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7.  The specific drug examples found on your drug list under each drug classification including generic (lowercase) and brand (capitalized in parentheses with the trademark symbol at the end- ®) 

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7.  The specific drug examples found on your drug list under each drug classification including generic (lowercase) and brand (capitalized in parentheses with the trademark symbol at the end- ®) 

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I.               Alpha-1 Adrenergic Agonists

ephedrine

phenylephrine (Neo-Synephrine®)

II.             Adrenergic Agonists

epinephrine (Adrenalin®)

III.           Alpha-1 Adrenergic Blocker

prazosin (Minipress®)

terazosin (Hytrin®)

doxazosin (Cardura®)

IV.          Beta-1 Adrenergic Agonist

dobutamine

V.            Beta-2 Adrenergic Agonist

formoterol (Foradil®)

albuterol (Proventil® /Ventolin®)

terbutaline (Brethine®)

VI.          Beta Blocker

Nonselective

nadolol (Corgard®)

propranolol (Inderol®)

timolol (Blocadren®)

Selective

atenolol (Tenormin®)

metoprolol (Lopressor®)

VII.        Direct Acting Cholinergic Agonist

acetylcholine

pilocarpine (Pilocar®)

bethanechol (Urecholine®)

VIII.    Indirect Acting Cholinergic Agents

neostigmine (Prostigmin®)

VIII.      Anticholinergic

atropine

dicyclomine (Bentyl®)

IX.          Skeletal Muscle Relaxants

a.     Peripherally Acting

Depolarizing Agent:

succinylcholine

Non-depolarizing Agent

rocuronium bromide (Zemuron®)

Direct Acting

dantrolene (Dantrium®)

b.     Centrally Acting

cyclobenzaprine (Flexeril®)

carisoprodol (Soma®)

methocarbamol (Robaxin®)

orphenadrine citrate (Norflex®)

chlorzoxazone  (Parafon Forte DSC®)

metaxalone (Skelaxin®)

Respiratory Drugs

I.     Mast Cell Stabilizers

cromolyn Sodium (Intal® / Nasalcrom®)

II.     Bronchodilators

Sympathomimetics “B-2 agonist”  (Short and long acting)

albuterol (Proventil®/Ventolin®)

formoterol (Foradil®)
terbutaline (Brethine®)                                                                                                          salmeterol (Serevent®)

Xanthine Derivatives

theophylline (Theo-Dur®)

aminophylline (Paladron®)

III.         Cysteinyl Leukotriene Receptor Antagonist

montelukast    (Singulair®)

IV.         Anticholinergic

ipratropium bromide   (Atrovent®)

V.     Combination Bronchodilator

ipratropium bromide and albuterol sulfate (Combivent®)

VI.     Antihistamine
Generation I (sedating)

brompheniramine (Dimetapp®)

chlorpheniramine (Chlor-Trimeton®)

clemastine (Tavist®)

diphenhydramine (Benadryl®)

hydroxyzine (Atarax®)

promethazine (Phenergan®)

azelastine (Astelin® or Astepro®)

Generation II (non-sedating)

loratidine (Claritin®)

fexofenadine (Allegra®)

cetirizine (Zyrtec®)

VII.     Corticosteroid (asthma or allergic rhinitis)

budesonide (Rhinocort® or Pulmicort®)

mometasone (Nasonex® or Asmanex®)

fluticasone (Flonase® or Flovent®)

flunisolide (Nasalide®)

triamcinolone (Nasacort®/Azmacort®)

VIII.     Antitussives

a.     Narcotic

hydrocodone (Hycodan®)

codeine/guaifenesin (Robitussin AC®)

b.     Nonnarcotic

dextromethorphan/guaifenesin (Robitussin DM®)

benzonatate  (Tessalon Perles®)

IX.     Decongestants

oxymetazoline (Afrin®)

pheniramine (Dristan®)

phenylephrine (Neo-Synephrine®)

pseudoephedrine (Sudafed®)

X.     Expectorants

guaifenesin (Robitussin®, Mucinex®, Organidin®)

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 6.  The drug classifications for each division of the ANS. Under each classification, identify which receptors are interacted with, then include the action that occurs. 

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 6.  The drug classifications for each division of the ANS. Under each classification, identify which receptors are interacted with, then include the action that occurs. 

