Hillary Bell

ATTR 326
Clinical Drug Application
Pharmacology NoteBook
Drug Reference Sources
Physicians Desk Reference (PDR)
- Available for about 60 years
- New edition is published annually
- Not all drugs/medications will be listed in the PDR
o Must pay to be included in this publication
PDR Contents
White Pages: manufacturers index (and product information)
- List the drugs manufacturer, address, contacts, medications sold
etc. and the associated page numbers
- Lists the entries of over 3,000 various pharmaceuticals
alphabetically by the manufacturer
- Provides indications, contraindications, usages, adverse reactions,
warnings
Pink Pages: brand (trade) and generic name index
- All meds have a chemical name (long and difficult to pronounce) but
the generic name is shorter and derived from the chemical name
Ex) chemical name: (RS)-2-(4isobutylphenyl)-proplonic acid
generic name: Ibuprofen
brand name: Advil, Nuprin, Motrin (many companies
manufacture an identical generic product with different brand/trade
names)
- Generic names are listed followed by the brand name(s) with the
manufacturer listed in italics
Blue Pages: product category index
- Drugs are listed by category
i.e. analgesics, anesthetics, fertility, relaxants, etc.
Gray Pages: product identification guide
- Full color actual photo size of the various medications
- Drugs listed alphabetically by the manufacturer
Questions:
What happens when a patent expires on a drug?
When a patent expires on a drug, other companies may then
manufacture and identical
generic product
How long before a drug patent expires?
Drug patents expires after 17 22 years
How do you know that a generic medication is safe?
The manufacturer must prove that it is a chemical duplicate of the
original and have
bioavailability*
What happens to the name of a drug when a generic equivalent is
produced?
Companies must list a new trade name (most generic manufacturers
simply list the drugs generic name)

*Vocabulary:
Bioavailability: rate and extent of absorption into the bloodstream

Drug Sources
Traditionally drugs came from natural sources
- Plants
- Animals
- Minerals
Many medications today are synthetic
Synthetic meds usually are free of impurities
Synthetic: produce artificially through the combination of other
substances
Natural medications contain many impurities
Drug manufacturers can manipulate the molecular structure of synthetic
drug/medication to alter its chemical composition
- May make the drug effective against different organisms
Active Components of Drugs
- How the drug/meds provide strength and power to fulfill its purpose
Alkaloids: most active component in plants
- React with acids to form a salt that more readily dissolves in body
fluids
- Alkaloids and alsts usually end in the ine
Ex) caffeine, morphine, nicotine
Gums: gives the product ability to attract and hold water
Ex) seaweed and seed with starch
Resins: chief source is pine tree sap
- Acts as a local irritant, laxative or caustic* agent
Oils: volatile or fixed
Ex) Volatile: peppermint, spearmint, juniper
Ex) Fixed: dont evaporate as easily and include castor and olive
Castor: comes from a bean plant and irritates the intestines
- Sold as an OTC laxative
Midwife cocktail: castor oil and juice to induce labor
Body fluids or glands of animals are used to manufacture drugs such as:
- Hormones: insulin
- Oils and fats: cod liver oil
- Vaccines: microorganisms that are killed or modified
o Cows produce milk containing lactoferrin to treat human
infections
o Goats milk contains antithrombin III to prevent blood
coagulation
Other drug information:
- Minerals from nature in combination with other substances, are used
in iron iodine and Epson salts
- Drugs today produced in labs and may be all synthetic or
natural/synthetic combinations
- Also use DNA to alter genetic chain to develop bacteria to produce
insulin for humans
*Vocabulary
Caustic: burns your skin
Quinine: poisoning

Cathartic Effect: cleansing as to evacuate and purge the bowels

Pharmacy Regulation and the Food and Drug Administration
(FDA)
Formed in the 1800s as The Bureau of Chemistry
1st Major Reforms were the food and drug act and the meat inspection
act
- 1906 occurred as a result of The Jungle
Pharmaceutical regulation began in 1938
- An antibiotic was manufactured in 1937 and contained diethylene
glycol (antifreeze)
- No safety warning, killed 107 people, many were children
1938 the Federal Food, Drug and Cosmetic (FDC) Act is passed by
congress to assure all new medications are safe before marketing
Beginning of safe drug regulations in the US
All new drugs and medications must go thru the FDA
- Takes about 12 years
FDA doesnt develop or test products but reviews the animal and
clinical studies
- Determines is it safe, effective, should it be marketed?
Most criticism of the slow process and developed a fast track for drug
approval in 1992
- Reason was AIDS, Alzheimers
- Process may take as little as 6 months
Many drugs and medications in other countries, many only go through
a 1 year process available then over seas
Europe in the 50s had a popular sleeping aid, Thalidomide
- Was marketed to pregnant women
- FDA wouldnt approve this because of major birth defects, seal like
extremities
- Phocomelia: hands and feet attached to the trunk by small irregular
shaped bones
FDA is also responsible for monitoring adverse drug reactions
- Online reporting system known as MedWatch where a
consumer/health professional can report
Other Acts
Kevauver-Harris Amendment (1962): all drugs must be evaluated for
safety and efficacy
AntiTampering Act (1984): all OTC medications must have tamper
resistant packaging
Ex) Tylenol: cyanide
Medication management and athletic training
- State and federal dispensing laws state and federal government
closely aligned with prescription medications, if conflict follow
stricter codes
- Only VA, OH, CA, SC, and FL acknowledge that medical practice
exists in athletic training facilities
- No ATC can dispense meds

