Pharm Exam 8 Cyanne Distel

Treatment of Allergic Rhinitis & Common Cold

Chapter 45 p. 753
Allergic Rhinitis p.754
Inflammation of the nasal mucosa from exposure to allergen
hay fever
Red, swollen eyes, sneezing, itching, congestion, postnasal drip, cough, scratchy throat
Allergens include: weeds, pollens, grasses, trees, mold, spores, dust, chemical pollutants
As with other types of allergies the cause is exposure to an antigen
Anti-Histamines p.755
Anti-histamines selectively block H receptors thus alleviating allergic symptoms
Activation of H1 receptors causes:
Typical symptoms of allergy Increased capillary permeability CNS effects (ex. Itching)
Vasodilation Bronchoconstriction
Anti-histamines are the first line drug for allergic rhinitis
Cross blood-brain barrier causing anticholinergic effects-dry membranes
Most effective when taken prophylactically
Limited ability to reverse symptoms that have already started
Used as adjunct to treat severe allergic reactions = anaphylaxis
First generation: older drugs, cause drowsiness -Diphenhyrdramine (Benadryl)
Second generation: dont cross BBB so cause less sedation Antihistamine: Fexofenadine (Allegra)
Inhaled Corticosteroids p.759
Work directly on nasal mucosa
No serious adverse effects
First line drug for allergic rhinitis Inhaled Corticosteroid: Fluticasone (Flonase)
Decongestants p.763
Decongestants work to reduce congestion caused by the inflammatory process
sympathomimetics or adrenergic agonists
Activation of the adrenergic receptors causes activation of the sympathetic fight or flight nervous system
S/S: dysrhythmias, HTN, dry mouth, palpitations, tachycardia
Most limiting adverse effect of intranasal meds=rebound congestion Decongestant: Pseudoephedrine (Sudafed
Antitussives p.765
Used commonly to suppress cough Antiussive: Dextromethorphan (Delsym, Robitussin)
Expectorants p.767
Increase bronchial secretions thereby reducing the thickness or viscosity of secretions
Allows mucus to be removed more easily by coughing Guafenesin (Mucinex)
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 Pharm Exam 8 Cyanne Distel
Mucolytics
Break up mucus to help loosen thick bronchial secretions (break up mucus molecules)
Used in patients with cystic fibrosis, chronic bronchitis

Drugs that Treat Allergic Rhinitis & the Common Cold Ch.45
Drug: Mechanism Of Action: Treatment Of: Adverse Effects: Notes:

Fexofenadine (Allegra) 1) Competes with histamine for binding Allergic Rhinitis Infrequent and usually minor: Do not cause drowsiness
H1 Receptor Antagonist to histamine receptor sites (H) Headache because it does not readily cross
(2nd generation) Nausea the BBB
Antihistamine Dyspepsia Most effective when taken
Dysmenorrhea before symptoms develop
p.758 Absorption when taken with
grapefruit & orange/apple juice

Fluticasone (Flonase) 1) Acts to decrease local inflammation Allergic Rhinitis When administered by the Use with caution with black
Inhaled Corticosteroid in the nasal passages through intranasal route adverse effects licorice
vasoconstriction and anti-inflammatory Reduces bronchial are uncommon:
p.762 mechanisms hyperreactivity Headache
2) Inhibits mast cells, macrophages, and Decreases airway mucus Cough
inflammatory mediators such as Decreases Nasal ulceration
prostaglandins, histamine, kinins, and infiltration/activity of Epitaxis
eukotrienes. inflammatory cells Local burning
Decreases edema of the
airway mucosa

Pseudoephedrine 1) Activate Alpha adrenergic receptors Allergic Rhinitis CNS stimulation (insomnia, No rebound congestion of
(Sudafed) vasoconstriction in nasal mucosa = Sinus Congestion restlessness, anxiety) given PO - not intranasal
Decongestant decreases mucosal swelling Common Cold Symptoms High doses=seizures,
2) Stimulates beta adrenergic psychosis
p.763 receptors in the lungs Dysrhythmias, HTN,
bronchodialation palpitations, tachycardia, dry
mouth

