PHARMACY TECHNICIAN CHAPTER TWENTY THREE 1 Amino Acids • The body can produce 11 types of amino acids, referred to as nonessential • There are 9 types of amino acids that the body requires, but cannot produce – These are referred to as essential amino acids (See table 23.9) • Essential amino acids have to be derived from food intake 2 Vitamin A (Retinol) • Helps with eyesight and epithelial cells and tissues (skin cells) • Deficiencies in vitamin A may cause: – Night blindness – Xerosis (dryness) of the conjunctiva and cornea – Xerophthalmia and keratomalacia – Keratinization of lung, GI tract, and urinary tract – Increased susceptibility to infections • DRI is 900 µg/day for males and 700 µg/day for females 3 Vitamin D • Helps with the absorption of calcium from the intestine to make stronger bones and teeth • Deficiency causes metabolic bone softening: – Called rickets in children – Called osteomalacia in adults • DRI is 5 µg/day (ages 19–50) for both males and females • DRI is 10 µg/day (ages 51–70) for both males and females 4 Vitamin E • A strong antioxidant for lipids • Deficiency is generally caused by malabsorption rather than lack of ingestion • Vitamin E deficiency may cause: – Disorders of the reproductive system – Abnormalities of muscle, liver, and bone marrow – Hemolysis of RBCs – Defective embryo genesis – Brain dysfunction – A disorder of capillary permeability • DRI is 15 mg/day for both males and females 5 Vitamin K • Necessary for blood coagulation • Controls formation of coagulation factors II, VII, IX, and X in the liver • Also needed for calcium uptake in bones • Can be used as an antidote for coumadin overdoses • Deficiency is rare • DRI is 120 µg/day for males and 90 µg/day for females 6 Vitamin B1 (thiamine) • Necessary for carbohydrate metabolism • Deficiency causes the disease beriberi – Affects the peripheral neurologic, cerebral, cardiovascular, and GI systems • DRI is 1.2 mg/day for males and 1.1 mg/day for females 7 Vitamin B2 (riboflavin) • Necessary for the health of the mucous membranes in the digestive tract • Aids absorption of iron and vitamin B6 • Deficiency leads to: – – – – Oral, eye, skin, and genital lesions Hair loss Light sensitivity Retarded growth responses – Burning feet - Dizziness - Insomnia - Poor digestion - Slow mental 8 Vitamin B3 (niacin) • Important in oxidation-reduction reactions • Vital in protein metabolism • Deficiency leads to the disease pellagra: – Affects skin, mucous membranes, GI, and brain/CNS systems – Causes photosensitive rash, scarlet stomatitis, glossitis, diarrhea, and mental aberrations • Deficiency found in diets high in corn • DRI is 16 mg/day for males and 14 mg/day for females 9 Vitamin B5 (pantothenic acid) • Important for secretion of hormones such as cortisone • Important for maintenance of healthy skin, muscles, and nerves • B5 deficiency extremely rare • Symptoms of B5 deficiency include: – – – – – Insomnia Depression Nausea Headache Muscle spasm 10 Vitamin B6 (pyridoxine) • Needed for: – Red blood cell formation - Antibody production – Cell respiration - Cell growth – Conversion of tryptophan to niacin – Helps convert stored carbohydrate to glucose to maintain normal blood sugar levels – Synthesis of neurotransmitters such as serotonin and dopamine • Deficiency can cause: – – – – Anemia similar to iron-deficiency anemia Decreased antibody production Suppressed immune response Symptoms such as dermatitis, a sore tongue, depression, confusion, and convulsions 11 Vitamin B9 (folic acid) • Important for: – – – – – Energy production -Formation of red blood cells Strengthening immune system Promoting healthy cell division and replication Protein metabolism Preventing depression and anxiety • Deficiency can be serious and may result in: – – – – – Anemia Digestive disturbances Growth impairment Labored breathing Paranoia - Apathy - Fatigue - Insomnia - Memory problems - Weakness 12 Vitamin B12 (cyanocobalamin) • Needed for healthy nerve cells, to make DNA, and for the formation of RBCs • Deficiency leads to irreversible nerve damage • Signs and symptoms include: – Fatigue - weakness – Nausea - constipation – Flatulence - loss of appetite – weight loss - depression – Confusion - poor memory 13 Vitamin C (ascorbic acid) • • • • • • Antioxidant Essential for collagen formation Maintains integrity of