Pharm Test 3: drugs affecting calcium levels and bone mineralization, Drug therapy of Gout, Pharm Exam 5: Chapter 75 - Calcium Levels & Bone Mineralization Part B, week 6 A/C Agonists & Antagonists, Drug Therapy for Rheumatoid Arthritis & gout, Advan...

Nurse Resp. for ALL Adrenergics

- monitor BP & HR - report tachycardia, palpitations, dizziness, increased BP - may give w/ food - monitor urinary output (urinary retention) - monitor blood glucose levels (hyperglycemia) - avoid OTCs

Ach

- present at all preganglionic neurons, all postganglionic neurons of parasympathetic system, all motor neurons to skeletal muscle, postganglionic to sweat glands

Lithium Cautions

-Abormal sodium loss = dehydration -Dangers in Pregnancy Cardiovascular malformation, *kidney damage*, euthyroid goiter, hypoglycemia

Factors Affecting Excretion

-Age -Concomitant disease -pH dependent ionization (urine) -Competition for active tubular transport

Dextromethorphan

-Antitussive (antagonizes NMDA glutamate receptors). -Synthetic codeine analog. Has mild opioid effect when used in excess. -Naloxone can be given for overdose. Mild abuse potential. -May cause serotonin syndrome if combined with other serotonergic agents

Enzyme Inhibition

CYP Substrate + CYP Inhibitor --> increased substrate concentration and decreased risk of toxicity

Biphosphonates

Alendronate (Fosamax) prevent and treat bone loss (dexa scan and bone density test to diagnose)

Drugs for hyperuricemia

Allopurinol, Probenecid

Alpha blockers in BPH

reduce contract of smooth muscle in prostatic capsule and bladder neck (trigone&sphincter) s/s= daytime freq, dysuria, nocturia, hesitancy, urgency, sensation of incomplete void= improve

Dyskinesias managed in (3) ways

reduce levodopa dose (PD may re-emerge) give amantadine (works in some) surgery and electrical stimulation (if above fail)

T or F: Somatic motor neurons always release ACh and effect is always excitatory, while autonomic motor neurons release either ACh or NE and they can e excitatory or inhibitory

TRUE

somatic nervous system

the division of the peripheral nervous system that controls the body's skeletal muscles

MAO-B

the enzyme that inactivates dopamine in striatum

erectile dysfunction (ED)

the inability of the male to attain or maintain an erection sufficient to perform sexual intercourse

Preparations: Carbidopa alone

Name: Lodosyn available at special request when carbidopa added to L/C combo it can ↓ levodopa induced N/V allows↓levodopa dose-promotes ↑fast response

Reversible Cholinesterase Inhibitors

Neostigmine (Prostigmin) Physostigmine Ambenonium, eddrophonium, pyridostigmine Echothiophate Drugs for Alzheimer disease

Febuxostat (Uloric)

New and expensive Alternative to Allopurinol Reduces blood levels of uric acid Used for chronic tophaceous gout

Rhabdomyolysis

dissolution of striated muscle (caused by trauma, extreme exertion, or drug toxicity; in severe cases renal failure can result)

teratogenic

disturbance of the development of a fetus or embryo

Anti-depressants - What is the main neurotransmitter involved?

Norepinephrine

transmitter released by practically all postganglionic neurons of the sympathetic nervous system

Norepinephrine

Glucocorticoids used as antiemetic

Not approved by FDA. Solumedrol and dexamethasone. Given IV.

Defective genes coding for all (3) proteins have been found in

families with inherited forms of of PD.

sympathetic

fight or flight

sloughing

formation of dead tissue that separates from living tissue

A drug that induces a loss of consciousness is a

general anesthetic

Failure to degrade alpha-synuclein appears to result from (2) causes

genetic vulnerability toxins in the environment

describe Transmitter Storage

Once transmitter is synthesized, it must be stored until the time of its release Transmitter storage takes place within vesicles - tiny packets present in the axon terminal

Dual control

Organs may receive dual innervation from parasympathetic and sympathetic causing opposing responses

Potential interventions to IMPROVE or MAINTAIN cognitive function: SOCIAL/BEHAVIORAL FACTORS

QUALITY OF EVIDENCE SHOWS SMALL PROTECTIVE EFFECT: Cognitive Training Physical Activity Non-Cognitive, Non-PhysicalLeisure Activity

The nurse is teaching a client how to recognize the symptoms of a cholinergic crisis. The nurse knows that the client understands the information when she identifies which as symptoms of this type of crisis? Select all that apply. Rapid heart rate Headache Mydriasis Nausea Muscle weakness

Rapid heart rate Headache Nausea Muscle weakness

Ballismus

Rapid involuntary jerking or clinging of proximal muscle groups

The Parasympathetic Nervous System

goes all the way across and its end point is a Muscarinic receptor, and ACh is the neurotransmitter that works on that receptor.

therapeutic agents that alter the sympathetic nervous system are used primarily for effects on the

heart, blood vessels, and lungs

bisphosphonates

help with osteoporosis pts by treating their calcium levels - "nate" alendronate risedronate ibandronate tiludronate etidronate zoledronate pamidronate

Alpha 1 adverse effects

hypertension, necrosis, bradycardia

overview of motor symptom management- therapeutic goal

ideal tx doesn't exist no cure, prevention, or reversal only provide symptomatic relief no convincing proof of delayed progression improve ability to perform ADLs

Physical measures should also be used for spasm:

immobilization cold press whirlpool baths PT

Entacapone does what?

inhibits catechol-O-methyltransferase

Parenteral Administration

injectable IV, IM, SC, intra-articular, intrathecal

epi-pen

injectable epinephrine used by pts with severe allergies, high risk for anaphylaxis injected into the thigh must carry at all times

Zolpidem (Ambien)

insomnia Ambien, Edluar, and Zolpimist are used to help you fall asleep when you first go to bed. Intermezzo, is used to help you fall back to sleep if you wake up in the middle of the night and then have trouble sleeping.

Selegiline drug interaction with levodopa

intensifies adverse effects of levo psych, dysk, OH

adrenal medulla

neuroendocrine tissue associated with the sympathetic branch

muscle relaxants

relieve muscle spasms and stiffness Possible side effects 1. Drowsiness or dizziness. 2. Possible addiction or dependence. 3. Dry mouth. 4. Urinary retention.

Dopamine agonists- Disadvantages

serious side effects: hallucinations daytime sleepiness postural hypotension USUALLY reserved for YOUNGER patients -tolerate side effects better than older pts do

Ergot Derivatives cause mild blockage of

serotonergic and alpha-adrenergic receptors = more side effects

Somatic Nervous system

single neuron, CNS origin, myelinated

*raloxifene [evista]*

structurally similar to estrogen and binds to estrogen receptors therapeutic uses: - osteoporosis - breast cancer adverse effects: - *thromboembolic events* (ex: DVT) - pulmonary embolism - stroke - fetal harm

neurochemical basis of parkinsonism

too little striatal dopamine too much acetylcholine

Mesalamine

treats ulcerative colitis

Schedule 3 controlled substances

Substances with some potential for abuse and with currently accepted medical uses. Abuse may lead to moderate or low physical dependence or high psychological dependence. Examples - Codeine, Ketamine, Anabolic Steroids, Opium or Morphine Mixtures

Which supplies more organs? Parasympathetic or sympathetic?

Sympathetic

parasympathetic effect of the bladder

urine release

sympathetic effect of the bladder

urine retention

Tizanidine promotes presynaptic inhibition by

acting as an agonist at presynaptic alpha2 receptors

Levodopa enters the brain through

active transport that carries it across BBB

drugs that tx spasticity do not tx _____

acute muscle spasm

herpes simplex Treatment

acyclovir, famciclovir, valacyclovir

atropine

anticholinergic drug that blocks muscarinic ACh receptors (dries up salvations during surgery, dilates pupils for eye exams, speeds up HR)

Pegloticase

Accelerates uric acid secretion

Haloperidol

Antipsychotic

Renal Excretion

Depends on the GFR, impaired renal function = drug dose adjustment Estimate GFR with creatinine clearance using Cockroft and Gault Formula --> creatinine is a measure of muscle breakdown and is 100% filtered by kidneys

Analgesic

(chiefly of a drug) acting to relieve pain. Tylenol!

what is highest normal BP

140/90

Beta blockers reduction of preoperative mortality

BB ↓risk for mortality associated w/ non cardiac surgery in high-risk patients. pre-treatment with bisoprolol ↓incidence of perioperative MI and death. for safe/effective Tx: dosing should begin early (days-weeks before surgery). doses should be low initially then titrated up. Tx should cont for 1 month post surgery NOTE: if BB started late (days before) and at large doses= risk of mortality actually is ↑

No drug measures for RA

Balance between rest and exercise Massage Warm baths Heat to affected extremities

Beta 1

Cardiac - 1. inc heart rate, 2. inc force of contraction, 3. inc velocity of impulse conduction through AV node Kidney 1. - release of renin-Aldosterone - vasoconstriction--BP up Used for Heart Failure, Shock, AV heart block, Cardiac arrest Adverse effects: 1. Tachycardia- from over stimulation 2. Dysrhythmias- irregular heart rhythm 3. Angina

First Generation: Nonselective BB

Carteolol (Cartrol)= beta-1, beta-2 Nadolol (Corgard)= beta-1, beta-2 Pindolol (Visken)= beta-1, beta-2 Propranolo (Inderal)l= beta-1, beta-2 Sotalol (Betapace)= beta-1, beta-2 Timolol (Blocadren)= beta-1, beta-2

Central acting alpha 2 agonists

Drugs that act within the CNS to reduce outflow if impulses along sympathetic neurons

Which of the following observations might indicate that timolol is achieving the desired effect in a patient?

The patient's intraocular pressure decreases

Pharmacodynamics

The process by which a medication works on the body.

Pharmacokinetics

The process by which drugs are absorbed, distributed within the body, metabolized, and excreted.

Cocaine/Cocaine Derivatives

Therapeutic uses: local anesthetics (Lidcocaine, etc)

idiopathic

unknown cause

cholinergic receptors are subdivided into what?

nicotinic and muscarinic

Dissociation of transmitter from receptor

(reuptake into presynaptic cell, enzymatic degradation, diffusion away from gap).

Master Molecule of Addiction

*Dopamine*

Functions of Adrenergic (sympathetic) Receptors

1. Alpha 1 2. Alpha 2 3. Beta 1 4. Beta 2 5. Dopamine

Levodopa: Drug Interactions

1. First generation antipsychotics 2. MAOIs 3. Anticholinergic 4. Pyridoxine (Vitamin B6)

autonomic nervous system (ANS)

3 principle functions - regulation of the: 1.heart 2.secretory glands, 3.smooth muscle

A nurse is monitoring the drug level of a client receiving quinidine. Which serum drug level would the nurse immediately report to the primary health care provider? 2.5 mcg/mL 4.1 mcg/mL 3.8 mcg/mL 6.2 mcg/mL

6.2 mcg/mL

Sympathetic - fight or flight HHH

3 primary functions Homeostatic Objectives 1. CV (HEART) 2. Temperature (HEAT) Regulation 3. Fight-or Flight (HECK) HEART HEAT HECK Beat the heck out of them or get the heck outta there

nystagmus

constant, involuntary movement of the eyeball

Sulfasalazine (Azulfidine)

5-aminosalicylate,, DMARD Decrease inflammation by inhibiting prostaglandin synthesis Used for IBD (Crohn's, UC), RA Can cause agranulocytosis, hemolytic and macrocytic anemia,, hepatic dusfunction, bone marrow suppression

Ephedrine

A 1 and A2, Beta 1 and 2 Receptor -Asthma Adverse Effects: -same as epi- hypertensive crisis (cerebral hemorrhage), dysrhythmias, angina, necrosis, hyperglycemia

A nurse is preparing to administer IV calcium chloride to a patient with a low serum calcium level. Which drug on the patient's medication record, administered concurrently, would require additional patient monitoring by the nurse? a.Digoxin [Lanoxin] b.Furosemide [Lasix] c.Lorazepam [Ativan] d.Pantoprazole [Protonix]

ANS: A Parenteral calcium may cause severe bradycardia in patients taking digoxin; therefore, the heart rate should be monitored closely. Concurrent administration of calcium chloride and pantoprazole, lorazepam, or furosemide is not known to lead to drug interactions.

antibiotic

A chemical secreted by a living organism that kills or reduces the reproduction rate of other organisms

addiction

A physiological or psychological dependence on a drug

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

medication reconcilliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

Insulin

A protein hormone secreted by the pancreas that is essential for the metabolism of carbohydrates and the regulation of glucose levels in the blood. Insulin Lispro: rapid acting Insulin Glargine: long acting

Other Muscarinic Agonists

A) Cevimeline (Evoxac): used for relief of dry mouth like in patients with Sjogren syndrome B) Pilocarpine: topical therapy of glaucoma and oral therapy for Sjogren C) Acetylcholine: used for rapid pupil constriction after cataract surgery

Pathophysiology of Rheumatoid Arthritis

A-healthy joint B-inflammation of synovial membranes C-onset of pannus formation and cartilage erosion D-Pannus formation continues and cartilage deteriorates further E-Comlete destruction of joint cavity together with fusion of bones

cholinergic receptors bind to what?

ACh

Drug interactions with Probenecid

ASA- increases uric acid crystals

Efficacy

Ability of a drug to illicit an effect also called intrinsic activity

Ethosuximide

Absence seizures thalmic T type ca++ channel blocker

Cyclophosphamide (Cytoxan)

Alkylating agent (cytotoxic antineoplastic) Kills rapidly growing cells by interrupting DNA/RNA synthesis Can cause bone marrow suppression, N/V, acute hemorrhagic cystitis, alopecia

Phenylephrine

Alpha 1 receptors -nasal congestion Adverse effects: inc. BP

Pharmacokinetic Drug-Drug Interactions

Alter ADME

PK Drug-Drug: Distribution

Altered protein binding --> co-admin of drugs that bind to same site on protein (e.g., albumin) clinical significance depends on degree of binding and Vd Increased concern with highly protein-bound drugs (when displacement occurs there will be an increased effect)

The only drug recommended for dyskinesias is

Amantadine

Acetaminophen (Tylenol)

Analgesic S/E Anemia (long term use) Liver and kidney failure Dyspnea (prolonged high doses) angioedema hives, itching

Beta Blockers: Therapeutic Uses

Angina pectoris HTN Cardiac Dysrhythmias Myocardial Infarction Reduction of Peri-operative Mortality Heart Failure Hyperthyroidism Migraine Prophylaxis Performance Anxiety Pheochromocytoma Glaucoma

Which medications are classified as neuromuscular ​blockers? Select all that apply. Atracurium besylate​ (Tracrium) Mecamylamine hydrochloride​ (Inversine) Dicyclomine hydrochloride​ (Bentyl) Succinylcholine chloride​ (Anectine) Ipratropium bromide​ (Atrovent)

Atracurium besylate​ (Tracrium) Succinylcholine chloride​ (Anectine)

Treatment for toxicology of muscarnic agonists

Atropine and supportive therapy

isoproterenol HCl

Beta agonist: B1, B2 PROTOTYPE - more specific than epinephrine - treats bronchospasms, asthma, emphysema, CHF, heart block, cardiac arrest

Adverse Effects of beta-2 blockade

Bronchoconstriction (beta-2 cause constriction) Hypoglycemia (inhibition of glycogenolysis)

epinephrine

C/I in HTN BPH (difficulty urinating) DM (hyperglycemia) Hyperthyroidism (overactive metabolism)

isoproterenol HCl

C/I in tachydysrhythmias, CAD, DM Adverse - tachycardia, angina, palpitations

According to the continuum chart, anxiety is a sign of

CNS Stimulation

Third Generation: BB w/ Vasodilating Action

Carvedilol (Coreg)= beta-1, beta-2, alpha-1 Labetalol (Trandate)= beta-1, beta-2, alpha-1 Nebivolol (Bystolic)= beta-1

Which (2) BB also block alpha receptors?

Carvedilol, Labetalol, also block alpha-adrenergic receptors in addition to beta receptors. Can cause postural hypotension.

3rd generation BBs that cause vasodilation

Carvedilol, Labetalol, Nebivolol.

Too Much Norepinephrine

Causes Anxiety

Drug-Drug Interactions

Change in pharmacologic effect of a drug when given concurrently with another drug unwanted effects --> Increased toxicity, decreased efficacy desired effects --> enhance effect, increase efficacy

The nurse is preparing discharge teaching for a client prescribed chronic antiarrhythmic medication therapy. Which signs/symptoms should be reported to the health care provider immediately? (Select all that apply.) Chest pain Nausea Dyspnea Diarrhea Heart palpations

Chest pain Dyspnea Heart palpations

Primary Receptor Types (2)

Cholinergic Receptors Adrenergic Receptors

Nicotinic M

Contraction of skeletal muscle

antitussives/expectorants

Control cough, promote elimination of mucus Ex: dextromethorphan, codeine, guaifenesin Codeine (decreases the frequency and intensity of cough)

Digoxin reversal agent

Digibind

1st choice of med for patients with mild-mod symptoms...

Dopamine agonists

COMT inhibitors

Entacapone [comtan] 200mg tabs: (initial) 200 mg daily ⇢⇡8 doses (max) 1600mg/day take w/each dose of levo/carb Tolcapone [tasmar] 100mg tabs: (initial) 100 mg TID ⇡⇢200mg TID PRN take 1st dose in am with levo/carb take next two doses 6 and 12 hrs later.

the major transmitter released by the adrenal medulla

Epinephrine

Disulfuram (Antabuse)

Ethanol Aversion Agent

Alpha- and beta- specific adrenergic agonists are primarily used to treat obstructive pulmonary conditions.

False, used to treat hypotensive states

Cytochrome P450 Enzymes

Family of heme proteins most predominant in liver but also found in the intestines, lungs, and other organs Phase I drug metabolism Most important: CYP3A*, CYP2D6, CYP2C* *Most abundant in the liver

Michaelis-Menten Kinetics

Follows linear kinetics until enzymes become saturated Enzymes responsible for metabolism/elimination become saturated resulting in non-proportional increases in drug levels *True for phenytoin and alcohol

Quinine/Quinidine

For Anti-malarial parenteral use. Anti-malarial: Suppresses parasite in the RBC (heme metabolism inhibitors/ schizonticide)

Goals of urate lowering therapy

For chronic gouty attacks Promote dissolution of urate crystals Prevent new crystal formation Prevent disease progression Reduce the frequency of acute attacks Improve quality of life

Antisecretory anticholinergics

Glycopyrrolate (Robinul, Cuvposa) mepenzolate (Cantil) methscopolamine (Pamine) propantheline Overall-reduce salivation

Gonorrhea treatment

Gonorrhea TX: IM Ceftriaxone *Cover Chlamydia with: azithromycin : 1 g orally as a single dose IM doxycycline : 100 mg orally twice daily for 7 days

Nicotene substitute

Gum, patches, nasal sprays that deliver small amounts of nicotine when trying to give up the habit

Ranitidine (Zantac)

H2 receptor antagonist. Potent inhiitor of gastric acid secretion Indications: GERD, ulcers, H. pylori, reflux, indigestion ADR: Pain, constipation, diarrhea, headache. Can cause jaundice

parasympathetic effect of the heart

HR decreases

Beta 1 hits?

Heart and lungs

toxicities of methotrexate

Hepatic fibrosis Bone marrow suppression GI ulceration Pneumoonitis- pulmonary infection Not good with pregnancies

Irreversible Cholinesterase Inhibitors

Highly toxic Used as Insecticides ONLY clinical application: Glaucoma Contains Phosphorous Lipid soluble Absorbed several routes Chemical warfare TREAT: mechanical ventilation, pralidoxime (specific antidote to poisoning by early administration), diazepam

Intra-articular Administration

Injection of drug into the joints

Antimuscarinic Toxicity

Hot as a hare (hyperthermia) Dry as a bone (dry eyes, mouth skin) Red as a beet (flushed face) Blind as a bat (mydriasis - very dilated pupils) Mad as a hatter (delirium)

Adverse effects of Allopurinol (Zyloprim)

Hypersensitivity syndrome- rash (head to toe), fever, liver or kidney Gastrointestinal effects Neurological effects

Before administering an adrenergic​ agonist, for what health conditions should the nurse assess in ​particular? Select all that apply. Hyperthyroidism Hypertension Diabetes Psoriasis Angina

Hyperthyroidism Hypertension Angina Diabetes

Volume of Distribution (Vd)

Hypothetical volume into which a drug is "dispersed" Represents a relationship between the amount of drug in the body to the plasma concentration

Methyltrexate

Immunossuppressant. Can promote short-term remission and reduce need for glucocorticoids in patients with Crohn's disease

Memantine: Therapeutic Effects

In severe AD- appears to confer modest benefits For many= can slow decline in fx In some= causes improvement of symptoms 28 wk use= ↑score on cog fx than placebo *suggests memantine slowed fx decline 24 wk mem+donepezil= ↑score> donepezil alone *suggests independent or synergistic benefits Does NOT benefit those with MILD AD

In the SNS:

In the SNS most the neurons are coming out of thorasic and lumbar areas Most the SNS are made of adrenergic fibers -> release NE-->acts on alpha and beta receptors-->acts on SNS--> bronchodilation etc. The SNS stays stimulated by catecolines (preganglionic) --> NE and EPI

An ED patient presents with dyspnea, tachycardia, and chest pain. The patient has a history of cardiomyopathy. The nursing assessment reveals hypotension with an apical pulse of 134 bpm. What would the nurse conclude might be causing the symptoms? Adequate cardiac output Inadequate cardiac output Asthma attack Hypokalemia

Inadequate cardiac output

Antidepressant MOA

Increase nor-epi and often serotonin levels in the synapse (mostly re-uptake inhibitors)

Which is a potential effect of​ low-dose nicotinic​ agonists? Relief of nausea Decreased pulse rate Increased blood pressure Symptoms of sedation

Increased blood pressure

The nurse is administering quinidine to a client who is also taking digoxin. The nurse will assess this client for which important adverse effect? Increased anticoagulant effects Decreased white blood cell count Decreased red blood cell count Increased digoxin level

Increased digoxin level

PK Drug-Drug: Elimination

Increased filtration --> consequence of tissue or protein binding displacement; increased free fraction resulting in increased amount of drug presented to kidney Interfere with tubular secretion --> prevents excretion (e.g., probenecid) Interference with tubular reabsorption --> sensitive to changes in urine pH and urine flow rate

Adverse effects of Tumor necrosis factor antagonists

Injection site reactions Serious infections Severe allergic reactions HF Hematologic disorders Cancer- leukemia, lymphoma Liver injury CNS demyelination gang disorders

sexually transmitted infections (STIs)

Infections that can be, but are not always, transmitted from one person to the next through sexual contact.

TCAs (tricyclic antidepressants)

Inhibit serotonin and NE re-uptake (Amitrptyline, Desipramine, exepin, imipramine, and Clomipramine-OCD)

Intrathecal (IT) Administration

Injection of a drug through the theca of the spinal cord and into the subarachnoid space "Into the CSF" --> usually oncology agents and antibiotics

A patient is prescribed esmolol for treatment of supraventricular tachycardia. The nurse would expect to administer this drug by which route? Intramuscular Oral Subcutaneous Intravenous

Intravenous

A client is admitted to the emergency department in ventricular fibrillation. The client is administered amiodarone hydrochloride (Cordarone). What is the major effect of this medication? It produces skeletal muscle relaxation. It slows the conduction through the AV node. It stimulates the sympathetic nervous system. It inhibits the increase of the refractory period of the cells.

It slows the conduction through the AV node.

Parkinson's Disease - Drug of choice?

Leva-dopa - it replaces dopamine but only works for five years!!! Shuttles Dopamine into the brain

Dopaminergic Drugs

Levodopa (PO) Carbidopa (PO) Pramipexole (PO) Entacapone (PO) Selegiline (PO, ODT) Amantadine (SQ)

Treatment for manic depression/bipolar disorder

Lithium - is the only drug to specifically treat bipolar disorder How does it work: - *Lithium is a monovalent cation that competes with calcium, magnesium, potassium and sodium in body tissues and at binding sites* -It alters sodium transmission in nerve and muscle cells - antimanic - both acute and recurrent attacks -takes 7-10 days to take affect -initially used in conjuction with phenothiazines -MUST KNOW *Lithium is a mood stabilizer (very weird drug)* *caution* tricyclics can cause mani relapses

Adverse effects of Febuxostat

Liver function abnormalities Nausea Arthralgia Rash Cardiac effects (in high dosages)

one example of a drug that works by altering Axonal Conduction

Local anesthetics

Inhalation Administration

Localized/topical or systemic effect Can be difficult for patient to self-administer (metered dose inhaler - use a spacer) Can be irritating

Beta blockers in Myocardial Infarction

MI= regional of myocardial necrosis by localized interruption of blood flow to heart wall. Tx w/ BB= ↓pain, infarct size, mortality, and risk of reinfarction. Effectiveness= must begin soon after MI, cont for several years.

Differences between barbiturates and benzodiazepines.

MOA: - both act at gabba receptors / chloride ion channel complex. - bind different allosteric sites. -Gabba is an inhibitory postsynaptic potentials.- Chloride flows through the channel and decreases resting membrane potential. -The neuron, therefore, is less likely to be stimulated. Benzos: major side effects and the most horrible withdrawal symptoms

Parkinson's disease cardinal symptoms

MOTOR SYMPTOMS: tremor rigidity postural instability slowed movement

Sulfasalazine

Management of RA nonbiolgic DMARDs Anti-inflammatory and immunomodulatory actions Also used for IBS Slows progression of joint deterioration Onset within one month

Hydroxychloroquine (Plaquenil)

Management of RA nonbiolgic DMARDs Early use improves long term outcomes Combined with methotrexate Take with food or milk Most serious toxicity is retinal damage- pre eye exam and then every 6 months due to adverse effect 3-6 months for therapeutic effects

Leflunomide (Arava)

Management of RA nonbiolgic DMARDs Immunosuppressant Reserved for second line use Toxic to liver; severe risk for infection

Memantine: Mechanism of Action

Memantine modulates effects of glutamate Glutamate: major excitatory transmitter in CNS NMDA receptor play critical role- learn/memory -NMDA receptor- transmembrane protein -regulate Ca+ entry into neurons (central channel) -Glutamate binds NMDA= promotes Ca+ influx Memantine displaces glutamate stops Ca+ entry -Ca+ entry= signal in learning & memory process -Excess Ca influx= impairs. possible neuron death

Alpha 2

Minimal clinical significance in PNS

1st neuron of two neuron chain

PREganglionic neuron

Amphetamines: main indications

STIMULANT: Therapeutic uses: narcolepsy, weight control, most common for ADHD

A patient, admitted to a health care facility with cardiac arrhythmia, is prescribed propranolol. Which factor should the nurse closely monitor as a part of the ongoing assessment during the therapy? Tendon reflexes Visual acuity Pulse rate Hydration

Pulse rate

Linear Pharmacokinetics

Rate of elimination is proportional to amount of drug present Dosage increases result in proportional increase in plasma drug levels

A client has been prescribed disopyramide (Norpace) to treat a tachydysrhythmia. Which factor would necessitate that the dose be reduced? Chronic diarrhea Immobility Hypertension Renal impairment

Renal impairment

A client has been prescribed disopyramide (Norpace) to treat a tachydysrhythmia. Which factor would necessitate that the dose be reduced? Renal impairment Immobility Chronic diarrhea Hypertension

Renal impairment

Which factor would necessitate a reduction in the dosage of disopyramide? Immobility Hypertension Renal impairment Chronic diarrhea

Renal impairment

Available in (3) trade names

Rytary, Sinemet, Duopa

Osmotic Laxatives

Salts draw water into the intestine causing fecal mass to soften and swell stimulating peristalsis. Low dose 6-12 hours, high dose 2-6 hours. magnesium hydroxide, magnesium citrate, polyethylene glycol, lactulose (can be used to lower blood ammonia in liver disease) * Increase fluid intake. Not good for kidney disease. Sodium phosphate exacerbates cardiac disease.

