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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

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which provide anonymized data to the appropriate national or regional Drug Misuse Database (DMD). Key points Prescription of controlled drugs Preparations which are subject to the prescription requirements of the Misuse of Drugs Regulations 2001 are labelled CD. The principal legal requirements are as follows: Prescriptions ordering Controlled Drugs subject to prescription requirements must be signed and dated by the prescriber and specify the prescriber’s address. The prescription must always state in the prescriber’s own handwriting in ink or otherwise so as to be indelible: • the name and address of the patient; • in the case of a preparation, the form and, where appropriate, the strength of the preparation; • the total quantity of the preparation, or the number of dose units, in both words and figures; • the dose. Prescriptions ordering ‘repeats’ on the same form are not permitted. It is an offence for a doctor to issue an incomplete prescription (see the British National Formulary for full details). DRUGS THAT ALTER PERCEPTION Cannabis (marijuana) is the most widely used illicit drug in the UK. The most active constituent is Δ-9-tetrahydrocannabinol, which produces its effects through actions on cannabinoid CB1 receptors. It is most commonly mixed with tobacco and smoked, but it may be brewed into a drink or added to food. The pleasurable effects of cannabis include a sensation of relaxation, heightened perception of all the senses and euphoria. The nature and intensity of the effects varies between individuals, and is related to dose, and to the mood of the subject. The effects usually occur within minutes and last for one to two hours. Conjunctival suffusion is common. Tetrahydrocannabinol and other cannabinoids are extremely lipid soluble and are only slowly released from body fat. Although the acute effects wear off within hours of inhalation, cannabinoids are eliminated in the urine for weeks following ingestion. It is claimed that cannabis may be of value in the symptomatic management of multiple sclerosis, particularly if nausea is a prominent symptom. It has no approved medicinal use in the UK. Acute adverse effects include dysphoric reactions, such as anxiety or panic attacks, the impairment of performance of skilled tasks, and sedation. This may lead to road traffic accidents. Chronic use has been associated with personality changes, including ‘amotivational syndrome’ which is characterized by extreme lethargy. The association of chronic cannabis use with onset of schizophrenia is unproven. A physical dependence syndrome has been reported for cannabis, but only after extremely heavy and frequent intake. Dependence on cannabis as a primary problem is rare and there are no specific DRUGS THAT ALTER PERCEPTION 437 treatments for cannabis dependence. Similarly, there are no treatments for cannabis intoxication, although dysphoric reactions may require brief symptomatic treatment (e.g. with benzodiazepines). LYSERGIC ACID DIETHYLAMIDE AND OTHER PSYCHEDELICS Psychedelics produce hallucinations (e.g. visual, somatic, olfactory) and other changes in perception, e.g. feelings of dissociation and altered perception of time. Psychedelics can be divided into serotonin- or indoleamine-like psychedelics (e.g. lysergic acid diethylamide (LSD) and psilocybin) and phenylethylamines (e.g. mescaline, phencyclidine – angel dust – and methylenedioxymethylamphetamine – MDMA or ‘ecstasy, XTC’). These are agonists at the serotonin 5-HT 2-receptor and their potency as hallucinogens is closely correlated with their affinity for this receptor. Some phenethylamine psychedelics stimulant properties and can produce feelings of increased energy and euphoria and heightened perception. MDMA is the most commonly abused recreational hallucinogenic central stimulant in the UK. The most common users are adolescents. In high-dose hyperpyrexia, trismus, dehydration, hyponatraemia, rhabdomyolysis, seizures, coma, hepatic damage and death have been reported. Interactions with antidepressants are life-threatening. Impulsivity and impaired memory are serious long-term effects. Chronic MDMA usage produces degeneration of serotonergic neurones. MDMA is metabolized via the CYP 2D6 system and is a potent CYP 2D6 inhibitor. The elimination kinetics are saturable. Psychedelics were used historically as adjunctive treatment in psychotherapy, but were subsequently found to be of no benefit. Most are taken orally and perceptual changes occur approximately one hour later. The duration depends on dose and clearance, and is often several hours to one day. Tolerance to behavioural effects can occur, but no withdrawal syndrome has been demonstrated. In addition to the uncommon life-threatening adverse effects caused by MDMA, physicians come into contact with psychedelic drug abusers when they contact emergency services, e.g. as a result of dysphoric reactions or ‘bad trips’. These symptoms can respond to reassurance and quiet surroundings, although chlorpromazine (which has 5-HT 2-antagonist effects) or diazepam may be of benefit. Phencyclidine (‘PCP’, ‘angel dust’) was originally developed as an injectable anaesthetic. It binds to the glutamate ion channel. Its therapeutic use in humans was stopped after early clinical studies showed that it produced confusion, delirium and hallucinations. It is used for anaesthetic purposes by veterinarians. Patients may show extreme changes in behaviour and mood (e.g. rage and aggression, lethargy and negativism, euphoria), hallucinations, autonomic arousal (hypertension, hyperthermia) and, in extreme cases, coma and seizures. Symptoms of PCP intoxication should be treated symptomatically. PCP abuse is rare in the UK.

