Dental Decks NDB Exam Part 2 pharmacology

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1.

2.

3.

4.

5.

which corticosteroid is
adminsitered by inhalation to
treat asthma?
hydrocortisone, prednisone,
cortisone, fluticasone (Flonase),
or Methylprednisolone (Medrol)

Fluticasone (Flonase)
- others inhaled are Triamcinolone (azmacort), Beclomethasone (Beconsase), and Budesonide
(Pulmicort)

the major natural

mineralcorticoid in humans is ?

ALDOSTERONE.
- cortisol, prednisone and dexamethasone are glucocorticoids.

which gland secretes aldosterone

?

secreted by cells in the ZONE GLOMERULOSA of the adrenal cortex.

- secretion is regulated by the ACTH and by the renin-angiotensin system.
- aldosterone promotes the reabsorption of sodium into the blodo from the glomerular filtrate.
potassium is lost in the urine becsue of the electronegativey that is created by the reabsorption of
hte sodium in the kidney tubules.
Due to this increased blood aldosterone levels result in high sodium and low potassium levels in
the plasma.......if this were lacking:
decreased sodium concentration causes the juxtaglomerular cells of the kidneys to secrete renin,
which converts angiotensinogen to angiotensin 1. angiotensin 1 converts to angiotensin II which
in turn stimulates the adrenal cortex to release aldosterone.
- ADH (Vasopressin - antidiuretic hormone) decreases urine production by increasing the
reabsorption of water by renal tubule (increases permeability of collecting ducts and distal
tubules).
------ at high concnetrations ADH can cause arterioles to constrict (increases blood pressure) .

Name a disease that is caused by

the hyposecretion of aldosterone
and cortisol?

Addison's disease is caused by the hyposecretion of aldosterone and cortisol. Addisonian crisis is
an illness wherethere may be very low blood pressure (low Na in blood) and a coma.
- ACTH is produced by the pituitary gland. adrenocorticotropic hormone. (stress rises -> acth up -> cortisol up)
- CRH released by hypothalamus (corticotropin releasing hormone) - polypeptide hormone and
neurotransmitter. crh stimulates ACTH

name two types of

corticosteroids:

1. glucocorticoids: affect carbo, lipid and protein metabolism. used as anti-inlammatory agnets.
2. mineralocorticoids regulate sodium and potassium metabolsim.

- adv of inhaled are decrease inflammatio in airway in asthma. lower inflammation enhances
bronchodilating effects of the beta 2 adrenergic agonists.
- disadvantage of inhaled steroids is a cause of fungal infection of the mouth and throat.

Adverse reactions include Cushing's syndrome (obesity and weakening of muscles),

hyperglycemia, osteoporosis, peptic ulcers, and increased risk of infection. Contraindications
include latente infections (fungal,viral, or bacterial), AIDS, herpes, gastric ulcers, and CHF.
Inhaled corticosteroids do not achieve sig blood levels to cause adverse effects but aerosol
corticosteroids like triamcinolone (Azmacort), beclomethasone (Beconase), fluticasone (Flovent)
and budesonide (Pulmicort) can lead to localized infections and Candida albicans .
6.

Alprazolam (Xanax) and

Triazolam (Halcion) are what
type of drugs?

Tranquilizers (Benzodiazepines)
others are chlordiazepoxide (Librium), diazepam (Valium), flurazepam (Dalmane), midazolam
(Versed), lorazepam (Ativan).
- IV benzos cause conscious-sedatio for outpatient surgery.
- depress limbic system and reticular formation through potentiation of the inhibitor
neurotransmitter gamma-amino-butyric acid (GABA) found in the brain.
- adverse effects are: fatigue, slurred spech, drowsiness, DRY MOUTH, nausea as well as
hypotension and muscle relaxation.
- tolerance nad phys dependence can occur with prolonged high dosage.

7.

8.

9.

10.

11.

12.

which benzodiazepine comes as a liquid for pre op

sedation in children and injectable for IV conscious
sedation?

Midazolam (Versed)
- flurazepam (Dalmane), temazepam, and midazolam (Versed) are
prescribed for treatment of insomnia.

the most common adverse effects associated with

benzodiazepines include all of the following except:
- cns depression (drowsiness and sedation)
- gi disturbances (nausea, vomitting and diarrhea)
- confusion
- respiratory depression
- disorientation
- ataxia

Answer: respiratory depression. (if taken w/ alcohol serious

potentiation of sedative effects leads to respiratory depression).
- with normal dosing benzos have little effect on respiraotry systems.
- benzodiazepines, barbiturates, and narcotic analgesics all prodcue
sedation and have the ability to produce dependence!

Name a benzodiazepine antagonist that may be used to

reverse the residual effects of benzodiazepines in the
event of an overdose.

Flumazenil (Mazicon).

Busprione (BuSpar) is clasified as a minor trnaguilizer

which works by what mechanism?
-GABAmimetic
- diminish serotonergic activity
- Cholinomimetic
- diminish glutamate activity

Buspirone diminishes serotonergic activity.

- oral anxiolytic
- distinct pharmacology and also no anticonvulsant or muscle
relaxant properties.
- does NOT impair psychomotor function and does NOT cause
sedation or physical dependence.
- slow onset of action (couple weeks), probably acts on 5hydroxytryptamine (serotonin) receptors to diminish serotonergic
action.
- side effects are restlessness, dizziness, headache, nausea, diarrhea,
and paresthesias.
Long term risk --- tardive dyskinesia.

Most common side effect of diazepam (Valium) is?

drowsiness, fatique.
- tx nervous tension, ms spasm, and anticonfulsant.
- contraindications: acute narrow angle glaucoma and psychoses.
- agent of choise to reverse status epilepticus induced by a local
anesthtic overdose.
- if given intravenously use a large vein to decrease the risk of
thrmobophlebitis.(thrombo - vein inflammation, phlebitis - blood
clot) . propylene glycol in the IV mix is hte main cause of
thrombophlebitis.

the barbiturates phenobarbital (Luminal),

mephobarbital (mebaral), and Primidone (Mysoline) are
classified as what type of barbiturate (wrt duration of
action)?

Long acting
- relates to lipid solubility. ultrashort being the most lipid soluble and
long acting the least lipid soluble.
- metabolized by liver.
-- ultrashort - 5-20 minutes for induction of general anesthsia. ie
thiopental (Pentothal) and methohexital (Brevital).
-- short acting - 1-3 hrs for treating insomnia like secobarital
(Seconal) and pentobarbital (Nembutal).
-- intermediate 3-6 hrs - also insomina and include amobarbital
(Amytal) and butabarbital (Butisol)
-- Long acting for daytime sedation and as an anticonfulsant.
examples are phenobarbital (Luminal) and mephobarbital (Mebaral)
and primidone (Mysoline)

- ataxia is the gross lack of coordination of muscle movements. (

movement coordinated in the cerebellum).
- barbituates are largely replaced by benzodiazepines due to less risk
of overdose. pentobarbital and phenobarbital are examples.
phenobarbital used for anti-convulsants.

13.

do barbiturates possess
analgesic properties?

No, barbiturates do not posses analgesic properties.

- barbiturates are from barbituric acid.
- act on GABA receptors but different than benzos.. a GABA potentiator.....
- also acts on AMPA which is a non- NMDA type -ionotropic transmembrane receptor for glutamate
(major neurotransmitter of the body).
- barbituate poisoning - respiratory failure - assure adequtae respiration.

14.

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16.

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19.

the brief duration of general

anesthetic action of an ultrashort-acting barbituate is
due to what factor?

- rapid rate of redistribution for the brain to peripheral tissues.

- these agents maintain anesthesia only while in the brain. because of their high lipid solubility they
rapidly leave the brian.
- examples of ultra short are thiopental (Penthothal) and methohexital (Brevital).
- these durges have hte ability to produce dependence!
- contraindications: porphyria (porphyrin is the main precursor to heme), liver dysfunction,
emphysema, previous sedative addition.

All of the following are

pharmacologic effects of
glucocorticoids except:
- decrease in gluconeogenesis
- decrease in utilization of
glucose
- inhibition of protein
synthesis
- an increase in protein
catabolsim
- impaired wound healing
- a decreased resistance to
infection

answer: a decresae in gluconeogenesis!

- glucocorticoids ENHANCE gluconeogenesis through the breakdown of endogenous proteins to
amino acids, when are then converted to glucose for storage in the liver.
- other effects: anti-inflammatory action, immunosuppression, anti-alergenci.
Mineralocorticoidds: increase sodium retentions and increase potassium deplection can lead to
edema and hypertension if excessive.

beclomethasone, budesonide,
and flunisolide are what type
of drugs?

they are special glucocorticoids (inhalers). developed for chrnoic asthma and bronchial disease.
penetrate the airway mucosa but very short half-lives after they enter the blood so systemic effects and
toxicity is greatly reduced.

the major natural

glucocorticoid is?

