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A Textbook of Clinical Pharmacology and Therapeutics

A Textbook of Clinical Pharmacology and Therapeutics

METABOLISM At birth, the

METABOLISM At birth, the hepatic microsomal enzyme system (see Chapter 5) is relatively immature (particularly in the preterm infant), but after the first four weeks it matures rapidly. Chloramphenicol can produce ‘grey baby syndrome’ in neonates due to high plasma levels secondary to inefficient elimination. Conversely, hepatic drug metabolism can be increased once enzyme activity has matured in older infants and children, because the ratio of the weight of the liver to body weight is up to 50% higher than in adults. Drugs administered to the mother can induce neonatal enzyme activity (e.g. barbiturates). Phenobarbitone metabolism is faster in children than in adults because of greater induction of hepatic enzyme activity. Key points Prevalence of chronic illness in children requiring drug therapy: • one in eight children have asthma; • one in 250 children have epilepsy; • one in 750 children have diabetes mellitus. Key points At birth, renal and hepatic function are less efficient than in adulthood. Drug effects may be prolonged and accumulation may occur. These factors are exaggerated in the premature infant. EXCRETION All renal mechanisms (filtration, secretion and reabsorption) are reduced in neonates, and renal excretion of drugs is relatively reduced in the newborn. Glomerular filtration rate (GFR) increases rapidly during the first four weeks of life, with consequent changes in the rate of drug elimination (Table 10.1). Table 10.1: Changes in rate of drug elimination with development Stage of development Premature infant Plasma half-life of gentamicin �48 hours old 18 hours 5–22 days old Normal infant 6 hours 1–4 weeks old 3 hours Adult 2 hours PHARMACODYNAMICS BREAST-FEEDING 53 Documented evidence of differences in receptor sensitivity in children is lacking, and the apparently paradoxical effects of some drugs (e.g. hyperkinesia with phenobarbitone, sedation of hyperactive children with amphetamine) are as yet unexplained. Augmented responses to warfarin in prepubertal patients occur at similar plasma concentrations as in adults, implying a pharmacodynamic mechanism. Ciclosporin added in vitro to cultured monocytes (hence there is no opportunity for a pharmacokinetic effect) has greater effects in cells isolated from infants, providing another example of an age-related pharmacodynamic difference. BREAST-FEEDING Breast-feeding can lead to toxicity in the infant if the drug enters the milk in pharmacological quantities. The milk concentration of some drugs (e.g. iodides) may exceed the maternal plasma concentration, but the total dose delivered to the baby is usually very small. However, drugs in breast milk may cause hypersensitivity reactions even in very low doses. Virtually all drugs that reach the maternal systemic circulation will enter breast milk, especially lipid-soluble unionized lowmolecular-weight drugs. Milk is weakly acidic, so drugs that are weak bases are concentrated in breast milk by trapping of the charged form of the drug (compare with renal elimination; see Chapter 6). However, the resulting dose administered to the fetus in breast milk is seldom clinically appreciable, although some drugs are contraindicated (Table 10.2), and breast-feeding should cease during treatment if there is no safer alternative. Appendix 5 of the British National Formulary provides very helpful practical advice. Table 10.2: Some drugs to be avoided during breast-feeding Amiodarone Aspirin Benzodiazepines Chloramphenicol Ciclosporin Ciprofloxacin Cocaine Combined oral contraceptives Cytotoxics Ergotamine Octreotide Stimulant laxatives Sulphonylureas Thiazide diuretics Vitamin A/retinoid analogues (e.g. etretinate)

