USMLE PHARMACOLGY WORKSHEETS

Drug mechanism of action side effects

ANS
Cholinergic agonists DUMBELS
Direct acting acetylcholine D iarrhea and Decr BP
bethanechol stims bladder and bowel U rination
carbachol M iosis
pilocarpine miosis and contraction of ciliary mm B ronchoconstriction
methacholine E xcitation of skeletal mm
nicotine L acrimation
S alivation and Sweating
Indirect acting edrophonium dx of myasthenia gravis
physostigmine tertiary amine - can enter CNS
neostigmine quaternary amine – no CNS

Cholinergic antagonists opposite of DUMBELS

Muscarinic antags atropine
scopolamine
ipratropium

NMJ blockers Non-depolarizing eye and face first, respiratory last bronchoconstrict and hypotension
ƒ tubocurarine
ƒ vecuronium
ƒ atracurium
Depolarizing - succinylcholine metab’d by plasma cholinesterase

Ganglionic blockers nicotine depolarizing – no clinical uses tachy, vasodilate, mydriasis, ↓ GI

Parasympathetic
Agonists Synthetic choline esters
ƒ carbachol no hydrolysis by AChE
ƒ bethanechol no hydrolysis by AChE
ƒ methacholine small hydrolysis by AChE
 Drug mechanism of action side effects
Muscarinic agonists
ƒ muscarine
ƒ pilocarpine
Nicotinic agonists – nicotine
Indirect agonists inhib AChE
ƒ edrophonium short acting, reversible
ƒ neostigmine medium acting, reversible
ƒ physostigmine medium acting, reversible
ƒ pyridostigmine long acting, reversible
ƒ organophosphates irreversible

Antagonists Muscarinic antags

ƒ atropine
ƒ scopolamine
ƒ homotropine
ƒ ipratropium bromide
Nicotinic antags
ƒ hexamethonium non-depolarizing, ganglia and NMJ
ƒ D-tubocurarine non-depolarizing, NMJ only
ƒ succinylcholine depolarizing, NMJ only, short acting
ƒ decamethonium depolarizing, NMJ only
Indirect antagonists
ƒ hemicholimium blocks vesicular uptake of choline

Sympathetic
α – Adrenergic receptors Agonists effects of stimulation:
ƒ NE not used clinically ƒ vasoconstriction
ƒ phenylephrine ƒ mydiasis radial mm in eye
ƒ methoxamine ƒ ejaculation
ƒ metaraminol has both direct and indirect effects ƒ stim of pilomotor mm
ƒ clonidine α2-selective partial agonist
ƒ guanabenz, guanfacine α2-selective

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 Drug mechanism of action side effects
Antagonists
ƒ ergot alkaloids
ƒ phentolamine reversible
ƒ phenoxybenzamine irreversible
ƒ prazosin α1-selective
ƒ terazosin α1-selective

β receptor agonists β1 selective agonists effects of stim: ↑ HR, ↑CTY,

ƒ dobutamine ↑ CTY without ↑ heart rate or SVR ↑ AV node condctn, ↑ CO
β2 selective agonists asthma effects of stim:
ƒ albuterol ƒ ↑ bronchodilation
ƒ salmeterol ƒ ↑ relaxation of viscera
ƒ terbutaline
ƒ metaproterenol
β1, β2 nonselective agonists pressor agent
ƒ isoproterenol
Mixed agonists (α and β) α1 Epi > NE >> Iso
ƒ epi α2 Epi > NE >> Iso
ƒ ephedrine β1 Iso > Epi = NE
ƒ mephantermine β2 Iso > Epi >> NE

β receptor antagonists β1 selective antagonists anti-HTN

ƒ metoprolol
ƒ atenolol
ƒ esmolol
ƒ acebutolol
β1, β2 nonselective antagonists
ƒ propranolol
ƒ nadolol
ƒ timolol
ƒ pindolol
Adrergic neuron blockers
ƒ reserpine blocks vesicular uptake of NE
ƒ guanethidine blocks NE release

