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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

● Introduction 97 ●

● Introduction 97 ● Garlic 97 ● Ginseng 98 ● Ginkgo biloba 99 ● Echinacea 99 ● Soy 99 CHAPTER 17 ALTERNATIVE MEDICINES: HERBALS AND NUTRACEUTICALS INTRODUCTION ‘Alternative’ therapies (i.e. alternative to licensed products of proven quality, safety and efficacy) span a huge range from frank charlatanry (e.g. products based on unscientific postulates, composed of diluent or of snake oil), through physical therapies such as massage and aroma therapies which certainly please (‘placebo’ means ‘I will please’) and do a great deal less harm than some conventional therapies (e.g. surgery, chemotherapy), through to herbal medications with undoubted pharmacological activity and the potential to cause desired or adverse effects, albeit less predictably than the licensed products that have been derived from them in the past and will no doubt be so derived in the future. Medicine takes an empirical, evidence-based view of therapeutics and, if supported by sufficiently convincing evidence, alternative therapies can enter the mainstream of licensed products. Overall, efforts to test homeopathic products have been negative (Ernst, 2002) and it has been argued that no more resource should be wasted on testing products on the lunatic fringe, even when they come with royal endorsement and (disgracefully) public funding. Here we focus on herbal and nutraceutical products that may cause pharmacological effects. Herbal remedies include dietary supplements (any product other than tobacco intended for ingestion as a supplement to the diet, including vitamins, minerals, anti-oxidants – Chapter 35 – and herbal products), phytomedicines (the use of plants or plants components to achieve a therapeutic effect/outcome) and botanical medicines (botanical supplements used as medicine). The recent increase in the use of herbal remedies by normal healthy humans, as well as patients, is likely to be multifactorial and related to: (1) patient dissatisfaction with conventional medicine; (2) patient desire to take more control of their medical treatment; and (3) philosophical/cultural bias. In the USA, approximately one-third of the population used some form of complementary or alternative medicine (the majority consuming herbal products) in the past 12 months. At a clinical ● Saw palmetto 100 ● St John’s wort 100 ● Glucosamine 101 ● Miscellaneous herbs recently found to be toxic or meriting their withdrawal from the market 101 therapeutic level, it is disconcerting that 15–20 million Americans regularly take herbal remedies, while concomitantly receiving modern prescription drugs, implying a significant risk for herb–drug interactions. In Scotland, some 12% of general practitioners and 60% of general practices prescribe homeopathic medicines! Herbal remedies are particularly used by certain groups of patients, notably HIV and cancer patients. The stereotypical user is a well-educated, career professional, white female. From a therapeutic perspective, many concerns arise from the easy and widespread availability, lack of manufacturing or regulatory oversight, potential adulteration and contamination of these herbal products. Furthermore, there is often little or no rigorous clinical trial evidence for efficacy and only anecdotes about toxicity. Many patients who are highly attuned to potential harms of conventional drugs (such as digoxin, a high quality drug derived historically from extracts of dried foxglove of variable quality and potency) fail to recognize that current herbals have as great or greater potential toxicities, often putting their faith in the ‘naturalness’ of the herbal product as an assurance of safety. This chapter briefly reviews the most commonly used herbals (on the basis of sales, Table 17.1) from a therapeutic perspective and addresses some of the recently identified problems caused by these agents. GARLIC Garlic has been used as a culinary spice and medicinal herb for thousands of years. One active compound in garlic is allicin, and this is produced along with many additional sulphur compounds by the action of the enzyme allinase when fresh garlic is crushed or chewed. Initial clinical trials suggested the potential of garlic to lower serum cholesterol and triglyceride, but a recent trial has shown limited to no benefit. Garlic has been advocated to treat many conditions, ranging from many cardiovascular diseases, e.g. atherosclerosis including peripheral vascular disease, hypertension, lipid disorders and sickle