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Cholinomimatic:
Directly acting drugs act on both muscarinic and nicotinic receptors
Muscarinic receptors action are as follows
-Heart: ACh like acting drugs hyperpolarize SA nodal cells and decrease  t     their rate of diastolic depolarization which in turn causes the rate of impulse generation to decrease
- Blood Vessel: blood vessels are dilated and decrease in blood pressure and flushing occurs. When cholinergic nerves are stimulated and release nitric oxide causes your cavernosal vessels to dilate causing an erection
- Smooth muscle: when taking cholinergic drugs, it contracts the smooth muscle. For example, peristalsis of the GI tract increases and the sphincter relaxes, causing you to pee or poop.
-Action on the M3 Receptors causes an increase in glandular secretions
- Miosis happens in your eyes
Nicotinic receptors action are as follows
- Autonomic ganglia: for the P&S divisions the autonomic ganglia are stimulated and a high dose of ACh is given atropine causing a rise in BP and tachycardia
-Skeletal Muscle: twitching and fasiculations happens
Indirectly acting drugs inhibit ACh lowering enzyme acetylcholinerase which in turn causing ACh concentration increase at the nerve endings

Adrenergic drugs: act on both alpha and beta receptors
Alpha 1:
-blood vessel constriction causing an increase in BP
- acts on your heart causing an arrythmia
- mydriasis in eye, decrease in aqueous secretion
- contraction in the uterus and bladder
-ejaculation
- spleen is contracted
Alpha 2:
- blood vessels contract and increase BP
- inhibits insulin secretion
Beta 1:
- increase of HR and FOC by stimulating your heart
- kidney releases renin
- adh is released from your pitutary
Beta 2:
- vessels dilate, decreasing BP
- GI relaxes
- bronchodilation
- glycogenolysis
-urinary bladder relaxes (detrusor muscle)

Anticholinergic drugs:
Natural anticholinergic: atropine
Semi Synthetic: ipratropium bromide, homatropine
Synthetic: dicyclomine, cyclopentolate, tropicamide, glycopyrolate
*They block ACh action and block cholinergic drugs action which produce action opposite to cholingeric drugs

Alpha Blockers
Selective (act on alpha 1) - doxazosin, prazosin, terazosin
Selective (act on alpha 2) - yohimbine
Nonselective (act on. both alpha 1,2) - phentolamine, phenoxybenzamine
* alpha blockers prevent the action of catecholamines and adrenergic drugs

Beta Blockers
Nonselective (act on beta receptors) - sotalol, propranolol, pindolol, timolol
Selective on beta 1 (cardioselective) - atenolol, bisoprolol, esmolol, metoprolol
* beta blockers block action of catecholamines and adrenergic drugs on beta receptors and produce action opposite to that of adrenergic drugs

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Continuing Education Activity

The basis of autonomic pharmacology reflects the physiology of the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS) to regulate involuntary reactions to stresses on multiorgan systems within the body. When a pathologic process is present that affects the homeostasis achieved between the SNS and PSNS in this process, either of these branches can become overactive while the other is excessively inhibited. This activity outlines the indications, mechanism of action, safe administration, adverse effects, contraindications, toxicology, and monitoring of the broad array of physiological possibilities when using autonomic pharmacology.

Objectives:

Identify the four major classes of pharmacological agents in autonomic pharmacology.

Summarize the mechanism of action of each of the four main categories of autonomic pharmacological agents.

Review the side effects of each of the four classes of autonomic pharmacological agents.

Outline interprofessional team strategies for improving care coordination and communication to advance appropriate clinical outcomes with these classes of medications, leading to optimal patient outcomes.

Access free multiple choice questions on this topic.
Indications

The basis of autonomic pharmacology reflects the physiology of the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS) to regulate involuntary reactions to stresses on multiorgan systems within the body. When a pathologic process is present that affects the homeostasis achieved between the SNS and PSNS in this process, either of these branches can become overactive while the other is excessively inhibited.[1] This break in homeostasis results in various clinical manifestations that can range in severity from simply presenting rhinorrhea symptomology to fatal presentations like cardiovascular collapse.[2] For a wide range of presentations and severity of pathologies, the agents classified in autonomic pharmacology are indicated to re-establish the homeostasis that the human body attempts to produce via the autonomic nervous system (ANS).[3]

Within autonomic pharmacology, there are four specific categories of drugs based on how they affect the ANS:

1. Cholinomimetics/cholinesterase antagonists

2. Adrenoreceptor agonists/sympathomimetics

3. Adrenoreceptor antagonists

The clinical indications of medications from each of the four categories are listed below. Important to note is that this is not a complete list due to the vastness of this topic; the drugs included are representative of each category.

