PHARMACY TECHNICIAN

1. PHARMACY TECHNICIAN CHAPTER TWENTY FOUR

2. Bone • Composed of two different kinds of bony tissue • Cancellous or “spongy” bone—porous, inner bone that provides volume • Compact bone—hard, outer covering that provides strength and shape • The rounded end of a bone is covered with smooth, slippery articular cartilage • Many bones are hollow, and contain marrow: • Red marrow in children • Fatty yellow marrow in adults

3. Bone and Muscle

4. Types of Muscle • Skeletal muscles—attached to bones; provide body movement • Voluntary, striated in shape, contain multiple peripheral nuclei • Cardiac muscle—tissue that composes the heart • Contracts rhythmically, coordinated by transmission of electrical impulses from nerve to muscle fibers Smooth or “visceral” muscle—attached to or lines other organs such as the stomach, intestines, lungs, and blood vessels

5. Five Categories of Bone: • Flat bones—generally more flat than round • Irregular bones—have no defined shape • Sesamoid bones—have cartilage or fibrous tissue mixed in • Short bones—generally cube-shaped • Long bones—the most common bone • Epiphysis (the rounded end of the bone) • Diaphysis (the main shaft or central part of the bone)

6. Disorders of the Bone Osteomyelitis • Bacterial Infection Inside the Bone Destroys bone tissue • Original site of infection is frequently in another part of body • Infection spreads to the bone via the blood Osteoporosis—bone brittleness due to lack of calcium • Prevalent in postmenopausal women because of estrogen deficiency Paget’s disease—changes the normal process of bone growth • Causes bone to break down more quickly and grow back softer than normal bone

7. Musculoskeletal Diseases/Disorders • Bursitis—inflammation of the small, fluid-filled pouches between bones • Tendonitis—inflammation of the cords of connective tissue that attach muscle to bone • Myalgia—muscle pain

8. Skeletal Muscle Relaxants • MOA: may block action of calcium in muscles • Indications: painful muscle spasms, neurological spinal cord injury • Main Side Effects: Drowsiness, weakness

9. Arthritis—Inflammation of a Joint • Rheumatoid—an autoimmune disorder • Osteoarthritis—caused by physical degeneration of connective tissue • Gout—caused by crystals of uric acid in blood

10. Treatments Osteomyelitis • Anti-infective agent is best treatment for osteomyelitis Osteoporosis • Vitamin D and mineral calcium replacement therapy • Hormone therapy (estrogen, calcitonin) and bisphosphonates • SERMs for postmenopausal women • Gold compounds used to treat osteoarthritis

11. Treatments Gout • Colchicine used to alter ability of phagocytes to attack uric acid crystals • Anti-inflammatory analgesics can be used to reduce pain and inflammation Inflammation • Salicylates relieve inflammation by inhibiting the synthesis of prostaglandin • Topical corticosteroids treat most causes, including chemical, mechanical, microbiological, and immunological

12. Musculoskeletal Pharmaceuticals • ASA (acetylsalicylic acid) • Relieves inflammation by inhibiting the synthesis of prostaglandin • Salicylates are also used as analgesics and antipyretics • NSAIDs (nonsteroidal anti-inflammatory drugs) • Inhibit or block the enzyme that starts the reaction of inflammation by making prostaglandin • COX-2 inhibitors • Block only the cyclooxygenase II that makes PGE-2, but not C-1 (PGE-1) • Inflammation is inhibited, but not the viscosity of the mucosal linin

13. Non Steroidal Anti Inflammatory Drugs • Called the NSAIDS • Excellent drugs for pain relief and reducing fever and inflammation • Developed as an alternative to corticosteroids • MOA: blocks the COX enzyme to block prostaglandin formation • Side effects are: severe GI bleeding (possible), GI upset and gastritis, kidney insufficiency, edema and elevated blood pressure, hyperkalemia risk

