RESPIRATORY DRUGS

Albuterol HTN), hyperthyroidism, or diabetes mellitus and in

Therapeutic class: Bronchodilators those who are unusually responsive to adrenergics.
 Use extended-release tablets cautiously in patients with
Pharmacologic class: Adrenergics GI narrowing.
 Dialyzable drug: Unknown.
Indications & Dosages  Overdose Signs & Symptoms: Exaggeration of adverse
 To prevent or treat bronchospasm in patients with reactions, seizures, angina, hypotension,
reversible obstructive airway disease HTN, tachycardia, arrhythmias, nervousness, headache,
 To prevent exercise-induced bronchospasm tremor, dry
mouth, palpitations, nausea, dizziness, fatigue, malaise,
 Adjuvant therapy for acute treatment of moderate to sleeplessness, hypokalemia, cardiac arrest.
severe hyperkalemia Nursing Considerations
Administration:  Drug may decrease sensitivity of spirometry used for
PO diagnosis of asthma.
 When switching patient from regular to extended-  Syrup contains no alcohol or sugar and may be taken
release tablets, remember that a regular 2-mg tablet by children as young as age 2.
every 6 hours is equivalent to an extended-release 4-  In children, syrup may rarely cause erythema
mg tablet every 12 hours. multiforme or SJS.
 Give extended-release tablets whole; don’t break or  Monitor patient for effectiveness. Using drug alone
crush tablets or mix them with food. may not be adequate to control asthma in some patients.
Inhalational Long-term control medications may be needed.
 If more than 1 inhalation is ordered, wait at least 2  In patients with COVID-19 who require a
minutes between inhalations. bronchodilator for asthma or COPD symptoms, use of
 Inhalation powder inhaler device doesn’t require pressurized metered-dose inhalers as opposed to
priming. Use spacer device to improve drug delivery, if nebulized delivery is preferred. Nebulized delivery
appropriate. Don’t use ProAir RespiClick with a spacer may increase transmission of particles (SARS-CoV2)
or volume holding chamber. into the environment and potentially decrease the life
 Discard ProAir RespiClick 13 months after opening of expiratory circuit filter.
foil pouch, when dose counter displays “0,” or after  Alert: Drug may cause paradoxical bronchospasm.
expiration date on product, whichever comes first. Monitor patient closely; discontinue drug immediately
 Shake the aerosol inhaler well before use and prime and use alternative therapy if paradoxical
inhaler according to manufacturer’s instructions before bronchospasm occurs. Bronchospasm with inhaled
first use, when it has been dropped, or when it hasn’t formulations frequently occurs with first use of new
been used for more than 2 weeks. canister or vial.
 Keep cap on inhaler closed during storage.  Alert: Patient may use tablets and aerosol together.
Monitor these patients closely for signs and symptoms
Interactions of toxicity.
 Look alike-sound alike: Don’t confuse albuterol
Drug-drug
with atenolol or Albutein.
Antiarrhythmics (amiodarone, bretylium, Patient Teaching
disopyramide, dofetilide, procainamide, quinidine,  Warn patient about risk of paradoxical bronchospasm
sotalol), arsenictrioxide, chlorpromazine, dolasetron, droper and advise patient to stop drug immediately if it occurs.
idol, mefloquine, mesoridazine, moxifloxacin, pentamidine,  Teach patient to perform oral inhalation correctly.
pimozide, tacrolimus, thioridazine, ziprasidone: May  If prescriber orders more than 1 inhalation, tell patient
to wait at least 2 minutes before repeating procedure.
prolong QT interval and increase risk of life-threatening
 Tell patient that use of a spacer device with appropriate
arrhythmias, including torsades de pointes. Monitor QT
inhaler may improve drug delivery to lungs.
interval and patient.
 If patient is also using a corticosteroid inhaler, instruct
CNS stimulants: May increase CNS stimulation. Avoid patient to use the bronchodilator first and then to wait
using together. about 5 minutes before using the corticosteroid.
 Tell patient to remove canister and wash aerosol
Digoxin: May decrease digoxin level. inhaler with warm, soapy water at least once a week.
Monitor digoxin level closely.  Warn patient not to wash or place any part of powder
inhaler in water. If mouthpiece needs cleaning, advise
Diuretics (furosemide, thiazides): May cause ECG changes patient to gently wipe it with dry cloth or tissue.
and hypokalemia. Monitor potassium level. Use caution  Advise patient not to use more than prescribed and not
when administered with non-potassium-sparing diuretics. to increase dose or frequency without consulting
physician. Fatalities have been reported from excessive
Linezolid, MAO inhibitors, TCAs: May increase adverse use.
CV effects. Consider alternative therapy.  Instruct patient to report worsening symptoms.
 Advise patient not to chew or crush extended-release
Effects on Lab Test Results tablets or mix them with food.
 May decrease potassium level.

Contraindications & Cautions

 Contraindicated in patients hypersensitive to drug or its
ingredients.
 Use cautiously in patients with CV disorders
(including coronary insufficiency and
RESPIRATORY DRUGS

