Drugs acting on Autonomic Nervous System

Autonomic nervous system controls involuntary activities of smooth muscle, secretory glands and the visceral organs of the body such as the heart (involuntary activities of smooth muscle). The autonomic system (ANS) regulates the everyday requirements of vital body functions without the conscious participation of the mind. Sympathetic System Fight or Flight stimulated by physical or emotional stress (exercise or work), pain, hemorrhage, intense emotions, temperature extremes Protective mechanisms designed to help person cope with the stress or get away from it. Activates and prepares the body for vigorous muscular activity, stress, and emergencies.

The two systems generally act in opposition to each other. For example, a stimulation by the sympathetic system on the heart would increase contractions, while a stimulation by the parasympathetic system would decrease heart contractions. Where dual control of an organ exists, both systems operate simultaneously although one may be operating at a higher level of activity than the other. The operation is similar to the operation of a car with both the accelerator and brake pedals depressed. The Autonomic drugs mimic, intensify, or block the effects of the parasympathetic and sympathetic divisions of the autonomic nervous system. They are divided into the following groups: I. Cholinergic Agonists II. Cholinergic Antagonists III. Adrenergic Agonists IV. Adrenergic Antagonists

Parasympathetic System Rest and Digest Save energy Decreased heart rate Lowers the activity, operates during normal situations, permits digestion, and conservation of energy.

I. Cholinergic Agents Drugs that stimulate the parasympathetic nervous system (PSNS) The PSNS is the opposing system to the SNS Also known ascholinergic agonists or parasympathomimetics Mimic the effects of the PSNS neurotransmitter Acetylcholine (ACh)

In Summary : The somatic nervous system controls functions that are under conscious voluntary control such as skeletal muscles and sensory neurons of the skin. The autonomic nervous system, mostly motor nerves, controls functions of involuntary smooth muscles, cardiac muscles, and glands. The autonomic nervous system provides almost every organ with a double set of nerves - the sympathetic and parasympathetic. These systems generally but not always work in opposition to each other. The sympathetic system activates and prepares the body for vigorous muscular activity, stress, and emergencies. While the parasympathetic system lowers activity, operates during normal situations, permits digestion, and conservation of energy.

Drug Effects of Cholinergic Agents SLUDGE Salivation, Lacrimation, Urinary incontinence, Diarrhea, Gastrointestinal cramps, Emesis Stimulate intestine and bladder Stimulate pupil Increased salivation and sweating Cardiovascular effects Respiratory effects Cholinergic Agents:Therapeutic Uses Treatment of urinary retention and abdominal retention Miosis during ocular surgery Reduce intraocular pressure in open angle and narrow angle glaucoma Treat myasthenia gravis

Relaxes sphincters in bladder and GI tract, allowing them to empty Used in the treatment of mild to moderate Alzheimers disease. Helps to increase or maintain memory and learning capabilities

Atropine is the antidote for cholinergics. It should be available in the patients room for immediate use if needed. Patients should notify their physician if they experience muscle weakness, abdominal cramps, diarrhea, or difficulty breathing.

Monitor for side effects, including: Cholinergic Agents: Side Effects Side effects are a result of overstimulation of the PSNS. Cardiovascular: Increased respiratory Abdominal cramping secretions Bronchospasms Dysrhythmias Difficulty breathing Hypotension Nausea and vomiting Bradycardia Diarrhea Increased sweating Increase in frequency and urgency of voiding patterns Alleviated signs and symptoms of myasthenia gravis

-Bradycardia, hypotension, conduction abnormalities (AV block and cardiac arrest) CNS: -Headache, dizziness, convulsions Gastrointestinal: -Abdominal cramps, increased secretions, nausea, vomiting Respiratory: Increased bronchial secretions, bronchospasms Other: Lacrimation, sweating, salivation, loss of binocular accommodation, miosis Cholinergic Agents: Nursing Implications Keep in mind that these agents will stimulate the PSNS and mimic the action of ACh. Assess for allergies, presence of GI or GU obstructions, asthma, peptic ulcer disease, or coronary artery disease. Perform baseline assessment of VS and systems overview. Medications should be taken as ordered and not abruptly stopped. The doses should be spread evenly apart to optimize the effects of the medication. Overdosing can cause life-threatening problems. Patients should not adjust the dosages unless directed by the physician. Encourage patients with myasthenia gravis to take medication 30 minutes before eating to help improve chewing and swallowing. When donepezil is prescribed for Alzheimers disease, be honest with caregivers and patients that the drug is for management of symptoms, not for a cure. Therapeutic effects of donepezil may not occur for up to 6 weeks.

