Chapter 9

Respiratory Drugs

Chapter 9 Topics

• Asthma• Emphysema• Other Lung Diseases• Cough and Cold• Smoking Cessation

Learning Objectives

• Differentiate the pulmonary diseases

• Learn the pathophysiology and treatment of asthma

• Define the goals of asthma treatment

• Discuss the pathophysiology and treatment of emphysema and chronic bronchitis

Learning Objectives

• Describe other diseases related to the lungs

• Be aware of the reemergence of tuberculosis and of treatment for this disease

Learning Objectives

• Understand how the antitussives, expectorants, decongestants, and antihistamines differ, and be able to describe their uses

• Know why some drugs are prescribed for their side effects

• Outline smoking cessation plans and supportive therapy

Asthma

• Inflammatory disease that affects the airways causing a reversible airway obstruction

• Intermittent attacks are precipitated by specific triggering events

• Causes a decrease in the amount of oxygen and carbon dioxide exchanged

Asthma Classes

• Allergic– Present in 35%-55% of patients

Asthma Classes

• Allergic– Present in 35%-55% of patients

• Exercise Induced

Asthma Classes

• Allergic– Present in 35%-55% of patients

• Exercise Induced

• Nonallergic

Upper and Lower Respiratory Tracts

Exchange of Oxygen and Carbon Dioxide

Asthma

• Asthmatic lung is more sensitive to lower doses of allergens

• Asthma has shown to have genetic predisposition

Asthma Characteristics

1. Reversible small airway obstruction

2. Progressive airway inflammation

3. Increased airway responsiveness to stimuli

These characteristics translate into:1. Wheezing

2. Dyspnea

3. Acute and Chronic Cough

Asthma Attack – 1st Response

• Triggered by an antigen-antibody reaction

• Causes degranulation of mast cells: histamine released

• Results in bronchospasm and mucus production that plugs the small airways

Asthma Attack – 2nd Response

• Bronchoconstriction with delayed, sustained reactions

• Causes self-sustaining inflammation

Asthmatic Response

Peak Flow Meter

• Assesses severity of disease and aids in determining course of therapy

• Measures maximum flow rate in forced expiratory maneuvers

Goals of Asthma Care

• Sleep well every night

• Be able to go to work or school every day

• Be free from wheezing all day

• Have good control of coughing

• Be able to continue with activities and exercise

• Tolerate medicines well

Asthma Therapy

• Know the triggers and try to avoid them

• Accurately use a Peak Flow Meter regularly

• Be aware of status asthmaticus and the treatment for it.

**This is a medical emergency.**

Stepwise Approach to Asthma Therapy

Step 1. Short-acting oral or inhaled beta-2 agonist (less than once a week); no daily medications

Stepwise Approach to Asthma Therapy

Step 1. Short-acting oral or inhaled beta-2 agonist (less than once a week); no daily medications

Step 2. Short-acting oral or inhaled beta-2 agonist (not to exceed three to four times in one day); daily medications (e.g., inhaled corticosteroids)

Stepwise Approach to Asthma Therapy

Step 3. Short-acting oral or inhaled beta-2 agonist; daily medications (e.g., inhaled corticosteroid and long-acting bronchodilator)

Stepwise Approach to Asthma Therapy

Step 3. Short-acting oral or inhaled beta-2 agonist; daily medications (e.g., inhaled corticosteroid and long-acting bronchodilator)

Step 4. Short-acting oral or inhaled beta-2 agonist; daily medications; inhaled corticosteroid, long-acting bronchodilator, long-acting beta-2 agonist, and oral corticosteroids long term

Asthma Drug Therapy

• Treatment should start at the most appropriate step• Start with an aggressive initial approach• Rescue corticosteroids may be used at any time• Treatment should be reviewed every 3-6 months• For exercise-induced asthma, using terbutaline or

albuterol before exercise gives protection for 2 hours

Devices Used in Asthma Therapy

• Uses a stream of air that flows through liquid medication to make a fine mist to be inhaled

• Very effective• Must be cleaned and

taken care of to reduce risk of contamination

Nebulizer

Devices Used in Asthma Therapy

• Metered Dose Inhaler (MDI)– Contains medication and compressed air– Delivers a specific amount of medication with

each puff

Devices Used in Asthma Therapy

• Metered Dose Inhaler (MDI)– Contains medication and compressed air– Delivers a specific amount of medication with

each puff

• Spacer– Used with MDIs to help get medication into the

lungs instead of depositing on the back of the throat

Devices Used in Asthma Therapy

• Dry powder inhalers– Starting to replace MDIs– The patient turns the dial and a capsule full of

powder is punctured– The patient then inhales the powder

Asthma AgentsBronchodilators

• albuterol (Proventil, Proventil HFA, Ventolin, Ventolin HFA)

