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Hints on Respiratory system

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I.

Cough preparations: Introduction: - Causes of cough:

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Types of cough: 1. Dry cough: all causes can cause dry cough No mucus is present Usually due to a minor irritation in the throat or larynx 2. Productive cough: specially tracheo-broncho-alveolar causes Mucus is present Usually due to an infection Can be blood-streaked in smokers with COPD 3. Acute cough: New < 3 weeks Usually due to an infection 4. Chronic cough: Longstanding > 3weeks Due to an underlying illness, such as smokers cough caused by COPD Management: 1. Cough preparations are adjuvant therapy or supportive treatment and the actual treatment is treatment of the definitive cause 2. If u can't suggest the cause by history and clinical examination you can follow this algorithm

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Dry cough preparations: 1. Rhinotus syrup and caps Contain dextromethorphane which has a little evidence of dependence of the morphine type 2. Sinecod 7.5 syrup Centrally acting cough suppressant with bronchodilatation effect 3. Selgon 20 tab.: Suppress cough center with bronchodilatation effect

Productive cough preparations: 1. Mucolytics: ( may disturb the gastric mucosal barrier so used cautiously with PU) - A mucolytic agent is an agent which dissolves thick mucus and is usually used to help relieve respiratory difficulties. - It does so by dissolving various chemical bonds within secretions, which in turn can lower the viscosity by altering the mucin-containing components. a) Ambroxol: (metabolite of bromhexine) It promotes mucus clearance, facilitates expectoration and eases productive cough, allowing patients to breathe freely and deeply. Ambroxol also provides pain relief in acute sore throat. Also it has anti inflammatory properties so used as lozenge in acute pharyngitis Trade names: (( 3-4 Ambroxol 20mg tab., 150mg cap., 15mg syp Muco 15mg cap. And syp. Mucosin 15mg cap., syp, lozenges

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b) Acetyl cisteine: Uses of ACC: Mucolytic as adjuvant therapy in respiratory disorders associated with excessive mucous production or thick mucous IV in paracetamol overdose Treatment of interstitial lung disease as it reduce the progression of the disease Treatment of cyclophosphamide-induced hemorrhagic cystitis due to the ability of acetylcysteine to diminish the effectiveness of cyclophosphamide Treatment of Polycystic Ovary Syndrome PCO. Its efficacy is the same as metformin IN psychiatry ,Acetylcysteine has been shown to reduce the symptoms of both schizophrenia and bipolar disorder. Also used in autism, cocaine craving, smoking, and obsessive symptoms IN Microbiology, Acetylcysteine can be used in Petroff's method i.e. liquefaction and decontamination of sputum, in preparation for diagnosis of tuberculosis Oral acetylcysteine is used for the prevention of radiocontrast-induced nephropathy with big controversy and recent studies proved that it has no rule in reducing nephropathy. Acetylcysteine continues to be commonly used in individuals with renal impairment to prevent the precipitation of acute renal failure Trade names: Acetylcistein 200mg sach. (( 3 Mucosolvan 7.5 syp and tab.

c) Bromhexine: Increase the proportion of serous bronchial secretion, making it more easily expectorated. Bromhexine also enhances mucus transport by reducing mucus viscosity and by activating the ciliated epithelium. Trade names: Bisolvon 8mg tab., 4mg syp. 11 | P a g e

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d) Carbocisteine: a mucolytic that reduces the viscosity of sputum and so can be used to help relieve the symptoms of chronic obstructive pulmonary disorder (COPD) and bronchiectasis by allowing the sufferer to bring up sputum more easily. Should not be used with antitussives (cough suppressants) or medicines that dry up bronchial secretions. Trade names: Mucosol 250mg adult syp, 375 cap. e) Erdosteine: Erdosteine modulates mucus production and viscosity and increases mucociliary transport, thereby improving expectoration. It also exhibits inhibitory activity against the effects of free radicals produced by cigarette smoke. Erdosteine 300 mg twice daily reduced cough (both frequency and severity) and sputum viscosity more quickly and more effectively than placebo and reduced the adhesivity of sputum more effectively than bromhexine 30 mg twice daily. Co-administration of erdosteine and amoxicillin in patients with acute infective exacerbation of chronic bronchitis resulted in higher concentrations of the antibiotic in the sputum, leading to earlier and more pronounced amelioration of clinical symptoms. Trade names: Mucotec 150,300mg cap 2. Mucolytic + bronchodilator (e.g. salbutamol, terbutaline, theophylline, etc) - Mucophylline, mucovent, etc

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3. Mucolytic + broncodilator + Expectorant (Guaifenesin) N.B. Guaifenesin: Acts as an expectorant by increasing the volume and reducing the viscosity of secretions in the trachea and bronchi. It also stimulates the flow of respiratory tract secretions, allowing ciliary movement to carry the loosened secretions upward toward the pharynx. Other uses are treatment of gout and facilitation of conception - Farcosolvin, trisolvin, All-Vent, etc

Multi-ingredient preparations: - Theyre mixture of many groups e.g. mucolytic, antitussive, expectorant, bronchodilator, analgesics, antihistaminics, etc - The most common trade names are: Expectyl, oplex, osipect, toplexil, ultrasolv, tusskan, etc

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Herbal cough preparations: - Suitable for pregnant, lactating mother, hepatic & renal impairment - The most common trade names are: Balsam, bronchicum, broncho, guava, guasol, guaflex, herbal bronch, etc

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II.

Bronchodilators: Introduction: - A bronchodilator is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs. - They are most useful in obstructive lung diseases, of which asthma and chronic obstructive pulmonary disease are the most common conditions. - Although this remains somewhat controversial, they might be useful in bronchiolitis. - They are often prescribed but of unproven significance in restrictive lung diseases. Classifications: a) Short acting 2-agonists e.g. salbutamol, terbutaline b) Long acting 2-agonists (LABA) e.g. salmeterol, formoterol, bambuterol c) Anticholinergics e.g. tiotropium, ipratopium bromide d) Theophylline e) Acefylline f) Multi-ingredient bronchodilators

a) Short acting 2-agonists: These are quick-relief or "rescue" medications that provide quick fast, temporary relief from asthma symptoms or flare-ups. These medications usually take effect within 20 minutes or less, and can last from four to six hours. These inhaled medications are best for treating sudden and severe or new asthma symptoms. Taken 15 to 20 minutes ahead of time, these medications can also prevent asthma symptoms triggered by exercise or exposure to cold air. 1. Salbutamol: Salbutamol was the first selective 2-receptor agonist to be marketed in 1968. Medical uses: Salbutamol is typically used to treat bronchospasm (due to either allergen asthma or exercise-induced), as well as chronic obstructive pulmonary disease Was used as tocolytic but it is now replaced by CCBs e.g. nifedipine which is more effective, better tolerated and orally administered. Side effects: The most common side effects are fine tremor, anxiety, headache, muscle cramps, dry mouth, and palpitation. High doses may cause hypokalaemia, which is of concern in patients with renal failure and those on certain diuretics and xanthine derivatives. 15 | P a g e

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Preparations: Capsules: Activent 8 SR, broncal 4,8 SR Tablets: salbovent 2mg, farcolin 2mg, vental 2mg, ventolin 2mg, salbovent forte 4mg Inhaler: vental, ventolin Syrup: salbovent, vental, ventolin Solution for nebulizer: farcolin 0.5 Ampoules: salbovent, ventolin

2. Terbutaline: Medical uses: Terbutaline is used as a fast-acting bronchodilator (often used as a short-term asthma treatment. The inhaled form of terbutaline starts working within 15 minutes and can last up to 6 hours. Was used as tocolytic but nowadays its not approved by FDA as tocolytic Side effects: tachycardia,nervousness, tremors, headache, hyperglycemia, hypokalemia, and rarely, pulmonary edema. Preparations: Aironyl 2.5 tab. & 3mg syp. bricanyl 2.5 tab. & 3mg syp. & 0.25 inhaler 16 | P a g e

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b) Long acting 2-agonists (LABA): These are long-term medications taken routinely in order to control and prevent bronchoconstriction. Are usually prescribed for moderate to severe persistent asthma patients or patients with chronic obstructive pulmonary disease (COPD). They are not intended for fast relief. These medications may take longer to begin working, but relieve airway constriction for up to 12 hours. They are designed to reduce the need for shorter-acting 2-agonists such as salbutamol, as they have duration of action of approximately 12 hours in comparison with the 4- to 6-hour duration of salbutamol. Commonly taken twice a day with an anti-inflammatory medication, they maintain open airways and prevent asthma symptoms, particularly at night. 1. Salmeterol: Medical uses: It is a long-acting beta-adrenoceptor agonist (LABA), usually prescribed only for severe persistent asthma following previous treatment with a short-acting beta agonist such as salbutamol and is prescribed concurrently with a corticosteroid, such as beclomethasone. When used regularly every day as prescribed, inhaled salmeterol decreases the number and severity of asthma attacks. However, like all LABA medications, it is not for use for relieving an asthma attack that has already started. Side effects: In most cases, salmeterol side effects are minor and either don't require treatment or can easily be treated. The common side effects of salmeterol are dizziness, sinus infection, and migraine headaches. Some of these more serious side effects include a very fast heart rate, high blood pressure, and worsening breathing problems. Preparations: Metrovent 25 inhaler Seretide discus (salmetrol + fluticasone)

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2. Formoterol: Medical uses: As salmeterol but: Have a faster onset of action than salmeterol as a result. More potent - a 12 g dose of formoterol has been demonstrated to be equivalent to a 50 g dose of salmeterol. Preparations: Foradil 12 30 inh. Caps.

3. Bambuterol: The same like other LABAs Preparations: Lelafree 10,20 mg tabs Dosage: 10mg once daily and can be increased after 1-2 weeks to 20 mg once daily

N.B. Indacaterol: an ultra-long-acting beta-adrenoceptor agonist that has a duration of action of 24 hours It needs to be taken only once a day, unlike the currently available formoterol and salmeterol. It is licensed only for the treatment of chronic obstructive pulmonary disease (COPD) (long-term data in patients with asthma are thus far lacking). It is delivered as an aerosol formulation through a dry powder inhaler. Approved by FDA in July 2011

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c) Anticholinergics: An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system . Anticholinergics are a class of medications that inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The nerve fibers of the parasympathetic system are responsible for the involuntary movements of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, etc. Anticholinergics are divided into three categories in accordance with their specific targets in the central and/or peripheral nervous system: antimuscarinic agents, ganglionic blockers, and neuromuscular blockers. We will focus on antimuscarinic e.g. tiotropium & ipratropium 1. Tiotropium: Mechanism of action: Tiotropium is a muscarinic receptor antagonist, often referred to as an antimuscarinic or anticholinergic agent. Although it does not display selectivity for specific muscarinic receptors, on topical application it acts mainly on M3 muscarinic receptors located on smooth muscle cells and submucosal glands leading to a reduction in smooth muscle contraction and mucus secretion, thus producing a bronchodilatory effect. Medical uses: Tiotropium is used for maintenance treatment of chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and emphysema. It is not however used for acute exacerbations. Side effects: Antimuscarinic effects including dry mouth, thickened respiratory tract secretions, blurring of vision, urinary difficulties or retention, constipation, .etc Preparations: Spiriva caps. For inhalation

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2. Ipratropium: Medical uses: Ipratropium is administered by inhalation for the treatment of chronic obstructive pulmonary disease (COPD). It is also combined with salbutamol under the trade names Combivent (metered-dose inhaler or MDI) for the management of COPD and asthma. Side effects: Antimuscarinic effects including dry mouth, thickened respiratory tract secretions, blurring of vision, urinary difficulties or retention, constipation, .etc Inhaled ipratropium does not decrease mucociliary clearance. Preparations: Atrovent 1-2 puffs 3-4 times daily Combivent (salbutamol + Ipratropium)

d) Theophylline: Actions of theophylline: relaxing bronchial smooth muscle increasing heart muscle contractility and efficiency; as a positive inotropic increasing heart rate: positive chronotropic increasing blood pressure increasing renal blood flow some anti-inflammatory effects Central nervous system stimulatory effect mainly on the medullary respiratory center. Medical uses: chronic obstructive pulmonary disease (COPD) asthma infant apnea Blocks the action of adenosine 20 | P a g e

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Side effects: It has a narrow therapeutic index, so its use must be monitored to avoid toxicity. (Therapeutic serum level ranges 10 to 20mcg/mL. At higher levels (>20mg/L), serious toxic effects such as arrhythmias and convulsions may occur without warning.) It can also cause nausea, diarrhea, increase in heart rate, arrhythmias, and CNS excitation (headaches, insomnia, irritability, dizziness and lightheadedness). Seizures can also occur in severe cases of toxicity and is considered to be a neurological emergency. Its toxicity is increased by erythromycin, cimetidine, and fluoroquinolones, such as ciprofloxacin. It can reach toxic levels when taken with fatty meals Theophylline toxicity can be treated with beta blockers. In addition to seizures, tachyarrhythmias are a major concern. Preparations: Minophylline syrup, 300mg tabs. , 500mg supp & amp. Quibron-T SR 300mg tabs. Theo SR 100, 200, 300 mg caps. Uniphylline 300, 400 caps.

Dosage : 300-400 mg daily

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e) Acefylline : The same as theophylline but less toxic Trade names: epicophylline syp. And etaphylline Z supp. Phenobarbitone is added to regulate CNS functions due to its sedative and hypnotic effect. Papaverine is a direct smooth muscle relaxant. Trade names: etaphylline Phen. Papaverine supp

f) Multi-ingredient bronchodilators: Asmacid tab , Asmolin tab , allerase cap etc

III.

Leukotriene Receptor Antagonist (LTRA): Introduction: - A leukotriene antagonist is a drug that inhibits leukotrienes, which are fatty compounds produced by the immune system that cause inflammation in asthma and bronchitis, and constrict airways. - Leukotriene inhibitors (or modifiers) are used to treat those diseases. - They are less effective than corticosteroids and thus less preferred in the treatment of asthma. Preparations: 1. Montelukast: montekal, singulair 10mg (1 tab. Daily) 2. Ketotifen (also 2nd generation antihistaminic): zaditen 1mg bid 3. Zafirlukast: monokast, ventair 20mg bid 1hr. before meal or 2hrs. after meal

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IV.