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 Drug mechanism of action side effects
CNS/Neurologic
Antiparkinson
drugs that replete dopamine Levdopa prodrug
Carbidopa inhib Lev→DA conversion in periphery
Entacapone COMT inhib (prolongs DA ½ life)

dopamine agonists Bromocriptine D2 agonist – not very effective

Apomorphine D2 agonist – very effective
Pramipexole D2/D3
Ropinarole D2/D3

ACh neuron inhibitors Trihexyphenidyl helps sialorrhea, not bradykinesia

Benzotropine
Diphenhydramine

Adjuvants Amantadine treats Levdopa side effects

Diprenyl allows lower dose of Levdopa

Stimulants
drugs affecting catechol amphetamine
neurons methamphetamine
ephedrine
methylphenidate (Ritalin)
cocaine

Alzheimers AChE inhibitors low therapeutic index

ƒ Donezapil
ƒ Rivastigmine
memantine non-competitive antag of NMDA low therapeutic index

other stimulants caffeine

theobromine
modafinil

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 Drug mechanism of action side effects
ETOH naltrexone opioid antag
acamprosate glutamate antag
disulfiram aldehyde dehydrogenase inhib

Anti-epileptics
Na channel inactivators phenytoin inactivates rapid firing Na channel arrhythmias
fosphenytoin prodrug of phenytoin, less toxic
carbamazepine prolongs inactivation of Na diplopia
lamotrigine
tobrimate
valproate liver, GI, no use w/phenobarb

Ca channel blockers valproate

ethosuxamide

GABA potentiators tigapine prevents GABA reuptake

phenobarbitol post-synaptic GABA agonist
felbamate post-synaptic GABA agonist aplastic anemia

Unknown GABApentin

Status epilepticus diazepam

lorazapam
phenytoin

Psychiatric
Anti-psychotics
typical reserpine parkinsonism, tardive dyskinesia
chlorpromazine (after prolonged use), sedation,
thioridazine anti-cholinergic
haloperidol
domperidone
thiothixine
benzotropine
trihexyphenidyl
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 Drug mechanism of action side effects
atypical clozapine not as many extra-pyramidal
olanzapine effects, weight gain
risperidone
aripiprazole

Anxiolytics
Anxiety Benzodiazepines GABA inhibs, can not OD dependence
ƒ alprazolam short acting
ƒ diazepam intermediate acting
ƒ lorazapam long acting
ƒ triazolam
5HT/NE uptake inhibs
ƒ SSRI
ƒ SNRI
ƒ imimpramine
ƒ venalfixine
Buspirone
Herbal
ƒ kava kava + diazepam = coma
ƒ valerian

Insomnia Benzodiazepines
ƒ Flurazepam
ƒ Temazepam
Non-benzos
ƒ zolpidem (ambien)
Barbituates sedative
ƒ pentobarbital ½ life – 18-48h
ƒ phenobarbitol ½ life – 4 days

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 Drug mechanism of action side effects
Anti-depressants
Depression TCA’s low therapeutic index, dry mouth,
ƒ Tertiary amines inhibit 5HT uptake, muscarinic & dizziness, constipation, tachy,
ƒ Imipramine α-1 antags orthostatic HTN
ƒ Amitryptiline
ƒ Secondary amines inhibit NE uptake, muscarinic &
ƒ Desipramine α-1 antags
ƒ Nortryptiline
MAOIs MAO-A – NE and DA neurons,
ƒ Phenalzine non-selective MAOI involved in tyramine metab in gut
ƒ Tranylcypromide MAO-B – 5HT neurons
ƒ deprenyl MAO-B but non-selective at dose

SSRIs 5 HT uptake inhib

ƒ Fluoxetine
ƒ Sertraline
ƒ Paroxetine
Other
ƒ Trazadone
ƒ Nefazadone
ƒ Venalfixine
ƒ Buproprion NE and DA uptake inhib
ƒ Mirtazapine

Bi-polar Lithium low therapeutic index

Valproate
Lamotrigine
Olanzapine

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 Drug mechanism of action side effects
Cardiovascular
Atherosclerosis
Statins Lovastatin HMG Co-A reductase inhib which upregs GI upset, muscle ache, hepatitis
Fluvastatin LDL receptors
Atorvastatin
Pravastatin
Simvastatin

Bile acid binding resins Cholestyramine prevent reabsorp of bile bloating

Colestipol

Niacin Nicotinic acid inhibit mobilization or peripheral FFAs flushing

Vitamin B3

Fibrates Gemfibrozil enhanced oxidation of FFAs potentiates warfarin

Clofibrate
Fenofibrate

Antithrombosis
Anticoagulants heparin stims antithrombin III which binds
thrombin
fondaparinaux sulfate binds to ATIII selective inhib of FX/Xa
warfarin (coumadin) vitK analog – competive inhibitor

