Pulmonary Drugs
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| Spacers | Increased delivery of drug to lungs; use especially w/ corticosteroids due to risk of thrush
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| Metered Dose Inhalers | Small, hand held, pressurized devices, hand-lung coordination. 10% reaches lung, 80% hits oropharynx and is swallowed
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| Dry Powder Inhalers | Breath activated, no hand lung coordination, 20% gets to lung
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| Nebulizers | Converts liquid to mist. Face mask or mouthpiece used; med delivers over several minutes; same amount of med as in one puff
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| Glucocorticoids | Vancenase, Pulmicort, Flovent/Flonase, Nasonex, Nasocort
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| Nasonex & Nasocort | Intranasal. S/E: drying of nasal mucosa, burning/itching, sore throat, epistaxis, not as effective if nasal congestion present
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| Corticosteroids | Inhaled = 1st line of therapy for asthma. Oral use for severe asthma; when symptoms not controlled with inhalation and bronchodilators
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| Vancenase, Pulmicort, Flovent/Flonase, Nasonex, Nasocort | S/E w/ chronic use: adrenal suppression & bone loss, oropharyngeal candidiasis and dysphonia. Prevent by gargling after admission, use spacer. Prevent bone loss by using lowest dose possible, adequate Ca+, Vit D, & wt bearing exercises
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| Leukotriene Modifiers | Compounds that promote bronchoconstriction, inflammation, mucus production and edema. -- Effects are not immediate
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| Name the Leukotriene Modifiers | Zyflo & Singulair
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| Zyflo | Blocks leukotriene synthesis, used for adults and children >12 yrs; hepatotoxic, monitor ALT, competes with theophylline & coumadin (increases drug levels)
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| Singulair | Leukotriene receptor blocker. Use prophylactically and maintenance; Prevention of exercise induced bronchospasm; relief of allergic rhinitis; not immediate, not hepatotoxic, does not increase drug levels
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| Methylxanthines | Theophylline
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| Theophylline | Causes bronchodilation; narrow therapeutic range; only given PO. Used w/ chronic, stable asthma to decrease frequency and severity of attacks. Wide variations in metabolic rates
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| Theophylline (2) | Dosage based on individual and therapeutic range 5-15. Levels 20-25 = nauseau, vomiting, restleness. Levels >30 dysrhythmias (Vfib), seizures, avoid w/ caffeine
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| Cromolyn (Nasalcrom, Intal) | Used for seasonal allergy attacks and exercise induced bronchospasm - give 15 minutes before.
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| Nasalcrom | Given intranasal for allergic rhinitis
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| Intal | Given inhalation
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| Nasalcrom & Intal | Decrease bronchial inflammation, not a bronchodilator. Used prophylactically, not quick relief, no systemic effects, may be used instead of steroids
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| Beta 2 Adrenergic Agonist (Bronchodilators) | Albuterol, Levalbuterol, Serevent, Advair
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| Beta II Adrenergic Agonist | Provides symptomatic relief but does not address underlying cause; most need w/ long term steroid. Most effective for relieving acute bronchospasm
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| Activate Beta 2 receptors | In smooth muscle of lungs causing bronchodilation suppressing histamine release in lung and increase ciliary motility. Available PO or inhalation. PO = long acting
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| Short Acting Beta 2 Adrenergic Agonist | Albuterol, Levalbuterol
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| Albuterol & Levalbuterol | Given by inhalation. Begin Immediately; peak 30-60 min, persist for 3-5 hrs. Used to abort an attack but not effective for long term prophylaxis
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| Short Acting (albuterol & levalbuterol) | Exercise induced bronchospasm - take 15 minutes before. Available MDI, DP, nebs, inhalers
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| Long Acting Beta 2 Adrenergic Agonist | Serevent
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| Serevent | Takes effect in 10-30 minutes.