Inhaled Corticosteroids (ICS): Definition: - Inhaled corticosteroids are glucocorticoids (a class of steroid hormones that are synthesized by the adrenal cortex and have anti-inflammatory activity) formulated to be used in the respiratory tract and lungs. Medical uses: - The intranasal are deposited into the nasal passages and may be used to treat nasal polyps, perennial allergic rhinitis, seasonal allergic rhinitis, and recurrent chronic sinusitis. - Oral inhalations are used when the steroids are designed for deposition further into the respiratory tract. These are used for treatment of chronic asthma and prevention of asthmatic attacks. Recently can be used COPD. Side effects: - Local: 1. Dysphonia: The most common complaint is of hoarse voice (dysphonia) and may occur in over 50 percent of patients using metered dose inhalers (MDIs). Incidence may be lower with dry powder devices. 2. Thrush: Oropharyngeal candidiasis (thrush) may be a problem in some patients, particularly elderly patients, patients taking concomitant oral glucocorticoids, and patients inhaling glucocorticoids more often than twice daily. 3. Contact hypersensitivity: Allergic contact dermatitis has occasionally been described due to inhaled glucocorticoids, particularly budesonide. 4. Others: Cough and throat irritation, sometimes accompanied by reflex bronchoconstriction. 5. Other unusual local complications of ICS include infectious perioral dermatitis, tongue hypertrophy, and increased thirst. Systemic: 1. Skeletal effect: Osteoporosis the effects of oral glucocorticoids on osteoporosis and increased risk of vertebral and rib fractures are well known. 2. Adrenal suppression: still under investigations and studies 3. Other side effects of systemic steroids may occur but all are under studying. N.B. Ciclesonide are slightly different from other ICS because ciclesonide is delivered to the airways as an inactive compound that is subsequently converted by esterases to the active metabolite. It also has low oral bioavailability and a high clearance rate, potentially decreasing systemic side effects.

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Preparations: - There are many preparations for ICS listed below: 1. Fluticasone 2. Beclomethasone 3. Budesonide 4. Ciclesonide 5. Flunisolide 6. Mometasone - Not all preparations are available in Egypt so we will mention the available ones

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Preparations that contain steroids only: 1. Beclomethasone: Trade names: clenil forte, beclosone

2. Budesonide: Trade names: miflonide 400, pulmicort 100,200

3. Ciclesonide: Trade names: alvesco 80, 160

4. Fluticasone: Trade names: flixotide 50, 100, 125, 250

Preparations contain steroids plus bronchodilator: 1. Beclomethasone + Salbutamol: clenil compositum, vental compositum 2. Budesonide + Formetrol: symbicort 3. Fluticasoe + salmeterol: seretide discus 250, 500

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Overview of Asthma Management

COMPONENTS OF ASTHMA MANAGEMENT: 1. Routine monitoring of symptoms and lung function 2. Patient education to create a partnership between clinician and patient 3. Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity 4. Pharmacologic therapy Goals of Asthma treatment: 1. Reduce impairment : Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath), including symptoms that disturb sleep Minimal need (2 times per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms Optimization of lung function Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise Satisfaction with asthma care on the part of patients and families 2. Reduce risk: Prevention of recurrent exacerbations and need for emergency department or hospital care Prevention of reduced lung growth in children, and loss of lung function in adults Optimization of pharmacotherapy with minimal or no adverse effects

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Classification of asthma severity & stepwise approach for managing asthma

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Introduction:
Symptomatic therapy remains the mainstay of common cold treatment. In the absence of convincing evidence of a secondary bacterial infection, antibiotics are not effective in the treatment of the common cold and should not be prescribed. 2008 NICE (National Institute for Health and Clinical Excellence) guidelines from the UK recommend that patients seeking medical evaluation for cold symptoms should: Be advised that the usual course and duration of illness is up to one and a half weeks for patients with a cold; symptoms persist an additional three days on average in smokers Be informed regarding the risks and benefits of symptomatic management, including analgesics and antipyretics Be informed and reassured that antibiotics are not needed and may have side effects Have their concerns and expectations discussed Be advised to return for review if their condition worsens or exceeds the expected time for recovery supportive Analgesics Antihistamines Decongestants Decongestants: For example pseudoephedrine, etilefrine, phenylpropanolamine, phenylephrine, phenyltoloxamne etc Theyre sympathomimetics so their vasoconstrictive activity on nasal capillaries prevent the nasal discharge which is usually occur during common cold and influenza Should be avoided for hypertensive patients Antihistamines: For example chorpheniramine, pheniramine etc a 1955 study of "antihistaminic drugs for colds," carried out by the U.S. Army Medical Corps, reported that "there was no significant difference in the proportion of cures reported by patients receiving oral antihistaminic drugs and those receiving oral placebos. The authors of the American College of Chest Physicians Updates on Cough Guidelines (2006) recommend that, for cough associated with the common cold, firstgeneration antihistamine-decongestants are more effective than newer, non-sedating antihistamines. Analgesics antipyretics: For example paracetamol and NSAIDs etc Used cautiously in patients with peptic ulcer Caffeine: Enhance the analgesic effect of codeine and paracetamol or aspirin

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Active Ingredients Decongestant pseudoephedrine Analgesic (+/-caff) paracetamol Antihistamine chlorpheniramine

Trade Name

Panadol cold ,Congestal ,Cold free ,123 ,Noflu , Fever and flu

pseudoephedrine

paracetamol

Carbinoxamine maleate

Michaelon

pseudoephedrine +

Paracetamol caffeine

chlorpheniramine

Flurest ,Power cold and flu ,Nova-c

pseudoephedrine

Paracetamol+ caffeine

Doxylamine succinate

Cafamol extra

pseudoephedrine pseudoephedrine

Ibuprofen Ibuprofen+ caffeine

chlorpheniramine chlorpheniramine

Sinlerg Antiflu

pseudoephedrine

Propyphenazone

chlorpheniramine

Contaflu

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Phenylepherine

Paracetamol

chlorpheniramine

Sine up

Phenylepherine

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Carbinoxamine maleate

Rhinopro

pseudoephedrine

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Loratadine

Decongess-L ,Clarinase

pseudoephedrine pseudoephedrine

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Cetrizine Triprolidine

Clearest Actifed

pseudoephedrine

Ibuprofen

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Powercaps ,Brufen flu ,Dolo-D, Farex

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Paracetamol

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Other common supportive treatment for common cold:

I. Nasal decongestants: All nasal decongestants shouldnt be used more than 5 days or maximum 7 days as they may affect nasal mucosa producing Rhinitis Medicamentosa 1. Oxymetazoline: A direct sympathomimetic vasoconstrictor Relieves nasal congestion within few minutes & its effect lasts for several hours Side effect: Rebound congestion may occur after frequent or prolonged nasal use Rhinitis medicamentosa after frequent or prolonged nasal use Dosage: one drop in each nostril 2-3 times daily Trade names: Afrin 0.5% adult drops & adult spray Oxymet 0.05% adult drops

2. Xylometazoline hydrochloride: A direct sympathomimetic vasoconstrictor with marked adrenergic activity It is a vasoconstrictor reducing swelling and congestion of mucous membrane The effect begins within 5-10 minutes of application and lasts for up to 10 hours Side effects: like oxymetazoline Dosage: one drop in each nostril 2-3 times daily Trade names: Otrivin: 1% adult drops 0.1% adult nasal spray Rhinex 1% adult drops Balks, nasostop etc

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3. Naphazoline + chlorpheniramine maleate: Naphazoline: Decongestant for nose & eye Alpha agonist Rebound congestion may occur after prolonged use Dosage: one drop 3 times daily Trade names: Prisoline, Nostamine, Neozolineetc nasal and eye drops

4. Rinosin nasal/eye drops and nasal gel: Naphazoline + cetrimide (i.e. antiseptic)

5. Vibrocil nasal gel and adult spray: Dimetindenum )antihistamine) + phenylephrine (decongestant) + neomycin (antibiotic)

II. Antiseptic lozenges:

Lozenges are a pharmaceutical form to be chewed not swallowed Used every 2-3 hours Antiseptic for mouth and throat Trade names: Bradoral, Larypro, Orofar, Strepsils, Tantum Verde.etc

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HINTS ON URINARY TRACT

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I.

Drugs used for Acute Gout:

Introduction: - Pharmacologic modalities employed in the treatment of gout can be classified as antiinflammatory, prophylactic, and antihyperuricemic. These designations reflect the three distinctive aims of treatment: Antiinflammatory therapy for prompt and safe termination of the acute arthritic attack Antiinflammatory prophylaxis for prevention of recurrences of acute gouty arthritis Antihyperuricemic (urate-lowering) therapy for prevention and reversal of the consequences of urate crystal deposition in joints (gouty arthropathy), urinary tract (nephrolithiasis), renal interstitium (rarely producing renal failure due to urate nephropathy), and tissues and parenchymal organs (tophi) Acute gout is an intensely painful inflammatory arthritis that typically involves a single joint, but can affect multiple joints The goal of therapy in an acute gout attack is prompt and safe termination of pain and disability Without therapy, acute gouty arthritis usually resolves within a few days to several weeks. However, symptoms improve more quickly with administration of any of a broad array of anti-inflammatory drugs. Symptom resolution is more prompt and complete with early initiation of therapy. A number of drugs have been used for the treatment of acute gout: Nonsteroidal anti-inflammatory drugs Colchicine Intraarticular or systemic glucocorticoids Interleukin 1 beta inhibition (investigational) Upon resolution of the acute attack, the patient is said to have entered the intercritical (between attacks) period, which may or may not require prophylactic therapy to prevent recurrent gout and chronic tophaceous disease.

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Nonsteroidal anti-inflammatory drugs: (for more details revise analgesics chapter) - They are first-line therapy for most patients with for acute gouty arthritis. Complete or nearly complete resolution of pain and disability typically occurs within several days to one week. Aspirin is usually avoided because of the paradoxical effects of salicylates on serum urate A number of randomized trials have compared different NSAIDs with each other, without any apparent differences in efficacy. Significant pain relief was noted at the initial assessment four hours after the first dose Caution is necessary in patients with known cardiovascular disease or with multiple risk factors for atherosclerotic coronary disease, since an increased risk of myocardial infarction, stroke, and heart failure have been associated with use of both selective COX2 inhibitors and, perhaps to a lesser degree, nonselective NSAIDs. Unless contraindicated (eg, by gastrointestinal, cardiovascular, or renal disease, or allergy), we suggest administration of a potent oral nonselective NSAID (such as naproxen or indomethacin) for reduction of acute gouty inflammation, especially if treatment is initiated within 24 hours of the onset of symptoms. A typical starting dose for naproxen is 500 mg twice daily and for indomethacin 150 mg/day given in three divided doses. In view of the frequent gastrointestinal intolerance associated with NSAIDs, the dose should be reduced by one-half as soon as objective and subjective improvement is noted, often within three days. Further dose reductions and withdrawal over several more days is safe and practical. Most patients are on NSAIDs until the attack has completely resolved; this may be a total of seven to ten days. In an attack of several days duration a longer course of treatment may be necessary and an antiinflammatory agent with fewer gastroduodenal side effects (such as nabumetone or a selective COX-2 inhibitor) may be preferred. In patients at high risk of gastric ulcer or gastrointestinal bleeding addition of an antiulcer medication to a nonselective NSAID may be helpful.

. -

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Colchicine: - Many patients report that incipient attacks can be aborted with oral colchicine taken at the first symptom. - Usage: Oral colchicine can be effective for the treatment of acute gouty arthritis, and side effects are less likely when a low-dose regimen is used at the onset of symptoms of flare. - Dosage (regimen): Low dose regimen: The regimen recommended by the FDA for administration of this agent (in the absence of concurrent use of interacting drugs or of endstage renal disease/renal dialysis) is a low-dose course consisting of 1.2 mg (2 tablets) at the first dose followed one hour later by 0.6 mg (1 tablet), to give a total dose of 1.8 mg on the first day of colchicine treatment Traditional regimen: The traditional regimen of 0.6 mg (one tablet) per hour or every two hours until there was either relief of gouty pain and inflammation, a total dose of 4 to 6 mg was reached, or GI symptoms occurred. Was limited by adverse gastrointestinal effects (diarrhea, abdominal cramping, nausea, vomiting). Side effects: GIT irritation BM suppression Hepatotoxicity Colchicine may interact with other commonly prescribed drugs, such as atorvastatin and erythromycin, among others. Preparations: Oral form: Colchicine, Colmediten 0.5mg tab Sachet form: i.e. used for acute gout and urate crystalluria Urosolvin, Urivin, Ur-Aid, Uricol plus .etc

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Recommendations for low-dose colchicine treatment in acute gout rather than higherdose treatment. In patients on ongoing colchicine prophylaxis therapy who have an acute flare, a course of low-dose colchicine could be followed by return to the preceding prophylaxis dose on the day after low-dose flare treatment. When low-dose first day oral colchicine treatment of acute flare is beneficial but the response is incomplete in a patient not receiving ongoing colchicine prophylaxis therapy, the guidelines for use of colchicine prophylaxis can be applied on subsequent days until resolution of the acute flare When low-dose colchicine therapy is ineffective or minimally effective in suppressing acute gout in timely fashion, alternative anti-inflammatory agents, including an intraarticular glucocorticoids, should be considered.

Glucocorticoids: (for more details revise immunosuppressive & immunomodulatory chapter) - Glucocorticoid therapy can be injected into the affected joint(s) or given systemically, either orally or parenterally. - Intraarticular: Intraarticular (depot) glucocorticoids are a reasonable option in patients with only one or two actively inflamed joints We consider this option preferable to systemic glucocorticoids in patients who cannot take NSAIDs or colchicine The diagnosis of acute gouty arthritis should be secure and infection must be ruled out before injection is considered. We typically use triamcinolone acetonide 40 mg for knee joints and lower doses for smaller joints. Equivalent doses of depo-methylprednisolone may also be used. - Systemic: Systemic glucocorticoids may be administered orally in patients who cannot take NSAIDs or colchicine and who are not candidates for intraarticular glucocorticoid injection because of polyarticular disease. Prednisone or prednisolone in doses of 30 to 50 mg/day (or other equivalent glucocorticoid) for one to two days, then tapered over seven to ten days, effectively reduces acute symptoms to a similar extent as do NSAIDS. However, rebound attacks are relatively common once glucocorticoids are withdrawn, especially in patients who have previously suffered a number of prior attacks and whose intercritical periods have progressively shortened.