Any time prescription items are in an AT room, a licensed physician

must be responsible for the medications doesnt matter if its 1 or
100 lively
Team Physicians
Must maintain a DEA certificate to prescribe controlled substances
Ways team physicians deliver medications
- Administer: medication to be consumed within 24 hours
- Dispensing: medications to be consumed over 24 hours
- Treatment: medications is administered as therapeutic injections,
ionto, or phono
Storage and inventory of medications
- Must be stored at room temperature in a dry environment
- Secured and locked in the ATR
- At home, dont keep in a medicine cabinet humidity some may
have to be refrigerated
- Shelf life: length of time a product can be kept in stock before
contents altered with age
- Expiration date: date after which the stability and potency of a drug
cannot be assured
Dont sell, use, or purchase beyond that date
Most are not at full strength after, most lose potency before
Scheduled drugs and controlled substances
Schedule 1 drugs no medicinal purpose in the US
Ex) Heroin, LSD, THC, Peyote
Schedule 2 drugs high abuse potential
Ex) Morphine, Demerol, Codeine
Schedule 3 drugs low abuse potential
Ex) Tylenol with codeine
Schedule 4 drugs low potential for abuse
Schedule 5 drugs low potential
Adverse Drug Reactions (ADR): any undesirable response from a drugfrom dry mouth to life threatening condition
Different types of ADR
Side Effect: expected responses from a drug or medication
- Dry mouth, constipation, increased HR, GI upset, drowsiness
- If too severe, decrease dosage
Organ Cytotoxic Effects: when some drugs have adverse effects on
organs, liver, kidney and pancreas
- NSAIDS, acetominophin, etc
- Nausea/Vomiting are typical
ldiosyncracy: unusual or particular response to a drug
i.e. very sensitive to a small dose or highly insensitive to a large dose
- Respons is individual
Drug-Drug Interaction: taking several medications at the same time,
one may negate the other
Types of drug-drug interactions:
Synergistic : drugs interact and produce a much greater reaction
than when taken alone
Antagonist: one drug interferes with the action of the other

i.e. certain meds decrease effectiveness of oral contraceptives

(antifungals)
Drug-Food Interaction: food diminishing the effects of a medication
i.e. food containing vitamin K (broccoli, lettuce, are antagonists to
Coumadin)
Ex) birth control grapefruit
Allergic Reactions: immune responses to a drug, vary from person to
person, can be mild Skin reactions to anaphylaxis
Anaphylaxis
- Reaction/allergy to a foreign protein or substance
- Medical emergency
- Treated with epinephrine intramuscularly, or subcutaneously
EpiPen
Quick acting but of short duration
Epinephrine relaxes smooth muscle in the airway and lungs to
improve breathing
- Also constricts blood vessels to stimulate heartbeat, reduce hives
and reduce swelling around face and lips
Other Conditions
Toxic drug overdose can occur if taken in large dosages or when
blood concentration levels exceed therapeutic levels
- Irreversible liver damage, hearing loss
Substance abuse is the excessive use of a product, especially
alcohol or a drug

Pharmokinetics and Pharmodynamics

therapeutic effects of drugs
Pharmokinetics
what the body does to the body
Absorbed taken into the body
Absorption movement of a drug across the cell membrane
- Usually not administered at the site of action
- Must be absorbed into the blood stream and transported to the area
- Rate, speed, efficiency and extent that a drug is absorbed depends
on its chemical/physical composition
Other factors: pH of the body, whether the drug is fat soluble or water
soluble (the more fat soluble the greater the chance more tissue is
affected wider distribution- more potential to effect CNS) surface area of
intended site of action
Distributed: moved into various tissues
Metabolized: changed into a form that can be utilized and excreted
Excreted: removed from the body
Routes of Administration
Enteral oral ingestion most common, convenient, safest
- also referred to as alimentary, as it enters through the alimentary
canal or the GI tract
Sublingual under the tongue
Ex) Nitroglycerin is taken like this (for angina)
Buccal oral mucosa
Oral mouth
Drug action occurs within one hour of ingesting and absorbed into
duodenum
Take on empty stomach with water assists with dissolving the
medication
Pain/stress may also decrease the amount of drug absorbed 0 chance
in the blood flow and pain is usually an autonomic nervous system
response
Oral medication may have a bearing on rate of absorption
Types of Oral medications
Solutions: drugs in liquid form
Syrups: high sugar content water soluble difficult to dissolve in syrup
Elixors: drug is dissolved in alcohol content 4-5%
Capsules: powder substances in gelatin shell
Tablets: swallowed or chewed, most common
- May be enteric coated gel layer, delays release of med
- Intact in stomach but dissolves in duodenum
- Protects the drug from acid and pepsin and the stomach from
discomfort
- Sustained release capsules: special coating that releases a drug
over a period of time
o Fewer doses thru the day
o Stronger
o More expensive
GI Absorption Route

