AUTONOMICS Ma. Janetth B. Serrano, MD, DPBA
NERVOUS  SYSTEM CENTRAL NERVOUS SYSTEM PERIPHERAL NERVOUS SYSTEM BRAIN SPINAL CORD EFFERENT Division AFFERENT Division AUT...
NERVOUS  SYSTEM <ul><li>SOMATIC  N.S. </li></ul><ul><li>Skeletal, motor, voluntary  </li></ul><ul><li>No ganglias or plexu...
NEUROTRANSMITTERS: <ul><li>Sympathetic: ADRENERGIC </li></ul><ul><ul><ul><li>Central: EPINEPHRINE </li></ul></ul></ul><ul>...
RECEPTORS: <ul><li>Sympathetic:  ADRENOCEPTORS </li></ul><ul><ul><ul><li>Alpha     α 1  ,  α 2  </li></ul></ul></ul><ul><...
Stimulation of adenyl cyclase ↑  cAMP Postsynaptic effector cells esp. lipocytes Beta 3 Stimulation of adenyl cyclase ↑  c...
Inhibition of adenyl cyclase Brain, Cardiovascular System D 4 Inhibition of adenyl cyclase Brain D 3 Inhibition of adenyl ...
MUSCARINIC RECEPTORS Na + , K +   depolarizing ion channel Postganglionic cell body, dendrites N N Na + , K +   depolarizi...
SUMMARY OF NEUROHUMORAL TRANSMISSION PROCESS: <ul><li>Synthesis and Storage of Neurotransmitter </li></ul><ul><li>Release ...
METYROSINE COCAINE, TCA, IMIPRAMINE RESERPINE
HEMICHOLINIUM VESAMICOL BOTULINUM TOXIN
 
EFFECTOR  ORGANS Autonomic  Nervous System
Autonomic  Nervous System Some Sweat glds & some BV RVSM Acetylcholine Acetylcholine Acetylcholine Dopamine Nicotinic Rece...
Somatic  Nervous  System
Enteric Nervous System  <ul><li>Third division of the ANS </li></ul><ul><li>Innervates GIT, pancreas, gallbladder </li></u...
Autonomic  Nervous System
Sympathetic N. S. relaxation  2 Lung bronchial m. ↑  Heart rate ↑  conduction velocity ↑  contraction  1  1  1 Heart S...
Sympathetic N. S. Constriction Relaxation Ejaculation α 1  2 α 1 GUT sphincter bladder wall Penis, seminal v. Constrictio...
Sympathetic N. S. Secretion of cathecolamines ↑  renin release Glycogenolysis ↓  insulin release Lipolysis N N  1  2 α 2...
Parasympathetic N. S. contraction M 3 Lung bronchial m. ↓  Heart rate ↓  conduction velocity ↓  contraction M 2 M 2 M 2 He...
Parasympathetic N. S. Relaxation Increase Erection M 3 M 3 M GUT trigone & sphincter m. bladder wall & detrusor m. Penis, ...
Parasympathetic N. S. Generalized secretion ↑  secretion ↑  secretion Profuse secretion M M 3 M M Secretory glands sweat i...
<ul><li>Site and Mode of Action: </li></ul><ul><li>1. Direct Acting </li></ul><ul><ul><li>-  Epinephrine -  Dobutamine </l...
Sympathetic  Agonists SYMPATHOMIMETICS
Sympathetic Agonists (Sympathomimetics)  EPINEPHRINE NOREPINEPHRINE DOPAMINE IBOPAMINE AMPHETAMINE METHAMPHETAMINE EPHEDRI...
Sympathetic Agonists (Sympathomimetics)  PHENYLEPHRINE METHOXAMINE MEPHENTERMINE METARAMINOL MITODRINE β 1  and  β 2 α 1  ...
Sympathetic Agonists (Sympathomimetics)  METHYLDOPA CLONIDINE GUANABENZ GUANFACINE β 1  and  β 2 α 1   and  α 2 β 2 β 1 α ...
Sympathetic Agonists (Sympathomimetics)  NAPHAZOLINE TETRAHYDROZOLINE β 1  and  β 2 α 1   and  α 2 β 2 β 1 α  and  β α 2 α 1
Sympathetic Agonists (Sympathomimetics)  NAPHAZOLINE TETRAHYDROZOLINE OXYMETAZOLINE XYLOMETAZOLINE β 1  and  β 2 α 1   and...