Dextromethorphan 1) Acts directly on the cough center in Cough suppressant Almost no effects at Carries no risk of dependence
(Delsym, Robitussin) the medulla of the brain to elevate cough Allergic Rhinitis (cough) therapeutic doses.
Antitussive threshold Common Cold (cough) Higher doses may cause:
Sedation
p.766 Dizziness

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 Pharm Exam 8 Cyanne Distel
Pharmacological Treatment of Asthma & COPD
Chapter 44 p.730
Asthma p.732 COPD: Chronic Obstructive Pulmonary Disease
Chronic inflammatory disorder of the airway Chronic & recurrent obstruction of airflow
50% caused by allergens Chronic bronchitis-excessive mucus
50% unknown etiology Emphysema-loss of elasticity & destruction of alveoli
Allergen induced asthma:
Mediators of the immune system/inflammatory response
are released by mast cells
Airway becomes swollen and edematous
Spasms of the bronchial passages

Asthma - Treatment Asthma Treatment Goal

Asthma = inflammation + bronchoconstriction Establish long-term control-reduce frequency of attacks and stop
Medications/treatment must address both acute bronchospasms
Prevention:
Controlling activity
Allergy medications

Medication Delivery p.733

Inhalation (INH)
Deliver drugs directly to the site of action
Systemic effects are minimized
Relief of acute attacks is rapid
PO
Three types of Inhalants p.733:
Metered-dose inhalers Dry-powder inhalers Nebulizers

Metered-Dose Inhalers (MDI)

Delivers a measured dose of drug with each puff Dry-Powder Inhalers (DPI)
If > one puff needed, 1 minute between each puff Drug in dry, micronized powder form
Begin inhaling prior to activating device Use no propellant; breath activated
Use a spacer to increase drug delivery to lungs Deliver more drug to the lungs than MDI
Count doses (or float) to plan for new inhaler 20% as compared to only 10%
Fast inhalation but if whistling, slow down

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 Pharm Exam 8 Cyanne Distel
Nebulizers
Small machine used to convert a drug solution into a fine mist
Face mask or mouthpiece
Several minutes to deliver the equivalent drug contained in one puff of an MDI
More effective delivery since the drug gains deeper access as the airways slowly dilate

Quick Relief Medications

Short acting beta adrenergic agonists Anticholinergics Corticosteriods-systemic:
Bronchodilator Bronchodilator Anti-inflammatory
Albuterol (Proventil, Ventolin) Ipratropium(Atrovent) Beclomethasone (Beconase)

Short Acting Beta-Adrenergic Agonists (SABA) p.735 Anticholinergics p.738

Selective activation of beta-adrenergic receptors to cause bronchodilation Alternative bronchodilators
Most effective for relieving bronchospasm and preventing exercise-induced Block the parasympathetic nervous system
bronchospasm Similar effects to beta adrenergic agonists
Albuterol (Proventil, Ventolin) May be paired with beta adrenergic agonists-added effect
Inhaled, intranasal
Ipratropium (Atrovent)

Inhaled Corticosteroids p.740 Inhaled corticosteroids- Adverse Effects

Very potent anti-inflammatory drug Contraindicated in active infection, may cause candidiasis in throat
Decrease inflammation of the airways-inhibit synthesis & release of Systemic corticosteroids- Adverse Effects
inflammatory Adrenal suppression, osteoporosis, hyperglycemia, peptic ulcer disease,
mediators (histamine, leukotrienes, cytokines, prostaglandins) inhibition of growth in children
Decrease mucus & edema
Beclomethasone (Beconase)

Corticosteroids - Teaching
Gargle with water after each administration
S/S of oral candidiasis
Use a spacer
Participate in weight-bearing exercise to minimize bone loss
Supplemental calcium + vitamin D
NSAIDs with caution

