Afectiuni respiratorii

Mecanism
Teofilina Inhiba neselectiv PD
Sulfat de Mg Blocheaza influxul de Ca
Zileuton inh 5-LOX
Omalizumab Anticorp anti Ig-E
Astmul bronsic
1. BADSA SALBUTAMOL, LEVALBUTEROL(x2 mai potent)
- in bronhospasm si de electie in astm sever acut

2. BADLA FORMOTEROL, SALMETEROL

- D= 12h
- Adjuvant + CSI

3. BAD ultralunga de actiune INDACATEROL, OLODATEROL, VILANTEROL

- D=24h -> in astm nocturn

4. CS sistemici PREDNISON, PREDNISOLON, METILPREDNISOLON

- In astm sever acut
- Cura 5-7 zile (3-5 zile la copii)
- Dexametazona la copii
- Toxicitate -> terapie discontinua/CSI Dmari
- Dexametazona- antiinflamator, Dmare si T1/2

5. Anticolinergice IPRATROPIU Br, TIOTROPIU Br

+BADSA sau la raspuns initial insuficient

CSI difuziune
Fluticazona furoat 80-85%
Flunisolid 68%
Beclometazona 50-60%
Ciclesonid 50%
6. CSI
- Electie in astm persistent
- Doze mai mari la inceput
- Efect-1-2sapt; efect maxim=4-8sapt

7. Metilxantine TEOFILINA
- doar sistemic
- 1A2 si 3A4
- Cp OK = 5-15mcg/ml
- ef toxice: tahicardii si convulsii
- <<<CSI,BDLA,antileuk si cromoglicat
- Inductorii enz ↑ clearance : CARBAMAZEPINA FFF RIFAMPICINA +HIPERTIROIDISM
- Inhib enz : ALOPURINOL, CIMETIDINA, antibiotice(macrolide, fluorochinolone), INTERFERON, PROPRANOLOL,
TICLOPIDINA, ZILEUTON, afectare hepatica, infectii pulmonare

8. Sulfat de Mg
- Bronhodil + antiinflamator
- Perfuzie
- RA naspa (ex: deprimare resp si SNC, hipotensiune)
 9. Antileucotriene ZAFIRLUKAST, MONTELUKAST
- Nu in acut
- Adm regulat
- <CSI
- RA: afectare hepatica, sindrom idiosincrazic

10. Zileuton
- Creste enz hepatice
- Inhiba CYP3A4

11. Omalizumab
- In astm necontrolat cu CS
- Adm sc /2-4 saptamani
- Soc anafilactic
- Cost ridicat -> linia 5-6

BADSA<2/luna Nimic
Ocazional simptome+ noaptea/ BADSA 2/luna CSI D mici
Simptome deranjante ziua si noaptea CSI  BADLA
Astm sever necontrolat/ exacerbari CS oral si CSI Dmari/ CSI+BADLA

Evaluare dupa tratament initial cu BADSA inh 2 adm/20min, 2-6 puf

PEF  80% BADSA (la 3-4h 1-2zile)
+CS oral durata scurta
PEF 50-79% +CS oral+ BADSA + specialist
PEF < 50% +CS oral + BADSA + specialist+ UPU

BPOC
Obiectiv: Pa>60 mmHg

Simptome intermitente BADSA/ACDSA la nevoie

Simptome persistente BADLA/ACDLA
Risc de exacerbari CSI +BADLAACDLA
Terapie initiala: BADSA /Anticolinergice

1. BADSA SALBUTAMOL, LEVALBUTEROL, TERBUTALINA(po)

2. BADLA: SALMETEROL, FORMOTEROL, ARFORMOTEROL, INDACATEROL, OLODATEROL, VILANTEROL

- INDACATEROL-singurul adm la 24h (restul la 12h)

