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Bone and Muscles1Bone and Muscle

2Disorders of the BoneOsteomyelitisBacterial Infection Inside the Bone Destroys bone tissueOriginal site of infection is frequently in another part of bodyInfection spreads to the bone via the bloodOsteoporosisbone brittleness due to lack of calciumPrevalent in postmenopausal women because of estrogen deficiencyPagets diseasechanges the normal process of bone growthCauses bone to break down more quickly and grow back softer than normal bone

3Musculoskeletal Diseases/DisordersBursitisinflammation of the small, fluid-filled pouches between bonesTendonitisinflammation of the cords of connective tissue that attach muscle to boneMyalgiamuscle painRheumatoid Arthritisan autoimmune disorderOsteoarthritiscaused by physical degeneration of connective tissueGoutcaused by crystals of uric acid in blood

4TreatmentsGoutColchicine used to alter ability of phagocytes to attack uric acid crystalsAnti-inflammatory analgesics can be used to reduce pain and inflammationInflammationSalicylates relieve inflammation by inhibiting the synthesis of prostaglandinTopical corticosteroids treat most causes, including chemical, mechanical, microbiological, and immunological

5Skeletal Muscle RelaxantsMOA: may block action of calcium in musclesIndications: painful muscle spasms, neurological spinal cord injuryMain Side Effects: Drowsiness, weakness

GenericBrandCyclobenzaprineFlexerilMethocarbamolRobaxinBaclofenLioresalMusculoskeletal PharmaceuticalsASA (acetylsalicylic acid)Relieves inflammation by inhibiting the synthesis of prostaglandinSalicylates are also used as analgesics and antipyreticsNSAIDs (nonsteroidal anti-inflammatory drugs)Inhibit or block the enzyme that starts the reaction of inflammation by making prostaglandinCOX-2 inhibitorsBlock 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

7Non Steroidal Anti Inflammatory DrugsCalled the NSAIDSExcellent drugs for pain relief and reducing fever and inflammationDeveloped as an alternative to corticosteroidsMOA: blocks the COX enzyme to block prostaglandin formationSide effects are: severe GI bleeding (possible), GI upset and gastritis, kidney insufficiency, edema and elevated blood pressure, hyperkalemia risk

GenericBrandIbuprofenMotrin, AdvilNaproxenNaprosynKetorolacToradol (IV available)DiclofenacVoltarenCelecoxibCelebrex (COX2 inhibitor)Musculoskeletal PharmaceuticalsBisphosphonatesindicated for osteoporosisMimic the natural organic bisphosphonate salts found in the bodyInhibit bone resorption and osteoclast activityRestore bone mass and densityRisedronate (Actonel)Ibandronate (Boniva)SERMs (selective estrogen receptor modulators)Indicated for postmenopausal womenProtective effect on bones and heartRaloxifene (Evista)Skeletal muscle relaxantsused to relax specific muscles in the bodyRelieve pain, stiffness, and discomfortBlock muscle contraction at the neuromuscular junction9Asthma and Respiratory Drugs10The Respiratory SystemDivided into the upper respiratory tract and the lower respiratory tractThe upper respiratory tract consists of:Nose or nasal cavityParanasal sinusesPharynx and larynx11The Respiratory System (cont.)The lower respiratory tract consists of:TracheaTwo lungsTwo main bronchi

12The lower respiratory tract.13

Common ColdCaused by a viral infection that inflames the membranes in nose and throatAntibiotics will not cure a cold or any other viral infectionTreatment is considered symptomaticCoughMay be a symptom of a cold, flu, respiratory problems, or nonrespiratory diseasesMost likely begins with an irritation of nerves in the respiratory tractNonproductive cough treated with cough suppressantProductive cough treated with an expectorant

14Allergies and AsthmaAllergiesCaused by the immune system reacting to a substance that does not cause diseaseTreatment may be palliative, with antihistamines and antitussivesTreatment may be preventive, with mast cell stabilizersAsthmaChronic respiratory diseaseCharacterized by inflammation of airways, tightening of muscles around airwaysTreatment is palliative with albuterol and other bronchodilators

15Nasal Congestion and RhinitisNasal CongestionInflamed, stuffy noseTreatment may be palliative, to promote easier breathingIndications for use of decongestants are nasal and bronchial congestionRhinitisInflammation of nasal membranes, and/or runny noseCommon component of colds and allergiesTreatment is considered symptomaticDrugs to treat include:

16GenericBrandOxymetazolineAfrin Nasal SprayPhenylephrineNeoSynephrine Nasal SprayFluticasoneFlonase (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 patientsChronic Obstructive Pulmonary Disease (COPD)Umbrella term for emphysema and chronic bronchitis, and asthmaCharacterized by partially blocked bronchi and bronchioles, mucus plugging and bronchoconstrictionCauses shortness of breathTreatment may be palliative, with bronchodilatorsBeta Agonist Drugs

