Exam 6 - Alpha/Beta Adrenergic Agonists and Antagonists
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| What type of receptor is the alpha-1 adrenergic receptor? | G-protein coupled receptor
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| What is the primary effect of alpha-1 stimulation? | Vasoconstriction of smooth muscle
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| What types of effects occur with stimulation of alpha-1 stimulation? | Arterial and venous vasoconstriction; decreased GI motility
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| Where are the catecholamines epinephrine, norepinephrine, and dopamine produced? | Adrenal medulla **norepi also produced from sympathetic nerve fibers**
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| Fibers that run from the ganglion to the effector organ are called ______. | post-ganglionic fibers
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| The neurotransmitters of post-ganglionic nerve fibers are divided into what two divisions? | Sympathetic and parasympathetic
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| Postganglionic fibers of the parasympathetic division are primarily________. | Cholinergic
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| What is the primary neurotransmitter of the parasympathetic nervous system? | acetylcholine
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| The sympathetic neurons of the ANS are mostly _______. | adrenergic
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| What are the primary neurotransmitters of the SNS? | epinephrine, norepinephrine, dopamine
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| Fibers that run from the CNS to the ganglion are known as _______. | pre-ganglionic nerve fibers
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| Which pre-ganglionic fibers are closer to the ganglia: sympathetic or parasympathetic? | sympathetic
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| Identify the 4 steps of agonist binding with the alpha-1 receptor. | 1)binding activates phospholipase C 2)2nd messengers are generated 3)2nd messengers cause phosphorylation of Ca++ ion channels 4) Ca++ ions facilitate the release of bound intracellular calcium at the end organ (vasoconstriction)
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| What effect does alpha-1 agonism have on the lungs? | May result in bronchospasm
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| Alpha-1 receptors are found primarily in what 4 areas of the body? | Heart, blood vessels, glands, gut
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| Identify the 4 steps of agonist binding with the alpha-2 receptor. | 1)stimulation inhibits adenylate cyclase activity 2)decreased adenylate cyclase decreases cAMP levels in neurons 3)presynaptic release of neurotransmitters is blocked 4)decrease sympathetic or adrenergic outflow
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| What 6 things does alpha-2 agonism inhibit? | Pancreatic insulin release, lipolysis, norepinephrine, Ach, contraction of sphincters of the GI tract, norepinephrine in the brain
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| What benefit does alpha 2 stimulation have in anesthesia? | Sedation, skeletal muscle relaxation, analgesia
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| How does alpha-2 agonism affect platelets? | Stimulates aggregation
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| How does alpha-2 agonism affect the GI tract and salivary glands? | Relaxes GIT and decreases salivary secretions
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| In what two ways is the pancreas affected by alpha-2 agonism? | Increased glucagon and decreased insulin release
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| Describe the consequences of alpha blockade of catecholamines and sympathomimetics? | The heart and peripheral vasculature (alpha receptors) become relaxed, leading to orthostatic hypotension, baroreceptor mediated reflex tachy, impotence
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| T/F: Alpha blockers are effective in the treatment of essential HTN. | False - d/t hypotensive and tachycardic (reflexive) effects
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| What is the difference b/w direct and indirect sympathomimetics and give examples of each. | Direct: act on the alpha/beta receptors (neo, albuterol); Indirect: release endogenous catecholamines from sympathetic nerve endings (amphetamines), inhibit reuptake of catecholamines (cocaine),& inhibit enzymes that metabolize catecholamines (entacapone)
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| Which alpha receptors are presynaptic and which are postsynaptic? | alpha1 = post; alpha2 = pre
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| Both phentolamine and phenoxybenzamine have both been used in the treatment of what disease? | pheochromocytoma
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| What type of tissue is affected by phentolamine? | vascular smooth muscle
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| What two conditions is phentolamine indicated for? | pheochromocytoma and autonomic hyperreflexia
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| What alpha blocker can be used to reverse dental local anesthetic effects? | phentolamine
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| What are the bolus and infusion doses of phentolamine? | Bolus=30-70mcg/kg (generally 5mg bolus); Infusion=10-20mcg/kg/min (ceiling effect over 20mcg/kg/min)
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| Extravasation from a peripherally injected vasoconstrictor can be treated with ______ at a dose of _______. | phentolamine; 2.5-5mg
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| What effects does phentolamine have on the heart? | Increases HR, CO, may precipitate dysrhythmias
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| T/F: Phentolamine is useful in anginal patients. | False
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| How do alpha-adrenergic receptor blockers affect arteries and veins, and how does this affect HR? | Reduces arteriolar resistance and increases venous capacitance, which leads to reflex tachycardia
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| Phentolamine and phenoxybenzamine are (selective/non-selective) alpha-adrenergic blocking agents. | non-selective