98 ALTERNATIVE MEDICINES: HERBALS AND NUTRACEUTICALS cell anaemia. Garlic can alter blood coagulability by decreasing platelet aggregation and increasing fibrinolysis. Adverse effects The adverse effects of garlic use involve gastro-intestinal symptoms including halitosis, dyspepsia, flatulence and heartburn. Other reported adverse effects include headache, haematoma and contact dermatitis. Drug interactions Garlic inhibits many drug-metabolizing (CYP450) enzymes in vitro, but induces CYP450s when administered chronically in vivo (reminiscent of many anticonvulsant drugs – Chapter 22 – as well as ethanol). Clinical studies using probe-drug cocktails have shown that garlic has no significant effect on the activity of CYP1A2 (caffeine), CYP2D6 (debrisoquine, dextromethorphan) and CYP3A4 (alprazolam, midazolam). Clinical studies suggest that garlic significantly decreases the bioavailability of saquinavir and ritonavir. These HIV protease inhibitors are not only metabolized by CYP3A4, but are also substrates for P-glycoprotein. The clinical importance of these interactions is uncertain, but potentially appreciable. GINSENG Table 17.1: Most commonly used herbal products based on dollar sales Product Plant Intended condition to Annual sales in be used for USA ($ millions) Garlic Allium sativum Hyperlipidaemia– hypercholesterolaemia 34.5 Ginkgo Ginkgo biloba Dementia and claudication 33.0 Echinacea Echinacea purpurea Prevention of common cold 32.5 Soy Glycine max Symptoms of menopause 28.0 Saw palmetto Serenoa repens Prostatic hypertrophy 23.0 Ginseng Panax ginseng Fatigue 22.0 St John’s wort Hypericum perforatum Depression (mild) 15.0 Black cohosh Actaea racemosa Menopausal symptoms 12.3 Cranberry Vaccinia macrocarpon Cystitis and UTI 12.0 Valerian Valeriana officinalis Stress and sleeplessness 8.0 Milk thistle Silybum marianum Hepatitis and cirrhosis 7.5 Evening primrose Oenothera biennis Premenstrual symptoms 6.0 Bilberry Vaccinia myrtillus Diabetic retinopathy 3.5 Grape seed Vitis vinifera Allergic rhinitis 3 UTI: urinary tract infection There are several types of ginseng (Siberian, Asian, American and Japanese), the most common type used in herbal preparations being the Asian variety (Panax ginseng). In humans, ginseng has been suggested to be a sedative-hypnotic, an aphrodisiac, an antidepressant and a diuretic, and therapeutic benefits have been claimed for many indications (see below). Its pharmacologic properties include actions as a phytoestrogen, suggesting that its use, as with soy supplementation, could be disadvantageous in women with oestrogen-sensitive cancers (e.g. breast or endometrium). The active component of ginseng, ginsenoside, inhibits cAMP phosphodiesterase and monamine oxidase. These properties may partly explain purported central nervous system (CNS) stimulant actions of ginseng (though not sedative/hypnotic effects), potential modulation of the immune system and increase of glycogen storage. However, possible efficacy of ginseng in improving physical or psychomotor performance, cognitive function, immune function, diabetes mellitus and herpes simplex type 2 infections is not established beyond reasonable doubt. Adverse effects The adverse effects of ginseng are primarily CNS effects – agitation, irritability, insomnia and headache. Others noted include hypertension and mastalgia. Drug interactions In vitro evidence suggests that ginseng extracts inhibit CYP3A4 in human hepatocytes. These in vitro data are consistent with study data during an 18-day course of ginseng where it significantly increased the peak plasma concentration of nifedipine, a CYP3A4 substrate, in healthy volunteers. As with other herbs (e.g. echinacea), substantial variability in ginsenoside content has been reported among commercially available ginseng preparations, indicating that clinically significant effects on the pharmacokinetics of drugs that are metabolized by CYP3A4 could be highly variable between batches.

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    A Textbook of Clinical Pharmacology

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    A Textbook of Clinical Pharmacology

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    This fifth edition is dedicated to

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    FOREWORD viii PREFACE ix ACKNOWLEDG

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    PREFACE Clinical pharmacology is th

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    PART I GENERAL PRINCIPLES

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    ● Use of drugs 3 ● Adverse effe

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    and acquired factors, notably disea

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    100 Effect (%) 0 0 5 10 1 10 100 (a

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    Dose ratio -1 100 50 The relationsh

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    ● Introduction 11 ● Constant-ra

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    In reality, processes of eliminatio

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    lood (from which samples are taken

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    ● Introduction 17 ● Bioavailabi

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    ROUTES OF ADMINISTRATION ORAL ROUTE

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    Transdermal absorption is sufficien

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    FURTHER READING Fix JA. Strategies

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    and thromboxanes are CYP450 enzymes

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    and lorazepam. Some patients inheri

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    Orally administered drug Parenteral

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    ● Introduction 31 ● Glomerular

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    ACTIVE TUBULAR REABSORPTION This is

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    DISTRIBUTION Drug distribution is a

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    Detailed recommendations on dosage

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    DIGOXIN Myxoedematous patients are

