5/18/15

Vd= amount of drug given [IV]/ [drug] plasma

CL = (0.7 * Vd) /t1/2
LD = Css * Vd
MD = Css * CL
Competitive inhibitors the Km?
o Increase
Noncompetitive inbhitors Km?
o Does not change.
In enzyme kinetics, the vlue of Km reflect the ?
of the enzyme for the substruate?
o Affinity
In enzyme kinetics, Vmax is directly
proportional to the?
o Enzyme concentration
Competive inhibitor substrate?
o Resemble
Noncompetive inhibitor substrate)
o Not resemble a substrate
In enzyme kinetics, the higher the Km, the
affinity?
o Lower
322 = 32
o 322- 32 = 290
245 290 = 45
45 + 32 = 77
o 77/7
11

46-11 = 35 = 76%
As substurate concentration increases, velocity
of reaction ?
o Increase, decrease, increases then plautes?
Velocity of reaction increases as
substratce concentration increases, and
platuea when the enzyme is saturated
Competitive inhibitors the Vmax?
o Do not change
nonC inh Vmax?
o Decrease
What is the formula for calculating the
clearance of a drug?
o CL (L/min) = [rate of elimination of the drug
(g/min)]/plasma drug concentration (g/L)
What is the definiation of the half life of a drug?
o The time of elimination or constant
infecustion required to change the amount of
the drug in the body by one-half.
USMLE: The T1/2 of a drug is 4 hours. How long
must eht drug be infused at a constant rate
before reaching 94% of Css (steady state
concentration)
o 16 hours (4 half-lifes)
USMLE
o After 3 half-lifes, given constant IV infusion of
a drug, how close to steady state is the
concentration of the drug?
87.5% of steady-state concentration.

A drug with a medium volume of distrubtion of

15L is most likely to be found in the (blood,
ECS/tissue)
o Extracellular space; these drugs disturbed
throughout the total body water.
USMLE:
o A drug has a bioavailability of 60%. What
dosage is needed to ensure that 300 mg of
the drug reaches the systemic circulation
unchanged?
500 mg
What ist he forumula for calculating the volume
distrubiton of a drug?
o Volume of distribution = Vd =amount of drug
in the body / plasma drug concentraction
The bioavailabilty fo a drug taken orally is 70%.
What 2 factors likely cause this decrease in
bioaviabilty from the IV form?
o Incomplete absorption fo the drug and first
pass metabolism
Drugs with a low volume of distribution such as
4 to 8 L, are found in the (blood, tissue, ECS)?
o Blood ONLY!!!
These drugs do not distribute
outside the plasma
After one half-life, given constant IV infusion of
adrug, how close to steady state ist eh
concentraction fo the drug?
o 50% of Css

USMLE: in a 75 kg man, a drug has a Vd of 40L.

It can be expected to be found in
(blood/tissue/ECS)
o Tissue
What is the formual for calculating the half life
of a drug?
o Half life (T1/2) = (0.7 x Vd)/CL
What si the formula for the Loading dose of ad
rug?
o LD = (target plasma concenctration x volume
of distribution) / bioavailability
USMLE
o On pt has cirrhosis and another has chronic
renal failure. How do the LD and MD of drugs
change for these patients?
For both heaptic and renal disease, LD?
Does not change
But maintenance dose decreases
What is the formula for maintenance dose of a
drug adminstred intravenously?
o MD = rate of the elmiatnion/bioaviailty (target
paslama cocnenctration x
clearance)/bioavailability)
In zero-order elimination fo a drug from the
body, what ist he relationship between the rate
of elmaitnion an dthe drug concenctration?
o There is no relationship; the rate of elmiatino
is constant regarlgdess of the drug
concentraction