17GenericBrandAlbuterolProventilPirbuterolMaxairSalmeterolSerevent FormoterolForadilLevalbuterolXopenexAlbuterol 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

Anticholinergic (Antimuscarinic) DrugsAct on muscarinic (cholinergic) receptors as antagonistsResults in bronchodilation

18GenericBrandIpratropiumAtroventIpratropium + AlbuterolCombiventTiotropiumSpirivaSteroid / Beta Agonist Combination productsThese products are not meant as rescue agents but for chronic long term use in prevention of COPDAvailable as MDI and for Advair as dry powdered inhaler as wellPatients should rinse after use to prevent oral fungal infections

19GenericBrandFluticasone-SalmeterolAdvair DiskusBudesonide-FormoterolSymbicortLeukotriene antagonistsDrugs block the action of leukotrienes on their receptorsLeukotrienes are potent bronchoconstrictors in COPDContraindicated in patient with hepatic disease

20GenericBrandMontelukastSingulairZafirlukastAccolateZileutonZyflo CRSteroid Products for COPD or RhinitisGenericBrandDose FormBeclomethasone Beconase AQNasal InhalerFluticasoneFlovent , FlonaseInhaler, Nasal ProductMethylprednisoloneMedrolTabletsPrednisolonePediapred, OrapredOral liquid, tabletTriamcinoloneNasacort AQNasal Inhaler21Mucolytic AgentsUsed to thin bronchial mucus and secretions from COPD and other lung diseases

22GenericBrandSpecial ConsiderationAcetylcysteineMucomystUsed for many lung conditions; used for acetaminophen overdose; has a horrible scent and flavorDornase AlfaPulmozymeUsed primarily for cystic fibrosisHeart and Kidneys23The heart.24

2424Anatomy of the HeartComposed of four chambers: two upper and two lowerAtriatop two chambersVentriclesbottom two chambersSeptumdivides heart into right and left sides252525Valves of the HeartTricuspid valvelocated between the right atrium and the right ventriclePulmonary valvelocated between the right ventricle and the pulmonary arteryMitral or bicuspid valvelocated between the left atrium and the left ventricleAortic valvelocated between the left ventricle and the aorta262626Layers of the HeartPericardiumfluid-filled sac that surrounds and protects the heartPermits free movement of the heart during contractionEndocardiuminnermost wall layer; covers the inside surface of the heartMyocardiumsurrounds heart and causes chamber contractions272727Function of the HeartProvides oxygenated blood throughout the body by a pumping mechanismOxygenated blood deposits materials necessary for growth and nourishmentReceives from tissues the waste products resulting from metabolism282828HypertensionSustained elevation of systemic arterial blood pressureSymptoms include:Severe headacheChest painIrregular heartbeatFatiguePharmaceutical treatment includes diuretics, vasodilators, ACE inhibitors, beta blockers, and calcium channel blockers

292929Congestive Heart FailureHeart pumps out less blood than it receivesResults in weakened and enlarged heartSymptoms of CHF include:Upright posture or leaning forwardAnxiety and restlessnessCyanotic and clammy skinPersistent coughRapid breathingFast heart rateEdema of the lower limbsPharmaceutical treatment includes cardiac glycosides, diuretics, vasodilators, ACE inhibitors, beta-adrenergic blockers, and phosphodiesterase inhibitors

303030Coronary Artery DiseaseOccurs when there is insufficient blood flow to the heartCan lead to:AnginaHeart attackArrythmiasStrokePulmonary embolismHeart failureEarly CAD is closely monitored and symptomatic relief is given by the use of nitroglycerin and other nitrate drugs. NTGISDN (isosorbide dinitrate)Once CAD has progressed to the point where a patient has angina at rest. Two procedures can be takenPCI with stentsCABG (Coronary artery bypass graft)313131Cardiovascular PharmaceuticalsAntiarrhythmic drugsrestore normal rhythm patterns but do not cure the cause of the irregular heartbeatCardiac glycosidesused to increase the force of myocardial contraction, without causing an increase in the consumption of oxygenDiureticsused to eliminate excess sodium and water via the urinary tractVasodilatorsallow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure

