1. DH206: Pharmacology CH 19:Respiratory Lisa Mayo, RDH, BSDH
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

2. Respiratory Drugs Diseases treated with respiratory drugs Asthma
COPD: emphysema, bronchitis
Upper respiratory infections

4. Class of Resp. Diseases Clinic III
Location
Acute
Chronic
Upper Resp
Rhinitis
Sinusitis
Pharyngitis/Tonsillitis
Flu
Allergic rhinitis
Lower Resp
Acute bronchitis
Pneumonia TB
Asthma
COPD
Cystic bronchitis

5. Respiratory Drugs Asthma Considered an inflammatory disease
Chronic lung disease
Drug therapy aimed at relieving broncho-spasm & inflammation
Airway Obstruction
Caused By:
Notations
Bronchoconstriction
Loss lung elasticity
Mediated through ß-2 receptors
Inflammation
Results from mucous production
Mediators are histamine, prostaglandins, leukotrienes, cytokines
Results from air sac enlargement
Tx is difficult (long-term, high dose meds)

6. 2007 Guidelines for Management of Asthma
USE THIS INSTEAD P.221, TABLE 19-1
EASIER TO UNDERSTAND THIS WAY
ASTHMA TYPE
THERAPY
1st LINE DRUGS
2nd LINE DRUGS
Intermittent
No meds
Albuterol prn (B2-agonist)
Mild
Daily meds
Inhaled corticosteroid
Leukotriene modifier
Methylxanthine
Mast cell stabilizer
Moderate
Inhaled corticosteroid OR LABA
Severe
Inhaled corticosteroid + LABA

7. 2007 Guidelines for Diagnosis & Management of Asthma
Respiratory Drugs
2007 Guidelines for Diagnosis & Management of Asthma
Number & frequency of meds ↑ as severity of asthma worsens
Beginning therapy: start with highest recommendations & stair-step down as patient needs
Inhaled meds preferred agents
High concentrations of drug delivered to airways with few systemic side effects
Severe asthma attacks
ß-2 agonist preferred agent (EPI)
Corticosteroid tablets to relieve inflammation
Oxygen

8. Respiratory Drugs Drug Delivery Systemic: oral, parental
Inhaled: shorter onset, fewer side effects
Nebulizer
Dry powder inhaler
Metered-dose inhalers (most common delivery system)

9. Respiratory Drugs Asthma Medications: 2 classes of medications
Quick-relief medications
Reliever/Acute rescue drugs
Long-term medications
Control, Maintenance meds
Taken daily
Most have anti-inflammatory effects

10. Respiratory Drugs Asthma Medications 2 classes of medications
Quick-relief medications
Reliever/Acute rescue drugs
Long-term medications (mild, moderate, severe asthma & COPD)
Control, Maintenance meds
Taken daily
Most have anti-inflammatory effects

11. Quick-Relief Meds Produce bronchodilation
Protype: albuterol(Ventolin, Proventil)
Tx acute symptoms
Not used for daily prevention
Patients need to rinse after use (NBQ)
DRUG CATEGORIES
MECHANISM OF ACTION
USES
Beta-Adrenergic Agents (Sympathomimetic Agents)
Stimulate beta-2 adrenergic receptors
prn
Anticholinergics
Block cholinergic (muscarinic) receptors
COPD
Systemic corticosteroids
Emergencies Asthma or COPD

12. Quick-Relief Meds ß-2 Adrenergic Drugs p. 224
Beta-Adrenergic Agents (Sympathomimetic Agents)
ß-2 Adrenergic Drugs
Albuterol(Proventil, Ventolin)
Metaproterenol(Alupent)
Levalbuterol(Xopenex)

13. Quick-Relief Meds Beta-Adrenergic Agents (Sympathomimetic Agents)
NON-SELECTIVE (stimulate β-1 & β-2)
2 drugs: Epi & isopreterenol(Isuprel)
When used to tx asthma – will also ↑ heart rate
SELECTIVE
Selective beta-2 drugs are BEST: bronchodilators
Fewer effects on beta-1

15. β-agonist stimulates enzyme AC to ↑ cAMP levels – results in dilation

16. Can be difficult for kids to use: use a separate connector – can decrease amt of drug administered

17. NBQ
After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?
Ipratropium
Cromlyn sodium
Metaproterenol
Theophylline

