Pharma & Misccelaneous

Pharma & miscellaneous
Basic Concepts for PLAB1
AHMED S. YOUSSEF MSC, MBBCH

Assistant Lecturer of Cardiology
Suez Canal Univeristy
Plab1 Course Dr. Osama & Dr. Ahmed
Warm up- cardiology Quizz
Question1
A 57 year male smoker HTN presented with retrosternal heavness radiate to both shoulders and associated with nausea. His ECG is
as shown.
What would be the diagnosis?
A) Anterior STEMI.
B) Posterior STEMI.
C) Inferior STEMI.
D) Lateral STEMI.
E) Pericarditis.
Warm up- cardiology Quizz
Question 2:
A 59 year-old lady with presented to ER with Anterior MI. following giving her morphia and Aspirin, she immediately transferred to
CCU. While preparing her to do immediate PCI, she collapsed and the monitor showed the following ECG.
What would be the drug of choice following resuscitation?
A) I.V Calcium gluconate.
B) I.V Magnesium sulphate.
C) I.V Amiodarone.
D) I.V Lidocaine.
E) I.V Metoprolol.
Warm up- Emergency
A 36 year old woman attends the Emergency Department with epigastric pain and vomiting. Three days before she took an overdose
of some tablets and excess alcohol. She does not remember which tablets she took, as she was drunk at the time. She has low mood
and has recently been prescribed an anti-depressant by her GP.
Investigations:
Serum creatinine 190 micromol/L (45-95)
Serum total bilirubin 24 µmol/L (<17)
Serum aspartate aminotransferase 75 U/L (10–40)
Prothrombin time 43 seconds (10–12)
Which drug is the most likely cause of these abnormalities?
A) Amitriptyline
B) Aspirin
C) Fluoxetine
D) Mirtazapine
E) Paracetamol
Warm up- Emergency Quizz
A 16 year old boy was in a comatose state having taken methadone. He was given naloxone in the Emergency
Department and rapidly became alert. Two hours later he is drowsier, with a Glasgow Coma Scale of 10. His temperature
is 36.5˚C, pulse 82 bpm, BP 108/72, respiratory rate 10 breaths per minute and oxygen saturations of 94% breathing air.
Which is the most likely cause of the drop in Glasgow Coma Scale?
A) Methadone hepatotoxicity causing acute liver failure

B) Methadone is eliminated from the body more slowly than naloxone
C) Naloxone is a partial agonist at the central nervous system opioid receptor
D) Patient has taken another drug that has caused an intracranial bleed
E) Patient has taken another drug that is absorbed more slowly than methadone
AGENDA
I. Pharmacokinetics.
II. Pain & Analgesics.
III.Alcohol.
IV.Antibiotics.
V. GIT: Anti-emtics.
VI.CNS: Anti-psychotic – Anti-depressant- mood stabilizers.
VII.Respiratory: Asthma.
VIII.Drug Side effects : CVS- drug interactions.
IX.Miscellaneous drugs.
References
§ https://ia800108.us.archive.org/30/items/OxfordHandbookOfClinicalMedicine10thEd/Oxford%20Handbook%20of%20Clinical%20Me
dicine%2010th%20Ed.pdf
§ Plab 1 Keys.
§ Palpable vascular questions.
I. Pharmacokinetics
Administration:
• Some drugs causes gastric irritation (nausea – vomiting) when taken on
empty stomach--> Taken with meals. E.g. Doxycycline.
Absorption:
• IV route is faster than oral route because ➔ Hepatic first pass elimination
IV drug goes directly to the systemic circulation "blood" i.e. it does not go to liver for metabolism which takes time
and reduces the drug bioavailability .
Distribution:
• If drug strongly bond to plasma Albumin➔ reduce dose 7 increase dosing interval.
I. Pharmacokinetics
Dose Calculation:
• Identify the concentration: 1% = 10 mg/ml.
• Calculate the max dose: max allowed dose x weight (kg).
Example:
A 42 YO man weighs 80 kg presents for a procedure. He was given 20 ml of 1% lidocaine without epinephrine prior to the
procedure . If the maximum allowed dose is 4 mg/kg , how much of 1% lidocaine can be given to him?
• Identify the concentration: 1% = 10 mg/ml.
• Calculate the max dose: max allowed dose x weight (kg)= 4 x 80 = 320 mg.
1 ml à 10 mg
?? (X) ml à 320 mg
(X)= (320 x 1) ÷ 10 = 32 ml.
He was already given 20 mg. So, the remaining dose = 32 - 20 = 12 ml
I. Pharmacokinetics
Dose Calculation in pediaterics:
• Identify the concentration: 5 ml à 50 mg
• Calculate the max dose: max allowed dose x weight (kg).
Example:
10-month-old child who weighs 10 kg has been prescribed trimethoprim for UTI at a dose of 4 mg/kg twice a day . The
preparation of trimethoprim is 50mg/5ml. What is the dose to be given to this child?
• Identify the concentration: 5 ml à50 mg.
• Calculate the max dose: max allowed dose x weight (kg)= 4 x 10 = 40 mg.
5 ml à 50 mg
?? (X) ml à 40 mg
(X)= (40 x 5 ) ÷ 50 = 4 ml.
The answer would be 4 m BID.
II. Pain Management Analgesia Ladder
Pain Analgesia Ladder
Step 1 (simple Analgesics): Paracetamol – NSAIDs- Aspirin We go forward
We Add on
Never go back
Step 2 (weak opioids) : Codeine – Dihydrocodeine - Tramadol
Step 3 (strong opioids) : Morphine- Dimorphine- Buprenorphine patches-

