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Sympathomimetic drug abuse masking an endogenous hyperadrenergic state, Graves' disease.

Sympathomimetic drug use or abuse in a thyrotoxic individual can be clinically devastating as a result of enhanced cellular sensitivity to adrenergic stimulation. Thus, it is critical to recognize thyrotoxicosis in a patient with coexistent sympathomimetic drug abuse. This case report describes a patient with Graves' disease and severe hyperadrenergic symptomatology that was thought to result from sympathomimetic drug abuse.

Adolescent↗

Sympathomimetic amines and cardiac arrhythmias.

STUDY OBJECTIVE: The aim was to investigate the arrhythmogenic properties of several sympathomimetic amines and their antagonism by adrenergic blocking drugs. DESIGN: Arrhythmia was induced by the investigated drugs, injected intravenously: adrenaline (ADR); noradrenaline (NA); phenylephrine (PE); isoprenaline (IP); terbutaline (Tb) and salbutamol (Sb). ADR and PE were also tested for their arrhythmogenic properties after the administration of the adrenergic antagonists propranolol, phentolamine, or both. The dose required to induce arrhythmia and the proportion of animals that developed arrhythmia at a given dose were recorded. SUBJECTS: 63 anaesthetised cats of either sex, weight 2.0-4.3 kg, were used. MEASUREMENTS AND RESULTS: The electrocardiogram was recorded continuously. The arrhythmogenic potency sequence (expressed as arrhythmogenic dose, AD50 in micrograms) was: ADR 16; NA 24; PE 75; IP 133; Tb 500; Sb greater than 1000. The arrhythmogenic efficacy (in %) was: ADR 97; NA 91; PE 90; IP 82; Tb 50; and Sb 0. Propranolol and phentolamine were both effective in reducing the arrhythmogenic effects of ADR and PE. However, their combined administration was most effective and abolished the arrhythmias. CONCLUSIONS: Arrhythmogenicity is a property of sympathomimetic amines with either alpha or beta adrenergic effects, but simultaneous activation of both types of receptors is required for maximal manifestations. Similarly, antagonism at both sites is necessary in order to abolish arrhythmias induced by sympathomimetic amines completely.

Adrenergic alpha-Antagonists↗

Treatment of attentional and hyperactivity problems in children with sympathomimetic drugs: a comprehensive review.

Issues concerning sympathomimetic drug treatment of children with attentional problems and hyperactivity are considered in light of cumulative and current research. These issues concern the atypical or "paradoxical" drug response of such children, predictability of drug response from neurological or biochemical assessments, and, especially, long-term outcome or effectiveness of sympathomimetic medication. Short-term drug effects on behavior and performance are well documented. However, follow-up studies that exist presently suggest little long-term impact of sympathomimetic drugs on school achievement, peer relationships, or behavior problems in adolescence. Questions remain concerning development of tolerance in children, ways to define subgroups of disordered children who may respond uniquely to stimulants, the efficacy of medication in combination with other treatments, and possible long-term negative consequences of medication.

Arousal↗

Diuresis in rats: effects of sympathomimetic and sympathetic blocking agents.

Dopamine and tyramine possess diuretic properties resembling but weaker than those of noradrenaline in the rat. These three amines produce a relatively smaller loss of sodium than does adrenaline. Bretylium shows a diuretic action which is apparently associated with its sympathomimetic properties and which is antagonized by phenoxybenzamine. However, bretylium causes a relatively greater loss of potassium and chloride than do the sympathomimetic amines. A slight antidiuretic action is shown by bretylium after its diuretic effect has subsided and a similar effect is produced by BW 172C58, which has relatively weak sympathomimetic properties. In contrast to these adrenergic neurone blocking agents, phenoxybenzamine and a ganglion blocking agent (pentacynium) show powerful antidiuretic effects. These observations are consistent with the view that the adrenal medulla has an important role in facilitating water diuresis in rats.

Adrenergic Agents↗

Effect of sympathomimetic amines on the blocking action of guanethidine, bretylium and xylocholine.

