Autonomic nervous

system drugs
 Peripheral nervous system
CNS PNS

BRAIN SPINAL CORD AUTONOMIC N.S SOMATIC N.S

SYMPATHETIC PARASYMPATHETIC
BODY TISSUE/ORGAN SYMPATHETIC PARASYMPATHETIC
EYE DILATE PUPILS CONSTRICT PUPILS
LUNGS DILATE BRONCHIOLES CONSTRICT BRONCHIOLES/INCREASE
SECRETION/ SALIVATION

HEART INCREAES HEART RATE DECREASE HEART RATE

BLOOD VESSELS CONSTRICT BLOOD VESSELS DILATE BLOOD VESSELS
GASTRO RELAXES SMOOTH MUSCLES OF GI INCREASE PERISTALSIS
BLADDER RELAX BLADDER MUSCLES CONSTRICTS BLADDER
UTERUS RELAX UTERINE MUSCLES
Drug groups that affects sympathetic
nervous system
1. Adrenergic agonist/ adrenergics/
sympathomimetics
➢drugs that stimulates the Sympathetic
Nervous System (SNS)
2. Adrenergic antagonist/ adrenergic blockers/
symphatholytics
➢Drugs that block the effects of adrenergic
neurotransmitters. They block the alpha and
beta receptor site
 Adrenergic agonist
Ephedrine HCL; For hypotension and bronchospasm. May cause weakness, restlessness,
Ephedrine sulfate: headache dizziness, tremor, dysrhythmia, tachycardia, HPN and
palpitations
Norepinephrine For acute hypotension, cardiogenic shock, and septic shock. Monitor BP and
bitartrate rhythm every 2-5mins during infusion. May cause anxiety, headache confusion,
bradycardia, hypertension, pulmonary edema, dyspnea, tissue necrosis
Phenylephrine For sinus and nasal congestion, hypotension and shock, glaucoma, pupillary
HCL dilation. Have patient blow nose before drug is administered. May cause
headache, blurred vision, nasal irritation, tachycardia, tissue necrosis
Albuterol For bronchospasm. May cause headache, nasopharyngitis, tremor, dizziness,
nausea, vomiting, muscle cramps, infection, palpitations, tachycardia and
palpitations
Terbutaline sulfate For acute bronchospasm. May cause nervousness, tremors, dizziness,
confusion, fatigue, pruritus, abdominal pain, nausea, vomiting, hyperglycemia,
hypotension and hypokalemia
Clonidine HCL For hypertension. May cause dizziness, drowsiness, hypotension, depression,
bradycardia, peripheral edema, angina, constipation, erectile/ejaculatory
dysfunction
 Drug in focus: dobutamine(dobutrex)
C Sympathomimetic, increase force for cardiac contraction
H Improve blood flow through adequate heart pumping
E Administered as a continuous intravenous infusion in acute emergencies
C Monitor urine output, ECG, BP
Common side effects: nausea, vomiting, fever, headache, leg cramps
Report signs of an allergic reaction: hives, difficulty of breathing swelling of
face, lips, tongue and throat
During administration report any signs of dyspnea, chest pain, headache and
IV site discomfort
K Do not mix with alkaline solution
For adults: 2.5-10mcg is the usual IV rate
For congestive heart failure management in adults:
initial dose: 0.5-1mcg/kg/min
Maintenance dose: 2-20mcg/kg/min IV infusion
Maximum dose: 40mcg/kg/min IV infusion
 Drug in focus: dopamine HCL
C Inotropic, Dopaminergic
H Adequate renal perfusion, stronger heart contractions
E Administer as prescribed
C Side effects: nausea, vomiting, palpitation, hypotension
K When extravasation occurs, have phentolamine ready
Calculate extreme caution
Remember that doses of dopamine come in: 40, 80 and
160mg/dl
Conversion: 1000mcg=1 mg
 1. Adrenergic agonist: EPINEPHRINE
DRUG CLASS: ADRENERGIC AGONIST DOSAGE: ANAPHYLAXIS- 0.3MG EpiPen
> to treat allergic reaction, anaphylaxis, autoinjector
bronchospasm, asthma exacerbation, status May repeat 5-20mon PRN max 2 doses
asthmaticus, cardiac arrest, cardiac resuscitation IV: 0.1-0.25mg of 0.1mg/ml solution may repeat
q5-15min PRN
Contraindication: cardiac dysrhythmia, Drug-Lab Interaction: Increased effect with
cerebrovascular disease. Labor, closed angle TCAs, MAOIs, methyldopa, digoxin may cause
glaucoma, HPN, pulmonary edema, dysrhythmias in epinephrine
hyperthyroidism, DM, renal dysfunction, Lab: Increase blood glucose and serum lactic
pregnancy acid
Pharmacokinetics: Absorption: IM/IV Pharmacodynamics: IM onset: variable
Metabolism: <5 min IV Duration: 1-4 h
Excretion: Urine and breastmilk IV onset: Immediate
Peak: 2-5 mins
Side Effects: nausea, vomiting, restlessness, Adverse Reaction: Palpitations, tachycardia,
tremor, agitation, sweating, headache, pallor, HPN, dyspnea, MI., renal insufficiency, injection
oliguria, weakness, paresthesia site reaction
Life threatening: dysrhythmia, pulmonary edema
 Central acting alpha agonist
drug in focus: methyldopa
C Anti Hypertensive