Long Acting Medications p.742

Mast Cell Stabilizers p.742 Leukotriene modifiers p.743 Methylxanthines p.744
Anti-Inflammatory Anti-Inflammatory Bronchodialator
Cromolyn Zafirlukast (Accolate) Theophylline (Theo-Dur)

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 Pharm Exam 8 Cyanne Distel
Drugs that Treat Asthma and COPD Chapter 44
Drug: Mechanism Of Action: Treatment Of: Adverse Effects: Notes:
Albuterol (Proventil, 1) Acts by selectively binding to beta- Drug of choice for relieving Inhaled-uncommon Can give PO or inhaled but if you
Ventolin) adrenergic receptors in the bronchial bronchospasm PO: Palpitations, give it PO you can have more
Beta-Adrenergic smooth muscle to cause bronchodilation Facilitates mucus drainage headaches, tremors, systemic effects in the sympathetic
Agonists Inhibits release of nervousness, restlessness, nervous system
inflammatory chemicals from tachycardia, insomnia, dry
p.736 mast cells mouth Drug interactions: Betablockers:
PO, Inhaled bronchospasm
MAOIs: hypertensive crisis
Thyroid hormone: stimulatory
effects
Ipratropium (Atrovent) 1) Causes bronchodilation by blocking Bronchospasm from asthma Dry mouth Contraindications
Anticholinergic cholinergic receptors in bronchial and COPD Nausea Patients sensitive to soy, soybean, &
smooth muscle GI distress peanut
p.739 Bitter taste
Inhaled, intranasal
Beclomethasone 1) Decreases inflammation of the Asthma & Allergic Rhinitis Corticosteroid toxicity NOT a bronchiodialator and should
(Beconase) airways and immune responses (inhibits Decreases mucus & Local effects= hoarseness, not be used to terminate asthma
Corticosteroid synthesis & release of histamine, edema dry mouth, change in taste, attacks in progress
leukotrienes, cytokines, prostaglandins) development of cataracts
p.740 decreases frequency of asthma **Review contraindications for
attacks corticosteroids on main paper

Inhaled, intranasal
Cromolyn 1) Prevent degranulation of the mast Asthma & COPD Bronchospasm
Mast Cell Stabilizer cell-prevent release of histamine prophylactically Cough
(inflammatory response) Not used to treat acute Pharyngeal irritation
p.742 asthma or COPD attacks
Inhaled-MDI, nebulizer used for long term
Zafirlukast (Accolate); 1) Prevents airway edema and Prophylaxis of persistent, Headache Delayed onset of action
Montelukast (Singulair) inflammation by blocking leukotriene chronic, asthma Less effective to than inhaled
receptors in airways corticosteroids
Leukotriene Modifier
Given PO Drug interactions
p.743 Warfarin-increased prothrombin
time (PT)
Theophylline (Theo- 1) Relaxes bronchial smooth muscle Was the principal N/V Headache Narrow therapeutic range- toxicity
Dur) bronchodilation methylxanthine used for Irritability Insomnia not really used anymore
Methylxanthin 2) Suppresses airway responsiveness to asthma Dysrhythmias Older drug
stimuli that may cause bronchospasm Hypotension A lot of drug interactions
p.744 Seizures Safer drugs than methylxanthines
available now
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 Pharm Exam 8 Cyanne Distel
Pharmocotherapy for Peptic Ulcer Disease
Chapter 59 p.1005
Objectives
Explain the pathogenesis of GERD, PUD, constipation, and diarrhea.
Introduce the treatment for GERD, PUD
Compare the mechanisms of different laxatives
Identify the prototype drug and explain the mechanism, indications, contraindications, drug interactions for drugs acting on the gastrointestinal system
Describe the effect of medications on absorption

