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PHARMACY TECHNICIANCHAPTER TWENTY FOUR1BoneComposed of two different kinds of bony tissueCancellous or spongy boneporous, inner bone that provides volumeCompact bonehard, outer covering that provides strength and shapeThe rounded end of a bone is covered with smooth, slippery articular cartilageMany bones are hollow, and contain marrow:Red marrow in childrenFatty yellow marrow in adults

222Bone and Muscle

3Types of MuscleSkeletal musclesattached to bones; provide body movementVoluntary, striated in shape, contain multiple peripheral nucleiCardiac muscletissue that composes the heartContracts rhythmically, coordinated by transmission of electrical impulses from nerve to muscle fibersSmooth or visceral muscleattached to or lines other organs such as the stomach, intestines, lungs, and blood vessels

444Five Categories of Bone:Flat bonesgenerally more flat than roundIrregular boneshave no defined shapeSesamoid boneshave cartilage or fibrous tissue mixed inShort bonesgenerally cube-shapedLong bonesthe most common boneEpiphysis (the rounded end of the bone)Diaphysis (the main shaft or central part of the bone)

555Disorders of the BoneOsteomyelitisBacterial Infection Inside the Bone Destroys bone tissueOriginal site of infection is frequently in another part of bodyInfection spreads to the bone via the bloodOsteoporosisbone brittleness due to lack of calciumPrevalent in postmenopausal women because of estrogen deficiencyPagets diseasechanges the normal process of bone growthCauses bone to break down more quickly and grow back softer than normal bone

6Musculoskeletal Diseases/DisordersBursitisinflammation of the small, fluid-filled pouches between bonesTendonitisinflammation of the cords of connective tissue that attach muscle to boneMyalgiamuscle pain

7Skeletal Muscle RelaxantsMOA: may block action of calcium in musclesIndications: painful muscle spasms, neurological spinal cord injuryMain Side Effects: Drowsiness, weakness

GenericBrandCyclobenzaprineFlexerilMethocarbamolRobaxinBaclofenLioresalArthritisInflammation of a JointRheumatoidan autoimmune disorderOsteoarthritiscaused by physical degeneration of connective tissueGoutcaused by crystals of uric acid in blood9TreatmentsOsteomyelitisAnti-infective agent is best treatment for osteomyelitisOsteoporosisVitamin D and mineral calcium replacement therapyHormone therapy (estrogen, calcitonin) and bisphosphonatesSERMs for postmenopausal womenGold compounds used to treat osteoarthritis

10TreatmentsGoutColchicine used to alter ability of phagocytes to attack uric acid crystalsAnti-inflammatory analgesics can be used to reduce pain and inflammationInflammationSalicylates relieve inflammation by inhibiting the synthesis of prostaglandinTopical corticosteroids treat most causes, including chemical, mechanical, microbiological, and immunological

11Musculoskeletal PharmaceuticalsASA (acetylsalicylic acid)Relieves inflammation by inhibiting the synthesis of prostaglandinSalicylates are also used as analgesics and antipyreticsNSAIDs (nonsteroidal anti-inflammatory drugs)Inhibit or block the enzyme that starts the reaction of inflammation by making prostaglandinCOX-2 inhibitorsBlock only the cyclooxygenase II that makes PGE-2, but not C-1 (PGE-1)Inflammation is inhibited, but not the viscosity of the mucosal linin

12Non Steroidal Anti Inflammatory DrugsCalled the NSAIDSExcellent drugs for pain relief and reducing fever and inflammationDeveloped as an alternative to corticosteroidsMOA: blocks the COX enzyme to block prostaglandin formationSide effects are: severe GI bleeding (possible), GI upset and gastritis, kidney insufficiency, edema and elevated blood pressure, hyperkalemia risk

GenericBrandIbuprofenMotrin, AdvilNaproxenNaprosynKetorolacToradol (IV available)DiclofenacVoltarenCelecoxibCelebrex (COX2 inhibitor)Musculoskeletal PharmaceuticalsBisphosphonatesindicated for osteoporosisMimic the natural organic bisphosphonate salts found in the bodyInhibit bone resorption and osteoclast activityRestore bone mass and densitySERMs (selective estrogen receptor modulators)Indicated for postmenopausal womenProtective effect on bones and heartSkeletal muscle relaxantsused to relax specific muscles in the bodyRelieve pain, stiffness, and discomfortBlock muscle contraction at the neuromuscular junctio14PHARMACY TECHNICIANCHAPTER TWENTY FIVE15The Respiratory SystemDivided into the upper respiratory tract and the lower respiratory tractThe upper respiratory tract consists of:Nose or nasal cavityParanasal sinusesPharynx and larynx16The Respiratory System (cont.)The lower respiratory tract consists of:TracheaTwo lungsTwo main bronchi