Anti-platelets inhibs of platelet signaling

ƒ aspirin irreversibly inhib cyclooxygenase
ƒ clopidigrel irreversibly blocks platelet P2Y12 ADP
ƒ ticlopidine interferes w/platelet aggegation neutropenia and TTP
ƒ dipyridamole ↑ platelet cAMP → ↓platelet activation cardiac death
glycoprotein IIb/IIIa antags
ƒ abmixicab
ƒ eptifibitide
ƒ tirofiban

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 Drug mechanism of action side effects
Thrombolytics streptokinase convert plasminogen → plasmin contraindicated in pxs w/strep inf
TPA (alteplase & retaplase)
urokinase
anistrplase

Prothrombotics aprotinin inhibs lakikrein-kinin → inhibs

fibrinolysis

Anti-arrhythmics
Class I – Na channel
Class Ia incr ARP and AP sudden death arrhythmias
ƒ quinidine
ƒ procainamide
Class Ib – lidocaine raise threshold and prolong RRP pro-arrhythmic (not as bad)
Class Ic – flecainide raise threshold and slow conduction sudden death arrythmias

Class II – β blockers propanolol contraindicated w/asthma

Class III – K channel amiodarone block DRK channels + Class I, II, and IV
soltalol block DRK channels + Class II torsades de pointed (ventr tachy)

Class IV – Ca channel verapamil

diltiazem

other adenosine temporary asystole

digitalis

Cardiac glycosides
Digitalis glycosides digoxin
digitoxin
digoxin immune Fab

Bipyridines milnirone

select α non-selec β blocker carvidilol

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 Drug mechanism of action side effects
β1 agonist dobutamine

Anti-hypertensives
Central acting clonidine stimulates central α2
guanbenz
methyldopa

Noradrenergic blockers guanethidine

Adrenreceptor antags Beta blockers

ƒ propranolol
ƒ pindalol
ƒ labetolol
ƒ metoprolol
ƒ atenolol
Alpha blockers
ƒ prazosin
ƒ phentolamine

Diuretics see below

Ca channel blocker see below

ACE inhibitors see below

ARBs see below

Diuretics
Osmotic mannitol
urea

Carbonic anhydrase inhibs acetazolamide block HCO3 reabsorption

Loop furosemide block Na/K/2 Cl

bumetanide
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 Drug mechanism of action side effects
Thiazides HCTZ block Na/Cl
metolazone

K sparing spironolactone blocks upreg of Na channel

amiloride blocks Na channel
triamterene block Na channel

Vasodilators & antianginal

K channel openers minoxidil

Ca channel blockers verapamil

diltiazem
nifedipine
nimodapine

Nitrodilators nitroglycerin
isosorbide dinitrate
nitric oxide
nitroprusside

ACE inhibs captopril

enalapril
ramipril

ARBs losartan

cGMP PDE Type 5 inhibs sildenafil

Natiuretic factors nesiritide

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 Drug mechanism of action side effects
GI Drugs
Control of gastric acidity
PPIs omeprazole irreversible proton pump inhibs nausea and diarrhea
lansoprazole
labeprazole
pantoprazole
esomeprazole

H2R antagonists cimetidine inhibs GS protein needed to activate pump p450 inhib, nausea, ↑ prolactin
ranitidine
famotidine
nizatidine

Prostaglandin analog misoprostol stims Gi which inhibs proton pump diarrhea, uterine contractions

Anti-emetics
5HT3R antagonists odansetron
granisetron
dolasetron

Dopamine R antagonists thenothiazine antag the DA R on the Chemoreceptor TZ

metaclopramide CNS effects
domperidone No CNS effects

Antihistamines cyclizine
hydroxyzine
promethazine
diphenhydramine

Anticholinergics scopolamine

dronabinol

Glucocorticoids & NSAIDs

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 Drug mechanism of action side effects
Prokinetics
Cholinergic agonists carbechol ACh is main NT for GI motility lots of global side effects
bethanechol

