Stop Asthma Naturally

Asthma Free Forever

Jerry Ericson is a researcher and alternative medical practitioner. Jerry created this asthma treatment book basing on over 20 years of his personal experience in helping asthma sufferers relieve their symptoms within minutes, and get rid of asthma permanently without medications. A well organized and precisely explained all natural asthma recovery methods keeps you out from having on the counter drugs pr from so highly priced medicines prescribed by the doctors, even you need to revolve around the doctor for good results to be shown, there is all consists inside the content of this online health guide and by following it properly and timely you will get treated soon. With the help of Asthma Free Forever, you can solve your asthma problem for good in just a few days right in the comfort of your own home. This treatment is based on proven medical research, so you can be sure that it's safe and guaranteed to work. Just apply the info that you will learn from this guide and you can breathe easily without coughing and congestion. You can strengthen your respiratory system and live a healthy and active lifestyle again. Read more here...

Asthma Free Forever Summary


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The author presents a well detailed summery of the major headings. As a professional in this field, I must say that the points shared in this manual are precise.

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Theophylline and other xanthines

A retrospective analysis of 3995 patients treated with azithromycin did not show any pharmacokinetic interactions in patients who were also taking various other drugs, including theophylline (1,45). In two double-blind, randomized, placebo-controlled studies there was no inhibition of the metabolism of theo-phylline by azithromycin (53,54). However, there has been a report of reduced theophylline concentrations after withdrawal of azithromycin (55). The authors concluded that the mechanism of interaction was best explained by concomitant induction and inhibition of theophylline metabolism by azithromycin, followed by increased availability of unbound enzyme sites as azithro-mycin was cleared from the system.

Summary Drug Table Bronchodilators

Bronchospasm, induced bronchospasm Asthma, bronchospasm Asthma, bronchospasm Asthma, bronchospasm of asthma, prevention Asthma, bronchospasm Bronchospasm during Bronchospasm Asthma, bronchospasm Maxair Autohaler, Asthma, bronchospasm Asthma, bronchospasm Asthma bronchospasm

Theophylline and St Johns Wort

A 42-year-old female taking an unusually high dose of theophylline (1600 mg per day) indicated that prior to her recent hospitalization she was stabilized on a twice daily theophylline dose of 300 mg. This dosage produces a theophylline serum concentration of 9.2 g mL. The patient informed during interview that she was taking St John's wort (0.3 hypericin) 300 mg per day for the last 2 months. She had been decided to discontinue St. John's wort, and 7 days later her theophylline level was increased to 19.6 g mL and her dosage was consequently adjusted downwards (25). In vitro study with intestinal LS 180 cells indicted that St. John's wort increased the expression of CYP1A2 in a concentration-dependent manner, and this induction maybe responsible for reduced plasma theophylline concentrations upon co-administration of St. John's wort (26). However, Morimoto et al. (27) found no significant interaction between St. John's wort and theophylline where healthy volunteers consumed St....

Anti Asthmatic Activity

Early reports indicated that acute inhalation increased airway patency in healthy individuals (Tashkin et al., 1973 Vachon et al., 1973 Shapiro and Tashkin, 1976) and improved specific airway conductance in asthmatics (Tashkin et al., 1974, 1975b Vachon et al., 1976). However, there is good evidence that chronic smoking of cannabis restricts the airways and that, as with tobacco, unspecified irritants in the smoke can cause bronchospasm (Henderson et al., 1972). Aerosolised preparations of THC have produced bronchodilation in both healthy individuals and asthmatics (Tashkin et al., 1974, 1975a Abboud and Sanders, 1976 Williams et al., 1976) but in asthmatic subjects, bronchoconstriction has also been observed. For example, Abboud and Sanders (1976) administered aerosolised THC to six asthmatic patients, three of whom showed increases in specific airway conductance indicating bronchodilation the remaining three subjects showed a decrease in conductance and the overall mean, excluding...

Bronchodilators Sympathomimetic

A bronchodilator is a drug used to relieve bron-chospasm associated with respiratory disorders, such as bronchial asthma, chronic bronchitis, and emphysema. These conditions are progressive disorders characterized by a decrease in the inspiratory and expiratory capacity of the lung. Collectively, they are often referred to as COPD. The patient with COPD experiences dyspnea (difficulty breathing) with physical exertion, has difficulty inhaling and exhaling, and may exhibit a chronic cough. The two major types of bronchodilators are the sym-pathomimetics and the xanthine derivatives. The anti-cholinergic drug ipratropium bromide (Atrovent) is used for bronchospasm associated with COPD, chronic bronchitis, and emphysema. Ipratropium is included in the Summary Drug Table Bronchodilators. Chapter 25 Examples of sympathomimetic bronchodilators include albuterol (Ventolin), epinephrine (Adrenalin), salme-terol (Serevent), and terbutaline (Brethine). Many of the sympathomimetics used as...

Drug Drug Interactions Theophylline

An interaction of pyrantel with theophylline has been reported (3). An 8-year-old boy with status asthmaticus was given intravenous aminophylline and then switched to mod-ified-release oral theophylline on day 3, when his serum theophylline concentration was 15 mg ml. On day 4 he was given a single dose of pyrantel 160 mg (for A. lumbricoides infection) at the same time as his second oral dose of theophylline. About 2.5 hours later his serum theophylline concentration was 24 mg ml, and a further 1.5 hours later it had risen to 30 mg ml. No further theophylline was given and no theophylline toxicity occurred.

Cromoglycate nedocromil and lodoxamide

Sodium cromoglycate is widely used in the prophylactic treatment of allergic diseases, especially bronchial asthma and allergic rhinitis. It inhibits histamine release from mast cells by a stabilizing effect on the cell membrane. It is usually given by inhalation or intranasally. The bioavailability following inhalation is low (

Therapeutic Drug Monitoring of Antiasthmatic Drugs

Theophylline is a bronchodilator and respiratory stimulant effective in the treatment of acute and chronic asthma. The drug is readily absorbed after oral absorption, but peak concentration may be observed much later with sustained release tablets. The bronchodilator effect of theophylline is proportional to the log of serum drug concentration over a range of 5-20 g mL (129). Adverse reactions may be observed at concentrations exceeding 20 g mL. However, serum therapeutic concentrations between 10 and 20 g mL have also been reported (130). Theophylline is metabolized by hepatic cytochrome P450, and altered pharmacokinetics of theophylline in disease states have been reported. Clearance of theophylline is slow in neonates compared with that in adults, while theophylline metabolism is also altered in hepatic disease. Acute viral illness associated with fever may prolong the half-life of theophylline (131). Patients with pneumonia and episodes of severe airways obstruction also may...

The safety of fenoterol in severe asthma

Debate continues about the safety of fenoterol in the treatment of severe asthma. A sharp rise in asthma mortality in 1977 in New Zealand provoked debate about the safety of beta2-adrenoceptor agonists, especially the short-acting compound fenoterol. This led to the withdrawal of fenoterol in New Zealand and amendment of the American Asthma Guidelines, suggesting caution in the regular use of beta2-adrenoceptor agonists (1). Although there is evidence linking fenoterol to increased morbidity and mortality in asthma (2), the underlying mechanisms were not known. It was suggested that the increase in mortality might be linked to fatal cardiac dysrhythmias, developing under conditions of asthma-induced hypoxia and high doses of beta2-adrenoceptor agonists (3). In a report the manufacturers have discussed the epi-demiological data linking the use of fenoterol to asthma mortality in New Zealand. They pointed out that asthma mortality started to fall in 1979 while fenoterol sales were still...

Asthma and pregnancy

An increasing number of pregnancies (5-8 ) are complicated by asthma. The course and severity of asthma can change during pregnancy, and may improve, remain unchanged or worsen. Asthmatic women have an increased risk of pregnancy complications and adverse outcome, such as hypertensive disorders, preterm labor and delivery, intrauterine growth restriction, placenta praevia, cesarean delivery and low birth weight, especially when asthma is inadequately or poorly controlled (Beckmann 2003, Bracken 2003, Mihrshahi 2003, Wen 2001, Kallen 2000, Alexander 1998, Demissie 1998). However, when asthma is aggressively controlled and well-managed, there has been no reported association with adverse infant and maternal outcomes or asthma complicating pregnancies (Olescn 2001, jana 1995, Schatz 1995). Stenius-Aamiala and colleagues report that there is no serious effect on pregnancy outcome if an acute asthma attack is adequately treated (Stenius-Aamiala 1996). The risk of suffering an acute attack...


