- Chemical name --> Specific chemical structure

- Code name --> Chosen by the manufacter during development

- Proprietary name --> Brand or trade name

- Official name --> Chosen by the US Adopted Name Council --> Generic name

- First-order kinetics --> Rate is dependent on concentration gradient NOT dose

- Tight junctions and lack of cell porosity helps determine diffusion extent

- Chemical attributes of drugs: Lipophilicity, ionizable residues, and molecular weight

- Solubility of drug in lipid vs water

- Measured by the oil/water partition coefficient

- Ionization decreases the lipophilicity of the drug

- Ionizable drugs are polar --> Do not readily diffuse through cell membranes

- Ex. quaternary ammonium, base at low pH (+), and acid at high pH (-)

- Drugs with MW <1,000 daltons will diffuse

- Tissue plasminogen activator (TPA) --> MW of 70,000 daltons, will NOT passively diffuse --> Transported via endocytosis

- Depends on hydrostatic pressure, MW, size, charge and binding to plasma proteins

- Also depends on tissue porosity

- Saturatable kinetics --> Can become zero order

- Possible substrate competition

- Differences in tissue expression of carriers --> Difference in uptake and concentration

- Primarily mediates the excretion of compounds

- P-glycoprotein 1 (Pgp) multidrug resistant protein (MDR 1)

- ABC transporter --> ABCB1 gene product

- Amphipathic cationic and neutral substances

- Verapamil sensitive transporter

- Drugs that bind this receptor will be pumped out of the tissue

- Could result in very low concentrations of drug in target tissue

- Solute carrier family --> SLC22A6 gene product

- Organic anionic substrates

- Probenecid sensitive

- Eliminates compounds from tissues

- Intestinal mucosa

- Hepatocyte --> Into bile

- Proximal renal tubule --> Into nephron lumen

- Blood-brain barrier --> Back into plasma --> Found in vascular endothelium and choroid plexus

- Important in selective tissue uptake

- Rate is dependent on receptor expression

- Saturable kinetics --> Can become zero order

- Mechanism for some protein therapeutics

- Represented by the absorption constant (Ka)

- Time it takes for drug to get from the site of administration into the blood stream

- Characterized by the absorption half-life and the percent dose absorbed (bioavailability)

- Intravenous

- Intramuscular

- Sub-cutaneous

- Topical

- Interosseous

- Oral

- Ear

- Eye

- Sublingual

- Rectal

- Vaginal

- 100% bioavailability for drug

- Fastest input rate

- Rate is dependent on technique of administration --> Bolus or IV drip

- Need sterility, lack of particulates, and drug to be solubilized in an aqueous solution

- Low MW lipophilic drugs --> Into blood depending on the blood flow to area

- High MW drugs --> Into lymphatics

- Improved bioavailability over oral administration for polar and high MW drugs

- Good for sustained release of drugs

- Rapid absorption --> High blood flow and low diffusional distance across alveoli

- Drug must be in the form of a gas or vapor

- Great for localized delivery of drugs to the lungs

- Avoids systemic absorption of drug

- Slow absorption due to stratum corneum of skin

- Drugs must be sufficiently lipophilic

- Avoids first-pass effect through the liver

- May have low bioavailability due to mucosal barrier

- Especially low bioavailability for drugs of high MW, low lipophilicity, and carrier-mediated extrusion from mucosa

- Also first-pass effect occurs through the liver

- Absorption half-life: Affected by formulation of drug, gastric emptying time, and drug/dietary interactions

- Through portal vein

- Blood flow from the spleen and GI tract to portal vein

- Rate and extent of distribution from the vascular space to the tissue space

- Determined by the blood flow to a particular organ

- Lung, kidney, liver, and brain are highly perfused

- Fat has low perfusion

- Tissue factors: Vascular permeability and binding to plasma proteins

- Physiochemical factors: MW, lipophilicity, and affinity for carriers

- Created by tight junctions between endothelial cells

- Excludes high MW and non-lipophilic drugs

- Transporters will actively transport drugs back into the blood and out of the brain

- Albumin and alpha-acid glycoprotein are two common plasma binding proteins

- Warfarin --> 99% bound to albumin --> Only 1% of dose active --> Greatly affected in people with lung disease (Decreased albumin)

- Codeine --> 7% bound in plasma

- For 70 kg adult

- Plasma --> 3L/4% --> 131I-albumin indicator

- ECF --> 12L/17% --> Sucrose indicator

- TBW --> 41L/58% --> D2O indicator

- Volume of the body into which the drug appears to have distributed

- Vd=amount in body(g)/volume (L) --> Cp (g/l)

- One vs. two compartment model

- High MW --> Vd=4% --> Plasma

- Small MW and polar --> Vd=17%

- Small MW and lipophilic --> Vd>58% or greater

- BW --> Vd~BW

- Body composition --> % fat and % fluid compartments

- Concentrations of plasma and tissue binding sites --> Albumin for low MW drugs

- Has different effects on different drugs --> Depends on the chemical structure of each drug

- Theophylline --> from 47% to 32% in obese patients

- Diazepam --> From 150% to 260% in obese patients

- Diazepam is highly lipophilic --> Larger fat content, larger build up of drug in fatty tissue

- Theophylline has TBW distribution --> Lower % TBW in obese patients --> Shows difference in numbers

- Rate and extent of elimination by excretion or biotransformation

- Total clearance (ClT): Volume of plasma cleared of compound per unit time by all routes and mechanisms

- Cl organ= (plasma flow) (Cpa-Cpv)/Cpa

- Total clearance: (ClT)(Cp)= dA/dt --> Rate

- ClT= ClR + ClNR

- Non-renal clearance: Unchanged excretion and biotransformation excretion

- Unchanged excretion --> Lungs and bile

- Phase I: Oxidation, reduction, and hydrolysis

- Phase II: Conjugation

- Metabolite can be inactive, active or toxic

- First-order kinetics applies --> Half-life always the same for drug

- Therapeutic levels >> Km: Ethanol and aspirin --> Zero order kinetics

- Overdose levels >> Km: Acetaminophen --> Zero order kinetics

1. Dietary and drug interactions

- Inhibition: substrate competition or suicide inhibition --> Grapefruit juice

- Induction: Promotes enzyme expression --> Cigarette smoke

2. Disease

- Cytokine-induced inhibition of hepatic enzyme production

- Reduction in hepatic blood flow

3. Genetic polymorphisms in enzymes of biotransformation --> Longer half-lifes for drugs 

- Phase I enzyme

- Heme-containing enzyme imbedded in SER

- Highest concentrations in the liver

- Catalyze the addition of O2

- Produced from 17 different genes --> 3A4 and 2D6 important

- Isozymes differ in substrate specificity, inducers and inhibitors

- Cigarette smoke (PAHs): Induces CYP1A1 through the Ah receptor

- Barbiturates: Induces CYP2B through CAR receptor

- Steroids: Induces CYP3A4 through PXR receptor

- Can add glucuronic acid, sulfate, methyl groups, glutathione, acetyl groups, and glycine

