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Renal 2 > Pharm - Colinergic Agonists and Antagonists > Flashcards

Pharm - Colinergic Agonists and Antagonists Flashcards

1
Q

What are the 4 cholinergic agonists classified as choline esters?

A

Acetylcholine, carbachol, bethanechol, and methacholine

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2
Q

Describe the absorption, distribution, and metabolism of the choline esters.

A

All contain quaternary ammonium groups preventing absorption and distribution into the CNS. Hydrolyzation will occur in the GI tract leading to lower activity for oral administrations. All are metabolized at different rates by cholinesterase (acetylcholine > methacholine > carbachol > bethanechol)

Note: Methacholine and bethanechol do not have action at nicotinic receptors

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3
Q

What are the 3 cholinergic agonists classified as alkaloids?

A

Muscarine, nicotine, and pilocarpine

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4
Q

Describe the absorption, distribution, and metabolism of the cholinergic alkaloids.

A

All the alkaloids are uncharged tertiary amines, with the exception of muscarine (quaternary). All are readily available through most sites of administration (especially nicotine through skin).

Although it is quaternary, muscarine found in mushroom can be highly toxic when ingested because it is still able to enter the CNS.

All are readily excreted by the kidneys facilitated by acidifcation of the urine.

Note: Muscarine and Pilocarpine bind to mAChRs

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5
Q

What is the location and mechanism of action for the M1 receptor?

A

Nerves and IP3, DAG cascade

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6
Q

What is the location and mechanism of action for the M2 receptor?

A

Nerves, Cardiac, and smooth muscle

Inhibition of cAMP production and activation of K+ channels

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7
Q

What is the location and mechanism of action for the M3 receptor?

A

Glands, smooth muscle, and endothelium

IP3, DAG cascade

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8
Q

What is the location and mechanism of action for the M4 receptor?

A

CNS

Inhibition of cAMP production

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9
Q

What is the location and mechanism of action for the M5 receptor?

A

CNS

IP3, DAG production

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10
Q

What is the location and mechanism of action for the Nm receptor?

A

Skeletal muscle at the neuromuscular junction

Na+ and K+ depolarizing channels

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11
Q

What is the location and mechanism of action for the Nn receptor?

A

Postganglionic cell bodies, CNS, and dendrites

Na+ and K+ depolarizing channels

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12
Q

Describe the effects of direct-acting cholinergics on skeletal muscle.

A

These drugs must have affinity for nAChRs - carbachol, acetylcholine, and nicotine (which is preferential to nerves)

Contraction of skeletal muscle will be stimulated until a depolarizing blockade is reached and flaccid paralysis is assumed

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13
Q

Describe the effects of direct-acting cholinergics on the eye.

A

Causes constriction of the iris –> increased aqueous humor outflow from the anterior chamber

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14
Q

Describe the cardiovascular effects mediated by cholinergic agonists via M2 receptor

A

The M2 receptor is primarily responsible for controlling the speed of AV node conduction

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15
Q

Describe the cardiovascular effects mediated by cholinergic agonists via M3 receptor

A

Stimulation of the M3 receptor will result in systemic vasodilation by causing the production of cGMP.

cGMP –> EDRF –> NO –> smooth muscle relaxation

Note: At low doses decreased TPR is accompanied by homeostatic reflexive tachhycardia. At high doses TPR is accompanied by bradycardia

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16
Q

Describe the effects of direct-acting cholinergics on the GI/GU tracts

A

Increased glandular secretion tends to occur in the salivary and gastric glands.

M3 receptors cause direct contraction of smooth muscle, while M2 receptors cause reduction in cAMP formation, reducing relaxation

NO stimualtes sphincter relaxation

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17
Q

Describe the effects of direct-acting cholinergics on the brain

A

The brain is rich in mAChRs

Stimulatory mAChRs will result in increased cognitive function and inhibitory mAChRs result in tremors, hypothermia, and analgesia.

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18
Q

Describe the effects of direct-acting cholinergics on the spinal cord.

A

The spinal cord is rich in nAChRs

Effects of nicotine here are dose dependent. Moderate doses - alerting brain aciton. High doses - emesis, tremors, and activation of the respiratory center. Lethal doses - convulsions and fatal coma

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19
Q

Describe the effects of direct-acting cholinergics on the PNS

A

At autonomic ganglia nicotine seems to trigger both sympathetic and parasympathetic discharge.

In the CV system the response is hypertension with alternating tachycardia and bradycardia.

In the GI/GU system the response is parasympathomimetic,

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20
Q

What are three clinical uses of direct-acting cholinergic agonists?