FDA-labeled indications:

Cholinomimetics/Cholinesterase antagonists[4][5][6][7]:

Atropine - used in ACLS guidelines to correct bradyarrhythmias and in ophthalmic surgery as a retinal dilator

Ipratropium and tiotropium - correct acute exacerbations of bronchospasm (asthma, COPD), as well as exacerbation prophylaxis for those conditions

Scopolamine - prevents motion sickness and postoperative nausea/vomiting

Oxybutynin - urge incontinence and postoperative bladder spasm

Dicyclomine, glycopyrrolate - can be used for reducing diarrhea output in irritable bowel syndrome; glycopyrrolate can also be added to cholinesterase reversal of neuromuscular blockades in postoperative anesthesia care to prevent bronchospasm and is currently undergoing investigation as an adjunct treatment in COPD

Clonidine - used as an antihypertensive

Dobutamine, phenylephrine, epinephrine - used to correct severe hypotension in cardiogenic shock and acute heart failure exacerbation; epinephrine specifically also used in ACLS guidelines for non-shockable heart rhythms in cardiac arrest and rapid reversal of fatal anaphylactic reactions

Albuterol - fast-acting bronchodilator used in acute asthma exacerbations

Fenoldopam - corrects hypertension

Bromocriptine - involved in the maintenance of Parkinson disease and conditions involving prolactinoma

Adrenoreceptor antagonists[22][23][24]:

Phenoxybenzamine, phentolamine - used to correct high catecholamine states

Prazosin, doxazosin, terazosin, tamsulosin - indicated to correct urinary retention in benign prostatic hyperplasia

Beta-blockers (propranolol, metoprolol, labetalol, etc.) - indicated for many cardiovascular conditions since they are in the classification of class II antiarrhythmics; these agents are used to manage tachyarrhythmias, hypertension, angina, heart failure, and migraine prophylaxis

Mechanism of Action

As with the homeostasis established via processes performed by the SNS and PSNS, drugs from each of the four categories listed above also work inversely to each other. The primary mechanism of action for most of these agents are to serve as either agonists or antagonists of specific receptors within these systems.[2] The receptors with their locations and physiologic actions are listed below.

For adrenoreceptors stimulated by norepinephrine (synapses) and epinephrine (endocrine), involved in SNS processes[25][26]:

Alpha-1 (A1) - located mostly in postsynaptic effector cells found in smooth muscle; effects mediated by IP3/DAG path, include mydriasis due to contraction of radial muscles, constriction of arteries and veins, urinary retention due to internal/external urethral sphincter contraction, and a decrease in renin release from renal juxtaglomerular cells

Alpha-2 (A2) - located in presynaptic adrenergic terminals found in lipocytes and smooth muscle; effects mediated by decreasing cAMP, including a decrease in norepinephrine release, stimulates platelet aggregation and decreases insulin secretion

Beta-1 (B1) - located in postsynaptic effector cells in the SA node of the heart, lipocytes, brain, juxtaglomerular apparatus of renal tubules, and the ciliary body epithelium; effects mediated by increasing cAMP, including increased heart rate and the conduction velocity through the cardiac nodes, also increases renin release from renal juxtaglomerular cells

Beta-2 (B2) - located in postsynaptic effector cells in smooth muscle and cardiac myocytes; effects mediated by increasing cAMP, include vasodilation, bronchiole dilation, increased insulin secretion, and uterine relaxation

Beta-3 (B3) - located in postsynaptic effector cells in lipocytes and myocardium; similar effects to beta-1 receptors mediated by increasing cAMP

For cholinoreceptors stimulated by acetylcholine, most involved in PSNS processes[27]:

Muscarinic-1 (M1) - important to note is the only cholinoreceptor involved in an SNS process, located in sweat glands of the skin; effects mediated by IP3/DAG path, include glandular contraction and increased secretion

Muscarinic-2 (M2) - located in SA and AV nodes and myocardium; effects mediated by decreasing cAMP, include decreasing heart rate and myocardial conduction velocity

Muscarinic-3 (M3) - located in the smooth muscle of various organ systems; effects mediated by IP3/DAG path, include contraction of the ciliary muscle causing miosis, contraction of bronchioles, increased bronchiole secretions, increased GI motility, detrusor muscle contraction, and internal/external urethral sphincter relaxation