What can cause cholinergic ​crisis? Select all that apply. Sarin poisoning Understimulation of the parasympathetic nervous system Insecticide poisoning Overdosage of AChE inhibitors Pralidoxime chloride​ (2-PAM) poisoning

Sarin poisoning Insecticide poisoning Overdosage of AChE inhibitors

Pharmacology

Science that deals with the origin, nature, chemistry, effects, and uses of drugs; the characteristics or properties of a drug, especially those that make it medically effective

Nitroprusside

Short acting; increase cGMP via direct release of NO. Can cause cyanide toxicity (releases cyanide) a vasodilator that works by relaxing the muscles in your blood vessels to help them dilate (widen). This lowers blood pressure and allows blood to flow more easily through your veins and arteries. Given IV and titrated for therapeutic dose.

Nasal Decongestants

Shrink mucosal membranes and reduces fluid secretion, should not be used for more than 48 hours Afrin, Phenylephrine, pseudophedrine

***Which would be a contraindication for the use of a class II antiarrhythmic? Sinus bradycardia Hepatic dysfunction Thyroid dysfunction Diabetes

Sinus bradycardia

Pramipexole: Dangerous SE

Sleep attacks- 911 while driving Impulse control disorders- are dose related START-9 mths after. RESOLVE- after D/C compulsive gamble, shop, binge eat, hypersexual RF- young adult, fam/personal hx of ETOH abuse, and personality trait of novelty seeking (impulsivity, quick temper, low threshold for boredom)

Drug interactions with Colchicine

Statins- increased risk of muscle injury

The nurse is preparing to administer adrenergic agonists to several clients on a neurological unit. Which medication can be administered by mouth Isoproterenol ​Catechol-O-methyltransferase Dopamine Terbutaline

Terbutaline

GABA Neurotransmitter

The Neurotransmitter GABA is Responsible for Relaxation of Brain and Muscle. Inhibitory Neurotransmitter

A patient has recently been prescribed a drug that treats his hypertension by blocking the sympathetic receptors in his sympathetic nervous system. This action is characteristic of

an adrenergic antagonist

absence

The fact of not being present or available.

first pass effect

The initial metabolism in the liver of a drug absorbed from the gastrointestinal tract before the drug reaches systemic circulation through the bloodstream.

What is the relationship between multiple receptor types and selectivity of drug action

The more types of receptors we have to work with, the greater our chances of producing selective drug effects

Benzodiazepines

The most common group of antianxiety drugs, which includes Valium and Xanax.

What main neurotransmitter imbalance exists with anxiety?

The neurotransmitters targeted in anxiety disorders are gamma-aminobutyric acid (GABA), serotonin, dopamine, and epinephrine. Serotonin appears to be specifically important in feelings of well being, and deficiencies are highly related to anxiety and depression. Stress hormones such as cortisol also play a role.

tonic seizure

a seizure in which the muscles stiffen before the sufferer losses consciousness

Choreoathetosis

a slow involuntary writhing movement

Pharmacodynamics

The relationship between drug concentration at the site of action and the resulting effect --> "what the drug does to the body/result you see in the pt at a predefined dosage regimen" Pharmacological effect is due to the alteration of an intrinsic physiologic process and not the creation of a new process. Looks at mechanism of drug action, efficacy, and safety profile. -Receptor interaction -Signal transduction -Physiologic effect -Pt's functional status

Xanthines: main indications

Therapeutic uses: pain from headache (vasoconstriction in brain), asthma, bronchitis, *emphysema (bronchorelaxation)*, counter drowsiness.

ANILINE TYPE (ACETAMINOPHEN) (Tylenol) Non-narcotic analgesics - What are the main side effects

There is no GI irritation nor is there CNS Stimulation Aniline Derivatives is a non-narcotic analgesic agent that has the potential to cause irreversible liver damage with even a single overdose! ie Tylenol!

Tolterodine

Tolterodine Anticholinergic Drugs for Overactive bladder Nonselective muscarinic antagonist Fewer anticholinergic side effects QT interval

In nervous system​ communication, what happens with neurotransmitters when the action potential reaches the synaptic ​cleft? Select all that apply. They use the mechanism of diffusion. They are absorbed into presynaptic neuron vesicles. They help move the impulse across the cleft. They are released by presynaptic neuron vesicles. They block the mechanism of diffusion.

They help move the impulse across the cleft. They are released by presynaptic neuron vesicles. They use the mechanism of diffusion

MedWatch Program

This voluntary program encourages nurses and other health care professionals to use the MedWatch form to report when a medication, product, or medical event causes serious harm to a patient.

Methimazole (Tapazole)

Thyroid hormone antagonist. Inhibits synthesis of thyroid hormone. Used for hyperthyroidism, preoperative thyroidectomy, thyrotoxic crisis, and thyroid storm.

During the implementation phase of administering an adrenergic​ antagonist, for what adverse effects should you especially ​monitor? Select all that apply. Tinnitus Orthostatic hypotension Hypertension Syncope Double vision

Tinnitus Orthostatic hypotension syncope

What is Parkinson's Disease

Too Little Dopamine Problem: loss of dopaminergic neurons resulting in an imbalance of dopamine and acetylcholine in the basal ganglia (substancia nigra)

Nicotinic N

Transmission at all ganglia of sympathetic and parasympathetic nervous systems. Release of Epi from adrenal medulla

Drugs can act on any of these processes

Transmitter Synthesis Transmitter Storage Transmitter Release Receptor Binding Termination of Transmitter Action

Steroids in asthma

Treat flair up intermittently. May cause irritability and increased hunger. Not long term Methylprednisone, prednisone, dexamethasone

The teaching plan for a client taking amiodarone should include which instruction? Take this medication with grapefruit juice for optimal absorption. Use a reliable form of birth control while taking this medication. Drowsiness is common but will not interfere with any of your usual activities. Urinary retention is common and no need for concern.

Use a reliable form of birth control while taking this medication.

somatic nervous system

Voluntary control (skeletal muscle) Receptor is called a nicotinic M

The nurse is teaching a group of clients about effective therapies for nasal congestion. Which alpha-adrenergic agonist medications might be useful for these clients? Select all that apply. Phenylephrine hydrochloride​ (Sinex) Tetrahydrozoline hydrochloride​ (Tyzine) Midodrine hydrochloride​ (ProAmatine) Oxymetazoline hydrochloride​ (Afrin) Xylometazoline hydrochloride​ (Otrivin)

Xylometazoline hydrochloride (Otrivin) Oxymetazoline hydrochloride (Afrin) Phenylephrine hydrochloride (Sinex) Tetrahydrozoline hydrochloride (Tyzine)

Multiple Sclerosis (MS)

destruction of the myelin sheath on neurons in the CNS and its replacement by plaques of sclerotic (hard) tissue

tolcapone causes certain side effects with monotherapy

diarrhea, hematuria, yellow/orange urine

Give examples of ways in which neurotransmitters are removed from the synapse

diffuse away, metabolized by enzymes in the extracellular fluid, actively transported into cells, or MAO degrades norepinephrine

sympathetic effect of the pupils

dilate

Levodopa and Anticholinergics

excessive stimulation of cholinergic receptors contributes to the dyskinesias of PD blocking these receptors, anticholinergic agents can enhance responses to Levodopa

In the absence of dopamine, the excitatory influence of acetylcholine goes unopposed causing...

excessive stimulation of the neurons that release GABA

Acetylcholine is an

excitatory transmitter

Levodopa Food Interactions

high protein- ↓therapeutic response to levodopa neutral amino acids compete w/ levodopa for absorption in intestine and transport across BBB high protein can significantly ↓both amount of levodopa absorbed & transported into the brain suggests that high protein triggers an abrupt loss effect (an "off" episode) advise to spread protein consumption evenly throughout the day

Overactivity of these GABAergic neurons contributes to the

motor symptoms that characterize PD

Colchicine ADRs

n/v, diarrhea, abdominal pain, cause leukopenia, granulocytopenia, thrombocytopenia, and pancytopenia, rhabdomyolysis

Sustained-Release

often capsules filled with tiny spheres containing drug and the coating on the spheres dissolve at variable rates OR drug is imbedded in the matrix drug released steadily throughout the day usually cannot be crushed Sustained release (SR), extended release (ER, XR, XL), time release, controlled release (CR) or continuous release

autonomic nervous system

the part of the peripheral nervous system that controls the glands and the muscles of the internal organs (such as the heart). Its sympathetic division arouses; its parasympathetic division calms.

Name 2 anatomical differences between sympathetic and parasympathetic divisions

the pathways point of origin in the CNS and the location of autonomic ganglia.

seizure threshold

the point at where a seizure may be induced

describe axonal conduction

the process of conducting an action potential down the axon of the neuron

Management of Motor Fluctuations: long-term tx w/ levodopa or dopamine agonists is associated with (2) types of motor fluctuations

(1) off times- loss of symptoms relief (2) drug induced dyskinesias- involuntary movements

levodopa: wearing off can be minimized in (3) ways:

(1) shortening the dose interval (2) giving a drug that prolongs levodopa's plasma half-life (ex. entacapone) (3) giving direct acting dopamine agonist

Why is PD treated with levodopa and not with dopamine itself?

(2) reasons... dopamine cannot cross BBB dopamine has short half-life in blood (impractical to use even if it could cross BBB)

describe the 3 pathways of Termination of Transmission

(a) reuptake into the nerve terminal axon terminals contain "pumps" that transport transmitter molecules back into the neuron (b) enzymatic degradation the synapse contains large quantities of transmitter-inactivating enzymes (c) diffusion away from the gap very slow and generally of little significance

Adrenergic Antagonists cause direct

(reversible) blockade of adrenergic receptors

Type I Allergic Hypersensitivity

-Class: anaphylaxis -Mechanism: IgE mediated -Common manifestations: anaphylaxis, urticaria, angioedema -Timing: within min to hours after exposure (provided an initial antigen exposure and sensitization have occurred)

Type IV Allergic Hypersensitivity

-Class: cell mediated -Mechanism: drug-specific T lymphocytes -Common manifestations: contact dermatitis -Timing: 2-7d after exposure

Type II Allergic Hypersensitivity

-Class: cytotoxic -Mechanism: IgG or IgM mediated -Common manifestations: hemolytic anemia, thrombocytopenia, granulocytopenia -Timing: variable, typically at least 7d after exposure

clinical treatment of hypercalcemia

1) administer bolus fluid of normal saline - keeps pt from getting dehydrated 2) give pt a loop diuretic - balances out electrolytes - relationship between K and Ca - ex: *furosemide*

Agonists

A substrate (drug) which interacts with a receptor and elicits a subsequent intracellular reaction affinity + efficacy

Antagonists

A substrate (drug) which interacts with receptor (occupies it) but does not elicit an intracellular reaction. No activity. Response is determined by how much agonist is present. Affinity, but lacks efficacy

Fesoterodine

Fesoterodine Anticholinergic Drugs for Overactive bladder Nonselective muscarinic antagonist Dry mouth Constipation

Dopamine Agonists

Goal: improve ADL. not a cure. no delay of progression Apomorphine reserved for "off" episodes in PD Baseline data: assess motor symptoms: bradykinesia, akinesia, postural instability, tremor, rigidity and extent to which they interfere with life. High risk patients: caution use in elderly & psychiatric pts. pramipexole- caution in kidney dysfunction ropinirole- avoid in pregnancy compulsive dis- avoid pramipexole & ropinirole Administration concerns: PD makes self-administration of medication difficult. enlist family's help. Ongoing evaluation and interventions: evaluate for improvements during therapy med adjustments for halluc, dys, sleep attacks NV, OH- patient teaching to minimize fetal injury- stop ropinirole & switch dop-agonist impulse control dis- screen patients for RF

Selegiline does what?

Inhibits monoamine oxidase-B

Beta blockers in performance anxiety

"stage fright" s/s- diaphoresis, tachycardia, tremors by generalized discharge of the sympathetic nervous system. prevent beta-1 mediated tachycardia.

(8) alpha blockers

(1) Prazosin (2) Terazosin (3) Doxazosin (4) Tamsulosin (5) Alfuzosin (6) Silodosin (7) Phentolamine (8) Phenoxybenzamine

Adrenergic Antagonists can be divided into (2) groups:

(1) alpha-adrenergic blocking agents- drugs that produce selective blockade of alpha-adrenergic receptors (2) beta-adrenergic blocking agents- drugs that produce selective blockade of beta receptors

Lidocaine (Xylocaine) is available in a variety of dosage forms. How should a nurse administer lidocaine to a client with a ventricular arrhythmia? Topically Intravenously Intramuscularly Orally

Intravenously

Methotrexate (Rheumatrex)

It can treat cancer of the blood, bone, lung, breast, head, and neck. It can also treat rheumatoid arthritis and psoriasis.

At autopsy, these fibrils are visible as

Lewy bodies characteristic of PD pathology

A patient with cardiac arrhythmia is prescribed verapamil. Which of the following possible adverse effects should the nurse inform the patient about? Hypertension Diarrhea Peripheral edema Hyperactivity

Peripheral edema

Alpha2

location - parasympathetic nerve terminals, Referred to as "presynaptic or prejunctional" response - inhibition of transmitter release The function of these receptors is to regulate transmitter release presynaptic alpha2 receptors can help reduce transmitter release when too much transmitter has accumulated in the synaptic gap

Levodopa Acute Loss of Effect

occurs in (2) patterns: gradual loss abrupt loss

psychomotor

occurs in temporal lobe epilepsy, characterized by a temporary loss of consciousness, loss of judgement, automatic behavior, and abnormal acts

Transdermal Administration

often via patch or cream/ointment; need highly lipid soluble substance bypasses first-pass metabolism by the liver, release medications for periods of time (ranges) e.g., fentanyl, clonidine

dantrolene acts directly

on skeletal muscle

Action Potential

originates in the neuron conducting down the axon of the neuron to terminal makes everything work in our body

gingival hyperplasia

overgrowth of gums or reddened gums that bleed easily

Because this loss takes place over 5-20 yrs neuronal degeneration begins long before

overt motor symptoms appear

Cholinergic Receptors - define and give subtypes (3)

receptors that mediate responses to acetylcholine nicotinicN nicotinicM Muscarinic

Adrenergic Receptors - define and subtypes (5)

receptors that mediate responses to epinephrine (adrenaline) and norepinephrine Alpha1 Alpha2 Beta1 Beta2 Dopamine

Gout patho

recurrent inflammatory disorder characterized by hyperuricemia and episodes of severe joint pain, typically in large toe

Beta blockers in HTN

reduce peripheral vascular resistance in long-term use accounting for much of their anti-HTN effects.

Allopurinol

reduces the production of uric acid in your body. Uric acid buildup can lead to gout or kidney stones. Allopurinol is used to treat gout or kidney stones, and to decrease levels of uric acid in people who are receiving cancer treatment. ex zyloprim, aloprim Given short term for flair up, and long term to prevent Rash is side effect - stop med.

parasympathetic

rest and digest

When the parasympathetic nervous system is activated things happen:

rest and digest (house keeping) heart slows lungs constrict (airways) bladder contracts and sphincter relaxes so you can pee, can cry now increase GI motility, gastric motility/ juices increase pupils constrict (so we can see close up) errection- preparing for ejaculation.

while in the brain, Levodopa undergoes...

reuptake: into remaining dopaminergic nerve terminals that remain in the striatum after uptake: is converted to dopamine (its active form) b/c levodopa has not direct effects of its own. as dopamine: levodopa helps restore a proper balance between dopamine and acetylcholine

Dangerous reaction between selegiline and meperidine (demerol)

stupor, rigidity, agitation, hyperthermia avoid combination

Additive PD Drug-Drug

sum of the individual drug effects (1+1=2) overlapping toxicities/ADEs or increased pharmacologic effect/PD effect

Rectal Administration

suppository or enema dosage form; local or systemic effects, undergo relatively little first-pass metabolism

Sympathetic supplies visceral structures in superficial body such as:

sweat glands, arteries, and veins

variscosity

swollen regions along autonomic axons that store and release neurotransmitters

where are adrenergic receptors found?

sympathetic

Autonomic nervous system consists of:

sympathetic and parasympathetic

what controls temp regulation?

sympathetic nervous system to do that it regulates blood from to the skin

Most neuropharmacologic agents act by altering ___ why?

synaptic transmission Drugs that alter synaptic transmission can produce effects that are much more selective than those produced by drugs that alter axonal conduction (much less common)

The nurse is monitoring a client for adverse effects associated with the administration of an adrenergic antagonist. The nurse correctly teaches the client that which adverse effect is related to the first-dose phenomenon? Syncope Edema Blurred vision Urinary hesitancy

syncope

Name the effects of drugs

they can block receptors, mimic effects of neurotransmitters, or inhibit enzymes that degrade them- prolonging their effect

treatment of levodopa-induced psychosis with first generation antipsychotics is problematic.

they can ↓psychological symptoms BUT will intensify PD symptoms b/c they block receptors for dopamine in the striatum

Levothyroxine (Synthroid)

thyroid hormone Don't switch brands Take for at least 3 weeks to see if effective. Take on empty stomach and don't eat or drink for at least 30 min.

___________ refers to the state where a patient must continue to increase the dose of the drug in order to achieve the desired effect.

tolerance

describe Receptor Binding

transmitter molecules diffuse across the synaptic gap and then undergo reversible binding to receptors on the postsynaptic cell

PD: dyskinesias that characterize PD

tremor at rest rigidity postural instability bradykinesia (slowed movement) Severe PD- bradykinesia may progress to akinesia (complete absence of movement)

What class of antidepressant agents are indicated for severe depression?

tricyclics

Which type is recommended for severe depression?

tricyclics

t/f: Benzodiazepines - diazepam (valium) bind to receptor components and thereby enhance receptor activation by the natural transmitter at the site.

true

t/f: The ability of a neuron to influence the behavior of another cell depends upon the ability of that neuron to alter receptor activity on the target cell

true

t/f: dopamine itself is the only transmitter capable of activating dopamine receptors

true

t/f: there is only one neuron in the pathway from the spinal cord to the muscles innervated by somatic motor nerves

true

t/f: In some organs that receive nerves from both divisions of the autonomic nervous system, the effects of sympathetic and parasympathetic nerves are complementary, rather than opposite

true For example, in the male reproductive system, erection is regulated by parasympathetic nerves while ejaculation is controlled by sympathetic nerves

t/f:n A few structures under autonomic control receive innervation from only one division

true The principal example is blood vessels, which are innervated exclusively by sympathetic nerves

patient taking MOA inhibitor hypertensive crisis can be triggered by eating what food

tyramine certain drugs- sympathomimetics

idiosyncratic response

unpredictable and unexplained drug reaction

Functions we are aware of in the ANS

upset stomach and full bladder

Tophi

uric acid crystal deposits in joints

A client with systemic lupus erythematosus is hospitalized following total knee replacement. Eight hours after the procedure, the nurse prepares to administer bethanechol chloride (Duvoid). The nurse tells the client that the medication is being administered to treat which disorder? Urinary retention Glaucoma Dry mouth Sjogren syndrome

urinary retention

Your​ client, Carrie​ Nelson, is experiencing fluid retention a day after an operation on her hand. What is a likely outcome of administering an oral cholinergic agonist to Ms.​ Nelson? Blood pressure rises Pulse increases temporarily Muscle weakness increases Urination and digestion are aided

urination and digestion are aided

Alpha-2 Selective Agonists

used as antihypertensives (ex. clonidine)

norepinephrine

used in critical care units in shocky states, hypotension, cardiac arrest LOTS of vasoconstriction

Sulfinpyrazone (Anturane)

used in the treatment of chronic gout (gouty arthritis), which is caused by too much uric acid in the blood. The medicine works by removing the extra uric acid from the body. Sulfinpyrazone does not cure gout, but after you have been taking it for a few months it may help prevent gout attacks. Sulfinpyrazone will help prevent gout attacks only as long as you continue to take it.

*ibandronate [boniva]*

uses: - prevention and treatment of postmenopausal osteoporosis dosing: - once a month or once every 3 months adverse effects: - GI effects- (ex: esophagitis dyspepsia, abdominal pain) - ocular inflammation - atypical fractures - osteonecrosis of the jaw - renal damage if IV administered too rapidly

hypercalcemia

usually asymptomatic symptoms that present occur in: - kidneys - GI tract - CNS causes: - cancer - hyperparathyroidism - vitamin D intoxication - sarcoidosis - use of thiazide diuretics if elevated levels of calcium in the blood --> less calcium in the bones (not good)

Ulcer treatment

usually includes medication to decrease stomach acid production like antacids; if bacteria is cause, antibiotics may be needed; avoid smoking and drinking

Parasympathetic preganglionic axons

very long and extend all the way to target organs

Sympathetic fiber lengths:

very short preganglionic axons with long post ganglionic

Action potential causes ....

vesicles to fuse with surface of terminal and be released into synapse action potential is conducting down the axon of the neuron to terminal

Carbidopa Combination Benefit

w/o carbidopa about 98% is lost in periphery leaving 2% available to the brain when decarboxylases are inhibited by carbidopa only 90% of levodopa is lost in periphery leaving 10% for actions in the brain

SALICYTES (aspirin) Toxicities with Chronic Use

•*Hearing* (ringing in ears; hearing loss(reversable); dizziness (inhibits enzyme in the cochlea) •Possible slight decrease in GFR (glomerular filtration rate) - this is negligible compared to phenaetin or even acetaminophen toxicity - No significant liver damage - Caution if patient already has liver or kidney damage •No blood disease •No link to bladder cancer

Anti-epileptic frequent adverse effects

• Sedation - locomotor and CNS • Kidney and liver damage • Blood diseases • Each agent has it's own adverse effects

The nurse is caring for a client who developed extravasation from a dopamine drip. The nurse anticipates that the health care provider will order which medication to treat this disorder? Doxazosin mesylate​ (Cardura) Alfuzosin​ (UroXatral) Phenoxybenzamine hydrochloride​ (Dibenzyline) Phentolamine mesylate​ (Regitine)

Phentolamine mesylate​ (Regitine)

Beta-Adrenergic Antagonists (beta blockers)

Practically all results from Beta-1 blockade in the heart. (1) ↓HR (2) ↓force of contraction (3) ↓impulse conduction velocity thru AV node

Preperations: Dopamine Agonists- NonErgot Derivitatives [Pramipexole, Ropinirole, Rotigotine]

Pramipexole [Mirapex, Mirapex ER] IR tabs: 0.125, 0.25, 0.5, 0.75, 1, 1.5 (mg) ER tabs: 0.375, 0.75, 1.5, 2.25, 3, 4.5 (mg) Ropinirole [Requip, Requip XL] IR tabs: 0.25, 0.5, 1, 2, 3, 4, 5 (mg) ER tabs: 2, 4, 6, 8, 12 (mg) Rotigotine [Neupro] 24hr Transdermal Patch: 1, 2, 3, 4, 6, 8 (mg)

BLACK BOX WARNING selegiline

antidepressants associated with risk of suicide in patients younger than 24. selegiline, antidepressant and drug for PD, is included in this warning. carries an ↑ risk for HTN crisis in younger pts contraindicated in patients < 12

PD becomes clinically recognizable when

between 70-80% of these neurons must be lost

Casodex

bicalutamide Prostate cancer

Colestipol (Colestid)

bile acid sequestrant (older agent). Decreases fat absorpion and may decrease uptake of fat-soluble vitamins.

Colesevelam (Welchol)

bile acid sequestrants used for antilipemic meds. bile acid sequestrants reduce LDL.

Agonists

bind to receptors and cause activation

Antagonists

bind to receptors and thereby block receptor activation by other agents

phenylephrine

binds to adrenergic receptors (nasal decongestant, constricts nasal blood vessels, inhibiting secretions and reducing sinus pressure)

Competitive Antagonist

binds to same site as agonist

epoetin alfa (Epogen, Procrit)

biosynthetic form of erythropoietin

Levodopa/Carbidopa: disadvantages

carbidopa= no adverse effect on its own adverse effects of combo= carbidopa potentiating the effects of levodopa combo= abn mvmts & psych disturb can occur sooner & be ↑intense than w/ levodopa alone

Beta blockers in Angina

cardiac pain due to ischemia that occurs when O2 supplied to heart through coronary circulation not sufficient to meet cardiac O2 demand. block beta-1 receptors in heart ↓workload ↓O2 demand back into balance with O2 supply Prevents ischemia and pain.

Beta blockers in pheochromocytoma

cardiac stimulation from ↑release of catecholamines can be prevented by beta-1 blockade.

somatic motor division

carries signals to skeletal muscles with nicotinic ACh receptors

Anaphylaxis

causes hypotension, bronchoconstriction, glottis edema Treatment; epinephrine (epi-pen) IM Activated 3 types of adrengic receptors -Beta 1 -Alpha 1 -Beta 2

Topical lidocaine

causes localized vasoconstriction, producing a white ring around the wound application area. The preparation provides anesthesia in the immediate are.

Antiviral

chemical that combats a specific viral disease (e.g. herpes) (Denavir, Famivir, Relenza, Retrovir, Tamiflu, Zovirax)

Fibers that release ACh

cholinergic fibers

(2) second generation antipsychotics have been used successfully to manage levodopa-induced psychosis

clozapine quetiapine

AAN recommends use of (2) 2nd generation antipsychotics

clozapine and quetiapine clozapine can cause agranulocytosis quetiapine preferred. don't use olanzopine (2nd gen)

Ganglion

collection of cell bodies outside CNS

Spasticity is tx with

combination of drugs & PT

Selegiline should not be combined with SSRIs

combo of MAO-B inhibitor + SSRI can cause fatal serotonin syndrome withdraw SSRIs at least 5 wks before starting selegiline

Which type of neuron in the peripheral nervous system carries impulses away from the brain and spinal cord to the muscles and​ glands? Afferent Efferent Autonomic Sensory

efferent

Two Neuron Chain

efferent pathway to ANS effectors

diazepam & tizanidine thought to relieve spasm by:

enhancing presynaptic inhibition of motor neurons in the CNS

Diazepam promotes presynaptic inhibition by

enhancing the effects of gamma-aminobutyric acid (GABA) an inhibitory neurotransmitter

In people with PD that is not inherited

environmental toxins may explain the inability to degrade alpha-synuclein

Spasm can result from

epilepsy, hypocalcemia, acute & chronic pain syndromes, & trauma

Which endogenous substance is also known as​ adrenaline? Epinephrine Dopamine Norepinephrine Neurohormone

epinephrine

primary neurohormone of the adrenal medulla

epinephrine - secreted into the blood

adrenergic receptors bind to what?

epinephrine/NE

bromocriptine

ergot derivative direct-acting dop-agon activate DA receptors at striatum similar responses as pramipexole, ropinirole mono- early stage combo w/ levo- adv stage allows ↓levo dose= ↓levo induced dyskinesias adverse effects: dose dependent. 30-50% pts. nausea most common. OH and dyskinesias Corfused, nightmares, halluc, paranoid, agitated occur in 30% pts= when dose is HIGH. Rarely: retroperitoneal fibrosis, pum infiltrates, Raynaud like phenom, erythromelalgia (vasodilation in feet/hands=swell, red, pain, warm)

Zafirlukast

eukotriene (loo-koe-TRY-een) inhibitor. Leukotrienes are chemicals your body releases when you breathe in an allergen (such as pollen). These chemicals cause swelling in your lungs and tightening of the muscles around your airways, which can result in asthma symptoms. Zafirlukast is used for chronic treatment of asthma, and to prevent asthma attacks in adults and children as young as 5 years old. Take on empty stomach 1-2 hours before eating. Do not prescribe for people with liver disease.