• epinephrine (EpiPen)• formoterol (Foradil)• ipratropium (Atrovent)• ipratropium-albuterol (Combivent)• isoetharine (Beta-2)

Drug List

Asthma AgentsBronchodilators

• isoproterenol (Isuprel)• levalbuterol (Xopenex)• metaproterenol (Alupent)• pirbuterol (Maxair)• salmeterol (Serevent)• terbutaline (Brethine)• tiotropium (Spiriva)

Drug List

albuterol (Proventil, Proventil HFA, Ventolin, Ventolin HFA)

• Used in cases of airway obstruction

• Relaxes bronchial smooth muscle with little effect on heart rate

• HFAs do not contain chlorofluorocarbons which deplete the ozone

levalbuterol (Xopenex)

• Isomer of albuterol

• Has fewer side effects than albuterol

• Must be used with a nebulizer

• Vials should be stored in foil package; once the foil is opened, vials must be used within 1 to 2 weeks

salmeterol (Serevent)

• Indicated for maintenance therapy

• Has a long duration of action

• Onset of action is 30-60 minutes

• Should not be used in rescue situations

• Available in MDI and dry powder inhaler

ipratropium (Atrovent)

• Blocks ACh in bronchial smooth muscle causing bronchodilation

• Used for prevention of attacks, not rescue situations

Atrovent Dispensing Issues

• If patient is allergic to peanuts, they may be allergic to the suspending agent in this inhaler

Warning!

ipratropium-albuterol (Combivent)

• Combination bronchodilator

• Should inquire about peanut allergy as well

Asthma AgentsXanthine Derivatives

• aminophylline (Truphylline)

• theophylline

Drug List

Asthma AgentsLeukotriene Inhibitors

• montelukast (Singulair)

• zafirlukast (Accolate)

• zileuton (Zyflo)

Drug List

Leukotrienes

• Increase edema, mucus, and vascular permeability

• 100 to 1,000 times more potent than histamine

• Inhibitors block the synthesis of or the body’s response to leukotrienes

montelukast (Singulair)

• Indicated for the prophylaxis and chronic treatment of asthma

• Do not use to treat acute attacks

• Approved for use in children over 12 months

• Used once a day

• Available in tablet and chewable tablet

Asthma AgentsCorticosteroids

• beclomethasone (Beconase,Vanceril)

• budesonide (Pulmicort, Rhinocort)

• dexamethasone (Decadron)

• flunisolide (AeroBid)

• fluticasone (Flonase, Flovent)

• hydrocortisone (Solu-Cortef)

Drug List

Asthma AgentsCorticosteroids

• methylprednisolone (Medrol Dose-Pack, Solu-Medrol)

• mometasone furoate (Nasonex)

• prednisolone (Orapred, Pediapred)

• prednisone (Deltasone)

• triamcinolone (Azmacort, Nasacort AQ)

Drug List

Corticosteroids

• Anti-inflammatory agent to suppress the immune response

• Inhibit late-phase inflammatory reaction

• Reserved for more difficult cases

Corticosteroid Side Effects

• Primary:– Oral candidiasis– Irritation and burning of the nasal mucosa– Hoarseness– Dry mouth

Corticosteroid Side Effects

• If used for a long period of time, it can cause:– Growth of facial hair in females– Breast development in males– Weight gain– “buffalo hump” – “moon face”– Easy bruising – Edema

Corticosteroid Dispensing Issues

• Patient should rinse mouth with water after using these inhalers to prevent oral candidiasis

• Patient should be taught how to correctly use these medications

Warning!

fluticasone (Flonase, Flovent)

• Flonase is a nasal spray used for allergies

• Flovent is an MDI that comes in 3 different strengths

• May take 2 weeks to reach maximum benefit

budesonide (Entocort EC, Pulmicort Respules, Pulmicort Turbuhaler,

Rhinocort)

• Pulmicort Turbuhaler – dry powder inhaler that is breath activated and is easier to use

• Coughing is a less frequent side effect

mometasone furoate (Nasonex)