Codeine Sulfate Contraindications & Cautions

Therapeutic class: Opioid analgesics Boxed Warning: Contraindicated in children younger than
Pharmacologic class: Opioids age 12, and for postoperative management in children
Controlled substance schedule: II younger than age 18 after tonsillectomy or adenoidectomy.
 Contraindicated in patients hypersensitive to drug and
Indications & Dosages in patients with significant respiratory depression,
acute or severe bronchial asthma in an unmonitored
 Mild to moderately severe pain setting or in the absence of resuscitative equipment,
Administration and in those with known or suspected GI obstruction,
PO including paralytic ileus.
 Give drug with milk or meals to avoid GI upset.  Boxed Warning: Opioids should only be prescribed
 Initiate dosing regimen for each patient individually, with benzodiazepines or other CNS depressants to
taking into account patient’s severity of pain, patient patients for whom alternative treatment options are
response, prior analgesic treatment experience, and risk inadequate.
factors for addiction, abuse, and misuse.  Boxed Warning: Drug exposes users to the risks of
Action opioid addiction, abuse, and misuse, which can lead to
May bind with opioid receptors in the CNS, altering overdose and death. To ensure that the benefits of
perception of and emotional response to pain. Also opioid analgesics outweigh the risks of addiction,
suppresses the cough reflex by direct action on the cough abuse, and misuse, the FDA has required a REMS
center in the medulla. program for these products. Assess each patient’s risk
(previous substance use disorder, younger age,
Interactions major depression, psychotropic drug use) before
Drug-drug prescribing drug.
 Boxed Warning: Benzodiazepines, CNS  Alert: Safety and effectiveness and pharmacokinetics
depressants: May cause slow or difficult breathing, of codeine in children younger than age 18 haven’t
sedation, and death. Avoid use together. If use been established.
together is necessary, limit dosage and duration of  Boxed Warning: Children who receive codeine for
each drug to the minimum necessary for desired pain relief after a tonsillectomy or adenoidectomy and
effect. are ultrarapid metabolizers due to a CYP2D6
 Cimetidine: May lead to increased effect or toxicity. polymorphism have an increased risk of death.
Monitor patient response Codeine is contraindicated for pain management after
 CNS depressants, general anesthetics, hypnotics, other these surgeries.
opioid analgesics, sedatives, TCAs, tranquilizers: May  Alert: Drug may lead to a rare but serious decrease in
cause additive effects. Use together cautiously; adrenal gland cortisol production.
monitor patient response.  Alert: Drug may decrease sex hormone levels with
 Boxed Warning: CYP3A4 inducers and long-term use.
inhibitors, CYP2D6 inhibitors: Effects of concomitant  Alert: Patients are at increased risk of oversedation
use or discontinuation of these drugs with codeine are and respiratory depression if they have snoring or
complex. Their use with codeine sulfate requires history of sleep apnea, no recent opioid use or are
careful consideration of the effects on the parent drug, first-time opioid users, have increased opioid dose
codeine, and the active metabolite, morphine. requirements or opioid habituation, received general
 MAO inhibitors: May cause serotonin syndrome or anesthesia for longer lengths of time, received other
opioid toxicity (respiratory depression, coma). Use sedating drugs, have preexisting pulmonary or cardiac
together or within 14 days is contraindicated. If urgent disease, or have thoracic or other surgical incisions
use of an opioid is necessary, use test doses and that may impair breathing. Monitor patients carefully.
frequent titration of small doses of other opioids (such  Boxed Warning: Accidental ingestion of even one
as oxycodone, hydrocodone, oxymorphone, dose of codeine sulfate tablets, especially by children,
or buprenorphine) to treat pain while closely can result in a fatal overdose.
monitoring BP and signs and symptoms of CNS and  Use cautiously in older adults, patients who are
respiratory depression. debilitated, and in those with head injury, increased
 Opioid antagonists: May reduce analgesic effect or ICP, increased CSF pressure, hepatic or renal
precipitate withdrawal symptoms. Consider therapy disease, hypothyroidism, Addison disease,
modification. acute alcoholism, seizures, severe CNS depression,
 Alert: Serotonergic drugs (amoxapine, antiemetics bronchial asthma, COPD, respiratory depression, and
[dolasetron, granisetron, ondansetron, palonosetron], shock.
antimigraine drugs, buspirone, cyclobenzaprine,  Dialyzable drug: Unknown.
dextromethorphan, lithium, maprotiline, methylene  Overdose Signs & Symptoms: CNS depression,
blue, mirtazapine, nefazodone, SSNRIs, SSRIs, TCAs, respiratory depression, apnea, flaccid skeletal
trazodone, tryptophan, vilazodone): May increase risk muscles, bradycardia, hypotension, circulatory
of serotonin syndrome. Use together cautiously and collapse, death.
monitor patient for serotonin syndrome.
 Drug-lifestyle Nursing Considerations
 Boxed Warning: Alcohol use: May cause slow or
 Boxed Warning: Serious, life-threatening, or fatal
difficult breathing, sedation, and death. Avoid use
respiratory depression may occur with use of codeine
together.
sulfate tablets. Monitor patients for
respiratory depression, especially during initiation or
Effects on Lab Test Results
after a dosage increase. Boxed Warning: Monitor all
 May increase amylase and lipase levels.
patients regularly for development of opioid addiction,
 May cause urine drug screen to be positive for
abuse, and misuse, which can lead to overdose and
morphine.
death.
RESPIRATORY DRUGS

 Alert: If patient is taking opioids with serotonergic Don’t abruptly discontinue drug in patient who is
drugs, watch for signs and symptoms of serotonin physically dependent.
syndrome (agitation, hallucinations, rapid HR, fever,  Look alike-sound alike: Don’t confuse codeine with
excessive sweating, shivering or shaking, muscle Cardene or Cordran.
twitching or stiffness, trouble with
coordination, nausea, vomiting, diarrhea), especially Patient Teaching
at start of treatment or after dosage increases. Signs
 Boxed Warning: Caution patient or caregiver of
and symptoms may occur within several hours of
patient taking an opioid with a benzodiazepine, CNS
coadministration but may occur later, especially after
depressant, or alcohol to seek immediate medical
dosage increase. Discontinue opioid, serotonergic
attention for dizziness, light-headedness, extreme
drug, or both if serotonin syndrome is suspected.
sleepiness, slowed or difficult breathing, or
 Alert: Monitor patient for signs and symptoms
unresponsiveness.
of adrenal insufficiency (nausea, vomiting, loss of
 Alert: Warn patient and caregiver of patient taking
appetite, fatigue, weakness, dizziness, low BP).
codeine to watch for slow or shallow breathing,
Perform diagnostic testing if adrenal insufficiency is
difficult or noisy breathing, confusion, excessive
suspected. If adrenal insufficiency is confirmed, treat
sleepiness, or trouble breastfeeding or limpness (in
with corticosteroids and wean patient off opioids if
infant). If any of these signs occur, tell patient or
appropriate. Discontinue corticosteroids when
caregiver to stop drug and immediately seek
clinically appropriate.
emergency medical attention.
 Alert: Monitor patient for signs and symptoms of
 Alert: Encourage patient to report all medications
decreased sex hormone levels (low libido, erectile
being taken, including prescriptions and OTC
dysfunction, amenorrhea, infertility). If signs and
medications and supplements.
symptoms occur, evaluate patient and obtain lab
 Alert: Caution patient to immediately report signs and
testing.
symptoms of serotonin syndrome, adrenal
 Alert: Don’t stop drug abruptly; withdraw slowly and
insufficiency, and or decreased sex hormone levels.
individualize the gradual taper plan to prevent signs
 Alert: Counsel patient not to discontinue opioids
and symptoms of withdrawal, worsening pain, and
without first discussing the need for a gradual tapering
psychological distress in patients who are physically
regimen with prescriber.
dependent. Refer to manufacturer’s label for specific
 Teach patients that naloxone is prescribed in
tapering instructions.
conjunction with the opioid when beginning and
 Alert: When tapering opioids, monitor patient closely
renewing treatment as a preventive measure to reduce
for signs and symptoms of opioid withdrawal
opioid overdose and death.
(restlessness, lacrimation, rhinorrhea, yawning,
 Advise patient that GI distress caused by taking drug
perspiration, chills, myalgia, mydriasis,
orally can be eased by taking drug with milk or meals.
irritability, anxiety, insomnia, backache, joint pain,
 Instruct patient to ask for or to take drug before pain is
weakness, abdominal
intense.
cramps, anorexia, nausea, vomiting, diarrhea,
 Caution patient who is ambulatory about getting out
increased BP or HR, increased respiratory rate). Such
of bed or walking. Warn outpatient to avoid driving
symptoms may indicate a need to taper more slowly.
and other hazardous activities that require mental
Also monitor patient for suicidal thoughts, use of
alertness until drug’s effects on the CNS are known.
other substances, and mood changes.
 Advise patient to avoid alcohol during therapy.
 Reassess patient’s level of pain at least 15 and 30
 Boxed Warning: Warn patient that accidental
minutes after use.
ingestion of even one dose of codeine sulfate,
 For full analgesic effect, give drug before patient has
especially by children, can result in a fatal overdose of
intense pain.
codeine.
 Drug is an antitussive and shouldn’t be used when
 Warn patient who is breastfeeding to watch for
cough is a valuable diagnostic sign or is beneficial (as
increased sleepiness, difficulty breastfeeding or
after thoracic surgery). Monitor cough type and
breathing, or limpness (in infant). Tell her to
frequency.
immediately seek medical attention if this occurs.
 Monitor respiratory and circulatory status.
 Opioids may cause constipation. Assess bowel
function and need for stool softeners and stimulant
laxatives.
 Codeine may delay gastric emptying, increase biliary
tract pressure from contraction of the sphincter of
Oddi, and interfere with hepatobiliary imaging studies.
 When patient who has been taking codeine sulfate
regularly and who may be physically dependent no
longer requires codeine sulfate, taper dosage gradually.
Initiate taper by a small enough increment (e.g., no
greater than 10% to 25% of the total daily dose) to
avoid withdrawal symptoms, and proceed with dose-
lowering at an interval of every 2 to 4 weeks. Patients
who have been taking opioids for briefer periods of
time may tolerate a more rapid taper. Monitor patient
carefully for signs and symptoms of withdrawal. If
patient develops withdrawal signs or symptoms, raise
dosage to previous level and taper more slowly, either
by increasing the interval between decreases,
decreasing the amount of change in dosage, or both.
RESPIRATORY DRUGS