The American Academy of Neurology (AAN) has developed

evidenced based guidelines for Tx of PD and management of individual manifestations of the disease recommendations follow the disease across the lifespan

Parasympathetic : BBBBMVP

housekeeping chores: 1. Slows heart rate (BRADYCARDIA) B 2. Increased gastric secretion (BELLY) B 3. Empties the BLADDER (B) Empties the BOWEL (B) 4. CONTRACTION of Smooth Muscle (M) 5.Focus eye for near VISION (V) 6. Pupil constriction (P) 7.Bronchial contraction 8. HR down before ejaculation

Allopurinol ADRs

hypersensitivity syndrome (rash, fever, eosinophilia and dysfunction of the liver and kidneys), initial therapy could cause acute gouty attack, Gi reactions, drowsiness, headache, metallic taste, cataracts

Propranolol is ordered for a client who has a cardiac arrhythmia. It will be important for the nurse to determine if the person has a history of: idiosyncratic reaction to cinchona derivatives. chronic heart failure secondary to a tachyarrhythmia. hypersensitivity to sulfonylureas. hypersensitivity to beta blockers.

hypersensitivity to beta blockers.

Glatirimer

immunomodulator medication currently used to treat multiple sclerosis. Reduces relapses, does not stop progress of disease.

testosterone therapy

improve sexual interest (increase libido) increase prostate cancer risk increase cholesterol levels and cause liver damage worsen BPH symptoms (not used with 5 alpha reductase inhibitor)

PD symptoms first appear

in middle age AND progress relentlessly

MAO-A

inactivate NE and Serotonin imposes risk for hypertensive crisis

A drug that increases transmitter synthesis will cause receptor activation to (increase or decrease)

increase

Drugs that promote release will (increase or decrease) receptor activation

increase

(MOA) monoamine oxidase

increase level of Dopamine in the brain

Levodopa does what?

increases dopamine synthesis

hypocalcemia

increases neuromuscular excitability clinical presentations: - *tetany* - *convulsions* - *spasm of the pharynx* ^ want to draw Ca levels if seen in a pt causes - deficiency of vitamin D - deficiency of PTH or dietary calcium - chronic renal failure - long-term use of certain medications, such as magnesium-based laxatives, and drugs used to manage osteoporosis (ex: bisphosphonates and denosumab)

Catechol-O-Methyltransferase Inhibitors (COMT) Tolcapone [tasmar] BLACK BOX WARNING

increases risk of hepatotoxicity liver injury/failure may be fatal close monitor required D/C if s/s of liver injury occur AST/ALT elevation is double upper range normal Tx limited to 3 wks in absence of beneficial resp

oral calcium salts

indications: - mild hypocalcemia - dietary supplements - colorectal adenoma adverse effects: - hypercalcemia drug interactions: - corticosteroids - tetracycline - fluoroquinolone - thyroid hormone - phenytoin - bisphosphonates (reaction depends on serum calcium levels) - loop diuretics - thiazide diuretics

Non-selective inhibitors of MAO

inhibit MAO-A and MAO-B used to treat depression pose risk for HTN crisis

Allopurinol mechanism of action

inhibit XO, an enzyme required for uric acid formation

First Generation histamine- 1 antagonists

inhibit allergic reactions of inflammation, redness, and itching caused by the release of histamine Can be used with cold symptoms. Anticholinergic property (dry mouth, urinary hesitancy) CNS depressant (sleepiness) Caution in Asthmatic patients (thickens bronchial secretions impairing breathing) Ex. diphenhydramine, promethazine, chlorpheniramine

hydantoins

inhibit sodium influx, stabilize cell membranes, reduce repetitive neuronal firing and limit seizures

A 70-year-old woman with a history of atrial fibrillation takes digoxin and verapamil to control her health problem. Verapamil achieves a therapeutic effect by: inhibiting the movement of calcium ions across the cardiac muscle cell membrane. blocking adrenergic receptors and producing antisympathetic effects. decreasing sodium and potassium conduction. weakening diastolic depolarization and the action potential duration.

inhibiting the movement of calcium ions across the cardiac muscle cell membrane.

GABA is an

inhibitory neurotransmitter

Dopamine is an

inhibitory transmitter

IM Administration

into muscle (IM) Drug needs to be in solution or particle suspension IM preparations can be immediate release or depot formulations

Meridia

intrauterine device that contains levonorgestrel. Prevent conception by producing a harmless local inflammatory response that is spermicidal. Also treats menorrhagia. Light spotting and amenorrhea are common. Risk : PID good for up to 5 years.

muscle spasm

involuntary ctx of a muscle group or muscle often painful and interferes w/ fx

Levodopa: Dyskinesias

ironically- given to alleviate movement disorders-can actually cause movement disorders about 80% develop involuntary mvmt in 1st yr some just annoying-head bobbing, tic, grimacing some disabling- ballismus, choreoathetosis some develop just before/soon after optimal dosing achieved

The nurse is caring for a client who states that he is taking dicyclomine hydrochloride (Bentyl). The nurse reviews the client 's history and determines that this medication is intended to treat which condition? Peptic ulcer disease Motion sickness Irritable bowel syndrome Asthma

irritable bowel syndrome

Aniline Derivatives

is a non-narcotic analgesic agent that has the potential to cause irreversible liver damage with even a single overdose! ie Tylenol!

IV main anesthetic

ketamine: incr. resp. and H.R., acts as stimulant, no skeletal muscle relaxation

Drugs used for motor symptoms

levodopa levodopa/carbidopa

dopaminergic agents act by several mechanisms

levodopa is converted to dopamine, which: activates dopamine receptors directly monoamine oxidase-B inhibitors (MAO-B): prevent dopamine breakdown amantadine promotes dopamine release and may also block dopamine reuptake catechol-O-methyl-transferase (COMT) inhibitors: enhance levodopa effects by block degradation

B/c of peripheral metabolism less than 2% of each dose reaches the brain if

levodopa is given alone. only small fraction of each dose reaches brain most metabolized in periphery by decarboxylase enzymes and to a lesser extent by COMT

If improving motor fx is primary objective then...

levodopa is preferred

Ulcers treatment

likely caused by H. pylori. Treat with antibiotic and pepto bismol, proton pump inhibitors (prilosec, prevacid, aciphex, nexium, protonix), H-2 blockers (zantac, pepcid, tagamet, nazatidine), antacids, and cytoprotective agens (carafate, cytotec)

nicotinicN

location - all autonomic nervous system ganglia and the adrenal medulla response - stimulation of parasympathetic and sympathetic postganglionic nerves and release of epinephrine from adrenal medulla

nicotinicM

location - neuromuscular junction response - contraction of skeletal muscle

Antineoplastics (anti-tumor)

"Stine" cytotoxic systemic chemotherapy or targeted biological therapy; designed to target specific molecular components in tumor cell biology with the hope of minimizing cytotoxicity to noncancerous cells.

Muscarinic

(target organs of ParaNS and sweat glands of SymNS) Increased glandular secretions, Contraction bronchi/sweat glands, Slowing heart rate Contraction of iris (miosis), Contraction of ciliary muscle of eye (near-vision), Dilation of blood vessels, Urinary voiding

Dopamine

*responds only to dopamine, a neurotransmitter found primarily in the CNS kidney - dilation of kidney vasculature (enhancing renal perfusion)

SALICYTES (aspirin) Non-narcotic analgesics - Acute Side Effects and Toxicities

*•G.I. irritation and decreased coagulation (bleeding) with continued use* •Gastric mucosa usually heals in 3 days •Caution Black Stools •CNS stimulation •respiratory stimulation to point of respiratory alkalosis

A client experiencing a ventricular dysrhythmia has received a bolus of lidocaine. What is the recommended rate for continuous infusion of lidocaine IV now prescribed for this client? 10 to 20 mg/min 0.25 to 0.75 mg/min 1 to 4 mg/min 6 to 8 mg/min

1 to 4 mg/min

Long Acting Beta Agonists (LABA)

1) Formoterol & Salmeterol 2) Onset 20 minutes so NOT for ACUTE attacks 3) Lasts up to 12 hours 4) *Never used alone in ASTHMA, always with inhaled corticosteroids* different with COPD. This is bc smart study showed that LABA alone for asthma can cause death.

Sources of muscarinic poisoning

1) Ingestion of certain mushrooms 2) OD on direct acting muscarinic agonists (bethanechol, pilocarpine) AND cholinesterase inhibitors (indirect acting cholinomimetics)

status epilepticus

A condition in which seizures recur every few minutes or last more than 30 minutes.

Osteoporosis

A condition in which the body's bones become weak and break easily. Treatment: Raloxifene - hormone that improves bone density Denosumab- hormone that prevents bone loss Biphosphonates: Alendronate · Ibandronate · Zoledronic acid. Prevents bone loss.

autonomic nervous system

A division of the peripheral nervous system. Controls involuntary activity of visceral muscles and internal organs and glands. Autonomic is divided into 1. Parasympathetic 2. Sympathetic

What is a Sedative?

A drug administered at a dose level to cause mild drowsiness or sedation or to reduce restlessness & anxiety. (Benzodiazapine/Xanax)

What is a general anesthetic?

A drug given at a dose to depress the CNS to a degree that causes a loss of consciousness (unarousable), as well as analgesia (cannot feel pain).

Intermittent Dose

A drug must be administered for 4-5 half-lives before steady state is reached. Peaks are the high points of fluctuation. toxic effects are most likely to be observed during peak drug concentration. Troughs are the low points of fluctuation. Lack of drug effect is most likely to occur during troughs.

Neuroleptic Malignant Syndrome (NMS)

A rare and sometimes fatal reaction to high-potency neuroleptic drugs. Symptoms include muscle rigidity, fever, and elevated white blood cell count. It is thought to result from dopamine blockage at the basal ganglia and hypothalamus. Treatment: support body through withdrawal.

After reviewing antiarrhythmic drugs, a group of nursing students demonstrate understanding of the drugs when they identify which as a class II antiarrhythmic? Select all that apply. Ibutilide Amiodarone Propranolol Verapamil Acebutolol

Acebutolol Propranolol

Epinephrine

Activates all 4 receptors Therapeutic Uses: 1. A1 delay anesthesia absorption, control superficial bleeding. 2. B1 AV block, asystole. 3. B2 asthma (others preferred). DOC for anaphylactic shock. Pharmacokinetics: Not oral (rapid destruction). Short half-lifeAdverse Effects Drug Interactions: 1. MAOI-inc effect b/c less breakdown. 2. Tricyclic antidepressants - inc effect. 3. General anesthetics - tachydysrhythmias, 4. Alpha-adrenergic blockers, 5. Beta-adrenergic blockers Administration: -watch for extravasation, -constant cardiac monitoring if IV, -not oral, can give intracardiac. -Comes in multiple concentrations - pay close attention

Receptor binding activation/inhibition

Activation - EG morphine (CNS). Epinephrine (CV), Insulin (DM) Inhibition - Naloxone (CNS). Antihistamines (allergic d/o). Propanolol (CV)

Colchicine

Acute gouty attacks PO Anti-inflammatory action only in gout (doesn't work for other inflammatory disorders) Mechanism of action largely unknown Not an analgesic, doesn't relieve pain in conditions other than gout Does not affect uric acid production or clearance

KNOW/MEMORIZE TABLE 13-2 TABLE 13-3 page 113-114 Go back over this in your voice recording!

Alpha 1: -Hit the eye-mydriasis (bigger) -Bladder contration -Constrict peripheral arterioles, -Constrict veins, -Sex organs -Ejaculation, -Contracts prostate (Sympathetic NS!) Alpa 2: Mostly in the CNS Beta 1: -heart- increased rate and force -kidney- release of renin (Parasympathetic ) Beta 2: -Lungs dilate, -Relaxes uterus, heart and skelatal muscle dilate, stimulates liver to do gluconeogenesis. arterioles (Peripheral Dopamine: Kidney (dilates)

Antiepileptic Drugs (AEDs)

Also known as anticonvulsants Goals of therapy -To control or prevent seizures while maintaining a reasonable quality of life -To minimize adverse effects and drug-induced toxicity -AED therapy is usually lifelong -Combination of drugs may be used

Pharmacodynamic Drug-Drug Interactions

Alter overall effect related to the drug's effects in the body, one drug modulates the effect of another

PK Drug-Drug: Metabolism

Alterations in hepatic blood flow Alteration in drug-metabolizing enzymes --> inducers and inhibitors of CYP450 enzymes

PD drugs: Antiviral Agent

Amantadine [generic] tablet: 100mg capsule: 100mg syrup: 10mg/mL 100mg BID (initial) ⇢⇡400mg/day (divided doses) Dose when used w/ high doses of other PD drugs 100mg/day (initial)⇢⇡200mg/day (divided doses)

Half-Life

Amount of time required for the total amount of drug in the body to decrease by one-half -important to determine time to steady state -important to determine elimination from the body

The nurse is preparing to teach a client about cholinergic antagonists. The nurse plans to explain to the client that the healthcare provider or pharmacist may also refer to this type of drug by what other name? ​Indirect-acting muscarinic agonists ​Direct-acting muscarinic agonists Muscarinic agonists Anticholinergics

Anticholinergics

Haloperidol (Haldol)

An antipsychotic drug thought to block receptor sites for dopamine, making it effective in treating the delusional thinking, hallucinations and agitation commonly associated with schizophrenia. -Preferred treatment for Tourette syndrome. -Hepatic metabolism, excreted in urine. -early extrapyramidal reactions occur frequently. Long Q-T .

Solifenacin

Anticholinergic Drugs for Overactive bladder Similar to darifenacin not as M3 selective Adverse effects: dry mouth and blurred vision QT interval

Scopolamine

Anticholinergic drug similar to atropine Therapeutic doses: sedation (versus atropine that causes excitation) Scopolamine: suppresses emesis and motion sickness (atropine does not) Principal uses: motion sickness, production of cycloplegia, mydriases, preanesthetic sedation and obstetric amnesia

Phenytoin (Dilantin)

Anticonvulsant. SEs: Nysagmus, diplopia, EOM palsies, ataxia, gingival hyperplasia. Slows down impulses of the brain that cause seizure activity.

Fluoxetine (Prozac)

Antidepressant, SSRI Treats: Depression (also bipolar, ocd, panic disorder, bulimia, pmdd). S/E: sexual dysfunction in 70% of adults. Treatment for this would involve decreasing dose, drug holiday on weekends, add a drug to treat this such as bupropion, nefazodone, mirtazapine. Weight gain and serotonin syndrome can be other side effects. Abrupt withdrawal can cause dizziness, headaches, nauea, sensory issues, tremors, anxiety and dysphoria - should be tapered down. Do not use in 3rd trimester

5FU

Antimetabolite. Anti-cancer drug used topically for skin cancer. Injection for colon and rectal, breast, gastrointestinal (anal, esphageal, pancreas and stomach), head and neck, liver, and ovarian.

Aripiprazole (Abilify)

Antipsychotic Aripiprazole is used to treat certain mental/mood disorders. It may also be used in combination with other medication to treat depression. Dizziness, Lightheadedness, Drowsiness, Nausea, Vomiting, Tiredness, Excess saliva/drooling, Blurred, vision, Weight gain

Clinical Pharmacokinetics

Application of pharmacokinetic principles to the safe and effective therapeutic management of drugs in an individual patient --> what dose to give how often, etc.

Other biological DMARDs

B-Lymphocyte- depleting agent (Rituxan) T-cell activation inhibitors (Orencia)

Schedule 1 controlled substances

Are classified as high potential for abuse. No accepted medical use. Labeled C-1. -Examples: 1. heroin 2 hallucinogens 3. LSD 4. Marijuana(except when prescribed for cancer treatment.

The nurse is preparing to administer a cholinergic antagonist to a client. When reassessing the client, which finding would the nurse consider an adverse effect of the medication? Dry mucous membranes Increased blood pressure Increased pulse rate Arrhythmia

Arrhythmia

Probenecid interactions

Aspirin and other salicylates

Muscarinic antagonists--Atropine

Atropine Best-known muscarinic antagonist Found in nature Heart: increases heart rate Exocrine Glands: decreases secretions Smooth Muscle: relaxes bronchi, decreases tone of bladder, decreases tone of GI Eyes: pupil dilation CNS: mild excitation to hallucinations and delirium

Anticholinergics

Atropine GI - Slows motility, spasm Eyes - Dilates pupils *DO NOT GIVE TO GLAUCOME PTS* Heart - Increase HR Resp - bronchodilator (Atrovent)

Dobutamine

B1 Receptor TX: Heart Failure Adverse Effects - tachycardia Drug Interactions - MAOI, tricyclic antidepressants anesthetics

dopamine

B1 selective agonist PROTOTYPE low: increased renal profusion mod: increased force of contraction high: increased BP (vasoconstriction) BUT decreased renal profusion

dobutamine

B1 selective agonist increased contractility and SV lead to an increased cardiac output

albuterol sulfate

B2 selective agonist PROTOTYPE - bronchodilation!!!

Gabba Indenpendent

Barbiturates

Selectivity

Because axonal transmission is non-specific, receptor sites must be specific

The nurse is caring for a client who is taking an adrenergic agonist. Which cardiopulmonary system effects should the nurse expect this medication to produce? Bronchospasm Decreased heart rate Decreased blood pressure Bronchodilation

bronchodilation

Gabba Dependent

Benzos Alcohol

Centrally Acting anticholinergic drug

Benztropine (PO/IM)

Albuterol

Beta 2 receptor -Asthma Adverse Effects: -tremor

Muscarine Agonists

Bethanechol

Termination of Transmitter Action

Block reuptake Inhibit degredation

Which statement would be true about the mechanism of action of class II antiarrhythmic agents? Stimulate the uptake of potassium in the tissues Block the stimulation of the adrenergic receptors Block the influx of sodium into the cells Cause depression in phase 2 of repolarization

Block the stimulation of the adrenergic receptors

When describing the action of class II antiarrhythmics, which would the nurse include? Membrane stabilization with depression of phase 0 action potential Blockage of beta receptors in the heart and kidneys Interference with calcium ion movement across the membrane Blockage of potassium channels during phase 3 action potential

Blockage of beta receptors in the heart and kidneys

A patient with type 1 diabetes is prescribed acebutolol. What would be most important to monitor? Electrocardiogram Blood glucose levels Serum electrolyte levels Liver function studies

Blood glucose levels

what toxin inhibits ACh release

Botulinum

Beta-2 Selective Agonists

bronchodilators "-erol" suffix

Digoxin (Lanoxin)

Cardiac glycoside Positive inotrope, negative chronotrope and dromotrope Used for HF, a-fib Can cause dysrhythmias, bradycardia, GI effects (EARLY), vision changes (EARLY) Hypokalemia = toxicity; hyperkalemia = decreased effects Avoid verapamil Hold if pulse < 60 Therapeutic level = 0.5-2.0ng/mL Antidote: cholestyramine or Digibind Interacts w/ many meds and bran, oats, sunflower seeds.

Alpha blockers in pheochromocytoma

Catecholamine secreting tumor derived from cells of sympathetic nervous system. Usually located in Adrenal Medulla If secretions of catecholamines (Epi, NE) is sufficiently great, persistent hypertension results HTN main cause= alpha-1 on blood vessels (also beta-1 on heart contributes) Preferred Tx: removal of tumor. Adrenergic Agonists used: (1) w/ inoperable tumors to suppress HTN. (2) preoperatively to reduce acute HTN in Sx. surgical patient at risk because manipulating tumor can cause massive catecholamine release

Too Little Norepinephrine

Causes Depression

PID treatment

Ceftriaxone 250mg IM single dose PLUS Doxycycline 100mg po bid (14days) OPTIONAL Metronidazole 500mg po bid (14 days)

Dopamine Agonists: Beneficial effects result from...

Direct activation- dopamine receptors in striatum

autonomic preganglionic neurons

cholinergic neurons

parasympathetic postganglionic neurons

cholinergic neurons

After receiving a​ medication, the client is experiencing dysphagia. Which intervention by the nurse is the most​ appropriate? Provide orange juice for the client. Ascertain fluid intake and urinary output. Raise the dose of the client​'s anticholinergic agent. Contact the health care provider immediately.

Contact the health care provider immediately

Phase I Metabolism

Create or unmask a more polar group required for phase II reactions Oxidative, hydrolyic, reductive reactions Enzymes involved (oxidation) --> CYP450 enzymes

Where are cholinergic receptors found?

parasympathetic

Drugs that help reduce off times

DEFINITELY EFFECTIVE Entacapone- COMT Inhibitor Rasagiline- MAO-B inhibitor PROBABLY EFFECTIVE Rotigotine- DA agonist Pramipexole- DA agonist Ropinirole- DA agonist Tolcapone- COMT Inhibitor POSSIBLY EFFECTIVE Apomorphine- DA agonist Cabergoline- DA agonist Selegiline- MAO-B Inhibitor

The nurse is caring for a client with Raynaud's syndrome who has been prescribed adrenergic antagonist therapy. Which effect of this medication will alleviate the client 's symptoms? Decreased vasospasms Increased urinary output Decreased blood pressure Decreased heart rate

Decreased vasospasms

Tolterodine

Detrol, Detrol LA Stops bladder spasms / urinary frequency or urgency S/E anticholinergic (less than Oxybutynin)

So if a pt. was given a drug to slow down their intestines and its a sympathetic agonist what type of side effects are you going to get?

Dilated pupils weak salivary flow accelerated heart rate bronchi's dilated inhibited stomach motility relaxes bladder- no peeing uterine muscle relaxes

Etanercept (Enbrel)

Disease-modifying antirheumatic drug (DMARD). Interrupts complex immune responses, preventing disease progression. Uses: slow joint degeneration and progression of rheumatoid arthritis.

Your​ client, Jill​ Aquino, presents with ophthalmic congestion. Her husband brought her to the​ clinic, where her health care provider prescribed naphazoline​ (Naphcon). During client​ education, what do you tell Ms. Aquino to​avoid? Driving a vehicle after administration Lying down during administration Shaking the bottle before administration Removing contact lenses before administration

Driving a vehicle after administration

Cannabinoids

Dronabinol (marinol) and Nabilone (cesamet). Suppresses CINV.

Parkinson's Disease - What do the drugs do?

Drug Treatment: 1. Increases dopamine 2. Decrease acetylcholine

Factors Affecting Absorption

Drug characteristics: molecular weight, ionization, solubility, formulation --> the bigger the drugs are the harder it is for them to get through the membrane Patient end: route of administration, gastric pH, contents of GI tract

Biliary Excretion & Enterohepatic Cycling

Drugs can be excreted in the bile as parent compound or metabolite Biliary flow --> intestines In intestines drug may be hydrolyzed releasing active drug again --> absorbed --> liver & repeated -This may prolong drug action If not reabsorbed will be excreted in feces.

Movement of Drugs Across Membranes

Drugs pass through cells via: -Channels and pores --> small so only only small compounds can move this way (Na, K, etc) -Transport systems --> carriers that move drugs from one side to the other, often selective (depends on drug structure), some require energy -Direct penetration of the membrane --> must be lipid soluble (lipophilic) e.g., transdermals *NOTE: drugs can exist in charged or uncharged forms, ions are unable to travel across membranes - only neutral molecules will travel through membranes!

Adrenergic neuron blocking agents

Drugs that act within the terminals of sympathetic neurons to decrease NE release

What is a Hypnotic?

Drugs which are administered at a dose level to induce sleep or allow an individual to stay asleep

Parkinson's Drugs given through PEG-J tube

Duopa suspension and Duodopa gel [levodopa/carbidopa] given via PEG-J Tube

Olanzapine (Zyprexa)

antipsychotic (atypical), mood stabilizer, thienobenzodiazepine antagonizes dopamine and seratonin type 2 in the CNSalso has antocholinergic, antihistiminic, and anti alpha1 adernergic effects decreases manifestations of psychoses Metabolized by the liver. Peaks in 6 hours 21-54 hour half-life contraindicated in lactation S/D metabolic. can cause leukopenia and neutropenia increasing risk for infection. Somnolence.

Antagonistic control example

Effector organ: Heart sympathetic response increases heart rate parasympathetic response slows rate

Bethanechol Pharmacokinetics

Effects begin in 30-60 minutes and persist for about 1 hour The drug crosses membranes POORLY

Adrenergic agonists (sympathomimetics)

Endogenous (naturally occurring in the body) and synthetic chemicals that activate adrenergic receptors in effector cells. In doing so they mimic the action of the sympathetic nervous system, which is why they are also called "sympathomimetics". The five main categories of adrenergic receptors are: α₁, α₂, β₁, β₂, and β₃, although there are more subtypes, and agonists vary in specificity between these receptors, and may be classified respectively.

Mrs. Laura Luchow is brought to the emergency department following a barbiturate overdose. What nonselective sympathomimetic could be of therapeutic use to Mrs.​ Luchow? Naphazoline hydrochloride​ (Naphcon) Ephedrine hydrochloride​ (Efedron) Oxymetazoline hydrochloride​ (Afrin) Pseudoephedrine hydrochloride​ (Novafed)

Ephedrine hydrochloride (Efedron)

(2) groups of dopamine agonists

Ergot Derivative- (alkaloid found in plants) LESS selective for dopamine receptors Bromocriptine [Cycloset, Parlodel] Cabergoline [Dostinex] Non Ergot Derivative- HIGHLY selective for dopamine receptors Pramipexole [Mirapex] Ropinirole [Requip] Rotigotine [Neupro] Apomorphine [Apokyn]

(2) BBs not used for hypertension

Esmolol- short half life (15 mins) Only approved therapy: emergency IV for SVT Sotalol- inducable arrhythmias Only approved therapy: Tx of ventricular dysrhythmias and to maintain NSR in those with previous Afib/Aflutter

Alpha-Adrenergic Antagonists (alpha blockers): Therapeutic Uses

Essential HTN Reversal of toxicity Alpha-1 Agonists (Epi) BPH Pheochromocytoma Raynaud Disease

explain how neuropharmacologic drugs exert their effects

Excitation or suppression of neuronal activity By mimicking or blocking neuronal regulation, neuropharmacologic drugs can modify such diverse processes as skeletal muscle contraction, cardiac output, vascular tone, respiration, GI function, uterine motility, glandular secretion, and functions unique to the CNS, such as ideation, mood, and perception of pain

Danny​ Feld, a healthy young​ male, comes into the emergency department after being mugged near the hospital. He has sustained minor cuts and​ bruises, but mainly he is upset. Mr. Feld asks you why his mouth is​ dry, yet he is sweating. How might​ you, as the​ nurse, best reassure Mr.​ Feld? Explain to Mr.​ Feld, in simple​ terms, the​ body's natural​ fight-or-flight response. Tell Mr. Feld that you will request a comprehensive blood panel. Tell Mr. Feld that you will ask the health care provider to prescribe a heavy sedative. Recommend to Mr. Feld that he follow up with his health care provider.

Explain to Mr. Feld, in simple terms, the body's natural fight-or-flight response.

T or F: all sympathetic postganglionic axons release NE

FALSE; most do

The nurse is caring for a client who is receiving glycopyrrolate (Robinul) for the treatment of peptic ulcer disease. The nurse should assess the client for which symptoms that indicate the presence of an anticholinergic crisis? Select all that apply. Fever Incontinence Dysphagia Hallucinations Confusion

Fever Dysphagia Hallucinations Confusion

2nd generation antihistamines

Fexofenadine, loratadine, and cetirizine non sedating less crossing of blood brain barrier, does not suppress CNS Take daily to prevent allergic reaction.