• Decreases the amount of inflammation- causing chemicals that are released

• Reverses dilation and permeability of vessels

• May be used in children over 12 to prevent allergy symptoms

Asthma AgentsMast Cell Stabalizers

• cromolyn sodium (Crolom, Gastrocrom, Intal, Opticrom)

• nedocromil (Tilade)

Drug List

Asthma AgentsMonoclonal Antibody

• omalizumab (Xolair)

Drug List

Asthma AgentsCombination

• fluticasone-salmeterol (Advair Diskus)

Drug List

fluticasone-salmeterol (Advair Diskus)

• Combines corticosteroid (anti-inflammatory) and a beta-2 agonist

• Indicated for maintenance therapy in patients 12 years and older

• Available in powder for inhalation

Discussion

Are there any problems with this order?

Discussion

Are there any problems with this order?

Answer: Serevent should be used BID and shouldn’t receive 3 MDIs at a time…

Emphysema

• Characterized by destruction of air sacs

• Air sacs are not able to exchange oxygen and carbon dioxide

• Causes tachypnea which gives the patient a flushed look

Major Risk Factors For Emphysema

• Cigarette smoking

• Occupational exposure

• Air pollution

• Genetic factors

Bronchitis

• Lining of the bronchial airways becomes inflamed

• Acute

• Chronic

Bronchitis

• Lining of the bronchial airways becomes inflamed

• Acute – Runs a brief course

• Chronic – Longer lasting condition

Chronic Bronchitis

• Difficult to breathe out

• Characterized by cough that produces purulent, green, or blood-streaked sputum

• Major Risk Factors:– Cigarette smoking, occupational hazards,

fumes, environmental pollution, bacterial infection

The Body’s Defense System

• In a properly functioning lung:– Immune system provides good protection– Adequately removes potentially infectious

agents from the lungs

The Body’s Defense System

• In a properly functioning lung:– Immune system provides good protection– Adequately removes potentially infectious

agents from the lungs

• Types of Body Defense Cells:– Ciliary carpet: rhythmically moves fluid or

mucus away from the lungs

The Body’s Defense System

• Types of Body Defense Cells:– Goblet cells: produce mucus, increase due to

smoking– Epithelial cells: produce protein-rich exudate– Type I pneumocytes: phagocytes– Type II pneumocytes: synthesize and secrete

surfactant

Cellular Makeup of an Alveolus and Capillary Supply

COPD Agents

• acetylcysteine (Acetadote, Mucomyst) – Mucolytic

• dornase alfa (Pulmozyme) – Mucolytic

• tiotropium (Spiriva) – Anticholinergic

Drug List

Other Emphysema and Bronchitis Treatments

• Antibiotics are sometimes needed

• Oxygen therapy

• Expectorants (Water!!!)

• Receive flu and pneumonia vaccinations each year

Other Lung Diseases

• Prevention:– Do not smoke– Avoid second-hand smoke– Avoid air pollution– Get vaccinated– WASH HANDS

Pneumonia

• Common lung disease that affects all ages

• 3 ways to become infected:1. Inhalation of aerosolized particles

2. Entrance through the bloodstream

3. Aspiration

• Aspiration commonly occurs during sleep

X-Ray of Pneumonic Lung

X-Rays can be performed to check for pneumonia or to see the progression of the disease.

Discussion

Why is cigarette smoke implicated in many diseases that affect the lung?

Discussion

Why is cigarette smoke implicated in many diseases that affect the lung?

Answer: Destroys the walls of the lungs, including the protective mechanisms

Cystic Fibrosis

• Hereditary disease that affects the gastrointestinal and respiratory systems

• This is a fatal disease; death is associated with the pulmonary system

• Patients have an increase in production and viscosity of mucus as well as decreased pancreatic enzymes needed for digestion

Cystic Fibrosis Therapy

• Percussion

• Nebulizer therapy

• Antibiotic therapy

• Strict diets

Respiratory Distress Syndrome (RDS)

• Occurs in newborns during the first few hours of life

• Acute asphyxia with hypoxia and acidosis inhibit the production of surfactant

Respiratory Distress Syndrome (RDS)

• Occurs in newborns during the first few hours of life

• Acute asphyxia with hypoxia and acidosis inhibit the production of surfactant

• 2 Causes:– Prematurity– Maternal diabetes

Surfactants for RDS

• beractant (Survanta)