Fentanyl patch - oxycodone
Step 4 : Epidural nerve block

1. Chronic Somatic stable pain management
1. Start with oral morphine.
2. If pain still present ➔ Oral Oxycodone
3. If there's a problem with oral medication:
ü Pain is stable (controlled) (e.g. stable cancer patient) ➔ Transdermal fentanyl patch
ü Pain isn't stable (e.g. postoperative) ➔ IV or SC Morphine
In palliative patients, IV medications aren't ideal as they cause discomfort, SC routes are often preferred
Fentanyl patch
• It Has slow onset of Action.
• Fentanyl takes around 36h to completely leave the system.
• Fentanyl patch is contraindicated with ➔ Paralytic ileus or Night sweats:
üWith night sweats ➔ remove fentanyl patch for 6-8h then add subcutaneous opioids
When to Use Fentanyl patch?!
• if the oral route is not tolerated and the pain is STABLE at the shifting time.
• Terminal patients with unstable pain on fentanyl patch ➔ Keep the patch+ add Subcutaneous
morphine.
Oral Codeine
• codeine phosphate has the highest rate of side effects such as nausea, constipation and
confusion specially in elderly.
• Conversion from Codeine to step 3 if side effects & according:
1. If pain controlledà Buprenorphine patches ( NOT Fentanyl patch) why??!
2. If pain not controlled (not stable)à S.C Morphine.
If constipation 2ry to opioids: If oral morphine develop side effects (nausea-

Give Sienna (stimulant laxative) vomiting-drowsiness)à Oral Oxycodone.
It has double potency but lesser side effects.
If Vomiting 2ry to opioids:
Give Metoclopramide
Strong Analgesia
Morphine conversions
Oral morphine has½ the potency of oral oxycodone:
When converting from oral morphine to oxycodone ➔ Use½ the dose
Oral morphine has the½ the potency of injectable morphine:

When converting from oral morphine to injectable morphine ➔ Use ½ the dose
Oral morphine has the 1/3 the potency of injectable diamorphine:

When converting from oral morphine to injectable diamorphine ➔ Divide the dose by 3
Oral morphine to step 2 ( tramadol- codeine-dihydrocodeine)= X 10

From Oral Tramadol to I.V morphine à divide by 20
The dose of normal lease morphine for breakthrough pain should be 1/6 of the total 24-h morphine dose:
i.e. calculate total amount used by the patient daily, then calculate the breakthrough dose (1/6 the total dose).
Morphine conversions
The dose of normal lease morphine for breakthrough pain should be 1/6 of the total 24-h morphine dose:
i.e. calculate total amount used by the patient daily, then calculate the breakthrough dose (1/6 the total dose).
Scenario:
patient on oral morphine who are still in pain and need to take additional dose (Breakthrough) to achieve pain relief?
Main dose: sum all amounts of morphine that is taken by a patient in 24 hours to achieve his relief, then
divide it by 2 - so you can give it twice a day as a main dose) .
Breakthrough Take 1/6 (the total daily dose given PRN 4 hourly) or 10% of total dose.
Example: patient with bone metastasis on oral morphine needs to take 60 mg twice a day + 20 mg each 4 hours
to relieve her bone pain. What should be the new regimen for analgesia?
Painful Muscle Spasm ➔ Give muscle relaxant e.g. Baclofen or diazepam
Capsular pain e.g. Splenomegaly / hepatomegalyà NSAIDS e.g. Naproxen
Somatic painà Pain Ladder

Neuropathic pain (tingling- burning-paresthesia-shooting-numbness)à Amitriptyline (TCA) –
Gabapentin (Lyrica) –Duloxetine or Pregabalin can be used ➔ [Away Goes Da Pain]
Trigeminal Neuralgia à carbamazepine 1st (Anti-convulsant) then
Pain killer in pregnancyà Paracetamol only.
Bone pain due to cancerà 1st line Radiotherapy – 2nd line: Bisphosphonates + NSAIDs.
Pain due to vertebral metastasis ➔ Give 3 lines e.g. Paracetamol + NSAIDS + Morphine
2nd step if still painà Radiotherapy
3rd step (if no radiotherapy or still pain)à Bisphosphonate
If vertebral metastasis associated with neuropathic painà Amitriptyline or

Gabapentin
Bisphosphonate e.g. Alendronate- Zoledronic acid- Risedronate
• First line management in Osteoporosisà Elderly + multiple fractures + T score < -2.5.
• 3rd line in bone pain management due to metastasis.
T score
Assessed by DEXA scan for BMD

