Pharmacology Review II

1. Pharmacology Review II Chapters 28 - 38 All Materials in this presentation come from: Karch, A. (2008). Focus on: nursing pharmacology. New York, NY: Lippincott Williams & Wilkins.

2. Sympathetic response Eyes wide open Stress Causes Release of Norepinephrine Breath hard Heart pounds Hormones released

3. Sympathetic response Alpha 1 receptors Stress Causes Release of Norepinephrine Beta 2 receptors Beta 1 receptors (1 heart) (2 lungs) Alpha 2 receptors

4. Sympathetic response Alpha 1 receptors Stress Causes Release of Norepinephrine Beta 1 Receptors Beta 2 Receptors Alpha 2 receptors

5. Sympathetic response Alpha 1 receptors Dilate pupils Close bladder spinchter Vasoconstrict blood vessels Stress Response Beta 1 receptors Increase heart rate Breakdown fat for energy Beta 2 receptors Dilate bronchi Breakdown glycogen Relax uterine muscle Alpha 2 receptors Regulate norepinephrine Moderate insulin release

6. Sympathetic response Alpha 1 receptors Agonists “ine” Blockers “zosin” Stress Response Beta 1 receptors Blockers “olols” Beta 2 receptors Blockers “olols” Alpha 2 receptors Clonidine

7. Parasympathetic Response Acetylcholine responses Heart slows Digestion starts Bladder works Eyes constrict Bronchi constrict

8. Parasympathetic Response Muscarinic Receptors (Smooth muscle) Pupils, bladder, GI motility Heart vessels Nicotinic Receptors NMJ Muscle constractions

9. Too Low Too fast Heart Rate medications • Adrenergic Agonists • Epinephrine • Dopmaine • Dobutamine • Adrenergic Blockers • Amiodarone • Bretylate • Carvediol

10. Adrenergic Agonists - “ine” “ine” it to win it! The race against time with shock • Ephedrine • Dopamine • Dobutamine • Aramine • Norepinephrine • Epinephrine David Price

11. Case Study # 1 Adrenergic Agonists • Your patient, 70 yr old diabetic, suddenly goes into shock….. • knowing that diabetes contributes to nephropathy… • You quickly tell the rapid response team because they will want to use what? Instead of epinephrine for him…….

12. Dopamine Dopamine stimulates heart and blood pressure and Increases blood flow to the kidneys to prevent renal shutdown Help me! I need oxygen…

13. Case Study # 2Adrenergic Blockers • Daniel’s grandfather told him to start taking saw palmetto for BPH. • Daniel is not old enough to be worried about BPH, but since he knows grandpa is hypertensive and has CHF… • He warns him about…..

14. Increased adrenergic efffects Herbs, teas, and alternative medicines (like saw palmetto) can cause serious arrhythmias or blood pressure changes Carvediol (Coreg) is used for hypertension and CHF

15. Case Study # 3Adrenergic Blockers • Stephanie, a new nurse, forgot to take Mrs. Jones’ HR before giving her her morning dose of amiodarone. Now, her heart rate is very low, 49 bpm… • Why?

16. Adrenergic Blockers • Amiodarone and carvedilol work to slow the heart rate. • Mrs. Jones’ may have had bradycardia and it has become worse. • Patients in shock, CHF or with asthma should also avoid these drugs.

17. Alpha Adrenergic Blockers That patient is not “dozin” on the floor! Orthostatic hypotension Is a side effect of Prazosin (anti-hypertensive) • Doxazosin • Alfuzosin • Terazosin • Tamulosin • Prazosin (Minipress)

18. Case Study # 4 Adrenergic blockers Speaking of prostrates and BPH, • Which adrenergic blocker used to treat hypertension is also effective in the treatment of BPH?

19. Adrenergic Blockers - “zosins” • Doxazosin (Cadura)1 - 8 mg PO/day treats hypertension, BPH • Tamsulosin (Flomax) BPH only • lfuzosin (Uroxatral) BPH only Have the PSA level checked regularly

20. Beta Blockers Inderal… kick in about now!!! • Treat • hypertension • Angina • Migraines • Reinfarction after MI • Syncope • Cardiac arrhythmias • Stage fright These block the “fight or flight” response….

21. Beta Blockers - “olols” What’s all that “lol” crap on the cell phone. I got all the “lols” I need • Carteolol • Nadolol - Corgrad • Penbutolol - Levator • Pindolol • Propranolol - Inderal • Sotalol - Betapace • Timolol For my hypertension

22. Beta Blockers • Timolol*, also a beta blocker, is used to treat glaucoma. • Do not use if patient has bradycardia *(Material in ATI prep) Apply cotton ball here to prevent Systemic effect

23. Case Study # 5Beta Blockers Kasey’s mom has been taking Nadolol (Corgard) to control her hypertension and angina (she’s a nurse and it’s stressful). The family went on a picnic to enjoy all the spring flowers in Knoxville…. Now she’s in ER because she can’t breathe… what’s going on?

24. Beta blockers Remember: Beta 2 receptors dilate the lungs • Beta blockers inhibit this response • Bronchospam, COPD, Asthma, diabetes and hypoglycemia are all contraindicted Kasey’s mom’s lungs were unable to dilate with the inflammation caused by the pollen

25. Beta 1 blockers If you work in East Tennessee, get use to : • Sectral (acebuterol) • Zebeta (bisoprolol • Lopressor (metropolol) • Toprol • Atenolol for COPD, hypertension and seasonal rhinitis

26. Case Study # 6Cholinergic agents • Mrs. Brown had a bladder lift surgery (urethral sling). She has high expectations but right now she can’t even pee…. • The doctor prescribes: Urecholine (bethanechol). • How will you monitor her progress?

