DRUGS AFFECTING THE DRUGS AFFECTING THE RESPIRATORY SYSTEMRESPIRATORY SYSTEM

Department of PharmacologyDepartment of Pharmacology

Medical Faculty Brawijaya Medical Faculty Brawijaya UniversityUniversity

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

UPPER RESPIRATORY TRACT COMON COLD

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

LOWER RESPIRATORY TRACT ASTHMA, COPD, BRONCHITIS, EMPHYSEMA

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

Understanding the Common Understanding the Common ColdCold

• Rhinitis, pharyngitis, laryngitisRhinitis, pharyngitis, laryngitis• Most caused by viral infection Most caused by viral infection

(rhinovirus or influenza virus(rhinovirus or influenza virusthe “flu”)the “flu”)• Virus invades tissues (mucosa) of upper Virus invades tissues (mucosa) of upper

respiratory tract, causing upper respiratory tract, causing upper respiratory infection (URI)respiratory infection (URI)

• Difficult to identify whether cause is Difficult to identify whether cause is viral or bacterialviral or bacterial

Treatment of the Common Treatment of the Common ColdCold

Treatment is Treatment is symptomaticsymptomatic only, not curative only, not curative Symptomatic treatment does not eliminate the Symptomatic treatment does not eliminate the

causative pathogencausative pathogen Involves combined use of Involves combined use of antihistamines, nasal antihistamines, nasal

decongestants, antitussives, and expectorantsdecongestants, antitussives, and expectorants

Treatment is Treatment is “empiric therapy,”“empiric therapy,” treating the treating the

most likely causemost likely cause

Antivirals and antibiotics may be used, but a Antivirals and antibiotics may be used, but a

definite viral or bacterial cause may not be easily definite viral or bacterial cause may not be easily

identifiedidentified

AntihistaminAntihistamineses

Drugs that directly compete with histamine Drugs that directly compete with histamine for specific receptor sitesfor specific receptor sites

• Two histamine receptorsTwo histamine receptors• HH11 (histamine (histamine11))• HH22 (histamine (histamine22))

• H1 histamine receptorH1 histamine receptor found on smooth muscle, found on smooth muscle, endothelium, and central endothelium, and central

nervous system tissue;nervous system tissue;

causes causes vasodilationvasodilation, bronchoconstriction, , bronchoconstriction, smooth smooth musclemuscle activation, and separation of activation, and separation of endothelia cellsendothelia cells (responsible for (responsible for hives hives), ), pain and itching due to pain and itching due to insect stings insect stings

HH11 antagonists are commonly referred to antagonists are commonly referred to as antihistaminesas antihistamines• Antihistamines have several propertiesAntihistamines have several properties

• AntihistaminicAntihistaminic• AnticholinergicAnticholinergic• SedativeSedative

• HH22 blockers or H blockers or H22 antagonists antagonists• Used to reduce gastric acid in Peptic UlcerUsed to reduce gastric acid in Peptic Ulcer• Examples: cimetidine, ranitidine, famotidine Examples: cimetidine, ranitidine, famotidine

AntihistaminAntihistamineses

Antihistamines: Antihistamines: Mechanism of ActionMechanism of Action

BlockBlock action of histamine at the H action of histamine at the H11 receptor sites receptor sites Compete with histamine for binding at unoccupied Compete with histamine for binding at unoccupied

receptorsreceptors Cannot push histamine off the receptor if already Cannot push histamine off the receptor if already

boundbound The binding of HThe binding of H11 blockers to the histamine receptors blockers to the histamine receptors

prevents the adverse consequences of histamine prevents the adverse consequences of histamine stimulationstimulation• VasodilationVasodilation• Increased GI and respiratory secretionsIncreased GI and respiratory secretions• Increased capillary permeabilityIncreased capillary permeability

More effective in preventing the actions of histamine More effective in preventing the actions of histamine rather than reversing themrather than reversing them

Should be given early in treatment, before all the Should be given early in treatment, before all the histamine binds to the receptorshistamine binds to the receptors

