_________ Drugs stimulate the parasympathetic nervous system in the same manner as acetylcholine.

In normal neuromuscular function __________ is released from nerve endings and binds to nicotinic receptors on cell membranes of muscles contraction. ______________ ___________ is an autoimmune disorder in which autoantibodies are thought to destroy nicotinic receptors for acetylcholine on skeletal muscle. Alzheimer's disease the most common type of dementia in adults, is characterized by abnormalities in the cholinergic, serotonergic, noradrenergic, and ___________ neurotransmission systems. Acetylocholine stimulates __________ receptors in the gut to promote normal secretory and motor activity. Used to treat mild to moderate Alzheimer's disease Synthetic derivative of choline Short acting cholinergic drug used to diagnose myasthenia gravis The only anticholinesterase capable of crossing the blood brain barrier. The prototype anticholinesterase agent

Cholinergic

Acetylcholine

Myasthenia Gravis

Glutamatergic

Cholinergic Donepezil (Aricept) Bethanechol (Urecholine) Edrophonium Physostigmine salicylate (Antilirium) Neostigmine (Prostigmin)

What is the function of cholinergic drugs on body systems?

Cholinergic drugs stimulate the parasympathetic nervous system in the same manner as acetylcholine. Some drugs act directly to stimulate cholinergic receptors; others act indirectly by inhibiting the enzyme acetylcholinesterase, thereby slowing acetylcholine metabolism at autonomic nerve synapses. In normal brain function, acetylcholine is an essential neurotransmitter and plays an important role in cognitive functions including memory storage and retrieval. Acetylcholine stimulates cholinergic receptors in the gut to promote normal secretory and motor activity. Cholinergic stimulation results in increased peristalsis and relaxation of flatus and feces. The secretory functions of the salivary and gastric glands are also stimulated. Acetylcholine stimulates cholinergic receptors receptors in the urinary stimulation results in contraction of the detrusor muscle and relaxation of the urinary bladder. Direct acting cholinergic drugs are synthetic derivatives of choline. Most direct acting cholinergic drugs are quaternary amines, carry a positive charge, and are lipid insoluble. Because they do not readily enter the central nervous system, their effects occur primarily in the periphery. Direct acting cholinergic drugs are highly resistant to metabolism by acetylcholinesterase, the enzyme that normally metabolizes acetylcholine.

What is the role of acetylcholine as it relates to neurological function

What is the role of acetylcholine as it relates to the gastrointestinal system?

What is the role of acetylcholine as it relates to the urinary system?

What is the mechanism of action for direct acting cholinergic drugs?

Mr. Bates is treated in the critical care unit for overdose of indirect cholinergic drugs. What is the treatment of choice in this situation? a. An anticholinesterase reactivator b. Atropine c. Pralidoxime d. A cholinesterase reactivator

c Rationale: Pralidoxime a cholinesterase re-activator is the specific treatment of neuromuscular blockade due to over dose with irreversible indirect cholinergic drugs.

Mr. Chin is experiencing paralysis due to overdose of indirect cholinergic drugs, but which of the following will it not reverse? a. Cholinergic effects of skeletal muscle weakness or paralysis b. Nicotinic effects of skeletal muscle weakness or paralysis c. Ketoacidosis in the skeletal muscle d. Lactic acid accumulated in the skeletal muscle. ___________ is used to differentiate between myasthenic crisis (too little cholinergic medication) and cholinergic crisis (too much cholinergic medication). Indirect acting cholinergic or anticholinesterase drugs are indicated to treat myasthenia gravis as well as which of the following conditions? a. Muscular dystrophy b. Musculoskeletal cancer c. Alzheimer's disease d. Cerebrovascular dementia Mrs. Belts had surgery 24 hrs ago to repair a hernia. You find that she has not had a bowel movement since the day before the surgery. She is experiencing abdominal distention, and during auscultation you note an absence of bowel sounds. Further examination and testing reveal a paralytic ileus. The physician order bethanechol. What type of drug is bethanechol? a. Anticholinergic medication b. Direct acting cholinergic drug c. Indirect acting cholinergic drug d. Indirect acting anticholinergic medication. Indirect acting cholinergic drugs also stimulate nicotinic receptors in skeletal muscles, resulting in which of the following? a. Increased smooth muscle tone b. Decreased musculoskeletal pain. c. Improved skeletal muscle tone and strength. d. Decreased muscle spasticity. Both direct acting cholinergic drugs and indirect acting cholinergic drugs ( or anticholinesterase drugs) have widespread ____________ effects when they activate muscarinic receptors in cardiac muscle, smooth muscle, exocrine glands and the eye.