18. NBQ
After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?
Ipratropium
Cromlyn sodium
Metaproterenol
Theophylline

19. NBQ
Which of the following drugs is the drug of choice for the quick relief of bronchospasm?
Albuterol
Ipratropium
Hydrocortisone
Salmeterol

20. NBQ
Which of the following drugs is the drug of choice for the quick relief of bronchospasm?
Albuterol
Ipratropium
Hydrocortisone
Salmeterol

21. NBQ
Which of the following drugs is classified as a β2-agonist bronchodilator?
Albuterol
Ipratropium
Hydrocortisone
Montelukast

22. NBQ
Which of the following drugs is classified as a β2-agonist bronchodilator?
Albuterol
Ipratropium
Hydrocortisone
Montelukast

23. Quick-Relief Drugs
p.226
Anticholinergic Agents: used for tx COPD, not asthma
DRUG
NOTATIONS
Ipratropium bromideHFA(Atrovent)
PROTYPE
Nasal spray: useful for rhinitis
Ipratropium bromide + albuterol sulfate(Combivent)
Tiotropium bromide(Spiriva)
LONG-TERM, NOT SHORT ACTING FOR TX COPD

24. Quick-Relief Drugs Anticholinergic Agents
Action: Inhibit ACH receptors on smooth muscle= bronchodilation
Protype: ipratropium bromide(Atrovent)
Adverse effects
Xerostomia
Taste alteration
Instruct pt to rinse mouth after each inhalation (NBQ)

25. Muscarinic antagonists block effects of ACH & PANS – leads to bronchodilation

26. Quick-Relief Drugs Systemic corticosteroids
Used when asthma cannot be controlled by bronchodilators alone
Short-term
Decrease inflammation
Systemic delivery = acute attacks
Inhaled delivery = chronic, long-term therapy

27. Respiratory Drugs Asthma Medications 2 classes of medications
Quick-relief medications
Reliever/Acute rescue drugs
Long-term medications
Control, Maintenance meds
Taken daily
Most have anti-inflammatory effects

28. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

29. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

30. Long-Term Meds Inhaled corticosteroids
Drug of choice for persistent asthma
1st line long-term therapy
Potent & effective anti-inflammatory agents
Decrease airway hyper-reactivity & swelling
Rinse mouth after inhaler use (NBQ)

31. Long-Term Meds Inhaled Corticosteroids Inhaled corticosteroids
Beclomethasone dipropionate(Beclovent, Vanceril)
Budesonide(Pulmicort)
Flumisolide(Aerobid)
Fluticasone(Flovent, Advair)
Mometasone(Asmanex)
Triamcinolone(Azmacort)

32. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

33. Long-Term Meds Selective long-acting ß-2 Agonists (LABA)
Bronchodilators
Not used alone – usually in combo w/corticosteroids
Black box: NOT to be used as stand alone tx – increase risk of asthma-related deaths
Selective long-acting ß-2 Agonists
Salmeterol(Serevent)
Formoterol(Foradil)

34. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

35. Long-Term Meds Methylxanthines Methylxanthines
Bronchodilators that relax the airway smooth muscle
COPD
Many drug interactions
Erythromycin
Clarithromycin
Caffeine: can cause mild bronchodilation in patients with asthma (100mg which is in a cup of coffee)
Methylxanthines
Theophylline(Slo-Phyllin),TheoDur, Theo-24)
Aminophylline(norphyl)

36. Theophylline inhibits enzyme PDE, slows inactivation of cAMP, leads to dilation
Theophylline antagonizes adenosine (bronchoconstrictior)

37. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

38. Long-Term Meds
Mast cell stabilizers p.225, books calls this category cromolyn
Inhibit release of histamine (decrease inflammation)
Mast Cell Stabilizers
Cromolyn sodium(Intal)
Nedocromil(Tilade)

39. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

40. Long-Term Meds Leukotrienes Modifiers
Block activity of arachidonic acid derivatives = decrease inflammation
P-450 enzyme induction
Drug interactions
Aspirin
Erythromycin
Increase effect Warfarin
Leukotriene Modifiers
Zafirukast(Accolate)
Montelukast(Singular)
Zileutron(Zyflo)

41. zafirlukast
(Accolate),
montelukast
(Singular)
Zileutron
(Zoflo)

