Compilation of Drugs involved in specific conditions (2)

Enzyme Inducers  (NO GAS in CaR)
  • NNRTIs – Nevirapine *
  • Omeprazole – Induces P-450 1A2 **
  • Griseofulvin, Glucocorticoids
  • Alcohol (chronic)
  • Sulphonyureas/ St John’s Wort
  • Carbamazepine,  Pheytoin, barbiturates, Primidone
  • Rifampicin, Quinine
*    NNRTIs either induce or inhibit depending on the concomitantly administered drug
**  competitive inhibitor of the enzymes CYP2C19 and CYP2C9
Enzyme Inhibitors  (DOG RAISE)
  • Diltiazem, Verapamil
  • Omeprazole, Cimetidine,
  • Gemfibrozil, Grapefruit juice
  • Ritonavir (PI in HAART)
  • Amiodarone/ Allopurinol/ Acute alcohol intake, metahnol(acute), Disulfiram;
  • Isoniazid, Imidazoles (ketoconazole, fluconazole)
  • Sulphonamides, Sodium valproate, SSRIs (fluoxetine, sertraline)
  • Erthyromycin, Ciprofloxacin, quinupristin, metronidazole, quinidine
  • * Drugs that cause displacement of warfarin from protein
NSAID, OHA, metronidazole, salicylates, Co-trimoxazole
Drugs which are known to cause impaired glucose tolerance include:

  • Thiazides, furosemide (less common)
  • Steroids
  • Tacrolimus, Ciclosporin
  • Interferon-alpha
  • Nicotinic acid
  • Atypical Antipsychotics e.g. Olanzapine
  • Beta-blockers cause a slight impairment of glucose tolerance.
They should also be used with caution in diabetics as they can interfere with the metabolic and autonomic responses to hypoglycaemia
Drug-induced thrombocytopenia (probable immune mediated)

  • quinine
  • abciximab
  • NSAIDS
  • diuretics: furosemide
  • antibiotics: penicillins, sulphonamides, rifampicin
  • anticonvulsants: carbamazepine, valproate
  • heparin
Drug causes of gingival hyperplasia

  • phenytoin
  • ciclosporin
  • calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include

acute myeloid leukaemia (myelomonocytic and monocytic types)
Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed.
There is however considerable overlap, with some drugs causing a range of changes to the liver
The following drugs tend to cause a hepatocellular picture:

  • Paracetamol (Acetaminophen)
  • Diclofenac
  • Sodium Valproate, Phenytoin
  • MAOIs
  • Halothane
  • Anti-Tuberculosis: isoniazid, rifampicin, pyrazinamide
  • Statins
  • Alcohol
  • Ecstasy/ amphetamine
  • Amiodarone
  • Methotrexate
  • Methyldopa
The following drugs tend to cause cholestasis (+/- hepatitis):
  • Oral Contraceptive pill
  • Antibiotics: ciprofloxacin, flucloxacillin, co-amoxiclav, erythromycin*, nitrofurantoin
  • anabolic Steroids, testosterones
  • Phenothiazines: chlorpromazine, prochlorperazine
  • Sulphonylureas
  • Fibrates
  • rare reported causes: nifedipine
*risk may be reduced with erythromycin stearate
Drugs affected by acetylator status

  • isoniazid
  • procainamide
  • hydralazine
  • dapsone
  • sulfasalazine
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Compilation of Drugs involved in specific conditions (1)

1. Drugs that may increase the risk of neurotoxicity by Lithium:

  • Diuretics (esp. thiazides),
  • ACEI/ ARBs
  • Diltiazem or verapamil

2. Drugs that can be cleared with haemodialysis – mnemonic: BLAST

  • arbiturate
  • ithium
  • lcohol (inc methanol, ethylene glycol)
  • alicylates
  • heophyllines (charcoal haemoperfusion is preferable)
 Drugs which cannot be cleared with haemodialysis include
  • tricyclics
  • benzodiazepines
  • dextropropoxyphene (Co-proxamol) – opioid analgesic
  • digoxin
  • beta-blockers
3. Drugs apparently safe in breast feeding:

  • antibiotics: penicillins, cephalosporins, trimethoprim
  • endocrine: glucocorticoids (avoid high doses), levothyroxine*
  • epilepsy: sodium valproate, carbamazepine
  • asthma: salbutamol, theophyllines
  • psychiatric drugs: tricyclic antidepressants, antipsychotics**
  • hypertension: beta-blockers, hydralazine, methyldopa
  • anticoagulants: warfarin, heparin
  • digoxin
Drugs that should be avoided in breast feeding:

  • antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • psychiatric drugs: lithium, benzodiazepines
  • aspirin
  • carbimazole
  • sulphonylureas
  • cytotoxic drugs
  • amiodarone

*the BNF advises that the amount is too small to affect neonatal hypothyroidism screening
**clozapine should be avoided

 
4. Drug causing oculogyric crisis :

  1. phenothiazines
  2. haloperidol
  3. metoclopramide
  4. postencephalitic Parkinson’s disease

5. Acute intermittent Porphyria (AIP)

a. Drugs which may precipitate attack

  • barbiturates
  • benzodiazepines
  • halothane
  • alcohol
  • oral contraceptive pill
  • sulphonamides
b. Drugs considered safe to use

  • paracetamol
  • aspirin
  • codeine
  • morphine
  • chlorpromazine
  • beta-blockers
  • penicillin
  • metformin
Unsafe/ High risk/ To avoid :
  • Arsine
  • Chloramphenicol
  • Chloroquine, Primaquine, Pamaquine, Pentaquine
  • Ciprofloxacin
  • Probenecid
  • Dapsone
  • Dimercaprol
  • Doxorubicin
  • Furazolidone
  • Glibenclamide
  • Glucosulfone
  • Isobutyl Nitrite
  • Menadiol (Vit K3, K4)
  • Mesalazine (5-ASA), O-ASA
  • Metamizole
  • Methylene Blue
  • Nalidixic acid
  • Nitrofurantoin
  • Naphtalene
  • Urate Oxidase
  • Phenacetin
  • phenazopyridine
  • Phenylhydrazine
  • Sulfamethoxazole, Sulfasalazine, Sulfapyridine
Low-risk drugs which can probably be given in NORMAL THERAPEUTIC DOSES to G-6-PD-deficient subjects without nonspherocytic hemolytic anemia
  • Acetaminophen (paracetamol, Tylenol, Tralgon, hydroxyacetanilide)
  • Acetophenetidin (phenacetin)
  • Aminopyrine (Pyramidon, amidopyrine)
  • Antazoline (Antistine)
  • Antipyrine
  • Ascorbic acid (vitamin C)
  • Benzhexol (Artane)
  • Chloramphenicol [high risk for Mediterranean and Asian variants]
  • Chlorguanidine (Proguanil, Paludrine)
  • Chloroquine
  • Colchicine
  • Diphenhydramine (Benadryl)
  • Isoniazid
  • L-Dopa
  • Menadione sodium bisulfite (Hykinone)
  • Menapthone
  • p-Aminobenzoic acid
  • Phenylbutazone
  • Phenytoin
  • Probenecid (Benemid)
  • Procain amide hydrochlonde (Pronestyl)
  • Pyrimethamine (Daraprim)
  • Quinidine
  • Quinine
  • Streptomycin
  • Sulfacytine
  • Sulfadiazine
  • Sulfaguanidine
  • Sulfamerazine
  • Sulfamethoxypyridazine (Kynex)
  • Sulfisoxazole (Gantrisin)
  • Trimethoprim
  • Tripelennamine (pyribenzamine)
  • Vitamin K

Medical Apps for Android

Here, I would like to mention the medical apps that I am using on my android tablet (nexus 7). All of them are available on google playstore for free.