b. Atropine will reverse muscarinic effects due to overdose of cholinergic drugs but will not reverse the nicotinic effects of skeletal muscle weakness or paralysis due to overdose of indirect cholinergic drugs.

Edrophonium

c. Rationale: Indirect acting cholinergic or anticholinesterase drugs are indicated to treat myasthenia gravis and alzheimers disease.

b. Rationale: The direct acting cholinergic drug, bethanechol, is used to treat urinary retention due to urinary bladder atony and postoperative abdominal distention due to paralytic ileus.

c. Rationale: Indirect acting cholinergic drugs also stimulate nicotinic receptors in skeletal muscles, resulting in improved skeletal muscle tone and strength.

Parasympathetic

Mr. Baton age 75, is diagnosed with myasthenia gravis . As his home care nurse, how can you assist him with medication compliance? a. Pre - pouring his medications one week at a time. b. Ensuring that all medications have safety caps. c. Persuading his son to call once a week to encourage him to take his medications. d. Asking the housekeeping to administer the medications. Mr. Gates is diagnosed with hepatitis C and myasthenia gravis. His prescriptions include neostigmine. you are concerned because Mr. Gates may experience which of the following? a. Increased absorption b. Increased adverse effects c. Increased resistance to the medication d. Decreased absorption of the medication. Mr. Gibbons, age 65 takes cholinergic medication. He presents to the ER with symptoms associated with GI distress. He is diagnosed with a small bowel obstruction. Which of the following actions would you expect the physician to take? a. Increased the dose of the cholinergic medications b. Decrease the dose of the cholinergic medication to slow peristalsis. c. Maintain the same dosage of cholinergic medication because it will not affect the diagnosis. d. Discontinue the cholinergic medication to prevent injury to the areas proximal to the obstruction. Individuals with peptic ulcer disease should not use cholinergic drugs because they increase ______________ secretion. Mrs. Baton is taking cholinergic medication to control bladder retention. She presents to the emergency department with confusion, shortness of breath, and an apical pulse of 42 beats per minute and irregular. Which of the following action would you expect the physician to take? a. Increase the cholinergic medication to increase cardiac contractility. b. Increase the cholinergic medication to increase oxygenation to the heart through vasodilation. c. Decrease the cholinergic medication to alleviate the symptom of confusion. d. Discontinue the cholinergic medication secondary to the diagnosis of bradycardia.

a. Rationale: The patient with myasthenia gravis may have diplopia or diminished muscle strength that makes it difficult to self administer medications. Pre pouring medications in an easy to open device facilitates medication administration. b. Rationale: The hepatic metabolism of neostigmine and pyridostigmine may be impaired by liver disease resulting resulting in increased adverse effects.

d. Rationale: Cholinergic drugs are contraindicated in urinary or GI tract obstruction because they increased the contractility of smooth muscle in the urinary of GI systems and may result in injury to structures proximal to the obstruction.

Gastric Acid

d. Rationale: Individuals with coronary artery disease should not take cholinergics because they can result in bradycardia, vasodilation, and hypotension.

Patients with hyperthyroidism should avoid cholinergic drugs. Which of the following is a symptom associated with the administration of cholinergic medication to an individual with the diagnosis of hyperthyroidism? a. Hyperglycemia b. Decreases TSH c. Increased TSH d. Reflex tachycardia

d. Rationale: Patients with hyperthyroidism should avoid cholinergic drugs. the individual with hyperthyroidism, initial response to cholnergic medications (bradycardia and hypotension) triggers the baroreceptor reflex. As this reflex attempts to resolve the hypotension, norepinephrine is secreted from sympathetic nerves regulating the heart. Norepinephrine may trigger reflex tachycardia and other cardiac dysrhythmias.

