Pharma presentation

Skills , Knowledge , attitude

Skills

• Selling skills : from the selling skills verbal are the

following ( Rapport , Probing & Question F&B, or selling
point, Cross sales , Up sales, active listening ,
persuading & influencing the customers, objection&
handling the objection, buying signals , consultation
selling, customer focused ,customer networking , types
of customer ,…..
• Merchandizing
• Customer care
• Communication
• Social style
Skills

• OTC. Guide line

• Counter & counter cases management
• Skills depend on the knowledge as history ,
diagnosis , lines of treatment
Knowledge

• Product knowledge : generic & trade name ,

dosage form & conc. , Frequency of the dose,
quantity of the dose , main use & side effect
• Counseling with the drugs
• The classification & its importance :
• Feature & sales point in the products
• Cases : history , counter diagnosis , lines of
treatment , patient education , closing
Knowledge

• The classification importance :2 main point

are :
• Through the classification know the main use
• Problem solving as the following
1. To change to other drug when the 1st one is
not effective
2. To give combination
Knowledge

1. As problem solving for allergy

2. To overcome the other side effect
3. To decrease the need for maximum dose
Knowledge

• Frequency of the dose :

1. To be professional consultant by specific
knowledge
2. Considered as one of (F.B.T) or sales point
which help in the persuading ,
3. To overcome the problem of over dose
specially in the narrow therapeutic index
drugs
Knowledge

1. To be official in the prescribing specially for

hesitated customer
2. Help patient to become more compliance
3. Also help in problem solving as customer
service (not able to take 3 time daily ) ,
children in night ), Seasonal OTC
side effect remember : patient education ,
C.S. , problem solving & also sales
I-Anti infection

• Antibiotics
• Sulphonamide
• Ant mycobacterium
• Anti viral systemic &topical
• Antifungal systemic & topical
• Anthelmentics & antiprotrazoal
Antibiotic class

According to the mechanism of action can be

classified the antibiotic to the following :
• Inhibition of cell wall synthesis
B-lactams (penicillin , cephalosporin ,
carbapenems ,monobactams )
Non B- lactams as the following
Fosfomycin as Monurol,
Glycopeptide as vancomycin
Antibiotic class

• Polypeptide antibiotic as bacitracin topically

used
• Cycloserine antibiotic it is secondary drug for
tuberculosis
• Also inhibition of cell membrane as polymyxin,
also other antibacterial as group has
antifungal effect as amphotericin , imidazole ,
nystatin, …
Antibiotic class

• Inhibition of DNA synthesis as following

DNA gyrase inhibitor as Quinolone , Rifambicin
Folate or Competitive antagonist as
Dihydroperfolate synsetase inhibitor Ex.
sulphonamide (folate antagonist )
Dihydrofolate reductase inhibitor Ex.
trimethoprim (folate antagonist ) there
fore the combination of sulphonamide and
trimethoprime lead to bactericidal effect .
Antibiotic class

• Inhibition of protein synthesis where inhibit

bacterial ribosome through binding the
activity at
30s subunit reversible binding ex. Tetracycline
Bacteriostatic effect
30s subunit irreversible binding ex.
Aminoglycoside. Bactericidal effect
Antibiotic class

50s subunit reversible binding ex.

Chloramphenicol (bacteriostatic effect )
50s subunit irreversible binding ex. Macrolide &
clindamycin ( bactericidal effect )
Antibiotic class

• Penicillin & beta lactam group

• Cephalosporin group (1st ,2nd ,3rd ,4th , 5th ,… )
• Tetracycline group
• Quinolone group
• Macrolide group
• Lincosamide group
• Amino glycoside group
• Other antibiotic ( glycopeptides antibiotic )
Antibiotic class

• Combination of antibiotic with sulphonamide

& other
• In the different classes we will discus the
following : as FBT or sales point
1. Spectrum
2. Frequency of the dose as (official frequency,
sales point or F.B.T)
3. Taste for antibiotic syp. As sales point or F.B.T.
Antibiotic class

4. The main side effect & cross sensitivity as

customer services , & problem solving & sales
5. Counseling during dispensing or prescribing of
the antibiotic where it is necessary in some
type
Penicillin & beta lactam group

I – Penicillin
• Penicillin is narrow spectrum gm +ve *
• Penicillin injection not taken orally where will
be destructed by stomach juice
• Frequency ; there are different types :
1. Short acting penicillin as penicillin G sodium
1*3
Penicillin & beta lactam group

1. Intermediate acting as penicillin procaine 1*2

2. Long acting penicillin (Benthazine penicillin )
1200000 : according to the case may be
1*month, 1*21 day , 1*15 d
• The main side effect is anaphylactic shock
• There are cross sensitivity between all
members of beta lactam group &
cephalosporin group
Penicillin & beta lactam group

• The 2nd type is (penicillin V ) the product is

phenoxy methyl penicillin it is orally penicillin
where not affected by stomach juice as ospen
• Ospen narrow spectrum +ve
• Frequency of the dose is 1*3 or 1*4 short
where it is duration of action
Penicillin & betalactam gp.

• Example for long acting penicillin (benthacin

penicillin ) are retarpen & durapen
• Example for oral penicillin is ospen
• II- Ampicillin :
• Spectrum is broad spectrum
• Frequency of the dose is short duration 1*3
• Safe in the pregnant
• The main side effect is diarrhea
Penicillin betalactam group

• May be severe diarrhea due to

psedomembrenous colitis
• Ampicillin combination as ampiclox (Ampicillin
+ Cloxacillin
• III- Amoxycillin :
• The spectrum is broad spectrum
• Amoxicillin is more absorbable than Ampicillin
therefore it is rapid onset of action & less S.E.
Penicillin betalactam group

• Therefore amoxicillin is more suitable for

hepatic patient but vice versa in Ampicillin
therefore Ampicillin is suitable for kidney
problem * ‫هذة المعلومة تحتاج الي مراجعة‬
• Amoxicillin combination : clavulonic A. has bitter taste
• Amoxicillin & Clavulonic acid as augmentin
• Spectrum is broad spectrum
• Clavulonic acid has synergism effect due to
betalactamse inhibitor role, no antibac. effect
Penicillin betalactam group

• Frequency of the dose as the following :

• Conc. 100 , 125 , 250 , 500 mg , is 1*3
• Conc. 200 , 400 , 875 mg , is 1* 2 this is sales
point in the product , C.S. & problem solving &
patient more compliance
• It is first choice in the pregnant
• The main side effect is the diarrhea
• Amoxicillin more secreted through kidney but
Ampicillin more secreted through G.I.T
Penicillin betalactam group

• Amoxiclave is highly effective

• It is drug of choice in tonsillitis
• Frequency of the dose as the following :
• Conc. 62.5 , 156 , 312, 375 , 625 mg is 1*3
• Conc. 228 , 457, 600 ES , 1 gm & 1gm ES sales
point , more C.S. , more problem solving ,
patient more compliance
• The conc. 600 SR depend on more high conc.
Of amoxicillin
Penicillin betalactam group

• But the same conc. Of clavulonic acid this lead

to high effect but less side effect
• The main side effect of amoxiclave is diarrhea
• V- Other B. lactam antibiotic also called
broad spectrum & antipsedomonal penicillin
(carbinocillin,pipercillin,…. ) these drugs has
beta lactamase inhibitor effect , wide range
gm. –ve effect & effect on pseudomonas m. o ,
examples for these antibiotics are ( Azactam,
Tienam , pepril , ) & Azetreonam
Cephalosporin group

• VI- Cephalosporin group :

• There is cross sensitivity with Penicillin .&beta.
Lactam group
• Spectrum is broad spectrum but :
• 1st & 2nd generation has more effect on gm.
+ve m. O also 1st generation considered as
anti staphylococcal drugs due to effect on
staphylococcus &penicillinase producing
staphylococci
• 3rd generation has more effect on gm –ve m.o
Cephalosporin

• 4th generation has high effect on gm-ve & gm

+ve m. O it is considered (extended spectrum )
• Diarrhea is the main side effect but
• 1st & 2nd generation are high S. E (diarrhea )
• 2nd & 3rd generation are very low S.E. (diarrhea
• Also 3rd &4th generation cross the blood brain
barrier therefore it is one of drug of choice for
meningitis, also only cefuroxime of 2nd
generation
Cepalosporin

• 1st generation as cephradine as velosef ,

cephalaxin as cephalax , & frequency of the
dose of them is 1*3
• And Cephadroxil as cephadrox & F. of the dose
is 1*2 as sales point with its different rational
• 2nd generation as Cefuroxime Ex. Zinnate , … &
cefprozil ex. Cefzil or cefproz , & F. of the dose
of the last 2 drugs are 1*2
Cephalosporin

• And cefaclor as ceclor or tabiclor ; the F. of

the dose of cefaclor according to the conc. as
the following :
• Cefaclor 125 , 250 , 500 mg is 1*3 but
• Cefaclor 375 suspension or 750mg is 1*2 also
selling point in the products
Cepalosporin

• An other selling point in the Cefaclor products

is acceptable taste where it is by strawberry
taste
• 3rd generation as cefexime ex. Suprax N.B, in
children the dose of cefixime equal the weight
of cefixime multiply 0 .4 . Other drugs of 3rd
generation as cefdinir ex. Omenicef & the F.
of the dose is total calculated dose dose once
/day or total dose divided to twice day
Cephalosporin

• Also 3rd generation as cefpodoxime ex.

Cefodox & cefditrone ex. Miact & F. of the
dose of these drugs are twice /day
• 4th generation as cefopime & all products are
injection
• Remember that the frequency of the dose
& taste is selling point apply in the persuading
, problem solving , C.S. , & more compliance
patient ,
Cephalosporin

• 4th generation of cephalosporin is cefopime

• 5th generation of cephalosporin ceftaroline as
fosamil
• They are wide therapeutic index where can
ranged from 50 mg to 100 mg / kg /day
* ‫ إستكمال هذة الشريحة‬Selling point .‫بأنواع متعددة‬

• From suspension products have acceptable

taste as selling point are ceclor , omnicef ,
augmentin , zithromax, ………………………… but
zinnate not acceptable need to shacking for
long time to decrease it
• From products has frequency of the dose as
selling point are all products its frequency
once or twice ex. Cefixime , omnecif ,
doxycycline , but once daily only as
azithromycin , klacid Xl
Tetracycline group

• This is broad spectrum bacteriostatic , also

active against mycoplasma , richettsia ,
spirochaetes , aerobic & anaerobic M.o
• Two main drugs are available the first one
tetracycline ex. Tetracycline cap. Its F. of the
dose is 1*3 or 1*4
• The 2nd drug is doxycycline Ex. Vibramycin
cap.& its F. of the dose is 1*2 as in traveler
diarrhea but other frequency has 2 regimen
Tetracycline group

• 1st regimen for acne loading dose 2 capsules

together 1st dose then 1cap. Daily for month
• 2nd regimen for treatment of trachoma also
loading dose 2 cap. 1st dose then one cap.
Daily for 14 day
• The main side effect : GIT up set (irritation of
the stomach , Nausea ,… ) , precipitated in the
bone lead to bone discoloration(yellow bone ),
• Vestibular disturbance ( dizziness )
,Nephrotoxicity , hepatotoxicity
Tetracycline group

Also photosensitivity , & decrease the

absorption of other drugs when take together
• Precaution & counseling before prescribing or
dispending the tetracycline group
1. Take with large amount of water
2. Not take with high calcium containing
products as milk & milk products
3. Not take with other drugs specially Ca., iron ,
Tetracycline group

And plain antacids where make complex with

these drugs & decrease its absorption
4- Avoid sun exposure or use sun screen due to
photosensitivity effect
5-Not prescribe for age less than 12 year where
precipitate in bone & lead to yellow teeth
• Contra indication : children less than 12 year ,
pregnant , kidney & liver failure
Quinolone group

• The nucleus of Quinolone group is nalidexic

acid which is safe in the pregnant but
• Quinolone as antibiotic is fluorinated analogs
of nalidexic acid & not safe in the pregnant
• it is very effective against gm – ve cocci ,
bacilli & Pseudomonas aeruginosa
• but developed fluoroquinolone has effect on
gm +ve, gm –ve m.o , also effect on
Quinolone group

• mycoplasma , richetssia mycobacterium &

Plasmodium falciparum , but less effective on
streptococci & staphylococci
• Some members of quinolone effective on
Chlamydia trachomatis as ofloxacin, …….
• 4th generation act on Top isomeraze lead to
less resistance
Quinolone group

• Fluroquinolone has liver enzyme inhibitor

effect lead to decrease hepatic drug
metabolism lead to increase the conc. of the
drug in the plasma as theophyline
Quinolone group

• Main side effect of quinolone : *Nausea ,

vomiting , diarrhea , *headache , dizziness ,
*insomnia ,* Skin rash ( photosensitivity ) ,
tendinitis
• New generation lead to arrhythmia due to
prolongation of Q.T. interval
• N.B the photosensitivity is less in 3rd & 4th
generation
• Epilepsy attack increase with NSAIDs & old
Quinolone
Quinolone group

• But the epilepsy attack less affected with 3rd &

4th generation
• New generation lead to arrhythmia due to
prolongation of Q.T. interval
• Precaution during prescribing or dispending of
quinolone group :
1. Take with large amount of water
Quinolone

1. Not take with high calcium containing

products as milk & milk products
2. Not take with other drugs specially Ca., iron ,
and plain antacids where make complex with
these drugs & decrease its absorption
4- Avoid sun exposure or advice by use sun
screen due to photosensitivity effect
5-Not prescribe for age less than 18 year due to
articular erosion
Quinolone

• Avoid prescribing Quinolone & ant epilepsy &

NSAIDs with each other where increase
episode specially 1st & 2nd generation
• Also avoid prescribing for age above 70 year *
• Contraindication :age less than 18 year ,
pregnant , hepatic & kidney failure , Fauvism ,.
• Quinolone drugs classified to
•
Quinolone

• 1st is nalidexic acid ( nalgram ) narrow

spectrum Gm –ve & mainly on urinary tract
infection , short duration of action 1*3
• 2nd generation Gm-ve more effective as
norfloxacin ex. Noroxin, & ofloxacin ex. Tarvid
• & the frequency of the dose is 1*2
•
Quinolone

• Also 2nd generation as ciprofloxacin ex.

Ciprobay , & enoxacin ex.penetrex 400,200 mg
& the frequency of the dose is 1*2
• 3rd gen. as Lomefloxacin ex. Lomax
gemifloxacin ( Factive ) , Levofloxacin(Tavanic )
, Levox
• 4th gen. Moxifloxacin ex. Avalox , Maxima
• the frequency of the dose of 3rd & 4th is once
/day, also highly effective gm + ve cocci
Quinolone

• ( streptococcus pneumonia ) , also has activity

against anaerobic there fore highly effective in
chronic bronchitis & sinusitis
• The main application of quinolone as
following :
• Sinusitis, otitis media , chronic bronchitis, &
chronic bronchopneumonia , meningococcal
inf., anal abscess , gonorrhea , brucella ,
trachoma , conjunctivitis due to pseudomonas
• Enteritis , urinary tract infection
Macrolide

• Sale point
• More active against +ve M.o* anaerobic M.o
‫البحث‬,
• Has effect on Atypical M.O*
mycoplasma,chlamedia, also pseudomonas,
there fore it is the drug of choice in
mycoplasma respiratory infection,
campylobacter gastroenteritis ( diarrhea in
children ) , diphtheria, pyogenic skin infection
• Due to last effect & no cross sensitivity with,
Macrolide

• penicillin so it is good alternative to penicillin

& betalactam group
• It has effect on Haemofillus but the
azithromycin is the better in this effect also
azithromycin has short course 3 day regimen
,single daily dose & still in tissue for 7 day
• Macrolide effective on toxoplasmosis during
pregnancy specially spiramycin then josamycin
• Macrolide effective on H.pylori
Macrolide

• Bactericidal at normal & high dose but

bacterostatic at low dose ( dose dependent )
• Have competitive inhibition for liver enzyme
i.e decrease the drugs metabolism lead to
increase the drugs plasma conc.
• But Azithromycin & Clarithromycin are less
one in liver inhibiting enzyme & erythromycin
is the highest one
• Clarithromycin bioavailability less affected by
food
Macrolide

• Also azithromycin & erythromycin used in

treatment of cervical chlamydial infection
during preg., azithromycin can used one shout
• The main side effect is mild gastric upset &
diarrhea ,disturbance in taste & smell , Ch. Ju.
the s. Effect decrease with new products &
azithromycin & clarithromycin are less s. Effect
Macrolide

• Macrolide should avoided with jaundice

• NB . New Research on Azithromycin may be
has an arrhythmia
• Macrolide drugs as :
• Erythrocin ex. Erythrodar F. of dose is 1*3 or
1*4 , Clarithromycin ex. Klacid 1*2 & xl once
/day , Azithromycin 1*1 , roxitheromycin 1*2
, spiramycin & josamycin ex. Josaxin 2*2
Macrolide

• Azithromycin dosage form & concentration

• Cap. 250 mg 6 cap. 2 cap. Once daily before
meal or after meal by 2 hours
• Tab. 500 mg ex. Azimack one tab. Daily not
related to meal ( sales point )
• Zithromax cap. 250mg 4 cap. Take as one
shout dose in case of gonorrhea
• Suspension : this dosage form has different
volume but by the same concentration
Macrolide

• Different volume of azithromycin to be

suitable for different age & weight as the
following :
• 15 ml suitable till 20 kg & the dose 5 ml/day
• 22.5 ml suitable till 30kg, the dose 7.5 ml/day
• 30 ml suitable till 40 kg , the dose 10ml/day
• The conc. Is 40 mg /1ml
• Weight divided on 4 give the dose per ml for
any age or any weight in children
Lincosamide group

• Sales point
• Clendamycin also more effective on gm +ve ,
penicillin resistant & some anaerobic m.o
• No cross sensitivity with penicillin
• Short duration of action therefore the
preferable F. of the dose is 1*3 but practically
double dose quantity & twice frequency
• The main side effect is diarrhea may be severe
diarrhea due to pseudo membranous colitis
Lincosamide

• Clendamycin dosage form & conc.