In postoperative patients with decreased GI peristalsis, look for: Increased bowel sounds Passage of flatus Occurrence of bowel movements

In patients with urinary retention/hypotonic bladder, urination should occur within 60 minutes of bethanecol administration II. Cholinergic Antagonist Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS) Drug Effects of Cholinergic Blocking Agents tremors Large doses: drowsiness, disorientation, hallucinations Gastrointestinal Relax smooth muscle tone of GI tract Decrease intestinal and gastric secretions Decrease motility and peristalsis Eye 2 Cardiovascular Small doses: decrease heart rate Large doses: increase heart rate CNS Small doses: decrease muscle rigidity and

Dilated pupils (mydriasis) Decreased accommodation due to paralysis of ciliary muscles (cycloplegia) Genitourinary Relaxed detrusor muscle Increased constriction of internal sphincter Result: urinary retention Glandular Decreased bronchial secretions, salivation, sweating Respiratory Decreased bronchial secretions Dilated bronchial airways

Cardiovascular dysrhythmias CNS irritability,

Increased heart rate,

CNS excitation, restlessness, disorientation, hallucinations, delirium

Eye Dilated pupils, decreased visual accommodation, increased intraocular pressure Gastrointestinal Decreased salivation, decreased gastric secretions, decreased motility Genitourinary Glandular Urinary retention Decreased sweating Decreased bronchial secretions

Cholinergic Blocking Agents: Therapeutic Uses CNS Decreased muscle rigidity and muscle tremors Parkinsons disease Drug-induced extrapyramidal reactions Cardiovascular Affect the hearts conduction system Low doses: slow the heart rate High doses: block inhibitory vagal effects on the SA and AV node pacemaker cells Result: increased heart rate Respiratory Blocking the cholinergic stimulation of the PSNS allows unopposed action of the SNS. Results: Decreased secretions from nose, mouth, pharynx, bronchi Relaxed smooth muscles in bronchi and bronchioles Decreased airway resistance, Bronchodilation Gastrointestinal PSNS controls gastric secretions and smooth muscles that produce gastric motility. Blockade of PSNS results in: Decreased secretions Relaxation of smooth muscle Decreased GI motility and peristalsis Genitourinary Relaxed detrusor muscles of the bladder Increased constriction of the internal sphincter Reflex neurogenic bladder Incontinence Cholinergic Blocking Agents: Side Effects Body System Side/Adverse Effects Respiratory Cholinergic Blocking Agents: Nursing Implications Keep in mind that these agents will block the action of ACh in the PSNS. Assess for allergies, presence of BPH, glaucoma, tachycardia, MI, CHF, hiatal hernia, and GI or GU obstruction. Perform baseline assessment of VS and systems overview. Medications should be taken exactly as prescribed to have the maximum therapeutic effect. Overdosing can cause life-threatening problems. Cholinergic Blocking Agents: Nursing Implications Blurred vision may cause problems with driving or operating machinery. Patients may experience sensitivity to light and may want to wear dark glasses or sunglasses. When giving ophthalmic solutions, apply pressure to the inner canthus to prevent systemic absorption. Dry mouth may occur; can be handled by chewing gum, frequent mouth care, and hard candy. Check with physician before taking any other medication, including OTC medications. ANTIDOTE for atropine is physostigmine salicylate (Antilirium). Cholinergic Blocking Agents: Nursing Implications Anticholinergics may lead to higher risk for heat stroke due to effects on heat-regulating mechanisms. 3

Teach patients to limit physical exertion, and avoid high temperatures and strenuous exercise. Emphasize the importance of adequate fluid and salt intake. Patients should report the following to their physician: urinary hesitancy and/or retention, constipation, palpitations, tremors, confusion, sedation or amnesia, excessive dry mouth (especially if they have chronic lung infections or disease), or fever

III. Adrenergic Agents Drugs that stimulate the sympathetic nervous system (SNS) Also known as adrenergic agonists or sympathomimetics Mimic the effects of the SNS neurotransmitters: norepinephrine (NE) and epinephrine (EPI) Drug effects of Adrenergic Agents on smooth muscles results in: Vasoconstriction of blood vessels Relaxation of GI smooth muscles Contraction of the uterus and bladder Male ejaculation Decreased insulin release Contraction of the ciliary muscles of the eye (dilated pupils)

on the airways results in: Bronchodilation (relaxation of the bronchi) Uterine relaxation Glycogenolysis in the liver

Adrenergic Agents: Therapeutic Uses Bronchodilators: treatment of asthma and bronchitis Agents that stimulate beta2-adrenergic receptors of bronchial smooth muscles causing relaxation Examples: albuterol ephedrine epinephrine isoetharine isoproterenol levalbuterol metaproterenol salmeterol terbutaline