323232Cardiovascular Pharmaceuticals (cont.)Angiotensin-converting enzyme inhibitors (ACE inhibitors)lower high blood pressure; thought to reshape the heart; prevent the body from producing natural vasodilatorsAngiotensin II receptor blockerssimilar to ACE inhibitors; block the bodys natural vasodilatorsBeta-adrenergic blockersused to block cells from receiving natural vasoconstrictorsPlatelet aggregation inhibitorsreduce the ability of the blood to coagulate333333Cardiovascular Pharmaceuticals (cont.)Anticoagulantsprevent clots from forming or existing clots from getting biggerTissue plasminogen activatorsbreak down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factorsThrombin inhibitorsinactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrinAntihyperlipidemicshelp prevent the progression of coronary artery disease by lowering plasma lipid levels

343434AnticoagulantsDo not thin out the bloodPrevent clots from formingPrevent existing clots from getting biggerCannot dissolve existing blood clots353535WarfarinOral drug of choiceWorks by preventing the synthesis of clotting factors II, VII, IX, and XUsed in the long-term prevention or management of venous thromboembolic disorders, including:Deep vein thrombosisPulmonary embolismClotting associated with atrial fibrillation and prosthetic heart valvesVitamin K may be used as an antidote when too much warfarin has been givenFor 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

363636HeparinParenterally administered drug of choiceWorks by inactivating clotting factors IX, X, XI, and XIIUsed prophylactically to:Prevent and treat deep vein thrombosisPrevent and treat pulmonary embolismTreat thrombophlebitisPrevent clotting during cardiac and vascular surgeryThe only antidote for heparin overdose is protamine sulfatePTT testing is required

373737Low Molecular Weight HeparinsDrugs that a similar to heparinUsed as IV or SubQ injectionsPTT test not requiredProtamine sulfate is antidote

38GenericBrandEnoxaparinLovenoxDalteparinFragminTinzaparinInnohepNewer anticoagulantsUsed primarily for anticoagulation for atrial fibrillationDoes not required INR testing like warfarinLess drug interactionsCant be reversed by vitamin K

39GenericBrandSpecial ConsiderationDabigatranPradaxaMust be dispense in original containerRivaroxabanXeraltoNAApixabanEliquisNACholesterol and TriglyceridesHDLhigh-density lipoproteins or good cholesterolLDLlow-density lipoproteins or bad cholesterolTriglyceridesa form of energy stored in adipose and muscle tissuesOften measured to depict fat ingestion and metabolismCan be used to assess CAD risk factorsStatins- drugs used to lower LDL cholesterol

40GenericBrandAtorvastatinLipitorSimvastatinZocorFluvastatinLescolRosuvastatinCrestorMajor: Side effects are nausea, GI and a reaction called Rhabdomyolysis and myopathy where patient experiences muscle pain and at the extreme renal failure and hospitalizationStatins are drug interactions with medications that block the livers CYP450 systems: Diltiazem, amiodarone, HIV protease inhibitors, KetoconazoleGenericBrandSimvastatin + EzetimibeVytorinLovastatin + NiacinAdvicorSimvastatin + NiacinSimcor41Above 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 HDLOne unique combination product is Caduet, which is a combination of Atorvastatin and Amlodipine (calcium channel blocker ). This product is used to treat metabolic syndromeNon Statin Antilipidemic drugsOther drugs that target lowing VLDL, triglycerides, and raising HDL have a beneficially affect on coronary artery disease

42GenericBrandIndicationsGemfibrozilLopidHigh VLDLFenofibrateTricorHigh VLDL, low HDLNiacinNiaspanHigh VLDL, low HDLOmega 3 Fatty acidLovazaHigh VLDL, low HDLDrugs used in the Treatment of MIMI 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 shockEven if treat mortality is high from secondary ventricular fibrillationEven if treated, patient will suffer irrevocable heart damage resulting in CHF and/or damage to cardiac conduction system leading to pacemaker or ICD placementThe main goal is to relieve the blood vessel of the clot and reestablish coronary blood flowCan 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 clot43GenericBrandUseAspirinEcotrinTo stop platelet action at the clotClopidogrelPlavixTo stop platelet action at the clotTicagrelorBrilintaTo stop platelet action at the clot

