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229 Cards in this Set
- Front
- Back
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APAP overdose is the leading cause for call to Posion control centers
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YES
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APAP is overdose and alcohol is assoicated with
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Actue liver failure
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COX-2 inhbitors were developed ont he premise the these more selective agents would lead to reduction in pain and imfalmamtion, hwoever what seem to be a class effect of all COX-2 inhibtior
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cardiovascular toxicty is a class effect--
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What are types of drug related problems
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overdose, sub thearapetic use, drug interaction, ADR, untreateated,
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What is the major cost of drug related morbidity and moraility
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drug-related hospitalizaotin
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What is difference between a drug recall and drug withdrawl
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drug recall is temporary
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In most cases FDA drug recall are done volunatrily
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YES
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What are the categories of drug recalls
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Class I
Class II Class II |
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What are Class I recalls
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recalls for danegous or defective products that coudl cause serious health problems or death
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What is Class II recall
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recalls for pudcts the MIGHT cause a TEMPORARY health problems or pose slight threat of a serous nature
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What is Class III recall
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recalls for products are are UNLIKELY to cause any adverse health reactions, but violate FDA regulations
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What is definintion of drug
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chemicals foregin to the body that can use to treat disease
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Drugs can cause desirable (therapetic) and undesisable effects, what are 2 types of undersirable effects
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1. non-deleterious
2. delterious |
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What are non-deleterious
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side effects
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What are deleterious
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toxci effections that can be pharamcological, patholigical or genotoxic
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Undesirable effects are deletrioues to humans and are referred to as adverse, deetlerios or toxic which inlcude
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allergic reactions
idosyncratic reactions immediate and delayed toxicity reversible and irreversbile toxicity |
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What is the definaiton of toxicology
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science of adverse effects of chemicals on living organisms
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Toxicology disiclpine is divided into several areas which are
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descriptive
mechansistic regulatory |
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What is descriptive
mechansitsic regulatory toxicology |
descriptive--evaluating risk fo exposure to particular chemical
mechansistic--detmeine how the exert their effects regulator--judes wther a drug has low enough risk to jusity making it availbe to humans |
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All substances are poison, toxicity depnds on
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the dose, type of substance, and freqnecue of exposure
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What is dose, and how evaulated
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the quantity of the compound receive the by organsism--evaluated by dose response
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What are the major pathways which toxic agents gain access to the body
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GI
Lungs Skin other |
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What is seelctive toxciity
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a drug may affect a partulcar cell type b/c of its uptake, meatolism or inhert properties of cell
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What is selctive toxicity of APAP
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liver
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Does ADME affect toxic response
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YES
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Rate of absroption depends on
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lpipid solubility and % ionization
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Distribution is the concentration of the compound in the plasma--comounds that distributed to ALL tissue will ahve
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low plasma concentration and high volume of distribution
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Substances taht are ionized at pH of the plasma will NOT
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distribue well
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What is biotransformation
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making lipophilic substance more hydrophilic
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Metabolism is the body's reponse to
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lipophilic substance and converts to hydrophilic to excrete
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Drugs are converted to oxygenated intermidates that are ACTIVE, than
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conjugated to innoucous production and then excreted
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The more rapidly compounds are excreted,
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the less likely ther are to accumtulated and exert toxic effects
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What are major routes of elmination
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urine, bile, lungs, secretion into GI, and body fluids
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What is the utility of studing mechanisms of toxciity
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predictino of drug toxicity
design antidotal therapies health risk/regulatory limits monitor elucidation selective toxicity cuase/progession of disease state |
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What are electrophils
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agetns that are electron deficient
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What are examples of electrophiles (nonionic/cationic)
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ketones, expoxides, aldehydes and quinones/quinonemimies_
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When are electrophiles produced
