DENT 3005: Introduction to Pharmacology¹

Respiratory Drugs²

Dr Thuy Linh Truong thuy.truong@uwa.edu.au Acknowledgement: Sheetal Maria Rajan

	Emphysema “Pink Puffers”	Chronic Bronchitis “Blue Bloaters”
Usual Presentation	Shortness of breath and scant sputum production	Chronic productive cough
General Appearance	Thin, sometimes cachectic, with rosy skin tones	Often overweight, obese
Adventitious Sounds	Less common	Ronchi and Wheezes
Sputum	Scanty, Mucoid (Evaporated Milk)	Copious, Purulent (Condensed Milk)
Cough	Dyspnea before cough (less prominent)	Cough before dyspnea (more prominent)
Cor Pulmonale	Rare, except at the late stages	More prominent
Radiographic Findings	Hyper-inflated lungs	Normal sized lungs
	Small heart	(R) Ventricular hypertrophy
	Diaphragm: low & flat	Normal shaped diaphragm
	+/- bullae (pockets of air)	(+) Dirty lung appearance
Other Findings	(+) Barrel Chest	(+) Cyanotic
	(+) Use of accessory muscles of respiration	(+) Peripheral Edema

Drug Therapy Comparison³

ASTHMA	COPD
- Short acting Beta₂ Agonist	- Short acting bronchodilators
- ICS	- SABA
- Long acting Beta₂ agonist	- SAMAs
- Always with ICS	- Long-acting bronchodilators
- Montelukast	- LABAs
- Omalizumab	- LAMAs
	- Corticosteroids
	- No role in monotherapy
	- Other
	- Theophylline

Respiratory Medications⁴

Category	Medications
Relievers	- SABA (Short-acting $β 2$ agonist) - LABA (Long-acting $β 2$ agonist with Rapid onset)
Preventers	- ICS (Inhaled Corticosteroids) - Leukotriene Modifiers - Mast Cell Stabilizers
Adjuvant	- LABA - Theophylline - Anti-immunoglobulin (IgE) – Omalizumab - Anti-interleukin-5 (IL5) - Mepolizumab - LAMA (Long-acting muscarinic antagonist)

Drug Classes in Detail⁵

Short acting Beta₂ Agonists – (SABAs) Relievers

MOA: relax bronchial smooth muscle
Indication
- Sx relief of asthma & COPD
- Prevention of exercise induced bronchoconstriction
ADR
- Tremor, palpitations, headache
- Serious hypokalemia in high doses
Salbutamol (Ventolin/asmol)
- 100-200mcg prn
Terbutaline (Bricanyl)
- 500-1500mcg prn

Long acting Beta₂ Agonists (LABAs) Relievers⁶

MOA: relax bronchial smooth muscle
Indication
- Maintenance tx of asthma in patients on inhaled/oral CS
- COPD
ADR
- Tremor, palpitations, headache
- Serious hypokalemia in high doses
Eformoterol (Turbuhaler/Rapihaler)
Indacaterol (capsules)
Salmeterol (MDI/Accuhaler)

Description of the product images: Inhalers and their packaging, including Symbicort Turbuhaler, Onbrez Breezhaler, and a Seretide diskus.

Short acting anticholinergic (SAMAs)⁷

MOA
- Relaxes airway smooth
- Block M3 muscarinic receptor
- Rapid bronchodilation (15-30 mins)
Indication
- Initial management of sx in mild COPD
- Severe acute asthma attack when SABA is inadequate
ADR
- Dry mouth, throat irritation
Ipratropium (Atrovent)

Long acting anticholinergic (LAMAs)⁸

MOA
- Relaxes airway smooth
- Block M3 muscarinic receptor
Indication
- Treatment of COPD
ADR
- Dry mouth, throat irritation
Tiotropium (Spiriva)
Glycopyrronium (Seebri)

Dental Implications of Specific Drug Classes⁹

Beta₂ agonists & anticholinergics

Anticholinergics: lower saliva secretions
- Dry mouth $\to$ caries risks
Combination w/ ICS
- Oral candidiasis
Patient factors
- Sx control: increase inhaler use increases dental risks
- Oral hygiene: poor oral hygiene predispose to increase caries risks

Xanthine Bronchodilator¹⁰

MOA
- Relax smooth muscles in AW
- Reduce AW responsiveness to histamine, adenosine, methacholine & allergens
Indication
- Severe AW obstruction, including acute asthma
- Maintenance tx in severe asthma & COPD
Side effects
- Nausea, vomiting, GORD, headache, anxiety, tremor, palpitations
Aminophylline & theophylline
Not commonly used

PDE inhibitors Dental implications¹¹

Narrow therapeutic index
- Know signs of adverse effects
Drug interaction(s)
- Acyclovir
- Benzodiazepine
- Beta₂ agonists
- Macrolide Abs (alternative in penicillin allergy)
Patient factors
- Can they be placed in supine position?