• calfactant (Infasurf)

• colfosceril palimate (Exosurf Neonatal)

• poractant alfa (Curosurf)

Drug List

beractant (Survanta)

• Drug of choice for RDS

• Extracted from cattle lung

• Lowers surface tension between the alveoli to keep them from collapsing

beractant (Survanta)

• Prophylactic therapy: for high risk infants

• Rescue therapy: to be used within 8 hours of birth

Tuberculosis

• Caused by mycobacterium tuberculosis

• Primarily affects the lungs, but may also affect the bone and kidney tissue

• Transmission: through inhaled droplets from an infected person (droplets descend 1-2 inches per hour)

Tuberculosis

• Seen primarily in:– Alcoholics– Prison population– Immunocompromised– Elderly

2 Classes of Tuberculosis

1. Exposed, but no disease• Test positive on TB test, but show no signs of

active disease

2 Classes of Tuberculosis

1. Exposed, but no disease• Test positive on TB test, but show no signs of

active disease

2. Exposed and have active organisms• Signs and symptoms are present: weight loss,

spitting blood, night sweats, night fever, chest pain, malaise

TB Test

• A protein derivative from killed bacteria is injected intradermally

• If the patient has been exposed to this organism, the test will be positive

• If positive, the patient must have x-rays taken to look for signs of active disease

Goals of TB Therapy

1. Initiate treatment promptly

2. Convert sputum culture to negative ASAP

3. Achieve cure without relapse

4. Prevent emergence of drug-resistant strains

Tuberculosis Agents

• capreomycin (Capastat)

• ciprofloxacin (Cipro)

• cycloserine (Seromycin)

• ethambutol (Myambutol)

• ethionamide (Trecator-SC)

• isoniazid(INH) (Laniazid, Nydrazid)

Drug List

Tuberculosis Agents

• isoniazid-pyrazinamide-rifampin (Rifater)• isoniazid-rifampin (Rifamate)• ofloxacin (Floxin)• pyrazinamide • rifampin (Rifadin, Rimactane)• rifapentine (Priftin)• streptomycin

Drug List

Treatment Regimens

• Patients with no symptoms, but a positive x-ray:– INH 300 mg QD X 12 months

Treatment Regimens

• Patients with no symptoms, but a positive x-ray:– INH 300 mg QD X 12 months

• Patients with clinical disease:– At least 2 agents at a time to prevent drug-

resistance

Multidrug Resistant Tuberculosis

• New strain has developed that is resistant to several drugs

• Risk factors for acquiring MDR-TB:– Being exposed to MDR-TB– Not completing TB therapy– Being prescribed the inappropriate agents– Having immune deficiencies– Having recurrence of TB

rifampin Side Effects

• Causes a reddish-orange discoloration of:– Urine– Tears, sweat– Other body fluids

• Can permanently stain soft contact lenses

Discussion

Why is patient compliance such an issue with tuberculosis patients?

Discussion

Why is patient compliance such an issue with tuberculosis patients?

Answer: Length of therapy, side effects, inherent in some patient groups

Histoplasmosis

• Fungal pulmonary disease• Caused by breathing in spores from

droppings of chickens, pigeons, starlings and other birds and bats

• Called the summer flu because of the flu-like symptoms

• Amphotericin B and itraconazole are used for treatment

Cough and Cold

• Common colds are the most prevalent respiratory tract infections

• Symptoms:– Mild malaise– Runny nose– Sneezing– Scratchy throat– Fever

Colds

• Bacterial sinusitis and otitis media are frequent complications warranting antibiotic therapy

• OTC remedies are often used for symptom relief

• Technicians should be knowledgeable about OTC preparations and be able to explain proper uses and side effects

Antitussives

• Coughing clears the airways of excess secretions and foreign materials

• Antitussives can be useful for dry, nonproductive coughs by causing:

1. CNS depression of the cough center (reflex)

2. Suppression of the nerve receptors in the respiratory tract

Cough Reflex

• Stimulated by stretch receptors and irritant receptors

• Follows a series of 6 events:1. Inspiration interrupts regular breathing rhythm

2. Thorax and abdominal muscles contract rapidly

3. Airway closes

Cough Reflex

4. Peristaltic muscular wave moves over the bronchi and bronchioles

5. Pressure forces the glottis open and the laryngeal muscles relax

6. Air flows outward, carrying mucus and foreign bodies

Antitussives

• benzonatate (Tessalon)

