1. Adrenergic agemts

2. Learning Objectives Understand the central and peripheral nervous systems, their functions, and their relationship to drugs. Become aware of the role of neurotransmitters. Learn how adrenergic drugs affect body systems and where they work in the body.

3. Learning Objectives Define the action of neuromuscular blocking agents in reducing muscle activity. Distinguish between narcotic and nonnarcotic analgesia. Become familiar with the various types of agents for migraine headaches.

4. Divisions of the Nervous System Central Nervous System –Brain –Spinal cord Peripheral Nervous System –Nerves –Sense organs

5. Divisions of the Nervous System Central Nervous System Peripheral Nervous System

6. Divisions of the Nervous System Central Nervous System Peripheral Nervous System –Somatic Nervous System –Autonomic Nervous System

7. Divisions of the Nervous System Central Nervous System Peripheral Nervous System –Somatic Nervous System Voluntary action: skeletal muscle contraction and movement –Autonomic Nervous System Involuntary activities: respiration, circulation, digestion, sweating

8. Autonomic Nervous System

9. Review The nervous system has two components. What are they?

10. Review The nervous system has two components. What are they? Answer –Central nervous system (CNS) –Peripheral nervous system (PNS)

11. Major Neurotransmitters Acetylcholine GABA Dopamine Epinephrine Serotonin

12. Major Neurotransmitters Acetylcholine (ACh) –Smooth muscle, cardiac muscle, and exocrine glands –Anticholinergics block ACh receptors GABA Dopamine Epinephrine Serotonin

13. Major Neurotransmitters Acetylcholine GABA (gamma-aminobutyric acid) Regulates message delivery system of the brain Dopamine Epinephrine Serotonin

14. Major Neurotransmitters Acetylcholine GABA Dopamine Acts on the CNS and kidneys Epinephrine Serotonin

15. Major Neurotransmitters Acetylcholine GABA Dopamine Epinephrine –Acts on cardiac and bronchodilator receptors –Known as Adrenaline Serotonin

16. Major Neurotransmitters Acetylcholine GABA Dopamine Epinephrine Serotonin –Acts on smooth muscle and gastric mucosa (causes vasoconstriction) –Emotional responses: depression, anxiety

17. Communication by Neurotransmitters Neurotransmitters are released from one axon and received by another neuron’s dendrites.

18. Discussion What are three important types of receptors in the study of drugs?

19. Discussion What are three important types of adrenergic receptors in the study of drugs? Answer –Alpha –Beta-1 –Beta-2

21. Types of Receptors Alpha Vasoconstriction, raise BP Beta-1 Heart stimulation Beta-2 Vasodilation and bronchodilation

22. Drugs Affecting The Autonomic Nervous System Adrenergic Agents and Adrenergic-Blocking Agents

23. The Sympathetic Nervous System in Relationship to the Entire Nervous System

24. Adrenergic Agents Drugs that stimulate the sympathetic nervous system (SNS)

25. Adrenergic Agents Also known as adrenergic agonists or sympathomimetics

26. Adrenergic Agents Mimic the effects of the SNS neurotransmitters: norepinephrine (NE) and epinephrine (EPI)

27. Adrenergic Receptors Located throughout the body Are receptors for the sympathetic neurotransmitters Alpha-adrenergic receptors: respond to NE Beta-adrenergic receptors: respond to EPI

28. Alpha-Adrenergic Receptors Divided into alpha1 and alpha 2 receptors Differentiated by their location on nerves

29. Alpha 1 -Adrenergic Receptors Located on postsynaptic effector cells (the cell, muscle, or organ that the nerve stimulates)

30. Alpha 2 -Adrenergic Receptors Located on presynaptic nerve terminals (the nerve that stimulates the effector cells) Control the release of neurotransmitters

31. The predominant alpha- adrenergic agonist responses are: Vasoconstriction and CNS stimulation

32. Beta-Adrenergic Receptors All are located on postsynaptic effector cells Beta 1 -adrenergic receptors—located primarily in the heart Beta 2 -adrenergic receptors—located in smooth muscle of the bronchioles, arterioles, and visceral organs

33. The beta-adrenergic agonist response results in: Bronchial, GI, and uterine smooth muscle relaxation Glycogenolysis Cardiac stimulation

34. Dopaminergic Receptors An additional adrenergic receptor Stimulated by dopamine Causes dilation of the following blood vessels, resulting in INCREASED blood flow –Renal –Mesenteric –Coronary –Cerebral

