Prescription-Only Medicines now Accessible to Podiatrists The Science Behind Them Dr Jean Mooney...
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![Page 1: Prescription-Only Medicines now Accessible to Podiatrists The Science Behind Them Dr Jean Mooney PhD, FChS, FCPodS, FCPodMed, FHEA.](https://reader035.fdocuments.us/reader035/viewer/2022062718/56649e615503460f94b5bc69/html5/thumbnails/1.jpg)
Prescription-Only MedicinesPrescription-Only Medicines now Accessible to Podiatristsnow Accessible to Podiatrists
The Science Behind ThemThe Science Behind Them
Dr Jean Mooney Dr Jean Mooney PhD, FChS, FCPodS, FCPodMed, FHEAPhD, FChS, FCPodS, FCPodMed, FHEA
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Pods and POMs: HistoryPods and POMs: History
~1980~1980 Statutory Instrument gave access to Statutory Instrument gave access to 4 injectable plain local anaesthetic solutions4 injectable plain local anaesthetic solutions
~1996~1996 Further SI gave access to Further SI gave access to 2 adrenalinised local anaesthetics2 adrenalinised local anaesthetics Topical anti-fungal agentsTopical anti-fungal agents Topical 1% corticosteroidTopical 1% corticosteroid 3-day course Ibuprofen, 200mg tds3-day course Ibuprofen, 200mg tds
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Patient Group DirectionsPatient Group Directions
Legal framework Legal framework (August 2000)(August 2000) Allowed Podiatrists to supply and administer specified Allowed Podiatrists to supply and administer specified
medicines to patients who are designated as within a medicines to patients who are designated as within a group as group as defined by the PGD defined by the PGD
e.g: Diabetics with soft tissue or bone infectionse.g: Diabetics with soft tissue or bone infections POMs supplied directly to a patient without the need for POMs supplied directly to a patient without the need for
a separate prescriptiona separate prescription from a prescriber. from a prescriber. PGD allows access to POMs for specific types of patient PGD allows access to POMs for specific types of patient
presenting with a specific need: it is NOT a form of prescribingpresenting with a specific need: it is NOT a form of prescribing PGD does not require the podiatrist to have any additional PGD does not require the podiatrist to have any additional
qualificationqualification Employing organisation must ensure that only fully competent, Employing organisation must ensure that only fully competent,
trained health care professionals use PGDs. trained health care professionals use PGDs.
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Supplementary Prescribing (2005)Supplementary Prescribing (2005)
Voluntary Voluntary prescribing partnershipprescribing partnership between between IP and SPIP and SP
Implements an Implements an agreed agreed patient-specificpatient-specific clinical management plan (CMP)clinical management plan (CMP)
CMP agreed betweenCMP agreed between IP: doctor IP: doctor SP: podiatristSP: podiatrist PatientPatient
Podiatrist must undergo Podiatrist must undergo training (~6/12)training (~6/12) to to become SPsbecome SPs
HPC-Register annotatedHPC-Register annotated Allows them to Allows them to prescribe or adapt dosage of prescribe or adapt dosage of
POMs specified within the CMP without POMs specified within the CMP without recourse back to IPrecourse back to IP
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Pods and POMs: 17.11.2006Pods and POMs: 17.11.2006 SI extended accessSI extended access to the list of POMs to the list of POMs that that
can be administered, sold and supplied to can be administered, sold and supplied to patients by Podiatristspatients by Podiatrists Schedule 5, Articles 4(2) and 4(4) amended Part Schedule 5, Articles 4(2) and 4(4) amended Part
I and III of Schedule 5 to the Prescription Only I and III of Schedule 5 to the Prescription Only Medicines (Human Use) Order 1997Medicines (Human Use) Order 1997
Also Also regularised accessregularised access to some Pharmacy to some Pharmacy medicines (P) for topical application e.g.: medicines (P) for topical application e.g.: 1% Griseofulvin1% Griseofulvin 1% Terbinafine1% Terbinafine
2006
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Additional POMs from 17.11.06Additional POMs from 17.11.06
AdrenalineAdrenaline 2 more plain LA solutions2 more plain LA solutions
LevobupivacaineLevobupivacaine RopivacaineRopivacaine
4 Anti-microbial agents4 Anti-microbial agents AmoxicillinAmoxicillin ErythromycinErythromycin FlucloxacillinFlucloxacillin Silver SulfadiazineSilver Sulfadiazine
Anti-inflammatoryAnti-inflammatory MethylprednisoloneMethylprednisolone
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Further amendments allowed additional Further amendments allowed additional
access to other medicines from 10.03.2011access to other medicines from 10.03.2011
Ibuprofen (400mg)Ibuprofen (400mg) Codeine phosphateCodeine phosphate
Co-codamol Co-codamol Co-dydramol (10/500)Co-dydramol (10/500)
Pre-mix injectable solutionsPre-mix injectable solutions E.g.: Depomedrone (Pre-mixed Lidocaine and E.g.: Depomedrone (Pre-mixed Lidocaine and
Methylprednisolone)Methylprednisolone)
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Recommendations
Continue to use all means of access to POMs e.g.: PGDs
Train as a Supplementary Prescriber Not easy for those in private practice
Gain HPC annotation POMs LA
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College of Podiatrists Recommendations
Codeine, Co-codamol and Co-dydramol
Indicated for Indicated for short term treatmentshort term treatment of acute / of acute / moderate pain unrelieved by paracetamol, moderate pain unrelieved by paracetamol, ibuprofen or aspirinibuprofen or aspirin
Limited to a Limited to a maximum of 3 daysmaximum of 3 days prior to direct prior to direct patient reviewpatient review
even though the pack size may exceed that dose leveleven though the pack size may exceed that dose level Essential that all Medicines are Essential that all Medicines are correctly labelled correctly labelled
and supplied with an explanatory leafletand supplied with an explanatory leaflet that that clearly statesclearly states
DosageDosage Side effects (e.g.: constipation)Side effects (e.g.: constipation) Possibility of addiction or habituationPossibility of addiction or habituation
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PharmacodynamicsPharmacodynamics
Adverse Drug ReactionsAdverse Drug Reactions
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PharmacodynamicsPharmacodynamics
The The effects of the drug on the bodyeffects of the drug on the body desired and undesired effects of the drug on desired and undesired effects of the drug on
body systemsbody systems Intended effectsIntended effects