Bisphosphonate e.g. Alendronate- Zoledronic acid- Risedronate
• Swallowed whole (not sucked or chewed, because of risk of oropharyngeal ulceration)
• Take with a whole glass of plain water.
• Shouldn't be administered with milk or supplements so absorption wouldn't be affected.
• Take in an upright position, don't lie down for at least 30 mins after taking the medication, risk of GERD.
• seek advice if new symptoms of burn develop. Dyspepsia or reflux is common in the first month of treatment and often
improves with continued use
• Can either be prescribed once weekly (70mg) or once daily (10mg)
• Maximum duration to take it with low risk of vertebral fractures ➔ 5 years, high risk (>75 years/ a previous hip or vertebral
fracture) ➔ 10 years
• DEXA should be done every 3-5 years, if patient stops the drug ➔ should be checked after 2 years Take on an empty stomach
III. Alcohol Units
A. Beer:
1 pint of beer (3.5%) = 2 Units .
1 pint of premium beer (5-6%) = 3 Units.
B. Wine:
Small glass 125 ml= 1.5 Units
v Medium glass 175 ml= 2 units
v Large glass 250 ml = 3 unit
C. Cider:
1 pint of cider= 3 units .
III. Alcohol Units
Calculation units of Alcohol
Strength ABV (in%) X Volume (in ml) ÷1000 = ... Units.
UK guide on Alcohol
Example: A man drinks half a litre of vodka (ABV 40%) and a pint of beer (3.5%) a 1. ≤ 14 unit per week.
week. 2. ≤ 3 units per day.
3. 2 alcohol free days a
week.
III. Alcohol
Alcohol medications summary
Patient asks for: abstinence promotion / deterrent Disulfiram
Patient asks for reduce craving Acamprosate
Social service / Alcohol

Patient asks for support
withdrawal clinic
Patient asks for: reduce withdrawal symptoms Chlordiazepoxide
Acute Alcohol withdrawal (Delirium Tremens): sweating, tremors, altered mentation, ± Hallucination 1st Chlordiazepoxide + Thiamine
If with Seizures I.V lorazepam or Diazepam
Werneck's Encephalopathy: CAS Thiamine (I.V vitamin B1) or Pabrinex or high potency Vit B complex
IV. Antibiotics
Classification of Antibiotics
B-lactam Macrolides Aminoglycosides Quinolones Sulphonamides Others
Penicillin Cephalosporines Clarithromycin Gentamycin Ofloxacin Sulfamethoxazole Tetracycline
Ampicillin First generation Erythromycin Streptomycin Norfloxacin Sulfametho + Doxycycline

• Cefazolin Trimethoprime
Amoxicillin Azithromycin
• Cephalexin Ciprofloxacin
Second generation
•Cefuroxime.
Third generation
•Cefotaxime.
•Ceftriaxone.
Fourth generation
•Cefepime.
IV. Antibiotics
Indications of Antibiotics
I. Respiratory Conditions
Mild Community Acquired Penumonia Amoxicillin
Moderate Community Acquired Pneumonia Amoxicillin + Clarithromycin
Severe Community Acquired Pneumonia Co-amoxiclav (Augmentin) + Clarithromycin
Pneumocystis Jirovecii "P. Carinii" Co-Trimoxazole = {Trimethoprim + Sulfamethoxazole) = Bactrim®
Tuberculosis (TB) ü First 2 months ➔ {Ripe) ➔ Rifampicin, lsoniazid, Pyrazinamide,
Ethambutol.
ü The next 4 months {Ri) ➔ Rifampicin, lsoniazid .
Aspiration Pneumonia Amoxicillin + Metronidazole
IV. Antibiotics
II. CNS Meningitis
Out of -hospital Meningitis (GP clinic) Benzylpenicillin
In-hospital meningitis (most types) Ceftriaxone
Listeria Meningitis Ceftriaxone + Ampicillin + Gentamicin
Cryptococcal Meningitis Amphotericin B
Meningitis Prophylaxis "for contacts" ü Ciprofloxacin “preferred” or
ü Rifampicin.
IV. Antibiotics
III. GenitoUrinary
Lower uncomplicated UTI Trimethoprim or Nitrofurantoin
(in a non-pregnant )
Candida albicans (Vulvovaginal Candidiasis) Clotrimazole or Fluconazole
Trichomonas Vaginalis Metronidazole
Bacterial Vaginosis (Gardnerella Vaginalis)
Cervicitis (Chlamydia) 1 line ➔ Doxycycline 100 mg BID for 7 Days.

Another line: Azithromycin 1-gram PO Followed by 500 mg PO OD for 2
days.
Cervicitis (N. Gonorrhea) ■ Ceftriaxone 1 gm IM (single dose) . Or:
■ Ciprofloxacin 500 mg PO (Single dose).
IV. Antibiotics
III. GenitoUrinary
PID "Pelvic Inflammatory Disease" CDM: Ceftriaxone + Doxycycline + Metronidazole
Syphilis Penicillin G
Genital Herpes "HSV" Acyclovir
IV. GIT
Salmonella/ Shigella/ Campylobacter Erythromycin or Azithromycin or Clarithromycin Or Ciprofloxacin
Clostridium Difficile v Oral Metronidazole "first line"
"Pseudomembranous colitis" v Vancomycin " if severe"
H. Pylori OAC Regimen
v Omeprazole (PPI)
v Amoxicillin
v Clarithromycin
IV. Antibiotics
V. ENT
Acute "bacterial" Otitis Media Amoxicillin
URTI "Pharyngitis/ Tonsillitis / Laryngitis" Phenoxymethylpenicillin
VI. Others
-Cellulitis – Mastitis- Diabetic Foot Infection Flucloxacillin
Septic arthritis- Osteomyelitis Flucloxacillin + Sodium Fusidate
Scabies 5% Permethrin
Toxoplasmosis Pyrimethamine + Sulfadiazine
MRSA Vancomycin
Propionibacterium (Acne) benzoyl peroxide
IV. Antibiotics
Antifungal
• Red circular itchy rash ➔ Likely fungal infection

