1. Bone and Muscle 2 Musculoskeletal Diseases/Disorders Bursitis—inflammation of the small,...

Bone and Muscle 2

Musculoskeletal Diseases/Disorders Bursitisinflammation of the small, fluid-filled pouches between bones Tendonitisinflammation of the cords of connective tissue that attach muscle to bone Myalgiamuscle pain Rheumatoid Arthritisan autoimmune disorder Osteoarthritiscaused by physical degeneration of connective tissue Goutcaused by crystals of uric acid in blood Bone and Muscles tend to be rich in neurons that transmit pain 3

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 4

Analgesics Narcotics MOA: bind to opiate receptors in brain and spinal cord Indications: Analgesia Main Side effects: N/V, constipation, physical and psychological dependence. In overdose, respiratory depression. See text for complete list. Fentanyl is available as a IV injection, patches, oral lozenges but not as a tablet Oxycodone is not available as an injection only orally High potency opiates include fentanyl, remifentanil and hydromorphone (Dilaudid). High risk of overdose Combination product: Tylenol with Codeine denoted as follows Tylenol#2 as Codeine 15 mg/APAP 300 mg Tylenol #3 as Codeine 30 mg/APAP 300 mg Tylenol#4 as Codeine 60 mg/APAP 300 mg

Skeletal Muscle Relaxants MOA: may block action of calcium in muscles Indications: painful muscle spasms, neurological spinal cord injury Main Side Effects: Drowsiness, weakness GenericBrand CyclobenzaprineFlexeril MethocarbamolRobaxin BaclofenLioresal

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 GenericBrand IbuprofenMotrin, Advil NaproxenNaprosyn KetorolacToradol (IV available) DiclofenacVoltaren CelecoxibCelebrex (COX2 inhibitor)

Musculoskeletal Pharmaceuticals Bisphosphonatesindicated 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 relaxantsused to relax specific muscles in the body Relieve pain, stiffness, and discomfort Block muscle contraction at the neuromuscular junction 9

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: 16 GenericBrand OxymetazolineAfrin Nasal Spray PhenylephrineNeoSynephrine Nasal Spray FluticasoneFlonase (Nasal Steroid preparation) MometasoneNasonex (Nasal Steroid preparation) Oxymetazoline and Phenylephrine are sympathomimetic and can raise blood pressure. They also should be used with caution in gluacoma patients

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 17 GenericBrand AlbuterolProventil PirbuterolMaxair SalmeterolSerevent FormoterolForadil LevalbuterolXopenex 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

Drugs used for COPD 18 http://www.steroidology.com/bodybuilding-uses-for-albuterol/ http://imgbuddy.com/flovent-220.asp /http://www.goodrx.com/proventil-hfa/latest-newshttp://www.wsj.com/articles/SB1000142405274870362820457561833 2675513808

Anticholinergic (Antimuscarinic) Drugs Act on muscarinic (cholinergic) receptors as antagonists Results in bronchodilation 19 GenericBrand IpratropiumAtrovent Ipratropium + AlbuterolCombivent TiotropiumSpiriva

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 20 GenericBrand Fluticasone-SalmeterolAdvair Diskus Budesonide-FormoterolSymbicort

Leukotriene antagonists Drugs block the action of leukotrienes on their receptors Leukotrienes are potent bronchoconstrictors in COPD Contraindicated in patient with hepatic disease 21 GenericBrand MontelukastSingulair ZafirlukastAccolate ZileutonZyflo CR

Steroid Products for COPD or Rhinitis GenericBrandDose Form BeclomethasoneBeconase AQNasal Inhaler FluticasoneFlovent , FlonaseInhaler, Nasal Product MethylprednisoloneMedrolTablets PrednisolonePediapred, OrapredOral liquid, tablet TriamcinoloneNasacort AQNasal Inhaler 22

Mucolytic Agents Used to thin bronchial mucus and secretions from COPD and other lung diseases 23 GenericBrandSpecial Consideration AcetylcysteineMucomystUsed for many lung conditions; used for acetaminophen overdose; has a horrible scent and flavor Dornase AlfaPulmozymeUsed primarily for cystic fibrosis

The heart. 25

Anatomy of the Heart Composed of four chambers: two upper and two lower Atriatop two chambers Ventriclesbottom two chambers Septumdivides heart into right and left sides 26