438 DRUGS AND ALCOHOL ABUSE CENTRAL STIMULANTS Amphetamines are abused for their stimulant properties, which are related acutely to the release of dopamine and noradrenaline. Their therapeutic use is limited to specialist treatment of narcolepsy and hyperactivity in children. They should not be prescribed in the management of depression or obesity. Acutely they may alleviate tiredness and induce a feeling of cheerfulness and confidence, and because of their sympathomimetic effects they raise blood pressure and heart rate. With high doses, particularly after intravenous use, a sensation of intense exhilaration may occur. Users tend to become hyperactive at high doses, especially if these are repeated over several days. Repeated use of amphetamines can produce ‘amphetamine psychosis’, which is characterized by delirium, panic, hallucinations and feelings of persecution, and can be difficult to distinguish from acute schizophrenia. Anxiety, irritability and restlessness are also common. Prolonged use leads to psychological dependence, tolerance and hostility, as well as irritation due to lack of sleep and food. The most commonly used amphetamine is amphetamine sulphate in oral or injectable forms, which are only available illegally. More recently, free-base amphetamine has become available (‘ice’), which can be smoked, and this has pharmacokinetic and subjective effects similar to those of injected amphetamine sulphate. There are no specific drug treatments for amphetamine dependence, and the mainstay of therapy involves counselling and social management. MDMA is described under drugs that alter perception. Cocaine is derived from the Andean coca shrub. It has powerful stimulant properties which are related to its action in blocking synaptic re-uptake of dopamine, and to a lesser extent noradrenaline and serotonin. As the salt it is most commonly sniffed up the nose, although it can also be injected. In the USA, the free base of cocaine (‘crack’) is widely available. The pharmacokinetics of smoked crack cocaine are almost identical to those of intravenous cocaine. Acutely cocaine causes arousal, hypertension, exhilaration, euphoria, indifference to pain and fatigue, and the sensation of having great physical strength and mental capacity. Repeated large doses commonly precipitate an extreme surge of agitation and anxiety. Myocardial infarction or arterial dissection can occur acutely. In contrast to alcohol and opioids, which addicts tend to use on a regular basis, cocaine is used in binges, where doses may be taken several times an hour over a day or several days until exhaustion or lack of money prevents this. Tolerance of the euphoric effects occurs. However, upon stopping a cocaine binge, withdrawal symptoms including excessive sleep, fatigue and mild depression, may occur. Repeated cocaine use may produce adverse effects including anorexia, confusion, exhaustion, palpitations, damage to the membranes lining the nostrils and, if injected, blood-borne infections. Use of cocaine in pregnancy is associated with damage to the central nervous system of the fetus. ‘Crack babies’ can usually be cured of their ‘addiction’ by abstinence over a few weeks. Currently, there are no specific drug treatments for cocaine dependence. Counselling and social management of patients have been shown to be of only modest benefit in maintaining abstinence. Nicotine is an alkaloid present in the leaves of the tobacco plant. The only medical use of nicotine is as an aid in smoking cessation. Its importance relates to its addictive properties and its presence in tobacco. The smoke of a completely burned cigarette usually contains 1–6 mg and that of a cigar contains 15–40 mg of nicotine. Acute administration of 60 mg of nicotine orally may be fatal. Nicotine first stimulates the nicotinic receptors of autonomic ganglia and then blocks them. Thus smoking can accelerate the heart via sympathetic stimulation, or slow it by sympathetic block or parasympathetic stimulation. Adrenaline and noradrenaline are secreted from the adrenal medulla. The motor