17The lower respiratory tract.18

RespirationDiaphragmdome-shaped layer of muscle that lies across bottom of chest cavityBreathing occurs as diaphragm contracts and relaxesCarbon dioxide pushed out of the lungs during relaxationOxygen pulled into the lungs during contraction19Structure of LungsAbout 10 percent solid tissueRemainder of structure filled with air and bloodThe functional structure can be divided into two parts:Conducting airways (bronchi and bronchioles)tubes lined by cilia and respiratory mucosaCartilagesupports and cushions the bronchi20Common ColdCaused by a viral infection that inflames the membranes in nose and throatAntibiotics will not cure a cold or any other viral infectionTreatment is considered symptomaticCoughMay be a symptom of a cold, flu, respiratory problems, or nonrespiratory diseasesMost likely begins with an irritation of nerves in the respiratory tractNonproductive cough treated with cough suppressantProductive cough treated with an expectorant

21Allergies and AsthmaAllergiesCaused by the immune system reacting to a substance that does not cause diseaseTreatment may be palliative, with antihistamines and antitussivesTreatment may be preventive, with mast cell stabilizersAsthmaChronic respiratory diseaseCharacterized by inflammation of airways, tightening of muscles around airwaysTreatment is palliative with albuterol and other bronchodilators

22EmphysemaChronic destruction of alveoliExternal exchange interrupted when alveoli become permanently damagedTreatment may be palliative, with stimulant inhalersTreatment may be preventive, with anti-inflammatory corticosteroids23Nasal Congestion and RhinitisNasal CongestionInflamed, stuffy noseTreatment may be palliative, to promote easier breathingIndications for use of decongestants are nasal and bronchial congestionRhinitisInflammation of nasal membranes, and/or runny noseCommon component of colds and allergiesTreatment is considered symptomaticDrugs to treat include:

24GenericBrandOxymetazolineAfrin Nasal SprayPhenylephrineNeoSynephrine Nasal SprayFluticasoneFlonase (Nasal Steroid preparation)MometasoneNasonex (Nasal Steroid preparation)Oxymetazoline and Phenylephrine are sympathomimetic and can raise blood pressure. They also should be used with caution in gluacoma patientsChronic Obstructive Pulmonary Disease (COPD)Umbrella term for emphysema and chronic bronchitis, and asthmaCharacterized by partially blocked bronchi and bronchioles, mucus plugging and bronchoconstrictionCauses shortness of breathTreatment may be palliative, with bronchodilatorsDrugs

25GenericBrandAlbuterolProventilPirbuterolMaxairIpratropiumAtroventFluticasone/SalmeterolAdvair DiskusBudesonide/FormoterolSymbicortAlbuterol and Pirbuterol and Beta 2 agonist but can cause tachycardia in some people.All of the above drugs are available as MDIAdvair is a DPI (Dry powder inhaler system) (no CFC propellants)With Advair and Symbicort advise the patient to rinse the mouth with water to prevent candida infection (Trush or moniliasis)PHARMACY TECHNICIANCHAPTER TWENTY SIX26The heart.27

2727Anatomy of the HeartComposed of four chambers: two upper and two lowerAtriatop two chambersVentriclesbottom two chambersSeptumdivides heart into right and left sides282828Valves of the HeartTricuspid valvelocated between the right atrium and the right ventriclePulmonary valvelocated between the right ventricle and the pulmonary arteryMitral or bicuspid valvelocated between the left atrium and the left ventricleAortic valvelocated between the left ventricle and the aorta292929Layers of the HeartPericardiumfluid-filled sac that surrounds and protects the heartPermits free movement of the heart during contractionEndocardiuminnermost wall layer; covers the inside surface of the heartMyocardiumsurrounds heart and causes chamber contractions303030Function of the HeartProvides oxygenated blood throughout the body by a pumping mechanismOxygenated blood deposits materials necessary for growth and nourishmentReceives from tissues the waste products resulting from metabolism313131HypertensionSustained elevation of systemic arterial blood pressureSymptoms include:Severe headacheChest painIrregular heartbeatFatiguePharmaceutical treatment includes diuretics, vasodilators, ACE inhibitors, beta blockers, and calcium channel blockers

323232Congestive Heart FailureHeart pumps out less blood than it receivesResults in weakened and enlarged heartSymptoms of CHF include:Upright posture or leaning forwardAnxiety and restlessnessCyanotic and clammy skinPersistent coughRapid breathingFast heart rateEdema of the lower limbsPharmaceutical treatment includes cardiac glycosides, diuretics, vasodilators, ACE inhibitors, beta-adrenergic blockers, and phosphodiesterase inhibitors