1. Medscape – my favorite reference app; you can have offline access except pictures and videos if you downloaded the data; it is all about:

  1. MEDICAL NEWS FROM MEDSCAPE NEWS
  2. CLINICAL REFERENCE FROM MEDSCAPE REFERENCE – Drugs; Diseases, Conditions & Procedures; Medical Calculators
  3. CONTINUING MEDICAL EDUCATION FROM MEDSCAPE EDUCATION

2. Epocrates – my second-line reference; I like the calculators in it too

3. Calculate by QxMD – Calculate, calculate, calculate everything !

4. NICE Guidance – no need to explain; the name implies; just the UI making me disappointed

5. Prognosis : Your Diagnosis – great case scenarios for clinical practice, judgement and decision; discussion part is really awesome

  • Prognosis : STD
  • Prognosis : Respiratory
  • Prognosis : Diabetes
  • Prognosis : Cardiology
  • Prognosis : Questions

6. Quick LabRef – Quick Clinical Laboratory Values Reference

7. MPR – Monthly Prescribing Reference (MPR) provides concise prescription and OTC drug information, side effects and interactions

8. Ophthalmology – intended for medical students but I found really helpful and informative

9. Heart Sounds & Murmurs – sounds too low to hear with normal speakers in normal surrounding; better study with your headphones (noise cancelled) in a quiet environment

I know there are paid apps out there that are really nice and useful . But, for me the above FREE apps are more than enough.

Nevertheless, if you know any good app for android, please give me a link and the information under the comments below.

Thank you.

Basic clinical guideline for your diabetic patient

Today, let me share a post of my senior doctor, Dr. Khin Swe Myint about an advice and the basic guideline on treating diabetic patients because I see this helpful for junior doctors, GPs and clinicians in their daily practice. Of course, you adjust with your local guidelines and NICE guidelines as culture, eating habit/ dietary pattern, treatment facility etc. may vary.
Here is what she said :

If you are treating any patient with type 2 diabetes, please make sure you go though all check lists, not only to help their glycaemic control but also screen for any micro and macro vascular complication, as well addressing their cardiovascular risk and deal with this.

My advices are:

A. Check list
1. All patients with diabetes must have HbA1c check at least every 6 months bare minimal. Medication adjustment should be based on HbA1c. Not one of “fasting or random glucose” (which is not helpful at all). I am sure it is cheaper than some of specialist consultation fees.

2. Put all patients on statin (either simvastatin 40mg Od or atovastatin 10mg) unless contraindicated or women of child being age who have plan for pregnancy

3. Check their BP– keep target at least <140/90. If evidence of chronic kidney disease keep lower <130/80.

4. Look at their fundi for any retinopathy at least once a year.

5. Once a year, check their feet for any peripheral neuropathy (10 g monofilament and vibration sense will be enough to pick up any early sign) and circulation.

6. Counseling for stop smoking (nicely don’t tell them off)

7. Weight control and regular excercise

8. Labs – U&E, LFT, Lipid profile, urine Albumin creatinine ratio – once a year minimal

9. Please support your patients with some education. This is not only dietary advice but also important of monitoring and watch out for the complication.

B. glyceamic control
1. If you are starting someone with anti diabetes agent, start with Metformin 500mg Od for a week and gradually titrated up to 1g BD if patients can tolerate. Try to avoid if creatinine >150µmol/l and any acute metabolic state (liver failure, uncontrolled heart failure, acute renal failure). Otherwise, it is the safest drug.

2. Next step is to add on Sulphonylurea (e.g., gliclazide- maximal dose is 160mg BD)

3. Then you can add your fancy DDP-4 inhibitor or gliptins if you wish

4. Please learn from your colleagues who had experience in starting people on insulin as inevitably all patients with type 2 will need insulin, the only question is how soon. One easy way to start is adding basal insulin like insulatard e.g., 12 to 16 units at bedtime and titrated with fasting glucose reading.

C. BP control
1. you can start ACE-i. If you do, start small dose, check U&E a week later to make sure it suits and then make sure you titrated up to maximum. This is also applied for patients with microalbumiuria

2. Secondly, add thiazide diuretics which is cheap. It will be a good combination with ACEI. Most Myanmar patients will have high salt intake and therefore, they will response better to diurectics. (Bendroflumethiazide 2.5mg is pretty good start)

3. Then add calcium blocker if BP still not controlled. Do not ever use short acting nifedipine. All CCB are pretty much good. Nifedipine M/R, Amlodipine etc. Do warn patients about potential headache and ankle swelling.