AChE inhibitor neostigmine

Dopamine D2R antags metaclopramide dopamine inhibs gastric motility

domperidone

Serotonin R modulators metaclopramide 5HT4R agonist (stimulatory receptor)

cisparide blocks DRKs in heart-arrhythmia
tegaserod

Somatostatin analog octreotide enhances gastric emptying

Motilin R agonist erythromycin Motilin is a potent contractile hormone

IBS
5HT4R agonist tegaserod

Diarrhea
Intraluminal fiber

Opiates loperamide anti-secretory and anti-motility

dipenoxylate
difenoxen

Somatostatin analog octreotide

cholestyramine binds bile acids can bind and inactivate drugs

bismuth antisecretory, -inflammatory, -microbial

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 Drug mechanism of action side effects
IBD
5 aminosalicylates sulfasalazine

COX/lipoox pthwy inhibs mesalamine

Immunosuppression 6-mercaptopurine
methotrexate inhibs DHFR
cyclosporine

Monoclonal antibody Inflliximab Monoclonal Ab to TNFα

Respiratory
Asthma
β2 agonists albuterol short acting tachy and tremor
salmeterol long acting

Corticosteroids beclomethasone all the probs with steroids

fluticasone

Anticholinergics ipratropium few due to poor systemic absorp

Leukotriene inhibs zileuton inhib Arach Acid → Leuko – 5-lipox inhib not for acute
zafirlukast LTD4 R antag

Methylxanthines theophylline ↑cAMP → bronchodilation seizures and arrythmias

cromolyn sodium prophylactic - stabilize mast cells laryngeal edema

nedocromil prophylactic - stabilize mast cells bad taste

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 Drug mechanism of action side effects
Endocrine
Osteoporosis
Ca and Vit D supplements
ERT
SERM raloxifene agonist on bones, antag on breasts
tamoxifen

Bisphosphonates etidronate long term inhibs of bone resorption

pamidronate
alendronate
risendronate

calcitonin decr osteoclast activity

anabolic agents teriparatide stims bone formation

Insulin and anti-diabetics

Biguanides metformin ↓ gluconeogenesis in liver, insulin dep lactic acidosis

Thiazolidinediones pioglitazone ↑↑ glucose uptake peripherally via PPARγ edema and weight gain
rioglitazone activation, ↓ gluconeo in liver

Sulfonylureas and glinides nateglinide insulin secretagogues, stimulate beta cell hypoglycemia
repaglinide production of insulin
meglitinide
glipizide

Alpha-glucosidase inhibs acarbose delay absorption of carbs and so moderate flatulence and incr LFTs
miglitol post prandial spike

Insulin glargine slow absorp and sustained release

lispro and aspart fast acting – moderate post prandial spike
regular fast acting but give 30 mins before meal
NPH long acting but not as long as glargine

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 Drug mechanism of action side effects
Hyperlipidemia
Statins see above lower LDL

Bile acid sequestrants cholestyramine lower LDL

colestipol
colesevalam

Cholesterol absorp inhibs ezetimibe lower LDL

plant stanol and sterol esters

Niacin see above lower TGs

Fibrates see above lower TGs and incr HDL + statin = rhabdomyalisis

Omega 3 fatty acids lower TGs

Anti-obesity
Adrenergic dexamphetamine
phentermine

Serotonergic sibutramine reuptake inhibitor

fenfluramine dexfenfluramine serotonin releasers

nutrient absorption blockers orlistat

Antibiotics
Nucleic acid inhibs
sulfamethoxazole bacteriostatic PABA analog kernicterus,p450 inhib,crystalluria

trimethoprim bacteriostatic DHFR inhib, can cross BBB

nitrofurantoin uncomplicated UTI

Fluoroquinolones ciprofloxacin DNA gyrase inhib cartilage dmg

ofloxacin
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 Drug mechanism of action side effects
β-lactams
Penicillins penG inhib bacterial cell wall transpeptidation
penV
penicillinase resistant β-lactamase producing S. aureus
ƒ oxacillin
ƒ nafcillin
ampicillin
ampicillin + sulbactam
amoxicillin
amoxicillin + clavulante
ticaracillin
ticaracillin + clavulante
piparcillin
piparacillin + tazobactam
aztreonam
imipenem broad spectrum but not MRSA
β-lactamase inhibs
ƒ sulbactam
ƒ clavulante
ƒ tazobactam

