Practical Review of Pharm a c o l o g y C o n c e p t s

Sue M. Janda Nancy L. Fagan

he term p h a rm a c o l o g y concepts are used ro u t i n e ly in nu rsing practice.T h e s e is derived from the concepts may be as simple as names and side effe c t s , or as G reek words “phar- c o m p l ex as or pharmacody n a m i c s . All play major makon,” meaning dru g s , roles in drug and safe t y. A practical rev i ew of pharmacology, Tand “logos,” meaning science. i n cluding pharmacokinetic and pharmacodynamic concepts, will be P h a r macology dates back to p r e s e n t e d . ancient times when man used plants and roots to treat ailments. © 2010 Society of Urologic Nurses and Associates In more recent times, the United U rologic Nurs i n g, p p . 1 5 - 2 1 . States Congress has passed re g u- lations that re q u i re drug manu- f a c t u r ers to study and pro v e Key Wo rd s : Pharmacology, adverse effects, pharmacokinetics, d r ugs are safe and eff e c t i v e , . b e f o r e being approved, pre- scribed, and sold to the public. O b j e c t i v e s Even with these studies, no d r ugs are perfectly safe. 1. Explain the four phases of pharmacokinetics. Although all produce dif- 2. Discuss the various ways a drug can be absorbed into the body. f e rent side effects, the objective 3. Describe pharmacodynamics. of drug therapy is to pro v i d e maximum benefits with minimal 4. Explain how patients can respond differently to drugs. h a r m. Pharmacology concepts a re used routinely in nursing practice (see Table 1). These con- cepts may be as simple as dru g names and side effects, or as will provide a practical review of administration can be divided complex as pharmacokinetics or p h a rma cokinetic and pharm a c o- into three categories: enteral, par- p h a rma codynamics. This art i c l e dynamic concepts. enteral, and other (non-enteral or p a r enteral) routes. The enteral P h a r m a c o k i n e t i c s route includes any route using the gastrointestinal tract – oral, Sue M. J a n d a , P h a r m D, FA S H P, is a Staff Pharmacokinetic concepts sublingual, buccal, and re c t a l . P h a rmacist, Alegent Health Immanu e l come into play once a drug enters The parenteral route entails intra- Medical Center, Omaha, NE, and an the body. They include the phases venous, intramuscular, and sub- A d j u n c t i ve Faculty Member, Department of of absorption, distribution, metab- C h e m i s t ry, Midland Lutheran College, cutaneous administrations. The Fremont, NE. olism, and (Lilley, other route consists of inhalation, H a r rington, & Snyder, 2007). topical, transdermal, intranasal, N a n cy L. Fag a n , P h a r m D, is an Assistant intrathecal, intraventricular, and P r o fessor of Pra c t i c e, D e - Absorption ophthalmic (Lilley et al., 2007). p a r tment of Pharmacy Pra c t i c e, Creighton U n i ve r s i t y, Omaha, NE. Absorption is an import a n t The three most common phase of pharmacokinetics and methods of absorption are passive N o t e : The authors reported no actual or includes three aspects: 1) ro u t e s absorption, active absorption, potential conflict of interest in relation to this of administration, 2) methods of and pinocytosis. Passive absorp- c o n t i nuing nursing education art i c l e. absorption, and 3) factors that tion is also known as passive or N o t e : O b j e c t i ves and CNE Evaluation Fo rm a f fect the absorption pro c e s s simple diffusion. It is dependent appear on page 21. (Lilley et al., 2007). Routes of on a concentration gradient and is

UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1 15 Ta ble 1. Definitions of Pharmacology Concepts

Te r m D e f i n i t i o n A b s o r p t i o n The uptake of substance by a tissue, such as nu t ri e n t s, though the wall of the gastrointestinal t ra c t . A g o n i s t A drug or other chemical that can combine with a on a cell to produce a phy s i o l o g i c reaction typical of a naturally occurring substance.

