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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

● Introduction 45 ●

● Introduction 45 ● Harmful effects on the fetus 45 ● Recognition of teratogenic drugs 46 INTRODUCTION CHAPTER 9 DRUGS IN PREGNANCY The use of drugs in pregnancy is complicated by the potential for harmful effects on the growing fetus, altered maternal physiology and the paucity and difficulties of research in this field. Key points • There is potential for harmful effects on the growing fetus. • Because of human variation, subtle effects to the fetus may be virtually impossible to identify. • There is altered maternal physiology. • There is notable paucity of and difficulties in research in this area. • Assume all drugs are harmful until proven otherwise. HARMFUL EFFECTS ON THE FETUS Because experience with many drugs in pregnancy is severely limited, it should be assumed that all drugs are potentially harmful until sufficient data exist to indicate otherwise. ‘Social’ drugs (alcohol and cigarette smoking) are definitely damaging and their use must be discouraged. In the placenta, maternal blood is separated from fetal blood by a cellular membrane (Figure 9.1). Most drugs with a molecular weight of less than 1000 can cross the placenta. This is usually by passive diffusion down the concentration gradient, but can involve active transport. The rate of diffusion depends first on the concentration of free drug (i.e. non-protein bound) on each side of the membrane, and second on the lipid solubility of the drug, which is determined in part by the degree of ionization. Diffusion occurs if the drug is in the unionized state. Placental function is also modified by changes in blood flow, and drugs which reduce placental blood flow can reduce birth weight. This may be the mechanism which causes the small reduction in birth weight following treatment ● Pharmacokinetics in pregnancy 47 ● Prescribing in pregnancy 48 Maternal blood space Trophoblast Small (MW 1000) drugs D D D Passive diffusion Passive diffusion D D D D+ D− Figure 9.1: Placental transfer of drugs from mother to fetus. of the mother with atenolol in pregnancy. Early in embryonic development, exogenous substances accumulate in the neuroectoderm. The fetal blood–brain barrier is not developed until the second half of pregnancy, and the susceptibility of the central nervous system (CNS) to developmental toxins may be partly related to this. The human placenta possesses multiple enzymes that are primarily involved with endogenous steroid metabolism, but which may also contribute to drug metabolism and clearance. The stage of gestation influences the effects of drugs on the fetus. It is convenient to divide pregnancy into four stages, namely fertilization and implantation (�17 days), the organogenesis/embryonic stage (17–57 days), the fetogenic stage and delivery. Key points • A cellular membrane separates the maternal and fetal blood. • Most drugs cross the placenta by passive diffusion. • Placental function is modified by changes in blood flow. • There are multiple placental enzymes, primarily involved with endogenous steroid metabolism, which may also contribute to drug metabolism.