4. For any resistant hypertension patients, check whether they are taking too much liquorice, that can increase BP very high and also hypokalemia. Of course all preserved foods to avoid if possible.

5. Then you add more drugs like alpha blocker (doxazosin etc)

6. Beta blocker may be useful in younger people. If you are using betablocker, I would advice to use Bisoprolol or nevibolol. NOT atenolol. Be ware of Bronchial asthma

D. Know when to refer to specialists
1. If you cannot start insulin by yourselves and patient glycemic control remain poor.

2. In case of acute metabolic complication such as Hyper osmolar nonketotic diabetes state with very high glucose

3. When proliferative retinopathy, new vessels and suspected maculopathy (or sudden reduction in visual acuity)- I will encourage you to invest an ophthalmoscope

4. CKD 3/ 4- they need further assessment including checking for renal bone disease, iron deficiency anaemia etc.

5. Any suspected Charcot joints.

6. Or anything you are not very comfortable looking after.

Enjoys reading. Any question, please let me know.

Pharmacology for Urology

When I was in Urology as a SHO (senior house officer), I have learned my cases and the medications that are used particularly in those urological conditions. So, I made a note for quick review and recall which could be helpful for other junior doctors like me.

First, the two most commonly used drugs in BPH are 5-alpha reductase inhibitors and the alpha blockers. 5-alpha reductase inhibitors have prostate volume reduction effect or apototic effect but the latter have not. However, it takes about 6 months to show the effect of 5-alpha reductase inhibitors and so alpha 1 blockers are used as first line symptomatic agents.

5-alpha reductase inhibitors

Dutasteride and Finasteride – inhibits the conversion of testosterone to dihydrotestosterone; used in combination with alpha-blockers in many cases

Dutasteride (Avodart)dual 5-alpha reductase inhibitor

– 0.5 mg po od

Finasteride (Proscar -5mg and Propecia-1mg) (type 2) 5-alpha reductase inhibitor

– 5mg po od; (1mg od is used in male pattern baldness MPB)

SE –
impotence (1.1% to 18.5%), abnormal ejaculation (7.2%), decreased ejaculatory volume (0.9% to 2.8%), abnormal sexual function (2.5%), gynecomastia (2.2%), erectile dysfunction (1.3%), ejaculation disorder (1.2%) testicular pain and depression. * ?increased risk of high-grade prostate cancer.

pregnancy category X – Mom ! don’t touch the pill, beware of blood transfusion

Alpha Blockers

Selective alpha-1 blockers – Doxazosin, Tamsulosin, Terazosin etc. – inhibits the binding of norepinephrine to the alpha-1 receptors on the membrane of vascular smooth muscle cells

Doxzosin mesylate ( Cardura, Carduran)

Dose: 1mg >>2mg>>4mg>> 8mg (max dose)/day.

Tamsulosin (Flomax, Flomaxtra, Contiflo XL and Urimax) 0.4mg >> 0.8mg od

Two major ADRs (Adverse Drug Reactions) :

  • Immunologic: contains sulfa moiety causing typical reactions to sulfa drugs.
  • Ophthalmologic: ” floppy iris syndrome” during cataract surgery.

Others : Retrograde ejaculation, dizziness and fainting due to BP drop.

N.B. Although prostate specific, it does not have the prostate apoptotic effects of other prostate drugs such as the 5 alpha-reductase inhibitors such as dutasteride and finasteride.

Trial

CombAT (Combination of Avodart and Tamsulosin) trial in 2008,- approved by the FDA on June 14, 2010

provides greater symptom benefits compared to monotherapy with either agent alone for treatment of benign prostatic hyperplasia.

Anticholinergics

Oxybutynin and Tolteredine

Oxybutynin – competitively antagonizes the M1, M2, and M3; also has direct spasmolytic effects on bladder smooth muscle as a calcium antagonist and local anesthetic in very high dose

– used in Overactive bladder/ urinary incontinence; possible treatment of hyperhidrosis

N.B. There was no difference in transdermal oxybutynin and extended-release oral tolterodine.

