KERALA STATE DRUG FORMULARY

NUMBER 2
(April 2009)

DEPARTMENT OF PHARMACOLOGY
GOVERNMENT MEDICAL COLLEGE
THIRUVANANTHAPURAM INDIA

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

CENTRAL DRUG FORMULARY COMMITTEE
CHAIRMAN :

Dr. K.V. KRISHNADAS, B.Sc., MBBS, FRCP, FAMS, DTM & H,
Director and Professor of Medicine and Vice Principal (Retd.) Government Medical College, Thiruvananthapuram. CONVENOR : Dr. RENEEGA GANGADHAR, M.D. Professor & Head, Department of Pharmacology Government Medical College, Thiruvananthapuram. MEMBERS : 1. Dr. V. Geetha, Director of Medical Education. 2. Dr. Shylaja, Director of Health Services 3. Dr. C. Sudheendra Ghosh, Joint Director of Medical Education. 4. Dr. Ramdas Pisharody, Principal, Government Medical College, Thiruvananthapuram. 5. Dr. B Jayakumar, Professor & Head, Department of Medicine, Government Medical College, Thiruvananthapuram. 6. Dr. Lalitha Kailas, Professor & Head, Department of Paediatrics, Government Medical College, Thiruvananthapuram. 7. Dr. Abdul Salim, Professor & Head of Surgery, Government Medical College, Thiruvananthapuram. 8. Dr. Ramani P.T., Professor of Pharmacology, Government Medical College, Thiruvananthapuram. 9. Dr. Raymond Morris, Professor & Head, Department of Neurosurgery, Government Medical College, Thiruvananthapuram. iii

10. Dr. C.P. Vijayan, Professor of O & G, Government Medical College, Kottayam. 11. Dr. Thomas Mathew, Professor & Head, Department of Community Medicine, Government Medical College, Alappuzha. 12. Dr. Krishnan Namboodhiri, Professor & Head, Department of Cardiology, Government Medical College, Kozhikode. 13. Dr. Joyamma, Professor of Pharmacology, College of Pharmaceutical Sciences, Government Medical College, Thiruvananthapuram. SCIENTIFIC ASSISTANTS 1. Dr. Dhanya T.H., Department of Pharmacology, Government Medical College, Thiruvananthapuram. 2. Dr. Gayathri M Kapse, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 3. Dr. Jesitha Jayaraj, Department of Pharmacology, Government Medical College, Thiruvananthapuram. COMPUTER PROGRAMMERS 1. Dr. Deepu Jacob Chacko, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 2. Dr. Amal Abraham Mathew, Department of Pharmacology, Government Medical College, Thiruvananthapuram. 3. Mr. Rethna Senan, Department of Pharmacology, Government Medical College, Thiruvananthapuram.

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LIST OF CONTRIBUTORS
1. Dr. K.V. Krishna Das, Director & Professor of Medicine and Vice Principal (Retd.), Government Medical College, Thiruvananthapuram. 2. Dr. Reneega Gangadhar, Professor & HOD of Pharmacology Government Medical College, Thiruvananthapuram. 3. Dr.C.Sudheendra Ghosh, Joint Director of Medical Education 4. Dr. Ramdas Pisharody, Principal & Dr Jacob George, HOD in charge, Department of Nephrology, Government Medical College, Thiruvananthapuram. 5. Dr. Shylaja, Director of Health Services & Deputy Directors of Health Services Dr Lali D.L and Dr Molly Paul 6. Dr. Lalitha Kailas, Professor & HOD of Paediatrics, SAT Hospital, Government Medical College Thiruvananthapuram. 7. Dr. K. Rajmohan, Associate Professor of Paediarics, SAT Hospital and Directory CERTC, Government Medical College, Thiruvananthapuram. 8. Dr. K.L Jayakumar, Professor & Head & Dr. R. Sivaramakrishnan, Associate Professor, Department of Radiotherapy, Government Medical College, Thiruvananthapuram. 9. Dr. Manoj T, Assistant Professor, Department of Radiodiagnosis, Government Medical College, Thiruvananthapuram. 10. Dr. K. Suresh,Professor & Head and Dr James Department of Cardiology, Government Medical College, Thiruvananthapuram. 11. Dr. B. Jayakumar, Professor & Head, Dr Jayaprakash Nath and Dr Vipin V.P Department of Medicine, Government Medical College, Thiruvananthapuram. 12. Dr. Usha K.C,Professor & HOD of Transfusion Medicine, Government Medical College, Thiruvananthapuram. 13. Dr. K. Anitha Kumari, Professor & Head and Dr Nandini V Respiratory Medicine, Government Medical College, Thiruvananthapuram. 14. Dr. K.R. Vinayakumar, Vice Principal & Professor & HOD of Medical Gastroenterology, Government Medical College, Thiruvananthapuram.

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15. Dr. Biju John, Assistant Professor, Department of Ophthalmology, RIO, Government Medical College Thiruvananthapuram. 16. Dr. K.P. Jhansi, Professor & Head and Dr. Regi Mohan, Senior Lecturer, Department of O&G, SAT Hospital, Government Medical College Thiruvananthapuram. 17. Dr. Vijayalakshmi L,Professor & HOD of Nutrition, Government Medical College, Thiruvananthapuram. 18. Dr. Abdul Salim,Professor & HOD of Surgery, Government Medical College, Thiruvananthapuram. 19. Dr. Mini S.S, Assistant Professor, Department of Community Medicine, Government Medical College, Thiruvananthapuram. 20. Dr. Thomas Iype,Professor & HOD of Neurology, Government Medical College, Thiruvananthapuram. 21. Dr. D. Raju,Professor & HOD of Psychiatry, Government Medical College, Thiruvananthapuram. 22. Dr. Joyamma Varkey, Professor of Pharmacology, College of Pharmaceutical Science, Government Medical College, Thiruvananthapuram. 23. Dr. Devayani,Professor & HOD of Anaesthesiology, Government Medical College, Thiruvananthapuram. 24. Postgraduates of the Department of Pharmacology, Government Medical College Thiruvananthapuram – Dr. Dhanya T.H, Dr. Gayathri M. Kapse, Dr. Jesitha Jayaraj, Dr. Deepu Jacob Chacko, Dr. Amal Abraham Mathew, Dr. Siddalingesh Salimath and Dr. Meenakshy T.V, Dr S P Dhanya 25. Faculties of the Department of Pharmacology Government Medical College, Thiruvananthapuram Dr Ramani P.T, Dr Bindu Latha Nair.R, Dr Asha S, Dr Annapurna Y, Dr Ajith Thomas, Dr Syam S, Dr Nasar A, Dr Shermin Nasreen, Dr Parvathy V Nair, Dr Prasanth M, Dr Resmi Douglas, Dr Dawnji S.R, Dr Preeja K.S 26. Dr. P. V. Narayanan, Professor & Head and Dr Anuradha, Assistant Professor Department of Pharmacology and HODs of other Departments, Government Medical College, Calicut. 27. Dr. Elsy M.I, Professor & HOD of Pharmacology and HODs of other Departments, Government Medical College, Thrissur. 28. Dr. Pradeep S, Professor & Head and Dr Manju Nair, Assistant Professor Department of Pharmacology and HODs of other Departments, Government Medical College, Alappuzha. 29. Dr. Kala Kesavan, Professor & HOD of Pharmacology and HODs of other Departments, Government Medical College, Kottayam.

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FOREWORD
Medicines play a crucial role in the prevention and treatment of diseases. When used correctly, they can offer simple and cost effective solutions to many health problems. Today many people have little access to safe and effective drug therapies and may be at risk of serious health problems due to treatment with ineffective, poor quality products, or incorrect and irrational use of medicines. This drug formulary can be a useful tool in solving some of these problems as they can provide impartial and correct drug information to fill the gaps, wherever up to date information is not available. It may also help to promote rational use of safe medication and cost effective utilization of drugs besides improving the access to essential medicines. It can bring focus on available and affordable medicines that are most relevant to the treatment of diseases. The guidelines for first line management of clinical emergencies encountered in peripheral hospitals will also help those doctors who manage hospitals single handed. I am sure this book will be of immense help and contribute positively in the development of a better Health Care System. The committee led by Dr. K.V Krishna Das, Chairman and Dr. Reneega Gangadhar, Convener has put in commendable efforts in preparation of this book in a meticulous manner in a limited time and deserves all appreciation and encouragement of the medical fraternity and the public at large. I am very happy to foreword this on behalf of all those who were actively involved in this unique venture, which make Kerala a Role Model in Health Care Services.

DR. VISHWAS MEHTA IAS

Secretary to Government,
Health and Family Welfare Department Kerala

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PREFACE
SECOND EDITION OF KERALA STATE DRUG FORMULARY APRIL 2009 The need for a drug formulary and practice guidelines for its health care personnel working in the various hospitals and other health care related institutions in Kerala State has been recognized by the Government as early as 1997 and the first edition of the Drug Formulary was published in the year 1999 (April). This book was distributed to the various hospitals for use by the doctors and paramedics. It is now 10 years since the first edition was published. It has served its purpose in a limited way by acting as a reliable source of ready reference when facing medical emergencies. It also contained sections dealing with the directions for maintaining drug stocks in different level hospitals based on morbidity patterns prevailing then, and the prescribing practices of the doctors. Part II of this book gives the emergency management of several diseases and indications regarding further management had also been added. The Government desired to publish the second edition of the Kerala State Drug Formulary before the end of this financial year. A committee was formed at the Directorate of Medical Education to update the existing drug formulary. This second edition is the result of the effort of this committee which met repeatedly to complete the task assigned to it. Part I deals with the essential details of common drugs used by doctors in the State, with particular emphasis on the essential drug list formulated by the Government of India. Unbiased drug information is given. The cost factor of drugs with similar action has been given to enable the doctor to manage the patients cost effectively. Section 19 gives information on vaccines and immunoglobulins.Part II dealing with the primary management of medical emergencies has been trimmed to contain only the emergencies. Elective Management of several diseases has been removed since the Kerala Government is in the process of publishing a treatment Guideline Manual, which will contain the management guidelines for most of the diseases - both acute and chronic. Part III A contains list of Essential drugs to be stocked at different levels in Government hospitals. Part III B gives the details of the National Programmes formulated by the Government of India and implemented through the State Governments. Acknowledgement: The Central Drug Formulary Committee headed by viii

Dr. V. Geetha, Director of Medical Education (DME), Dr. C. Sudhendra Ghosh, JDME and Dr. Ramdas Pisharody, Principal,Government Medical College, Thiruvananthapuram did the organizational work in planning the whole project, facilitating interaction between the contributors, arranging meetings and procuring funds for updating of formulary. The interest shown by the Hon’ble. Minister for Health and Family Welfare Smt. Sreemathy teacher, was the starting point of this project.Dr. Vishwas Mehta IAS, Secretary to Government,Health and Family Welfare evinced very keen interest in getting this project completed and his timely action and advices have guided the Drug Formulary Committee to proceed ahead without hitch to complete the assignment. Dr. Reneega Gangadhar,Professor and Head of Department of Pharmacology acted as the kingpin for the project, by collecting the material from the contributors, editing them, interacting with the printers, correcting the proof and bringing the material to the present shape. In this stupendous task she had the full cooperation and services of the department teaching faculties Dr Ramani P.T, Dr Bindu Latha Nair.R, Dr Asha S, Dr Annapurna Y, Dr Ajith Thomas, Dr Syam S, Dr Nasar A, Dr Shermin Nasreen, Dr Parvathy V Nair, Dr Prasanth M, Dr Resmi Douglas, Dr Dawnji S.R, Dr Preeja K.S and postgraduate students Dr. Dhanya T.H, Dr. Gayathri M Kapse, Dr. Jesitha Jayaraj, Dr. Deepu Jacob Chacko, Dr. Amal Abraham Mathew, Dr. Meenakshy T.V,Dr. Siddalingesh Salimath and Dr S P Dhanya who spent long hours on updating this project.Secretarial assistance rendered by Mr. RethnaSenan and timely organizational assistance from the other non teaching staff are acknowledged.The photographer Mr Rajmanu,artist Mr Rajashekaran Nair and modeller Mr Byju S.R have taken lot of pains in preparing the cover of this book and they deserve our heartfelt thanks.The prompt services of the office staff of the Directorate of Medical Education and Principal’s office are all acknowledged. The printing undertaken by Kerala State Audio Visual and Reprographic Centre, Head Office Complex, Thiruvananthapuram- 13 was completed within the stipulated time and the services of the staff from this centre are all gratefully acknowledged.

K.V. KRISHNADAS

Chairman
Drug Formulary Committee ix

INTRODUCTION
The Kerala State Drug Formulary was first published in April 1999. For updating the above formulary care has been taken to delete obsolete drugs, to add more essential drugs, to modify drug entries and bring possible changes in scope and presentation. This second edition is developed to complement the National Essential Drug List of India. We have followed the structure and topics used in the Essential Drug List. It gives unbiased drug information including adverse effects, drug interactions and costs of most medications. The basic information on drugs is drawn from various standard resources like Martindale’s Pharmacopoeia, WHO formulary 2008 and Medical literature. It also takes into account guidelines for emergency management at peripheral hospitals carefully prepared by Dr. K.V. Krishnadas, Former Director and Professor of Medicine, Government Medical College, Thiruvananthapuram and Chairman of the Committee. Drugs in pregnancy, breast feeding, liver and renal diseases are also included .An ADR reporting form is also attached which can be photocopied for ADR reporting or downloaded from the site www.cdsco.nic.in. It is hoped that this publication will serve as a ready reference and guide for medical practitioners, pharmacists, dentists, nurses, house surgeons, postgraduates and others who have the necessary training and experience to interpret the information it provides.

DR. SUDHEENDRA GHOSH JDME DR. RENEEGA GANGADHAR Convenor
Central Drug Formulary Committee

DR.V. GEETHA DME

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ABBREVIATIONS
A/E .......................... amp ......................... BD/bid/bd ................. bw ........................... C/I ........................... Cap .......................... CNS .......................... D/I ........................... g ............................. GI/GIT ...................... hs ............................ I .............................. IG ............................ IM ........................... Inj ........................... IV ............................ IU ............................ kg ............................ L ............................. max .......................... mcg ......................... mdi .......................... mg ........................... min .......................... mL ........................... od ........................... P/A .......................... P/C .......................... q ............................. qid/qds ..................... SC ........................... SJS .......................... SLE .......................... sos .......................... SR ........................... stat .......................... tab .......................... tid/tds ...................... adverse effects ampoule two times daily body weight contraindication capsule central nervous system drug interaction gram gastro intestinal tract at bed time indication Immunoglobulin intramuscularly injection intravenously international units kilogram litre maximum microgram metered dose inhalation milligram minute milliliter once daily preparations available precaution every four times daily subcutaneously Steven Johnson’s Syndrome Systemic Lupus Erythematosus when required sustained release immediately tablet three times daily xi

.... 8 P – drug concept .................................... 30 SECTION – 2: ANALGESICS............................................................................ 47 SECTION – 3: ANTICONVULSANTS / ANTIEPILEPTICS ......................................................... 49 SECTION – 4: ANTIINFECTIVE DRUGS ............................................ 18 General anaesthetics and oxygen ......... 1 Rational approach to therapeutics ....................... 61 Antileprotic drugs ...........................MEDICINES USED TO TREAT GOUT..... 85 xii .................................... 83 Antituberculous drugs .......... 14 SECTION –1: DRUGS USED IN ANAESTHESIA ........................ 22 Preoperative medication and sedation ......... 12 Sample Prescription ...................................................... 1 Variation in dose response ................ 11 Prescription writing ....................... 3 Adherence with drug treatment .......... 83 Antifungal drugs .......... 38 Disease modifying agents used in Rheumatoid disorders ............................................. 31 Opioid analgesics .............. 83 Antiviral drugs ........................................................................... 14 Assessing cost effectiveness in clinical Medicine ...... NONSTEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS)....CONTENTS PART I GENERAL ADVICE TO PRESCRIBERS .................................. 61 Antimicrobials ................. DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDS) ........................................... 5 Adverse effects and drug interactions .................................................................................................... 31 Non opioid Non steroidal anti-inflammatory drugs ................... 42 Drugs used in Gout ............................ ANTIPYRETICS............................................................................. 27 Muscle relaxants .......................................................................................................................................................................................................................... 18 Local Anaesthetics .........................

............. 103 Treatment for acute migraine attack ........................... 117 Tyrosine kinase inhibitors ...................... 88 Antimalarial drugs ............... 119 SECTION – 7 : ANTIPARKINSONIAN DRUGS ........................................................ 95 Anthelmintic drugs ..................................................................................................................................................................... 131 Haemoglobinopathies ............................................................. 118 Bisphosphonates . 128 Haemolytic anaemias ..... 110 Taxanes ...................................................................................................................... 133 xiii ............................................................................................................................................................................... 101 SECTION – 5: ANTIMIGRAINE DRUGS .................................................. 127 Drugs affecting coagulation ......................................................................... 113 Mitotic inhibitors ........................................... 104 SECTION – 6: ANTINEOPLASTIC DRUGS .................................................................... 114 Hormones and hormonal antagonists .......................................................................................................................................................................................... 115 Biological response modifiers .................................................................. 105 Alkylating agents ........ 99 Antifilarial drugs ..... 119 Antiemetics used in cancer chemotherapy ................................... 132 Drugs used in Leukaemias ..................... 113 Miscellaneous agents ................................ 120 SECTION – 8: DRUGS ACTING ON BLOOD AND BLOOD FORMING ORGANS ...................... 117 Targeted agents .................... 103 Migraine prophylaxis ............................... 107 Cytotoxic antibiotics ......................... 118 Cytoprotective agents ........................... 91 Antiamoebic and other antiprotozoal drugs ........... 127 Antianaemic drugs ........... 105 Antimetabolites ..............................Antiretroviral drugs ..................................... 131 Iron chelating drugs .......................

...... 199 xiv ........ 182 Superficial mycosis ............................................................................. 190 Scabicides and pediculocides ..................................................................................................... 187 Drugs used in Psoriasis . 147 SECTION – 10: CARDIOVASCULAR DRUGS .......................... 186 Antiinflammatory and antipruritic medicines ......... 139 Antifibrinolytics ............................................................................. 180 SECTION – 11: DERMATOLOGICAL DRUGS ..................................................... 155 Antiplatelet drugs ...................................... 195 SECTION – 12: DIAGNOSTIC AGENTS . 173 Drugs used in Heart failure ......................Plasma cell dyscrasias ........................ 176 Positive inotropic agents ................ 138 Antiplatelet drugs ........................................... 182 Deep mycosis ...... 188 Drugs for warts .................................................................................. 151 Drugs used in thrombolytic therapy .................... 156 Anticoagulants ....... 144 Plasma substitutes ...... 158 Drugs used in pulmonary hypertension .............................................................................................................................................................................................................................................. 184 Antibacterials –topical and systemic use .................................................................................................... 156 Antihypertensive drugs .......... 199 Radio contrast media .... 146 Plasma fractions for specific use .............................................. 191 Other dermatological conditions ....... 138 Thrombolytics ................................................................................................ 142 SECTION – 9: BLOOD PRODUCTS AND PLASMA SUBSTITUTES ............................................................................................... 144 Whole blood / components ............................................................... 174 Antiarrhythmic drugs ........................... 151 Drugs used in the treatment of Angina ...... 192 Drugs used in Leprosy ...................................................................................................... 156 Lipid lowering drugs .

........... 222 Antacids and ulcer healing drugs .............................................. 228 Laxatives .... 261 SECTION ............................................................................... 204 SECTION – 13: DISINFECTANTS AND ANTISEPTICS ...... 237 Adrenal hormones and synthetic substance .................. 230 Drugs used in inflammatory bowel diseases ................ 244 Oestrogens and antioestrogens ......... 226 Antidiarrhoeals ................................................................................ 218 SECTION – 17: GASTROINTESTINAL DRUGS ................................ 256 SECTION – 19: IMMUNOLOGICALS ................................................................. 253 Vitamin D derivatives .......................................................................................................................................................... 222 Antispasmodics .............. 205 SECTION – 14: DIURETICS ....................................... 242 Androgens .......................................................... 247 Ovulation inducers .............................................................................................. 258 Sera and immunoglobulin .................................................................................................................................................. 267 xv ..................................................................... 233 Drugs used in gall stones ........................................... 225 Antiemetics and prokinetics ........... 236 SECTION – 18: HORMONES AND OTHER ENDOCRINE DRUGS ....... 242 Antiandrogens ..... 215 SECTION – 16: DRUGS USED IN ENT INFECTIONS .................. 244 Progestins and antiprogestins .......................................................................... 248 Insulins and other Antidiabetic drugs .......................................... 258 Vaccines .... 210 SECTION – 15: DRUGS USED IN DENTISTRY .............................. 243 Contraceptives ................. 235 Antihaemorrhoidal drugs ........... 255 Bisphosphonates .......................................... 248 Thyroid hormones and antithyroid drugs ...................................... 237 Sex Hormones .................................Dyes used in ophthalmology .............................20: IMMUNOSUPPRESSANT DRUGS .......................

...................................................................... 306 SECTION ............................................. 290 Antifungal agents ........22: MUSCLE RELAXANTS AND ANTICHOLINESTERASES ... 296 Drugs and pregnancy ................... 300 Induction of abortion ........... and cycloplegic drugs ................................. 272 SECTION ............ 297 Oxytocics ......... 295 SECTION .............................................................................. 292 Drugs used in medical management of glaucoma . 292 Mydriatics ......................................................................... 298 Induction of labour ................................. 281 SECTION ............................... 295 Nutritional disorders affecting the eye .................................... 291 Topical NSAIDS ..................................................................................................................................................................................... 295 Local anaesthetics ............. 305 Hypertension in pregnancy .........................................................................23: OPHTHALMOLOGICAL PREPARATIONS ................ 292 Antiallergics ............................................................... miotics ..... 290 Antiseptics ..................................................................................................... 302 Contraceptives ....................................................................................................................24: DRUGS USED IN OBSTETRICS AND GYNAECOLOGY . 296 Dos and don’ts in pregnancy ............................................... 293 Ocular lubricants .................. 296 Nutritional requirement in pregnancy .... 306 Tocolytics ........ 303 Drugs for induction of ovulation ................................................... 291 Corticosteroids .................................SECTION ....................................................................25: PSYCHOTHERAPEUTIC DRUGS .................... 307 xvi ................................................21 : DRUGS USED IN DISEASES OF KIDNEY AND URINARY TRACT .. 289 Antiviral agents .............................................. 289 Antibacterial agents ..................................... 304 Drugs used in DUB ......................... 301 Vaginitis .................................

..................................................................... 435 Shock .......................................... General Topics ....... 329 SECTION ... 315 Mood stabilizers ............................................................................................................ 379 SECTION ...... 437 xvii ............. 360 SECTION – 28 : SOLUTIONS CORRECTING WATER............................................................................... 428 Resuscitation of newborn .................. 407 Hyperpyrexia ......................... 424 Diarrhoea and dehydration ............................................................... 325 Sedative hypnotics .......................................... 426 Asthma in children <5 years ........ 398 PART ............................ 430 3......................................................................................... 410 Envenomation ....... 429 Poisoning in children .............................. 433 Chest pain .......................................................................................................... 433 Angina pectoris ..Antipsychotic drugs ........................................... 331 SECTION – 27: DRUGS USED IN RESPIRATORY DISEASES ...............26: PAEDIATRIC DRUGS AND NUTRITION ............................ 307 Antidepressants .............. 423 2 Paediatrics ............... 407 Acute anaphylactic reactions ....................... 418 Drowning .................................................................... Cardiology ............ 328 Drugs used in substance dependence ........................................................................................................... 424 Acute severe asthma ... 408 Toxicology .. ELECTROLYTE AND ACID BASE DISTURBANCES .....................................II Guidelines for First Line Management of Clinical Emergencies encountered in Peripheral Hospitals 1.......... 324 Anxiolytics ..............................................................................29: VITAMINS AND MINERALS ........................

.................................................................................. 447 Foreign body aspiration ............... 441 Cardiac tamponade ............... 465 Antepartum Haemorrhage .............. 456 Hypoglycemia ................................................................................................................................................................................................ 464 Acute renal failure ... 453 Endocrinology ................................ Alimentary system ............................................................. 461 Status epilepticus ......................................... 463 8... Respiratory system ................................ 448 Haemoptysis ............................................................................ 456 Diabetic ketoacidosis ......................................................................... 451 Chronic asthma in adults .................................. 6....................... 442 Hypertensive emergencies ....... 439 Acute cardiogenic pulmonary oedema ................................................................................. 462 Cerebrovascular occlusive disease .................................... 461 Coma ............. 458 Myxoedema coma .............. 465 Ectopic gestation ............................................................................... 459 Adrenal crisis ..................................... 464 Obstetrics & Gynaecology ............................................................ 452 Pulmonary embolism .. Neurology ......................................... 450 Pleural effusion .................. 452 5.......... 446 Acute severe asthma ............. 9.......... 465 Hyperemesis gravidarum .............................................Cardiac arrest ................ 453 Hemetemesis ..................... 466 xviii ................................... Nephrology ....... 442 4......... 449 Tension Pneumothorax ...................................................................................................................... 446 Acute respiratory failure ....... 460 7............... 457 Thyroid storm .............................................................................

...................... 470 PART ............................... 511 National AIDS control programme . 468 10........................... National Health programmes of India ............ 469 Foreign body in the eye ......... 504 Diarrhoea control programme and ORS programme .. 504 Reproductive Child Health (RCH) .................................... 513 xix ...................... 475 Taluk Hospital ....... 470 Recognition of Refractive error in child ... 510 National Vector Borne disease Control Programme .................... 468 Epistaxis .... 469 Chemical burns ..... 467 Postpartum haemorrhage ...... 466 Preterm Labour .................................................... 481 Tertiary hospitals (District/General hospitals and Medical College Hospitals) ........Nose and Throat ...............................................................................................................Eclampsia .......... 491 B..................... 508 National programme for prophylaxis against blindness in children due to Vitamin A deficiency ..................III A........................................................... 470 Corneal ulcer .... 468 Acute laryngeal edema due to allergic angioedema ......... 471 Primary care hospitals ( Dispensary and mini PHC ) ................................................................................................... Ophthalmology ............................ List of essential drugs to be stocked in the Government Hospitals ...... 469 Conjunctivitis ............... 469 11.. 506 Acute Respiratory Infection Control programme ..................... 467 Prelabour rupture of membranes ...................................................................... Ear......... 508 National Immunization schedule .................. 471 Secondary care hospitals ( Block PHCs and CHCs) ................................................................................................................................................ 509 National TB control programme .......

................................................................................... 537 Appendix 7: Essential drug list (India) 2003 ............................. 515 Appendix 2: Breast feeding ................ 538 Appendix 8: List of drugs banned in India . 524 Appendix 3: Renal impairment ....................... 528 Appendix 4: Hepatic impairment ........................... 559 Appendix 9: Adverse drug event reporting form ...................... 532 Appendix 5: Drug Schedules and Acts ....................... 565 xx .....APPENDICES: Appendix 1: Pregnancy ............................. 536 Appendix 6: List of Emergency medicines/ Life saving drugs ..

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it also needs to take into account the total cost of all therapeutic options. distress and harm to the patient. Very often physicians must select more than one therapeutic goal for each patient. 3. Specify the therapeutic objective Doctors must clearly state their therapeutic objectives based on the pathophysiology underlying the clinical situation. 2. X-rays and other investigations. this agreement on outcome. „ „ The following steps will help to remind prescribers of the rational approach to therapeutics. a detailed history.The selected treatment can be non-pharmacological and/or pharmacological. laboratory tests. is termed concordance. Bad prescribing habits lead to ineffective and unsafe treatment. This will help in rational prescribing. always bearing in mind that diseases are evolutionary processes. Define the patient’s problem Whenever possible. and higher cost. and in all cases the benefit of administering the medicine should be considered in relation to the risks involved. 1 . making the right diagnosis is based on integrating many pieces of information: the complaint as described by the patient. exacerbation or prolongation of illness. physical examination. 1. Selecting therapeutic strategies The selected strategy should be agreed with the patient.PART .I GENERAL ADVICE TO PRESCRIBERS Rational approach to therapeutics Variation in dose response „ Adherence(compliance) with drug treatment „ Adverse effects and interactions „ P-drug concept „ Prescription writing „ Sample prescription „ Assessing cost effectiveness in drug therapy RATIONAL APPROACH TO THERAPEUTICS Drugs should only be prescribed when they are necessary. and how it may be achieved.

health problems can be resolved by a change in life style or diet.This step is based on evidence about maximal clinical benefits of the drug for a given indication (efficacy) with the minimum production of adverse effects (safety). Giving information. standard dosage schedule and standard duration of treatment are suitable for each patient. Pharmacological treatment Selecting the correct group of drugs Knowledge about the pathophysiology involved in the clinical situation of each patient and the pharmacodynamics of the chosen group of drugs. Selecting the drug from the chosen group The selection process must consider benefit/risk/cost information. 2 .General advice to Prescribers a. b. Non-pharmacological treatment It is very important to bear in mind that the patient does not always need a drug for treatment of the condition. Verifying the suitability of the chosen pharmaceutical treatment for each patient The prescriber must check whether the active substance chosen. its dosage form. and other non-pharmacological treatments. Not all drug-induced injury can be prevented but much of it is caused by inappropriate selection of drugs. This item is covered in more detail in the following section. provision of adequate psychological support. use of physiotherapy or exercise.It must be remembered that each drug has adverse effects and it is estimated that up to 10% of hospital admissions in industrialized countries are due to adverse effects. explained and monitored in the same way. the cost of the total treatment and not only the unit cost of the drug must be considered. are two of the fundamental principles for rational therapeutics. Prescription writing The prescription is the link between the prescriber. the pharmacist (or dispenser) and the patient so it is important for the successful management of the presenting medical condition. Drug treatment should be individualized to the needs of each patient. these have the same importance as a prescription drug. Very often. In cost comparisons between drugs. instructions and warnings This step is important to ensure patient adherence and is covered in detail in the following section. and instructions must be written.

while a large fat mass can store large excesses of highly lipid soluble drugs compared to lean patients of the same weight. This step gives rise to important information about the effects of drugs contributing to building up the body of knowledge of pharmacovigilance. genetic. Unfortunately drug treatment frequently fails because the dose is too small or produces adverse effects because it is too large.This is because most texts. changes in absorption can produce sudden changes in drug concentration. variation in absorption. For such drugs. metabolism and excretion. adult doses have been assumed to be the same irrespective of size or shape. In drugs with a narrow therapeutic to toxic ratio. Adolescents may oxidize some drugs relatively more rapidly than adults. Entericcoated drugs have been known to pass through the gastrointestinal tract intact.The concept of a standard or ‘average’ adult dose for every medicine is firmly rooted in the mind of most prescribers. After the initial ‘dose ranging’ studies on new drugs. quality control surveillance should be carried out. while the elderly may have reduced renal function and eliminate some drugs more slowly. manufacturers recommend a dosage that appears to produce the desired response in the majority of subjects. Yet adult weights vary two to threefold. 3 . needed to promote the rational use of drugs.Age changes can also be important. There are many reasons for this variation which include adherence (see below). young male Caucasian volunteers. Body weight and age Although the concept of varying the dose with the body weight or age of children has a long tradition.variation in pharmacodynamics. These studies are usually done on healthy. disease variables. composition. drug formulation.General advice to Prescribers Monitoring treatment Evaluation of the follow up and the outcome of treatment allows the stopping of it (if the patient’s problem is solved) or to reformulate it when necessary. and environmental variables. but in reality there is considerable variation in drug response. teachers and other drug information sources continue to recommend standard doses. Drug formulation Poorly formulated drugs may fail to disintegrate or to dissolve. distribution. rather than on older men and women with illnesses and of different ethnic and environmental backgrounds. body weight and age. VARIATION IN DOSE RESPONSE Success in drug treatment depends not only on the correct choice of drug but on the correct dose regimen. The use of standard doses in the marketing literature suggest that standard responses are the rule.

Physiological and pharmacokinetic variables Drug absorption rates may vary widely between individuals and in the same individual at different times and in different physiological states. however. Drugs taken after a meal are delivered to the small intestine much more slowly than in the fasting state. In pregnancy gastric emptying is also delayed.Where the dose for children is not readily available. The most reliable methods are those based on body surface area. dose should be calculated from an ideal weight. Drug metabolism and excretion Drug metabolism is affected by genetic. Children’s doses may be calculated from adult doses by using age. is polygenic. acidic drugs bind strongly to plasma albumin and basic drugs to muscle cells. prescribers should seek specialist advice before prescribing for a child. Renal disease or toxicity of other drugs on the kidney can therefore slow excretion of some drugs. and although a small proportion of the population can be classified as very slow oxidizers of some drugs. fat content or muscle mass may all contribute to dose variation. environmental. or body surface area. body weight. related to height and age. Drug distribution Drug distribution varies widely: fat-soluble drugs are stored in adipose tissue. For example. calculation by body weight in an overweight child may result in much higher doses being administered than necessary. Young children may require a higher dose per kilogram than adults because of their higher metabolic rates.Many drugs are eliminated by the kidneys without being metabolized. a small change of albumin concentration can produce a big change in free drug and a dramatic change in drug effect. With very highly albumin bound drugs like warfarin.Body weight may be used to calculate doses expressed in mg/kg. Hence variation in plasma-albumin concentration. while some drugs may increase or decrease gastric emptying and affect absorption of other drugs. Other problems need to be considered. Nomograms are available to allow body surface values to be calculated from a child’s height and weight. leading to much lower drug concentrations. Drug acetylation shows genetic polymorphism.General advice to Prescribers Dose Calculation in Children. water-soluble drugs are distributed chiefly in the extracellular space. 4 . in such cases. and diseasestate factors. or by a combination of these factors. Drug oxidation. whereby individuals fall clearly into either fast or slow acetylator types. for most drugs and most subjects there is a normal distribution of drug metabolizing capacity.

the disease. the prescription correctly written and the medication correctly dispensed. Even with good prescribing. Environmental variables Many drugs and environmental toxins can induce the hepatic microsomal enzyme oxidizing system or cytochrome P450 oxygenases. ADHERENCE (COMPLIANCE) WITH DRUG TREATMENT It is often assumed that once the appropriate drug is chosen. Unfortunately this is very often not the case.There are sometimes valid reasons for poor adherence— the drug may be poorly tolerated. the doctor. the prescription. the pharmacist or the health system and can 5 . but also by their effect on plasma albumin (increased free drug also increasing toxicity). chiefly by the effect on metabolism and elimination respectively (increasing toxicity). charcoal cooked foods and certain other foods act as metabolizing enzyme inducers.For example in infantile malnutrition and in malnourished elderly populations drug oxidation rates are decreased. especially central nervous system responses. Respiratory disease and hypothyroidism can impair drug oxidation. propranolol). Diet and nutritional status also affect pharmacokinetics. for example pain and sedation. Failure to adhere with such a prescription has been described as ‘intelligent non-compliance’.General advice to Prescribers Pharmacodynamic variables There is significant variation in receptor response to some drugs. but in the presence of high circulating alcohol concentrations drug metabolism may be inhibited. Environmental pollutants. anaesthetic drugs and other compounds such as pesticides can also induce metabolism. This can be because of genetic factors. that it will be taken correctly and treatment will be successful. tolerance. Disease variables Both liver disease and kidney disease can have major effects on drug response. drug interactions. Heart failure can also affect metabolism of drugs with rapid hepatic clearance (for example lidocaine. Chronic alcohol use induces oxidation of other drugs. leading to more rapid metabolism and elimination and ineffective treatment. Bad prescribing or a dispensing error may also create a problem. while high protein diets. may cause obvious adverse effects or may be prescribed in a toxic dose. which patients may have neither the insight nor the courage to question. Factors may be related to the patient. and physicians overlook one of the most important reasons for treatment failure—poor adherence (compliance) with the treatment plan. and drug dependence. failure to adhere to treatment is common.

Low-cost strategies for improving adherence increase effectiveness of health interventions and reduce costs.Health care providers should be familiar with techniques for improving adherence and they should employ systems to assess adherence and to determine what influences it. Doctor reasons Doctors may cause poor adherence in many ways—by failing to inspire confidence in the treatment offered. The doctor-patient interaction There is considerable evidence that this is crucial to concordance. Disease reasons Conditions with a known worse prognosis (for example cancer) or painful conditions (for example rheumatoid arthritis) elicit better adherence than asymptomatic ‘perceived as benign’ conditions such as hypertension. There is no doubt that ‘doctor’ has a powerful effect on inspiring confidence and perhaps contributing directly to the healing process. Such strategies must be tailored to the individual patient. Patient disadvantages such as illiteracy. as may economic factors. by giving too little or no explanation. If they are in doubt or dissatisfied they may turn to alternative options. by making errors in prescribing. Patient reasons In general. it may not be 6 .General advice to Prescribers often be avoided. by thoughtlessly prescribing too many medicines. including ‘complementary medicine’. and people living alone are less adherent than those with partners or spouses. women tend to be more adherent than men. poor eyesight or cultural attitudes (for example preference for traditional or alternative medicines and suspicion of modern medicine) may be very important in some individuals or societies. Prescription reasons Many aspects of the prescription may lead to non-adherence (noncompliance). ‘Satisfaction with the interview’ is one of the best predictors of good adherence. Patients are often well informed and expect a greater say in their health care. it may get lost.Patients’ perceptions of the risk and severity of adverse drug reactions may differ from the health care provider and may affect adherence. younger patients and the very elderly are less adherent. or by their overall attitude to the patient.It may be illegible or inaccurate. Such limitations or attitudes need to be discussed and taken account of. Specific education interventions have been shown to improve adherence.

The health care system The health care system may be the biggest hindrance to adherence. Long waiting times. Write notes for them. and have amajor impact on adherence. raising suspicions or concerns. and review their regimen with them. Not surprisingly adverse effects like drowsiness. 7 . Some studies have confirmed the obvious. This has been reported in relation to generic drugs when substituted for brand-name drugs. that patients furthest from the clinic are least likely to adhere to treatment in the long term. to develop a team approach and to collaborate on helping and advising the patient. or a negative one. impotence or nausea reduce adherence and patients may not admit to the problem. as long as it agrees with the doctor’s advice. Also.General advice to Prescribers refilled as intended or instructed for a chronic disease. “ Encourage patients to bring their medication to the clinic. the prescription may be too complex. are all common problems in many settings. while multiple doses also decrease adherence if more than two doses per day are given. the greater the number of medicines the poorer the adherence. uncaring staff. Pharmacist reasons The pharmacist’s manner and professionalism. for example difficulty with reading the label or getting the prescription filled. Recommendations “ Review the prescription to make sure it is correct. Pharmacist information and advice can be a valuable reinforcement. “ Spend time explaining the health problem and the reason for the drug. unreliable drugs upplies and so on. “ Explore problems. like the doctor’s. “ Communicate with other health care professionals. “ Establish good rapport with the patient. An important problem is the distance and accessibility of the clinic from the patient. “ Involve the partner or another family member. may have a positive influence on adherence. uncomfortable environment. “ Listen to the patient. “ Encourage patients to learn the names of their medicines. “ Keep treatment regimens simple. so that tablet counts can be done to monitor compliance.

Other drugs associated with problems in children include chloramphenicol (grey baby syndrome). in patients taking combinations of drugs known to interact. and particularly neonates. such as kidney. differ from adults in their response to drugs. cannot be guaranteed to detect all adverse effects likely to be caused by a drug. They differ from accidental or deliberate excessive dosage or drug maladministration. liver or heart disease.All children. only a small number show any clinical evidence of interactions. If besides the condition being treated the patient suffers from another disease. ADRs may also be unrelated to the known pharmacology of the drug. The very old and the very young are more susceptible to ADRs. including idiosyncratic effects. the so-called‘A’ type reactions. diuretics. Drugs which commonly cause problems in the elderly include hypnotics. Other drugs (for example valproic acid) are associated with increased risk of ADRs in children of all ages. however thorough. the ‘B’ type reactions including allergic effects. which occur during its proper use. special precautions may be 8 .General advice to Prescribers ADVERSE EFFECTS AND INTERACTIONS Adverse drug reactions An adverse drug reaction (ADR) may be defined as ‘any response to a drug which is noxious. Extremes of age. ADRs may be directly linked to the properties of the drug in use. diagnosis. Some drugs are likely to cause problems in neonates (for example morphine). or therapy. Health workers are thus encouraged to record and report to their national pharmacovigilance centre any unexpected adverse effects with any drug to achieve faster recognition of serious related problems. For example. ADRs are therefore unwanted or unintended effects of a medicine. for example anaphylaxis with penicillins. there are characteristics of the patient which predispose to ADRs. acetylsalicylic acid (Reye syndrome). In addition to the pharmaceutical properties of the drug therefore. Major factors predisposing to adverse effects It is well known that different patients often respond differently to a given treatment regimen. but are generally tolerated in children. An example is hypoglycaemia induced by an antidiabetic drug. antiarrhythmics (worsening of arrhythmias). Thalidomide marked the first recognized public health disaster related to the introduction of a new drug. antihypertensives.psychotropics and digoxin. Intercurrent Illness. unintended and occurs at doses normally used for prophylaxis. non-steroidal anti-inflammatory drugs. It is now recognized that clinical trials.

distribution or elimination of another drug. ADR Reporting „ „ Report adverse experiences with medications Report serious adverse events. An event is serious when the patient outcome is Death Life threatening (real risk of dying) Hospitalisation(initial or prolonged) Disability (significant persistent or permanent) Congenital anomaly Required intervention to prevent permanent impairment or damage Report even if „ you are not certain the product caused adverse event „ you don’t have all the details Who can report? „ Any health care professional (Doctors including Dentists. or interact with each other. Interactions may occur between drugs which compete for the same receptor or act on the same physiological system.Nurses and Pharmacists) Where to report ? „ Nearest ADR monitoring centres „ Peripheral Pharmacovigilance centres (24) „ Regional Pharmacovigilance centres(5) „ Directly to www. such that the amount which reaches the site of action is increased or decreased.in Drug Interactions. They may also occur indirectly when a drug-induced disease or a change in fluid or electrolyte balance alters the response to another drug. the 9 . As newer and more potent drugs become available. they may either act independently of each other.When two drugs are administered to a patient. Interaction may increase or decrease the effects of the drugs concerned and may cause unexpected toxicity.General advice to Prescribers necessary to prevent ADRs. The genetic make-up of the individual patient may also predispose to ADRs.Drug-drug interactions are some of the commonest causes of adverse effects.nic.cdsco.Interactions may occur when one drug alters the absorption.

Haloperidol. Quinidine. tobacco. Remember that interactions which modify the effects of a drug may involve non-prescription drugs. at least in part. Saquinavir. Quinidine. Nifedipine. caused by such factors as age and gender.. The physiological changes in individual patients.Phenytoin CYP2C9 –Ibuprofen. Tamoxifen.Paracetamol CYP3A4.Codeine. Verapamil Inducers 1A2 Tobacco 2B6 phenobarbitone. Methadone. Inhibitors 1A2 Ciprofloxacin 2B6 2C19 2C9 Isoniazid 2D6 Haloperidol. Alterations in the rate of the metabolic reaction catalyzed by that isoform are likely to have effects on the pharmacokinetics of the drug.Sulfamethoxazole. as well as certain types of food for example grapefruit juice. Efavirenz CYP2C19— Amitriptyline. Vincristine. Tamoxifen.Clomipramine. The following table lists drugs under the designation of specific cytochrome P450 isoforms.Diazepam. via that isoform. Indinavir.Cyclophosphamide. Quinine. Erythromycin. Diazepam. Ritonavir. 7—Amlodipine. and social drugs such as alcohol.General advice to Prescribers number of serious drug interactions is likely to increase. non-medicinal chemical agents. and traditional remedies. Timolol CYP2E1—Alcohol. Ritonavir. Ciclosporin. Haloperidol. A drug appears in a column if there is published evidence that it is metabolized. Ritonavir 2E1 3A4 Erythromycin. Phenobarbital. Phenytoin. Grapefruit juice. Indinavir. Rifampicin 10 . 5. Nelfinavir. marijuana. Verapamil. Clomipramine. .Warfarin CYP2D6—Amitriptyline. also influence the predisposition to ADRs resulting from drug interactions. Substrates CYP1A2 — Theophylline CYP2B6 — Cyclophosphamide.Tamoxifen.

Adverse effects caused by traditional medicinesPatients who have been or are taking traditional herbal remedies may develop ADRs. some drugs are preferably taken with food.They are your priority choice for given indications. due to the acidity of these solutions. The effect of food on drug absorption Food delays gastric emptying and reduces the rate of absorption of many drugs.Certain drugs.for example diazepam and insulin . P-DRUG CONCEPT P-drugs are the drugs you have chosen to prescribe regularly. and chloramphenicol. and with which you have become familiar. by precipitation or by chemical reaction. may be inactivated by pHchanges. Make an inventory of effective group of drugs IV. Phenytoin. Phenobarbital. Define the diagnosis II. Benzylpenicillin and Ampicillin lose potency after 6–8 hours if added to dextrose solutions.efficacy. the total amount of drug absorbed may or may not be reduced.with obvious benefits to the patient. Specify the therapeutic objective III.They enable you to avoid repeated searches for a good drug in daily practice.General advice to Prescribers 2C19 2C9 Rifampicin 2D6 2E1 Alcohol 3A4 Carbamazepine. However. It is not always easy to identify the responsible plant or plant constituent.tetracycline. Hydrocortisone is incompatible with heparin.As you use your P-drugs regularly. Aminoglycosides are incompatible with penicillins and heparin. Rifampicin Incompatibilities between drugs and intravenous fluids Drugs should not be added to blood.you will get to know their effects and side effects thoroughly. Choose an effective group according safety. Choose a P-drug 11 to criteria – . amino acid solutions or fat emulsions. when added to intravenous fluids. either to increase absorption or to decrease the irritant effect on the stomach. Some drugs bind to plastic containers and tubing.suitability and costeffectiveness V. Choosing a drug is a process that can be divided into five steps I.

In many countries the validity of a prescription has no time limit. a midwife or a nurse.The following guidelines will help to ensure that prescriptions are correctly interpreted and leave no doubt about the intention of the prescriber. The guidelines are relevant for primary care prescribing. however. address. the trade name can be added. such as a medical assistant. The strength of the drug should be stated in standard units using abbreviations that are consistent with the Système Internationale (SI). but can be a pharmacy technician. and telephone number. The dispenser is not always a pharmacist. and its own laws and regulations to define which drugs require a prescription and who is entitled to write it. Every country has its own standards for the minimum information required for a prescription.General advice to Prescribers PRESCRIPTION WRITING A prescription is an instruction from a prescriber to a dispenser.‘units’ should not be abbreviated. be abbreviated. ‘eye ointment’) should also be stated. The International Nonproprietary Name of the drug should always be used. they may. If there is a specific reason to prescribe a special brand. ‘oral solution’.‘Microgram’ and ‘nanogram’ should not. but in some countries pharmacists do not dispense drugs on prescriptions older than 3 to 6 months. however. Generic substitution is allowed in some countries. The local language is preferred. and strength of the drug. Name. The following details should be shown on the form: „ The prescriber’s name. Avoid decimals whenever „ „ „ 12 . The pharmaceutical form (for example ‘tablet’. This will allow either the patient or the dispenser to contact the prescriber for any clarification or potential problem with the prescription. an assistant or a nurse. Also. It should be legible and indicate precisely what should be given. be adapted for use in hospitals or other specialist units. Prescription form The most important requirement is that the prescription be clear. form. Many countries have separate regulations for prescriptions for controlled drugs such as opioid analgesics. The prescriber is not always a doctor but can also be a paramedical worker. Date of the prescription.

For preparations which are to be taken on an ‘as required’ basis. Narcotics and controlled substances The prescribing of a medicinal product that is liable to abuse requires special attention and may be subject to specific statutory requirements. ‘at night as required to sleep’). Quantity to be dispensed The quantity of the medicinal product to be supplied should be stated such that it is not confused with either the strength of the product or the dosage directions. the length of the treatment course may be stated (for example‘for 5 days’). Directions Directions specifying the route. and age. It is good practice to qualify such prescriptions with the purpose of the medication (for example ‘every 6 hours as required for pain’. the strength. with all quantities written in words as well as in figures to prevent alteration. the maximum daily dose. the minimum dose interval should be stated together with. 13 . For liquid preparations. In particular. the quantity should be adjusted to match the pack sizes available. Other details such as patient particulars and date should also be filled in carefully to avoid alteration. If unavoidable. in such cases it might be necessary to indicate details of the authority on the prescription. „ Specific areas for filling in details about the patient including name. Practitioners may need to be authorized to prescribe controlled substances. the quantity should be stated in millilitres (abbreviated as ‘ml’) or litres (preferably not abbreviated since the letter ‘l’ could be confused with the figure ‘1’).address.General advice to Prescribers possible. dose and frequency should be clear andexplicit. a zero should be written in front of the decimal point. Wherever possible. where relevant. use of phrases such as ‘take as directed’ or ‘take as before’ should be avoided. Alternatively. directions and the quantity of the controlled substance to be dispensed should be stated clearly.

which is as necessary to the practice of medicine as is a sound scientific base Evidence based medicine(EBM) refers to integration of best available research evidence with clinical judgment and experience in the care of patients. Kumarapuram Tel: 0471-2345678 2/2/09 Name : Kamala Age: 30 years Address: Kumarapuram RX Cap Ampicillin 500mg (20) 1 Cap 6th hourly orally 1 hour after food ×5 days Sd/Dr. experience. Quantitative tools available to evaluate resource use in medicine • • • • 14 Cost minimization Cost-effectiveness Cost utility Cost benefit . decision analysis and cost-effectiveness analysis.General advice to Prescribers SAMPLE PRESCRIPTION Dr. The combination of medical knowledge. We understand how subtle changes in many different genes can affect the function of cells and organisms. Reg No 13105 TC Medical Council ASSESSING COST-EFFECTIVENESS IN DRUG THERAPY Dynamic explosion of scientific knowledge have altered the way we practice medicine and exchange information. Lovedale. and judgment defines the art of medicine. Science based technology and deductive reasoning form the foundation for the solution to many clinical problems. intuition . Amal MD. Amal MD. More research has been done on how doctors should make decisions than on how they actually do. Uncertainty in clinical decision making creates the need for probabilities and other quantitative tools like meta-analysis.

a new treatment is compared with current practice (the “low-cost alternative”) in the calculation of the cost-effectiveness ratio: It’s also worthwhile to recognize that CEA is only relevant to certain decisions.. In its most simple form..General advice to Prescribers Cost minimization Cost minimization is useful evaluation to choose the best alternative when the outcome of intervention is same.g. Cost-effectiveness analysis (CEA) Cost-effectiveness analysis (CEA) is a technique for selecting among competing wants wherever resources are limited.g. more expensive. aspirin and -blockers). Note that a CEA is relevant only if a new strategy is both more effective and more costly (or both less effective and less costly). Table 1 Conditions under which CEA is relevant COST EFFECTIVENESS New strategy is more effective New strategy is less effective NEW STRATEGY COSTS MORE CEA relevant New strategy is “dominated” NEW STRATEGY COSTS LESS Adopt newStrategy CEA relevant An Example Consider two strategies intended to lengthen life in patients with heart disease. and more effective (e. The Basics of CEA CEA is a technique for comparing the relative value of various therapeutic strategies. the other is more complex. medication plus 15 . One is simple and cheap (e. We can opt for the low cost alternative. CEA was first applied to health care in the mid-1960s and was introduced with enthusiasm to clinicians by Weinstein and Stason in 1977. Table 1 delineates the various ways a new therapeutic strategy might compare with an existing approach.

1000/yr Rs.General advice to Prescribers cardiac catheterization.90000/yr The result might be considered as the “price” of the additional outcome purchased by switching from current practice to the new treatment (e. Where do the cost data come from? The basic question here is. investigators have to make assumptions about which services are likely to be utilized differently-thus driving the difference in cost. and bypass). angioplasty. 0 5000 50000 Incremental Effectiveness Incremental Cost (Rs... For simplicity. “Was resource use modeled. If they don’t. 16 . extra testing. the data should come from randomized trials. The measurement of resource use in practice has the advantage of capturing utilization that may not be anticipated by investigators (e. Table 2 shows the relevant data. you’ll want to scrutinize the face validity of the assumptions. and readmissions).5 years CE RATIO Rs. someone else may not. or was it measured in real practice?” In modeling. critical readers should seek answers to the following questions. extra visits.) Effectiveness 5000 45000 0 years 5 years 5. we will assume that doing nothing has no cost and no effectiveness. the new strategy is considered “cost-effective. Table 2 CEA-examining three strategies Strategy Nothing Current New Cost Rs.g. Rs.” It means that the new treatment is a good value. stents.g. Ideally. If the price is reasonable enough.90. How good are the effectiveness data? While evaluating CEA one should examine the information used for effectiveness. and just because a strategy saves money doesn’t mean that it is costeffective. Also note that the very notion of cost-effective requires a value judgment—what you think is a good price for an additional outcome.000 per life year). Things to Ask If a study is of interest and its primary outcome is a cost-effectiveness ratio.5 years 5 years 0. Note that being cost-effective does not mean that the strategy saves money.

10.” Cost utility analysis (CUA) CUA is similar to CEA but the outcome is assessed considering the utility preference of the patients. Cost Benefit Analysis (CBA) For evaluating healthcare programs CBA is very helpful. > Rs. The final outcome measure for the analysis is the CE ratio: the ratio of incremental cost to incremental effectiveness.. The calculation is similar for effectiveness. < Rs. Here the health outcome is converted to money value and the net benefit is estimated to select the alternative.e. most fall somewhere in the middle. 200. Quality Adjusted Life Years(QALY) is composite outcome usually used for chronic ailments. So the incremental cost of a current strategy is the difference between the cost of that strategy and the cost of doing nothing.000 per quality-adjusted lifeyear—a good value).50.000 per quality-adjusted life-year—a poor value) and other have very low CE ratios (i. Although some CEAs have extremely high CE ratios (i. The incremental cost for the new strategy is the difference between the cost of the new strategy and the cost of the current strategy (not the cost of doing nothing).General advice to Prescribers Did we get anywhere? Finally. 17 .000 per quality-adjusted life-year may conclude with an assertion that the analyzed strategy is “cost-effective. readers may want to consider whether the entire exercise somehow helped them with a decision. Summary CEA is about incremental costs and incremental benefits. Analyses with CE ratios of Rs.e..

raised cerebrospinal fluid pressure. it is essential that facilities for intubation and mechanically assisted ventilation are available.5–2% P/C: A/E: Dose: Isoflurane Ideal for neurosurgery. Irrespective of whether a general or conduction (regional or local) anaesthetic technique is used. pregnancy arrhythmias. „ „ GENERAL ANAESTHETICS AND OXYGEN Inhalational agents Halothane I: C/I: induction and maintenance of anaesthesia history of unexplained jaundice or pyrexia following previous exposure to halothane.SECTION . A full preoperative assessment is required including.1 DRUGS USED IN ANAESTHESIA General anaesthetics and oxygen Local anaesthetics „ Preoperative medication and sedation for short-term procedures ANAESTHETICS To produce a state of prolonged full surgical anaesthesia reliably and safely. a variety of drugs is needed.5–2% (CHILD) in oxygen or nitrous oxide– oxygen Maintenance. appropriate fluid replacement. hepatic damage Induction. using specifically calibrated vaporizer. ADULT and CHILD 0. avoid for dental procedures in patients under 18 years unless treated in hospital (high risk of arrhythmias). These drugs may be fatal if used inappropriately and should be used by non–specialized personnel only as a last resort. if necessary. Special precautions and close monitoring of the patient are required. bradycardia. porphyria anaesthetic history should be carefully taken to determine previous exposure and previous reactions to halothane (at least 3 months should be allowed to elapse between each re-exposure). gradually increase inspired gas concentration to 2–4%( ADULT) or 1. family history of malignant hyperthermia. respiratory depression. 18 .

5–13 mg/kg (10 mg/kg usually produces 12–25 minutes of anaesthesia) Induction. psychiatric disorders. during recovery. intracerebral mass or haemorrhage or other cause of raised intracranial pressure.5-3% inhalation 1-3. particularly hallucinations. for example operating machinery or driving. cerebral trauma. administer an antisialogogue to prevent excessive salivation leading to respiratory difficulties. history of cerebrovascular accident. by intramuscular injection. patient must remain undisturbed but under observation. transient elevation of pulse rate and blood pressure common. for 24 hours and also to avoid alcohol for 24 hours hallucinations and other emergence reactions during recovery possibly accompanied by irrational behaviour (effects rarely persist for more than few hours but can recur at any time within 24 hours). hypertension (including pre-eclampsia).Inhalational agents I:. Since it is an irritant vapour it is less suitable for induction of anaesthesia especially in children. C/I:. arrhythmias have occurred. Intravenous anaesthetics induction and maintenance of anaesthesia. porphyria supplementary analgesia often required in surgical procedures involving visceral pain pathways (morphine may be used but addition of nitrous oxide will often suffice). by intravenous injection over 19 P/C: Skilled tasks: A/E: P/A: Dose: . pregnancy Warn patient not to perform skilled tasks.D/I: A/E: P/A: Dose: Maintenance: Children: Ketamine I: C/I: same as halothane Trigger malignant hyperthermia. Liquid 100 mL bottle Adults induction: inhalation 1. analgesia for painful procedures of short duration thyrotoxicosis. eye injury and increased intraocular pressure. ADULT and CHILD 6.5% dosage must be individualized. hypotension and bradycardia occasionally reported 50mg/mL in 2mL ampoule and 10mL vial Induction.

or up to 4 mg/kg (maximum 500 mg). by intravenous infusion of a solution containing 1 mg/ml. ADULT and CHILD initially 4 mg/kg For diagnostic procedures and other procedures not involving intense pain induction of anaesthesia prior to administration of inhalational anaesthetic.5 mg/kg (2 mg/kg usually produces 5–10 minutes of anaesthesia). for example operating machinery. breastfeeding Warn patient not to perform skilled tasks. anaesthesia of short duration inability to maintain airway.ADULT and CHILD total induction dose 0. ADULT and CHILD 1–4. hepatic impairment. dyspnoea or obstructive respiratory disease. pregnancy. arrhythmias. patients). allergic reactions. myocardial depression. followed by a further 100–150 mg if necessary according to response after 30–60 seconds. 1. hypersensitivity to barbiturates. for 24 hours and also to avoid alcohol for 24 hours rapid injection may result in severe hypotension and hiccup. injection-site reactions Powder for injection: 0. by intravenous injection usually as a 2. cardiovascular disease. by intramuscular injection.0 g (sodium salt) in ampoule Induction.5–2 mg/kg.General Anaesthetics Note: Thiopental I: C/I: at least 1 minute. rash. maintenance (using microdrip infusion). sneezing. rate adjusted according to response Analgesia. intra-arterial injection causes intense pain and may result in arteriospasm. CHILD 2–7 mg/kg repeated if necessary according to response after 60 seconds P/C: Skilled tasks: A/E: P/A: Dose: 20 .5 g. porphyria reconstituted solution is highly alkaline—extravasation can result in extensive tissue necrosis and sloughing. driving. cardiovascular disease. 10–45 micrograms/kg/minute. laryngeal spasm. myotonic dystrophy. cough.5% (25 mg/ml) solution ADULT 100–150 mg (reduced in elderly or debilitated over 10–15 seconds. Induction.

02-0. I: C/I: P/C: Induction and maintenance of GA. but at times it may lead to pain at the site of injection. hypotension pain at site of injection.5-g ampoule or 40 ml with the 1g ampoule. convulsions. preferred over Diazepam for anesthetic use:1-2. or ketamine) and muscle relaxants.Intravenous General Anaesthetics Reconstitution: Solutions containing 25 mg/ml should be freshly prepared by mixing 20 ml of water for injections with the contents of the 0. precipitation or crystallization is evident should be discarded Propofol It is widely used. Alcohol and CNS depressant drugs produce hypotension. anaphylaxis.5 mg I/V followed by 1/4th supplemental doses For sedation of intubated and mechanically ventilated patients and critical care anesthesia:0. The recovery is rapid without hangover.5mg/ml injection A/E: P/A: Dose: D/I: Midazolam I and Dose: P/A: Gaseous agent Nitrous oxide I: Inhalation gas maintenance of anaesthesia in combination with other anaesthetic agents (halothane. infusion at the rate of 80-150 mcg/kg/min. Emulsion 10 mg/mL 20 mg/mL in 10. It is ideal for day care surgery. Any solution made up over 24 hours previously or in which cloudiness. Monitor blood lipid concentration in patients at risk of fat overload and bacterial contamination. analgesia for obstetric practice. Bradycardia. For induction it is given by IV.1mg/kg/ hr continuous I/V infusion 1 mg/ml. sedation of ventilated patients receiving intensive care upto 3 days. during postoperative physiotherapy and for refractory pain in terminal illness 21 . 20 mL vials. ether. while drawing up propofol emulsion. delayed recovery from anaesthesia. for emergency management of injuries. Propofol allergy.

after prolonged administration megaloblastic anaemia. for brief and superficial interventions. Local anaesthetics are used very widely in dental practice. peripheral neuropathy ADULT and CHILD nitrous oxide mixed with 25–30% oxygen Analgesia. pericardial or peritoneal space. depressed white cell formation. pregnancy nausea and vomiting. arterial air embolism. occlusion of middle ear. to maintain an adequate oxygen tension in inhalational anaesthesia Avoid use of cautery when oxygen is used with ether. decompression sickness. chronic obstructive airway disease. Local Infiltration Many simple surgical procedures that neither involve the body cavities nor require muscle relaxation can be performed under local infiltration 22 . reducing valves on oxygen cylinders must not be greased (risk of explosion) concentrations greater than 80% have a toxic effect on the lungs leading to pulmonary congestion.General Anaesthetics C/I: P/C: A/E: Dose: Anaesthesia: D/I: Oxygen I: FIRE HAZARD: demonstrable collection of air in pleural. for obstetric procedures. intestinal obstruction. emphysema minimize exposure of staff. and for specialized techniques of regional anaesthesia calling for highly developed skills. Local anaesthetic injections should be given slowly in order to detect inadvertent intravascular injection. 50% nitrous oxide mixed with 50% oxygen Hypotensive effect occurs when used concurrently with any of the CNS depressants Inhalation (medicinal gas). exudation and atelectasis Concentration of oxygen in inspired anaesthetic gases should never be less than 21% Adverse effects: Dose: LOCAL ANAESTHETICS Drugs used for conduction anaesthesia (also termed local or regional anaesthesia) act by causing a reversible block to conduction along nerve fibres.

Bupivacaine has the advantage of a longer duration of action. and prolongs its effect. No more than 4 mg/kg choice is of plain lidocaine or 7 mg/kg of lidocaine with epinephrine should be administered on any one occasion. concomitant anticoagulant therapy.Local Anaesthetics anaesthesia. postoperative pain relief adjacent skin infection. The local anaesthetic drug of lidocaine 0. techniques such as axillary or ankle blocks can be invaluable. where the necessary skills are available. spinal or epidural anaesthesia in dehydrated or hypovolaemic patient with excessive dosage or following intravascular injection.5% in glucose can be used but the latter is often chosen because of its longer duration of action. lidocaine 5% in glucose or bupivacaine 0. Regional Block A regional nerve block can provide safe and effective anaesthesia but its execution requires considerable training and practice. occasionally. It should not be added to injections used in digits or appendages. blurred vision. Either lidocaine 1% or bupivacaine 0.5% is suitable. Spinal Anaesthesia This is one of the most useful of all anaesthetic techniques and can be used widely for surgery of the abdomen and the lower limbs. peripheral and sympathetic nerve block. restlessness. It is a major procedure requiring considerable training and practice. unconsciousness and 23 C/I: A/E: . Surface Anaesthesia Topical preparations of lidocaine are available and topical eye drop solutions of tetracaine are used for local anaesthesia of the cornea and conjunctiva. The addition of epinephrine (adrenaline) diminishes local blood flow. severe anaemia or heart disease. dizziness.5% with or without epinephrine. light-headedness. Bupivacaine I: infiltration anaesthesia. spinal anaesthesia. slows the rate of absorption of the local anaesthetic. Care is necessary when using epinephrine for this purpose since. inflamed skin. Nevertheless. it may produce ischaemic necrosis. tremors and. Lower-segment caesarean section can also be performed under local infiltration anaesthesia. convulsions rapidly followed by drowsiness. in excess.

5% solution. hypersensitivity and allergic reactions also occur. ischaemic heart disease.25–0. hepatic impairment. using 0.5% solution. ADULT up to 150 mg (maximum 30 ml) Caudal block in labour. transient paraesthesia and paraplegia very rarely. using 0.25%.General Anaesthetics P/C: P/A: Dose: NOTE: respiratory failure. respiratory impairment.5% (hydrochloride) in 4-ml ampoule to be mixed with 7. using 0.25% solution. using 0. Adult 50-100mg(10–20 ml) Lumbar epidural block in labour.5% solution. ADULT up to 150 mg (up to 60 ml) Peripheral nerve block. headache. ADULT (female) up to 100 mg (maximum 20 ml) Use lower doses for debilitated or elderly. epidural anaesthesia occasionally complicated by urinary retention. cardiovascular toxicity includes hypotension. ADULT (female) up to 60 mg (maximum 12 ml) Caudal block in surgery. or in epilepsy. epidural. Injection for spinal anaesthesia: 0. caudal.5% (hydrochloride) in vial.5% glucose solution. diabetes mellitus. heart block and cardiac arrest. pregnancy and breastfeeding Injection 0. faecal incontinence. myasthenia gravis. Local infiltration.25–0. or acute illness Do not use solutions containing preservatives for spinal.5% solution ADULT up to 150 mg (up to 30 ml) ADULT 50–100 mg Lumbar epidural block in surgery. hypertension.5% solution.pregnancy and breastfeeding 24 . using 0. backache or loss of perineal sensation. 0. angle-closure glaucoma. epilepsy. using 0. porphyria.25–0. or intravenous regional anaesthesia Ephedrine Ephedrine hydrochloride is a complementary drug I: P/C: prevention of hypotension during delivery under spinal or epidural anaesthesia hyperthyroidism. renal impairment .

To prevent hypotension during delivery under spinal anaesthesia. nausea. occasionally. porphyria. sweating. severe anaemia or heart disease. intravenous regional anaesthesia. changes in bloodglucose concentration 30 mg (hydrochloride)/ml in 1-ml ampoule.Local Anaesthetics A/E: P/A: Dose: anorexia. arrhythmias C/I: adjacent skin infection. spinal anaesthesia. tremor. avoid (or use with great care) solutions containing epinephrine (adrenaline) for ring block of digits or appendages (risk of ischaemic necrosis). myasthenia gravis. dental anaesthesia. anginal pain. inflamed skin. impaired cardiac conduction. dizziness. headache. 3–6 mg slow intravenous injection of solution containing 3 mg/mL. epilepsy. cardiovascular toxicity includes hypotension. dizziness. restlessness. convulsions rapidly followed by drowsiness. blurred vision. (maximum single dose 9 mg). pregnancy . light-headedness. heart block and cardiac arrest. anxiety. vasoconstriction with hypertension. tremors and. dyspnoea. severe shock. spinal or epidural anaesthesia in dehydrated or hypovolaemic patient P/C: bradycardia. epidural anaesthesia occasionally complicated by 25 . respiratory impairment. repeated if necessary every 3–4 minutes. breastfeeding A/E: with excessive dosage or following intravascular injection. infiltration anaesthesia. unconsciousness and respiratory failure. restlessness. difficulty in micturition. arrhythmias. hepatic impairment . hypersalivation. Various drugs can serve as alternatives I: surface anaesthesia of mucous membranes. renal impairment. maximum cumulative dose 30 mg Lidocaine Lidocaine is a representative local anaesthetic. vomiting. hypersensitivity and allergic reactions also occur. confusion. concomitant anticoagulant therapy. peripheral and sympathetic nerve block. flushing. vasodilation with hypotension. tachycardia (also in fetus).

General Anaesthetics

P/A:

Dose:

NOTE:

Injection: Dental cartridge: 26

urinary retention, faecal incontinence, headache, backache or loss of perineal sensation; transient paraesthesia and paraplegia very rare Injection: 1%, 2% (hydrochloride) in vial. Injection for spinal anaesthesia: 5% (hydrochloride) in 2-ml ampoule to be mixed with 7.5% glucose solution. Topical forms: 2-4% (hydrochloride). Plain Solutions Local infiltration and peripheral nerve block, using 0.5% solution, ADULT up to 250 mg (up to 50 mL) Local infiltration and peripheral nerve block, using 1% solution, ADULT up to 250 mg (up to 25 mL) Surface anaesthesia of pharynx, larynx, trachea, using 4% solution, ADULT 40–200 mg (1–5 mL) Surface anaesthesia of urethra, using 4% solution, ADULT 400 mg (10 mL) Spinal anaesthesia, using 5% solution (with glucose 7.5%), ADULT 50–75 mg (1–1.5 mL) Solutions containing epinephrine Local infiltration and peripheral nerve block, using 0.5% solution with epinephrine, ADULT up to 400 mg (up to 80 mL) Local infiltration and peripheral nerve block, using 1% solution with epinephrine, ADULT up to 400 mg (up to 40 mL) Dental anaesthesia, using 2% solution with epinephrine, ADULT 20–100 mg (1–5 mL) Maximum safe doses of lidocaine for ADULT and CHILD are: 0.5% or 1% lidocaine, 4 mg/kg; 0.5% or 1% lidocaine + epinephrine 5 micrograms/mL (1 in 200 000), 7 mg/kg Use lower doses for debilitated, or elderly, or in epilepsy, or acute illness Do not use solutions containing preservatives for spinal, epidural, caudal, or intravenous regional anaesthesia Lidocaine + epinephrine (adrenaline) 1%, 2% (hydrochloride) + epinephrine 1:200 000 in vial. 2% (hydrochloride) + epinephrine 1:80 000.

Preoperative Medication

PREOPERATIVE MEDICATION AND SEDATION Pre-anaesthetic medication is often advisable prior to both conduction and general anaesthetic procedures. Sedatives improve the course of subsequent anaesthesia in apprehensive patients. Diazepam and promethazine are effective. Diazepam can be administered by mouth, by rectum, or by intravenous injection. Promethazine , which has antihistaminic and antiemetic properties as well as a sedative effect, is of particular value in children. A potent analgesic such as morphine should be administered preoperatively to patients in severe pain or for analgesia during and after surgery. Anticholinergic (more correctly antimuscarinic) drugs such as atropine are also used before general anaesthesia. They inhibit excessive bronchial and salivary secretions induced, in particular, by ether and ketamine. Intramuscular administration is most effective, but oral administration is more convenient in children. Lower doses should be used in cardiovascular disease or hyperthyroidism.

Atropine
I: to inhibit salivary secretions; to inhibit arrhythmias resulting from excessive vagal stimulation; to block the parasympathomimetic effects of anticholinesterases such as neostigmine; organophosphate poisoning ; mydriasis and cycloplegia angle-closure glaucoma; myasthenia gravis; paralytic ileus, pyloric stenosis; prostatic enlargement Down syndrome, children, elderly; ulcerative colitis, diarrhoea; hyperthyroidism; heart failure, hypertension; pyrexia; pregnancy and breastfeeding Since atropine has a shorter duration of action than neostigmine, late unopposed bradycardia may result; close monitoring of the patient is necessary dry mouth; blurred vision, photophobia; flushing and dryness of skin, rash; difficulty in micturition; less commonly arrhythmias, tachycardia, palpitations; confusion (particularly in elderly); heat prostration and convulsions, especially in febrile children 27

C/I: P/C:

DURATION OF ACTION.

A/E:

General Anaesthetics

P/A: Dose:

Injection: 1 mg (sulfate) in 1-mL ampoule Premedication, by intravenous injection, ADULT 300– 600 micrograms immediately before induction of anaesthesia CHILD 20 micrograms/kg (maximum 600 micrograms); by subcutaneous or intramuscular injection, ADULT 300– 600 micrograms 30–60 minutes before induction; (maximum 600 micrograms) Intraoperative bradycardia, by intravenous injection, ADULT 300–600 micrograms (larger doses in emergencies); CHILD 1–12 years 10–20 micrograms/kg Control of muscarinic side-effects of neostigmine in reversal of competitive neuromuscular block, by intravenous injection, ADULT 0.6–1.2 mg; CHILD under 12 years (but rarely used) 20 micrograms/kg (maximum 600 micrograms) with neostigmine 50 micrograms/kg

Diazepam
Drug subject to international control under the Convention on Psychotropic Substances (1971) I: premedication before major or minor surgery; sedation with amnesia for endoscopic procedures and surgery under local anaesthesia; when anaesthetic not available, for emergency reduction of fractures; epilepsy; anxiety disorders central nervous system depression or coma; shock; respiratory depression; acute pulmonary insufficiency; sleep apnoea; acute alcohol intoxication; severe hepatic impairment; marked neuromuscular respiratory weakness including unstable myasthenia gravis respiratory disease; muscle weakness and myasthenia gravis; history of alcohol or drug abuse; marked personality disorder; elderly or debilitated patients (adverse effects more common in these groups); hepatic impairment or renal failure; pregnancy and breastfeeding ; close observation required until full recovery after sedation; porphyria; Warn patient not to perform skilled tasks, for example operating machinery, driving, for 24 hours

C/I:

P/C:

SKILLED TASKS: 28

Preoperative Medication

A/E:

P/A: Dose:

ADMINISTRATION.

central nervous system effects common and include drowsiness, sedation, confusion, amnesia, vertigo, and ataxia; hypotension, bradycardia, or cardiac arrest, particularly in elderly or severely ill patients; also paradoxical reactions, including irritability, excitability, hallucinations, sleep disturbances; pain and thromboembolism on intravenous injection Injection: 5 mg/mL in 2-mL ampoule. Tablet : 5 mg. Premedication, by mouth 2 hours before surgery ADULT and CHILD over 12 years, 5–10 mg Sedation, by slow intravenous injection immediately before procedure, ADULT and CHILD over 12 years, 200 micrograms/kg Absorption following intramuscular injection slow and erratic; route should only be used if oral or intravenous administration not possible.Slow intravenous injection into large vein reduces risk of thrombophlebitis Resuscitation equipment must be available 10 mg (sulfate or hydrochloride) in 1-ml ampoule. Refer to section on analgesics 5 mg (hydrochloride)/5 mL. premedication prior to surgery; antiemetic Child under 1 year; impaired consciousness due to cerebral depressants or of other origin; porphyria prostatic hypertrophy, urinary retention; glaucoma; epilepsy; hepatic impairment,pregnancy and breastfeeding Warn patient not to perform skilled tasks, for example operating machinery, driving, for 24 hours drowsiness (rarely paradoxical stimulation in children); headache; anticholinergic effects such as dry mouth, blurred vision, urinary retention CHILD over 1 year 0.5–1 mg/kg Premedication, by mouth 1 hour before surgery, Premedication, by deep intramuscular injection 1 hour before surgery, ADULT 25 mg 29

Morphine
Injection:

Promethazine
Oral liquid: I: C/I: P/C:

SKILLED TASKS. A/E:

Dose:

General Anaesthetics

Glycopyrrolate
Same as atropine. Glaucoma, obstructive uropathy, myasthenia gravis, severe ulcerative colitis P/A: Injection 200 mcg/mL,1 mL amp, 3 mL amp. Dose: For premedication it is given by IM or IV 10 mcg/kg, 200-400 mcg or 4-5 mcg/kg to a maximum of 400 mcg. For children it is given by IM or IV , 4-8 mcg/kg upto a maximum of 200 mcg. For intraoperative use it is given by IV injection as for premedication. For control of muscarinic side effects of neostigmine during reversal of competitive neuromuscular block it is given in a dose of 10 mcg/kg with 50 mcg/kg neostigmine. MUSCLE RELAXANTS I : P/C:, A/E: C/I :

Pancuronium
Refer Section 22, Muscle Relaxants.

Succinyl Choline
Refer Section 22, Muscle Relaxants.

30

SECTION - 2 ANALGESICS, ANTIPYRETICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS(NSAIDS), MEDICINES USED TO TREAT GOUT AND DISEASE MODIFYING AGENTS IN RHEUMATOID DISORDERS (DMARDS)
NON-OPIOIDS AND NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) Non-opioid analgesics are particularly suitable for musculoskeletal pain whereas the opioid analgesics are more suitable for moderate to severe visceral pain.

