Kerala State Drug Formulary

KERALA STATE DRUG FORMULARY
NUMBER 2
(April 2009)
DEPARTMENT OF PHARMACOLOGY
GOVERNMENT MEDICAL COLLEGE
THIRUVANANTHAPURAM INDIA
CENTRAL DRUG FORMULARY COMMITTEE Directorate of Medical Education, Thiruvananthapuram 695 011, Kerala State All rights reserved No part of this publication may be reproduced, stored in a retrieval system and transmitted in any form without prior written permission of the Government of Kerala. Copies can be obtained from the Directorate of Medical Education. Prices for most of the drugs provide an indication of relative cost of medicines for cost effective prescribing. Prices given are not absolute and may change from time to time according to market variations. The committee shall not be liable for any damages incurred as a result of using information contained in this formulary. Comments and constructive criticism are welcome and should be sent to the above mentioned committee.
CENTRAL DRUG FORMULARY COMMITTEE

CHAIRMAN :
Dr. K.V. KRISHNADAS, B.Sc., MBBS, FRCP, FAMS, DTM & H,

Director and Professor of Medicine and Vice Principal (Retd.) Government Medical College, Thiruvananthapuram. CONVENOR : Dr. RENEEGA GANGADHAR, M.D. Professor & Head, Department of Pharmacology Government Medical College, Thiruvananthapuram. MEMBERS : 1. Dr. V. Geetha, Director of Medical Education. 2. Dr. Shylaja, Director of Health Services 3. Dr. C. Sudheendra Ghosh, Joint Director of Medical Education. 4. Dr. Ramdas Pisharody, Principal, Government Medical College, Thiruvananthapuram. 5. Dr. B Jayakumar, Professor & Head, Department of Medicine, Government Medical College, Thiruvananthapuram. 6. Dr. Lalitha Kailas, Professor & Head, Department of Paediatrics, Government Medical College, Thiruvananthapuram. 7. Dr. Abdul Salim, Professor & Head of Surgery, Government Medical College, Thiruvananthapuram. 8. Dr. Ramani P.T., Professor of Pharmacology, Government Medical College, Thiruvananthapuram. 9. Dr. Raymond Morris, Professor & Head, Department of Neurosurgery, Government Medical College, Thiruvananthapuram. iii
10. Dr. C.P. Vijayan, Professor of O & G, Government Medical College, Kottayam. 11. Dr. Thomas Mathew, Professor & Head, Department of Community Medicine, Government Medical College, Alappuzha. 12. Dr. Krishnan Namboodhiri, Professor & Head, Department of Cardiology, Government Medical College, Kozhikode. 13. Dr. Joyamma, Professor of Pharmacology, College of Pharmaceutical Sciences, Government Medical College, Thiruvananthapuram. SCIENTIFIC ASSISTANTS 1. Dr. Dhanya T.H., Department of Pharmacology, Government Medical College, Thiruvananthapuram. 2. Dr. Gayathri M Kapse, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 3. Dr. Jesitha Jayaraj, Department of Pharmacology, Government Medical College, Thiruvananthapuram. COMPUTER PROGRAMMERS 1. Dr. Deepu Jacob Chacko, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 2. Dr. Amal Abraham Mathew, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 3. Mr. Rethna Senan, Department of Pharmacology, Government Medical College, Thiruvananthapuram.
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LIST OF CONTRIBUTORS
1. Dr. K.V. Krishna Das, Director & Professor of Medicine and Vice Principal (Retd.), Government Medical College, Thiruvananthapuram. 2. Dr. Reneega Gangadhar, Professor & HOD of Pharmacology Government Medical College, Thiruvananthapuram. 3. Dr.C.Sudheendra Ghosh, Joint Director of Medical Education 4. Dr. Ramdas Pisharody, Principal & Dr Jacob George, HOD in charge, Department of Nephrology, Government Medical College, Thiruvananthapuram. 5. Dr. Shylaja, Director of Health Services & Deputy Directors of Health Services Dr Lali D.L and Dr Molly Paul 6. Dr. Lalitha Kailas, Professor & HOD of Paediatrics, SAT Hospital, Government Medical College Thiruvananthapuram. 7. Dr. K. Rajmohan, Associate Professor of Paediarics, SAT Hospital and Directory CERTC, Government Medical College, Thiruvananthapuram. 8. Dr. K.L Jayakumar, Professor & Head & Dr. R. Sivaramakrishnan, Associate Professor, Department of Radiotherapy, Government Medical College, Thiruvananthapuram. 9. Dr. Manoj T, Assistant Professor, Department of Radiodiagnosis, Government Medical College, Thiruvananthapuram. 10. Dr. K. Suresh,Professor & Head and Dr James Department of Cardiology, Government Medical College, Thiruvananthapuram. 11. Dr. B. Jayakumar, Professor & Head, Dr Jayaprakash Nath and Dr Vipin V.P Department of Medicine, Government Medical College, Thiruvananthapuram. 12. Dr. Usha K.C,Professor & HOD of Transfusion Medicine, Government Medical College, Thiruvananthapuram. 13. Dr. K. Anitha Kumari, Professor & Head and Dr Nandini V Respiratory Medicine, Government Medical College, Thiruvananthapuram. 14. Dr. K.R. Vinayakumar, Vice Principal & Professor & HOD of Medical Gastroenterology, Government Medical College, Thiruvananthapuram.
15. Dr. Biju John, Assistant Professor, Department of Ophthalmology, RIO, Government Medical College Thiruvananthapuram. 16. Dr. K.P. Jhansi, Professor & Head and Dr. Regi Mohan, Senior Lecturer, Department of O&G, SAT Hospital, Government Medical College Thiruvananthapuram. 17. Dr. Vijayalakshmi L,Professor & HOD of Nutrition, Government Medical College, Thiruvananthapuram. 18. Dr. Abdul Salim,Professor & HOD of Surgery, Government Medical College, Thiruvananthapuram. 19. Dr. Mini S.S, Assistant Professor, Department of Community Medicine, Government Medical College, Thiruvananthapuram. 20. Dr. Thomas Iype,Professor & HOD of Neurology, Government Medical College, Thiruvananthapuram. 21. Dr. D. Raju,Professor & HOD of Psychiatry, Government Medical College, Thiruvananthapuram. 22. Dr. Joyamma Varkey, Professor of Pharmacology, College of Pharmaceutical Science, Government Medical College, Thiruvananthapuram. 23. Dr. Devayani,Professor & HOD of Anaesthesiology, Government Medical College, Thiruvananthapuram. 24. Postgraduates of the Department of Pharmacology, Government Medical College Thiruvananthapuram Dr. Dhanya T.H, Dr. Gayathri M. Kapse, Dr. Jesitha Jayaraj, Dr. Deepu Jacob Chacko, Dr. Amal Abraham Mathew, Dr. Siddalingesh Salimath and Dr. Meenakshy T.V, Dr S P Dhanya 25. Faculties of the Department of Pharmacology Government Medical College, Thiruvananthapuram Dr Ramani P.T, Dr Bindu Latha Nair.R, Dr Asha S, Dr Annapurna Y, Dr Ajith Thomas, Dr Syam S, Dr Nasar A, Dr Shermin Nasreen, Dr Parvathy V Nair, Dr Prasanth M, Dr Resmi Douglas, Dr Dawnji S.R, Dr Preeja K.S 26. Dr. P. V. Narayanan, Professor & Head and Dr Anuradha, Assistant Professor Department of Pharmacology and HODs of other Departments, Government Medical College, Calicut. 27. Dr. Elsy M.I, Professor & HOD of Pharmacology and HODs of other Departments, Government Medical College, Thrissur. 28. Dr. Pradeep S, Professor & Head and Dr Manju Nair, Assistant Professor Department of Pharmacology and HODs of other Departments, Government Medical College, Alappuzha. 29. Dr. Kala Kesavan, Professor & HOD of Pharmacology and HODs of other Departments, Government Medical College, Kottayam.
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FOREWORD
Medicines play a crucial role in the prevention and treatment of diseases. When used correctly, they can offer simple and cost effective solutions to many health problems. Today many people have little access to safe and effective drug therapies and may be at risk of serious health problems due to treatment with ineffective, poor quality products, or incorrect and irrational use of medicines. This drug formulary can be a useful tool in solving some of these problems as they can provide impartial and correct drug information to fill the gaps, wherever up to date information is not available. It may also help to promote rational use of safe medication and cost effective utilization of drugs besides improving the access to essential medicines. It can bring focus on available and affordable medicines that are most relevant to the treatment of diseases. The guidelines for first line management of clinical emergencies encountered in peripheral hospitals will also help those doctors who manage hospitals single handed. I am sure this book will be of immense help and contribute positively in the development of a better Health Care System. The committee led by Dr. K.V Krishna Das, Chairman and Dr. Reneega Gangadhar, Convener has put in commendable efforts in preparation of this book in a meticulous manner in a limited time and deserves all appreciation and encouragement of the medical fraternity and the public at large. I am very happy to foreword this on behalf of all those who were actively involved in this unique venture, which make Kerala a Role Model in Health Care Services.
DR. VISHWAS MEHTA IAS
Secretary to Government,
Health and Family Welfare Department Kerala
vii
PREFACE
SECOND EDITION OF KERALA STATE DRUG FORMULARY APRIL 2009 The need for a drug formulary and practice guidelines for its health care personnel working in the various hospitals and other health care related institutions in Kerala State has been recognized by the Government as early as 1997 and the first edition of the Drug Formulary was published in the year 1999 (April). This book was distributed to the various hospitals for use by the doctors and paramedics. It is now 10 years since the first edition was published. It has served its purpose in a limited way by acting as a reliable source of ready reference when facing medical emergencies. It also contained sections dealing with the directions for maintaining drug stocks in different level hospitals based on morbidity patterns prevailing then, and the prescribing practices of the doctors. Part II of this book gives the emergency management of several diseases and indications regarding further management had also been added. The Government desired to publish the second edition of the Kerala State Drug Formulary before the end of this financial year. A committee was formed at the Directorate of Medical Education to update the existing drug formulary. This second edition is the result of the effort of this committee which met repeatedly to complete the task assigned to it. Part I deals with the essential details of common drugs used by doctors in the State, with particular emphasis on the essential drug list formulated by the Government of India. Unbiased drug information is given. The cost factor of drugs with similar action has been given to enable the doctor to manage the patients cost effectively. Section 19 gives information on vaccines and immunoglobulins.Part II dealing with the primary management of medical emergencies has been trimmed to contain only the emergencies. Elective Management of several diseases has been removed since the Kerala Government is in the process of publishing a treatment Guideline Manual, which will contain the management guidelines for most of the diseases - both acute and chronic. Part III A contains list of Essential drugs to be stocked at different levels in Government hospitals. Part III B gives the details of the National Programmes formulated by the Government of India and implemented through the State Governments. Acknowledgement: The Central Drug Formulary Committee headed by viii
Dr. V. Geetha, Director of Medical Education (DME), Dr. C. Sudhendra Ghosh, JDME and Dr. Ramdas Pisharody, Principal,Government Medical College, Thiruvananthapuram did the organizational work in planning the whole project, facilitating interaction between the contributors, arranging meetings and procuring funds for updating of formulary. The interest shown by the Honble. Minister for Health and Family Welfare Smt. Sreemathy teacher, was the starting point of this project.Dr. Vishwas Mehta IAS, Secretary to Government,Health and Family Welfare evinced very keen interest in getting this project completed and his timely action and advices have guided the Drug Formulary Committee to proceed ahead without hitch to complete the assignment. Dr. Reneega Gangadhar,Professor and Head of Department of Pharmacology acted as the kingpin for the project, by collecting the material from the contributors, editing them, interacting with the printers, correcting the proof and bringing the material to the present shape. In this stupendous task she had the full cooperation and services of the department teaching faculties Dr Ramani P.T, Dr Bindu Latha Nair.R, Dr Asha S, Dr Annapurna Y, Dr Ajith Thomas, Dr Syam S, Dr Nasar A, Dr Shermin Nasreen, Dr Parvathy V Nair, Dr Prasanth M, Dr Resmi Douglas, Dr Dawnji S.R, Dr Preeja K.S and postgraduate students Dr. Dhanya T.H, Dr. Gayathri M Kapse, Dr. Jesitha Jayaraj, Dr. Deepu Jacob Chacko, Dr. Amal Abraham Mathew, Dr. Meenakshy T.V,Dr. Siddalingesh Salimath and Dr S P Dhanya who spent long hours on updating this project.Secretarial assistance rendered by Mr. RethnaSenan and timely organizational assistance from the other non teaching staff are acknowledged.The photographer Mr Rajmanu,artist Mr Rajashekaran Nair and modeller Mr Byju S.R have taken lot of pains in preparing the cover of this book and they deserve our heartfelt thanks.The prompt services of the office staff of the Directorate of Medical Education and Principals office are all acknowledged. The printing undertaken by Kerala State Audio Visual and Reprographic Centre, Head Office Complex, Thiruvananthapuram- 13 was completed within the stipulated time and the services of the staff from this centre are all gratefully acknowledged.
K.V. KRISHNADAS
Chairman
Drug Formulary Committee ix
INTRODUCTION
The Kerala State Drug Formulary was first published in April 1999. For updating the above formulary care has been taken to delete obsolete drugs, to add more essential drugs, to modify drug entries and bring possible changes in scope and presentation. This second edition is developed to complement the National Essential Drug List of India. We have followed the structure and topics used in the Essential Drug List. It gives unbiased drug information including adverse effects, drug interactions and costs of most medications. The basic information on drugs is drawn from various standard resources like Martindales Pharmacopoeia, WHO formulary 2008 and Medical literature. It also takes into account guidelines for emergency management at peripheral hospitals carefully prepared by Dr. K.V. Krishnadas, Former Director and Professor of Medicine, Government Medical College, Thiruvananthapuram and Chairman of the Committee. Drugs in pregnancy, breast feeding, liver and renal diseases are also included .An ADR reporting form is also attached which can be photocopied for ADR reporting or downloaded from the site www.cdsco.nic.in. It is hoped that this publication will serve as a ready reference and guide for medical practitioners, pharmacists, dentists, nurses, house surgeons, postgraduates and others who have the necessary training and experience to interpret the information it provides.
DR. SUDHEENDRA GHOSH JDME DR. RENEEGA GANGADHAR Convenor

Central Drug Formulary Committee
DR.V. GEETHA DME
ABBREVIATIONS
A/E .......................... amp ......................... BD/bid/bd ................. bw ........................... C/I ........................... Cap .......................... CNS .......................... D/I ........................... g ............................. GI/GIT ...................... hs ............................ I .............................. IG ............................ IM ........................... Inj ........................... IV ............................ IU ............................ kg ............................ L ............................. max .......................... mcg ......................... mdi .......................... mg ........................... min .......................... mL ........................... od ........................... P/A .......................... P/C .......................... q ............................. qid/qds ..................... SC ........................... SJS .......................... SLE .......................... sos .......................... SR ........................... stat .......................... tab .......................... tid/tds ...................... adverse effects ampoule two times daily body weight contraindication capsule central nervous system drug interaction gram gastro intestinal tract at bed time indication Immunoglobulin intramuscularly injection intravenously international units kilogram litre maximum microgram metered dose inhalation milligram minute milliliter once daily preparations available precaution every four times daily subcutaneously Steven Johnsons Syndrome Systemic Lupus Erythematosus when required sustained release immediately tablet three times daily xi
CONTENTS
PART I GENERAL ADVICE TO PRESCRIBERS ........................................ 1 Rational approach to therapeutics ........................................ 1 Variation in dose response .................................................. 3 Adherence with drug treatment ........................................... 5 Adverse effects and drug interactions ................................... 8 P drug concept ............................................................ 11 Prescription writing ........................................................ 12 Sample Prescription ........................................................ 14 Assessing cost effectiveness in clinical Medicine ..................... 14 SECTION 1: DRUGS USED IN ANAESTHESIA ............................ 18 General anaesthetics and oxygen ...................................... 18 Local Anaesthetics ......................................................... 22 Preoperative medication and sedation ................................. 27 Muscle relaxants ............................................................ 30 SECTION 2: ANALGESICS, ANTIPYRETICS, NONSTEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS),MEDICINES USED TO TREAT GOUT, DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDS) ...................................................... 31 Non opioid Non steroidal anti-inflammatory drugs .................... 31 Opioid analgesics ............................................................ 38 Disease modifying agents used in Rheumatoid disorders ............ 42 Drugs used in Gout ......................................................... 47 SECTION 3: ANTICONVULSANTS / ANTIEPILEPTICS .................. 49 SECTION 4: ANTIINFECTIVE DRUGS .................................... 61 Antimicrobials ................................................................ 61 Antileprotic drugs .......................................................... 83 Antituberculous drugs ..................................................... 83 Antifungal drugs ............................................................. 83 Antiviral drugs ............................................................... 85 xii
Antiretroviral drugs ......................................................... 88 Antimalarial drugs ........................................................... 91 Antiamoebic and other antiprotozoal drugs ........................... 95 Anthelmintic drugs .......................................................... 99 Antifilarial drugs ............................................................ 101 SECTION 5: ANTIMIGRAINE DRUGS .................................. 103 Treatment for acute migraine attack .................................. 103 Migraine prophylaxis ....................................................... 104 SECTION 6: ANTINEOPLASTIC DRUGS ............................... 105 Alkylating agents ........................................................... 105 Antimetabolites ............................................................. 107 Cytotoxic antibiotics ...................................................... 110 Taxanes ...................................................................... 113 Mitotic inhibitors .......................................................... 113 Miscellaneous agents ...................................................... 114 Hormones and hormonal antagonists ................................... 115 Biological response modifiers ............................................ 117 Targeted agents ............................................................ 117 Tyrosine kinase inhibitors ............................................... 118 Bisphosphonates ........................................................... 118 Cytoprotective agents .................................................... 119 Antiemetics used in cancer chemotherapy ......................... 119 SECTION 7 : ANTIPARKINSONIAN DRUGS ........................... 120 SECTION 8: DRUGS ACTING ON BLOOD AND BLOOD FORMING ORGANS ............................................... 127 Antianaemic drugs ......................................................... 127 Drugs affecting coagulation .............................................. 128 Haemolytic anaemias ...................................................... 131 Haemoglobinopathies ...................................................... 131 Iron chelating drugs ....................................................... 132 Drugs used in Leukaemias ................................................ 133 xiii
Plasma cell dyscrasias ..................................................... 138 Antiplatelet drugs .......................................................... 138 Thrombolytics .............................................................. 139 Antifibrinolytics ............................................................ 142 SECTION 9: BLOOD PRODUCTS AND PLASMA SUBSTITUTES .... 144 Whole blood / components ............................................ 144 Plasma substitutes ......................................................... 146 Plasma fractions for specific use ........................................ 147 SECTION 10: CARDIOVASCULAR DRUGS ............................ 151 Drugs used in the treatment of Angina ................................ 151 Drugs used in thrombolytic therapy .................................... 155 Antiplatelet drugs .......................................................... 156 Anticoagulants .............................................................. 156 Lipid lowering drugs ....................................................... 156 Antihypertensive drugs ................................................... 158 Drugs used in pulmonary hypertension .............................. 173 Drugs used in Heart failure .............................................. 174 Antiarrhythmic drugs ...................................................... 176 Positive inotropic agents ................................................. 180 SECTION 11: DERMATOLOGICAL DRUGS ........................... 182 Superficial mycosis ......................................................... 182 Deep mycosis ............................................................... 184 Antibacterials topical and systemic use .............................. 186 Antiinflammatory and antipruritic medicines ......................... 187 Drugs used in Psoriasis .................................................... 188 Drugs for warts ............................................................. 190 Scabicides and pediculocides ........................................... 191 Other dermatological conditions ....................................... 192 Drugs used in Leprosy .................................................... 195 SECTION 12: DIAGNOSTIC AGENTS ................................... 199 Radio contrast media ...................................................... 199 xiv
Dyes used in ophthalmology ............................................. 204 SECTION 13: DISINFECTANTS AND ANTISEPTICS .................. 205 SECTION 14: DIURETICS ................................................ 210 SECTION 15: DRUGS USED IN DENTISTRY ........................... 215 SECTION 16: DRUGS USED IN ENT INFECTIONS .................... 218 SECTION 17: GASTROINTESTINAL DRUGS ........................... 222 Antacids and ulcer healing drugs ....................................... 222 Antispasmodics ............................................................. 225 Antiemetics and prokinetics ............................................. 226 Antidiarrhoeals ............................................................. 228 Laxatives ..................................................................... 230 Drugs used in inflammatory bowel diseases ........................... 233 Drugs used in gall stones ................................................ 235 Antihaemorrhoidal drugs .................................................. 236 SECTION 18: HORMONES AND OTHER ENDOCRINE DRUGS ...... 237 Adrenal hormones and synthetic substance ......................... 237 Sex Hormones .............................................................. 242 Androgens ................................................................... 242 Antiandrogens .............................................................. 243 Contraceptives ............................................................. 244 Oestrogens and antioestrogens ......................................... 244 Progestins and antiprogestins ........................................... 247 Ovulation inducers ......................................................... 248 Insulins and other Antidiabetic drugs .................................. 248 Thyroid hormones and antithyroid drugs .............................. 253 Vitamin D derivatives ....................................................... 255 Bisphosphonates ........................................................... 256 SECTION 19: IMMUNOLOGICALS ...................................... 258 Sera and immunoglobulin ................................................. 258 Vaccines ..................................................................... 261 SECTION - 20: IMMUNOSUPPRESSANT DRUGS ...................... 267 xv
SECTION - 21 : DRUGS USED IN DISEASES OF KIDNEY AND URINARY TRACT ..................................................... 272 SECTION - 22: MUSCLE RELAXANTS AND ANTICHOLINESTERASES .................................................. 281 SECTION - 23: OPHTHALMOLOGICAL PREPARATIONS ............. 289 Antibacterial agents ...................................................... 289 Antiviral agents ............................................................. 290 Antifungal agents ........................................................... 290 Antiseptics .................................................................. 291 Corticosteroids ............................................................. 291 Topical NSAIDS ............................................................ 292 Antiallergics ................................................................. 292 Drugs used in medical management of glaucoma .................... 292 Mydriatics , miotics , and cycloplegic drugs ......................... 293 Ocular lubricants .......................................................... 295 Local anaesthetics ......................................................... 295 Nutritional disorders affecting the eye ................................ 295 SECTION - 24: DRUGS USED IN OBSTETRICS AND GYNAECOLOGY ............................................................ 296 Nutritional requirement in pregnancy ................................ 296 Drugs and pregnancy ...................................................... 296 Dos and donts in pregnancy ........................................... 297 Oxytocics .................................................................... 298 Induction of labour ........................................................ 300 Induction of abortion ..................................................... 301 Vaginitis ...................................................................... 302 Contraceptives ............................................................. 303 Drugs for induction of ovulation ........................................ 304 Drugs used in DUB ....................................................... 305 Hypertension in pregnancy .............................................. 306 Tocolytics ................................................................... 306 SECTION - 25: PSYCHOTHERAPEUTIC DRUGS ........................ 307 xvi
Antipsychotic drugs ....................................................... 307 Antidepressants ............................................................ 315 Mood stabilizers ............................................................ 324 Anxiolytics ................................................................... 325 Sedative hypnotics ......................................................... 328 Drugs used in substance dependence ................................. 329 SECTION - 26: PAEDIATRIC DRUGS AND NUTRITION ................. 331 SECTION 27: DRUGS USED IN RESPIRATORY DISEASES ............ 360 SECTION 28 : SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACID BASE DISTURBANCES ...................... 379 SECTION - 29: VITAMINS AND MINERALS ............................ 398
PART - II
Guidelines for First Line Management of Clinical Emergencies encountered in Peripheral Hospitals
1. General Topics .................................................... 407 Hyperpyrexia ....................................................... 407 Acute anaphylactic reactions ................................... 408 Toxicology .......................................................... 410 Envenomation ...................................................... 418 Drowning ............................................................ 423 2 Paediatrics ......................................................... 424 Diarrhoea and dehydration ...................................... 424 Acute severe asthma ............................................. 426 Asthma in children <5 years ..................................... 428 Resuscitation of newborn ....................................... 429 Poisoning in children ............................................. 430 3. Cardiology ......................................................... 433 Chest pain .......................................................... 433 Angina pectoris .................................................... 435 Shock ................................................................ 437 xvii
Cardiac arrest ...................................................... 439 Acute cardiogenic pulmonary oedema ........................ 441 Cardiac tamponade ................................................ 442 Hypertensive emergencies ...................................... 442 4. Respiratory system .............................................. 446 Acute respiratory failure ........................................ 446 Acute severe asthma ............................................. 447 Foreign body aspiration .......................................... 448 Haemoptysis ........................................................ 449 Tension Pneumothorax ........................................... 450 Pleural effusion .................................................... 451 Chronic asthma in adults ......................................... 452 Pulmonary embolism .............................................. 452 5. 6. Alimentary system ............................................... 453 Hemetemesis ....................................................... 453 Endocrinology .................................................... 456 Diabetic ketoacidosis ............................................. 456 Hypoglycemia ....................................................... 457 Thyroid storm ...................................................... 458 Myxoedema coma ................................................. 459 Adrenal crisis ....................................................... 460 7. Neurology ......................................................... 461 Coma ................................................................. 461 Status epilepticus ................................................. 462 Cerebrovascular occlusive disease ............................. 463 8. 9. Nephrology ........................................................ 464 Acute renal failure ................................................ 464 Obstetrics & Gynaecology ...................................... 465 Hyperemesis gravidarum .......................................... 465 Ectopic gestation .................................................. 465 Antepartum Haemorrhage ....................................... 466 xviii
Eclampsia ............................................................ 466 Preterm Labour .................................................... 467 Prelabour rupture of membranes .............................. 467 Postpartum haemorrhage ........................................ 468 10. Ear,Nose and Throat ............................................. 468 Epistaxis ............................................................. 468 Acute laryngeal edema due to allergic angioedema ........ 469 11. Ophthalmology ................................................... 469 Foreign body in the eye ......................................... 469 Chemical burns ..................................................... 469 Conjunctivitis ....................................................... 470 Corneal ulcer ....................................................... 470 Recognition of Refractive error in child ...................... 470
PART - III
A. List of essential drugs to be stocked in the Government Hospitals .......................................... 471 Primary care hospitals ( Dispensary and mini PHC ) ...... 471 Secondary care hospitals ( Block PHCs and CHCs) .......... 475 Taluk Hospital ...................................................... 481 Tertiary hospitals (District/General hospitals and Medical College Hospitals) ....................................... 491 B. National Health programmes of India ........................ 504 Reproductive Child Health (RCH) ............................... 504 Diarrhoea control programme and ORS programme ........ 506 Acute Respiratory Infection Control programme ............ 508 National programme for prophylaxis against blindness in children due to Vitamin A deficiency ......... 508 National Immunization schedule ................................ 509 National TB control programme ................................ 510 National Vector Borne disease Control Programme ......... 511 National AIDS control programme .............................. 513 xix
APPENDICES: Appendix 1: Pregnancy ................................................ 515 Appendix 2: Breast feeding ........................................... 524 Appendix 3: Renal impairment ...................................... 528 Appendix 4: Hepatic impairment .................................... 532 Appendix 5: Drug Schedules and Acts .............................. 536 Appendix 6: List of Emergency medicines/ Life saving drugs . 537 Appendix 7: Essential drug list (India) 2003 ...................... 538 Appendix 8: List of drugs banned in India ......................... 559 Appendix 9: Adverse drug event reporting form ................ 565
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PART - I
GENERAL ADVICE TO PRESCRIBERS
Rational approach to therapeutics Variation in dose response Adherence(compliance) with drug treatment Adverse effects and interactions P-drug concept Prescription writing Sample prescription Assessing cost effectiveness in drug therapy RATIONAL APPROACH TO THERAPEUTICS Drugs should only be prescribed when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risks involved. Bad prescribing habits lead to ineffective and unsafe treatment, exacerbation or prolongation of illness, distress and harm to the patient, and higher cost.

The following steps will help to remind prescribers of the rational approach to therapeutics.
1.
Define the patients problem
Whenever possible, making the right diagnosis is based on integrating many pieces of information: the complaint as described by the patient; a detailed history; physical examination; laboratory tests; X-rays and other investigations. This will help in rational prescribing, always bearing in mind that diseases are evolutionary processes.
2.
Specify the therapeutic objective
Doctors must clearly state their therapeutic objectives based on the pathophysiology underlying the clinical situation. Very often physicians must select more than one therapeutic goal for each patient.
3.
Selecting therapeutic strategies
The selected strategy should be agreed with the patient; this agreement on outcome, and how it may be achieved, is termed concordance.The selected treatment can be non-pharmacological and/or pharmacological; it also needs to take into account the total cost of all therapeutic options. 1
General advice to Prescribers
a.
Non-pharmacological treatment It is very important to bear in mind that the patient does not always need a drug for treatment of the condition. Very often, health problems can be resolved by a change in life style or diet, use of physiotherapy or exercise, provision of adequate psychological support, and other non-pharmacological treatments; these have the same importance as a prescription drug, and instructions must be written, explained and monitored in the same way. b. Pharmacological treatment Selecting the correct group of drugs Knowledge about the pathophysiology involved in the clinical situation of each patient and the pharmacodynamics of the chosen group of drugs, are two of the fundamental principles for rational therapeutics. Selecting the drug from the chosen group The selection process must consider benefit/risk/cost information.This step is based on evidence about maximal clinical benefits of the drug for a given indication (efficacy) with the minimum production of adverse effects (safety).It must be remembered that each drug has adverse effects and it is estimated that up to 10% of hospital admissions in industrialized countries are due to adverse effects. Not all drug-induced injury can be prevented but much of it is caused by inappropriate selection of drugs. In cost comparisons between drugs, the cost of the total treatment and not only the unit cost of the drug must be considered. Verifying the suitability of the chosen pharmaceutical treatment for each patient The prescriber must check whether the active substance chosen, its dosage form, standard dosage schedule and standard duration of treatment are suitable for each patient. Drug treatment should be individualized to the needs of each patient. Prescription writing The prescription is the link between the prescriber, the pharmacist (or dispenser) and the patient so it is important for the successful management of the presenting medical condition. This item is covered in more detail in the following section. Giving information, instructions and warnings This step is important to ensure patient adherence and is covered in detail in the following section. 2
Monitoring treatment Evaluation of the follow up and the outcome of treatment allows the stopping of it (if the patients problem is solved) or to reformulate it when necessary. This step gives rise to important information about the effects of drugs contributing to building up the body of knowledge of pharmacovigilance, needed to promote the rational use of drugs. VARIATION IN DOSE RESPONSE Success in drug treatment depends not only on the correct choice of drug but on the correct dose regimen. Unfortunately drug treatment frequently fails because the dose is too small or produces adverse effects because it is too large.This is because most texts, teachers and other drug information sources continue to recommend standard doses.The concept of a standard or average adult dose for every medicine is firmly rooted in the mind of most prescribers. After the initial dose ranging studies on new drugs, manufacturers recommend a dosage that appears to produce the desired response in the majority of subjects. These studies are usually done on healthy, young male Caucasian volunteers, rather than on older men and women with illnesses and of different ethnic and environmental backgrounds. The use of standard doses in the marketing literature suggest that standard responses are the rule, but in reality there is considerable variation in drug response. There are many reasons for this variation which include adherence (see below), drug formulation, body weight and age, composition, variation in absorption, distribution, metabolism and excretion,variation in pharmacodynamics, disease variables, genetic, and environmental variables.
Drug formulation
Poorly formulated drugs may fail to disintegrate or to dissolve. Entericcoated drugs have been known to pass through the gastrointestinal tract intact. In drugs with a narrow therapeutic to toxic ratio, changes in absorption can produce sudden changes in drug concentration. For such drugs, quality control surveillance should be carried out.
Body weight and age

Although the concept of varying the dose with the body weight or age of children has a long tradition, adult doses have been assumed to be the same irrespective of size or shape. Yet adult weights vary two to threefold, while a large fat mass can store large excesses of highly lipid soluble drugs compared to lean patients of the same weight.Age changes can also be important. Adolescents may oxidize some drugs relatively more rapidly than adults, while the elderly may have reduced renal function and eliminate some drugs more slowly. 3
Dose Calculation in Children. Childrens doses may be calculated from adult doses by using age, body weight, or body surface area, or by a combination of these factors. The most reliable methods are those based on body surface area.Body weight may be used to calculate doses expressed in mg/kg. Young children may require a higher dose per kilogram than adults because of their higher metabolic rates. Other problems need to be considered. For example, calculation by body weight in an overweight child may result in much higher doses being administered than necessary; in such cases, dose should be calculated from an ideal weight, related to height and age. Nomograms are available to allow body surface values to be calculated from a childs height and weight.Where the dose for children is not readily available, prescribers should seek specialist advice before prescribing for a child.
Physiological and pharmacokinetic variables

Drug absorption rates may vary widely between individuals and in the same individual at different times and in different physiological states. Drugs taken after a meal are delivered to the small intestine much more slowly than in the fasting state, leading to much lower drug concentrations. In pregnancy gastric emptying is also delayed, while some drugs may increase or decrease gastric emptying and affect absorption of other drugs.
Drug distribution
Drug distribution varies widely: fat-soluble drugs are stored in adipose tissue, water-soluble drugs are distributed chiefly in the extracellular space, acidic drugs bind strongly to plasma albumin and basic drugs to muscle cells. Hence variation in plasma-albumin concentration, fat content or muscle mass may all contribute to dose variation. With very highly albumin bound drugs like warfarin, a small change of albumin concentration can produce a big change in free drug and a dramatic change in drug effect.
Drug metabolism and excretion

Drug metabolism is affected by genetic, environmental, and diseasestate factors. Drug acetylation shows genetic polymorphism, whereby individuals fall clearly into either fast or slow acetylator types. Drug oxidation, however, is polygenic, and although a small proportion of the population can be classified as very slow oxidizers of some drugs, for most drugs and most subjects there is a normal distribution of drug metabolizing capacity.Many drugs are eliminated by the kidneys without being metabolized. Renal disease or toxicity of other drugs on the kidney can therefore slow excretion of some drugs. 4
Pharmacodynamic variables There is significant variation in receptor response to some drugs, especially central nervous system responses, for example pain and sedation. This can be because of genetic factors, tolerance, drug interactions, and drug dependence. Disease variables Both liver disease and kidney disease can have major effects on drug response, chiefly by the effect on metabolism and elimination respectively (increasing toxicity), but also by their effect on plasma albumin (increased free drug also increasing toxicity). Heart failure can also affect metabolism of drugs with rapid hepatic clearance (for example lidocaine, propranolol). Respiratory disease and hypothyroidism can impair drug oxidation. Environmental variables Many drugs and environmental toxins can induce the hepatic microsomal enzyme oxidizing system or cytochrome P450 oxygenases, leading to more rapid metabolism and elimination and ineffective treatment. Environmental pollutants, anaesthetic drugs and other compounds such as pesticides can also induce metabolism. Diet and nutritional status also affect pharmacokinetics.For example in infantile malnutrition and in malnourished elderly populations drug oxidation rates are decreased, while high protein diets, charcoal cooked foods and certain other foods act as metabolizing enzyme inducers. Chronic alcohol use induces oxidation of other drugs, but in the presence of high circulating alcohol concentrations drug metabolism may be inhibited. ADHERENCE (COMPLIANCE) WITH DRUG TREATMENT It is often assumed that once the appropriate drug is chosen, the prescription correctly written and the medication correctly dispensed, that it will be taken correctly and treatment will be successful. Unfortunately this is very often not the case, and physicians overlook one of the most important reasons for treatment failurepoor adherence (compliance) with the treatment plan.There are sometimes valid reasons for poor adherence the drug may be poorly tolerated, may cause obvious adverse effects or may be prescribed in a toxic dose. Failure to adhere with such a prescription has been described as intelligent non-compliance. Bad prescribing or a dispensing error may also create a problem, which patients may have neither the insight nor the courage to question. Even with good prescribing, failure to adhere to treatment is common. Factors may be related to the patient, the disease, the doctor, the prescription, the pharmacist or the health system and can 5
often be avoided.Patients perceptions of the risk and severity of adverse drug reactions may differ from the health care provider and may affect adherence. Low-cost strategies for improving adherence increase effectiveness of health interventions and reduce costs. Such strategies must be tailored to the individual patient.Health care providers should be familiar with techniques for improving adherence and they should employ systems to assess adherence and to determine what influences it.
Patient reasons
In general, women tend to be more adherent than men, younger patients and the very elderly are less adherent, and people living alone are less adherent than those with partners or spouses. Specific education interventions have been shown to improve adherence. Patient disadvantages such as illiteracy, poor eyesight or cultural attitudes (for example preference for traditional or alternative medicines and suspicion of modern medicine) may be very important in some individuals or societies; as may economic factors. Such limitations or attitudes need to be discussed and taken account of.
Disease reasons
Conditions with a known worse prognosis (for example cancer) or painful conditions (for example rheumatoid arthritis) elicit better adherence than asymptomatic perceived as benign conditions such as hypertension.
Doctor reasons
Doctors may cause poor adherence in many waysby failing to inspire confidence in the treatment offered, by giving too little or no explanation, by thoughtlessly prescribing too many medicines, by making errors in prescribing, or by their overall attitude to the patient.
The doctor-patient interaction

There is considerable evidence that this is crucial to concordance. Satisfaction with the interview is one of the best predictors of good adherence. Patients are often well informed and expect a greater say in their health care. If they are in doubt or dissatisfied they may turn to alternative options, including complementary medicine. There is no doubt that doctor has a powerful effect on inspiring confidence and perhaps contributing directly to the healing process.
Prescription reasons
Many aspects of the prescription may lead to non-adherence (noncompliance).It may be illegible or inaccurate; it may get lost; it may not be 6
refilled as intended or instructed for a chronic disease. Also, the prescription may be too complex; the greater the number of medicines the poorer the adherence, while multiple doses also decrease adherence if more than two doses per day are given. Not surprisingly adverse effects like drowsiness, impotence or nausea reduce adherence and patients may not admit to the problem.
Pharmacist reasons
The pharmacists manner and professionalism, like the doctors, may have a positive influence on adherence, or a negative one, raising suspicions or concerns. This has been reported in relation to generic drugs when substituted for brand-name drugs. Pharmacist information and advice can be a valuable reinforcement, as long as it agrees with the doctors advice.
The health care system

The health care system may be the biggest hindrance to adherence. Long waiting times, uncaring staff, uncomfortable environment, unreliable drugs upplies and so on, are all common problems in many settings, and have amajor impact on adherence. An important problem is the distance and accessibility of the clinic from the patient. Some studies have confirmed the obvious, that patients furthest from the clinic are least likely to adhere to treatment in the long term. Recommendations Review the prescription to make sure it is correct. Spend time explaining the health problem and the reason for the drug. Establish good rapport with the patient. Explore problems, for example difficulty with reading the label or getting the prescription filled. Encourage patients to bring their medication to the clinic, so that tablet counts can be done to monitor compliance. Encourage patients to learn the names of their medicines, and review their regimen with them. Write notes for them. Keep treatment regimens simple. Communicate with other health care professionals, to develop a team approach and to collaborate on helping and advising the patient. Involve the partner or another family member. Listen to the patient. 7
ADVERSE EFFECTS AND INTERACTIONS
Adverse drug reactions

An adverse drug reaction (ADR) may be defined as any response to a drug which is noxious, unintended and occurs at doses normally used for prophylaxis, diagnosis, or therapy. ADRs are therefore unwanted or unintended effects of a medicine, including idiosyncratic effects, which occur during its proper use. They differ from accidental or deliberate excessive dosage or drug maladministration. ADRs may be directly linked to the properties of the drug in use, the so-calledA type reactions. An example is hypoglycaemia induced by an antidiabetic drug. ADRs may also be unrelated to the known pharmacology of the drug, the B type reactions including allergic effects, for example anaphylaxis with penicillins. Thalidomide marked the first recognized public health disaster related to the introduction of a new drug. It is now recognized that clinical trials, however thorough, cannot be guaranteed to detect all adverse effects likely to be caused by a drug. Health workers are thus encouraged to record and report to their national pharmacovigilance centre any unexpected adverse effects with any drug to achieve faster recognition of serious related problems.
Major factors predisposing to adverse effects

It is well known that different patients often respond differently to a given treatment regimen. For example, in patients taking combinations of drugs known to interact, only a small number show any clinical evidence of interactions. In addition to the pharmaceutical properties of the drug therefore, there are characteristics of the patient which predispose to ADRs. Extremes of age. The very old and the very young are more susceptible to ADRs. Drugs which commonly cause problems in the elderly include hypnotics, diuretics, non-steroidal anti-inflammatory drugs, antihypertensives,psychotropics and digoxin.All children, and particularly neonates, differ from adults in their response to drugs. Some drugs are likely to cause problems in neonates (for example morphine), but are generally tolerated in children. Other drugs (for example valproic acid) are associated with increased risk of ADRs in children of all ages.Other drugs associated with problems in children include chloramphenicol (grey baby syndrome), antiarrhythmics (worsening of arrhythmias), acetylsalicylic acid (Reye syndrome). Intercurrent Illness. If besides the condition being treated the patient suffers from another disease, such as kidney, liver or heart disease, special precautions may be 8
necessary to prevent ADRs. The genetic make-up of the individual patient may also predispose to ADRs.
ADR Reporting

Report adverse experiences with medications Report serious adverse events. An event is serious when the patient outcome is Death Life threatening (real risk of dying) Hospitalisation(initial or prolonged) Disability (significant persistent or permanent) Congenital anomaly Required intervention to prevent permanent impairment or damage
Report even if you are not certain the product caused adverse event you dont have all the details Who can report? Any health care professional (Doctors including Dentists,Nurses and Pharmacists) Where to report ? Nearest ADR monitoring centres Peripheral Pharmacovigilance centres (24) Regional Pharmacovigilance centres(5) Directly to www.cdsco.nic.in Drug Interactions. Interactions may occur between drugs which compete for the same receptor or act on the same physiological system. They may also occur indirectly when a drug-induced disease or a change in fluid or electrolyte balance alters the response to another drug.Interactions may occur when one drug alters the absorption, distribution or elimination of another drug, such that the amount which reaches the site of action is increased or decreased.Drug-drug interactions are some of the commonest causes of adverse effects.When two drugs are administered to a patient, they may either act independently of each other, or interact with each other. Interaction may increase or decrease the effects of the drugs concerned and may cause unexpected toxicity. As newer and more potent drugs become available, the 9
number of serious drug interactions is likely to increase. Remember that interactions which modify the effects of a drug may involve non-prescription drugs, non-medicinal chemical agents, and social drugs such as alcohol, marijuana, tobacco, and traditional remedies, as well as certain types of food for example grapefruit juice. The physiological changes in individual patients, caused by such factors as age and gender, also influence the predisposition to ADRs resulting from drug interactions. The following table lists drugs under the designation of specific cytochrome P450 isoforms. A drug appears in a column if there is published evidence that it is metabolized, at least in part, via that isoform. Alterations in the rate of the metabolic reaction catalyzed by that isoform are likely to have effects on the pharmacokinetics of the drug. Substrates CYP1A2 Theophylline CYP2B6 Cyclophosphamide, Efavirenz CYP2C19 Amitriptyline, Clomipramine,Cyclophosphamide, Diazepam, Phenobarbital,Phenytoin CYP2C9 Ibuprofen, Phenytoin,Sulfamethoxazole,Tamoxifen,Warfarin CYP2D6Amitriptyline,Clomipramine,Codeine,Haloperidol, , Tamoxifen, Timolol CYP2E1Alcohol,Paracetamol CYP3A4, 5, 7Amlodipine, Ciclosporin,,Diazepam, Erythromycin, Haloperidol, Indinavir, Methadone, Nifedipine, Quinidine, Quinine, Ritonavir, Saquinavir, Tamoxifen, Verapamil, Vincristine. Inhibitors 1A2 Ciprofloxacin 2B6 2C19 2C9 Isoniazid 2D6 Haloperidol, Quinidine, Ritonavir 2E1 3A4 Erythromycin, Grapefruit juice, Indinavir, Nelfinavir, Ritonavir, Verapamil Inducers 1A2 Tobacco 2B6 phenobarbitone, Rifampicin 10
2C19 2C9 Rifampicin 2D6 2E1 Alcohol 3A4 Carbamazepine, Phenobarbital, Phenytoin, Rifampicin Incompatibilities between drugs and intravenous fluids Drugs should not be added to blood, amino acid solutions or fat emulsions.Certain drugs, when added to intravenous fluids, may be inactivated by pHchanges, by precipitation or by chemical reaction. Benzylpenicillin and Ampicillin lose potency after 68 hours if added to dextrose solutions, due to the acidity of these solutions. Some drugs bind to plastic containers and tubing,for example diazepam and insulin . Aminoglycosides are incompatible with penicillins and heparin. Hydrocortisone is incompatible with heparin,tetracycline, and chloramphenicol. Adverse effects caused by traditional medicinesPatients who have been or are taking traditional herbal remedies may develop ADRs. It is not always easy to identify the responsible plant or plant constituent. The effect of food on drug absorption Food delays gastric emptying and reduces the rate of absorption of many drugs; the total amount of drug absorbed may or may not be reduced. However, some drugs are preferably taken with food, either to increase absorption or to decrease the irritant effect on the stomach. P-DRUG CONCEPT P-drugs are the drugs you have chosen to prescribe regularly, and with which you have become familiar.They are your priority choice for given indications.They enable you to avoid repeated searches for a good drug in daily practice.As you use your P-drugs regularly,you will get to know their effects and side effects thoroughly,with obvious benefits to the patient. Choosing a drug is a process that can be divided into five steps I. Define the diagnosis II. Specify the therapeutic objective III. Make an inventory of effective group of drugs IV. Choose an effective group according safety,efficacy,suitability and costeffectiveness V. Choose a P-drug 11 to criteria
PRESCRIPTION WRITING A prescription is an instruction from a prescriber to a dispenser. The prescriber is not always a doctor but can also be a paramedical worker, such as a medical assistant, a midwife or a nurse. The dispenser is not always a pharmacist, but can be a pharmacy technician, an assistant or a nurse. Every country has its own standards for the minimum information required for a prescription, and its own laws and regulations to define which drugs require a prescription and who is entitled to write it. Many countries have separate regulations for prescriptions for controlled drugs such as opioid analgesics.The following guidelines will help to ensure that prescriptions are correctly interpreted and leave no doubt about the intention of the prescriber. The guidelines are relevant for primary care prescribing; they may, however, be adapted for use in hospitals or other specialist units.
Prescription form
The most important requirement is that the prescription be clear. It should be legible and indicate precisely what should be given. The local language is preferred. The following details should be shown on the form:
The prescribers name, address, and telephone number. This will allow either the patient or the dispenser to contact the prescriber for any clarification or potential problem with the prescription. Date of the prescription. In many countries the validity of a prescription has no time limit, but in some countries pharmacists do not dispense drugs on prescriptions older than 3 to 6 months. Name, form, and strength of the drug. The International Nonproprietary Name of the drug should always be used. If there is a specific reason to prescribe a special brand, the trade name can be added. Generic substitution is allowed in some countries. The pharmaceutical form (for example tablet, oral solution, eye ointment) should also be stated. The strength of the drug should be stated in standard units using abbreviations that are consistent with the Systme Internationale (SI).Microgram and nanogram should not, however, be abbreviated. Also,units should not be abbreviated. Avoid decimals whenever
12
possible. If unavoidable, a zero should be written in front of the decimal point.
Specific areas for filling in details about the patient including name,address, and age.
Directions
Directions specifying the route, dose and frequency should be clear andexplicit; use of phrases such as take as directed or take as before should be avoided. For preparations which are to be taken on an as required basis, the minimum dose interval should be stated together with, where relevant, the maximum daily dose. It is good practice to qualify such prescriptions with the purpose of the medication (for example every 6 hours as required for pain, at night as required to sleep).
Quantity to be dispensed
The quantity of the medicinal product to be supplied should be stated such that it is not confused with either the strength of the product or the dosage directions. Alternatively, the length of the treatment course may be stated (for examplefor 5 days). Wherever possible, the quantity should be adjusted to match the pack sizes available. For liquid preparations, the quantity should be stated in millilitres (abbreviated as ml) or litres (preferably not abbreviated since the letter l could be confused with the figure 1).
Narcotics and controlled substances

The prescribing of a medicinal product that is liable to abuse requires special attention and may be subject to specific statutory requirements. Practitioners may need to be authorized to prescribe controlled substances; in such cases it might be necessary to indicate details of the authority on the prescription. In particular, the strength, directions and the quantity of the controlled substance to be dispensed should be stated clearly, with all quantities written in words as well as in figures to prevent alteration. Other details such as patient particulars and date should also be filled in carefully to avoid alteration. 13
SAMPLE PRESCRIPTION Dr. Amal MD. Lovedale, Kumarapuram Tel: 0471-2345678 2/2/09 Name : Kamala Age: 30 years Address: Kumarapuram RX Cap Ampicillin 500mg (20) 1 Cap 6th hourly orally 1 hour after food 5 days Sd/Dr. Amal MD. Reg No 13105 TC Medical Council ASSESSING COST-EFFECTIVENESS IN DRUG THERAPY Dynamic explosion of scientific knowledge have altered the way we practice medicine and exchange information. Science based technology and deductive reasoning form the foundation for the solution to many clinical problems. We understand how subtle changes in many different genes can affect the function of cells and organisms. The combination of medical knowledge, intuition , experience, and judgment defines the art of medicine, which is as necessary to the practice of medicine as is a sound scientific base Evidence based medicine(EBM) refers to integration of best available research evidence with clinical judgment and experience in the care of patients. More research has been done on how doctors should make decisions than on how they actually do. Uncertainty in clinical decision making creates the need for probabilities and other quantitative tools like meta-analysis, decision analysis and cost-effectiveness analysis.
Quantitative tools available to evaluate resource use in medicine

14 Cost minimization Cost-effectiveness Cost utility Cost benefit
Cost minimization Cost minimization is useful evaluation to choose the best alternative when the outcome of intervention is same. We can opt for the low cost alternative. Cost-effectiveness analysis (CEA) Cost-effectiveness analysis (CEA) is a technique for selecting among competing wants wherever resources are limited. CEA was first applied to health care in the mid-1960s and was introduced with enthusiasm to clinicians by Weinstein and Stason in 1977. The Basics of CEA CEA is a technique for comparing the relative value of various therapeutic strategies. In its most simple form, a new treatment is compared with current practice (the low-cost alternative) in the calculation of the cost-effectiveness ratio:
Its also worthwhile to recognize that CEA is only relevant to certain decisions. Table 1 delineates the various ways a new therapeutic strategy might compare with an existing approach. Note that a CEA is relevant only if a new strategy is both more effective and more costly (or both less effective and less costly). Table 1 Conditions under which CEA is relevant COST EFFECTIVENESS New strategy is more effective New strategy is less effective NEW STRATEGY COSTS MORE CEA relevant New strategy is dominated NEW STRATEGY COSTS LESS Adopt newStrategy CEA relevant
An Example Consider two strategies intended to lengthen life in patients with heart disease. One is simple and cheap (e.g., aspirin and -blockers); the other is more complex, more expensive, and more effective (e.g., medication plus 15
cardiac catheterization, angioplasty, stents, and bypass). For simplicity, we will assume that doing nothing has no cost and no effectiveness. Table 2 shows the relevant data. Table 2 CEA-examining three strategies Strategy Nothing Current New Cost Rs. 0 5000 50000 Incremental Effectiveness Incremental Cost (Rs.) Effectiveness 5000 45000 0 years 5 years 5.5 years 5 years 0.5 years CE RATIO Rs.1000/yr Rs.90000/yr
The result might be considered as the price of the additional outcome purchased by switching from current practice to the new treatment (e.g., Rs.90,000 per life year). If the price is reasonable enough, the new strategy is considered cost-effective. It means that the new treatment is a good value. Note that being cost-effective does not mean that the strategy saves money, and just because a strategy saves money doesnt mean that it is costeffective. Also note that the very notion of cost-effective requires a value judgmentwhat you think is a good price for an additional outcome, someone else may not.
Things to Ask
If a study is of interest and its primary outcome is a cost-effectiveness ratio, critical readers should seek answers to the following questions. How good are the effectiveness data? While evaluating CEA one should examine the information used for effectiveness. Ideally, the data should come from randomized trials. If they dont, youll want to scrutinize the face validity of the assumptions. Where do the cost data come from? The basic question here is, Was resource use modeled, or was it measured in real practice? In modeling, investigators have to make assumptions about which services are likely to be utilized differently-thus driving the difference in cost. The measurement of resource use in practice has the advantage of capturing utilization that may not be anticipated by investigators (e.g., extra testing, extra visits, and readmissions). 16
Did we get anywhere? Finally, readers may want to consider whether the entire exercise somehow helped them with a decision. Although some CEAs have extremely high CE ratios (i.e., > Rs, 200,000 per quality-adjusted life-yeara poor value) and other have very low CE ratios (i.e., < Rs.10,000 per quality-adjusted lifeyeara good value), most fall somewhere in the middle. Analyses with CE ratios of Rs.50,000 per quality-adjusted life-year may conclude with an assertion that the analyzed strategy is cost-effective. Cost utility analysis (CUA) CUA is similar to CEA but the outcome is assessed considering the utility preference of the patients. Quality Adjusted Life Years(QALY) is composite outcome usually used for chronic ailments. Cost Benefit Analysis (CBA) For evaluating healthcare programs CBA is very helpful. Here the health outcome is converted to money value and the net benefit is estimated to select the alternative. Summary CEA is about incremental costs and incremental benefits. So the incremental cost of a current strategy is the difference between the cost of that strategy and the cost of doing nothing. The incremental cost for the new strategy is the difference between the cost of the new strategy and the cost of the current strategy (not the cost of doing nothing). The calculation is similar for effectiveness. The final outcome measure for the analysis is the CE ratio: the ratio of incremental cost to incremental effectiveness.
17
SECTION - 1 DRUGS USED IN ANAESTHESIA

General anaesthetics and oxygen Local anaesthetics Preoperative medication and sedation for short-term procedures ANAESTHETICS To produce a state of prolonged full surgical anaesthesia reliably and safely, a variety of drugs is needed. Special precautions and close monitoring of the patient are required. These drugs may be fatal if used inappropriately and should be used by nonspecialized personnel only as a last resort. Irrespective of whether a general or conduction (regional or local) anaesthetic technique is used, it is essential that facilities for intubation and mechanically assisted ventilation are available. A full preoperative assessment is required including, if necessary, appropriate fluid replacement.

GENERAL ANAESTHETICS AND OXYGEN
Inhalational agents
Halothane I: C/I: induction and maintenance of anaesthesia history of unexplained jaundice or pyrexia following previous exposure to halothane; family history of malignant hyperthermia; raised cerebrospinal fluid pressure; porphyria anaesthetic history should be carefully taken to determine previous exposure and previous reactions to halothane (at least 3 months should be allowed to elapse between each re-exposure); avoid for dental procedures in patients under 18 years unless treated in hospital (high risk of arrhythmias); pregnancy arrhythmias; bradycardia; respiratory depression; hepatic damage Induction, using specifically calibrated vaporizer, gradually increase inspired gas concentration to 24%( ADULT) or 1.52% (CHILD) in oxygen or nitrous oxide oxygen Maintenance, ADULT and CHILD 0.52%
P/C:
A/E: Dose:
Isoflurane Ideal for neurosurgery. 18
Inhalational agents
I:, C/I:,D/I: A/E:
P/A: Dose: Maintenance: Children: Ketamine I: C/I:
same as halothane Trigger malignant hyperthermia. Since it is an irritant vapour it is less suitable for induction of anaesthesia especially in children. Liquid 100 mL bottle Adults induction: inhalation 1.5-3% inhalation 1-3.5% dosage must be individualized.
Intravenous anaesthetics
induction and maintenance of anaesthesia; analgesia for painful procedures of short duration thyrotoxicosis; hypertension (including pre-eclampsia); history of cerebrovascular accident, cerebral trauma, intracerebral mass or haemorrhage or other cause of raised intracranial pressure; eye injury and increased intraocular pressure; psychiatric disorders, particularly hallucinations; porphyria supplementary analgesia often required in surgical procedures involving visceral pain pathways (morphine may be used but addition of nitrous oxide will often suffice); administer an antisialogogue to prevent excessive salivation leading to respiratory difficulties; during recovery, patient must remain undisturbed but under observation; pregnancy Warn patient not to perform skilled tasks, for example operating machinery or driving, for 24 hours and also to avoid alcohol for 24 hours hallucinations and other emergence reactions during recovery possibly accompanied by irrational behaviour (effects rarely persist for more than few hours but can recur at any time within 24 hours); transient elevation of pulse rate and blood pressure common, arrhythmias have occurred; hypotension and bradycardia occasionally reported 50mg/mL in 2mL ampoule and 10mL vial Induction, by intramuscular injection, ADULT and CHILD 6.513 mg/kg (10 mg/kg usually produces 1225 minutes of anaesthesia) Induction, by intravenous injection over 19
P/C:
Skilled tasks:
A/E:
P/A: Dose:
General Anaesthetics
Note: Thiopental I: C/I:
at least 1 minute, ADULT and CHILD 14.5 mg/kg (2 mg/kg usually produces 510 minutes of anaesthesia); Induction, by intravenous infusion of a solution containing 1 mg/ml,ADULT and CHILD total induction dose 0.52 mg/kg; maintenance (using microdrip infusion), 1045 micrograms/kg/minute, rate adjusted according to response Analgesia, by intramuscular injection, ADULT and CHILD initially 4 mg/kg For diagnostic procedures and other procedures not involving intense pain induction of anaesthesia prior to administration of inhalational anaesthetic; anaesthesia of short duration inability to maintain airway; hypersensitivity to barbiturates; cardiovascular disease; dyspnoea or obstructive respiratory disease; myotonic dystrophy; porphyria reconstituted solution is highly alkalineextravasation can result in extensive tissue necrosis and sloughing; cardiovascular disease; intra-arterial injection causes intense pain and may result in arteriospasm; hepatic impairment; pregnancy; breastfeeding Warn patient not to perform skilled tasks, for example operating machinery, driving, for 24 hours and also to avoid alcohol for 24 hours rapid injection may result in severe hypotension and hiccup; arrhythmias, myocardial depression, cough, laryngeal spasm, sneezing, allergic reactions, rash, injection-site reactions Powder for injection: 0.5 g, 1.0 g (sodium salt) in ampoule Induction, by intravenous injection usually as a 2.5% (25 mg/ml) solution ADULT 100150 mg (reduced in elderly or debilitated over 1015 seconds, patients), followed by a further 100150 mg if necessary according to response after 3060 seconds; or up to 4 mg/kg (maximum 500 mg); CHILD 27 mg/kg repeated if necessary according to response after 60 seconds
P/C:
Skilled tasks:
A/E:
P/A: Dose:
20
Intravenous General Anaesthetics
Reconstitution:
Solutions containing 25 mg/ml should be freshly prepared by mixing 20 ml of water for injections with the contents of the 0.5-g ampoule or 40 ml with the 1g ampoule. Any solution made up over 24 hours previously or in which cloudiness, precipitation or crystallization is evident should be discarded
Propofol It is widely used. The recovery is rapid without hangover, but at times it may lead to pain at the site of injection. It is ideal for day care surgery. I: C/I: P/C: Induction and maintenance of GA, sedation of ventilated patients receiving intensive care upto 3 days. Propofol allergy. Monitor blood lipid concentration in patients at risk of fat overload and bacterial contamination, while drawing up propofol emulsion. Bradycardia, convulsions, anaphylaxis, delayed recovery from anaesthesia, hypotension pain at site of injection. Emulsion 10 mg/mL 20 mg/mL in 10, 20 mL vials. For induction it is given by IV. infusion at the rate of 80-150 mcg/kg/min. Alcohol and CNS depressant drugs produce hypotension. preferred over Diazepam for anesthetic use:1-2.5 mg I/V followed by 1/4th supplemental doses For sedation of intubated and mechanically ventilated patients and critical care anesthesia:0.02-0.1mg/kg/ hr continuous I/V infusion 1 mg/ml,5mg/ml injection
A/E: P/A: Dose: D/I: Midazolam I and Dose:
P/A:
Gaseous agent
Nitrous oxide I: Inhalation gas maintenance of anaesthesia in combination with other anaesthetic agents (halothane, ether, or ketamine) and muscle relaxants; analgesia for obstetric practice, for emergency management of injuries, during postoperative physiotherapy and for refractory pain in terminal illness 21
C/I:
P/C: A/E:
Dose: Anaesthesia: D/I: Oxygen I: FIRE HAZARD:
demonstrable collection of air in pleural, pericardial or peritoneal space; intestinal obstruction; occlusion of middle ear; arterial air embolism; decompression sickness; chronic obstructive airway disease, emphysema minimize exposure of staff; pregnancy nausea and vomiting; after prolonged administration megaloblastic anaemia, depressed white cell formation; peripheral neuropathy ADULT and CHILD nitrous oxide mixed with 2530% oxygen Analgesia, 50% nitrous oxide mixed with 50% oxygen Hypotensive effect occurs when used concurrently with any of the CNS depressants Inhalation (medicinal gas). to maintain an adequate oxygen tension in inhalational anaesthesia Avoid use of cautery when oxygen is used with ether; reducing valves on oxygen cylinders must not be greased (risk of explosion) concentrations greater than 80% have a toxic effect on the lungs leading to pulmonary congestion, exudation and atelectasis Concentration of oxygen in inspired anaesthetic gases should never be less than 21%
Adverse effects:
Dose:
LOCAL ANAESTHETICS Drugs used for conduction anaesthesia (also termed local or regional anaesthesia) act by causing a reversible block to conduction along nerve fibres. Local anaesthetics are used very widely in dental practice, for brief and superficial interventions, for obstetric procedures, and for specialized techniques of regional anaesthesia calling for highly developed skills. Local anaesthetic injections should be given slowly in order to detect inadvertent intravascular injection. Local Infiltration Many simple surgical procedures that neither involve the body cavities nor require muscle relaxation can be performed under local infiltration 22
Local Anaesthetics
anaesthesia. Lower-segment caesarean section can also be performed under local infiltration anaesthesia. The local anaesthetic drug of lidocaine 0.5% with or without epinephrine. No more than 4 mg/kg choice is of plain lidocaine or 7 mg/kg of lidocaine with epinephrine should be administered on any one occasion. The addition of epinephrine (adrenaline) diminishes local blood flow, slows the rate of absorption of the local anaesthetic, and prolongs its effect. Care is necessary when using epinephrine for this purpose since, in excess, it may produce ischaemic necrosis. It should not be added to injections used in digits or appendages. Surface Anaesthesia Topical preparations of lidocaine are available and topical eye drop solutions of tetracaine are used for local anaesthesia of the cornea and conjunctiva. Regional Block A regional nerve block can provide safe and effective anaesthesia but its execution requires considerable training and practice. Nevertheless, where the necessary skills are available, techniques such as axillary or ankle blocks can be invaluable. Either lidocaine 1% or bupivacaine 0.5% is suitable. Bupivacaine has the advantage of a longer duration of action. Spinal Anaesthesia This is one of the most useful of all anaesthetic techniques and can be used widely for surgery of the abdomen and the lower limbs. It is a major procedure requiring considerable training and practice. lidocaine 5% in glucose or bupivacaine 0.5% in glucose can be used but the latter is often chosen because of its longer duration of action.
Bupivacaine
I: infiltration anaesthesia; peripheral and sympathetic nerve block; spinal anaesthesia; postoperative pain relief adjacent skin infection, inflamed skin; concomitant anticoagulant therapy; severe anaemia or heart disease; spinal or epidural anaesthesia in dehydrated or hypovolaemic patient with excessive dosage or following intravascular injection, light-headedness, dizziness, blurred vision, restlessness, tremors and, occasionally, convulsions rapidly followed by drowsiness, unconsciousness and 23
C/I:
A/E:
P/C:
P/A:
Dose:
NOTE:
respiratory failure; cardiovascular toxicity includes hypotension, heart block and cardiac arrest; hypersensitivity and allergic reactions also occur; epidural anaesthesia occasionally complicated by urinary retention, faecal incontinence, headache, backache or loss of perineal sensation; transient paraesthesia and paraplegia very rarely. respiratory impairment; hepatic impairment; epilepsy; porphyria; myasthenia gravis; pregnancy and breastfeeding Injection 0.25%, 0.5% (hydrochloride) in vial. Injection for spinal anaesthesia: 0.5% (hydrochloride) in 4-ml ampoule to be mixed with 7.5% glucose solution. Local infiltration, using 0.25% solution, ADULT up to 150 mg (up to 60 ml) Peripheral nerve block, using 0.5% solution ADULT up to 150 mg (up to 30 ml) ADULT 50100 mg Lumbar epidural block in surgery, using 0.5% solution, Adult 50-100mg(1020 ml) Lumbar epidural block in labour, using 0.250.5% solution, ADULT (female) up to 60 mg (maximum 12 ml) Caudal block in surgery, using 0.250.5% solution, ADULT up to 150 mg (maximum 30 ml) Caudal block in labour, using 0.250.5% solution, ADULT (female) up to 100 mg (maximum 20 ml) Use lower doses for debilitated or elderly, or in epilepsy, or acute illness Do not use solutions containing preservatives for spinal, epidural, caudal, or intravenous regional anaesthesia
Ephedrine
Ephedrine hydrochloride is a complementary drug I: P/C: prevention of hypotension during delivery under spinal or epidural anaesthesia hyperthyroidism; diabetes mellitus; ischaemic heart disease, hypertension; angle-closure glaucoma; renal impairment ;pregnancy and breastfeeding
24
Local Anaesthetics
A/E:
P/A: Dose:
anorexia, hypersalivation, nausea, vomiting; tachycardia (also in fetus), arrhythmias, anginal pain, vasoconstriction with hypertension, vasodilation with hypotension; dyspnoea; headache, dizziness, anxiety, restlessness, confusion, tremor; difficulty in micturition; sweating, flushing; changes in bloodglucose concentration 30 mg (hydrochloride)/ml in 1-ml ampoule. To prevent hypotension during delivery under spinal anaesthesia, 36 mg slow intravenous injection of solution containing 3 mg/mL, (maximum single dose 9 mg), repeated if necessary every 34 minutes; maximum cumulative dose 30 mg
Lidocaine
Lidocaine is a representative local anaesthetic. Various drugs can serve as alternatives I: surface anaesthesia of mucous membranes; infiltration anaesthesia; peripheral and sympathetic nerve block; dental anaesthesia; spinal anaesthesia; intravenous regional anaesthesia; arrhythmias C/I: adjacent skin infection, inflamed skin; concomitant anticoagulant therapy; severe anaemia or heart disease; spinal or epidural anaesthesia in dehydrated or hypovolaemic patient P/C: bradycardia, impaired cardiac conduction; severe shock; respiratory impairment; renal impairment; hepatic impairment ; epilepsy; porphyria; myasthenia gravis; avoid (or use with great care) solutions containing epinephrine (adrenaline) for ring block of digits or appendages (risk of ischaemic necrosis); pregnancy ; breastfeeding A/E: with excessive dosage or following intravascular injection, light-headedness, dizziness, blurred vision, restlessness, tremors and, occasionally, convulsions rapidly followed by drowsiness, unconsciousness and respiratory failure; cardiovascular toxicity includes hypotension, heart block and cardiac arrest; hypersensitivity and allergic reactions also occur; epidural anaesthesia occasionally complicated by 25
P/A:
Dose:
NOTE:
Injection: Dental cartridge: 26
urinary retention, faecal incontinence, headache, backache or loss of perineal sensation; transient paraesthesia and paraplegia very rare Injection: 1%, 2% (hydrochloride) in vial. Injection for spinal anaesthesia: 5% (hydrochloride) in 2-ml ampoule to be mixed with 7.5% glucose solution. Topical forms: 2-4% (hydrochloride). Plain Solutions Local infiltration and peripheral nerve block, using 0.5% solution, ADULT up to 250 mg (up to 50 mL) Local infiltration and peripheral nerve block, using 1% solution, ADULT up to 250 mg (up to 25 mL) Surface anaesthesia of pharynx, larynx, trachea, using 4% solution, ADULT 40200 mg (15 mL) Surface anaesthesia of urethra, using 4% solution, ADULT 400 mg (10 mL) Spinal anaesthesia, using 5% solution (with glucose 7.5%), ADULT 5075 mg (11.5 mL) Solutions containing epinephrine Local infiltration and peripheral nerve block, using 0.5% solution with epinephrine, ADULT up to 400 mg (up to 80 mL) Local infiltration and peripheral nerve block, using 1% solution with epinephrine, ADULT up to 400 mg (up to 40 mL) Dental anaesthesia, using 2% solution with epinephrine, ADULT 20100 mg (15 mL) Maximum safe doses of lidocaine for ADULT and CHILD are: 0.5% or 1% lidocaine, 4 mg/kg; 0.5% or 1% lidocaine + epinephrine 5 micrograms/mL (1 in 200 000), 7 mg/kg Use lower doses for debilitated, or elderly, or in epilepsy, or acute illness Do not use solutions containing preservatives for spinal, epidural, caudal, or intravenous regional anaesthesia Lidocaine + epinephrine (adrenaline) 1%, 2% (hydrochloride) + epinephrine 1:200 000 in vial. 2% (hydrochloride) + epinephrine 1:80 000.
Preoperative Medication
PREOPERATIVE MEDICATION AND SEDATION Pre-anaesthetic medication is often advisable prior to both conduction and general anaesthetic procedures. Sedatives improve the course of subsequent anaesthesia in apprehensive patients. Diazepam and promethazine are effective. Diazepam can be administered by mouth, by rectum, or by intravenous injection. Promethazine , which has antihistaminic and antiemetic properties as well as a sedative effect, is of particular value in children. A potent analgesic such as morphine should be administered preoperatively to patients in severe pain or for analgesia during and after surgery. Anticholinergic (more correctly antimuscarinic) drugs such as atropine are also used before general anaesthesia. They inhibit excessive bronchial and salivary secretions induced, in particular, by ether and ketamine. Intramuscular administration is most effective, but oral administration is more convenient in children. Lower doses should be used in cardiovascular disease or hyperthyroidism.
Atropine
I: to inhibit salivary secretions; to inhibit arrhythmias resulting from excessive vagal stimulation; to block the parasympathomimetic effects of anticholinesterases such as neostigmine; organophosphate poisoning ; mydriasis and cycloplegia angle-closure glaucoma; myasthenia gravis; paralytic ileus, pyloric stenosis; prostatic enlargement Down syndrome, children, elderly; ulcerative colitis, diarrhoea; hyperthyroidism; heart failure, hypertension; pyrexia; pregnancy and breastfeeding Since atropine has a shorter duration of action than neostigmine, late unopposed bradycardia may result; close monitoring of the patient is necessary dry mouth; blurred vision, photophobia; flushing and dryness of skin, rash; difficulty in micturition; less commonly arrhythmias, tachycardia, palpitations; confusion (particularly in elderly); heat prostration and convulsions, especially in febrile children 27
C/I: P/C:
DURATION OF ACTION.
A/E:
P/A: Dose:
Injection: 1 mg (sulfate) in 1-mL ampoule Premedication, by intravenous injection, ADULT 300 600 micrograms immediately before induction of anaesthesia CHILD 20 micrograms/kg (maximum 600 micrograms); by subcutaneous or intramuscular injection, ADULT 300 600 micrograms 3060 minutes before induction; (maximum 600 micrograms) Intraoperative bradycardia, by intravenous injection, ADULT 300600 micrograms (larger doses in emergencies); CHILD 112 years 1020 micrograms/kg Control of muscarinic side-effects of neostigmine in reversal of competitive neuromuscular block, by intravenous injection, ADULT 0.61.2 mg; CHILD under 12 years (but rarely used) 20 micrograms/kg (maximum 600 micrograms) with neostigmine 50 micrograms/kg
Diazepam
Drug subject to international control under the Convention on Psychotropic Substances (1971) I: premedication before major or minor surgery; sedation with amnesia for endoscopic procedures and surgery under local anaesthesia; when anaesthetic not available, for emergency reduction of fractures; epilepsy; anxiety disorders central nervous system depression or coma; shock; respiratory depression; acute pulmonary insufficiency; sleep apnoea; acute alcohol intoxication; severe hepatic impairment; marked neuromuscular respiratory weakness including unstable myasthenia gravis respiratory disease; muscle weakness and myasthenia gravis; history of alcohol or drug abuse; marked personality disorder; elderly or debilitated patients (adverse effects more common in these groups); hepatic impairment or renal failure; pregnancy and breastfeeding ; close observation required until full recovery after sedation; porphyria; Warn patient not to perform skilled tasks, for example operating machinery, driving, for 24 hours
C/I:
P/C:
SKILLED TASKS: 28
Preoperative Medication
A/E:
P/A: Dose:
ADMINISTRATION.
central nervous system effects common and include drowsiness, sedation, confusion, amnesia, vertigo, and ataxia; hypotension, bradycardia, or cardiac arrest, particularly in elderly or severely ill patients; also paradoxical reactions, including irritability, excitability, hallucinations, sleep disturbances; pain and thromboembolism on intravenous injection Injection: 5 mg/mL in 2-mL ampoule. Tablet : 5 mg. Premedication, by mouth 2 hours before surgery ADULT and CHILD over 12 years, 510 mg Sedation, by slow intravenous injection immediately before procedure, ADULT and CHILD over 12 years, 200 micrograms/kg Absorption following intramuscular injection slow and erratic; route should only be used if oral or intravenous administration not possible.Slow intravenous injection into large vein reduces risk of thrombophlebitis Resuscitation equipment must be available 10 mg (sulfate or hydrochloride) in 1-ml ampoule. Refer to section on analgesics 5 mg (hydrochloride)/5 mL. premedication prior to surgery; antiemetic Child under 1 year; impaired consciousness due to cerebral depressants or of other origin; porphyria prostatic hypertrophy, urinary retention; glaucoma; epilepsy; hepatic impairment,pregnancy and breastfeeding Warn patient not to perform skilled tasks, for example operating machinery, driving, for 24 hours drowsiness (rarely paradoxical stimulation in children); headache; anticholinergic effects such as dry mouth, blurred vision, urinary retention CHILD over 1 year 0.51 mg/kg Premedication, by mouth 1 hour before surgery, Premedication, by deep intramuscular injection 1 hour before surgery, ADULT 25 mg 29
Morphine
Injection:
Promethazine
Oral liquid: I: C/I: P/C:
SKILLED TASKS. A/E:
Dose:
Glycopyrrolate
Same as atropine. Glaucoma, obstructive uropathy, myasthenia gravis, severe ulcerative colitis P/A: Injection 200 mcg/mL,1 mL amp, 3 mL amp. Dose: For premedication it is given by IM or IV 10 mcg/kg, 200-400 mcg or 4-5 mcg/kg to a maximum of 400 mcg. For children it is given by IM or IV , 4-8 mcg/kg upto a maximum of 200 mcg. For intraoperative use it is given by IV injection as for premedication. For control of muscarinic side effects of neostigmine during reversal of competitive neuromuscular block it is given in a dose of 10 mcg/kg with 50 mcg/kg neostigmine. MUSCLE RELAXANTS I : P/C:, A/E: C/I :
Pancuronium
Refer Section 22, Muscle Relaxants.
Succinyl Choline
Refer Section 22, Muscle Relaxants.
30
SECTION - 2 ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS), MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDS)
NON-OPIOIDS AND NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Non-opioid analgesics are particularly suitable for musculoskeletal pain whereas the opioid analgesics are more suitable for moderate to severe visceral pain.
Acetylsalicylic acid
I: Mild to moderate pain including dysmenorrhoea, headache; pain and inflammation in rheumatic disease and other musculoskeletal disorders (including juvenile arthritis); pyrexia; acute migraine attack; antiplatelet Hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to acetylsalicylic acid or any other NSAID; children and adolescents under 16 years (Reye syndrome); previous or active peptic ulceration; haemophilia and other bleeding disorders; not for treatment of gout Asthma,allergic disease; renal impairment; hepatic impairment pregnancy;breastfeeding; elderly; G6PDdeficiency; dehydration Generally mild and infrequent for lower doses, but common with anti-inflammatory doses; gastrointestinal discomfort or nausea, ulceration with occult bleeding (occasionally major haemorrhage); also other haemorrhage (including subconjunctival); hearing disturbances such as tinnitus (rarely deafness), vertigo, confusion, hypersensitivity reactions (angioedema, bronchospasm and rash); increased bleeding time; rarely oedema, myocarditis, blood disorders (particularly thrombocytopenia) Tab 100mg, 150mg, 325mg 31
C/I:
P/C:
A/E:
P/A:
Non-Steroidal Anti-Inflammatory Drugs
Dose:
Cost:
Mild to moderate pain, pyrexia, by mouth with or after food, ADULT 300900 mg every 46 hours if necessary; maximum 4 g daily; CHILD under 16 years not recommended. ADULT 48 g daily in divided doses in acute rheumatoid arthritis. Juvenile arthritis, by mouth with or after food CHILD up to 130 mg/kg daily in,56 divided doses in acute conditions; 80100 mg/kg daily in divided doses for maintenance 100mg (10) Rs 6.20 ,150mg (10) Rs 4.20 Mild to moderate pain including dysmenorrhoea, headache; pain relief in osteoarthritis and soft tissue lesions; pyrexia including post-immunization pyrexia; acute migraine attack Hepatic impairment; renal impairment; alcohol dependence; breastfeeding; overdosage Rare but rashes and blood disorders reported; important: liver damage (and less frequently renal damage) following overdosage Tablet: 100-500 mg;. Oral liquid: 125 mg/5 ml;Suppository: 100 mg Post-immunization pyrexia, by mouth,INFANT 23 months, 60 mg followed by a second dose, if necessary, 46 hours later; warn parents to seek medical advice if pyrexia persists after second dose. Mild to moderate pain, pyrexia, by mouth, ADULT 0.51 g every 46 hours, maximum 4 g daily; CHILD under 3 months see note below, 3 months1 year 60125 mg, 15 years 120250 mg, 612 years 250500 mg, these doses may be repeated every 46 hours if necessary (maximum 4 doses in 24 hours).Mild to moderate pain, pyrexia, by rectum, ADULT 0.51g; CHILD 15 years 125250 mg, 612 years 250500 mg; doses inserted every 46 hours if necessary, maximum 4 doses in 24 hours Infants under 3 months should not be given paracetamol unless advised by a doctor; a dose of 10 mg/kg (5 mg/ kg if jaundiced) is suitable 500mg (10) Rs 4.80- 12.30
Paracetamol
I:
P/C: A/E:
P/A: Dose:
NOTE:
Cost: 32
Diclofenac
I: C/I: P/C: Pain and inflammation, including rheumatic disease and musculoskeletal disorders Active peptic ulcer, GI bleeding, asthma History of GI ulcer, disorders of blood coagulation, impaired hepatic , renal, cardiac function; pregnancy Similar to Ibuprofen Enteric coated tablets 50mg, dispersible Tab 50mg, Sustained release tabs75mg, 100mg, Inj 25mg/ml, 3mL ampoules Adult oral 75 -150mg in 2-3 divided doses I.M 75mg once daily, twice daily in severe cases for maximum of two days 50mg (10) Rs 15/-to 20/Pain and inflammation in rheumatic disease and other musculoskeletal disorders including juvenile arthritis; mild to moderate pain including dysmenorrhoea, headache; pain in children; acute migraine attack Hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to acetylsalicylic acid or any other NSAID; active peptic ulceration Renal impairment; hepatic impairment; preferably avoid if history of peptic ulceration; cardiac disease; elderly; pregnancy; breastfeeding; coagulation defects;allergic disorders Gastrointestinal disturbances including nausea, diarrhoea,dyspepsia, ulceration, and haemorrhage; hypersensitivity reactions including rash, angioedema, bronchospasm; headache, dizziness, nervousness, depression, drowsiness, insomnia, vertigo, tinnitus, photosensitivity,haematuria; fluid retention (rarely precipitating congestive heart failure in elderly), raised blood pressure, renal failure; rarely hepatic damage, alveolitis, pulmonary eosinophilia, pancreatitis, visual disturbances, erythema multiforme (Stevens-Johnson syndrome), toxic dermal necrolysis (Lyell syndrome), colitis, aseptic meningitis. 33
A/E: P/A:
Dose:
Cost:
Ibuprofen
I:
C/I:
P/C:
A/E:
P/A : Dose:
Cost:
Tablet: 200 mg; 400 mg Mild to moderate pain, pyrexia, inflammatory musculoskeletal disorders, by mouth with or after food, ADULT 1.21.8 g daily in 34 divided doses, increased if necessary to maximum 2.4 g daily (3.2 g daily in inflammatory disease); maintenance dose of 0.61.2 g daily may be sufficient .Juvenile arthritis, by mouth with or after food CHILD over 7 kg, 3040 mg/kg daily in 34 divided doses. Pain in CHILDREN (not recommended for child under 7 kg), by mouth with or after food, 2040 mg/kg daily in divided doses or 12 years 50 mg 34 times daily, 37 years 100 mg 34 times daily, 812 years 200 mg 34 times daily 200mg Rs 3.40-15/Analgesic and anti-inflammatory in musculoskeletal and joint disorders. Active peptic ulcer, history of Gl lesions, pregnancy. Renal, hepatic or cardiac dysfunction, bleeding or CNS disorders, epilepsy, breastfeeding, parkinsonism, psychiatric disorders, infants. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur, renal failure may be provoked by NSAIDs especially in patients with pre-existing renal impairment; rarely drowsiness, confusion, insomnia, convulsions, psychiatric disturbances,depression, syncope,thrombocytopenia, hypertension, hypergly caemia, blurred vision,corneal deposits, peripheral neuropathy and intestinal strictures; suppositries may cause rectal irritation and occasional bleeding. Capsules, 25mg ADULT: Oral: 25mg 2-3 times daily with food, increased if necessary by 25-50mg daily at weekly intervals to 150-200mg daily.Rectal: 100mg at night and in the morning if required. CHILD Stills disease, oral, lmg/ kg/day in 3 divided doses. 25mg (10) Rs 15.80-17.50
Indomethacin
I: C/I: P/C:
A/E:
P/A: Dose:
Cost: 34
Mefenamic acid
I: C/I: A/E: P/A: Dose: Cost: Mild to moderate pain, dysmenorrhoea , menorrhagia, osteoarthritis, rheumatoid arthritis, juvenile arthritis Active peptic ulcer.history of GI lesion, pregnancy, lactation Similar to Ibuprofen Tablets,250mg,500mg Adult, oral 500mg three times daily,after food 250mg (10) Rs10-16/Pain and inflammation in rheumatoid arthritis, osteoarthritis a ankylosing spondylitis. Asthma, angioedema, urticaria or rhinitis, pregnancy, breastfeeding severe congestive heart failure, history of cardiac failure, left ventricular dysfunction, hypertension, oedema, active peptic ulceration. Elderly, allergic disorders; renal, cardiac or hepatic impairment;avoid in porphyria. GI discomfort, nausea, diarrhoea, occasionally bleeding and ulceration;hypersensitivity reactions, headache, dizziness, nervousness, depression drowsiness, insomnia, vertigo, hearing disturbances such as tinnitus photosensitivity and haematuria; blood disorders; fluid retention; blood pressure may be raised; rarely papillary necrosis or interstitial fibrosis hepatic damage, alveolitis, pulmonary eosinophilia, pancreatitis,eye changes, Stevens-Johnson syndrome and toxic epidermal necrolysis, Induction of or exacerbation of colitis has been reported. Tablet, 100 mg. ADULT: Oral, 100 mg twice daily. (reduce to 100 mg daily, initially in hepatic impairment).CHILD:Not recommended. 100mg (10) Rs16.25-20/Pain and inflammation in osteoarthritis and in rheumatoid arthritis; acute gout. 35
Aceclofenac
I: C/I:
P/C: A/E :
P/A: Dose:
Cost:
Etoricoxib
I:
C/I:
P/C: A/E :
P/A: Dose: Cost:
Sulphonamide sensitivity; renal impairment (creatinine clearance less than 30ml/minute); inflammatory bowel disease; severe congestive heart failure; hypersensitivity to aspirin or any other NSAID; active peptic ulceration; current or previous GI ulceration or bleeding. Elderly;history of ischaemic heart disease. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur,renal failure may be provoked by NSAIDs especially in patients with pre-existing renal impairment,flatulence, insomnia, pharyngitis, sinusitis; less frequently stomatitis, constipation, palpitations, anxiety,depression, fatigue, paraesthesia, muscle cramps; rarely taste alteration,alopecia; also dry mouth, taste disturbance,mouth ulcers, flatulence, constipation, appetite and weight changes, chest pain, fatigue, paraesthesia, influenza like syndrome, myalgia. Tablets, 90mg, 120mg. ADULT Osteoarthritis, oral, 60mg once daily.Rheumatoid arthritis, 90mg once daily. Acute gout, 120mg once daily. 90mg (10) Rs52-109/Musculoskeletal and joint disorders like rheumatoid and Osteoarthritis, ankylosing spondylitis, acute gout. Aspirin or NSAID induced allergy, active peptic ulcer, history of recurrent ulceration, porphyria. Surgery, haemorrhagic disorders, impaired renal or hepatic function,hypertension, asthma. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur,renal failure may be provoked by NSAIDs especially in patients with pre-existing renal impairment
Piroxicam
I:
C/I: P/C: A/E :
36
P/A: Dose:
Cost:
Dispersible tablets 20mg., Capsules 10mg, 20mg ADULT: Rheumatic disease: oral, 20mg daily initially; 10-30mg daily in single or divided doses as maintenance dose.Acute gout :oral, 40mg daily in single or divided doses for 5-7days.Acute musculoskeletal disorders: oral, 40mg daily in single or divided doses for 2 days, then 20mg daily for 7-14 days.Topical gel,0.5% is applied 34 times daily.CHILD . Juvenile arthritis above 6 years: oral, less than 15kg, 5mg; 16-25kg,10mg; 26-45kg, 15mg; over 46kg, 20mg daily. Capsule 10mg (10) Rs14 -22/Short term management of moderate to severe acute postoperative pain. Prophylaxis and reduction of inflammation and associated symptoms following ocular surgery History of hypersensitivity to aspirin or any other NSAIDs or to any ingredients of the formulation; children below 3 years; asthma, angioedema or bronchospasm, history of peptic ulcer; moderate to severe renal impairment, coagulation disorders, pregnancy and lactation. Asthma, GI diseases, renal or hepatic disorder, allergy, haemostasis,children below 16 years. There is a potential for cross sensitivity to aspirin, phenylacetic acid derivatives and other NSAIDs , hence caution should be used when treating individuals who have previously exhibited sensitivities to these drugs; bleeding disorders. Anaphylaxis; fluid retention, nausea, dyspepsia, abdominal discomfort, bowel changes, peptic ulceration; GI bleeding (elderly at greater risk),convulsions, myalgia, aseptic meningitis, hyponatraemia, hyperkalaemia, A raised blood urea and creatinine, urinary symptoms and acute renal failure, flushing or pallor, bradycardia, hypertension, purpura, thrombocytopenia, dyspnoea and pulmonary oedema, skin reactions (Stevens-Johnson & Lyells syndromes), post operative wound haemorrhage, haematoma, epistaxis, oedema, liver function changes. 37
Ketorolac
I:
C/I:
P/C:
A/E:
P/A: Dose:
Cost: Morphine I:
Theoretical risk of prolonged bleeding time, transient stinging and blurring of eyes on instillation Film coated tablets, 10mg; Injection, 30mg/mL, lmL ampoules.Ophthalmic solution 0.5% w/v, 5ml. ADULT : Oral:l0mg every, 4-6 hours (elderly every 6-8 hours); max.40mg daily, max. duration of treatment 7 days.I.M.or IM initially 10mg, then 10-30mg every 46 hours upto a max.of 90mg daily. ADULT: Instill 1 drop 3 times daily starting 24 hours pre-operatively and continuing for upto 3 weeks.CHILD: Not recommended under 16 years. Tablet 10mg (10) Rs 18 29.90 OPIOID ANALGESICS Severe pain (acute and chronic); myocardial infarction, acute pulmonary oedema; adjunct during major surgery and postoperative analgesia Avoid in acute respiratory depression, acute alcoholism, and where risk of paralytic ileus; also avoid in raised intracranial pressure or head injury (affects pupillary responses vital for neurological assessment); avoid injection in phaeochromocytoma Renal and hepatic impairment; reduce dose or avoid in elderly and debilitated; dependence (severe withdrawal symptoms if withdrawn abruptly); hypothyroidism; convulsive disorders; decreased respiratory reserve and acute asthma; hypotension; prostatic hypertrophy; pregnancy; breastfeeding; overdosage Nausea, vomiting (particularly in initial stages) constipation; drowsiness; also dry mouth, anorexia, spasm of urinary and biliary tract; bradycardia, tachycardia, palpitation, euphoria, decreased libido, rash, urticaria, pruritus, sweating, headache, facial flushing, vertigo, postural hypotension, hypothermia, hallucinations, confusion, dependence, miosis; larger doses produce respiratory depression, hypotension, and muscle rigidity
C/I:
P/C:
A/E:
38
Opioid Analgesics
P/A : Oral liquid:
Dose:
NOTE.
Injection: 10 mg (morphine hydrochloride or morphine sulfate) in 1-ml ampoule. 10 mg (morphine hydrochloride or morphine sulfate)/5 ml.Tablet: 10 mg (morphine sulfate).Tablet (prolonged release): 10 mg; 30 mg; 60 mg (morphine sulfate). Acute pain, by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection ADULT 10 mg every 4 hours if necessary; Chronic pain, by mouth (immediate-release tablets) or by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection 520 mg regularly every 4 hours; dose may be increased according to need; oral dose should be approximately double corresponding intramuscular dose; by mouth (sustained release tablets), titrate dose first using immediate-release preparation, then every 12 hours according to daily morphine requirement.Myocardial infarction, by slow intravenous injection (2 mg/minute), 10 mg followed by a further 510 mg if necessary; elderly or debilitated patients, reduce dose by half. Acute pulmonary oedema, by slow intravenous injection (2 mg/minute), 510 mg The doses stated above refer equally to morphine sulfate and hydrochloride. Sustained-release capsules designed for once daily administration are also available PATIENT ADVICE. Sustained-release tablets should be taken at regular intervals and not on an as-needed basis for episodic or breakthrough pain.Sustained-released tablets should not be crushed. Moderate to severe pain, pre operative medication as an adjuvant to anaesthesia for sedative and anxiolytic effects, Obstetrical analgesia. Similar to morphine Local pain at injection site,sedation, nausea, light headedness, vomiting. Inj 50mg/mL, 1mL ampoule, Tab 50mg-100mg Acute pain,IM/SC 50-100mg;IV 25-50mg,For preoperative medication : 50-100 mg, 30-90 minutes before surgery, 39
Pethidine
I:
C/I: P/C:A/E: A/E: P/A: Dose:
Obstetric analgesia : 50-100 mg, as soon as pain starts, repeated at 1-3 hourly intervals, upto a maximum of 400 mg/day.
Pentazocine
I: C/I: Relief of moderate to severe pain, in postoperative period in bony metastatsis in cancer patients etc. In the post myocardial infarction period as it increases cardiac work load, in acute alcoholism, head injuries and conditions in which increased intra cranial pressure occurs Use with caution in bronchial asthma, chronic lung diseases, where respiratory reserve is decreased because of its respiratory depressant effects, avoid in antihypertensives and cardiac disorders, in patients with heart failure as it causes rise in B.P. and causes tachycardia, dose adjustments in liver and kidney failure, use with caution after biliary surgery, since opioids increase biliary tract pressure by constriction of sphincter of oddi, chronic users not to drive or operate machinery. Drowsiness, light headedness or euphoria, nausea, vomiting. Tablet 25mg, Injection 30mg/mL Adults: 30-60 mg every 4-6 hours. Moderate to severe pain Avoid in acute respiratory depression, acute alcoholism and conditions where there is risk of paralytic ileus, pheochromacytoma and addissons disease. This is not indicated for acute abdominal pain. This has to be avoided in raised intracranial tension or in head injury. Hypotension, hypothyroidism, asthma, decreased respiratory reserve, prostatic hypertrophy, pregnancy and breast feeding, hepatic impairment, renal impairment and opioid dependence. Severe withdrawal symptoms occur if withdrawn abruptly. Adverse effects less than morphine. Tablets and cap 50 mg. inj. 50 mg/mL. Oral: 50-100 mg every 4 hr;Parenteral dosage IM or by IV infusion, 50-100 mg every 4-6 hr.Post operative
P/C:
A/E: P/A: Dose:
Tramadol
I: C/I:
P/C:
A/E: P/A: Dose: 40
Opioid Analgesics
Cost:
pain, 100 mg initially, then 50 mg every 10-20 minMaximum of total dose during the first hr should not exceed 250 mg including the initial dose. There after 50-100 mg is given every 4-6 hr up to a maximum of 600 mg daily. Cap 50 mg (10) Rs. 60.00;Inj. 50 mg/mL (2mL) Rs. 25.00 Moderate to severe pain, perioperative analgesia same as morphine Tablet 200 mcg; Inj. 300 mcg/ml and 300 mcg/2 mL Sublingual to start with 200-400 mcg every 8h increasing if necessary to 200-400 mcg every 6-8 hour. Children over 6 months, 16-25 kg 100 mcg; 25-37.5 kg100-200 mcg;37.5-50 kg 200-300 mcg; Parenteral- IM or slow IV 300-600 mcg every 6-8 hr Tab 200 mcg (10) Rs.25.00; Inj. 0.3 mg (1mL)Rs. 10.00 mild to moderate pain; diarrhoea respiratory depression, obstructive airways disease, acute asthma attack; where risk of paralytic ileus renal and hepatic impairment; dependence; pregnancy; breastfeeding; overdosage constipation particularly troublesome in long-term use; dizziness, nausea, vomiting; difficulty with micturition; ureteric or biliary spasm; dry mouth, headaches, sweating, facial flushing; in therapeutic doses, codeine is much less liable than morphine to produce tolerance, dependence, euphoria, sedation or other adverse effects Tablet: 30 mg (phosphate). Mild to moderate pain, by mouth, ADULT 3060 mg every 4 hours when necessary, mild pain same as morphine Cap 60 mg 60 mg every 6-8 hr necessary Cap 60 mg (10) Rs. 9.00 41
Buprenorphine
I: C/I:P/C; A/E: P/A : Dose:
Cost:
Codeine
I: C/I: P/C: A/E:
P/A: Dose:
Dextropropoxyphene hydrochloride
I: C/I: P/C: A/E: P/A: Dose: Cost:
DISEASE MODIFYING AGENTS USED IN RHEUMATOID DISORDERS (DMARDS) The process of cartilage and bone destruction which occurs in rheumatoid arthritis may be reduced by the use of a diverse group of drugs known as DMARDs (disease-modifying antirheumatic drugs). DMARDs include chloroquine, penicillamine, sulfasalazine and immunosuppressants (azathioprine, methotrexate).Treatment should be started early in the course of the disease, before joint damage starts. Treatment is usually initiated with a NSAID when the diagnosis is uncertain and the disease course unpredictable. However, when the diagnosis, progression and severity of rheumatic disease have been confirmed,a DMARD should be introduced. DMARDs do not produce an immediate improvement but require 46 months of treatment for a full response. Their long-term use is limited by toxicity and loss of efficacy. If one drug does not lead to objective benefit within 6 months,it should be discontinued and another DMARD substituted.
Azathioprine
Azathioprine is a complementary drug for rheumatoid arthritis I: Rheumatoid arthritis in cases that have failed to respond to chloroquine or penicillamine; psoriatic arthritis; transplant rejection inflammatory bowel disease Hypersensitivity to azathioprine or mercaptopurine Monitor for toxicity throughout treatment; monitor full blood counts frequently; hepatic impairment; renal impairment; elderly(reduce dose); pregnancy, breastfeeding BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Hypersensitivity reactions requiring immediate and permanent withdrawal include malaise, dizziness, vomiting, diarrhoea, fever, rigors,myalgia, arthralgia, rash, hypotension and interstitial nephritis; doserelated bone marrow suppression; liver impairment, cholestatic jaundice; hair loss and increased suceptibility to infections and colitis in patients also receiving corticosteroids; nausea; rarely pancreatitis and pneumonitis. hepatic veno-occlusive disease; also herpes zoster infection
C/I: P/C:
A/E:
42
Drugs in Rheumatoid Disorders
P/A: Dose:
Cost:
Tablet: 50 mg. Administered on expert advice.Rheumatoid arthritis, by mouth, initially, 1.52.5 mg/kg daily in divided doses,adjusted according to response; maintenance 1 3 mg/kg daily; consider withdrawal if no improvement within 3 months Tablet50mg (10) Rs48.60-81.20 Rheumatoid arthritis (including juvenile arthritis); malaria Psoriatic arthritis Monitor visual acuity throughout treatment; warn patient to report immediately any unexplained visual disturbances; hepatic impairment; renal impairment; pregnancy breastfeeding; neurological disorders including epilepsy; severe gastrointestinal disorders; G6PD deficiency; elderly; may exacerbate psoriasis and aggravate myasthenia gravis; porphyria; Gastrointestinal disturbances, headache, skin reactions (rash,pruritus); less frequently ECG changes, convulsions, visual changes, retinal damage, keratopathy, ototoxicity, hair depigmentation, alopecia,discoloration of skin, nails and mucous membranes; rarely blood disorders(including thrombocytopenia, agranulocytosis, aplastic anaemia); mental changes (including emotional disturbances, psychosis), myopathy (including cardiomyopathy and neuromyopathy), acute generalized exanthematous pustulosis, exfoliative dermatitis, erythema multiforme (Stevens-Johnson syndrome), photosensitivity, and hepatic damage; important: arrhythmias and convulsions in overdosage Tablet: 100 mg; 150 mg (as phosphate or sulfate). Chloroquine base 150 mg is approximately equivalent to chloroquine sulfate 200 mg or chloroquine phosphate 250 mg Administered on expert advice 43
Chloroquine
I: C/I: P/C:
A/E:
P/A: NOTE.
Dose:
NOTE.
Cost:
All doses in terms of chloroquine base Rheumatoid arthritis, by mouth, ADULT 150 mg daily; maximum 2.5 mg/kg daily; NOTE. To avoid excessive dosage in obese patients the dose of chloroquine should be calculated on the basis of lean body weight Tablet 250mg (10) Rs 5.20
Methotrexate
Methotrexate is a complementary drug for rheumatoid arthritis I: C/I: P/C: Rheumatoid arthritis; malignant disease Pregnancy and breastfeeding, immunodeficiency syndromes; significant pleural effusion or ascites Monitor throughout treatment including blood counts and hepatic and renal f u n c t i o n tests; r e n a l impairment (avoid if moderate or severe), hepatic impairment (avoid if severe; reduce dose or withdraw if acute infection develops; for woman o r man, contraception during and for at least 6 months after treatment; peptic ulceration, ulcerative colitis, diarrhoea, ulcerative stomatitis; advise patient to avoid self-medication with salicylates or other NSAIDs; warn patient with rheumatoid arthritis to report cough or dyspnoea; BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Blood disorders (bone marrow suppression), liver damage,pulmonary toxicity; gastrointestinal disturbances if stomatitis and diarrhoea occur, stop treatment; renal failure, skin reactions, alopecia,osteoporosis, arthralgia, myalgia, ocular irritation, precipitation of diabetes Tablet: 2.5 mg (as sodium salt). Administered on expert advice ADULT 7.5 mg once weekly (as a single dose for Rheumatoid arthritis, by mouth,divided into 3 doses of 2.5 mg given at intervals of 12 hours), adjusted according to response; maximum total dose of 20 mg once weekly
A/E:
P/A: Dose:
44
Drugs in Rheumatoid Disorders
IMPORTANT. Cost:
The doses are weekly doses and care is required to ensure that the correct dose is prescribed and dispensed Tablet 2.5mg (10) Rs 23.40-49.25
Sulfasalazine
Sulfasalazine is a complementary drug for rheumatoid arthritis I: C/I: P/C: Severe rheumatoid arthritis; ulcerative colitis and Crohns disease Hypersensitivity to salicylates and sulfonamides; severe renal impairment; child under 2 years; porphyria Monitor blood counts and liver function during first 3 months of treatment ; monitor r e n a l function regularly; renal impairment pregnancy, breastfeeding, history of allergy; G6PD deficiency; slow acetylator status;BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Tablet: 500 mg. Nausea, diarrhoea, headache, loss of appetite; fever; blood disorders (including Heinz body anaemia, megaloblastic anaemia,leukopenia, neutropenia, thrombocytopenia); hypersensitivity reactions (including rash, urticaria, erythema multiforme (Stevens-Johnson syndrome),exfoliative dermatitis, epidermal necrolysis, pruritus, photosensitization, anaphylaxis, serum sickness, interstitial nephritis, lupus erythematosus-like syndrome); lung complications (including eosinophilia, fibrosing alveolitis);ocular complications (including periorbital oedema); stomatitis, parotitis; ataxia, aseptic meningitis, vertigo, tinnitus, alopecia, peripheral neuropathy,insomnia, depression, hallucinations; renal effects (including proteinuria, crystalluria, haematuria); oligospermia; rarely acute pancreatitis, hepatitis;urine may be coloured orange; some soft contact lenses may be stained Administered on expert advice.ADULT initially , by mouth as gastro-resistant tablets, 500 mg daily, 45
P/A: A/E:
Dose:
Cost:
increased by 500 mg at intervals of 1 week to a maximum of 23 g daily in divided doses Tablet 500mg (10) Rs 41.40- 56.80
Penicillamine
Penicillamine is a complementary drug for rheumatoid arthritis I: C/I: P/C: Severe rheumatoid arthritis; copper and lead poisoning Lupus erythematosus Monitor throughout treatment including blood counts and urine tests; renal impairment; concomitant nephrotoxic drugs (increased risk of toxicity); pregnancy; breastfeeding ; avoid concurrent gold, chloroquine or immunosuppressive treatment; avoid oral iron within 2 hours of a dose; patients hypersensitive interactions: to penicillin may react rarely to penicillamine; BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Initially nausea (reduced if taken before food or on retiring,and if initial dose is increased gradually), anorexia, fever and skin reactions;taste loss (mineral supplements not recommended); blood disorders including thrombocytopenia, leukopenia, agranulocytosis and aplastic anaemia; proteinuria, rarely haematuria (withdraw immediately); haemolytic anaemia, nephrotic syndrome, lupus erythematosuslike syndrome, myasthenia-like syndrome, polymyositis (rarely with cardiac involvement), dermatomyositis, mouth ulcers, stomatitis, alopecia, bronchiolitis and pneumonitis, pemphigus, glomerulonephritis (Goodpasture syndrome) and erythema multiforme (Stevens-Johnson syndrome) also reported; male and female breast enlargement reported; rash (early rash disappears on withdrawing treatmentreintroduce at lower dose and increase gradually; late rash is more resistanteither reduce dose or withdraw treatment) Capsule or tablet: 250 mg
A/E:
P/A: 46
Medicines used for Gout
Dose:
Administered on expert advice ADULT : Rheumatoid arthritis initially 125250 mg daily before food by mouth,for 1 month, increased by similar amounts at intervals of not less than 4 weeks to usual maintenance of 500750 mg daily in divided doses;ELDERLY initially up to 125 mg daily before food for maximum 1.5 g daily;1 month increased at intervals of not less than 4 weeks; maximum 1 g daily Capsule 250mg (10) Rs 110/-
Cost:
MEDICINES USED TO TREAT GOUT
Acute gout
Acute attacks of gout are usually treated with high doses of a NSAID such as indomethacin (150200 mg daily in divided doses); ibuprofen has weaker anti-inflammatory properties than other NSAIDs and is therefore less suitable for treatment of gout. Salicylates, including acetylsalicylic acid are also not suitable because they may increase plasma-urate concentrations.NSAIDs are contraindicated. Its use is limited by toxicity with high doses. It does not induce fluid retention and can therefore be given to patients with heart failure; it can also be given to patients receiving anticoagulants.
Chronic gout
For long-term control of gout in patients who have frequent acute attacks, the presence of tophi, or chronic gouty arthritis, the xanthine oxidase inhibitor allopurinol may be used to reduce production of uric acid. Treatment for chronic gout should not be started until after an acute attack has completely subsided, usually 23 weeks. The initiation of allopurinol treatment may precipitate an acute attack and therefore a suitable NSAID should be used as a prophylactic and continued for at least one month after the hyperuricaemia has been corrected. If an acute attack develops during treatment for chronic gout, then allopurinol should continue at the same dosage and the acute attack should be treated in its own right. Treatment for chronic gout should be continued indefinitely to prevent further attacks of gout.
Allopurinol
I: Prophylaxis of gout; prophylaxis of hyperuricaemia associated with cancer chemotherapy 47
C/I:
P/C:
A/E:
P/A: Dose:
Cost: 48
Acute gout; if an acute attack occurs while receiving allopurinol, continue prophylaxis and treat attack separately Ensure adequate fluid intake of 23 litres daily; pregnancy breastfeeding; renal impairment (hepatic impairment; withdraw treatment if rash occurs, reintroduce if rash is mild but discontinue immediately if it recurs Rash (see Precautions above), hypersensitivity reactions occur rarely and include fever, l y m p h a d e n o p a t h y, arthralgia, eosinophilia, erythema multiforme (StevensJohnson syndrome) or toxic epidermal necrolysis, vasculitis, hepatitis, renal impairment and, very rarely, seizures;gastrointestinal disorders; rarely malaise, headache, vertigo, drowsiness, visual and taste disturbance, hypertension, alopecia, hepatotoxicity, paraesthesia, neuropathy, gynaecomastia, blood disorders (including leukopenia, thrombocytopenia, haemolytic anaemia and aplastic anaemia) Tablet: 100 mg. ADULT initially 100 mg daily as a single dose,Prophylaxis of gout, by mouth, preferably after food, then adjusted according to plasma or urinary uric acid concentration; usual maintenance dose in mild conditions 100200 mg daily,in moderately severe conditions 300600 mg daily, in severe conditions 700900 mg daily; doses over 300 mg daily given in divided doses NOTE. Initiate 23 weeks after acute attack has subsided and administer a suitable NSAID (not ibuprofen or a salicylate) or colchicine from the start of allopurinol treatment and continue for at least 1 month after hyperuricaemia corrected. Prophylaxis of hyperuricaemia, by mouth, ADULT maintenance doses as for acute gout, adjusted according to response, started 24 hours before cancer treatment and continued for 710 days afterwards;CHILD under 15 years 1020 mg/kg daily (maximum 400 mg daily) Tablet 100mg (10) Rs 14.80-20.00/-
SECTION - 3 ANTI CONVULSANTS/ANTIEPILEPTICS

Phenobarbitone
I: C/I: All forms of epilepsy and status epilepticus except absence seizures. Hypersensitivity, acute intermittent porphyria, severe renal and hepatic disorders and severe myocardial damage. Elderly, debilitated, children, impaired renal or hepatic function, respiratory depression, breast feeding, avoid sudden withdrawal. Drowsiness, lethargy, mental depression, ataxia and allergic skin reactions; paradoxical excitement, restlessness and confusion in the elderly and hyperkinesia in children; megaloblastic anaemia. Tablets 30mg, 60mg. Injection 200 mg/ mL Oral: Adult- 60 to 180 mg at night. Parenteral : I.M. or I.V. 50-200 mg, repeated every 6 h if necessary; maximum 600 mg daily. Dilute injection 1 in 10 with water before, intravenous administration for status epilepticus. Reduced effect of antiarrhythmics, theophylline, cyclosporine, antibacterials and anticoagulants. Tab 30 mg (10) Rs. 4.00 6.00 Inj 200 mg/mL (10 x 1 mL) Rs. 125.00 -126.00 All forms of epilepsy especially tonic-clonic and partial seizure except absence seizure, trigeminal neuralgia. A V block, acute intermittent porphyria Phenytoin should not be given I.M and it should not be added to I.V. infusion along with other drugs; Impaired liver function pregnancy and lactation. Nausea, vomiting, mental confusion, dizziness, headache, tremor, transient nervousness and drowsiness occur commonly; rarely dyskinesias, peripheral neuropathy; ataxia, slurred speech, nystagmus and blurred vision are signs of overdose; rashes, coarse 49
P/C:
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Phenytoin
I: C/I: P/C:
A/E:
Antiepileptics
P/A:
Dose:
D/I:
Cost :
facies, acne, hirsutism, fever and hepatitis; lupus erythematosus, erythema multiforme (Stevens-Johnson Syndrome), toxic epidermal necrolysis, polyarteritis nodosa; lymphadenopathy; gingival hypertrophy and tenderness; rarely hematological effects including megaloblastic anaemia ( may be treated with folic acid), leucopenia, thrombocytopenia, agranulocytosis, and aplastic anaemia; plasma calcium may be lowered (rickets and osteomalacia). Tablet 50 mg and 100 mg Capsule 100 mg, Injection 50 mg/mL. Oral : Adultinitially 3-4 mg/kg daily or 150-300 mg daily as a single dose or in two divided doses increased gradually as necessary. The usual dose 300-400 mg daily upto a maximum 600 mg daily. Parenteral : Adult-slow I.V. or infusion in status epilepticus, with blood pressure and ECG monitoring in a dose of 15 mg/ kg at a rate not exceeding 50 mg per minute, as the loading dose. Maintenance doses of about 100 mg should be given thereafter at intervals of 6 - 8 h, monitored by measurement of plasma concentrations, rate and dose reduced according to weight. It increases degradation of steroids, oral contraceptives and theophylline; INH and warfarin inhibit phenytoin metabolism. Tab 100 mg (10) Rs. 9.50; Inj 50 mg/2 mL Rs. 9.75 Status epilepticus, seizures during neurosurgery, as short term substitute for oral phenytoin. Hypersensitivity to hydantoin derivatives, porphyria, sinus bradycardia, sino-atrial block, second and third degree A-V block, and Stokes-Adams syndrome, pregnancy, lactation. Seizures on drug withdrawal, hypotension and heart blocks on IV administration (careful cardiac monitoring is required), patients on phosphate restriction, renal and hepatic disease, hypoalbuminemia, potential to lower serum folate levels.
Fosphenytoin
I: C/I:
P/C:
50
Antiepileptics
A/E:
P/A:
Dose:
Cost:
Cardiovascular collapse, hypotension, sinus bradycardia, heart block, atrial/ventricular fibrillation, central nervous system depression, nystagmus, dizziness, pruritus / paresthesia (specially in the groin area), headache, somnolence, and ataxia. Injection 2ml (fosphenytoin sodium 150 mg equivalent to 100 mg of phenytoin sodium), 10ml (fosphenytoin sodium 750 mg equivalent to 500 mg of phenytoin sodium) As phenytoin sodium equivalents (PE); loading dose is 15 to 20 mg PE/kg administered at 100 to 150 mg PE/ min (never faster than 150 mg PE/min). Maintenance: initially 4-5mg PE/kg/day at a rate of 50-100 mg PE/ min, subsequently adjust dose according to response and trough plasma phenytoin levels. Inj 2 mL Rs 30.00 Inj 10mL Rs 140.00 Generalized tonic- clonic and partial seizures; trigeminal neuralgia; bipolar disorder Atrioventricular conduction abnormalities; history of bonemarrow depression; porphyria Hepatic impairment; renal impairment; cardiac disease; skin reactions; history of blood disorders (blood counts before and during treatment); glaucoma; pregnancy ; breastfeeding; avoid sudden withdrawal. Dizziness, drowsiness, headache, ataxia, blurred vision, diplopia (may be associated with high plasma levels); gastrointestinal intolerance including nausea and vomiting, anorexia, abdominal pain, dry mouth, diarrhoea or constipation; commonly, mild transient generalized erythematous rash (withdraw if worsens or is accompanied by other symptoms); leukopenia and other blood disorders (including thrombocytopenia, agranulocytosis and aplastic anaemia); cholestatic jaundice, hepatitis, acute renal failure, StevensJohnson syndrome (erythema multiforme), toxic epidermal necrolysis, alopecia, thromboembolism, arthralgia, fever, proteinuria, lymph node enlargement, arrhythmias, heart block and heart failure, dyskinesias, paraesthesia, depression, impotence, male infertility, 51
Carbamazepine
I: C/I: P/C:
A/E:
Antiepileptics
P/A: Dose:
Cost:
gynaecomastia, galactorrhoea, aggression, activation of psychosis, photosensitivity, pulmonary hypersensitivity, hyponatraemia, oedema, disturbances of bone metabolism like osteomalacia also reported; confusion and agitation in elderly Tablet : 100 mg; 200 mg. Generalized tonic-clonic seizures, partial seizures, by mouth, initially 100200 mg 12 times daily, increased gradually according to response to usual maintenance dose of 0.81.2 g daily in divided doses; in some cases 1.62 g daily may be needed ELDERLY reduce initial dose; Trigeminal neuralgia, by mouth, initially 100 mg 12 times daily increased gradually according to response; usual dose 200 mg 34 times daily with up to 1.6 g daily in some patients NOTE. Plasma concentration for optimum response 412 mg/litre (17 50 micromol/ litre) Tab 100mg (10)Rs7-10; Tab 200 mg (10) 16.50 Monotherapy or adjunctive therapy in the treatment of partial seizures Hypersensitivity Pregnancy, l a c t a t i o n , h y p e r s e n s i t i v i t y to carbamazepine, cognition disturbances may interfere with ability to operate machinery. Dizziness, somnolence, diplopia, fatigue, nausea, vomiting, ataxia, nystagmus, dyspepsia, hypotension, hyponatremia, hypersensitivity (anaphylaxis / angioedema) Tablets 150mg, 300mg , 600 mg 600mg/day initially in 2 divided doses; maximum increments of 600mg/day at weekly intervals; maximum dose - 2400mg/day. Decreased levels of other antiepileptics like phenytoin, phenobarbitone, carbamezapine, valproic acid, hormonal contraceptives, calcium channel blockers like felodipine. Tab 150 mg (10) Rs 27.00 - 33.00 Tab 300 mg (10) Rs 49.00 - 60.00 Tab 600 mg (10) Rs 90.00 - 120.00
Oxcarbazepine
I: C/I : P/C:
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52
Antiepileptics
Ethosuximide
I: Drug of choice in simple absence seizures; it may also be used in myoclonic seizures and in atypical, absence, atonic, and tonic seizures. Hypersensitivity Same as for carbamazepine. In addition pregnancy and breast feeding. Gastrointestinal disturbances, weight loss, drowsiness, dizziness, ataxia, dyskinesia, hiccup, photophobia, headache, depression, and mild euphoria. Psychotic states, rashes, hepatic and renal changes and haematological disorders such as agranulocytosis and aplastic anaemia occur rarely.Systemic lupus erythematosus and erythema multiforme may occur.Other side effects include gum hypertrophy, swelling of tongue, irritability, hyperactivity, sleep disturbances, night terrors, inability to concentrate, aggressiveness, increased libido, myopia and vaginal bleeding. Syrup 250 mg/5ml 20-30 mg/kg/day orally Syrup 50 mg /mL (114 mL) Rs. 40.00 All forms of epilepsy. It is effective in controlling tonicclonic seizures, particularly in primary generalised epilepsy. It is a drug of choice in primary generalised epilepsy, generalised absence and myoclonic seizures, and may be tried in atypical, absence, atonic, and tonic seizures. Active liver disease, family history of severe hepatic dysfunction. Monitor liver function before therapy and during the first 6 months especially in patients at higher risk. ln patients receiving this drug exclude bleeding tendency before major surgery; severe renal impairment; pregnancy, breast-feeding, systemic lupus erythematosus, acute porphyria. False positive urine tests for ketosis may occur. Avoid sudden withdrawal. There is increased risk of neural tube defects and neonatal bleeding and neonatal hepatotoxicity if the 53
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Sodium Valproate
I:
C/I: P/C:
Antiepileptics
A/E:
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drug is given during pregnancy. Liver dysfunction including fatal hepatic failure has occurred in association with valproate (especially in children under 3 years of age). Gastric irritation, nausea, ataxia and tremor, increased appetite and weight gain, transient hairloss, oedema, thrombocytopenia and inhibition of platelet aggregation, impaired hepatic function leading rarely to fatal hepatic failure, rashes, sedation, rarely pancreatitis, leucopenia, red cell hypoplasia, fibrinogen reduction, irregular periods, amenorrhoea and gynaecomastia. Tablet 200 mg and 500 mg Adult initially, 600 mg daily given in 2 divided doses, preferably after food, increased by 200 mg/ day at 3 day intervals to a maximum of 2.5 g daily in divided doses. Usual maintenance is 1-2 g daily (20- 30 mg/ kg body weight daily). Children Upto 20 kg : 20mg/ kg bw daily in divided doses. This may be increased depending on the response. lf doses above 40 mg/ kg daily are given it is preferable to monitor plasma levels. Over 20 kg : initially 400 mg daily in divided doses increased until control. Usually 20-30mg/kg body weight daily may be required upto a maximum of 35 mg/ kg daily. Enhanced effect by aspirin. With antidepressants and antipsychotics, antagonism of anticonvulsant effect. Enhanced toxic effects with other antiepileptics Tab 200 mg (10) Rs. 27.50; Tab 500 mg (10) Rs. 46.50 Clonazepam has been primarily used in petitmal. It is also used as an adjuvant in myoclonic and akinetic epilepsy and may afford some benefit in infantile spasms. Respiratory depression, acute pulmonary insufficiency, porphyria. Respiratory disease, hepatic and renal impairment, elderly and debilitated, pregnancy and breast feeding. Sedation, dullness, behavioural abnormalities in children, drowsiness, fatigue, dizziness, muscle
Clonazepam
I:
C/I: P/C: A/E: 54
Antiepileptics
P/A: Dose:
D/I: Cost:
hypotonia, coordination disturbances, hypersalivation in infants, blood disorders. Tablets 0.5 mg, 2 mg. Orally - 1 mg (elderly 500 mcg), initially at night for 4 night, increased over 2-4 weeks to a usual maintenance dose of 4-8 mg daily in divided dose. Metabolism of clonazepam accelerated by carbamazepine, phenobarbitone and phenytoin. Tab 2 mg (10) Rs. 30.00- 42.00
Diazepam See section 25 (Psychotherapeutic drugs). Lorazepam - See section 25 (Psychotherapeutic drugs). Clobazam
I: CI: Short term management of anxiety; as an adjunct in epilepsy Hypersensitivity, history of drug dependence, myasthenia gravis, pregnancy, lactation, liver failure, sleep apnoea syndrome, impaired respiratory function. Driving, operating machines, impaired renal or hepatic function, pregnancy. Drowsiness, ataxia, dizziness, behaviour disorders, confusion, depression, lethargy, slurred speech, tremor, anterograde amnesia; Rash, pruritus, urticaria; Weight gain (2%); Xerostomia, constipation, nausea; respiratory depression; Muscle spasm; Blurred vision (1%) Tablets 5mg,10mg, 20mg. Initial, Orally 5-15 mg/day; dosage may be gradually adjusted (based on tolerance and seizure control) to a maximum of 80 mg/day. Decreased levels of drug is seen with phenytoin, phenobarbitone and carbamazepine. Tab 10mg (10) Rs 43.60 Anticonvulsant adjunctive therapy in the treatment of partial seizures in adults with epilepsy. Hypersensitivity, lactation. Hepatic and renal impairment, close monitoring during long term therapy is required, children below 16 years, elderly, pregnancy, during discontinuation of therapy. Diplopia, drowsiness, dizziness, ataxia, headache, nausea and vomiting. 55
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Lamotrigine
I: C/I: P/C:
A/E:
Antiepileptics
P/A: Dose:
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Tablets 25 mg, 100 mg, 150 mg, 200 mg. Starting dose of 25 mg hs. increasing in 25 mg/ day increments at 2 week intervals to a maximum of 100 mg/day. Valproic acid blocks the elimination of lamotrigine. Tab 25 mg (10) Rs. 33.00 Adjunctive treatment of partial seizures with or without secondary generalisation not satisfactorily controlled with other antiepileptics. Hypersensitivity Avoid sudden withdrawal. The drug should be tapered off over at least 1 week. Somnolence, dizziness, ataxia, tremor, diplopia, nausea and vomiting, also convulsions. Capsule 300 mg and 400 mg. 300 mg on first day, then 300 mg bd on second day, then 300 mg tds. on third day, then increased according to response to 1.2 g daily (in 3 equally divided doses). Not recommended for children. Reduced absorption with antacids; Caps 300 mg (10) Rs. 98.50 313.00 Simple and complex pastial seizures; generalised seizures. Pregnancy and breast feeding Renal impairment, closely monitor neurological functions, avoid sudden withdrawal. Mild, drowsiness, mental confusion, amnesia, behavioural changes and agitation in children. Tablet 500mg With current antiepileptic therapy, initially 1 g daily in single or 2 divided doses, then increased according to response in steps of 500mg; usual range 2-4 g daily. Causes a 20% decrease in plasma phenytoin concentration.
Gabapentin
I:
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Vigabatrin
I: C/I: P/C: A/E: P/A: Dose:
D/I: 56
Antiepileptics
Topiramate
I: Adjunctive / monotherapy for partial seizures and primary generalized tonic-clonic seizures; treatment of seizures associated with Lennox-Gastaut syndrome; prophylaxis of migraine. Hypersensitivity, lactation Hepatic or renal impairment, maintain adequate hydration to avoid renal stones, glaucoma, concurrent valproate therapy, inborn errors of metabolism, influence psychomotor performance / ability to handle machines, acidosis, hyperthermia, pregnancy, children below 2 years. Dizziness, ataxia, somnolence, psychomotor slowing, nervousness, memory difficulties, speech problems, fatigue, acidosis, dehydration, nystagmus, diplopia, abnormal vision, xerostomia, gingivitis, weight loss, renal calculi, encephalopathy with valproate. Tablets 25mg, 50mg, 100mg >16 yr: Initially, 25 mg at night for 1 wk increased by 25-50-mg increments at 1-2 wk intervals until effective dose is reached. Daily doses >25 mg should be taken in 2 divided doses. Usual dose: 200-400 mg daily. Max: 800 mg. Coadministration with antiepileptic drugs like phenytoin, carbamazepine, phenobarbital decreases plasma concentration of topiramate; Possible increase in phenytoin levels. Increased risk of renal stones with carbonic anhydrase inhibitors like acetazolamide; CNS depression with CNS depressants and alcohol; hyperammonaemia and encephalopathy with valproic acid; contraceptive failure. Tab 50mg (10) Rs 45.00 87.00 As adjunctive for refractory partial seizures with or without secondary generalisation Hepatic impairment, pregnancy, breast feeding, careful withdrawal of the drug. Dizziness, tiredness, nervousness, somnolence, tremor, irritability, confusion, depression, psychosis, nystagmus. 57
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Tiagabine
I: P/C: A/E:
Antiepileptics
P/A: Dose:
D/I:
Tab 5mg, 10mg, 15mg Children >12yrs and adults 5mg BD oral for one week, increase weekly 5-10mg increments, maximum of 3045mg daily in three divided doses. Plasma concentration of the drug is decreased (upto three fold) by carbamazepine, phenobarbitone, phenytoin or primidone. Adjunctive anti epileptic in partial seizures. Hypersensitivity to sulfonamides, pregnancy, breast feeding. Hepatic renal impairment and history of nephrolithiasis. Anorexia, nausea, somnolence, skin reactions, Steven Johnsons Syndrome, renal calculi. Tab 50mg, Tab 100mg, 200mg Adults >18yrs 50mg daily in two divided doses increased to 100mg daily. Increased according to response to a maximum of 600mg. Cap (10) Rs. 82.00 Adjuvant in the treatment of partial seizures with or without secondary generalisation; Second line drug in generalized tonic clonic seizures; In myoclonus including juvenile myoclonic epilepsy and for atonic and tonic seizures. Renal/hepatic impairment, hemodialysis patients, pregnancy, lactation. Somnolence,weakness, dizziness, anorexia, diarrhea, headache, ataxia, amnesia, emotional lability, insomnia, tremor, vertigo, diplopia, rash. Tab 250mg, 500mg, 750mg Initial adult dose 1g on the first day thereafter daily dose may be increased in increments of 1g every 2-4 weeks according to response. Maximum dose 3g daily. Tab 250mg (10) Rs 92.00 - 96.00 Tab 500mg (10) Rs 180.00 - 189.00
Zonisamide
Cost:
Levetiracetam
I:
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Cost:
58
Antiepileptics
Felbamate
I: Unresponsive cases of epilepsy, refractory partial seizures with or without secondary generalization. In children as an adjunctive therapy in seizures associated with Lennox Gastaut Syndrome History of blood disorders and hepatic impairment. To be used only in severe refractory epilepsy because of risk of fatal aplastic anemia or acute liver failure. Pregnancy, breastfeeding, elderly, renal impairment. Anorexia, nausea, vomiting, weight loss, rash, insomnia, headache, dizziness, somnolence, diplopia, Aplastic anemia and acute liver failure. Photosensitivity and rarely Steven Johnsons Syndrome. Orally 1.2g daily in three or four divided doses; increments of 600mg every 2 weeks; maximum of 3.6g daily if necessary (monotherapy). Metabolism is increased by phenytoin, phenobarbitone and carbamezapine. Half life is prolonged by Gabapentin. Oral contraceptive failure/breakthrough bleeding. Used as an adjunct in partial seizures with or without secondary generalization, generalized anxiety disorder, neuropathic pain. Hypersensitivity, pregnancy and lactation. Care in operating machinery, care in withdrawing therapy Dizziness, somnolence, blurred vision, diplopia, increased appetite, weght gain, dyspepsia, erectile dysfunction, irritability, ataxia. Disturbances of attention, memory and coordination. Rarely increase in creatinine kinase and rhabdomyolysis. Cap 75mg, 150mg, 300mg Initially in epilepsy 150mg daily; increase after 1 week according to response to 300mg daily maximum 600mg/ day. Tab 75mg, 150mg Cap 75mg (10) Rs 68.00-75.00 Cap 150mg (10) Rs 129.00-139.00 59
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Pregabalin
I:
C/I: P/C: A/E:
P/A: Dose:
Cost:
Antiepileptics
Magnesium Sulphate:
Prevention of recurrent seizures in eclampsia; prevention of seizures in pre-eclampsia P/C: Myasthenia gravis; hepatic impairment; renal impairment; pregnancy A/E: Generally associated with hypermagnesemia, nausea, vomiting, thirst, flushing of skin, hypotension, arrhythmias, coma, respiratory depression, drowsiness, confusion, loss of tendon reflexes, muscle weakness P/A: Injection: 500 mg/ml in 2-ml ampoule; 500 mg/ml in 10-ml ampoule. Dose: Prevention of recurrent seizures in eclampsia, by intravenous injection, ADULT and ADOLESCENT initially 4 g over 515 minutes followed either by intravenous infusion, 1 g/hour for at least 24 hours after the last seizure or delivery (whichever occurs later) or by deep intramuscular injection 5 g into each buttock then 5 g every 4 hours into alternate buttocks for at least 24 hours after the last seizure or delivery (whichever occurs later); recurrence of seizures may require additional intravenous injection of 2 g (4 g if bodyweight over 70 kg) Prevention of seizures in pre-eclampsia, by intravenous infusion, ADULT and ADOLESCENT initally 4g over 515 minutes followed either by intravenous infusion, 1 g/hour for 24 hours or by deep intramuscular injection 5 g into each buttock then 5 g every 4 hours into alternate buttocks for 24 hours; if seizure occurs, additional dose by intravenous injection of 2 g DILUTION AND ADMINISTRATION: According to manufacturers directions for intravenous injection concentration of magnesium sulfate should not exceed 20% (dilute 1 part of magnesium sulfate injection 50% with at least 1.5 parts of water for injection); for intramuscular injection, mix magnesium sulfate injection 50% with 1 ml lidocaine injection 2%. I:
60
SECTION - 4 ANTIINFECTIVE DRUGS