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* Adjust dose in patients with renal insufficiency.

II. Drugs used for interval gout: Introduction:

Upon resolution of an acute gouty attack, the patient is said to have entered an intercritical (between attacks) period. Intervals between attacks of acute gouty arthritis are of variable duration. Most untreated patients with gout will experience a second episode within two years. The following preventive issues should be addressed during the intercritical period: Lifestyle modification and agents for risk reduction Comorbid disease management The need for pharmacologic urate-lowering therapy Prophylactic nonsteroidal antiinflammatory drug or colchicine therapy, primarily to reduce the recurrence of acute attacks of gout during initiation of urate-lowering therapy In patients presenting with gouty arthritis and normal renal function but without visible or palpable tophaceous deposits or radiographic evidence of joint destruction or bony

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erosions, it should be possible to manage their disease successfully with life-style modifications, combined when necessary with pharmacologic therapy. - Pharmacologic urate-lowering measures are also effective in most patients with tophaceous gout. - In a few patients with complications due to tophaceous disease, surgical intervention may be an adjunct to medical management. - We will focus on PHARMACOLOGIC URATE-LOWERING THERAPY PHARMACOLOGIC URATE-LOWERING THERAPY: - Preventing recurrent and progressive gouty arthritis and tophi requires, in many patients, the long-term use of drugs that reduce the serum urate concentration: Either by enhancing renal excretion of uric acid (uricosuric agents) Or by decreasing urate synthesis (xanthine oxidase inhibitors). - Indications: Frequent and disabling attacks of gouty arthritis Clinical or radiographic signs of chronic gouty joint disease Tophaceous deposits in soft tissues or subchondral bone Gout with renal insufficiency Recurrent nephrolithiasis Urinary uric acid excretion exceeding 1100 mg/day (6.5 mmol), when determined in men less than 25 years of age or in premenopausal women - Goals: The general goal of antihyperuricemic therapy is a serum urate concentration of <6 mg/Dl - Initiation and duration of therapy: It is generally recommended that urate-lowering therapy not be initiated until the acute inflammatory event has resolved. Acute urate-lowering can precipitate an attack, and initiation of therapy during an acute attack can theoretically worsen the arthritis We generally wait until at least two weeks after an acute flare subsides to obtain baseline serum uric acid testing and to begin urate-lowering therapy. 1. Uricosuric drugs: Enhance renal excretion of uric acid Indicated in patients with relative renal underexcretion of uric acid Uricosuric treatment has been used rather uncommonly in the US since the introduction of the xanthine oxidase inhibitor, allopurinol. Agents: Probenicid: 500mg twice daily Sulfinpyrazone: 200mg twice daily These drugs should be given with plenty of fluids + alkalinaization of urine to avoid nephrolithiasis

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2. Xanthine oxidase inhibitors: Allopurinol and febuxostat are the only readily available xanthine oxidase inhibitors. xanthine oxidase inhibitors are likely to be effective in virtually all circumstances warranting urate-lowering therapy for gout. Allopurinol: Mechanism: inhibition of uric acid production is due to inhibition of xanthine oxidase (xanthine dehydrogenase) Dosage: The most commonly used daily dose of allopurinol is 300 mg We usually initiate allopurinol treatment at 100 mg daily in patients with weight-adjusted creatinine clearances >40 ml/min and titrate the dose according to the antihyperuricemic effect achieved. Maximum daily dose is 800mg Side effects: Diarrhea, dermatitis Increase liver enzymes Precipitation of acute gout Preparations: Zyloric No-Uric Lessuric 100, 300mg tablets Harpagin tab (100mg allopurinol + benzbromarone i.e. uricosuric)

Febuxostat: More effective than allopurinol Dosage: 40 mg or 80 mg once daily. Side effects: nausea, diarrhea, arthralgia, headache, increased hepatic serum enzyme levels and rash.

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*Dose adjustment of allopurinol and of colchicine in patients with renal insufficiency has been recommended. In the case of allopurinol, this recommendation is now controversial. No dose adjustment is required with febuxostat if creatine clearance 30 mL/min. Titration of dose of urate-lowering agent to serum urate goal of <6 mg/dL is recommended.

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III. Drugs used for urinary incontinence:

Introduction: - Urinary incontinence, the involuntary leakage of urine, often goes undetected by clinicians - A multicomponent stepped approach focused on the patient's most bothersome aspects of urinary incontinence is the key to successful therapy. - Treatment aimed at simply decreasing the number of incontinent episodes - Stepwise treatment strategies should be discussed with the patient. - In general, treatment should advance from least invasive (lifestyle changes, behavioral therapies, medications) to more invasive therapies - In older patients, correcting contributory factors such as comorbid conditions, functional impairment, and medications should be the initial focus - We will focus on PHARMACOLOGIC THERAPY Antimuscarinics: - Anticholinergic drugs with antimuscarinic effects are the most frequently prescribed medications for urge incontinence. - The choice of agent for an individual patient depends on cost, dosing frequency, drugdrug interactions, potential side effects, and comorbid conditions that may increase adverse drug effects. - A lack of response to one agent does not preclude response to another. - Especially in older patients, antimuscarinics should be started at the lowest possible dose and titrated as needed - Mechanism: These medications are thought to act primarily by increasing bladder capacity and decreasing urgency, and not decreasing involuntary detrusor contractions - Side effects: Significant peripheral adverse effects, attributed to blockade of muscarinic receptors throughout the body, may limit drug tolerability and dose escalation Dry mouth, blurred vision for near objects, tachycardia, drowsiness, decreased cognitive function, and inhibition of gut motility (constipation). Constipation and compensatory fluid intake for dry mouth may exacerbate urinary incontinence. Dry mouth predisposes to caries; dentulous patients should have regular dental care if they are maintained on antimuscarinics. Antimuscarinic agents are contraindicated in patients with gastric retention and angle closure glaucoma. Drug interactions occur with drugs that are potent CYP3A4 inhibitors (azole antifungals, macrolide antibiotics, cyclosporine, vinblastine)

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Members of the group: Oxybutynin: Has direct antispasmodic effects and inhibits the action of acetylcholine on smooth muscle. The initial dosage for IR is 2.5 mg two to three times daily, followed by titration as needed up to 20 mg/day in divided doses. Trade names: uripan 5mg tab uripan xr 10mg tab

Tolterodine: 1 to 2 mg twice a day IR, 2 to 4 mg per day ER Trade names: detrusitol 2mg, retard 4mg tab uricontrol 2mg tab

Trospium: 20 mg twice daily must be taken on an empty stomach. Trade names: trospikan 20mg tab Solifenacin: Used for the treatment of overactive bladder with urge incontinence, urgency, and urinary frequency More selective for the M-3 muscarinic receptor found in the bladder and GI tract, but whether this translates to better tolerability or clinical efficacy is unclear. 5 to 10 mg daily Trade name: vesicare 10mg tab

Tricyclic antidepressants: (Imipramine) - Has dual alpha agonist and anticholinergic activity - It is not recommended for older patients in whom anticholinergic adverse effects and orthostatic hypotension may be significant - 75mg at bed time - Trade names: tofranil, imipramine, toframine 25mg tab

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IV. Urinary antiseptics & antispasmodics:

Nitrofurantoin: - Mechanism of action: The drug works by damaging bacterial DNA - Medical uses: It is usually used in treating urinary tract infection. Nitrofurantoin is only clinically proven for use against E. coli or Staph. saprophyticus. Nitrofurantoin must never be used to treat pyelonephritis,prostatitis, renal abscess, and pyeloempyema because of extremely poor tissue penetration and low blood levels. Urinary catheter infections may be treated with nitrofurantoin if there are no systemic features; the catheter must be changed after 48 hours of antibiotics and treatment is ineffective if the catheter is not replaced or removed. - Side effects: The most common side effects with nitrofurantoin are nausea, vomiting, and diarrhea Less common reactions include fever, chills, and various other hypersensitivity reactions. It can also cause pulmonary fibrosis and Drug-induced autoimmune hepatitis. All these side effects are much more common in the elderly hence this antibiotic is strongly not recommended for older adults Patients should be informed that nitrofurantoin colors urine brown; this is completely harmless. - Dosage: 50-100 mg/dose every 6 hours; administer for 7 days or at least 3 days Nitrofurantoin should be taken with food, as this improves the absorption of the drug by 45%. - Preparations: Macrofuran 50, 100mg cap mepafuran 100mg cap uvamin 100mg cap

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Other antiseptic antispasmodics:

They have different active ingredients They have antiseptic antispasmodic effect They prevent stone formation and help expulsion They have different forms tab, cap, sachets We will mention the common and famous agents: 1. Cystone: Dose of 2 tablets 2-3 times daily

2. Rowatinex & urinex: Dose of 1-2 capsules 3 times before meals 3. Proximol compound: 3

4. Coli-Urinal: 3

5. Spasmo-Urgenin: Dose of 1-2 tabs tds

6. Genurin: Dose of 1-2 tabs tds

7. Sham cap, Kellagon cap, Renal-S sach, Uricol sach ..etc

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V. Magnesium Citrate:
Medical uses: - Prevent oxalate calculus by the formation of the soluble Mg oxalate - To completely empty the bowel prior to a major surgery or colonoscopy. - Laxative (osmotic) Dose: - For calculi: 3 Trade names: - Epimage, Xenomag sach .etc

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Introduction:
The common symptoms of BPH are increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. These symptoms typically appear slowly and progress gradually over a period of years. In general, these symptoms only require therapy if they have a significant impact on a patient's quality of life. Even without therapy, many men will experience stabilization or improvement in symptoms over time. One review found that over a follow-up period of 2.6 to 5 years, 16 percent of men had stable symptoms and 38 percent improved. Thus, the decision to treat BPH/LUTS involves balancing the severity of the patient's symptoms with potential side effects of therapy. BPH may also require therapy if BOO (Bladder outlet obstruction) is creating a risk for upper tract injury such as hydronephrosis or renal insufficiency, or lower tract injury such as urinary retention, recurrent infection, or bladder decompensation (e.g., low pressure detrusor contractions; post-void residuals of >25 percent of total bladder volume). In general, patients who develop these symptoms will require invasive therapy. The bladder outlet obstruction of BPH has two components: 1. A dynamic (physiologic, reversible) component related to the tension of prostatic smooth muscle in the prostate, prostate capsule, and bladder neck 2. A fixed (structural) component related to the bulk of the enlarged prostate impinging upon the urethra Two classes of drugs, alpha-adrenergic antagonists and 5-alpha-reductase inhibitors, act upon the dynamic and fixed components of bladder outlet obstruction, respectively. Alpha-adrenergic antagonists appear to be more effective than 5-alpha-reductase inhibitors for short-term and long-term treatment of BPH/LUTS. However, only 5-alpha-reductase inhibitors have demonstrated the potential for long-term reduction in prostate volume and need for prostate surgery. The use of agents from both classes in combination may be superior to using either class alone. Antiandrogens and gonadotropin-releasing hormone (GnRH) agonists also have been used. GnRH agonists may be somewhat more effective for BPH/LUTS than the above medications, but the resulting androgen deficiency generally makes their use unacceptable to patients. Studies, using surveys and claims data, have shown that initial therapy with an alphaadrenergic antagonist appears to be most common

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Alpha-1-adrenergic antagonists:
Introduction: Five long-acting alpha-1-antagonists, terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin have been approved by the Food and Drug Administration in the United States for treatment of the symptoms of BPH. Prazosin, a short-acting alpha-1-antagonist, is generally not used for BPH, due to need for frequent dosing and the potential for more cardiovascular side effects. Mechanism: Act against the dynamic component of bladder outlet obstruction by relaxing smooth muscle in the bladder neck, prostate capsule, and prostatic urethra. Alpha-1 receptors are abundant in the prostate and base of the bladder, and sparse in the body of the bladder. The density of these receptors is increased in hyperplastic prostatic tissue Efficacy: The approved alpha-1-adrenergic antagonists appear to have similar efficacy In a meta-analysis comparing alpha-adrenergic antagonist monotherapy versus finasteride (a 5-alpha-reductase inhibitor): doxazosin and terazosin were more effective in improving urinary symptoms compared to finasteride. Tamsulosin and finasteride were equally effective. Alfuzosin and silodosin were not studied in this meta-analysis Side effects: The most important side effects are orthostatic hypotension and dizziness Terazosin and doxazosin generally need to be initiated at bedtime (to reduce postural lightheadedness soon after starting the medication) and the dose should be titrated up over several weeks. If there is a hiatus in drug administration, retitration is usually required. The hypotensive action can be useful in older men who have hypertension, but they require careful monitoring. Alpha-1-adrenergic antagonists may increase the incidence of heart failure when used as monotherapy for hypertension Tamsulosin, alfuzosin, and silodosin have lower potential to cause hypotension and syncope than either terazosin or doxazosin, and tamsulosin may further have slightly less effect on blood pressure than alfuzosin. Other common side effects of alpha-1-antagonists include asthenia and nasal congestion. Tamsulosin and silodosin, in particular, can affect ejaculation: Tamsulosin decreased mean ejaculate volume in more than 90 percent of patients, with 35 percent having no ejaculate Silodosin produces retrograde ejaculation in approximately 28 percent of patients

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Drug interaction: The hypotensive effects of terazosin and doxazosin can be potentiated by concomitant use of the phosphodiesterase-5 (PDE-5) inhibitors sildenafil or vardenafil. The risks with tadalafil are less clear. Men who are on lower doses of terazosin or doxazosin and are not experiencing orthostatic blood pressure changes can be treated with PDE-5 inhibitors as long as dosing is separated by at least four hours. Tamsulosin at a dose of 0.4 mg/day does not appear to significantly potentiate the hypotensive effects of sildenafil. Dosage:

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Titrate dose as tolerated and as needed for effect. Oral administration for all medications is once daily at bedtime. Peak effect of a given dose on BPH symptoms may not be fully evident until 4 to 6 weeks. If therapy is interrupted for three or more days, reinitiate at lowest dose and re-titrate according to schedule. Due to lower risk of orthostatic hypotension and syncope, uroselective agents do not require gradual dose titration. Oral administration for all medications is once daily at bedtime.

