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Special Topics

Pharmacology

QuestionAnswer
Medical Pharmacology -Science of chemicals that interact with the human body
Basic facts: 1970 Controlled Substance Act -Established schedules of abusable drugs -Lower the number; the more addictive -Higher numbers may be obtained OTC
Pharmaceutical Phase -Disintegration/Dissolution of various drug forms(tablet, capsule, liquid, topical) -Influences pharmacokinetic and pharmacodynamic phases
Pharmacokinetic Phase -Determines site concentration/general effects -Absorbed, distribution, metabolized(mostly by liver, limited by enteric coating) and excreted(mostly by kidneys and intestines)
Pharmacodynamic Phase -Determines specific cellular mechanisms of the drug interactions and it's effects by 3 theories: -Specific receptor target(i.e. cancerous tissue) -Enzyme interaction- stimulant of inhibitor of chemical reactions -Non-specific-more general effects
Drug names -Each drug has a generic name/chemical (i.e. Ibuprofen and a brand/trade name- Advil) -Generic versions use the chemical name -Generic versions may: -Use less expensive ingredients -Use differenti nactive ingredients -Have a different effectiveness
Consult Physician's Desk Reference to obtain information on... -Manufacturer -Indications -Standard doses -Possible side effects -Drug interactions
Drugs: Generic/Chemical names -Generic/chemical name will be followed by brand/trade name -Most known by trade names but some by generic/chemical names -Take special note of bolded desired and/or side effects and how they may influence PT interventions
Drugs by Numbers -2009 prescriptions filled per person -19-64 yrs of age -US- 11.3 -TN #3- 16.3 -#1 and #2 were WV and KY - 65 and older: US-31.2 -TN #1 47.1
Death rate for drug overdoses -Tripled to 16 deaths per 100000 in TN since 1999 per TN Division of Health -TN ranks #8 in US per 2010 Centers for Disease Control
Health rankings -TN ranks 42 out of 50 states as of 2013: -Diabetes= 12% -Obesity= 31% -High cholesterol= 39% -Hypertension= 39% -Stroke= 4% -Heart attack= 7% -Heart disease= 7% -Physically active= 71%
HTN -BP= HR x SV x TPR -Lowering BP pf patients with a diastolic pressure > 90 mm HG decreases mortality rate in 25% of the population -CDC: over half of the 67 million American adults with HTN cannot get it under control even with medications
Pre- and Stage 1 HTN Rx -Weight reduction -Decreased salt in diet -Smoking cessation -Reduced alcohol consumption -Exercise
Stage 2 HTN Rx -Continue lifestyle modifications plus... -1 to 3 different types of drugs may be used at the same time
Drugs used in HTN -Diuretics -Beta blockers -ACE inhibitors -Calcium channel blocker -Alpha blocker -Centrally acting adrenergic inhibitors -Vasodilators
Diuretics -Controls fluid volume; blocks NaCl reabsorption in kidneys -3 types: Thiazide, Loop, Potassium-Sparing
Thiazide Diuretics -Chlorothiazide (Diuril) -Side effects: gout, weakness, increased urination
Loop Diuretics -Furosemide (Lasix) -Bumetanide (Bumex)
Potassium-Sparing Diuretics -Spirionolactone (Aldactone)
Beta-adrenoceptor antagonists -A.k.a Beta-blockers -Decreases BP by decreasing cardiac output by decreasing HR
Beta-blockers -Propranolol (Inderal) -Atenolol (Tenormin) -Metoprolol (Lopressor) -Nadolol (Corgard) -Side effects: cold hands, fatigue, increased asthma and triglycerides, and decreased HDL and HR -Banned by Olympics
Angiotensin Converting Enzyme Inhibitors -A.k.a. ACE inhibitors -Block vasoconstriction resulting in vasodilation thus less TPR
ACE inhibitors -Not as many side effects: dry cough, hyperkalenemia -Benazepril (Lotensin) -Enalapril (Vasotec) -Captopril (Capoten)