- Volume of plasma cleared by excretion unchanged into urine

- Mechanisms: Glomerular filtration, proximal tubule carrier-mediated secretion, and passive reabsorption

- Filtration, reabsorption and secretion

- ClR= urinary excretion rate/Cp

- ClR = 120 --> Filtration without reabsorption

- ClR= 0-120 --> Reabsorption

- ClR= 120-640 --> Secretion

- Proportional to BW^0.7

- Decreases with age --> Kidney decline by 50% at age 90

- Altered by drug interactions --> Carrier competition, pH change by ionizable drug

- Reduced by renal disease

- Single compartment distribution

- Drug rapidly equilibrates into the volume of distribution

- First-order elimination occurs

- Elimination constant: Kel

- Cp=Cp0e-(kel t)

- Exponential decay

- Linearization: lnCp=lnCp0 - Kel t --> Slope:Kel and y intercept: ln Cp0

- time required to eliminate 50% of the drug from the plasma

- Dose-independent under first-order kinetics

- Determined by both Vd and ClT

- t 1/2 = 0.693/Kel = 0.693 Vd/ClT

- Single compartment analysis

- Administer IV dose

- Collect plasma at various times --> Measure Cp

- Estimate Cp0 by extrapolation

- Vd = Dose/Cp0

- Determined from Cp vs. Time data

- ClT= (Kel)(Vd) = (0.693/t 1/2)(Vd)

- Larger Vd --> Lower the Cp0 and longer t 1/2

- Higher ClT --> Shorter t 1/2 and no effect on Cp0 --> Increased Kel (elimination constant)

- Cp increases with dose

- Vd, ClT and t 1/2 do NOT change with dose

- 2X dose --> Duration increases by 1 t 1/2 unit

- Dose-dependence in PK parameters

- Saturation of enzymatically mediated clearance

- Saturation of plasma or tissue binding sites

- Zero order kinetics --> Constant reaction rate due to enzyme saturation --> Cp vs. time is linear --> Only Vmax removed

- Mixed order kinetics --> Multiple elimination pathways with varying kinetics

- Bi-exponential graph --> A + B phase

- Multiple different difussion constants for different tissues

- High vs. low perfusion tissue rates

- Duration of action of drug can be short due to redistribution

- Elimination half-life could still be long even though duration of action is very short

- Both absorption and elimination kinetics are important

- Bioavailability is also very important

- Cp = (KaFD/Vd (Ka-Kel))(e-(Kel t)- e-(ka t))

- F: Bioavailability

- Depends on the route of administration

- Determined by examination of the drug's plasma concentrations

- Area under Cp vs. time curve (AUC)

- Integral Cp=AUC= F D/ClT

- ClT must be constant --> Cross-over study design

- Absolute: AUC of nonIV/ AUC of IV

- Relative: AUC of formulation 1/ AUC of formulation 2

- Relative is used for generics --> Must equal 1

- Begins with a rapidly and completely available drug

- Equivalent Ka but with only half of the bioavailability (F) --> 1/2 AUC and drug never reaches TC

- Same availability (F) but 1/2 Ka --> Same AUC but Cp doesn't stay above TC for as long

1. Kel < Ka: t 1/2 elim is longer than t 1/2 absorption

- Terminal slope is the same for IV and PO

2. Ka > Kel: t 1/2 elim is shorter than t 1/2 absorption

- Terminal slope is shallower for PO vs. IV route --> Reflects the Ka

- Constant rate of input

- First-order elimination/output

- Single compartment model in order to simplify

- Cp= Cpss (1-e-(Kel t))

- Once at steady state --> input rate=output rate

- Input rate= (Cpss)(ClT)

- Cpss=Infusion rate (Ko)/ClT

- Achieving Cpss depends on the elimination half-life

- 93% of Cpss after 4 elimination half-lives

- Decreased clearance --> Longer half-life and greater Cpss value

- Exercise decreases hepatic blood flow --> Decreases clearance of drugs

- Administered to reach Cpss immediately

- Important for drugs with long elimination half-lives and slow attainment of steady-state

- Loading dose does NOT affect the Cpss by continuous infusion

- First-order elimination --> Single compartment distribution

- Constant rate of input --> maintained dose/dosing interval (D/t)

- Each dose D is diluted into Vd and adds Co to Cp

- D/Vd=Co

- Cp rises from Cpmin to Cpmax after each dose

- Cpmin + Co= Cmax

- Cmin is "trough" Cp

- Therapeutic window: Range between Cmaxss and Cminss

- Shorter the dosing interval relative to half-life --> Greater the drug accumulation

- Dosing interval > 7 half-lives --> Less than 1% remains after dose and accumulation is negligible

- Dosing interval = 1 half-life --> Accumulation is 2 fold after each dose

- Dosing interval > 1 half-life --> Cmaxss even higher

- Reaches steady state at about 4 half-lives

-Fluctation around Cpaverage within a window of Cmax and Cmin

- Cpav = (D/t)/ClT

- Same Cpav can be reached by continuous infusion, small dosing at frequent intervals or high dosing at long intervals

- Solutions, tablets and controlled release capsules

- Absorption half-life and bioavailability depends on the disintegration and dissolution rates from the formulation

- Depends on: Crystal size, excipients, and tablet compressive force

- Larger crystal size --> Slower dissolution

- Larger content of starch --> Faster dissolution

- Larger compression force --> Slower dissolution

- Buccal fentanyl tablet --> Dissolves in mouth --> Avoids first-pass effect

- Gastrointestinal Therapeutic System: Osmotic pump --> Capsule doesn't disintegrate --> Pore present due to manufacturing --> Water permeates mebrane --> Increased pressure pushes drug out of pore at constant state

- Extended release tablets --> Also have pore present

- Ophthalmic

- Uterine and vaginal

- Subcutaneous

- Intravenous

- Transdermal

- Pulmonary

- Hormones contained within plastic ring

- Ring inserted within the vagina

- Allows for localized systemic absorption of hormones into the body

- Subcutaneous implant for long-term birth control

- Hormone contained within copolymer core

- Hormone slowly permeates the rod and then diffuses into systemic circulation

- Inserted in the coronary artery

- Releases localized dose of drug to prevent restenosis of the vessel

- Cannot be administered orally because systemic effects would be detrimental and with alot of side effects

