausal women d. people of Mediterranean origin e. young women

29 SLE (systemic lupus erythematosus) occurs more frequently in: a. male African Americans b. Asians c. post-menopausal women d. people of Mediterranean origin e. young women SLE (systemic lupus erythematosus) occurs more frequently in: a. male African Americans b. Asians c. post-menopausal women d. people of Mediterranean origin e. young women

30 Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia b. rhabdomylosis c. intermittent claudication d. dopamine deficiency e. myocardial infarction Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia b. rhabdomylosis c. intermittent claudication d. dopamine deficiency e. myocardial infarction

31 Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia (cramps) b. rhabdomylosis (statins) c. intermittent claudication (PVD) d. dopamine deficiency (RLS) e. myocardial infarction Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia (cramps) b. rhabdomylosis (statins) c. intermittent claudication (PVD) d. dopamine deficiency (RLS) e. myocardial infarction

32 Trigeminal neuralgia is treated by the use of: a. aspirin b. carbamazepine c. dipyridamole d. methylprednisolone e. thiamine Trigeminal neuralgia is treated by the use of: a. aspirin b. carbamazepine c. dipyridamole d. methylprednisolone e. thiamine

33 Trigeminal neuralgia is treated by the use of: a. aspirin b. carbamazepine c. dipyridamole d. methylprednisolone e. thiamine Trigeminal neuralgia is treated by the use of: a. aspirin b. carbamazepine c. dipyridamole d. methylprednisolone e. thiamine

34 When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating: I. May cause drowsiness II. Shake well before using III. Finish all of this medication a. I only b. III only c. I and II only d. II and III only e. I, II, and III When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating: I. May cause drowsiness II. Shake well before using III. Finish all of this medication a. I only b. III only c. I and II only d. II and III only e. I, II, and III

35 When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating: I. May cause drowsiness II. Shake well before using III. Finish all of this medication a. I only b. III only c. I and II only d. II and III only e. I, II, and III When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating: I. May cause drowsiness II. Shake well before using III. Finish all of this medication a. I only b. III only c. I and II only d. II and III only e. I, II, and III

36 Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches? I. Do not cut patches before applying II. Not intended for use in children under the age of 12 III. Replace patch every day unless pain is under control a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches? I. Do not cut patches before applying II. Not intended for use in children under the age of 12 III. Replace patch every day unless pain is under control a. I only b. III only c. I and II only d. II and III only e. I, II, and III

37 Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches? I. Do not cut patches before applying II. Not intended for use in children under the age of 12 III. Replace patch every day unless pain is under control a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches? I. Do not cut patches before applying II. Not intended for use in children under the age of 12 III. Replace patch every day unless pain is under control a. I only b. III only c. I and II only d. II and III only e. I, II, and III

38 The upper daily dosing regimen for naproxen is NOT more than: a. 0.5 g b. 1 g c. 1.5 g d. 2.5 g e. 4 g The upper daily dosing regimen for naproxen is NOT more than: a. 0.5 g b. 1 g c. 1.5 g d. 2.5 g e. 4 g

39 The upper daily dosing regimen for naproxen is NOT more than: a. 0.5 g b. 1 g (mefenamic) c. 1.5 g (naproxen) d. 2.5 g e. 4 g (acetaminophen) Ibuprofen (3.2g) Indomethacin (200mg) The upper daily dosing regimen for naproxen is NOT more than: a. 0.5 g b. 1 g (mefenamic) c. 1.5 g (naproxen) d. 2.5 g e. 4 g (acetaminophen) Ibuprofen (3.2g) Indomethacin (200mg)

40 Which of the following ingredients is are present in Percodan but not in Percocet: I. Aspirin II. Acetaminophen III. Oxycodone a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following ingredients is are present in Percodan but not in Percocet: I. Aspirin II. Acetaminophen III. Oxycodone a. I only b. III only c. I and II only d. II and III only e. I, II, and III

41 Which of the following ingredients is are present in Percodan but not in Percocet: I. Aspirin II. Acetaminophen III. Oxycodone a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following ingredients is are present in Percodan but not in Percocet: I. Aspirin II. Acetaminophen III. Oxycodone a. I only b. III only c. I and II only d. II and III only e. I, II, and III