ANTIMICROBIALS
PENICILLINS Highly effective against gram positive bacteria BENZYL PENICILLIN AND ITS CONGENERS Benzyl penicillin (Penicillin G) Benzathine penicillin. Procaine penicillin Phenoxymethyl penicillin (Penicillin V) Benzyl penicillin (Penicillin G) l: Acute tonsillitis,pharyngitis,otitis media,streptococcal endocarditis,pneumonia, m e n i n g o c o c c a l and pneumococcal meningitis C/I: Hypersensitivity to penicillin. P/C: History of allergy;Renal impairment A/E: Anaphylaxis,Serum sickness like reactions, Jarisch Herxheimer reaction is seen in syphilitic patients, Paraesthesia with prolonged use, Pain at IM injection site, Nausea on oral ingestion P/A: Sodium Penicillin G(Crystalline Penicillin)0.5, 1 MU injection(powder for reconstitution) Dose: 0.5-5 MU IM or IV 6 12 hourly D/l: Probenecid reduces urinary excretion of penicillins. So it can increase blood levels of penicillin. Note: Whenever possible penicillin should be administered only after testing for hypersensitivity to avoid unexpected fatal reactions. A drop of weak solution containing 1000 unit / ml is tested on the forearm by a scratch test. lf the test is negative 10,000 units is given by intra dermal test. lf there is no reaction up to 30 min the drug may be given parenterally. ln any case drugs for emergency resuscitation such as adrenaline, hydrocortisone and IV glucose, and respiratory support should be available at hand. 61
Antiinfective Drugs
Cost:
Benzyl penicillin lnjection 10 lac units (vial) Rs. 7.00 8.00 Pharyngitis,Prophylaxis of Rheumatic Fever,Syphilis As for Benzyl Penicillin,should not inject intravascularly As for Benzyl Penicillin,not recommended in neurosyphilis due to its inadequate penetration into CSF. As for Benzyl Penicillin Injection 600,000 and 1,200,000 units/vial (powder for reconstitution) 900 mg Benzathine penicillin is approximately equivalent to 720 mg of Benzyl Penicillin(1.2 million units) Adult Rheumatic fever 12 lakh units (900 mg) deep IM repeated every 3-4 weeks Syphilis:24 lakh units 1.8 g deep IM at weekly intervals for 3 consecutive weeks. Child:<30 kg,6 lakh units(450 mg) IM repeated every 34 weeks Benzathine penicillin lnj 24 lac units (vial) Rs. 16.00 18.00 Should be restricted to organisms that are highly sensitive to penicillins; Syphilis; Gonorrhoea, Anthrax, Pneumonia As for Benzathine Penicillin As for Benzyl Penicillin;penicillin sensitivity test must be done before use;avoid in new born infants As for Benzyl Penicillin 0.5, 1 MU dry powder and vial Adult-0.6-1.2 g of Procaine Penicillin deep IM daily in 1 or 2 divided doses;upto 4.8 g as a single dose given at 2 injection sites in Gonorrhoea. Syphilis:1.2 g IM daily for 10-15 days;treatment may be continued for 3 weeks in patients with late Syphilis. Child:upto 2 years with congenital Syphilis:50 mg/kg of Procaine Penicillin deep IM once daily per vial Rs-28-30/-
Benzathine penicillin
I: C/I: P/C:
A/E: P/A: Note:
Dose:
Cost:
Procaine penicillin
I:
Cost: 62
Pencillins
Phenoxymethyl penicillin (Penicillin V)

Dose: Cost: Cloxacillin I: C/I: P/A: Infections due to penicillinase resistant staphylococci P/C: A/E: D/I: Similar to that of Benzyl penicillin Capsules 250 mg, 500 mg, Injection 250 mg, 500 mg(Powder for reconstitution) Combination preparations (tablet, injection, syrup) with ampicillin in different ratios are available. 250-500 mg orally 4 times daily half an hour before food;250 mg IM every 4-6 hours;500 mg slow IV every 4-6 hours. Caps 500 mg (10) Rs. 63.00; Injection 250 mg (1 vial) Rs. 6.00 -10.00 500 mg every 6 hours orally,increase upto 750 mg in severe infections. 250 mg (10) Rs:13.50/-
Beta lactamase resistant penicillins
Dose:
Cost:
Broad spectrum penicillins

Spectrum of Penicillin G + activity against g ve bacteria
Ampicillin
I: Urinary tract infection, respiratory tract infections,otitis media,sinusitis,chronic bronchitis, invasive salmonellosis and gonorrhea. Penicillin hypersensitivity As for of benzyl penicillin. As for of benzyl penicillin;nausea,diarrhoea,rashes Capsules 250 mg, 500 mg Injection 500 mg/vial (Powder for reconstitution) 250 mg-1 g 6 hourly atleast 30 minutes before or 2 hours after food;500 mg IM/slow IV every 4-6 hours Caps 250mg (10) Rs. 32.00 - 36.00 Injection 500 mg (vial) Rs.10.00 - 23.00 Infections caused by beta lactamase producing organisms Injection Ampicillin1g + Sulbactam 0.5g 1.5 3 g IV/deep IM 6-8 hourly Injection Ampicillin1g + Sulbactam 0.5g vial Rs. 78.00 110.00 63
C/l: P/C: D/I: A/E: P/A: Dose : Cost:
Ampicillin + Sulbactam
I: P/A: Dose: Cost:
Antiinfective Drugs
Ampicillin + Cloxacillin
I: P/A: Infections caused by beta lactamase producing organisms Capsule 500mg (250 +250) Syrup 125mg/5ml (30ml) Injection 500mg (250 + 250),1g (500mg+ 500mg) 1 Cap (250mg Ampicillin + 250 mg Cloxacillin)4-6th hourly Capsule 500mg (10)Rs. 31.00 Similar to ampicillin. Similar to that of Ampicillin Capsule 250 mg, 500 mg Injection 250 mg, 500 mg Combination preparation with cloxacillin,clavulanic acid are available 500 mg 8th hourly atleast 30 minutes before or 2 hours after food,500 mg IM/slow IV every 4-6 hours Caps 500 mg (10) Rs. 67.00 -86.00 Inj 250 mg (1 vial) Rs. 13.00 - 20.00
Dose: Cost:
Amoxycillin
I: C/I:P/C:A/E:D/I: P/A:
Dose : Cost:
Antipseudomonal Penicillins
Piperacillin I: C/I:A/E: P/C: P/A : Dose : D/ I: Cost: I: C/I:P/C:A/E: P/A: Dose: Infections due to pseudomonas and klebsiella. As for benzyl penicillin. As for benzyl penicillin;Renal impairment. Injection lg, 2g, 4g vials ;Piperacillin + Tazobactam also available 2 g 6 hourly or 8 hourly IV Piperacillin may inactivate aminoglycosides. Inj 2 g (vial) Rs. 260.00 Infections due to Pseudomonas and Proteus species As for Benzyl penicillin Injection 1 gm vial 3g IV every 6-8 hours
Ticarcillin+Clavulanic acid
CEPHALOSPORINS First generation Cephalosporins

g+Cocci>g-Bacilli>g+Bacilli>-Cocci 64
Cephalosporins
Cephazolin
I: Surgical prophylaxis where skin flora are the likely pathogen;Skin and soft tissue infections due to S. aureus and S. pyogenes. Hypersensitivity Penicillin sensitivity,Renal impairment Skin rash,GI disturbances Injection 500 mg and 1 g vial. 500 mg - 1 g IM/IV every 6 - 12 hours. Injection 500 mg (vial) Rs. 26.50/Upper respiratory tract infections, urinary tract infections and soft tissue infections As for Cephazolin Capsule 250 mg, 500 mg. 1 - 4gm daily in 4 divided doses Cap 500 mg (10) Rs. 70.00 - 120.00/-
C/I: P/C: A/E: P/A: Dose: Cost :
Cephalexin
I: C/I:P/C:A/E: P/A: Dose : Cost:
Second generation Cephalosporins

g-Cocci/g-Bacilli>g+cocci>g+Bacilli;also includes Anaerobes
Cefuroxime
I: Upper respiratory tract infections, urinary tract infections and soft tissue infection, surgical prophylaxis,meningitis,gonorrhoea As for Cephazolin Injection 250mg,500mg vial;Cefuroxime axetil oral 250 and 500 mg capsule Injection 3g 8h;Oral 250 mg twice daily Cap 250 mg (4) Rs. 80.00 130.00
C/I:P/C:A/E: P/A: Dose: Cost:
Third generation Cephalosporins g-Cocci,g-Bacilli and Anaerobes>g+Cocci and g+Bacilli Cefotaxime

I: C/I:P/C:A/E: P/A : Dose : Cost : Cellulitis, meningitis, septicaemia,respiratory and urinary tract infections, intra abdominalinfections As for Cephalexin Injection 250 mg, 500 mg vials;Cefotaxime + Sulbactam also available 1-2 g IM or IV 12 h Inj 1g vial (5ml) Rs. 46.00 65
Antiinfective Drugs
Ceftriaxone
I: Gonorrhoea, Enteric fever, Meningitis, Endocarditis, Urinary tract infections, Lower respiratory tract infections, Surgical Prophylaxis As for Cephalexin Injection 500 mg and 1 g(Powder for Injection) 1 g IM/IV daily as a single dose Typhoid fever 4 g IV daily for 2 days followed by 2 g daily till 2 days after fever subsides Injection 1g vial Rs. 62.00 90.00 Pseudomonal infections like pneumonia, meningitis, septicaemia, respiratory infections, urinary tract infections,skin and soft tissue,bone and joint infections As for Cephalexin;Pain at injection site,rise in liver enzymes Injection 250mg, 500mg, 1g(Powder for reconstitution) 1g IM/IV every 8 hours or 2 g every 12 hours. Injection 1g vial Rs. 334.00/Infections caused by pseudomonas & bacteroides like urinary tract infections, skin & soft tissue infections, severe respiratory infections, meningitis, septicaemia, GI infections As for Cephalexin;Reversible neutropenia Disulfiram like reaction with alcohol Injection 250mg, 500mg, 1g 1-2g IM/IV every 12 hour Injection 1g vial Rs.84.00 Skin and soft tissue infection; respiratory tract infection, urinary tract infections, otitis media gonorrhoea. As for Cephalexin Tablet 100mg, 200mg 200 -400mg orally 12hourly Tablet 200mg (10) Rs. 150.00
C/I:P/C:A/E: P/A: Dose:
Cost:
Ceftazidime
I:
C/I: P/C:A/E: P/A: Dose: Cost:
Cefoperazone
I:
C/I:P/C:A/E: D/I: P/A: Dose: Cost: I:
Cefpodoxime proxetil
C/I:P/C:A/E: P/A: Dose: Cost: 66
Pencillins
Cefdinir
I: C/I:P/C:S/E: P/A: Dose: Cost: Pneumonia, chronic bronchitis, ENT and skin infections As for Cephalexin Capsule 300mg 300mg twice daily Capsule 300mg (10) Rs. 250.00/-
Cefixime
Capsules 200mg, 400mg 200-400mg orally twice daily Fourth generation cephalosporins g-Cocci and g-Bacilli resistant to 3rd generation>cocci as of 3rd generation; no Anaerobes No g +Bacilli P/A: Dose:
Cefepime
I: C/I: P/C: A/E: P/A: Dose: Hospital acquired pneumonia, urinary tract infections, intra abdominal infections, septicemia Hypersensitivity Severe renal impairment,history of Penicillin or Cephalosporin allergy Rash GI disturbances,Neutropenia Injection 1g, 2g(Powder for reconstitution) 1-2 g IV every 12 hours for 7-10 days Same as Cefipime;taste disturbance shortly after injection Injection 1g vial(Powder for reconstitution) 1-2g IV/IM every 12hours Other betalactam antibiotics Treatment of aerobic and anaerobic gram +ve and gramve infections;surgical prophylaxis; hospital-acquired septicaemia. Hypersensitivity to imipenem or cilastatin, breastfeeding. Patients known to be hypersensitive to other betalactam antibiotics, renal impairment, CNS disorders, pregnancy. Hypersensitivity reactions, GI disturbances, pseudomembranous colitis,elevation of liver enzymes, 67
Cefpirome
I: C/I:P/C:A/E: P/A: Dose:
Imipenem + Cilastatin
I:
C/I : P/C:
A/E:
Antiinfective Drugs
P/A : Dose :
abnormalities in haematological parameters, positive Coombs test, seizures, taste disturbances, allergic reactions;myoclonic activity, convulsions, confusion and mental disturbances reported; slight increase in liver enzymes and bilirubin reported, rarely hepatitis; increase in serum creatinine and blood urea. Injection, 250mg/vial, 500mg/vial as imipenem (powder for reconstitution) I.M(as imipenem) 500-750mg, every l2 hours in mild to moderate infections. I.V(as imipenem) 1-2g daily in 3-4 divided doses, max. 4g or 50mg/kg daily Aerobic and Anaerobic gram + and gram infections Hypersensitivity. History of hypersensitivity to other beta-lactam antibiotics, infants <3 months, hepatic and renal in sufficiency, neurological disorders, pregnancy, lactation. Anaphylaxis, pseudomembranous colitis, GI disturbances, pruritus, disturbances in LFT 500mg and 1 g vial( Powder for reconstitution) Injection 500-1 g 8 hours IV Hospital acquired infections originating from urinary, biliary, respiratory ,GI and female genital tract Hypersensitivity, lactation Renal and hepatic impairment; pregnancy. Pain and thrombophlebitis at the injection site,seizures 0.5g, 1g, 2g vial 1-2 g, 6 8h 1g vial Rs. 450.00
Meropenem:
I: C/I: P/C:
A/E: P/A: Dose:
Aztreonam
I: C/I: P/C: A/E: P/A: Dose: Cost:
AMINOGLYCOSIDES Mainly effective against gram ve aerobic bacilli(E Coli,Klebsiella,Shigella,Proteus including Enterobacter and Pseudomonas aeruginosa except salmonella) They exhibit synergism when combined with a betalactam
Streptomycin:(Refer section 27)

68
Aminoglycosides
Gentamicin
I: Urinary tract infections, pneumonia (caused by pseudomonas aeruginosa, klebsiella, E.coli or proteus and mycoplasma), meningitis ( specially pseudomonas and acinetobacter ),peritonitis, enterococcal endocarditis (gram-negative bacillary species, groupA beta haemolytic streptococci, and staphylococci). Pregnancy, lactation and known sensitivity to the drug. Renal insufficiency, myasthenia gravis, hearing disorders, reduced dose in elderly and children. Nephrotoxicity, irreversible ototoxicity. Injection 40 mg/ mL 2 mL vials Injection 2 - 5 mg/kg IM/IV daily in 3 divided doses Inj 40 mg/ml (2 ml) Rs. 7.00 - 8.00
C/I: P/C: A/E: P/A: Dose: Cost:
Kanamycin:(Refer section 27) Amikacin

l: Serious nosocomial gram negative infections resistant to Gentamycin and Tobramycin, second line treatment of T.B, atypical mycobacterial infections Same as gentamicin Injection 100mg/2ml Injection 15 mg/kg IM or slow IV daily in 2-4 divided doses upto a maximum 1.5 g daily in life threatening infections Loop diuretics increase nephrotoxicity and ototoxicity.Neuromuscular blockers increase muscle weekness.Synergism with penicillins, cephalosporins and newer beta lactam antibiotics Inj 100 mg (vial) Rs. 16.00 17.00 Urinary tract infections, serious systemic infections (enterobacteriaceae,and gentamicin resistant pathogens), Klebsiella,staphylococci Hypersensitivity. Neurotoxicity and nephrotoxicity Same as other aminoglycosides, but milder. lnjection 50mg/mL 2mL ampoule;100 mg/mL, 2mL ampoule 69
C/I:P/C: A/E: P/A: Dose:
D/I:
Cost:
Netilmicin
I:
C/l: P/C: A/E: P/A:
Antiinfective Drugs
Dose :
D/I: Cost:
Injection 4-6 mg/kg IM/IV as a single dose or in divided doses every 8 or 12 hours;in severe infections upto 7.5 mg daily in divided doses every 8 hours. Same as aminoglycosides. ln] 50 mg (1mL) Rs. 67.00 - 68.00 Topical application for burns, ulcers. Preparation of the bowel for surgery. Adjunct for hepatic coma. Hypersensitivity and renal impairment. Malabsorption syndrome on chronic use. Hypersensitivity reactions, rashes, nephrotoxicity and ototoxicity,malabsorption and superinfection. Tablets 500 mg;Capsules 350 mg;Ointments/creams 5 mg/g 0.25 - 1g bd for sterilizing bowel. Same as streptomycin. Cap 350 mg (10) Rs. 26.00 - 30.00 Staphylococcal skin infections and nasal carriers of staphylococci. Burns, otitis externa, ocular infections like conjunctivitis, blepharitis and keratitis. Hypersensitivity, perforated ear drum, resistant infection. Increased risk of toxicity on application to large area, use with caution in elderly and children, and those with renal failure. Contact dermatitis, irritation and itching. Ointment 0.5% 0.5 % ointment for staphylococcal skin infections & nasal carriers of staphylococci. Same as streptomycin. Ointment 0.5% (5g) Rs. 6.00 8.00 BROADSPECTRUM ANTIBIOTICS
Neomycin
I: C/I: P/C: A/E: P/A: Dose: D/I: Cost:
Framycetin
I:
C/I: P/C:
A/E: P/A: Dose: D/I: Cost :
Tetracycline
Almost all g+ve and g-ve Cocci have become resistant except for Neisseria gonorrhea.Highly active against Rickettsiae, Chlamydia, Spirochetes, Mycoplasma pneumonia, Vibrio cholera etc 70
Broad spectrum antibiotics
I:
C/I:
P/C:
A/E :
P/A: Dose:
Cost:
Rickettsia,mycoplasma and ureaplasma infections, chronic respiratory infections by H influenzae, klebsiella; brucellosis, plague. Impaired renal/ hepatic function and hypersensitivity, children less than 8 years, SLE, blood dyscrasias, pregnancy, lactation. With caution in elderly and patients with benign intracranial hypertension.Superinfection with proteus, candida albicans, pseudomonas or clostridium may occur. In long term therapy hepatic, renal and haemopoietic function should be monitored. Supplementation of B complex factors is necessary since long term therapy suppresses the intestinal bacteria. Intolerance eg. rashes, photosensitivity, nail discoloration etc., Gl disturbances; superinfection, hepatic failure, pancreatitis, renal impairment, weight loss. Tetracycline orthophosphate deposits on developing teeth and bones. Capsule 250 mg,500 mg. Oral : 250 - 500 mg 6 hourly Take on an empty stomach 1 h before or 2 h after food with one glassful of water. Caps 250 mg (10) Rs. 12.00 - 13.00 Same as for Tetracyclines Capsule 100 mg 200 mg (single dose) on day one followed by 100 mg o.d. Severe infections 100 mg bd. for 5-10 days. Caps 100 mg (10) Rs. 16.00 - 23.00 Vestibular toxicity 50 and 100 mg capsules 200mg initially 100 -200 mg once daily Enteric fever, meningitis(H.influenza), cystic fibrosis and infections resistant to other antibiotics. 71
Doxycycline
I:C/I:P/C:A/E: P/A: Dose:
Cost :
Minocycline
A/E: P/A: Dose:
Chloramphenicol
I:
Antiinfective Drugs
C/I:
P/C: A/E:
P/A:
Dose:
D/l:
Cost:
Hypersensitivity, minor infections, blood dyscrasias, bone marrow depression, pregnancy, lactation and porphyria. Use with caution in renal or hepatic diseases. Blood examinations to be done periodically. Bone marrow depression, Grey syndrome, irreversible aplastic anaemia, peripheral neuritis, optic neuritis, nocturnal haemoglobinuria, tingling, impaired vision, weakness. Tablet 250 mg Capsules 125 mg, 250 mg, 500 mg Syrup 125 mg/ 5 ml Injection 500 mg, 1 g Applicaps 1 %; Eye Drops 0.4, 0.5, 1 %; Ointment 1 % Ear Drops 5 % Adults: 50 mg/kg/ day oral, IM, IV in 4 divided doses Ear infection - 2 to 3 drops bd - tds. Eye infection - use drops or ointment bd- qds. Increases the effect of phenytoin, oral antidiabetics, oral anticoagulants. Phenobarbitone and rifampicin may reduce the effect of chloramphenicol. Chloramphenicol may inhibit the antibacterial effect of penicillins. Paracetamol may prolong the duration of action of chloramphenicol. Tablet 250 mg (10) Rs. 8.00-10.00 Capsules 250 mg (10) Rs. 18.00-24.00 Applicaps 1 % (50 Nos.) Rs. 22.00 - 25.00 Eye Drops 1 % (5 ml) Rs. 5.00 - 7.00 Ointment 1 % (3 g) Rs. 5.00 -6.00 Ear Drops 5 % (5 ml) Rs. 8.00 - 10.00
MACROLIDES Spectrum similar to penicillin including g-ve Cocci like N gonorrhea and M catarrhalis;g +ve Bacilli like C diphtheria,B anthracis,Clostridium tetani;g-ve Bacilli like Legionella, Pertussis,H influenzae,H ducreyi,C jejuni and H pylori;Acid fast Bacilli like MAC and M leprae;Spirochetes like Tryponema pallidum;other organisms like Mycoplasma pneumonia and Chlamydia trachomatis
Erythromycin
I: 72 Acute bacterial pharyngitis, tonsillitis, sinusitis, otitis, mastitis, cellulitis, mycoplasma pneumonia, diphtheria,
Macrolides
C/l: P/C: A/E: P/A:
Dose: D/l:
Cost:
pertussis, endemic trachoma, legionellosis, Campylobacter jejuni enteritis, acne, leptospirosis, Lyme disease, endocarditis, prophylaxis before dental procedure, community acquired pneumonia, relapsing fever, tetanus in patients allergic to penicillin, nocardiosis. Hypersensitivity to erythromycin, history of jaundice. Cholestatic hepatitis and history of hepatic disease, pregnancy,lactation. Gl upset,Rash, hepatitis Available as Erythromycin estolate and Erythromycin stearate. Tablet 250 and 500 mg. Capsules 250 mg Ointment 2% w/w, 3% w/w Gel 4% w/ w 250-500 mg orally 6th hourly Increased risk of cardiotoxicity with increased plasma concentration and toxicity of carbamazepine, valproic acid, astemizole, terfenadine, cyclosporin, digoxin, statins, theophylline, warfarin Antagonises effect of chloramphenicol , lincomycin and penicillins Increased potential for ototoxicity with other ototoxic medications in patients with renal impairment Caps 250 mg (10) Rs. 40.00 - 42.00 Cream 3% w/w (20 g) Rs. 29.00 - 42.00 Oint 3% w/w (10 g) Rs. 15.00 - 16.00 Gel 4 % w/w (20 g) Rs. 37.00 - 41.00 Mycoplasma pneumoniae, mycobacterium leprae, community acquired a typical pneumonia, atypical mycobacterial infection, prophylaxis against MAC, H. pylori, nocardiosis, upper and lower respiratory tract infections, skin and soft tissue infections. Hypersensitivity. Patients on terfenadine or astemizole, cardiac abnormality or electrolyte disturbance, safety in pregnancy and lactating period is not established. 73
Clarithromycin
I:
C/l :
Antiinfective Drugs
P/C :
A/E: P/A : Dose : D/I:
Cost :
Caution should be exercised in patients with impaired hepatic function or with moderate to severe renal impairment, not recommended in children; prolongation of QT interval As for Erythromycin Tablet 250 mg, 500mg. 250-500 mg twice daily Same as for erythromycin. Rifampicin decreases serum concentration of clarithromycin. Zidovudine delays the action. Tab 250 mg (4) Rs. 110.00 - 140.00 Pneumonia, acute bronchitis, sinusitis, pharyngitis, tonsilitis, genital infection. (Higher concentration achieved in pulmonary, prostate and tonsilar tissue and in tear and pleural fluid) Concomitant use of ergotamine type compounds Hepatic dysfunction. Nausea, vomiting, diarrhoea, skin rash, transient rise in liver transaminases. Tablet 50 mg, 150 mg, 300 mg;Liquid 50 mg/ 5 mL. 150 mg bd. or 300 mg od., oral for 10 - 14 days. Increases the absorption of digoxin; increases half life of midazolam; displaces disopyramide from its protein binding sites; increases serum level of terfenadine leading to ventricular arrhythmias. Tab 150 mg (10) Rs. 70.00 - 130.00 High activity against respiratory pathogens.More active against H influenza.Genital chlamydial infection, mycoplasma pneumonia, community acquired typical pneumonia, non-tuberculosis mycobacteria, prophylaxis against mycobacterium avium complex (MAC). Hypersensitivity Impaired liver or renal function, pregnancy, lactation and children. As for Erythromycin; anorexia, dyspepsia, flatulence, constipation, pancreatitis; syncope, dizziness, headache, drowsiness, agitation, anxiety, hyperactivity;
Roxithromycin
I:
C/I: P/C: A/E: P/A: Dose : D/I:
Cost :
Azithromycin
I:
C/I: P/C: A/E:
74
Macrolides
P/A: Dose: D/I: Cost:
photosensitivity; hepatitis, interstitial nephritis, acute renal failure, asthenia,paraesthesia, arthralgia, convulsions, mild neutropenia, thrombocytopenia, tinnitus, hepatic necrosis, hepatic failure, tongue discoloration, and taste disturbances Tablet 250-500 mg film coated 500 mg once daily for 3 days Antacids decrease the peak serum concentration of azithromycin. Tab 250-500 mg (1 tablet)Rs. 15.00 25.00
Spiramycin
Spectrum similar to Erythromycin; highly efficacious against Toxoplasma gondii I: C/I: P/C: A/E: P/A : Dose: Respiratory infections, prostatitis, urethritis, skin infections,toxoplasmosis during pregnancy. Meningitis, hypersensitivity . Same as for erythromycin. Nausea, vomiting, abdominal pain, urticaria, benign hepatitis. Tablet 1.5 million IU, 3 million IU Toxoplasmosis in pregnancy - 6 - 9 million IU (4 - 6 tab) in 2- 4 divided dose for 3 weeks. Repeated at 2 weekly intervals till delivery. Food reduces bioavailability. It increases blood level of theophylline and carbamazepine, warfarin and digoxin. Tab 1.5 million IU (10) Rs. 47.00 - 51.00
D/I:
Cost:
Clindamycin
Highly active against streptococci, pneumococci,(except enterococci) and staphylococci(except MRSA); B .fragilis ,Clostridium(except Clostridium difficile)and other anaerobes are usually susceptible.Have excellent activity against Corynebacterium acnes. I: Intra abdominal abscess, pelvic abscess, peritonitis, lung abscess, acne vulgaris, malaria, encephalitis by toxoplasma, endocarditis, UTI. It can be used as an alternative to penicillin. 75
Antiinfective Drugs
C/I: P/C: A/E:
P/A: Dose:
Diarrhoeal states Chronic liver disease, renal disease, pregnancy, lactation Diarrhoea, pseudomembranous colitis, skin rash, Stevens Johnson syndrome, hepatic enzyme elevation, granulocytopenia, anaphylaxis, local thrombophlebitis, inhibit neuromuscular transmission, cardiac arrest with rapid i.v. infusion, oesphageal ulceration. Capsule 150 mg Injection 150 mg/ mL 2ml,4 ml vials Adults - 150 to 300 mg 6 hours upto 450 mg every 6 hours in severe infections Parenteral - 0.6-2.7 g/ day IM/IV in 2 -4 divided dose
Vancomycin
Active against aerobic as well as anaerobic g+ve species such as Streptococci as well as Staphylococci(including MRSA),Enterococci etc I: MRSA,empyema, infective endocarditis, osteomyelitis, disseminated staphylococcal infection, infections in patients with end stage renal disease(ESRD) or on hemodialysis or peritoneal dialysis, endocarditis due to enterococcus fecalis and in pseudomembranous colitis. In severe hepatic and renal impairment . Local thrombophlebitis, r e d n e c k syndrome characterised by sudden fall in BP with or without maculopapular rash over the face and upper body. Generalized cutaneous rash caused by histamine release if administered rapidly IV, ototoxicity partly reversible, sensorineural deafness, nephrotoxicity. Tablet 50mg Injection 0.5 mg, 1 g per ml vial (Powder for reconstitution) 2 g daily in 2-4 divided doses Pseudomembranous colitis - 125 to 500 mg 6 h, orally. Antagonism of oral vancomycin by cholestyramine, increased risk of nephrotoxicity with aminoglycosides and cephalosporins notably cephalothin, increased risk of ototoxicity with loop diuretics.
P/C: A/E:
P/A:
Dose: D/I:
76
Teicoplanin
Cost:
Tab 50 mg (10) Rs. 70.00 - 72.00 Inj 0.5 g (vial) Rs. 255.00
TEICOPLANIN Spectrum same as for Vancomycin I: Potentially serious gram positive bacteria especially MRSA, infective endocarditis, in penicillin and cephalosporin allergic patients, peritonitis in patients on CAPD (continuous ambulatory peritoneal dialysis). Renal failure, hypersensitivity, pregnancy and lactation. Reduce dose in renal insufficiency. Thrombophlebitis, pruritus, transient eosinophilia, allergic rashes. Injection 200mg,400 mg (vial) Injection 400 mg loading dose IM/IV followed by 200 mg od daily
Mupirocin
Inhibits Staphylococci including MRSA,Streptococci and L monocytogenes(g +ve aerobes)G-ve aerobes are not sensitive anaerobes are resistant. I: A/E: P/A: Furunculosis,Folliculitis,Impetigo,Infected insect bite and small wounds Local itching irritation and redness 2% Ointment for topical application thrice daily POLYENE ANTIBIOTICS
Bacitracin
Spectrum Gram + ve organism both Cocci and Bacilli I: Topical application for wounds,ulcers,eye infectionsgenerally in combination with Neomycin and Polymyxin C/l: Not used parenterally(Nephrotoxic) P/A: 250 U/gm powder,skin ointment,eye ointment(1 U=26microgram)
Polymyxin B
Active against g-ve bacteria only;all except Proteus,Serratia and Neiserria are inhibited I: Topically usually in combination with other antimicrobials for skin infections,burns,otitis externa,conjunctivitis and corneal ulcer 77
Antiinfective Drugs
P/C: A/E: P/A:
Renal dysfunction, myasthenia gravis, perforated tympanic membrane. Monitor renal functions. Topically no sensitisation Powder,ear drops,eye drops
Linezolid
Effective for treatment of resistant g+ve coccal(aerobic and anaerobic)and bacillary infections;MRSA,VRSA and VRE.G-ve bacteria not affected I: C/I : P/C : Pneumonia, complicated skin and soft tissue infections caused by Gram+ve bacteria Hypersensitivity to the drug, breast feeding. Hepatic impairment; renal impairment; pregnancy ; monitor full blood count including platelet count, avoid in uncontrolled hypertension, phaeochromocytoma, carcinoid tumor,thyrotoxicosis, bipolar depression, schizophrenia, or acute confusional states, concomitant use of other MAO inhibitors. GI disturbances,Rash,pruritus,headache, thirst, dry mouth, glossitis, stomatitis, tongue discolouration, oral and vaginal candidiasis, leucopenia, thrombocytopenia Tablets, 600mg;200 mg/100 ml infusion Adult Oral/I.V, 600mg twice daily for 10-14 days; upto 28 days in vancomycin-resistant cases Being MAO Inhibiter it interacts with adrenergic/ serotonergic drugs. FLUOROQUINOLONES
A/E :
P/A : Dose: D/I:
First Generation fluoroquinolones

Very effective against gram negative bacilli and cocci including Enterobacteriacea, H influenzae and N gonorrhea,Mycobacterium tuberculosis,Mycoplasma pneumonia, P aeruginosa, Chlamydia,Rickettsiae and Legionella.No activity against MRSA and anaerobes. Examples:Norfloxacin,Ciprofloxacin,Ofloxacin,Pefloxacin and Lomefloxacin
Norfloxacin
I: C/I: 78 Urinary tract infection, genital and GIT infections Pregnancy, lactation and children < 3 years
Fluoroquinolones
A/E: P/A:
Nausea, epigastric distress, abdominal cramps, rash, anorexia, diarrhoea. Tablet 400 mg(10) Rs 11-68/Typhoid and Paratyphoid fever, Respiratory tract infection, UTI, Acute bacterial diarrhoeas, Bone and soft tissue infection,Gonorrhoea, Anthrax, Acute exacerbation of Cystic fibrosis with Pseudomonas aeroginosa In pregnancy, children < 6 years, allergy GI disturbances-anorexia, nausea, vomiting and diarrhoea, CNS effects - confusion, agitation, hallucination and convulsions, cartilage damage in young children, leucopenia, allergic reactions, rash, pruritus, photosensitivity. Tablet 250mg(10) 25-40 and Tablet 500 mg(100)Rs 4090/Injection 2 mg/ml 100 ml Rs 32/Eye Drop 0.3% w/v (5 ml, 10 ml) Eye ointment 0.3% w/w (5 g) Same as for Ciprofloxacin including Leprosy Same as for Ciprofloxacin Same as for Ciprofloxacin,psychotic reactions neuropathy Tablet 200 mg(10)Rs 25-90;Tablet 400 mg(10)Rs 48-154 Injection 200 mg Rs 42-90/Same as for Ciprofloxacin including meningitis Same as for Ciprofloxacin Tablet 200 and 400 mg to be taken with meals Injection 4 mg/5ml ,to be diluted in 100-250 ml of glucose solution but not saline since it precipitates in presence of Cl- ions.
Ciprofloxacin
I:
C/I: A/E:
P/A:
Ofloxacin
I: C/I: A/E: P/A:
Pefloxacin
I: C/I: P/A:
Lomefloxacin
Similar to ciprofloxacin P/A: Dose: Tablet 400 mg 400 mg o.d. for 10 -14 days. 79
Antiinfective Drugs
Same as for Norfloxacin except that oral iron increases the absorption of Lomefloxacin. Second generation fluoroquinolones Better activity for g +ve Cocci such as Streptococcus pneumonia and for other microorganisms like mycoplasma,Legionella and Chlamydia Examples:Levofloxacin,Fleroxacin,Clinafloxacin
D/I:
Levofloxacin
A/c bacterial sinusitis, a/c exacerbation of COPD, CAP, nosocomial pneumonia, UTI, Mycobacterial infection, anthrax, skin & suture infection. C/I: Hypersensitivity, CNS disorder A/E: GI disturbances, headache, insomnia P/A: Tablet(10) of 250mg Rs 30-52/Tablet(10) of 500mg Rs 60-87/Tablet (10)of 750mg Rs 35-118/Dose: 250-500mg OD Third generation fluoroquinolones Enhanced activity against g+ve Cocci such as Streptococci,Staphylococci and Enterococci as well as for M tuberculosis and MAC in AIDS Examples: Sparfloxacin,Gatifloxacin I:
Sparfloxacin
I: C/I: P/C: Community Acquired Pneumonia, a/c exacerbation of COPD and MAC in AIDS Hypersensitivity, pregnancy, lactation Slight prolongation of QTc interval.So avoid in patients taking Tricyclic antidepressants Class I A and Class III antiarrhythmics Same as moxifloxacin Tablet 100mg(6tab)Rs 22-65;Tablet 200mg(10tab) Rs 75 100-300mg OD RTI, UTI, Community Acquired Pneumonia,sinusitis Hypersensitivity, age < l8yrs, concurrent use of class IA/II antiarrhythmics, uncorrected hypokalemia, renal & hepatic impairment. Bradycardia,acute Myocardial ischemia,patients with known prolongation of QT interval
A/E: P/A: Dose:
Gatifloxacin
I: C/I:
P/C: 80
Sulphonamides
same as in ciprofloxacin & tachycardia, inflammation of tongue/mouth, vaginitis, hallucination. P/A: Tablet (5) of 200mg Rs 8.50-50/-;Tablet(5) of 400mg Rs 25.00/Dose: 400mg OD Fourth generation fluoroquinolones Enhanced activity against g+ve organisms;significantly greater activity against Anaerobes Example: Moxifloxacin
A/E:
Moxifloxacin
I: C/I: A/E: P/A: Dose: A/c bacterial sinusitis, CAP, skin infection, intra abdominal infection Hypersensitivity, Age< 18, pregnancy, lactation, bradycardia, heart failure, hypokalemia. Similar to ciprofloxacin & hematological disturbances, peripheral neuropathy. Tablet(5) of 400mg Rs 350/;Injection 400mg - Rs 160/ 400mg OD SULPHONAMIDES
Cotrimoxazole (Trimethoprim + Sulphamethoxazole)

l: Acute uncomplicated UTI (except those by enterococci), prevention of recurrent UTI, shigellosis, enteric fever, typhoid carrier, pneumocystis carinii infection, brucellosis, cdonovanosis, listeriosis, legionellosis, non tuberculous mycobacterial skin diseases, pertussis, acute maxillary sinusitis and plague. Creatinine clearance < 15 ml / min, infants < 2 months, pregnancy at term and during lactation. Renal disease, history of hypersensitivity to sulphonamides, patients taking pyrimethamine, immunocompromised patients. Precipitates megaloblastic anaemia, leukopenia, thrombocytopenia, exfoliative dermatitis, Stevens Johnson syndrome, toxic epidermal necrolysis, nausea, vomiting, stomatitis, aplastic, haemolytic and macrocytic anemia, coagulation disorders, sulphahaemoglobinaemia, nausea, crystalluria. 81
C/I: P/C:
A/ E:
Antiinfective Drugs
P/ A:
Dose:
D / I:
Cost : I: P/A: 82
Tablet Sulphamethoxazole 400 mg + Trimethoprim 80 mg (Regular strength) Tablet Sulphamethoxazole 800 mg + Trimethoprim 160 mg (Double strength) Acute uncomplicated UTI : single dose treatment 1600 mg Sulphamethoxazole + 320 mg Trimethoprim Prevention of recurrent UTI : Trimethoprim+Sulphamethoxazole 80/400, 0d. or thrice a week Shigellosis:2 Regular strength tabs bd. for 5 days To eradicate typhoid carriers : Trimethoprim+Sulphamethoxazole 160/800 bd. + rifamycin 400 mg / day, for 6 weeks. Pneumocystis carinii infection : 100 mg / kg / day Sulpha + 20 mg/ kg/ day Trimethoprim in 2-3 divided doses for 14 days; for 21 days, in AIDS. Prophylaxis - 1 double strength tab o.d. indefinitely. Brucellosis :Along with rifampicin for 8 - 12 weeks. Donovanosis : Trimethoprim+Sulphamethoxazole 160/ 800mg bd. until lesions completely heal. Non-tuberculous mycobacterial skin diseases : 160/800mg bd. for 3 months. Pertussis : 8/40 mg/kg/d in 2 divided dose for 2 weeks. Acute maxillary sinusitis : Trimethoprim+Sulphamethoxazole 160/ 800 b.d. for 1-2 weeks. Effect of thiopentone enhanced, effect warfarin enhanced, effect of sulphonylureas enhanced, antifolate effect and plasma concentration of phenytoin increased by co-trimoxazole and possibly other sulphonamides, increased risk of antifolate effect with pyrimethamine, increased risk of nephrotoxicity with cyclosporin. Antifollate effect of methotrexate increased by cotrimoxazole Tab Regular strength (10) Rs. 7.50 - 9.00 To reduce microbial colonisation in burns. Cream 1 %w/w(25g) Rs.12.00 - 15.00/-
Silver sulphadiazine
Antifungal drugs
Sulphacetamide
I: Topically for ocular infection due to Chlamydia Sulphacetamide Eye drops 10%, 20%, 30% w/ v; 6% Eye Ointment
DRUGS USED IN LEPROSY(REFER SECTION 11) ANTITUBERCULOUS DRUGS (REFER SECTION 27) ANTIFUNGAL DRUGS
Amphotericin B
I: Oral, vaginal and cutaneous candidiasis and otomycosis, systemic mycoses especially for histoplasmosis, candidiasis, blastomycosis, cryptococcosis, paracoccidiomycosis, cocccidioidal meningitis, refractory cryptococcal meningitis.Reserve drug for persisitance cases of kalaazar - mucocutaneous leishmaniasis Hypokalaemia Renal impairment; hepatic and renal function tests, blood counts, plasma electrolyte monitoring required; nephrotoxic drugs and corticosteroids; pregnancy and breast-feeding; avoid rapid infusion (risk of arrhythmias), test dose required before starting I.V.therapy. GI disturbances; febrile reactions, headache, muscle and joint pain; anaemia; disturbances in renal function and renal toxicity; also cardiovascular toxicity; blood disorders,neurological disorders (including hearing loss, diplopia, convulsions, peripheral neuropathy), abnormal liver function (discontinue treatment), rash, anaphylactoid reactions; pain and thrombophlebitis at injection site. Injection, 50mg/vial (Powder for reconstitution) Rs 45.00 Systemic infections: IV Infusion, initial test dose of l mg over 20-30minutes, then 250mcg/kg daily, infused over 6 hours, gradually increased to a max. of Img/kg daily, upto 1.5mg/kg daily or on alternate days in seriously ill patients. 83
C/I : P/C :
A/E :
P/A: Dose:
Antiinfective Drugs
Liposomal amphotericin: I.V.infusion, initial test dose of Img over 10 minutes, then 1mg/kg daily as a single dose, increased gradually if necessary to 3mg/kg daily as a single dose.
Nystatin
l: C/l: P/C: A / E: P/A: Dose: Monilial vaginitis, conjunctivitis, corneal and cutaneous candidiasis, monilial diarrhoea. Hypersensitivity. lneffective in dermatophytosis. Rash, diarrhoea, nausea, vomiting Tablet 5,00,000 units and 1,00,000 units. Monilial vaginitis - 1,00,000 unit tab inserted bd. Monilial diarrhoea - 5,00,000 unit tds. Oral thrush the tablets can be sucked or applied after powdering. No known interactions. Tab 5,00,000units (10) Rs. 50.00 - 51.00/-
D/I: Cost :
Griseofulvin (Refer section 11) Flucytosine

I: Systemic yeast and fungal infections; adjunct in cryptococcal meningitis and severe systemic candidiasis. Renal impairment; elderly; blood disorders or bone marrow depression;liver and kidney function tests and blood counts required; pregnancy; breast feeding. GI disturbances; rashes; less frequently confusion, hallucinations,convulsions,headache, sedation, vertigo, alterations in liver function tests (hepatitis and hepatic necrosis reported); thrombocytopenia, leucopenia, and aplastic anaemia reported. Tablets, 500mg Oral, 50l50mg/kg daily in 4 divided doses;I.V.infusion, 200mg/kg in 4 divided doses for 7 days; 100-150mg/kg daily for extremely sensitive organisms; (4 months for cryptococcal meningitis).
P/C:
A/E :
P/A: Dose:
Clotrimazole; Miconazole; Ketoconazole; Itraconazole; Fluconazole; Terbinafine (Refer section 11)

84
Antiviral drugs
ANTI VIRAL DRUGS
Anti herpes virus drugs

Acyclovir I: C/I: P/C : A/E : Herpes simplex and varicella zoster. Hypersensitivity to the drug. Renal impairment, pregnancy and breastfeeding; maintain adequate hydration. Rashes; Gl disturbances; rise in bilirubin and liver enzymes,increase in blood urea and creatinine, decrease in haematological indices, headache, neurological reactions (including dizziness), fatigue; on LV. infusion,severe local inflammation (sometimes leading to ulceration), also confusion, hallucinations, agitation, tremors, somnolence, psychosis,convulsions and coma. Herpes simplex;Oral, 200mg (400mg if absorption impaired or in immunocompromised) 5 times daily, for 5-10 days.l.V.infusion. 5mg/kg every 8 hours for 5-7 days, upto l0mg/kg every 8 hours for l0 days in herpes simplex encephalitis and in varicella zoster in the irnmunocornpromised. Varicella and herpes zoster; oral ,800mg 5 times daily for 7 days. Tablets 200, 400, 800mg. Injection, 25mg/ml, 10ml; 250mg (powder for reconstitution)
Dose:
P/A:
Ganciclovir and Valganciclovir

Valganciclovir is a L valine ester prodrug of Ganciclovir I: Treatment of cytomegalovirus retinitis in immunosuppressed patients, prevention of cytomegalovirus (CMV) disease in organ transplant recipient, treatment of CMV-associated syndromes pneumonia, oesophago-gastrointestinal infections, hepatitis, wasting illness Pregnancy, neutropenia. Additive bone marrow suppression with zidovudine. Bone marrow suppression especially neutropenia. 85
C/ I: P/C: A/E:
Antiinfective Drugs
Capsules 250 mg Injection 500 mg (vial) Dose : Oral: 1 g tds. Parenteral IV 5 mg/kg every 12 h for 14 to 21 days followed by a maintenance dose of 5 mg/ kg IV per day or 5 times per week, possibly for as long as immunosuppression exists. D/ I : Increased risk of myelosuppression with zidovudine and other myelosuppressive drugs. ANTI INFLUENZA VIRUS DRUGS
P/A:
Amantidine and rimantadine

I: Prophylaxis and treatment of Influenza A in adults, (particularly elderly) and prophylaxis in susceptible children. Hypersensitivity Chronic hepatic dysfunction, chronic renal dysfunction, peptic ulcer, epilepsy, eczema. Dizziness, anxiety, insomnia, difficulty in concentrating, seizures and worsening of congestive heart failure. Capsules 100 mg 100 to 200 mg / day orally for 5 to 7 days Prophylaxis 100 to 200 mg/ day orally daily for the peak duration of the outbreak. Concurrent use of antihypertensives, antimuscarinics, antipsychotics, domperidone, metoclopramide, tetrabenazine with amantidine potentiates the anticholinergic-like side effects.
C/I; P/ C: A/E: P/A: Dose:
D/I:
Oseltamivir
It inhibits amantadine and rimantadine-resistant influenza A viruses and some zanamivir-resistant variants. I: Oral Oseltamivir is effective in the treatment and prevention of influenza A and B virus infections A/E: Oral oseltamivir is associated with nausea, abdominal discomfort, and, less often, emesis, probably owing to local irritation. Gastrointestinal complaints usually are mild-to-moderate inintensity, typically resolve in 1 to 2 days despite continued dosing, and 86
Non selective antiviral drugs
are preventable by administration with food. Headache is reported. Dose: Treatment of previously healthy adults (75 mg twice daily for 5 days) or children aged 1 to 12 years (weightadjusted dosing) with acute influenza reduces illness duration by about 1 to 2 days, speeds functional recovery, and reduces the risk of complications leading to antibiotic use by 40% to 50%. Treatment is associated with approximate halving of the risk of subsequent hospitalization in adults. When (approximately 70% to 90%) in reducing the likelihood of influenza illness in both unimmunized working adults and in immunized nursing home residents; short-term use (7 to 10 days) protects against influenza in household contacts. Not reported
D/I:
NON SELECTIVE ANTIVIRAL DRUGS
Interferon alpha
I: Treatment of chronic Hepatitis B and C;hairy cell leukaemia;chronic granulomatous disease;Kaposis sarcoma,Chronic myelogenous leukemia It increases the effects of theophyllines. Headache, lethargy, fever, neurotoxicity - numbness, neuropathy and tremor, digestive disturbances, alopecia,flu-like syndromes Injection Alpha-2a 3MU/ vial Injection Alpha-2b 3MU, 5MU / vial Interferon Alpha-2b in chronic HBV infection - 5 million units daily for 16 weeks. Interferon Alpha2b in chronic non-A non-B C infections Hepatitis- 3 million units three times a week for 6 months. Interferon Alpha2a - individualised based on the patient. Concurrent use of myelosuppressive drugs increases bone marrow toxicity, concurrent use of interferons with sedatives like antianixety drugs, antihistamines 87
P/C: A/E:
P/A: Dose:
D/I:
Antiinfective Drugs
and antidepressants potentiates the sedative effects. On concurrent use the effect of theophylline is occasionally enhanced. ANTIRETROVIRAL DRUGS
Nucleoside reverse transcriptase inhibitor Zidovudine

I: Used as part of combination antiretroviral therapy for patients with HIV infection and a count less than 500 CD4+ T cells/ml Monotherapy is restricted to the prevention of mother to child transmission of HIV. Abnormally low neutrophil counts or haemoglobin value. Patients starting therapy should be monitored for hematological toxicity at least every other week for the first month and then monthly;Chronic hepatic or renal dysfunction. Anemia,GI disturbances,Fatigue, malaise, nausea, headache, bone marrow suppression, proximal myopathy, cardiomyopathy, bluish discolouration of nails,taste disturbance Capsules 100 mg, 300mg 300 mg three times a day, to be taken with plenty of water. Increased risk of toxicity with other nephrotoxic and myelosuppressive drugs. Extreme lethargy is reported with IV acyclovir. Profound myelosuppression with ganciclovir. HIV infection in combination with other antiretroviral drugs. Pregnancy; breast-feeding. Chronic hepatitis B or C ( greater risk of hepatic sideeffects); hepatic impairment; renal impairment. GI disturbances, anorexia, pancreatitis, liver damage, lactic acidosis;dyspnoea, headache, insomnia, fatigue; blood disorders including anaemia, neutropenia and thrombocytopenia; myalgia, arthralgia, rash,urticaria, fever, lipodystrophy, hypersensitivity reactions. Tablet, 300 mg.
C/I: P/C:
A/E:
P/A: Dose : D/I:
Abacavir
I: C/I: P/C: A/E:
P/A: 88
Antiretroviral drugs
Dose:
Oral, 300 mg every 12 hours in combination with other antiretroviral agents. HIV infection with other antiretroviral drugs. Breast-feeding. History of pancreatitis; peripheral neuropathy or hyperuricaemia; history of liver disease; hepatic and renal impairment; pregnancy; retinal examination recommended if visual changes occur. Same as Abacavir;also pancreatitis; liver failure, anaphylactic reactions, peripheral neuropathy; diabetes mellitus,hyperglycaemia, acute renal failure, rhabdomyolysis, dry eyes. Retinal and optic nerve changes (especially in children), dry mouth, parotid gland enlargement, alopecia; hyperuricaemia. Enteric coated capsule, 400mg. Oral, under 60kg, 250mg daily in 1-2 divided doses, 60kg and above, 400mg daily in 1-2 divided doses. HIV infection with other antiretroviral drugs. First trimester of pregnancy, breast-feeding. Renal impairment, hepatic disease, lactic acidosis, chronic hepatitis B. Same as Abacavir; also peripheral neuropathy, muscle disorders including rhabdomyolysis, nasal symptoms, alopecia. Film coated tablets, 150mg. HIV infection: oral, 150mg every 12 hours;Chronic hepatitis B: oral, 100mg once daily. HIV infection with other anti-retroviral drugs. Breast feeding. History of peripheral neuropathy ; history of pancreatitis or concomitant use with other drugs associated with pancreatitis; chronic hepatitis B or C; hepatic or renal impairment; pregnancy; monitor liver enzymes. 89
Didanosine
I: C/I: P/A:
A/E :
P/A: Dose:
Lamivudine
I: C/I : P/C: A/E :
P/A: Dose:
Stavudine
I: C/I : P/C :
Antiinfective Drugs
A/E:
P/A: Dose:
Same as Abacavir ;also peripheral neuropathy (doserelated); abnormal dreams, cognitive dysfunction, drowsiness,depression; less commonly anxiety, gynaecomastia. Capsules 30mg and 40mg <60kg 30mg every 12 hours preferably atleast 1 hour before food; 60kg and above 40mg every 12 hours
Protease Inhibitors
Indinavir I: C/I: P/C : HIV infection in combination with nucleoside reverse transcriptase inhibitors. Breast-feeding. Chronic hepatitis B or C ( greater risk of hepatic sideeffects); liver disease or hepatic impairment; ensure adequate hydration ( risk of nephrolithiasis especially in children); patients at risk of nephrolithiasis;diabetes; haemophilia; avoid in porphyria; pregnancy. GI disturbances; hepatic dysfunction, pancreatitis; blood disorders including anaemia, neutropenia and thrombocytopenia; sleep- disturbances, fatigue, headache, dizziness, paraesthesia, myalgia, myositis, rhabdomyolysis; taste disturbances; rash, pruritus, Stevens-Johnson syndrome, hypersensitivity reactions including anaphylaxis;lipodystrophy syndrome; also dry mouth, dry skin, hyperpigmentation,alopecia, paronychia, intestitial nephritis, nephrolithiasis, dysuria, haematuria, crystalluria, haemolytic anaemia. Capsules, 400mg. Oral, 800mg every 8 hours.
A/E :
P/A: Dose:
NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
Efavirenz
I: C/I : P/C: HIV infection in combination with other antiretroviral drugs. Breast feeding. Chronic hepatitis B or C ( greater risk of hepatic side effects), hepatic impairment; severe renal impairment; pregnancy; elderly; history of mental illness (or) seizures.
90
Antiretroviral drugs
A/E :
P/A : Dose:
Rash including StevensJohnson syndrome; dizziness, headache,insomnia, somnolence; abnormal dreams, fatigue, impaired concentration; nausea; less frequently vomiting, diarrhoea, hepatitis,depression, anxiety, psychosis, amnesia, ataxia, stupor, vertigo; also reported abdominal pain, raised serum cholesterol, elevated liver enzymes, hepatic failure, pancreatitis, convulsions, gynaecomastia,pruritus, blurred vision. Capsules, 200 mg. Oral, 600 mg once daily. Progressive or advanced HIV infection, in combination with atleast two other antiretroviral drugs. Breast-feeding; severe hepatic impairment; post exposure prophylaxis. Hepatic impairment; chronic hepatitis B or C, patients with high CD4 cell counts and women ( all at greater risk of sideeffects); pregnancy. Rash including Stevens- Johnson syndrome and rarely toxic epidermal necrolysis; nausea, hepatitis; less commonly GI disturbances, fatigue,fever, myalgia; angioedema, anaphylaxis, hypersensitivity reactions, may involve hepatic reactions and rash); arthralgia, anaemia, granulocytopenia(more frequent in children); very rarely neuropsychiatric reactions. Tablets, 200mg. Oral, 200mg once daily for first 14 days, then (if no rash present)200mg twice daily. ANTIMALARIAL DRUGS
Nevirapine
I: C/I: P/C:
A/E :
P/A: Dose:
Chloroquine
I: Malaria (p. vivax & falciparum), rheumatoid arthritis, extra intestinal amoebiasis, lupus erythematosus, lepra reaction Hypersensitivity, G6PD deficiency, pregnancy, lactation, psoriasis, porphyria cutanea tarda Prolonged use may cause reversible lichenoid skin erruptions, use with caution in hepatic or renal 91
C/I: P/C:
Antiinfective Drugs
A/E:
P/A: Dose: D/l: Cost :
dysfunction, epilepsy , myasthenia , G6PD deficiency, regular ocular examination on long term use GIT symptoms - nausea and vomiting, visual disturbances, headache, peripheral neuropathy, toxic myopathy, keratopathy, and psychiatric illness. If retinopathy occurs this may progress and worsen even if the drug is withdrawn. Keratopathy may regress on stopping the drug. Tablet 250 mg, 500 mg Injection 40 mg/mL, Refer Part III B- National Health programmes of India Increased risk of seizures with Mefloquine. Increases plasma levels of digoxin and cyclosporin Tab 250 mg (10) Rs. 5.00 -10.00;Inj 40 mg/ml (30 ml vial) Rs. 13.54/Schizonticidal activity against asexual forms of P.falciparurn and P.vivax. Effective against all strains resistant to other anti-malarial agents. Used in severe complicated falciparum infection including cerebral malaria. Hypersensitivity, pregnancy. Avoid concomitant use of drugs causing ECG abnormalities and constantly monitor such patients. GI symptoms, bradycardia, AV block, reduced leucocyte and reticulocyte counts, nausea, vomiting, transient increase in serum transaminases, QT prolongation Injection 80 mg Rs 114/Capsules 40 mg Rs 65/Oral 80 mg bd. on day 1 followed by 80 mg od. for next 4 days. Injection IM loading dose 3.2mg/kg followed by 1.6mg/ kg daily for a maximum of 7 days Antagonises pyrimethamine,Synergism with mefloquine, prirnaquine and tetracyclines, ECG abnormalities with quinidine, terfenadine, amiodarone, tricyclic antidepressants and some phenothiazines.
Artemether
I:
C/I: P/C: A/E:
P/A: Dose:
D/I:
92
Antimalarial drugs
Artesunate
I: P/C: A/E: Mlalaria of multidrug resistance Pregnancy Mild GI disturbances, dizziness,tinitus, neutropenia, elevated liver enzyme values, and ECG abnormalities including prolongation of QT interval. Injection, 60mg/vial (powder for reconstitution)Rs 149 Oral, 5mg/kg on the first day with 2.5mg/kg on the second and third days, along with a single dose of mefloquine 15mg/kg given on the second day for radical cure; given for 5 days if used alone IM/I.V, loading dose, 2mg/kg, followed after 4 hours and daily thereafter by a dose of Img/kg for a max. of 7 days. Additional single oral dose of mefloquine should be given to effect radical cure. Patient should be transferred to oral therapy as soon as possible. Prevention and treatment of chloroquine resistant and multidrug resistant P. falciparum malaria. Prophylaxis for non-immune travellers staying for short duration in endemic zones. Hypersensitivity, pregnancy, lactation and history of convulsions or psychiatric illness. Use with caution in cardiovascular disorders, hypertension, coagulation disorders, epilepsy, hepatic or renal impairment. Avoid alcohol during treatment as it may cause increased adverse effect pregnancy Nausea, vomiting, diarrhoea, dizziness, itching, rash, hallucination and depression, SJS Tablet 250 mg (film coated)(5)Rs 200/Multi-drug resistant case : 20-25 mg/kg b.w. single dose max up to 1.5g Prophylaxis : 250 mg weekly one week before entering an endemic area and for 4 weeks after leaving. ECG abnormalities with beta blockers and halofantrine Potentiation of cardiotoxicity and neurotoxicity with quinine, Increased metabolism of valproic acid, decreased metabolism of mefloquine with ketoconazole. 93
P/A: Dose:
Mefloquine
I:
C/I: P/C:
A/E: P/A: Dose:
D/I:
Antiinfective Drugs
Primaquine
l: lt is highly effective against the exoerythrocytic stage of Pvivax and against gametocyte of P.falciparum and all species of plasmodia. Rheumatoid arthritis, G6PD deficiency, SLE, hypersensitivity, pregnancy, lactation, on current administration of haemolytic drugs. Conduct routine blood examination during the course of therapy. Gl symptoms, haemolytic anaemia, methaemoglobinaemia, granulocytopenia, granulocytosis. Tablet 7.5 mg(10)Rs 17/- and Tablet 15 mg(7) Rs 25/15 mg od. for 2 weeks lnhibits metabolism of chloroquine. Haemolytic drugs (sulfonamides) and bone marrow suppressants (methotrexate, chloramphenicol) potentiates toxicity of primaquine Chloroquine resistant falciparum malaria (used only in combination with dapsone or sulphadoxine); toxoplasmosis.(with sulfadiazine) Anaemia, bone marrow depression, hypersensitivity, seizure disorders. Use with caution in hepatic and renal impairment, G6PD deficiency and severe allergy or asthma. Folinic acid should be supplemented when given in pregnancy, blood counts required with prolonged treatment. Rash, loss of appetite, gastric irritation, insomnia, sore throat, fever (and unusual bleeding) All preparations contain pyrimethamine 1 part plus sulfadoxine 20 parts. Tablet 25mg Concurrent use of pyrimethamine with bone marrow depressants may increase the leukopenic and thrombocytopenic effects. Increased anti folate effect with methotrexate. Tab (pyrimethamine25 mg + sulpha 500mg) (2) Rs. 4.00 -6.00
C/l :
P/C: A/E:
P/A : Dose: D/l:
Pyrimethamine
I:
C/I: P/C:
A/E: P/A:
D/I :
Cost: 94
Antimalarial drugs
Quinine
I: C/l: P/C: A/E: Acts on mature trophozoites of all species of plasmodium; nocturnal leg cramps Hypersensitivity, G6PD deficiency, pregnancy, lactation. Use with caution in chronic renal dysfunction, optic neuritis, myasthenia gravis, cardiac dysfunction Cinchonism - tinnitus, nausea, headache and disturbed vision, Gl symptoms, angioedema, hyperinsulinemic hypoglycemia,excitement, delirium, thrombocytopenia, agranulocytosis, hypotension, muscle paralysis in myasthenic patients. Tablet 100 mg, , 300 mg, Injection 300 mg/ mL . 300 - 600 mg tds. for 5 - 7 days. IV loading dose 20mg/kg max to 1.4g infused over 4h Maintenance dose 10mg/kg max 700mg infused over 4 hours every 8 to 12 hours until patient can swallow tablets to complete 7 day course (5to 7 mg/kg if the IV therapy is beyond 48 hours) Blood levels of digoxin increased, hypoprothrombinemic effect of warfarin enhanced, hypoglycemic effect of oral antidiabetics enhanced. Tab 300 mg (10) Rs. 35.00 - 60.00 Injection 300 mg/mL (2 mL) Rs. 11.00 -19.00
P/A: Dose:
D/I:
Cost:
ANTIAMOEBIC AND OTHER PROTOZOAL DRUGS ANTIAMOEBIC DRUGS
Metronidazole
l: Amoebiasis, giardiasis, trichomonal vaginitis, anaerobic infections, ulcerative gingivitis, trench mouth, guinea worm infestation, H.pylori infection, Vincents angina, pseudomembraneous colitis by C.difficile, Bacteriodes fragilis infection. Neurological disease, blood dyscrasias, first trimester of pregnancy. Though no teratogenic effect has yet been demonstrated, its mutagenic potential warrants caution. 95
C/l:
Antiinfective Drugs
P/C:
A/E:
P/A :
Dose :
D/I:
Cost : 96
Carcinogenicity, pregnancy, breast feeding, adjustment of dosage in old people. Metronidazole may cause dry mouth contributing to the development of caries, periodontal diseases, oral candidiasis, and discomfort. Anorexia, nausea, metallic taste and abdominal cramps, less frequently causes headache, glossitis, dryness of mouth, dizziness, rashes and transient neutropenia. Prolonged administration cause peripheral neuropathy, and CNS effects like seizures have followed very high doses Tablet 200mg, 400 mg, 600 mg. Injection 500mg/ 100mL. Gel 1% Intestinal Amoebiasis:Oral 800 mg every 8 hours for 5 days Extraintestinal Amoebiasis:Oral 400-800 mg every 8 hours for 5-10 days Trichomoniasis: Oral 400 mg thrice daily for 7 days Giardiasis: Oral 400 mg tds. for 7 days. Invasive Dysentry and Liver abscess:Oral 800 mg thrice daily for 7-10 days Clostridium difficile colitis: Oral 800 mg tds. for 7- 10 days H.pylori eradication:Oral 400 mg thrice daily along with Amoxycillin/Clarithromycin and a Proton Pump Inhibitor in triple drug 2 week regimens Pelvic inflammatory disease (PID): 500 mg bd for 14 days along with ofloxacin. Disulfiruam like reaction with alcohol, effect of warfarin enhanced.It inhibits metabolism of phenytoin (increased plasma - phenytoin concentration), Phenobarbitone accelerates metabolism of metronidazole (reduced plasma metronidazole concentration)It inhibits metabolism of flurouracil (increased toxicity), increased toxicity reported with lithium. Tab 400mg (10) Rs.6.20 6.60/-
Antiamoebic and other protozoal drugs
Tinidazole
I: Effective in infections due to amoebiasis, trichomonas vaginalis, giardia lamblia, anaerobic bacterial and H.Pylori infections. As for Metronidazole Tablets 300 mg, 500 mg, 600 mg, 1 g, 2 g Injection 2 mg/mL(400 mL) Intestinal Amoebiasis : Oral 2 g daily for 2-3 days or 500 mg bd for 5-10 days Trichomoniasis, giardiasis: 2 g single dose Anaerobic infection :2 g followed by 500mg bd for 5 days. Surgical prophylaxis : 2 g single dose before surgery orally H pylori:500 mg twice daily for 2 weeks in triple combination Tab 300 mg (10) Rs. 8.60-19/Treatment of Amoebiasis,Giardiasis and Trichomoniasis As for Metronidazole 1 gm film coated tablets Rs 31.50-37/Oral 2 gm single dose Hepatic amoebiasis 600 mg base for 2 days followed by 300 mg daily for 2-3 weeks. It is used only when Metronidazole is not effective or not tolerated. Chronic intestinal amoebiasis, cyst passers 1st trimester pregnancy, lactation Gastrointestinal disturbances Tablets 500 mg Oral 500 mg tds for 5-10 days DRUGS FOR LEISHMANIASIS
C/I: P/C: A/ E: P/A: Dose:
Cost:
Secnidazole
I: C/I: P/C: A/ E: P/A: Dose: Dose:
Chloroquine(Refer anti Malarial drugs)
Diloxanide furoate
I: C/I: A/E: P/A: Dose:
Sodium Stibogluconate
I: C/I: Drug of choice for kala azar Pneumonia, myocarditis, nephritis, hepatitis 97
Antiinfective Drugs
P/C: A/E:
P/ A: Dose: D/I:
IV injection must be given slowly and stopped if coughing or substernal pain develops,IM is painful. Nausea vomiting, metallic taste in the mouth, pain, stiffness of injected muscle, sterile abscess, ECG abnormalities, elevation of hepatic transaminases. Injection 100 mg/ml in 30 ml (vial) 20 mg/ kg daily IM (buttocks) or IV injection for 20 - 30 days or more. Concurrent use with nephrotoxic drugs increases nephrotoxicity. Active against L donovani, pneumocystis carinii, kala azar- salvage therapy of antimony failure cases, pneumocystis pneumonia in AIDS patients and trypanosomiasis. Impaired renal function. Reduce dose in renal failure, risk of hypotension, monitor kidney/liver function, blood glucose, blood count and ECG. Toxicity is due to histamine release. hypotension, palpitation, fainting, vomiting, rigor and fever after IV Injection, kidney and liver damage, cardiac arrhythmias, hypoglycemia, hyperglycemia, pancreatitis, neutropenia, unpleasant metalic taste, nausea, headache, anxiety. Pentamidine Injection 200mg and 300 mg vials,Dry powder. 4 mg / kg deep IM or slow IV infusion over 1 hour on alternate days for 5-15 weeks till no parasites are demonstrated in 2 splenic aspirates taken 2 weeks apart. Abnormal haematological effect with bone marrow depressants,increased risk of pancreatitis with didanosine.Increased risk of torsades de pointes with erythromycin r e v e r s i b l e hypocalcemia, hypomagnesemia and nephrotoxicity with Foscarnet
Pentamidine
I:
C/I: P/C:
A/E:
P/A: Dose:
D/I:
98
Anthelmintics drugs
Other drugs used in resistant cases

1. Amphotericin - B 2. Ketoconazole 3. Allopurinol DRUGS FOR GIARDIASIS
Metronidazole and Tinidazole (Refer Antiamoebics)

DRUGS FOR TRICHOMONIASIS 1. Drugs used orally Metronidazole and Tinidazole (Refer Antiamoebics) 2. Drugs used intravaginally Clotrimazole - 100 mg vaginal tablet inserted high up in vagina every night for 6 - 12 days. Povidone iodine - 400 mg pessaries inserted in vagina daily at night for 2 weeks Hamycin 4-8 lac U ovules intravaginally daily for 15 days ANTHELMINTICS DRUGS
Mebendazole
Broad spectrum anthelmintic I: C/I: P/C: A/E: Roundworm,hookworm,thread worm and whipworm infestations Children below 2 years Pregnancy,Lactation Diarrhoea, nausea, abdominal pain when used in heavy infestation, allergic reactions, alopecia, granulocytopenia. Tablet 100 mg Round worm, hook worm,whipworm:Oral 100 mg bd. for 3 consecutive days,repeat after 2 weeks if necessary Threadworm: Oral 100 mg single dose repeated after 2 - 3 weeks. Tab 100 mg (6) Rs 3.60-17.10/-
P/A: Dose:
Cost:
Albendazole
Broad spectrum activity anthelmintic. l: Same as that of Mebendazole. ln addition it is also effective in Neurocysticercosis, Hydatid disease, Strongyloidosis. 99
Antiinfective Drugs
C/l: A/E: P/A: Dose:
Cost:
Pregnancy,hepatic and renal imparment Gastro intestinal -nausea, vomiting and abdominal pain, dizziness Chewable tablet 400 mg Round worm, hook worm, whipworm one single dose 400 mg for adults to be chewed. Tape worms, strongyloidosis :400 mg daily for 3 consecutive days Neurocysticercosis :7.5-10 mg/kg twice daily for 7-14 days Hydatid disease:7.5-10mg/kg (maximum 400 mg) twice daily for 28 days,repeat after 14 drug free days for upto 2-3 cycles Tab 400 mg (2) Rs 6-14.30/Single or Mixed infections due to Roundworm,hookworm and thread worm Pregnancy, children and those with impaired liver function. To be given with care in pregnant women and children below 2 years. Gl side effects, headache and dizziness. Tablet 250 mg Oral Round worm 5 mg/kg as single dose. Hook worm 10 mg/kg daily for 3 days;repeat if necessary after 2 weeks for threadworm and 1 month for hookworm Mixed infection 10 mg/kg as single dose Tab 250 mg (2) Rs 9.40/Highly active against Roundworm and threadworm, can be used in pregnancy. Renal insufficiency and epileptics Safe and well tolerated. Occasionally nausea, vomiting, abdominal discomfort, urticaria, dizziness, excitement and convulsions in toxic doses. Tablet 500 mg Round worm:4 g once a day for 2 consecutive days Safe during pregnancy Threadworm: 50 mg/kg (maximum 2g)once a day for 7 days,repeated after 3 weeks. Tab 500 mg (8) Rs. 4.00/-
Pyrantel pamoate
Cost:
Piperazine
I: C/I: A/E:
P/A: Dose:
Cost: 100
Antifilarial drugs
SCHISTOSOMICIDES
Praziquantel
I: C/I: P/C: A/E: Schistosomiasis; liver,lung and intestinal fluke infections;tape worm infections. Ocular cysticercosis, known hypersensitivity to praziquantel. Severe hepatic disease; patients with cerebral cysticercosis require hospitalization Dizziness, headache, malaise, abdominal pain, loss of appetite, nausea,vomiting, sweating; skin rash, itching, CSF reaction syndrome in patients being treated for neurocysticercosis, fever, diarrhoea. Schistosomiasis: Oral 20mg/kg/dose 2-3 times a day at 4 to 6 hour intervals. Flukes: Oral 25mg/kg/dose every 8 hours for 1-2 days. Cysticercosis: Oral 50mg/kg/day divided every 8 hours for 14 days. Tapeworm: Oral 10-20mg/kg as a single dose. Tablets 600mg(20)Rs 850-920/ANTIFILARIAL DRUGS
Dose:
P/A:
Diethylcarbamazine citrate
l: Effective drug available for filariasis caused by W.bancrofti, B.malayi, Loa loa,O volvulus and tropical eosinophilia Pregnancy, hypersensitivity. The first dose should be given with caution since intense allergic reactions may follow. Nausea, loss of appetite, headache, dizziness, febrile reaction with rash, pruritus, and enlargement of lymphnodes. Tablets 50 and 100mg to be taken after meals Filariasis: Oral 1 mg/kg on 1 st day increased gradually over 3 days to 6 mg/kg daily in divided doses for 21 days Tropical eosinophilia: 2-4mg/kg three times daily for 10 days Tab 100 mg (10) Rs 7.70/-, Tab 50mg (10) Rs 2.90-44.30 101
C/I: P/C: A/E:
P/A: Dose:
Cost:
Antiinfective Drugs
Ivermectin
l: C/l: P/C: A/E: P/ A: Dose: Onchocerciasis, strongyloidosis, cutaneous larva migrans,scabies ,head lice and filariasis Pregnancy Use with caution children < 5 years, allergic reactions. Mild itching, postural hypotension, dizziness, transient ECG changes 3mg and 6 mg tablets to be taken on empty stomach Filariasis: Oral single 10-15mg Ivermectin preferably with 400 mg Abendazole given annually for 5-6 years Strongyloidosis: 0.15-0.2 mg/kg single dose Onchocerciasis:Single dose of 150 mg/kg orally for patients over 5 years of age is given every 6 months on empty stomach Scabies and Pediculosis: Single oral dose of 200mcg/kg Tablet 3mg(1) Rs 8-11.80/-,Tablet 6mg(1) Rs 12-16.50
Cost:
102
SECTION - 5 ANTIMIGRAINE MEDICINES

The two principal strategies of migraine management are treatment of acute attacks and prevention of attacks. TREATMENT FOR ACUTE ATTACK Treatment of acute attacks may be non-specific using simple analgesics; if nausea and vomiting are features of the attack, an antiemetic drug may be given. Treatment is generally by mouth; some drugs are available as suppositories which may be used if the oral route is not effective (poor oral bioavailability, or absorption from the gut impaired by vomiting), or not practicable (patient unable to take drugs orally). Excessive use of antimigraine medication (analgesics, 5HT1 agonists and ergotamine) is associated with medication-overuse, headache (analgesic-induced headache); therefore, increased consumption of these medicines needs careful monitoring. Simple analgesics including NSAIDs (nonsteroidal anti-inflammatory drugs) can be effective in mild to moderate forms of migraine if taken early in the attack; most migraine headaches respond to paracetamol (acetaminophen), acetyl salicylic(aspirin) or an NSAID such as ibuprofen. Peristalsis is often reduced during migraine attacks and, if available, a dispersible or effervescent preparation of the drug is preferred because of enhanced absorption compared with a conventional tablet. The risk of Reye syndrome due to acetylsalicylic acid in children can be avoided by giving paracetamol instead. An antiemetic such as metoclopramide, given as a single dose orally or by intramuscular injection at the onset of a migraine attack, preferably 1015 minutes before the analgesic, is useful not only in relieving nausea but also in restoring gastric motility, thus improving absorption of the analgesic. Specific antimigraine drugs, such as the 5HT1 agonist sumatriptan are used when analgesics are ineffective; they act on 5HT (serotonin) 1B/1D receptors and can be used during the established headache phase of an attack. Ergot alkaloids should no longer be used; they are associated with many side-effects and must be avoided in cerebrovascular or cardiovascular disease. Products which contain barbiturates or codeine are undesirable since they may cause physical dependence and withdrawal headaches.
Acetylsalicylic acid - refer section 2.

P/A: Tablet: 300-500 mg. 103
Antimigraine Medicines
Dose:
Treatment of acute migraine attack, by mouth preferably with or after food, 300900 mg at first sign of attack, may be repeated every 46 hours if necessary; maximum 4 g daily.
Paracetamol
Refer Section 2 500 mg. Treatment of acute migraine attack, by mouth 0.51 g at first sign of attack, may be repeated every 46 hours if necessary, maximum 4 g daily; CHILD 612 years 250 500 mg at first sign of attack, may be repeated every 46 hours if necessary, maximum 4 doses in 24 hours. MIGRAINE PROPHYLAXIS Prophylactic treatment for migraine should be considered for patients in whom: treatment of acute migraine attacks is ineffective or not possible the frequency of migraine attacks is increasing migraine attacks occur more than once or twice a month the severity or duration of migraine attacks is disabling Prophylaxis can reduce the severity and frequency of attacks but does not eliminate them completely; additional symptomatic treatment is still needed. However, long-term prophylaxis is undesirable and treatment should be reviewed at 6-monthly intervals. Of the many drugs that have been advocated for migraine prophylaxis, beta- adrenoceptor antagonists (betablockers) are most frequently used. Propranolol, a non-selective beta-blocker and other related compounds with similar profile such as atenolol are generally preferred. Tricyclic antidepressants, such as amitriptyline or calcium-channel blocking drugs such as verapamil may be of value. I:P/C:A/E: P/A: Dose:
Propranolol
Tablet: I: C/I:P/A:A/E: Dose: 20 mg; 40 mg (hydrochloride). Prophylaxis of migraine Refer Section 10 Prophylaxis of migraine, by mouth, ADULT initially 40 mg 23 times daily, increased by same amount at weekly intervals if necessary; usual range 80160 mg daily; CHILD under 12 years, 20 mg 23 times daily.
104
SECTION 6 ANTINEOPLASTIC DRUGS

ALKYLATING AGENTS Cyclophosphamide : I: Lymphomas, germ cell tumour, Sarcoma Multiple Myelomas, Carcinoma of cervix, ovary, Lung, Breast, Acute Leukemia and several others C/I: Pregnancy and lactation, severe renal and hepatic failure, thrombocytopenia. P/C : Renal failure. Dehydration should be avoided to minimize renal and vesical damage A/E : Bonemarrow suppression, nausea, vomiting, alopecia, haemorrhagic cystitis, bladder carcinoma, bladder fibrosis, sterility foetal damage,cardiac damage, pulmonary fibrosis, fever, anaphylaxis, skin and nail hyperpigmentation, mucosal ulceration, liver damage, urticaria, transient cerebral symptoms, blurred vision. P/A: Tablets 50 mg Inj 100,200,500mg,1g. Dose : Oral: 100-200 mg/kg bw to be given along with immunosuppressant drug. Parenteral: 3-5 mg / kg bw to be given maximum in a single dose IV as push dose or as an IV infusion. D/I: When given with other myelotoxic drugs or radiotherapy the combined adverse effects are increased. Cost: Inj 1g vial Rs-110/- ;200mg vial Rs-27/Chlorambucil I: Chronic lymphatic leukaemia(CLL), lymphomas, multiple myeloma, macroglobulinemia, chorio carcinoma, testicular tumours and others. C/I : Hypersensitivity; pregnancy, lactation. P/C : Blood counts should be monitored every week. A/E: Immunosuppression,myelosuppression, gastrointestinal symptoms, hepatotoxicity ,dermatitis, wasting syndrome. P/A: Tablets 2mg, 4mg, 5mg Dose : 0.1 mg/kg/day for 3 to 6 weeks.Maintenance dose 2 mg daily. 105
Antineoplastic Drugs
D/I: Cost : Melphalan I: C/I : P/C : A/E:
Phenylbutazone and warfarin potentiate efficacy of chlorambucil Tab 2 mg Rs. 129.50 Multiple myeloma, breast cancer, advanced ovarian carcinoma, malignant melanoma, polycythemia vera. Hypersensitivity, pregnancy, lactation Blood counts once a week at the initiation of therapy, later at longer intervals. Nausea, allergic reactions, thrombocytopenia, bone marrow depression, inappropriate ADH secretion, amenorrhoea, leukemia,sterility, pulmonary infiltration. Tablets 2mg, 5mg. Injection 50 mg vial 0.25 mg/kg/day x 4 days repeated 4 - 6 weekly Maintenance dose 4 mg/ day. Risk of renal failure with cyclosporine. Lung toxicity with carmustine. Renal dysfunction with cisplatin. Tab 2 mg- Rs. 192.70 (50 mg) Vial Rs. 1519.90 Germ cell tumours, lymphomas, sarcomas, cervical, ovarian lung and breast cancer. Thrombocytopenia, severe leucopenia, severe renal and hepatic impairment, pregnancy, lactation. Hepatic and renal impairment, bone marrow suppression,dehydration. Haemorrhagic cystitis, nausea, anorexia, hallucination, somnolence,confusion,leucopenia, immunosuppression, delayed wound healing. Injection 1 g vial 60mg / kg bw (upto 1.5 g / m2 body surface) daily I.V. on 5 conscecutive days. Attention should be paid to the specified doses of the relevant treatment regimen. Additive bone marrow depression may occur with radiation therapy. There is adverse interaction with live and killed virus vaccines.
P/A : Dose : D/I :
Cost: Inj: Ifosfamide I: C/I: P/C : A/E :
P/A: Dose:
D/I:
106
Antimetabolites
Cost : Dacarbazine I: C/I : P/C : A/E :
Inj: 1 g vial (Rs. 322.20) Malignant melanoma, Hodgkins, Soft tissue sarcomas Pregnancy, lactation, persons with severe myelosuppression. Hepatic / renal impairment, haematologic monitoring, restrict food intake 4-6 hrs before therapy. Nausea, vomiting, diarrhoea, anaphylaxis, bone marrow depression, urticaria, photosensitivity, hepatic necrosis, renal impairment, thrombocytopenia, blurred vision, flu-like syndrome, myalgia. Injection 200mg vial 2.5 - 4.5 mg/kg/day x 5-10 days or 250 mg/m2/day x 5 days every 3 weeks or 850mg/ m2 every 3-6 weeks given IV. lmpairs the immunogenicity of the live attenuated vaccine. It forms precipitate with the hydrocortisone hemisuccinate. Inj: (100 mg) vial Rs 294 Rs. 298 Inj: 200 mg vial Rs. 360 Rs. 550 Glioblastoma, Anaplastic Astrocytoma, refractory to nitrosoureas, Melanoma, and Metastatic Carcinomas to brain. Hypersensitivity to dacarbazine Myelosuppression, Nausea, Vomiting, Alopecia 1. 150 to 200 mg/m2 orally on an empty stomach for 5 days every 28 days. 2. 75 mg/ m2 orally on an empty stomach daily during radiation therapy for up to 7 weeks. Cap 20 mg (5) Rs. 1812.00
P/A : Dose :
D/ I :
Cost: Temozolamide : I:
C/I : A/E : Dosage Schedule:
Cost : ANTIMETABOLITES:
Methotrexate
I: Lymphoblastic leukemia, choriocarcinoma, hydatidiform mole, non-metastatic osteosarcoma and in small doses as immunosuppressant 107
C/I: P/C : A/E : P/A: Dose:
D/I:
Cost:
Severe hepatic or renal impairment, severe anaemia thrombocytopenia or leucopenia. Children, CNS disorders, GI disorders, bone marrow depression. Nausea, vomiting, diarrhoea, anaphylaxis, hepatic necrosis, fibrosis, renal toxicity, depigmentation. Tablets 2.5 mg, 5 mg Injection 5mg,15 mg, 50 mg ampoules. Leukemia: Maintenance of remission 30 mg/m2 I.M. twice a week. Choriocarcinoma 15 - 30 mg orally, daily x 5 days weekly repeated doses, 3-5 courses. Aminoglycosides decrease absorption and serum level of oral methotrexate. Etretinate causes hepatotoxicity. Folic acid or derivatives decrease response to methotrexate. NSAIDs increase plasma level of methotrexate.Serum concentration of phenytoin decreased. Probenecid, salicylates and sulfonamides increase efficacy and toxicity of methotrexate. Procarbazine increases nephrotoxicity of methotrexate. Asparaginase reduce toxicity. Food reduces the absorption of methotrexate when taken orally. Tab 2.5 mg , Rs. 23.00 Rs. 37.45,In j. 15 mg Vial Rs. 40.34 In combination therapy for acute leukemia, chronic granulocytic leukemia. Breast feeding , pregnancy. Impaired renal or hepatic function, monitor uric acid level, blood counts, liver function test. Nausea, vomiting, diarrhoea, cholestasis bone marrow depression, pancreatitis oral and intestinal ulceration, hepatic necrosis. Tablets 50 mg 2-3 mg/kg /bw oral single or divided doses continuously. Allopurinol delays catabolism of mercaptopurine resulting in severe toxicity. Other myelosuppressive
Mercaptopurine
I: C/I: P/C : A/E :
P/A: Dose : D/ I :
108
Cost :
agents enhance antineoplastic effect of mercaptopurine. Trimethoprim-sulfamethoxazole enhances bone marrow suppression Tab 50 mg Rs210-Rs765 Adjuvant in the treatment of carcinoma of breast, pancreas, urinary bladder, hepatoma, carcinoma of colon, and other parts of Gl tract, premalignant keratosis of skin (topical treatment), multiple superficial basal cell carcinoma. Serious infection, depressed bone marrow function. Anemia, leucopenia, skin pigmentation, hepatic or renal impairment hypersensitivity. Nausea, vomiting, diarrhoea, alopecia conjunctivitis, bone marrow depression, angina pectoris, cardiac arrhythmias, oral and Gl ulcers, hyperpigmentaion, chestpain, breathlessness. Injection 250 mg, 500 mg ampoules,Cream 5% 12 mg/kg o.d. x 4 days I.V. (maximum 8000 mg) . If no toxicity 6 mg/kg on days 6, 8, 10, 12. Maintenance 10 - 15 mg / Kg/ week. Other bone marrow depressants immunosuppresive agents, irradiation all lead to additive effect. With leucovorin, calcium toxicity of 5 flurouracil increased. Enhanced toxicity with metronidazole. Elevation in alkaline phosphatase and transaminases, serum bilirubin Inj: 50 mg vial Rs. 19.00 AML, ALL, CML blast phase, NHL in children. Treatment and maintenance of meningeal neoplasms, Erythroleukemia. Pregnancy, lactation Monitor hepatic function, haematological parameters, uric acid levels, women of child bearing age, intrathecal administration in, infants. Leucopenia, anaemia, thrombocytopenia, reticulo cytopenia, GI disturbances, oral and anal ulcerations,hepatic and renal dysfunction, 109
5-Fluorouracil
I:
C/I: P/C : A/E :
P/A: Dose :
D/I :
Cost: I:
Cytarabine (cytosine arabinoside)
C/I : P/C:
A/E:
P/ A: Dose : D/I:
Cost :
thrombophlebitis, peripheral neuro toxicity, high doses,rhabdomyolysis, conjunctivitis, anaphylaxis. Injection 100 mg, 500 mg, 1000 mg vial 100 mg/m2 IV bd. x 7 days. Radiotherapy and other myelotoxic drugs potentiate myelotoxic effect. Increased serum levels of digoxin when concurrently used.Efficacy of both gentamicin and flucytosine is decreased. Inj. 1 g;(10 ml vial) Rs. 965.00 100 mg,1ml vial Rs. 185.00
Gemcitabine
Metastatic or locally advanced carcinoma of Pancreas, Non small cell carcinoma of lungs, carcinoma of Breast, Biliary tract, bladder, ovary. Non Hodgkin lymphoma. P/C: Prolongation of infusion time > 60 mins increases toxicity. A/E: Myelosuppression and other haematological effects, nausea, vomiting, rash, alopecia. Dosage and Schedule: 1,000 mg/m2 IIV over 30 min once weekly for upto 7 weeks when used as a single agent. After 1 week of rest, subsequent cycles are given once weekly for 3 consecutive weeks out of 4. Cost : Inj. ( 1 g) vial Rs. 5460 Rs. 6200 CYTOTOXIC ANTIBIOTICS: I:
Doxorubicin
I: Gl tract carcinoma, AML, bronchogenic carcinoma, breast and ovarian carcinoma, soft tissue, and bone sarcoma malignant lymphoma, non metastatic bladder carcinoma (intravesical) Wilms tumour, neuroblastoma. Buccal ulceration, bone marrow depression, pre existing heart disease, pregnancy. Cardiac and hepatic dysfunction, haematological and cardiac monitoring, hyperuricemia, infection. Nausea, vomiting, diarrhoea, fever, red urine, ventricular arrhythmia,tissue damage on extravasation, cardiotoxicity, bone marrow depression, anorexia, stomatitis, alopecia, conjunctivitis.
C/I : P/C: A/ E :
110
Cytotoxis Antibiotics
P/A: Dose : D/I:
Cost :
Injection l0mg,20mg,50mg. 60 -75 mg/m2 slow I.V. injection every 21 days. Repeat after 4 weeks. Maximum dose 550 mg/m2. Enhanced hepatotoxicity with mercaptopurine with cyclophosphomide exacerbation of neurologic cystitis, increased clearance of doxorubicin with barbiturates, decreased serum level of digoxin. Inj. (10 mg) vial Rs. 200 Rs. 250. AML, ALL, disseminated neuroblastoma, Rhabdomyosarcoma. Hypersensitivity, CHF, arrhythmias, bone marrow suppression,previous full cumulative dose of doxorubicin or daunorubicin. Cardiac, haematological monitoring, hepatic and renal impairment. Nausea, vomiting, bone marrow depression, stomatitis, alopecia, rash, hyperpigmentation, cardiotoxicity, CHF, fever, chills, diarrhoea, local tissue damage, anaphylactical reaction, red urine. Injection 20mg vial 45 mg / m2 I.V. days 1,2,3. Immunisation with live vaccine not recommended. Enhanced radiation toxicity. .Heparin, aluminium, dexamethasone are incompatible with daunorubicin. Inj. 20 mg vial Rs. 350 Rs. 430 Palliative and adjuvant to surgery and radiotherapy. Testicular tumour, squamous cell carcinoma of skin, neck and head, genito urinary tract, oesophagus, carcinoma of cervix, Hodgkins and Non- Hodgkins Lymphoma, choriocarcinoma, embryonal cell carcinoma of testis, brain tumour, glioma. Pre exisitng pulmonary disease hypersensitivity. Lymphoma patients, monitor pulmonary function, anaesthesia. Nausea, vomiting, allergic reactions, fever, anaphylaxis, skin rashes, Raynauds phenomenon, stomatitis, 111
Daunorubicin
I: C/I:
P/C: A/E:
P/A: Dose : D/I:
Cost :
Bleomycin
I:
C/I : P/C : A/E :
P/A: Dose :
D/ I :
Cost :
pulmonary fibrosis, hyper-pigmentation, renal and hepatic toxicity. Injection 15 mg,30 mg vial. 30 mg twice weekly I.V. or I.M. Total dose 300 - 400 mg Small cell cancer - 0.25 mg - 0.5 mg / kg IV, IM, SC once or twice weekly. Hodgkins - 0.25 - 0.5 mg/kg IV, IM, SC. Digoxin and phenytoin levels decreased, increased radiation toxicity. Oxygen increased pulmonary toxicity. Cisplatin toxicity increased. Inj. (15 mg) Vial Rs. 838.00 Adenocarcinoma, lymphosarcoma, seminoma, superficial bladder cancer, recurrent pterygium. Haemorrhagic tendency, bonemarrow depression, thrombocytopenia. Should not be given IM or SC. Leucopenia, oral ulcers, monitor renal and haematological status. Leucopenia, thrombocytopenia, pneumopathy, renal toxicity, stomatitis, thrombophlebitis, loss of appetite, nausea, vomiting, loss of hair, skin rash and possible haemolytic - uremic syndrome. Injection 2 mg, 10mg vials 10 mg/m2 infused IV divided in 5 doses and infused over 5 days. Vinca alkaloids produce bronchospasm, bone marrow depression on radiation therapy, increased cardiotoxicity with doxorubicin, decreased antibody response to vaccines. Inj. 2 mg vial Rs. 95.00 Rs. 210.00 Gestational Trophoblastic Neoplasm, Wilms tumour, childhood rhabdomyosarcoma, Ewings Sarcoma. Slow IV push through side arm of running IV infusion. Similar to Gemcitabine including mucocutancous effect. 0.5 mg /vial inj 15mcg/ kg IV daily for 5 days. Inj. (0.5 mg) vial Rs. 425.00
Mitomycin
I: C/I: P/C : A/E:
P/A: Dose : D/I:
Cost :
Dactinomycin
I: P/C: A/E: P/A: Dose: Cost : 112
Mitotic Inhibitors
Epirubicin
I: P/C: A/E: Dose: Cost: Carcinoma Breast, Esophagus, Ovary, Stomach, Hodgkins and Non Hodgkins lymphoma. Avoid extravasation, reduce dose if patient has impaired liver function. Myelosuppression, Nausea, Vomiting, Alopecia, Cardiac effects like irreversible congestive heart failure. 100 mg / m2 I.V. infusion repeated every 3 weeks. Inj. (10 mg) vial Rs. 380 Rs. 522.00 TAXANES Metastatic carcinoma of Breast, Non small cell carcinomas of lung, head and neck, ovary, Melanoma Same as Dactinomycin 175 mg/m2 by IV infusion over 3 hours, repeated every 3 weeks. Inj. 30 mg vial Rs. 1400 Rs. 2100.00 Carcinoma Breast, Stomach, Lung, Ovary and Prostate. Same as Dactinomycin 100 mg/m2 IV over 1 hour; repeat at 3 days. Inj. (20 mg) vial Rs. 3500.00 Rs. 4000.00 MITOTIC INHIBITORS Hodgkins disorders, non-Hodgkins Lymphomas, mycosis fungoids, testicular cancer, kaposis sarcoma Leucopenia, bacterial infections, significant granulocytopenia. Needle should be properly positioned in vein as leakage may cause considerable irritation. Hepatic function impairment, leucopenia, azoospermia, nausea,vomiting, hypertension, alopecia. Injection 10 mL vial 0.1 - 0.15 mg/kg IV weekly for 3 doses. Concurrent use with mitomycin cause acute shortness of breath and severe bronchospasm. Reduced plasma levels of phenytoin.Concurrent use with erythromycin cause severe myalgia, neutropenia and constipation Inj. (10 mg) vial Rs. 245.00 113
Paclitaxel :
I: A/E: Dose: Cost:
Docetaxel
I: A/E: Dose: Cost:
Vinblastine
I: C/I: P/C : A/E: P/A: Dose : D/I :
Cost:
Vincristine
I: C/I: P/C : Acute leukaemia, lymphoma, neuroblastoma, Wilms tumour. Intrathecal administration, demyelinating Charcoat Marie disease, pregnancy, tooth syndrome. Infection, neuromuscular disease, leucopenia, pulmonary diseases, leukaemia, radiation therapy, extravasation, concomitant neurotoxic drugs, eye contact, concurrent vaccination. Local reaction if extravasation occurs, constipation, paralytic ileus, jaw pain, bone marrow depression, peripheral neuropathy, syndrome of inappropriate antidiuretic hormone (SIADH), breath-lessness, hyper or hypotension. Injection 1 mg, 5 mg ampoules. 1.5 - 2 mg/m2 IV weekly Decreased plasma digoxin level. Hepatic clearance of vincristine is reduced if L-asparaginase is administered first. So Vincristine should be given 12-24 hrs before Lasparaginase, acute pulmonary reaction may occur with mitomycin,reduced plasma phenytoin levels. Inj. (1 mg) vial Rs 48.00 Rs. 63.00 MISCELLANEOUS AGENTS Acute Lymphocytic Leukemia for induction therapy. Pancreatitis, serious allergic reactions Myelosuppression, Nausea,Vomiting, Anaphylaxis 20 30% 10,000 KU/vial injection. 50-200 KU/kg IV daily for 2 to 4 weeks. Inj. (5000 IU) vial Rs. 970.00 Testis, ovary, endometrial, cervical, bladder, head and neck, gastro intestinal and lung carcinomas; soft tissue and bone sarcomas, Non hodgkins lymphoma. Do not administer if serum creatinine level > 1.5 mg/dL Same as above drug, including renal tubular damage, ototoxicity.
A/E:
P/A : Dose : D/I :
Cost:
L- Asparaginase:
I: C/I: A/E: P/A: Dose: Cost:
Cisplatin
I:
P/C: A/E: 114
Hormones and Hormonal antagonists
P/A: Dose: Cost :
10 mg/10 mL and 50 mg/50 mL vials. Slow IV infusion 50 - 100 mg/m2 every 3 - 4 weeks. Inj. (20 ml) vial Rs.80.00 (50 ml) vial Rs. 300.00 400 mg/m2 as an IV infusion over 15-16 minutes, to be repeated only after 4 weeks. Inj. 150 mg (15 mL) vial Rs.990.00 450 mg (45 ml) vial Rs. 2394.00 Carcinoma colon and rectum, carcinoma of stomach, non small cell lung cancer. Avoid cold drinks or food along with drug. Nausea, vomiting, diarrhea common; laryngospasm 130 mg/m2 as a two hour infusion every 3 weeks Inj. 50 mg (vial) Rs. 2385.00 Rs. 5175.00
Carboplatin
Dose: Cost:
Oxaliplatin
I: P/C: A/E: Dose: Cost:
Etoposide
Small cell anaplastic and Non small cell lung carcinoma, stomach carcinoma, germ cell cancers, lymphomas, Acute leukemia, Neuroblastoma. P/C: Administer as 30 to 60 min infusion to avoid severe hypotension. Must be diluted in 20 to 50 volumes (100 to 250 ml) of isotonic saline before use. Avoid extravasation. Decrease dose by 25% if creatinine clearance is 30 mL / min. A/E: Similar to L-Asparaginase. Dose: 120 mg/m2 IV. on days 1 to 3 every three weeks. Cost: Inj. (50 mg) vial Rs. 372 Rs. 546 HORMONES AND HORMONAL ANTAGONISTS I:
Androgen Antagonist
Bicalutamide I: P/C: A/E: P/A: Dose: Cost: Carcinoma of Prostate Moderate to Severe hepatic impairment Nausea, diarrhoea, flatulence, elevated liver function. Tab 50 mg. 50 mg orally daily morning or evening. Tab (50 mg) Rs. 423 Rs. 1050 115
Aromatase Inhibitors
Anastrazole I: Carcinoma Breast as adjuvant treatment in Post Menopausal Women, with positive or unknown hormonal receptors, advanced or metastatic carcinoma breast as Ist therapy in post menopausal women, in women not responding to tamoxifen. Pregnancy Nausea, vomiting, rash are uncommon, musculoskeletal pain is common, hot flushes. 2.5 mg orally daily. Tab 2.5 mg Rs. 95 Rs 235 Advanced or metastatic carcinoma of breast i.e. hormone receptor positive or unknown in post menopausal women with progression following anti estrogen therapy. Pregnancy. Nausea, vomiting, rash are uncommon, musculo skeletal pain is common, hot flushes. 2.5 mg orally daily. Tab-2.5 mg Rs. 95-Rs. 235 .
C/I: A/E: Dose: Cost:
Letrozole
I:
C/I: A/E: Dose: Cost:
Estrogen Antagonist
Tamoxifen It is a non steroidal antioestrogen. I: Advanced or metastatic carcinoma breast C/I : Hypersensitivity, pregnancy P/C : Premenopausal women A/E : Nausea, vomiting, hot flushes, vaginal bleeding, dermatitis, pruritus vulvae, menstrual irregularities. P/A: Tablets 10 mg, 20 mg Dose : 10 - 20 mg od. D/I : Antagonism to the action of oral anticoagulants, serum tamoxifen level is increased with bromocryptine. Cyclophosphamide level is increased. Cost: Tab 10 mg Rs. 18.00 Rs. 150 116
Targeted agents
Progestins
Medroxy Progesterone Acetate I: Endometrial Carcinoma A/E: Increased apetite and weight gain are common, menstrual irregularities are common. Dose: 1000 to 1500 mg IM weekly Or 400 to 800 mg orally twice weekly. Cost: Tab 10 mg Rs. 44 - 50 Inj. 150 mg/30 ml Rs 60.00 BIOLOGICAL RESPONSE MODIFIERS
Interferon Alpha
I: P/C: A/E: Melanoma, renal cell carcinoma, multiple myeloma, kaposis sarcoma, CML, chronic hepatitis B and C Aggravate life threatening neuropsychiatric autoimmune, ischemic and infectious disorders. Myelosuppression and other haematological effects, anorexia and nausea, partial alopecia, flu like syndrome, parasthesia, mild hypotension. 3 -10 million IU IM in various schedules. Interferon alph 2A Inj. 3 mIU vial Rs. 1190 Interferon alph 2B Inj 3 mIU vial Rs 895. Multiple myeloma, myelodysplastic syndromes. Pregnancy. Constipation, macular rash involving trunk, peripheral neuropathy with chronic therapy,Hypothyroidism is occasional. Starting dose of 50 100 mg once daily in the evening. Dose is escalated weekly by 50 100mg until the maximum dose of 400 mg. TARGETED AGENTS
Dose: Cost:
Thalidomide
I: C/I: A/E:
Dose:
Monoclonal Antibodies
Rituximab I: Non Hodgkins B cell lymphoma i.e. low grade or follicular CD 20 Positive and diffuse large B cell, Chronic lymphocytic leukemia. Infusion related symptoms like fever and chills, hepatitis B reactivation with related fulminant hepatitis. 117
P/C:
A/E: Dose: Trastuzumab I:
Nausea ,infusion related hypersensitivity reactions, myalgia, arthralgia. 375 mg/m2 given as slow I.V. infusion. Carcinoma of breast that has over expression of HER 2/ neu (C-ERB-2) either in advanced disease or as an adjuvant therapy Pre existing cardiac dysfunction Nausea, vomiting, diarrhoea ,infusion related reactions,rashes, chest pain, back pain, dyspnoea and cough. 4 mg /kg IV loading dose over 90 mins. 2 mg / kg IV over 30 mins. TYROSINE KINASE INHIBITORS CML in Chronic phase, Acceralated or blast phase of the disease. All Ph+ chromosome positive GIST (Gastrointestinal stromal tumour) Moderate neutropenia and thrombocytopenia ,Nausea, vomiting, diarrhoea and abdominal pain, skin rash. 400 to 600 mg orally daily in chronic phase of CML and ALL. Carcinoma of lung Diarrhoea may be dose limiting and require discontinuation of drug. Nausea, vomiting, diarrhoea folliculitis type rash 200 to 500 mg daily BISPHOSPHONATES Hypercalcemia associated with malignancy. Bone metastasis from breast cancer, Prostate cancer and from other solid tumours. Multiple Myeloma (Osteolytic and osteoporotic bone lesions) Do not infuse over less than 15 mins potential for renal tubular damage if infused rapidly. Osteonecrosis of jaw with tooth extraction.
P/C: A/E:
Dose:
Imatinib Mesylate:
I:
A/E: Dose:
Gefitinib
I: P/C: A/E: Dose: Zoledronic Acid : I:
P/C:
118
Cytoprotective agents
A/E: P/A: Dose:
Infusion site reactions, potential bronchoconstriction in aspirin sensitive patients,nausea, vomiting occasional 4 mg/Vial injection. 4 mg diluted in 100 ml saline/glucose solution and infused IV. over 15 minutes; may be repeated after seven days and then at 3 - 4 weeks interval. CYTOPROTECTIVE AGENTS Prophylaxis for Ifosfamide induced haemorrhagic cystitis. Patients sensitive to thiol compounds. Nausea, vomiting, diarrhoea (occasional) bad taste in mouth. At least 20% of Ifosfamide dose on weight basisI administered just before Ifosfamide dose and again at 4 and 8 hour after the Ifosfamide, to detoxify the urinary metabolites that cause haemorrhagic oystitis. Inj. 100 mg / 2 ml Rs. 93.00
Mesna :
I: C/I: A/E: Dose:
Cost:
Amifostine :
For reduction of cumulative renal toxicity associated with repeated administration of Cisplatin in patients with advanced cancer. For reduction of moderate to severe xerostomia from radiation of head and neck. P/C: To minimize hypotension during infusion; blood pressure to be monitored every 5 mins during Infusion. A/E: Nausea and vomiting , transient hypotension. Dose: 910 mg/m2 IV over 15 mins once daily, starting 30 mins before chemotherapy. Cost: Inj. 500 mg vial Rs. 997 Rs. 1400 ANTIEMETICS USED IN CANCER CHEMOTHERAPY : (REFER SECTION 17) 1. ONDANSETRON 2. GRANISETRON 3. PALONOSETRON 4. METOCLOPRAMIDE I:
119
SECTION - 7 ANTIPARKINSONIAN DRUGS

Carbidopa + Levodopa:
Carbidopa is a representative peripheral dopa decarboxylase inhibitor. Various drugs can serve as alternatives I: C/I: All forms of parkinsonism other than drug-induced Concurrent use of monoamine oxidase inhibitors; angle closure glaucoma; confirmed or suspected malignant melanoma Pulmonary disease, peptic ulceration, cardiovascular disease (including previous myocardial infarction); diabetes mellitus, osteomalacia, open-angle glaucoma, history of melanoma (risk of activation), psychiatric illness (avoid if severe); close monitoring of hepatic, haematological, psychiatric, cardiovascular, and renal function required in long-term therapy; elderly: avoid rapid dose increases; warn patients to resume normal activities gradually; avoid abrupt withdrawal; pregnancy (toxicity in animals), breastfeeding Nausea, anorexia and vomiting, particularly at the start of treatment; postural hypotension at the start of treatment, particularly in elderly and those receiving antihypertensives; excessive drowsiness and sudden onset of sleep (warn patient of these effects); confusion, vivid dreams, dizziness, tachycardia, arrhythmias; reddish discoloration of body fluids; insomnia, headache, flushing, gastrointestinal bleeding, peripheral neuropathy; taste disturbances, pruritis, rash, liver enzyme changes; psychiatric symptoms including psychosis, depression, hallucinations, delusions and neurological disturbances including dyskinesias may be doselimiting; painful dystonic spasms (end-of-dose effects) and (on-off effects) after prolonged treatment; neuroleptic malignant syndrome, on sudden withdrawal; rarely hypersensitivity.
P/C:
A/E:
120
Dopaminergic agonist
P/A: Dose:
Tablet 100 mg + 10 mg; 250 mg + 25 mg. Parkinsonism, by mouth, ADULT expressed in terms of levodopa, initially 100 mg (with carbidopa 10 mg) twice daily, increased by 100 mg (with carbidopa 10 mg) every few days as necessary, to a maximum of levodopa 1.5 g Optimum daily dose must be determined for each patient by careful monitoring and be taken after meals DOPAMINERGIC AGONIST Parkinsonism, prolactinomas, galactorrhoea and cyclical benign breast disease. Eclampsia, uncontrolled hypertension; porphyria, hypersensitivity, lactation. Monitor for pituitary enlargment particularly during pregnancy, annual gynaecological assessment, and monitor for retroperitoneal fibrosis; history of mental disorders or cardiovascular disease or Raynauds syndrome; contraceptive advise if appropriate (oral contraceptives may increase prolactin concentration). GI disturbances, headache, dizziness, postural hypotension, drowsiness, vasospasm of fingers and toes particularly in-patients with Raynauds syndrome. Tablets, 2.5mg. Parkinsonism: oral, first week 1-1.25mg at night; second week 2-2.5mg at night, third week 2.5mg twice daily, fourth week 2.5mg 3 times daily, then increasing by 2.5mg every 3-14 days according to response to a usual range of 10-40mg daily. Prevention or suppression of lactation oral: 2.5 mg on day 1(prevention) or daily for 2-3 days (suppression), then 2.5mg twice daily for 14 days. Galactorrhoea: oral, initial, 1-2.5mg at bedtime increased gradually to 7.5mg daily in divided doses, max. 30mg daily. Prolactinoma oral, initial, 1-1.25mg at bedtime increased gradually to 5mg every 6 hours, max.30mg daily. Tab 2.5mg (10) Rs 72.00 - 290 121
Bromocriptine. I: C/I : P/C:
A/E:
P/A : Dose:
Cost:
Antiparkinsonian Drugs
Ropinirole I: C/I : P/C : Parkinsons disease, either used alone or as an adjunct to levodopa. Pregnancy and breast-feeding. Hepatic impairment, renal impairment; severe cardiovascular disease, major psychotic disorders, avoid abrupt withdrawal. Nausea, drowsiness, leg edema, abdominal pain, vomiting and syncope; dyskinesia, hallucinations and confusion reported in adjunctive therapy; occasionally severe hypotension and bradycardia. Tablets, 0.25mg, 0.5mg, 1mg, 2mg Oral, initially 750mcg daily in 3 divided doses, increased by increments of 750mcg at weekly intervals to 3mg daily; further increased by increments of upto 3mg at weekly intervals according to response; usual range 39mg daily; maximum 24mg daily. Tab 0.25mg (10) Rs 16.00 Tab 0.5mg (10) Rs 23.50 - 27.00 Tab 1mg (10) Rs 44.50 - 47.50 Tab 2mg (10) Rs 76.00 - 86.50 Parkinson disease either alone or as an adjunct to levodopa therapy to reduce the end of dose or on-off fluctuations in response. Moderate to severe restless leg syndrome. Used with caution in patients with renal impairment and regular ophthalmologic monitoring for visual impairment. GI disturbances, headache, dizziness, postural hypotension, drowsiness, vasospasm of fingers and toes particularly in-patients with Raynauds syndrome, pathological gambling. Initial dose 125mcg tds increased to 250 -500mcg tds according to response to a maximum dose of 4.5mg daily. Sedating drugs and alcohol used with pramipexole leads to additive effects and sudden onset of sleep.
A/E:
P/A: Dose:
Cost:
Pramipexole I:
P/C:
A/E:
Dose:
D/I:
122
MAO B Inhibitor
MAO B Inhibitor
Selegiline I: P/C: Parkinsons disease or symptomatic parkinsonism used alone as an adjunct to levodopa. Gastric and duodenal ulceration (avoid in acute ulceration), uncontrolled hypertension, arrhythmias, angina, psychosis, pregnancy and breast-feeding, side effects of levodopa may be increased, concurrent levodopa dosage may need to be reduced by 10-50%. GI disturbances, dry mouth, stomatitis, sore throat, hypotension, depression, confusion, psychosis, agitation, headache, tremor, dizziness, vertigo, sleep disturbances; back pain, muscle cramps, joint pain, difficulty in micturition, skin reactions, transient increase in liver enzymes. Oral, 10mg in the morning or 5mg at breakfast and midday. Tablets, 5mg. Tab 5mg (10) 32.50 49.10 In parkinsonism either alone or as an adjunct to levodopa therapy to reduce end of dose fluctuation in response. Severe/moderate hepatic impairment. Mild hepatic impairment. Head ache, flu like syndrome, malaise, neck pain, angina pectoris, dyspepsia, anorexia, leucopenia, vertigo, rhinitis, conjunctivitis, melanoma, urinary urgency. Tab 1 mg 1 mg once daily Hypertension with MAO inhibitors, CYP450 inhibitors increase blood levels, tobacco smoking decreases plasma drug levels, entacapone increases clearance.
A/E :
Dose : P/A: Cost: Rasagiline I:
C/I: P/C: A/E:
P/A: Dose: D/I:
COMT inhibitors
Entacapone I: In Parkinsons disease as an adjunct to combination preparation of levodopa and dopa decarboxylase inhibitors. 123
C/I:
P/C: A/E:
Dose:
D/I:
In patient with pheochromocytoma and in patients with history of neuroleptic malignant syndrome or non traumatic rhabdomyolysis; patients with hepatic impairment, combination with non-selective MAO inhibitors. Biliary obstruction, driving and operating machinery, gradual drug withdrawal. Nausea, vomiting, abdominal pain, constipation, diarrhoea, dry mouth and dyskinesias. Night mares hallucinations, increased sweating, rarely cholestatic hepatitis, neuroleptic malignant syndrome, rhabdomyolysis and harmless reddish brown discolouration of urine. Given by mouth 200mg at the same time as each dose of levodopa with dopa decarboxylase inhibitors up to maximum of 200mg 10 times daily. Drugs metabolized by COMT including adrenaline, apomorphine, dobutamine, dopamine, isoprenaline, paroxetine, rimiterol. Use with caution with tricylic antidepressants, reversible inhibitors of MOA-A and venlafexine, aggravates levodopa induced orthostatic hypotension, chelates Iron preparations. DOPAMINE FACILITATOR
Amantadine I: C/I: P/C: Parkinsonism, herpes zoster and influenza A. Epilepsy, gastric ulceration, breast-feeding, pregnancy, and severe renal disease. Hepatic or renal impairment, congestive heart disease, confused or hallucinatory states, elderly; avoid abrupt discontinuation in Parkinsons disease, may affect performance of skilled tasks. Anorexia, nausea, nervousness, inability to concentrate, insomnia, dizziness, convulsions, hallucinations or feeling of detachment, blurred vision, GI disturbances, livedo reticularis and peripheral oedema. Cap l00mg Parkinsonism: oral, 100mg daily and increased after 1 week to 100mg twice daily upto 400mg maximum
A/E :
P/A: Dose: 124
Central Anticholinergics
daily (with close supervision). Herpes zoster: Oral, 100mg twice daily for 14 days, if necessary extended for further 14 days for post-herpetic pain. Influenza A: oral, treatment, l00mg daily for 4-5 days; prophylaxis, 100mg daily for 6 weeks. CENTRAL ANTICHOLINERGICS Trihexyphenidyl / Benzhexol I: Parkinsonism, drug-induced extrapyramidal symptoms (but not tardive dyskinesia). C/I: Untreated urinary retention, angle closure glaucoma and GI obstruction. P/C : Cardiovascular disease, hepatic or renal impairment, elderly, avoid abrupt discontinuation of treatment, liable to abuse, may affect performance of skilled tasks. A/E : Dry mouth, GI disturbances, dizziness, blurred vision less commonly urinary retention, tachycardia, hypersensitivity, nervousness, and with high doses in susceptible patients, mental confusion, excitement psychiatric disturbances. P/A: Tab 2mg, 5mg, Inj. 2mg/mL Dose: Oral, 1 mg daily, gradually increased by 2mg increments to maintenance dose of 6-10mg daily in 3-4 divided doses, 12-15mg or more daily in severe cases. Cost: Tab 2mg (10) Rs 3.00 17.20 Tab 5mg (10) Rs 22.20 Inj 2mg/mL (10) Rs 15.20 Procyclidine I: Parkinsonism, dystonias. P/C, A/E: Similar to atropine. Psychotic episodes may be precipitated in patients with mental disorders. D/I: Similar to atropine. Paroxetine increases plasma procyclidine concentration. P/A: Tab 2.5mg, 5mg Dose: Initial dose 2.5mg tds; increase gradually by 2.5mg to 5mg every 2-3 days until the maintenance dose usually 10-30mg daily in three divided doses. In emergency 510mg by IV injection. Cost: Tab 2.5mg (10) Rs 16.30 125
Orphenadrine I:
P/C, A/E: D/I: P/A: Dose: Cost: Promethazine I: C/I : P/C: A/E : P/A: Dose:
In Parkinsonism especially for alleviation of drug induced extra pyramidal syndromes, relieve pain due to skeletal muscle spasm, in combination with NSAID for musculoskeletal and joint disorders. Similar to atropine. Unsafe in porphyria. May also cause insomnia. Similar to atropine. Caution with bupropion. Tab 50mg Initially 150mg daily increased by 50mg every 2-3 days and maintenance dose is 150-300mg daily. Tab 50mg (10) Rs 12.40 Allergy, emergency treatment of anaphylactic reactions, premedication. Comatose patients. Cardiovascular, hepatic disease, children, pregnancy. As for chlorpheniramine. Tab 10mg, 25 mg, Injection 25mg/ml, 2ml ampoules. Oral, 25mg at night increased to 25mg twice daily if necessary or 10-20mg 2-3 times daily. Slow IV/deep IM,: 25-50mg, upto a max. of 100mg. Tab 25mg (10) Rs 11.00 23.50
Cost:
126
SECTION - 8 DRUGS ACTING ON BLOOD AND BLOOD FORMING ORGANS

ANTI ANAEMIC DRUGS
Nutritional anemia a) Iron deficiency anemia Oral iron preparations