What are 3 drugs that exhibit zero order

elimation )
o PEA is round like the 0 in zero order.
Phenytoin
Ethanol
Aspirin
In first order elmaitno fo fdrugs from the body,
what ist he relationship between the rate of
elmation and drug concentraction?
o Rate of the elmation if directly proprotioant to
the drug concenctraation
A constant fraction (rather than a
constant amount) is eliminated
Weak base get trapped in acidic environment
USMLE: What substance is given to enhance the
renal clrearnce weakly acidic drug i.e. aspirin,
methotrexate, phenobarbital?
o Bicarbonate
Weak acids get trapped basic environment
What substance is given to enhance the renal
CL of a weakly basic drug i.e. an amphetamine

o Ammonium chloride
USMLE
o 3 hoursafter consuming a bottle of aspirin, a
boy is put on IV saline with bicaronbate. By
what mechanism doe sthis help him?
Bicarbonate alkalnize the lumen of
nephrons trapping acetylsalicylic acid, a

weak acide that can be ionized in basic

environments.
The products of phase II metabolism of drugs
are typically excrted by what organ?
o Kidney
Phase II metabolism of drugs yield
nonpolar/very polar/ slightly polar molecues
thare inactive/often still active)
o Very polar, inactive
What 3 types of bioche mical reaction sar
einvovled in the phase I metabolism fo drugs?
o Reduction
o Oxidation
o Hydrolysis
What enz sysmte mediates phase 1 metaoblism
of drugs int eh body?
o cP450
USMLE:
o A 98 year old man is likely to have preserved
which phase of drug metabolism?
Phase II
Do geriatric patietns lose the abilty for phase I
or phase II drug metabolism first?
o Phase I (geratrict patietns have GAS of phase
II:
Glucuronidation
Acetylation
Sulfation

What 3 types of biochemical reaction sare

involve din the phase II metabolism fo drugs?
o GAS
Conjation reactions
Phase I metabolism of drugs yields
(nonpolar/slightly polar/very polary ) molecues
that are (inactive/often still active)
o Slightly polar, often still active)
USMLE:
o An oncology patient receives a
chemotherupatic agent. It likely has affinity
for its receptor?
Chemotheraptuci drugs highly potent
High affinity for the receptor
What is the definition fo ?
o Maximal effect a drug can produce?
Efficacy
Amount fo drug needed for agiven effect?
o Potency
A drug that requires a very low dose to achieve
its desired effected is considered?
o Potent
How does the potency of a partial agonist relate
tot eh potency of a full agonist of the same
receptor?
o A partial agonist may be more potent than,
less potean thtan or equally as potent as a
full agonist

In pharmcodyanicms, the addiotn of a nonC

agonist (increase, decrease does not change)
the efficacy of the agonist?
o Decrease
When a competibve antagonist is given, the
maximal effect of an agonist is (constant,
decrease increased)
o Constant; maximal effect is achievable in the
presence of a competitive antagonist if
icnerased amoutns of the agonist are given
How does the efficacy of a partial agonist realte
to the efficacy of a fulla gonsti of the same
receptor?
o A partial agonist has lower maximal effeciay
than afull agonist
Safer drugs have (higher or lower) therauptic
index value?
o Higher
What ist he formula that describte the TI of a
drug?
o TI = LD50 (median toxic dose) / ED 50
(median effective dose)
TD is same as LD
(TILE)
TITE
What property of a drug is determined by its
TI?
o Safety (drugs with higher therapeutic indices
are less likely to cause toxicities )

USMLE:
o The lowest effective dose of a drug X is 200
mg/dL. If given at 600 mg/dL, drug X is
lethal. What is the Therapeutic window of
drug X?
(minimum effective dose to minimum
toxic dose)
400 mg/dL
o 600 - 200
What property of a drug is determined by its
therautpic window?
o The range of a clinical drug safety
PS axons on neurons in the peripheral ganglia?
o Synapse
How many synapses are involved in activation
of the adrenal medulla?
o One
Hwo many neurons are involved in PS
transmission formt eh spinal cord to the target
organ?
o 2
A pt affected by botulumin toxin will be affected
at which neurotnramistter/receptor groups?
o All neutrotransmitter/receptor gupos with
acetylcholine as the neurotransmitter
Which 2 componetnet of the symapthic nervous
ystem are innverabed by cholinergic fibers?
Sweat glands and Adrenal medulla

What NT receptor mediates PS NS function at

the periphaeral ganglia?
o Receptor?
Nicotinic acetylcholine recpetors
How many neurons are involved in the
symapthic trnamsision from the spinal cord t
the garget organ?
o 2
What are 4 cell tyeps in which which alpha and
beta adrenric recptors mediate sympathietic
tone?
o Cardiac
o Smooth muscle
o Glandular cells
o Terminal ends of neurons
What NT mediates symapthic tone int eh renal
vascular smooth muscle?
o Dopamine
At the paravertebral ganglia, the NT
acetyacyhole acts on nictoniec acyletchoni
recptors to te hmediate SNS function
What NT recptor mediates PST int eh cardiac
muscle?
o Musc acetyl receptors
What NT recptors mediate the symaptic NS
function at the sweat glands?
o Musc acetyl receptors

