Pharmacology 2 Flashcards
Explain the action of statins
- Inhibit HMG-CoA reductase so decrease cholesterol production in liver
- Increase production of LDL receptors on cell membrane
- Increased uptake of LDL cholesterol, further reducing circulating cholesterol
What are the contraindications of statins?
Pregnancy
What are the important drug-drug interactions of statins?
- CYP inducers/inhibitors
- OATP2 inhibitors - prevents excretion into bile
- May increase effect of warfarin - increase INR
What are the secondary benefits of statins?
- Anti-inflammatory
- Cause plaque reduction
- Improve endothelial cell function
- Reduce thrombotic risk
Describe the action of cholesterol absorption inhibitors and give an example
Ezetimibe
Inhibits cholesterol absorption in small intestine. This causes decreased [cholesterol] in liver which upregulates LDL receptors, causing further decrease in circulating cholesterol
Describe the action of niacin
- Inhibits lipolysis in adipose tissue
- Reduces production of free fatty acids - decrease in triglyceride synthesis in liver
What is the difference between enteral and paraenteral delivery of drugs?
Enteral = drug routes via GI tract
Paraenteral = drug routes not via GI tract
Describe factors affecting systematic entry of a drug
Passive factors:
- Drug lipophilicity
- Molecular size
- pH changes
Active factors:
- Presence of active transport systems
- Splanchnic blood flow (reduced in HF and shock)
- Drug destruction by gut
What is bioavailability?
Fraction of dose that finds its way into a body compartment
e.g. bioavailability for IV bolus is 100%
Name some factors that affect bioavailability
- Drug formation
- Age
- Food (water soluble drugs less likely to be affected by food)
- Vomiting
- Malabsorption
- First pass metabolism
What is oral bioavailability? How is it calculated?
Proportion of orally taken drug (or any other route that is not IV) that enters systemic circulation unchanged
Oral bioavailability = [AUC (oral)/AUC (IV)] x 100
What is first pass metabolism? What can affect first pass metabolism?
- Any metabolism that occurs before the drug enters systemic circulation
- Can occur in gut lumen, gut wall, liver
- Drugs affecting gut motility and pass/active absorption will affect uptake of original drug
- Liver disease will affect amount of metabolism of drug in liver
What does drug distribution mean?
Ability of a drug to enter different compartments of the body (plasma, ECF, ICF)
What factors can affect drug distribution?
- Lipophilicity
- Protein binding - reduced entry into tissues
- Volume of distribution
- Tissue protein binding - e.g. bind to muscle
- Tissue mass/volume and binding site density
What is volume of distribution?
A hypothetical measure of how widely a drug is distributed in body tissues
When is displacement of drugs from proteins important?
If there is:
- High protein binding
- Low Vd
- Narrow therapeutic ratio
What is phase I metabolism?
Reactive group on parent molecule exposed or added by oxidation, reduction or hydrolysis reactions
Requires CYP450 enzymes and NADPH (high energy)
Name the CYP450 inducers?
- P = phenytoin
- C = carbamazepine
- B = barbituates
- R = rifampicin
- A = alcohol (chronic)
- S = sulphonylureas & St John’s Wort
Name the CYP450 inhibitors
- G = Grapefruit juice
- O = Omeprazole
- D = Disulfiram
- E = Erythromycin
- V = Valproate
- I = Isoniazid
- C = Cimetidine & Ciprofloxacin
- E = Ethanol (acute)
- S = Sulphonamides
How are drugs excreted in the kidneys?
- Passive glomerular diffusion
- Organic anion and cation transporters - active tubular secretion
What factors will affect renal excretory elimination?
- Protein binding
- Tubular secretion - NSAIDs reduce tubular secretion
- Urinary pH
- Renal blood flow
What does phase II metabolism involve? Give the common molecules used
Conjugation of reactive intermediate with polar molecule to form water-soluble complex
Glutathione, sulphate ions, glucoronic acid
Define clearance with regards to pharmacodynamics.
Volume of plasma that is completely cleared of drug per unit time.
How does the heart affect drug elimination?
Reduced organ perfusion (reduced cardiac output or excessive vasodilation)
Which drugs exhibit zero order/non-linear kinetics at therapeutic doses?
- High dose aspirin
- Phenytoin
- Verapamil
- Fluoxetine
- Alcohol
- MDMA
What is the difference between first order and zero order kinetics?
First order = elimination determined by concentration of drug
Zero order = drug eliminated in set amount per time
What is the action of salbutamol?
- Activates B2-adrenoceptors on bronchial smooth muscle
- Increases cAMP, increases PKA, sequesters Ca2+ in SR, decreases intracellular calcium
- Prevents binding of calcium to myosin light chain
- Causes vasodilation
What is the mechanism of action of inhaled corticosteroids in asthma?
- Binds to intracellular receptors that travel to nucleus
- Up or down-regulates gene transcription
- Inhibits pro-inflammatory cytokines from Th2
- Inhibits phospholipase A2 - blocks arachidonic acid and therefore prostaglandins production
- Increases B2-adrenoceptor expression
- Stabilises mast cell membane - decreases histamine
Describe mechanism of action of muscarinic receptor antagonists used in asthma
- Blocks action of M3-adrenoceptor
- Prevents phospholipase C activated release of Ca2+ from SR
- Causes bronchodilation
Which patients should antimuscarinics be used in with caution?
- Prostatic hyperplasia
- Bladder outflow obstruction
Which patients should omeprazole be avoided in?
- Omeprazole is a CYP450 inhibitor - increases concentrations of other drugs
- Those on warfarin or phenytoin
What is important therpaeutically regarding PPIs?
- PPI action takes 2-3 days for max efficiency
- Not all pumps active all the time
- It also takes a few days for restoration of stomach acid, de novo synthesis
Which patients should cimetidine be avoided in?
Cimetidine is a CYP450 inhibitor and therefore should be avoided in patients on warfarin or phenytoin
What is the mechanism of action of bulk laxatives?
Increase volume of non-absorbable solid residue in gut causing distension and therefore stimulating peristaltic movement
What is the mechanism of action of faecal softeners?
Lubricate and soften stool - given as an enema or suppository
What is the mechanism of action of osmotic laxatives?
Increase water content of bowel via osmosis
What is the mechanism of action of irritant laxatives?
Irritates mucosa causing increase peristalsis and water/electrolyte secretion by mucosa
What is the mechanism of action of anti-motility antidiarrhoeals?
- Act on opioid receptors in bowel reducing motility
- This increases time for fluid reabsorption
- It also increases anal tone and decreases sensory defecation reflex
What is the mechanism of action for D2-receptor antagonists used as anti-sickness medication?
- Blocks D2 receptors found in chemoreceptor trigger zone
- This prevents stimulation of vomiting centre in lateral reticular formation of medulla
What is the mechanism of action of serotonin antagonists?
- Block serotonin receptors in chemoreceptor trigger area
- Blocks serotonin receptors of vagal sensory fibres stimulated by serotonin released from enterochromaffin cells
What is the mechanism of action of fibrates?
- PPAR agonist (peroxisome proliferator-activated receptors)
- Increases production of lipoprotein lipase
- Increases fatty acid uptake and B-oxidation which reduces triglyceride production
What channel do thiazide diuretics inhibit?
Na/Cl co-transporter in early DCT