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Home , Anticholinergic, Antispasmodic

ANTICHOLINERGIC

Prof. Hanan Hagar Unit Medical College King Saud University What students should know: Student should be able to :

• Identify the classification of drugs • Describe pharmacokinetics and dynamics of muscarinic antagonists • Identify the effects of on the major systems. • list the clinical uses of muscarinic antagonists. • know adverse effects & contraindications of anticholinergic drugs. • Identify at least one antimuscarinic agent for each of the following special uses: , cyclopedia, peptic ulcer & .

Anticholinergic Drugs

Antimuscarinics Antinicotinics

Ganglionic Neuromuscular blockers blockers

Muscarinic Neuromuscular blockers Ganglionic blockers Ach Nn AnticholinergicGanglionicGanglionic blockers blocker blockers Ach Nm M NnAch Nn Drugs Anticholinergic Drugs Antimuscarinic Drugs

According to source

oAtropine () Natural o Hyoscine ()

Semisynthetic

Synthetic Antimuscarinics Muscarinic antagonists

Semisynthetic & Synthetic atropine substitutes (semisynthetic) Tropicamaide Benztropine Ipratropium Glycopyrrolate , Anticholinergic Drugs Antimuscarinic Drugs According to structure

Tertiary amines oAtropine (Hyoscyamine) o Hyoscine (scopolamine) o lipid soluble

Quaternary ammonium o Glycopyrrolate o water soluble Anticholinergic Drugs

Antimuscarinic Drugs

According to selectivity

Non-selective oAtropine, Hyoscine o Ipratropium

Selective o Pirenzepine(M1) o Darifenacin(M3) Mechanism of action

Competitively block muscarinic receptors Pharmacokinetics Natural o Atropine (Hyoscyamine) o Hyoscine (scopolamine) o Lipid soluble o Good oral absorption o Good distribution o Cross blood brain barrier (have CNS actions) o Hyoscine has better BBB penetration. Pharmacodynamic Actions CNS: o Atropine at clinical dose, initial stimulation followed by depression (sedative effect). o Hyoscine →sedative effect o effect (block center). o Antiparkinsonian effect (block ). Pharmacodynamic Actions CNS:

o High doses of atropine cause cortical excitation, restlessness, disorientation, , and followed by respiratory depression and coma.

CVS: oAtropine causes initial bradycardia followed by due to blockade of M2-receptors on SA node. o↑ AV conduction ( + dromotropic effect). oAtropine does not influence BP. o↓ Vasodilatation induced by . oToxic dose: Cutaneous vasodilatation→ (atropine flush).

Eye:

oPassive mydriasis due to paralysis of circular muscle

oCycloplegia (loss of near accommodation) due to paralysis of ciliary muscle.

oLoss of light reflex.

o Increase I.O.P # .

o↓ Lacrimal secretion → sandy eye

Eye: Respiratory system

Relaxation of bronchial muscles () ↓ Bronchial secretion → ↑ viscosity GIT:

o Dryness of mouth o ↓ Gastric acid production o Relaxation of smooth muscles. o ↓ GIT motility → effect. o ↑ Sphincter contractions

o Genitourinary tract: o Relaxation of smooth muscles of . o Sphincter contraction. o . o Urinary retention can occur in old men with prostatic hyperplasia.

Secretions

↓ Salivary secretion → (Dry mouth). ↓ Sweating → dry skin In children modest doses →”atropine fever” ↓ Bronchial secretion → ↑ Viscosity ↓ Lacrimal secretion → Sandy eye

Clinical Uses

— Parkinsonism — Vomiting () — Pre-anesthetic

— & COPD

— Peptic ulcer — Intestinal as

— Urinary urgency, Clinical Uses

CNS:

Parkinsonism e.g. Benztropine

Clinical Uses

CNS:

Motion sickness e.g. Hyoscine Ophthalmic disorders:

Ophthalmoscopic examination of retina

e.g. , homatropine GIT: e.g. Glycopyrrolate, Hyocine butyl bromide. o Intestinal spasm o Biliary and renal colics. oIrritable bowel syndrome o Atropine + used for treatment of Traveler's with GUT:

Urinary incontinence & Urinary urgency caused by minor inflammatory bladder disorders e.g. Oxybutynin e.g. Darifenacin Respiratory disorders:

Bronchial asthma & chronic obstructive pulmonary disease (COPD) e.g. Ipratropium (inhalation)

Cardiovascular effects:

Sinus bradycardia Cholinergic poisoning

Cholinesterase inhibitors “insecticides”.

Mushroom poisoning.

Adverse Effects oMydriasis, blurred vision o Confusion, agitation, delirium oDry mouth , hot flushed skin o Constipation, urinary retention o Tachycardia o↑ Body temperature ()

The Mnemonic

Mad as a hen Red as a beet Dry as a boneFull as a FlaskBlind as a bat Hot as Hell fire Contra-indications

— Glaucoma (angle closure glaucoma) — Tachycardia secondary to thyrotoxicosis or cardiac insufficiency — Old patients with prostate hypertrophy. — Paralytic — Constipation — Children in case of atropine.

Uses of antimuscarinic drugs Drugs organ Uses Atropine CNS Pre-anesthetic medication Antispasmodic Hyoscine CNS Pre-anesthetic medication, Motion sickness, antispasmodic Benztropine CNS Parkinson's disease Homatropine Eye Fundus examination Tropicamide Ipratropium Respiratory asthma, COPD, inhalation system Pirenzepine Peptic ulcer Glycopyyrolate GIT Antispasmodics in hypermotility

Oxybutynin UT Urinary urgency, Urinary Darifenacin incontinence Quiz 1?

A patient is brought into the emergency room. Upon examination you find the following: a high fever, rapid pulse, no bowel sounds and dilated pupils that do not respond to light. His are clear. His face is flushed and his skin is dry. He is confused, disorientated and reports 'seeing monsters'. Based on these symptoms, you suspect he has been 'poisoned'. Which of the following, is the MOST obvious cause of poisoning? A. Neostigimine B. C. Atropine sulfate D. Quiz 2?

You are working in the post care unit of a hospital. You have just received a patient back from surgery and you are monitoring his status. Knowing that the patient has received atropine, which of the following statements/ observations is UNEXPECTED? A. The patient is complaining of extreme thirst. B. The patient complains he is unable to clearly see the clock located just across from him. C. The patient's heart rate is elevated. D. The patient reports he has cramping and diarrhea. Thank you

Questions ?