Montelukast Sodium  Boxed Warning: Serious neuropsychiatric events

have been reported in patients taking montelukast.
Therapeutic class: Antiasthmatics The benefits may not outweigh the risk of
neuropsychiatric symptoms in patients with allergic
Pharmacologic class: Leukotriene-receptor rhinitis; reserve use for patients who have an
antagonists inadequate response or intolerance to alternative
therapies. Discuss risks with patients and caregivers.
Indications & Dosages  Boxed Warning: The neuropsychiatric events
reported in patients taking montelukast include, but
 Asthma aren’t limited to, agitation, aggressive behavior or
 Seasonal allergic rhinitis, perennial allergic hostility, anxiousness, depression, disorientation,
rhinitis disturbance in attention, dream abnormalities,
 Prevention of exercise-induced hallucinations, insomnia, irritability, memory
bronchoconstriction impairment, restlessness, somnambulism, suicidal
thinking and behavior (including suicide), and
Administration tremor.
 Use cautiously in patients with hepatic
PO disease, jaundice, or hepatitis.
 Give oral granules directly in the mouth,  Dialyzable drug: Unknown.
dissolved in 5 mL of cold or room-temperature  Overdose Signs & Symptoms: Headache, vomiting,
baby formula or human milk, or mixed with a psychomotor hyperactivity, thirst, somnolence,
spoonful of cold or room-temperature soft foods hyperkinesia, abdominal pain.
(use only applesauce, carrots, rice, or ice cream).
Use within 15 minutes of opening the packet. Nursing Considerations
 May be given without regard to food.
 Assess patient’s underlying condition; monitor
 If a dose is missed, omit the dose; give next dose patient for effectiveness.
at regularly scheduled time.  Alert: Don’t abruptly substitute drug for inhaled or
oral corticosteroids. Dose of inhaled corticosteroids
Action may be reduced gradually.
 Reduces early and late-phase bronchoconstriction  Alert: Drug isn’t indicated for use in patients with
from antigen challenge. acute asthmatic attacks, status asthmaticus, or as
monotherapy for management of exercise-induced
bronchospasm. Continue appropriate rescue drug
for acute worsening.
Interactions  Boxed Warning: Monitor patients for
Drug-drug neuropsychiatric symptoms. Discontinue drug
 Gemfibrozil: May increase montelukast level. immediately if neuropsychiatric symptoms occur.
Monitor therapy.
 Lumacaftor–ivacaftor: May decrease montelukast Patient Teaching
level. Monitor therapy.  Explain how to properly administer drug in
prescribed formulation.
Effects on Lab Test Results  Advise patient to take drug daily, even if
 May increase ALT and AST levels. asymptomatic, and to contact prescriber
if asthma isn’t well controlled.
Contraindications & Cautions  Warn patient not to reduce or stop taking other
prescribed antiasthmatics without prescriber’s
 Contraindicated in patients hypersensitive to drug approval.
or its ingredients.  Advise patient to seek medical attention if short-
 Avoid use with aspirin and other NSAIDs in acting inhaled bronchodilators are needed more
patients with known aspirin sensitivity because often than usual during drug therapy.
drug hasn’t been shown to affect the Warn patient that drug isn’t beneficial in

bronchoconstrictor response to aspirin and other acute asthma attacks or in acute exercise-induced
NSAIDs in patients with asthma who are aspirin- bronchospasm. Advise patient to keep appropriate
sensitive. rescue drugs available.
 Patients with asthma may present with systemic  Boxed Warning: Advise patient and caregivers of
eosinophilia that may manifest as clinical features the risk of neuropsychiatric symptoms and to
of vasculitis consistent with Churg-Strauss immediately report symptoms if they occur.
syndrome. Churg-Strauss syndrome is often treated  Advise patient with known aspirin sensitivity to
with systemic corticosteroid therapy. These continue to avoid using aspirin and NSAIDs during
reactions have sometimes been associated with drug therapy.
reduction of oral corticosteroid dosage. Be alert to  Alert: Advise patient with phenylketonuria that
development of eosinophilia, vasculitic rash, chewable tablet contains phenylalanine.
worsening pulmonary symptoms, cardiac
complications, or neuropathy.
 Use cautiously and with appropriate monitoring in
patients whose dosages of systemic corticosteroids
are reduced.
RESPIRATORY DRUGS