- Pumps insulin through a catheter and into abdominal fat

- Insulin then travels into systemic circulation

- Can be placed near the spinal cord

- Can treat intractable pain or muscle spasticity

- Ex. nicotine and nitroglycerine patches

- Avoids the first pass effect

- Crucial for nitroglycerine --> Eliminated almost entirely by first-pass when taken orally

- Improves the selectivity of bronchodilators and anti-inflammatory agents

- Particularly useful in treating asthma and COPD

- Permits routine outpatient use

- Administered using metered dose inhalers, nebulizers, and diskus

- Ultrasonic nebulizer --> Great for localized delivery of drugs for lung disease

- Physiological Receptors

- Enzymes

- Transporters

- Voltage-gated Ion Channels

- Structural proteins

- Nucleic acid

- Biological mediators

1. Ligand-gated ion channels --> Ionotropic receptor where ligand binds ion channel --> Responds in milliseconds

2. G-protein-coupled receptors --> Metabotropic receptor --> Ligand binds receptor which then opens a different ion channel --> Responds in seconds

3. Kinase-linked receptors --> Ligand binds receptor --> Signal transduction to nucleus --> Responds in hours

4. Nuclear receptors --> Ligand binds intracellularly --> Affects gene transcription --> Responds in hours/days

- Usually inhibitory

- Can bind enzymes of invading organisms --> Antibiotics and antivirals

- Can bind endogenous enzymes

1. Digitalis: Inhibits Na/K ATPase

2. Sildenafil/Viagra: Inhibits phosphodiesterase hydrolysis of cGMP

3. Physostigmine: Inhibits acetylcholine hydrolysis

- Bind and inhibit cellular transporters

1. Cocaine: Inhibits uptake of catecholamines and serotonin

2. Fluoxetine and other SSRIs: Inhibits serotonin reuptake

- Local anesthetics: Inhibit voltage gated Na channels in nerves around the injection site

- Ca Channel Blockers: Inhibit the voltage gated Ca channels --> Treats blood pressure, etc

- Bind to the cytoskeletal elements within cells

- Colchicine and vincristine: Interfere with microtubule polymerization

- Cyclophosphamide: DNA alkylating agent used in chemotherapy and immunosepression

- Infliximab: Monoclonal antibody against TNF-alpha

- Etanercept: Soluble decoy for TNF-alpha receptor

- Currently small molecular weight drugs (<1,000)

- Progression towards polypeptides, small proteins, macromolecules and nucleic acid based therapeutical agents

- Chemical

- Pharmacokinetic

- Physiological

- Pharmacological --> Reversible or irreversible competitive, non-competitive, and allosteric modulation

- Ability of drug to bind receptor depends on the dissociation constant (Ka)

- Rt=[R]+[AR]

- Ka=[A][R]/[AR]

- [AR]/Rt=[A]/[A]+Ka= 1/(1+Ka/[A])

- Ka is the concentration at which half Rt is bound to drug

- [AR] vs. [A] graph shows sigmoidal curve

- 

- The binding affinity of the drug to the receptor

- Values represented as EC50 or ED50

- Potency does not necessarily mean efficacy

- Right shift on graph shows decreased potency

- Overall therapeutic effect of a drug

- Represented as Emax for each drug

- Stimulus=e[AR] --> efficacy constant (e) relates the amount of receptor bound to drug to the effect

- Effect=f(e[AR]) --> Overall effect is represented as a function of the stimulus produced

- Efficacy does not necessarily mean potency

- Therapeutically efficacy means more than potency

- Based on relative shifts of graph for concentration vs. % response graph

- Read left to right for max to min potency

- Separate graphs for individual receptor types

- Drug binds to active site of enzyme

- Bmax stays the same but right shift of graph

- a'>a (right shift) for .5[AR] binding

- a'/a=1+[B]/Kb

- When [B]=Kb --> 2a necessary to produce the same effect as without presence of B

- Different Kbs are possible in different tissues --> Different receptor!!

- When [B]/Kb increases --> Increased inhibition

- B is partial agonist and A is full agonist

- A + B bind the same site

- Emax lower and right shift

- Graphs will have an upwards or downwards slope based on where the graph starts

- Emax for both will equal EmaxB

- Drug binds a site other than the active site but binding essentially inactivates receptor

- Emax will decrease

- Ratio of [AR] will decrease in response to increased [B]

- Potency will not change --> EC50 doesn't change

- Drug irreversibly binds active site --> Kills receptor

- Looks the same as non-competitive inhibition

- Emax decreases as B increases

- Long lasting response --> Depends on the cell/tissue turnover time

- Potency (EC50) of the drug does not change

- Represents the extracellular receptor reserve present on some cell types

- Rate limiting step is the binding of intracellular signaling components

- Generally is the case for skeletal muscle ACh receptors --> Rate limiting is the amount of actin/myosin in cell NOT ACh binding

- Can block many of these extracellular receptors and still get the same response

- Only 3% of receptors need to be bound to get .5 Emax

- Right shift for both Emax and binding ratio graphs

- Emax does not change but EC50 increases --> Apparent decrease in potency

- Decrease in binding ratio maximum

- No actual decrease in potency due to spare receptors still only needing 3% of receptors bound to produce .5 Emax

- Looks like normal competitive inhibition

- Still only 3% of receptors needed for .5 Emax

- Right shift for both effect and ratio of binding curves

- 3 fold shift for both curves

- Doesn't matter whether the spare receptors are present or not

1. Bell shaped curve --> Due to different receptors and different affinities --> Different receptors have opposing effects

2. Steep dose-effect curve --> Positive cooperativity --> Multiple binding sites

3. Shallow dose-effect curve --> Heterogeneity of receptors with different affinites

- Shows the basis of efficacy

- Receptors have an active and inactive state

- At rest, equilibrium favors the inactive state

- Agonist A has a higher affinity for the active state (Kinactive>Kactive)

- Agonist stabilizes the active form --> Enables the agonist to activate the receptor

- Competitive antagonists: Kinactive=Kactive

- Inverse agonist: Kactive>Kinactive --> Actively turns receptors off --> Negative efficacy

1. Summation: Effect adds

2. Synergism: Effect is more than the expected summation

3. Potentiation: One drug only works in the presence of another --> Increased potency and/or efficacy

- Allosteric modulation is an example of potentiation --> Benzodiazepines and GABA on GABA receptors --> Apparent left shift

- Flumazenil: Competitive inhibitor for the benzo binding site --> Allosteric antagonist

1. Tolerance --> Same dose doesn't have same effect

- Cross-tolerance: Drugs of same class show less effect

- Tachyphylaxis: Rapid change in receptor response

- Desensitization: Protein conformational change that reduces response to stimulus

2. Sensitization --> Increased response of receptor due to stimulus

- Bell-shaped frequency distribution

- Sigmoidal shaped cumulative frequency distribution

- Sigmoidal shaped curve is an integrated curve of the frequency distribution graph

1. Nature of variation

- Clearance and distribution (pharmacokinetic)

- Receptor number, type, location, and endogenous mediators (pharmacodynamic)

2. Sources of variation

- Genetic heterogeneity of the population

- Disease

- Physiological states

- Drug interactions

- Side effects: Pharmacologic, pharmacokinetic, allergic, idiosyncratic

- Toxic effects: Overdose and side effects

- Unintended or unexpected response

- Noxious

- Licit use

- Severe

- Ascribable to drug: Known effect of drug/class, no other cause, timing consistent with drug administration, consistent blood levels, and reproducible

- Therapeutic Index: LD50/ED50

- Standardized Safety Margin: (LD1-ED99)/ED99 x 100

- Possible to have the same therapeutic index but very different safety margins! 