27. Cholinergics • Monitor her BP, ECG, urine output and lung sounds • These drugs stimulate the parasympathetic system. • Side effects include: increased salivation, diarrhea, GI upset

28. Case Study # 7Indirect acting cholinergics If you have myasthenia gravis and become exposed to nerve gas… Good News ! Why?

29. Pyridostigmine • Pyridostigmine acts as an antidote. • This drug allows Ach to accumulate in the synaptic cleft to give patients some control of muscles. • Nerve gas causes paralysis as ACH accumulates at the NMJ.

30. Prostigmin (neostigmine) Another cholinergic for mysastenia gravis that increases GI motility Side effects: • urinary frequency • Incontinence (on ATI practice exam) Know this!

31. Case Study # 8Alzheimer’s Disease • Many older patients are now taking Aricept (donepezil) for mild to moderate Alzheimer’s. • How would you counsel the caregiver of a patient starting Aricept?

32. Aricept (donepezil) • 5 -10 mg PO at bedtime • Eat frequent small meals to offset nausea, vomiting • Side effects do include insomnia and fatigue • Increased risk of GI bleeding with NSAIDs

33. Anticholinergics • Inhibit vagal responses in the heart • Relaxes the GI • Inhibits GI secretions • Causes mydriasis, cyclopegia • Treats parkinsonism “Can’t see, can’t pee, can’t eat!”

34. Case Study # 9Anticholinergics • What are the contraindications? • Think of any condition that could be aggravated by blocking the parasympathetic system…..

35. Contraindications: Glaucoma, Paralytic ileus Tachycardia Myasthenia gravis Side effects: Blurred vision Pupil dilation Weakness Insomnia Dry mouth Constipation Urine retention example: Atropine Anticholinergics Dries you out like a desert..

36. Case Study # 10Vasopressin

38. Case Study # 11Glucocrticoids • Laura hurt her knee running the mini-marathon. Her doctor prescribed short term treatment with prednisone and told her to come back in two weeks to see if she needed knee surgery…. • Should she go ahead and get her chicken pox vaccine for nursing school while she’s there?

39. No! Laura! Glucocorticoids block the immune response and cause a risk of infection to live virus vaccines. Live Vaccines: Measles Mumps Rubella Polio Varicella (chicken pox) Glucocoticoids and vaccines

40. Case Study # 12Glucocorticoids Pat goes from doctor to doctor. She has no idea how long she’s been taking prednisone for back pain. She’s had hydrocortisone injections in both knees. Now, Pat is taking prednisolone for her asthma…besides gaining a ton of weight… what else is going on?

41. Glucocorticoids Prolonged use causes risk of: • Adrenal insufficiency (ACTH depleting) • Diabetes (glucose elevating) • Fluid retention (weight gaining) • Protein breakdown (muscle shrinking) • Immunosuppression (germs getting) • Osteoporesis (bone shrinking)

42. Case Study # 13 • What does Katy Perry (Pink) have in common with the thyroid? • Hint: “Your hot, then your cold, up then your down!” The thyroid regulates????

43. Thryoid function • Thyroid hormones affect: • Heat production • Body temperature • Oxygen consumption • Cardiac output • Blood volume • Metabolism Hey, don’t forget us! The parafollicular cells Reduce clacium resoprtion

44. Hypo Most common Women over 50 Elderly Goiter, obesity, lethargy, coarse skin, thick tongue Hyper Graves’ disease Tachycardia Palpitations Intolerance to heat Flushing hypertension Thyroid function Treat with Levothyroxine (Synthroid) Treat with PTU (propylthiouracil)

45. Case Study # 14 • Joan has typical Graves’ disease symptoms: puffy eyes, increased body temp., tachycardia and hypertension. • You tell her that PTU treatment will help her attention span and focus* but she needs to know…… (*this info from ATI material, not textbook)

46. Graves’ disease • PTU causes an increased risk for bleeding with oral anticoagulants • Monitor serum levels of digoxin, metoprolol, and propranolol as patient heart rate returns to normal (euthyroid state).

47. Case Study # 15Antihypercalcemic agents • Christine’s mom has been taking Fosamax (Alendronate) for several weeks. She says, “I know I need it for my bones, but it upsets my stomach awful…” • Christine finds out her mom has been taking it with breakfast and then lays back down for awhile…should she stop taking it?

48. Fosamax (alendronate) Christine tells her mom: For maximum effect with Fosamax, Take it 30 minutes before breakfast and remain upright at least 30 minutes. Christine is going to order the newspaper for her mom to read before breakfast.

49. Hyperglycemia Blood sugar > 126 mg/dL Can contribute to: Atherosclerosis Retinopathy Neropathy Nephropathy Watch for: Fruity breath Fatigue Irritation Itchy skin Dehydration Kussmaul’s respirations

50. Hypoglycemia • Blood Sugar < 40 mg/dL Recognize these signs: Headache Blurred vision Tachycardia Hunger, nausea Diaphoresis, cool clammy skin Patient may appear drunk !