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Netter s Illustrated Pharmacology 2 Pap/Psc Edition
Robert B. Raffa Digital Instant Download
Author(s): Robert B. Raffa, Scott M. Rawls, Elena Portyansky Beyzarov
ISBN(s): 9780323220910, 0323220916
Edition: 2 Pap/Psc
File Details: PDF, 182.52 MB
Year: 2013
Language: english
Netter’s Illustrated
Pharmacology
UPDATED EDITION

Robert B. Raffa, PhD

Scott M. Rawls, PhD
Temple University School of Pharmacy
Philadelphia, Pennsylvania

Elena Portyansky Beyzarov, PharmD

Director of Scientific Affairs
Pharmacy Times
Plainsboro, NJ

Illustrations by Frank H. Netter, MD

Contributing Illustrators
James A. Perkins, MS, MFA
John A. Craig, MD
Carlos A. G. Machado, MD
Dragonfly Media Group
Elsevier Inc.
1600 John F. Kennedy Boulevard
Suite 1800
Philadelphia, PA 19103-2899

NETTER’S ILLUSTRATED PHARMACOLOGY ISBN: 978-0-323-22091-0

Updated Edition

Copyright © 2014, 2005 by Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or an information storage and retrieval system,
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This book and the individual permissions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Permission for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing
Department in Philadelphia, PA: phone 800-523-1649, ext. 3276, or 215-239-3276; or email
[email protected].

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products lia-
bility, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.

ISBN: 978-0-323-22091-0

Content Strategist: Elyse O’Grady

Content Development Manager: Marybeth Thiel
Publishing Services Manager: Patricia Tannian
Project Manager: Carrie Stetz

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 DEDICATION

To my family; to Temple University School of Pharmacy;

and to Dr. Ronald J. Tallarida, mentor and friend.

Robert B. Raffa

To my mother, whose support, love, dedication, and

sacrifices over the years have made this book possible,
and to my readers, whose thanks and suggestions for
improvement are appreciated.

Scott M. Rawls

To my parents, who gave me their spirit,

encouragement, and guidance when I needed it most
and who convinced me that pharmacy is a far better
career choice than aerospace engineering. To my
husband and daughter, for their infinite patience and
support while I barricaded myself with books and a
computer.

Elena Portyansky Beyzarov

v
This page intentionally left blank
PREFACE
Nothing enhances the efficient learning of scien- better starting point for this task than the
tific material more than good artwork. Personal renowned work of physician-artist Frank H. Net-
teaching experience has shown us the power of ter, MD, whose illustrations have educated gen-
visual learning in the classroom and the positive erations of students. Having access to the Netter
effect it has on students. A well-done, accurate, collection of illustrations was a rare opportunity
and eye-catching illustration captures one’s to approach the subject of pharmacology visu-
attention and stimulates one’s imagination. Visu- ally. To provide illustrations of more recently
alization of a concept enhances and solidifies discovered concepts, we called upon James A.
one’s understanding and internalization of it, Perkins, MS, MFA, and other talented artists to
and a good illustration becomes the template create dynamic new illustrations of the detailed
upon which future learning can be superim- molecular events that underlie drug action. The
posed. We were thus excited when we were translation by these artists of recent complex
approached with the idea of publishing a visual research findings into clear, precise, and engag-
pharmacology book. That is the intent of this ing artwork was a pleasure to observe and is a
book—to provide high-quality illustrative aids highlight of this book.
that will enhance the learning of the basic prin- Three authors with different but complemen-
ciples of pharmacology and present them in a tary backgrounds and expertise jointly wrote this
manner that is both scientifically rigorous and book. Our collaboration was intended to pro-
enjoyable. It is designed for the visual learner vide the most authoritative and broadest possible
in all of us. coverage of both the basic science and the clini-
But can there be illustrations of pharmacol- cal applications of pharmacology.
ogy? Isn’t the study of pharmacology the memo- We have written this book with medical, phar-
rization of innumerable drugs, their trade names, macy, dental, nursing, and other professional
their doses, and other nonvisual material? students in mind, hoping that it will serve as a
Hardly. Just as all other basic sciences have valuable adjunct to their more comprehensive
their practical side, pharmacology has its appli- textbooks. Each of us has found the illustrations
cation in the use of drugs for treatment of dis- to be useful in our own learning or teaching of
eases and disorders. But in the past couple of the material. However, this book was also
years, there has been a virtual explosion in designed to be a stand-alone, discussing phar-
understanding of the biologic features and macologic principles in a manner that allows a
events that underlie the therapeutic action of a great deal of material to be covered in a concise
drug. It is now possible, with the creative input fashion. It is thus also appropriate for use in an
and insight of an artist’s eye, to visualize the introductory course for undergraduate students
anatomical, physiologic, biochemical, and or even for the interested general reader. We
molecular underpinnings of pharmacology. This sincerely hope that all find the book useful and
exciting new aspect of pharmacology is the the presentation enjoyable.
focus of this book.
We believe that this is the first book to place Robert B. Raffa, PhD
such emphasis on artwork for the explanation of Scott M. Rawls, PhD
pharmacologic principles. There is, of course, no Elena Portyansky Beyzarov, PharmD

