PART 2: PARASYMPATHETIC DIVISION Flashcards by Shaquan Moore

Parasympathetic/Cholinergic Drugs

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

Bethanechol

Pyridostigmine

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Anti-Cholinergic Drugs

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine- – SOFT Bladder
Pyridostigmine

Atropine

Oxybutynin, Solifenacin, Tolterodine- – SOFT Bladder

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Parasympathetic/Cholinergic Drugs- Direct Acting:

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

Bethanechol

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Parasympathetic/Cholinergic Drugs- Indirect Acting:

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

Pyridostigmine

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“Rest and Digest” system

Para or Sympathic

Para

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keeping energy use low in the body

Para or Sympathic

Para

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D activities – digestion, defecation, and
diuresis

Para or Sympathic

Para

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Blood pressure, heart rate, and respiratory rates are low

Para or Sympathic

Para

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Gastrointestinal tract activity is high

Para or Sympathic

Para

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The skin is warm and the pupils are constricted (miosis)

Para or Sympathic

Para

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Produce effects that mimic Acetylcholine (ACh)

Direct Acting Agents or Indirect Acting Agents

Direct Acting Agents

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Are typically agonists at Muscarinic receptors

Direct Acting Agents or Indirect Acting Agents

Direct Acting Agents

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inhibit acetylcholinesterase, an enzyme that breaks
down acetylcholine

Direct Acting Agents or Indirect Acting Agents

Indirect Acting Agents

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– Nicotinic
– Muscarinic

Parasympathetic Division Receptors
Sympathetic Division Receptors

Parasympathetic Division Receptors

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Drugs for anesthesia/paralyzing agents

Nicotinic
Muscarinic

Muscarinic

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• Important for ED, ICU, OR, Anesthesia

Nicotinic
Muscarinic

Muscarinic

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• We will treat as a separate group

Nicotinic
Muscarinic

Muscarinic

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USED TO TREAT
Urinary retention

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

Bethanechol

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Most ? drugs target:
– GI Tract
– Eyes
– Bladder
– Heart (smaller percentage)

cholinergic or adrenaline drugs

cholinergic

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MECHANISM OF ACTION:
• Directly stimulate the parasympathetic division (muscarinic)
receptors) mainly located in the BLADDER

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

Bethanechol

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Match 
LOCK: ?
AGONISTS-?
KEY: ?
DRUG: ?

BethaneCHOL
Stimulate a response
Muscarinic Receptor
Natural-AcetylCHOLINE

LOCK: Muscarinic Receptor
AGONISTS-stimulate a response
KEY: Natural-AcetylCHOLINE
DRUG: BethaneCHOL

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Do BOTH DRUG AND KEY WILL BIND TO SAME RECEPTOR (MUSCARINIC) focused on the BLADDER

T or F

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ADVERSE EFFECTS
Increased salivation, gastric acid secretion, abdominal
cramps and diarrhea
– Exacerbation of asthma

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

BethaneCHOL

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ADVERSE EFFECTS
EXTREMELY RARE: hypotension and/or bradycardia

Atropine
Bethanechol
Oxybutynin, Solifenacin, Tolterodine
Pyridostigmine

BethaneCHOL

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Increased BP/HR Sympathetic or PARAsympathetic

Sympathetic

Decreased BP or HR Sympathetic or PARAsympathetic

PARAsympathetic

``` SLUDGE and the Killer B's • Salivation/Secretions • Lacrimation (tear production) • Urination • Defecation/Diarrhea • GI cramping (abdominal) • Emesis (vomiting) • Bradycardia, Bronchospasm, Bronchorrhea ``` cholinergic or adrenaline drugs

cholinergic Drugs

``` DUMBELS • Diarrhea • Urination • Miosis (pupil constriction) • Bradycardia/Bronchospasm/Bronchorrhea • Emesis • Lacrimation • Salivation ``` cholinergic or adrenaline drugs

cholinergic Drugs

``` S L U D G E B*3- ``` * Diarrhea * Salivation/Secretions * Lacrimation (tear production) * Urination * Miosis (pupil constriction) * Defecation/Diarrhea * GI cramping (abdominal) * Emesis (vomiting) * Bradycardia, Bronchospasm, Bronchorrhea