Preparations: 1. Doxazosin: Dosin: 1, 2, 4mg tab Cardura: 1, 4mg tab cardura XL 4mg S.R. cap Other trade names: duracin, doxazin, doxacor etc

2. Terazosin: E-Ze-P: 1, 2, 5mg cap Prostasin: 2, 5mg tab Other trade names: itrin, teracin, terazin etc

3. Tamsulosin: Omnic, tamsul, tamsulin 0.4mg cap tamic 0.4mg tab .etc 4. Alfuzosin: Xatral 5mg tab

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5-alpha-reductase inhibitors:
There are two 5-alpha-reductase inhibitors approved in the United States, finasteride and dutasteride. Mechanism: These drugs act by reducing the size of the prostate gland. Treatment for 6 to 12 months is generally needed before prostate size is sufficiently reduced to improve symptoms. The type 2 form of 5-alpha-reductase catalyzes the conversion of testosterone to dihydrotestosterone in the prostate, hair follicles, and other androgen-sensitive tissues. Its clinical importance is suggested by the observation that men with inactivating mutations of the gene for the enzyme have very small prostate glands and do not develop BPH. The type 1 form of the enzyme is present in liver, non-genital skin, and some areas of the brain Efficacy: Finasteride: The efficacy of finasteride is greater in men with larger prostate volumes than in men with smaller prostate volumes. The following benefits were noted in the men treated with finasteride: Serum dihydrotestosterone concentrations decreased by about 70 percent A reduction in obstructive and non-obstructive symptom scores by 23 and 18 percent, respectively, in the men given 5 mg daily but less in the men given 1 mg daily An increase in maximal urinary flow rate A reduction in mean prostatic volume by 19 and 18 percent The efficacy of finasteride appears to persist with long-term treatment. The most important findings were that finasteride treatment decreased the probability of surgery and acute urinary retention Finasteride increases the apoptotic index of epithelial and stromal cells and decreases the volume of epithelium Dutasteride: May be more potent than finasteride. However some studies suggest no difference in efficacy between dutasteride and finasteride The 5-alpha-reductase inhibitors are more effective in men with larger prostates, and their effects on acute urinary retention and reduction in need for surgery require chronic treatment for more than a year. Side effects: The major side effects of these drugs are decreased libido and ejaculatory or erectile dysfunction. 5-alpha-reductase inhibitors significantly decrease the incidence of prostate cancer.

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Dosage: Unlike with alpha antagonists, dosing with 5-alpha-reductase inhibitors do not require titration Finasteride can be initiated and maintained at 5 mg once daily. Similarly, dutasteride can be initiated and maintained at 0.5 mg once daily. Preparations: 1. Fnasteride: proscar, prostride 5mg tab etc 2. Dutasteride: avodart 0.5mg cap The data concerning efficacy of these therapies are conflicting. Until additional studies of herbals are performed, we suggest using alpha-adrenergic antagonists and 5-alpha-reductase inhibitors rather than any of herbal therapies. 1. Pygeum africanum: Dose: 50mg tds Trade names: prostacure prostacure plus (with doxazosin 1mg) 2. Saw palmetto: Dose: 150mg twice daily Trade names: prostanorm, prosta-s cap .etc

Herbal preparations:
-

3. Pumpkin seed oil: Used in prostate inflammation & as lipid lowering agent Dose: 1-2 cap tds Trade names: pepon 300mg cap pepon plus cap (plus Saw palmetto) .etc Other suppositories for BPH and prostate inflammation: - Dose: one supp twice daily - Trade names: decongestyl, de-prostyl-2, prostalin etc

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HINTS ON ANALGESICS

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Introduction:
An analgesic (also known as a painkiller) is any member of the group of drugs used to relieve pain Analgesic drugs act in various ways on the peripheral and central nervous systems There are many categories: paracetamol, NSAIDs & Opioids They are distinct from anesthetics, which reversibly eliminate sensation. In choosing analgesics, the severity and response to other medication determines the choice of agent The WHO pain ladder, originally developed in cancer-related pain, is widely applied to find suitable drugs in a stepwise manner. The analgesic choice is also determined by the type of pain: for neuropathic pain, traditional analgesics are less effective, and there is often benefit from classes of drugs that are not normally considered analgesics, such as tricyclic antidepressants and anticonvulsants.

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Main classes of analgesics:

Paracetamol NSAIDs & COX-2 inhibitors Opiates and centrally acting analgesics Spacific agents Combinations Other analgesics

I.

Paracetamol: Mechanism of action: - To date, the mechanism of action of paracetamol is not completely understood. - The main mechanism proposed is the inhibition of cyclooxygenase (COX), and recent findings suggest that it is highly selective for COX-2 (The COX family of enzymes are responsible for the metabolism of arachidonic acid to prostaglandin H2, an unstable molecule that is, in turn, converted to numerous other pro-inflammatory compounds). - Paracetamol reduces the oxidized form of the COX enzyme, preventing it from forming proinflammatory chemicals. This leads to a reduced amount of Prostaglandin E2 in the CNS, thus lowering the hypothalamic set-point in the thermoregulatory centre. Medical uses:
Fever: Its a safe antipyretic used in children from day one and in adults (safe during pregnancy) WHO recommends that paracetamol only be used to treat fever in children if their temperature is greater than 38.5 C. The efficacy of paracetamol by itself in children with fevers has been questioned and a meta-analysis showed that it is less effective than ibuprofen. Pain: It has analgesic properties comparable to those of aspirin, while its anti-inflammatory effects are weaker. It is better tolerated than aspirin in patients in whom excessive gastric acid secretion or prolongation of bleeding time may be a concern. Paracetamol has relatively little anti-inflammatory activity, unlike other common analgesics such as the NSAIDs aspirin and ibuprofen.

Side effects: - Paracetamol is well tolerated with mild to non-existent side effects. - Prolonged daily use increases the risk of upper gastrointestinal complications such as stomach bleeding, and may cause kidney or liver damage. - Paracetamol is metabolized by the liver and is hepatotoxic; side effects may be more likely in chronic alcoholics or patients with liver damage. - Doesnt affect coagulation profile or make gastric irritation like aspirin - Compared to ibuprofen which can have adverse effects that include diarrhea, vomiting, and abdominal pain, paracetamol is well tolerated with fewer side effects. - Paracetamol hepatotoxicity is, by far, the most common cause of acute liver failure in both the United States and the United Kingdom. N acetylcysteine is the antidote. 68 | P a g e

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Preparations & Dosage: - The onset of analgesia is approximately 11 minutes after oral administration of paracetamol, and its half-life is 14 hours. - safe for use at recommended doses (1,000 mg per single dose and up to 4,000 mg per day for adults) - Oral: panadol, abimol, adol, paramol (paracetamol 500mg tab)

With caffeine: panadol extra, abimol extra, adol extra, pronto plus.

Vial: Perfalgan vial (paracetamol 1000mg i.v.)

With methionine (reduce paracetamol hepatotoxicity so its suitable for patients with hepatic insufficiency): Hepamol (paracetamol 500mg + methionine 100mg).

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II.

Non-steroidal anti-inflammatory drugs (NSAIDs):

Mechanism of action: - Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. - COX catalyzes the formation of prostaglandins and thromboxane - COX-1 is a constitutively expressed enzyme with a "house-keeping" role in regulating many normal physiological processes. One of these is in the stomach lining, where prostaglandins serve a protective role, preventing the stomach mucosa from being eroded by its own acid. - COX-2 is an enzyme facultatively expressed in inflammation, and it is inhibition of COX-2 that produces the desirable effects of NSAIDs. - When nonselective COX-1/COX-2 inhibitors (such as aspirin, ibuprofen, and naproxen) lower stomach prostaglandin levels, ulcers of the stomach or duodenum internal bleeding can result. - The discovery of COX-2 led to research to development of selective COX-2 inhibiting drugs that do not cause gastric problems characteristic of older NSAIDs. - Mechanism of antipyretic activity: Fever is caused by elevated levels of prostaglandin E2, which alters the firing rate of neurons within the hypothalamus that control thermoregulation. Antipyretics work by inhibiting the enzyme COX, which causes the general inhibition of prostanoid biosynthesis (PGE2) within the hypothalamus. PGE2 signals to the hypothalamus to increase the body's thermal set point. Ibuprofen has been shown more effective as an antipyretic than acetaminophen (paracetamol). Medical uses: NSAIDs are generally indicated for the symptomatic relief of the following conditions: - Rheumatoid arthritis - Osteoarthritis - Inflammatory arthropathies (e.g. ankylosing spondylitis, psoriatic arthritis, Reiter's syndrome) - Acute gout - Dysmenorrhoea (menstrual pain) - Metastatic bone pain - Headache and migraine - Postoperative pain - Mild-to-moderate pain due to inflammation and tissue injury - Muscle stiffness and pain due to Parkinson's disease - Pyrexia (fever) - Ileus - Renal colic

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They are also given to neonate infants whose ductus arteriosus is not closed within 24 hours of birth Aspirin, the only NSAID able to irreversibly inhibit COX-1, is also indicated for inhibition of platelet aggregation. This is useful in the management of arterial thrombosis and prevention of adverse cardiovascular events. Aspirin inhibits platelet aggregation by inhibiting the action of thromboxane A2.

Side effects: - The two main adverse drug reactions (ADRs) associated with NSAIDs relate to the gastrointestinal (GI) and renal effects of NSAIDs. - Gastrointestinal ADRs: NSAIDs cause a dual assault on the GI tract: the acidic molecules directly irritate the gastric mucosa, and inhibition of COX-1 and COX-2 reduces the levels of protective prostaglandins. Inhibition of prostaglandin synthesis in the GI tract causes increased gastric acid secretion, diminished bicarbonate secretion, diminished mucus secretion and diminished trophic effects on epithelial mucosa. Common gastrointestinal ADRs include: 1. Nausea & vomiting 2. Dyspepsia 3. Gastric ulceration and bleeding 4. Diarrhea These side effects can occur with any preparation of the NSAIDs i.e. oral, rectal or i.v. & also can occur in patients with achlorhydria GI ADRs occur commonly with indomethacin, ketoprofen & piroxicam and less common with ibuprofen (low doses) & diclofenac In practice doctors usually combine NSAIDs with PPI and H2 blockers - Renal ADRs: Common ADRs: 1. Salt and water retention 2. Hypertension Rare ADRs: 1. Interstitial nephritis 2. Nephritic syndrome 3. Acute renal failure 4. Acute tubular necrosis - Cardiovascular ADRs: (except low dose aspirin) Increases the risk of MI an stroke (Naproxen seems least harmful) Increases the risk of HF - Erectile dysfunction - Used cautiously with IBD due to risk of bleeding from ulcerations (paracetamol and other combinations with codeine are more safe) - NSAIDs are not recommended during pregnancy, particularly during the third trimester. While NSAIDs as a class are not direct teratogens, they may cause premature closure of the fetal ductus arteriosus and renal ADRs in the fetus. Additionally, they are linked with premature birth and miscarriage 71 | P a g e

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Photosensitivity Common adverse drug reactions (ADR), other than listed above, include: raised liver enzymes, headache, dizziness. Uncommon ADRs include: hyperkalaemia, confusion, bronchospasm, rash.[3] Rapid and severe swelling of the face and/or body. Ibuprofen may also rarely cause irritable bowel syndrome symptoms.

Drug interaction: - Daily use of aspirin i.e. for cardiac protection shouldnt be combined with other NSAIDs use as they block the cardioprotective effect of aspirin - SAIDs reduce renal blood flow and thereby decrease the efficacy of diuretics - NSAIDs cause hypocoagulability, which may be serious when combined with other drugs that also decrease blood clotting, such as warfarin. - NSAIDs may aggravate hypertension (high blood pressure) and thereby antagonize the effect of antihypertensives such as ACE Inhibitors. - NSAIDs may interfere and reduce efficiency of SSRI antidepressants Classifications of NSAIDs: - Salicylates Aspirin (acetylsalicylic acid): See part one Diflunisal: Trade name: Doloban 250, 500mg tab Propionic acid derivatives Ibuprofen: Dosage: daily dose1200-1600mg in 3-4 divided doses with maximum dose 2400mg Trade name: brufen 200, 400, 600mg tab 500mg supp 600mg sach

Naproxen: Suppositories may cause rectal irritation and occasionally bleeding Dosage: 500mg to 1g as a single dose or in 2 divided doses Trade name: naprofen 500mg tab naprogesic 250mg tab & 500mg tab, supp maxipan 250mg tab, supp 72 | P a g e

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Fenoprofen: Trade name: fenoprofen 200, 300, 600mg cap Ketoprofen: Suppositories may cause rectal irritation and IM injection may cause pain at the site of injection Dosage: 25-50mg 3 times daily as pain killer and 200mg once daily after meal as anti-rheumatic antiinflammatory analgesic Preparations: 1. Biprofenid 75mg tab 2. Alcofan 25, 50mg cap 100mg supp 3. Bi-alcofan 150mg tab 4. Kefen Tech Plaster: 30mg / sheet 5. Ketofan 25mg tab 50, 100, 200mg cap 150mg supp 100mg amp 6. Ketolgin 25, 50mg tab 100mg amp and supp 200mg cap 7. Ketoprek 75mg cap 8. Profenid 50mg cap 100mg supp and amp

Loxoprofen: Preparations: roxonin 60mg or roxogesic 60mg tab Loxoprofen should not be administered at the same time as second-generation quinolone antibiotics such as ciprofloxacin and norfloxacin, as it increases their inhibition of GABA and this may cause seizures. Acetic acid derivatives Indomethacin: Preparations: 1. Indocid: 25mg cap 50mg vials 100mg supp 2. Indomethacin: 25, 50mg cap 100mg supp

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3. Liometacen: 50mg vials

Dosage: 1. Oral: 25-50mg 2-4 times daily durng or after meals 2. Rectal: 100mg supp at bed time Increase plasma concentrations of aminoglycosides

Tolmetin: Preparations: 1. Rumatol 200, 400mg cap 2. Tolmet DS 400mg cap Sulindac: Dosage: 150mg twice daily with meal & the maximum recommended dose is 400mg daily for acute gouty arthritis 200mg twice daily with food for 7 days Preparations: 1. Rudac 150, 200mg tab 2. Hi dac 200mg tab Its metabolites are components of renal stones so used cautiously with patent with previous history of renal stones and should be kept well hydrated Etodolac: Dosage: 200-300mg daily after food Preparations: etodine 200, 300mg cap etodolac 300 tab napilac 200 cap May produce agranulocytosis

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Ketorolac: Has more potent analgesic action than other NSAIDs High incidence of side effects made some countries withdraw ketorlac Common side effects are GIT bleeding and PU also hypersensitivity Not recommended for children Dosage: Maximum duration of treatment should not exceed five days for tablets, or two days for continuous daily dosing with intravenous or intramuscular formulations. Initially 30-60mg by IM then 10-30mg every 4-6 hours. Maximum 150mg for 1st day and 120mg/day thereafter Preparations: 1. Adolor 15, 30mg amp. 2. Fam 10mg tab 3. Ketolac 10mg tab and 30mg amp.