vii
This page intentionally left blank
ABOUT THE AUTHORS
Frank H. Netter, MD, was born in 1906, in New choice among medical and health professions
York City. He studied art at the Art Student’s students the world over.
League and the National Academy of Design The Netter illustrations are appreciated not only
before entering medical school at New York Uni- for their aesthetic qualities, but, more importantly,
versity, where he received his MD degree in for their intellectual content. As Dr. Netter wrote
1931. During his student years, Dr. Netter’s note- in 1949, “.  .  .  clarification of a subject is the aim
book sketches attracted the attention of the medi- and goal of illustration. No matter how beautifully
cal faculty and other physicians, allowing him to painted, how delicately and subtly rendered a
augment his income by illustrating articles and subject may be, it is of little value as a medical
textbooks. He continued illustrating as a sideline illustration if it does not serve to make clear some
after establishing a surgical practice in 1933, but medical point.” Dr. Netter’s planning, concep-
he ultimately opted to give up his practice in tion, point of view, and approach are what inform
favor of a full-time commitment to art. After ser- his paintings and what makes them so intellectu-
vice in the United States Army during World War ally valuable.
II, Dr. Netter began his long collaboration with Frank H. Netter, MD, physician and artist, died
the CIBA Pharmaceutical Company (now Novartis in 1991.
Pharmaceuticals). This 45-year partnership Learn more about the physician-artist whose
resulted in the production of the extraordinary work has inspired the Netter Reference collection:
collection of medical art so familiar to physicians http://www.netterimages.com/artist/netter.htm
and other medical professionals worldwide.
In 2005, Elsevier, Inc. purchased the Netter Carlos Machado, MD, was chosen by Novartis to
Collection and all publications from Icon be Dr. Netter’s successor. He continues to be the
Learning Systems. There are now over 50 main artist who contributes to the Netter collec-
publications featuring the art of Dr. Netter tion of medical illustrations.
available through Elsevier, Inc. (in the US: Self-taught in medical illustration, cardiologist
www.us.elsevierhealth.com/Netter and outside Carlos Machado has contributed meticulous
the US: www.elsevierhealth.com) updates to some of Dr. Netter’s original plates
Dr. Netter’s works are among the finest exam- and has created many paintings of his own in the
ples of the use of illustration in the teaching of style of Netter as an extension of the Netter col-
medical concepts. The 13-book Netter Collection lection. Dr. Machado’s photorealistic expertise
of Medical Illustrations, which includes the and his keen insight into the physician/patient
greater part of the more than 20,000 paintings relationship informs his vivid and unforgettable
created by Dr. Netter, became and remains one visual style. His dedication to researching each
of the most famous medical works ever pub- topic and subject he paints places him among the
lished. The Netter Atlas of Human Anatomy, first premier medical illustrators at work today.
published in 1989, presents the anatomical paint- Learn more about his background and see
ings from the Netter Collection. Now translated more of his art at: http://www.netterimages.com/
into 16 languages, it is the anatomy atlas of artist/machado.htm