42 Drugs for the Treatment of Asthma NAPLEX PG 142

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45 SymptomsNighttime Symptoms Lung Function Step 1 Mild Intermittent Symptoms 2 times a week Asymptomatic and normal PEF between exacerbations Exacerbations brief (from a few hours to a few days); intensity may vary 2 times a month FEV1/PEF 80% predicated PEF variability < 20% Step 2 Mild Persistent Symptoms > 2 times a week but < 1 time a day Exacerbations may affect activity > 2 times a month FEV1/PEF 80% predicated P EF variability < 20- 30% Step 3 Moderate Persistent Daily symptoms Daily use of inhaled short- acting beta-2 agonist Exacerbations affect activity Exacerbations 2 times a week; may last day > 1 time a week FEV1/PEF > 60 - < 80% predicated PEF variability > 30% Step 4 Severe Persistent Continual Symptoms Limited Physical Activity Frequent Exacerbations Frequent FEV1/PEF 60% predicated PEF variability > 30% Classification

46 PG 142 Drugs for the Treatment of Asthma phosphodiesterase phosphodiesterase Adenyl cyclasecyclic AMP (bronchodilation) elimination Sympathomimetics Increase formation of cyclic AMP Nonselective Ephedrine Ephedrine Epinephrine (Adrenalin, Medihaler-Epi, Bronkaid, Primatene, etc.) Epinephrine (Adrenalin, Medihaler-Epi, Bronkaid, Primatene, etc.) Ethylnorepinephrine (Bronkephrine) Ethylnorepinephrine (Bronkephrine)

47 PG 143 Drugs for the Treatment of Asthma Selective Short-Acting Beta-2 Agonists. Provide quick relief; may cause tachycardia, tremor, etc. Albuterol (Proventil, Ventolin, Airet, Volmax) 0.5hr peak, 4 hours duration Albuterol (Proventil, Ventolin, Airet, Volmax) 0.5hr peak, 4 hours duration Albuterol - oral sustained-release product Albuterol - oral sustained-release product Pirbuterol (Maxair) – Autoinhaler – longer duration 6 hrs (tertiary butyl group) Pirbuterol (Maxair) – Autoinhaler – longer duration 6 hrs (tertiary butyl group) Levalbuterol (Xopenex) – active isomer of albuterol, neb., less cardiac side effects Levalbuterol (Xopenex) – active isomer of albuterol, neb., less cardiac side effects Metaproterenol (Alupent, Metaprel) – delayed onset (1 hour) & prolonged effect (4 hour) Metaproterenol (Alupent, Metaprel) – delayed onset (1 hour) & prolonged effect (4 hour) Terbutaline (Brethine, Bricanyl) – delayed onset 1 hour & prolonged duration (6hr) – no-inhalation in U.S. & (management of pretermed labor) Terbutaline (Brethine, Bricanyl) – delayed onset 1 hour & prolonged duration (6hr) – no-inhalation in U.S. & (management of pretermed labor) isoproterenol (Isuprel, Medihaler-Iso) – beta-1 & beta-2 activity isoproterenol (Isuprel, Medihaler-Iso) – beta-1 & beta-2 activity

48 Drugs for the Treatment of Asthma (cont.) Long-Acting Beta-2 Agonists. For long-term symptom control; frequently used with inhalational corticosteroids; may cause tachycardia, tremor, etc.; for prophylaxis only. Formoterol (Foradil) – DPI - capsule Formoterol (Foradil) – DPI - capsule Salmeterol (Serevent) – DPI – Diskus Salmeterol (Serevent) – DPI – Diskus NOT SUITABLE AS A RESCUE INHALER!!!!!!!!!!!!!! PG 142

49 Drugs for the Treatment of Asthma Xanthines Phosphodiesterase inhibitors; generally for prophylaxis; adverse effects similar to caffeine Theophylline (Slo-Phyllin, Theolair, Theo-Dur)----Think drug interactions, serum levels 10-20, arryhthimogenic at high levels Theophylline (Slo-Phyllin, Theolair, Theo-Dur)----Think drug interactions, serum levels 10-20, arryhthimogenic at high levels Dyphylline (Lufyllin) theophylline derivative Dyphylline (Lufyllin) theophylline derivative Aminophylline (Somophyllin-CRT) anhydrous contains 86% Aminophylline (Somophyllin-CRT) anhydrous contains 86% - 300mg theo (PO) = 380mg Amino (IV) - 300mg theo (PO) = 380mg Amino (IV) theophylline, dihydrate 79% theophylline, dihydrate 79% Oxtriphylline (Choledyl) contains 64% theophylline Oxtriphylline (Choledyl) contains 64% theophylline Leukotriene receptor drugs For prophylaxis; may reduce need for beta-2 agonist Zafirlukast (Accolate) leukotriene receptor antagonist Zafirlukast (Accolate) leukotriene receptor antagonist Montelukast Sodium (Singulair) leukotriene receptor antagonist Montelukast Sodium (Singulair) leukotriene receptor antagonist Zileuton (Zyflo) inhibits leukotriene formation (5-lipoxygenase inhibitor); Zileuton (Zyflo) inhibits leukotriene formation (5-lipoxygenase inhibitor); monitor hepatic function, think DIs---potent inhibitor monitor hepatic function, think DIs---potent inhibitor

