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1 Bone and Muscle 2 Disorders of the Bone Osteomyelitis Bacterial Infection Inside the Bone Destroys bone tissue Original site of infection is frequently in another part of body Infection spreads to the bone via the blood Osteoporosis—bone brittleness due to lack of calcium • Prevalent in postmenopausal women because of estrogen deficiency Paget’s disease—changes the normal process of bone growth • Causes bone to break down more quickly and grow back softer than normal bone 3 Musculoskeletal Diseases/Disorders Bursitis—inflammation of the small, fluid-filled pouches between bones Tendonitis—inflammation of the cords of connective tissue that attach muscle to bone Myalgia—muscle pain Rheumatoid Arthritis—an autoimmune disorder Osteoarthritis—caused by physical degeneration of connective tissue Gout—caused by crystals of uric acid in blood 4 Treatments Gout Colchicine used to alter ability of phagocytes to attack uric acid crystals Anti-inflammatory analgesics can be used to reduce pain and inflammation Inflammation Salicylates relieve inflammation by inhibiting the synthesis of prostaglandin Topical corticosteroids treat most causes, including chemical, mechanical, microbiological, and immunological 5 Skeletal Muscle Relaxants MOA: may block action of calcium in muscles Indications: painful muscle spasms, neurological spinal cord injury Main Side Effects: Drowsiness, weakness Generic Brand Cyclobenzaprine Flexeril Methocarbamol Robaxin Baclofen Lioresal Musculoskeletal Pharmaceuticals ASA (acetylsalicylic acid) Relieves inflammation by inhibiting the synthesis of prostaglandin Salicylates are also used as analgesics and antipyretics NSAIDs (nonsteroidal anti-inflammatory drugs) Inhibit or block the enzyme that starts the reaction of inflammation by making prostaglandin COX-2 inhibitors Block only the cyclooxygenase II that makes PGE-2, but not C-1 (PGE-1) Inflammation is inhibited, but not the viscosity of the mucosal linin 7 Non Steroidal Anti Inflammatory Drugs Called the NSAIDS Excellent drugs for pain relief and reducing fever and inflammation Developed as an alternative to corticosteroids MOA: blocks the COX enzyme to block prostaglandin formation Side effects are: severe GI bleeding (possible), GI upset and gastritis, kidney insufficiency, edema and elevated blood pressure, hyperkalemia risk Generic Brand Ibuprofen Motrin, Advil Naproxen Naprosyn Ketorolac Toradol (IV available) Diclofenac Voltaren Celecoxib Celebrex (COX2 inhibitor) Musculoskeletal Pharmaceuticals Bisphosphonates—indicated for osteoporosis Mimic the natural organic bisphosphonate salts found in the body Inhibit bone resorption and osteoclast activity Restore bone mass and density Risedronate (Actonel) Ibandronate (Boniva) SERMs (selective estrogen receptor modulators) Indicated for postmenopausal women Protective effect on bones and heart Raloxifene (Evista) Skeletal muscle relaxants—used to relax specific muscles in the body Relieve pain, stiffness, and discomfort Block muscle contraction at the neuromuscular junction 9 10 The Respiratory System Divided into the upper respiratory tract and the lower respiratory tract The upper respiratory tract consists of: Nose or nasal cavity Paranasal sinuses Pharynx and larynx 11 The Respiratory System (cont.) The lower respiratory tract consists of: Trachea Two lungs Two main bronchi 12 The lower respiratory tract. 13 Common Cold Caused by a viral infection that inflames the membranes in nose and throat Antibiotics will not cure a cold or any other viral infection Treatment is considered symptomatic Cough May be a symptom of a cold, flu, respiratory problems, or nonrespiratory diseases Most likely begins with an irritation of nerves in the respiratory tract Nonproductive cough treated with cough suppressant Productive cough treated with an expectorant 14 Allergies and Asthma Allergies Caused by the immune system reacting to a substance that does not cause disease Treatment may be palliative, with antihistamines and antitussives Treatment may be preventive, with mast cell stabilizers Asthma Chronic respiratory