• Cap. 150mg , 300 mg ex. Dalacin cap.
• Solution 1% suitable for oily skin
• Lotion 1% suitable for dry skin
• Gel 1% suitable for all type of skin
• Vaginal cream 2% local antibacterial effect
• It is suitable for skin infection , soft tissue as
dental infection , acne problem , ….
Amino glycoside

• All oral product of amino glycoside not

absorbed therefore it has local effect only
except neomycin has some systemic effect
• Neomycin used in hepatic comma (hepatic
encephalopathy) with lactulose
• The dosage form in the pharmacy are drops &
creams or oint
• It has bactericidal effect with more effect on
gm –ve m.o (GIT & U.T infection )
Amino glycoside

• It has synergism effect with beta lactam group

• Its systemic effect through injection dosage
form as gentamycin , streptomycin injection
• Streptomycin considered the 2nd line of
treatment of T.B
• The main side effect of amino glycoside are :
Nephro toxicity , oto toxicity , & neuromuscular
blokade ( paralysis of muscle )
Dose is 5mg /kg /day divided into 2 dose
Chloramphenicol& aminoglycoside

Nephro toxicity , oto toxicity , & neuromuscular

blokade ( paralysis of muscle )
Dose is 5mg /kg /day divided into 2 dose
Chloramphenicol :
• Spectrum : it is broad spectrum,
bacteriostatic,
• The drugs as chloramphenicol & thiophenicol
• The drug of choice in treatment of typhoid
Chloramphenicol

• Chloramphenicol drops stimulate optic nerve

• The main side effect are bone marrow
depression , bleeding , optic nerve atrophy ,
high dose in children lead to gray syndrome*,
• Contra indicated in newborn due to gray
syndrome due to glucouronyltransferase def.
Quantity of the dose of anti biotic

• Equation for weight calculation till 10 year old

• Amoxicillin 25 – 50 mg /kg / day
• Amoxicillin + clavulanic A. 25 – 50 mg /kg/day
• Amoxicillin + Clavulanic A ES 50 – 90 mg/kg/d
• Cephalexin 25 – 50 mg /kg/day
• Cefadroxil 25 – 50 mg /kg/day
• Cefaclor 20 – 40 mg /kg/day
• Cefuroxime 20 – 40 mg /kg/day
• Cefprozil 20 – 40 mg /kg/day
Quantity of the dose of anti biotic & anti infection

• Cefpodoxime 10 – 12 mg /kg/day
• Cefdinir 8 – 14 mg /Kg/day
• Cefxime 8 mg /kg /day
• Clarithromycin 15 mg /kg /day
• Azithromycin 10 – 20 mg /kg / kg/day
• Spiramycin 100000 - 150000 IU may to
300 thousand divided into 2 dose for 5 day
• Roxitheromycin 5-8 mg/kg/day divided 2 dose
• Clendamycin 8 – 14mg /kg/day
Quantity of the dose of anti biotic & anti infection

• Sulphamethoxazole 20 – 30mg/kg/day
• Trimethoprime 6 mg /kg /day
• Acyclovir 10mg /kg/dose for 7-10 day
• Amantadine 100 – 400 mg /day for adult
but for children 5- 10 mg /kg/day in 2 dose
not exceed 200 mg daily
• A Lamivudine 3 mg /kg /day for child
• Lamivudine 100 mg – 300 mg for adult
• Adevofir 10 mg / day
Quantity of the dose of other anti infection

• Chloroquine 8 mg /kg/dose
• Mefloquine 20 – 25mg/kg/dose
• Fluconazole 100 mg /day but till maximum
dose 800 mg/daily for adult but for
children 3- 6 mg / kg/day
• Fluconazole syp. 25 mg / 5 ml
• Itraconazole 100 mg / daily but till maximum
dose 400 mg / daily
Quantity of the dose of other anti infection

• Ketoconazole 100 – 400 / daily

• Nystatin 100.000 unit /dose = 1ml = one
dropper every 6 hour but for infant can use ½ d.
• Miconazole 30mg /dose every 6 h. for infant
60mg / dose every 6 h. for children
for 7- 10 day
Miconazole 2% oral gel = 120 mg /spoon
• Griseofulvin 10 mg /kg/day
• Griseofulvin suspension 125 mg/5 ml
Quantity of the dose of other anti infection

• Metronidazole 25 – 50 mg /kg/day divided in

3 equal dose or( 8- 16 mg/dose ) & according
the severity of problem & type of parasite
where giardia need to minimum dose
• Metronidazole susp. 125 ,250 , 200 mg /5ml
• Tinidazole 30 - 50 mg /kg /day as single dose
available in tab. 500mg per tab. Practically one
tab. For each 15 kg
Quantity of the dose of other anti infection

• Secnidazole ( flagentyl 500mg/ tab. ) as

tinidazole
• Drugs effect on nematodes
• Mebendazole 100 mg /dose twice daily 3 day
is the same for all ages available in 100 mg / 5
ml but tab. 100 mg *
• Albendazole 100 mg /dose one shout or
twice* but 200 mg for adult
• Flubendazole as mebendazole
NSAIDs & Pain management

• Pain definition : is unpleasant sensation due

to the tissue damage or inflammation process
, where the prostaglandin E2 is thought to
sensitize nerve ending to the action of
bradykinin , histamine & other chemical
mediator which also released locally by
inflamatory process & damage of the tissue
there are different type of pain as the
following
NSAIDs & Pain management

• Breakthrough pain ; mostly intermittent ,

transitory increase in pain that occur at greater
intensity ( certain type of tooth pain ) , certain
type of renal pain, birth pain , broken bone …
• Acute pain ; this may be last for 30 day or
more ( but days ) & occur after muscle strains
, tissue injury as trauma or surgery , this type
is usually self- limited , & Decrease with time
where the injury will heal,
NSAIDs & Pain management

• Chronic pain ; it is persistent or episodic of

duration or intensity or may define it as lasting
more than 6 month (several months ) ex.
Osteoarthritis , rheumatoid arthritis ,
degenerative disorder with age ,
• Neuropathic pain it is progressive peripheral
neuropathy ,progressive nerve degeneration ,
it is described as burning , shooting , stinging ,
throbbing , tenderness of the skin
•
NSAIDs & Pain management

• Idea about the NSAIDs effect & action :

• Cell wall (cell membrane ) which contain
phospholipids ‫ سهم‬gives arachidonic acid on
which occur 2 pathways :
• 1st is cyclooxygenase pathway (cox )
• 2nd is lipoxygenase pathway (lipox )
• Cox pathway ; Arachidonic acid ‫ سهم‬by
cyclooxygenase 1 ‫ سهم‬gives the (prostaglandin
, thromboxan ,& prostacycline ) are
synthesized
NSAIDs & Pain management

• Via cyclooxygenase pathway & remember that

there are 2 related isoform of cyclooxygenase
enzymes are cyclooxygenase 1 (cox 1 ) &
cyclooxygenase 2 (cox 2 ),
• Where cyclooxygenase 1 is responsible for
cytoprotective (house keeping ) i.e lead to
synthesis to prostanoids which protect
gastric mucosa , vascular homeostasis ,
platelet aggregation , & kidney function ,
NSAIDs & Pain management

• But cyclooxygenase 2 (cox2 ) produce

prostaglandins responsible for the pain &
inflammation there for cox1 inhibitor drugs
has less safety on the stomach & less suitable
for chronic pain
• but cox2 inhibitor drugs is more safe on the
stomach & more suitable for chronic pain
• But leflunomide capturing or binding with
excess of TNF alfa ( one of domninant
NSAIDs & Pain management

• cytokines ) or proteins that play important

Role in response as in rheumatoid arthritis
there fore it used in rheumatoid arthritis
• But 2nd lipoxgenase pathway (lipox ) cell
membrane phospholipids ‫ سهم‬gives
arachidonic acid by 5- lipoxygenase ‫ سهم‬gives
leukotrienes
• N.B there are thought that when inhibit the
cox pathway lead to increase the lipox
pathway i.e increase in Leukotriene synthesis
NSAIDs & Pain management
II- Analgesic anti-inflammatory & other specific drugs

• Classification of NSAIDs. According to the

arachidonic acid & cox pathway it classified to
1. Non selective
2. Semi selective or preferential
3. Selective CoxII. Inhibitors
4. Other classification depend on the original
source ( on the counter for alternative )
(Propionic acid , Acetic acid , fenamates ,
II- Analgesic anti-inflammatory & other specific drugs

• , hetero aryl acetic acid , oxicam & coxibe , )

• Frequency of dose
• Maximum dose of NSAID
• Paracetamol
• ASA
• Tenoxicam 10/1 coxII/CoxI ‫للبحث‬
• Lornoxicam , peroxicam 6/1 CoxII/CoxI ‫للبحث‬
• Diclofenac has the same mechanism of
corticosteroids in anti inflammatory effect
&asthma ‫للبحث‬
Therapeutic effects & sales point of NSAIDs

• From therapeutic effects & sales point of

NSAIDs :
• Analgesic effect where it inhibit the
prostaglandin E2 synthesis which stimulate
the nerve ending to the inflammatory
mediator (bradykinin, histamine , …) & lead to
feel by pain
• Antipyretic except diflunisal (dolobid ) where
not cross the blood brain barrier
• Anti inflammatory except paracetamol
Therapeutic effects & sales point of NSAIDs

• Remember that the anti inflammatory effect

but need to high dose & long time than
antipyretic & analgesic effect
• Ibuprofen till 1200mg/day has good analgesic
& antipyretic effect but anti-inflammatory
effect more than till 2400 mg or 3200 mg /day
• Aspirin is dose dependent & high side effect
on stomach
• Ibuprofen as one of non selective group may
Therapeutic effects & sales point of NSAIDs

considered as the less one effect on the stomach

• More selective cox 2 drugs does not inhibit
cox1 ‫ سهم‬does not inhibit platelets
aggregation & not increase the bleeding time (
pain with wound , or pain with surgy , … )
• All NSAIDs are time dependent reversible
effect on platelets aggregation except ASA,
where ASA lead to acetylation irreversible
cyclooxygenase inhibitor there fore it is used
for hypertensive patient
Therapeutic effects & sales point of NSAIDs

• & after 40 year as heart protective to prevent

blood clotting problem & used once daily
• Some molecules has analgesic & anti
inflammatory effect by the same level (
diclofenac & indomethacin )but other may be
preferable as analgesic effect
• Salt has effect on the choice of NSAID
(diclofenac Na & diclofenac K )
• Dosage form has effect on the choice of NSAID
Therapeutic effects & sales point of NSAIDs

• Ibuprofen is only one of NSAIDs compatible

with breast feeding
• Naproxen is the safest one of NSAID in the
cardiovascular problem
• Mefenamic acid containing drugs are the best
choice in menorrhagia & dysmenorrhea pain
• Mefenamic A & danazole leading to reduce
estrogen mediated cyclooxygenase activity
Therapeutic effects & sales point of NSAIDs

• Also mefenamic acid increase endometrial PG

metabolism (PGF2alpha which increase the
contraction ), & ( PGE which increase the
vasodilation ) ,
• But also mefenamic acid block PG receptor in
uterine tissue
• In selective cox II Etrocoxibe ( 60mg , 90 mg ,
120mg , ) in gouty pain conc. 120 is preferable
& other conc. In Rheumatoid & osteoarthritis
Therapeutic effects & sales point of NSAIDs

• Some members as naproxen , celecoxib ,

Etoricoxibe , oxicam , leflunomide , less
frequently may be once / day
• Divido sales point
• Topical NSAIDs patches
• Azapropozan ( prolixan ) is the best one has
uricosouric effect
• All do not cause tolerance
• All do not cause dependence
Quantity of the dose analgesic & antipyretic
(optimum )

• Paracetamole 10 – 15 mg /kg/dose
• Ibuprofen 7 – 10 or 15 mg /kg/dose
• Or ibuprofen 20 – 30 mg / kg / day in divided
dose
• ASA 10 mg/kg/dose
• Mefenamic A. 5 mg /kg /dose
• Diclofenac 0.5 – 1.0 mg /kg/dose or 2 - 2.5
mg/kg /day
•
Precaution during prescribing the NSAID

• Asthmatic patient
• Un controlled hypertensive patient
• Peptic ulcer
• Pregnancy & breast feeding
• Blood bleeding
• Liver problem & kidney problem& chronic
renal insufficiency
• with warfarin
Precaution during prescribing the NSAID

• Cross sensitivity with sulphonamide ( selective

coxII ) specially celecoxibe
• Risk of cardiovascular problem , edema (
selective cox II)
• Carful use of other NSAIDs than ibuprofen &
parecetamol for children
Analgesic anti-inflammatory & other specific drugs

• Specific ant rheumatic drugs (active

rheumatoid arthritis , active psoriatic arthritis
• Specific drugs for articular degeneration ,
osteoarthritis (generally it help the regeneration of the
cartilage , & maintain the synovial fluid in joint & prevent
progression of osteoarthritis
• Joint caremax ( 1+1 *1 ) … (Omega 3 +
glucosamine sulphate ), Dorofen (gincobiloba
+ glucosamine ) 1* 3 /day for 4 week &
maintenance dose twice / day
Analgesic anti-inflammatory & other specific drugs

• Other drugs as glucosamine plus

• Chondritin
• Avocadoextract (piascldin )
• MSM
• Omega 3
• Gincobiluba
• Main S.E of dorofen : Mild may be heartburn,
GIT upset , headache
Analgesic anti-inflammatory & other specific drugs

• Osteoarthritis : chronic inflammation of joint

affect the cartilage ( pad between bone ) &
synovial fluid ( lubricant ) it may be primary
associated with aging but secondary develop
early in life after specific cause ( trauma,
injury , or obesity )
• Counter difference between the Articular
degeneration & Rheumatoid arthritis
• Muscle relaxant drugs
• Gout & hyperuricemia drugs
Gout & hyperurcemia drugs

• Precipitation of uric acid in the joint specially

peripheral joint , increase in big toe joint ,
knee & ankle joint , when the uric A. increase
than the normal level lead to acute then
chronic stage
• 1st drug Colchicine (colmedetene ) 0.5mg or
0.6mg treat gout attack (flare ) , used in acute
stage of gout , interferes with inflammatory
process , (as anti inflammatory drug )
Gout & hyperurcemia drugs

• Frequency of the dose is generally 1*3

• Quantity of the dose is loading dose 1 to 1.2
mg then 0.5 mg to 0.6 mg every 6 hour or till
side effect ( diarrhea ) appear , or till response
or till maximum dose as course 6 to 10 mg
then stop & can repeat an other course after 3
day ,
• The S.E of colchicine when increase the dose
is diarrhea & bloody diarrhea , alopecia
Gout drugs

• Other use for colchicine is Mediterranean sea

fever where it decrease the certain protein
production ( amyloid ) responsible for the pain
• 2nd dug is allopurinol (Xanthine oxidase
inhibiting drugs ) inhibit uric A. synthesis not
used in acute stage
• As no uric , purol , zyloric conc. 100, 300
• Frequency of the dose according to the
severity , must add colchicine in first doses
Gout drugs

• Mild & moderate case begin by low conc.

(100mg ) once per day & increase gradually
every week till 200 to 300 mg / day
• The maximum dose is 800mg to 900 mg /day
• The main S.E are G.I.T up set , Alopecia,
Cataract , bone marrow depression
• 3rd drug is uricoseric agent ; dugs inhibit
reabsorption of uric acid & this lead to
increase its excretion
Gout dugs

• Uricoseric agent as Propancid , urolyte U. ,

Urosolvin , jedcourine , peprazine in coliurinal
, herbal product as parsley , & ‫الحنظل‬
• Patient education with gout : High fluid intake
2-3 liter /day to prevent kidney stone , Avoid
high purine diet ( Red meat ,Milk & milk
products, bean & its products ,…. ) avoid
xanthine containing products ( red tea , Pepsi ,
coffee , precaution with using some drugs as
diuretic , ACEI,
Gout drugs

• Theophylline , ampicillin , aspirin in normal

analgesic & antipyretic dose , methotrexate
,trental (pentoxyphylline )..
• N.B coli urinal & other eff. Containing
hexamine with sulphonamide increase the risk
of kidney stone precipitation
• Immuran & allopurinol dugs inter action
Antiprotozoal

 Malaria ( plasmodium malaria & other plasmodium )

The main antimalarial drugs
• Chloroquine Sulfate ( Roschin & chloroquin )
• Mefloquine Mefaquine
• Pyrimethamine+Sulphadoxin Fansidar
Dose: ( prophylactic & specific )
(taken after meals)
For prophylactic:
Antiprotozoal

• Difference between Malaria & Danke fever

• Malaria
• Protozoal infection
• Victor mosquito
• Specific fever ( intermittent differ according to
type of plasmodium )
• Coldness
• Tremors or shivering
• Sweating
Antiprotozoal

• Danke fever
• Viral infection
• Continuous fever
• Victor different & anopheles mosquitos
• Antipyretic must be paracetamol only where
other NSAIDs increase the risk of blood
bleeding specially aspirin
Antiprotozoal

Amoabiasis (encysted & vegetative form )

Trichomoniasis (Trichomonus Vaginalis)
Giardiasis (Giardia)
Toxoplasmosis (Need Victor) as Cat
Leshmaniasis (Leshmania) affected by
Pentostan injection
Sleeping sickness the victor is tse – tse
Antiprotozoal

• Metronidazole
• Flagyl
• Flazol
• Amrizole
Metronidazole:
• Effective on Fagitative more than Cystic
• Metronidazole Combination
Diloxanide:
• Effective on Cystic more than Fagitative
Antiprotozoal

Dose:
One tablet Three times Daily .(1*3)
For Short Time (7-10 Days)
For Children (20-30 mg/kg/day)
Side effect:
Metalic Taste.
Dark urine.
G.I.T upset.
Disulfuram Reaction.
Antiprotozoal

Tinidazol ( Fasgin , Protagen )

Dose:
• Four tablets Once Daily .(4*1)
• For Short Time (3 Days)
• For Children: (One tablet/16kg/day)
• Side effect as metronidazole but less in
severity
• Secondazole ( secanid )
Anthelmintic drugs

• The last Anthelmintic drugs effect on

nematodes parasite ( mostly round worm )
• The more common nematodes are : ascaris
ankylostoma(hook worm ), enterobus
vermicularis oxyuris (pinworm), trichuris ,
strongyloides , eye worm (Loa) S/c filariasis ,
Bacerofti ( Lymphatic filariasis ) elaphantiasis
Anthelmintic drugs

• In all drugs oxyuris can be treated using signle

dose
• Albendazole & flubendazole can effect aganist
cestodes ( tapeworm ) but not common use
Anthelmintic drugs

• Dugs for cestodes (tape worm) as ; taenia

saginata , taenia solium , hymenolepis nana
(dwarf tape) , diphyllobothrium latum ( fish
worm ) all can be treated by :
• 1st drug niclosamide (yomesan or niclosan
500mg)
According to the age children 2 – 4 year ½ gm
daily , above 4 year 1 gm daily
but adult 2 gm daily
Anthelmintic

• in case of hymenolepis nana , some other the

daily dose continued for other 6 day
• The tab. Should be chewed thoroughly .
• Take purgative after finish from treatment
2nd drug Praziquentel 15-20 mg/ kg oral single
dose used
Trematoda (fluke ) as fasciola hepatica ( liver
fluke ) , also intestinal fluke
Anthelmintic

Trematoda (fluke ) as:

 fasciola hepatica ( liver fluke ) , also intestinal
fluke
Schistosoma ( blood fluke ) as S. haematobium
, S. Japanicum , S. mansoni
Paragonim ( lung fluke )
Anthelmintic drugs

• Drugs effect on the trematodes (antibilharzial ) it

is the drug of choice for all types of bilharzias
30 – 40 mg /kg oral single dose the maximum
dose is 60 mg/kg single dose
• Practical above 45 kg take 4 tab. , less 45 kg
take 2 tab. Or One tab. For each 20kg
• Available in biltricid 600 mg , distocid 600 mg
Anthelmintic

• Mebendazole ( Vermox , Protazol )

Dose:
• (1*2 OR 1*1) for three days Repeat after 2
weeks
• Albendazole ( Albenda )
Dose:
• One Shot Repeat after 2 weeks
• Patient education
Anthelmintic

• Mebendazole & albendazole has effect on

giardia & cystodes but not 1st choice
• In giardia take one dose daily for 5 days
• Side effect : Headache , dizziness , fever ,
vomiting , temporary hair loss , also
prazoquentil may cause transitory loss of taste
• All anthelmintic has the same side effect
• All anthelmintic (Class C ) in pregnant
Anthelmintic

• Neclosamide ( yomesan ) effect on tap. Worm

& other cestodes & fish worm
 Dose: On empty stomach.
For Adult 4Boxs (16 tabs)
• First Day 4 chewable Tablets
• From Second Day to rest of week 2 Tablets per Day
For Children: (4-9 years) 2Boxs (8tabs)
• First Day 2 chewable Tablets
• From Second Day to rest of week 1 Tablet per Day
Anthelmentics

• Praziquantel ( Biltracid ) effect on Schistosoma

also effect on cestode
Dose:
• For Adult: 4tabs One Shot
• May be 2 then 2 Due to allergy
• For Children: 1 tab/20kg (30-40 mg/kg/dose)
Praziquantel Can be used by half dose instead
of Neclosamide if not avalable
•
Anthelmintic

For Infants: (2-4 years) 1Boxs (4tabs)

• First Day 1 chewable Tablets
• From Second Day to rest of week 1/2 Tablet per
Day
Counseling during dispensing of the drug :
Chewable
Adult Take Magnesium Sulfate (purgative )
Children Take Liquid Parafen
Antiviral

• Generally : it is DNA Neocletide transcriptase

inhibitor drugs
• GroupI
• Acyclovir
• Famciclovir
• Valaciclovir
• Oseltamivir
• Zanamivir
• Amantadine & tramantadine (virumerz )
Antiviral
• GroupII
• Lamivudine
• Adefovir
Antiviral

Group I more effective on the following :

Herpes Simplex
Herpes Zoster
Mumps
Influenza A,B
Avian influenza
 Chicken Box
Cold Sores
Antiviral

• Zovirax & Virustate

 Dose:
• For Adult:200mg One Tablet Four Time or
more daily
• 400 & 800mg One tablet Twice or more daily
• For Children: 200mg susp.(10 mg/kg/dose)
• Famcyclovir ( Famvir )
 Dose:
• One Tablet Twice Daily or more
Antiviral

• Valcyclovir ( Valterex )
 Dose:
• One Tablet Twice Daily or more
• Osaltamivir ( Tamflu , Osalta )
 Dose:
• One Tablet Twice Daily or more
• Amantadine ( Pkamerz )
 Dose:
• One Tablet Twice Daily or more (100 – 400 )
Antiviral

• Zanamivir ( Ralenza ) Rotahalar

• Dose:
• Tab Device Powder Inhalation
• 2 Tabs Twice Daily For 5 Days
• OR 1 Tab Twice Daily For 10 Days
• Tramantadine ( Verumerz ) topical cream
• Used twice daily or more
Antiviral

• Group II ( Zeffix , Hepsera )

• More Effective on :
• Hepatitis.(B)
• AIDS.
• Zeffix :
• Dose:
• Once Daily Dose or ( 100 – 300 mg ) in
divided doses
Antiviral

• Side Effect of Ziffex

• Alopecia
• Constipation.
• Insomnia.& also peripheral neuropathy & …
• Hepsara ( Adevovir 10 mg )
• One Tablet Daily
• Influenza Vaccine (Vaxigrip or Influc )
• One injection / year
Antifungal
Antifungal
Antifungal

• Imidazole as the following

• Ketconazole all dosage form
• Miconazole
• Econazole
• Isoconazole
• Clotrimazole
• Clioquinol( Betnovate C )
Antifungal