Theophylline is a methylxanthine and has been used for many years as a bronchodilator in the treatment and the prophylaxis of chronic asthma it also has anti-inflammatory and immunomodulatory properties. Theophylline is also useful in the treatment of apnea in premature infants as it increases the sensitivity of the respiratory center in the brain, resulting in an increased respiratory frequency. Theophylline acts by inhibiting phosphodiesterase enzymes which cause an increase in the intracellular concentration of c-AMP, and a subsequent relaxation of the smooth muscles in the airways and the pulmonary artery. Since the availability of newer pharmacological agents, and because of concern about its toxicity, theophylline is no longer a first-line treatment. It may be added when severe symptoms do not respond rapidly to routine treatment with inhaled ,12-agonists and corticosteroids. Theophylline has a narrow therapeutic index therapeutic concentrations are between 10 and 20 jig ml. It...

Bronchial asthma

Beta-adrenoceptor antagonists should not be given to patients with bronchial asthma or obstructive airways disease, unless there are no other treatment options, because of the risk of precipitating bronchospasm resistant to bronchodilators. Celiprolol, a beta1-antagonist with beta2-agonist activity, has a theoretical but unproven advantage. Alternatively, cardioselective drugs should be chosen in the lowest possible dosages and in conjunction with a beta2-adrenoceptor agonist, such as salbutamol or terbutaline, to minimize bronchoconstriction.

Antiasthma Drugs

Asthma is a respiratory condition characterized by recurrent attacks of dyspnea (difficulty breathing) and wheezing caused by spasmodic constriction of the bronchi. With asthma, the body responds with a massive inflammation. During the inflammatory process, large amounts of histamine are released from the mast cells of the respiratory tract, causing symptoms such as increased mucous production and edema of the airway and resulting in bronchospasm and inflammation. With asthma the airways become narrow, the muscles around the airway tighten, the inner lining of the bronchi swell, and extra mucus clogs the smaller airways. (See Fig. 37-1.) Along with the bronchodilators, several types of drugs are effective in the treatment of asthma. These include corticosteroids, leukotriene formation inhibitors, leukotriene receptor agonists, and mast cell stabilizers. Antiasthma drugs are used in various combinations to treat and manage asthma. Using several drugs may be more beneficial than using a...


Although cannabis was used as a bronchodilator in the nineteenth century, modern human research seems to have been limited to a brief period in the 1970s. Small controlled studies in asthmatic volunteers (Tashkin et al. 1974 Williams et al. 1976 Tashkin et al. 1977) showed that oral, smoked and aerosolised THC had significant bronchodilator activity comparable to that of salbutamol, though slower in onset. Dose-related tachycardia and intoxication occurred at higher doses. An inhaled aerosol avoided systemic absorption of THC but induced cough and chest discomfort, which limited its usefulness.


Bronchodilators are drugs that open the airways in the respiratory tract. They are widely prescribed as pills and aerosol inhalers to patients with asthma to relieve the wheezing and difficulty in breathing characteristic of that disease. Most of these drugs work by stimulating the sympathetic nervous system, which regulates the muscular walls of the bronchial tubes. As a result, in addition to their desired effect, they commonly cause stimulation, anxiety, jittenness, and insomnia. Patients often dislike these side effects but have no alternatives to the drugs if they want to breathe. Another problem with the stimulant bronchodilators is their strong tendency to cause dependence. When the effect of a dose wears off, bronchial constriction increases as a reaction to the drug, making further doses necessary. Asthmatics frequently m- hide bronchodilators throughout the day, in addition to taking them regularly by mouth. This frequency of use increases risks of addiction and mood change....

Organs and Systems Respiratory

Aerosol therapy with acetylcysteine can cause broncho-constriction. In 31 ambulant asthmatics using 10 acet-ylcysteine solution, there was a mean reduction of 55 in the FEV1 in 19 subjects. The addition of 0.05 isoprena-line reduced the number of patients who developed bronchoconstriction from 19 to 5 (SEDA-5, 170). In two placebo-controlled studies, involving over 700 patients, there was no difference in adverse effects between oral acetylcysteine and a placebo. There was, however, no improvement in FEV1 in these studies (3).

General Information

Depending on the criteria used, the incidence of aspirin hypersensitivity is variously estimated as being as low as 1 or as high as 50 , the highest frequency being found in asthmatics. The condition is characterized by bronchospasm (asthma), urticaria, angioedema, and vasomotor rhinitis, each occurring alone or in combination, often leading to severe and even life-threatening reactions. There is no clear evidence of an association with tumors, apart from the possible peripheral contribution of aspirin to the development of urinary tract neoplasms in patients with analgesic nephropathy. Indeed, some authors have suggested a role for salicylates in reducing the incidence of color-ectal tumors and breast tumors.

Drug Administration Drug administration route

Intracoronary adenosine has been compared with intravenous adenosine for the measure of fractional flow reserve in 52 patients with coronary artery lesions (44). The intravenous dose was 140 micrograms kg minute and the intracoronary bolus dose was 15-20 micrograms to the right coronary artery and 18-24 micrograms to the left coronary artery. The two routes of administration were equally effective in measuring hyperemic flow, and adverse effects were limited to two patients who received intravenous adenosine one patient had severe nausea and one patient with asthma had an episode of bronchospasm.

Factors affecting serum drug concentrations

The serum concentration of a particular drug is determined by absorption, distribution, metabolism, and excretion of a drug. Major characteristics that affect serum drug concentrations include genetic make up of a patient as well as age, gender, weight, habits (such as smoking), and diet. Elderly and newborns may metabolize a particular drug more slowly than others. Some drugs, for example theophylline, distributes to lean weight only where other drugs, such as phenytoin, distributes to total weight. Diseases may alter serum drug concentrations dramatically. Hepatic disease may alter metabolism of a drug where a patient with renal failure may clear a drug in urine more slowly than a patient with normal renal function. Pregnancy alters metabolism of several drugs while drug-drug interactions may also significantly alter serum drug concentrations.

Gender Differences and Serum Drug Concentrations

Theophylline is metabolized by CYP1A2. In one study involving 24 subjects, it was observed that theophylline metabolism is faster in women than in men (6 h in female non-smoker vs. 9.3 h in male non-smokers) (46). Phenytoin and naproxen are mainly metabolized by CYP2C9. Rugstad et al. (47) reported that there was an increase in plasma naproxen concentrations with age and that females also had higher plasma concentrations of naproxen compared with males. Although women showed slightly lower concentration of phenytoin compared with men when corrected for body weight and height, the difference was not statistically significant (48). The activity of CYP2C19 may be higher in males than in females. The metabolism of mephobarbital was significantly faster in males than in females when compared after a single oral dose of 400 mg of the drug. The sex difference was more significant with the R-enantiomer (49). Clomipramine, which is metabolized by CYP2D6 and CYP2C19, has a higher clearance rate...

Organs and Systems Cardiovascular

Skin disinfection before insertion of peripheral infusion catheters is standard practice. Ethanol 70 has been compared with 2 iodine dissolved in 70 ethanol in a prospective, randomized trial in 109 patients who were given infusions of prednisone and theophylline (2). Phlebitis occurred six times in the ethanol group and 12 times in the iodine group. The relative risk reduction of 53 failed to reach significance, but the power of the study was only 0.55, so there was a 45 chance of missing a true difference. As vast numbers of catheters are inserted each year, a small difference in phlebitis rate could save many patients discomfort.

Risk communication prior to pharmacotherapeutic choice

Drug administration during pregnancy means that both the mother and unborn child are exposed. The drug or metabolite concentration may be even higher in the embryonic or fetal compartment than it is in the mother. The fetus as an additional patient therefore demands a strict pharmacotherapeutic approach, as it is imperative to try to restore maternal health without endangering the development of the child. In severe conditions, such as bronchial asthma, diabetes melli-tus, epilepsy or particular communicable diseases, treatment is obligatory regardless of pregnancy. In contrast, inessential products such as antitussive preparations, pregnancy-supporting substances, and high doses of vitamins and minerals should not be prescribed or used, as their potential risks outweigh their unproven benefits.

Nursing Responsibilities

The primary nursing responsibility is to provide the patient with proper instructions for administering the drug. For example, many patients with asthma use a metered-dose inhaler to dilate the bronchi and make breathing easier. Without proper instruction on how to use the inhaler, much of the drug can be deposited on the tongue, rather than in the respiratory tract. This decreases the therapeutic effect of the drug. Instructions may vary with each inhaler. To be certain that the inhaler is used correctly, the patient is referred to the instructions accompanying each device. Figure 2-9 illustrates the proper use of one type of inhaler.