Modes of action / drug-receptor interactionModes of action / drug-receptor interaction Doses and maximum safe dosesDoses and maximum safe doses
Undesired / unwanted / unexpected effectsUndesired / unwanted / unexpected effects = Adverse drug reactions (ADRs)= Adverse drug reactions (ADRs)
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Classes of Adverse Drug Reaction (1)Classes of Adverse Drug Reaction (1)
Type A:Type A: AddativeAddative effects effects Dose relatedDose related Predictable effectPredictable effect Not usually severeNot usually severe
ManagementManagement: : Dose modificationDose modification
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Classes of Adverse Drug Reaction (2)Classes of Adverse Drug Reaction (2)
Type BType B BizarreBizarre, unexpected effect, unexpected effect UnpredictableUnpredictable Immunological basisImmunological basis Rare: can be life threateningRare: can be life threatening
ManagementManagement:: Immediate withdrawal of drug Immediate withdrawal of drug Counter treatment, where possibleCounter treatment, where possible Avoid all future exposure to the Avoid all future exposure to the
drugdrug
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Comparison: Type A and Type B ADRSComparison: Type A and Type B ADRS
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Other Types of Adverse Drug ReactionOther Types of Adverse Drug Reaction
Type CType C Chronic administrationChronic administration Habituation; tolerance; dependenceHabituation; tolerance; dependence
Type DType D Delayed effectsDelayed effects Drug does not ‘kick in’ when expectedDrug does not ‘kick in’ when expected
Type EType E ExclusionExclusion Effects of drug withdrawalEffects of drug withdrawal
Type FType F Failure of therapyFailure of therapy Often due to drug interactionsOften due to drug interactions
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Frequency of ADR, by Class of DrugFrequency of ADR, by Class of Drug
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ADR-Risk PatientsADR-Risk Patients
Elderly Elderly Very youngVery young Renal diseaseRenal disease Liver diseaseLiver disease Genetic Genetic
predispositionpredisposition
ADRs attributed to Celecoxib
(COX2 inhibitor) in 6/12 period
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ADR avoidanceADR avoidance
Use prescribed medications only when Use prescribed medications only when necessarynecessary In the In the lowest doselowest dose, to achieve required effect, to achieve required effect For the For the shortest timeshortest time, to maintain the required effect, to maintain the required effect
Patients should be warnedPatients should be warned of the possibility of of the possibility of ADR occurringADR occurring Package Package advice leafletadvice leaflet
BNF BNF Yellow card systemYellow card system Report all suspected ADRsReport all suspected ADRs
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PharmacokineticsPharmacokinetics
Drug InteractionsDrug Interactions
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PharmacokineticsPharmacokinetics
The effects of the body on the drugThe effects of the body on the drug How the body deals with the drugHow the body deals with the drug What the body does to the drugWhat the body does to the drug
• AbsorptionAbsorption• MetabolismMetabolism• ExcretionExcretion
Drug interactionsDrug interactions
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Drug Interactions (DIs)Drug Interactions (DIs) Effect or action occurring in the body
Beneficial / desired Adverse / unwanted
Due to taking two or more drugs, or one drug+
OTC medicines Vitamin and mineral supplements Medicinal herbs Foods
Does not occur when taking either alone DIs usually inadvertent, e.g.:
POM + OTC Drugs supplied by more than one prescriber The more drugs that are taken, the more
likely that DI will occur Often under-reported as they mimic
exaggerated action of drug
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Drug InteractionsDrug Interactions Desired effectsDesired effects: potentiating effect of drugs used in combination : potentiating effect of drugs used in combination
e.g.: codeine combined with paracetamol gives greater pain relief e.g.: codeine combined with paracetamol gives greater pain relief Undesired effectsUndesired effects: one drug mitigates the effect of another : one drug mitigates the effect of another
e.g.: Erythromycin reduces the effectiveness of oral contraceptives e.g.: Erythromycin reduces the effectiveness of oral contraceptives Most Most DIs arise due to effects on Cytochrome P450 enzymeDIs arise due to effects on Cytochrome P450 enzyme system
absorption by small intestineabsorption by small intestine metabolism to non-active substances by livermetabolism to non-active substances by liver (non-active substances excreted via the kidney: may still carry some (non-active substances excreted via the kidney: may still carry some
drug effect) drug effect) DIs also occur when DIs also occur when drug constituents interact with e.g.: foods, drug constituents interact with e.g.: foods,
antacids, vitamin, mineral or herbal supplementsantacids, vitamin, mineral or herbal supplements e.g.: Antacids can bind with antibiotics preventing blood uptakee.g.: Antacids can bind with antibiotics preventing blood uptake
It is essential that the name and dosage of all medications It is essential that the name and dosage of all medications (including OTCs) are identified (including OTCs) are identified beforebefore supplying a POM to a supplying a POM to a patientpatient
Full medical historyFull medical history
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AntibioticsAntibiotics
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Antibiotics (ABx)Antibiotics (ABx) Substances that Substances that kill or inhibit a range of MOs kill or inhibit a range of MOs
Any MO-derived substance that antagonizes growth of another MO Any MO-derived substance that antagonizes growth of another MO in high dilutionin high dilution
Dose: usually minimum 5-7 daysDose: usually minimum 5-7 days to ensure full MO killto ensure full MO kill wound swabwound swab BEFORE starting ABx BEFORE starting ABx review patient after 3 daysreview patient after 3 days to check response to AB treatment to check response to AB treatment
Classified Classified By manufactureBy manufacture
• natural, semi-synthetic or synthetic analogues of natural natural, semi-synthetic or synthetic analogues of natural compoundscompounds
Spectrum of biological effectSpectrum of biological effect• Bactericidal / BacteriostaticBactericidal / Bacteriostatic
Susceptibility of a range of MOs to ABx effectSusceptibility of a range of MOs to ABx effect• Broad / Medium / Narrow spectrumBroad / Medium / Narrow spectrum
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AmoxicillinAmoxicillinFlucloxacillinFlucloxacillinErythromycinErythromycin
