Adrenergic Agonists (Sympathomimetics) Nursing Considerations & Management

The autonomic nervous system (ANS) works to keep the body’s homeostasis against internal and external changes in the environment which alter the body’s internal functions (e.g., blood pressure regulation, urinary excretion, water balance, and digestive functions).

Adrenergic agonists are autonomic nervous system drugs that stimulate the adrenergic receptors of the sympathetic nervous system (SNS), either directly (by reacting with receptor sites) or indirectly (by increasing norepinephrine levels). An adrenergic agonist is also called a sympathomimetic because it stimulates the effects of SNS.

Adrenergic agonists are further classified into three: alpha- and beta-adrenergic agonists, alpha-specific adrenergic agonists, and beta-specific adrenergic agonists.

Table of Common Drugs and Generic Names

Here is a table of commonly encountered adrenergic agonists, their generic names, and brand names:

Disease Spotlight: Glaucoma, Shock, and Asthma

• These agents are commonly used for treatment of glaucoma, asthma, and shock or shock-like conditions.
• Glaucoma is an eye condition characterized by increased in intraocular pressure. Alpha adrenergic agonists help dilate the pupils, decrease the secretion of aqueous humor, and increase the uveoscleral outflow. This mechanisms relieve the eyes of too much pressure.
• Shock is a complication most commonly caused by acute blood loss that can significantly alter the functions of the organs and tissues. The effects of these agents to cardiovascular system include pressure increase, vasoconstriction, and increase blood flow to the muscles.
• Asthma is a hypersensitivity reaction to specific triggers characterized by inflammatory reactions and bronchospasm. Beta agonists are usually used for treatment of bronchospasm and other obstructive respiratory conditions.

Alpha- and Beta-Adrenergic Agonists

Description

• Alpha- and beta- agonists are drugs that are generally sympathomimetic. These agonists stimulate all of the adrenergic receptors so they affect both alpha- and beta-receptors.
• Popular examples of drugs under this class include dopamine, dobutamine, and epinephrine.

Therapeutic Action

The desired and beneficial actions of alpha- and beta-agonists are as follows:

• Acting on the adrenergic receptors of the target organs, (i.e., increased heart rate and myocardial contractility with the heart, bronchodilation with lungs, decrease intraocular pressure with eyes).
• Other effects include: sweating, pupil dilation, increase in rate and depth of respirations
• Facilitating the breakdown of glucose stores (glycogenolysis) so it can be used as energy.

Indications

Alpha- and beta-agonists are indicated for the following medical conditions:

• Sympathomimetic of choice for shock is dopamine, a naturally occurring catecholamine. Aside from stimulating the heart to increase the rate and force of its contractions, it also causes dilation of the renal and splanchnic arterioles increasing blood flow to the kidneys. This way, renal shutdown is prevented.
• Dobutamine and ephedrine are synthetic catecholamines indicated for treatment of heart failure. They increase cardiac contractility without causing increase in oxygen demand.
• Ephedrine stimulates release of norepinephrine from nerve endings. Its use is declining because of availability of drugs with more predictable onset and action. Many OTC cold products contain this.

Here are some important aspects to remember for indication of adrenergic agonists in different age groups:

Children

• They are at greater risk for GI and CV complications. Dosage should be exact and should be validated.
•  NOTE  Phenylephrine is often found in OTC allergy and cold preparations so primary caregivers should be instructed to check labels for ingredients and not combine drugs with similar ingredients.

Adults

• Constant dosage adjustments based on response in patients with shock or shock-like states is needed, especially those on increased risk for cardiac complications.
• Most of these are emergency drugs and can be used in patients who are pregnant and/or lactating. While there are no adequate studies entailing their effects, use of these drugs is justified when benefits clearly outweigh the risks.

Older adults

• Dose adjustment is needed as this age group is also more susceptible to drug side effects.
• They are more likely to have toxic levels of the drug because of renal or hepatic impairments.
• Both adults and older adults must be cautioned against using OTC drugs and complementary therapies.