Somatic nerves arising form the spin innervate

skeletal muscle. What NT receptor on skeletal
muscle recives this input?
o Nictonic acetylchone recpetors
What NT mediates SNS function at eh sweat
glands?
o Acetylcholoine :_)
What NT recptors mediates syspethic tone int
eh renal vascular rsmooth muscle?
o D1 receptor
Which types of nerves arise from the spinal cord
and directly innerveat eskelta muscle?
o Somatic nerve
What NT mediates Symp tone int eh cardiac
muscle, smooth muscle an dglandualr clels?
o nEp
what 2 substances are released into the blood
from the adnreal medulla after the activation fo
the symsptic nervous sytem?
o nEp and Ep
preganglaionti csymspteic axons synapse on
neurons in the paravertebral ganglia
what NT mediates PSNS function?
o Acetylcholine
Are muscarinic acehtylchlin recptors lingade
gated sodium ptosum channels or G protein
couled recptors?
o M acet rectprso G protein couple drecptors
that act through second messengers

Are N Acetcyl recptors :

o Ligand-gatede Na/K channeles
Adenyl cyclase catalyzes the converstion of ATP
into what molecule?
o cAMP
what 5 types of recptors are couples with Gs
protein?
o B1, B2, H2, V2, D1
Gi is MAD and theyre all 2s
o M2, A2, D2
Gq is all the 1s except Bob and Dan which is
B and D
o So if I give you any number 1 except B and
D it will be Gq
The rest will fit into Gs
What enzyme is activated directly downstream
of the Gq coupled receptors?
o Phospholipase C
What enzyme is activated directly downstream
of Gs coupled receptor?
o Adenylyl cyclase (
What are the major effects of alpha receptor
activation?
o Vascular smooth muscle?
Increases
o Pupillary dilator muscle?
Contracts dilate mydriasis
o Insteintaal and bladder sphcinter muscle?
Contracts

To what class of G prtoeins are H2, V1 and V2

repctors linked?
o Qiss (kiss) and qiq (kick) till youre siq (sick)
of sqs (sex)
o S, q and s respectively
What enzyme is inhbited directly downstream of
Gi-coupled recptors?
o Adenyl cyclase
What 5 types of recptors are coupled with Gq
proteins?
o (HAVe 1 M&M)
H1, A1, M1 and M3
To what class of G prtoeins are D1, D2 and H1
recptors?
o D1 = Gs
o D2 = Gi
o H1 = Gq
Qiss and qiq till youre siq of sqs
What final effecto renyzme is activated by
recptor that are coupled with Gs prtoeins?
o Protein kinase A
What effect does V1 recptor activation have on
vasduclar smooth muscle?
o Vascular smooth msucl eocntraction?
Increase (
o Actgivation of what G protein couple
drepctors can increase vascular smooth msucl
eocntraction?

Alpha 1 and V1 recptor increase

contraction
o Relaxation?
Mediated?
B2 and D1 (renal only)
o Where are M1 recptors located?
Enteric nervous system and CNS
What are the effects of H1 recptor activation?
o Pruritus, pain, nasal and bronchial mucus
production, contarctoin of bronchioles
What is the effect of V2 recptor activation?
o Water permatiblyt
Increase
o Reabsorption of the collectinb tubles of the
kidney
Where are they located?
V2 is found in the 2 kidneys
To what class of G prtoeins are M1, M2 and M3
recptores linked?
o Gq,
o Gi
o Gq
What are the major functions of B1 recptor
activation
o Herat rate?
Increase
Contractility increase too
o Renin relase form the kidneys?
Increase
o Lipolysis of adipose tissue

Increase
o What is the effect of H2 recptor activation?
Gastir cacid secretion?
Increases
o What enzyme is activated by DAG
(diacylglyercol)
Protein kinase C
o What are the effect of M3 recptor activatin?
Exocrine gland secretion?
Increase
Gut peristalitic
Bladder? Contracts
Bronchoconstriction
Miosis
Pupiillar accomdiation
To what class of G prtoeins are alpha1, A2, B1
and B2 recptors linked?
o Gq
o Gi
o Gs
o Gs
What ist he effect of increased inositol
triphosate (IP3) ont eh ICC of calcium?
o Increaset eh inintracuellar calcium
concentraction smooth muscle contraction