The neurons that release acetylcholine excite the neurons that release

GABA

The neurons that release dopamine inhibit neurons that release

GABA gamma-aminobutyric acid

Adverse effects of colchicine

GI toxicity- N/V/D abd pain Myelosuppression- BM decrease Rhabdomyolysis- muscle degeneration; inflammatory response CNS effects and dizziness in the elderly Cleared by kidneys

Therapeutic agents that alter parasympathetic nervous system function are used primarily for their effects on the

GI tract, bladder, and eye

Probenecid

Generic only Increases excretion of uric acid by acting on renal tubules and inhibiting reabsorption of uric acid Acts on renal tubules to inhibit reabsorption of uric acid- prevents formation of new tophi and helps existing tophi decrease May exacerbate acute episodes of gout- add indomethacin or colchicine for relief

Oxybutynin (Ditropan)

Genitourinary Medication, Anticholinergic Stops bladder spasms S/E dry mouth

what is the goal for Urate-lowering therapy?

to promote dissolution of urate crystals, prevent new crystal formation, prevent disease progression, reduce the frequency of acute attacks and improve quality of life

Levodopa/Carbidopa (Sinemet)

Goal: Improve ADLs. Does NOT delay progression Baseline Data: assess motor symptoms: bradykinesia, akinesia, postural instability, tremor, rigidity and extent to which they interfere with life. High-Risk Patients: assess skin for changes. levo+MAO inhibitors can activate malignant melanoma. caution in pts w/ CV disease, psychiatric disorders, and those taking MAO-B inhibitors Administration concerns: easy open pill bottles. no childproof bottles. Managing acute loss of effect: "off" times can be reduce by combing levo/carb w/dopamine agonist (Pramipexole), a COMT inhibitor (entacapone) or an MAO-B inhibitor (rasagiline) Minimizing adverse effects: n/v decreased by taking med w/ food amantadine may help w/ dyskinesias monitor for dysrhythmias, psychosis, OH 1st gen antipsych- block DA sites, ↑motor deficits High protein competes w/levo-absorb/transport MAO-inbitors + levo/carb= HTN crisis Anticholinergic + levo/carb= enhance responses

sympathetic effect of the heart

HR increases

No single drug is more effective than the others so selection should be based on

tolerability, ease of use, cost

Olsalazine (Dipentum)

IBD Management - Salicylate Derivative

There are four primary classes of antidysrhythmic drugs. What class consists primarily of potassium channel blockers? III IV II I

III

Although, dopamine agonists LESS EFFECTIVE than levodopa, still has advantages....

IN CONTRAST TO LEVODOPA -not dependent on conversion to become active -not converted to potentially toxic metabolites -don't compete w/ dietary proteins (for uptake in GI or transport across BBB) CONTRASTING LEVODOPA-IN CHRONIC USE -a lower incidence of response failures -less likely to cause disabling dyskinesias

Enteral Administration

tongue --> down oral, rectal, sublingual, buccal

1st-in-class NMDA Receptor Antagonist: Memantine

INDICATED ONLY FOR MOD-SEVERE AD. unlike cholinesterase inhibitors (used for mild) unknown= >effective than cholinesterase inhibitor BUT WE DO KNOW, IT'S BETTER TOLERATED!

Memantine [Namenda, Namenda XR]

IR tab: 5, 10mg PO SOLN: 2mg/mL, 10mg/5mL Increase gradually using the following schedule: 5mg/day (5mg once)- 1 week or more 10mg/day (5mg BID)- 1 week or more 15mg/day (5mg + 10mg= AM/PM)- 1 week or more 20mg/day (10mg BID)- MAINTENANCE Admin: W/WO food SOLN: ⌀mix w/meds. use only provided device ER cap: 7, 14, 21, 28 mg Increase gradually using the following schedule: 7 mg QD x 1 week or more 14 mg QD x 1 week or more 21 mg QD x 1 week or more 21 mg QD= MAINTENANCE Mod Renal Dysfx: reduce dose D/C: patients with severe renal impairment Admin: swallowed whole or added to soft food (applesauce), contents NOT crushed/chewed

Balsalazide (Colazal)

IBD Management - Salicylate Derivative

Cyclosporine

Immunosuppressant

Allopurinol (Zyloprim)

Inhibits uric Acid formation- keeps uric acid down in cancer patients Maintenance therapy Reduce blood levels of uric acid Used for chronic tophaceous gout, hyperuricemia due to chemotherapy

Excretion

Kidney is the major site for drug excretion, cannot efficiently eliminate lipophilic drugs; can also eliminate via hepatobiliary system and lungs Most drugs excreted in urine as parent compound (UNCHANGED) or as metabolite; degree of renal excretion varies widely drug to drug 3 processes involved: -glomerular filtration -active tubular secretion -passive tubular reabsorption Total excreted = [(filtered+secreted) - reabsorbed]

Therapeutic Range

Least drug needed to be effective and least amount of drug needed to have toxic effects (NOTE: adverse effects can happen anywhere in this range) minimal effective/therapeutic/toxic relationship

Preperations: Levodopa Combinations (highly individualized doses)

Levodopa/Carbidopa (C/L) mg [Sinemet, Rytary, Duopa, Duodopa] Sinemet IR- 10/100, 25/100, 100/250 Sinemet CR- 25/100, 50/200 Rytary- 23.75/95, 36.25/145, 48.75/195 61.25/245 Duopa enteral suspen- 4.63mg/20mg per mL Duodopa intestinal gel- 5mg/20mg per mL -Initial Tx: typical dose is one tab QD or QOD. gradual↑to 8 tab QD(max) regardless of strength -Duopa/Duodopa-sometimes dose changes daily Levodopa/Carbidopa/Entacapone (C/L/E) mg [Stavelo] Stavelo- (50) 12.5/50/200, (125) 31.25/125/200 (100) 25/100/200, (150) 37.5/150/200 (75) 18.75/75/200, (200) 50/200/200 -Typical= 1 tab any strength@each dosing interval up to 8 tabs QD (max) of Stavelo 50-150 up to 6 tabs QD (max) of Stavelo 200 -Dosing intervals determined by pt response NO HIGH FAT. TAKE PILLS WHOLE.

First-Pass Metabolism

Loss of drug as it passes for the first time through an organ of elimination, the liver, during the absorption process May also be the conversion of a pro-drug to an active form (and may still "lose" drug because not all is converted to active form) Pertains to oral dosing only

What are the Anti-epileptic agents?

MOA: 2 Ways 1. Decrease movement of ions into the nerve cells (block Na) and therefore, reduce repetitive firing of neurons. 2. Alter activity of neurotransmitter (inc. GABA or dec. glutamate Phenytoin (not general depressant), Valproic Acid, carbamazepine, phenobarbital - all used as first line of therapy bc they are effective and cheaper.

Methyldopa Methyldopate

Lowers BP Activates alpha 2 Vasodilator Used in HTN in pregnancy Adverse effects: hemolytic anemia Check COombs test on starting and during treatment 6-12 months Hepatotoxic Xerostomia Sexual dysfunction Ortho hypo CNS effects

Miscellaneous Laxatives

Lubiprostone, mineral oil, glycerin suppository, polyethylene glycol- electrolyte solution, Sodium picosulfate / magnesium oxide/anhydrous citric acid

Buspirone (Buspar)

anxiolytic Buspirone is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety. Buspirone is used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms. No MAOI

Selegiline prevents development of Parkinsonism

MPTP- neurotoxin causes selective degeneration of dopaminergic neurons not caused by MPTP itself, but by toxic metabolite formation of toxic metabolite is catalyzed by MOA-B inhibition of MOA-B= prevents metabolite formation and protects against neuronal injuries. humans exposed to MPTP develop SEVERE parkonisism

Most common causes of spasticity

MS and cerebral palsy (other causes stroke, traumatic spinal cord lesions)

alzheimers RF

Major known RF- advancing age 90% pts- age of onset > 65 risk of AD double Q 10 yrs after 65 until age 85-90= risk levels off/declines other known RF- familial history female MAY be a RF possible RF: head injury, low education level, apoE4 protein production, high homocysteine levels, low folic acid levels, estrogen/progestin therapy, sedentary lifestyle, nicotine in cig smoker

Surfactant Laxatives

Meds: Docusate sodium (Colace) Docusate calcium (Surfak) temporary treatment of constipation * avoid if narrowing of intestines Give with a full glass of water or juice

(2) BBs that have high solubility

Metoprolol and Propranolol Highly lipid soluble Penetrate BBB with ease Eliminated primarily by hepatic metabolism.

What are first line agents for relieving pain of acute gouty attack?

NSAIDs

Infliximab (Remicade)

Monoclonal Antibody that binds to tumor necrosis factor (TNF) & neutralizes its activity by preventing it from binding to the cell membrane in the blood. It is an immunosuppressant & is indicated for treatment of active Crohn disease & ulcerative colitis & is generally reserved for moderate - severe cases. It is given in IV form & the vials need to be refrigerated.

Bethanechol--general

Muscarinic Agonist/Parasympathomimetic agent Selective agonist at muscarinic cholinergic receptors Therapeautic uses: Urinary retention and investigational GI uses A) Heart: Bradycardia B) Smooth Muscle: 1) Constriction of bronchi in lungs 2) increased tone and motility in GI 3) Contraction of detrusor muscle in Bladder C) Exocrine glands: increased sweating, salivation, bronchial secretions, and gastric acid D) Eye: contraction

Dicyclomine

Muscarinic Antagonists For IBS (spastic colon, mucous colitis) Functional bowel disorders (diarrhea and hypermotility)

Drugs for acute gouty arthritis

NSAIDs, glucocorticoids

Treatment of gout

NSAIDs- 1st choice, Indomethacin, Naproxen, Diclofene Glucocorticoids- prednisone, PO or IM

(2) BBs that have low solubility

Nadolol and Atenolol Low lipid solubility Penetrate BBB poorly Eliminated primarily by renal excretion.

Opioid reversal agent

Naloxone (Narcan)

Neurotransmitters of ANS

NE secreted by most sympathetic fibers & ACh released by parasympathetic

Administration: PO Parkinson's Meds

NO FOOD: Levodopa/Carbidopa= take on empty stomach Selegiline= dissolve tab on top of tongue before breakfast. wait 5 mins before eat/drink FOOD: All others= can be taken W/WO food. Food does ↓ GI upset ER tabs/Stavelo- MUST be swallowed WHOLE Levo/Carb/Enta= NO high fat foods ↓absorp (compete- absorption and transport to BBB) TIMEFRAME: Cycloset- take within 2 hrs of awakening Entacapone- take w/each dose of levo/carb Tolcapone- 1st dose w/ levo/carb QAM, next two doses 6 and 12 hrs later. Selegiline- before breakfast 5min wait before PO

Alpha-Adrenergic Antagonists (alpha-1 blockers): Adverse Responses

Orthostatic hypotension- alpha receptors on veins ↓tone in venous wall. Reflex tachycardia- baroreceptor reflex- dilation=↓BP=receptor=↑HR Nasal congestion- alpha blockade can dilate nasal mucosa vessels Inhibition of ejaculation- sexual dysfunction r/t blockade of alpha-1 Sodium retention & increased blood volume- ↓BP, ↑renal retention Na+ water, ↑blood volume

2nd neuron of two neuron chain

POSTganglionic neuron

Neurons alter receptor activity by releasing

transmitter molecules, which diffuse across the synaptic gap and bind to receptors on the postsynaptic cell

Which muscarinic agonist may be prescribed for​ xerostomia? Donepezil hydrochloride​ (Aricept) Pilocarpine hydrochloride​ (Salagen) Bethanecol chloride​ (Duvoid) Carbachol​ (Miostat)

Pilocarpine hydrochloride​ (Salagen)

Single Dose Regimen

Plasma concentration of drug rises as the drug distributes to the bloodstream, then falls as the drug is distributed to tissues, metabolized, and excreted. Drugs administered orally reach a peak plasma concentration at a later time than drugs administered IV. Oral agents must be absorbed across GI mucosa and capillary walls before entering systemic circulation.

Muscarinic Antagonists--Atropine therapeutic use

Preanesthetic medications Disorder of the eye Bradycardia Intestinal hypertonicity and hypermotility Muscarinic agonist poisoning Peptic Ulcer disease Asthma Bilary colic

Levodopa: CV effects

Postural hypotension COMMON in early Tx hypotension↓ by ↑salt and water intake alpha adrenergic agonist can help too levodopa conversion in periphery can produce excessive b1 receptor activation in the heart DYSRHYTHMIAS result, esp in pts w/ CVD

Dosing/Administration: Dopamine Agonists- NonErgot Derivatives [Pramipexole, Ropinirole, Rotigotine]

Pramipexole: IR: 0.125mg TID (initial)→↑1.5mg TID (max) ER: 0.375mg QD (initial)→↑4.5mg QD (max) -Titrate= (IR) ↑over 7 wks, (ER) ↑gradually -↓dosage for significant impairment Ropinirole: IR: 0.25 mg TID (initial)⇢⇡8mg TID (max) ER: 2mg QD (initial)⇢⇡24mg QD (max) -Titrate (PRN)= ⇡s over several months Rotigotine: -EARLY STAGE PD: {1} 2-mg patch/24hrs (initial)→↑2mg weekly OR until lowest effective dose attained OR until (max) 6mg/24hrs -ADVANCED STAGE PD: {1} 4-mg patch/24hrs (initial)→↑2mg weekly up to 8mg/24 hrs (max) -If D/C: withdrawal= same rate= ↓2mg/wk Apomorphine: Injectable: 10mg/mL, comes in 3mL cartridge Used with multi-dose injector pen 2-6mg (0.2-0.6 mL) SQ w/ each "off" episode Max: 5 doses/day Start antiemetic 3 days prior to 1st dose.

The nurse is caring for a client with myasthenia gravis. In reviewing the client 's medication list, which medications does the nurse identify as being given for treatment of this condition? Select all that apply. Donepezil hydrochloride​ (Aricept) Cyclosporine​ (Sandimmune) Pyridostigmine bromide​ (Mestinon) Physostigmine salicylate​ (Antilirium) Prednisone​ (Deltasone)

Prednisone​ (Deltasone) Pyridostigmine bromide​ (Mestinon) Cyclosporine​ (Sandimmune)

A patient is admitted to the cardiology unit of a health care facility for ventricular arrhythmia. In which condition can an anti-arrhythmic drug be safely administered? Severe congestive heart failure Premature ventricular contraction Third-degree heart block Aortic stenosis

Premature ventricular contraction

antipsychotic medications

Prescription drugs that are used to reduce psychotic symptoms; frequently used in the treatment of schizophrenia; also called neuroleptics. Block dopamine, acetylcholine, histamine, and norepinephrine receptors in the brain and periphery. Acute and chronic psychosis, schizophrenia, manic phase of bipolar disorders, Tourette's syndrome, delusional and schizoaffective disorders, dementia. Conventional (typical) or atypical. Patient education: s/s of orthostatic hypotension - move slowly when standing up. Sedation - avoid hazardous activities such as driving until sedation wears off. Impaires libido and erection / ejaculation *avoid anticholinergic drugs, barbiturates, benzos and alcohol.

Cholinesterase Inhibitors: Donepezil, Rivastigmine, Galantamine

Prevent breakdown of ACh by AChE ↑available ACh at cholinergic synapses In AD: enhanced transmission by central cholinergic neurons that have not yet been destroyed. do NOT stop disease progression BUT may slow progression by a few months

Apomorphine: antiemetic combination

Prevent n/v- treat 3 days prior w/ antiemetic Trimethobenzamide [Tigan] CANT USE: ZOFRAN OR COMPAZINE serotonin recep-antag- zofran. ↑OH. ⌀△in N/V DA recep-antag- compazine.↓effect of PD drugs

Potential interventions to delay ONSET of Alzheimer's disease: NUTRITION

QUALITY OF EVIDENCE SHOWS POSSIBLE BENEFITS: Mediterranean Diet Light-Mod Alcohol Intake Folic Acid NO BENEFITS: Ginkgo Biloba Vitamin E Homocysteine Vitamin B12 Vitamin C Omega-3 Fatty Acids Beta-Carotene

Potential interventions to delay ONSET of Alzheimer's disease: SOCIAL/BEHAVIORAL FACTORS

QUALITY OF EVIDENCE SHOWS SMALL PROTECTIVE EFFECT: Cognitive Training Physical Activity

Goals of RA

Relieve symptoms Maintain joint function Minimize systemic involvement Delay disease progression Mobility

Pharmacokinetics

Relationship between the dose and the concentration of that drug in body fluids and tissues over time "what the body does with drug" --> study of the time course of a drug -Absorption -Distribution -Metabolism/biotransformation -Excretion/elimination

Neostigmine (Prostigmin)

Reversible Cholinesterase Inhibitor (drugs that prevent degradation of acetylcholine) Used for management of Myasthenia Gravis: increases force of contraction in skeletal muscle Cannot readily cross membranes Absorbed poorly with oral administration Minimal effects on brain and fetus Poor substrate for cholinesterase Response: identical to muscarinic agonist response (the direct type)

when the sympathetic Nervous System is at work these things happen

Running from a bear fight or flight heart rate up lungs dialate- lungs open to move more oxygen stops GI system- salivation (starts digestion) don't need this right now. bladder muscle will relax and sphincter will constrict so that you won't pee, and many other unwanted things when you are ie. running from a bear. pupils dilate( get bigger) (mydriasis) ejaculation- heart rate up

albuterol sulfate

S/E - tremors, dizziness, palpitations, dysrhythmias AVOID w/ hypertension or severe cardiac disease AVOID w/ MAOIs --> hypertensive crisis

Raloxifine (Evista)

SIDE EFFECTS: - DVT, PE, and fetal harm NURSING CONSIDERATIONS: - n/a

Denosumab (Prolia, Xgerva) - monthy subQ injections

SIDE EFFECTS: - In postmenopausal women back pain, pain in extremities, musculoskeletal pain, hypercholesterolemia, bladder infections - Hypocalcemia, serious infections, dermatologic reactions, and osteonecrosis of jaw (ONJ) NURSING CONSIDERATIONS: - n/a

Conjugated Estrogen (Premarin)

SIDE EFFECTS: - Increased risk of breast cancer, cholecystitis, MI and CVA NURSING CONSIDERATIONS: - Women with intact uterus requires progestin - This drug is no longer the best treatment option

Calcitonin-Salmon Nasal Spray

SIDE EFFECTS: - Nasal dryness and irritation NURSING CONSIDERATIONS: - Should be given with supplemental calcium and vitamin D - Pulled from Canadian market in 2013 due to increased risk of malignancy

Teriparatide (Forteo) - daily subQ injections

SIDE EFFECTS: - Nausea, headache, arthralgia, back pain, leg cramps - Orthostatic hypotension and dizziness after injection NURSING CONSIDERATIONS: - Black box warning due to increased risk of osteosarcoma - Should be used with extreme caution in those with bone metastasis or history of skeletal cancer

Clozapine (Clozaril)

Second Generation (Atypical) Antipsychotic low affinity to D2 dopamine receptors treats schizophrenia and suicidal behavior. Not many EPSs. S/E weight gain, orthostatic hypotension, sedation, cholinergic, urinary retention, constipation, tachycardia.

Metoprolol (Lopressor) Info

Second generation BB Selective blockade of beta-1 At high doses- will block beta-2 as well. Preferred in asthma and DM b/c no bronchoconstriction and hypoglycemia (beta-2) ↓HR, ↓contraction force, ↓conduction velocity through AV node. (beta-1 blockade) ↓renin secretion at kidneys. does NOT block bronchial beta-2= does NOT ↑airway resistance. very lipid soluble. absorbs well after PO admin Only 40% reaches circulation after first pass. eliminated by hepatic metabolism/renal excretion Uses: Primary-HTN. Angina, HF, MI Adverse Effects: Brady, ↓CO, AV block, abrupt withdrawal causes cardiac excitation. Can cause HF even though it can treat HF. Contraindicated: Brady, AV block >1st degree. Caution: HF patients Safer than Propranolol in asthma/severe allergy and DM= Min blockade of beta-2 that cause bronchoconstriction and hypoglycemia.

Benzo & Barbiturates Therapeutic Uses

Sedative Hypnotics *Relieves anxiety *Sleep Disorders *Epilepsy (barbiturates)

Zaleplon

Sedative/Hypnotic a sedative that is used to treat insomnia. zaleplon causes relaxation to help you fall asleep and stay asleep.

Alpha blockers can be divided into (2) groups

Selective alpha-1 blockade (prazosin= block alpha-1) Nonselective alpha blockers (phentolamine= block alpha-1 and alpha-2)

MAO-B Inhibitors

Selegiline [Eldepryl, Zelapar] Capsule: (elderyl, generic) 5 mg Tablet: (generic) 5mg ODT: (Zelapar) 1.25 mg Cap/Tab: 5mg breakfast & lunch. Total= 10mg/day Dose=complete MAO-B inhibition. NO ↑dose. ODT: 1.25mg QD x 6wks⇢⇡2.5mg QD (max) PRN Dissolve on top of tongue. 5 min wait before PO. Rasagiline {Azilect] 0.5mg, 1mg tablets Monotherapy: 1mg QD or 0.5mgQD (↓hepatic Fx) W/levo: 0.5mg QD (initial) ⇢⇡1mg QD (PRN)

describe a reflex

Sensor -monitor the status of a physiologic process Information picked up by the sensor is sent to the CNS (spinal cord and brain), where it is integrated with other relevant information Effector -makes appropriate adjustments neurons connecting the sensor to the effector

The nurse is preparing to educate a client who has been prescribed an adrenergic agonist inhaler. The nurse should include which instructions in the client education? Select all that apply. Rinse the mouth with water after using the inhaler. Avoid sharing the inhaler with other family members. Monitor for rebound congestion. Sit straight up when administering the inhaler. Shake the inhaler prior to administration.

Sit straight up when administering the inhaler. Shake the inhaler prior to administration. Rinse the mouth with water after using the inhaler. Avoid sharing the inhaler with other family members.

Factors Influencing Bioavailability

Solubility of the drug --> able to cross lipid membranes and have water-solubility Drug formulation --> must "dissolve", how well? Chemical instability --> may be unstable or destroyed in GI tract (acid labile) First-pass hepatic metabolism --> drug vs. prodrug

Which division of the nervous system is responsible for voluntary control of skeletal​ muscles? Sympathetic nervous system Parasympathetic nervous system Somatic nervous system Autonomic nervous system

Somatic Nervous system

Peripheral Nervous System (PNS)

Somatic motor system **Controls voluntary movement Autonomic nervous system (think automatic not voluntary) *Regulates involuntary processes **Parasympathetic **Sympathetic MEMORIZE THIS PICTURE!!

Which PD drug should you avoid a high fat diet with?

Stavelo levodopa/carbidopa/entacapone

Continuous IV Infusion

Steady state (equilibrium) plasma drug concentration is reached after continuous infusion for 4-5 half-lives. Increasing the rate of infusion will not decrease the time needed to reach steady state. Increasing the rate of the infusion will, however, increase the plasma drug concentration at steady state.

Describe the steps in synaptic transmission (5)

Step 1: Transmitter Synthesis Step 2: Transmitter Storage Step 3: Transmitter Release Step 4: Receptor Binding Step 5: Termination of Transmission

Glipizide (Glucotrol)

Stimulates insulin release from the pancreatic beta cells; reduces glucose output from the liver; insulin sensitivity is increased at peripheral target sites

Glyburide

Stimulates insulin release from the pancreatic beta cells; reduces glucose output from the liver; insulin sensitivity is increased at peripheral target sites

Hypoglycemics: Action

Stimulates liver to change glycogen to glucose, used for hypoglycemia (when unconscious) Glucagon.

Anti-diarrheals

Stops further occurrence of diarrhea. Notable medicines are Loperamide "Immodium", Diphenoxylate Hcl with Atropine "Lomotil", Bismuth subsalicylate "Pepto bismul" Pepto s/e: black stools and tongue

Schedule 2 controlled substances

Substances with high potential for abuse and currently accepted medical uses. Abuse may lead to severe psychic or physical dependance. Examples - Opium, Morphine, Fentanyl, Methadone, Cocaine, and Oxycodone

Schedule 5 controlled substances

Substances with very low potential for abuse and currently accepted medical uses. The substances has very limited physical or psychological dependence liability. Examples - Codeine mixtures, Ephedrine

The nurse notes that a client's current medications include both diltiazem for a dysrhythmia and nitroglycerin. The nurse should recognize the need to closely monitor the which client assessment datum? blood pressure level of consciousness oxygen saturation levels peripheral pulses

blood pressure

Toxicology of Muscarinic Antagonists

Symptoms: dry mouth, blurred vision, photophobia, hyperthermia, CNS effects, hot/dry/flushed skin Treatment: physostigmine; inhibitor of acetylcholinesterase

describe Transmitter Synthesis

Synthesis/construction of transmitter from precursor molecules

T or F: ACh binding to muscarinic can be either inhibitory or stimulatory

TRUE

Pt teaching for clonidine

Take a bedtime to reduce sedation Record BP Monitor for low BO Chew gum, sugarless candy for dry mouth Advise about CNS depression

Beta 2

Used for Asthma: -selective B2 are preferred -most by inhalation, reduces systemic effects - causes-Lung - bronchial dilation Used to delay preterm labor -relaxes uterine sm smooth muscle Adverse effects: -Hyperglycemia in diabetes -tremor

What do anticholinergic medications​ do? Select all that apply. Treat target SNS organ conditions Block acetylcholine from binding to receptor sites Inhibit the PNS Stimulate the PNS Aid acetylcholine in binding to receptor sites

Treat target SNS organ conditions Block acetylcholine from binding to receptor sites Inhibit the PNS

Silver sulfadiazine (Silvadene)

Treatment of burns; usually used with open method of wound care; used to avoid acid=base complication; keeps eschar soft, making debridement easier; adverse reactions: penetrates wound slowly; administer pain medication prior to dressing change

Permethrin

Treats scabies and lice

Mesalamine

Treats ulcerative colitis and mild to moderate IBD

Guanfacine

Used for HTN adhd Adverse effects: ceros Tomis, sedation, rebound HTN Take at bedtime to minimize sedation Do not take with grapefruit juice

Lubiprostone (Amitiza)

Used for IBS-C and chronic constipation Increases fluid secretion in intestine, promotes motility Can cause diarrhea, nausea (take w/ food)

Alosetron (Lotronex)

Used for IBS-D in women that has lasted > 6 months Blocks 5-HT3 receptors resulting in firm stool and decrease in urgency and frequency of defecation Can cause constipation

Alosetron (Lotronex)

Used for IBS-D in women that has lasted > 6 months Blocks 5-HT3 receptors resulting in firm stool and decrease in urgency and frequency of defecation Can cause constipation / bowel obstruction and perforation

Trospium

Trospium Anticholinergic Drugs for Overactive bladder Nonselective muscarinic antagonist Generally well tolerated Dry mouth Constipation

T or F: most of the body's regulation/adaption of internal environments involves both muscle (somatic) and smooth, cardiac or gland functioning (autonomic)

True

PD drugs benefit patient by improving

bradykinesia gait disturbance postural instability tremor and rigidity= disturbing, but less disabling

Parasympathetic fibers emerge from:

brain and sacral spinal cord

Allopurinol interactions

Warfarin

alpha-synuclein

a potentially toxic protein synthesized by dopaminergic neurons

Memantine: Pharmacokinetics

Well absorbed after PO dosing BOTH w/wo food Peak: 3-7 hrs. Met/Exc: min metab, excret unchanged in urine Half-Life is LONG: 60-80 hrs Clearance reduced in renal impaired pts. SE: Well tolerated(Min SE)- dizzy, HA, confus, constip incidence of effects same w/placebo in trials Drug Interactions: Combo: Memantine w/another NMDA antagonist (Amantadine, Ketamine)= possible (-) effects Use combination therapy w/ CAUTION

Smooth muscle

bronchi, blood vessels, urogenital system, GI tract

Serotonin Syndrome

With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures. -Treatment: cyproheptadine (5-HT2 receptor antagonist). Can resolve on it's own by discontinuing the drug.