Acetylsalicylic acid
I: Mild to moderate pain including dysmenorrhoea, headache; pain and inflammation in rheumatic disease and other musculoskeletal disorders (including juvenile arthritis); pyrexia; acute migraine attack; antiplatelet Hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to acetylsalicylic acid or any other NSAID; children and adolescents under 16 years (Reye syndrome); previous or active peptic ulceration; haemophilia and other bleeding disorders; not for treatment of gout Asthma,allergic disease; renal impairment; hepatic impairment pregnancy;breastfeeding; elderly; G6PDdeficiency; dehydration Generally mild and infrequent for lower doses, but common with anti-inflammatory doses; gastrointestinal discomfort or nausea, ulceration with occult bleeding (occasionally major haemorrhage); also other haemorrhage (including subconjunctival); hearing disturbances such as tinnitus (rarely deafness), vertigo, confusion, hypersensitivity reactions (angioedema, bronchospasm and rash); increased bleeding time; rarely oedema, myocarditis, blood disorders (particularly thrombocytopenia) Tab 100mg, 150mg, 325mg 31

C/I:

P/C:

A/E:

P/A:

Non-Steroidal Anti-Inflammatory Drugs

Dose:

Cost:

Mild to moderate pain, pyrexia, by mouth with or after food, ADULT 300–900 mg every 4–6 hours if necessary; maximum 4 g daily; CHILD under 16 years not recommended. ADULT 4–8 g daily in divided doses in acute rheumatoid arthritis. Juvenile arthritis, by mouth with or after food CHILD up to 130 mg/kg daily in,5–6 divided doses in acute conditions; 80–100 mg/kg daily in divided doses for maintenance 100mg (10) Rs 6.20 ,150mg (10) Rs 4.20 Mild to moderate pain including dysmenorrhoea, headache; pain relief in osteoarthritis and soft tissue lesions; pyrexia including post-immunization pyrexia; acute migraine attack Hepatic impairment; renal impairment; alcohol dependence; breastfeeding; overdosage Rare but rashes and blood disorders reported; important: liver damage (and less frequently renal damage) following overdosage Tablet: 100-500 mg;. Oral liquid: 125 mg/5 ml;Suppository: 100 mg Post-immunization pyrexia, by mouth,INFANT 2–3 months, 60 mg followed by a second dose, if necessary, 4–6 hours later; warn parents to seek medical advice if pyrexia persists after second dose. Mild to moderate pain, pyrexia, by mouth, ADULT 0.5–1 g every 4–6 hours, maximum 4 g daily; CHILD under 3 months see note below, 3 months–1 year 60–125 mg, 1–5 years 120–250 mg, 6–12 years 250–500 mg, these doses may be repeated every 4–6 hours if necessary (maximum 4 doses in 24 hours).Mild to moderate pain, pyrexia, by rectum, ADULT 0.5–1g; CHILD 1–5 years 125–250 mg, 6–12 years 250–500 mg; doses inserted every 4–6 hours if necessary, maximum 4 doses in 24 hours Infants under 3 months should not be given paracetamol unless advised by a doctor; a dose of 10 mg/kg (5 mg/ kg if jaundiced) is suitable 500mg (10) Rs 4.80- 12.30

Paracetamol
I:

P/C: A/E:

P/A: Dose:

NOTE:

Cost: 32

Non-Steroidal Anti-Inflammatory Drugs

Diclofenac
I: C/I: P/C: Pain and inflammation, including rheumatic disease and musculoskeletal disorders Active peptic ulcer, GI bleeding, asthma History of GI ulcer, disorders of blood coagulation, impaired hepatic , renal, cardiac function; pregnancy Similar to Ibuprofen Enteric coated tablets 50mg, dispersible Tab 50mg, Sustained release tabs75mg, 100mg, Inj 25mg/ml, 3mL ampoules Adult oral 75 -150mg in 2-3 divided doses I.M 75mg once daily, twice daily in severe cases for maximum of two days 50mg (10) Rs 15/-to 20/Pain and inflammation in rheumatic disease and other musculoskeletal disorders including juvenile arthritis; mild to moderate pain including dysmenorrhoea, headache; pain in children; acute migraine attack Hypersensitivity (including asthma, angioedema, urticaria or rhinitis) to acetylsalicylic acid or any other NSAID; active peptic ulceration Renal impairment; hepatic impairment; preferably avoid if history of peptic ulceration; cardiac disease; elderly; pregnancy; breastfeeding; coagulation defects;allergic disorders Gastrointestinal disturbances including nausea, diarrhoea,dyspepsia, ulceration, and haemorrhage; hypersensitivity reactions including rash, angioedema, bronchospasm; headache, dizziness, nervousness, depression, drowsiness, insomnia, vertigo, tinnitus, photosensitivity,haematuria; fluid retention (rarely precipitating congestive heart failure in elderly), raised blood pressure, renal failure; rarely hepatic damage, alveolitis, pulmonary eosinophilia, pancreatitis, visual disturbances, erythema multiforme (Stevens-Johnson syndrome), toxic dermal necrolysis (Lyell syndrome), colitis, aseptic meningitis. 33

A/E: P/A:

Dose:

Cost:

Ibuprofen
I:

C/I:

P/C:

A/E:

Non-Steroidal Anti-Inflammatory Drugs

P/A : Dose:

Cost:

Tablet: 200 mg; 400 mg Mild to moderate pain, pyrexia, inflammatory musculoskeletal disorders, by mouth with or after food, ADULT 1.2–1.8 g daily in 3–4 divided doses, increased if necessary to maximum 2.4 g daily (3.2 g daily in inflammatory disease); maintenance dose of 0.6–1.2 g daily may be sufficient .Juvenile arthritis, by mouth with or after food CHILD over 7 kg, 30–40 mg/kg daily in 3–4 divided doses. Pain in CHILDREN (not recommended for child under 7 kg), by mouth with or after food, 20–40 mg/kg daily in divided doses or 1–2 years 50 mg 3–4 times daily, 3–7 years 100 mg 3–4 times daily, 8–12 years 200 mg 3–4 times daily 200mg Rs 3.40-15/Analgesic and anti-inflammatory in musculoskeletal and joint disorders. Active peptic ulcer, history of Gl lesions, pregnancy. Renal, hepatic or cardiac dysfunction, bleeding or CNS disorders, epilepsy, breastfeeding, parkinsonism, psychiatric disorders, infants. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur, renal failure may be provoked by NSAIDs especially in patients with pre-existing renal impairment; rarely drowsiness, confusion, insomnia, convulsions, psychiatric disturbances,depression, syncope,thrombocytopenia, hypertension, hypergly caemia, blurred vision,corneal deposits, peripheral neuropathy and intestinal strictures; suppositries may cause rectal irritation and occasional bleeding. Capsules, 25mg ADULT: Oral: 25mg 2-3 times daily with food, increased if necessary by 25-50mg daily at weekly intervals to 150-200mg daily.Rectal: 100mg at night and in the morning if required. CHILD Stills disease, oral, lmg/ kg/day in 3 divided doses. 25mg (10) Rs 15.80-17.50

Indomethacin
I: C/I: P/C:

A/E:

P/A: Dose:

Cost: 34

Non-Steroidal Anti-Inflammatory Drugs

Mefenamic acid
I: C/I: A/E: P/A: Dose: Cost: Mild to moderate pain, dysmenorrhoea , menorrhagia, osteoarthritis, rheumatoid arthritis, juvenile arthritis Active peptic ulcer.history of GI lesion, pregnancy, lactation Similar to Ibuprofen Tablets,250mg,500mg Adult, oral 500mg three times daily,after food 250mg (10) Rs10-16/Pain and inflammation in rheumatoid arthritis, osteoarthritis a ankylosing spondylitis. Asthma, angioedema, urticaria or rhinitis, pregnancy, breastfeeding severe congestive heart failure, history of cardiac failure, left ventricular dysfunction, hypertension, oedema, active peptic ulceration. Elderly, allergic disorders; renal, cardiac or hepatic impairment;avoid in porphyria. GI discomfort, nausea, diarrhoea, occasionally bleeding and ulceration;hypersensitivity reactions, headache, dizziness, nervousness, depression drowsiness, insomnia, vertigo, hearing disturbances such as tinnitus photosensitivity and haematuria; blood disorders; fluid retention; blood pressure may be raised; rarely papillary necrosis or interstitial fibrosis hepatic damage, alveolitis, pulmonary eosinophilia, pancreatitis,eye changes, Stevens-Johnson syndrome and toxic epidermal necrolysis, Induction of or exacerbation of colitis has been reported. Tablet, 100 mg. ADULT: Oral, 100 mg twice daily. (reduce to 100 mg daily, initially in hepatic impairment).CHILD:Not recommended. 100mg (10) Rs16.25-20/Pain and inflammation in osteoarthritis and in rheumatoid arthritis; acute gout. 35

Aceclofenac
I: C/I:

P/C: A/E :

P/A: Dose:

Cost:

Etoricoxib
I:

Non-Steroidal Anti-Inflammatory Drugs

C/I:

P/C: A/E :

P/A: Dose: Cost:

Sulphonamide sensitivity; renal impairment (creatinine clearance less than 30ml/minute); inflammatory bowel disease; severe congestive heart failure; hypersensitivity to aspirin or any other NSAID; active peptic ulceration; current or previous GI ulceration or bleeding. Elderly;history of ischaemic heart disease. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur,renal failure may be provoked by NSAID’s especially in patients with pre-existing renal impairment,flatulence, insomnia, pharyngitis, sinusitis; less frequently stomatitis, constipation, palpitations, anxiety,depression, fatigue, paraesthesia, muscle cramps; rarely taste alteration,alopecia; also dry mouth, taste disturbance,mouth ulcers, flatulence, constipation, appetite and weight changes, chest pain, fatigue, paraesthesia, influenza like syndrome, myalgia. Tablets, 90mg, 120mg. ADULT Osteoarthritis, oral, 60mg once daily.Rheumatoid arthritis, 90mg once daily. Acute gout, 120mg once daily. 90mg (10) Rs52-109/Musculoskeletal and joint disorders like rheumatoid and Osteoarthritis, ankylosing spondylitis, acute gout. Aspirin or NSAID induced allergy, active peptic ulcer, history of recurrent ulceration, porphyria. Surgery, haemorrhagic disorders, impaired renal or hepatic function,hypertension, asthma. GI discomfort,occasionally bleeding and ulceration, hypersensitivity reactions, headache, dizziness, vertigo, tinnitus, photosensitivity, hematuria, fluid retension may occur,renal failure may be provoked by NSAID’s especially in patients with pre-existing renal impairment

Piroxicam
I:

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

36

Non-Steroidal Anti-Inflammatory Drugs

P/A: Dose:

Cost:

Dispersible tablets 20mg., Capsules 10mg, 20mg ADULT: Rheumatic disease: oral, 20mg daily initially; 10-30mg daily in single or divided doses as maintenance dose.Acute gout :oral, 40mg daily in single or divided doses for 5-7days.Acute musculoskeletal disorders: oral, 40mg daily in single or divided doses for 2 days, then 20mg daily for 7-14 days.Topical gel,0.5% is applied 34 times daily.CHILD . Juvenile arthritis above 6 years: oral, less than 15kg, 5mg; 16-25kg,10mg; 26-45kg, 15mg; over 46kg, 20mg daily. Capsule 10mg (10) Rs14 -22/Short term management of moderate to severe acute postoperative pain. Prophylaxis and reduction of inflammation and associated symptoms following ocular surgery History of hypersensitivity to aspirin or any other NSAIDs or to any ingredients of the formulation; children below 3 years; asthma, angioedema or bronchospasm, history of peptic ulcer; moderate to severe renal impairment, coagulation disorders, pregnancy and lactation. Asthma, GI diseases, renal or hepatic disorder, allergy, haemostasis,children below 16 years. There is a potential for cross sensitivity to aspirin, phenylacetic acid derivatives and other NSAIDs , hence caution should be used when treating individuals who have previously exhibited sensitivities to these drugs; bleeding disorders. Anaphylaxis; fluid retention, nausea, dyspepsia, abdominal discomfort, bowel changes, peptic ulceration; GI bleeding (elderly at greater risk),convulsions, myalgia, aseptic meningitis, hyponatraemia, hyperkalaemia, A raised blood urea and creatinine, urinary symptoms and acute renal failure, flushing or pallor, bradycardia, hypertension, purpura, thrombocytopenia, dyspnoea and pulmonary oedema, skin reactions (Stevens-Johnson & Lyell’s syndromes), post operative wound haemorrhage, haematoma, epistaxis, oedema, liver function changes. 37

Ketorolac
I:

C/I:

P/C:

A/E:

Non-Steroidal Anti-Inflammatory Drugs

P/A: Dose:

Cost: Morphine I:

Theoretical risk of prolonged bleeding time, transient stinging and blurring of eyes on instillation Film coated tablets, 10mg; Injection, 30mg/mL, lmL ampoules.Ophthalmic solution 0.5% w/v, 5ml. ADULT : Oral:l0mg every, 4-6 hours (elderly every 6-8 hours); max.40mg daily, max. duration of treatment 7 days.I.M.or IM initially 10mg, then 10-30mg every 46 hours upto a max.of 90mg daily. ADULT: Instill 1 drop 3 times daily starting 24 hours pre-operatively and continuing for upto 3 weeks.CHILD: Not recommended under 16 years. Tablet 10mg (10) Rs 18 – 29.90 OPIOID ANALGESICS Severe pain (acute and chronic); myocardial infarction, acute pulmonary oedema; adjunct during major surgery and postoperative analgesia Avoid in acute respiratory depression, acute alcoholism, and where risk of paralytic ileus; also avoid in raised intracranial pressure or head injury (affects pupillary responses vital for neurological assessment); avoid injection in phaeochromocytoma Renal and hepatic impairment; reduce dose or avoid in elderly and debilitated; dependence (severe withdrawal symptoms if withdrawn abruptly); hypothyroidism; convulsive disorders; decreased respiratory reserve and acute asthma; hypotension; prostatic hypertrophy; pregnancy; breastfeeding; overdosage Nausea, vomiting (particularly in initial stages) constipation; drowsiness; also dry mouth, anorexia, spasm of urinary and biliary tract; bradycardia, tachycardia, palpitation, euphoria, decreased libido, rash, urticaria, pruritus, sweating, headache, facial flushing, vertigo, postural hypotension, hypothermia, hallucinations, confusion, dependence, miosis; larger doses produce respiratory depression, hypotension, and muscle rigidity

C/I:

P/C:

A/E:

38

Opioid Analgesics

P/A : Oral liquid:

Dose:

NOTE.

Injection: 10 mg (morphine hydrochloride or morphine sulfate) in 1-ml ampoule. 10 mg (morphine hydrochloride or morphine sulfate)/5 ml.Tablet: 10 mg (morphine sulfate).Tablet (prolonged release): 10 mg; 30 mg; 60 mg (morphine sulfate). Acute pain, by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection ADULT 10 mg every 4 hours if necessary; Chronic pain, by mouth (immediate-release tablets) or by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection 5–20 mg regularly every 4 hours; dose may be increased according to need; oral dose should be approximately double corresponding intramuscular dose; by mouth (sustained release tablets), titrate dose first using immediate-release preparation, then every 12 hours according to daily morphine requirement.Myocardial infarction, by slow intravenous injection (2 mg/minute), 10 mg followed by a further 5–10 mg if necessary; elderly or debilitated patients, reduce dose by half. Acute pulmonary oedema, by slow intravenous injection (2 mg/minute), 5–10 mg The doses stated above refer equally to morphine sulfate and hydrochloride. Sustained-release capsules designed for once daily administration are also available PATIENT ADVICE. Sustained-release tablets should be taken at regular intervals and not on an as-needed basis for episodic or breakthrough pain.Sustained-released tablets should not be crushed. Moderate to severe pain, pre operative medication as an adjuvant to anaesthesia – for sedative and anxiolytic effects, Obstetrical analgesia. Similar to morphine Local pain at injection site,sedation, nausea, light headedness, vomiting. Inj 50mg/mL, 1mL ampoule, Tab 50mg-100mg Acute pain,IM/SC 50-100mg;IV 25-50mg,For preoperative medication : 50-100 mg, 30-90 minutes before surgery, 39

Pethidine
I:

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

Non-Steroidal Anti-Inflammatory Drugs

Obstetric analgesia : 50-100 mg, as soon as pain starts, repeated at 1-3 hourly intervals, upto a maximum of 400 mg/day.

Pentazocine
I: C/I: Relief of moderate to severe pain, in postoperative period in bony metastatsis in cancer patients etc. In the post myocardial infarction period as it increases cardiac work load, in acute alcoholism, head injuries and conditions in which increased intra cranial pressure occurs Use with caution in bronchial asthma, chronic lung diseases, where respiratory reserve is decreased because of its respiratory depressant effects, avoid in antihypertensives and cardiac disorders, in patients with heart failure as it causes rise in B.P. and causes tachycardia, dose adjustments in liver and kidney failure, use with caution after biliary surgery, since opioids increase biliary tract pressure by constriction of sphincter of oddi, chronic users not to drive or operate machinery. Drowsiness, light headedness or euphoria, nausea, vomiting. Tablet 25mg, Injection 30mg/mL Adults: 30-60 mg every 4-6 hours. Moderate to severe pain Avoid in acute respiratory depression, acute alcoholism and conditions where there is risk of paralytic ileus, pheochromacytoma and addisson’s disease. This is not indicated for acute abdominal pain. This has to be avoided in raised intracranial tension or in head injury. Hypotension, hypothyroidism, asthma, decreased respiratory reserve, prostatic hypertrophy, pregnancy and breast feeding, hepatic impairment, renal impairment and opioid dependence. Severe withdrawal symptoms occur if withdrawn abruptly. Adverse effects less than morphine. Tablets and cap 50 mg. inj. 50 mg/mL. Oral: 50-100 mg every 4 hr;Parenteral dosage IM or by IV infusion, 50-100 mg every 4-6 hr.Post operative

P/C:

A/E: P/A: Dose:

Tramadol
I: C/I:

P/C:

A/E: P/A: Dose: 40

Opioid Analgesics

Cost:

pain, 100 mg initially, then 50 mg every 10-20 minMaximum of total dose during the first hr should not exceed 250 mg including the initial dose. There after 50-100 mg is given every 4-6 hr up to a maximum of 600 mg daily. Cap 50 mg (10) Rs. 60.00;Inj. 50 mg/mL (2mL) Rs. 25.00 Moderate to severe pain, perioperative analgesia same as morphine Tablet 200 mcg; Inj. 300 mcg/ml and 300 mcg/2 mL Sublingual to start with 200-400 mcg every 8h increasing if necessary to 200-400 mcg every 6-8 hour. Children over 6 months, 16-25 kg 100 mcg; 25-37.5 kg100-200 mcg;37.5-50 kg 200-300 mcg; Parenteral- IM or slow IV 300-600 mcg every 6-8 hr Tab 200 mcg (10) Rs.25.00; Inj. 0.3 mg (1mL)Rs. 10.00 mild to moderate pain; diarrhoea respiratory depression, obstructive airways disease, acute asthma attack; where risk of paralytic ileus renal and hepatic impairment; dependence; pregnancy; breastfeeding; overdosage constipation particularly troublesome in long-term use; dizziness, nausea, vomiting; difficulty with micturition; ureteric or biliary spasm; dry mouth, headaches, sweating, facial flushing; in therapeutic doses, codeine is much less liable than morphine to produce tolerance, dependence, euphoria, sedation or other adverse effects Tablet: 30 mg (phosphate). Mild to moderate pain, by mouth, ADULT 30–60 mg every 4 hours when necessary, mild pain same as morphine Cap 60 mg 60 mg every 6-8 hr necessary Cap 60 mg (10) Rs. 9.00 41

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

Cost:

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

P/A: Dose:

Dextropropoxyphene hydrochloride
I: C/I: P/C: A/E: P/A: Dose: Cost:

Non-Steroidal Anti-Inflammatory Drugs

DISEASE MODIFYING AGENTS USED IN RHEUMATOID DISORDERS (DMARDS) The process of cartilage and bone destruction which occurs in rheumatoid arthritis may be reduced by the use of a diverse group of drugs known as DMARDs (disease-modifying antirheumatic drugs). DMARDs include chloroquine, penicillamine, sulfasalazine and immunosuppressants (azathioprine, methotrexate).Treatment should be started early in the course of the disease, before joint damage starts. Treatment is usually initiated with a NSAID when the diagnosis is uncertain and the disease course unpredictable. However, when the diagnosis, progression and severity of rheumatic disease have been confirmed,a DMARD should be introduced. DMARDs do not produce an immediate improvement but require 4–6 months of treatment for a full response. Their long-term use is limited by toxicity and loss of efficacy. If one drug does not lead to objective benefit within 6 months,it should be discontinued and another DMARD substituted.

Azathioprine
Azathioprine is a complementary drug for rheumatoid arthritis I: Rheumatoid arthritis in cases that have failed to respond to chloroquine or penicillamine; psoriatic arthritis; transplant rejection inflammatory bowel disease Hypersensitivity to azathioprine or mercaptopurine Monitor for toxicity throughout treatment; monitor full blood counts frequently; hepatic impairment; renal impairment; elderly(reduce dose); pregnancy, breastfeeding BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Hypersensitivity reactions requiring immediate and permanent withdrawal include malaise, dizziness, vomiting, diarrhoea, fever, rigors,myalgia, arthralgia, rash, hypotension and interstitial nephritis; doserelated bone marrow suppression; liver impairment, cholestatic jaundice; hair loss and increased suceptibility to infections and colitis in patients also receiving corticosteroids; nausea; rarely pancreatitis and pneumonitis. hepatic veno-occlusive disease; also herpes zoster infection

C/I: P/C:

A/E:

42

Drugs in Rheumatoid Disorders

P/A: Dose:

Cost:

Tablet: 50 mg. Administered on expert advice.Rheumatoid arthritis, by mouth, initially, 1.5–2.5 mg/kg daily in divided doses,adjusted according to response; maintenance 1– 3 mg/kg daily; consider withdrawal if no improvement within 3 months Tablet50mg (10) Rs48.60-81.20 Rheumatoid arthritis (including juvenile arthritis); malaria Psoriatic arthritis Monitor visual acuity throughout treatment; warn patient to report immediately any unexplained visual disturbances; hepatic impairment; renal impairment; pregnancy breastfeeding; neurological disorders including epilepsy; severe gastrointestinal disorders; G6PD deficiency; elderly; may exacerbate psoriasis and aggravate myasthenia gravis; porphyria; Gastrointestinal disturbances, headache, skin reactions (rash,pruritus); less frequently ECG changes, convulsions, visual changes, retinal damage, keratopathy, ototoxicity, hair depigmentation, alopecia,discoloration of skin, nails and mucous membranes; rarely blood disorders(including thrombocytopenia, agranulocytosis, aplastic anaemia); mental changes (including emotional disturbances, psychosis), myopathy (including cardiomyopathy and neuromyopathy), acute generalized exanthematous pustulosis, exfoliative dermatitis, erythema multiforme (Stevens-Johnson syndrome), photosensitivity, and hepatic damage; important: arrhythmias and convulsions in overdosage Tablet: 100 mg; 150 mg (as phosphate or sulfate). Chloroquine base 150 mg is approximately equivalent to chloroquine sulfate 200 mg or chloroquine phosphate 250 mg Administered on expert advice 43

Chloroquine
I: C/I: P/C:

A/E:

P/A: NOTE.

Dose:

Non-Steroidal Anti-Inflammatory Drugs

NOTE.

Cost:

All doses in terms of chloroquine base Rheumatoid arthritis, by mouth, ADULT 150 mg daily; maximum 2.5 mg/kg daily; NOTE. To avoid excessive dosage in obese patients the dose of chloroquine should be calculated on the basis of lean body weight Tablet 250mg (10) Rs 5.20

Methotrexate
Methotrexate is a complementary drug for rheumatoid arthritis I: C/I: P/C: Rheumatoid arthritis; malignant disease Pregnancy and breastfeeding, immunodeficiency syndromes; significant pleural effusion or ascites Monitor throughout treatment including blood counts and hepatic and renal f u n c t i o n tests; r e n a l impairment (avoid if moderate or severe), hepatic impairment (avoid if severe; reduce dose or withdraw if acute infection develops; for woman o r man, contraception during and for at least 6 months after treatment; peptic ulceration, ulcerative colitis, diarrhoea, ulcerative stomatitis; advise patient to avoid self-medication with salicylates or other NSAIDs; warn patient with rheumatoid arthritis to report cough or dyspnoea; BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Blood disorders (bone marrow suppression), liver damage,pulmonary toxicity; gastrointestinal disturbances — if stomatitis and diarrhoea occur, stop treatment; renal failure, skin reactions, alopecia,osteoporosis, arthralgia, myalgia, ocular irritation, precipitation of diabetes Tablet: 2.5 mg (as sodium salt). Administered on expert advice ADULT 7.5 mg once weekly (as a single dose for Rheumatoid arthritis, by mouth,divided into 3 doses of 2.5 mg given at intervals of 12 hours), adjusted according to response; maximum total dose of 20 mg once weekly

A/E:

P/A: Dose:

44

Drugs in Rheumatoid Disorders

IMPORTANT. Cost:

The doses are weekly doses and care is required to ensure that the correct dose is prescribed and dispensed Tablet 2.5mg (10) Rs 23.40-49.25

Sulfasalazine
Sulfasalazine is a complementary drug for rheumatoid arthritis I: C/I: P/C: Severe rheumatoid arthritis; ulcerative colitis and Crohn’s disease Hypersensitivity to salicylates and sulfonamides; severe renal impairment; child under 2 years; porphyria Monitor blood counts and liver function during first 3 months of treatment ; monitor r e n a l function regularly; renal impairment pregnancy, breastfeeding, history of allergy; G6PD deficiency; slow acetylator status;BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Tablet: 500 mg. Nausea, diarrhoea, headache, loss of appetite; fever; blood disorders (including Heinz body anaemia, megaloblastic anaemia,leukopenia, neutropenia, thrombocytopenia); hypersensitivity reactions (including rash, urticaria, erythema multiforme (Stevens-Johnson syndrome),exfoliative dermatitis, epidermal necrolysis, pruritus, photosensitization, anaphylaxis, serum sickness, interstitial nephritis, lupus erythematosus-like syndrome); lung complications (including eosinophilia, fibrosing alveolitis);ocular complications (including periorbital oedema); stomatitis, parotitis; ataxia, aseptic meningitis, vertigo, tinnitus, alopecia, peripheral neuropathy,insomnia, depression, hallucinations; renal effects (including proteinuria, crystalluria, haematuria); oligospermia; rarely acute pancreatitis, hepatitis;urine may be coloured orange; some soft contact lenses may be stained Administered on expert advice.ADULT initially , by mouth as gastro-resistant tablets, 500 mg daily, 45

P/A: A/E:

Dose:

Non-Steroidal Anti-Inflammatory Drugs

Cost:

increased by 500 mg at intervals of 1 week to a maximum of 2–3 g daily in divided doses Tablet 500mg (10) Rs 41.40- 56.80

Penicillamine
Penicillamine is a complementary drug for rheumatoid arthritis I: C/I: P/C: Severe rheumatoid arthritis; copper and lead poisoning Lupus erythematosus Monitor throughout treatment including blood counts and urine tests; renal impairment; concomitant nephrotoxic drugs (increased risk of toxicity); pregnancy; breastfeeding ; avoid concurrent gold, chloroquine or immunosuppressive treatment; avoid oral iron within 2 hours of a dose; patients hypersensitive interactions: to penicillin may react rarely to penicillamine; BONE MARROW SUPPRESSION. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression, for example unexplained bruising or bleeding, purpura, infection, sore throat Initially nausea (reduced if taken before food or on retiring,and if initial dose is increased gradually), anorexia, fever and skin reactions;taste loss (mineral supplements not recommended); blood disorders including thrombocytopenia, leukopenia, agranulocytosis and aplastic anaemia; proteinuria, rarely haematuria (withdraw immediately); haemolytic anaemia, nephrotic syndrome, lupus erythematosuslike syndrome, myasthenia-like syndrome, polymyositis (rarely with cardiac involvement), dermatomyositis, mouth ulcers, stomatitis, alopecia, bronchiolitis and pneumonitis, pemphigus, glomerulonephritis (Goodpasture syndrome) and erythema multiforme (Stevens-Johnson syndrome) also reported; male and female breast enlargement reported; rash (early rash disappears on withdrawing treatment—reintroduce at lower dose and increase gradually; late rash is more resistant—either reduce dose or withdraw treatment) Capsule or tablet: 250 mg

A/E:

P/A: 46

Medicines used for Gout

Dose:

Administered on expert advice ADULT : Rheumatoid arthritis initially 125–250 mg daily before food by mouth,for 1 month, increased by similar amounts at intervals of not less than 4 weeks to usual maintenance of 500–750 mg daily in divided doses;ELDERLY initially up to 125 mg daily before food for maximum 1.5 g daily;1 month increased at intervals of not less than 4 weeks; maximum 1 g daily Capsule 250mg (10) Rs 110/-

Cost:

MEDICINES USED TO TREAT GOUT

Acute gout
Acute attacks of gout are usually treated with high doses of a NSAID such as indomethacin (150–200 mg daily in divided doses); ibuprofen has weaker anti-inflammatory properties than other NSAIDs and is therefore less suitable for treatment of gout. Salicylates, including acetylsalicylic acid are also not suitable because they may increase plasma-urate concentrations.NSAIDs are contraindicated. Its use is limited by toxicity with high doses. It does not induce fluid retention and can therefore be given to patients with heart failure; it can also be given to patients receiving anticoagulants.

Chronic gout
For long-term control of gout in patients who have frequent acute attacks, the presence of tophi, or chronic gouty arthritis, the xanthine oxidase inhibitor allopurinol may be used to reduce production of uric acid. Treatment for chronic gout should not be started until after an acute attack has completely subsided, usually 2–3 weeks. The initiation of allopurinol treatment may precipitate an acute attack and therefore a suitable NSAID should be used as a prophylactic and continued for at least one month after the hyperuricaemia has been corrected. If an acute attack develops during treatment for chronic gout, then allopurinol should continue at the same dosage and the acute attack should be treated in its own right. Treatment for chronic gout should be continued indefinitely to prevent further attacks of gout.

Allopurinol
I: Prophylaxis of gout; prophylaxis of hyperuricaemia associated with cancer chemotherapy 47

very rarely. headache. hepatotoxicity. rarely malaise. blood disorders (including leukopenia. gynaecomastia. paraesthesia. renal impairment and. Initiate 2–3 weeks after acute attack has subsided and administer a suitable NSAID (not ibuprofen or a salicylate) or colchicine from the start of allopurinol treatment and continue for at least 1 month after hyperuricaemia corrected. doses over 300 mg daily given in divided doses NOTE.Prophylaxis of gout.in moderately severe conditions 300–600 mg daily. Prophylaxis of hyperuricaemia. neuropathy. l y m p h a d e n o p a t h y. seizures. started 24 hours before cancer treatment and continued for 7–10 days afterwards. adjusted according to response. hypertension. hypersensitivity reactions occur rarely and include fever. in severe conditions 700–900 mg daily. visual and taste disturbance. by mouth.gastrointestinal disorders. drowsiness. ADULT maintenance doses as for acute gout. withdraw treatment if rash occurs.00/- . alopecia.CHILD under 15 years 10–20 mg/kg daily (maximum 400 mg daily) Tablet 100mg (10) Rs 14. reintroduce if rash is mild but discontinue immediately if it recurs Rash (see Precautions above).Non-Steroidal Anti-Inflammatory Drugs C/I: P/C: A/E: P/A: Dose: Cost: 48 Acute gout. usual maintenance dose in mild conditions 100–200 mg daily. if an acute attack occurs while receiving allopurinol. vasculitis. erythema multiforme (StevensJohnson syndrome) or toxic epidermal necrolysis. continue prophylaxis and treat attack separately Ensure adequate fluid intake of 2–3 litres daily. hepatitis. vertigo. renal impairment (hepatic impairment. preferably after food.80-20. haemolytic anaemia and aplastic anaemia) Tablet: 100 mg. then adjusted according to plasma or urinary uric acid concentration. by mouth. pregnancy breastfeeding. arthralgia. thrombocytopenia. eosinophilia. ADULT initially 100 mg daily as a single dose.

paradoxical excitement. restlessness and confusion in the elderly and hyperkinesia in children. Hypersensitivity. 50-200 mg. rashes. vomiting. nystagmus and blurred vision are signs of overdose.V. children. repeated every 6 h if necessary.V. acute intermittent porphyria.00 Inj 200 mg/mL (10 x 1 mL) Rs. lethargy. impaired renal or hepatic function. antibacterials and anticoagulants.60 to 180 mg at night. Impaired liver function pregnancy and lactation. dizziness. or I. severe renal and hepatic disorders and severe myocardial damage. ataxia.00 -126. 4. tremor. Nausea. ataxia and allergic skin reactions. slurred speech.M. rarely dyskinesias. breast feeding. Reduced effect of antiarrhythmics.00 All forms of epilepsy especially tonic-clonic and partial seizure except absence seizure. intravenous administration for status epilepticus. transient nervousness and drowsiness occur commonly. Drowsiness. 60mg. Tab 30 mg (10) Rs. avoid sudden withdrawal. Elderly.3 ANTI CONVULSANTS/ANTIEPILEPTICS Phenobarbitone I: C/I: All forms of epilepsy and status epilepticus except absence seizures. Injection 200 mg/ mL Oral: Adult. infusion along with other drugs. maximum 600 mg daily. peripheral neuropathy. megaloblastic anaemia. headache. Parenteral : I. 125. debilitated. coarse 49 P/C: A/E: P/A: Dose: D/I: Cost : Phenytoin I: C/I: P/C: A/E: . A V block. Tablets 30mg.SECTION .M and it should not be added to I. mental depression. acute intermittent porphyria Phenytoin should not be given I. mental confusion. cyclosporine.00 — 6. Dilute injection 1 in 10 with water before. trigeminal neuralgia. respiratory depression. theophylline.

hypotension and heart blocks on IV administration (careful cardiac monitoring is required). seizures during neurosurgery. monitored by measurement of plasma concentrations.8 h. It increases degradation of steroids. as short term substitute for oral phenytoin. toxic epidermal necrolysis. Seizures on drug withdrawal. 9. sinus bradycardia. pregnancy. INH and warfarin inhibit phenytoin metabolism. Injection 50 mg/mL. Oral : Adult—initially 3-4 mg/kg daily or 150-300 mg daily as a single dose or in two divided doses increased gradually as necessary. Hypersensitivity to hydantoin derivatives. and Stokes-Adams syndrome. agranulocytosis.50. rarely hematological effects including megaloblastic anaemia ( may be treated with folic acid). oral contraceptives and theophylline. Maintenance doses of about 100 mg should be given thereafter at intervals of 6 .Antiepileptics P/A: Dose: D/I: Cost : facies. hirsutism. polyarteritis nodosa. lupus erythematosus. fever and hepatitis. lactation. gingival hypertrophy and tenderness.75 Status epilepticus. lymphadenopathy. Inj 50 mg/2 mL Rs. Parenteral : Adult-slow I. 9. as the loading dose. sino-atrial block. hypoalbuminemia. or infusion in status epilepticus. acne. potential to lower serum folate levels. porphyria. erythema multiforme (Stevens-Johnson Syndrome). with blood pressure and ECG monitoring in a dose of 15 mg/ kg at a rate not exceeding 50 mg per minute. Tablet 50 mg and 100 mg Capsule 100 mg.V. and aplastic anaemia. Tab 100 mg (10) Rs. leucopenia. plasma calcium may be lowered (rickets and osteomalacia). rate and dose reduced according to weight. second and third degree A-V block. Fosphenytoin I: C/I: P/C: 50 . thrombocytopenia. The usual dose 300-400 mg daily upto a maximum 600 mg daily. patients on phosphate restriction. renal and hepatic disease.

drowsiness.00 Inj 10mL Rs 140. Inj 2 mL Rs 30. abdominal pain. diplopia (may be associated with high plasma levels). pruritus / paresthesia (specially in the groin area). atrial/ventricular fibrillation. cardiac disease. glaucoma.Antiepileptics A/E: P/A: Dose: Cost: Cardiovascular collapse. history of blood disorders (blood counts before and during treatment). bipolar disorder Atrioventricular conduction abnormalities.00 Generalized tonic. male infertility. hepatitis. gastrointestinal intolerance including nausea and vomiting. breastfeeding. history of bonemarrow depression. somnolence. thromboembolism. fever. impotence. 10ml (fosphenytoin sodium 750 mg equivalent to 500 mg of phenytoin sodium) As phenytoin sodium equivalents (PE). commonly. renal impairment. cholestatic jaundice. lymph node enlargement. blurred vision. Injection 2ml (fosphenytoin sodium 150 mg equivalent to 100 mg of phenytoin sodium). pregnancy . hypotension. sinus bradycardia. Maintenance: initially 4-5mg PE/kg/day at a rate of 50-100 mg PE/ min. Dizziness. toxic epidermal necrolysis. acute renal failure.clonic and partial seizures. diarrhoea or constipation. anorexia. heart block. dry mouth. depression. arrhythmias. 51 Carbamazepine I: C/I: P/C: A/E: . headache. heart block and heart failure. nystagmus. trigeminal neuralgia. headache. skin reactions. and ataxia. arthralgia. subsequently adjust dose according to response and trough plasma phenytoin levels. loading dose is 15 to 20 mg PE/kg administered at 100 to 150 mg PE/ min (never faster than 150 mg PE/min). StevensJohnson syndrome (erythema multiforme). dyskinesias. central nervous system depression. ataxia. paraesthesia. porphyria Hepatic impairment. leukopenia and other blood disorders (including thrombocytopenia. agranulocytosis and aplastic anaemia). proteinuria. avoid sudden withdrawal. alopecia. dizziness. mild transient generalized erythematous rash (withdraw if worsens or is accompanied by other symptoms).

oedema. 600 mg 600mg/day initially in 2 divided doses. Decreased levels of other antiepileptics like phenytoin. diplopia. valproic acid.50 Monotherapy or adjunctive therapy in the treatment of partial seizures Hypersensitivity Pregnancy. cognition disturbances may interfere with ability to operate machinery. usual dose 200 mg 3–4 times daily with up to 1.8–1.00 Tab 300 mg (10) Rs 49.6–2 g daily may be needed ELDERLY reduce initial dose.00 . Generalized tonic-clonic seizures.00 .00 Oxcarbazepine I: C/I : P/C: A/E: P/A: Dose: D/I: Cost: 52 . 200 mg.2 g daily in divided doses. somnolence. Tab 200 mg (10) 16.00 .00 Tab 600 mg (10) Rs 90. Trigeminal neuralgia.120. initially 100–200 mg 1–2 times daily. dyspepsia. hypotension. vomiting. in some cases 1. h y p e r s e n s i t i v i t y to carbamazepine.Antiepileptics P/A: Dose: Cost: gynaecomastia. hypersensitivity (anaphylaxis / angioedema) Tablets 150mg. nystagmus.2400mg/day. pulmonary hypersensitivity. Dizziness. hyponatraemia. galactorrhoea.6 g daily in some patients NOTE. Plasma concentration for optimum response 4–12 mg/litre (17– 50 micromol/ litre) Tab 100mg (10)Rs7-10. aggression. initially 100 mg 1–2 times daily increased gradually according to response. calcium channel blockers like felodipine. maximum dose . activation of psychosis. ataxia.60. l a c t a t i o n . by mouth. photosensitivity. fatigue. disturbances of bone metabolism like osteomalacia also reported. hormonal contraceptives. confusion and agitation in elderly Tablet : 100 mg. maximum increments of 600mg/day at weekly intervals. increased gradually according to response to usual maintenance dose of 0. partial seizures. Tab 150 mg (10) Rs 27. by mouth. nausea. phenobarbitone.33. 300mg . hyponatremia. carbamezapine.

rashes. Active liver disease. increased libido. and may be tried in atypical. There is increased risk of neural tube defects and neonatal bleeding and neonatal hepatotoxicity if the 53 C/l : P/ C: A/E: P/A: Dose: Cost : Sodium Valproate I: C/I: P/C: . Gastrointestinal disturbances. and tonic seizures. severe renal impairment. particularly in primary generalised epilepsy. swelling of tongue. absence.Other side effects include gum hypertrophy. generalised absence and myoclonic seizures. myopia and vaginal bleeding. absence.00 All forms of epilepsy. 40. systemic lupus erythematosus. hepatic and renal changes and haematological disorders such as agranulocytosis and aplastic anaemia occur rarely. inability to concentrate. pregnancy.Antiepileptics Ethosuximide I: Drug of choice in simple absence seizures. It is effective in controlling tonicclonic seizures. and mild euphoria. photophobia. False positive urine tests for ketosis may occur. family history of severe hepatic dysfunction. ln patients receiving this drug exclude bleeding tendency before major surgery. Syrup 250 mg/5ml 20-30 mg/kg/day orally Syrup 50 mg /mL (114 mL) Rs. hiccup. irritability. atonic. hyperactivity. Psychotic states. breast-feeding. It is a drug of choice in primary generalised epilepsy. weight loss. headache. and tonic seizures. dizziness.Systemic lupus erythematosus and erythema multiforme may occur. dyskinesia. In addition pregnancy and breast feeding. it may also be used in myoclonic seizures and in atypical. acute porphyria. drowsiness. ataxia. sleep disturbances. Hypersensitivity Same as for carbamazepine. night terrors. depression. aggressiveness. atonic. Avoid sudden withdrawal. Monitor liver function before therapy and during the first 6 months especially in patients at higher risk.

preferably after food. Liver dysfunction including fatal hepatic failure has occurred in association with valproate (especially in children under 3 years of age). acute pulmonary insufficiency. Enhanced effect by aspirin. 46. Usually 20-30mg/kg body weight daily may be required upto a maximum of 35 mg/ kg daily. red cell hypoplasia. leucopenia. behavioural abnormalities in children. impaired hepatic function leading rarely to fatal hepatic failure. dizziness. amenorrhoea and gynaecomastia. increased appetite and weight gain.50. fibrinogen reduction. Gastric irritation.30 mg/ kg body weight daily). Respiratory depression. elderly and debilitated.50 Clonazepam has been primarily used in petitmal. 600 mg daily given in 2 divided doses. rarely pancreatitis.5 g daily in divided doses. irregular periods. increased by 200 mg/ day at 3 day intervals to a maximum of 2. sedation. hepatic and renal impairment. fatigue. transient hairloss. Tablet 200 mg and 500 mg Adult — initially. Respiratory disease. oedema.Antiepileptics A/E: P/A: Dose: D/I: Cost : drug is given during pregnancy. Enhanced toxic effects with other antiepileptics Tab 200 mg (10) Rs. Usual maintenance is 1-2 g daily (20. Children Upto 20 kg : 20mg/ kg bw daily in divided doses. lf doses above 40 mg/ kg daily are given it is preferable to monitor plasma levels. thrombocytopenia and inhibition of platelet aggregation. nausea. antagonism of anticonvulsant effect. Sedation. With antidepressants and antipsychotics. 27. pregnancy and breast feeding. dullness. It is also used as an adjuvant in myoclonic and akinetic epilepsy and may afford some benefit in infantile spasms. drowsiness. rashes. Over 20 kg : initially 400 mg daily in divided doses increased until control. Tab 500 mg (10) Rs. ataxia and tremor. muscle Clonazepam I: C/I: P/C: A/E: 54 . This may be increased depending on the response. porphyria.

Clobazam I: CI: Short term management of anxiety. ataxia. close monitoring during long term therapy is required. initially at night for 4 night. pregnancy. lactation. Metabolism of clonazepam accelerated by carbamazepine. nausea. Rash. nausea and vomiting. as an adjunct in epilepsy Hypersensitivity. myasthenia gravis.1 mg (elderly 500 mcg). liver failure. dizziness. hypersalivation in infants.60 Anticonvulsant — adjunctive therapy in the treatment of partial seizures in adults with epilepsy. anterograde amnesia. Lorazepam . respiratory depression. coordination disturbances. pruritus. urticaria. ataxia. pregnancy. drowsiness. Xerostomia. dizziness. Tab 2 mg (10) Rs. Muscle spasm. lethargy.10mg. slurred speech. dosage may be gradually adjusted (based on tolerance and seizure control) to a maximum of 80 mg/day. 20mg. history of drug dependence. pregnancy. phenobarbitone and phenytoin. depression. blood disorders.5 mg. 30. headache. Diplopia.42. 55 P/C: A/E: P/A: Dose: D/I: Cost: Lamotrigine I: C/I: P/C: A/E: . Tablets 0.00‘ Diazepam – See section 25 (Psychotherapeutic drugs). increased over 2-4 weeks to a usual maintenance dose of 4-8 mg daily in divided dose. Weight gain (2%). Hepatic and renal impairment. Orally 5-15 mg/day. 2 mg. Hypersensitivity. Driving.See section 25 (Psychotherapeutic drugs).Antiepileptics P/A: Dose: D/I: Cost: hypotonia. Drowsiness. elderly. Orally . sleep apnoea syndrome. impaired respiratory function. operating machines. Blurred vision (1%) Tablets 5mg. Decreased levels of drug is seen with phenytoin. confusion.00. during discontinuation of therapy. behaviour disorders. phenobarbitone and carbamazepine. lactation. impaired renal or hepatic function. tremor. constipation. Tab 10mg (10) Rs 43. Initial. children below 16 years.

Tablet 500mg With current antiepileptic therapy. 200 mg. tremor. then increased according to response to 1. Reduced absorption with antacids.00 Adjunctive treatment of partial seizures with or without secondary generalisation not satisfactorily controlled with other antiepileptics. 100 mg. Pregnancy and breast feeding Renal impairment. Mild. then 300 mg tds.50 – 313. 33. Capsule 300 mg and 400 mg. behavioural changes and agitation in children. generalised seizures. Starting dose of 25 mg hs. Gabapentin I: C/I: P/C: A/E: P/A: Dose: D/I: Cost : Vigabatrin I: C/I: P/C: A/E: P/A: Dose: D/I: 56 .2 g daily (in 3 equally divided doses).Antiepileptics P/A: Dose: D/I : Cost : Tablets 25 mg. then increased according to response in steps of 500mg.00 Simple and complex pastial seizures. drowsiness. Not recommended for children. 150 mg. also convulsions. Valproic acid blocks the elimination of lamotrigine. Somnolence. dizziness. Tab 25 mg (10) Rs. Causes a 20% decrease in plasma phenytoin concentration. amnesia. 98. The drug should be tapered off over at least 1 week. ataxia. mental confusion. Caps 300 mg (10) Rs. 300 mg on first day. closely monitor neurological functions. on third day. initially 1 g daily in single or 2 divided doses. usual range 2-4 g daily. Hypersensitivity Avoid sudden withdrawal. then 300 mg bd on second day. diplopia. avoid sudden withdrawal. increasing in 25 mg/ day increments at 2 week intervals to a maximum of 100 mg/day. nausea and vomiting.

100mg >16 yr: Initially. Usual dose: 200-400 mg daily. Daily doses >25 mg should be taken in 2 divided doses. contraceptive failure. pregnancy. weight loss. inborn errors of metabolism. memory difficulties. 25 mg at night for 1 wk increased by 25-50-mg increments at 1-2 wk intervals until effective dose is reached. hyperthermia. tiredness. Hypersensitivity. encephalopathy with valproate. renal calculi. acidosis. Possible increase in phenytoin levels. CNS depression with CNS depressants and alcohol. treatment of seizures associated with Lennox-Gastaut syndrome. gingivitis. acidosis. nystagmus. Dizziness. xerostomia. Dizziness. 57 C/I: P/C: A/E: P/A: Dose: D/I: Cost: Tiagabine I: P/C: A/E: . Max: 800 mg. breast feeding. careful withdrawal of the drug. prophylaxis of migraine. ataxia. confusion. abnormal vision. somnolence. influence psychomotor performance / ability to handle machines. Tablets 25mg. speech problems. Increased risk of renal stones with carbonic anhydrase inhibitors like acetazolamide. somnolence. hyperammonaemia and encephalopathy with valproic acid. phenobarbital decreases plasma concentration of topiramate. nervousness. children below 2 years. irritability. Tab 50mg (10) Rs 45. carbamazepine. psychomotor slowing. fatigue. tremor. Coadministration with antiepileptic drugs like phenytoin. nystagmus. lactation Hepatic or renal impairment. glaucoma. nervousness. dehydration. psychosis. diplopia.00 – 87.Antiepileptics Topiramate I: Adjunctive / monotherapy for partial seizures and primary generalized tonic-clonic seizures. maintain adequate hydration to avoid renal stones. 50mg. concurrent valproate therapy. pregnancy.00 As adjunctive for refractory partial seizures with or without secondary generalisation Hepatic impairment. depression.

Anorexia. Somnolence. headache. rash. Tab 50mg. tremor. pregnancy. lactation. renal calculi. 10mg.189.00 Adjuvant in the treatment of partial seizures with or without secondary generalisation. breast feeding. 82. In myoclonus including juvenile myoclonic epilepsy and for atonic and tonic seizures. diplopia.weakness.Antiepileptics P/A: Dose: D/I: Tab 5mg. Cap (10) Rs. Tab 250mg. somnolence. Second line drug in generalized tonic clonic seizures. insomnia. phenytoin or primidone. Adjunctive anti epileptic in partial seizures.00 . ataxia. 15mg Children >12yrs and adults – 5mg BD oral for one week. 200mg Adults >18yrs 50mg daily in two divided doses increased to 100mg daily. Maximum dose 3g daily. hemodialysis patients. Hypersensitivity to sulfonamides. Tab 100mg. diarrhea. increase weekly 5-10mg increments. Tab 250mg (10) Rs 92. Increased according to response to a maximum of 600mg. pregnancy. Hepatic renal impairment and history of nephrolithiasis.00 . nausea. amnesia. anorexia. phenobarbitone. Steven Johnson’s Syndrome. 750mg Initial adult dose 1g on the first day thereafter daily dose may be increased in increments of 1g every 2-4 weeks according to response. Renal/hepatic impairment. maximum of 3045mg daily in three divided doses.96.00 Zonisamide I: C/I: P/C: A/E: P/A: Dose: Cost: Levetiracetam I: P/C: A/E: P/A: Dose: Cost: 58 . emotional lability. vertigo. skin reactions. dizziness. 500mg. Plasma concentration of the drug is decreased (upto three fold) by carbamazepine.00 Tab 500mg (10) Rs 180.

dyspepsia. Orally 1. Hypersensitivity. 150mg Cap 75mg (10) Rs 68. nausea. Metabolism is increased by phenytoin. vomiting.6g daily if necessary (monotherapy). Rarely increase in creatinine kinase and rhabdomyolysis. To be used only in severe refractory epilepsy because of risk of fatal aplastic anemia or acute liver failure. phenobarbitone and carbamezapine. Used as an adjunct in partial seizures with or without secondary generalization. erectile dysfunction. rash.00 Cap 150mg (10) Rs 129. diplopia. somnolence.00-75.2g daily in three or four divided doses. elderly. maximum of 3. blurred vision.Antiepileptics Felbamate I: Unresponsive cases of epilepsy.00 59 C/I: P/C: A/E: Dose: D/I: Pregabalin I: C/I: P/C: A/E: P/A: Dose: Cost: . refractory partial seizures with or without secondary generalization. neuropathic pain. somnolence. Care in operating machinery. insomnia. Aplastic anemia and acute liver failure. weight loss. 150mg. 300mg Initially in epilepsy 150mg daily. Cap 75mg. breastfeeding. Pregnancy. renal impairment. ataxia. irritability. dizziness. memory and coordination. In children as an adjunctive therapy in seizures associated with Lennox Gastaut Syndrome History of blood disorders and hepatic impairment. Tab 75mg. Disturbances of attention. increased appetite. Anorexia. generalized anxiety disorder. pregnancy and lactation. diplopia. headache. Half life is prolonged by Gabapentin. increase after 1 week according to response to 300mg daily maximum 600mg/ day. care in withdrawing therapy Dizziness. weght gain. increments of 600mg every 2 weeks.00-139. Oral contraceptive failure/breakthrough bleeding. Photosensitivity and rarely Steven Johnsons Syndrome.

hypotension. respiratory depression.Antiepileptics Magnesium Sulphate: Prevention of recurrent seizures in eclampsia. ADULT and ADOLESCENT initially 4 g over 5–15 minutes followed either by intravenous infusion. ADULT and ADOLESCENT initally 4g over 5–15 minutes followed either by intravenous infusion. muscle weakness P/A: Injection: 500 mg/ml in 2-ml ampoule. confusion. prevention of seizures in pre-eclampsia P/C: Myasthenia gravis. arrhythmias.5 parts of water for injection). coma. if seizure occurs. flushing of skin. loss of tendon reflexes. for intramuscular injection. 1 g/hour for 24 hours or by deep intramuscular injection 5 g into each buttock then 5 g every 4 hours into alternate buttocks for 24 hours. by intravenous injection. I: 60 . renal impairment. by intravenous infusion. vomiting. drowsiness. additional dose by intravenous injection of 2 g DILUTION AND ADMINISTRATION: According to manufacturer’s directions for intravenous injection concentration of magnesium sulfate should not exceed 20% (dilute 1 part of magnesium sulfate injection 50% with at least 1. nausea. thirst. 500 mg/ml in 10-ml ampoule. pregnancy A/E: Generally associated with hypermagnesemia. recurrence of seizures may require additional intravenous injection of 2 g (4 g if bodyweight over 70 kg) Prevention of seizures in pre-eclampsia. mix magnesium sulfate injection 50% with 1 ml lidocaine injection 2%. Dose: Prevention of recurrent seizures in eclampsia. 1 g/hour for at least 24 hours after the last seizure or delivery (whichever occurs later) or by deep intramuscular injection 5 g into each buttock then 5 g every 4 hours into alternate buttocks for at least 24 hours after the last seizure or delivery (whichever occurs later). hepatic impairment.

SECTION . Note: Whenever possible penicillin should be administered only after testing for hypersensitivity to avoid unexpected fatal reactions. ln any case drugs for emergency resuscitation such as adrenaline. 1 MU injection(powder for reconstitution) Dose: 0.5-5 MU IM or IV 6 – 12 hourly D/l: Probenecid reduces urinary excretion of penicillins.pharyngitis. Procaine penicillin Phenoxymethyl penicillin (Penicillin V) Benzyl penicillin (Penicillin G) l: Acute tonsillitis. 61 .5. Jarisch Herxheimer reaction is seen in syphilitic patients. Paraesthesia with prolonged use.Renal impairment A/E: Anaphylaxis. hydrocortisone and IV glucose. lf the test is negative 10. m e n i n g o c o c c a l and pneumococcal meningitis C/I: Hypersensitivity to penicillin.4 ANTIINFECTIVE DRUGS ANTIMICROBIALS PENICILLINS Highly effective against gram positive bacteria BENZYL PENICILLIN AND ITS CONGENERS Benzyl penicillin (Penicillin G) Benzathine penicillin. So it can increase blood levels of penicillin. Nausea on oral ingestion P/A: Sodium Penicillin G(Crystalline Penicillin)0. Pain at IM injection site. P/C: History of allergy. and respiratory support should be available at hand. A drop of weak solution containing 1000 unit / ml is tested on the forearm by a scratch test. lf there is no reaction up to 30 min the drug may be given parenterally.Serum sickness like reactions.otitis media.pneumonia.000 units is given by intra dermal test.streptococcal endocarditis.

8 g as a single dose given at 2 injection sites in Gonorrhoea.avoid in new born infants As for Benzyl Penicillin 0. Pneumonia As for Benzathine Penicillin As for Benzyl Penicillin.00 8.000 units/vial (powder for reconstitution) 900 mg Benzathine penicillin is approximately equivalent to 720 mg of Benzyl Penicillin(1. Syphilis.6 lakh units(450 mg) IM repeated every 34 weeks Benzathine penicillin lnj 24 lac units (vial) Rs. Anthrax.000 and 1.Antiinfective Drugs Cost: Benzyl penicillin lnjection 10 lac units (vial) Rs. 1 MU dry powder and vial Adult-0.penicillin sensitivity test must be done before use.upto 4.00 18. 7. Syphilis:1.5.00 Should be restricted to organisms that are highly sensitive to penicillins. As for Benzyl Penicillin Injection 600.6-1.200.8 g deep IM at weekly intervals for 3 consecutive weeks. 16.Prophylaxis of Rheumatic Fever.00 Pharyngitis.2 million units) Adult Rheumatic fever 12 lakh units (900 mg) deep IM repeated every 3-4 weeks Syphilis:24 lakh units 1. Child:upto 2 years with congenital Syphilis:50 mg/kg of Procaine Penicillin deep IM once daily per vial Rs-28-30/- Benzathine penicillin I: C/I: P/C: A/E: P/A: Note: Dose: Cost: Procaine penicillin I: C/I: P/C: A/E: P/A: Dose: Cost: 62 .2 g of Procaine Penicillin deep IM daily in 1 or 2 divided doses. Child:<30 kg. Gonorrhoea.treatment may be continued for 3 weeks in patients with late Syphilis.Syphilis As for Benzyl Penicillin.2 g IM daily for 10-15 days.should not inject intravascularly As for Benzyl Penicillin.not recommended in neurosyphilis due to its inadequate penetration into CSF.

500 mg.increase upto 750 mg in severe infections.nausea.500 mg IM/slow IV every 4-6 hours Caps 250mg (10) Rs.chronic bronchitis.Pencillins Phenoxymethyl penicillin (Penicillin V) Dose: Cost: Cloxacillin I: C/I: P/A: Infections due to penicillinase resistant staphylococci P/C: A/E: D/I: Similar to that of Benzyl penicillin Capsules 250 mg.rashes Capsules 250 mg.10. Injection 250 mg.00.36. 6. 250-500 mg orally 4 times daily half an hour before food. injection. Caps 500 mg (10) Rs. As for of benzyl penicillin. invasive salmonellosis and gonorrhea.5g 1.23.500 mg slow IV every 4-6 hours.00 .00 Injection 500 mg (vial) Rs.otitis media. 63. respiratory tract infections. syrup) with ampicillin in different ratios are available. 500 mg(Powder for reconstitution) Combination preparations (tablet.250 mg IM every 4-6 hours.00 – 110. 78.00 .sinusitis.00 Infections caused by beta lactamase producing organisms Injection Ampicillin1g + Sulbactam 0.00 500 mg every 6 hours orally. Penicillin hypersensitivity As for of benzyl penicillin. 32. 250 mg (10) Rs:13. 500 mg Injection 500 mg/vial (Powder for reconstitution) 250 mg-1 g 6 hourly atleast 30 minutes before or 2 hours after food.diarrhoea.00 63 C/l: P/C: D/I: A/E: P/A: Dose : Cost: Ampicillin + Sulbactam I: P/A: Dose: Cost: .5g vial Rs.00 -10.50/- Beta lactamase resistant penicillins Dose: Cost: Broad spectrum penicillins Spectrum of Penicillin G + activity against g –ve bacteria Ampicillin I: Urinary tract infection. Injection 250 mg (1 vial) Rs.5 – 3 g IV/deep IM 6-8 hourly Injection Ampicillin1g + Sulbactam 0.

clavulanic acid are available 500 mg 8th hourly atleast 30 minutes before or 2 hours after food. 2g. 67.500 mg IM/slow IV every 4-6 hours Caps 500 mg (10) Rs.Piperacillin + Tazobactam also available 2 g 6 hourly or 8 hourly IV Piperacillin may inactivate aminoglycosides.Antiinfective Drugs Ampicillin + Cloxacillin I: P/A: Infections caused by beta lactamase producing organisms Capsule 500mg (250 +250) Syrup 125mg/5ml (30ml) Injection 500mg (250 + 250).1g (500mg+ 500mg) 1 Cap (250mg Ampicillin + 250 mg Cloxacillin)4-6th hourly Capsule 500mg (10)Rs. 500 mg Combination preparation with cloxacillin.20. Similar to that of Ampicillin Capsule 250 mg.00 -86.00 Infections due to Pseudomonas and Proteus species As for Benzyl penicillin Injection 1 gm vial 3g IV every 6-8 hours Ticarcillin+Clavulanic acid CEPHALOSPORINS First generation Cephalosporins g+Cocci>g-Bacilli>g+Bacilli>-Cocci 64 . 500 mg Injection 250 mg. 260.00 Inj 250 mg (1 vial) Rs. Injection lg. 13. 4g vials .00 Similar to ampicillin. 31. Inj 2 g (vial) Rs.00 Dose: Cost: Amoxycillin I: C/I:P/C:A/E:D/I: P/A: Dose : Cost: Antipseudomonal Penicillins Piperacillin I: C/I:A/E: P/C: P/A : Dose : D/ I: Cost: I: C/I:P/C:A/E: P/A: Dose: Infections due to pseudomonas and klebsiella.Renal impairment. As for benzyl penicillin. As for benzyl penicillin.00 .

Hypersensitivity Penicillin sensitivity.Cefuroxime axetil oral 250 and 500 mg capsule Injection 3g 8h. 80.00 .g-Bacilli and Anaerobes>g+Cocci and g+Bacilli Cefotaxime I: C/I:P/C:A/E: P/A : Dose : Cost : Cellulitis. 26.Skin and soft tissue infections due to S.50/Upper respiratory tract infections.Cefotaxime + Sulbactam also available 1-2 g IM or IV 12 h Inj 1g vial (5ml) Rs. pyogenes.00 C/I:P/C:A/E: P/A: Dose: Cost: Third generation Cephalosporins g-Cocci. aureus and S. urinary tract infections and soft tissue infections As for Cephazolin Capsule 250 mg.respiratory and urinary tract infections.00 – 130. surgical prophylaxis. Injection 500 mg (vial) Rs.1 g IM/IV every 6 . 500 mg vials. 500 mg .also includes Anaerobes Cefuroxime I: Upper respiratory tract infections. 46.gonorrhoea As for Cephazolin Injection 250mg.Oral 250 mg twice daily Cap 250 mg (4) Rs. 500 mg.Cephalosporins Cephazolin I: Surgical prophylaxis where skin flora are the likely pathogen. 70.meningitis.00 65 . intra abdominalinfections As for Cephalexin Injection 250 mg.00/- C/I: P/C: A/E: P/A: Dose: Cost : Cephalexin I: C/I:P/C:A/E: P/A: Dose : Cost: Second generation Cephalosporins g-Cocci/g-Bacilli>g+cocci>g+Bacilli.Renal impairment Skin rash. urinary tract infections and soft tissue infection.4gm daily in 4 divided doses Cap 500 mg (10) Rs. septicaemia. meningitis.120. 1 .500mg vial.12 hours.GI disturbances Injection 500 mg and 1 g vial.

00 Skin and soft tissue infection. 334. Urinary tract infections. Enteric fever. septicaemia. GI infections As for Cephalexin. Injection 1g vial Rs. 62.00 – 90. respiratory infections. 1g(Powder for reconstitution) 1g IM/IV every 8 hours or 2 g every 12 hours. As for Cephalexin Tablet 100mg. respiratory tract infection. septicaemia.rise in liver enzymes Injection 250mg.skin and soft tissue.00/Infections caused by pseudomonas & bacteroides like urinary tract infections. severe respiratory infections. otitis media gonorrhoea. meningitis.Reversible neutropenia Disulfiram like reaction with alcohol Injection 250mg. urinary tract infections. 1g 1-2g IM/IV every 12 hour Injection 1g vial Rs. 150.Antiinfective Drugs Ceftriaxone I: Gonorrhoea.bone and joint infections As for Cephalexin.84. 200mg 200 -400mg orally 12hourly Tablet 200mg (10) Rs. urinary tract infections. 500mg. Lower respiratory tract infections. Endocarditis.00 C/I:P/C:A/E: P/A: Dose: Cost: Ceftazidime I: C/I: P/C:A/E: P/A: Dose: Cost: Cefoperazone I: C/I:P/C:A/E: D/I: P/A: Dose: Cost: I: Cefpodoxime proxetil C/I:P/C:A/E: P/A: Dose: Cost: 66 . Surgical Prophylaxis As for Cephalexin Injection 500 mg and 1 g(Powder for Injection) 1 g IM/IV daily as a single dose Typhoid fever 4 g IV daily for 2 days followed by 2 g daily till 2 days after fever subsides Injection 1g vial Rs. Meningitis.00 Pseudomonal infections like pneumonia. skin & soft tissue infections.Pain at injection site. meningitis. 500mg.

renal impairment. pseudomembranous colitis.00/- Cefixime Capsules 200mg. urinary tract infections. breastfeeding. ENT and skin infections As for Cephalexin Capsule 300mg 300mg twice daily Capsule 300mg (10) Rs. CNS disorders. pregnancy. Patients known to be hypersensitive to other betalactam antibiotics.history of Penicillin or Cephalosporin allergy Rash GI disturbances. 2g(Powder for reconstitution) 1-2 g IV every 12 hours for 7-10 days Same as Cefipime. no Anaerobes No g +Bacilli P/A: Dose: Cefepime I: C/I: P/C: A/E: P/A: Dose: Hospital acquired pneumonia. 400mg 200-400mg orally twice daily Fourth generation cephalosporins g-Cocci and g-Bacilli resistant to 3rd generation>cocci as of 3rd generation. septicemia Hypersensitivity Severe renal impairment.taste disturbance shortly after injection Injection 1g vial(Powder for reconstitution) 1-2g IV/IM every 12hours Other betalactam antibiotics Treatment of aerobic and anaerobic gram +ve and gramve infections. chronic bronchitis.elevation of liver enzymes. Hypersensitivity reactions.Pencillins Cefdinir I: C/I:P/C:S/E: P/A: Dose: Cost: Pneumonia. GI disturbances. 67 Cefpirome I: C/I:P/C:A/E: P/A: Dose: Imipenem + Cilastatin I: C/I : P/C: A/E: .surgical prophylaxis.Neutropenia Injection 1g. hospital-acquired septicaemia. intra abdominal infections. Hypersensitivity to imipenem or cilastatin. 250.

convulsions.Antiinfective Drugs P/A : Dose : abnormalities in haematological parameters. Pain and thrombophlebitis at the injection site. increase in serum creatinine and blood urea. respiratory . seizures. History of hypersensitivity to other beta-lactam antibiotics.5g. GI disturbances.myoclonic activity. every l2 hours in mild to moderate infections. I. confusion and mental disturbances reported.Shigella. biliary. lactation. disturbances in LFT 500mg and 1 g vial( Powder for reconstitution) Injection 500-1 g 8 hours IV Hospital acquired infections originating from urinary.V(as imipenem) 1-2g daily in 3-4 divided doses.00 Meropenem: I: C/I: P/C: A/E: P/A: Dose: Aztreonam I: C/I: P/C: A/E: P/A: Dose: Cost: AMINOGLYCOSIDES Mainly effective against gram –ve aerobic bacilli(E Coli. 2g vial 1-2 g. Anaphylaxis. rarely hepatitis. lactation Renal and hepatic impairment. 450. max. pruritus. neurological disorders. positive Coomb’s test.seizures 0. infants <3 months. slight increase in liver enzymes and bilirubin reported.M(as imipenem) 500-750mg.Proteus including Enterobacter and Pseudomonas aeruginosa except salmonella) They exhibit synergism when combined with a betalactam Streptomycin:(Refer section 27) 68 .GI and female genital tract Hypersensitivity. hepatic and renal in sufficiency. pseudomembranous colitis. Injection. 500mg/vial as imipenem (powder for reconstitution) I. 1g. 6 – 8h 1g vial Rs. 250mg/vial. taste disturbances. 4g or 50mg/kg daily Aerobic and Anaerobic gram + and gram – infections Hypersensitivity. pregnancy.Klebsiella. pregnancy. allergic reactions.

00 — 17. lnjection 50mg/mL 2mL ampoule.staphylococci Hypersensitivity. 2mL ampoule 69 C/I:P/C: A/E: P/A: Dose: D/I: Cost: Netilmicin I: C/l: P/C: A/E: P/A: .Neuromuscular blockers increase muscle weekness. enterococcal endocarditis (gram-negative bacillary species.coli or proteus and mycoplasma).100 mg/mL.Aminoglycosides Gentamicin I: Urinary tract infections. serious systemic infections (enterobacteriaceae. 16.5 g daily in life threatening infections Loop diuretics increase nephrotoxicity and ototoxicity. Pregnancy. atypical mycobacterial infections Same as gentamicin Injection 100mg/2ml Injection 15 mg/kg IM or slow IV daily in 2-4 divided doses upto a maximum 1. myasthenia gravis. Neurotoxicity and nephrotoxicity Same as other aminoglycosides.5 mg/kg IM/IV daily in 3 divided doses Inj 40 mg/ml (2 ml) Rs.and gentamicin resistant pathogens).00 C/I: P/C: A/E: P/A: Dose: Cost: Kanamycin:(Refer section 27) Amikacin l: Serious nosocomial gram negative infections resistant to Gentamycin and Tobramycin.8.peritonitis. klebsiella. lactation and known sensitivity to the drug. reduced dose in elderly and children. second line treatment of T. groupA beta haemolytic streptococci. and staphylococci).B. pneumonia (caused by pseudomonas aeruginosa. hearing disorders. Nephrotoxicity. Klebsiella. E. Renal insufficiency. but milder. irreversible ototoxicity. 7.00 .Synergism with penicillins.00 Urinary tract infections. Injection 40 mg/ mL 2 mL vials Injection 2 . meningitis ( specially pseudomonas and acinetobacter ). cephalosporins and newer beta lactam antibiotics Inj 100 mg (vial) Rs.

malabsorption and superinfection.5% 0. Ointment 0. Increased risk of toxicity on application to large area.00 . Same as aminoglycosides.00 — 8.00 . Malabsorption syndrome on chronic use.in severe infections upto 7. Tablets 500 mg. Mycoplasma pneumonia.5 mg daily in divided doses every 8 hours. Vibrio cholera etc 70 . Ointment 0.Antiinfective Drugs Dose : D/I: Cost: Injection 4-6 mg/kg IM/IV as a single dose or in divided doses every 8 or 12 hours. rashes.00 BROADSPECTRUM ANTIBIOTICS Neomycin I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Framycetin I: C/I: P/C: A/E: P/A: Dose: D/I: Cost : Tetracycline Almost all g+ve and g-ve Cocci have become resistant except for Neisseria gonorrhea. Chlamydia.Capsules 350 mg. Same as streptomycin.5 % ointment for staphylococcal skin infections & nasal carriers of staphylococci. 6. Adjunct for hepatic coma. Spirochetes. irritation and itching. blepharitis and keratitis.68. Hypersensitivity. 67. and those with renal failure. ocular infections like conjunctivitis. use with caution in elderly and children. 26. ln] 50 mg (1mL) Rs.Ointments/creams 5 mg/g 0. Hypersensitivity and renal impairment. resistant infection.00 Staphylococcal skin infections and nasal carriers of staphylococci. Hypersensitivity reactions. perforated ear drum.30. Contact dermatitis. otitis externa. Cap 350 mg (10) Rs.1g bd for sterilizing bowel. nephrotoxicity and ototoxicity.Highly active against Rickettsiae.5% (5g) Rs.00 Topical application for burns. Burns. ulcers. Preparation of the bowel for surgery. Same as streptomycin.25 .

children less than 8 years.00 . 16.00 Same as for Tetracyclines Capsule 100 mg 200 mg (single dose) on day one followed by 100 mg o. Supplementation of B complex factors is necessary since long term therapy suppresses the intestinal bacteria. With caution in elderly and patients with benign intracranial hypertension. nail discoloration etc. cystic fibrosis and infections resistant to other antibiotics. SLE. Gl disturbances.00 . klebsiella. renal impairment.Superinfection with proteus. Impaired renal/ hepatic function and hypersensitivity.mycoplasma and ureaplasma infections. 71 Doxycycline I:C/I:P/C:A/E: P/A: Dose: Cost : Minocycline A/E: P/A: Dose: Chloramphenicol I: .. Caps 100 mg (10) Rs. Oral : 250 . lactation.Broad spectrum antibiotics I: C/I: P/C: A/E : P/A: Dose: Cost: Rickettsia. Tetracycline orthophosphate deposits on developing teeth and bones.23. pseudomonas or clostridium may occur. 12. chronic respiratory infections by H influenzae. In long term therapy hepatic.d. blood dyscrasias. Severe infections 100 mg bd. pregnancy.500 mg 6 hourly Take on an empty stomach 1 h before or 2 h after food with one glassful of water. plague. weight loss. superinfection. pancreatitis.13. Caps 250 mg (10) Rs. candida albicans. photosensitivity. hepatic failure. brucellosis. meningitis(H.influenza).00 Vestibular toxicity 50 and 100 mg capsules 200mg initially 100 -200 mg once daily Enteric fever. Intolerance eg. for 5-10 days.500 mg. Capsule 250 mg. rashes. renal and haemopoietic function should be monitored.

22.00 Capsules 250 mg (10) Rs. mycoplasma pneumonia. blood dyscrasias. 5. weakness. Chloramphenicol may inhibit the antibacterial effect of penicillins.00 .qds. 0.Acid fast Bacilli like MAC and M leprae. mastitis. IV in 4 divided doses Ear infection .other organisms like Mycoplasma pneumonia and Chlamydia trachomatis Erythromycin I: 72 Acute bacterial pharyngitis.Clostridium tetani.) Rs. oral antidiabetics. Eye Drops 0. Ointment 1 % Ear Drops 5 % Adults: 50 mg/kg/ day oral. Pertussis. Tablet 250 mg Capsules 125 mg.g +ve Bacilli like C diphtheria. bone marrow depression. IM. Blood examinations to be done periodically. 1 %.H influenzae. Paracetamol may prolong the duration of action of chloramphenicol. pregnancy. oral anticoagulants. cellulitis.Spirochetes like Tryponema pallidum. 1 g Applicaps 1 %.5.10. 8.00 Ointment 1 % (3 g) Rs. Use with caution in renal or hepatic diseases.Antiinfective Drugs C/I: P/C: A/E: P/A: Dose: D/l: Cost: Hypersensitivity.00 Ear Drops 5 % (5 ml) Rs. lactation and porphyria. diphtheria.B anthracis.00-10. otitis.00 . minor infections. 500 mg Syrup 125 mg/ 5 ml Injection 500 mg. Eye infection .C jejuni and H pylori. tingling. 5. optic neuritis. Phenobarbitone and rifampicin may reduce the effect of chloramphenicol. nocturnal haemoglobinuria. Bone marrow depression. tonsillitis.00 MACROLIDES Spectrum similar to penicillin including g-ve Cocci like N gonorrhea and M catarrhalis.00 . impaired vision.00-24.7.4.00 Eye Drops 1 % (5 ml) Rs. 8.25. . 18. irreversible aplastic anaemia. Grey syndrome.2 to 3 drops bd .00 Applicaps 1 % (50 Nos. Tablet 250 mg (10) Rs.tds. 250 mg.g-ve Bacilli like Legionella.00 -6. peripheral neuritis.use drops or ointment bd.H ducreyi. Increases the effect of phenytoin. sinusitis.

00 Oint 3% w/w (10 g) Rs. 73 Clarithromycin I: C/l : . warfarin Antagonises effect of chloramphenicol .Rash. acne. Patients on terfenadine or astemizole. safety in pregnancy and lactating period is not established. 3% w/w Gel 4% w/ w 250-500 mg orally 6th hourly Increased risk of cardiotoxicity with increased plasma concentration and toxicity of carbamazepine. pylori. astemizole. history of jaundice. tetanus in patients allergic to penicillin. Capsules 250 mg Ointment 2% w/w. prophylaxis before dental procedure. endemic trachoma. cyclosporin. nocardiosis. 15. Tablet 250 and 500 mg.16. cardiac abnormality or electrolyte disturbance. Hypersensitivity to erythromycin. leptospirosis. nocardiosis. Lyme disease.Macrolides C/l: P/C: A/E: P/A: Dose: D/l: Cost: pertussis. Cholestatic hepatitis and history of hepatic disease.00 Cream 3% w/w (20 g) Rs.00 Mycoplasma pneumoniae. atypical mycobacterial infection. pregnancy.00 .00 Gel 4 % w/w (20 g) Rs. Campylobacter jejuni enteritis. legionellosis. 37. upper and lower respiratory tract infections. digoxin. Gl upset. mycobacterium leprae. H. relapsing fever. community acquired a typical pneumonia.00 . valproic acid. endocarditis. statins. lincomycin and penicillins Increased potential for ototoxicity with other ototoxic medications in patients with renal impairment Caps 250 mg (10) Rs.41.42. terfenadine.lactation. skin and soft tissue infections. community acquired pneumonia. 29.00 . theophylline. Hypersensitivity. hepatitis Available as Erythromycin estolate and Erythromycin stearate.42. prophylaxis against MAC. 40.00 .

tonsilitis. hyperactivity. 110. prophylaxis against mycobacterium avium complex (MAC). 250-500 mg twice daily Same as for erythromycin. flatulence. lactation and children. pregnancy. increases half life of midazolam. Tab 150 mg (10) Rs. 500mg. oral for 10 .00 Pneumonia. skin rash. prolongation of QT interval As for Erythromycin Tablet 250 mg. transient rise in liver transaminases.Genital chlamydial infection.130.Liquid 50 mg/ 5 mL. pharyngitis.00 . Zidovudine delays the action. Hypersensitivity Impaired liver or renal function.. mycoplasma pneumonia. agitation.00 High activity against respiratory pathogens. diarrhoea.00 . 150 mg bd.More active against H influenza. 70. sinusitis. Tab 250 mg (4) Rs. 150 mg. or 300 mg od. dizziness. non-tuberculosis mycobacteria.Antiinfective Drugs P/C : A/E: P/A : Dose : D/I: Cost : Caution should be exercised in patients with impaired hepatic function or with moderate to severe renal impairment. Nausea. headache.140. vomiting. anorexia. pancreatitis. Roxithromycin · I: C/I: P/C: A/E: P/A: Dose : D/I: Cost : Azithromycin I: C/I: P/C: A/E: 74 . drowsiness. (Higher concentration achieved in pulmonary. syncope. Rifampicin decreases serum concentration of clarithromycin. community acquired typical pneumonia. increases serum level of terfenadine leading to ventricular arrhythmias. acute bronchitis.14 days. As for Erythromycin. not recommended in children. constipation. 300 mg. prostate and tonsilar tissue and in tear and pleural fluid) Concomitant use of ergotamine type compounds Hepatic dysfunction. Increases the absorption of digoxin. Tablet 50 mg. displaces disopyramide from its protein binding sites. genital infection. anxiety. dyspepsia.

paraesthesia. and taste disturbances Tablet 250-500 mg film coated 500 mg once daily for 3 days Antacids decrease the peak serum concentration of azithromycin. tinnitus.Have excellent activity against Corynebacterium acnes. 15. encephalitis by toxoplasma. It can be used as an alternative to penicillin. skin infections.5 million IU (10) Rs. mild neutropenia.(except enterococci) and staphylococci(except MRSA).00 Spiramycin Spectrum similar to Erythromycin. Food reduces bioavailability. thrombocytopenia. Repeated at 2 weekly intervals till delivery. B .9 million IU (4 . Nausea.toxoplasmosis during pregnancy. hepatitis. asthenia.4 divided dose for 3 weeks.Clostridium(except Clostridium difficile)and other anaerobes are usually susceptible.5 million IU.00 D/I: Cost: Clindamycin Highly active against streptococci.Macrolides P/A: Dose: D/I: Cost: photosensitivity. lung abscess. convulsions. peritonitis. Meningitis. acute renal failure. hepatic failure. acne vulgaris. hypersensitivity . warfarin and digoxin. tongue discoloration.6 . 3 million IU Toxoplasmosis in pregnancy . urticaria. 75 . benign hepatitis.fragilis . urethritis. pneumococci. endocarditis. I: Intra abdominal abscess.00 . abdominal pain. interstitial nephritis. Tab 250-500 mg (1 tablet)Rs. prostatitis. UTI. hepatic necrosis. Tab 1. 47. highly efficacious against Toxoplasma gondii I: C/I: P/C: A/E: P/A : Dose: Respiratory infections. malaria. arthralgia. Same as for erythromycin. vomiting. pelvic abscess.00 — 25.6 tab) in 2. Tablet 1.51. It increases blood level of theophylline and carbamazepine.

Tablet 50mg Injection 0.Antiinfective Drugs C/I: P/C: A/E: P/A: Dose: Diarrhoeal states Chronic liver disease. disseminated staphylococcal infection. infective endocarditis. anaphylaxis. granulocytopenia.4 ml vials Adults . sensorineural deafness. Generalized cutaneous rash caused by histamine release if administered rapidly IV. Antagonism of oral vancomycin by cholestyramine. orally.6-2. increased risk of nephrotoxicity with aminoglycosides and cephalosporins notably cephalothin. skin rash.Enterococci etc I: MRSA.150 to 300 mg 6 hours upto 450 mg every 6 hours in severe infections Parenteral . endocarditis due to enterococcus fecalis and in pseudomembranous colitis. pseudomembranous colitis. r e d n e c k syndrome characterised by sudden fall in BP with or without maculopapular rash over the face and upper body. osteomyelitis. Stevens Johnson syndrome.v. infusion. 1 g per ml vial (Powder for reconstitution) 2 g daily in 2-4 divided doses Pseudomembranous colitis .0. ototoxicity partly reversible. infections in patients with end stage renal disease(ESRD) or on hemodialysis or peritoneal dialysis. nephrotoxicity. In severe hepatic and renal impairment .7 g/ day IM/IV in 2 -4 divided dose Vancomycin Active against aerobic as well as anaerobic g+ve species such as Streptococci as well as Staphylococci(including MRSA).empyema. local thrombophlebitis. pregnancy. increased risk of ototoxicity with loop diuretics. cardiac arrest with rapid i.5 mg. P/C: A/E: P/A: Dose: D/I: 76 . renal disease. Capsule 150 mg Injection 150 mg/ mL 2ml. oesphageal ulceration. lactation Diarrhoea. hepatic enzyme elevation.125 to 500 mg 6 h. Local thrombophlebitis. inhibit neuromuscular transmission.

transient eosinophilia.00 TEICOPLANIN Spectrum same as for Vancomycin I: Potentially serious gram positive bacteria especially MRSA. 70.Serratia and Neiserria are inhibited I: Topically – usually in combination with other antimicrobials for skin infections.all except Proteus.burns.Streptococci and L monocytogenes(g +ve aerobes)G-ve aerobes are not sensitive anaerobes are resistant.00 .conjunctivitis and corneal ulcer 77 .Folliculitis. Reduce dose in renal insufficiency.Impetigo. pruritus. in penicillin and cephalosporin allergic patients.Teicoplanin Cost: Tab 50 mg (10) Rs.00 Inj 0. 255. Renal failure. infective endocarditis. hypersensitivity.eye infectionsgenerally in combination with Neomycin and Polymyxin C/l: Not used parenterally(Nephrotoxic) P/A: 250 U/gm powder.72.400 mg (vial) Injection 400 mg loading dose IM/IV followed by 200 mg od daily C/I: P/C: A/E: P/A: Dose: Mupirocin Inhibits Staphylococci including MRSA.eye ointment(1 U=26microgram) Polymyxin – B Active against g-ve bacteria only. allergic rashes.Infected insect bite and small wounds Local itching irritation and redness 2% Ointment for topical application thrice daily POLYENE ANTIBIOTICS Bacitracin Spectrum Gram + ve organism both Cocci and Bacilli I: Topical application for wounds. pregnancy and lactation.skin ointment. I: A/E: P/A: Furunculosis. Injection 200mg. peritonitis in patients on CAPD (continuous ambulatory peritoneal dialysis).5 g (vial) Rs.otitis externa. Thrombophlebitis.ulcers.

Monitor renal functions.Rash.ear drops.eye drops Linezolid Effective for treatment of resistant g+ve coccal(aerobic and anaerobic)and bacillary infections.thyrotoxicosis. Chlamydia. genital and GIT infections Pregnancy. or acute confusional states. upto 28 days in vancomycin-resistant cases Being MAO Inhibiter it interacts with adrenergic/ serotonergic drugs.Ofloxacin.VRSA and VRE. P aeruginosa.V.MRSA. thirst. perforated tympanic membrane. renal impairment. Examples:Norfloxacin. lactation and children < 3 years .Ciprofloxacin. leucopenia. phaeochromocytoma. carcinoid tumor. pregnancy .G-ve bacteria not affected I: C/I : P/C : Pneumonia. complicated skin and soft tissue infections caused by Gram+ve bacteria Hypersensitivity to the drug.Pefloxacin and Lomefloxacin Norfloxacin I: C/I: 78 Urinary tract infection.Mycobacterium tuberculosis. 600mg twice daily for 10-14 days. Topically no sensitisation Powder. glossitis. schizophrenia. monitor full blood count including platelet count. myasthenia gravis. tongue discolouration.Mycoplasma pneumonia. breast feeding. avoid in uncontrolled hypertension. 600mg.200 mg/100 ml infusion Adult Oral/I.headache. concomitant use of other MAO inhibitors. thrombocytopenia Tablets. FLUOROQUINOLONES A/E : P/A : Dose: D/I: First Generation fluoroquinolones Very effective against gram negative bacilli and cocci including Enterobacteriacea.No activity against MRSA and anaerobes.Rickettsiae and Legionella. dry mouth. stomatitis.Antiinfective Drugs P/C: A/E: P/A: Renal dysfunction. H influenzae and N gonorrhea.pruritus. bipolar depression. GI disturbances. Hepatic impairment. oral and vaginal candidiasis.

hallucination and convulsions. Acute bacterial diarrhoeas. Acute exacerbation of Cystic fibrosis with Pseudomonas aeroginosa In pregnancy. 79 .to be diluted in 100-250 ml of glucose solution but not saline since it precipitates in presence of Cl. allergy GI disturbances-anorexia. pruritus. rash. leucopenia. children < 6 years.Gonorrhoea.Fluoroquinolones A/E: P/A: Nausea. agitation. UTI. cartilage damage in young children. for 10 -14 days. Tablet 400 mg(10) Rs 11-68/Typhoid and Paratyphoid fever.confusion. Tablet 250mg(10) 25-40 and Tablet 500 mg(100)Rs 4090/Injection 2 mg/ml 100 ml Rs 32/Eye Drop 0.3% w/v (5 ml. rash. 10 ml) Eye ointment 0. Bone and soft tissue infection. diarrhoea.Tablet 400 mg(10)Rs 48-154 Injection 200 mg Rs 42-90/Same as for Ciprofloxacin including meningitis Same as for Ciprofloxacin Tablet 200 and 400 mg to be taken with meals Injection 4 mg/5ml .d. CNS effects . Respiratory tract infection. allergic reactions.3% w/w (5 g) Same as for Ciprofloxacin including Leprosy Same as for Ciprofloxacin Same as for Ciprofloxacin. epigastric distress.ions. vomiting and diarrhoea. abdominal cramps. Ciprofloxacin I: C/I: A/E: P/A: Ofloxacin I: C/I: A/E: P/A: Pefloxacin I: C/I: P/A: Lomefloxacin Similar to ciprofloxacin P/A: Dose: Tablet 400 mg 400 mg o.psychotic reactions neuropathy Tablet 200 mg(10)Rs 25-90. Anthrax. photosensitivity. nausea. anorexia.