Sympathetic Agonists (Sympathomimetics)  METAPROTERENOL TERBUTALINE, ALBUTEROL RITODRINE ISOETHARINE, PILBUTEROL BITOLTERO...
<ul><li>Special sympathomimetics: </li></ul><ul><li>COCAINE </li></ul><ul><ul><li>Local anesthetic </li></ul></ul><ul><ul>...
<ul><li>Special sympathomimetics: </li></ul><ul><li>TYRAMINE </li></ul><ul><ul><li>Normal by-product of tyrosine metabolis...
Sympathetic  Antagonists SYMPATHOLYTICS
<ul><li>Adrenergic Neuron Blockers (ANB) </li></ul><ul><ul><li>Guanethedine, Reserpine </li></ul></ul><ul><li>Adrenergic R...
Sympathetic Antagonists (Sympatholytics)  YOHIMBINE BUTOXAMINE LABETALOL CARVEDILOL Β 1  and  β 2 α 1  and  α 2 β 2 β 1 α ...
Sympathetic Antagonists (Sympatholytics)  PRAZOSIN, TERAZOSIN DOXAZOSIN, TRIMAZOSIN INDORAMIN, URADIPIL KETANSERIN, ALFUZO...
Sympathetic Antagonists (Sympatholytics)  PHENOXYBENZAMINE PHENTOLAMINE ERGOT  ALKALOIDS NEUROLEPTIC DRUGS Β 1  and  β 2 α...
PHENOXYBENZAMINE <ul><li>irreversible noncompetetive blockade  (14-48 hrs) </li></ul><ul><li>inhibits NE reuptake </li></u...
PHENTOLAMINE <ul><li>Competetive antagonist (4 hrs) </li></ul><ul><li>Epinephrine- reversal  </li></ul><ul><li>reduce PVR ...
Beta-Adrenergic Blocking Agents <ul><li>BETA - BLOCKERS </li></ul>
Sympathetic Antagonists (Sympatholytics)  METOPROLOL ATENOLOL ACEBUTOLOL BETAXOLOL CELIPROLOL ESMOLOL Β 1  and  β 2 α 1  a...
Sympathetic Antagonists (Sympatholytics)  PROPRANOLOL NADOLOL, TIMOLOL PINDOLOL, LEVOBUNOLOL CARTEOLOL, BISOPROLOL Β 1  an...
Beta- blockers <ul><li>Pharmacokinetics: </li></ul><ul><ul><li>oral: peak in 1-3 hrs </li></ul></ul><ul><ul><li>extensive ...
<ul><li>PHARMACODYNAMICS: </li></ul><ul><ul><li>CVS: (-) chronotropic, (-) inotropic effects </li></ul></ul><ul><ul><li>Re...
Properties of Beta-receptor blocking agents:   50 3-4 hrs Mod + - Metoprolol 70 4-5 hrs No data - + Celiprolol 0 8-10 min ...
Properties of Beta-receptor blocking agents:  90 3-4 hrs Mod + + Pindolol 50 4-50 hrs Mod - - Timolol 33 14-24 hrs Low - -...
<ul><li>CLINICAL INDICATIONS: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Cardiac arrhythmias </li></ul>...
<ul><li>Clinical toxicities: </li></ul><ul><ul><li>Drug allergy – rare </li></ul></ul><ul><ul><li>CNS effects – sedation, ...
<ul><li>DRUG INTERACTION: </li></ul><ul><ul><li>Calcium- channel  VERAPAMIL </li></ul></ul><ul><ul><ul><li>Severe hypotens...
“ A heartfelt apology can’t change the past,  but it can brighten the future.”
QUIZ <ul><li>Major neurotransmitter of the Sympathetic Nervous System </li></ul><ul><li>Write A if Agonist or B if Antagon...
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Autonomics & Sympathetics

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Autonomics & Sympathetics

  1. 1. AUTONOMICS Ma. Janetth B. Serrano, MD, DPBA
  2. 2. NERVOUS SYSTEM CENTRAL NERVOUS SYSTEM PERIPHERAL NERVOUS SYSTEM BRAIN SPINAL CORD EFFERENT Division AFFERENT Division AUTONOMIC N.S. SOMATIC N.S. Sympathetic N.S. Parasympathetic N.S. Enteric N.S.