Suppository: solid or semi-solid compound inserted into a body orifice

usually works on the lower GI
- Body temp melts and can have a local systemic effect
First Pass Metabolism: process in which a drug is ingested and then
absorbed from the GI tract to the portal venous system
- Must pass through liver first before reaching the body, some meds
are metabolized and broken down so drastically in the liver that
taking them orally has no effect.
Ex) lidocaine administered IV/IM
Parenteral: administer a drug by a non-oral route
Common routes include: subcutaneous, intramuscular, IV, intrathecal,
and intra articular.
Inhalation (respiration): administered with fine mists and aerosols
- Absorbed in lungs and distributed to the blood, lungs have large
surface area and rich blood supply used for pulmonary conditions
Topical (transdermal) applied directly to the skin and mucous
membranes fat soluble meds more readily absorbed thru the skin
than water soluble
- Epidermis may limit absorption
- Transdermal patches (nicotine or estrogen) provide a slow controlled
drug release
Distribution process by which the drug is delivered to the tissues and
fluid within your body
Factors such as blood flow, solubility (water or fat), and protein binding
can affect
- Drug is distributed to organs with major blood flow (liver, kidneys)
o Distribution to the skin, fat and muscles is slower
o Fat soluble drugs can cross through cell membranes while
water soluble cannot.
Fat soluble can cross the blood brain barrier and enter
into the brain
Circle of Willis vascular complex at base of brain
- Blood Brain Barrier mesh of tightly packed cells in the brains
capillaries walls that filter certain substances
o Prohibits large harmful molecules from crossing into the brain
o Thus some drugs can pass through while others cannot
- Metabolism (biotransformation) change a drug from its dosage
form to be excreted
o Rate of metabolism is different for all individuals
Affected by smoking, age, disease
o Most drugs are metabolized in the liver using enzymes
o End product becomes more water soluble, this making it
easier to eliminate from the body
- Excretion how the drug is eliminated from the body
o Main route is urine, feces, bile
o Kidneys are primary organ of excretion
o Also the lungs, saliva, sweat and mammary glands
- Half Life amount of time required for 50% of the drug remaining in
the body to be eliminated

o Important for several reasons:

Can vary from minutes to days
Allows for comparison between drugs
Determines frequency of multidose administration
Ex: vicodin is 3-4 hours so it can be prescribed every 4-6
hours for maximum pain relief
o Half-life does not change with dosage if you take half the
dose, you still need the same amount of time to eliminate half
of the drug from the body
Pharmodynamics
what the drug does to the body and how it exerts and effect
o Drugs having an effect on the body are either endogenous or
exogenous
Endogenous originates within the body (hormones
produced by thyroid gland)
Exogenous originating outside the body
o Drugs and medications typically dont crease systemic
changes but rather to specific tissue, organs or locations
o For a drug to act locally, must have what is known as a drugreceptor interaction
Receptor is a component of a specific cell to which a
drug binds to produce an effect
Located on or within a cell
Receptor is a specialized macromolecule of that cell
Not all drug receptors have affinity for all drugs
Affinity force that makes two agents bond or
unite
Drugs interact with a receptor to produce a
pharmacological response are agonists
Agonists also have efficacy
Efficacy capacity to elicit a response
o Those that bind but dont produce a pharm response are
antagonists
Antagonists are blockers, have affinity but no efficacy
Narcon is an antagonist that blocks morphine,
used to reverse OD effects
o Potency is the amount of the drug that is necessary to
produce the desired pharmacological response
More potent drugs require a lower dose and less potent
drugs require a higher dose
Pharmokinetics/Dynamics of Medications/Drugs
- Exercise usually enhances delivery of medications when referring to
pharmodynamics
- More so though with the elderly and terminal population as opposed
to athletes
o Heart disease, diabetes, arthritis, hypertension
- No real research in this area and unlikely a significant impact from
exercise and pharmokinetics

Cardiovascular Medications and Drugs

Many CV conditions are related
- Hypertension increase your risk of MI, heart failure, angina, stoke
and kidney failure
- Angina increases your risk of MI
Diuretics used if life style modifications dont work, science isnt sure
how they work
o Increase urine output which promotes sodium, water and
electrolyte loss
o If taking diuretics watch your potassium levels, dont take a
potassium supplement but rather increase consumption of
fruits and vegies
Potassium protects against hypertension and may help
to lower bp in patients
May develop hypokalemia low potassium stores
and levels
Common diuretics include HCTZ (hydrochlorothiazide) and Lasix
Calcium channel blockers
o Vasodilators and block the movement of calcium into smooth
muscle
o Prevent calcium ions from crossing into the myocardial cell
and vascular smooth muscle
Causes dilation of the coronary arteries, thus decreases the
hearts contraction force and workload
Thus decreasing the bodies heart rate
ACE Inhibitors
o Angiotensin-converting enzyme (ACE) inhibitors
They block the conversion of angiotensin1 to
angiotensin2
Angiotensin 2 very powerful vasoconstrictor and
promotes retention of sodium
Results in:
Arterial and venus dilation
Decreased systemic vascular resistance
Increased in sodium and water excretion
Increased blood flow to the kidneys
No known side effects to athletes and performance

Usually a first choice if an athlete has high blood

pressure
Contraindicated for women during pregnancy
ACE Inhibitors can cause an annoying dry cough
Some ACE inhibitors have their own diuretic
capabilities
Commonly used to treat hypertension, MI, and heart
failure
Lotensin, Vasotec, and Monopril

Beta Blockers
o Used for long term prevention of angina and hypertension
Effects include decreased blood pressure, decreased
heart rate, and force of hearts contraction, thus
resulting in a lower demand of oxygen
Used by rifle athletes and banned by NCAA and USOC
NSAIDS may reduce the hypotensive effects of
betablockers
Used as prophylactic for migraines
Not good for asthmatic patients examples are
Lopressor and inderol
Antibiotics side effects and adverse reactions
- Nausea, vomiting, diarrhea
- Erythromycin is not as well tolerated as others
o s/s may range from a mild rash to anaphylaxis
- sulfa drugs can cause Stevens-Johnson syndrome
o rare but fatal hypersensitivity cutaneous skin reaction
o ttetracyclines may cause GI distress
eliminate if taken with food, increased sensitivity to UV
light, bad sunburn with moderate exposure