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| Oral Antihistamine drugs | Chlor-Trimeton, Benadryl, Tavist, Zyrtec, Allegra, Claritin, Clarinex
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| First Generation Oral Antihistamines | Chlor-Trimeton, Benadryl, Tavist
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| Second Generation Oral Antihistamines | Zyrtec, Allegra, Claritin, Clarinex
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| Oral Antihistamines | Relieve rhinorrhea, sneezing, nasal itching but not congestion, most effective when taken prophylactically on a regular basis
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| 1st Generation Oral Antihistamines | S/E: sedation, dry mouth, urinary hesitancy, constipation due to anticholinergic effects
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| 2nd Generation Oral Antihistamines | NO SEDATION, few side effects
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| Sympathomimetics | Neosynephrine, Sudafed, Dristan, Atrovent, Spiriva
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| Sympathomimetics (Decongestants) | Activating alpha adrenergic receptors, decrease nasal congestion by vasoconstriction, shrinks, swollen membranes
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| Sudafed | Can be converted to methamphetamine, must be kept behind counter, sign a log, no more than 9 g/month or 3.6 g at one time
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| Neosynephrine, Sudafed, Dristan | Allergic rhinitis to relieve stuffiness, lower congestion of sinusitis and coid. S/E: rebound congestion, increase dose for symptom relief, limit 3-5 days of use, may need steroid, CNS excitation, restless, anxiety, systemic vasoconstrict, watch heart pts
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| Atrovent | Onset 30 sec, max 3 min, last up to 6 hrs. S/E: dry mouth, irritation pharynx, avoid if peanut allergy, contains soya lectithin. 10% anaphylaxis. Combo w/ aluterol is called duoneb
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| Atrovent & Spiriva (anticholinergic) | Block muscarinic receptors in bronchi causing dilation, used on COPD, off label use for asthma. Inhalation only
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| Spiriva | Long acting, onset 30 min, peak 3 hrs, last 24 hrs, given 1x daily. S/E: dry mouth, DPI, additive benefits w/ Beta 2; two different ways to dilate
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| Drugs for Coughing | Codeine, Dextromethophan, Mucinex, Mucomyst
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| Antitussives | Codeine & Dextromethophan
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| Expectorants & Mucolytics | Mucines & Mucomyst
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| Codeine | Decreases frequency and intensity of cough; low dose; 1/10 of dose used for pain; potential for abuse
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| Dextromethophan | Non-opioid antitussive; taken at high doses can cause euphoria and can be abused for this purpose
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| Expectorant | Stimulates flow of respiratory secretions
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| Mucolytics | Breaks up mucus
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| Mucomyst | Given by inhalation; watch for bronchospasm, contains sulfur
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| Selective Toxicity | Ability of drug to injure a target cell or organism without injuring other cells; without causing injury to host
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| Inhibition of Enzyme | Unique to bacteria; ex) folic acid - bacteria make folic acid which is needed for bacterial survival
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| Disruption of protein synthesis | Ribosomes in bacteria are different than ribosomes of mammalian cells
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| Bactericidal | Directly lethal to bacteria
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| Bacteriostatic | Slows bacterial growth but does not cause cell death. Elimination of bacteria must be accomplished by host immune defenses
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| Penicillins & Cephalosporins | Inhibit bacterial cell wall synthesis or activate enzymes to disrupt cell wall
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| Increase cell membrane permeability | Amphotericin B - causes leakage of intracellular material
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| Aminoglycosides | Lethal inhibition of protein synthesis
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| Non-lethal inhibition of protein synthesis | Tetracyclines - only slow bacterial growth
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| Inhibit bacterial synthesis of DNA/RNA | Binds directly to nucleic acids or enzymes that make nucleic acids: rifampin, metronidazole, fluorquinolones
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| Antimetabolites | Disrupt specific biochemical reactions: Trimethoprim & Sulfonamides
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| Suppress viral replication | inhibit specific enzymes
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| Microbial Mechanism | Decrease drug concentration at its site of action (intracellular), ease active uptake, increase active export. Produce drug metabolizing agent.
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| Microbial Mechanism 2 | Change structure or receptor site or target molecules (ribosomes). Produces compound that antagonizes drug action
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| Acquired Resistance | Spontaneous (random) mutation. Conjugation: combining of 2 bacterial DNA; common in gram (-) bacteria; could use normal flora
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| Antibiotic Use | Normal flora competes w/ each other. When used, normal flora changes, bacterial flourish. Broad spectrum antibiotics increase chance of resistance
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| Antibiotic Use (2) | Nosocomial infections are among the most difficult to treat; more exposure to antibiotics
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| Vaccinate | Prevents infections
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| Disconnect invasive lines, catheters | Leading cause of nosocomial infections
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| Target the pathogen | Use only antibiotics the bacteria is sensitive to
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| Expert | Consult infectious disease specialist; right antibiotic for right amount of time
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| Antimicrobial control | Standing orders for bacteria/infections; evaluate effectiveness
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| Treat bacteria not colonization | Just because bacteria is present doesn't mean it is an infection
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| Gram (+) | PCN can easily penetrate thick cell wall and reach the PCN binding proteins on cytoplasmic membrane
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| Gram (-) | Most PCN's cannot penetrate outer membrane
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| Beta Lactamases | Enzymes that break down Beta lactam ring; can be produced by both gram (+-) bacteria.