  3. 3. NERVOUS SYSTEM <ul><li>SOMATIC N.S. </li></ul><ul><li>Skeletal, motor, voluntary </li></ul><ul><li>No ganglias or plexuses </li></ul><ul><li>Motor n. to skeletal muscles myelinated </li></ul><ul><li>Interruption of impulses  paralysis & atrophy </li></ul><ul><li>AUTONOMIC N.S. </li></ul><ul><li>Visceral, vegetative, involuntary </li></ul><ul><li>Efferent n. supply all except skeletal m. </li></ul><ul><li>Peripheral ganglias & plexuses </li></ul><ul><li>Postganglionic fibers unmyelinated </li></ul><ul><li>Interruption of transmission  spontaneous activity </li></ul>
  4. 4. NEUROTRANSMITTERS: <ul><li>Sympathetic: ADRENERGIC </li></ul><ul><ul><ul><li>Central: EPINEPHRINE </li></ul></ul></ul><ul><ul><ul><li>Peripheral: NOREPINEPHRINE </li></ul></ul></ul><ul><li>Parasympathetic: CHOLINERGIC </li></ul><ul><ul><ul><li>Acetylcholine </li></ul></ul></ul>
  5. 5. RECEPTORS: <ul><li>Sympathetic: ADRENOCEPTORS </li></ul><ul><ul><ul><li>Alpha  α 1 , α 2 </li></ul></ul></ul><ul><ul><ul><li>Beta   1 ,  2 ,  3 </li></ul></ul></ul><ul><li>Parasympathetic: CHOLINOCEPTORS </li></ul><ul><ul><ul><li>Muscarinic </li></ul></ul></ul><ul><ul><ul><li>Nicotinic </li></ul></ul></ul><ul><li>Dopaminergic: D 1 , D 2 </li></ul>
  6. 6. Stimulation of adenyl cyclase ↑ cAMP Postsynaptic effector cells esp. lipocytes Beta 3 Stimulation of adenyl cyclase ↑ cAMP Posynaptic effector cells esp. sm. m. & cardiac m. Beta 2 Stimulation of adenyl cyclase ↑ cAMP Postsynaptic effector cells esp.heart, lipocytes, brain Presyn cholinergic & adrenergic terminals Beta 1 Inhibition of adenyl cyclase ↓ cAMP Presynaptic adrenergic n. terminals, platelets, lipocytes, sm.m. Alpha 2 Formation of IP 3 and DAG ↑ IC calcium Postsynaptic effector cells esp. smooth m. Alpha 1 RESULT OF LIGAND BINDING TYPICAL LOCATIONS RECEPTOR NAME
  7. 7. Inhibition of adenyl cyclase Brain, Cardiovascular System D 4 Inhibition of adenyl cyclase Brain D 3 Inhibition of adenyl cyclase ↑ K + conductance Brain, effector tissues, esp. smooth m., presynaptic nerve terminals D 2 (DA 2 ) Stimulation of adenyl cyclase ↑ cAMP Brain, effector tissues esp. sm.m. of the renal vascular bed D 1 (DA 1 ), D 5 RESULT OF LIGAND BINDING TYPICAL LOCATIONS RECEPTOR NAME
  8. 8. MUSCARINIC RECEPTORS Na + , K + depolarizing ion channel Postganglionic cell body, dendrites N N Na + , K + depolarizing ion channel Skeletal muscle NMJ N M IP 3 , DAG cascade ? CNS M 5 Inhibition of cAMP production ? CNS M 4 IP 3 , DAG cascade Glands, smooth muscle, endothelium M 3 Inhibition of cAMP prod’n, activation of K + channels Heart, nerves, smooth muscles M 2 IP 3 , DAG cascade Nerves M 1 Postreceptor Mechanism Location Receptor Type
  9. 9. SUMMARY OF NEUROHUMORAL TRANSMISSION PROCESS: <ul><li>Synthesis and Storage of Neurotransmitter </li></ul><ul><li>Release of Neurotransmitter </li></ul><ul><li>Interaction with Postjunctional Cell and Initiation of Activity </li></ul><ul><li>Deactivation </li></ul>
  10. 10. METYROSINE COCAINE, TCA, IMIPRAMINE RESERPINE
  11. 11. HEMICHOLINIUM VESAMICOL BOTULINUM TOXIN
  12. 13. EFFECTOR ORGANS Autonomic Nervous System
  13. 14. Autonomic Nervous System Some Sweat glds & some BV RVSM Acetylcholine Acetylcholine Acetylcholine Dopamine Nicotinic Receptor Nicotinic Receptor Muscarinic Receptor D 1 Receptor
  14. 15. Somatic Nervous System