Dextromethorphan Hydrobromide Pseudoephedrine Hydrochloride

Therapeutic class: Antitussives Therapeutic class: Decongestants
Pharmacologic class: Levorphanol derivatives Pharmacologic class: Adrenergics

Indications & Dosages

Indications & Dosages  Nasal decongestant
 Nonproductive cough
Administration
Administration PO
PO  Don’t crush or break extended-release or abuse-
 Shake solution well before administering. deterrent tablets.
Action
 Store at controlled room temperature (59° to 86°
Stimulates alpha receptors in the respiratory tract,
F [15° to 30° C]). constricting blood vessels, shrinking swollen nasal mucous
Action membranes, increasing airway patency, and reducing tissue
 Suppresses the cough reflex by direct action on hyperemia, edema, and nasal congestion.
the cough center in the medulla. Interactions
Drug-drug
a. Antihypertensives: May inhibit hypotensive effect.
Interactions Monitor BP closely.
b. Linezolid, methyldopa: May increase pressor response.
Drug-drug Monitor patient closely.
MAO inhibitors: May cause risk of hypotension, c. MAO inhibitors (phenelzine, tranylcypromine): May
coma, hyperpyrexia, and death. Avoid using together. cause severe headache, HTN, fever, and hypertensive
Quinidine: May increase the risk of dextromethorphan crisis. Don’t use within 14 days of MAO inhibitor use.
adverse effects. Consider decreasing d. SNRIs: May enhance tachycardic and vasopressor
dextromethorphan dose if needed. effects. Consider therapy modification.

Effects on Lab Test Results Effects on Lab Test Results

 None reported.  May interfere with urine detection of amphetamine
(false-positive).
Contraindications & Cautions
Contraindications & Cautions
 Contraindicated in patients currently taking
 Contraindicated in patients with severe HTN or severe
MAO inhibitors or within 2 weeks of stopping CAD, and in those receiving MAO inhibitors.
MAO inhibitors. Extended-release forms are contraindicated in children
 Use cautiously in atopic children, sedated or younger than age 12.
debilitated patients, and patients confined to the  Use cautiously in older adults and patients with HTN,
supine position. cardiac disease, diabetes, glaucoma, hyperthyroidism,
 Use cautiously in patients sensitive to aspirin or bowel narrowing, and prostatic hyperplasia.
tartrazine dyes.  Dialyzable drug: Unknown.
 Alert: Use of OTC cough products is not  Overdose Signs & Symptoms: HTN, bradycardia,
recommended for neonates and children younger drowsiness, rebound hypotension.
than age 4.
 Dialyzable drug: Unknown. Nursing Considerations
 Older adults are more sensitive to drug’s effects. Don’t
Nursing Considerations give extended-release form to older adults
until safety with short-acting preparations has been
 Don’t use dextromethorphan when cough is a established.
valuable diagnostic sign or is beneficial (such as  Monitor BP carefully.
after thoracic surgery).  Monitor patients for abdominal pain or vomiting; drug
 Drug produces no analgesia or addiction and may need to be stopped.
little or no CNS depression.  Some liquid formulations may contain alcohol.
 Use drug with chest percussion and vibration.
 Monitor cough type and frequency. Patient Teaching
 Tell patient not to crush or break extended-release or
Patient Teaching abuse-deterrent tablets.
 Instruct patient to take drug exactly as prescribed,  Warn against using OTC products containing other
or as indicated in OTC labeling information, and sympathomimetics.
not to exceed recommended doses.  Instruct patient not to take drug within 2 hours of
 Tell patient to report adverse reactions. bedtime because it can cause insomnia.
 Tell patient to contact health care provider if  Tell patient to stop drug and notify prescriber if
cough lasts longer than 1 week, recurs frequently, experiencing unusual restlessness.
or is accompanied by high fever, rash, or  Warn patient taking 24-hour extended-release tablet
that shell from tablet may appear in stool.
severe headache.
RESPIRATORY DRUGS