333333Coronary Artery DiseaseOccurs when there is insufficient blood flow to the heartCan lead to:AnginaHeart attackArrythmiasStrokePulmonary embolismHeart failureEarly CAD is closely monitored and symptomatic relief is given by the use of nitroglycerin and other nitrate drugs. NTGISDN (isosorbide dinitrate)Once CAD has progressed to the point where a patient has angina at rest. Two procedures can be takenPCI with stentsCABG (Coronary artery bypass graft)343434Cardiovascular PharmaceuticalsAntiarrhythmic drugsrestore normal rhythm patterns but do not cure the cause of the irregular heartbeatCardiac glycosidesused to increase the force of myocardial contraction, without causing an increase in the consumption of oxygenDiureticsused to eliminate excess sodium and water via the urinary tractVasodilatorsallow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure

353535Cardiovascular Pharmaceuticals (cont.)Angiotensin-converting enzyme inhibitors (ACE inhibitors)lower high blood pressure; thought to reshape the heart; prevent the body from producing natural vasodilatorsAngiotensin II receptor blockerssimilar to ACE inhibitors; block the bodys natural vasodilatorsBeta-adrenergic blockersused to block cells from receiving natural vasoconstrictorsPlatelet aggregation inhibitorsreduce the ability of the blood to coagulate363636Cardiovascular Pharmaceuticals (cont.)Anticoagulantsprevent clots from forming or existing clots from getting biggerTissue plasminogen activatorsbreak down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factorsThrombin inhibitorsinactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrinAntihyperlipidemicshelp prevent the progression of coronary artery disease by lowering plasma lipid levels

373737AnticoagulantsDo not thin out the bloodPrevent clots from formingPrevent existing clots from getting biggerCannot dissolve existing blood clots383838WarfarinOral drug of choiceWorks by preventing the synthesis of clotting factors II, VII, IX, and XUsed in the long-term prevention or management of venous thromboembolic disorders, including:Deep vein thrombosisPulmonary embolismClotting associated with atrial fibrillation and prosthetic heart valvesVitamin K may be used as an antidote when too much warfarin has been given

393939HeparinParenterally administered drug of choiceWorks by inactivating clotting factors IX, X, XI, and XIIUsed prophylactically to:Prevent and treat deep vein thrombosisPrevent and treat pulmonary embolismTreat thrombophlebitisPrevent clotting during cardiac and vascular surgeryThe only antidote for heparin overdose is protamine sulfate

404040Cholesterol and TriglyceridesHDLhigh-density lipoproteins or good cholesterolLDLlow-density lipoproteins or bad cholesterolTriglyceridesa form of energy stored in adipose and muscle tissuesOften measured to depict fat ingestion and metabolismCan be used to assess CAD risk factorsStatins- drugs used to lower LDL cholesterol

41GenericBrandAtorvastatinLipitorSimvastatinZocorFluvastatinLescolRosuvastatinCrestorMajor: Side effects are nausea, GI and a reaction called Rhabdomyolysis and myopathy where patient experiences muscle pain and at the extreme renal failure and hospitalizationStatins are drug interactions with medications that block the livers CYP450 systems: Diltiazem, amiodarone, HIV protease inhibitors, KetoconazoleGenericBrandSimvastatin + EzetimibeVytorinLovastatin + NiacinAdvicorSimvastatin + NiacinSimcor42Above medications are combination products that contain a statin + one other drug. Exetimibe is a drug that block enteral absorption of cholesterol. Niacin is a B vitamin used to high doses to alter metabolism of triglycerides and raise HDLOne unique combination product is Caduet, which is a combination of Atorvastatin and Amlodipine (calcium channel blocker ). This product is used to treat metabolic syndromeNon Statin Antilipidemic drugsOther drugs that target lowing VLDL, triglycerides, and raising HDL have a beneficially affect on coronary artery disease

