Transcript Cholinergics

Cholinergics
Sara Trovinger PharmD
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Indications
• Cause SLUD: salivation, lacrimation, urination, and defication
• Used for contaction of muscles, bronchoconstriction, bradycardia
• Frequently used in eye drops to cause contraction of the iris
• Examples: Acetylcholine, Bethanechol, Pilocarpine, Carbachol
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Contraindications
• Asthma
• GI spasm
• Acute heart failure
• Hyperthyroidism
• Parkinson’s disease
• Peptic ulcer disease
• Urinary tract obstruction
Possible Adverse
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Effects
• Cardiovascular: Bradycardia, flushing, hypotension
• Ocular: Clouding, corneal edema
• Respiratory: Dyspnea
• Diaphoresis
Sedatives
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Indications
• Relief of anxiety
• Insomnia
• Sedation and amnesia before and during medical procedures
• Treatment of epilepsy and seizure states
• Control of withdrawal states
• Muscle relaxation in specific neuromuscular disorders
How They
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Work
• Bind to GABAA receptor
• GABA is a major inhibitory neurotransmitter
• Benzodiazepines potentiate the effect of GABA inhibition, increasing
the frequency of chloride ion channel opening
• Barbituates appear to increase the duration that these channels are
open
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Examples
• Benzodiazepines
• Diazepam
• Lorazepam
• Midazolam
• Barbiturates
• Pentobarbital
• Phenobarbital
• Miscellaneous
• Chloral hydrate
• Hydroxyzine
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Contraindications
• Increased sensitivity seen in patients with:
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Cardiovascular disease
Respiratory disease
Hepatic impairment
COPD
Sleep apnea
Elderly
• Barbiturates contraindicated:
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Acute intermittent porphyria
Variegate porphyria
Hereditary coproporphyria
Systemic porphyria
Adverse
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Events
• Drowsiness
• Impaired judgment
• Diminished motor skills
• Respiratory Depression
• Dependence
• Withdrawal
References
1. Drug Classes : Cholenergics. Access Pharmacy [database online].
Available at: http://accesspharmacy.mhmedical.com/drugs.aspx.
Accessed August 27, 2014.
2. Drug Monographs: Acetylcholine. Access Pharmacy [database
online]. Available at:
http://accesspharmacy.mhmedical.com/drugs.aspx?GbosID=13072
8. Accessed September 4, 2014.
3. Trevor, Anthony and Walter Way. Basic and Clinical Pharmacology.
McGraw-Hill Companies Inc. 2012. Web.
Anticholinergics
Trenton Shoda
PharmD Candidate
Purdue University
Indications
• Relieve cramps/painful menstruation or spasms of the stomach,
intestines, and bladder
• In combination w/antacids for treatment of peptic ulcers
• Prevent nausea, vomiting, and motion sickness
• Surgery and emergency procedures
• Runny nose
• Asthma
• Diarrhea
• Excessive saliva production
How do they work?
• Anticholinergic agents block acetylcholine's action by
competitively binding and blocking muscarinic
receptors.
Contraindications
• Elderly
• Dementia
• Gastrointestinal obstruction
• Glaucoma
• Ulcerative Colitis
• Breastfeeding
Possible Side Effects
Antiemetics
How do they work?
• Antihistamines – block H1 receptors centrally and in middle ear
• Anticholinergics - blockage of central muscarinic receptors
• Benzodiazepines – inhibitory effect on vomiting center and general
CNS depression
• Corticosteroids – inhibition of prostaglandin activity
• Serotonin Antagonists – selective 5-HT3 receptor antagonist
peripherally on vagal nerve terminals and centrally in the
chemoreceptor trigger zone
Contraindications
• Hypersensitivity
• Narrow angle glaucoma – Benzodiazepines
• Corticosteroids
• Glaucoma
• Current infection
Possible Side Effects
• Decrease in appetite
• Constipation
• Fatigue
• Reduced Libido
• Lightheadedness
• Hypertension
Narcotics/
Analgesics
How do they work?