Acetylcysteine after start of infusion and may require treatment and

Therapeutic class: Mucolytics drug discontinuation.
Pharmacologic class: L-cysteine derivatives  Use cautiously in older adults and patients with
debilitation and severe respiratory insufficiency. Use
Indications & Dosages IV form cautiously in patients with asthma or a history
 Adjunctive therapy for abnormal viscid or thickened mucous of bronchospasm, in those weighing less than 40 kg,
secretions in patients with pneumonia, and in patients requiring fluid restriction.
bronchitis, bronchiectasis, primary amyloidosis of the lung,  Dialyzable drug: Yes.
TB, cystic fibrosis, emphysema, atelectasis, pulmonary
complications of thoracic surgery, or CV surgery Nursing Considerations
 Diagnostic bronchial studies
 Monitor cough type and frequency.
 Routine tracheostomy care
 Alert: Monitor patient for bronchospasm, especially if
 Acetaminophen toxicity patient has asthma.
Administration: PO  Ingestion of more than 150 mg/kg
(inhalation formulation) of acetaminophen may cause hepatotoxicity.
 Administer via the oral route. Dilute oral dose (used Measure acetaminophen level 4 hours after ingestion to
for acetaminophen overdose) with diet cola or other diet soft determine risk of hepatotoxicity. See manufacturer’s
drinks or water. Dilute 20% solution to 5% (add 3 mL of
diluent to each milliliter of drug). If patient vomits within 1
information for nomogram for estimating potential for
hour of receiving loading or maintenance dose, repeat dose. hepatotoxicity from acute acetaminophen ingestion and
Use diluted solution within 1 hour. need for acetylcysteine therapy.
 Drug smells strongly of sulfur. Mixing oral form with juice  Alert: Drug is used for acetaminophen overdose within
or cola improves its taste. 24 hours of ingestion. Start drug immediately; don’t
 Drug delivered through NG tube may be diluted with water. wait for results of acetaminophen level. Give within 10
 Store opened, undiluted oral solution in the refrigerator for hours of acetaminophen ingestion to minimize hepatic
up to 96 hours. injury.
IV  For suspected acetaminophen overdose, obtain baseline
 Drug may turn from a colorless liquid to a slight pink or INR and AST, ALT, bilirubin, BUN,
purple color once the stopper is punctured. This color change creatinine, glucose, and electrolyte levels.
doesn’t affect the drug.  Check acetaminophen, ALT, and AST levels and INR
 Drug is hyperosmolar and is compatible with D5W, half-NSS, after the last maintenance dose. If acetaminophen level
and sterile water for injection. is still detectable, or if the ALT/AST level is still
 Adjust total volume given for patients who weigh less than increasing or the INR remains elevated, the
40 kg or who are fluid restricted.
maintenance doses should be continued and the
 For patients who weigh 41 kg or more, dilute loading dose in prescriber should contact a regional poison control
200 mL of D5W, second dose in 500 mL, and third dose in
center (1-800-222-1222) or a special health
1,000 mL. Refer to manufacturer’s instructions for dosage
and dilution for patients weighing 40 kg or less. professional assistance line (1-800-525-6115) for
 Reconstituted solution is stable for 24 hours at room assistance with dosing recommendations.
temperature.  Half-life elimination increases by 80% in patients with
 Vials contain no preservatives; discard after opening. severe liver damage.
 Incompatibilities: None listed by manufacturer. Consult a  Alert: Monitor patient receiving IV form for
drug incompatibility reference for more information. anaphylactoid reactions. Reactions involving more
Inhalational than simple skin flushing or erythema should be treated
 Use plastic, glass, stainless steel, or another nonreactive as anaphylactoid reactions. If anaphylactoid reaction
metal when giving by nebulization. Hand-bulb nebulizers occurs, stop infusion and treat reaction with
aren’t recommended because output is too small and particle antihistamines and epinephrine if needed.
size too large. Once anaphylaxis treatment starts, carefully restart
 If only a portion of the solution in a vial is used for inhalation, infusion. If anaphylactoid symptoms return, stop drug.
store remainder in refrigerator and use within 96 hours.  Flushing and skin erythema may occur within 30 to 60
 Incompatibilities: Physically or chemically incompatible with minutes of start of IV infusion and
inhaled tetracyclines, erythromycin usually resolve without stopping infusion.
lactobionate, amphotericin B, and ampicillin sodium. If given
by aerosol inhalation, nebulize these drugs separately.  When acetaminophen level is below toxic level
Iodized oil, trypsin, and hydrogen peroxide are physically according to nomogram, stop therapy.
incompatible with acetylcysteine; don’t add to nebulizer.  The vial stopper doesn’t contain natural rubber latex,
Action dry natural rubber, or blends of natural rubber.
Reduces the viscosity of pulmonary secretions by splitting  Look alike-sound alike: Don’t
disulfide linkages between mucoprotein molecular complexes. confuse acetylcysteine with acetylcholine.
Also restores liver stores of glutathione to
treat acetaminophen toxicity.
Drug-drug; Activated charcoal: May limit acetylcysteine’s Patient Teaching
effectiveness. Avoid using activated charcoal before or  Warn patient that drug may have a foul taste or
with oral acetylcysteine. smell that may be distressing.
 For maximum effect, instruct patient to cough to
Effects on Lab Test Results: None reported. clear airway before aerosol administration.

Contraindications & Cautions

 Contraindicated in patients hypersensitive to drug.
 Alert: Serious anaphylactoid reactions, including
rash, hypotension, dyspnea, and wheezing, have been
reported. Reactions usually occur 30 to 60 minutes
RESPIRATORY DRUGS

Theophylline h. St. John’s wort: May decrease drug level. Monitor therapy.
Therapeutic class: Bronchodilators Drug-food
Pharmacologic class: Xanthine derivatives i. Caffeine: May decrease hepatic clearance of drug and
increase drug level. Monitor patient for toxicity.
Drug-lifestyle
Indications & Dosages j. Alcohol use: Decreases theophylline clearance and increases
 Alert: Extended-release preparations shouldn’t be used to risk of adverse reactions. Discourage use together.
treat acute bronchospasm. k. High carbohydrate, low protein diet: May decrease
theophylline clearance and prolong half-life. Patient should
 Parenteral theophylline (preferred route) for acute avoid extremes of protein and carbohydrate intake.
bronchospasm in patients not currently
l. Smoking: May increase elimination of drug, increasing
receiving theophylline
dosage requirements. Monitor drug response and level
 Oral theophylline for acute bronchospasm in patients not Effects on Lab Test Results
currently receiving theophylline  May increase free fatty acid and blood glucose levels.
 Chronic bronchospasm using extended-release preparations  May increase uric acid, HDL, and total cholesterol levels and
Administration: PO urinary free cortisol excretion.
 Calculate the mg/kg dose based on ideal body weight  May decrease T3 measurements.
because drug distributes poorly into body fat.  May falsely elevate theophylline level in the presence
 Each 0.5-mg/kg PO loading dose will increase drug level by of acetaminophen, furosemide, probenecid,
1 mcg/mL. theobromine, caffeine, tea, chocolate, and cola, depending on
 Give drug with full glass of water after meals, if needed, to assay used.
relieve GI symptoms, although taking with food delays Contraindications & Cautions
absorption.  Contraindicated in patients hypersensitive to xanthine
 Give drug around-the-clock, using extended-release product compounds (caffeine, theobromine) and in those with active
at bedtime. peptic ulcer or poorly controlled seizure disorders.
 Don’t dissolve or crush extended-release products. Small  Use cautiously in young children, infants, neonates, older
children unable to swallow these can ingest (without chewing) adults, and those with COPD, cardiac failure, cor pulmonale,
the contents of capsules sprinkled over soft food. renal or hepatic disease, peptic ulceration, hyperthyroidism,
 Administer extended-release formulas in a consistent manner, diabetes mellitus, glaucoma, severe hypoxemia, HTN,
either always with or always without food. compromised cardiac or circulatory function, angina, acute
IV MI, or sulfite sensitivity.
 Each 0.5-mg/kg IV loading dose will increase drug level by 1  Dialyzable drug: Yes. Peritoneal dialysis ineffective
mcg/mL. for theophylline removal.
 Administer loading dose IV over 30 minutes.  Overdose Signs & Symptoms: Seizures; arrhythmias;
elevated CK, myoglobin, and calcium levels; elevated
 Use commercially available infusion solution, or mix in D5W leukocyte count; decreased phosphorus and magnesium
solution. levels; acute MI; urine retention in men with obstructive
 Use infusion pump for continuous infusion. uropathy.
 Incompatibilities: Don’t mix with other drugs. Nursing Considerations
 Alert: Ensure that patient’s drug list, including OTC drugs,
Action herbs, and supplements, is up-to-date; consult a drug
interaction source as necessary.
Inhibits phosphodiesterase, the enzyme that degrades cAMP,
resulting in relaxation of smooth muscle of the bronchial airways  Dosage may need to be increased in cigarette smokers and in
and pulmonary blood vessels. habitual marijuana smokers because smoking causes drug to
Interactions be metabolized faster.
Alert: According to the manufacturer, theophylline interacts with  Monitor vital signs; measure and record fluid intake and
many drugs and the prescribing information interactions list isn’t output. Expect improved quality of pulse and respirations.
comprehensive. Consult a drug interaction source for more  Patients metabolize xanthines at different rates; dosage is
information. determined by monitoring response, tolerance, pulmonary
Drug-drug function, and drug level. Optimal drug levels range from 10
a. Adenosine: May decrease antiarrhythmic effect. Higher to 15 mcg/mL; toxicity may occur at levels above 20
doses of adenosine may be needed. mcg/mL.
b. Allopurinol, calcium channel  Alert: Monitor patient for signs and symptoms of toxicity,
blockers, cimetidine, disulfiram, influenza virus including tachycardia, anorexia, nausea, vomiting, diarrhea,
vaccine, interferon, macrolides restlessness, irritability, seizures, and headache. If these signs
(erythromycin), methotrexate, mexiletine, oral and symptoms occur, check drug level and adjust dosage, as
contraceptives, quinolones (ciprofloxacin): May decrease indicated.
hepatic clearance of theophylline; may increase theophylline Patient Teaching
level. Monitor levels closely and adjust theophylline dose.  Supply instructions for home care and dosage schedule.
c. Barbiturates, nicotine, phenytoin, rifamycins: May enhance
 Warn patient not to dissolve, crush, or chew extended-release
metabolism and decrease theophylline level; theophylline
products. Small children unable to swallow these can ingest
may increase phenytoin metabolism. Monitor patient for
(without chewing) the contents of capsules sprinkled over
decreased therapeutic effect; monitor levels and adjust
soft food.
dosage.
d. Carbamazepine, loop diuretics: May increase or decrease  Tell patient to relieve GI symptoms by taking oral drug with
theophylline level. Monitor theophylline level. full glass of water after meals, although food in stomach
e. Carteolol, pindolol, propranolol, timolol: May act delays absorption.
antagonistically, reducing the effects of one or both drugs;  Warn patient to take drug regularly, only as directed.
may reduce elimination of theophylline. Monitor  Inform older adults that dizziness is common at start of
theophylline level and patient closely. therapy.
f. Ephedrine, other sympathomimetics: May exhibit  Urge patient to tell prescriber about any other drugs or
synergistic toxicity with these drugs, predisposing patient to supplements taken. OTC drugs or herbal remedies may
arrhythmias or increased CNS effects. Monitor patient contain ephedrine or theophylline salts; excessive CNS
closely. stimulation may result.
g. Lithium: May increase lithium excretion. Monitor patient  Tell patient who quits smoking to inform prescriber. Dosage
closely. reduction may be needed to prevent toxicity.
Drug-herb
RESPIRATORY DRUGS