35. Adrenergic Receptor Responses to Stimulation LOCATIONRECEPTORRESPONSE Cardiovascular Blood vesselsalpha 1 and beta 2 Constriction / dilation Cardiac musclebeta 1 Increased contractility AV Nodebeta 1 Increased heart rate SA Nodebeta 1 Increased heart rate

36. Adrenergic Receptor Responses to Stimulation LOCATIONRECEPTORRESPONSE Gastrointestinal Musclebeta 2 Decreased motility Sphinctersalpha 1 Constriction

37. Adrenergic Receptor Responses to Stimulation LOCATIONRECEPTORRESPONSE Genitourinary Bladderalpha 1 Constriction sphincter Penisalpha 1 Ejaculation Uterusalpha 1 and beta 2 Contraction/ relaxation

38. Adrenergic Receptor Responses to Stimulation LOCATIONRECEPTORRESPONSE Respiratory Bronchialbeta 2 Dilation/relaxation muscles

39. Catecholamines Substances that can produce a sympathomimetic response Endogenous: epinephrine, norepinephrine,dopamine Synthetic: isoproterenol, dobutamine, phenylephrine

40. Adrenergic Agents Mechanism of Action Direct-acting sympathomimetic: Binds directly to the receptor and causes a physiologic response

41. Direct-Acting Sympathomimetics

42. Adrenergic Agents Mechanism of Action Indirect-acting sympathomimetic: Causes the release of catecholamine from the storage sites (vesicles) in the nerve endings The catecholamine then binds to the receptors and causes a physiologic response

43. Indirect-Acting Sympathomimetics

44. Adrenergic Agents Mechanism of Action Mixed-acting sympathomimetic: Directly stimulates the receptor by binding to it AND Indirectly stimulates the receptor by causing the release of stored neurotransmitters from the vesicles in the nerve endings

45. Mixed-Acting Sympathomimetics

46. Drug Effects of Adrenergic Agents Stimulation of alpha-adrenergic receptors on smooth muscles results in: Vasoconstriction of blood vessels Relaxation of GI smooth muscles Contraction of the uterus and bladder Male ejaculation Decreased insulin release Contraction of the ciliary muscles of the eye (dilated pupils)

47. Drug Effects of Adrenergic Agents Stimulation of beta 2 -adrenergic receptors on the airways results in: Bronchodilation (relaxation of the bronchi) Uterine relaxation Glycogenolysis in the liver

48. Drug Effects of Adrenergic Agents Stimulation of beta1-adrenergic receptors on the myocardium, AV node, and SA node results in CARDIAC STIMULATION: Increased force of contraction (positive inotropic effect) Increased heart rate (positive chronotropic effect) Increased conduction through the AV node (positive dromotropic effect)

49. Adrenergic Agents: Therapeutic Uses Anorexiants: adjuncts to diet in the short-term management of obesity Examples: benzphetamine phentermine dextroamphetamine Dexedrine

50. Adrenergic Agents: Therapeutic Uses Bronchodilators: treatment of asthma and bronchitis Agents that stimulate beta 2 -adrenergic receptors of bronchial smooth muscles causing relaxation Examples: albuterolephedrineepinephrine isoetharine isoproterenollevalbuterol metaproterenolsalmeterolterbutaline These agents may also affect uterine and vascular smooth muscles.

51. Adrenergic Agents: Therapeutic Uses Reduction of intraocular pressure and mydriasis (pupil dilation): treatment of open-angle glaucoma Examples: epinephrine and dipivefrin

52. Adrenergic Agents: Therapeutic Uses Nasal decongestant: Intranasal (topical) application causes constriction of dilated arterioles and reduction of nasal blood flow, thus decreasing congestion. Examples: epinephrineephedrinenaphazoline phenylephrine tetrahydrozoline

53. Adrenergic Agents: Therapeutic Uses Ophthalmic Topical application to the eye surface affects the vasculature of the eye, stimulating alpha receptors on small arterioles, thus relieving conjunctival congestion. Examples:epinephrinenaphazoline phenylephrinetetrahydrozoline

54. Adrenergic Agents: Therapeutic Uses Vasoactive sympathomimetics (pressors, inotropes), also called cardioselective sympathomimetics Used to support the heart during cardiac failure or shock. Examples: dobutaminedopamineephedrine epinephrinefenoldopamisoproterenol methoxaminenorepinephrine phenylephrine