H Lowered BP

E Take the drug regularly exactly as prescribed

C Impotence can be expected; elevated hepatic

enzyme
K Check BP; may cause hypotension
 2. adrenergic antagonist/blockers
❑Alpha-Adrenergic Antagonist-drugs that
block or inhibit a response at the alpha-
adrenergic receptor site; also known as
alpha blockers
INDICATIONS: BPH, HPN, and PTSD
CONTRAINDICATIONS: History of
orthostatic hypotension and sever hepatic
impairment
 Adrenergic antagonist
Drug Uses and considerations
Phentolamine Antidote for dopamine, dobutamine, phenylephrine, epinephrine,
mesylate norepinephrine. May cause pain at the injection site
Doxazosin For hypertension and BPH. May cause dizziness, headache,
mesylate fatigue, edema, visual impairment, erectile dysfunction and
orthostatic hypotension
Prazosin For HPN. May cause dizziness, drowsiness, fatigue, weakness,
hydrochloride orthostatic hypotension, peripheral edema, nausea and
palpitations
Carvedilol For HPN and HF. May cause drowsiness, dizziness, orthostatic
hypotension, bradycardia, wt. gain, dyspnea, fatigue, headache,
diarrhea, peripheral edema, hyperglycemia,
Labetalol For acute/chronic HPN. May cause orthostatic hypotension,
nasal congestion, dizziness, fatigue, nausea, paresthesia, erectile
dysfunction, hyperhidrosis and depression
 Adrenergic antagonist
Nadolol For HPN and angina. May cause dizziness, drowsiness, fatigue, bradycardia,
hypotension, palpitations, erectile dysfunction, dysrhythmias
Pindolol For HPN. May cause bradycardia, hypotension, edema, fatigue, weakness,
dizziness, visual impairment and dyspnea
Sotalol For ventricular dysrhythmias, atrial flutter, and atrial fibrillation. May cause
dizziness, dyspnea, asthenia, bradycardia, palpitations, hypotension, HF,
hyperhidrosis, fatigue, dysrhythmia exacerbation
Metoprolol For HPN, angina, HF and acute MI. May cause bradycardia, dizziness, drowsiness,
tartrate fatigue, sleep disturbance, nightmares, diarrheas, depression, hypotension,
peripheral insufficiency/edema. HF and dysrhythmias
Betaxolol For HPN and glaucoma. May cause bradycardia, headache, dizziness, insomnia,
fatigue, nausea, arthralgia and chest pain
Bisoprolol For HPN. May cause dizziness, bradycardia, headache, fatigue, arthralgia, diarrhea,
fumarate orthostatic hypotension, and peripheral edema
Esmolol HCL For supraventricular tachydysrhythmia and HPN. May cause hypotension,
dizziness, drowsiness, diaphoresis, and injection site reaction
 adrenergic antagonist/blockers
❑ Beta-Adrenergic Antagonist- also called beta-blocker
Example: ATENOLOL
INDICATIONS: Hypertension, situational Drug-lab-food interaction: increased absorption with
anxiety, migraines, prophylaxis and treatment atropine and other anticholinergics; decreased effects
of acute MI, angina, glaucoma with NSAIDs; increased risk of hypoglycemia with
insulin and sulfonylureas; increased hypotension with
prazosin and terazosin; increased lidocaine and
verapamil levels with toxicity
CONTRAINDICATIONS: Bradycardia, Pharmacokinetics:
heart blockers, shock, asthma, and COPD, Absorption- 50% absorbed in the GI
pregnancy and lactation Metabolism: t1/2: 6-7 hours
Caution: Renal dysfunction, DM, Excretion: Urine and Feces
Bronchospasm, Myasthenia Gravis Pharmacodynamics: Oral- 1h
Peak:2-4h
Duration: 24h
Side effects: dizziness, headache, depression, Adverse Reaction: Bradycardia, tachycardia,
fatigue, nausea, diarrhea, edema, cool hypotension, chest pain, heart failure, dyspnea
extremities, erectile dysfunction Life threatening: Bronchospasm, renal failure,
dysrhythmia, thrombocytopenia
 Drug in focus: propranolol hcl
C Antianginal; antiarrhythmic; antihypertensive; reduces portal
pressure and decrease risk of bleeding from esophageal varices
H Normal BP

