UNIT 5–AUTONOMIC NERVOUS SYSTEM DRUGS

Ivory List Drugs Covered in this Unit

AHFS Subclass Descriptor
Generic/Trade Name Class Class/subclass identify drug type Drug uses and other pertinent information
TX ACUTE ASTHMA; anaphylactic shock; non-specific beta1 & 2
31 epinephrine/Adrenalin Anom Adrenergic bronchodilator agonist; vasoconstrictor with local anesthetic; INJECTED
33 pseudoephedrine/Sudafed* Anom Adrenergic vasoconstrictor TX NASAL CONGESTION; alpha1 adrenergic agonist
104 oxymetazoline/Afrin* EENT Adrenergic vasoconstrictor TX NASAL CONGESTION; SPRAY
27 albuterol/Proventil Anom Beta2 adrenergic bronchodilator TX ACUTE ASTHMA, INHALED; little cardiac stimulation
Alpha2 stimulator; central
72 clonidine/Catapres CV vasodilator (antiadrenergic*) TX HTN; causes initial sedation, has mild orthostatic effects
Alpha1 blocker; peripheral
79 terazosin/Hytrin CV vasodilator TX HTN, 1 x day dose, also, tx BPH
TX HTN; SLOWS HEART; ↓ sympathetic input, ↓ mortality after MI, tx
77 propranolol/Inderal CV Beta blocker
angina, arrhythmias, thyrotoxicosis, & migraine
70 atenolol/Tenormin CV Cardiospecific beta blocker TX HTN & angina, ↓ mortality after MI
106 timolol/Timoptic EENT Beta blocker TX GLAUCOMA; ↓ AQUEOUS HUMOR FORMATION, antiadrenergic
30 donepezil/Aricept Anom Cholinergic TX ALZHEIMER'S DEMENTIA, palliative, ↑ CNS acetylcholine
TX GLAUCOMA; constricts pupil, ↑ aqueous humor outflow;
105 pilocarpine/Ocusert EENT Cholinergic miotic
put reservoir system in conjunctival sac, each eye each week
PREVENTS BRADYCARDIA; USED PRE-OP; ↓ peristalsis
28 atropine/Generic Anom Anticholinergic
& secretions
102 atropine/Generic EENT Anticholinergic mydriatic DIAGNOSTIC, DILATES PUPILS FOR EXAMINATION
32 ipratropium/Atrovent Anom Anticholinergic bronchodilator TX ACUTE ASTHMA; INHALED
34 scopolamine/Transderm-V Anom Anticholinergic antiemetic PREVENTS MOTION SICKNESS, tx vertigo
29 benztropine/Cogentin Anom Anticholinergic TX PARKINSON'S early in DISEASE & PSEUDOPARKINSONISM
*Over-the-counter drugs (#21) **Common doses to memorize (#7)
<<<Using the CD review the drug pronunciations listed above>>>
*Remember: clonidine/Catapres is an alpha 2 stimulator. Alpha2 stimulation blocks actions, inhibiting
further release of norepinephrine at the nerve terminal. Thus, although it is an agonist, it is considered an
antiadrenergic. Compare this action to activating the brakes of your car, which makes the car stop. Your
action blocks the motion of the car.
Abrams Chapters & Study Notes for This Unit
Chapter 16 Physiology of the Autonomic Nervous system
1. Design a tree showing the relationships of the nervous system; include the central with the brain and spinal cord, the
peripheral nervous system, with the somatic and autonomic nervous system, and the major branches of the autonomic
nervous system including the parasympathetic and sympathetic nervous systems (see Abrams, page 266).
2. On the Nervous System Transmitters diagram, (at the end of these LOs), see the long and short fibers, the synapses,
and the neurotransmitters for the sympathetic nerves, the parasympathetic nerves, and the somatic nerves (also see
Abrams, page 267).
3. On the Catecholamine Table, at the end of these LOs, identify the neurotransmitter sequence, the alpha 1 and 2
actions and drugs and the beta 1 and 2 actions and drugs.
4. Make a synthesis card for each element of the Catecholamine Table. (You will need to know this information
throughout the course.)
5. Identify the physiologic effects of the sympathetic (adrenergic) nervous system (see the ANS Teacher's Note).
6. Identify the physiologic effects of the parasympathetic (cholinergic) nervous system (see the ANS Teacher's Note).
Chapter 17, Adrenergic Drugs
1. Describe the actions, indications for use, and contraindications, for epinephrine/Adrenalin, pseudoephedrine/Sudafed,
albuterol/Proventil (see Chapter 44), and oxymetazoline/Afrin (see Chapter 46).
Chapter 18, Antiadrenergic Drugs
1. Describe the actions, indications for use, and contraindications, for clonidine/Catapres, terazosin/Hytrin,
propranolol/Inderal, atenolol/Tenormin, and timolol/timoptic.
2. State the precaution for the use of propranolol/Inderal with severe congestive heart failure or asthma.
3. Explain why propranolol/Inderal can be illustrated as a Hawaiian Vacation for the Heart" (see illustration at the end of
these LOs.
Chapter 19, Cholinergic Drugs
1. Describe the actions, indications for use, and contraindications for donepezil/Aricept.
2. Briefly evaluate the efficacy of donepezil/Aricept in the treatment of Alzheimer's disease.
Chapter 20, Anticholinergic Drugs
1. Describe the actions, indications for use, and contraindications, for atropine/Generic, ipratropium/Atrovent,
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 scopolamine/Transderm V, benztropine/Cogentin, and oxybutynin/Ditropan.