50 Zyflo CR will be given BID instead of QID. But patients will still need liver function tests every month for the first 3 months...then every 2 to 3 months for the rest of the first year. – 2007 Omalizumab. Save the monoclonal antibody, Xolair, for patients with severe asthma and allergies...who are not responding adequately to high-dose inhaled steroids and long-acting beta- agonists. New NIH guidelines will improve asthma treatment. You'll see renewed emphasis on controlling symptoms...patient education...and avoiding allergens. Zyflo CR will be given BID instead of QID. But patients will still need liver function tests every month for the first 3 months...then every 2 to 3 months for the rest of the first year. – 2007 Omalizumab. Save the monoclonal antibody, Xolair, for patients with severe asthma and allergies...who are not responding adequately to high-dose inhaled steroids and long-acting beta- agonists. New NIH guidelines will improve asthma treatment. You'll see renewed emphasis on controlling symptoms...patient education...and avoiding allergens.

51 PG 142 Drugs for the Treatment of Asthma Corticosteroids Inhalational; reduce inflammation and bronchial reactivity; may cause oral candidiasis, cough, and other steroid effects (with prolonged use). Prophylaxis only. Beclomethasone dipropionate (Beclovent, Vanceril) Beclomethasone dipropionate (Beclovent, Vanceril) Triamcinolone acetonide (Azmacort) Triamcinolone acetonide (Azmacort) Flunisolide (Aerobid) Flunisolide (Aerobid) Fluticasone propionate (Flovent) Fluticasone propionate (Flovent) Mometasone (Asmanex Twisthaler) Mometasone (Asmanex Twisthaler) Budesonide (Pulmicort) (Pulmicort Respules – only neb ICS) Budesonide (Pulmicort) (Pulmicort Respules – only neb ICS)Anticholinergics Ipratropium bromide (Atrovent); bronchodilator. Reduces secretions; alternative to beta-2 agonists; anticholinergic adverse effects - combivent – albuterol and ipratropium - combivent – albuterol and ipratropium Tiotropium (Spiriva)----long acting, dry powder capsule for inhalation

52 PG 143 Drugs for the Treatment of Asthma Mast cell stabilizers Anti-inflammatory; very safe; for prophylaxis only Cromolyn sodium (Intal, Nasalcrom) Cromolyn sodium (Intal, Nasalcrom) Nedocromil sodium (Tilade) Nedocromil sodium (Tilade) Combination products Ipratropium bromide/albuterol sulfate (Combivent) Salmeterol xinafoate/fluticasone propionate (Advair Diskus) Symbicort contains the corticosteroid budesonide (Pulmicort)...plus the long-acting beta-agonist formoterol (Foradil). - 2007 - 2 puffs BID

53 Side effects of oral corticosteroids include all of the following except: a. hyperglycemia b. nervousness c. fluid retention d. HPA axis suppression e. thrombocytopenia Side effects of oral corticosteroids include all of the following except: a. hyperglycemia b. nervousness c. fluid retention d. HPA axis suppression e. thrombocytopenia

54 Side effects of oral corticosteroids include all of the following except: a. hyperglycemia b. nervousness c. fluid retention d. HPA axis suppression e. thrombocytopenia Side effects of oral corticosteroids include all of the following except: a. hyperglycemia b. nervousness c. fluid retention d. HPA axis suppression e. thrombocytopenia

55 Patients exhibiting Cushing syndrome should avoid products containing: a. corticosteriods b. iodine c. sulfas d. penicillins e. salicylates Patients exhibiting Cushing syndrome should avoid products containing: a. corticosteriods b. iodine c. sulfas d. penicillins e. salicylates