- T.I. reported for all drugs, SSM not reported for most drugs

- Spontaneous improvement

- Subsiding toxic effect of previous treatment

- Bias

- Power of suggestion

- All ACh neutrotransmitter release

- All muscarinic receptors on target tissues (M1-M5)

- NE, dopamine and ACh released at target tissues

- NE --> Alpha and beta receptors

- Dopamine --> Renal vasculature (vasodilation)

- ACh --> Sweat glands onto muscarinic receptors

- Ciliary muscle: Mainly parasympathetic control (M2+M3) --> Constricts ciliary muscle (near-sighted)

- Heart: Under both parasympathetic and sympathetic control --> B2 receptors increase HR and contractility while M2 receptors decrease HR and contractility

- Blood vessels --> Under sympathetic control but M receptors in endothelial cells release NO

- Bronchiolar smooth muscle --> Relaxed by B2 and contracted by M2+M3 receptors

- GI tract --> Sympathetic generally decreases function and parasympathetic generally increases function

- Bladder --> Relaxed by B2 receptors and contractred by M3 receptors

- Skin --> Sympathetic control (alpha receptors)

- Liver --> Sympathetic control

- Autonomic nerve endings: Decrease neurotransmitter release

- Hemicholine transported into cell by transporter

- Turned into choline

- Bound with AcCoA --> ACh

- ACh packed into vesicles

- Vesicles released by nerve depolarization

- ACh is a quaternary ammonium with a permanent + charge

- Ligand-gated Ion Channel --> Ionotropic

- Present on autonomic ganglia and skeletal muscle

- Contains an extracellular and transmembrane portion

- Endogenous agonist: Acetylcholine

- Nicotine --> Highly toxic to nerves --> Depolarizes nerves

- Carbachol --> Binds both N + M receptors and resistant to esterases (Long half-life)

- Succinylcholine --> Also a muscle relaxant

- Hexamethonium --> Ganglion cell blocker --> Competitive and non-competitive inhibitor --> Plugs up ion channel

- Tubocurarine --> Derived from the poison arrow toxin crurane

- Atracurium

- Non-depolarizing muscle relaxants: Tubocurarine and atracurium

- Tubocurarine, atracurium and succinylcholine

- Succinylcholine is depolarizing --> Desensitization of N receptor

- Tubocurarine and atracurium are non-depolarizing --> competitive inhibitor of the N-receptor

- Surgical muscle relaxation

- Tracheal intubation

- Setting of fractures --> Particularly mandibular

- Electroconvulsive therapy

- Non-depolarizing --> Histamine release with tubocurarine --> Allergy-like response but not a true allergy

- Depolarizing --> Prolonged action in patients with atypical levels of cholinesterase, hyperkalemia and malignant hyperthermia

- More common in patients with burns, denervation and prolonged immobalization

- Can cause arrest due to massive K+ efflux from cells

- Increased K+ efflux causes massive depolarization of the heart

- Denervated muscle increases ACh receptors on the cell surface --> Increased sensitization to ACh so drastically increased response --> Massive K+ efflux

- Occurs with a genetic disorder --> Ryanadine receptor deficiency

- Particular in combination with inhaled anesthetics

- Skeletal muscle cells die in malignant hyperthermia --> Rhabdomyalisis --> Kidney failure

- Cosmetic

- Treatment of focal dystonias, spasticity, nondystonic muscle activity, localized muscle cramps, smooth-muscle hyperactive disorders, and sweating disorders

- Botulinum toxin interferes with the vesicle binding proteins --> One molecule is enough to kill axon terminal

- Effect can persist for weeks

- Muscle weakness --> Difficulty swallowing and breathing can occur

- Antitoxin is available but only stops toxin from entering cell --> Nothing can be done once toxin enters cell

- G-protein coupled receptor (M1-M5) --> 7 transmembrane segments

- M1,M3, and M5 --> Increase PLC activity, IP3 and DAG produced

- M2 and M4 --> Decreased adenyl cyclase activity --> cAMP levels decrease --> Increased K channel activation and decreased Ca channel activation

- Endogenous agonist: Acetylcholine

- Pilocarpine and muscarine

- Promoting bladder emptying

- Stimulating GI activity

- Treating xerostomia (dry mouth)

- Contracting pupil

- Treating narrow angle glaucoma

- SLUDGE: Salivation, lacrimation, urination, diarrhea, GI upset, and emesis

- Bronchoconstriction

- Hypotension

- Bradycardia

- M receptors normally constrict the bronchi, decrease heart rate and decrease blood pressure

- Antimuscarinic drugs

- Atropine and scopolamine

- Also pirenzepine and ipatropium

- Treating excess salivation

- Treating overactive bladder

- Reducing tremor

- Preventing motion sickness (scopolamine)

- Dilating pupil and cycloplegia for retinal examination

- Bronchodilation

- GI smooth muscle relaxation for endoscopy

- Reversing muscarinic agonist overdose

- "Dry as a bone, red as a beet, blind as a bat, and mad as a hatter"

- Dry mouth

- Dry, hot skin

- Dilated pupils

- Flush

- Hallucinations and delirium

- Hyperthermia

- Tachycardia

- Acute narrow-angle glaucoma

- Urinary retention

- Exacerbation of BPH

- Constipation

- Exacerbation of gastric ulcer & acid reflux

- Acetylcholinesterases break down ACh

- Inhibitors would increase the amount of ACh in terminal --> Effectively work as agonists

- Edrophonium (alcohol based)

- Donepazil (piperidine) 

- Physostigmine and neostigmine (carbamates)

- Parathion, malathion, soman, and isoflurophate (organophosphates)

- First generation of antihistamines

- Tricyclic antidepressants

- Side effects are much more prominent in the elderly

- Treatment of Alzheimer's disease, myasthenia gravis, glaucoma, postsurgical paralytic ileus, and urinary bladder atony