Inhaled Corticosteroids (ICS)¹²

MOA
- Reduce AW inflammation and bronchial hyper-reactivity
Indication
- Maintenance tx of asthma and COPD
Side effects
- Dysphonia, oropharyngeal candidiasis, facial irritation w/ nebs
Inhalations: single agent or combination w/ Beta₂ agonist
Oral: acute severe asthma, not for prevention

Corticosteroids¹³

Inhaled	Oral
- Beclomethasone	- Hydrocortisone
- Qvar	- Solu-cortef inj
- Budesonide	- Methylprednisolone
- Pulmicort	- Methyl-pred, solu-Medrol inj
- Ciclesonide	- Prednisolone
- Alvesco	- Solone, predmix, redipred
- Fluticasone
- Flixotide

ICS in the dental setting¹⁴

Side effects
- Oropharyngeal candidiasis
- Increased susceptibility to infection*
- Impaired wound healing*
- *Prolonged oral dose
Increase carries risks
Pregnancy before 12 weeks linked w/ orofacial cleft
Drug interaction
- Budesonide, fluticasone, methylprednisolone + azole: increase steroid adverse effects
- Aspirin: decrease salicylate concentration
- NSAIDs + oral steroids: increase risks GI ulceration

Corticosteroids ADRs¹⁵

Infection
Delayed wound healing
Steroid rosacea
Perioral dermatitis
Skin atrophy
Bruising
Acne
Facial flushing
Pupura
Depigmentation
Telangiectasia
Steroid induced crushing’s

Leukotriene receptor antagonist¹⁶

MOA
- Inhibit cysteinyl leukotriene receptor
- Antagonist AW smooth muscle contraction
Indication
- Maintenance tx of asthma
- Prevention of exercise induced bronchoconstriction
Side effects
- Headache, nausea, vomiting, abdominal pain
Montelukast (singulair)

Monoclonal antibody against IgE¹⁷

MOA
- Reduces immune’s system response to allergen
Indication
- Maintenance tx of mod-severe allergic asthma in patients tx w/ ICS and w/ raised serum IgE levels
Side effects
- Inj site rxn, rash, bleeding
Omalizumab
- Xolair

Description of the drug presentation: Xolair (omalizumab) Injection 150 mg/mL pre-filled syringe

Other Monoclonal Antibodies¹⁸

Benralizumab (Fasenra 30ng inj)
- Binds to and blocks the interleukin-5 receptor
- ADR: pharyngitis
Dupilumab (Dupixent 200mg, 300mg inj)
- Inhibits activity of the cytokines interleukin-4 and -13
- ADR: labial herpes simplex
Mepolizumab (Nucala 100mg inj)
- Binds to interleukin-5 (IL-5), reducing the production and survival of eosinophils
- ADR: infections, nasal congestion

Cromones, Leukotriene Receptor Antagonists & Monoclonal Anti-IgE in the Dental Setting¹⁹

Medication factors
- No serious drug interactions
- Adverse rxn relating to cough & throat irritation
- Omalizumab: monitor bleeding
Patient factor: sx control of asthma

Asthma & COPD in the Dental Setting²⁰

Medications side effects
- Dry mouth → caries risks
- GORD
- Oropharyngeal candidiasis
- Enamel defects
- Periodontal disease
Patient factors
- Precipitating factors: avoidance
- Sx control
- Analgesic considerations
Recognize signs & symptoms of acute attack

Implications for Dentistry²¹

Oral Health

Preventative care
Mouth breathing
Reduced salivary flow
Increase risk dental decay

Patient education

Regular check ups
Dietary advice
Monitor dry mouth & tx accordingly
Spacer device
Rinse after ICS

Implications for Dentistry (Continued)²²

Hypoxia in COPD: impairs oral health and delays wound healing
Breathing difficulties: medications and physical limitations affect oral breathing
Xerostomia: reduced saliva due to anticholinergics and $β 2$ agonists
Inhaled corticosteroids: risk of oral candidiasis
Preventive care: rinse mouth after use, maintain regular brushing