Silver SulfadiazineSilver SulfadiazineAvailable to HPC POM-annotated Podiatrists since Nov 2006
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AmoxicillinAmoxicillin Beta-lactam penicillin-type antibiotic with Beta-lactam penicillin-type antibiotic with moderate-moderate-
spectrum of activityspectrum of activity BacteriolyticBacteriolytic Inhibits synthesis of G+ve and G-ve bacterial cell wallsInhibits synthesis of G+ve and G-ve bacterial cell walls
Good absorption with Good absorption with oral administrationoral administration MO resistance is commonMO resistance is common
MOs produce MOs produce beta-lactamase and degrade amoxicillinbeta-lactamase and degrade amoxicillin Often formulated in combination with clavulanic acid (Co-Often formulated in combination with clavulanic acid (Co-
amoxiclav / Augmentin) to overcome MO resistanceamoxiclav / Augmentin) to overcome MO resistance
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Amoxicillin ContdAmoxicillin Contd::
DoseDose:: 250mg / 500mg tds250mg / 500mg tds
UsesUses Skin infectionsSkin infections (No longer recommended for prevention of (No longer recommended for prevention of
bacterial endocarditis)bacterial endocarditis) Side effects (ADRs)Side effects (ADRs)
D+VD+V Non allergic rashes Non allergic rashes
• Affects 3-10% of childrenAffects 3-10% of children AnaphylaxisAnaphylaxis
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FlucloxacillinFlucloxacillin
Beta-lactam penicillin-type antibiotic with Beta-lactam penicillin-type antibiotic with narrow spectrum of activitynarrow spectrum of activity Inhibits synthesis of bacterial cell wallsInhibits synthesis of bacterial cell walls
Used to treat infections caused by susceptible G+ve bacteriaUsed to treat infections caused by susceptible G+ve bacteria Active against beta-lactamase MOs, such as Staph aureusActive against beta-lactamase MOs, such as Staph aureus Not effective against G-ve organisms or non-beta lactamase producing Not effective against G-ve organisms or non-beta lactamase producing
G+vesG+ves Ineffective against MRSAIneffective against MRSA MO ResistanceMO Resistance
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Flucloxacillin ContdFlucloxacillin Contd..
DoseDose 250-500mg qds 250-500mg qds
UsesUses Skin infectionsSkin infections Surgical prophylaxisSurgical prophylaxis CellulitisCellulitis
• May be combined with ampicillin (Co-fluampicil) if Strep May be combined with ampicillin (Co-fluampicil) if Strep pyogenes suspectedpyogenes suspected
ADRs includeADRs include D+V, superinfection (candidiasis), allergyD+V, superinfection (candidiasis), allergy Avoid use in patients with renal or hepatic impairmentAvoid use in patients with renal or hepatic impairment
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ErythromycinErythromycin
Bactericidal macrolide antibiotic Bactericidal macrolide antibiotic Slightly Slightly wider antimicrobial spectrum than wider antimicrobial spectrum than
penicillinspenicillins Unknown mechanism of activityUnknown mechanism of activity Taken up by macrophages so Taken up by macrophages so concentrates in area of concentrates in area of
infectioninfection Often used in Often used in subjects with penicillin allergysubjects with penicillin allergy
Indicated for skin infectionsIndicated for skin infections Metabolised in the liverMetabolised in the liver
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Erythromycin ContdErythromycin Contd..
DoseDose 250mg qds250mg qds Non acid-stable (give after meals)Non acid-stable (give after meals) Clarythromycin is acid-stableClarythromycin is acid-stable
ADRS includeADRS include D+V, nausea and abdo crampsD+V, nausea and abdo cramps Cardiac arrhythmias and deafnessCardiac arrhythmias and deafness
AllergiesAllergies To be avoided in infancy, pregnancy and lactationTo be avoided in infancy, pregnancy and lactation
Not used in conjunction with many drugsNot used in conjunction with many drugs e.g.: Warfarin, OCs, corticosteroids, simvastatin, anti-e.g.: Warfarin, OCs, corticosteroids, simvastatin, anti-
migraine drugs, verapamil, terfenadine, theophilline, migraine drugs, verapamil, terfenadine, theophilline, clindamycinclindamycin
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Silver SulfadiazineSilver Sulfadiazine Topical agent
1% cream Sulfonamide and Silver
Antibacterial: broad-spectrum activity in chronic wounds G+ve and G-ve bacteria (including Pseudomonas aeruginosa) Some yeasts and fungi Poor penetration on normal skin
Up to 1% show hypersensitivity reaction, e.g.: Rashes; erythema multiforme Skin discolouration (argyria) Avoid in late pregnancy / infancy Avoid in patients with G6PD deficiency
May increase wound healing times Not recommended by Cochrane review
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LET’S
See you again in 15 mins
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Pain controlPain control
AnalgesiaAnalgesia
AnaesthesiaAnaesthesia
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AnalgesicsAnalgesics Analgesic = painkillerAnalgesic = painkiller
anan = without; = without; algosalgos = pain = pain NB: Anaesthetics = without sensationNB: Anaesthetics = without sensation
ActAct at at PNS and / or CNS membrane receptorsPNS and / or CNS membrane receptors Include Include
ParacetamolParacetamol (acetaminophen in US), (acetaminophen in US), NSAIDsNSAIDs, e.g.: Salicylates (aspirin), Ibuprofen, e.g.: Salicylates (aspirin), Ibuprofen OpioidsOpioids, including Morphine and Codeine, including Morphine and Codeine
CoP advice: CoP advice: Max administration = 3 days, then direct patient reviewMax administration = 3 days, then direct patient review
Analgesic choice is determined by Analgesic choice is determined by Severity of painSeverity of pain Pain type, e.g.: neuropathic pain is more responsive to tricyclic Pain type, e.g.: neuropathic pain is more responsive to tricyclic
antidepressants and anticonvulsants (e.g.: gaba-pentin)antidepressants and anticonvulsants (e.g.: gaba-pentin)
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Codeine phosphateCodeine phosphate OpiateOpiate drug drug
Weak to mid-range opioidWeak to mid-range opioid Makes up 3% of opiumMakes up 3% of opium CSN and PNS actionCSN and PNS action
ActionsActions Analgesic, anti-tussive, anti-diarrhoealAnalgesic, anti-tussive, anti-diarrhoeal
Side effectsSide effects (especially in overdose) (especially in overdose) Gut immobilityGut immobility Respiratory suppressionRespiratory suppression Tolerance, habituation, addiction, coma, death Tolerance, habituation, addiction, coma, death Codeine is Codeine is metabolised to morphinemetabolised to morphine
• 5% show rapid metabolism to morphine 5% show rapid metabolism to morphine ‘High’ ‘High’ • Avoid use during lactationAvoid use during lactation
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Codeine contdCodeine contd..