connective tissue, bone, and teeth Important for wound healing and recovery from burns Helps the absorption of iron Severe deficiency results in scurvy: – Characterized by general weakness, bleeding gums, anemia, and skin bleeding • The DRI is 90 mg/day for males and 75 mg/day for females 14 Water • 60% of an adult’s body weight is water • Forms a major portion of every tissue • Provides the medium in which most of the body’s activities are conducted • Facilitates many of the metabolic reactions that occur in the body • Helps transport vital materials to the cells • Vehicle in which glycogen is transported into muscle cells 15 PHARMACY TECHNICIAN CHAPTER TWENTY FOUR 16 Bone • Composed of two different kinds of bony tissue – Cancellous or “spongy” bone—porous, inner bone that provides volume – Compact bone—hard, outer covering that provides strength and shape • The rounded end of a bone is covered with smooth, slippery articular cartilage • Many bones are hollow, and contain marrow: – Red marrow in children – Fatty yellow marrow in adults 17 Bone and Muscle 18 Types of Muscle • Skeletal muscles—attached to bones; provide body movement – Voluntary, striated in shape, contain multiple peripheral nuclei • Cardiac muscle—tissue that composes the heart – Contracts rhythmically, coordinated by transmission of electrical impulses from nerve to muscle fibers Smooth or “visceral” muscle—attached to or lines other organs such as the stomach, intestines, lungs, and blood vessels 19 Five Categories of Bone: • Flat bones—generally more flat than round • Irregular bones—have no defined shape • Sesamoid bones—have cartilage or fibrous tissue mixed in • Short bones—generally cube-shaped • Long bones—the most common bone • Epiphysis (the rounded end of the bone) • Diaphysis (the main shaft or central part of the bone) 20 Disorders of the Bone Osteomyelitis • Bacterial Infection Inside the Bone Destroys bone tissue • Original site of infection is frequently in another part of body • Infection spreads to the bone via the blood Osteoporosis—bone brittleness due to lack of calcium • Prevalent in postmenopausal women because of estrogen deficiency Paget’s disease—changes the normal process of bone growth • Causes bone to break down more quickly and grow back softer than normal bone 21 Musculoskeletal Diseases/Disorders • Bursitis—inflammation of the small, fluid-filled pouches between bones • Tendonitis—inflammation of the cords of connective tissue that attach muscle to bone • Myalgia—muscle pain 22 Bone Marrow Disorders (cont.) • Anemia—failure of the bone marrow to produce red blood cells – Most common cause is lack of iron – Lack of red blood cells leads to a systemic decrease in oxygen – Causes fatigue • Leukemia—blood-borne cancer; cancer of the blood – Begins when DNA of white blood cells is damaged or mutated – Damaged DNA is copied and passed on to subsequent generations of cells – Abnormal, cancerous cells do not die off like normal cells – Multiply unchecked within the body 23 Arthritis—Inflammation of a Joint • Rheumatoid—an autoimmune disorder • Osteoarthritis—caused by physical degeneration of connective tissue • Gout—caused by crystals of uric acid in blood 24 Treatments Osteomyelitis • Anti-infective agent is best treatment for osteomyelitis Osteoporosis • Vitamin D and mineral calcium replacement therapy • Hormone therapy (estrogen, calcitonin) and bisphosphonates • SERMs for postmenopausal women • Gold compounds used to treat osteoarthritis 25 Treatments Gout • Colchicine used to alter ability of phagocytes to attack uric acid crystals • Anti-inflammatory analgesics can be used to reduce pain and inflammation Inflammation • Salicylates relieve inflammation by inhibiting the synthesis of prostaglandin • Topical corticosteroids treat most causes, including chemical, mechanical, microbiological, and immunological 26 Treatments Multiple Sclerosis • Autoimmune disease in which body’s immune system begins to attack normal body tissue • Treatment of MS includes steroidal antiinflammatory agents and corticosteroids Cerebral Palsy • Affected person has poor control of the brain, muscles, and joints • Pharmaceutical therapy includes drugs to prevent seizures and spasticity 27 Musculoskeletal Pharmaceuticals • ASA (acetylsalicylic acid) – Relieves inflammation by inhibiting the synthesis