Pfaffia paniculata and ginseng

Asthma occurred in a patient who had been exposed to Pfaffia paniculata root powder used in the manufacturing of Brazil ginseng capsules (1). Airway hyper-reactivity was confirmed by a positive bronchial challenge to metha-choline and sensitivity to the dust was confirmed by immediate skin test reactivity, a positive bronchial challenge (immediate response), and the presence of a specific IgE to an aqueous extract detected by ELISA. The bronchial response was inhibited by sodium cromoglicate. Unexposed subjects did not react to this ginseng extract with any of the tests referred to above. The same study performed with Korean ginseng (Panax ginseng) was negative.

Cardiovascular Disease and Serum Drug Concentration

Cardiac failure is often associated with disturbances in cardiac output, influencing the extent and pattern of tissue perfusion, sodium and water metabolism as well as gastrointestinal motility. These factors affect absorption and disposition of many drugs requiring dosage adjustment. Vd and clearance of lidocaine are decreased in cardiac failure. For drugs that are metabolized by the liver, decreased blood flow in the liver accounts for reduced clearance, but impaired hepatic metabolism in these patients also plays a role. Accumulation of active metabolites of lidocaine and procainamide in these patients are clinically significant. Theophylline metabolism, which is largely independent of hepatic blood flow, is reduced in patients with severe cardiac failure and dose reduction is needed. Digoxin clearance is also decreased. Quinidine plasma level may also be high in these patients because of lower Vd (89). Elimination halflife is directly related to the Vd and inversely related to...

Drug Metabolism and Clearance in Pregnancy

The increased secretion of estrogen and progesterone in normal pregnancy affects hepatic drug metabolism differently depending on the specific drug. A higher rate of hepatic metabolism of certain drugs, for example phenytoin, can be observed because of the induction of the hepatic drug-metabolizing enzymes by progesterone. On the contrary, the hepatic metabolism of theophylline and caffeine is reduced secondary to the competition of these drugs with progesterone and estradiol for enzymatic metabolism by the liver. Cholestatic effect of estrogen may interfere with the clearance of drugs, for example, rifampin (93). By the end of pregnancy, total and unbound phenobarbital concentrations are reduced up to 50 of the original concentration, but primidone concentrations are altered marginally. Total phenytoin concentrations may fall by 40 compared with serum phenytoin levels before pregnancy. Total and free carbamazepine values may also alter because of pregnancy, but reports are...

Therapeutic drug monitoring of individual drugs

Usually, concentration of a therapeutic drug is measured in the serum or plasma. However, whole blood concentration of immunosuppressant drugs such as cyclosporine and tacrolimus is usually measured for therapeutic drug monitoring. Obtaining blood for measurement of a drug during the absorption or the distribution phase may lead to misleading information. Moreover, to measure the peak concentration of a drug, timing of the sample will depend on the route of administration. After intravenous administration, the peak concentration of a drug may be achieved in a few minutes. On the contrary, for a sustained release tablet, the mean time to reach the peak plasma concentration of theophylline was 7.9 h in one study (106). The trough concentration is clinically defined as the serum drug concentration just before the next dose. Usually, trough concentrations are monitored for most drugs, but for aminoglycosides and vancomycin, both peak and trough concentrations are monitored. For a...

Ineffective Therapeutic Regimen Management

When working with a patient who is not managing the drug regimen correctly, the nurse must ensure that the patient understands the drug regimen. It is essential to provide written instructions. If possible, the nurse should allow the patient to administer the drug before he or she is dismissed from the health care facility. The nurse should determine if adequate funds are available to obtain the drug and any necessary supplies. For example, when a bronchodilator is administered by inhalation, a spacer or extender may be required for proper administration. This device is an additional expense. A referral to the social services department of the institution may help when finances are a problem.

Observational studies

Appearance of TNF alfa in the plasma during the 3 hours after the start of antibody infusion, suggesting that they resulted from cytokine release. There was systolic hypotension, defined as a systolic pressure below 90 mmHg and a fall of at least 20 mmHg, in one patient who was given 10 mg. There were non-specific skin rashes in one patient in each of the groups who were given 10, 30, and 100 mg and in three of those given 300 mg. There were three serious adverse events fatal rupture of an aortic aneurysm, thought to be unrelated to the drug, an episode of severe reversible airways obstruction in a patient with asthma, and an episode of unexplained collapse, presumed to be vasovagal, followed by full recovery several hours after the end of the first infusion. No opportunistic or other infections were reported.

Placebocontrolled studies

Oral bambuterol 20 mg at night has been compared with inhaled salmeterol 50 mg bd for persistent nocturnal symptoms in 117 asthmatics already taking inhaled corticoster-oids in a randomized, double-blind, placebo-controlled trial for 6 weeks (2). The treatments resulted in significant and equivalent improvements in nocturnal and daytime asthma symptoms, peak flow, and the use of short-acting beta-adrenoceptor agonists. Drug-related adverse events included headache (six with bambuterol, two with salme-terol), tremor (three in each group), cramps (two with bambuterol), and palpitation (three with bambuterol, one with salmeterol). Four patients taking bambuterol withdrew owing to possible drug-related adverse effects (insomnia, headache, flushing, and mental excitation) compared with one patient taking salmeterol (tremor). Bambuterol appears to be a safe and effective alternative to inhaled long-acting beta2-adrenoceptor agonists for poorly controlled nocturnal symptoms in asthma.

Saliva and tears alternative to serum for therapeutic drug monitoring

Drugs that are not ionizable or are un-ionized within the salivary pH range (phenytoin, carbamazepine, and theophylline) are candidates for salivary therapeutic drug monitoring (102). Salivary flow rates vary significantly between individuals and under different conditions. The use of stimulated saliva has advantage over resting saliva. The salivary flow rate, pH and sampling condition, and other pathophysiological factors may influence the concentration of a particular drug in saliva. However, under well-controlled and standardized conditions, saliva can be used as an alternative matrix for monitoring of carbamazepine, phenytoin, primidone, and ethosuximide. One report also concluded that monitoring of salivary phenytoin and carbamazepine proved to be a realistic alternative to plasma-free level monitoring because excellent correlations were found between salivary levels and serum-unbound levels of both phenytoin and carbamazepine (103). However, a poor correlation was observed...

Identification of susceptible patients

An alternative explanation for the epidemic of asthma fatalities among users of beta-adrenoceptor agonist aerosols postulates the existence of a subset of asthmatic patients who are more sensitive than others to an adverse effect of beta-agonists. In this view the occurrence of a peak incidence of deaths will eliminate this subset and the overall death rate will thus fall once more without a proportionate reduction in the use of beta-agonists. A subset of asthmatic patients who develop a significant reduction in bronchodilator response to salbutamol after a short period of treatment has indeed been identified, although the number of patients studied was small. The subset developed a significant reduction in the Bmax for beta2-adrenoceptors in the lung. This was measured in vivo by PET scanning using a beta-antagonist ligand. Patients in the subset were homozygous for glycine at codon 16 on the beta2-adrenoceptor gene (SEDA-21,180). However, another and larger study failed to identify...

General adverse effects

The adverse effects of beta-blockers are usually mild, with occurrence rates of 10-20 for the most common in most studies. Most are predictable from the pharmacological and physicochemical properties of these drugs. Examples include fatigue, cold peripheries, bradycardia, heart failure, sleep disturbances, bronchospasm, and altered glucose tolerance. Gastrointestinal upsets are also relatively common. Serious adverse cardiac effects and even sudden death can follow abrupt withdrawal of therapy in patients with ischemic heart disease. Most severe adverse reactions can be avoided by careful selection of patients and consideration of individual beta-blockers. Hypersensitivity reactions have been relatively rare since the withdrawal of practolol. Tumor-inducing effects have not been established in man.

Partial agonist activity

Partial agonists, such as acebutolol, oxprenolol, pindo-lol, practolol, and xamoterol, produce less resting brady-cardia. It has also been claimed that such agents cause a smaller increase in airways resistance in asthmatics, less reduction in cardiac output (and consequently a lower risk of congestive heart failure), and fewer adverse effects in patients with cold hands, Raynaud's phenomenon, or intermittent claudication. However, none of these advantages has been convincingly demonstrated in practice, and patients with bronchial asthma or incipient heart failure must be considered at risk with this type of compound.

Adverse Reactions

Gastric upset, heartburn, nausea, vomiting, anorexia, and gastrointestinal bleeding may occur with salicylate use. Although these drugs are relatively safe when taken as recommended on the label or by the primary health care provider, their use can occasionally result in more serious reactions. Some individuals are allergic to aspirin and the other salicylates. Allergy to the salicy-lates may be manifested by hives, rash, angioedema, bronchospasm with asthma-like symptoms, and ana-phylactoid reactions.