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 Autonomic Nervous System and Drugs
Chapter 16, Anatomy and Physiology
1. Design a tree showing the relationships of the nervous system; include the central with the brain and spinal cord, the
peripheral nervous system, with the somatic and autonomic nervous system, and the major branches of the autonomic
nervous system including the parasympathetic and sympathetic nervous systems.
See the diagram at the end of these LOs and Abrams, Page 266, “Divisions of the Human Nervous System”

2. On the Nervous System Transmitters diagram at the end of these LOs, see the long and short fibers, the synapses,
and the neurotransmitters for the sympathetic nerves, the parasympathetic nerves, and the somatic nerves. Also see
“Organization of the Autonomic and Somatic Nervous Systems in Abrams, page 267.

3. Identify the neurotransmitter sequence, the alpha 1 and 2 actions and drugs and the beta 1 and 2 actions and drugs.
See the table "Catecholamine (Monoamines), at the end of these LOs.

4. Make a synthesis card for each element of the Catecholamine Table. (You will need to know this information
throughout the course.)
Review “Synthesis Cards” under the burgundy "Course Guide" button.

5. Identify the physiologic effects of the sympathetic (adrenergic) nervous system.

See “Autonomic Nervous System Responses:” Flight & fight (FF) response at the end of these Learning Objectives.

6. Identify the physiologic effects of the parasympathetic (cholinergic) nervous system.

See “Autonomic Nervous System Responses:” Feed & breed (FB) response at the end of these Learning Objectives.

Chapter 17, Adrenergic Drugs

1. Describe the actions, indications for use, and contraindications, for epinephrine/Adrenalin
Epinephrine/Adrenalin is an adrenergic bronchodilator. It is used to treat acute asthma; anaphylactic shock; non-
specific beta1 & 2 agonist; vasoconstrictor with local anesthetic. It is injected. It is a stimulant and can cause increased
heart rate, increased blood pressure, nervousness and sleeplessness, dry mouth, and urinary retention in men with
enlarged prostates.

Describe the actions, indications for use, and contraindications, for pseudoephedrine/Sudafed
Pseudoephedrine/Sudafed is an over-the-counter drug. It is an adrenergic vasoconstrictor. It is used to treat nasal
congestion; it is an alpha1 adrenergic agonist. It is a stimulant and can cause increased heart rate, increased blood
pressure, nervousness and sleeplessness, dry mouth, and urinary retention in men with enlarged prostates.

Describe the actions, indications for use, and contraindications, for oxymetazoline/Afrin
Oxymetazoline/Afrin is an over-the-counter drug. It is an adrenergic vasoconstrictor and is used to treat nasal
congestion. It comes as a spray. Because it is topical it does not cause the systemic stimulation of other adrenergic
drugs. If used over six doses it can cause rebound nasal congestion.