Cortisol (hydrocortisone)
- corticosteroids produced by adrenal cortex...two groups...glucocorticoids and mineralocorticoids.
- glucocorticoids - metabolism, catabolism, immunes repsone, and inlammation. they act on
arachidonic acid metabolism, induce syntheis of a protein that inhibits phospholipase A2 , thus
decreasing the production of both prostaglandins and leukotrienes. Synthetic glucocoritcoids are
prednisone, prednisolone, dexamethasone, and triamcinolone.
- mineralcorticoids regulate Na and K+ reabsorption in collecting tubules of the kidney. The major
natural mineralocorticoid is ALDOSTERONE.
- corticosteroids don't cure, just replace.
- may cause peptic ulcers.
- toxic effects of corticosteroids include growth inhibition, hyperglycemia, osteoporosis, psychosis
and salt retention.

posoning with an
organophosphate
cholinesterase inhibitor can
be treated with?

Pralidoxime (Protopam)
- a cholinesterase reactivator used as an antidote to reverse muscle paralysis resulting from
organophosphate anticholinesterase pesticide poisoning.
- used if overdose of anti-cholinesterase agents used to treat myasthenia gravis (ie neostigmine,
pyridostigmine, and ambenonium) - MG is muscle weakness and fatigue.
- organophosphate poisoning: excessive salivation, bronchoconstriction, diarrhea, and skeletal ms
fasciculations (twitching)

isoflurophate and
echothiophate are examples
of ?

organophosphates (inhibit cholinesterase)

- tx glaucoma.
malathion nad parathion are cholinesterase inhibitors used as insecticides.

20.

21.

22.

all are true of edrophonium except?

- direct acting cholinergic agonist
(cholinomimetic)
- rapid acting, short duration, injectable
cholinesterase inhibitor
- drug of choice for dx myasthenia gravis
because of rapid onset and reversibility.
- useful in differentiating a myasthenic crisis
form a cholinergic crisis

It is false that it is a direct acting cholinomimetic.

It is an indirect action cholinergic agonist (no cholinesterase - more cholinergic
action).....cholinomimetic.
- other cholinomimetics are neostigmine, pyridostigmine, and physostigmine- all
cholinesterase inhibitors)
------ cholinergic crissi: bradycardia (decreased heart rate), lacrimation, extreme
salivation, vasodilation, and muscle weakness.

why is it difficult to distinguish myasthenia

gravis and cholinergic crisis?

they both result in muscle weakness.

- administration of short acting cholinomimetic such as edrophonium will
improve myasthenic crisis but worsen the cholinergic crisis!

list typical cholinergic effects?

- salivation, miosis (constriction of the pupil), excessive sweating, flushing,

increased GI motility, and bradycardia.
- remember cholinergic effects are caused by the stimulation of acetylcholine
receptors (cholinergic receptors)
mydriasis is dilation (more vivid images at night)

23.

in dentistry a cholinergic drug is used to?

- treat a dry mouth by inducting salivation

24.

name two cholinergic drugs used in dentistry.

- pilocarpine (Salagen) - indicated for xerostomia caused by salivary gland

hypofunction resulting form radiotherapy for cancer of hte head nad neck. It is a
cholinergic agonist. Side effects are excess weating, nausea, heartburn, and
diarhea
- cevimeline (Evoxac) - tx of symptoms of xerostomia in patieths with Sjogren's
syndrome. It is a cholinergic agonist. Side effects are sweating, nausea, hearburn
nad diarrhea

25.

26.

All of the following are choline esters except?

pilocarpine (Pilocar)
methacholine (Provocholine)
Bethanechol (Urecholine)
Carbechol (Isopto-Carbachol)

-- Pilocarpine (Pilocar)
------- pilocarpine is a cholinergic alkaloid.

Name a non-dental use for pilocarpine?

- pilocarpine is the most useful alkaloid employed as a miotic and to treat open
angle glaucoma.
- glaucoma associated with optic nerve damage often due to increased pressure in
the eye (aqueous humor).
open v closed angle often differentiated by speed of onset (closed is rapid and
often painful, open is slower and people often put off tx until irreversible damage
occurs).

- choline esters lower blood pressure attributable to generalized vasodilation,

flushing of hte skin, and slowing of hte heart rate. There is increased tone nad
activity of GI and urinary tractis. These drugs tend to cause miosis and decrease
intraocular pressure. Carbachol used in ophthalmology to produce miosis.

- cholinesterase inhibitors like physostigmine, neostigmine, edrophium,

pyridostigmine, malathion, and parathion inhibit acetylcholinesterase at BOTH
muscarinic and nicotinic sites. indirect acting cholinomimetic agents.
27.

True or False: All the following drugs have an

action which results in increased effects of
acetylcholine within the autonomic nervous
system AND at hte neuromuscular junctions:
-neostimine
-physostigmine
- edrophonium
- pyridostigmine

True.
cholinestarase inhibitors - acetylcholine not broken odwn....
direct cholinergic effect are choline esters (methacholine, carbachol,
bethanechol) and choline alkaloids (pilocarpine).
- acetylcholine does stimulate skeletal ms contractions at the neuromuscular
junctions but the excess acetylcholine eventually results in muscle paralysis.

28.

The prototype
depolarizing
neuromuscular blocking
agent is?

Succinylcholine (Anectine)
- neuromuscular blockign drugs prodcue complete skeletal muscle relaxation and facilitate endotracheal
intubation. adjunt for surgical anesthesia.
- **** succinylcholine may cause MUSCARINIC responses such as bradycardia and increased glandular
secretions.

29.

30.

31.

what type of receptors to

neuromuscular blocking
drugs work on?

these neuromuscular blocking drugs interact with nicotinic receptors at the skeletal neuromuscular
junction. The two classes are nondepolarizing and depolarizing.
- nondepolarizing - competitive compete with acetylcholine at hte nicotinic receptor. prevent Ach from
stimulating so result is muscle paralysis.
- depolarizing (non-competitive) - Sucinylcholine (anectine) only one used in US. It desensitizes the
neuromuscular end plate. it binds to the ACh receptor and stimulates depolarization causing initial
excitation followed by block of neurotransmission and muscle paralysis.

name a currently
available ganglionic
blocker for clinical use:

mecamylamine (Inversine) and Trimethaphan (Arfonad)

---- when would you use mecamylamine and or trimethaphan.....an emergency hypertension.

ganglion blocking drugs

fall into what larger class
of drugs?

nicotinic receptor antagonists (nicotinic blocking agents)

- there are two types: ganglion-blocking drugs and neuromuscular blocking drugs.
- neuromuscular at at neuromuscular junction of hte somatic system
- gnaglionic blockers act at the autonomic ganglia (both symp and parasympathetic)
***side effects of blocking parasympathetic are severe xerostomia, constipation, and hypotension.
therefore, used for rapid and reversible fall in blood pressure..... an emergency hypertensive crisis......

32.

list the cholinergic

actions:

- cholinergic ----- "the colon is urgent!"

--- stim sweat, salivary, tear and bronchial glands
--- stim smooth muscles of the bronchi, GI tract, gallbladder, bilde duct, bladder and ureters (urination)
---slowing of the heart (bradycardia)
---constriction of the pupils (miosis)
*** Acetylcholine is the chem mediator at ALL autonomic ganglia and at the parasympathetic
postganglionic synapses. It is also the transmitter substance of the neuromuscular junction in skeletal
muscle (local anesthetics prevent or reduce the liberation of Ach at the NMJ and sweat glands).
Acetylcholine causes an alteration in CELL MEMBRANE PERMEABILITY to produce the appropriate
bodily actions.

33.

34.

Methyldopa (Aldomet) &

Clonidine (Catapres) are
what types of drugs?

centrally acting antihypertensives.

Tolazoline (Priscoline) is
what type of drug?

moderate alpha-2 adrenergic blocking activity.

--- leads to direct peripheral vasodilation.

- methyldopa produces alpha-methylnorepinephrine which replaces norepinephrine in the vesicular

storage sites and is released by the nerve impulse.Leads to hypotension and bradycardia.

remember peripheral nervous system--> somatic and autonomic. autonomic nervous system --->
parasympathetic nervous system and sympathetic nervous system.

35.

sympathetic is to
_____ as
parasympathetic
is to ____

sympathetic is to * adrenergic * as parasympathetic is to " muscarinic".