end-plate acetylcholine receptors are initially stimulated and then blocked, producing a paralysis of voluntary muscle. The results of extensive central stimulation include wakefulness, tremor, fits, anorexia, nausea, vomiting, tachypnoea and secretion of antidiuretic hormone (ADH). Adverse effects of smoking Smoking is a potent risk factor for malignant and cardiovascular disease. Some of the specific causes of death which are related to smoking are listed in Table 53.5. Chronic obstructive pulmonary disease including chronic bronchitis and emphysema are also associated with smoking as is peptic ulcer disease. Smoking during pregnancy is associated with spontaneous abortion, premature delivery, small babies, increased perinatal mortality and an increased incidence of sudden infant death syndrome (cot death). In households where the parents smoke, there is an increased risk of pneumonia and bronchitis in preschool and school-age children, which is most marked during the first year of life. Pharmacokinetics About 90% of nicotine from inhaled smoke is absorbed, while smoke taken into the mouth results in only 25–50% absorption. As well as being absorbed via the gastro-intestinal (GI), buccal and respiratory epithelium, nicotine is absorbed through the skin. A high concentration of nicotine may be present in the breast milk of smokers. Around 80–90% of circulating nicotine is metabolized in the liver, kidneys and lungs. The plasma elimination t1/2 is 25–40 minutes. Nicotine and its metabolites are excreted in the urine. The metabolite cotinine can be used to quatitate exposure. Table 53.5: Principal causes of death associated with smoking Ischaemic heart disease (strongest correlation) Cancers of the lung, other respiratory sites and the oesophagus, lip and tongue Chronic bronchitis and emphysema, respiratory tuberculosis Pulmonary heart disease Aortic aneurysm

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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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    • 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

  • Page 398 and 399: PART X HAEMATOLOGY
  • Page 400 and 401: ● Haematinics - iron, vitamin B 1
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  • Page 404 and 405: EPO Erythroid precursors Erythrocyt
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  • Page 410 and 411: ● Introduction 399 ● Immunity a
  • Page 412 and 413: Key points Antigen recognition Expr
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  • Page 418 and 419: DRUGS THAT ENHANCE IMMUNE SYSTEM FU
  • Page 420 and 421: PART XII THE SKIN
  • Page 422 and 423: ● Introduction 411 ● Acne 411
  • Page 424 and 425: DERMATITIS (ECZEMA) PRINCIPLES OF T
  • Page 426 and 427: SPECIALISTS ONLY SPECIALISTS ONLY E
  • Page 428 and 429: TREATMENT OF OTHER SKIN INFECTIONS
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  • Page 434 and 435: ● Introduction: ocular anatomy, p
  • Page 436 and 437: to cause pupillary dilatation, name
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  • Page 442 and 443: PART XIV CLINICAL TOXICOLOGY
  • Page 444 and 445: ● Introduction 433 ● Pathophysi
  • Page 446 and 447: Table 53.2: Central nervous system
  • Page 450 and 451: Peak plasma levels after smoking ci
  • Page 452 and 453: Key points Acute effects of alcohol
  • Page 454 and 455: FURTHER READING Goldman D, Oroszi G
  • Page 456 and 457: Table 54.2: Common indications for
  • Page 458 and 459: Table 54.5: Antidotes and other spe
  • Page 460 and 461: Commission on Human Medicines (CHM)
  • Page 462 and 463: Note: Page numbers in italics refer
  • Page 464 and 465: atrial fibrillation 217, 221 digoxi
  • Page 466 and 467: Cushing’s syndrome 302 cyclic ade
  • Page 468 and 469: 5-fluorouracil 375-6 fluoxetine, mo
  • Page 470 and 471: children 54 diazepam 108 iron prepa
  • Page 472 and 473: non-steroidal anti-inflammatory dru
  • Page 474 and 475: puberty (male), delay 314 puerperiu
  • Page 476: tolerance 9, 433 benzodiazepines 10
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