Experiments were carried out in which the adrenergic neurone blocking activity of xylocholine, bretylium and guanethidine was studied by the use of the inhibitory responses of the isolated rabbit ileum to lumbar sympathetic nerve stimulation, and the contractions of the nictitating membrane of the anaesthetized cat in response to stimulation of the cervical sympathetic nerves. In both these preparations, after blockade of the effects of sympathetic nerve stimulation had been produced with xylocholine, bretylium or guanethicdine, the sympathomimetic amines, dexamphetamine, mephentermine, hydroxyamphetamine, ephedrine and phenethylamine, reversed the blockade; if these amines were given first, then the adrenergic neurone blocking agents were ineffective. Tyramine and dopamine were effective on the isolated rabbit ileum but not on the cat's nictitating membrane. Effective antagonism of the adrenergic neurone blocking drugs was also shown by some substances which inhibit mono-amine oxidase but only those which in addition possess sympathomimetic effects. Thus phenelzine, pheniprazine and tranylcypromine were effective whereas iproniazid and nialamide were not. Since xylocholine, bretylium and guanethidine were all antagonized by the same agents, it seems likely that they all produce sympathetic blockade by a similar mechanism. The possibility is discussed that the sympathomimetic amines which antagonize the adrenergic neurone blocking drugs are competing with these substances for the same receptor sites.

Amidines↗

CARDIAC AND VASCULAR EFFECTS OF SYMPATHOMIMETIC DRUGS AFTER ADMINISTRATION OF TRI-IODOTHYRONINE AND RESERPINE.

In spinal cats treated with tri-iodothyronine, the effects of sympathomimetic drugs on cardiac contraction were diminished. Ouabain failed to restore the effects on the contractile force of the heart. The effects of sympathomimetic drugs on the force of contraction of papillary muscle were not reduced by tri-iodothyronine, but the threshold for induction of automaticity was lowered. There was no evidence that in cats treated with reserpine the sensitivity of peripheral vessels to sympathomimetic agents is decreased and that blood pressure changes are merely secondary to changes in cardiac contraction.

Blood Pressure↗

Excitatory action of sympathomimetic amines on 5-hydroxytryptamine receptors of gut.

1. Twenty-two sympathomimetic amines were tested for excitatory activity on isolated guinea-pig ileum, rabbit jejunum, and rat stomach.2. Eight amines contracted all or almost all guinea-pig ileum preparations; five amines contracted half the preparations and relaxed the others. Nine amines were consistently relaxant. Structural requirements for excitatory activity were not clear.3. Six amines contracted rat stomach and only four contracted rabbit jejunum. Only beta-phenylethylamine and (-)-amphetamine contracted all three preparations.4. The excitatory effects of the sympathomimetic amines on guinea-pig ileum seem to be due to an action on 5-hydroxytryptamine receptors. This conclusion is based on evidence that their excitatory action is antagonized by 2-bromolysergic acid diethylamide, by morphine and by desensitization with 5-hydroxytryptamine, and that there is cross-protection between 5-hydroxytryptamine and the excitatory sympathomimetic amines against block by phenoxybenzamine.

Amphetamine↗

Effects of some sympathomimetic drugs and their antagonists on afterdischarges elicited in chronically isolated slabs of cerebral cortex.

1. The role of sympathomimetic agents in the maintenance and termination of induced cortical epileptiform activity was studied in chronically neuronally isolated slabs of cerebral cortex in the suprasylvian gyrus of unanaesthetized, unrestrained cats.2. The administration of the sympathomimetic agents (+)-amphetamine, methamphetamine, tyramine, and ephedrine resulted in a highly significant decrease in the duration of epileptiform afterdischarge (EADs).3. The alpha-adrenoceptor blocking drugs phenoxybenzamine, phentolamine and tolazoline did not significantly alter the duration of EADs but prevented the decrease in duration of EADs produced by the sympathomimetic drugs.4. The effect of atropine and arecoline on the duration of EADs, previously described, were not modified by the alpha-adrenoceptor blocking drugs, but atropine prevented and reversed the inhibitory action of amphetamine.5. It is suggested that (1) in the chronically neuronally isolated cortical slab there is normally no spontaneous adrenergic activity, (2) a cortical, cholinergic inhibitory mechanism, previously described, is modulated by ascending adrenergic influences, (3) adrenergic cholinergic linkages might be arranged in the cortex in an alternating network, as proposed by Feldberg.

Adrenergic alpha-Antagonists↗

Inhibitory and excitatory effects of sympathomimetic amines on muscle strips from the stomach of the guinea-pig.