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drug the drug oxidation and covalent modification
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What is toxiciological importance of electrophiles
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they permanenetly ALTER the endougenous molecules
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Electrophiles interaction with 2 items
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1. DNA
2. Proteins |
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What is major player in APAP metabolism for toxicity
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CYP2E1
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In APAP overdose, excess APAP is metabolized by CYP2El, result in formatino of
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NAPQI
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NAPQI is usually immetidately converted to
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inactive by GSH or glutatione
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However is too much NAPQI is made then glutathione stores are depleted and results in
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NAPQI is an electrophile, and destroys liver
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What is a free radical
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compound with an unparied electrion
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How are free radicals produced
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oxidation/reduction rections by photolyis or radiation, where release or uptake an electron or cleave a covalent bond
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What are toxic consequences of free radicals
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1. interactions with DNA
2. Oxidative damge 3. lipid oeroxidation |
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Free radicals can interact with DNA (nucleic acis) result in damage, what happens with adriamycin
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radicals interaction and generate a hydroquione that binds DNA
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Redox cycling (bleomycin) can damage DNA in 2 ways
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hydroxyl radial react with sugar phoshapte backbone
ROS (reactive oxyen) can cause oxidative damage |
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Lipid peroxidation is a
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chain reaction of free radicals with PUFA and choesterol
poly-unstaurated fatty acids) |
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What are consequences of chain recation of free radical with lipids
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destory cell memabrane and elads to functional impairment of membrane bound proteins
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Lipid peroxidation reaults in generation of
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aldehydres (4-hydoxynoneal) which can cause protein modficaiton
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What are 3 distrubances of cellular mechansism
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distrubance of ionic balcnes, energy prodution, and redox balance
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WHat is the IDEAL protective mechanism of cellular defense
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excretion
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What are the protective processes against drug metabolites
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generation of polar metabolites, and enzymes
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What are the protective processes against free radicals
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1. enzymatic/non-enzymatic antioxidants
2. metal sequesting agents 3. DNA repair |
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What are the 3 polar metabolites
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1. sulfation (sulfotransferase)
2. glucuronidaiton (UDP lucoronyltransferases) 3. Glutathione-glutathion S-transferase |
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Glutathione is a tri-peptide tath plays a central role in cellular defrence,the reaction with GSH can be either
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chemical
enzymatic |
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GSH can directly inreact with the chemical by
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direct conjugation by addition, or direct conjugation by displacment
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Thre reaction with GSH can also be enzymatic via
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Glutathion S-stranserse
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Glutation is present in HIGH concetrations
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human erythocytes 2mM
hepatocytes 5mM up to 10mM |
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Where are mebrane bound GST foudn in
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ER and outer mitochorniral membrane
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Glutathion conjugates may be excreted
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in the BILE unchange, or undergo metabolism to mercapturic, which is excreted in URINE
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What are protective enzymes againsts drug metabolites
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1. DT diaphorase-NQo1
2. ALDH (aldehyde dehydrogenase) |
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What does NQ01--(NADPH-quinone oxidoreducaste prevent
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adds to 2 electrons that prevent free radicals
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What does aldehyde dehydrogenase do
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converts aldehyde to non-toxic carboxcili acid, can be excreted
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The protective mechansims against Free radicals are enzymatic antioxidation/nonenzymatic, adn metral sequesting agents and DNA repair--
What are the enzymatic antioxidants |
Superoxide dismutase, Catlase, Glutathione Perodixse,
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What are the Non-enzymatic antioxidants
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Vitae E and C
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What does Superoxide dismutase do
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converts superoxide radical to hydrogen peroxide
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What does Catalase and Glutathione peroxidase do
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convert Hydrogen peroxide to water
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GSH is converted by GSH peroxides to GSSG, what is needed to recycle GSSH back to GSH
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GSSG reducase and NADPH
NADPH is regenerted by G6PDH |
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What is Vitamin E
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lipid solulbe compound that protect against lipid peroxidation
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What is Vitamin C
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water soluble radial scavenger
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Can Glutathion be both an anti-oxdiation and polar metabolite
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YES
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What is teh metal sequesting agents MOA
