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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

increases, correlating

increases, correlating with the high efficacy of repeated-dose oral morphine. Morphine-6-glucuronide is eliminated in the urine, so patients with renal impairment may experience severe and prolonged respiratory depression. The birth of opiatedependent babies born to addicted mothers demonstrates the ability of morphine and its glucuronide to cross the placenta. Drug interactions • Morphine augments other central nervous system depressants. • Morphine should not be combined with MAOIs. • Opioid (μ) receptor antagonists (e.g. naloxone) are used in overdose. DIAMORPHINE (‘HEROIN’) Use Diamorphine is diacetylmorphine. Its actions are similar to those of morphine, although it is more potent as an analgesic when given by injection. Diamorphine has a reputation for having a greater addictive potential than morphine and is banned in the USA. The more rapid central effect of intravenous diamorphine than of morphine (the faster ‘buzz’), due to rapid penetration of the blood–brain barrier, makes this plausible (see below). Diamorphine is used for the same purposes as morphine. It is more soluble than morphine, and this may be relevant to limit injection volume (e.g. in epidural analgesia). Adverse effects The adverse effects of diamorphine are the same as those for morphine. Pharmacokinetics Diamorphine is hydrolysed (deacetylated) rapidly to form 6-acetylmorphine and morphine, and if given by mouth owes its effect entirely to morphine. Diamorphine crosses the blood–brain barrier even more rapidly than morphine. This accounts for its rapid effect when administered intravenously and hence increased abuse potential compared with morphine. PETHIDINE Use The actions of pethidine are similar to those of morphine. It causes similar respiratory depression, vomiting and gastrointestinal smooth muscle contraction to morphine, but does not constrict the pupil, release histamine or suppress cough. It produces little euphoria, but does cause dependence. It can cause convulsions. Pethidine is sometimes used in obstetrics because it does not reduce the activity of the pregnant uterus, but morphine is often preferred. Delayed gastric emptying (common to all opioids) is of particular concern in obstetrics, as gastric aspiration is a leading cause of maternal morbidity. Pharmacokinetics Hepatic metabolism is the main route of elimination. Norpethidine is an important metabolite since it is proconvulsant. The t1/2 of pethidine is three to four hours in healthy individuals, but this is increased in the elderly and in patients OPIOIDS 161 with liver disease. Pethidine crosses the placenta and causes respiratory depression of the neonate. This is exacerbated by the prolonged elimination t 1/2 in neonates of about 22 hours. Drug interactions • When pethidine is given with monoamine oxidase inhibitors, rigidity, hyperpyrexia, excitement, hypotension and coma can occur. • Pethidine, like other opiates, delays gastric emptying, thus interfering with the absorption of co-administered drugs. ALFENTANYL, FENTANYL AND REMIFENTANYL Use These are derivatives of pethidine. They are more potent but shorter-acting and are used to treat severe pain or as an adjunct to anaesthesia. Fentanyl is available as a transdermal patch which is changed every 72 hours. They can be given intrathecally and via patient-controlled devices. TRAMADOL Use Tramadol is widely used for moderate to severe pain, including post-operative pain. It can be administered by mouth, or by intramuscular or intravenous injection Mechanism of action Tramadol works partly through an agonist effect at μ receptors (opioid action) and partly by enhancing amine (5HT and catecholamine) transmission (and hence gating mechanism) by blocking neuronal amine re-uptake. Adverse effects These differ from pure opioid agonists, including less respiratory depression, constipation and abuse potential. Diarrhoea, abdominal pain, hypotension, psychiatric reactions, as well as seizures and withdrawal syndromes have been reported. METHADONE Use Methadone has very similar actions to morphine, but is less sedating and longer acting. Its main use is by mouth to replace morphine or diamorphine when these drugs are being withdrawn in the treatment of drug dependence. Methadone given once daily under supervision is preferable to leaving addicts to seek diamorphine illicitly. Many of the adverse effects of opioid abuse are related to parenteral administration, with its attendant risks of infection (e.g. endocarditis, human immunodeficiency virus or hepatitis). The object is to reduce craving by occupying opioid receptors, simultaneously reducing the ‘buzz’ from any additional dose taken. The slower onset following oral administration reduces the reward and reinforcement of dependence. The relatively long half-life reduces the intensity of withdrawal and permits once-daily dosing under supervision. Methadone is also becoming more widely used in the treatment of chronic or terminal pain patients where its additional property of being an NMDA antagonist may be helpful.

