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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

arrest. The

arrest. The electrocardiogram is likely to show asystole, severe bradycardia or ventricular fibrillation. Occasionally narrow complexes are present, but there is no detectable cardiac output (‘electromechanical dissociation’). The doses given below are for an average-sized adult. During the course of an arrest, other rhythm disturbances are frequently encountered (e.g. sinus bradycardia) and these are considered in the next section on other specific dysrhythmias. If intravenous access cannot be established, the administration of double doses of adrenaline (or other drugs as appropriate) via an endotracheal tube can be life-saving. ASYSTOLE Make sure ECG leads are attached properly and that the rhythm is not ventricular fibrillation, which is sometimes mistaken for asystole if the fibrillation waves are of low amplitude. If there is doubt, DC counter-shock (200J). Once the diagnosis is definite, administer adrenaline (otherwise known as epinephrine), 1 mg intravenously, followed by atropine, 3 mg intravenously. Further doses of adrenaline 1 mg can be given every three minutes as necessary. If P-waves (or other electrical activity) are present, but the intrinsic rate is slow or there is high grade heart block, consider pacing. VENTRICULAR FIBRILLATION The following sequence is used until a rhythm (hopefully sinus) is achieved that sustains a cardiac output. DC countershock (200J) is delivered as soon as a defibrillator is available and then repeated (200J, then 360J) if necessary, followed by adrenaline, 1 mg intravenously, and further defibrillation (360J) repeated as necessary. Consider varying the paddle positions and also consider amiodarone 300 mg, if ventricular fibrillation persists. A further dose of 150 mg may be required in refractory cases, followed by an infusion of 1 mg/min for six hours and then 0.5 mg/min, to a maximum of 2 g. Magnesium (8 mmol) is recommended for refractory VF if there is a suspicion of hypomagnesaemia, e.g. patients on potassium-losing diuretics. Lidocaine and procainamide are alternatives if amiodarone is not available, but should not be given in addition to amiodarone. During prolonged resuscitation, adrenaline (1 mg i.v.) every three minutes is recommended. ELECTROMECHANICAL DISSOCIATION When the pulse is absent, but the ECG shows QRS complexes, this is known as electromechanical dissociation. It may be the result of severe global damage to the left ventricle, in which case the outlook is bleak. If it is caused by some potentially reversible pathology such as hypovolaemia, pneumothorax, pericardial tamponade or pulmonary embolus, volume replacement or other specific measures may be dramatically effective. If pulseless electrical activity is associated with a bradycardia, atropine, 3 mg intravenously or 6 mg via the endotracheal tube, should be given. High-dose adrenaline is no longer recommended in this situation. TREATMENT OF OTHER SPECIFIC DYSRHYTHMIAS 221 TREATMENT OF OTHER SPECIFIC DYSRHYTHMIAS TACHYDYSRHYTHMIAS SUPRAVENTRICULAR Atrial fibrillation See also Figure 32.3, which outlines a useful algorithm for the general treatment of tachydysrhythmias including atrial fibrillation. Patients who have not been in atrial fibrillation for too long and in whom the left atrium is not irreversibly distended may ‘spontaneously’ revert to sinus rhythm. If this does not occur, such patients benefit from elective DC cardioversion, following which many remain in sinus rhythm. DC cardioversion is unlikely to achieve or to maintain sinus rhythm in patients with longstanding atrial fibrillation, or with atrial fibrillation secondary to mitral stenosis, especially if the left atrium is significantly enlarged; in such cases, it is quite acceptable to aim for rate control rather than rhythm conversion. Indeed, trials have demonstrated no difference in prognosis between patients with atrial fibrillation treated with a rate control vs. a rhythm control strategy, although patients who remain in atrial fibrillation are more likely to be persistently symptomatic. The main hazard of cardioversion is embolization of cerebral or peripheral arteries from thrombus that may have accumulated in the left atrial appendage. Patients should therefore be anticoagulated before elective cardioversion (usually for four to six weeks) to prevent new and friable thrombus from accumulating and to permit any existing thrombus to organize, thereby reducing the risk of embolization. An alternative is to perform early cardioversion provided that transoesophageal echocardiography can be performed and shows no evidence of thrombus in the left atrial appendage. Anticoagulation is continued for one month if the patient remains in sinus rhythm. Anticoagulation should be continued long term if fibrillation persists or intermittent episodes of dysrhythmia recur. Atrial flutter Atrial flutter is treated with the same drugs as are effective in atrial fibrillation, but tends to be more resistant to drug treatment. However, it is very responsive to DC cardioversion. As with atrial fibrillation, atrial flutter carries a risk of systemic embolization. Paroxysmal supraventricular tachycardias As discussed above, although supraventricular tachycardia is generally a narrow complex QRS tachycardia, the presence of rate-induced aberrant conduction can cause the QRS complexes to be wide, thus making it difficult to distinguish from ventricular tachycardia. Criteria exist for distinguishing broad complex supraventricular and ventricular tachycardias, but these are beyond the scope of this book, and in practice are often difficult to apply precisely. Figure 32.3 therefore