Muscarinic-4 (M4) and Muscarinic (M5) - located primarily in the CNS, e.g., forebrain and substania nigra, respectively

Nicotinic-N (NN) - located in postsynaptic dendrites of both sympathetic and parasympathetic postganglionic neurons; effects mediated by Na+/K+ depolarization, include increased neurotransmission

Nicotinic-M (NM) - located in neuromuscular endplates of skeletal muscle; effects mediated by Na+/K+ depolarization, include skeletal muscle contraction

For dopamine receptors, most involved in both SNS and PSNS processes[28]:

Dopamine 1-5 (D1-5) - located in the CNS, except for Dopamine-1 receptors, which also appear in renal vasculature; effects mediated by cAMP path, include renal artery vasodilation, increased renal blood flow, and modulation of neuroendocrine signaling

Administration

Adverse Effects

Contraindications

Based on the adverse reaction profiles of each category, several significant contraindications can be elucidated[34][35][31]:

Enhancing Healthcare Team Outcomes

Glaucoma - ocular telemetry sensors can help to continuously monitor intraocular pressure.

Shock - requires several monitoring functions as listed:

Maintaining a MAP of 65 and above

MAP measurements via an arterial line

Pulse pressure variation to guide fluid therapy

Bedside echocardiography to assess chambers of the heart and looking for cardiogenic shock vs. obstructive shock (massive PE) and calculate cardiac output/ejection fraction

Pulse index continuous cardiac output (PiCCO) device which can serve to continuously monitor continuous cardiac output and assess fluid response

Asthma/COPD - pulmonary function testing is the standard to diagnose and monitor the severity of pulmonary obstruction; can also evaluate the effectiveness of inhaled autonomic agents in reversing obstructive processes

Arrhythmias - for acute monitoring 4-lead ECG and 12-lead EKG are standard for monitoring tachycardias or bradycardias; if extended monitoring is required extended continuous ambulatory rhythm monitors (ECAM) is the monitoring modality of choice

Physicians, nurses, and pharmacists need to work collaboratively when using medications that interact with the autonomic nervous system to make sure that the pharmacotherapy is safe and effective for each patient. [Level V]

References

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The basis of autonomic pharmacology reflects the physiology of the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS) to regulate involuntary reactions to stresses on multiorgan systems within the body. When a pathologic process is present that affects the homeostasis achieved between the SNS and PSNS in this process, either of these branches can become overactive while the other is excessively inhibited.

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Generated in Specific Organs when Stimulated by the ANS Division

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Generated in Specific Organs when Stimulated by the ANS Division

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There are different organs that are stimulated by each division and have different responses

- For the eye (iris)
in the Parasympathetic Division: it narrows the pupils
in the Sympathetic Division: it widens the pupils
ex: when light is flashed into your eye

- For the heart
Parasympathetic Division:  it decreases HR, and FOC
Sympathetic Division: it increases HR and FOC

- For the Brain
Sympathetic Division: Epinephrine and norepinephrine is discharged from the           medulla cells into the bloodstream

-For the Kidney
Sympathetic Division: Urine output is decreased and vasoconstriction is created

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Main Location of Receptors for each Division

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Main Location of Receptors for each Division

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Sympathetic Division
When adrenaline is being released, the receptors correlated are the adrenergic receptors including Alpha, Beta 1 and Beta 2. They are found in your blood vessels, heart, bronchioles and digestive system.

Parasympathetic Division
When acetylcholine is being released in the parasympathetic division, cholinergic receptors are correlated with it. The main receptors are muscarinic and nicotinic that is found in your blood vessels.