Infection and Systemic Drugs

Antifungal medications
- most are topical but also available in oral and IV
- some have to be treated orally (hair, tinea capitis, nail beds to kill
the invading fungus)
- Different oral agents include
o Ketoconazole used less expensive, liver toxicity issues
o Traconazole used for tinea corporis and VYI
o Fluconazole single dose form for treating tinea corpris and
VYI
o Grisefulvin increased liver enzymes and treatment may last
up to two months
- Important that if an athlete is prescribed an antifungal the athlete
needs to inform the pharmacy of any other medications that they
are taking
Antiviral Medications
- Vaccines have helped to eliminate or reduce the severity of certain
conditions
o Chicken pox, shingles, HSV
- Anti-influenza drugs if taken within 48 hours of illness may
decrease severity of symptoms
o Tamiflu, Relenza
- Other considerations..
o Make sure athlete takes all the medications according to the
physicians guidelines
o If dosage schedule is more than twice daily, athlete is less
likely to adhere to the regimen of taking
Systemic Drugs to Treat Infections
- Antibiotics used often to fight bacterial infections
o MD has to know what bacteria is involved

o Sometimes may take 1-2 days to determine the specific

bacteria before a medicine can be prescribed
o Narrow spectrum antibiotics an antibiotic that is active
against a specific type of bacteria, limited side effects, doesnt
allow for antibiotic resistance
o Broad spectrum antibiotics an antibiotic that is active
against a wide range of bacteria
Careful with exposure as not to limit developing a
resistance to bacteria
- Athletes need to be reminded that bronchitis, colts etc. are viral and
do not respond to antibiotics
- Type of Antibiotic
o Penicillin discovered in 1928 and around since the 1940s
Most affective against gram positive bacteria
Gram positive- organisms that absorb a specific
dye and turn purple under a microscope
Many skin infections and respiratory infections are gram
positive
MRSA often is treated with a combination of several
different medications and some are often ineffective
Thus diagnosis is important
Other classes of antibiotics include:
o Cephalosporins very similar to penicillin by creating defects
in the bacterial wall
o Sulfonamides (sulfa drugs) around before penicillin not as
affective, good against MRSA
o Tetracyclines good for treating acne no longer available
Certain minerals impede absorption
Doxycycline is 3rd generation of tetracycline
o Macrolides similar to penicillin and can be used with those
allergic to penicillin
Good for respiratory infections (Zithromax)
- Penicillin is usually 100% effective against strep throat but
ineffective for skin conditions
- Some of the more commonly prescribed antibiotics include:
o Keflev, Cipro, Amoxicillin, Bactim, Duricef, Penicillin

Skeletal Muscle Relaxants (SMR)

Relieve musckuloskeletal pain/spasm and spasticity
Spasticity rigidity of musculature causing stiff, awkward
movement, often caused by a CNS lesion
MS, Cerebral palsy, stroke, and TBI are causes of spasticity conditions
Inflammation, strains, and cramps are the main reasons to prescribe
SMRs
AT sees spasm type injuries as opposed to spasticity
- Work to reduce the pain-spasm-pain cycle
Pharmacokinetics of SMR is somewhat unclear
- Absorbed from the GI tract, distributed in body, metabolized in liver
and excreted through kidneys
- Taken orally and 30-60 minutes for effects, lasts 4-6 hours
Flexeril will last 12-24 hours
- May decrease effectiveness of hypertensive meds
Pharmodynamics dont directly relax skeletal muscle, but action is CNS
depressing and sedating
Drug interactions
- Combine SMR with alcohol, narcotics, and/or barbiturates causes
increase in sedation, depressed respiration and impaired motor
function
- Almost double sedative properties
Adverse reactions
main effect is drowsiness-dont operate a motor vehicle or other type of
equipment
- Wont be mentally alert
- Any CNS depressant will make you drowsy and dizzy
SMR have a high potential for abuse

Most commonly abused drug according to PA/MDs

Physicians reluctant to prescribe to high school or college athletes
o Alcohol combination
Blurred vision, confusion, headaches, ataxia, skin rash
Ataxia failure of muscle coordination
SNR only treat symptoms and not the underlying condition
Examples of SMR
Robaxin, Norflex, Flexeril, Parafon Forte, Soma, Valium
Non-anti-inflammatory Analgesics
Relieve pain but no anti-inflammatory effects
Acetaminophen (Tylenol) is the most common
Most others are naroctics
- Most others are narcotics
Narcotic dulls the senses and alters pain perception
Opiate agonists
- Codeine: mild to moderate pain
- Meperidine: moderate to severe pain
- Morphine: severe pain
Tramadol (Ultram) mild to moderate pain
- Synthetic codeine
Combination products: Tylenol w/codeine (T3/T4)
Anesthetics
Numb an area for surgery or treat painful conditions
Local anesthetics
Drugs that produce a partial or complete loss of sensation to a specific
area
- Blocks pain sensation along with cold, heat and touch
Usually dont by injection but ice achieves same results
Infiltrating the spinal cord is using a local anesthetic
Local anesthetics date back to the 1500s
- Cocoa leaf used as an anesthetic
- Why anesthetics end in the suffix (caine)
- Cocaine sometimes used in nasal surgery as a vaso-constrictor
maybe combine a local with epinephrine (vessel constriction)to control
local bleeding
- Few side effects but higher doses may have cardiac complications
Examples of anesthetics
Lidocaine, Marcaine, novocaine, procaine
Mix Lido (short, used for sutures) and Marc (kicks in later)
Topical anesthetics
Apply directly to the skin, mucous membrane to prevent/ relieve minor
pain
- Sprays, lotion, creams, lozenges, suppository
Treat sunburn, itching, skin irritations
Pharmokinetics they produce little systemic absorption
- Except cocaine
Pharmodynamics they block nerve cell transmission