What 3 types of repctors are coupled with Gi

proteins?
o MAD
M2, A2, D2

Gi is MAD and theyre all 2s

o M2, A2, D2
Gq is all the 1s except Bob and Dan which is
B and D
o So if I give you any number 1 except B and
D it will be Gq
All the 2s beside the MAD are going to be Gs
o B1 and D1 Gs
What ist he major function fo B2 recptor
activation toeh bodys vasucatlur?
o Vasodilate
What effect does M2 repctor activation have on
cardiac function?
o Decrease HR and
Contractily of the atria?
Decreases
What final effector enzyme is inhibited by
recptors that are coupled with Gi proteins?
o PKA
What are the major functions of A2 recptor
activation?
o Synpathic outflow
Decrase
o Insuli release?
Decrease
Phospholipase C catalyzes the cleavnce of
membrane lipids into what molcuels?
o PIP2 which his futher divided into IP3 and DAG

What is the majoir function fo B2 recptora

cgiation on the respiratory system?
o Bronchodilation
What effect does the activation of ATII recptors
in the presynaptic sympsthic nerve timernal
have on nEP relase?
o Stimulates nEp release
nEp-mediated activation of A2 recptors on the
preasyantpic SN termains is ane xmapel of what
ytpe of feegacvk?
o Negative feedback
Tyrosine precurose to the formation of which
NT?
o DOPA, DA, nEp
What is the order for their synthesis?
Tyrosine, DOPA, DA, nEP
What 3 receptor types modulate the
presyantpic relase of nEp from the
noradregneric nerve temrinals?
o AGII recptors, A2,
M
Tyrosine is converted itno DA via what
intermidate precursor?
o DOPA: DOPA can be used as pharamoclig
canget to increase CNS DA
The entory of what ion into the nerve terminal
induces the release of acetylcholine into the
synaptic cleft?
o Calcium

What effect doet she activation fo M2 repctor in

presynaptic symspthic nerve temrainls have on
nEp relase?
o Inhibits
What enzyme breaks down Act int the synaptic
cleft?
o Ach-esterase
o 2 products
Choline and acetate
What enzyme is responsible for the formation of
acetylcholine?
o ChAT
Choline acetyltrasnferase
o What are its 2 substrates?
Acetyl-CoA and choline
Which 3 mechainsims are used to clear nEp
from the synaptic cleft?
o Diffusion, metabolism and reuptake
The entry of what what ion into the nerve
temrianl induces the release of nEp into the
synaptic cleft?
o Calcium
Tyrosine transporters are located in the nerve
temrianls of what type of cells?
o Noradrengic cells
Tyrosine is precursor nEp
DA is converted into nEp in presynaptic vesicles

Indirecit chlinvergic agonist increase

endogenous acetylchoine by inhbitiing what
enzyme?
o Acetylcholinestase
Pilocparine is to acet-esterase?
o Resistant
Why is pyridstoigment used to treat myasthenia
gravis
o Increase endogenous acetylcholine and
muscle strength (pyriddostimgein gets rid of
a MG)
4 direct cholinergic agonists?
o Betahnocol
o Carbachol
o Pilocarpine
o Methacoline
Carbachol and pilocarpine are effective for the
rx of open-ange glaucoma b/c they actgivae
what muscle?
o Ciliary muscle of the eye
You suspect a 22 yo has asthma. How does a
methacoline challenge test work?
o Methacolhine inhale stimulate muscarinic
repctors and induce bronchoconstriction
diagnose asthma
What is the mechians of action of bethanecol?
o Activate
Bladder and bowel

Pt with MG develos frequent asthma attacks.