GENERIC NAME TAB:[IRON CONTENT]/ MG FERROUS SULFATE EXTENDED RELEASE FERROUS FUMARATE FERROUS GLUCONATE POLY SACCHARIDE IRON 325 (65) 195 (39) 525 (105) 325 (107) 195 ( 64) 325 (39) 150 (150) 50 (50) ELIXIR [IRON CONTENT]/ MG IN 5 mL] 300 (60) 90 (18) 100 (33) 300 (35) 100 (100)
A/E: Dose:
Epigastric pain, heart burn, nausea, vomiting, staining of teeth, metallic taste, constipation Upto 300 mg of elemental iron per day, as 3 or 4 iron tablets [ each containing 50-65 mg elemental iron] per day. Prophylactic dose ; 30 mg/ day;pregnancy : 60-100 mg per day for atleast 100 days;children : 3-5 mg/kg/day in 2-3 divided doses,duration of treatment 6 -12 months after correction of anemia PARENTERAL IRON THERAPY
Iron sucrose
Sodium ferric gluconate I: Oral iron is not tolerated,failure to absorb oral iron : malabsorption, inflammatory bowel disease, chronic inflammation,non compliance,in presence of severe deficiency with chronic bleeding,alongwith erythropoietin : oral iron may not be absorbed at 127
Drugs acting on Blood and Blood Forming Organs
A/E: Dose:
sufficent rate to meet the demand of induced rapid erythropoiesis. Anaphylaxis, arthralgia, skin rash, low grade fever 100 mg iron preparation should be diluted in 5% dextrose in water or 9% NaCl solution infused over 60-90 minutes.
Other preparations of parenteral iron

Iron dextran A/E: P/A: Dose : Giddiness, paraethesias and constriction in the chest. 50 mg / mL, 2 mL ampoule 2 mL daily deep IM or on alternate day Iron dextran IV infusion Test dose of 0.5 mL iron dextran injected IV over 5 to 10 minutes. Total calculated dose (Parental iron requirement (mg)= 4.4xbody weight (kg) x Hb deficit g/dl) is diluted in 500 mL of glucose/saline solution and infused over 6 to 8 hours. Iron sorbitol citric acid complex P/A: 50 mg iron/mL Dose: 50mg IM only b) Megaloblastic anemia Treatment of cobalamin deficiency Parenteral: 1000 mcg IM injections of hydroxocobalamin given at 3-7 days interval for 6 doses; more frequent doses may be needed with cobalamine in neuropathy maintenance therapy 1000 mcg im monthly c) Folic acid deficiency 1 mg orally until deficiency is corrected.5 mg orally daily may be needed in patients with malabsorption syndromes. DRUGS AFFECTING COAGULATION Heparin Anticoagulant drug for parenteral use. I: Dilated cardiomyopathy, valvular heart disease, pulmonary embolism, atrial fibrillation, deep vein thrombosis, patients requiring cardioversion. Haemophilia and other bleeding disorders, thrombocytopenia,peptic ulcer, severe liver diseases, recent CVA, recent surgery,recent trauma.
C/I:
128
Drug affecting Coagulation
P/C: A/E: P/A: Dose :
D/I:
Note:
Cost:
Can induce thrombocytopenia, careful use in renal and hepatic diseases. Haemorrhage, thrombocytopenia, hypersensitivity reactions,osteoporosis after prolonged use, alopecia Injections 5000 IU,20,000 IU,25,000 IU Myocardial infarction, pulmonary embolism, deep vein thrombosis 5000 units IV bolus followed by continuous infusion of 1000 units hrly for 24 h.Subcutaneous heparin 7500 12500 units bd. Low dose heparin 1500 units subcutaneously is given prophylactically to prevent venous thrombosis. Aspirin enhances the anticoagulant effect of heparin, NSAIDs should be used with caution because of the risk of gastrointestinal bleeding. Dipyridamole also increases the anticoagulant effect. Overdose of heparin is treated by protamine administration. Dose of heparin should be adjusted depending on the partial thromboplastin time, the patients value should be 1 - 2 times the control value. Inj 5000 U/ mL (5 mL) Rs. 68.00 - 69.00/-
Low molecular weight heparin

A variety of preparations are available and have the same indications and contraindications that conventional heparin has: a. b. c. d. e. Dalteparin sodium Tinzaparin Enoxaparin Nadroparin (fraxiparine) Reviparine-6ml vial Rs 2950/-
Fondaparinux
Synthetic analogue of pentasaccharide sequence required for binding of heparin molecule to anti thrombin. Because of long half life, once daily dosing and because of predictable bioavailability no monitoring required. I: C/I: P/C: A/E: same as other LMW Heparin when Creatinine Clearance is <30ml/min Reduced dose needed with moderate renal dysfunction. Bleeding is a commonest complication. Thrombocytopenia rarely occur. 129
P/A: Dose:
Cost:
2.5mg injection 2.5mg SC daily for DVT prophylaxis and 7.5mg SC daily for DVT treatment, 2.5mg daily for Acute coronary syndrome. Rs. 600-700 for 2.5mg injection. Deep vein thrombosis, prosthetic valves, atrial fibrillation,pulmonary embolism, LV thrombus. Pregnancy, bleeding disorders, bacterial endocarditis. Recent surgery, hepatic disease, renal disease. Haemorrhage. Tablets 5 mg. Loading dose 10 mg for 2 days then adjust dose, according to prothrombin time (INR1.5 - times control). In cases of prosthetic valves, the INR should be kept at 3 -4.5.Patients should be instructed regarding bleeding complications when they are on warfarin. Alcohol, anabolic steroids, amiodarone, ciprofloxacin, erythromycin,antiplatelet drugs,simvastatin, thyroxine, all increase the anticoagulant effect. Vitamin K, barbiturates reduce the effect of anticoagulants. Tab 5 mg (10) Rs. 18.00 - 19.00/Anticoagulant in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA). Active major bleeding, hypersensitivity Cautious use during brachytherapy procedures Bleeding, hypotension, nausea,vomiting 250 mg vial Recommended dose is an intravenous (IV) bolus dose of 0.75 mg/kg. This should be followed by an infusion of 1.75 mg/kg/h for the duration of the PCI procedure. Five min after the bolus dose has been administered, an ACT should be performed and an additional bolus of 0.3 mg/kg should be given if needed.
Warfarin
I: C/I: P/C: A/E: P/A : Dose:
D/I:
Cost:
Bivalirudin
I:
130
Haemolytic Anaemias
HAEMOLYTIC ANAEMIAS
Autoimmune hemolytic anemia(AIHA)

Warm AIHA: Glucocorticoids : prednisone 1 mg/kg can be tapered over 2-3 months;Rituximab 375 mg/m2 BSA, IV weekly for 4 doses.IV IG is less effective than in ITP with a response rate of about 40%. Idiopathic cold (AIHA): Rituximab 375 mg/m2 BSA,IV weekly for 4 doses A/E: serious adverse events, which can cause death and disability include severe infusion reactions,cardiac arrest,tumor lysis syndrome causing acute renal failure,infections,hepatitis B reactivation,other viral infections progressive mutlifocal leukoencephalopathy (PmL),immune toxicity, with depletion of B cells in 70% to 80% of patients with Non Hodgkins lymphoma, pulmonary toxicity
Paroxysmal nocturnal hemoglobinuria(PNH)

Eculizumab: is a humanized monoclonal antibody against complement protein C5,administered IV at twice weekly intervals. Folic Acid supplements: 3 mg/day
Hemolytic disease of the new born

Exchange transfusion with Rh negative group O blood if say Bilirubin is > 20 mg% in term babies and >15 mg% in pre-term babies. (150ml/kg body weight of compatible blood is required for an exchange transfusion) HAEMOGLOBINOPATHIES
Sickle Cell Syndromes

Antibiotic prophylaxis appropriate for splenectomized patients during dental or other invasive procedures. Vigorous oral hydration during or in anticipation of periods of extreme exercise, exposure to heat or cold, emotional stress or infection. Pneumococcal and Haemophilus influenza vaccines are less effective in splenectomized individuals. Thus, patients with Sickle Cell Anemia should be vaccinated early in life.Bone marrow transplantation can provide definitive cures.Gene therapy is also useful.
Hydroxyurea
I: Myeloproliferative disorders (primarily polycythemia vera) not responding to venepuncture and essential 131
A/E:
Dose:
thrombocytosis), Sickle Cell Disease (Breaks down cells that are prone to sickle,as well as increasing content), Second Line treatment for Psoriasis Drowsiness, nausea, vomiting and diarrhea, mucositis, (which may take 7-21 days to recover after the drug has been discontinued), skin changes 10-30 mg/kg per day
Management of Acute painful crisis

Includes vigorous hydration, thorough evaluation for underlying causes (such as infection), and aggressive analgesia (Morphine 0.1 0.15 mg/kg every 3-4 h) or meperidine (0.75 -1.5 mg/kg every 2-4 h) should control severe pain). Inhalation of nitrous oxide, Nasal oxygen.
Acute Chest Syndrome

Is a medical emergency. Hydration should be monitored carefully to avoid the development of pulmonary edema, and oxygen therapy should be especially vigorous for protection of arterial saturation. Critical interventions are transfusion to maintain a hematocrit > 30, and emergency exchange transfusion if arterial saturation drops to < 90%.
Thalassemias
Two types of Thalassemias are there: Thalassemia major and Thalassemia minor. In the case of thalassemia major it is ideal to put them on super transfusion therapy from early life with the aim of maintaining the haemoglobin around 12g/dl, along with iron chelating therapy. Bone marrow transplantation is an attractive option for those who can afford and who have compatible donors. Cost of bone marrow transplantation in India is around Rs. 7,00,000-10,00,000. Drugs used in thalassemias include hydroxyurea in a dose of 500 - 1000 mg b.d. orally, cytosine arabinoside given IV or IM in different dosages and 5 - azacytidine (50 - 400 mg/m2 body surface,daily for 5 days). These drugs help to elevate the content of foetal haemoglobin,and thereby reduce the clinical severity of the disease. IRON CHELATING DRUGS
Desferrioxamine
It is a useful iron chelating agent. I: To prevent and treat iron overload in conditions requiring frequent,and repeated whole blood or packed red cell transfusions, haemochromatosis, haemosiderosis, acute toxicity by overdose of medicinal
132
Iron chelating drugs
C/I : P/C:
A/E:
P/A: Dose :
D/I :
Cost :
iron, aluminium overload in chronic haemodialysis patients. Renal impairment Impaired renal function, children below 3 years, increased susceptability to infection, pregnancy and lactation. Gastrointestinal disturbances, hepatic and renal damage,anaphylaxis, arrhythmia, hypotension, blurring of vision and local reactions at the site of injection. Injection 500 mg / vial 20 40 mg/kg/bw daily given as a, SC infusion overnight or along with the blood transfusion. This has to be repeated 4-5 times a week indefenitely as long as transfusion therapy is needed. Antipsychotic drugs administered concurrently may lead to adverse interaction. Vit C enhances the urinary elimination of iron and therefore acts synergistically. Inj 500 mg / vial (5) Rs. 700.00/-
Deferiprone
It is an oral iron chelating drug I: P/C: A/E: P/A : Dose : Cost: Iron chelation Pregnancy and lactation. Agranulocytosis, arthralgias, arthritis, drug induced lupus erythematosus, toxic overload of ron in the liver. Tablets 250 mg, 500 mg. 0.5 - 3 g daily (100 mg/kg bw) to be given 1 h before food, in three divided doses. Tablet 250 mg (50) Rs. 475.00
Heterozygous thalassemia (Thalassemia minor)

Essentials of therapy consist of strict avoidance of medicinal iron, genetic counselling and iron chelation therapy when indicated. DRUGS USED IN LEUKEMIA
Acute Lymphatic Leukemia

Remission induction therapy Prednisolone, 40 mg/m2 oral daily Vincristine 1-1.5 mg / m2 IV 7 days interval Asparaginase 10,000 U/m2 IV daily for 5 days 133
Other drugs used for induction are doxorubicin, etoposide, cytosine arabinoside. Maintenance therapy Methotrexate 15 mg/m2 oral single weekly dose. 6 Mercaptopurine 600 mg/m2 /week oral divided into daily doses. Vincristine 1.5 g / m2 IV every month. Maintenance therapy continued for 2 years. Details of above drugs refer section 6
Prednisone
I: Important chemotherapeutic agent in treatment of ALL. Used in induction and reinduction therapy. Also given as intermittent pulses during continuation therapy. ( Refer section 18 Hormones) Adult: 20-25 mg orally tid;Pediatric:40 mg/m2/daily orally tid Important chemotherapeutic agent in treatment of ALL. Used in induction and reinduction therapy. Also given as intermittent pulses during continuation therapy. ( Refer section 18 Hormones) Adult: 6-8 mg/m 2 /d orally divided tid;Pediatric: Administer as in adults Adult:-Induction therapy : 2 mg IV qwk;Continuation therapy : 2 mg IV every month;Pediatric:- 1.5 mg/m2 IV, not to exceed 2 mg/dose
C/I: P/C : Dose:
Dexamethasone
I:
C/I: P/C : Dose:
Vincristine ( Refer section 6 )

Dose:
Asparaginase (Refer section 6) Methotrexate (Refer section 6) 6-mercaptopurine (Refer section 6) AML (Acute Myelogenous Leukemia) Treatment for acute myeloid leukemia:
Chemotherapy is the main treatment used.These drugs are usually given in combination.People who have a type of AML called acute promyelocytic leukemia (APL) are usually treated with a drug called ATRA 134
Acute Myelogenous Leukemia
(All Trans-Retinoic Acid). It is a specialized form of Vitamin A and is also known as tretinoin.ATRA is given for up to three months alongside chemotherapy treatment. It makes the leukemia cells mature (differentiate), and so can reduce leukemia symptoms very quickly.
ATRA (All Trans-Retinoic Acid)

ATRA is given alongside chemotherapy to people with a type of acute myeloid leukemia called acute promyelocytic leukemia (APL). It works by making the leukemia cells mature. Tretinoin (45 mg/m2per day orally until remission is documented) plus concurrent anthracycline chemotherapy appears to be among the safest and most effective treatments for APL.) A/E: Tretinoin produce complication called the retinoic acid syndrome. Occuring within the first 3 weeks of treatment. It is characterized by fever, dyspnea, chest pain, pulmonary infiltrates, pleural and pericardial effusions and hypoxia. The syndrome is related to adhesion of differentiated neoplastic cells to the pulmonary vasculature endothelium. Glucocorticoids, chemotheraphy, and/ or supportive measures can be effective for management of the retinoic acid syndrome. The mortality of this syndrome is about 10%.
ATRA in pregnancy
It is important not to become pregnant while taking ATRA. ATRA shouldnt be given to women who are under 12 weeks pregnant as this can cause damage to the baby. After 12 weeks it can be given safely. Usually its given without chemotherapy as this is safer for the baby and still effective.
Induction chemotherapy in AML

The first cycles of chemotherapy are called induction chemotherapy. Most people have two cycles of induction chemotherapy. The most commonly used induction chemotherapy drugs are:Cytarabine (Ara-C) Daunorubicin Etoposide Fludarabine Idarubicin 135
Consolidation chemotherapy in AML

The most commonly used drugs for consolidation chemotherapy are:Cytarabine Etoposide Daunorubicin Mitoxantrone
Supportive Care
3+7 regimen is most popular regimen Doxorubicin 45 mg/m2 or 60 mg/m2 IV daily for 3 days. Cytosine arabinoside 100 mg/m2 continuous IV infusion or push doses 8 hourly for 7 days.Other drugs used instead of daunorubicin are idarubicin and mitoxantrone.
Chronic Lymphocytic Leukemia(CLL)

Specific treatment is with Chlorambucil.Combination therapy cyclophosphamide, doxorubicin, vincristine, prednisolone(Refer section 6). Drugs in refractory case Fludarabine and Alemtuzumab.
Fludarabine
I: Treatment of adult patients with B-cell chronic lynmphocytic leukemia (CLL) who have not responded to or whose disease has progressed during treatment with atleast one standard alkylating-agent containing regimen. neutropenia, thrombocytopenia, and /or anemia., pancytopenia, sometimes resulting in death, have been reported. Life-threatening and sometimes fatal autoimmune phenomena such as hemolytic anemia, autoimmune thrombocytopenia/ thrombocytopenic purpura (ITP), Evans syndrome, and acquired hemophilia have been reported ;Tumor lysis syndrome which include hyperuricemia, hyperphosphatemia, hypocalcemia, metabolic acidosis, hyperkalemia, hematuria, urate crystalluria and renal failure; Objective weakness, agitation, confusion, visual disturbances, optic neuritis, optic neuropathy, blindness;Pulmonary hypersensitivity reactions like
A/E:
136
Chronic Lymphocytic Leukemia
Dose:
dyspnea, cough and interstitial pulmonary infiltrate; Gastrointestinal disturbances such as nausea and vomiting, anorexia, diarrhea, stomatitis and gastrointestinal bleeding; Skin toxicity like skin rashes,Erythema multiforme, Steven-Johnson syndrome, toxic epidermal necrolysis and pemphigus The recommended adult dose for injection is 25 mg/ m 2 administered intravenously over a period of approximately 30 minutes daily for five consecutive days. Each 5 day course of treatment should commence every 28 days.
Alemtuzumab
As a single agent for the treatment of B-cell chronic lymphocytic leukemia (B-CLL). P/A: 30mg/1 mL single use vial A/E: Cytopenias,cardiomyopathy,optic neuropathy Dose: Administer as an IV infusion over 2 hours. Do not administer as intravenous push or bolus. Gradually escalate to the maximum recommended single dose of 30 mg. CHRONIC MYELOID LEUKEMIA(CML) I:
Imatinib
I: Newly diagnosed adult patients with Philadelphia chromosome positive(Ph+) chronic myeloid leukemia in chronic phase. Ph+ CML in Blast Crisis (BC), Accelerated Phase (AP) or Chronic Phase (CP) after Interferonalpha (IFN) therapy, pediatric Patients with Ph+ CML in Chronic Phase.Ph+ Acute Lynmphoblastic Leukemia, (ALL),Myelodysplastic/ Myeloproliferative Disease (MDS/MPD),Aggressive Systemic Mastocytosis (ASM),Hypereosinophilic Syndrome (HES) and/or Chronic Eosinophilic Leukemia (CEL) Dermatofibrosarcoma Protuberans (DFSP)Kit+ Gastrointestinal Stromal Tumors (GIST) Pregnancy Hepatotoxicity, Vascular Disorders like flushing, hemorrhage, hematoma, joint swelling, psychiatric symptoms, paraesthesia, epistaxis, conjunctivitis, 137
P/C: A/E:
Dose:
D/I:
vision blurred, eyelid edema, conjunctival hemorrhage, dry eye The prescribed dose should be administered orally, with a meal and a large glass of water. Doses of 400 mg or 600 mg should be administered once daily, whereas a dose of 800 mg should be administered as 400 mg twice a day. Other medications that should not be taken with imatinib are warfarin, erythromycin, and phenytoin. Patients should also be advised to tell their doctor if they are taking or plan to take iron supplements. Patients should also avoid grapefruit juice and other foods known to inhibit CYP3A4 while taking Imatinib.
Other drugs used: Hydroxyurea, busulfan, interferon alpha (Refer section 6) PLASMA CELL DYSCRASIAS
Multiple Myeloma
Melphalan 8 mg/m2 and prednisolone 60 mg/m2 orally after a breakfast for 4 consecutive days, repeated once in 4 weeks.Other drugs used are thalidomide and cyclophosphamide.In resistant cases-combination of vincristine,doxorubicin and dexamethasone are used. ANTIPLATELET DRUGS
Aspirin
I: Dose: Cost: Coronary artery disease, cerebrovascular diseases, fever, rheumatic fever, other arthritides. Antiplatelet dose : 75 to 150 mg daily along with food. 75mg(14 tab)Rs:4-9/After prosthetic valve implantation and dipyridamole stress echocardiography. Acute myocardial infarction, severe aortic stenosis, crescendo angina. Rapidly worsening angina, aortic stenosis, recent myocardial infarction, may exacerbate migraine, hypotension. Nausea, hot flushes, tachycardia, headache. Tablets 25 mg, 75 mg, 100 mg.
Dipyridamole
I: C/I: P/C:
A/E: P/A: 138
Antiplatelet drugs
Dose: D/I: Cost:
300 mg in divided doses daily. Increases the action of adenosine and anticoagulants. Tab 25 mg (10) Rs. 3.00 -6.00/Myocardial ischemia, thromboembolic strokes, following interventions like angioplasty and stent implantation post coronary bypass surgery. Haematological abnormalities. GIT disturbances, neutropenia, agranulocytosis. Neutropenia or agranulocytosis, thrombocytopenia, SLE, skin rash, gastrointestinal disturbances. Tablets 250 mg 250 mg bd. Risk of haemorrhage increased with aspirin and oral anticoagualnts,increase in theophylline half life, slight reduction in digoxin plasma levels. Tab 250 mg (10) Rs.50.00-100.00/Acute Coronary Syndrome, Recent MI, Recent Stroke or Established Peripheral Arterial Disease Hypersensitivity, bleeding, haemorrhage used with caution in patients who may be at risk of increased bleeding from trauma, surgery, or other pathological conditions Neutropenia, TTP, Haemorrhage, headache, dizziness Tablet 75 mg 75 mg od Risk of haemorrhage increased with aspirin and oral anticoagulants
Ticlopidine
l:
C/I: P/C: A/E: P/A: Dose : D/I:
Cost:
Clopidogrel
I: C/I: P/C:
A/E: P/A: Dose: D/I:
Thrombolytic drugs
Major current indication for thrombolytic drugs is in acute myocardial infarction (MI) preferably within 12 hours of onset of symptoms. Thrombolytic therapy does not require an ICCU setting for its administration. Since early clot lysis is the single most effective therapeutic tool which reduces mortality and morbidity. It should be the aim of the first contact physician to administer it whenever indicated. Other indications:Pulmonary embolism, thrombosed arteries, venous shunts and prosthetic valves. 139
Streptokinase
I: Acute myocardial infarction, pulmonary embolism, thrombosed arteriovenous shunts, prosthetic valve thrombosis, peripheral arterial embolism. Recent hemorrhage, CVA within 1 year. Blood dyscrasias with bleeding, recent surgery, peptic ulcer, bleeding hemorrhoids,variceal bleeding, aortic dissection. Use puncture sites (arterial and venous) which are compressible.After recent streptococcal infections, efficacy of the drug is less. Do not repeat in MI occurring 1 week - 1 year after administration due to the fear of sensitization. Allergy with anaphylaxis in severe cases. Hypotension bleeding from various sites especially cerebral bleeding. Available as injections 2,50,000 IU;7,50,000 IU;15,00,000 IU 1.5 million units to be administered as continous infusion in 100 ml saline over a period of l h in acute myocardial infarction. Pulmonary embolism 2,50,000 units in 30 min followed by 1,00,000 units/hour for 24 hours. Use with caution in patients already receiving anticoagulants like heparin, antiplatelet drugs such as aspirin or dipyridamole. Streptokinase is not at present indicated in acute MI presenting after 12 hours and also in cases with ST segment depression (except in cases of suspected true posterior MI). Can be given even with a delay upto 24 hrs if there is persistent cardiac pain. If streptokinase is repeated after 1 week to 1 year in patients who have recurrent infarction the efficacy is dampened due to the development of antibodies. In such situation alternate drugs such as urokinase or tPA are indicated.
C/I:
P/C:
A/E:
P/A : Dose:
D/I:
Special Note :
140
Thrombolytic drugs
Cost:
lnj vial (1500000 iu) about Rs. 2300.00 - 3500.00 Streptokinase injection should be reconstituted prior to the use and used immediately. lf it is not administered soon it should be stored at 2-8 o C
Urokinase
Fibrinolytic drug isolated from human urine I: Same as for streptokinase.For repeat thrombolysis in patients previously treated with streptokinase and allergic to streptokinase.Additional indication is intraocular clot lysis. Same as for streptokinase Bleeding from puncture site. Being a naturally occuring substance allergic reactions are considerably less. Hypotension is less compared to streptokinase. Less sustained systemic fibrinolysis when compared to streptokinase. Available as injections 50,000 IU;2,50,000 IU; 5,00,000 IU;7,50,000 IU;10,00,000 IU Acute myocardial infarction.3 million units in 100 mL saline to be given as infusion over 1 h. Pulmonary embolism. 4400 IU/ kg over 10 min followed by 4400 IU/kg/h for 12 hours. Aspirin and indomethacin can cause haemorrhage. Heparin and oral anticoagulants will increase the risk of bleeding. Inj vial (500000 IU) Rs. 3700.00 Storage ; Store between 2- 8 OC, protect from freezing. Because urokinase injection does not contain any preservatives it should not be reconstituted until immediately prior to use
C/I: P/C: A/E:
P/ A : Dose:
D/I:
Cost:
Tissue Plasminogen Activator (Altepase) tPA

Fibrinolytic drug manufactured by recombinant DNA technology. I: C/I: Acute myocardial infarction,Prosthetic valve thrombosis,Pulmonary embolism. Same as for streptokinase. 141
P/C:
Though, it is thought to be clot specific and less likely to cause bleeding due to fibrinolysis, still bleeding complication have to be watched for. When compared to streptokinase it produces a slight increase on the incidence of haemorrhagic stroke. Patients sensitive to gentamicin should not use tPA. Injections 50 mg vial. Total dose over 90 min Initial bolus 15 mg Intravenous infusion 50 mg over 30 min 35 mg over 60 min.Another dosage schedule is 50 mg IV bolus x 2 doses spaced at 3min interval. Increased risk of GI bleeding with NSAIDs, increased risk of haemorrhage with warfarin. Due to a very short half life, tPA administration should be followed by intravenous heparin injusion to prevent arterial occlusion by further thrombosis Inj vial (50 mg)Rs:39,375.00 Storage ; Store between 2 - 300C. Protect from excessive exposure to light
A/E:
P/A: Dose :
D/I: Note:
Cost:
Antifibrinolytics
These are indicated in primary fibrinolytic states with clinical haemorrhagic tendency and in the rare event of haemorrhagic complications caused by thrombolytic agents.The drugs include the synthetic aminoacids epsilon aminocaproic acid(EACA) and tranexamic acid and the polypeptide aprotinin.
Epsilon amino caproic acid (EACA)

P/A: Dose: Tablets 0.5 g, 1 g. Initial priming dose is 5 g oral/IV followed by 1 g hourly till bleeding stops.Maximum 30 g in 24 hours. EACA is excreted rapidly in urine and the urinary concentration exceeds the blood level. Therefore in bleeding from the urinary tract only smaller doses are required. It is used to arrest bleeding in prostatic surgery and after dental extractions.
142
Antifibrinolytics
Tranexamic acid
P/ A: Dose: Scored tablets of 500 mg Oral : 10 - 15 mg/kg bd or tds or Slow IV injection in a dose of 0.5 - 1 g tds. This inhibits the action of plasmin and kallikrein, thereby preventing fibrinolysis. It is used as an intraoperative infusion during major surgery such as open heart surgery in order to prevent excessive blood loss. Renal toxicity,stroke and myocardial infarction. Inj 5,00,000 KIU in 50 Ml 5,00,000 KIU(Kallikrein inactivator unit)initially followed by 2,00,000 KIU every 4 hour all as slow IV infusion.
Aprotinin
I:
A/E: P/A: Dose:
143
SECTION - 9 BLOOD PRODUCTS AND PLASMA SUBSTITUTES

WHOLE BLOOD/COMPONENTS No Blood is 100% safe for transfusion whatever test we do
Once issued, should not be taken back to the storage site Whole Blood I: Sudden Blood loss of >25% of the total Blood volume,Neonatal Exchange Transfusion (If possible remake whole blood by mixing packed red cells with fresh frozen plasma of the same group) Storage Optimum 40C in Blood Bank Refrigerator (range 20 60C) Shelf life - 30 35 days If there is suspicions of lysis (reddish discoloration of plasma) the unit should not be used for transfusion. Packed Red Cell I: Severe Anaemia (Hb<6gm%),Minor Volume correction Storage :- Same as Whole Blood Shelf life (with Additive solution)-42 days Without additive 28 days.
Avoid Transfusion as far as possible Promote Blood donation since it improves the health of the donor
Platelet Concentrate
Based on clinical symptoms,Thrombocytopenia,Platelet function defect,Viper bite,Massive Transfusion Storage Optimum temperature 22 0 C in platelet incubator with agitator Shelf life 3 days in Ordinary Bag 5-7 days in Special Bags Dose 1 unit/10kg body weight for adult 1 unit/2.5 kg body weight in paediatrics Platelet Rich Plasma I: Dengue Haemorrhagic Fever P/C : Possibility of circulatory over load. 144 I:
Whole Blood/Components
Storage and shelf life same as Platelet Concentrate Human Serum albumin I: Hypoalbuminaemia C/I: Hypersensitivity,cardiac failure, severe anemia P/C : Hypertension,low cardiac reserve,pregnancy, lactation,risk of viral transmission A/E : Allergic reactions,nausea,vomiting,pulmonary oedema Fresh Frozen Plasma I: Multiple Coagulation Factor deficiencies (IF PT/INR is > 1.5 times the normal) Storage : Frozen at -200C/-400C/-800C in a Deep Freezer Shelf Life : 1 year Dose : 12-15 ml/kg body weight Single Donor Plasma/Cryopoor Plasma/Liquid Plasma I: 1. As a volume expander 2. As a nutritional supplement in hypo proteinemia cases as in burns, c/c liver disease etc. -200C/-400C in a Deep Freezer 5 years Haemophilia,Von Willebrands Disease Congenital & Acquired Hypofibrinogenemia Frozen at -800C Stored at -200C/-400C/-800C in a Deep Freezer 1 year 1 unit / 10 kg body weight
Storage : Shelf life : Cryo precipitate Indications : Storage : Shelf Life : Dose:
Procedures to be followed in Blood transfusion services

z
z z
Proper washing of the hands of the person who is doing the transfusion procedure Proper cleaning of transfusion site of the patient Consider the transfusion of Blood/Products as a minor transplant since blood is a liquid connective tissue Identification of blood unit with regard to patients name,IP No. ,Age, Unit, Ward, Blood Group, gender etc. 145
Blood products and plasma substitutes
Record pulse temperature BP of the patient before transfusion, 15 mins. after transfusion,30 mins. after transfusion and on completion of transfusion. z A temperature rise of 10C/20F only can be attributed to transfusion. z If any untoward reaction is noticed, immediately stop the transfusion, resuscitate the patient and return the remaining bag of blood with fresh blood sample of the patient from the opposite hand to the Transfusion Medicine department. z For single unit transfusion, no need to bring the blood unit to room temperature. z For transfusion of multiple units at a time, FDA recognized blood warmers can be used to bring the units to room temperature z For Cardiac patients, transfusion rate is 1 ml/kg/hr and better to use packed red cells. PLASMA SUBSTITUTES Dextran 70 and polygeline are macromolecular substances which are metabolized slowly; they may be used to expand and maintain blood volume in shock arising from conditions such as burns or septicaemia. They are rarely needed when shock is due to sodium and water depletion as, in these circumstances, the shock responds to water and electrolyte repletion. Plasma substitutes should not be used to maintain plasma volume in conditions such as burns or peritonitis where there is loss of plasma protein, water and electrolytes over periods of several days. In these situations, plasma or plasma protein fractions containing large amounts of albumin should be given. Plasma substitutes may be used as an immediate short-term measure to treat massive haemorrhage until blood is available, but large volumes of some plasma substitutes can increase the risk of bleeding by depleting coagulation factors. Dextran may interfere with blood group cross-matching or biochemical measurements and these should be carried out before the infusion is started. Plasma substitutes are often used in very ill patients whose condition is unstable. Therefore, close monitoring is required and fluid and electrolyte therapy should be adjusted according to patients condition at all times.
z
Dextran 70
Injectable solution: 6%. Dextran is a representative plasma substitute. Various preparations can serve as alternatives (polygeline 3.5% infusion is considered equivalent) 146
Plasma substitutes
I: C/I:
P/C:
A/E:
Dose:
Short-term blood volume expansion Severe congestive heart failure, renal failure; bleeding disorders such as thrombocytopenia and hypofibrinogenaemia Cardiac disease, liver disease, or renal impairment; monitor urine output; avoid haematocrit falling below 2530%; where possible, monitor central venous pressure; can interfere with blood group cross-matching and biochemical teststake samples before start of infusion; monitor for hypersensitivity reactions; pregnancy hypersensitivity reactions including fever, nasal congestion, joint pains, urticaria, hypotension, bronchospasmrarely severe anaphylactoid reactions; transient increase in bleeding time Short-term blood volume expansion, by rapid intravenous infusion, ADULT 5001000 ml initially, followed by 500 ml if necessary; total dosage should not exceed 20 ml/kg during the initial 24 hours; if required 10 ml/kg daily may be given for a further 2 days (treatment should not continue for longer than 3 days); CHILD total dosage should not exceed 20 ml/kg
PLASMA FRACTIONS FOR SPECIFIC USE Factor VIII is essential for blood clotting and the maintenance of effective haemostasis; Von Willebrand factor is a mediator in platelet aggregation and also acts as a carrier for factor VIII. Blood coagulation factors VII, IX, and X are essential for the conversion of factor II (prothrombin) to thrombin. Deficiency in any of these factors results in haemophilia. Bleeding episodes in haemophilia require prompt treatment with replacement therapy. Factor VIII, used for the treatment of haemophilia A, is a sterile freeze-dried powder containing the blood coagulation factor VIII fraction prepared from pooled human venous plasma. Standard factor VIII preparations also contain Von Willebrand factor and may be used to treat Von Willebrand disease. Highly purified preparations, including recombinant factor VIII, are available; they are indicated for the treatment of haemophilia A but do not contain sufficient von Willebrand factor for use in the management of Von Willebrand disease. 147
Factor IX Complex is a sterile freeze-dried concentrate of blood coagulation factors II, VII, IX and X derived from fresh venous plasma. Factor IX complex which is used for the treatment of haemophilia B may also be used for the treatment of bleeding due to deficencies of factor II, VII, and X. High purity preparations of factor IX which do not contain clinically effective amounts of factor II, VII and X are available. A recombinant factor IX preparation is also available Factor IX Complex (Coagulation Factors, II, VII, IX, X) Concentrate Dried. Factor IX complex concentrate is a complementary preparation and a representative coagulation factor preparation. Various preparations can serve as alternatives I: Replacement therapy for factor IX deficiency in haemophilia; bleeding due to deficiencies of factors II, VII or X C/I: Disseminated intravascular coagulation P/C : Risk of thrombosis (probably less risk with highly purified preparations) A/E : Allergic reactions including chills, fever Dose : Haemophilia B, by slow intravenous infusion, ADULT and CHILD according to patients needs and specific preparation used Treatment of bleeding due to deficiencies in factor II, VII or X as well as IX, by slow intravenous infusion, ADULT and CHILD according to patients needs
Factor VIII concentrate

Dried Factor VIII concentrate is a complementary preparation and a representative coagulation factor preparation. Various preparations can serve as alternatives I: Control of haemorrhage in haemophilia A P/C : Intravascular haemolysis after large or frequently repeated doses in patients with blood groups A, B, or AB (less likely with high potency, highly purified concentrates) A/E : Allergic reactions including chills, fever Dose : Haemophilia A, by slow intravenous infusion, ADULT and CHILD according to patients needs 148
Plasma fractions for specific use
Human normal immunoglobulin

Intramuscular administration: 16% protein solution. Intravenous administration: 5%; 10% protein solution. Normal immunoglobulin Normal immunoglobulin solution is administered by intravenous infusion for primary immunodeficiencies and immunomodulation in autoimmune disease including Guillain-Barre syndrome and Kawasaki disease. Solutions for intramuscular and subcutaneous injection are used for primary immune deficiency. Normal immunoglobulin should be used in hospital settings where specialist supervision is available. Normal immunoglobulin (human, polyvalent) Injection, normal immunoglobulin for intravenous use, 5%, 10% protein solution Injection, normal immunoglobulin for intramuscular use, 16% protein solution Injection, normal immunoglobulin for subcutaneous use, 15%, 16% protein solution NOTE. Formulations from different manufacturers vary and should not be regarded as equivalent; consult individual manufacturers product literature I: Replacement therapy in primary immunodeficiency, Kawasaki disease P/C: Monitor vital signs; NOTE : National recommendations may vary Consult individual manufacturers product literature for dose and administration recommendations for specific diseases; recommended doses may vary to those listed below. For replacement therapy in primary immune deficiencies: Initial loading intravenously in divided doses until serum IgG level is > 6 g/l. Maintenance doses by intravenous, subcutaneous or intramuscular routes: normally 0.4 0.8 g/ Kg / month for children and adults. Dose to be titrated depending on inter-current infections or trough serum IgG level. Intravenous doses may be given at one, two, three or four week intervals. Subcutaneous doses may be given at one, two, three, four or seven day intervals. For immuno-modulation in autoimmune conditions: Maximum recommended dose is 2g/kg over at least 48 hours. Depending on specific autoimmune disease: 0.4 g/kg/day for 5 days or 0.8- 1 g/kg the first day and repeated once if indicated. 149
ADMINISTRATION. Infusion rates of < 8 g per hour are recommended. Immunoglobulin should be administered under the supervision of an immunologist or other experienced physician. In general, this should be in a hospital with adequate facilities for monitoring the infusion as well as the condition for which it is being administered, until the patient is stable, when treatment at home can be considered after formal training in an expert centre. A/E : Nausea, vomiting, headache (may develop 24 hours after infusion); dizziness, dry mouth, chills, sweating, hypothermia, fever, eczema, rash, urticaria, hypotension, wheezing; anaphylactoid reactions also reported; with immunomomodulatory doses also immune haemolysis, aseptic meningism, increased plasma viscocity, hypercoagulopathy, renal impairment
150
SECTION 10 CARDIOVASCULAR DRUGS

DRUGS USED IN TREATMENT OF ANGINA NITRATES Nitrates are mainly venodilators. Glyceryl Trinitrate I: Treatment of acute anginal episode, acute LVF, to reduce BP in markedly elevated blood pressure such as hypertensive crisis. C/I: Hypersensitivity to nitrates, hypovolemia, hypertrophic obstructive cardiomyopathy, aortic stenosis, cardiac tamponade, head injury,closed angle glaucoma. P/C: Renal disease, hepatic disease, hypothyroidism. Glyceryl trinitrate loses potency when stored for more than 6 months and should preferably be kept away from sunlight. Nitrates especially IV. nitrate injection should be used with caution in acute inferior wall MI with right ventricular infarction with hypotension. A/E: Most common side effect is headache. Flushing, postural hypotension causing giddiness, and tachycardia may occur. Development of tolerance . Many patients on regular nitrate therapy become tolerant to the drug after several weeks. Continuous IV. infusion results in tolerance leading to decreased effectiveness within 24 h. Development of tolerance can be prevented by giving nitrates in eccentric dosing so as to produce long (10 12 h) nitrate free intervals or by administration of drugs like captopril which contain SH group P/A: Tablets, buccal spray, transdermal preparation and IV. infusion. Tablets 0.5 mg, 2.6 mg and 6.4 mg long acting. Transdermal preparation : 2.5 mg, 5 mg, 10 mg and 15 mg released over 24 h. Ointment : 2% skin ointment contains 15 mg per inch. Buccal spray 2 metered dose of 400 mcg. IV infusion as 5 mg and 25 mg vials, 1 mg/mL or 5 mg/mL. 151
Cardiovascular Drugs
Dose :
D/I :
Cost :
Oral . 0.5 mg sublingually for angina.2.6 mg - 6.4 mg bd for long action Parenteral : IV administration : One vial is to be diluted in 500 mL normal saline prior to IV infusion and infused at a rate of 10 - 200 mcg/min depending upon the response. Low dose nitroglycerine therapy is preferable and effective compared to high dose infusions in many clinical situations. Careful monitoring of blood pressure essential. To prevent nitrate tolerance, give nitrate at eccentric dosage intervals eg. 8 am- 1 pm. Transdermal preparation should not be used continously for more than 12 h. Tricyclic antidepressants and disopyramide may reduce action of nitrates. The effect of heparin is reduced by increasing excretion of heparin Tab 0.5 mg (30) Rs.56/Cap 2.5 mg (50) Rs. 60.00/Inj 25 mg/5mL (5amp) Rs. 205.00/Ointment 30 mg (2 %) Rs. 34.00/Patch 5 mg (24 hrs) Rs. 41.10/Chronic angina pectoris, prevention of acute episodes of angina. Same as glyceryl trinitrate 5 mg, 10 mg tablets and 20 mg sustained release capsules.Spray 1.25 mg released / dose, 200 metered doses. 10 mg -30 mg three times a day. Use eccentric dosage schedule ie.instead of regular eight hourly dosage. 3 doses are given at 7 am,11 am, 4 pm; from 4 pm to 7 am no drug is administered so that a drug free interval of 15 h is produced. Tab 10 mg (100) Rs. 11.00 - 12.00/Cap 20 mg (25) Rs. 60.00 - 62.00/-
Isosorbide Dinitrate
I: C/I:, P/C:, D/I : P/A :
Dose:
Cost:
Isosorbide mononitrate
I: Angina of all types, chronic heart failure C/I, P/C, A/E, D/I: Same as for glyceryl trinitrate P/A : Tablets 10 mg 20 mg, 25 mg, 50 mg SR Tablets. 152
Drugs for Angina
Dose :
Cost : I:
Oral : 10 mg to 40 mg b.d. Long acting preparations are used once daily; eccentric dosage schedule prevents nitrate tolerance by producing nitrate free intervals of 12 h. Tabs 50 mg (10) Rs. 35.00 - 39.00/-
Intravenous nitroglycerine
Intravenous nitroglycerin is now being routinely used in coronary care units for acute myocardial infarction and other unstable ischemic syndromes.Unstable angina, refractory angina, coronary artery spasm, pulmonary oedema following LVF, infarct limitation, intraoperative hypertension. C/I : Increased intracranial pressure, hypovolemia, cardiac tamponade,obstructive lesions like aortic stenosis, mitral stenosis, hypertrophic cardiomyopathy, right ventricular infarction and glaucoma. P/A : The drug is diluted in normal saline (5 mg - in 500 mL) and administered as a constant infusion. It should be started at a small dose at 5 mcg/kg/min and increased gradually to achieve the desired clinical response. It can cause marked hypotension and hence blood pressure should be monitored every 15 min initially. The systemic BP should not drop more than 20 mm Hg. If the BP is less than 100 mm Hg the infusion has to be stopped or reduced temporarilly. Use of plastic IV infusion sets may reduce the availability of nitroglycerine since it adheres to the IV tubing. Methaemoglobinemia may occur on continuous infusion.
BETA BLOCKERS
Atenolol Atenolol is a representative beta-adrenoceptor antagonist. Various drugs can serve as alternatives I: C/I: Angina and myocardial infarction; arrhythmias; hypertension; migraine prophylaxis History of asthma or bronchospasm (unless no alternative,then with extreme caution and under specialist supervision); uncontrolled heart failure, Prinzmetal angina, marked bradycardia, hypotension, sick sinus syndrome, second- and third-degree atrioventricular block, cardiogenic shock; metabolic 153
acidosis; severe peripheral arterial disease; phaeochromocytoma (unless used with alpha-blocker) P/C : Avoid abrupt withdrawal especially in ischaemic heart disease;history of obstructive airway disease (use with caution and monitor lung functionsee also contraindications above); pregnancy breastfeeding first-degree atrioventricular block; liver function deteriorates in portal hypertension; reduce dose in renal impairment, diabetes mellitus (small decrease in glucose tolerance, masking of symptoms of hypoglycaemia). P/A: Tablet: 50 mg; 100 mg. Dose: Angina, by mouth , 50 mg once daily, increased if necessary to 50 mg twice daily or 100 mg once daily Myocardial infarction (early intervention within 12 hours), by intravenous injection over 5 minutes, 5 mg, then by mouth 50 mg after 15 minutes,followed by 50 mg after 12 hours, then 100 mg daily A/E: gastrointestinal disturbances (nausea, vomiting, diarrhoea,constipation, abdominal cramp); fatigue; bronchospasm; bradycardia, heart failure, conduction disorders, hypotension; sleep disturbances, including nightmares; depression, confusion; hypoglycaemia or hyperglycaemia. Cost: Oral 50mg(14 tab) Rs. 25/-;Inj 5mg(10ml)Rs 5/-
Other BetaBlockers-Metoprolol,Propranolol
CALCIUM-CHANNEL BLOCKERS A long-acting dihydropyridine calcium channel blocker (such as amlodipine) can be added to betablocker treatment if necessary for control of moderate stable angina. For those in whom a beta-blocker is inappropriate, verapamil may be given as an alternative to treat stable angina. Calciumchannel blockers can also be used in patients with unstable angina with a vasospastic origin, such as Prinzmetal angina, and in patients in whom alterations in cardiac tone may influence the angina threshold MISCELLANEOUS DRUGS USED IN TREATMENT OF ANGINA Trimetazidine It is an antianginal agent which acts by vasodilation and effects on cardiac metabolism 154
Drugs for Angina
I:
C/I : P/C : A/E : P/A : Dose : D/I : Cost : Ranolazine Its an antianginal drug, and is a late sodium current inhibitor and shifts metabolism towards carbohydrates oxidation. I: Chronic stable angina. May be used as an add on therapy/ first line/ second line agent C/I : Should not be used with other drugs producing QT prolongation and strong inhibitors of CYP3A. A/E : Rare. Dizzness, nausea, constipation P/A : 500mg tablets Dose : 500mg twice daily to begin with and if needed 1000mg twice daily D/I : Diltiazem, Verapamil, Macrolides increase ranolazine action. Cost : Rs. 6 per tab Nicorandil I: It is a potassium channel activator and dilates arterial and venous beds. Antianginal drug for refractory angina. C/I: Cardiogenic shock, hypotension. P/C: Hypovolemia, pregnancy, breast feeding. A/E : Headache, flushing, dizziness similar to that of nitrates. P/A: Tablet 5 mg, 10 mg. Dose : 5 mg tablets bd. (10 mg/24 h) the dose may be increased upto 30 mg bd. D/I: With alcohol and other vasodilators hypotensive action. Cost: Tab 5 mg (20) Rs. 149.00/DRUGS USED FOR THROMBOLYTIC THERAPY (Refer Section 8) 155
Angina pectoris and myocardial infarction. At present it is mainly used in refractory angina. Hypersensitivity Pregnancy. GI disturbances, vomiting, nausea. Tablet 20 mg 20 mg tablets tds. No significant drug interaction reported. Tab 20 mg (10) Rs. 29.00/-
ANTIPLATELET DRUGS AND ANTICOAGULANTS (Refer Section 8) LIPID LOWERING DRUGS
Statins
These drugs are useful in lowering of total cholesterol and LDL cholesterol, but are less useful in hypertriglyceridemia. Statins can reverse the already established atheromatous lesion in the coronary artery.
Atorvastatin
Most commonly used statin I: Primary hyperlipidemia with Increased LDL and total cholesterol level with or without raised TG levels, secondary hypercholesterolemia Hypersensitivity ,active liver disease, porphyria, pregnancy and lactation Alcohol, history of liver disease. Risk factors for myopathy, rhabdomyolysis.Hypothyroidism, age<10 years. Head ache nausea , bowel upset, rashes, sleep disturbances, rise in liver transaminase, muscle tenderness, rise in CPK levels, Myopathy (serious rare).Rhabdomyolysis (few reported) 10-40mg/day (max 80mg) Ketoconazole/Erythromycin given concurrently Rs.2.50/10mg tab Primary hypercholesterolaemia, mixed dyslipidaemia Active liver diseases, pregnancy, breast feeding. Hepatic diseases, high alcohol intake. Reversible myositis, headache, altered hepatic enzymes, abdominal pain, nausea. Tab 5mg,10mg, 20mg 5-10 mg daily, max upto 40mg Same as for Atorvastatin 10 mg(10) Rs. 80.00-100.00 Hypercholestrolemia, mixed hyperlipidemia. Active liver diseases, pregnancy, breast feeding. Hepatic diseases, high alcohol intake.
C/I: P/C:
A/E:
Dose: D/I: Cost:
Rosuvastatin
I: C/I: P/C: A/E: P/A: Dose: D/I: Cost:
Lovastatin
I: C/I: P/C: 156
Lipid Lowering Drugs
A/E: P/A: Dose : D/I:
Cost:
Reversible myositis, headache, altered hepatic enzymes, abdominal pain, nausea. Tablets 10 mg, 20 mg. 20- 40 mg to be given after dinner h.s. Increased action with anti coagulants , increased incidence of myopathy with fibric acid derivatives and cyclosporine, erythromycin. Tab 20 mg (10) Rs. 55.00/-
Simvastatin
I: C/I: P/C:A/E, D/I: Same as lovastatin P/A: Tablets 5 mg, 10 mg, 20 mg. Dose: 10 mg h.s. Cost: Tab 10 mg (10) Rs. 40.00 - 90.00/Other drugs in this class include fluvastatin, pravastatin,
Fibric acid derivatives

These are mainly used in the treatment of hypertriglyceridemia though they also reduce LDL cholesterol and increase HDL cholestrol to a small degree. The earliest drug in use was clofibrate which is not used nowadays.The commonly used drugs in this group are gemfibrozil and bezafibrate
Gemfibrozil
l: C/I: P/C: A/ E: P/ A: Dose: Cost : Hyperlipidemias type 3, 4, 5 Alcoholism, pregnancy, breast feeding, active liver disease. Myositis like syndrome, renal dysfunction, hepatic dysfunction. Nausea, vomiting, diarrhoea, skin rashes myopathy. Capsules 300 mg, 600 mg 600 mg bd before meals Cap 300 mg (10) Rs. 70.00 - 100.00/-
Bezafibrate
I, C/I, P/C, A/E, D/I: P/ A : Dose : Cost : Same as gemfibrozil Tablets 200 mg, 400 mg 200 mg tds. with meals Tab 200 mg (10) Rs. 77.00 - 78.00/-
Fenofibrate
Superior to others in lowering LDL CH,and raises HDL level. I, C/I, P/C,A/E:,D/I:Same as bezafibrate 157
Dose: Cost:
200 mg once daily with meals 200 mg (10) Rs. 70-200
Ezetimibe
Cholesterol absorption inhibitor I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Hyperlipidaemia, homozygous familial hypercholesterolemia Hypersensitivity, moderate to severe liver disease children <10year, lactation Renal or hepatic impairment , myopathy. Abdominal discomfort , head ache , dizziness , arthralgia, myalgia Tablet 10 mg,synergistic when given in combination with statins. 10mg orally once daily cholestyramine, cyclosporine Rs.5.60/tab Hyperlipidaemia Hypersensitivity, hepatic abnormality, active bleeding, pregnancy Hepatobiliary disease, peptic ulcer Arrhythmias, hypotension, dyspepsia, vomiting, jaundice, hyperpigmentation, hyperglycemia, hyperuricemia. 500 mg tab 1-2 g bd/tds Nicotinic acid may potentiate the effects of ganglionic blocking agents and vasoactive drugs resulting in postural hypotension. Tab 500 mg(10)Rs. 20.00 acid extended release tablets are now available for night ANTIHYPERTENSIVE DRUGS
Nicotinic Acid
I: C/I: P/C: A/E:
P/A: Dose: D/I:
Cost: Nicotinic time dosage
Diuretics
They are mainly used for treatment of oedematous states. They lead to renal excretion of sodium, potassium and water in varying proportions.They are indicated in fluid overload situations such as congestive heart 158
Antihypertensive Drugs
failure,nephrotic syndrome} cirrhosis or liver and others.They lower blood pressure and therefore they are employed either as primary or as adjuvant drugs in the treatment of hypertension.
Thiazide diuretics Hydrochlorothiazide

I: Dose : Congestive cardiac failure, renal oedema, ascites, systemic hypertension. 25 - 100 mg daily.
Chlorthalidone
l:C/I: P/C: A/E: D/I: Similar to hydrochlorothiazide but longer duration of action. Dose: 50 - 100 mg daily. Note: lt is better to supplement oral potassium in doses of 1-2 g bd or tds. along with thiazides and loop diuretics.
Indapamide
This is a weak diuretic. It potentiates the action of other standard antihypertensive drugs I: Systemic hypertension Dose: 2.5 mg daily for systemic hypertension.
Xipamide
I: Dose: Systemic hypertension,mild to moderate oedema. Oedema: start with 40mg/day orally reducing to 20 mg /day according to patient response. Hypertension : 20 mg daily as a single dose.
Potassium Sparing Diuretics

Spironolactone This potassium sparing diuretic is a competitive inhibitor of aldosterone. I: Weak diuretic used in cirrhosis, nephrotic syndrome and primary hyperaldosteronism in which it is the drug of choice. Also used along with thiazide and loop diuretics to counteract the loss of potassium. P/A: Tab 25 mg, 100 mg Dose: 25 mg 6 h upto 100 mg/day This dose may be increased upto 400 mg / day in divided doses in selected cases. 159
Triamterene
I: lt is indicated in oedematous states, in combination with thiazides or loop diuretics. When potassium loss is to be minimized.Uncontrolled use may lead to hyperkalemia. 100 mg daily; 50 mg in combination with thiazides.
Dose:
Amiloride
This is a potassium sparing diuretic used in combination with loop diuretics or thiazide. I: Dose: Oedematous states especially in prolonged administration. 5 mg - 10 mg / day.
Beta Adrenergic Blockers

Propranolol(non selective) Antianginal, antihypertensive, antiarrhythmic I: Systemic hypertension, coronary artery disease, effort angina,supraventricular tachyarrhythmias, ventricular arrhythmias,migraine, thyrotoxicosis, hypertrophic cardiomyopathy, congenital cyanotic heart disease with spells. AV Blocks, sick sinus syndrome, overt CHF, peripheral vascular disease, asthma. Early congestive cardiac failure, vasospastic angina, peripheral vascular disease, myasthenia gravis, bradycardia, chronic obstructive airway disease, diabetes mellitus, pregnancy, lactation,Raynauds disease. Should not be used alone in phaeochromacytoma. Bradycardia, cold extremities, gastrointestinal upset, fatigue,conduction disorders. Tablets 10 mg, 40 mg, 80 mg;Sustained release capsules 40 mg, 80 mg. Hypertension :40 mg b.d. or t.d.s. Maximum dose 160 mg -320 mg daily. Angina : 40 mg b.d. or t.d.s. Maintanance120-240 mg dose
C/I: P/C:
A/E: P/A: Dose :
160
Arrhythmias, anxiety, tachycardia: 10 - 40 mg t.d.s.; Post MI.Secondary prophylaxis : 40 mg tds. 5 days after Ml. D/I: Use with caution when patient is on verapamil or diltiazem since the risk of increase in AV block and worsening of heart failure exist. Intravenous verapamil or diltiazem should not be given in patients receiving betablockers; Betablocker mask cardiovascular symptoms of hypoglycemia when used with oral hypoglycemic hence hypoglycemia may go unrecognised, may worsen bradycardia when used with digoxin; antihypertensive effect is potentiated with diuretics. The dose requirement of beta blockers in Indian population is usually less than that of the Western population. It is better to start with smaller doses. Tab 10 mg (10) Rs. 4.00 -5.00
Note :
Cost: Metoprolol
Cardio selective betablockers .

I:C/I: P/C: A/E:D/I: Same as propranolol P/A : Dose : Tablets 50 mg, 100 mg, 200 mg (long acting) Injection 1 mg/ mL. ln hypertension - 50 mg b.d. increase to 200 mg daily in divided dose; In angina - 50 mg -100 mg bd - tds. Arrhythmias - 50 mg bd - tds; in acute Myocardial infarction IV metoprolol given at a dose of 5mg at 5 min. intervals for 3 doses upto a maximum of 15 mg within the first 6 hours has been shown to reduce the mortality in patients who have no contraindication to beta blockade therapy. Tab 50 mg (10) Rs. 82.00 - 83.00
Cost:
Atenolol
I:C/ I:P/C:A/E: D/I: Same as propranolol. P/A : Dose : Tablets 25 mg, 50 mg, 100 mg.Injection 500 mcg / mL. Hypertension 50 mg daily increase upto 100 mg;Effort angina 50 - 100 mg daily;Arrhythmias 50 - 100 mg daily. 161
In the absence of contraindication ,in post MI cases atenolol given in dose of 5 mg i.v. slowly helps to reduce arrhythmias and episodes of sudden death . Note: Being water soluble, it does not cross blood brain barrier. Therefore fatigue, nightmares and other CNS side effects are less. Tab 50 mg (14) Rs. 19.00 - 31.00 Hypertension, angina Same as propranolol. Tablet 5 mg 5 mg daily. Tab 5 mg (10) Rs. 82.00 83.00
Cost:
Bisoprolol
I: C/I:P/C:A/E:D/I: P/A: Dose : Cost:
Esmolol
Ultra short-acting betablocker for parenteral use, with a half life of 9 min. I: C/I: P/C : A/E : P/A: Dose: D/I: Supra ventricular arrhythmias,preoperative hypertension, tachycardia. Severe hypotension, asthma, severe COPD, other contraindication for betablockers use. Hypotension, diabetes mellitus, renal impairment, pregnancy Confusion,redness or swelling at the site of injection, reduction in peripheral circulation. Injection 10 mL ampoule each mL contains 100 mg. S.V.T 500 mcg / kg/ min for 4 min.Maintenence dose is 150 - 300 mcg/kg/rnin. Concurrent use of phenytoin with IV esmolol produces additive cardiac depressant effect, increases the risk of bradycardia, AV block, hypotension. When given along with calcium channel blockers IV cardiac failure may be precipitated. Esmpolol may increase blood digoxin levels. Inj 100 mg/10 mL (10 mL) Rs. 48.00 - 50.00
Cost:
Drugs with combined alpha and beta blocker effect 162
Labetolol
I: C/ I: P/ C: A/E: P/A: Dose : D/I: Cost: Systemic hypertension, hypertensive emergencies, phaeochromo-cytoma. AV Block, bronchospasm, cardiogenic shock. CHF, diabetes mellitus, liver dysfunction, postural hypotension. Headache, hallucination, impotence. Tablets. 50 mg, 100 mg, 200 mg. 50 mg b.d., increased to 100 - 200 mg b.d. Action of oral hypoglycemic agents increased, with anaesthetic agents may cause myocardial depression. Tab 50 mg (10) Rs. 15.00 - 16.00
Carvedilol
Carvedilol is a beta blocker with additional vasodilatory action.Therefore it lowers peripheral resistance also. Hypertension and in patients with mild CHF Same as propranolol postural hypotension, headache, fatigue, flu-like symptoms, rarely angina, heart block, allergic skin rashes, nasorespiratory allergy,mental depression, insomnia, paresthesia, hepatic dysfunction,leucopenia, thrombocytopenia. P/A: Tablets 12.5 mg, 25 mg Dose: Start with 6.25 mg daily orally and increased to 25-50 mg depending upon clinical response. Lower dose in elderly patients(25 mg) Cost: Tab 12.5 mg (10) Rs. 95.00-100.00 Other Beta blockers currently used are NEBIVOLOL, CELIPROLOL and ACEBUTOLOL I: C/I: P/C: A/E:
Calcium channel blockers

Verapamil This is a calcium channel blocker drug with antihypertensive,antianginal and antiarrhythmic properties. I: Supraventricular tachycardias, systemic hypertension, coronary artery disease with effort angina and vasospastic angina,hypertrophic cardiomyopathy, migraine. 163
C/I :
P/C: A/E:
P/A :
Dose :
D/I:
Cost :
Congestive heart failure, AV block, sinus node dysfunction,hypotension, atrial fibrillation and atrial flutter in WPW syndrome,porphyria. Intravenous verapamil should not be given to patients receiving parenteral or oral beta blockers due to the risk of development of cardiac asystole. Hepatic disease, pregnancy, breast feeding, concomitant administration of beta blockers (oral). Most important and frequent side effect is constipation. Others include headache, dizziness, ankle oedema, allergic reaction, nausea, vomiting, flushing. Tablets - 40 mg, 80 mg, 120 mg 240 mg sustained release form. Injections 5 mg in 2 ml 120 mg - 240 mg daily in divided doses or sustained release form. Intravenous dosage. 2.5 - 5 mg. Slow i.v. bolus upto 10 mg. Increased risk of bradycardia and AV block with betablockers. Serum digoxin levels may increase, risk of bradycardia with amiodarone, negative inotropism with disopyramide. Tab 40 mg (10) Rs. 5.00 -10.00 Inj 5 mg/ 2 mL (2 mL) Rs. 3.00 -4.00
Diltiazem
Antianginal, antiarrhythmic and antihypertensive. I: C/I: P/C: A/E : P/A: Dose : All types of angina, non - Q wave myocardial infarction, supraventricular tachycardia, systemic hypertension. In left ventricular failure, AV block, sick sinus syndrome, pregnancy. Hepatic and renal impairment, LV dysfunction, first degree heart block. Constipation, ankle oedema, hepatitis, manic depression, rashes, hypotension. Tablets 30 mg, 60 mg, 90 mg, 120 mg sustained release. Injection 5 mg/ mL (5 mL) 90 180 mg orally daily in divided doses to start with. This may be increased to 360 mg/day in severe cases.
164
Parenteral : D/I: Cost:
To be administered as slow IV 0.25 mg/kg or as a bolus of 10 - 12.5 mg for supraventricular tachycardia. Same as verapamil. Tab 30 mg (10) Rs. 18.00 -19.00 Inj 5 mg/mL (5 mL) Rs. 17.00 - 20.00
Nifedipine
This has antihypertensive, antianginal properties. When given sublingually it leads to rapid fall of blood pressure. I: C/I : P/C : Systemic hypertension, angina, Raynauds phenomenon. Severe aortic stenosis, severe hypotension including cardiogenic shock. May worsen angina if used alone in some patients. This drug should not to be used as monotherapy in patients after MI and unstable angina due to risk of higher mortality. In pregnant women it may cause inhibition of labour. Though negative inotropic effect is only slight, it should be used with caution in patients with heart failure. Headache, nausea, flushing, tachycardia, pedal / ankle oedema, constipation, gingival hyperplasia. Capsules and tablets - 5 mg, 10 mg, 20 mg retard tablets. 30 mg o.d. single dose. 30 mg GITS (Gastro intestinal delivery system). It is now considered prudent not to use small and frequent dose of nifedipine but to use sustained release form. Nifedipine may reduce quinidine levels, it may interact with prazosin . and cause severe hypotension. Hepatic metabolism of nifedipine may be affected by ranitidine or cimetidine. Nifedipine when given sublingually causes rapid fall of blood pressure, in hypertensive emergencies. Since this may lead to cerebrovascular insufficiency this route of administration should be used with caution. Cap 10 mg (10) Rs. 6.00 -20.00 SR Tab 20 mg (10) Rs. 10.00 165
A/E; P/A: Dose:
D/I :
Note:
Cost :
Amlodipine
I: C/I: P/C: Systemic hypertension, all types of angina pectoris. Severe aortic stenosis. Systemic hypotension. Use with caution in the elderly as its long duration of action may produce long periods of hypotension. Use with caution in hepatic dysfunction, pregnancy, lactation and fever. Pedal oedema, ankle oedema, constipation, nausea, flushing, hyperplasia of gums. Tablets / capsules 2.5 mg, 5 mg, 10 mg 5 - 10 mg daily as single dose. As for Nifedipine. It has beneficial effect in angina if combined with beta blockers. Tab 5 mg (10) Rs. 5.00 -30.00
A/E: P/A : Dose: D/I: Cost :
Felodipine
I: Systemic hypertension, angina C/I: P/C:, A/E:, D/I: Similar to Amlodipine P/A: Tablets 2.5 mg, 5 mg, 10 mg. Dose: Start with 2.5 - 5 mg daily as tablets or capsules and increase according to response upto a maximum dose of 20 mg daily. Cost: Tab 2.5 mg (10) Rs. 18.00 22.00
Nimodipine
Calcium channel blocker with particular effect in improving cerebral circulation. I: Cerebro vascular arterial spasm following subarachnoid hemorrhage. C/ I: Hypersensitivity, hypotension, lactation. P/ C: Raised intracranial pressure. A/E: Hypotension, flushing, headache, nausea. P/A; Tablet - 30 mg, Capsule - 30 mg, Injection IV 50 mL vial. Dose: 1.1 mg / hour initially as a infusion and increased to 2mg/hour after 2 hours, after subarachnoid haemorrhage to prevent neurological deficits and continue for 21 days orally 60 mg 4 hourly for 4 days. 166
1. 2. 3. 4.
Mainly these are indicated in hypertension. D/ I: Same as Nifedipine Cost: Tab 30 mg (10) I Rs. 50.00 - 60.00. Inj IV 50 mL (vial) Rs. 105.00. Other dihydropyridine drugs available in India include Nitrendipine Lacidipine Lercanidipine Cilnidipine
Vasodilator drugs
Hydralazine . I: C/I : Hypertension, parenteral use in hypertensive crisis. Dissecting aortic aneurysm, mechanical obstructive lesions like aortic stenosis, mitral stenosis, ischemic heart disease, older patients. May cause angina in ischaemic heart disease. Use with caution in lactating mothers. Lupus erythematosus like syndrome, tachycardia, fluid retention, headache, rashes, peripheral neuropathy. Tablets 25 mg Tablets 25 mg bd, increase upto 50 mg bd. Slow IV injection 5 - 10 mg over 20 min. May be repeated after 30 min. Hydralazine is not freely available at present, but has been favoured in the treatment of pregnancy induced hypertension earlier along with alpha methyldopa. Not freely available. Hypertensive crisis, to control blood pressure during anaesthesia, acute heart failure. Hepatic dysfunction, abnormalities of cyanide metabolism. Lebers optic atrophy, tobacco amblyopia, Vitamin B12 deficiency. Severe renal insufficiency, hypothyroidism, impaired cerebral circulation, elderly patients, hypothermia. 167
P/C : A/E: P/A: Dose :
Note:
Cost : I: C/I:
Sodium Nitroprusside
P/C :
A/E :
P/A: Dose:
D/I :
Note:
Cost : Clonidine I: C/I: P/C:
Tachycardia, dizziness (due to rapid fall in BP) abdominal pain, nausea, palpitation, retrosternal discomfort, cyanide toxicity. Injection 50 mg/ 5 mL 0.5 mg/kg/min to begin with increase gradually every 5 min till . the desired reduction is obtained. Average dose is 3 mg/kg/ min. Sensitivity enhanced by antihypertensives. Combination therapy with diuretics and ionotropic agents are useful in cardiac failure. Sodium nitroprusside is currently a very popular drug in producing controlled hypotension. The intravenous line should be protected from sunlight to prevent loss of efficacy Injection 50 mg/5 mL Rs. 45.00 - 130.00
Centrally acting antihypertensive drugs

Systemic hypertension. It is not recommended as the first line drug. Depression Sudden cessation of treatment with clonidine causes rebound hypertension. Use with caution in Raynauds syndrome , occlusive arterial disease and renal disease. Sedation, dry mouth, fluid retention, Raynauds phenomenon, headache, dizziness, constipation bradycardia Tablets 0.1 mg (100 mcg), 0.15 mg (150 mcg). 0.05-0.1 mg in divided doses orally Tricyclic antidepressants abolish the effect of clonidine. Beta blockers administration also not advocated concomitantly as risk of withdrawal hypertension is markedly increased. Also to be avoided if MAO inhibitors are used. Use in resistant case or where other antihypertensive drugs are contraindicated. Can be used in renal dysfunction and effective in controlling hypertensive crisis. Tab 100 mcg (10) Rs. 5.00 - 6.00
A/E:
P/A: Dose : D/I:
Note:
Cost: 168
Alpha Methyldopa
I: C/I : P/C: A/E: Systemic hypertension. This drug is especially safe in pregnancy induced hypertension. Active liver disease, depression, phaeochromocytoma, porphyria. May cause positive coombs test, sedation often troublesome. Dry mouth, diarrhoea, fluid retention, haemolytic anaemia, giddiness due to postural hypotension, sexual impotence. Tablet 250 mg Start with 250 mg bd and gradually increase depending on response upto 3 g/ day. Enhanced hypotensive effect with alcohol, anaesthetics, anti-depressants, other antihypertensives, anti-psychotics, beta blockers, calcium channel blockers, diuretics and nitrates. It is better to continue alpha methyl dopa with a diuretic as the combination is more effective and decreases the fluid retention caused by alpha methyl dopa. Tab 250 mg (10) Rs. 15.00 - 34.00
P/A: Dose: D/I:
Note :
Cost: Prazosin I: C/I: P/C:
Alpha adrenergic receptor blocking agents

Systemic Hypertension Prostate hyperplasia. Heart failure due to mechanical obstruction like aortic stenosis. May produce first dose hypotension and collapse. Withdraw diuretics if patient is already on diuretics. Reduce dose in renal impairment. Use with caution in pregnancy. The drug is preferably given at bed time. Urinary frequency, incontinence, dizziness, headache, lack of energy, nausea, postural hypotension. It may cause increase in renin levels. Tablets 1 mg, 2 mg and 5 mg (sustained release) Start with 0.5 mg h.s. If no syncope or giddiness in the morning, gradually increase dose to1 mg bd In the 169
A/E:
P/ A : Dose :
D/I:
Cost:
extended release form of prazosin containing 5 mg the first dose effect is not common. ACE inhibitors, alcohol, antidepressants, antipsychotics, anxiolytics, diuretics, betablockers and calcium channel blockers all potentiate the hypotensive action. Corticosteroids decrease the effect. Tab 2 mg (10) Rs. 38.00 - 39.00
Terazosin
I: C/I:, P/C:, A/E: P/ A : Dose : Systemic hypertension, benign prostatic hyperplasia. Similar to prazosin 1 mg, 2 mg, 5 mg tablets. Give 1 mg at h.s. gradually increase dose upto 10 mg daily. Single daily dose is enough compared to prazosin. D/I: Orthostatic hypotension potentiated by beta blockers, calcium channel blockers, diuretics. Synergistic effect with other antihypertensive drugs. Cost: Tab 2 mg (10) Rs. 60.00 151.00 DRUGS AFFECTING THE RENIN ANGIOTENSIN SYSTEM Antihypertensive, anticardiac failure, vasodilator drug. I: Systemic hypertension, congestive cardiac failure, myocardial infarction (large, anterior MI to prevent adverse remodelling.) C/I: Known hypersensitivity to ACE inhibitors, suspected neuro vascular disease, pregnancy, aortic stenosis and other LV outflow obstruction, porphyria. P/C: Reduce first dose if patient is on concomitant diuretic therapy. Watch for hyperkalemia if potassium sparing drugs are also given in renal impairment . Renal function is to be monitored before and during treatment. A/E: Persistent dry cough (most common side effect occuring in 10-20% of cases), taste alteration, blood dyscrasias (including agranulocytosis, neutropenia, aplastic anemia), thrombocytopenia, hyperkalemia, angioedema, proteinuria. P/A : Tablets 12.5 mg, 25 mg, 50 mg. 170
Captopril
Dose :
D/I:
Cost :
In hypertension. 12. 5 mg bd initialy. It may be wise to start with even lower doses of 6.25 mg bd to avoid first dose hypotension and gradually increases the dose to 25 mg tds to get the desired clinical effect. Maximum daily dose is 75 - 100 mg. In CHF start with 6.25 mg bd Gradually increase to 25 mg tds under supervision. Alcohol, NSAIDS, anaesthetics, antidepressants, levodopa and chlorpromazine potentiate the hypotension caused by ACE inhibitors. Plasma concentration of digoxin is increased, lithium excretion is decreased. Corticosteroids, oestrogen and progesterone, preparations decrease the hypotensive effect. Tab 25 mg (10) Rs. 10.00 - 49.00 Similar to captopril Similar to captopril Tablets 2.5 mg, 5 mg, 10 mg, 20 mg. Systemic hypertension - 5 mg daily initially to be increased to 10 - 20 mg daily. Maximum dose is 40 mg. ln cardiac failure dose is to be individualised. Post Ml start with 2.5 mg daily, and gradually increase to the usual maintenance dose of 5 10 mg in divided dose. Tab 2.5 mg (10) Rs. 7.00 -12.00 Similar to captopril Similar to captopril Tablets 2.5 mg, 5 mg, 10 mg. 2.5 mg daily; maintenance dose 10 - 20 mg upto a maximum dose of 40 mg single dose daily can be given. CHF: 2.5 mg daily initial dose; maintenence dose 5 -10 mg daily Post MI - 2.5-5 mg daily depending on the haemodynamic status of the patient. The drug may be 171
Enalapril
I:,C/I:,P/C: A/E:,D/I: P/A: Dose :
Cost:
Lisinopril I:, C/l;, P/C: A/E, D/I: P/A: Dose:
Cost :
discontinued after 6 weeks of the myocardial infarction if there is no heart failure. Tab 2.5 mg (10) Rs. 15.00 - 20.00 Similar to captopril Similar to captopril Capsules 1.5 mg, 2.5 mg, 5 mg. Hypertension: 1.25 mg daily increased to 2. 5 - 5 mg daily. CHF:1.25 mg initially gradually increase if required. Tab 2.5 mg (10) Rs. 40.00 - 41.00
Ramipril
I:, C/I, P/C: A/E, D/I: P/A : Dose :
Cost :
Perindopril
I:, C/I;, A/E:, P/C, D/I: Similar to captopril P/A : Dose : Cost: Tablets 2 mg, 4 mg. Start with daily dose 2 mg, increase to 4 mg daily depending on response. Tab 4 mg (10) Rs. 246.00 - 247.00
Other drugs in this group currently in use are - Fosinipril, Benazepril, Quinapril
Angiotensin II receptor antagonists

Properties are similar to ACE inhibitors but the major difference is that they do not affect the breakdown of bradykinins. The persistent cough of ACE I is thought to be bradykinin mediated. Hence these drugs may be useful in patients who have severe cough due to ACE inhibitor drugs.
Losartan
Antihypertensive : I: C/I: P/C; A/E: P/A : Systemic hypertension In pregnancy May produce hyperkalemia. Use with caution in renal artery stenosis. Giddiness, angioedema, hyperkalemia, rash. Tablets 25 mg, 50 mg.
Dose: 50 mg od Start with a lower dose of 25 mg daily in patients using diuretics or in elderly patients. 172
Drugs for Pulmonary Hypertension
D/I:
Diuretics and other antihypertensives potentiate the action of losartan, risk of hyperkalaemia with potassium sparing diuretics. NSAIDs may blunt hypotensive effect of losartan . Tab 25 mg (10) Rs, 40.00
Cost:
Newer drugs in this class includeTelmisartan, Valsartan, Olmisartan, Candesartan , Irbesartan DRUGS USED IN PULMONARY HYPERTENSION
Bosentan
Bosentan is the first of a new drug class, an endothelin receptor antagonist. I: C/I: P/C: A/E: P/A: Dose: Pulmonary arterial hypertension Pregnancy, hypersensitivity May cause elevation of AST/ALT and bilirubin, Hypersensitivity, Rash Thrombocytopenia, headache, palpitations, edema, abnormal LFTs 62.5 mg and 125 mg tablets initiated at a dose of 62.5 mg bid and then increased to the maintenance dose of 125 mg bid.
Sildenafil
selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type-5 (PDE5). I: C/I: P/C: pulmonary arterial hypertension, male erectile dysfunction co administration to patients on organic nitrates is contraindicated due to hypotensive effects patients with resting hypotension (BP <90/50), or with fluid depletion, severe left ventricular outflow obstruction, or autonomic dysfunction. epistaxis, headache, dyspepsia, insomnia, myalgia, paresthesia Tablet 20 mg 20 mg three times a day (tid) 173
A/E: P/A: Dose:
DRUGS USED IN HEART FAILURE
Digoxin
I: C/I: Heart failure; arrhythmias Hypertrophic obstructive cardiomyopathy (unless also severe heart failure); Wolff-Parkinson-White syndrome or other accessory pathway, particularly if accompanied by atrial fibrillation; ventricular tachycardia or fibrillation; intermittent complete heart block; seconddegree atrioventricular block Recent myocardial infarction; sick sinus syndrome; severe pulmonary disease; thyroid disease; elderly (reduce dose); renal impairment ; avoid hypokalaemia; avoid rapid intravenous administration (nausea and risk of arrhythmias); pregnancy ; breastfeeding Usually associated with excessive dosage and include anorexia, nausea, vomiting, diarrhoea, abdominal pain; visual disturbances, headache, fatigue, drowsiness, confusion, dizziness, delirium, hallucinations, depression; arrhythmias, heart block; rarely rash, intestinal ischaemia; gynaecomastia on long-term use; thrombocytopenia reported Injection: 250 micrograms/ml in 2-ml ampoule. 0.25 mg tablet Heart failure, orally, 11.5 mg in divided doses over 24 hours for rapid digitalization or 250 micrograms 12 times daily if digitalization less urgent; maintenance 62.5500 micrograms daily (higher dose may be divided), according to renal function and heart rate response; usual range 125250 micrograms daily (lower dose more appropriate in elderly) Emergency loading dose, by intravenous infusion over at least 2 hours, 0.751 mg Tab 0.25mg(10) Rs. 2.00-10.00 Inj 0.5mg/2ml Rs. 6.00 Infusion dose may need to be reduced if digoxin or other cardiac glycoside given in previous 2 weeks
P/C:
A/E:
P/A: Dose:
Cost: NOTE:
174
Drugs for Heart Failure
Dopamine
Dopamine hydrochloride is a complementary drug for inotropic support I: cardiogenic shock in myocardial infarction or cardiac surgery C/I: tachyarrhythmia, ventricular fibrillation; ischaemic heart disease; phaeochromocytoma; hyperthyroidism P/C: correct hypovolaemia before, and maintain blood volume during treatment; correct hypoxia, hypercapnia, and metabolic acidosis before or at same time as starting treatment; low dose in shock due to myocardial infarction; history of peripheral vascular disease (increased risk of ischaemia of extremities); breastfeeding ;elderly; A/E: nausea and vomiting; peripheral vasoconstriction; hypotension with dizziness, fainting, flushing; tachycardia, ectopic beats, palpitations, anginal pain; headache, dyspnoea; hypertension particularly in overdosage P/A: Injection: 40 mg (hydrochloride)/mL in 5-mL vial. Dose: Cardiogenic shock, by intravenous infusion into large vein, initially 25 micrograms/kg/minute; gradually increased by 510 micrograms/kg/minute according to blood pressure, cardiac output and urine output; seriously ill patients up to 2050 micrograms/kg/minute Cost: 200 mg/5mL vial Rs. 26.00
Enalapril
heart failure (with a diuretic); prevention of symptomatic heart failure in patients with left ventricular dysfunction; hypertension. C/I, P/C, A/E, P/A & Cost : Refer antihypertensive drugs Dose: Heart failure, asymptomatic left ventricular dysfunction, by mouth, initially 2.5mg daily under close medical supervision, increased over 2-4 weeks to usual maintenance dose 20mg daily in 1-2 divided doses; maximum 40mg daily. I:
Furosemide (Refer Section 14) Hydrochlorothiazide (Refer Section 14)

175
ANTI ARRHYTHMIC DRUGS
Quinidine
I: C/I: P/C: Supraventricular arrhythmias, ventricular arrhythmias. QT prolongation, AV block. Avoid intravenous administration as it may cause hypotension.Cardiac conduction abnormalities, proarrhythmia and AV block are to be looked for. Cinchonism, allergic reaction, thrombocytopenia, haemolytic anaemia, proarrhythmia. Quinidine Sulfate Tab 300 mg,Quinidine Gluconate Inj 76 mg of quinidine/ mL. Oral: 200-400 mg tds. lf necessary to be increased to 600 mg every 2-4 hrs. Start with 100 mg initially to avoid hypotension. Increases serum digoxin level. Tab 100 mg (20) Rs. 36.00 Ventricular and supraventricular arrhythmias. AV block, sinus node dysfunction, severe cardiac failure. Hepatic and renal impairment, glaucoma, heart failure, elderly patients, pregnancy. Hypotension, myocardial depression, AV block, dryness of mouth,urinary retension, blurring of vision. Capsules 100 mg, 150 mg.Tablets: 100 mg. . 100 - 150 mg 8 th hrly. Increased risk of ventricular tachycardia (Torsade de pointes) if used along with class 3 agents, diuretics and erythromycin. May worsen heart failure if used with other negative inotropic agents. Cap 100 mg (10) Rs. 60.00-61.00 Ventricular arrhythmias, atrial arrhythmias usually resistant to other drugs. Severe renal failure, heart block. Elderly patients, pregnancy, renal dysfunction, hepatic dysfunction,myasthenia. SLE like syndrome, nausea, diarrhoea, fever, myocardial depression. Capsules 250 mg; Injection 100 mg/mL.
A/E: P/A : Dose : Note : D/I: Cost:
Disopyramide
I: C/I: P/C; A /E: P/A: Dose: D/I:
Cost:
Procainamide
I: C/I: P/C; A/E; P/A: 176
Anti Arrhythmic Drugs
Dose:
D/ I:
Cost:
250 - 500 mg, initial dose 1 g followed by 500 mg 3 hrly for 24 - 48h then reduce dose to 500 mg tds. Intravenous dose 100 mg IV bolus, followed by 10 - 20 mg / min to a maximum of 1 g in the first hour. Maintenance dose is 1-4 mg/min.Due to the high incidence of adverse side effects procainamide should be given as IV infusion diluted with 5% glucose at a rate not exceeding 25-50 mg/min until the arrhythmia has been suppressed or a maximum dose of 1 g has been reached. Potentiates the action of neuromuscular blocking agents, impairs action of neostigmine and pyridostigmine. Cap 250 mg (10) Rs. 38.00 - 39.00 Inj 100 mg/mL (10 mL) Rs. 35.00 - 36.00
Lignocaine
I: C/I: P/C: A/E: P/A: Dose ; Ventricular tachycardia. S-A block, severe myocardial depression. Hypotension, renal and hepatic dysfunction, elderly patients. Paresthesia, drowsiness, confusional states (especially in old people),convulsion Injection 2%, 21.3 mg/mL. 1 mg/kg as a bolus dose upto a maximum of 100 mg, along with initiation of continuous infusion 2 mg / min which can be increased to 3 mg / min. Increased hepatic clearance in patients receiving propranolol and halothane. Routine administration of lignocaine is not recommended in acute myocardial infarction as a prophylactic for ventricular arrhythmias. Inj 2% (30 mL) Rs. 12.00 - 13.00 Ventricular arrhythmias (mainly in ventricular tachycardia.) as alternative to lignocaine in resistant cases. Sick sinus syndrome, high grade AV block, hypotension. Hepatic dysfunction, elderly patients. 177
D/I: Note:
Cost:
Mexiletine
I:
C/I: P/C:
A/E: P/A : Dose : D/I;
Cost:
Nausea, confusion (elderly patients), bradycardia, paresthesia, convulsions, ataxia, psychiatric disorders. Tablets 150 mg Injection 250 mg vials. Oral dose 150 mg 8 h with meals. 100-200mg IV over 10 minutes - 1 mg/min infusion. Phenytoin and rifampicin increase the metabolism. Diuretics decrease the action through the production of hypokalemia. Caps 150 mg (10) Rs. 195.00:Inj 250 mg (10 mL) Rs. 37.00 - 38.00 Ventricular arrhythmias, digitalis toxicity. A.V block, acute intermitent porphyria. Hepatic impairment, pregnancy Nausea, vomiting, dizziness, headache, tremor, peripheral neuropathy, ataxia, slurred speech, drug induced lupus erythematosus, gum hypertrophy, erythema multiforme, megaloblastic anaemia. 100 mg 8th hrly. Antibiotics, analgesics, amiodarone and antidepressants usually increase the plasma concentration of phenytoin. Phenytoin decreases the concentration of disopyramide, quinidine and mexiletine. Oral contraceptive effect is reduced. Mainly in refractory life threatening arrhythmias like ventricular tachycardia, atrial fibrillation in WPW syndrome and in prophylaxis of ventricular and supra ventricular arrhythmias not responding to usual line of management. Pregnancy, breast-feeding, severe bradycardia, conduction abnormalities, hypo / hyperthyroidism Check liver function tests, thyroid functions periodically. Chest X-ray should be checked before and periodically, use with caution in elderly patients and in renal dysfunction, and in bradycardia and conduction abnormality. Skin and corneal microdeposits, peripheral neuropathy,photosensitivity, pulmonary fibrosis, hepatic
Diphenyl hydantoin(Phenytoin)
I: C/I: P/C: A/E:
Dose : D/I:
Amiodarone
I:
C/I: P/C:
A/E: 178
Anti Arrhythmic Drugs
P/A: Dose:
D/I:
Note:
Cost;
enzyme elevation,haemolytic anemia, aplastic anaemia, hypo or hyperthyroidism,bradycardia, conduction abnormalities. Tablets 100 mg and 200 mg;Injection IV 50 mg / mL ampoules. 200 mg 8th hrly for the first week, 200 mg bd for the second week,100-200 mg o.d., subsequently. The dose should be the minimum effective strength in view of the marked side effects and toxicity of amiodarone. Intravenous administration 5 mg/kg over 20 min -2h by slow IV infusion. May cause hypotension if given rapidly.Alternate dose 150 mg given as bolus IV followed by 900 mg slow IV infusion for 24 hrs. Enhanced anticoagulant activity due to decreased metabolism of anticoagulants, increased action of other antiarrhythmic drugs,increased risk of severe bradycardia with beta blockers and calcium channel blockers, increased risk of arrhythmias with antidepressants, increased serum digoxin level, hypokalemia,induced by diuretics may worsen amiodarone toxicity, increased risk of hypothyroidism with lithium. Amiodarone has a half life of 30 - 110 days and the action of the drug will persist for upto 50 days after stopping treatment. Amiodarone is not to be started as a first line drug as far as possible. Tab 200 mg (10) Rs. 77.00 - 108.00;Inj:50 mg/ml. (3 ml.) Rs. 11.00 - 56.00
Sotalol
Beta blocker with antiarrhythmic activity (class 3) I: Ventricular arrhythmias, supraventricular arrhythmias including paroxysmal atrial fibrillation. C/I: AV block, congestive cardiac failure, sick sinus syndrome. P/C: Congestive heart failure, vasospastic angina, bradycardia, occlusive arterial disease, diabetes mellitus, pregnancy, breast feeding, Raynauds disease A/E: Cold peripheries, bradycardia, insomnia, bronchospasm, conduction abnormalities. 179
P/A: Dose: D/I:
Cost:
Tablets 40 mg, 80 mg . 80 - 160 mg b.d. Lower doses can be tried in certain cases. Can worsen bradycardia if combined with digoxin, verapamil,diltiazem,(can induce AV block in some cases). Masks hypoglycemia symptoms if used with hypoglycemic drugs in diabetic patients. Worsens heart failure in patients in combination with other negative inotropic agents. Tab 40 mg (10) Rs. 12.00 - 13.00
Calcium channel blockers -verapamil (Refer Section 10)

POSITIVE INOTROPIC AGENTS Positive inotropic agents are drugs that increase the contractility of the myocardium. They are useful in the treatment of patients with hypotension and congestive cardiac failure. The positive inotropic agents can be divided into: a) cardiac glycosides - digoxin b) phosphodiesterase inhibitors c) parenteral inotropic sympathomimetics.
Phosphodiesterase inhibitors
Amrinone, Milrinone, vesnarinone are drugs which have been tried in trials as positive inotropic agents.
Sympathomimetic positive inotropic drugs

The beta stimulant drugs used as positive inotropic agents include dopamine, dobutamine and isoprenaline.
Dobutamine
Synthetic sympathomimetic drug. I: Inotropic support in situations with hypotension. ln chronic refractory heart failure intermittent administration of dobutamine has been found to be effective.Compared to dopamine, dobutamine causes less increase in heart rate,lesser incidence of ventricular ectopy and reduces pulmonary capillary wedge pressure. C/I : Similar to dopamine A/ E : Hypertension, tachycardia, ventricular ectopy. P/A: Injection 50mg/4mL, 250mg/5mL, 250mg/20mL 180
Positive inotropic agents
Dose : D/I: Cost :
2.5 - 10 mcg/ kg/min adjusted according to clinical / haemodynamic response.Available as 250 mg vials. It antagonises the effect of phentolamine and prazosin. Inj 250mg/ 5mL (5mL) Rs.33500
Isoprenaline (Isoproterenol)
Sympathomimetic amine I: Hypotension associated with complete heart block, severe bradycardia. C/I : Hypertension, angina pectoris, acute left ventricular failure,halothane anaesthesia. P/C : Hyperthyroidism, coronary artery disease, diabetes mellitus. A/E; Hypotension, sweating, tremor, headache. P/A: Tablet 20mg Injection 2 mg/mL 2 mL ampoules, Inhalation 400mcg 200 metered dose Dose : 0.5 - 10 mcg/min. Available as 2 mL ampoules containing 1 mg/ mL. D/I : With digitalis glycosides and levodopa risk of cardiac arrythmia.Reduction of antianginal effects of nitrates. Cost : Tablet 20mg (10) Rs.9.00 Injection 2mg/ mL (2 mL ) Rs.6.00 Inhalation 400mcg (200 metered dose) Rs.88.00
181
SECTION 11 DERMATOLOGICAL DRUGS

SUPERFICIAL MYCOSIS Topical agents Benzoic acid + Salicylic acid (Whitfields ointment) I: A/E: P/A: Dose: Cost: Miconazole I: A/E: P/A: Dose: Mild dermatophyte infections, particularly tinea pedis and tinea corporis Irritation and burning sensation Cream or ointment: 5% + 3%. Fungal skin infections: apply twice daily until the infected skin is shed (usually at least 4 weeks) 15g Rs 23/Dermatophytosis, candidiasis, pityriasis versicolor, secondary infections caused by Gram-positive cocci occasional local irritation and burning, also contact dermatitis; discontinue if sensitization occurs 2% Cream or ointment Skin infections, apply twice daily,continuing for at least 10 days after the condition has cleared nail infections, apply 12 times daily 15g Rs 15-28/Dermatophytosis,oral,cutaneous and vaginal Candidiasis, Tinea versicolor Local Irritation Cream 1%;Lotion 1%;100 mg vaginal tablet,1% gel Dermatophytosis apply 2-3 times daily for 2-4 weeks Vaginitis:1 tablet inserted daily for 7 days Oropharyngeal candidiasis:10 mg troche of clotrimazole is allowed to dissolve in mouth 3-4 times a day;lotion/ gel is also applied. 15g Rs 19-33/-
Cost: Clotrimazole I: A/E: P/A: Dose:
Cost: Ciclopirox olamine I: Dermatophytosis,Dermatosis,Candidiasis A/E: Burning Sensation, Itching 182
Drugs for Superficial Mycosis
P/A: Cost: Ketoconazole I: A/E: P/A: Dose: Cost: Terbinafine I: A/E: P/A: Dose: Cost: Selenium sulfide I: C/I: P/C:
Cream 1% ,Topical solution 1% 15g Rs 29-44/Dermatophytosis, Deep mycosis Burning Cream 2% ,Lotion 2%,Shampoo 2% Apply twice a day 15 g cream Rs 42-49/-;Shampoo 30 ml Rs 35/Tinea infections,Pityriasis versicolor,Onychomycosis Erythema, Itching,Dryness,Irritation,Urticaria and rash Cream 1% 1-2 times daily for 2-6 weeks 10g cream Rs 49-52/Pityriasis versicolor (lotion), seborrhoeic dermatitis Children under 5 years Do not apply to damaged skin (risk of systemic toxicity); avoid contact with eyes; do not use within 48 hours of applying preparations for hair colouring, straightening, or permanent waving Local irritation, hair discoloration or loss 2.5% Suspension Pityriasis versicolor, apply lotion with a small amount of water to the entire affected area andrinse off after 10 minutes, repeat once daily for 714 days; or apply undiluted lotion at bedtime and rinse off the following morning, apply 27 times over 2 weeks; repeat course if necessary Seborrhoeic dermatitis, massage 510 ml of shampoo into wet hair and leave for 23 minutes before rinsing thoroughly; repeat twice weekly for 2 weeks,then once weekly for 2 weeks,thereafter only when needed 60 ml Rs 35/-
A/E: P/A: Dose:
Cost: Sodium thiosulfate I: Pityriasis versicolor; cyanide poisoning P/A: 20% Solution Dose: Pityriasis versicolor, apply twice daily for 4 weeks
183
Dermatological Drugs
Potassium permanganate I: Wet dressings to assist healing of suppurating superficial wounds,tropical ulcers, tinea pedis, pemphigus, impetigo P/C: Avoid occlusive dressings; irritant to mucous membranes A/E: Local irritation; skin and fabrics stained brown P/A: Condys lotion 1:4000-1:10,000 Dose: Suppurating superficial wounds and tropical ulcers, wet dressings of 1:10 000 (0.01%) solution, changed 2 or 3 times daily DEEP MYCOSIS
Systemic Antifungal Agents

Ketoconazole I: C/I: A/E: Dermatophytosis, subcutaneous and systemic mycosis, candidiasis, tinea versicolor. Hypersensitivity, Pregnancy, Lactation, Liver dysfunction. nausea,epigastric distress,vomiting,hepatitis,skin rash,gynaecomastia,loss of hair,libido menstrual irregularities Tablet 200 mg 200 mg tablet once or twice daily H2 blockers,proton pump inhibitors and antacids decrease its absorption. Tablet 200 mg (10) Rs 58-225/Dermatophytosis, systemic fungal infections, candidiasis,cryptococcal meningitis Hypersensitivity, Pregnancy, Lactation. Dose reduction in renal impairment Nausea, Abdominal pain, Vomiting, Skin rash, Diarrhoea, Head ache. Cap 50 mg, 100 mg, 150 mg, 200 mg ; 200 mg/100 ml IV Infusion Dermatophytosis 150 mg once a week for 4-6 weeks. Nail infections-longer duration (12 months) Systemic infections 200-400 mg daily for 4-12 weeks or longer
P/A: Dose D/I: Cost: Fluconazole I: C/I: P/C: A/E: P/A: Dose:
184
Drugs for Deep Mycosis
D/I: Cost: Itraconazole I: C/I: A/E: P/A: Dose:
Increase blood levels of Phenytoin, Astimizole, Cyclosporin and Warfarin Tablet 200 mg (2) Rs 76-89/Superficial and deep fungal infections Hypersensitivity, Pregnancy, Lactation, Liver dysfunction. Nausea, Vomiting, Vertigo, Skin rash, Loss of libido. Capsule 100 mg Aspergillosis: 200 mg capsule OD/BD with meals for 3 months or more Vaginal candidiasis: 200 mg capsule OD for 3 days Dermatophytosis:100-200 mg capsule OD for 7-15 days Onychomycosis: 200 mg capsule OD for 3 months Same as Ketoconazole Capsule 100 mg (4) Rs 173-230/-
D/I: Cost: Griseofulvin I: A/E: P/A: Dose:
D/I: Cost: Terbinafine I: A/E: P/A: Dose: Cost:
Dermatophytosis,not effective against candidiasis Nausea, vomiting, photosensitivity, headache, disulfiram like reaction Tab 125 mg, 250 mg 125-250mg QID with meals,duration differs with site Body skin 3 weeks Palm and sole 4-6 weeks Finger nails 4-6 months Toe nails 8-12 months Induce metabolism of Warfarin,Oral contraceptives; alcohol-disulfiram like reaction Tablet 250 mg (10) Rs 20-27/Dermatophytosis Nausea, Epigastric distress, Vomiting, Hepatitis, Skin rash, Gynaecomastia. Tab 250 mg 250 mg tab daily for 2-6 weeks in tinea infections and pityriasis versicolor; Onychomycosis 3-12 months Tablet 250 mg (7) Rs 140-280/185
ANTI-BACTERIALS FOR TOPICAL USE
Methylrosanilinium chloride (Gentian violet)

Superficial fungal and bacterial infections(staphylococci and other gram positive bacteria)furunculosis,bed sores,chronic ulcers,infected eczemas,thrush C/I: Excoriated or ulcerated lesions, broken skin, mucous membranes; porphyria A/E: Severe irritation (discontinue treatment); temporary staining of skin, permanent staining of fabrics P/A: 0.5-1% Solution Dose: Skin infections, apply 2 or 3 times daily for 3 days Neomycin sulfate + bacitracin I: Superficial bacterial infections of the skin due to staphylococci and streptococci C/I: Neonates P/C: Avoid application to substantial areas of skin or to broken skin(risk of significant systemic absorption); overgrowth of resistant organisms on prolonged use A/E: Sensitization, especially to neomycin, causing reddening and scaling; anaphylaxis reported rarely; systemic absorption leading to irreversible ototoxicity, particularly in children, the elderly, and in renal impairment P/A: Ointment: 5 mg neomycin sulfate + 250 IU bacitracin Dose: Bacterial skin infections, ADULT and CHILD over 2 years apply thin layer 3 times daily (short term use) I:
Mupirocin(Refer section 4 Anti-infectives)

Fusidic acid I: C/I: P/C: Cost: Sisomycin I: C/I: 186 Primary and secondary pyodermas caused by Gram positive organisms. Known hypersensitivity. Hepatic disease, Neonates, pregnancy lactation. 2% oint 10 gm Rs 50-62;Cream 10 gm Rs 60 Primary and secondary skin infections. Hypersensitivity to aminoglycoside antibiotics
Anti Bacterial for Topical Use
P/C: Renal impairment Cost: Cream 0.1% 15 gm Rs 37.50 Framycetin sulphate I: Skin infections, otitis externa, burns and scalds, ophthalmic infections. C/I: Hypersensitivity to aminoglycosides P/C: Ototoxicity if large areas are treated A/E: Contact dermatitis, Ototoxicity if used over large areas P/A: Impregnated gauze 1% 10 x 10 cm Rs. 15 10 x 15 cm Rs. 50
Anti-bacterials for systemic therapy(Refer section 4 Anti-infectives)

Penicillins (Crystalline and procaine penicillin) I: Syphilis, gonorrhoea, skin and soft tissue infections caused by streptococcus and staphylococcus Amoxycillin I: Skin and soft tissue infections caused by Gram positive and negative bacteria Ampicillin I: Active against Gram positive organisms sensitive to penicillin + many Gram negative bacilli. Eg. H. Influenzae, E-coli, Proteus, Salmonella and shigella. Cloxacillin I: Active against penicillinase producing staph, but not against MRSA Cephalosporins I: Bacterial skin infections, acne, rosacea, Hansens disease, UTI, chancroid, gonorrhoea, skin and soft tissue infections. ANTI-INFLAMMATORY AND ANTIPRURITIC MEDICINES Betamethasone I: Severe inflammatory skin conditions inluding contact dermatitis, atopic dermatitis (eczema), seborrhoeic dermatitis, lichen planus, psoriasis (under specialist supervision), intractable pruritus C/I: P/C:A/E: (Refer section 18 Hormones) P/A: Cream or ointment 0.05% 187
Dose:
Contact dermatitis, atopic dermatitis (eczema), lichen planus; intractable pruritus and phototoxic reactions, including polymorphic light eruptions and actinic pruritus; short-term treatment of psoriasis of the face and flexures C/I:P/C:A/E: (Refer section 18 hormones) P/A: Cream or ointment: 1% (acetate) Dose: Same as betamethasone Cost: Ointment 15 g Rs 42-45/-;Cream 25 g Rs 70/DRUGS USED FOR PSORIASIS Topical Preparations Emollients-Examples soft paraffin,liquid paraffin and creams Coal tar ointment I: C/I: P/C: P/A: Coal tar Solution: I:C/I:P/C: A/E: Dose: Psoriasis Acute onset psoriasis, Pustular and erythrodermic psoriasis Long term use may be carcinogenic, skin irritation Exetar(6% coal tar+salicylic acid 3% + sulfur 3%) 5%. Same as above Irritation, photosensitivity reactions; rarely hypersensitivity; skin, hair and fabrics discolored Psoriasis, apply 13 times daily, preferably starting with lower strength preparation. Coal tar bath, use 100 ml in bath of tepid water and soak for 1020 minutes; use once daily to once every 3 days for at least 10 baths; often alternated with ultraviolet (UVB) rays, allowing at least 24 hours between exposure and treatment with coal tar
Cost: Calamine lotion I: Dose: Hydrocortisone I:
Inflammatory skin conditions,adult and child over 2 years of age,apply small quantities to the affected area 1-2 times daily until improvement occurs,then less frequently 15 g Rs 23/Mild pruritus Mild pruritus, apply liberally 34 times daily
188
Drugs used for Psoriasis
Dithranol Moderately severe psoriasis Hypersensitivity; avoid use on face, acute eruptions, excessively inflamed areas P/C: Irritantavoid contact with eyes and healthy skin P/A: Ointment: 0.1-2%. A/E: Local irritation; discontinue use if excessive erythema or spread of lesions; conjunctivitis following contact with eyes; staining of skin,hair, and fabrics Dose: Psoriasis, initiate under medical supervision: starting with 0.1%, carefully apply to lesions only, leave in contact for 30 minutes, then wash off thoroughly; repeat application daily, gradually increasing strength to 2% and contact time to 60 minutes at weekly intervals; some 0.10.5% strength preparations are suitable for overnight use; wash hands thoroughly after use Calcipotriol (Topical vitamin D analogue) I: Plaque type psoriasis P/C: Avoid use on face,pregnancy,lactation A/E: Photosensitivity,skin irritation,erythema scaling P/A: Ointment 0.005% Cost: Ointment 30 mg Rs 998/Topical corticosteroids Hydrocortisone used on face and flexures Betamethasone scalp,hands and feet Triamcinalone acetone iodine 10 mg/ml intralesional,can be infiltrated into localized resistant psoriatic lesions or in nail folds for nail involvement. Topical Retinoids Tazarotene 0.1% gel Bexarotene 1% gel SYSTEMIC THERAPY FOR PSORIASIS Psoralen plus UVA (PUVA) I: Psoriasis,vitiligo,urticaria pigmentosa C/I: Pregnancy and lactation, hepatic diseases, Patients > 12 years, Cutaneous malignancies. 189 I: C/I:
A/E: P/A: Dose:
D/I: Cost: Methotrexate I: C/I: P/C: A/E: P/A: Dose:
A/c-erythema, pruritus, nausea, photosensitivity; C/c -cataract,freckles, malignancies, Tablet Methoxsalen10 mg; Solution-1%w/v 600 mcg/kg one and half to three hours before UVA exposure.Treatment given twice a week or increased as necessary with atleast 48 hours interval. Avoid other photosensitive drugs. Tablet 10 mg (40) Rs 59.60/Psoriasis, mycosis fungoides, pityriasis rubra pilaris, pemphigus, lupus erythematosis (Refer section 6 Anti neoplastic drugs) Tab 2.5 mg, 5 mg 7.5-15 mg/week orallyand increased by 2.5 mg every 2-4 weeks until a response is evident (maximum 25 mg/ week) Severe recalcitrant, plaque psoriasis in adult as a crisis management drug. 3mg/kg/day
Cyclosporine I:
Dose: Acitretin Synthetic retinoid for oral use. I: C/I:
P/C: A/E: P/A: Dose: Cost:
Severe forms of psoriasis Pregnancy,hypersensitivity,hyperlipidaenia,liver dysfunction, children, renal impairment, hypervitaminosis A. Avoid contact with eyes and mucosa, Avoid sunlight. and alcohol intake Drying of skin and eyes, gingivitis, erythema, alopecia, myalgia, liver damage Acitretin 10 & 25 mg (for psoriasis) 0.5-0.75mg/kg/day administered in 1 or 2 daily doses Capsule 10 mg (10) Rs 368/-
DRUGS FOR WARTS Podophyllum resin I: External anogenital warts; plantar warts C/I: Pregnancy;breastfeeding; children 190
Drugs used for Warts
P/C:
A/E:
P/A: Dose:
Cost: Benzyl benzoate I: P/C:
Avoid use on large areas, mucous membranes; very irritant to eyes;keep away from face; avoid contact with normal skin and open wounds Systemic effects resulting from cutaneous absorption include nausea, vomiting, abdominal pain and diarrhoea; also transient leucopenia and thrombocytopenia; renal failure; delayed neurotoxicity including visual and auditory hallucinations, delusions, disorientation, confusion and delirium following excessive application Solution: 10-25%. Apply carefully to warts, avoiding contact with normal tissue;rinse off after 16 hours; may be repeated at weekly intervals but no more than 4 times in all; only few warts to be treated at any one time 5mg/ml solution Rs 275.70/-
Scabicides and Pediculocides Scabies; head, body and pubic lice Do not use on inflamed or broken skin; avoid contact with eyes and mucous membranes; not recommended for children; breastfeeding (withhold during treatment) Local irritation, particularly in children Lotion: 25%. Scabies, ADULT, apply over whole body; repeat without bathing on the following day and wash off 24 hours later; a third application may be needed in some cases Pediculosis, ADULT, apply to affected area and wash off 24 hours later; further applications possibly needed after 7 and 14 days 100 ml Rs 24/Hyperkeratotic scabies not responding to topical treatment Single oral dose of 200 mcg/kg in combination with topical drugs 191
A/E: P/A: Dose:
Cost: Ivermectin I: Dose:
Permethrin I: P/C: A/E: P/A: Dose: Scabies; head and body lice Do not use on inflamed or broken skin; avoid contact with eyes;breastfeeding (withhold during reatment) local irritation; rarely rashes and oedema Cream: 5%; Lotion: 1 %( Head lice); Lotion 5% Scabies and body lice apply cream over whole body and wash off after 812 hours; if hands washed with soap within 8 hours of application, treat again; repeat application after 7 days Head lice, apply lotion to clean damp hair and rinse off after 10 minutes all family members have to be treated Pediculosis:1% lotion to be applied for 7 minutes Cream 5% 30 g Rs 37/-; Lotion 5% 30g Rs 59/-;1% cream 60g Rs 65/-
Cost:
OTHER DERMATOLOGICAL CONDITIONS ECZEMAS Topical preparations 1. Compresses Saline or potassium permanganate (1:4000 to 1:8000) I: Eczematous dermatosis 2. Antibacterial agents(Refer section 4 Anti-infective drugs) 3. Cortico steroids topical 4. Tacrolimus Calcineurin inhibitor I: Moderate/severe atopic dermatitis C/I: Infected lesions, chidren < 2 years;Immuno compromised adults, pregnancy, lactation A/E: Skin buring, pruritus, infections lymphomas, skin malignancies. P/A: Ointment 0.03%, 0.1% Cost: 0.1% 10 g Rs 28-235/Systemic drugs 1. Antihistamines 2. Systemic corticosteroids 192
Drugs for other Dermatological Conditions
PEMPHIGUS
Systemic Corticosteroids May be started with Betamethasone/Dexamethasone injection 4 mg BD To be tapered according to disease activity. May be changed to oral prednisolone as dose is tapered. In diabetics and hypertensives consider dexamethasonecyclophosphamide pulse therapy (Has to be admitted and given under close monitoring) Other Immunosuppressants In those requiring high maintenance dose of systemic steroids, consider other immunosuppressants as adjuncts: Azathioprine, Cyclophosphamide Immunomodulator drugs:Dapsone
TOXIC EPIDERMAL NECROLYSIS

Avoid suspected drugs (offending drug) and its chemically related drugs Systemic corticosteroids Use of systemic steroids is controversial, but a course of systemic steroids in the early stages may help Wet compresses in selected areas Supportive care Prophylactic antibiotics Fluid and electrolyte management (like second degree burns) Ophthalmologic care
DERMATITIS HERPETIFORMIS Gluten free diet Dapsone Dose : 100-200 mg OD orally may be required in some cases.
ERYTHEMA MULTIFORME, STEVEN JOHNSON SYNDROME Evaluate for cause and give specific treatment Avoid suspected drugs (offending drug) and its chemically related drugs Evaluate for cause and give specific treatment 193
Topical therapy Antibacterials; Corticosteroids Systemic therapy Corticosteroids;Acyclovir for recurrent Erythema Multiforme URTICARIA, ANGIOEDEMA Evaluate for the cause and give specific treatment Avoid inducing factors Symptomatic treatment includes:Antihistamines H1 receptor blocker Ketotifen Systemic corticosteroids Topical antipruritic lotions eg: Calamine lotion Danazol-Hereditary Angioneurotic oedema FIXED DRUG ERUPTION Avoid suspected drugs (offending drug) and its chemically related drugs Topical corticosteroids;Antihistamines LICHEN PLANUS Limited disease super potent topical steroid or intralesional steroid. Anti histamines Wide spread disease systemic steroid-short course. Photo therapy UVA1, PUVA, Topical PUVA Oral lesion Super potent topical steroid PITYRIASIS ROSEA Topical steroid & emollients Anti histamines ACNE VULGARIS
Topical therapy
Topical antibiotic Clindamycin, Erythromycin Benzoyl peroxide I: CI: 194 Acne, Acneform eruptions Hyper sensitivity, ulcerative lesion.
Drugs for other Dermatological Conditions
P/C: A/E: P/A: Dose: Cost: Tretinoin I: C/I: ` P/C:
Avoid contact with eyes, mucus membranes, use with caution in eczemas. Dryness, peeling, irritation, swelling & redness. Gel 2.5%, 5% Apply at night 2.5%gel 20g Rs 27-66/Acne Acute dermatitis, abrasions. Avoid contact with eyes, mucus membranes & use along with cosmetics Dryness, peeling, irritation, tightening & redness. 0.05% cream, 0.25% cream Apply at night
A/E: P/A: Dose: Adapalene P/A: 0.1% gel Dose: Apply at bed time Cost: 15 g Rs 75-86/Systemic therapy Antibiotics Moderate to severe cases Doxycycline, minocycline, erythromycin
ALOPECIA Topical
Minoxidil I: A/E: P/A: Dose: Cost: Androgenitic alopecia Local irritation, hypertrichosis, low incidence of contact dermatitis 2% solution ; 5% solution Should be continued indefinitely 2% solution Rs 135/DRUGS USED IN LEPROSY The causative organism of leprosy is the acid fast bacilli Mycobacterium leprae. It is a chronic granulumatous disease that primarily affects the peripheral nerves, skin and other organs. It is divided into multibacillary and paucibacillary type. 195
National Leprosy Eradication program Classification 1. Tuberculoid (TT) : Well defined hypopigmented anaesthetic macules and plaques with loss of hair and hypohidrosis. The lesions have dry surface. 2. Borderline Tuberculoid (BT): Hypopigmented anaesthetic macules and plaques with party well defined and partly ill defined borders. Satellite lesions present. 3. Borderline Borderline (BB): Multiple lesions. Annular, geographic, punched out and inverted saucer lesions present. Multiple nerve thickening present. 4. Borderline Lepromatous (BL): Multiple generalized asymmetric macules, papules and nodules. Bilateral asymmetrical nerve thickening. Smear positive. 5. Lepromatous (LL): Multiple generalized symmetric macules, papules and nodules. Leonine facies present. Bilateral symmetrical nerve thickening present. Smear positive 6. Indeterminate (IL): Single or multiple macules. No raised lesions. 7. Pure neuritic leprosy (PL): No skin lesions. Only nerve thickening. Dapsone I: C/I: P/C: Leprosy, Dermatitis herpetiformis, chloroquine resistant malaria, pneumocystis pneumonia in AIDs. Sulphone allergy, severe G6PD deficiency, severe anaemia, porphyria. Mild to moderate G6PD deficiency, sulphonamide allergy, moderate anaemia, cardiac and p u l m o n a r y disease, lactation and pregnancy. Hemolytic anaemia, methemoglobnemia, hepatitis, dapsone syndrome, rash, fixed drug eruption, psychosis, motor neuropathy, Stevens Johnson syndrome. Tablet 50 mg, 100 mg Paucibacillary leprosy: 100 mg daily self administered for 6 months Multibacillary leprosy: 100 mg daily self administered for 1 year Tab 50 mg (1000): Rs. 40 42/-
A/E:
P/A: Dose:
Cost: 196
Drugs forLeprosy
Rifampicin I: C/I: P/C: A/E: P/A: Dose: Cost: D/I: Clofazamine I: C/I: P/C: A/E: Leprosy, lepra reactions,vasculitis. First trimester of pregnancy, peptic ulcer, vomiting, diarrhea and steatorrhea. Hepatic and renal function tests are required. Reddish orange discoloration of body fluids, hyperpigmentation and ichtyosis of skin, gastritis and acute abdomen. Capsule 50 mg, 100 mg. Paucibacillary: Not given Multibacillary : 300 mg once monthly supervised and 50 mg daily self administered for 1 year. Capsule 50 mg (100) Rs. 113/Leprosy, Tuberculosis Sulphone First trimester of pregnancy. Hepatic and renal function tests required. Reddish discoloration of urine, hepatitis, rifampicin shock, flu like syndrome. Capsule 300 mg, 600 mg Paucibacillary : 600 mg monthly supervised for 6 months Multibacillary : 600 mg monthly supervised for 1 year 600 mg Rs. 8/- Capsule Hepatic microsomal enzyme inducer, hence numerous drug interactions reported.
P/A: Dose:
Cost:
The following drugs are given when resistance is suspected or first line drugs cannot be tolerated. Ofloxacin I: C/I: P/L: A/E: Dose: Cost: Leprosy. First trimester of pregnancy. Below 12 years of age Photosensitivity, gastritis Paucibacillary 400 mg daily 400 mg Rs. 7.50 /-Tablet 197
Minocycline I: C/I: P/C: A/E: P/A: Dose: Cost: Clarithromycin I: C/I P/C: A/E P/A Dose: Cost: Leprosy, acne vulgaris First trimester of pregnancy. Below 12 years of age Photosensitivity, bluish black pigmentation of skin Capsule 50 mg, 100 mg 100 mg daily 100 mg capsule Rs. 12/- capsule Leprosy, bacterial infections : Hepatitis Liver function tests required : Gastritis, hepatitis. : Tablets, 250 mg, 500 mg 500 mg daily Tablet 500 mg Rs. 50/-Tablet
198
SECTION 12 DIAGNOSTIC AGENTS

RADIOCONTRAST MEDIA Radiographic contrast media are needed for delineating soft tissue structures such as blood vessels, stomach, bowel loops and body cavities not otherwise visualized by standard X-ray examination. The contrast media in this group containing heavy atoms (metal or iodine) absorb a significantly different amount of X-rays than the surrounding soft tissue, thereby making the examined structures visible on radiographs. Barium sulfate is a metal salt which is used to delineate the gastrointestinal tract. It is not absorbed by the body and does not interfere with stomach or bowel secretion or produce misleading radiographic artefacts. Barium sulfate may be used in either single- or double-contrast techniques or computer assisted axial tomography. For double contrast examination gas can be introduced into the gastrointestinal tract by using suspensions of barium sulfate containing carbon dioxide or by using separate gas-producing preparations based on sodium bicarbonate. Air administered through a gastrointestinal tube can be used as an alternative to carbon dioxide to achieve a double-contrast effect. Amidotrizoates (meglumine amidotrizoate and sodium amidotrizoate) are iodinated ionic monomeric organic compounds. Both salts have been used alone in diagnostic radiography including computer-assisted axial tomography but a mixture of both is often preferred to minimize adverse effects and to improve the quality of the examination. Amidotrizoates are used in a wide range of procedures including urography and examination of the gallbladder,biliary ducts and spleen. Owing to their high osmolality and the resulting hypertonic solutions, they are associated with a high incidence of adverse effects. Radiodensity depends on iodine concentration, and osmolality depends on number of particles in a given weight of solvent. The osmolality for a given radiodensity can be reduced by using an ionic dimeric medium such as meglumine iotroxate which contains twice the number of iodine atoms in a molecule or by using a non-ionic medium such as iohexol. Low osmolality media such as iohexol are associated with a reduction in some adverse effects (see below), but they are generally more expensive. Iohexol is used for a wide range of diagnostic procedures including urography, angiography and arthrography and also in computer-assisted axial tomography. 199
Diagnostic agents
Meglumine iotroxate is excreted into the bile after intravenous administration and used for cholecystography and cholangiography. Anaphylactoid reactions to iodinated radiocontrast media are more common with ionic, high osmolality compounds. Patients with a history of asthma or allergy, drug hypersensitivity, adrenal suppression, heart disease, previous reaction to contrast media, and those receiving beta adrenoceptor antagonists (beta-blockers) are at increased risk. Non-ionic media are preferred for these patients and beta-blockers should be discontinued if possible.
Amidotrizoate
Amidotrizoates are representative iodinated ionic monomeric contrast media. Various media can serve as alternatives I: Urography, venography, operative cholangiography, splenoportography, arthrography, diskography; computer-assisted axial tomography Hypersensitivity to iodine-containing compounds History of allergy, atopy or asthma; severe hepatic impairment;renal impairment ; dehydrationcorrect fluid and electrolyte balance before administration; multiple myeloma (risk if dehydrated, may precipitate fatal renal failure); cardiac disease, hypertension, phaeochromocytoma, sickle-cell disease, hyperthyroidism, elderly,debilitated or children increased risk of adverse effects; pregnancy; breastfeeding; may interfere with thyroid-function tests; biguanides(withdraw 48 hours before administration; restart when renal function stabilized); important: because of risk of hypersensitivity reactions, adequate resuscitation facilities must be immediately available when radiographic procedures are carried out Injection: 140-420 mg iodine (as sodium or meglumine salt)/ml in 20-ml ampoule. Diagnostic radiography, ADULT and CHILD, route and dosage depend on procedure and preparation used (consult manufacturers literature) Only by specialist radiographers, according to manufacturers directions
C/I: P/C:
P/A: Dose:
ADMINISTRATION.
200
Diagnostic agents
A/E:
Nausea, vomiting, diarrhoea, metallic taste, flushing,sensations of heat, weakness, dizziness, headache, coughing, rhinitis,sweating, sneezing, lacrimation, visual disturbances, pruritus, salivary gland enlargement, pallor, cardiac disorders, haemodynamic disturbances and hypotension; disseminated intravascular coagulation; fibrinolysis and depression of blood coagulation factors; rarely, nephrotoxicity, convulsions,paralysis, coma, rigors, arrhythmias, pulmonary oedema, circulatory failure and cardiac arrest; occasionally anaphylactoid or hypersensitivity reactions;hyperthyroidism; pain on injection; extravasation may result in tissue damage, thrombophlebitis, thrombosis, venospasm and embolism
Barium sulfate
Aqueous suspension. I: Radiographic examination of the gastrointestinal tract (see notes above) C/I: Intestinal obstruction, conditions such as pyloric stenosis or lesions which predispose to obstruction; intestinal perforation or conditions with risk of perforation, such as acute ulcerative colitis, diverticulitis, or after rectal or colonic biopsy, sigmoidoscopy or radiotherapy P/C: adequate hydration after procedure to prevent severe constipation Dose: Radiographic examination of gastrointestinal tract, ADULT and CHILD,route and dosage depend on procedure and preparation used (consult manufacturers literature) ADMINISTRATION. Only by specialist radiographers, according to manufacturers directions A/E: Constipation or diarrhoea, gastrointestinal obstruction, appendicitis, abdominal cramps and bleeding; perforation of bowel resulting in peritonitis, adhesions, granulomas and high mortality rate; electrocardiographical changes may occur with rectal administration;pneumonitis or granuloma formation following accidental aspiration into lungs. 201
Diagnostic agents
Iohexol Iohexol is a representative iodinated non-ionic contrast medium. Various media can serve as alternatives I: urography, venography, angiography, ventriculography, operative cholangiography, splenoportography, arthrography, diskography; computerassisted axial tomography hypersensitivity to iodine-containing compounds history of allergy, atopy or asthma; severe hepatic impairment;renal impairment; dehydrationcorrect fluid and electrolyte balance before administration; multiple myeloma (risk if dehydrated, may precipitate fatal renal failure); cardiac disease, hypertension, phaeochromocytoma, sickle-cell disease, hyperthyroidism, elderly,debilitated or children increased risk of adverse effects; pregnancy; breastfeeding; may interfere with thyroid-function tests; biguanides(withdraw 48 hours before administration; restart when renal function stabilized); important: because of risk of hypersensitivity reactions, adequate resuscitation facilities must be immediately available when radiographic procedures are carried out Injection: 140-350 mg iodine/ml in 5-ml; 10-ml; 20-ml ampoules. Diagnostic radiography, ADULT and CHILD, route and dosage depend on procedure and preparation used (consult manufacturers literature) Only by specialist radiographers, according to manufacturers directions (see also notes above); nausea, vomiting, metallic taste,flushing, sensations of heat, weakness, dizziness, headache, coughing,rhinitis, sweating, sneezing, lacrimation, visual disturbances, pruritus, salivary gland enlargement, pallor, cardiac disorders, haemodynamic disturbances and hypotension, nephrotoxicity; rarely, convulsions, paralysis,coma, rigors, arrhythmias, pulmonary oedema, circulatory failure and cardiac arrest; occasionally anaphylactoid or hypersensitivity
C/I: P/C:
P/A : Dose:
ADMINISTRATION. A/E:
202
Diagnostic agents
reactions;hyperthyroidism; pain on injection; extravasation may result in tissue damage, thrombophlebitis, thrombosis, venospasm and embolism Meglumine iotroxate Meglumine iotroxate is a representative iodinated ionic dimeric contrast medium. Various media can serve as alternatives. It is a complementary drug I: C/I: P/C: examination of the gallbladder and biliary tract hypersensitivity to iodine-containing compounds history of allergy, atopy or asthma; severe hepatic impairment;renal impairment ;dehydrationcorrect fluid and electrolyte balance before administration; multiple myeloma (risk if dehydrated, may precipitate fatal renal failure); cardiac disease, hypertension,phaeochromocytoma, sickle-cell disease, hyperthyroidism, elderly, debilitated or children increased risk of adverse effects; pregnancy; breastfeeding; may interfere with thyroid-function tests; biguanides(withdraw 48 hours before administration; restart when renal function stabilized); important: because of risk of hypersensitivity reactions, adequate resuscitation facilities must be immediately available during radiographic proceduresSolution: 5-8 g iodine in 100-250 ml. Solution: 5-8 g iodine in 100-250 ml. Examination of gallbladder and biliary tract, by oral route ADULT 30-60mg of meglumine iotroxate in 1 litre of distilled water over at least 15 minutes(consult manufacturers literature) Only by specialist radiographers, according to manufacturers directions Nausea, vomiting, metallic taste, flushing, sensations of heat,weakness, dizziness, headache, cough, rhinitis, sweating, sneezing,lacrimation, visual disturbances, pruritus, salivary gland enlargement, pallor, cardiac disorders, haemodynamic disturbances and hypotension or hypertension; rarely, convulsions, paralysis, coma, rigors, arrhythmias,pulmonary oedema, circulatory failure and cardiac arrest; occasionally anaphylactoid 203
P/A: Dose:
ADMINISTRATION A/E:
Diagnostic agents
or hypersensitivity reactions; hyperthyroidism; pain on injection; extravasation may result in tissue damage, thrombophlebitis,thrombosis, venospasm and embolism MRI Contrast Media 1. Gadolinium DTPA 2. Gadodiamide DYES USED IN OPHTHALMOLOGY
Fluorescein Sodium
This is used to detect breaks in the corneal epithelium. Intact epithelium resists the penetration of this dye. When there is disruption of the epithelium, the cornea gets stained. I: P/C: To detect coreneal ulcers, fundus fluorescein angiography. Cross infection may develop due to contamination of the eye drops. This is avoided by using 1:25,000 phenyl mercuric nitrate as the preservative. Yellow discolouration of urine and skin (after i.v. use) for upto 24 hours. False positive Benedicts test in urine, Dyschromatopsia, Systemic effects like allergy, hypotension and shock. Iatrogenic infection of the eye. For i.v. use Solution 1%, 5%, 25% Topical use Solution 2% Not to exceed 15 mg/kg bw. TRYPAN BLUE (0.8 mg/ml), Indocyanin green, Lissamine green and Rose Bengal (both drops and strips)
A/E:
P/A: Dose: OTHER DYES :
204
SECTION 13 DISINFECTANTS AND ANTISEPTICS