"ringworm infection = denrmatophytosis”
• Give ➔ Clotrimazole cream
V. Anti emetics for nausea & vomiting
Drug list of Anti-emetics
Renal failure/ Hypercalcemia (metabolic cause) or 1st: 2nd:
Drug or Toxin induced vomiting HalOperidol Levomepromazine
If parkinsonian disease
ICP (e.g. intracerebral tumour) or vomiting Vertigo “ BPPV/ Meniere/VN) Buccal
Cyclizine
due to bowel obstruction Prochlorperazine
Anti -emetic due to ChemOtherapy, Radiotherapy or I.V Ondansetron

post Op intractable vomiting
1st line: Zines family ( Cyclizine – Promethazine)
Anti -emetics in Hyperemesis gravidarum 2nd line: I.V Metoclopramide or Ondansetron
3rd line: Steroids

Drug list of Anti-emetics
I.V or Oral
ICP (e.g. intracerebral tumour) or vomiting Dexamethasone
due to bowel obstruction
Cyclizine
To shrink the surrounding

edema & decrease ICP
• if GCS is< 8, we give "Mannitol" as it has a very rapid action.

• In intracranial Hemorrhage with Very Low GCS and Neurological deficit (e.g.Unequal Pupils) ➔ urgent Craniotomy
Hiccup
Treatment of Central hiccups (e.g. stroke, trauma, Chlorpromazine
space-occupying lesion)
Treatment of peripheral hiccups (e.g. Vagus

Metoclopramide
n. or phrenic n. irritation)
• Vagus irritation can be caused by gastric distension. Phrenic irritation can be caused by liver metastasis.
Anti-emetics side effect
Drug Side effects
1. Metoclopramide Extrapyramidal effects
➔ dystonia , akathisia, parkinsonism , bradykinesia , tremors .
Neuroleptic malignant syndrome
➔ high fever, sweating, tachycardia , agitation , confusion , muscle rigidity , neck
stiffness.
2. Haloperidol Sexual dysfunction – Gynecomastia – Neuroleptic malignant syndrome
• Do not use Metoclopramide in nauseous patients with Parkinson's.

• Do not use Haloperidol in psychotic patients with Parkinson's (use lamotrigine)à instead use I.M Lorazepam for
rapid tranquilizer.
Rare but life-threatening reaction to anti-dopaminergic medications: due to excessive intake of Dopamine antagonist or potent
antipsychotic.
• Antiemetics (Metoclopramide, Domperidone)
• Anti psychotic drugs (haloperidol, clozapine)
Onset: is usually within a few weeks of starting the medication but can occur anytime
Features:
• High fever, confusion, variable blood pressure, tachycardia.
• Extra-pyramidal symptoms (rigidity and tremors), dystonia, muscle weakness and stiffness.
Management:
Stopping the drugà Rapid coolingà> I.V fluids to prevent renal failureà Dantrolene (Post synaptic Muscle relaxant)à
Dopaminergic agent (Bromocriptine).
VI. Psychiatric medications
(A) Antipsychotic
Classification of Antipsychotics
• If the aggressive/ distressed patient has no Dementia ,
Alzheimer's, or Parkinson's ➔ Haloperidol or Olanzapine as a
Typical Anti-psychotics Atypical Anti-Psychotics short-term therapy if non-pharmacological (de-escalation)
(First generation) (second generation)
techniques have failed.
Block serotonin (5HT2) &

Block dopamine receptos
Dopamine receptors
• Do not use Haloperidol in psychotic patients with Parkinson's
à instead use Lamotrigine or I.M Lorazepam for rapid
1- Olanzapine
1- Haloperidol
2- Chlorpromazine
2- Clozapine tranquilizer.
3- Risperidone
(B) Antidepressants
Classification of Antidepressants
Selective Serotonin Reuptake Serotonine – Norepinephrine reuptake

Tricyclic antidepressants Atypical Antidepressnats
inhibitors (SSRI) inhibitors (SNRI)
Block reuptake of Noradrenaline 1- Venlafaxine

Block serotonin (5HT2) reuptake 1- Mirtazipine
and sertonin 2- Duloxetine
1- Sertraline.
1- Amitriptyline 2- Fluoxetine.
3- Citalopram
I. Emergency presentations (1) Coma.
Tricyclic Antidepressants e.g. Amitriptyline
Causes (clinical scenario) Clinical picture Investigations Management