You understand that cholinergic medications are contraindicated in clients with the asthmatic bronchitis because they may have which of the following effects? a. Cause bronchodilation b. Decrease secretions c. Cause secretions to thicken d. Cause bronchoconstriction A direct acting drug ___________ is used to treat urinary retention due to urinary bladder atony and postoperative abdominal distention due to paralytic ileus. Direct acting cholinergic drugs affect the bladder by causing which of the of the following? (select all that apply) a. Increased tone and contractility b. Relaxation of the sphincter c. Increased bladder capacity d. Reduction in UIT's Direct acting cholinergic drugs cause ______________ respiratory secretions. Indirect acting cholinergic or anticholinesterase drugs decrease the inactivation of ______________ in the synapse by the enzyme acetylcholinesterase. When indirect acting cholinergic drugs are used to treat Alzheimer's disease, they improve symptoms by doing which of the following? a. Improving cholinergic neurotrasmission to the brain. b. Improving anticholinergic neurotransmission to the brain. c. Improving medication absorption through the blood brain barrier. d. Causing vasodilation of the cerebral arteries. Anticholinesterase drugs are classifed as either reversible or irreversible inhibitors of ______________ Besides output to the various organs in the body, this nerve conveys sensory information about the state of the body's organs to the central nervous system. 80-90% of the nerve fibers in this nerve are afferent (sensory) nerves communicating the state of the viscera to the brain.

d. Rationale: Cholinergic drugs are contraindicated in individuals with asthma because they may cause bronchoconstriction and increased respiratory secretions.

Bethanechol

a, b. Rationale: Direct acting cholinergic drugs cause increased tone and contractility of smooth muscle (detrusor) in the urinary bladder and relaxation of the sphincter. Increased

acetylcholine a. Rationale: Indirect action cholinergic medications for Alzheimers disease are widely distributed including to the central nervous system. Thus, indirect acting cholinergic drugs are able to improve cholinergic neurotransmission in the brain. Acetycholinesterase

Cranial nerve X Vagus

True or false? Cholinergic drug are contraindicated in urinary or GI tract obstruction because they increase the contractility of smooth muscle in the urinary and GI systems and may result in injury to structures proximal to the obstruction. True or false Cholinergic drugs are contraindicated in patients with asthma because they may cause bronchoconstriction and increased respiratory secretions. Cholinergic drugs are contraindicated in individuals with peptic ulcer disease because they increase gastric acid secretion. True or falsePregnant women should not take cholinergic medications.

True

True

true True

Why would a nurse question an order for a cholinergic prescribed to a patient that had just under gone bowel surgery? Individuals with __________ should not take cholinergics because they can result in bradycardia, vasodilation, and hypertension.

Because the drugs can increase tone and motility of the intestinal smooth muscle and may lead to rupture of the bowel. Coronary artery disease

What are the general characteristics of cholinergic drugs?

1. Decreased heart rate 2. Increased tone and contracitility in GI smooth muscle, relaxation of sphincters, and increased salivary gland and GI secretions. 3. Increased tone and contractility of smooth muscle (detrusor) in the urinary bladder and relaxation of the sphincter 4. Increased tone and contractility of bronchial smooth muscle 5. Increased respiratory secretions 6. Constriction of pupils (miosis) and contraction of ciliary muscle resulting in accommodation for near vision. Bethanechol Tubocurarine glaucoma Bethanechol True 1. Neostigmine (Prostigmin)2. Edrophonium (Tensilon)3. Physostigmine salicylate (antilirium)4. Pyridostigmine (Mestinon) Neostigmine (Prostigmin) Neostigmine (Prostigmin)

__________ is used to treat urinary retention due to urinary bladder atony and postoperative abdominal distention due to paralytic ileus. Cholinergic drugs are used to reverse the action of nondepolarizing neuromuscular blocking agents such as _____________ used in surgery. Cholingerics are used to treat this eye disease? What are the direct acting cholinergics? True or false? Bethanechol should not be used in obstructions of the urinary or GI tracts. What are the reversible indirect acting cholinergics (anticholinersterases)?

