Pharm 17

Which are the primary side effects associated with the methylxanthines?

CNS stimulation, tachycardia, increased gastric secretion, and diuresisSide effects associated with the methylxanthines include central nervous system stimulation (nervousness and insomnia), cardiac stimulation, tachycardia, increased gastric secretion, and diuresis. Renal toxicity, hepatoxicity, CNS depression, decreased gastric secretion, and urinary retention are not adverse drug effects associated with the methylxanthines.

Oral adverse effects of chronic use of inhaled corticosteroids include:

CandidiasisCandidiasis of the oral cavity can result from the chronic use of an inhalation corticosteroid, and patients using oral corticosteroid inhalers should be advised to rinse the mouth with water after inhaler use to minimize the risk of candidiasis. Xerostomia, herpetic lesions, and aphthous stomatitis are not oral adverse effects of chronic inhaled corticosteroid use.

Nasal decongestants are α-adrenergic agonists whose primary action is

Constriction of the blood vessels of the nasal mucous membranesMany nasal decongestants such as pseudoephedrine (Sudafed, Sucrets, in Actifed) and phenylephrine (Neo-Synephrine, Sinex, Allerest) are available over the counter. Their primary action is constricting the blood vessels of the nasal mucous membranes, which reduces nasal congestion and rhinorrhea. These drugs cause adrenergic stimulation, not sedation, with patients reporting nervousness, tachycardia, increased blood pressure, and insomnia. They have no bronchodilating properties.

__________ is used only for the prophylaxis of asthma and not for treatment of an acute attack by preventing the antigen-induced release of histamine, leukotrienes, and other substances from sensitized mast cells.

Cromolyn (Intal, Nasalcrom)Cromolyn (Intal, Nasalcrom) is a drug that is effective only for the prophylaxis of asthma and not for treatment of an acute attack. This drug prevents antigen-induced histamine release, so it must be taken before exposure to the allergen to be effective. Beclomethasone (Beconase, Vancenase) and fluticasone (Flovent) are inhaled corticosteroids that can be used for treatment of the inflammation associated with asthma. Zileuton (Zyflo) and zafirlukast (Accolate) are leukotriene-receptor antagonists used to manage patients with asthma that is not controlled by β2 agonists and corticosteroid inhalers.

Which group of medications is often combined with H1 antihistamines?

Decongestants (adrenergic agents)H1 antihistamines are often combined with oral decongestants that are α-adrenergic agents such as pseudoephedrine and phenylephrine. The leukotriene receptor antagonist montelukast (Singulair) is approved for treatment of seasonal and perennial allergic rhiniitis, and is used as an adjunct therapy with H1 antihistamines and intranasal corticosteroids. Intranasal anticholinergic agents such as ipratropium bromide (Atrovent) decreases rhinorrhea in persons with allergic rhinitis, but is not combined with H1 antihistamines.

Which H1-blocker causes the most sedation and is used as an over-the-counter sleep aid?

Diphenhydramine (Benadryl)Diphenhydramine (Benadryl) is a first-generation H1-blocker that causes the most sedation of this group of medicines. Fexofenadine (Allegra), loratadine (Claritin), and desloratadine (Clarinex) are second-generation H1-blockers that have much less sedation associated with their use.

What mechanism reduces sedation in the second generation of H1-blockers?

Failure to penetrate the blood-brain barrierMembers of the second-generation, or nonsedating, H1-receptor antagonists do not penetrate the blood-brain barrier as readily as the first-generation H1-receptor antagonists. In usual therapeutic doses, they produce much less sedation.

All are effects of H1-agonists except:

H1-agonists promote the release of histamine, which causes vasodilation, not vasoconstriction, increased capillary permeability, bronchoconstriction, cholinergic effects, and pain and itching in nerve endings. Antihistamine agents work as H1-antagonists, blocking these unpleasant effects.

Which agent approved for treatment of seasonal and perennial allergic rhinitis has the mechanism of action of serving as a leukotriene receptor antagonist?