Pharmacokinetics

Here are the characteristic interactions of alpha- and beta-adrenergic agonists and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of alpha- and beta-agonists:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Pheochromocytoma. Systemic overload of catecholamines could be fatal.
• Pulmonary hypertension. Exacerbated by the effect of the drug.
• Tachyarrhythmias and ventricular fibrillation. Increased heart rate and oxygen consumption caused by drugs can exacerbate these conditions.
• Hypovolemia. Fluid replacement is the preferred treatment associated with hypotension.
• Halogenated hydrocarbon general anesthetics. This sensitizes the myocardium to catecholamines and could cause serious cardiac effects.
• Peripheral cardiovascular disease. Caution should be used as this can be exacerbated by systemic vasoconstriction effect of the drug.

Adverse Effects

Use of alpha- and beta-agonists may result to these adverse effects:

• Related to sympathetic stimulation: headache, sweating, feelings of tension or anxiety, piloerection
• CV: arrhythmias, hypertension, palpitations, angina, dyspnea
• GI: nausea, vomiting, constipation
•  WARNING   Because of vasoconstrictive effects, care must be taken to avoid extravasation of any infused drugs. The vasoconstriction in the area of extravasation can lead to necrosis and cell death in that area.

Interactions

The following are drug-drug interactions involved in the use of alpha- and beta-agonists:

• Tricyclic antidepressant (TCA) and monoamine oxidase inhibitors (MAOI).Increased effects of these drugs related to increased norepinephrine levels or increased receptor stimulation that occurs with both drugs. TCAs increase sympathomimetic effects with phenylephrine but decreased antihypertensive effects with clonidine.
• Ma huang, guarana, caffeine. Increased risk of hypertension especially with alpha agonists.
• Propranolol. Paradoxical hypertension with clonidine
• Any other adrenergic antagonist. Loss of effectiveness of drugs.

Nursing Considerations

Here are important nursing considerations when administering alpha- and beta-agonists:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g. history of allergy, pheochromocytoma, fatal arrhythmias, etc.) to avoid adverse effects.
• Establish baseline physical assessment to monitor for any potential adverse effects.
• Assess vital signs, especially pulse and blood pressure to monitor for possible excess stimulation of the cardiac system.
• Note respiratory rate and auscultate lungs for adventitious sounds to evaluate effects on bronchi and respirations.
• Monitor urine output to evaluate perfusion of the kidneys and therapeutic effects.
• Monitor laboratory test results (e.g. liver and renal function tests) to determine need for possible dose adjustment, and serum electrolyte levels to evaluate fluid loss and appropriateness of therapy.

Nursing Diagnosis and Care Planning

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Decreased cardiac output related to CV effects
• Ineffective tissue perfusion related to CV effects

Implementation with Rationale

These are vital nursing interventions done in patients who are taking alpha- and beta-agonists:

• Use extreme caution in calculating and preparing doses of these drugs because even small errors could have serious effects.
• Use proper, aseptic technique when administering ophthalmic or nasal agents (alpha- and beta- adrenergic agonists) to prevent injection and assure the therapeutic effectiveness of the drug.
• Monitor patient response closely (vital signs, ECG, urine output) to ensure the most benefit with the least amount of toxicity.
• Maintain phentolamine on standby in case extravasation occurs. Save the area by infiltrating 10 mL of saline containing 5-10 mg of phentolamine.
• Provide comfort measures (e.g. light control, encouragement to void, monitoring bowel functions, support and relaxation measures) to help patient cope with the sympathomimetic effects of the drug.
• Provide patient education about drug effects and warning signs to report.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (improvement in blood pressure, ocular pressure, bronchial airflow).
• Monitor for adverse effects (e.g. CV changes, decreased urine output, headache, GI upset).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy. 

Alpha-Specific Adrenergic Agonists

Description

• Alpha-specific adrenergic agonists or alpha-agonists are drugs that bind primarily to alpha-receptors rather than to beta-receptors.
• Popular examples of drugs under this class include clonidine, midodrine, and phenylephrine.

Therapeutic Action

The desired and beneficial action of alpha-agonists is:

• Acting as a powerful postsynaptic alpha-adrenergic receptor stimulant causing vasoconstriction and raising systolic and diastolic blood pressure with little effect on the beta-receptors of the heart.