ix
This page intentionally left blank
ABOUT THE AUTHORS
Robert B. Raffa, PhD, is Professor of Pharmacol- Washington College in Maryland, where he was
ogy at Temple University School of Pharmacy the recipient of an undergraduate distinguished
and Research Professor at Temple University teaching award. Dr. Rawls joined the faculty at
School of Medicine in Philadelphia. He has Temple University School of Pharmacy in the
earned bachelor’s degrees in Chemical Engineer- fall of 2004, where he currently teaches in the
ing and Physiological Psychology, master’s Pharmacology, Biochemistry, and Anatomy and
degrees in Biomedical Engineering and Toxicol- Physiology courses. Dr. Rawls investigates the
ogy, and a PhD in Pharmacology. Dr. Raffa has effects of cannabinoid, vanilloid, and opioid sys-
published more than 150 research articles in ref- tems on brain neurotransmitter levels in rats and
ereed journals and more than 70 abstracts and the role these interactions play in thermoregula-
symposia presentations. He is an associate editor tion and drug abuse.
of the Journal of Pharmacology and Experimental
Therapeutics and is founder and editor of the Elena Portyansky Beyzarov, PharmD, is a clini-
journal Reviews in Analgesia. Dr. Raffa is a past cal pharmacist at Newark Beth Israel Medical
president of the Mid-Atlantic Pharmacology Center. Dr. Beyzarov received her BS degree in
Society, the recipient of the Hofmann Research pharmacy in 1996 from Arnold and Marie
Award, the Lindback teaching award, and other Schwartz College of Pharmacy and Health Sci-
honors. He maintains an active research effort ences at Long Island University and received her
and teaching load. He is author of Quick-Look PharmD in 1999 from the College of Pharmacy
Review of Pharmacology; coauthor of Principles at the University of Arkansas for Medical Sci-
in General Pharmacology; editor of Antisense ences. Dr. Beyzarov’s career began in medical
Strategies for the Study of Receptor Mechanisms publishing, where she authored hundreds of
and Drug-Receptor Thermodynamics: Introduc- clinical articles for Drug Topics magazine on a
tion and Applications; and is a contributor to broad range of pharmacotherapeutic subjects. In
Pain: Current Understanding, Emerging Thera- 2002, she held an academic appointment as
pies, and Novel Approaches to Drug Discovery, adjunct associate professor of pharmacology in
Molecular Recognition in Protein-Ligand Interac- the Department of Professional Nursing at Feli-
tions, and Remington: the Science and Practice cian College. After deciding to become more
of Pharmacy. involved in clinical practice, Dr. Beyzarov
joined Newark Beth Israel Medical Center in
Scott M. Rawls, PhD, is Assistant Professor of 2003 as a clinical pharmacist. Her major activi-
Pharmacodynamics in the Department of Phar- ties include performing daily clinical interven-
maceutical Sciences at Temple University tions based on review of patient charts and
School of Pharmacy. Dr. Rawls received his PhD physician orders and providing drug information
(1999) from East Carolina University School of to staff pharmacists, physicians, and nurses. She
Medicine in neuroscience. He completed 2 also attends daily medical rounds, conducts drug
years of postdoctoral training in the Department utilization studies, and presents lectures to other
of Pharmacology at Temple University. In 2003, health care professionals on pharmacologic
Dr. Rawls was Assistant Professor of Biology at management of various disease states.

xi
ACKNOWLEDGMENTS
This book was a team effort from beginning to He and the other talented artists created illustra-
end. The idea for the book originated at Icon tions that capture not only the visual aspect of
Learning Systems and was developed in a the topic, but also its educational essence. It is
meeting with Paul Kelly, Executive Editor. anticipated that class after class of students will
The access to Netter art made the proposal remember this artwork when they think of phar-
irresistible. macologic principles.
It is fair to say that the project might not have Jennifer Surich, Managing Editor, did a yeo-
been completed without the help of Judith B. man’s job in keeping things going and made
Gandy, who, with skilled questioning and sure that this project was actually accomplished.
patience, transformed our rough early drafts into Thanks also go to Greg Otis, Nicole Zimmer-
what we were truly trying to say. man, and all of the others at Icon who converted
We knew that this book was going to attain its an idea into reality.
goal when we began to work with James A. Per- Thanks also to the staff at Elsevier for provid-
kins, MS, MFA. We had seen his artwork in pre- ing us an opportunity to update the text and add
vious publications, so his artistic talents were Student Consult access.
known, but the pleasant interactions and his
contributions to the subject matter were an Robert B. Raffa, PhD
unexpected bonus. The arrival of each new Scott M. Rawls, PhD
illustration was something looked forward to. Elena Portyansky Beyzarov, PharmD