GERD p.1008
Results when acidic stomach contents enter the esophagus
In adults, the cause of GERD is usually transient weakening or relaxation of the lower esophageal sphincter (LES), a specialized muscle segment at the end of the
esophagus. The sphincter may no longer close tightly, allowing movement of gastric contents upward into the esophagus when the stomach contracts.
Acid gastric contents cause heartburn and in some causes injury to the esophagus.
Pathogenesis of GERD also involves decreased salivary secretions and diminished esophageal motility.
TX: Remove acid-causing food and drugs, administer proton pump inhibitors, administer H receptor antagonists.
Peptic Ulcer Disease (PUD) p.1008
Peptic Ulcer: A lesion or erosion located in either the stomach (gastric) or the small intestine (duodenal) mucosa that is usually associated with acute inflammation.
PUD occurs when there is an imbalance of protective factors versus aggravating factors. The levels of protective mucus and bicarbonate ion secretions are unable
to protect against the aggravating factors of pepsin and gastric acid.
Complications: Bleeding, perforation, penetration, and GI obstruction due to scarring.
NSAIDS are likely responsible for almost half of peptic ulcer cases NSAIDS promote ulcer formation and inflammation both topically and systemically.
NSAIDS interfere with prostaglandin synthesis via the enzyme COX in the stomach, which normally aids in the production of mucus and bicarbonate.
NSAIDS decrease gastric blow flow and slow cellular repaid.
TX: Aggressive acid suppression with drugs. Eradicate H. Pylori (a bacterium associated with PUD) and discontinue NSAIDS when possible.
Proton Pump Inhibitors p.1010
Act by blocking H+, K+, ATPase, the enzyme that is responsible for secreting hydrochloric acid in the stomach (prevent acid from being released or produced)
PPIs reduce acid secretion to a greater extent than the H receptor antagonists and have a longer duration of action
About 95% of the acid production is blocked, making the PPIs the most efficient drugs available for treating acid-related disease.
Omeprazole (Prilosec)

H Receptor Antagonists (H Blockers) p.1013

Treatment for PUD and GERD promote healing and prevent recurrence
Available OTC and are used extensively in the treatment of mild to moderate hyperacidity disorders of the GI tract
Histamine has two receptors:
H: Activation of H receptors produces the classic symptoms of inflammation. Mainly used to allergy.
H (stomach): Activation of H receptors promotes gastric acid secretion.
H receptor antagonists effectively reduce both fasting and food stimulated secretion and are also helpful in decreasing nocturnal acid
secretion, which is largely dependent on histamine. (prevent acid from being released)
Ranitidine (Zantac)
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 Pharm Exam 8 Cyanne Distel
Antacids p.1015
Inorganic compounds containing aluminum, magnesium, sodium or calcium that neutralize gastric acid and inactive pepsin.
Neutralize the acidity that is in the stomach
Stimulate prostaglandin production and increase LES tone, which reduces gastroesophageal reflux.
Inexpensive and available OTC
Provide temporary relief from heartburn or indigestion, but they are no longer recommended as the primary drug class for acid-related disorders
They do NOT promote ulcer healing or help to eliminate H. pylori

Nursing Teaching p. 1020

H2 blockers QD/BID (bedtime) Take the drug immediately after meals unless otherwise instructed. Do not take concurrently with anacids unless using a
combination produce. Best at night because our acid production is peaking between 10PM-2AM
PPIs QD/BID Take 30 minutes before meals (empty stomach). If taking 1x a day take in the morning before breakfast. Do not continue taking beyond 3-4
months unless directed by a health care provider. Antacids may be used concurrently.
Antacids Take 2h before or after meals with a full glass of water. Do not take other medications concurrently unless available as a combination product or
directed to do so by the health care provider.
Evaluate for improvement
Long term use may mask serious conditions