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| Which alpha-adrenergic antagonist has irreversible binding with alpha receptors? | phenoxybenzamine
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| What type of bond is created between phenoxybenzamine and the affected alpha receptor? | covalent bond
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| What is the major use of phenoxybenzamine? | Pre-op preparation of patients w/pheochromocytoma
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| Why does the IV peak effect of phenoxybenzamine take up to 60min? | Requires structural modification for effect
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| Phenoxybenzamine has a (long/short) half life of _______. | long; 24hr
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| Phenoxybenzamine is an alpha antagonist that is a non-selective ________. | haloalkylamine
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| Why should patients who receive phenoxybenzamine remain supine? | Rx alters normal vasoconstrictive response
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| What should the anesthetist be prepared for after resection of a pheochromocytoma? | Drop in BP
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| What is the PO dose of phenoxybenzamine? | 0.5-1mg/kg
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| Prazosin causes (selective/nonselective) and (reversible/irreversible) inhibition of (alpha1/alpha2) receptors. | selective; reversible; alpha1
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| Prazosin works (pre-synaptically/post-synaptically). | post-synaptically on arterial and venous vessels
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| What is another indication for prazosin besides HTN? | BPH
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| Which two alpha blockers are used to improve erectile dysfxn? | phentolamine and yohimbine
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| Which alpha blocker is used to manage HTN from clonidine w/d? | phentolamine
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| Alpha2 agonism results in the (inhibition/release) of norepinephrine from presynaptic vesicles. | inhibition
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| Yohimbine is selective for what type of receptor? | alpha2
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| Which medication was used to treat impotence 2/t diabetic and vascular issues? | yohimbine (selective alpha2 blocker)
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| Which alpha blocker improves symptoms in asthmatics? | phentolamine
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| Which two alpha blockers can cross the BBB? Which causes sedation/depression and which increases motor activity/anxiety? | phenoxybenzamine (sedation/depression) and yohimbine (motor activity/anxiety)
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| Which alpha blocker is beneficial for decreasing cholesterol/LDL/triglyceride levels? | prazosin
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| Alpha2 agonism initiates the release of the neurotransmitter ________. | norepinephrine
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| What is the basic structure of catecholamines? | Hydroxyl groups on the 3 & 4 carbon position of the organic compound catechol
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| Catecholamines contain an _________ ring attached to the _________ group. | aromatic; amine
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| Where are catecholamines stored? | Chromafin vesicles in the adrenal medulla
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| Which electrolyte is essential for the release of norepi? | calcium
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| Alpha and beta receptors belong to what receptor family? | G-protein coupled receptors
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| What is the function of monoamine oxidase? | Metabolism of catecholamines by deamination
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| Where is MAO found? | Sympathetic nerve fibers just outside the mitochondrial membrane
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| Identify the 2 types of MAO and the neurotransmitters they deaminate. | MAO type A (epi and norepi); MAO type B (dopamine)
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| What is the end-product of norepi/epi metabolism? Of dopamine metabolism? | Norepi/epi=vanylyllmandelic acid; dopamine=homovanillic acid
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| Besides MAO, what other enzyme metabolizes catecholamines? | Catechol-O-Methyl transferase (COMT)
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| Where does COMT function? | Methylates catecholamines in the extraneural tissue
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| What are epi and norepi reduced to in the COMT pathway? | epi=metanephrine; norepi=normetinephrine
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| List the order of synthesis of catecholamines. | Phenylalanine, tyrosine, dopa, dopamine, noradrenaline, adrenaline
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| Which second messenger is increased by beta receptor stim? | cAMP
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| Describe the chain of events known as the "beta1 effect". | cAMP stimulates protein kinase > inward Ca++ ion flux is enhanced > incr. cytoplasmic reticulum Ca++ [] > actin-myosin interaction incr. > forceful myocardial contraction
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| Beta2 agonism results in the relaxation of what parts of the body? | bronchial, vascular, smooth muscle
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| How does beta2 achieve the effect of relaxation? | Hyperpolarization of the cell membrane, decreasing inward Ca++ ion flux
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| How do competitive antagonists affect to the Dose-Response curve? | Cause rightward shift
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| How will long-term administration of beta blockers affect beta receptors? | Causes upregulation and increased numbers of beta receptors
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| T/F: Beta blockers increase the slope of the Dose-Response curve. | False = shifts it right
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| What does beta adrenergic stimulation result in? | Positive chronotropic, inotropic and dromotropic effects