• codeine

• dextromethorphan (Delsym)

• diphenhydramine (Benadryl)

• hydrocodone-homatropine (Hycodan)

• promethazine-codeine

Drug List

AntitussivesDextromethorphan Combos

• dextromethorphan-pseudoephedrine-brompheniramine (Bromfed-DM, Myphetane DX)

• guaifenesin-dextromethorphan (Mucinex DM)

• promethazine-dextromethorphan

Drug List

codeine

• Considered the “Gold Standard”

• Has a drying effect on respiratory mucosa– Dangerous for patients with asthma or

emphysema

• Can be purchased without a prescription in some states; dispensing must be done by the pharmacist

Codeine Side Effects

• Nausea

• Drowsiness

• Light-headedness

• Constipation

benzonatate (Tessalon)

• Has local anesthetic effects

• Numbs the stretch receptors in the airway, lungs, and pleura

• Very dangerous if chewed

dextromethorphan (Delsym)

• Works as well as codeine without analgesic properties

• Does not depress respiration or have abuse potential

• Often combined with other cough and cold preparations

Expectorants

• Help rid the lungs and airway of mucus when coughing

• Decrease thickness and stickiness of mucus, decrease viscosity and increase expectoration of mucus

• Used for dry and productive coughs

Water

• Can work as well as, if not better than, medication expectorants

• Staying well-hydrated thins mucus and allows for easier expectoration

Expectorants

• guaifenesin (Mucinex)

• potassium iodide (Iossat, Lugol solution)

• guaifenesin-codeine (Robitussin A-C)

• guaifenesin-pseudoephedrine (Mucinex D)

Drug List

guaifenesin

• Loosens phlegm and thins bronchial secretions

• Available in capsule, tablet, sustained-release, and liquid forms

• Frequently combined with other cough and cold preparations

• Okay for patients with asthma or emphysema

Decongestants

• Swelling and stuffiness are caused by vasodilation and leakage of fluids into the nasal mucosa

• Decongestants cause constriction which promotes drainage, improves nasal ventilation, and relieves stuffiness, which then allows the sinus cavities to drain

Decongestants

• Length of therapy should not exceed 3-5 days

• Topical decongestants may cause rebound rhinitis medicamentosa

• Available in topical and oral forms

Decongestant Dispensing Issues

• Should be avoided in patients with:– Diabetes– Heart disease– Uncontrolled hypertension– Hyperthyroidism– Prostatic hypertrophy– Tourette’s syndrome

Warning!

Decongestants

• pseudoephedrine (Sudafed)

Combinations:

• APAP-clemastine-pseudoephedrine (Tavist Allergy/Sinus/Headache)

• brompheniramine-pseudoephedrine (Efidac 24)

Drug List

DecongestantsPseudoephedrine Combos

• cetirizine-pseudoephedrine (Zytrec-D)

• dexbrompheniramine-pseudoephedrine (Drixoral)

• fexofenadine-pseudoephedrine (Allegra-D)

• ibuprofen-pseudoephedrine (Advil Cold and Sinus, Sine-Aid IB)

Drug List

DecongestantsPseudoephedrine Combos

• loratadine-pseudoephedrine (Claritin D)

• naproxen-pseudoephedrine (Aleve Cold and Sinus)

Drug List

Decongestant Side Effects

• Oral:– Anxiety– CNS stimulation– Dizziness– Hallucinations– Headache– Increased BP– Increased heart rate– Insomnia– Tremor

• Topical:– Burning sensation– Contact dermatitis– Dry mouth– Rhinitis

medicamentosa– Sneezing– Stinging sensation

pseudoephedrine (Sudafed)

• Most-used decongestant; available in many combinations

• Current evidence shows that if hypertension is well controlled, these patients may be able to take decongestants

• Will very likely become a prescription drug due to abuse potential

Antihistamines

• Histamine is found throughout the body

• Causes increased gastric secretions, increased heart rate, and mediates hypersensitivity

• 2 Types of histamine receptors:– H1 – located in upper respiratory system

– H2 – located in gastrointestinal tract

Antihistamines

• Well absorbed and widely distributed in tissues

• Crosses the blood-brain barrier– Causes sedation

• Crosses the placenta– Adversely affects fetus

Antihistamines (H1)

• azatadine (Optimine)

• azelastine (Astelin, Optivar)

• cetirizine (Zyrtec)