xii
CONTENTS
CHAPTER 1. BASIC PRINCIPLES OF PHARMACOLOGY
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Major Ways in Which Drugs Work
External and Internal Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Endogenous Chemical Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Modulate Physiologic Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chemical Communication
Chemical Transmission at the Synapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Synapse Morphology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Pharmacodynamics
Receptors and Signaling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Receptor Subtypes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Agonists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Stereochemistry and 3-Dimensional Fit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Receptor-Effector Coupling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Signal Transduction and Cross Talk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Second-Messenger Pathways. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Ligand-Gated Ion Channels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
G Protein–Coupled Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Trk Receptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nuclear Receptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Up-regulation and Down-regulation of Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Dose-Response Curves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Inverse Agonists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Antagonists: Surmountable (Reversible) and Nonsurmountable (Irreversible). . . . . . . . . . . . . . . 24
Pharmacokinetics
Routes of Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
First-Pass Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Membrane Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Metabolism (Biotransformation) of Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Cytochrome P-450 (CYP450) Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Metabolic Enzyme Induction and Inhibition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

CHAPTER 2. DRUGS USED TO AFFECT THE AUTONOMIC AND SOMATIC

NERVOUS SYSTEMS
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Organization of the Nervous System
Organization of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Action of Drugs on Nerve Excitability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

xiii
Contents
Somatic Nervous System
Interface of the Central and Peripheral Nervous Systems and Organization of .
the Somatic Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Neuromuscular Transmission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Nicotinic Acetylcholine Receptor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Physiology of the Neuromuscular Junction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Pharmacology of the Neuromuscular Junction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Mechanism of Action of Acetylcholinesterase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Neuromuscular Blocking Agents: Nondepolarizing and Depolarizing. . . . . . . . . . . . . . . . . . . . 44
Autonomic Nervous System
Autonomic Nervous System: Schema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Sympathetic Fight or Flight Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Cholinergic and Adrenergic Synapses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Example of Cholinergic and Adrenergic Drug Treatment: Glaucoma . . . . . . . . . . . . . . . . . . . . 48
Cholinergic Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Cholinergic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Example of Cholinergic Drug Treatment: Myasthenia Gravis. . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Adrenergic Receptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Adrenergic Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Drugs That Act on the Autonomic Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Drug Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

CHAPTER 3. DRUGS USED IN DISORDERS OF THE CENTRAL NERVOUS SYSTEM AND

TREATMENT OF PAIN
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Introduction to the CNS and Drug Action
Development of the Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anatomy of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Functional Correlations and Visualization of Brain Structures . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Resting Membrane and Action Potentials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Excitatory and Inhibitory Postsynaptic Potentials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Central Nervous System Neurotransmitters, Receptors, and Drug Targets . . . . . . . . . . . . . . . . . 63
Sedative-Hypnotic Drugs
GABAA Receptor Complex and Sedative-Hypnotic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Anxiolytic Agents
Clinical Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Anxiolytic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Antiepileptic Agents
Causes of Seizures and Their Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Epilepsy: Generalized Seizures and Status Epilepticus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Epilepsy: Partial and Absence Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Antidepressants
Clinical Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Antidepressants: Mechanisms of Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Drugs Affecting Bipolar Disorder and OCD
Bipolar Disorder and Compulsive Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

