1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 20 Cholinergic-Blocking Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Definition Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS) Also known as anticholinergics

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Mechanism of Action (cont’d) Once these drugs bind to receptors, they inhibit nerve transmission at these receptors

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Chemical Class NaturalSynthetic/Semisynthetic atropinebenztropineclidinium belladonnadicyclomineglycopyrrolate hyoscyaminehomatropineipratropium scopolamineisopropamide methscopolamine oxybutyninpropantheline tolterodinetrihexyphenidyl Many others

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Effects  Cardiovascular  Small doses: decrease heart rate  Large doses: increase heart rate  CNS  Small doses: decrease muscle rigidity and tremors  Large doses: drowsiness, disorientation, hallucinations

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Effects (cont’d)  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

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Effects (cont’d)  Genitourinary  Relaxed detrusor muscle  Increased constriction of internal sphincter  Result: urinary retention  Glandular  Decreased bronchial secretions, salivation, sweating

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drug Effects (cont’d)  Respiratory  Decreased bronchial secretions  Dilated bronchial airways

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: CNS  Decreased muscle rigidity and muscle tremors  Parkinson’s disease  Drug-induced extrapyramidal reactions

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: 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

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: Atropine Used primarily for cardiovascular disorders  Diagnosis of sinus node dysfunction  Symptomatic second-degree heart block  Severe sinus bradycardia with hemodynamic compromise (advanced life support)

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: 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

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: Respiratory (cont’d) Respiratory drugs are used to treat:  Exercise-induced bronchospasms  Chronic bronchitis  Asthma  Chronic obstructive pulmonary disease

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: 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

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: Gastrointestinal (cont’d) Gastrointestinal drugs are used to treat:  Irritable bowel disease  GI hypersecretory states

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications: Genitourinary  Reflex neurogenic bladder  Incontinence

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Indications  Acute pancreatitis (reduces gastric and pancreatic secretions)  Preoperatively: to reduce salivary secretions

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Effects Body SystemAdverse Effects CardiovascularIncreased heart rate, dysrhythmias CNSCNS excitation, restlessness, irritability, disorientation, hallucinations, delirium

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Effects (cont’d) Body SystemAdverse Effects EyeDilated pupils, decreased visual accommodation, increased intraocular pressure GastrointestinalDecreased salivation, decreased gastric secretions, decreased motility

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Effects (cont’d) Body SystemAdverse Effects GenitourinaryUrinary retention GlandularDecreased sweating RespiratoryDecreased bronchial secretions

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Interactions  Antihistamines, phenothiazines, tricyclic antidepressants, MAOIs  When given with cholinergic blocking drugs, cause additive cholinergic effects, resulting in increased effects

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Keep in mind that these drugs will block the action of ACh in the PSNS  Assess for allergies, presence of BPH, glaucoma, tachycardia, MI, HF, hiatal hernia, and GI or GU obstruction  Perform baseline assessment of vital signs and systems overview

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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 overdose is physostigmine

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Anticholinergics taken by the elderly patient may lead to higher risk for heatstroke due to effects on heat- regulating mechanisms  Teach patients to limit physical exertion and avoid high temperatures and strenuous exercise  Emphasize the importance of adequate fluid and salt intake

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d) 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

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d) Monitor for therapeutic effects  For patients with Parkinson’s disease: fewer tremors and decreased salivation and drooling  For urologic problems: improved urinary patterns, less hypermotility, increased time between voiding Monitor for adverse effects