PTCE · Medications · 7 min read
Respiratory and Gastrointestinal Drugs
- Differentiate between rescue and controller respiratory therapies, including proper device handling and boxed warnings.
- Categorize gastrointestinal medications by class, mechanism of action, and critical clinical precautions.
- Distinguish the role of the pharmacy technician in order processing from the pharmacist's legal responsibilities regarding clinical evaluation and patient counseling.
Respiratory Medications: Bronchodilators and Anti-Inflammatory Agents
Lower respiratory medications include quick-relief and maintenance therapies; not all maintenance drugs reduce inflammation, and certain inhaled corticosteroid, formoterol regimens can also be used for quick relief in asthma. Short-acting beta-2 agonists (SABAs), including albuterol and its R-enantiomer levalbuterol, serve as quick-acting rescue bronchodilators to promptly relieve acute bronchospasm. For immediate symptom management in chronic obstructive pulmonary disease (COPD) or alongside other therapies during acute asthma exacerbations, the short-acting anticholinergic bronchodilator ipratropium bromide is also utilized. Combining albuterol and ipratropium into single products, such as Combivent Respimat and DuoNeb, produces additive bronchodilation by targeting distinct receptor pathways simultaneously.
Most maintenance therapies are not used for immediate relief, but an inhaled corticosteroid, formoterol inhaler may also be prescribed as a reliever in an appropriate asthma regimen. Inhaled corticosteroids (ICS), such as fluticasone and budesonide, act as controller medications to reduce chronic airway inflammation. Because residual corticosteroid in the mouth can foster local fungal growth, patients must rinse their mouths with water and spit it out after every dose to minimize the risk of oral candidiasis. Long-acting beta-2 agonists (LABAs), such as salmeterol and formoterol, provide extended bronchodilation in both asthma and COPD. Crucially, when treating asthma, a LABA must never be used alone without an accompanying ICS; however, this restriction against single-agent LABA therapy does not apply to COPD. Popular fixed-dose combination inhalers include Advair (fluticasone combined with salmeterol) and Symbicort (budesonide combined with formoterol). For maintenance of COPD, tiotropium functions as a long-acting anticholinergic bronchodilator.
Oral therapies also play a key role in chronic respiratory maintenance. Montelukast is an oral leukotriene receptor antagonist indicated for asthma prophylaxis as well as allergic rhinitis. Pharmacy technicians must be aware that montelukast packaging features a prominent boxed warning alerting healthcare providers and patients to potential neuropsychiatric events, including changes in mood and behavior.
| Medication Name | Drug Class | Role in Therapy | Key Clinical Considerations |
|---|---|---|---|
| Albuterol | Short-acting beta-2 agonist (SABA) | Rescue | Relieves acute bronchospasm. |
| Levalbuterol | Short-acting beta-2 agonist (SABA) | Rescue | R-enantiomer of albuterol; alternative rescue bronchodilator. |
| Fluticasone | Inhaled corticosteroid (ICS) | Controller maintenance | Rinse and spit with water after use to prevent candidiasis. |
| Salmeterol | Long-acting beta-2 agonist (LABA) | Maintenance | Must not be used without an ICS in asthma; restriction does not apply to COPD. |
| Advair | ICS + LABA combination | Maintenance | Contains fluticasone and salmeterol. |
| Symbicort | ICS + LABA combination | Maintenance | Contains budesonide and formoterol. |
| Ipratropium bromide | Short-acting anticholinergic | Rescue / Symptom relief | Used in COPD and with other agents in acute asthma flares. |
| Tiotropium | Long-acting anticholinergic | Daily maintenance | Primary long-acting maintenance agent for COPD. |
| Montelukast | Leukotriene receptor antagonist | Prophylaxis | Oral tablet; boxed warning for neuropsychiatric events. |
Common mistakes
- Assuming dry powder inhalers (DPIs) should be shaken like metered-dose inhalers (MDIs); while many MDIs require shaking, most DPIs should never be shaken.
- Believing long-acting beta-2 agonists (LABAs) can be used as monotherapy in asthma; in asthma, LABAs must always be combined with an inhaled corticosteroid (though this restriction does not apply to COPD).
- Explaining inhaler cleaning or breath coordination to a patient; demonstrating administration technique constitutes patient counseling and must be referred to the pharmacist.
- Recommending bismuth subsalicylate for pediatric viral symptoms, which is dangerous due to the risk of Reye's syndrome.
Key points
- Short-acting beta-2 agonists (albuterol, levalbuterol) act as quick-relief rescue inhalers, while inhaled corticosteroids (fluticasone, budesonide) provide daily controller maintenance.
- Patients using inhaled corticosteroids must rinse and spit with water after every dose to prevent oral candidiasis.
- Montelukast has a boxed warning for neuropsychiatric events; promethazine is contraindicated in children under two years and can cause severe tissue injury, including with IV administration, while deep intramuscular injection is the preferred injectable route; metoclopramide has a boxed warning for tardive dyskinesia.
- Federal law mandates that pseudoephedrine be stored behind the counter with sales logged and customer IDs verified.
- Proton pump inhibitors irreversibly inhibit the gastric proton pump and markedly reduce acid secretion, while H2 receptor antagonists such as cimetidine block gastric H2 receptors; cimetidine also inhibits several hepatic CYP450 enzymes.
- Pharmacy technicians assist with order entry, counting, compounding, and labeling under pharmacist supervision, while patient counseling, side effect explanations, and interaction evaluations remain strictly the pharmacist's clinical responsibility.
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