of prostaglandin – Salicylates are also used as analgesics and antipyretics • NSAIDs (nonsteroidal anti-inflammatory drugs) – Inhibit or block the enzyme that starts the reaction of inflammation by making prostaglandin • COX-2 inhibitors – Block 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 28 Musculoskeletal Pharmaceuticals (cont.) • Antigout agents—may be hypouricemic agents or uricosuric agents – Hypouricemic agents decrease production of uric acid in the blood – Uricosuric agents increase the excretion of uric acid through urination • Calcitonin—indicated for fragile or soft bones – Inhibits bone resorption – Decreases the number of bone fractures from low bone density 29 Musculoskeletal Pharmaceuticals • Bisphosphonates—indicated for osteoporosis – Mimic the natural organic bisphosphonate salts found in the body – Inhibit bone resorption and osteoclast activity – Restore bone mass and density • SERMs (selective estrogen receptor modulators) – Indicated for postmenopausal women – Protective effect on bones and heart • Skeletal muscle relaxants—used to relax specific muscles in the body – Relieve pain, stiffness, and discomfort – Block muscle contraction at the neuromuscular junctio 30 PHARMACY TECHNICIAN CHAPTER TWENTY FIVE 31 The Respiratory System • Divided into the upper respiratory tract and the lower respiratory tract • The upper respiratory tract consists of: – Nose or nasal cavity – Paranasal sinuses – Pharynx and larynx 32 The Respiratory System (cont.) • The lower respiratory tract consists of: – Trachea – Two lungs – Two main bronchi 33 The lower respiratory tract. 34 Respiration • Diaphragm—dome-shaped layer of muscle that lies across bottom of chest cavity • Breathing occurs as diaphragm contracts and relaxes • Carbon dioxide pushed out of the lungs during relaxation • Oxygen pulled into the lungs during contraction 35 Structure of Lungs • About 10 percent solid tissue • Remainder of structure filled with air and blood • The functional structure can be divided into two parts: – Conducting airways (bronchi and bronchioles)— tubes lined by cilia and respiratory mucosa – Cartilage—supports and cushions the bronchi 36 Common Cold • Caused by a viral infection that inflames the membranes in nose and throat • Antibiotics will not cure a cold or any other viral infection • Treatment is considered symptomatic Cough • May be a symptom of a cold, flu, respiratory problems, or nonrespiratory diseases • Most likely begins with an irritation of nerves in the respiratory tract • Nonproductive cough treated with cough suppressant • Productive cough treated with an expectorant 37 Allergies and Asthma Allergies • Caused by the immune system reacting to a substance that does not cause disease • Treatment may be palliative, with antihistamines and antitussives • Treatment may be preventive, with mast cell stabilizers Asthma • Chronic respiratory disease • Characterized by inflammation of airways, tightening of muscles around airways • Treatment is palliative with albuterol and other bronchodilators 38 Emphysema • Chronic destruction of alveoli • External exchange interrupted when alveoli become permanently damaged • Treatment may be palliative, with stimulant inhalers • Treatment may be preventive, with antiinflammatory corticosteroids 39 Nasal Congestion and Rhinitis Nasal Congestion • Inflamed, stuffy nose • Treatment may be palliative, to promote easier breathing • Indications for use of decongestants are nasal and bronchial congestion Rhinitis • Inflammation of nasal membranes, and/or runny nose • Common component of colds and allergies • Treatment is considered symptomatic 40 Bronchoconstriction • Occurs when the smooth muscles encircling the airways or tubes tighten, causing the airways to spasm • Treatment may be palliative • Treatment may be preventive 41 Chronic Obstructive Pulmonary Disease (COPD) • Umbrella term for emphysema and chronic bronchitis • Characterized by partially blocked bronchi and bronchioles • Causes shortness of breath • Treatment may be palliative, with bronchodilators • Treatment may be preventive, with mast cell stabilizers 42 PHARMACY TECHNICIAN CHAPTER TWENTY SIX 43 The heart. 