A

Glaucoma, GI/GU disorders, and Accomodative esotropia

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21
Q

Describe how glaucaoma can be treated with direct-acting cholinergic agonists

A

Cholinergic agonists cause contraction of the ciliary body, increasing outflow of aqueous humor through canal of schlemm

Note: this drug has been replaced by topical beta-blockers and prostaglandin derivatives

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22
Q

Describe accomodative esotropia

A

Children born with farsightedness overcorrect and develop misalignment of eyes

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23
Q

Describe how direct-acting cholinergic agonists can treat GI/GU disorders
(3 Drugs)

A

Bethanechol can be used to treat paralysis in these two systems: congenital megacolon, post-operative ileus, esophageal refulx, and urinary retention

Note: obstruction should be ruled out

Pilocarpine and cevimeline increase salivary secretions and treat xerostomia

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24
Q

Describe the effects of muscarinic toxicity and how it is treated

A

SLUDGE symptoms or DUMBELS

Treat with atropine, muscarinic antagonist

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25
Q

What are the contraindications for administering muscarininc agonists?

A

Asthma, coronary insufficiency, acid-peptic disease, and hyperthyroidism

26
Q

Describe the presentation of acute nicotine toxicity

A

Initially the patient will present with convulsions and muscle contractions. Convulsions will progress towards coma.

Muscle contractions progress towards depolarizing blockade and flaccid paralysis.

27
Q

How do you treat acute nicotine poisoning?

A

Administer atropine and a parenteral anticonvulsant

Note: Neuromuscular blockade does not respond to pharmacological treatment

28
Q

What is the clinical use of acetylcholine?

A

Normally prescribed to produce miosis for procedures.

Note: Not typically given systemically

29
Q

What are the clinical uses of bethanechol?

A

Used to treat esophageal reflux and urinary retention

Note: purely a muscarinic agonist with little cardiovascular effects

30
Q

What is the clinical use of cevimeline?

A

treatment of xerostomia in sjogren syndrome

31
Q

What is the clinical use of pilocarpine?

A

A pure mAChR agonist for treatment of xerostomia in sjogren syndrome or cancer of head and neck or production of miosis

32
Q

What is the clinical use, MOA, and adverse side effects of varenicline?

A

Clinical use - smoking cessation

MOA - partial agonist for nicotinic receptors in the brain

Adverse side effects - Nausea is most common but changes in behavior consisting of depression, aggression, and suicidal thinking have been noted

33
Q

What are the subgroups of indirect-acting cholinergic agonists

A

Alcohols, carbamic acid esters, and organophosphates

34
Q

Describe the pharmacokinetics of Quaternary AChE inhibitors and give examples (3).

A

These are charged compounds and will not pass into the CNS. Best administered parenterally. Duration of effect is proportional to the stability of the enzyme-inhibitor complex

Ex: neostigmine, pyridostigmine, and echothiophate

35
Q

Describe the pharmacokinets of tertiary AChE inhibitors and give examples (4)

A

Well absorbed and distributed to the CNS.

Ex: physostigmine, donepezil, tacrine, and rivastigmine

36
Q

Describe the pharmacokinetics of organophosphates

A

These are well absorbed through all sites and distribute everywhere

37
Q

Describe the duration of action of carbamic acid ester drugs

A

The drugs will bind to AChE and inhibit action. They undergo a two-step hydrolysis similar to that of acetylcholine. The second step of the hydrolysis forms a covalent bond between substrate and enzyme which last 30 minutes to 6 hours

38
Q

Describe the effects of AChE inhibitors on CNS, eye, and Cardiovascular systems

A

CNS - low doses cause diffuse activation on EEG; high doses cause convulsions

Eye - miosis leading to increased aqueous humor outflow

CV system - Stimulates sympathetic and parasympathetic outflow, but parasympathetic predominates.

39
Q

Describe the effects of AChE inhibitors at the NMJ

A

Causes strengthening of contraction at therapeutic doses, but at higher doses progression towards flaccid paralysis

40
Q

What are four therapeutic uses of AChE Inhibitors?

A

Dementia, visceral paralysis (paralytic ileus, etc.), glaucoma, and antidote to anticholinergic compounds (antihistamines, tricyclic antidepressants, and sleep aids)

41
Q

Describe the 4 identified clinical uses of AChE Inhibitors

A

Dementia - tertiary ions will cross the BBB and increase action of remaining intact cholinergic neurons

Anticholinergic Compounds - Increase the concentration of ACh near receptors

Glaucoma - increase ACh to cause contraction of ciliary body

Reversal of visceral paralysis - post-operative ileus, congenital megacolon, and urinary retention all treated with quaternary ions

42
Q

How do AChE inhibitors interact with non-depolarizing neuromuscular blocking agents? What is the one exception to this?

A

AChE inhibitors will diminished the duration of effect that these compounds have at the NMJ.

Mivacurium is metabolised by plasma AChE, so it’s effect will be prolonged

43
Q

How will AChE interact with succinycholine

A

Prolong phase I of depolarizing neuromuscular block, but antagonize phase 2

44
Q

How will AChE inhibitors interact with systemic corticosteroids?