Calcium anatgonists -A.k.a Calcium Channel Blocker -Block calcium flow into cells resulting in arterial relaxation; again a decrease in TPR
Calcium antagonists: side effects -Dizziness, hypotension, flushing, ankle edema, constipation -Nifedipine (Procardia) -Diltiazem (Cardizem, Dilacor) -Verapamil (Calan)
Alpha Adrenergic Blockers -A.k.a Alpha Blockers -Decrease in TPR -Prazosin (Minipress) -Terazosin (Hytrin)
Centrally Acting Adrenergic Inhibitors -Clonidine (Cataprs) -Methyldopa (Aldomet) -Guanfacine (Tenex)
Vasodilators -Decrease in TPR -Minoxidil (Loiten, Rogaine) -Hydralazine (Apresoline) -Diazoxide (Hyperstat) -Nitroprusside (Hypride, Nitropress): used for HTN crisis
Importance of HTN medications to PT -Beta blockers blunt HR response to activity so...even though the heart rate may not be as high as it should be doing a certain activity it is working just as hard.The medications just make it appear low. -Plenty of bathroom breaks 4 those on diurectics
Importance of HTN medications to PT cont.. -Potential fall risk -Be aware of timing of meds and fatigue
Angina -Usually due to increased plaque in coronary arteries: -Blocks blood flow to heart -So with increased activity of the heart, the heart muscle doesn't receive enough oxygen -Ischemic P! develops
Angina S&S -Chest P! or discomfort -P! in arms, neck, jaw, shoulder or back accompanying chest pain -Nausea -Fatigue -Shortness of breath -Anxiety -Sweating -Dizziness
Angina: basic aims of drug treatment is to... -Reduce demand for oxygen by decreasing HR/SV and thus CO -Increase oxygen supply by dilating coronary arteries thru decreasing TPR which decreases BP and subsequently SV
Angina medications -Nitrates -Beta Blockers -Calcium Antagonists
Nitrates -First line of defense -Cause arterial dilation and increase in TPR
Nitrates cont... -Nitroglycerin most common: -Sublingual tablet/spray- short acting & used for acute attacks -Patches-long acting and used for prevention -Also available in oral (Cardilate) & IV form (Nitrostat) -Isosorbide dinitrate (Isordil, Sorbitrate)- less common
Beta Blockers act to.. -Decrease CO by depressing myocardial contractility and reducing HR -Side effects are common: cold hands, fatigue, increased asthma and triglycerides, and decreased HDL and heart rate
Calcium Antagonists -Cause arterial vasodilation to decrease TPR and some cause changes -Side effects: dizziness, hypotension, flushing, ankle edema, constipation
Keep ____ handy if ____ angina is present -Nitro -Unstable
Unstable angina -More easily and unpredictably brought on
Also remember... -Decreased endurance associated with B-Blockers and other side effects from Calcium antagonists
Drugs used in blood coagulation -Anticoagulants -Antiplatelets -Thrombolytics
Deep Vein Thrombosis (DVT) S&S -Active cancer -Paralysis/immobilization -Bedridden/major sx -Tender along deep veins -Entire LE swelling -Pitting edema -Collateral superficial veins -Alternative diagnosis
Anticoagulants -Prevention and treatment of DVT and embolism -Primary side effects is hemorrhaging, especially intracranial
Anticoagulant: Heparin -(Hep-lock/Hepalean): -Decreases thrombin (clotting enzyme) -Injected or IV and is short-acting
Anticoagulant: Warfarin -(Coumadin) -VItamin K (need for clotting) antagonist -Active orally with a 1-3 day delayed affect & w/ gradual dosing -Interactions with other drugs than heparin -Neither Heparin or Warfarin advantage to aspirin or mechanical prophylaxis 4 prevention
Anticoagulant: Enoxaparin sodium -(Lovenox) -Injected subcutaneously or by IV -Max activity 3-5 hour after injection