1. Elderly on antidepressant (D features)
medications. 1. ECG: most important first 1st line: I.V fluids including
2. Child took his grandfather 1. Drowsiness/ sedation. investigation: NaHCO3 to correct
medications (empty bottle). 2. Dry mouth. ü Sinus tachycardia. metabolic acidosis with aim
3. Dry flushed skin. ü Wide QRS complex PH= 7.5-7.55:
4. Dilated pupild. tachycardia. I.V bolus 250 ml saline + 50
5. Shock: hypotension, ü Prolonged QRS, PR & QT. mmol NaHCO3 (8.4%) I.V
tachycardia & urine 2. ABG: Severe metabolic slowly.
retension. acidosis.
SSRI
• Selective serotonin reuptake inhibitors (SSRls) are considered first–line treatment for the majority of patients with
depression.
• Citalopram and fluoxetine are currently the preferred SSRls.
• Sertraline is Antidepressant of choice useful post myocardial infarction and is safe while breastfeeding.
• Fluoxetine is the drug of choice when an antidepressant is indicated in children and Adolescents.
• Gastrointestinal symptoms are the most common side-effect. There is an increased risk of gastrointestinal
bleeding in patients taking SSRlsà A proton pump inhibitor should be prescribed.
• Citalopram (a SSRI) is associated with acute angle-closure glaucoma as one of the side-effectsà urgent
referral to Ophthalmologist.
SSRI
• Selective serotonin reuptake inhibitors (SSRls) can take up to 2-4 weeks before Antidepressnat effect can be
seen.
ü If no response after 2-4 weeks ➔ Check patient's adherence (compliance).
ü If no response after 4 weeks + the patient is compliant ➔ either increase dose or switch antidepressant .
• If a patient makes a good response to antidepressant therapy, they should continue on treatment for at least 6
months after remission as this reduces the risk of relapse.
• When stopping a SSRI, the dose should be gradually reduced over a 4-week period (this is not necessary with
fluoxetine) . Paroxetine has a higher incidence of discontinuation symptoms.
Side effects
Drug Side effect
1. SSRI ( Fluoxetine) Anorgasmia (delayed ejaculation )à ercetion but no ejaculation. Other: hyponatremia
2. Venalafaxine Decreased libido, delayed orgasm and erectile dysfunction-painful ejaculation and priapism
3. TCA Decreased libido, erectile dysfunction, delayed orgasm and impaired ejaculation
• Haloperidol ➔ blocks dopamine II receptors ➔ Hyperprolactinemia ➔ Erectile dysfunction and gynecomastia

• Fluoxetine àAnorgasmia (delayed ejaculation)
• Paroxetine ➔ Erectile dysfunction and vaginal dryness
Serotonin Syndrome
• Excess intake of SSRls (e.g. Fluoxetine, Sertraline, Citalopram).
Features:
• fever , sweating , tachycardia , agitation , confusion , muscle rigidity/ twitching , neck stiffness, others

• due to excessive intake of Dopamine antagonist or potent antipsychotic.
• Antiemetics (Metoclopramide, Domperidone) - Anti psychotic drugs (haloperidol, clozapine)
Features:
• High fever, confusion, variable blood pressure, tachycardia.
• Extra-pyramidal symptoms (rigidity and tremors), dystonia, muscle weakness and stiffness.
(c) Mood stabilizer (Lithium)
Indication: For Biploar disorders ( mania-depressive disorder).
Investigations: Before commencing Lithium,
• Renal Function Tests - Liver Function Tests- Thyroid Function Tests- Baseline ECG.
• Others: Pulse, BP, Pregnancy Test, Parathyroid hormone , FBC, U&E, Ca, Mg.
After Lithium: check lithium levels 12 hours after taking the last lithium dose.
Features: Coarse Tremors – Nausea – Vomiting – Confusion.
interactions:
Diuretics and NSAIDs (e.g. Ibuprofen) and Aspirin increase renal reabsorption of lithium (decrease renal clearance) and
hence, the serum lithium increases and may lead to toxicity .
VII. Respiratory system Bronchial Asthma
Stepwise approach for management of Asthma
Step 1: Inhaled SABA (Short -acting beta-2 agonist e.g. inhaled salbutamol )
If Asthma is not controlled (a patient uses inhaled salbutamol > 3 doses/ week) ➔ Step 2
Step 2: Inhaled SABA+ Inhaled Corticosteroids (e.g. inhaled beclomethasone )
Step 3: Inhaled SABA+ Inhaled Corticosteroids + LTRA (leukotriene receptor antagonist ).
Step 1: Inhaled SABA+ Inhaled Corticosteroids + LABA (Long-acting beta-2 agonist e.g. inhaled salmeterol ). ± LTRA.
Among the common side effects of Inhaled Corticosteroids ( Beclomethasone) ➔ oral/ Pharyngeal Candidiasis- sore
Throat - Dry mouth and throatà Rinse mouth with water- good device spacer (inhalation technique)
VIII. Drugs side effects
(A) Cardiovascular drugs
Drug Toxicity
1. Beta blockers: Metoprolol Severe bradycardia or hypotension- Bronchoconstriction (wheezes) – Impotence-
nightmares
2. Digitalis GIT: nauea, Anorexia- Abodminal pain- CNS: impaired cognition- Eye: yellow green vision.
3. Iron Gastric irritation: nausea, vomiting, abdominal pain Acute fulminant liver failure
4. Beta agonist: salbutamol Tremors, tachycardia, palpitations- muscle twitching- shaky hands
5. Calcium channel blockers e.g. Diltiazem 2 swellings: Ankle swelling – Gingivial hyperplasia.
6. ACEi (Captopril) Angioedema – Cough dry ( shift to ARBS e.g. losartan) – Electrolyte Hyperkalemia
Beta-Agonists (e.g. Salbutamol, Salmeterol ) which are used for Asthma management can cause Tachycardia and Palpitation , worsen HF.
Beta-blockers (e.g. Atenolol , Propranolol) which are used for rate-control can worsen Asthma by causing bronchoconstriction
(B) Diuretics
Drug Toxicity
1. Thiazide Hyponatremia , Hypokalemia, Gout, Postural hypotension , Hyperglycemia
2. Loop diuretic e.g. Furosemide Hyponatremia , Hypokalemia, Gout (hyperuricemia) .
3. Potassium sparing diuretic e.g. Hyponatremia , HypeRkalemia, Gynecomastia
Spironolactone
Heart failure patient takes medication à worsening of goutà the cause is the Diuretic e.g. loop or thiazide.
Heart failure patient has gout takes medicationà worsening of HFà the cause is the NSAIDS (Salt & water retention)
Spironolactone is diuretic of choice in LCF (Ascites)