--- At the effector organs, sympathetic ganglionic neurons release noradrenaline (norepinephrine), along with other
cotransmitters such as ATP, to act on adrenergic receptors, with the exception of the sweat glands and the adrenal
medulla:
--- sweat glands are part of sympathetic nervous system but have muscarinic receptors.
--- In the parasympathetic system, ganglionic neurons use acetylcholine as a neurotransmitter, to stimulate
muscarinic receptors.
-- At the adrenal cortex, there is no postsynaptic neuron. Instead the presynaptic neuron releases acetylcholine to act
on nicotinic receptors.
---- t he adrenal medulla is the center part of the adrenal gland (surrounded by adrenal cortex) .

36.

Tolazolien
(Priscoline) is
what type of
drug?

parenteral antihypertensive moderate alpha-2 adrenergic blocking drug.

Antiadrenergic agents inhibit the signals of epinephrine and norepinephrine. They are primarily adrenergic
antagonists, (Alpha Blockers and Beta Blockers) inhibiting adrenergic receptors, but there are exceptions: clonidine
is an adrenergic agonist on the 2 receptor, since this receptor is located presynaptically to inhibit further release of
adrenaline and noradrenaline. (other exceptions are clonidine, guanfacine, and guanabenz)...stim central alpha-2
adrenergic receptors...thereby inhiitni gsympathetic nervous system outflow.
Other ways of inhibiting adrenergic signaling is by catecholamine synthesis blocking, e.g. by methyltyrosine.
Reserpine works by inhibiting transport into synaptic vesicles of noradrenaline by inhibiting the VMAT.

37.

38.

39.

what is a
clinically
significant
adverse reaction
to metoprolol?

drowsiness:
metoprolol (Lopressor) is a competitive beta-1 selective blocker.

if a drug is
selective beta 1
blocker it can be
said that it is
_____?

cardioselective.....
the most common cardioselective drug is Atenolol.
- Atenolol has a long plasma half life. It has low lipid solubility and minimally metabolized.
-- due to low lipid soluble beta blockers has a low potential for CNS side effects --- Metoprolol and atenolol are
cardioselective.
----- this is important....non-selective like propranolol have higher cns side effects and are a higher risk for pt's with
a history of asthma or bronchitis.

describe the
autonomic
function of
salivary glands:

sympathetic nervous system (adrenergic)

--- beta stimulates viscous, amylase secretions
--- alpha-1 stimulate potassium secretions

**** the most common side effects of beta blockers are weakness and drowsiness.

parasympathetic (muscarinic)
--- M3 stimulates watery secretions.
The parotid gland secretes alpha-amylase ( via Stensen's duct) which is the first step in the decomposition of
starches during mastication. It breaks down amylose (straight chain starch) and amylopectin (branched starch) by
hydrolyzing alpha 1,4 bonds.
The secretory viscous cells of the submandibular gland have distinct functions. The mucous cells are the most active
and therefore the major product of the submandibular glands is saliva. In particular, the serous cells produce
salivary amylase, which aids in the breakdown of starches in the mouth. Mucous cells secrete mucin which aids in
the lubrication of the food bolus as it travels through the esophagus.
The submandibular gland's highly active acini account for approximately 70% of salivary volume. The parotid and
sublingual glands account for the remaining 30%. (Sublingual gland via sublingual duct - Bartholin)

40.

epinephrine reversal is a
predictable result of the use of
epinephrine in a patient who
has received a/an.......?

alpha- blocker
--- alpha blocker is an antiadrenergic - these have the ability to reverse the actions of adrenaline
(epinephrine) ....sometimes called pressor actions because epi and norepi both cause blood pressure
to rise. If the alphas are blocked...effect of norepinephrine is reduce/abolished while epinephrine
brings about a FALL in blood pressure.
why would epi cause a fall?......epinephrine stimulate both alpha nad beta receptores in the
cardiovascular system!! Norepinephrine ("Nope Two Beta fun") has no beta 2 effects - just beta 1 . So,
epinephrine only effects beta receptors in this case.
--- remember beta-1's generally have to do with heart.... beta -1 bascially increase heart rate and
action at SA and AV nodes and contractility....no alpha adrenergic action...to relax it is
parasympathetic and mostly M2 receptors to relax....
---- beta - 2's relax vascular smooth ms and dilate veins. and dilate arteries to skeletal ms. alpha's
constrict the veins and vascular smooth ms.
----- a pressor response (inc blood pressure) mediated by alpha receptors and a depressor response
(decrease blood pressure) is mediated by beta-2 receptors.

41.

somebody is having an
anaphylactic reaction at the
dental office.......what is a type
of drug you could give and
why?

give the patient EPINEPHRINE:---- possibly sublingually.

this stimulates both the alpha nad beta adrenergic receptors. alpha receptors stimulate vasopressor
response (elevate blood pressure) and beta receptors stimulate air way dilation and increased cardiac
output. In this way, epinephrine counteracts the vascular effects of a histamine related anaphylaxis.
anaphylaxis results in throat rash, itchy rash, and low blood pressure.
Four types of histamine receptors. H1-H4. H1 causes bronchoconstriction and smooth muscle
constriction. they cause vasodilation and increased permeability.
remember- in the pulmonary system fight or flight sympathetic reaction...you would want more air to
fight....beta 2 response is to relax (alpha - 1 contracts but that is a minor effect --- the maor effect is
the beta-2). Here the parasympathetic contracts ....M3 stuff.

42.

43.

this agent produces

physiologic actions opposite
to that of histamine?

epinephrine:
- alleviate symptoms of an acute astham attack.
- tx bronchospasm associated with hypotension as in anaphylzx
--- treat hypersensitiivty reactions
- prolong activity of local anesthetic
- restore cardiac activity in a cardiac arrest
- relieve congestion of nose, sinus, and throat.
-.... common side effects are headaches, agitation and tachycardia.
use in caution w/ pt's who have high blood pressure, hyperthyroidism, etc.

Salmeterol and
metaproterenol are ?

beta 2 adrenergic receptor AGONISTS.

bronchodilators....along with albueterol (proventil) and epinephrine. stim beta recepotrs in airway
to cause bronchodilation. take via aerosol inhalers and nebulizer.
aminophylline is a "theophylline compound" ....administered orally as bronchodilators in reversible
airway obstruction due to asthma or copd. theophylline relax bronchial smooth muscle to improve
airway function.

44.

45.

all of the following neurons are

cholinergic except?
preganglionic sympathetic neurons
preganglionic parasympathetic
neurons
postganglionic sympathetic neurons
postganglionic parasympathetic
neurons

postganglionic sympathetic neurons are adrenergic and secrete norepinephrine.

alpha adrenergic receptors are located

on?
- vascular smooth muscle
-presynaptic nerve terminals
- blood platelets
- fat cells
- neurons in the cns
- all of the above.

all of the above

- alpha receptors mostly responsible for excitatory effects
- beta recepotrs mostly inhibitory effects like vasodilation and relaxation of respiratory
smooth muscles.
**** two important exceptions.
- alphas mediate relaxation of GI smooth ms.
- betas increase force and rate of contraction of heart.

- preganglionic of both sympathetic and parasympathetic are cholinergic neurosn that

secrete acetylcholine.
---- adrenergic blockign agents block the effect of impulses transmitted by the adrenergic
postganglionic nerusons of hte sympathetic branch. alpha and beta adrenergic blocking
agents act by "COMPETITIVE INHIBITION"

alphas are postjunctional alhpa1 and prejunctional alpha 2

-postjunction alpha 1 in radial smooht ms of the iris, arteries, arterioles, and veins...in
the GI tract.
-prejunction alpha 2 mediate the inhibition of relesae of norepinephrine.
betas are postjunctional beta1 and postjunctional beta 2
- postjunctional beta 1 in myocardium, intestinal tract smoooth muscle, and adipose
tissue.
-- postjunctional beta 2 in bronchiolar and vascular smooth ms.
46.

Tolazoline (Priscoline) and doxazosin

(Cardura) and Prazosin (Minipress)
are what type of drugs?

alpha blockers.
- alpha blockers competitively inhibit action of catecholamines at the alpha receptor sites.
they act on blood vessels causing them to relax.
- selective alpha antagonissts only block alpha-1 receptors are are common for cardiac
conditions.
- nonselective alpha antagonsists block both receptors . can cause tachycardia and
palpitations. sometimes used to treat raynaud's phenomenon.

47.

tyramine and methamphetamine are?

indirect-acting adrenergic agonists.

- cause release of stored norepinphrine at the post ganglioncic nerve endings to produce
their effects.
direct acting:
phenyleprine - alpha 1 agonist
albuterol - beta 2 agonist
epinephrine - alpha 1,2 and beta 1,2
norepinephrine - alpha 1,2 and beta1 (no beta 2!)