- Acclerating recovery from non-depolarizing muscle relaxants

- Antimuscarinic antidote

- Has many of the same uses as muscarinic agonists

- Organophosphates soman and isoflurophate are nerve gases

- SLUDGE and bronchoconstriction

- Confusion, convulsions, and coma

- Delayed development of peripheral neuropathy

- Neuromuscular blockade

- Pralidoxime --> Cholinesterase regenerator --> Antidote carried around by soldiers in the Gulf War in case of nerve gas exposure

- Norepinephrine made from tyrosine

- Tyrosine --> Dopamine --> NE

- NE, Epi, and Dopamine are not broken down in the synapse

- NE, Epi and Dopamine are passively and active transporters for reuptake

- Different potency of neurotransmitters for different receptors

- A1, A2, B1, B2, and D1 receptors

- A2, B1 + B2, and D1 receptors work via adenylyl cyclase activity

- B1, B2, and D1: Increase cAMP

- A2: Decreases cAMP

- A1 receptor: Activates PLC --> IP3+DAG --> Ca release --> Ca dependent kinase

1. A1: Vasoconstriction, Increased TPR, Decreased venous compliance, GI and GU function/muscle relaxation, dilates pupil through contracting the radial muscle, and increases glycogenolysis and gluconeogenesis

2. A2: Decreases insulin secretion, NE release, and sympathetic tone, and stimulates platelet aggregation

3. B1: Increased force of contraction, HR, and AV conduction velocity, and increased renin release

4. B2: GI smooth muscle relaxation, increased glycogenolysis in skeletal muscle and liver, and gluconeogensis in liver

5. D1: Dilates renal vasculature

- Endogenous: Epinephrine (A+B), norepinephrine (A +B1), and dopamine (D1, B1>B2)

- Phenylephrine (A1)

- Clonidine (A2)

- Isoproterenol (B1+B2)

- Dobutamine (B1)

- Albuterol (B2) and terbutaline (B2)

- Inhibit NE reuptake or stimulate its release

- Amphetamine, methyphenidate, and cocaine

- Ephedrine: Found in many supplements

- Tyramine: Found in foods and produced by gut flora --> Stimulates NE release --> Problem in patients on MAOIs -> Increased NE release --> Dangerous vasoconstriction and stroke

- Octopamine: Metabolite from tyramine --> Inactive replacement for NE --> Causes decreased NE tone with chronic MAOI treatment or high tyramine diets

- Baroreceptors: Increased firing with decreased BP --> Inhibits parasympathetic firing --> Increased HR, BP, and CO via A1+B1 receptors

- Renin-Angiotensin System: Released in response to decreased BP --> Increasese BP

- Must take into account these feedback mechanisms when dealing with agonists and antagonists

- Epinephrine: Decreased diastolic pressure (B2), increased systolic and CO (B1), increased HR (B1), and decreased TPR (B2)

- Norepinephrine: Increased TPR (A1), increased BP (A1), and decreased HR (reflex) --> Physiological antagonism between NE + ACh

- Isoproterenol: Decreased TPR (B2), decreased BP (B2), and increased HR (reflex)

- High doses of epi --> A1 binding

- Lower doses --> More B binding --> Direct B1 effect on heart without reflex response

- Add muscarinic antagonist (atropine) in order to eliminate reflex responses

1. Cardiovascular

- A1 receptor targets: Nasal decongestants, extend local anesthetic action, resuscitation after cardiac arrest, antidote to hypotensive drug, and maintaining BP in spinal damage or anesthesia

- A2 targets: Treatment of hypertension

- B1/D1 receptor targets: Restoring BP in cardiogenic shock

2. Ophthamology

- Mydriasis (A1) and glaucoma treatment (A1 + A2)

3. Allergic

- Asthma (B2) and anaphylactic shock (B2 + A1)

4. Other uses

- Delay premature labor (B2)

- Treatment of opiod withdrawl (A2) --> Decreased sympathetic tone

- Treatment of ADD

- Approaches: Decrease aqueous humor production or increase outflow

- Prostaglandins and B1 blockers are the most commonly used

- B1 blockers: Decreases aqueous humor production

- A2 agonists: Increases outflow and decreases production

- mACh agonists and AChE inhibitors: Increases outflow

- Carbonic anhydrase inhibitors: Decreased aqueous humor production

- Prostaglandins: Increased outflow

- Vasoconstriction and organ ischemia (A1)

- Hypertensive reactions (A1)

- Rebound nasal congestion (A1)

- Withdrawl symptoms (A2) --> Needs to be tapered for this reason

- Tachycardia (B1)

- Cardiac ventricular arrhythmias (B1)

- Myocardial ischemia (B1)

- Increased risk of asthma exacerbation with extended use

- CNS stimulation (unclear)

- Prazosin (A1), propranolol (B1+B2), metoprolol (B1), and carvedilol (B1+B2+A1)

- Also phentolamine (A1+A2), phenoxybenzamine (A1+A2), yohimbime (A2), pindolol (B1+B2), esmolol (B1), and labetalol (B1+B2+A1)

- Treatment of hypetension, pheochromocytoma, Raynaud's Disease, heart failure, and BPH

- B-blockers may be used but only AFTER use of an A1 blocker --> Specifically phenoxybenzamine

- Antidote to A-agonist overdose

- Postural hypotension leading to reflex tachycardia, myocardial ischemia (angina), salt + water retention, and peripheral edema

- Salt + water retention due to B receptor stimulated renin release

- GI stimulation/overactivity

- Inhibition of ejaculation

- Managing heart failure --> Standard of care

- Reducing mortality after MI --> Minimizes ventircular arrhythmias 

- Treatment of hypertension, cardiac arrhythmias, hyperthyroidism, anxiety, and open-angle glaucoma

- Relief of angina --> Decreases HR

- Migrain prophylaxis --> Reduces the likelihood of migraines

- Bronchoconstriction (B2)

- Bradycardia (B1)

- Fatigue

- Cold extremities --> Excessive A receptor tone

- Potentiation of epinephrine vasoconstriction

- Precipitation of CHF

- New onset diabetes

- Withdrawl symptoms: Exacerbation of angina with risk of sudden death

- Must be tapered down, do NOT suddenly stop!!!