Unwanted side effects includeUnwanted side effects include Euphoria, itching, nausea, vomiting, drowsiness, Euphoria, itching, nausea, vomiting, drowsiness,
orthostatic hypotension, urinary retention, depression, orthostatic hypotension, urinary retention, depression, constipation, and paradoxical coughingconstipation, and paradoxical coughing
Hives and rashes due to allergic reactionHives and rashes due to allergic reaction Long-term administration causes erectile dysfunction Long-term administration causes erectile dysfunction
and hypogonadism (especially in white males) and hypogonadism (especially in white males) Sugar cravingsSugar cravings
• Induces hypoglycaemia (the ‘munchies’)Induces hypoglycaemia (the ‘munchies’)• Was once used to control diabetes, as was morphineWas once used to control diabetes, as was morphine
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Co-dydramolCo-dydramol Compound analgesic Compound analgesic
DiDihydro-codeine tartratehydro-codeine tartrate 7.5 / 10 / 20 / 30mg 7.5 / 10 / 20 / 30mg + Paracetamol+ Paracetamol 500mg 500mg
Used to relieve Used to relieve moderate painmoderate pain Side effectsSide effects
Allergic reactions - urticaria, breathing difficulty, increased Allergic reactions - urticaria, breathing difficulty, increased sweating, facial flushing, mouth ulcers.sweating, facial flushing, mouth ulcers.
Abdominal pain Abdominal pain GIT upsets: abdominal pain, nausea, heartburn, GIT upsets: abdominal pain, nausea, heartburn,
constipation, loss of appetite, dry mouth, constipation, loss of appetite, dry mouth, Blood problems - anaemia, nose bleeds, increased risk of Blood problems - anaemia, nose bleeds, increased risk of
infection, bruising.infection, bruising.
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Co-dydramol Side Effects ContdCo-dydramol Side Effects Contd
UT upsets - pain or difficulty in passing urine.UT upsets - pain or difficulty in passing urine. Nervous system - confusion, drowsiness, dizziness, Nervous system - confusion, drowsiness, dizziness,
mood changes, depression, hallucinations, mood changes, depression, hallucinations, restlessness, excitation, fits, painful eyes, headache, restlessness, excitation, fits, painful eyes, headache, sleeping problems, sleeping problems,
Tolerance or dependence.Tolerance or dependence. Eyes - blurred or double vision, extremely small Eyes - blurred or double vision, extremely small
pupils.pupils. Other - trembling, tiredness. weakness, malaise, low Other - trembling, tiredness. weakness, malaise, low
body temperature, muscle stiffness, changes in libido.body temperature, muscle stiffness, changes in libido.
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Co-CodamolCo-Codamol
Compound analgesicCompound analgesic Codeine phosphateCodeine phosphate 8 / 12.8 / 15 / 30mg 8 / 12.8 / 15 / 30mg + Paracetamol+ Paracetamol 500 / 1000mg 500 / 1000mg
For the relief of For the relief of mild – moderate painmild – moderate pain, , where paracetamol alone, or NSAIDS (aspirin, where paracetamol alone, or NSAIDS (aspirin,
ibuprofen, naproxen) does not control the painibuprofen, naproxen) does not control the pain
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Co-codamol ContdCo-codamol Contd..
Side effects includeSide effects include Allergic reactionsAllergic reactions: Shortness of breath : Shortness of breath
Hypersensitivity, pruritis, Rashes, Hypersensitivity, pruritis, Rashes, CNS effectsCNS effects: Confusion, Loss of short : Confusion, Loss of short
term memory, Dizziness, Fainting, term memory, Dizziness, Fainting, Drowsiness, Sedation, Euphoria, Drowsiness, Sedation, Euphoria, dysphoria, addiction.dysphoria, addiction.
Blood changesBlood changes: bleeding gums, easy : bleeding gums, easy bruisingbruising
GIT effectsGIT effects: Abdominal pain, Nausea / : Abdominal pain, Nausea / vomiting, Constipationvomiting, Constipation
OthersOthers: Dry mouth; : Dry mouth;
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Paracetamol Paracetamol ((Acetaminophen) Acetaminophen)
OTC analgesic and antipyreticOTC analgesic and antipyretic Relief of minor aches and painsRelief of minor aches and pains
• COX2 inhibitorCOX2 inhibitor COX + arachidonic acid COX + arachidonic acid prostaglandin prostaglandin
• Reduces Prostaglandin E2 Reduces Prostaglandin E2 lowers temperature lowers temperature • Modulates endogenous canabinoid system Modulates endogenous canabinoid system
pain awareness reducedpain awareness reduced
• Inhibits sodium channels in pain fibres Inhibits sodium channels in pain fibres Constituent of many cold and ‘flu relief remediesConstituent of many cold and ‘flu relief remedies Does not cause gastric irritationDoes not cause gastric irritation Does not have marked anti-platelet effectDoes not have marked anti-platelet effect
Used in combination with opioid analgesics to Used in combination with opioid analgesics to control more severe pain, e.g.: post surgerycontrol more severe pain, e.g.: post surgery
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Paracetamol contdParacetamol contd..