1. Responses of muscle strips from the stomach of the guinea-pig have been recorded. Sympathomimetic amines cause inhibitory, motor or biphasic responses.2. The motor components of the responses of the preparations were greatly enhanced by the removal of the mucosal layers.3. The inhibitory responses to isoprenaline, noradrenaline and phenylephrine were antagonized by propranolol or by sotalol. The inhibitory responses to noradrenaline and phenylephrine but not isoprenaline were antagonized by phentolamine. Therefore, both alpha- and beta-adrenoceptors may subserve inhibition.4. The motor responses to noradrenaline and phenylephrine were often potentiated by propranolol or sotalol and were antagonized by phentolamine. Therefore, motor responses to sympathomimetic amines appear to involve alpha-adrenoceptors.5. The responses to sympathomimetic amines and their antagonists were not modified by hyoscine or by tetrodotoxin. It is concluded that the adrenoceptors mediating the responses recorded from these preparations are located on the smooth muscle cells rather than on a nervous pathway.

Anilides↗

Tolerance to sympathomimetic bronchodilators in guinea-pig isolated lungs following chronic administration in vivo.

1 Pretreatment of the guinea-pig subcataneously three times daily with either 5 mug/kg isoprenaline or adrenaline reduced the response of the isolated perfused histamine-constricted lung when challenged with either the same or a different sympathomimetic bronchodilator. The longer the animals were pretreated and the higher the dose of bronchodilator the greater was the degree of tolerance developed. 2 Tolerance was developed to aminophline in the same preparation when the guinea-pig had been pretreated with aminophyline or isoprenaline. Cross-tolerance also developed adrenaline when the guinea-pig had been pretreated with aminophyline. 3 Tolerance was still persistent in guinea-pigs one and two weeks after pretreatment three times daily with either isoprenaline of adrenaline (5 mu/kg s.c.) for seven days in the same preparation. Only after three weeks was the tolerance diminished. 4 These results suggest that asthmatic patients who use bronchodilators excessively may become refractory to the bronchodilator effect of these drugs. They also support the hypothesis that induced cross-resistance to endogenous sympathetic stimulation could lead to a deterioration of the asthmatic state in patients using the sympathomimetic bronchodilators and that this may explain the increase in asthma mortality rate. 5 A mechanism of tolerance to sympathomimetic bronchodilators is postulated.

Airway Resistance↗

Autonomic modulation of the u wave during sympathomimetic stimulation and vagal inhibition in normal individuals.

Prolonged repolarization time, an important contributor to the pathogenesis of ventricular arrhythmias, is usually identified by a long QT interval (QT) on the ECG but is frequently confounded by the presence of a U wave. The physiological basis and clinical relevance of the U wave is unresolved. To better understand the relationship between the T and U waves, this study examined their behavior during nonresting autonomic conditions. Twenty-five healthy subjects were evaluated during sympathomimetic infusion with isoproterenol and vagal inhibition with atropine. As heart rate (HR) increased in response to isoproterenol, the QU interval (QU) decreased by an eightfold greater extent than QT. Furthermore, a marked increase in U wave amplitude and decrease in T wave amplitude were observed with T and U wave fusion at higher HRs. During atropine, QU decreased by only a threefold greater extent than QT, T and U wave amplitudes were affected only minimally, and T-U wave fusion was not observed. These results demonstrate that sympathomimetic stimulation causes striking alterations in the timing and amplitude of U waves that differ from effects on the T wave. These effects are not observed during vagal inhibition. Thus, the U wave represents a component of cardiac repolarization that is electrocardiographically and physiologically distinct from the T wave with a unique response to sympathomimetic stimulation.

Adult↗

Sympathomimetic effects of exo- and endo-isomers of 2-aminobenzonorbornene in vitro and in vivo.

A stereospecific synthesis of endo-2-aminobenzornorbornene is described. Its sympathomimetic activities and those of its N-methyl derivative were compared with the equivalent exo-isomers using the isolated rat anococcygeus muscle and the anaesthetized rat blood pressure preparations. On the anococcygeus muscle preparation the endo- and exo-isomers of the primary amines had similar indirectly acting sympathomimetic activities. In contrast the exo-N-methyl derivative was a far more potent sympathometic in vitro than the endo-N-methyl isomer. In the anaesthetized rat the exo- and endo-isomers of 2-aminobenzonorbornene and their N-methyl derivatives all had similar pressor activities, though the successive injections of the two exo-derivatives suggested an additional alpha-adrenoceptor blocking activity. The actions of these rigid sympathomimetics are compared with those of the flexible amphetamine structure.