3. ACDSA: IPRATROPIU Br
- fata de BDSA: debut mai lent, efect mai lung
- D=8h
 4. ACDLA: TIOTROPIU Br, UMECLIDINIU, ACLIDINIU Br, GLICOPIRONIU Br
Asocieri:
- ACDSA+BADSA = IPRATROPIU+SALBUTAMOL
- ACDLA+BADLA = VILANTEROL/UMECLIDINIU; OLODATEROL/TIOTROPIU; INDACATEROL/GLUCOPIRONIU

5. Metilxantine: TEOFILINA, AMINOFILINA

- Tratam cronic, creste progresiv de la 200mg/zi la 400-900mg/zi

6. CS
- +BADLA : BUDESONIDA/FORMOTEROL; FLUTICAZONA/VILANTEROL; FLUTICAZONA/SALMETEROL
- Cazuri grave: terapia tripla: BADLA+ACDLA+CSI
- Durata mai mare a trat cu CS sist (10-14 zile)

7. Inh ai PD4 ROFLUMILAST

- Forme severe
- 1A2 si 3A4

Oxigenoterapia- Obiectiv: PaO2>60mmHg sau SaO2>90%

Ventilatia non-invaziva cu presiune pozitiva= VNI
8. Antibiotice:
- Macrolide: AZITROMICINA, CLARITROMICINA
- Cefalosporine GEN 2 SI 3
- DOXICICLINA
- In complicatii: AMOXI/AC CLAVULANIC SAU FLUOROCHINOLONE(levofloxacina, gemifloxacina, moxifloxacina)

Rinita alergica

SNC
 Tulburarea depresiva majora
Clasificare antidepresive:ISRS IRSN, ATC, 5HT MIXTE, IRND, 5HT SI ALFA2

+IMAO, sunatoare

1. ISRS
- Prima linie
- Escitalopram si sertralina – profil efic/RA

2. IRSN: DULOXETINA, LEVOMILNACIPRAN (DES)VENLAFAXINA

-venlafaxina mai eficienta
3. ATC
4. 5HT MIXTE
- Triazolopiridine:TRAZODONA, NEFAZODONA – 5HT2 si 5HT1A
- VILAZODONA- +anxiatate
- VORTIOXETINA- + tulb cognitive
5. IRND: BUPROPIONA
6. 5HT SI ALFA 2 MIRTAZAPINA
- In disfunctie sexuala la altele

7. IMAO: FENELZINA, TRANILCIPROMINA, SELEGILINA

- selegilina cerebral
- cresc 5HT,D si NA

RA comune: suicid si s.serotoninergic

ATC Toate: anticolinergice, sedare si alte RA( crestere in greutate, HO, tulb de conducere si sexuale
- ef rebound colinergic
DESIPRAMINA- risc de deces la istoric
MAPROTILINA- convulsii mai mult

ISRS Greata, varsaturi, diaree, cefalee, insomnie, oboseala, disf sexuale

- CITALOPRAM si ESCITALOPRAM >40mg/zi creste QT

Sedativ f slab: CITALOPRAM, FLUVOXAMINA, PAROXETINA

ESCITALOPRAM – nu produce convulsii !!! (restul scazut)

- Anxietate la inceputul trat

- Insomnie FLUOXETINA- activator, FLUVOXAMINA si PAROXETINA-sedativ

FLUOXETINA- greutate (din cauza anorexiei)

IRSN VENLAFAXINA, LEVOMILNACIPRAN – creste Tad

Ef Ach foarte scazute

DESVENLAFAXINA- hiperlipidemie
DULOXETINA-HO
VENLAFAXINA-HTA
5HT MIXTE 5HT crescut- VILAZODONA  S serotoninergic
NU CONVULSII
Sedare crescut: TRAZODONA DULOXETINA
Sedare moderat: NEFAZODONA
Convulsii scazut LEVOMILNACIPRAN
MIRTAZAPINA
ESCITALOPRAM
 NEFAZODONA- toxic hepatic
TRAZODONA- sedare, HO si priapism