A

Muscle weakness in myasthenia gravis patients will be increased

45
Q

Describe the presentation of acute AChE inhibitor toxicity and how it can be treated

A

The initial presentation of toxicity includes all muscarinic (SLUDGE) symptoms, which vary based on route of administration. Oral = GI symptoms. Percutaneous = local sweating and muscular fasciculations.

CNS symptoms (convulsions and coma) will rapidly follow. Ultimately death is a result of respiratory failure.

Treatment should entail administration of atropine (muscarinic antagonist), pralidoxime (AChE regenerator at NMJ), and benzodiazepam (anticonvulsant)

Note: pralidoxime is only effetive against organophosphates

46
Q

What is the half-life and distribution of atropine?

A

The half-life of atropine is 2 hours. Effects from this drug decrease rapidly except for in the eye.
Atropine is a tertiary amine and able to enter the eye and CNS. It does not distinguish between the subtypes of mAChRs

47
Q

Describe the CNS effects of atropine

A

Atropine will cause a mild sedative effect. Note: Beneficial in the treatment of tremors related to Parkinsons

48
Q

Describe the effects of scopolamine on the CNS

A

Scopolamine has a greater effect on the CNS than atropine including amnesia and drowsiness. Effective in the prevention of motion sickness

49
Q

Describe how muscarinic antagonists effect the eye

A

Ciliary contraction will be prevented causing unopposed sympathetic dilator activity and loss of accomodation. Decrease in lactimal secretions.

Note: Useful in ophthalmologic procedures

50
Q

Describe the effects of muscarinic antagonists on the cardiovascular and respiratory systems

A

Cardio - initially bradycardia will present, but as the dose increases tachycardia will occur due to blockade of vagal slowing

Respiratory - blockade of bronchoconstriction and bronchial secretions

51
Q

Describe the effects of muscarinic antagonists on the GI tract

A

Salivary glands will decrease in secretions. Pancreatic, gastric, and intestinal secretions will be minimally affected. Prolonged gastric emptying and intestinal transit times

52
Q

Describe the effects of muscarinic antagonists on genitourinary tract and sweat glands

A

Relaxation of the smooth muscle of the ureters and bladder slow voiding

Suppression of thermoregulatory sweating by inhibition of cholinergic SYMPATHETIC nerve fibers

Note: Children can develop atropine fever

53
Q

What CNS disorders (3) can anticholinergics be used to treat and what are the effects?

A

Parkinsons - reduces tremors, but not as effective as dopaminergic therapy

Motion sickness - effectively limits vestibular disturbances

Anesthesia - blocks vagal reflexes elicited by surgical manipulation and blocks parasympathetic effects when administered with neostigmine in reversal of skeletal muscle relaxation

54
Q

What ophthalmologic disorders can be treated with anticholinergics and what are the effects?

A

Prolonged mydriasis for procedures
Note: alpha agonists are preferred for short duration, also have less side effects

Prevention of synechia in cases of iritis and uveitis

55
Q

What would be the respiratory uses of anticholinergics?

A

Pre-operative - limited the secretions of the respiratory system elicited by irritating anesthetics like ether

COPD/Asthma

56
Q

Which antimuscarinics (2) would be used for the treatment of asthma/COPD? What are their half-times?

A

Ipratropium - half-life of 2 hours

Tiotropium - half-life of 120 hours

57
Q

What are cardiovascular conditions which can be treated with anticholinergics?

A

Note: antimuscarinics are rarely used for cardiovascular disorders

Can be used to treat depressed nodal conduciton of the heart due to vagal reflexes secondary to myocardial infarction. Also used to treat hyperresponsive carotid sinus reflexes.

58
Q

What GI disorders can anticholinergics be effective against?

A

Used to treat traveler’s diarrhea

Note: also combined with opioid anti-diarrheals to discourage drug abuse

59
Q

Which antimuscarinics (4) can be used to treat urinary disorders? describe any side effects and duration of aciton

A

Oxybutynin - selective M3 AChR antagonist which can treat urinary urgency. Side effects include xerostomia, dry eyes, blurred vision, dizziness, constipation, and UTIs

Darifenacin, solifenacin, and tolterodine - similar in action to oxybutynin, but longer duration of action and less occurrence of constipation and xerostomia

60
Q

What is an example of a ganglion blocker?

A

Mecamylamine

Note: this fucks your shit up

61
Q

What are adverse effects of atropine administration?

A

When used to treat one organ system it often has adverse effects at another organ system.

High doses will block all parasympathetic function. In adults this is still safe. In children this can cause atropine fever and death.

62
Q

What are contraindications for antimuscarinic use?

A

Glaucoma, history of prostatic hyperplasia, and peptic-acid disease

Note: selective antimuscarinics can be used to treat peptic-acid disease

Renal 2 (3 decks)

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