Question | Answer |
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 |