Montelukast (Singular)Montelukast (Singular) is a unique drug in the treatment of seasonal and perennial allergic rhinitis that has the mechanism of action of serving as a leukotriene receptor antagonist. During an allergic reaction, cysteinyl leukotriene is released in the nasal mucosa, causing nasal congestion. By blocking leukotriene release, relief is provided from sneezing, itching, discharge, and congestion, although it is less effective than the antihistamines. Montelukast is used as an adjunctive therapy to H1-antihistamines and intranasal corticosteroids and is usually well tolerated.

Antitussives are used in symptomatic relief of

Nonproductive coughAntitussives may be opioids or related agents used for the symptomatic relief of nonproductive cough. Opioids are the most effective, but due to their addiction potential, they are used secondarily after other nonopioid drugs. Antitussives are not used for symptomatic relief of asthma, COPD, cystic fibrosis, or productive cough.

Which are advantages of the metered-dose inhaler (MDI)?

Only a, b, d, and e are advantages.The MDI is the preferred route of delivery for most asthma drugs because of the advantages listed; however, these inhalers can be difficult to use, especially for children, and they can be abused, resulting in a decrease in response.

What is the mechanism of action used to treat asthma of the class of recombinant humanized monoclonal antibodies?

Prevention of immunoglobulin E from binding to mast cells and basophilsOmalizumab (Xolair) is a recombinant humanized monoclonal antibody that prevents immunoglobulin E from binding to mast cells and basophils, preventing the release of inflammatory mediators after allergen exposure. The blockage of effects of release of leukotrienes is the action of Zileuton (Zyflo) and zafirlukast (Accolate), leukotriene-receptor antagonists used to manage patients with asthma that is not controlled by β2 agonists and corticosteroid inhalers. The β-adrenergic agonists such as albuterol, ipratropium, and salmeterol cause bronchodilation. There is no agent at this time that prevents immunoglobulin G from binding to T lymphocytes and macrophages.

What is the first line of defense for an intermittent asthma attack?

Short-acting β2 agonistsThe first line of treatment for intermittent asthma is a short-acting β2 agonist, and they are the drugs of choice for the emergency treatment of an acute attack of asthma. Low-dose corticosteroids are used together with the long-acting β2 agonists for patients with persistent asthma that is not well controlled on low-dose inhaled steroids alone. Mucolytics are used in treatment of chronic bronchitis and cystic fibrosis.

In __________, patients have persistent life-threatening bronchospasm despite drug therapy.

Status asthmaticusStatus asthmaticus is a life-threatening condition in which bronchospasm persists despite treatment. Chronic bronchitis is often a component of COPD. Patients with intermittent asthma experience symptoms less frequently than two times a month and the symptoms do not interfere with normal activity. COPD is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema.

Intranasal corticosteroids are considered first-line therapy for treatment of moderate to severe allergic rhinitis. The onset of action is within minutes of drug administration.

The first statement is true; the second statement is false. Intranasal corticosteroids are considered first-line therapy for treatment of moderate to severe allergic rhinitis. They decrease inflammation in the airways and help control symptoms of rhinorrhea, itching, sneezing, and nasal congestions. The onset of action is about 12 hours, although full relief may take up to a week. They are effective if given once daily.

The adverse reactions of leukotriene modifiers include irritation of the stomach mucosa, headache, and alteration of liver function tests. Fortunately, few drug interactions occur with these drugs.

The first statement is true; the second statement is false.The first statement is true; the second statement is false. Adverse reactions of leukotriene modifiers include stomach mucosal irritation, headaches, and alteration of liver function tests. Multiple drug interactions occur when these drugs are taken, so caution should be used when the patient is taking any other medications.

Oral corticosteroids, such as prednisone, are sometimes indicated for severely asthmatic patients and even for patients with moderate asthma, especially during respiratory infections. Adverse reactions are similar to inhaled corticosteroids.

The first statement is true; the second statement is false.The first statement is true; the second statement is false. Control of severe and even moderate asthma may require an oral corticosteroid such as prednisone, especially in the presence of a respiratory infection. Adverse effects are more severe than they are for inhaled corticosteroids, and prolonged systemic use can result in adrenal suppression, poor wound healing, and immunosuppression.

Long-acting β2 agonists improve lung function, decrease symptoms, and reduce exacerbations and rescue use of short-acting β2 agonists. They are also recommended as monotherapy for asthma.