• Triazole as the following

• Fluconazole
• Itraconazole
Antifungal

• Ally amine : good dermatomycosis effect

specially oncomycosis :as
• Terbinafine ( lamisil , …..
• Naftifine ( exodril ,…
• Amorolifine ( Leceuryl lequer
Topical Preparation

• Topical preparation include the following

• 1- Topical anti fungal only
• 2- Topical anti fungal & corticosteroid
• 3- Topical corticosteroid & anti biotic
• 4- Topical multi component preparation
• 5- Topical corn , callus & warts preparation
• 6- Topical soothing & anti allergic preparation
Topical preparation

• 7- Topical skin ulcer & burns

• 8- Topical acne preparation
• 9- Topical skin bleaching
• 10- Topical preparation for Psoriasis &
dandruff
• 11- Local anaesthetics drugs
• 12- Topical Preparation for alopecia areata &
vetiligo
Topical Corticosteroids

• 13- Topical preparation for varicose &

hematoma
• 14- Topical preparation for scabies & lice

• 15- Topical preparation for hemorrhoid

• 16- Topical preparation for hair falling

• 17- Topical miscellaneous preparation

Topical Corticosteroids

Side effect:
Bleaching effect.
Hirsutism.
Immunosuppressive effect.
Dark Spots.
Thinning of the skin
H.P.A Axis Suppression.
Topical Corticosteroids

Bleaching effect. (pigmanorm)(whitening)

Dermovate
Hirsutism. (Alopecia areata)
Betnovate Scalp
Immunosuppressive effect.
• Flaring of infection.
• Decrease Healing.
• Skin transplantation
Topical Corticosteroids

H.P.A Axis Suppresion. (Hypothalamus

Pituitary Adrenalcortex)
• Linear Growth Retardation.
Topical Corticosteroids

Precautions:
Avoid long term use.
Avoid contact with Eye.
Avoid use with in contact skin , (infected)
skin.
If use with AB OR AF stop after 5 days.
Children:
• Use Mild to Moderate type (thin layer)
• If Potent use type with low systemic effect
give Once Daily.
Topical Corticosteroids

Face:
• Use suitable dosage form.(cream)
• Suitable duration.
• Cream (rapid absorbed, mild or moderate
effect)
Topical Corticosteroids

• Potency are :
• Mild
• Moderate
• Potent
• Very potent
Topical Corticosteroids

Potency affected by :
Salt.
Molecule
Conc.
Dosage Form.( solution , lotion , gel , cream ,
ointment )
Repeat. ( need to clarifying )
 cream:(Face) Rapid
absorbed, Mild effect , Moderate effect.
Topical Corticosteroids

Oint.: (Dry skin area) Delayed in

absorption, Potent effect
Mild Potency Corticosteriods :
Hydrocortisone Acetate.(Alfacort)
Flumetasone.(Locacortene)
Flucinolone.(synalar)
Triamcenolone (low Conc.)
Topical Corticosteroids

Moderate Potency Corticosteriods :

Hydrocortisone Butyrate.
Betamethasone Valerate.(Betnovate)
Triamcenolone (Med. Conc.)
Topical Corticosteroids

Potent Corticosteriods :
Fluticasone.(Cutivate)
Betamethasone Diprobionate.
Triamcenolone (High Conc.)
Mometasone.(Elica,Metaz)
 Very Potent Corticosteriods :
Clobetasol.(Dermovate)
Topical Corticosteroids

• Combination ofCorticosteriods
Betamethasone +Clotrimazole
Betamethasone +Clioquinol
Betnovate C
Betamethasone +Miconazole
Betazole
Betamethasone +Neomycin
Betnovate N.’ Betamed N
Combination of Corticosteriods :
Betamethasone +Clotrimazole
Lotriderm
Betamethasone +Clioquinol
Betnovate C
Betamethasone +Miconazole
Betazole
Betamethasone +Neomycin
Betnovate N
Betamethasone +Gentamycin
Garason Betamed N
 Combination of Corticosteriods :
Betamethasone +Fusidic acid
Fucicort
Betamethasone +Salisylic acid
Salibet Diprosalic
Betamethasone +Miconazole+Gentamycin
Betazole G
Betamethasone +Calcipotriol
Diavobet
Combination of Corticosteriods :
Betamethasone +Clotrimazole
Lotriderm
Betamethasone +Clioquinol
Betnovate C
Betamethasone +Miconazole
Betazole
Betamethasone +Neomycin
Betnovate N
Betamethasone +Gentamycin
Garason Betamed N
 Combination of Corticosteriods :
Triamcinolone + Econazole
Pevisone
Diflucortolone + Isoconazole
Travacort Vocort
Flumetasone + Clioquinol
Locacorten vioform
Triamcinolone + Neomycin +Gramicidin +nystatin
kenacomb Panderm
 Combination of Corticosteriods :
Hydrocortisone + Miconazole
Daktacort
Hydrocortisone + Clioquinol
Cliocort
Hydrocortisone + Iodohydroxyquin
Dermocort
Hydrocortisone + Fusidic acid
Fucidin H
Hydrocortisone + Neomycin + Natamycin
Pimafucort
 Combination of Corticosteriods :
Mometasone + Miconazole
Elica M
Mometasone + Miconazole +Gentamycin
Momenta
Mometasone + Salisylic acid
Elicasal
 Topical Antifungal
Clotrimazole
Canesten Clotrex
Dermatin Cozol
Miconazole 2%
Dacktarin Miconaz
mikozal Fungyzole
 Topical Antifungal
Ketoconazole 2%
Nizoral Vavo
Clarazole Droff
Tolnaftate
Tineacure
 Comparison between vaginitis
Trichomonus Bacterial Fungal
Yellow to Green  white toyellow White cheesy
discharge discharege discharge
Bad odour Mal odour Mild
Mild itching Mild itching Sever itching
Predicted with Predicted in Young ages.
Sexual intercorse post menoposal
Treatment Treatment
Trichomonus:
Vaginal douche.
Metronidazole (systemic,local)
Bacterial:
Vaginal douche.
Clindamycin.
Betadine vaginal douche:
Use for only from (3-5)days
Pregnant vaginal douche:
Natural douche (Estra Ex)
Dry eye

• Artelac Advanced active ingredient is Sodium-

Hyaluronate 0.2%,
• has a viscoelastic structure, with excellent
mucoadhesive properties
• it helps the epithelial healing process (a
cicatrizing effect).
• increased hydration of the corneal epithelium
as it is capable of holding a large water
volume and releasing it gradually ("water-
tank" effect).
Dry eye

• It is preservative free and compatible for use

with all types contact lenses
• 1 to 2 drops / day, or as required
• Optive™ UD
• Artificial Tears (Lubricant and Osmoprotectant)
• Lubrication by two polymers Carboxymethylcellulose
and Glycerine.
• Osmoprotection by two osmoprotectants
Levocarnitine and Erythritol.
Dry eye

• Place 1 or 2 drops in the eye(s) as needed.

• This product is recapped unit dose and preservative
free.
• Lorinex syp : contain desloratadine ( ) dose as
• Age 6-12 Month: 1mg Once daily.
• Age 1-6 Years: 1.25 mg Once daily.
• Age 6-11 Years: 2. 5 mg Once daily.
• >12 Years: 5 mg Once daily.
• Lorinex is Effective in relieving itching throughout the
treatment period(2weeks)
GIT system drugs

• The gastric secretion occur in 3 phases (

Cephalic stage due to vagal stimulation ( taste,
odor , … ) , gastric stage due to physical
action (food on the m.m) , chemical (Hcl
secretion) , intestinal phase due to partially
digested food
• Risk factor for hyperacidity & ulcer , drugs as
Corticosteroids , Caffeine containing products
,NSAIDs , Alcohol intake , smoking , stress ,
food style & fermentable food ,
GIT system drugs

• Symptoms of hyperacidity : ( heart burn ,

gases , indigestion , …
• Continuous hyperacidity or/ with other cause
as helicobacter pylori or some drugs may
cause peptic ulcer (duodenal or gastric ulcer )
• Roughly differentiation between duodenal &
gastric ulcer on the counter – pain occur
within 30- 60 min. after meal in gastric ulcer &
continue for 90 min.
GIT system drugs

• But 2 - 3 hours after meal in duodenal ulcer &

continue until next meal
• Vomiting occur with gastric ulcer
• Relief with food there for accompanied with
increase in the weight in duodenal ulcer
• The pain & vomiting increase with food
therefore accompanied by weight loss in
gastric ulcer
GIT system drugs

• 1st gp. Neutralizing anti acids as caco3 ,

NaHco3 , some product contain mag. Or Alu. ,
but other contain mag.+ Alu. ( Magalderate ) ,
other product contain alginate
• Different dosage form (Susp. , chewable tab. ,
effervescent powder , ….
• General side effect : Rebound effect specially
in bicarbonate containing products , diarrhea
in products containing Mag.
GIT system drugs

• Also occur constipation in drugs contain Alu.,

drugs contain sodium can occur (salt
retention ) & alkalosis there fore it is contra
indicated in C.H.F. ,uncontrolled hypertension
, kidney failure , some time taste lead to
nausea in suspension
• Make complex with different dugs as
tetracycline . Quinolone ,phenytion, isoniazide
, So must separated from each other
GIT system drugs

• Sales point ( Advantage ) rapid effect ,

Magalderate no diarrhea nor constipation as
moxal ,
• Algenate coate the M.M of the stomach , also
make barrier between esophagus & stomach
in Gerd as in gaviscon
• Some drugs contain local anesthetic as in
mucogel , other contain anti flatulance as
moxal plus & epicogel
GIT system drugs

• Neutralizing antacid frequency of dose is after

meal & at necessary
• but alginate take before meal in hyperacidity
& after meal in Gerd
• 2nd gps H2 blockers : blocking histamine
receptor in acid producing cell in stomach
there fore they block the formation of excess
acids
• Ex.Cimatidine Rantidine ,Famotidin nizatidine
• concentration
GIT system drugs

• Clinical application : hyperacidity , Gerd ,

peptic ulcer ,
• We treat. Hyperacidity only there fore they
should not be prescribe for more than 2 week,
then refer where duodenal ulcer take at least
4 week & gastric ulcer take at least 6 week
• In hyperacidity use the low conc. 75 mg but
physician prescribe high conc . 150mg or
300mg
GIT system drugs

• Famotidine low conc. 10 mg , but 20 & 40 mg

is high conc, but nizatidine is 150 & 300mg
• Frequency of dose twice daily before meal
• Side effect : Hypotension , Confusion ,
dizziness , Gynocomostia , Galactoria ,
ranitidine lead to reversable jundice ‫للبحث‬
• 3rd gp. Proton pump Inhibitor : block H/K
atapse enzyme in parietal cell in the stomach
this inhibit H entrance to the cell & this
inhibit Hcl synthesis
GIT system drugs

• The available molecules of proton pump

inhibitor : Omeprazole ( Losec ) , Pantiprazole
(pantazole ) , Lanzoprazole (lanzor ) ,
esemoprazole ( Nexium ) , Rabiprazole (
pariete )
• Proton pump is molecule in certain cell
(parietel ) pumps the acid into stomach where
it take K ion out & replace H ion by stop this
process stop Hcl synthesis & pump in stomach
GIT system drugs

• Comparison between P.P.I & H2 blocker : the

main point are ( Action , onset of action,
frequency of dose) where P.P.I delayed onset
of action but H2 blocker begin with 1 hour ,
duration of action is long duration of action 24
h or more in some members, but H2 blocker
extend for 12 hour
• Use of H2 blocker with proton Pump inhibitor
enhance the treatment & increase controlling
GIT system drugs

• Sales point : is the most widest use now

• Is the most effective one now , long duration
of action the official Fre.of dose is once daily
before meal , one of triple therapy , one
member as pantoprazole has steady conc. &
long duration of action may extend more one
day effect ( as prophylactic day after day or
more ) , low conc. Can be used for
hyperacidity for 2 week only ,
• Omeprazole effective in bleeding gastritis
GIT system drugs

• Lanzoprazole , esoprazole ,omeprazole can be used

for Gerd & erosive esophagitis in children
• Clinical application : hyperacidity ,peptic ulcer
• GERD , Zollinger Ellison ( autoimmune
disease ) , prophylactic with different drugs
specially chemotherapy , ….
• All proton pump inhibitor is pro drug with
acid resistant enteric coated to protect them
from premature degradation by gastric acid
juice
GIT system drugs

• Where the coating of products is removed by

alkaline media in the duodenum therefore
must not take with neutralizing anti acids in
the same time
GIT system drugs

• All proton pump inhibitor take before meal to

be more effect but rapiprazole is less one
affected , then pantiprazole
• N.B : P.P.I & Plavix drug interaction due to
liver inhibiting enzyme specially omeprazol
• Triple therapy is 3 drugs used to control the H.
pylori after diagnosed by C. urea test (
collection of breath samples before & after
ingestion of oral solution of C. urea kit , or
antibody test ,
GIT system drugs

• Must not take drugs as anti secretion or

antibiotic before test by 2 week
• Different combination of triple therapy but
the recent one is ( P.P.I. + Amoxycillin +
Clarithromycin)
• The main side effect & precaution with use of
the proton pump inhibitor : Constipation ,
diarrhea , headache , dizziness , increase the
liver enzyme but pantoprazole is less one ,
using of P.P.I. for long periods can lead to
GIT system drugs

• Hypochlorhydria (chlorohydra ) this lead to

decrease absorption of vit. B12 & folic & Mg & Ca
,zinc ,copper, iron, ( coss sales supplementation ) ,
• Also decrease absorption Of some drugs as
domperidone & fluconazole & itraconazole ,
• metaplasia , also use for long periods lead to
• Also using of P.P.I for long period without
consultant follow up may lead to musk for
carcinogenic symptoms
GIT system drugs

• 4th gp . Coating drugs Sucralfate ( gastrofait )

coating for mucous membrane of stomach &
begin its action in some acidic media &
gnerally take 1- 2 gm twice daily
• Main side effect is constipation , complex with
other drugs
• Also bisthmus used as coating as in ( Danol )
also has different S.E as constipation , complex
with other drugs but also heavy metal toxicity
GIT system drugs

• By cumulative effect (antidote is pencillamine

) , also black tongue , black stool
• 5th gp. Prostaglandin analogue ( Misoprositol )
as in cytotic which lead to abortion
• 6th gp. M1 receptor antagonist which decrease
the gastric secretion as gastrozepin or sulpride
• NSAIDs – associated ulcer can be controlled or
treated by misoprositol, then H2 blocker, then
GIT system drugs

• Then proton pump inhibitor

• Sucralfate also enhance healing process as in
avene sucalfate
• H. pylori ( helicobacter pylori )
• Ulcerative colitis : as Sulphasalazine as in
salazopyrine , Methalazine as in pentasa ,
Asacol , Sulofalc , Budosinide corticosteriod
• Liver support drugs : sylamarine as in legalon ,
GIT system drugs

• , Mepasil ( sylam. + milk thistil ) , cefsylamarin

• Other liver support Hepamerz (L.ornithine +..)
but ursofalk used for gallbladder stone
• Antidiarrheal drugs : Non infected diarrhea
used astringent & adsorpant ( Kapect ,
kapeten ,Codiene containing drugs , Tanic
acids containing prod., but drugs decrease the
peristalsis movement as lopidium Hcl (
Imodium ) but infected diarrhea not use drugs
stop the perstalsis mov.
GIT system drugs

• &the infected diarrhea according to the type

of infection
• General symptoms of infected diarrhea ( may
be viral or bacterial or fungal )
GIT system drugs

• Prokinetics : drugs stimulate GIT motility as

Metoclopramide (primperan ),domperidone
(motilium),cisapride (praplcid ), Mesopride ,
eteprid , antibiotic. as erythromycin
• The action of prokinetics occur through ;
increase in the cholenergic activity lead to
release of acetyl choline , dopamine D2
receptor antagonist ,
GIT system drugs

• Also some drugs has agonist activity at 5HT4

receptor as mesopride , etepride
• General clinical use of prokinetics (remember
that motilimum is preffered drug ) :
Gasroesophageal reflux ( GERD ) , Indigestion
& dyspepsia ( non ulcer dyspepsia ) , Hiccup ,
colon problems , post partum as lactating
stimulation , post surgery to correct impaired
gastric emptying ,
GIT system drugs

• Also support treatment as some members as

mesopride used for constipation ,
• Also preventing the vomiting where increase
the gastro esophageal sphincter pressure
• The general side effect of prokinetics :
extrapyramidal effect = Parkinson's like effect
due to central dopamine antagonist ,also
Galactoria & Gynocomastia …. Impotency &
menstrual disturbance , also C.N.S. symptoms
GIT system drugs

• As drowsiness , insomnia , anxiety, agitation

• The effect appear due to high dose about 25%
of reported side effect but 5% of receiving the
prokinetics for long period
• Domperidone ( Motilium ) sales point it is not
cross blood brain barrier by significant value
there fore it is less side effect ( no or less
central effect ) , it has peripheral effect (
gastro kinetics ) , also it has dopamine
receptor antagonist but in the
GIT system drugs

• Chemoreceptor trigger zone which lies outside

the blood brain barrier ,
• Domperidone increase the gastro esophageal
sphincter pressure also regulate the peristalsis
movement but there is no effect on gastric
secretion ,
• Domperidone take before meal by 15- 30
min. 3 time / day for adult one to 2 tab. 3 time
daily with maximum dose 80 - 120 mg / day
GIT system drugs

• But children dose 1mg /kg/day divided to 3- 4

doses I.e 0 .25- 0.5mg /kg/dose
maximum dose 2mg/kg/day in sever cases
• But metoclopramide roughly half the dose of
domperidone i.e 0.5 - 1mg/kg/day in sever
cases divided in 3 – 4 doses
• Different dosage form of domperidone are
tab. 10mg , suspension 1mg/1ml , supp.
Available in 10 mg , 30 mg , 60 mg
GIT system drugs

• N.B. to be more accurate & more safe

according to the last dose information not
prescribe supp. 30 mg before 10 year there
fore 10 mg used till 10 year age , 30mg from
10 year till adult & also for adult then 60 mg
for adult & not increase than twice /day
• Any reduction for gastric acidity impaired the
absorption of domperidone , it excreted
urinary &GIT , & half life 7- 9 hours
GIT system drugs

• Some cases contra indicate domperidone as

-prolactin- releasing pituitary tumor , - co
administration with oral anti acid ,or ketconzol
- gastro intestinal hemorrhage , - Mechanical
intestinal obstruction ,- intestinal perforation
• Other anti emetic drugs : 5HT3 serotonin
antagonist as anti emesis for chemotherapy
drugs as ondanosetron ( Zofran )
GIT system drugs

• Antiemetic for pregnant : vit. B6 , navidoxine

(pyridoxine + miclizine ) , also can be use as
2nd choice ( domperidone , metclopromide ) ,
also zofran class B in pregnant ‫للبحث‬
• N.B ginger as natural product not used as
antiemetic in pregnant where lead to some
uterine contraction
• Dexamethasone with metclopromide increase
the anti emetic effect of metclopromide , also
domperidone & metclopromide can be used
GIT system drugs

• With zofran as antiemetic in chemotherapy

treatment protochol
• Chlorpromazine (neurazine , largectil ) has
also dopamine receptor antagonist action can
also be used as antiemetic beside
antipschychotic effect
• Promethazine (promentine ), Histoloc as anti
histamine has anticholinergic activity can be
used as anti emetic effect specially with
diarrhea , also used as anti dote with S.E of
pro kinitics
GIT system drugs

• Laxative : products enhance the defecation &

include the following : - 1st gp. Bulk forming
laxative as bran , aspigengal , mucevital , all
products contain methyl cellulose , this
products effect after 48hour , there for it
suitable for chronic cases , also suitable for
pregnant , also used for slimming but some
cons as : intestinal obstruction there for must
advice by taking large amount of water , not
suitable for
GIT system drugs

• Acute cases or sudden cases of constipation

• Bulk forming products used as laxative &
slimming but the dose of slimming double
dose as , bran as laxative 2 tab. 3 time but as
slimming 4- 6 tab. 3 time daily before meal
• 2nd gp. Stimulant (contact ) laxative then
become ( purgative or cathartic ) it increase
the contraction of the smooth muscle , its
effect begin after 6- 12 hour, examples for this
GIT system drugs

• Group : Senna (sennalax ), bisacodyl(dulcolax )

, Recinoic acid (castor oil ), cascarra ( tobesta
tea , diafa tea ) , … castor oil cap. Dose 6 cap.
• Precaution during use or prescribe : - do not
use in child , - don't use in pregnant except
dulcolax , - senna & cascara may lead to red or
dark yellow urine color ,- repeat use may lead
to dehydration ( electrolyte loss) , preferable
use once daily & repeat when needed ,
GIT system drugs

• Stimulant laxative is suitable for acute or

sudden constipation , some senna of herbal
product as arcopharma senna recommended
3 time daily
• Osmatic cathartics :- glycerin ( laxoline ) its
effect after 15- 60 min, suitable to acute &
sudden cases also can be used for pregnant &
baby ,- Lactulose its effect after 24 hours
,suitable for chronic cases , pregnant , diabetic
patient ,
GIT system drugs