Second generation fluoroquinolones Better activity for g +ve Cocci such as Streptococcus pneumonia and for other microorganisms like mycoplasma.Fleroxacin. a/c exacerbation of COPD. skin & suture infection. anthrax. UTI.Legionella and Chlamydia Examples:Levofloxacin.So avoid in patients taking Tricyclic antidepressants Class I A and Class III antiarrhythmics Same as moxifloxacin Tablet 100mg(6tab)—Rs 22-65. Community Acquired Pneumonia. Bradycardia. CAP.patients with known prolongation of QT interval A/E: P/A: Dose: Gatifloxacin I: C/I: P/C: 80 . headache. CNS disorder A/E: GI disturbances.Staphylococci and Enterococci as well as for M tuberculosis and MAC in AIDS Examples: Sparfloxacin.Gatifloxacin I: Sparfloxacin I: C/I: P/C: Community Acquired Pneumonia. Mycobacterial infection. renal & hepatic impairment. a/c exacerbation of COPD and MAC in AIDS Hypersensitivity. concurrent use of class IA/II antiarrhythmics. nosocomial pneumonia.Tablet 200mg(10tab)— Rs 75 100-300mg OD RTI. insomnia P/A: Tablet(10) of 250mg Rs 30-52/Tablet(10) of 500mg Rs 60-87/Tablet (10)of 750mg Rs 35-118/Dose: 250-500mg OD Third generation fluoroquinolones Enhanced activity against g+ve Cocci such as Streptococci. UTI.sinusitis Hypersensitivity.Clinafloxacin D/I: Levofloxacin A/c bacterial sinusitis.acute Myocardial ischemia. age < l8yrs. pregnancy. C/I: Hypersensitivity. uncorrected hypokalemia.Antiinfective Drugs Same as for Norfloxacin except that oral iron increases the absorption of Lomefloxacin. lactation Slight prolongation of QTc interval.

lactation. listeriosis. typhoid carrier. intra abdominal infection Hypersensitivity. enteric fever.Rs 160/ 400mg OD SULPHONAMIDES Cotrimoxazole (Trimethoprim + Sulphamethoxazole) l: Acute uncomplicated UTI (except those by enterococci). pregnancy at term and during lactation. immunocompromised patients.00/Dose: 400mg OD Fourth generation fluoroquinolones Enhanced activity against g+ve organisms. acute maxillary sinusitis and plague. shigellosis. nausea. inflammation of tongue/mouth. Tablet(5) of 400mg Rs 350/. Stevens Johnson syndrome.Sulphonamides same as in ciprofloxacin & tachycardia. Renal disease. P/A: Tablet (5) of 200mg Rs 8. pregnancy. pneumocystis carinii infection. 81 C/I: P/C: A/ E: . Precipitates megaloblastic anaemia. bradycardia. Similar to ciprofloxacin & hematological disturbances. peripheral neuropathy. heart failure. patients taking pyrimethamine. vaginitis. cdonovanosis.Tablet(5) of 400mg Rs 25.Injection 400mg . vomiting. haemolytic and macrocytic anemia. toxic epidermal necrolysis. prevention of recurrent UTI. leukopenia. Creatinine clearance < 15 ml / min. thrombocytopenia. crystalluria. skin infection. pertussis. nausea. infants < 2 months. exfoliative dermatitis. brucellosis. sulphahaemoglobinaemia. hypokalemia. stomatitis. Age< 18. hallucination.significantly greater activity against Anaerobes Example: Moxifloxacin A/E: Moxifloxacin I: C/I: A/E: P/A: Dose: A/c bacterial sinusitis. legionellosis. coagulation disorders.50-50/-. history of hypersensitivity to sulphonamides. non tuberculous mycobacterial skin diseases. aplastic. CAP.

Pneumocystis carinii infection : 100 mg / kg / day Sulpha + 20 mg/ kg/ day Trimethoprim in 2-3 divided doses for 14 days. indefinitely. 0d. antifolate effect and plasma concentration of phenytoin increased by co-trimoxazole and possibly other sulphonamides.trimoxazole Tab Regular strength (10) Rs. + rifamycin 400 mg / day. Prophylaxis . Pertussis : 8/40 mg/kg/d in 2 divided dose for 2 weeks. increased risk of antifolate effect with pyrimethamine. for 6 weeks.d. for 5 days To eradicate typhoid carriers : Trimethoprim+Sulphamethoxazole 160/800 bd.9.d. until lesions completely heal. for 1-2 weeks.12 weeks. Brucellosis :Along with rifampicin for 8 . Acute maxillary sinusitis : Trimethoprim+Sulphamethoxazole 160/ 800 b. Cream 1 %w/w(25g) Rs. for 21 days.Antiinfective Drugs P/ A: Dose: D / I: Cost : I: P/A: 82 Tablet Sulphamethoxazole 400 mg + Trimethoprim 80 mg (Regular strength) Tablet Sulphamethoxazole 800 mg + Trimethoprim 160 mg (Double strength) Acute uncomplicated UTI : single dose treatment 1600 mg Sulphamethoxazole + 320 mg Trimethoprim Prevention of recurrent UTI : Trimethoprim+Sulphamethoxazole 80/400. for 3 months. Antifollate effect of methotrexate increased by co. Effect of thiopentone enhanced.12.1 double strength tab o. 7. Donovanosis : Trimethoprim+Sulphamethoxazole 160/ 800mg bd.00/- Silver sulphadiazine . in AIDS.50 . or thrice a week Shigellosis:2 Regular strength tabs bd. increased risk of nephrotoxicity with cyclosporin.00 . Non-tuberculous mycobacterial skin diseases : 160/800mg bd. effect warfarin enhanced.15.00 To reduce microbial colonisation in burns. effect of sulphonylureas enhanced.

Injection.therapy. infused over 6 hours. blood counts. convulsions. peripheral neuropathy). disturbances in renal function and renal toxicity. GI disturbances.00 Systemic infections: IV Infusion. then 250mcg/kg daily. refractory cryptococcal meningitis. anaphylactoid reactions. headache. 83 C/I : P/C : A/E : P/A: Dose: . of Img/kg daily. plasma electrolyte monitoring required. pain and thrombophlebitis at injection site. 6% Eye Ointment DRUGS USED IN LEPROSY(REFER SECTION 11) ANTITUBERCULOUS DRUGS (REFER SECTION 27) ANTIFUNGAL DRUGS Amphotericin B I: Oral. upto 1. 50mg/vial (Powder for reconstitution) Rs 45. muscle and joint pain. test dose required before starting I.mucocutaneous leishmaniasis Hypokalaemia Renal impairment. blastomycosis.5mg/kg daily or on alternate days in seriously ill patients. candidiasis. systemic mycoses especially for histoplasmosis. hepatic and renal function tests. also cardiovascular toxicity.Antifungal drugs Sulphacetamide I: Topically for ocular infection due to Chlamydia Sulphacetamide Eye drops 10%. abnormal liver function (discontinue treatment). paracoccidiomycosis.V. anaemia. nephrotoxic drugs and corticosteroids. diplopia. febrile reactions. initial test dose of l mg over 20-30minutes. 20%. gradually increased to a max. avoid rapid infusion (risk of arrhythmias). cryptococcosis. cocccidioidal meningitis. vaginal and cutaneous candidiasis and otomycosis. blood disorders. pregnancy and breast-feeding. rash.Reserve drug for persisitance cases of kalaazar .neurological disorders (including hearing loss. 30% w/ v.

vertigo.51. thrombocytopenia. (4 months for cryptococcal meningitis). corneal and cutaneous candidiasis.infusion.1.Antiinfective Drugs Liposomal amphotericin: I.00.V. and aplastic anaemia reported.infusion.00. Itraconazole. rashes. hallucinations. less frequently confusion. Rash.00.00/- D/I: Cost : Griseofulvin (Refer section 11) Flucytosine I: Systemic yeast and fungal infections. Hypersensitivity. 500mg Oral. 50.000units (10) Rs. nausea. initial test dose of Img over 10 minutes. elderly. GI disturbances. No known interactions. vomiting Tablet 5. Ketoconazole. 50—l50mg/kg daily in 4 divided doses. Monilial vaginitis . sedation. diarrhoea. Fluconazole. Nystatin l: C/l: P/C: A / E: P/A: Dose: Monilial vaginitis.00.000 unit tab inserted bd. lneffective in dermatophytosis. conjunctivitis.5. Tab 5.convulsions.liver and kidney function tests and blood counts required. Monilial diarrhoea . adjunct in cryptococcal meningitis and severe systemic candidiasis. monilial diarrhoea.000 unit tds. increased gradually if necessary to 3mg/kg daily as a single dose. Miconazole. 100-150mg/kg daily for extremely sensitive organisms. 200mg/kg in 4 divided doses for 7 days. Tablets.I.000 units and 1. Oral thrush — the tablets can be sucked or applied after powdering.V.00 .headache. leucopenia. breast feeding. P/C: A/E : P/A: Dose: Clotrimazole. blood disorders or bone marrow depression. alterations in liver function tests (hepatitis and hepatic necrosis reported).00. pregnancy. Terbinafine (Refer section 11) 84 .000 units. then 1mg/kg daily as a single dose. Renal impairment.

Herpes simplex. 400. 85 C/ I: P/C: A/E: . headache. maintain adequate hydration. oesophago-gastrointestinal infections. Renal impairment. neutropenia.severe local inflammation (sometimes leading to ulceration). Injection.V. Hypersensitivity to the drug. Rashes. agitation. “wasting illness” Pregnancy. on LV.increase in blood urea and creatinine. rise in bilirubin and liver enzymes.Antiviral drugs ANTI VIRAL DRUGS Anti herpes virus drugs Acyclovir I: C/I: P/C : A/E : Herpes simplex and varicella zoster. infusion. neurological reactions (including dizziness).infusion. Gl disturbances. oral . Varicella and herpes zoster. decrease in haematological indices.convulsions and coma. fatigue. Bone marrow suppression especially neutropenia. 800mg. Tablets 200. 10ml. pregnancy and breast—feeding. also confusion. tremors. upto l0mg/kg every 8 hours for l0 days in herpes simplex encephalitis and in varicella zoster in the irnmunocornpromised. somnolence.800mg 5 times daily for 7 days. 25mg/ml. prevention of cytomegalovirus (CMV) disease in organ transplant recipient. psychosis. 250mg (powder for reconstitution) Dose: P/A: Ganciclovir and Valganciclovir Valganciclovir is a L valine ester prodrug of Ganciclovir I: Treatment of cytomegalovirus retinitis in immunosuppressed patients. for 5-10 days.l. hepatitis. treatment of CMV-associated syndromes pneumonia. Additive bone marrow suppression with zidovudine. hallucinations.Oral. 5mg/kg every 8 hours for 5-7 days. 200mg (400mg if absorption impaired or in immunocompromised) 5 times daily.

I: Oral Oseltamivir is effective in the treatment and prevention of influenza A and B virus infections A/E: Oral oseltamivir is associated with nausea. Gastrointestinal complaints usually are mild-to-moderate inintensity. Parenteral IV 5 mg/kg every 12 h for 14 to 21 days followed by a maintenance dose of 5 mg/ kg IV per day or 5 times per week. antimuscarinics. ANTI INFLUENZA VIRUS DRUGS P/A: Amantidine and rimantadine I: Prophylaxis and treatment of Influenza A in adults. Concurrent use of antihypertensives. less often. eczema. metoclopramide. C/I.Antiinfective Drugs Capsules 250 mg Injection 500 mg (vial) Dose : Oral: 1 g tds. typically resolve in 1 to 2 days despite continued dosing. antipsychotics. probably owing to local irritation. abdominal discomfort. Hypersensitivity Chronic hepatic dysfunction. (particularly elderly) and prophylaxis in susceptible children. emesis. tetrabenazine with amantidine potentiates the anticholinergic-like side effects. chronic renal dysfunction. anxiety. insomnia. difficulty in concentrating. and 86 . domperidone. Capsules 100 mg 100 to 200 mg / day orally for 5 to 7 days Prophylaxis 100 to 200 mg/ day orally daily for the peak duration of the outbreak. D/ I : Increased risk of myelosuppression with zidovudine and other myelosuppressive drugs. peptic ulcer. Dizziness. seizures and worsening of congestive heart failure. epilepsy. P/ C: A/E: P/A: Dose: D/I: Oseltamivir It inhibits amantadine and rimantadine-resistant influenza A viruses and some zanamivir-resistant variants. and. possibly for as long as immunosuppression exists.

Treatment is associated with approximate halving of the risk of subsequent hospitalization in adults. Dose: Treatment of previously healthy adults (75 mg twice daily for 5 days) or children aged 1 to 12 years (weightadjusted dosing) with acute influenza reduces illness duration by about 1 to 2 days.Non selective antiviral drugs are preventable by administration with food. fever.Chronic myelogenous leukemia It increases the effects of theophyllines.3 million units three times a week for 6 months. short-term use (7 to 10 days) protects against influenza in household contacts. Interferon Alpha—2a .flu-like syndromes Injection Alpha-2a 3MU/ vial Injection Alpha-2b 3MU. Headache is reported.individualised based on the patient. alopecia.Kaposi’s sarcoma. Interferon Alpha—2b in chronic non-A non-B C infections Hepatitis. neuropathy and tremor. digestive disturbances. lethargy.chronic granulomatous disease. neurotoxicity . 5MU / vial Interferon Alpha-2b in chronic HBV infection .hairy cell leukaemia. antihistamines 87 P/C: A/E: P/A: Dose: D/I: .numbness.5 million units daily for 16 weeks. speeds functional recovery. Concurrent use of myelosuppressive drugs increases bone marrow toxicity. and reduces the risk of complications leading to antibiotic use by 40% to 50%. Headache. Not reported D/I: NON SELECTIVE ANTIVIRAL DRUGS Interferon alpha I: Treatment of chronic Hepatitis B and C. When (approximately 70% to 90%) in reducing the likelihood of influenza illness in both unimmunized working adults and in immunized nursing home residents. concurrent use of interferons with sedatives like antianixety drugs.

lactic acidosis. myalgia. renal impairment. neutropenia and thrombocytopenia. Profound myelosuppression with ganciclovir. Pregnancy. breast-feeding. 300 mg. hypersensitivity reactions. liver damage. 300mg 300 mg three times a day. cardiomyopathy. Chronic hepatitis B or C ( greater risk of hepatic sideeffects). to be taken with plenty of water. Anemia. proximal myopathy. bluish discolouration of nails. On concurrent use the effect of theophylline is occasionally enhanced. headache.Antiinfective Drugs and antidepressants potentiates the sedative effects.urticaria. insomnia. fatigue.taste disturbance Capsules 100 mg.Fatigue. rash. pancreatitis. nausea. Extreme lethargy is reported with IV acyclovir. fever. HIV infection in combination with other antiretroviral drugs.Chronic hepatic or renal dysfunction. hepatic impairment.GI disturbances. lipodystrophy. malaise. ANTIRETROVIRAL DRUGS Nucleoside reverse transcriptase inhibitor Zidovudine I: Used as part of combination antiretroviral therapy for patients with HIV infection and a count less than 500 CD4+ T cells/ml Monotherapy is restricted to the prevention of mother to child transmission of HIV. headache. blood disorders including anaemia. anorexia. Tablet. GI disturbances. Abnormally low neutrophil counts or haemoglobin value. Increased risk of toxicity with other nephrotoxic and myelosuppressive drugs. bone marrow suppression. C/I: P/C: A/E: P/A: Dose : D/I: Abacavir I: C/I: P/C: A/E: P/A: 88 .dyspnoea. arthralgia. Patients starting therapy should be monitored for hematological toxicity at least every other week for the first month and then monthly.

60kg and above. 300 mg every 12 hours in combination with other antiretroviral agents. Retinal and optic nerve changes (especially in children). hepatic disease. diabetes mellitus. History of pancreatitis. liver failure. 100mg once daily. 250mg daily in 1-2 divided doses. parotid gland enlargement. Same as Abacavir. 89 Didanosine I: C/I: P/A: A/E : P/A: Dose: Lamivudine I: C/I : P/C: A/E : P/A: Dose: Stavudine I: C/I : P/C : . monitor liver enzymes. alopecia. Breast feeding. HIV infection with other antiretroviral drugs. hyperuricaemia. Renal impairment. Same as Abacavir. also peripheral neuropathy. hepatic or renal impairment. retinal examination recommended if visual changes occur. dry mouth. Breast-feeding. lactic acidosis. acute renal failure. HIV infection with other antiretroviral drugs. rhabdomyolysis. 150mg. Film coated tablets. history of liver disease. dry eyes.Chronic hepatitis B: oral. Enteric coated capsule. peripheral neuropathy. peripheral neuropathy or hyperuricaemia. nasal symptoms. hepatic and renal impairment. alopecia. History of peripheral neuropathy .also pancreatitis.hyperglycaemia. anaphylactic reactions. 400mg daily in 1-2 divided doses. pregnancy. chronic hepatitis B or C. First trimester of pregnancy. 400mg. breast-feeding. under 60kg. Oral. HIV infection with other anti-retroviral drugs. chronic hepatitis B. HIV infection: oral. pregnancy. 150mg every 12 hours. muscle disorders including rhabdomyolysis.Antiretroviral drugs Dose: Oral. history of pancreatitis or concomitant use with other drugs associated with pancreatitis.

nephrolithiasis. taste disturbances. rash. sleep. pruritus. ensure adequate hydration ( risk of nephrolithiasis especially in children). pregnancy.Antiinfective Drugs A/E: P/A: Dose: Same as Abacavir . headache. elderly. hyperpigmentation. dysuria. abnormal dreams. Capsules 30mg and 40mg <60kg 30mg every 12 hours preferably atleast 1 hour before food. dizziness. A/E : P/A: Dose: NON—NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS Efavirenz I: C/I : P/C: HIV infection in combination with other antiretroviral drugs. 400mg.alopecia.diabetes. hepatic impairment. paronychia. less commonly anxiety.also peripheral neuropathy (doserelated). Capsules.lipodystrophy syndrome. paraesthesia. haematuria. GI disturbances. neutropenia and thrombocytopenia. avoid in porphyria. dry skin. hepatic dysfunction. fatigue. gynaecomastia. Breast-feeding. 800mg every 8 hours. history of mental illness (or) seizures. pancreatitis. cognitive dysfunction. haemolytic anaemia. liver disease or hepatic impairment. Stevens-Johnson syndrome. Chronic hepatitis B or C ( greater risk of hepatic side effects). hypersensitivity reactions including anaphylaxis. myositis.disturbances. intestitial nephritis. Breast feeding. severe renal impairment. pregnancy.depression. patients at risk of nephrolithiasis. 60kg and above 40mg every 12 hours Protease Inhibitors Indinavir I: C/I: P/C : HIV infection in combination with nucleoside reverse transcriptase inhibitors. Oral. rhabdomyolysis. 90 . haemophilia. crystalluria. also dry mouth. blood disorders including anaemia. drowsiness. myalgia. Chronic hepatitis B or C ( greater risk of hepatic sideeffects).

dizziness. chronic hepatitis B or C. lactation. Hepatic impairment. may involve hepatic reactions and rash). lepra reaction Hypersensitivity. granulocytopenia(more frequent in children). fatigue. pregnancy. psoriasis. hepatitis.Antiretroviral drugs A/E : P/A : Dose: Rash including Stevens—Johnson syndrome. pancreatitis. arthralgia. post— exposure prophylaxis. anaphylaxis. 200mg. porphyria cutanea tarda Prolonged use may cause reversible lichenoid skin erruptions. hepatic failure. ANTIMALARIAL DRUGS Nevirapine I: C/I: P/C: A/E : P/A: Dose: Chloroquine I: Malaria (p. patients with high CD4 cell counts and women ( all at greater risk of side—effects). nausea.pruritus. in combination with atleast two other antiretroviral drugs.insomnia. less frequently vomiting. diarrhoea. somnolence. angioedema. Oral. G6PD deficiency. Oral. vivax & falciparum). anxiety. Breast-feeding. lupus erythematosus. rheumatoid arthritis. pregnancy. nausea. psychosis. 200 mg.fever. hepatitis. elevated liver enzymes. convulsions. extra intestinal amoebiasis. Capsules. very rarely neuropsychiatric reactions. impaired concentration. severe hepatic impairment. Tablets. use with caution in hepatic or renal 91 C/I: P/C: . anaemia. then (if no rash present)200mg twice daily. stupor. Rash including Stevens. headache. less commonly GI disturbances. Progressive or advanced HIV infection. raised serum cholesterol. ataxia. also reported abdominal pain. hypersensitivity reactions. blurred vision. 600 mg once daily. gynaecomastia. amnesia. myalgia.depression. vertigo. 200mg once daily for first 14 days. fatigue. abnormal dreams.Johnson syndrome and rarely toxic epidermal necrolysis.

peripheral neuropathy. vomiting. Tablet 250 mg. bradycardia. Keratopathy may regress on stopping the drug. keratopathy. If retinopathy occurs this may progress and worsen even if the drug is withdrawn.Inj 40 mg/ml (30 ml vial) Rs. prirnaquine and tetracyclines. Hypersensitivity. 13. ECG abnormalities with quinidine. nausea.Antiinfective Drugs A/E: P/A: Dose: D/l: Cost : dysfunction.falciparurn and P. Injection IM loading dose 3. amiodarone. for next 4 days. tricyclic antidepressants and some phenothiazines. QT prolongation Injection 80 mg Rs 114/Capsules 40 mg Rs 65/Oral 80 mg bd. GI symptoms. myasthenia .6mg/ kg daily for a maximum of 7 days Antagonises pyrimethamine. 5.00 -10. G6PD deficiency.National Health programmes of India Increased risk of seizures with Mefloquine. transient increase in serum transaminases. toxic myopathy. Effective against all strains resistant to other anti-malarial agents. regular ocular examination on long term use GIT symptoms .54/Schizonticidal activity against asexual forms of P. Increases plasma levels of digoxin and cyclosporin Tab 250 mg (10) Rs. Artemether I: C/I: P/C: A/E: P/A: Dose: D/I: 92 . AV block. on day 1 followed by 80 mg od. reduced leucocyte and reticulocyte counts. headache. Refer Part III B. Used in severe complicated falciparum infection including cerebral malaria. visual disturbances.vivax. 500 mg Injection 40 mg/mL. and psychiatric illness. terfenadine. pregnancy.nausea and vomiting. epilepsy .2mg/kg followed by 1.Synergism with mefloquine. Avoid concomitant use of drugs causing ECG abnormalities and constantly monitor such patients.00.

5g Prophylaxis : 250 mg weekly one week before entering an endemic area and for 4 weeks after leaving. hallucination and depression. Patient should be transferred to oral therapy as soon as possible. of 7 days. 60mg/vial (powder for reconstitution)Rs 149 Oral. pregnancy. decreased metabolism of mefloquine with ketoconazole. falciparum malaria. given for 5 days if used alone IM/I. loading dose. followed after 4 hours and daily thereafter by a dose of Img/kg for a max. dizziness. single dose max up to 1. hepatic or renal impairment. Injection. neutropenia. dizziness. elevated liver enzyme values. Use with caution in cardiovascular disorders. 93 P/A: Dose: Mefloquine I: C/I: P/C: A/E: P/A: Dose: D/I: . ECG abnormalities with beta blockers and halofantrine Potentiation of cardiotoxicity and neurotoxicity with quinine. rash.tinitus. vomiting. lactation and history of convulsions or psychiatric illness.V. coagulation disorders.w. 2mg/kg. 5mg/kg on the first day with 2.5mg/kg on the second and third days. Increased metabolism of valproic acid. diarrhoea. along with a single dose of mefloquine 15mg/kg given on the second day for radical cure. Prevention and treatment of chloroquine resistant and multidrug resistant P. and ECG abnormalities including prolongation of QT interval. Hypersensitivity. Additional single oral dose of mefloquine should be given to effect radical cure. epilepsy. SJS Tablet 250 mg (film coated)(5)Rs 200/Multi-drug resistant case : 20-25 mg/kg b.Antimalarial drugs Artesunate I: P/C: A/E: Mlalaria of multidrug resistance Pregnancy Mild GI disturbances. Avoid alcohol during treatment as it may cause increased adverse effect pregnancy Nausea. itching. Prophylaxis for non-immune travellers staying for short duration in endemic zones. hypertension.

(with sulfadiazine) Anaemia. Tab (pyrimethamine25 mg + sulpha 500mg) (2) Rs. pregnancy. G6PD deficiency and severe allergy or asthma. hypersensitivity. loss of appetite. bone marrow depression. Use with caution in hepatic and renal impairment. haemolytic anaemia. SLE. Tablet 7. on current administration of haemolytic drugs.00 -6. insomnia. Rash. Gl symptoms.00 C/l : P/C: A/E: P/A : Dose: D/l: Pyrimethamine I: C/I: P/C: A/E: P/A: D/I : Cost: 94 . sore throat. fever (and unusual bleeding) All preparations contain pyrimethamine 1 part plus sulfadoxine 20 parts.Antiinfective Drugs Primaquine l: lt is highly effective against the exoerythrocytic stage of Pvivax and against gametocyte of P. 4.5 mg(10)Rs 17/. G6PD deficiency. seizure disorders. Folinic acid should be supplemented when given in pregnancy. methaemoglobinaemia. hypersensitivity. Rheumatoid arthritis. Haemolytic drugs (sulfonamides) and bone marrow suppressants (methotrexate. blood counts required with prolonged treatment. granulocytopenia. granulocytosis. lactation. chloramphenicol) potentiates toxicity of primaquine Chloroquine resistant falciparum malaria (used only in combination with dapsone or sulphadoxine).and Tablet 15 mg(7) Rs 25/15 mg od. Conduct routine blood examination during the course of therapy. Tablet 25mg Concurrent use of pyrimethamine with bone marrow depressants may increase the leukopenic and thrombocytopenic effects. Increased anti folate effect with methotrexate.falciparum and all species of plasmodia. gastric irritation. for 2 weeks lnhibits metabolism of chloroquine. toxoplasmosis.

pylori infection.difficile.00 Injection 300 mg/mL (2 mL) Rs. guinea worm infestation.00 .600 mg tds. pseudomembraneous colitis by C. cardiac dysfunction Cinchonism . trench mouth. giardiasis. Use with caution in chronic renal dysfunction. pregnancy. hypotension. Tab 300 mg (10) Rs. 300 mg. H. ulcerative gingivitis. muscle paralysis in myasthenic patients.tinnitus.7 days. lactation. hyperinsulinemic hypoglycemia. Injection 300 mg/ mL . Neurological disease. Bacteriodes fragilis infection.excitement. 300 . Vincent’s angina. thrombocytopenia. nausea. angioedema. optic neuritis.Antimalarial drugs Quinine I: C/l: P/C: A/E: Acts on mature trophozoites of all species of plasmodium. Gl symptoms. IV loading dose 20mg/kg max to 1. G6PD deficiency. delirium. for 5 . anaerobic infections. blood dyscrasias. . myasthenia gravis. headache and disturbed vision. 35. 11.00 -19. its mutagenic potential warrants caution.00 P/A: Dose: D/I: Cost: ANTIAMOEBIC AND OTHER PROTOZOAL DRUGS ANTIAMOEBIC DRUGS Metronidazole l: Amoebiasis. trichomonal vaginitis. first trimester of pregnancy. hypoglycemic effect of oral antidiabetics enhanced.4g infused over 4h Maintenance dose 10mg/kg max 700mg infused over 4 hours every 8 to 12 hours until patient can swallow tablets to complete 7 day course (5to 7 mg/kg if the IV therapy is beyond 48 hours) Blood levels of digoxin increased. Though no teratogenic effect has yet been demonstrated.60. Tablet 100 mg. nocturnal leg cramps Hypersensitivity. hypoprothrombinemic effect of warfarin enhanced. agranulocytosis. 95 C/l: .

dizziness. breast feeding. nausea. 400 mg. Invasive Dysentry and Liver abscess:Oral 800 mg thrice daily for 7-10 days Clostridium difficile colitis: Oral 800 mg tds.10 days H.20 – 6.phenytoin concentration). Phenobarbitone accelerates metabolism of metronidazole (reduced plasma metronidazole concentration)It inhibits metabolism of flurouracil (increased toxicity). and CNS effects like seizures have followed very high doses Tablet 200mg. increased toxicity reported with lithium. Anorexia.60/- . less frequently causes headache. Gel 1% Intestinal Amoebiasis:Oral 800 mg every 8 hours for 5 days Extraintestinal Amoebiasis:Oral 400-800 mg every 8 hours for 5-10 days Trichomoniasis: Oral 400 mg thrice daily for 7 days Giardiasis: Oral 400 mg tds. Tab 400mg (10) Rs. dryness of mouth. periodontal diseases. oral candidiasis.It inhibits metabolism of phenytoin (increased plasma . rashes and transient neutropenia.pylori eradication:Oral 400 mg thrice daily along with Amoxycillin/Clarithromycin and a Proton Pump Inhibitor in triple drug 2 week regimens Pelvic inflammatory disease (PID): 500 mg bd for 14 days along with ofloxacin. effect of warfarin enhanced. for 7 days. and discomfort. adjustment of dosage in old people. Injection 500mg/ 100mL. for 7. Prolonged administration cause peripheral neuropathy.Antiinfective Drugs P/C: A/E: P/A : Dose : D/I: Cost : 96 Carcinogenicity. Metronidazole may cause dry mouth contributing to the development of caries. metallic taste and abdominal cramps. 600 mg.6. pregnancy. glossitis. Disulfiruam like reaction with alcohol.

60-19/Treatment of Amoebiasis.Pylori infections. cyst passers 1st trimester pregnancy.Giardiasis and Trichomoniasis As for Metronidazole 1 gm film coated tablets Rs 31.50-37/Oral 2 gm single dose Hepatic amoebiasis 600 mg base for 2 days followed by 300 mg daily for 2-3 weeks. giardiasis: 2 g single dose Anaerobic infection :2 g followed by 500mg bd for 5 days. hepatitis 97 . 2 g Injection 2 mg/mL(400 mL) Intestinal Amoebiasis : Oral 2 g daily for 2-3 days or 500 mg bd for 5-10 days Trichomoniasis. 600 mg. As for Metronidazole Tablets 300 mg. 1 g. Chronic intestinal amoebiasis. trichomonas vaginalis. myocarditis. giardia lamblia.Antiamoebic and other protozoal drugs Tinidazole I: Effective in infections due to amoebiasis. nephritis. lactation Gastrointestinal disturbances Tablets 500 mg Oral 500 mg tds for 5-10 days DRUGS FOR LEISHMANIASIS C/I: P/C: A/ E: P/A: Dose: Cost: Secnidazole I: C/I: P/C: A/ E: P/A: Dose: Dose: Chloroquine(Refer anti Malarial drugs) Diloxanide furoate I: C/I: A/E: P/A: Dose: Sodium Stibogluconate I: C/I: Drug of choice for kala azar Pneumonia. Surgical prophylaxis : 2 g single dose before surgery orally H pylori:500 mg twice daily for 2 weeks in triple combination Tab 300 mg (10) Rs. 8. It is used only when Metronidazole is not effective or not tolerated. 500 mg. anaerobic bacterial and H.

pneumocystis carinii. pain. unpleasant metalic taste. Concurrent use with nephrotoxic drugs increases nephrotoxicity. Injection 100 mg/ml in 30 ml (vial) 20 mg/ kg daily IM (buttocks) or IV injection for 20 . Abnormal haematological effect with bone marrow depressants. palpitation. blood glucose. sterile abscess. ECG abnormalities. fainting. Reduce dose in renal failure. stiffness of injected muscle. hypotension. vomiting. pneumocystis pneumonia in AIDS patients and trypanosomiasis. Active against L donovani.Antiinfective Drugs P/C: A/E: P/ A: Dose: D/I: IV injection must be given slowly and stopped if coughing or substernal pain develops.salvage therapy of antimony failure cases. elevation of hepatic transaminases. risk of hypotension. neutropenia. rigor and fever after IV Injection. anxiety. cardiac arrhythmias. hyperglycemia. 4 mg / kg deep IM or slow IV infusion over 1 hour on alternate days for 5-15 weeks till no parasites are demonstrated in 2 splenic aspirates taken 2 weeks apart.increased risk of pancreatitis with didanosine. kidney and liver damage. monitor kidney/liver function. nausea.Increased risk of torsades de pointes with erythromycin r e v e r s i b l e hypocalcemia. Nausea vomiting.IM is painful. metallic taste in the mouth. pancreatitis. headache. Pentamidine Injection 200mg and 300 mg vials. kala azar. Impaired renal function. blood count and ECG. Toxicity is due to histamine release. hypoglycemia.Dry powder. hypomagnesemia and nephrotoxicity with Foscarnet Pentamidine I: C/I: P/C: A/E: P/A: Dose: D/I: 98 .30 days or more.

alopecia. l: Same as that of Mebendazole. Strongyloidosis. Allopurinol DRUGS FOR GIARDIASIS Metronidazole and Tinidazole (Refer Antiamoebics) DRUGS FOR TRICHOMONIASIS 1. granulocytopenia.whipworm:Oral 100 mg bd.Lactation Diarrhoea. Tab 100 mg (6) Rs 3. Drugs used orally Metronidazole and Tinidazole (Refer Antiamoebics) 2. ln addition it is also effective in Neurocysticercosis.60-17.repeat after 2 weeks if necessary Threadworm: Oral 100 mg single dose repeated after 2 .100 mg vaginal tablet inserted high up in vagina every night for 6 . Tablet 100 mg Round worm. Amphotericin .3 weeks. 99 . nausea. Hydatid disease. Povidone iodine . abdominal pain when used in heavy infestation.hookworm. hook worm.10/- P/A: Dose: Cost: Albendazole Broad spectrum activity anthelmintic. Drugs used intravaginally Clotrimazole . for 3 consecutive days.Anthelmintics drugs Other drugs used in resistant cases 1.400 mg pessaries inserted in vagina daily at night for 2 weeks Hamycin – 4-8 lac U ovules intravaginally daily for 15 days ANTHELMINTICS DRUGS Mebendazole Broad spectrum anthelmintic I: C/I: P/C: A/E: Roundworm.B 2.12 days. allergic reactions. Ketoconazole 3.thread worm and whipworm infestations Children below 2 years Pregnancy.

vomiting. 4. dizziness. strongyloidosis :400 mg daily for 3 consecutive days Neurocysticercosis :7. whipworm one single dose 400 mg for adults to be chewed.30/Single or Mixed infections due to Roundworm.hookworm and thread worm Pregnancy. Tape worms. vomiting and abdominal pain.repeat if necessary after 2 weeks for threadworm and 1 month for hookworm Mixed infection 10 mg/kg as single dose Tab 250 mg (2) Rs 9. Tablet 250 mg Oral Round worm 5 mg/kg as single dose.5-10mg/kg (maximum 400 mg) twice daily for 28 days.00/- Pyrantel pamoate I: C/I: P/C: A/E: P/A: Dose: Cost: Piperazine I: C/I: A/E: P/A: Dose: Cost: 100 . Tablet 500 mg Round worm:4 g once a day for 2 consecutive days Safe during pregnancy Threadworm: 50 mg/kg (maximum 2g)once a day for 7 days. To be given with care in pregnant women and children below 2 years. hook worm.repeat after 14 drug free days for upto 2-3 cycles Tab 400 mg (2) Rs 6-14. Gl side effects. excitement and convulsions in toxic doses.repeated after 3 weeks. abdominal discomfort. Renal insufficiency and epileptics Safe and well tolerated. urticaria. can be used in pregnancy.40/Highly active against Roundworm and threadworm. children and those with impaired liver function. Occasionally nausea. Tab 500 mg (8) Rs.hepatic and renal imparment Gastro intestinal -nausea.Antiinfective Drugs C/l: A/E: P/A: Dose: Cost: Pregnancy. Hook worm 10 mg/kg daily for 3 days.5-10 mg/kg twice daily for 7-14 days Hydatid disease:7. dizziness Chewable tablet 400 mg Round worm. headache and dizziness.

nausea.vomiting. sweating.30 101 C/I: P/C: A/E: P/A: Dose: Cost: . dizziness.O volvulus and tropical eosinophilia Pregnancy. Cysticercosis: Oral 50mg/kg/day divided every 8 hours for 14 days. known hypersensitivity to praziquantel. febrile reaction with rash.Antifilarial drugs SCHISTOSOMICIDES Praziquantel I: C/I: P/C: A/E: Schistosomiasis. Loa loa. The first dose should be given with caution since intense allergic reactions may follow. Tablets 600mg(20)Rs 850-920/ANTIFILARIAL DRUGS Dose: P/A: Diethylcarbamazine citrate l: Effective drug available for filariasis caused by W. Tab 50mg (10) Rs 2. abdominal pain. Severe hepatic disease. malaise. and enlargement of lymphnodes. headache. Schistosomiasis: Oral 20mg/kg/dose 2-3 times a day at 4 to 6 hour intervals. skin rash. fever.lung and intestinal fluke infections. headache. patients with cerebral cysticercosis require hospitalization Dizziness.malayi. loss of appetite.bancrofti. Tablets 50 and 100mg to be taken after meals Filariasis: Oral 1 mg/kg on 1 st day increased gradually over 3 days to 6 mg/kg daily in divided doses for 21 days Tropical eosinophilia: 2-4mg/kg three times daily for 10 days Tab 100 mg (10) Rs 7.90-44. pruritus.70/-. Nausea. Tapeworm: Oral 10-20mg/kg as a single dose. liver. Flukes: Oral 25mg/kg/dose every 8 hours for 1-2 days. CSF reaction syndrome in patients being treated for neurocysticercosis. itching.tape worm infections. hypersensitivity. diarrhoea. loss of appetite. B. Ocular cysticercosis.

strongyloidosis.50 Cost: 102 . transient ECG changes 3mg and 6 mg tablets to be taken on empty stomach Filariasis: Oral single 10-15mg Ivermectin preferably with 400 mg Abendazole given annually for 5-6 years Strongyloidosis: 0. dizziness.80/-.scabies . cutaneous larva migrans.2 mg/kg single dose Onchocerciasis:Single dose of 150 mg/kg orally for patients over 5 years of age is given every 6 months on empty stomach Scabies and Pediculosis: Single oral dose of 200mcg/kg Tablet 3mg(1) Rs 8-11.Tablet 6mg(1) Rs 12-16.Antiinfective Drugs Ivermectin l: C/l: P/C: A/E: P/ A: Dose: Onchocerciasis. Mild itching. postural hypotension.15-0.head lice and filariasis Pregnancy Use with caution children < 5 years. allergic reactions.

they act on 5HT (serotonin) 1B/1D receptors and can be used during the established headache phase of an attack. if nausea and vomiting are features of the attack. thus improving absorption of the analgesic. acetyl salicylic(aspirin) or an NSAID such as ibuprofen. Specific antimigraine drugs. The risk of Reye syndrome due to acetylsalicylic acid in children can be avoided by giving paracetamol instead. P/A: Tablet: 300-500 mg.refer section 2. most migraine headaches respond to paracetamol (acetaminophen). 103 . headache (analgesic-induced headache).SECTION .5 ANTIMIGRAINE MEDICINES The two principal strategies of migraine management are treatment of acute attacks and prevention of attacks. Acetylsalicylic acid . TREATMENT FOR ACUTE ATTACK Treatment of acute attacks may be non-specific using simple analgesics. some drugs are available as suppositories which may be used if the oral route is not effective (poor oral bioavailability. Ergot alkaloids should no longer be used. Treatment is generally by mouth. such as the 5HT1 agonist sumatriptan are used when analgesics are ineffective. increased consumption of these medicines needs careful monitoring. or not practicable (patient unable to take drugs orally). preferably 10–15 minutes before the analgesic. they are associated with many side-effects and must be avoided in cerebrovascular or cardiovascular disease. An antiemetic such as metoclopramide. therefore. given as a single dose orally or by intramuscular injection at the onset of a migraine attack. Simple analgesics including NSAIDs (nonsteroidal anti-inflammatory drugs) can be effective in mild to moderate forms of migraine if taken early in the attack. or absorption from the gut impaired by vomiting). a dispersible or effervescent preparation of the drug is preferred because of enhanced absorption compared with a conventional tablet. Excessive use of antimigraine medication (analgesics. is useful not only in relieving nausea but also in restoring gastric motility. Peristalsis is often reduced during migraine attacks and. Products which contain barbiturates or codeine are undesirable since they may cause physical dependence and withdrawal headaches. 5HT1 agonists and ergotamine) is associated with medication-overuse. if available. an antiemetic drug may be given.

additional symptomatic treatment is still needed. 104 . usual range 80–160 mg daily. Of the many drugs that have been advocated for migraine prophylaxis. 300–900 mg at first sign of attack. maximum 4 g daily. by mouth preferably with or after food. MIGRAINE PROPHYLAXIS Prophylactic treatment for migraine should be considered for patients in whom: treatment of acute migraine attacks is ineffective or not possible the frequency of migraine attacks is increasing migraine attacks occur more than once or twice a month the severity or duration of migraine attacks is disabling Prophylaxis can reduce the severity and frequency of attacks but does not eliminate them completely. a non-selective beta-blocker and other related compounds with similar profile such as atenolol are generally preferred. However. such as amitriptyline or calcium-channel blocking drugs such as verapamil may be of value.adrenoceptor antagonists (betablockers) are most frequently used. increased by same amount at weekly intervals if necessary. long-term prophylaxis is undesirable and treatment should be reviewed at 6-monthly intervals. by mouth. ADULT initially 40 mg 2–3 times daily. 20 mg 2–3 times daily. Prophylaxis of migraine Refer Section 10 Prophylaxis of migraine. 40 mg (hydrochloride). may be repeated every 4–6 hours if necessary. by mouth 0. may be repeated every 4–6 hours if necessary. beta. maximum 4 g daily. CHILD under 12 years. Treatment of acute migraine attack. CHILD 6–12 years 250– 500 mg at first sign of attack. may be repeated every 4–6 hours if necessary. Tricyclic antidepressants. maximum 4 doses in 24 hours. I:P/C:A/E: P/A: Dose: Propranolol Tablet: I: C/I:P/A:A/E: Dose: 20 mg.Antimigraine Medicines Dose: Treatment of acute migraine attack. Propranolol. Paracetamol Refer Section 2 500 mg.5–1 g at first sign of attack.

alopecia. mucosal ulceration. multiple myeloma.200mg vial Rs-27/Chlorambucil I: Chronic lymphatic leukaemia(CLL).1 mg/kg/day for 3 to 6 weeks. P/A: Tablets 2mg. blurred vision. Carcinoma of cervix. haemorrhagic cystitis. P/C : Blood counts should be monitored every week.dermatitis. ovary.. A/E: Immunosuppression. 105 . bladder carcinoma. skin and nail hyperpigmentation. Sarcoma Multiple Myelomas. testicular ‘tumours and others. lymphomas.myelosuppression. 5mg Dose : 0. severe renal and hepatic failure. Lung. transient cerebral symptoms.200. liver damage. fever. P/C : Renal failure. gastrointestinal symptoms.500mg. urticaria. nausea. P/A: Tablets 50 mg Inj 100.Maintenance dose · 2 mg daily. Acute Leukemia and several others· C/I: Pregnancy and lactation. 4mg. germ cell tumour. Dose : Oral: 100-200 mg/kg bw to be given along with immunosuppressant drug.SECTION 6 ANTINEOPLASTIC DRUGS ALKYLATING AGENTS Cyclophosphamide : I: Lymphomas.cardiac damage. C/I : Hypersensitivity. Breast.1g. Dehydration should be avoided to minimize renal and vesical damage A/E : Bonemarrow suppression. hepatotoxicity . D/I: When given with other myelotoxic drugs or radiotherapy the combined adverse effects are increased. anaphylaxis. wasting syndrome. Cost: Inj 1g vial Rs-110/. Parenteral: 3-5 mg / kg bw to be given maximum in a single dose IV as push dose or as an IV infusion. thrombocytopenia. macroglobulinemia. bladder fibrosis. pregnancy. lactation. sterility foetal damage. chorio carcinoma. pulmonary fibrosis. vomiting.

50 Multiple myeloma. amenorrhoea. bone marrow suppression. pregnancy.dehydration. lactation Blood counts once a week at the initiation of therapy. Additive bone marrow depression may occur with radiation therapy.confusion. bone marrow depression. Tablets 2mg.V. breast cancer. Thrombocytopenia. sarcomas. pregnancy.sterility. on 5 conscecutive days. P/A : Dose : D/I : Cost: Inj: Ifosfamide I: C/I: P/C : A/E : P/A: Dose: D/I: 106 .90 Germ cell tumours. hallucination. Haemorrhagic cystitis. allergic reactions. polycythemia vera. leukemia.Antineoplastic Drugs D/I: Cost : Melphalan I: C/I : P/C : A/E: Phenylbutazone and warfarin potentiate efficacy of chlorambucil Tab 2 mg – Rs. malignant melanoma.5 g / m2 body surface) daily I. Nausea. 129. 192. immunosuppression. later at longer intervals. Attention should be paid to the specified doses of the relevant treatment regimen. Hypersensitivity. Injection 50 mg vial 0. Risk of renal failure with cyclosporine. delayed wound healing. Lung toxicity with carmustine. advanced ovarian carcinoma. cervical. pulmonary infiltration. Tab 2 mg. anorexia. severe leucopenia. nausea.25 mg/kg/day x 4 days repeated 4 .leucopenia. inappropriate ADH secretion. Renal dysfunction with cisplatin. There is adverse interaction with live and killed virus vaccines.6 weekly Maintenance dose 4 mg/ day. severe renal and hepatic impairment. Injection 1 g vial 60mg / kg bw (upto 1. 1519. somnolence.Rs. lymphomas. thrombocytopenia. 5mg. lactation. ovarian lung and breast cancer. Hepatic and renal impairment.70 (50 mg) Vial Rs.

00 P/A : Dose : D/ I : Cost: Temozolamide : I: C/I : A/E : Dosage Schedule: Cost : ANTIMETABOLITES: Methotrexate I: Lymphoblastic leukemia. 75 mg/ m2 orally on an empty stomach daily during radiation therapy for up to 7 weeks. persons with severe myelosuppression. lmpairs the immunogenicity of the live attenuated vaccine. It forms precipitate with the hydrocortisone hemisuccinate. Anaplastic Astrocytoma. 322. and Metastatic Carcinomas to brain. lactation. urticaria. Nausea. Soft tissue sarcomas Pregnancy. bone marrow depression. Hodgkins.20) Malignant melanoma. 2.4. refractory to nitrosoureas. renal impairment. vomiting. Injection 200mg vial 2.Antimetabolites Cost : Dacarbazine I: C/I : P/C : A/E : Inj: 1 g vial (Rs. Alopecia 1. thrombocytopenia. Hypersensitivity to dacarbazine Myelosuppression. non-metastatic osteosarcoma and in small doses as immunosuppressant 107 . myalgia. hepatic necrosis. blurred vision. Cap 20 mg (5) Rs. choriocarcinoma. 150 to 200 mg/m2 orally on an empty stomach for 5 days every 28 days. flu-like syndrome. 298 Inj: 200 mg vial – Rs. haematologic monitoring. Vomiting. Hepatic / renal impairment. Melanoma. Inj: (100 mg) vial – Rs 294 – Rs. Nausea.5 mg/kg/day x 5-10 days or 250 mg/m2/day x 5 days every 3 weeks or 850mg/ m2 every 3-6 weeks given IV. anaphylaxis. 550 Glioblastoma.5 . hydatidiform mole. photosensitivity. restrict food intake 4-6 hrs before therapy. 360 – Rs. 1812. diarrhoea.

30 mg orally. daily x 5 days weekly repeated doses. renal toxicity.In j. blood counts. hepatic necrosis. Tablets 2. twice a week. 50 mg ampoules. Breast feeding . fibrosis. cholestasis bone marrow depression.Serum concentration of phenytoin decreased. Probenecid. vomiting. salicylates and sulfonamides increase efficacy and toxicity of methotrexate. depigmentation. NSAIDs increase plasma level of methotrexate. Leukemia: Maintenance of remission 30 mg/m2 I. CNS disorders. diarrhoea.45. Food reduces the absorption of methotrexate when taken orally. severe anaemia thrombocytopenia or leucopenia. Etretinate causes hepatotoxicity. bone marrow depression. vomiting. 3-5 courses. Nausea. diarrhoea. GI disorders. anaphylaxis.34 In combination therapy for acute leukemia. 40. Rs.5 mg . Allopurinol delays catabolism of mercaptopurine resulting in severe toxicity. pregnancy. monitor uric acid level. Impaired renal or hepatic function. Procarbazine increases nephrotoxicity of methotrexate. Asparaginase reduce toxicity. Folic acid or derivatives decrease response to methotrexate. Tab 2. hepatic necrosis. Choriocarcinoma 15 .Antineoplastic Drugs C/I: P/C : A/E : P/A: Dose: D/I: Cost: Severe hepatic or renal impairment.00 – Rs.15 mg. 23. 37. 5 mg Injection 5mg.5 mg. chronic granulocytic leukemia.M. Aminoglycosides decrease absorption and serum level of oral methotrexate. Other myelosuppressive Mercaptopurine I: C/I: P/C : A/E : P/A: Dose : D/ I : 108 . Nausea. 15 mg Vial Rs. liver function test. Children. Tablets 50 mg 2-3 mg/kg /bw oral single or divided doses continuously. pancreatitis oral and intestinal ulceration.

skin pigmentation.Antineoplastic Drugs Cost : agents enhance antineoplastic effect of mercaptopurine. lactation Monitor hepatic function. alopecia conjunctivitis. uric acid levels. Treatment and maintenance of meningeal neoplasms. calcium toxicity of 5 flurouracil increased. bone marrow depression. 109 5-Fluorouracil I: C/I: P/C : A/E : P/A: Dose : D/I : Cost: I: Cytarabine (cytosine arabinoside) C/I : P/C: A/E: . oral and Gl ulcers. x 4 days I. angina pectoris. hepatic or renal impairment hypersensitivity. Maintenance 10 . 12. haematological parameters. diarrhoea. multiple superficial basal cell carcinoma. 19. (maximum 8000 mg) . CML blast phase. vomiting. and other parts of Gl tract. cardiac arrhythmias. chestpain. Elevation in alkaline phosphatase and transaminases. Injection 250 mg. Erythroleukemia. women of child bearing age. 8. With leucovorin. Anemia.hepatic and renal dysfunction. Other bone marrow depressants immunosuppresive agents. intrathecal administration in. infants. carcinoma of colon. Serious infection. serum bilirubin Inj: 50 mg vial – Rs.d. 10. Nausea. pancreas. hyperpigmentaion. GI disturbances. Enhanced toxicity with metronidazole. Leucopenia. thrombocytopenia. reticulo cytopenia. Pregnancy. If no toxicity 6 mg/kg on days 6. premalignant keratosis of skin (topical treatment). irradiation all lead to additive effect. NHL in children. leucopenia. breathlessness.00 AML. depressed bone marrow function.V.Cream 5% 12 mg/kg o.15 mg / Kg/ week. anaemia. oral and anal ulcerations. ALL. 500 mg ampoules. urinary bladder. Trimethoprim-sulfamethoxazole enhances bone marrow suppression Tab 50 mg Rs210-Rs765 Adjuvant in the treatment of carcinoma of breast. hepatoma.

and bone sarcoma malignant lymphoma. Inj. Cardiac and hepatic dysfunction. nausea.Antineoplastic Drugs P/ A: Dose : D/I: Cost : thrombophlebitis. alopecia. bone marrow depression. 965. bone marrow depression. alopecia. bronchogenic carcinoma.000 mg/m2 IIV over 30 min once weekly for upto 7 weeks when used as a single agent. conjunctivitis. subsequent cycles are given once weekly for 3 consecutive weeks out of 4.rhabdomyolysis. carcinoma of Breast. Cost : Inj.Efficacy of both gentamicin and flucytosine is decreased. 1000 mg vial 100 mg/m2 IV bd. ( 1 g) vial – Rs. Dosage and Schedule: 1. Non Hodgkin lymphoma. AML. rash. stomatitis. anaphylaxis. haematological and cardiac monitoring. anorexia. 1 g. soft tissue. Injection 100 mg. · Radiotherapy and other myelotoxic drugs potentiate myelotoxic effect. C/I : P/C: A/ E : 110 . pregnancy. 5460 – Rs. Increased serum levels of digoxin when concurrently used. diarrhoea. ovary.tissue damage on extravasation. Buccal ulceration. 500 mg. neuroblastoma. A/E: Myelosuppression and other haematological effects. vomiting. After 1 week of rest. Biliary tract. non metastatic bladder carcinoma (intravesical) Wilm’s tumour. 185. pre existing heart disease. x 7 days. 6200 CYTOTOXIC ANTIBIOTICS: I: Doxorubicin I: Gl tract carcinoma. ventricular arrhythmia.00 100 mg. Nausea. cardiotoxicity.00 Gemcitabine Metastatic or locally advanced carcinoma of Pancreas. breast and ovarian carcinoma. bladder. conjunctivitis. infection. vomiting. high doses. P/C: Prolongation of infusion time > 60 mins increases toxicity. red urine. peripheral neuro toxicity. hyperuricemia.1ml vial – Rs.(10 ml vial) – Rs. fever. Non small cell carcinoma of lungs.

embryonal cell carcinoma of testis. aluminium. squamous cell carcinoma of skin.50mg. 200 – Rs. carcinoma of cervix. vomiting. fever. genito urinary tract. Hodgkin’s and Non. monitor pulmonary function. days 1. arrhythmias.3. Raynaud’s phenomenon. disseminated neuroblastoma. CHF. 430 Palliative and adjuvant to surgery and radiotherapy. CHF. stomatitis.V. Lymphoma patients. Rhabdomyosarcoma. vomiting. . haematological monitoring. hepatic and renal impairment. fever. Injection 20mg vial 45 mg / m2 I.V. red urine. Nausea. Hypersensitivity. anaphylaxis. hyperpigmentation. local tissue damage. oesophagus. diarrhoea. bone marrow suppression.2. 250. increased clearance of doxorubicin with barbiturates. Inj. (10 mg) vial – Rs. cardiotoxicity. skin rashes. neck and head. AML. Inj. ALL. brain tumour.Cytotoxis Antibiotics P/A: Dose : D/I: Cost : Injection l0mg. Repeat after 4 weeks.previous full cumulative dose of doxorubicin or daunorubicin. Immunisation with live vaccine not recommended. choriocarcinoma. Testicular tumour. 111 Daunorubicin I: C/I: P/C: A/E: P/A: Dose : D/I: Cost : Bleomycin I: C/I : P/C : A/E : . chills.20mg. 20 mg vial – Rs. Maximum dose 550 mg/m2. Nausea. allergic reactions. Pre exisitng pulmonary disease hypersensitivity. anaphylactical reaction. bone marrow depression.Heparin. 60 -75 mg/m2 slow I. decreased serum level of digoxin. injection every 21 days. anaesthesia. Cardiac. 350 – Rs.Hodgkin’s Lymphoma. dexamethasone are incompatible with daunorubicin. stomatitis. Enhanced radiation toxicity. rash. glioma. Enhanced hepatotoxicity with mercaptopurine with cyclophosphomide exacerbation of neurologic cystitis. alopecia.

Similar to Gemcitabine including mucocutancous effect. decreased antibody response to vaccines. Leucopenia. or I. increased cardiotoxicity with doxorubicin. monitor renal and haematological status. Inj. SC once or twice weekly.M.0. nausea. 95.00 Adenocarcinoma. Injection 2 mg.00 Mitomycin I: C/I: P/C : A/E: P/A: Dose : D/I: Cost : Dactinomycin I: P/C: A/E: P/A: Dose: Cost : 112 . IM. 210. IM.5 mg /vial inj 15mcg/ kg IV daily for 5 days. bone marrow depression on radiation therapy. Inj. Wilm’s tumour.5 mg/kg IV. Injection 15 mg. loss of hair. pneumopathy. thrombophlebitis. bonemarrow depression. 10mg vials 10 mg/m2 infused IV divided in 5 doses and infused over 5 days.30 mg vial.Antineoplastic Drugs P/A: Dose : D/ I : Cost : pulmonary fibrosis. renal and hepatic toxicity. Total dose 300 . SC.00 – Rs. Hodgkins .00 Gestational Trophoblastic Neoplasm.0. (0. Should not be given IM or SC. loss of appetite. skin rash and possible haemolytic . childhood rhabdomyosarcoma. (15 mg) Vial – Rs.0. Haemorrhagic tendency. Vinca alkaloids produce bronchospasm. lymphosarcoma. Cisplatin toxicity increased. 0.5 mg) vial – Rs. Digoxin and phenytoin levels decreased. recurrent pterygium. Leucopenia.400 mg Small cell cancer . thrombocytopenia.25 mg . oral ulcers. stomatitis.V. 30 mg twice weekly I.25 . thrombocytopenia. increased radiation toxicity. 838. Slow IV push through side arm of running IV infusion.0.uremic syndrome.5 mg / kg IV. hyper-pigmentation. Oxygen increased pulmonary toxicity. renal toxicity. Inj. superficial bladder cancer. seminoma. vomiting. 2 mg vial Rs. 425. Ewing’s Sarcoma.

Mitotic Inhibitors Epirubicin I: P/C: A/E: Dose: Cost: Carcinoma Breast. Alopecia. 2100.00 MITOTIC INHIBITORS Hodgkin’s disorders. Inj. 245. Avoid extravasation. Inj. Non small cell carcinomas of lung.15 mg/kg IV weekly for 3 doses. reduce dose if patient has impaired liver function. repeated every 3 weeks. infusion repeated every 3 weeks.vomiting. Ovary. 522.1 . significant granulocytopenia.00 – Rs. Cardiac effects like irreversible congestive heart failure.00 113 Paclitaxel : I: A/E: Dose: Cost: Docetaxel I: A/E: Dose: Cost: Vinblastine I: C/I: P/C : A/E: P/A: Dose : D/I : Cost: . bacterial infections. testicular cancer. Hodgkins and Non Hodgkins lymphoma. head and neck. (20 mg) vial – Rs. 1400 – Rs. leucopenia. 380 – Rs. mycosis fungoids. non-Hodgkin’s Lymphomas. Vomiting. 3500. hypertension. ovary. (10 mg) vial – Rs. Hepatic function impairment. Lung. kaposis sarcoma Leucopenia. Concurrent use with mitomycin cause acute shortness of breath and severe bronchospasm. 30 mg vial Rs.00 TAXANES Metastatic carcinoma of Breast. Nausea. (10 mg) vial Rs. 4000. Esophagus. Ovary and Prostate. Reduced plasma levels of phenytoin. repeat at 3 days. Melanoma Same as Dactinomycin 175 mg/m2 by IV infusion over 3 hours. 100 mg / m2 I. Injection 10 mL vial 0. neutropenia and constipation Inj.00 Carcinoma Breast.Concurrent use with erythromycin cause severe myalgia. Needle should be properly positioned in vein as leakage may cause considerable irritation. Stomach. Stomach. azoospermia. nausea. Myelosuppression.0. Inj.V. Same as Dactinomycin 100 mg/m2 IV over 1 hour. alopecia.

5 . demyelinating Charcoat Marie disease. pregnancy. neuromuscular disease. jaw pain. Nausea. leukaemia.Antineoplastic Drugs Vincristine I: C/I: P/C : Acute leukaemia. Anaphylaxis 20 –30% 10.00 Testis. pulmonary diseases. endometrial. bladder. extravasation. tooth syndrome. Hepatic clearance of vincristine is reduced if L-asparaginase is administered first. Pancreatitis. (5000 IU) vial – Rs. Infection. So Vincristine should be given 12-24 hrs before Lasparaginase. acute pulmonary reaction may occur with mitomycin. neuroblastoma. concomitant neurotoxic drugs. Inj. Intrathecal administration. 50-200 KU/kg IV daily for 2 to 4 weeks. A/E: P/A : Dose : D/I : Cost: L. head and neck. leucopenia. 63. eye contact. Local reaction if extravasation occurs. (1 mg) vial –Rs 48. Injection 1 mg. breath-lessness. serious allergic reactions Myelosuppression. peripheral neuropathy. ototoxicity. gastro intestinal and lung carcinomas. Do not administer if serum creatinine level > 1.00 MISCELLANEOUS AGENTS Acute Lymphocytic Leukemia for induction therapy. lymphoma.000 KU/vial injection. paralytic ileus. 1. Non hodgkin’s lymphoma.Vomiting. syndrome of inappropriate antidiuretic hormone (SIADH). concurrent vaccination.5 mg/dL Same as above drug. hyper or hypotension. cervical.00 – Rs. constipation. radiation therapy. 970.Asparaginase: I: C/I: A/E: P/A: Dose: Cost: Cisplatin I: P/C: A/E: 114 .2 mg/m2 IV weekly Decreased plasma digoxin level. bone marrow depression. Wilm’s tumour. ovary.reduced plasma phenytoin levels. Inj. 5 mg ampoules. soft tissue and bone sarcomas. including renal tubular damage.

Tab (50 mg) Rs. stomach carcinoma. Decrease dose by 25% if creatinine clearance is 30 mL / min. Inj.4 weeks. flatulence. on days 1 to 3 every three weeks. vomiting. diarrhoea. Slow IV infusion 50 . carcinoma of stomach. Nausea. Inj. P/C: Administer as 30 to 60 min infusion to avoid severe hypotension.100 mg/m2 every 3 . (20 ml) vial – Rs.00 (50 ml) vial – Rs.00 – Rs. A/E: Similar to L-Asparaginase.Hormones and Hormonal antagonists P/A: Dose: Cost : 10 mg/10 mL and 50 mg/50 mL vials. 300. 150 mg (15 mL) vial – Rs. (50 mg) vial – Rs. 546 HORMONES AND HORMONAL ANTAGONISTS I: Androgen Antagonist Bicalutamide I: P/C: A/E: P/A: Dose: Cost: Carcinoma of Prostate Moderate to Severe hepatic impairment Nausea.00 450 mg (45 ml) vial – Rs.00 400 mg/m2 as an IV infusion over 15-16 minutes. diarrhea common. Tab 50 mg. to be repeated only after 4 weeks. non small cell lung cancer. laryngospasm 130 mg/m2 as a two hour infusion every 3 weeks Inj. lymphomas.80.990. 5175. elevated liver function. 1050 115 . 2394. 372 – Rs. 50 mg orally daily morning or evening. Avoid cold drinks or food along with drug. Neuroblastoma. 50 mg (vial) Rs.00 Carcinoma colon and rectum. Avoid extravasation. Dose: 120 mg/m2 IV. Cost: Inj. germ cell cancers.00 Carboplatin Dose: Cost: Oxaliplatin I: P/C: A/E: Dose: Cost: Etoposide Small cell anaplastic and Non small cell lung carcinoma. 423 – Rs. Must be diluted in 20 to 50 volumes (100 to 250 ml) of isotonic saline before use. Acute leukemia. 2385.

Pregnancy Nausea. 18.00 – Rs.5 mg – Rs. C/I: A/E: Dose: Cost: Letrozole I: C/I: A/E: Dose: Cost: Estrogen Antagonist Tamoxifen It is a non steroidal antioestrogen. advanced or metastatic carcinoma breast as Ist therapy in post menopausal women. D/I : Antagonism to the action of oral anticoagulants. 2.5 mg orally daily. Cyclophosphamide level is increased. Pregnancy. pregnancy P/C : Premenopausal women A/E : Nausea. rash are uncommon. 235 . 150 116 . with positive or unknown hormonal receptors. Tab-2. hot flushes. hot flushes. hormone receptor positive or unknown in post menopausal women with progression following anti estrogen therapy. dermatitis. Tab – 2. Nausea. I: Advanced or metastatic carcinoma breast C/I : Hypersensitivity. 20 mg Dose : 10 .Antineoplastic Drugs Aromatase Inhibitors Anastrazole I: Carcinoma Breast as adjuvant treatment in Post Menopausal Women.5 mg – Rs.e. serum tamoxifen level is increased with bromocryptine. 95-Rs. musculoskeletal pain is common. rash are uncommon. menstrual irregularities. musculo skeletal pain is common. hot flushes.20 mg od. vomiting.5 mg orally daily. 95 – Rs 235 Advanced or metastatic carcinoma of breast i. P/A: Tablets 10 mg. vaginal bleeding. pruritus vulvae. Cost: Tab 10 mg Rs. 2. vomiting. vomiting. in women not responding to tamoxifen.

parasthesia. Interferon alph 2A Inj. renal cell carcinoma. 3 -10 million IU IM in various schedules. 3 mIU vial Rs. Myelosuppression and other haematological effects. 117 P/C: .50 Inj. 1190 Interferon alph 2B Inj 3 mIU vial Rs 895. kaposi’s sarcoma. Infusion related symptoms like fever and chills. partial alopecia. chronic hepatitis B and C Aggravate life threatening neuropsychiatric autoimmune. Starting dose of 50 – 100 mg once daily in the evening. mild hypotension. CML. flu like syndrome. menstrual irregularities are common. Dose is escalated weekly by 50 – 100mg until the maximum dose of 400 mg. TARGETED AGENTS Dose: Cost: Thalidomide I: C/I: A/E: Dose: Monoclonal Antibodies Rituximab I: Non Hodgkin’s B cell lymphoma i. ischemic and infectious disorders.00 BIOLOGICAL RESPONSE MODIFIERS Interferon Alpha I: P/C: A/E: Melanoma. Cost: Tab – 10 mg Rs. peripheral neuropathy with chronic therapy. Multiple myeloma.Hypothyroidism is occasional. Chronic lymphocytic leukemia. hepatitis B reactivation with related fulminant hepatitis. 150 mg/30 ml –Rs 60.Targeted agents Progestins Medroxy Progesterone Acetate I: Endometrial Carcinoma A/E: Increased apetite and weight gain are common.e. low grade or follicular CD 20 Positive and diffuse large B cell. Pregnancy. anorexia and nausea. multiple myeloma. myelodysplastic syndromes. Constipation. 44 . Dose: 1000 to 1500 mg IM weekly Or 400 to 800 mg orally twice weekly. macular rash involving trunk.

Carcinoma of breast that has over expression of HER 2/ neu (C-ERB-2) either in advanced disease or as an adjuvant therapy Pre existing cardiac dysfunction Nausea. 2 mg / kg IV over 30 mins. All Ph+ chromosome positive GIST (Gastrointestinal stromal tumour) Moderate neutropenia and thrombocytopenia .Antineoplastic Drugs A/E: Dose: Trastuzumab I: Nausea . Bone metastasis from breast cancer. Carcinoma of lung Diarrhoea may be dose limiting and require discontinuation of drug. skin rash. TYROSINE KINASE INHIBITORS CML in Chronic phase. 4 mg /kg IV loading dose over 90 mins.V. Acceralated or blast phase of the disease. chest pain.infusion related reactions. dyspnoea and cough. P/C: A/E: Dose: Imatinib Mesylate: I: A/E: Dose: Gefitinib I: P/C: A/E: Dose: Zoledronic Acid : I: P/C: 118 .Nausea.rashes. diarrhoea and abdominal pain. Nausea. Osteonecrosis of jaw with tooth extraction. vomiting. myalgia. diarrhoea . infusion. 400 to 600 mg orally daily in chronic phase of CML and ALL. vomiting. 375 mg/m2 given as slow I. back pain. arthralgia. Prostate cancer and from other solid tumours.infusion related hypersensitivity reactions. diarrhoea folliculitis type rash 200 to 500 mg daily BISPHOSPHONATES Hypercalcemia associated with malignancy. vomiting. Multiple Myeloma (Osteolytic and osteoporotic bone lesions) Do not infuse over less than 15 mins – potential for renal tubular damage if infused rapidly.

Cytoprotective agents A/E: P/A: Dose: Infusion site reactions. ONDANSETRON 2. 93. PALONOSETRON 4. Cost: Inj.4 weeks interval.nausea. may be repeated after seven days and then at 3 . 500 mg vial – Rs. P/C: To minimize hypotension during infusion. Nausea. transient hypotension. A/E: Nausea and vomiting . Inj. vomiting. over 15 minutes. For reduction of moderate to severe xerostomia from radiation of head and neck. 4 mg diluted in 100 ml saline/glucose solution and infused IV. blood pressure to be monitored every 5 mins during Infusion. At least 20% of Ifosfamide dose on weight basisI administered just before Ifosfamide dose and again at 4 and 8 hour after the Ifosfamide. 100 mg / 2 ml – Rs. Dose: 910 mg/m2 IV over 15 mins once daily. Patients sensitive to thiol compounds.00 Mesna : I: C/I: A/E: Dose: Cost: Amifostine : For reduction of cumulative renal toxicity associated with repeated administration of Cisplatin in patients with advanced cancer. CYTOPROTECTIVE AGENTS Prophylaxis for Ifosfamide induced haemorrhagic cystitis. GRANISETRON 3. 1400 ANTIEMETICS USED IN CANCER CHEMOTHERAPY : (REFER SECTION 17) 1. diarrhoea (occasional) bad taste in mouth. to detoxify the urinary metabolites that cause haemorrhagic oystitis. starting 30 mins before chemotherapy. 997 – Rs. METOCLOPRAMIDE I: 119 . vomiting occasional 4 mg/Vial injection. potential bronchoconstriction in aspirin sensitive patients.

vivid dreams. confusion. taste disturbances. confirmed or suspected malignant melanoma Pulmonary disease. tachycardia. particularly at the start of treatment. osteomalacia. dizziness. psychiatric.7 ANTIPARKINSONIAN DRUGS Carbidopa + Levodopa: Carbidopa is a representative peripheral dopa decarboxylase inhibitor. insomnia. neuroleptic malignant syndrome. peripheral neuropathy. postural hypotension at the start of treatment. on sudden withdrawal. rash. history of melanoma (risk of activation). angle closure glaucoma. arrhythmias. anorexia and vomiting. delusions and neurological disturbances including dyskinesias may be doselimiting. warn patients to resume normal activities gradually. open-angle glaucoma. flushing. excessive drowsiness and sudden onset of sleep (warn patient of these effects). P/C: A/E: 120 . and renal function required in long-term therapy. hallucinations. haematological. cardiovascular disease (including previous myocardial infarction). rarely hypersensitivity. depression. Various drugs can serve as alternatives I: C/I: All forms of parkinsonism other than drug-induced Concurrent use of monoamine oxidase inhibitors. painful dystonic spasms (‘end-of-dose’ effects) and (‘on-off’ effects) after prolonged treatment. reddish discoloration of body fluids.SECTION . liver enzyme changes. pregnancy (toxicity in animals). psychiatric symptoms including psychosis. pruritis. gastrointestinal bleeding. peptic ulceration. breastfeeding Nausea. cardiovascular. psychiatric illness (avoid if severe). diabetes mellitus. close monitoring of hepatic. headache. particularly in elderly and those receiving antihypertensives. avoid abrupt withdrawal. elderly: avoid rapid dose increases.

porphyria.00 . first week 1-1. Prevention or suppression of lactation oral: 2.5 mg on day 1(prevention) or daily for 2-3 days (suppression).5mg twice daily.5mg twice daily for 14 days. annual gynaecological assessment. 30mg daily.5mg at bedtime increased gradually to 7. history of mental disorders or cardiovascular disease or Raynaud’s syndrome. by mouth. Tablets.Dopaminergic agonist P/A: Dose: Tablet 100 mg + 10 mg. postural hypotension. 1-1. initially 100 mg (with carbidopa 10 mg) twice daily. GI disturbances. prolactinomas. third week 2. hypersensitivity. Tab 2.25mg at night. Monitor for pituitary enlargment particularly during pregnancy.5mg at night.5 g Optimum daily dose must be determined for each patient by careful monitoring and be taken after meals DOPAMINERGIC AGONIST Parkinsonism.290 121 Bromocriptine. vasospasm of fingers and toes particularly in-patients with Raynaud’s syndrome.5mg 3 times daily. initial. ADULT expressed in terms of levodopa. drowsiness. second week 2-2.30mg daily. galactorrhoea and cyclical benign breast disease.5mg. 250 mg + 25 mg. Prolactinoma oral. then increasing by 2. increased by 100 mg (with carbidopa 10 mg) every few days as necessary. uncontrolled hypertension. Parkinsonism. then 2.5mg every 3-14 days according to response to a usual range of 10-40mg daily. to a maximum of levodopa 1. initial. max. 1-2.5mg daily in divided doses. contraceptive advise if appropriate (oral contraceptives may increase prolactin concentration). dizziness. 2.25mg at bedtime increased gradually to 5mg every 6 hours. Eclampsia. I: C/I : P/C: A/E: P/A : Dose: Cost: . headache. lactation.5mg (10) Rs 72. fourth week 2. Galactorrhoea: oral. Parkinsonism: oral. and monitor for retroperitoneal fibrosis. max.

headache. increased by increments of 750mcg at weekly intervals to 3mg daily. drowsiness. Tablets. Sedating drugs and alcohol used with pramipexole leads to additive effects and sudden onset of sleep. Initial dose 125mcg tds increased to 250 -500mcg tds according to response to a maximum dose of 4. severe cardiovascular disease. occasionally severe hypotension and bradycardia. pathological gambling.25mg (10) Rs 16.5mg (10) Rs 23. Tab 0.5mg daily. leg edema. either used alone or as an adjunct to levodopa. major psychotic disorders.00 Tab 1mg (10) Rs 44.00 Tab 0. postural hypotension. Moderate to severe restless leg syndrome. A/E: P/A: Dose: Cost: Pramipexole I: P/C: A/E: Dose: D/I: 122 . abdominal pain.47. 1mg. Used with caution in patients with renal impairment and regular ophthalmologic monitoring for visual impairment. Nausea. GI disturbances. dizziness. dyskinesia.50 . hallucinations and confusion reported in adjunctive therapy.86. initially 750mcg daily in 3 divided doses.5mg. renal impairment. vomiting and syncope.00 . Pregnancy and breast-feeding.25mg. 0. 2mg Oral. 0.50 Parkinson disease either alone or as an adjunct to levodopa therapy to reduce the end of dose or on-off fluctuations in response. Hepatic impairment. maximum 24mg daily.Antiparkinsonian Drugs Ropinirole I: C/I : P/C : Parkinson’s disease. vasospasm of fingers and toes particularly in-patients with Raynaud’s syndrome. drowsiness.50 .27. further increased by increments of upto 3mg at weekly intervals according to response. usual range 39mg daily.50 Tab 2mg (10) Rs 76. avoid abrupt withdrawal.

psychosis. leucopenia. skin reactions. transient increase in liver enzymes. muscle cramps. rhinitis. arrhythmias. 10mg in the morning or 5mg at breakfast and midday. Head ache. 123 . vertigo. depression. angina pectoris. Mild hepatic impairment. anorexia. Severe/moderate hepatic impairment. hypotension. dry mouth. difficulty in micturition. Tab 1 mg 1 mg once daily Hypertension with MAO inhibitors. conjunctivitis. sore throat. joint pain. pregnancy and breast-feeding. tremor. Tablets.MAO B Inhibitor MAO B Inhibitor Selegiline I: P/C: Parkinson’s disease or symptomatic parkinsonism used alone as an adjunct to levodopa. GI disturbances. sleep disturbances. dyspepsia. stomatitis.50 – 49. melanoma. malaise. dizziness. tobacco smoking decreases plasma drug levels. urinary urgency. 5mg. Gastric and duodenal ulceration (avoid in acute ulceration). entacapone increases clearance. side effects of levodopa may be increased. concurrent levodopa dosage may need to be reduced by 10-50%. CYP450 inhibitors increase blood levels. headache. psychosis. back pain.10 In parkinsonism either alone or as an adjunct to levodopa therapy to reduce end of dose fluctuation in response. Tab 5mg (10) 32. agitation. confusion. neck pain. A/E : Dose : P/A: Cost: Rasagiline I: C/I: P/C: A/E: P/A: Dose: D/I: COMT inhibitors Entacapone I: In Parkinson’s disease as an adjunct to combination preparation of levodopa and dopa decarboxylase inhibitors. Oral. vertigo. uncontrolled hypertension. angina. flu like syndrome.

Biliary obstruction. constipation. convulsions. Hepatic or renal impairment. Cap l00mg Parkinsonism: oral. dobutamine. abdominal pain. insomnia. rimiterol. DOPAMINE FACILITATOR Amantadine I: C/I: P/C: Parkinsonism. Nausea. Given by mouth 200mg at the same time as each dose of levodopa with dopa decarboxylase inhibitors up to maximum of 200mg 10 times daily. neuroleptic malignant syndrome. 100mg daily and increased after 1 week to 100mg twice daily upto 400mg maximum A/E : P/A: Dose: 124 . nervousness. Epilepsy. elderly. Use with caution with tricylic antidepressants. combination with non-selective MAO inhibitors. Anorexia. Night mares hallucinations. confused or hallucinatory states. diarrhoea. herpes zoster and influenza A. driving and operating machinery. increased sweating. vomiting. apomorphine. blurred vision. livedo reticularis and peripheral oedema. patients with hepatic impairment. inability to concentrate.Antiparkinsonian Drugs C/I: P/C: A/E: Dose: D/I: In patient with pheochromocytoma and in patients with history of neuroleptic malignant syndrome or non traumatic rhabdomyolysis. aggravates levodopa induced orthostatic hypotension. hallucinations or feeling of detachment. nausea. dizziness. gastric ulceration. pregnancy. dopamine. avoid abrupt discontinuation in Parkinson’s disease. Drugs metabolized by COMT including adrenaline. dry mouth and dyskinesias. gradual drug withdrawal. paroxetine. rarely cholestatic hepatitis. and severe renal disease. may affect performance of skilled tasks. congestive heart disease. reversible inhibitors of MOA-A and venlafexine. GI disturbances. breast-feeding. isoprenaline. rhabdomyolysis and harmless reddish brown discolouration of urine. chelates Iron preparations.

D/I: Similar to atropine.5mg to 5mg every 2-3 days until the maintenance dose usually 10-30mg daily in three divided doses. Inj. if necessary extended for further 14 days for post-herpetic pain.30 125 . nervousness. l00mg daily for 4-5 days. tachycardia.5mg.5mg (10) Rs 16. A/E : Dry mouth. P/A: Tab 2mg. hepatic or renal impairment.20 Tab 5mg (10) Rs 22. Paroxetine increases plasma procyclidine concentration. and with high doses in susceptible patients.20 Inj 2mg/mL (10) Rs 15. 100mg twice daily for 14 days. mental confusion. increase gradually by 2. hypersensitivity. P/A: Tab 2. gradually increased by 2mg increments to maintenance dose of 6-10mg daily in 3-4 divided doses.Central Anticholinergics daily (with close supervision). drug-induced extrapyramidal symptoms (but not tardive dyskinesia). 5mg Dose: Initial dose 2. Cost: Tab 2mg (10) Rs 3. avoid abrupt discontinuation of treatment. dizziness. elderly. Cost: Tab 2.20 Procyclidine I: Parkinsonism. dystonias. Psychotic episodes may be precipitated in patients with mental disorders. blurred vision less commonly urinary retention. treatment. Herpes zoster: Oral. A/E: Similar to atropine. 100mg daily for 6 weeks. C/I: Untreated urinary retention. CENTRAL ANTICHOLINERGICS Trihexyphenidyl / Benzhexol I: Parkinsonism. 2mg/mL Dose: Oral. prophylaxis. 12-15mg or more daily in severe cases. excitement psychiatric disturbances. may affect performance of skilled tasks.5mg tds. angle closure glaucoma and GI obstruction. 5mg. P/C.00 – 17. liable to abuse. P/C : Cardiovascular disease. GI disturbances. 1 mg daily. In emergency 510mg by IV injection. Influenza A: oral.

