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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

CHAPTER 41 REPRODUCTIVE

CHAPTER 41 REPRODUCTIVE ENDOCRINOLOGY CONTRIBUTION BY DR DIPTI AMIN ● Female reproductive endocrinology 307 ● Male reproductive endocrinology 313 FEMALE REPRODUCTIVE ENDOCRINOLOGY INTRODUCTION Appropriate sexual development at puberty and the cyclical processes of ovulation and menstruation involve a complex interaction of endocrine and target organs. Gonadotrophinreleasing hormones (GnRH) regulate the release of the gonadotrophins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary gland. LH and FSH promote maturation of ova and secretion of oestrogen and progesterone from the ovaries. Oestrogen and progesterone are derived from cholesterol. They stimulate the breast, uterus and vagina and exert both negative and positive feedback on the central nervous system (CNS)–hypothalamic–pituitary unit resulting in inhibition and stimulation of gonadotrophin secretion. The main hormones secreted by the ovary are oestradiol- 17β, oestrone, progesterone and androgens. Oestrogens influence the development of secondary sexual characteristics, including breast development and the female distribution of fat, as well as ovulation during the reproductive years. From the start of menses until the menopause, the primary oestrogen is oestradiol-17β, whereas in post-menopausal women oestrone predominates. Oestriol is only present in significant amounts during pregnancy and is made by the placenta which converts dehydroisoepiandrosterone (DHEA) from the adrenal cortex of the fetus to oestriol. OESTROGENS Properties The properties of oestrogens include the following: • stimulation of endometrial growth; • maintenance of blood vessels and skin; • reduction of bone resorption and increase of bone formation; • increase uterine growth; • increase the hepatic production of binding proteins; • increase circulating clotting factors II, VII, IX, X and plasminogen; • increase high-density lipoprotein (HDL); • increase biliary cholesterol; • control salt and water retention. Uses Oestrogens are used in: • oral contraception; • the treatment of symptoms of menopause; • the prevention of osteoporosis. Fractures of the spine, wrist and hips are reduced by 50–70% and there is about a 5% increase in spinal bone density in those women treated with oestrogen within three years of the onset of menopause and for five to ten years thereafter. • the treatment of vaginal atrophy; • the treatment of hypo-oestrogenism (as a result of hypogonadism, castration or primary ovarian failure); • treatment of primary amenorrhoea; • treatment of dysmenorrhoea; • treatment of oligomenorrhoea; • treatment of certain neoplastic diseases; • treatment of hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu syndrome); • palliative treatment of prostate cancer. Ethinylestradiol, a synthetic oestrogen, is an alternative for many of the above indications. Oestrogens are no longer used to suppress lactation because of the risk of thromboembolism. Bromocriptine is used instead. Key points Main uses of oestrogen • oral contraception; • replacement therapy. Adverse effects Common symptoms include nausea and vomiting, abdominal cramps and bloating, breast enlargement and tenderness, premenstrual symptoms, sodium and fluid retention. Salt and water retention with oedema, hypertension and exacerbation of heart failure can occur with pharmacological doses. In men,

