CASE: AUTONOMIC DRUGS

R.G., a 72 year-old male patient was admitted to the emergency room because of eye
pain, blurring of vision and difficulty in depth perception. Review of systems revealed
that the patient has narrow-angle glaucoma. Review of current medications revealed
that the patient has colds for which the patient was prescribed a nasal decongestant,
oral phenylephrine at the out-patient department. Patient also has Parkinson’s disease
and is currently taking the drug selegiline.

Leader: Benedict Mamaril

Group Members: Mamaril, Luy, Macababbad, Lim, Macalino, Madrilejo, Maban, Malaki,
Manahan, Mabasa, Diaz, Malit, Magsino

Questions:
1. What is the patient’s chief complaint? What could be its cause?

Chief complaint: eye pain, blurring of vision and difficulty in depth perception

Parkinson's Disease
PATHOPHYSIOLOGY
● The chief complaints are actually manifestations of Parkinson’s. Risk of vision
impairment is potentially common for patients with PD because this disease is
linked with retinal dopamine depletion and decreased dopaminergic innervation
of the visual cortex, which can lead to visual problems such as diminished
oculomotor control, contrast sensitivity, color vision, and visuospatial
construction.
● Neurodegenerative disorder of the nigrostriatal tract or the substantia nigra pars
compacta
● This disease is primarily concerned with the gradual loss of cells in the substantia
nigra of the brain, which is responsible for the production of dopamine. Dopamine
is a chemical messenger that transmits signals between two regions of the brain
to coordinate activity (e.g. it connects the substantia nigra and the corpus
striatum to regulate muscle activity). If there is deficiency of dopamine in the
striatum the nerve cells in this region “fire” out of control. This leaves the
individual unable to direct or control movement
● PD patients have dopaminergic deficits, causing hypokinetic states and
movement disorders which are classical PD manifestations
● Decreased blinking can cause dry eyes. In addition, as a result of the dysfunction
of the autonomic nervous system, blepharitis, or irritation of the eyelids can occur

2. What autonomic receptor is affected by the nasal decongestant?

● Alpha1 receptors
 ○ Oral phenylephrine is a common sympathomimetic drug which is a common
component of decongestants.
○ It is known to be an alpha1 adrenergic agonist. It binds to a specific receptor to
stimulate a response.
○ Phenylephrine will bind to the adrenergic receptors in bronchioles of the lungs
and cause them to dilate. By opening these structures, accumulated mucus can
be cleared out of the lower respiratory tract.
○ Phenylephrine is not as effective as a drug because it can be partially broken
down in the digestive tract before it is ever absorbed.

3. What is the relationship of the drug phenylephrine to the patient’s chief

complaint? Is it preventable?
● Phenylephrine causes the mydriasis due to its direct affectation of the α1-agonist
(pupillary vasodilation as an effect of the sympathomimetic drug)
● What happens after is that the iris is pushed towards the irido-corneal angle that blocks
the drainage of the aqueous humor
● There is a build-up of aqueous humor in the eye resulting to an increase in intra-orbital pressure
→ AGGRAVATE narrow angle glaucoma → (+) pain, blurring of vision, difficulty of depth
perception

● Yes, it is preventable.
○ Yes, it is preventable.
■ Withdrawal of the alpha-1 adrenergic agonist like phenylephrine
■ Iridectomy - surgical removal of the iris
■ Iridotomy - use of laser to make a hole in the iris allowing the aqueous
humor to move from posterior to anterior chamber

4. What other systemic symptoms might the patient experience?

Phenylephrine (ADRENERGIC AGONIST / SYMPATHOMIMETIC DRUGS)

S/sx ● Acts directly on alpha receptors

● Selective alpha 1 agonist
● Used as a decongestant
● Sympathetic Response
○ produces dose-dependent vasoconstriction of
cutaneous, muscular, mesenteric, splanchnic, and
renal vasculature. Systemic arterial
vasoconstriction increases systolic, diastolic, and
MAPs, with reflex bradycardia.
■ Due to the vasoconstriction effect, the
patient’s blood pressure might rise. This will
contribute to the increase in systemic
 vascular resistance in the skin, splanchnic,
skeletal muscles, and renal system. This
triggers the systemic reflex.
■ Through the baroreceptors, the increased
blood pressure is sensed and thus a
compensatory decrease in heart rate will
occur, or the occurrence of reflex
bradycardia.
■ Vascular disorders might arise such as
Hypertension due to the increased systemic
vascular resistance
● Pupillary dilation (mydriasis)
● Nervous system symptoms might include having
headaches, numbness, tremor and weakness
● Gastrointestinal symptoms might include nausea and
vomiting
● Psychiatric symptoms can include anxiety
● [Priapism might be experienced in a prolonged dose]
● [Additionally, it produces local vasoconstriction on dilated
arterioles of the conjunctiva and nasal mucosa]
● It’s also important to take note that our patient also has
Parkinson’s Disease. For this, our patient takes Selegiline.
○ Some symptoms that can be experienced are
insomnia, mood changes, dyskinesias, GI distress,
skin rashes, weight loss