Onset of analgesiaOnset of analgesia is approximately 11 minutes after oral is approximately 11 minutes after oral administrationadministration Half-life = 1–4 hours.Half-life = 1–4 hours. Metabolised by liverMetabolised by liver
Recommend Recommend dose = 1g tdsdose = 1g tds 3g daily3g daily
• 2g daily maximum for heavy drinkers2g daily maximum for heavy drinkers• 325mg tds in USA325mg tds in USA
Acute overdose causes potentially fatal liver damageAcute overdose causes potentially fatal liver damage• First aid = activated charcoalFirst aid = activated charcoal• Paracetamol toxicity is foremost cause acute liver failureParacetamol toxicity is foremost cause acute liver failure• Rare individuals develop irreversible liver damage at normal Rare individuals develop irreversible liver damage at normal
dosedose Risk of overdose increased by alcohol consumptionRisk of overdose increased by alcohol consumption
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Local AnaestheticsLocal Anaesthetics
Lidocaine hydrochloride (Lidocaine hydrochloride (XylocaineXylocaine)) Lidocaine hydrochloride + 1:200,000 adrenalineLidocaine hydrochloride + 1:200,000 adrenaline
Bupivacaine hydrochloride (Bupivacaine hydrochloride (MarcainMarcain)) Bupivacaine hydrochloride + 1:200,000 adrenalineBupivacaine hydrochloride + 1:200,000 adrenaline
Mepivacaine (Mepivacaine (ScandonestScandonest)) Prilocaine (Prilocaine (CitanestCitanest)) Levo-Bupivacaine (Levo-Bupivacaine (ChirocaineChirocaine)) Ropivacaine (Ropivacaine (NaropinNaropin))
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LAs prevent generation of nerve impulses (action potentials) in pain fibres
Injected Injected LA diffuses into nerve fibreLA diffuses into nerve fibre LA molecule blocks NaLA molecule blocks Na++channels in nerve fibre channels in nerve fibre
membranemembrane Nerve impulse cannot be generatedNerve impulse cannot be generated
LA LA gradually diffuses out of the nervegradually diffuses out of the nerve fibre fibre Nerve function returns to normalNerve function returns to normal
Impulse can be generated and propagatedImpulse can be generated and propagated LA taken upLA taken up from site of injection from site of injection into general into general
circulationcirculation LA LA metabolised in liver and excreted via kidneymetabolised in liver and excreted via kidney
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Onset of ActionOnset of Action
Lidocaine hydrochloride = 5 minsLidocaine hydrochloride = 5 mins Bupivacaine hydrochloride = 20 minsBupivacaine hydrochloride = 20 mins Mepivacaine = 10 minsMepivacaine = 10 mins Prilocaine = 10 minsPrilocaine = 10 mins Levo-Bupivacaine = 20 minsLevo-Bupivacaine = 20 mins Ropivacaine = 10-30 minsRopivacaine = 10-30 mins
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Duration of ActionDuration of Action Lidocaine = 1-2 hoursLidocaine = 1-2 hours
Lidocaine + 1:200,000 adrenaline = 2-4 hoursLidocaine + 1:200,000 adrenaline = 2-4 hours Bupivacaine = 6-8 hoursBupivacaine = 6-8 hours
Bupivacaine + 1:200,000 adrenaline = 12-16 hoursBupivacaine + 1:200,000 adrenaline = 12-16 hours Mepivacaine = 2-4 hoursMepivacaine = 2-4 hours Prilocaine = 2-4 hoursPrilocaine = 2-4 hours Levo-Bupivacaine = 5-15 hoursLevo-Bupivacaine = 5-15 hours
Up to 30 hours post-op analgesiaUp to 30 hours post-op analgesia Ropivacaine = 4-8 hours Ropivacaine = 4-8 hours
Up to 24 hours post-op analgesiaUp to 24 hours post-op analgesia
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CautionsCautions
Do not inject adrenalinised solutions into the Do not inject adrenalinised solutions into the distal footdistal foot Causes ischaemiaCauses ischaemia ‘‘Chemical tourniquet’Chemical tourniquet’ Ischaemic effect persists for duration of anaesthesiaIschaemic effect persists for duration of anaesthesia
Avoid adrenalinised solutions in patients takingAvoid adrenalinised solutions in patients taking Beta-blockersBeta-blockers MAOIsMAOIs Tri-cyclic anti-depressantsTri-cyclic anti-depressants
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Calculation (in mg) of total LA dose administered Calculation (in mg) of total LA dose administered from drug labelled as % solutionfrom drug labelled as % solution
Percentage MassPercentage Mass 1% solution = 10mg of drug in 1ml 1% solution = 10mg of drug in 1ml 2% solution = 20 mg of drug in 1ml 2% solution = 20 mg of drug in 1ml 3% solution = 30mg of drug in 1ml3% solution = 30mg of drug in 1ml
THUSTHUS 3.5ml of 1% soln delivers 35mg of drug3.5ml of 1% soln delivers 35mg of drug 8.3ml of 2% soln delivers 166mg of drug8.3ml of 2% soln delivers 166mg of drug 5.6ml of 3% soln delivers 168mg of drug5.6ml of 3% soln delivers 168mg of drug
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Maximum safe doses Maximum safe doses 70Kg or >70Kg person70Kg or >70Kg person
Lidocaine Lidocaine 200mg (3mg / Kg)200mg (3mg / Kg) 20ml of 1% OR 10ml of 2% soln20ml of 1% OR 10ml of 2% soln
Bupivacaine / LevobupivacaineBupivacaine / Levobupivacaine 150mg (2mg / Kg)150mg (2mg / Kg) 30ml of 0.5% OR 60ml of 0.25% soln30ml of 0.5% OR 60ml of 0.25% soln