54 DRUGS IN INFANTS AND CHILDREN The infant should be monitored if β-adrenoceptor antagonists, carbimazole, corticosteroids or lithium are prescribed to the mother. β-Adrenoceptor antagonists rarely cause significant bradycardia in the suckling infant. Carbimazole should be prescribed at its lowest effective dose to reduce the risk of hypothyroidism in the neonate/infant. In high doses, corticosteroids can affect the infant’s adrenal function and lithium may cause intoxication. There is a theoretical risk of Reye’s syndrome if aspirin is prescribed to the breast-feeding mother. Warfarin is not contraindicated during breast-feeding. Bromocriptine suppresses lactation and large doses of diuretics may do likewise. Metronidazole gives milk an unpleasant taste. PRACTICAL ASPECTS OF PRESCRIBING COMPLIANCE AND ROUTE OF ADMINISTRATION Sick neonates will usually require intravenous drug administration. Accurate dosage and attention to fluid balance are essential. Sophisticated syringe pumps with awareness of ‘dead space’ associated with the apparatus are necessary. Children under the age of five years may have difficulty in swallowing even small tablets, and hence oral preparations which taste pleasant are often necessary to improve compliance. Liquid preparations are given by means of a graduated syringe. However, chronic use of sucrosecontaining elixirs encourages tooth cavities and gingivitis. Moreover, the dyes and colourings used may induce hypersensitivity. Pressurized aerosols (e.g. salbutamol inhaler, see Chapter 33) are usually only practicable in children over the age of ten years, as co-ordinated deep inspiration is required unless a device such as a spacer is used. Spacers can be combined with a face mask from early infancy. Likewise, nebulizers may be used to enhance local therapeutic effect and reduce systemic toxicity. Only in unusual circumstances, i.e. extensive areas of application (especially to inflamed or broken skin), or in infants, does systemic absorption of drugs (e.g. steroids, neomycin) become significant following topical application to the skin. Intramuscular injection should only be used when absolutely necessary. Intravenous therapy is less painful, but skill is required to cannulate infants’ veins (and a confident colleague to keep the target still!). Children find intravenous infusions uncomfortable and restrictive. Rectal administration (see Chapter 4) is a convenient alternative (e.g. metronidazole to treat anaerobic infections). Rectal diazepam is particularly valuable in the treatment of status epilepticus when intravenous access is often difficult. Rectal diazepam may also be administered by parents. Rectal administration should also be considered if the child is vomiting. Paramount to ensuring compliance is full communication with the child’s parents and teachers. This should include information not only on how to administer the drug, but also on why it is being prescribed, for how long the treatment should continue and whether any adverse effects are likely. Case history A two-year-old epileptic child is seen in the Accident and Emergency Department. He has been fitting for at least 15 minutes. The casualty officer is unable to cannulate a vein to administer intravenous diazepam. The more experienced medical staff are dealing with emergencies elsewhere in the hospital. Question Name two drugs, and their route of administration, with which the casualty officer may terminate the convulsions. Answer Rectal diazepam solution. Rectal or intramuscular paraldehyde. DOSAGE Even after adjustment of dose according to surface area, calculation of the correct dose must consider the relatively large volume of distribution of polar drugs in the first four months of life, the immature microsomal enzymes and reduced renal function. The British National Formulary and specialist paediatric textbooks and formularies provide appropriate guidelines and must be consulted by physicians who are not familiar with prescribing to infants and children. ADVERSE EFFECTS With a few notable exceptions, drugs in children generally have a similar adverse effect profile to those in adults. Of particular significance is the potential of chronic corticosteroid use, including high-dose inhaled corticosteroids, to inhibit growth. Aspirin is avoided in children under 16 years (except in specific indications, such as Kawasaki syndrome) due to an association with Reye’s syndrome, a rare but often fatal illness of unknown aetiology consisting of hepatic necrosis and encephalopathy, often in the aftermath of a viral illness. Tetracyclines are deposited in growing bone and teeth, causing staining and occasionally dental hypoplasia, and should not be given to children. Fluoroquinolone antibacterial drugs may damage growing cartilage. Dystonias with metoclopramide occur more frequently in children and young adults than in older adults. Valproate hepatotoxicity is increased in young children with learning difficulties receiving multiple anticonvulsants. Some adverse effects cause

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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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    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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