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PHYSIOLOGY OF THE ANS
Overview
As discussed previously, nerves of the ANS extend from the CNS to smooth, or cardiac muscle, organs, and glands via a two neuron system-; namely a preganglionic neuron and a postganglionic neuron. In this system, there are 2 synapses-; one separating preganglionic and postganglionic neurons, and the other between the postganglionic neuron and effector (see figure below). The preganglionic neuron releases neurotransmitters stored in synaptic vesicles of axon terminals. An action potential reaching the axon terminal causes release of these stored neurotransmitters into the synaptic cleft. After crossing the synapse, neurotransmitters bind to receptors imbedded in postganglionic cell membranes (see figure below). This binding depolarizes the postsynaptic cell membrane (EPSP) and results in action potentials. Action potentials arriving at the axon terminal lead to release of neurotransmitters into the synaptic cleft, separating the postganglionic neuron and effector (neuro-effector junction). Finally, binding of neurotransmitter to the receptor expressed on effector cells can result in excitation or inhibition of the effector. Sympathetic and parasympathetic divisions differ in the types of neurotransmitters they release and the receptors and second messenger systems they express.
Image by Nate Shoemaker Spring 2016 ANS preganglionic and postganglionic neurons and locations of ANS receptors. Nicotinic receptors are located on the postganglionic neurons of the sympathetic and parasympathetic cell bodies. Nicotinic receptors respond to the binding of acetylcholine (ACH), which causes an excitatory effect. Muscarinic receptors are located on all parasympathetic effector cells and some (generalized sweat glands) sympathetic effector cells. Muscarinic receptors respond to the binding of ACH, and may have an excitatory or inhibitory effect. Adrenergic receptors are located on most sympathetic effector cells. Adrenergic receptors respond to the binding of norepinephrine (NE), which may have an excitatory or inhibitory effect. Neurotransmitters of the ANS
Neurotransmitters are chemicals that travel across the synapse connecting two neurons, or between a neuron and an effector. For example, when we discussed the neuromuscular junction we were talking about a neuron-effector synapse and the neurotransmitter used was acetylcholine (ACH). ACH is also one of the neurotransmitters used by the ANS. Cholinergic neurons produce ACH and store ACH in their synaptic terminals. The preganglionic neuron for both parasympathetic and sympathetic nervous systems is cholinergic. The postganglionic neuron of the parasympathetic division is also cholinergic. The postganglionic neuron for the sympathetic division is usually an adrenergic neuron which means that it produces norepinephrine (NE) as its neurotransmitter. Sympathetic postganglionic neurons innervating sweat glands and some blood vessels are the exception-; they are cholinergic and release ACH.
Receptors of the ANS
Usually a particular receptor subtype for each division of the ANS will dominate in a certain gland or organ. In general, activation of some receptor subtypes lead to stimulation of the effector and activation of others to inhibition of the effector. Even numbered subtypes are usually inhibitory and odd numbered subtypes are usually excitatory, but there are no hard and fast rules. Ultimately, the relative amounts of each receptor subtype expressed in the tissue will determine the overall effect (stimulation or inhibition) on the particular gland or organ.
Cholinergic Receptors
As mentioned, preganglionic neurons of both sympathetic and parasympathetic divisions produce and release ACH. The receptors for ACH are known as cholinergic receptors. There are two main subtypes of cholinergic receptors-; nicotinic and muscarinic. They are named after alkaloids found in tobacco and certain mushrooms respectively. The alkaloid nicotine specifically activates nicotinic cholinergic receptors, while muscarine activates muscarinic cholinergic receptors, and ACH activates both types. The cell bodies of postganglionic neurons for both sympathetic and parasympathetic nervous systems express nicotinic receptors (see figure above). To distinguish nicotinic receptors in neurons from nicotinic receptors found in the neuromuscular junction, we use the terms nicotinic neural (N N or N 2) cholinergic receptors and nicotinic muscle (N M or N 1) cholinergic receptors respectively. Muscarinic receptors (M) are located on cells of all parasympathetic effectors and on cells of some sweat glands innervated by the sympathetic nervous system. There are several subtypes of muscarinic receptors (M 1-M 5) which may be stimulatory or inhibitory.
Adrenergic Receptors
As mentioned, neurons that produce and release the neurotransmitter NE are known as adrenergic neurons. NE is secreted by postganglionic neurons of the sympathetic nervous system and binds to adrenergic receptors expressed on effector cells. Epinephrine (EPI) released by the adrenal gland also binds to adrenergic receptors expressed on effectors (see figure above). There are two main types of adrenergic receptors, namely, alpha and beta which have several subtypes. For our purposes, we will focus on the following four subtypes: alpha 1, 2, and beta 1, 2, and 3. Activation of adrenergic receptors expressed on effectors by NE or EPI may result in stimulation or inhibition of the effector depending on the tissue involved. Odd subtypes of adrenergic receptors (alpha 1, and beta 1, and 3) generally have stimulatory effects and even subtypes (alpha 2 and beta 2) have inhibitory effects. The next section explores the effects of a ligand binding to its receptor in a particular tissue.
**You may use the buttons below to go to the next or previous reading in this Module**

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Overview As discussed previously, nerves of the ANS extend from the CNS to smooth, or cardiac muscle, organs, and glands via a two neuron system-; namely a preganglionic neuron and a postganglionic neuron. In this system, there are 2 synapses-; one separating preganglionic and postganglionic neurons, and the other between the postganglionic neuron and effector (see figure below).