• clemastine (Tavist Allergy)

• cyproheptadine

• desloratadine (Clarinex)

Drug List

Antihistamines (H1)

• diphenhydramine (Benadryl)

• fexofenadine (Allegra)

• hydroxyzine (Atarax, Vistaril)

• loratadine (Claritin)

• meclizine (Antivert)

• promethazine (Phenergan)

Drug List

Antihistamine (H1) Combinations

• brompheniramine-dextromethorphan-pseudoephedrine (Bromfed-DM)

• chlorpheniramine-pseudoephedrine (Chlor-Trimeton)

• hydrocodone-chlorpheniramine (Tussionex)

• triprolidine-pseudoephedrine

Drug List

Therapeutic Uses

• Allergies• Insomnia• Rash, edema, and hay

fever• Cough• Vertigo• Nausea and vomiting• Serum sickness

• Control venom reactions

• Lessens extrapyramidal side effects of antipsychotics

• Prevent certain drug reactions and allergies

• Hypersensitivity

Hypersensitivity Reactions

• Excessive immune response to a foreign agent

• Can range from a rash to a deadly reaction

Antihistamine Side Effects

• Anticholinergic responses– Dry mouth– Drying of the URT mucosa– Blurred vision– Constipation– Urinary retention

• Hyperactivity in some children• Sedation is the most common

Smoking Cessation

• On average, cigarette smokers lose about 15 years of life

• The smoke contains 4,000 chemical compounds with at least 43 carcinogens

• Secondhand smoke contains all 43 carcinogens

Smoking

• Can lead to:– Leukemia

– Cancers of the mouth, pharynx, larynx, esophagus, pancreas, cervix, kidney, bladder, ovaries, uterus, and prostate

• Increases risk of:– Heart disease

– COPD

– Stroke

Smoking

• Is related to birth defects of smoking mothers

• Secondhand smoke puts children at risk of developing asthma

• Nicotine can react with certain medications

Nicotine Effects

• CNS and PNS stimulation and depression

• Respiratory stimulation

• Skeletal muscle relaxation

• Increase in BP

• Increase in heart rate• Increase in cardiac

output• Increase in oxygen

consumption• Physical and

psychological dependence

Personal Benefits to Smoking Cessation

• Improved performance in sports and sex

• Better-smelling home, car, clothing, and breath

• Economic savings• Freedom from

addiction• Healthier babies

• Improved health• Improved self-esteem• Improved sense of

taste and smell• No concern about

exposing others to smoke

• Setting a good example

5 Step Quit Plan

1. Set a date

5 Step Quit Plan

1. Set a date

2. Inform family, friends and coworkers

5 Step Quit Plan

1. Set a date

2. Inform family, friends and coworkers

3. Remove cigarettes from daily life

5 Step Quit Plan

1. Set a date

2. Inform family, friends and coworkers

3. Remove cigarettes from daily life

4. Review previous attempts and analyze what caused relapse

5 Step Quit Plan

1. Set a date

2. Inform family, friends and coworkers

3. Remove cigarettes from daily life

4. Review previous attempts and analyze what caused relapse

5. Anticipate challenges

Smoking Cessation

• Abstinence is the key

• Some fears that keep people from quitting:– Weight gain– Nicotine withdrawal

Symptoms of Nicotine Withdrawal

• Anxiety• Craving tobacco• Decreased blood

pressure and heart rate• Depression• Difficulty in

concentrating• Drowsiness

• Frustration, irritability• Gastrointestinal

disturbances• Headache• Hostility• Increased appetite• Increased skin temp• Insomnia

Smoking Cessation Agents

• bupropion (Wellbutrin SR, Zyban)

• nicotine (Commit, Habitrol, Nicoderm CQ, Nicorette, ProStep, Nicotrol)

Drug List

Smoking Cessation Agent Dispensing Issues

• Smoking while on nicotine replacement therapy could cause signs of nicotine excess

Warning!

Symptoms of Nicotine Excess

• Abdominal pain• Confusion• Diarrhea• Dizziness• Headache• Hearing loss

• Hypersalivation• Nausea• Perspiration• Visual disturbances• Vomiting• Weakness

Smoking Cessation Agent Dispensing Issues

• Lozenges should not be chewed

• Patch application site should be rotated to prevent skin reactions

Warning!

Discussion

You are trying to get a friend to stop smoking. Name 5 reasons he/she should quit.