Atropine Adverse effects

Xerostomia-dry mouth Blurred vision and photophobia Elevation of intraocular pressure Urinary retention Constipation Anhidrosis Tachycardia Asthma

Ondesetron Class: 5HT3 receptor antagonist

Zofran Indication: Chemotherapy N/V, postoperative N/V, radiation induced N/V Oral or Parental * Prolonges QT interval (leading to torsades de pointes)

Theophylline

a bronchodilator. It works by relaxing muscles in the lungs and chest, making the lungs less sensitive to allergens and other causes of bronchospasm. Theophylline is used to treat symptoms such as wheezing or shortness of breath caused by asthma, bronchitis, emphysema, and other breathing problems Tablet form: do not crush, chew or break open. Take with full glass of water.

Crohn's disease

a chronic autoimmune disorder that can occur anywhere in the digestive tract; however, it is most often found in the ileum and in the colon

clonic seizure

a convulsive seizure

How is hyperuricemia defined?

above 7mg/dL in men or 6 in women

Continuous Infusion

administered over 24 hours

Transmitters

are made and stored in terminal in vesicles. More transmitters =more effects on cell

miosis

constricted pupils

All antipsychotic agents block the effects of

dopamine

antiseizure drugs

drugs used for epileptic seizures

Beta blockers in glaucoma

glaucoma= elevated IOP BB important drugs in Tx of glaucoma BB differ from one discussed here.

Cimetidine (a drug for PUD) can inhibit renal excretion of pramipexole, thereby

increasing its blood level

atonic seizure

loss of normal muscle tension;

Housekeeping chores

slowing functions, at rest functions

t/f: Where acetylcholine can activate all three subtypes of cholinergic receptors, not every adrenergic transmitter (epinephrine, norepinephrine, dopamine) can interact with each of the five subtypes of adrenergic receptors

true

Glycogenolysis

turn glycogen into glucose

Beta blockers in hyperthyroidism

↑thyroid hormone associated with ↑sensitivity of the heart to catecholamines (norepinephrine, epi) normal levels of sympathetic activity can generate tachy/dysrhythmias and angina. blockade of beta-1 suppresses responses.

Levodopa: mechanism of action

↓symptoms by ↑dopamine synthesis in striatum

Functions of the Parasympathetic Nervous System (rest and digest)

Slowing of heart rate Increased gastric secretion Emptying of the bladder Emptying of the bowel Focusing the eye for near vision Constricting the pupil Contracting bronchial smooth muscle

Pharmacogenetics

Study of how genetic makeup affects response to drugs (identifying genes that account for varying drug reactions in different people) Most common DNA variation are single nucleotide polymorphisms Most focused on genes encoding: -metabolic enzymes --> alter a drug's activity -defective structural proteins --> increased susceptibility to disease

buprenorphine/naloxone

Suboxone. used to treat narcotic (opiate) addiction.

Most m. receptors are in the PNS but we do have one muscarinic receptor in our ..?

Sympathetic Nervous system

T or F: all ANS (both sympathetic and parasympathetic) preganglionic axons and all parasympathetic postganglionic axons release ACh

TRUE

Non Ergot Derivatives have less side effects b/c

they are more selective highly selective to dopamine receptors

Parkinsonism may be treated with

anticholinergic drugs

Schedule 4 controlled substances

anticonvulsants, antianxiety agents: valium, phenobarb, meprobamate

fortunately, levodopa is now available only in combination with

carbidopa carbidopa and entacapone

Other TNF antagonists

Adalimumab (Humira) SQ Cerolizumab pegol (Cimizia) SQ Infliximab (Remicade) IM

Alpha-2

receptor responsible for inhibiting the release of norepinephrine (dilates blood vessels to decrease BP) Tx: hypertension

Beta-3

receptor responsible for relaxation of the bladder and lipolysis Tx: overactive bladder

Alpha-1

receptor responsible for vasoconstriction (increase BP) Tx: nasal congestion and hypotension

Neuropharmacology

study of drugs that alter processes controlled by the nervous system

describe general steps of neural communication

"Input" is received onto dendrites or cell body. (Input = excitatory or inhibitory) If the "axon hillock" is depolarized to threshold, then an "impulse" (action potential) is generated. Action Potential (electrical current) is conveyed down axon (ie "axonal conduction.") When AP reaches the axon terminus (aka synaptic bouton), it causes vesicles containing signaling molecules (neurotransmitter) to be released into synaptic gap. Signaling molecules diffuse across synaptic gap, then bind to receptors on post-synaptic cell. Neurotransmitter— Receptor binding has effect on post-synaptic cell.

ACE inhibitors

"PRIL" ex. Captopril, Enalapril, Afosiopril Antihypertensive. Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension

levodopa abrupt loss effect

"on-off" phenomenon occurs at any time during the dosing interval EVEN if drug levels are HIGH "off" times may last mins-hrs over course of Tx= off times likely-↑intensity/freq

Tizanidine (Zanaflex)

- Central alpha 2 agonist; a short-acting muscle relaxer. It works by blocking nerve impulses (pain sensations) that are sent to your brain. (treats MS symptoms) S/E: Liver damage, Hypotension, Dizziness, xerostomia, weakness, QT prolongation * important * > Contraindicated with ciprofloxacin and fluvoxamine due to elevated tizanidine levels

Chlorpromazine (Thorazine)

- Chlorpromazine is used to treat psychotic disorders such as schizophrenia or manic-depression, and severe behavioral problems in children ages 1 through 12. Chlorpromazine is also used to treat nausea and vomiting, anxiety before surgery, chronic hiccups, acute intermittent porphyria, and symptoms of tetanus. S/E: - This medication can cause photophobic skin reactions and damage to the retina of the eye if exposed to direct sunlight. PTs taking this should be reminded to wear protective clothing, apply sunscreen and wear sunglasses when they are outside. sedation, orthostatic hypotension, anticholinergic effects.

treatment of hypocalcemia

- IV calcium supplementation (*calcium gluconate*) once calcium levels have been restored: - calcium citrate for maintenance - vitamin D

insulin regular (Humulin R, Novolin R)

- Short-Acting Insulin - Onset: 30-60 minutes - Peak: 2-4 hours - Duration: 5-7 hours - Nursing considerations: give 30-60 minutes before meal, can mix with NPH, ONLY insulin that can be given IV!

Schizophrenia

- Too much dopamine - Anti-psychotic will decrease dopamine - Caution: extrapyramidal for locomotor affects such as the tongue rolling and lip smacking/biting

Colchicine therapeutic use

- can be used short term to treat acute gouty attack (oral, pt. can walk within hours, inflammation is completely gone in 2-3 days) - can be used long term to prevent attacks from recurring (decreases frequency and intensity of flare ups)

vitamin D

- increases calcium resorption within the bones - decrease calcium excretion by the kidney - increases calcium absorption within the intestine

calcitonin

- released from the thyroid gland when calcium levels in the blood are too high *lowers calcium levels* - inhibiting resorption of calcium within the bones - increasing calcium excretion by the kidney does not influence calcium absorption

Alpha-1 Selective Agonists

- vasoconstriction and decongestant - treat hypotension & shocky states

Individual Variation in Drug Responses

-Body weight and composition -Age --> organ immaturity/organ degeneration -Gender -End-organ function --> kidney and liver disease -Variable absorption -Adherence --> expect pt to take drugs as prescribed -Drug interactions -Genetics

Factors contributing to drug dependence

-Dependence causing drugs -Addiction ***Degree of dependence is NOT synonymous with degree of "addiction"***

Important Drug Characteristics

-Effectiveness* -Safety* -Selectivity --> don't want the drug to do more than it has to

Drug Actions at Targets

-Hormone and neurotransmitters --> e.g., histamine receptors (cemetidine), opioid receptors (morphine), beta-receptors (metoprolol) -Enzymes --> e.g., cyclooxygenase (aspirin) -Membrane transport proteins --> e.g., voltage gated ion channels (lidocaine), ion transporters (furosemide) -Other macromolecules --> e.g., membrane lipids (amphotericin B)

Factors Affecting Distribution

-Organ blood flow --> rate of distribution determined by proportion of cardiac output received by the organs (heart, liver, kidneys > skeletal muscle > skin, fat) -Protein binding --> drugs bind to plasma proteins (only UNBOUND considered active), depends on affinity of drug for the protein, > 90% considered significant; increased protein binding = decreased distribution; can have drug competition - the drug with higher protein affinity will bind -Molecular size -Lipid solubility

Treatment for erectile dysfunction

-viagra and other ED drugs -injection of vasodilating drugs into the penis -penile prosthesis or implants -vascular surgery -vacuum device therapy (few medical procedures for female sexual dysfunction)

MAOIs (monoamine oxidase inhibitors)

-antidepressants that inhibit the action of an enzyme (monoamine oxidase) that is responsible for breakdown of NE and 5-HT Ex: isocarboxizid (marplan), phenelzine (nardil), selegiline (emsam). -can have fatal side effects (hypertensive crisis) if foods rich in amino acid TYRAMINE are consumed -thus, not used unless other classes of medication have failed -Depression with ATYPICAL features respond well to MAOIs

sympathetic

-division of the autonomic nervous system for fight-or-flight response -epinephrine and norepinephrine are main neurotransmitters -excitability

Tolerance

-the state where one must increase the dose of a drug in order to achieve/maintain the drug -Metabolic or receptor-based -Always occurs during the process of physical addiction

What are the three type of main anti-depressants discussed; what are the main side affects?

1. *Tricyclics - for severe depression* Why? chiefly used in neurotic cases; inhibits reuptake of nor-epi upon release in synapse (it stays in) 2. Monoamine Oxidase Inhibitors (MOA) used only if Tricyclics failed; patient cannot be trusted not to take overdoase or with certain S/E hypertensive crisis, hypotension, constipation; anticholinergic - blurred vision, dry mouth, urinary retention 3. New agents: "Atypical" Antidepressant Agents a. Serotonin / Dopamine reuptake inhibitors (Bupropion, wellButrin) b. Tetracyclics - not tricyclic - Advantage over Tricyclic it has slightly less anticholinergic affect *Disadvantage it can cause convulsions -even grand mal with therapeutic dosage!* Side Effects: vary, however, sexual dysfunction is common with all antidepressants. All agents work; chosen depending on S/E. All claims faster onset but truth of this claim not yet established - can be compared with tricyclics.

What are the goals of anesthesia?

1. Analgesia (narcotics, Ketamine) 2. Loss of consciousness (gases, nitrous oxide) 3. Muscle relaxation (maybe curare)

Sympathetic: cardio vascular

1. Maintains blood flow to brain, 2. Redistributes blood flow during exercise 3. compensate for blood loss (vasoconstriction)

Functions of Cholinergic (Parasympathetic) Receptors

1. Nicotinic N 2. Nicotinic M 3. Muscarinic

Noraepinephrine (Levophed)

1. No Beta 2, so just like epi except no lung effects 2. Rapid inactivation Levophed - "Leave- 'em - dead"

Metronidazole (Flagyl)

1. Used to treat anaerobic infections 2. DO NOT USED ALCOHOL (antabuse effect will be nauseous) treats mild to moderate crohns diease.

Drug therapy for spasm include 2 groups:

1. analgesic antiinflammatory drusg 2. centrally acting muscle relaxants

Fight-of-flight

1. inc HR and BP, 2. shunt blood from skin and viscera to skeletal muscle 3. dilate bronchi, 4. dilate pupils- wide eyed to see better 5. mobilize energy (glucose) need energy to fight or flee

TWO MAJOR TYPES OF DEPRESSION

1. situational or reactive 2. endogenous or neurotic - some people just depressed their whole life

Sympathetic: Temperature Regulation

1.regulating blood flow to skin 2. sweat gland secretion 3. inducing piloerection- hair follicle erection

How does hyperuricemia happen?

1: excessive production of uric acid 2: impaired excretion of uric acid

Two ways that drugs work

1: short term to relieve symptoms of an acute gouty attack 2: given long term to lower blood levels of uric acid

Alpha-1 adrenergic antagonists cause orthostatic hypotension, what is first-dose effect?

1st dose may cause fainting from severe orthostatic hypotension. Take 1st dose at bedtime to minimize.

Levodopa and 1st gen Psychotics

1st gen psychotics block dopamine receptors example: chlorpromazine, haloperidol AVOID concurrent use of these meds 2nd gen can be used safely

Propranolol (Inderal) Info

1st generation BB Non-selective= beta-1 and beta-2 beta-1= ↓HR + ↓contraction force + suppress impulse conduction through AV node= ↓CO renal beta-1= suppress secretion of renin beta-2= bronchoconstriction, vasoconstriction, ↓glycogenolysis highly lipid soluble. readily cross membranes. <30%each PO dose reaches circulation= 1st pass reaches CNS. Hepatic metabolism and then excreted in urine. Uses: HTN, angina, MI, cardiac dysrhythmias Adverse Effects: Brady, AV block, HF, Rebound cardiac excitation, Bronchoconstriction, inhibition of glycogenolysis, CNS effects. Warnings/contraindications: DM: ↓glucose, but masks signs of hypoglycemia. Can exacerbate HF, AV block, Brady, asthma, bronchospasm- contraindicated in all. Caution in patients Hx of depression. Drug Interactions: CCB (verapamil/diltiazem) Effects identical to propranolol. Excessive cardiosuppresion may result.

Dopamine Agonists

1st line drugs for PD

Chlamydia

1st line: Azithromycin 1g po single dose or Doxycycline 100mg po bid x 7 days 2nd line: Erythromycin base or fluoroquinolone(levofloxacin or ofloxacin)- No sex for 7 days after initiation of treatment- Canadian guidelines state to retest after 6 months

No matter what the precise mechanism is, neuropharmacologic drugs ultimately work by influencing

receptor activity

The nurse is preparing to administer an indirect-acting cholinergic agonist to help promote chewing and swallowing for a client on a medical-surgical unit. When will the nurse plan to administer this medication? 30 minutes prior to meals 15 minutes prior to meals 60 minutes prior to meals Anytime within the medication administration window

30 minutes prior to meals

Reversible binding occurs with

receptor on postsynaptic cell

The nurse is checking a client 's blood pressure in preparation for administering an adrenergic antagonist medication. Which systolic blood pressure is unsafe for administering this class of medication? 130 mmHg 90 mmHg 150 mmHg 110 mmHg

90

Neuroleptic Malignant Syndrome (NMS)

A rare and sometimes fatal reaction to high-potency neuroleptic drugs. Symptoms include muscle rigidity "lead pipe", fever, Sweating, autonomic instability and elevated white blood cell count. It is thought to result from dopamine blockage at the basal ganglia and hypothalamus. Treatment: supportive measures, drug therapy and immediate withdrawal of antipsychotic medication.

Drug-Receptor Interactions

A receptor is anything the drug binds to to produce its effect (including enzymes and ribosomes) -could bind as is -or cause a conformational change to receptor --> this could render receptor non-functional after dissociation) D+R <--> D-R Complex ==> response Binding can be reversible or irreversible or selective or non-selective --> selective limits the types of receptors the drug binds to which limits its effects

phenylephrine

A1 selective agonist PROTOTYPE - OTC for nasal congestion - not used for shocky states - may lead to systemic hypertension & H/A

Treat of ADHD and side effects of treatment

ADHD is treated with amphetamines • Ritalin, Concerta, Focaline and Adderall Side Effects: • CNS: too much stimulation....nervousness, anxiety, sleeplessness • Cardiovascular: to much nor-epi...increase adrenergic response. Increase HR. BP, potential arrhythmias • Weight Loss, malnutrition • Kids: suppression of growth, failure to thrive, not eat • Possible bone marrow suppression

A patient with metastatic cancer has had several fractures secondary to bone metastases. The provider orders denosumab [Xgeva]. What will the nurse teach this patient? a.Denosumab may delay healing of these fractures. b.Denosumab should be given subcutaneously every 12 months. c.Denosumab will improve hypocalcemia. d.Unlike bisphosphonates, denosumab does not increase osteonecrosis of the jaw (ONJ).

ANS: A Because denosumab suppresses bone turnover, fracture healing may be delayed. Denosumab is given every 6 months. Denosumab can exacerbate hypocalcemia. Denosumab can increase the incidence of ONJ.

A patient taking risedronate IR [Actonel] for osteoporosis reports experiencing diarrhea and headaches. What will the nurse tell this patient? a.These are common side effects of this drug. b.These symptoms indicate serious toxicity. c.The patient should discuss taking risedronate DR [Atelvia] with the provider. d.The medication should be taken after a meal to reduce symptoms.

ANS: A Diarrhea and headaches are common adverse effects of risedronate IR. These symptoms do not indicate toxicity. The side effects of Atelvia are similar to those of Actonel. Taking the medication after a meal will not reduce these effects

A nurse is providing education to a patient who will begin taking alendronate [Fosamax]. Which complication should the patient be instructed to report immediately? a.Difficulty swallowing b.Dizziness c.Drowsiness d.Pallor

ANS: A Esophagitis is the most serious adverse effect of alendronate, sometimes resulting in ulceration. The nurse should instruct the patient to report difficulty swallowing immediately, because it can be a sign of esophageal injury. Dizziness is not an adverse effect of alendronate. Drowsiness is not a symptom associated with alendronate. Pallor is not a symptom associated with alendronate.

A patient with severe glucocorticoid-induced osteoporosis will start therapy with teriparatide [Forteo]. What will the nurse expect to administer? a.20 mcg once daily subQ b.20 mcg twice daily subQ c.10 mcg once daily subQ d.10 mcg twice daily subQ

ANS: A The dose of teriparatide for all indications is 20 mcg once daily subQ.

A nurse is discussing the role of vitamin D in calcium regulation with a nursing student. Which statement by the student indicates a need for further teaching? a."Adequate amounts of vitamin D occur naturally in the diet." b."Vitamin D3 is preferred over vitamin D2." c."Vitamin D can promote bone decalcification." d."Vitamin D increases the absorption of calcium and phosphorus from the intestine."

ANS: A Vitamin D does not occur naturally in the diet. Adequate amounts are gained through fortified foods, supplements, and exposure to sunlight. Vitamin D3 is preferred. If calcium intake is not sufficient, vitamin D can promote bone decalcification. Vitamin D acts to increase the absorption of calcium and phosphorus from the intestine.

Which drugs are approved for treating osteoporosis in men? (Select all that apply.) a.Alendronate [Fosamax] b.Calcitonin c.Raloxifene [Evista] d.Teriparatide [Forteo] e.Zoledronate [Reclast]

ANS: A, D, E Only five drugs have been approved to treat osteoporosis in men, including alendronate, teriparatide, and zoledronate. Calcitonin has been tried, but without proof of efficacy. Raloxifene is a SERM, used in women only.

A patient who takes teriparatide [Forteo] administers it subcutaneouslywith a prefilled pen injector. The patient asks why she must use a new pen every 28 dayswhen there are doses left in the syringe. Which is the correct response by the nurse? a."Go ahead and use the remaining drug; I know it is so expensive." b."The drug may not be stable after 28 days." c."You are probably not giving the drug accurately." d."You should be giving the drug more frequently.

ANS: B Teriparatide is supplied in 3-mL injectors. The pen should be stored in the refrigerator and discarded after 28 days, even if some drug remains in the syringe. Although the drug is expensive, it is not correct to use what is in the syringe after 28 days. Drug may be left in the syringe even with correct dosing.

A nurse provides teaching for a woman who will begin taking supplemental calcium. Which statement by the woman indicates understanding of the teaching? a."Chewable calcium tablets are not absorbed well and are not recommended." b."I should not take more than 600 mg of calcium at one time." c."I should take enough supplemental calcium to provide my total daily requirements." d."If I take calcium with green, leafy vegetables, it will increase absorption."

ANS: B To help ensure adequate absorption of calcium, no more than 600 mg should be consumed at one time. Chewable calcium tablets are recommended because of their more consistent bioavailability. The amount of supplemental calcium should be enough to compensate for what is not consumed in the diet and should not constitute the total amount needed per day. Green, leafy vegetables reduce the absorption of calcium.

A 65-year-old female patient tells a nurse that she has begun taking calcium supplements. The nurse learns that the patient consumes two servings of dairy products and takes 1200 mg in calcium supplements each day. The patient's serum calcium level is 11.1 mg/dL. What will the nurse tell this patient? a.She should increase her dietary calcium in addition to the supplements b.The amount of calcium she takes increases her risk for heart attack and stroke c.To continue taking 1200 mg of calcium supplement since she is over age 50 d.To supplement her calcium with 10,000 units of vitamin D each day

ANS: B Women older than 50 years need 1200 mg of calcium per day. Patients should take only enough supplemental calcium to make up for the difference between what the diet provides and the RDA. This patient is getting 1800 mg/day. Excess supplemental calcium can increase risks for vascular calcification, MI, stroke, and kidney stones. She does not need to increase calcium intake. Supplementing with 10,000 units of vitamin D is indicated for documented vitamin D deficiency, which is not evident in this case.

A patient who has developed postmenopausal osteoporosis will begin taking alendronate [Fosamax]. The nurse will teach this patient to take the drug: a.at bedtime to minimize adverse effects. b.for a maximum of 1 to 2 years. c.while sitting upright with plenty of water. d.with coffee or orange juice to increase absorption.

ANS: C Alendronate can cause esophagitis, and this risk can be minimized if the patient takes the drug with water while in an upright position. Taking the drug at bedtime is not indicated. The drug may be taken up to 5 years before re-evaluation is indicated. Coffee and orange juice reduce the absorption of alendronate and should be delayed for 30 minutes after taking the drug

drug tolerance

the tendency for larger doses of a drug to be required over time to achieve the same effect

A postmenopausal patient develops osteoporosis. The patient asks the nurse about medications to treat this condition. The nurse learns that the patient has a family history of breast cancer. The nurse will suggest discussing which medication with the provider? a.Estrogen estradiol b.Pamidronate [Aredia] c.Raloxifene [Evista] d.Teriparatide [Forteo]

ANS: C Raloxifene is a selective estrogen receptor modulator (SERM) that has estrogenic effects in some tissues and antiestrogenic effects in others. It can preserve bone mineral density while protecting against breast and endometrial cancers. Estrogen promotes breast cancer and would not be indicated. Pamidronate and teriparatide are not protective against breast cancer.

A patient has severe Paget's disease of the bone. The patient asks the nurse what can be done to alleviate the pain. The nurse will suggest that the patient discuss the use of which medication with the provider? a.Alendronate [Fosamax] b.Calcifediol [25-Hydroxy-D3] c.Calcitonin-salmon [Miacalcin] d.Long-acting NSAIDs

ANS: C Salmon calcitonin is the drug of choice for rapid relief of pain associated with Paget's disease. Alendronate, calcifediol, and NSAIDs are not indicated.

A 55-year-old female patient asks a nurse about calcium supplements. The nurse learns that the patient consumes two servings of dairy products each day. The patient's serum calcium level is 9.5 mg/dL. The serum vitamin D level is 18 ng/mL. The nurse will recommend adding ____ daily and ____ IU of vitamin D3 each day. a.1200 mg of calcium once; 10,000 b.1500 mg of calcium twice; 1000 c.600 mg of calcium once; 10,000 d.600 mg of calcium twice; 2000

ANS: C Women older than 50 years need 1200 mg of calcium per day. This patient is getting 600 mg/day. She should add 600 mg/day to compensate for what she does not get in her diet, because the amount of a supplement should be enough to make up the difference. Her vitamin D level is low, so she needs a vitamin D supplement. To treat deficiency, adults older than 19 years should get 10,000 IU/day. An additional intake of 1200 mg of calcium once daily is too much calcium. An additional intake of 1500 mg of calcium twice daily is too much calcium, and 1000 IU of vitamin D is not enough to treat deficiency. An additional intake of 600 mg of calcium twice daily is too much calcium, and 2000 IU of vitamin D is not sufficient to treat deficiency.

A nurse is providing teaching for a patient with osteoporosis who has just switched from alendronate [Fosamax] to zoledronate [Reclast]. Which statement by the patient indicates a need for further teaching? a."I will need to have blood tests periodically while taking this drug." b."I will only need a dose of this medication every 1 to 2 years." c."This drug is less likely to cause osteonecrosis of the jaw." d."This drug is only given intravenously."

ANS: C Zoledronate has an increased risk of osteonecrosis of the jaw, as does alendronate. The patient is correct to identify the need for periodic blood tests. Zoledronate is given only every 1 to 2 years and is given only intravenously.

A patient is taking alendronate [Fosamax] to treat Paget's disease. The patient asks the nurse why calcium supplements are necessary. The nurse will tell the patient that calcium supplements are necessary to: a.reduce the likelihood of atrial fibrillation. b.maximize bone resorption of calcium. c.minimize the risk of esophageal cancer. d.prevent hyperparathyroidism.

ANS: D Alendronate can induce hyperparathyroidism in patients with Paget's disease; calcium supplementation can prevent this effect. Giving calcium does not reduce the incidence of atrial fibrillation, maximize bone resorption of calcium, or minimize the risk of esophageal cancer.

A postmenopausal patient is at high risk for developing osteoporosis. The patient's prescriber orders raloxifene [Evista], and the nurse provides teaching about this drug. Which statement by the patient indicates understanding of the teaching? a."I may experience breast tenderness while taking this drug." b."I may experience fewer hot flashes while taking this drug." c."I should discontinue this drug several weeks before any surgery." d."I should walk as much as possible during long airline flights."

ANS: D Like estrogen, raloxifene increases the risk of deep vein thrombosis. Patients taking this drug should be cautioned to take walks on long flights or whenever they must sit for long periods. The drug does not increase breast tenderness or decrease hot flashes. There is no need to discontinue this drug before surgery

A patient reports experiencing weakness, fatigue, nausea, vomiting,constipation, and nocturia. Total serum calcium is 10.5 mg/dL. A dipstick urinalysis shows a positive result for protein. When questioned, the patient reports taking vitamin D and calcium supplements. The nurse will counsel the patient to: a.reduce the amount of vitamin D and stop taking the calcium. b.discuss taking calcitonin-salmon [Fortical] with the provider. c.stop both supplements and discuss the use of a diuretic with the provider. d.stop taking vitamin D, reduce the amount of calcium, and increase the fluid intake.

ANS: D Vitamin D toxicity can occur, and early responses include the symptoms described. Patients should be counseled to stop taking vitamin D, reduce their calcium intake, and increase their fluid intake. It is not correct to reduce the vitamin D intake and the calcium intake. Calcitonin-salmon is not indicated. A diuretic is indicated when hypercalciuria is severe.

Consequences of Metabolism

Accelerated renal drug excretion --> conversion into more polar/water soluble compounds Drug inactivation --> conversion to inactive metabolites "Increased" or "Alternate" therapeutic action --> conversion to an [more or less] active metabolite Activation of pro-drugs --> conversion to active form of drug Changes in toxicity potential --> parent compound and metabolite potential for toxicity

When educating a group of nursing students on the mechanism of the action of various anti-arrhythmic drugs, the nurse identifies which drugs as inhibiting the beta-adrenergic receptors of the heart and the kidney? Disopyramide Amiodarone Acebutolol Propafenone

Acebutolol

Second Generation: CardioSelective BB

Acebutolol (Sectral)= beta-1 Atenolol (Tenormin)= beta-1 Betaxolol (Kerlone)= beta-1 Bisoprolol (Zebeta)= beta-1 Esmolol (Brevibloc)= beta-1 Metoprolol (Lopressor)= beta-1

what is employed at most junctions of the PNS

Acetylcholine

ACh

Acetylcholine is a neurotransmitter, which is a chemical released by a nerve cell or neuron. ... Acetylcholine causes muscles to contract, activates pain responses and regulates endocrine and REM sleep functions. Deficiencies in acetylcholine can lead to myasthenia gravis, which is characterized by muscle weakness.