A/E: D/I: P/A: Dose: Cost: Promethazine I: C/I : P/C: A/E : P/A: Dose: In Parkinsonism especially for alleviation of drug induced extra pyramidal syndromes. emergency treatment of anaphylactic reactions.50 Cost: 126 . Injection 25mg/ml. Tab 10mg. Tab 50mg (10) Rs 12. Comatose patients. 2ml ampoules. relieve pain due to skeletal muscle spasm. 25mg at night increased to 25mg twice daily if necessary or 10-20mg 2-3 times daily. Tab 25mg (10) Rs 11. Caution with bupropion.00 – 23. children. Similar to atropine.: 25-50mg.Antiparkinsonian Drugs Orphenadrine I: P/C. As for chlorpheniramine. Tab 50mg Initially 150mg daily increased by 50mg every 2-3 days and maintenance dose is 150-300mg daily. premedication. Similar to atropine.40 Allergy. Cardiovascular. hepatic disease. 25 mg. of 100mg. in combination with NSAID for musculoskeletal and joint disorders. Unsafe in porphyria. Oral. upto a max. Slow IV/deep IM. May also cause insomnia. pregnancy.

alongwith erythropoietin : oral iron may not be absorbed at 127 . inflammatory bowel disease.pregnancy : 60-100 mg per day for atleast 100 days.failure to absorb oral iron : malabsorption.duration of treatment 6 -12 months after correction of anemia PARENTERAL IRON THERAPY Iron sucrose Sodium ferric gluconate I: Oral iron is not tolerated. Prophylactic dose .8 DRUGS ACTING ON BLOOD AND BLOOD FORMING ORGANS ANTI ANAEMIC DRUGS Nutritional anemia a) Iron deficiency anemia Oral iron preparations GENERIC NAME TAB:[IRON CONTENT]/ MG FERROUS SULFATE EXTENDED RELEASE FERROUS FUMARATE FERROUS GLUCONATE POLY SACCHARIDE IRON 325 (65) 195 (39) 525 (105) 325 (107) 195 ( 64) 325 (39) 150 (150) 50 (50) ELIXIR [IRON CONTENT]/ MG IN 5 mL] 300 (60) 90 (18) 100 (33) 300 (35) 100 (100) A/E: Dose: Epigastric pain. nausea. as 3 or 4 iron tablets [ each containing 50-65 mg elemental iron] per day. staining of teeth. vomiting. 30 mg/ day. chronic inflammation.non compliance. metallic taste.SECTION .in presence of severe deficiency with chronic bleeding. heart burn. constipation Upto 300 mg of elemental iron per day.children : 3-5 mg/kg/day in 2-3 divided doses.

skin rash. 2 mL ampoule 2 mL daily deep IM or on alternate day Iron dextran IV infusion Test dose of 0. patients requiring cardioversion. low grade fever 100 mg iron preparation should be diluted in 5% dextrose in water or 9% NaCl solution infused over 60-90 minutes. Anaphylaxis.5 mL iron dextran injected IV over 5 to 10 minutes. Other preparations of parenteral iron Iron dextran A/E: P/A: Dose : Giddiness. valvular heart disease. paraethesias and constriction in the chest.Drugs acting on Blood and Blood Forming Organs A/E: Dose: sufficent rate to meet the demand of induced rapid erythropoiesis.4xbody weight (kg) x Hb deficit g/dl) is diluted in 500 mL of glucose/saline solution and infused over 6 to 8 hours. Total calculated dose (Parental iron requirement (mg)= 4. severe liver diseases.peptic ulcer. recent surgery. Haemophilia and other bleeding disorders.5 mg orally daily may be needed in patients with malabsorption syndromes. arthralgia. Iron sorbitol citric acid complex P/A: 50 mg iron/mL Dose: 50mg IM only b) Megaloblastic anemia Treatment of cobalamin deficiency Parenteral: 1000 mcg IM injections of hydroxocobalamin given at 3-7 days interval for 6 doses.recent trauma. DRUGS AFFECTING COAGULATION Heparin Anticoagulant drug for parenteral use. thrombocytopenia. C/I: 128 . pulmonary embolism. 50 mg / mL. more frequent doses may be needed with cobalamine in neuropathy maintenance therapy 1000 mcg im monthly c) Folic acid deficiency 1 mg orally until deficiency is corrected. deep vein thrombosis. I: Dilated cardiomyopathy. atrial fibrillation. recent CVA.

129 . Bleeding is a commonest complication. Low dose heparin 1500 units subcutaneously is given prophylactically to prevent venous thrombosis. d. Haemorrhage.00/- Low molecular weight heparin A variety of preparations are available and have the same indications and contraindications that conventional heparin has: a.25. once daily dosing and because of predictable bioavailability no monitoring required. c. Inj 5000 U/ mL (5 mL) Rs.osteoporosis after prolonged use. Overdose of heparin is treated by protamine administration. the patient’s value should be 1 ½ . hypersensitivity reactions. Because of long half life.Drug affecting Coagulation P/C: A/E: P/A: Dose : D/I: Note: Cost: Can induce thrombocytopenia.2 times the control value. Dose of heparin should be adjusted depending on the partial thromboplastin time.000 IU Myocardial infarction. pulmonary embolism.69. thrombocytopenia. I: C/I: P/C: A/E: same as other LMW Heparin when Creatinine Clearance is <30ml/min Reduced dose needed with moderate renal dysfunction. Dipyridamole also increases the anticoagulant effect.Subcutaneous heparin 7500 — 12500 units bd. e. Dalteparin sodium Tinzaparin Enoxaparin Nadroparin (fraxiparine) Reviparine-6ml vial Rs 2950/- Fondaparinux Synthetic analogue of pentasaccharide sequence required for binding of heparin molecule to anti thrombin.20. Thrombocytopenia rarely occur. 68. Aspirin enhances the anticoagulant effect of heparin.00 . careful use in renal and hepatic diseases.000 IU. b. deep vein thrombosis 5000 units IV bolus followed by continuous infusion of 1000 units hrly for 24 h. NSAIDs should be used with caution because of the risk of gastrointestinal bleeding. alopecia Injections 5000 IU.

Drugs acting on Blood and Blood Forming Organs P/A: Dose: Cost: 2.5mg injection.5mg daily for Acute coronary syndrome. Alcohol. 18. nausea. Vitamin K. atrial fibrillation. erythromycin.75 mg/kg/h for the duration of the PCI procedure. Recent surgery.times control). Warfarin I: C/I: P/C: A/E: P/A : Dose: D/I: Cost: Bivalirudin I: C/I: P/C: A/E: P/A: Dose: 130 .3 mg/kg should be given if needed. bacterial endocarditis.19. hypersensitivity Cautious use during brachytherapy procedures Bleeding. the INR should be kept at 3 -4. Rs. Five min after the bolus dose has been administered.5. Deep vein thrombosis. prosthetic valves. Haemorrhage. all increase the anticoagulant effect.vomiting 250 mg vial Recommended dose is an intravenous (IV) bolus dose of 0. renal disease. amiodarone. hypotension.5mg injection 2. Loading dose 10 mg for 2 days then adjust dose. In cases of prosthetic valves. Active major bleeding. thyroxine. hepatic disease. Tab 5 mg (10) Rs.00/Anticoagulant in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA).5mg SC daily for DVT treatment.Patients should be instructed regarding bleeding complications when they are on warfarin.simvastatin. an ACT should be performed and an additional bolus of 0.00 . anabolic steroids. barbiturates reduce the effect of anticoagulants. bleeding disorders. 600-700 for 2.pulmonary embolism.5 . according to prothrombin time (INR1. Tablets 5 mg. Pregnancy. This should be followed by an infusion of 1. 2.5mg SC daily for DVT prophylaxis and 7.75 mg/kg. ciprofloxacin.antiplatelet drugs. LV thrombus.

cardiac arrest.Rituximab 375 mg/m2 BSA.tumor lysis syndrome causing acute renal failure. Hydroxyurea I: Myeloproliferative disorders (primarily polycythemia vera) not responding to venepuncture and essential 131 .administered IV at twice weekly intervals.Bone marrow transplantation can provide definitive cures.immune toxicity. exposure to heat or cold.IV weekly for 4 doses A/E: serious adverse events.IV IG is less effective than in ITP with a response rate of about 40%. Pneumococcal and Haemophilus influenza vaccines are less effective in splenectomized individuals.Haemolytic Anaemias HAEMOLYTIC ANAEMIAS Autoimmune hemolytic anemia(AIHA) Warm AIHA: Glucocorticoids : prednisone 1 mg/kg can be tapered over 2-3 months.hepatitis B reactivation. patients with Sickle Cell Anemia should be vaccinated early in life. with depletion of B cells in 70% to 80% of patients with Non Hodgkin’s lymphoma. IV weekly for 4 doses.Gene therapy is also useful. Folic Acid supplements: 3 mg/day Hemolytic disease of the new born Exchange transfusion with Rh negative group ‘O’ blood if say Bilirubin is > 20 mg% in term babies and >15 mg% in pre-term babies. Thus. which can cause death and disability include severe infusion reactions.other viral infections progressive mutlifocal leukoencephalopathy (PmL). Idiopathic cold (AIHA): Rituximab 375 mg/m2 BSA.infections. (150ml/kg body weight of compatible blood is required for an exchange transfusion) HAEMOGLOBINOPATHIES Sickle Cell Syndromes Antibiotic prophylaxis appropriate for splenectomized patients during dental or other invasive procedures. pulmonary toxicity Paroxysmal nocturnal hemoglobinuria(PNH) Eculizumab: is a humanized monoclonal antibody against complement protein C5. emotional stress or infection. Vigorous oral hydration during or in anticipation of periods of extreme exercise.

5 mg/kg every 2-4 h) should control severe pain).75 -1. Sickle Cell Disease (Breaks down cells that are prone to sickle.000-10. Bone marrow transplantation is an attractive option for those who can afford and who have compatible donors. and oxygen therapy should be especially vigorous for protection of arterial saturation. These drugs help to elevate the content of foetal haemoglobin.00. skin changes 10-30 mg/kg per day Management of Acute painful crisis Includes vigorous hydration. Drugs used in thalassemias include hydroxyurea in a dose of 500 . Acute Chest Syndrome Is a medical emergency. Hydration should be monitored carefully to avoid the development of pulmonary edema.1000 mg b.azacytidine (50 .1 – 0. In the case of thalassemia major it is ideal to put them on super transfusion therapy from early life with the aim of maintaining the haemoglobin around 12g/dl.00. I: To prevent and treat iron overload in conditions requiring frequent.Drugs acting on Blood and Blood Forming Organs A/E: Dose: thrombocytosis). vomiting and diarrhea.as well as increasing content). Thalassemias Two types of Thalassemias are there: Thalassemia major and Thalassemia minor. cytosine arabinoside given IV or IM in different dosages and 5 . mucositis.and thereby reduce the clinical severity of the disease. orally. Second Line treatment for Psoriasis Drowsiness.and repeated whole blood or packed red cell transfusions. haemochromatosis.400 mg/m2 body surface. along with iron chelating therapy. Critical interventions are transfusion to maintain a hematocrit > 30. and emergency exchange transfusion if arterial saturation drops to < 90%. acute toxicity by overdose of medicinal 132 .15 mg/kg every 3-4 h) or meperidine (0. nausea. IRON CHELATING DRUGS Desferrioxamine It is a useful iron chelating agent. Inhalation of nitrous oxide. (which may take 7-21 days to recover after the drug has been discontinued). Nasal oxygen. thorough evaluation for underlying causes (such as infection). Cost of bone marrow transplantation in India is around Rs. 7. haemosiderosis.000. and aggressive analgesia (Morphine 0.d.daily for 5 days).

arthritis. Agranulocytosis. hypotension. DRUGS USED IN LEUKEMIA Acute Lymphatic Leukemia Remission induction therapy Prednisolone. in three divided doses. hepatic and renal damage. genetic counselling and iron chelation therapy when indicated.5 . toxic overload of ron in the liver. Tablets 250 mg.5 mg / m2 IV 7 days interval Asparaginase 10. Inj 500 mg / vial (5) Rs. drug· induced lupus erythematosus. 500 mg.00/- Deferiprone It is an oral iron chelating drug I: P/C: A/E: P/A : Dose : Cost: Iron chelation Pregnancy and lactation. arthralgias. SC infusion overnight or along with the blood transfusion. 700. pregnancy and lactation. arrhythmia. Injection 500 mg / vial 20 — 40 mg/kg/bw daily given as a. Renal impairment Impaired renal function. blurring of vision and local reactions at the site of injection. Gastrointestinal disturbances. 0. Vit C enhances the urinary elimination of iron and therefore acts synergistically.000 U/m2 IV daily for 5 days 133 . 475.00 Heterozygous thalassemia (Thalassemia minor) Essentials of therapy consist of strict avoidance of medicinal iron.anaphylaxis.Iron chelating drugs C/I : P/C: A/E: P/A: Dose : D/I : Cost : iron. aluminium overload in chronic haemodialysis patients. children below 3 years. Antipsychotic drugs administered concurrently may lead to adverse interaction. 40 mg/m2 oral daily Vincristine 1-1. This has to be repeated 4-5 times a week indefenitely as long as transfusion therapy is needed.3 g daily (100 mg/kg bw) to be given 1 h before food. Tablet 250 mg (50) Rs. increased susceptability to infection.

Pediatric:40 mg/m2/daily orally tid Important chemotherapeutic agent in treatment of ALL. etoposide.People who have a type of AML called acute promyelocytic leukemia (APL) are usually treated with a drug called ATRA 134 .1.Pediatric:. Details of above drugs refer section 6 Prednisone I: Important chemotherapeutic agent in treatment of ALL. Also given as intermittent pulses during continuation therapy.These drugs are usually given in combination. Also given as intermittent pulses during continuation therapy. ( Refer section 18 Hormones) Adult: 20-25 mg orally tid. Used in induction and reinduction therapy.5 mg/m2 IV.5 g / m2 IV every month.Continuation therapy : 2 mg IV every month. Maintenance therapy continued for 2 years. cytosine arabinoside.Drugs acting on Blood and Blood Forming Organs Other drugs used for induction are doxorubicin. not to exceed 2 mg/dose C/I: P/C : Dose: Dexamethasone I: C/I: P/C : Dose: Vincristine ( Refer section 6 ) Dose: Asparaginase (Refer section 6) Methotrexate (Refer section 6) 6-mercaptopurine (Refer section 6) AML (Acute Myelogenous Leukemia) Treatment for acute myeloid leukemia: Chemotherapy is the main treatment used. Used in induction and reinduction therapy. Vincristine 1. Maintenance therapy Methotrexate 15 mg/m2 oral single weekly dose. 6 – Mercaptopurine 600 mg/m2 /week oral divided into daily doses. ( Refer section 18 Hormones) Adult: 6-8 mg/m 2 /d orally divided tid.Pediatric: Administer as in adults Adult:-Induction therapy : 2 mg IV qwk.

It is characterized by fever. ATRA shouldn’t be given to women who are under 12 weeks pregnant as this can cause damage to the baby. Occuring within the first 3 weeks of treatment. ATRA in pregnancy It is important not to become pregnant while taking ATRA.ATRA is given for up to three months alongside chemotherapy treatment. It is a specialized form of Vitamin A and is also known as tretinoin. Glucocorticoids. The most commonly used induction chemotherapy drugs are:Cytarabine (Ara-C) Daunorubicin Etoposide Fludarabine Idarubicin 135 . Usually it’s given without chemotherapy as this is safer for the baby and still effective.) A/E: Tretinoin produce complication called the retinoic acid syndrome. pleural and pericardial effusions and hypoxia. pulmonary infiltrates. Tretinoin (45 mg/m2per day orally until remission is documented) plus concurrent anthracycline chemotherapy appears to be among the safest and most effective treatments for APL. ATRA (All Trans-Retinoic Acid) ATRA is given alongside chemotherapy to people with a type of acute myeloid leukemia called acute promyelocytic leukemia (APL). and/ or supportive measures can be effective for management of the retinoic acid syndrome. It works by making the leukemia cells mature. Induction chemotherapy in AML The first cycles of chemotherapy are called induction chemotherapy. and so can reduce leukemia symptoms very quickly. The mortality of this syndrome is about 10%. It makes the leukemia cells mature (differentiate). chest pain. After 12 weeks it can be given safely. chemotheraphy. The syndrome is related to adhesion of differentiated neoplastic cells to the pulmonary vasculature endothelium. dyspnea. Most people have two cycles of induction chemotherapy.Acute Myelogenous Leukemia (All Trans-Retinoic Acid).

hyperphosphatemia. vincristine. confusion.Other drugs used instead of daunorubicin are idarubicin and mitoxantrone. pancytopenia.Drugs acting on Blood and Blood Forming Organs Consolidation chemotherapy in AML The most commonly used drugs for consolidation chemotherapy are:Cytarabine Etoposide Daunorubicin Mitoxantrone Supportive Care 3+7 regimen is most popular regimen Doxorubicin 45 mg/m2 or 60 mg/m2 IV daily for 3 days. sometimes resulting in death.. optic neuritis. Cytosine arabinoside 100 mg/m2 continuous IV infusion or push doses 8 hourly for 7 days. urate crystalluria and renal failure. have been reported. and /or anemia. Objective weakness. hematuria. hypocalcemia.Pulmonary hypersensitivity reactions like A/E: 136 . autoimmune thrombocytopenia/ thrombocytopenic purpura (ITP). visual disturbances. optic neuropathy. and acquired hemophilia have been reported . agitation. Drugs in refractory case Fludarabine and Alemtuzumab. prednisolone(Refer section 6). thrombocytopenia. Evan’s syndrome. neutropenia. Chronic Lymphocytic Leukemia(CLL) Specific treatment is with Chlorambucil. hyperkalemia. blindness.Combination therapy cyclophosphamide. Life-threatening and sometimes fatal autoimmune phenomena such as hemolytic anemia. doxorubicin. metabolic acidosis.Tumor lysis syndrome which include hyperuricemia. Fludarabine I: Treatment of adult patients with B-cell chronic lynmphocytic leukemia (CLL) who have not responded to or whose disease has progressed during treatment with atleast one standard alkylating-agent containing regimen.

Steven-Johnson syndrome.Erythema multiforme. (ALL). hematoma.Ph+ Acute Lynmphoblastic Leukemia. CHRONIC MYELOID LEUKEMIA(CML) I: Imatinib I: Newly diagnosed adult patients with Philadelphia chromosome positive(Ph+) chronic myeloid leukemia in chronic phase. Do not administer as intravenous push or bolus.Chronic Lymphocytic Leukemia Dose: dyspnea. pediatric Patients with Ph+ CML in Chronic Phase. stomatitis and gastrointestinal bleeding. psychiatric symptoms. epistaxis. P/A: 30mg/1 mL single use vial A/E: Cytopenias. Each 5 day course of treatment should commence every 28 days.Myelodysplastic/ Myeloproliferative Disease (MDS/MPD).Aggressive Systemic Mastocytosis (ASM).optic neuropathy Dose: Administer as an IV infusion over 2 hours. Skin toxicity like skin rashes. hemorrhage. cough and interstitial pulmonary infiltrate. Accelerated Phase (AP) or Chronic Phase (CP) after Interferonalpha (IFN) therapy. Gastrointestinal disturbances such as nausea and vomiting. Alemtuzumab As a single agent for the treatment of B-cell chronic lymphocytic leukemia (B-CLL). anorexia. Vascular Disorders like flushing. paraesthesia. joint swelling. 137 P/C: A/E: . Ph+ CML in Blast Crisis (BC). toxic epidermal necrolysis and pemphigus The recommended adult dose for injection is 25 mg/ m 2 administered intravenously over a period of approximately 30 minutes daily for five consecutive days. Gradually escalate to the maximum recommended single dose of 30 mg. conjunctivitis.cardiomyopathy. diarrhea.Hypereosinophilic Syndrome (HES) and/or Chronic Eosinophilic Leukemia (CEL) Dermatofibrosarcoma Protuberans (DFSP)Kit+ Gastrointestinal Stromal Tumors (GIST) Pregnancy Hepatotoxicity.

hypotension. erythromycin. Patients should also avoid grapefruit juice and other foods known to inhibit CYP3A4 while taking Imatinib. whereas a dose of 800 mg should be administered as 400 mg twice a day. other arthritides. Other medications that should not be taken with imatinib are warfarin. 100 mg. Nausea. Tablets 25 mg. headache. severe aortic stenosis.In resistant cases-combination of vincristine. aortic stenosis. Patients should also be advised to tell their doctor if they are taking or plan to take iron supplements. 75mg(14 tab)Rs:4-9/After prosthetic valve implantation and dipyridamole stress echocardiography. eyelid edema. with a meal and a large glass of water. and phenytoin. hot flushes. 75 mg. crescendo angina. ANTIPLATELET DRUGS Aspirin I: Dose: Cost: Coronary artery disease. rheumatic fever.Other drugs used are thalidomide and cyclophosphamide. Dipyridamole I: C/I: P/C: A/E: P/A: 138 . conjunctival hemorrhage. Antiplatelet dose : 75 to 150 mg daily along with food. cerebrovascular diseases. Other drugs used: Hydroxyurea.doxorubicin and dexamethasone are used. Doses of 400 mg or 600 mg should be administered once daily. Acute myocardial infarction. recent myocardial infarction. dry eye The prescribed dose should be administered orally. fever. busulfan. interferon alpha (Refer section 6) PLASMA CELL DYSCRASIAS Multiple Myeloma Melphalan 8 mg/m2 and prednisolone 60 mg/m2 orally after a breakfast for 4 consecutive days. Rapidly worsening angina. may exacerbate migraine.Drugs acting on Blood and Blood Forming Organs Dose: D/I: vision blurred. repeated once in 4 weeks. tachycardia.

00 -6. agranulocytosis. 139 . or other pathological conditions Neutropenia. Neutropenia or agranulocytosis. venous shunts and prosthetic valves.00/Acute Coronary Syndrome. neutropenia. Recent MI. Haemorrhage. TTP. slight reduction in digoxin plasma levels. Thrombolytic therapy does not require an ICCU setting for its administration. following interventions like angioplasty and stent implantation post coronary bypass surgery.00-100. thrombosed arteries. SLE. It should be the aim of the first contact physician to administer it whenever indicated. skin rash. Risk of haemorrhage increased with aspirin and oral anticoagualnts. Haematological abnormalities.Antiplatelet drugs Dose: D/I: Cost: 300 mg in divided doses daily. Since early clot lysis is the single most effective therapeutic tool which reduces mortality and morbidity.50.00/Myocardial ischemia. thrombocytopenia. haemorrhage used with caution in patients who may be at risk of increased bleeding from trauma. headache. GIT disturbances. dizziness Tablet 75 mg 75 mg od Risk of haemorrhage increased with aspirin and oral anticoagulants Ticlopidine l: C/I: P/C: A/E: P/A: Dose : D/I: Cost: Clopidogrel I: C/I: P/C: A/E: P/A: Dose: D/I: Thrombolytic drugs Major current indication for thrombolytic drugs is in acute myocardial infarction (MI) preferably within 12 hours of onset of symptoms. Other indications:Pulmonary embolism. 3. Increases the action of adenosine and anticoagulants. gastrointestinal disturbances. bleeding. Tab 250 mg (10) Rs.increase in theophylline half life. thromboembolic strokes. surgery. Tablets 250 mg 250 mg bd. Tab 25 mg (10) Rs. Recent Stroke or Established Peripheral Arterial Disease Hypersensitivity.

recent surgery.15. Recent hemorrhage. Available as injections 2.After recent streptococcal infections. peripheral arterial embolism.Drugs acting on Blood and Blood Forming Organs Streptokinase I: Acute myocardial infarction. Pulmonary embolism 2. Use with caution in patients already receiving anticoagulants like heparin. efficacy of the drug is less. C/I: P/C: A/E: P/A : Dose: D/I: Special Note : 140 . Allergy with anaphylaxis in severe cases. Hypotension bleeding from various sites especially cerebral bleeding.5 million units to be administered as continous infusion in 100 ml saline over a period of l h in acute myocardial infarction. thrombosed arteriovenous shunts. Blood dyscrasias with bleeding. peptic ulcer.000 IU 1. prosthetic valve thrombosis. pulmonary embolism.7. Can be given even with a delay upto 24 hrs if there is persistent cardiac pain. Streptokinase is not at present indicated in acute MI presenting after 12 hours and also in cases with ST segment depression (except in cases of suspected true posterior MI). Do not repeat in MI occurring 1 week . aortic dissection.000 IU.000 units/hour for 24 hours.50.50. antiplatelet drugs such as aspirin or dipyridamole. Use puncture sites (arterial and venous) which are compressible.50.000 IU.00.1 year after administration due to the fear of sensitization. CVA within 1 year.00. bleeding hemorrhoids. In such situation alternate drugs such as urokinase or tPA are indicated.variceal bleeding.000 units in 30 min followed by 1. If streptokinase is repeated after 1 week to 1 year in patients who have recurrent infarction the efficacy is dampened due to the development of antibodies.

141 . Less sustained systemic fibrinolysis when compared to streptokinase. 4400 IU/ kg over 10 min followed by 4400 IU/kg/h for 12 hours. Same as for streptokinase Bleeding from puncture site.For repeat thrombolysis in patients previously treated with streptokinase and allergic to streptokinase. Same as for streptokinase.3500.Pulmonary embolism. lf it is not administered soon it should be stored at 2-8 o C Urokinase Fibrinolytic drug isolated from human urine I: Same as for streptokinase. 2300.Prosthetic valve thrombosis. Aspirin and indomethacin can cause haemorrhage. Store between 2.00.7.3 million units in 100 mL saline to be given as infusion over 1 h.50.Additional indication is intraocular clot lysis. Heparin and oral anticoagulants will increase the risk of bleeding.000 IU.000 IU.50.8 OC. 3700. Because urokinase injection does not contain any preservatives it should not be reconstituted until immediately prior to use C/I: P/C: A/E: P/ A : Dose: D/I: Cost: Tissue Plasminogen Activator (Altepase) tPA Fibrinolytic drug manufactured by recombinant DNA technology. Being a naturally occuring substance allergic reactions are considerably less.00 Streptokinase injection should be reconstituted prior to the use and used immediately. protect from freezing.2.10.000 IU Acute myocardial infarction.000 IU. Hypotension is less compared to streptokinase. Inj vial (500000 IU) Rs.00. Available as injections 50.00 Storage .00 .000 IU. Pulmonary embolism. 5.Thrombolytic drugs Cost: lnj vial (1500000 iu) about Rs. I: C/I: Acute myocardial infarction.

5 g. Epsilon amino caproic acid (EACA) P/A: Dose: Tablets 0.Another dosage schedule is 50 mg IV bolus x 2 doses spaced at 3min interval. Therefore in bleeding from the urinary tract only smaller doses are required. EACA is excreted rapidly in urine and the urinary concentration exceeds the blood level.375. Injections 50 mg vial. Patients sensitive to gentamicin should not use tPA. Store between 2 . 142 . still bleeding complication have to be watched for. tPA administration should be followed by intravenous heparin injusion to prevent arterial occlusion by further thrombosis Inj vial (50 mg)Rs:39. It is used to arrest bleeding in prostatic surgery and after dental extractions. Initial priming dose is 5 g oral/IV followed by 1 g hourly till bleeding stops. Protect from excessive exposure to light A/E: P/A: Dose : D/I: Note: Cost: Antifibrinolytics These are indicated in primary fibrinolytic states with clinical haemorrhagic tendency and in the rare event of haemorrhagic complications caused by thrombolytic agents.00 Storage .Maximum 30 g in 24 hours.The drugs include the synthetic aminoacids epsilon aminocaproic acid(EACA) and tranexamic acid and the polypeptide aprotinin. Total dose over 90 min Initial bolus 15 mg Intravenous infusion 50 mg over 30 min 35 mg over 60 min. increased risk of haemorrhage with warfarin. When compared to streptokinase it produces a slight increase on the incidence of haemorrhagic stroke. 1 g. Increased risk of GI bleeding with NSAIDs.Drugs acting on Blood and Blood Forming Organs P/C: Though.300C. Due to a very short half life. it is thought to be clot specific and less likely to cause bleeding due to fibrinolysis.

Antifibrinolytics Tranexamic acid P/ A: Dose: Scored tablets of 500 mg Oral : 10 .15 mg/kg bd or tds or Slow IV injection in a dose of 0. thereby preventing fibrinolysis. This inhibits the action of plasmin and kallikrein.00. Inj 5.000 KIU(Kallikrein inactivator unit)initially followed by 2.5 .stroke and myocardial infarction.00.000 KIU in 50 Ml 5. Renal toxicity.1 g tds. Aprotinin I: A/E: P/A: Dose: 143 .00. It is used as an intraoperative infusion during major surgery such as open heart surgery in order to prevent excessive blood loss.000 KIU every 4 hour all as slow IV infusion.

SECTION . 144 I: .Platelet function defect.Thrombocytopenia.Same as Whole Blood Shelf life – (with Additive solution)-42 days Without additive – 28 days. should not be taken back to the storage site Whole Blood I: Sudden Blood loss of >25% of the total Blood volume.5 kg body weight in paediatrics Platelet Rich Plasma I: Dengue Haemorrhagic Fever P/C : Possibility of circulatory over load.9 BLOOD PRODUCTS AND PLASMA SUBSTITUTES WHOLE BLOOD/COMPONENTS • No Blood is 100% safe for transfusion whatever test we do Once issued. Packed Red Cell I: Severe Anaemia (Hb<6gm%).Neonatal Exchange Transfusion (If possible remake whole blood by mixing packed red cells with fresh frozen plasma of the same group) Storage • Optimum 40C in Blood Bank Refrigerator (range 20 – 60C) • Shelf life .Viper bite. • • • Avoid Transfusion as far as possible Promote Blood donation since it improves the health of the donor Platelet Concentrate Based on clinical symptoms.30 – 35 days • If there is suspicions of lysis (reddish discoloration of plasma) the unit should not be used for transfusion.Minor Volume correction Storage :.Massive Transfusion Storage – Optimum temperature 22 0 C in platelet incubator with agitator Shelf life – 3 days in Ordinary Bag 5-7 days in Special Bags Dose 1 unit/10kg body weight for adult 1 unit/2.

-200C/-400C in a Deep Freezer 5 years Haemophilia.vomiting. .pregnancy.Whole Blood/Components Storage and shelf life – same as Platelet Concentrate Human Serum albumin I: Hypoalbuminaemia C/I: Hypersensitivity. Unit.cardiac failure.nausea. 145 . Ward.IP No.5 times the normal) Storage : Frozen at -200C/-400C/-800C in a Deep Freezer Shelf Life : 1 year Dose : 12-15 ml/kg body weight Single Donor Plasma/Cryopoor Plasma/Liquid Plasma I: 1. As a volume expander 2. Blood Group.low cardiac reserve.pulmonary oedema Fresh Frozen Plasma I: Multiple Coagulation Factor deficiencies (IF PT/INR is > 1. gender etc. As a nutritional supplement in hypo proteinemia cases as in burns. severe anemia P/C : Hypertension.risk of viral transmission A/E : Allergic reactions.Von Willebrand’s Disease Congenital & Acquired Hypofibrinogenemia Frozen at -800C Stored at -200C/-400C/-800C in a Deep Freezer 1 year 1 unit / 10 kg body weight Storage : Shelf life : Cryo precipitate Indications : Storage : Shelf Life : Dose: Procedures to be followed in Blood transfusion services z z z z Proper washing of the hands of the person who is doing the transfusion procedure Proper cleaning of transfusion site of the patient Consider the transfusion of Blood/Products as a minor transplant since blood is a liquid connective tissue Identification of blood unit with regard to patients name. lactation. c/c liver disease etc.Age.

in these circumstances. z For transfusion of multiple units at a time. water and electrolytes over periods of several days.5% infusion is considered equivalent) 146 . z A temperature rise of 10C/20F only can be attributed to transfusion.30 mins. z For single unit transfusion. they may be used to expand and maintain blood volume in shock arising from conditions such as burns or septicaemia. Plasma substitutes are often used in very ill patients whose condition is unstable. Therefore. Dextran is a representative plasma substitute. but large volumes of some plasma substitutes can increase the risk of bleeding by depleting coagulation factors. immediately stop the transfusion. close monitoring is required and fluid and electrolyte therapy should be adjusted according to patients condition at all times. Various preparations can serve as alternatives (polygeline 3. after transfusion and on completion of transfusion. z Dextran 70 Injectable solution: 6%. after transfusion. z If any untoward reaction is noticed. FDA recognized blood warmers can be used to bring the units to room temperature z For Cardiac patients. transfusion rate is 1 ml/kg/hr and better to use packed red cells. Plasma substitutes should not be used to maintain plasma volume in conditions such as burns or peritonitis where there is loss of plasma protein. They are rarely needed when shock is due to sodium and water depletion as. Plasma substitutes may be used as an immediate short-term measure to treat massive haemorrhage until blood is available. no need to bring the blood unit to room temperature.Blood products and plasma substitutes Record pulse temperature BP of the patient before transfusion. 15 mins. Dextran may interfere with blood group cross-matching or biochemical measurements and these should be carried out before the infusion is started. resuscitate the patient and return the remaining bag of blood with fresh blood sample of the patient from the opposite hand to the Transfusion Medicine department. PLASMA SUBSTITUTES Dextran 70 and polygeline are macromolecular substances which are metabolized slowly. In these situations. the shock responds to water and electrolyte repletion. plasma or plasma protein fractions containing large amounts of albumin should be given.

joint pains. is a sterile freeze-dried powder containing the blood coagulation factor VIII fraction prepared from pooled human venous plasma. Deficiency in any of these factors results in haemophilia. followed by 500 ml if necessary. used for the treatment of haemophilia A. Standard factor VIII preparations also contain Von Willebrand factor and may be used to treat Von Willebrand disease. renal failure. IX. liver disease. hypotension. nasal congestion. avoid haematocrit falling below 25–30%. Von Willebrand factor is a mediator in platelet aggregation and also acts as a carrier for factor VIII. and X are essential for the conversion of factor II (prothrombin) to thrombin. they are indicated for the treatment of haemophilia A but do not contain sufficient von Willebrand factor for use in the management of Von Willebrand disease. Blood coagulation factors VII. 147 . pregnancy hypersensitivity reactions including fever. CHILD total dosage should not exceed 20 ml/kg PLASMA FRACTIONS FOR SPECIFIC USE Factor VIII is essential for blood clotting and the maintenance of effective haemostasis. transient increase in bleeding time Short-term blood volume expansion. bleeding disorders such as thrombocytopenia and hypofibrinogenaemia Cardiac disease. by rapid intravenous infusion. ADULT 500–1000 ml initially. if required 10 ml/kg daily may be given for a further 2 days (treatment should not continue for longer than 3 days). urticaria. including recombinant factor VIII. Highly purified preparations. bronchospasm—rarely severe anaphylactoid reactions. Bleeding episodes in haemophilia require prompt treatment with replacement therapy. where possible. monitor for hypersensitivity reactions. monitor urine output. are available. can interfere with blood group cross-matching and biochemical tests—take samples before start of infusion. monitor central venous pressure. total dosage should not exceed 20 ml/kg during the initial 24 hours. Factor VIII. or renal impairment.Plasma substitutes I: C/I: P/C: A/E: Dose: Short-term blood volume expansion Severe congestive heart failure.

by slow intravenous infusion. by slow intravenous infusion. II. IX and X derived from fresh venous plasma. fever Dose : Haemophilia B. highly purified concentrates) A/E : Allergic reactions including chills. High purity preparations of factor IX which do not contain clinically effective amounts of factor II. ADULT and CHILD according to patient’s needs 148 . and X.Blood products and plasma substitutes Factor IX Complex is a sterile freeze-dried concentrate of blood coagulation factors II. VII or X C/I: Disseminated intravascular coagulation P/C : Risk of thrombosis (probably less risk with highly purified preparations) A/E : Allergic reactions including chills. ADULT and CHILD according to patient’s needs and specific preparation used Treatment of bleeding due to deficiencies in factor II. A recombinant factor IX preparation is also available Factor IX Complex (Coagulation Factors. Various preparations can serve as alternatives I: Control of haemorrhage in haemophilia A P/C : Intravascular haemolysis after large or frequently repeated doses in patients with blood groups A. VII. Various preparations can serve as alternatives I: Replacement therapy for factor IX deficiency in haemophilia. bleeding due to deficiencies of factors II. VII. X) Concentrate Dried. VII and X are available. VII or X as well as IX. or AB (less likely with high potency. VII. fever Dose : Haemophilia A. ADULT and CHILD according to patient’s needs Factor VIII concentrate Dried Factor VIII concentrate is a complementary preparation and a representative coagulation factor preparation. by slow intravenous infusion. Factor IX complex which is used for the treatment of haemophilia B may also be used for the treatment of bleeding due to deficencies of factor II. IX. Factor IX complex concentrate is a complementary preparation and a representative coagulation factor preparation. B.

Depending on specific autoimmune disease: 0. Solutions for intramuscular and subcutaneous injection are used for primary immune deficiency.4 – 0. Formulations from different manufacturers vary and should not be regarded as equivalent. Maintenance doses by intravenous. NOTE : National recommendations may vary Consult individual manufacturer’s product literature for dose and administration recommendations for specific diseases. recommended doses may vary to those listed below. Dose to be titrated depending on inter-current infections or trough serum IgG level. two. three. consult individual manufacturer’s product literature I: Replacement therapy in primary immunodeficiency.8 g/ Kg / month for children and adults. 10% protein solution. Normal immunoglobulin (human. For immuno-modulation in autoimmune conditions: Maximum recommended dose is 2g/kg over at least 48 hours.1 g/kg the first day and repeated once if indicated. Intravenous doses may be given at one. normal immunoglobulin for intravenous use. 149 . two. Intravenous administration: 5%. Normal immunoglobulin Normal immunoglobulin solution is administered by intravenous infusion for primary immunodeficiencies and immunomodulation in autoimmune disease including Guillain-Barre syndrome and Kawasaki disease. 16% protein solution NOTE. For replacement therapy in primary immune deficiencies: Initial loading intravenously in divided doses until serum IgG level is > 6 g/l. normal immunoglobulin for subcutaneous use.4 g/kg/day for 5 days or 0. four or seven day intervals. 16% protein solution Injection. Kawasaki disease P/C: Monitor vital signs. normal immunoglobulin for intramuscular use. subcutaneous or intramuscular routes: normally 0. Normal immunoglobulin should be used in hospital settings where specialist supervision is available. 10% protein solution Injection.8. 5%. Subcutaneous doses may be given at one. three or four week intervals.Plasma fractions for specific use Human normal immunoglobulin Intramuscular administration: 16% protein solution. polyvalent) Injection. 15%.

with immunomomodulatory doses also immune haemolysis. chills. rash. this should be in a hospital with adequate facilities for monitoring the infusion as well as the condition for which it is being administered. A/E : Nausea. vomiting. hypothermia. increased plasma viscocity. aseptic meningism. fever. when treatment at home can be considered after formal training in an expert centre. until the patient is stable. headache (may develop 24 hours after infusion). Infusion rates of < 8 g per hour are recommended. In general. urticaria. renal impairment 150 . anaphylactoid reactions also reported. dizziness. hypotension. wheezing. sweating. dry mouth. Immunoglobulin should be administered under the supervision of an immunologist or other experienced physician.Blood products and plasma substitutes ADMINISTRATION. eczema. hypercoagulopathy.

Flushing. head injury. postural hypotension causing giddiness.closed angle glaucoma. transdermal preparation and IV.5 mg. and tachycardia may occur. hypovolemia. Glyceryl Trinitrate I: Treatment of acute anginal episode. Tablets 0. hypertrophic obstructive cardiomyopathy. acute LVF. nitrate injection should be used with caution in acute inferior wall MI with right ventricular infarction with hypotension. cardiac tamponade. Buccal spray 2 metered dose of 400 mcg.6 mg and 6.5 mg. Glyceryl trinitrate loses potency when stored for more than 6 months and should preferably be kept away from sunlight. Development of tolerance can be prevented by giving nitrates in eccentric dosing so as to produce long (10 — 12 h) nitrate free intervals or by administration of drugs like captopril which contain – SH group P/A: Tablets. 5 mg.4 mg long acting. IV infusion as 5 mg and 25 mg vials. infusion results in tolerance leading to decreased effectiveness within 24 h. to reduce BP in markedly elevated blood pressure such as hypertensive crisis. Many patients on regular nitrate therapy become tolerant to the drug after several weeks.SECTION 10 CARDIOVASCULAR DRUGS DRUGS USED IN TREATMENT OF ANGINA NITRATES Nitrates are mainly venodilators. infusion. 1 mg/mL or 5 mg/mL. Transdermal preparation : 2. Nitrates especially IV. A/E: Most common side effect is headache. Development of tolerance . 2. aortic stenosis. 151 . Continuous IV. hypothyroidism. Ointment : 2% skin ointment contains 15 mg per inch. P/C: Renal disease. buccal spray. 10 mg and 15 mg released over 24 h. C/I: Hypersensitivity to nitrates. hepatic disease.

00 .00/Cap 20 mg (25) Rs.6 mg . P/C:. 0. prevention of acute episodes of angina. Same as glyceryl trinitrate 5 mg. 152 .00/- Isosorbide Dinitrate I: C/I:.11 am.1 pm.00/Ointment 30 mg (2 %) Rs. Transdermal preparation should not be used continously for more than 12 h. 34. from 4 pm to 7 am no drug is administered so that a drug free interval of 15 h is produced.200 mcg/min depending upon the response. P/C. chronic heart failure C/I. A/E. 10 mg tablets and 20 mg sustained release capsules.4 mg bd for long action Parenteral : IV administration : One vial is to be diluted in 500 mL normal saline prior to IV infusion and infused at a rate of 10 . The effect of heparin is reduced by increasing excretion of heparin Tab 0. give nitrate at eccentric dosage intervals eg. 205.25 mg released / dose.instead of regular eight hourly dosage. 41. Tricyclic antidepressants and disopyramide may reduce action of nitrates.5 mg (30) Rs. Tab 10 mg (100) Rs.12. 25 mg.6. 4 pm.5 mg (50) Rs. 60. 8 am. Use eccentric dosage schedule ie. To prevent nitrate tolerance. 11. 50 mg SR Tablets.2.00/Patch 5 mg (24 hrs) Rs. D/I : P/A : Dose: Cost: Isosorbide mononitrate I: Angina of all types.Spray 1.10/Chronic angina pectoris. Low dose nitroglycerine therapy is preferable and effective compared to high dose infusions in many clinical situations. 200 metered doses.56/Cap 2. D/I: Same as for glyceryl trinitrate P/A : Tablets 10 mg 20 mg.62. Careful monitoring of blood pressure essential.5 mg sublingually for angina. 60.00/Inj 25 mg/5mL (5amp) Rs. 3 doses are given at 7 am.Cardiovascular Drugs Dose : D/I : Cost : Oral . 10 mg -30 mg three times a day.00 .

hypovolemia. second. hypertension. cardiac tamponade. The systemic BP should not drop more than 20 mm Hg. If the BP is less than 100 mm Hg the infusion has to be stopped or reduced temporarilly. sick sinus syndrome. Use of plastic IV infusion sets may reduce the availability of nitroglycerine since it adheres to the IV tubing. right ventricular infarction and glaucoma. P/A : The drug is diluted in normal saline (5 mg . Tabs 50 mg (10) Rs.d. Various drugs can serve as alternatives I: C/I: Angina and myocardial infarction. mitral stenosis. uncontrolled heart failure. 35.in 500 mL) and administered as a constant infusion.00 . infarct limitation. arrhythmias. BETA BLOCKERS Atenolol Atenolol is a representative beta-adrenoceptor antagonist. coronary artery spasm. Long acting preparations are used once daily. migraine prophylaxis History of asthma or bronchospasm (unless no alternative. Methaemoglobinemia may occur on continuous infusion. It can cause marked hypotension and hence blood pressure should be monitored every 15 min initially. pulmonary oedema following LVF. intraoperative hypertension.00/- Intravenous nitroglycerine Intravenous nitroglycerin is now being routinely used in coronary care units for acute myocardial infarction and other unstable ischemic syndromes. hypertrophic cardiomyopathy.then with extreme caution and under specialist supervision). C/I : Increased intracranial pressure.Unstable angina. cardiogenic shock. It should be started at a small dose at 5 mcg/kg/min and increased gradually to achieve the desired clinical response.Drugs for Angina Dose : Cost : I: Oral : 10 mg to 40 mg b. hypotension. marked bradycardia. metabolic 153 . eccentric dosage schedule prevents nitrate tolerance by producing nitrate free intervals of 12 h. refractory angina. Prinzmetal angina.obstructive lesions like aortic stenosis.and third-degree atrioventricular block.39.

verapamil may be given as an alternative to treat stable angina. abdominal cramp). conduction disorders. then 100 mg daily A/E: gastrointestinal disturbances (nausea. Cost: Oral 50mg(14 tab) Rs. P/A: Tablet: 50 mg. by intravenous injection over 5 minutes. For those in whom a beta-blocker is inappropriate. heart failure. such as Prinzmetal angina. 100 mg. then by mouth 50 mg after 15 minutes. hypotension.Propranolol CALCIUM-CHANNEL BLOCKERS A long-acting dihydropyridine calcium channel blocker (such as amlodipine) can be added to betablocker treatment if necessary for control of moderate stable angina. vomiting. depression. diabetes mellitus (small decrease in glucose tolerance.followed by 50 mg after 12 hours. bronchospasm. by mouth . 25/-. liver function deteriorates in portal hypertension.history of obstructive airway disease (use with caution and monitor lung function—see also contraindications above). increased if necessary to 50 mg twice daily or 100 mg once daily Myocardial infarction (early intervention within 12 hours). confusion.Inj 5mg(10ml)Rs 5/- Other BetaBlockers-Metoprolol.constipation. pregnancy breastfeeding first-degree atrioventricular block. severe peripheral arterial disease. 5 mg. including nightmares. and in patients in whom alterations in cardiac tone may influence the angina threshold MISCELLANEOUS DRUGS USED IN TREATMENT OF ANGINA Trimetazidine It is an antianginal agent which acts by vasodilation and effects on cardiac metabolism 154 . masking of symptoms of hypoglycaemia). sleep disturbances. Dose: Angina.Cardiovascular Drugs acidosis. phaeochromocytoma (unless used with alpha-blocker) P/C : Avoid abrupt withdrawal especially in ischaemic heart disease. hypoglycaemia or hyperglycaemia. 50 mg once daily. diarrhoea. reduce dose in renal impairment. fatigue. bradycardia. Calciumchannel blockers can also be used in patients with unstable angina with a vasospastic origin.

00/DRUGS USED FOR THROMBOLYTIC THERAPY (Refer Section 8) 155 Angina pectoris and myocardial infarction. I: Chronic stable angina. At present it is mainly used in refractory angina. constipation P/A : 500mg tablets Dose : 500mg twice daily to begin with and if needed 1000mg twice daily D/I : Diltiazem. breast feeding. GI disturbances. D/I: With alcohol and other vasodilators hypotensive action. P/A: Tablet 5 mg. 149. Macrolides increase ranolazine action. Dose : 5 mg tablets bd. flushing. vomiting. C/I: Cardiogenic shock. A/E : Rare. 10 mg. dizziness similar to that of nitrates.00/- . nausea. A/E : Headache. (10 mg/24 h) the dose may be increased upto 30 mg bd. Cost: Tab 5 mg (20) Rs. and is a late sodium current inhibitor and shifts metabolism towards carbohydrates oxidation. Tab 20 mg (10) Rs. hypotension. P/C: Hypovolemia. 6 per tab Nicorandil I: It is a potassium channel activator and dilates arterial and venous beds. nausea. May be used as an add on therapy/ first line/ second line agent C/I : Should not be used with other drugs producing QT prolongation and strong inhibitors of CYP3A. Antianginal drug for refractory angina. pregnancy. Hypersensitivity Pregnancy. Dizzness.Drugs for Angina I: C/I : P/C : A/E : P/A : Dose : D/I : Cost : Ranolazine Its an antianginal drug. Tablet 20 mg 20 mg tablets tds. No significant drug interaction reported. 29. Cost : Rs. Verapamil.

breast feeding. porphyria. headache. pregnancy.2. secondary hypercholesterolemia Hypersensitivity . Hepatic diseases. mixed hyperlipidemia. breast feeding. age<10 years. pregnancy.Cardiovascular Drugs ANTIPLATELET DRUGS AND ANTICOAGULANTS (Refer Section 8) LIPID LOWERING DRUGS Statins These drugs are useful in lowering of total cholesterol and LDL cholesterol. Hepatic diseases. rise in liver transaminase. Active liver diseases. Head ache nausea . altered hepatic enzymes. but are less useful in hypertriglyceridemia. rise in CPK levels. high alcohol intake.00-100.Hypothyroidism. nausea.Rhabdomyolysis (few reported) 10-40mg/day (max 80mg) Ketoconazole/Erythromycin given concurrently Rs. Myopathy (serious rare).10mg.50/10mg tab Primary hypercholesterolaemia. history of liver disease. muscle tenderness.00 Hypercholestrolemia. rhabdomyolysis. bowel upset. Statins can reverse the already established atheromatous lesion in the coronary artery. Tab 5mg.active liver disease. rashes. mixed dyslipidaemia Active liver diseases. Atorvastatin Most commonly used statin I: Primary hyperlipidemia with Increased LDL and total cholesterol level with or without raised TG levels. 80. sleep disturbances. 20mg 5-10 mg daily. pregnancy and lactation Alcohol. C/I: P/C: A/E: Dose: D/I: Cost: Rosuvastatin I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Lovastatin I: C/I: P/C: 156 . Reversible myositis. Risk factors for myopathy. abdominal pain. max upto 40mg Same as for Atorvastatin 10 mg(10) Rs. high alcohol intake.

C/I.00 . abdominal pain. increased incidence of myopathy with fibric acid derivatives and cyclosporine. P/C.s. pregnancy. Nausea. A/E. 20. altered hepatic enzymes. 600 mg 600 mg bd before meals Cap 300 mg (10) Rs. 20 mg. Capsules 300 mg. 70.Lipid Lowering Drugs A/E: P/A: Dose : D/I: Cost: Reversible myositis. Fibric acid derivatives These are mainly used in the treatment of hypertriglyceridemia though they also reduce LDL cholesterol and increase HDL cholestrol to a small degree. Tab 20 mg (10) Rs. 20 mg.00/Other drugs in this class include fluvastatin. 55. The earliest drug in use was clofibrate which is not used nowadays. pravastatin.A/E:. diarrhoea.00/- Fenofibrate Superior to others in lowering LDL – CH. 400 mg 200 mg tds.00 . 40. 4.00/- Simvastatin I: C/I: P/C:A/E. I. Tablets 10 mg. renal dysfunction.D/I:Same as bezafibrate 157 . P/C. D/I: P/ A : Dose : Cost : Same as gemfibrozil Tablets 200 mg. Myositis like syndrome. C/I. Dose: 10 mg h. active liver disease. Increased action with anti coagulants .40 mg to be given after dinner h. breast feeding.90. nausea.00 . erythromycin. vomiting.00/- Bezafibrate I.100. 5 Alcoholism.78. 10 mg.s. Cost: Tab 10 mg (10) Rs. headache. skin rashes myopathy. hepatic dysfunction. 77.and raises HDL level.The commonly used drugs in this group are gemfibrozil and bezafibrate Gemfibrozil l: C/I: P/C: A/ E: P/ A: Dose: Cost : Hyperlipidemias type 3. D/I: Same as lovastatin P/A: Tablets 5 mg. with meals Tab 200 mg (10) Rs.

cyclosporine Rs. moderate to severe liver disease children <10year.5. hyperuricemia.60/tab Hyperlipidaemia Hypersensitivity.Cardiovascular Drugs Dose: Cost: 200 mg once daily with meals 200 mg (10) Rs. 20. hyperglycemia. head ache . 500 mg tab 1-2 g bd/tds Nicotinic acid may potentiate the effects of ganglionic blocking agents and vasoactive drugs resulting in postural hypotension. jaundice. hyperpigmentation. They lead to renal excretion of sodium.synergistic when given in combination with statins. dyspepsia. dizziness . myopathy. Abdominal discomfort . pregnancy Hepatobiliary disease. myalgia Tablet 10 mg. hepatic abnormality. 10mg orally once daily cholestyramine. potassium and water in varying proportions. 70-200 Ezetimibe Cholesterol absorption inhibitor I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Hyperlipidaemia.00 acid extended release tablets are now available for night ANTIHYPERTENSIVE DRUGS Nicotinic Acid I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Nicotinic time dosage Diuretics They are mainly used for treatment of oedematous states. homozygous familial hypercholesterolemia Hypersensitivity. Tab 500 mg(10)Rs. vomiting. active bleeding. arthralgia.They are indicated in fluid overload situations such as congestive heart 158 . hypotension. lactation Renal or hepatic impairment . peptic ulcer Arrhythmias.

100 mg daily. nephrotic syndrome and primary hyperaldosteronism in which it is the drug of choice. Note: lt is better to supplement oral potassium in doses of 1-2 g bd or tds. ascites. Chlorthalidone l:C/I: P/C: A/E: D/I: Similar to hydrochlorothiazide but longer duration of action. Hypertension : 20 mg daily as a single dose. 25 . 159 .mild to moderate oedema. Also used along with thiazide and loop diuretics to counteract the loss of potassium. 100 mg Dose: 25 mg 6 h upto 100 mg/day This dose may be increased upto 400 mg / day in divided doses in selected cases. Indapamide This is a weak diuretic. systemic hypertension.5 mg daily for systemic hypertension.nephrotic syndrome} cirrhosis or liver and others. It potentiates the action of other standard antihypertensive drugs I: Systemic hypertension Dose: 2. Dose: 50 . Thiazide diuretics Hydrochlorothiazide I: Dose : Congestive cardiac failure.100 mg daily. renal oedema. Potassium Sparing Diuretics Spironolactone This potassium sparing diuretic is a competitive inhibitor of aldosterone. I: Weak diuretic used in cirrhosis. Xipamide I: Dose: Systemic hypertension. P/A: Tab 25 mg. Oedema: start with 40mg/day orally reducing to 20 mg /day according to patient response.They lower blood pressure and therefore they are employed either as primary or as adjuvant drugs in the treatment of hypertension.Antihypertensive Drugs failure. along with thiazides and loop diuretics.

d. gastrointestinal upset. 40 mg.migraine. ventricular arrhythmias. antihypertensive. lactation.s. antiarrhythmic I: Systemic hypertension.d.supraventricular tachyarrhythmias. peripheral vascular disease. Beta Adrenergic Blockers Propranolol(non selective) Antianginal. Should not be used alone in phaeochromacytoma. thyrotoxicosis.10 mg / day. Dose: Amiloride This is a potassium sparing diuretic used in combination with loop diuretics or thiazide. pregnancy.d.Raynaud’s disease. Hypertension :40 mg b. Maximum dose 160 mg -320 mg daily. or t. effort angina. asthma. 80 mg. peripheral vascular disease. Angina : 40 mg b. myasthenia gravis.conduction disorders.Uncontrolled use may lead to hyperkalemia. Early congestive cardiac failure. 100 mg daily. Tablets 10 mg. 5 mg . When potassium loss is to be minimized. bradycardia. vasospastic angina. sick sinus syndrome. diabetes mellitus. overt CHF. or t. coronary artery disease. Bradycardia. congenital cyanotic heart disease with spells. fatigue. I: Dose: Oedematous states especially in prolonged administration. hypertrophic cardiomyopathy. 50 mg in combination with thiazides. chronic obstructive airway disease. AV Blocks.Sustained release capsules 40 mg. Maintanance120-240 mg dose C/I: P/C: A/E: P/A: Dose : 160 . cold extremities.s. in combination with thiazides or loop diuretics.d. 80 mg.Cardiovascular Drugs Triamterene I: lt is indicated in oedematous states.

tds. 82.Injection 500 mcg / mL. anxiety.d. P/A : Dose : Tablets 25 mg. D/I: Use with caution when patient is on verapamil or diltiazem since the risk of increase in AV block and worsening of heart failure exist.40 mg t.50 mg bd . I:C/I: P/C: A/E:D/I: Same as propranolol P/A : Dose : Tablets 50 mg. 50 mg.. intervals for 3 doses upto a maximum of 15 mg within the first 6 hours has been shown to reduce the mortality in patients who have no contraindication to beta blockade therapy. Tab 10 mg (10) Rs.00 Cost: Atenolol I:C/ I:P/C:A/E: D/I: Same as propranolol. The dose requirement of beta blockers in Indian population is usually less than that of the Western population. Betablocker mask cardiovascular symptoms of hypoglycemia when used with oral hypoglycemic hence hypoglycemia may go unrecognised. Intravenous verapamil or diltiazem should not be given in patients receiving betablockers. 100 mg.50 mg b.s. Hypertension 50 mg daily increase upto 100 mg. 4.00 Note : Cost: Metoprolol Cardio selective betablockers . 5 days after Ml.Effort angina 50 . tachycardia: 10 .50 mg -100 mg bd .Secondary prophylaxis : 40 mg tds. in acute Myocardial infarction IV metoprolol given at a dose of 5mg at 5 min.100 mg daily.Antihypertensive Drugs Arrhythmias.Arrhythmias 50 .00 -5.00 . antihypertensive effect is potentiated with diuretics.d.100 mg daily. 100 mg.83. Arrhythmias . In angina . Tab 50 mg (10) Rs. 161 . increase to 200 mg daily in divided dose. 200 mg (long acting) Injection 1 mg/ mL. ln hypertension . It is better to start with smaller doses.tds. may worsen bradycardia when used with digoxin. Post MI.

V.v.31.50.300 mcg/kg/rnin. slowly helps to reduce arrhythmias and episodes of sudden death .00 Cost: Bisoprolol I: C/I:P/C:A/E:D/I: P/A: Dose : Cost: Esmolol Ultra short-acting betablocker for parenteral use. 19. severe COPD.Maintenence dose is 150 . AV block. Concurrent use of phenytoin with IV esmolol produces additive cardiac depressant effect. other contraindication for betablockers use. Esmpolol may increase blood digoxin levels. Severe hypotension. Note: Being water soluble. pregnancy Confusion.00 . with a half life of 9 min. increases the risk of bradycardia. renal impairment.00 Hypertension.00 Cost: Drugs with combined alpha and beta blocker effect 162 . Tab 5 mg (10) Rs. nightmares and other CNS side effects are less. it does not cross blood — brain barrier. reduction in peripheral circulation. asthma. angina Same as propranolol. Inj 100 mg/10 mL (10 mL) Rs. diabetes mellitus.T 500 mcg / kg/ min for 4 min.in post MI cases atenolol given in dose of 5 mg i.00 . Tablet 5 mg 5 mg daily. Therefore fatigue. I: C/I: P/C : A/E : P/A: Dose: D/I: Supra ventricular arrhythmias. Injection 10 mL ampoule each mL contains 100 mg.preoperative hypertension. Tab 50 mg (14) Rs. hypotension.redness or swelling at the site of injection. When given along with calcium channel blockers IV cardiac failure may be precipitated.Cardiovascular Drugs In the absence of contraindication .00 · 83. 82. Hypotension. tachycardia. S. 48.

d. phaeochromo-cytoma. headache. coronary artery disease with effort angina and vasospastic angina. P/A: Tablets 12. 95. insomnia. bronchospasm. hepatic dysfunction. hypertensive emergencies.antianginal and antiarrhythmic properties. Hypertension and in patients with mild CHF Same as propranolol postural hypotension. systemic hypertension. paresthesia. 163 . cardiogenic shock. Tablets. 100 mg.200 mg b.. heart block.Antihypertensive Drugs Labetolol I: C/ I: P/ C: A/E: P/A: Dose : D/I: Cost: Systemic hypertension. 50 mg b.00 . AV Block.leucopenia. 15. CHF. migraine. liver dysfunction. 50 mg. nasorespiratory allergy. I: Supraventricular tachycardias. 25 mg Dose: Start with 6. diabetes mellitus.Therefore it lowers peripheral resistance also.16. rarely angina. thrombocytopenia.00 Carvedilol Carvedilol is a beta blocker with additional vasodilatory action.d. Headache. allergic skin rashes.5 mg (10) Rs. Lower dose in elderly patients(25 mg) Cost: Tab 12.00-100.mental depression. 200 mg. increased to 100 .25 mg daily orally and increased to 25-50 mg depending upon clinical response. CELIPROLOL and ACEBUTOLOL I: C/I: P/C: A/E: Calcium channel blockers Verapamil This is a calcium channel blocker drug with antihypertensive. with anaesthetic agents may cause myocardial depression. fatigue. postural hypotension.hypertrophic cardiomyopathy.00 Other Beta blockers currently used are NEBIVOLOL. hallucination. impotence. flu-like symptoms. Tab 50 mg (10) Rs.5 mg. Action of oral hypoglycemic agents increased.

00 -10. breast feeding. Tab 40 mg (10) Rs. pregnancy. rashes. 80 mg. 90 mg. AV block. vomiting.Q wave myocardial infarction. sinus node dysfunction. 60 mg. Injection 5 mg/ mL (5 mL) 90 · 180 mg orally daily in divided doses to start with. Serum digoxin levels may increase. ankle oedema. risk of bradycardia with amiodarone.240 mg daily in divided doses or sustained release form.Cardiovascular Drugs C/I : P/C: A/E: P/A : Dose : D/I: Cost : Congestive heart failure. AV block. 164 .hypotension. Tablets . This may be increased to 360 mg/day in severe cases.5 mg. bolus upto 10 mg.00 Inj 5 mg/ 2 mL (2 mL) Rs. 120 mg 240 mg sustained release form.v. supraventricular tachycardia. atrial fibrillation and atrial flutter in WPW syndrome. Tablets 30 mg. ankle oedema. 3.00 Diltiazem Antianginal. hepatitis. pregnancy. Constipation.5 . Most important and frequent side effect is constipation. Intravenous verapamil should not be given to patients receiving parenteral or oral beta blockers due to the risk of development of cardiac asystole.porphyria. In left ventricular failure. LV dysfunction. nausea. concomitant administration of beta blockers (oral). allergic reaction.40 mg. 2. Hepatic and renal impairment. 5. Intravenous dosage. Injections 5 mg in 2 ml 120 mg . I: C/I: P/C: A/E : P/A: Dose : All types of angina. sick sinus syndrome. flushing. Others include headache. hypotension. systemic hypertension.00 -4. antiarrhythmic and antihypertensive. non . first degree heart block. dizziness. Increased risk of bradycardia and AV block with betablockers. 120 mg sustained release. negative inotropism with disopyramide. Hepatic disease. Slow i. manic depression.

angina. Headache. pedal / ankle oedema. 17. Since this may lead to cerebrovascular insufficiency this route of administration should be used with caution.00 Nifedipine This has antihypertensive. May worsen angina if used alone in some patients. 6. and cause severe hypotension.12. gingival hyperplasia. it should be used with caution in patients with heart failure. constipation. 18. 30 mg GITS (Gastro intestinal delivery system). severe hypotension including cardiogenic shock.00 -20.5 mg. It is now considered prudent not to use small and frequent dose of nifedipine but to use sustained release form. nausea. I: C/I : P/C : Systemic hypertension. This drug should not to be used as monotherapy in patients after MI and unstable angina due to risk of higher mortality.Antihypertensive Drugs Parenteral : D/I: Cost: To be administered as slow IV 0. it may interact with prazosin .00 SR Tab 20 mg (10) Rs. Capsules and tablets . 10.00 .25 mg/kg or as a bolus of 10 . Severe aortic stenosis. When given sublingually it leads to rapid fall of blood pressure. In pregnant women it may cause inhibition of labour. Cap 10 mg (10) Rs. Hepatic metabolism of nifedipine may be affected by ranitidine or cimetidine.00 -19. Nifedipine may reduce quinidine levels. antianginal properties.5 mg for supraventricular tachycardia. P/A: Dose: D/I : Note: Cost : .d.00 165 A/E. Same as verapamil. flushing. Tab 30 mg (10) Rs. Nifedipine when given sublingually causes rapid fall of blood pressure. Though negative inotropic effect is only slight. tachycardia. in hypertensive emergencies. 20 mg retard tablets.00 Inj 5 mg/mL (5 mL) Rs. single dose. 10 mg. Raynaud’s phenomenon.20. 30 mg o.

ankle oedema.5 mg. 10 mg. all types of angina pectoris.5 mg.00 Nimodipine Calcium channel blocker with particular effect in improving cerebral circulation. hyperplasia of gums. Injection IV 50 mL vial. C/ I: Hypersensitivity. hypotension. Tab 5 mg (10) Rs. A/E:.00 -30.10 mg daily as single dose.5 . lactation. Systemic hypotension. flushing. P/A. A/E: Hypotension. angina C/I: P/C:. constipation. It has beneficial effect in angina if combined with beta blockers. Cost: Tab 2.00 A/E: P/A : Dose: D/I: Cost : Felodipine I: Systemic hypertension. 5 mg. nausea. nausea. Use with caution in hepatic dysfunction. 18. headache. Severe aortic stenosis. pregnancy.5 mg (10) Rs. 10 mg 5 . Capsule .00 · 22. lactation and fever. 5.5 mg daily as tablets or capsules and increase according to response upto a maximum dose of 20 mg daily.1 mg / hour initially as a infusion and increased to 2mg/hour after 2 hours. I: Cerebro vascular arterial spasm following subarachnoid hemorrhage. Pedal oedema.Cardiovascular Drugs Amlodipine I: C/I: P/C: Systemic hypertension. Tablet . P/ C: Raised intracranial pressure. Tablets / capsules 2. after subarachnoid haemorrhage to prevent neurological deficits and continue for 21 days orally 60 mg 4 hourly for 4 days. D/I: Similar to Amlodipine P/A: Tablets 2.30 mg. 5 mg. As for Nifedipine. Use with caution in the elderly as its long duration of action may produce long periods of hypotension.30 mg. 166 . Dose: 1. Dose: Start with 2. flushing.

Vitamin B12 deficiency. 4.00. rashes. ischemic heart disease. Slow IV injection 5 . tachycardia. 50. I: C/I : Hypertension. mechanical obstructive lesions like aortic stenosis. peripheral neuropathy. to control blood pressure during anaesthesia. Hydralazine is not freely available at present. Lupus erythematosus like syndrome. Tablets 25 mg Tablets 25 mg bd. but has been favoured in the treatment of pregnancy induced hypertension earlier along with alpha methyldopa. acute heart failure. abnormalities of cyanide metabolism. mitral stenosis. hypothyroidism.60. tobacco amblyopia. Mainly these are indicated in hypertension. Use with caution in lactating mothers. D/ I: Same as Nifedipine Cost: Tab 30 mg (10) I Rs. headache. 167 P/C : A/E: P/A: Dose : Note: Cost : I: C/I: Sodium Nitroprusside P/C : .10 mg over 20 min. fluid retention. hypothermia. Dissecting aortic aneurysm. May be repeated after 30 min. Severe renal insufficiency. 2. Not freely available. Inj IV 50 mL (vial) Rs. Hepatic dysfunction. older patients. 105. 3. Hypertensive crisis.Antihypertensive Drugs 1. Other dihydropyridine drugs available in India include Nitrendipine Lacidipine Lercanidipine Cilnidipine Vasodilator drugs Hydralazine . impaired cerebral circulation.00 .00. May cause angina in ischaemic heart disease. parenteral use in hypertensive crisis. elderly patients. Lebers optic atrophy. increase upto 50 mg bd.

fluid retention.6. The intravenous line should be protected from sunlight to prevent loss of efficacy Injection 50 mg/5 mL Rs.15 mg (150 mcg). Injection 50 mg/ 5 mL 0.5 mg/kg/min to begin with increase gradually every 5 min till . dizziness (due to rapid fall in BP) abdominal pain.00 Centrally acting antihypertensive drugs Systemic hypertension. Use with caution in Raynaud’s syndrome . Also to be avoided if MAO inhibitors are used. dizziness.05-0. Tab 100 mcg (10) Rs. Sodium nitroprusside is currently a very popular drug in producing controlled hypotension. It is not recommended as the first line drug.00 . 5.00 .00 A/E: P/A: Dose : D/I: Note: Cost: 168 . headache.1 mg (100 mcg). retrosternal discomfort. Depression Sudden cessation of treatment with clonidine causes rebound hypertension. Use in resistant case or where other antihypertensive drugs are contraindicated.1 mg in divided doses orally Tricyclic antidepressants abolish the effect of clonidine.Cardiovascular Drugs A/E : P/A: Dose: D/I : Note: Cost : Clonidine I: C/I: P/C: Tachycardia. Combination therapy with diuretics and ionotropic agents are useful in cardiac failure. 0. 0. occlusive arterial disease and renal disease. palpitation. Average dose is 3 mg/kg/ min. dry mouth. nausea. cyanide toxicity.130. the desired reduction is obtained. 45. constipation bradycardia Tablets 0. Sensitivity enhanced by antihypertensives. Raynauds phenomenon. Can be used in renal dysfunction and effective in controlling hypertensive crisis. Sedation. Beta blockers administration also not advocated concomitantly as risk of withdrawal hypertension is markedly increased.

lack of energy. May cause positive coombs test. Enhanced hypotensive effect with alcohol. Tab 250 mg (10) Rs. anti-psychotics. anaesthetics. phaeochromocytoma. Tablet 250 mg Start with 250 mg bd and gradually increase depending on response upto 3 g/ day. 15.00 . haemolytic anaemia. porphyria. Urinary frequency.Antihypertensive Drugs Alpha Methyldopa I: C/I : P/C: A/E: Systemic hypertension. fluid retention. anti-depressants. Active liver disease. headache. postural hypotension. It is better to continue alpha methyl dopa with a diuretic as the combination is more effective and decreases the fluid retention caused by alpha methyl dopa. Withdraw diuretics if patient is already on diuretics. The drug is preferably given at bed time. gradually increase dose to1 mg bd In the 169 A/E: P/ A : Dose : .s. depression. Use with caution in pregnancy. giddiness due to postural hypotension. It may cause increase in renin levels.34. calcium channel blockers. Reduce dose in renal impairment. incontinence. sedation often troublesome. Dry mouth. This drug is especially safe in pregnancy induced hypertension. diuretics and nitrates.00 P/A: Dose: D/I: Note : Cost: Prazosin I: C/I: P/C: Alpha adrenergic receptor blocking agents Systemic Hypertension Prostate hyperplasia. If no syncope or giddiness in the morning. dizziness. nausea. other antihypertensives. diarrhoea.5 mg h. beta blockers. Heart failure due to mechanical obstruction like aortic stenosis. May produce first dose hypotension and collapse. Tablets 1 mg. sexual impotence. 2 mg and 5 mg (sustained release) Start with 0.

hyperkalemia. neutropenia. benign prostatic hyperplasia. congestive cardiac failure. A/E: Persistent dry cough (most common side effect occuring in 10-20% of cases). Watch for hyperkalemia if potassium sparing drugs are also given in renal impairment . angioedema. 50 mg. anxiolytics. Tab 2 mg (10) Rs.) C/I: Known hypersensitivity to ACE inhibitors. antidepressants. 60. ACE inhibitors. I: Systemic hypertension.00 .s. myocardial infarction (large. P/A : Tablets 12. diuretics. D/I: Orthostatic hypotension potentiated by beta blockers. pregnancy. Similar to prazosin 1 mg. calcium channel blockers. thrombocytopenia. Cost: Tab 2 mg (10) Rs. 25 mg. betablockers and calcium channel blockers all potentiate the hypotensive action. 5 mg tablets. vasodilator drug. P/C: Reduce first dose if patient is on concomitant diuretic therapy. Corticosteroids decrease the effect.00 DRUGS AFFECTING THE RENIN ANGIOTENSIN SYSTEM Antihypertensive. suspected neuro vascular disease. diuretics. Single daily dose is enough compared to prazosin. aortic stenosis and other LV outflow obstruction. alcohol. Synergistic effect with other antihypertensive drugs. anticardiac failure. blood dyscrasias (including agranulocytosis.Cardiovascular Drugs D/I: Cost: extended release form of prazosin containing 5 mg the first dose effect is not common. anterior MI to prevent adverse remodelling. 2 mg.39. aplastic anemia). A/E: P/ A : Dose : Systemic hypertension. P/C:. Renal function is to be monitored before and during treatment.00 Terazosin I: C/I:. Give 1 mg at h.00 — 151. porphyria. antipsychotics. taste alteration. proteinuria.5 mg. 38. gradually increase dose upto 10 mg daily. 170 Captopril .

CHF: 2. anaesthetics.5 mg daily initially to be increased to 10 .20 mg daily. and gradually increase to the usual maintenance dose of 5 — 10 mg in divided dose. Maximum dose is 40 mg. 5 mg.49. The drug may be 171 Enalapril I:. 5 mg. Post Ml start with 2. D/I: P/A: Dose: .5 mg daily. P/C: A/E.00 Similar to captopril Similar to captopril Tablets 2. 2. Tab 2.P/C: A/E:. maintenance dose 10 .5 mg. 10 mg.. Corticosteroids. Systemic hypertension . Tab 25 mg (10) Rs. Maximum daily dose is 75 .5 mg daily. C/l.00 . antidepressants.5 mg. In CHF start with 6.5-5 mg daily depending on the haemodynamic status of the patient. 10 mg. It may be wise to start with even lower doses of 6. Alcohol.D/I: P/A: Dose : Cost: Lisinopril I:.25 mg bd to avoid first dose hypotension and gradually increases the dose to 25 mg tds to get the desired clinical effect. maintenence dose 5 -10 mg daily Post MI .5 mg daily initial dose.5 mg (10) Rs. oestrogen and progesterone. preparations decrease the hypotensive effect. 7. 10. 20 mg. Plasma concentration of digoxin is increased.20 mg upto a maximum dose of 40 mg single dose daily can be given. NSAIDS. levodopa and chlorpromazine potentiate the hypotension caused by ACE inhibitors.C/I:. 12. lithium excretion is decreased.Antihypertensive Drugs Dose : D/I: Cost : In hypertension. 5 mg bd initialy.25 mg bd Gradually increase to 25 mg tds under supervision. ln cardiac failure dose is to be individualised.00 Similar to captopril Similar to captopril Tablets 2.2.00 -12.100 mg.

Tab 4 mg (10) Rs..247. Use with caution in renal artery stenosis. rash.00 Similar to captopril Similar to captopril Capsules 1. P/C. Losartan Antihypertensive : I: C/I: P/C. C/I. The persistent cough of ACE I is thought to be bradykinin mediated. 50 mg. CHF:1. Giddiness. angioedema.20. Tab 2. 246. Benazepril.00 Other drugs in this group currently in use are . hyperkalemia. D/I: Similar to captopril P/A : Dose : Cost: Tablets 2 mg.5 mg.00 . Dose: 50 mg od Start with a lower dose of 25 mg daily in patients using diuretics or in elderly patients.00 . Tab 2. 5 . increase to 4 mg daily depending on response.Cardiovascular Drugs Cost : discontinued after 6 weeks of the myocardial infarction if there is no heart failure.00 Ramipril I:. 40. Tablets 25 mg.25 mg initially gradually increase if required. Quinapril Angiotensin II receptor antagonists Properties are similar to ACE inhibitors but the major difference is that they do not affect the breakdown of bradykinins. 5 mg. P/C: A/E. A/E:. C/I.5 mg.25 mg daily increased to 2. 2. A/E: P/A : Systemic hypertension In pregnancy May produce hyperkalemia. Start with daily dose 2 mg. 15. D/I: P/A : Dose : Cost : Perindopril I:. 4 mg.00 .41. 172 .Fosinipril. Hence these drugs may be useful in patients who have severe cough due to ACE inhibitor drugs. Hypertension: 1.5 mg (10) Rs.5 mg daily.5 mg (10) Rs.

epistaxis. male erectile dysfunction co administration to patients on organic nitrates is contraindicated due to hypotensive effects patients with resting hypotension (BP <90/50).5 mg and 125 mg tablets initiated at a dose of 62. Tab 25 mg (10) Rs.00 Cost: Newer drugs in this class include—Telmisartan. an endothelin receptor antagonist. myalgia. Rash Thrombocytopenia.5 mg bid and then increased to the maintenance dose of 125 mg bid. Candesartan . 40. Valsartan. insomnia. headache. Hypersensitivity. risk of hyperkalaemia with potassium sparing diuretics. I: C/I: P/C: pulmonary arterial hypertension. paresthesia Tablet 20 mg 20 mg three times a day (tid) 173 A/E: P/A: Dose: . hypersensitivity May cause elevation of AST/ALT and bilirubin. abnormal LFTs 62. NSAIDs may blunt hypotensive effect of losartan . severe left ventricular outflow obstruction. dyspepsia. or autonomic dysfunction. I: C/I: P/C: A/E: P/A: Dose: Pulmonary arterial hypertension Pregnancy. Irbesartan DRUGS USED IN PULMONARY HYPERTENSION Bosentan Bosentan is the first of a new drug class. Olmisartan. or with fluid depletion. palpitations. Sildenafil selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type-5 (PDE5). headache.Drugs for Pulmonary Hypertension D/I: Diuretics and other antihypertensives potentiate the action of losartan. edema.

intermittent complete heart block. 0. renal impairment . delirium. according to renal function and heart rate response. arrhythmias. gynaecomastia on long-term use. intestinal ischaemia. pregnancy . confusion. rarely rash. thrombocytopenia reported Injection: 250 micrograms/ml in 2-ml ampoule.00-10. headache. depression. severe pulmonary disease. 2. heart block. diarrhoea. fatigue. breastfeeding Usually associated with excessive dosage and include anorexia.25 mg tablet Heart failure. sick sinus syndrome. seconddegree atrioventricular block Recent myocardial infarction.00 Inj 0.5–500 micrograms daily (higher dose may be divided). avoid hypokalaemia. 0. particularly if accompanied by atrial fibrillation. orally. avoid rapid intravenous administration (nausea and risk of arrhythmias). ventricular tachycardia or fibrillation. nausea. maintenance 62. thyroid disease.00 Infusion dose may need to be reduced if digoxin or other cardiac glycoside given in previous 2 weeks P/C: A/E: P/A: Dose: Cost: NOTE: 174 . visual disturbances. Wolff-Parkinson-White syndrome or other accessory pathway. by intravenous infusion over at least 2 hours.25mg(10) Rs. drowsiness.5 mg in divided doses over 24 hours for rapid digitalization or 250 micrograms 1–2 times daily if digitalization less urgent. vomiting. 1–1. dizziness.75–1 mg Tab 0.Cardiovascular Drugs DRUGS USED IN HEART FAILURE Digoxin I: C/I: Heart failure. abdominal pain. usual range 125–250 micrograms daily (lower dose more appropriate in elderly) Emergency loading dose. arrhythmias Hypertrophic obstructive cardiomyopathy (unless also severe heart failure). elderly (reduce dose).5mg/2ml Rs. 6. hallucinations.

P/A & Cost : Refer antihypertensive drugs Dose: Heart failure.00 Enalapril heart failure (with a diuretic). initially 2–5 micrograms/kg/minute. peripheral vasoconstriction. hypotension with dizziness. palpitations. by mouth. dyspnoea. A/E: nausea and vomiting. 26. maximum 40mg daily. gradually increased by 5–10 micrograms/kg/minute according to blood pressure. and metabolic acidosis before or at same time as starting treatment. hypertension particularly in overdosage P/A: Injection: 40 mg (hydrochloride)/mL in 5-mL vial. ischaemic heart disease. fainting. Dose: Cardiogenic shock. seriously ill patients up to 20–50 micrograms/kg/minute Cost: 200 mg/5mL vial Rs. headache. by intravenous infusion into large vein. hyperthyroidism P/C: correct hypovolaemia before. ventricular fibrillation. history of peripheral vascular disease (increased risk of ischaemia of extremities). low dose in shock due to myocardial infarction. I: Furosemide (Refer Section 14) Hydrochlorothiazide (Refer Section 14) 175 . hypertension. ectopic beats. anginal pain. prevention of symptomatic heart failure in patients with left ventricular dysfunction. flushing. correct hypoxia.elderly. increased over 2-4 weeks to usual maintenance dose 20mg daily in 1-2 divided doses. C/I. and maintain blood volume during treatment. cardiac output and urine output.Drugs for Heart Failure Dopamine Dopamine hydrochloride is a complementary drug for inotropic support I: cardiogenic shock in myocardial infarction or cardiac surgery C/I: tachyarrhythmia.5mg daily under close medical supervision. phaeochromocytoma. breastfeeding . hypercapnia. A/E. tachycardia. asymptomatic left ventricular dysfunction. initially 2. P/C.

pregnancy. Elderly patients. AV block.Cardiovascular Drugs ANTI ARRHYTHMIC DRUGS Quinidine I: C/I: P/C: Supraventricular arrhythmias. 100 .150 mg 8 th hrly. SLE like syndrome. Capsules 250 mg. Capsules 100 mg.urinary retension. heart failure. AV block. fever. 60. Avoid intravenous administration as it may cause hypotension. nausea. May worsen heart failure if used with other negative inotropic agents.myasthenia. pregnancy. A/E. proarrhythmia and AV block are to be looked for. Cap 100 mg (10) Rs. P/A: 176 . thrombocytopenia. Quinidine Sulfate Tab 300 mg. diuretics and erythromycin. lf necessary to be increased to 600 mg every 2-4 hrs. haemolytic anaemia. 150 mg. elderly patients. renal dysfunction. Cinchonism. AV block. myocardial depression. Injection 100 mg/mL. .Cardiac conduction abnormalities. Tab 100 mg (20) Rs. ventricular arrhythmias. A /E: P/A: Dose: D/I: Cost: Procainamide I: C/I: P/C. diarrhoea. atrial arrhythmias usually resistant to other drugs.00-61. sinus node dysfunction. dryness of mouth.00 Ventricular and supraventricular arrhythmias. Increases serum digoxin level. blurring of vision. Increased risk of ventricular tachycardia (Torsade de pointes) if used along with class 3 agents. heart block.Quinidine Gluconate Inj 76 mg of quinidine/ mL. glaucoma.00 Ventricular arrhythmias. QT prolongation. Oral: 200-400 mg tds. Hypotension. allergic reaction. Hepatic and renal impairment. hepatic dysfunction. Severe renal failure. myocardial depression. proarrhythmia. 36.Tablets: 100 mg. Start with 100 mg initially to avoid hypotension. A/E: P/A : Dose : Note : D/I: Cost: Disopyramide I: C/I: P/C. severe cardiac failure.