Pharmacokinetic interactions

Lipophilic beta-adrenoceptor antagonists are metabolized to varying degrees by oxidation by liver microso-mal cytochrome P450 (for example propranolol by CYP1A2 and CYP2D6 and metoprolol by CYP2D6). These agents can therefore reduce the clearance and increase the steady-state plasma concentrations of other drugs that undergo similar metabolism, potentiating their effects. Drugs that are affected in this way include theo-phylline (393), thioridazine (394), chlorpromazine (395), warfarin (396), diazepam (397), isoniazid (398), and fle-cainide (399). These interactions are most likely to be of clinical significance when the affected drug has a low therapeutic ratio, for example theophylline or warfarin.

Aerosolized Amphotericin B

Amphotericin B has been the most widely studied aerosolized antifungal agent thus far. One survey reported use of aerosolized amphotericin B as prophylaxis in 61 of transplant centers (65). However, variability exists between centers as to the formulation and dose administered and the aerosolization procedures (i.e. nebulizer) used. Several centers have reported the aerosolization of amphotericin B deoxycholate. Nebulized amphotericin B lipid complex has also been used and shown to be safe in lung transplant recipients with few adverse effects (66,67). Adverse effects that have been reported include cough, dyspnea, bronchospasm, nausea, and vomiting (66-68). In a comparative safety study, adverse effects were more common with the deoxycholate formulation compared to the amphotericin B lipid complex (66). However, decreases in FEV1 of greater than 20 in addition to cough, shortness of breath, and wheezing were reported following the administration of these formulations (32,69). The...


All narcotic analgesics are contraindicated in patients with known hypersensitivity to the drugs. These drugs are contraindicated in patients with acute bronchial asthma, emphysema, or upper airway obstruction and in patients with head injury or increased intracranial pressure. The drugs are also contraindicated in patients with convulsive disorders, severe renal or hepatic dysfunction, acute ulcerative colitis, and increased intracranial pressure. The narcotic analgesics are Pregnancy Category C drugs (oxycodone, Category B) and are not recommended for use during pregnancy or labor (may prolong labor or cause respiration depression of the neonate). The use of narcotic analgesics is recommended during pregnancy only if the benefit to the mother outweighs the potential harm to the fetus.

And Antiretroviral Drugs

Immunoassays are commercially available for TDM of antiasthmatic drugs theophylline and caffeine. The manufacturer of the FPIA assay for determination of total tricyclic antidepressants (TCA) in serum only recommends this assay for screening of TCA in serum in a patient with suspected overdose and cautions against using this assay for routine TDM of TCA. A patient overdosed with carbamazepine may show a falsely elevated TCA level if the FPIA assay is used because of cross-reactivity of carbamazepine with the antibody used in this immunoassay (39,40). Both HPLC and GC or GC combined with mass spectrometry can be used for routine TDM of various TCA. Methods for TDM of TCA are discussed in detail in Chapter 8. Recently, Wille et al. (41) reported HPLC and GC MS analysis of 13 new-generation antidepressants (venlafaxine, fluoxetine, viloxazine, fluvoxamine, mianserin, mirtazapine, melitracen, reboxetine, citalopram, maprotiline, sertraline, paroxetine, and trazodone) together with eight...

Syndromes of Anxiety and Their Treatment

Work with your doctor to avoid theophylline preparations used for asthma. Avoid decongestants like pseudoephedrine (Sudafed) and phenylephrine, as they invariably make people more anxious. The recreational drug that worsens anxiety the most is caffeine. Don't forget that caffeine is

Susceptibility Factors Age

Xanthines have been given to infants at the risk of sudden infant death syndrome or idiopathic apnea of prematurity (see monograph on Theophylline). About 50 of 30 infants treated with caffeine (and 12 of 18 infants treated with theophylline) had significant increases in episodes of gastroesophageal reflux (36). The authors stressed that screening for reflux should precede the administration of caffeine (and theophylline) to infants at the risk of sudden infant death syndrome. As expected, the frequency of adverse effects such as tachycardia and gastroesophageal reflux is lower with lower doses of caffeine for example 2.5 mg kg qds (SEDA-17, 1).

Contraindications Precautions And Interactions

These drugs are contraindicated in patients with an allergy to the p blockers, in patients with sinus bradycardia, second- or third-degree heart block, heart failure, and those with asthma, emphysema, or hypotension. The drugs are used cautiously in patients with diabetes, thyrotoxicosis, and peptic ulcer.

Psychological psychiatric

The Early Treatment of the Atopic Child (ETAC) Study has provided evidence that cetirizine may be able to halt the progression to asthma in high-risk groups of young children and infants with atopic dermatitis (9). However, the study involved giving relatively high doses of cetirizine to very young children (aged 1-2 years at study entry) over a long period of time. Therefore, the impact of prolonged use of high-dose cetirizine (0.25 mg kg bd over 18 months) on behavior and cognitive ability in young children and infants has been assessed in a double-blind, randomized, placebo-controlled study (10). Well-validated and standardized assessments of behavior or cognition were used, and the ages at which psychomotor milestones were attained were established. The authors concluded that, compared with placebo, cetirizine had no significant effects on behavior, cognition, or psychomotor milestones in young children with atopic dermatitis.

Potential Effects Of Airway Obstruction And Concurrent Lung Disease

Moreover, tumor masses within the airways are likely to cause changes in airflow patterns. Under these conditions, aerosol deposition in the airways and lungs deviates from that observed in healthy individuals, a scenario that is not unique to aerosol delivery for lung cancer treatment. Most marketed inhaler systems are designed for use in pulmonary diseases with varying degrees of obstruction and abnormal lung function (i.e. asthma, cystic fibrosis, etc.).

Drug Administration Drug overdose

There have been many cases of intoxication with oral Dettol liquid, a widespread household disinfectant that contains chloroxylenol 4.8 , pine oil, and isopropyl alcohol (4-8). Dettol was involved in 10 of hospital admissions related to self-poisoning in Hong Kong. In a retrospective study of 67 cases, serious complications were relatively common (8 ) and these included aspiration of Dettol with gastric contents, resulting in pneumonia, cardiopulmonary arrest, bronchospasm, adult respiratory distress syndrome, and severe laryngeal edema with upper airway obstruction. Of 89 patients, five developed minor hematemesis, in the form of coffee-colored or blood-stained vomitus (6). One patient had a gastroscopy performed on the day after admission, which showed signs of chemical burns in the esophagus and stomach. Gastroscopy in another patient on day 11, done to rule out an esophageal stricture, showed no abnormality. All patients with hematemesis recovered completely. The authors suggest...

IL12 Knockout and Transgenic Mice

IL-12 has entered clinical trials for cancer (538-541), chronic hepatitis C (542), and asthma (543). Preliminary analysis shows some positive benefit in patients with cutaneous T-cell lymphoma (541). To avoid severe toxicity, an 1L-12 pretreatment regimen appears to be necessary (544). Administration of IL-12 to patients with mild allergic asthma significantly decreased peripheral blood eosinophils and sputum eosinophils (543). However, in contrast to the mouse model, there was no clinical improvement in airway hyperresponsiveness to hista- mine, nor was there an effect on the late asthmatic reaction. As with anti-IL-5, which shows a similar clinical nonresponse, this calls into uestion the role of the eosinophil in this disease, as well as the concept of asthma being governed by a Th2 phenotype. The involvement of IL-13 in allergic disease is supported by genetic data linking IL-13 polymorphism to asthma. An association between iL-13 promoter polymorphism and increased riskof...

IL13 Modulators Clinical Data An

In a chronic model of Aspergillus fumiga-tus-induced allergic asthma, immunoneutral-ization of IL-13 has marked effects (555). The use of anti-IL-13 antibody results in a significant attenuation of airway hyperreactivity in this model. When IL-4 is neutralized, no statistically significant decrease was observed. In addition, neutralization of IL-13 inhibits collagen deposition, subepithelial fibrosis, and goblet cell hyperplasia. None of these effects was observed when neutralization of IL-4 was performed. Again, these results point to a broader spectrum of effects for IL-13 compared to that of IL-4, and for this reason IL-13 may be a more favorable target for asthma.

Pregnancy Category C

The drug was first isolated from coca plants in the mid-1800s. Cocaine apparently functions as an insecticide in the plants, but the substance has had no commercial agricultural use for that purpose. Early medical applications included administration to treat addiction to alcohol and opiates, but persons addicted to those drugs did not better on cocaine. Like many stimulants, cocaine has anorectic (weight-reducing) properties that decline as usage stretches over time but the drug's main medical use has been as a local anesthetic, particularly in ear, nose, and mouth surgery. Experimental use as an antide-pressant has been unsuccessful. Cocaine has been used to treat tonsillitis, earache, toothache, burns, skin rash, hay fever, asthma, hemorrhoids, nerve pain, nausea, and vomiting. It makes the body's immune system more active. For medical purposes cocaine has been largely superseded by drugs having less potential for abuse, but it is still called an excellent anesthetic for nose...