Antihistamines: IndicationsAntihistamines: Indications

Management of:Management of:• Nasal allergiesNasal allergies• Seasonal or perennial allergic rhinitis Seasonal or perennial allergic rhinitis

(hay fever)(hay fever)• Allergic reactionsAllergic reactions• Motion sicknessMotion sickness• Also used to relieve symptoms Also used to relieve symptoms

associated with the common coldassociated with the common cold•Sneezing, runny noseSneezing, runny nose•Palliative treatment, not curativePalliative treatment, not curative

Antihistamines: Side effectsAntihistamines: Side effects

• Anticholinergic (drying) effects, most Anticholinergic (drying) effects, most commoncommon• Dry mouthDry mouth• Difficulty urinatingDifficulty urinating• ConstipationConstipation• Changes in visionChanges in vision

• DrowsinessDrowsiness• Mild drowsiness to deep sleepMild drowsiness to deep sleep

Antihistamines: Two TypesAntihistamines: Two TypesTraditionalTraditional• OlderOlder• Work both peripherally and centrallyWork both peripherally and centrally• Have anticholinergic effects, making them more Have anticholinergic effects, making them more

effective than nonsedating agents in some caseseffective than nonsedating agents in some cases• Examples:Examples: DDiphenhydramine (Benadryl, Delladryl)iphenhydramine (Benadryl, Delladryl)

Chlorpheniramin maleat Chlorpheniramin maleat (ChlorTriMethon=CTM)(ChlorTriMethon=CTM)

Nonsedating/peripherally actingNonsedating/peripherally acting• Developed to eliminate unwanted side effects, mainly Developed to eliminate unwanted side effects, mainly

sedationsedation• Work peripherally to block the actions of histamine; Work peripherally to block the actions of histamine;

thus, fewer CNS side effectsthus, fewer CNS side effects• Longer duration of action (increases compliance)Longer duration of action (increases compliance)• Examples: Examples: Terfenadin, LoratadinTerfenadin, Loratadin

DecongestantDecongestantss

Nasal CongestionNasal Congestion• Excessive nasal secretionsExcessive nasal secretions• Inflamed and swollen nasal mucosaInflamed and swollen nasal mucosa• Primary causesPrimary causes

• AllergiesAllergies• Upper respiratory infections (common cold)Upper respiratory infections (common cold)

DecongestantDecongestant Adrenergic-Adrenergic-αα agonist agonist Constriction blood vessels surrounding nasal sinusesConstriction blood vessels surrounding nasal sinuses

Two dosage forms decongestantTwo dosage forms decongestant OralOral Inhaled/topically applied to the nasal membranesInhaled/topically applied to the nasal membranes

Oral DecongestantsOral Decongestants

• Prolonged decongestant effects, but delayed onsetProlonged decongestant effects, but delayed onset• Effect less potent than topical Effect less potent than topical • No rebound congestionNo rebound congestion• Exclusively adrenergicsExclusively adrenergics• Example: Example: Pseudoephedrine, Phenylpropanolamin Pseudoephedrine, Phenylpropanolamin

(PPA)(PPA)

Topical Nasal DecongestantsTopical Nasal Decongestants• Topical adrenergics Topical adrenergics

• DesoxyephedrineDesoxyephedrine• PhenylephrinePhenylephrine

• Prompt onset, PotentPrompt onset, Potent• Sustained use over several days causes rebound Sustained use over several days causes rebound

congestion, making the condition worsecongestion, making the condition worse• Intranasal steroidsIntranasal steroids

• Beclomethasone dipropionate Beclomethasone dipropionate • Fluticasone Fluticasone

Nasal Decongestants:Nasal Decongestants:Mechanism of ActionMechanism of Action

AdrenergicsAdrenergics Constrict small blood Constrict small blood vessels that supply vessels that supply URI structuresURI structures As a result these As a result these tissues shrink, and nasal tissues shrink, and nasal secretions in the swollen secretions in the swollen mucous membranes are mucous membranes are better able to drainbetter able to drain Nasal stuffinessNasal stuffiness is is relievedrelieved