Valves of the Heart Tricuspid valvelocated between the right atrium and the right ventricle Pulmonary valvelocated between the right ventricle and the pulmonary artery Mitral or bicuspid valvelocated between the left atrium and the left ventricle Aortic valvelocated between the left ventricle and the aorta 27

Layers of the Heart Pericardiumfluid-filled sac that surrounds and protects the heart Permits free movement of the heart during contraction Endocardiuminnermost wall layer; covers the inside surface of the heart Myocardiumsurrounds heart and causes chamber contractions 28

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 29

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 30

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 31

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) 32

Cardiovascular Pharmaceuticals Antiarrhythmic drugsrestore normal rhythm patterns but do not cure the cause of the irregular heartbeat Cardiac glycosidesused to increase the force of myocardial contraction, without causing an increase in the consumption of oxygen Diureticsused to eliminate excess sodium and water via the urinary tract Vasodilatorsallow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure 33

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 blockerssimilar to ACE inhibitors; block the bodys natural vasodilators Beta-adrenergic blockersused to block cells from receiving natural vasoconstrictors Platelet aggregation inhibitorsreduce the ability of the blood to coagulate 34

Cardiovascular Pharmaceuticals (cont.) Anticoagulantsprevent clots from forming or existing clots from getting bigger Tissue plasminogen activatorsbreak down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factors Thrombin inhibitorsinactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrin Antihyperlipidemicshelp prevent the progression of coronary artery disease by lowering plasma lipid levels 35

Cardiovascular Drugs Beta Blockers: drugs that block the beta receptors in the heart which blocks attachment of norepinephrine and results in bradycardia and reduced blood pressure. ACE inhibitors (angiotensin converting enzyme inhibitor) blocks the enzyme (ACE) responsible to converting angiotensin I to angiotensin II (ATII). ATII is a potent vasoconstrictor in humans This drug is important in hypertensive patients and patients with CHF and MI. ACEI are also important in preservation of kidney function in diabetics

Antianginal agents: used to widen coronary arteries to increase myocardial oxygen delivery and reduce chest pain. Examples: nitroglycerin (NTG), and isosorbide (Imdur, Isordil) Calcium channel blockers: blocks the entry of calcium ions in the heart muscle and in the muscle that control blood vessel diameter. Reduced heart rate and reduces blood pressure. Some are used to control a type of cardiac arrhythmia called atrial fibrillation. Examples: Diltiazem (Tiazac, Cardizem), amlodipine (Norvasc) Antiarrhythmial agents: block the entry of sodium into the heart. The drugs in this class have several mechanisms of action. Examples: Lidocaine, amiodarone (Cordarone), Procainamide (Procanbid)

Angiotensin 2 Receptor blockers (ARBs): similar to ACEI except these drug works on a receptor for ATII Anticoagulation agents: drugs that block the formation of blood clots. Different mechanisms of action. Examples: warfarin (coumadin), dibigatran (Pradaxa) Antiplatelet agents: drugs that block the action of platelets in the formation of a blood clot. Used in the prevention of stroke or MI. Examples: (Plavix) and Aspirin (Ecotrin) Cardiac glycosides: drugs used to boost the strenght of the hearts contraction. Example: Digoxin (Lanoxin)

Alpha Receptor blockers MOA: blocks alpha receptors on smooth muscle in the arteries Indication: blood pressure control Side effects: edema, dizziness Examples Prazosin (Minipress) Terazosin (Hytrin) Doxazosin (Cardura) The following alpha blockers are used for enlarged prostate symtom relief Tamsulosin (Flomax) Alfuzoxin (Uroxatral) The following drugs are both alpha and beta receptor blockers Labetolol (Trandate) Carvedilol (Coreg)

Anticoagulants Do not thin out the blood Prevent clots from forming Prevent existing clots from getting bigger Cannot dissolve existing blood clots 40

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 41

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 42

Low Molecular Weight Heparins Drugs that a similar to heparin Used as IV or SubQ injections PTT test not required Protamine sulfate is antidote 43 GenericBrand EnoxaparinLovenox DalteparinFragmin TinzaparinInnohep

Newer anticoagulants Used primarily for anticoagulation for atrial fibrillation Does not required INR testing like warfarin Less drug interactions Cant be reversed by vitamin K 44 GenericBrandSpecial Consideration DabigatranPradaxaMust be dispense in original container RivaroxabanXeraltoNA ApixabanEliquisNA