Amphetamine↗

Inhibitory effects of sympathomimetic drugs on cholinergically mediated contractions of guinea-pig isolated tracheal muscle.

The experiments examine the actions of sympathomimetic drugs on the responses evoked by electrical field stimulation or by acetylcholine in guinea-pig tracheal strip chains. Electrical field stimulation evoked contractions which were cholinergically mediated, in the presence of guanethidine (10 microM) and indomethacin (2 microM). All the sympathomimetic drugs tested caused a concentration-dependent reduction in the height of these contractions. Inhibitory effects of isoprenaline and terbutaline were largely prevented by propranolol (2 microM) alone, whereas those of clonidine, oxymetazoline, lidamidine and WHR1370 were prevented by yohimbine alone (2 microM). Treatments with both propranolol and yohimbine were required to prevent the inhibitory effects of noradrenaline, adrenaline and dopamine. Contractions evoked by exogenous acetylcholine (0.1-3 microM) were also inhibited by all catecholamines and terbutaline, but not by clonidine, oxymetazoline, lidamidine and WHR1370. The inhibitory effects were antagonized by propranolol (2 microM) alone. The results suggest that in guinea-pig isolated tracheal muscle, sympathomimetic drugs can inhibit cholinergic neurotransmission not only by postjunctional beta 2-adrenoceptors but also by prejunctional alpha 2-adrenoceptors.

Acetylcholine↗

Responses of the isolated rectum of the rainbow lizard (Agama agama) to sympathomimetics.

The relaxant effects of isoprenaline, noradrenaline, and adrenaline on the isolated rectum of the rainbow lizard (Agama agama) were studied. Responses were measured as a reduction of carbachol-induced contractions for each sympathomimetic agent. Isoprenaline, adrenaline, noradrenaline produced a dose-dependent relaxation of this preparation and the order of potency was as given. The pD2 value of 8.15 +/- 1.88 obtained for isoprenaline was significantly different (p less than 0.05) from those for adrenaline (5.80 +/- 0.90) and noradrenaline (5.25 +/- 1.18). H35/25, propranolol, and practolol competitively antagonized the relaxant effects of isoprenaline on the isolated lizard rectum. The pA2 values for these beta-adrenoceptor antagonists did not differ significantly (at p less than 0.05). alpha-Adrenoceptor antagonists, phentolamine and phenoxybenzamine, failed to alter the relaxant responses of these sympathometics to any appreciable extent. These results are interpreted to suggest that the relaxant effect produced by these sympathomimetics are mediated predominantly by beta-adrenoceptors that are not significantly differentiated into subtypes. alpha-Adrenoceptors in this preparation contribute minimally to the observed inhibitory response following sympathomimetic stimulation.

Adrenergic alpha-Antagonists↗

Reduced adipsin expression in murine obesity: effect of age and treatment with the sympathomimetic-thermogenic drug mixture ephedrine and caffeine.

Adipsin gene expression is greatly diminished in certain forms of genetic and acquired obesity. In the present study we evaluate the time course for the development of adipsin deficiency in obesity and its regulation by the sympathomimetic-thermogenic drug mixture ephedrine and caffeine. Previously, it was unknown whether adipsin deficiency occurred before or after the development of massive obesity. In the first series of experiments in which mice were treated with monosodium glutamate (MSG) for the first week of life, we demonstrate that adipsin deficiency occurs early in the development of MSG-induced obesity as evidenced by decreased circulating adipsin concentrations by 1 week of age and deficient adipsin mRNA levels in white adipose tissue (WAT) by 2 weeks. In db/db mice, diminished circulating adipsin was noted at 2 weeks of age. In both models, decreased adipsin gene expression precedes the development of marked obesity. Little is known about the factors which regulate adipsin gene expression in obesity. Common to the ob/ob, db/db and MSG models is diminished thermogenesis and sympathetic nervous system activity. In a second series of experiments we sought to determine whether adipsin deficiency in obesity could be corrected by treatment with ephedrine and caffeine (E+C), a sympathomimetic-thermogenic mixture previously shown to increase thermogenesis and reverse obesity in some models. In the present study, E+C treatment of MSG obese mice reversed obesity and markedly increased serum adipsin and adipsin mRNA levels in WAT and brown adipose tissue (BAT). In ob/ob mice, however, E+C treatment produced a negligible increase in adipsin mRNA levels in WAT and BAT as well as serum adipsin concentrations and this correlated with only a very small decrease in obesity. Thus, the ability of E+C to increase adipsin gene expression correlated with its ability to reverse obesity in these two models. Finally, the effect of E+C on adipsin gene expression may not be exerted directly on the fat cell since treatment of cultured 3T3-F442A adipocytes and isolated rat adipocytes in primary culture produced no effect on adipsin mRNA or secreted protein despite a lipolytic effect as measured by increased glycerol release. In summary, decreased adipsin gene expression occurs early in the development of MSG and db/db obesity and is markedly increased in the MSG model by the sympathomimetic-thermogenic drug mixture, E+C, which also reverses obesity. Elucidation of the factors responsible for these effects may enhance our understanding of fat cell gene regulation and obesity.