56 Patients exhibiting Cushing syndrome should avoid products containing: a. corticosteriods b. iodine c. sulfas d. penicillins e. salicylates Patients exhibiting Cushing syndrome should avoid products containing: a. corticosteriods b. iodine c. sulfas d. penicillins e. salicylates

57 Which of the following drugs is/are administered by dry powder inhalation? I. Ipratropium (atrovent of combivent) II. Pirbuterol (MaxAir Turboinhaler) III. Salmeterol (Diskus) a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following drugs is/are administered by dry powder inhalation? I. Ipratropium (atrovent of combivent) II. Pirbuterol (MaxAir Turboinhaler) III. Salmeterol (Diskus) a. I only b. III only c. I and II only d. II and III only e. I, II, and III

58 Which of the following drug(s) is/are administered by dry powder inhalation? I. Ipratropium (atrovent of combivent) II. Pirbuterol (MaxAir Turboinhaler) III. Salmeterol (Diskus) a. I only b. III only c. I and II only d. II and III only e. I, II, and III Which of the following drug(s) is/are administered by dry powder inhalation? I. Ipratropium (atrovent of combivent) II. Pirbuterol (MaxAir Turboinhaler) III. Salmeterol (Diskus) a. I only b. III only c. I and II only d. II and III only e. I, II, and III

59 All of the following drugs are available as aerosol units EXCEPT: a. Spiriva b. Azmacort c. Rhinocort d. Beconase e. Combivent All of the following drugs are available as aerosol units EXCEPT: a. Spiriva b. Azmacort c. Rhinocort d. Beconase e. Combivent

60 All of the following drugs are available as aerosol units EXCEPT: a. Spiriva b. Azmacort c. Rhinocort d. Beconase e. Combivent All of the following drugs are available as aerosol units EXCEPT: a. Spiriva b. Azmacort c. Rhinocort d. Beconase e. Combivent

61 Drugs Used to Treat Glaucoma NAPLEX

62 PG 136 Causes of Glaucoma Wide or open angle – most common, malfunction of trabecular meshwork Wide or open angle – most common, malfunction of trabecular meshwork Narrow angle or closed angle – obstruction of the outflow of aqueous humor through the trabecular meshwork. Narrow angle or closed angle – obstruction of the outflow of aqueous humor through the trabecular meshwork.

63 An instrument used to measure intraocular pressure is a(n): a. gonioscope b. otoscope c. ophthalmoscope d. tonometer e. barometer An instrument used to measure intraocular pressure is a(n): a. gonioscope b. otoscope c. ophthalmoscope d. tonometer e. barometer

64 An instrument used to measure intraocular pressure is a(n): a. gonioscope (lens to study angle of eye) b. otoscope (instrument to examine the drum membrane of the ear) c. ophthalmoscope (device to study interior of eye) d. tonometer (device to measure intraocular pressure) e. barometer (device to measure the atmospheric pressure) An instrument used to measure intraocular pressure is a(n): a. gonioscope (lens to study angle of eye) b. otoscope (instrument to examine the drum membrane of the ear) c. ophthalmoscope (device to study interior of eye) d. tonometer (device to measure intraocular pressure) e. barometer (device to measure the atmospheric pressure)

65 PG 136 Drugs for Glaucoma Treatment Goal of Therapy – reduced intraocular pressure (IOP) - measured by a tonometer (10-20mmhg) - decrease rate of aqueous humor production - increase rate of outflow (drainage) of aqueous humor humor Sympathomimetics increase outflow and decrease production of aqueous humor - epinephrine (Epifrin, Glaucon) – discard if color change occurs - dipiverfrin (Propine) – epinephrine prodrug – less side effects - apraclonidine (Iopidine) – alpha-2 agonist; watch for ocular allergy - brimonidine (Alphagan) - alpha-2 agonist, more selective

66 PG 136 Drugs for Glaucoma Treatment Miotics (direct acting)have direct cholinergic action causing miosis; increases outflow, may cause eye pain, burning, blurred vision; less with gel and Ocusert formulations - acetylcholine (Miochol) - carbachol (Isoptocarbachol) - Pilocarpine (Isoptocarpine, Pilocar, Pilostat, Pilopine HS, Ocusert Pilo) Miotics (cholinesterase inhibitors)increase cholinergic action by inhibiting cholinesterase; similar adverse effects as direct-acting miotics - physostigmine (Eserine) – may cause cataracts - Demecarium (Humersol) - Echothiophate (phospholine iodide) mydriasis

67 PG 136 Drugs for Glaucoma Treatment Beta-adrenergic blocking agents reduce production of aqueous humor; watch for possible breathing difficulty, bradycardia, hypotension, and CNS depression - betaxolol (Betopic, Betoptic S) – beta 1 selective - levobetaxolol (Betaxon) – beta 1 selective - carteolol (Ocupress), levobunolol (Betagan, AKBeta) - metipranolol (Optipranolol), - timolol (Timoptic, Timoptic XE) B1 & B2 Prostaglandin analogs increase outflow of aqueous humor; may darken iris color and cause thickened lashes - latanoprost (Xalatan) - bimatoprost (Lumigan) - travoprost (Travatan) - Unoprostone (Rescula) Not available in U.S.

