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Home , Tiotropium bromide

Appendix L: Chart found on page 114-121 of original guideline Nursing Care of Dyspena: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD) has been replaced with the chart below. Medications Actions Side Effects Nursing Considerations

Short acting β2 agonists:

• Promotes bronchodilation through stimula- • tremor salbutamol First Line Medication for treatment • Airomir® MDI (HFA) 100 μg tion of 2-adrenergic receptors thereby relax- • tachycardia Absorption: 20% inhaled, well absorbed (PO) of dyspnea. • Ratio-Salbutamol® MDI (HFA) 100 μg ing airway smooth muscle • headache Distribution: 30% inhaled, crosses blood brain • Alti-Salbutamol® MDI (HFA) 100 μg • nervousness barrier, crosses placenta • Ventolin® Diskus® PD 200 μg Onset of action: a few minutes • palpitations Metabolism: liver extensively, tissues • Ventolin® MDI (HFA) 100 μg Peaks: 15-20 minutes • insomnia : mostly urine, feces, breast milk • Ventolin® Nebuamp® Duration: 2-4 hours, up to 8 hours Half-Life: 4-6 hrs Wet Nebulization 1.25 or 2.5 mg

terbutaline • Bricanyl® Turbuhaler® PD 500 μg  Absorption: partially absorbed (PO), minimal (inhalation) Distribution: crosses placenta Metabolism: liver, gut wall Excretion: bile, feces, urine, breast milk Half-Life: unknown

fenoterol fenoterol • Berotec® MDI 100 μg Absorption: inhalation, minimal; incomplete PO • Berotec® vials Wet Nebulization Distribution: unknown 0.25 mg/ml, 0.625 mg/ml Metabolism: liver, 90% Excretion: breast milk, kidney 12% Half-Life: 7 hours

formoterol • Oxeze® Turbuhaler® PD 6 μg and 12 μg Absorption: rapid, lung deposition 21-37% • Foradil® PD 12 ug Distribution: plasma protein binding approximately 50% Metabolism: liver, extensive Excretion: 10% unchanged in urine Half-Life: approximately 8-10 hours

COPD Medications • 1 : An anticholinergic drug that has been shown • dry mouth ipratropium bromide Avoid contact with eyes. • Atrovent® MDI 20 μg to have properties • bad taste Absorption: minimal • Atrovent® Wet Nebulization 125 μg/ml • Reduces vagal tone to the airways • tremor Distribution: does not cross blood-brain barrier Use a holding chamber. and 250 μg /ml Onset of action: 5 – 15 minutes Metabolism: liver, minimal Peaks: 1 – 2 hours Excretion: urine feces Duration: 4 – 5 hours Half-Life: 3-5 hrs tiotropium bromide • An anticholinergic drug that inhibits M3- • dry mouth tiotropium bromide Contraindicated in patients with • Spiriva for oral inhalation only receptors at the smooth muscle leading to • constipation Absorption: highly bioavailable in the lung, hypersensitivity to or its • 18 μg tiotropium light green capsule bronchodilation • heart rate poorly absorbed from the GI tract derivatives or lactose monohydrate. • HandiHaler is an inhalation device Onset of action: 30 minutes • blurred vision Distribution: does not cross blood-brain barrier used to inhale the dry powder contained Peaks: 1 – 4 hours • Metabolism: liver, minimal Administer at the same time each day. in the capsule Duration: 24 hours • glaucoma Excretion: urine feces Capsules sensitive to light and moisture. Half Life: 5 – 7 days Half-Life: 5-7 days Avoid contact with eyes.