Antiseptics
An antiseptic is a type of disinfectant, which destroys or inhibits growth of micro-organisms on living tissues without causing harm when applied to surfaces of the body or to exposed tissues. Some antiseptics are applied to the unbroken skin or mucous membranes, to burns and to open wounds to prevent sepsis by removing or excluding microbes from these areas. Iodine has been modified for use as an antiseptic. The iodophore, povidone iodine, is effective against bacteria, fungi, viruses, protozoa, cysts and spores and significantly reduces surgical wound infections. The solution of povidoneiodine releases iodine on contact with the skin.Chlorhexidine has a wide spectrum of bactericidal and bacteriostatic activity and is effective against both Gram-positive and Gram-negative bacteria although it is less effective against some species of Pseudomonas and Proteus and relatively inactive against mycobacteria. It is not active against bacterial spores at room temperature. Chlorhexidine is incompatible with soaps and other anionic materials, such as bicarbonates, chlorides, and phosphates, forming salts of low solubility which may precipitate out of solution.
Chlorhexidine
Solution: 5% (digluconate) for dilution. Chlorhexidine gluconate is a representative disinfectant and antiseptic. Various agents can serve as alternatives I: P/C: Antiseptic; disinfection of clean instruments Aqueous solutionssusceptible to microbial contaminationuse sterilized preparation or freshly prepared solution and avoid contamination during storage or dilution; instruments with cemented glass components (avoid preparations containing surface active agents); irritantavoid contact with middle ear, eyes, brain and meninges; not for use in body cavities; alcoholic solutions not suitable before diathermy; syringes and needles treated with chlorhexidine (rinse thoroughly with sterile water or saline before use); inactivated by cork (use glass, plastic or rubber closures); alcohol based solutions are inflammable 205
Disinfectants And Antiseptics
ADMINISTRATION.
A/E:
Antiseptic (pre-operative skin disinfection and hand washing), use 0.5% solution in alcohol (70%) or 2 or 4% detergent solution Antiseptic (wounds, burns and other skin damage), apply 0.05% aqueous Solution Disinfection of clean instruments, immerse for at least 30 minutes in 0.05% solution containing sodium nitrite 0.1% (to inhibit metal corrosion) Emergency disinfection of clean instruments, immerse for 2 minutes in 0.5% solution in alcohol (70%) DILUTION AND ADMINISTRATION. According to manufacturers directions occasional skin sensitivity and irritation
Ethanol
Solution: 70% (denatured). Ethanol is a representative disinfectant. Various agents can serve as alternatives I: P/C: disinfection of skin prior to injection, venepuncture or surgical procedures Inflammable; avoid broken skin; patients have suffered severe burns when diathermy has been preceded by application of alcoholic skin disinfectants ADMINISTRATION. Disinfection of skin, apply undiluted solution skin dryness and irritation with frequent application
A/E:
Povidone iodine
Solution: 10%. Povidone-iodine is a representative antiseptic. Various agents can serve as alternatives I: Antiseptic; skin disinfection C/I: Avoid regular or prolonged use in patients with thyroid disorders or those taking lithium; avoid regular use in neonates; avoid in very low birthweight infants P/C: pregnancy; breastfeeding ,broken skin(see below); renal impairment Large Open Wounds. The application of povidone-iodine to largewounds or severe burns may produce systemic adverse effects such as metabolic acidosis, hypernatraemia, and impairment of renal function 206
ADMINISTRATION.
Pre- and post-operative skin disinfection, ADULT and CHILD apply undiluted (see also Contraindications above) Antiseptic (minor wounds and burns), ADULT and CHILD apply twice daily (see also Contraindications above) irritation of skin and mucous membranes; may interfere with thyroid function tests; systemic effects (see under Precautions)
A/E:
Disinfectant: A disinfectant is a chemical agent, which destroys or inhibits growth of pathogenic micro-organisms in the non-sporing or vegetative state.Disinfectants do not necessarily kill all organisms but reduce them to a level,which does not harm health or the quality of perishable goods. Disinfectantsare applied to inanimate objects and materials such as instruments and surfaces to control and prevent infection. They may also be used to disinfect skin and other tissues prior to surgery (see also Antiseptics, above).Disinfection of water can be either physical or chemical methods. Physical methods include boiling, filtration and ultraviolet irradiation. Chemical methods include the use of chlorine releasing compounds, such as sodium hypochlorite, tosylchloramide sodium (chloramine), halazone, or sodium dichloroisocyanurate. Where water is not disinfected at source it may be disinfected by boiling or by chemical means for drinking, cleaning teeth andfood preparation.Chlorine is a hazardous substance. It is highly corrosive in concentrated solution and splashes can cause burns and damage the eyes. Appropriate precautions must be taken when concentrated chlorine solutions or powders are handled. The chlorinated phenolic compound, chloroxylenol, is effective against a wide range of Gram-positive bacteria. It is less effective against staphylococci and Gram-negative bacteria; it is often ineffective against Pseudomonas spp. and it is inactive against spores.The aldehyde bactericidal disinfectant, glutaral, is rapidly effective against both Gram-positive and Gram-negative bacteria. It is active against the tuberculosis bacillus, fungi such as Candida albicans, and viruses such as HIV and hepatitis B; it is slowly effective against bacterial spores. A 2% w/v aqueous alkaline (buffered to pH 8) glutaral solution can be used to sterilize heat-sensitive precleansed instruments and other equipment. 207
Chlorine base compound

Powder: (0.1% available chlorine) for solution. Chlorine releasing compounds are representative disinfectants. Various agents can serve as alternatives I: C/I: Disinfection of surfaces, equipment, water Avoid exposure of product to flame; activity diminished in presence of organic material and increasing pH (can cause release of toxic chlorine gas) Surface disinfection (minor contamination), apply solutions containing 1000 parts per million Instrument disinfection, soak in solution containing 1000 parts per million for a minimum of 15 minutes; to avoid corrosion do not soak for more than 30 minutes; rinse with sterile water DILUTION AND ADMINISTRATION. According to manufacturers directions A/E: Irritation and burning sensation on skin
ADMINISTRATION.
Chloroxylenol
Solution: 4.8%. Chloroxylenol is a representative disinfectant and antiseptic. Various agents can serve as alternatives I: P/C: Antiseptic; disinfection of instruments and surfaces Aqueous solutions should be freshly prepared; appropriate measures required to prevent contamination during storage or dilution Antiseptic (wounds and other skin damage), apply a 1 in 20 dilution of 5% concentrate in water Disinfection of instruments, use a 1 in 20 dilution of 5% concentrate in alcohol (70%) DILUTION AND ADMINISTRATION. According to manufacturers directions A/E: skin sensitivity reported
ADMINISTRATION.
208
Glutaral
Solution: 2%. I: P/C: Administration: Disinfection of clean instruments, immerse in undiluted solution for 1020 minutes; up to 3 hours may be required for certain instruments (for example bronchoscopes with possible mycobacterial contamination); rinse with sterile water or alcohol after disinfection Sterilization of clean instruments, immerse in undiluted solution for up to 10 hours; rinse with sterile water or alcohol after disinfection A/E: (occupational exposure) nausea, headache, airway obstruction, asthma, rhinitis, eye irritation and dermatitis and skin discoloration Disinfection and sterilization of instruments and surfaces Minimize occupational exposure by adequate skin protection and measures to avoid inhalation of vapour
209
SECTION 14 DIURETICS
THIAZIDE DIURETICS Hydrochlorothiazide I: Congestive cardiac failure, nephrotic syndrome, ascites, systemic hypertension. C/I: Hypvolemia, hyponatremia, moderate and severe renal impairment, Addisons disease. P/C: Hypokalemia, pregnancy, diabetes, gout, hyperlipidemia, hepatic and renal impairment, potentiates the effects of other antihypertensive drugs. A/E: Postural hypotension, rash, impotence, fatigue, cramps, diarrhoea, nausea. On prolonged use dyslipidemia, hyperuricemia, hyperglycemia and hypokalemia can occur. P/A: Tablets 25 mg, 50 mg Dose: 25 - 100 mg daily. D/I: Increase in serum lithium. NSAIDs reduce the diuretic effect. Digoxin toxicity occurs if hypokalernia is present Cost: 12.5mg (10). Rs 6/- to Rs 10/25mg (10) Rs 11/- to Rs16.80 Indapamide & Xipamide (Refer Section 10) LOOP DIURETICS Frusemide (furosemide) This is the most common loop diuretic currently in use. I: C/I: P/C: Oedematous states, oliguria due to renal failure, acute pulmonary oedema, incipient acute renal failure Severe sodium and water depletion, allergy to sulfonamide, Addisons disease. Pregnancy, severe hepatic dysfunction, hypovolemia, hypokalemia, diabetes, gout, lower urinary tract obstruction. Hypokalemia, hyponatremia, hypomagnesemia, postural hypotension, hyperuricemia, hyper glycemia, hypertriglyceredemia, tinnitus, cramps, rash.
A/E:
210
Loop Diuretics
Tablets 40 mg, 100 mg, up to 500 mg Injection 20 mg/ mL 2 mL vials Dose: Oral tablets Oedema: 40mg daily, maintenance 20-40mg daily, resistant oedema 80-120mg daily. Oliguria and renal failure : Higher doses in presence of renal failure.Initially 250mg daily may be stepped up in increments of 125-250mg up to a maximum dose of 2g.Slow intravenous injection or intramuscular injection IV rate not exceeding 4mg / min, 20- 40 mg initially, increase to 80-120 mg if necessary Child 0.5 1.5mg/ kg.May be given by intramuscular route in situations where venous access is not obtained. The onset of action is delayed when given IM Intravenous infusion 250mg over 1 h followed by 500mg in 2 h in oliguric renal failure up to lg can be repeated every 24 h. This mode enables titration of dose and is thus beneficial in acute renal failure. D/I: Furosemide potentiates antihypertensive action of other drugs, especially ACE inhibitors and alpha blockers. When administered concurrently with aminoglycosides the ototoxicity of the latter is increased. Serum lithium levels are increased. NSAIDs decrease the diuretic effect. Cost : Tab 40 mg (10) Rs25.95 Inj 10 mg /mL (20ml)(amp) Rs.28. Note: It is better to use frusemide in oedema states and thiazide diuretics in systemic hypertension For acute oliguric renal failure and in incipient renal failure, vials containing larger doses upto 250mg are available. Potassium supplements are required except in patients with renal failure.Prolonged use in chronic oedema beneficial to combine with potassium sparing diuretic Torasemide(Torsemide) Similar to Furosemide but 3 times more potent. I: P/A : Oedema and hypertension 5mg, 10mg, 20mg. 211
P/A:
Diuretics
Dose: Cost:
Hypertension 2.5-5mg OD;Oedema 5-20 mg/day;Renal failure-upto 100 mg daily 10mg (10) - Rs. 21.50.
POTASSIUM SPARING DIURETICS Spironolactone This potassium sparing diuretic is a competitive inhibitor of aldosterone. I: Oedema and ascites of cirrhosis, nephrotic syndrome and congestive heart failure. Used along with thiazides to counteract potassium losing effect. Drug of choice in primary hyperaldosteronism. C/I: Moderate and severe hyperkalemia, renal failure. P/C: Chronic hepatic or renal disease, Addisons disease, hyperkalernia. A/E: Gynecomastia, gastrointestinal side effects, impotence, menstrual irregularities, lethargy, rash, headache. P/A: Tablets 25 mg, 100 mg Dose: 25 mg 6 h upto 200 mg/ day This dose may be increased upto 400 mg / day in divided doses in selected cases. D/I: lt increases serum digoxin levels. Aspirin blocks the action of spironolactone. When NSAIDs are given concurrently with spironolactone this may lead to acute renal failure. Cost: Tab 25 mg (10) Rs. 17/-
Triamterene
I: lt is indicated in oedematous states, in combination with thiazides or loop diuretics, when potassium loss is to be minimized. Uncontrolled use may lead to hyperkalemia. Hyperkalemia, renal failure. Monitor plasma urea and potassium particularly in the elderly and in renal impairment. GI disturbances, hyperkalemia, hyponatremia, photosensitivity, renal failure. Combination tablet (Triamterene 50 mg, frusemide 20 mg). 150 - 250 mg daily, 50 mg in combination with thiazides.
C/I: P/C: A/E: P/A: Dose: 212
Osmotic Diuretics
D/I: Cost :
Increases digoxin and lithium levels. Tab Benzthiazide 25mg + Triamterene 50 mg Rs.32.50.
Amiloride
This is a potassium sparing diuretic used in combination with loop diuretics or thiazide. I: Chronic oedematous states especially for in prolonged administration. C/I: Hyperkalemia, hypersensitivity. P/C: Pregnancy, diabetes mellitus. A/E: Rash, dry mouth, GI side effects, hypokalemia, hyponatremia. P/A: Combination tablets(frusemide 40 mg and amiloride hydrochloride 5 mg) Dose: 1-2 tablet daily, preferably in the morning. Cost : Rs. 14.00. D/I: Increases lithium levels and causes lithium toxicity. ACE inhibitors increase the risk of hyperkalernia. OSMOTIC DIURETICS Mannitol Osmotic diuretics, such as mannitol , are administered in sufficiently large doses to raise the osmolarity of plasma and renal tubular fluid. Osmotic diuretics are used to reduce or prevent cerebral oedema, to reduce raised intraocular pressure or to treat disequilibrium syndrome. Mannitol is also used to control intraocular pressure during acute attacks of glaucoma. Reduction of cerebrospinal and intraocular fluid pressure occurs within 15 minutes of the start of infusion and lasts for 38 hours after the infusion has been discontinued; diuresis occurs after 13 hours.Circulatory overload due to expansion of extracellular fluid is a serious adverse effect of mannitol; as a consequence, pulmonary oedema can be precipitated in patients with diminished cardiac reserve, and acute water intoxication may occur in patients with inadequate urine flow. I: C/I: Cerebral oedema; raised intraocular pressure (emergency treatment or before surgery) Pulmonary oedema; intracranial bleeding (except during craniotomy); severe congestive heart failure; 213
Diuretics
P/C: P/A:
Dose:
A/E:
metabolic oedema with abnormal capillary fragility; severe dehydration; renal failure (unless test dose produces diuresis) monitor fluid and electrolyte balance; monitor renal function Injectable solution: 10%; 20%. Solutions containing more than mannitol 15% may crystallize during storage, crystals must be redissolved by warming solution before use and solution must not be used if any crystals remain; intravenous administration sets must have a filter; mannitol should not be administered with whole blood or passed through the same transfusion set as blood Test dose if patient oliguric or renal function is inadequate, by intravenous infusion, as a 20% solution, 200 mg/kg body weight infused over 35 minutes; repeat test dose if urine output less than 3050 ml/hour; if response inadequate after second test dose, re-evaluate patient.Raised intracranial or intraocular pressure, by intravenous infusion, as a 20% solution infused over 30 60 minutes, ADULT 0.252 g/kg; CHILD 0.51.5 g/kg Cerebral oedema, by intravenous infusion, as a 20% solution infused rapidly,ADULT and CHILD 1 g/kg body weight Fluid and electrolyte imbalance, circulatory overload, acidosis; pulmonary oedema particularly in diminished cardiac reserve; chills, fever, chest pain, dizziness, visual disturbances; hypotension or hypertension; urticaria, hypersensitivity reactions; extravasation may cause oedema, skin necrosis, thrombophlebitis;rarely, acute renal failure (large doses)
214
SECTION 15 DRUGS USED IN DENTISTRY

Generally medicines used in dentistry are the same as those in the field of medicine.This is especially true for the surgical departments in dentistry.But lot of substances are used in dentistry which finds application only in dentistry as far as medical field is concerned.
Analgesics
Aspirin I: Dose : Paracetamol I: Mild to moderate dental pain 300 600 mg. 6 8 hourly orally Mild to moderate dental pain where anti-inflammatory action is not required and following simple dental extractions 500 mg. 8 hourly Mild to moderate pain following traumatic dental extractions
Dose : Ibuprofen I:
Antibiotics generally used in Dentistry

Phenoxy methyl penicillin out patient odontogenic infections Ampicillin dentoalveolar infections Amoxycillin drug of choice for prophylaxis of infective endocarditis in patients undergoing surgical procedures Erythromycin used in patients allergic to penicillin Clindamycin useful in oral infections especially in Ludwigs angina Other drugs used. Doxycycline, Cloxacillin, Ciprofloxacin, Amoxycillin+Clavulanic acid and Ofloxacin Metronidazole gel 1% - topical dressing in periodontal conditions Tinidazole, Ornidazole are also used 215
Drugs for Dentistry
Antseptics in dental plaque and periodontal disease

Chlorhexidine antiplaque activity. Rinse twice daily for 1- 3 min with10-15ml of 0.2 % chlorhexidine solution A/E : brown staining of teeth and tongue Cetrimide or Cetylpyridinium chloride A/E : burning sensation in the mouth, bad taste, discoloration of teeth and oral ulcers Phenolic antieptics like Listerine also have antiplaque activity Other antiseptics used in mouth rinses and oral products Thymol, Sodium perborate, Hydrogen peroxide, iodine, povidone iodine,Hexachlorophene, alcohol and benzalkonium chloride
Styptics
They are local haemostatics.They arrest local bleeding following tooth extraction and other dental procedures Eg. Adrenaline 1 : 10,000 solution, Tannic acid, Gelatin foam Systemic coagulant Ethamsylate 250 500 mg. oral dose or IM / IV injection repeated every 4 6 hours ANTIFUNGAL AGENTS : Clotrimazole : oropharyngeal candidiasis 1 % mouth paint applied twice daily for 7 consecutive days Fluconazole : severe mucosal candidiasis Miconazole : oral gel used in chronic mucocutaneous and chronic hyperplastic candidiasis Miconazole cream for angular cheilitis Amphotericin B lozenges 10 mg. dissolved slowly in the mouth four times daily for 10 15 days ANTIVIRAL DRUGS Acyclovir Herpetic stomatitis 200 mg.orally five times daily for 5 days 216
Drugs for Dentistry
STEROIDS Triamcinolone in carboxy methyl cellulose paste used in recurrent apthous ulcers,lichen planus etc. Injection Dexamethasone : oral submucosal fibrosis 1.5 ml with 0.5 ml lignocaine injection bilaterally in buccal mucosa twice a week for 5 weeks Reduces salivary secretion sulphate,Glycopyrrolate Atropine
Dose : Antisialogogue
ANTIANXIETY DRUGS Alprazolam 0.25 0.5 mg. tablet one hour before procedure and the night before procedure ; sedation is minimal LOCAL ANAESTHETIC AGENTS Lignocaine hydrochloride 5% ointment/spray (10%) for suture removal,mobile deciduous teeth extraction Lignocaine hydrochloride 2 % with Adrenaline 1 : 100,000 produces good soft tissue as well as pulpal anaesthesia and reduces post extraction bleeding VITAMINS AND MINERALS Vitamin A used in diffuse leukoplakia Vitamin C used in bleeding spongy gums 500 mg. OD Vitamin E and other antioxidants used for oral submucous fibrosis,lichen planus, leukoplakia Dose of antioxidants 1 capsule thrice daily for 2 months and then once daily till conditions subside. Obtundents Decrease dental hypersensitivity eg. Clove oil,thymol,absolute alcohol Anticaries drugs: Fluoride dentrifrices
217
SECTION 16 DRUGS USED IN ENT INFECTIONS

TOPICAL MEDICATIONS
NASAL PREPARATION Local sympathomimetic decongestants Oxymetazoline, Xylometazoline I: Allergic rhinitis, vasomotor rhinitis, sinusitis. C/I : Glaucoma, rhinitis sicca, acute porphyria. P/C : Prolonged use, pregnancy and lactation, hypotension, coronary artery disease, patients on monoamine oxidase inhibitors. A/E: Slight tingling or burning sensation in nose, rebound nasal congestion. P/A: Oxymetazoline Solution 0.01 %, 0.025%, 0.05% w/ v. Xylometazoline - 0.025% w/v Nasal drops 0.05%, 0.1% w/v Cost : Oxymetazoline Rs. 26/- (10ml) Xylometazoline Rs. 20/-(10ml) Naphazoline hydrochloride I: Decongestant C/I: Glaucoma, CV diseases, diabetes mellitus, hypertension,hyperthyroidism, hypersensitivity, pregnancy, lactation and children. P/C: Stop medication and check with physician if changes in vision occur or if the condition worsens. A/E: Hyperemia, dizziness, headache, increased sweating, nausea,nervousness, decrease in body temperature, weakness and drowsiness. P/A: Nasal drops (combination) 0.025%, 0.05% w/v. Dose: 1-2 drops into each nostril 3-4 times a day. D/I: Pressor effect of naphazoline potentiated by TCAs or maprotiline.
Corticosteroid nasal spray

I: Seasonal and perennial allergic rhinitis, vasomotor rhinitis.
218
Drugs for ENT
A/E: P/A: Cost : Budesonide
Candidiasis of nose. Beclomethasone Nasal spray 50 mcg/puff (150 md) Rs. 100.25
Nasal spray 50 mcg/puff (200 md) Dose: 1 - 2 sprays into each nostril bd. Cost: Rs. 178.80 Other drugs are Mometazone,Fluticasone,Ciclesonide
Mast cell stabilizers

Sodium cromoglycate I: Allergic rhinitis. P/A: Nasal spray 2%w/v Dose: 1 spray into each nostril 4 - 6 times a day. Cost: Rs. 77.20 (20ml) AURAL PREPARATIONS These include ear drops containing antibiotics, corticosteriods, antifungal agents and ceruminolytics. Antibacterials I: C/I : P /C : A/ E : Chronic otitis media, otitis externa. Allergy to the antibiotics. Prolonged use should be avoided, aminoglycosides carry the risk of ototoxicity. Meatal sensitivitiy, development of resisitant flora, cochlear damage.On an average their use should be restricted to a total of 18 days. Chloramphenicol Ear drops 5% Cost : Rs. 7.10 (5 mL) Cost : Rs. 14.00 (10 mL) Cost : Rs. 18.00 (5 mL)
P/A: Ciprofloxacin Ear drops 0.3%w/v
Norfloxacin Ear drops 0.3% w/v Ofloxacin Ear drops 0.3% w/v
Dose : 2-3 drops 3 - 4 times daily. 219
Drugs for ENT
Gentamicin Ear drops 0.3% w/v
Cost : Rs. 7.65 (5 mL)
Corticosteroids
Betamethasone I: Eczematous inflammation, otitis externa. C/I: Infection, hypersensitivity, pregnancy, lacation. P/C: Avoid prolonged use. P/A: Ear drops 0.1%w/v Dose : 2 - 3 drops tds. Cost : Rs.8.80 (5ml) In general corticosteroid ear drops are used in combination with antibiotics.
Antifungals
Clotrimazole I: Otomycosis A/E : Occasional skin irritation or sensitivity. P/A: Ear drops 1%w/v Dose: 4 - 5 drops tds. or qds. Cost: Rs. 20/Combination of antibiotics, corticosteroids and antifungal agents are also available as ear drops. Ceruminolytics Action : I: P/A: Softening of ear wax. Hard wax filling external auditory canal. Sodium bicarbonate (5% w/v) Docusate sodium (5% w / v) Local preparation of ear drops Sodium bicarbonate 5g SYSTEMIC ANTIHISTAMINES
Chlorpheniramine Maleate
I: Dose: Cetirizine I: Allergic rhinitis, acute and chronic urticaria, atopic dermatitis,angioneurotic oedema. Adults - 4 mg tds or qds. Allergic rhinitis, chronic urticaria, allergic conjuntivitis, atopic dermatitis, pruritus, adjunct in asthma management.
220
Drugs for ENT
C/I : P/C : A/E: P/A: Dose : D/ I : Cost: Fexofenadine I: C/I: P/C: A/E: P/A: Dose: D/I : Cost:
Hypersensitivity to the drug, lactation. Pregnancy, renal impairment, elderly. Mild and transient side effects such as headache, drowsiness, agitation, dry mouth, GIT discomfort. Tablet 5 mg, 10 mg (10) Adults - 10 mg once daily Alcohol may potentiate CNS depression. Tablet 10mg (10) Rs. 20/Allergic rhinitis, chronic idiopathic urticaria Hypersensitivity, lactation Renal and hepatic impairment, pregnancy Drowsiness, headache, nausea, leucopenia Tablet 120 mg, 180 mg Allergic rhinitis - 120 mg/ day Chronic idiopathic urticaria - 180 mg/ day Erythromycin and ketaconazole increases plasma concentration of the drug. Tab 120 mg (6) Rs.9.10.
Loratidine Dose: 10mg OD Cost: Tab 10 mg (10) Rs.37/Hydroxyzine It has both antianxiety and antihistaminic activity I: C/I: P/C: A/E: P/A: Cost : Pruritus, acute and chronic urticaria and dermatosis, anxiety Pregnancy, neonates, urinary and GI obstruction. Renal impairment, lactation, peptic ulcer, BPH. (Benign Prostatic hypertrophy) Tachycardia, arrhythmias, headache, blood dyscrasias, tinnitus. Tablet 10 mg, 25 mg Injection 25 mg/mL Tab 10mg (10) Rs. 7.15/ Injection 2mg/mL (2mL) Rs. 6.50.
221
SECTION 17 GASTROINTESTINAL DRUGS

ANTACIDS AND ULCER HEALING DRUGS
Aluminium Hydroxide, Magnesium Hydroxide,Magnesium trisilicate

Antacids neutralizes gastric hydrochloric acid by forming chlorides, water and carbon dioxide. I: Peptic ulcer, gastro-oesophageal reflux, neutralization of gastric acid to protect from aspiration pneumonitis during anaesthesia,preparation of endoscopy, prophylaxis of stress ulceration. C/I: Renal insufficiency, heart failure, hypertension, young children. P/C: Antacids are considered safe as long as high doses are avoided on a long term basis. Antacids should not be given to young children (up to 6 years of age ) unlesss specifically indicated. A/E: Aluminium salts: constipation, phosphate depletion, muscle weakness, and osteoporosis. Magnesium salts:diarrhoea. P/ A: Only combinations are available. Chewable tablets, gel Dose: Aluminiumhydroxide: Tabs : 0.5-1 g qds. Magnesium hydroxide: 5 mL as milk of magnesia qds. Magnesium trisilicate: 1-2 g qds. D/I: Antacids impair the absorption of several drugs and thereby their effects are reduced. Most interaction can be avoided by taking antacids 2 hrs before or after ingestion of other drugs. The bioavailability of iron, theophylline, quinolones, tetracycline, INH, ketoconazole, ethambutol, benzodiazepines, phenothiazines, ranitidine, phenytoin, indomethacin, nitrofurantoin, fluoride, phosphate, prednisone, procainamide, atenolol and propranolol is decreased. Rate of elimination for salicylates and phenobarbital are increased. In the case of amphetamine, ephedrine, 222
Ulcer Healing Drugs
Cost:
mecamylamine,pseudoephedrine and quiniuine rate of elimination is reduced. (Combination) Gelusil tab (10)-Rs.1.81; Liquid - (170 ml) -Rs.13.50
H2 RECEPTOR ANTAGONISTS Ranitidine In general the H 2receptor antagonists and proton pump inhibitors are given in full doses for 46 weeks and thereafter at a lower doses for 1 or 2 months by which time ulcer would have healed.Cigarette smoking,alcoholism and irregular timing of food are the common causes for relapse ofthe ulcer. These should be avoided. I: Duodenal ulcer, gastric ulcer, stress ulcers and gastritis, reflux oesophagitis, Zollinger- Ellison syndrome, prophylaxis of aspiration pneumonia during anaesthesia and surgery. C/I : Known hypersensitivity to the drug. P/C: Impaired renal function, pregnancy and lactation, not recommended for children below 8 years. Exclude gastric malignancy before starting treatment. It may cause headache, dizziness and rarely hepatitis and thrombocytopenia. A/E Headache, Diarrhoea/constipation and dizziness P/A: Tablets 150 mg, 300 mg Injection 50 mg / 2 mL Dose : For ulcer healing : 150 mg bd or 300 mg at hs for 4 -5 weeks Maintenance ; 150 mg at hs for 6 months to 1 year. Zollinger-Ellison syndrome : 150 mg tds. to a maximum of 900 mg / day in divided doses. Parenteral : IM 50 mg 6 to 8 hourly IV 2 mL ampoule to 20 mL with Normal saline and inject over 5 minutes every 6 to 8h. D/ I : It does not significantly inhibit hepatic metabolism of other drugs. Cost: Tab. 150 mg (10)Rs. 6.76; Inj. 25 mg/ml(1 vial)Rs. 2.30 223
Gastrointestinal Drugs
Famotidine I:;C/I:;D/I : P/C:, A/E: P/A: Dose:
Cost :
Same as ranitidine. Same as ranitidine. Tablet 20 mg , 40 mg Injection 20 mg/2 mL Benign gastric and duodenal ulceration - 40 mg orally at hs for 4 -8 weeks Maintenance:20 mg orally at hs. Zollinger-Ellison syndrome : 20 mg every 6 h. orally Parenteral: 20 mg IV every 12 h. after dilution to 5 -10 mL with a compatible IV solution. Tab 20 mg. (10) Rs. 11.10. Inj. 20 mg/mL Rs. 2.30. PROTON PUMP INHIBITORS
Omeprazole I: Promote healing of ulcers in the stomach, duodenum and oesophagus. Patients who do not respond adequately with H2 receptor antagonists,Zollinger Ellison syndrome. Pregnancy and lactation. Exclude gastric malignancy before and during treatment. Haematological abnormalities, specifically anaemia, haematuria,urinary tract infections, nausea, occasional headache, diarrhoea,constipation, flatulence and rashes. Capsule 10 mg and 20 mg. Reflux oesophagitis: 40 mg daily for 8 weeks. Duodenal ulcer: 20 mg daily for 4 weeks. Gastric ulcer: 20 mg daily for 8 weeks. Omeprazole reduce the metabolism of diazepam phenytoin and R-isomer of warfarin. Tab 20 mg. (10) Rs. 32.40; Inj. 40 mg. (1 vial) Rs.48.00 Duodenal and benign gastric ulcer, gastro oesophageal reflux disease, particular value in patients who do not respond to H2 receptor antagonists, Zollinger - Ellison
C/I: P/C: A/E:
P/A: Dose :
D/I: Cost : Lansoprazole I:
224
Antispasmodics
syndrome. Lansoprazole has been shown to be more effective in patients with reflux oesophagitis. C/I:,P/C:,A/E:,D/I: Similar to omeprazole. P/A: Capsule 15 mg, 30 mg. Dose: 15 - 30 mg daily. Duodenal ulcer: 30 mg daily for 4 weeks. Gastric ulcer: 30 mg daily. Gastro oesophageal reflux disease(GERD) - 30 mg daily for 4 - 8weeks. D/I: Decrease the metabolism of phenytoin, diazepam and R-isomer of warfarin Cost : Tab 30 mg (10) - Rs. 45.00
Pantoprazole :
I: Same as above,particularly in bleeding peptic ulcer C/I, P/C, A/E, D/I : Similar to omeprazole Dose : Tab 20 mg. once daily orally Inj. 40 mg. for intravenous use Cost : Tab. 20 mg. (10) Rs. 18.55 Inj. 40 mg. (10 ml) Rs. 49.95
Rabeprazole
Similar to omeprazole , but has fastest acid suppression and aids in gastric mucin synthesis Dose : 10 - 20 mg. once daily Cost : Tab. 20 mg. (10) Rs. 20.25 Drugs used in H-pylori Omeprazole 20 mg(2 cap)+Amoxycillin 750 mg(2 tab)+tinidazole 500mg(2 tab) kit , 1 BD x 2 weeks ANTISPASMODICS
Dicyclomine
I: C/I: Intestinal colic, ureteric colic, biliary colic, dysmenorrhoea. Intestinal obstruction, urinary retention, glaucoma, infants below 6 months, reflux oesophagitis, liver disease, renal disease,pregnancy and lactation. Can cause respiratory arrest in infants below 1 month, exacerbation of glaucoma, exacerbation of acute urinary retention. 225
P/C :
A/ E:
P/A : Dose: D/I: Cost :
Dry mouth with difficulty in swallowing and thirst, dilatation of the pupils with loss of accomodation and sensitivity to light,increased intra ocular pressure, flushing, dry skin, bradycardia followed by tachycardia, palpitations and arrhythmias, difficulty in micturition, constipation; rarely fever, confusional states and rashes. Tablet 20 mg Injection 10mg/ mL, 20mg/ 2mL Oral: 10 - 20 mg tds. Parenteral route Adults 20 mg IM 8 h . No significant interactions Tab.20 mg. (10) - Rs. 12.00 Inj.10 mg/ml(2mL) Rs. 4.45 Intestinal, biliary and ureteric colics, spasmodic dysmenorrhoea,preparatory regimen for special radiological investigations such as hypotonic duodenography and for GI endoscopy. Intestinal obstruction, glaucoma, hepatic or renal failure, pregnancy ,and lactation. Avoid driving or operating machinery. Dry mouth, thirst, increased intraoccular pressure, flushing,palpitations followed by arrhythmias, constipation and difficulty in micturition, rashes. Tablets 10mg; Inj 20mg/mL lnjection 20mg/ mL Oral: 10 mg t.d.s Parenteral route: 10 - 20 mg IM or IV 8 h. Other anticholinergic drugs and tricyclic antidepressants and alcohol potentiates the effects of hyoscine butyl bromide. Tab 10 mg. (10) Rs. 19.53; Inj. 20 mg /ml (1ml) Rs. 9.70. ANTIEMETICS AND PROKINETICS
Hyosine butyl bromide

I:
C / I: P/C: A/E:
P/ A: Dose: D / I:
Cost :
Metoclopramide
I: Nausea and vomiting associated with Gl disorders, post surgical conditions such as postoperative gastric stasis and regurgitation,treatment with cytotoxics and
226
Antiemetics And Prokinetics
C/I: P/C: A/E:
P/A: Dose : Cost :
radiotherapy in cancer patients. As a prokinetic agent in vague gaseous dyspepsias and reflux oesophagitis. Carcinoma breast, phaeochromocytoma, extra pyramidal disease, mechanical obstruction of Gl tract. Hepatic and renal impairment, pregnancy and lactation. For the elderly and children reduce the dose Extrapyramidal symptoms such as parkinsonism, sedation, muscle dystonias, galactorrhoea and gynaecomastia. Tablet 10 mg, Injection 5mg/ mL Syrup 5 mg/ml Tab. 5 10 mg. tds; Inj. 0.3-1mg/kg slow IV or IM Tab 10 mg (10) Rs. 11.75; Inj. 5 mg/ml (2 ml vial) Rs.5.90. Nausea and vomiting associated with gastrointestinal disorders,functional dyspepsia, and motility disorders such as hypomotility,irritable bowel syndrome and others. It is used as an antiemetic in cancer chemotherapy. Pregnancy. Reduce the dose in children. Raised prolactin concentrations possibly leading to galactorrhoea and gynecomastia, acute dystonic reactions. Tablets 10mg 10 - 20 mg tds or qds. Opioid analgesics and antimuscarinics cause antagonism of the effect on GI activity. Tab 10 mg. (10 ) Rs.25.20. Nausea and vomiting associated with cancer chemotherapy and radiotherapy, post operative nausea and vomiting. Hypersensitivity, lactation. Hepatic impairment, elderly, pregnancy Constipation,diarrhoea, fever, headache are more frequent. 227
Domperidone
I:
C/I: P/C: A/E:
P/A: Dose : D/I: Cost : Ondansetron I:
C/I : P/C : A/E:
P/A : Dose:
D/I: Cost :
Tablets 4mg, 8mg,Injection 2mg/ mL in 2mL and 4mL ampoules. 8 mg slow IV give 30-45 min before chemotherapy / radiotherapy or 8 mg orally 1 - 2 h before chemo/ radiotherapy followed by 8mg orally 12h. Dexamethasone potentiates the effect of the drug. Tab 4 mg. (10) Rs. 98.44; Inj. 2 mg/ml (2 ml) Rs. 28.89
Granisetron
Similar to Ondansetron but more potent Dose : Adult : 1 -2 mg within 1 hour before start of chemotherapy 2 mg. daily in 1 2 divided doses during treatment Cost : Tab (1 mg) (8) Rs. 164.00 Inj. I mg/ml (2 ml) Rs. 30.00
Palonosetron:
Similar to above but more potent Dose : Adult : 250 mcg. As a single dose to be given over 30 seconds and 30 minutes before chemotherapy and do not repeat during 7 days P/A : Only injections
Mosapride :
( 5 HT 4 Agonist and 5 HT 3 Antagonist ) I: Gastro oesophageal reflux disease P/C : Elderly, renal impairment, hepatic impairment A/E : Diarrhoea,Dry mouth, abdominal pain,raised liver enzymes Dose : Oral - 2.5 , 5 mg. tid Cost : Tab. 2.5 mg. (10 ) Rs. 16.50 ANTI DIARRHOEALS Diarrhoea is a symptom of several different types of pathological processes affecting different parts of the alimentary tract. eg. enteritis and malabsorption affecting the small intestine; colitis affecting the large intestine;irritable bowel syndrome affecting several parts of the GIT and pancreatic cholera which is due to extra alimentary causes.The other common causes include adverse side effects of drugs, anxiety and thyrotoxicosis. Therefore the symptomatic treatment of diarrhoea by antidiarrhoeal drugs is to be decided on individual merits. In case of infective diarrhoea such as 228
Anti Diarrhoeals
gastroenteritis and dysenteries, treatment of the primary condition arrests the diarrhoea usually. ln infective diarrhoea and mal absorption states primary antidiarrhoeal agents are generally contraindicated. Specific antidiarrhoeal agents are indicated in special situations as adjuvant to primary therapy or in conditions where no other primary removable causes are detectable.
ORS : Refer to Section 26

Loperamide : I: C/I : Acute nonspecific diarrhoea, chronic diarrhoea in adults. Infective Diarrhoea, severe diarrhoea where inhibition of peristalsis is not desirable, acute pseudomembraneous enterocolitis and children < 4 years. Children upto 6 years, in geriatric patients. Allergic reaction, toxic megacolon, bloating, loss of appetite, severe abdominal pain with nausea and vomiting, dizziness, dryness of mouth. Tablets 2mg, Capsules 2 mg. 2-4 mg repeated after each loose motion, not to exceed 10 mg/day. None reported. Cap 2 mg. (10) Rs. 15.00 Tab 2 mg (100 Rs. 10.00
P/C: A/E :
P/A: Dose : D/I: Cost :
Racecadotril:
Enkephalinase inhibitor; decrease secretion of water and electrolytes I: C/I : A/E: Dose : Cost : Acute symptomatic diarrhoea renal insufficiency,pregnancy,lactation vomiting, nausea, constipation, abdominal pain, thirst, vertigo, headache 100 mg. tid upto 7 days Cap 100 mg (10) Rs. 72.00 Sachet 15mg Rs.7.00
Lactobacillus Acidophilus
This is not a primary antidiarrhoeal agent. ln conditions where the intestinal flora have been deranged as a result of antibiotic and other forms of therapy, it can be used as an adjunct to restore intestinal microbial flora and give symptomatic relief. Promotes the growth of saccharolytic flora and alter the intestinal pH so as to inhibit the growth of pathogens. 229
Used in the treatment of certain chronic diarrhoea. Only combinations are available.Dispersible tablets, capsules, sachets. Dose : 1 Capsule per day; 1 sachet b.d. Cost : Cap. (10) Rs. 16.14 LAXATIVES: These drugs are employed to relieve constipation. They act in several ways softening the faecal matter, increasing its bulk and improving intestinal motility. They are drugs which are widely sold over the counters and hence greatly misused, especially by the elders. Absolute medical indications for laxatives are only limited. These include symptomatic discomfort due to constipation occuring as the result of recumbency, febrile states, dehydration or any other causes where correction of the primary cause takes time. I: Symptomatic constipation, discomfort and anxiety due to prolonged constipation. Clearance of the loaded colon prior to contrast radiography, endoscopic procedures. In hepatic failure where bacterial action in the colon leads to excess formation of ammonia which may be absorbed. Purgatives and laxatives are employed to reduce bacterial growth in the colon. Absolute : Mechanical obstruction of the GI tract, acute surgical conditions such as perforation, haemorrhage, volvulus, paralytic ileus, etc.. Relative C/I : ln anxious subjects who are likely to develop habituation and misuse the laxatives. Irritant laxatives should be avoided during pregnancy as these may cause pelvic congestion, although abortion following therapeutic doses of laxatives is most unlikely. Similarly, these drugs should also be avoided in case of typhoid fever and in very ill cardiac patients. Laxatives used occasionally are not harmful but their repeated administration may produce gastro intestinal disturbances like spastic colitis, dyspepsia, anorexia and nausea; nutritional deficiency of calories, vitamins and minerals due to interference with their absorption; loss of fluids and electrolytes particularly potassium and calcium giving rise to hypokalemia and
I: P/ A:
C/I:
P/C :
A/E:
230
Laxatives
D/l:
osteomalacia; complete dependence on drugs and later even resistance to all the mild laxatives, due to the development of spastic colon. Laxatives and purgatives may lead to malabsorption of nutrients and drugs if used continuously
Bisacodyl
Stimulant laxative I: Constipation, prior to radiological procedures and surgery. C/I: Intestinal obstruction, children. P/C : Should not be given within 1 hour following antacid or milk. A/E: Increased intestinal motility, abdominal cramps, colonic atony,faecal impaction. P/A : Tablet 5mg,Suppositories 5mg, 10mg. Dose: 5 - 10 mg hs (adults), 5 mg hs in children or 10 mg rectal suppository in the morning. D/I: None reported. Cost : Tab 5 mg (10) Rs. 7.68;Suppository 10 mg. (5) Rs. 35.40/-
Lactulose :
Osmotic laxtive I: Constipation, hepatic encephalopathy.lts metabolite is lactic acid which can bind ammonia and inhibit its absorption. Galactosemia, intestinal obstruction Young children. Flatulence, cramps, and abdominal discomfort. Liquid 10 g/15ml For Constipation : 10 g bd.; Hepatic encephalopathy 20 - 30 g tds. Not reported. Liquid 100 mL. - Rs. 61.50
C/I : P/C : A/E: P/A : Dose : D/I: Cost:
Liquid paraffin
Emollient laxative I: C/I: P/C : Constipation. Children less than 3 years of age. Avoid prolonged use 231
A/E:
P/A: Dose : D/I :
Anal seepage of paraffin and consequent anal irritation after prolonged use. Granulomatous reactions caused by absorption of small quantities of liquid paraffin. Oral emulsion, also combinations are availableCremaffin 10 - 30 mL hs. Not reported.
Cost: Cremaffin emulsion 170 ml
Rs. 57.00
Glycerine Osmotic laxative I: Constipation P/A : Rectal suppository, rectal liquid. Dose: 3 gm for adults Cost : Rectal liquid (enema) 20 ml - Rs. 20.00 Ispaghula husk I: Relieve constipation by increasing faecal mass. C/I : Intestinal obstruction, colonic atony, faecal impaction. P/C: Adequate fluid intake should be maintained to avoid intestinal obstruction. A/E: Flatulence, abdominal distension. P/A: Powder 65 g/100g granules Dose: Adults and children over 12 years :1 measureful (5.4 g) in morning and at hs or 2 measurefuls at hs Cost : Powder 100 gm - Rs. 65 .00
Tegaserod
5HT4 partial agonist-stimulates peristaltic reflex and intestinal secretaion. Decreases visceral sensitivity. I: Chronic idiopathic constipation. IBS with constipation. C/I: Severe renal failure, Moderate to severe hepatic failure, Bowel obstruction, Hypersensitivity, Lactation. A/E: Diarrhoea, abdominal pain, nausea, flatulence, headache, migraine, MI, stroke. D/I: Reduces the dose of Digoxin Dose: Tab 2-6 mg b.i.d before meals Cost: Tab 2 mg (10) Rs. 25.00 232
Drugs Used In Inflammatory Bowel Diseases
Calcium Polycarbophil
Bulk Laxative MOA-Increases water content in stool making it easy to pass. I: Chronic idiopathic constipation, IBS C/I: Intestinal obstruction, Dysphagia P/C: Pregnancy, Breast feeding, children A/E: Chestpain, Nausea, Vomiting, Abdominal pain, Flatulence, Rectal bleeding, Intestinal obstruction. D/I: Impairs absorbtion of tetracyclines Dose 500mg in qid dose max daily dose 6 g. Should be taken with plenty of water. DRUGS USED IN INFLAMMATORY BOWEL DISEASES
Sulfasalazine: ( Sulfonamide anti-inflammatory)

I: C/I : Oral : Inflammatory bowel diseases Hypersensitivity to sulfonamide or salicylate,Porphyria < 2 years of age,Intestinal or urinary obstruction,Blood dyscrasias Hepatic and renal impairment G6 PD deficiency, Allergic bronchial asthma Anorexia , nausea, vomiting, diarrhoea, crystalluria, allergic reactions Enteric coated tablets Intially 1 2 g 4 times daily until remission occurs, Maintainance - 2 gm /day Plasma levels reduced by rifampicin and ethambutol. Interferes with absorption of folic acid Tab 500 mg (10) Rs 56.00 Local anti inflammatory action Crohns disease Chronic infection, Uncontrolled blood pressure, Chronic liver disease, osteoporosis, Glaucoma Abdominal pain, dizziness, fatique, immunosupression, back pain, acne, easy bruising pedal odema. 3 mg, 6 mg, 9 mg, Capsules should not be chewed. 233
P/C : A/E : P/A : Dose : D/I : Cost : MOA: I: P/C: A/E: P/A:
Budesonide Capsules
Steroid enemas
COMPOUNDs Hydrocortisone, Dexamethasone, Betamethasone, Budesonide, Methyl prednisolone, Prednisolone, Triamcinolone, MOA: Local Anti inflammatory I: Crohns disease, Ulcerative colitis
Balsalazide
MOA: I: C/I: A/E: Delivered directly to colon where it is enzymatically cleaved to 5-ASA which is the active component. Treatment of ulcerative colitis (mild to moderate) and maintenance of remission Renal impairment, pregnancy, lactation. Diarrhoea, hypersensitivity rare side effects include pancreatitis, hepatitis, fibrosing alveolitis, agranulocytosis, aplastic anemia, interstitial nephritis, myocarditis, pericarditis, SLE, Steven Johnson syndrome. 2.25 g tid (max 6.75g/day) in acute attacks for maintenance 1.5 g bid adjusted according to response Capsule 750 mg (9) Rs. 87.70. Treatment of IBD Hypersensitivity, severe impaired renal or hepatic function. Abdominal pain, flu, diarrhea, hypersensitivity, constipation, pancreatitis, hepatitis, fibrosing alveolitis, agranulocytosis, aplastic anemia, interstitial nephritis, myocarditis, peripheral neuropathy, Steven Johnson syndrome. Oral 2.4 g/day in divided doses, maintenance 1.2-2.4 g/day in divided doses., Rectal -0.75 g -3 g as suppositories or 1.2 g daily as enema Drug interaction should not be given with lactulose or other drugs which lower PH as they prevent drug release. Tab. 400mg (10) Rs. 58.50. Chimeric monoclonal antibody against TNF alpha Fistulising Crohns disease, Ulcerative colitis
Dose: Cost :
Mesalazine
I: C/L: A/E:
Dose:
D/I:
Cost :
Infliximab
MOA: I: 234
Drugs Used In Gall Stones and Heamorrhoids
C/I:
P/C: A/E:
Dose:
Untreated chronic infection TB, Moderate to severe congestive cardiac failure, known hypersensitivity to murine proteins or any other component of the drugs. Mild heart failure, seizures, Renal or hepatic failure, Pregnancy and breast feeding. Infection, fever, fatigue, muscle weakness agranulocytosis, hypersensitivity, lupus like symptoms, steven Johnson syndrome, toxic epidermal necrolysis. Infliximab is administered as a single dose for fistulizing crohns disease, the dose is 5 mg/kg followed by additional doses of 5 mg/kg two and six week after the first dose. DRUGS USED IN GALL STONES
Chenodeoxycholic acid
I: C/l: Gallstone disease. Pregnancy, lactation, hypersensitivity, atherosclerosis, biliary cirrhosis, pancreatitis, cholecysti tis, hepatic impairment. Determination of hepatic function and ultrasonogram is advised prior to treatment. Serum cholesterol concentration determination recommended at 6 month interval during therapy. Diarrhoea, indigestion, loss of appetite, nausea, vomiting, stomach cramps. Capsule 250 mg 250 mg/day taken with food or milk in the morning and at night. Antacids, colestipol, cholestyramine decrease the absorption of the drug. Clofibrate, oestrogens, neomycin or progestins increase cholesterol saturation of bile thereby decrease the effect of chenodeoxycholic acid. Tab 250 mg (10) Rs. 85.00 90.00 Gallstone disease, biliary cirrhosis, chronic hepatitis and cystic fibrosis. P/C :A/E :D/I: Same as for chenodeoxycholic acid. 235
P/C ;
A/E: P/A : Dose : D/I :
Cost : I: C/I:
Ursodeoxycholic acid
P/A : Dose :
Tablet 150 mg 8 - 10 mg/kg/day in divided doses, taken with meals.
ANTIHAEMORRHOIDAL DRUGS
Haemorrhoids are to be treated surgically for complete relief.Symptomatic treatment for constipation, local pain, discomfort, inflammation are managed medically. A mild laxative such as liquid paraffin or bulk laxative such as Ispaghula helps to soften the faeces.Inflammation is to be treated with antibacterial agents such as Ciprofloxacin or Amoxicillin. Pain relief is obtained by a NSAID such as diclofenac or Ibuprofen P/A : Cost : Anovate to be applied twice a day once following defaecation and once at bed time . Anovate 15 g - Rs. 9.70; 20 gms - Rs.49.56; Shield 15 g Rs 45 .00
236
SECTION 18 HORMONES AND OTHER ENDOCRINE DRUGS

ADRENAL HORMONES AND SYNTHETIC SUBSTANCES The adrenal hormones are steroids synthesized from cholestrerol derived from the diet. The main groups of hormones are glucocorticoids (cortisol), mineralocorticoids (aldosterone) and adrenal androgens. (dehydroepiandrosterone) each produced in a specific zone of the cortex. At present all the available adrenal hormones are synthetic.
Glucocoricoids
Short acting Hydrocortisone Intermediate acting Prednisolone Methyl Prednisolone Triamcinolone Long Acting Betamethasone Dexamethasone Mineralocorticoids Deoxycorticosterone acetate Fludrocortisone
Prednisolone
I: C/I : P/C : Suppression of inflammatory and allergic disorders. asthma ,immunosuppression, rheumatic disease. Systemic infection; avoid live virus vaccines in those receiving immunosuppressive doses Adrenal suppression, children and adolescents, elderly; frequent monitoring required if history of tuberculosis, hypertension,myocardial infarction, congestive heart failure, liver failure, impairment, diabetes mellitus, osteoporosis, glaucoma, epilepsy,ulcer, hypothyroidism, history of steroid myopathy; pregnancy and breast feeding, avoid sudden withdrawal. 237
Hormones and other endocrine drugs
A/E :
P/A: DOSE : CHILD -
COST :
GI disturbances, acute pancreatitis, oesophageal ulceration and candidiasis; osteoporosis, vertebral and long bone fractures, adrenal suppression, menstrual irregularities, Cushings syndrome, hirsutism, weight gain, negative nitrogen and calcium balance, increased susceptibility to infection; neuropsychiatric effects, aggravation of epilepsy; glaucoma; fluid and electrolyte disturbance, leucocytosis, hypersensitivity reactions, thromboembolism. Injection, Tablet(5mg,10mg,20mg,40mg), Suspension, Eye Drops, Syrup ADULT - Oral, initially, upto 10-20mg daily (upto 60mg in severe disease), maintenance, 2.5-15mg daily usually. Juvenile arthritis: oral, upto 2mg/kg once daily or on alternate days. Renal transplant immunosuppression: oral, 10mg/ m2twice daily, reducing to 10mg/m2 on alternate days over a period of 3-12 months. Tab-5mg (10) Rs 3-5 ,Tab-10 mg(10) Rs 14.72;Inj 500mg vial Rs 565-630;Eye Drops 5 ml 1% - Rs 30 Suppression of inflammatory and allergic disorders, cerebral oedema,bronchial asthma, certain types of glomerulonephritis, multiple sclerosis rheumatic disease. As for prednisolone As for prednisolone. As for prednisolone Tab-4mg;Injection (as acetate), 40mg/ml,lml & 2ml Injection (as sodium succinate), 40mg, 125mg, 500mg, 1 g (powder reconstitution). ADULT: Intensive or emergency therapy: I.M/I.V as sodium succinate,10-500mg daily. Graft rejection:IV upto 1g for 3 days. Intra-articular injection: as acetate, 4 -80mg according to size of joint. CHILD: Juvenile arthritis: IM as sodium succinate, 30mg/kg daily single dose for 3 days, max.1gm/day
Methylprednisolone
I:
C/I : P/C : A/E : P/A:
DOSE :
238
Adrenal Hormones And Synthetic Substances
Cost: I: C/I : P/C : A/E : P/A: DOSE :
Graft rejection: IV, as sodium succinate, 10-20mg/kg as a single dose for 3 days, max. lg/day. Tab 4 mg (10)Rs 11.85/Suppression of inflammatory and allergic disorders, congenital adrenal hyperplasia and cerebral oedema. As for prednisolone As for predmsolone As for prednisolone Tab ,inj,drops, ADULT :I.M/lV 4-20mg (betamethasone) repeated upto 4 times in 24 hours. CHILD : Slow IV upto 1 year, Img; I-5 years, 2mg; 6-I2 years, 4mg repeated 3-4 times in 24 hours if necessary. Tab 0.5mg(10) Rs-3-5/- inj 4mg Rs 3-8/- drops ,0.5mg /5 ml (15 ml )Rs 10.28/Suppression of inflammatory and allergic disorders. As for prednisolone As for prednisolone As for prednisolone Tablets, 6mg, 30mg. ADULT: Oral, Acute disorders, initially up to 120 mg daily; maintenance 3-18 mg daily. CHILD: Oral, 0.251.5 mg/kg daily. Suppression of inflammatory and allergic disorders, shock, cerebral . oedema and diagnosis of Cushings disease. As for prednisolone As for prednisolone As for prednisolone Tablets, 0.5mg ;Injection (as phosphate), 4mg/ml, 2ml. ADULT Oral, 0.5-10mg daily in divided doses. IV/IM initially 0.5-20mg (as dexamethasone phosphate).In cerebral oedema: (as dexamethasone phosphate), 10mg initially by IV; then 4mg by I.M every 239
Betamethasone Sodium Phosphate
Cost:
Deflazacort
I: C/I : P/C : A/E : P/A : DOSE :
Dexamethasone
I:
C/I : P/C: A/E : P/A : DOSE :
Note: COST: I: C/I: P/C: A/E: P/A: Dose :
6 hours as required for 2-10 days.In severe shock: (as dexamethasone phosphate), IM 2-6mg/kg repeated after 2-6 hours if necessary.CHILD: IV/IM, 250500mcg/kg (as dexamethasone phosphate) once daily. Dexamethasone lmg=Dexamethasone phosphate 1.2mg = Dexamethasone sodium phosphate 1.3mg. 0.5 mg(10) Rs 2-4 ;Inj 4 mg/ml (2 ml) Rs 7-11; Adrenocortical insufficiency, supression of inflammatory and allergic disorders, shock and rheumatic disease. As for prednisolone As for prednisolone As for prednisolone Injection, 25mg/ml, 5ml vials. ADULT: Intra-articular,(as acetate), 5-50mg depending on size of joint. CHILD : Replacement therapy, oral, 4mg/m2, 3 times a day. Adrenocortical insufficiency, shock, hypersensitivity reactions(anaphylactic shock and angioedema), acute severe asthma. As for prednisolone As for prednisolone As for Prednisolone Tablets (as hydrocortisone), 5mg, 10mg, 20mg. Injection (as sodium succinate), 100mg/vial (powder for reconstitution). ADULT: As hydrocortisone, I.M/IV 100-500mg 3-4 times in 24 hours ;or as required. Oral, 4mg/m2 three times daily.Slow IV upto 1 year 25mg; 1-5 years, 50mg; 6-12 years 100mg. 100mg vial Rs 32- 60/Suppression of inflammatory and allergic disorders. As for prednisolone As for prednisolone, high doses may cause proximal myopathy, avoid in chronic therapy. As for prednisolone
Hydrocortisone acetate
Hydrocortisone Sodium Succinate

I:
C/I: P/C: A/E: P/A:
DOSE : CHILD: Cost : I: C/I : P/C : A/E : 240
Triamcinolone Acetonide
Adrenal Hormones And Synthetic Substances
P/A : DOSE :
Cost :
Tab- 4mg; Injection, 10mg/ml,40mg/ml, lml vials. ADULT: Deep I.M, 40mg for depot effect, repeated at intervals according to patients response, max.single dose 100mg.Intra-articular, 2.5-40mg depending on size of the joint. CHILD: I-18 years: Intra-articular, Img/kg (large joints); max. 40mg;10.5mg/kg (smaller joints), max. 20mg. Tab 4 mg (10) Rs 19/-; Inj 10mg/mL Rs 24.40/-
Replacement therapy for adrenocortical insufficiency

Acute Hydrocortisone or Dexamethasone are given IV 1st as bolus injection then as infusion along with Isotonic saline and Glucose infusion. Chronic(Addisons disease) Hydrocortisone : 20 - 30 mg /day with food;15 to 20 mg morning (8.00 am);5 to 10 mg evening (4.00 pm) Mineralocorticoid 0.05 to 0.1 mg of fludrocortisone orally daily. Recommended sodium Intake = 3 - 4 g/ day. Special requirements 1. During times of stress like intercurrent illness, surgery or dental extraction the dose of glucocorticoid is increased to 75 - 150 mg/day. 2. Increase the dose of fludrocortisone and add salt during periods of strenuous excercise with sweating, extremely hot weather and with gastrointestinal upset. 3. After the stress the increased doses are tapered by 20 - 30 % daily. 4. Parenteral mineralocorticoid administration is unnecessary, at hydrocortisone doses > 100 mg. Congenital adrenal hyperplasia Tab Hydrocortisone 0.6 mg/kg daily in divided doses round the clock to maintain feedback suppression of pituitary Metyrapone Metyrapone is a competitive inhibitor of 11 alfa hydroxylation in the adrenal cortex,which causes increased synthesis and release of cortisol precursors. I: Differential diagnosis of ACTH - dependent Cushings syndrome, management of Cushings syndrome, 241
C/I : P/C : A/E:
P/A: Dose :
D/I:
Cost:
resistant oedema due to increased aldosterone secretion in cirrhosis, nephrosis and congestive heart failure Adrenocortical insufficiency, pregnancy and breast feeding. Gross hypopituitarism, hypertension on long term administration, hyperthyroidism or hepatic impairment. Nausea, vomiting, dizziness, headache, hypotension, sedation, abdominal pain, allergic skin reactions, hypoadrenalism, hirsutism. Tablet 250 mg;Capsule 250 mg. 1. Differential diagnosis of ACTH - dependent Cushings syndrome - 750 mg every 4 hrs for 6 doses. 2. Management of Cushings syndrome : 0.25 - 6 g daily. 3. Resistant oedema due to increased aldosterone secretion in cirrhosis, nephrosis and congestive heart failure - 3 g daily in divided doses. Phenytoin increases metabolism of metyrapone. Therefore double dose of metyrapone must be given. Metyrapone increases metabolic clearance rate of hydrocortisone. Not freely available. SEX HORMONES
Androgens
Testosterone and its esters I: Primary and secondary hypogonadism, breast cancer, delayed puberty and impotence. C /I: Breast cancer in men, prostate cancer, hypercalcemia, pregnancy, nephrosis. P/C: Cardiac, renal and hepatic impairment, elderly, ischemic heart disease, hypertension, epilepsy, migraine. A/E: Headache, depression, sodium retention with oedema,, hypercalcemia, prostate cancer, seborrhoea, acne, premature closure of epiphysis, suppression of spermatogenesis. P/A: Testosterone Capsule 40 mg Injection 25mg, 50 mg, 100 mg and 250 mg. 242
Antiandrogens
Dose:
D/I:
Ointment 2 % w/w, 5 % w/w Patch 4 mg Fluoxymesterone Tablet 2 mg, 5 mg, 10 mg Methyl testosterone Tablet 10mg, 25mg; Capsules 10 mg 25 - 50 mg i.m. every 1 - 2 weeks for 6 - 8 weeks. Androgen deficiency : 120 160 mg/day for 2 - 3 weeks. Potentiates anticoagulants, and oral hypoglycemic agents. Rifampicin and phenobarbitone may increase the rate of metabolism of testosterone.
Antiandrogens
Finasteride I: C/I: P / C: A/ E: P/A: Dose: D/ I: Cost: Danazol I: C/I : Endometriosis, benign breast disorders, menorrhagia and gynaecomastia. Thromboembolic disorder, marked hepatic, renal or cardiac dysfunction,undiagnosed genital bleeding, androgen dependent tumours, pregnancy;breastfeeding; porphyria. Cardiac, hepatic or renal impairment, elderly, polycythaemia, migraine,epilepsy, diabetes, hypertension, lipoprotein disorder; history of thrombosis or thromboembolic disease. Nausea, dizziness, skin reactions, photosensitivity and exfoliative dermatitis, nervousness, changes in libido, 243 Benign prostate hyperplasia, acne and hirsutism in females, male pattern baldness Hypersensitivity, pregnancy, lactation and neonates. Obstructive uropathy, prostate cancer. Impotence, decreased libido and ejaculation, breast tenderness and enlargement, hypersensitivity reactions Tablet 1mg;5 mg . 5 mg o.d.review after 6 months; 1mg for male pattern baldness Increases clearance of theophylline, half-life of aminophylline may be reduced. Tab 5 mg (10) Rs.105/-;Tab 1 mg (10) Rs.38/-
P/C :
A/E :
vertigo, weight gain; menstrual disturbances, vaginal dryness, flushing, reduction in breast size; hair loss; androgenic effects; blood disorders; benign intracranial hypertension; rarely cholestatic jaundice, pancreatitis. P/A: Capsules, 50mg, 100mg, 200mg. Dose : ADULT : Endometriosis: oral, 200-800mg daily upto 4 divided doses, for 3-6 months (upto 9 months in some cases). Benign breast disorders: oral, initial, 100-400mg daily in 2 divided doses,adjusted according to response and continued for 3-6 months.Menorrhagia: oral, 200mg daily, usually for 3 months.Gynaecomastia: oral, 400mg daily upto 4 divided doses for 6 months(adolescents, 200mg daily, increased to 400mg daily if no response after 2 months). Flutamide Nonsteroidal drug having specific anti androgen effect. I: C /I: P/C: A/E: P/A: Dose: D/I: Cost: Advanced prostate cancer. Hypersensitivity, pregnancy. Cardiac disease, monitor hepatic function. Gynaecomastia, nausea, vomiting, diarrhoea, increased appetite insomnia, tiredness. Tablet 250mg 250 mg t.d.s. . Increased prothrombin time in patients on long-term warfarin treatment. Tab 250 mg (10) Rs. 100.25/-
CONTRACEPTIVES (REFER SECTION 24) OESTROGENS AND ANTIOESTROGENS
Oestrogens
Hormone Replacement Therapy (HRT) I: Hormone replacement therapy, for inducing secondary sexual characters in hypogonadism; for contraception. C/I: Pregnancy, oestrogen depended cancer, thrombophlebitis, thromboembolism, liver disease, breast feeding and undiagnosed vaginal bleeding. P/C: Unopposed exposure to oestrogens pre dispose to cystic hyperplasia of the endometrium and endometrial 244
Oestrogens And AntiOestrogens
A/E: P/A : Dose : Ethinyl oestradiol P/A :
cancer, migraine, fibro cystic disease of heart, thromboembolism and precipitate porphyria. Nausea, vomiting, breast tenderness, weight gain, cholestatic jaundice, headache, depression. Conjugated oestrogen Tablet 0.625 mg, 1.25 mg Injection 25 mg vial 0.625 - 1.25 mg daily
Tablet 0.01 mg, 0.02 mg, 0.05 mg, 1 mg Injection 10 mg / mL Patch 25 mcg, 50 mcg, 100 mcg. , Combination preparation with other derivatives are also available. Dose : Menopausal symptoms - 10 to 20 mcg daily. Hormone deficiency - 10 to 50 mcg daily. Contraception - 20 to 50 mcg daily depending on preparation. Cost: Tab 0.01 mg (10) Rs.13.50/Conjugated Oestrogens I: Menopausal osteoporosis,primary ovarian failure,HRT C/I: Undiagnosed vaginal bleeding;Hypersensitivity to oestrogens; thrombophlebitis; liver disease; pregnancy; carcinoma breast; oestrogen dependent tumours P/C : Asthma, epilepsy, migraine, diabetes, cardiac or renal dysfunction,increased risk of endometrial carcinoma; may cause premature closure of epiphyses in young children. A/E : Nausea and vomiting, abdominal cramps and bleeding, weight changes,breast enlargement and tenderness, premenstrual like syndrome, sodium and fluid retention, changes in liver function, cholestatic jaundice, rashes,changes in libido, depression, headache, migraine, dizziness, contact lenses may irritate. P/A : Sugar coated tablets, 0.625mg.Cream, 0.625mg/ 1 g, 42.5g. 245
Dose :
ADULT: Postmenopausal osteoporosis: oral, 0.3-1.25mg daily (usually 0.625mg) along with progestogen for part of the cycle.ie Primary ovarian failure: oral, 1.25mg daily.Prostatic carcinoma: oral, 1.25-2.5mg 3 times daily.
Tibolone It is a synthetic preparation with oestrogen and progestogen activity with mild androgenic activity. I: Menopausal syndrome;Delayed puberty in girls C/I: Hormone dependent tumors, history of thromboembolism, severe liver disease, pregnancy, history of cardio vascular or cerebrovascular disease, premenopausal women. P/C: Renal impairment, epilepsy, migraine, diabetes mellitus and hypercholestrolemia. A/E: Weight gain, ankle edema, abdominal pain, gastrointestinal disturbances, arthralgia. myalgia, rash, pruritis. P/A: Tablet 2.5 mg Dose: 2.5 mg o.d. D/I: Sensitivity to anticoagulants increased, enzyme inducers like phenytoin, carbamazepine and rifampicin, accelerate, tibolone metabolism. Insulin or oral hypoglycemic requirement increased in diabetics Cost: Tab 2.5 mg (28) Rs.990/-
Antioestrogen
Raloxifene I: C/I : Treatment and prevention of postmenopausal osteoporosis. History of venous thromboembolism, undiagnosed uterine bleeding.Endometrial cancer, hepatic impairment, cholestasis, severe renal impairment; pregnancy and breast-feeding. Risk factors for venous thromboembolism [discontinue if prolonged immobilisation]; breast cancer; history of oestrogen-induced hypertriglyceridaemia [monitor serum triglycerides].
P/C:
246
Progestins And Antiprogestins
A/E :
P/A : Dose : Cost:
Venous thromboembolism, thrombophlebitis, hot flushes, leg cramps,peripheral oedema, influenza-like symptoms; rarely rashes, GI disturbances, hypotension, headache including migraine, breast discomfort. Tablet, 60mg. ADULT: Oral, 60mg once daily. Tablet, 60mg (10)Rs 48 -106/PROGESTINS AND ANTIPROGESTINS
Progestins
These are important female hormone concerned with reproduction. Natural Progestins Progesterone I: Progesterones are widely use for the treatment of endometriosis, menorrhagia, severe dysmenorrhoea, premenstrual tension and for habitual abortions. Progesterone is also used as part of hormone replacement therapy in women with uterus and as a part of contraceptive medication. C/I: Pregnancy, lactation, thromboembolism, hormone dependent carcinoma, incomplete abortion, liver diseases. P/C: Use with caution in hypertension, mental depression, renal diseases, diabetes, asthma, epilepsy and migraine. A/E : Gl distrubances, acne, oedema, weight gain, changes in libido, altered menstrual cycle, virilization of female foetus, congenital abnormalities. Sterile abscess with IM injection, anal soreness and flatulance with rectal administration, thromboembolic disorders and possible foreign body carcinogenesis with intradermal implants. P/A: Capsule 100 mg Dose : Individualised dosing by physician. D/ I: Decreases effect of tricyclic antidepressants, hypoglycemic agents and anticoagulants. Cost : Cap 100 mg (10) Rs. 74.90 - 105.00/Synthetic Progestins Dehydrogesterone, Medroxy Progesterone Acetate, Norethisterone, Hydroxyprogesterone caproate 247
I:C/I:P/C:A/E:D/I : Same as for progesterone. P/A: Dehydrogesterone Tablet 5 mg Medroxyprogesterone Tablet 2.5 mg, 5 mg and 10 mg; Injection 150 mg/mL Norethisterone Tablet 1 mg and 5 mg; lnjection 200 mg/ml Hydroxyprogesterone: Injection 500 mg/mL in 1 and 2 mL ampoules Dose: Endometriosis , Norethisterone 10 25 mg daily for 49 months; Medroxyprogesterone oral 10 mg 3 times daily for 90 consecutive days beginning on day 1 of the cycle;Menorrhagia 2.5-10 mg daily for 5-10 days starting on 16-21st day of cycle,repeat for 2 cycles and 3 cycles in secondary amenorrhoea. Cost: Medroxyprogesterone acetate;Tab 2.5mg (10) Rs. 13.00 18.00 Tab 5mg (10) Rs. 28.00 43.00 Norethisterone:Tab 5 mg (10) Rs. 39.00 50.00 Inj 200 mg (1mL) Rs. 126.00
OVULATION INDUCERS(Refer Section 24) INSULINS AND OTHER ANTIDIABETIC DRUGS
General Principles
To employ measures that will help the patients to attain the best possible control of plasma glucose concentration. All patient should try to maintain ideal body weight. All diabetics should have regular excercise for atleast 20 - 30 min/ day. They should be very punctual with their medicine intake, food and excercise.
Prescription of Good Diabetic Diet

There is no single recommended diabetic diet. Diet should be prescribed with commonly available foods with scope for adequate flexibility and variety. Energy and carbohydrate intake rnust be adequate to allow normal growth and development. The total intake must be distributed between various meals in a day. Recommended caloric intake. 36 Kcal / kg for men 34 Kcal / kg for women
248
Insulin and Other Anidiabetic Drugs
Recommended protein intake - 1 - 1.5 / kg/ day. If the patient has diabetic nephropathy 0.8 g / kg / day. 10 % of calories from proteins. The distribution of calories between fat and carbohydrates depends on whether the patient is obese or normal weight. The consumption of fat is to be reduced in the obese. 30 % of total calories should be obtained from dietary fat with less than 10 % from saturated fat. Remaining calories (60%) to be obtained from carbohydrates. Dietary management most important in NIDDM patients not on insulin therapy.
Oral hypoglycemic agents

Sulphonyl Ureas Glibenclamide (Gliburide) I: NIDDM (Type 2) C/I ; Pregnancy, Type I diabetes, diabetic ketoacidosis. P/C: Underweight individuals prone to hypoglycemia especially after unusual exercise, hypoglycemia. A/E; Nausea, vomiting, anorexia, pruritus, urticaria, leukopenia,thrombocytopenia.Metabolised by liver/ kidney P/A: Tablet 2.5 mg, 5 mg. Dose: 1.25 to 20 mg/day. Start as a single dose in the morning, and increase slowly.If the requirrnent is more than 10 mg, then given bd with a major morning and smaller evening dose. D/I: Synergisitic hypoglycemic effect with metformin. warfarin,salicylates, sulphonamides and alcohol potentiates hypoglycemic effect. Glucocorticoids, diuretics and oestrogens reduce hypoglyceinic effect. Cost: Tab 5 mg (10) Rs. 4.00 - 5.00 Glimepiride I: C/I : P/C : A/E : Type II diabetes. As for glibenclamide severe renal and hepatic impairment, pregnancy and breastfeeding. As for glibenclamide regular hepatic and haematological monitoring required. As for glibenclamide 249
P/A : DOSE :
Cost:
Tablets, 1mg and 2mg.3mg,4mg ADULT: Oral, initial, lmg daily, adjusted according to response in 1mg 1-2 week intervals; max. 4mg daily (exceptionally, upto 6 mg daily may be used); taken shortly before or with first main meal. Tab 1 mg Rs 16-62/-;Tab 2mg Rs 33-103/NIDDM (Type 2) Pregnancy, Type I Diabetes, Diabetic ketoacidosis Under weight, hepaticorenal disease, lactation Nausea, vomiting, urticaria, thrombocytopenia, diarrhoea,drowsiness, headache or pruritis. Metabolised by liver / kidney. Tablet 2.5 mg, 5 mg. 2.5 to 40 mg / day. Start with 2.5 mg and increase by 2.5 to 5 mg at weekly intervals according to blood sugar measurement Hypoglycemia augmented by alcohol, sulphonamides, salicylates and NSAIDs. Thiazide diuretics counteract hypoglycemic action. Tab 5 mg (10) Rs. 4.00 - 10.00 NIDDM (TYPE II) Pregnancy, lactation severe renal or hepatic failure, severe ketosis or acidosis. May require insulin during metabolic stress. Care when transferring from combination therapy. Cutaneous reaction, blood dyscrasias, no adverse effect with alcohol. It has both metabolic and vascular properties. It combats microthrombosis by decreasing platelet hyper adhesiveness and hyperaggregation increasing fibrinolytic activity, normalizing prostaglandin metabolism Tablet 80 mg 80 to 320 mg daily, usually in two divided doses. Hypoglycemic effect antagonised by rifampicin, barbiturates,alcohol., diuretics, glucocorticoids and
Glipizide
I: C/I : P/C : A/E:
P/A: Dose :
D/I:
Cost:
Gliclazide
I: C/ I : P/ C : A/E:
P/A: Dose : D/I: 250
Insulin and Other Anidiabetic Drugs
Cost:
oestrogen. Hypoglycemic effect increased by aspirin phenylbutazone, clofibrate, su fonamides,MAO inhibitors Tab 80 mg (10) Rs. 23.00 - 37.00
Biguanides
Metformin I: Type 2 obese diabetes in whom dietary therapy has failed or as a combination in those in whom sulphonylureas fail to control the blood sugar. Can also be combined with insulin in Type II diabetes. Renal disease, alcoholism, hepatic disease, conditions pre-disposing to tissue anorexia Avoid alcohol as it could lead to lactic acidosis. Anorexia, nausea, vomiting, abdominal discomfort, diarrhoea.They are dose related and usually transient. Metformin Tablet 500 mg, 850 mg Metformin hydrochloride 500 mg to 3 g / day, in divided doses. Hypoglycemic effect potentiated by alcohol. Metformin : Tab 500 mg (10) Rs. 7.00 - 16.00 All forms of Diabetes Mellitus,must for Type 1 cases,post pancreatectomy cases and gestational diabetes,not controlled by diet and exercise,primary or secondary failure of Oral Hypoglycemics or when these drugs are not tolerated,underweight patients, to tide overinfections,trauma,surgery and diabetic ketoacidosis.
C/I : P/C ; A/E: P/A: Dose: D/I: Cost: Insulins I:
INSULIN FORMULATIONS
Rapid acting insulins

Insulin Lispro Unlike regular insulin it needs to be injected immediately before or after the meal,so that dose can be altered according to the quantity of food consumed.Better control of meal time glycemia and lower incidence of post prandial glycemia. P/A: Dose : 100 U/ml injection Using a regimen of 2-3 daily meal time insulin Lispro injections 251
Insulin Aspart Closely mimic physiologically insulin release pattern after a meal.The same advantages as Insulin Lispro. Insulin Glargine Suitable for once daily injection.Lower incidence of night time hypoglycemic episodes compared to isophane insulin. Short acting insulins. Regular insulin Can be given intravenously(Diabetic Ketoacidosis) or subcutaneously Intermediate acting insulins NPH (Neutral Protamine Hagedorn) Lente Insulin Long acting insulins Ultra lente Protamine Zinc Insulin Human Insulin Preparations Human Actrapid:Human Regular Insulin;40 U/ml,100U/ml Human Monotard:Human Lente Insulin;40 U/ml,100 U/ml Human Insulatard:Human Isophane Insulin;40 U/ml
Drugs that raise blood sugar in acute hypoglycemia

Glucagon Polypeptide hormone produced by the alpha cells in the pancreatic islets. It mobilises glycogen from the liver and thus raising plasma glucose concentration. It may be used on an emergency basis. I: C/I: P/C: A/E: P/A: Dose : D/I: 252 Acute hypoglycemia Insulinoma, phaeochromocytoma and glucagonoma, hypersensitivity. Ineffective in chronic hypoglycemia, starvation and adrenal insufficiency. Nausea, vomiting, diarrhoea, hypokalemia, hypersensitivity reactions. Injection 1 mg/mL By SC, IV or IM 0.5 to 1 unit; if no response within 10 min IV glucose must be given. Hypoprothrombinemic effect of oral anticoagulants may be increased.
Thyroid and Anit Thyroid Drugs
Cost:
Inj 1 mg/mL (vial) Rs. 115.00 - 205.00
THYROID HORMONES AND ANTITHYROID DRUGS
Thyroxin Sodium (T4)
Levothyroxine sodium I: Hypothyroidism - primary and secondary, suppressive therapy in non toxic goitre, thyroid cancer and hashimotos thyroiditis. C/I: Thyrotoxicosis, hypersensitivity. P/C: In hypothyroidism secondary to hypopituitarism, thyroid supplementation to be started after corticosteroid therapy initiation.In patients with cardiovascular diseases and ischemic heart diseases start with very low dose. A/E: Arrhythmias, anginal pain, insomnia, loss of weight, headache,flushing, excitability. P/A: Tablet (levothyroxine sodium) 0.025, 0.05, 0.1 and 0.2 mg Dose: Start with single daily dose of 50-100 mcg and slowly increase to 100-200 mcg on an empty stomach. D/I: Enhances effect of anticoagulants, amiodarone elevates thyroxine level, effect of TCAs enhanced. Cost: Tab 50 mcg (100) Rs. 45.00 99.00
Tri-iodo-thyronine (T3)
I: C/I: P/C: A/E:
Dose: Note:
Hypothyroidism Same as for thyroxine sodium This preparation is available on special request. lt has much faster action than T4 and in some situations of myxeodema coma this has to be used as life saving drug. Oral, 10 - 20 mcg daily in divided doses,gradually increased to 60 mcg daily in 2-3 divided doses. Even though thyroid hormone is the main stay of hypothyroid condition, sometimes other drugs may also have to be used. These include general supportivetreatment, mood elevators, antihypertensive drugs, drugs for lowering cholesterol and others. 253
Drugs Used For Hyperthyroidism

Antithyroid drugs Carbimazole I: C/I: P/C:
A/E: P/A: Dose :
D/I: Cost: Propyl thiouracil I: C/I : P/C : A/E:
Hyperthyroidism Tracheal obstruction, blood disorders. Liver disorders, pregnancy, breast feeding. Patient should report development of sore throat, mouth ulcer, rash, etc. indicative of abnormalities in blood,large goiter Nausea, vomiting, rashes, pruritis, arthralgia, hepatitis, agranulocytosis, headache Tablet 5 mg, 10 mg and 20 mg. Starting dose 20 - 60 mg / day in 3 divided doses for 48 weeks Maintanance 5 - 15 mg/day for 1-2 years Increased sensitivity to warfarin in hyperthyroidism. Tab 5 mg (100) Rs. 20.00 - 157.50/Hyperthyroidism. Hypersensitivity, pregnancy, lactation. Same as for carbimazole. Fever, leukopenia, agranulocytosis, peripheral neuropathy,nephritis, renal vasculitis, changes in menstrual period, headache,nausea and vomiting. Tablets 50 mg, 100 mg Hyperthyroidism - 300 to 900 mg/ day in divided doses till patient becomes euthyroid. Maintenance - 50 to 600 mg/ day in divided doses. Decreased response to propyl thiouracil on concommitant use with iodine or potassium iodide, response to oral anticoagulants may be decreased, increased risk of digitalis toxicity. Though anti thyroid drugs are specific agents to reduce the levels of circulating thyroid hormones, other auxiliary treatment are often required since the oral antithyroid drugs produce their full effect only within 2 - 3 weeks. Tachycardia and cardiac irritability can be controlled by propranolol in a dose of 10 40 mg/day
P/A: Dose:
D /I :
Note :
254
Vitamin D Derivatives
orally. Anxiety and excitement can be controlled by anxiolytic drugs like diazepam. ln atleast a few cases hyperthyroidism is associated with abnormalities of serum potassium. This has to be monitored and appropriate steps taken. Lugols iodine I: Preoperative preparations for thyroidectomy,generally given for 10 days just preceeding surgery.
CALCIUM AND ITS SALTS Several preparations are available that can raise systemic concentration of calcium I: Used in treatment of deficiency states and as a dietary supplement when intake is inadequate. Used in severe manifest tetany,hyperkalemia. Calcium chloride is contraindicated in the treatment of hypocalcemia of renal insufficiency. Most of the preparations available for parenteral use should be used only intravenously as there is a high chance of necrosis or local abscess if used intramuscularly. Calcium Gluconate 9 % Calcium. Oral calcium gluconate tablets available as 500, 650, 975 or 1000 mg For IV injection administered as 10 % solution (0.45 meq calcium/ mL)
C/I: P/ C:
P/A :
Dose:
Vitamin D Derivatives
Ergocalciferol and Cholecalciferol I: Hypocalcemia, nutritional, pregnancy, lactation. C/I : Hypercalcemia. A/E: Overdosage - nausea, vomiting. Dose : 1.25 to 5 mg (50,000 - 2,00,000 units) / day. Dihydrotachysterol It is a pure crystalline compound obtained by reduction of Vitamin D I: C/I: Hypoparathyroidism Pregnancy, lactation, hypercalcemia, hypervitaminosis D, renal osteodystrophy with hyperphosphatemia, hypersensitivity. 255
P/C: A/E:
P/A:
Dose: D/ I:
Use with caution in children. Constipation, diarrhoea, dryness of mouth, increased thirst and urination, loss of appetite, nausea, vomiting, lethargy, itching,irregular heartbeat, muscle pain and pancreatitis. Tablet 125 mcg, 200 mcg, 400 mcg. Capsule 125 mcg. Solution 200 mcg/mL. Adult : 0.25 to 0.5 mg/day Increased potential for toxicity with other Vitamin D analogues;hyperphosphatemia with phosphorous containing preparations;hypercalcemia due to the drug potentiates digitalis toxicity; reduced absorption of drug by mineral oil, cholestyramine or colestipol; increased risk of hypercalcemia with thiazide diuretics; antagonises calcitonin, etidronate or plicamycin in the treatment of hypercalcemia; hydantoin, barbiturates or primidone accelerates metabolism of drug by hepatic microsomal drug induction. Hypocalcemia of malabsorption, CRF and hypoparathyrodism. Hypocalcemia : Adult : 0.25 - 2.0 mcg/ day, oral.
1,25 dihydroxy Cholecaliceferol (Calcitriol)

I: Dose :
BISPHOSPHONATES These are groups of drugs which inhibit calcium mobilization from bone. It includes etidronate and alendronate. Sodium Etidronate I: Hypercalcemia of malignancy, Pagets disease of bone. C/I: Hypersensitivity, pregnancy, hypercalcemia, cardiac failure,enterocolitis,hyperphosphatemia, hypocalcemia or hypovitaminosis D, impaired renal function. P/C: Careful monitoring of fluid.and electrolyte status in elderly since they are more prone to over hydration with etidronate. Use with caution in children. A/E: Bone pain or tenderness, osteomalacia, diarrhoea, nausea, urticaria. P/A: Tablet 200 mg, 400 mg. Injection 50 mg/ mL. 256
Bisphosphonates
Hypercalcemia : Oral 5-7.5mg/ kg/ day Absorption of oral etidronate prevented by antacids, milk, dairy products as well as by calcium, iron, magnesium and aluminium containing preparations. Alendronate Sodium I: Post menopausal osteoporosis. C/I : Hypocalcemia, hypersensitivity, oesophageal abnormalities, severe renal failure insufficiency, and completely bedridden. P/C : Vit D and calcium deficiency if present should be corrected before alendronate therapy. A/E: Dysphagia, heartburn, abdominal pain, oesophageal ulcers,flatulence, headache, rash, erythema. P/A: Tablets 10 mg Dose: 10 mg od in the morning 30 min before breakfast with full glass of water. D/ I : Calcium supplements and antacids decrease absorption, and aspirin increases GI sideeffects. Mineral water, coffee, tea and orange juice decrease drug absorption
Dose: D/I:
257
SECTION 19 IMMUNOLOGICALS
ACTIVE IMMUNITY Active immunity may be induced by the administration of microorganisms or their products which act as antigens to induce antibodies to confer a protective immune response in the host. Vaccination may consist of (a) a live attenuated form of a virus or bacteria, (b) inactivated preparations of the virus or bacteria,or (c) extracts of or detoxified exotoxins. Live attenuated vaccines usually confer immunity with a single dose which is of long duration. Inactivated vaccines may require a series of injections in the first instance to produce an adequate antibody response and in most cases, require reinforcing (booster) doses. The duration of immunity varies from months to many years. Extracts of or detoxified exotoxins require a primary series of injections followed by reinforcing doses. PASSIVE IMMUNITY Passive immunity is conferred by injecting preparations made from the plasma of immune individuals with adequate levels of antibody to the disease for which protection is sought. Treatment has to be given soon after exposure to be effective. This immunity lasts only a few weeks but passive immunization can be repeated where necessary. SERA AND IMMUNOGLOBULINS Antibodies of human origin are usually termed immunoglobulins. Material prepared from animals is called antiserum. Because of serum sickness and other allergic-type reactions that may follow injections of antisera, this therapy has been replaced wherever possible by the use of immunoglobulins. C/I:P/C: Anaphylaxis, although rare, can occur and epinephrine (adrenaline) must always be immediately available during immunization.Immunoglobulins may interfere with the immune response to live virus vaccines which should normally be given either at least 3 weeks before or atleast 3 months after the administration of the immunoglobulin. Intramuscular injection. Local reactions including pain and tenderness may occur at the injection site.
A/E:
258
Sera and immunoglobulins
Hypersensitivity reactions may occur including, rarely, anaphylaxis. Intravenous injection. Systemic reactions including fever, chills, facial flushing,headache and nausea may occur, particularly following high rates of infusion.Hypersensitivity reactions may occur including, rarely, anaphylaxis. Anti-D immunoglobulin (human) Anti-D immunoglobulin is prepared from plasma with a high titre of anti-D antibody. It is available to prevent a rhesus-negative mother from forming antibodies to fetal rhesus-positive cells which may pass into the maternal circulation. The aim is to protect any subsequent child from the hazard of haemolytic disease of the newborn. It should be administered following any potentially sensitizing episode (for example abortion, miscarriage, still-birth)immediately or within 72 hours of the episode but even if a longer period has elapsed it may still give protection and should be used. The dose of anti-D immunoglobulin given depends on the level of exposure to rhesus-positive blood. The injection of anti-D immunoglobulin is not effective once the mother has formed anti-D antibodies. It is also given following Rh0 (D) incompatible blood. Prevention of formation of antibodies to rhesuspositive blood cells in rhesus-negative patients (see notes above) C/I: See introductory notes; known hypersensitivity P/C: See introductory notes; caution in rhesus-positive patients for treatment of blood disorders; caution in rhesus-negative patients with anti-D antibodies in their serum A/E: Local reactions with pain and tenderness at the site of injection,hypersensitivity reactions(rarely) P/A: Injection 300mcg Dose: For Rh-negative women,IM 200-300mcg within 72 hours following birth of Rh-positive infant;50-100 mcg during gestation;10 mcg/ml of Rh-positive blood in mismatched transfusion. Antitetanus immunoglobulin (human) Antitetanus immunoglobulin of human origin is a preparation containing immunoglobulins derived from the plasma of adults immunized with tetanus toxoid. It is used for the management of tetanus-prone wounds 259 I:
Immunologicals
in addition to wound toilet and with appropriate antibacterial prophylaxis and adsorbed tetanus vaccine. I: C/I: P/C: A/E: P/A: Dose: Passive immunization against tetanus as part of the management of tetanus-prone wounds See introductory notes;IV administration see introductory notes;avoid tetanus immunoglobulin and tetanus vaccine injecting at the same site. See introductory notes Injection: 250 IU in vial. Adult:prophylaxis:IM 250 U increased to 500 U if more than 24 hours have elapsed,or there is risk of heavy contamination IM 150 U/kg multiple sites Prevention:250 U(1ml)single dose 150 U/kg in multiple sites
Therapeutic: Child: Treatment:
ANTIVENOM IMMUNOGLOBULINS(Refer Part II) Rabies immunoglobulin(Human) I: Passive immunization either post-exposure or in suspected exposure to rabies in high-risk places in unimmunized individuals (in conjunction with rabies vaccine) Avoid repeat doses after vaccine treatment initiated; intravenous administration Rabies vaccine if schedule requires rabies vaccine and rabies immunoglobulin to be administered at the same time, they should be administered using separate syringes and separate sites Pain at injection site,fever Injection: 300 IU/ml in vial. Adult and Child 20 IU/kg on the day of injury;half by IM in the gluteal muscle and half by infiltration around the cleansed wound; if wound not visible or healed or if infiltration of whole volume not possible, give remainder by intramuscular injection into anterolateral thigh
C/I: P/C:
A/E: P/A: Dose:
260
Vaccines
Hepatitis B Immunoglobulin I: Passive immunisation of persons exposed to hepatitis B virus,prophylaxis of infants born to HBs Ag +ve mothers. C/I: Anaphylactic reactions to previous dose. P/C: History of allergy, thrombocytopenia and coagulation disorders, not to be administered intravenously, pregnancy. A/E: Local reactions with pain and tenderness at the site of injection. P/A: Injection, l00units / 0.5ml. Dose: Adult:I.M, 500 units (given preferably within 48 hours of exposure and not more than l week after exposure) Child: Neonates, I.M, 200 units as soon as possible after birth, preferably within 48 hours of birth; under 5 years, 200 units; 5 - 9 years, 300 units. VACCINES BCG vaccine I: C/I : Active immunization against tuberculosis HIV infection, immunodeficiency, patients receiving immunosuppressive therapy;generalized septic skin conditions Pregnancy; eczema, scabies-vaccine site must be lesion-free See introductory notes; rarely lymphadenitis, local ulceration,disseminated BCG infection in immunodeficient individuals, osteitis 1,00,000 U/0.5 mL 0.1ml intradermally in the deltoid region Active immunization against diphtheria, tetanus and pertussis Acute illness or infection,CNS disorder,adults and children above 6 years Should be used only in infants and children <6 years of age Local reactions at injection sites 261
P/C : A/E :
P/A : Dose : I: C/I : P/C : A/E :
Diphtheria, Pertussis and Tetanus vaccine (DPT)
Immunologicals
Dose :
IM 3 doses of 0.5 ml each in 6,10 and 14 weeks of age with 4 weeks interval between each dose and booster doses of 0.5 ml each at 18 months and 5 years of age Active immunisation against poliomyelitis. Acute febrile illness, vomiting, diarrhoea, dysentery, leukaemia,lymphoma, malignancy, therapy with corticosteroids, radiation, Immunodeficiency disorders, acute illness, hypersensitivity, pregnancy. Oral solution as above formula (Govt. supply to the wellbaby clinicdirectly). Child:Oral 0.1ml in 0, 6, 10, 14 weeks and in 6-9 months (if not receiving HBV booster doses in 18 months and 5 years). Booster dose to children above 5 years of age and children allergic to pertussis component of DPT. Pain at the site of injection. 0.5 mL IM usually 1 booster dose at school entry Active immunization against tetanus Acute illness,corticosteroid or immunosuppressive therapy Hypersensitivity,booster doses should not be given at intervals of <10 years Local reactions Adult:IM,2 Doses,each of 0.5 mL;at an interval of 4-6 weeks,reinforcing dose after 9 -12 months in a booster dose of 0.5 mL every 5 years.
Poliomyelitis Vaccine (Oral) IP I: C/I :
P/A : Dose:
Diphtheria and tetanus vaccine (for children under 7 years) I: A/E: Dose: I: C/I: P/C: A/E: Dose:
Tetanus Toxiod, Adsorbed IP
Measles vaccine
Live attenuated vaccine I: A/E: 262 Active immunization against measles L o c a l l y m p h a d e n o p a t h y, thrombocytopenia purpura rash; rarely
Vaccines
Primary immunization of children against measles, by intramuscular or subcutaneous injection, infants and child 0.5 mL at 9 or 12 months of age; a reinforcing dose of 0.5 mL can be given after four weeks or up to 6 years of age.Immunization of HIV-infected infants against measles (unless severely immunocompromised), by intramuscular or subcutaneous injection, infants 0.5 mL dose at 6 months of age followed by 0.5 mL at 9 months of age.Prophylaxis in susceptible individuals after exposure to measles, by intramuscular or subcutaneous injection within 48 hours of contact,adult and child over 9 months of age 0.5 mL Mumps, Measles & Rubella (MMR) I: Active immunization in children aged 12-15 months against measles, mumps and rubella infections. C/I: Pregnancy, acute febrile illness, congenital or acquired immunodeficiency, allergy to chick egg proteins, recent therapy with steroids or immunosuppresants, active tuberculosis and hypersensitivity to neomycin, Kanamycin and documented history of MMR vaccination. P/C: Postpone the vaccination in patients suffering from acute illness,pregnancy and lactation. A/ E: Local erythema, pain and induration, regional lymphadenopathy,rash and parotitis. Dose: Child 0.5mL SC, as a single dose at the age of 12-15 months,a booster dose may be given at the age of 3-5 years into outer part of upper arm. Rubella vaccine I: Active immunisation against rubella virus C/I : Acute infectious diseases, leukaemia, severe anaemia, severe renal impairment, decompensated heart diseases, following administration of gammaglobulin or blood transfusions, pregnancy. P/C: Individuals receiving corticosteroids and other immunosuppressants or undergoing radiation therapy may not develop an optimal immune response, women 263
Dose:
Immunologicals
A/E:
Dose: Typhoid vaccine I: C/I:
of child beating age are advised not to become pregnant for 2 months after vaccination. Skin rashes, pharyngitis, fever, lymphadenopathy, arthralgia, arthropathy, thrombocytopenia and neurological symptoms including neuropathy and paraesthesia have been reported rarely Adult and Child:12 months and above, deep SC, 0.5mL as single dose. Active immunization against typhoid Congenital acquired immunodeficiency,treatment with immunosuppressives and antimitotic drugs; acute febrile illness,acute intestinal infection thrombocytopenia;avoid simultaneous administration of antibacterials.Mefloquine should not be taken at least 12 hours before or after a dose Redness pain and swelling, fever, headache, malaise, nausea, itching, rarely anaphylaxis Adult:IM single dose of 0.5 ml,revaccinated every 3 years if necessary Child:>2 years, same as adult dose Active immunization against cholera Hypersensitivity to previous dose Immunity last only upto 6 months,hence attention to hygiene food and water is essential Mild transient gastrointestinal disturbances reported Adult 0.5 ml IM second dose after 4 weeks 1 ml IM; Child 1-5 years 0.1ml second dose 0.3 ml; 6-10 years,0.3 ml,second dose 0.5 ml
P/C:
A/E: Dose:
Cholera vaccine I: C/I: P/C: A/E: Dose:
Hepatitis A vaccine I: active immunization against hepatitis A virus infection C/I: Hypersensitivity P/C: Serious infections,cardiovascular disease pulmonary disorders pregnancy,breast feeding A/E: Fatigue,fever,transient LFT abnormalities, headache, reactions at injection sites rarely Dose: Adult:IM,1 ml as a single dose;and a booster dose 1 ml 6-12 months after usual dose 264
Vaccines
Child:1-15 years: IM, 0.5 ml and a booster dose of 0.5 ml 6-12 months after the 1st dose Hepatitis B vaccine I: Active immunization against hepatitis B virus infection C/I: Hypersensitivity,severe febrile illness P/C: Pregnancy Dose: Adult:IM,3 Doses of 1 ml,the second 1 month and third 6 months after the first dose
Japanese encephalitis vaccine

I: C/I: A/E: Dose: Active immunization against Japanese encephalitis Children below 1 year, Hypersensitivity to first dose,immunosupression and pregnancy Local reaction, rarely encephalitis 1- 3 years - 0.5 ml subcutaneously;Above 3 years 1 ml subcutaneously.Number of doses and interval : Two doses at 1 month and booster every 3 years Active immunization against rabies; pre-exposure prophylaxis, postexposure treatment Allergy Acute illness,hypersensitivity,impaired immunological response,malignant neoplasm Reaction at injection site, fever, head ache, neuroparalytic reactions with animal brain tissue vaccines Adult and Child:Preexposure immunization:IM/SC,1 ml on days,0,7 and 28 days Postexposure immunization:IM/SC,1 ml on 0,3,7,14 and 30 and a booster dose on day 90 Active immunization against varicella in seronegative individuals who are at high risk of severe varicella infection Pregnancy, acute severe febrile illness, total lymphocyte count <1200/mm3,hypersensitivity Hypersensitivity,history of seizures, avoid pregnancy for 3 months after immunization Mild and transient reaction at the injection site 265
Rabies vaccine
I: C/I: P/C: A/E:
Dose:
Varicella vaccine I:
C/I: P/C: A/E:
Immunologicals
Adult: SC, 2 doses of 0.5 ml each at an interval of 4-8 weeks Child: SC 12 months-12 years 0.5 ml(one dose);>12 years same as adult dose Pneumococcal vaccine(Polyvalent) I: Active immunization of those at risk from streptococcal infection C/I: Hypersensitivity,pregnancy,breast feeding P/C: Multiple myeloma,Hodgkins and NonHodgkins Lymphomaespecially during treatment and in chronic alcohols; chemotherapy or radiation;should be given at least 10 days before starting immunosuppressive therapy or be delayed until atleast 6 months after completion of therapy A/E: Hypersensitivity reactions,local reaction at injection site Dose: Adult:SC/IM,single dose of 0.5 mL Child: Not recommended in children < 2years Yellow fever vaccine I: Active immunization against yellow fever Infant at 9 12 months of age,0.5 ml Immunization of travellers and others at risk against yellow fever, by deep subcutaneous or by intramuscular injection, Adult and Child over 9 months of age 0.5 mL C/I: Not recommended for infants under 9 months of age A/E: Headache, myalgia, weakness; very rarely encephalitis (infants more susceptible); viscerotropic disease, multiple organ failure (elderly more susceptible)
Dose:
266
SECTION 20 IMMUNOSUPPRESSANT DRUGS

T CELL INHIBITORS
Cyclosporine
More specific immunosupressive, widely used in transplantation to prevent rejection, is also used in certain primary glomerular diseases I: Steroid resistant minimal change disease, focal segmental glomerulosclerosis, membraneous nephropathy and membrane proliferative glomerulo nephritis. C/I : Severe hypertension, severe renal and hepatic failure. P/C : Monitor renal and hepatic function, monitor blood pressure and serum potassium. Caution in porphyria, hyperuricemia. To be used under specialist care only. A/E : Dose dependent increase in urea and creatinine in early phase and chronic nephrotoxicity in prolonged use, hypertrichosis, tremor, hypertension, hepatic dysfunction, gingival hypertrophy, metabolic effects such as hyperkalemia, hypercholestrolemia, pancreatitis,convulsions, neuropathy, myopathy, haemolytic uremic syndrome, lymphoproliferative disorders. P/A : Capsules 25, 50, 100 mg ~ Oral solution 100 mg / mL. Dose : Renal transplantation 5 - 15 mg / kg in 2 divided doses initially, taper to 2 -6 mg/ kg maintenenace. Nephrotic syndrome 3 to 5 mg/ kg/ day for varying periods of time usually 3 months to 6 months. D/I: Increased nephrotoxicity with NSAID and allopurinol, aminoglycosides and doxycyline. Various antibacterial drugs and hypertensives alter cyclosporine levels in blood and thereby enhances toxicity or reduces effect. Cyclosporine has a narrow therapeutic window. ACE inhibitors and spironolactone increases risk of hyperkalemia. 267
Immunosuppressant Drugs
Tacrolimus
I: Dose: Prophylaxis of organ allograft rejection Oral : Adult renal transplant 0.2 mg/kg/day in 2 divided doses staring within 24 hours, can be delayed if renal functions are not normal. Nephrotoxicity, neurotoxicity, tremor, headache, motor disturbances, seizures, GI Complaints, hypertension, hyperkalemia, hyperglycemia and diabetes. Also increased risk of secondary tumours and opportunistic infections. hypersensitivity, pregnancy ,lactation 0.05-0.1 mg/kg BD oral for renal transplant;0.1-0.2mg/ kg BD for liver transplant cap 1mg (10) Rs 349/Prophylaxis of Organ Rejection in Renal Transplantation.Therapeutic drug monitoring is recommended for all patients receiving sirolimus In patients at low-to-moderate immunologic risk, it is recommended that sirolimus be used initially in a regimen with cyclosporine and corticosteroids. Cyclosporine should be withdrawn 2 to 4 months after transplantation. Anaemia, leucopenia, thrombocytopenia, hypo/ hyperkalemia, fever, GI upset. There is increased risk of neoplasms especially lymphomas and infections like CMV and pneumocystis carinii. Tab 1mg (10) Rs 1300/CYTOTOXIC DRUGS
A/E:
C/I: Dose; Cost:
Sirolimus
I:
A/E:
Cost :
Cyclophosphamide (Refer section 6)

Azathioprine I: C/I: P/C: Lupus nephritis class III and IV, prevention of rejection in renal transplantation. Hypersensitivity to mercaptopurine, allopurinol and azathioprine. Monitoring of blood counts weekly for 8 weeks and thereafter every month. Reduce dose in hepatic and renal dysfunction and elderly.To be used under specialist care only.
268
Cytotoxic drugs
A/E:
P/A: Dose: D/I:
Hypersensitivity reactions including deranged liver function, cholestatic jaundice, interstitial nephritis calls for permanent withdrawal. Dose related bonemarrow suppression, increased susceptibility to infections, pancreatitis, pneumonitis and alopecia. Tablet 50 mg 1-3 mg/kg/day Increased toxicity with other cytotoxic drugs and allopurinol. Rifampicin reduces blood levels.
Methotrexate (refer section 6)

Chlorambucil Alkylating agent preferred by some due to its beneficial effects and relative safety. I: Preferred immunosuppressive in membraneous nephropathy.alter nated with oral prednisolone every 4 weeks for 6 months. Also useful in steroid resistant minimal change disease. 0.1 to 0.3 mg /kg /day for 6 to 8 weeks in MCNS and alternate 4 weeks for 6 months in membraneous nephropathy In General, mycophenolate is used for the prevention of organ transplant rejection in adults and renal transplant rejection in children >2 years; whereas mycophenolate sodium has also been used for the prevention of rejection in liver, heart, and or lung transplants in children >2 years. Common adverse drug reactions (>1% of patients) associated with mycophenolate therapy include diarrhea, nausea, vomiting, infections, leucopenia, and / or anemia. Mycophenolate sodium is also commonly associated with fatigue, headache, and/ or cough, Intravenous (IV) administration of mycophenolate mofetil is also commonly associated with thrombophlebitis and thrombosis. Infrequent adverse effects (0.1 1% of patients) include esophagitis, gastritis, gastrointestinal tract hemorrhage, and/or invasive cytomegalovirus (CMV) infection. 269
Dose :
Mycophenolate mofetil
I:
A/E:
Immunosuppressant Drugs
Dose:
Cost :
Adults 1 g IV twice a day for upto 4 days starting within 24 hours of transplant and then shift to oral maintenance therapy. Adults 1 g orally twice a day starting within 72 hours of transplant. Tab 500mg (10) Rs 880/-
GLUCOCORTICOIDS They are widely used as immunosuppressants in many immune mediated primary and secondary glomerular diseases and in renal transplantation. It inhibits interleukin-1(IL-1), T-helper cell activation, antibody production and also has antiinflammatory properties.
Prednisolone
Prednisolone is the preferred corticosteroid for oral immunosuppression, because of its lesser suppressive effect on the hypothalamopituitary axis. I: Nephrotic syndrome produced by minimal change disease and membraneous nephropathy, lupus nephritis, other autoimmune disorders, vasculitis and renal transplantation. Dose : Nephrotic syndrome In adults: Img/kg/day or 2mg/ kg/alternate day is recommended. In children 2mg/ kg or 40mg/mg daily for 4 to 8 weeks, followed by alternate day therapy for a similar duration. Maintenance therapy in low dose of 0.1 to 0.2 mg on alternate days indicated in membranous nephropathy and steroid dependent minimal change disease for a period of 6 months. Lupus nephritis: 2 mg/kg bw for 4 8 weeks followed by 0.2 mg/kg maintenance 3 to 5 years. Renal transplant:1 mg/ kg to start, taper to 0.1 mg/kg by 3 - 6 months and continue lifelong. Usually combined with azathioprine and cyclosporine.
Methyl Prednisolone
Intravenous infusion of methyl prednisolone in high doses of upto 1 g daily for 3 - 5 days is called steroid pulse therapy and is used for early response in severely ill patients. 270
Glucocorticoids
I:
C/I: P/C : A/E:
P/A:
Dose:
Severe renal disease due to SLE, vasculitis, crescentic nephritis and severe acute interstitial nephritis with renal failure, acute transplant rejection. Peptic ulcer, acute psychosis, Cushings syndrome, herpes simplex,. keratitis, infections, lactation. Diabetes, pregnancy, seizure disorder. To be used by specialist only. Besides the usual steroid side effects, acute hyperglycemia, hypokalemia, infections, and convulsions are more frequently encountered. Bolus injections may produce sudden cardiac death. Injection methyl prednisolone sodium succinate and methyl prednisolone acetate in aqueous solution. 500 mg 1 g vials. 10 to 40 mg/ kg/ day not exceeding 1000 mg is given as IV infusion in 200 mL of 5% dextrose over a period of 30 min and is repeated consecutively for 3 to 5 days. This is usually followed by oral prednisolone at a dose of 1mg/ kg. MONOCLONAL ANTIBODIES.
BASILIXUMAB DACLIZUMAB ALEMTUZUMAB. IMMUNOSUPPRESSANT ANTIBODIES THYMOGLOBULIN (Antithymocyte globulin) I: To suppress acute allograft regection episodes especially in steroid resistant cases A/E: serum sickness and anaphylaxis P/A: thymoglobulin (rabbit)inj.25 mg/vial ATG 100 mg injection. Dose: 1.5-2.5mg/kg/day - Thymoglobulin ATG 200mg IV/day
271
SECTION 21 DRUGS USED IN DISEASES OF KIDNEY AND URINARY TRACT

DIURETICS: REFER SECTION 14 DRUG TREATMENT OF UROLITHIASIS Stones in the urinary tract are composed of calcium oxalate, calcium phosphate, uric acid, triple phosphate (magnesium, ammonium phosphate) and cystine. Calcium stones account for 70 to 80% and triple phosphate 1020% of all renal stones. Stones are formed when the concentration of the constituent substances in the urine exceeds the formation product (super saturation) or due to an imbalance between the promoters and inhibitors of stone formation.The predominant inhibitors are citrate, magnesium, pyrophosphates and certain glycopeptides in the urine.
General measures
If a single stone is found, after ruling out renal failure and UTI, dietary advice is given 1. Increase fluid intake to ensure at least 2 L of urine / day, 2. Reduce the protein intake to 1g/ kg or less. Calcium intake in the range of 800-1000 mg / day. Limit the salt intake to 100 mmol (5 g) or less. 3. He / she should be monitored annually to determine whether their stone disease is active. In a recurrent calcium stone, rule out systemic and renal disease that can cause calculi.When these dietary measures fail, pharmacological therapy is resorted to.
Thiazide diuretics
I: Dose: Idiopathic hypercalciuria Chlorthalidone : 25-50mg/day Hydrochlorothiazide : 25-100mg/ day
Indapamide A modified thiazide diuretic Dose : 2.5mg/day Potassium citrate Mechanism of action lowers urinary calcium excretion as well as increases urinary citrate excretion. Also alkalinises the urine. 272
Drug treatment of Urolithiasis
I:
C/I ;P/C : A/E : P/A: Dose: Allopurinol Mechanism of action Uric acid synthesis is reduced by inhibition of xanthine oxidase. I: A / E:
Idiopathic hypercalciuria, idiopathic calcium stone formation,hypocitraturia, urate calculi, cystine stones, and prevention of growth of residual stone fragments after lithotripsy of struvite stones. Hyperkalemia and renal failure. GI disturbances and hyperkalemia. Powder 1 g : 14 mEq 60-80 mEq/ day
P/A: Dose:
Primary and secondary hyperuricaemia, hyperuricosuria, gout, urate calculi. Hypersensitivity reactions including fever, lymphadenopathy and eosinophilia and exfoliation resembling Steven ]ohnson Syndrome, leukopenia, leukocytosis, elevated aminotransferase levels and progressive renal insufficiency. Taste disturbances, vertigo, alopecia and neuropathy are other side effects. Tablets 100 mg 100 mg daily gradually increased to 300 mg daily over 3 weeks. Not to exceed 900 mg.
Pyridoxine Mechanism of action Pyridoxal phosphate (Vit B6) is a cofactor for the enzyme alanine glyoxalate transaminase I: Primary hyperoxaluria, dietary hyperoxaluria. P/A: Tablet 10 mg, 40 mg and 100mg Dose : Primary hyperoxaluria 100 1000 mg/ day. Dietary hyperoxaluria 25 100 mg/ day. Neutral phosphate Mechanism of action decrease in urinary calcium excretion, increase in urinary pyrophosphate, and an increase in plasma phosphate which deregulates calcitrol production. I: Idiopathic calcium stone former, idiopathic hypercalciuria 273
Drugs used in diseases of kidney and urinary tract
Orthophosphate Mechanism of action Reduction in urinary calcium excretion by unknown mechanism, and urinary pyrophosphate increases. I: Primary hyperoxaluria, idiopathic calcium stone former used in combination with pyridoxine. Dose : 30-40mg/kg/day. Cholestyramine Mechanism of action binds oxalate in the lumen of the bowel I: Enteric hypercalciuria A/E: Steatorrhoea due to binding of bile salts, deficiency of fat soluble vitamins. Dose : 4g qds. Chelating agents used in the treatment of cystine stones Mechanism of action increase cystine solubility Penicillamine A/ E: Blood dyscrasias and nephropathy Dose: 250mg of penicillamine can lower urine cystine by about 100mg
TREATMENT OF VOIDING DYSFUNCTION AND OTHER COMMON LOWER URINARY PROBLEMS

DRUGS FOR BENIGN PROSTATIC HYPERTROPHY (BPH) Alpha adrenergic blockers: These drugs relax the smooth muscles of the prostate and bladder outlet and increase urine flow. Drugs used: Prazosin, Terazosin,Tamsulosin, Alfuzosin Prazosin, Terazosin I: BHP grade I and II with post void residual urine volume less than 150 mL C/I: Orthostatic hypotension, hypersensitivity. P/C: First dose effect may cause collapse, to be taken while retiring to bed. A/E: Dizziness, hypotension, postural hypotension, drowsiness, headache, lethargy, dry mouth, urinary incontinence. Dose: Prazosin : 0.5 mg daily for 3 to 5 days, then progressively increased to 2 mg bd. 274
Benign prostatic hypertrophy
Terazosin :
1mg h.s.daily to be increased to a maximum of 10 mg daily.
Tamsulosin Uroselective alpha 1A/1D blocker I: same but does not cause significant changes in BP. C/I: Hypersensitivity, hepatic impairment,postural hypotension A/E: Dizziness and Retrograde ejaculation P/A: 0.2 and 0.4 mg Capsules Dose: 1 capsule( maximum 2)in the morning with meals Cost: Tablets 0.4 mg(10)Rs 39-60/Alfuzosin I: C/I :A/E:same as above Dose: Adult 2.5 mg tds maximum 10 mg daily Cost: Tablets 10 mg(10)Rs 80-90/-
Alpha redcuctase inhibitors

Finasteride Dose : Cost: Dutasteride Dose: Cost: 5 mg daily increased upto 20 mg daily. Tablets 5 mg(10) Rs 105/0.5 mg daily Tablet 0.5 mg(10) Rs 89- 130/-
TREATMENT OF NEUROGENIC VOIDING DYSFUNCTION Parasympathomimetics Improves voiding efficiency by increaing detrusor contraction. I: non obstructive neurogenic urinary retention. Bethanechol I: Postoperative retention, neurogenic bladder (large capacity low pressure) sensory atonia C/I : Parkinsonism, myocardial infarction, arrhythmia, asthma, epilepsy, peptic ulcer, pregnancy, vagotonia. A/E: Parasympathomimetic effects - nausea, vomiting, abdominal colic, blurred vision, bradycardia, sweating. P/A: Tablets Bethanechol chloride 25 mg Dose: Bethanechol : 10 to 25 mg tds to qds daily. Cost: Tablet 25 mg (50) Rs 480-750/275
DRUGS FOR URINARY FREQUENCY AND ENURESIS Antimuscarinic drugs Flavoxate I: Urinary frequency, dysuria, urgency, incontinence, bladder spasms. C/I: Intestinal obstruction, ulcerative colitis, megacolon, bladder neck obstruction, glaucoma, myasthenia. P/C: Glaucoma, prostate hypertrophy, hiatus hernia with reflux oesophagitis. A/ E: Antimuscarinic effects as for atropine. P/A: Tablet 200 mg Dose: 200 mg t.d.s. Cost: Tablet 200 mg(10)Rs 25-79/Amitriptyline Dose: Nocturnal Enuresis > 11 years 25-50 mg at bed time,610 years 10-20 mg at bed time. Cost: Tablet 10 mg(10) Rs 8-12/Imipramine Dose: Nocturnal Enuresis 6-7 years 25mg,8-11 years 2550mg,>11 years 50 -75mg Cost: Tablet 25 mg(10)Rs 6-8/-
Oxybutynin Chloride
I: C/I : Urinary frequency, urgency and incontinence, neurogenic bladder instability, and nocturnal enuresis. Intestinal obstruction or atony; severe ulcerative colitis or toxic megacolon; significant bladder outflow obstruction; myasthenia gravis. Frail elderly; hepatic and renal impairment; neuropathy; hyperthyroidism;cardiac disease where increase in heart rate undesirable; prostatic hypertrophy; hiatus hernia with reflux oesophagitis; pregnancy and breast feeding; porphyria. Dry mouth, constipation, blurred vision, nausea, abdominal discomfort,facial flushing, difficulty in micturition; drowsiness, dry skin, rash, angioedema, photosensitivity, diarrhoea, arrhythmia, restlessness, disorientation, hallucinations; convulsions.
P/C :
A/E :
276
Urinary Frequency and Enuresis
ADULT: Oral, 5mg 2-3 times daily, upto 5mg 4 times daily if necessary; elderly, 2.5-3mg twice daily initially, increased to 5mg twice daily according to response and tolerance. CHILD: Neurogenic bladder instability: above 5 years, 2.5-3mg twice daily increased to 5mg twice daily (max. 5mg three times daily);Nocturnal enuresis: (preferably over 7 years), 2.5-3mg twice daily increased to 5mg 23 times daily (last dose before bedtime). P/A : Tablets 2.5mg, 5mg;Extended release tablets, 5mg. Cost : Tab 5mg (10) Rs 75-80/Tolterodine tartrate I: Urinary frequency, urgency and incontinence. C/I : Avoid in patients with myasthenia gravis, glaucoma, significant bladder outflow obstruction or urinary retention, severe ulcerative colitis, toxic megacolon, and in gastrointestinal obstruction or in intestinal atony; pregnancy and breastfeeding. P/C : Elderly, autonomic neuropathy, hepatic and renal impairment, hyperthyroidism, coronary artery disease, congestive heart failure,prostatic hypertrophy, arrhythmias and tachycardia. A/E: Dry mouth, constipation, blurred vision, drowsiness, nausea, vomiting,abdominal discomfort, difficulty in micturition, palpitations and skin reactions; headache, diarrhoea, angioedema, arrhythmias and tachycardia; restlessness, disorientation, hallucination and convulsions;may reduce sweating leading to heat sensations and fainting in hot environments. Dose: ADULT:Oral, initially 2 mg twice daily; reduce to l mg twice daily if necessary to minimise side-effects. CHILD: Not recommended. P/A: Tablet, 2mg, 4mg;Sustained release tablets, 3mg, 4mg. Cost: Tab 2mg (10) Rs 80-85/ALKALINISATION OF URINE Decreases discomfort in cystitis, retards bacterial growth especially E.coli. Drugs used include 277
Dose:
Potassium citrate I:
Other uses-relief of discomfort in mild UTI,to prevent recurrence of urinary stones C/I: Metabolic or Respiratory Acidosis P/C: Potassium containing salts to be avoided in renal failure. A/E: Hyperkalemia on high dosage Dose: Adult oral 15 ml tds,Child oral 5 ml tds Sodium bicarbonate I: same as above drug P/C: Sodium containing drugs are to be used with caution in patients with oedema and CCF A/E: Hypokalemia and metabolic alkalosis in patients with renal impairment P/A: Tablet 300mg(1 mmol=84 mg) Dose: Oral 1-10 mmol/Kg/day in divided doses. ACIDIFICATION OF URINE ASCORBIC ACID I: Infection by urease splitting organisms especially proteus, presence of stones, catheter induced mixed infections. Drug used include 4 g daily in divided doses. DRUGS FOR IMPOTENCE Alprostadil I: C/I : Erectile dysfunction, neonatal congenital heart defects. Predisposition to prolonged erection; not for use with other agents for erectile dysfunction, in patients with penile implants or when sexual activity medically inadvisable; urethral application also contraindicated in urethral stricture, severe hypospadia, severe curvature, balanitis, urethritis. Priapismpatients should be instructed to report any erection lasting 4 hours or longer-anatomical deformations of penisfol1ow up regularly to detect signs of penile fibrosis.
Dose:
P/C :
278
Drugs For Impotence
Penile pain, priapism; reactions at injection site; local reactions like urethral burning, urethral bleeding, penile warmth, numbness, penile infection, irritation, sensitivity; testicular pain and swelling, scrotal disorders, changes in micturition, hypotension or hypertension, rapid pulse, vasodilatation, chest pain, supraventricular extrasystole, peripheral vascular disorder, dizziness. DOSE : ADULT: Intracavernosal injection, erectile dysfunction; first dose 2.5mcg, second dose 5mcg (if some response to first dose) or 7.5 mcg (if no response to first dose), increasing in steps of 5-10mcg to obtain,dose suitable for producing erection not lasting more than 1 hour; if no response to dose then next higher dose can be given within 1 hour, if there is a response the next dose should not be given for at least 24 hours; usual range 520mcg; max. 60mcg (max. frequency of injection not more than once daily and not more than 3 times in any one week) CHILD : To maintain the patency of ductus arteriosus in neonates: I.V infusion, initially 50-100 nanograms/kg/minute, then decrease to lower effective dose. P/A: Injection (intracavernosa),20mcg,500mcg/mL, 1mL. Papaverine Hydrochloride I: impotence; relief of peripheral and cerebral ischaemia associated with arterial spasm. C/I : Complete arterioventricular block; Parkinsons disease P/C : Glaucoma; administer IV cautiously since apnoea and arrythmias may result A/E : Flushing of face, sweating, tachycardia, hypotension, anythmias,with rapid IV use; depression, dizziness, vertigo, drowsiness, sedation lethargy, headache, pruritus, dry mouth, nausea, constipation, hepatic hypersensitivity, thrombosis at the IV administration site. DOSE : Adult: Oral, 100-300mg 3-5 times daily IM, IV : 30-120mg every 3 hours as needed. P/A: Injection, 30mg/mL,2mL:Capsules, 60mg. 279
A/E :
Sildenafil I: C/I : Erectile dysfunction. Treatment with nitrates; conditions in which vasodilation or sex activity is inadvisable; recent stroke or myocardial infarction, blood pressure below 90/ 50mmHg and hereditary degenerative retinal disorders. Cardiovascular disease; anatomical deformation of penis; predisposition to prolonged erection (as in sicklecell anaemia, multiple myeloma ,leukaemia); hepatic and renal impairment. Dyspepsia; headache, flushing, dizziness, visual disturbances increased intra-ocular pressure, nasal congestion; rash and priapism reported; serious cardiovascular events also reported. Tablets, 25 mg, 50mg ADULT: Oral, initial, 50mg (elderly 25mg) approximately one hour before sexual activity, subsequent doses adjusted according to response to 25-100mg as a single dose as needed; max. one dose in 24 hours(max. single dose 100mg). hypotension when used with alpha blockers; erythromycin increases its plasma concentration 25mg (4tablets) Rs 60- 80/Erectile dysfunction. As for sildenafil; also moderate heart failure, uncontrolled arrhythmia, uncontrolled hypertension. As for sildenafil. As for sildenafil; also back pain, myalgia. Tablets, 10mg, 20mg. ADULT: Oral, initially 10mg at least 10 minutes before sexual activity, subsequent doses adjusted according to response to 20mg as a single dose ; Maximum 1 dose in 24 hours (but daily use not recommended). Effect may persist for longer than 24 hours.
P/C :
A/E :
P/A : Dose :
D/I:
Tadalafil I: C/I : P/C : A/E : P/A : Dose :
Note:
280
SECTION 22 MUSCLE RELAXANTS AND ANTICHOLINESTERASES