48.

adrenaline stimulates?

both alpha 1,2 and beta 1,2 receptors.

alpha 1 is the most common alpha receptor and beta 2 is the most common beta receptor.
--- remember .. norepeinphrine doesn't interact with the most common beta receptor.

49.

if you need to control superficial

hemorrhage what could you use?

use an adrenergic agonist: specifically an alhpa 1 adrenergic agonist... a

vsoconstricotr....epinephrine (adrenalin)
- for a nasal decongestant use an alhpa 1 adrenergic agonsit as well...a vasoconstrictor
...phenylephrine (neosynephrine) is a good option ...

50.

list the four types of

sympatholytic drugs:

sympatholytic = anti-adrenergic.....all use to treat hypertension.

1. beta adrenergic blockers
- propranolol - beta 1 and beta 2 blocker.
atenolol adn metoprolol are selective beta 1 blockers.
2. alpha adrenergic blockers
- tolazoline blocks alpha 2 receptors.
- phentolamine blck alpha 1 and alpha 2.
- prazosin block alpha 1
3. centrally acting agents...inihibit nerve transmission through cns actions
- clonidine, guanfacine, guanabenz, and methyldopa
4. neuronal depleting agents - deplete catecholamine (NE) and serotonin stores from adrenergic terminals and
in the brain.
- reserpine
- guanethidine

51.

52.

the following four

symptoms result
from what type of
drug?
- lower blood
pressure
- vasodilation
- tachycardia
- orthostatic
hypotension

alpha adrenergic blocker.

- doxazosin, prazosin and terazosin are all selective alpha 1 blockers to treat hypertension...terazosin also used
to treat benign prostate hyperplasia.

list three therapeutic

uses of
amphetamines?

- they are sympathomimetic amines that effect both peripheral and sympathetic nervous systems.
- amphetamines INCREASE systolic and diastolic blood pressures and they act as weak bronchodilators and
respiratory stimulants.
- they have a HIGH POTENTIAL FOR ABUSE...they readily pas into the cns nad cuase a rapid release of
norepinephrine in the brain.
treat:
1 - adhd (amphetamine (adderall)
2 - narcolepsy (dextroamphetamine) to prevent daytime sleepiness
3 - weight loss

53.

T/F epinephrine is
ideal to prevent
angina pectoris?

false
- i tis contraindicated in angina conditions becasue its cardiostimulatory effects would aggravate this
condition.
- epinephrine could though restore cardiac activity in a cardiac arrest.
epinephrine is ideal to reverse an anaphylactic rxn. anaphylaxis is
charactehttp://quizlet.com/7951803/edit/rized by rapid, exreme reduction in blood presure nad
bronchospsms. epi would reverse hypotesion via alpha 1 stim, dilate bronchial tubes via beta 2 and increase
cardiac output via beta 1.

54.

55.

56.

halothane and
isoflurane are?

inhalational anesthetics
- simple lipohilic molecules.

What is considered
the first symptom of
NO2

- tingling in the hands

- main tehrapeutic effect of nitrous oxide (N20) is relaxation/sedation. Mild analgesia is a secondary effect.

what color tank is

nitrous oxide stored
in?

blue (oxygen is green)

57.

58.

59.

60.

what is the failsafe

mechansim for
nitrous oxide delivery?

mechanism doesn't allow less tan 20% oxygen to the patient.

List the typical bodily

responses to nitrous
oxide at both 10-20%
and 20-40% nitrous.

10-20: tingling of hands, feet, and body warmth

20-40: mild sleepiness, relaxation, some analgesia, mind dissociation, heightened audiotry perception.

list three reasons why

epinephrine is
included in dental
anesthetics?

epinephrine is a vasoconstrictor so it:

1. prolongs duration of local anesthetic
2. provides hemostasis
3. delay absorption of anesthetic into the systemic circulation thus reducing hte chance of systemic toxicities

name the four stages of

general anesthesia
with respect to
inhalants.

1. amnesia/anelgesia
2. delirium (dilated pupils, tachycardia, hypertension)
3. surgical (four planes)
4. medullary paralysis (cessation of respiration)

above 50 --- too much nitrous leads to nausea and sweating

some inhalants are desflurane, sevoflurane, halothane, isoflurane, and enflurane

61.

62.

name the only amidetype local anesthetic

that is metabolized in
the bloodstream
rather than the liver.

articaine (septocaine)

which component of
lidocaine local
anesthetic solution
causes an allergy?

bisulfites

- an amide-type local but it is unique due to the ester group attached to its molecule which can be acted upon
by plasam cholinesterase to render it ineffective.

- other components are water, lidocaine, and epinephrine.

- sodium metabisulfite preetns the oxidation of epi vasoconstrictor in thos ecomercial preps containing epi.
most patients reacting to bisulfites have a hisory of asthma nad the airway is hyperactive to hte sulfite.s
allergic rxn usually is an asthmatic syndrome of whezing and bronchial constriction.
**** hypersensitivity or allergic reactions ot local anesthetics, particularly the amides, are much more rare
than allergic reactions to the bisulfites.

63.

64.

65.

Name a local
anesthetic
preparation that does
not have
vasoconstrictor.

mepivacaine 3% (carbocaine 3%)

-- no epi..therefore no bisulfites....therefore less chance of a hypersensitivity reaction.

why do you give 100%

oxygen following
nitrous oxygen use?

prevent diffusion hypoxia

name
contraindications for
nitrous oxide use?

upper respirotry infections, emphysema, bronchitis, and first trimester of pregnancy.

Emphysema is called an obstructive lung disease because the destruction of lung tissue around smaller sacs,
called alveoli, makes these air sacs unable to hold their functional shape upon exhalation. It is often caused
by long-term exposure to air pollution or smoking. (The anteroposterior diameter of their chest may increase;
this symptom is sometimes referred as "barrel chest." The patient may lean forward with arms extended or
resting on something to help them breathe.)

66.

a "blue
bloater" is
said to have?

chronic bronchitis.
Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in
clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years.[12] In
the airways of the lung, the hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size
(hypertrophy) of the goblet cells and mucous glands of the airway. As a result, there is more mucus than usual in the
airways, contributing to narrowing of the airways and causing a cough with sputum. Microscopically there is
infiltration of the airway walls with inflammatory cells. Inflammation is followed by scarring and remodeling that
thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there is squamous
metaplasia (an abnormal change in the tissue lining the inside of the airway) and fibrosis (further thickening and
scarring of the airway wall). The consequence of these changes is a limitation of airflow.[13]
Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred
to as "Blue Bloaters" because of the bluish color of the skin and lips (cyanosis) seen in them.[14] The hypoxia and fluid
retention leads to them being called "Blue Bloaters".
[edit] Emphysema
Main article: emphysema
Lung damage and inflammation of the air sacs (alveoli) results in emphysema. Emphysema is defined as enlargement
of the air spaces distal to the terminal bronchioles, with destruction of their walls.[12] The destruction of air space
walls reduces the surface area available for the exchange of oxygen and carbon dioxide during breathing. It also
reduces the elasticity of the lung itself, which results in a loss of support for the airways that are embedded in the lung.
These airways are more likely to collapse causing further limitation to airflow. The effort made by patients suffering
from emphysema during exhalation, causes a pink color in their faces, hence the term commonly used to refer to them,
"Pink Puffers".
There are 4 types of emphysema:
Centriacinar / centrilobular: proximal to central parts of acini (air spaces closer to bronchioles) are affected
Panacinar / panlobular: enlargement of all air spaces (from bronchioles to terminal blind alveoli). This type is
associated with alpha-1-antitrypsin deficiency
Distal acinar / paraseptal: proximal acinus normal, distal acinus affected
Irregular: various parts of acinus involved. Associated with fibrosis.[15]

67.

what is the
max dose in
mg/kg for
articaine for
children?
adults?

7 mg/kg for both.

for a 70 kg adult male (a bit over 150lb) would be 490 mg.....if 1.7 mL carpule.... then 68 mg/carpule 2 carp 136 , 4
carps 272, 7 carpules is 476 mg. Also remember .017 mg epi per carpule for 1.7 mL......all other anesthetics are 1.8 mL
carpules..
my math: 7mg/kg divided by 2.2 lb/kg equals 3.18 mg/lb.......approx 3mg/lb......safety factor.....150 lb
person......450mg

68.

69.

local
anesthetics
depress
which type of
nerve fiber
first?

small unmyelinated fibers (they conduct pain and temperature)

list the
general order
of loss of
function due
to use of local
anesthetics.....