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| What does a dromotropic agent affect? | Speed of conduction in the AV node
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| 75% of beta receptors in the myocardium are (beta1/beta2) and 20% are (beta1/beta2). | beta1; beta2
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| Where are beta3 receptors primarily located and what is their role? | Located in adipose tissue and involved in lipolysis and thermogenesis
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| What determines the agonist-antagonist activity of a beta receptor agent? | Benzene ring substituents
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| What form is more potent for beta blockers and agonists: levorotary or dextrorotary? | levorotary
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| Name the 4 beta blockers that affect the entire family of beta receptors. | Pindolol, Inderal, Nadolol, Timolol
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| Name the 2 selective beta blockers for beta1 receptors. | Metoprolol & atenolol
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| T/F: Metoprolol, atenolol, and esmolol only block beta1 receptors. | False = large enough dose of esmolol can block beta2 receptors (lungs->bronchoconstriction)
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| Which receptors does labetalol affect? At what ratio? | beta & alpha at a ratio of 7(b):1(a)
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| Which receptors does carvedilol antagonize? | Beta1, beta2, alpha1
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| What is the T1/2 of carvedilol and which patients is it indicated for? | T1/2=10h; CHF & HTN
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| Non-selective beta blockers are contraindicated in which patients? | Ventricular failure, conduction abnormalities, bronchospastic dz, vasospastic angina
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| Agents that exhibit intrinsic sympathomimetic activity have what types of properties? | Have beta antagonism and partial agonism -- better tolerated in CHF
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| What is the best beta blocker for patients where airway resistance is an issue and why? | Acebutolol b/c it is B1 specific w/partial agonism (intrinsic sympathomimetic activity)
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| Which beta blocker is efficient at treating HTN in patients with bronchospastic Dz? | Acebutolol
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| Which 4 beta blockers exhibit partial agonism? | Cartelol, oxprenolol, pindolol, acebutolol
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| Beta blockers exhibit membrane effects that are similar to what other class of agents? | Class IA antiarrhythmics (block fast Na channels)
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| In what ways do beta blockers mimic class IA antiarrhythmics? | Prolong the action potential duration and slow conduction
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| Name a class IA antiarrhythmic. | Quinidine
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| How can beta blockers benefit performers and musicians? | Makes the myocardium less susceptible to endogenous and exogenous catecholamines that cause tachycardia as a result of anxiety
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| What important metabolic functions does Inderal interfere with? | Glycogenolysis and gluconeogenesis
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| Which beta receptors are important contributors to glycogenolysis? | beta2
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| (Tachycardia/Bradycardia) is a warning sign of hypoglycemia. | Tachycardia
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| Why are non-selective beta blockers not recommended for diabetics at risk for hypoglycemia? | Blunts the tachycardic warning sign of hypoglycemia and interferes w/the metabolism of glycogen
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| Glycogenolysis ordinarily occurs in response to what neurotransmitter? | epinephrine
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| Beta2 stim facilitates potassium to move (into/out of) the cell. | into
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| How does beta blockade affect potassium? | Inhibits uptake of potassium into skeletal muscle (increasing plasma [])
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| How much can K []'s rise after giving succ in the presence of beta blockers? | 0.5-1meq
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| Which beta blockers result in less muscle uptake of potassium? | Selective B1 blockers
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| Which beta blocker is associated w/profound bradycardia in the presence of anesthetic gas? | Timolol
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| Which inhaled agents are not associated w/significant additive effects of BB? | Iso, sevo, des
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| What two things can unmask the negative inotropic effects of concomitantly administered agents? | Ketamine and/or hypercarbia
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| What is the T1/2 of esmolol? Inderal? Nadolol? | 10min; 2hr; 24hr
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| Which BB is highly protein bound? | Inderal
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| How are BB primarily eliminated? | via hepatorenal pathways
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| How long will it take for rebound effects to occur after abrupt discontinuation of chronic BB therapy? | 24-48
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| What is the dose for an Inderal infusion? | 2-3mg/hr
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| What does beta agonism stimulate the release of by the kidneys? | Stimulates renin release from juxtaglomerulus
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| What is the function of renin? | Convert angiotensinogen to angiotensin I
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| Why are BB given with vasodilating agents? | The decrease in blood pressure simulates release of renin, which ultimately leads to retention of sodium and water as a compensatory mechanism. Beta blockers prevent this release of renin.