Nasal steroidsNasal steroidsWork to turn off the Work to turn off the immune system cells immune system cells involved in the involved in the inflammatory responseinflammatory responseDecreased Decreased inflammation results in inflammation results in decreased congestiondecreased congestionAnti-inflammatory Anti-inflammatory effecteffectNasal stuffiness is Nasal stuffiness is relievedrelieved

Nasal Decongestants: Nasal Decongestants: IndicationsIndications

Relief of nasal congestion associated with:Relief of nasal congestion associated with:• Acute or chronic rhinitisAcute or chronic rhinitis• Common coldCommon cold• SinusitisSinusitis• Hay feverHay fever• Other allergiesOther allergies

May also be used to reduce swelling of the May also be used to reduce swelling of the

nasal passage and facilitate visualization of the nasal passage and facilitate visualization of the

nasal/pharyngeal membranes before surgery or nasal/pharyngeal membranes before surgery or

diagnostic proceduresdiagnostic procedures

Nasal Decongestants: Nasal Decongestants: Side EffectsSide Effects

AdrenergicsAdrenergics SteroidsSteroids

NervousnessNervousness Local mucosal Local mucosal drynessdryness

Insomnia Insomnia and irritation and irritation

PalpitationsPalpitations

TremorsTremors

(systemic effects due to (systemic effects due to adrenergic stimulation of theadrenergic stimulation of theheart, blood vessels, and CNS) heart, blood vessels, and CNS)

AntitussivesAntitussives

Cough PhysiologyCough PhysiologyRespiratory secretions and foreign objects are Respiratory secretions and foreign objects are naturally removed by the naturally removed by the Cough reflex Cough reflex

• Induces coughing and expectorationInduces coughing and expectoration• Initiated by irritation of sensory receptors Initiated by irritation of sensory receptors

in the respiratory tractin the respiratory tract

Two basic type of coughTwo basic type of coughProductive coughProductive cough

o Congested, removes excessive secretionsCongested, removes excessive secretionsNonproductive coughNonproductive cough

o Dry coughDry cough

CoughinCoughingg

Most of the time, coughing is Most of the time, coughing is beneficialbeneficial• Removes excessive secretionsRemoves excessive secretions• Removes potentially harmful foreign Removes potentially harmful foreign substancessubstances

In some situations, coughing can be In some situations, coughing can be harmful, such as after hernia repair harmful, such as after hernia repair surgerysurgery

AntitussivesAntitussivesDrugs used to stop or reduce coughingDrugs used to stop or reduce coughing• Opioid and nonopioid (narcotic and non narcotic)Opioid and nonopioid (narcotic and non narcotic)• Used only for Used only for nonproductivenonproductive coughs! coughs!OpioidsOpioids• Suppress the cough reflex by direct action on the Suppress the cough reflex by direct action on the

cough centre in the medulla (CNS)cough centre in the medulla (CNS)Examples:Examples:• Codeine Codeine • HydrocodoneHydrocodone

Non opioidsNon opioids• Suppress the cough reflex by numbing the stretch Suppress the cough reflex by numbing the stretch

receptors in the respiratory tract and preventing the receptors in the respiratory tract and preventing the cough reflex from being stimulatedcough reflex from being stimulatedExamples:Examples:• Dextromethorphan (DMP), NoskapinDextromethorphan (DMP), Noskapin

Antitussives: Antitussives: IndicationsIndications

Used to stop the cough reflex when the cough is Used to stop the cough reflex when the cough is nonproductive and/or harmfulnonproductive and/or harmful

Antitussives: Side EffectsAntitussives: Side EffectsDextromethorphanDextromethorphan•Dizziness, drowsiness, nauseaDizziness, drowsiness, nausea

Opioids (Codein)Opioids (Codein)•Sedation, nausea, vomiting, lightheadedness, Sedation, nausea, vomiting, lightheadedness, constipationconstipation

ExpectorantsExpectorants

• Drugs that aid in the expectoration Drugs that aid in the expectoration (removal) of mucus(removal) of mucus

• Reduce the viscosity of secretionsReduce the viscosity of secretions• Disintegrate and thin secretionsDisintegrate and thin secretions