• Also suitable for hepatic comma with

neomycin , the cons is flatulence
• Saline Cathartic as Mg sulphate ,Na
phosphate (picolax drop) , Na picosulphate
drop , has the effect of osmotic cathartic &
quickly effect after 2- 6 hours ,
• Saline cathartic preferable in remove the
parasite , eliminate the poisons , but do not
use in renal impairment
GIT system drugs

• Wetting agent (laxative ),long term use as

liquid paraffin (mineral oil ),docusate
(dioctylsulphosuccinate ) in Norgalax may be
added in enema (adult & child) , but long
term use of liquid parafin must compensate
by KEDA fat soluable vit. Supplementation
• Norgalax not use for pregnant , less 12 year
• Fiber laxative (also bulk forming laxative ) but
in different products in the pharmacy &
famous use & some member as benefiber
GIT system drugs

• used In diarrhea & constipation where in

diarrhea absorb the water from the stool &
make the bulk , but in constipation absorb the
water from adjacent organ & make the bulk
• Examples for these drugs in the pharmacy are
Bane fiber , agiolax , normacol , normacol plus
, fybogel (orange taste ) , Movicol , …
• Some sales point : taste as orange taste in
fybogel , apple taste as banefiber , odoless as
GIT system drugs

• Banefiber powder odor less there fore can be

used on tea or juice ,but apple taste in
suspension
• Some members take as granules (‫ ) سافوف‬in
mouth direct then large amount of water as
agiolax , normacol , normacol plus ,
• Used for all cases also in pregnant but must be
carful with combined product where may
contain senna by large amount
GIT system drugs

• Anti spasmodic : it is one of anti muscarinic

drugs , the pro type of antispasmodic is
atropine has different indication ( anti dote for
organ phosphorus compound, mydriatic effect
,antispasmodic effect in different system , but
has different side effect called atropine like
effect ( blurred vision , dry mouth ,
constipation , urine retention ) may occur
transient Brady cardia then followed by tacky
GIT system drugs

• cardia , palpitation & arrhythmia , mydriasis ,

angle closure glaucoma , flushing & dry skin
Not available in the pharmacy or available in
belladonna extract
• but the products available are
- Hyocine N butyl bromide as in buscopan , less
absorbed from intestine than atropine there for
less in side effect & has effect in different system
,also it is preferable used in acute cases
GIT system drugs

• - Verine drugs as mebevrine ( duspatalin ) ,

alverine ( spasmonal ) , peniverine (dicetel )
• This group of antispasmodic less side effect
than hyocine N butyl bromide but has good
effect on colon muscle , there fore it is
preferable use in aspastic colon , the
frequency of the dose is 3 time / day before
meal but mebeverine (duspatalin) as the
following mebeverine 135mg & 100 mg used
GIT system drugs

• 3 time /day before meal but mebeverine

200mg has sales point where used twice / day
before meal , also peppermint oil ( colpermin )
used for aspastic colon where has spasmolytic
effect & carminative effect but has some side
effect ( heart burn , perianal irritation ) there
for preferable use after meal to decrease s.e
• - other antispasmodic as spasmourginin ,
Genurin forte mainly used in UT spasm
GIT system drugs

• Anti flatulence : product decrease the gases in

the GIT by broken the gas, adsorption the gas
or by carminative effect
• Example of anti flatulence simethecone (
dysflatyl , deflate ,… ) , Charcoal ( used in
flatulence , diarrhea , constipation , poison ) ,
herbal products as fennel , caraway , dill oil ,
menthol , herbal tea, or combination as
infacol …..
• Flatulence in infant : GIT system in infant not
GIT system drugs

• Adapted on the new environment & continue

about 4 month there fore the flatulence in the
first 4 month is expected complain & can
controlled by – anti flatulence , Massage of
the abdomen , Eructate the baby , put infant
in prone position but notice respiration ,if
there is constipation i.e 48 – 72 hours can use
glycerin supp.
• Digesting dugs : drugs used to help or
enhance
GIT system drugs

• The digestion & available in the pharmacy in 2

group 1st gp. Direct digestant effect has
different digestive enzyme as zymogen ,
spasmocnulase , or combination as
pancreoflate , aerodigest , digestyl , or herbal
digestant as artichute , all this gp. Used with
meal 3time / day 2nd gp. Indirect digestant
effect through stimulation of the intestinal
flora which increase the digestibility as
probiotic products
GIT system drugs

• Examples for probiotic products : it is type of

fiber with lactobacilli , acidobacilli some
products also with vitamins specially vit. B
stimulate the intestinal flora as Bion 3 ,
protexin , Kalsis , all these drugs used one or 2
tab. Once / day after lunch & children one
schaet / day , also can repeat the dose , but
the kalsis according to the recommendation of
the company can be repeated /day
The Respiratory System
The Respiratory Organs
Conducting zone
– Respiratory passages that carry air to the site of gas exchange
– Filters, humidifies and warms air
Respiratory zone
– Site of gas exchange
– Composed of
• Respiratory bronchioles
• Alveolar ducts
• Alveolar sacs

Conducting zone labeled

205
Paranasal sinuses
– Frontal, sphenoid, ethmoid and maxillary bones
– Open into nasal cavity
– Lined by same mucosa as nasal cavity and perform
same functions
– Also lighten the skull
– Can get infected: sinusitis

206
Respiratory system drugs

• Common cold products ; products used to

common cold case & runny nose problem ,
according the customer needs & problems will
divided to : 1st gp. Without decongestant
products 2nd gp. With decongestant products
• 1st gp. Products without decongestant as
cafamol (Paracetamol + doxylamine + caffine )
,Adol P.M ( paracetamol + diphenhydramine )
,Paracetamol + fenstil , paracetamol + telfast,
Respiratory system drugs

• parcetamole + chlorphenramine maleate

• This gp. Is suitable for the following cases –
infant , - uncontrolled hypertensive patient , -
pregnant , - BPH , - glucoma patient , …. N.B ,
in glucoma & BPH the preferable combination
is Paracetamol + telfast where is less one in
anti cholinergic activity & infant the best
combination is paracetamol + fenstil (one
dp/kg ) twice /day
Respiratory system drugs

• 2nd gp products contain decongestant divided

• Divided into products contain - phenylephrine
as decongestant as sine up( phenylephrine +
chlorphenramine) , panadol cold & flow
yellow ( phenylephrine + paracetamol +
caffine ) , vibrocil gel local effect (
phenylephrine + dimethendene ) or –
products contain psedoephadrine as
decongestant as different drugs with different
combination
Respiratory system drugs

• mainly sedating & non sedating products

• According to customer needs drugs containing
the psedoephdrine divided to – non sedating
as clarinase ( Ps 120mg + loratidine ) , cirrus
(Ps 120mg + citrizine ) & mostly used twice
daily , but - sedating as actifed , rinofed ( Ps
60mg + tripoloridine ) & also use twice or
3time daily , also other products contain Ps as
Fludrex , panadol cold & flu (green ) , flumed (
Respiratory system drugs

• Ps + chlorphenramine + Paracetamol ) , but

• Also other products as flumed DM ( flumed +
dextromethorphane ) , rinofed expectorant (
Rinfed + guafinasine ) , flutab (Ps +
paracetamol +diphenhydramine ) , Adol sinus
(ps + paracetamol only )also flutab sinus , sino
free , sapofen plus & advil cold sinus (Ps +
Ibuprofen ) they preferable in sinusitis ,
•
Respiratory system drugs

• Side effect of decongestant ( Psedoephadrine

) , -hypertension , - insomnia & due to
variation may lead to sedation & high dose
may cause respiratory depression , - risk for
glaucoma ,& prostata - irritability specially in
baby ,
• Contra indication : - pregnant , Un controlled
hypertensive , Myocardial infarction ,
glaucoma, infant , hyperthyroidism ,
• Difference ( comparison ) between common
Respiratory system drugs

• Common cold & influenza :

• Cause : influenza ; influenza type A & B virus ,
controlled by vaccination (vaxigripe ) or
influvac , avian influenza virus, swine
influenza virus all are series of HN virus
(pandemic ) , but common cold there are
more than 200 different viruses that can
cause the cold ( as coronavirus , rhinovirus ,
adenovirus ,para infl. ,coxsackie , paramyxo
virus ,…. There are no ,
•
Respiratory system drugs

Cure for cold but treatment can relief the sym.

• Onset of symptoms : influenza sudden onset
but common cold gradually appear
• Fever : Influenza lead to high fever but
common cold lead to mild to moderate fever
• Chest discomfort & cough: influenza begin by
chest discom. &dry painful cough (ascending )
but common cold (descending) finished by
hacking & productive cough
Respiratory system drugs

• Congestion, stuffy & runny nose : in influenza

rare but in common cold is the 1st symptoms
then pain in pharyngeal cavity & trachea then
bronchitis begin by dry then hacking wet
cough ( descending infection )
• Lines of treatment for common cold :
Respiratory system drugs

• Cough : is signs due to problem in respiratory

system (lower & upper)
• Risk factor for cough : smoke , fumes ,
allergen as pollen grains , dust ,other pollution
• Other important risk factors as bacterial &
viral infection , different type of stress , ……
Respiratory system drugs

• Cough products according to type of cough

divided to : –
• dry cough products ; suppress the cough as
dextromethorphan ( kafosed ) , codeine
containing products , honey containing
products or as honey but thyme containing
products ( mellrusum ), bronchicum (thyme +
primula & Ezypan, thyme cap. , also herbal
cough syrup contain ivy where
Respiratory system drugs

• used for dry & wet cough but mainly in wet

cough , also propalsoft
• Application for cough suppressing medication
:- dry cough , or produce little sputum , wet
cough but cause chest pain , or disturb the
sleeping ,
• N.B honey not given for infant less than 12
month where may lead to risk of botulism
Respiratory system drugs

• - wet cough lead to large amount of sputum

& may accompanied by other symptoms as
blood , chest pain ,fever , & the products in
the pharmacy include the following :
Respiratory system drugs

• Expectorant cough products : expel sputum

as in Guafisine (guaphan, rubitussin , mucinic )
• Mucolytic cough products :liquefy sputum as
in bromohexine ( bisolvon) , it depolarize the protien in
the mucous , ……

• ambroxol is metabolite for bromohexine as

(mucosolvan), ….. , all mucolytic must take
after meal to protect the mucous memb. Of
the stomach , it is preferable in the children
but notice the infection ,
Respiratory system drugs

• Other application for mucolytic : - in fertility

• To decrease the viscosity of semen & cervical
mucous , - to liquefy the mucous in sinusitis ,
to liquefy the discharge in otitis media, swelling
• Mucoregulator : can broke the disulphide bonde in the mucous
as in carbocystine (rhinathiol) 2% , 5% & with
promethazine , acetylcystine (acc 200 , 600 ,…
) some specialist prefer the mucoregulator
where not increase the cough
Respiratory system drugs

• as expectorant or increase the descending

infection as mucolytic ,
• Wheezy cough : remember that the
decongestant has good role in control the this
type of cough
• Irritant cough : remember that the soothing &
demulcent products has good role in this type
of cough
Respiratory system drugs

• Also from other use for acetylcystine ; it is

used as antidote for paracetamol toxicity
• Multicomponent cough syp. This products
contain different ingredient by different effect
as expectorant , mucolytic , cough suppressant
, antihistamine , decongestant . As mentex ,
rinofed expectorant , flumed Dm , exylene
amydramine expectorant, codilar ,….. These
type of cough syp is suitable for cough after
common cold
Respiratory system drugs

• Herbal cough products these products mostly

contain ivy but also may contain thyme or
eucalyptus , … , this products is widely used
now , & all products contain ivy used for , wet
cough mainly & which contain alchol can
effect in dry cough as actifox , bronchicum ,
mellorsum , but ivy contain saponin &
emetine which stimulate vomiting specially in
children
Respiratory system drugs

• Some precaution in prescribing the ivy

containing products :
- check the bottle before use
• not prescribe for children less than 6 year
• Some products with high concentration of ivy
as sinuc must give the recommended dose for
adult 2 ml ,- bronchicum elixir is one of herbal
Respiratory system drugs

• Examples for ivy containing products

(prospan , tusipan , juspan , sinuc ,ezipan ……
),
• New herbal drug : Plerus = Pelagonium
sedoids has ant inflammatory , antiviral effect
, effect on all types of cough
Respiratory system drugs
Respiratory system drugs

Cough products for children : as exylline for

children , amydramine for children , rhinatiol 2%
, rhinathiol promethazine , Soolan , …..
• similar to honey as mollrusim , bronchicum
contain glycerol , …. Therefore can be used as
demulcent effect in irritant or dry cough but
must be used by small dose numerous
number
Respiratory system drugs

• Honey containing products, as propalsaft ,

sale point it is suitable for children but not
suitable for diabetic patient & propal saft not
suitable for asthmatic pat. but now contain alchol
• Cough products suitable for diabetic patient :
all sugar free cough syp , herbal cough syp ….
• Cough products suitable for pregnant : Herbal
cough products , jospan , prospan, ….
• Cough products with bronchodilator is
Bronqium
Respiratory system drugs

Drugs used for bronchial asthma patient :

Bronchial Asthma mean an inflammatory
disease of the airway characterized by episodes
of acute bronchoconstriction causing (the
symptoms of bronchial asthma patient ) :
difficult breathing specially in expiration , rapid
respiration , chest tightness , wheezing ,
repeated cough also increase in night , all these
symptoms repeated weekly or daily ,…
Respiratory system drugs

• acute symptoms may resolve spontaneously

or with use of quick relief medication ( short
acting B2 agonist drugs )
• Asthma mediator as - histamine , tryptase , -
Lukotrienes , bradikinine , these mediators
diffuse through out the air way wall and cause
muscle contraction & vascular leakage , -
other mediator is called cytokines transmitted
by lymphocyte . Cytokines as mediators
Respiratory system drugs

• Responsible for the more sustained bronchi-

constriction each type of mediator is inhibited
by certain drug as histamine inhibited by anti
histamine,lukotriene inhibited by montolukast
but Cytokines inhibited only by corticosteroids
• Risk factor for the bronchial asthma or tigger
stimuli : as risk factor for the cough
• The drugs bronchial asthma is divided into –
bronchodilator & anti allergic products
Respiratory system drugs

• Bronchodilator products include the following

Methyl xanthine containing products these
drugs has phosphodiastrase inhibitor effect
this lead to increase in cyclic AMP which lead
to the bronchodilator effect example
theophylline containing drugs ( theoped ,
theodur , Euphylline , quibiron , minophylline,)
• Point about theophylline containing drugs are
:1st drug of bronchodilator , more effective in
Respiratory system drugs

• Treatment of nocturnal bronchospasm ,

narrow therapeutic index drug there fore the
usual dose is 3-4 mg /kg of theophylline 3 - 4
time daily in non sustained release drug but in
sustained release must follow the
recommended frequency of the dose which is
mostly twice /day ( begin by low dose ) , the
smoker need to increase the dose , or 15- 20
mg /kg / day divided in 3 – 4 doses
Respiratory system drugs

• Side effect of theophylline :

• GIT up set there fore must take after meal ,
Anxiety ,insomnia , tremor, nervousness & may
be tacky cardia , ………
• Beta agonist drugs B. act on the receptor as
agonist & increase the C AMP which lead to
bronchodilator effect & classified to :
Respiratory system drugs

• - Non selective B. agonist Hexaprenaline (

Ipradol ) , isoprenaline , - alpha & beta agonist
( ephedrine ) but –
• selective beta agonist as
• * short acting
• *long acting beta agonist ,
Respiratory system drugs

• Short acting as salbutamol ( ventolin ) , terbutaline (

bricanyl ) , this type of beta agonist is very important
in acute attack or during the asthma attack ,
• Salbutamol may be less effective in the age less than
18 month due the development of beta receptor
• Long acting beta agonist bronchodilator :
1. salmetrol ( servent )
2. or in seratide as combination with corticosteriod
3. formoterol as in ( foradil ) or in combination with
corticosteroids as in symbicort
Respiratory system drugs

• Other use for beta agonist

1. Pregnancy fixation as rotidrine (utopar )
2. Fat burner as clembutrol
• Side effect of beta agonist
1. Tacky cardia
2. Arrhythmia or (palpitation )
3. Nervousness ,insomnia , anxiety ,
4. Irretability , sweating
Respiratory system drugs

• Muscarinic receptor antagonist

• Side effect : lead to anticholinergic effect
(atropine like effect ) dry mouth , blurred
vision ,urine retention , constipation ,
exacerbation of cough ,
– Ipratrobium ( atrovent ) ( inhaler & nubilizer )
– Thiatropium ( spireva ) rotahaler
• Bronchodilators combination as combivent
( salbutamol + Ipratrobium )
Respiratory system drugs

• Corticosteroids :has indirec effect it inhibit the

mediator & prescribe orally , injection , or by
inhaler ( surface active effect ) as following
• Corticosteroids only as
1. fluticasone ( flixotide ),
2. budosinide (pulmicort )
3. Cyclosinide ( alvesco )
4. Beclomethsasone ( Beclosone )
• Corticosteroids combination with brondilator
as the
Respiratory system drugs

1. Symbicort ( budesonide + formoterol )

2. Seratide ( fluticasone + salmetrol )
• Dosage form : there are different dosage form
for asthma drugs as the following :
1. Syrup , tab. , supp. , injection
2. Inhaler & this dosage form need spacer (infant ,
children , adult )
3. Rota haler haler dosage form ( how to use )
4. Turbo haler dosage form ( how to use )
Respiratory system drugs

5. Discus dosage form ( how to use )

6. Nebulizer dosage form ( this need to nebulizer
equipment ) the nebulizer drugs as ( ventolin
solution , pulmicort nebulizer , flixotide nebulizer,
atrovent nebulizer , bisolvon drops , Na cl ,….. (&
how use the nebulizer equipment )
• Side effect due to using of corticosteroids as
turbo haler , Rota haler , inhaler :
1. Candida infection , oro pharengeal fungal
infection
Respiratory system drugs

2. Precipitate on the vocal cord & lead to horse

sound ( ‫) للمراجعة‬
• Advice or patient education with using of
surface active corticosteroids
– Mouth wash with water at least or mouth wash
– Immune stimulant to prevent the infection
– Increase the salivation by use gum to prevent
dryness & infection
Respiratory system drugs

• Mild attack of bronchial asthma : use one

bronchodilator as :
• Children below 6 years use theophylline 15 –
20 mg / kg /day in divided doses 3- 4 dose
or salbutamol , terbutaline 0.1 – 0.3
mg/kg/day divided in 3- 4 dose ,
N.B. ventolin sy.5ml = 2mg
• or salbutamol nubilzer 0.25 – 0.5 ml with 3ml
saline 3 -4 doses / day , above
Respiratory system drugs

• Moderate attack : use two bronchodilator

with each other 3- 4 day till wheeze free
Also cough product mucolytic or expectorant
with bronchodilator is good
• Mild or moderate persistent corticosteroid is
necessary
• Sever cases : hospital management &
Nebulizer
Respiratory system drugs

• Patient education & emotional support :

asthmatic patient should be educated about :
• Nature of disease & prognosis
• How to avoid the trigger stimuli
• What to do in acute attack
• Correct use of inhaler & nebulizer
Respiratory system drugs

• Common mistakes in asthma therapy :

• Use of B2 agonist in age below 18 month only
where the receptors are not well developed &
the effect is minimal therefore use of
corticosteroid with it to increase the effect
• Use of corticosteroids as first line drug in
acute severe attack but nebulized salbutamol
is the most rapid drug , adrenaline &
theophylline are also rapid then corticosteroid
Respiratory system drugs

• Also use of antibiotic in acute asthmatic attack

will not alter the course of illness where the
infection almost always viral infection ,
• Use of cough drug , not mainly but
bronchodilator ,
• Avoidance of food , where asthmatic patient
must avoid only the food which increase
attack
• Restriction the physical activity this harmful
but must be share may use inhalation before
CNS

• Drugs affecting central nervous system

:include the following
• Neuroleptic drugs = Antipsychotic drugs =
Major tranquilizer drugs
• Antidepressant drugs
• Anticonvulsant drugs = ant epilepsy drugs
• Anxiolytics drugs = hypnotics drugs = Minor
tranquilizer
• CNS stimulant drugs
CNS

• Drugs for brain aging these group of drugs act

centrally & main uses are dementia ,Alzheimer
,learning difficult in children these drugs
classified into
• A)Psych stimulant & Nootropics : drugs
protect cerebralcortics from hypoxia ,increase
cerebral circulation & utilization of oxygen in
cerebral cortex as piracetam ( nootropil ) ,
Vinpoctine (cavinton ) , pyritinol( encephabol )
•
CNS

• B) Peripheral vasodilator & brain blood vessels

vasodilator as pantoxyphyline ( trental ) ,
codergocrine ( hydergine ) , nicergoline
(sermion ) , isoxsuprine ( duvadilan ) ,
phentolamine (vosamax ) , papaverine
(vasorin )
• C) Herbal supplementation as gincobiloba ,
ginsing , arcalion , phosphorus
• D) specific drugs alzheimer as different class
•
CNS