Diclofenac: 1. Diclofenac sodium: Preparations: 1. Voltaren (most famous): Tablets: voltaren 25, 50, 75mg voltaren SR 100mg tab Suppositories: voltaren 12.5, 25mg (ped.) 100mg (adult) Ampoules: voltaren 75mg amp. Gel: voltaren emulgel 2. Other trade names: Olfen, Rheumafen, Rheumarene, Epifenac, Declophen .etc

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Dosage: 2-3 times after meal daily.

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2. Diclofenac potassium: Has analgesic power more than the sodium form Dosage: 2-3 times after meal daily Preparations: 1. Cataflam (most famous): Tablets: cataflam 25, 50mg tab Suppositories: cataflam 75mg supp Ampoules: cataflam 75mg amp Sachets: catafast 50mg sach 2. Other trade names: Adwiflam, antiflam, flector, actifast .etc Diclofenac + vitamin B complex: Used in treatment of different types of pain accompanied by neuritis Preparations: arthineur, declonerve, neurofenac, pain releifer

3. Diclofenac cholestyramine: Chlestyramine keeps steady and continuous plasma level of diclofenac Preparations: Flotac 75mg cap Voltaren Resinate 75mg cap Dosage: one cap / 12 hours Aceclofenac: Related to diclofenac Aceclofenac has higher anti-inflammatory action than conventional NSAIDs It should not be given to people with porphyria or breast-feeding mothers, and is not recommended for children Dosage: The dose is 100 mg twice daily Preparations: amoflam 100mg tab fenac 100mg tab bristaflam 100mg tab & sach.

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Nabumetone: Preparations: nabutone, nabuxan, rheumon 500mg film coated tab Dosage: one gram as asingle dose at the evening and a dose of 500mg at the morning may be added Bumadizone: Has analgesic anti-inflammatory effect on skeletal-muscular system Its use was limited by the risk of agranulocytosis and other hematological adverse effects Dosage: one tab 3-4 times daily Trade name: Octomotol 110mg tab

Enolic acid (Oxicam) derivatives Piroxicam: Local irritation and bleeding may occur with suppositories Pain and tissue damage may occur at the site on IM injection Dosage: starting dose is 40mg for the 1st two days (single or divided doses) then maintenance is 20mg daily Preparations: 1. Feldene: 10, 20mg cap 20mg amp 20mg supp feldene flash 20mg SL tab - gel 2. Brexin: 20mg tab, sach, supp 3. Dispercam: 20mg tab, amp, supp gel 4. Other trade names: feldoral, inflacam, piroxiden .etc

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Meloxicam: Meloxicam has been shown, especially at its low therapeutic dose, selectively to inhibit COX-2 over COX-1. Rectal preparations should be avoided in patent with a history of proctitis, haemorrhoids or rectal bleeding Dosage: 7.5-15 mg as a single dose after meal daily Preparations: 1. Mobic: 7.5, 15mg tab 15mg amp 7.5mg supp 2. Mobitil: 7.5, 15mg tab 15mg amp 15mg supp 3. Other trade names: anti-cox II, melocam, meloxicam

Tenoxicam: Dosage: course is initiated by one vial of 20mg im or iv daily for 1-2 days followed by oral therapy i.e. 20mg daily Preparations: 1. Epicotil: 20mg tab, supp, vials 2. Other trade names: soral, tenocam, tenoxicam, anoxicam

Lornoxicam: Dosage: 12-16mg before meals daily on 2-3 doses Preparations: 1. Lomoxicam: 4, 8mg tab 2. Xefo: 4, 8mg tab 8mg vials 3. Other trade names: rheuxicam, zeficam, toprano ..etc

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Fenamic acid derivatives (Fenamates ) Mefenamic acid: Should be stopped if diarrhea or rash occur or appearance of hematological changes e.g. thrombocytopenia or hemolytic anemia Dosage: initially 500mg followed by 250mg every 6 hours with food Preparation: mefenam 500mg cap mefentan 250 cap and supp ponstan 250mg cap ponstan forte 500mg tab ..etc

Selective COX-2 inhibitors (Coxibs) Celecoxib: Non-steroidal anti-inflammatory drug (NSAID) and selective COX-2 inhibitor Same uses as other NSAIDs & additionally used to reduce numbers of colon and rectum polyps in patients with familial adenomatous polyposis. Its primary indication is in patients who need regular and long term pain relief; there is probably no advantage to using celecoxib for short term or acute pain relief over conventional NSAIDs, except in the situation where non-selective NSAIDs or aspirin cause cutaneous reactions (urticaria or "hives"). In addition, the pain relief offered by celecoxib is similar to that offered by paracetamol Used cautiously in patient with previous history of IHD, CVD or PVD Dosage: The usual adult dose of celecoxib is 100 to 200 mg once or twice a day after meal. The lowest effective dose should be used. Preparations: 1. Celebrex 100, 200mg cap 2. Other trade names: celoxib, arythrex, eurocox .etc

Drug interaction: 1. Celecoxib is predominantly metabolized by cytochrome P450 2C9. Caution must be exercised with concomitant use of 2C9 inhibitors, such as fluconazole, which can greatly elevate celecoxib serum levels. 2. In addition, celecoxib may increase the risk of renal failure with angiotensin converting enzyme-inhibitors, such as lisinopril, and diuretics, such as hydrochlorothiazide

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Sulphonanilides Nimesulide: (Systemic preparations are banned by several countries for the potential risk of hepatotoxicity)

III. Opiates and centrally acting analgesics: Morphine, the archetypal opioid, and various other substances (e.g. codeine, oxycodone, hydrocodone, dihydromorphine, pethidine) all exert a similar influence on the cerebral opioid receptor system. Buprenorphine is thought to be a partial agonist of the opioid receptor, and tramadol is an opiate agonist with SNRI properties When used appropriately, opioids and similar narcotic analgesics are otherwise safe and effective However risks such as addiction and the body becoming used to the drug (tolerance) can occur. The effect of tolerance means that frequent use of the drug may result in its diminished effect so, when safe to do so, the dosage may need to be increased to maintain effectiveness. This may be of particular concern regarding patients suffering with chronic pain. IV. Specific agents: In patients with chronic or neuropathic pain, various other substances may have analgesic properties. Tricyclic antidepressants, especially amitriptyline, have been shown to improve pain in what appears to be a central manner. Nefopam is used in Europe for pain relief with concurrent opioids The exact mechanism of carbamazepine, gabapentin and pregabalin is similarly unclear, but these anticonvulsants are used to treat neuropathic pain with differing degrees of success. Anticonvulsants are most commonly used for neuropathic pain as their mechanism of action tends to inhibit pain sensation. Anticonvulsants will be discussed in CNS chapter

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V. Combinations: Combination of two group of analgesics While the use of paracetamol, aspirin, ibuprofen, naproxen and other NSAIDS concurrently with weak to mid-range opiates (up to about the hydrocodone level) has been said to show beneficial synergistic effects by combating pain at multiple sites of action, several combination analgesic products have been shown to have few efficacy benefits when compared to similar doses of their individual components. Famous examples are e.g. 1. Paracetamol + Ibuprofen: megafen & cetafen tab 2. Paracetamol + aspirin + caffeine : Excedrin tab

VI. Other analgesics: Diacerein: - It works by inhibiting interleukin-1. - Diacerein is a drug used in the treatment of osteoarthritis. - The most common side effects of diacerein treatment are gastrointestinal, such as diarrhea. - The dosage of Diacerein is 50 mg twice daily, after meals, for 2 or more years - The dose is halved in patient with creatinine clearance less than 30ml/minute - Preparations are Diacerein and osteocerein 50mg capsules

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Pain management and how to choose analgesic

Introduction: - Before considering pain management, a review of pain definitions and mechanisms may be useful. - Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. - A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

The transmission of incoming nociceptive impulses is modulated by dorsal horn circuitry that receives input from peripheral touch receptors and from descending pathways that involve the limbic cortical systems (orbital frontal cortex, amygdala, and hypothalamus), periaqueductal endogenous analgesic center in the midbrain, pontine noradrenergic neurons, and the nucleus raphe magnus (NRM) in the medulla. Dashed lines indicate inhibition or modulation. * Location of opioid receptors.
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Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord. Pain is generally divided into two categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually resolves once the condition that caused it is resolved. Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. chronic pain is among the most common reasons for seeking medical attention and is reported by 20 to 50 percent of patients seen in primary care.

Managing Pain: - Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. - The elements of this approach include treating the underlying cause of pain, pharmacological and non-pharmacological therapies, and some invasive (surgical) procedures.

- 1. Acute pain: Because pain of these types is expected to be short term, the long-term side
effects of analgesic therapy may routinely be ignored. Thus, these patients may safely be treated with narcotic analgesics without concern about possible addiction, or NSAIDs with only limited concern for the risk of ulcers.

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NSAIDs 2. Chronic pain: Treatment options for chronic pain generally fall into six major categories:
pharmacologic, physical medicine, behavioral medicine, neuromodulation, interventional, and surgical approaches. Medication should not be the sole focus of treatment, but should be used when needed, in conjunction with other treatment modalities, to meet treatment goals Patients with chronic pain require ongoing evaluation, education and reassurance, as well as help in setting reasonable expectations for response. Currently available treatment modalities on average result in only about a 30 percent decrease in pain. But even a partial response of 30 percent can be clinically significant and improve the patients quality of life Co morbidities should be evaluated and treated. In particular, major depression and chronic pain frequently coexist, and both conditions must be addressed to maximize the treatment response for either disorder The choice of an appropriate initial therapeutic strategy is dependent upon an accurate evaluation of the cause of the pain and the type of chronic pain syndrome. In particular, neuropathic pain should be distinguished from nociceptive pain. Neuropathic pain, resulting from damage to or pathology within the nervous system, can be central or peripheral. Causes of neuropathic pain are multiple, and include diabetes mellitus, postherpetic neuralgia, and stroke. Nociceptive pain, in contrast, is caused by stimuli that threaten or provoke actual tissue damage. Nociceptive pain is often due to musculoskeletal conditions, inflammation, or mechanical/compressive problems.

Drugs and doses should be adjusted based on observation of healing rate, switching patients from high to low doses, and from narcotic analgesics to nonnarcotics when circumstances permit. inflammation NSAIDs used in conditions associated with inflammatory process like those of joints analgesic ladder

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Neuropathic pain: Initial management of the patient with neuropathic pain involves establishing a diagnosis,
whenever possible, and pursuing treatment targeted to the specific diagnosis.

Thus, if nerve function is impaired by compression or drugs, alleviating the compression or

removing the offending agent, if accomplished early enough, may be all that is needed. When pharmacologic management of chronic neuropathic pain is required, the choice of an initial agent will be guided by individual patient factors including the pathophysiology of the pain syndrome, other symptoms and comorbidities, other medications being taken, organ reserves, pharmacokinetics/pharmacodynamics, and the likelihood of adverse effects. This is an algorithm for management of neuropathic pain

SNRI: serotonin-norepinephrine reuptake inhibitor; TCA: tricyclic antidepressant; NMDA: N-methyl-D-aspartate.

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Nociceptive pain:
In contrast to neuropathic pain, the pharmacologic approach to nociceptive pain primarily involves non-narcotic and opioid analgesia. Medication is used in conjunction with nonpharmacologic therapies and approaches to relieve the source of the pain. When pharmacotherapy for nociceptive pain is required, acetaminophen is typically recommended as a first-line therapy for pain related to osteoarthritis and chronic low back pain. However, acetaminophen is less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) and has the potential for hepatic toxicity at doses of >4 g per day. An alternative first line agent is an oral NSAID, which is effective for mild-to-moderate chronic low back pain or osteoarthritis. Opioid medications should be used on a chronic basis only in patients who are assessed to be at low risk for substance abuse, and who have persistent pain despite trials of nonopioid analgesics and antidepressants. It should be recognized that the evidence for the effectiveness of long-term opioid therapy in terms of pain relief and improved functional outcomes is limited, and that the risk of opioid overdose increases with increasing dosing This is an algorithm for management of nociceptve pain

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Risk factors:

Chronic kidney disease, advanced age - avoid NSAIDs and COX-2 inhibitors Peptic ulcer disease, glucocorticoid use - avoid NSAIDs Hepatic disease - avoid NSAIDs, COX-2 inhibitors, and acetaminophen (APAP); use TCAs or duloxetine first line Cardiovascular disease or risk - use lowest effective dose of NSAIDs; in patients who require treatment, suggest naproxen NSAID: nonsteroidal anti-inflammatory drug; COX-2: cyclooxygenase 2 inhibitor; APAP: acetaminophen/paracetamol; TCA: tricyclic antidepressant; PPI: proton pump inhibitor.