By loosening and thinning sputum and By loosening and thinning sputum and bronchial secretions, the tendency to cough bronchial secretions, the tendency to cough is indirectly diminishedis indirectly diminished

Expectorants: Expectorants: Mechanisms of Mechanisms of

ActionAction• Reflex stimulationReflex stimulation

• Agent causes irritation of the GI tractAgent causes irritation of the GI tract• Loosening and thinning of respiratory tract Loosening and thinning of respiratory tract

secretions occur in response to this irritationsecretions occur in response to this irritation• Example: Example: ipekak, guaifenesin, glyceril guaicolateipekak, guaifenesin, glyceril guaicolate

• Direct stimulationDirect stimulation• The secretory glands are stimulated directly to The secretory glands are stimulated directly to

increase their production of respiratory tract fluidsincrease their production of respiratory tract fluids• Examples: iodine-containing products such as Examples: iodine-containing products such as

iodinated glycerol iodinated glycerol and and potassium iodidepotassium iodide

• Final result: thinner mucus that is easier toFinal result: thinner mucus that is easier to removeremove

MucolyticMucolytic

• Mechanisme of action Mechanisme of action Mucolytic Mucolytic to degrade mucoprotein to degrade mucoprotein lysis lysis

thiny mucus thiny mucus easier to remove easier to remove• Mucolytic :Mucolytic : bromhexinbromhexin

ambroxolambroxol acetyl cysteinacetyl cystein

Drugs use inDrugs use in Bronchial Asthma Bronchial Asthma

Clinical features of bronchial Clinical features of bronchial asthmaasthma

1.1. Acute attacks of dyspnea associated with Acute attacks of dyspnea associated with acute airway obstruction due to acute airway obstruction due to contraction of airway smooth musclecontraction of airway smooth muscle

2.2. Mucus hypersecretionMucus hypersecretion, which may lead , which may lead to mucus pluggingto mucus plugging

3.3. Airway inflammationAirway inflammation

4.4. Bronchial hyperresponsivenessBronchial hyperresponsiveness

Normal airway Asthmatic airway

Early ResponseEarly Response

Inflammatory mediators Chemotactic factors

Mast cell degranulation

Allergen binds to IgE on mast cell

Smooth muscle

PMN

Eosinophils

Broncho- constriction

Edema

Mucus hypersecretion

Goblet cell Columnar cell

Allergen

Late ResponseLate Response

Mucus hypersecretion Ciliary function

Epithelial damage

Afferent nerve discharge

Broncho- constriction

Efferent (vagal) nerve discharge

Ag (polutan, alergen)

Ag-Ab/IgE di mast cell

MEDIATOR

Early response : Late response : Bronchoconstriction Inflamation

Symptom Hyperreactivity

Ag (polutan, alergen) avoid

Ag-Ab/IgE di mast cell cromolin, steroid

MEDIATORagonist, steroidtheophyllin,anti cholinergicEarly response : Late response : Bronchoconstriction Inflamation

Symptom Hyperreactivity

THERAPY

Pharmacotherapy of Bronchial Asthma :1.Bronchodilator2.Anti inflamatory drug3.(Prophilactic drugs)

BronchodilatorsBronchodilators

BronchodilatorsBronchodilators

• Adrenergic agonistsAdrenergic agonists

• MethylxanthinesMethylxanthines

• AnticholinergicsAnticholinergics

For acute reversible bronchospasm

A. Adrenergic agonists A. Adrenergic agonists ((22 receptor agonists) receptor agonists)

1.1. Clinical Effects:Clinical Effects:2.2. Mechanism of Action:Mechanism of Action:

a. a. 11 receptor receptor- increases heart rate- increases heart rate- increases contractile force- increases contractile force

b. b. receptor receptor- - relaxes bronchial smooth musclerelaxes bronchial smooth muscle- relaxes vascular smooth muscle- relaxes vascular smooth muscle- relaxes uterine smooth muscle- relaxes uterine smooth muscle