• Parkinson drugs as different class

•
•
CNS

• Antipsychotics drugs used in psychotic states

& sever behavioral disorders they induce state
of calm without causing sleeping , the main
indication specially in pediatric are the
following :
1. Sever anxiety & agitation
2. Aggressive behavior specially in mentally
retarded patient
3. Childhood & adolescent schizophrenia
4. Hyperactivity & Aggressiveness
CNS

Neuroleptics drugs = Antipsychotic drugs =

Major tranquilizers is classified to :
• Typical low potency as chlorpromazine
(largictil , Neurazine ) , Thiaridazine (Mellaril )
• Typical high potency as Haloperidol(seranace)
, Fluphenazine (motival ), Zuclopenthixol (
Clopixol ) , Flupenthixol(Flunxol ) , thiothixene
, Chlorprothixen ( Truxal ), Trifluroperazine
(stelazine ) , pimozide ( Orap )
CNS

Atypical Neuroleptic as Olanzapine ( zyprexa ),

Quetiapen ( seraquel ) , Aripiprazole (Abilify
Resperidone (Respirdal,Redon, )
Clozapine (Leponex ),
Invega , Welbetron,
Paliperidone , Ziprasidone
Also other neurolyptics
Hydroxyzine (atarax ), Sulpiride (Dogmatil ),
Amisulpiride (Solian ) ,
CNS

• Anti schizophrenia drugs as Quetiapine

(seroquel 300 , rezal 200 ) , Olanzepine (
Zyprexa ) , Aripeprazole (abilify ) , …..
• Anti schizophrenia & other Antipsychotic
drugs as Respirdal,Redon, Leponex , Invega ,
Welbetron
• Anti schizophrenia, Antipsychotic & Anti
mania drugs as serenace (halloperidol ),
melleril (thioredazine )
CNS

Antimania drugs Lathium containing drugs as

Lethiofore
CNS

• Other antipsychotic drugs with different

indications as
1. Chlorpromazine (largectil & Neurazine ) which is
phenothiazine derivatives which has multiple
therapeutic action as - sedating & hypnotic , -
neuroleptic (antipsychotic )it induces quieting ,
indifference & psychomotor slowing - it is very
useful to “tame” (hyperactive & aggressive
behavior ) – it is used in hyperpyrexia to
decrease shivering – it is used in sever pain to
potentiate the action of analgesic
CNS

– it is preoperative medication where it

potentiate the action of anesthetics , also used
in hiccup, ……. the main S.E is sedation &
anticholinergic effect
N.B thioredazine ( Melleril 10 , 25 ) is also
phenothiazine derivatives it is mainly used for
sedating & neuroleptics effect
2- Sulpride (dogmatil )
3- Amisulpride ( solian ) 4- stabilon
CNS

• Anti depressant drugs

1. Tricyclic antidepressant (TCA) as Imipramine
(tofranil ) , Colmepramine (anafranil ) ,
Amitryptaline (tryptizole ) ,
2. Tetracyclic antidepressant (benzodiazepam
derivatives as Mirtazipine (rameron , mirzagen)
3. SSRI (nontricyclic ) as Seroxate , prozac , cipram ,
cipralex , faverine , lusteral , Valdoxine ‫… للبحث‬..
4. SSNRI as effexor (venlafaxine ) , Prestiqu
(desvenlafaxine ), cymbalta (duloxatine )
CNS

5-Atypical antidepressant as Maprotilin (ludiomil

Also other atypical drugs as nefzedon , trazedon
, …….
• Other types of antidepressant
1. Herbal antidepressant as St. John’worts (st. johns
worts herb , procalmil ) ,…..
2. Drugs has an other main indication as tegretol ,
depakine there main indication is anti epilepsy
3. Lathium has main indication antimania but also
has used as antidepressant
CNS

• Other use of antidepressant drugs :

1. Premature ejaculation specially anafranil ,
cipram , joybox , ……
2. Nouctornal enuresis specially tofranil
3. Neuropathic pain specially cymbalta
(duluxatine ) & tryptizole ( amitryptilline )
4. Magrain as prophylactic specially tryptizole
5. As anxiolytic effect as in aspastic colon
6. P.M.S
CNS

• Anticonvulsants & anti epileptic drugs

• Epilepsy : is medical condition that produce
seizures that affect mental & physical
function when person has two or more
seizures considered epilepsy & produced by
abnormal electrical charge in the brain (EEG)
• Epilepsy : an abnormal electrical activity lead
to loss of consciousness & abnormal
movement & maybe idiopathic epilepsy or
symptomatic epilepsy
CNS

• Idiopathic epilepsy :there is no clear cause &

need to chronically ant seizures
• Symptomatic : due to number of causes as
illicit drugs use , tumor , head injury ,
meningeal infection, rapid withdraw of alcohol
, hypoglycemia , ……
• classification of seizures :
I_ partial seizures
II_ Generalized seizures
•
CNS

I_Partial seizures : only portion of the brain ,

only one lobe & symptoms depend on site of
neuronal discharge also partial seizures may be
simple or complex
• Simple partial seizures : group of electrical
discharge does not spread , patient does not
loss consciousness , but abnormal activity in
single limb , group of muscles , occur in all
ages
CNS

• Complex partial seizures : loss of

consciousness , motor dysfunction may
involve ( chawing , diarrhea , urination ) &
occur in all ages
II_ Generalized seizures : abnormal electrical
discharge through out hemisphere of the brain
• Tonic – clonic (grand mal seizures ) loss of
consciousness & violent muscle contraction
where tonic ( continuous contraction), but
CNS

• clonic ( rapid contraction & relaxation )

phases , then followed by period of confusion
, exhaustion due to glucose depletion
• Absence seizures : involve brief , abrupt &
self limiting loss consciousness , age 3 – 5
year till puberty age diagnosed by (electro
encephalogram EEG )
• Myoclonic : short episode of muscles
contraction in any age
CNS

• Febrile seizures : in young children with high

fever , consists of generalized tonic – clonic of
short duration
• Status epileptics (recur ) means 2 or more
seizures recurs without recovery of full
consciousness between them
CNS

• General mechanism of action :

• Block of voltage – gated channel (Na or Ca ), ..
….. enhance inhibitory GABAergic impulse , &
interfere with excitatory glutamate
transmitting , the drugs suppress seizures but do
not cure or prevent the epilepsy .
CNS

The anti epilepsy drugs in the market may be

intravenous or orally
• Anticonvulsant I/V drugs that used to control
the ongoing convulsive fit 1st line of these
drugs are diazepam , phenobarbital ,
• midazolam & phenytion but 2nd line for
refractory cases (lidocaine , phenobarbital ,
paraldehyde )
CNS

Antiepileptic oral drugs given for long periods

( long term therapy ) can be arranged in 2
generation as following :
• 1st generation ; phenytoin , Valproic acid ,
Carbamazipine , phenobarbital derivatives ,
• 2nd generation gabapentin ,pergabalin ,
lamotrigin , topiramate , oxycarbimazipine ,
CNS

• Epanutin(phenytoin), Tegretol ( carbamazipine

) , topamax ( topramate ) , depakine( valproic
A) , Neurantin (Gabapentin) , ( Lyrica , Nervax ,
prex 150 ,75 , (pergabalene ), trileptal
(oxycarbamezipine ) , Lamical (Lamotrigine ),
Keppra (levetiracetam ) , Lioresal ( baclofen ) ,
tiagabine (gabatril ) , sabril ( vigabatrin) , also
other drugs can be used for epilepsy beside its
anxiolytics effect as phenobarbital
(sominaletta ) ,
CNS

• Phenytoin : block Na , Ca also interfere with

release of monoamineric neurotransmitters,
• Application treatment status epileptics
• Sales point bounded with plasma protein
(albumin ) …. ,
• Liver inducing enzyme
• Long term application : peripheral neuropathy
, Osteoporosis , gingival hyperplasia
• Fosphenytoin (cerebrex)Prod rug of phenytoin
CNS

• Cerebex available in I/M & I/V but phenytoin

lead to damage of tissue
• Pregabalin may bind to Ca channel in CNS ,
the exact role in treatment is unknown
….Application of lyrica partial seizures ,
Neuropathic pain associated with diabetes ,
peripheral neuropathy, post herpetic neuralgia
S.E drowsiness , blurred vision , weight gain ,
peripheral edema , addiction ,
CNS

Topiramate several action (broad spectrum )

antisezures , it block voltage dependent Na
channel , increase frequency of Cl . Channel
opening by binding the GABA a receptor , may
act at glutamate (NMDA ) site , …. Application in
partial & primary generalized epilepsy ,
Migraine , it is liver inhibited enzyme
Lamictal with topiramate increase conc. of top.
S.E aggressiveness , somnolence , weight loss ,
renal stone ( glucoma ) ‫للبحث‬
CNS

• Tegretol block Na. channel ,…. application

effectiveness in partial seizures & secondary
generalized Tonic – Clonic ( grand mal )
seizures , trigeminal neuralgia , bipolar disease
• Not prescribe for absence seizures ‫للبحث‬
• It liver inducer enzyme ( Tegretol & Phenytoin)
• Gabapentin : it analogue for Gaba but it does
not act on it , its action unknown , application
…. Partial seizures , post herpetic neuralgia
CNS

• it is tolerated specially by elderly population

with partial seizures
• Lamotrigine block Na channel , Ca channel ,
application effective in all types of seizures ,
partial seizures & absence seizures also
bipolar disorder , t ½ = 24 – 35 hour
• it is tolerated specially by elderly population
with partial seizures
• Increase its conc. Level may be life threating
CNS

• Levetiracetam (Keppra ) is unknown mech. ,

application partial onset seizures , myoclonic
seizures , primary tonic – clonic (grand mal )
in adult & children ,
• S.E dizness , sleep disturbance , headache ,
weakness , ….
• Oxycarbazepine ( Trileptal ) , prodrug is Na
channel blocker , used in adult & children in
partial seizures , absence seizures
CNS

• Less effective on metabolic enzyme … less

potent inducer than carbamazepin
• S . E nausea , vomiting , headache , visual
disturbance
• Broad spectrum ant epilepsy are Topramate ,
Lamotrigene , Levetiracetam
CNS

• Less effective on metabolic enzyme … less

potent inducer than carbamazepin
• S . E nausea , vomiting , headache , visual
disturbance
•
CNS

• benzodizepam derivatives as
clonazepam(rivotril )
• Other use for antiepileptic's drugs
1. Neuropathic pain tegretol , lyrica,neurontin ,
2. Magrain as topamax , tryptizol , phenytoin
3. Ms relaxant as lioresal
4. Hiccup as lioresal
5. With anti depressant drugs
6. Digitalis induced arrhythmia ( Phenytoin )
‫‪CNS‬‬

‫‪• Frist aid for epilepsy patient :‬‬

‫يترك هاديء ونطمئن من حوله‬ ‫•‬
‫ال تحاول وقف حركته‬ ‫•‬
‫فك كل األشياء حول الرقبة‬ ‫•‬
‫ضع شيء مبطط وناعم تحت الرأس وكذلك بالفم‬ ‫•‬
‫تضع الشخص في إتجاه واحد حتي تسمح له بالتنفس الطبيعي‬ ‫•‬
‫ال تحاول فتح الفم بأشياء حادة‬ ‫•‬
‫ال تجعل الشخص يبلع لسانه‬ ‫•‬
‫‪CNs‬‬

‫• ال تحاول أن تعطيه تنفس صناعي أثناء التشنج إال الذي‬

‫أنتهي من التشنج وكان لديه مشكلة في التنفس‬
‫• الحظ فترة حدوث التشنج حيث غالبا ً تستغرق من بعض‬
‫ثواني الي بعض دقائق ال تزيد عن ‪ 5‬دقائق‬
‫• ال يوجد بجوار الشخص أي أشياء صلبة أو حادة‬
CNs

• Anxiolytics drugs : therapeutic application

- Hypnosis - sedation - Idiopathic Articaria ,
aspastic colon , P. M . S , Social fearing …
- Barbiturates derivatives , - benzodiazepam
derivatives but not apply , but the following
molecules are used – buspirone - , passiflour ,
Valeriana , Sleeping aid , Songanight , also
sedating antihistamine as diphenhydramine ,
doxylamine , dimenhydranate
CNS

• Other sedating antihistamine as, clemestine

chlorphenramine maleate , dimethenidine ,
cyproheptadine , all sedating antihistamine
mostly descriped once before bed time but ,
the herbal drugs described as the following ;
Valarina & pasiflour 2 capsules at begin of night
& other 2 capsules before bed time but
songanight & sleeping aid take 2 tab. Before bed
time , all sedating may cause headach, nausea ,
CNS

• due to the sleep is not deep sleeping

• Also valerina mostly used for insomnia , but
passiflour used in intermittent sleeping
• All antidepressant can be prescribed by
specialist as anxiolytic
CNS

• CNS. Stimulant drugs : as amphetamine

containing product ex. ‫القات اليمني‬, …. ,….., …..,
.also theophylline containing products , also
nicotine , caffeine , tetrahydrocannbenol &
datura , also lysergic acid but we study 2
I- Non nicotine drugs : Champix ( Varenicline ) ,
it is alpha 4 B2 nicotinic receptor partial agonist
in the brain, start with champix for 12 week ,
extending therapy an additional 12 weeks
CNs

• Help the patient to maintain abstinence &

avoid relapse
• The starter pack 0.5 + 1 mg begin by 0.5 for 3
days in the morning then continue 0.5 twice
daily for other 4 days then continue 1mg twice
daily morning & evening till complete 12
weeks
• Smoking can continue for 1st 14 days
CNS

• Side effect of varenicline are the following :

1. Depression & mood change
2. Nausea & vomiting
3. Weight gain
4. Night mares
II- Nicotinic drugs as :
1. Nicotinelle patch 30 , 20 , 10 , used according
to the smoker ( mild , moderate , sever
CNS

• Smoker ) where high smoker need to patch 30

& then decrease the concentration gradually
2- Nicotinelle chewable tab. Take 12 tab. /day
3- No Quit (No nicotine ) 2 mg , 4 mg where high
smoker more than 20 cigarette use 4mg in the
1st week every 2 hours , in the 2nd week every 4
hours , in the 3rd week every 8hours but if
smoker less 20 cigarette use the conc. 2 mg by
the same dose in conc. 4 mg
CNS

• Other drugs used for stop smoking as

Bupropion (wellbutrin ) which has different
uses as (antipsychotic effect , antidepressant ,
stop smoking , also used in slimming as
appetite suppression ,
• Bupropion act on adrenaline , serotonin &
dopamine
• In stop smoking : begin by 150 mg once daily
for 3 – 7 days then 300 mg divided in 2 dose
till stop smoking ‫للبحث لو هناك ما يفيد العمل‬
CNS

• Alzheimer is neurodegenerative disease is

characterized by loss of cholinergic neuron
the, loss of memory
• Alzheimer drugs include the following
1. ACHE inhibitor : used for treatment mild to
moderate dementia ex. Exylon (rivastigmine
) 1.5 , 4.5 mg tab. , patch , arisept (donepezil
), kemadrin (procyclidine ) ,
CNS

• Reminyl (galantamine ) the dose 5 mg

before sleeping can be increased after one
month to 10 mg
• S.E of ACHEI : are , nausea , vomiting ,
anorexia , diarrhea ,fatigue , dizziness ,
Abdominal pain , muscle cramp , dyspepsia ,
headache , somnolence , insomnia , sweating
, tremor & syncope
CNS

• NMDA receptor antagonist : NMDA is (one of

glutamate receptors ) the stimulation of these
glutamate receptors appear to be critical for
formation of certain memory
CNS

• But over stimulation of the glutamate

receptors specially NMDA lead to neuro
degenerative effect
• drug ex. Ebixa (Memantine ) where ebixa act
on NMDA receptor improving the
transmission of nerve signals & memory
• Ebixa used in moderate & severe alzheimer
• Dose of ebixa 1st week 5mg (1 tab.) daily , 2nd
week 5mg / 12 hour , 3rd one tab. In morning
CNS

• & half tab. After noon

, 4th week & continous twice daily
• S.E of ebixa : constipation ,
dizziness,headache, & somnolence ,
• dextromethorphan increase severity of S.E
• Other drugs considered as support drugs also
prescribed to increase the memory as
phosphorus containing drugs as
phosphogengal , Gincobiloba as memorex ,
arcalion ,Antioxidant , folic acid
CNS

• Parkinson’s is neurodegenerative disease

associated with loss of dopamine neuron &
characterized by disorder of movement
(tremor , rigidity , bradykinesia i.e. slowing in
initiating & carrying out of voluntary
movement
• Parkinson’s drugs include the following
1. Anticholinergic products used for
symptomatic treat. of Parkinson's including
CNS

• extrapyramidal syndrome induced by drugs

such as phenothiazines
• drugs ex. Cogentin (benzotropin 2 mg ) ,
parkinol (trihexphenidyl 5 or 2 mg ) ,
• akineton (Biperiden 20 mg ) tertiary amine
anti muscarinic uses similar to parkinol
• Dose mostly 2 mg 3 time daily but biperiden
dose can increase till maximum dose 16 mg
/day also can be use promethazine(histaloc )
,& promantine
CNS

• S.E atropine like effect , also drowsiness may

be severe specially in benzoatropine drug
• abuse of parkinol due to its euphoric effect
Dopaminergic & other mech. drugs ex.
• Sinemet (levodopa with carbidopa 1:10 )
levodopa is immediate precursor of
neurotransmitter of dopamine but it is rapidly
decarboxylated & become inactive before
enter the brain so
CNS

• , So carbidopa is mixed in the same

preparation where it is decarboxylase inhibitor
• The dose 1 tab./day Increase gradually to 2
or 4 tab./day
• Comatan (entacapon ) is selective , reversible
peripheral inhibitor of catechol-O-methyl
transferase (ComT) , an enzyme involved in
metabolism of dopamine & levodopa
• Stalevo is combination of (Sinemet +Comatan
CNs

• S.E nausea , vomiting , constipation or

diarrhea , dry mouth , dyskinesias, also
comatan is C.I in phaeochromocytoma
• parlodel ( Bromcriptine ) ,dopergine (lysuride
) dopamine agonist associated with dopamine
depletion there for used in parkinson’s
• S.E : G.I Nausea , vomiting , constipation , C.V
postural hypotension (syncope ) specially after
initial dose
CNS

• , CNS side effect confusion & hallucination

• sifrol (pramipexole ) is dopamine agonist with
action similar to those of bromocriptine
• peka merz ( amantadine ) ‫أتوقع مثل البارلوديل وللبحث‬
• Selegiline (tonus – jumex ) is selective
inhibitor of MAO type B used in early stage of
Parkinson's also can be used as adjuvant
treatment with levodopa
• In Parkinson's ask about the constipation
Gonadotrophin containing drugs

• Gonadotrophin hormone : The name is due to

secreted from gonadotrophin cell in the
anterior pituitary & due to its role on gonads
• The gonadotropins hormones are FSH & LH
• Role of gonadotropin hormones are :
1. FSH stimulate gametogenesis & follicular
development in female
2. Also stimulate spermatogenesis in men
3. LH stimulate androgen production by follicle
Gonadotropins containing drugs

1. 3- LH induce the ovulation

2. 4- FSH stimulate androgen conversion to
estrogen
• The drugs classified to HMG & HCG
1st group is HMG (human menopausal gonadotropin )
drugs its source is urine of postmenopausal
women & include - containing FSH + LH by the
same conc. (75 I.U) extracted from post
menopausal urine ex. Menogon , Marional ,
Humegon ,
Gonadotropins containing drugs

-Urofollitropins drugs containing only FSH is

named as urofollitropin & extracted from
postmenopausal urine but purified extraction i.e
free from LH ex. Metrodin , Fostimon , Brevella
- Synthetic follitropin drugs containing only FSH
but by RNA or DNA recombinant gives FSH of
glucoprotein series of alfa or beta subunit Ex .
Gonal F( Alfa follitropin ) purgon (betafollitropin)
– The main application is treatment of
infertility
Gonadotropin containing drugs

- In course 7- 12 day ( daily use ) from 75 to 300

IU till follicle development may above 14 mm
- ‫ تستعمل حديثا ً في التلقيح الصناعي‬in vivo fertilization
- ‫ تستعمل أيضا ً في الحقن المجهري‬in vitro fertilization
2nd group is HCG (human chorionic gonadotropin )
drug is extracted from urine of pregnant women where
it is secreted from placenta gives identical LH , Ex.
Profassi , pregnyl , choriomon ) , halflife 8hours ,
Synthetic DNA recombinant as ovitrelle 250mg
Gonadotropins containing drugs

• The application clinically :

1. Induce ovulation most use 5000 IU s/c, i/m
2. luteal phase is maintained with 1500 IU every
3 days for 12 days
3. Undescended testicle 500 IU 3 time /week
for 6 week
4. Spermatogenesis problem & androgen def.
GnRH analogous or gonadorelin or cytostatic GnRH
analogous

