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EXAM 2

COPD

Chronic Bronchitis- Acute exaserbation is because of infection, cough occurs

during 3 month pd for 2 years. (mucus) more mild

Emphysema- not due to an infection, loss of recoil..more severe

Hallmark of COPD is a decrease in FEV1 ratio to FVC below 75 percent.

FEV1

Nonsmokers- loss of 25-35 ml beigns at age 35

Smokers- can be up to 100 ml per year, because of reserve you may not have
symptoms until age 50 and Dypsnea until age 60.

DRUGS for COPD

1. Anticholinergic- (Ipatropium, Tiotropium, Atrpine) Nebulizer or MDI

-less systemic side effects than beta agonist but slower onset of action. For
chronic attacks use Ipatropium and a short acting beta 2 agonist as a rescue
inhaler.

2. Beta 2 agonist- (Albuterol, salmeterol, Levalbuterol)

- use in acute exacerbation; use Levalbuterol bc of the R isomers.

3. Methylaxthine (theophyline)

- has a narrow therapeutic index (moniter other drugs pr takes)

4. Glucocortoroid s

-Can be taken PO( prednisone) , IV (cortisones), Inhaled. Steroids rinse mouth out!

Leukotriene Antagonist- blocks the release of leukotriens in lungs, dec

inflammation

Methylaxthines (theophlyine) inc cyclic AMP keep mast cells.

Mast Cell stabilizer- inhibit release of histamine (cromylin)

Sympathetic Agonist- relax bronchial muscle spasm.

Corticosteroids- produce and anti-inflammatory effect and reduce mucus

secretions

Anticholingeric- reverse effects of ANS on pulmonary tree

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Asthma

Asthma Treatment Scale..see slides.

Inhalation Devices

1. meter dose Inhalers a. Chlorofluorocarbons, CFC b. Hydroflualkaline

(Cherry Hill Meters) – only 10 percent reaches the lungs, use spacers
2. Dry powder inhaler- (Advair, salmeterol 20 percent goes to lungs
3. Nebulizer (albuterol or ipatropium) produce a fine mist.

**use a beta 2 agonist 5 min before use a glucocort so it can penetrate.

Drugs for asthma are either 1. Anti-inflammatory (glucocort and cromolyn) 2.

Bronchodialator (Beta agonist)

Other classes are 1. Methylxanthines, antocholinergic, leukotrince modifiers.

Glucocorticoids (use Inhalation, PO, IV) not PRN.

- suppress inflammation.

1, inhaled Gluc- always rinse mouth out. BFF BMT (beclomethasone, budesonide,
flunisolide, fluticasone, mometasone, triamcinolone

Adverse effects: 1. use lowest dose possible. 2. Gargle, use spacers. Be careful if
diabetic, hyperglycemia

2. Oral (prednisone, prednisolone, fludrocortisones)

Only for patients with severe asthma.
May retard bone growth, take with food (dec peptic ulcers) caution
with diabetes,
KNOW causes 1, adrenal suppression, sodium retention and
potassium loss, osteoporosis, hyperglycemia, peptic ulcer dz,
suppression of bone growth in younger pple.

Prednisone stops swelling by suppression of migration of leukocytes. Inhalation

only for chronic use not PRN. Taper oral dose if used for more than 2 weeks. Take
with food. Don’t use NSAIDS.

Beta 2 Agonist

Usually by inhalation and are short acting except salmeterol and formoterol.
All oral beta 2 are long acting. Good for exercise induce asthma. Inc blood glucose.

Faster ones…albuterol, epi, isoetherine, pirbuterol, slower salmeterol, terbutaline,

metaproternol, formoterol
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Inhaled Short acting- terol (alubeterol, bitolterol, levalbuterol, taken PRN. Effecy
is almost immed and last for 3-5 hrs. (tachycardia, angina and tremor).

Inhaled long acting Beta 2 (formoterol, salmeterol)

Oral Bet 2- Albuterol, terbutaline *BET at mouth- slow effect so for long term tx.
Not selective so be careful for heart probs.

Not first line of tx given in combo with gluc. Not PRN.

Albuterol (beta 2 specific) relax smooth muscle. Sim. To Isoproterinol. Drug

interaction with EPI. Rinse mouth, be careful of rebound conjestion.