Mepivacaine OR PrilocaineMepivacaine OR Prilocaine 400mg (6mg /Kg)400mg (6mg /Kg) 13ml of 3% soln13ml of 3% soln
RopivacaineRopivacaine ~250mg (4mg/Kg)~250mg (4mg/Kg) 50ml of 0.5% OR 33ml of 0.75% soln50ml of 0.5% OR 33ml of 0.75% soln
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Maximum Safe Dose for patient <70kgMaximum Safe Dose for patient <70kg
MSD of 1% Lidocaine for 68kg person?MSD of 1% Lidocaine for 68kg person? MSD for 70kg = 200mgMSD for 70kg = 200mg MSD for 68kg in mg = 68/70*200 = 195mgMSD for 68kg in mg = 68/70*200 = 195mg MSD of 1% Lidocaine soln for 68kg, in ml = 195/10 = 19.5mlMSD of 1% Lidocaine soln for 68kg, in ml = 195/10 = 19.5ml
MSD of 3% Mepivacaine for 61kg person?MSD of 3% Mepivacaine for 61kg person? MSD for 70kg = 400mgMSD for 70kg = 400mg MSD for 61kg in mg = 61/70*400 = 349mgMSD for 61kg in mg = 61/70*400 = 349mg MSD of 3% Mepivacaine soln for 61kg, in ml = 349/30 = 11.6mlMSD of 3% Mepivacaine soln for 61kg, in ml = 349/30 = 11.6ml
MSD of 0.5% Bupivacaine for 58kg person?MSD of 0.5% Bupivacaine for 58kg person? MSD for 70kg = 150mgMSD for 70kg = 150mg MSD for 58kg in mg = 58/70*150 = 120mgMSD for 58kg in mg = 58/70*150 = 120mg MSD of 0.5% Bupivacaine soln for 58kg, in ml = 120/5 = 24.25mlMSD of 0.5% Bupivacaine soln for 58kg, in ml = 120/5 = 24.25ml
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ADRs of LAADRs of LA
Toxicity (Type A ADR)Toxicity (Type A ADR) High plasma concentrationHigh plasma concentration
• Actual overdoseActual overdose• Relative overdoseRelative overdose
FaintFaint Vasovagal attackVasovagal attack
• Psychosomatic effectPsychosomatic effect
Hypersensitivity reactionsHypersensitivity reactions Rare with amide-type LAsRare with amide-type LAs
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Toxic Effect of LAsToxic Effect of LAs
CNS effectsCNS effects Inebriation, Lightheaded-ness, DrowsinessInebriation, Lightheaded-ness, Drowsiness Numbness of tongue / peri-oral tissues, ParaestheiaeNumbness of tongue / peri-oral tissues, Paraestheiae Restlessness, Nausea + vomiting, Blurred vision Restlessness, Nausea + vomiting, Blurred vision Muscle twitching, Tremors, ConvulsionsMuscle twitching, Tremors, Convulsions Respiratory failure, ComaRespiratory failure, Coma
Cardiovascular effectsCardiovascular effects Myocardial depressionMyocardial depression Peripheral vasodilatationPeripheral vasodilatation Hypotension and BradycardiaHypotension and Bradycardia Arrhythmias and Cardiac arrestArrhythmias and Cardiac arrest
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Be cautious in using LAs on these patientsBe cautious in using LAs on these patients
Children, elderly or debilitated patients Children, elderly or debilitated patients Impaired cardiac conductionImpaired cardiac conduction Cardiovascular diseaseCardiovascular disease HypovolaemiaHypovolaemia ShockShock Impaired respiratory functionImpaired respiratory function EpilepsyEpilepsy Myaesthenia gravisMyaesthenia gravis
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Contra-Indications to LAContra-Indications to LA Inflamed / infected tissuesInflamed / infected tissues
Reduced anaesthetic effectReduced anaesthetic effect Increased rate of absorption predisposes to toxicityIncreased rate of absorption predisposes to toxicity
Patients with heart blockPatients with heart block
Adrenalinised LA solutionsAdrenalinised LA solutions Never into a digitNever into a digit
• Risk of ischaemic necrosisRisk of ischaemic necrosis Not with severe hypotensionNot with severe hypotension Not with unstable cardiac rhythm (e.g.: uncontrolled Not with unstable cardiac rhythm (e.g.: uncontrolled
AF)AF) Not with MAOIs and tricyclic antidepressantsNot with MAOIs and tricyclic antidepressants
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Drug Interactions and Local AnaestheticsDrug Interactions and Local Anaesthetics
Lidocaine + CimetidineLidocaine + Cimetidine Lidocaine metabolism reduced / plasma concentration Lidocaine metabolism reduced / plasma concentration
increasedincreased Lidocaine / Bupivacaine / Levo-bupivacaine / Lidocaine / Bupivacaine / Levo-bupivacaine /
Prilocaine / Ropivacaine + Propanolol / Prilocaine / Ropivacaine + Propanolol / Amiodarone Amiodarone Increased myocardial depressionIncreased myocardial depression
Lidocaine + antiviralsLidocaine + antivirals Increased plasma concentration of lidocaineIncreased plasma concentration of lidocaine
Lidocaine + Loop and Thiazide DiureticsLidocaine + Loop and Thiazide Diuretics Lidocaine effectiveness reducedLidocaine effectiveness reduced
Mepivacaine + opioid sedativesMepivacaine + opioid sedatives Increased risk of LA toxicityIncreased risk of LA toxicity
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Drug Interactions and Local Anaesthetics, Drug Interactions and Local Anaesthetics, ContdContd
Lidocaine + bupivacaineLidocaine + bupivacaine Increased risk of LA toxicityIncreased risk of LA toxicity Total dose should not exceed combined MSDsTotal dose should not exceed combined MSDs