Drugs that Treat Peptic Ulcers Ch.59

Drug: Mechanism Of Action: Treatment Of: Adverse Effects: Notes:
Omeprazole (Prilosec) 1) Inhibits proton pump (which Gastric Ulcers Diarrhea Drug Interactions
Proton Pump Inhibitor blocks secretion of hydrochloric acid GERD Headache Effects hepatic enzymes so
Antiulcer in the stomach) Maintenance of erosive Abd pain dont take with other drugs using
esophagitis Malabsorption the P450 system (warfarin,
p.1011 OTC = heartburn carbamazepine, diazepam,
phenytoin)
Ranitidine (Zantac) 1) Blocks H2 receptors to decrease Ulcers (healing takes 4-8 Neutropenia Drug Interactions
H Receptor Antagonist acid production weeks) Thrombocytopenia May reduce absorption of
Antiulcer Heartburn cefodozime, ketoconazole, and
GERD itraconazole because of the
p.1014 increase in gastric pH.
Aluminum Hydroxide 1) Combines with gastric Neutralize stomach pH Constipation Drug Interactions
(Alternagel) (hydrochloric) acid to produce Heartburn Reduces phosphate in GI Aluminum compounds should
Antacid aluminum chloride and water tract not be taken with other
(AlOH3+HCl>H2O+AlCl3). medications because they may
p.1016 2) Raises pH of the stomach contents interfere with their absorption
and inactivates pepsin (neutralizes Other antacids: TUMS
acid) (Calcium carbonate), Maalox,
MoM

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 Pharm Exam 8 Cyanne Distel
Pharmacology for Diarrhea and Constipation
Chapter 60 p.1024

Constipation p.1024 Constipation Assessment

Infrequent passage of abnormally hard and dry stools Pain, distention - confused patient may show agitation
Not a disease but a symptom of an underlying disorder or condition Diagnosis: <2 BM/week, hard stools, straining to pass stool
Causes: What is the cause of the constipation?
Lifestyle: Lack of exercise
Nutrition: Lack of fiber, fluid, or food intake. Alcohol, dairy, chocolate,
etc.
Medications: Opiods. CCBs, iron supplements, NSAIDS, etc.
Diseases: Diabetes, hypothyroidism, hypercalcium.

Pharmacotherapy for Constipation p.1025

Laxatives - Promote defecation
Prophylaxis (constipation) or treatment (people on drugs that cause
constipation)
Cathartics - More complete bowel emptying

Laxatives
Bulk Forming Laxatives p.1026 Stimulant/irritant Laxatives p.1026
Absorb water, thus adding size to the fecal mass. Promote peristalsis by irritating the bowel
Must be taken with plenty of water. Rapid and more likely to cause diarrhea and cramping than bulk-
Psyllium (Metamucil) (Onset: 12-24 hours) forming laxatives
bisacodyl (Dulcolax) (Onset: 8-12 PO/15 min. suppository/rectal)

Surfactant/Fecal Softeners Saline/Osmotic Cathartics

Cause more water and fat to be absorbed into the stools
Ineffective at treating constipation buy are most often used to prevent the
condition
Docusate (Colace) (Onset: 24-48 hrs)
Poorly absorbed in the intestine
Pull water into fecal mass to create a more watery stool
Can produce a bowel movement very quickly but should not be used
on a regular basis due to possibility of dehydration and F&E depletion.
Magnesium hydroxide (MoM)(30 min - 4 hours)

Lubricants Patient Education on Laxatives

Lubricate the stool and colon mucosa Laxative abuse
Mineral oil (6-8 hours PO/15 minutes PR) Adequate hydration
Use of mineral oil should be discouraged because it interferes with the Adequate fiber
absorption of fat-soluble vitamins and can cause other potentially serious Adequate exercise
adverse side effects