Salmeterol Xinafoate salmeterol and start alternative treatment if paradoxical

Therapeutic class: Bronchodilators bronchospasm occurs.
Pharmacologic class: Long-acting selective beta2 agonists  Alert: Don’t use drug with other medications containing
LABAs.
Indications & Dosages  Use cautiously in patients unusually responsive to
sympathomimetics and those with coronary insufficiency,
 Long-term maintenance of asthma; to prevent bronchospasm arrhythmias, HTN, other CV disorders, thyrotoxicosis,
only as concomitant therapy with an inhaled corticosteroid hepatic impairment, diabetes, or seizure disorders.
(ICS) in patients with reversible obstructive airway disease,  Dialyzable drug: Unknown.
including nocturnal asthma
 Overdose Signs & Symptoms: Exaggeration of adverse
Adults and children age 4 and older: 1 inhalation reactions, hypokalemia, seizures, angina, HTN, hypotension,
(50 mcg) b.i.d. in the morning and evening, about dry mouth, muscle
12 hours apart. cramps, dizziness, fatigue, insomnia, tachycardia, ventricular
 To prevent exercise-induced bronchospasm arrhythmias, cardiac arrest, sudden death.
Adults and children age 4 and older: 1 inhalation
(50 mcg) at least 30 minutes before exercise. Nursing Considerations
Additional doses shouldn’t be taken for at least 12
hours.  Boxed Warning: LABAs may increase risk of asthma-related
hospitalization in children and adolescents. For children and
 COPD, emphysema, or chronic bronchitis
adolescents with asthma who require addition of a LABA to
Adults: 1 inhalation (50 mcg) b.i.d. in the morning an ICS, a fixed-dose combination product containing both
and evening, about 12 hours apart. should be used to ensure adherence with both drugs. In cases
Administration in which use of an ICS and a LABA is clinically indicated,
Inhalational appropriate steps must be taken to ensure adherence with
 Give drug 30 minutes before exercise to prevent exercise- both treatment components. If adherence can’t be ensured, a
induced bronchospasm. fixed-dose combination product containing both an ICS and a
 Don’t use a spacer device with this drug. LABA is recommended.
 Don’t wash the inhaler and always keep it in a dry place.  Drug isn’t indicated for acute bronchospasm.
Action  Alert: Monitor patient for rash and urticaria, which may
Unclear. Selectively activates beta2 receptors, which results in signal a hypersensitivity reaction.
bronchodilation; also, blocks the release of allergic mediators  Monitor patient for hypokalemia and hyperglycemia.
from mast cells lining the respiratory tract.
Interactions
Drug-drug Patient Teaching
a. Antiarrhythmics (amiodarone, disopyramide,  Boxed Warning: Teach parents of child or adolescent who
sotalol), chlorpromazine, dolasetron, droperidol, moxifloxac requires the use of a separate ICS and a LABA that
in, pentamidine, pimozide, tacrolimus, thioridazine, ziprasid appropriate steps must be taken to ensure adherence with
one: May prolong QT interval and increase risk of life- both treatment components, because of the increased risk
threatening cardiac arrhythmias. Monitor QT interval of asthma-related death. If adherence can’t be ensured, a
closely. fixed-dose combination product containing both drugs is
b. Beta agonists, other methylxanthines, theophylline: May recommended.
cause adverse cardiac effects with excessive use. Monitor  Remind patient to take drug at about 12-hour intervals for
patient. optimal effect and to take drug even when feeling better.
c. Beta blockers (nonselective): May diminish bronchodilatory
effects. Use cardioselective beta blockers if therapy is  Advise patient that immediate hypersensitivity reactions
indicated. (such as urticaria, angioedema, rash, bronchospasm,
and hypotension, including anaphylaxis) may occur after
d. CYP3A4 inhibitors (atazanavir, clarithromycin, itraconazole,
administration of this drug and to seek immediate medical
ketoconazole, ritonavir): May increase cardiac effects.
Avoid use together. attention if such reactions occur.
e. Diuretics (non-potassium-sparing): May  If patient is taking drug to prevent exercise-induced
worsen hypokalemia and ECG changes. Use cautiously bronchospasm, tell patient to take it 30 minutes before
together. exercise.
f. MAO inhibitors: May cause risk of severe adverse CV  Alert: Tell patient drug shouldn’t be used to treat acute
effects. Avoid use within 14 days of MAO inhibitor therapy. bronchospasm. Patient must use a short-acting beta2 agonist,
g. TCAs: May cause risk of moderate to severe adverse CV such as albuterol, to treat worsening symptoms.
effects. Avoid use together within 14 days.  Tell patient to contact prescriber if the short-acting agonist
Effects on Lab Test Results no longer provides sufficient relief or if patient needs more
 May decrease potassium and glucose levels. than 4 inhalations daily. This may be a sign that
the asthma symptoms are worsening. Tell patient not to
increase the dosage of salmeterol.
Contraindications & Cautions
 If patient takes an ICS, patient should continue to use it
 Contraindicated in patients hypersensitive to drug, its regularly. Warn patient not to take other drugs without
ingredients, or milk proteins. prescriber’s consent.
 Alert: Contraindicated as the primary treatment for acute  If patient takes the inhalation powder (in a multidose inhaler),
episodes of asthma or COPD. instruct patient not to exhale into the device. Patient should
 Boxed Warning: Contraindicated for treatment activate and use it only in a level, horizontal position.
of asthma without an ICS. Using without an ICS may  Tell patient not to use dry-powder multidose inhaler with a
increase the risk of asthma-related death. spacer.
 Boxed Warning: Only use salmeterol as additional therapy  Instruct patient never to wash mouthpiece or any part of dry-
for patients whose condition isn’t adequately controlled on powder multidose inhaler; it must be kept dry.
other medications or patients whose disease severity warrants  Advise patient to contact physician if she becomes pregnant
initiation of treatment with two maintenance therapies. Don’t during therapy.
use salmeterol for patients whose asthma is adequately
controlled on low- or medium-dose ICS.
 Clinical trial data don’t suggest an increased risk of death
with the use of salmeterol in patients with COPD.
 Paradoxical bronchospasm that may be life-threatening may
occur; distinguish from inadequate response. Discontinue
RESPIRATORY DRUGS