The first statement is true; the second statement is false.The first statement is true; the second statement is false. Long-acting β2 agonists carry a black box warning about a higher risk of asthma-related deaths because of the asthma-related deaths reported with salmeterol therapy during clinical trials. They are not recommended as monotherapy for asthma but are best administered in a fixed-dose combination in the same inhaler with an inhaled corticosteroid.

All of these medications are nonsedating H1-receptor antagonists except:

The older H1-receptor antagonists, also called H1-blockers, such as diphenhydramine (Benadryl), have several pharmacologic effects, including antihistaminic, anticholinergic, antiserotonergic, and sedative effects.

First-generation H1-blockers have all actions except:

The older, or first-generation, H1-receptor antagonists, also called H1-blockers, have several pharmacologic effects, including antihistaminic, anticholinergic, antiserotonergic, and sedative effects. First-generation H1-antagonists cause significant sedation and anticholinergic effects, and although the sedation and anticholinergic effects are less severe with the second-generation agents, they still occur to some extent.

The ventilation drive for breathing in normal persons is stimulated by elevated levels of the partial pressure of oxygen, and the partial pressure of carbon dioxide can vary widely. In patients with COPD, a gradual rise in the partial pressure oxygen over time causes the ventilation drive to be triggered by an increase in carbon dioxide.

The ventilation drive for breathing in normal persons is stimulated by elevated levels of the partial pressure of carbon dioxide, and the partial pressure of oxygen can vary widely. In patients with COPD, compromised ventilation causes a gradual rise in the partial pressure of carbon dioxide, which, over time, causes the ventilation drive to be triggered by a decrease in oxygen. This factor is important because if these patients are given more than 3 L/min of oxygen, their respiratory drive may be removed, and apnea could occur.

Which components of asthma must be treated to control the disease?

a and c onlyFor effective treatment of asthma, both the inflammatory and bronchoconstriction components must be addressed. The inflammatory component is primarily treated with corticosteroids, cromolyn, and leukotriene-altering agents. The bronchoconstriction is treated with β-adrenergic agonists, xanthines and anticholinergic drugs.

Corticosteroids that are commonly used in inhaler devices include:

a and c, onlyCommon inhalers contain the corticosteroids beclomethasone and fluticasone (Flovent). Patients taking these corticosteroids have a significant improvement in pulmonary function along with a decrease in wheezing, tightness, and cough. β2 agonists may be combined with long-acting corticosteroids for treatment of asthma, but they are not steroids.

Which anticholinergic drugs are used in the management of COPD?

a and cIpratropium bromide (Atrovent) is a short-acting anticholinergic available for oral inhalation by people with COPD. Tiotropium bromide (Spiriva) is an inhaled long-acting anticholinergic drug that is used to treat COPD. Theophylline (Theo-Dur, Slo-Bid) is a methylxanthine used for treatment of asthma and bronchospasm associated with COPD. Omalizumab (Xolair) is the first of a new class of drugs introduced to treat asthma due to allergens. This drug is a recombinant monoclonal antibody that prevents the binding of IgE to the surface of mast cells and basophils, preventing the release of inflammatory mediators.

Which medications are used in the management of emphysema?

a, and b, onlyAnticholinergics are the first-line treatment, but β2-adrenergic agonists are also used to produce bronchodilation in these patients. Some patients receive a combination metered-dose inhaler with an anticholinergic drug and a β2 agonist. Corticosteroids and xanthines are used in the treatment of asthma.

The xanthines and methylxanthines include which medications?

a, b, and cThe xanthines and methylxanthines consist of theophylline (Theo-Dur, Slo-Bid), caffeine, and theobromine. Theophylline is a bronchodilator that can be combined with other drugs to treat persistent asthma and the bronchospasm associated with chronic bronchitis and emphysema. Short-acting inhaled anticholinergics such as ipratropium bromide (Atrovent) are the first choice for treatment of chronic obstructive pulmonary disease.

Chronic Obstructive Pulmonary Disease (COPD) is associated with which factors or conditions?

a, b, and d onlyCOPD is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema. Smoking is associated with almost all forms of COPD, as is increased sputum production.