E Best taken with meals

C Avoid drinking; do not discontinue abruptly

Side effects: bradycardia, hypotension, bronchospasm
Take with full glass of water at the same time each day
K Check the following:
BP: May cause hypotension
Respiration: May cause bronchospasm
Radial Pulse: if less than 50 beats per minute, hold the drug and notify the physician
Avoid: opening, chewing, crushing, extended release capsule; avoid stopping intake
abruptly: avoid using aluminum-containing antacid; may decrease absorption
 Drug in focus: Timolol (Timoptic Gel)

C Beta blocker; used for treatment of glaucoma and

ocular hypertension

H Normal intra ocular pressure

E Administer as prescribed

C Side effects: fatigue, weakness

k Place pressure on tear ducts for one minute after

administration of the drug
Cholinergic agonist and antagonist
1. Cholinergic agonist
➢Drugs that stimulates the parasympathetic N.S. They mimic
the parasympathetic neurotransmitter acetylcholine
2 types
❑Direct-acting cholinergic agonist- act on receptor to activate
a tissue response
❑Indirect-acting cholinergic agonist/ cholinesterase inhibitors-
inhibit the action of enzyme cholinesterase
INDICATIONS: Myasthenia Gravis, Alzheimer's disease
CONTRAINDICATION: Bradycardia, intestinal/ urinary tract
obstruction, pregnant women, hepatic and renal dysfunction
 Effects of cholinergic agonist
Cardiovascular Decrease heart rate, lowered BP bec. of vasodilation and slowed
conduction of AV node
Gastrointestinal Increased tone and motility of smooth muscle of stomach and
intestine, increase peristalsis, relaxed sphincter muscles
Genitourinary Contraction of muscle of the urinary bladder, increased tome of
ureters, relaxed bladder sphincter muscles and stimulated urine
Ocular Increased pupillary constriction or miosis, and increased
accommodation (flattening or thickening of eye lens for distant
or near vision
Glandular Increased salivation, perspiration and tears
Bronchi Stimulation of bronchial smooth muscles contraction and
increased bronchial secretions
Striated Muscle Increased neuromuscular transmission and maintenance of
muscle strength and tone
 Cholinergic: Bethanechol chloride
Drug Class: Cholinergic Parasympathomimetic Dosage: Urinary retention PO- Initially 5-10mg q1h
For urinary retention and neurogenic bladder subQ: 5MG tid/qid max: 40mg/dl

Contraindications: Intestinal or urinary tract Drug-Lab-Food interaction: Decrease bethanechol effect

obstruction, bradycardia, hypotension, COPD, with antidysrhythmic(procainamide); ganglion blocking
asthma, peptic ulcer, hyperthyroidism, seizure, agents(mecamylamine) cause significant hypotension after
parkinsonism severe abdominal symptoms. False test results (amylase,
lipase) may result. Atropine, flavoxate and opiates counteract
bethanechol action
Lab: increases AST, bilirubin, amylase, lipase
Pharmacokinetics: Pharmacodynamics: PO onset: 0.5-1.5h
Absorption PO; poorly absorbed Peak: 1-2h
Distribution: unknown Duration: 1-6h
Metabolism: t ½ Unknown SubQ Onset: 5-15mins
Excretion: Urine Peak: 15-30mins
Duration: 2 h
Side Effects: Nausea, vomiting, diarrhea, Adverse Reaction: Tachycardia, hypotension
abdominal cramps, hypersalivation, diaphoresis, Life threatening: Bronchospasm, wheezing, seizures
urinary urgency and frequency, weakness,
miosis, lacrimation
 Drug in focus: rivastigmine tartrate (Exelon)
c Treatment for mild to moderate Alzheimer's disease

h Decreased symptoms of Alzheimer's disease

e Best taken with food in the morning or in the evening

c Side effects: nausea, vomiting. Wt. loss, confusion, insomnia

k Store at room temperature in a tightly closed container

If a dose is missed, take it as soon as it is remembered
Drug in focus: Pyridostigmine (mestinon)
C Cholinesterase inhibitor; use for treatment for Myasthenia Gravis