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In the Sympathetic Nervous System, the neurotransmitter epinephrine is released in two areas, when released as a hormone, it's made from norepinephrine and released by your adrenal glands. When released as a neurotransmitter, it helps transmit nerve signals across nerve endings to another muscle, gland or nerve cell.
The other neurotransmitter norepinephrine, is also released in the same two areas as epinephrine. Although, epinephrine is made from norepinephrine, norepinephrine itself is made from dopamine as a neurotransmitter.

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What is norepinephrine?

Norepinephrine, also called noradrenaline, is both a neurotransmitter and a hormone. As a neurotransmitter, it's a chemical messenger that helps transmit nerve signals across nerve endings to another nerve cell, muscle cell or gland cell. As a hormone, it's released by your adrenal glands, which are hat-shaped glands that sit on top of each kidney.

As a neurotransmitter, norepinephrine is made from dopamine. Norepinephrine is made from nerve cells in the brainstem area of your brain and in an area near your spinal cord.

Norepinephrine is part of your sympathetic nervous system, which is part of your body's emergency response system to danger - the "fight-or-flight" response. Medically, the flight-or-flight response is known as the acute stress response.

What does norepinephrine do in the body?

As a neurotransmitter in your brain and spinal cord, norepinephrine:

Increases alertness, arousal and attention.

Constricts blood vessels, which helps maintain blood pressure in times of stress.

Affects your sleep-wake cycle, mood and memory.

What triggers norepinephrine release?

As a hormone, stress triggers the release of norepinephrine from your adrenal glands. This reaction causes a number of changes in your body and is known as the fight-or-flight response.

What's the fight-or-flight response?

The fight-or-flight response refers to your body's response to a stressful situation, such as needing to escape danger (moving away from a growling dog) or facing a fear (giving a speech for school or work). The term comes from the choice our ancestors faced when confronted with a dangerous situation - to stay and fight or run to safety.

During the fight-or-flight response, you (your brain) perceive danger. Next, nerves in an area of your brain called the hypothalamus send a signal down your spinal cord, then out to your body. The neurotransmitter that transmits your brain's nervous system message of what to do is norepinephrine (noradrenaline). The neurotransmitter noradrenaline reaches the following organs and tissues and causes these rapid body reactions:

Eyes: Pupils dilate to let more light in to better see more of your surroundings.

Skin: Skin turns pale as blood vessels receive a signal to divert blood to areas more in need of your blood's oxygen, such as your muscles, so you can fight or run away.

Heart: Heart pumps harder and faster to deliver more oxygenated blood to areas most in need, like your muscles. Blood pressure also increases.

Muscles: Muscles receive more blood flow and oxygen so they can react with greater strength and speed.

Liver: Stored glycogen in your liver is converted to glucose to provide more energy.

Airways: Breathing is deeper and faster. Your airways open up so more oxygen is delivered to your blood, which goes to your muscles.

The neurotransmitter noradrenaline also reaches your adrenal gland, which releases the hormones adrenaline (epinephrine) and noradrenaline (norepinephrine). These hormones travel through your blood to all parts of your body. They reach your eyes, heart, airways, blood vessels in your skin and your adrenal gland again. The "message" to these organs and tissues is to continue to react until you're out of danger.

This is a simple description of the fight-or-flight response. Other parts of your nervous system are also involved, as well as other organ systems, hormones and neurotransmitters.

How is norepinephrine used as a medication?

When used as medicine, norepinephrine is used to increase and maintain blood pressure in limited, short-term situations where low blood pressure is a problem. These conditions could include:

Cardiac arrest.

Spinal anesthesia.

Septicemia.

Blood transfusions.

Drug reactions.

Norepinephrine is usually used with other medicines for the conditions mentioned above.

Norepinephrine is also used to treat:

Septic shock, a life-threatening condition resulting in extremely low blood pressure following an infection.

Neurogenic shock, a life-threatening condition caused by injury to your spinal cord.

Pericardial tamponade, a condition in which extra fluid builds up in the space around your heart.

Critical hypotension.

What are the side effects of norepinephrine as a medication?

Side effects of norepinephrine as an injection that require medical attention include:

Allergic reactions like skin rash, itching or hives, swelling of your face, lips or tongue.

Difficulty breathing, wheezing.

Irregular heartbeats, palpitations or chest pain.

