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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

• If possible, use

• If possible, use oral medications. Once pain control is established (e.g. with frequent doses of morphine orally), change to a slow-release morphine preparation. This produces a smoother control of pain, without peaks and troughs of analgesia, which can still be supplemented with shorter duration morphine formulations for breakthrough pain. Tolerance is not a problem in this setting, the dose being increased until pain relief is obtained. Adverse effects of opioids should be anticipated. Prochlorperazine or metoclopramide can be used to reduce nausea and vomiting, and may increase analgesia. Stimulant laxatives, such as senna, and/or glycerine suppositories should be used routinely to reduce constipation. Spinal administration of opioids is not routinely available, but is sometimes useful for those few patients with opioid-responsive pain who experience intolerable systemic side effects when morphine is given orally. Bone pain is often most effectively relieved by local radiotherapy rather than by drugs, but bisphosphonates (see Chapter 39) and/or NSAIDs are useful. Key points Analgesics in terminal care • Stepwise use of non-opioid to opioid analgesics as per the WHO analgesic ladder (e.g. paracetomol)/weak opioid (e.g. codeine)/strong opioid (e.g. morphine) is rational when the patient presents with mild symptoms. • In cases where severe pain is already established, parenteral morphine is often needed initially, followed by regular frequent doses of morphine by mouth with additional (‘top-up’–’breakthrough’) doses prescribed as needed, followed by conversion to an effective dose of long-acting (slow-release) oral morphine, individualized to the patient’s requirements. • Chronic morphine necessitates adjunctive treatment with: – anti-emetics: prochloperazine, metoclopramide; – laxative: senna. • Additional measures that are often useful include: – radiotherapy (for painful metastases); – a cyclo-oxygenase inhibitor (especially with bone involvement); – bisphosphonates are also effective in metastatic bone pain – an antidepressant. MANAGEMENT OF POST-OPERATIVE PAIN Post-operative pain provides a striking demonstration of the importance of higher functions in the perception of pain. When patients are provided with devices that enable them to control their own analgesia (see below), they report superior pain relief but use less analgesic medication than when this is administered intermittently on demand. Unfortunately, post-operative pain has traditionally been managed by analgesics prescribed by the most inexperienced surgical staff and administered at the discretion of nursing staff. Recently, anaesthetists have become more involved in the management of post-operative pain and Key points MANAGEMENT OF POST-OPERATIVE PAIN 163 pain teams have led to notable improvements. There are several general principles: • Surgery results in pain as the anaesthetic wears off. This causes fear, which makes the pain worse. This vicious circle can be avoided by time spent on pre-operative explanation, giving reassurance that pain is not a result of things having gone wrong, will be transient and will be controlled. • Analgesics are always more effective in preventing the development of pain than in treating it when it has developed. Regular use of mild analgesics can be highly effective. Non-steroidal anti-inflammatory drugs (e.g. ketorolac, which can be given parenterally) can have comparable efficacy to opioids when used in this way. They are particularly useful after orthopaedic surgery. • Parenteral administration is usually only necessary for a short time post-operatively, after which analgesics can be given orally. The best way to give parenteral opioid analgesia is often by intravenous or subcutaneous infusion under control of the patient (patient-controlled analgesia (PCA)). Opioids are effective in visceral pain and are especially valuable after abdominal surgery. Some operations (e.g. cardiothoracic surgery) cause both visceral and somatic pain, and regular prescription of both an opioid and a non-opioid analgesic is appropriate. Once drugs can be taken by mouth, slow-release morphine, or buprenorphine prescribed on a regular basis, are effective. Breakthrough pain can be treated by additional oral or parenteral doses of morphine. • Tramadol is useful when respiratory depression is a particular concern. • Anti-emetics (e.g. metoclopramide, prochlorperazine) should be routinely prescribed to be administered on an ‘as-needed’ basis. They are only required by a minority of patients, but should be available without delay when needed. • A nitrous oxide/oxygen mixture (50/50) can be selfadministered and is useful during painful procedures, such as dressing changes or physiotherapy, and for childbirth. It should not be used for prolonged periods (e.g. in intensive care units), as it can cause vitamin B 12 deficiency in this setting. Analgesia and post-operative pain • Pre-operative explanation minimizes analgesic requirements. • Prevention of post-operative pain is initiated during anaesthesia (e.g. local anaesthetics, parenteral cyclooxygenase inhibitor). • Patient-controlled analgesia using morphine is safe and effective. • The switch to oral analgesia should be made as soon as possible. • Anti-emetics should be prescribed ‘as needed’, to avoid delay if they are required.