- Epi-pen injection in finger

- Risk of localized tissue damage --> Necrosis

- Dramatically increased A1 stimulation in localized tissue

- Treat with prazosin (A1 antagonist)

- Produced in mast cells and basophils

- Released by bradykinin, C3a, C5a, antigen binding to IgE, and basic drugs such as tubocurare, opioids, and vancomycin

- Must be careful giving patients opioids for fear of histamine release and allergy-like response

- Histamine-induced reaction

- Triple Response of Lewis

- Red spot due to vasodilation

- Flare due to axonally mediated reflexive vasodilation

- Swelling due to increased vascular permeability

- H1 receptor: IP3/DAG --> Ca++ --> Vasodilation due to NO release, increased vascular permeability, large vessel contraction, itch and flare due to nerve stimulation, and CNS arousal

- H2: cAMP --> Stimulates acid secretion by parietal cells, relaxes vascular smooth muscle in GI tract, and increases HR and force of contraction

- High selectivity for H1 vs. H2 receptors

- Weak selectivity for H1 vs. other receptors

- Has antimuscarinic activity, alpha adrenergic antagonistic activity, and 5HT antagonist activity

- Also can be used as a local anesthetic

- Sedative effect due to its ability to cross BBB

- Histamine-induced allergic reactions --> Itching, rhinitis, conjunctivitis, and urticaria

- Histamine-induced symptoms of mastocytosis and myelogenous leukemia

- NOT bronchodilators --> NOT for asthma

- Nausea, vomiting, motion sickness, and sedative/sleep aid

- Atropine-like/Antimuscarinic effect

- Fixed, dilated pupils

- Dry mouth

- Tachycardia

- Urinary retention

- Hallucinations

- Fever

- High selectivity for H1 

- Minimal antimuscarinic effects

- Lower incidence of sedation --> Carboxylate residue limits crossing BBB

- RARE

- Increased risk of sudden death due to ventricular arrhythmia (Torsades de pointes) --> Prolongued QT interval and inhibition of K+ channel in the heart

- Drugs periodically taken off the market and reintroduced in an other formulation (first metabolite used as drug instead)

- Shifts payment from third-party payer to the consumer

- Increases drug use

- Decrease in physician visits

- Decreased payments for insurance companies in regards to this drug

- Aspirin, ibuprofen, and acetominophen

- Nonopioid/nonnarcotic

- Antipyretic analgesics

- COX 1 + COX2 inhibitors

- Phospholipids from cell membrane

- Arachidonic acid --> Prostaglandins and thromboxane via COX1 + COX2

- COX1: Constitutively active, maintains GI integrity and activates platelet aggregation

- COX2: Inducible by proinflammatory mediators and maintains ovarian and renal function

- Acetylation by aspirin (salicylates) --> Irreversible

- Generates anti-inflammatory mediators --> 15-lipoxin epimers

- COX 1 Inhibition --> Blocks channel and reversible

- COX 2 Inhibition --> Channel side pocket allows for selectivity and time-dependent inhibition

- Decreases body temperature but stimulating sweating and increased cutaneous blood flow (flushing)

- Response due to decreased amounts of PgE synthesis within the hypothalamus

- Must avoid salicylates in children with viral infections --> Reye's Syndrome

- Use acetaminophen (Tylenol) in children

- Major metabolites: Inactive polar conjugates

- Minor metabolites: CYP450 oxidation product --> Causes centrilobular hepatic necrosis

- Minor metabolite is inactivated by glutathione

- Salicylates

- Ibuprofen and congeners

- Diclofenac

- Indomethacin

- NOT acetaminophen

- Inflammation of joints caused by RA, PA, and OA

- Inflammatory bowel disease --> Ulcerative colitis and Crohn's disease --> Prodrugs or formulations that deliver 5-aminosalicylic acid

- Inhibition of NF-kB transcription factor

- Cytokines

- Chemokines

- Adhesion molecules

- Receptors

- Cell proliferation genes

- Cell growth genes

- Cell differentiation genes

- Rel and IkB (NF-kB inhibitor) proteins

- Due to COX1 inhibition

- Aspirin is a selective and irreversible platelet inhibitor --> Lasts for about 1 week

- NSAIDs also prolong bleeding time

- Acetaminophen does NOT affect platelet function

- Antiplatelet: 81 mg/day

- Analgesia: 650-1000 mg/day

- Anti-inflammatory: 3g/day

- May block vasoprotective prostacyclin synthesis by endothelial cells

- Prostacyclin is a vasodilator and platelet inhibitor

- This is due to the fact that prostacyclin is produced by COX2

- Increased clotting risk with inhibition

- Much higher risk in patients with atherosclerosis --> May cause excessive clotting and may cause MI

1. GI --> Dyspepsia, GI bleeding, erosions and ulcers

- Due to COX 1 inhibition

2. Renal --> Sodium retention and edema, papillary necrosis and interstitial nephritis

- Due to decreased prostaglandin production in the kidney

- Due to COX2 inhibition

- Bronchospasm, rhinorrhea and/or hives

- Induced by NSAIDs except acetaminophen

- More common in asthmatics

- Mediated by leukotrienes

- Due to both COX1 + COX2 inhibition

- Antimalarials

- Sulfasalazine

- IL-1 receptor antagonist

- Immunosuppressants such as TNF-A antagonists, methotrexate and glucocorticoids

- High MW proteins

- IV or SC administration possible

- Long half-lives --> Given every couple weeks

- Indicated for arthritis and inflammatory bowel disease

- Very expensive and not always covered by insurance

- Monoclonal antibody or solubilized receptor --> Same overall effect but different pharmacokinetics

- Endogenous: Cortisol --> Equal affinity for GC and MC receptor

- Cortisol is turned into cortisone via 11B hydroxysteroid dehydrogenase in kidney, salivary gland, and colon

- Cortisone has low affinity for MC receptor

- Exogenous: Dexamethasone and prednisone

- Interaction with cytosolic hGR alpha

- Translocation into nucleus

- Binding to GRE --> Promotes gene expression

- Interaction of GR with transcriptional regulations

- Inhibits gene expression

- Antagonises NF-kB --> Increased transcription of I-kB --> Decreased cytokine and chemokine transcription

- Blocks the release of prostaglandins and thromboxane A --> Increased transcription of lipocortin and decreased transcription of COX2

- Decreased conversion of arachidonic acid to PGs and leukotrienes

- Decreased extravasation of leukocytes

- Decreased fibrosis with reduced production of collagen

- Inhibition of macrophage activity

- Inhibition of cytokine secretion by macrophages and T-cells --> IL-1 through IL-6, IL-8, TNF-A, cell adhesion factors, and GM-CSF

- Inhibition of T and B cell replication

- Decreased IgG production

- GC selectivity: Dexamethasone --> 36-72 hours

- MC selectivity: Fludrocortisone --> 8-12 hours

- Longer half-life and duration of action

- All have the same 11-OH moiety --> Essential for GC receptor binding

- Replacement therapy for adrenal disorders or after removal of an adrenal tumor --> High doses of hydrocortisone or hydorcortisone and fludrocortisone combination therapy