Use of Oral NSAIDs in Uncontrolled Asthma²³

Oral NSAIDs may worsen uncontrolled asthma
Inhibit cyclooxygenase (COX) enzymes
Leads to overproduction of cysteinyl leukotrienes (CysLT)
Increases type 2 eosinophilic inflammation
Results in increased bronchoconstriction and asthma exacerbation
Management: Use inhaled corticosteroids $\pm$ long-acting $β_{2}$ agonists

NSAID-Exacerbated Respiratory Disease (NERD)²⁴

Moderate-to-severe asthma
Increased risk of chronic rhinosinusitis/nasal polyps
NSAIDs (e.g., aspirin, ibuprofen) can worsen respiratory symptoms
Management:
- Inhaled corticosteroids ± long-acting β2 agonists
- Acetaminophen preferred for pain relief over NSAIDs

Image depicting a Seretide $Accuhaler$ device and packaging

Seretide Accuhaler

50/250 mcg

Salmeterol

Fluticasone Propionate

Powder for inhalation

$1 Accuhaler$

$60 inhalations$

Signs of poor asthma control²⁵

Use of relivers >3x/week (not during times of illness/exercise)
Sx of asthma on most days of the week
- Wheezing, coughing etc
Early-morning or night-time sx at least once a week
Frequent exacerbation of asthma at least every 6wks
Poor level of peak expiratory flow
- Less than 80% of their best score
Attacks may occur infrequently but are life threatening or severe
Referral to MGP for assessment and medication review

Community first aid protocol²⁶

Rule of 4’s

Sit the patient comfortably in an upright position
Give 4 puffs of salbutamol
Give each puff one at a time, with 4 breaths after each puff
Use a spacer if possible
Wait 4 minutes
If no improvement give 4 more puffs
If still no improvement call 000 immediately
Continue to give 4 puffs every 4 minutes until the ambulance arrives

Terbutaline / ICS+LABA

Give 2 doses initially, wait 4 minutes then give 1 more dose
If no improvement call 000 and continue to give 1 dose every 4 minutes

References²⁷

Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. Rang & Dale’s pharmacology. 10th ed. Edinburgh: Elsevier; 2023
Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Respiratory, Genitourinary; [updated 2025; cited 2025]. Available from: UWA Onesearch
Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021
Ali K. Clinical dental pharmacology. 1st ed. Oxford: Wiley-Blackwell; 2023
Bullock S, Manias E. Fundamentals of pharmacology. 8th ed. Frenchs Forest, NSW: Pearson Australia; 2017
MIMS Australia. eMIMSelite: Consumer medicine information, specific clinical monograph [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. Available from: UWA Onesearch

Opioid cough suppressants²⁸

MOA
- Depress medullary cough centers
Indication
- Symptom relief in non-productive cough
Side effects
- Drowsiness, constipation, nausea, vomiting
Precaution
- Asthma
Contra-indication
- COPD
Codeine, dextromethorphan, dihydrocodeine, pholcodine

Mucolytics

MOA
- Reduce mucous viscosity & aid expectoration
Indication
- Adjunct in disease w/ excessive mucous production
Side effects
- Nausea, bronchospasm, cough
Not for chronic bronchitis & COPD
Acetylcysteine, bromhexine

Discontinued: Cromones²⁹

MOA
- Inhibit release of inflammatory mediators from mast cells
Indication
- Maintenance tx of asthma
- Prevention of exercise induced bronchoconstriction
Side effects
- Cough, throat irritation, bitter taste, transient bronchospasms
Cromoglycate
Nedocromil

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L7 Respiratory System2025_formatted_text

DENT 3005: Introduction to Pharmacology1

Respiratory Drugs2

Drug Therapy Comparison3

Respiratory Medications4

Drug Classes in Detail5

Short acting Beta₂ Agonists – (SABAs) Relievers

Long acting Beta₂ Agonists (LABAs) Relievers6

Short acting anticholinergic (SAMAs)7

Long acting anticholinergic (LAMAs)8

Dental Implications of Specific Drug Classes9

Beta₂ agonists & anticholinergics

Xanthine Bronchodilator10

PDE inhibitors Dental implications11

Inhaled Corticosteroids (ICS)12

Corticosteroids13

ICS in the dental setting14

Corticosteroids ADRs15

Leukotriene receptor antagonist16

Monoclonal antibody against IgE17

Other Monoclonal Antibodies18

Cromones, Leukotriene Receptor Antagonists & Monoclonal Anti-IgE in the Dental Setting19

Asthma & COPD in the Dental Setting20

Implications for Dentistry21