Methylxanthine: • Relaxes airway smooth muscle • Usually caused by a high drug serum Take with food or after meals. • Phyllocontin SRT • May have some anti-inflammatory effect concentration or the patient’s inability Absorption: well absorbed (PO), slowly theophylline • Patients may benefit even when serum to tolerate the drug and include: absorbed (extended release) Monitor blood serum. • Apo-Theo-LA SRT levels are low • upset stomach with heartburn Distribution: crosses placenta, widely • Novo-Theophyl SRT • nausea distributed • Theochron SRT • diarrhea Metabolism: liver • Theolair SRT • loss of appetite Excretion: kidneys, breast milk 24-Hour: theophylline • headaches Half-Life: 3-13 hrs, increased in liver disease, • Uniphyl • nervousness CHF and elderly; decreased in smokers • insomnia • tachycardia Several drug interactions include: • seizures • antibiotics

Therapeutic Range: 29-55 umol/L

COPD Medications • 2 Inhaled/ Oral Steroids:

Glucocorticosteroids (Inhaled): • Prevents and suppresses activation and Inhaled route beclomethasone Rinsing, gargling and expectorating after beclomethasone migration of inflammatory cells • sore throat Absorption: 20% inhalation can minimize these side • Alti-beclomethasone® MDI (CFC) 50 g • Reduces airway swelling, mucus production, • hoarse voice Distribution: 10-25% in airways (no spacer) effects. • QVAR® MDI(HFA) 50 μg, 100 μg and microvascular leakage • thrush Metabolism: minimal • Increases responsiveness of smooth muscle Excretion: less than 10% in urine/feces A spacer should be used with MDIs to beta receptors Half-Life: 15 hrs reduce side,effects. budesonide Assess denture fit to avoid thrush. • Pulmicort® Nebuamp® Wet Nebulization Absorption: 39% 0.125 mg/ml, 0.25 mg/ml and 0.5 mg/ml Distribution: 10-25% in airways (no spacer) Rinse mouth, also prior to reinsertion • Pulmicort® Turbuhaler® PD100 μg, 200 Metabolism: liver of dentures. May irritate gum line and μg, and 400 μg Excretion: 60% urine, smaller amounts in feces medication deposits may accumulate Half-Life: 2-3 hrs in improper fitting dentures.

Ciclesonide •  is a nonhalogenated, Same as other inhaled corticosteroids. Ciclesonide is presented in HFA –134a *Not indicated for COPD at this time that is hydrolyzed propellant and ethanol as a solution aerosol. • Alvesco® MDI 100ug, 200ug to the pharmacologically active metabolite Absorption: > 50% (active metabolite) des-ciclesonide following administration. Distribution: protein binding 99%, lung • Des-ciclesonide has a high affinity for deposition - 52% the glucocorticoid receptor and exhibits Metabolism: ciclesonide hydrolyzed to active anti-inflammatory activity. metabolite, des-ciclesonide via esterases in lungs, further metabolism via hepatic CYP3A4 and 2D6 Excretion: feces (78%) Half-Life: 6 hours fluticasone Promote good dental hygiene. • Flovent® Diskus® PD 50 μg, 100 μg, Absorption: 30% aerosol, 13.5% powder 250 μg, and 500 μg Absorption: 10-25% in airways (no spacer), 91% • Flovent® MDI(HFA) 50 μg, 125 μg, and protein binding 250 μg Metabolism: liver Excretion: less than 5% in urine, 97-100% in feces Half-Life: 14 hrs

Glucocorticosteroids (oral): Oral or IV route-short term (less than 2 weeks): prednisone Assess baseline bone density. prednisone • weight gain Absorption: well absorbed • Prednisone 5 mg and 50 mg tablets • increased appetite Distribution: widely distributed; crosses placenta Dietary education (calcium, protein) • Deltasone® 5 mg and 50mg tablets • mood changes Metabolism: liver, extensively • easy bruising Excretion: urine, breast milk Promote eye/dental health and regular methylprednisolone • muscle cramps Half-Life: 3-4 hrs eye/teeth examinations. • Medrol® 4 mg tablets and 16 mg tablets • mild reversible acne