  15. 16. Enteric Nervous System <ul><li>Third division of the ANS </li></ul><ul><li>Innervates GIT, pancreas, gallbladder </li></ul><ul><li>Includes: </li></ul><ul><ul><ul><ul><li>Myenteric plexus </li></ul></ul></ul></ul><ul><ul><ul><ul><li> (Plexus of Auerbach) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Submucous plexus </li></ul></ul></ul></ul><ul><ul><li> (Plexus of Meissner) </li></ul></ul>
  16. 17. Autonomic Nervous System
  17. 18. Sympathetic N. S. relaxation  2 Lung bronchial m. ↑ Heart rate ↑ conduction velocity ↑ contraction  1  1  1 Heart SA node AV node Contractility Contraction (mydriasis) Relaxation α 1  2 Eye radial m. (iris) ciliary m. Action Receptor Effector Organs
  18. 19. Sympathetic N. S. Constriction Relaxation Ejaculation α 1  2 α 1 GUT sphincter bladder wall Penis, seminal v. Constriction Decrease α 1 α ,  2 GIT sphincter motility & tone Constriction Relaxation α 1  2 Blood Vessels most BV skeletal m. Action Receptor Effector Organs
  19. 20. Sympathetic N. S. Secretion of cathecolamines ↑ renin release Glycogenolysis ↓ insulin release Lipolysis N N  1  2 α 2  3 Metabolism adrenal medulla kidney skeletal m. Pancreas (B-cell) fat cells Localized secretion Inhibition - Moderate secretion α 1 α 2 - α Secretory glands sweat intestinal bronchial lacrimal Action Receptor Effector Organs
  20. 21. Parasympathetic N. S. contraction M 3 Lung bronchial m. ↓ Heart rate ↓ conduction velocity ↓ contraction M 2 M 2 M 2 Heart SA node AV node Contractility Contraction (miosis) Contraction (accomodation) M 3 M 3 Eye circular m. ciliary m. Action Receptor Effector Organs
  21. 22. Parasympathetic N. S. Relaxation Increase Erection M 3 M 3 M GUT trigone & sphincter m. bladder wall & detrusor m. Penis, seminal v. Relaxation Increase M 3 M 3 GIT sphincter motility & tone - - - - Blood Vessels most BV skeletal m. Action Receptor Effector Organs
  22. 23. Parasympathetic N. S. Generalized secretion ↑ secretion ↑ secretion Profuse secretion M M 3 M M Secretory glands sweat intestinal bronchial lacrimal Action Receptor Effector Organs
  23. 24. <ul><li>Site and Mode of Action: </li></ul><ul><li>1. Direct Acting </li></ul><ul><ul><li>- Epinephrine - Dobutamine </li></ul></ul><ul><ul><li>- Phenylephrine - Norepinephrine </li></ul></ul><ul><ul><li>- Isoproterenol - Clonidine </li></ul></ul><ul><li>2. Indirect Acting </li></ul><ul><ul><li>Tyramine, Amphetamine, Cocaine </li></ul></ul><ul><li>3. Mixed Acting Agonists </li></ul><ul><ul><li>- Dopamine - Ephedrine </li></ul></ul><ul><ul><li>- Amphetamine - Metaraminol </li></ul></ul><ul><ul><li>- Phenylpropanolamine </li></ul></ul>SYMPATHETIC DRUGS
  24. 25. Sympathetic Agonists SYMPATHOMIMETICS
  25. 26. Sympathetic Agonists (Sympathomimetics) EPINEPHRINE NOREPINEPHRINE DOPAMINE IBOPAMINE AMPHETAMINE METHAMPHETAMINE EPHEDRINE PSEUDOEPHEDRINE DOBUTAMINE ISOPROTERENOL β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  26. 27. Sympathetic Agonists (Sympathomimetics) PHENYLEPHRINE METHOXAMINE MEPHENTERMINE METARAMINOL MITODRINE β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  27. 28. Sympathetic Agonists (Sympathomimetics) METHYLDOPA CLONIDINE GUANABENZ GUANFACINE β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  28. 29. Sympathetic Agonists (Sympathomimetics) NAPHAZOLINE TETRAHYDROZOLINE β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  29. 30. Sympathetic Agonists (Sympathomimetics) NAPHAZOLINE TETRAHYDROZOLINE OXYMETAZOLINE XYLOMETAZOLINE β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  30. 