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Antipsychotic Agents
Psychosis and Dopamine Pathways. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Drugs Affecting Movement Disorders and Other Neurodegenerative Disorders
Motor Tracts, Basal Ganglia, and Dopamine Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Parkinsonism: Symptoms and Defect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Parkinsonism: Levodopa, Carbidopa, and Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Huntington Disease and Tourette Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Alzheimer Disease: Symptoms, Course, and Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Alzheimer Disease: Cholinergic Involvement and Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Stroke: Symptoms and Drug Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
CNS Skeletal Muscle Relaxants
Motor Neurons and Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Analgesics and Anesthetics
Pain Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Local Anesthetics: Spinal Afferents and Local Anesthetic Mechanisms of Action. . . . . . . . . . . . 86
General Anesthetics: Properties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Opioids: Endogenous Opioid Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Opioids: Receptor-Transduction Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Nonopioids: NSAIDs, Selective Cyclooxygenase-2 Inhibitors, and Acetaminophen. . . . . . . . . . 90
Sumatriptans and Reuptake Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

CHAPTER 4. DRUGS USED IN DISORDERS OF THE CARDIOVASCULAR SYSTEM

Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Cardiovascular System: Anatomy, Function, and Regulation of the Heart
Cardiovascular Function: Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Cardiovascular Function: Definition of Terms and Regulation. . . . . . . . . . . . . . . . . . . . . . . . . . 95
Role of Catecholamines in Heart Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Sympathetic and Parasympathetic Regulation of Heart Function. . . . . . . . . . . . . . . . . . . . . . . . 97
Synthesis and Storage of Catecholamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Regulation of Norepinephrine Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Inactivation of Norepinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Hypercholesterolemia and Atherosclerosis
Hypercholesterolemia: Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Hypercholesterolemia: Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Angina
Angina Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Nitrates for Angina Treatment: Classes, Administration Routes, Pharmacology, .
and Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Nitroglycerin in Angina Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Nitroglycerin: Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Calcium Channel Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Drug Summary for Angina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Heart Failure
Heart Failure Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Heart Failure: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Heart Failure Treatment: β-Adrenergic Stimulators and Blockers. . . . . . . . . . . . . . . . . . . . . . . 111
Heart Failure Treatment: Cardiac Glycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

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Arrhythmias
Cardiac Arrhythmias: General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Cardiac Arrhythmias: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Cardiac Arrhythmias: Drug Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Hypertension
Hypertension Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Hypertension: Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Hypertension Treatment: Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Hypertension Treatment: Angiotensin-Converting Enzyme Inhibitors . . . . . . . . . . . . . . . . . . . 121
Hypertension Treatment: β and α Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Hypertension Treatment: Minoxidil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Hypertension Treatment: Clonidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Hypertension in Elderly Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Pheochromocytoma-Induced Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Hypertension in Cushing Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Peripheral Vascular Disease
Peripheral Vascular Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

CHAPTER 5. DRUGS USED IN DISORDERS OF THE ENDOCRINE SYSTEM

Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Hypothalamic and Pituitary Disorders
Regulation of Hypothalamic and Pituitary Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Hypopituitarism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Growth Hormone Deficiency and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Growth Hormone Excess (Acromegaly) and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Thyroid Disorders
Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Thyroid Hormones: Synthesis, Release, and Regulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Hypothyroidism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Hypothyroidism: Treatment of Choice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Liothyronine and T4/T3 Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Hyperthyroidism: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Thioamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Thioamides: Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Radioactive Iodine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Iodide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Adrenergic Antagonists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Corticosteroids and Adrenocortical Dysfunction
Regulation of Adrenal Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Mineralocorticoids and Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Cushing Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Ketoconazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Metyrapone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Aminoglutethimide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Addison Disease, or Primary Adrenal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

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Diabetes Mellitus
The Pancreas and Insulin Production. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Insulin Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Lack of Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Type 1 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Type 2 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Insulin Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Reactions to Insulin: Hypoglycemia and Adipose Tissue Changes. . . . . . . . . . . . . . . . . . . . . . 161
Sulfonylureas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Biguanides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Meglitinides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
α-Glucosidase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Thiazolidinediones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Thiazolidinediones: Clinical Rationale and Adverse Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . 167