Epinephrine

Non- selective- bronkaid mist, Primatene mist . In emergency inject SQ.

Route to give Epi: Oral, SQ, Intramuscular, intraspinal, intravenous, intracardiac. SO

I4. Don’t give epi with beta adrengerics, allow 4 hrs.

Isoproterenol Don’t use if a precipitate or funny color, rinse mouth.

Cromolyn (mass cell stab)

Ends in CROm, dec eosinophils and stop histamine releae. NOT A bronchodialator,
prevents inflamtion.

Anticholinergic, ipatropim and tiotrpium. Bronchodialator. , can cause dry mouth, (

sensitivity to peanuts). Not for kids under 12.

Metylxanthines (theophyliline)

Adverse effects- life threatening, tachycardia =. Inc effect- corrhossis, pulmonary

edema, CHF, severe COPD.

THEOPH has a narrow tx range, given orally, no effect by inhilation.

Leukotriene Modifiers

1. zyflo Don’t combine with theopyline, warfin and propranolol. , use with a
glucocort. Or beta agonist.
2. Zafirlukast (Accolate) don’t give with food, less effective beclomethasone.
Hepaticly metabolized. (inhibts theophyline and warfarin)
3. Montelukast (singulair) chewable

Tuberculosis morbitity can be high, 2 billion affected each yr, kills more than
aids and malaria combined. Report sever GI problems, yellow scelera, dark urine,
clay stool

Treatment is divided in 2 stages so adherence is a problem. Induction phase

last 2 months
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Test for TB… Intraderman injection of Purified Protein derivative PPD. Smaller
size more aggressive the tx. 2 or more drugs used to kill active and resting bacilli.
Begin with 4 drugs, Isonizad, rifampin, pza, ethambutol.

Drugs Used

First line drugs- Isonizad, rafampin, rafpentin, rifabutin, pyrazinimide,

ethambutol. (RRR PIE)

Second line drugs- Sterptomycin, kanamycin.

Isoniazid bacterialcidal, bacterialstatic, Drugs that are resistant to INH are also
resistant to ethionamide. PO or IM. AVOID alchol and antacids, get a hangover
effect. Depletes pyridoxine b6 so take supplement. Dark urine.

Rifampin take for meningitis , adverse effects, tongue soreness, chills,

respiratory difficulty. NO alcohol. Give with 240 ml of water on EMPTY stomach.
One hr bf or 2 hrs after meal.

Ethambutol effects only actively dividing mycobacterium. Take with food.

Causes optic neuritits and renal impairment.

Streptomycin adverse effects 1. Tinnitus, nephrotoxicity, hepatoxicity

Expectorants (guaifensin) take with lots of water acts as a surfactant.

Misc.

Decongesants ( pseudoephedrine, phenylephrine)

Stop cough0 codeine

Caution used in pts with HTN

Anthihistamine loratidine, certirizine, INE

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Gastrointestinal Drugs

GERD reflux dz

H-pylori has no role in Gerd. Contents of the stomach empty into the esophagus.
Treat with PPI or Histamine 2 receptor antagonist.

PUD erosion of stomach. Because of H-pylori

Promoting factors h. pylori, nsaids, acid (activate pepsin), pepsin,( a proteolytic

enzyme in gastric juice promotes ulcers) smoking (reduces secretions of
bicarbonate)

Bodies Defense mucus, bicarbonate, blood flow, prostaglandins (promote

vasodilation to maintain mucosal blood flow and inc bicarbonate release.

Drugs

Antibiotics- (amoxicillin, clarithromycin, bismuch salicylate (not for kids)

tertracycline, metronidazole) ABC TM given over 14 days

Antisecretory agent enhances mucosal defenses (misoprostol)

Mucosal Protectant (sucralfate)

PPI- ending in PRAZOLE (stops gastric acid by inhibiting H/K atpase pump.

H2 receptor antagonist – ends in TIDINE (blocks histamine)

Antacids aluminum, hydroxide, calcium carbonate, magnesium hydroxide.

Muscarinic antagonist.

Goals of PUD., reduce gastric activity A. Antisecretory agents 1. H2 rec 2. PPI 3.