Thiazide is the diuretic of choice in HTN
Loop diuretic (Furosemide) is the diuretic of choice in HF
Drugs interaction
P450 enzyme inducers P450 enzyme inhibitors
(CRAP GPS) SICK FACES.COM
1. Carbamazepine. 1. Sodium Valproate. 2. Isonizde.
2. Rifampicin. 3. Cimirtidne. 4. Ketokonazole.
3. Alcohol (Chronic). 5. Fluconazole. 6. Alcohol (Acute).
4. Phenytoin. 7. Clormphenicole. 8. Carbamazepine.
5. Griseofulvin. 9. Erythromycin (Macrolides: Clarithromycin, Azithromycin)
6. Phenobarbital. 10. Sulfonamides. 11. Ciprofloxacin .
7. Sulphonylurea. 12. Omeprazole . 13. Metronidazole
•Breakdown OACà Decreases Warfarin effect ➔ INR

•Weaken COCP & POPà an alternative contraceptive • Increases Warfarin effect ➔ INR à Bleeding.
method is needed (e.g. Depo-Provera, IUS, barrier methods) • No effect on COCPà No need to change.
Drugs interaction
• Simvastatin should NOT be used with Macrolides (e.g. Clithromycin or Erythromycin) as it can lead to
➔ rhabdomyolysis. Both drugs together can increase serum levels Statin ➔ withhold statins for 5 days/
Stop Simvastatin / shift to Atorvastatin.
• Antibiotics e.g. Clarithromycine à increases toxicity of Warfarin (Bleeding)à reduce the dose.
• Vitamin K (multivitamins) & green leafy vegetables-à decrease Warfarin à increase dose.
Drugs interaction (DAMN)
• Drugs that should be put down in patients with diarrhea and vomiting [DAMN]à as they increase
dehydration and risk of AKI:
• Diuretics (Furosemide / Thiazide)à dehydration.
• ACEi / ARBSà AKI.
• Metforminà Lactic Acidosis.
• NSAIDSà AKI.
VIII. Anticoagulants
Side
Class Examples M.O.A Indication Antidot Advantages Disadvantages
effects
Warfarin Marevan Inhibit hepatic synthesis of
Vitamine K dependent
1- Prohylaxis against stroke, 1- Bleeding. 1st Vitamin K. Cheap INR monitoring
clotting factors à
TIA in AF patients according to Intracranial 2nd fresh frozen Available P$%) enzyme
CHADVASc score. Hemorrhage plasma. antidot inducers &
Prothrombin (II), factors
VII,IX,X. 2- prevention of Pulmonary 3rd inhibitors
embolism in DVT and following
(Headache) Prothrombin
orthopedic surgery. GIT complex
3- Valvular AF. Hemorrhage concntrate
4- Mechanical prothesis. (stomach pain)
5- 2nd and 3rd trimester of
pregnancy+ AF.
DOAC / Dabigatran Dabigatranà direct 1- Non-ValvularAF. 1- bleeding. Not available. No need to Bleeding cannot
factor II (thrombin) 2- Prohylaxis against stroke, 2- not used in 1- fresh frozen monitor INR be reversed
NOACs Rivaroxiban inhibitor. TIA in AF patients according to impaired plasma Rapid onset of Requires strict
Apixiban Riavroxiban, othersà CHADVASc score. kidney 2- Prothrombin action patient
Edoxiban direct factor X inhibitor. 3- prevention of Pulmonary function. complex Less compliance
embolism in DVT and following concntrate intracranial
orthopedic surgery. bleeding risk
Heparine UFH àIV Activates Anti-thrombin 1- Brdiging before surgeries. 1- Bleeding. Protamine
III, heparine co-factor 2- 1st trimester and before 2- HIT. sulphate.
Enoxparine / IIà inhibit conversion delivery.
fondapreinux S.C of prothrombin to 3- ACS.
thrombin.
IX. Miscellaneous drugs
(A) DMARD
Methotrexate:
• is a DMARD and is used to treat RA & cancer patients➔
• SE: GI upset, Folate deficiency, angular stomatitis and Pulmonary fibrosis - dyspnea, cough and fever
• Prolonged intake of methotrexate can rarely lead to a severe condition ➔ Pulmonary Fibrosis.
o Pulmonary Fibrosis ➔ Dry cough, Dyspnea even on mild exertion , Diffuse bilateral interstitial infiltrates on CXR.
• • Hydroxychloroquine is also a DMARD ➔ SE: Visual loss – long QT ➔ eye examination is mandatory
every 6 months
(B) Chemotherapy
Vincristine ➔ peripheral neuropathy, felt as numbness and tingling "glove-and-stock distribution" with sensory loss
and hypersensitivity and in some cases, motor and autonomic dysfunction.
Capecitabine ➔ Diarrhoea, if not addressed, the patient may not be able to replace fluid lost leading to severe
dehydration
(C) Obs & Gyna
• Tranexamic Acid (for menorrhagia) ➔ inhibits fibrinolysis.