A n t a g o n i s t A drug that counteracts the effect of another dru g . B i o ava i l a b i l i t y The fraction of an administered that reaches the systemic circulation. C l e a ra n c e A measure of how well a patient can metabolize or eliminate a drug per unit time. Creatinine cleara n c e A measure of the kidney s ’ ability to eliminate creatinine from the body. E f fe c t i ve dose (ED50) The dose required to produce a specific therapeutic response in 50% of the patients. F i r s t - Pass D r ug removed from the blood or plasma fo l l owing absorption from the gastrointestinal tra c t b e fore reaching the systemic circulation. G l o m e rular filtra t i o n The volume of water filtered out of the plasma though glomerular capillary walls into Bow m a n ’s rate (GFR) capsules per unit of time. H a l f - l i fe The time required for the plasma concentration to be reduced to one-half of the original va l u e. Lethal dose (LD50) A dose that will produce a lethal in 50% of studied gr o u p. Data obtained from T D 5 0 . Pa r tial A drug that produces a we a ker or less efficient response than an agonist. P h a rm a c o d y n a m i c s The study of the biochemical and physiological interactions of drugs at their sites of activity. P h a rm a c o k i n e t i c s The study of the absorption, distri bution, metabolism, and excretion of a drug, and its metabolites in the body. P h a rm a c o l o g y The science of dru g s, including their composition, uses, and effe c t s. P r o d ru g An inactive drug dosage fo rm that is conve r ted to an active metabolite by va rious biochemical reactions once it is inside the body. R e c e p t o r A molecular structure or site on the surface or interior of a cell that binds with substances, such as horm o n e s, antigens, dru g s, or neurotra n s m i t t e r s. Steady state Rate of drug administration is equal to the rate of drug elimination. Toxicity dose (TD50) A dose that will produce a given toxicity in 50% of the studied gr o u p. T h e rapeutic class A group of drugs with similar mechanism of actions that treat the same disease state. T h e rapeutic index The ratio of the dru g ’s LD50 to its ED50 and measures drug safety margins. Volume of distri bu t i o n The apparent volume required to account for all the drug in the body in the same concentra t i o n as in the sample from the plasma.

S o u rc e s : D i c t i o n a ry.com, 2010a, 2010b, 2010c; W i n t e r, 2004. the most important mechanism m o re efficiently absorbed in the f rom an area of low concentra- for drug absorption. In simple stomach than in the intestine. In tion to an area of high concentra- d i ffusion, particles move from an contrast, the intestine is a basic tion. The third method is called a rea of high concentration to an e n v i ron ment and would favor pinocytosis. This process allows a rea of low concentration. There non-ionization of weak bases, cells to carry the drug acro s s is no energy expenditure during such as diazepam, which is more their membrane by engulfing the this process, and drugs must be e fficiently absorbed in the intes- d rug particles (Adams, Holland, small, lipid or fat soluble, and tine than in the stomach. The & Bostwick, 2008; Kee, Hayes, & non-ionized (no positive or nega- second method of absorption is McCuistion, 2009). tive charge) to cross the mem- active absorption, also known as Multiple factors affect absorp- branes. An acidic enviro n m e n t , active transport. Since this tion, including rate of dissolution, such as the stomach, favors non- method re q u i res energ y, it is the blood flow, and contact time. The ionization of weak acids, such as opposite of passive diff u s i o n , rate of dissolution determines the aspirin. There f o r e, aspirin is which means it moves part i c l e s rate of absorption. If the drug dis-