Adrenergic non selective Adrenergic non selective - adrenalin/ epinefrin- adrenalin/ epinefrin- efedrin- efedrin

22 receptor agonists receptor agonists- isoproterenol, isoprenalin- isoproterenol, isoprenalin

2 2 receptor agonistreceptor agonist selectiveselective- - Terbutalin (Allupent)- Albuterol (Salbutamol)- Metaproterenol- Fenoterol- Formoterol- Salmetrol

Adrenergic Adrenergic (Symphatomimetic) Drugs(Symphatomimetic) Drugs

Β AdrenergicAgonist

Mechanism of Action Β-Adrenergic Receptor Agonist

Mechanism of Action Mechanism of Action ββ2 2 Adrenergic Receptors Adrenergic Receptors

Bronchodilation is promoted by cAMPBronchodilation is promoted by cAMP

A. Adrenergic agonists A. Adrenergic agonists ((22 receptor agonists) receptor agonists)

4. Kinetics - measured by forced expiratory flow 4. Kinetics - measured by forced expiratory flow rateratea. a. isoproterenolisoproterenol - approximately 30 minutes - approximately 30 minutesb. short acting; b. short acting; albuterol, terbutalinealbuterol, terbutaline – half-life; 2- – half-life; 2-3 hours3 hoursc. long acting agonists; c. long acting agonists; salmeterolsalmeterol, formoterol, formoterol; up ; up to 15 hoursto 15 hours

5. Adverse effects5. Adverse effectstremortremor, hypokalemia, tachycardia, hypokalemia, tachycardia

B. MethylxanthinesB. Methylxanthines

Mechanism of Action Mechanism of Action a.a. Phosphodiesterase inhibitor, therefore, Phosphodiesterase inhibitor, therefore,

increased cAMP increased cAMP relaxation relaxationb.b. blocks the action of adenosineblocks the action of adenosine

IndicationIndicationDilation of airways in asthma, chronic bronchitis, Dilation of airways in asthma, chronic bronchitis,

and emphysemaand emphysemaMild to moderate cases of acute asthmaMild to moderate cases of acute asthmaAdjunct agent in the management of COPDAdjunct agent in the management of COPD

Xanthine &Derivates

B. MethylxanthinesB. Methylxanthines

4. Administration: usually given orally; IV4. Administration: usually given orally; IV

5. Kinetics – short biological half-life;5. Kinetics – short biological half-life;

‘‘slow-release’ preparationsslow-release’ preparations

6. Side effects: 6. Side effects:

narrow therapeutic windownarrow therapeutic window

generally safe; nausea, cardiac generally safe; nausea, cardiac arrhythmias and convulsions.arrhythmias and convulsions.

B. MethylxanthinesB. Methylxanthines

Drug interactionsDrug interactionsthe serum theophylline concentration can bethe serum theophylline concentration can be

decreased by (enzyme inducer) decreased by (enzyme inducer) barbiturates barbiturates benzodiazepinesbenzodiazepinescigarete smokecigarete smoke

increased by increased by cimetidinecimetidineerythromycin; M. peumoniaeerythromycin; M. peumoniaeciprofloxacin; Gram - ciprofloxacin; Gram - allopurinolallopurinol

C. AnticholinergicsC. Anticholinergics

C. Anticholinergics;C. Anticholinergics;muscarinic receptor muscarinic receptor

antagonistsantagonists

1.1. Atropine sulfateAtropine sulfate – not used today in treatment of – not used today in treatment of asthma because of too many side effects (urinary asthma because of too many side effects (urinary retention, tachycardia, loss of visual retention, tachycardia, loss of visual accommodation, and agitation)accommodation, and agitation)

2.2. New Agents: New Agents: ipratropium bromide, oxitropium ipratropium bromide, oxitropium

bromidebromide

poorly absorbed from the lung and do not cross poorly absorbed from the lung and do not cross blood-brain barrier; less systemic adverse effects.blood-brain barrier; less systemic adverse effects.