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CHLEATION--formation of a metal complex
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Ideal chelating actings should
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be water solution,
resistant to meabolism formin non-toxic complexes low affinity for essentail metals |
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Chealting should have LOW affintiy for essentail metals ,pariculatly
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calcium and zinc
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What allow for DNA repair
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06 methylguanine-DNA methyltransferase
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Methlattion attached to base of O6 methylguanine and commints sucidice to
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remove methyl group
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Antioxidants do not cure but may
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prevent degration and loss
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What are the 4 main functions of the liver
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1. Bioactivation and detoxifcation
2. Repsiraotion 3. Storage |
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What is the respiration component of liver function
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metabolizes sugars and aa through krebs ccyle
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Toxcity moves from Zone 1 to
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Zone 3
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The liver is 97% heaptocytes but also contains
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Kepler cells
Fat-stroign cells (Stellate) Endotherlia cells |
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What are the 6 mechanisms of liver toxcity
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1. Distruption of Ca+ homeostatis--necoris
2. Choelsttis--Accumation of biles 3. Drug-metabolism induced 4.Immune response 5. Apotisis 6. Inhibting B-oxidationa or respsiration, increases lactate and O2 reactive |
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Drug induced toxicity of liver can be divided into
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Idiosyncratic
Predictable |
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Idiosyncratic reactions occur indepcnetly from dose, and 2 types
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hypersensitivity
genetic polymorphislsm |
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What is an example of hypersenstivity
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acute choestatic hpeatitis after fulfasalazine
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What is an example of genetic polymorphism
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Isnonizid
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What type of reactions ARE dose dependent
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predictable reactions
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What is an example of direct toxoity
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APAP
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What are 2 clinical scenarios that cause driect toxic reaction
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1. interntionl suicidual overdose
2. therapetic misadvnation |
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As long as enthanol remains in the body there is competition between APAP and ethranol for
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CYP2E1--NAPQI formation is diminshed when alcohol is present
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NAPQI formation is diminshed when alcohol is present, however 24 hrs after cessation of alcohol
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NAPQI formation is enhance result in increased heaptic injury 24hrs after cessation alcohol
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The classic Idiosyncratic reaction is
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Isonizaid
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What is classic Toxic and Allergic reactions
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Halothane toxicity
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Toxicity from halothane requires multiple exposures, and pts present with centrolbular necossis in 1 of 2 ways
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1. Eelevation of serum transaminases
2. N/V upper abd pain and juaice |
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What is early stage of Halthane toxic-allergic reactions that can be easily treated
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Elevation of serum transaminases with NO external symptoms
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N/V upper abd pain,and juanidece represent MORE advanced stage of liver damge, and without intensive care is
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fatal
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What is Cholestatis
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decrease volume of bile formed or imparied secretion
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What drug induced hepatocelluar choestatis
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chlropromazine--usually in the 1st 4 months
captopril, sulfonamides, suflonglyeruea, and eryhtomycin |
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Cholangiodestruive choestatis is AKA
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blue duct damage
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Bile duct damage results in increase serum levels of
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alkaline phosphatase
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What disease involes damge to the bile canaliculi AND bile ducts
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Choestatic Juanice
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What cuases Cholestatic Jaundice
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Long term estrogen therapy, and alpha-tocopherol acetat
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Premateiure infants often have Vit E defiicency, what drug was administerd that caused a huge incidence of choestatic juandice
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alpha-tocopherol acetate
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What drugs cause allergic Hepatitis
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Phenytoin/Erythromycin/Sulfonamdies
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Bioactivation is often require for HEPTATIS to occur but NOT though production of toxic metabolites, RATHER
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Hapens that promote an immune resonse to ceullar proteins
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What drugs cause Crhonic hepatitis
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Nitrofuantoin, and Methlydopa
HAATK |
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Alcoholic Hepatitis results in Steatosis (fatty liver), what drug is associated
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Amiodarone (anti0arrhymtic drug)
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APAP (direct), and Halothane(allergic-toxic), also cause
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chornic hepatitis
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What is microvesicular steatosis
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abnormal accumulation of numerous SMALL cytopaslmic lipid droplets in hepatocyes