Cholesterol and Triglycerides HDLhigh-density lipoproteins or good cholesterol LDLlow-density lipoproteins or bad cholesterol Triglyceridesa 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 45 GenericBrand AtorvastatinLipitor SimvastatinZocor FluvastatinLescol RosuvastatinCrestor 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 livers CYP450 systems: Diltiazem, amiodarone, HIV protease inhibitors, Ketoconazole

GenericBrand Simvastatin + EzetimibeVytorin Lovastatin + NiacinAdvicor Simvastatin + NiacinSimcor 46 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

Non Statin Antilipidemic drugs Other drugs that target lowing VLDL, triglycerides, and raising HDL have a beneficially affect on coronary artery disease 47 GenericBrandIndications GemfibrozilLopidHigh VLDL FenofibrateTricorHigh VLDL, low HDL NiacinNiaspanHigh VLDL, low HDL Omega 3 Fatty acid LovazaHigh VLDL, low HDL

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 48

GenericBrandUse AspirinEcotrinTo stop platelet action at the clot ClopidogrelPlavixTo stop platelet action at the clot TicagrelorBrilintaTo stop platelet action at the clot NitroglycerinVariousTo 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 HeparinN/AA potent blood anticoagulant that stop further coagulation MetoprololLopressorA beta blocker that slows heart rate and slows spread of infarction 49

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 50

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 51 GenericBrand PropranololInderal MetoprololLopressor TimololBlocadren AtenololTenormin CarvedilolCoreg

ACE Inhibitors Used to decrease mortality in post MI and CHF patients Used with beta blockers and often in combination with them 52 GenericBrand CaptoprilCapoten EnalaprilVasotec LisinoprilZestril, Prinivil BenazaprilLotensin RamiprilAltace 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

ACE inhibitors combination products Often ACE inhibitors are combined with diuretics to negate the potassium loss and to synergize to lower blood pressure more 53 GenericBrand Lisinopril + HCTZPrinzide Enalapril + HCTZVaseretic Benzapril + HCTZLotensin HCT

Angiotensin Receptor Blockers Similar to ACEI but works at a receptor for angiotensin 2 If patient has angioedema to ACEI; ARBs can be tried Used in MI and renal disease, HTN and CHF 54 GenericBrand Losartan Losartan + HCTZ Cozaar Hyzaar Valsartan Valsartan + HCTZ Diovan Diovan HCT Irbasartan Irbasartan + HCTZ Avapro Avalide

The renal system. 55

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 56

Diuretics Drugs that work at the kidney to help remove sodium, water, calcium, and potassium from the body. Each class of diuretic is named for the most part according to its mechanism of action or the site of action in the kidney. Loop Diuretics work in a section of the kidney called the loop of henle. This is where most of the water and sodium and potassium is lost from the body. These drugs are used to treat edema in CHF patients and other patient that hold on the water. Example(s): Furosemide (Lasix), Torsemide (Demadex)

Carbonic anhydrase inhibitors act on the proximal tubule of the kidney by blocking the enzyme, carbonic anhydrase which cause sodium retention and acid loss. Example: acetazolamide (Diamox) Carbonic anhydrase inhibitor are pretty much weak diuretics and can produce profound lose of potassium

Thiazide Diuretics Thiazide diuretics act on the distal convoluted tubule to block the NaCL cotransporter in the kidney. Generally good diuretics Produce a sodium rich urine Example: Hydrochlorothiazide (HydroDiuril)

Potassium Sparing diuretics Most of the above diuretics cause profound lose of potassium. To circumvent this, these diuretic are usually taken with potassium supplements. A class of diuretic that spares potassium in the body are know and are used for many indications Examples are: spironolactone (aldactone), Amiloride (Midamor), and the ACE inhibitors with ARBs. These diuretics unlike the ones mentioned before should not be used with a potassium supplement.

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 61

Drugs to lower patients potassium levels K binding resins Kayexalate is sodium polystrene sulfonate resin and bind K in the GI prevent absorption In emergency situation, where life threatening 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 ) 62

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) 63

1. Bone and Muscle 2 Musculoskeletal Diseases/Disorders Bursitis—inflammation of the small,...

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