Ipratropium Bromide  Alert: Drug isn’t indicated for initial treatment of

Therapeutic class: Bronchodilators acute episodes of bronchospasm, for which rescue
Pharmacologic class: Anticholinergics therapy is required for rapid response.
 Safety and effectiveness of intranasal use beyond
Indications & Dosages 4 days in patients with a common cold haven’t
 Bronchospasm in chronic been established.
bronchitis and emphysema  Safety and effectiveness of nebulization or inhaler
in children younger than age 12 haven’t been
 Rhinorrhea caused by allergic and nonallergic
established.
perennial rhinitis
 Dialyzable drug: Unknown.
 Rhinorrhea caused by the common cold
 Rhinorrhea caused by seasonal allergic rhinitis Nursing Considerations
 Acute asthma exacerbations, in combination with
 If patient uses a face mask for a nebulizer, take
a short-acting beta agonist
care to prevent leakage around the mask
because eye pain or temporary blurring of vision
Administration may occur.
Inhalational
 Prime inhaler before initial use by releasing 2 test Patient Teaching
sprays into the air. If inhaler not used for more
 Warn patient that drug isn’t effective for treating
than 3 days, reprime.
acute episodes of bronchospasm when rapid
 If more than 1 inhalation is ordered, wait at least
response is needed.
15 seconds between inhalations.
 Teach patient to use metered-dose inhaler (MDI)
 Use spacer device to improve drug delivery, if
or oral nebulizer correctly. Refer to
appropriate.
manufacturer’s instructions for use.
 Wash mouthpiece once a week for 30 seconds in
 Tell patient to prime inhaler before initial use by
warm water only and let air dry.
releasing 2 test sprays into the air. If inhaler
 Don’t puncture inhaler, throw into a fire or
hasn’t been used for more than 3 days, advise
incinerator, or use or store near heat or open flame.
patient to reprime.
 Inhalation solution is for use with oral nebulizer.
 Instruct patient to wash mouthpiece once a week
Refer to manufacturer’s instructions for use.
for 30 seconds in warm water only and let air dry.
 Protect solution from light. Store unused vials in
 Inform patient that use of a spacer device with an
foil pouch.
MDI may improve drug delivery to lungs.
 Store inhaler and solution between 59° and 86° F
 Warn patient to avoid accidentally spraying drug
(15° and 30° C).
into eyes. Temporary blurring of vision may
Intranasal
result.
 Prime nasal spray with 7 sprays of pump before
 If more than 1 inhalation is prescribed, tell patient
first use; prime with 2 sprays after pump hasn’t
to wait at least 15 seconds before repeating
been used for more than 24 hours.
procedure.
 Tilt patient’s head backward after dose to allow
 Advise patient who is also using a corticosteroid
drug to spread to back of nose.
inhaler to use ipratropium first and then to wait
 Store between 59° and 77° F (15° and 25° C);
about 5 minutes before using the corticosteroid.
avoid freezing.
This lets the bronchodilator open air passages for
maximal effectiveness of the corticosteroid.
Action  Instruct patient to prime nasal spray by pumping
Inhibits vagally mediated reflexes by antagonizing seven times before first use or after it has not been
acetylcholine at muscarinic receptors on bronchial used for 1 week. Prime with two pumps after it
smooth muscle. has not been used for 1 day.
 Instruct patient to sniff deeply after each spray
Interactions and to breathe out through mouth. Tell patient to
Drug-drug tilt head backward to allow drug to spread to back
Anticholinergics: May increase anticholinergic effects. of nose.
Avoid using together.

Effects on Lab Test Results

None reported.