COPD Medications • 3 Corticosteroids (intravenous): Oral route-long term (more than 2 weeks): IV steroids: Monitor glucose level • methylprednisolone • adrenal suppression Absorption: rapid Skin care education re: dry, thin, bruising. • SoluCortef ® • immune-suppression Distribution: widely distributed Avoid use of adhesive bandages. • SoluMedrol ® • osteoporosis Metabolism: liver Use Vitamin E lotion. • hyperglycemia Excretion: urine • hypertension Half-Life: 18 to 36 hrs, depending on the drug • weight gain • cataracts • glaucoma • peptic ulcer • ecchymosis • avascular necrosis of the hip

Long-Acting β2 agonists: formoterol • Promotes bronchodilation through stimula- • tremor formoterol • Oxeze® Turbuhaler® PD 6 μg and 12 μg tion of 2-adrenergicreceptors thereby relax- • tachycardia Absorption: rapid, lung deposition 21-37% • Foradil® PD 12 μg ing airway smooth muscle • headache Distribution: plasma protein binding • nervousness approximately 50% formoterol • palpitations Metabolism: liver, extensive Onset of action: 1-3 minutes • insomnia Excretion: 10% unchanged in urine Duration: 12 hours Half-Life: approximately 8-10 hours salmeterol salmeterol • Serevent® Diskus® PD 50 μg Onset of action: 10-20 minutes Absorption: minimal systemic • Serevent® MDI(HFA) 25 μg Duration: 12 hours Distribution: local Metabolism: liver first pass Excretion: unknown Half-Life: 5.5 hrs

Combination Drugs:

Two : • the same as those listed for each medication Dry Mouth-Rinse mouth due to dryness. ipratropium bromide and salbutamol separately • Combivent Wet Nebulization 0.5mg ipratropium/ 3 mg salbutamol per 2.5 ml vial

Long-acting bronchodilators Rinse mouth postinhalation to prevent and inhaled steroids: thrush. budesonide and formoterol • Symbicort® Turbuhaler® PD 100/6 βg, 200/6 βg fluticasone and salmeterol • Advair® Diskus® PD 100/50 μg, 250/50 μg, 500/50 μg • Advair® MDI(HFA) 125/25 μg, 250/25 μg

COPD Medications • 4 Macrolides/Anti-Infectives: clarithromycin (Biaxin) Binds to 50S ribosomal subunits of subunits • hepatotoxicity Absorption: 50% Be aware whether the antibiotic the patient is • PO 250-500 mg bid x 7-14 days of susceptible bacteria and suppresses protein • dizziness Distribution: widely distributed prescribed is to be taken with or without food. synthesis • headache Metabolism: liver • nausea Excretion: kidney’s unchanged (20%-30%) Determine if the patient has a sensitivity or • diarrhea Half-Life: 4-6 hrs allergy to the prescribed medication. • constipation azithromycin (Zithromax) • Binds to 50S ribosomal subunits of subunits • palpitations Absorption: rapid, (PO) up to 50% • PO 500 mg on day 1 then 250mg qd on of susceptible bacteria and suppresses protein • chest pain Distribution: widely distributed days 2-5 for a total dose of 1.5 g synthesis, much greater spectrum of activity • dizziness Metabolism: unknown, minimal metabolism • IV 500 mg qd > 2 days then 250 mg qd to than erythromycin • headache Excretion:unchanged (bile); kidney’s, minimal complete 7-10 day therapy (community • tremors Half-Life: 11-70 hrs acquired pneumonia) • nausea • diarrhea • hepatotoxicity erythromycin • Binds to 50S ribosomal subunits of subunits •  Absorption: well absorbed (PO), • PO 250-500 mg q6h (base, estolate, state), of susceptible bacteria and suppresses protein • dysrhythmias minimally absorbed (topically, ophthalmic) PO 400-800 mg q6h (ethylsuccinate) synthesis • vaginitis Distribution: widely distributed; minimally • IV inf 15-20 mg/kg/day (lactobionate) • nausea distributed (CSF); crosses placenta divided q6h • vomiting Metabolism: liver partially • diarrhea Excretion: unchanged (bile); kidney’s, minimal unchanged Half-Life: 1-3hrs amoxicillin (Amoxil) • Interfers with cell wall replication of susceptible • anaphylaxis Absorption: well absorbed (90%) • PO 750 mg-1.5g qd in divided doses q8h organisms by binding to the bacterial cell wall, • anemia Distribution: readily in body tissues, fluids, the cell wall, rendered osmotically unstable, • uticaria CSF; crosses placenta swells and bursts from osmotic pressure • bone marrow depression Metabolism: liver (30%) • dizziness Excretion: breast milk, kidney, unchanged (70%) • headache Half-Life: 1-1.3hrs • fever • nausea • diarrhea doxycycline (Doxy, Doxycin) • Inhibits protein synthesis, phosphorylation in • vomiting Absorption: well absorbed • PO/IV 100 mg q12h on day 1 then 100mg/ microorganisms by binding to 30S ribosomal • fever Distribution: widely distributed; crosses placenta day; IV 200mg in 1-2 infusion on day 1 subunits, reversibly binding to 50S ribosomal • diarrhea Metabolism: some hepatic recycling then 100-200mg/day subunits, bacteriostatic • pericarditis Excretion: bile, feces, kidney, unchanged (20%-40%) • increased BUN Half-Life: 15-22 hours; increased in severe renal • hemolytic anemia disease. ciprofloxacin (Cipro) • Interferes with conversion of intermediate • headache Absorption: well absorbed (75%) (PO) Monitor for Achilles Tendonitis • For respiratory infections PO 500 mg q12h DNA fragments into high-molecular-weight • dizziness Distribution:widely distributed DNA in bacteria; DNA gyrase inhibitor • nausea Metabolism: liver (15%) • rash Excretion: kidneys (40-50%) • vomiting Half-Life: 3-4 hr; increased in renal disease • diarrhea