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    ● Introduction 41 ● Role of dru

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    25 20 10 Life-threatening toxicity

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    ● Introduction 45 ● Harmful eff

  • Page 58 and 59: vagina in girls in their late teens
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  • Page 62 and 63: Case history A 20-year-old female m
  • Page 64 and 65: METABOLISM At birth, the hepatic mi
  • Page 66 and 67: lifelong effects as a result of tox
  • Page 68 and 69: DISTRIBUTION Ageing is associated w
  • Page 70 and 71: DIGOXIN Digoxin toxicity is common
  • Page 72 and 73: FURTHER READING Dhesi JK, Allain TJ
  • Page 74 and 75: Factors involved in the aetiology o
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  • Page 96 and 97: Key points • Genetic differences
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  • Page 114 and 115: PART II THE NERVOUS SYSTEM
  • Page 116 and 117: ● Introduction 105 ● Sleep diff
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  • Page 120 and 121: Key points • Insomnia and anxiety
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  • Page 134 and 135: Case history A 45-year-old man with
  • Page 136 and 137: Levodopa PRINCIPLES OF TREATMENT IN
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  • Page 140 and 141: CHOREA The γ-aminobutyric acid con
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  • Page 144 and 145: ● Introduction 133 ● Mechanisms
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  • Page 150 and 151: FURTHER ANTI-EPILEPTICS Other drugs
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    is the theoretical concern of a ‘

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    • Respiratory system - apnoea fol

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    Competitive antagonists (vecuronium

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    have also proved useful in combinat

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    ● Introduction 155 ● Pathophysi

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    ASPIRIN (ACETYLSALICYLATE) Use Anti

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    Key points Drugs for mild pain •

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    increases, correlating with the hig

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    • If possible, use oral medicatio

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    PART III THE MUSCULOSKELETAL SYSTEM

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    ● Introduction: inflammation 167

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    Chapter 33). All NSAIDs cause wheez

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    • Stomatitis suggests the possibi

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    Pharmacokinetics Allopurinol is wel

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    PART IV THE CARDIOVASCULAR SYSTEM

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    ● Introduction 177 ● Pathophysi

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    esponsible for the strong predilect

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    Ezetimibe Fat Muscle Dietary fat In

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    educed). The risk of muscle damage

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    ● Introduction 185 ● Pathophysi

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    Each of these classes of drug reduc

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    AT 1 receptor) produce good 24-hour

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    Table 28.2: Examples of calcium-cha

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    Key points Drugs used in essential

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    Case history A 72-year-old woman se

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    Assess risk factors Investigations:

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    Persistent ST segment elevation Thr

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    Mechanism of action GTN works by re

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    Because of the risks of haemorrhage

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    Intrinsic pathway XIIa XIa the acti

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    that the pharmacodynamic response i

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    used with apparent benefit in acute

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    ● Introduction 211 ● Pathophysi

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    The drugs that are most effective i

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    therapeutic plasma concentration ca

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    ● Common dysrhythmias 217 ● Gen

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    BASIC LIFE SUPPORT CARDIOPULMONARY

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    arrest. The electrocardiogram is li

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    should be given to insertion of an

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    Drug interactions Amiodarone potent

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    effect when treating sinus bradycar

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    Case history A 24-year-old medical

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    PART V THE RESPIRATORY SYSTEM

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    CHAPTER 33 THERAPY OF ASTHMA, CHRON

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    STEP 5: CONTINUOUS OR FREQUENT USE

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    Adenylyl cyclase Table 33.1: Compar

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    Drug interactions Although synergis

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    use in asthma has declined consider

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    α 1-antitrypsin deficiency, neutro

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    PART VI THE ALIMENTARY SYSTEM

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    ● Peptic ulceration 247 ● Oesop

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    PEPTIC ULCERATION 249 • With rega

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    Ranitidine has a similar profile of

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    Vestibular stimulation ? via cerebe

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    cortical centres affecting vomiting

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    • in hepatocellular failure to re

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    Ciprofloxacin is occasionally used

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    withdrawal), small doses of benzodi

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    Table 34.7: Dose-independent hepato

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    ● Introduction 265 ● General ph

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    dinucleotide (NAD) and nicotinamide

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    Table 35.1: Common trace element de

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    PART VII FLUIDS AND ELECTROLYTES

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    ● Introduction 273 ● Volume ove

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    Key points Diuretics Diuretics are

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    is sometimes caused by drugs, notab

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    or with potassium-sparing diuretics