Pharmacokinetics And Glucodynamics

Formulation, a unique insulin delivery packaging, and a unique delivery device. Though they all may be characterized as inhaled insulin systems, these unique characteristics require us to individually scrutinize each product. The inhalers range from handheld breath actuated devices to meter dose inhalers similar to those used for asthma agents. Insulin delivery packaging ranges from dry-powder blister packs or capsules, to liquid blisters or liquid in asthma type canisters. Diverse particle technologies have also been investigated for the delivery of insulin. The Exubera and AERx systems were first technologies investigated in the 1990s.

Pituitaryadrenal axis

It has been said that Cushing-like effects are to be expected if the function of the adrenal cortex is suppressed by daily doses of more than 50 mg hydrocortisone or its equivalent. However, pituitary-adrenal suppression has been described at lower dosage equivalents, for example during prolonged intermittent therapy with dexamethasone (88). The secondary adrenal insufficiency caused by ther-apeutically effective doses can be observed even after giving prednisone 5 mg tds for only 1 week after withdrawal, adrenal suppression lasts for some days. If one continues this treatment for about 20 weeks, maximal atrophy of the adrenal cortex results, and lasts for some months. This effect begins with inhibition of the hypothalamus, and culminates in true atrophy of the adrenal cortex. It can occur even with glucocorticoids given by inhalation (89). Inhaled fluticasone is associated with at least a twofold greater suppression of adrenal function than inhaled budesonide microgram for microgram,...

Leukotriene receptor antagonists

In a probable pharmacodynamic interaction, severe peripheral edema followed treatment with montelukast and prednisone for asthma (424). A 23-year-old man, with a history of asthma, house dust mite allergy, and rhinoconjunctivitis, presented with acute respiratory symptoms. He was given oral cetirizine, inhaled salmeterol, and fluticasone propionate, and oral prednisone 40 mg day for 1 week and 20 mg day for 1 week. His asthma recurred when prednisone was withdrawn and he took oral prednisone 60 mg day for 1 week and 40 mg day for 1 week. He also took mon-telukast 10 mg day. He then developed severe peripheral edema with a gain in weight of 13 kg. Prednisone

Systemic availability of inhaled glucocorticoids

The extent of absorption of inhaled glucocorticoids tends to be less in asthmatic subjects than in healthy volunteers. In a study of fluticasone (500 micrograms via a dry powder device) in asthmatic patients with a wide range of severity, there was a highly significant linear correlation between lung function (expressed as percentage predicted FEVi) and the absolute magnitude of adrenal suppression (4). In 11 patients with moderately severe asthma (mean FEV1 54 predicted), who took fluticasone 1000 micro-grams day via a metered-dose inhaler with a spacer, the systemic availability of fluticasone was significantly less (10 ) than in 13 healthy controls (21 ). The plasma fluticasone concentrations (expressed as AUC) correlated positively with gas transfer (5). In contrast, there was no difference in plasma concentrations of fluticasone and budesonide between 15 mild asthmatics (mean FEV1 81 predicted) and healthy volunteers after inhalation of 1000 micrograms of either drug with single...

Local adverse effects

The local adverse effects of inhaled glucocorticoids have been studied in a prospective, cross-sectional, cohort study in 639 asthmatic children using beclomethasone (721 micrograms day) or budesonide (835 micrograms day) for at least one month (28). The local adverse effects included cough (40 ), thirst (22 ), hoarseness (14 ), dysphonia (11 ), oral candidiasis (11 ), perioral dermatitis (2.9 ), and tongue hypertrophy (0.1 ). A spacer doubled the incidence of coughing. A local myopathy caused by inhaled glucocorticoids can also cause dysphonia. However, patients with asthma have more dysphonia and vocal fold pathology than healthy controls and inhaled glucocorticoids can improve the voice in some patients (SEDA-21, 188).

Adrenal suppression by inhaled glucocorticoids in children

Inhaled glucocorticoids are being prescribed more and more in younger children at an earlier stage of their disease and for longer periods children with severe asthma are also treated with larger doses than licensed. Two girls aged 11 and 16 years, one boy aged 12 years, and one woman aged 54 years developed hypothala-mic-pituitary-adrenal axis suppression during treatment with inhaled fluticasone propionate 220880 micrograms bd for long-term control of asthma however, two of the patients also took oral prednisone or prednisolone (43). Because of poor growth, an 8-year-old girl's asthma medication was changed from budesonide to fluticasone propionate 250 micrograms day (44). However, 5 months later she had developed a round face. Her early morning cortisol concentration was less than 30 nmol l (reference range 140-720) and her growth had been no more than 0.5 cm during the past 5 months. Fluticasone propionate was discontinued. After 1 month, her Cushingoid features had resolved and...

CysLTl Antagonist Clinical Studies

Aerosolized SKF 104353, 100 and 800 jmg, shifted LTD4-induced bronchoconstriction by about 10-fold in normal and asthmatic individuals, respectively, when administered 2-3.5 h before challenge (242). The same dose protected against exercise-induced asthma (243). SKF 106203 was examined in normal volunteers and a 200 mg p.o. dose was effective in reducing LTD4-induced bronchoconstriction, with the maximal effect being observed 8 h after dosing (244). The Merck group has entered the greatest number of CysLTl antagonists into clinical studies. Extensive trials were performed with MK-0571 (L-660,711), its single enantiomer MK-0679, and with MK-0476. This compound montelukast (Singulair) has been approved for clinical use in the United States and internationally for the treatment of asthma in adults and children (245). Montelukast underwent extensive clinical testing. The studies used to support the clinical use of this agent have been reviewed in several venues (256-258). A daily oral...

Treatment Options for Insomnia

Avoid caffeine, alcohol, tobacco, and recreational drugs. Avoid nonprescription preparations that contain stimulating adrenaline-like decongestants like pseu-doephedrine (Sudafed), phenylephrine, or phenylpropranolamine. If you have asthma, work with your physician to find medications that will not impair your sleep.

Ongoing Assessment

Occasionally the patient may experience an acute bronchospasm either as a result of the disease, after exposure to an allergen, or as an adverse reaction to some antiasthma drugs, such as cromolyn inhalation. An inhaled sympathomimetic, such as albuterol, may be prescribed initially. Salmeterol, a long-acting p-ago-nist, is contraindicated because of its slowed onset of action. During an acute bronchospasm, the nurse checks the blood pressure, pulse, respiratory rate, and response to the drug every 15 to 35 minutes until the patient's condition stabilizes and respiratory distress is relieved.

Antihistamines H1 receptor antagonists

Histamine release from mast cells and basophils makes a major contribution to the allergic response, and antihistamines are widely used in the treatment of certain symptoms of allergic disease. However, histamine also functions as a neurotransmitter in the central nervous system, being particularly important in maintaining a state of arousal or awareness (1R). First-generation H1 receptor antagonists easily cross the blood-brain barrier, and their consequent well-documented sedative and an-ticholinergic effects, together with short half-lives, greatly limit their use in the treatment of allergic symptoms. However, despite these deficiencies it must be remembered that firstgeneration drugs are still widely used, mainly as over-the-counter products, often in combination with other drugs. Second-generation H1 receptor antagonists have major advantages over the earlier drugs most notably they lack significant CNS and anticholinergic adverse effects. They have proved to be important...

Systemic availability of inhaled corticosteroids SEDA23175 SEDA24 185

Plasma concentrations have been measured in 13 healthy subjects and eight patients with mild asthma using inhaled fluticasone propionate 1000 g twice daily via Diskus or pressurized metered-dose inhaler and ofbudes-onide 1000 g twice daily via Turbuhaler for 7 days. 24-hour plasma cortisol concentrations were determined to assess the systemic activity of fluticasone propionate and budesonide. At steady state, the systemic availability of budes-onide via Turbuhaler (39 ) was significantly higher than that of fluticasone propionate via Diskus (13 ) or inhaler (21 ). Fluticasone propionate had a larger distribution volume and slower rates of absorption and clearance. Despite a significantly higher pulmonary availability of budesonide via Turbuhaler, plasma cortisol suppression was less than that offlu-ticasone propionate via inhaler and similar to that offluticasone propionate via Diskus. There were no differences between healthy subjects and patients with mild asthma in subgroup...