Antiplatelet drugs -Salicylate (Aspirin) is the most common -Better for arterial thromboses since they consist of mostly platelets rather than fibrin
Thrombolytics (Fibrinolytics) -Used as clot busters -Used for extensively in MI pts to lyse the thrombi that block coronary arteries
Thrombolytics: Streptokinase (Streptase) or SK -Made in Streptococci bacteria -Increases conversion of plasminogen to plasmin to break up clot
Thrombolytics: Tissue Plasminogen Activator (tPA, Alteplase) -Naturally occurring enzyme that is more "clot specific" than SK -Only drug approved by the US Food and Drug Administration for the acute(urgent) treatment of ischemic stroke -Side effect: hemorrhagic stroke
Common orthopedic drugs -Analgesics -Anti-inflammatories -Muscle relaxors
Analgesics -Opioids (aka narcotics)- psycho-active drugs -Narcotic antagonists -Non-opioids -Muscle relaxants -Anti-inflammatories
Opioids -From poppy plant -17 different alkaloids which are synthetically altered -Mimic endogenous opiate(endorphins, enkephalins) -Produce: analgesia, respiratory depression, euphoria, sedation -Cont. use results in tolerance and dependence/addiction
Opioids: 1070 Controlled Substance Act -Established schedules of abusable drugs -Lower the number; the more addictive -Higher numbers may be obtained OTC -52 million people use prescription painkillers
Morphine -Injected for severe pain -Orally for terminal P! for terminal care -Schedule II
Diamorphine (Heroin) -Twice as potent as morphine but slower acting -Schedule I- no medically accepted use
Methadone -Used in drug rehab to replace heroin
Meperidine (Demerol) -Schedule II
Methylmorphine (Codeine) -Schedule II if given alone -Schedule III in combination with others
Oxycodone -With aspirin (Percodan)-schedule II -With acetaminophen (Tylox, percocet)- schedule II
Hydrocodone (Lortab) -With acetaminophen (Lorcet, Vicodin)- schedule III
Prolonged use of Opioids side effetcs -Musculoskeletal: muscle rigidity and osteoporosis -Other systems are slowed down and supressed -Ineffectiveness of analgesics leads to addiction and withdrawal issues
Narcotic Antagonists: Naloxone (Narcan) -IV medicine -Used to treat an overdose
Narcotic Antagonists: Naltrexone (Texan) -Oral medicine -Used to prevent abuse
Non-opioids or OTC P! medication -Acetaminophen (Tylenol) -Found in 600 different drugs -Also a anti-pyrectic (fever reducer) -No anti-flammatory effects -Ineffective for LBP and only minimal short term benefit for people with OA
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) -Analgesic and anti-inflammatory agent -May also be an anti-pyretic
Anti-inflammatories -NSAIDs -Corticosteroids -Supplements
NSAIDs -Drugs that combat swelling by blocking prostaglandins -OTC or prescription -Some may also include analgesic and/or anti-pyretic agents -More effective for OA P! than Tylenol
Most common NSAIDs -Salicylates= Aspirin -Ibuprofen= Motrin, Advil, Midol -Naproxen sodium= Aleve -Naproxen= Naprosyn/ prescription Aleve -Piroxicam=Feldene -Etodolac= Lodine -Nabumetome= Relafen
NSAIDs: COX 2 (cyclooxygenase) inhibitors -Celebrex- COX 2 inhibitor -Limit formation of prostaglandins which promote inflammation -Same P! relieving and anti-inflammatory effects as traditional NSAIDs w/o causing the gastric irritation -More expensive
Other COX 2 inhibitors -Vioxx and Bextra: withdrawn from market bc of higher risk of cardiovascular problems than Celebrex
NSAID side effects -GI tract irritation due to increased sensitivity to stomach acid except with Cox 2 inhibitors -Nephrotoxicity -Skin rash -Tinnitus -Allergic reactions
NSAID application: Acute symptoms -PRICED over NSAIDs most often -NSAIDs- more side effects but small benefit as Tylenol if PRICED not effective
