Pulmonary Drugs

• Albuterol (Proventil)
• Bitolterol (Tornalate)
• Levalbuterol (Xopenex)
• Pirbuterol (Maxair)

• Formeterol (Foradil Aerolizer)
• Salmeterol (Serevent Diskus)

• Albuterol (Proventil, Volmax)
• Terbutaline (Brethine)

• Selectively activate beta 2 adrenergic receptors in smooth muscle of the lung
• 1. causes bronchodilation
• Supresses histamine release
• Increases ciliary motility

• Last up to 12 hrs
• Prolonged prophylaxis only
• Should never be used alone to prevent asthma related death

tachycardia, angina, tremor

Long Acting - can cause respiratory arrest, death, severe asthma

Oral - dysrythmias

• Metered Dose:
• 1 minute interval
• Administer Short acting Beta 2 Agonist before glucocorticoids

• Theophylline oral - Theolair
• Theophysine IV - emergencies
• Aminophylline (IV) - Truphylline

• Relaxes smooth muscle causing bronchodilation
• Maintenance therapy for chronic, stable asthma
• Decreases frequency and severity (though less effective)

• Do not chew SR (sustained release)
• SR more stable plasma level
• SR affected by food

• Metabolized in liver
• 10-20 mcg/ml plasma drug level

• Drug levels between 20-25 mcg/ml
• Nausea / Vomiting
• Diarrhea
• Insomnia
• Restlessness

• Caffeine
• Phenobarbital
• Phenytoin
• Rifampin
• Fluoroquinolone antibiotics (Cipro, Levaquin, Avelox)

Usual adult dose: 200-300 mg, 2-3 times / day

• Ipratropium (Atrovent HFA)
• Tiotropium (Spiriva)

Both inhaled

• Blocks muscarcinic receptors in bronchi
• Used for COPD
• Less effective for asthma
• Additive effects with Beta 2 agonists
• Not for acute attacks

• Common: Dry mouth, irritation of pharynx
• Rare: increase in intraoccular pressure in patients with glaucoma, urinary retention

Contraindicated in those allergic to soy / peanuts

2-4 puffs QID

Combivent or DuoNeb (Combined with Beta 2 agonists - albuterol)

• blocks muscarcinic receptors in lung - bronchodilation
• Long acting, approved for COPD bronchospasm
• Usual dosing: 18 mcg capsules in dry powder inhaler

• Most common: dry mouth
• teach to suck on sugarless candy for relief
• Systemic: constipation, urinary retention, tachycardia, blurred vision

• Montelukast (Singulair)
• Zafirlukast (Accolate)
• Zileuton (Zyflo)

all PO

• Antiinflammatory - blocks leukotriene receptors
• Not for quick relief
• For all patients over 1 yo
• Once a day dosing (give in evening)

• Rapidly absorbed: peak in 3-4 hours
• Maximal effects: 24 hrs
• Metabolized in liver, excreted in bile
• Available in standard and chewable tablets, granules

• CNS: headache, anxiety fatigue
• Resp: cough
• GI: abdominal discomfort, diarrhea, nausea, dyspepsia (heartburn)

• Antiinflammatory for > 12 yo
• not for acute asthma

Asthma prophylaxis and maintenance

• with or without food
• peak in 2-3 hours
• metabolized in liver
• excreted in urine
• usual dosage: 600 mg QID
• Interacts with theophylline, warfarin, propanolol (Can increase their levels)
• Adverse Effects: Similar to Singulair

• Antiinflammatory
• Use for asthma in > 5 yo

• give 1 hr before meals (or 2 hrs after)
• metabolized in liver
• excreted in feces
• usual dosage: 10-20 mg BID
• interacts with: theophylline, warfarin, propanolol (can increase their levels)

• expensive
• antiinflammatory
• unknown long term safety
• for moderate to severe asthma
• > 12 yo
• sub-q absorption
• peak in 7-8 days
• half-life: 26 days

• pain at injection site
• upper respiratory infections
• sinusitis
• headache
• cancer & anaphylaxis

• Cromolyn (Intal)
• Nedocromil (Tilade)

by inhalation

• prophylaxis of asthma
• not for acute attack
• exercise induced asthma
• allergic rhinitis

• full effects may take several weeks
• 2-4 puffs QID (MDI, nebulizer)

• Usual dosage: 2 puffs daily, MDI
• Most common adverse effect: unpleasant taste

• Inhaled
• - Beclometasone
• - Budesonide (Pulmicort)
• - Flunisolide (Aerobid)
• - Flucticasone propionate (Flovent)
• - Triamcinolone acetonide (Azmacort)
• Oral
• - Prednisone, Prednisolone

• anti-inflammatory
• prophylaxis for asthma

increases beta 2 agonists

cannot be used in times of stress

adrenal suppresion

Most common: bone loss and adrenal supression

Gargle after use, use spacer

• Infection
• Fluid & Electrolyte imbalance
• Cataracts and glaucoma
• Mood changes
• Cushing's Syndrome

Withdrawl must be done slowly

• IM, IV, oral
• not inhaled

• Advair Diskus - flovent & serevent
• Bronchodilation & antiinflammatory

• Therapeutic uses: Asthma & COPD
• 50/100 mcg, 50/250 mcg, 50/500 mcg
• BID inhalation

- inflammatory disorder of the airways and eyes

• Symptoms:
• sneezing
• rhinorrhea
• pruritus
• nasal congestion

• Seasonal - outdoor allergens (fungi, pollen)
• Perennial - indoor allergens (dust mites, pet dander)

• Oral antihistamines
• Intranasal glucocorticoids
• Intranasal cromolyn
• Sympathomimetics (oral/nasal)

• relieve itching, rhinorrhea, sneezine
• NOT congestion

• Sedation
• Anticholinergic effects:
• dry mouth, constipation, urinary retention

• antiinflammatory (MDI, QD or BID)
• suppresses symptoms of allergic rhinitis and congestion
• adverse effects:
• drying of nasal mucosa, epistaxis, burning or itching, may suppress adrenal glands

• stimulates alpha 1 adrenergic receptors
• adverse effects:

rebound congestion, rebound rhinitis

• Antitussives
• opiod: codeine and hydrocodone
• nonopiod: dextromethorphan and diphenhydramine

• Increases cough threshold
• Sedation / Drowsiness
• Dizziness, Fatigue, Dry Mouth, Constipation, Euphoria, Hallucinations, Resp. Depression

• Dextromethorphan (Robitussin) most effective
• Diphenhydramine
• Benzonatate (Tessalon)

Side Effects: Dizziness, constipation, dry mouth