• NSAIDs & Acetaminophen – inhibition of prostaglandin synthesis
• Opioids – react with opioid mu-receptors in the central nervous
system
Contraindications
• NSAIDs
• Hypersensivity
• <18 yo (aspirin)
• Acetaminophen
• Active and severe hepatic disease
• Hepatic impairment
• Hypersensitivity
• Opioids
• Respiratory depression
• Hypersensitivity
• Hypercarbia
Possible Side Effects
• Hypotension
• Constipation, Nausea, Vomiting
• Dizziness, Lightheadedness, Sedation
• Increased risk of bleeding
References
• Norco. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village,
CO. Available at: http://www.micromedexsolutions.com. Accessed September 5, 2014.
Laxatives
Claire McClain
2015 PharmD Candidate
Purdue College of Pharmacy
Indications
• Encourage bowel movements to relieve constipation
• Bowel evacuation before gastrointestinal procedures
How do they work?
• Bulk laxatives: stimulate peristalsis by causing the retention of
fluid and an increase in mass of fecal material (psyllium,
polycarbophil)
• Stimulant laxatives: increase muscle contractions to move the
stool along by directly stimulating nerve endings (bisacodyl,
senna)
• Osmotic laxatives: draw water into the intestine from
surrounding tissues resulting in a bulky soft stool to stimulate
peristalsis ( saline laxatives, Lactulose, sorbitol)
• Stool softeners: help to mix liquids in the stool and prevent
hard, dry stools(docusate)
• Lubricant laxatives: coat the stool and intestinal track to keep
water in the stool (mineral oil)
Contraindications
• Patients with signs of appendicitis or inflamed bowel
• Not intended for patients who miss only a day or two of bowel
movements
• Patients with a documented allergic reaction to any of these
medications
• Children under 6 years of age unless prescribed by a doctor
• Avoid saline laxatives in patients with reduced kidney function
Possible adverse effects
• Increased blood sugar in diabetic patients
• Exacerbation of heart disease or high blood pressure
• Mineral oil can increase a patient’s risk of pneumonia
• Diarrhea, bloating, cramping, belching
• Difficulty swallowing (lump in throat)
• Overuse of some laxatives has caused damage to the nerves, muscles,
and tissues of the intestines and bowel.
Corticosteroids
Indications
• Anti-inflammatory agent
• Immunosuppressant
• Used in active ulcerative colitis and Crohn's disease
How do they work?
• Closely resemble cortisol, a hormone produced by the adrenal glands
• Reduce the production of inflammatory chemicals
• Reduce the activity of the immune system by altering the function of
white blood cells
• Induce remission in patients with inflammatory bowel disease
• Examples include: prednisone, prednisolone, methylprednisolone,
belcometasone
Contraindications
• Acute infections uncontrolled by antimicrobial therapy
• Patients with active tuberculosis
• Caution in patients with heart failure, recent myocardial infarction,
diabetes, or hypertension
• Caution in septic shock patients
Possible Adverse Effects
• Mood swings, irritability
• Weight gain, increased appetite
• Increased risk of infection
• Puffy face, water retention
• Increased blood sugar
• Increased blood pressure
• Easy bruising
• Slower wound healing
• Osteoporosis (long term)
Possible Adverse Effects
• CUSHINGOID
• C – Cataracts
U – Ulcers
S – Striae, Skin thinning
H – Hypertension, Hirsutism
I – Immunosuppression,
Infections
N – Necrosis of femoral
heads
G – Glucose elevation
O – Osteoporosis, Obesity
I – Impaired wound healing
D – Depression/mood
changes
Sclerosants5
Indication
• Acute endoscopic hemostasis
• Elective obliteration of bleeding esophageal varices
• Can be used alone or in combo with ligation for the treatment of
bleeding esophageal or junctional varices
• Not indicated for primary prophylactic treatments of varices that have
not bled
How do they work?