16 UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1 solves quickly, it will be absorbed, The of a dru g n e y, and brain. Drugs are then and the e ffects will be appare n t can be altered by drug form , distributed to areas with lower in a short period of time. With a metabolism, surface area, and blood flow, such as muscles, slow-dissolving drug, the dru g food. If a drug is administere d skin, and fat. In these low-flow must move from the stomach into i n t r a v e n o u s l y, it has a bioavail- a reas, it is difficult to obtain high the intestine, and the effects may ability of 100% because the dru g d rug concentrations, so diff e re n t not be seen for a longer period of is injected directly into a vein, routes of administration may be time (Adams & Koch, 2010). This and the body absorbs the entire needed. Some areas, such as is a key concept with immediate d rug. However, a drug adminis- bone, have a very poor blood or sustained release products, t e red orally has a bioavailability supply and are difficult to obtain such as tolterodine (Detrol®/ of less than 100% for two re a- adequate drug concentrations. Detrol LA®) or oxybutynin sons: 1) absorption is reduced, or The blood-brain barrier is a barr i- ( D i t ro p a n ®/ D i t ropan XL®), often 2) the drug is absorbed by the er that inhibits many chemicals used for an overactive bladder. intestine, transported by the por- and drugs from exiting the blood. Blood flow impacts the rate tal vein to the liver, and is metab- Most medications do not easily of absorption. If an area has a high olized before reaching the sys- c ross this barr i e r, making infec- blood flow, there may be temic circulation. Since this tions difficult to treat. With cer- i n c reased absorption from that d e c rea ses the amount of dru g tain infections, such as meningi- site. The intestine has more blood available to the systemic circ u l a- tis, the blood-brain barrier be- flow than the stomach; there f o re , tion, it is known as the first-pass comes more permeable when m o re absorption may occur. e ffect. Surface area is a principle inflamed and infections are more C o n v e r s e l y, shock reduces blood element because drugs are easily treated (Adams & Koch, flow to cutaneous tissue, and absorbed slower in the stomach, 2010). d rug absorption may be de- which has a smaller surface are a . The volume of distribution is c reased in that area (Adams & C o n v e r s e l y, drugs are absorbed a term used to quantify the distri- Koch, 2010). If a patient uses a faster in the intestine, which has bution of a medication between d rug in a patch form, such as oxy- a larger surface area. Some dru g s plasma and the rest of the body butynin (Oxytro l®) or fentanyl a re absorbed faster when taken after oral or parenteral doses. A ( D u r a g e s i c ®), and absorption in- with food, whereas other dru g s small volume of distribution and c reases, some side effects of toxi- may absorb better if taken on an high blood concentration usually city may be seen. However, if empty stomach (Kee et al., 2009). occur with highly water- s o l u b l e blood flow is decreased, the med- After drugs are absorbed into d rugs. The high water content ications may not work as well on the bloodstream, they are distrib- allows the drug to stay within the these patients. Using higher doses uted or transported through the blood compartment. Wa t e r- s o l u- or switching to another form of b o d y. Drugs are distributed into ble drugs that are highly pro t e i n the medication may be needed to the plasma, extracellular fluid, bound are more strongly bound optimize the desired effect. total body water, and the blood- to proteins and are less likely to Contact time also aff e c t s brain barr i e r. Drugs bound to be absorbed into tissues, and absorption. If a drug is not in plasma proteins, most commonly thus, usually concentrated in the contact with absorption sites for bound to albumin, are known as blood compartment. Atenolol a specific period of time, the dru g bound drugs, which are not phar- ( Te n o rm i n ®) is an example of a will not be completely absorbed. macologically active. Drugs that w a t e r-soluble drug. Conversely, a For example, diarrhea occurs a re not bound are known as fre e l a rge volume of distribution and because the decreased transit d rugs, which are active and able low blood concentration are seen time in the gastrointestinal tract to produce a pharm a c o l o g i c a l with fat-soluble drugs. Fat-solu- can affect the absorption of dru g s response. This is an import a n t ble drugs, such as diazepam in the body. Dru g - d rug interac- consideration in patients with ( Va l i u m ®), are usually poorly tions and drug-food interactions hypoalbuminemia. If a drug is bound to protein but are easily may increase or decrease absorp- highly protein bound and a absorbed into tissue and distrib- tion of a drug (Sloan, 1992). One patient has low albumin levels, uted throughout the body. d r ug may bind or alter the pro p e r- m o re free drug would be avail- Because of this, they may be ties of another drug. Specific able to the body, and the patient reabsorbed into the circ u l a t i o n d r ugs can react with a number of may experience toxic effects (Kee f r om tissue (Adams & Koch, d r ugs, food, or , and can be et al., 2009). 2010). a f fected by various diseases and conditions (Anastasio, Cornell, & Distribution Metabolism M e n s c e r, 1997; Kirk, 1995; Sloan, I n i t i a l l y, drugs are distrib- Metabolism is primarily asso- 1992; Ya m reudeewong, Henann, uted to the highest areas of blood ciated with termination of dru g Fazio, Lower, & Cassidy, 1995). f l o w, such as the heart, liver, kid- action. Metabolites often exhibit

UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1 17 lower pharmacologic activity and Figure 1. a re more water soluble, and there- Estimated Creatinine Rate Using Cock c roft-Gault Formu l a f o re, are more easily excreted (Kee et al., 2009). Pro - d rugs have no A commonly used marker for estimate of creatinine clearance is the Cock c r o f t - Gault Fo rmula, which estimates GFR. It is named after the scientists who first pharmacological activity and p u blished the fo rmula, and it employs serum creatinine measurements and a must be metabolized to become p a t i e n t ’s weight in kilograms to predict the creatinine cleara n c e.The fo r mula, as ® active. Clopidogrel (Plavix ), an o riginally published, is: antiplatelet drug used for coro- n a ry art e ry disease, peripheral e C C r = (140) – Age) x Mass (in kilograms) x [0.85 if Fe m a l e ] vascular disease, and c e re b ro v a s- 72 x Serum Creatinine (in mg/dL) cular disease, is an example of a p r o - d rug. It undergoes rapid This fo r mula expects weight to be measured in kilograms and creatinine to be h y d rolysis to its active form by measured in mg/dL, as is standard in the U. S.The resulting value is multiplied by the cytochrome P450 system a constant of 0.85 if the patient is fe m a l e ; a value of 1 is used if the patient is m a l e. This fo rmula is useful because the calculations are simple and can often (Savi et al., 1994). be perfo r med without the aid of a calculator. The primary site of metabo- lism for drugs is the liver. The rate Another va riation of the fo r mula simplifies the calculation by using a Lean Body of metabolism is dependent on Weight calculation that accounts for the constant number of 0.85 for women or 1 the blood flow. Other sites of for men as fo l l ows : metabolism include skin, lung, kidneys, and gastrointestinal Creatinine Clearance (CrCl) = (140 – Age) x Lean body Weight (LBW)* tract. The most common dru g 72 x Serum Creatinine (Scr) (in mg/dL) metabolism action is perf o rm e d by a large class of enzymes called *LBW (males) = 50 kg + (2.3 x eve r y inch over 5 fe e t ) ; LBW (females) = 45 kg + (2.3 x eve ry inch over 5 fe e t ) . m i c rosomal enzymes, also known as the Cytochrome P-450 enzyme S o u rc e : W i n t e r, 2004. system (Adams & Koch, 2010). The metabolism capabilities of the liver can vary from patient to of minutes, hours, or days. The Side Effects/Adverse Effects patient. Factors that can alter longer the half-life, the longer it Side effects are types of metabolism include , dis- takes for a drug to be excreted. It adverse effects that are pre- eases, and concurrent use of other usually takes four to five half-lives dictable and may occur even at d r u g s . for a drug to be at steady state. therapeutic doses. An adverse T h e re f o re, if a drug is ingested e ffect, however, is an undesirable E x c retion and the half-life is 2 hours, then in and potentially harmful action Routes of drug excre t i o n about 10 hours the drug will be caused by the administration of include urine, bile, feces, expire d out of the body’s system (Adams & medications. The number of a i r, sweat, tears, saliva, and Koch, 2010; Kee et al., 2009). d rugs a patient is taking incre a s- b reast milk. Renal excretion of Clearance depends on blood es the chance of an adverse eff e c t d r ugs is usually thro u g h flow and the ability of the org a n or drug interaction. This risk is g l o m e rular filtration, pro x i m a l to remove the drug. Total body estimated to be 6% when two tubular secretion, and distal tubu- clearance is the sum of all the medications are taken, 50% with lar reabsorption (Lilley et al., clearances in the body. This five medications, and almost 2007). Urinary excretion is the includes hepatic clearance, re n a l 100% with eight or more concur- primary route of excretion. clearance, pulmonary clearance, rent medications (Adams & E x c retion can be affected by alter- and other organ clearances Koch, 2010; Te rrie, 2004). ing urinary pH. Acidification of ( Wi n t e r, 2004). urine increases the excretion of Renal disease can aff e c t Pharmacodynamics weak bases, such as diazepam. g l o m e rula r filtration rate (GFR), Alkaline urine can i n c rease the which may reduce the amount of While pharmacokinetics re- e x c retion of weak acids, such as d rug that is excreted by the kid- lates to how the body changes the aspirin. This is important espe- ney and could produce toxic d r ug, pharmacodynamics refers to cially in cases of overdose of e ffects. Creatinine clearance is how a drug changes the body. these medications (Kee et al., used to evaluate renal function in Patients can respond very diff e r- 2 0 0 9 ) . milliliters per minute and can be ently to drugs. This can be shown The elimination half-life calculated by many equations, on a frequency distribution curv e , (t1/2) is a pharmacokinetic term the most common being the which is a graphic re p r e s e n t a t i o n that describes a dru g ’s duration of C o c k c r oft-Gault equation (see of patients’ response to a dru g action. Drugs may have a half-life F i g u re 1) (Wi n t e r, 2004). action at diff e rent doses and usu-