``` D U M B E L S ``` * Diarrhea * Salivation/Secretions * Lacrimation (tear production) * Urination * Miosis (pupil constriction) * Defecation/Diarrhea * GI cramping (abdominal) * Emesis (vomiting) * Bradycardia, Bronchospasm, Bronchorrhea

``` DUMBELS • Diarrhea • Urination • Miosis (pupil constriction) • Bradycardia/Bronchospasm/Bronchorrhea • Emesis • Lacrimation • Salivation ```

Antidote= Atropine Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

BethaneCHOL | Pyridostigmine

SLUDGE and the Killer B’s or DUMBELS =>CHOLINERGIC CRISIS Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

BethaneCHOL | Pyridostigmine

Exacerbation of asthma Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

BethaneCHOL | Pyridostigmine

EXTREMELY RARE: hypotension and/or bradycardia Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

BethaneCHOL | Pyridostigmine

GI concern- give 1 hour before or 2 hours after a meal Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

BethaneCHOL | Pyridostigmine

USED TO TREAT • Myasthenia Gravis Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

USED TO TREAT Reverse effects of Neuromuscular Blocking Agents Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

USED TO TREAT • Pre-treatment for exposure to nerve gas (military) Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

Can be used for Alzheimer's Disease Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

• Reverse Anticholinergic Effects Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

Directly stimulate the parasympathetic division (muscarinic receptors) mainly located in the BLADDER Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Bethanechol

Inhibits acetylcholinesterase, thereby increasing acetylcholine's activity in the parasympathetic system Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

ADVERSE EFFECTS – SLUDGE – Vital Signs (drop in BP and/or HR) – Cholinergic Crisis! Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

ADVERSE EFFECTS – Cholinergic Crisis! ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Pyridostigmine | Organophosphates/Carbamates

Reversal of NMB- Improve breathing status/respiratory function Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine

Pyridostigmine

Alzheimer's Disease- maintain cognition ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Pyridostigmine

Myasthenia Gravis-recovery of muscle strength ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Pyridostigmine

• Watch out for Cholinergic Crisis- concern is respiratory blockade ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Pyridostigmine | Organophosphates/Carbamates

POISONINGS ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Organophosphates/Carbamates

Insecticides (malathion) ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Organophosphates/Carbamates

Nerve Gas- V agents (VX), Sarin ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Organophosphates/Carbamates

MOA: acetylcholinesterase inhibitors, potentially irreversible ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Organophosphates/Carbamates

Can cause: Cholinergic Crisis ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Pyridostigmine | Organophosphates/Carbamates

USED TO TREAT – Symptomatic Bradycardia ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

• USED TO TREAT Poisoning by Cholinergic Drugs, Insecticides, Nerve Gas • Known as “Cholinergic Crisis” ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

• USED TO TREAT Reduce Salivation and secretions (mucus) ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

Used in the OR (to reduce secretions) ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

Palliative Care, “Death Rattle” ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

Hospitals Stockpile This Drug! Why? 1) ACLS 2) Antidote ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

• (this medication increases the HR!) – BLOCKS PARASYMPATHETIC (BLOCKS REST AND DIGEST) – ALLOWS SYMPATHETIC TO TAKE CONTROL OF THE HEART (^^HR) – HEART- BATTLE SYMPATHETIC VS PARASYMPATHETIC ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

Antagonists at various muscarinic receptors in the parasympathetic division of the body ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

– Particularly the Heart! This allows the sympathetic division to take control ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

• (Yin and Yang) Opposition ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

``` ADVERSE EFFECTS: Can’t See Can’t Pee Can't Spit Can’t **** ``` ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

``` Atropine ADVERSE EFFECTS: Can’t ? Can’t ? Can't ? Can’t ? ```

Can’t See Can’t Pee Can't Spit Can’t ****

*Contra-indicated in Glaucoma ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

*Contra-indicated Benign Prostatic Hyperplasia ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine - SOFT

*Avoid in urinary retention/hesitancy! ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

• Blurred vision, dry eyes, increased IOP (CI in glaucoma!) – Mydriasis- allow more light in at night » Protect the eyes with sunglasses ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Can’t See (mydriasis)

* Report a distended bladder! * Do not give in patients with enlarged prostate (BPH ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Can’t Pee (Urinary retention/hesitation)

– Sugar Free Gum/Candy (avoid sugar, if possible, to reduce risk of cavities) – Avoid Alcohol based mouthwash (use artificial saliva) ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Can’t Spit (Xerostomia)

Increase Fiber, Fluid intake! Exercise! ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Can’t **** (constipation)

Can’t sweat • Risk for Hyperthermia • Be careful outdoors ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Confusion! (Benadryl like state!)

– Avoid Alcohol based mouthwash (use artificial saliva) ``` – Can’t See (mydriasis) – Can’t Spit (Xerostomia) – Can’t **** (constipation) – Confusion! (Benadryl like state!) – Can’t Pee (Urinary retention/hesitation) ```

– Can’t Spit (Xerostomia)

*Contraindicated in Glaucoma and BPH, urinary retention ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

Too much anticholinergic activity (drying someone out), Lifespan consideration (Geriatrics)) ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

Can’t Sweat, don’t forget to expand upon the Toxidrome! ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine

Can’t See, Can’t Pee, Can’t Spit, Can’t **** ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Atropine | Oxybutynin, Solifenacin, Tolterodine

``` USED TO TREAT Overactive Bladder (OAB) ``` ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Oxybutynin, Solifenacin, Tolterodine

USED TO TREAT Urinary Incontinence ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Oxybutynin, Solifenacin, Tolterodine

– SOFT Bladder= ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Oxybutynin, Solifenacin, Tolterodine

NURSING CONSIDERATIONS: Overactive Bladder (OAB)- patients should have decrease in urinary urgency/frequency, nocturia ``` Atropine Bethanechol Oxybutynin, Solifenacin, Tolterodine Pyridostigmine Organophosphates/Carbamates ```

Oxybutynin, Solifenacin, Tolterodine