Athletics may also see ethyl chloride used cooling effect similar to ice
but is much quicker
- Use caution may cause frostbite
Examples of topical anesthetics
Benzocaine, Nupercainal, xylocaine
Nupercainal - hemorrhoids
General anesthtics
Injection and inhalation are the 2 types:
Infection used when anesthesia only needed for a short amount of time
out patient
- Promotes rapid anesthesia
Inhalation complex procedure of combined drugs
Needed to prepare, achieve and bring the patient back from
anesthesia
Pharmokinetics of inhalation enters from the lungs and distributed to
other tissues
- Most rapid to the heart, brain, liver and kidneys
- Eliminated primarily by the lungs
Pharmodynamics depresses the CNS, producing a LOC, loss of
responsiveness to sensation/pain and muscle relaxation
Side effects are lethargy, confusion, depressed breathing, hypothermia
Nitrous oxide and isoflurane are examples
Malignant hyperthermia
Sudden and lethal increase in body temperature
- Serious and unexpected to inhalation anesthetics
May also occur to athletes in hot/humid conditions
- Breakdown of muscle tissue due to lack of water intake, leads to
calcium inbalance and cellular damage
Non-Steroidal Anti-imflammatory Drugs (NSAIDS)
NSAIDS inhibit the boddys inflammatory response and produce several
effets:
- Analgesia: reduce pain
- Antipyresis: reduce fever
- Anti-coagulation: thinning of blood
- Anti-inflammatory
Five signs of inflammation:
- Pain, swelling, erythema, heat, loss of function
Inflammation and drug therapy
Vascular response to physiological tissue damage
Short period of vasoconstriction and then a release of what?
- Chemical mediators such as:
o Histamines
o Bradykinin
o Leukotrienes
o Prostaglandins
Causes vessel vasodilation, making them more permeable and allowing
WBC to enter the injury site
- With a membrane permeability, there is an increased flow of cellular
fluid causing edema (swelling)

Prostaglandins limit inflammation and fever by blocking coclooxygenase

(cox) pathway and by increasing the pain threshold by clocking pain
producing substances like bradykinins
- May also provide gastric protection by producing a protective
mucous layer in the gastric region
Prescribe NSAIDS when the body cannot handle inflammation
Efficacy of NSAIDS will vary from person to person
- Use a specific NSAID for 1 2 weeks
- No results, switch to different NSAID
Indicated uses for NSAIDS
Primary purpose is to inhibit inflammatory response by decreasing pain,
inflammation and tissue damage
NSAIDS have the same properties as aspirin
- However, anti-coagulant properties are much shorter for NSAIDs in
comparison to aspirin
Used often in athletics but not much research to support its use with
musculoskeletal conditions
Should use only 3 days for fever reduction and 10 days for pain relief
NSAIDs side effects
Side effects: gastric upset(most common), GI bleeding, tinnitus, ulcers
However, NSAIDS are easier on the stomach than aspirin
Increased risk for MI with some NSAIDS
- Vioxx and Bextra taken off the market in 2004
May decrease the effectiveness of hypertensive meds
Common Anti-inflammatory medications
Ibuprofen
First NSAID and the 1st to be available OTC
OTC in 200mg tablets
- Adults 2 tablets every 4-6 hours
- 1200mg max in 24 hours
Naproxen sodium (Aleve) is 220mg and should not exceed 3 tablets in 24
hours
Aspirin (acetylsalicylic acid)
Both are NSAID and analgesic
- First NSAID introduced in 1899
- Derivative of salicylic acid which is found in the bark of willow trees
Anticoagulant effect of aspirin will continue for one week after aspirin is
discontinued
Side effects: gastric upset, GI bleeding, tinnitus, ulcers
Other trade names are ASA, Aspergum, Ecotrin, Empirin
Buffered aspirin have antacids added to reduce gastric upset
- Doesnt provide faster or longer pain relief
Delayed release aspirin
Dissolved in small intestine to avoid GI upset
- Delayed pain relief, possibly up to 2 hours
Aspirin with caffeine
Caffeine enhances aspirins analgesic properties
- Anacin
Other NSAIDS

Indomethacin (Indocin)
Strong COX inhibitor and one of the first NSAIDS to be developed in 1965
- Take with milk/food to minimize GI upset
- Abdominal discomfort, headaches, dizziness are side effects
Ketorolac (Toradol)
Newer NSAID that has been around 20-25 years
- Produces excellent analgesia similar to morphine and minimal side
effects (no side effects)

Drug Testing Randy Meador

WVU Drug Testing
Recreational amphetamines, barbiturates, phencydidine,
benzodiasepines, cannabinoid, methaqualone, cocaine, opiates
Cost: $23
Steroids - special test
Cost: $126
Random Testing-all sports: 30 coliseum side of campus/ monthly, 12 from
football/monthly
Computer Program
- Try to stay removed
Failure to appear positive if notified
Dilutes doesnt count as positive but retest
First Positive retest
- Sample retested, meeting with: coach, ATC, S-A, call parents notify
of failed drug test, A.D. and counselor notified too
- HIPAA, cant tell why suspended from games, practices, activities,
meeting, meals.
Return to team
- Negative

- Cooperate with counselor

Previous positive
- Surprise test
Second positive surprise test
- Same as first, meet with A.D., must miss 10% season (no matter
when)
Third Positive
- Meeting with all, plus team physician, call parents, remove
permanently, referred, 3 and done.
NCAA Drug Testing
- Almost every year
Championships can be tested anytime
On campus 18 football, 8 track (now 8 of any sport) = 26 total
Positive
- Out for a year
Big 12 Drug Testing
- Identical to NCAA (once a semester)
- 18 Football and 8 other sports

Anti-Inflammatory Drugs Corticosteroids

Adrenal steroid compounds
mineralocorticoids - used to supplement adrenal production and maintain
electorlytes
glucocorticoids excellent anti-inflammatory properties and also effective
for treating asthma
- Inhibits leukotriene production which suppress the bodys
inflammatory response
Types of glucocorticoids
Cortisone - short acting steriod
- In athletics, pill or close pack form
- Can suppress inflammation and asthma
- Only available via prescription
Corticosteroids available in topical creams, oral, or inhalation solutions
(asthma)
Common cortisone medications include Hydrocortisone, Prednisone,
Methylprednizone, and Dexamethasone
Prednisone is a commonly prescribed oral corticosteroid
- Also topical and injectable and four times more potent than
hydrocortisone

