Year 4 Medical Pharmacology Therapeutic
Case 1 <ul><li>ABC, a 16-year old girl presented with difficulty in breathing and coughing progressively worsened over the...
<ul><li>Diagnosis? </li></ul><ul><ul><li>Acute exacerbation of bronchial asthma </li></ul></ul><ul><li>Further history to ...
<ul><li>What is the drug of choice and why?  </li></ul><ul><ul><li>Β 2- receptor agonist (short acting) </li></ul></ul><ul...
<ul><li>Any role of corticosteroids? </li></ul><ul><ul><li>Antiinflammatory.  </li></ul></ul><ul><ul><li>Block the reactio...
<ul><li>ABC responded well to treatment. She was discharged after 3 days in the ward </li></ul><ul><li>What advice you wou...
Case 2 <ul><li>XYZ, a 45-year old man with a long history of persistent asthma went to A&E with complaint of severe SOB an...
Case 2 <ul><li>On examination </li></ul><ul><li>HR 130/min </li></ul><ul><li>RR 30/min </li></ul><ul><li>BP 130/90mmHG </l...
ABG in Acute ASTHMA Mild    pH    PaO 2    PaCO 2    HCO 3 - Moderate    pH    PaO 2    PaCO 2    HCO 3 - Severe*...
Case 2 <ul><li>ECG showed sinus tachycardia with occasional premature ventricular contractions. </li></ul><ul><li>XYZ was ...
Summary of lab resuts <ul><li>Before terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.4 </li></ul></ul><ul><ul...
Case 2 <ul><li>ECG showed sinus tachycardia with occasional premature ventricular contractions. </li></ul><ul><li>XYZ was ...
Summary of lab resuts <ul><li>Before terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.4 </li></ul></ul><ul><ul...
That’s all, Thank you
 
 
 
 
 
ASTHMA DRUGS Bronchodilatation  ↓  Inflammation  ß2 receptor  Agonist Salbutamol Methylxanthines Theophylline, aminophylli...
severity reliever preventer controller Short acting  ß2 agonists Inhaled corticosteroids Cromoglycates Theophylline Leukot...
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Management of asthma and copd therapeutics yr 5 2010 11a

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Management of asthma and copd therapeutics yr 5 2010 11a