Which medication could be underlying these
sxs?
o Cholinomietics (used to treat MG like
pyridstigmine)
esxacerbate asthma
What are the clinical indication for use of
neostigmine?
o MG,
o Postoperative and neurogenic ileus and
urinary retention.
o Reversal of neuromsucluar junction blockage
(postoperative)
Which pharm agent is used to rx atropine
overdose?
o Physostigmine. Why?
MOA?
b/c it corsses the BBB and is able to
reverse central and peripheral
nervous system effects.
What 2 direct agonist cholimiments drugs can
be used to rx glaucoma?
o Carbochol
o Pilocarpine
Name 5 indirect cholinergic agonists?
o Neostigmine
o Pyridostimin
o Edrophonium

Diagnose MG : now dif between MG and

cholinergic toxicity
So if someone has organophosphate
toxicity and they have a lto of
Actylcholine it will rpesent as MG and
b/c nicotinic recptors gets
desenstiizied and if you give them
edorhonium and nothing changes
then its toxicity and if it gets better
its MG.
o Physostigmine
o Donepezil
Which antichlinease is used to diagnose MG?
o Edrophonium
Why?
The effects last for minutes and if
weakenss is transicetly reversed it is
diagnostic of myasthineic gravis
What effect does neostigmine have on the CNS?
o None it does ?
Does not penetrate the BBB
Neo CNS = no CNS
Pilocaprine is effective fo trthe Rx of closed
angle galucome b/c it activae what muscle?
o Pupillary sphincter
What are the clinical indication for use of
bethanocol?
o Postoperiative and neurogenic ilus and
Urinary retention

Organopshoate poisoing is due to?

o Inbhitoin of acety-0ease?
Irreversible
A pt is exposed to parathion and devloep sxs.
what ist he antitdtoe?
o Atropine + pralidoxime
What sxs indicate chliensease ibhtior
poisotine?
o DUMBBELSS
Diarrhea
Urination
Miosis
Bronchospasma.
Bardycardia
Exaction fo skelet muscle/CNS and then
paralysis thats why edrophonium is used
b/c the nicotinc recptors get desensitized
quicker
Lacrmation
Sweating
Salivation
What medications can be given for
organophaose (oftesn found in inseiction )
poisoing and how do they work
o Atropine and pralidoxime.
The symeos of organosphaose poising i.e.
parhatyoin are caused by inbhitoin fo what
enzyme?
o Acetylchoelinstease

What ist he mechainism of clinical application

for oxybutynin?
o Muscarinic antaongised used to reduced
urgency in mild cystitis and reduce bladder
spasm
On the damn toilet seat
On = oxybutynin
Darifencien
Solifenicine
Tropsium
You gave haloperidof for?
o Schiz but the pt developed Parksons like
motor effects. What drug could you add to
treat this?
benztropine
what ist he mechanism and lcincial application
for glycopyrrolate?
o Muscarnisms antagonis used to reduce
airway secrertions and drooling
What ist he clincila paplciation and MOA of
atropine, homatropine and tropicamide?
o These drugs mydraisis and cycloplegia?
By antaognizesing muscarinic recptors in
the eye
Which M agnostist is most commoly used to
trate motion sickness?
o Scopolamine
What is the MOA and clincail application for
benztorpine?

o M antagonis reduce sxs?

Parkins dsease
Tremor and rigidity
Bradycardia is due to lack fo DA and
not Ach
A boys severe asthma attack is unresponsive to
albuterol. What other med that acts as a M
antoagnist can be used?
o Ipratropium
M antosed => used rx asthma and COPD
I PRAY I can breath soon
What is the effects of atropine ont eh stomach?
o Decrfeaed acid secretion
Atropine toxicity
o Skin dry
stuck in a dessert so the sun makes
you hot and dry and red. And see water
source so thats delusion and its always
blurry.
o Flushed
Red as a beet
Dry as bone
What is the effect of atropine on GI motility?
o Decreased motility
Atropine etoixcity can cause urinary retention.
o Which is typicall seen in prostatic hyperplasia
can calso cause neonatal hyperthermia.
What ist he effect of atropine ont eh airway
mucosa?

o Secretions?
Decreased
A pt with jimson weed poisoning is likel y to be?
o Disoriented
Mad as a hatter
A pt starts on a bardycarid drug. She
experience severe right sided eye pain. What
dur gist h she taking and what side effect is
this?
o Atropione
acute angle-closure glaucoma
Body temperatue atropine toxicity ?
o Increased
Hot as a hare
Dessert sun hot
What are the efets of atropine ont eh eye?
o Pupil dilation.
o Cyclpleiga
What is the effect of atropine eont eh baldder in
a pti with cystitis?
o Decreased urgency
Why woud DA be used to Rx a hsptialized pt
with a BP of 80/40 and no urine production in
the past 24 hours?
o Increased in BP while maintine renal perfusion