Dexamethasone is a synthetic glucocorticoid and used as an antiinflammatory

- Parenteral route through injection or iontophoresis
- Longest acting with a duration of 1 3 days (acetic acid vinegar)
Adverse effects
Injectable may increase risk of tendon ruptures
Oral may suppress the bodys immune system
Systemic may increase risk of GI ulcers when combined with alcohol or
NSAIDS

Non-Anti-Inflammatory Sytemic Analgesics

Narcotic agents (opioids)
Endogenous opioids in out body on an (as needed) basis endorphins
and enkephalins
Endogenous originating or produced within our body
- morphine within considered to be stronger than morphine
- Acts as an natural opiad to alter perception of pain and stress
Exogenous originating or produced outside the body
- Heroin, morphine, and codeine
Heroin not used therapeutically, morphine controls moderate to sever pain
and codeine analgesic fo choice with severe pain and post-surgical
- Natcotics preferred binds with CNS to interrupt pain transmission
Demeral synthetic morphine
Tramadol (ultram) newer and used for mild to moderate pain
- Does produce physical dependence
If taking anti-depressants, may trigger seizures

Initially markted as not additive

- Manufacturer has since withdrawn this claim
- Same side effects as opiates
Opioid side effects
Drownsiness, dizziness, nausea, vomitin, blurred vision and
constipation
- Main side effect from codeine is constipation
Acetaminophen (Tylenol)
Analgesic and antipyretic but has no anti inflammatory properties
Can supplement with a strong narcotic (usually codeine) to increase
potency in treating mild to moderate pain
- Narcotic adds analgesia and thus becomes a controlled substance
- Doesnet produce GI disturbance or bleeding
- Use for mild pain and fever reduction

Gastrointestinal Disorders and Medications

GI problems in athletics usually cause discomfort and an upset stomach
Conditions such as peptic ulcer disease (PUC), diarrhea, constipation,
intestinal gas, heartburn, hemorrhoids, and gastroesophageal reflux
disease (GERD)
Anatomy of GI disprders
Lower esophageal sphincter (LES) acts as barrier between stomach
and esophagus
Usually constricted but relaxes during swallowing to
allow food to pass
Not as protective as the stomach but prevents stomach
acid and enzymes from coming into contact with
esophageal tissue
Prevents reflux of gastric acid
Peristalsis moves contents through the large and small intestines
If contents more too fast, results in diarrhea

Diarrhea insufficient absorption of water/food contents

from intestines
Certain medications increase the rate at which contents
move through the intestines while other medications
can cause constipation
Meds target parasympathetic and sympathetic systems
Peptic Ulcer Disease (PUD)
25 million Americans have PUD 6,500 annual deaths

NSAIDS use is a common cause

Protein Pump Inhibitors (PPIs) are used to treat PUD
Inhibit the secretion of gastric acid by blocking the
histamine and ATP system
PPIs include medications such as Nexium, Prilosec,
and Prevacid
Gastroesophageal Reflux Disease (GERD)
Retrograde movement of contents from stomach to
esophagus
LES doesnt close properly after eating and results
in esophageal ulcers
Most common symptom is pyrosis (heartburn)
o Heartburn is a burning/pain/discomfort in
the substernal region caused by reflux of
gastric juices into the esophagus
Occurs after eating
Treatmetn
Histamine Receptor Antagonists (H2RAs)
Used to treat GERD and PUD
Block the production of gastric acid
Antagonists to histamine receptors of parietal cells in
the stomach
Suppress gastric acid production
H2RAs and PPIs decrease acid production while antacids will
neutralize the acid after it is released
Can use in combination with antacids
Tagamet, pepsid, zantac
Antacids
Relieves mild to moderate symptoms of GERD by
decreasing gastric acidity
Quick onset of action 5-15 min but are very short
duration, less than 1 hour on empty stomach
Extend to 1-3 hours if taken within one hour of
eating
o As it delays gastric emptying and increases
time of contact with gastric acid
OTC medications and sold in forms as suspensions (fluid)
chewable, tablets, and powders

Active ingredients are aluminum hydrazine, magnesium

hydroxide, calcium carbonate and sodium bicarbonate
(baking soda)
Calcium carbonate and Sodium bicarbonate may
react with gastric acid to form carbon dioxide
o Causes belching and abdominal distension
Aluminum and magnesium may bind to certain
antibiotics thus diminishing absorption
o Therefore take 2 hours apart from other
medications
Some may cause diarrhea (magnesium products)
while others may cause constipation (aluminum
products)
Common antacids are Maalox, Mylanta, Gaviscon
Bismuth salicylate compounds (pepto-bismol) used to
treat GI problems
Dont use in patients whom aspirin is a precaution
May mix with hydrogen in the colon that forms a
compound to darken the stool

Topical Products Jana Ott

VI. Misc Products
A Topical antibacterials for minor abrasions, superficial infections,
prophylactically (prevent)
1 Action
3- 4 times a day, cleanse with soap and water before
application