disease Characterized by inflammation of airways, tightening of muscles around airways Treatment is palliative with albuterol and other bronchodilators 15 Nasal Congestion and Rhinitis Nasal Congestion Inflamed, stuffy nose Treatment may be palliative, to promote easier breathing Indications for use of decongestants are nasal and bronchial congestion Rhinitis Inflammation of nasal membranes, and/or runny nose Common component of colds and allergies Treatment is considered symptomatic Drugs to treat include: Generic Brand Oxymetazoline Afrin Nasal Spray Phenylephrine NeoSynephrine Nasal Spray Fluticasone Flonase (Nasal Steroid preparation) Mometasone Nasonex (Nasal Steroid preparation) Oxymetazoline and Phenylephrine are sympathomimetic and can raise blood pressure. They also should be used with caution in gluacoma patients 16 Chronic Obstructive Pulmonary Disease (COPD) Umbrella term for emphysema and chronic bronchitis, and asthma Characterized by partially blocked bronchi and bronchioles, mucus plugging and bronchoconstriction Causes shortness of breath Treatment may be palliative, with bronchodilators Beta Agonist Drugs Generic Brand Albuterol Proventil Pirbuterol Maxair Salmeterol Serevent Formoterol Foradil Levalbuterol Xopenex Albuterol and Pirbuterol and Beta 2 agonist but can cause tachycardia in some people. All of the above drugs are available as MDI Formoterol is beta agonist available as a capsule 17 Anticholinergic (Antimuscarinic) Drugs Act on muscarinic (cholinergic) receptors as antagonists Results in bronchodilation Generic Brand Ipratropium Atrovent Ipratropium + Albuterol Combivent Tiotropium Spiriva 18 Steroid / Beta Agonist Combination products These products are not meant as “rescue” agents but for chronic long term use in prevention of COPD Available as MDI and for Advair as dry powdered inhaler as well Patients should rinse after use to prevent oral fungal infections Generic Brand Fluticasone-Salmeterol Advair Diskus Budesonide-Formoterol Symbicort 19 Leukotriene antagonists Drugs block the action of leukotrienes on their receptors Leukotrienes are potent bronchoconstrictors in COPD Contraindicated in patient with hepatic disease Generic Brand Montelukast Singulair Zafirlukast Accolate Zileuton Zyflo CR 20 Steroid Products for COPD or Rhinitis Generic Brand Dose Form Beclomethasone Beconase AQ Nasal Inhaler Fluticasone Flovent ®, Flonase® Inhaler, Nasal Product Methylprednisolone Medrol Tablets Prednisolone Pediapred, Orapred Oral liquid, tablet Triamcinolone Nasacort AQ Nasal Inhaler 21 Mucolytic Agents Used to thin bronchial mucus and secretions from COPD and other lung diseases Generic Brand Special Consideration Acetylcysteine Mucomyst Used for many lung conditions; used for acetaminophen overdose; has a horrible scent and flavor Dornase Alfa Pulmozyme Used primarily for cystic fibrosis 22 23 The heart. 24 Anatomy of the Heart Composed of four chambers: two upper and two lower Atria—top two chambers Ventricles—bottom two chambers Septum—divides heart into right and left sides 25 Valves of the Heart Tricuspid valve—located between the right atrium and the right ventricle Pulmonary valve—located between the right ventricle and the pulmonary artery Mitral or bicuspid valve—located between the left atrium and the left ventricle Aortic valve—located between the left ventricle and the aorta 26 Layers of the Heart Pericardium—fluid-filled sac that surrounds and protects the heart Permits free movement of the heart during contraction Endocardium—innermost wall layer; covers the inside surface of the heart Myocardium—surrounds heart and causes chamber contractions 27 Function of the Heart Provides oxygenated blood throughout the body by a pumping mechanism Oxygenated blood deposits materials necessary for growth and nourishment Receives from tissues the waste products resulting from metabolism 28 Hypertension Sustained elevation of systemic arterial blood pressure Symptoms include: Severe headache Chest pain Irregular heartbeat Fatigue • Pharmaceutical treatment includes diuretics, vasodilators, ACE inhibitors, beta blockers, and calcium channel blockers 