• N -Acetylcysteine (for paracetamol overdose)➔ Protection from free radicals.
• Copper IUD as an Emergency Contraception "after unprotected sex” ➔ inhibits Implantation (inhibits fertilisation).
• Oral Progesterone-only emergency contraceptive Pills - Levonorgestrel➔ inhibits Ovulation
• Ulipristal acetate (EllaOne) ➔ inhibits or delays Ovulation.
(D) Polypharmacy
Features:
• An old patient (usually> 60 YO) takes ~ 5 Medications
• Presents with dizziness, confusion , Frequent Falls (± Hx of feeling dizzy a few moments before a fall).
• Due to postural hypotension (caused by multiple drug intake especially anti-hypertensives and anti-cholinergics).
Management:
Blood pressure monitoring and review of his medications.
(E) Medications worse hair loss
HRT (estrogen)
COCP
Warfarin
Chemotherapy
ACE-inhibitors
Sodium valproate
Lithium
To treat hair lossà Minoxidil - Finasteride (only for men).
(F) Drugs should be Avoided (stopped in pregnancy)
• Cardiovascular: Antihypertensive (ACEi/ARBS/ Diuretics – Betablockers).

• Antibiotics: Streptomycine – Nitrofunatoin- Trimethoprime.
• Anticoagulants: Warfarine is tetratogenic in 1st trimester (safe in 2nd & 3rd) – But heparin is safe throughout
pregnancy.
Clinchers
Taxi driver has rash and requests medication that will not affect her alertness à Non-sedating anti-histaminic
e.g. Citrizine.
IX. Antiplatelets
Diagnosis Long term therapy: Statins +
ACS medical treatment Aspirin (lifelong) + Clopidogrel / Ticagrelor (12 months)
Following PCI Aspirin (lifelong) + Clopidogrel / Ticagrelor/ Prasugrel (12 months)
Transient ischemic attack (TIA) Aspirin 300 mg two weeks (14 days) then Clopidogrel 75 mg life long.
Ischemic stroke+ sinus rhythm Aspirin 300 mg two weeks (14 days) then Clopidogrel 75 mg life long.
Ischemic stroke + AF Aspirin 300 mg two week (14 days) then start OAC (warfarin or DOACs).
Peripheral arterial disease (PAD) Clopidogrel lifelong.

Palliative care
Anticipatory medications
Anticipatory medications ➔ given to patients "just in case" in end of life situations (All S.C).
• SC Morphine sulphate - SC Midazolam - SC Haloperidol - SC Hyoscine
• Pain and Breathlessness à SC Morphin.

• Nausea and Vomiting à SC Haloperidol.
• Anxiety, Delirium, Agitation à SC Midazolam
• Catastrophic bleeding in a palliative patient ➔ SC Midazolam + SC Morphine sulphate
• Terminal case with noisy breathing ➔ Terminal respiratory secretions (death rattle) à Hyoscine SC
(Scopolamine) or Glycopyrronium SC.
• At home", "end -of-life care” ➔ Rectal! "diazepam" (cheaper, more available)
Palliative care
Anticipatory medications
Watch out Euthanasia (a painless killing of a patient with a terminal disease) is a CRIME in the UK!
So if patient asks for

medication to end his life
Tell him that there are Refer him to Hospice care

medications that help him
ease pain
For the bed-ridden very elderly patients who still have mental capacity, if they develop a disease (e.g.
Pneumonia), we need toà Discuss their wishes on the management plan (home or hospital).
Palliative care
Palliative surgical options
Bowl obstruction due to advanced malignancyà Palliative Colostomy
Pleural effusion due to advanced malignancyà Pleural aspiration
vomiting of fecal contents or Persistent vomiting that does not respond to anti-emetic
(e.g. cyclizine)à NGT.
Dying patientà encourage small sips of water and mouth care.

Palliative care
Death Certificate
la part of the death certificate, write the "Disease or condition directly leading to death " clearly and specifically.
e.g. Anteiror Myocardia infarction – Squamous cell carcinoma of left main bronchus.
Avoid abbreviations
Write down date in words not numbers e.g. First of June

Palliative care
Valid Prescription
The quantity of any controlled drug (e.g. Morphine) must strictly be written in both Words and Figures
Morphine 20 mg modified release capsules

Supply 32 (sixty-two ) capsules
Take one capsule twice a day
The doctor's (signature) must be handwritten but the prescription it self does not matter .
Miscellaneous topics
1- Superior Vena Cava Obstruction
Causes Clinical picture Investigations Management
1. Malignancies: (D features)
• Non-small cell lung cancer. CT chest with contrast. 1st line: Dexamethasone.
• Breast cancer. 1. Dyspnea (SOB). Gold standard:
• Lymphoma. 2. Swelling face, neck &
Endovascular stenting of
• Kaposi sarcoma. arms.
1. Vascular: 3. Facial plethora. SVC.
• SVS thrombosis. 4. Morning headache. + treatment of cause.
• Aortic aneurysm. 5. Distension of veins of
3. Goitre – mediastinal fibrosis.
neck and chest.
1- Superior Vena Cava Obstruction
2- Malignant spinal cord compression
Causes & scenario Investigations
Malignancy: breast – Urgent MRI whole spine

prostate- myeloma +
Backpain +
Neurological symptoms:
Urine incontinence
Lower limb weakness
3- Radiological trick
Cervical vertebrae are from C1-C7 à There is no C8 vertebra.

Cervical nerve roots are from C1-C8 à There is C8 nerve root.
So,
Median nerveà C5-T1
Ulnar nerveà C8- T1 (nerve roots).
Neck injury (cervical fracture)
In suspected Cervical fracture à X-ray of all cervical vertebrae from C1-C7.