36. 12. confusional states (especially in old people).00 Ventricular arrhythmias (mainly in ventricular tachycardia.Anti Arrhythmic Drugs Dose: D/ I: Cost: 250 .500 mg. high grade AV block. 35.13. initial dose 1 g followed by 500 mg 3 hrly for 24 .convulsion Injection 2%.Due to the high incidence of adverse side effects procainamide should be given as IV infusion diluted with 5% glucose at a rate not exceeding 25-50 mg/min until the arrhythmia has been suppressed or a maximum dose of 1 g has been reached.00 . followed by 10 .00 . renal and hepatic dysfunction. Maintenance dose is 1-4 mg/min. hypotension. 21. Inj 2% (30 mL) Rs. elderly patients.48h then reduce dose to 500 mg tds. Potentiates the action of neuromuscular blocking agents. Paresthesia.00 Inj 100 mg/mL (10 mL) Rs. Ventricular tachycardia.20 mg / min to a maximum of 1 g in the first hour. Cap 250 mg (10) Rs. Hepatic dysfunction. 1 mg/kg as a bolus dose upto a maximum of 100 mg. severe myocardial depression.3 mg/mL.00 . S-A block. Sick sinus syndrome. 177 D/I: Note: Cost: Mexiletine I: C/I: P/C: . 38. impairs action of neostigmine and pyridostigmine. Routine administration of lignocaine is not recommended in acute myocardial infarction as a prophylactic for ventricular arrhythmias. elderly patients.39. Intravenous dose 100 mg IV bolus. along with initiation of continuous infusion 2 mg / min which can be increased to 3 mg / min. Increased hepatic clearance in patients receiving propranolol and halothane.) as alternative to lignocaine in resistant cases. Hypotension. drowsiness.00 Lignocaine I: C/I: P/C: A/E: P/A: Dose .

37. drug induced lupus erythematosus. erythema multiforme. Diuretics decrease the action through the production of hypokalemia. Skin and corneal microdeposits. amiodarone and antidepressants usually increase the plasma concentration of phenytoin. Cost: Nausea. Tablets 150 mg Injection 250 mg vials. Phenytoin decreases the concentration of disopyramide. headache. atrial fibrillation in WPW syndrome and in prophylaxis of ventricular and supra ventricular arrhythmias not responding to usual line of management. Hepatic impairment. A. digitalis toxicity. dizziness. Oral contraceptive effect is reduced. pulmonary fibrosis.38. analgesics. psychiatric disorders. hepatic Diphenyl hydantoin(Phenytoin) I: C/I: P/C: A/E: Dose : D/I: Amiodarone I: C/I: P/C: A/E: 178 . slurred speech. peripheral neuropathy. thyroid functions periodically. gum hypertrophy. Chest X-ray should be checked before and periodically. ataxia.00:Inj 250 mg (10 mL) Rs. 100 mg 8th hrly. severe bradycardia. Caps 150 mg (10) Rs. ataxia. Antibiotics. breast-feeding. Phenytoin and rifampicin increase the metabolism. pregnancy Nausea. bradycardia. 195. Mainly in refractory life threatening arrhythmias like ventricular tachycardia.00 Ventricular arrhythmias.Cardiovascular Drugs A/E: P/A : Dose : D/I.V block. convulsions. conduction abnormalities. paresthesia. confusion (elderly patients). quinidine and mexiletine. hypo / hyperthyroidism Check liver function tests.00 . vomiting.photosensitivity. megaloblastic anaemia. use with caution in elderly patients and in renal dysfunction. Oral dose 150 mg 8 h with meals. and in bradycardia and conduction abnormality. tremor. acute intermitent porphyria. Pregnancy. peripheral neuropathy.1 mg/min infusion. 100-200mg IV over 10 minutes .

00. increased serum digoxin level.d.108. Intravenous administration 5 mg/kg over 20 min -2h by slow IV infusion. insomnia. subsequently. enzyme elevation. bradycardia.Inj:50 mg/ml. breast feeding..00 . The dose should be the minimum effective strength in view of the marked side effects and toxicity of amiodarone. vasospastic angina.bradycardia. 77. P/C: Congestive heart failure. Amiodarone is not to be started as a first line drug as far as possible.Alternate dose 150 mg given as bolus IV followed by 900 mg slow IV infusion for 24 hrs. Enhanced anticoagulant activity due to decreased metabolism of anticoagulants. conduction abnormalities. congestive cardiac failure. 11. Raynaud’s disease A/E: Cold peripheries. aplastic anaemia. C/I: AV block. hypo or hyperthyroidism. 179 .00 . pregnancy. increased risk of hypothyroidism with lithium. 200 mg bd for the second week. (3 ml. increased action of other antiarrhythmic drugs. sick sinus syndrome. diabetes mellitus.100-200 mg o.induced by diuretics may worsen amiodarone toxicity. Tablets 100 mg and 200 mg. 200 mg 8th hrly for the first week. bronchospasm.56. Amiodarone has a half life of 30 . hypokalemia. increased risk of arrhythmias with antidepressants.haemolytic anemia. supraventricular arrhythmias including paroxysmal atrial fibrillation.increased risk of severe bradycardia with beta blockers and calcium channel blockers. Tab 200 mg (10) Rs. bradycardia.Anti Arrhythmic Drugs P/A: Dose: D/I: Note: Cost.) Rs.110 days and the action of the drug will persist for upto 50 days after stopping treatment. May cause hypotension if given rapidly. conduction abnormalities.Injection IV 50 mg / mL ampoules. occlusive arterial disease.00 Sotalol Beta blocker with antiarrhythmic activity (class 3) I: Ventricular arrhythmias.

Sympathomimetic positive inotropic drugs The beta stimulant drugs used as positive inotropic agents include dopamine. Worsens heart failure in patients in combination with other negative inotropic agents. They are useful in the treatment of patients with hypotension and congestive cardiac failure. Dobutamine Synthetic sympathomimetic drug.13. Can worsen bradycardia if combined with digoxin. Milrinone.Cardiovascular Drugs P/A: Dose: D/I: Cost: Tablets 40 mg. dobutamine causes less increase in heart rate. 80 mg . dobutamine and isoprenaline. 80 .d. The positive inotropic agents can be divided into: a) cardiac glycosides . tachycardia. vesnarinone are drugs which have been tried in trials as positive inotropic agents.160 mg b. I: Inotropic support in situations with hypotension. Masks hypoglycemia symptoms if used with hypoglycemic drugs in diabetic patients. 12. Tab 40 mg (10) Rs. C/I : Similar to dopamine A/ E : Hypertension. P/A: Injection 50mg/4mL. Phosphodiesterase inhibitors Amrinone. Lower doses can be tried in certain cases.00 Calcium channel blockers -verapamil (Refer Section 10) POSITIVE INOTROPIC AGENTS Positive inotropic agents are drugs that increase the contractility of the myocardium.00 . 250mg/20mL 180 . ventricular ectopy. verapamil.lesser incidence of ventricular ectopy and reduces pulmonary capillary wedge pressure. 250mg/5mL.Compared to dopamine.diltiazem.digoxin b) phosphodiesterase inhibitors c) parenteral inotropic sympathomimetics.(can induce AV block in some cases). ln chronic refractory heart failure intermittent administration of dobutamine has been found to be effective.

Inhalation 400mcg 200 metered dose Dose : 0. P/C : Hyperthyroidism.6. Hypotension.00 181 . headache. sweating.10 mcg/ kg/min adjusted according to clinical / haemodynamic response. C/I : Hypertension.Available as 250 mg vials.9. coronary artery disease. acute left ventricular failure.Positive inotropic agents Dose : D/I: Cost : 2. D/I : With digitalis glycosides and levodopa risk of cardiac arrythmia. diabetes mellitus.88.5 . A/E.5 .Reduction of antianginal effects of nitrates. Cost : Tablet 20mg (10) Rs. angina pectoris.10 mcg/min.00 Injection 2mg/ mL (2 mL ) Rs. tremor.halothane anaesthesia.00 Inhalation 400mcg (200 metered dose) Rs. Available as 2 mL ampoules containing 1 mg/ mL. severe bradycardia. P/A: Tablet 20mg Injection 2 mg/mL 2 mL ampoules. It antagonises the effect of phentolamine and prazosin.33500 Isoprenaline (Isoproterenol) Sympathomimetic amine I: Hypotension associated with complete heart block. Inj 250mg/ 5mL (5mL) Rs.

Fungal skin infections: apply twice daily until the infected skin is shed (usually at least 4 weeks) 15g Rs 23/Dermatophytosis.Candidiasis A/E: Burning Sensation. also contact dermatitis.continuing for at least 10 days after the condition has cleared nail infections. apply twice daily. 15g Rs 19-33/- Cost: Clotrimazole I: A/E: P/A: Dose: Cost: Ciclopirox olamine I: Dermatophytosis. candidiasis.Dermatosis.lotion/ gel is also applied. particularly tinea pedis and tinea corporis Irritation and burning sensation Cream or ointment: 5% + 3%.100 mg vaginal tablet. apply 1–2 times daily 15g Rs 15-28/Dermatophytosis.SECTION 11 DERMATOLOGICAL DRUGS SUPERFICIAL MYCOSIS Topical agents Benzoic acid + Salicylic acid (Whitfield’s ointment) I: A/E: P/A: Dose: Cost: Miconazole I: A/E: P/A: Dose: Mild dermatophyte infections. Itching 182 . Tinea versicolor Local Irritation Cream 1%.1% gel Dermatophytosis apply 2-3 times daily for 2-4 weeks Vaginitis:1 tablet inserted daily for 7 days Oropharyngeal candidiasis:10 mg troche of clotrimazole is allowed to dissolve in mouth 3-4 times a day. secondary infections caused by Gram-positive cocci occasional local irritation and burning. discontinue if sensitization occurs 2% Cream or ointment Skin infections. pityriasis versicolor.oral.cutaneous and vaginal Candidiasis.Lotion 1%.

seborrhoeic dermatitis Children under 5 years Do not apply to damaged skin (risk of systemic toxicity). hair discoloration or loss 2.Shampoo 2% Apply twice a day 15 g cream Rs 42-49/-. apply lotion with a small amount of water to the entire affected area andrinse off after 10 minutes. apply 2–7 times over 2 weeks. repeat course if necessary Seborrhoeic dermatitis.Shampoo 30 ml Rs 35/Tinea infections. avoid contact with eyes. repeat once daily for 7–14 days. cyanide poisoning P/A: 20% Solution Dose: Pityriasis versicolor.5% Suspension Pityriasis versicolor. massage 5–10 ml of shampoo into wet hair and leave for 2–3 minutes before rinsing thoroughly.Dryness. repeat twice weekly for 2 weeks. Itching. or permanent waving Local irritation. or apply undiluted lotion at bedtime and rinse off the following morning.Topical solution 1% 15g Rs 29-44/Dermatophytosis.Lotion 2%.Pityriasis versicolor. straightening. Deep mycosis Burning Cream 2% .then once weekly for 2 weeks. apply twice daily for 4 weeks 183 .Urticaria and rash Cream 1% 1-2 times daily for 2-6 weeks 10g cream Rs 49-52/Pityriasis versicolor (lotion). do not use within 48 hours of applying preparations for hair colouring.Irritation.Drugs for Superficial Mycosis P/A: Cost: Ketoconazole I: A/E: P/A: Dose: Cost: Terbinafine I: A/E: P/A: Dose: Cost: Selenium sulfide I: C/I: P/C: Cream 1% .thereafter only when needed 60 ml Rs 35/- A/E: P/A: Dose: Cost: Sodium thiosulfate I: Pityriasis versicolor.Onychomycosis Erythema.

01%) solution.tropical ulcers. skin and fabrics stained brown P/A: Condy’s lotion 1:4000-1:10. Pregnancy. Cap 50 mg. tinea pedis. Lactation. 150 mg.vomiting. 200 mg/100 ml IV Infusion Dermatophytosis – 150 mg once a week for 4-6 weeks. irritant to mucous membranes A/E: Local irritation.cryptococcal meningitis Hypersensitivity. pemphigus. Vomiting.epigastric distress. wet dressings of 1:10 000 (0.proton pump inhibitors and antacids decrease its absorption.gynaecomastia. Liver dysfunction. Tablet 200 mg (10) Rs 58-225/Dermatophytosis. impetigo P/C: Avoid occlusive dressings. tinea versicolor. Dose reduction in renal impairment Nausea. Skin rash.hepatitis.libido menstrual irregularities Tablet 200 mg 200 mg tablet once or twice daily H2 blockers.loss of hair. candidiasis. candidiasis. Pregnancy. 200 mg . 100 mg. Hypersensitivity.Dermatological Drugs Potassium permanganate I: Wet dressings to assist healing of suppurating superficial wounds. Lactation. systemic fungal infections. nausea. Nail infections-longer duration (12 months) Systemic infections 200-400 mg daily for 4-12 weeks or longer P/A: Dose D/I: Cost: Fluconazole I: C/I: P/C: A/E: P/A: Dose: 184 . subcutaneous and systemic mycosis.000 Dose: Suppurating superficial wounds and tropical ulcers. Head ache.skin rash. Abdominal pain. changed 2 or 3 times daily DEEP MYCOSIS Systemic Antifungal Agents Ketoconazole I: C/I: A/E: Dermatophytosis. Diarrhoea.

Vertigo.not effective against candidiasis Nausea.Oral contraceptives. Onychomycosis 3-12 months Tablet 250 mg (7) Rs 140-280/185 . Pregnancy. disulfiram like reaction Tab 125 mg. Gynaecomastia. headache.Drugs for Deep Mycosis D/I: Cost: Itraconazole I: C/I: A/E: P/A: Dose: Increase blood levels of Phenytoin. Tab 250 mg 250 mg tab daily for 2-6 weeks in tinea infections and pityriasis versicolor. Epigastric distress. alcohol-disulfiram like reaction Tablet 250 mg (10) Rs 20-27/Dermatophytosis Nausea. Lactation. Hepatitis. Skin rash. photosensitivity. Astimizole. Skin rash. Vomiting. Vomiting. Capsule 100 mg Aspergillosis: 200 mg capsule OD/BD with meals for 3 months or more Vaginal candidiasis: 200 mg capsule OD for 3 days Dermatophytosis:100-200 mg capsule OD for 7-15 days Onychomycosis: 200 mg capsule OD for 3 months Same as Ketoconazole Capsule 100 mg (4) Rs 173-230/- D/I: Cost: Griseofulvin I: A/E: P/A: Dose: D/I: Cost: Terbinafine I: A/E: P/A: Dose: Cost: Dermatophytosis. Nausea. Liver dysfunction. Cyclosporin and Warfarin Tablet 200 mg (2) Rs 76-89/Superficial and deep fungal infections Hypersensitivity. Loss of libido.duration differs with site Body skin – 3 weeks Palm and sole – 4-6 weeks Finger nails 4-6 months Toe nails 8-12 months Induce metabolism of Warfarin. 250 mg 125-250mg QID with meals. vomiting.

2% oint 10 gm Rs 50-62.Dermatological Drugs ANTI-BACTERIALS FOR TOPICAL USE Methylrosanilinium chloride (Gentian violet) Superficial fungal and bacterial infections(staphylococci and other gram positive bacteria)furunculosis. permanent staining of fabrics P/A: 0.Cream 10 gm Rs 60 Primary and secondary skin infections. and in renal impairment P/A: Ointment: 5 mg neomycin sulfate + 250 IU bacitracin Dose: Bacterial skin infections. mucous membranes.5-1% Solution Dose: Skin infections. Known hypersensitivity. the elderly. Hypersensitivity to aminoglycoside antibiotics . apply 2 or 3 times daily for 3 days Neomycin sulfate + bacitracin I: Superficial bacterial infections of the skin due to staphylococci and streptococci C/I: Neonates P/C: Avoid application to substantial areas of skin or to broken skin(risk of significant systemic absorption). especially to neomycin.chronic ulcers.infected eczemas.thrush C/I: Excoriated or ulcerated lesions. particularly in children. overgrowth of resistant organisms on prolonged use A/E: Sensitization.bed sores. anaphylaxis reported rarely. temporary staining of skin. Neonates. broken skin. systemic absorption leading to irreversible ototoxicity. porphyria A/E: Severe irritation (discontinue treatment). pregnancy lactation. Hepatic disease. causing reddening and scaling. ADULT and CHILD over 2 years apply thin layer 3 times daily (short term use) I: Mupirocin(Refer section 4 – Anti-infectives) Fusidic acid I: C/I: P/C: Cost: Sisomycin I: C/I: 186 Primary and secondary pyodermas caused by Gram positive organisms.

Eg. seborrhoeic dermatitis. H. intractable pruritus C/I: P/C:A/E: (Refer section 18 Hormones) P/A: Cream or ointment 0. Proteus. UTI. but not against MRSA Cephalosporins I: Bacterial skin infections. acne. gonorrhoea.50 Framycetin sulphate I: Skin infections. Salmonella and shigella. Hansen’s disease. psoriasis (under specialist supervision). otitis externa. 15 10 x 15 cm Rs.Anti Bacterial for Topical Use P/C: Renal impairment Cost: Cream 0. gonorrhoea. Cloxacillin I: Active against penicillinase producing staph. atopic dermatitis (eczema). C/I: Hypersensitivity to aminoglycosides P/C: Ototoxicity if large areas are treated A/E: Contact dermatitis. chancroid. Influenzae. lichen planus. 50 Anti-bacterials for systemic therapy(Refer section 4 – Anti-infectives) Penicillins (Crystalline and procaine penicillin) I: Syphilis. E-coli. skin and soft tissue infections caused by streptococcus and staphylococcus Amoxycillin I: Skin and soft tissue infections caused by Gram positive and negative bacteria Ampicillin I: Active against Gram positive organisms sensitive to penicillin + many Gram negative bacilli. Ototoxicity if used over large areas P/A: Impregnated gauze 1% 10 x 10 cm Rs.1% 15 gm Rs 37. ANTI-INFLAMMATORY AND ANTIPRURITIC MEDICINES Betamethasone I: Severe inflammatory skin conditions inluding contact dermatitis.05% 187 . ophthalmic infections. rosacea. burns and scalds. skin and soft tissue infections.

Same as above Irritation.then less frequently 15 g Rs 23/Mild pruritus Mild pruritus.apply small quantities to the affected area 1-2 times daily until improvement occurs. intractable pruritus and phototoxic reactions. often alternated with ultraviolet (UVB) rays. Coal tar bath. including polymorphic light eruptions and actinic pruritus.adult and child over 2 years of age.Dermatological Drugs Dose: Contact dermatitis. atopic dermatitis (eczema). Pustular and erythrodermic psoriasis Long term use may be carcinogenic.liquid paraffin and creams Coal tar ointment I: C/I: P/C: P/A: Coal tar Solution: I:C/I:P/C: A/E: Dose: Psoriasis Acute onset psoriasis. use 100 ml in bath of tepid water and soak for 10–20 minutes. skin irritation Exetar(6% coal tar+salicylic acid 3% + sulfur 3%) 5%. preferably starting with lower strength preparation. skin. photosensitivity reactions. apply 1–3 times daily. hair and fabrics discolored Psoriasis. lichen planus. allowing at least 24 hours between exposure and treatment with coal tar Cost: Calamine lotion I: Dose: Hydrocortisone I: Inflammatory skin conditions. rarely hypersensitivity.Cream 25 g Rs 70/DRUGS USED FOR PSORIASIS Topical Preparations Emollients-Examples soft paraffin. use once daily to once every 3 days for at least 10 baths. short-term treatment of psoriasis of the face and flexures C/I:P/C:A/E: (Refer section 18 hormones) P/A: Cream or ointment: 1% (acetate) Dose: Same as betamethasone Cost: Ointment 15 g Rs 42-45/-. apply liberally 3–4 times daily 188 .

urticaria pigmentosa C/I: Pregnancy and lactation. 189 I: C/I: . acute eruptions. initiate under medical supervision: starting with 0.005% Cost: Ointment 30 mg – Rs 998/Topical corticosteroids Hydrocortisone –used on face and flexures Betamethasone –scalp. conjunctivitis following contact with eyes.lactation A/E: Photosensitivity. avoid use on face. hepatic diseases. Cutaneous malignancies. leave in contact for 30 minutes.can be infiltrated into localized resistant psoriatic lesions or in nail folds for nail involvement.Drugs used for Psoriasis Dithranol Moderately severe psoriasis Hypersensitivity. Topical Retinoids Tazarotene 0.1% gel Bexarotene 1% gel SYSTEMIC THERAPY FOR PSORIASIS Psoralen plus UVA (PUVA) I: Psoriasis.skin irritation. A/E: Local irritation.1–0.hands and feet Triamcinalone acetone iodine – 10 mg/ml intralesional. discontinue use if excessive erythema or spread of lesions.5% strength preparations are suitable for overnight use. staining of skin. wash hands thoroughly after use Calcipotriol (Topical vitamin D analogue) I: Plaque type psoriasis P/C: Avoid use on face.pregnancy.hair. then wash off thoroughly. some 0.1-2%. Patients > 12 years. gradually increasing strength to 2% and contact time to 60 minutes at weekly intervals. and fabrics Dose: Psoriasis.1%. excessively inflamed areas P/C: Irritant—avoid contact with eyes and healthy skin P/A: Ointment: 0.erythema scaling P/A: Ointment 0. carefully apply to lesions only. repeat application daily.vitiligo.

renal impairment. children 190 . plantar warts C/I: Pregnancy. nausea.5 mg every 2-4 weeks until a response is evident (maximum 25 mg/ week) Severe recalcitrant.5-15 mg/week orallyand increased by 2. Avoid sunlight.5 mg.60/Psoriasis.5-0.liver dysfunction. gingivitis. pemphigus.Dermatological Drugs A/E: P/A: Dose: D/I: Cost: Methotrexate I: C/I: P/C: A/E: P/A: Dose: A/c-erythema. Avoid contact with eyes and mucosa.hyperlipidaenia. C/c -cataract.freckles. hypervitaminosis A. alopecia.hypersensitivity.breastfeeding. myalgia. erythema.75mg/kg/day administered in 1 or 2 daily doses Capsule 10 mg (10) Rs 368/- DRUGS FOR WARTS Podophyllum resin I: External anogenital warts. liver damage Acitretin 10 & 25 mg (for psoriasis) 0. Tablet 10 mg (40) Rs 59. pruritus. 5 mg 7. 3mg/kg/day Cyclosporine I: Dose: Acitretin Synthetic retinoid for oral use. I: C/I: P/C: A/E: P/A: Dose: Cost: Severe forms of psoriasis Pregnancy. Avoid other photosensitive drugs. and alcohol intake Drying of skin and eyes. Solution-1%w/v 600 mcg/kg one and half to three hours before UVA exposure. children. Tablet Methoxsalen10 mg. pityriasis rubra pilaris. lupus erythematosis (Refer section 6 Anti neoplastic drugs) Tab – 2. photosensitivity.Treatment given twice a week or increased as necessary with atleast 48 hours interval. plaque psoriasis in adult as a crisis management drug. malignancies. mycosis fungoides.

particularly in children Lotion: 25%. renal failure. Scabies. body and pubic lice Do not use on inflamed or broken skin.rinse off after 1–6 hours. Apply carefully to warts. avoiding contact with normal tissue. repeat without bathing on the following day and wash off 24 hours later.keep away from face. mucous membranes. not recommended for children. also transient leucopenia and thrombocytopenia. further applications possibly needed after 7 and 14 days 100 ml Rs 24/Hyperkeratotic scabies not responding to topical treatment Single oral dose of 200 mcg/kg in combination with topical drugs 191 A/E: P/A: Dose: Cost: Ivermectin I: Dose: . apply to affected area and wash off 24 hours later. avoid contact with eyes and mucous membranes. apply over whole body. only few warts to be treated at any one time 5mg/ml solution Rs 275.Drugs used for Warts P/C: A/E: P/A: Dose: Cost: Benzyl benzoate I: P/C: Avoid use on large areas. very irritant to eyes. confusion and delirium following excessive application Solution: 10-25%. ADULT. breastfeeding (withhold during treatment) Local irritation. vomiting. ADULT. avoid contact with normal skin and open wounds Systemic effects resulting from cutaneous absorption include nausea. a third application may be needed in some cases Pediculosis. disorientation. may be repeated at weekly intervals but no more than 4 times in all. abdominal pain and diarrhoea. delusions. head. delayed neurotoxicity including visual and auditory hallucinations.70/- Scabicides and Pediculocides Scabies.

Lotion: 1 %( Head lice).1% 10 g Rs 28-235/Systemic drugs 1. chidren < 2 years.1% cream 60g Rs 65/- Cost: OTHER DERMATOLOGICAL CONDITIONS ECZEMAS Topical preparations 1. avoid contact with eyes. pregnancy. 0.Immuno compromised adults. treat again. apply lotion to clean damp hair and rinse off after 10 minutes all family members have to be treated Pediculosis:1% lotion to be applied for 7 minutes Cream 5% 30 g Rs 37/-. Lotion 5% Scabies and body lice apply cream over whole body and wash off after 8–12 hours. Systemic corticosteroids 192 . infections lymphomas.Dermatological Drugs Permethrin I: P/C: A/E: P/A: Dose: Scabies. Tacrolimus Calcineurin inhibitor I: Moderate/severe atopic dermatitis C/I: Infected lesions. repeat application after 7 days Head lice. Antihistamines 2. head and body lice Do not use on inflamed or broken skin. if hands washed with soap within 8 hours of application. skin malignancies. lactation A/E: Skin buring. Cortico steroids – topical 4. pruritus. Compresses Saline or potassium permanganate (1:4000 to 1:8000) I: Eczematous dermatosis 2. P/A: Ointment – 0. rarely rashes and oedema Cream: 5%.breastfeeding (withhold during reatment) local irritation.03%. Antibacterial agents(Refer section 4 Anti-infective drugs) 3.1% Cost: 0. Lotion 5% 30g Rs 59/-.

consider other immunosuppressants as adjuncts: Azathioprine. • May be changed to oral prednisolone as dose is tapered. but a course of systemic steroids in the early stages may help Wet compresses in selected areas Supportive care Prophylactic antibiotics Fluid and electrolyte management (like second degree burns) Ophthalmologic care DERMATITIS HERPETIFORMIS Gluten free diet Dapsone Dose : 100-200 mg OD orally may be required in some cases. • In diabetics and hypertensives consider dexamethasonecyclophosphamide pulse therapy (Has to be admitted and given under close monitoring) • Other Immunosuppressants In those requiring high maintenance dose of systemic steroids. STEVEN – JOHNSON SYNDROME • Evaluate for cause and give specific treatment • Avoid suspected drugs (offending drug) and its chemically related drugs • Evaluate for cause and give specific treatment 193 .Drugs for other Dermatological Conditions PEMPHIGUS Systemic Corticosteroids • May be started with Betamethasone/Dexamethasone injection 4 mg BD • To be tapered according to disease activity. Cyclophosphamide • Immunomodulator drugs:Dapsone TOXIC EPIDERMAL NECROLYSIS • • • • • • • • Avoid suspected drugs (offending drug) and its chemically related drugs Systemic corticosteroids Use of systemic steroids is controversial. ERYTHEMA MULTIFORME.

Erythromycin Benzoyl peroxide I: CI: 194 Acne.Antihistamines LICHEN PLANUS • Limited disease – super potent topical steroid or intralesional steroid. • Photo therapy –UVA1. ANGIOEDEMA • Evaluate for the cause and give specific treatment • Avoid inducing factors • Symptomatic treatment includes:Antihistamines – H1 receptor blocker Ketotifen Systemic corticosteroids Topical antipruritic lotions eg: Calamine lotion Danazol-Hereditary Angioneurotic oedema FIXED DRUG ERUPTION • Avoid suspected drugs (offending drug) and its chemically related drugs • Topical corticosteroids. ulcerative lesion. PUVA. Acneform eruptions Hyper sensitivity.Dermatological Drugs Topical therapy Antibacterials. . Topical PUVA • Oral lesion – Super potent topical steroid PITYRIASIS ROSEA • Topical steroid & emollients • Anti histamines ACNE VULGARIS Topical therapy Topical antibiotic Clindamycin. • Anti histamines • Wide spread disease – systemic steroid-short course. Corticosteroids Systemic therapy Corticosteroids.Acyclovir – for recurrent Erythema Multiforme URTICARIA.

5%gel 20g Rs 27-66/Acne Acute dermatitis. erythromycin ALOPECIA Topical Minoxidil I: A/E: P/A: Dose: Cost: Androgenitic alopecia Local irritation. 195 .1% gel Dose: Apply at bed time Cost: 15 g Rs 75-86/Systemic therapy Antibiotics – Moderate to severe cases Doxycycline. 5% Apply at night 2. peeling. skin and other organs. irritation. 5% solution Should be continued indefinitely 2% solution Rs 135/DRUGS USED IN LEPROSY The causative organism of leprosy is the acid fast bacilli Mycobacterium leprae. Avoid contact with eyes. mucus membranes & use along with cosmetics Dryness.5%. 0. use with caution in eczemas. mucus membranes. low incidence of contact dermatitis 2% solution .05% cream. minocycline. peeling.Drugs for other Dermatological Conditions P/C: A/E: P/A: Dose: Cost: Tretinoin I: C/I: ` P/C: Avoid contact with eyes.25% cream Apply at night A/E: P/A: Dose: Adapalene P/A: 0. It is divided into multibacillary and paucibacillary type. tightening & redness. It is a chronic granulumatous disease that primarily affects the peripheral nerves. swelling & redness. 0. hypertrichosis. Gel 2. Dryness. irritation. abrasions.

pneumocystis pneumonia in AIDs. Multiple nerve thickening present. punched out and inverted saucer lesions present. chloroquine resistant malaria. Bilateral asymmetrical nerve thickening. No raised lesions. 4. Pure neuritic leprosy (PL): No skin lesions. Smear positive 6. Lepromatous (LL): Multiple generalized symmetric macules. Tuberculoid (TT) : Well defined hypopigmented anaesthetic macules and plaques with loss of hair and hypohidrosis. Sulphone allergy. Tablet 50 mg. geographic. Leonine facies present. Borderline Lepromatous (BL): Multiple generalized asymmetric macules. 3. Borderline Borderline (BB): Multiple lesions. Dapsone I: C/I: P/C: Leprosy. cardiac and p u l m o n a r y disease.Dermatological Drugs National Leprosy Eradication program Classification 1. hepatitis. severe G6PD deficiency. Satellite lesions present. Bilateral symmetrical nerve thickening present. 2. severe anaemia. fixed drug eruption. 100 mg Paucibacillary leprosy: 100 mg daily self administered for 6 months Multibacillary leprosy: 100 mg daily self administered for 1 year Tab 50 mg (1000): Rs. moderate anaemia. Stevens Johnson syndrome. dapsone syndrome. Annular. lactation and pregnancy. The lesions have dry surface. Indeterminate (IL): Single or multiple macules. porphyria. Only nerve thickening. sulphonamide allergy. Mild to moderate G6PD deficiency. methemoglobnemia. Dermatitis herpetiformis. papules and nodules. Smear positive. rash. Borderline Tuberculoid (BT): Hypopigmented anaesthetic macules and plaques with party well defined and partly ill defined borders. Hemolytic anaemia. psychosis. motor neuropathy. 7. papules and nodules. 5. 40 – 42/- A/E: P/A: Dose: Cost: 196 .

Capsule 300 mg.vasculitis. gastritis Paucibacillary 400 mg daily 400 mg – Rs. rifampicin shock. gastritis and acute abdomen. P/A: Dose: Cost: The following drugs are given when resistance is suspected or first line drugs cannot be tolerated. Hepatic and renal function tests required. diarrhea and steatorrhea. hence numerous drug interactions reported. vomiting. 7. Reddish orange discoloration of body fluids. 113/Leprosy. 600 mg Paucibacillary : 600 mg monthly supervised for 6 months Multibacillary : 600 mg monthly supervised for 1 year 600 mg – Rs. First trimester of pregnancy. Ofloxacin I: C/I: P/L: A/E: Dose: Cost: Leprosy. lepra reactions. 8/.50 /-Tablet 197 . Capsule 50 mg (100) Rs. 100 mg.Capsule Hepatic microsomal enzyme inducer. Capsule 50 mg. Below 12 years of age Photosensitivity. flu like syndrome. Hepatic and renal function tests are required. hepatitis. Paucibacillary: Not given Multibacillary : 300 mg once monthly supervised and 50 mg daily self administered for 1 year. hyperpigmentation and ichtyosis of skin. First trimester of pregnancy. peptic ulcer. Tuberculosis Sulphone First trimester of pregnancy. Reddish discoloration of urine.Drugs forLeprosy Rifampicin I: C/I: P/C: A/E: P/A: Dose: Cost: D/I: Clofazamine I: C/I: P/C: A/E: Leprosy.

Dermatological Drugs Minocycline I: C/I: P/C: A/E: P/A: Dose: Cost: Clarithromycin I: C/I P/C: A/E P/A Dose: Cost: Leprosy. bluish black pigmentation of skin Capsule 50 mg. 250 mg. bacterial infections : Hepatitis Liver function tests required : Gastritis. 100 mg 100 mg daily 100 mg capsule – Rs. acne vulgaris First trimester of pregnancy. Below 12 years of age Photosensitivity. 12/. 500 mg 500 mg daily Tablet 500 mg – Rs.capsule Leprosy. : Tablets. 50/-Tablet 198 . hepatitis.

biliary ducts and spleen. Barium sulfate may be used in either single. Both salts have been used alone in diagnostic radiography including computer-assisted axial tomography but a mixture of both is often preferred to minimize adverse effects and to improve the quality of the examination. Barium sulfate is a metal salt which is used to delineate the gastrointestinal tract.or double-contrast techniques or computer assisted axial tomography. but they are generally more expensive. Amidotrizoates are used in a wide range of procedures including urography and examination of the gallbladder.SECTION 12 DIAGNOSTIC AGENTS RADIOCONTRAST MEDIA Radiographic contrast media are needed for delineating soft tissue structures such as blood vessels. Air administered through a gastrointestinal tube can be used as an alternative to carbon dioxide to achieve a double-contrast effect. Amidotrizoates (meglumine amidotrizoate and sodium amidotrizoate) are iodinated ionic monomeric organic compounds. bowel loops and body cavities not otherwise visualized by standard X-ray examination. thereby making the examined structures visible on radiographs. Owing to their high osmolality and the resulting hypertonic solutions. For double contrast examination gas can be introduced into the gastrointestinal tract by using suspensions of barium sulfate containing carbon dioxide or by using separate gas-producing preparations based on sodium bicarbonate. The contrast media in this group containing heavy atoms (metal or iodine) absorb a significantly different amount of X-rays than the surrounding soft tissue. angiography and arthrography and also in computer-assisted axial tomography. they are associated with a high incidence of adverse effects. 199 . Radiodensity depends on iodine concentration. It is not absorbed by the body and does not interfere with stomach or bowel secretion or produce misleading radiographic artefacts. stomach. and osmolality depends on number of particles in a given weight of solvent. Low osmolality media such as iohexol are associated with a reduction in some adverse effects (see below). The osmolality for a given radiodensity can be reduced by using an ionic dimeric medium such as meglumine iotroxate which contains twice the number of iodine atoms in a molecule or by using a non-ionic medium such as iohexol. Iohexol is used for a wide range of diagnostic procedures including urography.

200 . Patients with a history of asthma or allergy. breastfeeding.renal impairment . heart disease. arthrography. sickle-cell disease. cardiac disease. atopy or asthma. and those receiving beta adrenoceptor antagonists (beta-blockers) are at increased risk. hypertension. Non-ionic media are preferred for these patients and beta-blockers should be discontinued if possible.debilitated or children— increased risk of adverse effects. venography. phaeochromocytoma. drug hypersensitivity. restart when renal function stabilized).Diagnostic agents Meglumine iotroxate is excreted into the bile after intravenous administration and used for cholecystography and cholangiography. adequate resuscitation facilities must be immediately available when radiographic procedures are carried out Injection: 140-420 mg iodine (as sodium or meglumine salt)/ml in 20-ml ampoule. operative cholangiography. ADULT and CHILD. severe hepatic impairment. high osmolality compounds. dehydration—correct fluid and electrolyte balance before administration. diskography. pregnancy. hyperthyroidism. may precipitate fatal renal failure). previous reaction to contrast media. route and dosage depend on procedure and preparation used (consult manufacturer’s literature) Only by specialist radiographers. elderly. according to manufacturer’s directions C/I: P/C: P/A: Dose: ADMINISTRATION. important: because of risk of hypersensitivity reactions. Amidotrizoate Amidotrizoates are representative iodinated ionic monomeric contrast media. biguanides(withdraw 48 hours before administration. computer-assisted axial tomography Hypersensitivity to iodine-containing compounds History of allergy. may interfere with thyroid-function tests. adrenal suppression. Diagnostic radiography. Various media can serve as alternatives I: Urography. multiple myeloma (risk if dehydrated. Anaphylactoid reactions to iodinated radiocontrast media are more common with ionic. splenoportography.

electrocardiographical changes may occur with rectal administration. ADULT and CHILD. pruritus. thrombosis. gastrointestinal obstruction. conditions such as pyloric stenosis or lesions which predispose to obstruction. pain on injection. Only by specialist radiographers. haemodynamic disturbances and hypotension. convulsions.paralysis.sensations of heat. venospasm and embolism Barium sulfate Aqueous suspension. rhinitis. such as acute ulcerative colitis. circulatory failure and cardiac arrest. diarrhoea. appendicitis. perforation of bowel resulting in peritonitis.sweating. headache. adhesions. disseminated intravascular coagulation. thrombophlebitis. pulmonary oedema. lacrimation. vomiting.pneumonitis or granuloma formation following accidental aspiration into lungs.hyperthyroidism. dizziness.Diagnostic agents A/E: Nausea. flushing. salivary gland enlargement. weakness.route and dosage depend on procedure and preparation used (consult manufacturer’s literature) ADMINISTRATION. according to manufacturer’s directions A/E: Constipation or diarrhoea. cardiac disorders. visual disturbances. or after rectal or colonic biopsy. extravasation may result in tissue damage. sigmoidoscopy or radiotherapy P/C: adequate hydration after procedure to prevent severe constipation Dose: Radiographic examination of gastrointestinal tract. diverticulitis. sneezing. coughing. coma. rarely. rigors. abdominal cramps and bleeding. intestinal perforation or conditions with risk of perforation. I: Radiographic examination of the gastrointestinal tract (see notes above) C/I: Intestinal obstruction. arrhythmias. 201 . fibrinolysis and depression of blood coagulation factors. metallic taste. pallor. nephrotoxicity. occasionally anaphylactoid or hypersensitivity reactions. granulomas and high mortality rate.

pruritus. angiography. 20-ml ampoules. 10-ml. convulsions. lacrimation. coughing. weakness. venography. arthrography. dehydration—correct fluid and electrolyte balance before administration. rarely. nephrotoxicity. severe hepatic impairment.debilitated or children— increased risk of adverse effects. hyperthyroidism. occasionally anaphylactoid or hypersensitivity C/I: P/C: P/A : Dose: ADMINISTRATION. circulatory failure and cardiac arrest. ADULT and CHILD. arrhythmias. according to manufacturer’s directions (see also notes above). dizziness. biguanides(withdraw 48 hours before administration. hypertension. operative cholangiography. may interfere with thyroid-function tests. restart when renal function stabilized). pallor. Diagnostic radiography. pulmonary oedema. adequate resuscitation facilities must be immediately available when radiographic procedures are carried out Injection: 140-350 mg iodine/ml in 5-ml. rigors. atopy or asthma. multiple myeloma (risk if dehydrated.Diagnostic agents Iohexol Iohexol is a representative iodinated non-ionic contrast medium.renal impairment. sneezing. sensations of heat. splenoportography. vomiting.flushing. diskography. computerassisted axial tomography hypersensitivity to iodine-containing compounds history of allergy. cardiac disorders. visual disturbances. ventriculography. headache. important: because of risk of hypersensitivity reactions.rhinitis. paralysis. route and dosage depend on procedure and preparation used (consult manufacturer’s literature) Only by specialist radiographers. sweating. salivary gland enlargement. cardiac disease. nausea. A/E: 202 . Various media can serve as alternatives I: urography. phaeochromocytoma. breastfeeding. haemodynamic disturbances and hypotension. sickle-cell disease. pregnancy. may precipitate fatal renal failure). metallic taste.coma. elderly.

adequate resuscitation facilities must be immediately available during radiographic proceduresSolution: 5-8 g iodine in 100-250 ml. venospasm and embolism Meglumine iotroxate Meglumine iotroxate is a representative iodinated ionic dimeric contrast medium. pruritus.lacrimation. dizziness. flushing. thrombophlebitis. circulatory failure and cardiac arrest. biguanides(withdraw 48 hours before administration.pulmonary oedema. may interfere with thyroid-function tests. Solution: 5-8 g iodine in 100-250 ml. extravasation may result in tissue damage. haemodynamic disturbances and hypotension or hypertension. rhinitis.hyperthyroidism. convulsions. debilitated or children— increased risk of adverse effects. occasionally anaphylactoid 203 P/A: Dose: ADMINISTRATION A/E: . visual disturbances. coma. hypertension. atopy or asthma.Diagnostic agents reactions. cardiac disorders. Various media can serve as alternatives. sweating. pregnancy. arrhythmias.weakness. sickle-cell disease. breastfeeding. vomiting. sensations of heat.renal impairment . thrombosis. headache. salivary gland enlargement. may precipitate fatal renal failure). multiple myeloma (risk if dehydrated. pallor. cardiac disease. by oral route ADULT 30-60mg of meglumine iotroxate in 1 litre of distilled water over at least 15 minutes(consult manufacturer’s literature) Only by specialist radiographers. severe hepatic impairment. hyperthyroidism. rigors. paralysis. important: because of risk of hypersensitivity reactions. according to manufacturer’s directions Nausea. elderly. rarely.dehydration—correct fluid and electrolyte balance before administration. It is a complementary drug I: C/I: P/C: examination of the gallbladder and biliary tract hypersensitivity to iodine-containing compounds history of allergy. Examination of gallbladder and biliary tract. cough. metallic taste. restart when renal function stabilized). sneezing.phaeochromocytoma. pain on injection.

Gadolinium DTPA 2. I: P/C: To detect coreneal ulcers. thrombophlebitis. 25% Topical use Solution 2% Not to exceed 15 mg/kg bw.Diagnostic agents or hypersensitivity reactions. extravasation may result in tissue damage. Dyschromatopsia. 5%. fundus fluorescein angiography. use Solution 1%. the cornea gets stained.8 mg/ml).thrombosis. Intact epithelium resists the penetration of this dye.v. Indocyanin green. Iatrogenic infection of the eye. TRYPAN BLUE (0. Gadodiamide DYES USED IN OPHTHALMOLOGY Fluorescein Sodium This is used to detect breaks in the corneal epithelium. hyperthyroidism. Yellow discolouration of urine and skin (after i. hypotension and shock. use) for upto 24 hours. This is avoided by using 1:25. venospasm and embolism MRI Contrast Media 1. For i. Systemic effects like allergy. Cross infection may develop due to contamination of the eye drops. Lissamine green and Rose Bengal (both drops and strips) A/E: P/A: Dose: OTHER DYES : 204 . pain on injection.000 phenyl mercuric nitrate as the preservative. False positive Benedict’s test in urine. When there is disruption of the epithelium.v.

fungi. alcoholic solutions not suitable before diathermy. is effective against bacteria. Chlorhexidine Solution: 5% (digluconate) for dilution. Various agents can serve as alternatives I: P/C: Antiseptic. irritant—avoid contact with middle ear. Some antiseptics are applied to the unbroken skin or mucous membranes. brain and meninges. disinfection of clean instruments Aqueous solutions—susceptible to microbial contamination—use sterilized preparation or freshly prepared solution and avoid contamination during storage or dilution. povidone iodine. protozoa. to burns and to open wounds to prevent sepsis by removing or excluding microbes from these areas. eyes. viruses. alcohol based solutions are inflammable 205 . Chlorhexidine gluconate is a representative disinfectant and antiseptic. The solution of povidoneiodine releases iodine on contact with the skin.SECTION 13 DISINFECTANTS AND ANTISEPTICS Antiseptics An antiseptic is a type of disinfectant. such as bicarbonates. forming salts of low solubility which may precipitate out of solution. syringes and needles treated with chlorhexidine (rinse thoroughly with sterile water or saline before use). Chlorhexidine is incompatible with soaps and other anionic materials.Chlorhexidine has a wide spectrum of bactericidal and bacteriostatic activity and is effective against both Gram-positive and Gram-negative bacteria although it is less effective against some species of Pseudomonas and Proteus and relatively inactive against mycobacteria. which destroys or inhibits growth of micro-organisms on living tissues without causing harm when applied to surfaces of the body or to exposed tissues. plastic or rubber closures). cysts and spores and significantly reduces surgical wound infections. Iodine has been modified for use as an antiseptic. not for use in body cavities. It is not active against bacterial spores at room temperature. chlorides. inactivated by cork (use glass. The iodophore. and phosphates. instruments with cemented glass components (avoid preparations containing surface active agents).

immerse for 2 minutes in 0.5% solution in alcohol (70%) or 2 or 4% detergent solution Antiseptic (wounds. avoid broken skin. Ethanol is a representative disinfectant.Disinfectants And Antiseptics ADMINISTRATION. A/E: Antiseptic (pre-operative skin disinfection and hand washing).1% (to inhibit metal corrosion) Emergency disinfection of clean instruments. Various agents can serve as alternatives I: Antiseptic. apply undiluted solution skin dryness and irritation with frequent application A/E: Povidone iodine Solution: 10%. The application of povidone-iodine to largewounds or severe burns may produce systemic adverse effects such as metabolic acidosis.05% solution containing sodium nitrite 0.5% solution in alcohol (70%) DILUTION AND ADMINISTRATION. avoid regular use in neonates. Various agents can serve as alternatives I: P/C: disinfection of skin prior to injection. patients have suffered severe burns when diathermy has been preceded by application of alcoholic skin disinfectants ADMINISTRATION. breastfeeding .05% aqueous Solution Disinfection of clean instruments. apply 0. hypernatraemia. use 0. According to manufacturer’s directions occasional skin sensitivity and irritation Ethanol Solution: 70% (denatured). avoid in very low birthweight infants P/C: pregnancy. skin disinfection C/I: Avoid regular or prolonged use in patients with thyroid disorders or those taking lithium. Disinfection of skin. immerse for at least 30 minutes in 0. venepuncture or surgical procedures Inflammable.broken skin(see below). Povidone-iodine is a representative antiseptic. burns and other skin damage). renal impairment Large Open Wounds. and impairment of renal function 206 .

such as sodium hypochlorite. chloroxylenol. A 2% w/v aqueous alkaline (buffered to pH 8) glutaral solution can be used to sterilize heat-sensitive precleansed instruments and other equipment.The aldehyde bactericidal disinfectant. Disinfectantsare applied to inanimate objects and materials such as instruments and surfaces to control and prevent infection. tosylchloramide sodium (chloramine).which does not harm health or the quality of perishable goods. ADULT and CHILD apply twice daily (see also Contraindications above) irritation of skin and mucous membranes. systemic effects (see under Precautions) A/E: Disinfectant: A disinfectant is a chemical agent. Appropriate precautions must be taken when concentrated chlorine solutions or powders are handled. Where water is not disinfected at source it may be disinfected by boiling or by chemical means for drinking.Disinfectants And Antiseptics ADMINISTRATION. halazone.Chlorine is a hazardous substance. above).Disinfection of water can be either physical or chemical methods. may interfere with thyroid function tests. cleaning teeth andfood preparation. ADULT and CHILD apply undiluted (see also Contraindications above) Antiseptic (minor wounds and burns). is rapidly effective against both Gram-positive and Gram-negative bacteria. Physical methods include boiling. Pre. 207 . is effective against a wide range of Gram-positive bacteria. and it is inactive against spores. The chlorinated phenolic compound. fungi such as Candida albicans.Disinfectants do not necessarily kill all organisms but reduce them to a level. or sodium dichloroisocyanurate. it is often ineffective against Pseudomonas spp. It is less effective against staphylococci and Gram-negative bacteria. It is active against the tuberculosis bacillus.and post-operative skin disinfection. and viruses such as HIV and hepatitis B. which destroys or inhibits growth of pathogenic micro-organisms in the non-sporing or vegetative state. filtration and ultraviolet irradiation. glutaral. They may also be used to disinfect skin and other tissues prior to surgery (see also Antiseptics. it is slowly effective against bacterial spores. Chemical methods include the use of chlorine releasing compounds. It is highly corrosive in concentrated solution and splashes can cause burns and damage the eyes.

According to manufacturer’s directions A/E: skin sensitivity reported ADMINISTRATION.1% available chlorine) for solution. soak in solution containing 1000 parts per million for a minimum of 15 minutes. Chlorine releasing compounds are representative disinfectants. activity diminished in presence of organic material and increasing pH (can cause release of toxic chlorine gas) Surface disinfection (minor contamination).8%.Disinfectants And Antiseptics Chlorine base compound Powder: (0. 208 . Various agents can serve as alternatives I: P/C: Antiseptic. rinse with sterile water DILUTION AND ADMINISTRATION. disinfection of instruments and surfaces Aqueous solutions should be freshly prepared. equipment. Various agents can serve as alternatives I: C/I: Disinfection of surfaces. to avoid corrosion do not soak for more than 30 minutes. water Avoid exposure of product to flame. Chloroxylenol is a representative disinfectant and antiseptic. Chloroxylenol Solution: 4. use a 1 in 20 dilution of 5% concentrate in alcohol (70%) DILUTION AND ADMINISTRATION. According to manufacturer’s directions A/E: Irritation and burning sensation on skin ADMINISTRATION. apply solutions containing 1000 parts per million Instrument disinfection. apply a 1 in 20 dilution of 5% concentrate in water Disinfection of instruments. appropriate measures required to prevent contamination during storage or dilution Antiseptic (wounds and other skin damage).

immerse in undiluted solution for 10–20 minutes. headache. eye irritation and dermatitis and skin discoloration Disinfection and sterilization of instruments and surfaces Minimize occupational exposure by adequate skin protection and measures to avoid inhalation of vapour 209 . up to 3 hours may be required for certain instruments (for example bronchoscopes with possible mycobacterial contamination). immerse in undiluted solution for up to 10 hours. airway obstruction. I: P/C: Administration: Disinfection of clean instruments. asthma. rinse with sterile water or alcohol after disinfection Sterilization of clean instruments.Disinfectants And Antiseptics Glutaral Solution: 2%. rhinitis. rinse with sterile water or alcohol after disinfection A/E: (occupational exposure) nausea.

gout. hyponatremia. impotence. 50 mg Dose: 25 . Rs 6/. Addison’s disease. A/E: Postural hypotension. fatigue. hypertriglyceredemia. Hypokalemia.5mg (10). A/E: 210 .80 Indapamide & Xipamide (Refer Section 10) LOOP DIURETICS Frusemide (furosemide) This is the most common loop diuretic currently in use. hypokalemia. Pregnancy. hypomagnesemia. cramps. On prolonged use dyslipidemia.100 mg daily. postural hypotension. allergy to sulfonamide. tinnitus. hyperlipidemia. severe hepatic dysfunction. pregnancy. hypovolemia. rash. gout.to Rs16. moderate and severe renal impairment. C/I: Hypvolemia.SECTION 14 DIURETICS THIAZIDE DIURETICS Hydrochlorothiazide I: Congestive cardiac failure. diarrhoea. Addison’s disease. hyperglycemia and hypokalemia can occur. rash. P/C: Hypokalemia. acute pulmonary oedema. oliguria due to renal failure. Digoxin toxicity occurs if hypokalernia is present Cost: 12. ascites. nausea. I: C/I: P/C: Oedematous states. D/I: Increase in serum lithium. incipient acute renal failure Severe sodium and water depletion. systemic hypertension.to Rs 10/25mg (10) Rs 11/. P/A: Tablets 25 mg. hyponatremia. potentiates the effects of other antihypertensive drugs. diabetes. diabetes. cramps. hyperuricemia. hepatic and renal impairment. hyper glycemia. NSAID’s reduce the diuretic effect. lower urinary tract obstruction. hyperuricemia. nephrotic syndrome.

20mg.40 mg initially. maintenance 20-40mg daily.May be given by intramuscular route in situations where venous access is not obtained. 100 mg.Prolonged use in chronic oedema· beneficial to combine with potassium sparing diuretic Torasemide(Torsemide) Similar to Furosemide but 3 times more potent.95 Inj 10 mg /mL (20ml)(amp) Rs. Note: It is better to use frusemide in oedema states and thiazide diuretics in systemic hypertension For acute oliguric renal failure and in incipient renal failure. 20. I: P/A : Oedema and hypertension 5mg.Slow intravenous injection or intramuscular injection IV rate not exceeding 4mg / min. Serum lithium levels are increased. The onset of action is delayed when given IM Intravenous infusion 250mg over 1 h followed by 500mg in 2 h in oliguric renal failure up to lg can be repeated every 24 h. increase to 80-120 mg if necessary Child 0. 10mg.5 — 1. When administered concurrently with aminoglycosides the ototoxicity of the latter is increased.5mg/ kg.Initially 250mg daily may be stepped up in increments of 125-250mg up to a maximum dose of 2g. Oliguria and renal failure : Higher doses in presence of renal failure. Cost : Tab 40 mg (10) Rs25. vials containing larger doses upto 250mg are available.28. up to 500 mg Injection 20 mg/ mL 2 mL vials Dose: Oral tablets Oedema: 40mg daily. D/I: Furosemide potentiates antihypertensive action of other drugs. NSAID’s decrease the diuretic effect. This mode enables titration of dose and is thus beneficial in acute renal failure. Potassium supplements are required except in patients with renal failure. 211 P/A: . resistant oedema 80-120mg daily. especially ACE inhibitors and alpha blockers.Loop Diuretics Tablets 40 mg.

hyponatremia.Renal failure-upto 100 mg daily 10mg (10) . C/I: Moderate and severe hyperkalemia. photosensitivity. C/I: P/C: A/E: P/A: Dose: 212 . D/I: lt increases serum digoxin levels. P/C: Chronic hepatic or renal disease. menstrual irregularities. Addisons disease. A/E: Gynecomastia. gastrointestinal side effects. frusemide 20 mg). 17/- Triamterene I: lt is indicated in oedematous states. headache. in combination with thiazides or loop diuretics. Drug of choice in primary hyperaldosteronism. Combination tablet (Triamterene 50 mg. 100 mg Dose: 25 mg 6 h upto 200 mg/ day This dose may be increased upto 400 mg / day in divided doses in selected cases. 150 .Rs.Oedema 5-20 mg/day. renal failure. Monitor plasma urea and potassium particularly in the elderly and in renal impairment. Cost: Tab 25 mg (10) Rs.250 mg daily.Diuretics Dose: Cost: Hypertension 2. I: Oedema and ascites of cirrhosis. Aspirin blocks the action of spironolactone. renal failure. When NSAIDs are given concurrently with spironolactone this may lead to acute renal failure. Uncontrolled use may lead to hyperkalemia. when potassium loss is to be minimized. lethargy. Used along with thiazides to counteract potassium losing effect. P/A: Tablets 25 mg. GI disturbances. Hyperkalemia. rash.5-5mg OD. renal failure. 21. hyperkalernia. impotence. hyperkalemia. POTASSIUM SPARING DIURETICS Spironolactone This potassium sparing diuretic is a competitive inhibitor of aldosterone. nephrotic syndrome and congestive heart failure. 50 mg in combination with thiazides.50.

Amiloride This is a potassium sparing diuretic used in combination with loop diuretics or thiazide. P/C: Pregnancy.Osmotic Diuretics D/I: Cost : Increases digoxin and lithium levels. diabetes mellitus. hypokalemia.32. hyponatremia. raised intraocular pressure (emergency treatment or before surgery) Pulmonary oedema. Cost : Rs. to reduce raised intraocular pressure or to treat disequilibrium syndrome. dry mouth. intracranial bleeding (except during craniotomy). A/E: Rash. ACE inhibitors increase the risk of hyperkalernia. Tab Benzthiazide 25mg + Triamterene 50 mg Rs. and acute water intoxication may occur in patients with inadequate urine flow. OSMOTIC DIURETICS Mannitol Osmotic diuretics. I: Chronic oedematous states especially for in prolonged administration. Mannitol is also used to control intraocular pressure during acute attacks of glaucoma. are administered in sufficiently large doses to raise the osmolarity of plasma and renal tubular fluid. hypersensitivity. preferably in the morning. GI side effects. such as mannitol .50. 14. diuresis occurs after 1–3 hours. 213 . as a consequence. severe congestive heart failure. pulmonary oedema can be precipitated in patients with diminished cardiac reserve. Reduction of cerebrospinal and intraocular fluid pressure occurs within 15 minutes of the start of infusion and lasts for 3–8 hours after the infusion has been discontinued.Circulatory overload due to expansion of extracellular fluid is a serious adverse effect of mannitol. P/A: Combination tablets(frusemide 40 mg and amiloride hydrochloride 5 mg) Dose: 1-2 tablet daily. I: C/I: Cerebral oedema.00. Osmotic diuretics are used to reduce or prevent cerebral oedema. D/I: Increases lithium levels and causes lithium toxicity. C/I: Hyperkalemia.

chills. chest pain. 200 mg/kg body weight infused over 3–5 minutes. skin necrosis.5 g/kg Cerebral oedema. if response inadequate after second test dose. as a 20% solution infused rapidly. hypersensitivity reactions. monitor renal function Injectable solution: 10%. visual disturbances. acidosis. extravasation may cause oedema. renal failure (unless test dose produces diuresis) monitor fluid and electrolyte balance.rarely. repeat test dose if urine output less than 30–50 ml/hour. crystals must be redissolved by warming solution before use and solution must not be used if any crystals remain. fever.Diuretics P/C: P/A: Dose: A/E: metabolic oedema with abnormal capillary fragility.ADULT and CHILD 1 g/kg body weight Fluid and electrolyte imbalance. by intravenous infusion. Solutions containing more than mannitol 15% may crystallize during storage. CHILD 0. re-evaluate patient. 20%.25–2 g/kg. thrombophlebitis. as a 20% solution infused over 30– 60 minutes.Raised intracranial or intraocular pressure. pulmonary oedema particularly in diminished cardiac reserve. ADULT 0. urticaria. intravenous administration sets must have a filter. by intravenous infusion. by intravenous infusion. circulatory overload. mannitol should not be administered with whole blood or passed through the same transfusion set as blood Test dose if patient oliguric or renal function is inadequate. acute renal failure (large doses) 214 . severe dehydration. hypotension or hypertension. dizziness.5–1. as a 20% solution.

6 – 8 hourly orally Mild to moderate dental pain where anti-inflammatory action is not required and following simple dental extractions 500 mg.This is especially true for the surgical departments in dentistry. Ciprofloxacin. 8 hourly Mild to moderate pain following traumatic dental extractions Dose : Ibuprofen I: Antibiotics generally used in Dentistry Phenoxy methyl penicillin out patient odontogenic infections Ampicillin dentoalveolar infections Amoxycillin drug of choice for prophylaxis of infective endocarditis in patients undergoing surgical procedures Erythromycin used in patients allergic to penicillin Clindamycin useful in oral infections especially in Ludwig’s angina Other drugs used. Doxycycline. Ornidazole are also used 215 .topical dressing in periodontal conditions Tinidazole. Cloxacillin. Analgesics Aspirin I: Dose : Paracetamol I: Mild to moderate dental pain 300 – 600 mg.SECTION 15 DRUGS USED IN DENTISTRY Generally medicines used in dentistry are the same as those in the field of medicine. Amoxycillin+Clavulanic acid and Ofloxacin Metronidazole gel 1% .But lot of substances are used in dentistry which finds application only in dentistry as far as medical field is concerned.

povidone iodine. Rinse twice daily for 1.000 solution. Hydrogen peroxide.3 min with10-15ml of 0.2 % chlorhexidine solution A/E : brown staining of teeth and tongue Cetrimide or Cetylpyridinium chloride A/E : burning sensation in the mouth.Drugs for Dentistry Antseptics in dental plaque and periodontal disease Chlorhexidine antiplaque activity. iodine. discoloration of teeth and oral ulcers Phenolic antieptics like Listerine also have antiplaque activity Other antiseptics used in mouth rinses and oral products Thymol. oral dose or IM / IV injection repeated every 4 – 6 hours ANTIFUNGAL AGENTS : Clotrimazole : oropharyngeal candidiasis 1 % mouth paint applied twice daily for 7 consecutive days Fluconazole : severe mucosal candidiasis Miconazole : oral gel used in chronic mucocutaneous and chronic hyperplastic candidiasis Miconazole cream for angular cheilitis Amphotericin B lozenges 10 mg. Adrenaline 1 : 10.orally five times daily for 5 days 216 . dissolved slowly in the mouth four times daily for 10 – 15 days ANTIVIRAL DRUGS Acyclovir Herpetic stomatitis – 200 mg.They arrest local bleeding following tooth extraction and other dental procedures Eg. bad taste.Hexachlorophene. alcohol and benzalkonium chloride Styptics They are local haemostatics. Tannic acid. Sodium perborate. Gelatin foam Systemic coagulant Ethamsylate 250 – 500 mg.

5 ml with 0. Obtundents Decrease dental hypersensitivity eg.000 – produces good soft tissue as well as pulpal anaesthesia and reduces post extraction bleeding VITAMINS AND MINERALS Vitamin A – used in diffuse leukoplakia Vitamin C – used in bleeding spongy gums 500 mg. leukoplakia Dose of antioxidants – 1 capsule thrice daily for 2 months and then once daily till conditions subside.5 mg.Drugs for Dentistry STEROIDS Triamcinolone in carboxy methyl cellulose paste used in recurrent apthous ulcers. tablet one hour before procedure and the night before procedure . OD Vitamin E and other antioxidants – used for oral submucous fibrosis. sedation is minimal LOCAL ANAESTHETIC AGENTS Lignocaine hydrochloride 5% ointment/spray (10%) for suture removal.thymol. Injection Dexamethasone : oral submucosal fibrosis 1.mobile deciduous teeth extraction Lignocaine hydrochloride 2 % with Adrenaline 1 : 100.absolute alcohol Anticaries drugs: Fluoride dentrifrices 217 .25 – 0.5 ml lignocaine injection bilaterally in buccal mucosa twice a week for 5 weeks Reduces salivary secretion sulphate.lichen planus etc. Clove oil.lichen planus.Glycopyrrolate Atropine Dose : Antisialogogue ANTIANXIETY DRUGS Alprazolam 0.

025%. headache. CV diseases. hypotension. 0. patients on monoamine oxidase inhibitors. 0. 0. P/C: Stop medication and check with physician if changes in vision occur or if the condition worsens. decrease in body temperature. acute porphyria.05% w/v. vasomotor rhinitis.(10ml) Xylometazoline Rs. rebound nasal congestion.hyperthyroidism. C/I : Glaucoma. pregnancy. Xylometazoline I: Allergic rhinitis.025%.05% w/ v. hypersensitivity. 0.0.1% w/v Cost : Oxymetazoline Rs. 20/-(10ml) Naphazoline hydrochloride I: Decongestant C/I: Glaucoma. D/I: Pressor effect of naphazoline potentiated by TCAs or maprotiline. diabetes mellitus.01 %. dizziness. sinusitis. Xylometazoline .SECTION 16 DRUGS USED IN ENT INFECTIONS TOPICAL MEDICATIONS NASAL PREPARATION Local sympathomimetic decongestants Oxymetazoline. P/C : Prolonged use. vasomotor rhinitis. nausea. A/E: Hyperemia. Dose: 1-2 drops into each nostril 3-4 times a day. Corticosteroid nasal spray I: Seasonal and perennial allergic rhinitis. rhinitis sicca. coronary artery disease. A/E: Slight tingling or burning sensation in nose. 218 .05%. increased sweating. weakness and drowsiness. pregnancy and lactation. P/A: Oxymetazoline Solution 0. hypertension.025% w/v Nasal drops 0. P/A: Nasal drops (combination) 0. lactation and children.nervousness. 26/.

178. Beclomethasone Nasal spray 50 mcg/puff (150 md) Rs. Cost: Rs.4 times daily. 219 .Drugs for ENT A/E: P/A: Cost : Budesonide Candidiasis of nose. Antibacterials I: C/I : P /C : A/ E : Chronic otitis media. Allergy to the antibiotics. 14. Meatal sensitivitiy. otitis externa. 77. 100.6 times a day.2 sprays into each nostril bd. antifungal agents and ceruminolytics. Cost: Rs.25 Nasal spray 50 mcg/puff (200 md) Dose: 1 .3%w/v Norfloxacin Ear drops 0. cochlear damage.00 (10 mL) Cost : Rs.3% w/v Dose : 2-3 drops 3 . Prolonged use should be avoided. development of resisitant flora.80 Other drugs are Mometazone.00 (5 mL) P/A: Ciprofloxacin Ear drops 0.20 (20ml) AURAL PREPARATIONS These include ear drops containing antibiotics.Ciclesonide Mast cell stabilizers Sodium cromoglycate I: Allergic rhinitis.3% w/v Ofloxacin Ear drops 0. Chloramphenicol Ear drops 5% Cost : Rs.10 (5 mL) Cost : Rs. 7.Fluticasone. 18.On an average their use should be restricted to a total of 18 days. P/A: Nasal spray 2%w/v Dose: 1 spray into each nostril 4 . aminoglycosides carry the risk of ototoxicity. corticosteriods.

3% w/v Cost : Rs. P/A: Ear drops 0.3 drops tds.angioneurotic oedema. pruritus.65 (5 mL) Corticosteroids Betamethasone I: Eczematous inflammation. Antifungals Clotrimazole I: Otomycosis A/E : Occasional skin irritation or sensitivity. acute and chronic urticaria. P/C: Avoid prolonged use. Hard wax filling external auditory canal. corticosteroids and antifungal agents are also available as ear drops.1%w/v Dose : 2 . 20/Combination of antibiotics. 220 . Cost : Rs. 7. otitis externa.5 drops tds.Drugs for ENT Gentamicin Ear drops 0. pregnancy.80 (5ml) In general corticosteroid ear drops are used in combination with antibiotics. or qds. P/A: Ear drops 1%w/v Dose: 4 . allergic conjuntivitis. Cost: Rs.4 mg tds or qds. adjunct in asthma management. Adults . Allergic rhinitis. atopic dermatitis. lacation. Ceruminolytics Action : I: P/A: Softening of ear wax. atopic dermatitis. chronic urticaria. hypersensitivity. Sodium bicarbonate (5% w/v) Docusate sodium (5% w / v) Local preparation of ear drops Sodium bicarbonate 5g SYSTEMIC ANTIHISTAMINES Chlorpheniramine Maleate I: Dose: Cetirizine I: Allergic rhinitis.8. C/I: Infection.

9. Tab 120 mg (6) Rs.120 mg/ day Chronic idiopathic urticaria . tinnitus. headache. Pregnancy.Drugs for ENT C/I : P/C : A/E: P/A: Dose : D/ I : Cost: Fexofenadine I: C/I: P/C: A/E: P/A: Dose: D/I : Cost: Hypersensitivity to the drug. peptic ulcer. renal impairment. lactation Renal and hepatic impairment. drowsiness. chronic idiopathic urticaria Hypersensitivity.10 mg once daily Alcohol may potentiate CNS depression. anxiety Pregnancy. 10 mg (10) Adults . Tablet 10mg (10) Rs.180 mg/ day Erythromycin and ketaconazole increases plasma concentration of the drug. 180 mg Allergic rhinitis . blood dyscrasias. BPH.15/ Injection 2mg/mL (2mL) Rs. agitation. 7. arrhythmias. leucopenia Tablet 120 mg. acute and chronic urticaria and dermatosis. Mild and transient side effects such as headache. elderly. (Benign Prostatic hypertrophy) Tachycardia. 6. lactation. GIT discomfort. lactation. neonates. urinary and GI obstruction.50. nausea. Loratidine Dose: 10mg OD Cost: Tab 10 mg (10) Rs.10. 20/Allergic rhinitis. 221 . Renal impairment. Tablet 5 mg. 25 mg Injection 25 mg/mL Tab 10mg (10) Rs.37/Hydroxyzine It has both antianxiety and antihistaminic activity I: C/I: P/C: A/E: P/A: Cost : Pruritus. dry mouth. pregnancy Drowsiness. Tablet 10 mg. headache.

P/C: Antacids are considered safe as long as high doses are avoided on a long term basis. indomethacin. phosphate. D/I: Antacids impair the absorption of several drugs and thereby their effects are reduced. In the case of amphetamine. phenytoin. nitrofurantoin. I: Peptic ulcer. gastro-oesophageal reflux. Chewable tablets. P/ A: Only combinations are available. prednisone. Rate of elimination for salicylates and phenobarbital are increased. tetracycline. young children. and osteoporosis. The bioavailability of iron. atenolol and propranolol is decreased. Magnesium hydroxide: 5 mL as milk of magnesia qds. phosphate depletion. ketoconazole. Most interaction can be avoided by taking antacids 2 hrs before or after ingestion of other drugs. gel Dose: Aluminiumhydroxide: Tabs : 0. muscle weakness. ranitidine.Magnesium trisilicate Antacids neutralizes gastric hydrochloric acid by forming chlorides. theophylline. phenothiazines. INH. Magnesium salts:diarrhoea. prophylaxis of stress ulceration. fluoride. procainamide. heart failure. C/I: Renal insufficiency. Antacids should not be given to young children (up to 6 years of age ) unlesss specifically indicated. quinolones. benzodiazepines. ethambutol. A/E: Aluminium salts: constipation. Magnesium Hydroxide. Magnesium trisilicate: 1-2 g qds. neutralization of gastric acid to protect from aspiration pneumonitis during anaesthesia. hypertension.5-1 g qds. ephedrine. water and carbon dioxide.SECTION 17 GASTROINTESTINAL DRUGS ANTACIDS AND ULCER HEALING DRUGS Aluminium Hydroxide.preparation of endoscopy. 222 .

(Combination) Gelusil tab (10)-Rs.Ulcer Healing Drugs Cost: mecamylamine. I: Duodenal ulcer. Parenteral : IM 50 mg 6 to 8 hourly IV 2 mL ampoule to 20 mL with Normal saline and inject over ≥5 minutes every 6 to 8h. Diarrhoea/constipation and dizziness P/A: Tablets 150 mg.76.30 223 . 300 mg Injection 50 mg / 2 mL Dose : For ulcer healing : 150 mg bd or 300 mg at hs for 4 -5 weeks Maintenance . D/ I : It does not significantly inhibit hepatic metabolism of other drugs.pseudoephedrine and quiniuine rate of elimination is reduced. 150 mg (10)Rs.Cigarette smoking. gastric ulcer.1.81. not recommended for children below 8 years.50 H2 RECEPTOR ANTAGONISTS Ranitidine In general the H 2receptor antagonists and proton pump inhibitors are given in full doses for 4·6 weeks and thereafter at a lower doses for 1 or 2 months by which time ulcer would have healed. prophylaxis of aspiration pneumonia during anaesthesia and surgery. C/I : Known hypersensitivity to the drug. 150 mg at hs for 6 months to 1 year. Zollinger-Ellison syndrome : 150 mg tds. It may cause headache.13. 6.(170 ml) -Rs. P/C: Impaired renal function. Inj. Cost: Tab. A/E Headache.alcoholism and irregular timing of food are the common causes for relapse ofthe ulcer. stress ulcers and gastritis. pregnancy and lactation. Liquid . 2. to a maximum of 900 mg / day in divided doses. These should be avoided.Ellison syndrome. reflux oesophagitis. 25 mg/ml(1 vial)Rs. dizziness and rarely hepatitis and thrombocytopenia. Exclude gastric malignancy before starting treatment. Zollinger.

Reflux oesophagitis: 40 mg daily for 8 weeks. Zollinger-Ellison syndrome : 20 mg every 6 h. specifically anaemia.00 Duodenal and benign gastric ulcer. Tab 20 mg.10. Zollinger .40. Haematological abnormalities. 20 mg/mL Rs. Duodenal ulcer: 20 mg daily for 4 weeks. Same as ranitidine.constipation. Inj. diarrhoea. Capsule 10 mg and 20 mg. 40 mg. (10) Rs. particular value in patients who do not respond to H2 receptor antagonists. Patients who do not respond adequately with H2 receptor antagonists. occasional headache. gastro oesophageal reflux disease. (1 vial) Rs. A/E: P/A: Dose: Cost : Same as ranitidine.C/I:. (10) Rs. Tab 20 mg. after dilution to 5 -10 mL with a compatible IV solution. Pregnancy and lactation. flatulence and rashes.urinary tract infections. 11.D/I : P/C:. Tablet 20 mg . haematuria. duodenum and oesophagus. Exclude gastric malignancy before and during treatment. 2. Gastric ulcer: 20 mg daily for 8 weeks. Omeprazole reduce the metabolism of diazepam phenytoin and R-isomer of warfarin. Inj.Gastrointestinal Drugs Famotidine I:. PROTON PUMP INHIBITORS Omeprazole I: Promote healing of ulcers in the stomach. orally Parenteral: 20 mg IV every 12 h. 32.Zollinger Ellison syndrome.Ellison C/I: P/C: A/E: P/A: Dose : D/I: Cost : Lansoprazole I: 224 .30.48. 40 mg Injection 20 mg/2 mL Benign gastric and duodenal ulceration . nausea.40 mg orally at hs for 4 -8 weeks Maintenance:20 mg orally at hs.

8weeks. Duodenal ulcer: 30 mg daily for 4 weeks.00 Pantoprazole : I: Same as above.20 mg. for intravenous use Cost : Tab.Rs. 225 P/C : .P/C:. (10 ml) Rs. once daily orally Inj. (10) Rs. ureteric colic. C/I:. dysmenorrhoea. P/C.D/I: Similar to omeprazole. D/I : Similar to omeprazole Dose : Tab 20 mg.particularly in bleeding peptic ulcer C/I.25 Drugs used in H-pylori Omeprazole 20 mg(2 cap)+Amoxycillin 750 mg(2 tab)+tinidazole 500mg(2 tab) kit . Dose: 15 . 45. (10) Rs. 1 BD x 2 weeks ANTISPASMODICS Dicyclomine I: C/I: Intestinal colic. 20. diazepam and R-isomer of warfarin Cost : Tab 30 mg (10) . Intestinal obstruction. D/I: Decrease the metabolism of phenytoin. but has fastest acid suppression and aids in gastric mucin synthesis Dose : 10 . 20 mg. 18. Gastro oesophageal reflux disease(GERD) .30 mg daily for 4 .55 Inj. infants below 6 months. reflux oesophagitis. A/E. once daily Cost : Tab. liver disease. glaucoma. Can cause respiratory arrest in infants below 1 month.pregnancy and lactation.95 Rabeprazole Similar to omeprazole . 20 mg. renal disease.Antispasmodics syndrome. biliary colic. 40 mg. 30 mg. exacerbation of acute urinary retention. 49. Lansoprazole has been shown to be more effective in patients with reflux oesophagitis. 40 mg. P/A: Capsule 15 mg.A/E:.30 mg daily. Gastric ulcer: 30 mg daily. exacerbation of glaucoma. urinary retention.

20 mg. 4. flushing. palpitations and arrhythmias.Rs.20 mg tds. Tablets 10mg. difficulty in micturition.increased intra ocular pressure. thirst. flushing. 12. Tablet 20 mg Injection 10mg/ mL. ANTIEMETICS AND PROKINETICS Hyosine butyl bromide I: C / I: P/C: A/E: P/ A: Dose: D / I: Cost : Metoclopramide I: Nausea and vomiting associated with Gl disorders. Intestinal obstruction.10 mg/ml(2mL) Rs.20 mg IM or IV 8 h. hepatic or renal failure. 20mg/ 2mL Oral: 10 . confusional states and rashes. constipation and difficulty in micturition. rashes. increased intraoccular pressure.and lactation.00 Inj. post surgical conditions such as postoperative gastric stasis and regurgitation. 9. Other anticholinergic drugs and tricyclic antidepressants and alcohol potentiates the effects of hyoscine butyl bromide. (10) . bradycardia followed by tachycardia.palpitations followed by arrhythmias. Tab 10 mg. Dry mouth. constipation. Inj 20mg/mL lnjection 20mg/ mL Oral: 10 mg t. rarely fever. dry skin. (10) Rs. No significant interactions Tab.Gastrointestinal Drugs A/ E: P/A : Dose: D/I: Cost : Dry mouth with difficulty in swallowing and thirst. Avoid driving or operating machinery.53.s Parenteral route: 10 .70. glaucoma. 20 mg /ml (1ml) Rs. Inj.d. spasmodic dysmenorrhoea. pregnancy . Parenteral route Adults 20 mg IM 8 h .preparatory regimen for special radiological investigations such as hypotonic duodenography and for GI endoscopy. 19. biliary and ureteric colics.45 Intestinal. dilatation of the pupils with loss of accomodation and sensitivity to light.treatment with cytotoxics and 226 .

5. fever.90. extra pyramidal disease. 5 mg/ml – (2 ml vial) Rs. tds. Hypersensitivity. elderly.20 mg tds or qds. and motility disorders such as hypomotility. pregnancy Constipation. Nausea and vomiting associated with gastrointestinal disorders. As a prokinetic agent in vague gaseous dyspepsias and reflux oesophagitis. mechanical obstruction of Gl tract. phaeochromocytoma. 5 – 10 mg. Nausea and vomiting associated with cancer chemotherapy and radiotherapy. Carcinoma breast. Injection 5mg/ mL Syrup – 5 mg/ml Tab. pregnancy and lactation. It is used as an antiemetic in cancer chemotherapy. Inj.75. (10 ) Rs.20. For the elderly and children reduce the dose Extrapyramidal symptoms such as parkinsonism. sedation. Hepatic impairment.25. headache are more frequent. muscle dystonias. acute dystonic reactions. 0. Inj. Raised prolactin concentrations possibly leading to galactorrhoea and gynecomastia. 227 Domperidone I: C/I: P/C: A/E: P/A: Dose : D/I: Cost : Ondansetron I: C/I : P/C : A/E: . galactorrhoea and gynaecomastia.3-1mg/kg slow IV or IM Tab 10 mg (10) Rs. Hepatic and renal impairment. Pregnancy. lactation.Antiemetics And Prokinetics C/I: P/C: A/E: P/A: Dose : Cost : radiotherapy in cancer patients. Tablets 10mg 10 .diarrhoea. Reduce the dose in children.irritable bowel syndrome and others. 11.functional dyspepsia. Tablet 10 mg. post operative nausea and vomiting. Opioid analgesics and antimuscarinics cause antagonism of the effect on GI activity. Tab 10 mg.

8mg. Inj. (10) Rs. Tab 4 mg. 2. 164. tid Cost : Tab.2.00 Palonosetron: Similar to above but more potent Dose : Adult : 250 mcg.Gastrointestinal Drugs P/A : Dose: D/I: Cost : Tablets 4mg.The other common causes include adverse side effects of drugs.2 h before chemo/ radiotherapy followed by 8mg orally 12h. (10 ) Rs. In case of infective diarrhoea such as 228 . I mg/ml (2 ml) Rs.5 . 8 mg slow IV give 30-45 min before chemotherapy / radiotherapy or 8 mg orally 1 .raised liver enzymes Dose : Oral .Dry mouth. 30. Dexamethasone potentiates the effect of the drug.50 ANTI DIARRHOEALS Diarrhoea is a symptom of several different types of pathological processes affecting different parts of the alimentary tract.00 Inj. renal impairment.irritable bowel syndrome affecting several parts of the GIT and pancreatic cholera which is due to extra alimentary causes.44. enteritis and malabsorption affecting the small intestine.89 Granisetron Similar to Ondansetron but more potent Dose : Adult : 1 -2 mg within 1 hour before start of chemotherapy 2 mg. 28.5 mg. Therefore the symptomatic treatment of diarrhoea by antidiarrhoeal drugs is to be decided on individual merits. anxiety and thyrotoxicosis. hepatic impairment A/E : Diarrhoea. abdominal pain. 2 mg/ml (2 ml) Rs.Injection 2mg/ mL in 2mL and 4mL ampoules. 16. 5 mg. colitis affecting the large intestine. eg. 98. As a single dose to be given over 30 seconds and 30 minutes before chemotherapy and do not repeat during 7 days P/A : Only injections Mosapride : ( 5 HT 4 Agonist and 5 HT 3 Antagonist ) I: Gastro oesophageal reflux disease P/C : Elderly. daily in 1 – 2 divided doses during treatment Cost : Tab (1 mg) (8) Rs.