Antitussive agents that are commonly used today include

a, c, and d onlyOpioids are the most effective, but because of their addicting properties, other agents are often used. Codeine-containing (codeine is a weak opioid) cough preparations are commonly used, but their histamine-releasing properties may precipitate bronchospasm. Dextromethorphan (identified by the DM in cough medicines such as Robitussin DM), an opioid-like compound, suppresses the cough reflex by its direct effect on the cough center. Pseudoephedrine (Sudafed, Sucrets, in Actifed) is a decongestant with no antitussive properties.

When cells produce leukotrienes in response to inflammation, which physiologic action occurs?

a, c, and dLeukotrienes (LTs) are produced by inflammatory cells and cause bronchoconstriction, increased mucus secretion, mucosal edema, and increased bronchial hyperreactivity. The LT pathway inhibitor drugs such as Zileuton (Zyflo), Zafirlukast (Accolate), and montelukast (Singular) block these actions of inflammation, although they are not as effective as the corticosteroid inhalers.

Which is the primary mechanism of action of inhaled corticosteroids in asthma treatment?

b and d onlyInhaled corticosteroids are useful for reducing inflammation, secretions, and swelling in the lungs after an asthma attack. Although the steroids produce no immediate benefit in an acute asthmatic attack, they speed recovery and decrease morbidity in these patients. They also reduce hyperreactive airways.

Which patients are most likely to have central nervous system excitation when taking antihistamines?

b and d onlySedation is the most common side effect associated with the older antihistamines. However, stimulation or excitation can occur in a few cases. Excitation is more common in children, elderly patients, and persons who use a larger dose than prescribed.

Adverse effects of the short-acting β2 agonists include:

b, c, and d onlySide effects of the short-acting β2 agonists include nervousness, tachycardia, and insomnia. These agents are the drug of choice for emergency treatment of an acute asthma attack. Overuse of these drugs can result in airway hyperresponsiveness and a decrease in the desired response. These agents should be primarily reserved for the treatment of acute problems and not for management of normal breathing function.

Medications that are currently delivered by MDIs include:

b, c, d, and e onlyMedications currently delivered in MDIs include β-adrenergic agonists, both specific and nonspecific, corticosteroids, anticholinergic agents, and cromolyn. Xanthines are not currently available in MDIs.

Which drugs are categorized as leukotriene modifiers?

b, d, and e onlyZileuton (Zyflo) prevents the synthesis of the leukotrienes. Zafirlukast (Accolate) and montelukast (Singulair) are leukotriene-receptor antagonists. They are not as effective as the corticosteroid inhalers, such as beclomethasone (Beconase, Vancenase) or fluticasone (Flovent).

Which treatment considerations should the dental health care worker make for patients with asthma?

All of the above apply.All of the considerations listed will help prevent an acute asthma attack during a dental appointment. Additional considerations include careful analgesic use and avoiding aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and strong opioids. Weak opioids and acetaminophen are the preferred analgesics for patients with asthma. Sulfiting preservatives in local anesthetic agents with vasoconstrictors may trigger allergic reactions and bronchoconstriction. Patients using theophylline should not be given erythromycin to avoid theophylline toxicity. If the patient is using a corticosteroid inhaler, he or she should be advised to rinse the mouth after inhaler use to avoid oral candidiasis. Patients on long-term corticosteroids may need supplemental steroids if the appointment will be stressful. Nitrous oxide may be used for sedation, but the patient should be carefully observed to avoid hypoxia.

Inhaled corticosteroids are the most effective long-term treatment for control of symptoms in all patients with which conditions?

All of the aboveInhaled corticosteroids are the most effective long-term treatment for control of symptoms in all patients with mild, moderate, or severe persistent asthma; they also improve pulmonary function, thereby preventing the symptoms and severity of asthma and reducing the need for emergency room visits.

All of these medication groups are used in treatment of asthma except:

Anticholinergic, not cholinergic, agents are used to treat asthma. Other drugs used to treat asthma include β-adrenergic agonists, xanthines, cromolyn, corticosteroids, and leukotriene-altering agents.