55. Adrenergic Agents: Side Effects Alpha-Adrenergic Effects CNS: –headache, restlessness, excitement, insomnia, euphoria Cardiovascular: –palpitations (dysrhythmias), tachycardia, vasoconstriction, hypertension Other: –anorexia, dry mouth, nausea, vomiting, taste changes (rare)

56. Adrenergic Agents: Side Effects Beta-Adrenergic Effects CNS: –mild tremors, headache, nervousness, dizziness Cardiovascular: –increased heart rate, palpitations (dysrhythmias), fluctuations in BP Other: –sweating, nausea, vomiting, muscle cramps

57. Adrenergic Agents: Interactions Anesthetic agents Tricyclic antidepressants MAOIs Antihistamines Thyroid preparations Antihypertensives Will directly antagonize another adrenergic agent, resulting in reduced effects

58. Adrenergic Agents: Nursing Implications Assess for allergies and history of hypertension, cardiac dysrhythmias, or other cardiovascular disease. Assess renal, hepatic, and cardiac function before treatment. Perform baseline assessment of vital signs, peripheral pulses, skin color, temperature, and capillary refill. Include postural blood pressure and pulse. Follow administration guidelines carefully.

59. Adrenergic Agents: Nursing Implications IV administration: Check IV site often for infiltration Use clear IV solutions Use an infusion device/IV pump Infuse agent slowly to avoid dangerous cardiovascular effects Monitor cardiac rhythm

60. Adrenergic Agents: Nursing Implications With chronic lung disease: Instruct patients to avoid factors that exacerbate their condition. Encourage fluid intake (up to 3000 mL per day) if permitted. Educate about proper dosing and equipment care. Salmeterol is indicated for PREVENTION of bronchospasms, not management of acute symptoms.

61. Adrenergic Agents: Nursing Implications Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations. Avoid OTC or other medications because of possible interactions. Administering two adrenergic agents together may precipitate severe cardiovascular effects such as tachycardia or hypertension. Inform patients taking inhaled isoproterenol that their sputum or saliva may turn pink.

62. Adrenergic Agents: Nursing Implications Monitor for therapeutic effects (cardiovascular uses): Decreased edema Increased urinary output Return to normal vital signs Improved skin color and temperature Increased LOC

63. Adrenergic Agents: Nursing Implications Monitor for therapeutic effects (asthma): Return to normal respiratory rate Improved breath sounds, fewer rales Increased air exchange Decreased cough Less dyspnea Improved blood gases Increased activity tolerance

64. Adrenergic-Blocking Agents Bind to adrenergic receptors, but inhibit or block stimulation of the sympathetic nervous system (SNS)

65. Adrenergic Blocking Agents Have the opposite effect of adrenergic agents Also known as –adrenergic antagonists or sympatholytics

66. Adrenergic Blocking Agents Sympatholytics inhibit—or LYSE— sympathetic neurotransmitters (norepinephrine and epinephrine)

67. Adrenergic Blocking Agents Classified by the type of adrenergic receptor they block Alpha 1 and alpha 2 receptors Beta 1 and beta 2 receptors

68. Alpha-Blocker Mechanisms

69. Adrenergic-Blocking Agents: Drug Effects and Therapeutic Uses Ergot Alkaloids (Alpha-Blockers) Constrict dilated arteries going to the brain (carotid arteries) Used to treat vascular headaches (migraines) Stimulate uterine contractions by inducing vasoconstriction Used to control postpartum bleeding

70. Adrenergic-Blocking Agents: Drug Effects and Therapeutic Uses Alpha-Blockers Cause both arterial and venous dilation, reducing peripheral vascular resistance and BP Used to treat hypertension Effect on receptors on prostate gland and bladder decreased resistance to urinary outflow, thus reducing urinary obstruction and relieving effects of BPH

71. Adrenergic-Blocking Agents: Drug Effects and Therapeutic Uses Alpha-Blockers Phentolamine –Quickly reverses the potent vasoconstrictive effects of extravasated vasopressors such as norepinephrine or epinephrine. –Restores blood flow and prevents tissue necrosis.