2 Precautions
Not on burns
3 Examples (Neosporin, Bacitracin)
Neomysin antibiotic, can be senstivit to use single entity
item then
Antiseptics broad range of activity, anti-bacterial, cleanse
1 Action
Cleanse wound
2 Examples (betadine)
Betadine iodine contained in, can be sensitive to hibiclens
Phisohex was popular in the 50s but wasnt washed off and
deaths occured
Antifungals
1 Action
2 Examples (tinactin, Desenex, micatin)
Fungistatic keep under control (foot powder) doesnt treat
Fungicidal killing (majority fall under this (tinactin))
Toe nail systemic (vicks vapo rub works well for toe fungus)
Antibiotics can allow overgrowth
Cannot be cured overnight, must be patient
Steroidal antiflammatory (can mask inflammation)
1 Action
2 Examples (Cortaid, Cortizone-10)
Can thin the skin (avoid face) - benydryl is a nice option
Emollients lubricant, lotion (to hydrate the skin)
1 Action
2 Examples (Vaseline, Eucerin, Lubriderm)
Vaseline best for lips (classic example)
Lanolin like vasoline, people can be sensitive to (red bumps)
Petroleum based is better vs water based or alcohol based
Aqua 4 good healing (not antibiotic) just moisturizing,
hydrating
Cleansing Agents not a lot of antibacterial
1 Action
2 Examples (hydrogen Peroxide, Isopropyl alcohol)
Water/saline work well
Ear Products wax or water in ears
1 Action
Thin wax hydrogen peroxide
Dry water - alcohol
2 Examples (Debrox, swim ear)
Eye Products dryness, allergies (red itchy), contacts
1 Action
2 Examples (Murine, Tears Naturale)
Eye wash (mild purified water, berolic acid) cleanse irritants
For allergies anti-histamines in eye drops (visine A)
Decongestant- vasoconstricts redness
Some people react to preservatives
Hydrate eyes at night

Dental Products tooth loss, ulcer, gums (keep clean & numb)
1 Actions
Quick but short durations
2 Examples (Anbesol, Orabase w/Benxocaine, Glyoxide)
Glyoxide peroxide based
Anbesol numbing
Orabase w/Benzocaine paste (numbing)
Extremely temporary, every couple hours
Bit tongue heals well on its own just keep clean
Gastrointestinal Products stomach diarrhea, constipation
1 Action
2 Examples (Kaopectate, Emetrol)
Emetrol works like pepto (carbohydrate base) eat with ice
chips
Imdium calms down, slows down diarrhea
Diarrhea - excess fluid
Outside environment, hydrate, sometimes dont treat let
resolve in 24 hours
Constipation lack of fluid
Look at diet, dehydration (add water, eat fruit), change
normal environment
Post-surgery medication to avoid constipation
Tums as calcium supplement more often than emergency
antacid
Pepto aspirin based, poor product (can cause irritation)

Respiratory Medications
Athsma, allergies, common cold, coughs are treated with different
medications
o Inhalers, decongestants, expectorants, antitussive, steroids
Antihistamines

o Local honey used as an antihistamine

o Allergies, common cold, hay fever
Also used as a sedative
Active ingredient in Dramamine
Newer antihistamines dont cross the blood/brain barrier
Thus less sedation, but dries mucosa
Careful giving to athletes, tired and fatigue
Use a decongestant instead
Brand names include : seldane, Benadryl, tavist, chlortrimeton
Decongestants
o Used with sinus congestion with and without nasal discharge
Congestion occurs when upper airway mucosa becomes
inflamed
o Treat common cold and allergic rhinitis
Decongestants wont make you lethargic or fatigued
o Most common are Pseudoephedrine (Actifed, Sudafed) and
Oxymetazoline (Affrin)
Side effects are: headache, nausea, dry mouth,
dizziness and possible CV irregulations
Phenylpropanolamine popular until 2000
FDA removed due to increased risk of hemorrhagic
stroke in women
Antitussives
o Suppress a cough but only for a short period of time
o Dextromethorphan (DM) most common ingredient in OTC
cough suppressants
Nyquil and Robutissin
If ineffective, will use a narcotic with codeine
Only prescribe 1 per week, addictive properties
o Tessalon Perle also serves as an anesthetic to respiratory
mucosa and tissues
Prescription item
o Asthma Greek for panting
Not a problem inhaling, but a problem exhaling
20 million in the US have asthma
Manu different meds are used to treat this
condition
Therapeutic effects of asthma medications:
Quick relief of acute attacks (rescue therapy)
Obtain long term control to decrease number of
attacks
Types:
Asthma inflammatory disease resulting in
edema, bronchoconstriction and excess mucous in
the respiratory tract

Control the inflammation with NSAIDs which

prevents the bronchoconstriction onset
Exercise induced bronchospasm (EIB) or asthma
(EIA)
o EIB asthma symptoms brought on by
exercise/activity with no inflammation, very
short term
o EIA - symptoms occur to do physical activity
Must have good control of EIA to be
active
asthma meds effect the autonomic nervous
system (ANS) and neurotransmitters to achieve
smooth muscle relaxation in the airways
Anti-inflammatory asthma medications consist of
steroidal and non-steroids to control the inflammatory
response.
Glucocorticoids (cortisol or hydrocortisone) slow or stop
inflammation by inhibiting protein formation that is
associated with inflammation
Oral steroids are administered in a tapered dose so they
dont suppress the bodys natural cortisol production
Complex association between the pituitary adrenal
glands and the hypothalamus
Non-Steroidal Asthma Medication
NSAIDS arent effective as a rescue medication
during an acute asthma attack
NSAIDS prevent mast cells from rupturing and
releasing inflammatory responses (histamines)
o Prevent bronchoconstriction
Cromlyn Sodium is a common mast cell stabilizer
and available in MDI (meter dosed inhalers)
Common MDI medications are:
o Albuterol, Proventil, Ventolin
Adverse effects of asthma medications:
Primary objective: minimize acute attacks
o Many acute attacks indicate poor control of
asthma
MDI Medications have less adverse effects than
oral medications
o MDI more local as opposed to systemic with
oral
Inhaled steroids have little effect systemically
o May cause throat irritation/hoarseness after
dose
o Steroid residue remains in throat, alters
bacteria and may cause a yeast infection
Rinse out mouth to alleviate