44 Anatomy of the Heart • Composed of four chambers: two upper and two lower • Atria—top two chambers • Ventricles—bottom two chambers • Septum—divides heart into right and left sides 45 Valves of the Heart • Tricuspid valve—located between the right atrium and the right ventricle • Pulmonary valve—located between the right ventricle and the pulmonary artery • Mitral or bicuspid valve—located between the left atrium and the left ventricle • Aortic valve—located between the left ventricle and the aorta 46 Layers of the Heart • Pericardium—fluid-filled sac that surrounds and protects the heart – Permits free movement of the heart during contraction • Endocardium—innermost wall layer; covers the inside surface of the heart • Myocardium—surrounds heart and causes chamber contractions 47 Function of the Heart • Provides oxygenated blood throughout the body by a pumping mechanism • Oxygenated blood deposits materials necessary for growth and nourishment • Receives from tissues the waste products resulting from metabolism 48 Hypertension • Sustained elevation of systemic arterial blood pressure • Symptoms include: – Severe headache – Chest pain – Irregular heartbeat – Fatigue • Pharmaceutical treatment includes diuretics, vasodilators, ACE inhibitors, beta blockers, and calcium channel blockers 49 Congestive Heart Failure • Heart pumps out less blood than it receives • Results in weakened and enlarged heart • Symptoms of CHF include: – – – – – – – Upright posture or leaning forward Anxiety and restlessness Cyanotic and clammy skin Persistent cough Rapid breathing Fast heart rate Edema of the lower limbs • Pharmaceutical treatment includes cardiac glycosides, diuretics, vasodilators, ACE inhibitors, beta-adrenergic blockers, and phosphodiesterase inhibitors 50 Coronary Artery Disease • Occurs when there is insufficient blood flow to the heart • Can lead to: – Angina – Heart attack – Arrythmias – Stroke – Pulmonary embolism – Heart failure • Pharmaceutical treatment includes platelet aggregation inhibitors, anticoagulants, tissue plasminogen activators, and thrombin inhibitors 51 Cardiovascular Pharmaceuticals • Antiarrhythmic drugs—restore normal rhythm patterns but do not cure the cause of the irregular heartbeat • Cardiac glycosides—used to increase the force of myocardial contraction, without causing an increase in the consumption of oxygen • Diuretics—used to eliminate excess sodium and water via the urinary tract • Vasodilators—allow more blood to exit the heart, preventing or mitigating congestion; lower blood pressure 52 Cardiovascular Pharmaceuticals (cont.) • Angiotensin-converting enzyme inhibitors (ACE inhibitors)—lower high blood pressure; thought to reshape the heart; prevent the body from producing natural vasodilators • Angiotensin II receptor blockers—similar to ACE inhibitors; block the body’s natural vasodilators • Beta-adrenergic blockers—used to block cells from receiving natural vasoconstrictors • Antiadrenergic agents—interfere with the manufacture of vasoconstrictors at nerve endings • Platelet aggregation inhibitors—reduce the ability of the blood to coagulate 53 Cardiovascular Pharmaceuticals (cont.) • Anticoagulants—prevent clots from forming or existing clots from getting bigger • Tissue plasminogen activators—break down blood clots by reversing the clotting order and interfering with the synthesis of various clotting factors • Thrombin inhibitors—inactivate bound thrombin by binding to the enzyme and blocking its interaction with its substrates of fibrin • Antihyperlipidemics—help prevent the progression of coronary artery disease by lowering plasma lipid levels 54 Anticoagulants • • • • Do not thin out the blood Prevent clots from forming Prevent existing clots from getting bigger Cannot dissolve existing blood clots 55 Warfarin • Oral drug of choice • Works by preventing the synthesis of clotting factors II, VII, IX, and X • Used in the long-term prevention or management of venous thromboembolic disorders, including: – Deep vein thrombosis – Pulmonary embolism – Clotting associated with atrial fibrillation and prosthetic heart valves • Vitamin K may be used as an antidote when too much warfarin has been given 56 Heparin • Parenterally administered drug of choice • Works by inactivating clotting factors IX, X, XI, and XII • Used prophylactically to: – Prevent and treat deep vein thrombosis – Prevent and treat pulmonary embolism – Treat thrombophlebitis – Prevent clotting during cardiac and vascular surgery • The only antidote for heparin overdose is protamine sulfate 57 Cholesterol and Triglycerides • HDL—high-density lipoproteins or “good” cholesterol • LDL—low-density lipoproteins or “bad” cholesterol • Triglycerides—a form of energy stored in adipose and muscle tissues – Often measured to depict fat ingestion and metabolism – Can be used to assess CAD risk factors 58 Lymphatic System • Complex system of lymph organs, nodes, ducts, tissues, vessels, and capillaries • Transports lymph fluid to the circulatory system • Cardiovascular and lymphatic systems work in tandem – Joined by a capillary system through which lymph and blood move 59 Lymphatic System (cont.) • Lymphatic system supports the immune system by: – Filtering out organisms that cause disease – Producing specific white blood cells – Manufacturing antibodies – Distributing fluids and nutrients throughout the body – Draining excess fluids and protein so that tissues do not swell or become inflamed 60 PHARMACY TECHNICIAN CHAPTER TWENTY SEVEN 61 Nonspecific Defenses • Considered a “first line of defense” against disease and infection • Nonspecific defense mechanisms include: – Physical barriers (unbroken skin) – Natural deterrents (fluids and immune cells that attack invaders) – Inflammatory process 62 Specific Defenses • Specific defense mechanisms are called the immune system • Immune system has specialized molecules and cells that fight foreign invaders • Immune system molecules consist of two types of protein molecules: – Antibodies—identify foreign particles – Complement—destroys foreign particles 63 Parasites • Multicellular organisms or single-celled organisms that are not bacteria or fungi • Asymmetrical symbiotic relationship: – Parasite benefits from host – Host receives no benefit from or is harmed by relationship • Most common parasites in the United States are: – Pinworms – Roundworms – Tapeworms • Transmission usually occurs via ingestion of contaminated food or soil 64 Bacteria and Virus Bacteria • Unicellular, prokaryotic microorganisms • May be round (coccus/cocci), rod (bacillus/bacilli), or spiralshaped • May cause disease; may also have beneficial relationships (E. coli, etc.) Virus • • • • Ultramicroscopic infectious pathogen Can replicate itself only within cells of a living host Uses the DNA and RNA of the host Antibiotics are ineffective against viruses 65 HIV (Human Immunodeficiency Virus) • Can be categorized as either HIV-1 or HIV-2 • Most references to HIV refer to HIV-1, the most common worldwide • Both types are transmitted: – By sexual contact – Through bodily fluids – At birth from mother to child • Both types of HIV cause clinically indistinguishable AIDS – Acquired immune deficiency syndrome – Immune system becomes severely suppressed – Body cannot fight opportunistic infections or cancers 66 Five Stages of HIV Progression to AIDS • Stage 1—initial transmission and infection with HIV • Stage 2—infected without presentation of signs or symptoms (10 or more years) • Stage 3—signs and symptoms of HIV begin to appear • Stage 4—AIDS opportunistic infections lead to a CD4 cell count or level below 200 per cubic millimeter of blood • Stage 5—last and final stage of wasting to death 67 Classes of HIV Drugs • Vaccine – Not yet developed – Would enable immune system to destroy HIV before infection occurs • Attachment inhibitors – Not yet developed – Would prevent HIV from attaching to host cells • Inhibitors – Block the synthesis of copies of the viral RNA – Virus cannot duplicate itself 68 Autoimmune Disease • Occurs when immune system mistakenly attacks the cells, tissues, and organs of its own body • Immune system cells and molecules accumulate at a target site – This gathering is broadly referred to as inflammation • Autoimmune diseases are not contagious and are not related to AIDS or cancer 69 Drug Resistance • Defined as a microorganism’s ability to live and grow in the presence of an anti-infective or antimicrobial drug • Is a result of genetic mutation during cell division • Allows the pathogen to evade or avoid the destructive mechanism of a drug • Bacteria are especially prone to develop drug resistance • The increasing use of antibiotics contributes to this action and is called antibiotic resistance 70 Preventing Antibiotic Resistance • • • • • Avoid unnecessary antibiotic use in