  1. 1. Year 4 Medical Pharmacology Therapeutic
  2. 2. Case 1 <ul><li>ABC, a 16-year old girl presented with difficulty in breathing and coughing progressively worsened over the past 2 days </li></ul><ul><ul><li>Symptoms preceded by sore throat, rhinorrhoea and cough for 3 days </li></ul></ul><ul><ul><li>History of cough on and off, went to GP and was given cough medication. </li></ul></ul><ul><li>On examination </li></ul><ul><ul><li>Dyspnoeic, wheezing+, able to speak in short sentences </li></ul></ul><ul><ul><li>BP 110/83 mmHg, PR 130/min, T- 37.8oC </li></ul></ul><ul><ul><li>hyperinflated chest, intercostal recession+ Rhonci++ with decreased breath sound on the left side </li></ul></ul>
  3. 3. <ul><li>Diagnosis? </li></ul><ul><ul><li>Acute exacerbation of bronchial asthma </li></ul></ul><ul><li>Further history to ask? </li></ul><ul><ul><li>Recurrent night cough </li></ul></ul><ul><ul><li>Family history of asthma </li></ul></ul><ul><li>How do you assess asthma severity? </li></ul><ul><li>In your opinion how is her condition? </li></ul>
  4. 4. <ul><li>What is the drug of choice and why? </li></ul><ul><ul><li>Β 2- receptor agonist (short acting) </li></ul></ul><ul><ul><li>For fast relief </li></ul></ul><ul><li>Why not use other bronchodilators such as aminophylline or ipratropium? </li></ul><ul><ul><li>Aminophylline is not as efficacious as SABA and has more risk for serious adverse effects than SABA </li></ul></ul><ul><ul><li>Ipratropium is not as efficacious as SABA </li></ul></ul><ul><li>What is the preferred route of administration? </li></ul><ul><ul><li>Nebulizer </li></ul></ul><ul><ul><li>Combination with ipratroprium improve pulmonary function and reduce rate of hospitalization </li></ul></ul>
  5. 5. <ul><li>Any role of corticosteroids? </li></ul><ul><ul><li>Antiinflammatory. </li></ul></ul><ul><ul><li>Block the reaction to allergen and reduce airway hyperresponsiveness. </li></ul></ul><ul><ul><li>Inhibit cytokine production, adhesion protein activation and inflammatory cell migration and activation. </li></ul></ul><ul><ul><li>Reverse β 2 receptor downregulation. </li></ul></ul><ul><ul><li>Inhibit microvascular leakage </li></ul></ul><ul><li>What is the mode of administration for the patient? </li></ul><ul><ul><li>Oral vs parenteral </li></ul></ul>
  6. 6. <ul><li>ABC responded well to treatment. She was discharged after 3 days in the ward </li></ul><ul><li>What advice you would give ABC before discharge? </li></ul><ul><li>What type of medication would you prescribe to ABC and why </li></ul><ul><li>SABA? </li></ul><ul><li>Corticosteroid inhaler? </li></ul><ul><li>Continue oral prednisolone for 5-7 days then off </li></ul><ul><li>Review? </li></ul>
  7. 7. Case 2 <ul><li>XYZ, a 45-year old man with a long history of persistent asthma went to A&E with complaint of severe SOB and wheezing. </li></ul><ul><li>Able to speak two or three words without taking a breath. </li></ul><ul><li>On inhaler beclomethasone 4 puff (80mcg/puff) bd, salbutamol prn. </li></ul><ul><li>Ran out of beclomethasone 1 week ago, been taking salbutamol only with increasing frequency upto every 3 hours on the day of admission </li></ul>
  8. 8. Case 2 <ul><li>On examination </li></ul><ul><li>HR 130/min </li></ul><ul><li>RR 30/min </li></ul><ul><li>BP 130/90mmHG </li></ul><ul><li>ABG under room air </li></ul><ul><ul><li>pH 7.4 (N 7.35-7.45) </li></ul></ul><ul><ul><li>PaO2 55mmHg (>80 mmHg) </li></ul></ul><ul><ul><li>PaCO2 40 mmHg (35-45 mmHg) </li></ul></ul>Comment the ABG results – normal or not normal??
  9. 9. ABG in Acute ASTHMA Mild  pH  PaO 2  PaCO 2  HCO 3 - Moderate  pH  PaO 2  PaCO 2  HCO 3 - Severe*  pH   PaO 2  PaCO 2  HCO 3 - <ul><li>* Beware the following : </li></ul><ul><li>Speechless patient </li></ul><ul><li>PEFR <50% </li></ul><ul><li>Resp Rate >25 </li></ul><ul><li>Tachycardia >110 (pre  2 agonist) </li></ul>
  10. 10. Case 2 <ul><li>ECG showed sinus tachycardia with occasional premature ventricular contractions. </li></ul><ul><li>XYZ was given SC 0.5mg terbutaline with minimal improvement, O2 at 4L/min by nasal cannula. </li></ul><ul><li>Another SC 0.5mg terbutaline was then given. Subsequently his HR 145/min and he complained of palpitations and shakiness. </li></ul><ul><li>ABG pH 7.39, PaO2 60mmHg, PaCo2 42 mmHg </li></ul>
  11. 11. Summary of lab resuts <ul><li>Before terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.4 </li></ul></ul><ul><ul><li>PaO2 55 mmHg </li></ul></ul><ul><ul><li>PaCO2 40 mmHg </li></ul></ul><ul><li>BUSE </li></ul><ul><ul><li>Na 140 mEq/L </li></ul></ul><ul><ul><li>K 4.1 mEq/L </li></ul></ul><ul><ul><li>Cl 105 mEq/L </li></ul></ul><ul><li>After 2 nd terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.39 </li></ul></ul><ul><ul><li>PaO2 60 </li></ul></ul><ul><ul><li>PaCO2 42 </li></ul></ul><ul><li>BUSE </li></ul><ul><ul><li>Na 138 </li></ul></ul><ul><ul><li>K 3.5 </li></ul></ul>What adverse effects experienced by XYZ are consistent with systemic β 2 agonist administration?
  12. 12. Case 2 <ul><li>ECG showed sinus tachycardia with occasional premature ventricular contractions. </li></ul><ul><li>XYZ was given SC 0.5mg terbutaline with minimal improvement, O2 at 4L/min by nasal cannula. </li></ul><ul><li>Another SC 0.5mg terbutaline was then given. Subsequently his HR 145/min and he complained of palpitations and shakiness. </li></ul><ul><li>ABG pH 7.39, PaO2 60mmHg, PaCo2 42 mmHg </li></ul>Β 2 agonist are cardiac stimulants that may cause tachycardia and rarely arrhythmias
  13. 13. Summary of lab resuts <ul><li>Before terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.4 </li></ul></ul><ul><ul><li>PaO2 55 mmHg </li></ul></ul><ul><ul><li>PaCO2 40 mmHg </li></ul></ul><ul><li>BUSE </li></ul><ul><ul><li>Na 140 mEq/L </li></ul></ul><ul><ul><li>K 4.1 mEq/L </li></ul></ul><ul><ul><li>Cl 105 mEq/L </li></ul></ul><ul><li>After 2 nd terbutaline </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.39 </li></ul></ul><ul><ul><li>PaO2 60 </li></ul></ul><ul><ul><li>PaCO2 42 </li></ul></ul><ul><li>BUSE </li></ul><ul><ul><li>Na 138 </li></ul></ul><ul><ul><li>K 3.5 </li></ul></ul>Decrease could be due to β 2 adrenergic activation of Na+ K+ pump and subsequent transport of K intracellularly. At usual doses, inhaler salbutamol or terbutaline cause relatively little effects on K, effect more noticeable with systemic administration.
  14. 14. That’s all, Thank you
  15. 20. ASTHMA DRUGS Bronchodilatation ↓ Inflammation ß2 receptor Agonist Salbutamol Methylxanthines Theophylline, aminophylline Anticholinergics Ipratropium bromide Mast cell stabilizer sodium cromoglycate Corticosteroids Beclomethasone, budesonide Leukotriene pathway inhibitors montelukast Anti-IgE monoclonal Antibodies omalizumab
  16. 21. severity reliever preventer controller Short acting ß2 agonists Inhaled corticosteroids Cromoglycates Theophylline Leukotriene antagonists Long acting ß2 agonists Oral steroids

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