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 Pharm Exam 8 Cyanne Distel

Diarrhea Anticholinergic
Increase in the frequency and fluidity of bowel movements Parasympatholytic = anticholinergic = anti-acetylcholine
Type of body defense to rapidly and completely eliminate the boy of toxins Effect on GI motility = slows the GI and allows for more water to be
and pathogens absorbed into the stool.
Causes of Diarrhea: Can increase absorption of drugs due to slowing GI motility
Medications: Antibiotics, laxatives, magnesium antacids, digoxin, Also reduces acid production; stop pancreatic secretions
orlistat, and NSAIDS. Atropine - reduces oral secretions, reduces spasms
Disease processes: Viral and bacteria infections. Adverse effects: Drowsiness, blurred vision, tachycardia
Foods - intolerance, spicy foods
Risk for fluid deficit

Pharmacotherapy of Nausea and Vomiting

Affect on Absorption:
Increase GI motility = less drug absorbed
Decreased GI motility = more drug absorbed
Change in pH increases/decreases absorption

Drugs that treat Bowel Disorders and Other GI Conditions Ch.60

Drug: Mechanism Of Action: Treatment Of: Adverse Effects: Notes:
Psyllium (Metamucil) 1) Expands the size of the stool and Constipation Safest laxative and rarely Drug Interactions
Bulk-Type Laxative promotes colon peristalsis that produces adverse side effects May decrease the absorption
closely resembles a natural bowel If taken with insufficient and effects of warfarin, digoxin,
p.1026 movement water, psyllium may swell in nitrofurntoin, antibiotics and
the esophagus and cause salicylates
(Know HOW each laxative obstruction
works)
Mineral Oil 1) Lubricates the stool and the colon Constipation Use of mineral oil should Onset (6-8 hours PO/15
mucosa be discouraged because it minutes PR) according to lecture
p.1026 interferes with the absorption Onset 24-48 hrs according to
of fat-soluble vitamins and BOOK
can cause other potentially
serious adverse side effects
Docusate (Colace) 1) Permits additional water and Prevents constipation but Rare Contraindications
Stool Softener lipids to penetrate the stool does NOT treat Sodium restrictions or w/ renal
p.1027 Most frequently prescribed impairment
stool softener Mineral oil
Certain herbal supplements
(senna, cascara, rhubarb, or aloe)
= absorption = liver toxicity

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Bisacodyl (Dulcolax) 1) Irritates the mucosa in the colon
Bulk-Type Laxative and alters intestinal and electrolyte
absorption
p.1027
Only 15% of the drug is absorbed
after oral administration
Magnesium Hydroxide 1) Neutralizes gastric hydrocholic
(Milk of Magnesia) acid to form magnesium chloride
Bulk-Type Laxative 2) Exerts a laxative effect in the
colon by drawing water and
p.1027 electrolytes to form a larger and
softer fecal mass
Diphenoxylate w/ 1) Acts on smooth muscle of the
Atropine (Lomotil) intestine to slow peristalsis
Opiod/Antidiarrheal
Controlled substance (atropine
p.1029 reduces abuse)
Ondansetron (Zofran) 1) Blocks serotonin receptors in the
Antiemetic chemoreceptor trigger zone, an area
Serotonin 5-HT receptor of the brain responsible for nausea
anatagonist and vomititng
Pharm Exam 8 Cyanne Distel
Most frequently used Abdominal Pain Onset of action 8-12 hours PO;
stimulant-type laxative Cramping or 15-60 minutes PR (rectal)
F&E imbalance Should not be taken with dairy
products because these can
dissolve the enteric coating and
cause dyspepsia
Enteric-coated should not be
crushed or chewed
PO: Antacid effect N/V Can bind to other drugs
Laxative Abdominal cramping delays their absorption (take 2
hours apart from other meds)
Diarrhea Well tolerated at normal Acts with 5-60 minutes
doses. Some experience: Do not drive or operate
Dizziness machinery until effects of the
Lethargy drug are known
Drowsiness
Taken before chemotherapy Headache Monitor for dehydration
sessions to prevent nausea Constipation OR diarrhea Patient should take this
and vomiting Dizziness BEFORE they come for their
chemotheraphy session

p.1040
Atropine Reduces oral secretions Drowsiness
Reduces spasms Blurred vision
Tachycardia

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