1. pain
2. temp
3. touch
4. proprioception
5. skeletal muscle tone.

--- they depress the large myelinated fibers last.......the small nerves have the greater surface-volume ration (thisis wy
they have a rapid onset of action).

70.

71.

72.

describe in general terms, how

local anesthetics work.

they appear to become incorporated within hte nerve membrane or to ind to specific membrane
sodium ion channels
- restric sodium permeability in response to PARTIAL DEPOLARIZATION.

max dose of local anesthetic to a

child less than 10 years ld is
determined by?

weight.

the max recommended adult dose

of lidocaine is 300 mg. How many
milliliters of 2% lido is needed to
reach this?

15 mL

for lidocaine...don't exceed 4.4 mg/kg with max of 300 mg.

2% lido so 20mg for every milliliter. 300 mg is max dose so 300/20 = 15...therefore 15mL's.
and 300mg / 36 mg per carpule ....leaves 8.3 carpules...max

73.

74.

what are the max recommended

doses for lidociane, mepivacaine
(Carbocaine), prilocaine
(Citanest), and bupivacaine
(Marcaine)?

lidocaine (Xylocaine) 300 mg

mepivacaine (Carbocaien) 300 mg
prilocaine (Citanest) 400mg
Bupivacaine (Marcaine) 90 mg

local anesthetics theoretically

should be less effective in acutely
inflamed tissue than normal tissue
because?

the pH decreases, thus decreasing hte available free base.

body pH of 7.4 - locals have a portion ionized (proton attached - aka a H+ atom) and a portion
non-ionized (no proton attached). The part that is ionized has difficulty penetrating the nerve
and wil not be effective.
The non-ionized portion (free base) is more effective.
at pH of 7.4 then 10-20% of a local anesthetic is in the form of the free base (this is apparently
enough for anesthesia)

75.

name a local anesthetic that has no

place in the routine practice of
dentistry?

Cocaine!
- a naturally occurring ester of benzoidc acid.
first local anethetic used in dentistry and medicine.
- cocaine is commercially available in a variety of forms and is applied ot mucous membranes
of hte oral, laryngeal, and nasal cavities.
- despite being an excellent local anesthetic, risk of abuse and intense local vasoconstriction
prevent cocaine from being a more widely used clinical anesthetic.
- cocaine pharmacology is different as well.... it inhibits the uptake of catecholamines by
adreneric nerve terminals. it therefore potentiates the action of endogenously released and
exogenously administered sympathomimetic amines such as dobutamine, dopamine, or
epinephrine. an increased risk of developign cardiac arrhythmias and hypertension.

76.

77.

78.

list a contraindication / precaution

for the use of prilocaine.

- hepatic disease
also - prilocaine (citanest) is metabolized to orthotoluidine which prodcued
methamoglobinemia...characterized by increased levels of methamoglobin in the blood which
is less effective than hemoglobin in carrying oxygen in the blood.
** all amides are metabolized primarily in the liver, and the metabolites are then renally
excreted.

where are ester type local

anesthetics metabolized?

plasma
- by the plasma enzyme plasma cholinesterase (aka pseudocholinesterase) ....it splits the ester
- procaine (Novocaine) was the original ester-type anestheti.
- an ester grouping is essentially a bridge or link containing the - COOCH2 configuration.

what are ester type local

anesthetics mainly used for today?

topical anesthetics.
-- benzocaine, tetracaine, and dibucaine. medical anesthetic preparations to inclu
propoxycaine (ravocaine).

79.

80.

81.

describe why a patient is

allergic to procaine
(Novocaine)

plasma cholinesterase breaks the ester into a compound called paraminobenzoic acid (PABA). many
patietns develped an allergy to paba.

Name the only

nonbarbiturate sedativehypnotic agent that is
indicated in dentistry.

chloral hydrate
- traditionally used as an oral preoperative managemnt of the anxious pediatric patient...bad odor,
bitter, and caustic tase..... onset in 15 minutes and lasts 4 hours.
- children often enter a period of excitement and irritability before becoming sedated. chloral hydrate
doesn't relieve pain.
- chloral hydrate is a prodrug and is metabolized to the active metabolite trichloroethanol
- trichloroethanol may displace warfarin from its protein binding sites resulting in an increase in the
hypoprothrombinemic response to warfarin.
- sedative effects and or respiratory depression with chloral hydrate may be aditive with other cns
depressants. montior for increased effect ... includeds ethanol, antidepressants, narcotic analgesics,
and benzodiazepines.

which form of a local

anesthetic can readily
penetrate tissue
membranes?

nonionized free-base form.

free bases are fat soluble lipophilic drugs.
the potential action of all local anesthetics depends on the ability of hte anesthetic salt to liberate the
free base.

82.

describe the mechanism of

action of local anesthetics on
the nerve axon.

decreases sodium uptake through sodium channels of the axon. this decreases the nerves excitability
below a critical level and nerve impulses fail to propagate along the axon.
**** local anesthetics have no effects on potassium at the nerve axon.

83.

what are some adverse side

effects of local anesthetic?

toxicities and allergies.

toxicity: too much leads to toxicities to the cns and cardiovascular system. CNS effects include
restlessness, stimulation, tremors, convulsive seizures, followed by cns depresion, slowed respiration
and even coma. Cardiovascular effects include bradycardia and reduction of cardiac output.
allergy: hypersensitivities or allergic reactionsot local anesthetics, particularly from amides are rare.
usually manifested as dermatological reactions and edema at injection site. asthmatic wheezing
syndromes have occured. allergic reaction are more prevalent with ester-type rahter htan amide-type.
- ester local anesthetic allergic manifestations include nasolabial swelling, itchinga nd oral mucosal
swelling.

84.

85.

the amide local anesthetics

are metabolized primarily in
the ?

liver - use with caution for all patients with compromised liver function.

which amide type local

anesthetic has the longest
duration of action?

bupivacaine (marcaine) has the longest duration of action of any dental local anesthetic presently
available.
carbocaine (mepivacaine) 3% has 20 minutes or 40 minutes duration depending on route (infiltration
and IAN block)
citanest plain (prilocaine) 4% has 20 min & 2.5 hr.
citanest forte w/ epi (prilo) 4% has 2.25 hrs and 3 hrs.
lido 2% w/ epi has 60 and 90 minutes
marcaine (bupivacaine) 0.5% w/ epi has 60 min and 5-7 hrs.
articaine 4% w/ epi has 60 min and 60 min.

86.

the following drugs belong to what

pharmaceutical class of agents:
darbepoetin alfa, pegfilgrastim, and
sargramostin

answer: colony stimulating factors

darbeoetin: induces erythropoiesis by stim division and differentiation of erythroid
progenitor cells. used to treat anemia associated with chronic renal failure
pegfilgrastim: stim production, maturation, and activation of neutrophils. decreases
the incidence of infection by stimulation of granulocyte production in patients iwth
nonmyeloid malignancies.
sargramostin: used for myeloid reconstitution after autologous bone marrow
transplantation.
(myeloid cells describe any cells that are leukocytes but not lymphocytes)

87.

exemestane (Aromasin) and letrozole

(Femara) are anticancer drugs classified
under what category?

aromatase inhibitors
-- exemestane is an irreversible steroidal aromatase inactivator. prevents the
conversion of androgens to estrogens by tying up the enzyme aromatase. in breas
cancers wehre the growth is estrogen dependent, this drug will lower circulating
estrogens.
--- letrozole (Femara) works like exemestane. it is used as a first line treatment of
hormone receptor positive or metastatic breast cancer in postmenopausal women. it is
also indicated as an extend adjuvant treatment of early breast cancer in post
menopausal women who hae received 5 years of adjuvant tamoxifen therapy.

88.

your patient has a history of breast cancer

and is undergoing chemotherapy with a
drug called cisplatin (platinol). What are
the drug's expected adverse effects?

nausea and vomiting (75-100% dose related)

hair lose (alopecia)
xerostomia
changes within the tissues of hte oral cavity such as mucositis.
mucosisits is a common reaction to cancer chemotherapy. it is an inflammation of hte
mucousmembranes. during chemo and radiation therapy, mucosal tissues begin to
desquamate and develop into ulcerations. the mucosal integrity is broken and is
secondarily infected by the oral flora.
palliative tx is indicated for mucositis.

89.

What type of drugs are methotrexate,

doxorubicin, and 5-fluorouracil?

anti-neoplastics
*** these are commonly associated with the development of oral mucositis

90.

which complication is most likely seen

with chemotherapy treatment?

alopecia.
this occurs one to two weeks after treatment. other common side effects include GI
upset, increaed incidence of infection (especially candidiasis) and degeneration of
lymphatic tissue.
most chemotherapy agents have shown to be teratogenicin humans and should be
avoided by pregnant women

91.

name the 8 classes of drugs used in cancer

chemotherapy.