CENTRAL MUSCLE RELAXANTS Methocarbamol I: C /I: P/C: A/E: P/A: Dose: Oral: Parenteral : D/I: Short term symptomatic relief of muscle spasm. Coma, brain damage, epilepsy, and myasthenia gravis. Hepatic and renal impairment. Lassitude, confusion, allergic rash and convulsions. Tablet 500 mg, Injection 100mg/ 10 mL. 1.5 g q.d.s. may be reduced to 750 mg tds. slow IV infusion, 1-3 g (maximum rate 300mg/ min) maximum dose 3 g daily for 3 days. CNS depressant effects is potentiated with alcohol and other CNS depressant drugs, efficacy of anoretics and anticholinergics increased. Inj 100 mg/mL (25x10mL) Rs 500.00, Tab 500 mg (10 x 10) Rs. 425.00 Muscle spasm of varied etiology, including tetanus. Oral : 2-15 mg daily in divided doses, increased if necessary in spastic conditions to 60 mg daily according to response by IM. or by slow IV. in acute muscle spasm, 10 mg repeated if necessary after 4 hrs. Tetanus adult and child by IV100 - 300 mcg/kg repeated every 1-4 h; by IV infusion (or by nasoduodenal tube 3-10mg/kg over 24 hrs, adjusted according to response. Chronic severe spasticity resulting from disorders such as multiple sclerosis or traumatic partial injury to spinal cord. Peptic ulceration. Psychiatric illness, cerebrovascular disease, diabetes mellitus; respiratory, hepatic or renal impairment; epilepsy; history of peptic ulcer; pregnancy; porphyria. 281
Cost :
Diazepam
I: Dose:
Parenteral :
Baclofen
I:
C/I: P/C:
Muscle Relaxants and Anticholinesterases
A/E:
P/A: Dose:
D/I :
Cost :
Sedation, drowsiness, nausea, confusion, ataxia, hallucination, insomnia, convulsion, respiratory and cardiovascular depression, hypotension. Tablet 10mg and 25 mg. Oral : 5 mg t.d.s., preferably after food, gradually increased; maximum 100 mg daily; For children over 10 years 0.75-2mg/ kg daily, maximum 2.5 mg/kg daily, or 2.5 mg q.d.s increased gradually according to age to the , effective maintenance dose: 1-2 years 10-20 mg daily, 2-6 years 20-30 mg daily, 6-10 years 30-60 mg daily. Mutual potentiation with CNS depressants and alcohol. Concomitant use with levodopa in Parkinson patients may result in - confusion, agitation, hallucinations. When given concurrently with antihypertensive drug the hypotensive effect may be aggravated. Tab 10 mg(10) Rs. 61.50 65.00 Muscle spasm Severe hepatic dysfunction Hepatic / renal insufficiency, pregnancy, lactation, children, elderly Hypotension, risk of liver injury, sedation, psychotic symptoms, bradycardia, dryness of mouth Tablets/Capsules 2mg, 4mg , 6 mg 2mg once daily (increased by 2mg at intervals of at least 3-4days upto a maximum of 24mg daily in 3-4 divided doses) Alcohol, CYP inhibitors like fluvoxamine or ciprofloxacin increases plasma drug levels, women concurrently taking oral contraceptives had 50% lower clearance of tizanidine. Tab 2 mg (10) Rs 24.00 - 57.00 Hemi-facial spasm, blepharospasm, spasmodic torticollis, lowerlimb spasticity in children with cerebral palsy and upper limb spasticity associatied with stroke in adults. Used in treatment of strabismus and hyperhidrosis.
Tizanidine
I: C/I : P/C: A/E: P/A: Dose:
D/I:
Cost:
Botulinum Toxin
Botulinum A:
282
Central Muscle Relaxants
Botulinum B I:
C/I: P/C:
A/E:
D/I:
Dose:
spasmodic torticollis and in patients who develop resistance to treatment due to development of antibodies to type A toxin. Myasthenia gravis, breast feeding, infection at the injection site. Inject with great care in muscles around neck, eyes. Corneal sensation should be tested in previously treated eyes. Injection into lower eyelid area is avoided. Caution in breathing and swallowing difficulties. Handle toxin with care. Blurring and burning sensation, bruising at the injection site and local weakness. Deep injections paralyses nearby muscle group. Rarely arrhythmias and MI and hypersensitivity reactions. After injection into the eye muscles ptosis, lacrimation, photophobia and facial swelling. Injection into the neck muscles may lead to dysphagia and pooling of saliva with risk of aspiration. Paralysis of vocal cords and weakness around neck muscles. Injection in to lower limbs causes leg pain and leg cramps. Injection in the upper limb causes hypertonia and arm pain. Injection in to the muscles around forehead causes headache. Effect potentiated by spectinomycin. Interactions also occur with lincosamide, polymyxins, tetracyclines and muscle relaxants. According to the indications. Short-term symptomatic relief of muscle spasm Acute pulmonary insufficiency; porphyria Respiratory disease, muscle weakness, epilepsy, pregnancy. Drowsiness, gastrointestinal disturbances, hypotension. Tablet 350 mg. 350 mg tds. Additive actions with concurrent use of alcohol, other CNS depressants or psychotropic drugs. Tab 350 mg (10) Rs. 28.00 30.00 283
Carisoprodol
I: C/I: P/C : A/E: P/A: Dose: D/I: Cost :
PERIPHERAL MUSCLE RELAXANT Atracurium I: This is a non-depolarising muscle relaxant of intermediate duration and is widely used. Histamine release may occur, related to total dose and speed of injection, which can be prevented by concurrent administration of H1 and H2 receptor blockers. This drug is non-cumulative. Metabolised by pH and temperature dependent Hoffman degradation, therefore ideal in hepatic and renal failure. Hypersensitivity Myasthena gravis and other neuromuscular disorders, pregnancy, neonates, asthma. Histamine release may occur, give rise to urticaria, laryngospasm and cause hypotension. lnjection 10 mg/mL - 2.5 mL, 5 mL, 10 mL ampoules. By IV injection for adults and children over 1 month the initial dose is 300-600 mcg/kg. Thereafter 100-200 mcg /kg is repeated as required. By IV infusion, it can be given in a dose of 5-10 mcg kg /min 300600mcg/kg/hr Quinidine and propranolol enhance the muscle relaxant effect. lnj 10 mg/ml. (2.5 ml.) Rs. 111.00 - 125.00 Non-depolarising muscle relaxant, long acting, produces moderate vagolytic action, tachycardia and hypertension; so avoid in coronary artery disease. Hypersensitivity, anuria. Hepatic impairment, reduce dose in renal impairment. Itching of skin, excessive salivation, relatively low risk of side effects with histamine release. Injection pancuronium bromide 2 mg / ml - 2 ml amp By IV initially for intubation 80-120 mcg / kg then 1020 mcg / kg every 1-1.5 hrs.
C /I: P/C: A/E: P/A: Dose:
D/I: Cost :
Pancuronium
I:
C/I: P/C: A/E: P /A: Dose :
284
Peripheral Muscle Relaxant
D/I: Cost :
Same as atracurium Inj 2 mg/mL (2 mL) Rs. 16.00 - 18.00 Non-depolarising, intermediate duration, large doses may have cumulative effect, no histamine release, sympathetic blockade or vagolytic effect and it is ideal for cardiac surgery. Same as atracurium. Pregnancy, reduce dose in renal impairment and hepatic impairment. Powder for reconstitution - 4 mg/mL - 1 mL. amp. By IV injection, initially 80-100 mcg / kg (maximum 250 mcg/kg), then 30- 50 mcg/kg as required; By IV infusion, 50- 80 mcg/kg/h. For children: as adult dose (onset more rapid). Inj 4 mg (1mL) Rs. 113.00 - 120.00 Depolarising muscle relaxant, short duration (5 min), rapid, complete, predictable paralysis, spontaneous recovery, action cannot be reversed with drugs. Hypersensitivity, severe liver disease, burns. The action cannot be reversed and clinical application is therefore limited. Prolonged muscle paralysis may occur in patients with low or atypical plasma pseudocholine esterase enzyme. Injection 50 mg/ mL in 1 vial. By IV injection 600 mcg/ kg (range 0.3-1.1 mg/ kg depending on degree of relaxation required ) usual range, 20-100 mg. By IV infusion, as a 0.1% solution, 25 mg/ min (2-5 mL/ min ). By IM injection, adults and children, up to 2.5 mg / kg maximum 150 mg. Arrhythmias develop if Sch is given with digoxin. Cyclophosphamide and thiotepa enhance the effect of Succinyl choline Inj 50mg/mL (2mL) Rs 8.65 12.95 285
Vecuronium
I:
C/I, A/E, D/I: P/C: P/A: Dose:
Cost : I:
Suxamethonium (Succinyl choline)
C/I: P/C: A/E:
P/A: Dose:
D/I:
Cost:
ANTICHOLINESTERASES
Neostigmine
I: C/I: P/C: Myasthenia gravis, reversal of non-depolarising neuromuscular blockade. Intestinal or urinary obstruction. Asthma, recent myocardial infarction, epilepsy, hypotension, parkinsonism, peptic ulceration,renal impairment, pregnancy and breast-feeding. Nausea, vomiting, diarrhoea, and abdominal cramps. Signs of overdose are increased, gastro-intestinal motility, bronchial secretions, and sweating, involuntary defecation and micturition, miosis, hypotension, and weakness leading to fasciculation and paralysis. Tablet 15 mg, Injection 0.5mg/ mL Oral : neostigmine bromide 15-30 mg at regular intervals throughout day, total daily dose 75-300 mg. Neonate 1-5 mg every 4 hours, half an hour before feeds. For children : up to 6 years initially 7.5 mg. 6-12 years initially 15 mg, usual total daily dose 15-90 mg. Parenteral: By SC or IM, neostigmine methylsulphate 1-2.5 mg Myasthenia gravis. Same as for neostigrnine; weaker muscarinic action. Tablet 60 mg Oral 30-120 mg at regular intervals as required, total daily dose 0.3-1.2 g; neonate 5-10 mg every 4 h, 1/2 1 hr before feeds; For children upto 6 years initially 30mg, 6-12 years initially 60 mg, usual total daily dose 30-360 mg Same as neostigmine. Tab 60mg (150) Rs. 600.00 Has a very brief action and is used mainly for the diagnosis of myasthenia gravis. It is also used to determine whether a patient with myasthenia is
A/E:
P/A: Dose:
Pyridostigmine
I: C/I, P/C, A/E: P/A: Dose:
D/I: Cost : I:
Edrophonium Chloride
286
Anticholinesterases
C/I: P/C: A/E: D/I: P/A: Dose:
receiving inadequate or excessive treatment with cholinergic drugs. Same as neostigmine. Injection 10 mg/mL (1 mL ampoule) Diagnosis of myasthenia gravis, IV 2 mg followed after 30 second by 8 mg. Detection of overdose or underdosage of cholinergic drugs, IV 2mg. For children IV, 20 mcg/ kg followed after 30 seconds by 80 mcg / kg. Severe dementia in Alzheimers disease. Moderate to severe dementia in idiopathic Parkinsons disease. Same as for Donepezil. Cap 1.5mg, 3mg, 4.5mg, 6mg. Initial dose is 1.5mg twice daily in increments of 1.5mg twice daily at interval of 2 weeks to a maximum dose of 6mg twice daily. Cap 1.5mg (10) Rs 45.00, Cap 3 mg (10) Rs 65.00, Cap 4.5 mg (10) Rs 85.00, Cap 6 mg (10) Rs 105.00 Mild to moderate dementia in Alzheimers disease. Hypersensitivity to donepezil & piperidine derivatives, pregnancy & breast feeding. Sick sinus syndrome or other supraventricular conduction abnormalities; susceptibility to peptic ulcers; asthma, chronic obstructive pulmonary disease; may exacerbate extrapyramidal symptoms; hepatic impairment. GI disturbances, fatigue, insomnia, headache, dizziness, syncope, psychiatric disturbances,musc1e cramps, urinary incontinence, rash, pruritus; less frequently bradycardia, convulsions, gastric and duodenal ulcers, gastrointestinal haemorrhage; rarely sino-atrial block, AV block, hepatitis reported; potential for bladder outflow obstruction. Tablet, 5 mg, 10 mg. 287
Rivastigmine
I: P/C, A/E: P/A: Dose:
Cost:
Donepezil
I: C/I : P/C :
A/E:
P/A:
Dose :
D/I:
Cost:
Adult- Oral, 5 mg once daily at bedtime, increased if necessary after 1 month to 10 mg daily; maximum 10 mg daily. Rise in the plasma concentration by ketoconazole, itraconazole, erythromycin, fluoxetine, quinidine. Reduced plasma concentration by rifampicin, phenytoin, carbamazepine. Tab 5mg (10) Rs 80.00 90.00, Tab 10 mg (10) Rs 110.00 140.00. In Alzheimers disease Severe hepatic and renal impairment. Renal impairment Tab 4mg, 8mg, 12mg. Initial dose 4mg twice daily with food for 4 weeks then increase to 8mg BD. Maximum upto12mg BD. Galantamine levels are increased by quinidine, fluoxetine, fluoxamine, paroxetine. Dose should be reduced.
Galantamine
I: C/I: A/E: P/A: Dose: D/I:
288
SECTION 23 OPHTHALMOLOGICAL PREPARATIONS

ANTIBACTERIAL AGENTS: I: Infective blepharitis, conjunctivitis, gonococcal ophthalmitis, dacryocystitis, panophthalmitis, orbital cellulitis, corneal ulcers and all other bacterial diseases. Can be used topically and systemically.
Eye drops
Penicillin G Gentamicin Tobramycin Chloramphenicol Norfloxacin Ciprofloxacin Gatifloxacin Ofloxacin Moxifloxacin Levofloxacin Vancomycin Sulphacetamide : 10,000 units/mL : 0.3% : 0.3% : 0.5% : 0.3% : 0.3% : 0.3% (Rs. 15-40/-) : 0.3% : 0.5% (Rs. 20-50/-) : 0.5% (Rs. 20-50/-) : 20-50 mg/ml : 10, 20 & 30%
Eye ointments
Chloramphenicol applicaps:1% Tetracycline Norfloxacin Ciprofloxacin Moxifloxacin Gatifloxacin Tobramycin Erythromycin Dose: HCl 1% 0.3% 0.3% 0.3% 0.3% 0.3% 0.5% Eye drops : 1 drop every 2 hour initially and tapered according to response. Eye Ointment : Twice or thrice daily. 289
Ophthalmological Preparations
ANITIVIRAL AGENT
Acyclovir
Reaches adequate concentration in aqueous humour. Less toxic, wide spectrum against lesions caused by HSV, VZV, EB virus, CMV. P/ A : Eye ointment 3 %;Cream 5 % Dose : Apply 5 times/day till lesions heal.Systemic therapy is also necessary.Along with the antiviral medication. Corticosteroid therapy may be required in lesions caused by herpes viruses. ANTIFUNGAL AGENTS
Amphotericin B
Dose : Topical use 0.1 to 0.2 % solution hourly Subconjunctival injection 2 to 5 mg in 0.5 mL Anterior chamber irrigation 500 mcg in 0.1 mL lntravitreal injection 5 mcg in 0.1 mL
Nystatin
P/A: Ocular cream - 3.3 % (1 lakh unit/g) Ocular ointment- 3.3 % (1 lakh unit/g) Ocular suspension -1 lakh unit/mL
Clotrimazole
P/A : Dose : Drops 1 % in arachis oil Every hour till response occurs, then qds for 8 12 weeks. Drops 1% in arachis oil Cream 2% Every hour during day and 2 h during night. Solution 1 % Every hour during day and 2 h during night. Drops 1 % in arachis oil Every hour during day and 2 h during night. Natamycin suspension 5% Itraconazole suspension 1% Flucytosine solution 0.5% 1 drop hourly or 2 hourly and tapered according to response. Rs. 50 60/-
Miconazole
P/A : Dose :
Econazole
P/A: Dose :
Ketoconazole
P/A ; Dose :
Dose : Cost : 290
Corticosteroids used in Ophthalmology
ANTISEPTICS Povidone iodine eye drops 5% CORTICOSTEROIDS USED IN OPHTHALMOLOGY Systemic administration is needed in several conditions and these follow the same guidelines for systemic therapy in other conditions.Topical corticosteroids are employed for several allergic and inflammatory lesions where immunosuppression and antiinflammatory actions are desirable. I: Contact dermatitis of lids, allergic lesions of the eyes, phlycten, ocular pemphigus, Moorens ulcer, keratitis, corneal burns, iritis,iridocyclitis, posterior uveitis, optic neuritis, retrobulbar neuritis, endocrine exophthalmos, postoperative states. Local and systemic infection. Glaucoma, cataract, xerophthalmia, ptosis, mydriasis, allergic keratitis, infections by bacteria and fungi, and rarely systemic side effects. Cortisone, Suspension 0.5 %, Ointment 1.5 %
C/ I : A/E:
P/A:
Hydrocortisone
Suspension 0.5 % , Ointment 1.5 %, Solution 0.2 %
Prednisolone
Ointment 0.2 % , Solution 0.5 %
Dexamethasone
Ointment 0.5 %, Solution 0.1 %
Betamethasone
Ointment 0.5 %, Solution 0.1 %
Fluromethalone
Suspension 0.1 %
Triamcinolone
Ointment 0.1 % Depends on the clinical indication.Drop 2-3 times daily or even more frequently.Injections into the eye subconjunctival, anterior and posterior subtenon and retrobulbar - are done in different indications. All the NSAIDs can be used to suppress inflammation and give pain relief.Allergic conditions, demand the administration of sytemic antihistamines 291 Dose :
TOPICAL NSAIDS Diclofenac sodium Flurbiprofen Ketorolac Dose : 1 drop 4 times a day ANTI ALLERGIC (TOPICAL) Decongestant drops. Oxymetazoline 0.05%, 0.1% Dose : 1 drop 4 times daily
0.1% 0.03% 0.5%
Antihistamine
Chlorpheniramine maleate 0.01% Dose : Cost : Ketotifen Cromolyn sodium Azelastine Dose : Cost : 1 drop 3 time daily Rs. 10 20/: : : 0.05% 2%, 4% 0.05%
2 times to 4 times daily Rs. 40 50/-
DRUGS USED IN MEDICAL MANAGEMENT OF GLAUCOMA
Topical Drugs
Cholinergic drugs Increase the outflow of aqueous humor Pilocarpine 2%, 4% Dose : 1 drop 4 times daily Adrenergic drugs Drugs acting on the adrenergic system are also used in the management of glaucoma. They alter the dynamics of aqueous humour as given below. Agonists Selective alpha2 agonists - reduces the formation of aqueous humour. eg : apraclonidine 0.5% & 1%, Cost : brimonidine 0.15% 292 Cost : Rs. 30 50/Rs. 100 150/-
Drug used for Glaucoma
Antagonists
Selective Beta1 Antagonists and non selective Beta Antagonistreduces the formation of aqueous humour.
Timolol
Non selective beta antagonists. Intraocular pressure starts falling in 30 minutes and action lasts for 24 - 48 hours. The initial beneficial effect starts falling in a few weeks. P/A: Dose : Solution 0.25 % and 0.5 % To be used bd.
Betaxolol
Selective beta1 antagonist. Reaches high concentration in ciliary epithelium P/ A: Solution 0.5 % Dose : Applied bd. Levobunolol Non selective Beta antagonists. P/A: 0.5% Solution applied od. or bd.
Carbonic anhydrase inhibitors

Dorzolamide solution 2% Dose : Latanoprost Dose : Cost : 1 drop twice daily 0.005% 1 drop at bed time Rs. 250 350/-
Prostaglandin analogs
Systemic drugs in glaucoma

Carbonic anhydrase inhibitor : Acetazolamide P/A: Dose : 250 mg 250 mg od - bid
Hyperosmotic agents
Intravenous mannitol Dose : 2.5 7 ml/kg body weight of 20% solution IV. MYDRIATICS, MIOTICS AND CYCLOPLEGIC DRUGS These are commonly used in day to day ophthalmological practice. A. Parasympatholytic drugs Atropine, homatropine, scopolamine, cyclopentolate, tropicamide are used as mydriatic and cycloplegic drugs. 293
B. Sympathomimetic drugs Phenylephrine 5-10% eye drops C. Parasympathomimetic drugs Pilocarpine is used as miotic 4% eye drops.
Atropine sulphate
Mydriatic and cycloplegic, action lasts for 7-10 days. I: Iritis - to allay pain, prevent synechiae, give rest to the muscles. Intraocular surgery - pre and postoperatively. Narrow angle galucoma, allergy. Avoid atropine drops in children due to risk of systemic absorption.In them ointment is preferred. Contact dermatitis, xerostomia, flushing of skin and delirium. 1% eye drops, 1 % eye ointment Injection 0.3 , 0.4 and 0.6 mg/ mL IM or IV
C/I: P/C : A/E : P/A :
Homatropine
Synthetic alkaloid similar in action to atropine, but weaker and of shorter duration (1 to 2 days). I: P/A: Refraction testing postoperatively to relieve spasm, uveitis. 1%, 2% eye drops.
Cyclopentolate
Action starts within 30-60 min and it lasts for 12 - 24 hours. I: C/I : A/E : P/A: Refraction testing ciliary spasm, postoperative state, iridocyclitis. Narrow angle glaucoma. Visual hallucination, incoherence of speech. Ointment 1 %, 0.5% eye drops
Tropicamide
Rapid action, onset of action within 15 min and it last for upto 2 hours. I: P/A: Refraction testing, fundus examination and fundus photography. Drops 0.5 %, 1 %. eye drops.
Phenylephrine
Produces mydriasis without cycloplegia. Effects occur within 30 min and lasts for 2-3hours. . 294
Nutritional Disorders affecting the Eye
I: For fundoscopy, preopertively, malignant glaucoma. C /I: New born infants cardiac failure. P/ A : Solution 5 %, 10% OCULAR LUBRICANTS Carboxy methyl cellulose : 0.5 1% Dose : 1 drop 4 to 6 times daily LOCAL ANAESTHETICS Xylocaine 4% Proparacaine HCl 0.5% Bupivacaine 0.5%
Antioxidants
ZEBI D tablets ; RENERVE tablets: Vitamin E tablets 200mg NUTRITIONAL DISORDERS AFFECTING THE EYE Vitamin A deficiency Night blindness, Bitots spots, corneal ulceration, xerophthalmia, keratomalacia, blindness. Recommended dose of Vitamin A is 2,00,000 units daily for 2 days orally once in 6 months, or 1,00,000 unit i.m. injection.Thiamine deficiency, niacin deficiency, riboflavin deficiency, pyridoxine deficiency, Vitamin B12 deficiency, biotin deficiency and Vitamin C deficiency also cause nutritional disorder of the eye. Drugs which are particularly prone to cause ocular toxicity Antibacterials - chloramphenicol, ethambutol, isoniazid, nalidixic acid,rifampicin, griseofulvin, chloroquine, quinine
NSAIDs
Cardiovascular drugs - amiodarone, digoxin, quinidine Drugs acting on the nervous system - anticonvulsants (phenytoin), antidepressants, antiparkinsonism drugs, hypnotics, tranquillizers,ethyl alcohol, methyl alcohol, anticancer drugs Miscellaneous - continuous oxygen in infants, tobacco, excess Vitamin A and Vitamin D.
295
SECTION 24 OBSTETRICS AND GYNAECOLOGY

NUTRITIONAL REQUIREMENT IN PREGNANCY Diet in pregnancy should be light, digestable, nutritious and rich in proteins, vitamins and minerals. The dietary requirements in pregnancy . Total calories 2200 - 2500 Kcals. Proteins- 55 g, Fat 40 g Half of the protein should be first class protein containing essential aminoacids. Fat should include animal fat which contains Vitamins A & D. Daily diet should generally include 1/2 litre of milk, one egg, green leafy vegetables and fruits. Along with this supplementation of minerals and vitamins must be given.
Ideal diet prescribed for antenatal woman

National Institute of Nutrition (ICMR) Diet for pregnant women Food stuff Light Work Cereals Pulses Green leafy vegetables Other vegetables Roots and tubes Milk Fat and oil Sugar and jaggery Calories Protein Fat 445 g 55 g 100 g 40 g 50 g 200 mL 20 g 30 g 2200 K. cal 70 g 40 g
Moderate work 475 g 60 g 100 g 40 g 50 g 250 mL 20 g 30 g 2500 K. cal 75 g 50 g
Non vegetarians substitute pulses with 2 egg / 50 g fish or meat plus 10 g fat. The pregnant women should be advised to have her usual diet with additional provisions of green leafy vegetables, fruits, milk, and eggs. It is better to have snacks in between principal meals. DRUGS AND PREGNANCY Drugs should be used in pregnancy with caution. Certain drugs are absolutely contraindicated in pregnancy. 296
Drugs and Pregnancy
Drugs to be avoided in Ist trimester

Thalidomide, androgen and androgen derivatives, diethyl stilbesterol,tetracyclines, warfarin, folate antagonists like methotrexate.
Drugs which are possibly teratogenic and better avoided in pregnancy unless absolutely indicated
High dose aspirin, quinine derivatives, fluoroquinolones, indomethacin,lithium, phenytoin, gaseous general anaesthetics.
Drugs to be avoided in 3rd trimester as far as possible

Aminoglycosides, tetracyclines, beta blockers. Aminoglycosides and beta blockers may be used with caution where it is absolutely indicated.
Drugs contraindicated in lactation

Indomethacin, norfloxacin, lithium, anti malignant drugs. DOS AND DONT IN PREGNANCY
Confirmation of pregnancy can be done by

1. Urine test : _ a. card test as early as 3 - 5 day after missed period b. pregcolor c. gravindex test 2. Vaginal examination - as early as 6 weeks of pregnancy 3. Ultrasound examinations - from 5 weeks onwards.
Pattern of antenatal visits

First visit in the first trimester as early as 1 - 2 weeks after missing menstrual period. This is for confirmation of uterine pregnancy and for excluding other pathology like ectopic gestation, tumors, complicating pregnancy etc. Then the pregnant woman should be examined once in every months until 28 weeks, once in 2 weeks till 36 weeks and thereafter once in aweek.
What should be done at each visit?

Detailed history about present and past pregnancies, past medical and surgical illness, diseases and congenital anomalies in the family should be taken.Socioeconomic status of the patient should be assessed. A general and systemic examination should be done and then a detailed obstetric examination. ln the later weeks of pregnancy, obstetric examination should be made to assess the lie, presentation and position of the foetus. A vaginal examination should be done for a primigravidae near term to assess cephalopelvic disproportion. 297
Obstetrics and Gynaecology
Basic investigations to be done

This includes Hb estimation, Blood group and Rh, VDRL and urine for albumin and sugar. A glucose challenge test should be done for all pregnant women in the late 2 nd trimester, to detect impaired glucose tolerance and gestational diabetes mellitus (GDM). Glucose challenge test (GCT) is done by estimating random blood sugar I h after 50 g of oral glucose. If value is 130 or above a glucose tolerance test (GTT) should be done. A routine ultra sound scanning examination is advisable for all pregnant women by around 18 - 20 weeks of gestation. This will help to assess gestational age correctly and also to rule out gross congenital anomalies. But ultra sound examination (USE) is not a substitute for clinical assesment. X-ray should not be taken in pregnancy unless absolutely indicated. Screening of HIV and HBsAg should also be done. OXYTOCICS Oxytocics are drugs which make the uterus contract. They are used for induction of labour and abortions and also to treat post partum haemorrhage.
Oxytocin
I: C/I : Induction of labour, uterine inertia, postpartum haemorrhage,abortion. Cephalopelvic disproportion. In grand multipara, previous ceasarian section should be used with great caution. Monitor maternal and foetal cardiovascular status. Also see the uterine tone, adjust the rate of infusion accordingly . Hypertonic uterine contraction and rupture of uterus can occur if given without adequate supervision foetal hypoxia. Injection 5 IU Postpartum hemorrhage/induction of abortion : 5 units diluted in 500 ml. of 5% glucose or saline IV infusion Induction of Labour : It is given as an IV infusion with 2.5-5 IU in 500 mL of 5% dextrose saline or normal saline.
P/C:
A/E:
P/A: Dose:
298
Oxytocics
D/I:
Cost: I: C/l: P/C: A/E: P/A: Dose:
The drip is started with a rate of 4 drops per minute and slowly increased until effective contractions are established. Pressor effect of sympathomimetics may be increased by oxytocin leading to postpartum hypertension. With prostaglandins there is risk of uterine rupture and cervical lacerations. With ergotamine synergestic effect in control of postpartum haemorrhage. Inj 5IU/ml ,1ml cost Rs 15/To hasten placental separation, to reduce lll stage haemorrhage, to treat atonic PPH. Coronary and peripheral vascular disease, pregnancy, cardiovascular disease. Avoid in hepatic and renal insufficiency. Thrombosis, gangrene Tablets 0.125 mg Injection 0.2mg, 0.5mg/ mL Oral 0.25 mg IV 0.2 0.5mg Methyl ergometrine is used intravenously in the 2nd stage of labour in cephalic presentation as the anterior shoulder of the baby is being delivered. This is for reducing 3rd stage haemorrhage and also to hasten placental seperation. It is also used as a first line of treatment for atonic PPH, where it is given as IV or IM bolus close. Risk of vascular occlusion increased with beta blockers, methysergide, and smoking.Erythromycin increases the plasma concentration of ergot alkaloids.Oral contraceptives increases the risk of thrombosis. Tablet, 0.125mg 10 tablets Rs 46/Inj 0.2mg/ml Rs12/-
Methyl Ergometrine
D/I:
Cost:
Prostaglandin
PGF2 alpha is the drug that is used. Given as IM injection for treatment of PPH. I: C/I: Therapeutic abortion, in postpartum bleeding, induction of labour. Cardiac, hepatic, pulmonary and renal diseases. 299
Raised intraoccular pressure, hypertension, diabetes,epilepsy. A/E: Nausea, vomiting, diarrhoea, fever. P/A: Injection 0.5 mg, Tablet 0.5 mg Dose: 0.25mcg/min IV given in normal saline PGF2 gel is used for cervical ripening as local application to cervical canal. D/I: Enhanced efficacy of oxytocics leading to uterine rupture. Antiprogestins enhance the efficacy. Cost: Inj 250mcg/ml Rs 98.42/INDUCTION OF LABOUR Labour is induced for various indications : The common indications are 1. Post dated pregnancy 2. Pregnancy induced hypertension and pre eclampsia. 3. Intra uterine growth restriction and foetal compromise when the continuation of intra uterine life is unfavorable for the foetus. 4. Intra uterine demise of the foetus. Methods of Induction can be medical and surgical Medical methods - several drugs are used Advantages are: 1. The dose of the drug can be adjusted. 2. Cheap and easily available. 3. Side effects are minimal. How to monitor the patient who is on oxytocin drip? 1. Watch uterine contractions - duration, intensity and interval. 2. Ensure that uterus relaxes in between contractions. If uterus remains tonically contracted,the infusion should be stopped. 3. Foetal heart rate, maternal pulse and temperature should be noted. Infusion should be stopped 1. If there is hypertonic uterine contractions. 2. Bradycardia or irregularity of foetal heart rate. 3. Maternal tachycardia or fever. Note: When labour is induced or augmented with oxytocin, the drip should be continued after delivery. The dose should be increased to 10 units/ 500 mL to prevent PPH. 300
P/C:
Drugs for Induction of Labour
PROSTAGLANDINS
Misoprostol (PGE1)
Uterine stimulant I: Cervical ripening, PPH, termination of pregnancy less than 49 days. C/I: Pregnancy, lactation P/C: Hypotension, IBD, renal disease. P/A: 25,50,100,2OO microgram Cost: Tablet 200mcg,(4Tab) Rs 61/-
PGE2 gel (0.5mg)

This is administered intra cervically. It is relatively convenient and effective method of induction of labour. But this drug should not be used if there is a history of bronchial asthma.
Surgical method of induction

This is by a low rupture of membranes. Conditions to be satisfied: Cervix should be partially effaced and at least 1 cm dilated. Presenting part must be vertex and fixed at the brim of the pelvis. INDUCTION OF ABORTION (MTP)
Upto 12 weeks MIFEPRISTONE

Progesterone antagonist I: C/I: P/C: A/E: MTP upto 49 days along with Misoprostol Suspected ectopic, hypersensitivity, porphyria, anticoagulant therapy, pregnancy, lactation. Asthma, COPD, prosthetic heart valve Anorexia, nausea, abdominal discomfort, loose stools, uterine cramps
Dose: 600mg single oral dose Cost: Tablet 200mg 1Tab Rs 325/Surgical methods Evacuation upto 6 weeks. This can be done using a menstrual regulation syringe (Karmans syringe) 6 8 weeks - Rapid dilatation using metal dialator under para cervical block followed by suction evacuation. 8 - 12 weeks- 2 stage dialatation using laminaria tent is done. Then suction evacuation is done. 301
2nd trimester abortion

Best method is extra amniotic instillation of ethacridine lactate. This is a sterile solution of coloured dye. It is introduced into the uterine cavity extra amniotically through a foleys catheter. lt acts by mechanical irritation.Can be followed by oxytocin drip. HYPEREMESIS GRAVIDARUM Ondansetron 4mg and 8mg tablet. VAGINITIS Abnormal vaginal discharge is a very common symptom in the female.Excessive vaginal secretion is normal in the pre pubertal, ovulation time,premenstrual period and during pregnancy. This has to be differentiated from vaginal discharge due to infections. Normal vaginal secretion is white in colour, odourless, and not associated with itching or soreness and will not contain any microorganism except Doderleins bacilli. ln the ovulation time the discharge is mucoid and colourless.
Monilial vaginitis
Caused by Candida albicans - a fungus which thrive in acidic pH. Hence common in pregnancy where vaginal pH is low. Also seen in diabetic woman.Can be transmitted to the sexual partner, also by contaminated water, towels etc. Also seen in patients taking antibiotics and steroids.
Diagnosis
Intense itching and discharge per vagina. Discharge is curdy white and thick. The fungus can be demonstrated in the vaginal discharge by preparing a wet smear by adding one drop of saline to a little discharge and examining under the microscope.
Treatment
1. Local vaginal pessaries containing : Nystatin (100,000 U) Clotrimazole - 1% vaginal cream 5g for 7- 14 days,100 mg vaginal tab one tab daily for 7 days,500 mg vaginal tab single dose. Miconazole 2% vag gel. (5 g) for 7 days,100 mg vag vaginal ovules one daily for 7 days Povidone iodine 200 mg ovules one daily for 3 days The pessaries are inserted for 3 6 consecutive days. 302
Drugs for Vaginitis
2. Oral : fluconazole - 150 mg - single dose Ketoconazole - (200mg tab)1 tab b.d. x 5 days Both partners should be treated.
Trichomonas vaginitis
Caused by the protozoa Trichomonas vaginalis. Symptoms are intense itching and profuse foul smelling discharge p/v. Treatment : Metronidazole is the drug of choice 200 mg thrice daily x 7 days for both partners. Single dose of 2 g for both partners also can be given. Tinidazole 2 g stat. also may be given.
Clindamycin vag tab

I: C/I: P/C: Dose: Topical treatment of bacterial vaginosis. Hypersensitivity Hepato renal ,Gl disease, atopy, pregnancy, lactation. 2% cream at night for 3-7 days.
Atrophic vaginitis
Occurs in the post menopausal women. This is due to oestrogen deficiency.Malignancy should be excluded by a cervical smear (pap - smear) Treatment : Local oestriol cream is applied 2 - 3 times daily until patient gets symptomatic relief. CONTRACEPTIVES
Oral contraceptives Combined pills having oestrogen and progestogens (Mala-D, Mala-N) are usually used.The estrogen is ethinyl oestradiol 20/30 mcg. The progestogen is either norgestrel or desogestrel. Tablets should be started from the lst day of periods, continued for 21days. The fresh packet should be taken exactly on the 7th day. Some OC pill packet have 7 placebo tablets of iron to be taken following the hormone tablets,so the patient need to remember just to take one tablet a day only.
Contraindications
Thromboembolic disorders or history of thromboembolism, active liver disease, cancer of the genital tract or breast, avascular headache. .
Injectable contraceptives
Usually used once are progesterone only. Contraceptives like Depot. Medroxyprogesterone acetate. 303
Dose: 150 mg given IM once in 3 months. Action - like OC pills.
Contraindication
Active liver disease, malignancy of cervix or breast.
Emergency contraception
This is advised when the women has an unprotected coitus in the fertile period.
Methods
1. Oral administration of 2 tablets of combined OC pill (Ethinyl Estradiol and Levonorgestrel) as early as possible with in 72 hours and then repeated after 12 hours. 2. Mifeprestone 600 mg single dose taken with in 72 hours 3. Post coital insertion of IUCD within 5 days. 4. Levonorgestrel (0.15mg 1 tab) with in 72 hrs of intercourse(iPill) DRUGS USED FOR INDUCTION OF OVULATION Induction of ovulation is needed in treatment of infertility due to anovulation. The usual drugs used are: 1. Clomiphene citrate 2. Gonadotrophins FSH & LH.
Clomiphene citrate
50 mg is given from the 3rd or 5th day of periods for 5 days.The dose may be increased upto 150mg/ day Complication is hyperstimulation and multiple ovulation resulting in multiple pregnancy. Ideally patient should be monitored with serial ultrasound examination for evidence of ovulation and number of follicles. Cost: Tab 50 mg(10 tab) Rs 55/-
Gonadotrophins
They are used when the patient fails to ovulate with clomiphene. Human menopausal gonadotrophin which has mainly the FSH activity is used for follicular growth. Human chorionic gonadotrophins which has the LH activity is used for inducing follicular rupture. 75 - 150 IU of HMG is given from 2 nd or 3rd day of period. The follicular development should be watched by U.S.S examination. When the follicular size reaches 18 mm and oestradiol level is 200mcg, HCG is administered 5000 - 10,000 IU for follicular rupture. It is better that these drugs are used in bigger hospitals or infertility centres where there are facilities for monitoring the patients. 304
Drugs for Dysfunctional Uterine Bleeding
DRUGS USED IN DUB (DYSFUNCTIONAL UTERINE BLEEDING)
Danazol (Refer Section 18) Mefenamlc acld

I: P/A: A/E: C/I P/C: Dose: Cost: Dysmenorrhoea, as an analgesic in muscle joint and soft tissue pain. 250mg, 500 mg tab. Diarrhoea, epigastric discomfort, rash, dizziness, haemolytic anaemia Active Peptic Ulcer,Gl bleed, hypersensitivity, porphyria, lBS Bleeding disorder, asthma, hypertension, hepatic, renal or cardiac disease. 250-500mg TDS Tab 250mg(10tab) Rs10/-
Tranexamic acid
Antifibrinolytic I: P/A: Dose: Prevention of excessive bleeding, menorrhagia due to IUCD. 500mg tab. lnj.100mg/ml. 1-1.5 g TDS oral O.51 g TDS slow IV infusion Menorrhagia: 2.5-10mg daily in a cyclical regimen, Severe hepatic dysfunction, Dubin Johnson syndrome, Rotors syndrome, porphyria, pregnancy, undiagnosed vaginal bleeding. hypertension, hepatic dysfunction, epilepsy, lactation Endometriosis: 5-15mg daily continuously for 4-9 months. Contraception: 0.6mg daily/1-1.5 daily when combined with estrogen. 5mg 10 tab Rs.50 Menorrhagia, secondary amenorrhoea:2.5-10 mg daily for 5 to 10 days starting on day16 of the cycle; mild to moderate endometriosis:10mg TDS/50mg weekly. Hypersensitivity, thrombophlebitis, cerebral apoplexy, severe hepatic dysfunction,pregnancy, hormone dependent carcinoma. 305
Norethisterone
I: C/l:
P/C: Dose:
Cost: I:
Medroxy progesterone acetate
C/I:
P/C:
Cost:
depression, Diabetes Mellitus,epilepsy, asthma, migraine, visual disturbances, lactation, renal and cardiac dysfunction. Tab 10mg(10 tab) Rs 44/-;Inj 150mg/30ml(3ml) Rs 60/HYPERTENSION IN PREGNANCY
Alpha methyl dopa

Alpha methyldopa 250mg BD
ECLAMPSIA
Magnesium Sulphate has a major role in eclampsia for the prevention of recurrent seizures. Monitoring of bloodpressure, respiratory rate and urinary output is carried out, as is monitoring for clinical signs of overdosage (loss of patellar reflexes, weakness, nausea,sensation of warmth, flushing, double vision and slurred speechcalcium gluconate injection is used for the management of magnesium toxicity. Magnesium sulfate is also used in women with pre-eclampsia who are at risk of developing eclampsia; careful monitoring of the patient is necessary.
LABETALOL (Refer Section 10) HYDRALAZINE (Refer Section 10)

TOCOLYTIC
Terbutaline sulphate
I: C/I: P/C: P/A: A/E: Dose: Cost: To prevent preterm labour Hypersensitivity, arrhythmia, eclampsia, intrauterine infection, placenta previa, threatened abortion Pregnancy, DM, hypertension, hyperthyroidism Tab.2.5/5.0 mg. inj.500mcg/ampoule Fine tremor, tachycardia, palpitation, muscle cramps, angioedema, urticaria 250mcg SC hourly till contraction subsides, then 5mg oral 4th hourly Tab 2.5mg(20 tab)Rs 13.62/-;Inj 0.5mg/ml Rs 8.29/-
306
SECTION 25 PSYCHOTHERAPEUTIC DRUGS

ANTIPSYCHOTIC DRUGS
Chlorpromazine
I: Schizoprenia and other psychoses, mania, short term adjunctive management of anxiety, psychomotor agitation, induction of hypothermia, antiemetic and in terminal illness, intractable hiccups. Comatosed states, bone marrow depression and phaeochromocytoma. Cardiovascular and cerebrovascular disease, respiratory disease, parkinsonism, pregnancy, breastfeeding, renal and hepatic impairment, leucopenia, hypothyroidism, myasthenia gravis, prostatic hypertrophy, and angle-closure glaucoma. Drowsiness, extrapyramidal symptoms such as drug induced parkinsonism, occasionally tardive dyskinesia, akathisia, hypothermia, apathy, pallor, nightmares, insomnia, depression Antimuscarinic symptoms like dryness of the mouth, constipation, difficulty with micturition, and blurring of vision; cardiovascular symptoms such as hypotension, tachycardia, and arrhythmias; respiratory depression. Endocrine effects such as menstrual disturbances, galactorrhoea, gynaecomastia, impotence and weight gain. Toxic effects such as leucopenia, leucocytosis, agranulocytosis and haemolytic anaemia, jaundice. Neuroleptic malignant syndrome, corneal and lens opacities Tablets 10 mg, 25 mg, 50 mg, 100 mg, 200 mg, Injection 25mg/ mL Schizophrenia and other psychoses Oral- start initially with 25-50 mg tds, or 75-150 mg at night, adjusted according to response.The usual maintenance dose is 75-300 mg od, rarely up to 1 g od be required for psychoses. Elderly, one-third to half adult dose. 307
C/l: P/C:
A/E:
P/A: Dose:
Psychotherapeutic Drugs
D/I:
Cost:
Intractable hiccup - 25 to 50 mg tds or qds orally or by IM injection . Enhanced sedative effect with alcohol, anxiolytics and hypnotics enhanced hypotensive effect with anaesthetics and antihypertensives. Reduced absorption of chlorpromazine with antacids. Antagonism of antipsychotic effect with dopaminergics. Tab 25 mg (10) Rs. 1.70-5.70 Inj 25 mg/mL (2 mL) Rs. 4.20 -21.20 Schizophrenia and other psychoses, psychomotor agitation, anxiety, antiemetic. Same as for chlorpromazine. Tablets 1 mg, 5 mg, 10 mg. Schizophrenia, other psychoses and psychomotor agitation. Start initially with 5 mg bd, or 10 mg od in modified release form and increase by 5 mg after 1 week according to the response to a maximum of 20 mg/ day in divided doses. Tab 5 mg (10) Rs. 4.50-6.00
Trifluoperazine Hydrochloride
I: C/l, P/C, A/E, D/I: P/A: Dose:
Cost: I:
Thioridazine Hydrochloride
Schizophrenia and other psychoses, psychomotor agitation, anxiety. C / I, P/C, A/E, D/ I: Same as for chlorpromazine. Additional side effects include delayed ejaculation, pigmentary retinopathy and lenticular opacity if dose is more than 800 mg/ day. P/A: Tablets 5 mg, 10 mg, 25 mg, 50 mg and 100 mg. Dose: Oral: schizophrenia and other psychoses 150-600 mg od initially in divided doses, up to a maximum of 800 mg daily in hospitalized patients. For psychomotor agitation, excitement and violent behavior 75-200 mg od Anxiety, and agitation in the elderly, 30-100 mg od Cost: Tab 50 mg(10) Rs. 30.50-37.50 308
Antipsychotic Drugs
Fluphenazine Hydrochloride
I: Schizhophrenia and other psychoses, mania, short term adjunctive management of severe anxiety, psychomotor agitation, excitement and violent, dangerously impulsive behaviour. Same as for chlorpromazine. Tablet 1 mg, 2.5 mg, 5 mg, Injection 25 mg /mL contain oily solution of fluphenazine decanoate for depot use. Schizophrenia and other psychoses Oral : 2.5 -10 mg od in 2-3 divided doses; adjusted according to response to 20 mg od; doses above 20 mg (10 mg in elderly) should be given cautiously. Parenteral: 25 mg as deep IM injection once in 2 - 4 weeks. Anxiety, agitation and excitement Oral: initially 1 mg bd, increased as necessary to 2 mg bd. Inj 25 mg/ml. (1 mL) Rs. 26.90-29.90 Schizophrenia and other psychoses, mania, severe anxiety, nausea, vomiting, vertigo, labyrinthine disorders. Same as for chlorpromazine. Tablets 5 mg, 25mg Injection 12.5 mg/mL. Schizophrenia and other psychosis Mania: start with 12.5 mg bd for 7 days and adjust at intervals of 4-7 days to reach the usual dose of 75-100 mg od according to response; Anxiety: 15 to 20 mg od in divided doses upto a maximum of 40 mg. Parenteral: IM 12.5 mg initially and followed if necessary after 6 hours an oral dose. Labyrinthine disorders: 5 mg t.d.s., gradually increased upto 30 mg od and then reduced after several weeks to the maintenance dose of 5-10 mg od Tab 5 mg (10) Rs. 8.00 - 9.00 lnj 12.5 mg/mL (10 mL) Rs. 40.00 - 43.00 Schizophrenia and other psychoses, mania, short term adjunctive management of psychomotor agitation, 309
C/l, P/C, A/E, D/I: P/A: Dose:
Cost :
Prochlorperazine
I:
C/I, P/C, A/E, D/l: P/A: Dose: Oral:
Cost:
Haloperidol
I:
excitement and violent or dangerously impulsive behaviour, severe anxiety, intractable hiccup,motor tics. C / I, P /C, A/ E, D/I:Same as for chlorpormazine hydrochloride. P/A: Tablets 0.25 mg, 1 mg, 1.5 mg, 5 mg, 10 mg, 20 mg, Injection 5mg/ 1 mL, Drops 10 mg/ mL . Syrup 2 mg/ mL, 10 mg/ mL, Depot Injection 50 mg/ mL as decanoate. Dose: Schizophrenia and other psychoses. Oral : Start initially with 1.5 -3 mg bd or tds or 3-5 mg bd or tds in severely affected or resistant patients. In resistant schizophrenia up to 100mg (rarely upto 120 mg) od may be needed. Maintenance dose is adjusted as the lowest effective dose which may be as low as 5-10 mg od. Elderly initially half adult dose; Adolescents upto 30 mg od, exceptionally upto 60 mg. Parenteral 2mg by IM injection, 2-10 mg, subsequent doses being given every 4-8 h according to response upto a total maximum of 60 mg. Severely disturbed patients may require initial dose of upto 30 mg. Anxiety - adults 0.5 mg bd. Hiccup 1.5 mg tds, adjusted according to response.Nausea and vomiting 0.5-2 mg. Motor tics and adjunctive treatment of chorea - orally, 0.5-1.5 mg tds, adjusted according to the response. Upto 10 mg od. or more may be needed. Cost : Tab 1.5 mg (10) Rs. 6.60-12.20 Inj 5 mg/mL (1 mL) Rs. 4.75-4.90
Flupenthixol
I: Schizophrenia and other psychoses, particularly with apathy and withdrawal but not mania or psychomotor hyperactivity, depression. Same as for chlorpromazine. Tablets 0.5 mg, 1 mg, 3mg Injection 20 mg/ 1mL, 40 mg/ 2mL. . Psychoses: Initially 3-9 mg b.d. adjusted according to the response upto a maximum of 18 mg od; Elderly -
C/I, P/C, A/E, D/I: P/A: Dose:
310
Antipsychotic Drugs
Cost:
start initially with quarter to half adult dose; Depression: Initially 1 mg in the morning, increased after 1 week to 2 mg if necessary to maximum 3 mg o.d., doses above 2 mg are divided into 2 portions, second dose not after 4 p.m. Discontinue if no response after 1 week at maximum dosage.Elderly 0.5 mg to 2 mg/ day Parenteral dose: Schizophrenia and other psychoses, 20-40 mg deep IM as depot injection every 2-4 weeks. Tab 1 mg (10) Rs. 28.00 Inj 40 mg (2 mL) Rs. 147.00 Acute and chronic psychoses Same as for chlorpromazine hydrochloride Capsules 10 mg, 25 mg, 50 mg. Oral initially 20-50 mg od in 2 divided doses, increased as necessary over 7-10 days to 60-100 mg od upto a maximum of 250 mg in 2-4 divided doses. The usual maintenance dose of 20- 100 mg od Caps 50 mg (6) Rs. 73.00 77.00.
Loxapine
I: C/I, P/C, A/E, D/I: P/A: Dose:
Cost :
Pimozide
Schizophrenia, monosymptomatic hypochondriacal psychoses, paranoid psychoses, mania. C/1, P/C, A/E, D/I: Same as for chlorpromazine, but less sedating. It is contraindicated in breast feeding. Serious cardiac arrhythmias may occur and therefore ECG has to be taken before treatment in all patients and repeated during the course. P/A: Tablets 2mg, 4 mg, 10 mg. Dose: Schizophrenia. Oral : Initially 10 mg o.d., adjusted according to response with increments of 2 - 4 mg at intervals of 1 week or more upto a maximum of 20 mg od For prevention of relapse the maintenance dose may vary from 2-20 mg/day. For elderly, start with half the adult dose. Monosymptomatic hypochondriacal psychoses and paranoid psychoses. Start initially with 2 mg od, and adjust according to response with increments of 311 I:
Cost:
2 - 4 mg at intervals of 1 week or more upto a maximum of 16 mg od Elderly, half usual starting dose. Mania, hypomania, short-term adjunctive management of excitement and psychomotor agitation. Start initially 2-4 mg od and adjust according to response with increments of 2-4 mg at intervals of 1 week or more upto a maximum of 20 mg od. Tab 2 mg (10) Rs. 12.00 - 30.00 Schizophrenia in patients unresponsive to, or intolerant of conventional antipsychotic drugs. Severe cardiac disease; history of drug-induced neutropenia or agranulocytosis; bone marrow disorders; alcoholic and toxic psychoses; history of circulatory collapse or paralytic ileus; drug intoxication, coma or severe CNS depression, uncontrolled epilepsy, pregnancy and breastfeeding. Leucocyte and differential blood counts must be normal before treatment and must be monitored weekly for first 18 weeks, then fortnightly. Avoid drugs which depress leucopoiesis, withdraw treatment if leucocyte count falls below 3000/ mm3 or absolute neutrophil count falls below 1500/ mm 3. Patients should report any infections, hepatic or renal impairment, epilepsy, cardiovascular disorders, prostatic enlargement, glaucoma, paralytic ileus. Avoid abrupt withdrawal, avoid in children. High incidence of antimuscarinic symptoms; extrapyramidal symptoms may occur less frequently, neutropenia and potentially fatal agranulocytosis, fever, headache, dizziness, urinary incontinence, priapism, pericarditis, myocarditis, delirium, hypotension, sialorrhea, skin rashes and convulsions (if dosage is above 800 mg/ day). Tablets 25 mg, 100 mg Start 12.5 mg od or bd on first day, then 25-50 mg on second day, then increase gradually in steps of 25-50 mg over 7-14 days to 300 mg od in divided doses. Larger
Clozapine
I: C /I:
P/C:
A/E:
P/A: Dose:
312
Antipsychotic Drugs
D/ I :
Cost :
dose upto 200 mg od may be taken as a single dose at hs Further increased in steps of 50-100 mg once or twice weekly may be required. Usual antipsychotic dose 200-450 mg od upto a maximum of 900 mg od Subsequent maintenance dose of 150-300 mg. Elderly, 12.5 mg once on first day subsequent adjustments restricted to 25 mg od. Clozapine cause agranulocytosis when used concurrently with drugs associated with a substantial potential for causing agranulocytosis, such as cotrimoxazole, chloramphenicol, sulphonamides, penicillamine, cytotoxics or carbamazepine. Tab 100 mg (10) Rs. 19.80-52.10 Acute and chronic psychoses. Same as for chlorpromazine. Tablets: 1mg, 2 mg, 3 mg, 4 mg Liquid 1 mg / mL Oral : 2 mg in 1-2 divided doses on first day, and increased to 4 mg on second day, 6 mg in 1-2 divided doses on third day upto the usual range of 4-8 mg od Upto 16 mg od may be given exceptionally only if benefit is considered to outweigh the risk. Elderly, 0.5 mg bd, increased in increments of 0.5 mg bd to 1-2 mg bd. For children under 15 years not recommended. . Tab 2 mg (10) 12.90-19.50 Schizophrenia, therapeutic and prophylactic for bipolar disorder- acute mania/ mixed mania and depression Hypersensitivity Myocardial infarction, ischemia, heart failure, conduction abnormalities, cerebro-vascular disease, seizure, hepatic impairment, impaired motor activity, conditions which predispose to hypotension, elderly, previously detected breast cancer, pituitary tumours Postural hypotension, constipation, dizziness, weight gain, agitation, somnolence, akathisia, tremor, personality disorders, hyperprolactinemia. 313
Risperidone
I: C/I, P/C, A/E, D/I: P/ A: Dose:
Cost :
Olanzapine
I:
C/I: P/C:
A/E:
P/A: Dose:
Cost:
Tablets 2.5 mg, 5mg, 7.5 mg and 10 mg Injection 5mg/ml, each vial contains 10mg 5- 20 mg/ day. Initially 5- 10 mg once daily. Increase by 5mg/ week until desired a maximum dose of 20 mg/day is reached. Tabs 2.5 mg (10) Rs. 12.00 5mg (10) Rs. 24.00 7.5 mg (10) Rs. 35.75 10 mg (10) Rs. 47.00 Schizophrenia, acute mania Patients below 18 yrs Renal or hepatic impairment, epilepsy, cardiovascular or cerebro-vascular disease, hypotension Hyperglycemia, weight gain, sedation, dizziness. Rarely, Neuroleptic Malignant Syndrome (NMS), seizures 25mg, 50mg, 100mg, 200mg, 300mg Sustained Release preparation- 50mg, 100mg, 200mg 50- 800 mg/day. Initially 25 mg twice daily. Increase by 25-50 mg twice daily. Maximum dose- 800mg/ day Tabs 25mg (10) Rs. 17.00 - 20.00 100mg (10) Rs. 40.00 - 47.00 200mg(10) Rs. 78.00 - 89.00 Schizophrenia, delaying relapse in schizophrenia, acute agitation in schizophrenia, acute mania or mixed mania Recent acute MI, uncompensated heart failure, conditions that may increase QT interval or history of QT prolongation, congenital long QT syndrome, concomitant use with other drugs known to increase QT interval, arrhythmias treated with class i & iii antiarrhythmic drugs Patients predisposed to significant electrolyte disturbances especially hypokalemia should have baseline serum K+ and serum Mg2+. It should be corrected before treatment. Concomitant diuretic treatment, cerebro-vascular disease, significant cardiovascular illness, history of seizures, pituitary tumours, hepatic impairment, pregnancy and lactation.
Quetiapine
I: C/I: P/C: A/E:
P/A: Dose: Cost:
Ziprasidone
I: C/I:
P/C:
314
Antipsychotic Drugs
A/E:
P/A: Dose: Cost:
Discontinue, if persistent QTc measurements of >500msec. May impair ability to drive or operate machinery. Avoid alcohol. Somnolence, akathisia, extra pyramidal syndrome, dizziness, dystonia, headache, GI disturbances, asthenia, agitation, hypertonia, less elevated SGPT, musculoskeletal complaints, CNS disturbances, rhinitis, maculopapular rash, urticaria, visual disturbances, urinary incontinence. Tablets- 20 mg, 40 mg, 60 mg and 80 mg 40- 200 mg/ day. Initial dose 20 mg twice daily. Maximum approved dose 100 mg twice daily. Tablet 20 mg (10) Rs. 32.00 Tablet 40 mg (10) Rs. 63.00 Tablet 60 mg (10) Rs. 94.50 Tablet 80 mg (10) Rs. 125.50 Schizophrenia, bipolar disorder, aggression Hypersensitivity, circulatory collapse, CNS depression, comatose state, blood dyscrasias and phaeochromocytomas Pregnancy, diabetes mellitus Drowsiness, extrapyramidal symptoms, tardive dyskinesia Injection- 50mg/ 1mL Depot injection- 200mg/ 1mL Tablets- 25mg Initially 10-15 mg/ day in divided doses. Increase by 10-20 mg/day every 2-3 days. Maximum dose- 100 mg/ day Injection- Initial dose- 100mg- 200mg I/M once in 2-4 weeks Tabs 25mg(10)Rs. 150.00 Injection - 1ml vial Rs. 70.00 2ml vial Rs. 110.00 Depot injection 1ml vial Rs. 175.00
Zuclopenthixol
I: C/I:
P/C: A/E: P/A: Dose:
Cost:
ANTIDEPRESSANTS
Amitriptyline I: Depressive illness particularly where sedation is required. Nocturnal enuresis in children, Prophylaxis of migraine 315
C/I:
P/C :
A/E:
P/A: Dose :
D/I :
Recent myocardial infarction, arrythmias particularly heart block,manic phase of depression, severe liver disease. Cardiac disease, history of epilepsy, pregnancy and breast feeding,elderly subjects, hepatic impairment, phaeochromocytoma, history of mania, psychoses, angle-closure glaucoma, history of urinary retention. Abrupt withdrawal should be avoided. It should be used with caution in subjects requiring anaesthesia. Drowsiness may affect skilled tasks such as driving and handling of machinery during work. The effects of alcohol are enhanced. Dry mouth, sedation, blurred vision, constipation, nausea, urinary retention; cardiovascular side effects such as arrhythmias, postural hypotension, tachycardia, hypersensitivity reactions including urticaria and photosensitivity; hypomania, mania, confusion, interference with sexual function, increased appetite and weight gain, endocrine sideeffects such as testicular enlargement, gynaecomastia, galactorrhoea; neurological features such as tremors, convulsions, movement disorders and dyskinesias, fever, agranulocytosis and jaundice. Tablet 10 mg, 25 mg, 50 mg , 75 mg. Oral: Start initially with 25 mg daily and increase gradually to a maximum of 150 mg either as single dose hs or in divided doses. The usual maintenance dose is 50-100 mg od, For the elderly and adolescents the average dose is smaller (30- 75 mg/ day). For migraine prophylaxis initially 10 mg as a single bedtime dose, to be increased gradually if necessary up to 100 mg. Nocturnal enuresis. Enhanced sedative effect with alcohol, CNS excitation and hypertension with MAOIs, antagonism of antidepressant effect with antiepileptics, hypotensive effect enhanced with antihypertensives, increased sedative effect with antihistaminics,
316
Antidepressants
Cost :
reduction of effect of sublingual nitrates, oral contraceptives antagonise antidepressant effect, potentiation of hypertension and arrhythmias with adrenaline. Tab 10 mg (10) Rs. 8.00-11.00
Imipramine
I: Depressive illness, nocturnal enuresis in children C/ I, P /C, A/E, D/ I: Similar to amitriptyline hydrochloride, but the drug is less sedative. P/ A: Tablet 25 mg and 75 mg, Capsule 25 mg and 75 mg. Dose: Depressive illness: Start with upto 25 mg daily and increased gradually upto 150-200 mg, even upto 300 mg in hospitalized patients. Upto 150 mg may be given as a single dose hs The usual maintenance dose is 50-100 mg od. For the elderly, start initially with 10 mg od and increase gradually to 30-50 mg od. Nocturnal enuresis For children upto7 years, 25 mg, 8 - 11 years, 25-50 mg over 11 years, 50-75 mg single dose given hs. The maximum period of treatment including gradual withdrawal should not exceed 3 months. Cost : Tab 25 mg (10) Rs. 5.00 - 7.00 Caps 75 mg (10) Rs. 21.00 - 28.00
Nortriptyline
I: C/I:,P/C:,A/E:,D/I: P/ A: Dose: Depressive illness, nocturnal enuresis in children Similar to amitriptyline hydrochloride but less sedating. Tablet 25 mg Depressive illness: Start with low dose initially and increase as is necessary to 75 - 100 mg od in divided doses or as a single dose. For adolescent and elderly 30-50 mg od in divided doses. Not recommended for children. Nocturnal enuresis : For children below 12 years 25 mg, over 12 years 50 mg hs. The maximum period of treatment including gradual withdrawal should not exceed 3 months. Tab 25 mg(10) Rs 10.00 317
Cost :
Amoxapine
I: Depressive illness C / I, P/ C, A/E, D/I: Similar to amitriptyline. Additional side effects include tardive dyskinesia, akathesia,menstrual irregularities, breast enlargement and galactorrhoea. P/A: Tablet 50 mg and 100 mg Dose: Initially 100-150 mg od in divided doses or as a single dose at hs, increased gradually to a maximum of 300 mg od The usual maintenance dose is 150-250 mg. For the elderly the dose is initially 25 mg bd increased as is necessary after 5-7 days to a maximum of 50 mg tds. Cost : Tab 50 mg(10) Rs. 38.00
Clomipramine
Depressive illness, phobic and obsessional states; adjunctive treatment of cataplexy associated with narcolepsy. C/I , P/C, A/E, D/I : Same as for amitriptyline hydrochloride P/A: Tablets 10 mg, 25 mg and 50 mg. Capsule 10 mg and 25 mg. Dose: Initially 10 mg od, increased gradually as necessary to 30-150 mg od in divided doses or as a single dose at hs upto a maximum of 250 mg od The usual maintenance dose is 30-50 mg o.d. For the elderly start with 10 mg od and increase over 2 weeks to 100-150 mg od For adjunctive treatment of cataplesy associated with narcolepsy, start with 10 mg od and gradually increase to 10- 75 mg/day until satisfactory response is obtained . Cost : Cap 25 mg (10) Rs. 29.00 - 35.00 Tab 25 mg (10) Rs. 27.00 - 30.00 I:
Dothiepin
Depressive illness particularly where sedation is required C/I , P/C , A/E , D/I: Same as for amitriptyline hydrochloride P/A: Tablet 25 mg and 75 mg. Capsules 25 mg Dose: Initially 25 mg daily increased gradually as necessary to 150 mg daily, and even up to 225 mg daily at times. For the elderly 75 mg may be sufficient. 318 I:
Antidepressants
Doxepin
Depressive illness, particularly where sedation is required. C/I ,P/C, A/E, D/I: Similar to amitriptyline hydrochloride. This drug should be avoided during breast feeding. P/A: Capsule 10 mg, 25 mg and 75 mg. Dose: Start with 30 mg od or in divided doses or as a single dose hs, and increase as necessary to maximum of 300 mg od, in 3 divided doses of 100 mg each. The usual range is 30-300 mg od In the majority 30-50 mg od may be adequate. For the elderly initial dose is 10-50 mg od This drug is not recommended for children. Cost : Cap 25 mg (10) Rs. 15.00-29.00 I:
Fluoxetine:
I: C/I : P/C : A/E : Depression, obsessive compulsive disorder (OCD), panic disorders, anxiety disorders. Pregnancy, lactation. Use with caution in patients with seizures and diabetes. Insomnia, anorexia, nausea, diarrhoea, headache, nervousness, anxiety, seizures in high doses, sexual dysfunction. Capsule 20 mg. Suspension 20 mg/ 5 mL Depression - 20 mg/ day. OCD - 60 mg/day. Increased sedation with other drugs having sedative effect on central nervous system. Produces agitation, restlessness and gastric distress with tryptophan. Produces changes in serum lithium level. Produces sedation, dry mouth and constipation with other antidepressants. Cap 20 mg (10) Rs. 14.50 - 30.00 Susp 20 mg/5 mL (60 mL) Rs. 35.00 Same as for fluoxetine. Hypersensitivity, pregnancy, lactation, history of drug abuse, hepatic or renal impairment, seizure disorders. Tablet 50 mg 319
P/A: Dose : D/I :
Cost:
Sertraline
I, P/C, A/E, D/I: C/I: P/A:
Dose : Cost :
100 - 150 mg/day. Tab 50 mg (10) Rs. 35.00 Depressive disorder, Obsessive Compulsive Disorder (OCD) Lactation, patients below 18yrs, concomitant use of pimozide, thioridazine, MAOI or within 2 weeks of stopping MAOI or 1 day of stopping Moclobemide Pregnancy, history of seizures or diabetes mellitus or mania/ hypomania, bleeding disorders, hepatic or renal insufficiency Same as for fluoxetine Tablet 50mg and 100mg Tablet 50- 330 mg/day Depression- Initially 50 or 100 mg as a single dose. Usually maintenance dose -100mg/ day. Maximum dose- 300 mg/day OCD- Usually 100-300 mg/day 50mg (10) Rs. 85.00- 110.00 Tab 100mg (10) Rs. 150.00- 195.00 Depressive disorder, OCD, panic disorder, social phobia, Generalized Anxiety Disorder (GAD), Post- traumatic Stress Disorder (PTSD) Pregnancy, patients below 18 yrs, concomitant use of thioridazine or pimozide, concomitant use of MAOI Same as for fluoxetine Tablets- 10mg, 30mg and 40 mg Depression- 20 mg once daily OCD- Initially 20mg once daily, increase 10mg/week to a maximum dose of 40 mg GAD- 20 mg/day Social phobia- 20- 40mg/day PTSD- 20 mg/day Tab 10mg (10) Rs. 70.00 Tab 30mg (10) Rs. 140.00 Tab 40mg (10) Rs. 170.00
Fluvoxamine
I: C/I:
P/C:
A/E and D/I: P/A: Dose:
Cost: Tab
Paroxetine
I:
C/I: P/C, A/E and D/I: P/A: Dose:
Cost:
320
Antidepressants
Citalopram
I, A/E and D/I: C/I and P/C: P/A: Dose: Same as for fluoxetine Same as for fluvoxamine Tablets-10mg, 20mg and 40 mg 20-60 mg/day. Initially 10-20 mg/day for 1 week. Increase by 10 mg every 2-3 weeks. Maximum dose60 mg/day Tab 10mg (10) Rs. 30.00 Tab 20mg (10) Rs. 55.00 Tab 40mg (10) Rs. 99.00 Same as for fluoxetine Same as for fluvoxamine Tablets 5mg, 7.5mg, 10mg, 15mg and 20 mg 10-20 mg/day. Maximum dose- 20mg/day Tab 5mg (10) Rs. 29.00 Tab 10mg (10) Rs. 49.50 Tab 20mg (10) Rs. 99.50 Depression, Generalized Anxiety Disorder, Social Phobia, anxiety disorder Pregnancy, lactation, uncontrolled hypertension, concomitant use of MAOI, patients below 18 yrs Renal or hepatic impairment, seizure disorder, mania/ hypomania, coronary artery disease, bleeding tendencies, glaucoma Nausea, G-I upset, headache, insomnia, somnolence, sexual dysfunction, liver dysfunction, elevated BP, Steven Johnsons syndrome, Toxic Epidermal Necrolysis, serotonin syndrome Capsules- 25mg, 37.5mg and 75mg Extended release capsules- 37.5 mg, 75mg and 150mg 75-375 mg/day. Initially 37.5 mg twice daily, increase to 75mg twice daily after 2 weeks. If needed, increase by 75 mg/day, once in every 4 days to a maximum of 375 mg/day Serotonergic drugs increase the risk for serotonin syndrome. 321
Cost:
Escitalopram
I, A/E and D/I: C/I and P/C: P/A: Dose: Cost:
Venlafaxine
I: C/I: P/C:
A/E:
P/A: Dose:
D/I:
Cost:
Cap 25mg (10) Rs. 12.50- 30.00 Cap 37.5mg (10) Rs. 18.00- 50.00 Cap 75mg (10) Rs. 35.00- 80.00 Extended release cap-37.5mg (10) Rs. 20.00- 60.00 Extended release cap-75mg (10) Rs. 38.00-100.00 Extended release cap-150mg (10) Rs. 75.00
Duloxetine
Depression, neuropathic pain associated with diabetes mellitus, stress urinary incontinence C/I, P/C, A/E and D/I: Same as for Venlafaxine P/A: Capsules 20mg and 30 mg Dose: 60 mg/day. Initially 20mg twice daily, increase to 60 mg/day Cost: Cap 20mg (10) Rs. 44.00 Cap 30mg (10) Rs. 65.00 I:
Milnacipran
I: C/I: P/C: A/E: P/A: Dose: Depression, chronic pain Hypersensitivity, patients below 15 yrs, concomitant use of MAOI, pregnancy and lactation Advanced renal disease, prostatic hypertrophy, hypertension, heart disease, open angle glaucoma Itching, nausea, vertigo, increased activity, sweats, shivering, dysuria, elevation of liver enzymes, delirium Capsules 25mg and 50mg Capsule 50- 100 mg/day. Initially 50 mg/day orally as single dose, then increase to maximum dose of 100mg/day With MAOI, lithium, clonidine, epinephrine and digitalis Cap 25mg (10) Rs. 40.00 Cap 50mg (10) Rs. 80.00 Depression Pregnancy, lactation, concomitant use with or within 14 day of use of MAOI
D/I: Cost:
Mirtazapine
I: C/I:
322
Antidepressants
P/C:
A/E:
P/A: Dose:
D/I: Cost:
Renal or hepatic impairment, epilepsy, organic brain syndrome, cardiac conduction disturbances, angina, glaucoma, mania, psychosis Increased appetite, weight gain, drowsiness, dizziness, somnolence, nausea, constipation, asthenia, flu syndrome, headache, bone marrow depression, agranulocytosis Tablets- 15mg and 30mg Tab 15-45 mg/day. Initially 15mg once per day at night. Increase 15 mg/day once in every 5 days to a maximum dose of 60 mg/day Potentiates the effect of CNS depressants Tab 15mg (10) Rs. 60.00 Tab 30mg (10) Rs. 115.00 Depression Pregnancy, lactation, narrow angle glaucoma Renal or hepatic impairment, cardiac and cerebro vascular disease, hypertension especially in elderly, epilepsy, hyperthyroidism Dry mouth, taste perversion, nausea, constipation, insomnia, dizziness, headache, sweats, chills, urinary retention, sexual dysfunction. Tablets 2mg and 4mg 4-12 mg/day. Initially, 4mg twice daily. Increase after 3-4 weeks to 10 mg daily or to a maximum of 12 mg/day With MAOI, fluvoxamine, antipsychotics, lithium, carbamazepine, antihypertensives Tab 2mg (10) Rs. 165.00 Tab 4mg (10) Rs. 310.00 Depression, social phobia, panic disorder Acute confusional states, concomitant use of SSRIs & TCAs, phaeochromocytoma 323
Reboxetine
I: C/I: P/C:
A/E:
P/A: Dose:
D/I: Cost:
Moclobemide
I: C/I:
P/C:
A/E:
P/A: Dose: D/I:
Cost:
Severe hepatic dysfunction, thyrotoxicosis, hypertension (avoid excessive tyramine rich food, pregnancy and lactation Sleep disturbances, agitation, restlessness, irritability, dizziness, headache, paraesthesias, nausea, vomiting, diarrhoea and constipation Tablets- 150mg and 300mg 300-600 mg/day. Initially 300 mg/day in 2 or 3 divided doses. Increase after several weeks to 600 mg/day Avoid TCAs, SSRIs, MAOI, 5HT reuptake inhibitor, trazodone, metoprolol, sympathomimetics, antihypertensives. Tab 150mg (10) Rs. 67.50 Tab 300mg (10) Rs. 125.00 Depression, bipolar disorder, smoking cessation, Attention Deficit Hyperactivity Disorder (ADHD), cocaine detoxification, hypoactive sexual desire disorder Seizure disorder, anorexia nervosa, bulimia nervosa, CNS tumour, alcohol/ benzodiazepine withdrawal, pregnancy and lactation History of seizures, unstable angina, hypertension, hepatic or renal impairment Insomnia, headache, dry mouth, nausea, tremor, GI upset, tachycardia, hypertension, rash, risk of seizures Tablets- 150 mg 150- 450 mg/day. Initially 1 tab daily for 6 days. Increase to 1 tab twice daily with 8 h between doses Antipsychotics, antimalarials, theophyllines, antihistamines Tab 150mg (10) Rs. 400.00 MOOD STABILISERS
Bupropion
I:
C/I:
P/C: A/E: P/A: Dose: D/I: Cost:
Lithium
I: Treatment and prophylaxis of mania and manicdepressive illness and recurrent depression; aggressive or selfmutilating behavior.
324
Anxiolytics
C/I:
P/C:
A/E:
P/A: Dose:
D/l:
Cost: Other drugs
Renal failure and cardiac failure, disturbed electrolyte balance, major surgery, pregnancy and lactation, sicksinus syndrome. Avoid in renal impairment, cardiac failure, and Addisons disease, caution in pregnancy, breastfeeding, myasthenia gravis, surgery. Gastro-intestinal disturbances, fine tremor, polyuria and polydipsia, and oedema. hyperthyroidism, hypokalaemia. Signs of lithium intoxication are blurred vision, anorexia, vomiting and diarrhoea, muscle weakness,CNS disturbances and these require withdrawal of treatment. With severe overdose convulsions, toxic psychoses, coma and occasionally death may occur. Tablets 150 mg, 300 mg, 450 mg, Capsule 300 mg. 600-800 mg / day in divided doses till a blood level of 1-1.55 mEq/L is achieved. Maintenance level should aim at 0.7-1 mEq/L. Serum levels should be maintained during treatment at this level. Levels above 1.5 mEq/ L are dangerous. Lithium toxicity is made worse by sodium depletion therefore concurrent use of diuretics particularly thiazides is hazardous and should be avoided. Tab 300 mg (10) Rs. 11.00 -13.00 Carbamazepine, Sodium Valproate, Lamotrigine, Levetiracetam, Zonisamide. ANXIOLYTICS
Diazepam
I: Short-term use in anxiety or insomnia, adjunct in alcohol withdrawal; status epilepticus and febrile convulsion. Respiratory depression, acute respiratory failure, severe hepatic impairment. Respiratory disease, myasthenia gravis, pregnancy and breast feeding, hepatic and renal impairment. Drowsiness, confusion and ataxia, amnesia, dependence, paradoxical increase in aggression. 325
C/I: P/C: A/E:
P/A:
Dose:
D / I:
Cost :
Tablets 2mg, 5 mg, 10 mg Capsule 2mg, 5mg, 10 mg, Injection 5mg/ mL. Injection (emulsion) 5mg/ mL for i.v. injection or as infusion. Anxiety Oral - 2 mg tds increased if necessary to 15-30 mg od in divided doses; Elderly half the adult dose; Insomnia associated with anxiety 5-15 mg hs; Children with night terrors and somnabulism, 1-5 mg hs Parenteral - slow IV injection into a large vein at a rate of not more than 5 mg/ min, for the management of severe acute anxiety, control of acute panic attacks, and acute alcohol withdrawal. 10 mg may be repeated, if necessary after 4 h. Injection (IM) canbe given but absorption from the site is erratic and the are unpredictable. Rectal for acute anxiety and agitation, as rectal solution or suppositories 10 mg. If necessary a further 10mg may be given after at least 10 min.; elderly 5 mg. Isoniazid, omeprazole and disulfiram inhibit metabolism of diazepam and other benzodiazepines. Benzodiazepines antagonise the effect of levodopa. Tab 10 mg (10) Rs. 4.00 24.00 Cap10 mg (10) Rs. 12. 00- 13.00 Inj 5 mg/mL ( 2 mL) Rs. 10.00 For the short term management of anxiety states. Same as for diazepam. Tablets 0.25 mg, 0.5 mg, I mg Sustained Release (SR) 1.5 mg 0.25-0.5 mg tds, Elderly 250 mcg bd tds, increased if necessary to a total of 3 mg Same as for diazepam Tab 0.5 mg (10) Rs. 14.00 15.00 For short term use in anxiety. Adjunct in acute alcohol withdrawal symptoms. Same as diazepam. Tablets 10 mg and 25 mg Anxiety 10 mg tds increased if necessary to 60-100 mg od in divided doses; For elderly half adult dose.
Alprazolam
I: C/I, P/C, A/E: P/A: Dose: D/I: Cost:
Chlordiazepoxide
I: C/I, P/C, A/E, D/I: P/A: Dose:
326
Anxiolytics
Cost :
Adjunct in acute alcohol withdrawal symptom: 10- 50 mg qds.,gradually reducing over 7-14 days. Tab 25 mg (10) Rs. 9.00-30.00
Lorazepam
Short term use in anxiety or insomnia; Status epilepticus C/I, P/C, A/E, D/I ; Same as for diazepam. P/A; Dose: Tablets 1 mg, 2 mg. Injection 2mg/ mL Oral : anxiety 1-6 mg od in divided doses; Elderly start at 1-2 mg/ day in divided doses. Insomnia associated with anxiety 1to 2 mg hs Parenteral ; IM or IV injection into a large vein. This is indicated in acute panic attacks, dose is 20-30 mcg/ kg, repeated every 6 h if necessary. Tab 1 mg (10) Rs. 5.00 18.00 Inj 2 mg/mL (2 mL) Rs. 7.00 8.00 I:
Cost :
Oxazepam
This is a short acting drug with a half life of 6-10 hrs compared to diazepam which has a half life of 60 h. I: C/I, P/C, A/E, D/I: P/A: Dose: Short term use in anxiety As for diazepam; short acting. Tablets 15 mg, 30 mg Anxiety, 15-30 mg Elderly 10-20 mg tds or qds; Insomnia associated with anxiety 15-25 mg, upto a maximum of 50 mg hs. Tab 15 mg(10) Rs. 9.00 Anxiety Epilepsy, severe hepatic or renal impairment, pregnancy and breast-feeding. Presence of hepatic or renal impairment Nausea, dizziness, headache, nervousness,excitement, tachycardia and confusion. Tablet 5mg and 10 mg. 327
Cost :
Buspirone
I: C/I: P/C: A/E: P/A:
Dose:
Initially 5 mg b.d. or t.d.s., increased every 2-3 days if needed. The usual dose ranges from 15-30 mg o.d. upto a maximum of 45 mg o.d. Tab 5 mg (10) Rs. 8.35-18.00 SEDATIVE HYPNOTICS
Cost:
Nitrazepam
I: C/I: P/C : A/E: P/A: Dose: D/I: Short term use in insomnia Myaesthenia gravis, respiratory depression, acute pulmonary insufficiency, severe hepatic impairment. Respiratory disease, muscle weakness, hepatic and renal impairment. Drowsiness, confusion and ataxia, dependence. Tablet 2.5 mg, 5 mg, 10 mg 5-10 mg hs Elderly 2.5-5 mg; Enhanced sedative effect with alcohol and opioid analgesics, enhanced hypotensive effect with antihypertensives. Tab 5 mg . (10) Rs. 9.50.00 17.00\ Same as for nitrazepam. Capsule 15 mg 15 - 30 mg h.s. Elderly 15 mg. Cap 15 mg (10) Rs. 25.00 38.00 Short term use in insomnia . Myasthenia gravis, respiratory failure, severe sleep apnoea syndrome, hepatic impairment, pregnancy and lactation. Pregnancy, hepatic and renal insufficiency. Duration of treatment with zopiclone should not exceed 4 weeks. Bitter or metallic taste; gastro-intestinal disturbances including nausea and vomiting, drowsiness, incoordination, headache, hypersensitivity reactions, hallucinations, amnesia and behavioral disturbances. Tablet 7.5 mg. Dose : 7.5 mg hs Elderly 3.75 mg hs increased if necessary.
Cost :
Flurazepam
I, C/I, P/C,A/E, D/I: P/A: Dose: Cost :
Zopiclone
I: C/I :
P/C:
A/E:
P/A:
328
Drugs used in substance dependence
D/I: Cost :
General sedative interactions as for benzodiazepines and other anxiolytics and hypnotics. Tab 7.5 mg (10) Rs. 37.00 -50.00 DRUGS USED IN SUBSTANCE DEPENDENCE
Methadone
I: C/I: Adjunct in treatment of opioid dependence Acute respiratory depression, acute alcoholism, risk of paralytic ileus; raised intracranial pressure or head injury (affects papillary responses vital for neurological assessment) Renal and hepatic impairment, severe withdrawal symptoms on abrupt withdrawal; hypothyroidism, convulsive disorders, decreased respiratory reserve and acute asthma; hypotension, prostatic hypertrophy; pregnancy, breast-feeding. Nausea, vomiting, constipation; drowsiness; also dry mouth,anorexia, difficulty with micturiction, spasm of urinary and biliary tract, bradycardia, tachycardia, palpitation, dysphoria, mood changes, decreased libido or potency, rash, urticaria, pruritus, sweating, headache, facial flushing, vertigo, postural hypotension, hypothermia, hallucinations, confusion, miosis, larger doses produce respiratory depression, hypotension, and muscle rigidity Concentrate for oral liquid: 5 mg/mL;10 mg/mL (hydrochloride). Oral liquid: 5 mg/5 mL; 10 mg/5 mL. Adjunct in treatment of opioid dependence, by mouth, initially 1040 mg daily, increased by up to 10 mg daily (maximum weekly increase 30 mg) until no signs of withdrawal or intoxication; usual dose range 60120 mg daily. Adjunct in the treatment of chronic alcohol dependence. Cardiac failure, coronary artery disease and history of cerebrovascular accident, hypertension,psychoses, pregnancy and breast-feeding. 329
P/C:
A/E:
P/A: Dose:
Disulfiram
I: C/I:
P/C:
A/ E: P/ A: Dose:
D / I:
Cost:
Ensure that alcohol is not consumed for at least 24 hours before initiating treatment, hepatic and renal impairment, respiratory disease, diabetes mellitus, epilepsy. Drowsiness and fatigue; nausea and vomiting, reduced libido, rarely psychotic reactions. Tablet 250 mg. 1 g as a single dose on first day, reduced over 4 days to 0.75g to 0.25g od; should not be continued for longer than 6 months without review. Psychotic reaction with metronidazole, inhibition of metabolism of tricyclic antidepressants. Inhibition of metabolism of phenytoin. Inhibition of metabolism of benzodiazepines, leading to enhanced sedative effect. Tab 250 mg (10) Rs. 15.00
330
SECTION 26 PAEDIATRIC DRUGS AND NUTRITION

ANTIMICROBIALS IN CHILDREN
331
Paediatric drugs
332
Paediatric drugs
333
Paediatric drugs
334
Paediatric drugs
335
Paediatric drugs
336
Paediatric drugs
337
Paediatric drugs
ANTHELMINTICS Albendazole: P/A : Dose: Tab 400 mg ;Suspension: 400 mg/10 mL >2 yrs. 400 mg hs (maybe repeated in pinworm infestation after consultation) ; 1-2 yrs. 200 mg.
Note: In hydatid cyst & cysticercosis, 15 mg/kg/day in divided doses (14 days) Mebendazole: P/A: Dose: Tab 100 mg;Suspension: 100 mg/5 mL 100 mg BD X 3 days (not below 2 yrs. of age)
Diethyl carbamazine: P/A: Dose: Tab 50 mg, 100 mg;Syrup 50 mg/5 mL 6 mg/kg/24h q8h X 14-31 days (Filariasis) 10 mg/kg/24h q8h X 14-21 days (tropical eosinophilia)
Piperazine citrate :
P/A: Dose : Syrup. 750 mg/5 mL;Tab: 500 mg 75-100 mg/kg OD X 2 days (Ascariasis) 65 mg/kg X 7 days (Pinworm infestation) Ivermectin : P/A : Dose : Pyrantel : P/A : Dose : Tab 250 mg Syrup. 250 mg/ 5 ml 11 mg/kg hs X 1 day For pinworm & hookworm repeat after 14 days. DOSE ADJUSTMENT OF COMMONLY USED ANTIBIOTICS WITH RENAL FAILURE Dose with renal function (% normal) 338 Tab 6 mg 150 mcg/kg (approved for children >5 years)
Paediatric drugs
Medication Teicoplanin
>50 %
10-50 %
<10 %
10 mg/kg/q 12H for 3 Reduce dose by 50% Reduce dose by 60% Doses, then 10 mg/kg/q24h 10 mg/kg q8h 10-15 mg/kg q6-8h 2.5 mg/kg q12h 10 mg/kg q24h Reduce daily dose by 50% q12h 2 mg/kg q12h Reduce daily dose by 50% q8h No change Nochange 1 mg/kg q23h 10 mg/kg q48-72h Not recommended
Tobramycin Vancomycin
Cotrimoxazole 6-10 mg/kg/day q12h
Gentamicin Imipenem+ Cilastatin Linezolid Metronidazole Meropenem
2-2.5 mg/kg/q8-12h 30-60 mg/kg/day q6h
1 mg/kg q24-48h Reduce daily dose by 75% q12h No change Reduce daily dose by 50%
10 mg/kg q8h 20-25 mg/ kg/day q8h 60-120 mg/ kg/day q8h
Reduce dose by 50% Reduce dose by 50% q12h q24h Reduce dose by 50% Reduce dose by 75%
ANTIPYRETICS AND ANALGESICS Paracetamol P/A: Dose : A/E : Ibuprofen P/A: Dose : A/E: Tab 250,500,650 mg . Suspension: 125 or 250 mg/ml. Inj: 150 mg/mL 10-15 mg/kg/dose q 6h Gi upset,> 150mg/kg causes fatal liver cell failure.
Tab 200,400 mg. Suspension: 100mg/5mL. 8-10 mg/kg/dose q 6-8 hrly Gi symptoms, hypersensitivity reaction,renal failure,rarely hepatic damage. Acetyl salicylic acid P/A: Tab 75,100,150,350 mg. Dose: Rheumatic fever : 75-100 mg/kg/day q6h. Antiplatelet dose :3-5mg/kg single dose Analgesic : 10mg/kg/dose q6h. 339
Paediatric drugs
C/I : P/C : A/E : Naproxen P/A : Dose : Mefenamic acid P/A : Dose : Indomethacin Dose Chloroquine C/I: P/C: A/E : P/A: Dose: Methotrexate P/A: Dose:
coagulation disoders, thrombocytopenia. Vit K deficiency, viral fever for fear of Reye syndrome angioedema, anaphylaxis, bronchospasm, GI ulceration. Tab 250,500mg 10-20 mg/kg/day q12h Tab 250,500 mg Syr: 50mg/5mL 8- 10 mg/kg/dose q 8-12h 2-3 mg/kg/day
DISEASE MODIFYING ANTI RHEUMATOID DRUGS (DMARDS ) Psoriasis hepatic and renal involvement,monitor visual acuity. rash,peripheral neuropathy, hypotension(IV) Tab : 100 mg,250 mg(150mg base). 3mg/kg daily Tab: 2.5mg,5mg,7.5mg,10 mg. Inj: 50mg/2 mL. 5-15 mg/m2/week as a single dose,approximately 0.30.5 mg/kg/week. Monitor liver function and blood counts. 1 mg folic acid daily may prevent deficiency. Bone marrow suppression, gastric upset, rash, nephrotic syndrome, hemolytic anemia. Tab : 250 mg. 2.5-5 mg/kg daily, can be increased to 15-20 mg/kg daily. 2mg/kg/day ANTISPASMODICS Atropine P/A: Dose : 340 Injection 0.6 mg/mL 10-20 mcg/kg/dose IM or IV
Penicillamine A/E: P/A: Dose :
Azathioprine
Dose:
Paediatric drugs
Dicyclomine Hydrochloride P/A: Tablet 200mg; Syrup 10mg/5ml; Drops : 10 mg/mL Dose : Infants 5 drops/dose; older children0.5 mg/kg/dose Hyoscine Butylbromide P/A: Tablet : 10 mg; Injection : 20mg/mL Dose : >6 years 1 tab tds or 0.5 mL IM or IV ANTIHISTAMINES AND MEDICINES USED IN ANAPHYLAXIS Promethazine P/A : Syrup 5mg/5mL; Injection 25 mg/mL Dose : 0.5 mg/kg/dose Metoclopramide P/A : Tablet : 10mg; Injection: 5mg/ml; Syrup : 5mg/5mL Dose : 0.1-0.2 mg/kg/dose IM/oral. Domperidone P/A : Tablet : 10mg; Suspension 1mg/mL Dose : 0.2-0.4 mg/kg/dose, may be repeated. Pheniramine Maleate P/A : Tablet: 25, 50 mg; Syrup 15 mg/5mL; Injection : 22.75 mg/mL Dose : 1mg/kg/24h, 8-12 h oral or IM or IV Diphenhydramine P/A : Tablet : 25, 50 mg; Syrup 12.5 mg/5mL Dose : 5mg/kg/25 h, 8 h oral Cetirizine P/A : Tablet :10mg; Syrup 5mg/5mL Dose : 2-6 years 5mg daily; above 6 years 10 mg daily. Dexamethasone: I: Cerebral oedema: 1mg/kg/day q6h. P/A : Inj: 4mg/mL, Tab: 0.5mg, Drops 0.5mg/mL. Dose : Anti-inflammatory -0.2 mg/kg/day Epinephrine P/A: Inj : 1mg/mL of 1: 1000 solution. Dose : Anaphylaxis : 0.01 mg/kg of 1 : 1000 solution SC or IM or 0.1mg/kg of 1: 10,000 solution slow IV. 0.05-2 mcg/ kg/ minute infusion. SHOCK Hydrocortisone Dose: 10mg/kg/dose by slow IV as single dose. 341
Paediatric drugs
Prednisolone P/A Dose:
Tab: 5,10,20 mg. Syrup: 5mg/5mL. 1-2 mg/kg/day in divided doses. ANTI ASTHMA DRUGS
Relievers
Salbutamol A/E : P/A: Dose: tremor,palpitation,rarely hypokalemia. Tab:2mg,4mg. Syp: 2mg/5ml.Rotacap: 200mcg. MDI 100 mcg/puff. Respirator solution-5mg/ml. 0.1-0.2mg/kg/dose q6-8h. Nebulisation: 0.03ml/kg/dose with equal volume saline q 4-6 h ( 0.15mg/kg/dose). Continuous nebulisation : 0.5mg/kg/hour. Aerosol : 2 puff q6h. dry mouth, blurred vision. Respirator solution : 250mcg/mL. Aerosol: 20mcg/puff. 125 mcg in<5 yrs, 250mcg in >5yrs for nebulisation. (12.5mcg/kg/dose q6-8h)
Ipratropium
A/E: P/A: Dose:
Adrenaline(see section on anaphylaxis)

Aminophylline P/C: A/E: P/A: Dose: Deriphylline P/A: Dose: Never give IM. Not compatible with sodium bicarbonate. convulsions,arrhythmias,gastric upset Tab: 100mg. Inj: 250mg/10mL. 5mg/kg loading dose in 20 mL of dextrose solution followed by 1mg/kg/h infusion.
Tab: 100mg. Syrup: 50mg/5mL. Inj: 110 mg/mL. 5mg/kg/dose q8h. IM. Slow release preparation of theophylline: 10-15 mg/ kg/day q12h. Cap 125mg,250mg. Magnesium sulphate A/E: hypotonia, bradycardia, respiratory paralysis. P/A: Inj : 50% solution Dose: 0.1-0.2 mL/kg/dose of 50% solution ( 50-100 mg/kg/ dose) slow IV in 50 ml normal saline over 20 minutes.May repeat after 6 hrs. 342
Paediatric drugs
Terbutaline
A/E: P/A: Dose: Tremor,tachycardia. Tab : 2.5 mg, 5mg. Syrup : 1.5 mg/5mL Nebulisation solution 10mg/mL MDI: 250mcg/dose 0.005mg/kg/dose ( 0.01ml/kg/dose) SC. 0.05mg/kg/dose q8h oral nebulisation: 5 drops (<20kg) , 10 drops (> 20kg)
Prednisolone: (see section on anti-inflammamtory drugs)

Methyl Prednisolone P/A : Inj 500mg,1g Tab: 4mg,16 mg. Dose : A/c asthma: 2mg/kg/dose q8h. Auto-immune diseases and shock: 30mg/kg/dose. PREVENTORS
Salmeterol
A/E: Tachycardia, rarely prolonged QT interval in ECG, insufficient data in < 4 yrs. For preventive thereapy , its used in combination with Fluticasone. MDi 25mcg/puff Rotacaps: 50mcg/cap 1-2 puff 12 h. dysphonia,candidiasis .Insufficient data in < 2 yrs. MDi:nasal spray,0.05% cream,lotion 100 mcg or more q12 h as MDi MDi: 100 mcg,200mcg Rotacaps: 100,200,400 mcg/dose. Nasal spray: 50mcg/ puff low dose<400 mcg/day; medium dose: 400-800 mcg/ day; high dose: >800 mcg/day MDi:100 or 200 mcg/puff: rotacaps and nasal spray also available low dose<400 mcg/day; medium dose: 400-800 mcg/ day; high dose: >800 mcg/day Tab: 4mg chewable tab for 2-6 yrs ; 5mg for 6-12 yrs; 10mg for > 12 years. To be chewed 1 hour before or 2 hours after food. 343
P/A: Dose : Fluticasone A/E: P/A: Dose: Budesonide P/A:
Dose: Beclomethasone P/A: Dose: Montelukast P/A:
Paediatric drugs
OTHER RESPIRATORY DRUGS
Acetyl Cysteine
Mucolytic Dose: Bromhexine Mucolytic Dose: Ambroxol Mucolytic Tab: Dose: 4mg /dose q6-8h. Nebulisation with 20% solution-1-2 mL for infants.2-5 ml for children
30mg, syrup: 15mg/5ml depends on other active ingredients like salbutamol. DRUGS ACTING ON CVS
INOTROPES
Digoxin C/I: A/E: P/A: Dose: Significant Ventricular arrhythmias,AV block, HCM. bradycardia,AV block,GI symptoms. Tab: 250mcg,Inj: 50mcg/amp Elixir: 50mcg/mL Rapid digitalization: preterm:20mcg/kg; term infant: 30mcg/kg; Infant: 50mcg/kg; child:40mcg/kg Maintenance dose: 7.5-10 mcg/kg. IV: 75% of oral dose. 2-20mcg/kg/min
Dobutamine Dose: Dopamine: Low dose:
2-5mcg/kg/min ; intermediate dose: 5-15 mcg/kg/min; high dose: >15mcg/kg/min. Epinephrine(mentioned elsewhere) Milrinone: Dose: Load 50mcg/kg over 10 minutes Maintenance: 0.25-1 mcg/kg/min. ANTIARRHYTHMIC DRUGS Adenosine Dose: 100 250mcg/kg/dose rapid push with saline chase.Each increment at 2 minute intervals. Maximum12mg/dose.Same cycle can be repeated after 15-30 minutes.
344
Paediatric drugs
Amiodarone: A/E : Dose :
Hypothyroidism , lens toxicity, bradycardia, pulmonary fibrosis. Load 5mg/kg over 20-30minutes.Repeat after 1 hour. Maintenance 5-15 mcg/kg/minute. Oral Load 10 mg/kg; maintenance 2.5- 5 mg/kg Load 500mcg/kg over 2 minutes.Maintenance : 50-300 mcg/kg/min. Load 1.25 mg/kg .Repeat after 5 minutes. Maintenance 2.5- 5mg/kg. 0.5-1mg/kg bolus. Repeat after 5-10 minutes.Infusion 20-50 mcg/kg/minute. IV: 0.05-0.1 mg/kg/dose; max 1mg(infant) 2mg(children) oral 1-6 mg/kg/day. Max : 60 mg/day. In infants. IV: 0.1 mg/kg bolus over 2-5 minutes.(max-5mg) orall 2-3 mg/kg/day q8h ANTI-HYPERTENSIVES.
Esmolol Dose: Phenytoin Dose: Lidocaine Dose: Propranolol Dose: Verapamil C/I: Dose:
Captopril Dose: Enalapril Dose: Hydralazine Dose: Carvedilol Dose: Losartan Dose: Nifedipine Dose:
Neonate : 0.1-0.5 mg/kg/dose Infants and children- 1-2 mg/kg/dose. 0.1 mg/kg/dose Oral : 0.5-1.5 mg/kg IV: 0.1-2 mg/kg. Oral : 0.05 mg/kg/dose; titrate upto 0.4 mg/kg; step up on every 5th day. 0.7-1.4 mg/kg/day 0.5-3 mg/kg/day 345
Paediatric drugs
Amlodipine Dose:
0.05-5 mg/kg/day
Labetalol
Dose: 20mg/kg/day orally IV : 1-2 mg/kg/min. as infusion. Alpha methyl dopa Dose:10 mg/kg/day. Max: 30 mg/kg/day Prazosin Dose: 0.05-5 mg/kg/day Sodium nitroprusside Dose: IV: 0.5-10 mcg/kg/min DIURETICS Frusemide Dose: Torsemide Dose: oral 2-4 mg/kg/day IV :1-2 mg/kg/day. Infusion: 0.1-1 mg/kg/hour.
oral : 5-10 mg/kg/day od IV:10-20 mg OD for heart failure. Hydrochlorothiazide Dose: oral 1-2 mg/kg Spironolactone: Dose: 1-3 mg/kg/day MISCELLANEOUS DRUGS Heparin Dose: Enoxaparin Dose: Infusion: 10-20 U/kg/h; SC : 50-100 U/kg. SC: < 2 months- 1.5 mg/kg/dose; >2 months 1 mg/kg/ dose.
Streptokinase Dose: IV: 100 U /kg/h Indomethacin Indication : PDA closure in infants. Dose: oral: 0.2 mg/kg q12h 2 doses. Warfarin Dose : 0.05 -0.3 mg/kg; Max 10 mg/day 346
Paediatric drugs
STATINS Atorvastatin C/I: Dose: Lovastatin Dose: Simvastatin Dose : Morphine P/A: Dose : Pethidine P/A: Dose: Pentazocine P/A: Dose : 10mg, 15mg and 30 mg/mL 0.1-0.2 mg/kg/dose IM or SC. 50 mg/mL 0.5-1 mg/kg/dose IM or IV. Tablet : 20mg; Inj: 30 mg/mL Up to 0.5-1.0 mg/kg/dose IM or SC. In < 2 yrs. 5-10 mg/kg/day(preferably > 8 yrs). 10-40 mg/day 10-20 mg/day SEDATIVES
IMMUNOSUPPRESSANTS IN PAEDIATRIC PRACTICE
Cyclophosphamide
P/A Dosage : SLE : Inj:100mg, 200mg, 500mg, 1g, 2g Tab: 25 mg, 50 mg
IV 500-750mg/m2 every month . Maximum 1mg/m2 Nephrotic Syndrome : Oral 2-2.5 mg/Kg /day for 8-12 week along with oral steroids. JRA/ Vasculitis : IV 10 mg/kg very 2 weeks The total cumulative dose in children should be <170mg/kg Mycophenolate Mofetil: P/A: Capsule : 250mg; Inj: 500mg/vial I: Transplant recipients ,Systemic lupus erythematosis Dose: 600mg/m2/dose twice daily Tacrolimus P/A : Caps 0.5 mg, 1mg, 5mg; Inj: 5mg/mL; Topical 0.03% ointment. Dose : Oral :0.15-0.4 mg/kg/day divided every 12 hours, IV Continuous infusion : 0.03-0.15mg/kg/day. 347
Paediatric drugs
Cyclosporine : Dose in FSGS :
3-5mg/kg/day q12h PO Rheumatoid arthritis : 2.5mg/kg/day q12h4 mg/kg/day
DRUGS ACTING ON GASTROINTESTINAL TRACT Ranitidine P/A: Tab 150 mg, 350 mg ; inj: 50 mg/2mL Dose : 2mg/kg/dose x 2 PO 1-2 mg/kg/dose x 2-3 IV Omeprazole P/A: Cap 20mg, 10 mg; Tab 20mg, 10mg; Dose : 1mg/kg/day od orally Pantoprazole P/A: Tab 40 mg; Cap 40 mg; Inj: 40 mg/2mL; Dose : 0.5 1 mg/kg/day Ondansetron P/A: Tab 5mg, 8mg; Susp: 1mg/mL; Inj: 2mg/mL ANTIEPILEPTIC DRUGS Diazepam P/A : Dose : Lorazepam P/A: Dose : Midazolam P/A: Dose : Phenobarbitone P/A: Dose : Inj 5mg/mL: 0.3 mg/kg Inj: 1mg/mL 0.1 mg/kg Inj : 5mg/5mL 0.1mg/kg IV Infusion : 1-2 mcg/kg/min Inj : 200mg/mL; Tab : 30 mg, 60 mg ; Syrup: 15mg/5mL; 20mg/5mL Status : 20mg/kg slow IV (1mg/kg/min.). 10mg/kg can be repeated. Maintenance : 3-5 mg/kg/day Inj: 50mg/mL; Tab : 50mg, 100mg; Syrup: 30mg/5mL Status : 20mg/kg slow IV (1mg/kg/min.) dilute in normal saline Maintenance : 5-8 mg/kg/day q 12h
Phenytoin P/A: Dose:
348
Paediatric drugs
Fosphenytoin P/A: Dose : Carbamazepine P/A: Dose : Clonazepam P/A: Dose : Ethosuximide P/A: Dose : Topiramate P/A Dose : Oxcarbazepine P/A: Dose : Levetiracetam P/A: Dose : Lamotrigine P/A: Dose : Gabapentin P/A: Dose :
50 mg phenytoin = 75 mg Fosphenytoin 15-20 mg/kg of Phenytoin equivalent at 3mg/kg/min. Syrup:100mg/5ml; Tab: 100mg, 200mg, 400mg (200, 300, 400 SR) 10-30 mg/kg/day Tab : 0.25, 0.5, 1, 2 mg 0.05 3 mg/kg/day Cap : 250 mg, Syrup: 250 mg/5mL 20-50 mg/kg/day Tab : 25mg, 50mg, 100mg, 200mg Start with 1-3 mg/kg/day, increase weekly to maximum of 5-9 mg/kg/day Tab : 150, 300, 600 mg and SR 8-10 mg/kg/day to 20-40 mg/kg/day Tab : 250, 500, 750 mg; Syrup: 100mg/mL 10mg/kg/day to 40-60mg/kg/day Tab :5mg, 25mg, 50mg, 100mg, 150 mg, 250mg 0.6mg/kg/day to 2-8mg/kg/day If used with valproate, start on 0.15 mg/kg/day Tab : 150, 300, 600, 1200mg 20-70 mg/kg/day ORAL REHYDRATION SALTS
Two types of ORS 1. WHO ORS for Cholera diarrhea 2. Hypoosmolar ORS for non cholera diarrhea Available as sachets to be dissolved in 1 litre water. 349
Paediatric drugs
Constituents (1 sachet) Item NaCl KCl NaCitrate Glucose Na K Cl Citrate Glucose Osmolarity I: P/C: A/E: Dose: WHO ORS 3.5g 1.5g 2.9g 20g 90mEq/L 20mEq/L 80mEq/L 10mEq/L 111mEq/L 311mOsm/L Hypoosmolar ORS 2.6g 1.5g 2.9g 13.5g 75mEq/L 20mEq/L 65mEq/L 10mEq/L 75mEq/L 245mOsm/L
Small sachets to be dissolved in 200ml water are also available. For preventing and treating dehydration from acute diarrhoea Renal impairment Vomiting, hypernatremia and hyperkalemia Children with no dehydration, 10mL/kg/ stool Children with some dehydration 75 -100 mL/kg over 4 hrs
ReSoMal 40 ml of mineral mix solution to be added along with one sachet WHO ORS to 2 liters of water to make 2 liters of ReSoMal. It will contain 125 mMol glucose, 45 mMol Na, 40 mMol K, 70 mMol Cl, 7mMol citrate , 3mMol Mg, o.3 mMol Zn and 0.045mMol Cu/Liter Mineral Mix Solution for preparing ReSoMal (Rehydration Solution for the Malnourished) Content KCl Tripot Citrate MgCl2 CuSO 4 Zn Acetate Water 350 Quantity(per 40 ml) 22.4g 81 g 76g 1.4g 8.2g 2.5g
Use: for correcting dehydration in malnourished child
Paediatric Nutrition
NUTRITION
Recommended Balanced Diets (ICMR Recommendation)

Parentral Nutrition 1. Glucose I: Treatment of hypoglycemia, maintenance fluid in newborn, fluid replacement without significant electrolyte deficit, management of hyperkalemia, to provide calorie requirements A/E: Thrombophlebitis with hypertonic dextrose solutions; fluid and electrolyte disturbances; hyperglycemia P/A: Injectable solution: 5%; 10% isotonic solutions of 500mL bottles. 10% and 20% solutions 1000ml for parenteral nutrition, 25%, 50% hypertonic solutions as 25 mL ampoules. Dose: Hypoglycemia 10% dextrose 5mL/kg. 25% dextrose 2mL/kg with insulin for correction of hyperkalemia Higher concentrations of glucose are used for parenteral nutrition. Minimum 20% of calorie requirements should be provided by the maintenance fluid . 2. Amino acid infusions Essential amino acids are available as parenteral solutions. They contain a mixture of essential and nonessential aminoacids. 5%, 6%,10% aminoacid infusion solutions 500mL and 100mL bottles Dose: 2-5g/kg/day 3. Lipid emulsions 10%, 20%, 30% emulsions 500ml bottle. Dose: 1-3 g/kg/day 3 in 1 solution containing dextrose, amino acids and lipid is also available for parenteral nutrition commercially. 4. Water for injection 2-mL ,5-mL, 10-mL ampoules. Uses: in preparations intended for parenteral administration and in other sterile preparations 351
Paediatric drugs
VITAMINS ( Majority of vitamins are available as combination of multivitamin syrup and injection) 1. Vitamin A (Retinol) Capsule: 50 000 IU; 100 000 IU; 200 000 IU Oral oily solution: 100 000 IU /mL in multi dose dispenser. Tablet (sugar-coated): 10 000 IU, 50,000IU. Water-miscible injection: 100 000 IU in 2-mL ampoule 1microgram=3IU Uses: prevention and treatment of vitamin A deficiency; prevention of complications of measles Daily requirements : 1200-1800 IU day Prevention of vitamin A deficiency (by mouth): infant under 6 months,50 000 units, infant 612- months 100 000 units, Child 1-5years: 200 000 units every 6 months; An additional dose should be given the next day in hospitalized children with measles infection.For treatment of xerophthalmia, the same dose to be repeated on the next day, and then after 2-4 weeks. Adverse effects: high intake may cause birth defects; pseudotumour cerebri, enlarged liver, raised erythrocyte sedimentation rate, raised serum calcium and raised serum alkaline phosphatase concentrations 2. B complex vitamins i. Thiamine (Vitamin B1) Tablet: 50 mg, 75mg tab. Inj Thiamine 50mg/mL, 2mL ampoules Uses: prevention and treatment of vitamin B1 deficiency, Neurometabolic disease like maple syrup urine disease and thiamine responsive megaloblastic anemia. Daily requirements: 0.5-1.5mg/day Dose 1025 mg daily for treatment. Adverse effects: Anaphylaxis (parenteral use) ii. Riboflavin (Vitamin B2) Tablet: 10 mg. Uses: vitamin B2 deficiency 352
Daily requirements: 0.5-1.5mg/day Treatment of vitamin B2 deficiency: 10 to 30 mg daily in divided doses iii. Nicotinamide (Niacin) Tablet: 50 mg, 100mg tab Daily requirements: 5-15mg/day Dose: 50-300mg/day for pellagra Adverse effects: Flushing with high doses. iv. Pyridoxine (Vitamin B6) Tablet: 40mg, 100mg; inj along with other B complex vitamins Daily requirements: 0.5 to 1.5mg/day Uses: treatment of pyridoxine deficiency due to metabolic disorders, Pyridoxine withdrawal seizures; sideroblastic anemia Dose: For seizures 50 - 100mg IM Adverse effects: chronic administration of high doses may cause peripheral neuropathies v. Folic Acid Tablet: 5mg Daily requirements: 50-150mcg/day Use: Folic acid deficiency anemia, Hemolytic anemia , prevention of neural tube defect ( to be given to pregnant mother) vi. VitaminB12 (cobalamin) Tablet:500gm, Syrup:500mcg/5ml, Injection: 500mcg/ml Daily requirements: 0.5-1150mcg/day Use: anemia, neurometabolic conditions (methylmalonic academia) Dose: 1mg/day for methylmalonic academia vii. Biotin Tablet: 5mg, Syrup: 5mg/mL Daily requirements: 100-200mcg/day Use: treatment of biotin deficiency due to metabolic disorders like multiple carboxylase deficiency Dose: 10mg/day (Multiple carboxylase deficiency) 353
Paediatric drugs
3. Ascorbic acid (vitamin C) Tablet: 100mg, 500mg, Drops: 100mg/ml Daily requirements: 40-50mg/day Dose: 100-200 for treatment of scurvy. Adverse effects: gastrointestinal disturbances reported with large doses 4. Vitamin D i.Cholecalciferol (vit D3) 60000 IU/sachet oral; 300000IU /ml inj 1gm= 40IU Daily requirements: 400IU/day Uses: vitamin D deficiency; hypocalcaemia of hypoparathyroidism Contraindications: hypercalcaemia; metastatic calcification Dose: Prevention of vitamin D deficiency 10 micrograms (400 units) daily orally. Treatment of vitamin D deficiency-6 lakhs IU oral or IM Adverse effects: anorexia, lassitude, nausea and vomiting, diarrhea, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised serum calcium and phosphate , tissue calcification on prolonged treatment ii. 1, 25 dihydroxy D3 0.25mcg,1 mcg Tabs Use: For renal diseases and vit D dependent rickets Dose: Vit D dependent rickets type I: 0.25-2mcg/day, Vit D dependent rickets type II: 50-60 mcg/day 5. Vitamin E Drops- 50mg/ml; Capsule 100mg, 200mg, 400mg Daily requirements: 5-15mg/day ( 1mg = 1IU) Use: Supplementation, hemolytic anemia of prematurity, bronchopulmonary dysplasia, myopathies, neonatal cholestasis. Dose:15-25 IU/day. Higher doses for cholestasis. Adverse effects: excess doses cause NEC in newborn 354
6. Vitamin K Menandione sodium 10mg/mL ampoules Phytomenadione inj 10mg/mL ampoule, phytomenadione tablet 10mg Use: Hemorrhagic disease of newborn(HDN), liver diseases, malabsorption, oral anticoagulant toxicity Dose: Treatment of HDN 2-5mg IV; prevention of HDN: 1-2 mg IM Adverse effects: Hyperbilirubinemia in new born MINERALS
Sodium
Daily requirement: 2-3meq/kg/day. Available preparations Sodium chloride ( 1gm = 17 meq of Na and Chloride) i. Sodium chloride Injectable solution: 0.9% isotonic (equivalent to Na+ 154 mmol/l, Cl- 154mmol/L). Uses: electrolyte and fluid replacement, Correction of Shock Dose: In shock bolus intravenous dose of 20mL /kg. Adverse effects: large doses may give rise to sodium accumulation and edema ii. Sodium chloride injectable solution: 0.45 %Saline (equivalent to Na+ 77 mmol/l, Cl- 77mmol/L). Uses: DKA management, hypernatremia correction, electrolyte and fluid replacement iii. Sodium chloride Injectable solution: 3% Hypertonic (equivalent to Na+ 510mmol/:L, Cl- 510 mmol/L). Uses: Hyponatremia Dose: 3-4mL/kg iv . Glucose with sodium chloride. Injectable solution: 5% glucose, 0.9% sodium chloride (equivalent to Na+154mmol/L, Cl-154 mmol/L). 500ml bottles v . Injectable solution: 5% glucose, 0.45 % sodium chloride (equivalent to Na+77 mmol/l, Cl-77 mmol/L). 500ml bottles Uses: fluid and electrolyte replacement, Diabetes ketoacidosis management 355
Paediatric drugs
Sodium Bicarbonate i. Sodium bicarbonate tablet 325mg (4meq) and 650mg (8meq) ii. Shohls Solution Citric acid 140ml and sodium citrate 90g in 1 litre with water (1ml=1mEq Bicarbonate) iii. Polycitra Potassium citrate-550mg ,sodium citrate -500mg , citric acid -334mg in 1liter water( 1ml= 1meq of Na and K & 2 mEq of HCO3) Use: To treat metabolic acidosis, Renal tubular acidosis (RTA), Dose: proximal RTA 5-20 mEq/kg/day Distal RTA 2-3 mEq/day Injectable solution: 7.5% in 10-ml ampoule (equivalent to Na+ 0.9meq/mL, HCO3-0.9meq/mL). Uses: metabolic acidosis, hyperkalemia, Dose: In acidosis 0.3x body weight x based deficit as infusion over 4 h Adverse effects: hypokalemia and metabolic alkalosis, sodium retention Potassium Daily requirement: 2-3meq/kg/day Available preparation: Potassium chloride i. Potassium chloride oral solution. 15 mEq in 20 mL solution, 200mL and 450mL bottles Uses: prevention and treatment of hypokalemia Contraindications: severe renal impairment; hyperkalemia Dose: Prevention of hypokalemia 2-3 mEq/kg/day. For treating hypokalemia needs higher doses Adverse effects: gastrointestinal irritation ii. Injectable solution: 15% in 20-mL ampoule (equivalent to K+ 2 mmol/ mL, Cl- 2mol/mL), 10% in 10 mL ampoule (1.342mmol/L). Dose: 05-1meq/kg diluted. Adverse effects: cardiac toxicity on rapid infusion. 356
Calcium
Calcium gluconate injection: 10% in 10-mL ampoule. 1mL = 9mg Oral- calcium phosphate and calcium carbonate Daily requirements: 400-600mg/day Uses: Nutritional supplementation., hypocalcaemic tetany, preterm newborns, rickets, hyperkalemia Dose: Nutritional supplementation 500-1000g/day In deficiency 100-200mg/kg/day. Calcium phosphate preparation to be avoided in renal impairment. Hypocalcaemic tetany /seizures: Inj calcium gluconate 2mL/kg slowly Adverse effects: gastrointestinal disturbances; bradycardia, arrhythmia; injection-site reactions; peripheral vasodilation; fall in blood pressure Sodium Lactate, compound solution IP Injectable solution. Contains Na- 131 mEq, K- 5meq, Ca -4 mEq, Bicarbonate (as lactate)- 29 mEq Cl- 111meq/L. Uses: Correct severe dehydration in acute diarrheal diseases, preand perioperative fluid and electrolyte replacement; hypovolemic shock Dose: 100ml/kg for correcting dehydration Adverse effects: excessive administration may cause metabolic alkalosis and edema Phosphorus Daily requirements: 600-1000mg/day Oral: Joules solution (Disodium orthohydrogen phosphate 136g and orthophosphoric acid 32ml) provides 30 mg phosphate/mL Available as combination with sodium, potassium and calcium. Use: osteopenia hypophosphatemic rickets Dose: 600-1000mg/day Adverse effects: Hyperphosphatemia, diarrhoea Magnesium 25% MgSO4 (2 mEq/ml), 50% MgSO4 (4 mEq/mL) 10mL ampoules Oral- Magnesium gluconate (5.4 elemental magnesium/100mg), magnesium sulphate (10mg of elemental magnesium/100mg) 357 of prematurity, hypophosphatemia,
Paediatric drugs
Daily requirements: 200-300mg/day Use: Magnesium deficiency (Protein Energy malnutrition, infant of diabetic mother), Bronchial asthma Dose: oral-3-6mg/kg/day for nutritional supplementation. In PEM0.1-0.2 mL/kg of 50% solution intramuscularly. Bronchial asthma 25% solution 0.2mL/kg diluted in 30mL glucose and given as infusion. Adverse effects: hypotonia, hyporeflexia, hypotension, diarrhea Multiple Electrolytes and Dextrose injection type 1- USP ( paediatric maintenance solution with 5% dextrose injection) Inj solution containing Na 25meq/L, K 20 mEq/L, Mg 3meq/L, acetate 22meq/L, Cl 22meq/L, Phosphate 3meq/L as 500ml bottles. Use: As pediatric maintenance fluid Dose: depending on the daily maintenance requirements Copper Oral as constituent of multivitamin syrup Daily requirements: 1-2mg/day Inj copper histidine Use: copper deficiency, Menkes disease Dose: oral-1-2mg/day, in Menkes disease 50-150mcg elemental copper/kg/24hr SC Zinc sulfate Oral liquid: in 10 mg and 20mg per unit dosage forms. Tablet: in 10 mg and 20mg per unit dosage forms. Daily requirements: 5-15mg/day Uses: adjunct to oral rehydration therapy in acute diarrhea, acrodermatitis enteropathica, Wilsons disease Dose: in acute diarrhoea, infant under 6 months, 10 mg (elemental zinc) daily for 1014 days; child 6 months5years, 20 mg (elemental zinc) daily for 1014 days, 25mg tid in Wilsons disease. Adverse effects: GI upset, copper deficiency Iron Ferrous sulphate 200mg tab ( 65mg elemental iron) Chelated iron as polysaccharide iron complex 100mg/5mL, iron dextran complex 50 mg iron/mL. 358
Combination with folic acid and vit B12 Daily requirements: 10-20mg/day Use: Prevention and treatment of iron deficiency Dose : prevention 2mg/kg/day. For treatment 4-6mg/kg/day. Parenteral: 0.4 * body weight* Hb deficit Adverse reaction: GI upset, hepatic injury. Iodine Lugols iodine 5% iodine diluted in 10% potassium iodide ( 10mg iodine /drop) Iodized oil: 1 ml (480 mg iodine); 0.5 mL (240 mg iodine) in ampoule (oral or injectable); Iodized salt 15mcg/g (15ppm) Daily requirements: 50-150 mcg/day Uses: prevention and treatment of iodine deficiency . Adverse effects: hypersensitivity reactions; goiter and hypothyroidism;
Hyperthyroidism
Sodium fluoride In any appropriate topical formulation. Uses: prevention of dental caries Daily requirements : 1-5mg/day Contraindications: not for areas where drinking water is fluoridated Dose: Prevention of dental caries, as oral rinse child over 6 years, 10 ml 0.05% solution daily or 10 mL 0.2% solution weekly. Fluoridated toothpastes are also advised. Adverse effects: in recommended doses toxicity unlikely
359
SECTION 27 DRUGS USED IN RESPIRATORY DISEASES

UPPER RESPIRATORY TRACT INFECTIONS
Common cold (Rhinitis)

Viral aetiology. Usually self limiting. Symptomatic treatment alone is required. Topical or systemic nasal decongestants and antihistaminics are used.
Topical Nasal Decongestants & Xylometazoline (Refer Section 16)

Azelastine hydrochloride I: Allergic rhinitis. C/I: Hypersensitivity, lactation. P/C: Pregnancy, not to use longer than 6 months once after opening the bottle. Should not share the spray with others. Tip of the bottle should be dipped in boiled water, dried and capped appropriately after every use. A/E: Nasal mucosal irritation, nasal bleeding. P/A: Nasal spray 10 mL Dose : Adults and children over 5 years 0.14 mL metered dose. One spray into each nostril bid. Cost : Nasal spray (10 mL) Rs. 120.00
Sodium chloride
I: P/ A: Dose : Cost : Phenylephrine I: C/I : Nasal congestion. Solution (0.9 %): 500 mL, 1000 mL Sodium chloride (0.9%) given as nasal drop. Solution (500 mL) Rs. 10.00
Sympathomimetics
Nasal congestion, sinusitis, common cold Avoid excessive and prolonged use. Caution in infants under 3 months, patients with cardiac diseases, hypertension, hyperthyroidism and glaucoma. Hyperthyroidism, cardiac diseases Sneezing, mild burning sensation. After excessive use, tolerance with diminished effect - rebound congestion.
P/C : A/E:
360
Drugs for Respiratory Diseases
P/A:
Dose : D/1: Cost :
Capsules, Tablets, Syrup, Nasal drops. Most of the preparations contain other drugs like naphzoline, pheniramine maleate etc. Orally 5-10 mg bid. Prolongs the effect of local anaesthetics, hypotension with MAO inhibitors, antidepressants and methyl dopa. No pure preparation available. Only combination preparations.
ALLERGIC RHINITIS AND NASOBRONCHIAL ALLERGY Drugs are usually used as nasal sprays and nasal drops.