NitroglycerinVariousTo vasodilate coronary artery to relieve painTissue plasminogen activatorTPAAlteplase (Activase)Reteplase (Retavase)Tenecteplase (Tnkase)Activate plasmin, a blood protein that opens blood clotsHeparinN/AA potent blood anticoagulant that stop further coagulationMetoprololLopressorA beta blocker that slows heart rate and slows spread of infarction44Drug used in the treatment of Atrial FibrillationAtrial Fibrillation is a heart rate disturbance in which the atrium/ atria are beating extremely rapidlyCan lead to cardiogenic shock if the rate reaches the ventriclesTherapy 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 cardioversionRate controlDiltiazemVerapamilBeta blockersAmiodaroneAnticoagulationWarfarinApixaban (Eliquis)CardioversionIbutilide (Tikosyn)High dose Amiodarone 45Ventricular FibrillationVentricular Fibrillation, VF, is a cardiac arrythmia where the ventricles beat extremely rapidly to the point where no coordinated contraction occursMedical emergencyVF lasting more than the 90 seconds leads to asystole, sudden cardiac death and cardiogenic shock. Brain death from cerebral hypoxiaTherapyDirect DC shock with ACD: delivery of DC shock with about 360 Joules of electricity to bring about normal sinus rhythm. Best chance at survival but not always successfulDrug treatment used in conjunction with ACD if shock initially unsuccessfulAmiodarone: 300 mg IV push with 150 mg IV supplemental dosesLidocaine: 100 mg IV pushEpinephrine or Atropine can be tried after failed attempts at shockOther drugs include calcium chloride 10%, magnesium sulfate and vasopressin

46Beta BlockersVery useful in extending the life expectancy of patients post MI and in CHF patientsDue 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

47GenericBrandPropranololInderalMetoprololLopressorTimololBlocadrenAtenololTenorminCarvedilolCoregACE InhibitorsUsed to decrease mortality in post MI and CHF patientsUsed with beta blockers and often in combination with them

48GenericBrandCaptoprilCapotenEnalaprilVasotecLisinoprilZestril, PrinivilBenazaprilLotensinRamiprilAltacePotassium levels should be monitoredACE inhibitors are pregnancy category XMay cause relentless coughing in some patient requiring discontinuation due to potent edema and closure of the airwayACE inhibitors combination productsOften ACE inhibitors are combined with diuretics to negate the potassium loss and to synergize to lower blood pressure more

49GenericBrandLisinopril + HCTZZestoretic, PrinzideEnalapril + HCTZVasereticBenzapril + HCTZLotensin HCTAngiotensin Receptor BlockersSimilar to ACEI but works at a receptor for angiotensin 2If patient has angioedema to ACEI; ARBs can be triedUsed in MI and renal disease, HTN and CHF

50GenericBrandLosartanLosartan + HCTZCozaarHyzaarValsartanValsartan + HCTZDiovanDiovan HCTIrbasartanIrbasartan + HCTZAvaproAvalideThe renal system.51

The Renal SystemComposed of two kidneys, two ureters, one bladder, and the urethraFiltering system of the kidneys is composed of millions of nephronsWaste from food and drug metabolization is filtered through the nephronsWastes exit the kidneys as urine via the uretersUreters lead to the bladder, where urine is stored until releasedThe kidneys are located in the posterior abdomen just above the waist52NephronSmallest, most basic part of the kidneyFilters the blood that passes through the kidneysProduces urine through the processes of filtration, reabsorption, and secretionEnables blood to reabsorb water, electrolytes, and nutrients53Kidney and BladderKidney Built almost entirely of nephronsOrgan that filters blood and produces urineUrine produced by the kidneys is conducted to the bladderBladderOrgan used for waste storageCan collect approximately 350 mL to 500mL of urineAllows for discretionary voiding

54Drugs for Kidney DisordersFailing kidneys cause disorders relating to retention of toxins in the blood, acidity and electrolytes abnormalitiesKidney disorders effects blood potassium, calcium, phosphate levels, and levels of various hormones in the body.Patients have high PTH levelsLow vitamin D levelsLow erythropoetin levelsPatients have high levels of urea and other nitrogenous toxin that causes damage to the CNS55Drugs to lower patients potassium levelsK binding resinsKayexalate is sodium polystrene sulfonate resin and bind K in the GI prevent absorptionIn emergency situation, where life threating hyperkalemia exists the following is given (in a hospital ICU)Insulin 10 units IVPCalcium choride 10% 300 mg -1 gram IVPAlbuterol USP solution Kayexalate 30 g orally Drug that lower phosphate levelsSevelamer (Renagel, Renvela Lanthanum Carbonate Calcium Acetate (Phoslo )56Drugs used to correct PTH levels (secondary hyperparathyroidism)Calcitriol (Calcijex, Rocaltrol)IV form is given with dialysisOral capsule (Rocaltrol ) is given as maintanence tx outpatientParicalitolZemplar (IV form given with dialysis)Drugs used to correct renal induced red blood cell anemiaEpogen (Erythropoetin)Procit (erythropoetin)Aranesp (darbepoetin)57ESRD, end stage renal disease is where there is no kidney function leftRenal transplantation is only curePeriodically patients require DialysisHemodialysisModality where a machine acts as an artificial kidneyRemoval excessive potassium, phosphatesAdded sodium, magnesium and calcium (MD must order)Removal of excessive water from body (hemofiltration)Number one cause of ESRD in the US is diabetes58