This writer responsible scientists and doctors advise

There is no pharmacological free lunch in cannabis or any drug. Negative reactions can result. A small percentage of people have negative or allergic reactions to marijuana. Heart patients could have problems, even though cannabis generally relieves stress, dilates the arteries, and in general lowers the diastolic pressure. A small percentage of people get especially high heart rates and anxieties with cannabis. These persons should not use it. Some bronchial asthma sufferers benefit from cannabis however, for others it may serve as an additional irritant.

Systemic effects of ophthalmic medications

The systemic effects exerted by eye-drops are most pronounced in the case of agonists and antagonists in the autonomic nervous system. For example, beta-blockers in eye-drops can cause bronchospasm, heart failure, syncope, and psychiatric disorders (4-6), especially at high doses and with non-selective beta-blockers, although these adverse reactions are usually related to failure to observe prescribing precautions (1).

Cyamopsis tetragonoloba

Guar gum can cause occupational rhinitis and asthma. Of 162 employees at a carpet-manufacturing plant, in which guar gum is used to adhere the dye to the fiber, 37 (23 ) had a history suggestive of occupational asthma and 59 (36 ) of occupational rhinitis (24). Eight (5 ) had immediate skin reactivity to guar gum. Eleven (8.3 ) had serum IgE antibodies to guar gum.

Hypochlorite SED14 767

Respiratory Hypochlorite is widely used as a cleaning agent and to deal with blood spillages. Chlorine gas, which is released during the use of hypochlorite, can cause mucous membrane irritation, bronchospasm, pneumonia, and pulmonary edema. It is believed that the low concentrations of hypochlorite that are used as a cleaning substance do not cause respiratory damage.

Sedation in intensive care

It remains a source of much concern that those working in operating theaters spend their time in such a polluted environment, in spite of attempts to introduce scavenging of waste anesthetic gases (12). This is not without its effects. There is, for example, a relation between asthma and occupational exposure to various respiratory hazards, including anesthetic gases (13).

Contraindications adverse effects precautions

- Nebulised salbutamol should be reserved for severe asthma attacks when inhalation of oxygen is also required. Otherwise, salbutamol should be delivered via a metered-dose inhaler with a spacer administration is easier and faster, the treatment is as effective, or even more effective, than with a nebuliser and causes fewer adverse effects.

Pregnancy Category None

Effects are similar to those of belladonna. Drugs found in jimson weed leaves, flowers, and seeds include atropine, hyoscyamine, and scopolamine, which are often called belladonna alkaloids. Folk medicine preparations from jimson weed flowers are put on bruises, wounds, or insect bites to diminish discomfort leaves and roots are used in a similar way and also to treat boils. A drink from the plant is given to help people endure the pain of setting broken bones. Inhaling jimson weed smoke is a traditional remedy for asthma, sore breathing, or coughing. Vapor from boiling the substance is used for the same purposes. Scientific measurement has confirmed that jimson weed smoke improves airway function of asthmatics. The natural product is also a treatment against cramps, eye inflammation, and feverish infection. The plant has been used as an aphrodisiac.

Impact on Therapeutic Drug Monitoring

Interactions between herbal supplements and drugs and between food and drugs are of significant clinical importance. St. John's wort, a popular herbal supplement, induces cytochrome P 450 mixed function oxidase as well as modulated P-glycoprotein in intestine and reduces plasma concentrations of cyclosporine, tacrolimus, amitriptyline, digoxin, fexofenadine, indinavir, methadone, midazolam, nevirapine, phenoprocoumon, squinavir, simvastatin, theophylline and warfarin. These reductions may cause treatment failures. Interaction of warfarin with herbal supplements may increase or decrease the anticoagulant effect of warfarin. Important interactions of various drugs with ginseng, ginkgo biloba, kava and garlic have also been reported. Consumption of a single glass of grapefruit juice caused a twofold to threefold increase in the plasma concentration of felodipine, and pharmocokinetics of approximately 40 other drugs are also affected by intake of grapefruit juice. In contrast,...

DrugSt Johns Wort Interactions Lower Concentrations of Therapeutic Drugs

John's wort may cause treatment failures due to significant reductions in plasma drug concentrations because of increase in clearance of drugs. Unrecognized use of St. John's wort is frequent among patients and may have important influences on the effectiveness and safety of drug therapy during hospital stay (23). Published reports indicate that St. John's wort significantly reduces steady-state plasma concentrations of cyclosporine, tacrolimus, amitriptyline, digoxin, fexofe-nadine, indinavir, methadone, midazolam, nevirapine, phenoprocoumon, squinavir, simvastatin, theophylline and warfarin (24). This long list of drugs includes immunosuppressant drugs (cyclosporine and tacrolimus), HIV protease inhibitors and HIV non-nucleoside reverse transcriptase inhibitors metabolized via CYP3A4. Increased clearance of oral contraceptives has also been reported.

Benefit to harm balance

The benefit to harm balance in desensitization treatment was examined in a meta-analysis published in 1995, covering 20 randomized, placebo-controlled, doubleblind trials of allergen immunotherapy for asthma. Systemic reactions occurred in a mean of 32 (20-44 ) of patients, but anaphylaxis was reported on only four occasions. It was concluded that immunotherapy was a treatment option in highly selected patients with extrinsic allergic asthma where a clinically relevant and unavoidable allergen is identified (7). The Committee on Safety of Medicines reviewed the UK experience with desensitization in 1986, weighing efficacy against risk. They considered the evidence for efficacy and found it convincing for ragweed pollen, bee and wasp venom, and some antibiotics, but thought the evidence for grass pollen and house-dust mite less convincing. The Committee warned of the dangers of ana-phylaxis and bronchospasm and noted that 26 patients had died since 1957, 5 in the preceding 18 months....

Fooddrug Interactions

Food-drug interactions may be pharmacokinetic or pharmacodynamic in nature. Certain foods alter activity of drug metabolic enzymes, and especially CYP3A4 appears to be the key enzyme in food-drug interaction (94). It has also long been recognized that intake of food and fluid can alter the extent of drug absorption. This alteration may be related to alteration of physiological factors in the gut such as gastric pH, gastric emptying time, intestinal motility, hepatic portal blood flow or bile flow rate. Moreover, direct interaction of food with drug may also alter bioavailability such as adsorption of a drug in insoluble dietary component, complex formation of a drug with a metal ion or partitioning of a drug in dietary fat. Food may be able to alter performance of modified released oral formulation (95). It has been recognized that smoking, intake of charcoal-broiled food or cruciferous vegetables induce the metabolism of multiple drugs, whereas grapefruit juice increases...

See also Anticholinergic drugs General Information

Ipratropium hydrobromide is a quaternary amine, the semisynthetic isopropyl derivative of atropine, which has low lipid solubility and is poorly absorbed. It has anti-cholinergic properties and is used to treat asthma. Ipratropium has established a place in the therapy of asthma as an alternative to beta2-adrenoceptor agonist aerosols for patients who fail to respond adequately to these agents. Ipratropium may be more effective than beta2-adrenoceptor agonists for patients with non-atopic asthma and chronic bronchitis. It has been reported to augment the effects of beta2-adrenoceptor agonists when given by nebulized inhalation in acute asthma (2).

Beta Blocker Medications

Beta-adrenergic blockers competitively antagonize nore-pinephrine and epinephrine at the beta-adrenergic receptor (Table 4-2). It is thought that the majority of positive effects of beta-blockers are due to their peripheral (rather than central) actions. Beta-blockers can decrease many of the peripheral manifestations of anxiety such as tachycardia, diaphoresis, trembling, and blushing. The advent of more selective beta-blockers that only block the beta-2-adrenergic receptor has been beneficial since blockade of beta-1-adrenergic receptors can be associated with bronchospasm.

Comparative studies

Increased FEVi (at peak 7 of predicted) for over 12 hours. Salmeterol plus ipratropium produced a greater bronchodilator response (at peak 11 of predicted) than salmeterol alone during the first 6 hours after inhalation. There were significant improvements in daytime symptom scores and peak flows with both salmeterol and salmeterol plus ipratropium compared with placebo. Adverse events were similar in the treatment groups headache (six patients with salmeterol plus ipratropium, four with salmeterol, and 11 with placebo) and cough were the most common drug-related adverse events. Over the 12 weeks, 35 patients had an exacerbation of COPD, 36 with placebo, 23 with salmeterol, and 13 with salmeterol plus ipratropium.