308 REPRODUCTIVE ENDOCRINOLOGY gynaecomastia and impotence are predictable dose-dependent effects. There is an increased risk of thromboembolism. Oestrogens are carcinogenic in some animals and there is an increased incidence of endometrial carcinoma in women who have uninterrupted treatment with exogenous oestrogen unopposed by progestogens. Pharmacokinetics Oestrogens are absorbed by mouth and via the skin and mucous membranes. The most potent natural oestrogen is oestradiol-17β which is largely oxidized to oestrone and then hydrated to produce oestriol. All three oestrogens are metabolized in the liver and excreted as glucuronide and sulphate conjugates in the bile and urine. Estimation of urinary oestrogen excretion provides a measure of ovarian function. Ethinylestradiol has a prolonged action because of slow hepatic metabolism with a half-life of about 25 hours. PROGESTOGENS Progesterone is a steroid hormone involved in the female menstrual cycle, pregnancy (it supports gestation) and embryogenesis. Progesterone is the precursor of 17-hydroxyprogesterone which is converted to androstenedione which subsequently is converted to testosterone, oestrone and oestradiol. Progesterone is produced in the adrenal glands, by the corpus luteum, the brain and by the placenta. Progestogens act on tissues primed by oestrogens whose effects they modify. There are two main groups of progestogens, namely the naturally occurring hormone progesterone and its analogues, and the testosterone analogues, such as norethisterone and norgestrel. All progestogens have antioestrogenic and anti-gonadotrophic properties, and differ in their potency and their side effects. Uses of progesterone The uses of progesterone are: • to control anovulatory bleeding; • to prepare the uterine lining in infertility therapy and to support early pregnancy; • for recurrent pregnancy loss due to inadequate progesterone production; • in the treatment of intersex disorders, to promote breast development. Uses of progestogens The uses of progestogens are: • as part of the combined oral contraceptive and in the progestogen-only pill. Medroxyprogesterone acetate administered by depot injection is used when parenteral contraception is indicated. • as an anti-androgen in androgen-sensitive tumours, such as prostate cancer, e.g. cyproterone acetate; • as part of hormone replacement therapy in women with an intact uterus to counteract the effects of unopposed oestrogen on the endometrium which can result in endometrial carcinoma; • endometriosis; • in menstrual disorders, such as premenstrual tension, dysmenorrhoea and menorrhagia; • progestogens in common use include norethisterone, levonorgestrel, desogestrel, norgestimate and gestodene, which are all derivatives of norgestrel. These differ considerably in potency. The newer progestogens, desogestrel, gestodene and norgestimate produce good cycle control and have a less marked adverse effect on plasma lipids; however, studies have shown that oral contraceptives containing desogestrel and gestodene are associated with an increase of around two-fold in the risk of venous thromboembolism compared to those containing other progestogens and should be avoided in women with risk factors for thromboembolic disease. Desogestrel, drospirenone (a derivative of spironolactone with anti-androgenic and anti-mineralocorticoid properties) and gestodene should be considered for women who have side effects, such as acne, headache, depression, weight gain, breast symptoms and breakthrough bleeding with other progestogens. The progestogen norelgestromin is combined with ethinylestradiol in a transdermal contraceptive patch. Mechanism of action Progestogens act on intracellular cytoplasmic receptors and initiate new protein formation. Their main contraceptive effect is via an action on cervical mucus which renders it impenetrable to sperm. Nortestosterone derivatives are partially metabolized oestrogenic metabolites which may account for some additional anti-ovulatory effect. A pseudodecidual change in the endometrium further discourages implantation of the zygote. Pharmacokinetics Progesterone is subject to presystemic hepatic metabolism and is most effective when injected intramuscularly or administered sublingually. It is excreted in the urine as pregnanediol and pregnanelone. It has prolonged absorption and an elimination half-life of 25–50 hours. It is highly protein bound. Norethisterone, a synthetic progestogen used in many oral contraceptives, is rapidly absorbed orally, is subject to little presystemic hepatic metabolism and has a half-life of 7.5–8 hours. THE COMBINED ORAL CONTRACEPTIVE Since the original pilot trials in Puerto Rico proved that steroid oral contraception was feasible, this method has become the leading method of contraception world-wide. Nearly 50% of all women in their twenties in the UK use this form of contraception. It is the most consistently effective contraceptive method and allows sexual relations to proceed without interruption, but it lacks the advantage of protection against sexually transmitted disease that is afforded by condoms. The most commonly used oestrogen is ethinylestradiol. The main contraceptive action of the combined oral contraceptive (COC) is to suppress ovulation by interfering with gonadotrophin

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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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    • 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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  • Page 346 and 347: PRINCIPLES OF MANAGEMENT OF MYCOBAC
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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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