Sierra Solina has been taking an AChE​ inhibitor, but is exhibiting signs of tachycardia and muscle weakness. After a small dose of edrophonium chloride​ (Enlon) is​administered, Ms. Solina shows no symptomatic improvement. What action do you expect the health care provider to take​ next? Discontinue the AChE inhibitor Increase the dose of the AChE inhibitor Increase the dose of edrophonium chloride​ (Enlon) Administer atropine sulfate

Administer atropine sulfate

Intravenous Administration

Administration directly into systemic circulation, increased reliability and control of the dose of drug reaching circulation but can be very dangerous --> rapid admin = serious toxicity many but not all will have a relatively immediate effect

Which statements accurately describe the mechanisms of action of adrenergic ​drugs? Select all that apply. Adrenergic agonists inhibit the SNS. Sympathomimetics inhibit the SNS. Adrenergic antagonists inhibit the SNS. Adrenergic agonists stimulate the SNS. All adrenergic drugs produce a​ fight-or-flight response.

Adrenergic antagonists inhibit the SNS. Adrenergic agonists stimulate the SNS.

Neostigmine (Prostigmin) Adverse effects

Adverse effects: excessive muscarinic stimulation, neuromuscular blockade Treat for adverse effects: Atropine

Factors Affecting Rate of Metabolism

Age Induction or inhibition of drug-metabolizing enzymes Competition between drugs First-pass effects

Cholinergic (Parasympathetic) Receptors

Also called Parasympathetic Refers to cells that use acetylcholine (ACh) as their synaptic transmitter.

Beta-1

receptor responsible for an increased HR and force of contraction Tx: cardiac arrest, heart failure, shocky states

Parkinson's Disease Injectables

Apomorphine [Apokyn] Dopamine Agonist- Non Ergot Derivative Prepared: 10mg/mL, 3-mL for multi-dose pen Dose: 2-6 mg (0.2-0.6 mL) SQ each "off" episode Max: 5 doses/day Other: start antiemetic 3 days prior to 1st dose Ex. trimethobenzamide 300mg TID 72hrs prior Benztropine [Congentin] Centrally Acting Anticholinergic Drugs Prepared: 1mg/mL, in 2-mL vials Dose: 0.5-1mg QHS⇢⇡0.5mg Q5-6days Max: 6mg/day Other: IM injectable preferred. In PD there is NO advantage in IV admin

Ciprofloxacin (Cipro)

Antibiotic, treats crohns, used with infliximab.

Syphilis treatment (primary, secondary, early latent)

Antibiotics: large, injected dose of penicillin is most effective Benzathine penicillin G 2.4 million units IM single dose Latent: Benzathine penicillin G 7.2 million units total2.4 million units IM weekly X 3 weeks

Oxybutin

Anticholinergic Drugs for Overactive Bladder Oxybutynin (Ditropan XL, Oxytrol, Gelnique) Act at M3 muscarinic receptors

Darifenacin

Anticholinergic Drugs for Overactive bladder Greatest degree of M3 selectivity Reduced OAB symptoms while having no effect on M1 in brain and M2 in heart Dry mouth and constipation

Risperidone (Risperdal)

Antipsychotic (Atypical) rapid-acting used for schizophrenia and acute bipolar mania. Absorbed rapidly, not effected by food, peaks 1 hour after dosing. Excreted through urine. S/E: increases prolactin levels but symptoms uncommon. Metabolic effects. Sedation in large doses.

Quetiapine (Seroquel)

Antipsychotic (Atypical). Treats: Schizophrenia, major depression, bipolar Improves positive symptoms and lowers negative symptoms by blocking 5-HT2 receptors and D2 receptors. CYP3A4 - hepatic metabolism and excreted in urine and feces. S/E: metabolic effect, cataracts, long Q-T

A common therapeutic use for benzodiazepines is

the treatment of anxiety disorders

Life Cycle of Acetylcholine

As soon as Ach released from receptor, almost immediately destroyed by aceylcholinesterase

Levodopa and Pyridoxine (Vitamin B6)

B6 can ↓ amount of levodopa reaching CNS by accelerating decarboxylation of levodopa in periphery HOWEVER b/c levodopa is now always combined with carbidopa (suppresses decarboxylase activity) this potential clinical interaction is no longer a concern.

Adverse effects in neonates for beta blockade (1 & 2)

BB during pregnancy= residual effects on infant BB can remain in circulation for days. At risk for: bradycardia (beta-1 blockade) respiratory distress (beta-2 blockade) hypoglycemia (beta-2 blockade)

Beta blockers in Heart failure

BB now considered standard therapy for HF. Used to be absolute contraindication. Only (3) BBs currently shown effective for HF. (1) Bisoprolol (2) Metoprolol (3) Carvedilol

PD drugs: Centrally Acting Anticholinergic Drugs

Benztropine [congentin] tab: 0.5, 1, 2 mg injectable: 1mg/mL in 2mL vials 0.5-1 mg QHS (initial)⇢⇡0.5mg Q 5-6days Max: 6 mg/day IM preferred. No advantage to IV in PD. Trihexyphenidyl [generic] tab: 2, 5 mg Elixir: 0.4/mL 1mg QD (initial)⇢⇡2mg Q 3-5days Max: 15mg/day

Beta blockers in Cardiac dysrhythmias

Beta-adrenergic blocking agents especially useful in dysrhythmias that involve excessive electrical activity in the sinus node and atria. block beta-1 by= (1) ↓rate of sinus node discharge. (2) suppress conduction of atrial impulses through AV node. preventing the ventricles from bing driven at an excessive rate.

The nurse knows that which class of drugs prevents epinephrine and norepinephrine from occupying receptor sites on the cell membranes?

Beta-adrenergic blocking drugs

PK Drug-Drug: Absorption

Binding/chelation in the gut --> prevent absorption Altered gastric/intestinal motility Changes in bacterial flora Food effects --> food delays rate of absorption but could increase or decrease the extent of absorption, food increases acid release which can affect acid-labile drugs

SSNRIs (selective serotonin and norepinephrine reuptake inhibitors)

Block 5-HT reuptake and thereby increase 5-HT in the synapse. Examples: Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Venlafaxine (Effexor XR), LEvomilnacipran (Fetzima).

Before administering a cholinergic antagonist to a​ client, for what should you specifically ​assess? Select all that apply. Bowel and bladder habits Symptoms of cholinergic crisis History of glaucoma Skin elasticity History of malignant hyperthermia

Bowel and bladder habits Symptoms of cholinergic crisis History of glaucoma History of malignant hyperthermia

Adverse Effects of beta-1 blockade

Bradycardia (beta-1 receptors) beta-adrenergic agonist to compete for binding Reduced Cardiac Output (↓tissue perfusion) extreme caution in HF patients Precipitation of Heart Failure (↓cardiac fx) actually causes HF. notify PCP for edema, SOB. AV Heart Block (can suppress AV conduction) contraindicated w/ pre-existing AV block. Rebound Cardiac Excitation (w/abrupt cessation) long-term use. sensitize heart to catecholamines.

Dosing/Administration: Dopamine Agonists- Ergot Derivitatives [Bromocriptine & Cabergoline]

Bromocriptine [Cycloset, Parlodel] Cycloset: 0.8-mg tablet (within 2hrs of awakening) Parlodel: 5-mg tablet -Initial: 1.25mg BID slowly↑dose until desired resp or intolerable SE -Maintenance: 30mg-100mg/day Cabergoline [Dostinex, Generic in US] 0.5-mg tablet -Initial: 1 mg QD ↑using 0.5-1 mg at 1-2 week intervals -Maintenance: 2-3 mg/day

The nurse would instruct a client receiving acebutolol about which adverse effect? Improved exercise tolerance Bronchospasm Hypertension Increased libido

Bronchospasm

What are possible adverse effects of various nonselective​ beta-adrenergic ​antagonists? Select all that apply. Bronchospasms Loss of energy in skeletal muscles Risk of hyperlipidemia Increased catecholamine action Reduced intraocular pressure

Bronchospasms Loss of energy in skeletal muscles Risk of hyperlipidemia

Bethanechol Adverse effects

CV: Hypotension GI: Increased tone and motility Exacerbation of asthma Dysrhythmias in pts in hyperthyroidism

Enzyme Induction

CYP Substrate + CYP Inducer --> decreased substrate concentration and decreased substrate efficacy

Enzyme Depletion/Competition

CYP Substrate + CYP Substrate --> increased, decreased, or even substrate concentration and increased, decreased, or even efficacy or toxicity

Dronabinol (Marinol)

Cannabinoid Used for chemo N/V and as an appetite stimulant in AIDS and Cancer patients Can cause dissociation/dysphoria, hypotension, tachycardia

Four drugs approved for treating AD dementia

Cholinesterase inhibitors Donepezil Galantamine Rivastigmine NMDA recep antagonist (N-methyl-D-aspartate) Memantine

Phase II Metabolism

Conjugation reactions with endogenous substance to facilitate elimination --> forms a larger, more water soluble substance Most metabolites are inactive Acetylation, glucoronidation, sulfation

Mnemonic for Muscarinic Toxicity

DUMBELS D: Diaphoresis/Diarrhea U: Urination M: Miosis B: Bradycardia/Bronchospasm/Bronchochorrhea E: Emesis L: Lacrimation S: Salivation

Memorize the continuum Chart Stimulation Increases: Sensory Acuity Motor Activity Depression Inhibits: Sensory Acuity Motor Activity

Death Convulsions or Seizures Tremors & Hallucinations Anxiety Euphoria NORMAL - NEUTRAL Sedation (Drowsy) Hypnosis (Sleep) General Anesthesia Coma Death

The nurse is preparing to administer a beta-adrenergic antagonist to a client. The nurse anticipates that this medication will have which effects on the client? Select all that apply. Increased conduction through the AV node Increased blood pressure Decreased heart rate Decrease in angina Decreased force of myocardial contraction

Decreased heart rate Decrease in angina Decreased force of myocardial contraction

Tachyphylaxis

Decreased response to drug as a result of repeated administration; tolerance -adaptive process in response to chronic receptor occupation/saturation -depletion or marked reduction of the ant of NT responsible for creating the drug's effect (sudafed, cocaine, amphetamines) -increase in the number of receptors needing to be occupied (beta-blocker) -metabolic tolerance due to accelerated drug metabolism

Metformin

Decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and utilization)

The nurse is visiting the home of a client who is prescribed antidysrhythmic medication. The nurse will teach the client to report which possible adverse effect? Improved mentation Improved functional status Dizziness Increased energy

Dizziness

The nurse is caring for a client who is experiencing tachycardia, muscle weakness, and respiratory distress. To determine whether he is experiencing a myasthenic crisis, which medication should be administered? Mecamylamine hydrochloride​ (Inversine) Atracurium besylate​ (Tracrium) Edrophonium chloride​ (Enlon) Succinylcholine chloride​ (Anectine)

Edrophonium chloride​ (Enlon)

Murray Lefkowitz presents with symptoms of​ ptosis, diplopia, excessive muscle​ fatigue, and difficulty swallowing. What drug can the health care provider prescribe for Mr.​ Lefkowitz, in order to make a​ diagnosis? Prednisone​ (Orasone) Edrophonium chloride​ (Tensilon) Cyclosporine​ (Sandimmune) Pyridostigmine bromide​ (Mestinon)

Edrophonium chloride​ (Tensilon)

Uses of clonidine

HTN Severe pain ADHD Off label: Opioid withdrawal Smoking cessation Tourette's

Alpha blockers in reversal of alpha-1 agonist toxicity

HTN produced r/t excessive alpha-1 activation reverse vasoconstriction w/ alpha-blocking agent phentolamine= for IV infiltration. reverse constrict

The nurse is educating a client about a spinal cord injury. Which statement by the client indicates the need for further teaching regarding the effect the injury will have on the autonomic nervous system? ​"My breathing may be affected by the​ injury." ​"I won​'t be able to feed​ myself." ​"My blood pressure may be affected by the​ injury." ​"I may not have control of bladder​ functions."

I wont be able to feed myself

Galantamine [Razadyne, Razadyne ER]

IR tabs: 4, 8, 12 mg PO SOLN: 4mg/mL IR/SOLN: 4mg BID x 4wks⇢⇡by 4mg BID Q 4wks Maintenance: 8-12 mg BID Admin: w/ morning & evening meals ER caps: 8, 16, 24 mg 8mg QD x 4wks⇢⇡16mg QD x 4wks⇢⇡24mg QD Maintenance: 16-24 mg QD Mod Hepatic/Renal Dys: 16 mg QD (max) Severe impairment: AVOID

Methotrexate

Immunosuppressant used to treat certain types of cancer or to control severe psoriasis or rheumatoid arthritis that has not responded to other treatments. It may also be used to control juvenile rheumatoid arthritis. (aka Rheumatrex) SE: nausea, feeling tired, fever, increased risk of infection, low white blood cell counts, and breakdown of the skin inside the mouth.

Can we prevent Alzheimer's disease or delay cognitive decline?

In 2010, Preventing Alzheimer's Disease and Cognitive Decline stated that we have NO good evidence supporting association of any modifiable factor w/ reduced risk for AD. STUDIED FACTORS: diet, exercise, social interaction, economic status, nutritional supplements, medications, environmental toxins

A nurse is caring for a patient on dopamine therapy. The patient is also to be administered phenytoin under close supervision. Which of the following adverse reactions should the nurse monitor for in the patient?

Increased risk of seizures

CNS Stimulants - how do they work? What are the main types we talked about in class the main indications for use.

Increases excitability of the CNS increases levels of norepinephrine in the brain -amphetamines, xanthines, cocaine

The nurse is teaching a client how antiepileptic medications can be used to treat her seizure disorder. The nurse plans the teaching based on the knowledge that medications affect the synaptic transmission through which means? Select all that apply. Enhancing the storage of neurotransmitters Increasing or decreasing neurotransmitter synthesis Increasing or decreasing the release of neurotransmitters Stimulating or inhibiting the autonomic nervous system Preventing the breakdown of neurotransmitters

Increasing or decreasing neurotransmitter synthesis Increasing or decreasing the release of neurotransmitters Stimulating or inhibiting the autonomic nervous system Preventing the breakdown of neurotransmitters

Methotrexate

Management of RA nonbiologic DMARDs Reduce activity of T & B lymphocytes Slow progression 3-6 months

Tumor necrosis factor antagonists

Management of RA with Biological DMARDs (uses DNA within body not man made) Blocks TNF from starting the inflammatory process in the joint Decrease inflammation

Etanercept (Enbrel)

Management of RA with Biological DMARDs (uses DNA within body not man made) TNF antagonists SQ Mild to moderate RA Binds to TNF Delays progression of joint damage, suppresses signs and symptoms of joint damage

What is true about cholinergic antagonists and adrenergic ​agonists? Select all that apply. Many bodily effects are similar Mechanisms of action are different Results differ dramatically Both block the action of ACh Mechanisms of action are similar

Many bodily effects are similar Mechanisms of action are different

Ganglionic blocking agents

Mecamlamine

Immunomodulating drugs

Medications that therapeutically alter a patient's immune response to malignant tumor cells Drugs that modify the body's own immune response so that it can destroy various viruses and cancerous cells Second line agents in inflammatory bowel.

Dopamine

Most action in CNS: -Dilates renal blood vessels--> increase renal blood flow. -To prevent kidney failure in shock -Enhances cardiac performance -Dopamine is only available drug Table 13-4 p. 112 Heart Failure - inc cardiac contraction Acute Renal Failure - inc renal blood flow Adverse Effects - -tachycardia -dysrhythmias -angina -necrosis Drug Interactions - MAO (inc effects), TCA (inc), General anesthetics (inc), Diuretics (improve kidney effects)

Apomorphine Adverse Effects:

Most common: inject site reactions, hallucinations, yawning, drowsy, dyskinesias, rhinorrhea, N/V Rare cases: sleep attacks, CV symptoms (angina, MI, cardiac arrest, sudden death), fainting, postural hypotension, hyper sexuality, enhanced erection, priapism

Levodopa/Carbidopa

Most effective therapy for PD

Autonomic Control Baroreceptor Reflex

Most important.! Frequently opposes our attempts to modify BP with drugs Baroreceptors in carotid sinus and aortic arch - Measure and detect blood pressure Tells brain if BP is up or down Brain sends impulses to to heart/blood vessels to adjust BP Receptors cause blood vessels to constrict or relax depending on blood pressure

Autonomic Regulation of the Body

Most structures are controlled by: both sympathetic and parasympathetic nerves.

Distribution

Movement of drugs in the body drugs are distributed to body fluid, organs, and tissues (aka compartments) via the circulation; will occur until there is an equilibrium of drug concentration between the vascular space and the tissues.

Eluxadoline (Viberzi)

Mu/Kappa opioid receptor agonist and delta opioid receptor antagonist in the gut used to treat IBS prone diarrhea

Baclofen

Muscle relaxant, GABAb receptor agonist, produces hyperpolarization by increased potassium conductance also used as an antispasmodic agent. Baclofen is used to treat muscle symptoms; such as spasm, pain and stiffness; caused by multiple sclerosis, spinal cord injuries, or other spinal cord disorders. It is given intrathecally (directly into the spinal cord) or orally (by mouth).

The nurse is educating a client on the effects that adrenergic antagonists have on the body. Which statement by the client indicates an appropriate understanding of the teaching provided? ​"My medication will cause my eyes to be​ dry." ​"My medication will decrease my heart​ rate." ​"My medication will cause my mouth to be​ dry." ​"My medication will increase my blood​ pressure."

My medication will decrease my heart rate

Adverse effects of sulfasalazine

N/V/D Anorexia, abd pain Hepatitis Bone marrow suppression Not given to patients with sulfa allergied

Life Cycle of Norepinephrine (Epi)

NE transmission terminated by reuptake. Then taken back into vesicles or inactivated by MAO (monoamine oxidase) Epi is basically the same

Drugs for Neuropsychiatric Symptoms

NEUROPSYCHIATRIC SYMPTOMS: agitations, aggression, delusions, hallucinations Occur in >80% pts with AD 2 ATYPICAL ANTIPSYCH= ↓NEUROPSYCH S/S Risperidone [Risperdal] Olanzapine [Zyprexa] BUT BENEFITS ARE MODEST SLIGHTLY INCREASE MORTALITY (CV, infection) Mult Drug classes tried as Tx= BUT few effective including: antipsych, cholinesterase inhibit, mood stabilizers, antidepressant, anxiolytics, NMDA recep agonists LITTLE/NO EVIDENCE OF BENEFIT FROM: conv antipsych- (haloperidol, chlorpromazine) mood stabile (valproate, carbamazepine, lithium) antidepressants memantine

Parkinson's other symptoms

NON-MOTOR SYMPTOMS: autonomic disturbances (most common) sleep disturbances depression psychosis dementia

Memantine: Mechanism of Action

NORMAL PHYSIOLOGY: Resting post-synaptic neuron: Mg+ @NMDA receptor channel- Blocks Ca+ entry Binding- glutamate+NMDA recep= displaces Mg+ allowing Ca+ to enter glutamate disassociates from receptor. Mg+ returns to channel=blocks further Ca+ inflow *the brief period of Ca+ entry constitutes a "SIGNAL" in the learning and memory process. PATHOPHYSIOLOGY: presyn-neuron⇢slow/steady glutamate leakage keeps NMDA receptor= constantly active state allowing excessive CA+ influx which can impair memory/learning can eventually cause neuronal death. MEMANTINE EFFECT: blocks Ca+ entry⇢extracellular glutamate low allows intracellular Ca+ levels to normalize when glutamate burst released-action potential high level glutamate result⇢displaces memantine causes brief period of Ca+ entry glutamate diffuses away⇢memantine reblocks stops further Ca+ entry despite low glutamate levels in the synapses.

Drug therapy for RA

NSAIDs & glucocorticoids- pain, inflammation Disease modifying Anti-rheumatic drugs (DMARDs)

Analgesics - narcotic vs. non-narcotic

Narcotics (Opioid): •Acts on CNS •For *severe* pain •Associated with tolerance abuse, physical dependence Non-Narcotic: •Acts on periphery & CNS •for low to moderate dependence pain such as headache arthritis, peripheral pain •not generally abused and does not cause addiction

Levodopa: Adverse Effects

Nausea & vomiting Dyskinesias Cardiovascular effects Psychosis CNS Effects Other: Darken sweat and urine (harmless) may activate malignant melanoma

Cholinesterase inhibitors

Neostigmine, Physostigmine

Neupogen (filgrastim)

Neupogen is a man-made form of a protein that stimulates the growth of white blood cells in your body. White blood cells help your body fight against infection. Neupogen is used to treat neutropenia, a lack of certain white blood cells caused by cancer, bone marrow transplant, receiving chemotherapy, or by other conditions

Ganglion Stimulating agents

Nicotine

Carbidopa: mechanism of action

No effects on its own inhibits decarboxylation of levodopa in intestine & peripheral tissues=↑levodopa available to CNS does NOT prevent in conversion of levodopa to dopamine by decarboxylases in brain b/c can't cross the BBB

Administration: Transdermal (TTS) Parkinson's Med

ONLY= Rotigotine (nonergot/dopamine agonist) Apply to clean, dry, hairless, intact skin. Rotate site to ↓skin irritation/reaction Allow {2 wks} before applying TTS in same spot Ensam- marketed patch for Seleginine (MAO-B inhibitor) BUT not approved in mgmt of PD.

Blood vessels are

Only innervated by the sympathetic nerves

Calcitonin

Osteoporosis treatment: a man-made form of a hormone that occurs naturally in the thyroid gland. It increases deposition of calcium and phosphate in the bone and lowers levels in the blood, so effectively it inhibits calcium resorption by binding to a specific receptor on the osteoclasts, and inhibits their action.

if a patient is not able to pee what drug will we give them??

Parasympathetic Agonists (makes parasympathetic stuff work) i.e lower heart rate constricts bronchi stimulates intestioinsl motility etc

Degradation of alpha-synuclein requires (2) other proteins

Parkin- enzyme that catalyzes the binding of alpha-synuclein to ubiquitin Ubiquitin- when bound to ubiquitin alpha-synuclein can be degraded

The nurse is describing how medication can affect synaptic transmission. The nurse correctly states that medications are capable of what actions? Select all that apply. Preventing the breakdown or reuptake of neurotransmitters after the action potential is conveyed Binding to the postganglionic cells to stimulate or inhibit the autonomic nervous system response Increasing the storage of neurotransmitters in synaptic vesicles Increasing or decreasing the release of neurotransmitters Increasing or decreasing neurotransmitter synthesis

Preventing the breakdown or reuptake of neurotransmitters after the action potential is conveyed Binding to the postganglionic cells to stimulate or inhibit the autonomic nervous system response Increasing or decreasing the release of neurotransmitters Increasing or decreasing neurotransmitter synthesis

Alpha 1 (Sympathetic)

Primarily present in the blood vessels Vasoconstriction 1. Eyes dilate (mydriasis) 2. Blood vessels constrict- BP up 3. Male sex organs - ejaculation 4. Prostatic capsule - contraction (BHP need Alpha 1 blockers) 5. Bladder - contraction of muscles at 6. bottom of bladder (urinary retention)

Topical Administration

Produce a localized effect. Application to skin, eyes, nose, mouth, throat, rectum, vagina

Clonidine

Promoted bradycardia Vasodilation Lipid soluble Readily absorbed Single dose may last 24 hours

Amantadine does what?

Promotes dopamine release

Bioavailability (F)

Proportion of the drug that reaches the systemic circulation after oral administration "how much you really absorb" NOTE: (F) of IV formulation considered 1.0 (100%) Bioavailability = AUC oral / AUC injected x 100

PPIs

Proton-pump inhibitors - pronounced and long-lasting reduction of gastric acid production - destroyed by stomach acid (take on empty stomach) - work really well - "attack from the back" - used as a controller Ex. Omeprazole (Prilosec)

Potential interventions to IMPROVE or MAINTAIN cognitive function: MEDICATIONS

QUALITY OF EVIDENCE SHOWS NO BENEFIT: Cholinesterase Inhibitors Statins Estrogen Antihypertensives NO BENEFIT BUT POSSIBLE INCREASED RISK: Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Potential interventions to IMPROVE or MAINTAIN cognitive function: NUTRITION

QUALITY OF EVIDENCE SHOWS NO EFFECT/NO CONSISTENT EFFECT: Vitamin E Vitamin B6 Vitamin B12 Folic Acid

Potential interventions to delay ONSET of Alzheimer's disease: MEDICATIONS

QUALITY OF EVIDENCE SHOWS POSSIBLE BENEFIT: Statins INCREASED RISK: Celecoxib, Naproxen Estrogen + Progestin NO BENEFIT: Cholinesterase Inhibitors Antihypertensives Estrogen (alone)

Your​ client, Mario​ Sabatini, has survived myocardial infarction. Mr. Sabatini has just been prescribed carvedilol​ (Coreg) for hypertension and left ventricular dysfunction. In reviewing Mr.​ Sabatini's medical​ history, you see that he also suffers from occasional bronchial asthma attacks. As his​ nurse, what should you​ do? Question the prescription of an​ alpha-adrenergic antagonist. Question the prescription of an adrenergic agonist. Question the prescription of a selective beta1​-adrenergic antagonist. Question the prescription of a nonselective​ beta-adrenergic antagonist.

Question the prescription of a nonselective​ beta-adrenergic antagonist.

Nonlinear Pharmacokinetics

Rate of elimination is constant regardless of amount of drug present Dosage increases saturate binding sites and result in non-proportional increase/decrease in drug levels May also be a result of "saturated" metabolism

Alpha blockers in Raynaud's

Raynaud= PVD w/ vasospasm in toes/fingers S/S= sensations of pain and cold. alpha blockers suppress symptoms by preventing alpha-mediate vasoconstriction generally ineffective against other PVDs. only relieve symptoms in Raynaud's.

Gout

Recurrent inflammatory disorder- seen mainly in men Disease of altered purine metabolism Hyperuricemia- Uris acid level greater than 7mg/dL in men or greater than 6mg/dL in women Tophi Caused by excessive production of uric acid, impaired renal excretion of uric acid

Adverse Effects of Alpha-2 Blockade

Reflex tachycardia- response to alpha-1 block peripheral alpha-2 located presynaptically & activation inhibits NE release. If alpha-2 are blocked than release of NE ↑. b/c reflex tachy caused by block of alpha-1 is ultimately result of ↑firing of sympathetic nerves of the heart and b/c alpha-2 blockade will cause each nerve impulse to release ↑amount of NE. alpha-2 blockade will potentiate reflex tachy imitated by blockade of alpha-1 receptors drugs such as phentolamine (blocks alpha-2 and alpha-1) cause greater reflex tachycardia than do drugs that block alpha-1 receptors only.

Functions of the Sympathetic Nervous System (fight or flight)

Regulating the cardiovascular system Regulating body temperature Implementing the acute stress response homeostatic objectives

describe Transmitter Release

Release of transmitter is triggered by the arrival of an action potential at the axon terminal The action potential initiates a process in which vesicles undergo fusion with the terminal membrane, causing release of their contents into the synaptic gap

A client has a complex cardiac history that includes recurrent ventricular fibrillation. After the failure of more conservative treatments, the care team has introduced oral amiodarone. What assessments should be prioritized by the nurse who is providing care for this client? Orientation and cognition Respiratory assessment Neurological assessment Active and passive range of motion

Respiratory assessment

Adrenergic (Sympathetic) Receptors

Responds to norepinephrine or epinephrine There are subtypes receptors Alpha 1 Alpha 2 Beta 1 Beta 2 The term also pertains to the receptors acted on by norepinephrine, that is, the adrenergic receptors.