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Introduction:
A muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics. Neuromuscular blockers act by interfering with transmission at the neuromuscular end plate and have no central nervous system (CNS) activity. They are often used during surgical procedures and in intensive care and emergency medicine to cause paralysis. Spasmolytics, also known as "centrally acting" muscle relaxants, are used to alleviate musculoskeletal pain and spasms and to reduce spasticity in a variety of neurological conditions. While both neuromuscular blockers and spasmolytics are often grouped together as muscle relaxants,the term is commonly used to refer to spasmolytics only. spasmolytics

Spasmolytics: - The generation of the neuronal signals in motor neurons that cause muscle contractions are dependent on the balance of synaptic excitation and inhibition the motor neuron receives. Spasmolytic agents generally work by either enhancing the level of inhibition, or reducing the level of excitation. Inhibition is enhanced by enhancing the actions of endogenous inhibitory substances e.g. GABA

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An image of the spinal cord and muscles showing the action of muscle relaxants or spasmolytics. Black lines ending in arrow heads represent chemicals or actions that enhance the target of the lines. Blue lines ending in squares represent chemicals or actions that inhibit the target of the line. Mechanism of action: Drug Mechanism Baclofen Inhibits monosynaptic and polysynaptic reflexes at the spinal level by hyperpolarization of afferent terminals Additionally acts at supraspinal sites Has general CNS depressant properties Carisoprodol It produces muscle relaxation by blocking interneuronal activity in the descending reticular formation and spinal cord. Acts primarily at the spinal cord level and subcortical areas of the brain, inhibiting multisynaptic reflex arcs involved in producing and maintaining skeletal muscle spasm of varied etiology Relieves skeletal muscle spasm of local origin without interfering with muscle function Ineffective in muscle spasm due to CNS disease dantrolene produced relaxation by affecting contractile response of the skeletal muscle at a site beyond the myoneural junction and directly on the muscle itself. In skeletal muscle, dantrolene dissociates the excitation-contraction coupling, probably by interfering with the release of calcium from the sarcoplasmic reticulum

Chlorzoxazone

Cyclobenzaprine

Dantrolene

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Methocarbamol

May be caused by general CNS depression The drug has no direct action on the contractile mechanism of striated muscle, the motor endplate, or the nerve fiber. Acts centrally at the brain stem Does not directly relax tense skeletal muscles Possesses anticholinergic actions Agonist at alpha2-adrenergic receptor sites Reduces spasticity by increasing presynaptic inhibition of motor neurons

Orphinadrine

Tizanidine

Indications: Drug Baclofen

Indications

For the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms, concomitant pain, clonus, and muscular rigidity
As an adjunct to rest physical therapy other measures for the relief of discomfort associated with acute, painful musculoskeletal conditions For the control of clinical spasticity resulting from upper motor neuron disorders such as spinal cord injury, stroke, cerebral palsy, or multiple sclerosis

Carisoprodol Chlorzoxazone Cyclobenzaprine Dantrolene

Methocarbamol

Orphinadrine Tizanidine

As an adjunct to rest physical therapy other measures for the relief of discomfort associated with acute, painful musculoskeletal conditions For the acute and intermittent management of increased muscle tone associated with spasticity

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Side effects:

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Contraindications: Contraindications and warnings Should be reduced slowly when discontinuing, as hallucinations and seizures have occurred on abrupt withdrawal of the drug. In patients with epilepsy, the clinical state and electroencephalogram should be monitored at regular intervals, since deterioration in seizure control and EEG have been reported occasionally in patients taking baclofen.

Drug Baclofen

Carisoprodol

dependence, withdrawal, and abuse have been reported with prolonged usage
rarely hepatotoxic

Chlorzoxazone Cyclobenzaprine

patients with hyperthyroidism, congestive heart failure, during the acute recovery phase of myocardial infarction, and in patients with arrhythmias and heart block conduction disturbances. Use of cyclobenzaprine in patients with moderate to severe hepatic function impairment is not recommended.
Its hepatotoxic so contraindicated with liver disease. Dantrolene is not for use where spasticity is utilized to sustain upright balance/posture in ambulation or when spasticity is utilized to obtain or maintain increased function.

Dantrolene

Orphinadrine

contraindicated in patients with glaucoma, pyloric or duodenal obstruction, stenosing peptic ulcers, prostatic hypertrophy or obstruction of the bladder neck, and myasthenia gravis concomitant use with ciprofloxacin (Cipro) or fluvoxamine is contraindicated Tizanidine occasionally causes liver injury Tizanidine use has been associated with hallucinations. Upon discontinuation, especially in patients who have been receiving high doses for long periods, decrease the dose slowly to minimize the risk of withdrawal and rebound hypertension, tachycardia, and hypertonia.

Tizanidine

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Dosage: Dose Maximum daily dose 80 mg

Drug Baclofen

Carisoprodol

5 mg three times daily; may be increased by 5 mg/dose every three days as needed to a max of 80 mg/day 250 mg to 350 mg three or four times daily

1,400 mg 750 mg 3-4 times daily 30 mg

Chlorzoxazone 250 mg to 750 mg three or four times daily Cyclobenzaprine 5 mg three times daily, may increase to 10 mg three times daily Dantrolene Initial dose 25 mg every day; increase at 4 to 7 day intervals to 25 mg twice daily to 4 times daily, up to max 100 mg twice daily to 4 times daily if necessary. Maintain each dosage level for four to seven days to determine response. methocarbamol 500 mg tablets: Initial dosage: 3 tablets four times a day. Maintenance dosage: 2 tablets four times a day. methocarbamol 750 mg tablets: Initial dosage: 2 tablets four times a day. Maintenance dosage: 1 tablet every 4 hours or 2 tablets three times a day. 1-2 tablets 3 tames daily after food 4 mg daily, increase dose by 2-4 mg gradually, repeat dose every six to eight hours. Target dose is 8 mg three times daily.

400 mg

Methocarbamol

8g

Orphinadrine Tizanidine

36 mg

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Trade names: Trade Name

Drug Baclofen

Baclofen 10, 25mg tab. Lioresal 10, 25mg tab.

Carisoprodol

Myorelax (carisoprodol 200mg + paracetamol 250mg) cap. Somadril Comp (carisoprodol 200mg + paracetamol 160mg + caffeine 32mg)

Chlorzoxazone

Chlorzoxazone + ketofan: flexofan cap Chlorzoxazone + ibuprofen: myofen, mark-fast etc cap

Chlorzoxazone + paracetamol: myolgin, myolax, myoflex etc cap

Cyclobenzaprine

Multi-Relax 5, 10mg tab.

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Dantrolene

Dantrelax 25mg cap Dantrelax compound cap (plus paracetamol).

Methocarbamol

Dimra & methoquick tab (plus diclophenac K) Methorelax & flexPro extra tab (plus paracetamol) Ibuflex & muslgix (plus ibuprofen)

Orphinadrine

Norflex 100mg tab and amp Norgesic, orphamol tab (plus paracetamol) Relatic tab (plus aspirin)

Tizanidine

Sirdalud 2, 4mg tab Caredalud S.R. 6mg tab S.M.R. 2mg tab

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1. Glucosamine:
Involved in the synthesis of glucosaminoglycan which forms cartilage tissue in the body Also present in tendons and ligaments Must be synthesized incide the body but the ability of synthesis decreases with age Trade names: dorofen, glucosamine, Joflex caps

2. Chondroitin:
Assist in joint lubrication

3. MSM(Methyl Sulphonyl Methane):

-

Natural source of sulphur, needed by joints and muscles Trade names are: MSM 1000mg tab, Joifit 500mg tab

combinations:
Glucosamine+chondroitin: elsticin, chondrogen, glucosaminecomp, move free glucosamine+chondroitin+MSM: Genuphil

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Trypsin and chymotrypsin:

Mechanism: Proteolytic enzymes >> remove coagulated blood and necrotic tissue Chemotrypsin: reduce soft tissues inflammation & edema from abscess, ulcers, trauma..etc Uses: Decrease and treatment of edema and inflammation after trauma, postoperative...etc Local inflammation like venous inflammation, bed sores etc Eye trauma Dosage: 1-2 tablets before meals three times daily Trade names: Alphintern and Ambezim tablets chemotrypsin vials

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Introduction:
In type I hypersensitivity allergic reactions, an allergen (a type of antigen) interacts with and cross-links surface IgE antibodies on mast cells and basophils. Once the mast cell-antibody-antigen complex is formed, a complex series of events that eventually leads to cell degranulation and the release of histamine (and other chemical mediators) from the mast cell or basophile occurs. Once released, histamine can react with local or widespread tissues through histamine receptors. Histamine, acting on H1-receptors, produces pruritus, vasodilation, hypotension, flushing, headache, tachycardia, bronchoconstriction, increase in vascular permeability, potentiation of pain, and more. While H1-antihistamines help against these effects, they work only if taken before contact with the allergen. Antihistamines suppress the histamine-induced wheal response (swelling) and flare response (vasodilatation) by blocking the binding of histamine to its receptors on nerves, vascular smooth muscle, glandular cells, endothelium, and mast cells. They exert a competitive antagonism to histamines. it has been discovered that these H1-antihistamines are actually inverse agonists at the histamine H1-receptor, rather than antagonists In severe allergies, such as anaphylaxis or angioedema, these effects may be so severe as to be life-threatening. Additional administration of epinephrine is required by people with such hypersensitivities. Antihistamines suppress the histamine-induced wheal response (swelling) and flare response (vasodilatation) by blocking the binding of histamine to its receptors on nerves, vascular smooth muscle, glandular cells, endothelium, and mast cells. They exert a competitive antagonism to histamines. It has been discovered that these H1-antihistamines are actually inverse agonists at the histamine H1-receptor, rather than antagonists
H1-antihistamines are clinically used in the treatment of histamine-mediated allergic conditions.

Mechanism of action:

Indications:
-

To be specific, these indications may include: 1. Allergic rhinitis 2. Allergic conjunctivitis 3. Allergic dermatological conditions (contact dermatitis) 4. Urticaria 5. Angioedema 6. Diarrhea 7. Pruritus (atopic dermatitis, insect bites) 8. Anaphylactic or anaphylactoid reactionsadjunct only 9. Nausea and vomiting (first-generation H1-antihistamines) 10. Sedation (first-generation H1-antihistamines)

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a 1955 study of "antihistaminic drugs for colds," carried out by the U.S. Army Medical Corps, reported that "there was no significant difference in the proportion of cures reported by patients receiving oral antihistaminic drugs and those receiving oral placebos. The authors of the American College of Chest Physicians Updates on Cough Guidelines (2006) recommend that, for cough associated with the common cold, first-generation antihistamine-decongestants are more effective than newer, nonsedating antihistamines.

Side effects:
Adverse drug reactions are most commonly associated with the first-generation H1antihistamines. This is due to their relative lack of selectivity for the H 1-receptor. 1st generation: The most common adverse effect is sedation Other common adverse effects in first-generation H1-antihistamines include dizziness, tinnitus, blurred vision, euphoria, uncoordination, anxiety, increased appetite leading to weight gain, insomnia, tremor, nausea and vomiting, diarrhea and antimuscarinic effects (dry mouth, constipation and dry cough). Infrequent adverse effects include urinary retention, palpitations, hypotension, headache, hallucination, and psychosis. 2nd generation: The newer, second-generation H1-antihistamines are far more selective for peripheral histamine H1-receptors and have a far better tolerability profile compared to the first-generation agents. The most common adverse effects noted for second-generation agents include drowsiness, fatigue, headache, nausea and dry mouth. 1st generation (sedating H1 antagonists, antimuscarinic effect and CNS effect) 2nd generation (non-sedating i.e. dont penetrate BBB so have no central side effects) 3rd generation (controversy)

Classifications:
-

I.

First generation antihistamines: 1. Chlorpheniramine maleate: Dosage: 15ml. or one tab 2-3 times daily Trade names: allergy 4mg tab anallerge 4mg tab

2. Clemastin: Has moderate sedative effects and has long duration of action 10-12 hrs. Trade names: tavegyl 1mg tab 2mg amp

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3. Dimethindene: Also has mast cell stabilizing effect Dosage: one tab tds 24 caps >> one cap/24hrs. Trade names: fenistil 1mg tab fenistil 4mg amp fenistil-24 4mg cap

4. Chlorphenoxamine: Has antimuscarinic and antihistaminic properties Used in nausea, vomiting, and vertigo `Trade names: allergex 20mg tab

5. Pheniramine: Has antimuscarinic and antihistaminic properties Trade names: Avil 75mg tab 24.5mg amp

6. Mequitazine: Dosage: one tab/12 hrs. Trade names: primalan 5mg tab

Triactin 4mg tab: Active ingredient is cyproheptadine has antiserotenin effect and appetite stimulant effect

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Adwisomn 25mg cap and donormyl 15mg tab: Active ingredient is doxylamine succinate has anti-allergy power superior to almost every other antihistamine

on the market, with the exception of diphenhydramine

Used in treatment of insomnia The dosage required to induce sleep can be as low as 6.25 mg, but is usually effective in dosages of up to 25 mg. Higher doses are not recommended by the United States Food and Drug Administration, although single dosage recommendations of up to 50 mg are common in some countries, including Australia Diphenhydramine: Despite being one of the oldest antihistamines on the market, it is more effective than even some of the latest prescription drugs. Consequently, it is frequently used when an allergic reaction requires fast, effective reversal of the often dangerous effects of a massive histamine release. Used also in motion sickness and insomnia Trade names: dramenex 50mg tab sultan 50mg cap Dosage: 2-3 times daily for sleep taken once 20 min. before bedtime II. Second generation antihistamines: 1. Cetirizine: Reduce the dose for hepatic and renal patients CI in pregnancy and lactation Dosage: 10mg in a single dose at the evening Trade names: Alerid, Cetrak, Cetritin, Histazine-1, Zyrtec .etc 10mg tablets

2. Loratadine: Metabolized by cytochrome P so should be avoided in drugs which inhibit these enzymes e.g. cimetidine, ketoconazole, fluconazole, erythromycin, fluoxetine etc Reduce the dose for severe hepatic impairment patient CI in pregnancy and lactation Dosage: 10mg once daily Trade names: claritin, mosedin, loratin, loratan .etc (10mg tablets)

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3. Ebastine: Dosage: 10mg daily may be taken with or without food Trade names: astin 10, 20mg tab evastine 10mg tab Has a favourable safety profile III. Third generation antihistamines: 1. Levocetirizine: Trade names: allevo, allear etc 5mg tablets

2. Desloratadine: Trade names: aerius, delarex etc 5mg tablets

3. Fexofenadine HCl: Trade names: Alertam: 60, 180mg tab Allerfen: 60, 180mg tab Fastel: 120, 180mg tab Telfast: 120, 180mg tab Fexon: 120, 180mg tab Dosage: Adults: 60 mg twice daily or 180 mg once daily Elderly: Starting dose: 60 mg once daily

N.B. However, there is little evidence for any advantage of 3 rd generation antihistamines compared to 2nd generation antihistamines. There is some controversy associated with the use of this term. Other non-sedating antihistamine is Allergex Caffeine with active ingredient chlorpheniramine maleate 20mg + caffeine 50mg (reduce the sedation of chlorpheniramine maleate) and dose is one tab 2-3times daily

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Introduction: - Immunosuppressive agents are drugs that inhibit or prevent activity of the immune system. They are used in immunosuppressive therapy to: Prevent the rejection of transplanted organs and tissues (e.g., bone marrow, heart, kidney, liver) Treat autoimmune diseases or diseases that are most likely of autoimmune origin e.g. rheumatoid arthritis multiple sclerosis myasthenia gravis systemic lupus erythematosus sarcoidosis focal segmental glomerulosclerosis Crohn's disease Behcet's Disease pemphigus ulcerative colitis Treat some other non-autoimmune inflammatory diseases (e.g., long term allergic asthma control).