00 Lactobacillus Acidophilus This is not a primary antidiarrhoeal agent. treatment of the primary condition arrests the diarrhoea usually. acute pseudomembraneous enterocolitis and children < 4 years. None reported.lactation vomiting. decrease secretion of water and electrolytes I: C/I : A/E: Dose : Cost : Acute symptomatic diarrhoea renal insufficiency. tid upto 7 days Cap 100 mg (10) Rs. Infective Diarrhoea. not to exceed 10 mg/day. (10) Rs. bloating. it can be used as an adjunct to restore intestinal microbial flora and give symptomatic relief.00 Tab 2 mg (100 Rs. Specific antidiarrhoeal agents are indicated in special situations as adjuvant to primary therapy or in conditions where no other primary removable causes are detectable. headache 100 mg. 229 . ORS : Refer to Section 26 Loperamide : I: C/I : Acute nonspecific diarrhoea.Anti Diarrhoeals gastroenteritis and dysenteries. constipation. nausea. toxic megacolon. Children upto 6 years.00 Sachet 15mg Rs. severe diarrhoea where inhibition of peristalsis is not desirable. severe abdominal pain with nausea and vomiting. Promotes the growth of saccharolytic flora and alter the intestinal pH so as to inhibit the growth of pathogens. ln infective diarrhoea and mal absorption states primary antidiarrhoeal agents are generally contraindicated. loss of appetite. dryness of mouth. abdominal pain. 72. in geriatric patients. Cap 2 mg. 15. thirst.pregnancy. Allergic reaction. vertigo. Tablets 2mg. 2-4 mg repeated after each loose motion. chronic diarrhoea in adults. dizziness.7. Capsules 2 mg.00 P/C: A/E : P/A: Dose : D/I: Cost : Racecadotril: Enkephalinase inhibitor. 10. ln conditions where the intestinal flora have been deranged as a result of antibiotic and other forms of therapy.

I: Symptomatic constipation. vitamins and minerals due to interference with their absorption.d. febrile states. Purgatives and laxatives are employed to reduce bacterial growth in the colon. Only combinations are available. They are drugs which are widely sold over the counters and hence greatly misused. sachets. Clearance of the loaded colon prior to contrast radiography. Similarly. Absolute medical indications for laxatives are only limited. (10) Rs. They act in several ways —softening the faecal matter.14 LAXATIVES: These drugs are employed to relieve constipation. anorexia and nausea. loss of fluids and electrolytes particularly potassium and calcium giving rise to hypokalemia and I: P/ A: C/I: P/C : A/E: 230 . Absolute : Mechanical obstruction of the GI tract. dehydration or any other causes where correction of the primary cause takes time. In hepatic failure where bacterial action in the colon leads to excess formation of ammonia which may be absorbed. endoscopic procedures. although abortion following therapeutic doses of laxatives is most unlikely. discomfort and anxiety due to prolonged constipation. dyspepsia. 16. Dose : 1 Capsule per day. Irritant laxatives should be avoided during pregnancy as these may cause pelvic congestion.Gastrointestinal Drugs Used in the treatment of certain chronic diarrhoea. acute surgical conditions such as perforation. volvulus. capsules.Dispersible tablets. 1 sachet b. etc. These include symptomatic discomfort due to constipation occuring as the result of recumbency. paralytic ileus. these drugs should also be avoided in case of typhoid fever and in very ill cardiac patients. haemorrhage. Laxatives used occasionally are not harmful but their repeated administration may produce gastro intestinal disturbances like spastic colitis. Relative C/I : ln anxious subjects who are likely to develop habituation and misuse the laxatives. Cost : Cap. nutritional deficiency of calories. increasing its bulk and improving intestinal motility.. especially by the elders.

prior to radiological procedures and surgery.Rs.Laxatives D/l: osteomalacia.50 C/I : P/C : A/E: P/A : Dose : D/I: Cost: Liquid paraffin Emollient laxative I: C/I: P/C : Constipation. Galactosemia. Avoid prolonged use 231 .. Hepatic encephalopathy 20 .10 mg hs (adults). 61. Dose: 5 . Children less than 3 years of age. hepatic encephalopathy. 35. C/I: Intestinal obstruction. and abdominal discomfort. intestinal obstruction Young children.68.Suppository 10 mg. P/A : Tablet 5mg. A/E: Increased intestinal motility. Flatulence. complete dependence on drugs and later even resistance to all the mild laxatives. 5 mg hs in children or 10 mg rectal suppository in the morning. Not reported. due to the development of spastic colon. children. cramps. Liquid 100 mL.Suppositories 5mg. Cost : Tab 5 mg (10) Rs. colonic atony. Liquid 10 g/15ml For Constipation : 10 g bd.30 g tds. P/C : Should not be given within 1 hour following antacid or milk.40/- Lactulose : Osmotic laxtive I: Constipation. abdominal cramps. D/I: None reported. (5) Rs. . 7. Laxatives and purgatives may lead to malabsorption of nutrients and drugs if used continuously Bisacodyl Stimulant laxative I: Constipation.lts metabolite is lactic acid which can bind ammonia and inhibit its absorption.faecal impaction. 10mg.

rectal liquid. P/A: Powder 65 g/100g granules Dose: Adults and children over 12 years :1 measureful (5.Rs. abdominal distension.00 Glycerine Osmotic laxative I: Constipation P/A : Rectal suppository.4 g) in morning and at hs or 2 measurefuls at hs Cost : Powder 100 gm . migraine. Granulomatous reactions caused by absorption of small quantities of liquid paraffin. abdominal pain.00 232 . Lactation. 20. MI. nausea. IBS with constipation. 57. D/I: Reduces the dose of Digoxin Dose: Tab 2-6 mg b. C/I : Intestinal obstruction.i.Gastrointestinal Drugs A/E: P/A: Dose : D/I : Anal seepage of paraffin and consequent anal irritation after prolonged use. flatulence. Dose: 3 gm for adults Cost : Rectal liquid (enema) 20 ml . Hypersensitivity. headache. Cost: Cremaffin emulsion 170 ml Rs. Oral emulsion.00 Tegaserod 5HT4 partial agonist-stimulates peristaltic reflex and intestinal secretaion.00 Ispaghula husk I: Relieve constipation by increasing faecal mass. Not reported. colonic atony. I: Chronic idiopathic constipation. C/I: Severe renal failure. Decreases visceral sensitivity. stroke. Bowel obstruction. 25.30 mL hs. faecal impaction. 65 . A/E: Flatulence. P/C: Adequate fluid intake should be maintained to avoid intestinal obstruction.d before meals Cost: Tab 2 mg (10) Rs. Moderate to severe hepatic failure.Rs. also combinations are availableCremaffin 10 . A/E: Diarrhoea.

Porphyria < 2 years of age. D/I: Impairs absorbtion of tetracyclines Dose 500mg in qid dose max daily dose 6 g. immunosupression. 6 mg. Breast feeding. Should be taken with plenty of water. nausea. vomiting. Interferes with absorption of folic acid Tab 500 mg (10) Rs 56. dizziness. osteoporosis. Abdominal pain. Dysphagia P/C: Pregnancy. Uncontrolled blood pressure. Maintainance . Glaucoma Abdominal pain. diarrhoea. 9 mg.Intestinal or urinary obstruction. back pain. Flatulence. 3 mg. DRUGS USED IN INFLAMMATORY BOWEL DISEASES Sulfasalazine: ( Sulfonamide anti-inflammatory) I: C/I : Oral : Inflammatory bowel diseases Hypersensitivity to sulfonamide or salicylate. children A/E: Chestpain. Capsules should not be chewed. fatique. I: Chronic idiopathic constipation.Drugs Used In Inflammatory Bowel Diseases Calcium Polycarbophil Bulk Laxative MOA-Increases water content in stool making it easy to pass. Allergic bronchial asthma Anorexia . acne. 233 P/C : A/E : P/A : Dose : D/I : Cost : MOA: I: P/C: A/E: P/A: Budesonide Capsules . Vomiting. IBS C/I: Intestinal obstruction.Blood dyscrasias Hepatic and renal impairment G6 PD deficiency. easy bruising pedal odema. crystalluria.00 Local anti inflammatory action Crohn’s disease Chronic infection. allergic reactions Enteric coated tablets Intially 1 – 2 g 4 times daily until remission occurs. Rectal bleeding.2 gm /day Plasma levels reduced by rifampicin and ethambutol. Nausea. Intestinal obstruction. Chronic liver disease.

Methyl prednisolone. lactation. Ulcerative colitis Dose: Cost : Mesalazine I: C/L: A/E: Dose: D/I: Cost : Infliximab MOA: I: 234 . Tab. 87. SLE.50. flu. myocarditis. myocarditis. Dexamethasone. Treatment of ulcerative colitis (mild to moderate) and maintenance of remission Renal impairment. pancreatitis. Ulcerative colitis Balsalazide MOA: I: C/I: A/E: Delivered directly to colon where it is enzymatically cleaved to 5-ASA which is the active component. 58.4 g/day in divided doses. agranulocytosis. hepatitis. hypersensitivity. constipation.2 g daily as enema Drug interaction should not be given with lactulose or other drugs which lower PH as they prevent drug release.Gastrointestinal Drugs Steroid enemas COMPOUNDs – Hydrocortisone. hypersensitivity rare side effects include pancreatitis. 2. fibrosing alveolitis. MOA: Local Anti inflammatory I: Crohns disease. pericarditis. pregnancy. Oral 2. interstitial nephritis.5 g bid adjusted according to response Capsule 750 mg (9) Rs. Prednisolone. Steven Johnson syndrome. peripheral neuropathy. aplastic anemia. Chimeric monoclonal antibody against TNF alpha Fistulising Crohn’s disease. Treatment of IBD Hypersensitivity. agranulocytosis. Abdominal pain. Betamethasone. Triamcinolone.4 g/day in divided doses. aplastic anemia.2-2. Rectal -0. 400mg (10) Rs.25 g tid (max 6. hepatitis. Diarrhoea. diarrhea. interstitial nephritis.70. severe impaired renal or hepatic function. maintenance 1..75g/day) in acute attacks for maintenance 1. Budesonide. fibrosing alveolitis.75 g -3 g as suppositories or 1. Steven Johnson syndrome.

Antacids. vomiting. Capsule 250 mg 250 mg/day taken with food or milk in the morning and at night. biliary cirrhosis. indigestion. 85. fatigue. stomach cramps.00 — 90. lupus like symptoms. toxic epidermal necrolysis. pancreatitis. Serum cholesterol concentration determination recommended at 6 month interval during therapy. known hypersensitivity to murine proteins or any other component of the drugs. Moderate to severe congestive cardiac failure. Infliximab is administered as a single dose for fistulizing crohn’s disease. chronic hepatitis and cystic fibrosis. cholestyramine decrease the absorption of the drug. oestrogens. hypersensitivity. muscle weakness agranulocytosis. Diarrhoea. Pregnancy and breast feeding. biliary cirrhosis. DRUGS USED IN GALL STONES Chenodeoxycholic acid I: C/l: Gallstone disease. Determination of hepatic function and ultrasonogram is advised prior to treatment.Drugs Used In Gall Stones and Heamorrhoids C/I: P/C: A/E: Dose: Untreated chronic infection TB. nausea. loss of appetite. colestipol. hypersensitivity. P/C :A/E :D/I: Same as for chenodeoxycholic acid. seizures. Mild heart failure. cholecysti tis. Infection. Renal or hepatic failure. the dose is 5 mg/kg followed by additional doses of 5 mg/kg two and six week after the first dose. Pregnancy. 235 P/C .00 Gallstone disease. neomycin or progestins increase cholesterol saturation of bile thereby decrease the effect of chenodeoxycholic acid. Tab 250 mg (10) Rs. hepatic impairment. lactation. fever. Clofibrate. steven Johnson syndrome. A/E: P/A : Dose : D/I : Cost : I: C/I: Ursodeoxycholic acid . atherosclerosis.

Anovate 15 g . ANTIHAEMORRHOIDAL DRUGS Haemorrhoids are to be treated surgically for complete relief.70.Symptomatic treatment for constipation.Gastrointestinal Drugs P/A : Dose : Tablet 150 mg 8 . 20 gms . local pain.56.Rs.00 236 . Shield 15 g Rs 45 .49. A mild laxative such as liquid paraffin or bulk laxative such as Ispaghula helps to soften the faeces.10 mg/kg/day in divided doses.Inflammation is to be treated with antibacterial agents such as Ciprofloxacin or Amoxicillin. Pain relief is obtained by a NSAID such as diclofenac or Ibuprofen P/A : Cost : Anovate to be applied twice a day once following defaecation and once at bed time . inflammation are managed medically. discomfort.Rs. 9. taken with meals.

Glucocoricoids Short acting Hydrocortisone Intermediate acting Prednisolone Methyl Prednisolone Triamcinolone Long Acting Betamethasone Dexamethasone Mineralocorticoids Deoxycorticosterone acetate Fludrocortisone Prednisolone I: C/I : P/C : Suppression of inflammatory and allergic disorders. impairment. avoid live virus vaccines in those receiving immunosuppressive doses Adrenal suppression. liver failure.myocardial infarction. frequent monitoring required if history of tuberculosis. Systemic infection. avoid sudden withdrawal. hypothyroidism. children and adolescents. mineralocorticoids (aldosterone) and adrenal androgens. asthma . elderly. (dehydroepiandrosterone) each produced in a specific zone of the cortex. hypertension.ulcer.SECTION 18 HORMONES AND OTHER ENDOCRINE DRUGS ADRENAL HORMONES AND SYNTHETIC SUBSTANCES The adrenal hormones are steroids synthesized from cholestrerol derived from the diet. osteoporosis. At present all the available adrenal hormones are synthetic. The main groups of hormones are glucocorticoids (cortisol). history of steroid myopathy. diabetes mellitus. congestive heart failure.immunosuppression. pregnancy and breast feeding. 237 . epilepsy. rheumatic disease. glaucoma.

bronchial asthma. max.5-15mg daily usually. Juvenile arthritis: oral. fluid and electrolyte disturbance. 10mg/ m2twice daily.20mg. upto 10-20mg daily (upto 60mg in severe disease). neuropsychiatric effects.40mg). Tab-5mg (10) Rs 3-5 . CHILD: Juvenile arthritis: IM as sodium succinate. Eye Drops. adrenal suppression.72. aggravation of epilepsy. 500mg. Intra-articular injection: as acetate.M/I. hypersensitivity reactions. leucocytosis. Injection. Suspension. cerebral oedema.10-500mg daily. Graft rejection:IV upto 1g for 3 days. 4 -80mg according to size of joint. hirsutism. 30mg/kg daily single dose for 3 days. 1 g (powder reconstitution). 40mg/ml. Tablet(5mg. vertebral and long bone fractures. Renal transplant immunosuppression: oral. 2.Tab-10 mg(10) Rs 14. ADULT: Intensive or emergency therapy: I. multiple sclerosis rheumatic disease.Eye Drops 5 ml 1% . osteoporosis.1gm/day Methylprednisolone I: C/I : P/C : A/E : P/A: DOSE : 238 .V as sodium succinate. thromboembolism. As for prednisolone As for prednisolone. increased susceptibility to infection.10mg. weight gain. oesophageal ulceration and candidiasis.Oral. reducing to 10mg/m2 on alternate days over a period of 3-12 months. acute pancreatitis.Hormones and other endocrine drugs A/E : P/A: DOSE : CHILD - COST : GI disturbances.lml & 2ml Injection (as sodium succinate). 40mg. maintenance. Syrup ADULT . upto 2mg/kg once daily or on alternate days. menstrual irregularities.Rs 30 Suppression of inflammatory and allergic disorders. initially. certain types of glomerulonephritis. negative nitrogen and calcium balance.Inj 500mg vial Rs 565-630.Injection (as acetate). glaucoma. 125mg. Cushing’s syndrome. As for prednisolone Tab-4mg.

5 mg/kg daily.Injection (as phosphate).drops. 2ml. CHILD : Slow IV upto 1 year.5mg /5 ml (15 ml )Rs 10.28/Suppression of inflammatory and allergic disorders. maintenance 3-18 mg daily. 10-20mg/kg as a single dose for 3 days. initially up to 120 mg daily.inj 4mg Rs 3-8/.0.Adrenal Hormones And Synthetic Substances Cost: I: C/I : P/C : A/E : P/A: DOSE : Graft rejection: IV. Acute disorders. 2mg.5mg .M every 239 Betamethasone Sodium Phosphate Cost: Deflazacort I: C/I : P/C : A/E : P/A : DOSE : Dexamethasone I: C/I : P/C: A/E : P/A : DOSE : . As for prednisolone As for prednisolone As for prednisolone Tablets. as sodium succinate.In cerebral oedema: (as dexamethasone phosphate). Tab 4 mg (10)Rs 11. lg/day. 6mg. 6-I2 years. Img. ADULT: Oral. ADULT :I. As for prednisolone As for prednisolone As for prednisolone Tablets.251. then 4mg by I. oedema and diagnosis of Cushing’s disease. 30mg. congenital adrenal hyperplasia and cerebral oedema. cerebral . Suppression of inflammatory and allergic disorders.M/lV 4-20mg (betamethasone) repeated upto 4 times in 24 hours. shock.85/Suppression of inflammatory and allergic disorders.drops .5mg(10) Rs-3-5/. 0. 0. 10mg initially by IV. As for prednisolone As for predmsolone As for prednisolone Tab .inj. 4mg repeated 3-4 times in 24 hours if necessary. 4mg/ml. Tab 0.5-20mg (as dexamethasone phosphate). 0. max. CHILD: Oral. IV/IM initially 0.5-10mg daily in divided doses. I-5 years. ADULT Oral.

100mg vial Rs 32.or as required. shock.5 mg(10) Rs 2-4 . 5mg.Hormones and other endocrine drugs Note: COST: I: C/I: P/C: A/E: P/A: Dose : 6 hours as required for 2-10 days. 10mg.60/Suppression of inflammatory and allergic disorders. 5-50mg depending on size of joint. 3 times a day. acute severe asthma. As for prednisolone Hydrocortisone acetate Hydrocortisone Sodium Succinate I: C/I: P/C: A/E: P/A: DOSE : CHILD: Cost : I: C/I : P/C : A/E : 240 Triamcinolone Acetonide . 6-12 years 100mg.M/IV 100-500mg 3-4 times in 24 hours . 250500mcg/kg (as dexamethasone phosphate) once daily.In severe shock: (as dexamethasone phosphate). 25mg/ml. supression of inflammatory and allergic disorders.CHILD: IV/IM. 1-5 years. I. 50mg.2mg = Dexamethasone sodium phosphate 1. 4mg/m2. oral.3mg. 0. IM 2-6mg/kg repeated after 2-6 hours if necessary. Dexamethasone lmg=Dexamethasone phosphate 1.Inj 4 mg/ml (2 ml) Rs 7-11. Adrenocortical insufficiency. avoid in chronic therapy. ADULT: Intra-articular. CHILD : Replacement therapy. hypersensitivity reactions(anaphylactic shock and angioedema). 100mg/vial (powder for reconstitution). Adrenocortical insufficiency. Oral. 20mg. 4mg/m2 three times daily.(as acetate). Injection (as sodium succinate). 5ml vials. As for prednisolone As for prednisolone As for Prednisolone Tablets (as hydrocortisone). As for prednisolone As for prednisolone As for prednisolone Injection. ADULT: As hydrocortisone. shock and rheumatic disease.Slow IV upto 1 year 25mg. As for prednisolone As for prednisolone. high doses may cause proximal myopathy.

2.30 % daily. Img/kg (large joints).1 mg of fludrocortisone orally daily.40/- Replacement therapy for adrenocortical insufficiency Acute Hydrocortisone or Dexamethasone are given IV 1st as bolus injection then as infusion along with Isotonic saline and Glucose infusion. Chronic(Addison’s disease) Hydrocortisone : 20 .15 to 20 mg morning (8. max.40mg/ml. During times of stress like intercurrent illness. at hydrocortisone doses > 100 mg. 20mg.5mg/kg (smaller joints). repeated at intervals according to patients response. Injection. lml vials. 3. extremely hot weather and with gastrointestinal upset. 241 .6 mg/kg daily in divided doses round the clock to maintain feedback suppression of pituitary Metyrapone Metyrapone is a competitive inhibitor of 11 – alfa hydroxylation in the adrenal cortex. management of Cushing’s syndrome. Increase the dose of fludrocortisone and add salt during periods of strenuous excercise with sweating. surgery or dental extraction the dose of glucocorticoid is increased to 75 .single dose 100mg.5 to 10 mg evening (4. Congenital adrenal hyperplasia Tab Hydrocortisone 0. ADULT: Deep I. Inj 10mg/mL Rs 24. 40mg for depot effect. 2.10.30 mg /day with food.Intra-articular. Recommended sodium Intake = 3 . max. 4.which causes increased synthesis and release of cortisol precursors. After the stress the increased doses are tapered by 20 . CHILD: I-18 years: Intra-articular.Adrenal Hormones And Synthetic Substances P/A : DOSE : Cost : Tab. 10mg/ml.4 g/ day. 40mg.05 to 0.4mg. Tab 4 mg (10) Rs 19/-. Special requirements 1.dependent Cushing’s syndrome. I: Differential diagnosis of ACTH . max.5-40mg depending on size of the joint.00 pm) Mineralocorticoid 0. Parenteral mineralocorticoid administration is unnecessary.M.150 mg/day.00 am).

prostate cancer. Therefore double dose of metyrapone must be given. allergic skin reactions. Not freely available. pregnancy and breast feeding. Differential diagnosis of ACTH . SEX HORMONES Androgens Testosterone and its esters I: Primary and secondary hypogonadism.. hirsutism. Resistant oedema due to increased aldosterone secretion in cirrhosis. P/A: Testosterone Capsule 40 mg Injection 25mg. Gross hypopituitarism. depression. nephrosis. renal and hepatic impairment.Capsule 250 mg. hypercalcemia. premature closure of epiphysis. sodium retention with oedema.25 . breast cancer. hypotension. hypertension. 2. ischemic heart disease. Nausea.6 g daily. prostate cancer.Hormones and other endocrine drugs C/I : P/C : A/E: P/A: Dose : D/I: Cost: resistant oedema due to increased aldosterone secretion in cirrhosis.dependent Cushing’s syndrome . 3.3 g daily in divided doses. 1. seborrhoea. A/E: Headache. C /I: Breast cancer in men. dizziness. migraine. elderly. 50 mg. abdominal pain. Metyrapone increases metabolic clearance rate of hydrocortisone. P/C: Cardiac. 100 mg and 250 mg.750 mg every 4 hrs for 6 doses. epilepsy. headache. hypercalcemia. 242 . nephrosis and congestive heart failure Adrenocortical insufficiency. sedation. Tablet 250 mg. Phenytoin increases metabolism of metyrapone. hypoadrenalism. nephrosis and congestive heart failure . Management of Cushing’s syndrome : 0. delayed puberty and impotence. acne. pregnancy. vomiting. suppression of spermatogenesis. hyperthyroidism or hepatic impairment. hypertension on long term administration.

Rifampicin and phenobarbitone may increase the rate of metabolism of testosterone. 5 mg. Thrombo—embolic disorder.epilepsy. 1mg for male pattern baldness Increases clearance of theophylline. history of thrombosis or thromboembolic disease. dizziness.105/-. elderly. skin reactions. hepatic or renal impairment.8 weeks. pregnancy. Antiandrogens Finasteride I: C/I: P / C: A/ E: P/A: Dose: D/ I: Cost: Danazol I: C/I : Endometriosis. Tab 5 mg (10) Rs.3 weeks.38/- P/C : A/E : . nervousness. prostate cancer. 5 mg o. migraine. renal or cardiac dysfunction. Obstructive uropathy. porphyria. menorrhagia and gynaecomastia. Impotence. pregnancy. 10 mg Methyl testosterone Tablet 10mg.Antiandrogens Dose: D/I: Ointment 2 % w/w. Nausea. benign breast disorders. polycythaemia. every 1 . diabetes.review after 6 months. hypertension.Tab 1 mg (10) Rs.d. changes in libido. acne and hirsutism in females.50 mg i. hypersensitivity reactions Tablet 1mg. Potentiates anticoagulants. 5 % w/w Patch 4 mg Fluoxymesterone Tablet 2 mg. Androgen deficiency : 120 — 160 mg/day for 2 . decreased libido and ejaculation. photosensitivity and exfoliative dermatitis.2 weeks for 6 . lactation and neonates. and oral hypoglycemic agents.undiagnosed genital bleeding. lipoprotein disorder. half-life of aminophylline may be reduced.m. Capsules 10 mg 25 .breastfeeding. 243 Benign prostate hyperplasia.5 mg . breast tenderness and enlargement. 25mg. male pattern baldness Hypersensitivity. Cardiac. androgen dependent tumours. marked hepatic.

oestrogen depended cancer. reduction in breast size. menstrual disturbances. 400mg daily upto 4 divided doses for 6 months(adolescents. increased to 400mg daily if no response after 2 months). 100. increased appetite insomnia. flushing. androgenic effects. Cardiac disease.Hormones and other endocrine drugs vertigo. monitor hepatic function.d.adjusted according to response and continued for 3-6 months. nausea. rarely cholestatic jaundice. Hypersensitivity.Gynaecomastia: oral. 200mg daily. P/C: Unopposed exposure to oestrogens pre dispose to cystic hyperplasia of the endometrium and endometrial 244 . tiredness. pregnancy.s. thromboembolism. 200mg.25/- CONTRACEPTIVES (REFER SECTION 24) OESTROGENS AND ANTIOESTROGENS Oestrogens Hormone Replacement Therapy (HRT) I: Hormone replacement therapy. Dose : ADULT : Endometriosis: oral. vaginal dryness. hair loss. blood disorders. thrombophlebitis. 200mg daily. for inducing secondary sexual characters in hypogonadism.Menorrhagia: oral. . 100mg. Tablet 250mg 250 mg t. usually for 3 months. Increased prothrombin time in patients on long-term warfarin treatment. C/I: Pregnancy. 50mg. vomiting. I: C /I: P/C: A/E: P/A: Dose: D/I: Cost: Advanced prostate cancer. Tab 250 mg (10) Rs. weight gain. Benign breast disorders: oral. Flutamide Nonsteroidal drug having specific anti androgen effect. for 3-6 months (upto 9 months in some cases). for contraception. pancreatitis. Gynaecomastia. 200-800mg daily upto 4 divided doses. initial. benign intracranial hypertension. P/A: Capsules. breast feeding and undiagnosed vaginal bleeding. diarrhoea. 100-400mg daily in 2 divided doses. liver disease.

Cream. P/A : Sugar coated tablets. may cause premature closure of epiphyses in young children.changes in libido. cardiac or renal dysfunction. Conjugated oestrogen Tablet 0. migraine.02 mg. migraine. headache. .625 mg. 0. depression. contact lenses may irritate.05 mg. abdominal cramps and bleeding. premenstrual like syndrome. thromboembolism and precipitate porphyria. 0. 100 mcg. cholestatic jaundice.1.20 to 50 mcg daily depending on preparation.HRT C/I: Undiagnosed vaginal bleeding. migraine.01 mg. Contraception .50/Conjugated Oestrogens I: Menopausal osteoporosis. weight gain.10 to 50 mcg daily.25 mg Injection 25 mg vial 0. 1 mg Injection 10 mg / mL Patch 25 mcg.01 mg (10) Rs. depression. breast tenderness. Nausea.increased risk of endometrial carcinoma. 0. 50 mcg. weight changes. 0.13. diabetes. rashes. Dose : Menopausal symptoms . fibro cystic disease of heart. changes in liver function.primary ovarian failure. Hormone deficiency . sodium and fluid retention. cholestatic jaundice. A/E : Nausea and vomiting.625 .5g. oestrogen dependent tumours P/C : Asthma. carcinoma breast.625mg. 42.10 to 20 mcg daily. 1. pregnancy. 245 . Cost: Tab 0. thrombophlebitis. dizziness.25 mg daily Tablet 0.breast enlargement and tenderness. liver disease. headache. epilepsy. vomiting.625mg/ 1 g.Hypersensitivity to oestrogens.Oestrogens And AntiOestrogens A/E: P/A : Dose : Ethinyl oestradiol P/A : cancer. Combination preparation with other derivatives are also available.

ie Primary ovarian failure: oral. 0.Prostatic carcinoma: oral. migraine. P/C: Renal impairment.Delayed puberty in girls C/I: Hormone dependent tumors. gastrointestinal disturbances. 1. pregnancy and breast-feeding. D/I: Sensitivity to anticoagulants increased.5 mg o. history of thromboembolism.25-2. abdominal pain. undiagnosed uterine bleeding. cholestasis.Endometrial cancer. pregnancy. ankle edema. breast cancer.990/- Antioestrogen Raloxifene I: C/I : Treatment and prevention of postmenopausal osteoporosis. diabetes mellitus and hypercholestrolemia.625mg) along with progestogen for part of the cycle. A/E: Weight gain. Tibolone It is a synthetic preparation with oestrogen and progestogen activity with mild androgenic activity.3-1. rash. History of venous thromboembolism. history of oestrogen-induced hypertriglyceridaemia [monitor serum triglycerides]. hepatic impairment.5mg 3 times daily.25mg daily (usually 0. carbamazepine and rifampicin. P/A: Tablet 2. premenopausal women. accelerate. Insulin or oral hypoglycemic requirement increased in diabetics Cost: Tab 2.5 mg (28) Rs. P/C: 246 .5 mg Dose: 2. pruritis.25mg daily. epilepsy. enzyme inducers like phenytoin. I: Menopausal syndrome.Hormones and other endocrine drugs Dose : ADULT: Postmenopausal osteoporosis: oral. arthralgia.d. tibolone metabolism. Risk factors for venous thromboembolism [discontinue if prolonged immobilisation]. 1. severe liver disease. myalgia. severe renal impairment. history of cardio vascular or cerebrovascular disease.

90 . changes in libido. anal soreness and flatulance with rectal administration. Tablet. P/A: Capsule 100 mg Dose : Individualised dosing by physician. acne. breast discomfort. hormone dependent carcinoma. epilepsy and migraine.Progestins And Antiprogestins A/E : P/A : Dose : Cost: Venous thromboembolism. menorrhagia.105. headache including migraine. congenital abnormalities. severe dysmenorrhoea. weight gain. Natural Progestins Progesterone I: Progesterones are widely use for the treatment of endometriosis. renal diseases. lactation. thromboembolic disorders and possible foreign body carcinogenesis with intradermal implants. premenstrual tension and for habitual abortions. hypotension. P/C: Use with caution in hypertension. Tablet. leg cramps. 60mg once daily. hot flushes. rarely rashes.00/Synthetic Progestins Dehydrogesterone. altered menstrual cycle. D/ I: Decreases effect of tricyclic antidepressants. liver diseases. thrombophlebitis. thromboembolism. 60mg (10)Rs 48 -106/PROGESTINS AND ANTIPROGESTINS Progestins These are important female hormone concerned with reproduction. ADULT: Oral. influenza-like symptoms. hypoglycemic agents and anticoagulants. Norethisterone. A/E : Gl distrubances. virilization of female foetus. Cost : Cap 100 mg (10) Rs.peripheral oedema. Medroxy Progesterone Acetate. Progesterone is also used as part of hormone replacement therapy in women with uterus and as a part of contraceptive medication. incomplete abortion. asthma. 74. Hydroxyprogesterone caproate 247 . diabetes. oedema. mental depression. 60mg. C/I: Pregnancy. GI disturbances. Sterile abscess with IM injection.

They should be very punctual with their medicine intake. Recommended caloric intake. Medroxyprogesterone oral 10 mg 3 times daily for 90 consecutive days beginning on day 1 of the cycle.00 OVULATION INDUCERS(Refer Section 24) INSULINS AND OTHER ANTIDIABETIC DRUGS General Principles To employ measures that will help the patients to attain the best possible control of plasma glucose concentration.00 — 18. The total intake must be distributed between various meals in a day.00 Norethisterone:Tab 5 mg (10) Rs.repeat for 2 cycles and 3 cycles in secondary amenorrhoea.5mg (10) Rs. • • • Energy and carbohydrate intake rnust be adequate to allow normal growth and development.00 Inj 200 mg (1mL) Rs. Prescription of Good Diabetic Diet There is no single recommended diabetic diet. 39. All diabetics should have regular excercise for atleast 20 . Diet should be prescribed with commonly available foods with scope for adequate flexibility and variety. Injection 150 mg/mL Norethisterone Tablet 1 mg and 5 mg. 126.00 — 43. 13. P/A: Dehydrogesterone Tablet 5 mg Medroxyprogesterone Tablet 2. All patient should try to maintain ideal body weight. Cost: Medroxyprogesterone acetate. food and excercise. 36 Kcal / kg for men 34 Kcal / kg for women 248 .Menorrhagia 2.30 min/ day.00 Tab 5mg (10) Rs. lnjection 200 mg/ml Hydroxyprogesterone: Injection 500 mg/mL in 1 and 2 mL ampoules Dose: Endometriosis . 28.Hormones and other endocrine drugs I:C/I:P/C:A/E:D/I : Same as for progesterone.5 mg. 5 mg and 10 mg. Norethisterone 10 – 25 mg daily for 49 months.00 — 50.Tab 2.5-10 mg daily for 5-10 days starting on 16-21st day of cycle.

urticaria.Metabolised by liver/ kidney P/A: Tablet 2.5 mg. Type I diabetes. then given bd with a major morning and smaller evening dose. P/C: Underweight individuals prone to hypoglycemia especially after unusual exercise. The consumption of fat is to be reduced in the obese. vomiting. Oral hypoglycemic agents Sulphonyl Ureas Glibenclamide (Gliburide) I: NIDDM (Type 2) C/I . 30 % of total calories should be obtained from dietary fat with less than 10 % from saturated fat. diabetic ketoacidosis. hypoglycemia.00 . As for glibenclamide severe renal and hepatic impairment. 5 mg. Glucocorticoids. Remaining calories (60%) to be obtained from carbohydrates. diuretics and oestrogens reduce hypoglyceinic effect. warfarin. 4.5 / kg/ day. sulphonamides and alcohol potentiates hypoglycemic effect. Dose: 1. Start as a single dose in the morning. leukopenia.Insulin and Other Anidiabetic Drugs • • • Recommended protein intake .25 to 20 mg/day.5. Pregnancy. As for glibenclamide regular hepatic and haematological monitoring required.thrombocytopenia. If the patient has diabetic nephropathy 0. and increase slowly.If the requirrnent is more than 10 mg. Nausea.8 g / kg / day. pregnancy and breastfeeding.00 Glimepiride I: C/I : P/C : A/E : Type II diabetes. D/I: Synergisitic hypoglycemic effect with metformin.1 . pruritus. anorexia. The distribution of calories between fat and carbohydrates depends on whether the patient is obese or normal weight. Dietary management most important in NIDDM patients not on insulin therapy. A/E.1. 10 % of calories from proteins.salicylates. As for glibenclamide 249 . Cost: Tab 5 mg (10) Rs.

5 mg. 2. It combats microthrombosis by decreasing platelet hyper adhesiveness and hyperaggregation increasing fibrinolytic activity. Cutaneous reaction. Thiazide diuretics counteract hypoglycemic action. glucocorticoids and Glipizide I: C/I : P/C : A/E: P/A: Dose : D/I: Cost: Gliclazide I: C/ I : P/ C : A/E: P/A: Dose : D/I: 250 . 4. Diabetic ketoacidosis Under weight. blood dyscrasias.5 to 5 mg at weekly intervals according to blood sugar measurement Hypoglycemia augmented by alcohol. It has both metabolic and vascular properties. Tab 5 mg (10) Rs. taken shortly before or with first main meal.drowsiness.Tab 2mg Rs 33-103/NIDDM (Type 2) Pregnancy. urticaria.3mg. Start with 2. severe ketosis or acidosis.alcohol. Type I Diabetes. vomiting. lactation Nausea. sulphonamides.5 mg.4mg ADULT: Oral. usually in two divided doses.00 NIDDM (TYPE II) Pregnancy. headache or pruritis. salicylates and NSAIDs. Hypoglycemic effect antagonised by rifampicin. adjusted according to response in 1mg 1-2 week intervals. upto 6 mg daily may be used). lmg daily. Tab 1 mg Rs 16-62/-. max. hepaticorenal disease.10. diarrhoea. 4mg daily (exceptionally. thrombocytopenia. lactation severe renal or hepatic failure.. diuretics. 1mg and 2mg. Tablet 2. barbiturates. Care when transferring from combination therapy. no adverse effect with alcohol.Hormones and other endocrine drugs P/A : DOSE : Cost: Tablets. Metabolised by liver / kidney. normalizing prostaglandin metabolism Tablet 80 mg 80 to 320 mg daily. May require insulin during metabolic stress.5 to 40 mg / day. initial.00 .5 mg and increase by 2.

not controlled by diet and exercise. in divided doses.Better control of meal time glycemia and lower incidence of post prandial glycemia.must for Type 1 cases. 23. 850 mg Metformin hydrochloride 500 mg to 3 g / day.00 . diarrhoea. Anorexia.37. su fonamides. vomiting. A/E: P/A: Dose: D/I: Cost: Insulins I: INSULIN FORMULATIONS Rapid acting insulins Insulin Lispro Unlike regular insulin it needs to be injected immediately before or after the meal. Metformin Tablet 500 mg.so that dose can be altered according to the quantity of food consumed.00 Biguanides Metformin I: Type 2 obese diabetes in whom dietary therapy has failed or as a combination in those in whom sulphonylureas fail to control the blood sugar.primary or secondary failure of Oral Hypoglycemics or when these drugs are not tolerated.00 All forms of Diabetes Mellitus.Insulin and Other Anidiabetic Drugs Cost: oestrogen.MAO inhibitors Tab 80 mg (10) Rs. nausea. to tide overinfections. P/A: Dose : 100 U/ml injection Using a regimen of 2-3 daily meal time insulin Lispro injections 251 .They are dose related and usually transient.underweight patients.00 .16. conditions pre-disposing to tissue anorexia Avoid alcohol as it could lead to lactic acidosis.trauma. C/I : P/C . Metformin : Tab 500 mg (10) Rs. clofibrate. Hypoglycemic effect increased by aspirin phenylbutazone. Hypoglycemic effect potentiated by alcohol. 7. Can also be combined with insulin in Type II diabetes. alcoholism. abdominal discomfort. hepatic disease.post pancreatectomy cases and gestational diabetes. Renal disease.surgery and diabetic ketoacidosis.

40 U/ml.Hormones and other endocrine drugs Insulin Aspart Closely mimic physiologically insulin release pattern after a meal. Nausea.The same advantages as Insulin Lispro. phaeochromocytoma and glucagonoma. Regular insulin Can be given intravenously(Diabetic Ketoacidosis) or subcutaneously Intermediate acting insulins NPH (Neutral Protamine Hagedorn) Lente Insulin Long acting insulins Ultra lente Protamine Zinc Insulin Human Insulin Preparations Human Actrapid:Human Regular Insulin.40 U/ml Drugs that raise blood sugar in acute hypoglycemia Glucagon Polypeptide hormone produced by the alpha cells in the pancreatic islets. I: C/I: P/C: A/E: P/A: Dose : D/I: 252 Acute hypoglycemia Insulinoma. vomiting.100 U/ml Human Insulatard:Human Isophane Insulin. Hypoprothrombinemic effect of oral anticoagulants may be increased. IV or IM 0. It may be used on an emergency basis.100U/ml Human Monotard:Human Lente Insulin. . Ineffective in chronic hypoglycemia. diarrhoea.40 U/ml. Insulin Glargine Suitable for once daily injection. Injection 1 mg/mL By SC. Short acting insulins.Lower incidence of night time hypoglycemic episodes compared to isophane insulin. hypersensitivity. hypokalemia. if no response within 10 min IV glucose must be given. hypersensitivity reactions.5 to 1 unit. starvation and adrenal insufficiency. It mobilises glycogen from the liver and thus raising plasma glucose concentration.

00 .gradually increased to 60 mcg daily in 2-3 divided doses. D/I: Enhances effect of anticoagulants. drugs for lowering cholesterol and others. P/C: In hypothyroidism secondary to hypopituitarism. sometimes other drugs may also have to be used. lt has much faster action than T4 and in some situations of myxeodema coma this has to be used as life saving drug.primary and secondary. anginal pain. 115.00 THYROID HORMONES AND ANTITHYROID DRUGS Thyroxin Sodium (T4) Levothyroxine sodium I: Hypothyroidism . P/A: Tablet (levothyroxine sodium) 0. excitability. 253 . 0. thyroid supplementation to be started after corticosteroid therapy initiation. Cost: Tab 50 mcg (100) Rs. loss of weight.05. amiodarone elevates thyroxine level.00 Tri-iodo-thyronine (T3) I: C/I: P/C: A/E: Dose: Note: Hypothyroidism Same as for thyroxine sodium This preparation is available on special request. insomnia. A/E: Arrhythmias. hypersensitivity. These include general supportivetreatment. antihypertensive drugs.025.flushing.205. C/I: Thyrotoxicosis. headache. effect of TCAs enhanced. Even though thyroid hormone is the main stay of hypothyroid condition.1 and 0.00 — 99. 45.20 mcg daily in divided doses. Oral. 10 . mood elevators. thyroid cancer and hashimotos thyroiditis. suppressive therapy in non toxic goitre.2 mg Dose: Start with single daily dose of 50-100 mcg and slowly increase to 100-200 mcg on an empty stomach.In patients with cardiovascular diseases and ischemic heart diseases start with very low dose.Thyroid and Anit Thyroid Drugs Cost: Inj 1 mg/mL (vial) Rs. 0.

60 mg / day in 3 divided doses for 48 weeks Maintanance 5 . Decreased response to propyl thiouracil on concommitant use with iodine or potassium iodide. mouth ulcer. other auxiliary treatment are often required since the oral antithyroid drugs produce their full effect only within 2 . rashes. Though anti thyroid drugs are specific agents to reduce the levels of circulating thyroid hormones. headache. vomiting. pregnancy.300 to 900 mg/ day in divided doses till patient becomes euthyroid. 100 mg Hyperthyroidism . pregnancy.Hormones and other endocrine drugs Drugs Used For Hyperthyroidism Antithyroid drugs Carbimazole I: C/I: P/C: A/E: P/A: Dose : D/I: Cost: Propyl thiouracil I: C/I : P/C : A/E: Hyperthyroidism Tracheal obstruction. agranulocytosis. response to oral anticoagulants may be decreased. Liver disorders.50 to 600 mg/ day in divided doses. pruritis. Starting dose 20 . Tab 5 mg (100) Rs.3 weeks. Tachycardia and cardiac irritability can be controlled by propranolol in a dose of 10 — 40 mg/day P/A: Dose: D /I : Note : 254 . etc. blood disorders. lactation.nephritis. Patient should report development of sore throat. renal vasculitis. peripheral neuropathy.15 mg/day for 1-2 years Increased sensitivity to warfarin in hyperthyroidism.large goiter Nausea.157. rash. breast feeding. Fever. increased risk of digitalis toxicity. 10 mg and 20 mg. hepatitis. arthralgia.nausea and vomiting. changes in menstrual period. agranulocytosis. indicative of abnormalities in blood. Hypersensitivity. leukopenia. Maintenance . Tablets 50 mg. 20.50/Hyperthyroidism.00 . Same as for carbimazole. headache Tablet 5 mg.

lactation. Anxiety and excitement can be controlled by anxiolytic drugs like diazepam.45 meq calcium/ mL) C/I: P/ C: P/A : Dose: Vitamin D Derivatives Ergocalciferol and Cholecalciferol I: Hypocalcemia.hyperkalemia.000 units) / day. lactation.generally given for 10 days just preceeding surgery.00. Calcium Gluconate 9 % Calcium. Oral calcium gluconate tablets available as 500.nausea. Dose : 1. Dihydrotachysterol It is a pure crystalline compound obtained by reduction of Vitamin D I: C/I: Hypoparathyroidism Pregnancy. hypervitaminosis D. 650.2. vomiting. pregnancy.Vitamin D Derivatives orally. Lugol’s iodine I: Preoperative preparations for thyroidectomy.000 . hypersensitivity. hypercalcemia. ln atleast a few cases hyperthyroidism is associated with abnormalities of serum potassium. Calcium chloride is contraindicated in the treatment of hypocalcemia of renal insufficiency. Most of the preparations available for parenteral use should be used only intravenously as there is a high chance of necrosis or local abscess if used intramuscularly. This has to be monitored and appropriate steps taken. 975 or 1000 mg For IV injection administered as 10 % solution (0. 255 . nutritional. A/E: Overdosage . C/I : Hypercalcemia. Used in severe manifest tetany. renal osteodystrophy with hyperphosphatemia.25 to 5 mg (50. CALCIUM AND ITS SALTS Several preparations are available that can raise systemic concentration of calcium I: Used in treatment of deficiency states and as a dietary supplement when intake is inadequate.

diarrhoea.hypercalcemia due to the drug potentiates digitalis toxicity. Solution 200 mcg/mL.25 to 0. nausea. A/E: Bone pain or tenderness. Use with caution in children. Capsule 125 mcg. cardiac failure. loss of appetite. Tablet 125 mcg. 200 mcg. Injection 50 mg/ mL. increased risk of hypercalcemia with thiazide diuretics. Sodium Etidronate I: Hypercalcemia of malignancy. hydantoin.5 mg/day Increased potential for toxicity with other Vitamin D analogues. 256 .25 . lethargy. pregnancy.Hormones and other endocrine drugs P/C: A/E: P/A: Dose: D/ I: Use with caution in children. Hypocalcemia : Adult : 0. reduced absorption of drug by mineral oil.hyperphosphatemia. dryness of mouth. Adult : 0. osteomalacia. C/I: Hypersensitivity.and electrolyte status in elderly since they are more prone to over hydration with etidronate. diarrhoea. muscle pain and pancreatitis. 1.2.enterocolitis. vomiting. urticaria. hypocalcemia or hypovitaminosis D. CRF and hypoparathyrodism. impaired renal function. nausea.0 mcg/ day. P/A: Tablet 200 mg. increased thirst and urination. Hypocalcemia of malabsorption. 400 mcg. Paget’s disease of bone. antagonises calcitonin.25 dihydroxy Cholecaliceferol (Calcitriol) I: Dose : BISPHOSPHONATES These are groups of drugs which inhibit calcium mobilization from bone.hyperphosphatemia with phosphorous containing preparations. hypercalcemia. barbiturates or primidone accelerates metabolism of drug by hepatic microsomal drug induction. oral. P/C: Careful monitoring of fluid. Constipation. itching. etidronate or plicamycin in the treatment of hypercalcemia.irregular heartbeat. It includes etidronate and alendronate. 400 mg. cholestyramine or colestipol.

tea and orange juice decrease drug absorption Dose: D/I: 257 . hypersensitivity.flatulence. magnesium and aluminium containing preparations. iron. headache. Mineral water. P/C : Vit D and calcium deficiency if present should be corrected before alendronate therapy. and aspirin increases GI sideeffects.5mg/ kg/ day Absorption of oral etidronate prevented by antacids. Alendronate Sodium I: Post menopausal osteoporosis. coffee. dairy products as well as by calcium. and completely bedridden. P/A: Tablets 10 mg Dose: 10 mg od in the morning 30 min before breakfast with full glass of water. erythema. D/ I : Calcium supplements and antacids decrease absorption. A/E: Dysphagia. heartburn. C/I : Hypocalcemia. rash. oesophageal ulcers. severe renal failure insufficiency. oesophageal abnormalities. abdominal pain. milk.Bisphosphonates Hypercalcemia : Oral – 5-7.

Material prepared from animals is called antiserum. Local reactions including pain and tenderness may occur at the injection site. although rare. Live attenuated vaccines usually confer immunity with a single dose which is of long duration.Immunoglobulins may interfere with the immune response to live virus vaccines which should normally be given either at least 3 weeks before or atleast 3 months after the administration of the immunoglobulin. C/I:P/C: Anaphylaxis. SERA AND IMMUNOGLOBULINS Antibodies of human origin are usually termed immunoglobulins. This immunity lasts only a few weeks but passive immunization can be repeated where necessary. A/E: 258 . this therapy has been replaced wherever possible by the use of immunoglobulins. PASSIVE IMMUNITY Passive immunity is conferred by injecting preparations made from the plasma of immune individuals with adequate levels of antibody to the disease for which protection is sought.or (c) extracts of or detoxified exotoxins. The duration of immunity varies from months to many years. Extracts of or detoxified exotoxins require a primary series of injections followed by reinforcing doses. (b) inactivated preparations of the virus or bacteria. Vaccination may consist of (a) a live attenuated form of a virus or bacteria. Because of serum sickness and other allergic-type reactions that may follow injections of antisera. Treatment has to be given soon after exposure to be effective. Inactivated vaccines may require a series of injections in the first instance to produce an adequate antibody response and in most cases. can occur and epinephrine (adrenaline) must always be immediately available during immunization. Intramuscular injection. require reinforcing (booster) doses.SECTION 19 IMMUNOLOGICALS ACTIVE IMMUNITY Active immunity may be induced by the administration of microorganisms or their products which act as antigens to induce antibodies to confer a protective immune response in the host.

The dose of anti-D immunoglobulin given depends on the level of exposure to rhesus-positive blood.hypersensitivity reactions(rarely) P/A: Injection 300mcg Dose: For Rh-negative women. Anti-D immunoglobulin (human) Anti-D immunoglobulin is prepared from plasma with a high titre of anti-D antibody. caution in rhesus-negative patients with anti-D antibodies in their serum A/E: Local reactions with pain and tenderness at the site of injection. The injection of anti-D immunoglobulin is not effective once the mother has formed anti-D antibodies. chills. Antitetanus immunoglobulin (human) Antitetanus immunoglobulin of human origin is a preparation containing immunoglobulins derived from the plasma of adults immunized with tetanus toxoid. The aim is to protect any subsequent child from the hazard of haemolytic disease of the newborn. It is available to prevent a rhesus-negative mother from forming antibodies to fetal rhesus-positive cells which may pass into the maternal circulation. anaphylaxis. It is also given following Rh0 (D) incompatible blood. It should be administered following any potentially sensitizing episode (for example abortion.IM 200-300mcg within 72 hours following birth of Rh-positive infant. Systemic reactions including fever. miscarriage.headache and nausea may occur. Intravenous injection. anaphylaxis. still-birth)immediately or within 72 hours of the episode but even if a longer period has elapsed it may still give protection and should be used.10 mcg/ml of Rh-positive blood in mismatched transfusion. caution in rhesus-positive patients for treatment of blood disorders. rarely. facial flushing. known hypersensitivity P/C: See introductory notes.Sera and immunoglobulins Hypersensitivity reactions may occur including. rarely. It is used for the management of tetanus-prone wounds 259 I: .Hypersensitivity reactions may occur including. Prevention of formation of antibodies to rhesuspositive blood cells in rhesus-negative patients (see notes above) C/I: See introductory notes. particularly following high rates of infusion.50-100 mcg during gestation.

half by IM in the gluteal muscle and half by infiltration around the cleansed wound.IV administration see introductory notes.or there is risk of heavy contamination IM 150 U/kg multiple sites Prevention:250 U(1ml)single dose 150 U/kg in multiple sites Therapeutic: Child: Treatment: ANTIVENOM IMMUNOGLOBULINS(Refer Part II) Rabies immunoglobulin(Human) I: Passive immunization either post-exposure or in suspected exposure to rabies in high-risk places in unimmunized individuals (in conjunction with rabies vaccine) Avoid repeat doses after vaccine treatment initiated. give remainder by intramuscular injection into anterolateral thigh C/I: P/C: A/E: P/A: Dose: 260 .fever Injection: 300 IU/ml in vial. I: C/I: P/C: A/E: P/A: Dose: Passive immunization against tetanus as part of the management of tetanus-prone wounds See introductory notes. intravenous administration Rabies vaccine if schedule requires rabies vaccine and rabies immunoglobulin to be administered at the same time.avoid tetanus immunoglobulin and tetanus vaccine injecting at the same site.Immunologicals in addition to wound toilet and with appropriate antibacterial prophylaxis and adsorbed tetanus vaccine. See introductory notes Injection: 250 IU in vial. they should be administered using separate syringes and separate sites Pain at injection site. Adult and Child 20 IU/kg on the day of injury. Adult:prophylaxis:IM 250 U increased to 500 U if more than 24 hours have elapsed. if wound not visible or healed or if infiltration of whole volume not possible.

l00units / 0.000 U/0. thrombocytopenia and coagulation disorders.M. local ulceration.CNS disorder. 5 .generalized septic skin conditions Pregnancy. pregnancy.1ml intradermally in the deltoid region Active immunization against diphtheria. Pertussis and Tetanus vaccine (DPT) . 200 units as soon as possible after birth. preferably within 48 hours of birth. A/E: Local reactions with pain and tenderness at the site of injection. 300 units.disseminated BCG infection in immunodeficient individuals.5ml. tetanus and pertussis Acute illness or infection. C/I: Anaphylactic reactions to previous dose. immunodeficiency. eczema. osteitis 1. under 5 years.M. 200 units.adults and children above 6 years Should be used only in infants and children <6 years of age Local reactions at injection sites 261 P/C : A/E : P/A : Dose : I: C/I : P/C : A/E : Diphtheria.00. P/A: Injection. I.9 years.5 mL 0. 500 units (given preferably within 48 hours of exposure and not more than l week after exposure) Child: Neonates. rarely lymphadenitis. P/C: History of allergy. not to be administered intravenously. scabies-vaccine site must be lesion-free See introductory notes.Vaccines Hepatitis B Immunoglobulin I: Passive immunisation of persons exposed to hepatitis B virus.prophylaxis of infants born to HBs Ag +ve mothers. VACCINES BCG vaccine I: C/I : Active immunization against tuberculosis HIV infection. patients receiving immunosuppressive therapy. Dose: Adult:I.

radiation. Child:Oral 0. rarely . therapy with corticosteroids. Acute febrile illness.lymphoma.5 ml each in 6.5 mL. Oral solution as above formula (Govt. 6.booster doses should not be given at intervals of <10 years Local reactions Adult:IM. 0. 10. diarrhoea. Booster dose to children above 5 years of age and children allergic to pertussis component of DPT.5 mL IM usually 1 booster dose at school entry Active immunization against tetanus Acute illness. pregnancy. supply to the “wellbaby clinic”directly). thrombocytopenia purpura rash. dysentery. Adsorbed IP Measles vaccine Live attenuated vaccine I: A/E: 262 Active immunization against measles L o c a l l y m p h a d e n o p a t h y.corticosteroid or immunosuppressive therapy Hypersensitivity. acute illness. malignancy. Immunodeficiency disorders. 14 weeks and in 6-9 months (if not receiving HBV booster doses in 18 months and 5 years).10 and 14 weeks of age with 4 weeks interval between each dose and booster doses of 0. leukaemia. Pain at the site of injection.each of 0.at an interval of 4-6 weeks.1ml in 0. hypersensitivity. vomiting. Poliomyelitis Vaccine (Oral) IP I: C/I : P/A : Dose: Diphtheria and tetanus vaccine (for children under 7 years) I: A/E: Dose: I: C/I: P/C: A/E: Dose: Tetanus Toxiod.Immunologicals Dose : IM 3 doses of 0.5 ml each at 18 months and 5 years of age Active immunisation against poliomyelitis.reinforcing dose after 9 -12 months in a booster dose of 0.5 mL every 5 years.2 Doses.

mumps and rubella infections. as a single dose at the age of 12-15 months.rash and parotitis. P/C: Postpone the vaccination in patients suffering from acute illness. infants 0.Vaccines Primary immunization of children against measles. Kanamycin and documented history of MMR vaccination. recent therapy with steroids or immunosuppresants.Immunization of HIV-infected infants against measles (unless severely immunocompromised). decompensated heart diseases. a reinforcing dose of 0. acute febrile illness. congenital or acquired immunodeficiency. regional lymphadenopathy.5 mL Mumps. pain and induration. by intramuscular or subcutaneous injection. severe anaemia. severe renal impairment.5 mL at 9 or 12 months of age. Rubella vaccine I: Active immunisation against rubella virus C/I : Acute infectious diseases. women 263 Dose: . P/C: Individuals receiving corticosteroids and other immunosuppressants or undergoing radiation therapy may not develop an optimal immune response. active tuberculosis and hypersensitivity to neomycin. following administration of gammaglobulin or blood transfusions.5mL SC. Dose: Child 0. Measles & Rubella (MMR) I: Active immunization in children aged 12-15 months against measles.Prophylaxis in susceptible individuals after exposure to measles.adult and child over 9 months of age 0. allergy to chick egg proteins.5 mL at 9 months of age. pregnancy. by intramuscular or subcutaneous injection.pregnancy and lactation. leukaemia.5 mL dose at 6 months of age followed by 0. A/ E: Local erythema. C/I: Pregnancy. infants and child 0.5 mL can be given after four weeks or up to 6 years of age.a booster dose may be given at the age of 3-5 years into outer part of upper arm. by intramuscular or subcutaneous injection within 48 hours of contact.

Active immunization against typhoid Congenital acquired immunodeficiency. headache.acute intestinal infection thrombocytopenia.breast feeding A/E: Fatigue. lymphadenopathy.hence attention to hygiene food and water is essential Mild transient gastrointestinal disturbances reported Adult 0. Skin rashes.5 ml P/C: A/E: Dose: Cholera vaccine I: C/I: P/C: A/E: Dose: Hepatitis A vaccine I: active immunization against hepatitis A virus infection C/I: Hypersensitivity P/C: Serious infections.avoid simultaneous administration of antibacterials.5 ml IM second dose after 4 weeks 1 ml IM.Mefloquine should not be taken at least 12 hours before or after a dose Redness pain and swelling.5 ml. deep SC. nausea.transient LFT abnormalities.cardiovascular disease pulmonary disorders pregnancy. reactions at injection sites rarely Dose: Adult:IM. Child 1-5 years 0. rarely anaphylaxis Adult:IM single dose of 0. acute febrile illness. pharyngitis.0. 0. headache.Immunologicals A/E: Dose: Typhoid vaccine I: C/I: of child beating age are advised not to become pregnant for 2 months after vaccination. malaise. thrombocytopenia and neurological symptoms including neuropathy and paraesthesia have been reported rarely Adult and Child:12 months and above. fever.revaccinated every 3 years if necessary Child:>2 years. arthralgia.treatment with immunosuppressives and antimitotic drugs.1 ml as a single dose.second dose 0.and a booster dose 1 ml 6-12 months after usual dose 264 . same as adult dose Active immunization against cholera Hypersensitivity to previous dose Immunity last only upto 6 months.1ml second dose 0. arthropathy.3 ml. fever. 6-10 years.3 ml.5mL as single dose.fever. itching.

3 Doses of 1 ml.3 years .5 ml and a booster dose of 0. rarely encephalitis 1. avoid pregnancy for 3 months after immunization Mild and transient reaction at the injection site 265 Rabies vaccine I: C/I: P/C: A/E: Dose: Varicella vaccine I: C/I: P/C: A/E: . head ache. total lymphocyte count <1200/mm3. postexposure treatment Allergy Acute illness.malignant neoplasm Reaction at injection site. acute severe febrile illness. fever.1 ml on days.5 ml 6-12 months after the 1st dose Hepatitis B vaccine I: Active immunization against hepatitis B virus infection C/I: Hypersensitivity.0.5 ml subcutaneously.the second 1 month and third 6 months after the first dose Japanese encephalitis vaccine I: C/I: A/E: Dose: Active immunization against Japanese encephalitis Children below 1 year.7 and 28 days Postexposure immunization:IM/SC.Number of doses and interval : Two doses at 1 month and booster every 3 years Active immunization against rabies.7.0.3.Vaccines Child:1-15 years: IM.history of seizures. 0.impaired immunological response. Hypersensitivity to first dose.hypersensitivity.hypersensitivity Hypersensitivity.immunosupression and pregnancy Local reaction.severe febrile illness P/C: Pregnancy Dose: Adult:IM.1 ml on 0. pre-exposure prophylaxis.Above 3 years – 1 ml subcutaneously.14 and 30 and a booster dose on day 90 Active immunization against varicella in seronegative individuals who are at high risk of severe varicella infection Pregnancy. neuroparalytic reactions with animal brain tissue vaccines Adult and Child:Preexposure immunization:IM/SC.

5 mL Child: Not recommended in children < 2years Yellow fever vaccine I: Active immunization against yellow fever Infant at 9– 12 months of age.5 mL C/I: Not recommended for infants under 9 months of age A/E: Headache.>12 years same as adult dose Pneumococcal vaccine(Polyvalent) I: Active immunization of those at risk from streptococcal infection C/I: Hypersensitivity. by deep subcutaneous or by intramuscular injection. chemotherapy or radiation.single dose of 0. viscerotropic disease. very rarely encephalitis (infants more susceptible). multiple organ failure (elderly more susceptible) Dose: 266 .Immunologicals Adult: SC. 2 doses of 0. myalgia. Adult and Child over 9 months of age 0.Hodgkins and NonHodgkins Lymphomaespecially during treatment and in chronic alcohols.local reaction at injection site Dose: Adult:SC/IM.5 ml each at an interval of 4-8 weeks Child: SC 12 months-12 years 0.pregnancy.breast feeding P/C: Multiple myeloma. weakness.should be given at least 10 days before starting immunosuppressive therapy or be delayed until atleast 6 months after completion of therapy A/E: Hypersensitivity reactions.0.5 ml Immunization of travellers and others at risk against yellow fever.5 ml(one dose).

widely used in transplantation to prevent rejection. Cyclosporine has a narrow therapeutic window. ACE inhibitors and spironolactone increases risk of hyperkalemia. D/I: Increased nephrotoxicity with NSAID and allopurinol. C/I : Severe hypertension. tremor. Caution in porphyria. 50. lymphoproliferative disorders. hyperuricemia. To be used under specialist care only. taper to 2 -6 mg/ kg maintenenace. is also used in certain primary glomerular diseases I: Steroid resistant minimal change disease. severe renal and hepatic failure. gingival hypertrophy.convulsions. metabolic effects such as hyperkalemia. 267 . neuropathy. hypertension. Dose : Renal transplantation 5 . haemolytic uremic syndrome. 100 mg ~ Oral solution 100 mg / mL.SECTION 20 IMMUNOSUPPRESSANT DRUGS T CELL INHIBITORS Cyclosporine More specific immunosupressive. pancreatitis. Nephrotic syndrome 3 to 5 mg/ kg/ day for varying periods of time usually 3 months to 6 months. focal segmental glomerulosclerosis. membraneous nephropathy and membrane proliferative glomerulo nephritis. monitor blood pressure and serum potassium. aminoglycosides and doxycyline. P/A : Capsules 25. myopathy. hypertrichosis.15 mg / kg in 2 divided doses initially. hepatic dysfunction. Various antibacterial drugs and hypertensives alter cyclosporine levels in blood and thereby enhances toxicity or reduces effect. A/E : Dose dependent increase in urea and creatinine in early phase and chronic nephrotoxicity in prolonged use. P/C : Monitor renal and hepatic function. hypercholestrolemia.

To be used under specialist care only. GI Complaints. it is recommended that sirolimus be used initially in a regimen with cyclosporine and corticosteroids. hypo/ hyperkalemia. hyperglycemia and diabetes. Nephrotoxicity. seizures. thrombocytopenia.05-0. headache. tremor. There is increased risk of neoplasms especially lymphomas and infections like CMV and pneumocystis carinii.1 mg/kg BD oral for renal transplant. pregnancy . Hypersensitivity to mercaptopurine.lactation 0. prevention of rejection in renal transplantation. GI upset. leucopenia. allopurinol and azathioprine. Tab 1mg (10) Rs 1300/CYTOTOXIC DRUGS A/E: C/I: Dose. 268 .2mg/ kg BD for liver transplant cap 1mg (10) Rs 349/Prophylaxis of Organ Rejection in Renal Transplantation. hyperkalemia.Therapeutic drug monitoring is recommended for all patients receiving sirolimus In patients at low-to-moderate immunologic risk. Monitoring of blood counts weekly for 8 weeks and thereafter every month.2 mg/kg/day in 2 divided doses staring within 24 hours. hypertension.Immunosuppressant Drugs Tacrolimus I: Dose: Prophylaxis of organ allograft rejection Oral : Adult – renal transplant – 0. can be delayed if renal functions are not normal.0. Anaemia. Also increased risk of secondary tumours and opportunistic infections. Reduce dose in hepatic and renal dysfunction and elderly. Cost: Sirolimus I: A/E: Cost : Cyclophosphamide (Refer section 6) Azathioprine I: C/I: P/C: Lupus nephritis class III and IV. hypersensitivity. Cyclosporine should be withdrawn 2 to 4 months after transplantation. fever. motor disturbances. neurotoxicity.1-0.

Rifampicin reduces blood levels. vomiting. I: Preferred immunosuppressive in membraneous nephropathy. Mycophenolate sodium is also commonly associated with fatigue. increased susceptibility to infections.1 to 0. Common adverse drug reactions (>1% of patients) associated with mycophenolate therapy include diarrhea.1 – 1% of patients) include esophagitis. gastritis.Cytotoxic drugs A/E: P/A: Dose: D/I: Hypersensitivity reactions including deranged liver function.alter nated with oral prednisolone every 4 weeks for 6 months. headache. whereas mycophenolate sodium has also been used for the prevention of rejection in liver. 269 Dose : Mycophenolate mofetil I: A/E: . Intravenous (IV) administration of mycophenolate mofetil is also commonly associated with thrombophlebitis and thrombosis. Infrequent adverse effects (0. nausea. leucopenia. gastrointestinal tract hemorrhage. Tablet 50 mg 1-3 mg/kg/day · Increased toxicity with other cytotoxic drugs and allopurinol.3 mg /kg /day for 6 to 8 weeks in MCNS and alternate 4 weeks for 6 months in membraneous nephropathy In General. and/or invasive cytomegalovirus (CMV) infection. 0. and / or anemia. pancreatitis. mycophenolate is used for the prevention of organ transplant rejection in adults and renal transplant rejection in children >2 years. Dose related bonemarrow suppression. interstitial nephritis calls for permanent withdrawal. heart. and or lung transplants in children >2 years. pneumonitis and alopecia. Also useful in steroid resistant minimal change disease. infections. Methotrexate (refer section 6) Chlorambucil Alkylating agent preferred by some due to its beneficial effects and relative safety. and/ or cough. cholestatic jaundice.

1 to 0. Renal transplant:1 mg/ kg to start. antibody production and also has antiinflammatory properties. Adults – 1 g orally twice a day starting within 72 hours of transplant.2 mg on alternate days indicated in membranous nephropathy and steroid dependent minimal change disease for a period of 6 months.2 mg/kg maintenance 3 to 5 years. I: Nephrotic syndrome produced by minimal change disease and membraneous nephropathy. vasculitis and renal transplantation. lupus nephritis. Lupus nephritis: 2 mg/kg bw for 4 — 8 weeks followed by 0. Dose : Nephrotic syndrome In adults: Img/kg/day or 2mg/ kg/alternate day is recommended. other autoimmune disorders. 270 . Usually combined with azathioprine and cyclosporine. T-helper cell activation. In children 2mg/ kg or 40mg/mg daily for 4 to 8 weeks. It inhibits interleukin-1(IL-1).6 months and continue lifelong. Tab 500mg (10) Rs 880/- GLUCOCORTICOIDS They are widely used as immunosuppressants in many immune mediated primary and secondary glomerular diseases and in renal transplantation. taper to 0. followed by alternate day therapy for a similar duration. Prednisolone Prednisolone is the preferred corticosteroid for oral immunosuppression. Methyl Prednisolone Intravenous infusion of methyl prednisolone in high doses of upto 1 g daily for 3 . Maintenance therapy in low dose of 0.5 days is called steroid pulse therapy and is used for early response in severely ill patients.1 mg/kg by 3 . because of its lesser suppressive effect on the hypothalamopituitary axis.Immunosuppressant Drugs Dose: Cost : Adults – 1 g IV twice a day for upto 4 days starting within 24 hours of transplant and then shift to oral maintenance therapy.

5-2. To be used by specialist only. Diabetes. acute transplant rejection. 10 to 40 mg/ kg/ day not exceeding 1000 mg is given as IV infusion in 200 mL of 5% dextrose over a period of 30 min and is repeated consecutively for 3 to 5 days. Peptic ulcer. Besides the usual steroid side effects. vasculitis. Bolus injections may produce sudden cardiac death. MONOCLONAL ANTIBODIES. crescentic nephritis and severe acute interstitial nephritis with renal failure. 500 mg 1 g vials.25 mg/vial ATG 100 mg injection. BASILIXUMAB DACLIZUMAB ALEMTUZUMAB. This is usually followed by oral prednisolone at a dose of 1mg/ kg. pregnancy. infections. Cushing’s syndrome. Dose: 1. infections. Injection methyl prednisolone sodium succinate and methyl prednisolone acetate in aqueous solution. hypokalemia. seizure disorder. and convulsions are more frequently encountered. IMMUNOSUPPRESSANT ANTIBODIES THYMOGLOBULIN (Antithymocyte globulin) I: To suppress acute allograft regection episodes especially in steroid resistant cases A/E: serum sickness and anaphylaxis P/A: thymoglobulin (rabbit)inj.5mg/kg/day .. acute psychosis. herpes simplex. lactation. acute hyperglycemia. keratitis.Thymoglobulin ATG 200mg IV/day 271 .Glucocorticoids I: C/I: P/C : A/E: P/A: Dose: Severe renal disease due to SLE.

Limit the salt intake to 100 mmol (5 g) or less. ammonium phosphate) and cystine. pyrophosphates and certain glycopeptides in the urine. calcium phosphate.When these dietary measures fail. 272 .5mg/day Potassium citrate Mechanism of action — lowers urinary calcium excretion as well as increases urinary citrate excretion. uric acid. Thiazide diuretics I: Dose: Idiopathic hypercalciuria Chlorthalidone : 25-50mg/day Hydrochlorothiazide : 25-100mg/ day Indapamide A modified thiazide diuretic Dose : 2. magnesium.SECTION 21 DRUGS USED IN DISEASES OF KIDNEY AND URINARY TRACT DIURETICS: REFER SECTION 14 DRUG TREATMENT OF UROLITHIASIS Stones in the urinary tract are composed of calcium oxalate.The predominant inhibitors are citrate. after ruling out renal failure and UTI. Reduce the protein intake to 1g/ kg or less. 3. Calcium stones account for 70 to 80% and triple phosphate 1020% of all renal stones. pharmacological therapy is resorted to. Stones are formed when the concentration of the constituent substances in the urine exceeds the formation product (super saturation) or due to an imbalance between the promoters and inhibitors of stone formation. Also alkalinises the urine. triple phosphate (magnesium. Increase fluid intake to ensure at least 2 L of urine / day. General measures If a single stone is found. He / she should be monitored annually to determine whether their stone disease is active. 2. Calcium intake in the range of 800-1000 mg / day. In a recurrent calcium stone. rule out systemic and renal disease that can cause calculi. dietary advice is given 1.

alopecia and neuropathy are other side effects. and prevention of growth of residual stone fragments after lithotripsy of struvite stones. Powder 1 g : 14 mEq 60-80 mEq/ day P/A: Dose: Primary and secondary hyperuricaemia. gout. Not to exceed 900 mg. 40 mg and 100mg Dose : Primary hyperoxaluria 100 — 1000 mg/ day. Neutral phosphate Mechanism of action — decrease in urinary calcium excretion. GI disturbances and hyperkalemia. I: Idiopathic calcium stone former. idiopathic calcium stone formation. I: A / E: Idiopathic hypercalciuria. Taste disturbances. Tablets 100 mg 100 mg daily gradually increased to 300 mg daily over 3 weeks. urate calculi.P/C : A/E : P/A: Dose: Allopurinol Mechanism of action — Uric acid synthesis is reduced by inhibition of xanthine oxidase.hypocitraturia. Dietary hyperoxaluria 25 — 100 mg/ day. P/A: Tablet 10 mg. leukopenia. hyperuricosuria. Pyridoxine Mechanism of action — Pyridoxal phosphate (Vit B6) is a cofactor for the enzyme alanine glyoxalate transaminase I: Primary hyperoxaluria. urate calculi. vertigo. increase in urinary pyrophosphate.Drug treatment of Urolithiasis I: C/I . Hypersensitivity reactions including fever. lymphadenopathy and eosinophilia and exfoliation resembling Steven ]ohnson Syndrome. and an increase in plasma phosphate which deregulates calcitrol production. leukocytosis. elevated aminotransferase levels and progressive renal insufficiency. Hyperkalemia and renal failure. dietary hyperoxaluria. idiopathic hypercalciuria 273 . cystine stones.

idiopathic calcium stone former used in combination with pyridoxine. 274 . lethargy.5 mg daily for 3 to 5 days. drowsiness. hypotension. deficiency of fat soluble vitamins. Drugs used: Prazosin.Drugs used in diseases of kidney and urinary tract Orthophosphate Mechanism of action — Reduction in urinary calcium excretion by unknown mechanism.Tamsulosin. P/C: First dose effect may cause collapse. and urinary pyrophosphate increases. Terazosin. urinary incontinence. Chelating agents used in the treatment of cystine stones Mechanism of action — increase cystine solubility Penicillamine A/ E: Blood dyscrasias and nephropathy Dose: 250mg of penicillamine can lower urine cystine by about 100mg TREATMENT OF VOIDING DYSFUNCTION AND OTHER COMMON LOWER URINARY PROBLEMS DRUGS FOR BENIGN PROSTATIC HYPERTROPHY (BPH) Alpha adrenergic blockers: These drugs relax the smooth muscles of the prostate and bladder outlet and increase urine flow. A/E: Dizziness. hypersensitivity. headache. then progressively increased to 2 mg bd. Terazosin I: BHP grade I and II with post void residual urine volume less than 150 mL C/I: Orthostatic hypotension. Cholestyramine Mechanism of action — binds oxalate in the lumen of the bowel I: Enteric hypercalciuria A/E: Steatorrhoea due to binding of bile salts. Dose : 4g qds. Dose: Prazosin : 0. Dose : 30-40mg/kg/day. to be taken while retiring to bed. I: Primary hyperoxaluria. dry mouth. postural hypotension. Alfuzosin Prazosin.

pregnancy.postural hypotension A/E: Dizziness and Retrograde ejaculation P/A: 0.4 mg(10)Rs 39-60/Alfuzosin I: C/I :A/E:same as above Dose: Adult 2.daily to be increased to a maximum of 10 mg daily. P/A: Tablets Bethanechol chloride 25 mg Dose: Bethanechol : 10 to 25 mg tds to qds daily. Tablets 5 mg(10) Rs 105/0. bradycardia.s.5 mg tds maximum 10 mg daily Cost: Tablets 10 mg(10)Rs 80-90/- Alpha redcuctase inhibitors Finasteride Dose : Cost: Dutasteride Dose: Cost: 5 mg daily increased upto 20 mg daily. arrhythmia. hepatic impairment. C/I: Hypersensitivity. sweating. myocardial infarction.Benign prostatic hypertrophy Terazosin : 1mg h.5 mg daily Tablet 0. A/E: Parasympathomimetic effects .nausea. vagotonia. Bethanechol I: Postoperative retention.130/- TREATMENT OF NEUROGENIC VOIDING DYSFUNCTION Parasympathomimetics Improves voiding efficiency by increaing detrusor contraction. abdominal colic. I: non obstructive neurogenic urinary retention. epilepsy. blurred vision.2 and 0.5 mg(10) Rs 89. peptic ulcer. vomiting. neurogenic bladder (large capacity low pressure) sensory atonia C/I : Parkinsonism. Cost: Tablet 25 mg (50) Rs 480-750/275 . asthma. Tamsulosin Uroselective alpha 1A/1D blocker I: same but does not cause significant changes in BP.4 mg Capsules Dose: 1 capsule( maximum 2)in the morning with meals Cost: Tablets 0.

diarrhoea. myasthenia. angioedema. hyperthyroidism. dry skin. prostate hypertrophy.Drugs used in diseases of kidney and urinary tract DRUGS FOR URINARY FREQUENCY AND ENURESIS Antimuscarinic drugs Flavoxate I: Urinary frequency. P/A: Tablet 200 mg Dose: 200 mg t. convulsions.facial flushing. bladder spasms.d. hiatus hernia with reflux oesophagitis. urgency. Intestinal obstruction or atony. glaucoma. Frail elderly. significant bladder outflow obstruction. disorientation.>11 years 50 -75mg Cost: Tablet 25 mg(10)Rs 6-8/- Oxybutynin Chloride I: C/I : Urinary frequency. A/ E: Antimuscarinic effects as for atropine. megacolon. hiatus hernia with reflux oesophagitis. arrhythmia. P/C: Glaucoma. Cost: Tablet 10 mg(10) Rs 8-12/Imipramine Dose: Nocturnal Enuresis 6-7 years 25mg. difficulty in micturition. porphyria. hallucinations. rash. hepatic and renal impairment. photosensitivity.610 years 10-20 mg at bed time. nausea. constipation. myasthenia gravis. and nocturnal enuresis. C/I: Intestinal obstruction. Cost: Tablet 200 mg(10)Rs 25-79/Amitriptyline Dose: Nocturnal Enuresis > 11 years 25-50 mg at bed time.8-11 years 2550mg. urgency and incontinence. pregnancy and breast feeding. bladder neck obstruction. restlessness. dysuria. drowsiness. neuropathy. ulcerative colitis. severe ulcerative colitis or toxic megacolon. Dry mouth. blurred vision. P/C : A/E : 276 . prostatic hypertrophy. incontinence. neurogenic bladder instability.cardiac disease where increase in heart rate undesirable. abdominal discomfort.s.

hepatic and renal impairment. difficulty in micturition. 4mg. 5mg three times daily). 5mg 2-3 times daily. headache.Urinary Frequency and Enuresis ADULT: Oral. congestive heart failure.5-3mg twice daily initially. 4mg. nausea. reduce to l mg twice daily if necessary to minimise side-effects. 2. hallucination and convulsions. blurred vision. pregnancy and breast—feeding. autonomic neuropathy.coli. 3mg. C/I : Avoid in patients with myasthenia gravis. constipation. Dose: ADULT:Oral. A/E: Dry mouth. restlessness.Extended release tablets. initially 2 mg twice daily. significant bladder outflow obstruction or urinary retention. elderly. Drugs used include 277 Dose: . urgency and incontinence. drowsiness. vomiting. increased to 5mg twice daily according to response and tolerance. 2. 5mg.5-3mg twice daily increased to 5mg 23 times daily (last dose before bedtime). glaucoma. Cost: Tab 2mg (10) Rs 80-85/ALKALINISATION OF URINE Decreases discomfort in cystitis. 2. coronary artery disease. CHILD: Not recommended. palpitations and skin reactions. arrhythmias and tachycardia.5-3mg twice daily increased to 5mg twice daily (max. severe ulcerative colitis. CHILD: Neurogenic bladder instability: above 5 years.5mg. Cost : Tab 5mg (10) Rs 75-80/Tolterodine tartrate I: Urinary frequency. P/C : Elderly.may reduce sweating leading to heat sensations and fainting in hot environments.Nocturnal enuresis: (preferably over 7 years). upto 5mg 4 times daily if necessary. diarrhoea. 5mg. and in gastro—intestinal obstruction or in intestinal atony. P/A: Tablet. retards bacterial growth especially E. disorientation.prostatic hypertrophy. hyperthyroidism. toxic megacolon. angioedema. P/A : Tablets 2.Sustained release tablets. arrhythmias and tachycardia.abdominal discomfort. 2mg.