Indications

Alpha-agonists are indicated for the following medical conditions:

• Phenylephrine is a potent vasoconstrictor and alpha₁-agonist with little or no effect on the heart or bronchi and is used in many combination cold and allergy products. Parenterally, it is used in the following medical conditions: shock or shock-like states and  paroxysmal supraventricular tachycardia. It is also used to prolong local anesthesia and to maintain blood pressure during spinal anesthesia. Topically, it used for treatment of allergic rhinitis and symptoms of otitis media.
• Midodrine is an oral drugs used to treat orthostatic hypotension in patients who do not respond to traditional therapy. It activates alpha₁-adrenergic receptors, leading to peripheral vasoconstriction and an increase in vascular tone and blood pressure.
• Clonidine specifically stimulates alpha₂-receptors of the CNS leading to decreased CNS outflow of norepinephrine. Orally and transdermally, it is used to control hypertension and as an injection, it is for epidural infusion for controlling cancer pain.

Pharmacokinetics

Here are the characteristic interactions of alpha-agonists and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of alpha-agonists:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Severe hypertension or tachycardia. Possible additive effects.
• Narrow-angle glaucoma. Can be exacerbated by arterial constriction.
• Pregnancy and lactation. No adequate studies on the effects so use is reserved for situations in which the benefit to the mother outweighs any potential risk to the fetus or neonate.
• CV disease and vasospasm. Caution is used because these conditions could be aggravate by the vascular effects of the drug
• Thyrotoxicosis and diabetes. Sympathetic stimulation has thyroid-stimulating and glucose-elevating effects
• Renal or hepatic impairment. Can interfere with metabolism and excretion of the drug.

Adverse Effects

Use of alpha-agonists may result to these adverse effects:

• CNS: anxiety, restlessness, depression, fatigue, strange dreams, personality changes
• Sympathetic stimulation: blurred vision, photosensitivity
• CV: arrhythmias, ECG changes, blood pressure changes, peripheral vascular problem
• GI: nausea, vomiting, anorexia
• GU: decreased urinary output, difficulty urinating, dysuria, changes in sexual function
•  WARNING  Sudden withdrawal can lead to: tachycardia, hypertension, arrhythmias, flushing, and even death. Taper drugs over 2-4 days.

Interactions

The following are drug-drug interactions involved in the use of alpha-agonists:

• MAOIs: severe hypertension, headache, and hyperpyrexia with phenylephrine
• TCA: increased sympathomimetic effects with phenylephrine; decreased antihypertensive effects with clonidine
• Digoxin, beta-blockers, antipsychotics: increased drug effects with midodrine
• Adrenergic antagonists: loss of effectiveness of adrenergic agonists

Nursing Considerations

Here are important nursing considerations when administering alpha-agonists:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g., history of allergy, CV diseases, thyrotoxicosis or diabetes, etc.) to avoid adverse effects.
• Establish baseline physical assessment to monitor for any potential adverse effects.
• Assess level of orientation, affect, reflexes, and vision to monitor for CNS changes related to drug therapy.
• Monitor blood pressure and pulse, assess peripheral perfusion, and obtain electrocardiogram, if indicated, to determine drug effectiveness and evaluate for adverse CV effects.
• Monitor urine output to evaluate perfusion of the kidneys and therapeutic effects.
• Evaluate patient for nausea and constipation to assess adverse effects of the drug and establish appropriate interventions.
• Monitor laboratory test results (e.g., liver and renal function tests) to determine need for possible dose adjustment.