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Fulminant or progessive causes of microvesicular steatosis may lead to
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liver failure and death
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Microvesicular steatosis is cause by
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pregnancy, tetracyclines, and Reye's sydrome with ASA
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Whati s Microvesicular steosisi MOA
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inhibition of B-oxidation of fatty acids
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Maco and microvesicular steotis occur in assoication with AIDS and
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zidovudine
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Reye's Sydnroms is an aggreive form of liver disease assoicated with ASA when administered to children with
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viral infection
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What is damaged in Reye's syndrome
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mitochonrida are damages leading to depletion fo Acytl CO and carintina, and fatty acids acuumatute, hypoglycemia
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What is assoicated wtih a rapid form of advanced steotonecrosis
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Reye's syndrome
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Cirrhois is end stage of chornic liver injry with extsive amnts of fibrous tissue--and effects on collagen
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1. increase collagen formation
2. decreases collagen degration 3. increases stellates 4. heapatocytes death |
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Are Stellate cells activated in Cirrhosis
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YES-
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What drugs cause Cirrhosis
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Methotrexate, Vitamin A, and Methyldopa and Alcohol
MMAA |
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Vascular disorders of the liver can occur in
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sinusoids or large vessels
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What happens in sinusoids or large vessels
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red cells are trapped into the liver and body goes into shock
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What drugs are associated with vascular disorders
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cytotoxic compound sin chemitherapy, azathioprine, and sex steriod hormones
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What re the pyrrolizines alkaloids include
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azathioprine, and tea--comfrey
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Adenoma is a benign tumor, but may rupture leading to icnrease bleeding to the intraperitoneal cavity--drugs
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hormonal contraceptives
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What is the FDAs Medwatch program
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parhamceutcal companies are required to report any seroius events to agency within 24
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Is surveillance a passive process once the drug is in the market
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YES
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What are the 2 drugs recently withdrawn from the market
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Bromfenac--NSAIDS
Troglitazone |
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Toxic nephropathy is a general term that descirbes reanl damge caused by either
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exogenous or endogenous compounds leading to renal dysdurction
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One fuction of kidney is concentrate materials in the PCT-which is where first changes to drugs occurs
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YES
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Does the kideny have about 25% of the metabolic capacity as the liver
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YES
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What are the metabolic compoents of the kidney
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1. CYP 450
2. GSH 3. Prostaglin synthase |
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What is a stressed kidney
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where GFP is sustaine dby compenstaory mechansism (prostaglands, AII)
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Stress kidney is GFR that is sustain by
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Hypovolemia, HF, Hepatic dysfunction, elderly
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What drugs can cause a stressed kidney
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diruetics, cyclopsorin, salt depletion
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What drugs cause pre-renal toxicity
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NSAIDS, ACE, and Cylosporin
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The acute reversible effects of NSADS on renal function is due to
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inhibition of renal prostalandis
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Is COX2 consitutvely expressed in the kidney
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YES
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ACE inhbitors dialte the effect arteriole, which can decrease GFR--is reversible
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YES
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Cyclosporin A is an important immunosuppressive agents tht si widely used to prevent grafy reguion in organ transplantation, it acts by selectively inhibiting
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T-cell activting
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Do Nearly all pts who receive cyclosporine exhibit neprhotoxocity
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YES
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What drugs cause Acute intersittial nepritits
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Antibiotics--Methicillin, sulphonamides, rifampicin
Direucts: Thiazies, fursemide |
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What drugs cause ATN (Acute Tubular necrosis
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Amingoglycosides
APAP Amphotercin B Cisplain Cephalosporins Tetracycline |
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AMinoglycosides are antibiotics that are drug of choice for many
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gram-negative infections
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Up to 30% of pts treated for 7 days with aminoglycosides show
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signs of neprotoxicity--accumulate in PCT
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An important risk factor for adminstration of aminoglycosides is other neprhotoxic drugs---order of neprhotoxic potential is related to number of
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ionizable amino groups
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What is Amphortercin B
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effective antifungal drug
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Toxicity of Amphoterin B is dose related, and predictable in doses >
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5grams