Prilocaine + dapsonePrilocaine + dapsone MethaemoglobinaemiaMethaemoglobinaemia
Ropivacaine + Fluvoxamine (Anti-depressant)Ropivacaine + Fluvoxamine (Anti-depressant) Ropivaciane metabolism inhibitedRopivaciane metabolism inhibited
Levo-bupivacaine + TCAs or MAOIsLevo-bupivacaine + TCAs or MAOIs Increased risk of LA toxicityIncreased risk of LA toxicity
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Anaphylaxis (Type B ADR)Anaphylaxis (Type B ADR)
Drugs: Antibiotics (LAs = rare)Drugs: Antibiotics (LAs = rare) Immunologically mediated responseImmunologically mediated response Tends to increase with repeat exposureTends to increase with repeat exposure
Angio-oedemaAngio-oedema Breathing difficulties (stridor)Breathing difficulties (stridor) HivesHives D+V; abdominal crampsD+V; abdominal cramps
Severe hypotensionSevere hypotension Loss of consciousnessLoss of consciousness DeathDeath
ManagementManagement Administer adrenalineAdminister adrenaline
• 0.5ml (0.5mg) 1:1000 adrenaline, • Repeated after 5 mins as necessary • 999
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Anti-Inflammatory Anti-Inflammatory AgentsAgents
NSAIDsNSAIDs
CorticosteroidsCorticosteroids
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IbuprofenIbuprofen
Iso-butyl-propanoic-phenolic acidIso-butyl-propanoic-phenolic acid OTC Non-steroidal anti-inflammatory agent (NSAID)OTC Non-steroidal anti-inflammatory agent (NSAID)
Used to control pain that has an inflammatory component Used to control pain that has an inflammatory component Mild, short-lasting anti-platelet effect (Mild, short-lasting anti-platelet effect (cfcf aspirin) aspirin) Vasodilatory actionVasodilatory action
Common adverse side effects include: Common adverse side effects include: GIT: Nausea, Indigestion, GIT ulceration/bleeding, Raised liver GIT: Nausea, Indigestion, GIT ulceration/bleeding, Raised liver
enzymes, Diarrhoea, Constipation, enzymes, Diarrhoea, Constipation, Cardiovascular effects: Epistaxis, Hypertension, Increased risk of Cardiovascular effects: Epistaxis, Hypertension, Increased risk of
myocardial infarction, Priapismmyocardial infarction, Priapism Neurological: Dizziness, Hearing loss, TinnitusNeurological: Dizziness, Hearing loss, Tinnitus Others: Skin rashes, Fluid retention, Spontaneous abortionOthers: Skin rashes, Fluid retention, Spontaneous abortion
All SEs minimised by low-dose administrationAll SEs minimised by low-dose administration
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Ibuprofen Contd.Ibuprofen Contd.
ActionAction:: Non-selective inhibition of Non-selective inhibition of
• COX-2 (prevents degradation of arachidonic acid to COX-2 (prevents degradation of arachidonic acid to prostaglandin) prostaglandin)
• COX-1 (prevents platelet aggregation)COX-1 (prevents platelet aggregation) Off label Off label
• Treatment of acneTreatment of acne• Prophylaxis of Alzheimer's disease and Parkinson’s diseases Prophylaxis of Alzheimer's disease and Parkinson’s diseases
(low dose, long term)(low dose, long term) Dose-dependent duration of actionDose-dependent duration of action (4-8 hrs) (4-8 hrs)
Self-medication: Max 1200mg (400mg tds) dailySelf-medication: Max 1200mg (400mg tds) daily Prescribed: Max 3200mg (800mg qds) dailyPrescribed: Max 3200mg (800mg qds) daily Stable in solution: topical gelStable in solution: topical gel
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CorticosteroidsCorticosteroids
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Anti-inflammatory effects of Anti-inflammatory effects of corticosteroidcorticosteroid
Modifies gene transcriptionModifies gene transcription ‘‘Switches off’ pro-inflammatory genes Switches off’ pro-inflammatory genes OR: ‘Switches on’ anti-inflammatory genesOR: ‘Switches on’ anti-inflammatory genes
Reduces formation of pro-inflammatory mediator Reduces formation of pro-inflammatory mediator chemicalschemicals, e.g.: cytokines, e.g.: cytokines Local pain reductionLocal pain reduction Reduction of local swellingReduction of local swelling Reduction of local erythema and tissue irritationReduction of local erythema and tissue irritation
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Anti-inflammatory Effects of GlucocorticoidAnti-inflammatory Effects of Glucocorticoid
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‘‘Dermatitis’ and Skin InflammationDermatitis’ and Skin Inflammation
Topical applicationTopical application 1% hydrocortisone acetate 1% hydrocortisone acetate
cream, e.g. HC45cream, e.g. HC45 DaktacortDaktacort
Standardized unit of application = Standardized unit of application = fingertip unit fingertip unit
FTUFTU.. One FTU = amount of topical One FTU = amount of topical
steroid squeezed from the tip of steroid squeezed from the tip of the index finger to dipjthe index finger to dipj
One FTU will treat an area of One FTU will treat an area of skin twice the size of an skin twice the size of an adult's hand.adult's hand.