Neurotransmitter dissociates from receptor, and then has three possible fates:

Reuptake Enzymatic degradation Or, diffuse away and get absorbed into extracellular fluid, then into venous system

Alendronate (Fosamax) - PO

SIDE EFFECTS: - Uncommon, but can cause esophagitis and esophageal ulcers - Can see musculoskeletal pain, ocular inflammation, and atypical demure fractures NURSING CONSIDERATIONS: - Taken at least 30 minutes before breakfast with full glass of water

Autonomic Control Feedback Regulation (Reflex)

Self-adjustment system Sensor (detects information) + effector (make changes/adjustment) = ANS feedback loop = reflex

DEA Schedules of Controlled Substances

The Controlled Substances Act of 1970 regulates the manufacturing, distribution, and dispensing of drugs that are known to have abuse potential. The Drug Enforcement Agency (DEA) is responsible for the enforcement of these regulations. The controlled drugs are divided into five DEA schedules based on their potential for abuse and physical and psychological dependence.

what influences the body by releasing epinephrine into the bloodstream, which then produces effects much like those that occur in response to stimulation of postganglionic sympathetic nerves

The adrenal medulla

Steady State

The amount of drug administered is equal to the amount of drug eliminated within on dosing interval "drug entering = drug leaving" "plateau"/constant serum drug level Usually about 4-5 half lives to reach steady state

A nurse is the cardiac care unit is preparing to hang an intravenous dose of dofetilide (Tikosyn) for a client who has just been admitted. What is the most likely goal of this intervention? To treat sinus bradycardia accompanied by hypotension To convert the client's atrial fibrillation to normal sinus rhythm To treat the client's ventricular tachycardia To resolve the client's uncompensated heart failure

To convert the client's atrial fibrillation to normal sinus rhythm

What are the four main Transmitters used for the Peripheral Nervous System

Transmitters 1. Acetylcholine (Ach) - multiple locations 2. Norepinephrine (NE) -- sympathetic 3. Epinephrine (Epi) - adrenal medulla 4. Dopamine (Dopa) - mostly CNS, but dopamine receptors in PNS Receptors 1. Cholinergic--> (Parasympathetic)--- responds ACH 2. Adrenergic--> Sympathetic--responds to norepinephrine or epinephrine (also has subtypes)

Analgesics

Treating Pain agents that relieve pain without a loss of consciousnes Two Kinds: 1. Narcotics *(morphine sulfate, methadone, fentanyl and oxycodone)* 2. Non-Narcotics *(salicylate, acetaminophen, NSAIDS)

Laxatives

Used to ease or stimulate defecation Soften the stool Increase stool volume Hasten fecal passage through the intestine Facilitate evacuation from the rectum *Misuse comes from misconceptions of what constitutes normal bowel function

Estimating CrCL

Uses ideal body weight (IBW, kg) unless actual body weight < IBW - then use ABW -males 50 + [2.3 x (# of inches > 60in.)] -females 45 + [2.3 x (# of inches > 60in.)] CrCL = [140 - age (yrs)] x IBW (kg) / 72 x serum creatinine (SCr in mg/dL) --> (x 0.85 if female) For pt >65 yrs with SCr <1.0 mg/dL, use minimum of 1 for SCr in calculation

Terbutaline (Brethine)

Uses to relax uterine smooth muscle to inhibit uterine activity Stops preterm labor Also used for asthma attacks.

Oprelvekin (Neumega)

Uses: stimulate platelet production, thrombocytopenia related to cancer. Side effects: fluid retention, papilledema, cardiac dysrhythmia Nursing interventions: administer within 6-24 hr after chemotherapy, subcutaneous

Adverse effects of Probenecid

Usually well tolerated, but mild GI effects occasionally occur; take with food Rash

Antipsychotics (neuroleptics)

a class of psychotropic medications used for the treatment of schizophrenia and other disorders that involve psychosis. Ex. olanzapine, risperidone, haloperidol. MAOI

seizure

a disorder that results from abnormal electrical discharges from the cerebral neurons, characterized by a loss or a disturbance of consciousness and usually involuntary uncontrolled movements

If drug-induced dyskinesias are a primary concern then...

a dopamine agonists would be preferred

first generation antipsychotics

a group of medications originally developed to combat psychotic symptoms by reducing dopamine levels in the brain; also called conventional or typical antipsychotics block receptors for dopamine, acetylcholine, histamine, and norepinephrine Ex. (low potency): Chlorpromazine, Thioridazine s/e orthostatic hyposension, long Q-T syndrome, high sedation (medium potency): loxapine, perhenazine, s/e moderate sedation (high potency):fluphenazine, haloperidol, pimozide, thiothoxene, frifluoperizine s/e movement problems

antiemetic

a medication that is administered to prevent or relieve nausea and vomiting

MRSA (methicillin-resistant Staphylococcus aureus)

a mutated strain of the bacterium Staphylococcus aureus that is resistant to the antibiotic, methicillin.

Spironolactone (Aldactone)

a potassium-sparing diuretic (water pill)that prevents your body from absorbing too much salt and keeps your potassium levels from getting too low. used to treat heart failure, high blood pressure (hypertension), or hypokalemia (low potassium levels in the blood).

Hydrochlorothiazide

a thiazide diuretic (water pill) that helps prevent your body from absorbing too much salt, which can cause fluid retention. HCTZ treats fluid retention (edema) in people with congestive heart failure, cirrhosis of the liver, or kidney disorders, or edema caused by taking steroids or estrogen. This medication is also used to treat high blood pressure (hypertension). No digoxin or nsaids.

Sedatives, Hypnotics, and Anxiolytics

a.k.a. Mood Depressants. The word "Sedative = Calming, "Hypnotics = Sleep - inducing, "Anxiolytics = Decrease Anxiety.

anoxia

absence of oxygen

regulation fo calcium levels

absorbed in the small intestine excreted by the kidneys reabsorbed by the bones regulated by: - parathyroid hormone - vitamin D - calcitonin

Fiber Laxatives

absorbs water, softening feces and increasing their mass. Can be digested by colonic bacteria, whose subsequent growth increases fecal mass. ex. Bran, veggies and fruits. Meds: mehylcellulose, psyllium, polycarbophil

Metabolism

accounts for decline of plasma drug concentrations liver is the major site of metabolism, other sites include: gut, kidneys, brain, lungs, skin -primary purpose is to inactivate the agent or detoxify drugs that can harm the body -can also convert pro-drugs to an active state -metabolites are usually more water soluble to facilitate excretion

Neurotoxic fibrils form as result of

accumulation of alpha-synuclein inside the cell

After successful treatment for a myocardial infarction, a 69-year-old man has developed a ventricular arrhythmia. His care team has opted for treatment with a Class II antiarrhythmic. The nurse would understand that this client is likely to be prescribed: lidocaine. verapamil. acebutolol. amiodarone.

acebutolol

SNS - one of the two exceptions, transmitter released at postganglionic sympathetic neurons that go to sweat glands

acetylcholine

which enzyme is primarily responsible for the degradation of acetylcholine?

acetylcholinesterase

Ergot Derivatives have been associated with valvular heart disease. Why?

activation of serotonin receptors on heart valves

Probenecid actions

acts on renal tubules to inhibit reabsorption of uric acid prevents formation of new tophi and facilitates regression of existing tophi

Beta-2

receptor responsible for bronchodilation and promoting GI & uterine relaxation Tx: asthma, premature labor contractions

Levodopa and MAOIs

admin of levodopa can cause a hypertensive crisis if taking nonselective inhibitor of MAO. Levodopa ↑stores of dopamine and NE by promoting synthesis of both neurotransmitters Intraneuronal MAO serves to inactivate dopamine and NE, inhibition of MAO allows ↑stores of both to grow even larger both dopamine and NE promote vasoconstriction release in massive amounts leads to massive vasoconstriction causing BP to rise dangerously high AVOID: w/d MAOIs 2 wks before levodopa

Levocardopa pharmokinetics

administered orally undergoes rapid absorption from small intestine food delays absorption= delays gastric emptying high-protein foods ↓effects= neutral amino acids compete w/ levodopa for intestinal absorption and for transport across BBB

Bolus

administered over seconds to minutes

Short/Intermittent Infusion

administered over ~30 minutes to several hours

fibers that release norepinephrine

adrenergic fibers

sympathetic postganglionic neurons

adrenergic neurons

Adverse Drug Reactions

adverse effects = side effects 2 types: -dose dependent: arise from extension of pharmacologic properties -uncommon/unexpected (intolerance, allergic, etc.) Risk factors: dose, route of admin, polypharmacy, age, disease state, organ function, gender, genetics

Dextroamphetamine

affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control. Dextroamphetamine is used to treat narcolepsy and attention deficit hyperactivity disorder (ADHD)

Lithium

affects the flow of sodium through nerve and muscle cells in the body. Sodium affects excitation or mania. Lithium is used to treat the manic episodes of bipolar disorder (manic depression). Manic symptoms include hyperactivity, rushed speech, poor judgment, reduced need for sleep, aggression, and anger. Lithium also helps to prevent or lessen the intensity of manic episodes. Check levels regularly lithium toxicity: muscle weakness, twitching, drowsiness, feeling light-headed, mood changes, blurred vision, ringing in your ears, irregular heartbeats, confusion, slurred speech, clumsiness. trouble breathing, or seizures.

Calcium Channel Blockers

agents that inhibit the entry of calcium ions into heart muscle cells, causing a slowing of the heart rate, a lessening of the demand for oxygen and nutrients, and a relaxing of the smooth muscle cells of the blood vessels to cause dilation; used to prevent or treat angina pectoris, some arrhythmias, and hypertension Ex. Nifedipine, amlodipine, Nicardipine, Diltiazam, Verapamil No grapefruit juice, Nsaids

epinephrine can activate

all alpha and beta receptors, but not dopamine receptors

A child taking methylphenidate may experience

all choices are possible possible choices: weight loss malnutrition increased heart rate and/or cardia arrhythmias suppression of growth

Cholinesterase Inhibitors: Therapeutic Effects

all cholinesterase inhibitors are approved for: mild-mod symptoms of AD donepezil- also approved for severe symptoms Con: Tx only benefits 1 in 12 pts Pros: ↑QOL/Cognitive Fx benefits in some improvements are MODEST/SHORT LASTING -are neither universal, dramatic, nor long lasting although SE common- benefit > risk in some

Adrenergic receptors are subdivided into what?

alpha and beta

norepinephrine can activate

alpha1, alpha2, and beta1 receptors, but not beta2 or dopamine receptors

dopamine can activate

alpha1, beta1, and dopamine receptors

ACh binding to nicotinic receptors are stimulatory or inhibitory?

always stimulatory

Sulconazole (Exelderm)

an antifungal medication of the imidazole class. It is available as a cream or solution to treat skin infections such as athlete's foot, ringworm, jock itch, and sun fungus

COMT converts Levodopa into

an inactive metabolite

sympathomimetic

another name for drugs that mimic the responses of the Sympathetic Nervous System, like Beta Agonists

the autonomic division is under what type of control?

antagonist (one branch is excitatory and the other branch is inhibitory)

Bicalutamide

anti-androgen. It works in the body by preventing the actions of androgens (male hormones). Bicalutamide is used together with another hormone to treat prostate cancer.

Colchicine action

anti-inflammatory agent with effects specific for gout

Ipratropium Bromide

anticholinergic drug Treat: asthma, COPD, rhinitis Inhalation or nasal spary

alzheimers symptoms

appear after 65, but may appear as young as 40 early in disease: memory loss confusion disoriented, get lost in familiar surrounds judgment becomes impaired personality may change progression of disease: self care difficult 70-90% develop behavioral problems -wander, pace, agitate, scream intensify in the evening- sundowning final stages: loses weight, appetite, speech, bladder/bowel fx unable to recognize family unable to communicate all sense of identity is lose completely dependent

Properties of Individual Cholinesterase Inhibitors: Rivastigmine [Exelon]

approved for AD and Dementia in PD IRREVERSIBLE inhibition (unlike donepezil) preparations: oral, oral soln, transdermal patch PO well absorbed-GI tract- especially w/food patch- blood levels↓/steadier⇢PO=↑tolerance patch beneficial- pts w/ difficulty swallowing 50% starting dose remains in patch after 24 hrs ESSENTIAL to remove old patch before new one to AVOID toxicity. Metab: convert inactive metabolites by AChE (not by cytochrome P450 enzymes in liver) Half-Life is short- 1.5 hrs. Elimination: urine Cause peripheral cholinergic SE N/V/D, abd pain, anorexia, weight loss Brady, faint, falls, fall related fractures ↓intensity SE w/ patch= no hepatic metabolism can intensify symptoms in patients with: PUD, Brady, SSS, urine obstruction, lung disease

Cabergoline

approved for Tx of hyperprolactinemic dis. occasional use in PD- not approved. "possibly" effective improving "off" times w/levo RARELY USED. SE: HA, dizzy, nausea, weak Adverse: development of HF & valve regurg, palm/pericardial fibrosis.

Conjugated drugs

are a class of biopharmaceutical drugs designed as a targeted therapy for treating cancer. Unlike chemotherapy, ADCs are intended to target and kill tumor cells while sparing healthy cells.

Opioids (narcotics)

are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always precedes respiratory depression.

Beta2

arterioles - dilation bronchi - dilation uterus - relaxation liver - glycogenolysis skeletal muscle - enhanced contraction, glycogenolysis

Functions we are not aware of in the ANS

artery constrictions and peristalsis

How long should you instruct a client to wait between inhaler​ doses? At least 10 seconds At least 1 minute At least 30 seconds At least 2 minutes

at least two minutes

The nurse is preparing to administer a metered-dose inhaler to a client with asthma. How long should the nurse instruct the client to wait before administering a second dose

at least two minutes

Muscarinic antagonists

atropine and scopolamine

Muscarinic Antagonists for mydriasis and cycloplegia during ophthalmic procedures

atropine, homatropine, scopolamine, cyclopentolate, and tropicamide

Cariprazine (Vraylar)

atypical antipsychotic Mechanism unknown. Similar to aripiprazole.

Aripiprazole (Abilify)

atypical antipsychotic dopamine system stabilizers. Treats schizophrenia, acute bipolar mania, major depressive disorder, agitation associated with psychosis and irritability associated with autism spectrum disorder. Does not have metabolic s/e or EPSs. Food does not effect, protein bound, metabolized by liver, long elimination. S/E headache, agitation, nervousness, anxiety, insomnia, nausea, vomiting, dizziness, somnolence. High suicidality

The nurse is preparing to administer a gastrointestinal medication to a client. Which portion of the nervous system is most likely to be affected by this medication? Autonomic nervous system Somatic nervous system Efferent neurons Afferent neurons

autonomic nervous system

A female patient diagnosed with chronic atrial flutter has been prescribed verapamil in conjunction with digoxin to control ventricular rate. To enhance the therapeutic effect of the drug, the nurse will instruct the patient to: avoid grapefruit and grapefruit juice. take the medication with meals. avoid fresh fruit. take an aspirin every day.

avoid grapefruit and grapefruit juice.

There are two basic steps in the process by which neurons elicit responses from other cells:

axonal conduction synaptic transmission

Centrally acting muscle relaxants include 9 drugs:

baclofen, carisoprodol, cholorzoxazone, cyclobenzaprine, diazepam, metaxalone, methocarbamol, orphenadrine, & tizanidine All have similar properties

3 drugs tx spasticity

baclofen, diazepam, dantrolene

PD: Drug selection: Severe symptoms

begin w/ either levodopa (combined w/ carbidopa) or dopamine agonist levodopa= more effective BUT long term use= higher risk for disabling dyskinesias choice of med must be tailored to patient

PD: Drug selection: Mild symptoms

begin with MAO-B inhibitors confer mild, symptomatic benefit

SC Administration

beneath the skin (SC) Drug needs to be in solution or particle suspension There is a slower prolonged release with SC

Levodopa Teaching

benefits delayed for wks-months possible abrupt loss of therapy in off times-notify avoiding high protein meals N/V reduced by taking with food notify if N/V persists or becomes severe possible levodopa induce movement disorders (tremor, dystonic mvmt, twitching) appt→develop signs of excessive cardiac stimulation (palp, tachy, irreg heartbeat)- notify if occur hypotension w/associated dizziness may occur move slowly and lie down if dizzy/lightheaded possible levodopa-induced psychosis (visual hallucinations, vivid dreams, paranoia) →911!

Stimulant Laxatives

bisacodyl: (tablets: give at night to have BM in am , no crushing or chewing, no milk or antacids;Suppositories: BM within 15-60 min, may cause proctitis); senna: BM 6-12 hours after. May cause pink or brown urine. castor oil: acts on small intestine 2-6 hour BM. Limit to only when prep for radiology procedures. Chill and mix in juice. * easily abused, Give with a full glass of water.

Alpha blockers in Essential HTN

block alpha-1 receptors on: arterioles/veins = ↓BP Directly = vasodilation. Indirectly = ↓CO in response to vasodilation

If antipsychotic med needed avoid 1st generation because

block dopamine receptors and intensify motor symptoms

Clozapine and quetiapine cause little or no

blockade of dopamine receptors in the striatum and hence do not cause EPS

anticholinergic agents share the same mechanism:

blockade of muscarinic receptors in the striatum (unlike dopaminergic agents which have multiple mechanisms of action)

Alpha-Adrenergic Antagonists (alpha blockers)

blocks alpha-1 receptors on blood vessels (HTN) blocks alpha-1 on bladder/prostate (BPH) NOTE: blockade of alpha-1 receptors in the eyes and alpha-2 receptors= no recognized therapeutic use.

Carbidopa does what?

blocks levodopa destruction

Orlistat

blocks some of the fat that you eat, keeping it from being absorbed by your body. Used to aid in weight loss, or to help reduce the risk of regaining weight already lost. This medicine must be used together with a reduced-calorie diet and increased physical activity. Orlistat is for use only in adults that are overweight or obese. S/E bowel urgency, frequent bowel movements, oily evacuation, oily rectal leakage, steatorrhea, and flatulence with discharge

Noncompetitive Antagonist

blocks the agonist site

Differences between somatic and autonomic nervous systems

both have motor fibers, but somatic only stimulate skeletal muscle - motor fibers are usually heavily myelinated in somatic, thinly or unmyelinated in automatic - the target organs have different responses to neurotransmitters

baclofen & diazepam can be used for

both spasm and spasticity

Ergot derivatives: bromocriptine and Cabergoline

bromocriptine is approved for PD cabergoline is not. both are poorly tolerate. use is limited. activate: DA receptors mild block: serotonergic, alpa-adrenergic recep B/C POORLY SELECTIVE

ANS function: smooth muscles

bronchi, blood vessels, urogenitary, GI tract

albuterol/ipratropium

bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Albuterol inhalation is used to treat or prevent bronchospasm, or narrowing of the airways in the lungs, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm.

When describing the drugs classified as class IV antiarrhythmics, the nurse would identify these as: cardiac glycosides. beta blockers. vasodilators. calcium channel blockers.

calcium channel blockers.

parenteral calcium salts

calcium chloride calcium gluconate adverse effects: - highly *irritating* - *DO NOT give IM* - can cause IV extravasation (can destroy surrounding tissue- pt could lose limb) MONITOR PT ^ slow pump infusion drug interaction: - *digoxin*

Beta blockers in migraine prophylaxis

can reduce frequency and intensity of migraine attacks when taken prophylactically BB are effective through prophylaxis BUT cannot abort migraine once begun. Prevention mechanism for migraines= unknown.

Etoposide

cancer medicine that interferes with the growth and spread of cancer cells in the body.

Rivastigmine [Exelon]

caps: 1.5, 3, 4.5, 6 mg PO solution: 2 mg/mL Mild-Mod: 1.5mg QD⇢⇡weekly by 3mg/day 1.5 each meal to a (max) of 6mg BID PO-should be taken with morning & evening meal 24hr patch: 4.6, 9.5, 13.3 mg/24 hrs 4.6 mg patch QD⇢⇡dose PRN Severe AD: 4.6 mg (initial)↑ 13.3mg QD (max) apply (1) QD- chest, upper arm/back, lower back apply ONLY after removing the previous patch change site QD. Don't repeat for 14 days. bathing does NOT effect treatment

Levodopa/Carbidopa: advantages

combo superior to levodopa alone in 3 ways: (1) ↑levodopa fraction available for CNS actions. allows ↓levodopa dose by 75%. Example: to provide 10mg dopamine to brain we must administer 500mg levodopa (alone) but only 100mg levodopa if carbidopa is present. (2) by ↓dopamine production in periphery carbidopa ↓CV response to levodopa & N/V (3) by causing direct inhibition of decarboxylase carbidopa eliminates concern about ↓ levodopa effects by taking vitamins containing pryridoxine

symptoms management in PD

constipation- reg exercise, active, stool soft/lax OH- ↑salt/water, move slow, lie down for dizzy PLMS- levo/carb, pramipexole & ropinirole (non) insomnia- levo/carb, melatonin EDS- modafinil (non amphetamine CNS stim) depression- amitriptyline (bad side effects) dementia- donepezil and rivastigmine

parasympathetic effect of the pupils

constrict

An adult client with no known history of cardiovascular disease presents with atrial flutter. The client is prescribed propafenone PO 150 mg every 8 hours for 24 hours. What is the cardiac care nurse's priority assessment during this period? echocardiography continuous ECG monitoring every 1-hour monitoring of potassium levels blood pressure monitoring every 10 minutes

continuous ECG monitoring

Somatic Motor Neurons

control skeletal muscles and voluntary movement

Metoclopramide (Reglan)

controls post-op NV suppresses emesis and increases upper GI mobility

Autonomic Motor Neurons

controls smooth muscle, cardiac muscle, glands, and some adipose tissue

tonic-clonic

convulsive, as with a tonic-clonic seizure

Enteric-Coated

covered with a pH-dependent material that will dissolve in small intestine but not the stomach helps to protect the drug from the acid and pepsin in the stomach, also protects the stomach from irritating drugs *usually* cannot be crushed

Neuromuscular blocking agents

d-Tubocurarine, succinylcholine

Hepatotoxicity

damage to the liver. Elevated transaminase levels, jaundice (rare). Check LFT's. Avoid statins in alcohol-induced hepatitis.

Dantrium

dantrolene Treats MS skeletal muscle relaxant. S/E constipation

conversion of levodopa to dopamine catalyzed by what enzyme?

decarboxylase removes a carboxyl group from levodopa

Why is Levodopa lost?

decarboxylases in GI tract & peripheral tissues convert it to dopamine which cannot cross BBB

drugs that inhibit release will (increase or decrease) receptor activation

decrease

Drugs that interfere with transmitter storage will cause receptor activation to (increase or decrease)

decrease disruption of storage depletes vesicles of their transmitter content

Beta Blockers

decrease heart rate and dilate arteries by blocking beta receptors "olol" in the end. Ex. propanolol, atenolol, metoprolol Treat: Irregular heart rhythm (arrhythmia) Heart failure Chest pain (angina) Heart attacks Migraine Certain types of tremors May cause edema, fatigue, weight gain, depression

Additional agents (carbidopa, entacapone) in formulary

decrease the amount of decarboxylation in the periphery so that more drug can enter the CNS

Which effects are associated with various adrenergic ​antagonists? Select all that apply. Decreased salivation Decreased heart rate Increased lacrimation Dilated bronchioles Increased urination

decreased heart rate increased urination increased lacrimation

The nurse has just administered a muscarinic agonist to a client on a medical-surgical unit. Which physiological effect does the nurse anticipate the client may experience as a result of the medication? Decreased pulse Increased blood pressure Decreased urinary output Decreased gastrointestinal motility

decreased pulse

Imbalance of dopamine and acetylcholine results from

degeneration of the neurons in the substantia nigra that supply dopamine to the striatum

If any of these proteins (alpha-synuclein, Parkin, or ubiquitin) is defective

degradation of alpha-synuclein cannot take place

Neil McLean is an​ 80-year-old male client who has​ Parkinson's disease. His health care provider just prescribed benztropine​(Cogentin), a muscarinic antagonist. Considering the possible adverse effects of this type of​ medication, what aspect of Mr.​McLean's health history causes you​ concern? Difficulty with urination Excessive sweating Muscular tremors Muscular rigidity

difficulty with urination

The health care provider orders quinidine for a client who is receiving a common treatment for atrial fibrillation. The nurse would monitor this client for: digoxin toxicity. increased quinidine effect. renal dysfunction. bleeding.

digoxin toxicity.

The nurse is teaching a group of clients with asthma about the ways in which adrenergic agonists stimulate the sympathetic nervous system. Which clinical effect is evidence of this type of stimulation? Increased peristalsis Decreased heart rate Dilated pupils Decreased blood pressure

dilated pupils

mydriasis (big word big pupil)

dilated pupils

Which class IV calcium channel blocker is exclusively administered to treat acute supraventricular tachycardia? bethanechol chloride midazolam hydrochloride diltiazem chlorambucil

diltiazem

Under normal conditions, alpha-synuclein is rapidly degraded

doesn't accumulate and no harm occurs

Proper striatum function requires a balance between (2) neurotransmitters

dopamine acetylcholine

Peripheral decarboxylases converts levodopa into

dopamine (an active metabolite)

"off" times can be reduced with (3) types of drugs:

dopamine agonists COMT inhibitors MAO-B inhibitors evidence of efficacy is strongest for: entacapone (COMT inhibitor) rasagiline (an MAO-B inhibitor)

If psychosis develops

dopamine agonists amantadine anticholinergic drugs should be withdrawn

In PD there is an imbalance between

dopamine and acetylcholine in the striatum

Pramipexole does what?

dopamine receptor agonist

extrapyramidal side effects result from

dopamine receptors in the striatum being blocked by antipsychotic drugs

Of the (2) groups (dopaminergic & anticholinergic) which is most commonly used

dopaminergic agents by far the more widely employed

(2) types of drugs are used:

dopaminergic agents- directly/indirectly activate dopamine receptors anticholinergic agents- block receptors for acetylcholine

the underlying cause of motor symptoms is the loss of

dopaminergic neurons in the substantia nigra

Most side effects of Levodopa are...

dose dependent older adult especially sensitive to adverse effects

Adverse effects of clonidine

drowsiness, xerostomia, rebound hypertension Abuse potential Constipation Impotence Gynecomastia CNS effects

Allopurinol therapeutic uses

drug of choice for chronic trophaceous gout, can also be used for hyperuricemia that develops secondary to cancer chemo and to certain blood dycrasias (polycythemia vera, myeloid metaplasia, and leukemia

Transmitter Release

drugs can... Increase and decrease

Transmitter Synthesis

drugs can... Increase transmitter synthesis Decrease transmitter synthesis Cause synthesis of more effective transmitter

Transmitter Storage

drugs can... Interrupt storage --> decreased action

Receptor Binding

drugs can... Most utilized drug alteration site 1. Bind to site themselves - agonists 2. Bind to receptors to block action- antagonists 3. Bind to receptor to enhance natural action

Drugs for Cognitive Impairment

drugs may slow loss of memory and cognition and prolong independent function cannot reverse decline

second generation antipsychotics

drugs that alleviate schizophrenia with less likelihood of movement problems S/E: are associated with metabolic adverse effects (eg. weight gain, dyslipidemia, hyperglycemia, and increased risk of diabetes). As such they should be monitored for changes. Olanzapine and clozapine carry the greatest risk. Ex. apripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone,

vitamin D toxicity

early symptoms: - weakness - fatigue - nausea - vomiting - anorexia - abdominal cramping - constipation later symptoms: kidney function is affected - polyuria - nocturia - proteinuria neurologic: - *seizures* - confusion - ataxia *cardiac dysrhythmias* coma calcium deposition in soft tissues decalcification of bone

drug therapy for hypercalcemia

edetate disodium glucocorticoids calcitonin bisphosphonates furosemide (loop diuretic)

Synergistic PD Drug-Drug

effect is greater than the sum of individual effects (1+1=3) +/- overlap toxicities/ADEs or increased pharmacologic effect/PD effect

Antagonsitic PD Drug-Drug

effect is less than expected by using the two drugs together (1+1=1) competition for same receptor binding site, counterbalanced effects

efficacy

effectiveness

Tolcapone advantages:

extends effective time of levo by 2.9 hrs/day improves motor fx and ↓levo dose required

Drug selection and dosage are determined by

extent to which PD interferes with work, walking, dressing, eating, bathing, and other activities

movement disorders similar to those of PD can occur as side effects of antipsychotic drugs- these dyskinesias are referred to as

extrapyramidal side effects

PD: Motor symptoms result from damage to the

extrapyramidal system a complex neuronal network that helps regulate movement when EP fx disrupted- dyskinesias (disorder of movement develop)

Alpha1

eye - dilation, mydriasis (increase pupil size) blood vessels - vasoconstriction male sex organ - ejaculation prostate - contraction bladder - contraction of trigone and sphincter

Inhaled Corticosteroids (ICS)

fluticasone mometasone budesonide beclomethasone pref for persistent asthma need consistent daily use for optimal effect (NOT PRN)

approach to treatment is obvious in PD

give drugs that restore functional balance between dopamine and acetylcholine

Sublingual Administration

good absorption through capillary bed under the tongue, fast absorption, not affected by first-pass metabolism e.g., nitroglycerin

Spasticity

group of movement d/o of CNS origin heightened muscle tone spasm loss of dexterity

SNS : Pilioerection

hair follicle erection SNS- think of a dog when aroused- their hair's stand up

In which organ are the majority of beta-adrenergic receptors found?

heart

Beta1

heart - increased rate, increase force of contraction, increase AV conduction kidney - release of renin *Because renin promotes synthesis of angiotensin, a powerful vasoconstrictor, activation of renal beta1 receptors is a means by which the nervous system helps elevate blood pressure

Avoiding high-protein meals

help with reducing "off" times

Describe the baroreceptor reflex

helps regulate blood pressure

Gout

hereditary metabolic disease that is a form of acute arthritis, characterized by excessive uric acid in the blood and around the joints

Levodopa Beneficial Effects

highly effective BUT beneficial effects diminish over time. most effective drug for PD 75% pts experience 50% reduction in symptom severity at beginning of treatment. beneficial effects likely to increase over first few mths. don't expect immediate improvement. symptoms well controlled during 1st 2 years by the end of year 5= ability to fx declines to pretreatment level reflects disease progression, not tolerance

The nurse is preparing to administer a cholinergic antagonist to a client on a medical-surgical unit. Which assessment parameter is most appropriate to review before administering this medication? History of diplopia History of glaucoma Muscle strength Ability to chew

history of glaucoma

Furosemide (Lasix)

loop diuretic (water pill) that prevents your body from absorbing too much salt. This allows the salt to instead be passed in your urine. Lasix is used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. Also used to treat high blood pressure High doses can cause hearing loss.