222 CARDIAC DYSRHYTHMIAS Synchronised DC shock* up to 3 attempts • Amiodarone 300 mg IV over 10–20 min and repeat shock; followed by; • Amiodarone 900 mg over 24 h Irregular Seek expert help Possibilities include: • AF with bundle branch block treat as for narrow complex • Pre-excited AF consider amiodarone • Polymorphic VT (e.g. torsades de pointes – give magnesium 2 g over 10 min) Unstable Is QRS regular? *Attempted electrical cardioversion is always undertaken under sedation or general anaesthesia provides a simple and practical algorithm for the management of tachydysrhythmias in general. Catheter ablation therapy is now possible for supraventricular tachycardias, atrial flutter and fibrillation. Advice from a consultant cardiac electrophysiologist should be sought regarding the suitability of a patient for this procedure. Ventricular dysrhythmias Ventricular ectopic beats: Electrolyte disturbance, smoking, alcohol abuse and excessive caffeine consumption should be sought and corrected if present. The only justification for treating patients with anti-dysrhythmic drugs in an attempt to reduce the frequency of ventricular ectopic (VE) beats in a chronic setting is if the ectopic beats cause intolerable palpitations, or if they precipitate attacks of more serious tachydysrhythmia (e.g. ventricular tachycardia or fibrillation). If palpitations are so unpleasant as to warrant treatment despite • Support ABCs; give oxygen; cannulate a vein • Monitor ECG, BP, SpO 2 • Record 12-lead if possible, if not record rhythm strip • Identify and treat reversible causes Broad Is patient stable? Signs of instability include: 1. Reduced conscious level 2. Chest pain 3. Systolic BP �90 mmHg 4. Heart failure (Rate related symptoms uncommon at less than 150 beats min �1 ) Regular Stable Is QRS narrow (�0.12 sec)? If ventricular tachycardia (or uncertain rhythm): • Amiodarone 300 mg IV over 20–60 min; then 900 mg over 24 h If previously confirmed SVT with bundle branch block: • Give adenosine as for regular narrow complex tachycardia Regular Narrow • Use vagal manoeuvres • Adenosine 6 mg rapid IV bolus; if unsuccessful give 12 mg; if unsuccessful give futher 12 mg. • Monitor ECG continuously Normal sinus rhythm restored? Yes Probable re-entry PSVT: • Record 12-lead ECG in sinus rhythm • If recurs, give adenosine again & consider choice of anti-dyshythmic prophylaxis Is rhythm regular? Irregular Irregular narrow complex tachycardia Probable atrial fibrillation Control rate with: • β-Blocker IV, digoxin IV, or diltiazem IV if onset �48 h consider: • Amiodarone 300 mg IV 20–60 min; then 900 mg over 24 h Seek expert help the suspicion that this may shorten rather than prolong life, an oral class I agent, such as disopyramide, may be considered. Sotalol with its combination of class II and III actions is an alternative, although a clinical trial with the D-isomer (which is mainly responsible for its class III action) showed that this worsened survival (the ‘SWORD’ trial). In an acute setting (most commonly the immediate aftermath of myocardial infarction), treatment to suppress ventricular ectopic beats may be warranted if these are running together to form brief recurrent episodes of ventricular tachycardia, or if frequent ectopic beats are present following cardioversion from ventricular fibrillation. Lidocaine is used in such situations and is given as an intravenous bolus, followed by an infusion in an attempt to reduce the risk of sustained ventricular tachycardia or ventricular fibrillation. Ventricular tachycardia: This is covered in Figure 32.3 (management of tachydysrhythmias). In the longer term, consideration No Possible atrial flutter • Control rate (e.g. β-Blocker) Figure 32.3: Scheme for the management of tachydysrhythmias. (Adapted with permission from the European Resuscitation Council Guidelines, 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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    The Boston Collaborative Survey ind

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    Oral medication, especially in liqu

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    e.g. interpersonal difficulties or

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    Partial response to first-line trea

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    Key points Drug treatment of depres

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    Case history A 45-year-old man with

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    Levodopa PRINCIPLES OF TREATMENT IN

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    • pulmonary, retroperitoneal and

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    CHOREA The γ-aminobutyric acid con

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    Cholinergic crisis Treatment of mya

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    ● Introduction 133 ● Mechanisms

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    absolute arbiter. The availability

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    Table 22.2: Metabolic interactions

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    FURTHER ANTI-EPILEPTICS Other drugs

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    Case history A 24-year-old woman wh

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    Assessment of migraine severity and

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    ● General anaesthetics 145 ● In

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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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  • Page 204 and 205: Key points Drugs used in essential
  • Page 206 and 207: Case history A 72-year-old woman se
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  • Page 210 and 211: Persistent ST segment elevation Thr
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  • Page 216 and 217: Intrinsic pathway XIIa XIa the acti
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  • Page 224 and 225: The drugs that are most effective i
  • Page 226 and 227: therapeutic plasma concentration ca
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  • Page 230 and 231: BASIC LIFE SUPPORT CARDIOPULMONARY
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  • Page 236 and 237: Drug interactions Amiodarone potent
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  • Page 240 and 241: Case history A 24-year-old medical
  • Page 242 and 243: PART V THE RESPIRATORY SYSTEM
  • Page 244 and 245: CHAPTER 33 THERAPY OF ASTHMA, CHRON
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  • Page 248 and 249: Adenylyl cyclase Table 33.1: Compar
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  • Page 260 and 261: PEPTIC ULCERATION 249 • With rega
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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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