14. Musculoskeletal Pharmaceuticals • Bisphosphonates—indicated for osteoporosis • Mimic the natural organic bisphosphonate salts found in the body • Inhibit bone resorption and osteoclast activity • Restore bone mass and density • SERMs (selective estrogen receptor modulators) • Indicated for postmenopausal women • Protective effect on bones and heart • Skeletal muscle relaxants—used to relax specific muscles in the body • Relieve pain, stiffness, and discomfort • Block muscle contraction at the neuromuscular junctio

15. PHARMACY TECHNICIAN CHAPTER TWENTY FIVE

16. The Respiratory System • Divided into the upper respiratory tract and the lower respiratory tract • The upper respiratory tract consists of: • Nose or nasal cavity • Paranasal sinuses • Pharynx and larynx

17. The Respiratory System (cont.) • The lower respiratory tract consists of: • Trachea • Two lungs • Two main bronchi

18. The lower respiratory tract.

19. Respiration • Diaphragm—dome-shaped layer of muscle that lies across bottom of chest cavity • Breathing occurs as diaphragm contracts and relaxes • Carbon dioxide pushed out of the lungs during relaxation • Oxygen pulled into the lungs during contraction

20. Structure of Lungs • About 10 percent solid tissue • Remainder of structure filled with air and blood • The functional structure can be divided into two parts: • Conducting airways (bronchi and bronchioles)—tubes lined by cilia and respiratory mucosa • Cartilage—supports and cushions the bronchi

21. Common Cold • Caused by a viral infection that inflames the membranes in nose and throat • Antibiotics will not cure a cold or any other viral infection • Treatment is considered symptomatic Cough • May be a symptom of a cold, flu, respiratory problems, or nonrespiratory diseases • Most likely begins with an irritation of nerves in the respiratory tract • Nonproductive cough treated with cough suppressant • Productive cough treated with an expectorant

22. Allergies and Asthma Allergies • Caused by the immune system reacting to a substance that does not cause disease • Treatment may be palliative, with antihistamines and antitussives • Treatment may be preventive, with mast cell stabilizers Asthma • Chronic respiratory disease • Characterized by inflammation of airways, tightening of muscles around airways • Treatment is palliative with albuterol and other bronchodilators

23. Emphysema • Chronic destruction of alveoli • External exchange interrupted when alveoli become permanently damaged • Treatment may be palliative, with stimulant inhalers • Treatment may be preventive, with anti-inflammatory corticosteroids

24. Nasal Congestion and Rhinitis Nasal Congestion • Inflamed, stuffy nose • Treatment may be palliative, to promote easier breathing • Indications for use of decongestants are nasal and bronchial congestion Rhinitis • Inflammation of nasal membranes, and/or runny nose • Common component of colds and allergies • Treatment is considered symptomatic • Drugs to treat include: Oxymetazoline and Phenylephrine are sympathomimetic and can raise blood pressure. They also should be used with caution in gluacoma patients

25. Chronic Obstructive Pulmonary Disease (COPD) • Umbrella term for emphysema and chronic bronchitis, and asthma • Characterized by partially blocked bronchi and bronchioles, mucus plugging and bronchoconstriction • Causes shortness of breath • Treatment may be palliative, with bronchodilators • Drugs Albuterol and Pirbuterol and Beta 2 agonist but can cause tachycardia in some people. All of the above drugs are available as MDI Advair is a DPI (Dry powder inhaler system) (no CFC propellants) With Advair and Symbicort advise the patient to rinse the mouth with water to prevent candida infection (Trush or moniliasis)

26. PHARMACY TECHNICIAN CHAPTER TWENTY SIX

27. The heart.

28. Anatomy of the Heart • Composed of four chambers: two upper and two lower • Atria—top two chambers • Ventricles—bottom two chambers • Septum—divides heart into right and left sides

29. Valves of the Heart • Tricuspid valve—located between the right atrium and the right ventricle • Pulmonary valve—located between the right ventricle and the pulmonary artery • Mitral or bicuspid valve—located between the left atrium and the left ventricle • Aortic valve—located between the left ventricle and the aorta