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| What is #1 adverse effect of PCN's | Allergic reaction
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| PCN Binding Proteins | Receptor site for drug; only available during growth and division of bacteria cell; PCN's have no direct effect on cells of host b/c they don't have cell wall making them very safe. PCN breaks cell wall; cell takes up H2O and ruptures. PCN is bactericidal
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| Penicillins | Penicillin G, Pipracil, Piperacillin/tazobactam, Augmentin
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| Penicillin G | first PCN available; active against most gram (+) bacteria. Most gram (-) are resistant; given IM or IV, intra arterial injection can produce severe reactions. MUST AVOID
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| Pipracil | Broad spectrum, given IV, decrease dosing for impaired renal function
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| Piperacillin/tazobactam (Zosyn) | Contains tazobactam, a beta lactamase inhibitor (prevents the bacterias beta lactase enzyme from breaking down the antibiotic which is the piperacillin)
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| Amoxicillin/clavulante(Augmentin) | May be given orally. S/E: rash & DIARRHEA. Clavulante, a beta lactamase inhibitor protecting the antibiotic (amoxicillin) from the bacterias beta lactamase enzymes
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| Cephalosporin | Binds to PCN binding proteins; has a beta lactam ring, bactericidial; most effective against bacteria undergoing cell division and growth
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| Cephalosporins Resistance | Based on bacteria's ability to break down beta lactam ring
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| 1st Generation Cephalosporin | Destroyed by beta lactamase enzymes; used for gram (+)
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| 2nd Generation Cephalosporin | Less sensitive to beta lactamase enzymes; first and second generation do not reach CSF
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| 3rd & 4th Generation Cephalosporin | Highly resistant to beta lactamases. Given IV. Reserved for active infections; strong antibiotics "big guns"
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| Cephalosporins Pharmacokinetics | PO absortion from GI tract; usually given IM/IV; most eliminated by kidneys, may need to decrease dose if renal impairment
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| Cephalosporins Adverse Effects | Hypersensitivity reactions: rash for several days after onset of use; risk of bleeding (interferes with vitamin K metabolism); thrombophlebitis
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| Cephalosporins Drug Interactions | Meds that promote bleeding; interacts with Probenecid (delays excretion)
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| Cephalosporin Drugs | Cefazolin, Cefzil, Ceftin, Rocephin, Maxipime
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| First Generation Cephalosporin (Drug & Routes) | Cefazolin: IM, IV
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| Second Generation Cephalosporins (Drugs & Route) | Cefzil, Ceftin, PO. Not typically used for active infections, used prophylactically w/ surgical pts
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| Third Generation Cephalosporin (Drug & Route) | Rocephin: IM, IV -- Do NOT mix w/ calcium containing IVF/IVPB
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| Fourth Generation Cephalosporin (Drug & Routes) | Maxipime: IM, IV
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| Carbapenems Drugs | Imipenem & Cilastatin
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| Cilastatin | Inhibits destruction of imipenem by renal enzymes
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| Carbapenems | Very broad spectrum antibiotic. IV only. Able to penetrate gram (-) outer membrane. S/E: N/V, diarrhea, hypersensitivity reactions
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| Vancomycin | Reserved for serious infections, does NOT contain beta lactam ring. Given IV except for infections of GI tract; excreted by kidneys. Uses: CDIFF, MRSA, allergy to PCN
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| Vancomycin S/E: | nephrotoxic, ototoxic (ringing in ears), loss of hearing, rapid infusion may cause "red man syndrome": flushing, tachycardia, hypotension, rash, pruritis. Monitor serum levels do peaks/troughs
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| Azactam | Binds to PCN binding proteins; not effective against anaerobes or gram (+) bacteria; only against gram (-). Highly resistant to beta lactamases
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| Azactam S/E: & Routes | Pain and thrombophlebitis at site of injection. Given IM/IV
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| Tetracycline Drugs | Tetracycline & Doxycycline = Suppress bacterial growth by inhibiting protein synthesis. Take w/ full glass of H2O, use straw if liquid formula (don't let touch teeth)
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| Tetracycline | Take on empty stomach, eliminated by kidneys, avoid w/ renal failure
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| Vibramycin | Can take w/ food, eliminated by liver, OK to use w/ liver failure
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| Tetracycline & Vibramycin S/E: | GI irritation, binds to salts, do not give w/ Ca+ supplements/dairy products/iron supplements/Mg containing antacids or laxatives (discolor teeth from yellow to brown). CDIFF is common
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| Macrolide Drugs | Biaxin & Zithromax
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| Macrolides | Broad spectrum antibiotics w/ BIG molecules, usually bacteriostatic; may be used as alternative to PCN; active against many gram (+) and some gram (-). Inhibits protein synthesis (binds to ribosomes)
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| Macrolide Uses | Pertussis, whooping cough, diptheria, chlamydia, some pneumonia. Feed decreased absorption; eliminated by liver