Dose: P/C : 278 . severe curvature.Drugs used in diseases of kidney and urinary tract Potassium citrate I: Other uses-relief of discomfort in mild UTI. Predisposition to prolonged erection. urethral application also contraindicated in urethral stricture. not for use with other agents for erectile dysfunction.Child oral 5 ml tds Sodium bicarbonate I: same as above drug P/C: Sodium containing drugs are to be used with caution in patients with oedema and CCF A/E: Hypokalemia and metabolic alkalosis in patients with renal impairment P/A: Tablet 300mg(1 mmol=84 mg) Dose: Oral 1-10 mmol/Kg/day in divided doses. in patients with penile implants or when sexual activity medically inadvisable. ACIDIFICATION OF URINE ASCORBIC ACID I: Infection by urease splitting organisms especially proteus. catheter induced mixed infections. presence of stones. neonatal congenital heart defects. Drug used include 4 g daily in divided doses. DRUGS FOR IMPOTENCE Alprostadil I: C/I : Erectile dysfunction. Priapism—patients should be instructed to report any erection lasting 4 hours or longer-anatomical deformations of penis—fol1ow up regularly to detect signs of penile fibrosis. severe hypospadia.to prevent recurrence of urinary stones C/I: Metabolic or Respiratory Acidosis P/C: Potassium containing salts to be avoided in renal failure. urethritis. A/E: Hyperkalemia on high dosage Dose: Adult oral 15 ml tds. balanitis.

priapism. initially 50-100 nanograms/kg/minute.with rapid IV use. hypotension or hypertension. first dose 2.dose suitable for producing erection not lasting more than 1 hour. if there is a response the next dose should not be given for at least 24 hours.5mcg. sedation lethargy. thrombosis at the IV administration site. increasing in steps of 5-10mcg to obtain. P/A: Injection. sensitivity. second dose 5mcg (if some response to first dose) or 7. P/A: Injection (intracavernosa). chest pain. numbness. 100-300mg 3-5 times daily IM. Papaverine Hydrochloride I: impotence. 279 A/E : . 60mcg (max. testicular pain and swelling. urethral bleeding. penile infection. DOSE : Adult: Oral. vasodilatation. depression. hypotension. then decrease to lower effective dose. DOSE : ADULT: Intracavernosal injection. supraventricular extrasystole.2mL:Capsules. constipation. relief of peripheral and cerebral ischaemia associated with arterial spasm. dizziness. 60mg. 30mg/mL. penile warmth. anythmias. local reactions like urethral burning. max. vertigo. dry mouth. IV : 30-120mg every 3 hours as needed. Parkinson’s disease P/C : Glaucoma. if no response to dose then next higher dose can be given within 1 hour. drowsiness. reactions at injection site. scrotal disorders.20mcg. peripheral vascular disorder. 1mL.V infusion. sweating. C/I : Complete arterioventricular block. dizziness. usual range 5—20mcg. rapid pulse. erectile dysfunction. headache. hepatic hypersensitivity.500mcg/mL. tachycardia.5 mcg (if no response to first dose). frequency of injection not more than once daily and not more than 3 times in any one week) CHILD : To maintain the patency of ductus arteriosus in neonates: I. nausea.Drugs For Impotence Penile pain. pruritus. irritation. administer IV cautiously since apnoea and arrythmias may result A/E : Flushing of face. changes in micturition.

anatomical deformation of penis. single dose 100mg). max. Effect may persist for longer than 24 hours. nasal congestion. uncontrolled hypertension. headache. also moderate heart failure. multiple myeloma . recent stroke or myocardial infarction. 10mg. subsequent doses adjusted according to response to 25-100mg as a single dose as needed. Treatment with nitrates. 20mg. visual disturbances increased intra-ocular pressure.80/Erectile dysfunction. dizziness. flushing. As for sildenafil. predisposition to prolonged erection (as in sickle—cell anaemia. 50mg ADULT: Oral. erythromycin increases its plasma concentration 25mg (4tablets) Rs 60. Tablets. hepatic and renal impairment. ADULT: Oral. Tablets. 25 mg. blood pressure below 90/ 50mmHg and hereditary degenerative retinal disorders.leukaemia). one dose in 24 hours(max. Dyspepsia. hypotension when used with alpha blockers.Drugs used in diseases of kidney and urinary tract Sildenafil I: C/I : Erectile dysfunction. As for sildenafil. P/C : A/E : P/A : Dose : D/I: Tadalafil I: C/I : P/C : A/E : P/A : Dose : Note: 280 . As for sildenafil. rash and priapism reported. myalgia. initially 10mg at least 10 minutes before sexual activity. uncontrolled arrhythmia. subsequent doses adjusted according to response to 20mg as a single dose . initial. Cardiovascular disease. conditions in which vasodilation or sex activity is inadvisable. Maximum 1 dose in 24 hours (but daily use not recommended). 50mg (elderly 25mg) approximately one hour before sexual activity. serious cardiovascular events also reported. also back pain.

pregnancy. Oral : 2-15 mg daily in divided doses. adjusted according to response. epilepsy. 1-3 g (maximum rate 300mg/ min) maximum dose 3 g daily for 3 days. Psychiatric illness. in acute muscle spasm. efficacy of anoretics and anticholinergics increased. CNS depressant effects is potentiated with alcohol and other CNS depressant drugs. 425.300 mcg/kg repeated every 1-4 h. 281 Cost : Diazepam I: Dose: Parenteral : Baclofen I: C/I: P/C: .d. brain damage. allergic rash and convulsions.00. Peptic ulceration.5 g q. by IV infusion (or by nasoduodenal tube 3-10mg/kg over 24 hrs. and myasthenia gravis. porphyria. diabetes mellitus. may be reduced to 750 mg tds. slow IV infusion. increased if necessary in spastic conditions to 60 mg daily according to response by IM. hepatic or renal impairment. Tab 500 mg (10 x 10) Rs.s. Injection 100mg/ 10 mL.00 Muscle spasm of varied etiology. or by slow IV. Hepatic and renal impairment. history of peptic ulcer. 10 mg repeated if necessary after 4 hrs. including tetanus. Lassitude. Tablet 500 mg. Inj 100 mg/mL (25x10mL) Rs 500. confusion. respiratory. epilepsy. Tetanus adult and child by IV100 .SECTION 22 MUSCLE RELAXANTS AND ANTICHOLINESTERASES CENTRAL MUSCLE RELAXANTS Methocarbamol I: C /I: P/C: A/E: P/A: Dose: Oral: Parenteral : D/I: Short term symptomatic relief of muscle spasm. cerebrovascular disease. 1. Chronic severe spasticity resulting from disorders such as multiple sclerosis or traumatic partial injury to spinal cord. Coma.

Used in treatment of strabismus and hyperhidrosis. Mutual potentiation with CNS depressants and alcohol.57. preferably after food. blepharospasm.Muscle Relaxants and Anticholinesterases A/E: P/A: Dose: D/I : Cost : Sedation.s increased gradually according to age to the . Tab 2 mg (10) Rs 24. 2-6 years 20-30 mg daily.00 Muscle spasm Severe hepatic dysfunction Hepatic / renal insufficiency. Tizanidine I: C/I : P/C: A/E: P/A: Dose: D/I: Cost: Botulinum Toxin Botulinum A: 282 . bradycardia. agitation. or 2. children. dryness of mouth Tablets/Capsules 2mg. Concomitant use with levodopa in Parkinson patients may result in . insomnia.5 mg/kg daily. 6-10 years 30-60 mg daily. maximum 2.00 Hemi-facial spasm. psychotic symptoms. sedation.50 – 65.d. confusion. 6 mg 2mg once daily (increased by 2mg at intervals of at least 3-4days upto a maximum of 24mg daily in 3-4 divided doses) Alcohol. Oral : 5 mg t. hallucinations. hypotension. drowsiness. spasmodic torticollis. hallucination. effective maintenance dose: 1-2 years 10-20 mg daily. When given concurrently with antihypertensive drug the hypotensive effect may be aggravated.00 . For children over 10 years 0. risk of liver injury. lowerlimb spasticity in children with cerebral palsy and upper limb spasticity associatied with stroke in adults. nausea. Tablet 10mg and 25 mg. gradually increased. maximum 100 mg daily. pregnancy. respiratory and cardiovascular depression.s. women concurrently taking oral contraceptives had 50% lower clearance of tizanidine. 4mg .d.confusion. convulsion.5 mg q. lactation. Tab 10 mg(10) Rs. 61. elderly Hypotension. CYP inhibitors like fluvoxamine or ciprofloxacin increases plasma drug levels..75-2mg/ kg daily. ataxia.

Rarely arrhythmias and MI and hypersensitivity reactions. Caution in breathing and swallowing difficulties. lacrimation. After injection into the eye muscles ptosis. Injection into lower eyelid area is avoided.00 283 Carisoprodol I: C/I: P/C : A/E: P/A: Dose: D/I: Cost : .00 — 30. hypotension. Injection in to lower limbs causes leg pain and leg cramps. photophobia and facial swelling. Interactions also occur with lincosamide. tetracyclines and muscle relaxants. Injection in the upper limb causes hypertonia and arm pain. Corneal sensation should be tested in previously treated eyes. According to the indications. muscle weakness. Paralysis of vocal cords and weakness around neck muscles. pregnancy. Handle toxin with care. breast feeding. Short-term symptomatic relief of muscle spasm Acute pulmonary insufficiency. Inject with great care in muscles around neck. eyes. Additive actions with concurrent use of alcohol.Central Muscle Relaxants Botulinum B I: C/I: P/C: A/E: D/I: Dose: spasmodic torticollis and in patients who develop resistance to treatment due to development of antibodies to type A toxin. Drowsiness. bruising at the injection site and local weakness. Blurring and burning sensation. Injection into the neck muscles may lead to dysphagia and pooling of saliva with risk of aspiration. porphyria Respiratory disease. Effect potentiated by spectinomycin. epilepsy. Deep injections paralyses nearby muscle group. polymyxins. 350 mg tds. Tablet 350 mg. Injection in to the muscles around forehead causes headache. infection at the injection site. Tab 350 mg (10) Rs. Myasthenia gravis. other CNS depressants or psychotropic drugs. gastrointestinal disturbances. 28.

Muscle Relaxants and Anticholinesterases PERIPHERAL MUSCLE RELAXANT Atracurium I: This is a non-depolarising muscle relaxant of intermediate duration and is widely used. it can be given in a dose of 5-10 mcg kg /min 300600mcg/kg/hr Quinidine and propranolol enhance the muscle relaxant effect. lnjection 10 mg/mL . By IV injection for adults and children over 1 month the initial dose is 300-600 mcg/kg. 5 mL. Metabolised by pH and temperature dependent Hoffman degradation. reduce dose in renal impairment. This drug is non-cumulative. relatively low risk of side effects with histamine release. Injection pancuronium bromide 2 mg / ml .5 ml. By IV infusion. Itching of skin. Hypersensitivity. which can be prevented by concurrent administration of H1 and H2 receptor blockers. laryngospasm and cause hypotension. 111.00 Non-depolarising muscle relaxant.5 mL. related to total dose and speed of injection. Hypersensitivity Myasthena gravis and other neuromuscular disorders. 10 mL ampoules. (2. produces moderate vagolytic action. so avoid in coronary artery disease.2. C /I: P/C: A/E: P/A: Dose: D/I: Cost : Pancuronium I: C/I: P/C: A/E: P /A: Dose : 284 . Histamine release may occur.5 hrs. excessive salivation. therefore ideal in hepatic and renal failure. give rise to urticaria. pregnancy. neonates. anuria.) Rs. long acting. lnj 10 mg/ml. Thereafter 100-200 mcg /kg is repeated as required. Histamine release may occur. asthma. Hepatic impairment.00 .125.2 ml amp By IV initially for intubation 80-120 mcg / kg then 1020 mcg / kg every 1-1. tachycardia and hypertension.

4 mg/mL . 50. predictable paralysis. 16. large doses may have cumulative effect. By IV injection 600 mcg/ kg (range 0. Prolonged muscle paralysis may occur in patients with low or atypical plasma pseudocholine esterase enzyme.00 Non-depolarising. no histamine release. short duration (5 min).18. then 30. By IV infusion.80 mcg/kg/h. For children: as adult dose (onset more rapid). 25 mg/ min (2-5 mL/ min ).Peripheral Muscle Relaxant D/I: Cost : Same as atracurium Inj 2 mg/mL (2 mL) Rs. action cannot be reversed with drugs. severe liver disease. By IV injection.1 mg/ kg depending on degree of relaxation required ) usual range.95 285 Vecuronium I: C/I.65 – 12. reduce dose in renal impairment and hepatic impairment. D/I: P/C: P/A: Dose: Cost : I: Suxamethonium (Succinyl choline) C/I: P/C: A/E: P/A: Dose: D/I: Cost: . intermediate duration.00 . initially 80-100 mcg / kg (maximum 250 mcg/kg). By IV infusion. 113. sympathetic blockade or vagolytic effect and it is ideal for cardiac surgery.1 mL.50 mcg/kg as required. By IM injection. Inj 4 mg (1mL) Rs. adults and children. Powder for reconstitution . A/E. burns. The action cannot be reversed and clinical application is therefore limited. as a 0. Injection 50 mg/ mL in 1 vial. amp.1% solution.00 . Cyclophosphamide and thiotepa enhance the effect of Succinyl choline Inj 50mg/mL (2mL) Rs 8. Hypersensitivity.00 Depolarising muscle relaxant. complete.3-1.5 mg / kg maximum 150 mg. rapid. Same as atracurium. up to 2. Arrhythmias develop if Sch is given with digoxin. Pregnancy. spontaneous recovery.120. 20-100 mg.

miosis. hypotension. epilepsy. Tablet 60 mg Oral 30-120 mg at regular intervals as required.3-1. Same as for neostigrnine. 6-12 years initially 15 mg. pregnancy and breast-feeding. recent myocardial infarction.2 g.Muscle Relaxants and Anticholinesterases ANTICHOLINESTERASES Neostigmine I: C/I: P/C: Myasthenia gravis. Signs of overdose are increased. Tab 60mg (150) Rs. and weakness leading to fasciculation and paralysis. Tablet 15 mg.5mg/ mL Oral : neostigmine bromide 15-30 mg at regular intervals throughout day. weaker muscarinic action. bronchial secretions. reversal of non-depolarising neuromuscular blockade. vomiting. Asthma. total daily dose 75-300 mg.00 Has a very brief action and is used mainly for the diagnosis of myasthenia gravis. For children : up to 6 years initially 7. parkinsonism. hypotension.5 mg. peptic ulceration. Intestinal or urinary obstruction.renal impairment. neonate 5-10 mg every 4 h.5 mg Myasthenia gravis. It is also used to determine whether a patient with myasthenia is A/E: P/A: Dose: Pyridostigmine I: C/I. involuntary defecation and micturition. P/C. neostigmine methylsulphate 1-2. Injection 0. diarrhoea. For children upto 6 years initially 30mg. usual total daily dose 30-360 mg Same as neostigmine. Nausea. half an hour before feeds. usual total daily dose 15-90 mg. gastro-intestinal motility. 6-12 years initially 60 mg. 600. A/E: P/A: Dose: D/I: Cost : I: Edrophonium Chloride 286 . Parenteral: By SC or IM. 1/2 — 1 hr before feeds. Neonate 1-5 mg every 4 hours. and abdominal cramps. total daily dose 0. and sweating.

GI disturbances.5mg. headache. asthma.5mg. Moderate to severe dementia in idiopathic Parkinsons disease. 5 mg. Injection 10 mg/mL (1 mL ampoule) Diagnosis of myasthenia gravis. gastro—intestinal haemorrhage. dizziness.5mg (10) Rs 45. Hypersensitivity to donepezil & piperidine derivatives. AV block. Severe dementia in Alzheimer’s disease.00. hepatitis reported. 6mg. IV 2 mg followed after 30 second by 8 mg. 287 Rivastigmine I: P/C. IV 2mg. Cap 6 mg (10) Rs 105. psychiatric disturbances. potential for bladder outflow obstruction. chronic obstructive pulmonary disease.Anticholinesterases C/I: P/C: A/E: D/I: P/A: Dose: receiving inadequate or excessive treatment with cholinergic drugs. A/E: P/A: Dose: Cost: Donepezil I: C/I : P/C : A/E: P/A: . Same as for Donepezil. Sick sinus syndrome or other supraventricular conduction abnormalities.00. pruritus. 20 mcg/ kg followed after 30 seconds by 80 mcg / kg. Cap 4. Initial dose is 1. hepatic impairment. 10 mg.5 mg (10) Rs 85. fatigue. susceptibility to peptic ulcers. For children IV. Cap 1. rarely sino-atrial block. rash. Tablet. Detection of overdose or underdosage of cholinergic drugs. gastric and duodenal ulcers. 3mg. convulsions.5mg twice daily at interval of 2 weeks to a maximum dose of 6mg twice daily. Same as neostigmine. 4. less frequently bradycardia. insomnia. urinary incontinence. Cap 1. syncope.00. pregnancy & breast feeding.00 Mild to moderate dementia in Alzheimer’s disease. Cap 3 mg (10) Rs 65. may exacerbate extrapyramidal symptoms.5mg twice daily in increments of 1.musc1e cramps.

Muscle Relaxants and Anticholinesterases Dose : D/I: Cost: Adult. quinidine.00 – 140. Dose should be reduced. 12mg. fluoxetine. 8mg. Galantamine I: C/I: A/E: P/A: Dose: D/I: 288 . Initial dose 4mg twice daily with food for 4 weeks then increase to 8mg BD.00. maximum 10 mg daily. Renal impairment Tab 4mg. Rise in the plasma concentration by ketoconazole.Oral. Galantamine levels are increased by quinidine.00. 5 mg once daily at bedtime.00 – 90. increased if necessary after 1 month to 10 mg daily. carbamazepine. In Alzheimer’s disease Severe hepatic and renal impairment. fluoxamine. itraconazole. erythromycin. fluoxetine. Maximum upto12mg BD. Tab 10 mg (10) Rs 110. phenytoin. Tab 5mg (10) Rs 80. paroxetine. Reduced plasma concentration by rifampicin.

3% : 0.3% 0.5% (Rs. 20-50/-) : 0. dacryocystitis.SECTION 23 OPHTHALMOLOGICAL PREPARATIONS ANTIBACTERIAL AGENTS: I: Infective blepharitis. 289 . corneal ulcers and all other bacterial diseases. Eye Ointment : Twice or thrice daily.5% (Rs. Eye drops Penicillin G Gentamicin Tobramycin Chloramphenicol Norfloxacin Ciprofloxacin Gatifloxacin Ofloxacin Moxifloxacin Levofloxacin Vancomycin Sulphacetamide : 10. 15-40/-) : 0.3% 0.000 units/mL : 0. orbital cellulitis.5% : 0.3% 0. Can be used topically and systemically.3% : 0.5% Eye drops : 1 drop every 2 hour initially and tapered according to response. 20-50/-) : 20-50 mg/ml : 10.3% : 0.3% 0.3% : 0. gonococcal ophthalmitis.3% : 0. panophthalmitis.3% (Rs.3% 0. conjunctivitis. 20 & 30% Eye ointments Chloramphenicol applicaps:1% Tetracycline Norfloxacin Ciprofloxacin Moxifloxacin Gatifloxacin Tobramycin Erythromycin Dose: HCl 1% 0.

Cream 5 % Dose : Apply 5 times/day till lesions heal.5 mL Anterior chamber irrigation — 500 mcg in 0. CMV.2 % solution hourly Subconjunctival injection · 2 to 5 mg in 0.5% 1 drop hourly or 2 hourly and tapered according to response. Corticosteroid therapy may be required in lesions caused by herpes viruses.3 % (1 lakh unit/g) Ocular ointment.Systemic therapy is also necessary.1 to 0. VZV. Rs. Less toxic. 50 – 60/- Miconazole P/A : Dose : Econazole P/A: Dose : Ketoconazole P/A .3 % (1 lakh unit/g) Ocular suspension -1 lakh unit/mL Clotrimazole P/A : Dose : Drops 1 % in arachis oil Every hour till response occurs. Natamycin suspension 5% Itraconazole suspension 1% Flucytosine solution 0.1 mL Nystatin P/A: Ocular cream .Ophthalmological Preparations ANITIVIRAL AGENT Acyclovir Reaches adequate concentration in aqueous humour. ANTIFUNGAL AGENTS Amphotericin B Dose : Topical use — 0. wide spectrum against lesions caused by HSV. Solution 1 % Every hour during day and 2 h during night. P/ A : Eye ointment 3 %. EB virus. Drops 1 % in arachis oil Every hour during day and 2 h during night.3. Drops 1% in arachis oil Cream 2% Every hour during day and 2 h during night.3. Dose : Dose : Cost : 290 .1 mL lntravitreal injection — 5 mcg in 0.Along with the antiviral medication. then qds for 8 — 12 weeks.

Solution 0.Corticosteroids used in Ophthalmology ANTISEPTICS Povidone iodine eye drops 5% CORTICOSTEROIDS USED IN OPHTHALMOLOGY Systemic administration is needed in several conditions and these follow the same guidelines for systemic therapy in other conditions.1 % Triamcinolone Ointment 0. Cortisone.Injections into the eye subconjunctival.5 %. Ointment 1.1 % Depends on the clinical indication.2 % Prednisolone Ointment 0.5 %. anterior and posterior subtenon and retrobulbar . Glaucoma. xerophthalmia.are done in different indications. Ointment 1.5 %. phlycten. Suspension 0. keratitis.Allergic conditions. Solution 0. postoperative states. Local and systemic infection.5 % Dexamethasone Ointment 0. Solution 0. I: Contact dermatitis of lids.2 % .Topical corticosteroids are employed for several allergic and inflammatory lesions where immunosuppression and antiinflammatory actions are desirable. corneal burns. ptosis. optic neuritis.5 % . All the NSAIDs can be used to suppress inflammation and give pain relief. retrobulbar neuritis. endocrine exophthalmos. allergic keratitis.5 % C/ I : A/E: P/A: Hydrocortisone Suspension 0. Solution 0. allergic lesions of the eyes.1 % Betamethasone Ointment 0. mydriasis. infections by bacteria and fungi. Mooren’s ulcer.iridocyclitis. and rarely systemic side effects. cataract.5 %. iritis. demand the administration of sytemic antihistamines 291 Dose : .Drop 2-3 times daily or even more frequently. posterior uveitis.1 % Fluromethalone Suspension 0. ocular pemphigus.

Cost : brimonidine 0.05% 2%.5% Antihistamine Chlorpheniramine maleate 0.5% & 1%. eg : apraclonidine 0. 100 – 150/- . 10 – 20/: : : 0.01% Dose : Cost : Ketotifen Cromolyn sodium Azelastine Dose : Cost : 1 drop 3 time daily Rs. 4% 0.reduces the formation of aqueous humour.05% Mast cell stabilizers 2 times to 4 times daily Rs.Ophthalmological Preparations TOPICAL NSAID’S Diclofenac sodium Flurbiprofen Ketorolac Dose : 1 drop 4 times a day ANTI ALLERGIC (TOPICAL) Decongestant drops.03% 0. Agonists Selective alpha2 agonists . 0.1% Dose : 1 drop 4 times daily 0.15% 292 Cost : Rs. 30 – 50/Rs. 40 – 50/- DRUGS USED IN MEDICAL MANAGEMENT OF GLAUCOMA Topical Drugs Cholinergic drugs Increase the outflow of aqueous humor Pilocarpine 2%.05%.1% 0. They alter the dynamics of aqueous humour as given below. Oxymetazoline 0. 4% Dose : 1 drop 4 times daily Adrenergic drugs Drugs acting on the adrenergic system are also used in the management of glaucoma.

005% 1 drop at bed time Rs. scopolamine. P/A: Dose : Solution 0. homatropine. cyclopentolate.48 hours. MIOTICS AND CYCLOPLEGIC DRUGS These are commonly used in day to day ophthalmological practice. Reaches high concentration in ciliary epithelium P/ A: Solution 0.5 % Dose : Applied bd. MYDRIATICS. Levobunolol Non selective Beta antagonists. P/A: 0. tropicamide are used as mydriatic and cycloplegic drugs. 293 . Parasympatholytic drugs Atropine.5 % To be used bd.5% Solution applied od. Intraocular pressure starts falling in 30 minutes and action lasts for 24 . 250 – 350/- Prostaglandin analogs Systemic drugs in glaucoma Carbonic anhydrase inhibitor : Acetazolamide P/A: Dose : 250 mg 250 mg od . The initial beneficial effect starts falling in a few weeks. Timolol Non selective beta antagonists. or bd.25 % and 0. A. Carbonic anhydrase inhibitors Dorzolamide solution 2% Dose : Latanoprost Dose : Cost : 1 drop twice daily 0. Betaxolol Selective beta1 antagonist.bid Hyperosmotic agents Intravenous mannitol Dose : 2.Drug used for Glaucoma Antagonists Selective Beta1 Antagonists and non selective Beta Antagonistreduces the formation of aqueous humour.5 – 7 ml/kg body weight of 20% solution IV.

onset of action within 15 min and it last for upto 2 hours. xerostomia. 0. Sympathomimetic drugs Phenylephrine 5-10% eye drops C. I: C/I : A/E : P/A: Refraction testing ciliary spasm. give rest to the muscles.pre and postoperatively. uveitis. Effects occur within 30 min and lasts for 2-3hours. Parasympathomimetic drugs Pilocarpine is used as miotic 4% eye drops. 1 %.Ophthalmological Preparations B. Cyclopentolate Action starts within 30-60 min and it lasts for 12 .6 mg/ mL IM or IV C/I: P/C : A/E : P/A : Homatropine Synthetic alkaloid similar in action to atropine. but weaker and of shorter duration (1 to 2 days). 1 % eye ointment Injection 0. 1% eye drops. Phenylephrine Produces mydriasis without cycloplegia.In them ointment is preferred.5 %.to allay pain. 1%. Visual hallucination. Intraocular surgery . Avoid atropine drops in children due to risk of systemic absorption. fundus examination and fundus photography.5% eye drops Tropicamide Rapid action. incoherence of speech.3 . Atropine sulphate Mydriatic and cycloplegic. 294 . 0. Narrow angle galucoma. iridocyclitis. Narrow angle glaucoma. Contact dermatitis. postoperative state. eye drops. .24 hours. I: P/A: Refraction testing. I: P/A: Refraction testing postoperatively to relieve spasm. allergy. I: Iritis . Drops 0.4 and 0. 2% eye drops. Ointment 1 %. flushing of skin and delirium. prevent synechiae. action lasts for 7-10 days.

chloroquine. digoxin. niacin deficiency. 295 . hypnotics. Bitot’s spots. C /I: New born infants cardiac failure. methyl alcohol.Nutritional Disorders affecting the Eye I: For fundoscopy.ethyl alcohol. P/ A : Solution 5 %.chloramphenicol.amiodarone.m. blindness. isoniazid. riboflavin deficiency.5% Antioxidants ZEBI – D tablets . quinidine Drugs acting on the nervous system . RENERVE tablets: Vitamin E tablets 200mg NUTRITIONAL DISORDERS AFFECTING THE EYE Vitamin A deficiency Night blindness. anticancer drugs Miscellaneous .00. biotin deficiency and Vitamin C deficiency also cause nutritional disorder of the eye. Recommended dose of Vitamin A is 2. 10% OCULAR LUBRICANTS Carboxy methyl cellulose : 0. excess Vitamin A and Vitamin D. xerophthalmia.rifampicin.continuous oxygen in infants. injection.5 – 1% Dose : 1 drop 4 to 6 times daily LOCAL ANAESTHETICS Xylocaine 4% Proparacaine HCl 0. keratomalacia. tranquillizers.000 units daily for 2 days orally once in 6 months. preopertively.Thiamine deficiency. corneal ulceration. tobacco. pyridoxine deficiency. malignant glaucoma. Drugs which are particularly prone to cause ocular toxicity Antibacterials . or 1.00. Vitamin B12 deficiency.000 unit i. antiparkinsonism drugs.anticonvulsants (phenytoin).5% Bupivacaine 0. antidepressants. ethambutol. quinine NSAIDs Cardiovascular drugs . griseofulvin. nalidixic acid.

DRUGS AND PREGNANCY Drugs should be used in pregnancy with caution. Proteins. Fat should include animal fat which contains Vitamins A & D. Fat 40 g Half of the protein should be first class protein containing essential aminoacids. vitamins and minerals. cal 75 g 50 g Non vegetarians substitute pulses with 2 egg / 50 g fish or meat plus 10 g fat. nutritious and rich in proteins. The pregnant women should be advised to have her usual diet with additional provisions of green leafy vegetables. Ideal diet prescribed for antenatal woman National Institute of Nutrition (ICMR) Diet for pregnant women Food stuff Light Work Cereals Pulses Green leafy vegetables Other vegetables Roots and tubes Milk Fat and oil Sugar and jaggery Calories Protein Fat 445 g 55 g 100 g 40 g 50 g 200 mL 20 g 30 g 2200 K. It is better to have snacks in between principal meals. The dietary requirements in pregnancy .55 g.2500 Kcals. cal 70 g 40 g Moderate work 475 g 60 g 100 g 40 g 50 g 250 mL 20 g 30 g 2500 K. Daily diet should generally include 1/2 litre of milk. Certain drugs are absolutely contraindicated in pregnancy.SECTION 24 OBSTETRICS AND GYNAECOLOGY NUTRITIONAL REQUIREMENT IN PREGNANCY Diet in pregnancy should be light. one egg. milk. Total calories — 2200 . digestable. and eggs. fruits. green leafy vegetables and fruits. 296 . Along with this supplementation of minerals and vitamins must be given.

2 weeks after missing menstrual period. Ultrasound examinations . What should be done at each visit? Detailed history about present and past pregnancies. folate antagonists like methotrexate.as early as 6 weeks of pregnancy 3. A general and systemic examination should be done and then a detailed obstetric examination. Drugs to be avoided in 3rd trimester as far as possible Aminoglycosides. anti malignant drugs. lithium.Drugs and Pregnancy Drugs to be avoided in Ist trimester Thalidomide. warfarin.lithium. DOS AND DON’T IN PREGNANCY Confirmation of pregnancy can be done by 1. Aminoglycosides and beta blockers may be used with caution where it is absolutely indicated. androgen and androgen derivatives. phenytoin. Drugs which are possibly teratogenic and better avoided in pregnancy unless absolutely indicated High dose aspirin. 297 .Socioeconomic status of the patient should be assessed. indomethacin. Vaginal examination . Drugs contraindicated in lactation Indomethacin. gravindex test 2. ln the later weeks of pregnancy. Then the pregnant woman should be examined once in every months until 28 weeks.tetracyclines.from 5 weeks onwards. obstetric examination should be made to assess the lie. This is for confirmation of uterine pregnancy and for excluding other pathology like ectopic gestation. quinine derivatives. fluoroquinolones. gaseous general anaesthetics. beta blockers. complicating pregnancy etc. diethyl stilbesterol. past medical and surgical illness. diseases and congenital anomalies in the family should be taken. Urine test : _ a. A vaginal examination should be done for a primigravidae near term to assess cephalopelvic disproportion. norfloxacin. card test — as early as 3 . once in 2 weeks till 36 weeks and thereafter once in aweek. tumors. tetracyclines. Pattern of antenatal visits First visit in the first trimester as early as 1 . presentation and position of the foetus. pregcolor c.5 day after missed period b.

Monitor maternal and foetal cardiovascular status. Oxytocin I: C/I : Induction of labour.20 weeks of gestation. They are used for induction of labour and abortions and also to treat post partum haemorrhage. In grand multipara. A glucose challenge test should be done for all pregnant women in the late 2 nd trimester. If value is 130 or above a glucose tolerance test (GTT) should be done.Obstetrics and Gynaecology Basic investigations to be done This includes Hb estimation. P/C: A/E: P/A: Dose: 298 . Screening of HIV and HBsAg should also be done. adjust the rate of infusion accordingly . previous ceasarian section should be used with great caution. Hypertonic uterine contraction and rupture of uterus can occur if given without adequate supervision foetal hypoxia. postpartum haemorrhage. to detect impaired glucose tolerance and gestational diabetes mellitus (GDM). Injection 5 IU Postpartum hemorrhage/induction of abortion : 5 units diluted in 500 ml. A routine ultra sound scanning examination is advisable for all pregnant women by around 18 . Blood group and Rh. X-ray should not be taken in pregnancy unless absolutely indicated.abortion. Cephalopelvic disproportion. This will help to assess gestational age correctly and also to rule out gross congenital anomalies. Glucose challenge test (GCT) is done by estimating random blood sugar I h after 50 g of oral glucose. But ultra sound examination (USE) is not a substitute for clinical assesment.5-5 IU in 500 mL of 5% dextrose saline or normal saline. OXYTOCICS Oxytocics are drugs which make the uterus contract. uterine inertia. of 5% glucose or saline IV infusion Induction of Labour : It is given as an IV infusion with 2. VDRL and urine for albumin and sugar. Also see the uterine tone.

With ergotamine synergestic effect in control of postpartum haemorrhage. Avoid in hepatic and renal insufficiency.125 mg Injection 0. I: C/I: Therapeutic abortion. Risk of vascular occlusion increased with beta blockers.125mg 10 tablets Rs 46/Inj 0. pregnancy. cardiovascular disease. methysergide. in postpartum bleeding. It is also used as a first line of treatment for atonic PPH. gangrene Tablets 0. This is for reducing 3rd stage haemorrhage and also to hasten placental seperation.Oral contraceptives increases the risk of thrombosis. to reduce lll stage haemorrhage.5mg Methyl ergometrine is used intravenously in the 2nd stage of labour in cephalic presentation as the anterior shoulder of the baby is being delivered. Cardiac.5mg/ mL Oral 0. 299 . 0. Given as IM injection for treatment of PPH.2mg/ml Rs12/- Methyl Ergometrine D/I: Cost: Prostaglandin PGF2 alpha is the drug that is used. Inj 5IU/ml .Erythromycin increases the plasma concentration of ergot alkaloids.25 mg IV 0.Oxytocics D/I: Cost: I: C/l: P/C: A/E: P/A: Dose: The drip is started with a rate of 4 drops per minute and slowly increased until effective contractions are established.2mg. With prostaglandins there is risk of uterine rupture and cervical lacerations. hepatic. where it is given as IV or IM bolus close. pulmonary and renal diseases. to treat atonic PPH. Thrombosis. 0.1ml cost –Rs 15/To hasten placental separation. and smoking. Pressor effect of sympathomimetics may be increased by oxytocin leading to postpartum hypertension. Coronary and peripheral vascular disease. Tablet.2 — 0. induction of labour.

Watch uterine contractions . Methods of Induction can be medical and surgical Medical methods . If there is hypertonic uterine contractions. 3. intensity and interval. Bradycardia or irregularity of foetal heart rate. 4. The dose of the drug can be adjusted. hypertension. 2. 2. 2. diarrhoea. Note: When labour is induced or augmented with oxytocin. How to monitor the patient who is on oxytocin drip? 1. Pregnancy induced hypertension and pre eclampsia. maternal pulse and temperature should be noted. Ensure that uterus relaxes in between contractions. Intra uterine demise of the foetus. Intra uterine growth restriction and foetal compromise — when the continuation of intra uterine life is unfavorable for the foetus. Antiprogestins enhance the efficacy.42/INDUCTION OF LABOUR Labour is induced for various indications : The common indications are 1. vomiting. 3. Side effects are minimal.duration. Infusion should be stopped 1. D/I: Enhanced efficacy of oxytocics leading to uterine rupture. the drip should be continued after delivery. fever. Foetal heart rate. diabetes. If uterus remains tonically contracted. Post dated pregnancy 2.epilepsy.25mcg/min IV given in normal saline PGF2 gel is used for cervical ripening as local application to cervical canal.Obstetrics and Gynaecology Raised intraoccular pressure. 300 P/C: . Tablet 0.the infusion should be stopped. Cheap and easily available.5 mg. A/E: Nausea. 3. 3.several drugs are used Advantages are: 1. Cost: Inj 250mcg/ml Rs 98.5 mg Dose: 0. Maternal tachycardia or fever. The dose should be increased to 10 units/ 500 mL to prevent PPH. P/A: Injection 0.

C/I: Pregnancy. hypersensitivity.100. INDUCTION OF ABORTION (MTP) Upto 12 weeks MIFEPRISTONE Progesterone antagonist I: C/I: P/C: A/E: MTP upto 49 days along with Misoprostol Suspected ectopic. This can be done using a menstrual regulation syringe (Karman’s syringe) 6 — 8 weeks . COPD. nausea.50. lactation P/C: Hypotension. Asthma. IBD. 8 . renal disease. prosthetic heart valve Anorexia. uterine cramps Dose: 600mg single oral dose Cost: Tablet 200mg 1Tab Rs 325/Surgical methods Evacuation upto 6 weeks. Surgical method of induction This is by a low rupture of membranes. But this drug should not be used if there is a history of bronchial asthma.2 stage dialatation using laminaria tent is done.Drugs for Induction of Labour PROSTAGLANDINS Misoprostol (PGE1) Uterine stimulant I: Cervical ripening. Presenting part must be vertex and fixed at the brim of the pelvis. porphyria. loose stools. anticoagulant therapy. 301 .(4Tab) Rs 61/- PGE2 gel (0. abdominal discomfort. P/A: 25. pregnancy.12 weeks. Conditions to be satisfied: Cervix should be partially effaced and at least 1 cm dilated. PPH. It is relatively convenient and effective method of induction of labour.5mg) This is administered intra cervically. lactation. termination of pregnancy less than 49 days.2OO microgram Cost: Tablet 200mcg.Rapid dilatation using metal dialator under para cervical block followed by suction evacuation. Then suction evacuation is done.

ovulation time.premenstrual period and during pregnancy. (5 g) for 7 days. ln the ovulation time the discharge is mucoid and colourless.Can be followed by oxytocin drip.100 mg vaginal tab one tab daily for 7 days. Diagnosis Intense itching and discharge per vagina. This has to be differentiated from vaginal discharge due to infections. Discharge is curdy white and thick. also by contaminated water. Treatment 1. towels etc.100 mg vag vaginal ovules one daily for 7 days Povidone iodine 200 mg ovules one daily for 3 days The pessaries are inserted for 3 — 6 consecutive days. Local vaginal pessaries containing : Nystatin — (100.14 days.000 U) Clotrimazole . The fungus can be demonstrated in the vaginal discharge by preparing a wet smear by adding one drop of saline to a little discharge and examining under the microscope. Hence common in pregnancy where vaginal pH is low.Can be transmitted to the sexual partner. lt acts by mechanical irritation. and not associated with itching or soreness and will not contain any microorganism except Doderleins bacilli. VAGINITIS Abnormal vaginal discharge is a very common symptom in the female.Excessive vaginal secretion is normal in the pre pubertal. Monilial vaginitis Caused by Candida albicans .a fungus which thrive in acidic pH.Obstetrics and Gynaecology 2nd trimester abortion Best method is extra amniotic instillation of ethacridine lactate. Also seen in patients taking antibiotics and steroids. 302 . ‘ Normal vaginal secretion is white in colour.500 mg vaginal tab single dose. odourless. This is a sterile solution of coloured dye. It is introduced into the uterine cavity extra amniotically through a foley’s catheter.1% vaginal cream 5g for 7. Miconazole 2% vag gel. HYPEREMESIS GRAVIDARUM Ondansetron 4mg and 8mg tablet. Also seen in diabetic woman.

also may be given. Contraindications Thromboembolic disorders or history of thromboembolism. Symptoms are intense itching and profuse foul smelling discharge p/v.single dose Ketoconazole .Malignancy should be excluded by a cervical smear (pap . 2% cream at night for 3-7 days.The estrogen is ethinyl oestradiol 20/30 mcg. This is due to oestrogen deficiency. Atrophic vaginitis Occurs in the post menopausal women. avascular headache. atopy. 303 .3 times daily until patient gets symptomatic relief. continued for 21days. The progestogen is either norgestrel or desogestrel. CONTRACEPTIVES Oral contraceptives Combined pills having oestrogen and progestogens (Mala-D. Contraceptives like Depot.(200mg tab)1 tab b. Hypersensitivity Hepato renal . Treatment : Metronidazole is the drug of choice 200 mg thrice daily x 7 days for both partners. lactation.Drugs for Vaginitis 2. Trichomonas vaginitis Caused by the protozoa Trichomonas vaginalis. active liver disease.smear) Treatment : Local oestriol cream is applied 2 .d. Medroxyprogesterone acetate. The fresh packet should be taken exactly on the 7th day. Tinidazole 2 g stat.Gl disease. Tablets should be started from the lst day of periods. cancer of the genital tract or breast. Some OC pill packet have 7 placebo tablets of iron to be taken following the hormone tablets.150 mg . . x 5 days Both partners should be treated. Single dose of 2 g for both partners also can be given. Mala-N) are usually used. pregnancy. Clindamycin vag tab I: C/I: P/C: Dose: Topical treatment of bacterial vaginosis. Injectable contraceptives Usually used once are progesterone only.so the patient need to remember just to take one tablet a day only. Oral : fluconazole .

Human chorionic gonadotrophins which has the LH activity is used for inducing follicular rupture. It is better that these drugs are used in bigger hospitals or infertility centres where there are facilities for monitoring the patients. Oral administration of 2 tablets of combined OC pill (Ethinyl Estradiol and Levonorgestrel) as early as possible with in 72 hours and then repeated after 12 hours. The follicular development should be watched by U. Action . Levonorgestrel (0. Gonadotrophins FSH & LH. 75 .150 IU of HMG is given from 2 nd or 3rd day of period. Ideally patient should be monitored with serial ultrasound examination for evidence of ovulation and number of follicles.10. malignancy of cervix or breast.S.The dose may be increased upto 150mg/ day Complication is hyperstimulation and multiple ovulation resulting in multiple pregnancy.15mg 1 tab) with in 72 hrs of intercourse(iPill) DRUGS USED FOR INDUCTION OF OVULATION Induction of ovulation is needed in treatment of infertility due to anovulation. Post coital insertion of IUCD within 5 days. Human menopausal gonadotrophin which has mainly the FSH activity is used for follicular growth. The usual drugs used are: 1. 4. 2. Mifeprestone 600 mg single dose taken with in 72 hours 3. 304 . Contraindication Active liver disease. Emergency contraception This is advised when the women has an unprotected coitus in the fertile period. When the follicular size reaches 18 mm and oestradiol level is 200mcg.S examination. Clomiphene citrate 2. Cost: Tab 50 mg(10 tab) Rs 55/- Gonadotrophins They are used when the patient fails to ovulate with clomiphene. Methods 1.000 IU for follicular rupture. Clomiphene citrate 50 mg is given from the 3rd or 5th day of periods for 5 days.Obstetrics and Gynaecology Dose: 150 mg given IM once in 3 months. HCG is administered 5000 .like OC pills.

pregnancy. Severe hepatic dysfunction.5—1 g TDS slow IV infusion Menorrhagia: 2. 250-500mg TDS Tab 250mg(10tab) Rs10/- Tranexamic acid Antifibrinolytic I: P/A: Dose: Prevention of excessive bleeding. haemolytic anaemia Active Peptic Ulcer. hepatic dysfunction. Contraception: 0. Hypersensitivity. as an analgesic in muscle joint and soft tissue pain. hypersensitivity.Gl bleed. epilepsy. 500mg tab. hypertension.5 daily when combined with estrogen. lactation Endometriosis: 5-15mg daily continuously for 4-9 months. secondary amenorrhoea:2. cerebral apoplexy. dizziness. 1-1.5-10 mg daily for 5 to 10 days starting on day16 of the cycle. lnj. epigastric discomfort.6mg daily/1-1.50 Menorrhagia.5 g TDS oral O.100mg/ml. Rotor’s syndrome. 5mg 10 tab Rs. hormone dependent carcinoma. renal or cardiac disease. mild to moderate endometriosis:10mg TDS/50mg weekly. rash.Drugs for Dysfunctional Uterine Bleeding DRUGS USED IN DUB (DYSFUNCTIONAL UTERINE BLEEDING) Danazol (Refer Section 18) Mefenamlc acld I: P/A: A/E: C/I P/C: Dose: Cost: Dysmenorrhoea. thrombophlebitis. 250mg. undiagnosed vaginal bleeding.5-10mg daily in a cyclical regimen. hypertension. 500 mg tab. porphyria. Diarrhoea. menorrhagia due to IUCD. hepatic.pregnancy. severe hepatic dysfunction. 305 Norethisterone I: C/l: P/C: Dose: Cost: I: Medroxy progesterone acetate C/I: . porphyria. lBS Bleeding disorder. asthma. Dubin Johnson syndrome.

Monitoring of bloodpressure.Inj 0. weakness. double vision and slurred speech—calcium gluconate injection is used for the management of magnesium toxicity.Obstetrics and Gynaecology P/C: Cost: depression. placenta previa. nausea. eclampsia. Diabetes Mellitus. migraine.5mg(20 tab)Rs 13.epilepsy. angioedema. then 5mg oral 4th hourly Tab 2. Tab – 10mg(10 tab) Rs 44/-.29/- 306 . hyperthyroidism Tab. lactation.5/5.500mcg/ampoule Fine tremor. urticaria 250mcg SC hourly till contraction subsides. inj. palpitation. Magnesium sulfate is also used in women with pre-eclampsia who are at risk of developing eclampsia.sensation of warmth. flushing.0 mg. intrauterine infection. as is monitoring for clinical signs of overdosage (loss of patellar reflexes. asthma. arrhythmia. threatened abortion Pregnancy.2. muscle cramps. respiratory rate and urinary output is carried out. careful monitoring of the patient is necessary.5mg/ml Rs 8. DM. hypertension. tachycardia. renal and cardiac dysfunction. LABETALOL (Refer Section 10) HYDRALAZINE (Refer Section 10) TOCOLYTIC Terbutaline sulphate I: C/I: P/C: P/A: A/E: Dose: Cost: To prevent preterm labour Hypersensitivity.Inj 150mg/30ml(3ml) Rs 60/HYPERTENSION IN PREGNANCY Alpha methyl dopa Alpha methyldopa 250mg BD ECLAMPSIA Magnesium Sulphate has a major role in eclampsia for the prevention of recurrent seizures.62/-. visual disturbances.

pregnancy. galactorrhoea. difficulty with micturition. psychomotor agitation. parkinsonism. depression Antimuscarinic symptoms like dryness of the mouth. tachycardia. impotence and weight gain. Drowsiness. Endocrine effects such as menstrual disturbances.The usual maintenance dose is 75-300 mg od.start initially with 25-50 mg tds. breastfeeding. Injection 25mg/ mL Schizophrenia and other psychoses Oral. hypothermia. Comatosed states. gynaecomastia. 50 mg. apathy. akathisia. cardiovascular symptoms such as hypotension. agranulocytosis and haemolytic anaemia. adjusted according to response.SECTION 25 PSYCHOTHERAPEUTIC DRUGS ANTIPSYCHOTIC DRUGS Chlorpromazine I: Schizoprenia and other psychoses. Elderly. rarely up to 1 g od be required for psychoses. intractable hiccups. 307 C/l: P/C: A/E: P/A: Dose: . Cardiovascular and cerebrovascular disease. respiratory depression. Toxic effects such as leucopenia. 100 mg. pallor. renal and hepatic impairment. mania. hypothyroidism. antiemetic and in terminal illness. jaundice. and angle-closure glaucoma. nightmares. prostatic hypertrophy. one-third to half adult dose. occasionally tardive dyskinesia. constipation. corneal and lens opacities Tablets 10 mg. respiratory disease. and blurring of vision. and arrhythmias. 200 mg. Neuroleptic malignant syndrome. myasthenia gravis. induction of hypothermia. insomnia. leucopenia. bone marrow depression and phaeochromocytoma. leucocytosis. or 75-150 mg at night. extrapyramidal symptoms such as drug induced parkinsonism. short term adjunctive management of anxiety. 25 mg.

25 to 50 mg tds or qds orally or by IM injection . For psychomotor agitation. 25 mg. P/C. 10 mg. Reduced absorption of chlorpromazine with antacids. Same as for chlorpromazine. psychomotor agitation. 4. up to a maximum of 800 mg daily in hospitalized patients. 30-100 mg od Cost: Tab 50 mg(10) Rs. 10 mg. other psychoses and psychomotor agitation. Tablets 1 mg. Start initially with 5 mg bd. anxiolytics and hypnotics enhanced hypotensive effect with anaesthetics and antihypertensives. Dose: Oral: schizophrenia and other psychoses 150-600 mg od initially in divided doses. Enhanced sedative effect with alcohol. Additional side effects include delayed ejaculation. A/E. excitement and violent behavior 75-200 mg od Anxiety. and agitation in the elderly. 50 mg and 100 mg. A/E. psychomotor agitation.00 Trifluoperazine Hydrochloride I: C/l. 30. 1. anxiety. 5 mg. C / I.70-5. antiemetic. D/I: P/A: Dose: Cost: I: Thioridazine Hydrochloride Schizophrenia and other psychoses. Tab 25 mg (10) Rs. anxiety. Tab 5 mg (10) Rs.70 Inj 25 mg/mL (2 mL) Rs. 4. pigmentary retinopathy and lenticular opacity if dose is more than 800 mg/ day.50-6.Psychotherapeutic Drugs D/I: Cost: Intractable hiccup .50 308 . or 10 mg od in modified release form and increase by 5 mg after 1 week according to the response to a maximum of 20 mg/ day in divided doses. Schizophrenia. Antagonism of antipsychotic effect with dopaminergics.20 Schizophrenia and other psychoses. D/ I: Same as for chlorpromazine.50-37. P/C.20 -21. P/A: Tablets 5 mg.

mania. short term adjunctive management of psychomotor agitation.00 . adjusted according to response to 20 mg od.. (1 mL) Rs. Tablet 1 mg. Parenteral: 25 mg as deep IM injection once in 2 .00 .00 lnj 12. doses above 20 mg (10 mg in elderly) should be given cautiously. Tablets 5 mg. Inj 25 mg/ml. mania.5 mg/mL. agitation and excitement Oral: initially 1 mg bd.5 -10 mg od in 2-3 divided doses. vertigo. P/C. 40. A/E.d. mania. excitement and violent.90 Schizophrenia and other psychoses. severe anxiety.5 mg.5 mg bd for 7 days and adjust at intervals of 4-7 days to reach the usual dose of 75-100 mg od according to response. D/I: P/A: Dose: Cost : Prochlorperazine I: C/I. labyrinthine disorders.00 Schizophrenia and other psychoses. D/l: P/A: Dose: Oral: Cost: Haloperidol I: . 309 C/l. 2. vomiting. Schizophrenia and other psychoses Oral : 2.s. Same as for chlorpromazine.4 weeks. Injection 25 mg /mL contain oily solution of fluphenazine decanoate for depot use. 5 mg.5 mg/mL (10 mL) Rs. Anxiety. dangerously impulsive behaviour. Anxiety: 15 to 20 mg od in divided doses upto a maximum of 40 mg. Labyrinthine disorders: 5 mg t. A/E. 25mg Injection 12. nausea.Antipsychotic Drugs Fluphenazine Hydrochloride I: Schizhophrenia and other psychoses. gradually increased upto 30 mg od and then reduced after several weeks to the maintenance dose of 5-10 mg od Tab 5 mg (10) Rs. 26. Same as for chlorpromazine. Parenteral: IM 12. short term adjunctive management of severe anxiety.9. 8.43. Schizophrenia and other psychosis Mania: start with 12.90-29. P/C. psychomotor agitation.5 mg initially and followed if necessary after 6 hours an oral dose. increased as necessary to 2 mg bd.

Hiccup 1. Motor tics and adjunctive treatment of chorea .5 mg (10) Rs. 4. adjusted according to response.5 -3 mg bd or tds or 3-5 mg bd or tds in severely affected or resistant patients.5-2 mg. Parenteral 2mg by IM injection.Psychotherapeutic Drugs excitement and violent or dangerously impulsive behaviour. Same as for chlorpromazine.60-12. 3mg Injection 20 mg/ 1mL. Dose: Schizophrenia and other psychoses. 1 mg. 40 mg/ 2mL.5-1. 5 mg. Elderly - C/I. P /C. . 20 mg. Elderly initially half adult dose. adjusted according to the response upto a maximum of 18 mg od. A/ E.5 mg bd. C / I.5 mg. In resistant schizophrenia up to 100mg (rarely upto 120 mg) od may be needed.75-4. intractable hiccup.5 mg tds. Adolescents upto 30 mg od. D/I:Same as for chlorpormazine hydrochloride.20 Inj 5 mg/mL (1 mL) Rs. Syrup 2 mg/ mL. D/I: P/A: Dose: 310 .motor tics.5 mg. depression. A/E.orally. Maintenance dose is adjusted as the lowest effective dose which may be as low as 5-10 mg od.90 Flupenthixol I: Schizophrenia and other psychoses.adults 0. Tablets 0. 0. severe anxiety. Drops 10 mg/ mL . subsequent doses being given every 4-8 h according to response upto a total maximum of 60 mg. Upto 10 mg od. adjusted according to the response.5 mg tds. 10 mg/ mL.25 mg.Nausea and vomiting 0. 10 mg.d. Depot Injection 50 mg/ mL as decanoate. or more may be needed. Psychoses: Initially 3-9 mg b. Severely disturbed patients may require initial dose of upto 30 mg. Anxiety . exceptionally upto 60 mg. 6. Cost : Tab 1. 1 mg. P/C. Injection 5mg/ 1 mL. 1. particularly with apathy and withdrawal but not mania or psychomotor hyperactivity. P/A: Tablets 0. Oral : Start initially with 1. 2-10 mg.

P/C.d. Depression: Initially 1 mg in the morning. 4 mg. paranoid psychoses.00 Inj 40 mg (2 mL) Rs.Elderly 0.00 — 77. 28. increased after 1 week to 2 mg if necessary to maximum 3 mg o. It is contraindicated in breast feeding.. Loxapine I: C/I. The usual maintenance dose of 20. Monosymptomatic hypochondriacal psychoses and paranoid psychoses. 73. but less sedating.100 mg od Caps 50 mg (6) Rs. Dose: Schizophrenia. D/I: P/A: Dose: Cost : Pimozide Schizophrenia.4 mg at intervals of 1 week or more upto a maximum of 20 mg od For prevention of relapse the maintenance dose may vary from 2-20 mg/day. 20-40 mg deep IM as depot injection every 2-4 weeks. doses above 2 mg are divided into 2 portions. and adjust according to response with increments of 311 I: . Oral initially 20-50 mg od in 2 divided doses. mania.m..00 Acute and chronic psychoses Same as for chlorpromazine hydrochloride Capsules 10 mg. D/I: Same as for chlorpromazine.d. start with half the adult dose. P/C. 50 mg. 25 mg. A/E.5 mg to 2 mg/ day Parenteral dose: Schizophrenia and other psychoses. Start initially with 2 mg od. Discontinue if no response after 1 week at maximum dosage. increased as necessary over 7-10 days to 60-100 mg od upto a maximum of 250 mg in 2-4 divided doses. Oral : Initially 10 mg o. A/E. Serious cardiac arrhythmias may occur and therefore ECG has to be taken before treatment in all patients and repeated during the course. monosymptomatic hypochondriacal psychoses. P/A: Tablets 2mg. 10 mg.Antipsychotic Drugs Cost: start initially with quarter to half adult dose. 147. For elderly. adjusted according to response with increments of 2 .00. second dose not after 4 p. Tab 1 mg (10) Rs. C/1.

Mania. bone marrow disorders. hypomania. then fortnightly. skin rashes and convulsions (if dosage is above 800 mg/ day). prostatic enlargement. history of circulatory collapse or paralytic ileus. short-term adjunctive management of excitement and psychomotor agitation. uncontrolled epilepsy. hypotension. sialorrhea. extrapyramidal symptoms may occur less frequently. Tablets 25 mg. cardiovascular disorders.feeding. dizziness. glaucoma.Psychotherapeutic Drugs Cost: 2 . Patients should report any infections. delirium. then 25-50 mg on second day. urinary incontinence. Avoid abrupt withdrawal. then increase gradually in steps of 25-50 mg over 7-14 days to 300 mg od in divided doses. history of drug-induced neutropenia or agranulocytosis. neutropenia and potentially fatal agranulocytosis. High incidence of antimuscarinic symptoms. Avoid drugs which depress leucopoiesis.00 . myocarditis. Severe cardiac disease. drug intoxication.30. alcoholic and toxic psychoses. or intolerant of conventional antipsychotic drugs. Tab 2 mg (10) Rs. pericarditis. headache.4 mg at intervals of 1 week or more upto a maximum of 16 mg od Elderly. fever.00 Schizophrenia in patients unresponsive to.5 mg od or bd on first day. avoid in children. 100 mg Start 12. Larger Clozapine I: C /I: P/C: A/E: P/A: Dose: 312 . half usual starting dose. pregnancy and breast. hepatic or renal impairment. coma or severe CNS depression. paralytic ileus. epilepsy. withdraw treatment if leucocyte count falls below 3000/ mm3 or absolute neutrophil count falls below 1500/ mm 3. 12. priapism. Start initially 2-4 mg od and adjust according to response with increments of 2-4 mg at intervals of 1 week or more upto a maximum of 20 mg od. Leucocyte and differential blood counts must be normal before treatment and must be monitored weekly for first 18 weeks.

and increased to 4 mg on second day.90-19. previously detected breast cancer. Tab 100 mg (10) Rs. chloramphenicol. akathisia. hyperprolactinemia.5 mg once on first day subsequent adjustments restricted to 25 mg od. conditions which predispose to hypotension.80-52. agitation. impaired motor activity. cerebro-vascular disease.5 mg bd. For children under 15 years not recommended. Tablets: 1mg. . P/C. Tab 2 mg (10) 12.acute mania/ mixed mania and depression Hypersensitivity Myocardial infarction. somnolence. 313 Risperidone I: C/I. hepatic impairment. 0. Usual antipsychotic dose 200-450 mg od upto a maximum of 900 mg od Subsequent maintenance dose of 150-300 mg. A/E. elderly. 19. Clozapine cause agranulocytosis when used concurrently with drugs associated with a substantial potential for causing agranulocytosis. conduction abnormalities. personality disorders. tremor. therapeutic and prophylactic for bipolar disorder.10 Acute and chronic psychoses. such as cotrimoxazole. 6 mg in 1-2 divided doses on third day upto the usual range of 4-8 mg od Upto 16 mg od may be given exceptionally only if benefit is considered to outweigh the risk. sulphonamides. increased in increments of 0. seizure. Same as for chlorpromazine. Elderly. D/I: P/ A: Dose: Cost : Olanzapine I: C/I: P/C: A/E: . 4 mg Liquid 1 mg / mL Oral : 2 mg in 1-2 divided doses on first day. 2 mg. Elderly. constipation. 3 mg.50 Schizophrenia.Antipsychotic Drugs D/ I : Cost : dose upto 200 mg od may be taken as a single dose at hs Further increased in steps of 50-100 mg once or twice weekly may be required.5 mg bd to 1-2 mg bd. dizziness. penicillamine. pituitary tumours Postural hypotension. ischemia. 12. weight gain. cytotoxics or carbamazepine. heart failure.

acute mania Patients below 18 yrs Renal or hepatic impairment.00 7. uncompensated heart failure.00 5mg (10) Rs. hypotension Hyperglycemia. 17.89. cardiovascular or cerebro-vascular disease.47. Increase by 25-50 mg twice daily. 12. 100mg. history of seizures. Increase by 5mg/ week until desired a maximum dose of 20 mg/day is reached. 24.50mg. congenital long QT syndrome. Concomitant diuretic treatment.20. 47. pregnancy and lactation. 300mg Sustained Release preparation. Rarely.5 mg (10) Rs. significant cardiovascular illness. delaying relapse in schizophrenia. 200mg 50.20 mg/ day.00 Schizophrenia. It should be corrected before treatment. each vial contains 10mg 5. 100mg. 5mg.75 10 mg (10) Rs. Quetiapine I: C/I: P/C: A/E: P/A: Dose: Cost: Ziprasidone I: C/I: P/C: 314 . 40. sedation.800mg/ day Tabs 25mg (10) Rs.00 Schizophrenia. seizures 25mg. 7. acute mania or mixed mania Recent acute MI.00 . Initially 5. conditions that may increase QT interval or history of QT prolongation.5 mg (10) Rs. epilepsy. 35.00 .Psychotherapeutic Drugs P/A: Dose: Cost: Tablets 2. Maximum dose. dizziness. pituitary tumours. hepatic impairment.00 . Initially 25 mg twice daily.5 mg and 10 mg Injection 5mg/ml.800 mg/day.00 100mg (10) Rs. cerebro-vascular disease. 200mg. arrhythmias treated with class i & iii antiarrhythmic drugs Patients predisposed to significant electrolyte disturbances especially hypokalemia should have baseline serum K+ and serum Mg2+.10 mg once daily. Neuroleptic Malignant Syndrome (NMS).5 mg. Tabs 2. acute agitation in schizophrenia. 78.00 200mg(10) Rs. 50mg. concomitant use with other drugs known to increase QT interval. weight gain.

110.00 Tablet 40 mg (10) Rs. 175.50mg/ 1mL Depot injection. Maximum approved dose 100 mg twice daily.200mg I/M once in 2-4 weeks Tabs 25mg(10)Rs. dystonia. Initial dose 20 mg twice daily.00 Injection .25mg Initially 10-15 mg/ day in divided doses. Avoid alcohol. aggression Hypersensitivity.20 mg. 60 mg and 80 mg 40. GI disturbances. Prophylaxis of migraine 315 . Somnolence.100mg. Maximum dose. 94. akathisia.50 Tablet 80 mg (10) Rs. 32. diabetes mellitus Drowsiness.00 Depot injection 1ml vial Rs. bipolar disorder. Nocturnal enuresis in children. comatose state. extrapyramidal symptoms.1ml vial Rs.00 2ml vial Rs. dizziness. 63. 125. May impair ability to drive or operate machinery. 40 mg. maculopapular rash. Increase by 10-20 mg/day every 2-3 days. 150. tardive dyskinesia Injection.00 Zuclopenthixol I: C/I: P/C: A/E: P/A: Dose: Cost: ANTIDEPRESSANTS Amitriptyline I: Depressive illness particularly where sedation is required.200mg/ 1mL Tablets.00 Tablet 60 mg (10) Rs.200 mg/ day. extra pyramidal syndrome. headache. asthenia. blood dyscrasias and phaeochromocytomas Pregnancy. 70. agitation.100 mg/ day Injection. hypertonia. less elevated SGPT. Tablet 20 mg (10) Rs. rhinitis. circulatory collapse. CNS depression. CNS disturbances.Initial dose. musculoskeletal complaints. if persistent QTc measurements of >500msec.Antipsychotic Drugs A/E: P/A: Dose: Cost: Discontinue. visual disturbances. urticaria.50 Schizophrenia. urinary incontinence. Tablets.

to be increased gradually if necessary up to 100 mg. psychoses. CNS excitation and hypertension with MAOIs. For migraine prophylaxis initially 10 mg as a single bedtime dose. gynaecomastia. severe liver disease. nausea. history of urinary retention. Oral: Start initially with 25 mg daily and increase gradually to a maximum of 150 mg either as single dose hs or in divided doses. interference with sexual function. Abrupt withdrawal should be avoided.Psychotherapeutic Drugs C/I: P/C : A/E: P/A: Dose : D/I : Recent myocardial infarction. hypotensive effect enhanced with antihypertensives. constipation. It should be used with caution in subjects requiring anaesthesia. hypomania. arrythmias particularly heart block. 25 mg. fever. increased sedative effect with antihistaminics. sedation. For the elderly and adolescents the average dose is smaller (30. postural hypotension. Nocturnal enuresis. Cardiac disease. agranulocytosis and jaundice.75 mg/ day). cardiovascular side effects such as arrhythmias. tachycardia. The usual maintenance dose is 50-100 mg od. 75 mg. Enhanced sedative effect with alcohol.elderly subjects. neurological features such as tremors. The effects of alcohol are enhanced. phaeochromocytoma. galactorrhoea. confusion. pregnancy and breast feeding.manic phase of depression. history of mania. urinary retention. hypersensitivity reactions including urticaria and photosensitivity. Drowsiness may affect skilled tasks such as driving and handling of machinery during work. mania. hepatic impairment. movement disorders and dyskinesias. increased appetite and weight gain. angle-closure glaucoma. history of epilepsy. antagonism of antidepressant effect with antiepileptics. blurred vision. 316 . 50 mg . Dry mouth. convulsions. endocrine sideeffects such as testicular enlargement. Tablet 10 mg.

Upto 150 mg may be given as a single dose hs The usual maintenance dose is 50-100 mg od.00 Imipramine I: Depressive illness. Not recommended for children. Nocturnal enuresis : For children below 12 years 25 mg. 21. Nocturnal enuresis For children upto7 years.00 . P/ A: Tablet 25 mg and 75 mg.28. nocturnal enuresis in children C/ I. P /C. oral contraceptives antagonise antidepressant effect. Capsule 25 mg and 75 mg. Tablet 25 mg Depressive illness: Start with low dose initially and increase as is necessary to 75 .D/I: P/ A: Dose: Depressive illness.Antidepressants Cost : reduction of effect of sublingual nitrates. 25-50 mg over 11 years. potentiation of hypertension and arrhythmias with adrenaline. even upto 300 mg in hospitalized patients. The maximum period of treatment including gradual withdrawal should not exceed 3 months.00 .00 Nortriptyline I: C/I:.00-11.100 mg od in divided doses or as a single dose.11 years. 50-75 mg single dose given hs. over 12 years 50 mg hs. For the elderly.P/C:. D/ I: Similar to amitriptyline hydrochloride. Cost : Tab 25 mg (10) Rs.7. but the drug is less sedative. start initially with 10 mg od and increase gradually to 30-50 mg od. A/E.00 317 Cost : .A/E:. nocturnal enuresis in children Similar to amitriptyline hydrochloride but less sedating. The maximum period of treatment including gradual withdrawal should not exceed 3 months. Tab 25 mg(10) Rs 10. Dose: Depressive illness: Start with upto 25 mg daily and increased gradually upto 150-200 mg. 5.00 Caps 75 mg (10) Rs. 25 mg. 8. 8 . For adolescent and elderly 30-50 mg od in divided doses. Tab 10 mg (10) Rs.

D/I: Similar to amitriptyline. 29. P/A: Tablet 50 mg and 100 mg Dose: Initially 100-150 mg od in divided doses or as a single dose at hs. 318 I: . phobic and obsessional states. C/I .00 I: Dothiepin Depressive illness particularly where sedation is required C/I .00 . 27. A/E . D/I : Same as for amitriptyline hydrochloride P/A: Tablets 10 mg. P/C. For the elderly the dose is initially 25 mg bd increased as is necessary after 5-7 days to a maximum of 50 mg tds.00 Tab 25 mg (10) Rs.30. For the elderly start with 10 mg od and increase over 2 weeks to 100-150 mg od For adjunctive treatment of cataplesy associated with narcolepsy. P/C . Cost : Cap 25 mg (10) Rs. A/E.menstrual irregularities. For the elderly 75 mg may be sufficient.35. Additional side effects include tardive dyskinesia. and even up to 225 mg daily at times.00 Clomipramine Depressive illness.00 . increased gradually to a maximum of 300 mg od The usual maintenance dose is 150-250 mg. 25 mg and 50 mg. adjunctive treatment of cataplexy associated with narcolepsy. akathesia. start with 10 mg od and gradually increase to 10. A/E. breast enlargement and galactorrhoea. D/I: Same as for amitriptyline hydrochloride P/A: Tablet 25 mg and 75 mg.d. Dose: Initially 10 mg od. Cost : Tab 50 mg(10) Rs.Psychotherapeutic Drugs Amoxapine I: Depressive illness C / I. increased gradually as necessary to 30-150 mg od in divided doses or as a single dose at hs upto a maximum of 250 mg od The usual maintenance dose is 30-50 mg o.75 mg/day until satisfactory response is obtained . Capsules 25 mg Dose: Initially 25 mg daily increased gradually as necessary to 150 mg daily. 38. Capsule 10 mg and 25 mg. P/ C.

lactation. Use with caution in patients with seizures and diabetes. and increase as necessary to maximum of 300 mg od. A/E. 14.Antidepressants Doxepin Depressive illness. dry mouth and constipation with other antidepressants. Pregnancy.P/C. Hypersensitivity. 35. Dose: Start with 30 mg od or in divided doses or as a single dose hs. Increased sedation with other drugs having sedative effect on central nervous system. 25 mg and 75 mg. nervousness. P/A: Capsule 10 mg. sexual dysfunction. nausea. Insomnia. P/C. Produces sedation. Capsule 20 mg. anxiety disorders. Cap 20 mg (10) Rs. pregnancy. OCD . hepatic or renal impairment.30. anorexia.20 mg/ day. This drug should be avoided during breast feeding. seizures in high doses. The usual range is 30-300 mg od In the majority 30-50 mg od may be adequate. Tablet 50 mg 319 P/A: Dose : D/I : Cost: Sertraline I. diarrhoea. Cost : Cap 25 mg (10) Rs.00 I: Fluoxetine: I: C/I : P/C : A/E : Depression. 15. panic disorders. particularly where sedation is required. anxiety. C/I .60 mg/day. seizure disorders. Suspension 20 mg/ 5 mL Depression . D/I: Similar to amitriptyline hydrochloride. history of drug abuse. lactation. For the elderly initial dose is 10-50 mg od This drug is not recommended for children.00 Same as for fluoxetine. in 3 divided doses of 100 mg each. Produces agitation. Produces changes in serum lithium level. headache. D/I: C/I: P/A: .00-29. A/E.50 . restlessness and gastric distress with tryptophan. obsessive compulsive disorder (OCD).00 Susp 20 mg/5 mL (60 mL) Rs.

panic disorder. bleeding disorders. increase 10mg/week to a maximum dose of 40 mg GAD. 140. thioridazine.00.00. concomitant use of pimozide. hepatic or renal insufficiency Same as for fluoxetine Tablet 50mg and 100mg Tablet 50.Psychotherapeutic Drugs Dose : Cost : 100 . Maximum dose.20. concomitant use of MAOI Same as for fluoxetine Tablets.Initially 20mg once daily. patients below 18 yrs.00 Depressive disorder. concomitant use of thioridazine or pimozide.traumatic Stress Disorder (PTSD) Pregnancy. Obsessive Compulsive Disorder (OCD) Lactation.20 mg once daily OCD.Usually 100-300 mg/day 50mg (10) Rs.20 mg/day Social phobia. patients below 18yrs.10mg. MAOI or within 2 weeks of stopping MAOI or 1 day of stopping Moclobemide Pregnancy.40mg/day PTSD.00 Fluvoxamine I: C/I: P/C: A/E and D/I: P/A: Dose: Cost: Tab Paroxetine I: C/I: P/C.110. social phobia. Usually maintenance dose -100mg/ day. history of seizures or diabetes mellitus or mania/ hypomania.300 mg/day OCD. 70.00 Tab 30mg (10) Rs.150 mg/day.330 mg/day Depression. Tab 50 mg (10) Rs. A/E and D/I: P/A: Dose: Cost: 320 . 30mg and 40 mg Depression. OCD. Generalized Anxiety Disorder (GAD).195.00 Depressive disorder.00 Tab 40mg (10) Rs.20 mg/day Tab 10mg (10) Rs. 35. 170.00 Tab 100mg (10) Rs. 150.Initially 50 or 100 mg as a single dose. 85. Post.

00 Tab 40mg (10) Rs. once in every 4 days to a maximum of 375 mg/day Serotonergic drugs increase the risk for serotonin syndrome. Steven Johnson’s syndrome. glaucoma Nausea. 99. 20mg and 40 mg 20-60 mg/day. 10mg. anxiety disorder Pregnancy. bleeding tendencies. liver dysfunction.50 Tab 20mg (10) Rs. concomitant use of MAOI. lactation. Initially 37. increase by 75 mg/day. sexual dysfunction. A/E and D/I: C/I and P/C: P/A: Dose: Same as for fluoxetine Same as for fluvoxamine Tablets-10mg. 29.00 Same as for fluoxetine Same as for fluvoxamine Tablets 5mg.Antidepressants Citalopram I. coronary artery disease. uncontrolled hypertension. Increase by 10 mg every 2-3 weeks. 55. 15mg and 20 mg 10-20 mg/day.37. increase to 75mg twice daily after 2 weeks.5 mg. 37.50 Depression. 321 Cost: Escitalopram I. insomnia.00 Tab 20mg (10) Rs. 75mg and 150mg 75-375 mg/day. patients below 18 yrs Renal or hepatic impairment. Maximum dose. somnolence. Generalized Anxiety Disorder.20mg/day Tab 5mg (10) Rs. Social Phobia.00 Tab 10mg (10) Rs. headache. mania/ hypomania. If needed. Toxic Epidermal Necrolysis.25mg. Maximum dose60 mg/day Tab 10mg (10) Rs.5mg. 99. 49. A/E and D/I: C/I and P/C: P/A: Dose: Cost: Venlafaxine I: C/I: P/C: A/E: P/A: Dose: D/I: .5 mg twice daily. seizure disorder. serotonin syndrome Capsules. elevated BP. Initially 10-20 mg/day for 1 week. G-I upset. 7. 30.5mg and 75mg Extended release capsules.

50. shivering.00. pregnancy and lactation Advanced renal disease.00-100.00 Depression Pregnancy. chronic pain Hypersensitivity. lithium.00 I: Milnacipran I: C/I: P/C: A/E: P/A: Dose: Depression. lactation.30.Psychotherapeutic Drugs Cost: Cap 25mg (10) Rs.60.00 Cap 37.00 Extended release cap-75mg (10) Rs.00 Cap 75mg (10) Rs. epinephrine and digitalis Cap 25mg (10) Rs. hypertension. delirium Capsules 25mg and 50mg Capsule 50.50. patients below 15 yrs. 12. heart disease. prostatic hypertrophy. increase to 60 mg/day Cost: Cap 20mg (10) Rs. concomitant use with or within 14 day of use of MAOI D/I: Cost: Mirtazapine I: C/I: 322 .00 Cap 50mg (10) Rs. stress urinary incontinence C/I. Initially 20mg twice daily. 65.100 mg/day. 75.00 Extended release cap-37. P/C. nausea.00 Duloxetine Depression. elevation of liver enzymes.5mg (10) Rs. increased activity. then increase to maximum dose of 100mg/day With MAOI. Initially 50 mg/day orally as single dose. 40. 35.5mg (10) Rs.00 Cap 30mg (10) Rs. vertigo. 38. A/E and D/I: Same as for Venlafaxine P/A: Capsules 20mg and 30 mg Dose: 60 mg/day. concomitant use of MAOI. 80.00.80. neuropathic pain associated with diabetes mellitus. 20. clonidine. open angle glaucoma Itching. sweats. 18. dysuria.00.00 Extended release cap-150mg (10) Rs. 44.

agranulocytosis Tablets. 4mg twice daily. headache. sexual dysfunction.00 Tab 4mg (10) Rs. glaucoma. organic brain syndrome. lithium. concomitant use of SSRIs & TCAs. antihypertensives Tab 2mg (10) Rs. nausea. lactation. 60. social phobia. headache. Tablets 2mg and 4mg 4-12 mg/day. epilepsy. 310. cardiac and cerebro vascular disease. hypertension especially in elderly. Initially 15mg once per day at night.15mg and 30mg Tab 15-45 mg/day.00 Depression. narrow angle glaucoma Renal or hepatic impairment. 165. constipation. nausea. psychosis Increased appetite. bone marrow depression. Initially. taste perversion. weight gain. antipsychotics. angina. asthenia. somnolence. sweats. Increase 15 mg/day once in every 5 days to a maximum dose of 60 mg/day Potentiates the effect of CNS depressants Tab 15mg (10) Rs. chills. dizziness. epilepsy.Antidepressants P/C: A/E: P/A: Dose: D/I: Cost: Renal or hepatic impairment.00 Depression Pregnancy. hyperthyroidism Dry mouth. Increase after 3-4 weeks to 10 mg daily or to a maximum of 12 mg/day With MAOI. phaeochromocytoma 323 Reboxetine I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Moclobemide I: C/I: . panic disorder Acute confusional states. mania.00 Tab 30mg (10) Rs. 115. flu syndrome. cardiac conduction disturbances. fluvoxamine. dizziness. insomnia. carbamazepine. urinary retention. constipation. drowsiness.

MAOI. tremor. 5HT reuptake inhibitor. vomiting.150mg and 300mg 300-600 mg/day. headache.150 mg 150.450 mg/day. thyrotoxicosis.Psychotherapeutic Drugs P/C: A/E: P/A: Dose: D/I: Cost: Severe hepatic dysfunction. hepatic or renal impairment Insomnia.00 Depression. rash. smoking cessation. antihistamines Tab 150mg (10) Rs. hypoactive sexual desire disorder Seizure disorder. 324 . antihypertensives. Tab 150mg (10) Rs. hypertension. Increase to 1 tab twice daily with 8 h between doses Antipsychotics. metoprolol. SSRIs.50 Tab 300mg (10) Rs. bulimia nervosa. bipolar disorder. aggressive or self—mutilating behavior. unstable angina. hypertension. diarrhoea and constipation Tablets. 125. sympathomimetics. 67. pregnancy and lactation Sleep disturbances. trazodone. Initially 300 mg/day in 2 or 3 divided doses. paraesthesias. theophyllines. dizziness. antimalarials. Attention Deficit Hyperactivity Disorder (ADHD). 400. alcohol/ benzodiazepine withdrawal. GI upset.00 MOOD STABILISERS Bupropion I: C/I: P/C: A/E: P/A: Dose: D/I: Cost: Lithium I: Treatment and prophylaxis of mania and manicdepressive illness and recurrent depression. anorexia nervosa. Increase after several weeks to 600 mg/day Avoid TCAs. tachycardia. cocaine detoxification. Initially 1 tab daily for 6 days. headache. risk of seizures Tablets. restlessness. nausea. irritability. dry mouth. hypertension (avoid excessive tyramine rich food. agitation. CNS tumour. pregnancy and lactation History of seizures. nausea.

adjunct in alcohol withdrawal. confusion and ataxia. Maintenance level should aim at 0. 600-800 mg / day in divided doses till a blood level of 1-1. Gastro-intestinal disturbances. vomiting and diarrhoea. Zonisamide. fine tremor. paradoxical increase in aggression.55 mEq/L is achieved.00 -13. amnesia. Signs of lithium intoxication are blurred vision. Sodium Valproate. hepatic and renal impairment. surgery. hyperthyroidism. myasthenia gravis. anorexia. hypokalaemia. Lithium toxicity is made worse by sodium depletion therefore concurrent use of diuretics particularly thiazides is hazardous and should be avoided. Lamotrigine. status epilepticus and febrile convulsion.00 Carbamazepine. With severe overdose convulsions. caution in pregnancy. sicksinus syndrome. dependence. ANXIOLYTICS Diazepam I: Short-term use in anxiety or insomnia. myasthenia gravis. Levetiracetam. pregnancy and lactation. breastfeeding. Drowsiness. Levels above 1. disturbed electrolyte balance.5 mEq/ L are dangerous. Avoid in renal impairment. coma and occasionally death may occur. Serum levels should be maintained during treatment at this level. toxic psychoses. 300 mg.Anxiolytics C/I: P/C: A/E: P/A: Dose: D/l: Cost: Other drugs Renal failure and cardiac failure. 450 mg. cardiac failure. major surgery. polyuria and polydipsia. and oedema. severe hepatic impairment. Respiratory disease. and Addison’s disease. Capsule 300 mg. 325 C/I: P/C: A/E: . Respiratory depression. Tab 300 mg (10) Rs. 11. muscle weakness.7-1 mEq/L.CNS disturbances and these require withdrawal of treatment. pregnancy and breast feeding. Tablets 150 mg. acute respiratory failure.

00. 10 mg Capsule 2mg. Same as for diazepam.slow IV injection into a large vein at a rate of not more than 5 mg/ min. A/E. Rectal — for acute anxiety and agitation. D/I: P/A: Dose: 326 . 1-5 mg hs Parenteral . If necessary a further 10mg may be given after at least 10 min. Isoniazid.v.2 mg tds increased if necessary to 15-30 mg od in divided doses. 5mg. Injection (IM) canbe given but absorption from the site is erratic and the are unpredictable. 12. injection or as infusion. Injection (emulsion) 5mg/ mL for i.5 mg.13. I mg Sustained Release (SR) 1.00 Cap10 mg (10) Rs. 14.00 Inj 5 mg/mL ( 2 mL) Rs. Elderly half the adult dose. For elderly half adult dose.5 mg tds. Elderly 250 mcg bd — tds. control of acute panic attacks. P/C. 10 mg may be repeated.25-0.00 — 15. A/E: P/A: Dose: D/I: Cost: Chlordiazepoxide I: C/I.. 4.Psychotherapeutic Drugs P/A: Dose: D / I: Cost : Tablets 2mg. 0.5 mg (10) Rs. and acute alcohol withdrawal.5 mg 0. 10 mg. elderly 5 mg. Insomnia associated with anxiety 5-15 mg hs. increased if necessary to a total of 3 mg Same as for diazepam Tab 0.00 For short term use in anxiety. Adjunct in acute alcohol withdrawal symptoms. omeprazole and disulfiram inhibit metabolism of diazepam and other benzodiazepines. Tablets 10 mg and 25 mg Anxiety 10 mg tds increased if necessary to 60-100 mg od in divided doses.00 — 24. Benzodiazepines antagonise the effect of levodopa. 10. as rectal solution or suppositories 10 mg. Tablets 0.00 For the short term management of anxiety states. Same as diazepam. Alprazolam I: C/I. if necessary after 4 h. 5 mg. for the management of severe acute anxiety. Children with night terrors and somnabulism.25 mg. Tab 10 mg (10) Rs. Anxiety Oral . P/C. Injection 5mg/ mL.

7. Dose: Tablets 1 mg. tachycardia and confusion. 15-30 mg Elderly 10-20 mg tds or qds.00-30. pregnancy and breast-feeding. repeated every 6 h if necessary. Tablet 5mg and 10 mg. Elderly start at 1-2 mg/ day in divided doses. dizziness. headache. dose is 20-30 mcg/ kg. P/C. This is indicated in acute panic attacks. D/I: P/A: Dose: Short term use in anxiety As for diazepam. Insomnia associated with anxiety 15-25 mg.gradually reducing over 7-14 days. IM or IV injection into a large vein. I: C/I. 9. 9. Tab 15 mg(10) Rs.excitement.. Injection 2mg/ mL Oral : anxiety 1-6 mg od in divided doses.00 — 8. P/A.00 Anxiety Epilepsy.50 mg qds.00 — 18. Tab 1 mg (10) Rs. 30 mg Anxiety. severe hepatic or renal impairment.Anxiolytics Cost : Adjunct in acute alcohol withdrawal symptom: 10. Presence of hepatic or renal impairment Nausea. ‘ Tablets 15 mg. D/I . A/E. A/E. Tab 25 mg (10) Rs. 327 Cost : Buspirone I: C/I: P/C: A/E: P/A: . Insomnia associated with anxiety 1to 2 mg hs Parenteral .00 Lorazepam Short term use in anxiety or insomnia.00 Inj 2 mg/mL (2 mL) Rs. upto a maximum of 50 mg hs. Status epilepticus C/I.00 I: Cost : Oxazepam This is a short acting drug with a half life of 6-10 hrs compared to diazepam which has a half life of 60 h. P/C. Same as for diazepam. 2 mg. short acting. 5. nervousness.