A common side-effect of many immunosuppressive drugs is immunodeficiency, because the majority of them act non-selectively, resulting in increased susceptibility to infections and decreased cancer immunosurveillance. There are also other side-effects, such as hypertension, dyslipidemia, hyperglycemia, peptic ulcers, lipodystrophy, moon face, liver and kidney injury. We will talk about some common immunosuppressive drugs: Glucocorticoids Azathioprine Methotrexate

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I. Glucocorticoids:
Introduction: - Natural and synthetic glucocorticoids are used in both endocrine and nonendocrine disorders. - In endocrine practice, glucocorticoids are given only to establish the diagnosis and cause of Cushing's syndrome and for treatment of adrenal insufficiency and congenital adrenal hyperplasia. - Pharmacologic doses of glucocorticoids are used to treat patients with inflammatory, allergic, immunological disorders. If chronic, this supra-physiologic therapy has many adverse effects, ranging from suppression of the hypothalamicpituitary-adrenal axis and Cushing's syndrome to infections and changes in mental status. Therapeutic uses of glucocorticoids: - Glucocorticoids may be used in low doses in adrenal insufficiency. In much higher doses, oral or inhaled glucocorticoids are used to suppress various allergic, inflammatory, and autoimmune disorders. They are also administered as post-transplantory immunosuppressants to prevent the acute transplant rejection and the graft-versus-host disease. Physiological replacement: Any glucocorticoid can be given in a dose that provides approximately the same glucocorticoid effects as normal cortisol production; this is referred to as physiologic, replacement, or maintenance dosing. This is approximately 612 mg/m/day (m refers to body surface area (BSA), and is a measure of body size; an average man's BSA is 1.7 m) Therapeutic immunosuppression: Glucocorticoids cause immunosuppression, and the therapeutic component of this effect is mainly the decreases in the function and numbers of lymphocytes, including both B cells and T cells. Anti-inflammatory: Glucocorticoids are potent anti-inflammatories, regardless of the inflammation's cause Glucocorticoids marketed as anti-inflammatories are often topical formulations, such as nasal sprays for rhinitis or inhalers for asthma. These preparations have the advantage of only affecting the targeted area, thereby reducing side effects or potential interactions. (revise ICS in respiratory chapter)

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Guidelines for pharmacological glucocorticoid therapy in general: - Initiate only if there is published evidence of objective therapeutic benefit - Use only after other specific therapies fail - Identify a specific therapeutic objective - Use objective criteria of response - Administer sufficient glucocorticoid for a sufficient time to achieve the desired response - Administer no more glucocorticoid for no longer than is necessary to achieve the desired response - Terminate if objective therapeutic benefit is not observed when expected, if complications arise, or if maximum benefit has been achieved Side effects: - Numerous toxicities, or adverse effects (AEs), have been attributed to glucocorticoids - Other factors that may contribute to such AEs include the nature and severity of the underlying disease being treated and the other medications being administered concurrently. - The adverse effects (AEs) of glucocorticoids are more common in patients receiving these drugs in high doses or over a long period of time.

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Withdrawal: - Short-term glucocorticoid therapy (up to three weeks), even if at a fairly high dose, can simply be stopped and need not be tapered. - HPA suppression due to glucocorticoid use of this duration will not persist and is highly unlikely to have any clinical consequence. - However, in a frail or dangerously ill patient, the clinician may elect to proceed more cautiously as noted below - In patients who have taken a glucocorticoid for a longer time, we suggest a regimen which is largely based upon experience and rests upon the following assumptions: Factors of age, frailty, concomitant illnesses, dangerousness and likelihood of flare of underlying illness, psychological factors, and duration of previous use of glucocorticoids are taken into account. The disease is sufficiently stable so that tapering of the dose is appropriate. The patient has received long-term steroid therapy, not recurrent "pulses" as might be used in asthma. The observation that HPA suppression is uncommon at prednisone doses below 5 mg/day. The goal of tapering is to use a rate of change that will prevent both recurrent activity of the underlying disease and symptoms of cortisol deficiency due to persistent HPA suppression. We generally aim for a relatively stable decrement of 10 to 20 percent, while accommodating convenience and individual patient response. The dose is tapered by: 5 to 10 mg/day every one to two weeks from an initial dose above 40 mg of prednisone or equivalent per day. 5 mg/day every one to two weeks at prednisone doses between 40 and 20 mg/day. 2.5 mg/day every two to three weeks at prednisone doses between 20 and 10 mg/day. 1 mg/day every two to four weeks at prednisone doses between 10 and 5 mg/day. 0.5 mg/day every two to four weeks at prednisone doses from 5 mg/day down. This can be achieved by alternating daily doses, eg, 5 mg on day 1 and 4 mg on day 2. This regimen will generally prevent symptoms of cortisol deficiency.

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Preparations: - A variety of synthetic glucocorticoids, some far more potent than cortisol, have been created for therapeutic use. - They differ in both pharmacokinetics (absorption factor, half-life, volume of distribution, clearance) and pharmacodynamics (for example the capacity of mineralocorticoid activity: retention of sodium (Na+) and water; renal physiology). - Because they permeate the intestines easily, they are administered primarily per os (by mouth), but also by other methods, such as topically on skin. - Glucocorticoid potency, duration of effect, and overlapping mineralocorticoid potency varies. - Cortisol (hydrocortisone) is the standard of comparison for glucocorticoid potency. - Hydrocortisone is the name used for pharmaceutical preparations of cortisol. - Oral potency may be less than parenteral potency because significant amounts (up to 50% in some cases) may not be absorbed from the intestine.

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Trade names: Hydrocortisone: Suitable for short term treatment only Dosage: one vial IM or IV can be repeated according to the case Trade name: Solu-Cortef vial Prednisone: Dosage: usually 30-60mg daily Trade name: Hostacortin 5mg tab Prednisolone: Dosage: usually 30-60mg daily Trade name: Hostacortin-H 5mg, predilone 5mg tab, solupred 5 & 20mg tab Methyl Prednisolone: Dosage: 16-40mg daily divided into 2-3 doses Trade name: Depo Medrol 40, 1000mg vial M.P.A. 40mg vial Urbasone 4, 8mg tab

Betamethasone: Trade name: Betasone 0.5mg tab Betafos IM, intra-articular, intralesional ampoule Diprofos ampoules

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Dexamethasone: Trade name: Tablets: deltasone 0.75mg dexazone, orazone 0.5mg Injection: dexamethasone, dexonium, fortecortin 8mg ampoules epidron 4mg vial Triamcinolone: Trade name: Amcinol, Kenacort-A 40mg vial Kenacort-A 4mg tab

II. Azathoprine:
Mechanism of action: - Azathioprine acts as a pro-drug for mercaptopurine, inhibiting an enzyme that is required for the synthesis of DNA. Thus it most strongly affects proliferating cells, such as the T cells and B cells of the immune system. Medical uses: Azathioprine is used alone or in combination with other immunosuppressive therapy to: - Prevent rejection following organ transplantation - Treat an array of autoimmune diseases, including rheumatoid arthritis (disease modifying agent), pemphigus, systemic lupus erythematosus,Behet's disease, autoimmune hepatitis, atopic dermatitis, myasthenia gravis,neuromyelitis optica (Devic's disease), restrictive lung disease, and others. - It is also an important therapy and steroid-sparing agent for inflammatory bowel disease (such asCrohn's disease and ulcerative colitis) and for multiple sclerosis, which are immune-mediated as well. - In the United States it is currently approved by the Food and Drug Administration (FDA) for use in kidney transplantation from human donors, and for rheumatoid arthritis. - Other uses are off-label. Side effects:
Nausea and vomiting are common adverse effects, especially at the beginning of a treatment. Side effects that are probably hypersensitivity reactions include dizziness, diarrhea, fatigue, and skin rashes. Because azathioprine suppresses the bone marrow, patients can develop anaemiaand will be more susceptible to infection; regular monitoring of the blood count is recommended during treatment Acute pancreatitis can also occur, especially in patients with Crohn's disease.

Drug interaction: Allopurinol inhibit xanthine oxidase, the enzyme that breaks down azathioprine, thus increasing the toxicity of azathioprine - Azathioprine decreases the effects of the anticoagulant warfarin

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Trade names: - Azathioprine Ait, Imuran 50mg tablets

III. Methotrexate:
Mechanism of action: It acts by inhibiting the synthesis of folic acid, therefore, inhibits the synthesis of DNA, RNA, thymidylates, and proteins. - Inhibition ofenzymes involved in purine metabolism, leading to accumulation of adenosine, or the inhibition of T cell activation and suppression ofintercellular adhesion molecule expression by T cells so helps in the treatment of rheumatoid arthritis Medical uses: - Chemotherapy: Methotrexate was originally developed and continues to be used for chemotherapy either alone or in combination with other agents. It is effective for the treatment of a number ofcancers including: breast, head and neck, leukemia, lymphoma, lung, osteosarcoma, bladder, and trophoblastic neoplasms - Autoimmune diseases: It is used as a treatment for some autoimmune diseases, including rheumatoid arthritis (disease modifying agent),psoriasis, psoriatic arthritis, lupus and Crohn's disease, to name a few. Although methotrexate was originally designed as a chemotherapy drug (in high doses), in low doses methotrexate is a generally safe and well tolerated drug in the treatment of certain autoimmune diseases. Because of its effectiveness, low-dose methotrexate is now first-line therapy for the treatment of rheumatoid arthritis. - Therapeutic abortion: Methotrexate is commonly used (generally in combination with misoprostol) to terminate pregnancies during the early stages. It is also used to treat ectopic pregnancies. Side effects: - The most common adverse effects include: ulcerative stomatitis low white blood cell count and thus predisposition to infection Nausea Abdominal pain Fatigue Fever

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Dizziness Acute pneumonitis Rarely pulmonary fibrosis. Bone marrow depression

Trade names: - Methotrexate tablets and vials

IV. Hydroxychloroquine:
Medical uses: - Hydroxychloroquine is classified as an anti-malarial medication and is one of a number of drugs that have been used for many years in the treatment of malaria. - It is also useful (i.e. reduce inflammation) in treating systemic lupus erythematosus, rheumatic disorders like rheumatoid arthritis (disease modifying agent) and Sjgren's Syndrome. Side effects: The most common side effects are a mild nausea and occasional stomach cramps with mild diarrhea. Generally side effects are not common, but can include (for short-term treatment of acute malaria) abdominal cramps, diarrhea, heart problems, reduced appetite, headache, nausea and vomiting. The symptoms for prolonged treatment of lupus or arthritis include the acute symptoms, plus altered eye pigmentation, acne, anemia, bleaching of hair, blisters in mouth and eyes, blood disorders, convulsions, significant vision difficulties, diminished reflexes, emotional changes, excessive coloring of the skin, hearing loss, hives, itching, liver problems or failure, loss of hair, muscle paralysis, weakness or atrophy, nightmares, psoriasis, reading difficulties, tinnitus, skin inflammation and scaling, skin rash, vertigo, and weight loss. Hydroxychloroquine can worsen existing cases of both psoriasis and porphyria. One of the most serious side effects is toxicity in the eye (generally with chronic use).

Dosage: - One tablets twice daily initially to be reduced to one tablet daily at maintenance Trade names: - Plaquenil 250mg tab - Hydroquine 200mg tab

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V. Leflunomide:
Mechanism of action: - Immunomodulatory agent with antiproliferative & anti-inflammatory effect Medical uses: - Used in active moderate to severe rheumatoid arthritis and psoriatic arthritis. To reduce signs and symptoms To inhibit structural damage as evidenced by X-ray erosions and joint space narrowing To improve physical function. The onset of clinical improvement can be expected after 4 to 6 weeks of continued therapy. Aspirin, or other nonsteroidal anti-inflammatory agents (NSAR), and/or low-dose corticosteroids may be continued during treatment with leflunomide. The combined use of leflunomide with antimalarials, intramuscular or oral gold, D-penicillamine, azathioprine, ormethotrexate has not been adequately studied and is, therefore, contraindicated - Leflunomide has recently been assigned orphan drug status (i.e. a pharmaceutical agent that has been developed specifically to treat a rare medical condition, the condition itself being referred to as an orphan disease) for the prevention of solid-organ rejection after allograft transplantations when co-administered with commonly used first-line agents (USA only). Side effects:
Most serious is symptomatic liver damage ranging from jaundice to hepatitis, which can be fulminant, severe liver necrosis, and liver cirrhosis. Also very important is a relatively high incidence of myelosuppression with leukopenia, and/or hypoplastic anemia, and/orthrombocytopenia. Interstitial lung disease may occasionally be noticed Other sites are: GIT, skin reactions, heart problems, alopecia (17%), CNS troubles etc.