Pain, redness or irritation at site where injected.

What health conditions result from low levels of norepinephrine?

Health conditions that result from low levels of norepinephrine include:

Depression.

Attention deficit hyperactivity disorder (ADHD).

Headaches.

Memory problems.

Sleeping problems.

Low blood pressure (hypotension)

Low blood sugar (hypoglycemia).

Changes in blood pressure, heart rate.

Dopamine beta-hydroxylase deficiency. This rare genetic disease prevents your body from converting dopamine into norepinephrine.

What health conditions result from high levels of norepinephrine?

Health conditions that result from high levels of epinephrine include:

High blood pressure (hypertension).

Rapid or irregular heartbeat.

Excessive sweating.

Cold or pale skin.

Severe headaches.

Nervous feeling, jitters.

Pheochromocytoma, which is an adrenal gland tumor.

People with high norepinephrine levels have a greater risk of heart, blood vessel and kidney damage.

What can I do to boost my norepinephrine levels naturally?

You can increase your levels of norepinephrine naturally by:

Exercising regularly (30 minutes a day at least five days a week).

Getting an adequate amount of sleep (try to get seven to nine hours a night).

Eating meats, chicken, fish, nuts, eggs and cheese.

Listening to music or doing something that brings you joy (feeling happy increases the release of norepinephrine).

What are the similarities and differences between epinephrine and norepinephrine?
A note from Cleveland Clinic
Norepinephrine is both a neurotransmitter and a hormone, but it acts mainly as a neurotransmitter. Norepinephrine, also known as noradrenaline, plays an important role in your body's fight-or-flight response. As a medication, norepinephrine is used to increase and maintain blood pressure in limited, short-term serious health situations.

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Norepinephrine: What It Is, Function, Deficiency & Side Effects

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Norepinephrine, also known as noradrenaline, is both a neurotransmitter and a hormone. Norepinephrine plays an important role in your body's fight-or-flight response.

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There are three main neurotransmitters used in the ANS. However they aren't used in both divisions.

The Parasympathetic System releases the acetylcholine (ACh) neurotransmitter that contracts smooth muscles, dilates blood vessels, increases bodily secretions and slows your heart rate.

The Sympathetic System releases epinephrine and norepinephrine. They act as both neurotransmitters and hormones. Norepinephrine is part of the body's "fight or flight" response. It increases alertness, attention and arousal, helps maintain your blood pressure by constricting the blood vessels on high times of stress and affects your mood, memory sleep wake cycle.
Epinephrine, also known as adrenaline, is a chemical messenger by helping transmit nerve signals across your muscle, nerve or gland cell. It is also both a hormone and neurotransmitter that plays a part in the "fight or flight" response when your body senses danger. Epinephrine plays a role in not only sensing danger but your metabolism, your focus, attention, excitement and panic.

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What is norepinephrine?

Norepinephrine, also called noradrenaline, is both a neurotransmitter and a hormone. As a neurotransmitter, it's a chemical messenger that helps transmit nerve signals across nerve endings to another nerve cell, muscle cell or gland cell. As a hormone, it's released by your adrenal glands, which are hat-shaped glands that sit on top of each kidney.

As a neurotransmitter, norepinephrine is made from dopamine. Norepinephrine is made from nerve cells in the brainstem area of your brain and in an area near your spinal cord.

Norepinephrine is part of your sympathetic nervous system, which is part of your body's emergency response system to danger - the "fight-or-flight" response. Medically, the flight-or-flight response is known as the acute stress response.

What does norepinephrine do in the body?

As a neurotransmitter in your brain and spinal cord, norepinephrine:

Increases alertness, arousal and attention.

Constricts blood vessels, which helps maintain blood pressure in times of stress.

Affects your sleep-wake cycle, mood and memory.

What triggers norepinephrine release?

As a hormone, stress triggers the release of norepinephrine from your adrenal glands. This reaction causes a number of changes in your body and is known as the fight-or-flight response.

What's the fight-or-flight response?

The fight-or-flight response refers to your body's response to a stressful situation, such as needing to escape danger (moving away from a growling dog) or facing a fear (giving a speech for school or work). The term comes from the choice our ancestors faced when confronted with a dangerous situation - to stay and fight or run to safety.

During the fight-or-flight response, you (your brain) perceive danger. Next, nerves in an area of your brain called the hypothalamus send a signal down your spinal cord, then out to your body. The neurotransmitter that transmits your brain's nervous system message of what to do is norepinephrine (noradrenaline). The neurotransmitter noradrenaline reaches the following organs and tissues and causes these rapid body reactions:

Eyes: Pupils dilate to let more light in to better see more of your surroundings.