162 ANALGESICS AND THE CONTROL OF PAIN Pharmacokinetics After oral dosage, the peak blood concentration is achieved within about four hours, and once-daily dosing is practicable because of its long half-life. CODEINE Use Codeine is the methyl ether of morphine, but has only about 10% of its analgesic potency. (Dihydrocodeine is similar, and is a commonly prescribed alternative.) Although codeine is converted to morphine, it produces little euphoria and has low addiction potential. As a result, it has been used for many years as an analgesic for moderate pain, as a cough suppressant and for symptomatic relief of diarrhoea. Adverse effects Common adverse effects involve constipation, nausea and vomiting. Pharmacokinetics Free morphine also appears in plasma following codeine administration, and codeine acts as a prodrug, producing a low but sustained concentration of morphine. Individuals who are CYP2D6 poor metabolizers convert much less codeine to morphine, and consequently experience less, if any, analgesic effect. PENTAZOCINE Pentazocine is a partial agonist on opioid receptors (especially κ-receptors, with additional actions on σ-receptors, which result in hallucinations and thought disturbance). It also increases pulmonary artery pressure. Its use is not recommended. BUPRENORPHINE Use Buprenorphine is a partial agonist. It is given sublingually. It antagonizes full agonists and can precipitate pain and cause withdrawal symptoms in patients who are already receiving morphine. It has recently (in the USA, as well as in the UK) become more widely used in the treatment of opiate withdrawal as an alternative to methadone. Pharmacokinetics Like other opiates, buprenorphine is subject to considerable pre-systemic and hepatic first-pass metabolism (via glucuronidation to inactive metabolites), but this is circumvented by sublingual administration. OPIOID ANTAGONISTS Minor alterations in the chemical structure of opioids result in drugs that are competitive antagonists. NALOXONE Naloxone is a pure competitive antagonist of opioid agonists at μ-receptors. It is given intravenously, the usual dose being 0.8–2.0 mg for the treatment of poisoning with full opiate agonists (e.g. morphine), higher doses (up to ten times the recommended dose, depending on clinical response) being required for overdosage with partial agonists (e.g. buprenorphine, pentazocine). Its effect has a rapid onset and if a satisfactory response has not been obtained within three minutes, the dose may be repeated. The action of many opioids outlasts that of naloxone, which has a t1/2 of one hour, and a constant-rate infusion of naloxone may be needed in these circumstances. Naloxone is used in the management of the apnoeic infant after birth when the mother has received opioid analgesia during labour. Naloxone can precipitate acute withdrawal symptoms in opiate-dependent patients. NALTREXONE Naltrexone is an orally active opioid antagonist that is used in specialized clinics as adjunctive treatment to reduce the risk of relapse in former opioid addicts who have been detoxified. Such patients who are receiving naltrexone in addition to supportive therapy, are less likely to resume illicit opiate use (detected by urine measurements) than those receiving placebo plus supportive therapy. However, the drop-out rate is high due to non-compliance. Naltrexone has weak agonist activity, but this is not clinically important, and withdrawal symptoms do not follow abrupt cessation of treatment. Treatment should not be started until the addict has been opioid-free for at least seven days for short-acting drugs (e.g. diamorphine or morphine), or ten days for longer-acting drugs (e.g. methadone), because it can precipitate a severe and prolonged abstinence syndrome. Naltrexone has not been extensively studied in non-addicts, and most of the symptoms that have been attributed to it are those that arise from opioid withdrawal. Its major side effects are various type of rash. ANALGESICS IN TERMINAL DISEASE The relief of pain in terminal disease, usually cancer, requires skilful use of analgesic drugs. There are several important principles: • Non-opioid analgesics minimize opioid requirement. The World Health Organization (WHO) has endorsed a simple stepwise approach (WHO ‘pain ladder’), moving from non-opioid to weak opioid to strong opioid. For mild pain, paracetamol, aspirin or codeine (a weak opioid) or a combined preparation (e.g. cocodamol) is usually satisfactory. • Morphine (or a congener) is the key treatment for severe pain. It is important to use a large enough dose, if necessary given intravenously, to relieve the pain completely. There is a wide range in dose needed to suppress pain in different individuals. • Drug dependence is not a problem in this type of patient. • It is much easier to prevent pain before it has built up than to relieve pain when it has fully developed.

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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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    DIGOXIN Digoxin toxicity is common

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    FURTHER READING Dhesi JK, Allain TJ

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    Factors involved in the aetiology o

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    analgesic. Following its release, t

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    antibiotics, such as penicillin or

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    predisposes to non-immune haemolysi

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    ● Introduction 71 ● Useful inte

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    Response Therapeutic range Toxic ra

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    Table 13.1: Interactions outside th

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    Table 13.5: Competitive interaction

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    ● Introduction: ‘personalized m

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    Table 14.2: Variations in drug resp

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    lipoprotein (LDL) is impaired. LDL

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    Key points • Genetic differences

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    • Discovery • • Screening Pre

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    Too many statistical comparisons pe

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    ETHICS COMMITTEES Protocols for all

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    Table 16.1: Recombinant proteins/en

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    duration and benefit. Adenoviral ve

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    ● Introduction 97 ● Garlic 97

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    A case report has suggested a possi

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    including hypericin and pseudohyper

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    PART II THE NERVOUS SYSTEM

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    ● Introduction 105 ● Sleep diff

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    and daytime sleeping should be disc

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    Key points • Insomnia and anxiety

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  • Page 134 and 135: Case history A 45-year-old man with
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  • Page 144 and 145: ● Introduction 133 ● Mechanisms
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  • Page 150 and 151: FURTHER ANTI-EPILEPTICS Other drugs
  • Page 152 and 153: Case history A 24-year-old woman wh
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  • Page 182 and 183: • Stomatitis suggests the possibi
  • Page 184 and 185: Pharmacokinetics Allopurinol is wel
  • Page 186 and 187: PART IV THE CARDIOVASCULAR SYSTEM
  • Page 188 and 189: ● Introduction 177 ● Pathophysi
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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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