Contraindications & Cautions

 Contraindicated in patients hypersensitive to drug,
atropine, or its derivatives.
 Use cautiously in patients with angle-
closure glaucoma, prostatic hyperplasia, or
bladder-neck obstruction.
RESPIRATORY DRUGS

fluticasone propionate–salmeterol (inhalation)  Overdose Signs & Symptoms: Hypercorticism, angina,

Therapeutic class: Antiasthmatics arrhythmias, dizziness, dry mouth, fatigue, headache,
Pharmacologic class: Corticosteroids–LABAs HTN, hypotension, insomnia, malaise, muscle
cramps, nausea, nervousness, palpitations,
seizures, tachycardia, prolonged QTc interval, hypokalemia,
Indications & Dosages hyperglycemia, cardiac arrest, death.
 Treatment of asthma for patients not adequately controlled Nursing Considerations
on a long-term asthma control medication such as inhaled  Alert: Patient shouldn’t be switched from systemic
corticosteroid (ICS) or whose disease warrants initiation of corticosteroids to Advair Diskus or Advair HFA because of
treatment with both ICS and LABA HPA axis suppression. Death from adrenal insufficiency can
 Maintenance therapy for airflow obstruction in patients with occur. Several months are required for recovery of HPA
COPD; to reduce exacerbations of COPD in patients with a function after withdrawal of systemic corticosteroids.
history of exacerbations  Don’t start therapy during rapidly deteriorating or potentially
 Adults: 1 inhalation of Advair Diskus 250/50 only b.i.d., life-threatening episodes of asthma. Serious acute respiratory
about 12 hours apart. events, including fatality, can occur.
Administration: Inhalational  The benefit of Advair 250/50 in treating patients with COPD
for more than 6 months is unknown. If drug is used for
 Prime Advair HFA before first use by releasing 4 test sprays longer than 6 months, periodically reevaluate patient to
into the air, away from the face, shaking well for 5 seconds assess for benefits or risks of therapy.
before each spray. If inhaler hasn’t been used for 4 weeks or
 Monitor patient for urticaria, angioedema, rash,
has been dropped, prime inhaler again by shaking well before
bronchospasm, or other signs of hypersensitivity.
each spray and releasing 2 test sprays into the air.
 Don’t use this drug to stop an asthma attack. Patients should
 Discard Advair HFA canister when counter reads “000.” carry an inhaled, short-acting beta2 agonist (such as albuterol)
 Airduo RespiClick doesn’t require priming. Never place for acute symptoms.
inhaler in water; clean mouthpiece with dry cloth or tissue as
 If drug causes paradoxical bronchospasm, treat immediately
needed.
with a short-acting inhaled bronchodilator (such as albuterol),
 After administration, have patient rinse mouth without and notify prescriber.
swallowing.
 Monitor patient for increased use of inhaled short-acting
Action
beta2 agonist. The dose of Advair may need to be increased.
Fluticasone is a synthetic corticosteroid with potent anti-
inflammatory activity. Salmeterol, an LABA, relaxes bronchial  Closely monitor children for growth suppression.
smooth muscle and inhibits release of mediators. Patient Teaching
Interactions: Drug-drug  Instruct patient on proper use of the prescribed inhaler to
Beta blockers: Blocked pulmonary effect of salmeterol may produce provide effective treatment.
severe bronchospasm in patients with asthma. Avoid using together. If  Tell patient to avoid exhaling into the dry-powder multidose
necessary, use a cardioselective beta blocker cautiously. inhaler; to activate and use the dry-powder multidose inhaler
Ketoconazole, other inhibitors of CYP450: May increase fluticasone level
and adverse effects. Use together cautiously.
in a level, horizontal position; and not to use Advair Diskus
Loop diuretics, thiazide diuretics: Potassium-wasting diuretics may cause with a spacer device.
or worsen ECG changes or hypokalemia. Use together cautiously.  Instruct patient to keep the dry-powder multidose inhaler in a
MAO inhibitors, TCAs: May potentiate the action of salmeterol on the dry place, away from direct heat or sunlight, and to avoid
vascular system. Separate doses by 2 weeks. washing the mouthpiece or other parts of the device. Patient
should discard device 1 month after removal from the
Effects on Lab Test Results: May increase liver enzyme levels. moisture-protective overwrap pouch or after every blister has
been used, whichever comes first. Warn patient not to
Contraindications & Cautions
attempt to take device apart.
 Contraindicated in patients hypersensitive to drug or its
 Instruct patient to rinse mouth after inhalation to prevent
components, as primary treatment of status asthmaticus or
oral candidiasis.
other acute episodes of asthma or COPD in which intensive
measures are required, and in those with severe  Instruct patient to discard Airduo RespiClick inhaler 30 days
hypersensitivity to milk proteins. after opening the foil pouch or when the counter reads “0,”
whichever comes first (device isn’t reusable).
 Use of LABA as monotherapy (without ICS) for asthma is
associated with an increased risk of asthma-related death.  Advise patient, after removing Advair Diskus from the box
Available data from controlled clinical trials also suggest that and foil pouch, to write the “Pouch opened” and “Use by”
use of LABA as monotherapy increases the risk of asthma- dates on the label on top of the Diskus. The “Use by” date is
related hospitalization in children and adolescents. These 1 month from date of opening the pouch.
findings are considered a class effect of LABA monotherapy.  Teach patient how to use the Diskus: Each time the lever is
When LABAs are used in fixed-dose combination with ICS, pushed back, a dose is ready to be inhaled. Don’t close or tilt
data from large clinical trials don’t show a significant the Diskus after the lever is pushed back. Don’t play with the
increase in the risk of serious asthma-related events lever or move the lever more than once. The dose indicator
(hospitalizations, intubations, death) compared with ICS displays how many doses are left; when the numbers 5 to 0
alone. appear in red, only a few doses remain.
 Alert: Don’t use drug for transferring patients from systemic  Advise patient to discard Diskus device 1 month after
corticosteroid therapy. Deaths from adrenal removing it from the foil pouch or when the dose counter
insufficiency have occurred in patients with asthma during reads “0” (whichever comes first).
and after transfer from systemic corticosteroids to less  Inform patient that improvement may occur within 30
systemically available inhaled corticosteroids. minutes after dose, but the full benefit may not occur for 1
 Use cautiously, if at all, in patients with active or quiescent week or more.
respiratory TB infection; untreated systemic fungal, bacterial,  Advise patient not to exceed recommended prescribing dose.
viral, or parasitic infection; or ocular herpes simplex.  Instruct patient not to relieve acute symptoms with Advair.
 Use cautiously in patients with CV disorders, seizure Treat acute symptoms with an inhaled short-acting
disorders, or thyrotoxicosis; in patients unusually responsive beta2 agonist.
to sympathomimetic amines; and in patients with hepatic  Instruct patient to report decreasing effects or use of
impairment. increasing doses of the inhaled short-acting beta2 agonist.
 Glaucoma, increased IOP, and cataracts have been reported  Tell patient to report all adverse reactions,
in patients with asthma and COPD after long-term ICS use. especially palpitations, chest pain, rapid HR, tremor, or
Consider referral to an ophthalmologist in patients who nervousness.
develop ocular symptoms or use drug long term.  Instruct patient to call prescriber immediately if exposed to
 Dialyzable drug: Unknown. chickenpox or measles.