IRND BUPROPIONA- Convulsii CRESCUT – Dmax 450mg/zi

5HT + ALFA2 MIRTAZAPINA- crestere in greutate

- Sedare si HO
- Somnolenta, usc gurii si comstipatie
IMAO FENELZINA- hipotensiune posturala + sedare
TRANILCIPROMINA-stimulant, afectare hepatica si greutate
Disf sexuale
!!!tiramina  CRIZE HIPERTENSIVE

Metaboliti:

Metaboliti Legare de pp
5HT mixte TRAZODONA Meta-clorfenil-piperazina >90%
NEFAZODONA
5HT si alfa2 BUPROPIONA Hidroxi, treohidro, eritrohidro
FLUOXETINA NORFLUOXETINA 94% si Bd95% T1/2 lung
ISRS SERTRALINA 99%
VENLAFAXINA O-desmetil-venlafaxina
DULOXETINA 90%
IRSN LEVOMILNACIPRA 22% Bd92%
N
AMITRIPTILINA nortriptilina 90-97%
DESIPRAMINA 2-OH-desipramina
DOXEPINA Desmetil-doxepina
ATC
IMIPRAMINA desipramina
NORTRIPTILINA 10-OH-nortriptilina

Inhibitie

FLUVOXAMINA 1A2
FLUOXETINA,PAROXETINA 2D6
NEFAZODONA 3A4
MIRTAZAPINA NU

Anxietate
HIDROXIZINA- linia 2

PREGABALINA

QUETIAPINA (antipsihotic) -150mg/zi

Linia 1- ISRS/IRSN
Med care dau anxietate

Anxietate acuta – BZD cu simptome somatice, ANTIDEPRESIVE- anxietate cronica

In special: ISRS, VENLAFAXINA, DULOXETINA

Sindrom de iritabilitate- cresterea initiala a anxietatii

BZD – cele mai frecvente si mai eficiente

- DIAZEPAM, CLORAZEPAT- T1/2 lung dar Dscurt

- LORAZEPAM, OXAZEPAM- T1/2 scurt dar Dlunga

CLORAZEPAT DESMETILDIAZEPAM

RA BZD: deprimare SNC, dezorientare, tulb psihomotorii, confuzia, agresivitatea, excitatia, ataxia, amnezia anterograda

ABUZ, DEPENDENTA, SEVRAJ ,TOLERANTA

Trat anxietate acuta: maxim 1 luna

BUSPIRONA- agonist 5HT1A

SOMN-VEGHE
Antihistaminice: DIFENHIDRAMINA, DOZILAMINA, PIRILAMINA

ATC: AMITRIPTILINA, DOXEPINA,NORTRIPTILINA

DOXEPINA-insomnia de mentinere

MIRTAZAPINA- somnolenta diurna si crester in greutate

TRAZODONA- insomnia data de bupropiona, isrs si pacienti predispusi la abuz

SUVOREXANT – antagonist; ut pt dificultati de initiere sau de mentinere a somnului; RA: narcolepsy-like

RAMELTEON- BPOC si apnee de somn

BZDRA – cele mai folosite

Apnee MODAFINIL, ARMODAFINIL

Narcolepsie cu somnolenta diurna MODAFINIL, OXIBAT, SELEGILINA
Narcolepsie cu paralizie VENLAFAXINA, FLUOXETINA,OXIBAT, IMIPRAMINA, PROTRIPTILINA,SELEGILINA
Insomnie acuta BZDRA cu Dscurta, RAMELTEON,
Daca nu: TRAZODONA, SUVOREXANT
Insomnie cronica BZDRA
Schimb de fus orar BZDRA cu Dscurta, RAMELTEON, MELATONINA
Lucru in schimuri BZDRA CU MODAFINIL

ZALEPLONA Scade timpul de adormire

ZOLPIDEM Adm si sublingual
ESZOPICLONA

FLURAZEPAM SI QUAZEPAM- N-desalchil

TEMAZEPAM- nu prin oxidare