NSAID application: Chronic symptoms -Low evidence of a small benefit vs.placebo for LBP -Increased risk of GI bleeding and other side effects with long term or recurrent use -Greater support for manual therapy, MET, and cognitive behavioral therapy for LBP
NSAID application: Bone and Tendon healing -Deleterious to fx healing -Varying negative effects with various NSAIDs -Tylenol good alternative for P! although it won't influence inflammation -Tendon healing: no influence unless at the insertion point
Glucocorticoids -Primarily anti-inflammatory agents: fast acting, very effective -Other functions: horomonal replacement, immunosuppression, adrenal horomone suppression
Glucocorticoids cont... -Facilitate conversion of protein to glycogen -Increases the ability of skeletal muscles to maintain contractions and avoid fatigue
Cortisone -Injected
Hydrocortisone -Oral replacement therapy -IV for shock -Topical for wound, rash, etc
Prednisone -Orally for severe inflammatory or allergic conditions -Medrol Dosepak
Dexamethasone -Iontophoresis
Glucocorticoid indications -Acute inflammatory conditions -Asthma -Autoimmune disease (RA, lupus, MS) -Skin conditions (eczema and poison ivy) -Some cancers
Glucocorticoid injections -Analgesic and/or anti-inflammatory -Procedures: intramuscular, epidural and intra-articular -Equipment: needles or catheters, fluoroscopy -Initially weakens tissue -For 2-3 days: avoid exer. and hot tubs/baths to prevent circulation of meds
Injection evidence -Major limitations are the lack of replication of the findings for MND
Intra-muscular injection: Lidocaine evidence -Effective for: Chronic MND & Myofasical trigger points -Moderate evidence that Botox A for chronic MND were no better than saline
Epidural injection evidence -Limited effectiveness of methylprednisolone and lidocaine for chronic MND with radicular findings
Intravenous injection evidence -Moderate evidence for the benefit of methylprednisolone given within eight hours of acute whiplash
Injection evidence: Sub-acute and chronic LBP -Intra and periarticular, nerve blocks, trigger points -No evidence for or against these injections -Can't rule out certain unspecified groups may receive a benefit -Side effects: small to rare
Glucocorticoid injection side effects -HA -Dizziness -Insomnia -Erythema -Rash/itching -Increase blood sugars(diabetic) -Mild BP changes -Increase P! -Fluid retention (cardiac pts) -Mood swings -Gastritis -Menstrual irregularities
Chronic Glucocorticoid Adverse Effects -Immunosuppressant effects -Cushing's syndrome -Ecchymosis -Fluid retention -Adrenal suppression -Peptic ulcer disease -Mm weakness & atrophy -Poor healing -Osteoporosis -Increases blood sugar so avoid diabetics
Don't do strenuous ____ or _______ for 48 to 72 hrs after injection -Exercise -Iontophoresis *Watch for bruising and skin tears after prolonged use
Do ___ activities in a pool or <____activities to combat osteoporosis -Wt. bearing -< FWB
Supplements: Glucosamine and chondroiten sulfate -NO evidence that minimum clinically important outcomes have been achieved compared to placebo in knee -P! improved in short term but functional changes and side effects were nearly absent
Different types of muscle relaxants -Diazepam= Valium -Tizanadine= Zanaflex -Cyclobenzaprine= Flexeril -Orphenadrine= Norflex -Metaxalone= Skelaxin -Carsioprodol= Soma -Baclofen= Lioresal
Muscle relaxers general -Brain relaxants-most don't have direct effect on muscle -Create mental and systemic sedation -Don't operate machinery, drive, perform safety sensitive jobs -Also have analgesic properties