Muscarinic antagonist B. misoprostol is a fake prostaglandin, last resort. And
Enhance mucosal defense 1. Sucralfate 2. Misoprostol

**eat smaller meals to dec fluctuation of pH. Stop smoking.

Only use drugs in Combo to treat H-pylori. (2 antibiotics and 1 PPI or H2

antag. for 10-14 days)

1. Have aci refluc RIGHT NOW- antacid, aluminum hydroxide

2. Have it when eat- take H2 receptor ant 30 min bf
3. ALL the time- PPI
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Cimetidine (h2 recep. Antag)

Can cause diarrhea/ constipation, Gynecomastia ,impotence. Has bad

interactions so not used a lot. Take 30 min bf food to slow absorpotion and
prolong effects. Drug interactions with theophyline, diazepam, phenyton,
Digoxin, warfin Will increase ethe half life bc competes for the same enzyme.
Give IV slowly.

Omeprazole (PPI)also for GERD, Take 30 min before morning meals. Causes
diarrhea, abdominal pan. Headache, rare thrombocytopeni. Drug interactions
Diazepam. Phenytoin, warfarin

Misoprostol( antisecretory prostaglandin)

Dec acid, inc bicarbonate and mucus. Serves as a replacemtn for NSaids and
asprin. Pregnancy X so check if preggers first. Can cause abdominal pain.

Cytoprotective Drugs

Sucrulfate – Contraindications: chronic renal failure, dialysis. (It binds to the

exudate) Adverse: constipation, farts. Drug interactions: digoxin, phenytoin,
theophyline, cimetidine give 1 hr bf meals and bed time 4 times a day. Give lots
of fluids and fiber!

Antacids magnesium, aluminun, calcium, sodium; used for PUD and GERD
stimulates production of prostaglandins. Not absorbed (except NA) so don’t
affect systemic ph!

Magnesium hydroxide rapid acting long duration, high ANC (anti neutralizing)
liq. Is milk of mag. CAUSE MD diahrea, Don’t give pple with renal probs.

Aluminum hydroxide has low ANC, helps ulcer healing, AC constipation be

careful with HTN.

Calcium Carbonate rapid acting and long duration, High ANC…causes

constipation

Sodium Bicarbonate – don’t use with ulcers, use for acid reflux (acidosis) only
one that’s absorbed. Causes farts burps. Dotn give with HTN

Constipation

Drugs that cause constipation: Antacid (aluminum), anticholinergics,

antidiarhea, antihistamine, iron supplements, muscle relaxant.

Treatments

1. bulk forming laxative promotes peristalisis – Methycllulose, psyllium,

polycaropjil
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2. surfactant laxative docusate sodium or calcium (water penetrates small

intestine)
3. Stimulant Laxative: Bisacodyl, Senna, (both are abused) Castor Oil (SI)
4. Osmotic Laxative: Magnesium, sodium phosphate, polyethylene glycol

5. Misc
1. mineral oil
2. glycerin supp
3. lactulose
4. lubiprostone- opens chloride channels- USED for idiopathic
constipation. Very little side effects bc none is absorbed.

Dose Response for laxative

1. immediate (5-30 min)

a. enema , sodium or mineral oil, glycerin supp
2. Quick (2-6 hrs)
a. osmotic laxative, magnesium and sodium salts, castor oil, PEG
solution
3. Semiquick( 6-12 hrs)
a.osmotic laxative, mag and sodium salts (low dose), stimulant
laxative, Bisacodyl and oral Senna
4. Delayed ( (1-3 days)
a. bulk forming laxatives, methycellulose, psylium polycarbophil,
docusate sodium and calcium and lactulose

Surfactant Laxatives

Docusate Sodium and Calcium – stool after 24 to 72 hrs , take with full
glass water

Stimulant Laxative

Bisacodyl, castor oil NOT for long term use, bc have rebound constipation.
HIHGLY ABUSED

Osmotic Laxatives

Mg hydroxide and Na phosphate use after surgery and for dead parasites

Bulk Forming Laxative

Methylcellulose, Psyllium produce soft stool 1-3 days after tx. Delayed response.
Take with water, get well formed stool acts like fiber.

Misc Laxative

Lactulose – promotes osmotic effects

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Mineral Oil- adverse effetcs, lipid pneumonia if drink 2 much, deposits on liver

Glycerin Supositories used after someone stops lax having abused them.
Evacuation in 30 min.