CHAPTER 6. DRUGS USED IN DISORDERS OF THE GASTROINTESTINAL SYSTEM

Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Function and Regulation of the GI System
Enteric Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Integration of the Autonomic and Enteric Nervous Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Gastrointestinal Motility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Control of Peristalsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Hormones of the Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Parietal Cell Function Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Pancreatic Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Defecation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Protein Digestion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Fat Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Disorders of Colonic Motility
Colonic Motility and Treatment of Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Antidiarrheal Drugs and Their Adverse Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Causes of Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Treatment of Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Functional Disorder of the Large Intestine
Treatment of Irritable Bowel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Protozoal GI Infection
Giardiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Peptic Ulcer
Helicobacter pylori Infection Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Treatment of Helicobacter pylori Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Peptic Ulcer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Gastroesophageal Reflux Disease Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Pancreatitis
Treatment of Pancreatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

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Cholelithiasis
Pathologic Features of Gallstones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Gallstone Pathogenesis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Liver Physiology and Pathology
Liver Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Bilirubin Production and Excretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Ascites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Nausea and Vomiting
Physiology of Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Antiemetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

CHAPTER 7. DRUGS USED IN DISORDERS OF THE RESPIRATORY SYSTEM

Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Respiration: Physiology and Pathology
Respiration Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Respiratory Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Allergy
Allergy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Leukocyte Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Allergic Rhinitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Asthma
Introduction to Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Extrinsic and Intrinsic Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Asthma Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Anti-IgE Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Mast Cell Degranulation Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Bronchodilators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Methylxanthines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Methylxanthines: Adverse Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
β-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Nonselective β-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Selective β2-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Antimuscarinic Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Antiinflammatory Agents: Corticosteroids
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Corticosteroids: Clinical Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Corticosteroids: Adverse Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Antiinflammatory Agents: Leukotriene Antagonists
Leukotrienes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Leukotriene Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Cough
Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Cough Suppressants (Antitussive Agents) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Emphysema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
xviii
Exploring the Variety of Random
Documents with Different Content
 Nursing - Revision Notes
Fall 2021 - Academy