. Describe the actions, indications for use, and contraindications, for albuterol/Proventil.
Albuterol/Proventil is a Beta2 adrenergic bronchodilator. It is used to treat acute asthma. It causes little cardiac
stimulation because it is designed to affect primarily the lungs and to spare the heart.

Phenylpropanolamine, another adrenergic vasoconstrictor, has been off the market for a few years.
Phenylpropanolamine is similar to pseudoephedrine and was used as a nasal decongestant and as a weight loss pill. It
was taken off the market after several young women suffered strokes after using it for a few days as a diet drug.

Chapter 18, Antiadrenergic Drugs

1. Describe the actions, indications for use, and contraindications, for clonidine/Catapres.
Clonidine/Catapres is an alpha2 stimulator. It is a central vasodilator. Alpha2 stimulation blocks actions, inhibiting
further release of norepinephrine at the nerve terminal. Thus, although it is an agonist, it is considered an
antiadrenergic. Clonidine/Catapres is a treatment for hypertension that causes initial sedation and has mild
orthostatic effects.

Describe the actions, indications for use, and contraindications, for terazosin/Hytrin.
Terazosin/Hytrin is an alpha1 blocker that causes peripheral vasodilation. It is treatment for hypertension. It is given
once a day and is also a treatment for benign prostatic hypertrophy.
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 Describe the actions, indications for use, and contraindications, for propranolol/Inderal.
Propranolol/Inderal is a nonselective beta blocker that blocks both alpha and beta receptors in both the heart and
lungs.
It is a treatment for hypertension. It slows the heart by decreasing sympathetic input and dilates blood vessels.
It decreases mortality after a heart attack (myocardial infarction-MI).
It is a treatment for angina because it slows the rate and decreases cardiac workload. It is a Hawaiian vacation for the
heart see illustration at the end of these LOs.
It treats arrhythmias by slowing the heart rate.
One dose before a performance reduces performance anxiety.
Thyrotoxicosis causes a very fast heart rate so propranolol/Inderal protects the heart by slowing the rate.
Propranolol/Inderal treats migraine headaches by unknown mechanisms.
Because it can have a deleterious effect on the lungs—it constricts bronchioles— it is contraindicated for people with
severe asthma.
It used to be contraindicated for people with congestive heart failure (CHF) because of its negative inotropic (strength)
and chronotropic (speed) effects but is now considered an appropriate treatment (except for severe [uncompensated]
CHF) because of its cardioprotective blockade of sympathetic stimulation.
Propranolol/Inderal should not be discontinued suddenly. The nurse should watch for a severely decreased blood
pressure, bradycardia, dyspnea, and severe fatigue or dizziness.
Propranolol/Inderal will be studied further in the Cardiovascular Unit

Describe the actions, indications for use, and contraindications, for atenolol/Tenormin.
Atenolol/Tenormin blocks only beta 1 receptors so is cardio specific. It is treatment for hypertension and angina. It
decreases mortality after MI. Because of its specificity for the heart, there is less chance of bronchospasm but it still
should be used cautiously for persons with even mild asthma.
Atenolol/Tenormin has the same precautions as propranolol/Inderal.
Atenolol/Tenormin will be studied further in the Cardiovascular Unit

Describe the actions, indications for use, and contraindications, for timolol/timoptic.
Timolol/Timoptic is a beta blocker. It is used to treat glaucoma and sometimes hypertension. It decreases aqueous
humor formation in the eye and is antiadrenergic. It will be covered in Eye and Skin Unit.

Chapter 19, Cholinergic Drugs

1. Describe the actions, indications for use, and contraindications for pilocarpine/Ocusert.
Pilocarpine/Ocusert is a cholinergic miotic (decreases pupil size by constricting the iris) and thus decreasing aqueous
humor outflow. It is a treatment for glaucoma. The patient puts the reservoir system in the conjunctival sac in each eye
each week.
It will be covered in Eye and Skin Unit.

