1. Drugs Affecting Autonomic Nervous System 2

2. Drugs Affecting the Autonomic Nervous System Cholinergic Agents Cholinergic Blocking Agents

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

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

5. Cholinergic Receptors Two types, determined by: Location Action once stimulated Nicotinic receptors and Muscarinic receptors

6. Drug Effects of Cholinergic Agents “SLUDGE” S alivation L acrimation U rinary incontinence D iarrhea G astrointestinal cramps E mesis

7. Drug Effects of Cholinergic Agents Stimulate intestine and bladder –Increased gastric secretions –Increased gastrointestinal motility –Increased urinary frequency Stimulate pupil –Constriction (miosis) –Reduced intraocular pressure Increased salivation and sweating

8. Drug Effects of Cholinergic Agents Cardiovascular effects –Decreased heart rate –Vasodilation Respiratory effects –Bronchial constriction, narrowed airways

9. Cholinergic Agents: Therapeutic Uses Direct-Acting Agents Reduce intraocular pressure Useful for glaucoma and intraocular surgery Examples: acetylcholine, carbachol, pilocarpine Topical application due to poor oral absorption

10. Cholinergic Agents: Therapeutic Uses Direct-Acting Agent—bethanechol Increases tone and motility of bladder and GI tract Relaxes sphincters in bladder and GI tract, allowing them to empty Helpful for postsurgical atony of the bladder and GI tract Oral dose or SC injection

11. Cholinergic Agents: Therapeutic Uses Indirect-Acting Agents Cause skeletal muscle contractions Used for diagnosis and treatment of myasthenia gravis Used to reverse neuromuscular blocking agents Used to reverse anticholinergic poisoning (antidote) Examples: physostigmine, pyridostigmine

12. Cholinergic Agents: Side Effects Side effects are a result of overstimulation of the PSNS. Cardiovascular: –Bradycardia, hypotension, conduction abnormalities (AV block and cardiac arrest) CNS: –Headache, dizziness, convulsions Gastrointestinal: –Abdominal cramps, increased secretions, nausea, vomiting

13. Cholinergic Agents: Side Effects Side effects are a result of overstimulation of the PSNS. Respiratory: –Increased bronchial secretions, bronchospasms Other: –Lacrimation, sweating, salivation, loss of binocular accommodation, miosis

14. Cholinergic Agents: Interactions Anticholinergics, antihistamines, sympathomimetics Antagonize cholinergic agents, resulting in decreased responses

15. 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.

16. Cholinergic Agents: Nursing Implications 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.

17. Cholinergic Agents: Nursing Implications Atropine is the antidote for cholinergics. It should be available in the patient’s room for immediate use if needed. Patients should notify their physician if they experience muscle weakness, abdominal cramps, diarrhea, or difficulty breathing.

18. Cholinergic Agents: Nursing Implications Monitor for side effects, including: Increased respiratory Abdominal cramping secretions BronchospasmsDysrhythmias Difficulty breathingHypotension Nausea and vomitingBradycardia DiarrheaIncreased sweating Increase in frequency and urgency of voiding patterns

19. Cholinergic Agents: Nursing Implications Monitor for therapeutic effects: Alleviated signs and symptoms of myasthenia gravis 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

20. Cholinergic Blocking Agents Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS)

21. Cholinergic Blocking Agents: Mechanism of Action Competitive antagonists Compete with ACh Block ACh at the muscarinic receptors in the PSNS –As a result, ACh is unable to bind to the receptor site and cause a cholinergic effect.

22. Cholinergic Blocking Agents: Mechanism of Action Once these drugs bind to receptors, they inhibit nerve transmission at these receptors.

23. Drug Effects of Cholinergic Blocking Agents Cardiovascular –Small doses: decrease heart rate –Large doses: increase heart rate CNS –Small doses: decrease muscle rigidity and tremors –Large doses: drowsiness, disorientation, hallucinations

24. Drug Effects of Cholinergic Blocking Agents Eye –Dilated pupils (mydriasis) –Decreased accommodation due to paralysis of ciliary muscles (cycloplegia) Gastrointestinal –Relax smooth muscle tone of GI tract –Decrease intestinal and gastric secretions –Decrease motility and peristalsis

25. Drug Effects of Cholinergic Blocking Agents 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

26. Cholinergic Blocking Agents: Therapeutic Uses CNS Decreased muscle rigidity and muscle tremors Parkinson’s disease Drug-induced extrapyramidal reactions

27. Cholinergic Blocking Agents: Therapeutic Uses Cardiovascular Affect the heart’s 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

28. Cholinergic Blocking Agents: Therapeutic Uses Atropine Used primarily for cardiovascular disorders Sinus node dysfunction Symptomatic second-degree heart block Sinus bradycardia with hemodynamic compromise (advanced life support)

29. Cholinergic Blocking Agents: Therapeutic Uses 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

30. Cholinergic Blocking Agents: Therapeutic Uses Respiratory agents are used to treat: Exercise-induced bronchospasms Chronic bronchitis Asthma Chronic obstructive pulmonary disease

31. Cholinergic Blocking Agents: Therapeutic Uses 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

32. Cholinergic Blocking Agents: Therapeutic Uses Gastrointestinal agents are used to treat: Peptic ulcer disease Irritable bowel disease GI hypersecretory states

33. Cholinergic Blocking Agents: Therapeutic Uses Genitourinary Relaxed detrusor muscles of the bladder Increased constriction of the internal sphincter Reflex neurogenic bladder Incontinence

34. Cholinergic Blocking Agents: Side Effects Body SystemSide/Adverse Effects CardiovascularIncreased heart rate, dysrhythmias CNSCNS excitation, restlessness, irritability, disorientation, hallucinations, delirium

35. Cholinergic Blocking Agents: Side Effects Body SystemSide/Adverse Effects Eye Dilated pupils, decreased visual accommodation, increased intraocular pressure GastrointestinalDecreased salivation, decreased gastric secretions, decreased motility

36. Cholinergic Blocking Agents: Side Effects Body SystemSide/Adverse Effects GenitourinaryUrinary retention GlandularDecreased sweating RespiratoryDecreased bronchial secretions

37. Cholinergic Blocking Agents: Interactions Antihistamines. When given with cholinergic blocking agents, cause ADDITIVE cholinergic effects, resulting in increased effects

38. 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.

39. Cholinergic Blocking Agents: Nursing Implications Medications should be taken exactly as prescribed to have the maximum therapeutic effect. Overdosing can cause life-threatening problems. 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.

40. Cholinergic Blocking Agents: Nursing Implications 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).

41. Question?