Prepared by: Dr. Smith

Date: July 28, 2025

Part 1: Practical applications and examples

Learning Objective 1: Ethical considerations and implications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Learning Objective 2: Current trends and future directions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Learning Objective 3: Fundamental concepts and principles
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 4: Current trends and future directions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 4: Diagram/Chart/Graph]
Learning Objective 5: Comparative analysis and synthesis
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 5: Key terms and definitions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 6: Interdisciplinary approaches
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Historical development and evolution
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Study tips and learning strategies
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Case studies and real-world applications
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Test 2: Best practices and recommendations
Example 10: Key terms and definitions
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 11: Study tips and learning strategies
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Comparative analysis and synthesis
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 13: Diagram/Chart/Graph]
Key Concept: Literature review and discussion
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 14: Critical analysis and evaluation
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Fundamental concepts and principles
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Study tips and learning strategies
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 17: Diagram/Chart/Graph]
Example 17: Interdisciplinary approaches
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Best practices and recommendations
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 19: Diagram/Chart/Graph]
Remember: Assessment criteria and rubrics
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Section 3: Current trends and future directions
Example 20: Historical development and evolution
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 21: Diagram/Chart/Graph]
Remember: Comparative analysis and synthesis
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 22: Ethical considerations and implications
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 23: Assessment criteria and rubrics
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 24: Diagram/Chart/Graph]
Definition: Critical analysis and evaluation
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Key Concept: Key terms and definitions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 26: Diagram/Chart/Graph]
Definition: Critical analysis and evaluation
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 27: Diagram/Chart/Graph]
Practice Problem 27: Theoretical framework and methodology
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Theoretical framework and methodology
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Assessment criteria and rubrics
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Conclusion 4: Case studies and real-world applications
Remember: Literature review and discussion
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 31: Diagram/Chart/Graph]
Example 31: Study tips and learning strategies
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Historical development and evolution
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 33: Diagram/Chart/Graph]
Key Concept: Experimental procedures and results
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Historical development and evolution
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 35: Interdisciplinary approaches
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Statistical analysis and interpretation
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Practical applications and examples
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 38: Diagram/Chart/Graph]
Note: Current trends and future directions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 39: Diagram/Chart/Graph]
Key Concept: Research findings and conclusions
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Section 5: Ethical considerations and implications
Practice Problem 40: Theoretical framework and methodology
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Study tips and learning strategies
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Ethical considerations and implications
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Practical applications and examples
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 45: Diagram/Chart/Graph]
Example 45: Study tips and learning strategies
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Interdisciplinary approaches
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 47: Diagram/Chart/Graph]
Note: Case studies and real-world applications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Theoretical framework and methodology
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 49: Research findings and conclusions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Appendix 6: Key terms and definitions
Important: Best practices and recommendations
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 51: Experimental procedures and results
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Interdisciplinary approaches
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Experimental procedures and results
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 54: Historical development and evolution
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 55: Critical analysis and evaluation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Study tips and learning strategies
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 57: Diagram/Chart/Graph]
Important: Learning outcomes and objectives
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Learning outcomes and objectives
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Best practices and recommendations
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 60: Diagram/Chart/Graph]
Conclusion 7: Critical analysis and evaluation
Important: Study tips and learning strategies
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Practical applications and examples
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Theoretical framework and methodology
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Statistical analysis and interpretation
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Practical applications and examples
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 65: Diagram/Chart/Graph]
Example 65: Fundamental concepts and principles
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 66: Diagram/Chart/Graph]
Practice Problem 66: Learning outcomes and objectives
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Problem-solving strategies and techniques
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Key terms and definitions
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Key terms and definitions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Conclusion 8: Ethical considerations and implications
Note: Experimental procedures and results
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Practical applications and examples
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 73: Diagram/Chart/Graph]
Note: Learning outcomes and objectives
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Experimental procedures and results
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Problem-solving strategies and techniques
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Case studies and real-world applications
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 78: Theoretical framework and methodology
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 79: Diagram/Chart/Graph]
Example 79: Practical applications and examples
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Module 9: Current trends and future directions
Important: Literature review and discussion
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Best practices and recommendations
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 82: Diagram/Chart/Graph]
Important: Problem-solving strategies and techniques
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Comparative analysis and synthesis
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Experimental procedures and results
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 85: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 86: Diagram/Chart/Graph]
Important: Learning outcomes and objectives
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Interdisciplinary approaches
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Current trends and future directions
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 89: Diagram/Chart/Graph]
Example 89: Experimental procedures and results
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 90: Diagram/Chart/Graph]
Appendix 10: Comparative analysis and synthesis
Important: Statistical analysis and interpretation
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 91: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 92: Diagram/Chart/Graph]
Note: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 93: Diagram/Chart/Graph]
Example 93: Case studies and real-world applications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 94: Diagram/Chart/Graph]
Example 94: Practical applications and examples
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Historical development and evolution
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Case studies and real-world applications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 97: Diagram/Chart/Graph]
Practice Problem 97: Current trends and future directions
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Experimental procedures and results
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 99: Diagram/Chart/Graph]
Practice Problem 99: Case studies and real-world applications
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Results 11: Comparative analysis and synthesis
Key Concept: Best practices and recommendations
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 101: Diagram/Chart/Graph]
Example 101: Problem-solving strategies and techniques
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 102: Theoretical framework and methodology
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Critical analysis and evaluation
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 104: Case studies and real-world applications
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Study tips and learning strategies
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 107: Comparative analysis and synthesis
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Learning outcomes and objectives
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Conclusion 12: Interdisciplinary approaches
Note: Interdisciplinary approaches
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 111: Diagram/Chart/Graph]
Key Concept: Ethical considerations and implications
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 112: Diagram/Chart/Graph]
Example 112: Research findings and conclusions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Key terms and definitions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Experimental procedures and results
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Learning outcomes and objectives
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Best practices and recommendations
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 118: Diagram/Chart/Graph]
Definition: Best practices and recommendations
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 119: Diagram/Chart/Graph]
Key Concept: Research findings and conclusions
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Methodology 13: Literature review and discussion
Definition: Comparative analysis and synthesis
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 121: Diagram/Chart/Graph]
Note: Practical applications and examples
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Ethical considerations and implications
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Best practices and recommendations
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Research findings and conclusions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
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