29 Congestive Heart Failure Heart pumps out less blood than it receives Results in weakened and enlarged heart Symptoms of CHF include: Upright posture or leaning forward Anxiety and restlessness Cyanotic and clammy skin Persistent cough Rapid breathing Fast heart rate Edema of the lower limbs • Pharmaceutical treatment includes cardiac glycosides, diuretics, vasodilators, ACE inhibitors, beta-adrenergic blockers, and phosphodiesterase inhibitors 30 Coronary Artery Disease Occurs when there is insufficient blood flow to the heart Can lead to: Angina Heart attack Arrythmias Stroke Pulmonary embolism Heart failure Early CAD is closely monitored and symptomatic relief is given by the use of nitroglycerin and other nitrate drugs. NTG ISDN (isosorbide dinitrate) Once CAD has progressed to the point where a patient has angina at rest. Two procedures can be taken PCI with stents CABG (Coronary artery bypass graft) 31 Cardiovascular Pharmaceuticals Antiarrhythmic drugs—restore normal rhythm patterns but do not cure the cause of the irregular heartbeat Cardiac glycosides—used to increase the force of myocardial contraction, without causing an increase in the consumption of oxygen Diuretics—used to eliminate excess sodium and water via the urinary tract Vasodilators—allow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure 32 Cardiovascular Pharmaceuticals (cont.) Angiotensin-converting enzyme inhibitors (ACE inhibitors)—lower high blood pressure; thought to reshape the heart; prevent the body from producing natural vasodilators Angiotensin II receptor blockers—similar to ACE inhibitors; block the body’s natural vasodilators Beta-adrenergic blockers—used to block cells from receiving natural vasoconstrictors Platelet aggregation inhibitors—reduce the ability of the blood to coagulate 33 Cardiovascular Pharmaceuticals (cont.) Anticoagulants—prevent clots from forming or existing clots from getting bigger Tissue plasminogen activators—break down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factors Thrombin inhibitors—inactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrin Antihyperlipidemics—help prevent the progression of coronary artery disease by lowering plasma lipid levels 34 Anticoagulants Do not thin out the blood Prevent clots from forming Prevent existing clots from getting bigger Cannot dissolve existing blood clots 35 Warfarin Oral drug of choice Works by preventing the synthesis of clotting factors II, VII, IX, and X Used in the long-term prevention or management of venous thromboembolic disorders, including: Deep vein thrombosis Pulmonary embolism Clotting associated with atrial fibrillation and prosthetic heart valves Vitamin K may be used as an antidote when too much warfarin has been given For immediate correction of bleeding: fresh frozen plasma is required Testing of bleeding is required for therapy test is called INR For most conditions INR should be between 2-3, INR in the range of 5 or more requires vitamin K 36 Heparin Parenterally administered drug of choice Works by inactivating clotting factors IX, X, XI, and XII Used prophylactically to: Prevent and treat deep vein thrombosis Prevent and treat pulmonary embolism Treat thrombophlebitis Prevent clotting during cardiac and vascular surgery • The only antidote for heparin overdose is protamine sulfate • PTT testing is required 37 Low Molecular Weight Heparins Drugs that a similar to heparin Used as IV or SubQ injections PTT test not required Protamine sulfate is antidote Generic Brand Enoxaparin Lovenox Dalteparin Fragmin Tinzaparin Innohep 38 Newer anticoagulants Used primarily for anticoagulation for atrial fibrillation Does not required INR testing like warfarin Less drug interactions Can’t be reversed by vitamin K Generic Brand Special Consideration Dabigatran Pradaxa Must be dispense in original container Rivaroxaban Xeralto NA Apixaban Eliquis NA 39 Cholesterol and Triglycerides HDL—high-density lipoproteins or “good” cholesterol LDL—low-density lipoproteins or “bad” cholesterol Triglycerides—a form of energy stored in adipose and muscle tissues Often measured to depict fat ingestion and