This drug is the prototype for the anticholinesterase agents and is used for the long term treatment of myasthenia gravis. This drug is used as an antidote for tubocurarine and other nondepolarizing skeletal muscle relaxants used in surgery. True or false? Like bethanecol neostigmine is a quaternary amine and carries a postive charge. This reduces the lipid solubility and results in poor absorption of the GI tract when it is used for long term treatment of myasthenia gravis resistance to its action may occur and larger doses maybe required. This is a short acting cholinergic drug used to diagnose myastheia gravis. __________ is the antidote for edrophonium (Tensilon). This drug is the only anticholinesterase capable of crossing the blood brain barrier. This drug is sometimes used as an antidote for the overdosage for anticholinergic drugs including atropine, antihistamines, tricyclinc antidepressants, and phenothiazine antipsychotics and sometimes used in the treatment of glaucoma.

True

Edrophonium (Tensilon) Atropine Physostigmine salicylate (Antilirium)

Physostigmine salicylate (antilirium)

________________ is similar to neostigmine in actions and in adverse effects. It may have a longer duration of action and lower incidence of side effects than neostigmine, and it is the maintenance drug of choice for patients with myasthenia gravis. It also comes in a slow release from and is effective for 8 to 12 hrs. What are the reversible indirect acting cholinergics used for treatment of Alzheimer's disease? This drug is used to treat mild to moderate Alzheimers disease. _______ is metabolized in the liver and used to treat mild to moderate Alzheimer's disease. Adverse effects are nausea, vomiting, diarrhea, bradycardia, and possible aggravation of asthma, peptic ulcer disease, and chronic obstructive pulmonary disease. __________ is a newer long acting reversible indirect acting cholinergic used to treat Alzheimers disease and is very similar pharmacokineticly to donepezil (Aricept) and Rivastigmine (Exelon). ___________ is a long acting central anticholinesterase agent approved for the treatment of mild to moderate dementia due to Alzheimers disease and Parkinsons disease. True or false? In patients known to have myasthenia gravis the nurse notices ptosis (drooping) of the upper eyelid and diplopia (double vision) caused by weakness of the eye muscles. As the disease progresses patients may have difficulty chewing, swallowing, and speaking; also beware of accumulation of oral secretions. When patient are taking tacrine what should care givers look for to avoid hepatotoxicity? What herbal medication should be avoided when taking donepezil? True or false? Take oral cholinergics on an empty stomach to lessen nausea and vomiting. Also, food decreases absorption of tacrine by up to 40%. Why do we give bethanechol before meals?

Pyridostigmine (mestinon)

1. Donepezil (Aricept) 2. Galantamine (Razadyne)3. Rivastigmine (exelon) 4. Tacrine (Cognex) Donepezil (Aricept)

Donepezil (Aricept)

Galantamine (Razadyne)

Rivastigmine (Exelon)

True

Skin rash, jaundice, and light colored stools. St. Johns wort because concurrent use may reduce blood levels of donepezil. True Nausea and vomiting may occur because the drug stimulates contraction of muscles in GI tract. For consistent blood levels and control of symptoms. These drugs increase the risk of GI distress and ulceration. Food decreases absorption and decreases serum drug levels by 30% or more. Corticosteroids, Aminoglycoside (ex. gentaminicin), Succinylcholine Cimetidine

Why do we give pyridostigmine and other drugs for myasthenia gravis at regularly scheduled intervals with food or milk? Why do we give tacrine on an empty stomach, 1hr before or 2hrs after a meal if possible at regular intervals around the clock? What drugs decrease the effects of anticholinesterase agents? What drugs increase the effects of tacrine?