- Asthma and COPD

- Severe allergic reactions

- RA and Lupus

- Psoriasis or other dermatologic disorders

- Ulcerative colitis, Crohn's disease or other GI diseases

- Cerebral edema

- Bell's palsy or other cases of neural inflammation

- Leukemias and lymphomas

- Tissue grafts and organ transplants

- Prematurity to increase lung maturation

- Anorexia

- Nausea and vomiting

- Fever

- Joint or muscle pain

- Postural hypotension

- Single large doses are safe

- Beneficial effects only palliative

- Prolonged treatment is NOT safe --> Cushing's syndrome, etc

- Cushing's syndrome

- Moon face, buffalo hump, and trunkal obesity

- Muscle wasting

- Poor wound healing and increased infections

- Skin striae

- Facial flushing

- Osteoporosis

- Hypertension

- Hyperglycemia

- GI ulcers

- Cataracts

- Behavioral disturbances

- Local administration through aerosols, nasal sprays, topical preparations, joint injection, and intrathecal

- Slow release capsules with high first pass effect

- Calcineurin inhibitors --> Blocks T-cell signaling and IL-2 synthesis --> Good for organ transplants

- Antiproliferative agents: Block T and B cell replication and purine antimetabolites (methotrexate)

1. Target CD3 on T-cells --> T-cell depletion and loss of immunocompetence (muromonab)

2. Target IL-2 receptors on T-cells --> Blocks T-cell activation (daclizumab)

3. Target a4-integrin on lymphocytes and monocytes --> Blocks T-cell interaction with VCAM-1 for diapedesis (natalizumab)

- Endogenous: Morphine, Met-Enkephalin, and codeine

- Semisynthetic: Heroine and hydromorphone

- Synthetic: Meperidine, methadone, and fentanyl

1. Pro-Opiomelanocortin (POMC) --> B-endorphin, MSH, and ACTH

2. Pro-Enkephalin A --> Met-Enkephalin and Leu-Enkephalin

3. Pro-Enkephalin B --> Dynorphin A --> Acts on nerve pathways

4. Pro-Orphanin --> Orphanan (Nociceptin)

5. Endomorphins 1 and 2 from an unknown precursor --> Tetrapeptides that maintain BP

- Depends on duration of action and half-life

- Long acting: Methadone and levorphanol --> Over a day

- Medium acting: Morphine and hydromorphone

- Short acting: Meperidine, fentanyl, and remifentanil --> Shortest action of <5 min

- M (1,2...)/MOP: Sufentanil/morphine, B-endorphin, and endomorphin-1

- K (1,2,3)/KOP: Nalorphine and dynorphin-A

- D (1,2,3)/DOP: Enkephalin, DPDPE

- ORL/NOP: Nociceptin

- Analgesia

- Respiratory Depression

- Sedation

- Vasodilation

- Bradycardia

- Nausea and vomitting

- Miosis

- Smooth muscle spasm

- Skeletal muscle hypertonus --> Decreased GABA release

- Tolerance

- Physical Dependence

- M, K, and D receptor agonists

- Decreased Ca influx and neurotransmitter release

- Decreases pain perception

- Increases K efflux post-synaptically --> Hyperpolarizes

- Opioid receptors found in peri-aqueductal gray --> Inhibits pain pathways in the spinal cord

- Stimulates the opioid receptors in the limbic system --> Decreases emotional response to pain

- Fentanyl --> CYP3A4 and CYP3A5

- Remifentanyl --> Hydrolyzed by esterases throughout the body --> Short half-life

- Codeine --> CYP2D6 --> Demethylates to morphine

- Morphine --> Glucuronidated to morphine-3-glucuronide and morphine-6-glucuronide

-Morphine-6-glucuronide: Active metabolite --> Thought to be the analgesic responsible for chronic administration since it has a long half-life in the CNS

- Meperidine/Demerol --> De-esterifies to norpethidine

- Normeperidine: Convulsant --> Dangerous in patients with renal failure

- Codeine --> Converted to morphine, then CYP2D6

- CYP2D6 deficiencies: No morphine production so little effect (Caucasians)

- Hypermetabolizers: Increased morphine production so much higher effect (North Africans) 

- Due to M receptors

- Right shift compared to analgesia

- Determined by testing the response to CO2: With higher CO2 levels, patient should breath faster but pt doesn't

- Treat with nalaxone to reverse respiratory issues

- Sleep perpetuates the respiratory depression

- Opioids stimulate the chemoreceptor trigger zone (CTZ)

- CTZ then stimulates the vomitting center

- Vomitting center is also stimulated by activation of the middle ear as with moving around

- Localized opioid receptors in the gut lining

- Slows peristalsis

- Reduces GI secretions

- N-methylnalaxone used to treat --> Has a quaternary ammonium so doesn't cross BBB --> Only alleviates constipation

- Naloxone

- Naltrexone

- Nalorphine

- Buprenorphine

- Vasodilation --> Centrally-mediated and both venous and arterial

- Bradycardia

- Shouldn't effect myocardial contractility, vascular reflexes with catecholamines, and sympathetic reflexes

- Opioids cause mast cells to degranulate and release histamine

- Hives, erticarya, and wheal and flare reaction

- No true immunologic response

- Very rare to have a true allergy to opioids

- Cross-tolerance also but incomplete --> Multiple receptor subtypes

- Possible mechanisms:

1. Phosphorylation and internalization

2. Increased signal transduction enzymes to compensate

3. Compensatory pain pathways with NMDA and NO

- Can become immune to opioids --> Tolerance of orders of magnitude

- Affects analgesia AND respiratory depression by the same magnitude

- Does not affect constipation and pupil constriction

- Causes withdrawl symptoms when administration stopped

- Symptoms: Nausea, vomitting, gooseflesh, mydriasis, sweating, muscle spasms, rhinorrhea, diarrhea, weight loss, and fever

- Stopped by a small dose of opioid

- Behavioral problem with drug seeking behavior

- Overwhelming preoccupation with obtaining and using the drug

- High tendency to relapse after withdrawl

- Long-acting drug

- Oral administration --> No needles

- Reduces drug seeking behavior

- Regular contact with caregivers

- Agent of choice for detoxification

- Patients often say they feel like they're chained to the clinic

- Buprenorphine is a partial agonist --> More potent but less effective

- Very high M receptor affinity

- Addition of buprenorphine reduces the maximum effect of heroin for the user

- Essentially works as a morphine antagonist

- Marketed with naloxone --> If injected, naloxone reverses the effect of buprenorphine, so no high results

- Can be prescribed by PCP --> Patients not tied to a daily clinic

- Range from 3-60 mg

- CYP2D6 polymorphism would cause decreased responsiveness to codeine/morphine

- Concommitant diseases such as renal failure can affect response and elimination