H Increased muscle strength

E Usually administered 30-60 minutes before meal

C Side effects: abdominal cramps, diarrhea, excessive tearing, excessive sweating, skin rash, twitching,
exacerbation of asthma
K Monitor for muscle weakness; Keep antidote, Atropine at the bedside table
 Drug in focus: neostigmine(prostigmin)
c Cholinesterase inhibitors; use for treatment for Myasthenia
Gravis
h Increased muscle strength

e Take tablets at suitable intervals so that the muscles are strongest

during activity ( for example, early in the morning and before
meals)

c Report nausea, diarrhea, abdominal pain and muscle weakness.

Avoid hot and excessively humid environment
k Keep the antidote, pralidoxime chloride or atropine SO4 at the
bedside
Store away from direct heat and light. Keep in a cool dry place
 Cholinergic agonist
Metoclopramide For GERD, gastroparesis, nausea and vomiting. May cause drowsiness,
HCL dizziness, fatigue, restlessness, headache, nausea.
Edrophonium To diagnose Myasthenia Gravis and for neuromuscular blockage reversal.
chloride/ Reversal Monitor pulse, RR,BP, neurologic status and ECG frequently during
administration. May cause diplopia, hypersalivation, dysphonia, dysphagia,
diaphoresis, depression and seizure
Pyridostigmine For Myasthenia Gravis and neuromuscular blockage reversal and for nerve
bromide/Mestinon gas exposure prophylaxis. May cause nausea vomiting, abdominal cramps,
diarrhea, bradycardia, blurred vision, bronchospasm, hypersalivation and
increased urinary frequency
Physostigmine For anticholinergic toxicity/ syndrome and glaucoma. May cause
salicylate diaphoresis, hypersalivation, bradycardia, hypotension, seizures, confusion,
muscle weakness and respiratory distress
Pralidoxime chloride For cholinesterase inhibitor toxicity and organophosphate pesticide toxicity.
May cause dizziness, blurred vision, headache, drowsiness, tachycardia,
hypertonia, seizure
 2. Cholinergic antagonist
➢Drugs that inhibit the actions of acetylcholine by occupying the
acetylcholine receptors; AKA anticholinergic drugs
Cardiovascular Heart rate increase with large doses, small doses can cause
decrease heart rate
GI Relaxed smooth muscle tone, decreased GI motility and peristalsis,
intestinal and gastric secretions are decreased
Urinary Relaxed bladder detrusor muscle and increased constriction of
internal sphincter; urinary retention can result
Ocular Dilated pupils (mydriasis) and paralyzed ciliary muscles
(cycloplegia) cause a decrease in accommodation
Glandular Salivation, perspiration and bronchial secretions are decreased
Bronchial Bronchi are dilated and bronchial secretions are decreased
CNS Tremors and rigidity of muscles are decreased; drowsiness,
disorientation and hallucinations can result on large doses
Dicyclomine HCL For IBS. May cause dry mouth, nervousness, dizziness, drowsiness, blurred vision, weakness,
drowsiness, blurred vision, weakness, nausea
Glycopyrrolate For duodenal ulcer, aspiration prophylaxis. May cause flushing, dry mouth, headache,
palpitations, hypotension, tachycardia, blurred vision, sinusitis, nausea, constipation and
urinary retention
Hyoscyamine Treatment for aspiration prophylaxis, gastric and duodenal ulcer and IBS. May cause flushing,
SO4 confusion, blurred vision, increased IOP, dysphagia, anhidrosis, constipation, palpitations,
erectile dysfunction
Methscopolamine For peptic ulcer. May cause confusion, anhidrosis, dysphagia, dry mouth, constipation,
bromide palpitations, tachycardia, urinary retention. And erectile dysfunction
Propantheline For peptic ulcer. May cause confusion, anhidrosis, dysphagia, dry mouth, constipation,
bromide palpitations, hypotension, weakness, blurred vision, erectile dysfunction