Inhalation of drugsInhalation of drugs

ANTI-INFLAMATORY ANTI-INFLAMATORY DRUGSDRUGS

Anti-inflammatory and Anti-inflammatory and prophylactic drugsprophylactic drugs

• Glucocorticosteroids Glucocorticosteroids • Cromolyn sodium and nedocromil Cromolyn sodium and nedocromil

sodiumsodium

Resolve existing bronchial inflammationPrevent subsequent inflammation in asthmaNot recommended for acute asthma attacks

GlucocorticoidsGlucocorticoids

1.1.Inhaled glucocorticosteroids:Inhaled glucocorticosteroids:triamcinolon, beclomethasone, triamcinolon, beclomethasone, budesonide and fluticasonebudesonide and fluticasone

2. Oral glucocorticosteroids for severe 2. Oral glucocorticosteroids for severe asthma: prednisone, or prednisoloneasthma: prednisone, or prednisolone

3. Metabolized in liver by hydroxylation3. Metabolized in liver by hydroxylation4. Side effects 4. Side effects

- suppression of the hypothalamus-- suppression of the hypothalamus-pituitary axispituitary axis- shunting of growth in children- shunting of growth in children

GlucocorticoidsGlucocorticoids

Mechanism of action Mechanism of action

- inhibit inflammatory cell - inhibit inflammatory cell infiltration into the airwaysinfiltration into the airways

- reduce edema formation by - reduce edema formation by acting on the vascular acting on the vascular endotheliumendothelium

Glucocorticoid : Clinical useGlucocorticoid : Clinical use• Treatment of adrenal insufficiencyTreatment of adrenal insufficiency• Decrease inflammationDecrease inflammation

• Asthma & COPDAsthma & COPD• Allergic reactions & rashesAllergic reactions & rashes• Other inflammatory processesOther inflammatory processes

• Suppression of immune responseSuppression of immune response• Autoimmune processesAutoimmune processes• Prevent transplant rejectionPrevent transplant rejection

• Start with high dose then taper down to prevent Start with high dose then taper down to prevent adrenal crisisadrenal crisis

• Steroids may be given for up to 5 days without taperSteroids may be given for up to 5 days without taper• po, im, iv, topicalpo, im, iv, topical

• Interaction w aspirin, AINS Interaction w aspirin, AINS insulin, OADinsulin, OAD

CromolynCromolyn

CromolynCromolyn

1.1. Anti-allergic drugs used Anti-allergic drugs used prophylacticallyprophylactically

2.2. Route of administration; poor Route of administration; poor absorption from GI tract, thus, must absorption from GI tract, thus, must be inhaled as a microfine powder or be inhaled as a microfine powder or aerosolized solution. aerosolized solution.

3.3. Ketotifen; orally active formKetotifen; orally active form

4.4. Side effects : rareSide effects : rare

CromolynCromolyn

Mechanism of action; Mechanism of action; not clearly understoodnot clearly understood

1.1. Prevents mast cell degranulation; Prevents mast cell degranulation; ‘‘mast cell stabilizermast cell stabilizer’; prevent the ’; prevent the release of inflammatory mediators release of inflammatory mediators including histamine.including histamine.

2.2. Also probably suppress the response of Also probably suppress the response of exposed irritant nerves; effective for exposed irritant nerves; effective for the treatment of ‘asthmatic cough’.the treatment of ‘asthmatic cough’.

Leukotriene pathway inhibitorsLeukotriene pathway inhibitors

Antileukotrienes

Also called leukotriene receptor antagonists (LRTAs)Newer class of asthma medicationsThree subcategories of agentsCurrently available agents:Montelukast (sold as Singulair®) Zafirlukast (sold as Accolate®)

Antileukotrienes:Antileukotrienes: Mechanism of ActionMechanism of Action

• Leukotrienes are substances released when a trigger, Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical such as cat hair or dust, starts a series of chemical reactions in the bodyreactions in the body

• Leukotrienes cause inflammation, bronchoconstriction, Leukotrienes cause inflammation, bronchoconstriction, and mucus productionand mucus production