18 UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1 ally looks like a bell curve. The s a f e t y, and cost. A more potent es. For example, Bactrim® c o m- median effective dose (ED50) is d rug will produce an effect at a bines trimethoprim and sul- in the middle of the distribution lower dose. The efficacy is the famethoxazole. Together they c u r ve and reflects the dose magnitude of maximal re s p o n s e work better against bacteria than re q u i red to produce a specific that can be produced from a either one by itself. An antago- therapeutic response in 50% of d rug. If two drugs are compare d , nistic effect is caused when the patients. Studies from animal the drug with the highest maxi- adding a second drug results in a data provide information to mal response is more eff i c a c i o u s diminished response and can d e t e rmine the (Adams & Koch, 2010). Safety cancel out the effects of the first (LD50). Since the median lethal would be determined based on d rug. This effect is seen fre q u e n t- dose (LD50) cannot be deter- side effects or toxicity. Cost is an ly when a narcotic, such as mor- mined experimentally in i m p o rtant aspect; however, it is phine, is given, and the patient humans, a median toxicity dose not the only issue when compar- has re s p i r a t o r y depre s s i o n . (TD50) is of value for clinical ing medications in diff e re n t Naloxone (Narc a n ®) is given to practice. The TD50 is a dose that classes. antagonize or block the effects of will produce a given toxicity in D rugs produce their actions morphine, thereby restoring re s- 50% of the studied group and is by activating or inhibiting re c e p- pirations. Incompatibility usual- extrapolated from animal data tors. Several possibilities may ly involves parenteral drugs, and and adverse drug effects that are occur when a drug binds to a it occurs when two pare n t e r a l re c o rded during the clinical tri- re c e p t o r, which includes ago- d r ugs or solutions are mixed als. By using the median eff e c t i v e nists, partial , and antag- t o g e t h e r. The result is a chemical dose and the median lethal dose, onists. An agonist activates a or physical reaction. The combi- the therapeutic index can be receptor and produces the same nation of the two drugs usually d e t e rmined. With the therapeutic type of response as the endoge- forms a precipitate, haziness index, the higher the safety mar- nous substance. Compared with c o l o r, or a temperature change gin, the safer the drug. A dru g an agonist, a pro- occurs (Lilley et al., 2007) as in with a low therapeutic index is duces a weaker or less eff i c i e n t intravenous phenytoin (Dilantin®) associated with a narrow safety response. An antagonist com- and Dextrose 5% in Water (D5W). m a rgin, whereby a drug with a petes with agonists for re c e p t o r Phenytoin will usually pre c i p i t a t e high therapeutic index is associ- binding sites (Adams & Koch, out when mixed in D5W. ated with a large safety marg i n . 2 0 1 0 ) . T h e re f o re, if a small medication D rug interactions can occur C o n c l u s i o n e rror would occur, the conse- e v e ry day. Individual drugs may quences from the drug with a interact with other drugs, food, P h a rma cokinetics and phar- n a rrow safety margin could be or laboratory tests. The occur- macodynamics play a major ro l e toxic or lethal (Adams & Koch, rence of a drug interaction is in drug efficacy and safety. As 2 0 1 0 ) . m o re likely with polypharm a c y. each individual’s response to Plasma levels must be moni- D rug interactions can either d rug therapy may be diff e re n t , t o red in drugs that have narro w i n c rease or decrease the actions these two concepts can have a safety margins. The concentra- of one or both of the involved significant impact on patient out- tion is measured usually at two d rugs, which can either be bene- comes. Nurses and health care points by obtaining peak and ficial or harmful (Adams & Koch, p roviders should be aware of the t rough blood levels. The peak 2 0 1 0 ) . p h a rma cokinetic and pharm a c o- level is the highest plasma con- D rug interactions can be cat- dynamic pro p e rties of the dru g s centration at a specific time, egorized as additive, synerg i s t i c , they administer. Absorption, dis- w h e reas the trough level is the antagonistic, and incompatibili- tribution, metabolism, and elimi- lowest plasma concentration and t y. Additive effects can occur nation of drugs are all import a n t m e a s u res the rate at which the when two drugs with similar factors that define the body’s d r ug is excreted (Kee et al., actions are given together and a reactions to drugs once they 2009). An example is gentamicin, combined summation re s p o n s e enter the body and the impact of an aminoglycoside antibiotic that occurs (for example, a diure t i c the drug on the body itself. may be used to treat urinary tract and a beta blocker – each dru g Equally important is the mecha- infections or urosepsis. Obtaining d e c r eases blood pre s s u re, but nism by which the drug works, peak and trough levels are neces- t o g e t h e r, they decrease blood and the relationship between the sary to determine therap e u t i c p re s s u r e to a greater degre e ) . d r ug concentration and the response and prevent toxicity. S y n e rgistic effect is when the b o d y ’s response. Knowledge of T h e re are four ways to com- e ffect of two drugs is greater than side effects, adverse drug re a c- p a re medications within a thera- would be expected from adding tions, and monitoring parameters peutic class: , eff i c a c y, the two individual drug re s p o n s- for drugs being administered are

UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1 19 c rucial elements of the clinical D i c t i o n a ry.com. (2010c). G l o m e rular fil - a metabolic activation by the hepat- practice of nursing. These factors tration rate. Retrieved January 7, ic cytochrome P450-1A. T h ro m b o s i s 2010, from http://dictionary. re f e r- Haemostasis, 72(2), 313-317. can be used to ultimately help e n c e . c o m / b ro w s e / g l o m e ru l a rf i l t r a - Sloan, R.W. (1992). Principles of drug ther- assess the therapeutic outcome of t i o n r a t e apy in geriatric patients. A m e r i c a n d rug therapy. Utilization of these L i l l e y, L.L., Harrington, S., & Snyder, J.S. Family Physician, 45(6), 2709-2718. concepts can assist health care (2007). P h a rmacology and the nurs - Te rrie, Y.C. (2004). Understanding and p roviders meet the objective of ing process (5th ed.). St. Louis, MO: managing polypharmacy in the eld- M o s b y. e r l y. P h a rma cy Times, 12, 9094. d rug therapy, which is to pro v i d e Kee, J.L., Hayes, E.R., & McCuistion, L.E. Retrieved from http://www. p h a rm a- maximum benefits with minimal (2009). P h a r macology: A nursing c y t i m e s . c o m / i s s u e / p h a r m a - h a rm. p rocess appro a c h (6th ed.). St.Louis, cy/2004/2004-12/2004-12-9094 MO: Saunders Elsevier. Wi n t e r, M.E. (2004). Basic clinical phar - R e f e re n c e s Kirk, J.K. (1995). Significant dru g - n u t r i- m a c o k i n e t i c s , (4th ed.). Philadelphia: Adams, M.P., Holland, L.N., & Bostwick, ent interactions. American Family Lippincott, Williams & Wi l k i n s . P.M. (2008). P h a rmacology for nurs - Physician, 51(5), 1175-1182, 1185. Ya m r eudeewong, W., Henann, N.E., es: A pathophysiologic appro a c h Savi, P., Combalbert, J., Gaich, C., Fazio, A., Lower, D.L., & Cassidy (2nd ed.). Upper Saddle River. NJ: Rouchon, M.C., Maffrand, J.P. , T.G. (1995). Drug-food interactions P e a r s o n . B e rg e r, Y., & Herbert, J.M. (1994). in clinical practice. J o u r nal of Adams, M.P., & Koch, R.W. (2010). The antiaggregating activity is due to Family Practice, 40(4), 376-384. P h a rmacology connections to nurs - ing practice (1st ed.). Upper Saddle R i v e r, NJ: Pearson. Anastasio, G.D., Cornell, K.O., & Menscer U rologic Nursing Editorial Board Statements of Discl o s u r e D. (1997). Drug interactions: Keeping In accordance with ANCC-COA gove rning rules Urologic Nursing E d i t o rial Board state- it straight. American Family ments of disclosure are published with each CNE offe ri n g . The statements of disclosure fo r Physican, 56(3), 883-888,891-894. this offe ring are published below. D i c t i o n a ry.com. (2010a). Agonist. R e t r i e v e d K aye K. G a i n e s , M S , A R N P, C U N P, disclosed that she is on the Speake r s ’ Bureau fo r J a n u a ry 7, 2010, from http:// P f i ze r, Inc., and Nova r tis Oncology. d i c t i o n a r y. r e f e r e n c e . c o m / b r o w s e / a g o n i s t Susanne A. Q u a l l i ch , A N P - B C , N P - C , C U N P, disclosed that she is on the Consultants’ Dictionary.com. (2010b). Antagonist. Bureau for Coloplast. Retrieved January 7, 2010, from h t t p : / /d i c t i o n a ry. re f e re n c e . c o m / b ro All other U rologic Nurs i n g E d i t o r ial Board members reported no actual or potential con- w s e / a n t a g o n i s t flict of interest in relation to this continuing nursing education art i c l e.

20 UROLOGIC NURSING / January-February 2010 / Volume 30 Number 1