Scopolamine Transdermal patch. For motion sickness, may cause drowsiness, confusion, blurred vision,
tachycardia, bradycardia, dry mouth, anhidrosis, orthostatic hypotension, dysphagia,
constipation, photophobia, urinary retention.
Benztropine Anti parkinsonism. Increase anticholinergic effect with phenothiazines and tricyclic
antidepressant. May cause nausea, vomiting, dry mouth, anhidrosis, dizziness, depression,
hallucinations, hyperthermia, paresthesia, mydriasis, ocular hypertension(life threatening)and
ileus
Ipratropium Inhalation. For bronchospasm associated with COPD and asthma. May cause headache,
bromide dyspnea, back pain, epistaxis, nasopharyngitis, bronchitis
 Anticholinergic: tolterodine tartrate
Anti cholinergic: antimuscarinic agent- to Dosage: PO: 1-2mg BID
decrease urinary frequency, urgency and
incontinence
Contraindications: Hypersensitivity, urinary Drug-Lab-Food Interaction: increased effect
retention, gastric paresis, and lactation with amantadine, amoxapine, bupropion,
Caution: alcoholism, HPN, bradycardia, heart clozapine, cyclobenzaprine, disopyramide,
failure, GERD, paralytic ileus ulcerative colitis, olanzapine. Decreased effect, with azole
DM, Myasthenia gravis, GI obstruction, antifungals(ketoconazole) or macrolide
glaucoma, prostatic hypertrophy, renal and hepatic antibiotics(erythromycin) cyclosporine
dysfunction, Alzheimer Food: Grapefruit may increase drug levels
Pharmacokinetics: Absorption is decreased with Pharmacodynamics: Po onset: unknown
food intake Metabolism: t1/2: 2-4h Peak: 1-2h
Excretion: Urine and feces Duration: Unknown
Side Effects: drowsiness, dizziness, dry mouth, Adverse Reaction: angioedema, chest pain,
eyes, and skin, headache, blurred vision, tachycardia, peripheral edema, dementia
confusion, diarrhea, abdominal pain, constipation, Life threatening: Stevens-Johnson syndrome
dyspepsia, dysuria, fatigue, wt. gain, arthralgia,
hallucinations, and urinary retention
 Anticholinergic: atropine
Drug class: Anticholinergic Dosage: Bradycardia
Preoperative medication to reduce salivation, IV: 0.5-1mg, repeat q3-5mins up to 3mg
increased heart rate for bradycardia,
neuromuscular blockage reversal
Contraindications: Hypersensitivity Drug-Lab-Food Interaction: Drug: Increases
Caution: Renal, hepatic or respiratory impairment, anticholinergic effect with phenothiazines,
COPD, cardiovascular disease, MI, GI antihistamines, amantadine, quinidine; high dose
obstruction, ileus, ulcerative colitis, glaucoma, may decrease effect or carbidopa/levodopa by
Hyperthyroidism, urinary retention, dysrhythmias, delaying gastric absorption
myasthenia gravis
Pharmacokinetics: PO/IM: well-absorbed Pharmacodynamics:
Metabolism: t1/2: 2-4h IM/onset: 10-30mins IV: immediately
Excretion: 75%-95% in urine Peak: 0.5-1h Peak: 5 mins
Duration 4h Duration: unknown
Side effects: drowsiness, dizziness, nausea, dry Adverse reaction: paradoxical bradycardia,
mouth, headache, confusion, insomnia, amnesia, hypotension, angina, dyspnea, pulmonary edema
constipation, flushing, hydronephrosis, blurred Life threatening: dysrhythmias, laryngospasm,
vision, photophobia, palpitations, hyperreflexia, coma
ataxia, weakness, dehydration
 Drug in focus: atropine
C Anticholinergic, Vagolytic, Drying agent

H It increases heart rate in a patient with heart block; used

preoperatively to decrease secretions
E Administer as prescribed

C Can cause facial flushing, blurred vision, dry eyes, dry mouth, and
constipation, decreased sweating, delay in starting to urinate
K Check BP, may cause hypotension
Atropine sulfate eye drops are used to dilate the pupils before eye
exams
It is usually instilled into both eyes once, the night before the eye
examinations, and again in the early morning of the appointment
Oral atropine is no longer available in the US