Which actions of H1-blockers have the greatest potential adverse effect for the oral health of the patient?

AnticholinergicAnticholinergic effects can lead to xerostomia, and xerostomia leads to dental problems such as an increased caries rate in patients taking antihistamines on a long-term basis. These patients should be observed for symptoms of xerostomia, and counseling about management techniques should be addressed. Patients taking first-generation, H1-receptor antagonists should be cautioned about sedation when driving and making important decisions.

The primary group of drugs used to treat COPD is the __________, which cause __________.

Anticholinergics, bronchodilationInhaled anticholinergic drugs appear to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine, thereby causing bronchodilation. Ipratropium bromide (Atrovent) is a short-acting anticholinergic agent available for oral inhalation by patients with COPD. Ipratropium bromide's bronchodilating effect is additive with β agonists. Tiotropium bromide (Spiriva) is an inhaled long-acting anticholinergic drug also used to treat COPD.

Which is the primary indication for used of leukotriene modifiers?

Asthma that is not controlled by β2 agonists and corticosteroid inhalersLeukotriene modifiers are used to manage patients with asthma that is not controlled by β2 agonists and corticosteroid inhalers. They are not indicated for emphysema, mild asthma, upper respiratory infections, or chronic bronchitis.

Management of normal breathing function is best achieved with treatment of short-acting β2 agonists, and no danger of overuse of these medications has been found.

Both parts of the statement are false. Short-acting β2 agonists should be used primarily for the treatment of acute problems, not for the management of normal breathing function, because overuse can lead to airway hyperresponsiveness and decreased lung response to these agents.

H1-receptors are primarily responsible for stimulating gastric acid secretion, and the H2-receptors are primarily related to vasodilation, increased capillary permeability, bronchoconstriction, and pain or itching at the nerve endings.

Both parts of the statement are false.Both parts of the statement are false. The H1-receptors are primarily related to vasodilation, increased capillary permeability, bronchoconstriction, and pain or itching at the nerve endings. The H2-receptors are responsible for stimulating gastric acid secretion in the parietal cells of the stomach.

Asthma is characterized by irreversible airway obstruction and is associated with a reduction in expiratory airflow. Chronic obstructive pulmonary disease (COPD) is characterized by reversible airway obstruction, such as in chronic bronchitis or emphysema.

Both statements are false. Asthma is characterized by reversible airway obstruction and is associated with reduction in expiratory airflow. COPD is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema.

Intranasal administration of antihistamines is preferable to oral administration. This is because antihistamines administered intranasally have few adverse effects.

Both statements are false. If possible, the oral dosage form is preferred due to the many adverse effects associated with the intranasal administration. Patients report nasal discomfort, epistaxis, headache, nasal mucosal irritation, and some cases of somnolence. Intranasal azelastine has been associated with unpleasant taste sensations.

Expectorants are drugs that destroy or dissolve mucus from the respiratory passages. Mucolytics promote the removal of exudate or mucus.

Both statements are false.Both statements are false. Expectorants are drugs that promote the removal of exudate or mucus from the respiratory passages by either liquefying the mucous to decrease its viscosity or increasing bronchial secretions. Mucolytics are enzymes that are able to digest mucus, decreasing its viscosity.

Intravenous aminophylline and rapidly absorbed oral liquid preparations are used to manage acute asthmatic attacks and status asthmaticus. Theophylline should be limited to patients whose asthma is not controlled with other agents.

Both statements are true.Both statements are true. Although these drugs may be used in emergency situations such as a severe asthma attack or status asthmaticus, weighing the risk of theophylline toxicity against the potential therapeutic benefit severely limits its use.

What is the action of sympathomimetic or adrenergic agonists in treatment of respiratory diseases?

Bronchodilation by β receptors of lungsSympathomimetic or adrenergic agonists produce bronchodilation by stimulation of the β receptors in the lungs. Selective β2 agonists produce fewer cardiac side effects because they produce less stimulation of the β receptors in the heart (β1). These agents actually decrease secretions, cause vasodilation of the arterioles, and decrease blood pressure in the lungs. The selective β2 agonists—used orally, by inhalation, and parenterally—are currently mainstays of respiratory therapy.