Describe the actions, indications for use, and contraindications for donepezil/Aricept.
Donepezil/Aricept is an autonomic-cholinergic drug. It is the treatment for Alzheimer’s dementia. It increases CNS
acetylcholine. It may cause nausea and vomiting, diarrhea and bradycardia. It should be used cautiously in patients
with cardiac disease, peptic ulcer disease, seizures, asthma, or obstructive pulmonary disease.

2. Evaluate the efficacy of donepezil/Aricept in the treatment of Alzheimer's disease.

It is only palliative.
Chapter 20, Anticholinergic Drugs
1. Describe the actions, indications for use, and contraindications for atropine/Generic.
Atropine/Generic is an anticholinergic autonomic drug. It prevents bradycardia. It is given by injection before surgery. It
also decreases peristalsis and secretions.

2. Describe the actions, indications for use, and contraindications for ipratropium/Atrovent.
Ipratropium/Atrovent is an autonomic drug, an anticholinergic bronchodilator. It is inhaled to treat acute asthma.

3. Describe the actions, indications for use, and contraindications for scopolamine/Transderm V.
Scopolamine/Transderm V is an autonomic drug, an anticholinergic antiemetic. It prevents motion sickness and treats
vertigo.

4. Describe the actions, indications for use, and contraindications for benztropine/Cogentin.
Benztropine/Cogentin is an autonomic anticholinergic. It is used to treat early Parkinson’s disease and
pseudoparkinsonism seen in the treatment of schizophrenia.
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 5. Describe the actions, indications for use, and contraindications for oxybutynin/Ditropan.
Oxybutynin/Ditropan is an anticholinergic urinary tract antispasmodic treatment for overactive bladder. It inhibits the
action of acetylcholine.
<<<>>>

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 Sympathetic Nervous System in Relation to the Entire
Nervous System

Nervous System

Central Peripheral

Brain Spinal Cord Autonomic Somatic

Parasympathetic Sympathetic
(Cholinergic) ACh (Adrenergic)

Alpha Beta

1 2 1 2

Parasympathetic system is the "Feed and Breed" system.

Sympathetic system is the "Fright, Flight, Fight" system.

Alpha 1 constricts blood vessels, dilates eyes.

Alpha 2 (a blocker) dilates blood vessels.

Beta 1 stimulates the heart.

Beta 2 dilates bronchioles in the lungs.

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 NERVOUS SYSTEM TRANSMITTERS

AUTONOMIC NERVOUS SYSTEM

1. The sympathetic/adrenergic pre-ganglionic neurotransmitter is ACETYLCHOLINE (ACh). The post-ganglionic
neurotransmitter at the junction with the organ is NOREPINEPHRINE (NE).
ACh NE
________ ↓ _________________________________ ↓ OOO
Short fiber Long fiber Organ

1. Sympathetic/Adrenergic Nerve(Fright, Flight, Fight)

2. The sympathetic/adrenergic hormone is EPINEPHRINE (EPI). It travels from the adrenals through the blood stream to
the junction with the organ.
_____________________________________
///\\\EPI _____________________________________ OOO
Adrenal Blood vessel Organ
Gland

2. Sympathetic Transport Via Blood Vessels(Fright, Flight, Fight)

3. The parasympathetic pre-ganglionic neurotransmitter is ACETYLCHOLINE. The post-ganglionic neurotransmitter at

the junction with the organ is also ACETYLCHOLINE.
ACh ACh

_________________________________ ↓ ________ ↓ OOO

Long fiber Short fiber Organ

3. Parasympathetic/Cholinergic Nerve(Feed and Breed)

SOMATIC NERVOUS SYSTEM

4. The somatic nervous system (voluntary and reflex movement) does not have ganglia. The neurotransmitter at the
junction with the muscle is ACETYLCHOLINE.
AC
h
____________________________________________ ↓ (((())))
Very long fiber Muscle

4. Somatic Nerve(Innervates Muscles)

<<<>>>

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 CATECHOLAMINES (MONOAMINES)
CENTRAL (brain) PERIPHERAL (body)
NEUROTRANSMITTERS: NEUROTRANSMITTERS:
Dopamine Norepinephrine at post-ganglionic sites
Norepinephrine Epinephrine Epinephrine from the adrenal medulla

NEUROTRANSMITTER SEQUENCE:
Phenylalanine becomes Tyrosine becomes Dopamine becomes Norepinephrine becomes Epinephrine
(Tyramine is synthesized by the body from tyrosine and found in aged meats, ripe cheese; it has action like epinephrine, but weaker.)