30. Layers of the Heart • Pericardium—fluid-filled sac that surrounds and protects the heart • Permits free movement of the heart during contraction • Endocardium—innermost wall layer; covers the inside surface of the heart • Myocardium—surrounds heart and causes chamber contractions

31. Function of the Heart • Provides oxygenated blood throughout the body by a pumping mechanism • Oxygenated blood deposits materials necessary for growth and nourishment • Receives from tissues the waste products resulting from metabolism

32. Hypertension • Sustained elevation of systemic arterial blood pressure • Symptoms include: • Severe headache • Chest pain • Irregular heartbeat • Fatigue • Pharmaceutical treatment includes diuretics, vasodilators, ACE inhibitors, beta blockers, and calcium channel blockers

33. Congestive Heart Failure • Heart pumps out less blood than it receives • Results in weakened and enlarged heart • Symptoms of CHF include: • Upright posture or leaning forward • Anxiety and restlessness • Cyanotic and clammy skin • Persistent cough • Rapid breathing • Fast heart rate • Edema of the lower limbs • Pharmaceutical treatment includes cardiac glycosides, diuretics, vasodilators, ACE inhibitors, beta-adrenergic blockers, and phosphodiesterase inhibitors

34. Coronary Artery Disease • Occurs when there is insufficient blood flow to the heart • Can lead to: • Angina • Heart attack • Arrythmias • Stroke • Pulmonary embolism • Heart failure • Early CAD is closely monitored and symptomatic relief is given by the use of nitroglycerin and other nitrate drugs. • NTG • ISDN (isosorbidedinitrate) • Once CAD has progressed to the point where a patient has angina at rest. Two procedures can be taken • PCI with stents • CABG (Coronary artery bypass graft)

35. Cardiovascular Pharmaceuticals • Antiarrhythmic drugs—restore normal rhythm patterns but do not cure the cause of the irregular heartbeat • Cardiac glycosides—used to increase the force of myocardial contraction, without causing an increase in the consumption of oxygen • Diuretics—used to eliminate excess sodium and water via the urinary tract • Vasodilators—allow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure

36. Cardiovascular Pharmaceuticals (cont.) • Angiotensin-converting enzyme inhibitors (ACE inhibitors)—lower high blood pressure; thought to reshape the heart; prevent the body from producing natural vasodilators • Angiotensin II receptor blockers—similar to ACE inhibitors; block the body’s natural vasodilators • Beta-adrenergic blockers—used to block cells from receiving natural vasoconstrictors • Platelet aggregation inhibitors—reduce the ability of the blood to coagulate

37. Cardiovascular Pharmaceuticals (cont.) • Anticoagulants—prevent clots from forming or existing clots from getting bigger • Tissue plasminogen activators—break down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factors • Thrombin inhibitors—inactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrin • Antihyperlipidemics—help prevent the progression of coronary artery disease by lowering plasma lipid levels

38. Anticoagulants • Do not thin out the blood • Prevent clots from forming • Prevent existing clots from getting bigger • Cannot dissolve existing blood clots

39. Warfarin • Oral drug of choice • Works by preventing the synthesis of clotting factors II, VII, IX, and X • Used in the long-term prevention or management of venous thromboembolic disorders, including: • Deep vein thrombosis • Pulmonary embolism • Clotting associated with atrial fibrillation and prosthetic heart valves • Vitamin K may be used as an antidote when too much warfarin has been given

40. Heparin • Parenterally administered drug of choice • Works by inactivating clotting factors IX, X, XI, and XII • Used prophylactically to: • Prevent and treat deep vein thrombosis • Prevent and treat pulmonary embolism • Treat thrombophlebitis • Prevent clotting during cardiac and vascular surgery • The only antidote for heparin overdose is protamine sulfate