72. Adrenergic-Blocking Agents: Side Effects Alpha Blockers Body SystemSide/Adverse Effects CardiovascularPalpitations, orthostatic hypotension, tachycardia, edema, dysrhythmias, chest pain CNSDizziness, headache, drowsiness, anxiety, depression, vertigo, weakness, numbness, fatigue

73. Adrenergic-Blocking Agents: Side Effects Alpha Blockers Body SystemSide/Adverse Effects GastrointestinalNausea, vomiting, diarrhea, constipation, abdominal pain OtherIncontinence, nose bleeding, tinnitus, dry mouth, pharyngitis, rhinitis

74. Beta Blockers Block stimulation of beta receptors in the SNS Compete with norepinephrine and epinephrine Selective and nonselective beta blockers

75. Beta Receptors Beta 1 Receptors Located primarily on the heart Beta blockers selective for these receptors are called cardioselective beta blockers

76. Beta Receptors Beta 2 Receptors Located primarily on smooth muscles of bronchioles and blood vessels

77. Nonspecific Beta Blockers Beta blockers that block both beta 1 and beta 2 receptors

78. Beta Blockers: Mechanism of Action Cardioselective (Beta1) Decreases heart rate Prolongs SA node recovery Slows conduction rate through the AV node Decreases myocardial contractility, thus decreasing myocardial oxygen demand

79. Beta Blockers: Mechanism of Action Nonspecific (Beta 1 and Beta 2 ) Effects on heart:Same as cardioselective Bronchioles:Constriction, resulting in narrowing of airways and shortness of breath Blood vessels:Vasoconstriction

80. Beta Blockers: Therapeutic Uses Anti-angina:decreases demand for myocardial oxygen Cardioprotective:inhibits stimulation by circulating catecholamines Class II antidysrhythmic

81. Beta Blockers: Therapeutic Uses Antihypertensive Treatment of migraine headaches Glaucoma (topical use)

82. Beta Blockers: Side Effects Body SystemSide/Adverse Effects BloodAgranulocytosis, thrombocytopenia CardiovascularAV block, bradycardia, congestive heart failure, peripheral vascular insufficiency CNSDizziness, mental depression, lethargy, hallucinations

83. Adrenergic-Blocking Agents: Side Effects Beta Blockers Body SystemSide/Adverse Effects GastrointestinalNausea, dry mouth, vomiting, diarrhea, cramps, ischemic colitis OtherImpotence, rash, alopecia, bronchospasms

84. Adrenergic Blocking Agents: Nursing Implications Assess for allergies and history of COPD, hypotension, cardiac dysrhythmias, bradycardia, CHF, or other cardiovascular problems Any preexisting condition that might be exacerbated by the use of these agents might be a CONTRAINDICATION to their use.

85. Adrenergic Blocking Agents: Nursing Implications Remember that alpha blockers may precipitate hypotension. Remember that beta blockers may precipitate bradycardia, hypotension, heart block, CHF, and bronchoconstriction.

86. Adrenergic Blocking Agents: Nursing Implications Avoid OTC medications because of possible interactions. Possible drug interactions may occur with: –Antacids (aluminum hydroxide type) –Antimuscarinics/anticholinergics –Diuretics and cardiovascular drugs –Neuromuscular blocking agents –Oral hypoglycemic agents

87. Adrenergic Blocking Agents: Nursing Implications Encourage patients to take medications as prescribed. These medications should never be stopped abruptly. Report constipation or the development of any urinary hesitancy or bladder distention.

88. Adrenergic Blocking Agents: Nursing Implications Teach patients to change positions slowly to prevent or minimize postural hypotension. Avoid caffeine (excessive irritability). Avoid alcohol ingestion and hazardous activities until blood levels become stable. Patients should notify their physician if palpitations, dyspnea, nausea, or vomiting occur.

89. Beta Blocking Agents: Nursing Implications Rebound hypertension or chest pain may occur if this medication is discontinued abruptly. Patients should notify their physician if they become ill and unable to take medication. Inform patients that they may notice a decrease in their tolerance for exercise; dizziness and fainting may occur with increased activity. Notify the physician if these problems occur.

90. Beta Blocking Agents: Nursing Implications Patients should report the following to their physician: Weight gain of more than 2 pounds (1 kg) within a week Edema of the feet or ankles Shortness of breath Excessive fatigue or weakness Syncope or dizziness

91. Adrenergic Blocking Agents: Nursing Implications Monitor for side effects, including: HypotensionFatigue Tachycardia (alpha blockers)Lethargy BradycardiaDepression Heart blockInsomnia CHFVivid nightmares Increased airway resistance

92. Adrenergic Blocking Agents: Nursing Implications Monitor for therapeutic effects Decreased chest pain in patients with angina Return to normal BP and P Other specific effects, depending on the use