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MOA of Amphortercin B
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alters mebrane permeability adn induces renal vasoconstriction
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Can APAP cause actue renal failure
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uncommon
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Cisplain is used against a vareity of solid tumors, is MOA may
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inhibition DNA and protein synthetis, and transport ruction
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How is Cisplatin toxicity minimized
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by vigours hydration prior and durign cisplaint therapty
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What is hydronephrosis
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distention and dilation of renal pelvis,cause by obstuction
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Renal obstuction is a common problems with
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methotrexate and acylovir
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Methotrexate also causes
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fibrosis (cirrhois) liver
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How can obsturction be avoided
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allopurinol and hydration
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What is the most common cuased of chronic renal failure
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combination of analgesics
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Moderate analgest use in health men was NOT assoicated with
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increase risk of renal dysfuciton
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Declingin renal function, and a reduction in both RBF, and GFR is a major contributor to drug toxicity in
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the elderly
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What is Tetrogenesis
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meanings malformation or monsitority
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What is a tetraogen
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is an agent that induces strucutal malformation
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Development toxicity is any sturcutal or functional alteration reversible/irreversible caused by
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environment insult
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<50% of pregnancies result in health invidiudal
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YES
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The nature and incidence of effects of developmental toxcities are dependent on
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TIMING and DOSE
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The most important concept in development toxicity is the concept of
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stage specfici sensitivity
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All cells carry essentially the same genetic information, what distingues cell types from one another
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differences in gene expression
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Normal dvelopment depends on sequential programm and locally singial events
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YES
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Teratoegencity is governed by
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dose-effect realtion and the cruve is steep
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Frequnecy and severity of malofrmation increase with
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dose
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Not all doses of a tetrogen are teratogenic only dose sufficnet to interfere with
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specific development events
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The embryo has great suscetibilty to checmial than adults, so a teratogen does NOT need to be toxic to the mother to be toxic
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to the fetus
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The dose-effect relations is dependent on FREQUENCY, and DRUG COMBINATIONS why
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Frequency--4 injections is more potent
Drug combinations can result in syngerism--increase potentiation of malformation |
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What are effects of oral distrubtion in pregnancy
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decrease in GI motility and delayed stomach empyting--leads to increased absorption
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What are topical effects in pregnacy
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increased
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What are effects of disbribution in prenacy
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Increase body water, and fat--can vary
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What are effects of metbolism in pregancy
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decreased in pregnancy
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What is primary route of extretion of fetal waste products, and GFR is increase 2-fold in pregant women
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via maternal blood flow
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The traditon view of the placenta as barrier is overrated, the issues is usally how FAST the molecules witll cross rather than
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whether they'll get acrosd
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Drugs >1000MW
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DO NOT CORSS the palcental membrane
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Drugs <600
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DO CROSS palcenta membrane
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What are Categories fo FDA Prenancy
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A-D X
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"Warning in the label indicated"
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Class D
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Contraindication in the label indicates what class
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Class X
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Thalidomide was used in teh 50s and 60s to treat morning sickess--the major defects of thalidomide were
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limb defects (kidney, eyes, ears GI, heart)
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The sensive period of exposure was between 20-40 days,
What days mainly affect arms What days arms and legs |
27-30 arms
>30 arms and legs |
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MOA of Thalidomide
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Unknown
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THalidomide has recently been approved by the FDA for treatment of
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Leprosy
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Thalidomide appears to moderate immune system reactiosn and can treat
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AIDS, and cancer
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DES (Diethystilbestrol) was used from the 40-70s to prevent