metabolism Can be used to assess CAD risk factors Statins- drugs used to lower LDL cholesterol Generic Brand Atorvastatin Lipitor Simvastatin Zocor Fluvastatin Lescol Rosuvastatin Crestor Major: Side effects are nausea, GI and a reaction called Rhabdomyolysis and myopathy where patient experiences muscle pain and at the extreme renal failure and hospitalization Statins are drug interactions with medications that block the liver’s CYP450 systems: Diltiazem, amiodarone, HIV protease inhibitors, Ketoconazole 40 Generic Brand Simvastatin + Ezetimibe Vytorin Lovastatin + Niacin Advicor Simvastatin + Niacin Simcor Above medications are combination products that contain a statin + one other drug. Exetimibe is a drug that block enteral absorption of cholesterol. Niacin is a B vitamin used to high doses to alter metabolism of triglycerides and raise HDL One unique combination product is Caduet, which is a combination of Atorvastatin and Amlodipine (calcium channel blocker ). This product is used to treat metabolic syndrome 41 Non Statin Antilipidemic drugs Other drugs that target lowing VLDL, triglycerides, and raising HDL have a beneficially affect on coronary artery disease Generic Brand Indications Gemfibrozil Lopid High VLDL Fenofibrate Tricor High VLDL, low HDL Niacin Niaspan High VLDL, low HDL Omega 3 Fatty acid Lovaza High VLDL, low HDL 42 Drugs used in the Treatment of MI MI is a myocardial Infarction. Heart attacks occurs because a arterial plaque raptures and triggers the coagulation cascade completely occudding a coronary artery. This cause necrosis of the heart muscle. If not treated MI result in death from cardiogenic shock Even if treat mortality is high from secondary ventricular fibrillation Even if treated, patient will suffer irrevocable heart damage resulting in CHF and/or damage to cardiac conduction system leading to pacemaker or ICD placement The main goal is to relieve the blood vessel of the clot and reestablish coronary blood flow Can use “clot busters” drugs or have percutaneous coronary intervention (PCI) which the femoral artery undergo catherization and a probe is guide to the site of occlusion and a ballon is inflated to push aside the clot 43 Generic Brand Use Aspirin Ecotrin To stop platelet action at the clot Clopidogrel Plavix To stop platelet action at the clot Ticagrelor Brilinta To stop platelet action at the clot Nitroglycerin Various To vasodilate coronary artery to relieve pain Tissue plasminogen activator TPA Alteplase (Activase) Reteplase (Retavase) Tenecteplase (Tnkase) Activate plasmin, a blood protein that opens blood clots Heparin N/A A potent blood anticoagulant that stop further coagulation Metoprolol Lopressor A beta blocker that slows heart rate and slows spread of infarction 44 Drug used in the treatment of Atrial Fibrillation Atrial Fibrillation is a heart rate disturbance in which the atrium/ atria are beating extremely rapidly Can lead to cardiogenic shock if the rate reaches the ventricles Therapy is aimed blocking this rate disturbance from reaching the ventricles (called rate control), preventing blood clots in the heart muscle wall from forming embolus (anticoagulation), and eventual cardioversion Rate control Diltiazem Verapamil Beta blockers Amiodarone Anticoagulation Warfarin Apixaban (Eliquis) Cardioversion Ibutilide (Tikosyn) High dose Amiodarone 45 Ventricular Fibrillation Ventricular Fibrillation, VF, is a cardiac arrythmia where the ventricles beat extremely rapidly to the point where no coordinated contraction occurs Medical emergency VF lasting more than the 90 seconds leads to asystole, sudden cardiac death and cardiogenic shock. Brain death from cerebral hypoxia Therapy Direct DC shock with ACD: delivery of DC shock with about 360 Joules of electricity to bring about normal sinus rhythm. Best chance at survival but not always successful Drug treatment used in conjunction with ACD if shock initially unsuccessful Amiodarone: 300 mg IV push with 150 mg IV supplemental doses Lidocaine: 100 mg IV push Epinephrine or Atropine can be tried after failed attempts at shock Other drugs include calcium chloride 10%, magnesium