• Tissue irritants that cause vascular thrombosis and endothelial
damage
• Leads to endofibrosis and vascular obliteration when injected into
adjacent blood vessels
• Most are fatty-acid derivatives (sodium morrhuate, ethanolamine
oleate) ,synthetic chemicals (sodium tetradecyl sulfate, polidocanol),
or alcohols (ethanol)
• Dispensed with a sclerotherapy needle passed through the working
channel of an endoscope
Possible adverse effects
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Chest pain
Mucosal ulceration
Bleeding
Esophageal strictures and fistulas
Pleural effusions
Sepsis/bactermia
Pneumonia
Hypoxia
* Complications may occur in as many as 25% of patients
Contraindications
• Patients with cirrhosis and patients who are immunocompromised
are at a greater risk for bacteremia
• Caution in patients with:
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Mechanical prosthetic devices
History of endocarditis
Vascular grafts
Surgical systemic-pulmonary shunts
Ascites
References
1. Laxatives. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at:
http://www.micromedexsolutions.com. Accessed August 27, 2014.
2. Cleavland Clinic. Drugs and Supplements. Available at:
http://my.clevelandclinic.org/drugs/corticosteroids/hic_corticosteroids.aspx. Accessed August 27,2014.
3. Mayo Clinic. Prednisone and other corticosteroids. Available at: http://www.mayoclinic.org/steroids/art20045692?pg=2. Accessed August 27,2014.
4. Corticosteroids.DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available
at: http://www.micromedexsolutions.com. Accessed August 27, 2014.
5. Croffie J, Somogyi L, Chuttani R, et al. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007;66:1-6.
doi:10.1016/j.gie.2007.02.014.
Antacids
Alice (Siyue) Li
2015 PharmD Candidate
Purdue College of Pharmacy
Indications
• Relieve heartburn, sour stomach, or acid indigestion
• Some contain simethicone, which may relieve the
symptoms of excess gas
How do they work?
• Neutralizing excess stomach acid
• Simethicone lower the surface tension of gas bubbles
Contraindications
• Aluminum-containing antacids
• Hypersensitivity
• Caution in HF, renal failure, edema, recent GI bleed
• Magnesium-containing antacids
• Hypersensitivity
• Extreme caution in myasthenia gravis or other neuromuscular
disease, renal impairment
• Calcium-containing antacids
• Hypersensitivity
• Caution in renal impairment, hx of kidney stones, hypoparathyroid
disease, achlorhydria
• Sodium bicarbonate-containing antacids
• Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia,
unknown abdominal pain
Possible Adverse Effects
• Aluminum-containing antacids
• Constipation, discoloration of feces (white speckles), fecal
impaction, N/V, stomach cramps
• Magnesium-containing antacids
• Diarrhea, N/V, dizziness, fatigue, electrolyte disturbances
• Calcium-containing antacids
• Constipation, bloating, gas, hypercalcemia, headache, acid rebound,
N/V anorexia, electrolyte disturbance
• Milk-alkali syndrome with very high, chronic dosing +/- renal failure
• Sodium bicarbonate-containing antacids
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Belching, flatulence, gastric distension, tetany,
Metabolic alkalosis, hypernatremia, hypocalcaemia
Milk-alkali syndrome especially with renal dysfunction
CHF exacerbation, edema, cerebral hemorrhage,
Antispasmodics
Belladonna alkaloids, Donatal (hyoscyamine, atropine,
scopolamine, phenobarbitol), Librax (clidinium,
chlordiazepoxide)
Indications
• Adjunct in treatment of irritable bowel syndrome,
acute enterocolitis, duodenal ulcer
How do they work?
• Anticholinergic agents inhibit the muscarinic
actions of acetylcholine at the postganglionic
parasympathetic neuroeffector sites, including
smooth muscle, secretory glands, and CNS
sites.