31. Sympathetic Agonists (Sympathomimetics) METAPROTERENOL TERBUTALINE, ALBUTEROL RITODRINE ISOETHARINE, PILBUTEROL BITOLTEROL, FENOTEROL FORMOTEROL, SALMETEROL PROCATEROL β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  31. 32. <ul><li>Special sympathomimetics: </li></ul><ul><li>COCAINE </li></ul><ul><ul><li>Local anesthetic </li></ul></ul><ul><ul><li>Inhibits uptake 1  Peripheral sympathomimetic action </li></ul></ul><ul><ul><li>CNS  inhibits reuptake of dopamine into neurons in the “pleasure centers” of the brain </li></ul></ul>Sympathetic Agonists (Sympathomimetics)
  32. 33. <ul><li>Special sympathomimetics: </li></ul><ul><li>TYRAMINE </li></ul><ul><ul><li>Normal by-product of tyrosine metabolism </li></ul></ul><ul><ul><li>Fermented foods  cheese, red wine </li></ul></ul><ul><ul><li>Metabolized by MAO </li></ul></ul><ul><ul><li>Release of stored catecholamines  indirect sympathomimetic action </li></ul></ul>Sympathetic Agonists (Sympathomimetics)
  33. 34. Sympathetic Antagonists SYMPATHOLYTICS
  34. 35. <ul><li>Adrenergic Neuron Blockers (ANB) </li></ul><ul><ul><li>Guanethedine, Reserpine </li></ul></ul><ul><li>Adrenergic Receptor Blockers (ARB) </li></ul><ul><ul><li>Reversible – Prazosin, Phentolamine, </li></ul></ul><ul><ul><li>Tolazoline, Labetalol, Ergot alkaloids </li></ul></ul><ul><ul><li>Irreversible – Phenoxybenzamine, </li></ul></ul><ul><ul><li>Dibenamine </li></ul></ul>Sympathetic Antagonists (Sympatholytics)
  35. 36. Sympathetic Antagonists (Sympatholytics) YOHIMBINE BUTOXAMINE LABETALOL CARVEDILOL Β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  36. 37. Sympathetic Antagonists (Sympatholytics) PRAZOSIN, TERAZOSIN DOXAZOSIN, TRIMAZOSIN INDORAMIN, URADIPIL KETANSERIN, ALFUZOSIN BUNAZOSIN, TAMSULOSIN α 1 and α 2 β 1 and β 2 β 2 β 1 α and β α 2 α 1
  37. 38. Sympathetic Antagonists (Sympatholytics) PHENOXYBENZAMINE PHENTOLAMINE ERGOT ALKALOIDS NEUROLEPTIC DRUGS Β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  38. 39. PHENOXYBENZAMINE <ul><li>irreversible noncompetetive blockade (14-48 hrs) </li></ul><ul><li>inhibits NE reuptake </li></ul><ul><li>Blocks H 1 , Ach and serotonin receptors </li></ul><ul><li>Blocks catecholamine-induced vasoconstriction </li></ul><ul><li>Epinephrine- reversal </li></ul><ul><li>Cl. Indication: pheochromocytoma </li></ul><ul><li>male erectile dysfunction </li></ul><ul><li>peripheral vascular diseases </li></ul><ul><li>Adv. Eff: postural hypotension, tachycardia </li></ul>
  39. 40. PHENTOLAMINE <ul><li>Competetive antagonist (4 hrs) </li></ul><ul><li>Epinephrine- reversal </li></ul><ul><li>reduce PVR </li></ul><ul><li>Cardiac stimulation  baroreflex & ↑ NE release </li></ul><ul><li>Inhibits serotonin responses </li></ul><ul><li>Indic: Pheochromocytoma, male erectile dysfunction </li></ul><ul><li>Adv. Eff: severe tachycardia, arrhythmia, myocardial ischemia, GI stimulation </li></ul>
  40. 41. Beta-Adrenergic Blocking Agents <ul><li>BETA - BLOCKERS </li></ul>
  41. 42. Sympathetic Antagonists (Sympatholytics) METOPROLOL ATENOLOL ACEBUTOLOL BETAXOLOL CELIPROLOL ESMOLOL Β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  42. 43. Sympathetic Antagonists (Sympatholytics) PROPRANOLOL NADOLOL, TIMOLOL PINDOLOL, LEVOBUNOLOL CARTEOLOL, BISOPROLOL Β 1 and β 2 α 1 and α 2 β 2 β 1 α and β α 2 α 1