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| Macrolide S/E: | GI upset, QT prolongation leading to TorSades and sudden cardiac death; avoid w/ antidysrhtymics and calcium channel blockers. Increases levels of theophylline and coumadin
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| Biaxin | Used for respiratory tract infections & H pylori
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| Zithromax | Used for respiratory tract infections, chlamydia; absorption increases w/ food
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| Cleocin | Severe group A streptococcal infections. Active against anaerobic bacteria (Gram + -). Usually bacteriostatic. Inhibits protein synthesis
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| Cleocin S/E: | Pseudomembranous colitis (CDIFF), abdominal pain, fever, leukocytosis; stools (+) for mucus & blood
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| Zyvox | Oxazolidinone; activity against multidrug resistant gram (+) bacteria, VRE, MRSA. Inhibits protein synthesis
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| Zyvox S/E: | myelosuppression AKA decreases WBC, RBC, platelet
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| Aminoglycosides - Drug | Gentamycin
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| Gentamycin | Disrupts protein synthesis, bactericidal d/to production of abnormal proteins
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| Gentamycin S/E: | ototoxic, nephrotoxic, monitor peaks and troughs
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| Gentamycin -- Uses & Routes | Aerobic gram (-) bacilli; cannot kill anaerobes, need O2 to transport medication across membrane. Given IV only, may give PO for bowel infection only; decrease dose or increase interval for renal pts
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| Fluoroquinolones - Drugs | Cipro & Levaquin
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| Cipro & Levaquin uses | Respiratory, Urinary, GI, bone/joint, skin, soft tissue infects. Absorption decreased w/ Al, Mg, Ca, Fe & dairy
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| Cipro & Levaquin S/E: | Tendon rupture (achilles), GI upset, candida inf of pharynx & vagina; CNS: dizziness, confusion (elderly), phototoxicity
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| Metronidazole Drug | Flagyl
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| Flagyl | Used for CDIFF, H Pylori, abdominal & vaginal surgery.
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| Flagyl S/E: | nausea, dry mouth, unpleasant metallic taste; darkening of urine; avoid alcohol, may need to decrease coumadin dose
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| Anti-fungal Drugs | Amphotericin B, Azoles (Sporonox, Diflucan, Vfend), Cancidas
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| Amphotericin B | Active against broad spectrum fungi, given IV. Used as last ditch effort, not common. BIG DANGEROUS DRUG!!!
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| Amphotericin B S/E: | Premedicate w/ Benadryl & Tylenol, corticosteriods. Phlebitis: change peripheral IV sites, give thru central line. Nephrotoxic: renal impairment occurs in almost all patients, avoid other nephrotoxic drugs. Bone marrow suppression
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| Azoles - Drugs | Sporonox, Diflucan, Vfend
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| Sporonox | Take w/ food NOT w/ antacids
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| Azoles action | Broad spectrum antifungal; lower toxicity than Ampho B, given PO. Increases membrane permeability
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| Sporonox, Diflucan, Vfend uses: | Blastomycosis, histoplasmosis, candidiasis
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| Azoles S/E: | Cardiosuppression & liver injury - use cautiously in cardiac & liver patients
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| Cancidas | Given IV, disrupts cell wall; Better tolerated than Ampho B, S/E: phlebitis. Used for aspergillus or candida only
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| TB Drugs | INH, Rifadin, PZA, Myambutol
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| INH | bactericidal to actively dividing organisms. Must take 6 mos, preferred 9.
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| INH S/E: | liver damage; excreted by kidneys, increase risk of liver damage w/ advancing age; peripheral neuropathy d/t lowered levels of vit B6
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| Rifadin | Bactericidal to TB. Take on empty stomach. Eliminated by hepatic metabolism; hepatotoxic
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| Rifampin S/E: | Red-orange discoloration of urine, tears, sweat & saliva
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| PZA | Bactericidal to TB, hepatotoxic, increases uric acid (inhibits excretion)
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| Myambutol | Bacteriostatic, may be used to treat TB resistant to INH or Rifadin
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| Myambutol S/E: | Optic neuritis (blurred vision, constriction of visual field, changes to color discrimination); inhibits uric acid excretion
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| Zovirax | Only active against herpes virus family (chicken pox, herpes, shingles) S/E: IV - phlebitis, nephrotoxic PO - N/V/D/HA not nephrotoxic
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| Chemo Agent Drugs | Carboplatin & Taxol
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| Carboplatin | Used for small cell lung cancer. S/E: bone marrow suppression, N/V, nephrotoxic. Watch for hearing loss
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| Taxol | Used for non-small cell lung cancer. S/E: severe hypersensitivity infusion reactions (hypotension, dyspnea, angioedema, urticaria-hives) premedicate w/ Benadryl, corticosteroids; bone marrow suppression; alopecia; bradycardia
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