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miscarriage
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DES MOA
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works via endocrine mechaism
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When is DES responsbile for genital tract anormalies in offspring
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<18th weeks
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Females offsprings that were exposed to DES, developed
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vaginal adencarcinomas
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Male offsprine exposed to DES develep
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gential anomalies--redcue semen volume/quality
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Valproic Acid is an anticonvulsant, what did it result in children
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spina bifida, menigocele, midfacial hypolasmia
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When is the critical period for this defect
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30 days post-conception
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What Class is valproic acid
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D
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When do fetus development warfarin syndrome
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6-9 weeks gestion
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Can exposure to warfarin at all other stages of prenacy cause CNS defect, spontanous abortion, increases risk of materal and fetal bleeding
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YES
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What is anticoagulant of chioce in pregancy
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Heparin
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What is the primary teratogenic effect of warfarin
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axial and appendicular skeleton, hypoplastic nose, mentral retardation, scolosis
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Effect of wafarin is DOSE and TIME denpendent--CNS disorders are due to
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later stage in pregny
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What is use of Lithium
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bi-polar (manic depressive phsychosis)
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What are abnormalites of Lithium
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Ebstein anormaly (tricuspid is in the right venticle), and clefty palate
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What is drug class of Lithium
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Class D
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When are ACE inhibitors a problem in pregancy
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LATER in pregnancy
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What are abnormalites of ACE
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adverse effects on fetal kidney which reduce volume of amniotic fluid--cause skull defects
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Accutane (retinoic acid) is used to treat acne-is tetrogenic in humans at low doses--what is exposure time during pregnacy
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3-5 weeks of pregancy
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What are abnormalites with Accutance (CLASS X)
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hydroceplay, ear malformations, decrease IQ
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Cocaine use results in reduced bith weight, CNS and cardiac effects, MOA
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disrupts the vasculature--causing hypoxia and malnutrtion
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What is more minor FAS (fetal alcohol syndrome) or FAE (fetal alcohol effect)
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FAE
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What is the major human teatogen in Western socieity
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etoh
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What is abnormalies of FAS
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craniofacial effects, nad severe intellculat and behvarioral effects
brain region most senstive to ethanol |
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Is Caffiene teratogenic
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NO
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Nicotine/Cigarettes are associated with
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low bith weight, and premature birth
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What advanced age effect on fetus
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increased risk for chromosomal anomilies
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What are adolescent age effects on fetus
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recude weight, increased risk for malformation
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Toxoplasma is a parasite that crosses the placents- when is the severity of fetal damge the worse
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3rd trimester (but occurs in all)
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What can toxoplasma result in
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hydrcephaly, micophtlamia, chorioretinitis, brain lesion, multiple organ damge
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25% of women ahve antiboidies against toxplasma--
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YES
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Insulin-dependent diabetes has been linked to mutiple congetial mallformations such as (3-4x risk)
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cardiac, and skeletal morfromation, CNS, and dysgensis
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25%of all cases fo hyraamnios (excess amniotic fluid are due to)
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maternal diabetes
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Diabetes controlled by insulin reduces the risk of congential malformation--is decreased glucose tertogenic
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YES
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What are the common drugs initally though to teratogenic--NOW SAFE
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BOSS D
Bendectin Oral contraceptives Spermicides Salicyltes Diazepam |
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Bendectin once prescribed to alleviate morning sickness, one case report started rumors
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YES
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How do you estimate the infants dose
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conc in milk X volume of milk consume
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How much volume of milk is typically consumed
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200ml/kg/day
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Why is the milk:plasma ratio important
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the concentration of mand drugs is similar in the mothers plasma and milk--but other drugs can be diffferent (cimetidine)
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What is the time require to eliminate 90-95% of a agents
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3-5 plasma elmination half-lives
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