Contraindications

Untreated angle closure glaucoma and in patients with untreated narrow anterior chamber angles;  partial or complete bowel obstruction, hiatal hernia, GERD, paralytic ileus, intestinal atony of the elderly or debilitated patient, megacolon, toxic megacolon complicating ulcerative colitis, severe colitis and myasthenia gravis. It is also contraindicated in patients with obstructive uropathy and in patients with unstable cardiovascular status in acute hemorrhage.

Tolterodine (DetrolDetrusitol) – acts on M2 and M3

Hormone therapy

Cyproterone acetate CPA (Androcur or Cyprostat) – synthetic steroidal antiandrogen and also has progestogen and antigonadotrophic properties

Uses

1) in OC pills (2mg of CPA +35 or 50mg ehtinyestradiol),

2) hypersexuality, hirsutism, male-female transsexuals (25mg po.bd, up to 100mg/day)

3) metastatic Prostate CA (300mg/day), monitor LFTs, often co-administered with a GnRH agonist and a 5-alpha-reductase inhibitor

SE:  liver toxicity (dose dependent), adrenal suppression (so, monitor cortisol level and U&Es), often co-administered with a GnRH agonist and a 5-alpha-reductase inhibitor

Flutamide – oral, non-steroidal antiandrogen drug, has been largely replaced by Bicalutamide (Casodex, Cosudex, Calutide, Kalumid) –

Uses

1) stage D2 metastatic prostate cancer in combination with a LHRH analogue or as a monotherapy.

2) hirsutism, trials in Ovarian CA , also used in combination with castration

3) andogen receptor positive ER-/PR- metastatic breast cancer

Dose – 50mg po od (recommended same time each day)

Leuprolein or Leuprolide acetate -pituitary GnRH analogue

Pregnancy Category X

Uses: Hormone responsive cancers (Prostate CA, breast CA),

Use in Gynecology – precocious puberty, gender incongruency,  menorrhagia, endometriosis, adenomyosis, Uterine fibroids, in IVF(in vitro fertilization) – control of ovarian hyperstimulation,

Severe cases of CAH (congenital adrenal hyperplasia)

also, possible treatment for Paraphilia and Alzheimer’s dz

SE: s/s of hypo-estrogenism such as headache, hot flushes and osteoporosis

increased risk of heart problems by ~30% (when used for advanced CA Prostate)

Urinary Alkalinizing Agents

Potassium citrate (Cytra-K, Urocit K)

Urinary citrate <150 mg/day: 60 mEq/day PO (20 mEq with each meal) OR

Urinary citrate >150 mg/day: 30 mEq/day PO (10 mEq with each meal)

Maintenance –

  • Titrate dose to achieve urinary citrate 320-640 mg/day & urinary pH 6.0-7.0 (maximum dose 100 mEq/day)

Local Analgesic

Phenazopyridine – Azo dye; 100mg-200mg po tid (no more than 2 days)

used in severe dysuria;  post-procedures

Bleeding control

tranexamic acid (Cyklokapron, Lysteda) – Inhibits fibrinolysis through inhibition of plasminogen activator substances; also exhibits antiplasmin activity

used in conjunction with bladder irrigation in hematuria cases

Alright, I think you should be ready to go to urology unit by now. Good Luck!

N.B. I have also used Doxorubicin (Adriamycin) in many cases with TCC bladder; it is an Anthracycline that intercalates between DNA base pairs, impairs topoisomerase II function and inhibits replication & transcription

Add other drugs and noteworthy facts in the comments below please.

Benign Lymphoepithelial lesion

  • Mikulicz’s disease – bilateral parotid and lacrimal gland enlargement
  • Mikulicz’s Syndrome – secondary to another disease, such as tuberculosis, sarcoidosis, lymphoma, and Sjögren’s syndrome
  • most likely to occur in adults >50 yrs; female preponderance
  • may need biopsy to differentiate  sialadenosis (sialosis)