1. alkylating agents - alkylate DNA so it can't replicate.

--- ie Cisplatin and cyclophosphamide.
2. anthracyclines - destroy DNA so ca'nt replicate
--- ie daunorubicin and doxorubicin
3. antibiotics
--- ie dactinomycin
4. antimetabolites - interfere with biochem rxn needed for cell growth.
--- ie 5-FU (fluorouracil), 6-Mercaptopurine and methotrexate.
5. antimicrotubular inhibits cell mitosis
--- ie pupular agent is paclitaxel (taxol)
6. antiestrogen - blck tumors on which estrogen has a stimulatory effect.
--- ie tamoxifen (Nolvadex)
7. vinca alkaloids - these are mitotic spindle posons
-- ie vinblastine and vincristine
8. gonadotropin hormone releasing antigen - inhibits gonadotropin secretion
which is effective in reducing certain carcinomas.
-- ie leuprolide.
- asparaginase deprievs tumor cells of certain amino acids such that protein
production is blocked.
- interferon boos the immune system.

92.

antimetabolites are cell cycle specific drugs

acting primarily in which phase of the cell
cycle?

S phase of the cell cycle. The S phase of the cell cycle = DNA synthesis.
- these antimetabolites attack the cells in the S phase of reproduction cycle by
interfering with the biosynthesis of the purine and pyrimidine bases.
Go phase is the resting phase of the cell cycle.
methotrexate is a folic acid analog - choriocarcinoma, leukemia in spinal fluid,
osteogenic sarcoma, beast cancer and head and neck cancer.
flurorouracil (5-FU) and floxuridine are pyrimidine analogs. 5-FU used in some
head and neck cancers.
mercaptopurine and thioguanine are purine analogs. used to treat leukemias.

93.

alkylating agents are most effective in

treating?

chronic leukemias, lymphomas, myelomas, and carcinomas of the breast and

ovary.
- alkylating agents are a diverse group of compoundswhich all form alkyl bonds to
nucleic acids. these agents share similar mech of action and mech of resistance.
- the alkylating agents form covalent bonds with nucleic acids and prtien. the N7
position of guanine is a common binding site.
- mechlorethamine, cyclophosphamide, chlorambucil, and melphalan are
nitrogen mustards.
- carmustine, lomustine, and semustine are nitrosureas.
- myleran is a busulfan

94.

name the
common
pharmalogic
antagonist of
aldosterone in
the collecting
tubule.

spironolactone (aldactone)
- potassium-sparing diuretcs result in increased sodium and decreased potassium concentrations at hte end ofhte
distal convuluted tubules. there are two categories of potassium spariing diuretics.
1. antagonist of aldosterone in the collecting tubules. spironolactone has been found to be effective in the treatment
of primary aldosteronism. it may be useful in the treatment of heart failure because hyperaldosteronism is commonly
seen in this condition.
2. block the osdium channels in the collecting tubules. triamterene (dyrenium) and amiloride (midamor)
*** toxic side effect of these potassium sparing diuretics is hyperkalemia.
Aldosterone is a hormone that increases the reabsorption of sodium ions and water and the release (secretion) of
potassium in the collecting ducts and distal convoluted tubule of the kidneys' functional unit, the nephron. This
increases blood volume and, therefore, increases blood pressure. Drugs that interfere with the secretion or action of
aldosterone are in use as antihypertensives. One example is spironolactone, which lowers blood pressure by
blocking the aldosterone receptor. Aldosterone is part of the renin-angiotensin system.

95.

96.

97.

name the three

categories of
widely used
diuretics

- treats chf by relieving edema and symptoms of dyspnea arising from pulmonary congestion.

what type of
drug is dyazide

brand name for the combination of triamterene (Dyrenium) and hydrochlorothiazide (HCTZ)

how does insulin

affect protein
synthesis?

insulin increases protein synthesis.

1. thiazides - inhibit soidum reabsorption in the distal portion of hte rneal tubule within the kidney causing increaed
excretion of sodium and water.
--- ie hydrochlorothiazide (HCTZ)
2. loop diuretics - inhibits reabsorption of sodium and chloride in the ascending loop of henle, thus causing
increased secretion of water, sodium, and chloride.
--- prototype agent is flurosemide (lasix)
3. potassium sparing diuretics - conserve potassium while causing diuresis. thus no potassium is lost from the body
as is the case with other diuretics such as the thiazides and the "loops."
--- ie spironolactone (aldactone) and triamterene (dyrenium)
- triamterene promotes sodium and water excretion while retaining potassium.
- spironolactone (aldactone) which competes with aldosteone receptor sites in renal tubules causing increased
secretion of sodium, chloride, and water while conserving potassium.

(also increases triglyceride storage, increases glycogen synthesis, and decreases gluconeogenesis).
insulin is secreted by the pancreatic beta-cells of hte islets of Langerhans an dis essential for hte metabolism of
glucose and for hte homeostasis of blood glucose.
the four types of insulin are ultra-rapid acting, rapid acting, immediate acting, and long acting.

98.

How do most
drugs travel
through the
blood stream?

Most drugs travel through the blood steram by binding to ALBUMIN PROTEIN. this is abundant in plasma. this
way drugs are carried toall the tissues and organs.
- a drug which is bound to plasma albumin always has some fraction which is not bound. the unbound portion is
free to leave the blood compartment and to be taken up by tissues wehre they elicit hte pharmacological effect. the
reamining bound fraction of hte drug then coninuously releases mroe free drug to be taken up by the tissues.
- this is important to understand for drug interactions!. if drug A is administered first and then drug B (which hhas a
stronger binding affinity to albumin than A) is administered later it will displace drug A from albumin resulting in
large amounts of UNBOUND drug A whihc could lead to adverse reactions.

99.

100.

101.

102.

oral contraceptives block

ovulation by inhibiting
which anterior pituitary
hormones?

follicle stimulating hormone (FSH) and luteinizing hormone (LH).

oral contraceptive agents

usually contain both an
______ agent and a
_______ agent.

estrogenic agent and a progestational agent.

all of the following are

central
neurotransmitters. which
elicit major excitatory
effects within the cns?
- acetylcholine
- dopamine
- norepinephrine
- serotonin
- gamma-aminobutyric
acid
- opioid pepieds like betaendorphin, enkephalins,
dynorphin
- glutamate
- aspartate

- glutamate and aspartate

*** both of these amino acids have powerful excitatory effects on neurons in virtually every region ofhte
cns.

list the prominent toxic

effects of mercury.

- loosened teeth, excessive saliva, gum disorders, slurred speech, tremors, and irritability.

- they also produce alterations in the genital tract, including changes in cervical mucus, rendering it
unfavorable for sperm penetration even if ovulation occurs. changes in the endometrium also occur
rendering it unfavorable for nidation (implantation of the fertilized ovum)

- estrogenic are ethinyl estradiol and mestranol.

- progestational agents include levonorgestrel, norethindrone, norgestimate, and norgestrel

- GABA is the major inhibitory transmitter in the cns.

- dopamine, norepinphrine, and epinephrine are all CATECHOLAMINEs.

- these are all the chronic form!

- Hg in body is determined by urien test.
British Antie-Lewisite (BAL) or Dimercaprol forms a stable complex with mercury and allows it to be
excreted as an inactive compound.
- mercury is not collected irreversibly in human tissues.
average half life of 55 days for transport through the body to the point of excretion.
103.

name a drug used to treat

diarrhea (reduce GI
motility)

- Loperamide (Imodium) and Diphenoxylate and atropine (lomotil)

- Loperamide (Imodium) is an anti-diarrheal which acts on the intestinal muscles to inhibit peristalsis.
It is a member of the OPIOID family. It does NOT cross the blood brain barrier like codeine.
- Lomotil requires a prescription due to the atropine.
atropine It is a competitive antagonist for the muscarinic acetylcholine receptor.
Atropine increases firing of the sinoatrial node (SA) and conduction through the atrioventricular node
(AV) of the heart, opposes the actions of the vagus nerve, blocks acetylcholine receptor sites, and
decreases bronchial secretions.
In general, atropine lowers the parasympathetic activity of all muscles and glands regulated by the
parasympathetic nervous system. This occurs because atropine is a competitive antagonist of the
muscarinic acetylcholine receptors (acetylcholine being the main neurotransmitter used by the
parasympathetic nervous system). Therefore, it may cause swallowing difficulties and reduced
secretions.