At ALPHA(α) receptors neurotransmitters are: At BETA(β) receptors the neurotransmitter is:

Norepinephrine Epinephrine
& Epinephrine

ALPHA1 stimulation causes ALPHA2 stimulation
actions
1. Constricts peripheral
vessels in the skin, kidney,
and viscera, to raise BP in
the heart and brain.
2. Constricts vessels in nasal
mucous mem branes, to
relieve a stuffy nose
3. Contracts the radial muscle
of the eyes, dilating the
eyes (mydriasis).
Agonist drugs:
epinephrine/Adrenalin,
oxymetazoline/Afrin, &
pseudoephedrine/Sudafed
Antagonist drug:
terazosin/Hytrin
BETA1 stimulation affects BETA2 stimulation affects the
blocks actions the heart lungs
1. Inhibits further release of 1. Stimulates the heart; 1. Dilates the bronchioles
norepinephrine at the increases rate and
nerve terminal, dilating strength
peripheral blood vessels
to lower blood pressure
2. Shunts blood from
peritoneal cavity to mucosa,
skeletal muscle, brain, and
heart
Agonist drug: Agonist drug: Agonist drugs:
clonidine/Catapres, an epinephrine/Adrenalin epinephrine/Adrenalin and
"alpha2 stimulator" albuterol/Proventil
hypotensive.* Albuterol/Proventil is more
lung-specific than epinephrine.
They both dilate the bronchi.
No antagonist drugs are Antagonist drugs are "beta No antagonist drugs are
commonly used. blockers." commonly used. There is no
Propranolol/Inderal and reason to constrict the
atenolol/Tenormin bronchi. Propranolol does
(cardiospecific) are both have antagonist activity as an
hypotensives. undesirable side effect. It is
Timolol/Timoptic decreases not used as a hypotensive for
aqueous humor in glaucoma. asthmatics.
O88/691/793/899

* Clonidine/Catapres acts in the medulla of the brain to stimulate alpha2-receptors that inhibit sympathetic vasomotor
centers. (The action is comparable to "stimulating" a car's brakes to "inhibit" its motion.) Clonidine/Catapres causes
sedation, a central (brain) action. It does not interfere with fine control of peripheral vessels, a peripheral action, so does
not cause orthostatic hypotension.
Serotonin (SE) is a naturally occurring derivative of tryptophan found in platelets, intestine, and brain. It is a potent
vasoconstrictor, stimulates intestinal smooth muscle contraction, and is a brain neurotransmitter. It is also called 5-
hydroxytryptamine (5-HT). Fluoxetine/Prozac is a selective serotonin reuptake inhibitor to treat depression;
amitriptyline/Elavil blocks reuptake of NE and SE to treat depression; lithium increases reuptake of NE and SE to treat
mania, risperidone/Risperdal blocks receptors for dopamine and SE, to treat schizophrenia; sumatriptan/Imitrex is a
selective serotonin agonist (vasoconstrictor) to treat migraines.
Adapted from Baer & Williams, 1988 and Rang, Dale, Ritter, & Gardner, 1995
<<<>>>

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 PROPRANOLOL
A Hawaiian Vacation for the Heart

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 AUTONOMIC NERVOUS SYSTEM RESPONSES
Flight & fight (FF) response. Feed & breed (FB) response.
Norepinephrine and epinephrine are associated Acetylcholine is associated with the
with the FF/adrenergic/sympathetic response. FB/cholinergic/parasympathetic response.