Organs and Systems Nervous system

There is considerable controversy about the frequency and severity of sedation. Although it is commonly reported when ketotifen is started (23 in one study), its incidence falls during the first 2 months to about 6 . Only 2-3 of patients discontinue therapy for this reason (8). In a study involving 1791 patients, with allergic paroxysmal asthma, somnolence occurred in 13 . This effect started early in treatment and wore off in more than one-third of the patients (2). A 3-month-old boy was given ketotifen, 0.1 mg kg day, for asthmatic bronchitis. After 10 days his facial movements altered and 1 month after ketotifen was started tonic spasms began. His seizures consisted of a sudden contraction, usually bilateral and symmetrical involving the muscles of the neck, trunk, and limbs. An electroencephalogram showed a hypsarrhythmic trace. He was treated with ACTH and clonazepam without benefit. Ketotifen was withdrawn and ACTH and clonazepam were replaced with valproic acid. This resulted...

Pregnancy Category D

Effectiveness of birth control pills and with actions of medicines used to control epilepsy and blood clotting. Drugs used to treat asthma, blood pressure, and heart ailment may not work as well if a person also takes mephobarbital. Cancer. Not enough scientific information to report.

Family Polygalaceae R Brown in Flinders 1814 nom conserv the Milkwort Family

Pharmaceutical interest The roots of Polygala nyikensis in Malawi, Polygala tenuifolia in China and Japan, and Polygala senega L. in North America have been used to treat skin diseases, alleviate cough, counteract snake-poison and invigorate the body since many decades ago. The roots of Polygala senega L. were first used in 1734 to treat pneumonia in several Western countries. In the Asia-Pacific, about 10 species of plants classified within the family Poly-galaceae are medicinal. Note that these plants are often used to counteract putrefaction, treat cough, asthma, bronchitis, promote fertility and to treat cerebral dysfunctions.

Sympathomimetic Drugs

These drugs are used cautiously during pregnancy (epinephrine and apraclonidine, Pregnancy Category C dipivefrin, Pregnancy Category B) and lactation and in patients with hypertension, diabetes, hyper-thyroidism, heart disease, cerebral arteriosclerosis, or bronchial asthma. Some of these drugs contain sulfites that may cause allergic-like reactions (hives, wheezing, anaphylaxis) in patients with sulfite sensitivity. See Chapter 22 for information on interactions.

Beta Adrenergic Blocking Drugs

The p-adrenergic blocking drugs are contraindicated in patients with bronchial asthma, obstructive pulmonary disease, sinus bradycardia, heart block, cardiac failure, or cardiogenic shock and in patients with hypersensitivity to the drug or any components of the drug. These drugs are Pregnancy Category C and are used cautiously during pregnancy and lactation and in patients with cardiovascular disease, diabetes (may mask the symptoms of hypoglycemia), and hyperthyroidism (may mask symptoms of hyperthyroidism). The patient taking p-adrener-gic blocking drugs for ophthalmic reasons may experience increased or additive effects when the drugs are administered with the oral beta blockers. Co-administration of timolol maleate and calcium antagonists may cause hypotension, left ventricular failure, and condition disturbances within the heart. There is a potential additive hypotensive effect when the beta-blocking ophthalmic drugs are administered with the phenothiazines.

Preadministration Assessment

Because the bronchodilators or antiasthma drugs may be given for asthma, emphysema, or chronic bronchitis, the preadministration assessment of the patient requires careful observation and documentation. The nurse takes the blood pressure, pulse, and respiratory rate before therapy with a bronchodilator or antiasthma drug is initiated. Respiratory rates below 12 min or above 24 min are considered abnormal. It is important to assess the lung fields and carefully document the sounds heard before therapy is begun. The nurse notes any dyspnea, cough, wheezing (a musical sound of the respiratory tract caused by air passing through a narrowed bronchial tube), noisy respirations, or use of accessory muscles when breathing. If the patient is raising sputum, the nurse records a description of the sputum. The nurse notes and records the patient's general physical condition. It is important to record any signs of hypoxia (eg, mental confusion, restlessness, anxiety, and cyanosis bluish...

Promoting an Optimal Response to Therapy

Nursing care of the patient receiving a bronchodilating drug or an antiasthma drug requires careful monitoring of the patient and proper administration of the various drugs. These drugs may be given orally, parenterally, or topically by inhalation or nebulization (see Chap. 2). In general, the nurse gives the drugs around the clock to maintain therapeutic blood levels. If the drug is to be administered once a day, the nurse should give it in the morning. Dosages are individualized for each patient, which allows the smallest effective dose to be given. The nurse can give oral preparations with food or milk if gastric upset occurs. The nurse may administer epinephrine subcuta-neously for an acute bronchospasm. Therapeutic effects occur within 5 minutes after administration and last as long as 4 hours. Salmeterol is a long-acting inhaled bronchodilator and is not used to treat acute asthma symptoms. It does not replace the fast-acting inhalers for sudden symptoms. Salmeterol should not...

Critical Thinking Exercises

Smith, age 68 years, returned to the clinic for a follow-up visit after receiving a diagnosis of COPD. She is taking theophylline daily and using a metered-dose inhaler 4 times a day. Determine what assessments would be most important for you to make at this time. 3. Discuss what to include in a teaching plan for a patient taking montelukast for asthma.

Infant characteristics

Renal excretion is also immature early in life and a drug that depends on renal excretion, such as caffeine, theophylline, and some antibiotics, will accumulate in the infant in the first weeks and months of life but will gradually be better tolerated as the infant excretes it more effectively. These same drugs when given to an infant directly are given less frequently (daily instead of twice daily) in the first week of life.

Poisoning cases and toxic and fatal concentrations

Case 2 14 an 18-year-old female ingested 20-30 of extended-release tablets of theophylline (Theodur ) at about 1 30 a.m. From about 3 00 a.m., vomiting was started at 5 45 a.m., she visited an emergency room of a hospital and was admitted. Until 3 00 p.m., she suffered from vomiting in the vomitus, the debris of the tablets were included. At about 4 00 p.m., she complained of a bad headache her heart beat rate was 120 min, and blood theophylline concentration was 66.6 p,g mL. At 4 30 p.m., gastrolavage was performed by inserting a gastric tube. Then, 60 g of activated charcoal, 250 mL of magnesium citrate solution and 500 mL saline solution were orally administered slowly. At the same time, an intravenous drip infusion of 2 ampoules of Primperan (metoclopramide) and 25 mg of Wintermin (chlorpromazine) were made to prevent her from vomiting. Thereafter, she showed a trend of recovery the blood theophylline concentration in the next morning was as low as 6.1 p,g mL. Blood therapeutic...

See also Monoclonal antibodies General Information

Omalizumab (formerly rhuMab-E25) is a humanized monoclonal antibody against IgE, which blocks the interaction of IgE with mast cells. Several phase I and phase II trials have demonstrated its efficacy in patients with allergic asthma (1-4). In another placebo-controlled trial in 525 patients with severe asthma, the adverse effects profiles were similar in the treatment and placebo groups (8).

Organs and Systems Skin

Years with moderate to severe allergic asthma requiring inhaled glucocorticoids in a randomized, placebo-controlled, double-blind trial (11). There were no serious treatment-related adverse events, and the frequencies of most adverse events were similar with omalizumab and placebo. However, urticaria was more frequent with omalizumab (4 versus 0.9 ). It usually resolved spontaneously or with antihistamine therapy and did not recur with subsequent treatment. Urticaria was also reported in a small number of adults (0.5 ) given omalizumab for allergic rhinitis (12).

Pregnancy Category X

Nandrolone is used to treat breast cancer and anemia, and the drug has improved asthma and Sjogren's syndrome, a disease that destroys salivary, sweat, and tear glands. Healing action on cornea afflictions has been observed, and rat experiments have explored nandrolone's potential for speeding recovery from tooth extractions. A skin cream containing nandrolone is used against eczema. Human research indicates that the drug can improve osteoporosis, a disease causing brittle bones, although results conflict on how long the improvement lasts. Among some diabetics with a kidney condition called Kimmelstiel-Wilson syndrome, nandrolone has helped both renal and eyesight difficulties. In kidney dialysis, patients' experimental use of nandrolone was able to improve weariness, increase muscle mass, and fight malnutrition. The compound has helped AIDS (acquired immunodeficiency syndrome) patients build up weight, muscles, and strength. The substance has also been given in hopes of...

Other features of the patient

In patients with reduced respiratory reserve, such as those with emphysema, severe obesity, cor pulmonale, and kyphoscoliosis, opioids must be used with caution. The relative benefits and harms of using opioids in patients taking monoamine oxidase inhibitors, those with a history of drug abuse, asthma, hepatic impairment, hypotension, raised intracranial pressure, or head injury, and during pregnancy or breast feeding, should be carefully considered. Dextropropoxyphene, pethidine, and methadone should be used with caution (SEDA-21, 85).