68 PG 136 Drugs for Glaucoma Treatment Carbonic anhydrase inhibitors suppress production of aqueous humor; watch for urinary frequency and nephrolithiasis - dichlorphenarnide (Daranide) - acetazolamide (Diamox)----oral capsules, IV – Also used for mountain sickness - methazolamide (Neptazane) - dorzolamide (Trusopt) - brinzolamide (Azopt) Osmotic diuretics----given orally or IV - glycerin (Osmoglyn), mannitol (Osmitrol) - urea (Ureaphil), isosorbide (Isomotic)

69 Timoptic dosage forms include: I. capsule II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III Timoptic dosage forms include: I. capsule II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III

70 Timoptic dosage forms include: I. capsule II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III Timoptic dosage forms include: I. capsule II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III

71 Dosage forms for timolol maleate include: I. gel II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III Dosage forms for timolol maleate include: I. gel II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III

72 Dosage forms for timolol maleate include: I. gel II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III Dosage forms for timolol maleate include: I. gel II. tablet III. ophthlamic solution a. I only b. III only c. I and II only d. II and III only e. I, II, and III

73 Glaucoma Case Study Page 138

74 Pilocarpine can be classified as a(n): a. anticholinergic agent b. carbonic anhydrase inhibitor c. beta-adrenergic blocking agent d. cholinergic agent e. sympathomimetic agent Pilocarpine can be classified as a(n): a. anticholinergic agent b. carbonic anhydrase inhibitor c. beta-adrenergic blocking agent d. cholinergic agent e. sympathomimetic agent

75 Pilocarpine can be classified as a(n): a. anticholinergic agent b. carbonic anhydrase inhibitor c. beta-adrenergic blocking agent d. cholinergic agent e. sympathomimetic agent Pilocarpine can be classified as a(n): a. anticholinergic agent b. carbonic anhydrase inhibitor c. beta-adrenergic blocking agent d. cholinergic agent e. sympathomimetic agent

76 An Ocusert Pilo-20 system: a. is administered orally once daily b. releases 20 mg of pilocarpine each day c. must be replaced each month d. releases 20 µg of pilocarpine each hour e. must be soaked in normal saline just prior to use An Ocusert Pilo-20 system: a. is administered orally once daily b. releases 20 mg of pilocarpine each day c. must be replaced each month d. releases 20 µg of pilocarpine each hour e. must be soaked in normal saline just prior to use

77 An Ocusert Pilo-20 system: a. is administered orally once daily b. releases 20 mg of pilocarpine each day c. must be replaced each month d. releases 20 µg of pilocarpine each hour e. must be soaked in normal saline just prior to use An Ocusert Pilo-20 system: a. is administered orally once daily b. releases 20 mg of pilocarpine each day c. must be replaced each month d. releases 20 µg of pilocarpine each hour e. must be soaked in normal saline just prior to use

78 A normal intraocular pressure reading would be: a. 10-20 mm Hg b. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg A normal intraocular pressure reading would be: a. 10-20 mm Hg b. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg

79 A normal intraocular pressure reading would be: a. 10-20 mm Hg b. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg A normal intraocular pressure reading would be: a. 10-20 mm Hg b. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg

80 Special caution must be used when timolol is used in patients with: a. sulfonamide allergy b. asthma c. cancer d. hypertension e. NSAID hypersensitivity Special caution must be used when timolol is used in patients with: a. sulfonamide allergy b. asthma c. cancer d. hypertension e. NSAID hypersensitivity

81 Special caution must be used when timolol is used in patients with: a. sulfonamide allergy b. asthma c. cancer d. hypertension e. NSAID hypersensitivity Special caution must be used when timolol is used in patients with: a. sulfonamide allergy b. asthma c. cancer d. hypertension e. NSAID hypersensitivity


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