Dosage: - Loading dose 100mg daily for 3 days then maintenance dose s 20mg daily Trade name: - Arthfree 20, 100mg tab - Avara 10, 20, 100mg tab - Others: apetoid, rafix, vamid etc

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I. Hyper function of the thyroid gland:

Carbimazole: - Mechanism of action: Carbimazole is a pro-drug as after absorption it is converted to the active form, methimazole. Methimazole prevents the thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4 (thyroxine). - Medical uses: Used to treat hyperthyroidism. The onset of anti-thyroid effect is rapid but the onset of clinical effects on thyroid hormone levels in the blood is much slower. This is because the large store of preformed T3 and T4 in the thyroid gland and bound to thyroid binding globulin (99% bound) has to be depleted before any beneficial clinical effect occurs. - Side effects: Rashes and pruritus are common; these can often be treated with antihistamines without stopping the carbimazole. For those patients where sensitivity reactions cannot be controlled, propylthiouracil may be used as an alternative. Its most serious rare side effect is bone marrow suppression causing neutropenia and agranulocytosis. This may occur at any stage during treatment and without warning; monitoring of white cell count is not useful. Patients are advised to immediately report symptoms of infection, such as sore throat or fever, so that a full blood count test may be arranged. If this confirms a low neutrophil count, discontinuation of the drug leads to recovery. - Dosage: Generally starts at a high daily dose of 1540 mg continued until the patient has normal thyroid function, and then reduced to a maintenance dose of 515 mg. Treatment is usually given for 1218 months followed by a trial withdraw. - Trade names: Carbimazol & Neomercazol 5mg tablets

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Propylthiouracil: - Mechanism of action: Central: PTU inhibits the enzyme thyroperoxidase, which normally acts in thyroid hormone synthesis. This is one of the essential steps in the formation of thyroxine (T4) Peripheral: PTU also acts by inhibiting the enzyme 5'-deiodinase, which converts T4 to the active form T3. This is in contrast to methimazole, which shares propylthiouracil's central mechanism, but not its peripheral one. - Medical uses: Used in treatment of hyperthyroidism - Side effects: The most common side effects are related to the skin, and include rash, itching, hives, abnormal hair loss, and skin pigmentation. Other common side effects are swelling, nausea, vomiting, heartburn, loss of taste, joint or muscle aches, numbness and headache, allergic reactions, and hair whitening. One possible side effect is agranulocytosis, a decrease of white blood cells in the blood. Symptoms and signs of agranulocytosis include infectious lesions of the throat, the gastrointestinal tract, and skin with an overall feeling of illness and fever. A decrease in blood platelets (thrombocytopenia) also may occur. Since platelets are important for the clotting of blood, thrombocytopenia may lead to problems with excessive bleeding. A more life threatening side effect is sudden, severe, fulminant hepatic failure resulting in death or liver transplantation, which occurs in up to 1 in 10,000 people taking propylthiouracil. Unlike agranulocytosis which most commonly occurs in the first three months of therapy, this side effect may occur at any time during treatment - Dosage: Initial: 100 to 150 mg orally every 8 hours. Rarely, a patient may require 200 to 300 mg orally every 8 hours. Initial doses are continued until 2 months after symptoms are fully controlled. Maintenance: 100 to 150 mg/day in equally divided doses every 8 to 12 hours. Therapy is usually continued until spontaneous remission occurs (up to 1 to 2 years) or ablative therapy is undertaken. - Trade name: Thyrocil 50mg tablet

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II. Hypo function of the thyroid gland:

Thyroxin: - Medical uses: Thyroid hormone replacement in cases of hypothyroidism - Side effects: Overdose produce symptoms of hyperthyroidism e.g. palpitation, sweating, irritability etc - Dosage: 50-100 g daily before food Increased or decreased according to patient response Maximum daily dose is 300 g - Trade names: Eltroxin 50, 100 g tablets T4-Thyro 50, 100 g tablets

Levothyroxine:
Is a synthetic form of the thyroid hormone thyroxine, which is normally secreted by the follicular cells of the thyroid gland. Medical uses: Levothyroxine is typically used to treat hypothyroidism. It may also be used to treat goiter via its ability to lower thyroid-stimulating hormone (TSH), a hormone that is considered goiter-inducing. Occasionally to prevent the recurrence of thyroid cancer. Side effects: The same as thyroxin Acute massive overdose may be life-threatening; treatment should be symptomatic and supportive. Massive overdose may require beta-blockers for increased parasympathetic activity. The effects of overdosing appear 6 hours to 11 days after ingestion. Dosage: Euthyroid goiter: 75-200 g Thyroid hormone replacement: initially 25-50 g daily and maintenance dose is 100-200 g daily For suppression of thyroid cancer recurrence: 150-300 g daily Trade names: Euthyrox 50, 100 g tablets

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HINTS ON CNS

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I. Anticonvulsants:
Introduction: - The anticonvulsants (also commonly known as antiepileptic drugs) are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. - Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers, and for the treatment of neuropathic pain. - The goal of an anticonvulsant is to suppress the rapid and excessive firing of neurons that start a seizure. - Failing this, an effective anticonvulsant would prevent the spread of the seizure within the brain and offer protection against possible excitotoxic effects, that may result in brain damage. - In epilepsy, an area of the cortex is typically hyper-irritable. - This condition can often be confirmed by completing a diagnostic EEG. - Antiepileptic drugs function to help reduce this area of irritability and thus prevent epileptiform seizures. - The major molecular targets of marketed anticonvulsant drugs are voltage-gated sodium channels and components of the GABA system. - Additional targets include voltage-gated calcium channels.

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Carbamazepine(CBZ): - Mechanism of action: Carbamazepine stabilizes the inactivated state of Voltage-gated sodium channels, making fewer of these channels available to subsequently open. This leaves the affected cells less excitable until the drug dissociates. Carbamazepine has also been shown to potentiate GABA receptors - Medical uses: Carbamazepine is typically used for the treatment of seizure disorders and neuropathic pain. It may be used as a second line treatment for bipolar disorder and along with antipsychotic agents in schizophrenia. - Side effects: Common adverse effects may include drowsiness, headaches and migraines, motor coordination impairment, and/or upset stomach. Carbamazepine preparations typically greatly decrease a person's alcohol tolerance. Less common side-effects may include cardiac arrhythmias, blurry or double vision and/or the temporary loss of blood cells or platelets and in rare cases can cause aplastic anemia. With normal use, small reductions in white cell count and serum sodium are common; however, in rare cases, the loss of platelets may become lifethreatening. - Dosage: Starting dose is 100-200mg daily increased gradually to maximum 800-1200mg daily on two divided doses - Trade names: Tegretol 200, 400mg tab Neurotop 200, 400mg neurotop ret. 300, 600mg tab Others: mazemal 200mg tab, tegral 200mg tab etc

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Oxacarbazepine: - A derivative of carbamazepine, reportedly has fewer and less serious side-effects. - Dosage: 300-600mg daily - Trade names: Trileptal 150, 300, 600mg tab Oxaleptal 600mg tab Sodium Valproate: - Mechanism of action: Sodium valproate is a weak blocker of sodium ion channels; it is also a weak inhibitor of enzymes that deactivate GABA such as GABA transaminase. It may also stimulate the synthesis of GABA, but the direct mechanism is not known. Because of its many mechanisms of action, sodium valproate has efficacy in all partial and generalised seizures including absence seizures. - Medical uses: Used in the treatment of epilepsy Anorexia nervosa, panic attack, anxiety disorder, posttraumatic stress disorder, migraine and bipolar disorder, as well as other psychiatric conditions requiring the administration of a mood stabilizer. Sodium valproate can be used to control acute episodes of mania and acute stress reaction. - Side effects: The common adverse effects include tiredness, tremor, sedation and gastrointestinal disturbances. In addition, about 10% of the users experience reversible hair loss. - Dosage: 15-30mg/kg/day - Trade names: Depakine: 200mg tab chrono 500mg tab Convulex: 150, 300, 500 cap

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Phenytoin sodium: - Mechanism of action: Phenytoin acts to suppress the abnormal brain activity seen in seizure by reducing electrical conductance among brain cells by stabilizing the inactive state of voltage-gated sodium channels. - Medical uses: A commonly used antiepileptic. Aside from seizures, it is an option in the treatment of trigeminal neuralgia in the event that carbamazepine or other first-line treatment seems inappropriate. - Side effects: CNS: At therapeutic doses, phenytoin may produce horizontal gaze nystagmus. At toxic doses, patients experience sedation, cerebellar ataxia, and ophthalmoparesis, as well as seizures Blood: Reduction in folic acid levels, predisposing patients to megaloblastic anemia. Other side effects may include: agranulocytosis, aplastic anemia, leukopenia, and thrombocytopenia. Phenytoin is a known teratogen. gingival enlargement Hypertrichosis, rash, exfoliative dermatitis, pruritis, Hirsuitism, and coarsening of facial features Phenytoin has been known to cause drug-induced lupus. - Dosage: 150mg daily increased gradually to maxium 300-400mg daily into two divided doses Trade names: Ipanten, Phenytoin 50, 100mg cap Epanutin, phenytin .etc

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Gabapentin: - Mechanism of action: Not yet fully understood Specifically a GABA analogue. The mechanism of action that leads to its rapid analgesic effect is simply unknown. Some of its activity may involve interaction with voltage-gated calcium channels. Another possible mechanism of action is that gabapentin halts the formation of new synapses. Medical uses: Gabapentin is used primarily for the treatment of seizures, neuropathic pain, and hot flashes. There are, however, concerns regarding the quality of the research on its use to treat migraines, bipolar disorders, and pain. When used for neuropathic pain it does not appear superior to carbamazepine. It appears to be equally effective as pregabalin and is of lower cost. Side effects: Gabapentin's most common side effects in adult patients include dizziness, fatigue, weight gain, drowsiness, and peripheral edema (swelling of extremities). These mainly occur at higher doses in the elderly. Children 312 years of age were observed to be susceptible to mild-to-moderate mood swings, hostility, concentration problems, and hyperactivity. Although rare, there are several cases of hepatotoxicity reported. Gabapentin should be used carefully in patients with renal impairment due to possible accumulation and toxicity. Dosage: 300-400mg once daily increased within two days to 800mg if needed Trade names: Gaptin, Conventin 100mg, 300mg, 400mg caps

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Pregabalin: - A successor of gabapentin. - Compared to gabapentin, pregabalin is more potent, absorbs faster and has greater bioavailability. - Higher potency means that less of the medication is required for the same effect. This does not necessarily result in fewer side effects - Medical uses: Treatment of epilepsy (adjunctive therapy for adults with partial onset seizures) Neuropathic pain associated with diabetes and with spinal cord injury Fibromyalgia, post-herpetic neuralgia, and generalized anxiety disorder. Treatment of Generalized anxiety disorder.The anxiolytic effects of prebabalin occur rapidly after administration, similar to the benzodiazepines, which gives pregabalin an advantage over many anxiolytic medications. Pregabalin is also used off-label for the treatment of chronic pain, neuropathic pain, perioperative pain, and migraine Side effects: Very common (>10% of patients): Dizziness & drowsiness. Common (110% of patients): blurred vision, diplopia, increased appetite, euphoria, confusion, vivid dreams, changes in libido (increase or decrease), irritability, ataxia, attention changes, abnormal coordination, memory impairment, tremors, dysarthria, parasthesia, vertigo, dry mouth and constipation, vomiting and flatulence, erectile dysfunction, fatigue, peripheral edema, drunkenness, abnormal walking, weight gain, asthenia, nasopharyngitis, increased creatine kinase level. Infrequent (0.11% of patients): depression, lethargy, agitation, anorgasmia, hallucinations, myoclonus, hypoaesthesia, hyperaesthesia, tachycardia, excessive salivation, sweating, flushing, rash, muscle cramp, myalgia, arthralgia, urinary incontinence, dysuria, thrombocytopenia, kidney calculus Rare (<0.1% of patients): neutropenia, first degree heart block, hypotension, hypertension, pancreatitis, dysphagia, oliguria, rhabdomyolysis, suicidal thoughts or behavior. Pregabalin may also cause withdrawal effects after long-term use if discontinued abruptly. Withdrawal symptoms include restlessness, insomnia, and anxiety. Pregabalin should be reduced gradually when finishing treatment. Because of complication risk associated with certain common side-effects in patients affected by other health issues, Pregabalin should not be used without regular medical supervision and any side effect should immediately be reported.

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Dosage: Pregabalin may be taken with or without food. Neuropathic pain: The initial dose is 50 mg three times a day (150 mg/day). The dose may be increased to a maximum dose of 100 mg 3 times daily (300 mg/day) after one week. Post herpetic neuralgia: The recommended dose is 75-150 mg twice daily or 50-100 mg three times daily. Begin dosing at 75 mg two times a day or 50 mg three times a day (150 mg/day). The dose may be increased to 100 mg 3 times daily (300 mg/day) after one week. If pain relief is inadequate after 2-4 weeks of treatment at 300 mg/day, the dose may be increased to 300 mg twice daily or 200 mg three times daily. Doses greater than 300 mg cause more side effects. Seizures: The recommended dose is 150-600 mg/day divided into 2 or 3 doses, starting at 150 mg daily and increasing based on response and tolerability. Fibromyalgia: 300-450 mg/day in 2 or 3 divided doses. Overdose: Several renal failure patients developed myoclonus while receiving pregabalin, apparently as a result of gradual accumulation of the drug. Acute overdosage may be manifested by somnolence, tachycardia and hypertonicity. Plasma, serum or blood concentrations of pregabalin may be measured to monitor therapy or to confirm a diagnosis of poisoning in hospitalized patients. Trade names: Lyrica: 75, 150mg caps Kemirica: 75, 150, 300mg caps Painica: 75, 150mg caps Pregdin Apex: 50, 100mg tab Pregavalex: 150mg caps Gablovac: 50mg caps

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II. Nootropic drugs:

Drugs that purportedly improve mental functions such as cognition, memory, intelligence, motivation, attention, and concentration. Piracetam: - Mechanism of action: Not well understood May protect cerebral cortex from hypoxia - Medical uses: Memory disturbances Loss of concentration Increase mental performance in aged people, stroke, chronic ischemia Decrease platelet aggregation and increase RBCs deformability in cases of clotting, coagulation, and vasospastic disorders such as Raynaud's phenomenon and deep-vein thrombosis. - Side effects: Insomnia Weight gain Hyperkinesia, nervousness and depression - Dosage: 1200-2400mg daily divided into 2-4 doses - Trade names: Nootropil: 400mg caps, 800mg tab, 1000mg ampoules Stimulan: 400mg caps, 800mg tab, 1000mg ampoules Neurocet 400mg caps Memoral 1000mg ampoules Vincamine: - Actions: A peripheral vasodilator that increases blood flow to the brain and utilization of oxygen - medical uses: Vincamine is often used as a nootropic agent to combat the effects of aging, or in conjunction with other nootropics (such as piracetam) for a variety of purposes. - Dosage: One capsule 2 times daily - Trade names: Brain OX 30mg caps Oxybral 30mg caps, 15mg ampoules 126 | P a g e

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Vinpocetine: - A derivative of vincamine - Used in cerebrovascular disorders and dementia - Dosage: one tab tds after meals - Trade names: Acapi-Cav, Angiovan, vinporal etc 5mg tab

Meclofenxate: - Actions: It aid cellular metabolism in the presence of diminished oxygen concentration Medical uses: In elderly patients, it has been clinically shown to improve memory, have a mentally stimulating effect, and improve general cognition. Used to treat the symptoms of senile dementia and Alzheimer's disease. Dosage: One tablet tds Trade names: Lucidril 250, 500mg tab 1000mg amp LuciForte 500mg vials il

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