Polyethylene Glycol used to cleanse bowel before colonoscopy. 4 L, 250 ml every

10 min for 2-3 hrs. know numbers

Diarrhea

Drugs that cause D…

1. magnesium antacids
2. antimicrobials
3. cholinergic agonist

Opiods most effective antidiarrheal.

Diphenoxylate/ Atropine – (lomotil, logen, lonox) and codine are

CONTROLLED DRUGS. Atropine is given to prevent abuse (schedule V). Take
after loose stool. Don’t take with Alcohol. Don’t use if have glaucoma.

(Loperamide- Immodium) OTC, does not cross BBB, decrese bowel motility
and suppresses fluid.

Anticholinergic/ Atropine relieves cramping but not diarrhea.

Antiemetics better at suppressing than preventing. Ondansetron, caution in

pregnancy (read slides)

Glucocorticoids Methylprednisolone IV not PO for emesis.

Aprepitant (emend) enhances effect when given in combo. Has prolonged

DOA so prevent acute and delayed emesis.

Dopamine Antagonist, idol blocks dopamine 2 rec in the chemo trigger

zone. Can cause irreversible shaking.

Cannabinoid (dronabionol) CONTROLLED adverse effects- gets u high

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ANTI INFECTION LECTURE

Gram negative- 3 layers

Gram neg 2 layers

MOA –

1. inhibit cell wall penicillin, cephalosporin’s, vamcomycin.

2. Inc cell wall permeability- amphtoricin b, daptomycin, ketoconazole
3. Lethal inhibition of protein synth.- aminoglycosides
4. Nonlethal inhibition- tetracylcines, lincosamides, macrolides, and linezolid.
5. Inhibit Dna or RNA synthesis (furoquin, rifampin, metranidazole)
6. Antimetablolite
7. Suppress viral replication

Selecting an antibiotic, want it to be secific so you don’t kill everything in site. If you
don’t get the M.I.C- Min, Inhibitory Concentration- you are not doing ANY good.

ANTiBIOTIC Classes: 1. Penicilins, 2. Cephlosporins 3. Macrolides 4.

Aminoglycosides 5. Lincomycin 6. Tetracylicnes 7. Chloramphenicol 8.
Fluoroquinolones 9. Sulfonamides.

Penicillins- has a beta lactam ring so same MIA as cephlosprins. Used for kids, may
cause diarrhea. Only effective against cells that are active. Usually for gram neg. Beta
Lactamase- peniciin cleaves the ring.

Spectrums of PCNS

1. Narrow Spectrum PCNs: SENSITIVE penicillinin G, Pencilin V

A. Penicilin G (narrow spec sensitive)- get more blood flow during
inflammation.

2. Narrow Spectrum PCN: RESISTANT: oxacillin, dicloxacillin (methicilin no

longer available bc resistance)
3. Broad Spectrum PCN’s:ampicilin, amoxicilin—E.COLI
a. PCn allergy 1-10% pple are allergic, 5-10% have cross allergy to
cephlosporins
4. Extended Spectrum PCN’s- Ticarcillin, piperacillin – P.Aeroginosa.
a. pen will inactivate amoniglygesides so don’t give them together!
b. Ticarcillin- careful for sodium overload. Be careful with pts with
CHF. (heart failure).

**adding claculanic acid tends to inc the potencial for diarheea esp in kids.

Cephalosporins – Very similar to PCN. (may cause resistance bc of

cephalosporinase ) 4 different generations
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1. 1st gen- destroyed by beta lactamases (doesn’t penetrate CSF so not for
meningtitis but can be used for staph and strep. )
2. 2nd gen less sensitve to descruction
3. 3rd and 4th – highly resistant. (4th gen Cefepime – good against P. aeuginosa.
3rd gen- good against Meningitis. Cefotaxime)
- is a 5-10 % cross resistance with PCN.

-imipenem given with cilastin.

Meropenum- given for bacterial meningitis for kids. Used for complicated intra-
abdominal inf in kids and adults.

Vancomycin (Vancocin, Vancoled) KNOW

- used for serious infections!