Muscle relaxers general cont... -Limited efficacy with chronic P!, best with acute P! -No studies that support their long term use -Long term use does not improve functional recovery and may hinder function
Oral evidence for MND -Psychotropic agents had mixed results -NSAIDs, had contradictory or limited evidence effectiveness -Muscle relaxants, analgesics, and NSAIDs had limited evidence and unclear benefits
Importance to PT -Taking orthopedic meds is not a license for the pt to over do it or for you to be overly aggressive -Few and rare situations exist where pts will not improve with proper activity modification, treatment, and the taking of meds as directed
Prolotherapy injections -Sclerosing agent -Purposed to stabilize jts -Absence or inconsistency in effectiveness for chronic LBP
Parkinsonism drugs -Disease of the nasal ganglia with deficient dopamine -Dopamine= neurotransmitter that enables smooth movements -Characterized by a slow movement, rigidity, impaired balance, tremor -Come out with new drugs/regimes every year
What do Monoamine Oxidase Inhibitors do -Reduce oxidative stress on neurons -Prevents break down of dopamine
MAOI-B's -Selegiline= Eldepryl -Rasagiline= Azilect -Decrease symptoms by only 10%
Dopaminergics -Replacement drug -Passes the blood-brain barrier unlike the actual dopamine itself -Levadopa= Sinemet, is the oldest one
Dopaminergics-L-dopa: Honeymoon period -Dramatic improvements that are initially seen -Therapeutic window is only 5-7 yrs -Begins to wear off quicker and have rebound effects
Dopaminergics S&S -N&V -Psychiatric problems -Orthostatic (postural) hypotension -Dyskinesias
Dopamine Agonists -Also activate the dopamine receptors -Used only in moderate to advance cases who aren't responding to L-dopa -Bromocriptine= Parlodel -Pergolide= Permax
Anti-cholinergics -Decreases tremors, but little to no effects on rigidity -May decrease memory along with dopaminergic side effects -Trihexyphenidyl= Artane -Beztropine= Cogentin
Anti-viral agents -Dopaminergic & anti-cholinergic properties -Amantadine= (Symmertral) -Few side effects -Quicker tolerance develops with only moderate symptom improvement
Importance to PT -PTs are seen for regular tune-ups as disease progresses and drugs lose effect -Do treatment when drugs are in effect (2-3 hr after taking) for best effort
Alzheimer's Disease Medications: Mild to moderate -Breakdown of neurotrnsmitter -1994 -Tacrine (Cognex) FDA approved - 2006: Cholinesterase inhibitors to prevent break down of acetylcholine=neurotransm. -Galantamine= Razadyne, Reminyl -Reivastigmine= Exelon -Donepezil= Articept -Tacrine= Cognex
AD medication: Moderate to severe -N-methyl D-aspartate (NMDA) antagonist which regulates glutamate -Glutamate is another neurotransmitter for memory and learning -Another is Memantine= Namenda
AD med S&S -All drugs only slow down the progression of the disease -N&V, diarrhea, weight loss -Muscle weakness -Dizziness, HA, confusion
PT implications -Drug interactions: NSAIDs and journaling
Psychiatric drugs -Sedatives for insomnia -Anxiolytics -Antipsychotics -Antidepressants -Alzheimer's
Insomnia medications: Prescription -Benzodiazepines- Schedule IV -Temazepam=Restoril -Triazolam= Halcion
Insomnia meds: OTC -Non-barbituates and non=benzodiazepines -Diphenhydramine -Found in Sominex, Benadryl, Tylenol PM, etc.
Anxiolytics -Nerve pills; minor tranquilizers -Benzodiazepines= used forminor imaging orsurgical procedures: -Alprazolam= Xanax -Chlordiazeposide= Librium -Midazolam= Versed
Anxiolytic others... -Beta blockers -Diphenhydramine= Benadryl -Phenobarbitol- Schedule IV -Buspione=BuSpar
Created by: alovedaytn