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    Greger R, Lang F, Sebekova, Heidlan

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    PART VIII THE ENDOCRINE SYSTEM

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    ● Introduction 285 ● Pathophysi

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    in prefilled injection devices (‘

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    Metformin should be withdrawn and i

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    FURTHER READING American Diabetes A

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    deficiency. Potassium iodide (3 mg

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    fertility. It is contraindicated du

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    ● Introduction 297 ● Vitamin D

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    effective in life-threatening hyper

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    Further reading Block GA, Martin KJ

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    Table 40.1: Actions of cortisol and

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    injection may be useful, but if don

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    CHAPTER 41 REPRODUCTIVE ENDOCRINOLO

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    elease by the pituitary via negativ

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    Treatment with depot progestogen in

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    infusion using an infusion pump to

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    significant proportion of men who r

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    with symptoms caused by the release

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    FURTHER READING Birnbaumer M. Vasop

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    PART IX SELECTIVE TOXICITY

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    ● Principles of antibacterial che

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    2. transfer of resistance between o

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    Pharmacokinetics Absorption of thes

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    Mechanism of action Macrolides bind

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    asic quinolone structure dramatical

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    Case history A 70-year-old man with

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    PRINCIPLES OF MANAGEMENT OF MYCOBAC

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    Pharmacokinetics Absorption from th

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    MYCOBACTERIUM LEPRAE INFECTION Lepr

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    POLYENES AMPHOTERICIN B Uses Amphot

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    therapy is adequate though more fre

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    NUCLEOSIDE ANALOGUES ACICLOVIR Uses

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    Table 45.3: Summary of available ac

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    Uses Interferon-α when combined wi

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    ● Introduction 351 ● Immunopath

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    Table 46.1: Examples of combination

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    NON-NUCLEOSIDE ANALOGUE REVERSE TRA

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    FUSION INHIBITORS Uses Currently, e

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    salvage therapy include azithromyci

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    ● Malaria 361 ● Trypanosomal in

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    Pharmacokinetics Chloroquine is rap

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    Table 47.2: Drug therapy of non-mal

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    ● Introduction 367 ● Pathophysi

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    Table 48.1: Classification of commo

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    Polymorph count/mm 3 (a) (b) 10 000

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    doses are used to prepare patients

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    Adverse effects Methotrexate Inhibi

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    Table 48.7: Summary of clinical pha

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    Table 48.9: Summary of the clinical

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    Plasma membrane Signal transduction

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    Table 48.10: Monoclonal antibodies

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    INTERFERON-ALFA 2B Interferon-alfa

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    PART X HAEMATOLOGY

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    ● Haematinics - iron, vitamin B 1

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    one marrow to produce red cells. Th

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    EPO Erythroid precursors Erythrocyt

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    Therapeutic principles The extent o

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    PART XI IMMUNOPHARMACOLOGY

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    ● Introduction 399 ● Immunity a

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    Key points Antigen recognition Expr

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    Table 50.1: Novel anti-proliferativ

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    Key points Treatment of anaphylacti

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    DRUGS THAT ENHANCE IMMUNE SYSTEM FU

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    PART XII THE SKIN

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    ● Introduction 411 ● Acne 411

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    DERMATITIS (ECZEMA) PRINCIPLES OF T

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    SPECIALISTS ONLY SPECIALISTS ONLY E

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    TREATMENT OF OTHER SKIN INFECTIONS

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    effect of too high a dose of UVB in

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    PART XIII THE EYE

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    ● Introduction: ocular anatomy, p

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    to cause pupillary dilatation, name

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    Table 52.3: Antibacterial agents us

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    Table 52.6: Common drug-induced pro

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    PART XIV CLINICAL TOXICOLOGY

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    ● Introduction 433 ● Pathophysi

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    Table 53.2: Central nervous system

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    which provide anonymized data to th

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    Peak plasma levels after smoking ci

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    Key points Acute effects of alcohol

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    FURTHER READING Goldman D, Oroszi G

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    Table 54.2: Common indications for

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    Table 54.5: Antidotes and other spe

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    Commission on Human Medicines (CHM)

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    Note: Page numbers in italics refer

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    atrial fibrillation 217, 221 digoxi

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    Cushing’s syndrome 302 cyclic ade

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    5-fluorouracil 375-6 fluoxetine, mo

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    children 54 diazepam 108 iron prepa

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    non-steroidal anti-inflammatory dru

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    puberty (male), delay 314 puerperiu

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    tolerance 9, 433 benzodiazepines 10

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