• Ex. Triptorelin (decapeptyl ) , buse relin (super

fact ) , goserelin ( Zoladex ) this group of drugs
has - stimulation action in deficiency cases
& - inhibition action by negative feed back
mechanism example in over secretion cases
due to cancer problem
• Decapeptyl injection available in :
- Aqueous form (7 syringe 0.1 mg ) mostly
prescribed once daily s/c or I/m most case is
infertility
GnRH analogous or gonadorelin or cytostatic GnRH
analogous

- Depot form one syringe 3.75 one injection

I/m every month most used in prostatic cancer
- if the concentration increase to 22.5 mg will
be used every 84 to 90 day but if the conc. is
30 mg will be used every 4 month
- Ex. For stimulation application :
1. Infertility
2. Delayed puberty
3. Hypogonadism
GnRH analogous or gonadorelin or cytostatic GnRH
analogous

- Other Ex. For inhibition (suppression effect ) :

1. Prostatic cancer
2. Endometriosis ‫تدعي البطانة المهاجرة وهي مثل الوحمة تتكون في أي مكان‬
3. Uterine fibroids
4. Early puberty (central precocious puberty )
– Cetrotide 0.25 mg = cetrorelaxin acetate
– Action of cetrotide is inhibition of LH- RH there
fore used to prevent premature ovulation which
is undesirable during hormonal treatment
Insulin

• Definition: insulin is polypeptide hormone

consisting of 2 peptide chains connected by
disulfide bonds
• Secretion : insulin secreted by beta cell of
pancreas ( islet of Langerhans's )
• Regulation the secretion of insulin through :
1. Blood glucose level
2. Incrtin intestinal hormones
Insulin

• Sources of insulin :
1. Extraction insulin from pork (pig ) , beef (cow )
2. Human insulin is produced by DNA technology
using special strains of E.Coli , or yeast
3. Recombinant human insulin analogue this new
generation of insulin produced by modification
of amino acid sequence of human insulin or
change in some amino acids & produce insulin
with different pharmacokinetics properties as
shorter duration of action & faster onset of
action
Insulin

• ex. Lispro ( lysine & proline )

• Other ex. Insulin aspart (novorapid ) (asparic
acid & proline ) , insulin glulisine (apidra )
• Also produce long acting insulin & slow flat
level ( No peak ) ex. Insulin glargine ( lantus ),
insulin detemir ( levemir ) , …..
• Insulin administration : insulin is polypeptide
hormones degraded by gastric juice there for
insulin administration through S/C injection
Insulin

• But short actin regular insulin can be used I/V

injection in emergency cases (hyper
ketoacidosis ) ex, actrapid , humulin R ,…
• Adverse effect :
1. Hypoglycemia
2. Weight gain
3. Allergic reaction but by human insulin this S.E
decreased
4. Reaction at site of injection ( lipodestrophy ) i.e
Insulin

• Lipodestrophy leadto ( hypertrophy or

hypotrophy) , also Renal insufficiency may
require to adjust the dose
• Insulin preparations in the pharmacy :
according to duration of action & according to
the company & it is turbid or clear insulin
1. According to duration of action
Regular = body insulin = short acting insulin
Rapid acting insulin = ultra hort insulin
Insulin

Intermediate (NPH ) = Isophan insulin

Long acting insulin
Mixed insulin
Regular insulin it is soluble crystalline insulin
as the body there fore named body insulin
where ; onset of action after 30 mint to 1 hour
,the peak after 3 – 4 hours , its duration from
7- 8 hour there for must be prescribed before
meal by half hour ex. Actrapid , Humulin R
Insulin

Rapid acting = ultra short insulin : its onset of

action from 10 mint to 20 mint , its peak from
1 hour to 2 hour & its duration of action from
2 hour to 5 hours there for can be prescribed
before meal or after meal directly ex.
Novorapid , homolog lispro , apidra
Intermediate insulin (NPH ) Neutral protamine
hagedorn = Isophane insulin this type is
soluble crystalline insulin combined with
Insulin

protamine at neutral PH give suspension of

turbid insulin , this turbid suspension insulin is
intermediate in its duration of action due to
delayed absorption because of its conjugation
with protamine , its onset of action from 1hour
to 2 hour , its peak from 4 to 8 hours , its
duration of action is 12 hours therefore it is
prescribed every 12 hours
Ex. Insulatard , Humlin N
Insulin

Long acting insulin : this type of insulin long

duration of action but without peak but
prolonged flat level , ex. In the pharmacy :
 Lantus ( insulin glargine ) its duration is 24
hours , the long duration of action due to
isoelectric point of insulin glargine is lower
than that of human insulin this leading to
insulin is clear in vial but precipitation at the
Insulin

, site of injection , there fore extend its action &

has flat prolonged hypoglycemic effect & also
due to change in sequence of amino acid series
 Levemir (Insulin detemir ) duration is 18 to 24
hours , by addition of the fatty acids side
chain , this enhance association to blood
albumin , then slow dissociation from albumin
result in long acting effect , also change in
sequence of amino acid series
Insulin

 Insulin lent is 3rd type of long acting insulin it

is insulin zinc suspension
Insulin combination ( Mixed insulin ) =
biphasic insulin it is combination of
intermediate insulin with short acting insulin ,
i.e gives the 2 effect rapid onset, short acting
effect & intermediate effect there for
prescribed every 12 hours ex. Maxitard ,
Humulin 70/30 , novomix , homlog mix , …..
Insulin

2 . preparation of insulin according to the

company & the insulin is turbid or clear insulin:
 Clear insulin
1. Novonordesk company
Actirapid
Novorapid
Levemer
Insulin

II- Lilly company

Humulin R
Humolog lispro
III- Avents company
Apidra
Lantus
 Turbid insulin
I- Avents no turbid insulin
Insulin

II- Lilly company

Humulin N
Humulin 70/30
Humulin lent
Homolog mix
III- novonordesk
Insulatard
Mixtard
Novomix
Insulin

 different types of short acting & rapid acting

– Actirapid
– Novorapid
– Humulin R
– Humolog lispro
– Apidra
Different types of intermediate insulin
– Insulatard ( NPH )
– Humulin N(NPH )
Insulin

Different types of mixed insulin

– Mixtard
– Novomix
– Humulin 70/30
– Humolog mix
Different types of long acting insulin
– Lantus
– levemir
– Humulin lent
Insulin

Different dosage form

Vials , pen fill (cartridge ) , disposable pen (
flexipen , solostar , optisite )
Oral hypoglycemic

Insulin secretagogues
 Sulphonylurea
 Meglitinide
Insulin sensitizer
 Thiazolidendione
 Biguanide
Alpha glycosidase inhibitor
Dpp-IV ihibitor drugs
Oral hypoglycemic

Insulin secretagogues: promote insulin release

from beta cell of pancreas through ATP –
sensitive K channel blocker ………. Beta cell
membrane depolarization ………… Calcium
influx ……… which result in pulsatile insulin
exocytosis ( I.e insulin secretion to circulation )
Other effect but not mainly as reduction of
hepatic glucose production , increase in
peripheral insulin sensitivity
Oral hypoglycemic

Insulin secretagogues
 Sulphonylurea
- glibenclamide as daonil , frequency of dose is
twice daily take before meal by 15 mint
- Gliclazide as dimicron take twice daily , dimicron
MR take once daily before meal , glaze 80
- Glipized as mindiab & sucrazide take twice daily
before meal & it is more suitable for kidney problem
- Glimipride as amaryl take once daily before meal ,
Piramyl 6mg ,
Oral hypoglycemic

• The main side effect of sulphonyurea are

– Hypoglycemia
– Weight gain
– Precaution with hepatic & renal insuff.
 Meglitinide not sulphony urea but has the
action of sulphonylurea , & it is suitable for
sulphonylurea sensitivity patient , & kidney
insuff . Meglitinide as nateglinide ,
repaglinide (novonorm 0.5 , 1 , 2 mg )
Oral hypoglycemic

• Also it has rapid onset & short duration of

action , it categorized as postprandial glucose
regulator , it can combined with metformin ,
or piaglutasone but not with sulphonylurea ,
novonorm take before meal or with meal 3
time daily , the same side effect of
sulphonylurea but less severity (hypoglycemia
, weight gain )
Oral hypoglycemic

 insulin sensitizer
 Thiazolidindione as piaglutasone ( Actos ) increase
the insulin receptor sensitivity ……… increase the
action of secreted insulin …….. Decrease the blood
glucose level , actos prescribe once daily , the
main side effect is Edema , headache , risk of
hepatotoxicity in 1st 14 day of using & hemolytic
anemia & may be urinary blader cancer, some
delisted drugs of this group as rosglotisone (
avandia ) lead to arrhythmia
 Biguanide as metformin has the different action :
Oral hypoglycemic

1. Decrease the absorption of glucose from

small intestine
2. Decrease the of hepatic glucose production
3. Increase peripherally utilization of glucose
4. Also has some insulin sensitizer effect
Metformin as glucophage has different conc. As
500 , 850 ,1000 mg prescribe 3 time daily after
meal , but conc. 750mg xL prescribe twice daily
Oral hypoglycemic

• Also metformin available in conc. 250 mg as in

melbin , metformin take after meal
• Different application of metformin are :
1. Blood glucose level regulator in diabetic
patient
2. Slimming there fore it is good choice in obese
diabetic patient
3. Also used in polycystic ovary
Oral hypoglycemic

• The main side effect of metformin :

1. GIT disturbance as nausea , gastric irritation ,
may be flatulence , may be mild diarrhea
2. Headache , N.B ant androgenic , renal pro ‫للبحث‬

3. In over dose may lead to lacto acidosis

 Alpha glycosidase inhibitor : inhibition of
this enzyme ……… inhibition for glucose
absorption ………. Decrease the blood glucose
level
Oral hypoglycemic

• Alpha glycosidase inhibitor as acarbose in

glucobay 50 mg , 100 mg , glucopay prescribe
3 time daily before meal
• Different application
1. Decrease the blood glucose level in diabetic
patient
2. Also used in slimming
• The main side effect of acarbose are :
Flatulence & mild diarrhea
Oral hypoglycemic

DPP-IV inhibitor drugs (dipeptydyl peptidase

no. IV inhibitor drugs ) ex. Sitagliptin
(Januvea ), 100 mg , vildagliptin (galvus 50mg )
,sexgliptin (Onglyza) these drugs inhibit
incretin intestinal hormones ( GLp , GIP )
breaks down ……. Which potentiate insulin
secretion & suppress release of glucacon
secretion by pancreas , lead to hypoglycemic
effect ,
Oral hypoglycemic

• These drugs prescribe once daily with or

without food
• The main side effect are :
Pancreatitis , hypoglycemia , peeling , & red
skin rash (skin leshin) , also may occur fever
,sore throat , diarrhea , abdominal pain
 combination oral hypoglycemic
Glucovance ( Metformin + glibenclamide ) ,
daonil M ,
Oral hypoglycemic

• Junoveamet, gliptinmet & galvusmet

Junoveamet ( sitgliptin + metformin )
Galvusmet ( vildagliptin + metformin )
Incretin mimic drugs used mainly for slimming
through decrease the appetite ex. Exenatide ,
victosa & bieta injection ‫للبحث‬
Optimum diabetes management

Diabetes mellitus is metabolic disease

characterized by hyperglycemia from defects
in insulin secretion , insulin action , or both
Types of diabetes mellitus
– Type 1 diabetes mellitus ( typ1 DM )or insulin
dependent diabetes
– Type 2 diabetes mellitus (type 2 DM )
– Gestational diabetes ( GDM )
– Other specific type diabetes
Optimum diabetes management

• Type 1 diabetes mellitus ( typ1 DM ) this type

resulting from beta cell destruction which
may be due to immunological reaction (one
of the cause ) , the destruction of beta cell
resulting in absolute stop of insulin secretion ,
& the C. Peptide test is negative , this type
represent (accounts ) 5 – 10 % of diabetic
patient , insulin is only treatment of this type
• Type 2 diabetes mellitus (type 2 DM ) this
type
Optimum diabetes management

Due to decrease in insulin secretion or increase

insulin resistance (decrease insulin sensitivity ) ,
this type2 represent (accounts ) 90 – 95 % of
diabetic patient
Factor affecting in development of typ2 DM or
predisposing factor , Risk factors
– Ethnicity ‫ العرق‬, environmental factor ,
– Obesity ,
– diet & in activity
– Family history
Optimum diabetes management

• Gestational diabetes ( GDM )

*this type in pregnant women with varying degree of
severity
*represent 2.5% of pregnant women develop GDM ,
*all pregnant women with diabetes treated by insulin
*GDM disappear in most women after delivery but
about 10 – 15 % of them go to develop type 2 DM
* Pathogenesis of GDM , pregnancy produce transient
insulin resistance ……. Postprandial hyperglycemia ,
Optimum diabetes management

* pregnancy hormones …… interfere with action of

insulin on insulin receptor , also the cortisol &
progesterone are the main culprits ‫المذنب الرئيسي‬
* also increase the fat deposit during pregnancy
decrease the insulin receptor sensitivity
Optimum diabetes management

• Other specific type of diabetes due to disease of

exocrine pancreas , drugs or chemical induce
diabetes treatment of aids , after organ
transplantation
Pathogenesis & onset of diabetes :
* All predisposing factor ( obesity , genetic suscep ….. )
…….. Increase insulin resistance …….. Hyperinsulinmia
…….. Beta cell exhaustion & diminished ……….
Hypoinsolinmia ………… diabetes type 2
Optimum diabetes management

Common symptoms of diabetes mellitus

*polydipsia , polyphagia , polyuria
*Extreme tiredness ( lack of energy )
*Sudden weight loss
*Slow healing of wounds
*Recurrent infection
*blurred vision
Optimum diabetes management

Some important measures :

General measure fasting blood glucose level is
70 – 110 mg dl ‫للمراجعة‬
But specific measures classify the people to 3
group ( Normal group , pre diabetic i.e. group of
high risk of diabetes , diabetic group ) these
measures are the following :
• Fasting plasma glucose level (FPG ) must fast
for 8 – 12 hours can take water only
Optimum diabetes management

≤ 100mg/dl(desliter) is normal but

≥ 126 mg/dl is diabetic but the read between
100 & 126 is the 3rd group ( high risk group )
• Oral glucose tolerance test (OGTT ) must take
75 gram of glucose then measures after 1 h , 2
h , …. These results after 2 hours postprandial
≤ 140 mg /dl is normal but
≥ 200 mg / dl is diabetic but the read between
140 &200 is the 3rd group ( high risk group )
Optimum diabetes management

• HBA1C = glycated or glycosylated protein test ,

this test reflects the average of blood glucose
level through the last 3 month I.e. measure
the degree of glucose level around the normal
≤ 5.7 mg/dl is normal but
≥ 6.5 mg/dl is diabetic but the read between
5.7 & 6.5 is the 3rd group ( high risk group )
• N.B mg /dl = mole /dl * 18
Optimum diabetes management

• Steps for management of diabetic patients

– MNT (Medical nutritional therapy )
– Physical activity
– Medication
– SMBG (self monitoring blood glucose )
– Diabetes education
• The aim of optimum management of
diabetic patient to control short term
complication (acute complication ) & also
long term
Optimum diabetes management

Long term complication (chronic complication)

& increase the trust (Rapport )
1st Short term complication(acute complication
) this include hypoglycemia or hyperglycemia
& comma , diabetic hyper ketoacidosis…….
acidosis ……..increase the osmolarity ……..
Dehydration ……...shock
Hypoglycemia controlled by glucose & glucagon
injection
Optimum diabetes management

but in hyperglycemia & hyper ketoacidosis …

the shock phase is controlled by glucose
& I/V suitable fluid & regular insulin I/V
then post acidotic phase by initiation of oral
feeding , calculation of insulin dose required
then life long management by apply last steps
2nd Long term (chronic complication) include
- Macro complication
- Micro complication
Optimum diabetes management

• Macro complication problem in large blood

vessels & include :
*coronary stroke & heart problem this is high
risk of death in diabetic patient
*cerebrovascular problem less risk than in
hypertensive patient i.e. more dangerous in B.P
* Peripheral vascular problem this lead to
 sexual dysfunction ,
diabetic foot
Optimum diabetes management

• Micro complication problem in small blood

vessels & include :
Retinopathy
Nephropathy
Neuropathy
There fore the steps for management of diabetic
patient & counseling is very important & as the
following : 1st MNT this simply by healthy plate
Optimum diabetes management

• Healthy plate ( My plate ) …… ½ plate

vegetable without starch & fruits + ¼ plate
roasted protein + ¼ plate starch or grains also
can use cup of free fat milk
2nd is physical activity : is very important but the
blood glucose level not less than 100 mg/dl &
not increase than 250 mg / dl before begin the
physical activity , NB Aerobic physical activity
Types suitable are walking ,swimming , bicycle
….
Optimum diabetes management

• The importance of physical activity : the

regular & mild to moderate different exercises
has the following importance :
1. Decrease the beta cell exhaustion by the
following decrease insulin resistance &
increase insulin sensitivity , increase glucose
utilization , also decrease glucose production
from the liver , all this decrease blood
glucose level …… decrease insulin secretion
Optimum diabetes management

1. Improve HBA1C level

2. Change in body weight to reduce
cardiovascular risk & hypertension problem
3. Improve lipids & carbohydrate metabolism
this lead to decrease the LDL & increase HDL
this decrease the hyper cholesterol
4. Physical activity treat osteoporosis
5. Increase joint flexibility , Muscle strength ,
6. Decrease anxiety , depression , …..
7. Good effect on colon ….Treat the constipation
Optimum diabetes management

• 3rd SMBG : management tools & education

tools also it is reliable , fast , portable , as or
more acceptable than lab. , also patient can
adjust & or plain the medication , exercise &
meal , also through SMBG can improve A1C
where decrease A1C by 1% decrease
complication by 50- 60%
* Type1 specially children &GDM measure 7 time
• 4th the medication explained last
Optimum diabetes management

• 5th step is very important education of

diabetic patient about the following :
 type of injection S/C but hyper ketoacidosis
Ergent case inject regular insulin I/V
Site of injection abdomen Right & lift , arms
right & lift , thigh right & lift , buttocks right &
lift , & the change every 3- 6 days from right in
abdomen then to arm then to thigh then to
buttocks then abdomen & repeat
Optimum diabetes management

Pinch up : yes but without the muscle it is

necessary in long needle
Angle 90 or 45 according to long of needle i.e.
not inject I/M but S/C injection
Insulin storage : * vial , pin fill & pen opened
or on use storage at ≤ 25 degree for 1 month
but in refrigerator 2- 8 degree for 3 month
* vial , pin fill & pen closed or not used keep in
refrigerator 2- 8 degree till expiry date
Optimum diabetes management

*Insulin no freezing where lead to denaturation

*Insulin above 35 degree lead to denaturation
 Precaution during using or application of
Insulin are the following :
1. If clear insulin & turned to cloudy
2. If expiry date is finished or expired
3. If insulin is frozen or exposed to high
temperature 35 – 45 degree
Optimum diabetes management

4- Insulin is discolored
5- After initial shaking of turbid insulin & there is
deposit , flakes or lumps in insulin but must be
homogenous
6- after injection of insulin still 6 second
7- shaking of insulin firstly between the palm of
hand then by one hand in one toward for
several time
Optimum diabetes management

Correction formula : this used to adjust the

quantity of dose of insulin depend on
insulin sensitivity factor ( ISF )
ISF = 1800/total daily dose (TDD) of insulin
Ex. If TDD of insulin = 60 IU & we need to change
the blood glucose level from 190 to 120
Solution : ISF = 1800/ 60 = 30IU
190 – 120/ 30 = 70/30 = 2.5 IU
End result we will increase the dose by 2.5 IU
Diabetic foot

• All diabetic patient considered diabetic foot

• One of macro vascular peripheral vascular
complication
• Causes : vascular problem , ischemia ,
metabolic alteration
• Types of diabetic foot :
- Neuropathic ulcer 70% of cases no pain but
has blood supply high result of treatment
Diabetic foot

- Ischemic ulcer 15 – 30 % pain but no blood

there fore the result of treatment is week
- Nero- ischemic has the 2 defect no pain & no
blood supply
- Steps occur in diabetic patient : ischemic ……
then red color ….. Then …… black color end by
gangrene ( dry gangrene , wet gangrene , gas
gangrene ) the dangerous one is gas gangrene
- Charcot joint ‫ شاركوت‬8%
Diabetic foot

• it is neuropathic-osteo arthropaty
Diabetic foot

Counseling & advice

• Stop smoking due to peripheral construction
• Inspect feet daily
• Use mirror to sure that feet free from any
wound or ulcer
• Check between toes
• Dry between toes
• Use moisturizer free from alcohol daily
‫‪Diabetic foot‬‬