Sodium Cromoglycate I: Prophylaxis of allergic rhinitis and asthma. C/I: Hypersensitivity. P/C: Pregnancy, lactation and neonates.Presence of pus may prevent proper penetration of drug. A/E : Bronchospasm, anaphylaxis, headache, sneezing and epistaxis. P/A: Inhaler 1 mg/mdi, 5 mg/mdi, 20 mg/cartridge.Spray 2 % w / v. Dose : 2 squeezes qid. Maintain with 1 squeeze tds. (2 %) D/I: None reported. Cost: Inhaler 1mg/mdi (400 mdi) Rs. 161.00
Corticosteroids
Beclomethasone I: C/I : P/C : A/E: Allergic rhinitis and inflammatory conditions ofthe nose, bronchial asthma. Hypersensitivity, systemic fungal infections, TB and diabetes. Pregnancy, children < 5 years. Unhealed nasal infection previous treatment with oral steroids. Local irritation, haemorrhagic secretion mild systemic steroid effects are produced. Candidial infection of mouth and throat.Increased incidence of intranasal and paranasal infection. Nasal spray 50 mcg, 100 mcg. 2 sprays (100 mcg) into each nostril bd. None reported. Inhaler 100 mcg (200 md) Rs. 150.00 - 220.00 361
P/A; Dose : D/I : Cost :
Budesonide
Allergic rhinitis and inflammatory conditions of the nose, bronchial asthma. C/I : Hypersensitivity. P/C: Care in patients with pulmonary tuberculosis, fungal and viral infections in airway, pregnancy and lactation, patients should be instructed to rinse the mouth with water after each dosing. A/E:D/I: None reported. P/A: Inhaler 100 mcg/md. Dose: Adults 100 - 200 mcg b.d. maximum 1600 mcg/day. Children 50 - 100 mcg b.d. maximum 800 mcg/day. Budesonide is not indicated for acute attacks of asthma. Cost: Inhaler 100 mcg (400 md) Rs. 320.00 ORAL ANTIHISTAMINES I:
Cetirizine HCl, Loratadine and Fexofenadine (Refer Section 16) Ketotifen

I: C/I : P/C : A/E: P/A: Dose: D/ I : Allergic rhinitis, prophylaxis of asthma. Age < 2 yrs, acute asthma, hypersensitivity and pregnancy. Not to operate machinery after taking the drug. Drowsiness, dry mouth, weight gain, nausea and headache. Tablet 1 mg Syrup 0.2 mg/mL, 1 mg/5 mL 1-2 mg b.d. Children < 2 years not recommended. > 2 years; 1 mg b.d. With oral hypoglycemic drugs it causes a fall in thrombocyte count. Potentiates the action of sedatives and hypnotics. Tab 1 mg (10) Rs. 10.00 - 14.00 Syrup 1 mg/5 mL (100 mL) Rs. 41.00.
Cost :
Antibiotics in Current use in Respiratory Infections (Refer section 4)

Penicillins: Penicillin G and Penicillin V Penicillinase resistant penicillins - cloxacillin Broad spectrum penicillins - ampicillin, amoxycillin Other penicillins, ticarcillin, azlocillin,piperacillin 362
Drugs for Upper Respiratory tract infections
Cephalosporines : 1st generation cephalexin, 2nd generation cefoxitin, cefuroxime 3rd generation ceftazidime, cefotaxime 4th generation cefpirome, cefepime Aminoglycosides:gentamicin, tobramycin, amikacin, netilmycin, streptomycin, kanamycin. Macrolides: erythromycin, clarithromycin. Tetracycline: doxycycline Fluoroquinolones:Levofloxacin, Sparfloxacin,Gatifloxacin Other beta lactams: aztreonam, imipenem, Others :Teicoplanin,Clindamycin,Linezolid Synergestic combination : amoxycillin + cloxacillin ampicillin +cloxacillin amoxycillin + clavulanic acid ticarcillin + clavulanic acid piperacillin+tazobactum roxithromycin, azithromycin,
Co-trimoxazole : trimethoprim sulfamethoxazole
Drugs used in Tuberculosis

These include isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin and others. Isoniazid (INH, Isonicotinic acid hydrazide) I: Treatment of tuberculosis, bactericidal against actively multiplying M.tuberculosis, M.bovis and M.kansasii. This is the most powerful and most extensively used antituberculosis drug. Hypersensitivity, hepatic insufficiency and psychosis. Monitor serum level of hepatic transaminases.Patients at risk of peripheral neuropathy (malnutrition, chronic alcoholism, diabetes and others) should additionally receive pyridoxine 20 mg dose.Epilepsy should be controlled effectively since INH may provoke attack. Hepatotoxicity - The incidence of 363
C/I: P/C:
P/A:
Dose: Adult :
D/I: Cost:
INH induced hepatitis increase with age, alcohol consumption and alcoholic liver disease. INH induced hepatitis usually resolves after discontinuation of the drug.Transient elevation of serum transaminase may occur, but resolves as drug therapy continues. This is not a contraindication for INH.Peripheral neuropathy is ,dose-related, probably due to increase dexcretion of pyridoxine. Patients with malnutrition and those predisposed to neuropathy by diabetes, alcoholism or uraemia, pregnant women and those with seizure disorders should be supplemented with pyridoxine 20 mg daily. Oral - tablet and liquid Parenteral preparation can be given IV or IM in special circumstances at the same as oral dose on those who cannot ingest orally. 5 mg/ kg bw Single dose. 300mg od 600 mg (10mg/kg) for intermittent regimen and for nervous system disease. 450 mg daily in tuberculous meningitis. The effects of anticonvulsants may be increased. Antacids may reduce the absorption of INH. Tab 300 mg (10) Rs. 9.00
Rifampicin
lt acts by inhibiting the synthesis of nucleic acids.Bactericidal and sterilizing drug for the treatment of tuberculosis.Bactericidal for most species of mycobacterium. It is also used for the treatment of leprosy. C/I: Hypersensitivity, severe liver disease. Thrombocytopenia and acute renal failure are absolute contraindications. P/C: Patient should be warned about the orange discolouration of body secretions and urine. It can permanently discolor soft contact lenses otherwise it is harmless. A/E : Flu like syndrome in intermittent dosage. Nausea, vomiting, muscle cramps, jaundice, and CNS disturbances, skin reactions,eosinophilia, transient leukopenia, thrombocytopenia, shock,drowsiness, 364
Drugs for Tuberculosis
P/A: Dose:
D/I :
headache, ataxia, visual disturbances and menstrual irregularities. Capsules 150, 300, 450, 600 mg Tablet 450, 600 mg Syrup 100 mg/ 5 mL 10 mg/ kg oral single dose. 450 mg for adults, 600mg for patients more than 60 kg weight. The drug should be given on an empty stomach and fluids and food should be taken only after 1 h. It reduces the effectiveness of oral contraceptives, corticosteriods,phenytoin, oral antidiabetics, oral anticoagulants and disopyramide by inducing hepatic metabolism. It reduce Vitamin D blood levels. Severe hepatitis when used along with isoniazid. Food will delay the absorption. Fixed drug combination are used to increase compliance.
Pyrazinamide (PZA)
Bactericidal to M.tuberculosis - sterilizing especially to intracellular organism I: Treatment of tuberculosis. The only one drug acting in the acidic pH. Intracellular organisms are killed. Bactericidal and sterilizing action - effective in the initial intensive phase. M.bovis is resistant to PZA. C/I: Hypersensitivity, pregnancy, existing liver disease and gout. P/C: Patients with diabetes should be carefully monitored since blood sugar levels may become labile. Gout may be exacerbated. A/E: Arthralgia, loss of appetite, malaise, nausea, and liver damage. P/A: Tablet 500 mg, 750 mg, 1000 mg and 1500 mg. Dose: 20- 35 mg/kg oral. One or two divided doses. D/I: Alters the action of oral antihypoglycemic agents and disturbs blood glucose levels. It decreases the serum INH concentration.
Ethambutol
It acts by possibly inhibiting RNA synthesis and also by affecting metabolism of cell wall. 365
I:
C/I:
P/C:
A/E:
P/A: Dose: D/I:
Treatment of tuberculosis. Bacteriostatic drug in usual dosage.(Bactericidal in higher dosage). It is used in combination with other drugs to prevent or delay the emergence of resistant strains. Optic neuritis, hypersensitivity, reduction of visual acuity -particularly inability to distinguish red and green. (eg . young age) Patients should be advised to discontinue treatment immediately and to report to the doctor if visual disturbances occur. Retrobulbar neuritis with reduction of visual acuity. Reduced renal clearance of urates. G.I disturbances, anorexia, false positive test for phaeochromocytoma. Tablet 200 mg, 400 mg, 800 mg, 1000 mg 15-25 mg/ kg bw. Single dose - oral. Absorption delayed or reduced by aluminum hydroxide. Synergistic effect with other antituberculous agents Aminoglycoside antibiotic. It acts by inhibiting protein synthesis.It was used as one of the powerful antituberculosis drug along with INH prior to the introduction of short course chemotherapy with rifampicin and other drugs. It is a bactericidal drug which has to be given by IM. injection over several months for its effect. Another disadvantage is the readiness of M.tuberculosis to develop resistance against streptomycin. Due to this reason at present it is used only as a reserve drug under special circumstances. Use is restricted to tuberculosis treatment as a component of several combined antituberculosis chemotherapeutic regimens. Hypersensitivity, renal or hepatic insufficiency, premature infants, pregnancy and myasthenia gravis. Avoid concurrent use of other ototoxic and nephrotoxic drugs. Anaphylactic shock. Vestibular dysfunction leading to giddiness and vertigo which may be persistant for
Streptomycin
I:
C/I: P/C: A/E: 366
several months even after stopping the drug. Nerve damage may occur insome cases but it was more common with dihydrostreptomycin which is not commonly used at present. P/A: Injection 0.75 g, 1 g vial. Dose: 0.75 g - 1 g IM.daily for adult,15-20 mg/ kg in children for 2 months in the initial intensive phase. D/I: Potentiate nephrotoxicity and ototoxicity produced by other aminoglycosides and cephalosporin, cisplatin, vancomycin. Ototoxicity potentiated by frusemide. Plasma level will be increased by indomethacin. Synergism with benzyl penicillin - when this combination is used for treating other infections. Potentiates the effect of neuromuscular blocking agents administered during anaesthesia. The Government provides the drugs for the total treatment period free of cost to the patients who come under the National TB control programme both hospital and domicilary treatment. Single drug should not be used for the treatment of tuberculosis. Combination packs are available for RNTCP programme.
Reserve drugs
Kanamycin Aminoglycoside antimicrobial I: Used as a second line drug to treat resistant tuberculosis. C/I: Pregnancy, renal failure and hypersensitivity. P/C: Breastfeeding. Monitor blood levels when the renal function is impaired. A/E: Fever, rash, exfoliative dermatitis, itching, nausea, and headache, neurotoxicity, nephrotoxicity, thrombocytopenia. P/A: Injection 0.5 g, 1 g vial. Dose: 15 mg/kg, 0.5 1 g IV/IM twice or thrice weekly. D/I: It potentiates the neuromuscular block by action of muscle relaxants used in anaesthesia. May be inactivated by beta-lactam antibiotics. Frusemide increases the nephrotoxicity. 367
Cycloserine
I: This is a second line antitubercular drug used in the treatment of resistant cases. It acts by inhibiting the cell walls synthesis. Psychosis, epilepsy, severe anxiety, alcohol dependence, depression,and renal failure. Discontinue if allergy or CNS toxicity occurs. Reduce dose in renal impairment. Causes Vit. Biz and folic acid deficiency. Nervousness, headache,convulsions, suicidal attempts, and psychotic states. Tablet 250 mg 10 mg/kg /day orally250-500 mg bd . Alcohol increases the risk of convulsions. INH and ethionamide increases CNS toxicity. Plasma level of phenytoin increases to toxic levels. As a second line drug to treat resistant tuberculosis. Hepatic dysfunction. Psychiatric illness, pregnancy, and lactation. G.l upsets, acne, alopecia, convulsions, diplopia, psychological disturbances, thrombocytopenia, gynaecomastia, impotence. Tablet 125 mg, 250 mg 12-15 mg/kg/day; 0.5 ~ 1.0 g in two divided doses daily. Convulsions may occur when used with cycloserine. Glycemic control may be difficult in diabetic patients.
C/I: P/C : A/E:
P/A : Dose: D/ I:
Ethionamide
I: C/I: P/C: A/E:
P/A: Dose: D/I:
Para Aminosalicyclic Acid (PAS)

This is a bacteriostatic drug for M.tuberculosis used prior to the development of the present day short course chemotherapy. PAS was a first line drug in the treatment of tuberculosis. Though its antituberculosis action is weak, it acts well to prevent the development of drug resistance against INH and streptomycin. At present PAS is only seldom used. It reduces the chance of developing resistance to INH. I: C/I: A/E: 368 Resistant tuberculosis as a companion drug. Hepatic and renal disorders GI upset. Hepatic and renal toxicity, thrombocytopenia and hypokalemia.Pro1onged use
Drugs for Asthma and COPD
may produce goiter and hypothyroidism. Urine show reducing agent - interferes with diabetic control. The urinary excretory product reduces Benedicts reagent and this may be mistaken for glycosuria occuring in diabetes mellitus. P/A: Tablet 0.5 g Granules 100 mg Dose: 300 mg/kg/day oral. 12-15g in two divided dose for adults. D/I: It reduces the absorption of rifampicin if taken together. Fluoroquinolones : Ciprofloxacin and sparfloxacin, ofloxacin Macrolides: Roxithromycin and clarithromycin Some points to be noted are: Refer cases which are difficult to diagnose, to a chest specialist. Do not attempt modifications of regimen. Consult chest physician in case of adverse effect to drugs Never attempt to treat resistant or suspected resistant cases. Refer to a chest specialist. DRUGS USED IN THE TREATMENT OF AIRWAY DISEASES 1. 2. 3. 4.
Asthma and Chronic Obstructive Pulmonary Disease (COPD)

Bronchodilators (Beta -2 adrenergic agonists)
Salbutamol
I: C/I : P/C : A/E: P/A: Dose: Asthma acute and chronic forms, COPD, prophylaxis of exercise induced asthma Thyrotoxicosis, hypersensitivity, premature labour. Patients with arrhythmias, elderly, pregnant women, those on other sympathomimetic drugs. Muscle tremor, tachycardia, hypokalemia, restlessness, muscle cramps. Tablets 2mg, 4 mg Capsules 4 mg,8mg Inhaler 100mcg/ md Syrup 2mg/ 5mL Oral tablets : 2-4 mg tds Children 2 mg tds Sustained release preparation : 4-8 mg bd. Inhaler : 100 - 200 mcg tds or qds. Rotahaler : 200 - 400 mcg tds or qds. Nebuliser : 5 mg / mL. Dose :2.5 - 5 mg diluted with saline tds or qds. 369
D/ I :
Cost :
Hypokalemia with steroids and diuretics, potentiates the vascular effects of MAO inhibitors and tricyclic antidepressants. Effects areantagonized by beta blockers. Tab 2mg (10) Rs.2.00-5.00 Cap 4 mg (10) Rs.8.00 Inhaler 100mcg/ md (200md) Rs.67.00 Asthma acute and chronic forms, COPD, prophylaxis of exercise induced asthma. Thyrotoxicosis, hypersensitivity, premature labour.
Terbutaline
I: C/I :
Anticholinergics
Ipratropium Bromide I: COPD, relief of acute bronchospasm especially in patients with intolerance to beta 2 agonists, drug of choice for bronchospasm due to beta blocker medication C/I: Hypersensitivity P/C: Narrow angle glaucoma, pregnancy, lactation, prostatic hypertrophy. A/E : Dry mouth, paradoxical bronchoconstriction, glaucoma. P/A : Inhaler 20 mcg/puff 200md Dose : 1 - 2 puffs (20 40) mcg tds or qds. D/I: None reported. Cost : Inhaler 20 mcg/puff (200md) Rs.131.00 Theophylline I: Acute asthma, long term control and prevention of symptoms, COPD. C/I: Hypersensitivity, neonates, lactation. P/C: Hypertension, myocardial infarction, hyperthyroidism, pregnancy,lactation, hepatic disease and acid peptic disease, A/E: Nausea, vomiting, gastric disturbances, headache, gastric reflux,diuresis, cardiac arrythmias,epilepsy. P/A: Tablets 200mg,300mg,400mg,600mg Capsule 100mg,200mg, 250mg Injection 2mL ampoule Syrup20mg/ mL 370
Dose: Oral dose : Children : Controlled release D/I :
Cost :
Etophylline 169.4 mg/mL IV dose 2 mL 8hrly. 80 240 mg tid. 24 mg/kg/bw in divided doses. preparation : 400 600 mg o.d. Metabolism is enhanced by rifampicin, phenobarbitone and alcohol, while it is reduced by ciprofloxacin, cimetidine, erythromycin and allopurinol. Tab200mg (10) Rs.9.0015.00 Inj (2mL ampoule) Rs.3.00 Syrup20mg/mL (100mL) Rs.11.00
Aminophylline
Asthma, COPD, congestive cardiac failure, respiratory failure. C/I : Acid peptic disease, seizures, hypersensitivity. P/C : Neonates, children, pregnancy, lactation, cardiac arrhythmias and- hepatic diseases. A/E : Hypotension, neurotoxicity, seizures, nausea, vomiting, insomnia,headache, CNS stimulation. P/A : Tablets 100mg Injection 250mg/ 2mL Dose : Initial loading dose : 4 - 6 mg/kg. Maintenance dose 2 3 - 4 mg / kg. Children 1 5 mg / kg D/I: Increases risk of arrhythmias with sympathomimetics and halothane. Tachycardia with pancuronium. Metabolism inhibited by beta blockers. Cost : Tab100mg (1000) Rs.96.00 Inj 250mg/ 2mL (10mL) Rs.7.00 Systemic steroids These act by relieving the inflammation of the bronchial mucosa in asthma. They are very potent and antiasthmatic drugs which are active when given orally, and for rapid action parenterally or directly into the bronchial tree by aerosols. They relieve acute attacks immediately. They also prevent the onset of acute paroxysms. Corticosteroids may be given in a moderate dose or high dose short time basis for few days or in the minimum effective dose on a long term basis, for symptom relief. Long term corticosteroid produce several adverse side effects and therefore it should be the aim to withdraw these as early as possible. Still a few persons become steroid dependent. 371 I:
Prednisolone (Refer Section 18) Hydrocortisone(Refer Section 18)

INHALED STEROIDS Corticosteroids can be delivered directly into the respiratory tract in the form of aerosols through nebulizeres, metered dose inhalers and rotahalers. The dose is also considerably smaller compared to oral andparenteral drugs. Adverse side effects are much less. When the drug is delivered as a inhalation only part of it reaches the respiratory tract, the restof it is swallowed.
Beclomethasone
I: C/I : P/C : A/E : P/A: Dose : D/I : Cost : Long term prevention of asthma. Acute asthma, hypersensitivity. Pregnancy, lactation, local fungal infections. Hoarseness, candidiasis. Inhaler 50mcg,100mcg,200mcg,250mcg Spray 50mcg / md Rotacap 100mcg 400 - 800 mcg/ day in 2 - 4 divided doses. Children :50 - 100 mcg / day. None reported Inhaler 100mcg (200md) Rs. 150.00 Rotacap 100mcg (30) Rs. 40.00 Long term prevention of asthma Acute asthma, hypersensitivity. Pregnancy, lactation, local fungal infections. hoarseness, candidiasis. Inhaler 100mcg/mdi 100 - 200 mcg b.d. Max 1600 mcg / day g Children 50 100 mcg b.d. None reported Inhaler 100mcg/ mdi (100md) Rs.146.00
Budesonide
I: C/I : P/C : A/E : P/A : Dose : D/I: Cost :
Fluticasone propionate
Glucocorticoid twice as potent as budesonide and beclomethasone. I: Preventive therapy of asthma. C/I : Hypersensitivity, age < 4 yrs, acute asthma P/C : Pregnancy, lactation, children. A/E : Candidiasis, hoarseness
372
Inhaler 50mcg,125 mcg Rotacaps 100mcg, 250mcg Cream 0.05 % w/w Dose : Adults : 250 - 500 mcg/ day Mild persistent asthma : 100 - 250 mcg Moderate persistent : 250 - 500 mcg Severe persistent : 500 - 1000 mcg Children : 50 - 100 mcg/ day D/I: None reported. Cost : Cream 0.05% w/w (5 g) Rs. 28.00 - 35.00 Inhalers (125 mcg) Rs. 350.00 Rotacap (30) Rs. 50.00 Compared to salbutamol inhaler, corticosteroids are less potent immediate bronchodilators. Their main role is to prevent asthmatic paroxysm therefore they may be given as regular night time dose of 100 - 200 mcg / day. Asthmatic attacks are managed by inhalation of salbutamol. Preparations containing both corticosteroids and salbutamol are available.
P/A:
Sodium cromoglycate
I: Long term prevention of asthma symptoms, preventive therapy prior to exposure to known allergen or exercise. Hypersensitivity. Neonates, pregnancy and lactation . Cough, rash, urticaria, bronchospasm. lnhaler 1 mg/mdi, 20 mg/cartridge 2 puffs qds (1 mg / puff) None reported Inhaler l mg/md (400md) Rs. 161.00 Long term prevention of asthma symptoms, preventive therapy prior to exposure to known allergen or exercise. Hypersensitivity Neonates, pregnancy and lactation Cough, rash, urticaria, bronchospasm. Inhaler 2 mg/md, 20 mg/cartridge By aerosol inhalation, 4mg (2 puffs) b.d. increase to q.d.s. if necessary, Children under 12 years, not yet recommended. 373
C/I : P/C : A/E : P/A: Dose: D/I : Cost : I:
Nedocromil sodium
C/I : P/C: A/E: P/A : Dose:
Ketotifen
I: C/I Prophylaxis of asthma, food allergy. Diabetics on oral hypoglycemic agents, neonates (children under years), hypersensitivity, pregnancy, lactation, acute attacks ofasthma. Previous anti-asthmatic treatment should be continued for a minimum of weeks after initiation of ketotifen treatment.Pregnancy and breast feeding. Drowsiness, dry mouth, slight dizziness, CNS stimulation, weight gain also reported. Syrup 1 mg/5 mL. Tablet 1 mg. 1 mg b.d. with food increased if necessary to 2 mg b.d.; Initial treatment in readly sedated patients 0.5 to 1 mg at night. Children : Over 2 years 1mg b.d. ~ Potentiate the effects of sedatives, hypnotics, antihistamines and alcohol. Reversible fall in platelet count with concomitant use of oral antidiabetics. Syrup 1mg/5 mL (60 mL) Rs. 23.00 - 42.00 Tab 1 mg (10) Rs. 10.00 - 15.00
P/C
A/E P/A Dose:
D/I:
Cost :
Leucotriene receptor antagonist

Zafirlukast I: C/I: P/C: A/ E: P/A : Dose : Long term control and prevention of symptoms in mild persistent asthma for patients > 12 years of age Children Food reduces the absorption of the drug. So taken 1 h prior to or 2 h after food. None reported so far Tablet 20 mg 20 mg bd. Inhibits warfarin metabolism. Tablet 10 at bedtime
Montelukast:
D/I: P/A: Dose :
Newer drug delivery systems in asthma

Metered Dose Inhalers Use chlorofluorocarbon propellant to carry the suspended drug particle at a great speed towards the pointed direction. 374
Drugs available are : Salbutamol, terbutaline, salmeterol, beclomethasone, budesonide, fluticasone, ipratropium andcromoglycate. Precautions : Good hand mouth coordination is required and good inhaler technique is also a must. The success of inhalation therapy depends upon perfecting the technique of inhalation so as to deliver the maximum amount into the tracheobroncheal tree. This should be taught to the patient and the physician should satisfy himself that the technique is mastered. So also inhalation should be takenat the earliest warning of asthma since inhalation will be ineffective if the paroxysm sets in. One of the frequent causes of failure if inhaled medication is improper technique.ln patients with poor hand mouth coordination, a spacer device is advisable in which the drug is delivered into a spacer and the patient inhales from this.
Dry Powder Inhalers

Here the drug is loaded as a capsule containing micronized particles in a lactose carrier called the rotacap. The apparatus used is called a rotahaler.Drugs available are : Salbutamol, salmeterol, beclomethasone, budesonide and fluticasone.
Nebulizers
Nebulized drugs are delivered by a gas flow driving a jet nebulizer unit, which produces the aerosol, or by an electric ultrasonic nebulizer.Drugs that are used with nebulizer : Salbutamol, terbutaline,ipratropium, budesonide and acetyl cystine. The advantage of nebulizer is that the aerosol reaches the respiratory tract alongwith inhaled air or oxygen without extra effort by the patient.Therefore this is the method of choice when asthma is severe.Aminophylline is reserved for those unresponsive to the maximal dose of beta 2 agonists. Dose is initially, 5 mg/ kg., then 0.5 mg/kg/h as i.v. drip.
Respiratory Stimulant Doxapram

I: Acute respiratory failure, postoperative respiratory failure,laryngospasm following intubation, drug induced CNSdepression Heart disease, epilepsy, cerebral oedema, phaeochromocytoma,recent cerebro vascular accidents. 375
C/ I:
P/C: A/ E: P/A: Dose: D/ I: Cost:
Pulmonary embolism, pneumothorax, neonates, pregnancy and liver diseases. Hypertension, tachycardia, fasciculations and dyspnoea Injection 20mg 5mL, 20 mL 1.5 - 4 mg/ min IV infusion. Repeat every 1 - 2 h till the patient wakes up. Produces agitation with theophyllines Inj 20mg (5mL) Rs.33.00
COUGH SUPPRESSANTS (Antitussives )

Codeine phosphate I: Dry unproductive cough. Cough which is hazardous or tiring hernia, occular surgery, cardiac disease. Dose : Adults: 30 - 60 mg 4 - 6 h Children : 1.5 - 2.5 mg/kg/day in 4 - 6 divided doses Dihydrocodeine I: Dry unproductive cough. C/I : Hypersensitivity. P/C : Caution if drowsiness, liver disease, dizziness occur. Caution if other medication containing opiods are used, avoid concurrent use of alcohol or other CNS depressant drugs. A/E : Constipation, allergic reactions, physical dependence P/A: Only combination preparations are available. Dose: Adults : 30-60 mg 4-6h Children 1.5 - 2.5 mg/kg/day in 4 6 divided doses D/I : Same as for codeine. Pholcodeine I: Dry unproductive cough. C/I : Hypersensitivity. P/C : Drowsiness, liver disease A/E : Constipation, allergic reactions, physical dependence P/A : Linctus (combination preparation) Dose: Adults : 5 - 10 mg 4 - 6 h. Children 1.5 2.5 mg/Kg/ 24 hours in 4 6 divided doses Cost : No pure preparations available. Dextromethorphan Non narcotic antitussive 376
Cough Suppressants and Mucolytics
I: Dry or painful cough C/I : Liver disease P/C : Same as codeine phosphate. A/E : Nausea, vomiting, headache P/A: Only combinations are available. Dose: 15 - 30 mg 4-6h D/I : MAO inhibitors Cost : Only combinations are available. Expectorants Increase bronchial secretions or reduce its viscosity. Directly acting Sodium/potassium citrate (0.3 -1 g ) Sodium/potassium acetate Potassium iodide (0.2 - 0.3 g) Guaiphenesin Vasaka (2 - 4 mL)
Reflexly acting
Ammonium chloride Potassium iodide Ipecacuanha
Mucolytics
Bromhexine I: C/ I P/C : A/E: P/A: Dose Cost Acetylcysteine I: C/I Conditions where the sputum is viscid and tenaceous. 1 Hypersensitivity. Use with caution in patients with gastric ulceration. Gastric irritation, allergic reactions, rhinorrhoea, lacrimation. Tablet 8 mg Syrup 4 mg / 5 mL 2 8-16 mg, tds-qds. 2 Tab 8 mg (10) Rs. 6.00 - 8.00 Syrup 4 mg/5 mL (100 mL) Rs. 20.00 - 25.00 Mucolytic, diagnostic aid in bronchial studies. Asthma, respiratory insufficiency, hypersensitivity. 377
P/C A/E :
Check with physician if condition worsens. Pungent smell, irritant to the bronchial tree. Hemoptysis, increasedairway obstruction, clammy skin, fever, nausea, vomiting, rhinorrhea. Granule sachet Nebulising solution 200 mg bd, 3 - 5 mL of 10 - 20% solution Tablet 30 mg Syrup 30 mg/ 5 mL Drops 7.5 mg/mL Adult- 15 to 30 mg bd or tds Children - 3.75 to 7.5 mg bd. To restore tissue oxygen tension towards normal by improving arterial oxygen content and subsequently to reduce the work of breathing and myocardial stress.
P/A : Dose : P/A : Dose :
Ambroxol Hydrochloride
Oxygen Therapy
Aim:
378
SECTION 28 SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACID BASE DISTURBANCES

ORAL
Oral rehydration salts

Replacement of fluid and electrolytes orally can be achieved by giving oral rehydration saltssolutions containing sodium, potassium, citrate and glucose. Acute diarrhoea in children should always be treated with oral rehydration solution according to plans A, B, or C as shown Treatment of dehydration: WHO recommendations According to the degree of dehydration, health professionals are advised to follow one of 3 management plans. Plan A: no dehydration. Nutritional advice, increased fluid intake (soup, rice, water and yoghurt, or even water) and zinc supplementation at home are sufficient. For infants aged under 6 months who have not yet started taking solids, oral rehydration solution must be presented before offering milk. Mothers milk or dried cows milk must be given without any particular restrictions. In the case of mixed breast-milk/formula feeding, the contribution of breastfeeding must be increased. Parents should be advised about circumstances in which they should seek further advice. Plan B: moderate dehydration. Whatever the childs age, a 4-hour treatment plan is applied to avoid short-term problems. It is recommended that parents are shown how to give approximately 75 ml/kg of oral rehydration solution over a 4-hour period, and it is suggested that parents should be watched to see how they cope at the beginning of the treatment. A larger amount of solution can be given if the child continues to have frequent stools. In case of vomiting, rehydration must be discontinued for 10 minutes and then resumed at a slower rate. Breastfeeding should be continued on demand; other children should receive milk and nutritious food as normal after completing the 4 hours of oral rehydration. The childs status must be reassessed after 4 hours to decide on the most appropriate subsequent treatment. Zinc supplementation should begin as soon as the child can eat and has completed 4 hours of rehydration. Oral rehydration solution should continue to be offered once dehydration has been controlled, for as long as the child continues to have diarrhoea. 379
Solutions correcting water, electrolyte and acid base disturbances
Plan C: severe dehydration. Hospitalization is necessary, but most urgent priority is to start rehydration. In hospital (or elsewhere), if the child can drink, oral rehydration solution must be given pending, and even during, intravenous infusion (20 ml/kg every hour by mouth before infusion, then 5 ml/kg every hour by mouth during intravenous rehydration). For intravenous supplementation, it is recommended that compound solution of sodium lactate (or, if this is unavailable, sodium chloride 0.9% intravenous infusion) is administered at a rate adapted to the childs age (infant under 12 months: 30 ml/kg over 1 hour then 70 ml/ kg over 5 hours; child over 12 months: the same amounts over 30 minutes and 2.5 hours respectively). If the intravenous route is unavailable, a nasogastric tube is also suitable for administering oral rehydration solution at a rate of 20 ml/kg every hour for 6hours. If the child vomits, the rate of administration of the oral solution should be reduced. Reassess the childs status after 3 hours (6 hours for infants) and continue treatment as appropriate with plan A, B or C.
Oral rehydration salts

Glucose: 75 mEq sodium: 75 mEq or mmol/L chloride: 65 mEq or mmol/L potassium: 20 mEq or mmol/Lcitrate: 10 mmol/L osmolarity: 245 mOsml glucose: 13.5 g/L sodium chloride: 2.6 g/L potassium chloride: 1.5 gl trisodium citrate dihydrate+: 2.9 g/L
Glucose salt solution

sodium chloride sodium citrate [dihydrate] potassium chloride glucose (anhydrous) 2.6 g/litre of clean water 2.9 g/litre of clean water 1.5 g/litre of clean water 13.5 g/litre of clean water
When glucose and sodium citrate are not available, they may be replaced by sucrose (common sugar) 27 g/litre of clean water sodium bicarbonate 2.5 g/litre of clean water NOTE. The solution may be prepared either from prepackaged sugar/ salt mixtures or from bulk substances and water. Solutions must be freshly prepared, preferably with recently boiled and cooled water. Accurate weighing and thorough mixing and dissolution of ingredients in the correct volume of clean water is important. Administration of more concentrated solutions can result in hypernatraemia 380
Oral rehydration Salts
I: P/C: A/E:
Dose:
dehydration from acute diarrhoea renal impairment vomitingmay indicate too rapid administration; hypernatraemia and hyperkalaemia may result from overdose in renal impairment or administration of too concentrated a solution Fluid and electrolyte loss in acute diarrhoea, by mouth,ADULT 200400 mL, solution after every loose motion; INFANT and CHILD according to Plans A, B or C (see above)
Potassium chloride
Powder for solution. Compensation for potassium loss is necessary in patients taking digoxin or antiarrhythmic drugs where potassium depletion may induce arrhythmias. It is (renal arterystenosis, liver cirrhosis, the nephrotic syndrome, severe heart failure) and those with excessive loss of potassium in the faeces (chronic diarrhoea associated with intestinal malabsorption or laxative abuse).Measures to compensate for potassium loss may also be required in the elderly since they often take inadequate amounts in the diet.Measures may also be required during long-term administration of drugs known to induce potassium loss (for example,corticosteroids). Potassium supplements are seldom required with the small doses of diuretics given to treat hypertension. Potassium-sparing diuretics (rather than potassium supplements) are recommended for prevention of hypokalaemia due to diuretics such as furosemide or the thiazides when these are given to eliminate oedema. For the prevention of hypokalaemia doses of potassium chloride 2 to 4 g (approximately 25 to 50 mmol) daily by mouth are suitable in patients taking a normal diet. Smaller doses must be used if there is renal insufficiency (common in the elderly) otherwise there is a danger of hyperkalaemia.Larger doses may be required in established potassium depletion, the quantity depending on the severity of any continuing potassium loss (monitoring of plasma potassium and specialist advice required). Potassium depletion is frequently associated with metabolic alkalosis and chloride depletion and these disorders require correction. I: C/I: prevention and treatment of hypokalaemia severe renal impairment; plasma potassium concentration above 5 mmol/litre 381
P/C:
elderly , mild to moderate renal impairment history of peptic ulcer; important: special hazard if given with drugs liable to raise plasma potassium concentrations such as potassium-sparing diuretics, ACE inhibitors or ciclosporin. nausea and vomiting, gastrointestinal irritation Prevention of hypokalaemia by mouth, adult 2050 mmol daily after meals.Potassium depletion, by mouth, adult 40100 mmol daily in divided doses after meals: adjust dose according to severity of deficiency and any continuing loss of potassium reconstitution and administration.
A/E: Dose:
Parenteral
Solutions of electrolytes are given intravenously, to meet normal fluid and electrolyte requirements or to replenish substantial deficits or continuing losses, when the patient is nauseated or vomiting and is unable to take adequate amounts by mouth.The nature and severity of the electrolyte imbalance must be assessed from the history and clinical and biochemical examination of each individual. Sodium, potassium, chloride, magnesium, phosphate, and water depletion can occur singly and in combination with or without disturbances of acid-base balance.Isotonic solutions may be infused safely into a peripheral vein. More concentrated solutions, for example 20% glucose, are best given through an indwelling catheter positioned in a large vein. Sodium chloride in isotonic solution provides the most important extracellular ions in near physiological concentrations and is indicated in sodium depletion which may arise from conditions such as gastroenteritis, diabetic ketoacidosis, ileus and ascites. In a severe deficit of from 4 to 8 litres, 2 to 3 litres of isotonic sodium chloride may be given over 2 to 3 hours; thereafter infusion can usually be at a slower rate.Excessive administration should be avoided; the jugular venous pressureshould be assessed; the bases of the lungs should be examined for crepitations,and in elderly or seriously ill patients it is often helpful to monitor the right atrial (central) venous pressure.Chronic hyponatraemia should ideally be managed by fluid restriction. However, ifsodium chloride is required, the deficit should be corrected slowly to avoid risk of osmotic demyelination syndrome; the rise in plasma-sodium concentration should not exceed 10 382
Parental Solutions
mmol/litre in 24 hours. In severe hyponatraemia, intravenous infusion of sodium chloride 1.8% may be used with caution.The more physiologically appropriate compound solution of sodium lactatecan be used instead of isotonic sodium chloride solution during surgery or in the initial management of the injured or wounded. Sodium chloride and glucose solutions are indicated when there is combined water and sodium depletion. A 1:1 mixture of isotonic sodium chloride and 5%glucose allows some of the water (free of sodium) to enter body cells which suffer most from dehydration while the sodium salt with a volume of water determined by the normal plasma Na+ remains extracellular. Combined sodium, potassium, chloride, and water depletion may occur, for example, with severe diarrhoea or persistent vomiting; replacement is carried out with sodium chloride intravenous infusion 0.9% and glucose intravenous infusion 5% with potassium as appropriate. Glucose solutions (5%) are mainly used to replace water deficits and should be given alone when there is no significant loss of electrolytes. Average water requirement in a healthy adult are 1.5 to 2.5 litres daily and this is needed to balance unavoidable losses of water through the skin and lungs and to provide sufficient for urinary excretion. Water depletion (dehydration) tends to occur when these losses are not matched by a comparable intake, as for example may occur in coma or dysphagia or in the elderly or apathetic who may not drink water in sufficient amount on their own initiative.Excessive loss of water without loss of electrolytes is uncommon, occurring in fevers, hyperthyroidism, and in uncommon waterlosing renal states such as diabetes insipidus or hypercalcaemia. The volume of glucose solution needed to replace deficits varies with the severity of the disorder, but usually lies within the range of 2 to 6 litres. Glucose solutions are also given in regimens with calcium, bicarbonate, and insulin for the emergency treatment of hyperkalaemia. They are also given, after correction of hyperglycaemia, during treatment of diabetic ketoacidosis, when they must be accompanied by continuing insulin infusion.If glucose or sugar cannot be given orally to treat hypoglycaemia, glucose 50% may be given intravenously into a large vein through a large-gauge needle; this concentration is very irritant on extravasation and it is also viscous and difficult to administer. Larger volumes of less concentrated glucose solutions (10% or 20%) can be used as alternatives and are less irritant. 383
Sodium hydrogen carbonate (sodium bicarbonate) is used to control severe metabolic acidosis (as in renal failure). Since this condition is usually attended by sodium depletion, it is reasonable to correct this first by the administration of isotonic sodium chloride intravenous infusion, provided the kidneys are not primarily affected and the degree of acidosis is not so severe as to impair renal function. In these circumstances, isotonic sodium chloride alone is usually effective as it restores the ability of the kidneys to generate bicarbonate. In renal acidosis or in severe metabolic acidosis of any origin, for example blood pH < 7.1, sodium hydrogen carbonate (1.4%) may be infused with isotonic sodium chloride when the acidosis remains unresponsive to correction of anoxia or fluid depletion; a total volume of up to 6 litres (4 litres of sodium chloride and 2 litres of sodium hydrogen carbonate) may be necessary in the adult. In severe shock due for example to cardiac arrest, metabolic acidosis may develop without sodium depletion; in these circumstances sodium hydrogen carbonate is best given in a small volume of hypertonic solution (for example 50 ml of 8.4% solution intravenously); plasma pH should be monitored. Sodium hydrogen carbonate is also used in the emergency management of hyperkalaemia. Intravenous potassium chloride in sodium chloride infusion is the initial treatment for the correction of severe hypokalaemia when sufficient potassium cannot be taken by mouth. Potassium chloride concentrate may be added to sodium chloride 0.9% infusion, thoroughly mixed, and given slowly over 2 to 3 hours with specialist advice and ECG monitoring in difficult cases. Repeated measurements of plasma potassium are necessary to determine whether further infusions are required and to avoid the development of hyperkalaemia which is especially likely to occur in renal impairment. Initial potassium replacement therapy should not involve glucose infusions because glucose may cause a further decrease in the plasmapotassium concentration. Glucose I: P/C: A/E: fluid replacement without significant electrolyte deficit);treatment of hypoglycaemia diabetes mellitus (may require additional insulin) glucose injections, especially if hypertonic, may have a low pH and cause venous irritation and thrombophlebitis; fluid and electrolyte disturbances;
384
Parental Solutions
oedema or water intoxication (on prolonged administration or rapid infusion of large volumes of isotonic solutions); hyperglycaemia (on prolonged administration of hypertonic solutions) P/A: Injectable solution: 5%; 10% isotonic; 50% hypertonic. Dose: Fluid replacement, by intravenous infusion, adult and child determined on the basis of clinical and, whenever possible, electrolyte monitoring Treatment of hypoglycaemia, by intravenous infusion of 50% glucose solution into a large vein, adult, 25 ml Glucose with sodium chloride I: fluid and electrolyte replacement P/C: restrict intake in impaired renal function, cardiac failure, hypertension, peripheral and pulmonary oedema, toxaemia of pregnancy A/E: administration of large doses may give rise to oedema P/A: Injectable solution: 4% glucose, 0.18% sodium chloride (equivalent to Na+30 mmol/l, Cl-30 mmol/l). Dose: Fluid replacement, by intravenous infusion, adult and child determined on the basis of clinical and, whenever possible, electrolyte monitoring Potassium chloride I: electrolyte imbalance; see also oral potassium P/C: for intravenous infusion the concentration of solution should not usually exceed 3.2 g (43 mmol)/litre; specialist advice and ECG monitoring; renal impairment. A/E: cardiac toxicity on rapid infusion P/A: Solution: 11.2% in 20-ml ampoule (equivalent to K+ 1.5 mmol/ml, Cl- 1.5 mmol/ml). Dose: Electrolyte imbalance, by slow intravenous infusion, adult and child depending on the deficit or the daily maintenance requirements (see also notes above)dilution and administration. Must be diluted and thoroughly mixed before use and administered according to manufacturers directions 385
Sodium chloride I: P/C:
A/E: P/A: Dose:
electrolyte and fluid replacement restrict intake in impaired renal function ,cardiac failure, hypertension, peripheral and pulmonary oedema, toxaemia of pregnancy administration of large doses may give rise to sodium accumulation and oedema Injectable solution: 0.9% isotonic (equivalent to Na+ 154 mmol/l, Cl- 154 mmol/L). Fluid and electrolyte replacement, by intravenous infusion, adult and child determined on the basis of clinical and, whenever possible, electrolyte monitoring (see notes above)
Sodium hydrogen carbonate

metabolic acidosis metabolic or respiratory alkalosis, hypocalcaemia, hypochlorhydria P/C: restrict intake in impaired renal function ,cardiac failure, hypertension, peripheral and pulmonary oedema, toxaemia of pregnancy; monitor electrolytes and acid-base status A/E: excessive administration may cause hypokalaemia and metabolic alkalosis, especially in renal impairment; large doses may give rise to sodium accumulation and oedema. P/A : Injectable solution: 1.4% isotonic (equivalent to Na+ 167 mmol/L, HCO3- 167 mmol/L). Solution: 8.4% in 10-ml ampoule (equivalent to Na+ 1000 mmol/L, HCO3- 1000 mmol/L). Dose: Metabolic acidosis, by slow intravenous injection, adult and child a strong solution (up to 8.4%) or by continuous intravenous infusion,adult and child a weaker solution (usually 1.4%), an amount appropriate to the body base deficit (see notes above) Sodium lactate, compound solution Injectable solution. Compound solution of sodium lactate is a representative intravenous electrolyte solution. Various solutions can serve as alternatives. 386 I: C/I:
Parental Solutions
I: C/I: P/C:
A/E: Dose:
pre- and perioperative fluid and electrolyte replacement; hypovolaemic shock metabolic or respiratory alkalosis; hypocalcaemia or hypochlorhydria restrict intake in impaired renal function, cardiac failure, hypertension, peripheral and pulmonary oedema, toxaemia of pregnancy excessive administration may cause metabolic alkalosis; administration of large doses may give rise to oedema Fluid and electrolyte replacement or hypovolaemic shock, by intravenous infusion, adult and child determined on the basis of clinical and, whenever possible, electrolyte monitoring (see notes above)
Miscellaneous
Water for injection 2-mL; 5-mL; 10-mL ampoules. Uses: in preparations intended for parenteral administration and in other sterile preparations
Total parenteral nutrition

Total parenteral nutrition (TPN), is the practice of feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins. Total parenteral nutrition (TPN), also referred to as Parenteral nutrition (PN), is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired (Kozier et al, 2004). It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Short-term TPN may be used if a persons digestive system has shut down (for instance by Peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term TPN is occasionally used to treat people suffering the extended consequences of an accident or surgery. Most controversially, TPN has extended the life of a small number of children born with nonexistent or severely deformed guts..The preferred method of delivering TPN is with a medical infusion pump. A sterile bag of nutrient solution, between 500 mL and 4 L is provided. The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open. Feeding schedules vary, but one common regimen ramps up the nutrition over one hour, levels 387
off the rate for a few hours, and then ramps it down over a final hour, in order to simulate a normal metabolic response resembling meal time. This should be done over 12 to 14 hours rather than intermittently during the day. Chronic TPN is performed through a central intravenous catheter, usually through the subclavian or jugular vein with the tip of the catheter at the superior vena cava without entering the right atrium. Another common practice is to use a PICC line, which originates in the arm, and extends to one of the central veins, such as the subclavian with the tip in the superior vena cava. In infants, sometimes the umbilical vein is used. Battery-powered ambulatory infusion pumps can be used with chronic TPN patients. Usually the pump and a small (100 mL) bag of nutrient (to keep the vein open) are carried in a small bag around the waist or on the shoulder. Outpatient TPN practices are still being refined but have been used for years. Patients can receive the majority of their infusions while they sleep and instill heparin in their catheters when they are done to simulate a more normal life style off the pump.Aside from their dependence on a pump, chronic TPN patients can live quite normal lives.
Complications
The most common complication of TPN use is bacterial infection, usually due to the increased infection risk from having an indwelling central venous catheter. In patients with frequent bacterial infections, fungal infections can also occur. Liver failure, often related to Fatty liver, may sometimes occur. This condition is generally due to excess in glucose provided in TPN solutions.Two related complications of TPN are venous thrombosis and rarely priapism. Fat infusion during TPN is assumed to contribute to both.Total parenteral nutrition increases the risk of acute cholecystitis due to complete unusage of gastrointestinal tract, which may result in bile stasis in the gallbladder. The risk of acute cholecystitis is increased accordingly.
In critical and/or perioperative care

Parenteral nutrition is indicated to prevent the adverse effects of malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. Other indications are short gut syndrome, highoutput fistula, prolonged ileus, or bowel obstruction. However, the decision to initiate TPN needs to be made on an individual patient basis, as different patients will have differing abilities to tolerate starvation. The nutrient 388
Total Parental Nutritions
solution consists of water and electrolytes; glucose, amino acids, and lipids; essential vitamins, minerals and trace elements are added or given separately. Previously lipid emulsions were given separately but it is becoming more common for a three-in-one solution of glucose, proteins, and lipids to be administered. Complications are either related to Catheter insertion, or Metabolic (including the Refeeding syndrome). Catheter complications include pneumothorax, accidental arterial puncture, and catheter-related sepsis. The complication rate at the time of insertion should be less than 5%. Catheter-related infections may be minimised by appropriate choice of catheter and insertion technique. Metabolic complications include the Refeeding Syndrome characterised by hypokalemia, hypophosphatemia and hypomagnesemia. Hyperglycemia is common at the start of therapy, but can be treated with insulin added to the TPN solution. Hypoglycaemia is likely to occur with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration (demonstrated by elevated transaminases). Severe hepatic dysfunction is a rare complication. Overall, patients receiving TPN have a higher rate of infectious complications. This can be related to hyperglycemia.
Intravenous therapy
Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip.. Compared with other routes of administration, the intravenous route is one of the fastest ways to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously. INTRAVENOUS ACCESS DEVICES Needle and syringe The simplest form of intravenous access is a syringe with an attached hypodermic needle. The needle is inserted through the skin into a vein, and the contents of the syringe are injected through the needle into the bloodstream. This is most easily done with an arm vein, especially one of the metacarpal veins. Usually it is necessary to use a tourniquet first to make the vein bulge; once the needle is in place, it is common to draw back slightly on the syringe to aspirate blood, thus verifying that the needle is really in a vein; then the tourniquet is removed before injecting. 389
Peripheral IV lines
Peripheral IV in hand This is the most common intravenous access method in both hospitals and pre-hospital services. A peripheral IV line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein. There are times, however, when underlying physiological factors (morbid obesity, peripheral vascular disease and IV drug abuse, to name a few) make insertion into any available vein a medical necessityparticularly if the patient is exsanguinating. The adage time is tissue should be paramount during times like these or if the patient is at risk for a cardiac event. Arm and hand veins are typically used although leg and foot veins are occasionally used. Veins in the arm are the common site in emergency settings, commonly performed by paramedics and emergency physicians. On infants the scalp veins are sometimes used. The part of the catheter that remains outside the skin is called the connecting hub; it can be connected to a syringe or an intravenous infusion line, or capped with a bung between treatments. Ported cannulae have an injection port on the top that is often used to administer medicine. The caliber of cannula is commonly indicated in gauge, with 14 being a very large cannula (used in resuscitation settings) and 24-26 the smallest. The most common sizes are 16-gauge (midsize line used for blood donation and transfusion), 18- and 20gauge (all-purpose line for infusions and blood draws), and 22-gauge (allpurpose pediatric line). 12- and 14-gauge peripheral lines actually deliver equivalent volumes of fluid faster than central lines, accounting for their popularity in emergency medicine; these lines are frequently called large bores or trauma lines. Blood can be drawn from a peripheral IV if necessary, but only if it is in a relatively large vein and only if the IV is newly inserted. Blood draws are typically taken with specialized IV access sets known as phlebotomy kits, and once the draw is complete, the needle is removed and the site is not used again. If a patient needs frequent venous access, the veins may scar and narrow, making any future access extremely difficult or impossible; this situation is known as a blown vein, and the person attempting to obtain the access must find a new access site proximal to the blown area. Originally, a peripheral IV was simply a needle that was taped in place and connected to tubing rather than to a syringe; this system is still 390
Intravenous access device
used for blood donation sets, as the IV access will only be needed for a few minutes and the donor may not move while the needle is in place. Today, hospitals use a safer system in which the catheter is a flexible plastic tube that originally contains a needle to allow it to pierce the skin; the needle is then removed and discarded, while the soft catheter stays in the vein. This method is a variation of the Seldinger technique. The external portion of the catheter, which is usually taped in place or secured with a self-adhesive dressing, consists of an inch or so of flexible tubing and a locking hub. For centrally placed IV lines, sets and flushes contain a small amount of the anticoagulant heparin to keep the line from clotting off, and frequently are called heparin locks or hep-locks. However, heparin is no longer recommended as a locking solution for peripheral IVs; saline is now the solution of choice for a vac lock. A peripheral IV cannot be left in the vein indefinitely, because of the risk of insertion-site infection leading to phlebitis, cellulitis and sepsis. The CDC updated their guidelines and now advise the cannula need to be replaced every 96 hours.[1] This was based on studies organised to identify causes of Methicillin-resistant Staphylococcus aureus MRSA infection in hospitals. In the United Kingdom, the UK Department of health published their finding about risk factors associated with increased MRSA infection, now include intravenous cannula, central venous catheters and urinary catheters as the main factors increasing the risk of spreading antibiotic resistant strain bacteria in hospitals. Central IV lines Central IV lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. This has several advantages over a peripheral IV:
It can deliver fluids and medications that would be overly irritating to peripheral veins because of their concentration or chemical composition. These include some chemotherapy drugs and total parenteral nutrition. Medications reach the heart immediately, and are quickly distributed to the rest of the body. There is room for multiple parallel compartments (lumen) within the catheter, so that multiple medications can be delivered at once even if they would not be chemically compatible within a single tube. 391
Caregivers can measure central venous pressure and other physiological variables through the line. There are several types of central IVs, depending on the route that the catheter takes from the outside of the body to the vein. Peripherally inserted central catheter PICC lines are used when intravenous access is required over a prolonged period of time, as in the case of long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition. The PICC line is inserted into a peripheral vein using the Seldinger technique under ultrasound guidance, usually in the arm, and then carefully advanced upward until the catheter is in the superior vena cava or the right atrium. This is usually done by feel and estimation; an X-ray then verifies that the tip is in the right place. A PICC may have two parallel compartments, each with its own external connector (double-lumen), or a single tube and connector (singlelumen). Triple connectors (triple-lumen) catheters and power-injectable PICCs are now available as well. From the outside, a single-lumen PICC resembles a peripheral IV, except that the tubing is slightly wider. The insertion site must be covered by a larger sterile dressing than would be required for a peripheral IV, due to the higher risk of infection if bacteria travel up the catheter. However, a PICC poses less of a systemic infection risk than other central IVs, because bacteria would have to travel up the entire length of the narrow catheter before spreading through the bloodstream. The chief advantage of a PICC over other types of central lines is that it is easy to insert, poses a relatively low risk of bleeding, is externally unobtrusive, and can be left in place for months to years for patients who require extended treatment. The chief disadvantage is that it must travel through a relatively small peripheral vein and is therefore limited in diameter, and also somewhat vulnerable to occlusion or damage from movement or squeezing of the arm. Central venous lines There are several types of catheters that take a more direct route into central veins. These are collectively called central venous lines. In the simplest type of central venous access, a catheter is inserted into a subclavian, internal jugular, or (less commonly) a femoral vein and 392
Intravenous access device
advanced toward the heart until it reaches the superior vena cava or right atrium. Because all of these veins are larger than peripheral veins, central lines can deliver a higher volume of fluid and can have multiple lumens. Another type of central line, called a Hickman line or Broviac catheter, is inserted into the target vein and then tunneled under the skin to emerge a short distance away. This reduces the risk of infection, since bacteria from the skin surface are not able to travel directly into the vein; these catheters are also made of materials that resist infection and clotting. Implantable ports A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does not have an external connector; instead, it has a small reservoir that is covered with silicone rubber and is implanted under the skin. Medication is administered intermittently by placing a small needle through the skin, piercing the silicone, into the reservoir. When the needle is withdrawn the reservoir cover reseals itself. The cover can accept hundreds of needle sticks during its lifetime. It is possible to leave the ports in the patients body for years; if this is done however, the port must be accessed monthly and flushed with an anticoagulant, or the patient risks it getting plugged up. If it is plugged it becomes a hazard as a thrombus will eventually form with an accompanying risk of embolisation. Removal of a port is usually a simple outpatient procedure; however, installation is more complex and a good implant is fairly dependent on the skill of the radiologist. Ports cause less inconvenience and have a lower risk of infection than PICCs, and are therefore commonly used for patients on long-term intermittent treatment.
Forms of intravenous therapy

Intravenous drip An intravenous drip is the continuous infusion of fluids, with or without medications, through an IV access device. This may be to correct dehydration or an electrolyte imbalance, to deliver medications, or for blood transfusion. IV fluids There are two types of fluids that are used for intravenous drips; crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. 393
Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by chrystalloids due to haemodilution. However, there is still controversy to the actual difference in efficacy by this difference. Another difference is that crystalloids generally are much cheaper than colloids The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Ringers lactate or Ringers acetate is another isotonic solution often used for large-volume fluid replacement. A solution of 5% dextrose in water, sometimes called D5W, is often used instead if the patient is at risk for having low blood sugar or high sodium. The choice of fluids may also depend on the chemical properties of the medications being given. Composition of Common Crystalloid Solutions Solution D5 Other Name 5% Dextrose 3.3% Dextrose / 0.3% saline 0.45% NaCl [Na+] [Cl-] [Glucose] [Glucose] (mmol/L) (mmol/L) (mmol/L) (mg/dl) 0 0 278 5000
2/3D & 1/3S
51
51
185
3333
Half-normal saline Normal saline Ringers lactate
77
77
0.9% NaCl
154
154
Lactated Ringer
130
109
Ringers lactate also has 28 mmol/L lactate, 4 mmol/L K+ and 3 mmol/ L Ca . Ringers acetate also has 28 mmol/L acetate, 4 mmol/L K+ and 3 mmol/L Ca2+.
2+
394
Forms of Intravenous Therapy
Effect of Adding One Litre Solution D5 2/3D & 1/3S Half-normal saline Normal saline Ringers lactate Change in ECF 333 mL 556 mL 667 mL 1000 mL 900 mL Change in ICF 667 mL 444 mL 333 mL 0 mL 100 mL
Infusion equipment A standard IV infusion set consists of a pre-filled, sterile container (glass bottle, plastic bottle or plastic bag) of fluids with an attached drip chamber which allows the fluid to flow one drop at a time, making it easy to see the flow rate (and also reducing air bubbles); a long sterile tube with a clamp to regulate or stop the flow; a connector to attach to the access device; and connectors to allow piggybacking of another infusion set onto the same line, e.g., adding a dose of antibiotics to a continuous fluid drip. An infusion pump allows precise control over the flow rate and total amount delivered, but in cases where a change in the flow rate would not have serious consequences, or if pumps are not available, the drip is often left to flow simply by placing the bag above the level of the patient and using the clamp to regulate the rate; this is a gravity drip. A rapid infuser can be used if the patient requires a high flow rate and the IV access device is of a large enough diameter to accommodate it. This is either an inflatable cuff placed around the fluid bag to force the fluid into the patient or a similar electrical device that may also heat the fluid being infused. Intermittent infusion Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional fluid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete dose of medication has been given, the tubing is disconnected from the IV access device. Some medications are also given by IV push, meaning that a syringe is connected to the IV access device and the medication is injected directly (slowly, if it might irritate the vein or cause a too-rapid effect). Once a medicine has been injected into the fluid 395
stream of the IV tubing there must be some means of ensuring that it gets from the tubing to the patient. Usually this is accomplished by allowing the fluid stream to flow normally and thereby carry the medicine into the bloodstream; however, a second fluid injection is sometimes used, a flush, following the injection to push the medicine into the bloodstream more quickly.
Risks of intravenous therapy

Infection Any break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation. Phlebitis Phlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around the vein. The IV device must be removed and if necessary re-inserted into another extremity. Due to frequent injections and recurring phlebitis, the peripheral veins of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become hardened and difficult to access over time. Infiltration Infiltration occurs when an IV fluid accidentally enters the surronding tissue rather than the vein. It is characterized by coolness and pallor to the skin as well as local edema. It is usually not painful. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. Infiltration is one of the most common adverse effects of IV therapy and is usually not serious unless the infiltrated fluid is a medication damaging to the surronding tissue, in which case the incident is known as extravasation 396
Forms of Intravenous Therapy
Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema. Electrolyte imbalance Administering a too-dilute or too-concentrated solution can disrupt the patients balance of sodium, potassium, magnesium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels. Embolism A blood clot or other solid mass, as well as an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV. Air bubbles of less than 30 milliliters are thought to dissolve into the circulation harmlessly. Small volumes do not result in readily detectable symptoms, but ongoing studies hypothesize that these micro-bubbles may have some adverse effects. A larger amount of air, if delivered all at once, can cause life-threatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart. One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by air embolism is vanishingly rare, in part because it is also difficult to diagnose. Extravasation Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue, either by leakage (e.g. because of brittle veins in very elderly patients), or directly (e.g. because the needle has punctured the vein and the infusion goes directly into the arm tissue). This occurs more frequently with chemotherapeutic agents.
397
SECTION 29 VITAMINS AND MINERALS

VITAMINS Vitamins are used for the prevention and treatment of specific deficiency states or when the diet is known to be inadequate. It has often been suggested but never convincingly proved, that subclinical vitamin deficiencies cause much chronic ill-health and liability to infections. This has led to enormous consumption of vitamin preparations, which have no more than placebo value. Most vitamins are comparatively non-toxic but prolonged administration of high doses of retinol (vitamin A), ergocalciferol (vitamin D) and pyridoxine (vitamin B) may have severe adverse effects.
Minerals
Calcium gluconate. Calcium supplements are usually only required where dietary calcium intake is deficient. This dietary requirement varies with age and is relatively greater in childhood, pregnancy and lactation due to an increased demand, and in old age, due to impaired absorption. In osteoporosis, a calcium intake which is double the recommended daily amount reduces the rate of bone loss. In hypocalcaemic tetany calcium gluconate must be given parenterally but plasma calcium must be monitored. Calcium gluconate is also used in cardiac resuscitation. Iodine is among the bodys essential trace elements. The recommended intake of iodine is 150 micrograms daily (200 micrograms daily in pregnant and breastfeeding women); in children the recommended intake of iodine is 50 micrograms daily for infants under 1 year, 90 micrograms daily for children aged 26 years, and 120 micrograms daily for children aged 712 years. Deficiency causes endemic goitre and results in endemic cretinism (characterized by deaf-mutism, intellectual deficit, spasticity and sometimes hypothyroidism), impaired mental function in children and adults and an increased incidence of still-births and perinatal and infant mortality. Iodine and iodides may suppress neonatal thyroid function and in general iodine compounds should be avoided in pregnancy. Where it is essential to prevent neonatal goitre and cretinism, iodine should not be witheld from pregnant women. Control of iodine deficiency largely depends upon salt iodization with potassium iodide or potassium iodate and through dietary diversification. In areas where iodine deficiency disorders are moderate to 398
Vitamins and Minerals
severe, iodized oil given either before or at any stage of pregnancy is found to be beneficial. Sodium fluoride. Availability of adequate fluoride confers significant resistance to dental caries. It is now considered that the topical action of fluoride on enamel and plaque is more important than the systemic effect. Where the fluoride content of the drinking water is less than 700 micrograms per litre, daily administration of fluoride tablets or drops is a suitable means of supplementation. Systemic fluoride supplements should not be prescribed without reference to the fluoride content of the local water supply; infants need not receive fluoride supplements until the age of 6 months at the earliest. Dentifrices which incorporate sodium fluoride are a convenient source of fluoride. Individuals who are either particularly caries prone or medically compromized may be given additional protection by the use of fluoride rinses or by application of fluoride gels. Rinses may be used daily or weekly; daily use of a less concentrated rinse is more effective than weekly use of a more concentrated one. High-strength gels must be applied on a regular basis under professional supervision; extreme caution is necessary to prevent the child from swallowing any excess. For the use of iron preparations in the treatment of anaemia see section on section on drugs affecting blood Retinol (vitamin A) is a fat-soluble substance stored in body organs, principally the liver. Periodic high-dose supplementation is intended to protect against vitamin A deficiency which is associated with ocular defects particularly xerophthalmia (including night blindness which may progress to severe eye lesions and blindness), and an increased susceptibility to infections, particularly measles and diarrhoea. Universal vitamin A distribution involves the periodic administration of supplemental doses to all preschool-age children with priority given to age groups, 6 months to 3 years, or regions at greatest risk. All mothers in high-risk regions should also receive a high dose of vitamin A within 8 weeks of delivery. Since vitamin A is associated with a teratogenic effect it should be given in smaller doses (no more than 10 000 units/day) to women of child-bearing age. It is also used in the treatment of active xerophthalmia. Doses of vitamin A should be administered orally immediately upon diagnosis of xerophthalmia and thereafter patients with acute corneal lesions should be referred to a hospital on an emergency basis. In women of child-bearing age there is a need to balance the possible teratogenic effects of vitamin A should they 399
be pregnant with the serious consequences of xerophthalmia. Where there are severe signs of xerophthalmia high dose treatment as for patients over 1 year should be given. When less severe symptoms are present (for example night blindness) a much lower dose is recommended. Vitamin A therapy should also be given during epidemics of measles to reduce complications. Vitamin B is composed of widely differing substances which are, for convenience, classed as vitamin B complex. Thiamine (vitamin B ) is used orally for deficiency due to to inadequate dietary intake. Severe deficiency may result in beri-beri. Chronic dry beri-beri is characterized by peripheral neuropathy, muscle wasting and weakness, and paralysis; wet beri-beri is characterized by cardiac failure and oedema. Wernicke-Korsakoff syndrome (demyelination of the CNS) may develop in severe deficiency. Thiamine is given by intravenous injection in doses of up to 300 mg daily (parenteral preparations may contain several B group vitamins) as initial treatment in severe deficiency states. Potentially severe allergic reactions may occur during, or shortly after parenteral administration, therefore intravenous injections should be administered slowly (over 10 minutes) and should be used only if parenteral treatment is essential. Facilities for resuscitation should be Riboflavin (vitamin B ) deficiency may result from immediately available. reduced dietary intake or reduced absorption due to liver disease, alcoholism, chronic infection or probenecid therapy. It may also occur in association with Pyridoxine (vitamin B ) deficiency is other deficiency states such as pellagra.rare as the vitamin is widely distributed in foods, but deficiency may occur during isoniazid therapy and is characterized by peripheral neuritis. High doses are given in some metabolic disorders, such as hyperoxaluria and it is also used in sideroblastic anaemia. Pyridoxine and thiamine also have a role in status epilepticus (see section 5). Nicotinic acid inhibits the synthesis of cholesterol and triglyceride and is used in some hyperlipidaemias. Nicotinic acid and nicotinamide are used to prevent and treat nicotinic acid deficiency (pellagra). Nicotinamide is generally preferred as it does not cause vasodilation. Hydroxocobalamin is the form of vitamin B used to treat vitamin B deficiency due to dietary deficiency or malabsorption Folic acid is essential for the synthesis of DNA and certain proteins. Deficiency of folic acid or vitamin B is associated with megaloblastic anaemia. Folic acid should not be used in undiagnosed megaloblastic anaemia unless vitamin B is administered concurrently, otherwise neuropathy may 400
be precipitated. Supplementation with folic acid 400 micrograms daily is recommended for women of child-bearing potential in order to reduce the risk of serious neural tube defects in their offspring Ascorbic acid (vitamin C) is used for the prevention and treatment of scurvy. Claims that ascorbic acid is of value in the treatment of common colds are unsubstantiated. The term vitamin D covers a range of compounds including ergocalciferol (vitamin D2)and cholecalciferol (vitamin D3 ). These two compounds are equipotent and either can be used to prevent and treat rickets. Simple deficiency of vitamin D occurs in those who have an inadequate dietary intake or who fail to produce enough cholecalciferol (vitamin D3) in their skin from the precursor 7-dehydrocholesterol in response to ultraviolet light. Children with dark skin must continue vitamin D prophylaxis for up to 24 months because of their inability to produce enough vitamin D in their skin. Dark skin with a high melanin content must be exposed to daylight longer than light skin in order to obtain the same synthesis of vitamin D is also used in deficiency states caused by intestinal malabsorption or chronic liver disease and for the hypocalcaemia of hypoparathyroidism. Vitamin K is necessary for the production of blood clotting factors Ascorbic acid (Vitamin C ) I: P/A: A/E: Dose: prevention and treatment of scurvy Tablet: 50 mg. gastrointestinal disturbances reported with large doses Prophylaxis of scurvy, by mouth, ADULT and CHILD 25 75 mg daily Treatment of scurvy, by mouth, ADULT and CHILD not less than 250 mg daily in divided doses Calcium gluconate I: C/I: hypocalcaemic tetany conditions associated with hypercalcaemia and hypercalciuria (for example some forms of malignant disease) 401
monitor plasma calcium concentration; renal impairment; sarcoidosis; history of nephrolithiasis; A/E: gastrointestinal disturbances; bradycardia, arrhythmia; injection-site reactions; peripheral vasodilation; fall in blood pressure P/A: Injection: 100 mg/mL in 10-mL ampoule. Dose: Hypocalcaemic tetany, by slow intravenous injection, ADULT 1 g (2.2 mmol) followed by continuous intravenous infusion of about 4 g (8.8 mmol) daily DILUTION AND ADMINISTRATION. According to manufacturers directions Ergocalciferol (Vitamin D) Ergocalciferol is a representative vitamin D compound. Various vitamin D compounds can serve as alternatives NOTE. If there is no plain vitamin D tablet available for the treatment of simple deficiency, calcium and ergocalciferol tablets may be used but the calcium is unnecessary I:: prevention of vitamin D deficiency; vitamin D deficiency caused by malabsorption or chronic liver disease; hypocalcaemia of hypoparathyroidism hypercalcaemia; metastatic calcification ensure correct dose in infants; monitor plasma calcium at weekly intervals in patients receiving high doses or those with renal impairment; nausea and vomitingmay indicate overdose and hypercalcaemia; pregnancy and breastfeeding symptoms of overdosage include anorexia, lassitude, nausea and vomiting, diarrhoea, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised concentrations of calcium and phosphate in plasma and urine; tissue calcification may occur if dose of 1.25 mg continued for several months. Capsule or tablet: 1.25 mg (50 000 IU). Oral liquid: 250 micrograms/mL (10 000 IU/mL). Prevention ofvitamin D deficiency, by mouth, ADULT and CHILD 10 micrograms (400 units) daily Treatment of vitamin D deficiency, by mouth, ADULT 1.25 mg (50 000 units)
P/C:
C/I: P/C:
A/E:
P/A: Dose:
402
CHILD 75125 micrograms (30005000 units) daily for a limited period; daily Hypocalcaemia associated with hypoparathyroidism, by mouth, ADULT 2.5 mg (100 000 units) daily; CHILD up to 1.5 mg (60 000 units) daily Iodine I: C/I: P/C: prevention and treatment of iodine deficiency breastfeeding over 45 years old or with nodular goitre (especially susceptible to hyperthyroidism when given iodine supplementsiodized oil may not be appropriate); may interfere with thyroid-function tests; pregnancy hypersensitivity reactions; goitre and hypothyroidism; hyperthyroidism Capsule: 200 mg. Iodized oil: 1 mL(480 mg iodine); 0.5 mL (240 mg iodine) in ampoule (oral or injectable); 0.57 mL (308 mg iodine) in dispenser bottle. Iodized oil may also be given by mouth Endemic moderate to severe iodine deficiency, by intramuscular injection, ADULT women of child-bearing age, including any stage of pregnancy, 480 mg once each year; by mouth, ADULT during pregnancy and one year postpartum, 300480 mg once a year or 100 300 mg every 6 months; women of child-bearing age, 400960 mg once a year or 200480 mg every 6 months Iodine deficiency, by intramuscular injection, INFANT up to 1 year, 190 mg; CHILD and ADULT 380 mg (aged over 45 years or with nodular goitre, 76 mg but see also Precautions) (provides up to 3 years protection) Iodine deficiency, by mouth, ADULT (except during pregnancy) and CHILD above 6 years, 400 mg once a year; ADULT during pregnancy, single dose of 200 mg; INFANT under 1 year, single dose of 100 mg; CHILD 15 years, 200 mg once a year
A/E: P/A:
NOTE. Dose:
Nicotinamide Nicotinamide is a representative vitamin B substance. Various compounds can serve as alternatives. 403
I: P/A: Dose:
treatment of pellagra Tablet: 50 mg. Treatment of pellagra, by mouth, ADULT up to 500 mg daily in divided doses
Pyridoxine Also known as Vitamin B I: treatment of pyridoxine deficiency due to metabolic disorders; isoniazid neuropathy; sideroblastic anaemia A/E: generally well tolerated, but chronic administration of high doses may cause peripheral neuropathies P/A: Tablet: 25 mg (hydrochloride). Dose: Deficiency states, by mouth, ADULT 2550 mg up to 3 times daily Isoniazid neuropathy, prophylaxis, by mouth, ADULT 10 mg daily Isoniazid neuropathy, treatment, by mouth, ADULT 50 mg 3 times daily Sideroblastic anaemia, by mouth, ADULT 100400 mg daily in divided doses Retinol I: prevention and treatment of vitamin A deficiency; prevention of complications of measles P/C: pregnancy (teratogenic); breastfeeding A/E: no serious or irreversible adverse effects in recommended doses; high intake may cause birth defects; transient increased intracranial pressure in adults or a tense and bulging fontanelle in infants (with high dosage); massive overdose can cause rough skin, dry hair, enlarged liver, raised erythrocyte sedimentation rate, raised serum calcium and raised serum alkaline phosphatase concentrations. P/A: Capsule: 50 000 IU; 100 000 IU; 200 000 IU (as palmitate). Oral oily solution: 100 000 IU (as palmitate)/ml in multidose dispenser. Tablet (sugar-coated): 10 000 IU (as palmitate). Water-miscible injection: 100 000 IU (as palmitate) in 2-mL ampoule. Dose: Prevention of vitamin A deficiency (universal or targeted distribution programmes) 404
INFANT under 6 months, 50 000 units, 612 months, , by mouth, 100 000 units every 46 months, preferably at measles vaccination; CHILD over 1 year (preschool), 200 000 units every 46 months; ADULT, 200 000 units every 6 months; ADULT pregnant woman, maximum of 10 000 units daily or maximum 25 000 units weekly; ADULT MOTHERS, 200 000 units at delivery or within 8 weeks of delivery NOTE. An additional dose should be given the next day in hospitalized children with measles infection. Treatment of xerophthalmia, by mouth,INFANT under 6 months, 50 000 units on diagnosis, repeated next day and then after 2 weeks; 612 months, 100 000 units immediately on diagnosis, repeated next day and then after 2 weeks; CHILD over 1 year and ADULT (except woman of childbearing age) 200 000 units on diagnosis, repeated next day and then after 2 weeks; ADULT (woman of child-bearing age, see notes above), severe signs of xerophthalmia, as for other adults; less severe cases (for example, night blindness), 500010 000 units daily for at least 4 weeks or up to 25 000 units weekly NOTE. Oral vitamin A preparations are preferred for the prevention and treatment of vitamin A deficiency. However, in situations where patients have severe anorexia or vomiting or are suffering from malabsorption, a water-miscible injection preparation may be administered intramuscularly Riboflavin Also known as Vitamin B2 I: vitamin B2 deficiency P/A: Tablet: 5 mg. Dose: Treatment of vitamin B2 deficiency, by mouth, ADULT and CHILD up to 30 mg daily in divided doses Prophylaxis of vitamin B2 deficiency, by mouth, ADULT and CHILD 12 mg daily Sodium fluoride In any appropriate topical formulation. I: prevention of dental caries 405
C/I: A/E:
Dose:
NOTE.
not for areas where drinking water is fluoridated or where fluorine content is naturally high in recommended doses toxicity unlikely; occasional white flecks on teeth at recommended doses; rarely yellowish-brown discoloration if recommended doses are exceeded Prevention of dental caries, as oral rinse, CHILD over 6 years, 10 ml 0.05% solution daily or 10 mL 0.2% solution weekly Fluoridated toothpastes are also a convenient source of fluoride for prophylaxis of dental caries
Thiamine Also known as Vitamin B1 I: P/C: P/A: Dose: prevention and treatment of vitamin B1 deficiency parenteral administration); breastfeeding Tablet: 50 mg (hydrochloride). Mild chronic thiamine deficiency, by mouth, ADULT 1025 mg daily
406
PART II
GUIDELINES FOR FIRST LINE MANAGEMENT OF CLINICAL EMERGENCIES ENCOUNTERED IN PERIPHERAL HOSPITALS
INTRODUCTION: Severe emergencies may crop up at dispensaries and small hospitals where the optimum number of health care personnel, equipment, drugs and specialists may not be available. Still it is the duty of the available medical team to attend to all sorts of emergencies, when called upon to do. Much can be done by appropriate first aid measures such as clearing the airway, giving pain relief, splinting a fractured limb, applying a tourniquet to prevent bleeding, stopping a seizure etc. Referral to the appropriate health care facility also helps to reduce the delay in proper management, which is crucial for the successful outcome. With this purpose in mind, the section on guidelines for clinical management which was included in Kerala State Drug Formulary, Number1 (Published in 1999) has been modified to include only the emergencies and their management possible at the peripheral hospitals. Since Kerala Government is also preparing a consensus book for treatment of the common diseases in the State, such diseases which do not require emergency management at the periphery have been deleted from this section. This section is written primarily with the view to provide ready reference for the doctor for immediate action. GENERAL TOPICS
Hyperpyrexia
The term hyperpyrexia denotes rise of temperature > 41.50C (1070F). Once the temperature rises > 410C the body behaves as a poikilothermic organism. Hyperpyrexia can be due a variety of clinical conditions such as malaria, septicemia, viral fevers, pneumonia, heat stroke, pontine haemorrhage and several others, especially infections. Uncontrolled hyperpyrexia is fatal due to damage to vital structures. Temperatures > 390C ( 1020F) themselves make the patient very uncomfortable and the relatives anxious and disturbed. Particularly in children high temperatures may be associated with convulsions (febrile seizures) which make the situation even more 407
Guidelines
alarming.Though febrile seizures are self terminating in the majority of cases and generally do not lead to more adverse sequelae their occurrence leads to panic among the relatives and this has to be deliberately managed by the attending doctor. Febrile fits also respond promptly to the reduction of body temperature. Paracetamol given in a dose of 1 g orally for an adult (Proportional dose for children see section 26)promptly brings down the temperature within 15 30 minutes.If needed paracetamol can be given IM in dose of 300 mg to be repeated later ,depending on the condition. Physical measures such as tepid sponging and exposure to breeze (by a fan), application of cold compresses to the forehead will help to bring down the temperature and provide relief. Since physical measures alone are inadequate to maintain the benefit, antipyretics have to be administered along with tepid sponging and cooling by breeze.The physical measures have to be continued till the medication brings in sustained benefit. Specific treatment for the cause should be instituted at the earliest on getting the proper diagnosis.Febrile seizures has to be managed on their own merits.
Anaphylaxis
This acute medical emergency can be precipitated by oral or parenteral administration of drugs or food or by inoculation of toxins brought about by insect or animal bites. Definition- Anaphylaxis is an immunoglobulin E(IgE) mediated rapidly developing systemic allergic reaction. Clinical features - Reactions usually occur within minutes of exposure to antigen, but occasionally may be delayed for hours. They are classified as mild, moderate and severe, based on the severity of clinical manifestations Mild ~ Skin and subcutaneous tissue only are affected, manifesting as generalised erythema, urticaria, periorbital edema, angioedema and the others. Moderate Respiratory, cardiovascular, gastrointestinal or other system may be involved.Main symptoms include dyspnoea, stridor or wheeze, nausea, vomiting, dizziness, diaphoresis, chest or throat tightness, abdominal pain and others Severe- Hypoxia, hypotension, Cyanosis (PaO2 <92%), systolic BP < 90mmHg, confusion ,loss of consciousness, autonomic failure. Differential diagnosis 1. Anaphylactic shock has to be differentiated from other causes of shock such as sudden hypotension due to internal bleeding, cardio 408
General Topics
pulmonary emergencies for eg. MI, acute laryngeal obstruction, poisoning ,panic reactions, snake bite etc 2. Other rare conditions include Non-IgE mediated anaphylactoid reactions like radiocontrast sensitivity reactions, certain drug reactions like opiate and fluoroquinolone induced reactions, systemic mastocytosis, flushing syndrome and others. Treatment 1. Epinephrine should be administered immediately 0.3 to 0.5 mL of 1 in 1000 solution IM repeated at 10 to 15 minutes intervals if necessary. 0.5 ml of 1 in 1000 solution in case of major airway compromise or hypotension 3-5 mL of 1 in 10,000 solution via central line 3-5 mL of 1 in 10,000 solution diluted with 10 mL of normal saline via endotracheal tube. Intravenous infusion of epinephrine can be given to maintain B.P >90 mmHg in case of protracted symptoms. 2. Establishment of airway Ventilation by mouth to mouth breathing or by Ambu bag Endotracheal intubation should be done if airway remains obstructed. In case of laryngeal edema not responding to epinephrine, cricothyroidotomy or tracheostomy may be required. 3. Glucocorticoids- can prevent relapse of severe reaction. Methylprednisolone 125 mg IV or hydrocortisone 500 mg; IV can be given. (equivalent betamethasone or dexamethasone 8mg) 4.. Volume expansion - IV normal saline 500 to 1000 ml by rapid infusion followed by maintenance dose based on BP and urine output. 5. Inhaled salbutamol- 2.5 mg can be used to treat resistant bronchospasm. Methyl Xanthines give relief of bronchspasm, common preparation is the combination etophylline 169.4 mg + theophylline 50. 6 mg given in slow IV injection or IV drip 6. Antihistamine such as chorpheniramine maleate given in dose of 4 mg 3 or 4 times a day orally relieves skin symptoms and decrease the duration of therapy. 7. Glucagon-1 mg bolus followed by an infusion up to 1 mg/h can be given in patients on beta blockers for inotropic support. 409
Guidelines
Note-glucagon and other more specialized drugs are generally available only in secondary or tertiary care centres. Monitoring of patient -Observation for a minimum of 6 hours should be made for patients with mild reaction limited to urticaria, angioedema and mild bronchospasm Patients with moderate to severe reaction should be admitted and observed for a minimum period of 24 hours. Prevention 1. Patients with past history of anaphylaxis or allergy should undergo detailed allergy tests and desensitization if indicated. 2. Patients with past history of anaphylaxis to food or hymenoptra sting should be taught self administration of epinephrine Though many cases of primary anaphylactic reactions can be managed in peripheral hospitals, some complicated cases require more specialized intervention. Recurrence of hypotension, necessity for tracheal intubation, prolonged fluid replacement etc. are indication for referral to higher medical facilities TOXICOLOGY The common poisons used for suicidal attempt found in Kerala include organophosphorus insecticides, carbamate insecticides, formic acid, plant products such as cerbera odollum, nerium oleandis, zinc phosphide, barbiturates, diazepam, other drugs acting on the CNS, paracetamol and others .Accidental poisoning is often due to organophosphorus insecticides or drugs used by psychiatric patients. Despite this general statement it should be remembered that any type of poison may be involved and the physician should have an open mind. General management of the poisoned patient Acute poisoning is a dire emergency. Suicidal poisoning is most common and next in frequency is accidental poisoning. Evaluation of the poisoned patient History: Ascertain the nature, quantity of the poison and the vehicle in which the same was consumed and the time elapsed before patient reaches the hospital. lf possible the specimen of the poison left over should be procured for confirmation 410
General Topics
If the patient is shocked or unconscious: 1. Start an IV line with normal saline through a large bore needle (18G) or cannula through which fluids and drugs can be administered rapidly. 2. Simultaneously maintain the airway by clearing the mouth and throat of foreign materials, dentures or vomitus and keep the patient with head lowered and neck held in extension. If the patient is unconscious, an airway is inserted. Some of the salient features of the commonly ingested poisons Finding 1. Aspiration Common cause Organophosphates, kerosene, solvents used for paints, CNS depressants.
2. Behavioural disturbances Anticholinergics, hallucinogens, CNS stimulants. 3. Bradycardia Digoxin, beta blockers, organo phosphates, calcium channel blockers, cerbera odollum, nerium oleandis. CNS stimulants, theophylline, cardiovascular drugs, cerebra odollum, nerium oleandis. Barbiturates, diazepam, antidepressant, anticholinergics, ethanol, phenothiazines. Antihistamines, hallucinogens. CNS stimulants,
4. Cardiac dysrrhythmia
5. Coma
6. Hallucinations 7. Hepatic failure 8. Hypercapnea 9. Hyperthermia 10. Hypothermia 11 . Intestinal ileus
Paracetamol, carbon tetrachloride, INH, mushroom. CNS stimulant, methanol. Phenothiazine, anticholenergics. CO, CNS salicylate, stimulant,
CNS depressants, alcohol. Narcotic analgesics, anticholenergic, antidepressant. 411
Guidelines
12. Metabolic acidosis 13. Nystagmus 14. Pulmonary oedema 15. Seizures 16. Tachycardia Laboratory tests
Alcohol, formic acid, salicylate, other corrosive acids. Anti convulsants, CNS depressants. Organophosphates, salicylates. Organophosphates, theophylline. CNS stimulants, anticholinergics, Theophylline
1. Qualitative and quantitative analysis are available for a number of poisons and are useful in confirming that a particular drug has been ingested and are of value in screening for unknown drugs. Facility for emergency determination of toxic substance is available at the College of Pharmaceutical Sciences, Medical college, Thiruvananthapuram round the clock, the specimen has to be sent by the physician with clinical details 2. Additional tests that may be of use include arterial blood gas analysis, chest radiograph, and ECG. Treatment: Emergency Management of poisoned patient includes A. Decontamination of the poison which limits the absorption and minimises the extent of toxicity: Clean up the body, remove all contaminated clothing and remove as much of the toxic agent from the oral cavity, pharynx and skin. B. Supportive care which limits the effects of serious complications of poisoning on the organ systems at risk. C. Definitive care which limits the severity or duration of toxicity through the use of antidotes and by enhanced elimination of the toxin by forced alkaline diuresis and haemodialysis procedures. Note :AlI doctors who see the patients first should undertake the first aid measures, i.e. 1. Removal of unabsorbed poison from the surface. 2. Induction of vomiting. 3. Cardio respiratory support. 4. Early administration of antidote before referring the patient to a higher centre. 412
General Topics
DECONTAMINATION The vast majority of serious poisonings are due to ingestion of toxic substances and gastrointestinal decontamination should be done without delay. 1. If the patient is fully conscious and the general condition is satisfactory, he can be induced to vomit by tickling the pharynx or administration of gastric irritants such as concentrated common salt solutions 200 -400 mL. Induction of vomiting is contraindicated in case of corrosive poisons and if the patient is comatose. 2. Gastric lavage. Using large bore (36 - 40 F) orogastric tube. Indicated in comatose patients as well as alert patients. Patients in Trendelenburg position and left lateral position. Decrease risk of aspiration by using cuffed endotracheal tube if available. After contents of the stomach are aspirated, aliquots of water at room temperature(50 -250 mL) should be administered and aspirated until the return is clear. Contraindicated in patients who have ingested corrosives or petroleum distillate hydrocarbons. 3. Activated charcoal. This acts by adsorbing molecules of chemicals on its surface, thereby inhibiting their absorption Dose is 1 g/kg suspended in water and introduced through the orogastric tube. 2 or 3 doses of charcoal given at 4 hourly intervals may be of more use than a single administration. Drugs adsorbed by charcoal Drugs not adsorbed by charcoal 1. Amphetamine 2. Chlorpheniramine 3. Phenytoin 4. Aspirin 5. Cyclic antidepressants 6. Chlorpromazine 7. Quinine 413 1. Ferrous sulphate 2. Malathion 3. Acids 4. Alkalis 5. Alcohol 6. Lithium
Guidelines
For better efficacy charcoal should be given before and after gastric lavage. 4. Cathartics ( purgatives) Include sorbitol, magnesium sulphate, magnesium citrate Speed up gastrointestinal motility, thereby shortening the absorption time. Unabsorbed toxin from the colon can be removed by a large enema (soap and water) or colonic wash out using flatus tube. Samples of materials obtained by vomiting, gastric lavage and colonic wash out should be procured for chemical analysis if a definitive clue regarding poisons has not been obtained. SUPPORTIVE CARE is directed towards the prevention or limitation of respiratory, cardiovascular and neurological complications. 1. Management of respiratory complications. Maintain the airway appropriately .Ventilatory support may be needed in selected cases. lf bronchospasm is present use salbutamol nebulisation or an IV injection of aminophylline 250 mg diluted in 10% glucose slowly. Non cardiogenic pulmonary oedema may be seen early, requiring treatment with high flow oxygen, positive pressure ventilation and PEEP . Aspiration in to the respiratory tract should be prevented. If it has occured, try conservative measures such as head low position, gentle tapping on the chest and suction of the tracheo bronchial tree. 2. Management of cardiovascular complications. Tachyarrhythmias usually requires only monitoring, but may need antiarrhythmic drugs. Brady arrhythmias are best treated with atropine, but may require temporary transvenous pacing. Hypotension usually reflects decreased peripheral vascular resistance and should be treated with fluid administration, only rarely are vasopressors like dopamine required. Hypertension, which is complicated by pulmonary oedema, cardiac ischemia or encephalopathy should be controlled by direct arterial vasodilators like nitroglycerine or nitroprusside. 3. Management of neurological complications Coma and altered level of consciousness require special care for maintenance of fluid and electrolyte levels. Seizures can be safely controlled with short acting benzodiazepines (diazepam 5 - 20 mg IV) or phenobarbitone (20 mg/ kg IV at 50 - 100 mg/ min). If phenytoin is given, electrocardiogram 414
General Topics
should be monitored. Behavioral abnormalities including combativeness and agitation are better controlled by physical restraints rather than chemical restraints .Diazepam enables rapid control of unmanageable patients while haloperidol is very effective for long term control. 4. Antidotes ; Next to the general emergency measures, antidotes form the mainstay of successful management of poisonings as early as possible and during the course of treatment blood and urine samples should be sent for drug level monitoring. DEFINITIVE CARE
POISON ANITDOTE ADULT DOSAGE COMMENT
1. Paracetam ol
N-acetylcysteine
Initial dose 140m g/ kg Most effective if give n within16h orally, the n70mg/kg4h Initial dose 0.52mgi IV 100%by face mask or Hyperbaric oxygen if available. Can produ ce convulsions Early treatment is successfu l This helps to re move the poison load but action is slow.
2. Atropine 3. Carbonm onoxide
Physostigm ine Oxyge n
4. Cyanide
Amylnitrite, sodium Am ylnitrite in halation nitrite eve ry2so dium thiosulph ate 3min, then 10mL of 3%sodium nitrite I.V o ver5min the n 50m L25% Sod. thiosolphate ove r 10min Desferrroxamine Hypote nsive patients 10mg/kg/h for 4 hours IV, 5mg/kg/h for 8 hours the n 25mg/kg/h Norm oten sive patients 40mg/kg IM 200m g/m l in am p of 5ml to be dilu ted in 5% glucose infu sed IV. Total dose of 5075m g/kg/day in 2 divided doses up to 5 days 5mg/kg deep intra muscu lar
5. Iron salts
6. Lead salt e.g. Lead acetate
Calcium di sodium ede tate
7. Mercu ry, Arsenic, BAL (Dim ercaprol) Gold
415
Guidelines
8. Methyl alcohol Ethyl alcohol Correction of metabolic acidosis by sodium bicarbonate 0.6-0.7g/kg IV diluted or oral, ethanol should be given orally in a dose of 30-50 mL in 2-4 h, if blood level of methanol exceeds 20mg/dl Hemodialysis to remove methyl alcohol if blood level >0.5g/L or total quantity ingested>30mL.Peritoneal dialysis only 1/8 th effective as haemodialysis. 1-2mg/kg of 1% solution 0-4-2mg IV 15mg IV every 15 min till drying of secretions. 1 g IV over 15-30 min 8 h Administration has to be continuous drip to maintain pupil size normal.very large doses of 250 -750 ampoules may be required for saving serious cases Early management may be successful
9. Nitrites 10.Opiates 11.Organophosphates
Methylene blue solution IV Naloxone Atropine Pralidoxime
May need exchange
12. Carbamates
Atropine
Glycopyrrolate
2-3 mg parenterally and repeat until signs of atropine intoxication appears It is an effective antidote It is available as ampoules containing 2mg of the drug to be given in a dose of 0.45 mg per kg body wt IM or IV to be repeated till symptoms are relieved.this drug is devoid of CNS side effects of atropine
416
General Topics
13. Benzodiazepines Flumazenil 0.2mg IV over 30 sec followed by 0.3mg at 1 min interval to a total dose of 3mg Dose (vials)=[injested dose (mg)x0.8]x1/2 15mg/kg IV followed by 10mg/kg IV 12 hrly for 4 doses 10mg IM,SC or IV
14. Digoxin 15. Ethylene Glycol
Anti digoxin fab fraction Fomipezole
16. Warfarin
Vitamin k1
Increasing the Drug Excretion

a. Forced alkaline diuresis Especially useful in phenobarbitone and salicylate over dosages. Close monitoring of fluid and electrolytes and pH are required for ideal results Adequate amounts of sodium bicarbonate (1 - 2 mg/kg/h IV.infusion) needed to maintain urine pH between 7.5 - 8.5. C/I : Congestive cardiac failure, renal failure, cerebral oedema b. Dialysis and haemoperfusion Dialysis is most effective with drugs of low molecular weights, small volume distribution and low protein binding. Drugs effectively eliminated by haemodialysis include: Barbiturates , Lithium salts, Bromides, Methanol, Chloral hydrate, Procainamide, Ethanol, Salicylates, Ethylene glycol, Theophylline, Isopropyl alcohol Haemoperfusion is more effective than dialysis in removing drugs with high molecular weight, lipid solubility and protein binding. Examples include Chloramphenicol Procainamide, Disopyramide, Theophylline, Hypnotic sedatives Phenytoin Peritoneal dialysis and exchange transfusion are less effective but may be used when other procedures are not available, are contraindicated or are technically difficult. (eg. in infants). c. Activated charcoal This is given repeatedly in a dose of 1 g/ kg bw every 2 - 4 h. Useful in Carbamazepine, Digoxin, Salicylates, Dapsone , Phenobarbitone, Sodium valproate, Diazepam, Phenytoin , Theophylline 417
Guidelines
Once the emergency is over these patients should be observed for long term complications such as pneumonia, neuropathy, hepatic damage and others. Suicidal patients should have proper psychiatric management to avoid recurrence. ENVENOMATION
Snake envenomation
Diagnosis and management of snake envenomation Clinical features Fear, toxicity of venom and side effects of treatment contribute to the symptoms and signs in those bitten by snakes. Bite by elapidae (cobra and krait mainly) Local effects include severe pain, mild oedema, faint bite marks or oozing from the wound. Sometimes local reaction may be absent or only minimal. Systemic effects are dominated by neuroparalytic symptoms. Paralysis is first noticed as ptosis and external opthalmoplegia followed by involvement of face, palate, jaws, tongue, vocal cords, and muscles of deglutition and neck muscles. Respiratory muscle paralysis can follow. Bite by viperidae (vipers) This produces severe local effects with more prominent bite marks, intense pain, swelling, haemorrhagic oedema and oozing from bite mark. Vomiting is one of the early symptoms of systemic envenomation. Hemostatic abnormalities are characterized by persistent bleeding manifestations. Direct myocardial involvement is suggested by abnormal ECG and arrhythmias and refractory hypotension. Renal failure is the leading cause of death and clinically it manifests with acute oliguric renal failure developing 18 to 36 hours after the bite. Laboratory diagnosis Estimation of the clotting time helps to determine the need for antivenom therapy and also for monitoring progress. Prolongation of the clotting time beyond 10 minutes should suggest systemic envenomation.Generally higher clotting times indicate more severe disease. Thrombocytopenia is common in viper bite. Fibrinogen is often reduced, APTT and PT are prolonged. Oliguria, proteinuria, haematuria and red blood cell casts may be seen in those with renal involvement. ECG abnormalities may be seen in those with cardiac involvement. 418
General Topics
FIRST AID 1. Reassure the victim that there is treatment. 2. Apply a tourniquet or a compressive bandage which would occlude lymphatic return from the periphery on an area of single bone in a limb.Tourniquet is preferably loosened only after administration of antivenom. 3. Wash the bitten area with soap and water. 4. Immobilise the limb with a sling or splint. 5. Carry the victim to the hospital as early as possible. Management at casualty 1. Reassure the patient. 2. Clinical examination. 3. Injection tetanus toxoid 0.5 ml IM. 4. Make an IV line and start normal saline 5. Blood sample for clotting time. 6. Tab paracetamol 500 mg stat, oral or injection tramadol 50 mg IV for pain. 7. Check whether tourniquet is applied correctly if not reapply it correctly. 8. Injection metoclopramide 10 mg IV sos to prevent nausea and vomiting. 9. Modify the treatment as per situation. 10. Indentification of poisonous snake bite..Only 15-20% of snake bites are by poisonous snakes which include cobras, viperidae, krait,occasionally sea snakes and possibly other varieties as well.Poisonous bites show following features . 1. Fang marks 2 or 1 2. Presence of multiple teeth indicate non poisonous nature of bite 3. Extreme pain at the site of bite 4. Local reactions like oedema, discoloration, bleeding, oozing, necrosis etc. 5. Presence of systemic manifestations such as bleeding tendencies shock neuroparalytic manifestations. 11. Admit all snake bite victims or suspected cases of snake bites. Management in the ward 1. All patients with features of systemic envenomation should have at least 2 IV lines 419
Guidelines
2. Complete clinical examination 3. Blood samples for investigation, ECG, CXR. Hospital Management Essentials of hospital treatment consist of rapid assessment of the bite and its complications and early administration of antivenom when indicated . Even patients with mild or inapparent symptoms, should be observed for upto 24 hours, since delayed envenomation is not rare Indications for Anti-snake venom (ASV) This is prepared by the Haffkine Institute Bombay, and Serum Institute of India, Pune. The available preparation is polyvalent ie. active against cobra krait and viper. (Storage:Antivenom should be stored at 2-8C, it should not be allowed to freeze and the shelf life is 4 years after manufacture). Indications (evidence of systemic envenomation) Neurotoxic signs. Recurrent vomiting. Haemostatic abnormalities Cardiovascular signs. Impaired consciousness. General rhabdomyolysis. Severe local reaction even in the absence of systemic signs. ASV should be given as early as possible for the best results and the dose may have to be repeated often, depending on the clinical status. Note: Before going to the full dose of ASV a sensitivity test should be done as follows: 0.1 mL intradermal. test, no reaction occurs 0.5 mL diluted in saline given IV. to test for reaction and if there is no reaction full dose of ASV is given. Hypersensitivity is uncommon and can be managed with IV hydrocortisone. Dose of antisnake venom When only local reaction is present- Give 3 - 6 vials of ASV after test dose as an infusion in 20 min and observe for other signs of envenomation When systemic envenomation is present- 10 vials of ASV as an infusion in 20 - 30 min and simultaneously start 6 vials of ASV in 5% glucose as drip to be run in 4 - 6 h. 420
General Topics
When to repeat ASV ASV is to be given if severe signs of envenomation persist after 1 - 2 h or if the clotting time is not restored within 6 h. Clotting time is to be repeated every 4 - 6 h and ASV administration repeated if necessary. Better late than never is to be the policy with ASV. It is atleast partially useful in patients with signs of systemic envenomation who come even a few days after the bite.In the vast majority, attention to the local site is also necessary. This should include cleaning, wound toilet, absorbent dressings and partial immobilisation of the limb. Antibiotics active against multiple infections has to be started. Ampicillin (0.5 g IV/IM. 6 h) or cloxacillin (250 500 mg 6 h) are reasonably good choices. Anaerobic infection demands the use of IV metronidazole 500 mg tds Tetanus prophylaxis has to be given to nonimmunized persons. Special problems in viper bites Prevention of acute renal failure( ARF) in viper bite is by prompt administration of ASV and maintenance of fluid volume. Coagulation disturbances are to be treated with fresh blood or blood components if ASV does not correct the abnormality. Volume replenishment should be stressed as patients can have severe hypovolemia due to several factors. Normal saline, plasma expanders and blood should be used judiciously as indicated. If patient is oliguric, conservative measures for treating ARF should be instituted. Antivenom has to be stocked in all the primary health centres at all times. Dialysis is indicated once acute renal failure is established. As snake venom is not dialysable there is no role for prophylactic dialysis. Special problems in elapidae bites These may cause acute myasthenic crisis due to neuromuscular blocking action of the toxin. They may present as acute respiratory paralysis, not readily relieved by ASV. Neostigmine given in a dose of 0.5 mg IV repeated at short intervals is dramatically effective and life saving. If the respiratory failure is not relieved promptly, ventilatory support is required and the patient has to be rushed to a proper centre Prevention of snake bite and health education of public Public should be instructed regarding the dos and donts of snake bite management through the media. 1. Need for immobilizing the bitten limb immediately after the bite and avoidance of panic. 421
Guidelines
2. Need for immediate transportation to the hospital. 3. Availability of effective medicines - ASV and other measures in hospitals practicing modern medicine. 4. To avoid incision, suction, cooling of the bitten part. 5. Principles of application of tourniquet or broad bandage. 6. Pursuing and killing the snake is not recommended; but if the snake is already killed, it should be taken with the patient for identification, but must not be handled because even a severed head can inflict lethal injury. Snake bite can be avoided by carrying a torch while walking at night, wearing shoes and protective clothings. Using a stick which is tapped on the ground while walking will scare away the snakes. Bee and wasp stings These are common. Most of the cases are mild and they clear up spontaneously. Multiple stings and especially on the face and head may give rise to severe local reactions, angioneurotic oedema, respiratory obstruction and death. Persons who are sensitised by previous exposure are at higher risk of angioneurotic oedema of the face, anaphylaxis and death. Stingers embedded in skin should be scraped or brushed off with a nail or finger nail but not removed with forceps, which may squeeze more venom out of the venom sac. The site should be cleansed with soap and water Ice packs applied locally slow the spread of the venom. Elevation of affected site. Administration of analgesics such as paracetamol 600mg orally and antihistamines such as chlorpheniramine(4 mg) and diphenhydramine (25 mg) provide symptomatic relief. If the local reaction is moderate or severe, oral prednisolone (20 mg) or injection betamethasone or dexamethasone (4 mg) should be given. Anaphylactic shock and respiratory obstruction demand emergency management.Emergency management in the presence of anaphylactic shock is to give 1 mL of adrenaline (epinephrine)1 in 1000 solution IM repeated if necessary. For further management refer to Anaphylaxis. Since delayed complications such as coagulopathy and renal failure may occur, these should be watched for. Persons allergic to these
422
General Topics
stings should be warned to avoid further exposure. Specific antisera are available in some countries, but not in Kerala. Drowning Drowning is the pathological state leading to death resulting from the aspiration of water into the respiratory tract or due to asphyxia on immersion. Two types of drowning have been recognized - dry drowning and wet drowning. ln dry drowning death is due to laryngeal spasm, which proves fatal in 20% of the subjects. This also prevents the entry of water into the lungs.In wet drowning water enters the lungs. The consequences differ between fresh water and sea water drowning. In fresh water drowning, water is quickly absorbed from the lungs, leading to hemodilution and hemolysis with release of potassium from the red blood cells. In addition to hypoxia and ventilatory failure,hyperkalemia precipitates ventricular arrhythmias, which may prove fatal. In salt water drowning the fluid in the lung is hyperosmotic. It absorbs more fluid into the alveoli causing pulmonary edema and respiratory failure.Hypernatremia follows later when the salt is absorbed into the circulation. Secondary Drowning or near-drowning occurs a few hours or few days after the initial resuscitation due to the secondary changes in the lungs such as pulmonary edema, pneumonia, pneumothorax, electrolyte disturbances and metabolic or respiratory acidosis. Immersion syndrome. ln this, sudden death occurs due to cardiac arrest caused by vagal stimulation brought about by sudden immersion into cold water. Management First aid: (1) clear the airway of water and foreign bodies by putting the patient head low and by suction (2) institute mouth-to-mouth breathing as early as possible (3) closed chest cardiac massage should be instituted if heart sounds are absent and (4) all cases must be hospitalized to prevent death from secondary drowning. Hospital treatment: This aims at 1) maintenance of adequate oxygenation (2) correction of metabolic and electrolyte imbalance 423
Guidelines
(3) prevention of secondary effects. Adequate oxygenation is achieved by the use of controlled ventilation with 100% oxygen, later to be reduced to 40%. If these measures fail to respond,intubation and application of positive end expiratory pressure (PEEP) respiration should be resorted to.
PAEDIATRICS
DIARRHOEA AND DEHYDRATION
Diarrhoeal illness is common in childhood and untreated severe diarrhea can be rapidly fatal.Prompt correction of dehydration and electrolyte imbalance helps to restore normalcy and prevent death.In acute diarrhoea ,the deterioration of general condition may be so rapid that occurs within hours ,so very prompt measures should be undertaken early enough.
Common causes of diarrhoea include1. Viruses like rotavirus,Norwalk virus,corona virus and others 2. Bacteria such as various strains of E.coli, vibrio cholera, campylobacter, shigella. 3. Protozoa such as giardia ,entaamoeba and others. 4. Food poisoning may lead to severe gastroenteritis characterized by vomiting and watery dirrhoea. Other less common causes include antibiotic associated diarrhoea, ulcerative colitis ,diverticulitis and others. Watery diarrhoea is characteristic of enteritis where as colitis is characterized by presence of blood and mucous in stools.(Dysentery) Laboratory investigations 1. microscopy of the faeces reveals protozoal or helminthic parasites 2. culture of the fresh stools directly into culture medium and further microbiological tests help to identify the invading bacterium. Common signs of dehydration are increased thirst, restlessness, dry tongue and decreased skin turgor. In severe dehydration there will be obtundation, floppy limbs, low volume pulse and oliguria. In mild diarrhoea child has none of the signs described above and the main goal of treatment is to replace ongoing losses using homemade fluids like salted kanji water or ORAL REHYDRATION SOLUTION (ORS). 424
Paediatrics
Dose: 1 packet of ORS dissolved in 1 L (5glasses) of potable water (boiled and cooled). After each motion give ORS 50mL (1/4 glass) for infants <6months, 1/2 glass for children upto 2 years and 1 glass for older children. Use cup and spoon to give ORS. Breast feeding should be continued in small frequent feeds. In moderate dehydration: ORS/IV fluids will be required. About 100 mL/kg ORS is given in 4 h. Breast feeding to be continued. Offer plain boiled water in between ORS in those who are not breast fed. Homemade fluids like salted rice water, coconut water or buttermilk can be used. IV fluids are used in similar lines for the treatment of severe dehydration (see below) except the initial emergency phase can be omitted. In Severe Dehydration: always use IV fluids with wide bore needle .Shock, acidosis and marked oliguria by themselves are indicative of severe dehydration. Ringer lactate or Normal saline is used initially Dose: 30mL/kg in first 1h followed by 70mL/kg over next 5 h. (100mL/ kg in 6 h). Dextrose saline may be used instead to prevent hypoglycaemia. For older children 100mL/kg should be given in 4 h .Add KCl 20mEq/L as soon as child passes urine. In cholera much more fluid will be required and constant monitoring of hydration is essential. ORS and feeding can be started at the end of 6h as the signs of dehydration disappears by this time. The IV fluid can then be changed to maintenance fluid if required eg. isolyte P. Holliday and Segar Formula is generally used to calculate maintenance requirement as given below. Dose: First 10 kg - 100 mL/kg/24 h. l020 kg -1000 + 50 mL/additional kg over 10 kg. Above 20 kg -1500 + 20 mL/kg for additional kg over 20 kg. Ongoing losses also should be replaced. Use 7.5% soda bicarb. 2 mL/ kg diluted with equal amount of distilled water or 5% dextrose IVslowly in severe acidosis. 425
Guidelines
An illustrative case eg. 2 year old weighing 12 kg