Organs and Systems Immunologic

Total serum IgE has been measured in 36 patients with allergic rhinitis and 11 healthy subjects given a submaximal dose of oxitropium bromide 600 micrograms by inhalation (2). FEV1 was greater than 80 of predicted in all subjects. Baseline FEV1 correlated negatively with serum IgE concentration. Oxitropium bromide inhalation produced an increase in FEV1 (mean 155 ml) that was significantly greater in allergic patients with high serum IgE than in healthy subjects (64 ml) or in those with allergic rhinitis and low serum IgE (82 ml). The effect of an inhaled beta2-adrenoceptor agonist (orciprenaline) was similar in all three groups. These findings may explain some of the variation in response to inhaled antimuscarinic drugs in patients with asthma. The data also suggested that IgE may itself modify airway tone by an increase in cholinergic responsiveness.

Susceptibility Factors

Patients with underlying bronchial asthma and pheochro-mocytoma are thought to be particularly at risk of acute histamine release due to polygeline. A 45-year-old woman, who had used salbutamol and budesonide inhalers and oral theophylline for asthma and who had developed bronchospasm during induction of general anesthesia 6 weeks before, was readmitted for surgery under spinal anesthesia (8). During the procedure she developed two episodes of hypotension, which was corrected with fluids and intravenous mephentermine 6 mg. When blood loss reached 750 ml she was given an infusion of polygeline 3.5 , and 10 minutes later complained of respiratory difficulty and developed severe respiratory distress. Polygeline was withdrawn and she was given 100 oxygen with halothane by face mask. The oxygen saturation fell by more than 80 and she developed severe bradycardia and ventricular fibrillation. She was resuscitated.

Thiazides and Related Diuretics

The thiazide diuretics are contraindicated in patients with known hypersensitivity to the thiazides or related diuretics, electrolyte imbalances, renal decompensation, hepatic coma, or anuria. A cross-sensitivity reaction may occur with the thiazides and sulfonamides. Some of the thiazide diuretics contain tartrazine, which may cause allergic-type reactions or bronchial asthma in individuals sensitive to tartrazine.

See also Neuromuscular blocking drugs General Information

Rapacuronium, an aminosteroid non-depolarizing neu-romuscular blocking agent with a rapid onset and a comparatively short duration of action (1,2), was withdrawn from the US market in March 2001 and subsequently worldwide. The manufacturers informed the FDA in an open letter about postmarketing reports of severe bronchospasm and some deaths of unknown origin associated with rapacuronium. The severity of the incidents recently reported to the manufacturers was impressive enough to cause fears about patient safety. This event highlights the need for continued surveillance, not only during clinical trials but also during the routine use of approved drugs.

Drug Administration Drug formulations

Adverse effects are generally more likely when salbutamol is given by injection. At therapeutic doses, the pressurized aerosol and dry powder inhalers produce equivalent bronchodilatation without significant adverse effects (SEDA-22, 191). Patients with severe asthma tolerate large doses of nebulized salbutamol. In severe asthma there is a reduction in early lung absorption of salbutamol after inhalation, which does not occur in mild asthma. This results in lower plasma concentrations of salbutamol and less tremor (SEDA-22, 191). This is consistent with the findings in 323 patients who attended emergency departments because of severe asthma. Initial treatment with nebulized salbutamol 7.5-10 mg or up to 3.5 mg by pressurized aerosol in 1 hour caused no serious adverse effects. Tremor was noted in about 15 of the patients. About one-third of these patients failed to achieve an adequate therapeutic response to salbutamol. The most serious adverse effect of highdose salbutamol would be...

Tacrine tetrahydroaminoacridine and hexafluorenium

Tacrine (tetrahydroaminoacridine) and hexafluorenium, used sometimes to potentiate and prolong the action of suxamethonium (333,334), inhibit plasma cholinesterase. Hexafluorenium also inhibits acetylcholinesterase and has a weak neuromuscular blocking action of the non-depolarizing type a phase II block develops fairly rapidly when repeated injections of even small doses (0.2-0.3 mg kg) of suxamethonium are given in combination with hexafluorenium (335). Fasciculation is reportedly reduced and hyperkalemia prevented (336), as is the increase in intraocular pressure (337), when hexafluorenium is given before suxamethonium. Because of a lack of consistency of successful results from various investigators, this method is not recommended for patients who are especially at risk from hyperkalemia or increased intraocular pressure. Simultaneous injection of hexafluorenium and suxa-methonium can cause severe bronchospasm.

Pharmaceutical interest

Uses In China, the juice expressed from the leaves of Eclipta prostrata (L.) L. is used to keep the hair black and to stimulate its growth. The pounded plant is used to check bleeding, to heal wounds and burn, and to soothe contusion. A decoction of the plant is used to check bleeding and to invigorate health. In India, Eclipta prostrata (L.) L. is used to invigorate health and to assuage hepatic and spleen discomfort. In Malaysia, the plant is used to promote recovery from childbirth. In the Philippines, the plant is used to assuage liver discomfort. In Vietnam, Eclipta prostrata (L.) L. is used to treat mycosis, assuage lung discomfort, treat asthma, bronchitis and to invigorate breathing.

Second Generation Effects Pregnancy

In pregnant women with a history of migraine or vascular headache the use of terbutaline (and its congeners) should be avoided because of the risk of cerebral ischemia (SEDA-8, 145). One pregnant woman with asthma suffered a hypotensive episode after treatment with subcutaneous terbutaline (SEDA-12, 123).

Drug Drug Interactions General

Both positive and negative drug interactions have been reported with theophylline. The usefulness of combination products has also been discussed (SEDA-6, 2) (SEDA-11, 7). The use of combinations complicates the evaluation of adverse effects, particularly those of theo-phylline and ephedrine. The likelihood of adverse effects of each component and synergistic effects between components must be evaluated in relation to the patient's clinical condition. A positive feature is the likelihood of greater compliance with an effective combination product. In one study, antacids increase the rate of theophylline absorption without a change in total systemic availability The concomitant use of drugs that reduce theophylline clearance can produce toxic serum concentrations with therapeutic doses of theophylline. Most of these drugs are believed to have this effect by inhibiting the hepatic microsomal P450-metabolizing enzymes that are responsible for the biotransformation of theophylline. Such...

Food Drug Interactions

Food can affect both the absorption and the clearance of theophylline. One study showed that the absorption of a modified-release formulation of theophylline was very slow after an overnight fast, in contrast to absorption after a test meal (86). The effect may be dose-related. More specifically, dietary protein significantly affects theophylline clearance a low-protein diet reduces theo-phylline clearance and a high-protein diet increases it. The implications for clinical practice have not been elaborated, but dietary extremes are contraindicated in patients taking theophylline (51).

Family Commelinaceae R Brown 1810 nom conserv the Spiderwort Family

Pharmaceutical interest An example of medicinal Commelinaceae is Mur-dannia edulis (musli siyah), used by Asian residing in Britain to invigorate health, regulate urination and to treat asthma and colic. A number of plants classified within the family Commelinaceae have been investigated for their therapeutic potential. Rhoeo spathacea (oyster plan) contains dopamine and could be of potential value in combating Parkinsonism. There is an expanding body of evidence to suggest that a-glucosidase inhibitors isolated from Commelinaceae prove positive in the treatment of diabetes. Approximately 20 species of Commelinaceae are medicinal in the Asia-pacific. Note that many of these plants are used to heal and soothe injured skin.

See also Individual agents General Information

In some highly developed countries that have had great success in reducing dangerous infectious diseases through immunization, there are controversial discussions regarding the benefits to harm balance of immunization. Because the incidence of vaccine-preventable diseases is reduced by increasing coverage with an efficacious vaccine, adverse events, both those caused by vaccines themselves (that is true adverse reactions) and those associated with immunization only by coincidence or as a result of faulty routines, become increasingly frequent. Not surprisingly, vaccine safety concerns have become increasingly prominent in successful immunization programs. Chronic illnesses recently claimed to be linked with immunizations include asthma, autism, diabetes, and multiple sclerosis. Given the current increasingly antivaccine'' environment that has developed in some countries, it is hard to imagine that the full potential of new vaccines will be harnessed. To avoid damage to current

General risks of multiple immunizations

The Safety Review Committee of the IOM has reviewed the evidence regarding multiple immunizations and immune dysfunction (60). The review did not support the hypothesis that an infant's immune system is inherently incapable of handling the number of antigens to which children in the USA are exposed during routine immunizations. The committee rejected a causal relation between multiple immunizations and increased risks of infections or type 1 diabetes mellitus. The evidence was inadequate to accept or reject a causal relation between multiple immunizations and allergic disease, particularly asthma.

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