Questions [1] A 62-year-old woman is noted to have open-angle glaucoma. She inadvertently applies excessive pilocarpine to her eyes. This may result in which of the following? A. Bronchial smooth muscle dilation B. Decreased gastrointestinal motility C. Dilation of blood vessels D. Mydriasis [2] Muscarinic cholinergic agonists A. Activate inhibitory G-proteins (Gi) B. Decrease production of IP3 C. Decrease release of intracellular calcium D. Inhibit the activity of phospholipase C [3] Choline esters like carbachol are most likely to cause which of the following adverse effects? A. Anhydrosis (dry skin) B. Delirium C. Salivation D. Tachycardia (rapid heart rate) Answers [1] C. Excessive pilocarpine may initially result in dilation of …
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The efferent nerves of the parasympathetic autonomic nervous system release the neurotransmitter ACh at both preganglionic and postganglionic (i.e., “cholinergic”) nerve endings, and also at somatic nerve endings. Nitric oxide is a cotransmitter at many of the parasympathetic postganglionic sites. The ACh released from nerve endings of the parasympathetic nervous system interacts at specialized cell membrane components called cholinoreceptors that are classified as either nicotinic or muscarinic after the alkaloids initially used to distinguish them. Nicotinic cholinoreceptors are localized at all postganglionic neurons (the autonomic ganglia), including the adrenal medulla, and skeletal muscle endplates innervated by somatic nerves. Muscarinic cholinoreceptors are localized at organs innervated by parasympathetic postganglionic nerve …
[ Continue Reading... ]A 61-year-old man is noted to have increased intraocular pressure on a routine eye examination. The visual acuity is normal in both eyes. The dilated eye examination reveals no evidence of optic nerve damage. Visual field testing shows mild loss of peripheral vision. He is diagnosed with primary open-angle glaucoma and is started on pilocarpine ophthalmic drops. What is the action of pilocarpine on the muscles of the iris and cilia? What receptor mediates this action? Is pilocarpine the appropriate first-line drug for treatment of primary open-angle glaucoma? Answers to case: Muscarinic cholinomimetic agents Summary: A 61-year-old man with open-angle glaucoma …
[ Continue Reading... ]In addition to alcohol, the major drugs of abuse are nicotine, marijuana (∆9-tetrahydrocannabinol), heroin, and the CNS stimulants, notably cocaine and amphetamine and its derivatives (Table Drugs of abuse). Table: Drugs of abuse NICOTINE MARIJUANA COCAINE/AMPHETAMINE Route of administration Smoking Smoking Smoking, oral IV Mechanism of action Mimics action of acetylcholine Interacts with G-protein-coupled cannabinoid receptors among other actions Cocaine binds the dopamine reuptake transporter. Amphetamine increases release of neuronal catecholamines, including dopamine Pharmacologic effects Stimulant and depressant actions on the CNS and cardiovascular system Euphoria, uncontrollable laughter, introspection, loss of sense of time, sleepiness, loss of concentration Euphoria, excitation, increased alertness, an orgasmic-like “rush” Tolerance and dependence Tolerance develops …
[ Continue Reading... ]A 50-year-old salesman was admitted to the hospital with acute appendicitis. He has no significant medical history, takes no medications, does not smoke cigarettes, and has an alcoholic beverage “once in a while with the boys.” He underwent an uncomplicated appendectomy. On the second hospital day, you find him to be quite agitated and sweaty. His temperature, heart rate, and blood pressure are elevated. A short time later he has a grand-mal seizure. You suspect that he is having withdrawal symptoms from chronic alcohol abuse and give IV lorazepam for immediate control of the seizures and plan to start him on …
[ Continue Reading... ]Challenges in Medicating the Senior Patient Choosing an appropriate dosage form of analgesic drug is essential to successfully manage pain in the older patient. Beyond the clinical recommendations, the pharmacist can be instrumental in providing information on products that will optimize pain relief in this patient population. Swallowing difficulties secondary to other medical conditions, such as Parkinson’s disease, dementia, or stroke, may preclude the use of large tablets or sustained-release medications that cannot be crushed. Liquid medications provide an acceptable alternative for administering analgesics. Unfortunately, few analgesic preparations are available in liquid form. Ibuprofen and naproxen suspensions are the few NSAIDs available as liquids …
[ Continue Reading... ]Drugs Used in Pain Management Pharmacologic options for pain management range from simple analgesics, such as acetaminophen or low-dose nonsteroidal anti-inflammatory agents (NSAIDs) for the relief of mild to moderate chronic pain, to opioids for more severe pain (Table 1). Simple Analgesics: Acetaminophen is useful for the relief of mild to moderate osteoarthritic pain in scheduled, divided doses not exceeding 4 g/day.NSAIDs may also be used in appropriate doses, for short periods of time. COX-2 inhibitors may be less likely to be associated with gastrointestinal bleeding and may be administered once daily, reducing nursing time for medication administration or the likelihood of missed doses. All NSAIDs …
[ Continue Reading... ]Managing Pain Clinical assessment of elderly patients must attempt to ascertain the presence of pain through both verbalized and nonverbalized symptoms. Selecting an optimal therapy depends on patient-specific criteria, including medical history, previous medications utilized, drug allergies, swallowing ability, and response to therapy. A description of the pain is also useful in determining initial therapy. Nociceptive pain, often the result of chronic or other conditions arising from actual tissue damage as in osteoarthritis, can be described as aching or soreness, rather than sharp pain. Neuropathic pain, arising from damaged nerve tissue, is usually described as burning, stinging or stabbing pain. To adequately manage chronic pain, the clinician should …
[ Continue Reading... ]Older patients have a variety of chronic illnesses that may result in pain. However, the daily presence of pain often goes unrecognized and, therefore, untreated in both the community-dwelling and institutionalized elderly. Chronic pain may be the result of comorbidities, including osteoarthritis, osteoporosis, cancer, peripheral vascular disease, or neuropathies secondary to complications of diabetes. Procedures such as surgery, open wounds and pressure ulcers can also be a source of pain. Identifying and adequately managing pain in the elderly patient presents unique challenges for the pharmacist and the entire healthcare team. The lack of recognition and consequent undertreatment of pain in all patient populations has resulted in new …
[ Continue Reading... ]A recent study concludes that cognitive psychotherapy can be just as effective for the treatment of atypical major depression as standard drug therapy with phenelzine sulfate. Researchers at the University of Texas-Southwestern Medical Center at Dallas randomized 108 patients suffering from atypical major depression to treat with the MAO inhibitor phenelzine sulfate, cognitive therapy, or placebo for 10 weeks to collect data. The study found that 58 percent of patients in both the cognitive therapy and phenelzine sulfate groups responded to treatment, compared to 28 percent of placebo recipients. Authors say the findings suggest that cognitive therapy is an effective and viable alternative to drug therapy for atypical major depression.
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