COPD Medications • 5 Fluoroquinolone/Antibacterial: moxifloxacin (Avelox) • Bacterialcidal, interferes with DNA replication, • nausea Absorption: unknown Allergy to fluoroquinolones • PO/IV 400 mg daily for 7-14 days repair, transcription and recombination in • headache Distribution: crosses placenta Hypokalemia susceptible gramnegative and gram-positive • insomnia Metabolism: liver Hepatic impairment bacteria, preventing cell reproduction and • diarrhea Excretion: feces, urine Monitor for tendon inflamation, rupture leading to cell death • tendon inflamation, rupture Half-Life: 12-13.5 hrs

Psychotropics: buspirone (BuSpar) • Acts by inhibiting the action of serotonin by • hyperventilation Absorption: rapidly absorbed • PO 5 mg tid; may increase by 5 mg/day q2-3 binding to serotonin and dopamine receptors • chest congestion Distribution: unknown days not to exceed 60 mg/day also increases norepinephrine metabolism • shortness of breath Metabolism: liver extensively • tachycardia Excretion: feces • palpitations Half-Life: 2-3 hours • hypertension • hypotension • dizziness • headache • tremors • nausea • diarrhea • constipation (Chlorpromanyl) • Depresses cerebral cortex, hypothalamus, • respiratory depression Absorption: variable PO, well absorbed IM • PO 10-50 mg q1-4h initially then increase up limbic system, which control activity • dyspnea Distribution: widely distributed; crosses placenta to 2g/day if necessary aggression, blocks neurotransmission • laryngospasm Metabolism: liver, GI mucosa extensively • IM 10-50 mg q1-4h produced by dopamine at synapse, exhibits • cardiac arrest Excretion: kidneys • In elderly, use lowest effective dose a strong alphaadrenergic, anticholinergic • orthostatic hypotension Half-Life: 30 hours blocking action, mechanism for antipsychotic • tachycardia effects is unclear. • headache • akathisia • dystonia

Opioids Opioid Analgesics:

Morphine (Morphine sulfate) • Depresses pain impulse transmission at the • constipation Absorption: variably absorbed (PO); well absorbed Nebulized opioids are almost exclusively • SC/IM 4-15 mg q4h prn spinal cord level by interacting with opioid • respiratory depression (IM, SC, rectally); completely absorbed IV used in palliative care in patients with • PO 10-30 mg q4h prn; ext rel q8-12h; rectal receptors, produces CNS depression • drowsiness Distribution: widely distributed, crosses placenta end-stage COPD. 10-20 mg q4h prn • dizziness Metabolism: liver extensively • IV 4-10 mg diluted in 4-5 ml water for • confusion Excretion: kidneys injection, over 5 min • sedation Half-Life: 1.5- 2 hours • bradycardia • hypotension • nausea • vomiting • constipation • urinary retention

COPD Medications • 6 hydromorphone (Dilaudid) • Depresses pain impulse transmission at the • respiratory depression Absorption: well absorbed (PO); completely Give injection when not contraindicated • Antitussive PO 1 mg q3-4h prn spinal cord level by interacting with opiod • drowsiness, dizziness absorbed IV (e.g., egg allergy, thimersol sensitivity) • Analgesic PO 2 mg q3- 6h prn, may increase receptors, increases respiratory tract fluid by • confusion Distribution: unknown, crosses placenta to 4 mg q4-6h decreasing surface tension and adhesiveness, • sedation Metabolism: liver extensively • SC/IM 1-2 mg q3-6h prn, may increase to which increases removal of mucus, analgesic, • bradycardia Excretion: kidneys 3-4 mg q4-6h antitussive • hypotension Half-Life: 2-3 hours • IV 0.5-1mg q3h prn; rec 3 mg q4-8h prn • nausea • vomiting • constipation

Vaccination:

Influenza Vaccination • Inhibits influenza virus neuraminidase with • pain and/or erythema at injection site Absorption: rapidly absorbed Revaccination recommended for high risk • 0.5ml IM possible alteration of virus particle aggregation • anaphylaxis Distribution: protein binding is low patients every 5-10 years/ and release Metabolism: converted to oseltamivir carboxylate Excretion: eliminated by conversion Half-Life: 1-3 hours

Pneumo 23 (Pneumococcal • pain and/or erythema at the injection site Allergy to any components of the drug. Polysaccharide Vaccine) • headache COPD • IM/SC immunizing dose is a single injection • general malaise of 0.5ml • uticaria • Revaccination: One injection of 0.5ml • anaphylaxis reaction

Pneumovax 23 (Pneumococcal Vaccine) • pain and/or erythema at the injection site • Administer a single 0.5ml dose of the vaccine • headache SC or IM (preferably in the deltoid muscle or • low grade fever anaphylaxis reaction lateral thigh)

Antiviral:

Zanamivir (Relenza) • Selectively inhibits influenza virus neuroam- • headache Absorption: inhalation 4% - 17% Oral inhalation inidase; by blocking the action of this enzyme, • nausea Distribution: protein binding, plasma<10% 5mg/blister (4 blisters per Rotadisk), packaged there is decreased viral release from infected • diarrhea Metabolism: liver with Diskhaler inhalation device 2 inhalations cells, increased formation of viral aggregates, • -use cautiously with patients Excretion: feces and urine (10mg) twice daily x 5 days. Begin within 2 days and decreased spread of virus with asthma or COPD-Fast acting bronchodilator Half-Life: 2.5-5 hrs of signs or symptoms. should be on hand osteltamivir (Tamiflu) • Inhibits influenza virus neuraminidase with • headache Absorption: rapidly absorbed • PO 75 mg x 5 days begin treatment within possible alteration of virus particle aggregation • fatigue Distribution: protein binding is low 2 days of onset of symptoms and release • nausea Metabolism: converted to oseltamivir carboxylate • vomiting Excretion: eliminated by conversion • diarrhea Half-Life: 1-3 hours • cough • abdominal pain

COPD Medications • 7