Symptoms & signs Mild Moderate None Restless Thirst increased Skin turgor reduced Dry mouth Lethargic Floppy Cold extremities rapid thready pulse Fluid deficit eg.2 yr old Wt.12 kg 500 mL 500 -1000mL Fluid replacement as ORS 1/2 glass=100mL after each stool In first 4 h, 600800mL (3 to 4 glasses of ORS) IV Fluid required 1st 6 hour 100mL/kg (Ringer lactate / N saline) 1st hr 30 mL/kg Next 5 h 70mL/ kg thereafter maintenance fluid if required
Severe
>1000 mL
Antibiotics may be required in many cases though their value is being debated.The commonly given antibiotics include doxycyline , ciprofloxacin, azithromycin,and erythromycin.Antibiotic associated diarrhoea responds to metronidazole 400 mg tid for 10 days or vancomycin 250 mg qid for 10 days. Nalidixic acid 55mg/kg in divided dose for 5 days is effective in cholera. Note 1. Once the acute condition is over the child should be referred for active immunization. 2. Occurence of cholera and gastroenteritis should be notified to the health authority for taking preventive measures. ACUTE SEVERE ASTHMA (in children) ln acute severe asthma early detection of severity of attack and prompt treatment is essential to prevent mortality. Signs indicative of acute severe asthma: 1. 2. 3. 4. 426 too breathless to feed or talk, respiratory rate over 40/min together with use of accessory muscles chest retraction, tachycardia over 140/ min
Paediatrics
5. 6. 7. 8.
fatigue and exhaustion, reduced level of consciousness, silent chest on auscultation, cyanosis, sudden onset of bradycardia and poor respiratory effort are all indicative of life threatening asthma.Inhaled beta2 agonist is the drug of choice. a) Beta2 agonists-salbutamol/ terbutaline, preferably using a Nebuliser.Dilute 0.5 mL (2.5mg) salbutamol respirator solution with 4 mL normal saline and place it in the nebulization chamber. Using pressurised air or oxygen the solution can be nebulized into fine particles which the child inhales using a mask or mouth piece. Repeat nebulisation 4-6 hrly or earlier as needed. b) In small children the dose is calculated as 150 mcg/ kg/dose of salbutamol respirator solution diluted with 10 times volume of normal saline and then nebulised. c) lf a nebulizer is not available a metered dose inhaler can be used in a dose of 2 puffs of salbutamol every 4 to 6 hour or earlier.A volumatic spacer or a plastic cup can be used for administering the drug in small children. d) Parenteral dose is 5mcg/kg of terbutaline/dose every 6th hrly SC or it can be given as a bolus dose diluted followed by an IV. infusion at a rate of 0.1 g/kg/minute of terbutaline, increasing 0.1 mcg/kg every 15 minutes to a maximum of 4 mcg/kg/minute. e) Anticholinergic drug like Ipratropium bromide 0.5ml1mL(125-250mcg) can be added to salbutamol nebulizer solution and the nebulized every 4-6 hrly in severe cases. f) Aminophylline. bolus dose of 6 mg/kg/diluted IV very slowly followed by an infusion of 0.7-0.9 mg/kg/h. Give only 3 mg/kg as bolus if child is already on theophylline or omit the bolus dose. g) Hydrocortisone 5 to 10 mg/kg/dose. Repeat 4 to 6 hrly or earlier in severe cases.
427
Guidelines
Oxygen inhalation and other treatment modes like antibiotics, alkali therapy, and I.V fluid if indicated. No sedation, but monitor carefully. Very few cases may need artificial ventilation to save life ASTHMA IN CHILDREN < 5 YEARS OF AGE Step Step 4 Severe Persistent High dose inhaled steroid with Bronchodilator as spacer. If needed add systemic needed for symptom steroids 2 mg/kg/day Step 3 Moderate persistent Medium dose inhaled steroid with spacer OR medium dose inhaled steroid with cromolyn OR medium dose inhaled steroid with long acting theophylline Step 2 Mild persistent Daily anti-inflammatory medication cromolyn or low either inhaled dose inhaled steroids Step1 Mild intermittent No daily medication needed Bronchodilator as needed for symptom relief-either inhaled short acting beta 2 agonist with spacer or oral beta 2 agonists 428 relief upto three times a day Long term control Quick Relief
h)
Paediatrics
RECUSCITATION OF NEWBORN Evaluate the neonate at birth for adequacy of respiration, heart rate and colour. Most newborn babies cry immediately at birth. Dry the baby in a clean warm towel.one of the most accepted objective method to initate recuscitative procedure is to determine the Apgar score which is given below
Score Respiratory effort Heart rate/ min Colour of the baby Muscle tone Reflex stimulation (catheter in the nose)
0 None Absent Blue or pale Flaccid No response
1 Slow irregular <100 Body pink, extremities blue Some flexion Grimace
2 Good, crying >100 Pink Actively moving the extremities Cries,coughs or sneezes
Normal babies have an apgar score of more than 8 at 1 & 5 min. Apgar score between 4-8 is moderately low while that less than 4 is very low 5 min apgar score is more important that 1 min apgar score If baby has not cried within 15-20 seconds after birth or if baby is apnoeic or gasping, place the baby on a flat resuscitation table under a warmer with head slightly extended by 30 degrees. Clean the airway by oropharyngeal suction, mouth first, then nose. Provide tactile stimulus by flicking the soles. Do not slap the baby or hang him upside down. If baby is still gasping/apnoeic immediately initiate assisted ventilation with a bag and mask using oxygen at 2-4 L/min. Use of oxygen reservoir will enable 100% oxygen administration. Count heart rate with a stethoscope for 6 seconds and multiply by 10 to get heart rate in 1 minute. If heart rate is less than 60 or fails to rise above 80 after 30 seconds of assisted ventilation, then initiate external cardiac massage by chest compression 120 times a minute. For every 2 chest compression one ventilatory breath is given. 429
Guidelines
If there is no reponse to bag and mask ventilation and chest compression then endotracheal intubation and positive pressure ventilation is given using oxygen. Endotracheal intubation is indicated if meconium aspiration or diaphragmatic hernia is suspected. Do not use bag and mask ventilation in these circumstances. If mother had received a narcotic within 4 hours prior to delivery then give naloxone 5-10 mg/kg or nalorphine 0.1 mg/kg IV or IM. Hypoglycaemia should be anticipated and corrected. Give 25% glucose 1 mL / kg over 4 min initially and then continue with 10% dextrose infusion 60-90 mL / kg / day. If heart rate remains less than 80 / min despite adequate resuscitation, give 1/10000 adrenaline 0.1 mL/ kg IV or via endotracheal tube or rarely intracardiac. If the baby is in shock with poor peripheral pulse and circulation give I.V N.saline or Ringer lactate or plasma at the rate of 10 mL/kg. Dopamine infusion 2-20 mcg / kg/ min may be used if shock does not improve. If after 8-10 min of adequate resuscitation baby does not show signs of improvement and acidosis is severe, then NaHCO3 (7.5%), 2 mL / kg / diluted with equal amount of distilled water is given slowly over 2-3 min. Note-neonatology and initial care of the newborn have assumed great importance since mishaps occurring in the first hours of life may lead to permanent disabilities in the child.With modern well equipped dedicated units even babies with birth weight of 600g (even lower birth weight in advanced centres) can be kept alive and made to thrive normally. Therefore it is preferable to send complicated pregnancies to tertiay care centres well before delivery. POISONING IN CHILDREN Diagnosis of poisoning in children is easy when history is forthcoming. Most of the poisoning in children is accidental. But it should be suspected in any healthy toddler with acute onset of unexplained symptoms like vomiting, abdominal pain, drowsiness or delerium. Common poisons include kerosene oil, other solvents ,detergents,cleaning solutions and a variety of drugs, chemicals, insecticides and vegetable poisons.Inadvertently kept drugs used by members of the household may be ingested by the child. Physical examination should focus on vital signs,and cardiopulmonary and 430
Paediatrics
neurological status. If the child is seen soon after ingestion, vomiting should be induced,by tricking the throat after giving 1 glass of water or fruit juice.. If induction of emesis is not successful gastric lavage should be done carefully using a ryles tube. 30 -50 mL water or 1/2 N. saline is introduced each time and then aspirated until returning fluid is clear. Specific antidote if available should be given immediately eg. Desferrioxamine for Iron poisoning. Close observation and masterly inactivity is all that is required in most cases. Symptomatic and supportive treatment will be required in all cases. Severe cases with organ dysfunction should be managed in secondary care units Therapeutic interventions include treatment of shock, anticonvulsants, correction of acidosis and fluid-electrolyte balance and infections .Urinary excretion of poisons like salicylate, and phenobarbitone can be hastened by forced alkaline diuresis.Haemodialysis may be required at times. At the time of discharge parents should be advised on prevention of poisoning Some Common Poisoning in Children and their Management .
Sl. No. Poison Clinical features 1. Acids Severe pain, erythema and swelling/ulceration of mouth Laryngeal oedema-watch for shock, renal failure 2 Alkali Pain, swelling, white plaques in the mouth Dysphagia, drooling No emetics/lavage. Cold Water milk IV. fluid, antibiotic surgical consultation No emetic/lavage cold water/milk, IVfluid antibiotic + steroid surgical consultation Treatment
3.
Aspirin Vomiting, flushing, tinnitus, abdominal. Pain, Gl bleed, acidotic breathing seizure, coma. hypoglycaemia, salicylate level >l00mg/dl. Lavage/emetics Fluid electrolyte therapy. Correct acidosis, Glucose, Vit.K, forced alkaline diuresis. Dialysis in severe poisoning
431
Guidelines 4. Kerosene oil Vomiting, cough, breathless, smell of kerosene, coma, cyanotic,chest X-ray, mottled appearance 5. Iron 5 stages stage 1. Within hours, vomiting abdominal.pain, Gl bleed. Emetic / lavage, chelation as early as possible desferrioxamine IM. or IV. Continue till urine is clear. Vin rose colour if serum Iron is high. No emetic or lavage. Oxygen, crystalline penicillin in case of aspiration; salbutamol and steroid in case of wheezing
Stage 2.of apparent recovery For few hrs stage 3. After 12 h. shock encephalopathy, acidosis Stage 4. 2-4 days, hepatic failure Stage 5. 2-4 weeks gastric scarring and intestinal obstruction. 6. Organophosphorous Sweating,salivation,small pupil, Lacrimation, bradycardia hypotension, twitching, seizure, pulmonary oedema, ventricular-arrhythmia. Choline esterase activity in RBC/serum <20% in severe cases.
Emetics/lavage,clean up contaminated skin. symptomatic and coma, supportive. Atropine 0.05mg/ kg IV at 5-10 min interval as needed Pralidoxine 25-50mg/kg/ IV as a 5% solution after atropinisation, haemodialysis may be useful
8.
Paracetamol Nausea, vomiting, Nypoglycaemia, Hepatic failure usually on 3 day. Renal failure, coma.
Emetic/lavage N-acetyl cysteine initially oral 140mg/ kg, then 70mg/ kg every 4 h, 17 such doses IV 50 mg/kg as loading dose. Then 50mg/ kg in 5% dextrose over 4-8 h x 3 doses
Doses above 100mg/kg body wt.can be toxic. With higher doses toxicity, risk of hepatic damage and death steadily increase. 432
CARDIOLOGY
Evaluation of chest pain One of the most challenging areas in clinical medicine is the evaluation of chest pain. The most important cause of acute chest pain is acute coronary syndrome either unstable angina or myocardial infarction. Early identification of angina and coronary artery disease is important since it is the main killer. It strikes not only the elderly but also the middle aged earning members of the family and even the young.No age is totally immune, though people below thirty years and women in their reproductive period are rarely only affected. Physical findings are few in acute coronary syndromes. The symptoms occur suddenly and a worse turn can occur at any time. Proper history elicitation and interpretation is the cornerstone in the evaluation of chest pain especially acute coronary syndromes. Common causes of chest pain A wide variety of diseases can cause chest pain. Most of the organs in the chest and some in the abdomen can cause chest pain. The major causes are myocardial ischemia (coronary artery disease), pericarditis, pleuritis, esophagitis, aortic dissection, acid peptic disease, gastritis and cholecystitis. Other rare causes are herpes zoster involving the thoracic dermatomes and breast inflammation and cancer. Myalgia and costochondritis are also common causes of chest pain.Chest pain is often a symptom brought about by anxiety and hypochondriasis Clinical evaluation of chest pain Angina is usually retrosternal in location. The pain may radiate to the throat or jaw or arms or rarely epigastrium and interscapular areas. Rarely pain is felt only at these sites. The pain is a felt as a constricting sensation or sensation of heaviness or pressure or choking feeling. It may be associated with breathlessness or sweating. Atypical pain. Rarely patients may not experience chest pain. They may have an atypical presentation like dyspnoea or pain at sites other than chest (jaw/ throat/arm). Some patients have syncope or extreme fatigue or sweating or nausea and vomiting. Such atypical presentations are common in diabetic patients, demented patients and in the elderly. 433
Guidelines
Pericardial pain Pericardial pain is of a catching nature. Pericardial pain usually radiates to the shoulder. It may vary with posture and respiration. It is usually accompanied by pericardial rub. Aortic dissection The pain of aortic dissection is usually of a tearing quality often referred to the lower limbs as well. The pain may radiate to the interscapular area. It is usually seen in hypertensive patients. The lower limb pulses may be weak or absent. Pleuritic pain It is usually felt on one side of the chest. It is of a catching nature and it increases on deep inspiration. There will be severe pain on coughing. The patient will have shallow respiration and pleural rub is usually present. Esophageal pain It is retrosternal burning type of pain usually persistent. It may be associated with dysphagia. Pulmonary embolism Patients have sudden onset of dyspnoea and chest pain. Chest pain is usually unilateral. The predominant symptom is dyspnoea. It is usually seen in a setting of a cause for deep vein thrombosis such as obesity, immobilization,use of oral contraceptives, prothrombotic conditions or post surgical state. Electrocardiogram The electrocardiogram (ECG) is one of the most important investigations that should be done in a patient with chest pain. This is the single most important source of data. It should be obtained as early as possible preferably within 10 minutes of presentation. The main ECG changes that can occur with angina are ST segment changes (ST segment depression or ST segment elevation) and T wave inversion. A new onset left bundle branch block is indicative of myocardial infarction. ST segment elevation is significant if there is 1 mm or more elevation. ST segment elevation is usually indicative of acute myocardial infarction. A transient ST segment elevation can occur in unstable angina especially in those with coronary spasm. ST segment depression of 0.5 mm or more ( 0.05 mv ) is significant. T wave changes like tall peaked T waves and T inversion are also suggestive of myocardial ischemia. 434
Cardiology
ST segment elevation can also occur in pericarditis, left bundle branch block, left ventricular hypertrophy and early repolarization syndrome. ST segment depression can also occur with left ventricular hypertrophy. Minor degrees of ST segment depression are sometimes seen in females especially in those with mitral valve prolapse. Minor T inversions (<0.02 mv) may rarely be seen in normal people. Serial ECG changes are most important and suggestive. Availability of a old ECG improves diagnostic accuracy. The disadvantage of ECG is that it is a brief sample and confounding baseline ST segment deviations are common.The sensitivity and specificity are not fully reliable so that both false positive and false negatives may occur.When the clinical suspicion of myocardial ischaemia is strong repeat ECGs done at 2 hourly intervals may demonstrate the evolving lesion. Patients who shows any abnormality of ECGor any sign of haemodynamic instability such as rapid pulse,falling B.P ,development of triple heart sounds should all be indications for referral to higher centres.If facilities exist presence of ST elevation along with typical chest pain is an indication for administering thrombolytic drugs such as streptokinase IVin a dose of 250,000 U diluted in 100 ml normal saline and infused over 1 hour or as a slow IVinjection. Further investigations include the following; determination of cardiac markers like troponins ,creatine kinase CK and CK-MB, cardiac Imaging like ECHO, CT angiogram, tread mill test and coronary angiography. Computerized chest pain protocols are available for triaging the patient and proceeding further. ANGINA PECTORIS MANAGEMENT 1. Nitrates: These are used for relief of anginal pain, as well as prevention of its recurrence. For immediate action glyceryl trinitrate is used IV or sublingually. The vasodilatory effect is immediate and action is of short duration. For maintenance therapy other preparations are used which have more prolonged actions. Indications In acute MI with angina, congestive heart failure, persistent angina or hypertension, nitrates are given for the first 24-48 hours. Maintenance dose is continued in patients with recurrence of angina and persistent pulmonary venous congestion. 435
Guidelines
Glyceryl trinitrate is available in vials of 5 and 25 mg at concentrations of 1 or 5 mg/mL. One vial is diluted in 500 mL normal saline prior to infusion and run at a rate of 5-10 mcg/minute to start with. It is increased by 5 to 10 mcg/minute until clinical effect is manifest. This includes relief of angina, fall of blood pressure by 10% in normotensive, and up to 30% in hypertensive patients. Sublingual Dose: Glyceryl trinitrate is available as tablets containing 0.5,2.6 and 6.4 mg. It is given initially at doses of 0.3-0.6mg. Additional doses of 0.3 mg may be repeated every 5 minutes to a maximum of 1.2 mg in 15 minutes. Other preparations are buccal spray containing 400 mcg metered doses, 2% skin ointment and transdermal patches containing 2.5, 5.0 and 15 mg, released over 24 hours. Side Effects of Glyceryl Trinitrate: Headache and flushing, hypotension, hypovolemia and ventilation-perfusion imbalance in the lungs. Methemoglobinemia may develop after large doses. In general, reduction or withdrawal of the dose helps to relieve the side effects. Hypotension and hypovolemia are managed by elevation of the foot-end of the bed and intravenous fluids. Tolerance to all forms of nitrates develops after continuous administration even within 12-24 hours, but generally it is delayed. Tolerance to nitrates is prevented by giving the drugs at eccentric intervals allowing 10-12 hours of nitrate free intervals in between, e.g. 8 am and 2 pm. Transdermal preparation of nitrates should not be used continuously for more than 12 hours. lsosorbide dinitrate: This is available as 5 mg, 10 mg and 20 mg sustained release tablets, or 1.25 mg metered dose buccal spray. Isosorbide mononitrate Short acting tablets of 10 and 20 mg and long acting tablets of 40, 50 and 60 mg are available. These are used for maintenance therapy and prevention of angina after the emergency is tided over. Beta Adrenergic Blockers If angina is severe and non-responsive to nitrates intravenous metoprolol is the drug of choice. If there are no contraindications, metoprolol is given IV in three boluses of 5 mg each at intervals of 2-5 minutes if the heart rate is >60/minute. If hemodynamic stability continues for 15 minutes after the last I.V dose, oral metoprolol 50 mg is given 6 hourly for two days and then changed to 100 mg bid. 436
Cardiology
Contraindications for beta blockers include cardiac failure evidenced by the presence of rales heard over the lower parts of the chest 10 cm above the the level of the diaphragm, hypotension (BP < 90), bradycardia (heart rate< 60/minute), prolonged PR interval > 0.24 second or, third degree heart block. Other commonly used beta blockers include atenolol 50-100 mg daily, and bisoprolol 5 mg daily, given orally. The ultra short acting drug Esmolol can be used in an emergency in a dose of 500 mcg/kg/minute for 4 minutes I V. SHOCK Clinically shock is usually accompanied by hypotension i.e, a mean arterial pressure < 60 mmHg in a previously normotensive person.The shock syndrome is characterized by rapid thready pulse and cold clammy skin. Alteration in the consciousness such as agitation, somnolence,confusion or coma is a common feature. The urinary output falls below 20 mL/h with the urinary sodium falling below 30 mmol/liter. Metabolic acidosis manifests with tachypnea and Kussmauls respiration. The majority of cases end up fatally, if left untreated. Cardiogenic Shock This form of shock is caused by failure of the heart to act as an effective pump. The onset is usually sudden. It occurs most commonly as a complication of acute myocardial infarction.Cardiogenic shock is characterized by low cardiac output, diminished peripheral perfusion pulmonary congestion, and elevation of systemic vascular resistance and pulmonary vascular pressures. In contrast to other forms of shock, absolute or relative hypovolemia is usually not present in cardiogenic shock.
Treatment
General measures: Shock should be diagnosed early. Survival is inversely related to the duration of the shock before starting treatment. Prompt institution of specific treatment reduces mortality. The patient is put to bed with foot-end of the bed elevated to increase the venous return to the heart. Patency of the airway is established by removing foreign bodies from the mouth and throat and by keeping the neck extended backwards to prevent the tongue from falling back. If there is pain, morphine 5 mg is given intravenously and repeated, if needed, every 10-15 minutes to reach a total dose of 15-20 mg. Vital signs like pulse, 437
Guidelines
respiration, blood pressure and urine flow are monitored. A venous cannula introduced into the jugular vein helps to monitor the central venous pressure and also to administer fluids, if prolonged treatment becomes necessary. It is ideal to keep the central venous pressure at 10- 14 cm of water. Metabolic acidosis is corrected by administration of 50-100 mmols of sodium bicarbonate given as a 7.5% solution. Vasopressor drugs: Sympathomimetic drugs are used to improve vascular tone. Dopamine is given intravenously at a rate of 3- 15 mcg/ kg/min, depending upon the response of blood pressure and urine output. Other drugs in this group are isoprenaline (4-8 mcg/min.) and dobutamine (3-15 mcg/kg/min). These drugs cause improvement in cardiac output and blood pressure, but cardiac arrhythmias may be precipitated. Vasodilator drugs: Commonly used vasodilator drugs include: 1. 2. 3. Sodium nitroprusside given IV at a dose of 10-20 mcg/ min Nitroglycerine given IV at a dose of 10-20 mcg/ min, Phentolamine given IV at a dose of 0.5 mcg/min.
Vasodilators should be started in small dosage and the dose should be worked up, depending on the response.Combination of vasodilators with inotropic agents gives better results. Apart from these general measures each type of shock demands appropriate specific management. For example, thrombolytic therapy and surgical revascularisation for acute myocardial infarction, antibiotics for septic shock and dialysis procedures for poisoning. Hypovolemic shock: Rapid replacement of the blood volume by administration of the appropriate fluid (depending on the fluid lost) is lifesaving and this should be undertaken without delay. Blood, isotonic- saline or plasma volume expanders such as 6% dextran or other colloidal solutions should be used. The rate of infusion should match the rate of fluid loss. In severe cases of gastroenteritis up to 3-4 litres of fluid may have to be infused in the first 1-2 hours. Fluid infusion is continued until the systolic blood pressure comes up to 100 mm Hg.Further maintenance depends on rate of fluid loss. If the shock is unresponsive to replacement of conventional fluids, infusion of 7.5% saline (100-400 mL) may help to restore the blood pressure. 438
Cardiology
Cardiac arrest and its management: Cardiac arrest is a most dramatic medical emergency which may happen in all unexpected situations from time-to-time. The picture is one of an apparently healthy or ailing person falling unconscious, with total loss of consciousness and cessation of heart beat and pulse. The most common causes are ventricular fibrillation and ventricular asystole. If cardiac standstill is not corrected within 3-4 minutes, irreversible damage occurs to the brain and vital centers. Resuscitation becomes futile thereafter or even if the cardiac rhythm is restored, full consciousness is not regained. Such a patient may continue to live a vegetative existence without regaining consciousness and other cerebral functions. Other supportive evidences are; 1. 2. 3. 4. The ECG will fibrillation. Dilation of the pupils. Cessation of breathing or gasping respiration. Cyanosis or pallor. Loss of consciousness. confirm whether the heart is in asystole or ventricular
A planned line of management is absolutely essential to avoid these catastrophies. Resuscitative measures should be instituted if the main pulses are not palpable and heart sounds are not heard. Management of cardiac arrest is a team work. One person starts the procedure, the others soon join him for assistance. It is mandatory to distinguish between the ventricular asystole and the ventricular fibrillation for Specific management Steps to be followed: 1. Put the patient on a firm non-resilient surface and clear the airway. Remove dentures and foreign bodies from the mouth and throat, loosen clothing, pull the chin up so that the tongue does not fall back to obstruct the throat, and remove secretions from the air passages by proper positioning and suction. Introduce an airway, if available. 2. Start external cardiac massage by pressing firmly over the sternum (so as to compress the precordium) and releasing it, at the rate of 50-60/min. If the maneuver is properly done, the carotid pulse will be felt. 439
Guidelines
3. Start artificial ventilation simultaneously by mouth- to-mouth respiration, or using an Ambu bag. lf facilities are available, the trachea is intubated with a cuffed endotracheal tube and positive pressure respiration given with oxygen-enriched air at the rate of 10-12 L/min without interference to the external cardiac massage. 4. Start an intravenous line with 5% glucose to act as a route of medication. 5. lf ECG shows ventricular fibrillation, apply the electrodes and give a DC shock of 200 joules (100400joules). Often the fibrillation disappears and heart resumes normal beat. The DC shock can be repeated if conversion is not achieved with single shock. lf ventricular asystole is detected adrenaline 0.5 mg is given intravenously or intracardiac (0.5 mL of 1/1000 solution into the cavity of the right ventricle using a lumbar puncture needle inserted through the third or fourth left intercostal space. Often this converts asystolc into ventricular fibrillation and this can be converted by DC shock. ln many centres adrenaline is given by the intravenous route. This is adequate if external cardiac massage is performed effectively. 6. Other drugs: Sodium bicarbonate is given l.V in a dose of 100 mmol ( 100 mL of 7.4 % solution )for an adult rapidly to counteract metabolic acidosis. 7. lf the heart returns to activity, continue massage till the systolic blood pressure is maintained at 70-80 mm Hg. 8. lf the heart is beating but BP is low, dopamine may be started as an intravenous drip at the rate of 2-3 mcg/kg/min. 9. lf the heart continues in asystole after adrenaline and massage, 20 mL of 5% solution of calcium chloride can be given after repeating sodium bicarbonate and adrenaline. External cardiac massage and resuscitatory measures are stopped if the heart fails to recover within one hour and the pupils remain dilated and fixed despite adequate massage. As soon as the emergency team starts to give first aid,steps are taken to transport the patient to the hospital in a suitably equipped ambulance. Emergency first aid management of cardiac arrest is taught to several groups such as ambulance personnel, paramedical staff, porters,scouts and so on. Periodically guidelines are published to simplify 440
Cardiology
the procedure so that more persons can practice emergency resuscitation. Life saving equipment such as defibrillators, ventilators and oxygen delivery systems are available in public places and in several aircraft. Emergency resuscitation helps to prevent death and permanent morbidity. ACUTE CARDIOGENIC PULMONARY EDEMA(ACUTE LEFT HEART FAILURE) 1. Patient is hospitalized and put to rest with a back rest or cardiac table, in the position of maximum comfort. 2. The patient is given oxygen immediately at a flow rate of 7-10 L / minute. 3. Morphine sulfate 3-5 mg is given intravenously over three minutes and repeated to a total dose of 15-20 mg, at 15 min. intervals. ln less acute cases the drug can be given intramuscularly in doses of 15-20 mg. Morphine abolishes anxiety, depresses the respiratory center, allays dyspnea, and reduces the adrenergic vasoconstrictor stimuli. 4. Diuretic: Frusemide 40 mg should be given intravenously. lf the effect is not evident in 30 min the dose may be repeated. 5. Aminophylline in a dose of 5 mg/kg given intravenously slowly is very effective in increasing the cardiac output and relieving bronchospasm. Aminophylline has different actions such as improvement of cardiac output, stimulation of the respiratory center, bronchodilation and diuresis. Hypotension and anaphylaxis are potential adverse effects of aminophylline. In many cases the effect of aminophylline is dramatic. 6. Reduction of preloads :Tourniquets are applied to the extremities proximally to reduce venous return and thus reduce preload. The venous return from three limbs is obstructed at a time and the tourniquets are rotated at 15 min. intervals. This method of physiological venesection is very effective. Rarely open venesection to remove 300500 mL blood rapidly may be required. Venesection should not be done on hypotensive patients. 7. Digitalisation: Rapid digitalisation is done by intravenous injection of 0.5-1 mg digoxin when there is clear indication. 8. Vasodilators such as nitroprusside given intravenously may be required in intractable cases. Once the emergency is managed successfully, further elective management depends upon the underlying condition. 441
Guidelines
Cardiac tamponade When sufficient amount of pericardial fluid accumulates, it can increase the intrapericardial pressure, cause obstruction to inflow of blood into the ventricles,particularly the right ventricle,and fall in cardiac output. This is cardiac tamponade. In cases of trauma rapid accumulation of even small quantities of blood can cause tamponade, whereas in cases of chronic effusions large quantity of fluid may accumulate before tamponade develops. Management In pericardial effusions without tamponade aim is to establish the etiology by a careful history including medication review and radiation therapy, general physical examination and investigations. Depending on the circumstances, the investigations should include, skin testing for tuberculosis, screening for neoplastic and autoimmune diseases, infections and hypothyroidism. Drainage of pericardial effusion is usually unnecessary unless purulent pericarditis is suspected or cardiac tamponade supervenes. If a definite etiology is not evident by non-invasive testing, pericardiocentesis is required. Pericardial Aspiration Those patients with tamponade should be considered as having a medical emergency. Volume expansion should be done with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary to maintain adequate intravascular volume. Removal of pericardial fluid is the definitive therapy for tamponade. Removal of small amounts of pericardial fluid (50 mL) produces considerable symptomatic and hemodynamic improvement. Most commonly employed method for closed pericardiocentesis is the subxiphoid approach. A 16 or 18 gauge needle is inserted at an angle of 30-45 to the skin, near the left xiphocostal angle, aiming towards the left shoulder. Surgical creation of a pericardial window, which involves the surgical opening of a communication between the pericardial space and the intrapleural space is sometimes required in recurrent effusions. Since cardiac care centers are available in many towns in Kerala, it is better to refer cases needing pericardial aspiration to such centers.
MANAGEMENT OF HYPERTENSIVE EMERGENCIES

Introduction Hypertension related emergencies account for nearly 25% of all acute medical emergencies. 442
Cardiology
Approach to treatment depends not only on the level of BP, but also on the rate of rise of the blood pressure and the severity of associated co-morbidity. A blood pressure of 140 / 90 mm Hg in a patient with aortic dissection would constitute an emergency, whereas a BP of 200 / 120 in a chronic hypertensive with no end organ damage would just need routine blood pressure control. Hypertensive crisis is a term that encompasses both hypertensive emergencies and hypertensive urgencies. The term hypertensive emergency refers to the condition where the immediate risks of target organ damage are high and B.P has to be reduced within hours. When immediate risks are not high, but short term risks are significant, and the B.P has to be brought down within 24 hours this is termed hypertensive urgency. The level of blood pressure and the risks of target organ damage determine hypertensive crisis. Hypertensive emergencies may require parenteral drug therapy, whereas urgencies can be controlled by oral medications. Definitions Hypertensive crisis is a term to describe both hypertensive emergencies and hypertensive urgencies. Hypertensive emergency is the situation with severe elevation of blood pressure, associated with severe symptoms, progressive target organ damage and demanding immediate reduction of blood pressure within one hour usually by using parenteral drugs. Often hospitilisation is necessary. Common hypertensive emergencies Hypertensive encephalopathy: clinical features. Headaches, visual disturbances, clouding of consciousness, focal or general neurological deficits, seizures, petechial hemorrhages in the retina are all associated with blood pressure often above 180/110 mm Hg. The level of blood pressure may vary and atleast in some it may be only below 180 mm Hg systolic. Cardiovascular complications: Aortic dissection, acute myocardial infarction or unstable angina, acute pulmonary oedema Cerebrovascular complications: Acute cerebral infarction, cerebral hemorrhage,subarachnoid haemorrhage and hypertensive encephalopathy
443
Guidelines
Management
General principles It is safer to reduce the BP gradually but promptly.Initial reduction of mean arterial BP[diastolic+1/3rd (systolic-diastolic)] of 25% over minutes to 1-2 hrs, followed by gradual reduction to about 160 / 100 mm Hg over the next 2-6 hours is safe in most cases. If the patient remains stable it is ideal to reduce the BP to < 140 / 90 mmHg over the next 12-24 hours.
Specific therapy Vasodilators

Sodium nitroprusside: For immediate reduction of BP the drug of choice is sodium nitroprusside in a dose of 0.25 10.0mcg/kg/min as IV infusion. This brings down the BP instantaneously but the effect is transient Nitroglycerine: Dominantly a venous dilator, Dose is 5 200 mcg /min as infusion, onset of action occurs in 2- 5 minutes,and the action lasts for 5 -10 minutes after infusion stopped. Titrate infusion every 5- 10 minutes for optimal BP control. Side effects are headache, tachycardia, vomiting, flushing. Very useful in hypertensive crisis associated with acute coronary syndromes. Hydralazine: Dominantly an arterial dilator, dose is 10-20 mg IV bolus, repeat every 4-6 hrs, onset in 10-20 minutes, lasts for 1-2 h, can be given IM also.Side effects are tachycardia, headache, vomiting and precipitation of angina. This drug is mostly of use in preeclampsia and eclampsia and it is contraindicated in the setting of acute coronary syndromes. Enalaprilat: This is an arterial dilator (ACE Inhibitor) Given in a dose of 0.625 1.25 mg Q6h IV. The onset of action occurs in 15- 30 minutes and it lasts for 12- 24 hours after last dose. The response is unpredictable . Enalaprilat should be used with caution in patients with renal failure, bilateral renovascular disease and a few others. Verapamil: This is a calcium channel blocker, which is quite effective to reduce BP . It should be used with caution in the presence of heart failure, heart blocks and bradycardia. The dose is 5 -10 mg IV as bolus , followed by infusions 3 25 mg /h. The effects start within 1-5 min and last for upto 60 minutes after cessation 444
Cardiology
Adrenergic inhibitors Labetolol: Usual dose is 20 -80 mg as IV bolus every 10 minutes, or upto 2 mg/ min as IV infusion. The onset of action is within 2- 5 minutes and the action lasts for 2 6h after the drug is withdrawn. Side effects include bronchoconstriction, heart blocks, hypotension , heart failure .Labetalol is often used in pregnancy related hypertension. Esmolol : This is an ultrashort acting betablocker. Onset of action is within 15 minutes and it last for 15 -30 minutes.The dose is either 500mcg /kg bolus injection or 25 -100 mcg / kg/min infusion.The bolus can be repeated after 5 minutes, so too the rate of infusion can be increased upto 300 mcg/kg/min.Adverse effects include asthma, heart blocks, heart failure and others
Oral drugs for hypertensive urgencies

z
z z
Adrenergic Drugs Clonidine:50-100 mcg tid Labetolol:200-400 mg repeated every 2-3 h Calcium channel blockers: Verapamil:240 mg daily in 2-3 divided doses Diltiazem:60-120 mg bd Amlodipine :5-10 mg od Beta adrenergic blockers: Propranolol:40-80 mg bd Atenolol:25-100 mg od Bisoprolol:2.5-10 mg od Metoprolol:50-100 mg daily Diuretics: Frusemide 40-80 mg daily ACE Inhibitors: Enalapril:10-20 mg od Lisinopril:5-10 mg daily Perindopril:2-8 mg daily ARBs : losartan 50-100 mg daily 445
Guidelines
Specific hypertensive emergencies

Hypertension in pregnancy: Gestational hypertension is more common in primigravida, and in those with multiple pregnancies.This usually resolves after delivery. There is increased susceptibility to hypertensive encephalopathy.The normal levels of blood pressure during pregnancy are lower than in the non-pregnant state(110/75 mm Hg).Sustained rise in BP of 30 mm Hg or more in systolic and 15 mm Hg or more in diastolic should be taken as hypertension. In preeclampsia the BP is elevated after the 20th week of pregnancy and it is associated with proteinuria The traditional drugs for the management of gestational hypertension are alpha methyl dopa, hydrallazine and labetolol.Bed rest, salt restriction and specialized obstetric management are essential for successful outcome. Diuretics and ACE inhibitors are contraindicated.
RESPIRATORY SYSTEM
ACUTE RESPIRATORY FAILURE (ARF)
Maintanence of the airway

Irrespective of the cause all cases of respiratory failure the upper air passages should be fully inspected and foreign bodies and secretions should be removed. In recumbent comatose patient chin should be pulled up to prevent the tongue from falling back and obstructing the pharynx.If the patient cannot expectorate freely secretion should be aspirated.If the patient can co-operate removal of secretion should be aided by postural coughing ,gentle tapping on the chest,steam inhalation and administration of drugs like bromhexine hydrochloride in a dose of 8mg tds.Mucolytic agents can be administered as aerosols eg acetyl cysteine.Patient should be adequately hydrated.If bronchospasm is present it can be relieved by drugs like salbutamol given 2 to 4 mg orally, 0.5 mg intramuscularly. Parenteral betamethasone 4 mg may have to given if bronchospasm is not relieved by simple measures.Salbutamol and beclomethasone can also be given as metered aerosols. Tracheostomy may be required in some cases where the tidal volume is low. ANTIBIOTICS. Assessment of the infecting agent can be made by gram staining and culture of the sputum and suitable antibiotic can be started. In the acute 446
Respiratory System
case crystalline penicillin and in the chronic case a broad spectrum antibiotic such as ampicillin or amoxicillin may be required. Antibiotic therapy may have to be reviewed when microbiological results are obtained. Correction of hypoxia: Oxygen is administered with nasal catheter, or by more effective methods such as masks or tents. If given by nasal catheter, the rate is 2 to 3 litres per minute and the catheter tip should be located 15 cm from the nostril. The venturi mask which delivers oxygen at a preset low concentration is ideal if available.The concentration of oxygen can be adjusted at 24, 28 or 35% by giving oxygen at rates ranging from 4 to 8 L/ min. It is desirable to bring the PaO2 level above 50mm Hg and pH above 7.25. In chronic respiratory failure administration of oxygen should be closely supervised to avoid the development of carbon dioxide narcosis.Once the emergency has been tided over, the patient is weaned off from oxygen gradually. Supportive measure If the respiratory failure does not clear up patient may require more advanced supportive measures such as fluid and electrolyte administration with monitoring of central venous pressure,assisted ventilation and so on.This have to be arranged in appropriate centres. ACUTE SEVERE ASTHMA Acute exacerbation of asthma can progress on to life threatening severity if not treated early. Intensification of bronchodilator regimen or a short course of corticosteroid can abort a life threatening asthma attack. In most situation patients respiratory distress itself is an indicator of severe asthma attack. The clinical clues are use of accessary muscles of inspiration,inability to speak continuously pulsus paradoxus and refusal to recline. If FEV1and PEFR remain less than 40% of the predicted value after one intense treatment hospitalization is required. Bronchodilator treatment Preparations : 1. lnhaled beta agonist - salbutamol / terbutaline 100 mcg 2 puffs every half an hour 2. Nebulizer device (wet aerosol) respirator solution salbutamol 5 mg / mL; 1 mL + 3 mL saline every 20 - 30 min. 3. I.V. aminophylline 250 mg mixed in 25 mL of 25% glucose bolus given in 7 - 10 min time repeated 6 h. 447
Guidelines
(6 mg/kg bw) the maximum dose should not exceed 6mg / kg bw in 24 h. In those already on oral theophylline the loading dose is best avoided. 4. 5. Anticholinergic drugs. Ipratropium respirator solution is given by inhaler / nebulizer or metered dose inhaler I.V. corticosteroid - hydrocortisone 2 mg/ kg bw IV bolus then 0.5 mg/ kg bw IV line. Or hydrocortisone 200 mg stat may be given and repeated as required. Methyl prednisolone 125 mg IV 6 h.
If after 60 - 90 min of treatment with the above drugs symptoms are not alleviated, intensive monitoring is essential as it can worsen to a life threatening attack. It is difficult to assess by clinical presentation alone.Measurement of forced expiratory volume in 1 second( FEV1),and peaked expiratory flow rate (PEFR) is mandatory. If FEV1 / PEFR remains less than 40 % of predicted that is acute severe asthma and the patient should be referred to a specialised centre for blood gas analysis and ventilator assistant management. After the acute attack is over therapy with corticosteroids should be maintained for 1- 3 weeks to prevent relapse. FOREIGN BODY ASPIRATION Acute laryngeal obstruction may present as a life threatening emergency.Foreign bodies may get impacted in the larynx. Foreign bodies include dentures, large chunks of meat or other matter. Obstruction by bolus of food is more common under alcohol intoxication. This is called Caf Coronary . Clinical features: Stridor, aphonia, and dyspnea are the hallmarks of laryngeal obstruction. Acute obstruction in children leads to cyanosis and inspiratory indrawing of the trachea. The movement of a foreign body within the larynx may be palpable during respiratory effort. When obstruction due to large bolus of food occurs at the table, the victim becomes anxious, restless, and cyanosed. He tries to cry, but the voice is lost. If the obstruction is not relieved immediately, he falls unconscious and death may occur within minutes. Causes of laryngeal obstruction 1. Foreign body 2. Inflammatory or allergic edema (including angio-neurotic edema due to food, irritant fumes, corrosives or insect stings) 448
Respiratory System
Acute Iaryngitis and epiglottitis (especially in infants) Exudates Laryngeal muscle spasm Inhaled blood clot/vomitus in the unconscious Tumors: Chronic progressive obstruction especially carcinoma Bilateral vocal cord paralysis Diagnosis: Acute laryngeal obstruction should be suspected when an otherwise healthy individual suddenly becomes choked and cyanotic with loss of voice. Management: First aid consists of the removal of the foreign body manually or with a pair of tongs. The impacted foreign body can be dislodged by a sudden forcible thud on the chest with the head lowered. Heimlich maneuver: This effective method is to be learnt by all first aid teams. The patient is hugged from behind with the rescuers hands crossing each other, over the patients epigastrium and the chest is compressed suddenly. This helps in dislodging the obstruction.If the above attempt fails, the airway should be made patent by tracheostomy or by inserting a few large-bore hypodermic needles into the trachea. The patient is transported to hospital for further management. Heimlich maneuver: Application of sudden pressure over the abdomino-thoracic region may dislodge the laryngeal foreign body HAEMOPTYSIS It is defined as expectoration of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial haemorrhage. Common causes include-1. pulmonary tuberculosis. 2. bronchiectasis 3. bronchogenic carcinoma. 4. lung abscess. 5. mitral stenosis. 6. pulmonary embolism and rarely haemorrhagic diseases.Migration of soil transmitted nematodes through the lungs used to be a frequent cause of mild haemoptysis .With the reduction of helminthic infection this condition has subsided .If the quantity of expectorated blood is more than 600 mL in 24 h or 300 mL in 12 h it is termed as massive haemoptysis and it is life threatening. 449
3. 4. 5. 6. 7. 8.
Guidelines
Treatment 1. Bed rest and proper positioning. Exclude hemetemesis, ENT sources of bleed and pulmonary thromboembolism. 2. Maintenance of airway. BP and pulse to be recorded every half an hour and the quantity of blood expectorated should be recorded. 3. Sedation - required to relieve restlessness and anxiety 5 mg diazepam stat-oral or IV. 4. Cough suppressant- codeine phosophate / sulphate 30 mg 6 h. 5. Antibiotics - broad spectrum, ampicillin 500 IV, 8 h 6. Blood transfusion has to be arranged if there is profuse bleeding. Patient has to be referred to higher centres for X-ray studies, HRCT,bronchoscopy and detailed sputum examination for proper diagnosis and management. .Bronchoscopy is indicated if 1. Patient is a smoker 2. Non smoker having an abnormal X-ray. 3. Non smoker aged > 35 years 4. Non smoker aged < 35 yrs, with normal chest X-ray and having recurrent haemoptysis. Note:Even though haemoptysis is alarming to the patient and the relatives majority of cases are mild and self limiting, which can be managed at small hospitals. Recurrent haemoptysis is a definite indication for full investigation TENSION PNEUMOTHORAX This is the condition in which air collects in the pleural cavity under pressure.This leads to compression of ipsilateral lung and later,contralateral lung also.Patient present with severe dyspnoea and chest pain with progressing distress. Common causes include rupture of sub pleural bullae,tuberculous cavities,cystic lung,lung abscess and trauma. The condition is fatal if severe. X-ray chest is confirmatory. Management : Immediate release of tension is necessary.Emergency treatment is to institute thoracostomy with a wide bore needle or a suitable catheter and connected to under water seal through a tube. If the patient is in distress and thoracostomy tube is not readily available, use a 20 guage needle connected to a 20 mL syringe containing 10 mL of sterile water and aspirate the air for immediate relief. After releasing the tension the patient should be transported to the nearest tertiary care centre. Once the emergency is tackled, identify the underlying cause for management 450
Respiratory System
PLEURAL EFFUSION Collection of free fluid in the pleural cavity is called the pleural effusion. It may present as an emergency with respiratory embarrassment.Common causes include pulmonary tuberculosis , pneumonias, pleural or pulmonary malignancy and generalized edema.Emergency aspiration is done if the fluid is massive or bilateral, producing respiratory distress.In bilateral effusion aspiration is done on the side of greater fluid collection. The fluid is aspirated by thoracocentesis done in the eigth or ninth intercostal space in the posterior axillary line after anesthetising the part. Sufficient fluid is removed to relieve the distress. Whenever pleural fluid is aspirated, it should be send for diagnostic investigations. Elective aspiration:Medical therapy is instituted depending on clinical features and pleural fluid analysis. It is ideal to aspirate the fluid after instituting specific drug therapy for 3-4 days. Indication for aspiration (1) to make the diagnosis.(2) to relieve distress. and (3) to remove the exudate so as to hasten full recovery of the pleura and avoid complications. lt is generally advisable to restrict the volume of fluid removed at one sitting to 1 litre or less in order to avoid pulmonary edema. Aspiration has to be repeated at times. Two or three aspirations will be adequate in most of the cases of tuberculous effusion. Sometimes aspiration of the pleural cavity may give rise to complications. These include pleural shock, anaphylactic shock due to anaesthetic, bleeding into the pleural cavity, pulmonary edema, infection, and accidental introduction of air into the pleura. Pleural shock : The patient develops vasomotor collapse on puncturing the pleura. Inadequate local anesthesia may be a predisposing factor. Urgent resuscitatory measures include the injection of adrenaline, parenteral steroids and intravenous fluids. Pleural shock may be fatal if not recognized in time.Bleeding should be suspected when the aspirated fluid becomes progressively blood stained. When bleeding is evident it is advisable to stop the procedure Entry of air inadvertently during aspiration converts a simple pleural effusion into hydropneumothorax.In mild cases the air is automatically absorbed. 451
Guidelines
Pulmonary edema occurs in some cases of chronic effusion when the lung expands on removal of the fluid.Slow aspiration and limiting the volume of fluid aspirated at one sitting to 1 litre help to reduce these complications CHRONIC ASTHMA IN ADULTS Classification
Step 4 Severe persistent PEFR < 60% Var : > 30% Long term High dose inhaled steroid +long acting bronchodilator like long acting inhaled beta agonist or sustained release theophylline or long acting beta agonist tablets. Oral steroids 2 mg/ kg/ day High dose inhaled steroid or low dose inhaled steroid + long acting beta agonist Inhaled low dose steroids cromolyn or nedocromyl Sustained release theophylline Montelukast (10 mg at bed time daily) or Zileuton Symptomatic treatment as and when required Quick relief Inhaled beta 2 agonist as needed
Step 3 Moderate persistent PEFR 60 - 80% Var : > 30% Step 2 Mild persistent PEFR > 80% Var 20 - 30% Step 1 Mild intermittent PEFR > 80% predicted Variability < 20%
PULMONARY EMBOLISM Clinical features of pulmonary thromboembolism will be non specific and vague in many cases.In some cases low grade fever may be caused by venous thrombosis. Acute massive pulmonary embolism: ln this condition more than 50% of the cross-sectional area of the pulmonary arterial tree is occluded. lt manifests with sudden dyspnea, angina pain, hemoptysis and circulatory collapse in a patient who is apparently well and progressing from other underlying disorders. The patient becomes cyanosed, convulsive and 452
Alimentary System
comatose. Cardiac auscultation reveals loud pulmonary second sound. Some cases present with signs of acute right ventricular failure with raised jugular venous pressure and hepatomegaly. lf not relieved in time massive pulmonary embolus is rapidly fatal within minutes. Clinically acute massive pulmonary embolism may mimic acute myocardial infarction or dissecting aneurysm of the aorta. Electrocardiogram shows evidence of right ventricular strain and in a patient who had normal ECG, sudden development of right ventricular strain should raise the possibility of massive pulmonary embolism. Examination of the limb may show edema or tenderness along the veins in some cases. Homans sign may be elicitable in a few . ln many, there may be no local signs to suggest venous thrombosis. Submassive pulmonary embolism: This presents with the triad of symptoms consisting of cough, pleuritic pain and hemoptysis.. Physical examination reveals the presence of pleural rub and signs of consolidation. Emergency management Patient is put to bed.Oxygen is administered and closed chest cardiac massage is started.An effective closed chest cardiac massage, in addition to restoring cardiac output,may help in fragmenting the thrombus and driving it into the peripheral branches.If shock ensues, this should receive prompt attention.All cases should be accessed for thrombolytic therapy early in the disease.In many cases, this is life saving measure.Patient should be transported rapidly to a centre where thrombolysis can be undertaken.
ALIMENTARY SYSTEM
HAEMATEMESIS (ACUTE GASTROINTESTINAL BLEEDING) Haematemesis results from bleeding proximal to the ligament of Treitz(tissue that connects duodenum to diaphragm.arises from around the stems of celiac trunk and superior mesenteric artery and inserts into 3rd or 4th portion of duodenum or more frequently into duodeno-jejunal flexure). It may occur from any part below the upper end of the esophagus up to the duodenum. The blood that is vomited out will be fresh blood if the bleeding is active and massive whereas in slow oozing the vomitus contains altered blood-(coffee ground). Proper examination of the nasal cavities, pharynx and throat should be made to distinguish true haematemesis from vomitus containing swallowed blood. The latter though alarming is not generally dangerous. Common causes of haematemesis include-acid peptic 453
Guidelines
disease, gastric erosions caused by drugs such as NSAIDs, oesophago-gastric varices in portal hypertension, malignancies in the stomach or the oesophagus,diverticula,haemorrhagic disorders and the gastro esophageal tear occurring in Mallory Weiss syndrome. In most cases of haematemesis ,malaena accompanies. Haematemesis which is the medical emergency requires urgent treatment, supportive first aid measures and later, definitive treatment in specialized units. The following clinical features indicate substantial loss of intravascular volume-(more than 1L in adults) 1. Pulse rate >100/min and steadily going up. 2. Hypotension-systolic B.P<100 mm Hg 3. Postural changes in pulse rate- increase of>20 beats /min or fall of systolic BP >20mm Hg on standing. 4. Pallor of mucous membrane , emptiness of neck veins and reduction in urine output<60mL/h all indicate fall in intravascular volume. 6. Elderly persons above 60 years do worse when large blood loss occurs. Procedure: 1. First priority is to replace fluid losses and restore hemodynamic stability by giving i.v. infusion of crystalloid fluid-normal saline using 1 or 2 large bore hypodermic needles 16-18 gauge or a central catheter if peripheral access is not available. 2. If the tachycardia or hypotension persists or if the hemoglobin level is below 10 g/dl especially in older patients with coexisting cardiovascular diseases , use of inhaled oxygen and transfusion of plasma expanders with fresh blood or packed erythrocytes should be considered in order to maintain adequate oxygen carrying capacity of the blood. 3. Insertion of Ryles tube and periodic aspiration will help to identify continuing bleeding. Such patients require further specialist management such as endoscopic procedures .Hence they have to be referred to higher medical centers without delay. Absence of blood in the aspirate is not a guarantee that bleeding has stopped. 4. If the patient is to be managed at the periphery start pantoprazole 40 mg IV as bolus followed by continuous infusion at the rate of 8 mg/hour for 24-72 hours .Ranitidine 50 mg I.V 6 hourly or cimetidine 200mg IV 6 hourly may be given to reduce the bleeding but they are less effective than proton pump inhibitors.Administration of antacids 454
Alimentary System
such as aluminium hydroxide gel 30 to 50 mg orally may act synergistically.If bleeding persists , the patient has to be referred for endoscopic management . Risk stratification can be done by Blatchford score which is given below. At presentation Systolic BP 100-109 mm Hg 90-99 mm Hg <90 mmHg Blood urea nitrogen 6.5 -7.9 mmol / L (18.2-22mg/dl) 8.0-9.9 mmol / L (22.4-27.7mg/dl) 10-24.9 mmol / L (28-69.7 mg/dl) >25 mmol / L (>70 mg/dl) Hemoglobin for men 12-12.9 g/dl 10-11.9 g/dl <10 g/dl Hemoglobin for women 10-11.9 g/dl <10 g/dl Other variables at presentation Pulse >100 Melena Syncope Hepatic disease Cardiac failure 1 1 2 2 2 1 6 1 3 6 1 2 3 2 3 4 6 Points
Higher scores indicate higher risk . Any score > 8 will be an indication of immediate referral. 455
ENDOCRINOLOGY
DIABETIC KETOACIDOSIS (DKA) Diabetic ketoacidosisis an acute metabolic complication of diabetes mellitus.This syndrome consists of the triad of hyperglycemia, ketosis and acidosis. As per the recommendations of American Diabetes Association, the criteria for DKA are Arterial pH <7.3 Bicarbonate level < 18 mEq/L Blood Glucose > 250 mg/dL Moderate degree of ketonemia and ketonuria(presence of ketone bodies in the urine). Factors which precipitate DKA Inadequate insulin administration Recent onset Type 1 DM Infections pneumonia/urinary tract infection( UTI)/ gastroenteritis/ sepsis Infarction myocardial/ cerebral/ mesenteric/ peripheral Drugs Steroids, thiazides, sympathomimetic drugs (dopamine,terbutaline), cocaine, atypical anti-psychotics (clozapine, olanzapine) Alcohol abuse Psychological problems accompanied by eating disorders may account for 20% of recurrent ketoacidosis in young individuals Unknown causes Diagnosis Although the symptoms of poorly controlled diabetes may be present for several days, the metabolic alterations in DKA evolve within a short time frame (<24hrs).In some cases at least, the diabetes may be presenting for the first time with ketoacidosis. History Polyuria, Polydipsia, Polyphagia,Nausea, vomiting, abdominal pain, muscle cramps,weakness,blurring of vision,respiratory distress,clouding of sensorium,coma. On examination: Dehydration : reduced skin turgor 456
Endocrinology
Tachycardia Hypotension / shock Hypothermia Altered level of consciousness confusion, drowsiness , stupor, coma Kussmauls breathing(deep sighing respiration) :- develops as a result of metabolic acidosis Smell of acetone in breath may be present in some cases. Abdominal tenderness- mimicking acute pancreatitis or a surgical abdomen Classification of DKA:
Mild 1 2 3 4 5 6 Plasma glucose (mg/dL) pH Serum bicarbonate Urine and serum ketones Anion gap Alteration in sensorium >250 7.25-7.30 15-18 Positive >10 Alert Moderate >250 7.00-7.24 10 to <15 Positive >12 Alert/drowsy Severe >250 <7.00 <10 Positive >12 Stupor/coma
On diagnosis, all patients must be started on IV normal saline, the first 500 mL should be given within 2 hrs and then 500 mL in 4 h, depending on the state of hydration. The IV,fluid must be changed to glucose saline once the random blood sugar (RBS) comes below 250 mg% or urine sugar becomes less than 1%. All patients must be started on IV bolus of regular insulin 0.15U/kg (10 -15U) followed by continous infusion at the rate of 0.1U/kg/h(5-7unit/h). Blood glucose should fall by 50-75mg/dL/hour.If serum glucose does not fall by 50-75 mg/dL in first hour,double the dose of insulin infusion hourly until glucose falls by 50-70mg/dL . Once the patient is having urinary output,1 ampoule of potassium chloride 10 mL must be added to every bottle of IV fluids. For proper management, frequent monitoring of blood sugar, electrolytes, blood urea and arterial blood gases are necessary and therefore the patient may be referred to a higher centre. HYPOGLYCEMIA This is a very common medical emergency which demands prompt action. Suspect hypoglycemia in a diabetic on antidiabetic drug treatment who missed a meal or was unable to take the food because of illness. Un 457
Guidelines
accustomed exertion,diarrhoea and vomiting precipitate hypoglycemia. Clinical features include anxiety ,mental confusion ,disorientation,tremor, feeling of emptiness in the epigastrium, profuse sweating,cold extremities, raised blood pressure, exaggerated reflexes, convulsion and coma.In elderly patients disturbances of higher functions may predominate (neuroglycopenia) .Though determination of blood glucose level is essential for proper diagnosis ,often this may not be available at hand and in many situations diagnosis has to be presumptive, later confirmed by the prompt response to glucose or sugar administration. Even when facilities for blood glucose estimation exist, emergency treatment should be started on clinical suspicion since there is no absolute diagnostic level for the development of symptoms in individual cases.In those patients who are exposed to high blood glucose levels for long period,even lowering of blood glucose to normal or near normal may precipitate symptoms.In the ordinary cases blood glucose levels of 60mg/dL or less may be taken as to be diagnostic.It is unusual for the blood glucose levels to go low (below 30mg/dL or even less) especially in patients receiving antidiabetic drug therapy.Hypoglycemia may occur less commonly in non diabetic subjects especially those with Addisons disease, hypopitutarism,prediabetic state,pancreatic islet cell tumours and disseminated malignancies.Several drugs may precipitate hypoglycaemia eg.quinine ,gatifloxacin and others. Treatment : If the patient is concious give either 25 g glucose dissolved in 200mL water orally. Alternatively sucrose 25 g in 200 mL of any drink, or any sweets (3-4 ordinary biscuits) if the patient is able to swallow. The condition improves within 10 minutes. If the patient is drowsy or comatose give I.V glucose 100 mL of 25 % solution rapidly within 2 min. Invariably the patient regains conciousness at the end of the injection. Once the patient is conscious give oral carbohydrates so that hypoglycaemia may not occur. In children in whom hypoglycemia, where intravenous injection may be difficult an I.M dose of 1 mg of glucagon will be helpful, if the drug is available .An alternative is to administer glucose solution 20% through a ryless tube. THYROID STORM(Thyroid crisis) This is a medical emergency caused by sudden release of thyroid hormones from the gland, spontaneously or immediately after surgery. Thyroid crisis is more frequent if surgery is undertaken during active thyrotoxicosis. 458
Endocrinology
Thyroid crisis can be precipitated by stress or infections. Thyroid crisis should be suspected if they develop high fever, severe tachycardia, restlessness,heart failure, peripheral vascular collapse or psychotic behaviour. Treatment 1. Diazepam is given in doses of 5-10 mg IV to allay the agitation and quieten the patient. Tepid sponging helps to keep the temperature down from rising to hyperpyrexia levels. 2. l.V glucose saline drip is started and hydrocortisone 100 mg is given at 4-6 hour intervals to combat shock. 3. Sodium iodide is given IV in a dose of 300-600 mg 8 hourly till the metabolic crisis is controlled. 4. Beta-adrenergic blockers are very effective in reducing tachycardia and adrenergic symptoms. Propranolol given IV in doses of 1-4 mg stat over a period of 5 minutes is very effective and the effect lasts for 3- 4 hours, after which it is to be repeated. In less severe cases propranolol can be given orally, in doses ranging from 120-240 mg in 24 hours,even upto 600-1200 mg. 5. If IV sodium iodide is not available, an effective antithyroid regimen is to give propylthiouracil 100 mg 6- hourly along with potassium iodide 50-100 mg orally,rectally or through a Ryles tube as the case may be.Iodine containing radio-contrast dyes such as sodium iopodate 500 mg orally daily will restore the serum T3 to normal in 2-3 days. Propranolol and sodium iopodate can be withdrawn after 14 days. Carbimazole can also be given 15-20 mg 6 h through a Ryles tube MYXOEDEMA COMA This condition should be suspected when a patient with hypothyroidism slips into hypothermia, hypotension, hypoventilation and coma It is more common in colder climates where exposure precipitates coma. Coma is usually precipitated by sepsis, surgery, cold environment and sedatives. The core temperature measured by rectal thermometer will be less than 35C. In addition to frank overt myxoedema ,even secondary hypothyroidism can give rise to coma when exposed to stress. Treatment of myxoedema coma: Treatment of myxedema coma is a medical emergency. Coma is the result of a combination of factors such as heart failure, Cerebral ischemia, hypothermia, and hypothyroidism.The patient should be hospitalized. The 459
Guidelines
drug of choice is tri-iodothyronine (T3) given lV in a dose of20mcg stat and repeated 4 hours later. At present parenteral preparation of levothyroxine sodium is also available for use, The dose is 500 mcg IV stat and repeated 4 hours later,and thereafter 100mcg per day . If parenteral preparations of thyroxine are not available, administration of thyroxine through a nasogastric tube in doses of 0.1 mg three times or four times a day is advised till the coma clears, and thereafter the dose is modified suitably. Hydrocortisone should he given along with thyroxine replacement in order to prevent hypoadrenal crisis and to help recovery from shock. The dose is 100 mg IV, 3-4 times a day Dexamethasone 2 mg IV 6 hourly is a suitable alternative. Supportive measures include gradual warming up of the patient with hot water bottles or other warming equipment. Intravenous glucose drips, maintenance of proper ventilation and the treatment of coexisting infections. Myxoedema coma is associated with high mortality and therefore best results are obtained if treatment is undertaken in well-equipped centers. ADRENAL CRISIS The secretions of the adrenal glands especially mineralocorticoids and less so glucocorticoids are vital and absence of these hormones are fatal.Hypoadrenal crisis may occur in patients with primary hypoadrenal states or in those with hypopitutarism with secondary hypoadrenal state.It is clinically characterised by nausea, vomiting,dehydration, weakness, lethargy and hypotension. It has to be suspected in any known patient with hypoadrenalism who gets infection, illness or stressful states.Laboratory investigations reveal hypoglycaemia ,hyponatremia,and normal or elevated serum potassium levels.Drugs such as morphine,diuretics and hypoglycaemic agents may precipitate hypoadrenal crisis. Emergency treatment is needed to save life. The best strategy is to prevent it by detecting it early and prevent it by increasing the dose of corticosteroids. Management The emergency management includes starting an IV line with 5 % glucose saline and a bolus injection of 100 mg hydrocortisone. After this, hydrocortisone may be given in doses of 100 mg 6 h or as a continuous infusion at the rate of 10 mg/h. Other measures to correct the precipitating factors should be undertaken along with. Once the patient is stabilised and the precipitating factor treated, he may be put on his usual maintenance dose of oral corticosteroids and investigations and long term management should be arranged in a specialized clinic. 460
NEUROLOGY
COMA Coma is one of the most serious medical emergencies in practice.There are several causes for coma.Depending upon the age the common causes are Children Intracranial infections meningitis ,encephalitis ,brain abscess,raised intracranial tension, seizures. Young adults Intracranial infections, trauma,poisoining,cerebrovascular accidents,seizures,raised intracranial tension,systemic infections such as cerebral malaria, hysterical coma, catatonia and others Elderly persons Cerebrovascular accidents, increased intracranial tension, subdural or extradural haematomas,cerebral tumours, metabolic abnormalities, cardiovascular disease and others. In evaluating a comatose patient a common clinical parameter which is used is the Glasgow coma scale which is useful both for initial assessment and monitoring of progress. Glasgow Coma Scale It is an objective method of evaluating the depth of coma. Glasgow Coma Scale(GCS) TEST SCORING
1.Eye opening(E) Spontaneous To sound To pain Nil Obeys commands Localises pain Normal flexion withdrawal Abnormal flexion(decorticate rigidity) Extension (decerebrate rigidity) No response Well-oriented Disoriented and converses Confusedly Inappropriate words Incomprehensible sound None 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1
2.Motor movements(M)
3. Verbal response(V)
461
Guidelines
A conscious individual will have a score of 15. The scores progressively diminish as the coma becomes deeper. The fallacy of Glasgow coma scale is that even a dead person will have a score of 3. This has not in any way reduced the importance of the Glasgow coma scale. MANAGEMENT OF COMATOSE PATIENT Comatose patients are very susceptible to develop several complications as a result of loss of protective reflexes and these have to be prevented.Maintenance of the airway is of utmost importance. The neck has to be kept extended to prevent falling back of the tongue. If necessary a patent airway should be introduced. Secretions have to be removed by postural drainage and suction. In cases with respiratory depression assisted ventilation has to be instituted early. Tracheostomy may be required in some cases. STATUS EPILEPTICUS When recurrent seizures occur at a frequency which does not allow consciousness to be regained in between seizures, it is called status epilepticus. Severe and permanent brain damage may result from status epilepticus persisting for more than an hour. It is the current consensus to consider any seizure (both clinical or electrical) lasting for more than 30 minutes, or more than one seizure within 30 minutes even if consciousness is not lost, as status epilepticus Management Time is a critical factor in the management of status epilepticus. There are many therapeutic regimes but none of them is totally satisfactorily. Benzodiazepines such diazepam, lorazepam, midazolam and clonazepam are all potent fast-acting antiepileptic drugs, preferred for terminating the attack immediately. Initially, when patient is first seen, 10 mg diazepam (0.3-0.5 mg/kg/bw) should be given slowly intravenously over a period of 2-5 minutes. Its action lasts for 20-30 minutes. Lorazepam in doses of 0.1 mg/kg at 2 mg/minute is preferable to diazepam as it has longer duration of action (> 4 hrs)and lesser respiratory depression. Simultaneously a loading dose of phenytoin, i.e.0.5-1g (18 mg/kg) is given intravenously over 20 minutes at a rate of 50 mg/min in those who are not already on this drug. This dose serves to achieve optimum therapeutic blood level and maintains the antiseizure effect, for a longer period. The 462
Neurology
anticonvulsant action of intravenous phenytoin is manifest within 10-20 minutes. Phenytoin is not absorbed properly after IM injection, and therefore this route should not be relied upon. Large doses of IV phenytoin may lead to hypotension and cardiac arrhythmias, and therefore the patient should be closely monitored clinically and with ECG. In the absence of such a facility phenytoin should be given as IV bolus in doses of 200 mg. Phenytoin levels can be maintained by giving it as an IV drip containing 100 mg in 500 mL of normal saline or distilled water, run at the rate of 40 mL per hour, the infusion lasting for 12 hours. Phenytoin is incompatable with glucose containing solutions and hence it should not be mixed with them. If status epilepticus still persists, phenytoin is to be repeated at a dose of 5 mg/kg IV till a maximal total dose of 30 mg/kg is reached. Fosphenytoin is a water soluble prodrug of phenytoin which is similar in action and dosage, but with less of local irritant property. 150 mg fosphenytoin is equivalent to 100 mg phenytoin. Phenobarbitone given intravenously in doses upto 0.8-1 g in 24 hours (20 mg/kg at 100 mg/min) is an effective anticonvulsant and this should be added if seizures are not controlled by diazepam and phenytoin. In intractable cases thiopental anesthesia is induced with IV injection of 0.3-0.6 g of the drug and this is very effective. Assisted ventilation is mandatory when phenobarbitone or thiopentone is given, especially after diazepam administration. Once the patient is seizure free, and is able to take oral medication, phenytoin or other antiepileptic drugs are introduced by the oral route. CEREBROVASCULAR OCCLUSIVE DISEASE Since modern investigations such as CT scan ,MR angiography,digital subtraction angiography,PET studies and others have revolutionalised ,the management of stroke, several dedicated stroke units have come up. Treatment in this units give better results as regards mortality, morbidity and functional recovery. Now thrombolytic agents are gaining acceptance in thrombotic occlusions, hence wherever possible patients with stroke should be referred to higher centers after initial first aid. Initial management at the periphery includes1. Maintenance of the airway,oxygen administration, proper positioning of the neck and control of hypertension by oral or parenteral antihypertensive drugs.It is ideal to maintain the blood pressure around 140/90 mmHg in those who are hypertensive. 463
NEPHROLOGY
ACUTE RENAL FAILURE It is potentially reversible rapid decline in the excretory function of the kidney which develops over hours to days leading to retention of nitrogenous waste products and the consequent clinical complications. ARF occurs due to a various etiological factors. The condition should be diagnosed when the urine output goes below 400mL in 24 hours and there are signs of retention of the waste products.
Management of ARF
Principles of management of ARF 1. Treatment of the underlying cause 2. Maintenance of fluid and electrolyte balance 3. Maintenance of nutritional status. 4. Monitor for life threatening complications 5. Renal replacement therapy when indicated Treatment of the Underlying Cause The cornerstone in the management of ARF is the treatment of the underlying cause. The most important factor determining the outcome is the severity of the underlying disease. For example ARF complicating sepsis in the ICU setting has a mortality of up to 70%. On the other hand, ARF following snake envenomation and leptospirosis have a mortality of only around 30 to 40 % though they are severe and they need dialysis support Prerenal ARF improves with restoration of renal perfusion, by appropriate fluid therapy. The use of vasodilators and ionotropes help to restore renal perfusion in congestive heart failure In postrenal ARF, relief of obstruction is the crucial factor influencing recovery of renal function. Specific therapy of the underlying cause of obstruction such as prostatic enlargement ensures recovery.
464
OBSTETRICS AND GYNECOLOGY

HYPEREMESIS GRAVIDARUM 1. Confirm the diagnosis of pregnancy by clinical examination. 2. Exclude other causes for vomiting like, gastritis, jaundice and diabetic ketoacidosis. 3. Check urine for sugar and acetone. 4. After making a diagnosis of hyperemesis, start IV fluids (5% or 10% dextrose, dextrose saline and Ringer lactate) until the dehydration is corrected.BP reaches normal levels ,skin turgor is restored and urine flow normalizes. 5. If vomiting is not controlled , anti-emetics like promethazine 25 mg IM, or metoclopramide 10mg IM can be given. 6. Once the patient tolerates oral feeds she must be advised to have sips of fluids. Instantly Oral Rehydration Solution ( ORS) is preferable. Oral antiemetics like doxylamine succinate(doxinate- 2mg tablets hs may be continued. 7. Exclude vesicular mole by ultrasonography in all cases of hyperemesis. ECTOPIC GESTATION Ectopic pregnancy should be suspected 1. When patient presents with abdominal pain with missed periods,with or without bleeding per vaginum (PV) 2. When products of conception are scanty during abortion or evacuation . 3. Diagnosis: a) Clinical examination : Movement of cervix is painful,the size of the uterus is less than what is expected for the period of amenorrhoea. Adnexal tenderness or mass may be palpable. If the ectopic pregnancy has ruptured, the patient will be pale and in shock b) Urine highly sensitive pregnancy test (like card test) is usually positive. c) Ultra sound examination (transvaginal ) will help in excluding intra uterine pregnancy.When ectopic pregnancy is suspected the patient should be 465
Guidelines
transfered to a referral centre with facilities for blood transfusions and surgery. In ruptured ectopic, patient should be transfered as early as possible to the referral centre, with IV line running. ANTEPARTUM HAEMORRHAGE Bleeding per vaginum after 28 completed weeks of gestation is called antepartum haemorrhage.Depending on the duration and amount of blood loss ,haemodynamic changes occurs. Management 1. Start an IV line with a wide bore needle preferably a cannula (18G) 2. Take blood for grouping, cross matching and clotting time. 3. Assess the general conditions of the patient - pulse, B.P.,respiratory rate record the rate of blood loss. 4. Sedate the patient by injection of pethidine 50-75 mg IM or morphine 5-7.5 mg IM depending on the weight of the patient. 5. Depending on the degree of hypotension and anoxia, give nasal oxygen if available, keep the foot end of the bed elevated. 6. Put in an indwelling catheter to record the urine output. 7. Make a quick examination to form a provisional diagnosis regarding the causes of antepartum haemorrhage. 8. If placenta previa is suspected avoid doing vaginal examination for confirmation. 9. Transfer the patient as quickly as possible to a centre where facilities for blood tranfusions and caesarean section are available. 10. The relatives should be informed about the seriousness of the disease and the need for blood transfusion. ECLAMPSIA 1. Take a quick history and do a quick examination to form a diagnosis (Tonic clonic convulsions - high blood pressure and oedema). 2. Give anticonvulsants (any of the following.) 1. Magnesium sulphate: 10 mL of 50% magnesium sulphate deep IM in each buttock as a loading dose using 20 guage needle Maintenance dose: 5 g every 4 h deep IM in the buttock. Keep an IV line running. 2. Phenytoin 400 mg IV should be given very slowly watching the pulse and respiration. 3. Diazepam 10 20 mg IV 466
Obstetrics and Gynecology
Transfer the patient to a referral centre with facilities for anaesthesia and caesarean section and intensive care unit facilities as quickly as possible. PRETERM LABOUR 1. Confirm that the patient is in labour by recording the regular intermittent and painful uterine contractions. 2. If pregnancy is less than 34 weeks, give tocolytics - drugs which inhibit uterine contractions. Terbutaline sulphate 250 mcg subcutaneous hourly till contraction subsides and thereafter 5 mg oral 4th hourly. 3. Give glucocorticoids IM a. Betamethasone 12mg IM 12 h 2 doses or b. Dexamethasone 6 mg IM 6 h and 4 more doses may be given further. Transfer the patient as quickly as to a centre with good facilities for managing preterm babies. If the patient cannot be monitored properly, tocolytics should not be given in the peripheral hospitals. Instead, after giving glucocorticoids, patient should be transferred to a tertiary care centre. If pregnancy is more than 34 weeks the patient should be transferred to the nearest First Referal Unit (FRU). If the patient is in advanced labour, conduct the delivery. Keep the baby as warm as possible and transfer immediately to a referal hospital. PRE- LABOUR RUPTURE OF MEMBRAN ES 1. Confirm diagnosis by giving a sterile pad, looking at the liquor or if needed, by speculum examination. 2. Make sure whether the liquor is clear, mature blood-stained or meconium stained. 3. Give parenteral antibiotics:A combination of Inj.ampicillin 500 mg IM 6 h with Inj.gentamicin 80 mg IM. 8 h is satisfactory. Metronidazole 500mg IV 8 h may be added if anaerobic infection is suspected or if pre-labour rupture of membrane is more than 24 hours duration. 4. If the gestational period is 37 weeks or more, induction of labour can be done by giving oxytocin drip or PGE2 gel. 2.5 to 5 units of oxytocin is given in 5% dextrose or normal saline infusion . PGE2 gel is applied to the cervical canal under aseptic precautions. This may have to be supplemented with oxytocin. 467
Guidelines
5. If the pregnancy less than 37 weeks duration, give antibiotics and transfer to the referal centre where preterm babies can be looked after. POSTPARTUM HAEMORRHAGE MANAGEMENT 1. Start IV line with a wide bore canula (18G) 2. Take blood for grouping and cross matching and clotting time. 3. Start I.V. fluids for volume replacement Normal saline, dextrose saline and blood volume expanders such as polygeline, are the ones usually given . 4. Give sedation with pethidine 50-75 mg IM or morphine 5-7.5 mg IM and oxygen inhalation. Keep the foot end of the bed raised by 9 inches(22 cm) if there is hypotension. Differentiate between atonic and traumatic haemorrhage. If atonic, the uterus will be flabby. Then give 1. Oxytocin 10-20 units in normal saline as I.V drip. 2. Ergometrine 0.2 mg IV 3. PGF2 alpha 250 mcg IM if bleeding persists 4. PGE1 800 mcg per rectum Traumatic postpartum haemorrhage is suspected when there is bleeding with a well contracted uterus. This should be suspected in instrumental deliveries . (vaccum extraction or forceps delivery). In traumatic postpartum haemorrhage, if there are no facilities for suturing and blood transfusions, a pressure pack should be kept in the vagina to arrest the bleeding temporarily. After giving the first aid care, the patient should be transferred to a tertiary care centre with facilities for blood - transfusion, anaesthesia and surgical intervention as quickly as possible. No time should be wasted. The patient should be transferred with IV fluid running.It is desirable to have a hospital staff accompanying the patient.
EAR,NOSE AND THROAT EMERGENCIES

EPISTAXIS Epistaxis is bleeding from the nasal cavity.It can be arterial or venous. Treatment consists of applying nasal packs dipped in adrenaline solution. Other measures include cauterization and ligation of bleeding spot in intractable cases.Hypertension which is a common cause of epistaxis 468
Ophthalmology
does not warrant any specific treatment except local measures, close monitoring, assurance and antihypertensive drugs. In selected cases sedatives may be required.
ACUTE LARYNGEAL OEDEMA DUE TO ALLERGIC ANGIOEDEMA

Patient presents with oedema of eyelids, lips or choking sensation. Ask for any history of food allergy; drug allergy; insect bite; viral infections or others. Management : Keep the airway patent . Parenteral steroids-Inj betamethasone 4- 8 mg IV. Adrenaline-1/1000 solution IM. Antihistamines Oxygen inhalation If there is progressing airway obstruction tracheostomy or tracheal intubation and ventilation.
OPHTHALMOLOGY
FOREIGN BODY IN THE EYE
On examination: Localized congestion over the bulbar conjunctiva with severe irritation.Identify the location of the foreign body by proper examination of the eye by everting the eyelids and with a proper source of light. Treatment: Wash the eye with distilled water or boiled cooled water loaded in a 5 cc syringe (without needle) with upper eye lid everted. Start antibiotic drops.If foreign body does not dislodge refer to an ophthalmologist. CHEMICAL BURNS These are common in persons who handle corrosive acids or alkalies during their occupation. Alkali burns are more dangerous than acid burns. Wash the eye with normal saline or Ringer lactate solution. Connect the drip bottle to IV. drip set and wash continuously with the upper eye lid everted. Apply antibiotic ointment. 469
Guidelines
CONJUNCTIVITIS On examination: Excessive discharge , matting of eye lashes , congestion +++ more in fornices Treatment: frequent washing, use cotton swab to clean the lid. Antibiotic drops to be used 2 hourly and refer to an ophthalmologist if there is no improvement within three days.Avoid topical steroids and topical steroid combination with the antibiotics. CORNEAL ULCER Any white spot in the eye with redness ,pain and watering should be diagnosed as corneal ulcer.Broad spectrum antibiotic drugs should be instilled into the eye hourly. Refer to opthalmologist if no improvement occurs in two days.Avoid combination preparations or exclusive preparations containing corticosteroids if corneal ulcer is suspected. RECOGNITION OF REFRACTIVE ERROR IN CHILD History of child with clumpsy handwriting, ,Disinterestedness in studies, mistakes in copying written matter from board ,strong family history of short sight. The condition can be easily recognized by testing each eye separately with the other eye covered. Early referral to ophthalmologist to make proper diagnosis and prescribing glasses is absolutely necessary to ensure proper learning facilities for the child.School medical examination programmes are available at present.
470
PART III
A. LIST OF ESSENTIAL DRUGS TO BE STOCKED IN GOVERNMENT HOSPITALS
z z z z
Primary care hospitals ( Dispensaries and mini PHCs) Secondary care hospitals ( Block PHCs and CHCs) Taluk hospitals Tertiary hospitals ( District / General hospitals and Medical college Hospitals) ESSENTIAL DRUGS LIST FOR PRIMARY CARE HOSPITALS (DISPENSARIES AND MINI PHCS)
Sl.No.
NAME OF THE DRUG
STRENGTH
PACKING
1. ANALGESICS, ANTIPYRETICS ANTINFLAMMATORY & ANTI ARTHRITICS 1.ACETYL SALICYLIC ACID TAB IP 2.ACETYL SALICYLIC ACID TAB IP 3.PARACETAMOL TAB IP 4.PARACETAMOL SYRUP IP 5.DICLOFENAC SODIUM TAB IP 6.IBUPROFEN TAB (FILM COATED) IP 2. ANTIBIOTICS&ANTIBACTERIALS 7.COTRIMOXAZOLE TAB IP 8.COTRIMOXAZOLE TAB IP 9.COTRIMOXAZOLE ORAL SUSP.IP 10.AMOXYCILLIN DISPERSIBLE TAB IP 11.AMOXYCILLIN CAP IP 12.AMOXYCILLIN CAP IP 13.DOXYCYCLINE CAP IP 14. ERYTHROMYCIN STEARATE TABLET IP 15.NORFLOXACIN TAB IP 80mg+400mg 160mg+800mg 125mg 250mg 500mg 100mg 250mg 400mg 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 471 300mg 75mg 500mg 250mg/5ml 50mg 400mg 10x14 10X14 10x10 60ml Bottle 10x10 10x10
40mg+200mg/5ml 150ml,susp
Essential Drugs
16.METRONIDAZOLE TAB IP 17.METRONIDAZOLE TAB IP 3. ANTITUBERCULAR DRUGS 18.STREPTOMYCIN INJ IP 19.RIFAMPICIN CAP IP 20.INH TAB IP 21.INH TAB IP 22.ETHAMBUTOL TAB IP 23.PYRAZINAMIDE TAB 24.RIFAMPICIN CAP IP 25.RIFAMPICIN ORAL SUS BP
200mg 400mg 1g 150mg 100mg 300mg 400mg 500mg 450mg 100mg /5ml
10x10 10x10 vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10
26.ETHAMBUTOL TAB IP 600mg 4. DRUGS ACTING ON THE RESPIRATORY TRACT 27. THEOPHYLLINE & 169.4 mg ETOPHYLLINE INJ 50.6mg 28. THEOPHYLLINE & ETOPHYLLINE TAB 23mg,77mg 29. AMINOPHYLLINE INJ IP 25mg/ml 30. SALBUTAMOL SULPHATE TAB IP 4mg 31. SALBUTAMOL NEBULISER SOLUTION 5mg/ml 32. EXPECTORANT MIXTURE, CONCENTRATED 5. ANAESTHETICS & ALLIED DRUGS 33.LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 34.ATROPINE INJ IP 0.6mg/ml 6. ANTIALLERGIC AND DRUGS USED IN ANAPHYLAXIS 35. HYDROCORTISONE SODIUM SUCCINATE INJ 100 mg 36. ADRENALINE INJ IP 1mg/ml 37. CHLORPHENERAMINE MALEATE TAB IP 4mg 38. CHLORPHENIRAMINE MALEATE INJ IP 10mg/ml 39. PROMETHAZINE INJ IP 25mg/ml 40. PREDNISOLONE TAB IP 10mg 472
2mL amp 10x10 10mlAmp 10x10 10ml 500ml Bottle 30ml vial 1 ml amp
vial 1 ml Amp 10x10 1ml amp 2ml amp 10x10
Primary Care Hospitals
7. ANTIEPILEPTIC DRUGS 41. PHENOBARBITONE TAB IP 42. PHENOBARBITONE TAB IP 43. PHENYTOIN SODIUM TAB IP 44. CARBAMAZEPINE TAB IP 8. ANTHELMINTICS 45. MEBENDAZOLE TAB IP 46.PIPERAZINE CITRATE ELIXIR IP 9. ANTIFILARIAL DRUGS 47. DIETHYLCARBAMAZINE CITRATE TAB IP 10.ANTIFUNGAL DRUGS 48. CLOTRIMAZOLE CREAM IP 49. CLOTRIMAZOLE VAG TAB IP 50. WHITFILEDS OINTMENT IP 11.ANTIMALARIAL DRUGS 51. CHLOROQUINE PHOSPHATE TAB IP 12.ANTILEPROTIC DRUGS 52.RIFAMPICIN CAP IP 53.DAPSONE TAB IP 54.CLOFAZIMINE CAP IP 13.DRUGS AFFECTING THE BLOOD 55. FOLIC ACID TAB IP 14.CARDIOVASCULAR DRUGS 56. ISOSORBIDE DINITRATE TAB IP 57. ISOSORBIDE DINITRATE TAB IP 58. ATENOLOL TAB IP 59. ATENOLOL TAB IP 60. AMLODIPINE TAB 61. AMLODIPINE TAB 62. DIGOXIN TAB IP 15.DERMATOLOGICAL DRUGS 63. SILVER SULFADIAZINE CREAM IP 64. GLYCERINE IP 65. LIQUID PARAFFIN IP 66. SALICYLIC ACID OINTMENT 67. BENZYL BENZOATE APPLICATION IP 68. GLYCERINE MAGSULPH PASTE BPC 69. POVIDONE IODINE SOLUTION IP 70. FRAMYCETIN SKIN CREAM
30mg 60mg 100mg 200mg 100mg 750mg/5ml 100mg 2% w/w 200mg
10x10 10x10 10x10 10x10 6x1 450mL 10x10 20g tube 3 tab 15 g tube 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 100g Bottle Drum Can 500g Bottle 500ml Bottle 500g Bottle 500mlBottle 20g tube 473
25mg 400mg 50mg 50mg 5mg 5mg 10mg 50mg 100mg 2.5mg 5mg 0.25mg 1%w/w 25kg 5 Litre 10% w/w 25% w/v 5% w/v 1% w/v
Essential Drugs
71. TURPENTINE LINIMENT IP 72. CALMINE LOTION IP 16.OPHTHALMIC DRUGS/ENT DRUGS 73.FRAMYCETIN EYE DROPS 74.CIPROFLOXACIN EYE/EAR DROPS 75.SALINE NASAL DROPS 17.PSYCHOTROPIC DRUGS 76. DIAZEPAM TAB IP 18.I.V FLUIDS AND ELECTROLYTES 77. SODIUM CHLORIDE 0.9% & DEXTROSE 78 DEXTROSE INJ IP 79 DEXTROSE INJ IP 80 STERILE WATER FOR INJECTION IP 19.DISINFECTANTS & ANTISEPTICS 81 CHLORHEXIDINE CETRIMIDE SOLUTION 82 CHLOROXYLENOL SOLUTION IP 20.DIURETICS 83 FRUSEMIDE TAB IP 84 FRUSEMIDE INJ IP 21.G.I.T.DRUGS 85 RANITIDINE HCL INJ IP 86 RANITIDINE HCL TAB IP 87 ALUMINIUM HYDROXIDE TAB IP 88 DOMPERIDONE TAB 89 DICYCLOMINE HCL TAB IP 90 DICYCLOMINE HCL INJ IP 91 ORS POWDER WHO, WITH CITRATE SALT 92 BISACODYL TAB IP 93 CARMINATIVE MIXTURE 22.HORMONES &ENDOCRINE DRUGS 94 GLIBENCLAMIDE TAB IP 95 METFORMIN TAB IP 96 INSULIN BOVINE, RAPID ACTING IP 97 INSULIN BOVINE, LONG ACTING IP 98 INSULIN HUMAN, RAPID ACTING 99 INSULIN HUMAN, LONG ACTING 474
500ml Bottle 500ml Bottle 0.5%w/v 0.3% w/v 0.9 % w/v 5mg 5% w/v IP 5%w/v 25%w/v 10ml 7.5%15% w/v 5% w/v 40mg 10mg/ml 50mg/2ml 150mg 500mg 10mg 10mg 10mg/ml 5 ml Bottle 5 ml Bottle 10ml Bottle 10x10 500mlBottle 500ml Bottle 25mL Amp 10mL Amp 1 L Bottle 1 L Bottle 10x10 2ml Amp 2ml Amp 10x10 10x10 10x10 10x10 2ml Amp
27.5g packet 5mg 10x10 (CPC FORMULA) 500ml Bottle 5mg 500mg 40IU/ml 40IU/ml 40IU/ml 40IU/ml 10x10 10x10 vial vial vial vial
Secondary Care Hospitals
23.IMMUNOLOGICALS 100TETANUS TOXOID INJ IP/BP 10 dose 101 ANTISNAKE VENOM FREEZE DRIED, POLYVALENT 24.VITAMINS & MINERALS 102.CALCIUM LACTATE TAB IP 300mg 103.VITAMIN B COMPLEX TAB NFI (STRONG) 104.ASCORBIC ACID TAB IP 100mg 105.MULTI. VITAMIN TAB NFI 106.VITAMINA & D CAP (HARD/SOFT) 6000/1000 IU 107.FERROUS SULPHATE TAB IP 200mg
5mL vial 10mLvial 10x10 10x10 10x10 10x10 10x10 10X10
ESSENTIAL DRUGS LIST FOR SECONDARY CARE HOSPITALS
(Blocks PHCs and CHCs)

SlNo NAME OF THE DRUG STRENGTH PACKING
1. ANALGESICS, ANTIPYRETICS, ANTI INFLAMMATORY ANTI ARTHRITIC 1. ACETYL SALICYLIC ACID TAB IP 2. ACETYL SALICYLIC ACID TAB IP 3. PARACETAMOL TAB IP 4. 5. PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP 300mg 75mg 500mg 250mg/ml 50mg 25mg/ml 10x14 10x14 10x10 60ml bottle 10x10 3ml Amp 10x10 2ml Amp 2ml Amp 1ml Amp 10x10 10x10 10x10 10x10 475
6. DICLOFENAC SODIUM INJ IP
7. IBUPROFEN TAB (FILM COATED) IP 400mg 8. PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml 9. PARACETAMOL INJ 10. TRAMADOL INJ 11. TRAMADOL TAB 2. ANTI BIOTICS & ANTI BACTERIALS 12 COTRIMOXAZOLE TAB 13 COTRIMOXAZOLE TAB 14 COTRIMOXAZOLE ORAL SUSP.IP 80mg+400mg 160mg+800mg 150mg/2ml 50mg/ml 100mg
40mg+200mg/5ml 50ml susp
15 AMOXYCILLIN DISPERSIBLE TAB IP 125mg
Essential Drugs
16 CLOXACILLIN CAP IP 17 AMOXYCILLIN CAP IP 18 AMOXYCILLIN CAP IP 19 AMPICILLIN INJ IP 20 BENZYL PENICILLIN INJ IP 21 CIPROFLOXACIN INJ IP 22 GENTAMICIN INJ IP 23 DOXYCYCLINE CAP IP 25 NORFLOXACIN TAB IP 26 CIPROFLOXACIN TAB IP 27 METRONIDAZOLE TAB IP 28 METRONIDAZOLE TAB IP 29 METRONIDAZOLE I.V INJ IP 3. ANTITUBERCULAR DRUGS 30 STREPTOMYCIN INJ IP 31 RIFAMPICIN CAP IP 32 INH TAB IP 33 INH TAB IP 34 ETHAMBUTOL TAB IP 35 PYRAZINAMIDE TAB 36 RIFAMPICIN CAP IP 37 RIFAMPICIN ORAL SUSP. IP 38 ETHAMBUTOL TAB IP 39 THEOPHYLLINE & ETOPHYLLINE INJ 41 AMINOPHYLLINE INJ IP 42 SALBUTAMOL SULPHATE TAB IP 43 SALBUTAMOL NEBULISER SOLUTION 476
250mg 250mg 500mg 500mg 10Lakhs Units 2mg/ml 80mg/2ml 100mg 400mg 500mg 200mg 400mg 5mg/ml 1g 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg
10x10 10x10 10x10 Vial Vial 100ml I.V Amp 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle Vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10
24 ERYTHROMYCIN STEARATE TAB IP 250mg
4. DRUGS ACTING THE RESPIRATORY TRACT 50.6mg 169.4mg 2ml Amp 10x10 10ml Amp 10x10 10mAmp 25mg/ml 4mg 5mg/ml
40 THEOPHYLLINE ETOPHYLLINE TAB 23mg 77 mg
44 TERBUTALINE INJ IP 45 EXPECTORANT MIXTURE CONCENTRATED 5. ANAESTHETICS & ALLIED DRUGS 46 LIGNOCAINE HYDROCHLORIDE GEL IP 47 LIGNOCAINE HYDROCHLORIDE INJ 48 ATROPINE INJ IP
0.5mg/ml
1ml Amp 500 bottle
2%w/v 2%w/v 0.6mg/ml
30ml vial 30ml vial 1ml Amp 2ml vial Vial 10x10 1ml Amp 10x10 1ml Amp 2ml amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x2ml 10x10 6x1 450ml 477
6. ANTI ALLERGICS AND DRUGS USED IN ANAPHYLAXIS 49 DEXAMETHASONE SODIUM INJ IP 4mg/ml 50 HYDROCORTISONE SODIUM SUCCINATE INJ 51 DEXAMETHASONE TAB IP 52 ADRENALINE INJ IP 53 CHLORPHENIRAMINE MALETE TAB IP 54 CHLORPHENIRAMINE MALEATE INJ IP 55 PROMETHAZINE INJ IP 56 CETIRIZINE TAB 57 PREDNISOLONE TAB IP 7. ANTI EPILEPTIC DRUGS 58 PHENOBARBITONE TAB IP 59 PHENOBARBITONE TAB IP 60 PHENYTOIN SODIUM TAB IP 61 CARBAMAZEPINE TAB IP 62 SODIUM VALPROATE TAB IP 63 DIAZEPAM INJ IP 64 SODIUM VALPROATE TAB 8. ANTHELMINTICS 65 MEBENDAZOLE TAB IP 66 PIPERAZINE CITRATE ELIXIR IP 100mg 750mg/5ml 30mg 60mg 100mg 200mg 200mg 5mg/ml 500mg 100mg 0.5mg 1mg/ml 4mg 10mg/ml 25mg/ml 10mg 10mg
Essential Drugs
9. ANTIFILARIAL DRUGS 67 DIETHYLCARBAMAZINE TAB IP 10.ANTIFUNGAL DRUGS 68 CLOTRIMAZOLE CREAM IP 69 CLOTRIMAZOLE VAG TAB IP 70 WHITFIELDS OINTMENT IP 11.ANTIMALARIAL DRUGS 71 CHLOROQUINE PHOSPHATE TAB IP 12.ANTILEPROTIC DRUGES 72 RIFAMPICIN CAP IP 73 CLOFAZIMINE CAP IP 74 DAPSONE TAB IP 13.ANTIPARKINSONIAN DRUGS 75 TRIHEXYPHENIDYL TAB IP 14. DRUGS AFFECTING THE BLOOD 76 FOLIC ACID TAB IP 15.CARDIOVASCULAR DRUGS 77 ISOSORBIDE DINTIRATE TAB IP 78 ISOSORBIDE DINTRATE TAB IP 79 NIFEDIPINE TAB IP 80 ATENOLOL TAB IP 81 ENALAPRIL MALEATE TAB 82 AMLODIPINE TAB 83 DIGOXIN TAB IP 84 HYDROCHLOROTHIAZIDE TAB IP 16.DERMATOLOGICAL DRUGS 85 SILVER SULFADIAZINE CREAM IP 86 GLYCERINE IP 87 LIQUID PARAFFIN IP 88 SALICYLIC ACID OINTMENT 89 BENZYL BENZOATE APPLICATION IP 478 1%w/v 25kg 5L 10% w/w 25%w/v 100g bottle drum can 500g bottle 500ml bottle 5mg 10mg 10mg 50mg 2.5mg 5mg 0.25mg 25mg 10x10 10x10 10x10 10x14 10x10 10x10 10x10 10x10 5mg 10x10 2mg 10x10 400mg 50mg 50mg 10x10 10x10 10x10 25mg 10x10 2%w/v 200mg 20g tube 3tab 15g tube 100mg 10x10
90 GLYCERINE MAGSULPH BPC 91 BETAMETHASONE VALERATE CREAM1% w/w 92 POVIDONE IODINE SOLUTION 93 FRAMYCETIN SKIN CREAM 94 TURPENTINE LINIMENT IP 17.OPHTHALMIC DRUGS/EAR DROPS 95 FRAMYCETIN EYE DROPS 96 CIPROFLOXACIN EYE/EAR DROPS 97 SODIUM BICARBONATE EAR DROPS BPC 98 SALINE NASAL DROPS 99 XYLOMETAZOLINE NASAL DROPS 18.OBSTETRIC & GYNAECOLOGY DRUGS 100 OXYTOCIN INJ IP 101 METHYLERGOMETRIN MALEATE INJ 102 CARBOPROST INJ 19.PSYCHOTROPIC DRUGS 103DIAZEPAM TAB IP 104 CHLORPROMAZINE TAB IP 105 CHLORPROMAZINE TAB IP 106 IMIPRAMINE TAB IP 107 AMITRIPTYLINE TAB IP 108 NITRAZEPAM TAB IP 109 ALPRAZOLAM TAB 110 ALPRAZOLAM TAB 111 HALOPERIDOL TAB 112 CHLORDIAZEPOXIDE TAB 20.I.V FLUIDS AND ELECTROLYTES 113 SODIUM CHLORIDE INJ IP 114 SODIUM CHLORIDE 0.9% & DEXTROSE 0.9%w/v 5% w/v 5mg 50mg 100mg 25mg 25mg 5mg 0.25mg 0.5mg 5mg 10mg 5 IU/ml 200mcg/ml 125 mcg/0.5ml 0.9%w/v 0.1%w/v 0.5%w/v 0.3%w/v 5% w/v 1% w/w
500g bottle 5g tube 500ml bottle 20g tube 500ml bottle 5ml bottle 5ml bottle 10ml bottle 10ml bottle 10ml bottle 1ml Amp 1ml Amp 0.5ml Amp 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 500ml bottle 500ml bottle 479
Essential Drugs
115 DEXTROSE INJ IP 116 DEXROSE INJ IP 117 RINGER LACTATE INJ IP 118 STERILE WATER FOR INJECTION IP 21.DISINFECTANTS & ANTISEPTICS 119CHLORHEXIDINE/ CETRIMIDE SOLUTION 120SURGICAL SPIRIT 121HYDROGEN PEROXIDE SOLUTION IP 122CHLOROXYLENOL SOLUTION IP 22.DIURETICS 123 FRUSEMIDE TAB IP 124 FRUSEMIDE INJ IP 23.G.I T.DRUGS 125 RANITIDINE HCL INJ IP 126 RANITIDINE HCL TAB IP 127 ALUMINIUM HYDROXIDE TAB IP 128 OMEPRAZOLE CAP 129 METOCLOPRAMIDE INJ 130 DICYCLOMINE HCL TAB IP 131 DICYCLOMINE HCL INJ IP 132 ORS POWDER WHO WITH CITRATE SALT 133 BISACODYL TAB IP 134 CARMINATIVE MIXTURE 135 DOMPERIDONE TAB IP 24. HORMONES & ENDOCRINE DRUGS 136 GLIBENCLAMIDE TAB IP 137 GLIBENCLAMIDE TAB IP 138 METFORMIN TAB 139 INSULIN BOVINE, RAPID ACTING IP 480
5% w/v 25% w/v
500ml bottle 25ml Amp 500ml 10ml Amp
7.5% 15% w/v 70% v/v 20%w/v 5%w/v 40mg 10mg./ml 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 10mg/ml 27.5g 5mg CPC Formula 10mg 5mg 2.5mg 500mg 40 IU/ml
1L bottle 500ml bottle 1L bottle 1L bottle 10 x 10 2mL Amp 2mL Amp 10 x 10 10 x 10 10 x 10 2mL Amp 10 x 10 2mL Amp Packet 10 x 10 500mL bottle 10 x 10 10 x 10 10 x 10 10 x 10 vial
Taluk Hospitals
140 INSULIN BOVINE, LONG ACTING IP 141 INSULIN HUMAN, RAPID ACTING 142 INSULIN HUMAN, LONG ACTING 143 THYROXINE SODIUM TAB IP 25.IMMUNOLOGICALS 144 TETANUS TOXOID INJ IP/BP 145 TETANUS IMMUNOGLOBULIN USP 146 ANTI SNAKE VENOM FREEZE DRIED, POLYVALENT IP 147 RABIES VACCINE HUMAN, CELL CULTURE IP 148 TRIPLE ANTIGEN IP 149 POLIO VACCINE, ORAL 26.VITAMINS & MINERALS 150 CALCIUM LACTATE TAB IP 151 VITAMIN B COMPLEX TAB NF1 (STRONG) 152 VITAMIN B COMPLEX INJ NF1 153 ASCORBIC ACID TAB IP 154 CALCIUM GLUCONATE INJ IP 155 MULTI VITAMIN TAB NFI
40 IU/ml 40 IU/ml 40 IU/ml 0.1mg 10 dose 250 IU/vial 10ml 2.5 IU 0.5ml /dose 20 doses 300mg
vial vial vial 10 x 10 5mL vial vial vial vial 0.5 mL Amp vial 10 x 10 10 x 10
10ml 100mg 10% w/v
vial 10 x 10 10 mL Amp 10 x 10 10 x 10 10 x 10
156 VITAMIN A & D CAP (HARD/SOFT) 6000IU/1000IU 157 FERROUS SULPHATE TAB IP 200mg
ESSENTIAL DRUG LIST FOR TALUK HOSPITAL

SI.No. NAME OF THE DRUG STRENGTH PACKING
1. ANALGESICS, ANTIPYRETICS, ANTINFLAMMATORY, ANTIARTHRITIC 1 2 ACETYL SALCYLIC ACID TAB IP ACETYL SALICYLIC ACID TAB IP1 300mg 75mg 10x14 10x14 481
Essential Drugs
3 4 5 6 7 8 9
PARACETAMOL TAB IP PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP DICLOFENAC SODIUM INJ IP
500mg 250mg/ml 50mg 25mg/ml
10x10 60mlBottle 10x10 3ml Amp 10x10 2ml Amp 1ml Amp 2ml Amp 1ml amp 1ml Amp 10x10 10x10 10x10 50ml susp 10x10 10x10 10x10 10x10 Vial Vial vial 100ml IV Amp 10x10 10x10 10x10 10x10 30ml bottle 10x10 10x10
IBUPROFEN TAB (FILM COATED ) IP 400mg PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml PENTAZOCINE LACTATE INJ IP 30mg/ml 150mg/2ml 15mg/ml 50mg/ml 100mg 80mg+400mg 160mg +800mg 40mg+200mg/ 5 mL 250mg 250mg 250mg 500mg 10 Lakhs units 250 mg 2mg/ml 80mg/2ml 100mg 400mg 500mg 125mg/5ml 200mg 400mg
10 PARACETAMOL INJ 11 MORPHINE SULPHATE INJ IP 12 TRAMADOL INJ 13 TRAMADOL TAB 2. ANTIBIOTICS & ANTIBACTERIALS 14 COTRIMOXAZOLE TAB IP 15 COTRIMOXAZOLE TAB IP 16 COTRIMOXAZOLE ORAL SUSP.IP
17 AMOXYCILLIN DISPERSIBLE TAB IP 125mg 18 AMOXYCILLIN CAP IP 19 CLOXACILLIN CAP IP 20 AMPICILLIN CAP IP 21 AMPICILLIN INJ IP 22 BENZYL PENICILLIN INJ IP 23 CEFOTAXIME SODIUM INJ IP 24 CIPROFLOXACIN INJ IP 25 GENTAMICIN INJ IP 26 DOXYCYCLINE CAP IP 28 NORFLOXACIN TAB IP 29 CIPROFLOXACIN TAB IP 30 CEPHALEXIN ORAL SUS (DRY) IP 31 METRONIDAZOLE TAB IP 32 METRONIDAZOLE TAB IP 482
Taluk Hospitals
33 METRONIDAZOLE INJ IP 34 CEFOTAXIME INJ IP 35 CEPHALEXIN CAP IP 3. ANTITUBERCULAR DRUGS 36 STREPTOMYCIN INJ IP 37 RIFAMPICIN CAP IP 38 INH TAB IP 39 INH TAB IP 40 ETHAMBUTOL TAB IP 41 PYRAZINAMIDE TAB 42 RIFAMPICIN CAP IP 43 RIFAMPICIN ORAL SUSP BP 44 ETHAMBUTOL TAB IP 45 THEOPHYLLINE & ETOPHYLLINE INJ 46 THEOPHYLLINE & ETOPHYLLINE tab 47 AMINOPHYLLINE 48 SALBUTAMOL SULPHATE TAB IP 49 SALBUTAMOL NEBULISER SOLUTION 50 Terbutaline Inj IP 51 BUDESONIDE RESPIRATORY SOLUTION 52 EXPECTORANT MIXTURE CONCENTRATED 5. ANAESTHETICS & ALLIED DRUGS 53 KETAMINE INJ IP 54 HALOTHANE USP LIQUID 55 LIGNOCAINE HYDROCHLORIDE GEL IP
5mg/ml 1g 250mg 1gm 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg 50.6mg 1669.4mg 23mg,77mg 25mg/ml 4mg 5mg/mL 0.5mg/ml 100mcg/mdi
100mL bottle Vial 10x10 vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml Bottle 10x10
4. DRUGS ACTING ON RESPIRATORY TRACT 2ml amp 10 x 10 10ml amp 10x10 10mL 1ml amp 200mdi 500ml bottle 50mg/ml 200ml 2% 10ml vial bottle tube 30g 483
Essential Drugs
56 LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 57 LIGNOCAINE HCL & DEXTROSE INJ IP 58 BUPIVACAINE inj IP 59 ATROPINE INJ IP 60 NEOSTIGMINE METHYL SULPHATE INJ IP 61 PANCURONIUM BROMIDE INJ BP 62 PROPOFOL INJ 63 PROPOFOL INJ 64 SODIUM BICARBONATE INJ IP 65 SUCCINYL CHOLINE CHLORIDE INJ IP 66 THIOPENTONE SODIUM INJ IP 67 OXYGEN IP 68 NITROUS OXIDE IP 6. ANTIALLERGICS & DRUGS USED IN ANAPHYLAXIS 69 HYDROCORTISONE SUCCINATE INJ 100mg 70 DEXAMETHASONE TAB IP 71 BETAMETHAZONE SODIUM INJ IP 72 ADRENALINE INJ IP 73 CHLORPHENIRAMINE MALEATE TAB IP 74 CHLORPHENIRAMINE MALEATE TAB IP 75 CHLORPHENIRAMINE MALEATE INJ IP 76 PROMETHAZINE INJ IP 77 CETIRIZINE TAB 78 PREDNISOLONE TAB IP 79 METHYL PREDNISOLONE ACETATE INJ IP 484 0.5mg 4 mg/mL 1mg/ml 4mg 2mg 10mg/ml 25mg/ml 10mg 10mg 40mg/ml 50mg & 75mg 0.5% 0.6mg/ml 0.5 mg/ml 2mg/ml 1% w/v 1%w/v 7,5% w/v 50mg/ml 0.5g
30 ml 2ml amp 4ml amp 1ml amp 1ml amp 2ml amp 20ml Amp 50ml amp 10ml Amp 10ml vial vial
10x10 10x10 1mL amp 1ml amp 10x10 10x10 1ml amp 2ml amp 10x10 10x10 1ml amp
Taluk Hospitals
7. ANTIDOTES AND OTHER SUBSTANCES IN POISONING 80 ATROPINE SULPHATE INJ IP 81 ACTIVATED CHARCOAL TAB 82 NALOXONE INJ 83 PRALIDOXIME INJ IP 8. ANTIEPILEPTIC DRUGS 84 PHENOBARBITONE TAB IP 85 PHENOBARBITONE TAB IP 86 PHENYTOIN SODIUM TAB IP 87 CARBAMAZEPINE TAB IP 88 SODIUM VALPROATE TAB 89 DIAZEPAM INJ IP 90 PHENYTOIN SODIUM INJ IP 91 SODIUM VALPROATE TAB 9. ANTHELMINTICS 92 MEBENDAZOLE TAB IP 93 PIPERAZINE CITRATE ELIXIR IP 10.ANTIFILARIAL DRUGS 94 DIETHYLCARBAMAZINE CITRATE TAB IP 11.ANTIFUNGAL DRUGS 95 GRISEOFULVIN TAB IP 96 KETOCONAZOLE TAB IP 97 CLOTRIMAZOLE CREAM IP 98 CLOTRIMAZOLE VAG TAB IP 99 WHITFIELDS OINTMENT IP 12. ANTIMALARIAL DRUGS 100 CHLOROQUINE PHOSPHATE TAB IP 101 QUININE INJ 102 PRIMAQUINE TAB IP 25mg 300mg/ml 7.5mg 10x10 2ml Amp 10x10 485 125mg 200mg 2%w/w 200mg 15g 10x10 10x10 5gm 3tab tube 100mg 10x10 100mg 750mg/5ml 6x1 450ml Bottle 30mg 60mg 100mg 200mg 200mg 5mg/ml 50mg/ml 500mg 10x10 10x10 10x10 10x10 10x10 2ml amp 2ml amp 10x10 0.6mg/ml 500mg 400mg/ml 1g 100ml 10x10 1mlamp vial
Essential Drugs
103 SULFADOXINE & PYRIMETHAMINE TAB IP 104 ARTEMETHER INJ 13.ANTIVIRALDRUGS/ ANTIAIDS 105 ACYCLOVIR TAB 14.ANTILEPROTIC DRUGS 106 107 CLOFAZIMINE CAP IP DAPSONE TAB IP
500mg+25mg 80mg/ml 200mg 50mg 50mg 2mg 10mg/100mg 100mcg/ml 5mg 10mg/ml
10x10 1ml Amp 10x10 10x10 10x10 10x10 10x10 2ml Amp 10x10 1ml Amp 500ml Bottle
15.ANTIPARKINSONISM DRUGS 108 TRIHEXYPHENIDYL TAB IP 109 CARBIDOPA 10mg+ LEVODOPA 100mg TAB IP 16. DRUGS AFFECTING THE BLOOD 110 CYANOCOBALAMIN INJ IP 111 FOLIC ACID TAB IP 112 PHYTOMENADIONE (VITK1) INJ 113 DEXTRAN 40 WITH SODIUM CHLORIDE 0.9% INFUSION 17.CARDIOVASCULAR DRUGS 114 ISOSORBIDE DINITRATE TAB IP 115 ISOSORBIDE DINITRATE TAB IP 117 ISOSORBIDE -5MONONITRATE TAB 118 DILTIAZEM TAB IP 119 ATENOLOL TAB IP 120 ATENOLOL TAB IP 121 ENALAPRIL MALEATE TAB 122 METHYL DOPA TAB IP 123 ENALAPRIL MALEATE TAB 124 AMLODIPINE TAB 125 AMLODIPINE TAB 486 5mg 10mg 10x10 11x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 10x10 10x10
116 ISOSORBIDE 5 MONONIRATE TAB 10mg 20mg 30mg 50mg 100mg 2.5mg 250mg 5mg 2.5mg 5mg
Taluk Hospitals
126 DIGOXIN TAB IP 127 DOPAMINE HCL INJ USP 128 DOBUTAMINE HCL INJ 129 130 METOPROLOL INJ 131 METOPROLOL TAB IP 132 METOPROLOL TAB IP 18.DERMATOLOGICAL DRUGS 133 SILVER SULFADIAZINE CREAM IP 134 GLYCERINE IP 135 LIQUID PARAFFIN IP 136 SALICYLIC ACID OINTMENT 137 BENZYL BENZOATE APPLICATION IP 138 GLYCERINE MAGSULPH BPC
0.25mg 40mg/ml 50mg/ml 5mg/ml 25mg 50mg 1% w/w 25kg 5 Litre 10% w/w 25%w/v
10x10 5ml 5ml amp 10x10 1ml amp 10x10 10x10 100g/bottle Drum Can 500g bottle 500ml bottle 500g bottle 25gm tub 5gm ube 100mlBottle 500ml bottle 20 g tube 500ml bottle
HYDROCHLOROTHIAZIDE TAB IP 25mg
139 POVIDONE IODINE OINTMENT IP 5%w/w 140 BETAMETHASONE VALERATE CREAM 141 GAMMA BENZENE HEXACHLORIDE SOLUTION 142 POVIDONE IODINE SOLUTION 143 FRAMYCETIN SKIN CREAM 144 TURPENTINE LINIMENT IP 19.OPHTHALMIC DRUGS/EAR/NASAL DROPS 145 FRAMY CETIN EYE DROPS 147 148 150 0.5%w/v 1%w/w 1%w/v 5%w/v 1%w/w
5ml Bottle 5ml bottle 5g tube 5ml bottle 5ml bottle 5ml bottle 5ml bottle 487
146 CIPROFLOXACIN EYE/EAR DROPS 0.3%w/v CIPROFLOXACIN EYE OINTMENT 0.3%w/w PILOCARPINE EYE DROPS TROPICAMIDE EYE DROPS 0.5w/v 0.5%w/v 1%w/v 0.1%w/v
149 TIMOLOL MALEATE DYE DROPS 151 BETAMETHASONE EYE DROPS
Essential Drugs
152 SODIUM BICARBONATE EAR DROPS BPC 153 XYLOMETAXOLINE NASAL DROPS IP 0.1%w/v
10ml bottle 10ml bottle
154 CHLORAMPHENICOL APPLICAPS 155 OXYTOCIN INJ IP 156 157 158 159 PROSTAGLANDIN INJ METHYLERGOMETRINE MALEATE TAB IP
1%w/v (250mg/cap) 50/bottle 5 IU/ml 250mcg/ml 0.125mg 1ml Amp 1ml Amp 10x10 1ml Amp 10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 1ml Amp 1mlAmp 10x10 10x10 500ml bottle 500ml Bottle
20.OBSTETRIC AND GYNAECOLOGY DRUGS
METHYLERGOMETRINEMALEATE INJ 200mcg/ml POVIDONE IODINE VAGINAL PESSARIES DIAZEPAM TAB IP CHLORPROMAZINE TAB IP AMITRIPTYLINE TAB IP NITRAZEPAM TAB IP ALPRAZOLAM TAB ALPRAZOLAM TAB FLUOXETINE CAP FLUOXETINE CAP HALOPERIDOL TAB CHLORDIAXEPOXIDE TAB HALOPERIDOL INJ CLOZAPINE TAB CLOZAPINE TAB SODIUM CHLORIDE INJ IP SODIUM CHLORIDE 0.9 % DEXTROSE 5% w/v INJ IP 200mg 5mg 50mg 25mg 5mg 0.25mg 0.5mg 10mg 20mg 5mg 10mg 5mg/ml 25mg 100mg 0.9%w/v 0.9%, 5%w/v
21. PSYCHOTROPIC DRUGS 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 488
FLUFENAZINE DECANOATE INJ IP 25mg/ml
22. IV FLUIDS & ELECTROLYTES
Taluk Hospitals
176 177 178 179 180 181 182
DEXTROSE INJ IP DEXTROSE INJ IP DEXTROSE INJ IP DEXTROSE INJ IP RINGER LACTATE INJ IP MANNITOL INJECTION IP STERILE WATER FOR IN JECTION IP CHLORHEXIDINE & CETRIMIDE SOLUTION
5%w/v 10%w/v 50%w/v 25%w/v 500ml 20%w/v 10ml
500mll bottle 500ml bottle 25mlAmp 25ml Amp Bottle 250ml bottle Amp
23. DISINFECTANTS & ANTISEPTICS 183 7.5% /15% w/v 70% w/v 20% w/v 7.5%w/v 1 L bottle 500ml bottle 1Lbottle 500ml Bottle 1Lbottle 1L bottle 10x10 2ml Amp 10x10 10x10 2ml Amp 10x10 10x10 10x10 2ml amp 10x10 10mlvial 10x10 10x10 489
184 SURGICAL SPIRIT 185 HYDROGEN PEROXIDE SOLUTION IP 186 187 188 189 190 191 192 POVIDONE IODINE SCRUB
CHLOROXYLENOL SOLUTION IP 5%w/v CHLOROXYLENOL SOLUTION IP 5%w/v FRUSEMIDE TAB IP FRUSEMIDE INJ IP SPIRONOLACTONE TAB IP SPIRONOLACTONE TAB IP 40mg 10mg/ml 25mg 100mg 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 5mg/ml 10mg 10mg
24.DIURETICS
25.G.I.T. DRUGS 193 RANITIDINE HCL INJ IP 194 RANITIDINE HCL TAB IP 195 196 197 198 199 200 201 ALUMINIUM HYDROXIDE TAB IP OMEPRAZOLE CAP METOCLOPRAMIDE INJ METOCLOPRAMIDE TAB METOCLOPRAMIDE INJ DOMPERIDONE TAB DICYCLOMINE HCL TAB IP
Essential Drugs
202 203 204 205 206
DICYCLOMINE HCL INJ IP ORS POWDER WHO WITHCITRATE SALT BISACODYL TAB IP CARMINATIVE MIXTURE (CPC FORMULA) SYRUP LACTULOSE
10mg/mL 27.5g 5mg
2ml amp Packet 10x10 500ml Bottle
667mg/ml 5mg 2.5mg 500mg 5mg
100ml Bottle 10x10 10x10 10x10 10x10 40 IU/ml 40 IU/ml Vial Vial 10x10 5ml vial Vial Vial 10 mlVial Vial Vial
26.HORMONES & ENDOCRINE DRUGS 207 GLIBENCLAMIDE TAB IP 208 GLIBENCLAMIDE TAB IP 209 METFORMIN TAB 210 GLIPIZIDE TAB 212 213 214 215 216 217 218 219 220 221 222 223 225 490
211 INSULIN BOVINE, RAPID ACTING IP INSULIN BOVINE LONG ACTING IP INSULIN HUMAN, RAPID ACTING 40 IU/ml INSULIN HUMAN, LONG ACTING 40 IU/ml THYROXINE SODIUM TAB IP TETANUS TOXOID INJ IP/BP TETANUS IMMUNOGLOBULIN USP HUMAN ANTID IMMUNOGLOBULIN USP ANTISNAKE VENOM FREEZE DRIED POLYVALENT RABIES VACCINE HUMAN, CELL CULTURE HEPATITIS B VACCINE IP HEPATITIS B VACCINE IP POLIO VACCINE, ORAL 250 IU 10 mcg/ml 20 mcg/ml 20 doses 0.5ml dose 0.1mg 10 dose 250 IU 250 mcg
27.IMMUNOLOGICALS
Vial 0.5ml amp 1ml amp 10ml 0.5ml Amp 2ml Amp
224 TRIPLE ANTIGEN IP
ANTIRABIES IMMUNOGLOBULIN HUMAN 150IU/ml
Tertiary Hospitals
28.VITAMINS & MINERALS 226 CALCIUM LACTATE TAB IP 227 VITMINE B COMPLEX TAB NFI (STRONG) 228 230 231 232 233 234 VITAMIN B COMPLEX INJ NFI 100mg 10%w/v CALCIUM GLUCONATE INJ IP MULTIVITAMIN TAB NFI FERROUS SULPHATE TAB IP THIAMINE HCL INJ IP 200mg 100mg/ml 229 ASCORBIC ACID TAB IP 300mg 10x10 10x10 10ml Amp 10x10 10ml amp 10x10 10x10 1ml Amp
VITAMIN A & D CAP (HARD/SOFT) 6000 IU/1000 IU 10x10
ESSENTIAL DRUGS LIST FOR TERTIARY HOSPITAL (DISTRICT /GENERAL HOSPITALS & MEDICAL COLLEGE HOSPITALS) Sl No NAME OF THE DRUG STRENGTH PACKING
1. ANALGESICS, ANTI PYRETICS,ANTI INFLAMMATORY & ANTI ARTHRITICS 1. ACETYL SALICYLIC ACID TAB IP 2 3 4 5 6 7 8 9 ACETYL SALICYLIC ACID TAB IP PARACETAMOL TAB IP PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP DICLOFENAC SODIUM INJ IP 300mg 75mg 500mg 250mg/ml 50mg 25mg/ml 10X14 10X14 10X10 60mL Bottle 10x10 3ml Amp 10x10 2ml amp 1ml Amp 2ml Amp 1ml Amp 1ml Amp 10x10 10x10 10x10 491
IBUPROFEN TAB (FILM COATED) IP 400mg PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml PENTAZOCINE LACTATE INJ IP 30mg/ml 150mg/2ml 15mg/ml 50mg/ml 100mg 100mg 500mg
10 PARACETAMOL INJ 11 MORPHINE SULPHATE INJ IP 12 TRAMADOL INJ 13 TRAMADOL TAB 14 ALLOPURINOL TAB IP 15 SULFASALAZINE TAB
Essential Drugs
2. ANTIBACTERIALS 16 COTRIMOXAZOLE TAB IP 17 COTRIMOXAZOLE TAB IP 18 COTRIMOXAZOLE ORAL SUSP IP 20 AMOXYCILLIN CAP IP 21 CLOXACILLIN CAP IP 22 AMPICILLIN CAP IP 23 AMPLICILLIN INJ IP 24 BENZYL PENICILLIN INJ IP 25 BENZATHINE PENICILLIN INJ IP 26 CEFOTAXIME SODIUM INJ IP 27 CIPROFLOXACIN INJ IP 28 GENTAMICIN INJ IP 29 FORTIFIED PROCAINE PENICILLIN IP 30 DOXYCYCLINE CAP IP 32 NORFLOXACIN TAB IP 33 OFLOXACIN TAB 34 OFLOXACIN INJ 35 CEFUROXIME INJ IP 36 CEFUROXIME INJ IP 37 AMIKACIN SULPHATE INJ IP 38 CIPROFLOXACIN TAB IP 39 CEPHALEXIN ORAL SUS (DRY)IP 40 METRONIDAZOLE TAB IP 41 METRONIDAZOLEL TAB IP 42 METRONIDAZOLE INJ IP 43 TETRACYCLINE CAP IP 44 CEFOTAXIME INJ IP 45 VANCOMYCIN INJ 492 80mg+400mg 160mg+800mg 10x10 10x10 10x10 10x10 10x10 10x10 Vial Vial Vial Vial 100ml vial Amp Vial 10x10 10x10 10x10 10x10 100ml bottle Vial Vial 2ml Vial 10x10 30ml bottle 10x10 10x10 100ml bottle 10x10 Vial Vial
40mg+200mg/5mL 50ml susp 250mg 250mg 250mg 500mg 10lakhs units 12 Lakhs Units 250mg 2mg/ml 80mg/2ml 500000IU 100mg 400mg 200mg 2mg/ml 250mg 750mg 250mg/ml 500mg 125mg/5ml 200mg 400mg 5mg/ml 250mg 1g 500mg
19 AMOXYCILLIN DISPERSIBLE TAB IP 125mg
Tertiary Hospitals
46 AZITHROMYCIN TAB 47 CEPHALEXINE CAP IP 48 CEFPIROME INJ 49 CLINDAMYCIN INJ 3. ANTI TUBERCULAR DRUGS 50 STREPTOMYCIN INJ IP 51 RIFAMPICIN CAP IP 52 INH TAB IP 53 INH TAB IP 54 ETHAMBUTOL TAB IP 55 PYRAZINAMIDE TAB 56 RIFAMPICIN CAP IP 57 RIFAMPICIN ORAL SUS BP 58 ETHAMBUTOL TAB IP 59 THEOPHYLLINE & ETOPHYLLINE INJ 60 THEOPHYLLINE & ETOPHYLLINE TAB 61 AMINOPYLLINE INJ IP 62 ALBUTAMOL SULPHATE TAB IP 63 SALBUTAMOL NEBULISER SOLUTION 64 TERBUTALINE INJ IP 65 BUDESONIDE RESPIRATORY SOLUTION 5. ANAESTHETICS & ALLIED DRUGS 67 KETAMINE INJ IP 68 HALOTHANE USP LIQUID 69 LIGNOCAINE HYDROCHLORIDE GEL IP
250mg 250mg 1g 300mg 1gm 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg
10x10 10x10 Vial 2ml Amp Vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10
4. DRUGS ACTING ON THE RESPIRATORY TRACT 50.6mg,169mg-2ml 23mg,77mg 25mg/ml 4mg 5mg/ml 0.5mg/ml 100mcg/mdi 2ml Amp
10x10 10mlAmp 10x10 10ml 1ml Amp 200mdi 500ml bottle 10ml vial Bottle Tube 30gm 493
66 EXPECTORANT MIXTURE CONCENTRATED 50mg/ml 200ml 2%
Essential Drugs
70 LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 71 LIGNOCAINE HCL & DEXTROSE INJ IP 72 BUPIVACAINE INJ IP 73 ATROPINE INJ IP 74 NEOSTIGMINE METHYL SULPHATE INJ IP 75 PANCURONIUM BROMIDE INJ BP 76 PROPOFOL INJ 77 PROPOFOL INJ 78 SODIUM BICARBONATE INJ IP 79 SUCCINYL CHOLINE CHLORIDE INJ IP 80 THIOPENTONE SODIUM INJ IP 81 NITROUS OXIDE IP 82 OXYGEN IP 6.ANTIALLERGIC AND DRUGS USED IN ANAPHYLAXIS 83 DEXAMETHASONE SODIUM INJ IP 84 HYDROCORTISONE SODIUM SUCCINATE INJ 85 DEXAMETHASONE TAB IP 86 BETAMETHASONE SODIUM INJ IP 87 ADRENALINE INJ IP 88 CHLORPHENIRAMINE MALEATE TAB IP 89 CHLORPHENIRAMINE MALEATE INJ IP 90 PROMETHAZINE INJ IP 91 CETIRIZINE TAB 92 PREDNISOLONE TAB IP 93 METHYL PREDNISOLONE SODIUM SUCCINATE INJ 94 METHYL PREDNISOLONE ACETATE INJ IP 494 4mg/ml 100mg 0.5mg 4mg/ml 1mg/ml 4mg 10mg/ml 25mg/ml 10mg 10mg 500mg 40mg/ml 50mg &75mg 0.5% 0.6mg/ml 0.5mg/ml 2mg/ml 1% w/v 1% w/v 7.5gm% w/v 50mg/ml 0.5g
30ml vial 2ml Amp 4ml Amp 1ml Amp 1ml Amp 2ml Amp 20ml Amp 50ml vial 10ml Amp 10ml vial vial
2ml vial Vial 10x10 1ml amp 1m amp 10x10 1ml amp 2ml amp 10x10 10x10 Vial 1ml amp
Tertiary Hospitals
7. ANTIDOTES AND OTHER SUBSTANCES IN POISONING 95 ATROPINE SULPHATE INJ IP 0.6mg/ml 96 ACTIVATED CHARCOAL POWDER IP 50g 97 NALOXONE INJ 400mcg/ml 98 PRALIDOXIME INJ IP 1g 99 PENICILLAMINE CAP IP 250mg 100 DESFERRIOXAMINE INJ 500mg 101 N-ACETYL CYSTEINE INJ 200mg/ml 102 DISULFIRAM TAB 250mg 103 DIMERCAPROL INJ IP 50mg/ml 104 SODIUM CALCIUM EDETATE INJ 200mg/ml 105 SODIUM NITRITE INJ 30mg/ml 106 SODIUM THIOSULPHATE INJ 250mg/ml 107 METHYLENE BLUE INJ 10mg/ml 8. ANTIEPILEPTIC DRUGS 108 PHENOBARBITONE TAB IP 109 PHENOBARBITONE TAB IP 110 PHENOBARBITONE SODIUM INJ 111 PHENYTOIN SODIUM TAB IP 112 CARBAMAZEPINE TAB IP 113 SODIUM VALPROATE TAB IP 114 DIAZEPAM INJ IP 115 PHENYTOIN SODIUM INJ IP 116 CLOBAZAM TAB 117 SODIUM VALPRDATE TAB 9. ANTHELMINTHICS 118 MEBENDAZOLE TAB IP 119 PIPERAZINE CITRATE ELIXIR IP 10. ANTI FILARIAL DRUGS 120 DIETHYLCARBAMAZINE CITRATE TAB IP 121 DIETHYLCARBAMZINE CITRATE SUSP 30mg 60mg 200mg/ml 100mg 200mg 200mg 5mg/ml 50mg/ml 5mg 500mg 100mg 750mg/5ml
100ml Packet 1ml amp Vial 10x10 Vial 2ml amp 10x10 2ml amp 5ml amp 10ml amp 50ml amp 10ml amp 10x10 10x10 1ml amp 10x10 10x10 10x10 2ml amp 2ml amp 10x10 10x10 6x10 450ml bottle
100mg 100mg/5ml
10x10 50ml bottle 495
Essential Drugs
11. ANTI FUNGAL DRUGS 122 GRISEOFULVIN TAB IP 123 KETOCONAZOLE TAB IP 124 CLOTRIMAZOLE CREAM IP 125 CLOTRIMAZOLE VAG TAB IP 126 WHITFIELDS OINTMENT IP 12 ANTIMALARIAL DRUGS 127 CHLOROQUINE PHOSPHATE TAB IP 128 QUININE INJ 129 PRIMAQUINE TAB IP 130 SULFADOXINE & PYRIMETHAMINE TAB IP 131ARTEMETHER INJ 132 ACYCLOVIR INJ 133 ACYCLOVIR TAB 134 ACYCLOVIR CREAM 135 ZIDOVUDINE CAPS 136 LAMIVUDINE TAB 137 INDINAVIR TAB 14. ANTI LEPROTIC DRUGS 138 RIFAMPICIN CAP IP 139 CLOFAZIMINE CAP IP 140 DAPSONE TAB IP 15. ANTI PARKINSONIAN DRUGS 141TRIHEXYPHENIDYL TAB IP 142 CARBIDOPA 10mg LEVODOPA 100mg TAB IP 16. DRUGS AFFECTING THE BLOOD 143 CYANOCOBALAMIN INJ IP 144 FOLIC ACID TAB IP 496 100mcg/ml 5mg 2ml amp 10x10 2mg 10mg/100mg 10x10 10x10 400mg 50mg 50mg 10x10 10x10 10x10 25mg 300mg/ml 7.5mg 500mg+25mg 80mg/ml 250mg 200mg 5%w/w 300mg 150mg 400mg/800mg 10x10 2ml amp 10x10 10x10 1ml amp Vial 10x10 5g tube 10x10 10x10 10x10 125mg 200mg 2%w/w 200mg 15gm 10x10 10x10 5g 3tab tube
13. ANTI VIRAL DRUGS/ANTI RETROVIRALS
Tertiary Hospitals
145 HEPARIN SODIUM INJ IP 146 PHYTOMENADIONE (VIT K1) INJ 147 HYDROXY ETHYL STARCH IV INFUSION 148 HYDROXY ETHYL STARCH 1.V 6% 130000 DALTONS /0.4m 149 DEXTRAN 40 WITH DEXTROSE 5% INFUSION 150 DEXTRAN 40 WITH SODIUM CHLORIDE 0.9% INFUSION 151 GELATIN POLYMER ELECTROLYTE INJ 152 FAT EMULSION I.V 153 AMINOACID+ ELECTROLYTE+ DEXTROSE 154 PROTAMINE SULPHATE INJ 155 WARFARIN SODIUM TAB IP 17. CARDIOVASCULAR DRUGS 156 ISOSORBIDE DINITRATE TAB IP 157 ISOSORBIDE DINITRATE TAB IP
5000 IU/ml 10mg/ml 6% 6%
5ml vial 1 ml amp 500ml 500ml Flexibag 500ml bottle 500ml bottle
0.63 g 30% 500ml 10mg/ml 2mg 5mg 10mg
500ml bottle 300ml bottle Bottle 5ml amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 10x10 497
158 ISOSORBIDE-5-MONONITRATE TAB 10mg 159 ISOSORBIDE -5-MONONITRATE TAB 20mg 160 DILTIAZEM TAB IP 161 NIFEDIPINE TAB IP 162 NIFEDIPINE TAB IP 163 NIFEDIPINE SOFT GELATIN CAP 164 VERAPAMIL TAB IP 165 ATENOLOL TAB IP 166 ATENOLOL TAB IP 167 ENALAPRIL MALEATE TAB 168 METHYL DOPA TAB IP 169 ENALAPRIL MALEATE TAB 170 AMLODIPINE TAB 30mg 20mg 10mg 5mg 40mg 50mg 100mg 2.5mg 250mg 5mg 2.5mg
Essential Drugs
171 AMLODIPINE TAB 172 DIGOXIN TAB IP 173 DIGOXIN INJ IP 174 DOPAMINE HCL INJ USP 175 DOBUTAMINE HCL INJ 176 HYDROCHLOROTHIAZIDE TAB IP 177 METOPROLOL INJ 178 METOPROLOL TAB IP 179 METOPROLOL TAB IP 180 CLOPIDOGREL TAB 181 NICOTINIC ACID TAB IP 182 NICOTINIC ACID TAB IP 183 STREPTOKINASE INJ 184 STREPTOKINASE INJ 185 SODIUM NITROPRUSIDE INJ 18. DERMATOLOGICAL DRUGS 186 SILVER SULFADIAZINE CREAM IP 187 GLYCERINE IP 188 LIQUID PARAFFIN IP 189 SALICYLIC ACID OINTMENT 190 BENZYL BENZOATE APPLICATION IP 191 GLYCERINE MAGSULPH BPC 192 POVIDONE IODINE OINTMENT IP 193 BETAMETHASONE VALERATE CREAM 194 GAMMA BENZENE HEXACHLORIDE SOLUTION 195 POVIDONE IODINE SOLUTION 196 FRAMYCETIN SKIN CREAM 197 TURPENTINE LINIMENT IP 498
5mg 0.25mg 0.5mg/2ml 40mg/ml 50mg/ml 25mg 5mg/ml 25mg 50mg 75mg 50mg 100mg 750000 IU 1500000 IU 50mg 1%w/w 25kg 5L 10%w/w 25%w/v 5%w/w 1%w/w 1%w/v 5%w/v 1%w/w 500ml
10x10 10x10 2ml 5ml 5ml Amp 10x10 1ml Amp 10x10 10x10 10x10 10x10 10x10 Vial Vial Vial 100g bottle Drum Can 500gbottle 500ml bottle 500g bottle 25g tab 5g/tube 100mL bottle 500ml bottle 20g tube Bottle
Tertiary Hospitals
19. OPHTHALMIC DRUGS/EAR/NASAL DROPS 198 FRAMYCETIN EYE DROPS 0.5%w/v 199 CIPROFLOXACIN EYE/ EAR DROPS 0.3%w/v 200 CIPROFLOXACIN EYE OINTMENT 201 PILOCARPINE EYE DROPS 202 TIMOLOL MALEATE EYE DROPS 203 TROPICAMIDE EYE DROPS 204 BETAMETHASONE EYE DROPS 206 XYLOMETAZOLINE NASAL DROPS IP 207 CHLORAMPHENICOL APPLICAPS 0.3%w/w 0.5%w/v 0.5%w/v 1%w/v 0.1%w/v
5ml bottle 5ml bottle 5g tube 5ml bottle 5ml bottle 5ml bottle 5ml bottle 10ml bottle 10ml bottle
205 SODIUM BICARBONATE EAR DROPS BPC 0.1%w/v
1%w/v(250mg/cap) 50/bottle 1ml Amp 1ml Amp 10x10 1ml Amp 10 10 2ml Amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 499
20. OBSETETRICS AND GYNAECOLOGY DRUGS 208 OXYTOCIN INJ IP 5 IU/ml 209 PROSTAGLANDIN INJ 210 METHYLERGOMETRINE MALEATE TAB IP 211 METHYLERGOMETRINE MALEATE INJ 212 NYSTATIN VAGINAL PESSARIES 213 POVIDONE IODINE VAGINAL PESSARIES 214 MAGNESIUM SULPHATE INJ 21.PSYCHOTROPIC DRUGS 215 DIAZEPAM TAB IP 216 CHLORPROMAZINE TAB IP 217 CHLORPROMAZINE TAB IP 218 IMIPRAMINE TAB IP 219 AMITRIPTYLINE TAB IP 220 NITRAZEPAM TAB IP 221 ALPRAZOLAM TAB 222 ALPRAZOLAM TAB 250mcg/ml 0.125mg 200mcg/ml 100000IU 200mg 500mg/ml 5mg 50mg 100mg 25mg 25mg 5mg 0.25mg 0.5mg
Essential Drugs
223 FLUOXETINE CAP 224 FLUOXETINE CAP 225 HALOPERIDOL TAB 226 CHLORDIAZEPOXIDE TAB 227 HALOPERIDOL LIQUID 228 HALOPERIDOL INJ 229 FLUFENAZINE DECANOATE INJ IP 230 CLOZAPINE TAB 231 CLOZAPINE TAB 232 CITALOPRAM TAB 233 LITHIUM CARBONATE TAB 234 SERTRALINE TAB
10mg 20mg 5mg 10mg 2mg/ml 5mg/ml 25mg/ml 25mg 100mg 20mg 150mg 50mg
10x10 10x10 10x10 10x10 30ml bottle 1ml Amp 1ml amp 10x10 10x10 10x10 10x10 10x10 500ml bottle 500ml bottle 500ml bottle 500ml bottle 25ml Amp 25ml amp Bottle Bottle Bottle 250ml bottle Amp 10ml Amp
22. I.V FLUIDS AND ELECTROLYTES 235 SODIUM CHLORIDE INJ IP 0.9% w/v 236 SODIUM CHLORIDE 0.9 % & DEXTROSE 5% w/vINJ IP 237 DEXTROSE INJ IP 238 DEXTROSE INJ IP 239 DEXTROSE INJ IP 240 DEXTROSE INJ IP 241 ELECTROLYTEP INJECTION (PAEDIATRIC) 242 ELECTROLYTE M INJ IP (MAINTENANCE) 243 RINGER LACTATE INJ IP 244 MANNITOL INJECTION IP 246 POTASSIUM CHLORIDE INJ IP 23. DISINFECTANTS & ANTISEPTICS 247 CHLORHEXIDINE/ CETRIMIDE SOLUTION 248 SURGICAL SPIRIT 500 0.9%/5%w/v 5%w/v 10%w/v 50%w/v 25%w/v 500ml 500ml 500ml 20%w/v 10% w/v
245 STERILE WATER FOR INJECTION IP 10ml
7.5%/15%w/v 70%v/v
1L bottle 500ml bottle
Tertiary Hospitals
249 HYDROGEN PEROXIDE SOLUTION IP 250 POVIDONE IODINE SCRUB 251 CHLOROXYLENOL SOLUTION IP 252 CHLOROXYLENOL SOLUTION IP 24. DIURETICS 253 FRUSEMIDE TAB IP 254 FRUSEMIDE INJ IP 255 SPIRONOLACTONE TAB IP 256 SPIRONOLACTONE TAB IP 25.G.I.T DRUGS 257 RANITIDINE HCL INJ IP 258 RANITIDINE HCL TAB IP 259 ALUMINIUM HYDROXIDE TAB IP 260 OMEPRAZOLE CAP 261 METOCLOPRAMIDE INJ 262 METOCLOPRAMIDE TAB 263 METOCLOPRAMIDE INJ 264 DOMPERIDONE TAB 265 DICYCLOMINE HCL TAB IP 266 DICYCLOMINE HCL INJ IP 267 DICYCLOMINE ORAL SOLUTION 268 ORS POWDER WHO, WITH CITRATE SALT 269 BISACODYL TAB IP 271 ONDANSETRON INJ 272 SYRUP LACTULOSE
20%w/v 7.5%w/v 5%w/v 5%w/v 40mg 10ml/ml 25mg 100mg 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 5mg/ml 10mg 10mg 10mg/ml 10mg/ml 27.5g 5mg 2mg/ml 667mg/ml
1L bottle 500ml bottle 1L bottle 5L bottle 10x10 2ml Amp 10x10 10x10 2ml amp 10x10 10x10 10x10 2ml amp 10x10 10ml vial 10x10 10x10 2ml Amp 30ml bottle Packet 10x10 500ml bottle 2ml Amp 100ml bottle 10x10 10x10 10x10 501
270 CARMINATIVE MIXTURE (CPC FORMULA)
26. HORMONES AND ENDOCRINE DRUGS 273 GLIBENCLAMIDE TAB IP 5mg 274 GLIBENCLAMIDE TAB IP 275 METFORMIN TAB 2.5mg 500mg
Essential Drugs
276 GLIPIZIDE TAB
5mg
10x10 Vial Vial Vial Vial 10x10 10x10 5 ml Vial Vial Vial vial vial 0.5 ml Amp. 1 ml Amp. 10 ml 0.5 ml Amp 2 ml Amp. vial vial vial 10 x 10 10x 10
277 INSULIN BOVINE, RAPID ACTING IP 40 IU/ml 278 INSULIN BOVINE, LONG ACTING IP 40 IU/ml 279 INSULIN HUMAN, RAPID ACTINE 280 INSULIN HUMAN LONG ACTING 281 THYROXINE SODIUM TAB IP 282 PROPYLTHIOURACIL TAB 27 283 284 285 40 IU/ml 40 IU/ml 0.1mg 50mg
IMMUNOLOGICALS TETANUS TOXOID INJ IP/BP 10 dose TETANUS IMMUNOGLOBULIN USP 250 IU HUMAN ANTI D IMMUNOGLOBULIN USP 250 mcg 286 ANTI SNAKE VENOM FREEZE DRIED POLYVALENT 10 ml 287 RABIES VACCINE HUMAN, CELL CULTURE 250 IU 288 HEPATITIS B VACCINE IP 10 mcg / ml 289 HEPATITIS B VACCINE IP 20 mcg / ml 290 POLIO VACCINE, ORAL 20 doses 291 TRIPLE ANTIGEN IP 0.5 ml / dose 292 ANTIRABIES IMMUNOGLOBULIN, HUMAN 150 IU/ ml 293 I.V.GAMMA GLOBULIN 2.5 g. 294 BCG VACCINE IP 295 MMR VACCINE 0.5 ml. 28. VITAMINES & MINERALS 296 CALCIUM LACTATE TAB IP 300 mg. 297 VITAMIN B COMPLEX TAB NFI (STRONG) 298 VITAMIN B COMPLEX INJ. NFI 299 ASCORBIC ACID TAB IP 300 CALCIUM GLUCONATE INJ. IP 301 MULTIVITAMIN TAB NFI 502 10 ml. Amp. 100 mg. 10 % w / v
10 x 10 10 ml. Amp. 10 x 10
302 VITAMIN A & D CAP (HARD/SOFT) 6000 IU/ 1000 IU 10 x 10
Tertiary Hospitals
303 FERROUS SULPHATE TAB IP 304 THIAMINE HCL INJ. IP 29. DIAGNOSTIC AGENTS 305 IOHEXOL INJ. 306 IOHEXOL INJ. 307 IOHEXOL INJ. 308 SODIUM& MEGLUMINE DIATRIZOATE INJ 309 SOD & MEGLUMINE DIATRIZOATE INJ 310 BARIUM SULPHATE SUSPENSION IP
200 mg. 100 mg./ml 240 mg./ml 300 mg./ml. 350 mg /ml 60% 76%
10 x 10 1 ml/Amp. 20 ml. 20 ml. 50 ml. 5 x20 ml. 5x20 ml. 500 ml. bottle vial vial vial vial 10 x 10 50 caps 10 x 10 10 x 10 vial 2 ml. Amp. vial vial vial vial vial vial
30. ANTICANCER DRUGS & IMMUNO SUPPRESSIVES 311 MITOMYCIN C INJ. USP 10 mg. 312 VINCRISTINE SULPHATE INJ. IP 313 CYCLOPHOSPHOMIDE INJ IP 314 CYCLOPHOSPHOMIDE INJ IP 315 BUSULPHAN TAB IP 316 CYCLOSPORIN CAP 317 AZATHIOPRINE TAB IP 318 METHOTREXATE TAB IP 319 BLEOMYCIN INJ 320 METHOTREXATE INJ IP 321 L-ASPARAGINASE INJ. 322 CISPLATIN INJ IP 323 CISPLATIN INJ IP 324 ETOPOSIDE INJ 325 LEUCOVORIN CALCIUM INJ. 326 AMIFOSTINE INJ. 327 PACLITAXEL INJ 328 PACLITAXEL INJ 1 mg./ 1 ml (I.V. USE) 200 mg. 500 mg. 2mg 25 mg. 50 mg. 2.5 mg 15 mg. 50 mg./2 ml 10000 KU 50 mg./50 ml. 10 mg./10 ml. 100 mg/5 ml. 50 mg./5ml 500 mg.
100 mg/16.67 ml vial 260 mg/43.34 ml vial 503
Essential Drugs
329 PACLITAXEL INJ 331 CYTOSINE ARABINOSIDE INJ 332 CYTOSINE ARABINOSIDE INJ 333 HYDROXY UREA TAB 334 DOXORUBICIN HCL INJ 335 INTERFERON ALPHA 2 A INJ 336 INTERFERON ALPHA 2 B INJ 337 TAMOXIFEN TAB
30 mg./5ml 100 mg 500 mg. 500 mg 50 mg. 3 MIU 5 MIU 10 mg.
vial vial vial vial 10 x10 vial vial vial 10 x 10
330 DAUNORUBICIN(LYOPHILISED) INJ 20 mg
B NATIONAL HEALTH PROGRAMMES OF INDIA

1. REPRODUCTIVE CHILD HEALTH (RCH) 1952-1956 Family Planning Programme 1977 National Family Welfare Programme 1992 CSSM 1997-2002 RCH 1 (CSSM + STI + RTI Component) 2004-2009 RCH II Components of RCH II 1. Population stabilization 2. Maternal Health 3. New born care 4. Child Health 5. Adolescent Health 6. RTI + STI treatment + control 7. Urban Health 8. Tribal Health I. POPULATION STABILIZATION 5 modern contraceptive options i. OCP ii. Condoms iii. IUDs iv . Sterlization v . Emergency Contraception : 2 types. 504
Child Health
1. Progesterone only pill 0.75 mg levonorgestrel (2 tab) 1st tab within 72 hours of unprotected intercourse 2nd tab 12 hours after 1st tab. 2. IUD within 5 days of unprotected intercourse. II. CHILD HEALTH 1. IMNCI / Integrated management of neonatal and childhood illness
OPD HEALTH FACILITY.
Check for danger signs - convulsions, lethargy, unconsciousness, inability to drink/breast feeding, persistent vomiting
Assess main symptoms Cough/difficult breathing, diarrheoa, fever, ear problems.
Assess Nutrition and immunisation status and potential feeding problem
Check for other problem
Classify conditions and identify Treatment
Action according to colour coding
PINK Urgent Referral
YELLOW Treatment of OPD Treat local infection
GREEN Home management
Flow chart for line of action of a health worker on observing a sick child 505
National Health Programme
2) Diarrhoea control Programme and ORS programme. Best treatment for dehydration is Oral Rehydration Therapy by Oral Rehydration Salt solution. New: Low osmolarity ORS
Management of diarrhoeas according to Diarrhoea control Programme.