Skin: Skin turns pale as blood vessels receive a signal to divert blood to areas more in need of your blood's oxygen, such as your muscles, so you can fight or run away.

Heart: Heart pumps harder and faster to deliver more oxygenated blood to areas most in need, like your muscles. Blood pressure also increases.

Muscles: Muscles receive more blood flow and oxygen so they can react with greater strength and speed.

Liver: Stored glycogen in your liver is converted to glucose to provide more energy.

Airways: Breathing is deeper and faster. Your airways open up so more oxygen is delivered to your blood, which goes to your muscles.

The neurotransmitter noradrenaline also reaches your adrenal gland, which releases the hormones adrenaline (epinephrine) and noradrenaline (norepinephrine). These hormones travel through your blood to all parts of your body. They reach your eyes, heart, airways, blood vessels in your skin and your adrenal gland again. The "message" to these organs and tissues is to continue to react until you're out of danger.

This is a simple description of the fight-or-flight response. Other parts of your nervous system are also involved, as well as other organ systems, hormones and neurotransmitters.

How is norepinephrine used as a medication?

When used as medicine, norepinephrine is used to increase and maintain blood pressure in limited, short-term situations where low blood pressure is a problem. These conditions could include:

Cardiac arrest.

Spinal anesthesia.

Septicemia.

Blood transfusions.

Drug reactions.

Norepinephrine is usually used with other medicines for the conditions mentioned above.

Norepinephrine is also used to treat:

Septic shock, a life-threatening condition resulting in extremely low blood pressure following an infection.

Neurogenic shock, a life-threatening condition caused by injury to your spinal cord.

Pericardial tamponade, a condition in which extra fluid builds up in the space around your heart.

Critical hypotension.

What are the side effects of norepinephrine as a medication?

Side effects of norepinephrine as an injection that require medical attention include:

Allergic reactions like skin rash, itching or hives, swelling of your face, lips or tongue.

Difficulty breathing, wheezing.

Irregular heartbeats, palpitations or chest pain.

Pain, redness or irritation at site where injected.

What health conditions result from low levels of norepinephrine?

Health conditions that result from low levels of norepinephrine include:

Depression.

Attention deficit hyperactivity disorder (ADHD).

Headaches.

Memory problems.

Sleeping problems.

Low blood pressure (hypotension)

Low blood sugar (hypoglycemia).

Changes in blood pressure, heart rate.

Dopamine beta-hydroxylase deficiency. This rare genetic disease prevents your body from converting dopamine into norepinephrine.

What health conditions result from high levels of norepinephrine?

Health conditions that result from high levels of epinephrine include:

High blood pressure (hypertension).

Rapid or irregular heartbeat.

Excessive sweating.

Cold or pale skin.

Severe headaches.

Nervous feeling, jitters.

Pheochromocytoma, which is an adrenal gland tumor.

People with high norepinephrine levels have a greater risk of heart, blood vessel and kidney damage.

What can I do to boost my norepinephrine levels naturally?

You can increase your levels of norepinephrine naturally by:

Exercising regularly (30 minutes a day at least five days a week).

Getting an adequate amount of sleep (try to get seven to nine hours a night).

Eating meats, chicken, fish, nuts, eggs and cheese.

Listening to music or doing something that brings you joy (feeling happy increases the release of norepinephrine).

What are the similarities and differences between epinephrine and norepinephrine?
A note from Cleveland Clinic
Norepinephrine is both a neurotransmitter and a hormone, but it acts mainly as a neurotransmitter. Norepinephrine, also known as noradrenaline, plays an important role in your body's fight-or-flight response. As a medication, norepinephrine is used to increase and maintain blood pressure in limited, short-term serious health situations.

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Norepinephrine: What It Is, Function, Deficiency & Side Effects

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Norepinephrine, also known as noradrenaline, is both a neurotransmitter and a hormone. Norepinephrine plays an important role in your body's fight-or-flight response.

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Two Divisions of the ANS & Alternate Names

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Two Divisions of the ANS & Alternate Names

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There are two divisions in the Autonomic Nervous System, the Sympathetic and Parasympathetic. Each division has other names that are used to help explain their role or function.
For example, the sympathetic is known as the "Fight or Flight" and the parasympathetic is known as "Rest and Digest"