sulfate and vasopressin 46 Beta Blockers Very useful in extending the life expectancy of patients post MI and in CHF patients Due to evidence from clinical trials like the Scandinavian Timolol study and the BHAT (beta block heart attack trial with propranolol) beta blocker are now an important drug in the therapy of post MI patients Generic Brand Propranolol Inderal Metoprolol Lopressor Timolol Blocadren Atenolol Tenormin Carvedilol Coreg 47 ACE Inhibitors Used to decrease mortality in post MI and CHF patients Used with beta blockers and often in combination with them Generic Brand Captopril Capoten Enalapril Vasotec Lisinopril Zestril, Prinivil Benazapril Lotensin Ramipril Altace Potassium levels should be monitored ACE inhibitors are pregnancy category X May cause relentless coughing in some patient requiring discontinuation due to potent edema and closure of the airway 48 ACE inhibitors combination products Often ACE inhibitors are combined with diuretics to negate the potassium loss and to synergize to lower blood pressure more Generic Brand Lisinopril + HCTZ Zestoretic, Prinzide Enalapril + HCTZ Vaseretic Benzapril + HCTZ Lotensin HCT 49 Angiotensin Receptor Blockers Similar to ACEI but works at a receptor for angiotensin 2 If patient has angioedema to ACEI; ARB’s can be tried Used in MI and renal disease, HTN and CHF Generic Brand Losartan Losartan + HCTZ Cozaar Hyzaar Valsartan Valsartan + HCTZ Diovan Diovan HCT Irbasartan Irbasartan + HCTZ Avapro Avalide 50 The renal system. 51 The Renal System Composed of two kidneys, two ureters, one bladder, and the urethra Filtering system of the kidneys is composed of millions of nephrons Waste from food and drug metabolization is filtered through the nephrons Wastes exit the kidneys as urine via the ureters Ureters lead to the bladder, where urine is stored until released The kidneys are located in the posterior abdomen just above the waist 52 Nephron Smallest, most basic part of the kidney Filters the blood that passes through the kidneys Produces urine through the processes of filtration, reabsorption, and secretion Enables blood to reabsorb water, electrolytes, and nutrients 53 Kidney and Bladder Kidney Built almost entirely of nephrons Organ that filters blood and produces urine Urine produced by the kidneys is conducted to the bladder Bladder Organ used for waste storage Can collect approximately 350 mL to 500mL of urine Allows for discretionary voiding 54 Drugs for Kidney Disorders Failing kidneys cause disorders relating to retention of toxins in the blood, acidity and electrolytes abnormalities Kidney disorders effects blood potassium, calcium, phosphate levels, and levels of various hormones in the body. Patients have high PTH levels Low vitamin D levels Low erythropoetin levels Patients have high levels of urea and other nitrogenous toxin that causes damage to the CNS 55 Drugs to lower patient’s potassium levels K binding resins Kayexalate ® is sodium polystrene sulfonate resin and bind K in the GI prevent absorption In emergency situation, where life threating hyperkalemia exists the following is given (in a hospital ICU) Insulin 10 units IVP Calcium choride 10% 300 mg -1 gram IVP Albuterol USP solution Kayexalate 30 g orally Drug that lower phosphate levels Sevelamer (Renagel®, Renvela ® Lanthanum Carbonate Calcium Acetate (Phoslo ®) 56 Drugs used to correct PTH levels (secondary hyperparathyroidism) Calcitriol (Calcijex, Rocaltrol®) IV form is given with dialysis Oral capsule (Rocaltrol ) is given as maintanence tx outpatient Paricalitol Zemplar ® (IV form given with dialysis) Drugs used to correct renal induced red blood cell anemia Epogen® (Erythropoetin) Procit ® (erythropoetin) Aranesp ® (darbepoetin) 57 ESRD, end stage renal disease is where there is no kidney function left Renal transplantation is only cure Periodically patients require Dialysis Hemodialysis Modality where a machine acts as an artificial kidney Removal excessive potassium, phosphates Added sodium, magnesium and calcium (MD must order) Removal of excessive water from body (hemofiltration) Number one cause of ESRD in the US is diabetes 58