Some experience early s/s of PD years before functional impairment develops

loss of smell excessive salivation clumsiness of hands worsening of handwriting bothersome tremor slower gait reduced voice volume

Statins

lower cholesterol in the blood and reduce its production in the liver by blocking the enzyme that produces it. Most effective. Reduces LDS and increases HDL. Oral, absorbed 30-90%. S/e: headache, rash, GI, muscle pain.

Beta 2 hits

lungs- dilate uterus- relax arterioles (around heart and lungs) Dialate

MOA

main enzyme responsible for breaking down catecholamines

Although there is no cure for motor symptoms, drug therapy can

maintain functional ability for years thereby substantially prolonging quality of life & life expectancy

Functions of the ANS

maintains internal conditions, has motor neurons that innervate smooth muscle, cardiac muscle and glands all throughout the body

What is the primary goal of antidysrhythmic drug therapy for a client who has been successfully cardioverted? increase in blood pressure maintenance of normal sinus rhythm (NSR) suppression of original dysrhythmia proof of increased cardiac contractility

maintenance of normal sinus rhythm (NSR)

abrupt withdrawal of tolcapone

malignant syndrome fever, muscle rigidity, altered conscious

Time of alz onset to time of death

may be 20 yrs or longer but typically is 4-8 years!

Diuretics

medications administered to increase urine secretion in order to rid the body of excess water and salt Thiazide is first line for hypertension. Loop Diuretics are common - monitor for hypokalemia

what can be looked on as the functional equivalent of a postganglionic neuron of the sympathetic nervous system

medulla of the adrenal gland

EEG (electroencephalogram)

method used to record electrical activity in the brain

Probenecid ADRs

mild GI effects (n/v, anorexia), hypersensitivity reactions, renal injury initial therapy can cause acute gouty attacks

Properties of Individual Cholinesterase Inhibitors: Donepezil

mild, mod, severe AD reversible inhibition of AChE more selective for AChE in brain than periphery Well absorbed after PO Metabolized: hepatic metabolism-P450 enzymes Eliminated: mainly in urine, partly in bile. Half-Life= prolonged= 60 hrs. Administered= ONLY once a day (half life) can cause peripheral SE- N/D (most common) Brady, faint, falls, fall related fractures Min SE: initial dose stabilized for 1-3 mths before any changes to be made

Tablets

mixture of drug + binders and fillers (powdered medication that is compacted to form a solid disc or other shapes) can differ in rates of disintegration and dissolution "delayed release"

which enzyme is primarily responsible for the degradation of catecholamines?

monoamine oxidase

Phenothiazines

more sedation, less extrapyramidal

osteoporosis

most common disorder of bone metabolism - low bone mass - increased bone fragility primary prevention: - calcium - vitamin D - lifestyle (ex: weight bearing exercise) diagnosis - measurement of bone mineral density (BMD) - dual-energy x-ray absorptiometry (DEXA)

CYP3A4

most common metabolic enzyme involved in drug interactions Inducers: phenytoin, rifampin, barbituates, carbamazepine Inhibitors: ketoconazole, itraconazole, fluconazole, erythromycin. if using these and taking drugs metabolized by this enzyme, levels will increase which may cause toxicity.

dual innervation

most viscera receive nerve fibers from both parasympathetic and sympathetic divisions the influence of sympathetic nerves opposes that of parasympathetic nerves For example, in the heart, sympathetic nerves increase heart rate, whereas parasympathetic nerves slow heart rate

Levo/Carb/Entac

now available in fixed dose combinations sold as Stalevo both carb and entac inhibit enzymatic degradation of levo= enhance therapeutic effects triple combo= more convenient= less money available ONLY in immediate release NOT= pts w/tight schedule OR if ER required

*alendronate [fosamax, fosamax plus D]*

most widely used oral bisphosphonate uses: - postmenopausal osteoporosis - male osteoporosis - glucocorticoid-induced osteoporosis adverse effects: generally safe - *esophageal ulceration* - atypical femoral fracture - esophageal cancer - musculoskeletal pain - ocular problems - osteonecrosis of the jaw - hyperparathyroidism - A-fib *pts MUST sit up for 30 mins after drug administration* - MAJOR risk for esophageal erosion - if pt cannot sit up for 30 mins then DO NOT administer - *pt should sit at at least 45 degrees*

Life Cycle of Epinephrine

much like that of norepinephrine The cycle begins with synthesis of epinephrine within chromaffin cells of the adrenal medulla These cells produce epinephrine by first making norepinephrine, which is then converted enzymatically to epinephrine. -(Because sympathetic neurons lack the enzyme needed to convert norepinephrine to epinephrine, epinephrine is not produced in sympathetic nerves.) Following synthesis, epinephrine is stored in vesicles to await release. Once released, epinephrine travels via the bloodstream to target organs throughout the body, where it can activate alpha1, alpha2, beta1, and beta2 receptors. Termination of epinephrine actions is accomplished primarily by hepatic metabolism, and not by uptake into nerves

The nurse is preparing to administer pyridostigmine bromide (Mestinon) to a client with myasthenia gravis, prior to discharge. The nurse tells the client that the medication is used to treat which symptoms associated with the disorder? Dry mouth Muscle weakness Visual disturbance Memory loss

muscle weakness

The nurse is talking to a client who has listed pseudoephedrine hydrochloride (Sudafed) as a medication taken on a daily basis. What condition is this client most likely treating with this medication? Cardiogenic shock Bronchospasms Nasal congestion High blood pressure

nasal congestion

management of PD is generally under the guidance of

neurologist who oversees pharmacologic management while other providers are over management of primary care needs and monitoring pt status.

alzheimer's patho

neuron degeneration reduced cholinergic transmission beta-amyloid and neuritic plaques neurofibrillary tangles and tau apolipoprotein E4 endoplasmic reticulum associate protein binding homocysteine

The nurse in the neurological unit is discussing the nervous system with a colleague who was recently transferred to that unit. The nurse tells the colleague that the central nervous system communicates with the parasympathetic nervous system through which cells? Acetylcholine Epinephrine Norepinephrine Neurons

neurons

Sympathetic preganglionic fibers arise from:

neurons in spinal cord T1 - L2

Neuroprotection in PD

no definitive findings for neuroprotection in PD some drugs are promising: MAO-B inhibitors: provided neuroprotective effects in animal studies dopamine agonists: demonstrated neuroprotective effects in lab studies human studies inconclusive in both levodopa= controversial. risk may outweigh benefits when given for this purpose.

What causes degeneration of dopaminergic neurons?

no one knows for sure

Pramipexole [mirapex]

non ergot dopamine receptor agonist used ALONE in early stage PD used w/ levodopa in advanced stage PD ↓motor control fluctuations allow for ↓dosage of levodopa also used for RLS

norepinephrine

non-selective agonist similar to epinephrine EXCEPT NO B2 (bronchodilation), NO Hyperglycemia

epinephrine

non-selective agonist: A1, B1, B2 PROTOTYPE - potent inotropic & vasoconstrictor - used to combat anaphylaxis

pseudoephedrine

non-selective agonist: A1, B2 - OTC cold meds - Tx rhinitis and nasal congestion

Isoproterenol

non-selective beta agonist Specific B-adrenergic (gets B1 and B2) AV block Restart heart after arrest Inc cardiac output during shock Bronchospasm during anesthesia Asthma - but now have better, more specific drugs for this Adverse Effects - I bet you can tell me... Drug Interactions - Nearly identical to epi IV, IM

Apomorphine

nonergot dop-agon approved use: acute tx of hypo mobility during "OFF" episodes in advanced PD NOT given by mouth. NOT indicated for routine mgmt. 62% improvement- pts at least 2hr off time/day benefits sustained during 4 wks of use derivative of morphine w/o opioid effects highly lipophilic BUT undergoes ext 1st pass ineffective orally, RAPID comp absorption w/SQ effects begin in 10-20 mins. persist 1 hr half-life is about 40 mins

Rotigotine

nonergot dop-agon improves DA transmission by activating post-syn DA receptors in substantia nigra approved use: early-adv stage PD, mild-mod RLS patch only. NO ORAL- b/c 1st pass= extensive TTS peak= 15-18 hrs w/ range of 4-27 hrs approx 90% of drug is protein bound half-life: 5-7 hrs after patch removal excretion: urine (70%) and feces Adverse effects: most common- CNS,neuromusc sleep dis, dizzy, HA. halluc & dysk (dose related) N/V common in beginning skin irritation at site is common hyperhidrosis (excessive perspiration) may occur

Ropinirole

nonergot dop-agon (similar to pramipexole) same receptors: highly selective D2, D3 same indications: PD, RLS early stage PD: mono therapy late stage PD: adjunctive w/ levo conversely: ropinirole- excreted by hep metab (not renal) same SE alone and w/ levodopa BUT occur less frequently in combo w/ levo than pramipexole CANNOT BE USED IN PREGNANCY- fetal harm

NSAIDs

nonsteroidal anti-inflammatory drugs S/E -Gastric ulcer/bleeding -Prolonged bleeding time (platelet interference) -Increased risk of cardiovascular events -Renal toxicity (including celecoxib)

Muscarinic

parasympathetic - rest and digest location and response: eyes - contraction, focuses for near vision, miosis heart - decreased rate lung - constriction of bronchi, promotes secretions bladder - contraction of detrusor, relaxation of trigone ad sphincter (causes voiding) GI tract - increased gastric secretions, tone, and motility (defection) sweat glands - sweating sex organs - erection blood vessels - vasodilation

irritable bowel syndrome (IBS)

periodic disturbances of bowel function, such as diarrhea and/or constipation, usually associated with abdominal pain. Intermittent diarrhea and constipation with pain. Treat and prevent symptoms: Antispasmodics, bulk forming agents, antidiarreheals and tricyclic antidepressants.

Liver function failure s/s

persistent nausea, fatigue, lethargy, anorexia, jaundice, dark urine

Buccal Administration

placed between the cheek and the gum, fast absorption, not affected by first-pass metabolism e.g., fentanyl lollipop, glucose

Initiation of the heart's electrical impulses depends predominantly on what electrolyte movement? Select all that apply. sodium and calcium ions out of a myocardial cell calcium ions into a myocardial cell potassium ions out of a myocardial cell potassium ions into a myocardial cell sodium and ions into a myocardial cell

potassium ions out of a myocardial cell sodium and ions into a myocardial cell calcium ions into a myocardial cell

Colchicine precautions and interactions

precautions: older adults, debilitated pt., cardiac, renal and GI disease Contraindicated: pt. with hepatic or renal impairment, pregnancy

Pramipexole: Adverse Effects

primarily caused by DA receptor activation most common SE when used alone: nausea, dizzy, daytime som, insomnia, constipation, weakness, hallucinations when combined w/levo 50% experience: OH, dyskinesias. Hallucination risk doubles

Tolcapone LFTs

prior Q 2 wks x 1st year Q 4 wks for next 6 months following

Levodopa: Psychosis

psychosis develops in about 20% prominent symptoms- visual hallucinations, vivid dreams/nightmares, paranoid ideation (fears of personal endangerment, sense of persecution, feelings of being followed or spied on) activation of dopamine receptors involved ↓symptoms=↓levodopa dose=BUT ↓benefits

in patients taking levodopa, clozapine and quetiapine can reduce

psychotic symptoms w/o intensifying symptoms of PD

isoproterenol HCl

pts on this beta agonist should be started on a low dose that is increased as they are able to handle it pts should also be placed on a heart monitor to look for dysrhythmias

The nurse is preparing to administer a medication that will suppress the parasympathetic nervous system. Which response does the nurse anticipate the client will experience after receiving the medication? Increased peristalsis Decreased heart rate Decreased blood pressure Pupil dilation

pupil dilation

Peripheral decarboxylases work faster in the presence of

pyridoxine

activity of decarboxylases is enhanced by

pyridoxine (vitamin B)

Selective Estrogen Receptor Modulator (SERM)

raloxifene [evista]

Levodopa: CNS Effects

range from: anxiety-depression-memory/cognitive impair insomnia and nightmares are COMMON impulse control, behavior changes associated w/ promiscuity, gambling, binge eating, ETOH abuse

Pramipexole- Pharmokinetics

rapidly absorbed. peak in 1-2 hrs. undergoes wide distribution achieves high concentration in RBCs excreted unchanged in urine

Properties of Individual Cholinesterase Inhibitors: Galantamine

reversible cholinesterase inhibitor→mild-mod AD extracted from daffodil bulbs. trials= ↑cog fx, QOL, behavior, ADL ability rapidly/completely absorbed after PO admin protein binding in plasma is low elimination is by CYP hepatic enzymes excretion is renal mod-sever liver/renal dys-delays excret+↑levels ↓dosage in these pts. AVOID if sever dysfunction Half life= about 7 hours (healthy adult) common SE: N/V/D, anorexia, weight loss (worst)donezepil > galantamin > rivastigmine(less) bronchoconstriction- avoid if asthma/copd AVOID drugs that block cholinergic receptors b/c ↓therapeutic effects

Autonomic (ANS) functions :secretory glands

salivary, gastric, sweat, bronchial

secretory glands

salivary, gastric, sweat, bronchial

Epi

secreted by adrenal medulla to act on various organs in sympathetic NS

SSRIs

selective serotonin reuptake inhibitors, used to relieve anxiety and depression by limiting reuptake of a neurotransmitter, takes about 3 weeks to work. Ex. end in [pram], [ine] citalopram [Celexa]; escitalopram [Lexapro]; fluoxetine [Prozac]; paroxetine [Paxil]

SSRIs (selective serotonin reuptake inhibitors)

selectively inhibits serotonin reuptake from synaptic gap and results in potentiation of serotonergic neurotransmissions. Examples: Luvox, Paxil, Prozac, Zoloft end in [pram], [ine] citalopram [Celexa]; escitalopram [Lexapro]; fluoxetine [Prozac]; paroxetine [Paxil] initial responses are seen approx. 1-3 weeks. Max responses can take up to 12 weeks. Take for at least 1 month before changing or increasing dose. Do NOT use with MAOIs

Selegiline (MOA-B Inhibitors)

selegiline & rasagilne= 1st line drugs BUT effects are MODEST. suggest delay dis progression by delaying neurodegeneration. neuroprotection NOT confirmed selective, irreversible inhibition of MAO-B helps preserve dopamine benefits decline dramatically in 12-24 mths

extrapyramidal symptoms

side effects of antipsychotic medications that affect a person's gait, movement, or posture Usually caused by high potency first gen. antipsychotics Also referred to as EPS Acute Dystonia: occurs within first few days of therapy. Severe spasm of the muscles of tongue, face, neck and back. Parkinsonism: bradykinesia, mask-like facies, drooling, tremor, rigidity, shuffling gait, stooped posture. Akathisia: pacing and squirming, need to move uncontrollably. develops in first 2 months of treatment. Tardive Dyskinesia: occurs with long-term therapy. Involuntary choreoathetoid movements of the tongue and face.

Parkinson's disease (PD)

slowly progressive neurodegenerative disorder that afflicts more than 1 million Americans. 2nd only to Alz as most common degenerative disease of neurons

Selegiline: selective inhibitor of MAO-B

so it is NOT used for tx of depression in little doses- does NOT pose risk of HTN crisis

Of the antiepliepleptic or anticonvulsant drugs

some are general depressants other possible answers were: some are general stimulants all are general stimulants all are general depressant

drugs that tx muscle spasm, do not tx

spasticity

Black Box Warning: Sotalol (Betapace)

starting or restarting: inpatient in facility w/ continuous ECG monitoring and cardiopulmonary resuscitation for minimum of 3 days to minimize problems associated with induced arrhythmia. Creatinine clearance should be established prior to initiating this drug. Betapace cannot be substitute for Betapace AF when treated atrial fibrillation

Colchicine interactions

statins, inhibitors of PGP and CYP3A4

Describe what is meant by "autonomic tone."

steady, day-to-day influence exerted by the autonomic nervous system on a particular organ or organ system In most organs, the parasympathetic nervous system provides the predominant tone The vascular system, which is regulated almost exclusively by the sympathetic nervous system, is the principal exception

idiosyncratic response

strange, unique, or unpredicted response to a drug

PD: neurotransmission is disrupted primarily in the brain's

striatum

Life Cycle of Acetylcholine

synthesis of ACh from two precursors: choline and acetylcoenzyme A Following synthesis, ACh is stored in vesicles and later released in response to an action potential Following release, ACh binds to receptors (nicotinicN, nicotinicM, or muscarinic) located on the postjunctional cell Upon dissociating from its receptors, ACh is destroyed almost instantaneously by acetylcholinesterase (AChE), an enzyme present in abundance on the surface of the postjunctional cell AChE degrades ACh into two inactive products: acetate and choline. Uptake of choline into the cholinergic nerve terminal completes the life cycle of ACh

Life Cycle of Norepinephrine

synthesis of norepinephrine from a series of precursors. The final step of synthesis takes place within vesicles, where norepinephrine is then stored before release. Following release, norepinephrine binds to adrenergic receptors. Norepinephrine can interact with postsynaptic alpha1 and beta1 receptors (but not with beta2 receptors) and with presynaptic alpha2 receptors. Transmission is terminated by reuptake of norepinephrine back into the nerve terminal. (Note that the termination process for norepinephrine differs from that for ACh, whose effects are terminated by enzymatic degradation rather than reuptake) Following reuptake, norepinephrine can undergo one of two fates: -uptake into vesicles for reuse -inactivation by monoamine oxidase (MAO), an enzyme found in the nerve terminal

Donepezil [Aricept]

tablet: 5, 10, 23 mg Mild-Mod: 5mg QD⇢⇡10mg QD after 4-6 wks Severe AD: 10mg QD⇢⇡23mg QD after 3 mths should be taken at bedtime taken W/WO food Aricept 23 mg MUST be swallowed WHOLE

Selegiline pharmacokinetics

tabs/cap rapid GI absorption, travels to brain, quickly penetrates BBB irreversible inhibition of MAO-B follows hepatic metabolism followed by renal excretion amp/methamphetamine produced= harmful CNS excitation persists until more MOA-B is synthesized because inhibition by selegiline was irreversible. bioavailability higher in ODT= doses can be lower absorbed through oral mucosa but same pharm.

Nitroglycerin (Nitrostat)

take up to 3 tabs during single episode place under tongue store in original container discard on expiration date May be taken on a schedule. Take prior to exercise / sexual activity

baclofen & diazepam work in

the CNS

FDA approval

the FDA can prevent marketing of any drug it judges to be incompletely tested or dangerous. -only drugs considered to be safe by the FDA are approved for marketing.

efficacy

the ability to produce a desired or intended result effectiveness

Half-life of a medication

the amount of time it takes for half of the drug to be eliminated. Liver and kidney disease, aging, absence of food, and slowed metabolic rate prolong half-life because of their effects on metabolism and excretion.

dependence

the condition that results when the brain develops a chemical need for a drug and cannot function normally without it

withdrawal

the discomfort and distress that follow discontinuing the use of an addictive drug

An adult client with a long-standing dysrhythmia has been taking oral propranolol for the last several months, resulting in acceptable symptom control. What is a priority teaching point for the nurse to communicate to this client? the need to limit intake of high-potassium foods the importance of not stopping the medication abruptly the need to measure the radial pulse for 1 minute prior to each dose of propranolol the need to avoid taking over-the-counter antacids

the importance of not stopping the medication abruptly

Movement in PD is normal when

the inhibitory influence of dopamine and the excitatory influence of acetylcholine are in balance

peripherally acting drugs that affect somatic motor system function have only one site of action:

the neuromuscular junction

Muscarinic receptors are in ?

the parasympathetic nervous system there is one in the sympathetic nervous system that acts on sweat glands but also responds to ACh

describe synaptic transmission

the process by which information is carried across the gap between the neuron and the postsynaptic cell requires the release of neurotransmitter molecules from the axon terminal followed by binding of these molecules to receptors on the postsynaptic cell

Potency

the size of the dose needed to elicit a given response

Define neuropharmacology

the study of drugs that alter processes controlled by the nervous system

most of our body is regulated by both parasympathetic and sympathetic

we call this a reflex. the baroreceptors are in our carotid artery and in our aortic arch

levodopa gradual loss

wearing off develops near end of the dosing interval indicates that drug levels have declined to sub therapeutic level

Tolcapone pharmokinetics

well absorbed after oral dosing peaks: 2 hrs highly bound-plasma proteins in blood > 99.9% undergoes ext hep metab followed by renal exc half life is 2-3 hrs.

Pharmacokinetics

what the body does to the drug

Pharmacodynamics

what the drug does to the body

what is divergence?

when a few presynaptic neurons branch to affect a larger number of postsynaptic neurons

terminal

where the neurotransmitter is released into the synapse to make an action on the next cell neurotransmitter will either freely disassociate from the receptor or an enzyme can make them disconnect

Avoid sympathomimetics/tyramine while on seglegiline

while taking medication and for 2 wks after stopping medication

Anti-Parkinsonian Agents

• *Leva-dopa - replaces dopamine for only works for five years!!* • Carbidopa (decarboxylase inhibitor = Sinemet) - if on exam if between Leva and Carb - chose carb bc you need less • Bromocriptine - stimulates postsynaptic dopamine receptors • Selegiline - decreases MAO-B, which leads to a decrease in the degradation of dopamine • Anticholinergic drugs: blocks ACH receptors and helps restore "false" balance • Artane, Gognetic Kemadrin • COMT inhibitor - entacapone • Amantadine

Benzodiazapines & Barbiturate Cautions

• Additive with other sedative-hypnotics • Drug abuse and habituation • Symptoms can last up to 6 weeks or longer

CNS depressants - how do they work?

• An agent which decreases the excitability of the tissue in the CNS. • Produces sedation hypnosis, general anesthesia, coma, death. • All drugs in this category can be used as sedatives, hypnotics or general anesthetics...it is dose dependent • The higher the dose the greater the depression.

Anti-epileptic Goal of Treatment

• Control seizures without significant CNS impairment (this is difficult bc they all hyperpolarize)

Benzodiazapines & Barbiturate Side Effects

• Drowsiness • Impaired performance or decreased perception and judgement • Hangover effect • Hyperalgesia (barbiturates only) - abnormally heightened sensitivity to pain. • Overdose - respiratory depression (barbiturates, but can be true of any depressants in combination)

Anti-anxiety agents - What are they? Major side effects?

• Prescribed more frequently than any other CNS class •Designed for short term use Drugs: •Sedative Hypnotics Common: Valium Caution: Insomnia may accompany anxiety or depression - insomnia may be treated with sedative hypnotic, however, if insomnia is accompanying depression, a sedative-hypnotic should *not* be used. •Beta Blockers - not approved by the FDA to help individuals through temporary stress, will alleviate "pounding" heart and may also lessen muscular "tremor" or shaking hands. Advantage: no sedation and no addiction potential •Buspirone (BuSpar) - a new chemical entity - not related to benzos - not a controlled substance - no euphoria or additive CNS depression - in contrast, nervousness may be a problem - not as effective as benzos - may take 1-2 weeks for effect - ok for short term use; long term safety needs to be established

ANILINE TYPE (ACETAMINOPHEN) (Tylenol)

•*extremely hard on the liver and many OD on this might be #1 or close to #1 for liver failure •*after acetaminophen OD, prompt treatment is necessary! Within 10 Hours!! With acetylcysteine (mucomyst) can prevent hepatic damage and death in many patients! •*Kidney or liver damage - irreversible liver damage with even one overdose* •Blood diseases - anemia •Possible link to bladder cancer

Psychotrophic Agents

•Antidepressants •Anti-anxiety agents •Antipsychotic agents •Drugs to treat manic depression episodes

ANILINE TYPE (ACETAMINOPHEN) (Tylenol) Non-narcotic analgesics - Therapeutic Effects/What are they and what are the indications

•Relief of pain such as headache, dysmenorrhea •Antipyretic - decreases fever *It is not an antiinflammatory nor is it an anticoagulant!*

SALICYTES (aspirin) Non-narcotic analgesics - Therapeutic Effects; What are they and what are the indications

•Relief of pain such as headache, dysmenorrhea, arthritis •Antpyretic - decreases fever *•Antiinflammatory* such as Rheumatoid arthritis and Rheumatic fever and decreases the scarring of heart valve *•Anticoagulant effect* - for veneous coronary thrombosis and after mycardial infarction to prevent stroke

Cholinesterase Inhibitors: Adverse Effects

↑ACh in periphery= typical cholinergic SE N/V, Dyspepsia, Diarrhea, Dizziness, Headache Bronchoconstriction (caution-asthma/COPD) UNCOMMON: serious CV effects- brady, faint, falls/fracture, PM CV-SE= withdrawal especially if NO cog benefit DRUG INTERACTIONS: drugs-block cholinergic rec↓therapeutic effects anticholinergics, 1st gen antihistamine, tricyclic antidepressant, conventional antipsychotics DOSAGE/DURATION OF TREATMENT: carefully titrate dose. cont as long as needed ↑dose= ↑benefits= ↑SE initial dose= low w/gradual ↑to tolerable level Tx cont indefinitely or until benefit is lost or SE become intolerable