Cephalosporins 1st generation – cephalexin gram pos

2nd generation – cefuroxime gram neg like HIB, Neisseria, S. pneumo
3rd generation gram neg
ƒ ceftriaxone
ƒ cefotaxime
ƒ ceftazadime

vancomycin inhib bacterial cell wall transglycosylation

Protein synthesis inhibitors

Aminoglycosides gentamicin bactericidal; aerobic; 30s subunit ototoxicity and nephrotoxicity
amikacin
trobramicin
streptamicin
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 Drug mechanism of action side effects
Tetracyclines doxycycline 30s, chlamydia, cholera, lyme hepatotox, dep in bones and teeth
minocycline

Macrolides erythromycin 50s,legionella,mycoplas,chlamdia,anthrax GI irrit, hepatotox, p450 inhib

azithromycin does NOT inhib p450
clarithromycin

chloamphenicol 50s, serious infections, incl CNS aplastic anemia and p450 inhib

clindamycin 50s; anaerobic, S.aureus, PCP psuedomemb colitis, hepatotox

Oxazolidinones linezoilid 50s, VRSE, MRSA, PRSP MAO inhib, superinfections

Streptogramins dalfopristin 50s, bactericidal when given together,

quinupristin VRSE, MRSA, PRSP

metronudazole anaerobes

TB drugs bactericidal except Ethambutol

isoniazid mycolic acid synth inhib; periph neuritis,slow/fast acetyl
rifampin Tb DNA dep RNA pol inhib GI, hepatotox, p450 induce
ethambutol only dividing mycobacs;for MAC + clarith retrobulbar neuritis,periph neuritis
pyrazinamide hepatotox, gout-like sx

Anti-fungals
Amphoteracin B complex w/sterols results in apoptosis nephro, cardio, and neurotoxic

Flucytosine fungal uracil analog; chain termin bone marrw suppr, alopecia, GItox

Azole family Imidizole – ketoconazole

Triazoles
ƒ fluconazole CSF
ƒ itraconazole

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 Drug mechanism of action side effects
Anti-parasitics
Entamoeba, giardia, trich metronidazole

Malaria chloroquine erythrocytic cidal

primaquine exoerythrocytic cidal; leukopenia, hemlytic crisis (G6PD
mefloquine

Trypanosomiasis saramin tx pre-CNS neurotox

Worms Round – mebendazole poor GI absorb so intraluminal effect

Flat
ƒ Flukes - praziquantal ↑ Ca++ perm of worm cell membrane
ƒ Tapeworms
ƒ niclosamide
ƒ praziquantal T. solium

Anti-virals
Influenza amantadine flu A by blocking M2 so no uncoating paranoia, depression
neuramidase inhibs prevent cleave of sialic acid-virus no exit
ƒ zanamivir inhaled can be prob for asthmatics
ƒ oseltamavir oral

Herpes trifluorothymadine thymidine analog, topical

acyclovir guanine analog; 100x affinity of viral TK

AIDS RT inhib – azidothymadine

Protease inhibitor combo
ƒ lopinavir-ritonavir inhib viral replic
Fusion inhib - enfuvirtide blocks HIV attachment to cells

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 Drug mechanism of action side effects
Analgesics and Anesthetics
Opioids opioid work on three receptors in CNS:
Endogenous endorphins µ – analges,euphor,resp depr,miosis,constp
enkephalins κ – analges, sedation, dysphoria, miosis
dynorphins δ - analgesia

Alkaloids morphine µκδ

codeine
heroin

Synthetic fentanyl µ
methadone µ long ½ life(resp dep after 2-3days)
pentazacine agonist κ δ antag µ δ
hydrocodone
meperidine µ + MAOIs = severe resp depression

Antagonists naloxone comp antag for µ κ δ

naltrexone comp antag for µ κ δ

Chronic pain
Non-opioid NSAIDs
Opioid Full agonist
ƒ fentanyl µ
ƒ hydromorphone µ
ƒ heroin µκδ
ƒ morphine µκδ
ƒ methadone µ
ƒ meperidine µ
Partial agonist
ƒ buprenorphine µ
ƒ oxycodone µ
ƒ hydrocodone µ
ƒ codeine µ
ƒ propoxyphene µ

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 Drug mechanism of action side effects
Adjuvant Muscle relaxants
ƒ cyclobenaprine
ƒ methocarbamol
ƒ diazepam
ƒ baclofen
anti-convulsants – see above
local anesthetics – see below
anti-depressants – see above