These agents may also affect uterine and vascular smooth muscles. Reduction of intraocular pressure and mydriasis (pupil dilation): treatment of open-angle glaucoma Examples: epinephrine and dipivefrin Anorexiants: adjuncts to diet in the short-term management of obesity Examples: benzphetamine phentermine dextroamphetamine Dexedrine Nasal decongestant: Intranasal (topical) application causes constriction of dilated arterioles and reduction of nasal blood flow, thus decreasing congestion. Examples: epinephrine ephedrine naphazoline phenylephrine tetrahydrozoline Ophthalmic Topical application to the eye surface affects the vasculature of the eye, stimulating alpha receptors on small arterioles, thus relieving conjunctival congestion. Examples: epinephrine naphazoline phenylephrine tetrahydrozoline Vasoactive sympathomimetics (pressors, inotropes), also called cardioselective sympathomimetics Used to support the heart during cardiac failure or shock. Examples: dobutamine dopamine ephedrine epinephrine fenoldopam isoproterenol methoxamine norepinephrine phenylephrine Adrenergic Agents: Side Effects CNS: -headache, restlessness, excitement, insomnia, euphoria, mild tremors, nervousness Cardiovascular: -palpitations (dysrhythmias), tachycardia, vasoconstriction, hypertension or fluctuations in BP Other: -anorexia, dry mouth, nausea, vomiting, taste changes (rare) Adrenergic Agents: Nursing Implications Assess for allergies and history of hypertension, cardiac dysrhythmias, or other cardiovascular disease. 4

Assess renal, hepatic, and cardiac function before treatment. Perform baseline assessment of vital signs, peripheral pulses, skin color, temperature, and capillary refill. Include postural blood pressure and pulse. Follow administration guidelines carefully.

Improved blood gases Increased activity tolerance

IV. Adrenergic-Blocking Agents Bind to adrenergic receptors, but inhibit or block stimulation of the sympathetic nervous system (SNS) Have the opposite effect of adrenergic agents Also known as adrenergic antagonists or sympatholytics Adrenergic-Blocking Agents: Therapeutic Uses Acute Athma Treatment of open angle glaucoma Treatment of shock Treatment of congestive heart failure As a nasal decongestant Treatment supraventricular tachycardia Treatment of bronchospasm Used to treat hypertension Adrenergic-Blocking Agents: Side Effects Side/Adverse Effects

IV administration: Check IV site often for infiltration Use clear IV solutions Use an infusion device/IV pump Infuse agent slowly to avoid dangerous cardiovascular effects Monitor cardiac rhythm Monitor for therapeutic effects (cardiovascular uses): Decreased edema Increased urinary output Return to normal vital signs Improved skin color and temperature Increased LOC

With chronic lung disease: Instruct patients to avoid factors that exacerbate their condition. Encourage fluid intake (up to 3000 mL per day) if permitted. Educate about proper dosing and equipment care.

Body System

* Salmeterol is indicated for PREVENTION of bronchospasms, not management of acute symptoms. Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations. Avoid OTC or other medications because of possible interactions. Administering two adrenergic agents together may precipitate severe cardiovascular effects such as tachycardia or hypertension. Inform patients taking inhaled isoproterenol that their sputum or saliva may turn pink.

Blood- Agranulocytosis, thrombocytopenia Cardiovascular- AV block, bradycardia, congestive, heart failure, peripheral vascular, insufficiency CNS- Dizziness, mental depression, lethargy, hallucinations Gastrointestina- Nausea, dry mouth, vomiting, diarrhea, cramps, ischemic colitis Other- Impotence, rash, alopecia, bronchospasms

Adrenergic Blocking Agents: Nursing Implications Assess for allergies and history of COPD, hypotension, cardiac dysrhythmias, bradycardia, CHF, or other cardiovascular problems Any preexisting condition that might be exacerbated by the use of these agents might be a CONTRAINDICATION to their use. Remember that alpha blockers may precipitate hypotension. Remember that beta blockers may precipitate bradycardia, hypotension, heart block, CHF, and bronchoconstriction. Encourage patients to take medications as prescribed. 5

Monitor for therapeutic effects (asthma): Return to normal respiratory rate Improved breath sounds, fewer rales Increased air exchange Decreased cough Less dyspnea

These medications should never be stopped abruptly. Report constipation or the development of any urinary hesitancy or bladder distention. Avoid OTC medications because of possible interactions.

Monitor for therapeutic effects Decreased chest pain in patients with angina Return to normal BP and P Other specific effects, depending on the use

Possible drug interactions may occur with: o o o o o Antacids (aluminum hydroxide type) Antimuscarinics/anticholinergics Diuretics and cardiovascular drugs Neuromuscular blocking agents Oral hypoglycemic agents

Teach patients to change positions slowly to prevent or minimize postural hypotension. Avoid caffeine (excessive irritability). Avoid alcohol ingestion and hazardous activities until blood levels become stable. Patients should notify their physician if palpitations, dyspnea, nausea, or vomiting occur.

Patients should report the following to their physician: Weight gain of more than 2 pounds (1 kg) within a week Edema of the feet or ankles Shortness of breath Excessive fatigue or weakness Syncope or dizziness Rebound hypertension or chest pain may occur if this medication is discontinued abruptly. Patients should notify their physician if they become ill and unable to take medication. Inform patients that they may notice a decrease in their tolerance for exercise; dizziness and fainting may occur with increased activity. Notify the physician if these problems occur.

Monitor for side effects, including: Hypotension Fatigue Lethargy

Tachycardia (alpha blockers) Bradycardia Heart block CHF Depression Insomnia

Vivid nightmares

Increased airway resistance