‫قص األظافر بشكل مستقيم وعدم قص األركان‬ ‫•‬

‫إرتداء شراب طبي فاتح قطني‬ ‫•‬
‫عدم إرتداء األحذيه الغير مناسبه مثل الكعب المرتفع‬ ‫•‬
‫فحص الحذاء ‪comfortable diabetic shoes‬‬ ‫•‬
‫إمتنع عن المشي حافيا ً ‪barefoot‬‬ ‫•‬
‫ال تجلس علي األرض طويالً حتي تمنع ‪keratosis‬‬ ‫•‬
‫ممنوع الكوي أو إستعمال اي ‪ keratolytic‬تحت الركبة‬ ‫•‬
‫‪Liquid hydrogen used in callus‬‬ ‫•‬
‫‪Diabetic foot‬‬

‫• الجروح غسل بالماء والصابون ثم المسحات الطبية ثم‬

‫المضاد الحيوي ثم التغطية لمنع الماء‬
‫• جرح مريض السكر يجب أن يبدأ األلتئام بعد ‪ 3‬أيام وإذا زاد‬
‫عن ذلك فيجب تحويله ألخصائي‬
‫• بعد ‪ 3‬أسابيع يجب أن يكون قد إلتئم تماما ً وخالف ذلك يجب‬
‫أن يحول ألخصائي‬
Systemic corticosteroids

According to the duration of action systemic

corticosteroids there are
• Short acting its duration 4- 6 hours &
prescribe 3 time daily after meal ex.
hydrocortisone , prednisolone as (prednisone
5 mg tab., predo 15 mg /5ml , methyl
prednesolone ( medrol , urbasone )
• Long acting its duration of action 8- 12 hours
& prescribe every 12 hours after meal
Systemic corticosteroids

• Examples for long acting corticosteroids

dexamethasone 4mg (oradexon ) ,
betamethasone 0.5mg ( betasone , celestone
• Inhalation (surface active corticosteroids )
include the following beclomethasone
(beclasone , rhinoclinil,….. ) , budesonide
(pulmicort , symbicort , rhinocort aqua,…. ),
fluticasone (flixotide , serotide , flixonase , …),
ciclesonide ( alvesco )
Systemic corticosteroids

• All inhalation or surface active corticosteroids

must advice by mouth wash after using it to
decrease ( oral candidiasis ,sound hoarseness )
According to the dosage form , tab. , surface
active form , supp. & parental dosage form
• Supp. As budesonide supp. Used for ulcerative
colitis , & crons disease
• Parenteral corticosteroids : are used in acute
life style threating condition ,
Systemic corticosteroids

• Life threating condition as acute severe

asthma, severe allergy ( urticarial , serum
sickness & transfusion reaction ) examples for
parenteral corticosteroids , hydrocortisone
(solucortef , hydrocortisone amp ) ,
methylprednisolone (solu medrol , depo
medrol ) , dexamethasone ( decadron ,
dexamethasone , forticortin ) , triamcinolone
(kenacort ) , betamethasone (celestone ,
diprofos )
Systemic corticosteroids

• Diprofos is parenteral corticosteroids

betamethasone diphosphate rapid onset short
effect & betamethasone dipropionate late
onset effect & long effect this parenteral is
prescribed at least every month & above may
be every 3 month
• Tetracosactide or Tetracosactrin (synactin )
synthetic polypeptide identical in 1st part
series of amino acid to corticotrophin (ACTH )
Systemic corticosteroids

Synactin stimulate the adrenal cortex to secrete

the natural cortisol
Indication mainly diagnosis of adrenal cortex
insufficiency or to detects the adrenal cortex
function
S.E : rarely occur as the following redness at
the site of injection , rash , itching , flushing ,
dizziness , nausea , difficult breathing , swelling
of face , lip & tongue
Systemic corticosteroids

• Role of corticosteroids : are potent anti-

inflammatory through inhibition of
*prostaglandin synthesis through inhibition of
arachidonic acid formation , , inhibition the
release of already formed prostaglandin ,
*inhibition of cytotoxin & other allergans
*Inhibition of interleukin formation by monocyte
* Increased synthesis of beta – adrenergic receptors
with the resultant increase in catecholamine
activity ‫للبحث‬
Systemic corticosteroids

• Relative potency of different drugs has

corticosteroids N.B. hydrocortisone and
aldosterone are principal hormones normally
produced by adrenal cortex , hydrocortisone
(cortisol ) has the following effect -
glucocorticoids ……… Anti inflammatory effect
,mineralocorticoids …….. Salt retaining effect
• The potency for anti inflammatory effect
where prednisone 5 time as hydrocortisone
Systemic corticosteroids

• …. While the sod. Effect is slightly less than

that of hydrocortisone ( about 0.8 )
• Dexamethasone & betamethasone anti
inflammatory effect is 50 times as that of
hydrocortisone while sod. Retaining effect is
negligible
• Side effect of prolonged steroids therapy :
short term of steroids for few day 3- 5 days no
side effect but prolonged use as the following
Systemic corticosteroids

1. Growth retardation especially in growing

child
2. Cushing syndrome (buffalo & hump , moon
face , hirsutism ,acne , stria
3. Hypertension
4. Potassium depletion
5. Wasting of the muscle
6. Osteoporosis
Systemic corticosteroids

Other side effect of corticosteroids

1. Salt retention (edema , weight gain )
2. Flaring of infection ( bacterial , viral ….. )
3. Peptic ulcer
4. Sudden withdrawal after prolonged use lead
to acute adrenal failure
5. Hyperglycemia
6. Immunosuppressive effect
Systemic corticosteroids

• Patient education, precautions & counseling

for patient take corticosteroids for long time
1. High protein diet to prevent muscles wasting
2. High calcium supplementation to prevent
osteoporosis
3. High supplementation of vit. B, vit D due to
deficiency by long term of corticosteroids
4. Fresh orange ,banana juice or pot.
Supplementation or ORS to compensate pot.
Depletion (hypokalemia )
Systemic corticosteroids

• Other counseling for long term of cort.

1. Infection should be diagnosed early to be
treated
2. Protect the stomach by using corticosteroids
after meal or using H2 blocker or PPI
3. Periodic monitoring of blood pressure , blood
glucose , growth(length ) specially in children
,weight gain
4. Sudden withdrawal should be avoided
Systemic corticosteroids

• Other precaution
1. Corticosteroids regimen gradually increase &
gradually decrease
2. Can apply alternative – day therapy , or every
other morning dose 6-8 a.m every other day
N.B hyperkalemia more dangerous than
hypokalemia therefore the advice is ORS or fresh
juice specially banana juice
ATIHYPERTENSIVE DRUGS & Hypertension

Hypertension, or high blood pressure, is defined as

a reading of the blood pressure above 140/90 on
three consecutive measurements at least six hours
apart. The definition varies for pregnant women,
where hypertension is defined as 140/90 on two
consecutive measurements six hours apart.
Consistently high blood pressure causes the heart to
work harder than it should and can damage the
coronary arteries, the brain, the kidneys, and the
eyes. Hypertension is a major cause of cerebral
stroke.
ATIHYPERTENSIVE DRUGS & Hypertension

Classification of blood pressure level :

• Normal BP 120/80 systolic BP mmHg / diastolic
• High normal BP 120-139/80-90 & high B.P 2 stages
• Stage 1 moderate hypertension 140-159/90-99
• Stage 2 sever hypertension 160 & above /100
&above
ATIHYPERTENSIVE DRUGS & Hypertension

• Types of hypertension
• Primary ( essential ) hypertension more common 90
– 95 % of cases the cause is unknown though
genetic factor , obesity , lack of exercise , excess of
sodium intake , hypercholesterolemia , smoking are
predisposing factors
ATIHYPERTENSIVE DRUGS & Hypertension

• Secondary hypertension less common 5- 10%

of cases as result of renal diseases , endocrine
diseases , vascular diseases or toxemia of
pregnancy
ATIHYPERTENSIVE DRUGS & Hypertension

• Complications of hypertension :
• Cerebral complications
• Renal complications
• Cardiac complications
• Ocular complications
• Factors increase the blood pressure :-
• Nervousness & anxiety
• Alcoholic drinking
ATIHYPERTENSIVE DRUGS & Hypertension

• High amount of salt & fat

• Increase the weight & fatness
• Smoking
• Some diseases as kidney, liver , heart &
thyroid disease , also diabetes
• Genetically or hereditary factors
• Due to certain drugs ( steroids, corticosteroids
, carbnoxolone, , NSAIDS), & drugs interaction
ATIHYPERTENSIVE DRUGS & Hypertension

• Due to hormonal disturbance

• Increase the age also due to unknown causes
• Symptoms : high blood pressure may be
without symptoms therefore can be called the
silent killer but if the following symptoms
appear must advice the patient to measure
the blood pressure ( continuous or
repeated headache , epistaxis , problem in
the vision , sweating , drowsiness , increase
the heart beats ,
ATIHYPERTENSIVE DRUGS & Hypertension

• tired from any effort , increase the breathing

• Counseling for hypertensive patient : control
the weight , decrease the fatty diet ,
decrease the salt or use potassium salt , do
not use alcoholic beverages , do not smoke ,
good life style ( suitable exercise , rest , good
& suitable diet ,... ) , no nervousness nor
anxiety , do not stop the treatment suddenly ,
some drugs increase blood pressure must be
carful , Monitoring the blood pressure
ATIHYPERTENSIVE DRUGS & Hypertension

• Herbals provoking hypotension

• Agrimony ‫الغافس‬ celery ‫الكرفس‬
• Corn silk wild carrot ‫الجزر البري‬
• Garlic ‫الثوم‬ squall ‫البصل‬
• Ginger ‫الزنجبيل‬ Sage ‫المرمية‬
• Goldenseal Pokeroot
• Hawthorn ‫زعرور‬ Parsley ‫بقدونس‬
• Mistletoe ‫الهدال‬ Nettle ‫نبات قراص‬
• Hibiscus green tea
ATIHYPERTENSIVE DRUGS & Hypertension

• Also other natural or herbal as green tea ,

hibiscus
• Increase the need to monitoring the B.P
• Choice of drugs for hypertensive patient
• The choice between the drugs is to a large degree determined by the
characteristics of the patient being prescribed for, the drugs' side-effects,
and cost. For example, asthmatics have been reported to have worsening
symptoms when using beta blockers. Most drugs have other uses;
sometimes the presence of other symptoms can warrant the use of one
particular antihypertensive (such as beta blockers in case of tremor and
nervousness, and alpha blockers in case of benign prostatic
hyperplasia).the others for certain individual patients.
ATIHYPERTENSIVE DRUGS & Hypertension

• Generally the choice of the therapy of hypertension

from the specialist mostly divided into
• Prehypertension ( 120 – 139 ) lifestyle modification
only without drugs
• Stage 1 hypertension ( 140-159 ) lifestyle
modification & one drug or drug combination
• Stage 2 hypertension ( 160 or more ) lifestyle
modification & two drugs combination
• The aim of this subject not for prescribing but for
counseling & advancing the hypertensive patient
• Color of the skin & antihypertensive drugs
ATIHYPERTENSIVE DRUGS & Hypertension

• Treatment classifaction
• There are mainly 2 lines for treatment:
• Lifestyle modification
• Drugs which classified into :
• Diuretics help the kidneys eliminate excess salt
and water from the body's tissues and blood.
• Loop diuretics:
– bumetanide ,, ethacrynic acid
– furosemide , , torsemide
ATIHYPERTENSIVE DRUGS & Hypertension

• Thiazide diuretics:
– chlortalidone ,, epitizide
– hydrochlorothiazide and chlorothiazide
– bendroflumethiazide
• Thiazide-like diuretics:
– indapamide , metolazone
• Potassium-sparing diuretics:
– amiloride , triamterene ,, spironolactone
ATIHYPERTENSIVE DRUGS & Hypertension

• Although the above is a thorough list of

diuretic agents, only the thiazide and thiazide-
like diuretics have good evidence of beneficial
effects on important endpoints of
hypertension. But also the specialist can
prescribe potassium sparing diuretic or
potassium supplemental for the patient
ATIHYPERTENSIVE DRUGS & Hypertension

• Adrenergic receptor antagonists

• Beta blockers:
– atenolol , metoprolol , bisoprolol nadolol , oxprenolol ,
pindolol ( nebivolol in nebilet )
– propranolol,, timolol ( non specific beta b locker )
– Other drugs decrease HR is Ivabradine (Procoralan 5, 7.5 )
• Mixed Alpha + Beta blockers:
– bucindolol , carvedilol , labetalol
• Alpha blockers:
– doxazosin , phentolamine , , phenoxybenzamine
– prazosin , terazosin , tolazoline
ATIHYPERTENSIVE DRUGS & Hypertension

• Alpha-2 agonists :
– Clonidine (catapress ) , Methyldopa ( Aldomet )
• Although beta blockers lower blood pressure, they
do not have as positive a benefit on endpoints as
some other antihypertensive. In particular, atenolol
seems to be less useful in hypertension than several
other agents. However, beta blockers have an
important role in the prevention of heart attack in
people who have already had a heart attack.
ATIHYPERTENSIVE DRUGS & Hypertension

• Centrally acting adrenergic drugs

• Central alpha agonists lower blood pressure
by stimulating alpha-receptors in the brain
which open peripheral arteries easing blood
flow. Central alpha agonists, like Clonidine, are
usually prescribed when all other anti-
hypertensive medications have failed.
• Clonidine , Guanabenz , Methyldopa
ATIHYPERTENSIVE DRUGS & Hypertension

• Despite lowering blood pressure, alpha

blockers have significantly poorer endpoint
outcomes than other antihypertensive, and
are no longer recommended as a first-line
choice in the treatment of hypertension.
However, they may be useful for some men
with symptoms of prostate disease.
ATIHYPERTENSIVE DRUGS & Hypertension

• Calcium channel blocker

• dihydropyridines: ( vasoselective ( ‫تحتاج بحث‬
– amlodipine , felodipine , isradipine , nifedipine ,
nimodipine nitrendipine
• non-dihydropyridines: (Cardioselective ) ‫تحتاج‬
‫بحث‬
– diltiazem
– verapamil
– With beta blocker may be problem ‫تحتاج لبحث‬
ATIHYPERTENSIVE DRUGS & Hypertension

• ACE inhibitors
• ACE inhibitors inhibit the activity of
Angiotensin-converting enzyme (ACE), an
enzyme responsible for the conversion of
angiotensin I into angiotensin II, a potent
vasoconstrictor.
• captopril, enalapril , fosinopril , lisinopril
perindopril , Imadipril ( Tanatril )
• Quinapril ( aqutel ), ramipril (tritace ) ,
trandopril , benzapril
ATIHYPERTENSIVE DRUGS & Hypertension

• Renin Angiotensin System ( RAS ) regulate

blood pressure & fluid balance in the body
where when blood volume & or sodium levels
in the body are low or blood potassium is high
the cell in the kidney release renin then renin
converts angiotensinogen which is produced
in the liver & give angiotensin I which by ACE (
which found in the lung ) give angiotensin II
which is potent vasoconstrictor ( blood vessels
constriction )
ATIHYPERTENSIVE DRUGS & Hypertension

• Also angiotensin II stimulate the release of

aldosterone H. in the adrenal gland ,
aldosterone H. cause the renal tubules to
retain sodium & water but excrete the
potassium
• Together angiotensin II & aldosterone work to
raise the blood pressure & blood volume
• Also if renin angiotensin system become over
active lead to high blood pressure
ATIHYPERTENSIVE DRUGS & Hypertension

• Angiotensin II receptor antagonists

• Angiotensin II receptor antagonists work by
antagonizing the activation of angiotensin
receptors.
• candesartan , eprosartan , irbesartan ,
losartan
• olmesartan , telmisartan , valsartan
ATIHYPERTENSIVE DRUGS & Hypertension

• Vasodilators in pharmacy only nitrate group

• Vasodilators act directly on arteries to relax their
walls so blood can move more easily through them;
they are only used in medical emergencies.
• sodium nitroprusside
• Adrenergic neuron blockers
• Guanethidine , Reserpine
ATIHYPERTENSIVE DRUGS & Hypertension

Heart failure drugs :

• Renin- angiotensin system blocker drugs ( ACEI ,
ARB’S )
• Beta blocker drugs ( atenolol , bisabrolol , metaprolol
, Carvidilol ‫) للبحث‬
• Diuretics ( Loop diuretic , thiazide , aldosterone
antagonist , )
• Direct vasodilator drugs as isorbid
• Inotropic agent as digoxin , dig toxin
ATIHYPERTENSIVE DRUGS & Hypertension

• Antiarrhythmic drugs :
• Na blocker as lidocaine
• K blocker Amiodarone as cordaron , sedacron
• Ca channel blocker
• Other drugs as Adenosine
• Anti angina drugs ;
• Nitrate drugs ( isosorbide as dinitrate,nitroglycerine )
• beta blocker
• Ca channel blocker
Hypotensive drugs

Hypotensive drugs :
• Gutron ( midodrine )
• Effortil ( Etilefrine )
• Heptamyl ( Heptaminol Hcl )
• Antiplatlets aggregation :
• ASA
• Clopidogril ( Plavix )
• Direct thrombin inhibitor ( dapigatron = paradoxa )
• Herbal & natural
ATIHYPERTENSIVE DRUGS & Hypertension

Hemostatic drugs :
Konakion (phytomenadion ) , dicynon (etamsylate ),
methergine ( ergometrine ) ,
Intensify blood vessel ( vein tonic drugs )
Daflon , horsechustnut , venoruton , anastex , vit C , …
Triglycerid & Hypercholestorimia drugs

• Fibrate group : as fenofibrate ( phenogel ,lipanthyl )

, etofibrate ( lipomerz ) , Gimfibrazole ( loopid ,lowlip )
• Lipase inhibitor drugs : inhibit the absorption of fat
as Orilestate , ….
• Prevention of cholesterol from the intestine : as
ezetimbe ( Ezetrol )
• Complex with cholesterol & bile salt : as
cholestramine in sequestran , ….
• MG CoA reductase inhibitor drugs ( Statin ) drugs as
Triglycerid & Hypercholestorimia drugs

• MG CoA reductase inhibitor drugs ( Statin ) drugs :

as following
• Simvastatin (Zocor )
• Atorvastatin ( Lipitor )
• Fluvastatin ( Lescol )
• Pravastatin ( lipostate )
• Rosuvastatin ( Crestor , Ivarin )
• Combination ( Ingy & caduet )
• S. E
• Patient education & cross sales
Drugs for vascular insufficiency

A)Psych stimulant & Nootropics : drugs protect

cerebralcortics from hypoxia ,increase cerebral
circulation & utilization of oxygen in cerebral cortex as
piracetam ( nootropil ) , Vinpoctine (cavinton ) ,
pyritinol( encephabol )
B) Peripheral vasodilator & brain blood vessels
vasodilator as pantoxyphyline ( trental ) , Gincobiloba ,
tabonina , phosphorus containing products ,
codergocrine ( hydergine ) , nicergoline (sermion ) ,
isoxsuprine ( duvadilan ) , phentolamine (vosamax ) ,
papaverine (vasorin )
Drugs for vascular insufficiency

C) Herbal supplementation as gincobiloba , ginsing ,

arcalion ,
D) Other vasodilator (general )
Piribedit ( trivistal ) non ergot dopamine agonist
increase the blood supply ischemic tissue & also used
for parkinson , vincamine ( Oxybral )
E ) drugs for inner ear circulatory disturbance anti
vertigo drugs as betahistine ( betaserc ) analogue for
histamine , to improve microcirculation of inner ear ,
also decrease end lymphatic pressure
F) Peripherally & brain circulation as cinnarazine
Hormones

• Use of oral contraceptive & other hormones &

hormones antagonist
• Oral contraceptive prescribe from specialist but we
have important role in counseling & advice
• Starting The Pill:
• There are several ways to begin taking The Pill. One common
way is to start on the first day of the period when the women
use oral contraceptive first time or the first day after an
abortion
• but women used pills before can be start after 7day from
last box
Hormones

• always remembers when occur any disturbance in

taking the pills must advice using of other methods
of control as condom , local spermicidal tab.
• Continuing:
Take one pill every day until you finish an entire pack. Try to link
taking The Pill with a regular activity that you do at the same
time every day, like eating a meal or brushing your teeth. If you
have a 28or more -day pack, start a new pack immediately after
you finish the old one. If you have a 21-day pack, take one pill
every day for 21 days, no pills for 7 days, then start the new pack
immediately.
Hormones

• Cautions
Women who are over 35 and smoke or who have any of the
following conditions should not take The Pill:
• History of heart attack or stroke
• Blood clots
• Unexplained vaginal bleeding
• Known or suspected cancer
• Known or suspected pregnancy
• Liver disease
Women who are under 35 and smoke, have migraines,
Hormones

& gallbladder disease, hypertension, diabetes, epilepsy, sickle

cell disease, elective surgery, a history of blood clots, liver or
heart disease may not be able to take The Pill. Your clinician or
doctor where women who use The Pill have a higher risk of
heart attack and stroke.
Side Effects & Disadvantages
• As the body adjusts to hormonal changes created by The Pill,
women often experience some minor side effects, including:
• Irregular bleeding or spotting
• Nausea
• Breast tenderness
Hormones

• Weight gain and/or water retention

• Spotty darkening of the skin
• Mood changes
• Does not protect against sexually transmitted infections,
including HIV/AIDS.
• Must be taken every day.
• Less effective when taken with some drugs.
• Raised risk of heart attack and stroke.
• Side effects usually disappear after 2-3 cycles. If the side
effects still after 2-3 cycles or if heavy bleeding occurs,
referred to specialist
Hormones

• Advantages
 Periods may be lighter or more regular.