Adipose Tissue, Brown↗

Sympathomimetic actions of reserpine administered during treatment with dopamine in the dog.

Reserpine injected intravenously during infusion with dopamine brought about sympathomimetic effects, but a second injection of reserpine after 120 minutes did not elicit such effects. This pressor effect was eliminated by phenoxybenzamine and this positive chronotrpic effect by propranolol. Reserpine induced similar but weak sympathomimetic effects after cocaine, while it induced no changes in blood pressure and heart rate after infusion with noradrenaline. Meanwhile, pressor response to dopamine was potentiated 24 hours after reserpine and was further potentiated after additional infusion with noradrenaline. The sympathomimetic actions induced by the concurrent administration of reserpine and dopamine may be attributable to a facilitation of those indirect mechanisms, prinicpally of endogenous catecholamine release.

Animals↗

Centrally mediated cardiovascular responses to intracisternal injections of sympathomimetic amines in anesthetized rats.

The cardiovascular effects resulting from intracisternal (i.c.) injections of sympathomimetic amines were studied in alpha-chloralose-urethanized rats. Norepinephrine (0.5-5 mug i.c.) caused a typical rise in blood pressure with no significant change in heart rate and a fall in blood pressure with a bradycardia, which were completely blocked after treatment with phentolamine (10-50 mug i.c.) L-isoproterenol (0.05-0.5 mug i.c.) and trimetoquinol (0.5-3 mug i.c.), a beta-sympathomimetic agent, usually caused a fall in blood pressure with a tachycardia, which was reduced after treatment with propranolol (10-50 mug i.c.), but trimetoquinol was inclined to cause a rise in blood pressure with a tachycardia. Epinephrine (5 mug i.c.) showed both centrally mediated alpha- and beta-sympathomimetic effects. Tyramine (0.5-1 mg i.c.) caused mixed blood pressure responses presumably due to a release of norepinephrine and epinephrine, and these responses were partially blocked after treatment with phentolamine (100 mug i.c.) or propranolol (50 mug i.c.). These observations suggest that both alpha- and beta-sensitive adrenergic zones may exist on the vasomotor center of the pons and medulla in rats, and both norepinephrine and epinephrine might centrally play a physiological role as the neurotransmitters controlling blood pressure in rats.

Animals↗

[Adverse cardiovascular and central neurologic reactions to sympathomimetics used as nasal decongestants: results of the French National Pharmacovigilance Survey].

Remedies for coughs and colds often contain both an indirect sympathomimetic agent plus another drug (anti-inflammatory, analgesic or antibiotic, etc.). In France, oral sympathomimetics are available over the counter, and preparations for topical use (nasal sprays or drops) require a medical prescription. Using the French Pharmacovigilance database, we performed a retrospective study to identify cardiovascular and neurological adverse drug reactions (ADRs) associated with the use of nasal decongestants containing a sympathomimetic agent. Of a total of 165 ADRs. 15 were strokes or cerebral haemorrhages. We also found the following: 67 cases of arterial hypertension, 33 of convulsions, 28 of headaches and 24 of vasomotor symptoms involving the extremities. In most of these cases, misuse or a predisposing factor was found (such as a history of arterial hypertension or headache, the combination of two decongestants, long-term use, etc.). The incidence of cardiovascular or neurological ADRs with cold remedies seems 'very rare' but some of these reactions, mainly stroke, are 'serious'. However, there is no available clinical evidence showing the benefit of such agents after repeated use over several days. Since most of the nasal decongestants are freely available without prescription, drug information is needed to advise prescribers and also patients about risk of 'serious' ADRs with these drugs.

Administration, Intranasal↗