Short term effects of oral medications may

include:
o Increased appetite
o Acne
o Insomnia
o Poor wound healing

Anabolic Androgenic Steriods

Anabolic-Androgenic Steriods (AAS) and athletics
o Introduced to US athletes in the 1950s
Primarily elite and competitive athletes
o Rumored as early as 1959 that high school athletes were
using AAS and confirmed through surveys in the early 1970s
o First drug testing for AAS was conducted at the Montreal
Olympics in 1976
o Got their beginning when Hitler wanted a more aggressive
soldier
o Lyle Alzado former pro football player for Oakland and
Denver, died of a malignancy in his brain from repetitive
steroid use
Incidence of Use
o Special Populations
Women and AAS use:
Studies indicate women also use AAS and other
performance enhancing substances
Researched indicates that the side effects
associated with AAS use are reversible in women
with the following exceptions:
o Menstrual irrectularities
o Hirsutism excessive facial hair
o Virilizing effects development of male
characteristics
Depends on extent and type of AAS
o Reduction in breast size
Common Brand names of AAS
o Deca Durabolin
o Winstrol
o Anavar
o Dianabol
o Maxibolin
o Equipoise
Characteristics of AAS Users
Physical Characteristics

Important to note that not all AAS produce the same

effects some will have more distinct effects on the
body as opposed to others
Other considerations
Mode of introduction
Pharmaceutical alteration to synthetic AAS
Combination of drugs used
Length of cycles
Dosages employed
Individual response
Physical Characteristics and Signs of AAS Users
Body composition alterations marked by hypertrophy
Development of male pattern baldness
Disproportionate development of the upper torso
Edema as a result of sodium retention
Epistaxis spontaneous nose bleeds
Gynecomastia male breasts
Increased susceptibility to tendon strains/injury
Jaundiced eyes
Needle marks in large muscle groups
Puffiness of the face, particularly around the face/eyes
Rapid weight gain
Right upper quadrant tenderness (liver)
Severe acne particularly on face, chest, and back
Stretch marks on the body, especially shoulders and
chest
Most of the psychological signs/symptoms associated
with AAS use occur while the individual is cycling
Only a small percent of AAS users will experience
mental disturbances severe enough to result in
clinical treatment
Increased aggression
Irritability
Slowed thought process with depressive states
Significantly more depression and anger
Reasons for using AAS
o Athletic Population:
To improve athletic skills and performance
Other reasons are to keep up with the competition and
to prevent/treat sports related injuries
o Non-Athletic Populations:
Main reason is to improve physical appearance
Adverse Effects from using AAS:
o Acne increase in sebaceous gland activity
o Alopecia accelerated with long term use (hair loss)
o Azoospermia due to suppressed gonadotropin production

o Epiphyseal growth plates prematurely closes in adolescents

and is irreversible
o Gynecomastia androgens aromatize and convert to estrogen
o HDL (good cholesterol) decrease- caused by inducing liver
enzyme activity
o Headache and dizziness due to hypertension
o Hepatomegaly results of elevated liver enzymes
o Hirsutism irreversible in women
o HIV/AIDS possible infection from sharing contaminated
needles
o Hypertension excessive water retention and weight gain
o Impotence decreased production of natural testosterone
affecting the endocrine system
o Insomnia causes a slight CNS stimulating effect
o LDL (bad cholestrerol) increase induces liver enzyme activity
o Musculotendinous injuries produces collagen abnormalities
which may increase risk of tendon injuries
o Prostate enlargement prostate is an androgen sensitive
target tissue
o Sodium retention due to an increase in body weight but its
unclear why it occurs
o Testicular atrophy natural testosterone production shuts
down due to the synthetic androgens being taken
o Water retention edema formation particularly around the
face, cheeks and eyes
o Wilms Tumor rare tumor of the kidney caused by taking high
doses of certain AAS
o List is not conclusive but indicative of what is discussed in the
literature
Whitehead R, Chillag S, Elliott D. Anabolic Steroid Use Among Adolescents
in a Rural State. The Journal of Family Practice. 1992;35;401-405.
- Two hundred and five male high school students in the state of WV
reported using AAS (5.3%)
- AAS users also reported a high prevalence of illicit drug and
cigarette use as opposed to non-users
- Primary reason for using AAS was to improve appearance (43%)
Stilger VG, Yesalis CE. Anabolic-Androgenic Steroid Use Among High
School Football Players. Journal of Community Health. 1999;24:131-145.
- 873 Indiana high school football players were surveyed 6.3% were
current or former AAS users
- Average age at time of first using AAS was 14 years, 15% began
taking them prior to the age of 10, and 67% before 15
- Half of the subjects indicated they could obtain AAS if they desired
- Athletes, physicians, and coaches were listed as the primary sources
for obtaining AAS
Other Issues

Denial is a major issue

o Athletes
o Coaches
o School boards
o Athletic directors
o Medical professionals
o Conference commissioners
- Size and strength of todays athletes
o Weight gains over the years
o Size of todays athlete
o Quick fixes
Human Growth Hormone (HGH)
- Extracted from the pituitary gland of cadavers
- Now is synthetically manufactured
o Difficult to detect in the urine
- Promotes lean body mass and decreases in fat
o Increases training intensity
No data or research to support that it works
o Particularly with speed and strength
Substance and Drug Abuse
You will have to deal with an individual who is taking illegal substances
or medications
Know that were not trained specifically in dealing with these
situations, but need to recognize, consult and perhaps refer.
Watch for personality changes
Substance abuse symptoms on hand out

FIN