Arrive at 7:30 AM

Give Labs
Check fridge temperature and record minimum, average, and maximum
9:15 host morning meeting

● First, thank you for spending your Saturday together with us. It means a lot to our patients.
Thank you for everyone your hard work and contributions.
● Ok, let's go back to the announcements.
● NEXT CLOSE DATE is on Saturday, the March 16, 2019 (the first day of spring break of the
medical school)
● We have liver-ultrasound on Sunday, March 3rd and Cardiopulm on Sunday, March 10th.
● Notify me of time sensitive labs in the morning, and Michelle in the PM shift.
● Remember to Initial your names next to the name of the preceptor (Cods/Officers have been
forgetting to do this. So it is just a quick reminder)
● List all labs at the end of your SOAP note (if no labs have been done, still write “No labs”)
● Review all labs results from previous encounters (regardless of reason of visit)
● Check tubes/needles for expiration before use
● Check IMI cards for updates and compliance
○ MSs please review the IMI cards with every patient, even if you are not making medication
changes. This means go over every listed medication on the card and asking the patient
about any other meds they are taking then updating the card to reflect what the patient told
you. It's very important for our patients to have an up to date record of the medications they
are taking, for both their own use and for emergencies.
● Guest MS/PA Student volunteers - send notes to me or Michelle to upload.
● All patients who go to specialty clinics must also be seen at Saturday primary care clinic and
receive routine blood test screenings here.
○ Remember to fill in blue lab tracking sheets as well.
● Also, we have dermatology clinic today. Two dermatologists are coming in today at 10am. So MSs
please be ready to represent to them if any of your patients have dermology-related problem.
● There’s all the announcements that I got. ​Are there any other announcements?

Drug of the Week

Drug: albuterol
Common Market name: Proair, Ventolin

It is a beta-2 agonist used to treat sudden constriction of the bronchioles that usually triggered by asthma. It
treats COPD (chronic obstructive pulmonary diseases) as well. It is also one of the most common medicines
used in rescue inhalers as a short-term bronchodilator to alleviate asthma attacks.

Class:
So it is a short-acting Beta-2 agonist Bronchodilator

Indications:
It is used in adults and children older than 4 years old for the management of asthma and acute asthma
attacks as well as the prevention of exercise-induced asthma, wheezing and shortness of breath
Also, it is used in treatment of COPD as well.
Mechanism of Action:
It activates beta2- receptors on the airway smooth muscle leads to the activation of (I-denter-low side-lase)
adenylyl cyclase, which increases in the intracellular concentration of cyclic AMP. The increase of cyclic
AMP leads to the activation of protein kinase A, which inhibits the phosphorylation of myosin and reduces
the intracellular calcium concentrations, resulting in smooth muscle relaxation. So, Albuterol relaxes the
smooth muscles of all airways, from the trachea to the terminal bronchioles. The increase in cyclic AMP also
inhibits inflammatory cells in the airway, such as basophils, eosinophils, and especially mast cells. It inhibits
them from releasing inflammatory mediators and cytokines. This can reduce the swelling of the airway, so
we have bigger airway, less resistance for breathing, and higher vital capacity.

Routes of Administration:
Albuterol can be administered as oral tablets or oral solution but is more commonly administered by
inhalation.

Dosage:
In people older than 4yro: 180 mcg (2 puffs) every 4 to 6 hours as needed. In some patients, 90 mcg (1 puff)
every 4 hours may be enough. FDA-approved labeling recommends to not exceed 12 puffs/day. But for the
acute treatment of severe episodes, the National Asthma Education and Prevention Program recommends
4 to 8 puffs every 20 minutes for up to 4 hours, then 4 to 8 puffs every 1 to 4 hours as needed.

Exercise–induced asthma prevention: 2 puffs 15 minutes before exercise. Because it take 5-15 minutes for
the drug to be effective.

In children younger than 4yro: usually not recommended as there are three clinical trials of albuterol
administered with a holding chamber and face mask failed to show a significant improvement in asthma
symptom children younger than 4 year old.

Pharmodyanamics/Kinetics
Albuterol can cross the blood-brain barrier and may cross the placenta. The liver extensively converts
albuterol to inactive compounds. The elimination half-life of albuterol ranges from 2.7 to 6 hours, with orally
administered albuterol having a shorter half-life than the albuterol inhaler.

Absorption ​Albuterol is absorbed in the airway and GI tract. Onset of action in the airway occurs within 5 to
15 minutes after 2 puffs of inhalation, peaks in 0.5 to 2 hours, and last for 2 to 6 hours. Onset of action in
the GI tract within 30 minutes, peak levels are reached in 2 to 3 hours, and duration of action is 4 to 6 hours.
Excreted:​ Albuterol is filtered out by the kidneys and excreted in the urine. 80% to 100% of a dose is
excreted within 72 hours.

Cost:​ Costco $52, Walgreens, CVS and Walmart are $51 for one 18g inhaler.

Side Effects:
Stimulation of beta2-receptors on peripheral vascular smooth muscle can cause vasodilation and so a little
bit of decrease in diastolic blood pressure. Stimulating beta2 receptor also results in accumulation of
intracellular potassium due to stimulation of the Na/K pump, so we have more potassium in the cell and less
potassium in the blood, leading to hypo​ka​ lemia in the blood.
Other side effects;
(Tram-ma)Tremor, anxiety, headaches, dizziness, hyperactivity, fatigue, tachycardia, irritation
(ir-Read-ation) of throat, hypersensitivity reactions (eg, rash)

Drug Interactions/Contraindications:

1. Of course it is not a smart idea to use albuterol and beta blockers together
Good thing is that usually patients with asthma will not be treated with beta-blockers. But in situation like
heart failure and there are no better alternatives and patient needs beta-blockers. It could be a problem.

2. Diuretics
The EKG changes (longer QT) and/or ​hypokalemia result from the administration of
non-potassium-sparing diuretics (such as loop or thiazide diuretics) can be acutely worsened by
albuterol, especially when we use more than the recommended dose.

So the take home message, do not use more than the recommended dosages; death have been reported in
association with excessive use. Also use with caution on patient with cardiovascular disease (eg, coronary
insufficiency, arrhythmias, hypertension). diabetes. Hyperthyroidism or seizure disorders. They need regular
re-evaluation.

Pregnancy and nursing mothers are not recommended to use albuterol because of the potential for it to
interfere with contraction of the uterus. Only using it in situation when benefits clearly outweigh the risk.

Also, Albuterol is classified as an FDA Pregnancy Category C drug. Animal reproduction studies have
shown malformation of the palate on the fetus, but there are no adequate and well-controlled studies in
humans, so pregnant women can still use it but Use it with caution.