42. Long-Term Meds Inhaled corticosteroids Asthma
Selective long-acting ß-2 Agonists (LABA)
Asthma or COPD
(never used as stand-along therapy, always in combo)
Methylxanthines
COPD
IV for status asthmaticus
Mast cell stabilizers
Leukotrienes Modifiers
Immunomodulators

43. Long-Term Meds Immunomodulators Immunomodulators Omalizumab(Xolair)
Prevent IgE from binding to mast cells
Immunomodulators
Omalizumab(Xolair)

44. Binds to receptors so allergen cannot
omalizumab(Xolair)
Binds to receptors so allergen cannot
omalizumab(Xolair)

45. NBQ
Which of the following drugs is preferred for long-term control of asthma?
B-1 agonist
B-2 agonist
Inhaled corticosteroid
Oral corticosteroids

46. NBQ
Which of the following drugs is preferred for long-term control of asthma?
B-1 agonist
B-2 agonist
Inhaled corticosteroid
Oral corticosteroids

47. NBQ
Which of the following drugs is used to control mild persistent asthma?
Albuterol
Ipratropium
Inhaled beclomethasone
Salmeterol

48. NBQ
Which of the following drugs is used to control mild persistent asthma?
Albuterol
Ipratropium
Inhaled beclomethasone
Salmeterol

50. DH Considerations
Aspirin & NSAIDs contraindicated in asthmatic patients (can lead to bronchospasm)
Anticholinergic side effects
Consult MD in SEVERE asthma cases
Inhalers brought to appts
Systemic corticosteroids – pt may need increase dose morning of apt
Inhalers: advise pt to rinse after to avoid dry mouth & oral candidiasis

51. Agents used to manage upper respiratory tract infections
Nasal Decongestants
Expectorants & Mucolytics
Antitussives

52. Agents used to manage upper respiratory tract infections
Nasal Decongestants
Constrict blood vessels in nasal mucous membranes
Chronic use may result in rebound swelling and congestion
Book correction: not all nasal decongestants are α-agonists (p.226)
Remember: Patanase is a nasal antihistamine, not a decongestant

53. Agents used to manage upper respiratory tract infections
Nasal Decongestants
phenylephrine (Neo-Synephrine, Sinex, Allerest)
α-agonist
pseudoephedrine(Sudafed, Sucrets, Actifed)
Beclomethasone(Beconase,Vancenase)
Corticosteroid Nasal spray
Mometasone(Nasonex)
Fluticasone(Flonase)
Budesonide(Rhinocort)
Flunisolide(Nasalide)
Cromolyn(Nasalcrom)
OTC nasal spray
Nedocromil(Tiladle)
Nasal spray for asthma & rhinitis

54. NBQ Which of the following types of agents are nasal decongestants?
B-1 agonist
B-2 blockers
Alpha-1 agonist
Alpha-2 blockers

55. NBQ Which of the following types of agents are nasal decongestants?
B-1 agonist
B-2 blockers
Alpha-1 agonist
Alpha-2 blockers

56. Agents used to manage upper respiratory tract infections
Expectorants & Mucolytics
Mucolytics
Promote removal of exudate or mucus from respiratory passages
Liquefying & decrease viscosity of mucus
Acetylcysteine(Mucosil): Useful in cystic fibrosis
Expectorants
Drugs that facilitate the removal of thickened mucus secretions from the lungs
Action: ↑ bronchial = liquefy mucus
Guaifenesin(Mucinex) most popular

58. Agents used to manage upper respiratory tract infections
Antitussives: agents used to suppress cough
Drugs
Notations
Opioids: (Codeine, Hydrocodone, Hydromorphone)
Narcotic opioid
Avoid in asthmatic (cause respiratory depression)
Dextromethorphan(Robitussin, Vicks)
Non-narcotic
Many OTC products contain
Benzonatate(Tessalon)

59. NBQ Which of the following terms defines “suppressing a cough?”
Expectorant
Antitussive
Antihistamine
Antiasthma

60. NBQ Which of the following terms defines “suppressing a cough?”
Expectorant
Antitussive
Antihistamine
Antiasthma

61. NBQ Which of the following drugs MAY be contraindicated in asthmatics?
Aspirin
Acetaminophen
Vitamin C
Folic acid

62. NBQ Which of the following drugs MAY be contraindicated in asthmatics?
Aspirin
Acetaminophen
Vitamin C
Folic acid