- Treats P. colitis (caused by c. difficile) but try flagyl first..DONT DRINK
Alcohol with it.
- Treats MRSA
- Give it SLOWLY..or cause redmans
- Can give for meningitits
- Adverse effects; nephrotoxicity, ototoxicity, red mans syndrome
thrombophelbitis.
- Check peak blood drug levels after infusion hour and half after. Peak levels of
30-40 mcg are good.
Bacteriostatic Inhibitors of Protein Synthesis- stop growth of
replication
- tetracylclines “cycline”
- Macrolides “mycin”
- Lincosamide”mycin”

Tetracyclins- tetracycline’s, oxtetracyclines, demeclocyclines, doxycycline,

minocycline. TAKE SHORT ACTING on EMPTY STOMACH! (tettracylin, oxy,
demecl)

- have overuse and resistance. Use for h.pylori. lyme disease. NO alcohol with
Metrinidazole
- Used for acne, pud, periodontal.
- DOxycyclin used for teeth. And minocyclin. Bc inhibits collagenase enzyme
that destroys connect. Tissues in the gums.
- Give PO,
- Short acting- tetracycline ON EMPTY STOMACH
- Long acting- doxyc and mino CAN EAT
- CHelation- don’t eat thing with pos charge. Like milk, iron mg+
- Short and int. acting should not be given to pts with renal failure instead give
long acting.
- Binds to bones and teeth so don’t give it to kids under 8 bc will turn teeth
brown. If give while preg only effects baby teeth. Can suppress longbone
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growth but reversible when stopped. Can CAUSe: C. difficile diarhea , give
metranidozole(first) or vancomycin to treat c. difficile. Also can cause yeast
infection. Adverse effect: renal toxicity, use long acting! Phototoxicity.

Macrolides

- broad spectrum antibiotic

- similar to PCN. USE if allergic to PCN or Cephlosporins
- Drug of choice for whooping cough
- Use for MAC (mycobacterium avium complex)
- Take on empty stomach
- DRUG Interactions: p450- theophyline, warfarin,
- Not good for meningitis.
- Adverse effects: Pseudomembranous colitits. – c. deficile
- Used to treat H.pylori, MAC
- Has metallic taste, take on empty stomach

Lincosamide (clindamycin) – another alternative if allergic to PCN

-can promote c. deficil , can get dehydrated so drink a lot, can eat

Chloramphinicol (chloromycetin)

-limited to serious and life threatening infection bc its ability to cause fatal
aplastic anemia.

-is dose dependent., gray syndrom in infants.

-treats Meningitis bc crosses CSF

-PO- active immed, IV- has to be metabolized.

-narrow therapeutic index, monitor serum levels esp babies. Use low doses and
check serum levels. – peaks and troughs. Can cause anemia which is not dose
relaed. Reversible bone marrow suppression.

- DRUG INTERaCTIONs: phenytoin, warfarin, narrow therapeutic index.

Aminoglycosides

Gentamicin, tobramycin, amikacin, kanamicicn, neomycin and

streptomycin.

- narror spectrum. Treats E.coli and p. aerogenousa.

- ONCE daily dosing moniter peaks and troughs.
- 0take peak levels after completing infusion, 30 min after.
- Causes OTOtoxicity and Nephrotoxicity- not absorbed into the GI tract.
Careful of renal impairment.
- Don’t mix with PCN.
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Sulfamethoxazole/ Trimethoprim- work in in conjuction, used for UTI take

with lots water.

Sulfonamides- take with a lot of water bc it is exctreted by kidneys. Treats

MRSA, Uti because of E.coli, causes Photosensitivity Drug interactions: warfarin
and phenytoin

Fluoroquinolones – only one for kids= ciproflaxacin, ends in “flozacin”

-broad spectrum. May cause C. deficil Use for UTI

- tendon injury so don’t use in kids.- don’t take with Keylations.

Fungal and Yeast Infections

Amphotericin B- antifungus

-DOC for systemic fungi infections but highly toxic. Only used for progressive
and fatal infections. – detected in tissue up to a year after withdrawl. LONG
DOSING. Causes Nephrotoxicity, usually reversible unless more than 4 grams

“Azole” Antifungals

Itraconazole – alternative to Amphotericin B bc safer. Liver injury.

-inhibits CYP-450, warfarin.

Flucytosine – MONITER RENAL FXN!!!

Antivirals

Acyclovir- DOC for herpes simplex virus, herpes zoster. Avoid Sex if lesions and
use condom if not. IV- if genital infection is severe infuse slowly.

Ganciclovir- can remain dormant in calls for life but becomes a prob in the
immunocomp pts. TERATOGENIC can kill pts with HIV.