- Age, gender, and receptor polymorphisms

- Botanical extracts

- Alcohol used as a solvent

- No controls over the content

- No controls over the claims of efficacy of the product

- Ex. Lydia Pinkham's Vegetable Compound --> Promoted for women's ailments (19% alcohol)

- 1902: Federal controls over vaccines

- 1906: Food and Drug Act --> Drugs shipped in interstate commerce must be labeled properly according to ingredients

- 1912: Amendments --> Prohibition of false advertising claims

- 1936-1937

- Elixir (alcohol) formulated with diethylene glycol (antifreeze) as solvent

- Resulted in over 100 deaths due to antifreeze poisoning

- Mislabeling conviction --> Elixir means alcohol

- Required proof of safety

- Drugs shipped in interstate commerce must be proven to be experimentally safe

- Must show efficacy for whatever the drug is labeled for

- Passed in 1951

- Distinction between over the counter and prescription drugs

- Standards of labeling and safety that apply to each group

- In 1961 --> Thalidomide given to patients suffer from morning sickness during pregnancy

- Found to cause the major limb malformation in babies in Europe

- FDA denied approval in the US

- Set the climate for regulation reforms in the US

- Passed in 1962

- Requires proof of effiacy experimentally

- Label and advertisements must list all ingredients and side effects

- Subjects in clinical trials must give informed consent to participate in trial

- Passed in 1991 to safeguard subjects in clinical trials

- Trial must be approved by an Institutional Review Board (IRB)

- Are subjects rights and welfare protected?

- Are risks to subject outweighed by the benefit or importance of new knowledge?

- Has subject given informed consent without coercion?

- New molecular entities, drug combinations, dosage forms and diagnostic tools

- Vaccinations and cell products

- Medical devices and materials

- Dietary supplements --> Prohibits false advertising only

- In order for a drug to come on the market efficacy and safety must be proven

- Dietary supplements can come on the market without proving efficacy and safety --> FDA must prove inefficacy and not safe in order to take it OFF the market

- In-vitro testing

- Animal testing

- Can take up to 4 years

- Submitted after animal trials have concluded

- Must provide information about the animal trials, composition, manufacturing, clinical protocols, and clinical investigators for the study

- Must be approved by the FDA before clincal trials begin

- Pilot study using 20-80 healthy volunteers

- Helps determine safety and pharmacokinetics

- Non-blinded study

- Only about 20% of drugs are approved through phase I

- 100-200 patients with target disease

- Placebo vs. active-drug controls

- Single-blinded study

- Only about 30% of the tested drugs make it through testing

- About 5,000 patients with target disease

- Determines the efficacy for indication and side effects

- Double-blinded and cross-over design with placebo or active control subjects

- About 70% of drugs make it through

- Submitted after Phase III trials by the pharmaceutical company

- Must submit the label as well

- Available in the Physician's Desk Reference

- Must contain the chemistry, pk, indication, side effects, toxicity, contraindications, dosage, and information for special populations

- Takes a fair amount of time for NDA to get reviewed and approved --> Delays availability for drug on the market

- Each drug costs about 1 billion dollars to bring to market

- Additional trials and post-marketing surveillance

- Helps detect the low-incidence side effects

- Physicians and hospitals report to the FDA and the manufacturer about the drug

- May result in a black-box warning on the label or a recall of the drug

- Drug cannot be shipped across state lines for any reason other than the label indication

- Physician may prescribe for off-label use for individual patients

- Companies may not advertise the use of a drug for off-label usage

- Label indications can change over time

- Work to approve generic versions

- Provide patient access to drugs in development

- FDA requires fees to drug sponsor for NDA review --> Means that there is an incentive to provide more complete data when submitting an NDA

- Patent lasts for 20 years

- Patent filing usually occurs early in development

- Effective patent for less than 14 years

- Generic formulations are heavily marketed after patent expires

- An additional NDA must be submitted for generic to be approved

- Must prove bioequivalance and equal relative bioavailability --> Reported in the "The Orange Book"

- Regulation passed as the Drug Price Competition and Patent Term Restoration Act in 1984

- Biologics Price Competition and Innovation Act (2009): Generic version of biologics --> Will be known as biosimilars

- Through Treatment INDs

- Allows access for patients to promising drugs in the late phase II or phase III clinical trials

- Regulatory safeguards still apply to patients

- Sped up access to HIV drugs back in the 1990s

- Prioritizing NDAs

- Priority for new drug classes or drugs with important therapeutic gain

- Standard for modest therapeutic gain or "me-too" drugs

- Prescription Drug User Fee Act (1992): Required manufacturer to cover NDA review

- Passed in 1997

- Access to information on clinical trials --> ClinicalTrials.gov

- Incentives for clinical trials for children

- Improve post-marketing drug safety surveillance and review of TV advertising

- Is the FDA serving the public need?

- Are the labeling requirements inadequate?

- Is supply-chain globailization overtaxing the inspection capabilities of the FDA?

- Only possible in the US and New Zealand

- Substantial expenditure since about 1997 --> 6 billion dollars in 2006

- Effective marketing strategy --> Increases consumer awareness of drug products, increases consumer request for brand name drugs, and increases prescribing by physicians

- Regulation by state legislation

- Prescribers must provide their name, patient's name, drug name, dose, quantity, insructions for use, refills, date and physician signature

- Moving to e-Prescribing

- MA monitors Class II-Class V scheduled substances

- Passed in 1914

- Regulates the production and use of narcotics (opioids, cocaine, and marijuana)

- Enforced by the Federal Bureau of Narcotics (Treasury Department) --> Tax physician prescriber

- Passed in 1970

- Decreased the availability of drugs to potential abusers

- Enforcers --> DEA (Department of Justice)

- 

- Schedule I: Heroin, marijuana, and LSD --> Research use only/illegal

- Schedule II: Morphine, amphetamine,cocaine, and barbiturates --> No prescription refills --> Highly addictive

- Schedule III: Codeine and steroids--> Limited refills --> Less addictive but still addictive

- Schedule IV: Benzodiazepines --> Limited refills --> Less addictive but still can be addictive

- Schedule V: Antitussives with low codeine --> Can be OTCs --> Low addictive potential

- Low FDA regulation --> Leads to varying levels of components in the supplement and possible to find toxic heavy metals in supplements

- Label must contain name and amount of product, health claim, nutrient content claim, and structure/function claim

- About 20% of Americans take an herbal supplement

- Used to treat GI issues, musculoskeletal issues, anxiety/depression, insomnia, headaches, and menopause

- Taken orally or applied topically

- Ex. red yeast rice vs. lovastatin for cholesterol