46 DRUGS IN PREGNANCY FERTILIZATION AND IMPLANTATION Animal studies suggest that interference with the fetus before 17 days gestation causes abortion, i.e. if pregnancy continues the fetus is unharmed. ORGANOGENESIS/EMBRYONIC STAGE At this stage, the fetus is differentiating to form major organs, and this is the critical period for teratogenesis. Teratogens cause deviations or abnormalities in the development of the embryo that are compatible with prenatal life and are observable postnatally. Drugs that interfere with this process can cause gross structural defects (e.g. thalidomide phocomelia). Some drugs are confirmed teratogens (Table 9.1), but for many the evidence is inconclusive. Thalidomide was unusual in the way in which a very small dose of the drug given on only one or two occasions between the fourth and seventh weeks of pregnancy predictably produced serious malformations. FETOGENIC STAGE In this stage, the fetus undergoes further development and maturation. Even after organogenesis is almost complete, drugs can still have significant adverse effects on fetal growth and development. • ACE inhibitors and angiotensin receptor blockers cause fetal and neonatal renal dysfunction. • Drugs used to treat maternal hyperthyroidism can cause fetal and neonatal hypothyroidism. • Tetracycline antibiotics inhibit growth of fetal bones and stain teeth. • Aminoglycosides cause fetal VIIIth nerve damage. • Opioids and cocaine taken regularly during pregnancy can lead to fetal drug dependency. • Warfarin can cause fetal intracerebral bleeding. • Indometacin, a potent inhibitor of prostaglandin synthesis, is used under specialist supervision to assist closure of patent ductus arteriosus in premature infants. • Some hormones can cause inappropriate virilization or feminization. Table 9.1: Some drugs that are teratogenic in humans. Thalidomide Androgens Cytotoxic agents Progestogens Alcohol Danozol Warfarin Diethylstilbestrol Retinoids Radioisotopes Most anticonvulsants Some live vaccines Ribavarin Lithium • Anticonvulsants may possibly be associated with mental retardation. • Cytotoxic drugs can cause intrauterine growth retardation and stillbirth. DELIVERY Some drugs given late in pregnancy or during delivery may cause particular problems. Pethidine, administered as an analgesic can cause fetal apnoea (which is reversed with naloxone, see Chapter 25). Anaesthetic agents given during Caesarean section may transiently depress neurological, respiratory and muscular functions. Warfarin given in late pregnancy causes a haemostasis defect in the baby, and predisposes to cerebral haemorrhage during delivery. Key points • Fertilization and implantation, �17 days. • Organogenesis/embryonic stage, 17–57 days. • Fetogenic stage. • Delivery. THE MALE Although it is generally considered that sperm cells damaged by drugs will not result in fertilization, the manufacturers of griseofulvin, an antifungal agent, advise men not to father children during or for six months after treatment. Finasteride, an antiandrogen used in the treatment of benign prostatic hyperplasia, is secreted in semen, and may be teratogenic to male fetuses. RECOGNITION OF TERATOGENIC DRUGS Major malformations that interfere with normal function occur in 2–3% of newborn babies, and a small but unknown fraction of these are due to drugs. Two principal problems face those who are trying to determine whether a drug is teratogenic when it is used to treat disease in humans: 1. Many drugs produce birth defects when given experimentally in large doses to pregnant animals. This does not necessarily mean that they are teratogenic in humans at therapeutic doses. Indeed, the metabolism and kinetics of drugs at high doses in other species is so different from that in humans as to limit seriously the relevance of such studies. 2. Fetal defects are common (2–3%). Consequently, if the incidence of drug-induced abnormalities is low, a very large number of cases has to be observed to define a significant increase above this background level. Effects on the fetus may take several years to become clinically manifest. For example, diethylstilbestrol was widely used in the late 1940s to prevent miscarriages and preterm births, despite little evidence of efficacy. In 1971, an association was reported between adenocarcinoma of the

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    A Textbook of Clinical Pharmacology

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    A Textbook of Clinical Pharmacology

  • Page 6 and 7: This fifth edition is dedicated to
  • Page 8 and 9: FOREWORD viii PREFACE ix ACKNOWLEDG
  • Page 10 and 11: PREFACE Clinical pharmacology is th
  • Page 12 and 13: PART I GENERAL PRINCIPLES
  • Page 14 and 15: ● Use of drugs 3 ● Adverse effe
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  • Page 18 and 19: 100 Effect (%) 0 0 5 10 1 10 100 (a
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  • Page 24 and 25: In reality, processes of eliminatio
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  • Page 30 and 31: ROUTES OF ADMINISTRATION ORAL ROUTE
  • Page 32 and 33: Transdermal absorption is sufficien
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  • Page 36 and 37: and thromboxanes are CYP450 enzymes
  • Page 38 and 39: and lorazepam. Some patients inheri
  • Page 40 and 41: Orally administered drug Parenteral
  • Page 42 and 43: ● Introduction 31 ● Glomerular
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  • Page 46 and 47: DISTRIBUTION Drug distribution is a
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  • Page 50 and 51: DIGOXIN Myxoedematous patients are
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  • Page 58 and 59: vagina in girls in their late teens
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  • Page 62 and 63: Case history A 20-year-old female m
  • Page 64 and 65: METABOLISM At birth, the hepatic mi
  • Page 66 and 67: lifelong effects as a result of tox
  • Page 68 and 69: DISTRIBUTION Ageing is associated w
  • Page 70 and 71: DIGOXIN Digoxin toxicity is common
  • Page 72 and 73: FURTHER READING Dhesi JK, Allain TJ
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  • Page 84 and 85: Response Therapeutic range Toxic ra
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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

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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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