humans Avoid unnecessary antibiotic use in animals Use most specific antibiotic possible Complete an antibiotic regimen (no leftover pills) There may be no ultimate cure for antibiotic resistance • However, development of resistance can be slowed down 71 Anti-Infectives • Umbrella name under which various types of drugs are then subclassified • Also called antimicrobial—against the growth of a microorganism or microbe – Antibacterials—treat bacteria only – Antivirals—treat viruses only – Antifungals—treat fungi only – Metronidazole—amoebicidal, bactericidal, and trichomonacidal 72 Tuberculosis • Caused by Mycobacterium tuberculosis bacterium • May attack any part of the body, but usually attacks the lungs • Spread by breathing air into which infected people have coughed or sneezed • Drug of choice for treatment is isoniazid (INH) – Taken for at least six to nine months – Longer if the patient has a weakened immune system 73 Malaria • Transmitted by parasites found in malaria-infected mosquitoes • Can be cured with prescription drugs • Type of drug used and duration of treatment depend on: – – – – Which type of malaria is diagnosed Where the patient was infected Age of the patient Orogression of the disease at the start of treatment 74 PHARMACY TECHNICIAN CHAPTER TWENTY EIGHT 75 The renal system. 76 The Renal System • Composed of two kidneys, two ureters, one bladder, and the urethra • Filtering system of the kidneys is composed of millions of nephrons • Waste from food and drug metabolization is filtered through the nephrons • Wastes exit the kidneys as urine via the ureters • Ureters lead to the bladder, where urine is stored until released • The kidneys are located in the posterior abdomen just above the waist 77 Nephron • Smallest, most basic part of the kidney • Filters the blood that passes through the kidneys • Produces urine through the processes of filtration, reabsorption, and secretion • Enables blood to reabsorb water, electrolytes, and nutrients 78 Kidney and Bladder Kidney • Built almost entirely of nephrons • Organ that filters blood and produces urine • Urine produced by the kidneys is conducted to the bladder Bladder • Organ used for waste storage • Can collect approximately 350 mL to 500mL of urine • Allows for discretionary voiding 79 Urinary Incontinence • Inability of the body to hold urine • Treatment will depend on the cause • Medications tend to increase the contraction of the urethral sphincter muscle • Treatment tends to be more successful in patients with mild to moderate stress incontinence • Estrogen replacement therapy can be used to decrease urinary frequency, urgency, and burning in postmenopausal women 80 Urinary Retention • Inability to urinate • Bladder is not able to release the urine even though the urge may exist • Treated with insertion of a Foley catheter • Antibiotics may be used to avoid or treat urinary tract infection 81 Urinary Tract Infections • Bacterial infections of the urinary system • Symptoms include: – Frequent urge to void – Burning sensation when voiding – Cloudy or strong-smelling urine – Blood in the urine 82 Treating UTIs • Cranberry juice: – A substance in cranberry juice keeps infectioncausing bacteria from attaching to the walls of the urethra – Also makes the urine more acidic • Anti-infectives – Destroy or inhibit bacterial growth • Phenazopyridine (200 mg tid pc) – Can be used to manage the symptoms of a burning and itching urethra 83 Kidney Stones • Common and painful urinary tract disorder • Solid mineral deposits accumulate in the urinary tract • Treatment is palliative, with pain management – Oral analgesics for mild to moderate pain may be used • Treatment is preventative, with diet – Mineral and vitamin supplements – Increased fluid intake 84 Edema and Hypertension • Consistently elevated blood pressure levels – Lead to damage of the kidney arteries • Treatment is with diuretics – Reduce high blood pressure 85 Diabetes Mellitus • Can cause diabetic kidney disease (diabetic nephropathy) – Leads to end-stage renal disease • ESRD requires dialysis or a kidney transplant 86 Homeostasis • Means “balance” or “equilibrium” • Water follows a high concentration of minerals and ions • The kidneys help with homeostasis by eliminating some ions and returning others to the blood • Keeps the blood at a proper pH level 87