Nursing Diagnosis and Care Planning

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Decreased cardiac output related to blood pressure changes, arrhythmias, or vasoconstriction
• Disturbed sensory perception related to CNS effects
• Risk for injury related to CNS or CV effects

Implementation with Rationale

These are vital nursing interventions done in patients who are taking alpha-agonists:

• Do not discontinue abruptly to prevent rebound hypertension.
• Monitor blood pressure, orthostatic blood pressure, pulse, rhythm, and cardiac output regularly to adjust dose or discontinue the drug of CV effects are severe.
• Maintain phentolamine on standby when administering phenylephrne in case extravasation occurs. Save the area by infiltrating 10 mL of saline containing 5-10 mg of phentolamine within 12 hours after extravasation to preserve tissue.
• Provide comfort measures (e.g., rest and environmental control) to help patient cope with the drug effects.
• Provide patient education about drug effects and warning signs to report to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (improvement in condition being treated).
• Monitor for adverse effects (e.g., GI upset, CNS, and CV changes).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.

Beta-Specific Adrenergic Agonists

Description

• Beta-specific adrenergic agonists or beta-agonists are drugs that bind primarily to beta-receptors rather than to alpha-receptors.
• Popular examples of drugs under this class include albuterol, salmeterol, and terbutaline.

Therapeutic Action

The desired and beneficial action of beta-agonists is:

• Acting on beta-adrenergic receptors to produce increased heart rate, positive inotropic effect, bronchodilation, and vasodilation.

Indications

Beta-agonists are indicated for the following medical conditions:

• Treatment of bronchial spasm, asthma, and other obstructive pulmonary conditions.

Pharmacokinetics

Here are the characteristic interactions of beta-agonists and the body in terms of absorption, distribution, metabolism, and excretion:

Contraindications and Cautions

The following are contraindications and cautions for the use of beta-agonists:

• Allergy to any component of the drug. To prevent hypersensitivity reactions.
• Pulmonary hypertension. Can be exacerbated by drug effects
• Anesthesia with halogenated hydrocarbons. Can sensitize the myocardium to catecholamines and could cause a severe reaction
• Eclampsia, uterine hemorrhage, and intrauterine death. Can be complicated by uterine relaxation or increased blood pressure
• Thyrotoxicosis and diabetes. Sympathetic stimulation has thyroid-stimulating and glucose-elevating effects
• Severe renal impairment. Can alter drug excretion

Adverse Effects

Use of beta-agonists may result to these adverse effects:

• CNS: anxiety, restlessness, fatigue, fear, tremor, headache
• CV: tachycardia, angina, myocardial infarction, palpitations
• Respiratory: difficulty of breathing, bronchospasm, severe pulmonary edema
• GI: nausea, vomiting, anorexia, GI upset
• Others: sweating, pupil dilation, rash, muscle cramps

Interactions

The following are drug-drug interactions involved in the use of beta-agonists:

• Other sympathomimetic drugs: increased sympathomimetic effects
• Beta-blockers: decreased therapeutic effects

Nursing Considerations

Here are important nursing considerations when administering beta-agonists:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for contraindications or cautions (e.g., history of allergy, uterine hemorrhage, thyrotoxicosis or diabetes, etc.) to avoid adverse effects.
• Establish baseline physical assessment to monitor for any potential adverse effects.
• Assess CV status (pulse rate and blood pressure) to evaluate for any CV effects associated with SNS stimulation.
• Assess respiratory status to monitor drug effects and assess for respiratory adverse effects.
• Monitor urine output to evaluate perfusion of the kidneys and therapeutic effects.
• Monitor laboratory test results (e.g., liver and renal function tests) to determine need for possible dose adjustment.

Nursing Diagnosis and Care Planning

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Acute pain related to CV and systemic effects
• Decreased cardiac output related to CV effects
• Ineffective tissue perfusion related to CV effects

Implementation with Rationale

These are vital nursing interventions done in patients who are taking beta-agonists:

• Monitor pulse and blood pressure carefully during administration to arrange to discontinue the drug at any sign of toxicity.
• Ensure that a beta-blocker is readily available when giving parenteral isoproterenol in case severe reaction occurs.
• Use minimal doses of isoproterenol needed to achieve desired effects to prevent adverse effects and maintain patient safety.
• Provide comfort measures to help patient cope with the drug effects.
• Provide patient education about drug effects and warning signs to report to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (improvement in condition being treated, stabilization of blood pressure, prevention of preterm labor).
• Monitor for adverse effects (e.g., GI upset, respiratory, and CV changes).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy. 

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