  43. 44. Beta- blockers <ul><li>Pharmacokinetics: </li></ul><ul><ul><li>oral: peak in 1-3 hrs </li></ul></ul><ul><ul><li>extensive first-pass metabolism </li></ul></ul><ul><ul><li>half- lives: 3 to 10 hrs </li></ul></ul><ul><ul><li>* Esmolol – 8 – 10 min </li></ul></ul><ul><ul><li>* Nadolol – 24 hrs </li></ul></ul>
  44. 45. <ul><li>PHARMACODYNAMICS: </li></ul><ul><ul><li>CVS: (-) chronotropic, (-) inotropic effects </li></ul></ul><ul><ul><li>Respiratory: bronchoconstriction </li></ul></ul><ul><ul><li>Eye: reduce IOP </li></ul></ul><ul><ul><li>Metabolic & Endocrine: </li></ul></ul><ul><ul><ul><li>inhibits lipolysis </li></ul></ul></ul><ul><ul><ul><li>partial inhibition of glycogenolysis </li></ul></ul></ul><ul><ul><ul><li>↑ VLDL and ↓ HDL </li></ul></ul></ul><ul><ul><ul><li>↓ HDL: LDL ratio </li></ul></ul></ul><ul><ul><li>ISA; MSA </li></ul></ul>Beta- blockers
  45. 46. Properties of Beta-receptor blocking agents: 50 3-4 hrs Mod + - Metoprolol 70 4-5 hrs No data - + Celiprolol 0 8-10 min Low - - Esmolol 90 14-22 hrs Low Slight - Betaxolol 40 6-9 hrs Low - - Atenolol 50 3-4 hrs Low + + Acebutolol Selective β 1 blockers Approxi-mate Bioavai-lability Elimination Half-life Lipid Solu-bility Local Anesthetic Activity (MSA) Partial Agonist Activity ( ISA)
  46. 47. Properties of Beta-receptor blocking agents: 90 3-4 hrs Mod + + Pindolol 50 4-50 hrs Mod - - Timolol 33 14-24 hrs Low - - Nadolol 30 5 hrs Mod + + Labetalol 25-35 6-8 hrs No Data - - Carvedilol 85 6 hrs Low - + Carteolol 30 3.5-6 hrs High + - Propranolol NonSelective β 1 Blockers Approxi-mate Bioavai-lability Elimina-tion Half-life Lipid Solu-bility MSA (Local Anesthetic Activity) ISA (Partial Agonist Activity )
  47. 48. <ul><li>CLINICAL INDICATIONS: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Cardiac arrhythmias </li></ul></ul><ul><ul><li>Angina </li></ul></ul><ul><ul><li>CHF: Metoprolol, Bisoprolol, Carvedilol </li></ul></ul><ul><ul><li>Glaucoma: Timolol, Betaxolol, Carteolol, Levobunolol, Metipranolol </li></ul></ul><ul><ul><li>Neurologic: Migraine, somatic mgt. of anxiety, alcohol withdrawal </li></ul></ul><ul><ul><li>Misc: reduce portal vein pressure in cirrhosis </li></ul></ul>Beta- blockers
  48. 49. <ul><li>Clinical toxicities: </li></ul><ul><ul><li>Drug allergy – rare </li></ul></ul><ul><ul><li>CNS effects – sedation, sleep disturbances, depression, psychotic rxns </li></ul></ul><ul><ul><li>Worsening of preexisting asthma & airway obstruction </li></ul></ul><ul><ul><li>Depress myocardial contractility & excitability </li></ul></ul><ul><ul><li>Hypoglycemic episodes </li></ul></ul>Beta- blockers
  49. 50. <ul><li>DRUG INTERACTION: </li></ul><ul><ul><li>Calcium- channel VERAPAMIL </li></ul></ul><ul><ul><ul><li>Severe hypotension </li></ul></ul></ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul><ul><ul><ul><li>CHF </li></ul></ul></ul><ul><ul><ul><li>arrhythmia </li></ul></ul></ul>Beta- blockers
  50. 51. “ A heartfelt apology can’t change the past, but it can brighten the future.”
  51. 52. QUIZ <ul><li>Major neurotransmitter of the Sympathetic Nervous System </li></ul><ul><li>Write A if Agonist or B if Antagonist: </li></ul><ul><li>2. Epinephrine 7. Phentolamine </li></ul><ul><li>3. Labetalol 8. Cocaine </li></ul><ul><li>4. Clonidine 9. Phenylephrine </li></ul><ul><li>5. Prazosin 10. Ephedrine </li></ul><ul><li>6. Terbutaline </li></ul>
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