• Result: coughing, wheezing, shortness of breathResult: coughing, wheezing, shortness of breath• Antileukotriene agents Antileukotriene agents preventprevent leukotrienes from leukotrienes from

attaching to receptors on cells in the lungs and in attaching to receptors on cells in the lungs and in circulationcirculation

• Inflammation in the lungs is Inflammation in the lungs is blockedblocked, and asthma , and asthma symptoms are relievedsymptoms are relieved

X

X

Antileukotrienes: Drug EffectsAntileukotrienes: Drug Effects

By blocking leukotrienes:By blocking leukotrienes:• Prevent smooth muscle contraction of the Prevent smooth muscle contraction of the

bronchial airwaysbronchial airways• Decrease mucus secretionDecrease mucus secretion• Prevent vascular permeabilityPrevent vascular permeability• Decrease neutrophil and leukocyte infiltration Decrease neutrophil and leukocyte infiltration

to the lungs, preventing inflammationto the lungs, preventing inflammation

Antileukotrienes: Antileukotrienes: IndicationsIndications

• Prophylaxis and chronic treatment Prophylaxis and chronic treatment of asthma in adults and children of asthma in adults and children older than age 12older than age 12

• NOT meant for management of NOT meant for management of acute asthmatic attacksacute asthmatic attacks

• Montelukast is approved for use in Montelukast is approved for use in children ages 6 and olderchildren ages 6 and older

Antileukotrienes: Side Antileukotrienes: Side EffectsEffects

zafirlukastzafirlukast• HeadacheHeadache• NauseaNausea• DiarrheaDiarrhea• Liver dysfunctionLiver dysfunction

montelukastmontelukast has has fewer side effectsfewer side effects

Pharmacotherapy of common Pharmacotherapy of common coldcold

• A man 66 years old, Pak Miftah, come to the A man 66 years old, Pak Miftah, come to the clinic with complain of common cold, nasal clinic with complain of common cold, nasal congestion. His blood pressure is 160/90. congestion. His blood pressure is 160/90.

• ProblemProblem : nasal congestion : nasal congestion• Therapeutical Objective Therapeutical Objective : remove nasal : remove nasal

congestioncongestion• P-treatment : advise, drug, reveralP-treatment : advise, drug, reveral• P-drugP-drug : choose drugs between : choose drugs between

pseudoephedrine and PPA pseudoephedrine and PPA with blood with blood pressure case we choose PSEUDOEPHEDRINEpressure case we choose PSEUDOEPHEDRINE

Prescription :Prescription :

Dr. Cika Dr. Cika

Jl.Watumujur no. ab Malang,(0341) xxxxxJl.Watumujur no. ab Malang,(0341) xxxxx

SIP : 1234567SIP : 1234567

R/ R/

Pseudoephedrine tab No. XPseudoephedrine tab No. X

∫ ∫ 3dd 1tab pc3dd 1tab pc

Pro : Pak MiftahPro : Pak Miftah

Communication :Communication :

• Information : common cold isn't Information : common cold isn't dangerous, but your BP is high so I dangerous, but your BP is high so I give you this ephedrine. It’s safe for give you this ephedrine. It’s safe for you. you.

• Instruction : drink it 3 times daily, one Instruction : drink it 3 times daily, one tablet each. tablet each.

• Warning : But if there is any dizziness, Warning : But if there is any dizziness, comeback to my place. comeback to my place.

• Recalling : for patient’s dataRecalling : for patient’s data

Pharmacotherapy Asthma Pharmacotherapy Asthma BronchialeBronchiale

• Girl, 3 years. Brought in with a severe acute Girl, 3 years. Brought in with a severe acute asthmatic attack, probably precipitated by a asthmatic attack, probably precipitated by a viral infection. She has great difficulty in viral infection. She has great difficulty in breathing (expiratory wheeze, no viscid breathing (expiratory wheeze, no viscid sputum), little coughing and a slight sputum), little coughing and a slight temperature (38.2oC). Further history and temperature (38.2oC). Further history and physical examination reveal nothing. Apart physical examination reveal nothing. Apart from minor childhood infections she has never from minor childhood infections she has never been ill before and she takes no drugs.been ill before and she takes no drugs.