43GenericBrandIndicationsGemfibrozilLopidHigh VLDLFenofibrateTricorHigh VLDL, low HDLNiacinNiaspanHigh VLDL, low HDLOmega 3 Fatty acidLovazaHigh VLDL, low HDLDrugs used in the Treatment of MIMI is a myocardial Infarction. Heart attacks occurs because a arterial plaque raptures and triggers the coagulation cascade completely occudding a coronary artery. This cause necrosis of the heart muscle.If not treated MI result in death from cardiogenic shockEven if treat mortality is high from secondary ventricular fibrillationEven if treated, patient will suffer irrevocable heart damage resulting in CHF and/or damage to cardiac conduction system leading to pacemaker or ICD placementThe main goal is to relieve the blood vessel of the clot and reestablish coronary blood flowCan use clot busters drugs or have percutaneous coronary intervention (PCI) which the femoral artery undergo catherization and a probe is guide to the site of occlusion and a ballon is inflated to push aside the clot44GenericBrandUseAspirinEcotrinTo stop platelet action at the clotClopidogrelPlavixTo stop platelet action at the clotNitroglycerinVariousTo vasodilate coronary artery to relieve painTissue plasminogen activatorTPAAlteplase (Activase)Reteplase (Retavase)Tenecteplase (Tnkase)Activate plasmin, a blood protein that opens blood clotsHeparinN/AA potent blood anticoagulant that stop further coagulationMetoprololLopressorA beta blocker that slows heart rate and slows spread of infarction45Drug used in the treatment of Atrial FibrillationAtrial Fibrillation is a heart rate disturbance in which the atrium/ atria are beating extremely rapidlyCan lead to cardiogenic shock if the rate reaches the ventriclesTherapy is aimed blocking this rate disturbance from reaching the ventricles (called rate control), preventing blood clots in the heart muscle wall from forming embolus (anticoagulation), and eventual cardioversionRate controlDiltiazemVerapamilBeta blockersAmiodaroneAnticoagulationWarfarinApixaban (Eliquis)CardioversionIbutilide (Tikosyn)High dose Amiodarone 46Ventricular FibrillationVentricular Fibrillation, VF, is a cardiac arrythmia where the ventricles beat extremely rapidly to the point where no coordinated contraction occursMedical emergencyVF lasting more than the 90 seconds leads to asystole, sudden cardiac death and cardiogenic shock. Brain death from cerebral hypoxiaTherapyDirect DC shock with ACD: delivery of DC shock with about 360 Joules of electricity to bring about normal sinus rhythm. Best chance at survival but not always successfulDrug treatment used in conjunction with ACD if shock initially unsuccessfulAmiodarone: 300 mg IV push with 150 mg IV supplemental dosesLidocaine: 100 mg IV pushEpinephrine or Atropine can be tried after failed attempts at shockOther drugs include calcium chloride 10%, magnesium sulfate and vasopressin

47Beta BlockersVery useful in extending the life expectancy of patients post MI and in CHF patientsDue to evidence from clinical trials like the scandinavian Timolol study and the BHAT (beta block heart attack trial with propranolol) beta blocker are now an important drug in the therapy of post MI patients

48GenericBrandPropranololInderalMetoprololLopressorTimololBlocadrenAtenololTenorminCarvedilolCoregACE InhibitorsUsed to decrease mortality in post MI and CHF patientsUsed with beta blockers and often in combination with them

49GenericBrandCaptoprilCapotenEnalaprilVasotecLisinoprilZestril, PrinivilBenazaprilLotensinRamiprilAltacePotassium levels should be monitoredACE inhibitors are pregnancy category XMay cause relentless coughing in some patient requiring discontinuation due to potent edema and closure of the airwayPHARMACY TECHNICIANCHAPTER TWENTY EIGHT50The renal system.51

The Renal SystemComposed of two kidneys, two ureters, one bladder, and the urethraFiltering system of the kidneys is composed of millions of nephronsWaste from food and drug metabolization is filtered through the nephronsWastes exit the kidneys as urine via the uretersUreters lead to the bladder, where urine is stored until releasedThe kidneys are located in the posterior abdomen just above the waist52NephronSmallest, most basic part of the kidneyFilters the blood that passes through the kidneysProduces urine through the processes of filtration, reabsorption, and secretionEnables blood to reabsorb water, electrolytes, and nutrients53Kidney and BladderKidney Built almost entirely of nephronsOrgan that filters blood and produces urineUrine produced by the kidneys is conducted to the bladderBladderOrgan used for waste storageCan collect approximately 350 mL to 500mL of urineAllows for discretionary voiding

54Urinary Tract InfectionsBacterial infections of the urinary systemSymptoms include:Frequent urge to voidBurning sensation when voidingCloudy or strong-smelling urineBlood in the urine55Treating UTIsCranberry juice:A substance in cranberry juice keeps infection-causing bacteria from attaching to the walls of the urethraAlso makes the urine more acidicAnti-infectivesDestroy or inhibit bacterial growthPhenazopyridine (200 mg tid pc)Can be used to manage the symptoms of a burning and itching urethra56Kidney StonesCommon and painful urinary tract disorderSolid mineral deposits accumulate in the urinary tractTreatment is palliative, with pain managementOral analgesics for mild to moderate pain may be usedTreatment is preventative, with dietMineral and vitamin supplementsIncreased fluid intake57Edema and HypertensionConsistently elevated blood pressure levelsLead to damage of the kidney arteriesTreatment is with diureticsReduce high blood pressure58