Contraindications
• Donatal
• Narrow angel glaucoma, GI/GU obstruction, myasthesia gravis,
paralytic ileus, intestinal atony; unstable cardiovascular status in
acute hemorrhage; severe ulcerative colitis (especially
complicated by toxic megacolon); hiatal hernia associated with
reflux esophagitis; acute intermittent porphyria; restlessness
and/or excitement caused by phenobarbital
• Librax
• Hypersensitivity, glaucoma, prostatic hyperplasia, benign bladder
neck obstruction
• Anticholinergic agents – avoid in geriatric patients
• Caution in patients with impaired renal/liver function,
impaired gag reflex, depression, hx of drug abuse and
respiratory disease
Possible Adverse Effects
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Antibiotics
Indications
• Intra-abdominal infection
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Bacterial cause of diarrhea
Bacterial gastroenteritis
Bowel perforation
Diverticulitis
Cholecystitis
Peptic ulcer caused by Helicobactor pylori
Clostridium difficile Colitis
How do they work?
• Eradicate or suppress bacterial growth by
interfering with production or functioning of
essential bacterial components
Common Antibiotics Used for GI
• Common initial empiric board spectrum antiobiotics used for
intra-abdominal infection
• Meropenem, ertapenem, imipenem, pip/tazo,
amp/sulbactam, Levofloxacin, ciprofloxacin, metronidazole,
ceftriaxone, cefuroxime, cefazolin, etc.
• Clostridium difficile infection
• Oral Metronidazole, Oral Vancomycin
• Peptic ulcer caused by Helicobactor pylori
• Clarithromycin plus amoxicillin/metronidazole if allergic
• De-escalate therapy to target particular bacteria
based on culture and sensitivity results to decrease
resistance
Contraindications
• Hypersensitivity
• Anaphylaxis to penicillin
• Do not try cephalosporin
• Itching, rash or hive to penicillin
• May still consider cephalosporin
Possible Adverse Effects
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Diarrhea
Nausea and vomiting
Thrush
C. diff
Antibiotic resistance
Reference
• Antispasmodics gastrointestinal, librax, donatol, sodium bicarb, calcium
bicarb, magniesium hydroxide, aluminun hydroxide. LexiDrugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available
at: http://online.lexi.com. Accessed September 4, 2014.
• Antacid, simethicone. DrugPoints Summary. Micromedex 2.0. Truven
Health Analytics, Inc. Greenwood Village, CO. Available at:
http://www.micromedexsolutions.com. Accessed September 4, 2014.
• Solomkin JS, mazuski JE, et al. Diagnosis and mangement of Complicated
Intra-abdominal Infection in Adults and Children: Guildline by the Surgical
Infection society and the Infectious Diseases Society of America. IDSA
guidelines, CID 2010:50 (15 Jan); 133-164.
Anti-Ulcers
Andy Campbell
2015 PharmD Candidate
Purdue College of Pharmacy
Ulcers
• Stress ulcer prophylaxis
• Active peptic ulcers:
• Gastric
• Esophageal
• Duodenal
Drug Subclasses
• Antacids
• Neutralize the stomach acid.
• H2- antagonists/blockers
• Block H2 receptors in parietal cells
• No effect on gastrin
• Proton pump inhibitors (PPIs)
• Irreversible inhibition of the H+, K+, ATPase
Adverse Effects
• Antacids
• Diarrhea and Constipation
• H2-antagonists
• Headache, fatigue, dizziness
• PPIs
• Headache, dizziness, Vitamin B12 deficiency
Contraindications
• Hx of hypersensitivity
• Generally safe
Antiflatulents
Gas and Bloating
• Type of diet
• Fatty foods
• Carbonated beverages
• Foods high in carbohydrates
• GI infection, blockage, or disease
• Celiac disease, lactose inolerance, or IBS
• Stress and anxiety
Drugs Commonly Used
• Simethicone
• Anti-foaming mechanism
• Beano
• Contains alpha galactosidase
• Lactaid, Dairy-Ease, etc.