164 ANALGESICS AND THE CONTROL OF PAIN Key points Opioids • The main drug is morphine, which is a full agonist at μ-receptors. • The effects of morphine include: – analgesia; – relief of left ventricular failure; – miosis (pupillary constriction); – suppression of cough (‘antitussive’ effect); – constipation; – nausea/vomiting; – liberation of histamine (pruritus, bronchospasm); – addiction; – tolerance; – withdrawal symptoms following chronic use. • Diamorphine (‘heroin’): – is metabolized rapidly to morphine; – gains access to the central nervous system (CNS) more rapidly than morphine (when given i.v. or snorted); – for this reason gives a rapid ‘buzz’; – may therefore have an even higher potential for abuse than morphine; – is more soluble than morphine. • Codeine and dihydrocodeine are: – weak opioid prodrugs; – slowly metabolized to morphine; – used in combination with paracetamol for moderate pain; – used for diarrhoea or as antitussives. • Pethidine: – is a strong synthetic opioid; – metabolized to normeperidine which can cause seizures; – does not inhibit uterine contraction; – is widely used in obstetrics; – can cause respiratory depression in neonates; – is less liable than morphine to cause bronchial constriction; – does not cause miosis; – has potential for abuse. • Buprenorphine and dextropropoxyphene are partial agonists. – Buprenorphine is used sublingually in severe chronic pain. – Dextropropoxyphene is combined with paracetamol for moderately severe chronic pain. This combination is no more effective than paracetamol alone for acute pain and is very dangerous in overdose. The March 2007 British National Formulary states ‘co-proxamol (dextropropoxyphene � paracetamol) is to be withdrawn from the market and the CSM has advised that co-proxamol treatment should no longer (their emphasis) be prescribed’. • Opioid effects are antagonized competitively by naloxone: very large doses are needed to reverse the effects of partial opiate agonists, e.g. buprenorphine, pentazocine. Case history A 55-year-old retired naval officer presents to the Accident and Emergency Department with sudden onset of very severe back pain. A chest x-ray reveals a mass, and plain spine films shows a crush fracture. He is admitted at 9 a.m. for further management and investigation. On examination he is pale, sweaty and distressed. The doctor on call prescribes morphine 10 mg subcutaneously, fourhourly as needed, and the pain responds well to the first dose, following which the patient falls into a light sleep. That evening his wife, scarcely able to contain her anger, approaches the consultant on the Firm’s round and strongly advocates that her husband be given some more analgesic. Comment Communication is key in managing pain. There are often difficulties when, as in the present case, the diagnosis is probable but not confirmed, and when the patient is admitted to a general ward which may be short of nursing staff. The Senior House Officer was concerned not to cause respiratory depression, so did not prescribe regular analgesia, but unfortunately neither medical nor nursing staff realized that the patient had awoken with recurrent severe pain. He had not himself asked for additional analgesia (which was prescribed) because his personality traits would lead him to lie quietly and ‘suffer in silence’. The good initial response suggests that his pain will respond well to regular oral morphine, and this indeed proved to be the case. A subsequent biopsy confirmed squamous-cell carcinoma, and a bone scan demonstrated multiple metastases, one of which had led to a crush fracture of a vertebral body visible on plain x-ray. A nonsteroidal drug (e.g. ibuprofen or ketorolac) reduced his immediate requirement for morphine, and radiotherapy resolved his back pain completely. Morphine was discontinued. He remained pain-free at home for the next four months and was then found dead in bed by his wife. Autopsy was not performed. One of several possibilities is that he died from pulmonary embolism. FURTHER READING Ballantyne JC, Mao JR. Opioid therapy for chronic pain. New England Journal of Medicine 2003; 349: 1943–53. Dahl JB, Kehlet H. The value of pre-emptive analgesia in the treatment of post-operative pain. British Journal of Anaesthesia 1993; 70: 434–9. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. British Medical Journal 2004; 328: 1401–4. McMahon S, Koltzenburg M. Wall and Melzack’s textbook of pain, 5th edn. Edinburgh: Churchill Livingstone, 2005.

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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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    Box 19.1: Dopamine theory of schizo

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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 186 and 187: PART IV THE CARDIOVASCULAR SYSTEM
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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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