1. Pupils dilate, to see better (mydriasis)
2. Bronchi dilate and respiratory rate increases, to get
more oxygen more quickly.
3. Blood sugar from the liver increases, to provide more
energy to run, think, or fight.
4. Heart beats faster and stronger to get more blood to
lungs, brain, and muscles. Increased blood flow/oxygen,
to the brain increases thinking and to the muscles
increases muscle strength and speed.
5. Blood clotting increases, to decrease bleeding from a
wound.
6. Cell metabolism increases, to do more cellular work
when the body is running, thinking, and fighting.
7. Sweat increases, so it is easier to slip out of the grasp
of an enemy.
8. Stomach, bowel, and peripheral blood vessels to the
skin constrict, to shunt blood to the brain and heart and
conserve blood for brain and muscle use.
Blood pressure increases.
Stomach and bowel peristalsis decreases, digestion
slows, and bowel function slows (constipation) to
conserve blood for muscles.
Skin becomes pale and cool.
Skin wounds do not bleed as much.
9 Digestive enzymes decrease.
10. Urinary bladder relaxes and urinary sphincter
contracts. There is no time to urinate now.
11. Genital blood vessels constrict to conserve blood for
vital organs.
1. Pupils constrict; pupils become smaller (miosis).
2. Bronchi "constrict." Actually, bronchi return to a normal
state with no dilation and a normal respiratory rate.
3. Blood sugar decreases and returns to normal.
4. Heart rate slows and returns to a normal strength.
Brain and muscle metabolism return to normal.
5. Blood clotting decreases to normal.
6. Cell metabolism slows and returns to normal.
7. Sweating decreases to normal.
8. Stomach, bowel, and skin blood vessels dilate.
Blood pressure decreases.
Stomach and bowel peristalsis increases, digestion
resumes, and bowel function returns to normal.
Skin becomes warm and pink.
9. Digestive enzymes increase from minimal amounts to
normal.
10. Urinary bladder contracts and urinary sphincter:
relaxes so urination can occur.
11. Genital blood vessels dilate to return to normal, not
constricted; then with sexual excitement they dilate.

A LITTLE STORY ABOUT OUR ANCESTORS

.......A cave person was in the forest picking berries when she noticed it was beginning to get dark. Suddenly fear seized her and she
remembered that she was far away from her home cave. She began to hear the noises of the night. Her eyes dilated, her muscles
tensed, and she drew in a gasp of air. Her heart began pounding as she started to run toward home. Suddenly she felt a burst of
strength as her liver pumped a vast amount of sugar into her blood stream. Her heart was pounding so fast it felt like it would jump out
of her chest. Her blood pressure skyrocketed as all her peripheral blood vessels constricted. The blood vessels to her muscles dilated
and filled with life-giving blood as she sped through the dark forest. Her breathing was fast and deep, pulling oxygen into her body so
she could use its strength to power her muscles to run faster and faster.

.......The oxygen had magically cleared her brain of every thought except the best route to get to the cave and that map was brilliantly
illustrated in her mind. Every cell in her body was functioning to one end--survival. She was ghostly pale and covered with a cold sweat
and knew that she would be able to slip out of the grasp of an enemy.

.......Suddenly, a huge roar sounded just behind her. Grrrrr! Growl! It was a saber-toothed tiger looking for his supper. He snarled as his
razor sharp claws raked down the back of her leg. Blood spurted out of the wound but stopped almost immediately because the
peripheral blood vessels had constricted and her clotting had increased. With one final burst of speed she dashed through the cave
entrance to safety.

.......As she lay panting on the cave floor she could hear the tiger growling as he paced back and forth in front of the fire at the cave
entrance and another cold shiver ran down her body. Her cave partner wrapped the wounds on her leg and after she had rested a little,
asked her to come and eat some stew. "I'm sorry, I can't eat. My stomach is hurting and I know I'll be sick if I eat anything."

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.......She rested for a while and then said, "I am feeling a little better since I've caught my breath. Maybe now I'll be able to 'pass my
water.' I needed to go while I was in the forest, but with that tiger after me, all I could do was run." My bowels feel twisted in knots. I
don't think I'll be back to normal until tomorrow."

.......A little time passed and the cave partner said, "I've just arranged all the furs on our bed. Since you don't want to eat, we might just
as well lie down and I'll hold you and keep you warm." Time passes. The cave partner can't sleep and suggests a little bedtime activity.
The cave person pushes her partner away. I'm not in the mood for that! I almost lost my life today and all you want is fun and games.
She turns her back to her partner, closes her eyes and falls into an exhausted sleep.
<<<>>>

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