Common signs of dehydration are increased thirst, restlessness, drytongue and decreased skin turgor. In severe dehydration there will be obtundation, floppy limbs, low volume pulse and oliguria.In mild diarrhoea child has none of the signs described above and the main goal of treatment is to replace ongoing losses using homemade Fuids like salted kanji water or ORAL REHYDRATION SOLUTION (ORS). Dose: 1 packet of ORS dissolved in 1 L (5glass) of potable water (boiled and cooled). After each motion give ORS 50mL ( glass) for infants <6months, 1/2 glass for children upto 2 years and 1 glass for older children. Use cup and spoon to give ORS. Breast feeding should be continued in small frequent feeds. In moderate dehydration: ORS/IV fluids will be required. About100 mL/kg ORS is given in 4 h. Breast feeding to be continued. Offer plain boiled water in between ORS in those who are not breast fed. Home made fluids like salted rice water, coconut water or buttermilk can be used. IV fluids are used in similar lines for the treatment of severe dehydration (see below) except the initial emergency phase can be omitted. In Severe Dehydration: always use i.v. fluids. Shock, acidosis and marked oliguria by themselves are indicative of severe dehydration. Ringer lactate or Normal saline is used initially Dose: 30mL/kg in first 1h followed by 70mL/kg over next 5 h.(100mL/ kg in 6 h). Dextrose saline may be used instead to prevent hypoglycaemia.For older children 100mL/kg should be given in 4 h .Add KCL 20mEq/L as soon as child passes urine. In cholera much more fluid will be required and constant monitoring of hydration is essential.ORS and feeding can be started at the 506
Diarrhoea Control Programme
end of 6h as the signs of dehydration disappears by this time. The i.v. fluid can then be changed to maintenance fluid if required eg. Isolyte P Holiday and Segar Formula is generally used to calculate maintenance requirement as given below. Dose: First 10 kg - 100 mL/kg/24 h. l020 kg Above 20 kg -1000 + 50 mL/additional kg over 10 kg. -1500 + 20 mL/kg for additional kg over 20 kg.
Ongoing losses also should be replaced. Use 7.5% soda bicarb. 2 mL/ kg diluted with equal amount of distilled water or 5% dextrose i.v. slowly in severe acidosis. DIARRHOEA AND DEHYDRATION eg. 1 year old weighing 10 kg Symptoms & signs Fluid deficit eg.2 yr old Wt.12 kg Mild Moderate None 500 mL Fluid replacement as ORS 1/2 glass=100mL after each stool In first 4 h, 600-800mL (3 to 4 glasses of ORS)
Restless 500-1000mL Thirst increased Skin turgor Dry mouth. Lethargic >1000 mL Floppy Cold extremities Rapid thready pulse
Severe
IV Fluid required 1st 6 hour 100mL/kg Ringer lactate / N saline 1st hr 30 mL/kg Next 5hr 70mL/ kg thereafter maintenance fluid if required.
Antidiarrhoeals are contra indicated. Antibiotics are not necessary except in invasive diarrhoea characterised by blood in stools due to Shigella infection or in cases of Typhoid or Cholera.In Shigella infection, drug given is Ciprofloxacin.In Cholera drugs given are Doxycycline, Tetracycline, Cotrimoxazole or Erythromycin. Zinc supplementation decreases episode,duration and severity.Dose is 10 mg Zinc for infants less than 6 months of age;20 mg Zinc for children >6 months of age. 507
3. Acute Respiratory Infection control Programme.

Management of ARI. Classification No Pneumonia Pneumonia Therapy Symptomatic / home remedy Cotrimoxazole oral (sulphmethoxazole 100 mg and Trimethoprim 20 mg) for 5 days Respiratory Rate/minute > 60 > 50 > 40 One Tablet BD Two Tablets BD Three Tablets BD Patient should be hospitalized Where to treat At Home At Home or Health facility
Age in month <2 2 -12 12 60 Severe Pneumonia
Antibiotics IM 50000 IU/kg/Dose 6 hourly OR Inj: Ampicillin 50 mg /kg/Dose
Chest in-drawing Injection Benzyl Pencillin
+ Inj: Gentamicin 2.5 mg/Dose x 8 hourly Very Severe Pneumonia
Inability to drink. Excessive

drowsiness
h/o of apnoea Chloromphenical cyanosis/ orally or IM convulsions 25 mg/kg/dose 6 hourly
Must always be admitted and treated at health facility with provision of oxygen
Stridor in calm child Hypothermia Respiratory severe Grunting malnutrition
4.
National Programme for prophylaxis against Blindness in children caused due to vit A deficiency
Starting at 9 months with measles as a first dose (1Lac1U) then at 15 months a second dose (2 Lac 1U) then every 6 months (2 Lac 1U) till the age of 5 years. Total doses = 9 508
National Immunization Schedule
5. National Immunization Schedule:

Age Birth 6 weeks 10 weeks 14 weeks 9 months 15-18 months 16-24 months 5-6 years 10-16 years Pregnant ( Un-immunized) Pregnant (immunized) Started in 1962 Revised in 1992 as Revised National Tuberculosis Control Programme Under this Directly Observed Treatment Short course strategy introduced. Components of DOTS 1. Political will 2. Case detection by Sputum microscopy 3. Adequate drug supply 4. Short course chemotherapy given under direct observation 5. Systematic monitoring and accountability for every patient diagnosed. 509 Vaccines BCG, OPV, Hepatitis B DPT, OPV, Hepatitis B DTP, OPV, Hepatitis B DPT, OPV, Hepatitis B Measles Measles, Mumps, Rubella DPT, OPV Booster DT, OPV Tetanus Toxoid 2 doses of TT with 1 month interval One dose of TT.
NATIONAL TB CONTROL PROGRAMME
Treatment categories and sputum examination schedule in DOTS

TREATMENT REGIMEN SPUTUMEXAMINATIONSFORPULMONARYTB PreTreatment Sputum
Category of Treatment I
Type of Patient New Sputum Smear Positive
Regimen
If Month result is _
Then
2(HRZE)3
Start continuation Phase, test sputum at 4, 6 months Continue intensive phase 1 more month
Seriously ill Sputum Smear ve Seriously ill Extra pulmonary
4 (HR)3 _
Start continuation phase test sputum at 6 months Continue intensive phase for 1 month,test Sputum at 3,4 & 7 months
2 +
II
Sputum smear +ve Relapse Sputum smear +ve Failure Sputum smear +ve Treatment after default
2(HRZES)3 _
Start continuation phase test sputum at 5 & 6 months Continue intensive phase for 1 more month,test sputum again at 4,6 & 9 months
1(HRZE)3
3 +
5 (HRE)3
III
New Sputum Smear ve not seriously ill New Extra pulmonary Not seriously ill
_ 2(HRZ)3 _ 2
Start Continuation phase, test sputum at 6 months
+ 4(HR)3
Re-register the patient and begin category II treatment
H : ISONIAZID 600 mg Z: PYRAZINAMIDE 1500 mg S: STREPTOMYCIN 750 mg Patient weight > 60 kg Patient > 50 years old 510
R: RIFAMPICIN ( 450 mg) E: ETHAMBUTOL (1200 mg) Receive additional Rifampicin 150 mg Receive Streptomycin 500 mg
National TB Control Programme
DOTS PLUS STRATEGY: Treatment of Multi Drug resistant TB Standardised treatment regimen (STR) comprising of 6 drugs kanamycin, ofloxacin, ethionamide, pyrazinamide, ethambutol and cycloserine) during 6 -9 months of Intensive phase and 4 Drugs (ofloxacin, ethionamide, ethambutol and cycloserine) during 18 months of the continuation phase. Para aminosalicylic acid (PAS) is included in the regimen as a substitute drug if any bactericidal drug (K,Ofl, Z and Eto) or any 2 bacteriostatic (E and Cs) drugs are not tolerated. Drugs < 45 kg > 45 kg Kanamycin 500 mg 750 mg Ofloxacin 600 mg 800 mg Ethionamide 500 mg 750 mg Ethambutol 800 mg 1000 mg Pyrazinamide 1250 mg 1500 mg Cycloserine 500 mg 750 mg PAS 10 mg 12 g All drugs should be given in a single daily dosage under directly observed treatment (DOT) by a DOT Provider NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME 2004 This Programme for control of 6 diseases namely, Malaria, Kala-azar, Filarial, Japanese Encephalitis, Dengue fever and Dengue haemorrhagic fever and Chikungunya fever. Malaria Drug Policy 2007 1. All fever cases should preferably be investigated for malaria by Microscopy or Rapid Diagnotic kit (RDK) 2. The first line of treatment is chloroquine and the 2nd line is ACT (Artesunate + sulpha pyrimethamine) combination. Resistant to these formulation and severe and complicated malaria Quinine will be the drug of choice. 3. Microscopically positive PF cases (Plasmodium Falciparam) should be treated with chloroquine in therapeutic dose of 25 mg / kg body weight over 3 days and single dose of primaquine 0.75 mg / kg body weight on the 1st day. 4. Microscopically positive PV cases (plasmodium Vivax) should be treated with chloroquine in full therapeutic dose of 25 mg/kg body weight over 3 days. Primaquine can be given in dose of 0.25 mg / kg 511
body weight daily for 14 days under medical supervision only to prevent relapse. 5. Treatment of PF in chloroquine resistant areas: DOC : ACT 4 mg/kg bw of artesunate daily for 3 days + 25 mg/kg bw of sulphadoxine/ sulphalene + 1.25 mg per kg bw of pyrimethamine on the 1st day. Primaquine may not be given with ACT combination as Artesunate reduces gametocyte carriage. 6. Chemoprophylaxis for selected cases: Given for (1) Pregnant woman in high risk areas (2) Travellers In Chloroquine sensitive areas, weekly dose of chloroquine will be given but in chloroquine resistant areas it should be supplemented by daily dose of proguanil. Chemoprophylaxis should not exceed 3 years due to the cumulative toxic effects of chloroquine. Chemoprophyl axis is to be started a week before arriving to malarious area for visitors and for pregnant women prophylaxis should be initiated from 2nd trimester. Start with loading dose of 10 mg/kg bw and followed by a weekly dose of 5 mg/kg bw. This is to continue till one month after delivery in case of pregnancy and in travellers till one month after return from endemic area. The terminating dose should be radical treatment for P.Vivax ie: 25 mg/ kg bw over 3 days alone with 0.25 mg / kg bw of primaquine for 14 days under medical supervision. In chloroquine resistant areas: Chloroqine 5 mg/kg bw weekly + Proguanil 200 mg daily. 7. Severe and complicated malaria cases In severe and complicated malaria of PF (clinically / microscopically/ confirmed) parenteral artemisinin or quinine is the drug of choice, irrespective of chloroquine resistance status of area. Quinine salt:10 mg/kg bw 8 hourly in 5% Dextrose saline. Patients should be switched over to oral quinine as early as possible. Oral dose10 mg/kg bw 8 hourly not exceeding 2 gm in a day in any case. Total duration of a quinine therapy 7 days including both parenteral and oral doses. 512
National Filaria Control Programme
Injectable form of artemisinin derivative, may be used for the management of severe and complicated malaria (for adults and non pregnant only) Dose: Artesunate 2.4 mg/kg bw IM/IV followed by 1.2 mg/kg bw after 12 hours then 1.2 mg/kg bw once daily for total duration of 5 days. Artemether 1.6 mg/kg bw IM followed by 1.6 mg/kg bw daily for total of 6 injections or 1.6 mg/kg bw IM injection twice daily for 3 days a total of 6 injection. Arteether 150 mg daily IM for 3 days in adults only. Artemisinin 10 mg/kg bw at 0 and 4 hours followed by 7 mg/kg bw at 24,36,48 and 60 hours. NATIONAL FILARIA CONTROL PROGRAMME Mass Drug Administration (MDA) Drugs Administered are DEC (Diethyl Carbamazine) and Albendazole Dose: DEC Adult Dose 6 mg/kg single dose DEC Preparations available Tab 50 mg, 100 mg 2-5 years 100 mg 1 Tab. 6 14 years 100 mg 2 Tabs 15 years and above 100 mg 3 Tabs. Albendazole 400 mg 1 Tab It is administered once a year for a total of 5 years. CI -< 2 years, Pregnancy, seriously ill persons and elderly. Disability management: Analgesic like Paracetamol,Antibiotics like Amoxicillin are given.If allergic to Penicillin Erythromycin is given.Antifungal creams are given for topical application.In severe cases,IV Benzyl Penicillin is given initially and then switched to oral Phenoxymethyl Penicillin.If allergic to penicillin Erythromycin is given.Antifilarial drugs are not given in acute stage. NATIONAL AIDS CONTROL PROGRAMME Post Exposure Prophylaxis: Recommended steps following HIV exposure: 1. 2. 3. 3. Rapid HIV testing facilities should be available. Exposure with HIV should be considered as a medical emergency. Chemoprophylaxis should be started immediately or within 4 hours Chemoprophylaxis should be monitored on 1,3 and 6 months interval 513
Drugs recommended in different types of exposures:

EXPOSURE PROPHYLAXIS ANTIRETROVIRAL REGIMEN
Percutaneous Blood Highest risk Increased risk Body fluid Mucous Membrane Blood Body fluid Skin Blood Body fluid Blood with highest Risk high titres of HIV Offer ,, ZDV + 3 Lamivudine + Indinavir/ Saquinavir ZDV + 3 Lamivudine both large Vol. of blood and blood with Offer ,, ZDV + 3 Lamivudine+ Indinavir/Saquinavir ZDV + 3 Lamivudine Recommended ,, Offer Offer ZDV + 3 Lamivudine+Indinavir/ Saquinavir ,, ZDV + 3 Lamivudine ,,
Increased Risk large vol. of blood but may be having low titres or blood with high titres only but may not exposed to large vol. ZIDUVUDINE (ZDV) : 300 mg BD X 4 weeks LAMIVUDINE : INDINAVIR : SAQUINAVIR : 150 mg BD X 4 weeks 800 mg Thrice Daily 600 mg Thrice Daily.
Ref: National Health Programme of India 5th Edition, J.Kishore. Community Medicine Park and Park
514
APPENDIX 1 PREGNANCY
During pregnancy the mother and the fetus form a non-separable functional unit. Maternal well being is an absolute prerequisite for the optimal functioning and development of both parts of this unit. Consequently, it isimportant to treat the mother whenever needed while protecting the unborn to the greatest possible extent. Drugs can have harmful effects on the fetus at any time during pregnancy. lt is important to remember this when prescribing for a woman of childbearing age or for men trying to father a child. However, irrational fear of using drugs during pregnancy can also result in harm. This includes untreated illness, impaired maternal compliance, suboptimal treatment and treatment failures. Such approaches may impose risk to maternal well-being, and may also affect the unborn child. It is important to know the background risk in the context of the prevalence of drug-induced adverse pregnancy outcomes. Major congenital malformations occur in 2-4% of all live births. Up to 15% of all diagnosed pregnancies will result in fetal loss. The cause of these adverse pregnancy outcomes is understood in only a minority of the incidents. During the first trimester drugs may produce congenital malformations (teratogenesis), and the greater risk is from third to the eleventh week of pregnancy. During the second and third trimester drugs may affect the growth and functional development of the fetus or have toxic effects on fetal tissues. Drugs given shortly before term or during labour may have adverse effects on labour or on the neonate after delivery. Few drugs have been shown conclusively to be teratogenic in man but no drug is safe beyond all doubt in early pregnancy. Screening procedures are available where there is a known risk of certain defects. Prescribing in pregnancy lf possible counselling of women before a planned pregnancy should be carried out including discussion of risks associated with specific therapeutic agents, traditional medicines and abuse of substances such as nicotine and alcohol.Folic acid supplements should be given during pregnancy planning because periconceptual use of folic acid reduces neural tube defects 515
Drugs should be prescribed in pregnancy only if the expected benefits to the mother are thought to be greater than the risk to the fetus. All drugs should be avoided if possible during the first trimester. Drugs which have been used extensively in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs and the smallest effective dose should be used. Well known single component drugs should usually be preferred to multi-component drugs. The following list includes drugs which may have harmful effects in pregnancy and indicates the trimester of risk lt is based on human data but information on animal studies has been included for some drugs when its omission might be misleading. Absence of a medicine from the list does not imply safety. Table of drugs to be avoided or used with caution in pregnancy Medicine Comment Acetylsalicylic acid Third trimester: Impaired platelet function and risk of haemorrhage; delayed onset and increased duration of labour with increased blood loss; avoid analgesic doses ifpossible in last few weeks (low doses probably not harmful); with high doses, closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of newborn; kernicterus in jaundiced neonates Not known to be harmful; limited absorption from topical preparations Contraindicated in cestode infections First trimester: avoid in nematode infections First, second trimesters: Regular daily drinking is teratogenic (fetal alcohol syndrome) and may cause growth retardation; occasional single drinks are probably safe
Aciclovir Albendazole
Alcohol
516
Third trimester: Withdrawal may occur in babies of alcoholic mothers Alcuronium Does not cross placenta in significant amounts; use only if potential benefit outweighs risk Manufacturer advises ,avoid unless essential, particularly during first and third trimesters Not known to be harmful Not known to be harmful Not known to be harmful but use only if potential benefit outweighs risk Not known to be harmful First trimester: Avoid First trimester: Avoid First trimester: Avoid May cause intrauterine growth restriction, neonatal hypoglycaemia, and bradycardia; risk geater in severe hypertension Not known to be harmful Limited information availableuse only if adequate altematives not available Benefit of treatment, for example in asthma, outweighs risk Not known to be harmful Third trimester: With large doses, neonatal respiratory depression, hypotonia, and bradycardia after 517
Amitriptyline
Amoxyillin Arnoxycillin + Clavulanic acid Amphotericin B Ampicillin Artcmether Artcmether + Lumefantrine Artesunate Atenolol
Atropine Azithromycin Beclomethasone Betamethasone Benzathine Benzylpenicillin Bupivacaine
paracervical or epidural block; lower doses of bupivicaine for intrathecal use during late pregnancy Carbamazepine First trimester: Risk of teratogenesis including increased risk of neural tube defects Not known to be harmful Not known to be harmful Not known to be harmful Not known to be harmful Third trimester: Neonatal grey baby syndrome First, third trimesters: Benefit of prophylaxis and treatment in malaria outweighs risk Third trimester: Extrapyramidal effects in neonate All trimesters: Avoidarthropathy in animal studies. Possible effects on fetal development Not known to be harmful Third trimester: Depresses neonatal respiration; withdrawal effects in neonates of dependent mothers; gastric stasis and risk of inhalation pneumonia in mother during labour Third trimester: Neonatal haemolysis and methaemoglobinaemia; Benefit of treatment, for example in asthma, outweighs risk; risk of intrauterine growth retardation on prolonged or repeated systemic treatment; Avoid regular use (risk of neonatal withdrawal symptoms); use only if clear
Cefazolin Cefixime Ceftazidime Ceftriaxone Chlorarnphenicol Chloroquine
Chlorpromazine Ciprofloxacin Clomifene Cloxacillin Codeine
Dapsone Dexamethasone
Diazepam 518
indication such as seizure control (high doses during late pregnancy or labour may cause neonatal hypothermia, hypotonia and respiratory depression) Didanosine Diethylcarbamazine Doxycycline Avoid in first trimester; increased risk of lactic acidosis and hepatic steatosis Avoid First trimester: Effects on skeletal development Second, third trimesters: Dental discoloration; maternal hepatotoxicity Avoid (potential teratogenic effects) All trimesters: Avoid; may adversely affect fetal and neonatal blood pressure control and renal function; also possible skull defects and oligohydramnios; Not known to be harmful Not known to be harmful no harmful effects on fetus Avoid (multiple congenital abnormalities reported with long-term high doses) Teratogenic in animal studies; Manufacturer advises use only if potential benefit outweighs risk; risk of neonatal withdrawal Third trimester: Extrapyramidal effects Second, third trimesters: Auditory or vestibular nerve damage. Third trimester: Neonatal hypoglycaemia; Avoid (fetotoxicity and teratogenicity in animals); Third trimester: Extrapyramidal effects in neonate Third trimester: Depresses neonatal respiration 519
Efavirenz Enalapril
Erythromycin Ethambutol Ethinylestradiol Fluconazole Flucytosine Fluoxetine
Fluphenazine Gentamicin Glibenclamide Griseofulvin Haloperidol Halothane
Heparin Hydralazine
Hydrochlorothiazide
Hydrocortisone
Ibuprofen
Indinavir
All trimesters: Maternal osteoporosis has been reported after prolonged use; Avoid during first and second trimesters; no reports of serious harm following use in third trimester Not used to treat hypertension in pregnancy Third trimester: May cause neonatal thrombocytopenia Benefit of treatment, for example in asthma, outweighs risk; risk of intrauterine growth retardation on prolonged or repeated systemic treatment; corticosteroid cover required by mother during labour; Avoid unless potential benefit outweighs risk Third trimester: With regular use closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of the newborn. Delayed onset and increased duration of labour Avoid if possible in first trimester; theoretical risk of hyperbilirubinaemia and renal stones in neonate if used at term; Second, third trimesters: Neonatal goitre and Hypothyroidism Not known to be harmful Not known to be harmful Monitor maternal serum-thyrotrophin concentrationlevothyroxine may cross the placenta and excessive dosage can be detrimental to fetus. Third trimester: With large doses, neonatal respiratory depression, hypotonia, and bradycardia alter paracervical or epidural block
Iodine Ipratropium Isoniazid Levothyroxine
Lidocaine
520
Magnesium sulfate
Third trimester: not known to be harmful for short-term intravenous administration in eclampsia but excessive doses may cause neonatal respiratory depression Avoid (genital malformations and cardiac defects reported in male and female fetuses); inadvertent use of depotmedroxyprogesterone acetate contraceptive injection in pregnancy unlikely to harm fetus All trimesters: Avoid; insulin is normally substituted Not known to be harmful Not known to be harmful Avoid high-dose regimens Third trimester: Depresses neonatal respiration; (withdrawal effects in neonates of dependent mothers; gastric stasis and risk of inhalation pneumonia in mother during labour Not known to be harmful First, third trimesters: Congenital malformations; risk of teratogenicity greater if more than one antiepileptic used. May possibly cause vitamin K deficiency and risk of neonatal bleeding; if vitamin K not given at birth, neonate should be monitored closely for signs of bleeding First, third trimesters: Congenital malformations (screening advised); risk of teratogenicity greater if more than one antiepileptic used. risk of neonatal bleeding; Third trimester: Neonatal haemolysis and methaemoglobinaemia. 521
Medroxyprogesterone
Metformin Methyldopa Metoclopramide Metronidazole Morphine
Paracetamol Phenobarbital
Phenytoin
Primaquine
Propranolol
May cause intrauterine growth restriction, neonatal hypoglycaemia, and bradycardia; risk greater in severe hypertension Second, third trimesters: Neonatal goitre and hypothyroidism Use only if potential benefit outweighs risk Third trimester: Neonatal myasthenia with large doses First trimester: teratogenic High doses are
Propylthiouracil Pyrazinamide Pyridostigmine Quinine Ranitidine Retinol Rifampicin Salbutamol
Not known to be harmful First trimester: Excessive doses may be teratogenic; First trimester: Very high doses teratogenic in animal studies Appropriate to use for asthma; high doses should be given by inhalation only; parenteral use can affect the myometrium and possibly cause cardiac problems Avoid congenital anomalies reported; decreased synthesis of cholesterol possibly affects fetal development All trimesters: Possibility of premature separation of placenta in first 18 weeks; theoretical possibility of fetal haemorrhage throughout pregnancy; risk of maternal haemorrhage on postpartum use Second, third trimesters: Auditory or vestibular nerve damage First trimester: Teratogenic risk Third trimester: Neonatal haemolysis and
Simvastatin
Streptokinase
Streptomycin Sulfamethoxazole + Trimethoprim 522
methaemoglobinaemia; fear of increased risk of kernicterus in neonates Suxamethonium Tamoxifen Testosterone Tetracycline Mildly prolonged maternal paralysis may occur Avoidpossible development; effects on fetal
All trimesters: Masculinization of female fetus First trimester: Effects on skeletal development Second, third trimesters: Dental discoloration Third trimester: Depresses neonatal respiration; dose should not exceed 250 mg First trimester: Teratogenic risk (folate antagonist) Not known to be harmful First trimester: Theoretical risk of congenital malformations Avoid; pregnancy should be avoided for l month after immunization Avoid; pregnancy should be avoided lor l month after immunization Avoid; pregnancy should be avoided for 3 months after immunization May reduce uterine blood flow with fetal hypoxia; may inhibit labour All trimesters: Congenital malformations; fetal and neonatal haemorrhage Avoid if possible in first trimester; benefit of treatment considered to outweigh risk in second and third trimesters Avoid - teratogenic
Thiopental
Trimethoprim Vaccine, Influenza Vaccine, Measles Vaccine, MMR Vaccine, Rubella Vaccine, Varicella Verapamil Warfarin Zidovudine
All anti malignant drugs
523
APPENDIX 2 BREAST FEEDING

Administration of some drugs (for example. ergotamine) to nursing mothers may harm the infant, whereas administration of others (for example digoxin) has little effect. Some drugs inhibit lactation (for example, estrogens).Toxicity to the infant can occur if the drug enters the milk in pharmacologically significant quantities. The concentration in milk of some drugs (for example, iodides) may exceed the concentration in the maternal plasma so that therapeutic doses in the mother may cause toxicity to the infant.Some drugs inhibit the infants sucking reflex (for example, phenobarbital).Drugs in breast milk may, at least theoretically, cause hypersensitivity in the infant even when the concentration is too low for a pharmacological effect. The following table lists drugs:
which should be used with caution or which are contraindicated in breastfeeding for the reasons given above which, on present evidence, may be given to the mother during breastfeeding, because they appear in milk in amounts which are too small to be harmful to the infant; which are not known to be harmful to the infant although they are present in milk in significant amounts.
For many drugs insufficient evidence is available to provide guidance and it is advisable to administer only drugs essential to a mother during breastfeeding.Because of the inadequacy of information on drugs in breast milk the following table should be used only as a guide; absence from the table does not imply safety. WHO POLICY. Infants should be exclusively breastfed for the first 6 months of life; thereafter they should receive appropriate complementary food and continue to be breastfed up to 2 years of age or beyond. 524
Table of medicines present in breast milk Medicine Comment Acetylsalicylic acid Short course safe in usual dosage; monitor infant; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infant if neonatal vitamin K stores low; possible risk of Rey syndrome Significant amount in milk after systemic administration, but considered safe to use A Large amounts may affect infant and reduce milk consumption Detectable in breast milk; continue breastfeeding;adverse effects possible, monitor infant for drowsiness Discontinue breastfeeding during and for 1 week after stopping treatment; Systemic effects in infant unlikely with matemal dose of less than equivalent of prednisolone 40 mg daily; Trace amounts in milk; safe in usual dosage; monitor infant Continue breastfeeding; adverse effects possible ;monitor infant for drowsiness Excreted in low concentrations; safe in usual dosage; Continue breast -feeding; use altemative drug if possible; may cause bone-marrow toxicity in infant;concentration in milk usually insufficient to cause grey syndrome For malaria prophylaxis, amount probably too small to be harmful; inadequate for 525
Acyclovir
Alcohol Amitriptyline
Artemether + Lumefantrine Beclomethasone Betamethasone Benzylpenicillin Carbamazepine Cefazolin
Cefixime, Ceftazidime Ceitriaxone Safe in usual dosage Chloramphenieol
Chloroquine
reliable protection against malaria; avoid breastfeeding when used for rheumatic disease Chlorpromazine Ciprofloxacin Clofazimine Continue breastfeeding; adverse effects possible; monitor infant for drowsiness Continue breastfeeding; use altemative drug if possible Limited information available, can cause reversible skin discoloration in nursing infant May inhibit lactation May inhibit lactation Although significant amount in milk risk toinfant very small; continue breastfeeding; monitor infant for jaundice Continue breastfeeding; adverse effects possible; monitor infant for drowsiness Continue breastfeeding; use altemative drug if possible (absorption and therefore discoloration of teeth in infant probably usually prevented by chelation with calcium in milk) Caution with high doses; may cause hypercalcaemia in infant Only small amounts in milk ,not known to be harmful Amount too small to be harmful Use alternative method of contraception; may inhibit lactation Significant amount in milk; continue breastfeeding; adverse effects possible; monitor infant for drowsiness safe in usual dosage; monitor infant
Clomifene Oral contraceptives Dapsone
Diazepam Doxycycline
Ergocalciferol Erythromycin Ethambutol Ethinylestradiol Ethosuximide
Fluconazole 526
Gentamicin Hydrochlorothiazide Insulin Iodine
Amount probably too small to be harmful; monitor infant for thrush and diarrhoea Continue breastfeeding; lactation may inhibit
Amount too small to be harmful Stop breastfeeding; danger of neonatal hypothyroidism or goitre; appears to be concentrated in milk Monitor infant for possible toxicity; theoretical risk of convulsions and neuropathy; prophylactic pyridoxine advisable in mother and infant Avoid treating mother until infant is l week old Breastfeeding contraindicated Present in milk-levodopa may inhibit lactation Significant amount in milk; Continue breastfeeding; avoid large doses; use alternative drug if possible Avoid breastfeeding for 14 days after administration Avoid breastfeeding during and for 72 hours after treatment; considered safe to continue breastfeeding in treatment of schistosomiasis risk of haemolysis in G6PD-deficient infants Amount too small to be harmful Amount probably too small to be harmful avoid administration of other folate antagonists to infant;avoid breastfeeding during toxoplasmosis treatment Breastfeeding contraindicated 527
Isoniazid
Ivermectin Levamisole Levodopa + carbidopa Metronidazole
Mifepristone Praziquantel
Primaquine Pyrazinamide Pyridostigmine Pyrimethamine
Ribavirin
Senna Tamoxifen Testosterone
Continue breastfeeding; monitor infant for diarrhoea Suppresses lactation; avoid unless potential benefit outweighs risk Avoid; may cause masculinization in the female infant or precocious development in the male infant; high doses suppress lactation Risk of haemorrhage; increased by vitamin K deficiency; Breast feeding recommended during first 6 months if no safe alternative to breastmilk
Warfarin Zidovudine
APPENDIX 3: RENAL IMPAIRMENT

Reduced renal function may cause problems with drug therapy for the following reasons: l. The failure to excrete a drug or its metabolites may produce toxicity. 2. The sensitivity to some drugs is increased even if the renal elimination is unimpaired. 3. The tolerance to adverse effects may be impaired. 4. The efficacy of some drugs may diminish. The dosage of many drugs must be adjusted in patients with renal impairment to avoid adverse reactions and to ensure efficacy. The level of renal function below which the dose of a drug must be reduced depends on how toxic it is and whether it is eliminated entirely by renal excretion or is partly metabolized to inactive metabolites. In general, all patients with renal impaimrent are given a loading dose which is the same as the usual dose for a patient with normal renal function.Maintenance doses are adjusted to the clinical situation. The maintenance dose of a drug can be reduced either by reducing the individual 528
dose leaving the normal interval between doses unchanged or by increasing the interval between doses without changing the dose. The interval extension method may provide the benefits of convenience and decreased cost, while the dose reduction method provides more constant plasma concentration. ln the following table drugs are listed in alphabetical order. The table includes only drugs for which specific information is available. Many drugs should be used with caution in renal impairment but no specific advice on dose adjustment is available; it is therefore important to also refer to the individual drug entries. The recommendations are given for various levels of renal function as estimated by the glomemlar filtration rate (GFR), usually measured by the creatinine clearance (best calculated from a 24-hour urine collection)The serumcreatinine concentration is sometimes used instead as a measure of renal function but it is only a rough guide even when corrected for age, sex and weight by special nomograms. Renal impairment is usually divided into three grades: mild-GFR 20-50 ml/minute or approximate serum creatinine 150-300 micromol/litre moderate-GFR l0-20 ml/minute or serum creatinine 300-700 micromol/ litre severeGFR <l0 ml/minute or serum creatinine >700 micromol/litre When using the dosage guidelines the following must be considered:
Drug prescribing should be kept to a minimum. Nephrotoxic drugs should, if possible, be avoided in all patients with renal disease because the nephrotoxicity is more likely to be serious. It is advisable to determine renal function not only before but also during the period of treatment and adjust the maintenance dose as necessary. Renal function (GFR, creatinine clearance) declines with age so that by the age oi80 it is half that in healthy young subjects. When prescribing for the elderly, assume at least a mild degree of renal impairment. 529
Uraemic patients should be observed carefully for unexpected drug toxicity. ln these patients the complexity of clinical status as well as other variables for example altered absorption, protein binding or metabolism, or liver function, and other drug therapy precludes use of fixed drug dosage and an individualized approach is required.
Table of medicines to be avoided or used with caution in renal impairment

Medicine Abacavir Acetazolamide Acetylsalicylic acid Degree of Impairment Severe Mild Severe Comment Avoid Avoid; metabolic acidosis Avoid; sodium and water retention; deterioration in renal function; increased risk of gastrointestinal bleeding Risk of crystalluria with high doses Reduce dose; rashes Risk of crystalluria Atenolol Mild to Moderate Severe Reduce dose to max. 50 mg daily if creatinine clearance 15-35mL/minute May reduce renal blood flow and adversely affect renal function; reduce dose to max. 25 mg daily if creatinine clearance less than 15 mL/minute
Amoxycillin
Mild to moderate Severe
530
Benzathine penicillin Benzylpenicillin
Severe Severe
Neurotoxicity; high doses may cause convulsions Maximum 6 g daily; neurotoxicityhigh doses may cause convulsions Reduce dose Reduce dose Reduce dose Maximum 2 g daily; also monitor plasma concentration Reduce dose in rheumatic disease Reduce dose for malaria prophylaxis; avoid in rheumatic disease Avoid if possible; nephrotoxic and Neurotoxic Reduce dose; toxicity increased by electrolyte disturbances clearance less than 30 ml/rninute. Hyperkalaemia and other adverse effects
Cefazolin Cefixime Ceftazidime Ceftriaxone
Moderate Moderate Mild Severe
Chloroquine
Mild to moderate Severe
Cisplatin
Mild
Digoxin
Mild
Enalapril
Mild
Furosemide
Moderate
May need high doses; deafness may follow rapid IV injection Reduce dose; monitor plasma Concentrations Avoid Reduce dose 531
Gentamicin Glibenclamide Imipenem + Cilastatin
Mild Severe Mild
Metformin Methotrexate
Mild Mild
Metoclopramide
Moderate Severe
Morphine Potassium chloride Procaine Benzylpenicillin Spironolactone
Moderate to Severe Moderate
Avoid; increased risk of lactic acidosis Reduce dose; accumulates; nephrotoxic Avoid Avoid or use small dose; increased risk of extrapyramidal reactions reduce dose or avoid Avoid routine use; high risk of Hyperkalaemia Neurotoxicity: high doses may cause Convulsions Monitor plasma K ; high risk of Hyperkalaemia in renal impairment Avoid Reduce dose ; monitor plasma-vancomycin concentration and renal function regularly Avoid
Severe Mild
Vancomycin
Moderate Mild
Warfarin
Severe
APPENDIX: 4 HEPATIC IMPAIRMENT

Liver disease may alter the response to drugs. However, the hepatic reserve appears to be large and liver disease has to be severe before important changes in drug metabolism take place. The ability to eliminate a specific drug may or may not correlate with livers synthetic capacity for substances such as albumin or clotting factors, which tends to decrease as hepatic function declines. Unlike renal disease, where estimates of renal function based on creatinine clearance correlate with parameters of drug 532
elimination such as clearance and half life, routine liver function tests do not reflect actual liver function but are rather markers of liver cellular damage. The altered response to drugs in liver disease can include all or some of the following changes: Impaired intrinsic hepatic eliminating (metabolizing) capacity due to lack of or impaired function of hepatocytes. Impaired biliary elimination due to biliary obstruction or transport abnormalities (for example rifampicin is excreted in the bile unchanged and may accumulate in patients with intrahepatic or extrahepatic obstructive jaundice). Impaired hepatic blood flow due to surgical shunting., collateral circulation or poor perfusion with cirrhosis and portal hypertension. Altered volume of distribution of drugs due to increased extracellular fluid (ascites, oedema) and decreased muscle mass. Decreased protein binding and increased toxicity of drugs highly bound to proteins (for example phenytoin) due to impaired albumin production. Increased bioavailability through decreased first-pass metabolism. Decreased bioavailability due to malabsorption of fats in cholestatic liver disease. ln severe liver disease increased sensitivity to the effects of some drugs can further impair cerebral function and may precipitate hepatic encephalopathy (for example morphine). Oedema and ascites in chronic liver disease may be exacerbated by drugs that cause fluid retention (for example acetylsalicylic acid, ibuprofen, prednisolone,dexamethasone). Usually drugs are metabolized without injury to the liver. A few drugs cause dose-related hepatotoxicity. However, most hepatotoxic reactions to drugs occur only in rare persons and are unpredictable. In patients with impaired liver function the doserelated hepatotoxic reaction may occur at lower doses whereas unpredictable reactions seem to occur more frequently. Both should be avoided. Information to help prescribing in hepatic impairment is included in the following table. The table contains only those drugs that need dose adjustment. However, absence from the table does not automatically imply safety as for many drugs data about safety are absent; it is therefore important to also refer to the individual drug entries. 533
Table of medicines to be avoided or used with caution in liver disease Medicine Comment Acetylsalicylic acid Avoid in severe hepatic impairment increased risk of gastrointestinal bleeding Sedative effects increased Half life prolonged ,may need dose reduction; consider initial dose of 2.5 mg Avoid (or reduce dose) in severe liver disease Metabolism impaired in advanced liver disease. Can precipitate coma; hepatotoxic Avoid in severe liver disease Sedative effects increased Avoid or reduce dosemay precipitate coma Avoid in active liver disease and if history of pruritus or cholestasis during pregnancy Can precipitate coma Avoid in severe liver disease May cause idiosyncratic hepatotoxicity Reduce dose or administer on altemate days Can precipitate coma; hepatotoxic Hypokalaemia may precipitate coma increased risk of hypomagnesaemia in alcoholic cirrhosis Increased risk of hypoglycaemia in severe liver disease; avoid or use small dose; can produce jaundice
Amitriptyline Amlodipine
Bupivacaine Carbamazepine Chlorpromazine Clomifene Clomipramine Codeine Contraceptives, oral
Diazepam Ergometrine Erythromycin Fluoxetine Fluphenazine Furosemide
Glibenclamide
534
Heparin Hydralazine Hydrochlorothiazide lbuprofen
Reduce dose in severe liver disease Reduce dose Avoid in severe liver disease; hypokalaemia may precipitate coma Increased risk of gastrointestinal bleeding and can cause fluid retention; avoid in severe liver disease ln severe liver disease, reduce: total daily dose to one-third and give once daily Avoid or reduce dose-may precipitate coma Hepatic dysfimction reported; reduce dose in severe liver disease Dose related toxicityavoid large doses Avoidmay precipitate coma in severe liver disease; Hepatotoxic Monitor hepatic functionidiosyncratic hepatotoxicity more common; avoid in severe hepatic impairment Impaired elimination; monitor liver function; avoid or do not exceed 8 mg/ kg daily Avoid in active liver disease or unexplained persistent elevations in serum transaminases Prolonged apnoea may occur in severe liver disease due to reduced hepatic synthesis of plasma cholinesterase Avoid if possible hepatotoxicity and hepatic failure Avoid in severe liver disease, especially if prothrombin time already prolonged.
Metronidazole
Morphine Ofloxacin Paracetamol Promethazine Pyrazinamide
Rifarnpicin
Simvastatin
Suxarnethonium
Valproate Warfarin
535
APPENDIX: 5 DRUG SCHEDULES AND ACTS

There are various drug schedules and acts in India. The important ones are as per Drugs and Cosmetics Act (l940) as amended in 2001 are: Schedule A : Schedule B : Schedule C : Schedule D : Schedule F : Schedule G : gives specimen of prescribed form gives fees for test and analysis of drugs gives details with biological and other special products is concerned with exemption regarding drug import gives details of standard ophthalmic solutions deals with details of drugs to be labeled CAUTlON it is dangerous to take this medicine except under medical supervision deals with drugs and medicine to be sold on prescription only lists all ailments for which no cure can be claimed eg AIDS deals with cosmetics deals with standards for contraception gives details of drugs which should be marketed under generic name only deals with psychotropic drugs which require special licence for manufacturing and sale (new addition): specifies the requirements and guidelines on conduct of clinical trials, import and manufacturing of new drugs
Schedule H : Schedule I : Schedule Q : Schedule R : Schedule W : Schedule X : Schedule Y :
536
APPENDIX : 6 LIST OF EMERGENCY MEDICINES / LIFE SAVING DRUGS

Adenosine Injection Adrenaline Bitartrate Injection Aminophylline Injection Amiodarone Injection Antisnake venom polyvalent Injection Antitetanus Human Immunoglobulin Injection Atropine sulphate O.6mg/ml Inject ion Calcium chloride Injection Chloroquine phosphate 64.5 mg/mI (5m1 amp) Injection Dextran-70 Injection Diazepam 5mg/ml Injection Dicyclomine hydrochloride I0mg/ml Injection Diphenhydramine Injection Diltiazem Injection Diphtheria Antitoxin Injection Dobutamine 50mg/ml (5 ml amp) Injection Dopamine hydrochloride 40 mg/ml (5ml amp) injection Epinephrine hydrochloride lmg /ml Injection Flumazenil Injection Fresh Frozen Plasma Injection Frusemide 10mg/mI Injection Glucose with sodium chloride Injection Glyceryl trinitrate 5mg/ml Injection Dextrose 50% Injection Haloperidol Injection Heparin sodium 50001U/ml Injection Hydrocortisone sodium succinate I00mg/ml Injection Insulin soluble (bovine + porcine or porcine) 401U/ml injection Lignocaine IV 2% Injection Lidocaine 2% Injection Magnesium sulphate Injection Mannitol 10%, 20% Injection Metoclopramide 5mg/ml 537
Metoprolol 1mg/ml Injection Morphine sulphate Injection N/2 saline Injection N/5 saline Injection Naloxonc 0.4mg/mI Injection Neostigmine 0.5, 2.5 mg/ml lnjection Oxygen Inhalation Oxytocin Injection Pancuronium 2mg/ml Injection Phenobarbitone 200mg/ml Injection Phenytoin 50 mg/ml Injection Potassium Chloride Injection Pralidoxime chloride (2-PAM) 25mg/ml Injection Protamine sulphate Injection Rabies vaccine Injection Ringer lactate Injection Salbutamol sulphate Inhalation Sodium bicarbonate Injection Succinyl choline 50mg/ml Injection Streptokinase Injection Tetanus toxoid Injection Vit K 10 mg/ml Injection.
APPENDIX : 7 ESSENTIAL DRUG LIST (INDIA) 2003

The names of drugs are followed by the following letters to indicate their need at various levels of medical care; P - Primary health care S - Secondary health care T - Tertiary health care U - Universal. The information is given as: Name of the Drug Category Medicine Category Route of Administration/ Strengths Dosage Form

538
1. ANAESTHETICS
1.1. General anesthetics and Oxygen Ether S, T Halothane Isoflurane* Ketamine HCI Nitrous Oxide Oxygen Thiopentone Na 0.5%, 0.5%+7.5% Glucose 1.2. Local Anaesthetics Bupivacaine HCL Ethyl Chloride Lignocaine HCI Injection 1-2% Spinal 5%+7.5% Glucose Lignocaine HCl+Adrenaline U Injection 1% - 2% + Adrenaline 1:200,000in vial. U U Spray 1% Topical Forms 2-5% S,T S, T U U U S, T S,T Inhalation Inhalation Inhalation Injection 10mg/ml 50mg/ml Inhalation Inhalation Injection 0.5g, 1g powder Injection 0.25g%
1.3 Preoperative medication and sedation for short term procedures Atropine Sulphate U Injection 0.6 mg/ml Diazepam Midazolam Morphine sulphate Promethazine Doxapram U U S,T U T Tablets 5 mg, Injection 5 mg/ml Injection 1mg/ml, 5 mg/ml Injection 10 mg/ml Syrup 5 mg/5 ml Inj 4mg/ml
2. ANALGESICS, ANTIPYRETICS, NSAIDS, MEDICINES IN GOUT AND RHEUMATOID DISORDERS. 2.1 Non opioid analgesics, antipyretics and nonsteroidal antiinflammatory medicines Acetyl Salicylic Acid U Tablets 300-350 mg Diclofenac Ibuprofen *
Complementary
T U
Tablets 50 mg,100mg, Injection 25 mg/ml Tablets 200mg, 400mg 539
Paracetamol
Injection 150 mg/ml Syrup 125 mg/5ml Tablets 500mg. Injection 10 mg/ml Tablets10mg Tablets25 mg Injection 30 mg/ml Injection 50mg/ml Tablets 100mg Tablets 0.5 mg
2.2. Opioid Anaglesics Morphine Sulphate Pentazocine Pethidine HCL
S,T S,T S,T
2.3. Medicines used to treat Gout Allopurinol S,T Colchicine S,T
2.4 Disease modifying agents used in rheumatoid disorders Azathioprine S,T Tablets 50mg Choroquine Phosphate Methotrexate Sulfasalazine Adrenaline Bitartrate Chlorpheniramine Maleate Dexamethasone S,T S,T S,T U U U Tablets 150mg Tablets 2.5 mg Tablets 500mg Injection 1 mg/ml Tablets 4 mg Syrup 0.5 mg/5ml Tablets 0.5 mg Injection 4 mg/ml Injection 100mg Injection 22.75 mg/ml Tablets 5 mg Tablets 10 mg, 25 mg Syrup 5 mg/5ml.
3. ANTIALLERGICS AND MEDICINES USED IN ANAPHYLAXIS
Dexchlorpheniramine Maleate
Hydrocortisone sodium Succinate U Pheniramine Maleate Prednisolone Promethazine U S U
4. ANTIDOTES AND OTHER SUBSTANCES USED IN POISONING 4.1. Nonspecific Activate Charcoal U Powder Atropine Sulphate 540 U Injection 0.6 mg/ml
4.2. Specific Antisnake Venom Calcium Gluconate Desferrioxamine Mesylate Dimercaprol Flumazenil* U S,T S,T S,T T Injection Polyvalent Injection 100mg/ml Injection 500mg Injection in oil 50 mg/ml Injection 0.1 mg/ml Solution/ Lyophilyzed Polyvalent serum
Methylthioninium Chloride (Methylene blue) S,T Injection 10 mg/ml Naloxone Penicillamine Sodium Nitrite Sodium thiosulphate 5. ANTIEPILEPTICS Carbamazepine Diazepam Magnesium Sulphate Phenobarbitone Phenytoin Sodium U U T U S,T U Tablets 100mg,200mg Syrup 20 mg/ml Injection 5 mg/ml Injection 500mg/ml Tablets 30 mg, 60 mg Injection 200 mg/ml Capsules or Tablets 50mg,100mg, Syrup 25 mg/ml Injection 50 mg/ml Tablets 200mg,500 mg Syrup 200mg/5ml S,T S,T S,T S,T Injection 0.4 mg/ml Tablets or Capsules 250 mg Injection 25 mg/ml Injection 30 mg/ml Injection 250mg/ml
Pralidoxime Chloride (2-PAM) S,T
Sodium Valprote 6. ANTIINFECTIVES
6.1. Anthelmintics
6.1.1. Intestinal anthelmintics Albendazole Mebendazole Niclosamide * Complementary U U U Tablets 400 mg Suspension 200mg/5ml Tablets 100 mg Suspension 100 mg/ 5ml Chewable Tablets 500 mg 541
Pyrantel Pamoate
Tablets 250 mg Suspension 250 mg/ml
6.1.2 Antifilarials Diethylcarbamazine Citrate U Tablets 50 mg 6.1.3 Antischistosomals and Antitrematode Praziquantel S,T Tablets 600 mg
6.2
Antibacterials
Powder for suspension 125 mg/5ml, Capsules 250 mg, 500 mg Capsules 250 mg, 500 mg Powder for suspension 125 mg/5ml Injection 500 mg Injection 6 lacs, 12 lacs, 24 lacs units Injection 5 lacs, 10 lacs units Injection 125, 250,500 mg Injection 250 mg, 1g Injection 250 mg, 1g Injection 250 mg, 750 mg Capsules 250 mg,500mg Injection 250 mg, Liquid 125mg/5ml
6.2.1 Beta lactam medicines Amoxicillin U
Ampicillin
Benzathine Benzylpenicillin Benzylpenicillin Cefotaxime* Ceftazidime* Cetriaxone* Cefuroxime* Cloxacillin
U U S,T S,T S,T S,T U
Injection Crystalline penicillin
U Injection 250 mg/2ml Capsules or Tablets 100 mg, 250mg,500mg Suspension 100 mg/5ml Injection 500mg Syrup 125 mg/5ml Capsules 250mg,500mg
6.2.2 Other antibacterials Amikacin* S,T Azithromycin* S,T
Cephalexin* 542
Clarithromycin* Chloramphenicol
S,T S,T S,T S,T
Capsules 500 mg Injection 1 g Suspesnion 125mg/5ml Capsules,Tablets 250 mg,500mg Injection 200 mg/100 ml Tablets 250 mg,500 mg Tablets 40+200 mg Suspension 40+200 mg/5ml
Ciprofloxacin Co-trimoxazole
HCI
U U
(Trimethoprim 80+400mg sulphamethoxazole) Doxycycline Erythromycin Estolate Gentamicin Metronidazole Nalidixic Acid Nitrofurantoin Norfloxacin Roxithromycin* Sulphadiazine* Tetracycline Vancomycin HCL* 6.2.3 Antileprosy Clofazimine Dapsone Rifampicin U U U U U U U S,T S,T U T S,T U U
Capsules 100 mg Syrup 125 mg/5ml Tablets 250 mg,500 mg Injection 10mg/ml, 40 mg/ml Tablets 200 mg,400 mg Injection 500 mg/100 ml Tablets 250 mg, 500 mg Tablets 100 mg Tablets 400 mg Tablets 50 mg,150 mg Tablets 500 mg Tablets or Capsules 250 mg Injection 500 mg,1 g Capsules 50 mg, 100mg Tablets 50 mg,100mg Capsules or Tablets 150,300mg Tab 200mg,400mg,600mg,800mg Tablets 50 mg,100 mg,300mg Tablets 100 mg,200 mg Syrup 50mg/5ml Tab 500 mg,750mg,1000mg,1500 mg 543
6.2.4 Antituberculosis medicines Ethambutol U Isoniazid Ofloxacin* Pyrazinamide *

Complementary
U S,T U
Rifampicin
Capusles/Tab50mg ,150mg, 300mg, 450 mg Syrup 100mg/5ml Injection 0.75g,1g Tablets 150mg+300mg Injection 50mg Pessaries 100 mg,200mg Gel 2% Capsules or Tablets 50 mg, 100 mg, 150mg, 200mg Capsules 250 mg Capsules or Tablets 125,250 mg Tablets 200 mg Tablets 500,000 IU Pessaries 100,000 IU
Streptomycin Sulphate Thiacetazone + Isoniazid
U S,T P,S,T U S,T S,T U S,T U
6.3 Antifungal medicines

Amphotericin Clotrimazole Fluconazole Flucytosine Griseofulvin Ketoconazole Nystatin
6.4
Antiviral medicines
Tablets 200mg,400mg Injection 250 mg,500 mg Suspension 400mg/5ml
6.4.1 Antiherpes medicines Acyclovir* S,T
6.4.2 Antiretroviral medicines* 6.4.2.1 Nucleoside reverse transcriptase inhibitors Didnosine* S,T Tablets 250 mg,400 mg Lamivudine* S,T Tablets 150 mg Tablets 150 mg+200 mg+30 mg Tablets 150 mg+300 mg Capsules 15mg,30mg,40mg Tablets 100 mg,300 mg Lamivudine+Nevirapine+Stavudine* S,T Lamivudine+Zidovudine* Stavudine* Zidovudine* S,T S,T S,T
6.4.2.2 Non-nucleoside reverse transcriptase inhibitors Efavirenz* S,T Capsules 200mg,600mg Nevirapine* S,T Capsules 200mg Suspension 50mg/5ml
544
6.4.2.3 Protease inhibitors Indinavir* S,T Nelfinavir Ritonavir* Saquinavir* S,T S,T S,T
Capsules 200mg,400mg Capsules 250mg Capsules 100mg Syrup 400 mg/ml Capsules 200mg
6.5
Antiprotozoal
Tablets 500 mg Tablets 200 mg.400mg Injection 500 mg/100ml Tablets 500 mg Injection 50 mg Injection 200 mg Injection 100 mg/ml
6.5.1 Antiamoebic and antigiardiasis Diloxanide Furoate U Metronidazole U Tinidazole 6.5.2 Antileshmaniasis Amphotericin Pentamidine Isothionate Sodium Stibogluconate U P,S,T S,T S,T
6.5.3 Antimalarial medicines 6.5.3.1 For curative treatment Artesunate T Chloroquine Phosphate base U
Injection 60 mg Tablets 150 mg Injection 40 mg/ml, syrup 50mg/5ml Tablets 2.5 mg,7.5mg Tablets 25 mg Tablets 300 mg Injection 300mg/ml Tablets 500 mg+25 mg
Primaquine Pyrimethamine Quinine Sulphate Sulfadoxine+Pyrimethamine 6.5.3.2 For Prophylaxis Choloroquine Phosphate base
U U U S,T U
Tablets 150 mg Syrup 50mg/5ml
Complementary
545
6.5.4. Antipneumocystosis and Antitoxoplasmosis Co-Trimoxazole (Trimethroprim+Sulphamethoxazole) U Pentamidine Isothionate Trimethoprim S,T U Tablets 40 +200mg,80mg+400mg Suspension 40+200 mg/5ml Inj 200mg Tablets 100mg
7. ANTIMIGRAINE MEDICINES
7.1
For Treatment of acute attack

U S, T U U Tablets 300 350 mg Tablets 1 mg Tablets 500mg Tablets 10mg, 40 mg
Acetyl Salicylic Acid Dihydroergotamine Paracetamol
7.2
For prophylaxis
Propranolol HCl
8. ANTINEOPLASTIC, IMMUNOSUPPRESSIVES AND MEDICINES IN PALLIAIVE CARE
8.1
Immunosuppressive medicines
T T Tablets 50mg Capsules 10mg, 25mg, 50mg,100mg Concentrate for Injection 100 mg/ml
Azathioprine* Cyclosporine
8.2
Cytotoxic medicines
T T T T T T T T T Injection 0.5 mg Injection 3 million IU Injection 15 mg Tablets 2mg Injection 10mg/vial 50mg/ vial Tablets 50mg Injection 200 mg, 500mg Injection 100 mg/ vial 500 mg/vial, 1000 mg/vial Capsules 50mg, 100mg Injection 10 mg, 50mg
Actinomycin D* Alpha Interferon Bleomycin* Busulphan* Cisplatin* Cyclophosphamide* Cytosine Arabinoside* Danazol* Doxorubicin* 546
Etoposide* Flutamide* 5-Fluorouracil* Folinic Acid Gemcitabine HCl* L-Asparaginase* Melphalan* Mercaptopurine* Methotrexate* Mitomycin-C* Paclitaxel* Procarbazine* Vinblastine Sulphate* Vincristine
T T T T T T T T T T T T T T S,T
Capsules 100mg Injection 100 mg/ 5ml Tablet 250 mg Injection 250mg/5ml Injection 3 mg/ml Injection 200mg, 1g Injection 10000 KU Tablets 2 mg, 5 mg Tablets 50 mg, Injection 100mg/ml Tablets 2.5 mg Injection 50mg/ml Injection 10 mg Injection 30mg/5ml Capsules 50 mg Injection 10 mg Injection1 mg/ml Tablets 5 mg Injection 20 mg 25 mg (as sodium phosphate or succinate)
8.3
Hormones and antihormones
Prednisolone*
Raloxifene* Tamoxifen Citrate
T T T S,T
Tablets 60 mg Tablets 10mg,20mg Tablets 10 mg Tablets 4 mg,8mg Injection 2mg/ml Syrup2mg/5ml Tablets 1.25 mg,2.5mg Tablets 100 mg+10 mg 250mg+25mg,100mg+25mg Tablets 2 mg 547
8.4
Medicnes used in palliative care
Morphine Sulphate* Ondansetron*
9. ANTIPARKINSONISM MEDICINES Bromocriptine Mesylate S,T Levodopa+ Carbidopa Trihexyphenidyl HCl * Complementary U U
10. MEDICINES AFFECTING BLOOD
10.1 Antianemia medicines

Cyanocobalamin Ferrous Salt U U Injection 1 mg/ml Tablets Equivalent to 60mg elemental iron
Oral solution25 mg elemental iron (as sulphate)/ml Folic Acid Iron Dextran Pyridoxine Acenocoumarol 4 mg Heparin Sodium Protamine sulphate Phytomenadione Warfarin Sodium S,T S,T S,T S,T Injection 1000 IU/ml, 5000IU/ml Tablets 10mg Injection 10mg/ml Injection 10mg/ml Tablets 5 mg Menadione sodium Sulphite S,T U S,T U Tablets 1 mg,5mg Injection 50 mg iron/ml Tablets 5 mg
10.2 Medicines affecting coagulation
11. BLOOD PRODUCTS AND PLASMA SUBSTITUTES
11.1. Plasma Substitutes

Dextran-40 Dextran-70 Fresh Frozen Plasma Hydroxyethyl Starch (Hetastrach) Polygeline U U T S,T S,T S,T S,T S,T *S,T Platelet Rich Plasma 548 S,T Injection 10% Injection 6% Injection Injection 6% Injection 3.5% Injection 5%,20% Injection Injection Dried Injection Dried Injection
11.2.
Albumin Cryoprecipitate Factor VIII Concentrate*
Plasma fractions for specific use
Factor IX Complex (Coagulation Factors II, VII, IX,X)
12. CARDIOVASCULAR MEDICINES
12.1. Antianginal medicines

Acetyl Salicyclic Acid* Diltiazem Glyceryl Trinitrate Isosorbide 5 Mononitrate/ Dinitrate Metoprolol* Propranolol U S,T U Tablets 75 mg,100mg, 350mg Tablets 30 mg,60mg Sublingual Tablets 0.5 mg, Injection 5mg/ml U U U Tablets 10 mg,20mg Tablets 25 mg,50mg Injection 1 mg/ml Tablets 10 mg, 40mg Injection 1mg/ml Injection 3mg/ml Tablets 100mg,200mg Injection 150 mg Injection1mg, 2mg, 4mg/ml Tablets 30mg,60mg Injection 5mg/ml Injection 10mg/ml Injection 2mg/ml Injection 1%,2% Capsules, 50mg,150mg Injection 25mg/ml Tablets 250 mg Injection 100mg/ml* Tablets 100 mg Tablets 40mg,80 mg Injection 2.5mg/ml Tablets 2.5 mg,5 mg,10mg Tablets 50mg, 100 mg Tablets 25mg,50 mg 549
12.2. Antiarrhythmic medicines

Adenosine* Amiodarone Bretylium Tosylate* Diltiazem Diltiazem Esmolol* Isoprenaline HCl* Lignocaine HCl Mexiletine HCl Procainamide HCl Quinidine Verapamil S,T S,T T S,T T T T S,T S,T T T S,T
12.3. Antihypertensive medicines

Amlodipine Atenolol Chlorthalidone* U U U
Clonidine HCl* Enalalpril maleate Losartan Potassium* Methyldopa Nifedipine Propranolol Sodium Nitroprusside* Terazosin* Digoxin
S,T U S,T U S,T U T S,T S,T
Tablets 100mg,150 mg Tablets 2.5,5,10 mg Injection 1.25 mg/ml Tablets 25,50 mg Tablets 250 mg Capsules 5,10 mg Tablets 10mg,40 mg Injection 50mg/5ml Tablets 1,2,5 mg Tablets 0.25 mg Injection 0.25 mg/ml Elixir 0.05 mg/ml
Tablets 10 mg, 20 mg, Sustained release capsules 10mg, or tablets 20 mg,
12.4 Medicines used in heart failure
Dobutamine* Dopamine HCl Acetyl Salicylic Acid Herparin sodium* Streptokinase Urokinase
S,T S,T U S,T S,T T
Injection 50mg/ml Injection 40 mg/ml Tablets 75,100mg Injection 1000,5000 IU/ml Injection 750,000, 15,00,000 IU Injection 500,000 IU/ml 10,00,000 IU/ml
12.5. Antithrombotic medicines
13. DERMATOLOGICAL MEDICINES (TOPICAL)
13.1. Antifungal medicines

Benzoic Acid+Salicyclic Acid U Miconazole Acyclovir Framycetin sulphate U S,T U U Neomycin+ Bacitracin 550 U Ointment or Cream 6%+3% Ointment or Cream 2% Cream 5% Cream 0.5% Aqueous solution 0.5% Ointment 5mg+500 IU
13.2. Antiinfective medicines
Methylrosanilinium Chloride (Gentian Violet)
Provide Iodine Silver Nitrate Silver Sulphadiazine
U U U
Solution or Ointment 5% Lotion 10% Cream 1% Cream/Ointment 0.05% Lotion Dusting powder Solution 5% Ointment 0.1-2% Solution Solution 5% Lotion 25% Lotion 1%
13.3 Antiinflammatory and antipruritic

Betamethasone Dipropionate U Calamine U 13.4 Astringent medicines Zinc Oxide U Coal Tar Dithranol* Glycerin Salicylic Acid Benzyl Benzoate Gamma Benzene Hexachloride 14. DIGNOSTIC AGENTS U T U U U U
13.5 Medicines affecting skill differentiation and proliferation
13.6 Scabicides and pediculicides
14.1 Opthalmic medicines

Fluorescein Lignocaine Tropicamide S,T S,T S,T S,T S,T S,T S,T S,T S,T S,T Eye drops 1% Eye drops 4% Eye drops 1% Suspension 100%w/v 250%w/v Injection 3 g Tablets 500 mg Injection 60% w/v (iodine= 280 mg/ml) Meglumine Iotroxate Propyliodone Sodium Iothalamate Solution 5-8 g (Iodine in 100-250 ml) Oily,suspension 500-600 mg/ml Injection 70% w/v (iodine = 420 mg/ml) 551
14.2 Radiocontast media

Barium Sulphate Calcium Ipodate Iopanoic Acid Meglumine Iothalamate
Sodium Melgumine Diatrizoate
S,T
Injection 60% w/v (Iodine conc.=292 mg/ml)76%w/v (Iodine conc. 370mg/ml)
15. DISINFECTANTS AND ANTISEPTICS
15.1. Antiseptics
Acriflavin+Glycerin Benzion Compound Cetrimide Chlorhexidine Ethyl Alcohol 70% Gentian Violent Hydrgoen Peroxide Povidone Iodine 15.2 Disinfectants Bleaching Powder Formaldehyde IP Glutaraldehyde Potassium Permanganate 16. DIURETICS Furosemide Hydrochlorothiazide Mannitol* Spironolactone U U S,T U U U U U Powder Solution Solution 2% Crystals for solution Injection, 10mg/ml Tablets 40 mg Tablets 25 mg, 50 mg Injection 10%,20% Tablets 25 mg U U U U U U U U Solution Tincture Solution 20% (conc. for dilution ) Solution 5% (conc. For dilution) Solution Paint 0.5%,1% Solution 6% Solution 5%,10%
17. GASTROINTESTINAL MEDICINES
17.1.
Antacids and other antiulcer medicines

U Tablet Suspension Capsules 10,20,40 mg Tablets 150, 300mg Injection 25 mg/ml.
Aluminium Hydroxide+ Magnesium Hydroxide Omeprazole Ranitidine HCl U U
552
17.2 Antiemetics
Domperidone Metoclopramide U U Tablet 10mg Syrup 1mg / ml Tablet 10mg Syrup 5mg/ml Injection 5mg / ml Tablet 5mg,25mg Tablet 10mg, 25mg Elixir or Syrup 5 mg/5ml Injection 25mg/ml
Prochlorperazine Promethazine
U U
17.3 Antihaemorrhoidal medicines

Local anaesthetic, Astringent and Antiinflammatory medicines U Ointment/ suppository
17.4 Antiinflammatory medicines

Sulfasalazine Dicyclomine HCl Hyoscine Butyl Bromide T U U Tablets 500mg Tablets 10 mg Injection 10 mg/ml Tablets 10 mg Injection 20mg/ml Tablets/ suppository 5 mg Granules Powder for solution As per IP Tablets 100 mg Syrup 25 mg/5 ml Capsules 2mg
17.5 Antispasmodic medicines
17.6 Laxatives
Bisacodyl Isphaghula U U
17.7 Medicines used in diarrhoea

17.7.1 Oral rehydration salts U 17.7.2 Antidiarrhoeal medicines Furazolidone S,T
Loperamide* S,T (Contraindicated for pediatric use) 18. HORMONES, OTHER ENDOCRINE MEDICINES AND CONTRACEPTIVES
18.1. Adrenal hormones and synthetic substitutes

Dexamethasone Hydrocortisone Sodium Succinate S,T Tablets 0.5 mg Injection 4 mg/ml Injection 100 mg/ml 553
Methylprednisolone Prednisolone
S,T U T T
Injection 40 mg/ml Injection 5 mg 10 mg Capsules 40 mg (as undecanoate) Injection 25 mg/ml (as propionate)
18.2. Androgens
Testosterone
18.3 Contraceptives
18.3.1 Hormonal contraceptives Enthinylestradiol+ Levonorgesterol U Enthinylestradiol+ Norethisterone Hormone Releasing IUD U T
Tablets 0.03+0.15 mg Tablet 0.035mg+1mg Levonorgesterol Releasing IUD
18.3.2 Intrauterine devices IUD containing Copper U 18.3.3 Condoms Barrier Methods U
18.3.4 Non hormonal contraceptives Centchroman U Tablets 30 mg
18.4 Estrogens
Ethinylestradiol U Tablets 0.01,0.05mg
18.5 Antidiabetics and hyperglycaemics

18.5.1 .Insulins and other antidiabetic Agents Glibenclamide U Tablets 2.5mg, 5mg Insulin Injection (Soluble) Internediate Acting Insulin (Lente/NPH Insulin) Metformin 18.5.2 Hyperglycaemics Glucagon* U U U T T Injection 40 IU/ml Injection 40 IU/ml Tablets 500 mg Injection 1mg/ml Tablets 25,50,100mg
18.6 Ovulation inducers

Clomiphene Citrate*
18.7 Progestogens
Medroxy Progresterone Acetate 554 U Tablets 5 ,10 mg
Norethisterone Carbimazole Levothryoxine Iodine 19. IMMUNOLOGICALS
U S,T S,T S,T
Tablets 5 mg Tablets 5 mg, 10 mg Tablets 0.1 mg Solution 8mg/5ml
18.8 Thyroid and antithyroid medicines
19.1 Diagnostic agents

Tuberculin, Purified Protein Derivative Anti-DS, Immunoglobulin (Human) Antisnake Venom Antitetanus Human Immunoglobin Diphtheria antitoxin Rabies Immunoglobulin U Injection
19.2 Sera and Immunoglobulins

T U U S,T U Injection 250,300 mg Injection 10ml Injection 250 IU, 500IU Injection 10,000 IU Injection 150 IU/ml
19.3 Vaccines
19.3.1 For universal immunization BCG Vaccine U DPT Vaccine Hepatitis B Vaccine Measles Vaccine U U U U Injection Injection Injection Injection Solution
Oral Poliomyelitis Vaccine (Live Attenuated) 19.3.2 For Specific group of individuals Rabies Vaccine U Injection Tetanus Toxoid U Injection 20 MUSCLE RELAXANTS (PERIPHERALLY ACTING) AND CHOLINESTERASE INHIBITORS Atracurium Besylate* S,T Injection 10mg/ml Neostigmine Pancuronium Bromide * Complementary S,T S,T Tablets 15 mg Injection 0.5 mg/ml Injection 2mg/ml 555
Pyridostigmine Bromide Succinyl Choline Chloride
S,T S,T
Tablet 60 mg Injection 1mg/ml Injection 50 mg/ml
21. OPTHALMOLOGICAL PREPARATIONS
21.1 Antinfective Agents

Chloramphenicol Ciprofloxacin HCI Gentamicin Miconazole Povidone Iodine Sulphacetamide Na Tetracycline HCI Prednisolone Acetate Prednisolone sodium Phosphate Xylometazoline U U U U S,T U U U U U U S,T S,T S,T S,T S,T U U U T Drops/ Ointment 0.4 %, 1% Drops/Ointment 0.3% Drops 0.3% Drops 1% Drops0.6% Drops 10%,20%,30% Ointment 1% Drops 0.1% Drops 1% Drops 0.05%, 0.1% Drops 0.5% Tablets 250 mg Drops 0.25%,0.5% Drops 0.25% Drops 2%,4% Drops 0.25%, 0.5% Drops/Ointment 1% Drops 2% Drops 5% Injection 2%
21.2 Antiinflammatory agents
21.3 Local anaesthetics

Tetracaine HCI Acetazolamide Betaxolol HCI Physostigmine Salicylate* Pilocarpine Timolol Maleate
21.4 Miotics and antiglaucoma medicines
21.5 Mydriatics
Atropine Sulphate Homatropine Phenylephrine Methyl Cellulose*
21.6 Ophthalmic Surgical Aids

22. OXYTOCICS AND ANTIOXYTOCICS
22.1 Oxytocics
556
Methyl Ergometrine Mifepristone Oxytocin
U T S, T S, T S, T
Tablets 0.125mg Injection 0.2 mg/ml Tablets 200mg Injection 5, 10 IU/ml Tablets 10 mg Injection 5 mg/ml Tablets 2.5 mg Injection 0.5 mg/ml
22.2 Antioxytocins
Isoxsuprine HCL Terbutaline Sulphate
23. PERITONEAL DIALYSIS SOLUTION Intraperitoneal Dialysis Solution (of approximate composition) 24. PSYCHOTHERAPEUTIC MEDICINES
24.1 Medicines used in psychotic disorders

Chlorpromazine U Tablets 25, 50,100 mg Syrup 25 mg/5 ml Injection 25 mg/ml Tablets 1.5, 5, 10 mg Injection 5 mg/ml Tablets 5 mg, 10 mg
Haloperidol Trifluoperazine
S, T S, T
24.2 Medicines used in mood disorders

24.2.1 Medicines used in depressive disorders Amitriptyline U Tablets 25 mg Fluoxetine HCL Imipramine U U Capsules 20 mg Tablets 25 mg, 75 mg
24.2.2 Medicines used in bipolar disorders Lithium Carbonate T Tablets 150 mg 24.3 Medicines used for generalized anxiety and sleep disorders Alprazolam U Tablets 0.25, 0.5 mg Diazepam Nitrazepam 24.4 U U Tablets 2, 5, 10 mg Tablets 5 mg, 10mg
Medicines used for obsessive compulsive disorders and panics attacks Clomipramine HCL S, T Tablets 10, 25 mg *
Complementary
557
25. MEDICINES ACTING ON THE RESPIRATORY TRACT
25.1 Antiasthmatic medicines

Aminophylline Beclomethasone Dipropionate Hydrocortisone Sodium Succinate Salbutamol Sulphate U U U U Injection 25 mg/ml Inhalation 50 mg, 250 mg/dose Injection 100, 200, 400 mg Tablets 2mg, 4 mg Syrup 2 mg/5 ml Inhalation 100 mg/dose Tablets 100, 200mg Tablets 10 mg Syrup 15 mg/5 ml Dextromethorphan U Tablets 30 mg
Theophylline Compounds 25.2 Antitussives Codeine Phosphate
U U
26.
SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACIDBASE DISTURBANCES 26.1 Oral

Oral Rehydration Salts U U Powder for Solution As per IP Injection 5% isotonic 50% hypertonic Injection 5%+ 0.9% Injection 0.9% Injection Injection Injection 11.2% Sol. Injection Injection Injection 2, 5, 10 ml Tablets 100,500 mg
26.2
Parenteral
Glucose Glucose with Sodium chloride Normal Saline N/2 Saline N/5 Saline Potassium Chloride Ringer Lactate Sodium Bicarbonate
U U S,T S,T U U U U U
26.3 Miscellaneous
Water for Injection 27. VITAMINS AND MINERALS Ascorbic Acid 558
Calcium salts Multivitamins Nicotinamide Pyridoxine Riboflavine Thiamine Vitamin A
U U U U U U U
Tablets 250,500 mg Tablets Tablets 50 mg Tablets 25 mg Tablets 5 mg Tablets 100 mg Tablets 5000 IU Capsules 10,000 IU 50,000 IU Injection 50,000 IU/ml
(Having composition as per schedule Y of drugs and cosmetics act,1940)
Vitamin D3 (Ergocalciferol)
S,T
Capsules 0.25 mg,1mg
APPENDIX 8 LIST OF DRUGS BANNED IN INDIA

LIST OF DRUGS PROHIBITED FOR MANUFACTURE AND SALE THROUGH GAZETTE NOTIFICATIONS UNDER SECTION 26 A OF DRUGS & COSMETICS ACT 1940 BY THE MINISTRY OF HEALTH AND FAMILY WELFARE
DRUGS PROHIBITED FROM THE DATE OF NOTIFICATION.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Amidopyrine Fixed dose combinations of vitamins with anti-inflammatory agents and tranquillizers. Fixed dose combinations of Atropine in Analgesics and Antipyretics. Fixed dose combinations of Strychnine and Caffeine in tonics. Fixed dose combinations of Yohimbine and Strychnine with Testosterone and Vitamins. Fixed dose combinations of Iron with strychnine, Arsenic and Yohimbine. Fixed dose combinations of Sodium Bromide/chloral hydrate with other drugs Phenacetin Fixed dose combinations of antihistaminic with antidiarrhoeals Fixed dose combinations of Penicillin with Sulphonamides 559
11. 12. 13. 14. 15. 16.
Fixed dose combinations of Vitamins with Analgesics. Fixed dose combinations of any other Tetracycline with Vitamin C. Fixed dose combinations of Hydroxyquinoline group of drugs with any other drug except for preparations meant for external use Fixed dose combinations of Corticosteroids with any other drug for internal use. Fixed dose combinations of Chloramphenicol with any other drug for internal use Fixed dose combinations of crude Ergot preparations except those containing Ergotamine, Caffeine, analgesics, antihistamines for the treatment of migraine, headaches Fixed dose combinations of Vitamins with anti TB drugs except combination of Isoniazid with pyridoxine Hydrochloride (Vitamin B6) Penicillin skin/eye Ointment. Tetracycline Liquid Oral preparations Nialamide Practolol Methapyrilene, its salts. Methaqualone Oxytetracycline Liquid Oral preparations Demeclocycline liquid oral preparations Combination of anabolic Steroids with other drugs. Fixed dose combinations of Oestrogen and Progestin (other than oral contraceptive) containing per tablet estrogen content of more than 50 mcg (equivalent to Ethinyl Estradiol) and progestin content of more than 3 mg (equivalent to Norethisterone Acetate) and all fixed dose combination injectable preparations containing synthetic Oestrogen and Progesterone. (Subs.By Noti.No.743 (E) dated 10-08-1989). Fixed dose combinations of Sedatives/hypnotics/anxiolytics with analgesics- antipyretics. Fixed dose combination of Rifampicin,isoniazid and Pyrazinamide, except those which provide daily adult dose given below
17.
18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
* 28. *29.
560
Drugs Rifampicin Isoniazid Pyrazinamide *30.
Minimum 450 mg 300 mg 1000mg
Maximum 600 mg 400mg 1500 mg
Fixed dose combination of Histamine H-2 receptor antagonists with antacids except for those combinations approved by Drugs Controller, India. The patent and proprietary medicines of fixed dose combinations of essential oils with alcohol having percentage higher than 20% proof except preparations given in the Indian Pharmacopoeia All pharmaceutical preparations containing Chloroform exceeding 0.5% w/w or v/v whichever is appropriate. Fixed dose combination of Ethambutol with INH other than the following: INH200mg +Ethambutol 600mg. or INH 300mg.+ Ethambutol 800mg. Fixed dose Combination containing more than one antihistamine. Fixed dose combination of any anthelmintic with cathartic/ purgative except for piperazine Fixed dose combination of Salbutamol or any other bronchodilator with centrally acting antitussive and/or antihistamine. Fixed dose combination of laxatives and/or anti-spasmodic drugs in enzyme preparations. Fixed dose combination of Metoclopramide with systemically absorbed drugs except fixed dose combination of metoclopramide with aspirin/paracetamol. Fixed dose combination of centrally acting, antitussive with antihistamine, having high atropine like activity in expectorants. Preparations claiming to combat cough associated with asthma containing centrally acting antitussive and/or an antihistamine. Liquid oral tonic preparations containing glycerophosphates and/ or other phosphates and/or central nervous system stimulant and such preparations containing alcohol more than 20% proof. Fixed dose combination containing Pectin and/or Kaolin with any drug which is systemically absorbed from Gl tract except for 561
*31.
*32. **33.
**34. **35. **36. **37. **38.
**39. **40. **41.
**42.
combinations of Pectin and/or Kaolin with drugs not systemically absorbed. *** 43. Chloral Hydrate as a drug. 44. 45. 46. 47. 48 49. Dovers Powder I.P. Dovers Powder Tablets I.P. Antidiarrhoeal formulations containing Koalin or Pectin or Attapulgite or Activated Charcoal. Antidiarrhoeal formulations containing Phthalyl Sulphathiazole or Sulphaguanidine or Succinyl Sulphathiazole. Antidiarrhoeal formulations containing Neomycin or Streptomycin or Dihydrostreptomycin including their respective salts or esters. Liquid Oral antidiarrhoeals or any other dosage form for pediatric use containing Diphenoxylate Lorperamide or Atropine or Belladona including their salts or esters or metabolites Hyoscyamine or their extracts or their alkaloids. Liquid Oral antidiarrhoeals or any other dosage form for pediatric use containing halogenated hydroxyquinolines. Fixed dose combination of antidiarrhoeals with electrolytes. Patent and Proprietary Oral Rehydration Salts other than those conforming to the following parameters (a) Oral rehydration salts on reconstitution to one litre shall contain: sodium-50 to 90mM; dextrose: sodium molar ratio-not less than1:1 and not more than 3:1 (b) Cereal based ORS on reconstitution to one litre shall contain: total osmolarity not more than2900mOsm.Precooked rice equivalent to not less than 50g and not more than 80g as total replacement of dextrose (c) ORS may contain amino acids in addition to ORS conforming to the parameters specified above and labeled with the indication for Adult choleratic Diarrhoea only (d) ORS shall not contain mono or polysaccharides or saccharin sweetening agent 53. Fixed dose combination of Oxyphenbutazone or Phenylbutazone with any other drug.
50. 51. 52.
562
54. 55.
Fixed dose combination of Analgin with any other drug. Fixed dose combination of dextropropoxyphene with any other drug other than antispasmodics and/or non-steroidal antiinflammatory drugs (NSAIDS) Fixed dose combination of a drug, standards of which are prescribed in the Second Schedule to the said Act with an Ayurvedic, Siddha or Unani drug. Mepacrine Hydrochloride (Quinacrine and its salts) in any dosage form for use for female sterilization or contraception. Fenfluramine and Dexfenfluramine. Fixed dose combination of Diazepam and Diphenhydramine Hydrochloride.
56.
57. 58. 59.
DRUGS PROHIBTED FOR MANUFACTURE,SALE AND DISTRIBUTION FROM SUBSEQUENT DATE

Drugs Formulation Effective date Notification
1.
2.
3.
4.
5.
6.
Cosmetics Licensed as toothpaste/tooth Powder containing tobacco Parenteral Preparations fixed dose Combination of streptomycin with Penicillin Fixed dose combination of Vitamin B1 Vitamin B6 and Vitamin B12 for human use Fixed dose combination of haemoglobin in any from (natural or synthetic). Fixed dose combination of Pancreatin or Pancrelipase containing amylase, protease And lipase with any other enzyme Fixed dose combination of Nitrofurantoin and trimethoprim.
With immediate effect Jan 1,1998
GSR 444 (E) dt.30.4.92 GSR 93 (E) dt. 25.2.97
Jan 1,2001
GSR702 (E) dt.14.10.99
Sep 1, 2000
GSR 814(E) dt. 16. 12. 99 GSR 814(E)
Sep. 1. 2000
dt16.12.99 Jan 1, 2002 GSR 170(E) dt. 12.3.01 563
7.
8.
9.
10
11.
12.
13.
14.
Fixed dose combination of Phenobarbitone with any anti-asthmatic drugs Fixed dose combination of Phenobarbitone with Hyoscine and/ or Hyoscyamine Fixed dose combination of Phenobarbitone with Ergotamine and/ or Belladona Fixed dose combination of Haloperidol with any anti-cholinergic agent including Propantheline Bromide Fixed dose combination of Nalidixic Acid with any anti-amoebic including Metronidazole Fixed dose combination of Loperamide Hydrochloride with Furazolidone Fixed dose combination of Cyproheptadine with Lysine or Peptone Astemizole
Jan 1,2002
GSR 170 (E) dt.12.3.01 GSR 170 (E) dt.12.3.01
Jan 1,2002
Jan 1,2002
GSR 170 (E) dt. 12.3.01
Jan 1,2002
GSR 170 (E) dt.12.3.01
Jan 1,2002
GSR170 (E) dt.12.3.01
Jan 1,2002
GSR170(E) dt.12.3.01
Jan 1,2003 Apr.1,2003 Apr.1,2003 Oct. 1, 2003 Dec 13, 2004 July 25, 2005
15. Terfinadine 16. Fenformin 17. Rofecoxib 18. Valdecoxib and its formulation 564
GSR170 (E) dt. 12.3.01 GSR 191 (E) dt.5.3.03 GSR 191 (E) dt.5.3.03 GSR 780(E) dt . 1. 10. 03 GSR 810(E) dt. 13. 12. 04 GSR 510(E) Dt25.07.05
APPENDIX 8 ADVERSE DRUG EVENT REPORTING FORM
565
INDEX
Abacavir ............................................................................ 88 Aceclofenac ....................................................................... 35 Acetazolamide .................................................................. 293 Acetretin ........................................................................ 190 Acetylcystine ................................................................... 344 Acetyl salicylic acid ................................................... 31,103,339 Activated charcoal ............................................................. 413 Acyclovir ........................................................................... 85 Adapalene ....................................................................... 195 Adenosine arabinoside ........................................................ 344 Adrenaline ....................................................................... 422 Alendronate ..................................................................... 257 Albendazole ....................................................................... 99 Alemtuzumab .................................................................... 137 Alkylating Agents ............................................................... 105 All Trans Retinoic Acid (ATRA) ............................................... 135 Allopurinol ....................................................................... 273 Anti D Immunoglobulin ........................................................ 259 Anti Tetanus Immunoglobulin ................................................ 259 AlphaMethyldopa ............................................................... 169 Alprazolam ....................................................................... 326 Altepase .......................................................................... 141 Aluminium hydroxide .......................................................... 222 Anastrazole ...................................................................... 116 Amantadine ................................................................... 88,124 Ambroxol ......................................................................... 344 Amidotrizoate ................................................................... 200 Amifostine ....................................................................... 119 Amikacin ........................................................................... 69 566
Amiloride .................................................................... 160,213 Aminoacid infusion ............................................................. 351 Aminoglycosides .................................................................. 11 Aminophylline .............................................................. 342,371 Amiodarone ................................................................ 178,345 Amitriptyline ............................................................ 10,276,315 Amlodipine ....................................................................... 166 Amoxapine ....................................................................... 318 Amoxycillin ................................................................... 64,187 Amphotericin B ................................................................. 83 Ampicillin ..................................................................... 63,187 Androgens ....................................................................... 242 Antacids .......................................................................... 222 Anti oestrogens ................................................................ 246 Antiandrogens .................................................................. 243 Anticoagulants .................................................................. 156 Antidepressants ................................................................ 315 Antifungal drugs .................................................................. 83 Antihistamines .................................................................. 220 Antimalarial drugs ................................................................ 91 Antispasmodic .................................................................. 225 Antithyroid drugs .............................................................. 254 Antiviral drugs .................................................................... 85 Aprotinin ......................................................................... 143 Artemether ........................................................................ 92 Artesunate ........................................................................ 93 Ascorbic acid .............................................................. 278,354 Asparaginase .................................................................... 114 Aspirin ............................................................................ 138 Atenolol ..................................................................... 153,161 Atorvastatin ..................................................................... 156 567
Atracurium ...................................................................... 284 Atropine sulphate ........................................................... 27,340 Azathioprine ....................................................................... 42 Azelastine ........................................................................ 360 Azithromycin ...................................................................... 74 Aztreonam ......................................................................... 68 Bacitracin ......................................................................... 77 Baclofen ......................................................................... 281 Balzalazide ....................................................................... 234 Barium sulphate ................................................................ 201 BCG vaccine ..................................................................... 261 Beclomethasone Dipropionate .................................... 343,361,372 Benzathine penicillin ............................................................ 62 Benzhexol ....................................................................... 125 Benzoyl peroxide ............................................................... 194 Benzylbenzoate ................................................................. 191 Benzyl penicillin .............................................................. 11,61 Beta blockers ................................................................... 153 Betamethasone ....................................................... 187,220,239 Betaxolol ......................................................................... 293 Bethanechol .................................................................... 275 Bezafibrate ...................................................................... 157 Biguanides ....................................................................... 251 Biotin ............................................................................. 353 Bisacodyl ......................................................................... 231 Bisoprolol ........................................................................ 162 Bisphosphonate ................................................................ 256 Bivalirudin ....................................................................... 130 Bleomycin ....................................................................... 111 Bosentan ......................................................................... 173 Botulinum toxin ................................................................ 282 568
Bromhexine ..................................................................... 344 Bromocriptine .................................................................. 121 Budesonide .................................................. 219,233,343,362,372 Bupivacaine ....................................................................... 23 Buprenorphine ................................................................... 41 Bupropion ....................................................................... 324 Buspirone ........................................................................ 327 Calamine ......................................................................... 188 Calcium polycarbophil ......................................................... 233 Calcium channel blockers .................................................... 163 Calcium gluconate ................................................... 255,306,357 Calcipotriol ...................................................................... 189 Captopril ......................................................................... 170 Carbamazepine .................................................................... 51 Carbimazole ..................................................................... 254 Carboplatin ...................................................................... 115 Carisoprodol ..................................................................... 283 Carvedilol ................................................................... 163,345 Cefdinir ............................................................................ 67 Cefazolin ........................................................................... 65 Cefepime ........................................................................... 67 Cefixime ............................................................................ 67 Cefoperazone ..................................................................... 66 Cefotaxime ........................................................................ 65 Cefpodoxime proxetil ........................................................... 66 Cefpirome ......................................................................... 67 Ceftazidime ........................................................................ 66 Ceftriaxone ........................................................................ 66 Cefuroxime ........................................................................ 65 Cephalexin ......................................................................... 65 Cephalosporins ................................................................... 64 569
Ceruminolytics .................................................................. 220 Cetirizine ................................................................... 220,341 Chenodeoxycholic acid ....................................................... 235 Chlorambucil ............................................................... 105,269 Chloramphenicol ............................................................ 11, 71 Chlorhexidine ................................................................... 205 Chloroquine .......................................................... 43,91,97,340 Chlorpheniramine Maleate ................................................... 220 Chlorpromazine ................................................................. 307 Chlorthalidone .................................................................. 159 Chloroxylenol ................................................................... 208 Cholestyramine ................................................................. 274 Cyclosporin ................................................................... 10,190 Ciclopiroxolamine .............................................................. 182 Ciprofloxacin ................................................................. 10, 79 Cisplatin .......................................................................... 114 Citalopram ....................................................................... 321 Clarithromycin ............................................................... 73,198 Clindamycin .................................................................. 75,303 Clobazam ........................................................................... 35 Clofazamine ...................................................................... 197 Clomiphene Citrate ............................................................ 304 Clomipramine ................................................................. 10,318 Clonidine ......................................................................... 168 Clopidogrel ...................................................................... 139 Clotrimazole ........................................................... 182,220,302 Cloxacillin ..................................................................... 63,187 Clozapine ........................................................................ 312 Coal Tar Ointment ............................................................. 188 Carbidopa +Levodopa .......................................................... 120 Codeine Phosphate ......................................................... 10, 41 570
Conjugated oestrogen ........................................................ 245 Copper ........................................................................... 358 Co-trimoxazole .................................................................... 81 Cyanocobalamin ................................................................ 353 Cyclopentolate ................................................................. 293 Cyclophosphamide ..................................................... 10,105,263 Cycloserine ...................................................................... 368 Cyclosporine .................................................................... 267 Cytarabine (cytosine arabinoside) .......................................... 109 Dacarbazine ..................................................................... 107 Dactinomycin ................................................................... 112 Danazol ........................................................................... 243 Dapsone ..................................................................... 193,196 Daunorubicin .................................................................... 111 Deferiprone ..................................................................... 133 Deflazacort ...................................................................... 239 Deriphylline ..................................................................... 342 Desferrioxamine ................................................................ 132 Dexamethasone ................................................................. 239 Dextran 70 ....................................................................... 146 Dextropropoxyphene ............................................................ 41 Diazepam ......................................................... 10,27,28,281,325 Diclofenac Sodium ............................................................... 33 Dicyclomine ................................................................ 225,341 Didanosine ......................................................................... 89 Diethylcarbamazine ............................................................ 101 Digoxin ...................................................................... 174,344 Dihydrotachysterol ............................................................ 255 1, 25 dihydroxy Cholecalciferol (Calcitriol) ....................................................................... 354 Diloxanide furoate ............................................................... 97 571
Diltiazem ......................................................................... 164 Diphenhydramine ............................................................... 341 Diphenylhydantoin ............................................................. 178 Dipyridamole .................................................................... 138 Disopyramide .................................................................... 176 Disulfiram ........................................................................ 329 Dithranol ......................................................................... 188 Dobutamine ................................................................ 180,344 Docetaxel ........................................................................ 113 Domperidone ............................................................... 227,341 Donepezil ........................................................................ 287 Dopamine ................................................................... 175,344 Dothiepin ........................................................................ 318 Doxapram ........................................................................ 375 Doxepin .......................................................................... 319 Doxorubicin ..................................................................... 110 Doxycycline ....................................................................... 71 DPT vaccine ..................................................................... 261 Duloxetine ....................................................................... 322 Dutasteride ...................................................................... 275 Eculizumab ....................................................................... 131 Edrophonium .................................................................... 286 Efavirenz ....................................................................... 10,90 Emollients ........................................................................ 188 Enalapril ..................................................................... 171,175 Entacapone ..................................................................... 123 Epinephrine .................................................................. 23,341 Epirubicin ........................................................................ 113 Epsilon amino caproic acid (EACA) .......................................... 142 Ergocalciferol ................................................................... 255 Erythromycin .................................................................. 10,72 572
Esmolol ...................................................................... 162,345 Ethambutol ...................................................................... 365 Ethinyloestradiol ............................................................... 245 Ethionamide ..................................................................... 368 Ethosuximide ...................................................................... 53 Ethanol ........................................................................... 206 Etoposide ........................................................................ 115 Etoricoxib ......................................................................... 35 Ezetimibe ........................................................................ 158 Famotidine ....................................................................... 224 Felbamate ......................................................................... 59 Felodipine ....................................................................... 166 Fenofibrate ...................................................................... 157 Fexofenadine ................................................................... 221 Finasteride ................................................................. 243,275 Flavoxate ......................................................................... 276 5 Fluorouracil ................................................................. 109 Fluconazole ..................................................................... 187 Fludarabine ...................................................................... 136 Flucytosine ........................................................................ 84 Fluorescein Sodium ............................................................ 204 Fluoxetine ....................................................................... 319 Flupenthixol ..................................................................... 310 Fluphenazine .................................................................... 309 Flurazepam ...................................................................... 328 Flutamide ........................................................................ 244 Fluticasone propionate .................................................. 343,372 Fluvoxamine ..................................................................... 320 Fondaparinux ................................................................... 129 Folic acid ........................................................................ 353 Fosphenytoin ..................................................................... 50 573
Framycetin ................................................................... 70,187 Frusemide (furosemide) ....................................................... 210 Fusidic Acid ..................................................................... 186 Gabapentin ........................................................................ 56 Galantamine ..................................................................... 288 Ganciclovir ........................................................................ 85 Gatifloxacin ....................................................................... 80 Gefitinib .......................................................................... 118 Gemcitabine ..................................................................... 110 Gemfibrozil ...................................................................... 157 Gentamicin ........................................................................ 69 Gentian Violet .................................................................. 186 Griseofulvin ...................................................................... 185 Glibenclamide .............................................................. 249,250 Gliclazide ........................................................................ 250 Glimipiride ....................................................................... 249 Glipizide .......................................................................... 250 Glucagon ......................................................................... 252 Glucose .......................................................................... 351 Glucocorticoids ................................................................ 237 Glutaral .......................................................................... 209 Glycerine ........................................................................ 232 Glyceryl Trinitrate ............................................................. 151 Glycopyrrolate .................................................................... 30 Granisetron ................................................................ 228,304 Haloperidol ................................................................... 10,309 Halothane ......................................................................... 18 Heparin ....................................................................... 11,128 Hepatitis B Immunoglobulin .................................................. 261 Homatropine .................................................................... 294 Hydralazine ...................................................................... 167 574
Hydrochlorothiazide ...................................................... 159,210 Hydrocortisone ............................................... 11,188,240,241,341 Hydroxocobalamine ............................................................ 128 Hydroxy pregesterone caproate ............................................ 247 Hydroxy Urea ................................................................... 131 Hydroxyzine ..................................................................... 221 Hyoscine butyl bromide ................................................. 226,341 Indinavir ........................................................................ 10,90 Ibuprofen ..................................................................... 33,339 Ifosfamide ........................................................................ 106 Imatinib ..................................................................... 118,137 Imipenem .......................................................................... 67 Imipramine ................................................................ 2, 76,317 Indapamide ............................................................ 106,159,272 Indomethacin ................................................................ 34,340 Infliximab ......................................................................... 234 Inhaled steroids ................................................................ 372 Injectable contraceptives .................................................... 303 Insulins ........................................................................... 251 Interferon Alpha ............................................................. 87,117 Immunoglobulins ................................................................ 258 Intravenous nitroglycerine ................................................... 153 Iodine ............................................................................ 359 Iohexol ........................................................................... 202 Ipratropium Bromide ...................................................... 342,370 Iron ..................................................................... 127,128,358 Isoflurane .......................................................................... 18 Isoniazid ....................................................................... 10,363 Isoprenaline ..................................................................... 181 Isosorbide 5 mononitrate ..................................................... 152 Isosorbide Dinitrate ............................................................ 152 575
Ispaghula husk .................................................................. 232 Itraconazole ..................................................................... 185 Ivermectin .................................................................. 102,191 Kanamycin .................................................................... 69,367 Ketamine ........................................................................... 19 Ketoconazole .............................................................. 183,184 Ketorolac .......................................................................... 37 Ketotifen ................................................................... 362,374 Labetalol ......................................................................... 163 Lactobacillus Acidophilus ..................................................... 229 Lactulose ........................................................................ 231 Lamivudine ......................................................................... 89 Lamotrigine ........................................................................ 55 Lansoprazole .................................................................... 224 Levetiracetam .................................................................... 58 Letrozole ........................................................................ 116 Levodopa ........................................................................ 120 Levofloxacin ....................................................................... 80 Levothyroxine sodium ......................................................... 253 Lignocaine .......................................................... 23, 26,177,345 Linezolid ........................................................................... 78 Liquid paraffin .................................................................. 231 Lisinopril ......................................................................... 171 Lithium Carbonate ............................................................. 324 Lomefloxacin ...................................................................... 79 Loperamide ...................................................................... 229 Loratidine ....................................................................... 221 Lorazepam ....................................................................... 327 Losartan ..................................................................... 172,345 Lovastatin ........................................................................ 156 Lugols Iodine .................................................................... 255 576
Loxapine ......................................................................... 311 Macrolides ......................................................................... 72 Magnesium hydroxide ......................................................... 222 Magnesium Salts ................................................................ 357 Magnesium trisilicate .......................................................... 222 Magnesium sulphate ................................................... 60,306,342 Mannitol ......................................................................... 213 Measles vaccine ................................................................ 262 Mebendazole ...................................................................... 99 Medroxy progesterone acetate ............................................. 305 Mefenamic Acid ........................................................ 35,305,340 Mefloquine ........................................................................ 93 Meglumine ....................................................................... 203 Melphalan ....................................................................... 106 Mercaptopurine ................................................................ 108 Meropenem ....................................................................... 68 Mesalazine ....................................................................... 234 Mesna ............................................................................ 119 Metformin ....................................................................... 251 Methadone ................................................................... 10,329 Methocarbamol ................................................................. 281 Methotrexate ...................................................... 44,107,190,340 Methyl Ergometrine ........................................................... 299 Methyl Prednisolone ...................................................... 238,270 Metoclopramide ................................................................ 226 Metoprolol ...................................................................... 161 Metronidazole .................................................................... 95 Metyrapone ..................................................................... 241 Mexiletine ....................................................................... 177 Miconazole ...................................................................... 182 Midazolam ......................................................................... 21 577
Milnacipran ...................................................................... 322 Mifepristone .................................................................... 301 Minerals .......................................................................... 403 Minocycline .................................................................. 71,198 Minoxidil ......................................................................... 194 Misoprostol ...................................................................... 301 Mirtazapine ...................................................................... 322 Mitomycin ....................................................................... 112 Moclobemide ................................................................... 323 Monteleukast ................................................................... 343 Morphine .......................................................................... 38 Mosapride ....................................................................... 228 Moxifloxacin ....................................................................... 81 Mupirocin ......................................................................... 77 Mycophenolate mofetil ....................................................... 269 Naphazoline ..................................................................... 218 Naproxen ........................................................................ 340 Nedocromil sodium ............................................................ 373 Neomycin .......................................................................... 70 Neomycin + Bacitracin ........................................................ 186 Neostigmine .................................................................. 27,286 Netilmicin .......................................................................... 69 Neutral phosphate ............................................................. 273 Nevirapine ......................................................................... 91 Nicorandil ....................................................................... 155 Nicotinamide .................................................................... 403 Nicotinic Acid ................................................................... 158 Nifedipine ............................................................... 10,165,345 Nimodipine ...................................................................... 166 Nitrates .......................................................................... 151 Nitrazepam ...................................................................... 328 578
Nitrous Oxide ................................................................ 18, 21 Norethisterone ................................................................. 305 Norfloxacin ........................................................................ 78 Nortriptyline .................................................................... 317 NSAIDs .............................................................................. 31 Nystatin ............................................................................ 84 Oestrogens ...................................................................... 244 Ofloxacin ..................................................................... 79,197 Olanzapine ....................................................................... 313 Omeprazole ..................................................................... 224 Ondansetron .................................................................... 227 Opioid Analgesics ................................................................. 38 Oral contraceptives ........................................................... 303 ORS ............................................................................... 350 Orphenadrine ................................................................... 126 Orthophosphate ................................................................ 274 Oseltamivir ......................................................................... 86 Oxcarbazepine .................................................................... 52 Oxaliplatin ....................................................................... 115 Oxazepam ........................................................................ 327 Oxybutinin ....................................................................... 276 Oxygen therapy .................................................................. 22 Oxymetazoline .................................................................. 218 Oxytocin ......................................................................... 298 Paclitaxel ........................................................................ 113 Pancuronium .................................................................... 284 Pantoprazole .................................................................... 225 Para Aminosalicyclic Acid (PAS) .............................................. 368 Paracetamol ........................................................ 10, 32,104,339 Parenteral nutrition ........................................................... 387 Papaverine ....................................................................... 279 579
Paroxetine ....................................................................... 320 Pefloxacin ......................................................................... 79 Penicillamine ............................................................ 46,274,340 Penicillin G ........................................................................ 61 Penicillin V ......................................................................... 63 Penicillins - Broad spectrum ................................................... 63 Penicillins - betalactamase resistant ......................................... 63 Penicillins .......................................................................... 11 Pentamidine ....................................................................... 98 Pentazocine ....................................................................... 40 Perindopril ....................................................................... 172 Permethrin ...................................................................... 192 Pethidine .......................................................................... 39 Pheniramine Maleate .......................................................... 341 Phenobarbitone ............................................................. 10, 49 Phenoxymethyl penicillin ....................................................... 63 Phenylephrine .................................................................. 360 Phenytoin ................................................................ 10, 49,178 Pholcodeine ..................................................................... 376 Phosphorus ...................................................................... 357 Pimozide .......................................................................... 311 Piperacillin ......................................................................... 64 Piperazine ....................................................................... 100 Piroxicam .......................................................................... 36 Podophyllum resin ............................................................. 190 Polyene Antibiotics .............................................................. 77 Polymyxin B ...................................................................... 77 Poliomyelitis vaccine (oral)IP ................................................. 262 Potassium ........................................................................ 356 Potassium citrate ............................................................... 272 Potassium permanganate ...................................................... 184 580
Povidone iodine ................................................................ 206 Pramipexol ....................................................................... 122 Praziquantel ..................................................................... 101 Prazocin .......................................................................... 169 Prednisone ............................................................ 131,134,270 Prednisolone ............................................................... 237,342 Pregabalin ......................................................................... 59 Primaquine ......................................................................... 94 Procainamide .................................................................... 176 Procaine penicillin ............................................................... 62 Prochlorperazine ............................................................... 309 Procyclidine ..................................................................... 125 Progesterone ................................................................... 247 Promethazine ...................................................... 27, 29,126,341 Propranolol ................................................................. 104,160 Propylthiouracil ................................................................ 254 Prostaglandin .................................................................... 299 Psoralen .......................................................................... 189 Pyrantel pamoate .............................................................. 100 Pyrazinamide .................................................................... 365 Pyridostigmine .................................................................. 286 Pyridoxine ....................................................................... 273 Pyrimethamine .................................................................... 94 Quinidine ..................................................................... 10,176 Quinine ....................................................................... 10, 95 Quetiapine ...................................................................... 314 Rabeprazole ..................................................................... 225 Rabies Immunoglobulin ........................................................ 260 Racecadotril .................................................................... 229 Ramipril .......................................................................... 172 Raloxifen ......................................................................... 246 581
Ranitidine ........................................................................ 223 Ranolazine ....................................................................... 155 Rasagiline ........................................................................ 123 Reboxetine ...................................................................... 323 Riboflavin ........................................................................ 352 Rifampicin ............................................................... 11,197,364 Rimantidine ........................................................................ 86 Risperidone ..................................................................... 313 Ritonavir ........................................................................... 10 Rituximab ........................................................................ 117 Ropinirole ....................................................................... 122 Rosuvastatin ..................................................................... 156 Roxithromycin .................................................................... 74 Salbutamol .................................................................. 342,369 Salicylic acid .................................................................... 182 Salmeterol ....................................................................... 343 Saquinavir .......................................................................... 10 Secnidazole ....................................................................... 97 Selegiline ........................................................................ 123 Selenium sulphide .............................................................. 183 Sertraline ........................................................................ 319 Sildenafil ......................................................................... 280 Silver-sulphadiazine .............................................................. 82 Sirolimus ......................................................................... 268 Sisomycin ........................................................................ 186 Sodium bicarbonate ................................................. 220,278,356 Sodium Chloride ................................................................ 355 Sodium cromoglycate .................................................... 219,361 Sodium Etidronate ............................................................. 256 Sodium Nitroprusside .......................................................... 167 Sodium Stibogluconate .......................................................... 97 582
Sodium Thiosulphate .......................................................... 183 Sodium valproate ................................................................. 53 Sotalol ............................................................................ 179 Sparfloxacin ....................................................................... 80 Spiramycin ......................................................................... 75 Spironolactone ............................................................ 159,212 Stavudine .......................................................................... 90 Streptokinase ................................................................... 140 Streptomycin ............................................................... 68,366 Sulphacetamide .................................................................. 83 Sulphasalazine ............................................................... 45,233 Sulphonamide ..................................................................... 81 SulphonylUreas ................................................................. 249 Suxamethonium Chloride ..................................................... 285 Synthetic progestins .......................................................... 247 Systemic corticosteroids ..................................................... 193 Tacrolimus ....................................................................... 268 Tadalafil .......................................................................... 280 Tamoxifen ..................................................................... 10,116 Tegaserod ....................................................................... 232 Teicoplanin ........................................................................ 77 Temozolamide ................................................................... 107 Terazosin .................................................................... 170,275 Terbinafine ................................................................. 183,185 Terbutaline ................................................................. 343,370 Terfenadine ..................................................................... 306 Testosterone .................................................................... 242 Tetracycline .................................................................. 11, 70 Thalidomide ..................................................................... 117 Theophylline ................................................................. 10,370 Thiamine ......................................................................... 352 583
Thiazide diuretics ......................................................... 210,272 Thiopentone sodium ............................................................. 20 Thioridazine ..................................................................... 308 Thymoglobulin .................................................................. 271 Thyroid Hormone .............................................................. 253 Thyroxin Sodium (T4) .......................................................... 253 Tiagabine .......................................................................... 57 Tibolone ......................................................................... 246 Ticarcillin .......................................................................... 64 Ticlopidine ...................................................................... 139 Timolol ............................................................................. 10 Tinidazole .......................................................................... 97 Tissue Plasminogen Activator (Altepase) ................................... 141 Tizanidine ....................................................................... 282 Tolterodine tartrate .......................................................... 277 Topical antibiotics ............................................................. 186 Topical Steroids ................................................................ 189 Topiramate ........................................................................ 57 Torasemide ...................................................................... 211 Tramadol ........................................................................... 40 Tranexamic acid ................................................................ 305 Trastuzumab ..................................................................... 118 Tretinoin .................................................................... 135,195 Triamcinolone ................................................................... 240 Triamterene ..................................................................... 160 Trifluoperazine .................................................................. 308 Trihexyphenidyl(benzhexol) ............................................. 125,253 Trimetazidine .................................................................... 154 Trimethoprim-Sulfamethoxazole ............................................... 81 Urokinase ........................................................................ 141 Ursodeoxycholic acid ......................................................... 235 584
Vaccines ......................................................................... 261 Valaganciclovir .................................................................... 85 Vancomycin ....................................................................... 76 Vecuronium ..................................................................... 285 Venlafaxine ...................................................................... 321 Verapamil ................................................................ 10,163,345 Vigabatrin .......................................................................... 56 Vinblastine ....................................................................... 113 Vincristine .................................................................... 10,114 Vitamin A ......................................................................... 352 Vitamin B2 ....................................................................... 352 Vitamin B6 ....................................................................... 353 Vitamin D ......................................................................... 354 Vitamin E ......................................................................... 355 Vitamin K ......................................................................... 355 Warfarin .......................................................................... 130 Xipamide ......................................................................... 159 Xylometazoline .................................................................. 218 Zafirlukast ....................................................................... 374 Zidovudine ......................................................................... 88 Zinc sulphate ................................................................... 358 Ziprasidone ...................................................................... 314 Zopiclone ........................................................................ 328 Zoledronic acid ................................................................ 118 Zuclopenthixol ................................................................. 315
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Kerala State Drug Formulary

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Kerala State Drug Formulary

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KERALA STATE DRUG FORMULARY

CENTRAL DRUG FORMULARY COMMITTEE

Dr. K.V. KRISHNADAS, B.Sc., MBBS, FRCP, FAMS, DTM & H,

DR. VISHWAS MEHTA IAS

DR. SUDHEENDRA GHOSH JDME DR. RENEEGA GANGADHAR Convenor

DR.V. GEETHA DME

Define the patients problem

Specify the therapeutic objective

Selecting therapeutic strategies

General advice to Prescribers

General advice to Prescribers

Body weight and age

General advice to Prescribers

Physiological and pharmacokinetic variables

Drug metabolism and excretion

General advice to Prescribers

General advice to Prescribers

The doctor-patient interaction

General advice to Prescribers

The health care system

General advice to Prescribers

ADVERSE EFFECTS AND INTERACTIONS

Adverse drug reactions

Major factors predisposing to adverse effects

General advice to Prescribers

General advice to Prescribers

General advice to Prescribers

General advice to Prescribers

General advice to Prescribers

possible. If unavoidable, a zero should be written in front of the decimal point.

Narcotics and controlled substances

General advice to Prescribers

Quantitative tools available to evaluate resource use in medicine

General advice to Prescribers

General advice to Prescribers

General advice to Prescribers

SECTION - 1 DRUGS USED IN ANAESTHESIA

GENERAL ANAESTHETICS AND OXYGEN

Isoflurane Ideal for neurosurgery. 18

I:, C/I:,D/I: A/E:

P/A: Dose: Maintenance: Children: Ketamine I: C/I:

Note: Thiopental I: C/I:

Intravenous General Anaesthetics

A/E: P/A: Dose: D/I: Midazolam I and Dose:

Dose: Anaesthesia: D/I: Oxygen I: FIRE HAZARD:

Injection: Dental cartridge: 26

SKILLED TASKS. A/E:

Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs

P/A: Dose: Cost:

C/I: P/C: A/E :

Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs

P/A : Oral liquid:

C/I: P/C:A/E: A/E: P/A: Dose:

Non-Steroidal Anti-Inflammatory Drugs

A/E: P/A: Dose:

A/E: P/A: Dose: 40

Non-Steroidal Anti-Inflammatory Drugs

Drugs in Rheumatoid Disorders