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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

Key points • Insomnia

Key points • Insomnia and anxiety are common. Most patients do not require drug therapy. • Benzodiazepines are indicated for the short-term relief (2–4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable levels of distress. • The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable. • Benzodiazepines should be used to treat insomnia only when it is severe, disabling or subjecting the individual to extreme distress. • There is no convincing evidence to support the use of non-benzodiazepine hypnotics and anxiolytics over benzodiazepines. FLUMAZENIL Flumazenil is a benzodiazepine antagonist. It can be used to reverse benzodiazepine sedation. It is short acting, so sedation may return. It can cause nausea, flushing, anxiety and fits, so is not routinely used in benzodiazepine overdose which seldom causes severe adverse outcome. OTHERS • Barbiturates are little used and dangerous in overdose. • Clomethiazole – causes conjunctival, nasal and gastric irritation. Useful as a hypnotic in the elderly because its short action reduces the risk of severe hangover, ataxia and confusion the next day. It is effective in acute withdrawal syndrome in alcoholics, but its use should be carefully supervised and treatment limited to a maximum of nine days. It can be given intravenously to terminate status epilepticus. It can also be used as a sedative during surgery under local anaesthesia. • Zopiclone, zolpidem and zaleplon – are nonbenzodiazepine hypnotics which enhance GABA activity by binding to the GABA–chloride channel complex at the benzodiazepine-binding site. Although they lack structural features of benzodiazepines, they also act by potentiating GABA. Their addictive properties are probably similar to benzodiazepines. • Buspirone – is a 5HT1A receptor partial agonist. Its use has not been associated with addiction or abuse, but may be a less potent anxiolytic than the benzodiazepines. Its therapeutic effects take much longer to develop (two to three weeks). It has mild antidepressant properties. • Cloral and derivatives – formerly often used in paediatric practice. Cloral shares properties with alcohol and volatile anaesthetics. Cloral derivatives have no advantages over benzodiazepines, and are more likely to cause rashes and gastric irritation. • Sedative antihistamines, e.g. promethazine, are of doubtful benefit, and may be associated with prolonged drowsiness, psychomotor impairment and antimuscarinic effects. BENZODIAZEPINES VS. NEWER DRUGS ANXIETY 109 Since the advent of the newer non-benzodiazepine hypnotics (zopiclone, zolpidem and zaleplon), there has been much discussion and a considerable amount of confusion, as to which type of drug should be preferred. The National Institute for Health and Clinical Excellence (NICE) has given guidance based on evidence and experience. In essence, 1. When hypnotic drug therapy is appropriate for severe insomnia, hypnotics should be prescribed for short periods only. 2. There is no compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics. It is reasonable to prescribe the drug whose cost is lowest, other things being equal. (At present, this means that benzodiazepines are preferred.) 3. Switching from one hypnotic to another should only be done if a patient experiences an idiosyncratic adverse effect. 4. Patients who have not benefited from one of these hypnotic drugs should not be prescribed any of the others. Case history A 67-year-old widow attended the Accident and Emergency Department complaining of left-sided chest pain, palpitations, breathlessness and dizziness. Relevant past medical history included generalized anxiety disorder following the death of her husband three years earlier. She had been prescribed lorazepam, but had stopped it three weeks previously because she had read in a magazine that it was addictive. When her anxiety symptoms returned she attended her GP, who prescribed buspirone, which she had started the day before admission. Examination revealed no abnormality other than a regular tachycardia of 110 beats/minute, dilated pupils and sweating hands. Routine investigations, including ECG and chest x-ray, were unremarkable. Question 1 Assuming a panic attack is the diagnosis, what is a potential precipitant? Question 2 Give two potential reasons for the tachycardia. Answer 1 Benzodiazepine withdrawal. Answer 2 1. Buspirone (note that buspirone, although anxiolytic, is not helpful in benzodiazepine withdrawal and may also cause tachycardia). 2. Anxiety. 3. Benzodiazepine withdrawal. FURTHER READING Fricchione G. Clinical practice. Generalized anxiety disorder. New England Journal of Medicine 2004; 351: 675–82. National Institute for Clinical Excellence. 2004: Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. www.nice.org.uk/TA077guidance, 2004. Sateia MJ, Nowell PD. Insomnia. Lancet 2004; 364: 1959–73. Stevens JC, Pollack MH. Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents. Journal of Clinical Psychiatry 2005; 66 (Suppl. 2), 21–7.

CHAPTER 19 SCHIZOPHRENIA AND BEHAVIOURAL EMERGENCIES ● Schizophrenia 110 ● Behavioural emergencies 114 SCHIZOPHRENIA INTRODUCTION Schizophrenia is a devastating disease that affects approximately 1% of the population. The onset is often in adolescence or young adulthood and the disease is usually characterized by recurrent acute episodes which may develop into chronic disease. The introduction of antipsychotic drugs such as chlorpromazine revolutionized the treatment of schizophrenia so that the majority of patients, once the acute symptoms are relieved, can now be cared for in the community. Previously, they would commonly be sentenced to a lifetime in institutional care. PATHOPHYSIOLOGY The aetiology of schizophrenia, for which there is a genetic predisposition, is unknown, although several precipitating factors are recognized (Figure 19.1). Neurodevelopmental delay has been implicated and it has been postulated that the disease is triggered by some life experience in individuals predisposed by an abnormal (biochemical/anatomical) mesolimbic system. Odds Ratio 0 1 2 3 4 5 6 7 8 9 10 Place/time of birth Winter Urban Influenza Respiratory Infection Rubella Poliovirus CNS Famine Bereavement Prenatal Flood Obstetric Unwantedness Maternal depression Rhesus Incompatibility Hypoxia CNS damage Low birth weight Pre-eclampsia Family history There is heterogeneity in clinical features, course of disease and response to therapy. The concept of an underlying neurochemical disorder is advanced by the dopamine theory of schizophrenia, summarized in Box 19.1. The majority of antipsychotics block dopamine receptors in the forebrain. 5-Hydroxytryptamine is also implicated, as indicated in Box 19.2. Glutamine hypoactivity, GABA hypoactivity and α-adrenergic hyperactivity are also potential neurochemical targets. About 30% of patients with schizophrenia respond inadequately to conventional dopamine D 2 receptor antagonists. A high proportion of such refractory patients respond to clozapine, an ‘atypical’ antipsychotic drug which binds only transiently to D 2 receptors, but acts on other receptors, especially muscarinic, 5-hydroxytryptamine receptors (5HT 2) and D 1, and displays an especially high affinity for D 4 receptors. The D 4 receptor is localized to cortical regions and may be overexpressed in schizophrenia. Regional dopamine differences may be involved, such as low mesocortical activity with high mesolimbic activity. Magnetic resonance imaging (MRI) studies indicate enlargement of ventricles and loss of brain tissue, whilst functional MRI and positron emission tomography (PET) suggest hyperactivity in some cerebral areas, consistent with loss of inhibitory neurone function. Figure 19.1: Predispositions to schizophrenia. Redrawn with permission from Sullivan PF. The genetics of schizophrenia. PLoS Medicine 2005; 2: e212.

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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

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    vagina in girls in their late teens

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    an anti-analgesic effect when combi

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    Case history A 20-year-old female m

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    METABOLISM At birth, the hepatic mi

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    lifelong effects as a result of tox

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    DISTRIBUTION Ageing is associated w

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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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