104.

105.

dexmethylphenidate
and atomoxetine
(Strattera) is used
to treat what
condition?

attention deficity hyperactivity disorder (ADHD)

amphetamine
description from
wikipedia

Substituted amphetamines are a chemical class of stimulants, entactogens, hallucinogens, and other drugs.
They feature a phenethylamine core with a methyl group attached to the alpha carbon resulting in
amphetamine, along with additional substitutions. Examples of amphetamines are amphetamine (itself),
methamphetamine, ephedrine, cathinone, MDMA ("Ecstasy"), and DOM ("STP").

- Methylphenidate (Ritalin) - mild cns stimulant. rsults in an increase in attention psan, reduction in
hyperactivity, and improvement in behavior.
- focalin - a new form of methylphenidate called dexmethylphenidate
- concerta - a long acting form of methyphenidate
- adderall -brand name for mixed amphetamine salts which as the same as methylphenidate in treating adhd
- strattera - brand name for atomoxetine, first non-stimulant approved for treating adhd.
- metadate cr - brand name for a controlled delivery methylphenidate, another long acting form of the drug.

Amphetamine derivatives occur in nature, for example in the leaves of Ephedra and khat plants. These have
been used since antiquity for their pharmacological effects. Amphetamines were first produced synthetically at
the end of the 19th century. By the 1930s such synthetic amphetamines found use as decongestants in the
symptomatic treatment of colds and also occasionally as psychoactive agents. Their effects on the central
nervous system are diverse, but can be summarized by three overlapping types of activity: psychoanaleptic,
hallucinogenic and empathogenic. Various amphetamines may cause these actions either separately or in
combination. Improper consumption of amphetamine derivatives may result in addiction and aggressiveness,
as well as in rapid deterioration of basic body functions and death. Therefore, production and distribution of
most related drugs are controlled by the authorities both nationally and internationally
106.

chronic caffeine
consumption can
cause the following
symptoms:

- feelings of anxiety and nervousness

- sleep disruption
- irritability
- diuresis
- stomach complaints
- palpitations and arrhythmias
Caffeine toxicity is thought to occur if intake is around 600-750 mg/day. A cup of coffee has 100-150 mg of
caffeine. A soda has abotu 50 mg. Vivarin has around 200 mg per serving.

107.

108.

109.

all are CNS

stimulants except:
pentylenetetrazol
(metrazol)
doxapram
(dopram)
phenobarbital
nikethamide
(coramine)
picrotoxin
strychnine

answer : phenobarbital!
***** phenobarbital is a barbituate (sedative -hypnotic)

define the term

analeptic

refers to a cns stimulant which has the ability to overcome drug-induced respiratory depression and hypnosis.
In the past cns stimulants were widely used, but today limited clinical application.

caffeine,
theophylline, and
theobromine are all
what type of drug?

xanthines.

the others listed are analeptics and respiratory stimulants (pulmonary disease or hasten recovery form general
anesthetic)

- stimulants that improve mental alertness, reduce the urge to sleep and elevate mood.
- theophylline and theobromein are weaker cns stimulants than caffeine.
- theophylline is hte only xanthine impoortnat i the treatme of asthma...stimulates respiratory centers of the
medulla nad is able to cause bronchial dilation in patients w/ asthma.
sympathomimetic amines include amphetamines and other related agents like methylphenidate and
phennmetrazine which are potent cns stimulants. used to treat narcolepsy, obesity and attention deficit
disorder.

110.

Bromocriptine (Parlodel) and Pergolide

(Permax) are prescribed to treat?

Parkinson's disease.
- In parinson's - nerve cells in the basal ganglia degenerate, resulting in lower
production of dopamine. Treated but not cured.
- levodopa is the precursor to dopamine. It is the MAIN treatment for pt's with
Parkinson's diseae. It is given in combination with carbidopa.
- bromocriptine or pergolide are dopamine agonsits which are often given in
additio to levodopa early in tx to enhancelevodopa..or alter when levodopa's side
effects are more of a problem.
- selegiline is a selective inhibitor of MAO type B , this enzyme is responsible for
the oxidative deamination of dopamine in the brain.
- amantadine - appears to potentiate dopaminergic responses.
- anticholineric drugs like benztropine and trihexyphenidyl .

111.

all of the following are skeletal muscle

spasmolytic drugs except:
- methocarbamol (Robaxin)
- cyclobenzaprine (Flexeril)
- Baclofen (Lioresal)
- Succinylcholine (Anectine)
- Carisoprodol (Soma)

all except : succinylcholine

*** this is the prototype depolarizing neuromuscular blocking drug.
spasmolytic drugs relieve muscle spasms wihtout paralysis. they act in the cns or
in the skeletal muscle cell rather then the neuromuscular end plate!!!
- they are used in certain chronic diseases of hte cns like ms, cerebral palsy and
cerebrovascular accidents. the drugs used to treat chronic and acute muscle
spasms.
chronic
- baclofen is a derivative of gaba..reduce spasms in spinal cord...tx ms and other
spinal cord diseases.
- carisoprodol (soma) used to treat ms spasms and pain associated with acute
temporomandiublar joint pain.
acute muscle spasms
- cyclobenzaprine - central action ...relieves acute, painful musculoskeltal
conditions. it is NOT effective for muscle spasms secondary to cerebral or spinal
cord disease.
- methocarbamol - used in mgnt of tetanus and used ot relieve acute, painful
musculoskeletal conditons.

112.

113.

name a popular drug to help relieve acute,

painful musculoskeletal pain associated with
acute temporomandibular joint pain:

carisoprodol (Soma)
- for chronic pain that has acute tmj affects.

define and list catecholamines.

catecholamines are any one of a group of symapthomimetic compounds

composed of a catechol molecule and the aliphatic portion of an amine. some are
produced naturally and are calle dendogenous (epi, norepi, dopa).
*** epinephrine, norepinephrine and isoproterenol are considered to be direct
acting catecholamines.
sympathomimetics that ar ecatecholamines are:
epi, norepi, dopamine, dobutamine, and isoproterenol.
sympathomimetics that are not catecholamines are:
amphetamine/phenmetrazine, ephedrine, phenylephrine, albuterol /
metaproterenol / terbutaline, and oxymetazoline / xylometazoline.

114.

115.

116.

the following drugs are

useful in the treatment of
what medical condition?
- colchicine, probenecid

GOUT
gout meds are colchicine, indomethacin, sulfinpyrazone, probenecid, allopurinol.

a pt needs antibiotics for an

oral infection. this pt also
has chronic gout. what
concerns might you have?

one concern is if the patient is taking the drug probenecid (Benemid) to increase uric acid clearance.
While this helps clear uric acid, it inhibits secretion of other weak acids like penicillin. Normally
cephalosporins and penicillins have to be given in high and frequen doses due to their high rate of
elimination by the kidneys. Their excretion is SLOWED by giving probenecid!

somatotropin is produced
by?

somatotropin (aka growth hormone GH) is produced by and secreted form the anterior pituitary gland.
- inc rate of protein synthesis
- decreased rate of carbo utilization
- inc mobilization of fats and use of fat for energy.

- three aspects of disease

1. reduce inflammation during acute attacks.
- colchicine may be used (serious side effects) and nsaid's like indomethacin may be used.
2. decrease uric acid production..... allopurinol ( Zyloprim) drug of choice for chronic gout. it inhibits
xanthine oxidase, an enzyme that converts hypoxanthine to xanthine, and xanthine to uric acid....
3. enhance uric acid clearane
-- probenecid (Benemid) and sulfinpyrazone (anturane). act on kidney and inhibit the secretion of
other weak acids and inhibit reabsorption of uric acid.

- gh usually given subcut inj or intramuscular injection 3x/week

117.

ethyl alcohol cuases a wellmarked diuresis by

inhibiting the production of
which hormone?

vasopressin .... aka antidiuretic hormone (ADH).

- ADH decreases urine y inc reabsorption of water by the renal tubules. w/out adh there would be
extreme loss of water into the urine.
- ethanol (ethyl alcohol) inhibits the adh production.
- ethyl alcohol also dilates blood vessels of hte skin and depresses the cns.

118.

inhaled ammonia is the

drug of choice for acting
against?

syncope
- it irritates the trigeminal nerve sensory endings, resulting a reflex stimulation of medullary
respiratory and vasomotor centers.
*** oxygen will aid in combating tisue anoxia
symptoms of syncope include beads of sweat on the upper lip, a weak thready pulse, cold clammy skin,
pallor and dzzy feeling. loss of norma vasomotor tonus produces pooling of blood peripherally so
normal blood volume becomes insufficient.
*** place patietn in a supine position and elevate the feet to give the pt a transfusion of whole blood .