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Methylprednisolone acetateMethylprednisolone acetate
Synthetic corticosteroidSynthetic corticosteroid Reduces normal cellular wall adhesionReduces normal cellular wall adhesion Reduces normal collagen productionReduces normal collagen production
Pharmacological effects by Pharmacological effects by topical, inhaled, injected, or systemic topical, inhaled, injected, or systemic
delivery delivery Glucocorticoid actionGlucocorticoid action
Hypertensive Hypertensive Immunosuppressive Immunosuppressive DiabetogenicDiabetogenic
Anti-inflammatory
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Intra-articular InjectionIntra-articular Injection
Dose: 40mg / ml
Delivered under U/S guidance
Forms a depot injection
Repeated x3 at monthly intervals
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Plantar FasciitisPlantar Fasciitis
Beneficial effects may not persist beyond 3/12
Indicated for short term relief of intractable heel pain
P
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Plantar Digital NeuromaPlantar Digital Neuroma
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CS Drug Interactions 1CS Drug Interactions 1 Systemic effects of corticosteroids are increased (or their Systemic effects of corticosteroids are increased (or their
hepatic metabolism is reduced) when administered withhepatic metabolism is reduced) when administered with ErythromycinErythromycin ClarithromycinClarithromycin Ketoconazole (NizoralKetoconazole (Nizoral Oestrogens, including OCs and HRTOestrogens, including OCs and HRT
Lower doses of corticosteroids may be indicated in these Lower doses of corticosteroids may be indicated in these casescases
The doses of both methylprednisolone and cyclosporin The doses of both methylprednisolone and cyclosporin may need to be reduced to if they are administered may need to be reduced to if they are administered concurrently, to avoid increased side effects of either concurrently, to avoid increased side effects of either drugdrug
Cyclosporin reduces the hepatic metabolism of Cyclosporin reduces the hepatic metabolism of methylprednisolonemethylprednisolone
Methylprednisolone reduces the metabolism of cyclosporinMethylprednisolone reduces the metabolism of cyclosporin
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CS Drug Interactions 2CS Drug Interactions 2
Increase or decreases the effect of warfarinIncrease or decreases the effect of warfarin Anti-coagulated patients on corticosteroids should be Anti-coagulated patients on corticosteroids should be
monitored and therapy adjusted to achieve the monitored and therapy adjusted to achieve the appropriate levels of anti-coagulationappropriate levels of anti-coagulation
Phenobarbital, Phenytoin and RifampicinPhenobarbital, Phenytoin and Rifampicin may may increase corticosteroid metabolism, increase corticosteroid metabolism, reducing reducing corticosteroid effects. corticosteroid effects. Dose of methylprednisolone may need to be Dose of methylprednisolone may need to be
increased increased The effects of CS in pregnancy and lactation The effects of CS in pregnancy and lactation
have not been fully evaluatedhave not been fully evaluated
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Systemic side effects of Systemic side effects of corticosteroid therapy 1corticosteroid therapy 1
Vary from mild temporary to severe and permanent body wide effects:Vary from mild temporary to severe and permanent body wide effects: Fluid retention, weight gain and central obesityFluid retention, weight gain and central obesity HypertensionHypertension Potassium depletionPotassium depletion HeadacheHeadache Muscle weaknessMuscle weakness Facial puffiness (moon face)Facial puffiness (moon face) HirsuitesHirsuites Thinning of the skinThinning of the skin GlaucomaGlaucoma CataractsCataracts Incidence or exacerbation of diabetesIncidence or exacerbation of diabetes Irregular mensesIrregular menses Growth retardation in childrenGrowth retardation in children ConvulsionsConvulsions
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Systemic side effects of Systemic side effects of corticosteroid therapy 2corticosteroid therapy 2
Psychic disturbances (depression, euphoria, mood swings, Psychic disturbances (depression, euphoria, mood swings, psychoses)psychoses)
Suppression of adrenal cortex activity, causing Addisonian crisis if the Suppression of adrenal cortex activity, causing Addisonian crisis if the corticosteroid therapy is stopped abruptlycorticosteroid therapy is stopped abruptly
Masked signs of infectionMasked signs of infection Impaired immune response to infectionImpaired immune response to infection Increased susceptibility to infectionIncreased susceptibility to infection Exacerbations of viral infectionsExacerbations of viral infections Development of e.g.: small pox if live vaccines administeredDevelopment of e.g.: small pox if live vaccines administered Reactivation of dormant TB and malariaReactivation of dormant TB and malaria Loss of vaccine-induced immunityLoss of vaccine-induced immunity False negative results from the TB (Heaf) testFalse negative results from the TB (Heaf) test Impaired calcium absorption causing osteoporosis and fracturesImpaired calcium absorption causing osteoporosis and fractures Aseptic necrosis of jointsAseptic necrosis of joints
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AdrenalineAdrenaline
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Epinephrine (Adrenaline)Epinephrine (Adrenaline)
Hormone secreted by the adrenal medullaHormone secreted by the adrenal medulla CatecholamineCatecholamine
Sympathetic neurotransmitterSympathetic neurotransmitter Nonselective agonist of all (α1, α2, β1, β2, and β3) adrenergic Nonselective agonist of all (α1, α2, β1, β2, and β3) adrenergic
receptorsreceptors Participates in the Participates in the fight or flight responsefight or flight response
Increases blood glucose levels Increases blood glucose levels • α-adrenergic receptors: inhibits pancreatic insulin secretion, α-adrenergic receptors: inhibits pancreatic insulin secretion,
stimulates pancreatic gluconeogenisis, and skeletal glcyolyisisstimulates pancreatic gluconeogenisis, and skeletal glcyolyisis• β-adrenergic receptors: triggers pancreatic glucagon secretion. β-adrenergic receptors: triggers pancreatic glucagon secretion.
increases pituitary ACTH secretion, and increases adipose lypolysisincreases pituitary ACTH secretion, and increases adipose lypolysis Increases heart rateIncreases heart rate Constricts blood vessels and increases blood pressureConstricts blood vessels and increases blood pressure Dilates bronchi and bronchiolesDilates bronchi and bronchioles Increases skeletal muscle contractionIncreases skeletal muscle contraction
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Epinephrine (Adrenaline) ContdEpinephrine (Adrenaline) Contd..
Adverse reactionsAdverse reactions to adrenaline include to adrenaline include Palpitations, tachycardia, arrhythmia, anxiety, Palpitations, tachycardia, arrhythmia, anxiety,
headache, tremor, hypertension and acute pulmonary headache, tremor, hypertension and acute pulmonary oedemaoedema
Contraindicated in people on non-selective beta-Contraindicated in people on non-selective beta-blockers blockers
Drug of choice for treatment of anaphylaxisDrug of choice for treatment of anaphylaxis Administered as 1:1000 dilutionAdministered as 1:1000 dilution 0.5mg / ml IM, repeated if necessary 5mins later0.5mg / ml IM, repeated if necessary 5mins later
Vasoconstrictor action in LAVasoconstrictor action in LA Pre-mix 1:200,000 dilutionPre-mix 1:200,000 dilution Reduced dose / prolonged actionReduced dose / prolonged action CI for LA is distal part of the footCI for LA is distal part of the foot CI for patients on MAOIsCI for patients on MAOIs
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And we are looking forward to Independent Prescribing!
Thank you for your kind attention