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| What type of BB is Inderal? | Non-selective w/o agonism
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| True/False: Inderal blocks b1 and b2 receptors equally. | True
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| How does inderal affect HR, contractility, and CO? | Decreases all measures
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| What 2 things does b2 blockade increase? | Peripheral and coronary vascular resistance
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| What effect does the prolonged systole from Inderal have on myocardial O2 demand? | Increases demand but effect is offset w/lower HR
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| What is the PO and IV dosing of Inderal? | PO 40-800mg qd; IV 0.5-1mg q5min to 0.05mg/kg
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| Which BB has an active metabolite? | Inderal w/IV dosing
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| Identify 3 key points of the metabolism of Inderal. | Highly protein bound; extensive 1st pass hepatic metabolism leading to unpredictable plasma []; hepatic clearance
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| How may Inderal influence its own clearance? | It decreases CO and hepatic blood flow, therefore decreasing its clearance
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| True/False: Renal failure also alters the elimination 1/2 time of Inderal. | False = but accumulation of metabolites may occur
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| What effect does Inderal have on the clearance of aminoamide local anesthetics? | Decreases their clearance by decreasing hepatic blood flow, and inhibits hepatic amide metabolism
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| Name two amide local anesthetics whose metabolism is decreased with Inderal. | Lidocaine, bupivicaine
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| What influence does Inderal have on the pharmacokinetics of fentanyl? What does this result in? | Decreases 1st pass pulmonary uptake; results in 2-4x more fentanyl in systemic circulation after IV bolus
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| Nadolol has a (long/short) duration of action with a T1/2 of ______ hr. | Long; 20-40
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| Nadolol is (selective/nonselective). | nonselective
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| How much of nadolol is excreted unchanged in urine and bile? What implication does this have? | 75%; safe to give in patients with hepatic issues but must have good renal function for clearance
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| What type of BB is metoprolol? | Selective B1 antagonist
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| Metoprolol is indicated for what patient populations? | HTN with chronic obstructive airway dz, PVD, hypoglycemia
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| How is the feature of selectivity removed from a BB? | Giving large doses
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| Metoprolol exhibits (high/low) protein binding. | low
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| What is the T1/2 of metoprolol? | 3-4hr
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| Which BB is the most selective? | Atenolol
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| Hypoglycemia is exacerbated with the administration of (selective/nonselective) BB. | nonselective
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| What is the T1/2 of atenolol? | 6hr
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| How is atenolol primarily metabolized? | renal elimination
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| What type of BB is esmolol? | rapid and short acting B1 selective
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| What is the bolus dose of esmolol? | 0.5mg/kg
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| What is the peak and duration for esmolol? | Peak=5min, Duration=10min
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| How is esmolol beneficial in anesthesia? | Blunts SNS response to intubation and emergence
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| What are diseases where esmolol could be used? What is the infusion rate? | Pheochromocytoma, thyrotoxicosis, cocaine intox., pregnancy induced HTN; 500mcg/kg/min
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| Which BB utilizes non-organ dependent pathways of metabolism? | Esmolol
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| T/F: Succinylcholine administration prolongs the duration of action of esmolol d/t competitive metabolism with plasma cholinesterase. | False = succ is plasma cholinesterase while esmolol is metabolized w/plasma esterase
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| What are 3 medications that can treat excess myocardial depression? | Atropine, isoproterenol, dobutamine
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| What is the dose of atropine? | 7mcg/kg IV
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| What Rx is used if atropine is not effective for myocardial depression? What is the dose? | Isopreterenol; 2-25mcg/min
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| Between isoproterenol and dobutamine, which is a selective beta agonist and which is nonselective? | Isopreterenol=nonselective; dobutamine=selective
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| What is the drug of choice for life-threatening beta blocker induced bradycardia? | Glucagon
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| How does glucagon work to reverse myocardial depression from BB? | Stimulates cAMP []'s independent of beta receptors
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| What benefit does CaCl serve in the treatment of excess myocardial depression 2/t BB? | Reverses myocardial depression and stabilizes cell membranes
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| Dopamine mediates the activation of what enzyme? What does this enzyme do? | Adenylate cyclase increases intracellular [] of cAMP
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| What second messenger is responsible for renal artery dilatation and activation of dopamine1 receptors? | cAMP
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| Adenylate cyclase is an example of a (first/second) messenger. | first
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| cAMP is an example of a (first/second) messenger. | second
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| What happens to receptors with sequestration? | Receptors are uncoupled and removed from the sarcolemma (down-regulation)