 Easy to use.
 Does not harm future fertility.
• May protect against uterine and ovarian cancers.
• Has other use as development of secondary character of
women , to regulate the period ,
• May reduce acne.
• Can be used for Emergency Contraception.
Hormones

• Future Fertility
• Women who want to become pregnant may stop using The
Pill at any time. Fertility may return immediately or after a few
months ( 6 – 9 )
• Drug Interactions
• The effectiveness of the Pill is lowered when taken with
certain medications, including antibiotics, anti-seizure,
tuberculosis, and migraine medications. If you are taking any
medications, must use other method , like condoms and
spermicidal. As with all drugs,
Hormones

• Danger Signs
• Women who experience any of the following symptoms while
taking The Pill should call the clinic immediately:
• Abdominal pains (severe)
• Chest pain or shortness of breath
• Headaches (severe)
• Eye problems, such as blurred vision
• Severe leg or arm pain or numbness
• Missed Pills: Late Start
• The most common way women get pregnant while using The
Pill due to starting late.
Hormones

• 1 day late starting the next package: Take 2 pills as soon as

you remember and one pill each day after. Use a backup form
of birth control as condom for two weeks.
• 2 days late starting the next package: Take 2 pills per day for 2
days, then continue as usual. Use a backup form of birth
control for two weeks.
• Missed Pills: During the Cycle
• 1 pill missed: Take it as soon as you remember and take your
next pill at your usual time. This may mean taking two pills in
one day. & if missing in 1st week must use other method as
condom but in the 2nd week use the pills only but in 3rd week
stop & begin after 7 day new box
Hormones

• 2 pills missed in a row in the first two weeks: Take two pills on
the day you remember and two pills the next day. Finish the
rest of the pack as usual. Use other method as condom for
one week at least.
• 2 pills missed in a row in the third week: stop & begin after
7 day new box but must be test the pregnancy if there is
no period
• Other method for missed pills
• If forget less than 12 hour will take the tab. only
• If forget for 24 hour take the tab. & use other method as
condom
• If forget for 48 hour must be stop 7 day & begin new cycle
with new box
Hormones

• One type hormone of oral contraceptive must be taken after

birth or 30 day after birth & not stop at all, if forget this type
for 1hour must use other method for 2 week at least
• If occur vomiting or diarrhea depend on the number of hours
from taking of pills
• Missed Periods
• Missing a period does not always mean that women is
pregnant but mostly occur due to :
• in the first few months of Pill use
• if you missed taking any Pills
• if you are taking another medication (especially antibiotics)
• if you have been sick (vomiting and/or diarrhea)
Hormones

• If women forgot one or more pills and do not have a period

that month, we recommend that she must be done pregnancy
test , Pregnancy tests are recommended right away. If she
become pregnant while on The Pill, there is probably no risk
of birth defects.
• Types of contraceptive available now :
– Oral contraceptive & injection
– Loops different type used by specialist
– Local spermicidal used locally before sexual
intercourse
– Patches used once weekly
Hormones

• Sales points dyrogestrone (duphoston ) are the following :

• Similar molecular structure & pharmacological effect of
endogenous progesterone
• No interaction with estrogen products therefore can be taken
with estrogen containing products in postmenopausal women
• It is orally active by lower dose
• It is not harmful for pregnant but must be recommended also
by physician & No effect on genital tract of female fetus
• It is free from estrogenic , androgenic ,anabolic &
corticosteroids effect of other steroids or at least it is the
less one
Hormones

• It change the proliferative phase (growing phase ) to

secretory phase therefore control endometriosis & also help
in producing protein needs to maintain the pregnancy
• Dose single or multiple not effect on pharmacokinetics &
steady conc. After 3 day
• Therefore can be take once or twice/ day
• Different indication : Hormonal replacement therapy with
estrogen to decrease the side effect of estrogen
• , threatened abortion , dysfunctional uterine bleeding ,
premenstrual syndrome (PMS) , reestablish regular menstrual
cycle by help restore natural hormone ,
• ,
Hormones

• , missed periods by use & stop , inhibit periods by continuous

use till finished
• Common S. E : may be somnolence or dizziness after oral
administration by some hour , migraine , headache , nausea
• According to company trials in Saudi Arabia ‫للمراجعة والبحث‬
• Recommended dose for missed period 1*3 for 5 – 7 days
• Recommended dose for delaying the period before
menstruation by more than 4 days & 2 tab. Morning , 2 tab.
Evening
Vitamins

• Vitamin A ( Retinol animal or chemical source

, B- carotene or pro-vit . A plant source )
• Natural source Carrots specially yellow , dark
green leaf , liver , egg yolk , fish,
• Antagonist with alcohol where it impair liver
storage , products inhibit fat absorption
• Deficiency . Night blindness
• Indication . Vision , prevent xerophthalmia
growth , antioxidant ,
Vitamins

• Recommended dietary allowance ; adult men

500 I.U , women 400 I.U , Preg. & lactation
400 I.U
• Tretinion & Isotretinion derivatives other
application & other use
• Vitamin D : Plant origin Ergocalciferol D2 ,
animal origin chole calciferol D3 , also D3
synthesized in the skin by ultraviolet
• Natural source : sun exposure , fish , liver , oils
, mushroom
Vitamins

• egg , milk , fruit , no vit. D ‫تحتاج للبحث‬

• Synergistic effect thiazide diuretic , also oral
contraceptive increase calcitriol blood level
• Antagonist : cholestramine , mineral oil ,
laxative , inhibit the absorption of vit. D , also
corticosteroid , anticonvulsant & alcohol
reduce the response for vit. D ‫تحتاج لبحث‬
• Defeciency : bone weakness muscle weakness
, tetany ,
Vitamins

• Indication : essential for mineral homeostasis ,

promotes bone formation by maintaining the
Ca & ph concentration & skeleton building ,
immune booster effect , anti tumor , also
muscle , nerve , blood clotting , ‫تحتاج بحث‬
• Recommended dietary allowance adult 200 IU
, infant less than 6 month 300 IU , but infant
more than 6 month 400 IU
Vitamins

• N.B remember that the treatment of rickets

the dose 1000 IU of D2 or D3 / day for 10 day
or more also remember that 1ug = 40 IU
Vitamins
Vitamins

• Vitamin E : Alpha tocopherol

• Natural source : vegetable oil as peanut , soya
, palm, & corn oil , also wheat germ oil
• Synergistic : antioxidant as vit.A , C , selenium
all these protect the vit. E action
• Antagonist : iron reduce the availability of vit.
E , polyunsaturated fatty acid in diet more vit
E is required ‫تحتاج لبحث‬
• Indication: Antioxidant , haemolytic anemia
Vitamins

• Also has effect in treatment of intermittent

claudication , prophylactic in cardiovascular
problem , lowering the risk of cancer &
cataract , immune function , neuromuscular
disorder , spermatogenesis & infertility ‫تحتاج‬
‫بحث‬
• Deficiency : children & pigment associated
with sickle cell disease (thalassemia ) I.E
predisposing factor
Vitamins

• Recommended dietary allowance : adult 10

mg ( 15 IU ) / day, pregnant 30IU ‫تحتاج لبحث‬
• Vitamin K : K1 Phytominadion plant , K2
menaquinone intestinal flora , K3 menadione
which change to K2 in the intestine
• Natural source : Potato , tomato , green leafy
veg. soybean, green tea , egg yolk ,butter ,
chees ,
• Antagonist : anticoagulant , antibiotic ,
intestinal illness & mineral oil
Vitamins

• Deficiency : is un expected
• Indication : it is clotting factor need for blood
clotting where it is necessary for
prothrombine , VII , IX, X factor action , , also
K1 used in bleeding expected operations , also
in hypoprothrombinemia , before delivery ,
• All last vit. is fat soluable vitamins
Vitamins

• Vitamin C : Ascorbic acid

• Natural source : citrus fruits , strawberry ,
parsely , califlower ,
• Synergistic : anti oxidant vit. A, E , protect vit.
C,
• Antagonist : industrial toxins , air pollution ,
tobacco smoke , also antidepressant & diuretic
increase vit. C requirement
Vitamins

• Indication : has role as cement substance in

vascular tissue , muscle , bone & cartilage ,
treatment fatigue , loss appetite , immune
function folic acid metabolisms scurvy ,
• Required for production of collagen , promote
skin repair & healing ,
• Recommended dietary allowance : adult 60 to
100 mg /day but preg. Increase by 30% &
lactating increase by 60%
Vitamins

• Vitamin B1 : thiamine , ant beriberi ,

• Dried brewer yeast , meat , grains , bran
• Synergist : B3 , B5 , B6 , B12
• Antagonist : Coffee , tea , raw fish , increase
nausea , diarrhea , urine excretion decrease it
• Deficiency : fatigue , lack of conc. ‫تحتاج للبحث‬
• Indication : it is essential for carbohydrate
metabolism , through coenzyme function
Vitamins

• Also in beriberi , Neuritis, 100 mg / day

• Recommended dietary allowance : adult 1.2
to 1.5 mg / day but preg. 1.6 mg /day , infant
0.3 mg , child 0.7 to 1.0 mg
• Vitamin B2 : riboflavin
• Natural source : yeast , liver , milk , meat , egg
• Synergistic thyroxin , anticholinergic increase
the its absorption
Vitamins

• Antagonists : theophylline , penicillin ,

chlorpromazine replace B2 from protein
• Deficiency rare not expected
• Indication : necessary for conversion of FA &
B6 into coenzyme form , can be used for treat
corneal ulcer , photophobia , non infective
conjunctivitis as treatment 5- 10 mg / day
• Recommended dietary allowance : adult 1 to 2
mg /day preg. 0.3 mg , infant & child 0.4mg
Vitamins

• Vitamin B3 or niacin : nicotinamide ,

niacinamide , last names vit. B3 , B4 , P.P
• Natural source : yeast , liver , meat ,milk , egg ,
tryptophaneis niacin containing product ,
• Synergistic : copper convert tryptophane to
niacin
• Antagonist : copper deficiency , peniciallamine
rifampicin & isoniazide ihibit absorption of B3
, also vit.B6 def. where it is necessary for
niacin formation ,
Vitamins

• Indication is essential for growth hormones

formation , high doses of nicotinic acid reduce
cholesterol ( 1gm *3*1 month ) ‫تحتاج لبحث‬
, vasodilator (100mg/day ) also treatment of
pellagra (disease caused by deficiency of niacin
& protein in the diet the main symptoms are
skin eruption as rash, itching, scales (dermatitis)
,digestive disturbance diarrhea , cirrhosis , also
CNS disturbance as mental disorder & insomnia
Vitamins

• Vitamin B6 : Pyridoxine
• Natural source : chicken , liver of beef , fish
(tuna & salmon )
• Synergistic : other type of vit. B complex as B2,
B3 , biotin
• Antagonist : Isoniazide , cycloserine ,
penicillamine , desoxypyridoxine , also B6 can
counteract the effect of L.dopa in
parkinsonism
Vitamins

• Indication & role : production of epinephrine ,

serotonin 5H2 , act as coenzyme …. Formation
of nicotinic acid , amino acid metabolism ,
glycogen breakdown , but therapeutically in
certain type of anemia , treatment of nausea
& vomiting in pregnancy ( 40 mg / day ),
improve glucose tolerance in DM, also with
other vit. B in neuritis , decrease the asthmatic
attack no. also used in amino acid metabolism
abnormalities , ( 40 – 200mg/day),
Vitamins

• Recommended dietary allowance : adult

2mg/day ,
• Vitamin B12 :cyanocobolamine , ant
pernicious anemia factor
• Natural source : animal products (liver , kidney
, heart , brain ), fish , egg , dairy products , but
plants free from vit B12
• Antagonist : alcohol decrease the absorption ,
def. of B6 , cholestyramine , colchicin ,
neomycin
Vitamins

Also neomycin , metformin , anticonvulsant as

phenytion , also nitrous oxide
• Indication : B12 is essential for formation of
Blood cells , nerve sheath ,various protein, fat
& carbohydrate metabolism ,essential for folic
acid regeneration , optic neuritis & other
neuritis , pernicious anemia , prusside &
cyanide induced toxicity
• Deficiency : Megaloblastic anemia ,
neuropathy
Vitamins

• Defective DNA synthesis ( numbness ) , spinal

cord degeneration , sore tongue
• Recommended dietary allowance : adult
2ug/day , preg. 2 – 2.6ug / day
but infant 0.3 – 0.5 ug /day
• Pantothenic acid : Vit.B5
• Natural source : distributed among food ,
yeast , meat , egg , milk , grain , veg.
Vitamins

B12 help to convert B5 to coenzyme , vit. A , B6

, folic acid , biotin are necessary for B5
utilization ,
• Antagonist : alcohol impair its utilization ,
• Indication & role : act as coenzyme in many
metabolism , inter in synthesis of sterols
hormones , antibodies , neurotransmitter ,
therapeutically enhance the healing as bed
sore , burns , sunburn , also other inflamed
area
Vitamins

• Folic acid : folacin , vitBc , vit B9 ,

• Natural sources : liver , dark green leaf , yeast ,
wheat germ
• Synergist : vit. B group , vit. C enhance
utilization folate
• Antagonist : chemotherapeutic ,
antimetabolite as methotraxate where inhibit
folate metabolism , but oral contraceptive
,alcohol , barbiturate , sulfasalazine , antiacids
Vitamins

• & also cholestyramine , inhibit the absorption

of folic acid
• Indication & role : act as coenzyme in
metabolic reaction , synthesis of nucleic A.
blood cell formation , folate deficiency 400-
500ug/day , abnormal tissue , for pregnant
5ug/day , also megaloplastic anemia with B12
• Biotin : vit H , vit B , Coenzyme R ,
• Natural source yeast ,liver , kidney , egg yolk
soya bean
Vitamins

• Antagonist : Avidin ( glycoprotein in raw egg

white inhibit biotin absorption , also antibiotic
damage the intestinal flora & reduce its level
• Deficiency : rare but if occur this lead to
anorexia ,nausea , vomiting , alopecia ,
• Indication & role : biotin form several enzyme
system , & necessary for normal growth body
function , therapeutically used for alopecia , in
seborrhoic dermatitis, , brittle finger
Vitamins

• Recommended dietary allowance : adult 30 –

100 ug / day but infant & young children 10 –
30 ug / day
• Remember the following
• All vitamins than KEDA are water soluble
vitamins ,
• Antioxidants are vit. A , C , E , & selenium
Mineral & trace element

• Calcium (Ca.)
• Natural source : Milk & dietary products , shell
fish , sardines , flour , sesame & almond oil
• Indication & role : necessary for the
development & maintenance of healthy bones
, teeth , …. Has an important role in blood
coagulation , Muscle convulsion , heart
function ‫ تحتاج بحث‬, & has role in absorption
of vit. B12
Mineral & trace element

• Phosphate (Ph) :
• Natural source : Chees , egg yolk , meat ,
chicken , vegetable ,
• Indication & role : one of the most essential
minerals for the body with calcium contribute
development of healthy bones , teeth ,&
production of energy of energy from food
• Selenium (Se) : Onion , Meat, milk ,vegetables
• Indication & role : anti oxidant together with
Mineral & trace element

Vitamin E. protect the cells from damage caused

by oxidation , it activate the cancer inactivating
genes there fore it has role in decreasing the
rate of prostate , lung , colon & rectum
• Zinc (zn) :
• Natural source : liver , shellfish , fish products ,
vegetables , milk , meat , egg , corn ,
• Indication & role : essential trace element for
enzyme reaction , good use of protein for
growth
Mineral & trace element

& for healthy reproduction , immunization

• Chromium (Cr) : sunflower oil , egg yolk ,
cheese ,, meat yeast , grains
• Indication & role : necessary for the
metabolism of sugar, its lack may be
predisposing for the appearance of diabetes &
cardiovascular disease in old age
• Iodine (I2) :
• Natural source : fish products , diary products
, salt
Mineral & trace element

• Indication & role : necessary for function of

thyroid , help in regulation of body fluid
• Magnesium :
• Natural source : whole meal grain , yeast ,
bran dried fruit , banana , green vegetable ,
chocolate
• Indication & role : it help the good functioning
of muscle tissue & skeleton growth
Mineral & trace element

• Manganese :
• Natural source : whole meal grain , yeast ,
bran dried fruit , banana , green vegetable ,
• Indication & role : it essential for growth of
bones , nervous system , hearing system , also
in its deficiency during pregnancy affect the
foetus
• Copper (Cu ) :
• Natural source : Mushroom , liver , shellfish
Mineral & trace element

& fish products , nuts , fruits

Indication & role : essential for metabolism of
iron , the functioning of enzyme , & melanin
production , help to keep blood pressure normal
• Potassium ( K ) :
• Vegetables & fruits specially banana & Kiwi
Mineral & trace element

• Also contain bilobalide protect the nerve cell

• Therefore application cerebral insufficiency ,
increase the memory & concentration ,
decrease the performance depression anxiety
, dizziness , tinnitus , headache , intermittent
claudication, Alzheimer's , dementia,
• Recommended dose 40mg 3 time daily , with
meal 4 – 6 week stander ( 6% terpene +24%
flavon )
Vitamin & disease as sales

• Diabetic patient : B1, B6, B12 but also

chromium & ginseng as tonic
• Hypertensive : multivitamins but not use
ginseng & chromium specially in un controlled
hypertensive
• Circulatory disturbance :ginkobilba , ginseng
,phospholipids
• Liver dysfunction : vitamin free from iron but
rich by lipotropic factor ( V2 plus )
Vitamin & disease as sales

& other liver support as sylmarine & hepamerz

• Pregnant : 1st trimester folic acid ,pyridoxine
B6 , multivitamins must be free from ginseng
also vitamin A by low conc. or Beta carotene ,
also iron preferable to be free where it
increase the symptoms (nausea ,constipation )
but not C.I where may be necessary
2nd 3rd trimester multivitamins , iron , but ca.
is necessary ‫ولكن يحتاج لبحث طريقة إعطائة‬
Vitamin & disease as sales

• Epilepsy : vitamin E where decrease the No. of

seizure
• El- zuhiemer : Acetyl L. carnitine , taurin , as
in exotique ,
• Neonates with skin & hair problem can advice
by multivitamins containing biotin as royal
jelly , junior ,…….
• Anemic patient : iron , folic A. , B12 , Protein
• Slimming : need to mulivit. & iron ,chromium,
Vitamin & disease as sales

• Prostatic patient : vit. E , & wheat germ oil,

• Hyperlipidemia : supplemental containing
garlic , parsley, …..
• Dry skin & lips , vit. A , E , B , co enzyme Q10 ,
• Eye problem : vit. A , vision nature ,
• Hair & nail as Zinc , Biotin , as hairdal , silica ok
, bioyeast
• Heart problem co enzyme Q10 , folic A , acetyl
Vitamin & disease as sales

, Acetyl L. carnitine , folic acid , adenoplex ,…

• Cold symptoms : Vit. C. , Echinace , as
phytocold , zinc
• Digestive Problem & diarrhea : vit. B ,
probiotic as bion 3 , protexin , kalsis ,
becombion , ginger ,….
• Decrease the weight problem : multivit , …
• Bleeding of gum & hemorrhoids : vit. C . ,
rutin , horse chestnut , daflon , anstex
Vitamin & disease as sales

Also zinc & panthenol has role in gum bleeding ,

& hemorrhoids
• Hyperuricemia : ‫تحتاج لبحث‬
• Total body function need body detoxication as
antioxidant (A,E, C , selenium ) garlic , parsely
• Cancer patient : Antioxidants
• Age related disorder : anti oxidants , acetyl L.
carnitine
Vitamin & disease as sales

• ‫البحث والتطوير واألضافة‬

Herbal products

• Gingko ( Ginkobiloba ) treatment of cerebral

circulatory disturbance , decrease the vertigo ,
tinnitus , weak memory , also peripheral
arterial circulatory disturbance as intermittent
claudication , ginko contain flavonoids ,
provides antioxidants , reduce the capillary
fragility , increase the threshold of blood loss
from capillary , it antagonize platelets
activating factor
•
Herbal products

• S.E Gastric upset , not increase the dose

• Drug interaction : anticoagulant , antiplatelet,
may lead to bleeding specially iris bleeding (
hyphema ) , Aspirin , warfarin , …
• Sawpalmetto ( Serenoa – repens )
• Treatment of micturition difficulties ,
associated with BHP
Herbal products

• Mech.1- Inhibit dihydrotestosterone to

androgen receptors in prostate hyperplasia
2- also it inhibit testosterone 5- alpha
reductase
Dosage 1- 2 gm. Twice or 160 mg of ing. Twice
Thank you