What effect t does nEp have on renal perfusion?

o Decrease renal perfusion
A man has daytime sleepiness.

o Hallucaiotnoins before/after sleep and

catalplexy.
What indirect symapthotmietic do use to
reat him?
Amphetamine
By what mecniams does ampethamein exert its
symapthomietmnic effect?
o Stimulate the relase of stored catehoclmaines
Hypertensive crisis pheo
Ritodrine acts on
o Ritodrine (discontinued preparation: Yutopar) is
a tocolytic drug, used to stop premature labor
B2

UTERINE RELAXATION
What are the three clinical
appcilation fo ephedrine?
o Nasal congestion
o Urinary incontinence
o Hypotension
What is the lcincial application for
albutoreol?
o Acute asthma
A pregnant 20 yo at 32 weeks
gestation breaks her water which

med can be used to delay the

onset of labor?
o ritodrine, Terbutaline which
reduce premature uterin
contractison
what are the clinical apcliation sof
Ep?
o Anaphlysix
o Open angle glaucoma
o Asthma
o Hypotension
Which tyeps of recptors are
activated by Ep?
o A1, @, B1 and B2
What ar the effects of cocaine
when used topically?
o Vasoconstriction
Local anehsteic
What ar the clincail aplciation of
phenylephrine?
o Treate nasa degoneaetion
Causes vasoconstriciotn
Dilate pupils

In the effect of nEp on B recptors

gerter than equal to or less tan its
effect on alpha recpeotrs?
o Less than.
High dose Ep
To dif between them you give
an alpha 1 blocker and if it
becomes
By what mechiancim does cocaine
exet it sysmsptehomimiet effect?
o Inhibits cathcoamoen uptake int
eh nerve terminal, do not use
?beta blocers can cause
unposed alpha1 activation
By what mecihani does ephdeinre
exert its symapthomimietn effect?
o Ephedrine indir4ct
syampthomeitc tha tsitmualte the
relase of sotred catechomains
Phyealphine is an agonist for which
repctor?
o Alpha 1> A2

What arteh clinical indication for

amepthmaines?
o Nacrolpesy
o Obesity
o ADHD
Isoproterenol is an agonist for
which recptors?
o B1 = B2
Dobutamine is an agonist for which
recptor?
o Strong agonist of B1 and weak
agonsti of A1, A2 and B2
What arteh clinical applciations for
dobuamtie?
o HF, cardiac stress testing
A, P, I can be used to rx nasal
congestion?
o Phenylephrine
Am,ph, Eph, and Coca are indirect
sym
DA treats HF

What is the clincali application for

isoproteronole?
o Bradyarrthymias
o Torsades de pointes
Which types of recptors does DA
activate, and how stonrlgy does it
acitave themr elative to one
another?
o D1 greater than B greater than A
recpetors
Does nEp have greater affinity for
alpha adnreic recptors or B1
recpeotrs?
o Alpha adren recpetors
Which types of recptors are
activated by nEp?
o A1, A2 and B1 (with lower affinity)
Metaproternole, albuyterol and
salmeterol and terbuatlin are
agonsti for which recptors?
o B2 > B1,

Albutoerl and salmtoerol are used

to treat?
Asthma and COPD
o What are th eefects of nEp on
systolic and diastolic BP, PP, and
HR?
Systolic/diastolic BP?
Increase
PP?
Increase
o Systolic more than
diastolic)
HR?
o Reduce via reflex
bradycardia
In the effect of isoproternoln on B
recptors gerta than, = or < its
effect on alpha recptors?
o >
What are the effects of
isoprtoeroneo on systolic and
diastolic BP, PP and HR?
o

Transiently increase (an dthen

decrease) systolic decreases
diastolic
o PP?
Increase
o HR?
Incrase
What is the effect of clonide and
alpha methyl dopa on central
adnrenig coutlfow?
o Decrease central andreglic fluidc,
Alpha2 agonists
What are the clincail indications of
clonidine and alpha methyldopa?
o HTN with renal disease
o b/c they do not decrease blodof
lwo tot eh kdineys
what is the clinical application and
MOA of mirtazapine?
o Alpha-selective blocer rx
depression
o