41. Cholesterol and Triglycerides • HDL—high-density lipoproteins or “good” cholesterol • LDL—low-density lipoproteins or “bad” cholesterol • Triglycerides—a form of energy stored in adipose and muscle tissues • Often measured to depict fat ingestion and metabolism • Can be used to assess CAD risk factors • Statins- drugs used to lower LDL cholesterol Major: Side effects are nausea, GI and a reaction called Rhabdomyolysis and myopathy where patient experiences muscle pain and at the extreme renal failure and hospitalization Statins are drug interactions with medications that block the liver’s CYP450 systems: Diltiazem, amiodarone, HIV protease inhibitors, Ketoconazole

42. Above medications are combination products that contain a statin + one other drug. Exetimibe is a drug that block enteral absorption of cholesterol. Niacin is a B vitamin used to high doses to alter metabolism of triglycerides and raise HDL One unique combination product is Caduet, which is a combination of Atorvastatin and Amlodipine (calcium channel blocker ). This product is used to treat metabolic syndrome

43. Non StatinAntilipidemic drugs • Other drugs that target lowing VLDL, triglycerides, and raising HDL have a beneficially affect on coronary artery disease

44. Drugs used in the Treatment of MI • MI is a myocardial Infarction. Heart attacks occurs because a arterial plaque raptures and triggers the coagulation cascade completely occudding a coronary artery. This cause necrosis of the heart muscle. • If not treated MI result in death from cardiogenic shock • Even if treat mortality is high from secondary ventricular fibrillation • Even if treated, patient will suffer irrevocable heart damage resulting in CHF and/or damage to cardiac conduction system leading to pacemaker or ICD placement • The main goal is to relieve the blood vessel of the clot and reestablish coronary blood flow • Can use “clot busters” drugs or have percutaneous coronary intervention (PCI) which the femoral artery undergo catherization and a probe is guide to the site of occlusion and a ballon is inflated to push aside the clot

46. Drug used in the treatment of Atrial Fibrillation • Atrial Fibrillation is a heart rate disturbance in which the atrium/ atria are beating extremely rapidly • Can lead to cardiogenic shock if the rate reaches the ventricles • Therapy is aimed blocking this rate disturbance from reaching the ventricles (called rate control), preventing blood clots in the heart muscle wall from forming embolus (anticoagulation), and eventual cardioversion • Rate control • Diltiazem • Verapamil • Beta blockers • Amiodarone • Anticoagulation • Warfarin • Apixaban (Eliquis) • Cardioversion • Ibutilide (Tikosyn) • High dose Amiodarone

47. Ventricular Fibrillation • Ventricular Fibrillation, VF, is a cardiac arrythmia where the ventricles beat extremely rapidly to the point where no coordinated contraction occurs • Medical emergency • VF lasting more than the 90 seconds leads to asystole, sudden cardiac death and cardiogenic shock. Brain death from cerebral hypoxia • Therapy • Direct DC shock with ACD: delivery of DC shock with about 360 Joules of electricity to bring about normal sinus rhythm. Best chance at survival but not always successful • Drug treatment used in conjunction with ACD if shock initially unsuccessful • Amiodarone: 300 mg IV push with 150 mg IV supplemental doses • Lidocaine: 100 mg IV push • Epinephrine or Atropine can be tried after failed attempts at shock • Other drugs include calcium chloride 10%, magnesium sulfate and vasopressin

48. Beta Blockers • Very useful in extending the life expectancy of patients post MI and in CHF patients • Due to evidence from clinical trials like the scandinavianTimolol study and the BHAT (beta block heart attack trial with propranolol) beta blocker are now an important drug in the therapy of post MI patients

49. ACE Inhibitors • Used to decrease mortality in post MI and CHF patients • Used with beta blockers and often in combination with them Potassium levels should be monitored ACE inhibitors are pregnancy category X May cause relentless coughing in some patient requiring discontinuation due to potent edema and closure of the airway

50. PHARMACY TECHNICIAN CHAPTER TWENTY EIGHT