• Contains lactase
Adverse Effects
• Mild diarrhea
• Nausea/Vomiting
• Regurgitation
Contraindications
• Hx of hypersensitivity
• Known or suspected intestinal perforation or obstruction
Anti-Diarrheals
Diarrhea
• Antibiotic-associated diarrhea
• Viral or bacterial infection
• Lactose intolerance
• GI disorder
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Crohn’s disease
Ulcerative colitis
Celiacs disease
Irritable bowel syndrome
Drugs used
• Loperamide
• Anticholinergics
• Lomotil
• Diphenoxylate and atropine
Adverse Reactions
• Hyperglycemia
• Abdominal pain, N/V, xerostomia
• Dizziness, somnolence
• Fatigue
Contraindications
• Loperamide
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Hx of hypersensitivity
Abdominal pain w/o diarrhea
Dysentery, not as primary therapy
Infants <24 months
Pseudomembranous colitis, not as primary therapy
• Lomotil
• Pseudomembranous colitis
• Obstructive jaundice
References
• Mayo Clinic. Bloating, belching and intestinal gas: How to avoid them. Available at:
http://www.mayoclinic.org/diseases-conditions/gas-and-gas-pains/in-depth/gas-and-gaspains/art-20044739. Accessed September 5, 2014.
• Lomotil. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood
Village, CO. Available at: http://www.micromedexsolutions.com. Accessed September 5, 2014.
IV Administration Risks
Sara Trovinger, PharmD
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Needlesticks
• Approximately 385,000 needlesticks and other sharps-related injuries
occur yearly to hospital-based healthcare personnel
• Primarily associated with transmission of:
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Hepatitis B
Hepatitis C
HIV
More than 20 other pathogens
Medication
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Spills
• Not only risk to patient and nurse, but also risk for anyone cleaning
up the spill or disposing of materials
• Many medication spills involve intravenous (IV) tubing leaking on the
floor, the patient, or on patient linens
• Most dangerous if the medication is classified as a hazardous drug
due to having one of the following traits:
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Carcinogenicity
Teratogenicity
Reproductive Toxicity
Organ Toxicity at Low Doses
Genotoxicity
Latex
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Allergies
• Affects less than 1% of Americans
• Allergy to proteins in the sap of the Brazilian rubber tree
• Can be aggregated by touching or breathing the protein
• Reactions range from localized rash to anaphylactic shock
• Can be found in many medical devices such as syringes, IV tubing, and
bandages
• Not all brands contain latex, always check packaging prior to using
Latex Allergies –
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cont.
• People with frequent contact with latex products are more likely to
develop a reaction
• Affects up to 12% of health care professionals
• Ways to reduce your risk of developing a latex allergy
• Use powder-free gloves with reduced protein content
• Use nitrile gloves
• Do not used creams or lotions while wearing gloves (may cause glove
deterioration)
• Wash hands with mild soap and dry after removing gloves
Complications of IV Therapy
• Phlebitis
• Infection
• Thrombus
• Infiltration or Extravastion
Indications for IV Medication
• Patient can not take medication via another route (PO, Rectal, Topical,
etc.)
• Medication only comes via IV route or is not absorbed via other
routes
• Fast onset is needed due to emergent procedure
IV
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Sedation
• Refer to previous slides on IV sedation
• Anterograde amnesia
• Dose-related
• Allows patient to cooperate with procedure, however have no recall of events
• Medications from home can interact with procedure medications
• Suggest using some sort of drug interaction checking software to
check for interactions if unsure
• Micromedex
• Epocrates
References
1. Sharps Safety for Healthcare Settings. Centers for Disease Control and
Prevention Website. http://www.cdc.gov/sharpssafety/ July 27, 2010.
Accessed July 23, 2014.
2. Hazardous Spills: The Safe Handling of Hazardous Drugs. Pennsylvania
Patient Safety Advisory Website.
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Sep
5(3)/Pages/96.aspx September 5, 2008. Accessed July 24, 2014.
3. Latex Allergy – Information for Health Professionals. New York State
Department of Health Website.
http://www.health.ny.gov/publications/1453/ July, 2014. Accessed July
29, 2014.
4. Trevor, Anthony and Walter Way. Basic and Clinical Pharmacology.
McGraw-Hill Companies Inc. 2012. Web.