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| Give two examples of direct acting sympathomimetics. | Phenylephrine and albuterol
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| Identify 3 ways in which indirect sympathomimetics function? | Release endogenous catecholamine stores from sympathetic nerve endings (norepi); inhibit reuptake of catecholamines into the neuron (cocaine); inhibit catecholamine metabolizing enzymes (MAO/COMT) allowing for accumulation in the synaptic cleft
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| Name 2 medications that inhibit MAO and COMT. | Parglyine and phenelzine
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| Which receptors do mixed drugs act on? What do they stimulate? | Alpha and beta; stimulate release of catecholamines from storage vesicles
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| Identify a mixed acting sympathomimetic. | Ephedrine
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| Ephedrine has a (small/large) therapeutic window. | large
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| Alpha1 agonism results in smooth muscle ______ and pupillary _______. | Contraction; dilatation
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| Which receptors does epinephrine interact with? | Alpha 1+2, Beta1+2
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| What structure secretes epinephrine? | adrenal medulla
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| How does epinephrine influence fatty acids and blood glucose? | Stimulates glycogenolysis and lipolysis which increases blood glucose and free fatty acids; also inhibits beta cell release of insulin
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| Agonism of ______ receptors stimulates platelet aggregation. | alpha
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| Name three actions of epinephrine in the body that makes it useful in the treatment of anaphylaxis. | Stabilizes mast cell membranes, increases BP, dilates bronchioles
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| What is the most potent activator of alpha adrenergic receptors? How active is it compared to its precursor? | epinephrine; 10x more active than norepi
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| Why does epi increase the likelihood of cardiac dysrhythmias? | Accelerates rate of phase 4 depolarization
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| How does epinephrine affect potassium? | Stimulates intracellular uptake of potassium
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| Where is norepi released? | Postganglionic sympathetic nerve endings
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| Norepi is a potent stimulator of what two receptors? | alpha1 and beta1
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| What receptors does norepi act on? | alpha1+2, beta1
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| Norepi (does/does not) stimulate bronchodilation and hyperglycemia. | Does not
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| Which catecholamine plays an important role in memory, attention, and neurocognitive functions? | dopamine
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| Which receptors does dopamine act on? | Alpha, beta, and dopaminergic
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| Dopamine1 receptors are (pre/post)synaptic and elicit _______ and ________ vasodilatation. | post; renal, cerebral
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| Dopamine2 receptors are (pre/post)synaptic and inhibit what two actions? | post; adenylate cyclase activity and norepi release
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| Nausea and vomiting may occur as a result of stim of which dopaminergic receptor? | Dopamine2
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| Which catecholamine is associated w/the reward mechanism associated w/drug and ETOH dependence? | Dopamine
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| Dopamine is metabolized (slowly/rapidly). | rapidly
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| What enhances the stability of dopamine for IV administration? | 5% glucose
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| Beta2 agonists cause relaxation in what areas of the body? | Bronchial and uterine smooth muscle
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| Beta2 agonists are resistant to metabolism by ______, and therefore have a (long/short) duration of action. | COMT; long
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| What is the key side effect of beta2 agonism? | Tremors from skeletal muscle stimulation
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| How do beta2 agonists affect glucose and electrolytes? | Causes hypokalemia, hypomagnesemia, hyperglycemia
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| What is the preferred beta2 selective agonist for acute bronchospasm? | Albuterol
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| What is the dose for albuterol via MDI? | 100mcg/puff; 2 puffs 1-5min apart NTE 20/qd
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| What is the duration of albuterol? | 4-8hr
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| Where and which receptors does clonidine act on? | Agonist of alpha2 receptors in the vasomotor center of the CNS-->this activity inhibits sympathetic vasomotor responses by lower HR, SBP+DBP
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| What are three high-risk surgeries that benefit from periop BB? | Vascular, thoracic, intraperitoneal
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| What is the goal HR periop? | 65-80bpm
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| Patients with what 3 diagnoses benefit from periop BB? | CAD, DM, LVH
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| What is the BB of choice for patients with pulmonary issues? | Acebutolol
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| Which 3 BB are indicated to reduce the risk of periop and postop MI? | Esmolol, metoprolol, atenolol
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| What medication is useful in the treatment of rebound HTN associated w/clonidine w/d? What other conditions is it useful in treating? | Labetalol; pheochromocytoma, cocaine w/d, ischemic episodes
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| What 3 medications are useful with intraoperative crisis? | labetalol, esmolol (better d/t shorter duration vs. labetalol), phentolamine (alpha blocker)
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| What is the first step in treating pheochromocytoma? What is the second step? | **Alpha blockade 1st** then BB 2nd
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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