Situational Analysis: 4.1 A patient with an acute attack of glaucoma is treated with pilocarpine.

The primary reason for its effectiveness in this condition is its: Answer: Ability to lower intraocular pressure. - Pilocarpine can abort an acute attack of glaucoma, because it causes papillary constriction to lower intraocular pressure. It binds mainly to muscarinic receptors and can enter the brain. It is not effective in inhibiting secretions. 4.2 A soldiers unit has come under attack with a nerve agent. The symptoms exhibited are skeletal muscle paralysis, profuse bronchial secretions, miosis, bradycardia, and convulsions. The alarm indicates exposure to an organophosphate. What is the correct treatment? Answer: Administer atropine and 2-PAM (pralidoxime) - Organophosphates exert their effect by irreversibly binding to acetylcholinesterase and, thus, can cause a cholinergic crisis. Administration of atropine will block the muscarinic sites; however, it will not reactivate the enzyme, which will remain blocked for a long period of time. Therefore, it is essential to also administer 2-PAM as soon as possible to reactivate the enzyme before aging occurs. Administering 2-PAM alone will not protect the patient against the effects of acetylcholine resulting from acetylcholinesterase inhibition. 4.3 A patient is being diagnosed for myasthenia gravis would be expected to have improved neuromuscular function after being treated with: Answer: Edrophonium - Edrophonium = is a short acting inhibitor of acetylcholinesterase that is used to diagnose myasthenia gravis. It is a quaternary compound and does not enter the CNS. - Donepezil = is used in the treatment of Alzheimers disease. - Ecothiophate = has some activity in treating openangle glaucoma. - Neostigmine = is used in the treatment of myasthenia gravis but is not employed in its diagnosis. - Atropine = is a cholinergic antagonist and, thus, would have the opposite effects. 4.4 The drug of choice for treating decreased salivation accompanying head and neck irradiation is: Choices: Physostigmine, Scopolamine, Carbachol, Acetylcholine, or Pilocarpine. Answer: Pilocarpine - Pilocarpine has proven to be beneficial in this situation. All the others except scopolamine are cholinergic agonists. However their ability to stimulate salivation is less than that of pilocarpine, and their other effects are more troublesome.

5.1 A 75-year-old man who was a smoker is diagnosed with chronic obstructive pulmonary disease and suffers from occasional bronchospasm. Which of the following would be effective in treating him? (Ipratropium aerosol, Scopolamine patches, Mecamylamine, Oxygen) Answer: Ipratropium aerosol This is a drug of choice, especially in patient who cannot tolerate an adrenergic agonist, which would dilate the bronchioles. Scopolamines main effect is atropinic, and is the most effective anti-motion sickness drug. Mecamylamine is a ganglionic blocker and completely inappropriate in this situation. Oxygen would improve aeration but would not dilate the bronchial musculature.

5.2 Which of the following may precipitate an attack of open-angle glaucoma if instilled into the eye? (Physostigmine, Atropine, Pilocarpine, Echothiophate) Answer: Atropine The mydriatic effect of atropine can result in the narrowing of the canal of Schlemm leading to an increase in intraocular pressure. The other agents would cause miosis.

5.3 The prolonged apnea sometimes seen in patients who have undergone an operation in which succinylcholine was employed as a muscle relaxant has been shown to be due to: (urinary atony, Depressed levels of plasma cholinesterase, A mutation in acetylcholinesterase, A mutation in the nicotinic receptor at the neuromuscular junction) Answer: Depressed levels of plasma cholinesterase These patients have a genetic deficiency of the nonspecific plasma cholinesterase that is required for the termination of succinylcholines action.

5.4 A 50-year-old male farm worker is brought to the emergency room. He was found confused in the orchard and since then has lost consciousness. His heart rate is 45, and his blood pressure is 80/40 mmHg. He is sweating and salivating profusely. Which of the following treatments is indicated? (Physostigmine, Norepinephrine, Trimethaphan, Atropine, Edrophonium) Answer: Atropine The patient is exhibiting signs of cholinergic stimulation. Because he is a farmer, insecticide poisoning is a likely diagnosis. Thus either intravenous or intramuscular doses of atropine are indicated to antagonize the muscarinic symptoms. Physostigmine and edrophonium are cholinesterase inhibitors and would exacerbate the problem. Norepinephrine would not be effective in combating the cholinergic stimulation. Trimethaphan, being a ganglionic blocker, would also worsen the condition.

6.1 A 69-year-old man presents to the emergency department with acute heart failure. You decide that this patient requires immediate drug therapy to improve his cardiac function. Which one of the following drugs would be most beneficial? (Albuterol, Dobutamine, Epinephrine, Norepinephrine, Phenylephrine) Answer: Dobutamine - Dobutamine increases cardiac output without significantly increasing heart rate a complicating condition in heart failure. Because epinephrine can significantly increase heart rate, it is not usually employed for acute heart failure. Both norepinephrine and phenylephrine have significant a1-receptorstimulating properties. The subsequent increase in blood pressure would worsen the heart failure. Albuterol, a b2-selective-receptor agonist, would not improve contractility of the heart significantly. 6.2 Remedies for nasal stuffiness often contain which one of the following drugs? (Albuterol, Atropine, Epinephrine, Norepinephrine, Phenyephrine) Answer: Phenylephrine - Phenylephrine is an a-agonist that constricts the nasal mucosa, thereby decreasing airway resistance, - Norepinephrine and epinephrine also constrict the mucosa but have much too short a duration of action. - Albuterol is a b2-agonist and has no effect on mucosal volume. Atropine, a muscarinic atagonist, only dries the mucosa it does not decrease its volume. 6.3 Which one of the following drugs, when admin. IV, can decrease blood flow to the skin, increase blood flow to the skeletal muscle, and increase the force and rate of cardiac contraction? (epinephrine, Isoproterenol, Norepinephrine, Phenylephrine, Terbutaline) Answer: Epinephrine - Exogenous epinephrine stimulates alpha and beta receptors equally well, leading to the constriction of blood vessels in tissues such as skin and dilation of other blood vessels in tissues such as skeletal muscle. - Epinephrine also has positive chonotropic and inotropic effects in the heart. Exogenous norepinephrine constricts blood vessels only and causes a reflex bradycardia because of its strong alpha adrenergic stimulating properties. Phenylephrine has similar effects. Isoproterenol stimulates beta receptors and would not cause vasoconstriction of cutaneous vessels. 6.4 The following circles represent papillary diameter in one eye prior to and following the topical application of Drug X:

(Physostigmine, Acetylcholine, Terbutaline, Phenyephrine, Isoproterenol) Answer: Phenylephrine Phenylephrine is the only drug in the list that causes mydriasis, because it stimulates a-receptors. Both physostigmine and acetylcholine cause papillary constriction. The b-blockers, terbutaline and isoproterenol, do not influence papillary diameter.

Control

Drug X

Which of the following is most likely to be Drug X?