5. What possible drug interaction can happen between phenylephrine and

Selegiline?
● Phenylephrine
○ Alpha 1 adrenergic agonist that mediates vasoconstriction and mydriasis depending
on the route of administration
○ Relieve nasal discomfort caused by colds, allergies, and hay fever.
○ Also used to relieve sinus congestion and pressure.
○ Phenylephrine will relieve symptoms but will not treat the cause of the symptoms or
speed recovery.
○ Phenylephrine is in a class of medications called nasal decongestants.
○ It works by reducing swelling of the blood vessels in the nasal passages

● Selegiline
○ Also known as L-deprenyl
 ○ Selective inhibitors of monoamine oxidase type B, the form of the enzyme that
metabolizes dopamine. Hepatic metabolism of selegiline results in the formation
of desmethylselegiline (possibly neuroprotective) and amphetamine.
○ Selegiline has minimal efficacy in parkinsonism if given alone but can be used
adjunctively with levodopa, and it is now available in a skin-patch formulation for
treatment of depression.

● Tox: GI distress, CNS stimulation, dyskinesias, serotonin syndrome if used with

selective serotonin reuptake inhibitors.

● What is the interaction between them?

● Pharmacokinetic
● Potentiation
● Drug B (Selegiline) has no individual effect/minimal effect when
administered on its own but when given with Drug A (Phenylephrine), its
sympathomimetic effects are enhanced.
● 0+1=2

6. What must be done regarding the patient’s current medications

● Since selegiline is a MAO inhibitor, which prolongs the effect of dopamine and NE in the
system, phenylephrine should not be taken together with this medication
● Phenylephrine (alpha 1 agonist) also is contraindicated to patients with narrow -angle
glaucoma since this causes mydriasis
● Intranasal sodium chloride or saline solution could be given instead
○ It is a purified salt solution used for wetting the nasal passages
○ It moisturizes the nose and helps dissolve and loosen thick mucus most often
associated with the common cold.

E S S C Grade

Phenylephrine HCl + +++ ++ 0 ++++ 9+

Chlorpheniramine (Php 5*4 =
Maleate + 20 )
Paracetamol 1 tab q 6 hrs
(Neozep Non-Drowsy)

Saline Nasal Spray ++++ ++++ ++++ ++ 14+

(Salinase) (Php
104.5*1) =
104.5

2 sprays in
each nostril
tid-qid or as
 needed.

E S S C Grade

Selegiline ++ +++ ++++ +++ 12+

(Selegos) (Php 72*2 =
144)
2 tab daily

Levodopa + ++++ ++ ++ ++++ 12+

Carbidopa (Php 21*3) =
(Carbidel) 63

Tid. Increase by
1 tablet/day every
1-2 days

What nonpharmacologic interventions can be instituted?

For Nasal congestion
● Advise oral fluid intake of at least 2L or 7-8 glasses a day to increase hydration as this
will thin out your mucus, which could help prevent blocked sinuses.
● Take long showers or breathe in steam from a pot of warm (but not too hot) water.
● Place a warm, wet towel on your face. It may relieve discomfort and open your nasal
passages.
● Air humidifier
● Use of nasal spray

For Parkinson’s
● Maintain a well balanced diet. Increasing intake of water and fiber reduces constipation
● Exercise: improves motor function and balance
● Physical therapy: to improve motor function, range of motion and endurance
● Occupational therapy: to maintain quality of life and be adaptive in overcoming physical
limitations
● Speech therapy: improve speech impairments and swallowing difficulties

What important lessons can be learned from this case?

It is very important to conduct a complete and thorough history taking and physical examination
of the patient to determine the best therapeutic treatment.
It is also important to be knowledgeable on the mechanism of action and drug interactions of the
medications to avoid aggravating symptoms or having side effects that are injurious to the
patient.

- In the case, it was noted that the patient is taking Selegiline, a Monoamine Oxidase
Inhibitor, that is contraindicated with the use of Phenylephrine, a sympathomimetic drug.
Combining these two drugs enhances sympathetic effects and cause acute hypertensive
episode, seizures, and hallucinations.
- By knowing the possible drug interactions, a better treatment option can be given to the
patient.

7. Give a chart order to relieve the nasal congestion in this patient using saline
nasal spray.

Progress Notes Doctor’s Notes

Aug 27, 2021 9:30 am ● Discontinue oral intake of

C/c eye pain, blurring of vision, difficulty in
depth perception (+) mydriasis
Patient was prescribed oral phenylephrine in
the ER.
(+) nasal congestion
Patient is taking Selegiline for Parkinson’s
Disease
(+) drug interaction w/ phenylephrine → narrow-
angle glaucoma symptoms
phenylephrine
● Start Sodium Chloride 0.65%
(Salinase) per nostril as needed for
nasal congestion
● Advise use of steam inhalation
therapy for 15 mins and humidifiers as
needed for nasal congestion
● Advise oral influid intake of at least 2L
or 7-8 glasses a day to increase
hydration
● Advise well-maintained diet and
exercise

Hannah Eloise H. Magsino, MD

Lic No. 029103
PTR No. 234901