119.

list the
types of
syncope

-vasovagal
- neurogenic
- orthostatic
- hyperventilation syndrome
----- tx vaasovagal, neurogenic, and orthostatic with 100% high flowing oxygen!
----- 100% oxygen is contraindicated for a person who suffers from copd.
In healthy people, high levels of carbon dioxide is what triggers respiration (to help get rid of the carbon dioxide), but
because people with COPD are used to having high levels of carbon dioxide their bodies become immune to it and
respiration in this case is triggered by low levels of oxygen. Therefore if you give a person with COPD high concentrations
of oxygen, you are removing their trigger to breath, leading to respiratory depression or even arrest (stop breathing
completely). This is known as hypoxic drive (hypoxia means low levels of oxygen)
The respiratory drive is normally largely initiated by PaCO2 but in chronic obstructive pulmonary disease (COPD) hypoxia
can be a strong driving force and so if the hypoxia is corrected then the respiratory drive will be reduced. There will also be
a loss of physiological hypoxic vasoconstriction which is partly protecting the patient from the effects of areas of gross
alveolar hypoventilation.1
Therefore, oxygen therapy in COPD must be used with care in the acute setting but it can have distinct benefits in the longterm.

120.

list the
aluminum
salts used
as
antacids:

hydroxide
carbonate
phosphate
aminoacetate
*** aluminum hydroxide is themsot potenet of these but has less neutralizing capacity than calcium carbonate or sodium
bicarbonate (the only systemic antacid).
sodium bicrabonate - alka-seltzer
calcium carbonate - tums
aluminum hydroxide - amphojel
magnesium hydroxide - milk of magnesia
bismuth salt products - pepto biasma
magnesium and aluminum - Maalox and Mylanta

121.

disulfiram
is used in
the mgmt
of ?

ETHANOL ABUSE
- it isn't a cure for alcoholism, but a deterrent. it is an antioxidant that interferes with hepatic oxidation of acetaldehyde
metabolized from alcohol. it inhibits aldehyde dehydrogenase (mitochondrial enzyme found in the liver). it is a
deterrent....even small amounts of ethanol results in high concentrations of acealdehyde and unpleasant reaction called
disulfiram-ethanol reaction or DER...... throbbing headache, dyspnea, throbbin in neck, nausea, copious vomiting, thirst,
tachycardia, and hypotension. metronidazole also inhibits aldehyde dehydrogenase.
ethanol is a sedative...other alcohols are methanol and ethylene glycol.
drugs synergistic with ethanol include diazepam, meperidine, pentobarbital and chlorpromazine.
diazepam - aka valium - a benzodiazepam
meperidine -aka demerol - fast acting opioid analgesic
pentobarbital - short acting barbituate (seizures/sedation)
chlorpromazine - first phenothiazine antipsychotic (sedates)

122.

which substance is an enzyme

formed in the kidney and released
into the bloodstream where it has
an important role in the
formation of angiotensin?

renin
- reniin is a proteolytic enzyme produced by and stored in the juxtaglomerular apparatus that
surrounds each arteriole as it enters a glomerulus. Renin acts on the precursor substance
angiotensinogen, which is manufactured by the liver and is present in the blood.
- Renin converts angiotensinogen to angiotensin 1. In turn, angiotensin 1 is converted to
angiotensin II by a converting enzmye associated with the walls of capillaries, paricularly in
the lungs (ACE) .
- Angiotensin II is a POTENT VASOPRESSOR. It is note only increases in total peripheral
resistance but, by stimulating aldosterone release, leads to an increase in plasma volume,
venous return, stroke volume, and ultimately cardiac output.
- wrong answers were plasmin, lysozyme, and heparin. Heparin come from the word "hepar ....
liver....coagulation stuff."
Heparin is a naturally occurring anticoagulant produced by basophils and mast cells.[10]
Heparin acts as an anticoagulant, preventing the formation of clots and extension of existing
clots within the blood. While heparin does not break down clots that have already formed
(unlike tissue plasminogen activator), it allows the body's natural clot lysis mechanisms to
work normally to break down clots that have formed. Heparin is generally used for
anticoagulation for the following conditions:

123.

name the high molecular weight

heteropolysaccharide that is
found especially in the lungs and
inactivates thrombin and other
coagulation factors and thus
prevents blood clotting.

heparin
- wrong answers were prothrombin, fibrin, and plasmin.
- Heparin is contained within mast cells and basophils. these cells occur in connective tissue
and in extracellular spaces near blood vessels, particularly the lungs. Heparin neutralizes tisue
thromboplastin and blocks thromboplastin generation.
- administering heparin to a pt increases bleeding time (antithrombin III inactivates thrombin
so prevents fibrinogen to fibrin.
- Plasmin is a serine protease that acts to dissolve fibrin blood clots. Apart from fibrinolysis,
plasmin proteolyses proteins in various other systems: It activates collagenases, some
mediators of the complement system and weakens the wall of the Graafian follicle (leading to
ovulation). It cleaves fibrin, fibronectin, thrombospondin, laminin, and von Willebrand factor.
Plasmin, like trypsin, belongs to the family of serine proteases.

124.

Your pt's medication history

includes modafinil (Provigil)
......why is your patient taking this
drug ?

- improve wakefulness during daytime sleepiness

- a cns stimulant. also treats atha (attention deficit/hyperactivity disorder)
- mechanism unknown...likely decreases GABA mediated neurotransmission.
- it is also thought to increase high frequency alpha waves while decreasing both delta and
theta activity, thus increasing mental alertness.

125.

The following drugs belong to what

pharmaceutical class of agents:
adalimumab, alefacept,
infliximab, trastuzumab

- monoclonal antibodies
adalimumab (Humira) is a recombinant monoclonal antibody that binds to human tumor
necrosis factor alpha receptor sites. it is used to treat active rheumatoid arthritis.
alefacept (amevive) treats severe plaque psoriasis

126.

the following drugs belong to what pharmaceutical class of

agents: pimecrolimus; sirolimus, tacrolimus?

immunosuppressants
- Pimecrolimus (Elidel) tx mild to moderate atopic dermatitis
- Sirolimus (rapamune) tx prophylaxis of organ rejection in
patients receiving renal transplants.
- tacrolimus (protopic) is an imunosuppressant agent used to treat
mod to severe atopic dermatitis in patients not responsive to
conventional therapy.

127.

Granisetron (Kytril) and ondansetron (Zofran) are

selective 5-HT3 receptor antagonists used to treat what
condition?

- emesis caused by cancer chemotherapy.

- 5-HT3 receptor is a serotonin receptor which when activated
during chemo for cancer, causes emesis (nausea and vomiting).
Both granisetron and ondansetron are indicated for proophylaxis
chemo related emesis,
- also treats PONV ----- post operative nausea and vomiting.
- 5HT3 stands for 5-hydroxytrypamine type 3 receptor.

128.

carbidopa is used to treat what disease? what must it be

used with.

Carbidopa us used in conjuction with levodopa to treat

Parkinson's disease.
- carbidopa reduces the levodopa needed because levodopa would
be quickly metabolized before it could reach the brain. carbidopa
inhibits the peripheral decarboxylation of levodopa. this reducs
likelihod of peripheral side effects and allows more levodopa to
reach the brain.
- carbidopa does not cros the blood-brain barrier. levodopa is
converted to dopamine in the brain.

129.

which antiarrhythmic agent is effective only on the

ventricle and is often administered IV to treat life
threatening ventricular arrhythmias?

lidocaine utilized IV
- acts on fibrillating ventricles to decrease the cardiac excitability
and spares the atria. it can effectively reverse a life threatening
situation.
- Quinidine is a prototype anti-arrhythmic used primarily to treat
atrial fibrillation. it is not effective in treating life threatening
ventricular fibrillation.

130.

131.

Triazolam (Halcion) is a pre-operative sedative used in

dentistry, it is metabolized in theliver by the P-450 isoform
CYP3A4 enzyme. Drugs which inhibit the actions of
CYP3A4 would affect triazolam in which way? (hint - relate
to serum levels)

- cause in increase in serum levels of triazolam

which drugs are common contraindications for triazolam?

antifungal agents can significantly elevate the serum levels of

triazolam resulting in toxicity with therapeutic doses. these
antifungal agents inhibit the cyp3a4 isoform responsible for
hepatic metabolsim of triazolam.

- drugs that inhibit hte metabolic pathway may have a profound

effect on the clearance of triazolam. could result in unexpected
increase in actions of triazolam.

(ie itraconazole, ketoconazole, fluconazole, miconazole, and

voriconazole)