Local anesthetics
Ester linked cocaine metabolized by blood = short ½ life; if arrythmias, euphoria
procaine administer w/epi, vasoconstr prevents
benzocaine blood from reaching site and incr ½ life
tetracaine

Amide linked lidocaine metabolized by liver = longer ½ life

etidocaine
mepvicaine
bupivacaine
(S)-ropivacaine

General anesthetics
Inhalational halothane hepatitis, malign hyperthermia
enflurane
isoflurane
desflurane
sevoflurane
nitrous oxide

Injectable/IV propofol
ketamine NMDA-R antag, dissociative anesthesia bad dreams
barbiturates – thiopental
benzodiazapenes
ƒ midazolam
ƒ diazepam
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 Drug mechanism of action side effects
ƒ lorazepam

Immunosuppression
Prototype mediators thromboxanes
prostacyclin (PGI2)
prostaglandin E2
leukotrienes
histamine
IL-1
IL-2
TNF

NSAIDs
Non-specific aspirin
acetaminophen
ibuprofen
naproxen
piroxicam
etodolac
nabumetone
endomethacin

COX-2 celecoxib

Leukotriene inhibitors zileuton

zafirlukast

Anti-rheumatics Disease modifying

ƒ entanercept “decoy” TNF-receptor
ƒ infliximab anti-TNF monoclonal antibody
Slow acting
ƒ methotrexate
ƒ gold salts
ƒ penicillamine
ƒ hydroxychloroquine
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 Drug mechanism of action side effects
Anti-gout indomethacin NSAID
colchicine acute attack – inhib MTs
allopurinol Inhib xanthine oxidase - uric acid synth
uricosuric agents reduce resorbtion of urate from the urine

Anti-histamine dimenhydrinate penetrate CNS - sedation

diphenhydramine penetrate CNS - sedation
loratidine
cetirizine
fexfenadine

Immunosuppressive
Cytotoxic methotrexate Inhibit prod of immune system cells
azathioprine
cyclophosphamide

Corticosteroids hydrocortisone interrupt of adren-pituit axis, Na &

dexamethasone H2O retention, cushingoid effects,
methylprednisone general immunosup, osteoporosis

Selective cyclosporine inhibition of clonal expansion of T cells

tacrolimus iInhibition of clonal expansion of T cells
sirolimus inhibition of clonal expansion of T cells
mycophenolate mofetil inhibits nucleoside synthesis in T cells
anti-CD3 monoclonal Ab against T cell receptor
anti-IL-2 monoclonal Ab against IL-2
ƒ daclizumab
ƒ basiliximab

Immunostimulant GM-CSF increase the production of hematopoietic

G-CSF cells

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 Drug mechanism of action side effects
Chemotherapy
Cell cycle nonspecific
Alkylating agents cyclophosphamide alkylate DNA, cause DNA cross-linking carcinogenic
nitrourea
cisplatin renal

Antibiotics (except bleo) anthracyclines intercalate DNA, breaks via Topo II cardiac, carcinogenic
ƒ doxorubicin
ƒ daunorubicin
dactinomycin intercalate DNA, inhib RNA synth

Cell cycle specific

Antimetabolites Folate analogs - methotrexate inhibs DHFR leucovorin reduces myelosuppres
Purine analogs antag HGPRT
ƒ 6-mercaptopurine
ƒ 6-thioguanine
Pyrimidine analogs
ƒ 5-fluorouracil inhib thymidilate synthase
ƒ cytosine arabinoside- ara-C inhib DNA pol

Plant deriviatives Vinca alkaloids bind tubulin → depol so no MTs form

ƒ vinblastine
ƒ vincristine peripheral neuropathy
Podophyllotoxins
ƒ etoposide inhib Topo II religation
ƒ tenoposide
Taxanes - paclitaxel bind to tubulin →pol & overstabilization

Antibiotics bleomycin DNA breaks via free radicals pulmonary

Hormones Anti-estrogen - tamoxifen estrogen antag

GnRH agonists initially agonists but cause recep downreg
ƒ leuprolide
ƒ goserelin
Steroids - prednisone
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 Drug mechanism of action side effects
Miscellaneous hydroxyurea inhib RNA reductase → inhib DNA synth
L-asparaginase uses up asparagine (essntl aa for tumors) hypersensitivity

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