Lowest level need to be seen on lateral X-rayà C7-T1.
The problem is,
Sometimes C7-T1 doesn’t appear on AP, lateral and open mouth odntoid (peg
view) x-rays, so we need to do:
Swimmer lateral view--> If not visualizedà CT scan.
4- US findings in Gyna
Snow storm appearance of mixed echogenicity
Hydatidiform mole Bilateral cystic mass (Theca lutein)
PCOS Multiple follicles / cysts
Dermoid cyst Uniocluar – Iceberg tip sign- Dermoid mesh

4- US findings in Gyna
Ground glass appearance
Ovarian endometrioma Thick wall uniocular cyst -Chocolate cyst
Ovarian teratoma Echogenic tubercle project into cyst lumen
Tubo-ovarian abscess Multi-ocular – separation, irregular thick

walls, debris
5- Lipoma
Pathology: Lipoma is Benign soft tissue mass of fatty tissue enclosed within fibrous capsule.
Gross: very slowly growing single mobile painless soft rubbery in consistency.
Management:
Typical lipoma: not growing & not interfering with life à Reassure.
Suspicious Liposarcoma: > 5 cm – increasing in size – painful- deep invasion
Do USà if suspicious à MRI + surgical removal.
6- Ascending cholangitis
Clinical picture Investigations
(Charcot Triad)
1. Fever. 1st: Abdominal US.
2. Right upper quadrant pain. 2nd: Blood culture.
3. Jaundice.
Miscellaneous Topics
7- Refeeding syndrome
To avoid refeeding syndrome--> slow feeds + give supplements of phosphate, potassium & magnesium

Pharma & Misccelaneous

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Pharma & miscellaneous

Basic Concepts for PLAB1

AHMED S. YOUSSEF MSC, MBBCH

A) Methadone hepatotoxicity causing acute liver failure

Step 3 (strong opioids) : Morphine- Dimorphine- Buprenorphine patches-

Step 4 : Epidural nerve block

1. Start with oral morphine.

2. If pain still present ➔ Oral Oxycodone

3. If there's a problem with oral medication:

ü Pain isn't stable (e.g. postoperative) ➔ IV or SC Morphine

If constipation 2ry to opioids: If oral morphine develop side effects (nausea-

Oral morphine has the½ the potency of injectable morphine:

Oral morphine has the 1/3 the potency of injectable diamorphine:

Oral morphine to step 2 ( tramadol- codeine-dihydrocodeine)= X 10

Capsular pain e.g. Splenomegaly / hepatomegalyà NSAIDS e.g. Naproxen

Somatic painà Pain Ladder

Pain killer in pregnancyà Paracetamol only.

2nd step if still painà Radiotherapy

3rd step (if no radiotherapy or still pain)à Bisphosphonate

If vertebral metastasis associated with neuropathic painà Amitriptyline or

Assessed by DEXA scan for BMD

Strength ABV (in%) X Volume (in ml) ÷1000 = ... Units.

Patient asks for reduce craving Acamprosate

Social service / Alcohol

Patient asks for: reduce withdrawal symptoms Chlordiazepoxide

If with Seizures I.V lorazepam or Diazepam

Penicillin Cephalosporines Clarithromycin Gentamycin Ofloxacin Sulfamethoxazole Tetracycline

Ampicillin First generation Erythromycin Streptomycin Norfloxacin Sulfametho + Doxycycline

Cervicitis (Chlamydia) 1 line ➔ Doxycycline 100 mg BID for 7 Days.

• Red circular itchy rash ➔ Likely fungal infection

Anti -emetic due to ChemOtherapy, Radiotherapy or I.V Ondansetron

3rd line: Steroids

To shrink the surrounding

• if GCS is< 8, we give "Mannitol" as it has a very rapid action.

Treatment of peripheral hiccups (e.g. Vagus

• Do not use Metoclopramide in nauseous patients with Parkinson's.

Block serotonin (5HT2) &

Selective Serotonin Reuptake Serotonine – Norepinephrine reuptake

Block reuptake of Noradrenaline 1- Venlafaxine

Causes (clinical scenario) Clinical picture Investigations Management

• Haloperidol ➔ blocks dopamine II receptors ➔ Hyperprolactinemia ➔ Erectile dysfunction and gynecomastia

Neuroleptic malignant syndrome

Step 2: Inhaled SABA+ Inhaled Corticosteroids (e.g. inhaled beclomethasone )

Step 3: Inhaled SABA+ Inhaled Corticosteroids + LTRA (leukotriene receptor antagonist ).

Spironolactone is diuretic of choice in LCF (Ascites)

•Breakdown OACà Decreases Warfarin effect ➔ INR

• Tranexamic Acid (for menorrhagia) ➔ inhibits fibrinolysis.

• Cardiovascular: Antihypertensive (ACEi/ARBS/ Diuretics – Betablockers).

ACS medical treatment Aspirin (lifelong) + Clopidogrel / Ticagrelor (12 months)

Following PCI Aspirin (lifelong) + Clopidogrel / Ticagrelor/ Prasugrel (12 months)

Peripheral arterial disease (PAD) Clopidogrel lifelong.

• SC Morphine sulphate - SC Midazolam - SC Haloperidol - SC Hyoscine

• Pain and Breathlessness à SC Morphin.

So if patient asks for

Tell him that there are Refer him to Hospice care

Bowl obstruction due to advanced malignancyà Palliative Colostomy

Pleural effusion due to advanced malignancyà Pleural aspiration

Dying patientà encourage small sips of water and mouth care.

Write down date in words not numbers e.g. First of June