Elderly 15 mg. headache. D/I: P/A: Dose: Cost : Zopiclone I: C/I : P/C: A/E: P/A: 328 .75 mg hs increased if necessary. Bitter or metallic taste. hepatic and renal impairment.d. Dose : 7. 25.30 mg h. hepatic impairment. drowsiness. or t.d. enhanced hypotensive effect with antihypertensives. 8. hepatic and renal insufficiency. muscle weakness.s. Respiratory disease. severe hepatic impairment. respiratory failure. gastro-intestinal disturbances including nausea and vomiting. C/I.00 · Short term use in insomnia . Duration of treatment with zopiclone should not exceed 4 weeks. pregnancy and lactation. hallucinations.5-5 mg. Tablet 7.5 mg hs Elderly 3. (10) Rs.00 — 38. Myasthenia gravis. confusion and ataxia. increased every 2-3 days if needed.00\ Same as for nitrazepam. Capsule 15 mg 15 .5 mg.00 — 17. 9. respiratory depression.00 SEDATIVE HYPNOTICS Cost: Nitrazepam I: C/I: P/C : A/E: P/A: Dose: D/I: Short term use in insomnia Myaesthenia gravis. P/C.5 mg. Enhanced sedative effect with alcohol and opioid analgesics. 5 mg.. hypersensitivity reactions. Tab 5 mg (10) Rs. dependence. Drowsiness. Cost : Flurazepam I. Tablet 2. Tab 5 mg . severe sleep apnoea syndrome. Cap 15 mg (10) Rs. Pregnancy.50.d. The usual dose ranges from 15-30 mg o. upto a maximum of 45 mg o.s. 10 mg 5-10 mg hs Elderly 2.35-18. acute pulmonary insufficiency.Psychotherapeutic Drugs Dose: Initially 5 mg b. incoordination.d.A/E. amnesia and behavioral disturbances.

pregnancy. Tab 7. Adjunct in the treatment of chronic alcohol dependence. dysphoria. 37.00 DRUGS USED IN SUBSTANCE DEPENDENCE Methadone I: C/I: Adjunct in treatment of opioid dependence Acute respiratory depression. constipation. hallucinations. confusion. pruritus. also dry mouth. vertigo. headache. sweating. Nausea. postural hypotension. tachycardia. hypothermia. pregnancy and breast-feeding. and muscle rigidity Concentrate for oral liquid: 5 mg/mL. difficulty with micturiction. risk of paralytic ileus. hypothyroidism.5 mg (10) Rs. decreased respiratory reserve and acute asthma.anorexia. Adjunct in treatment of opioid dependence. initially 10–40 mg daily.00 -50. hypotension. bradycardia. Oral liquid: 5 mg/5 mL. urticaria. breast-feeding. drowsiness. usual dose range 60–120 mg daily. vomiting. 329 P/C: A/E: P/A: Dose: Disulfiram I: C/I: . hypotension.10 mg/mL (hydrochloride). decreased libido or potency. acute alcoholism. Cardiac failure.psychoses. severe withdrawal symptoms on abrupt withdrawal. 10 mg/5 mL. spasm of urinary and biliary tract. mood changes. prostatic hypertrophy. facial flushing. larger doses produce respiratory depression. coronary artery disease and history of cerebrovascular accident. hypertension. by mouth. convulsive disorders.Drugs used in substance dependence D/I: Cost : General sedative interactions as for benzodiazepines and other anxiolytics and hypnotics. increased by up to 10 mg daily (maximum weekly increase 30 mg) until no signs of withdrawal or intoxication. raised intracranial pressure or head injury (affects papillary responses vital for neurological assessment) Renal and hepatic impairment. miosis. palpitation. rash.

25g od. diabetes mellitus. epilepsy. rarely psychotic reactions. hepatic and renal impairment. nausea and vomiting. reduced over 4 days to 0. Psychotic reaction with metronidazole. leading to enhanced sedative effect. respiratory disease.00 330 . Drowsiness and fatigue.75g to 0. 15. 1 g as a single dose on first day.Psychotherapeutic Drugs P/C: A/ E: P/ A: Dose: D / I: Cost: Ensure that alcohol is not consumed for at least 24 hours before initiating treatment. should not be continued for longer than 6 months without review. Inhibition of metabolism of phenytoin. Tablet 250 mg. inhibition of metabolism of tricyclic antidepressants. reduced libido. Tab 250 mg (10) Rs. Inhibition of metabolism of benzodiazepines.

SECTION 26 PAEDIATRIC DRUGS AND NUTRITION ANTIMICROBIALS IN CHILDREN 331 .

Paediatric drugs 332 .

Paediatric drugs 333 .

Paediatric drugs 334 .

Paediatric drugs 335 .

Paediatric drugs 336 .

Paediatric drugs 337 .

Paediatric drugs ANTHELMINTICS Albendazole: P/A : Dose: Tab 400 mg . 750 mg/5 mL. 1-2 yrs. 100 mg. DOSE ADJUSTMENT OF COMMONLY USED ANTIBIOTICS WITH RENAL FAILURE Dose with renal function (% normal) 338 Tab 6 mg 150 mcg/kg (approved for children >5 years) .Syrup 50 mg/5 mL 6 mg/kg/24h q8h X 14-31 days (Filariasis) 10 mg/kg/24h q8h X 14-21 days (tropical eosinophilia) Piperazine citrate : P/A: Dose : Syrup.Suspension: 400 mg/10 mL >2 yrs. 250 mg/ 5 ml 11 mg/kg hs X 1 day For pinworm & hookworm repeat after 14 days. 15 mg/kg/day in divided doses (14 days) Mebendazole: P/A: Dose: Tab 100 mg. 400 mg hs (maybe repeated in pinworm infestation after consultation) .Suspension: 100 mg/5 mL 100 mg BD X 3 days (not below 2 yrs. 200 mg. of age) Diethyl carbamazine: P/A: Dose: Tab 50 mg.Tab: 500 mg 75-100 mg/kg OD X 2 days (Ascariasis) 65 mg/kg X 7 days (Pinworm infestation) Ivermectin : P/A : Dose : Pyrantel : P/A : Dose : Tab 250 mg Syrup. Note: In hydatid cyst & cysticercosis.

500.100. hypersensitivity reaction.> 150mg/kg causes fatal liver cell failure.400 mg. Acetyl salicylic acid P/A: Tab 75. then 10 mg/kg/q24h 10 mg/kg q8h 10-15 mg/kg q6-8h 2. Inj: 150 mg/mL 10-15 mg/kg/dose q 6h Gi upset.5 mg/kg/q8-12h 30-60 mg/kg/day q6h 1 mg/kg q24-48h Reduce daily dose by 75% q12h No change Reduce daily dose by 50% 10 mg/kg q8h 20-25 mg/ kg/day q8h 60-120 mg/ kg/day q8h Reduce dose by 50% Reduce dose by 50% q12h q24h Reduce dose by 50% Reduce dose by 75% ANTIPYRETICS AND ANALGESICS Paracetamol P/A: Dose : A/E : Ibuprofen P/A: Dose : A/E: Tab 250. Suspension: 125 or 250 mg/ml. Dose: Rheumatic fever : 75-100 mg/kg/day q6h.rarely hepatic damage.650 mg . Antiplatelet dose :3-5mg/kg single dose Analgesic : 10mg/kg/dose q6h.Paediatric drugs Medication Teicoplanin >50 % 10-50 % <10 % 10 mg/kg/q 12H for 3 Reduce dose by 50% Reduce dose by 60% Doses. 8-10 mg/kg/dose q 6-8 hrly Gi symptoms. 339 .350 mg.renal failure.150.5 mg/kg q12h 10 mg/kg q24h Reduce daily dose by 50% q12h 2 mg/kg q12h Reduce daily dose by 50% q8h No change Nochange 1 mg/kg q23h 10 mg/kg q48-72h Not recommended Tobramycin Vancomycin Cotrimoxazole 6-10 mg/kg/day q12h Gentamicin Imipenem+ Cilastatin Linezolid Metronidazole Meropenem 2-2. Tab 200. Suspension: 100mg/5mL.

peripheral neuropathy.monitor visual acuity. Bone marrow suppression.30. viral fever for fear of Reye syndrome angioedema. bronchospasm.10 mg/kg/dose q 8-12h 2-3 mg/kg/day DISEASE MODIFYING ANTI RHEUMATOID DRUGS (DMARDS ) Psoriasis hepatic and renal involvement. GI ulceration.250 mg(150mg base).6 mg/mL 10-20 mcg/kg/dose IM or IV Penicillamine A/E: P/A: Dose : Azathioprine Dose: .500 mg Syr: 50mg/5mL 8.5-5 mg/kg daily. Monitor liver function and blood counts.500mg 10-20 mg/kg/day q12h Tab 250. thrombocytopenia. Inj: 50mg/2 mL. 5-15 mg/m2/week as a single dose. hemolytic anemia. 1 mg folic acid daily may prevent deficiency. gastric upset. Tab : 250 mg.5mg. anaphylaxis. rash. rash.7.5 mg/kg/week. nephrotic syndrome. can be increased to 15-20 mg/kg daily.5mg. hypotension(IV) Tab : 100 mg.5mg.Paediatric drugs C/I : P/C : A/E : Naproxen P/A : Dose : Mefenamic acid P/A : Dose : Indomethacin Dose Chloroquine C/I: P/C: A/E : P/A: Dose: Methotrexate P/A: Dose: coagulation disoders.approximately 0. Vit K deficiency. 3mg/kg daily Tab: 2. 2.10 mg. Tab 250. 2mg/kg/day ANTISPASMODICS Atropine P/A: Dose : 340 Injection 0.

2 mg/kg/day Epinephrine P/A: Inj : 1mg/mL of 1: 1000 solution. 8-12 h oral or IM or IV Diphenhydramine P/A : Tablet : 25. Drops 0. Suspension 1mg/mL Dose : 0.5 mg/kg/dose Metoclopramide P/A : Tablet : 10mg. Pheniramine Maleate P/A : Tablet: 25.01 mg/kg of 1 : 1000 solution SC or IM or 0.5 mL IM or IV ANTIHISTAMINES AND MEDICINES USED IN ANAPHYLAXIS Promethazine P/A : Syrup 5mg/5mL.1-0. 50 mg. Tab: 0. 8 h oral Cetirizine P/A : Tablet :10mg. Injection: 5mg/ml. Dose : Anti-inflammatory -0.1mg/kg of 1: 10.2 mg/kg/dose IM/oral. 0. SHOCK Hydrocortisone Dose: 10mg/kg/dose by slow IV as single dose.75 mg/mL Dose : 1mg/kg/24h. Syrup 15 mg/5mL. P/A : Inj: 4mg/mL.5 mg/5mL Dose : 5mg/kg/25 h.05-2 mcg/ kg/ minute infusion.2-0. Domperidone P/A : Tablet : 10mg. Syrup 10mg/5ml. Dexamethasone: I: Cerebral oedema: 1mg/kg/day q6h. Drops : 10 mg/mL Dose : Infants – 5 drops/dose. may be repeated. Syrup : 5mg/5mL Dose : 0.5 mg/kg/dose Hyoscine Butylbromide P/A: Tablet : 10 mg.5mg/mL.Paediatric drugs Dicyclomine Hydrochloride P/A: Tablet 200mg. 341 .4 mg/kg/dose. Injection : 22.5mg. 50 mg. above 6 years 10 mg daily.000 solution slow IV. Injection 25 mg/mL Dose : 0. older children–0. Syrup 5mg/5mL Dose : 2-6 years 5mg daily. Syrup 12. Injection : 20mg/mL Dose : >6 years 1 tab tds or 0. Dose : Anaphylaxis : 0.

Syrup: 5mg/5mL.1-0. Inj: 110 mg/mL. Respirator solution : 250mcg/mL. Not compatible with sodium bicarbonate. Aerosol : 2 puff q6h.rarely hypokalemia. respiratory paralysis. 0. Slow release preparation of theophylline: 10-15 mg/ kg/day q12h. Nebulisation: 0. P/A: Inj : 50% solution Dose: 0.2 mL/kg/dose of 50% solution ( 50-100 mg/kg/ dose) slow IV in 50 ml normal saline over 20 minutes.5mg/kg/hour.03ml/kg/dose with equal volume saline q 4-6 h ( 0. Respirator solution-5mg/ml.1-0. convulsions.gastric upset Tab: 100mg. MDI 100 mcg/puff.20 mg. 342 .15mg/kg/dose). Tab:2mg. ANTI ASTHMA DRUGS Relievers Salbutamol A/E : P/A: Dose: tremor. bradycardia. 1-2 mg/kg/day in divided doses.2mg/kg/dose q6-8h.4mg.May repeat after 6 hrs. 125 mcg in<5 yrs. Syp: 2mg/5ml. Syrup: 50mg/5mL. 5mg/kg loading dose in 20 mL of dextrose solution followed by 1mg/kg/h infusion. Inj: 250mg/10mL.arrhythmias. Magnesium sulphate A/E: hypotonia.Rotacap: 200mcg.5mcg/kg/dose q6-8h) Ipratropium A/E: P/A: Dose: Adrenaline(see section on anaphylaxis) Aminophylline P/C: A/E: P/A: Dose: Deriphylline P/A: Dose: Never give IM. (12. 250mcg in >5yrs for nebulisation. Tab: 100mg.250mg. Cap 125mg.palpitation. Aerosol: 20mcg/puff.Paediatric drugs Prednisolone P/A Dose: Tab: 5. blurred vision. dry mouth. 5mg/kg/dose q8h. IM. Continuous nebulisation : 0.10.

insufficient data in < 4 yrs.5 mg/5mL Nebulisation solution 10mg/mL MDI: 250mcg/dose 0.01ml/kg/dose) SC.05mg/kg/dose q8h oral nebulisation: 5 drops (<20kg) .16 mg. medium dose: 400-800 mcg/ day. high dose: >800 mcg/day MDi:100 or 200 mcg/puff: rotacaps and nasal spray also available low dose<400 mcg/day. MDi:nasal spray.1g Tab: 4mg. 343 P/A: Dose : Fluticasone A/E: P/A: Dose: Budesonide P/A: Dose: Beclomethasone P/A: Dose: Montelukast P/A: .200. MDi 25mcg/puff Rotacaps: 50mcg/cap 1-2 puff 12 h. 0. Nasal spray: 50mcg/ puff low dose<400 mcg/day. rarely prolonged QT interval in ECG. Auto-immune diseases and shock: 30mg/kg/dose.tachycardia. medium dose: 400-800 mcg/ day.005mg/kg/dose ( 0.candidiasis . dysphonia.5 mg. Tab : 2. To be chewed 1 hour before or 2 hours after food.lotion 100 mcg or more q12 h as MDi MDi: 100 mcg.200mcg Rotacaps: 100. 5mg for 6-12 yrs. 10 drops (> 20kg) Prednisolone: (see section on anti-inflammamtory drugs) Methyl Prednisolone P/A : Inj 500mg. PREVENTORS Salmeterol A/E: Tachycardia. Dose : A/c asthma: 2mg/kg/dose q8h.400 mcg/dose.Insufficient data in < 2 yrs. it’s used in combination with Fluticasone.05% cream. high dose: >800 mcg/day Tab: 4mg chewable tab for 2-6 yrs . 5mg.0. 10mg for > 12 years. For preventive thereapy .Paediatric drugs Terbutaline A/E: P/A: Dose: Tremor. Syrup : 1.

Tab: 250mcg.2-5 ml for children 30mg. ANTIARRHYTHMIC DRUGS Adenosine Dose: 100 – 250mcg/kg/dose rapid push with saline chase. term infant: 30mcg/kg. bradycardia. high dose: >15mcg/kg/min. Maximum12mg/dose. IV: 75% of oral dose. 344 .Each increment at 2 minute intervals.AV block. child:40mcg/kg Maintenance dose: 7. syrup: 15mg/5ml depends on other active ingredients like salbutamol. 2-20mcg/kg/min Dobutamine Dose: Dopamine: Low dose: 2-5mcg/kg/min .5-10 mcg/kg.25-1 mcg/kg/min. DRUGS ACTING ON CVS INOTROPES Digoxin C/I: A/E: P/A: Dose: Significant Ventricular arrhythmias. Epinephrine(mentioned elsewhere) Milrinone: Dose: Load 50mcg/kg over 10 minutes Maintenance: 0. Infant: 50mcg/kg.GI symptoms.Same cycle can be repeated after 15-30 minutes. Nebulisation with 20% solution-1-2 mL for infants.Inj: 50mcg/amp Elixir: 50mcg/mL Rapid digitalization: preterm:20mcg/kg.Paediatric drugs OTHER RESPIRATORY DRUGS Acetyl Cysteine Mucolytic Dose: Bromhexine Mucolytic Dose: Ambroxol Mucolytic Tab: Dose: 4mg /dose q6-8h. HCM.AV block. intermediate dose: 5-15 mcg/kg/min.

5 mg/kg Load 500mcg/kg over 2 minutes. bradycardia. max 1mg(infant) 2mg(children) oral 1-6 mg/kg/day. Maintenance 2.1-2 mg/kg.05-0. 0.Infusion 20-50 mcg/kg/minute.1 mg/kg/dose Oral : 0. maintenance 2. titrate upto 0.Repeat after 1 hour. 0.5mg/kg.1 mg/kg/dose.Maintenance : 50-300 mcg/kg/min.(max-5mg) orall 2-3 mg/kg/day q8h ANTI-HYPERTENSIVES. Max : 60 mg/day.5-1.7-1.5-3 mg/kg/day 345 . Repeat after 5-10 minutes. IV: 0. Oral Load 10 mg/kg. pulmonary fibrosis. Load 1. IV: 0. step up on every 5th day.5 mg/kg IV: 0. Esmolol Dose: Phenytoin Dose: Lidocaine Dose: Propranolol Dose: Verapamil C/I: Dose: Captopril Dose: Enalapril Dose: Hydralazine Dose: Carvedilol Dose: Losartan Dose: Nifedipine Dose: Neonate : 0.Repeat after 5 minutes. lens toxicity. Maintenance 5-15 mcg/kg/minute.4 mg/kg.4 mg/kg/day 0.1-0.5.1-2 mg/kg/dose. Oral : 0.1 mg/kg bolus over 2-5 minutes.5 mg/kg/dose Infants and children.Paediatric drugs Amiodarone: A/E : Dose : Hypothyroidism . 0. In infants.5-1mg/kg bolus.05 mg/kg/dose.5. Load 5mg/kg over 20-30minutes.25 mg/kg .

3 mg/kg. Max: 30 mg/kg/day Prazosin Dose: 0.05 -0. Dose: oral: 0. as infusion.1. Alpha methyl dopa Dose:10 mg/kg/day. Hydrochlorothiazide Dose: oral 1-2 mg/kg Spironolactone: Dose: 1-3 mg/kg/day MISCELLANEOUS DRUGS Heparin Dose: Enoxaparin Dose: Infusion: 10-20 U/kg/h.5 mg/kg/dose. Infusion: 0. SC : 50-100 U/kg. Streptokinase Dose: IV: 100 U /kg/h Indomethacin Indication : PDA closure in infants.1-1 mg/kg/hour.2 mg/kg q12h 2 doses. oral : 5-10 mg/kg/day od IV:10-20 mg OD for heart failure.5-10 mcg/kg/min DIURETICS Frusemide Dose: Torsemide Dose: oral 2-4 mg/kg/day IV :1-2 mg/kg/day. Warfarin Dose : 0. Max 10 mg/day 346 . SC: < 2 months. >2 months – 1 mg/kg/ dose.05-5 mg/kg/day Labetalol Dose: 20mg/kg/day orally IV : 1-2 mg/kg/min.05-5 mg/kg/day Sodium nitroprusside Dose: IV: 0.Paediatric drugs Amlodipine Dose: 0.

In < 2 yrs. Tablet : 20mg. 1g. Inj: 500mg/vial I: Transplant recipients .15mg/kg/day.2 mg/kg/dose IM or SC. Dose : Oral :0. 5-10 mg/kg/day(preferably > 8 yrs).5 mg. Maximum 1mg/m2 Nephrotic Syndrome : Oral 2-2.5-1 mg/kg/dose IM or IV. 5mg.03-0. 15mg and 30 mg/mL 0.03% ointment.0 mg/kg/dose IM or SC. 2g Tab: 25 mg. Topical – 0.1-0. IV Continuous infusion : 0.5 mg/Kg /day for 8-12 week along with oral steroids.5-1. 1mg.Systemic lupus erythematosis Dose: 600mg/m2/dose twice daily Tacrolimus P/A : Caps 0.Paediatric drugs STATINS Atorvastatin C/I: Dose: Lovastatin Dose: Simvastatin Dose : Morphine P/A: Dose : Pethidine P/A: Dose: Pentazocine P/A: Dose : 10mg. JRA/ Vasculitis : IV 10 mg/kg very 2 weeks The total cumulative dose in children should be <170mg/kg Mycophenolate Mofetil: P/A: Capsule : 250mg. 50 mg/mL 0. 500mg.4 mg/kg/day divided every 12 hours.15-0. Inj: 5mg/mL. Inj: 30 mg/mL Up to 0. 10-40 mg/day 10-20 mg/day SEDATIVES IMMUNOSUPPRESSANTS IN PAEDIATRIC PRACTICE Cyclophosphamide P/A Dosage : SLE : Inj:100mg. 347 . 50 mg IV 500-750mg/m2 every month . 200mg.

1mg/kg IV Infusion : 1-2 mcg/kg/min Inj : 200mg/mL. 8mg.5 – 1 mg/kg/day Ondansetron P/A: Tab 5mg. Susp: 1mg/mL. Tab : 30 mg. inj: 50 mg/2mL Dose : 2mg/kg/dose x 2 PO 1-2 mg/kg/dose x 2-3 IV Omeprazole P/A: Cap 20mg.Paediatric drugs Cyclosporine : Dose in FSGS : 3-5mg/kg/day q12h PO Rheumatoid arthritis : 2. 350 mg . Dose : 1mg/kg/day od orally Pantoprazole P/A: Tab 40 mg. 10 mg. Cap 40 mg.5mg/kg/day q12h–4 mg/kg/day DRUGS ACTING ON GASTROINTESTINAL TRACT Ranitidine P/A: Tab 150 mg.).) dilute in normal saline Maintenance : 5-8 mg/kg/day q 12h Phenytoin P/A: Dose: 348 .1 mg/kg Inj : 5mg/5mL 0.3 mg/kg Inj: 1mg/mL 0. 100mg. 60 mg . 20mg/5mL Status : 20mg/kg slow IV (1mg/kg/min. Tab : 50mg. Dose : 0. 10mg/kg can be repeated. Maintenance : 3-5 mg/kg/day Inj: 50mg/mL. Tab 20mg. Inj: 40 mg/2mL. Syrup: 15mg/5mL. 10mg. Syrup: 30mg/5mL Status : 20mg/kg slow IV (1mg/kg/min. Inj: 2mg/mL ANTIEPILEPTIC DRUGS Diazepam P/A : Dose : Lorazepam P/A: Dose : Midazolam P/A: Dose : Phenobarbitone P/A: Dose : Inj 5mg/mL: 0.

Paediatric drugs

Fosphenytoin P/A: Dose : Carbamazepine P/A: Dose : Clonazepam P/A: Dose : Ethosuximide P/A: Dose : Topiramate P/A Dose : Oxcarbazepine P/A: Dose : Levetiracetam P/A: Dose : Lamotrigine P/A: Dose : Gabapentin P/A: Dose :

50 mg phenytoin = 75 mg Fosphenytoin 15-20 mg/kg of Phenytoin equivalent at 3mg/kg/min. Syrup:100mg/5ml; Tab: 100mg, 200mg, 400mg (200, 300, 400 SR) 10-30 mg/kg/day Tab : 0.25, 0.5, 1, 2 mg 0.05 – 3 mg/kg/day Cap : 250 mg, Syrup: 250 mg/5mL 20-50 mg/kg/day Tab : 25mg, 50mg, 100mg, 200mg Start with 1-3 mg/kg/day, increase weekly to maximum of 5-9 mg/kg/day Tab : 150, 300, 600 mg and SR 8-10 mg/kg/day to 20-40 mg/kg/day Tab : 250, 500, 750 mg; Syrup: 100mg/mL 10mg/kg/day to 40-60mg/kg/day Tab :5mg, 25mg, 50mg, 100mg, 150 mg, 250mg 0.6mg/kg/day to 2-8mg/kg/day If used with valproate, start on 0.15 mg/kg/day Tab : 150, 300, 600, 1200mg 20-70 mg/kg/day ORAL REHYDRATION SALTS

Two types of ORS 1. WHO ORS for Cholera diarrhea 2. Hypoosmolar ORS for non cholera diarrhea Available as sachets to be dissolved in 1 litre water. 349

Paediatric drugs

Constituents (1 sachet) Item NaCl KCl NaCitrate Glucose Na K Cl Citrate Glucose Osmolarity I: P/C: A/E: Dose: WHO ORS 3.5g 1.5g 2.9g 20g 90mEq/L 20mEq/L 80mEq/L 10mEq/L 111mEq/L 311mOsm/L Hypoosmolar ORS 2.6g 1.5g 2.9g 13.5g 75mEq/L 20mEq/L 65mEq/L 10mEq/L 75mEq/L 245mOsm/L

Small sachets to be dissolved in 200ml water are also available. For preventing and treating dehydration from acute diarrhoea Renal impairment Vomiting, hypernatremia and hyperkalemia Children with no dehydration, 10mL/kg/ stool Children with some dehydration 75 -100 mL/kg over 4 hrs

ReSoMal 40 ml of mineral mix solution to be added along with one sachet WHO ORS to 2 liters of water to make 2 liters of ReSoMal. It will contain 125 mMol glucose, 45 mMol Na, 40 mMol K, 70 mMol Cl, 7mMol citrate , 3mMol Mg, o.3 mMol Zn and 0.045mMol Cu/Liter Mineral Mix Solution for preparing ReSoMal (Rehydration Solution for the Malnourished) Content KCl Tripot Citrate MgCl2 CuSO 4 Zn Acetate Water 350 Quantity(per 40 ml) 22.4g 81 g 76g 1.4g 8.2g 2.5g

Use: for correcting dehydration in malnourished child

Paediatric Nutrition

NUTRITION

Recommended Balanced Diets (ICMR Recommendation)
Parentral Nutrition 1. Glucose I: Treatment of hypoglycemia, maintenance fluid in newborn, fluid replacement without significant electrolyte deficit, management of hyperkalemia, to provide calorie requirements A/E: Thrombophlebitis with hypertonic dextrose solutions; fluid and electrolyte disturbances; hyperglycemia P/A: Injectable solution: 5%; 10% isotonic solutions of 500mL bottles. 10% and 20% solutions 1000ml for parenteral nutrition, 25%, 50% hypertonic solutions as 25 mL ampoules. Dose: Hypoglycemia 10% dextrose 5mL/kg. 25% dextrose 2mL/kg with insulin for correction of hyperkalemia Higher concentrations of glucose are used for parenteral nutrition. Minimum 20% of calorie requirements should be provided by the maintenance fluid . 2. Amino acid infusions Essential amino acids are available as parenteral solutions. They contain a mixture of essential and nonessential aminoacids. 5%, 6%,10% aminoacid infusion solutions 500mL and 100mL bottles Dose: 2-5g/kg/day 3. Lipid emulsions 10%, 20%, 30% emulsions 500ml bottle. Dose: 1-3 g/kg/day 3 in 1 solution containing dextrose, amino acids and lipid is also available for parenteral nutrition commercially. 4. Water for injection 2-mL ,5-mL, 10-mL ampoules. Uses: in preparations intended for parenteral administration and in other sterile preparations 351

Paediatric drugs

VITAMINS ( Majority of vitamins are available as combination of multivitamin syrup and injection) 1. Vitamin A (Retinol) Capsule: 50 000 IU; 100 000 IU; 200 000 IU Oral oily solution: 100 000 IU /mL in multi dose dispenser. Tablet (sugar-coated): 10 000 IU, 50,000IU. Water-miscible injection: 100 000 IU in 2-mL ampoule 1microgram=3IU Uses: prevention and treatment of vitamin A deficiency; prevention of complications of measles Daily requirements : 1200-1800 IU day Prevention of vitamin A deficiency (by mouth): infant under 6 months,50 000 units, infant 6–12- months 100 000 units, Child 1-5years: 200 000 units every 6 months; An additional dose should be given the next day in hospitalized children with measles infection.For treatment of xerophthalmia, the same dose to be repeated on the next day, and then after 2-4 weeks. Adverse effects: high intake may cause birth defects; pseudotumour cerebri, enlarged liver, raised erythrocyte sedimentation rate, raised serum calcium and raised serum alkaline phosphatase concentrations 2. B complex vitamins i. Thiamine (Vitamin B1) Tablet: 50 mg, 75mg tab. Inj Thiamine 50mg/mL, 2mL ampoules Uses: prevention and treatment of vitamin B1 deficiency, Neurometabolic disease like maple syrup urine disease and thiamine responsive megaloblastic anemia. Daily requirements: 0.5-1.5mg/day Dose 10–25 mg daily for treatment. Adverse effects: Anaphylaxis (parenteral use) ii. Riboflavin (Vitamin B2) Tablet: 10 mg. Uses: vitamin B2 deficiency 352

Paediatric Nutrition

Daily requirements: 0.5-1.5mg/day Treatment of vitamin B2 deficiency: 10 to 30 mg daily in divided doses iii. Nicotinamide (Niacin) Tablet: 50 mg, 100mg tab Daily requirements: 5-15mg/day Dose: 50-300mg/day for pellagra Adverse effects: Flushing with high doses. iv. Pyridoxine (Vitamin B6) Tablet: 40mg, 100mg; inj along with other B complex vitamins Daily requirements: 0.5 to 1.5mg/day Uses: treatment of pyridoxine deficiency due to metabolic disorders, Pyridoxine withdrawal seizures; sideroblastic anemia Dose: For seizures 50 - 100mg IM Adverse effects: chronic administration of high doses may cause peripheral neuropathies v. Folic Acid Tablet: 5mg Daily requirements: 50-150mcg/day Use: Folic acid deficiency anemia, Hemolytic anemia , prevention of neural tube defect ( to be given to pregnant mother) vi. VitaminB12 (cobalamin) Tablet:500μgm, Syrup:500mcg/5ml, Injection: 500mcg/ml Daily requirements: 0.5-1150mcg/day Use: anemia, neurometabolic conditions (methylmalonic academia) Dose: 1mg/day for methylmalonic academia vii. Biotin Tablet: 5mg, Syrup: 5mg/mL Daily requirements: 100-200mcg/day Use: treatment of biotin deficiency due to metabolic disorders like multiple carboxylase deficiency Dose: 10mg/day (Multiple carboxylase deficiency) 353

Paediatric drugs

3. Ascorbic acid (vitamin C) Tablet: 100mg, 500mg, Drops: 100mg/ml Daily requirements: 40-50mg/day Dose: 100-200 for treatment of scurvy. Adverse effects: gastrointestinal disturbances reported with large doses 4. Vitamin D i.Cholecalciferol (vit D3) 60000 IU/sachet oral; 300000IU /ml inj 1μgm= 40IU Daily requirements: 400IU/day Uses: vitamin D deficiency; hypocalcaemia of hypoparathyroidism Contraindications: hypercalcaemia; metastatic calcification Dose: Prevention of vitamin D deficiency 10 micrograms (400 units) daily orally. Treatment of vitamin D deficiency-6 lakhs IU oral or IM Adverse effects: anorexia, lassitude, nausea and vomiting, diarrhea, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised serum calcium and phosphate , tissue calcification on prolonged treatment ii. 1, 25 dihydroxy D3 0.25mcg,1 mcg Tabs Use: For renal diseases and vit D dependent rickets Dose: Vit D dependent rickets type I: 0.25-2mcg/day, Vit D dependent rickets type II: 50-60 mcg/day 5. Vitamin E Drops- 50mg/ml; Capsule 100mg, 200mg, 400mg Daily requirements: 5-15mg/day ( 1mg = 1IU) Use: Supplementation, hemolytic anemia of prematurity, bronchopulmonary dysplasia, myopathies, neonatal cholestasis. Dose:15-25 IU/day. Higher doses for cholestasis. Adverse effects: excess doses cause NEC in newborn 354

Paediatric Nutrition

6. Vitamin K Menandione sodium 10mg/mL ampoules Phytomenadione inj 10mg/mL ampoule, phytomenadione tablet 10mg Use: Hemorrhagic disease of newborn(HDN), liver diseases, malabsorption, oral anticoagulant toxicity Dose: Treatment of HDN 2-5mg IV; prevention of HDN: 1-2 mg IM Adverse effects: Hyperbilirubinemia in new born MINERALS

Sodium
Daily requirement: 2-3meq/kg/day. Available preparations · Sodium chloride ( 1gm = 17 meq of Na and Chloride) i. Sodium chloride Injectable solution: 0.9% isotonic (equivalent to Na+ 154 mmol/l, Cl- 154mmol/L). Uses: electrolyte and fluid replacement, Correction of Shock Dose: In shock bolus intravenous dose of 20mL /kg. Adverse effects: large doses may give rise to sodium accumulation and edema ii. Sodium chloride injectable solution: 0.45 %Saline (equivalent to Na+ 77 mmol/l, Cl- 77mmol/L). Uses: DKA management, hypernatremia correction, electrolyte and fluid replacement iii. Sodium chloride Injectable solution: 3% Hypertonic (equivalent to Na+ 510mmol/:L, Cl- 510 mmol/L). Uses: Hyponatremia Dose: 3-4mL/kg iv . Glucose with sodium chloride. Injectable solution: 5% glucose, 0.9% sodium chloride (equivalent to Na+154mmol/L, Cl-154 mmol/L). 500ml bottles v . Injectable solution: 5% glucose, 0.45 % sodium chloride (equivalent to Na+77 mmol/l, Cl-77 mmol/L). 500ml bottles Uses: fluid and electrolyte replacement, Diabetes ketoacidosis management 355

Paediatric drugs

Sodium Bicarbonate i. Sodium bicarbonate tablet 325mg (4meq) and 650mg (8meq) ii. Shohl’s Solution Citric acid 140ml and sodium citrate 90g in 1 litre with water (1ml=1mEq Bicarbonate) iii. Polycitra Potassium citrate-550mg ,sodium citrate -500mg , citric acid -334mg in 1liter water( 1ml= 1meq of Na and K & 2 mEq of HCO3) Use: To treat metabolic acidosis, Renal tubular acidosis (RTA), Dose: proximal RTA 5-20 mEq/kg/day Distal RTA 2-3 mEq/day Injectable solution: 7.5% in 10-ml ampoule (equivalent to Na+ 0.9meq/mL, HCO3-0.9meq/mL). Uses: metabolic acidosis, hyperkalemia, Dose: In acidosis 0.3x body weight x based deficit as infusion over 4 h Adverse effects: hypokalemia and metabolic alkalosis, sodium retention Potassium Daily requirement: 2-3meq/kg/day Available preparation: Potassium chloride i. Potassium chloride oral solution. 15 mEq in 20 mL solution, 200mL and 450mL bottles Uses: prevention and treatment of hypokalemia Contraindications: severe renal impairment; hyperkalemia Dose: Prevention of hypokalemia 2-3 mEq/kg/day. For treating hypokalemia needs higher doses Adverse effects: gastrointestinal irritation ii. Injectable solution: 15% in 20-mL ampoule (equivalent to K+ 2 mmol/ mL, Cl- 2mol/mL), 10% in 10 mL ampoule (1.342mmol/L). Dose: 05-1meq/kg diluted. Adverse effects: cardiac toxicity on rapid infusion. 356

Paediatric Nutrition

Calcium
Calcium gluconate injection: 10% in 10-mL ampoule. 1mL = 9mg Oral- calcium phosphate and calcium carbonate Daily requirements: 400-600mg/day Uses: Nutritional supplementation., hypocalcaemic tetany, preterm newborns, rickets, hyperkalemia Dose: Nutritional supplementation 500-1000g/day In deficiency 100-200mg/kg/day. Calcium phosphate preparation to be avoided in renal impairment. Hypocalcaemic tetany /seizures: Inj calcium gluconate 2mL/kg slowly Adverse effects: gastrointestinal disturbances; bradycardia, arrhythmia; injection-site reactions; peripheral vasodilation; fall in blood pressure Sodium Lactate, compound solution IP Injectable solution. Contains Na- 131 mEq, K- 5meq, Ca -4 mEq, Bicarbonate (as lactate)- 29 mEq Cl- 111meq/L. Uses: Correct severe dehydration in acute diarrheal diseases, preand perioperative fluid and electrolyte replacement; hypovolemic shock Dose: 100ml/kg for correcting dehydration Adverse effects: excessive administration may cause metabolic alkalosis and edema Phosphorus Daily requirements: 600-1000mg/day Oral: Joules solution (Disodium orthohydrogen phosphate 136g and orthophosphoric acid 32ml) provides 30 mg phosphate/mL Available as combination with sodium, potassium and calcium. Use: osteopenia hypophosphatemic rickets Dose: 600-1000mg/day Adverse effects: Hyperphosphatemia, diarrhoea Magnesium 25% MgSO4 (2 mEq/ml), 50% MgSO4 (4 mEq/mL) 10mL ampoules Oral- Magnesium gluconate (5.4 elemental magnesium/100mg), magnesium sulphate (10mg of elemental magnesium/100mg) 357 of prematurity, hypophosphatemia,

Paediatric drugs

Daily requirements: 200-300mg/day Use: Magnesium deficiency (Protein Energy malnutrition, infant of diabetic mother), Bronchial asthma Dose: oral-3-6mg/kg/day for nutritional supplementation. In PEM0.1-0.2 mL/kg of 50% solution intramuscularly. Bronchial asthma 25% solution 0.2mL/kg diluted in 30mL glucose and given as infusion. Adverse effects: hypotonia, hyporeflexia, hypotension, diarrhea Multiple Electrolytes and Dextrose injection type 1- USP ( paediatric maintenance solution with 5% dextrose injection) Inj solution containing Na 25meq/L, K 20 mEq/L, Mg 3meq/L, acetate 22meq/L, Cl 22meq/L, Phosphate 3meq/L as 500ml bottles. Use: As pediatric maintenance fluid Dose: depending on the daily maintenance requirements Copper Oral as constituent of multivitamin syrup Daily requirements: 1-2mg/day Inj copper histidine Use: copper deficiency, Menkes disease Dose: oral-1-2mg/day, in Menkes disease 50-150mcg elemental copper/kg/24hr SC Zinc sulfate Oral liquid: in 10 mg and 20mg per unit dosage forms. Tablet: in 10 mg and 20mg per unit dosage forms. Daily requirements: 5-15mg/day Uses: adjunct to oral rehydration therapy in acute diarrhea, acrodermatitis enteropathica, Wilson’s disease Dose: in acute diarrhoea, infant under 6 months, 10 mg (elemental zinc) daily for 10–14 days; child 6 months–5years, 20 mg (elemental zinc) daily for 10–14 days, 25mg tid in Wilson’s disease. Adverse effects: GI upset, copper deficiency Iron Ferrous sulphate 200mg tab ( 65mg elemental iron) Chelated iron as polysaccharide iron complex 100mg/5mL, iron dextran complex 50 mg iron/mL. 358

Paediatric Nutrition

Combination with folic acid and vit B12 Daily requirements: 10-20mg/day Use: Prevention and treatment of iron deficiency Dose : prevention 2mg/kg/day. For treatment 4-6mg/kg/day. Parenteral: 0.4 * body weight* Hb deficit Adverse reaction: GI upset, hepatic injury. Iodine Lugols iodine 5% iodine diluted in 10% potassium iodide ( 10mg iodine /drop) Iodized oil: 1 ml (480 mg iodine); 0.5 mL (240 mg iodine) in ampoule (oral or injectable); Iodized salt 15mcg/g (15ppm) Daily requirements: 50-150 mcg/day Uses: prevention and treatment of iodine deficiency . Adverse effects: hypersensitivity reactions; goiter and hypothyroidism;

Hyperthyroidism
Sodium fluoride In any appropriate topical formulation. Uses: prevention of dental caries Daily requirements : 1-5mg/day Contraindications: not for areas where drinking water is fluoridated Dose: Prevention of dental caries, as oral rinse child over 6 years, 10 ml 0.05% solution daily or 10 mL 0.2% solution weekly. Fluoridated toothpastes are also advised. Adverse effects: in recommended doses toxicity unlikely

359

SECTION 27 DRUGS USED IN RESPIRATORY DISEASES
UPPER RESPIRATORY TRACT INFECTIONS

Common cold (Rhinitis)
Viral aetiology. Usually self limiting. Symptomatic treatment alone is required. Topical or systemic nasal decongestants and antihistaminics are used.

Topical Nasal Decongestants & Xylometazoline (Refer Section 16)
Azelastine hydrochloride I: Allergic rhinitis. C/I: Hypersensitivity, lactation. P/C: Pregnancy, not to use longer than 6 months once after opening the bottle. Should not share the spray with others. Tip of the bottle should be dipped in boiled water, dried and capped appropriately after every use. A/E: Nasal mucosal irritation, nasal bleeding. P/A: Nasal spray 10 mL Dose : Adults and children over 5 years 0.14 mL metered dose. One spray into each nostril bid. Cost : Nasal spray (10 mL) Rs. 120.00

Sodium chloride
I: P/ A: Dose : Cost : Phenylephrine I: C/I : Nasal congestion. Solution (0.9 %): 500 mL, 1000 mL Sodium chloride (0.9%) given as nasal drop. Solution (500 mL) Rs. 10.00

Sympathomimetics
Nasal congestion, sinusitis, common cold Avoid excessive and prolonged use. Caution in infants under 3 months, patients with cardiac diseases, hypertension, hyperthyroidism and glaucoma. Hyperthyroidism, cardiac diseases Sneezing, mild burning sensation. After excessive use, tolerance with diminished effect - rebound congestion.

P/C : A/E:

360

Pregnancy. Tablets.Spray 2 % w / v.Increased incidence of intranasal and paranasal infection. Inhaler 100 mcg (200 md) Rs. bronchial asthma. pheniramine maleate etc. Local irritation.220.Presence of pus may prevent proper penetration of drug. Dose : 2 squeezes qid. Nasal drops. Dose : D/I : Cost : . Most of the preparations contain other drugs like naphzoline. Orally 5-10 mg bid. P/C: Pregnancy. A/E : Bronchospasm. sneezing and epistaxis. Candidial infection of mouth and throat. P/A: Inhaler 1 mg/mdi.00 361 P/A. headache. Maintain with 1 squeeze tds. anaphylaxis. antidepressants and methyl dopa. hypotension with MAO inhibitors.00 . 150. 5 mg/mdi. Mast cell stabilizers Sodium Cromoglycate I: Prophylaxis of allergic rhinitis and asthma. children < 5 years. Cost: Inhaler 1mg/mdi (400 mdi) Rs. Only combination preparations. Unhealed nasal infection previous treatment with oral steroids. 100 mcg. systemic fungal infections. ALLERGIC RHINITIS AND NASOBRONCHIAL ALLERGY Drugs are usually used as nasal sprays and nasal drops. (2 %) D/I: None reported. Syrup. Prolongs the effect of local anaesthetics. None reported.Drugs for Respiratory Diseases P/A: Dose : D/1: Cost : Capsules. C/I: Hypersensitivity. No pure preparation available. haemorrhagic secretion mild systemic steroid effects are produced. 161. TB and diabetes. lactation and neonates. 2 sprays (100 mcg) into each nostril bd. 20 mg/cartridge.00 Corticosteroids Beclomethasone I: C/I : P/C : A/E: Allergic rhinitis and inflammatory conditions ofthe nose. Nasal spray 50 mcg. Hypersensitivity.

41. dry mouth. prophylaxis of asthma. pregnancy and lactation. nausea and headache. 1 mg/5 mL 1-2 mg b. Dose: Adults 100 .d. 320. ticarcillin. amoxycillin Other penicillins. fungal and viral infections in airway. Budesonide is not indicated for acute attacks of asthma. 1 mg b. Tab 1 mg (10) Rs.00 . azlocillin. Drowsiness. hypersensitivity and pregnancy.piperacillin 362 .d. Tablet 1 mg Syrup 0.d.Drugs for Respiratory Diseases Budesonide Allergic rhinitis and inflammatory conditions of the nose. maximum 1600 mcg/day. Age < 2 yrs. maximum 800 mcg/day.00. A/E:D/I: None reported. C/I : Hypersensitivity.2 mg/mL. P/C: Care in patients with pulmonary tuberculosis.100 mcg b.00 Syrup 1 mg/5 mL (100 mL) Rs.200 mcg b.14. Cost: Inhaler 100 mcg (400 md) Rs. Cost : Antibiotics in Current use in Respiratory Infections (Refer section 4) Penicillins: Penicillin G and Penicillin V Penicillinase resistant penicillins . Potentiates the action of sedatives and hypnotics. With oral hypoglycemic drugs it causes a fall in thrombocyte count. patients should be instructed to rinse the mouth with water after each dosing. Children < 2 years not recommended. bronchial asthma. P/A: Inhaler 100 mcg/md.00 ORAL ANTIHISTAMINES I: Cetirizine HCl.ampicillin. > 2 years. acute asthma. Children 50 .d.cloxacillin Broad spectrum penicillins . 10. Not to operate machinery after taking the drug. Loratadine and Fexofenadine (Refer Section 16) Ketotifen I: C/I : P/C : A/E: P/A: Dose: D/ I : Allergic rhinitis. weight gain.

netilmycin. kanamycin. Others :Teicoplanin. Macrolides: erythromycin. This is the most powerful and most extensively used antituberculosis drug. hepatic insufficiency and psychosis.tuberculosis. chronic alcoholism. streptomycin. Monitor serum level of hepatic transaminases.Drugs for Upper Respiratory tract infections Cephalosporines : 1st generation cephalexin. ethambutol. Isonicotinic acid hydrazide) I: Treatment of tuberculosis.Gatifloxacin Other beta lactams: aztreonam.bovis and M. Hepatotoxicity . Sparfloxacin. clarithromycin. cefotaxime 4th generation cefpirome. M. pyrazinamide. diabetes and others) should additionally receive pyridoxine 20 mg dose.Epilepsy should be controlled effectively since INH may provoke attack. Co-trimoxazole : trimethoprim — sulfamethoxazole Drugs used in Tuberculosis These include isoniazid. tobramycin.Clindamycin. 2nd generation cefoxitin. Tetracycline: doxycycline Fluoroquinolones:Levofloxacin. streptomycin and others. azithromycin. amikacin. cefuroxime 3rd generation ceftazidime.Patients at risk of peripheral neuropathy (malnutrition. Hypersensitivity. imipenem. bactericidal against actively multiplying M. Isoniazid (INH.The incidence of 363 C/I: P/C: . rifampicin. cefepime Aminoglycosides:gentamicin.kansasii.Linezolid Synergestic combination : amoxycillin + cloxacillin ampicillin +cloxacillin amoxycillin + clavulanic acid ticarcillin + clavulanic acid piperacillin+tazobactum roxithromycin.

but resolves as drug therapy continues. vomiting. alcoholism or uraemia. 5 mg/ kg bw Single dose. jaundice. alcohol consumption and alcoholic liver disease.Bactericidal and sterilizing drug for the treatment of tuberculosis. Thrombocytopenia and acute renal failure are absolute contraindications. Oral .dose-related.eosinophilia. It is also used for the treatment of leprosy. shock. INH induced hepatitis usually resolves after discontinuation of the drug. and CNS disturbances. severe liver disease. Antacids may reduce the absorption of INH. Patients with malnutrition and those predisposed to neuropathy by diabetes.00 Rifampicin lt acts by inhibiting the synthesis of nucleic acids.drowsiness. pregnant women and those with seizure disorders should be supplemented with pyridoxine 20 mg daily. The effects of anticonvulsants may be increased. This is not a contraindication for INH. 364 .Transient elevation of serum transaminase may occur. probably due to increase dexcretion of pyridoxine. 300mg od 600 mg (10mg/kg) for intermittent regimen and for nervous system disease. A/E : Flu like syndrome in intermittent dosage.tablet and liquid Parenteral preparation can be given IV or IM in special circumstances at the same as oral dose on those who cannot ingest orally. skin reactions. Nausea. 9.Peripheral neuropathy is . P/C: Patient should be warned about the orange discolouration of body secretions and urine.Bactericidal for most species of mycobacterium.Drugs for Respiratory Diseases P/A: Dose: Adult : D/I: Cost: INH induced hepatitis increase with age. thrombocytopenia. C/I: Hypersensitivity. It can permanently discolor soft contact lenses otherwise it is harmless. 450 mg daily · in tuberculous meningitis. muscle cramps. Tab 300 mg (10) Rs. transient leukopenia.

Severe hepatitis when used along with isoniazid. loss of appetite. Capsules 150. Intracellular organisms are killed. 450 mg for adults. 450. Food will delay the absorption.effective in the initial intensive phase. Bactericidal and sterilizing action . 600 mg Syrup 100 mg/ 5 mL 10 mg/ kg — oral single dose.35 mg/kg oral.bovis is resistant to PZA. Pyrazinamide (PZA) Bactericidal to M. 300.phenytoin. oral anticoagulants and disopyramide by inducing hepatic metabolism. corticosteriods. 750 mg. nausea.sterilizing especially to intracellular organism I: Treatment of tuberculosis. It reduce Vitamin D blood levels. It decreases the serum INH concentration. visual disturbances and menstrual irregularities. and liver damage. M. pregnancy. 600 mg Tablet 450. D/I: Alters the action of oral antihypoglycemic agents and disturbs blood glucose levels. A/E: Arthralgia. Dose: 20. P/A: Tablet 500 mg. It reduces the effectiveness of oral contraceptives. 600mg for patients more than 60 kg weight.tuberculosis . Gout may be exacerbated. 365 . oral antidiabetics. The only one drug acting in the acidic pH. malaise. The drug should be given on an empty stomach and fluids and food should be taken only after 1 h. existing liver disease and gout. Fixed drug combination are used to increase compliance. Ethambutol It acts by possibly inhibiting RNA synthesis and also by affecting metabolism of cell wall. P/C: Patients with diabetes should be carefully monitored since blood sugar levels may become labile. C/I: Hypersensitivity. ataxia.Drugs for Tuberculosis P/A: Dose: D/I : headache. One or two divided doses. 1000 mg and 1500 mg.

renal or hepatic insufficiency.I disturbances.tuberculosis to develop resistance against streptomycin.It was used as one of the powerful antituberculosis drug along with INH prior to the introduction of short course chemotherapy with rifampicin and other drugs. Retrobulbar neuritis with reduction of visual acuity. anorexia. Use is restricted to tuberculosis treatment as a component of several combined antituberculosis chemotherapeutic regimens. Bacteriostatic drug in usual dosage. Reduced renal clearance of urates. Another disadvantage is the readiness of M. injection over several months for its effect. G. pregnancy and myasthenia gravis. 800 mg. Anaphylactic shock. It is used in combination with other drugs to prevent or delay the emergence of resistant strains. (eg . young age) Patients should be advised to discontinue treatment immediately and to report to the doctor if visual disturbances occur.oral. hypersensitivity. Single dose . premature infants. Optic neuritis.(Bactericidal in higher dosage). Vestibular dysfunction leading to giddiness and vertigo which may be persistant for Streptomycin I: C/I: P/C: A/E: 366 .Drugs for Respiratory Diseases I: C/I: P/C: A/E: P/A: Dose: D/I: Treatment of tuberculosis. false positive test for phaeochromocytoma. Synergistic effect with other antituberculous agents Aminoglycoside antibiotic. Due to this reason at present it is used only as a reserve drug under special circumstances. It is a bactericidal drug which has to be given by IM. Tablet 200 mg. Absorption delayed or reduced by aluminum hydroxide. 400 mg. Avoid concurrent use of other ototoxic and nephrotoxic drugs. 1000 mg 15-25 mg/ kg bw. It acts by inhibiting protein synthesis. Hypersensitivity. reduction of visual acuity -particularly inability to distinguish red and green.

Potentiates the effect of neuromuscular blocking agents administered during anaesthesia. renal failure and hypersensitivity.1 g IM.5 g. Dose: 15 mg/kg.Drugs for Tuberculosis several months even after stopping the drug. rash.when this combination is used for treating other infections. A/E: Fever. May be inactivated by beta-lactam antibiotics. nausea. itching. The Government provides the drugs for the total treatment period free of cost to the patients who come under the National TB control programme both hospital and domicilary treatment. D/I: Potentiate nephrotoxicity and ototoxicity produced by other aminoglycosides and cephalosporin. Reserve drugs Kanamycin Aminoglycoside antimicrobial I: Used as a second line drug to treat resistant tuberculosis. Frusemide increases the nephrotoxicity.75 g. C/I: Pregnancy. P/C: Breast·feeding. Dose: 0. thrombocytopenia. 0. P/A: Injection 0. 1 g vial. exfoliative dermatitis. cisplatin. neurotoxicity. D/I: It potentiates the neuromuscular block by action of muscle relaxants used in anaesthesia. P/A: Injection 0.daily for adult.15-20 mg/ kg in children for 2 months in the initial intensive phase. Combination packs are available for RNTCP programme. Single drug should not be used for the treatment of tuberculosis. 1 g vial. 367 .5 — 1 g IV/IM twice or thrice weekly. Synergism with benzyl penicillin . Ototoxicity potentiated by frusemide. Nerve damage may occur insome cases but it was more common with dihydrostreptomycin which is not commonly used at present. Monitor blood levels when the renal function is impaired.75 g . and headache. Plasma level will be increased by indomethacin. nephrotoxicity. vancomycin.

As a second line drug to treat resistant tuberculosis. thrombocytopenia and hypokalemia. Biz and folic acid deficiency. Tablet 125 mg. INH and ethionamide increases CNS toxicity. psychological disturbances. G. thrombocytopenia. acne. convulsions.Pro1onged use . gynaecomastia. and lactation. Psychosis.l upsets. impotence. and psychotic states. severe anxiety. Glycemic control may be difficult in diabetic patients. epilepsy. Plasma level of phenytoin increases to toxic levels. Nervousness. alopecia. It acts by inhibiting the cell walls synthesis. Alcohol increases the risk of convulsions.5 ~ 1. PAS was a first line drug in the treatment of tuberculosis. Psychiatric illness. pregnancy. Hepatic dysfunction. depression. 0. Causes Vit.0 g in two divided doses daily. Discontinue if allergy or CNS toxicity occurs. alcohol dependence. It reduces the chance of developing resistance to INH. Though its antituberculosis action is weak. Tablet 250 mg 10 mg/kg /day orally250-500 mg bd . suicidal attempts. headache.and renal failure. diplopia. Convulsions may occur when used with cycloserine.tuberculosis used prior to the development of the present day short course chemotherapy. it acts well to prevent the development of drug resistance against INH and streptomycin. 250 mg 12-15 mg/kg/day. At present PAS is only seldom used. Hepatic and renal toxicity. I: C/I: A/E: 368 Resistant tuberculosis as a companion drug. Reduce dose in renal impairment. C/I: P/C : A/E: P/A : Dose: D/ I: Ethionamide I: C/I: P/C: A/E: P/A: Dose: D/I: Para Aminosalicyclic Acid (PAS) This is a bacteriostatic drug for M. Hepatic and renal disorders GI upset.Drugs for Respiratory Diseases Cycloserine I: This is a second line antitubercular drug used in the treatment of resistant cases.convulsions.

Asthma and Chronic Obstructive Pulmonary Disease (COPD) Bronchodilators (Beta -2 adrenergic agonists) Salbutamol I: C/I : P/C : A/E: P/A: Dose: Asthma acute and chronic forms. 2. 3. Urine show reducing agent . 369 . premature labour.5 mg diluted with saline tds or qds.5 .200 mcg tds or qds. Do not attempt modifications of regimen.Drugs for Asthma and COPD may produce goiter and hypothyroidism.8mg Inhaler 100mcg/ md Syrup 2mg/ 5mL Oral tablets : 2-4 mg tds Children 2 mg tds Sustained release preparation : 4-8 mg bd. Patients with arrhythmias. DRUGS USED IN THE TREATMENT OF AIRWAY DISEASES 1. 12-15g in two divided dose for adults. The urinary excretory product reduces Benedict’s reagent and this may be mistaken for glycosuria occuring in diabetes mellitus. · Consult chest physician in case of adverse effect to drugs Never attempt to treat resistant or suspected resistant cases. Muscle tremor. Dose :2. Refer to a chest specialist. muscle cramps. elderly. those on other sympathomimetic drugs. pregnant women. 4 mg Capsules 4 mg. Tablets 2mg. restlessness.interferes with diabetic control. D/I: It reduces the absorption of rifampicin if taken together. COPD. prophylaxis of exercise induced asthma Thyrotoxicosis.5 g Granules 100 mg Dose: 300 mg/kg/day oral. P/A: Tablet 0.400 mcg tds or qds. Fluoroquinolones : Ciprofloxacin and sparfloxacin. tachycardia. hypersensitivity. Nebuliser : 5 mg / mL. ofloxacin Macrolides: Roxithromycin and clarithromycin Some points to be noted are: Refer cases which are difficult to diagnose. Inhaler : 100 . hypokalemia. to a chest specialist. 4. Rotahaler : 200 .

200mg.400mg.8. paradoxical bronchoconstriction. Tab 2mg (10) Rs.00-5. 250mg Injection 2mL ampoule Syrup20mg/ mL 370 . neonates. pregnancy.300mg.diuresis. lactation.600mg Capsule 100mg. COPD. vomiting.00 Asthma acute and chronic forms. hepatic disease and acid peptic disease.2 puffs (20 — 40) mcg tds or qds. A/E: Nausea. hypersensitivity. gastric disturbances.00 Inhaler 100mcg/ md (200md) Rs. COPD. gastric reflux. myocardial infarction. long term control and prevention of symptoms.Drugs for Respiratory Diseases D/ I : Cost : Hypokalemia with steroids and diuretics. A/E : Dry mouth. Terbutaline I: C/I : Anticholinergics Ipratropium Bromide I: COPD.epilepsy. prophylaxis of exercise induced asthma. lactation. relief of acute bronchospasm especially in patients with intolerance to beta 2 agonists. headache. Cost : Inhaler 20 mcg/puff (200md) Rs. hyperthyroidism. prostatic hypertrophy.131.2. potentiates the vascular effects of MAO inhibitors and tricyclic antidepressants.lactation.00 Theophylline I: Acute asthma. drug of choice for bronchospasm due to beta blocker medication C/I: Hypersensitivity P/C: Narrow angle glaucoma. premature labour. Thyrotoxicosis. P/A: Tablets 200mg.00 Cap 4 mg (10) Rs. P/C: Hypertension. Effects areantagonized by beta blockers. D/I: None reported. P/A : Inhaler 20 mcg/puff 200md Dose : 1 . glaucoma. cardiac arrythmias.67. C/I: Hypersensitivity. pregnancy.

371 I: . Children 1 5 mg / kg D/I: Increases risk of arrhythmias with sympathomimetics and halothane. 80 — 240 mg tid. A/E : Hypotension. for symptom relief. vomiting. erythromycin and allopurinol. Metabolism inhibited by beta blockers. and for rapid action parenterally or directly into the bronchial tree by aerosols. Cost : Tab100mg (1000) Rs. respiratory failure.d.Drugs for Tuberculosis Dose: Oral dose : Children : Controlled release D/I : Cost : Etophylline 169. hypersensitivity.6 mg/kg. 24 mg/kg/bw in divided doses.9. preparation : 400 — 600 mg o.headache.00 Systemic steroids These act by relieving the inflammation of the bronchial mucosa in asthma.7.96.00—15. CNS stimulation.00 Aminophylline Asthma. Metabolism is enhanced by rifampicin. cardiac arrhythmias and. neurotoxicity. Maintenance dose 2 3 . COPD.hepatic diseases. They relieve acute attacks immediately.4 mg / kg.00 Syrup20mg/mL (100mL) Rs. insomnia. seizures. lactation. pregnancy. congestive cardiac failure.4 mg/mL IV dose 2 mL 8hrly. seizures.00 Inj (2mL ampoule) Rs. Long term corticosteroid produce several adverse side effects and therefore it should be the aim to withdraw these as early as possible. Still a few persons become steroid dependent. Tab200mg (10) Rs. while it is reduced by ciprofloxacin. Corticosteroids may be given in a moderate dose or high dose short time basis for few days or in the minimum effective dose on a long term basis.3. C/I : Acid peptic disease. Tachycardia with pancuronium. children. phenobarbitone and alcohol. nausea. P/A : Tablets 100mg Injection 250mg/ 2mL Dose : Initial loading dose : 4 .00 Inj 250mg/ 2mL (10mL) Rs.11. They are very potent and antiasthmatic drugs which are active when given orally. P/C : Neonates. cimetidine. They also prevent the onset of acute paroxysms.

100mcg.Drugs for Respiratory Diseases Prednisolone (Refer Section 18) Hydrocortisone(Refer Section 18) INHALED STEROIDS Corticosteroids can be delivered directly into the respiratory tract in the form of aerosols through nebulizeres. Max 1600 mcg / day g Children 50 100 mcg b. When the drug is delivered as a inhalation only part of it reaches the respiratory tract. 40. None reported Inhaler 100mcg (200md) Rs. the restof it is swallowed. I: Preventive therapy of asthma. children.00 Rotacap 100mcg (30) Rs. Inhaler 50mcg. local fungal infections. hypersensitivity. age < 4 yrs.d. candidiasis. Adverse side effects are much less. Children :50 .800 mcg/ day in 2 . lactation.200mcg.100 mcg / day.d. Beclomethasone I: C/I : P/C : A/E : P/A: Dose : D/I : Cost : Long term prevention of asthma. 150. Pregnancy. lactation.00 Long term prevention of asthma Acute asthma.250mcg Spray 50mcg / md Rotacap 100mcg 400 . candidiasis. Pregnancy. A/E : Candidiasis.146. lactation. hoarseness.4 divided doses. The dose is also considerably smaller compared to oral andparenteral drugs. metered dose inhalers and rotahalers. hoarseness 372 . hypersensitivity. acute asthma P/C : Pregnancy.200 mcg b. Inhaler 100mcg/mdi 100 . local fungal infections.00 Budesonide I: C/I : P/C : A/E : P/A : Dose : D/I: Cost : Fluticasone propionate Glucocorticoid twice as potent as budesonide and beclomethasone. Hoarseness. C/I : Hypersensitivity. Acute asthma. None reported Inhaler 100mcg/ mdi (100md) Rs.

28. Cough. Neonates. corticosteroids are less potent immediate bronchodilators. Inhaler 2 mg/md. Hypersensitivity.00 Compared to salbutamol inhaler. preventive therapy prior to exposure to known allergen or exercise. increase to q.500 mcg Severe persistent : 500 . 161.500 mcg/ day Mild persistent asthma : 100 . Hypersensitivity Neonates.05 % w/w Dose : Adults : 250 . Cost : Cream 0.Drugs for Tuberculosis Inhaler 50mcg. urticaria. Asthmatic attacks are managed by inhalation of salbutamol.00 Inhalers (125 mcg) Rs. pregnancy and lactation .100 mcg/ day D/I: None reported. 250mcg Cream 0. 20 mg/cartridge By aerosol inhalation. rash.d. not yet recommended. 4mg (2 puffs) b. 50.05% w/w (5 g) Rs. bronchospasm. pregnancy and lactation Cough.250 mcg Moderate persistent : 250 . urticaria. rash.200 mcg / day. bronchospasm. Children under 12 years. P/A: Sodium cromoglycate I: Long term prevention of asthma symptoms.00 .125 mcg Rotacaps 100mcg. 350. Their main role is to prevent asthmatic paroxysm therefore they may be given as regular night time dose of 100 .35.s. if necessary. lnhaler 1 mg/mdi.00 Long term prevention of asthma symptoms.00 Rotacap (30) Rs. 20 mg/cartridge 2 puffs qds (1 mg / puff) None reported Inhaler l mg/md (400md) Rs. 373 C/I : P/C : A/E : P/A: Dose: D/I : Cost : I: Nedocromil sodium C/I : P/C: A/E: P/A : Dose: .1000 mcg Children : 50 . preventive therapy prior to exposure to known allergen or exercise.d. Preparations containing both corticosteroids and salbutamol are available.

food allergy.d.00 Tab 1 mg (10) Rs. lactation. 10. None reported so far Tablet 20 mg 20 mg bd.d.d. ~ Potentiate the effects of sedatives.00 P/C A/E P/A Dose: D/I: Cost : Leucotriene receptor antagonist Zafirlukast I: C/I: P/C: A/ E: P/A : Dose : Long term control and prevention of symptoms in mild persistent asthma for patients > 12 years of age Children Food reduces the absorption of the drug.42. slight dizziness.Pregnancy and breast feeding.00 . dry mouth. 1 mg b.Drugs for Respiratory Diseases Ketotifen I: C/I Prophylaxis of asthma. Drowsiness. pregnancy. CNS stimulation. Diabetics on oral hypoglycemic agents. Syrup 1 mg/5 mL. neonates (children under years). antihistamines and alcohol.15. 374 . So taken 1 h prior to or 2 h after food. Children : Over 2 years 1mg b. weight gain also reported. Tablet 1 mg.5 to 1 mg at night.00 . Previous anti-asthmatic treatment should be continued for a minimum of weeks after initiation of ketotifen treatment. Reversible fall in platelet count with concomitant use of oral antidiabetics. Inhibits warfarin metabolism. Syrup 1mg/5 mL (60 mL) Rs. with food increased if necessary to 2 mg b. hypnotics.. Initial treatment in readly sedated patients 0. hypersensitivity. acute attacks ofasthma. Tablet 10 at bedtime Montelukast: D/I: P/A: Dose : Newer drug delivery systems in asthma Metered Dose Inhalers Use chlorofluorocarbon propellant to carry the suspended drug particle at a great speed towards the pointed direction. 23.

epilepsy.Therefore this is the method of choice when asthma is severe. or by an electric ultrasonic nebulizer.Aminophylline is reserved for those unresponsive to the maximal dose of beta 2 agonists. 5 mg/ kg. This should be taught to the patient and the physician should satisfy himself that the technique is mastered. The success of inhalation therapy depends upon perfecting the technique of inhalation so as to deliver the maximum amount into the tracheobroncheal tree..laryngospasm following intubation.ln patients with poor hand mouth coordination.5 mg/kg/h as i. Nebulizers Nebulized drugs are delivered by a gas flow driving a jet nebulizer unit. budesonide and fluticasone. phaeochromocytoma. beclomethasone. 375 C/ I: . The advantage of nebulizer is that the aerosol reaches the respiratory tract alongwith inhaled air or oxygen without extra effort by the patient. budesonide. One of the frequent causes of failure if inhaled medication is improper technique. drug induced CNSdepression Heart disease. drip.v.Drugs available are : Salbutamol.ipratropium. post—operative respiratory failure. Respiratory Stimulant Doxapram I: Acute respiratory failure. then 0. beclomethasone. fluticasone. which produces the aerosol.Drugs that are used with nebulizer : Salbutamol. budesonide and acetyl cystine. Dry Powder Inhalers Here the drug is loaded as a capsule containing micronized particles in a lactose carrier called the rotacap. Precautions : Good hand mouth coordination is required and good inhaler technique is also a must. The apparatus used is called a rotahaler. ipratropium andcromoglycate. terbutaline.recent cerebro vascular accidents. salmeterol. So also inhalation should be takenat the earliest warning of asthma since inhalation will be ineffective if the paroxysm sets in. cerebral oedema.Drugs for Tuberculosis Drugs available are : Salbutamol. terbutaline. a spacer device is advisable in which the drug is delivered into a spacer and the patient inhales from this. salmeterol. Dose is initially.

60 mg 4 . Pholcodeine I: Dry unproductive cough. occular surgery.5 . P/C : Drowsiness. liver disease A/E : Constipation. cardiac disease. tachycardia. Dextromethorphan Non narcotic antitussive 376 . fasciculations and dyspnoea Injection 20mg 5mL.6 h. allergic reactions.6 h Children : 1. pneumothorax. avoid concurrent use of alcohol or other CNS depressant drugs. C/I : Hypersensitivity. Cough which is hazardous or tiring hernia.2.2 h till the patient wakes up.Drugs for Respiratory Diseases P/C: A/ E: P/A: Dose: D/ I: Cost: Pulmonary embolism. Caution if other medication containing opiods are used. Produces agitation with theophyllines Inj 20mg (5mL) Rs. physical dependence P/A: Only combination preparations are available. A/E : Constipation.5 .6 divided doses Dihydrocodeine I: Dry unproductive cough. liver disease. Hypertension. physical dependence P/A : Linctus (combination preparation) Dose: Adults : 5 . allergic reactions. C/I : Hypersensitivity. P/C : Caution if drowsiness. 20 mL 1.00 COUGH SUPPRESSANTS (Antitussives ) Codeine phosphate I: Dry unproductive cough.5 mg/Kg/ 24 hours in 4 — 6 divided doses Cost : No pure preparations available. Repeat every 1 . Dose: Adults : 30-60 mg 4-6h Children 1.5 .5 mg/kg/day in 4 · 6 divided doses D/I : Same as for codeine.5 — 2.2.5 mg/kg/day in 4 . neonates. dizziness occur.4 mg/ min IV infusion.10 mg 4 . pregnancy and liver diseases.33. Dose : Adults: 30 . Children 1.

4 mL) Reflexly acting Ammonium chloride Potassium iodide Ipecacuanha Mucolytics Bromhexine I: C/ I P/C : A/E: P/A: Dose Cost Acetylcysteine I: C/I Conditions where the sputum is viscid and tenaceous. diagnostic aid in bronchial studies. tds-qds. 6. 2 Tab 8 mg (10) Rs.3 -1 g ) Sodium/potassium acetate Potassium iodide (0. headache P/A: Only combinations are available. A/E : Nausea. lacrimation. Expectorants Increase bronchial secretions or reduce its viscosity.25.0. rhinorrhoea. Gastric irritation.2 . Use with caution in patients with gastric ulceration.00 Syrup 4 mg/5 mL (100 mL) Rs.00 Mucolytic. Dose: 15 . respiratory insufficiency.00 .8. hypersensitivity. allergic reactions.Cough Suppressants and Mucolytics I: Dry or painful cough C/I : Liver disease P/C : Same as codeine phosphate. Tablet 8 mg Syrup 4 mg / 5 mL 2 8-16 mg. 20. 1 Hypersensitivity. Directly acting Sodium/potassium citrate (0. vomiting. 377 .00 . Asthma.30 mg 4-6h D/I : MAO inhibitors Cost : Only combinations are available.3 g) Guaiphenesin Vasaka (2 .

nausea. To restore tissue oxygen tension towards normal by improving arterial oxygen content and subsequently to reduce the work of breathing and myocardial stress. clammy skin. Hemoptysis. rhinorrhea.5 mL of 10 .20% solution Tablet 30 mg Syrup 30 mg/ 5 mL Drops 7. fever.3. vomiting. Granule sachet Nebulising solution 200 mg bd. increasedairway obstruction.5 mg bd.75 to 7. P/A : Dose : P/A : Dose : Ambroxol Hydrochloride Oxygen Therapy Aim: 378 . Pungent smell. irritant to the bronchial tree.5 mg/mL Adult.Drugs for Respiratory Diseases P/C A/E : Check with physician if condition worsens. 3 .15 to 30 mg bd or tds Children .

Plan B: moderate dehydration. Breastfeeding should be continued on demand. Acute diarrhoea in children should always be treated with oral rehydration solution according to plans A. oral rehydration solution must be presented before offering milk. or even water) and zinc supplementation at home are sufficient. other children should receive milk and nutritious food as normal after completing the 4 hours of oral rehydration. For infants aged under 6 months who have not yet started taking solids. 379 . Whatever the child’s age. B. Plan A: no dehydration. It is recommended that parents are shown how to give approximately 75 ml/kg of oral rehydration solution over a 4-hour period. Nutritional advice. Zinc supplementation should begin as soon as the child can eat and has completed 4 hours of rehydration. health professionals are advised to follow one of 3 management plans. The child’s status must be reassessed after 4 hours to decide on the most appropriate subsequent treatment. potassium. citrate and glucose. a 4-hour treatment plan is applied to avoid short-term problems. the contribution of breastfeeding must be increased. rice. for as long as the child continues to have diarrhoea. and it is suggested that parents should be watched to see how they cope at the beginning of the treatment. In the case of mixed breast-milk/formula feeding. water and yoghurt. or C as shown Treatment of dehydration: WHO recommendations According to the degree of dehydration. Oral rehydration solution should continue to be offered once dehydration has been controlled. increased fluid intake (soup. In case of vomiting. A larger amount of solution can be given if the child continues to have frequent stools.SECTION 28 SOLUTIONS CORRECTING WATER. Mother’s milk or dried cow’s milk must be given without any particular restrictions. rehydration must be discontinued for 10 minutes and then resumed at a slower rate. ELECTROLYTE AND ACID BASE DISTURBANCES ORAL Oral rehydration salts Replacement of fluid and electrolytes orally can be achieved by giving oral rehydration salts—solutions containing sodium. Parents should be advised about circumstances in which they should seek further advice.

it is recommended that compound solution of sodium lactate (or. the rate of administration of the oral solution should be reduced. B or C.6 g/litre of clean water 2. sodium chloride 0.5 g/litre of clean water When glucose and sodium citrate are not available. If the child vomits.9 g/litre of clean water 1.5 hours respectively). child over 12 months: the same amounts over 30 minutes and 2.5 g/L sodium chloride: 2.9 g/L Glucose salt solution sodium chloride sodium citrate [dihydrate] potassium chloride glucose (anhydrous) 2. In hospital (or elsewhere). The solution may be prepared either from prepackaged sugar/ salt mixtures or from bulk substances and water. preferably with recently boiled and cooled water.9% intravenous infusion) is administered at a rate adapted to the child’s age (infant under 12 months: 30 ml/kg over 1 hour then 70 ml/ kg over 5 hours. Solutions must be freshly prepared. they may be replaced by sucrose (common sugar) 27 g/litre of clean water sodium bicarbonate 2. but most urgent priority is to start rehydration. Hospitalization is necessary. electrolyte and acid base disturbances Plan C: severe dehydration.5 g/litre of clean water 13. if the child can drink. Accurate weighing and thorough mixing and dissolution of ingredients in the correct volume of clean water is important. if this is unavailable. Oral rehydration salts Glucose: 75 mEq sodium: 75 mEq or mmol/L chloride: 65 mEq or mmol/L potassium: 20 mEq or mmol/Lcitrate: 10 mmol/L osmolarity: 245 mOsml glucose: 13.5 g/litre of clean water NOTE. a nasogastric tube is also suitable for administering oral rehydration solution at a rate of 20 ml/kg every hour for 6hours. and even during. For intravenous supplementation. Reassess the child’s status after 3 hours (6 hours for infants) and continue treatment as appropriate with plan A.5 gl trisodium citrate dihydrate+: 2. Administration of more concentrated solutions can result in hypernatraemia 380 . intravenous infusion (20 ml/kg every hour by mouth before infusion.Solutions correcting water.6 g/L potassium chloride: 1. then 5 ml/kg every hour by mouth during intravenous rehydration). If the intravenous route is unavailable. oral rehydration solution must be given pending.

by mouth. solution after every loose motion. Potassium supplements are seldom required with the small doses of diuretics given to treat hypertension. Compensation for potassium loss is necessary in patients taking digoxin or antiarrhythmic drugs where potassium depletion may induce arrhythmias. hypernatraemia and hyperkalaemia may result from overdose in renal impairment or administration of too concentrated a solution Fluid and electrolyte loss in acute diarrhoea. Potassium-sparing diuretics (rather than potassium supplements) are recommended for prevention of hypokalaemia due to diuretics such as furosemide or the thiazides when these are given to eliminate oedema. Smaller doses must be used if there is renal insufficiency (common in the elderly) otherwise there is a danger of hyperkalaemia.Larger doses may be required in established potassium depletion. the quantity depending on the severity of any continuing potassium loss (monitoring of plasma potassium and specialist advice required).corticosteroids). INFANT and CHILD according to Plans A.Oral rehydration Salts I: P/C: A/E: Dose: dehydration from acute diarrhoea renal impairment vomiting—may indicate too rapid administration. B or C (see above) Potassium chloride Powder for solution.Measures may also be required during long-term administration of drugs known to induce potassium loss (for example. liver cirrhosis. It is (renal arterystenosis. For the prevention of hypokalaemia doses of potassium chloride 2 to 4 g (approximately 25 to 50 mmol) daily by mouth are suitable in patients taking a normal diet. Potassium depletion is frequently associated with metabolic alkalosis and chloride depletion and these disorders require correction.ADULT 200–400 mL.Measures to compensate for potassium loss may also be required in the elderly since they often take inadequate amounts in the diet. plasma potassium concentration above 5 mmol/litre 381 . the nephrotic syndrome. severe heart failure) and those with excessive loss of potassium in the faeces (chronic diarrhoea associated with intestinal malabsorption or laxative abuse). I: C/I: prevention and treatment of hypokalaemia severe renal impairment.

ifsodium chloride is required. A/E: Dose: Parenteral Solutions of electrolytes are given intravenously.and in elderly or seriously ill patients it is often helpful to monitor the right atrial (central) venous pressure. for example 20% glucose.Chronic hyponatraemia should ideally be managed by fluid restriction. phosphate. ileus and ascites. the deficit should be corrected slowly to avoid risk of osmotic demyelination syndrome.Isotonic solutions may be infused safely into a peripheral vein. to meet normal fluid and electrolyte requirements or to replenish substantial deficits or continuing losses. ACE inhibitors or ciclosporin. Sodium chloride in isotonic solution provides the most important extracellular ions in near physiological concentrations and is indicated in sodium depletion which may arise from conditions such as gastroenteritis. In a severe deficit of from 4 to 8 litres. However.The nature and severity of the electrolyte imbalance must be assessed from the history and clinical and biochemical examination of each individual. the rise in plasma-sodium concentration should not exceed 10 382 . magnesium. electrolyte and acid base disturbances P/C: elderly . adult 20–50 mmol daily after meals. diabetic ketoacidosis.Solutions correcting water. 2 to 3 litres of isotonic sodium chloride may be given over 2 to 3 hours. adult 40–100 mmol daily in divided doses after meals: adjust dose according to severity of deficiency and any continuing loss of potassium reconstitution and administration. when the patient is nauseated or vomiting and is unable to take adequate amounts by mouth. chloride. the jugular venous pressureshould be assessed. thereafter infusion can usually be at a slower rate. and water depletion can occur singly and in combination with or without disturbances of acid-base balance. Sodium. are best given through an indwelling catheter positioned in a large vein.Potassium depletion. More concentrated solutions. gastrointestinal irritation Prevention of hypokalaemia by mouth. important: special hazard if given with drugs liable to raise plasma potassium concentrations such as potassium-sparing diuretics. potassium. mild to moderate renal impairment history of peptic ulcer.Excessive administration should be avoided. the bases of the lungs should be examined for crepitations. nausea and vomiting. by mouth.

The more physiologically appropriate compound solution of sodium lactatecan be used instead of isotonic sodium chloride solution during surgery or in the initial management of the injured or wounded. Combined sodium. Sodium chloride and glucose solutions are indicated when there is combined water and sodium depletion. and water depletion may occur. In severe hyponatraemia.9% and glucose intravenous infusion 5% with potassium as appropriate.Excessive loss of water without loss of electrolytes is uncommon.8% may be used with caution. this concentration is very irritant on extravasation and it is also viscous and difficult to administer. during treatment of diabetic ketoacidosis. replacement is carried out with sodium chloride intravenous infusion 0. The volume of glucose solution needed to replace deficits varies with the severity of the disorder. as for example may occur in coma or dysphagia or in the elderly or apathetic who may not drink water in sufficient amount on their own initiative. but usually lies within the range of 2 to 6 litres. 383 . chloride. for example. Water depletion (dehydration) tends to occur when these losses are not matched by a comparable intake. A 1:1 mixture of isotonic sodium chloride and 5%glucose allows some of the water (free of sodium) to enter body cells which suffer most from dehydration while the sodium salt with a volume of water determined by the normal plasma Na+ remains extracellular.5 litres daily and this is needed to balance unavoidable losses of water through the skin and lungs and to provide sufficient for urinary excretion. Glucose solutions (5%) are mainly used to replace water deficits and should be given alone when there is no significant loss of electrolytes. Larger volumes of less concentrated glucose solutions (10% or 20%) can be used as alternatives and are less irritant. Glucose solutions are also given in regimens with calcium. with severe diarrhoea or persistent vomiting.Parental Solutions mmol/litre in 24 hours. occurring in fevers.If glucose or sugar cannot be given orally to treat hypoglycaemia. when they must be accompanied by continuing insulin infusion. after correction of hyperglycaemia. Average water requirement in a healthy adult are 1. They are also given. potassium. intravenous infusion of sodium chloride 1. and in uncommon waterlosing renal states such as diabetes insipidus or hypercalcaemia. glucose 50% may be given intravenously into a large vein through a large-gauge needle. hyperthyroidism. and insulin for the emergency treatment of hyperkalaemia. bicarbonate.5 to 2.

384 . for example blood pH < 7. Intravenous potassium chloride in sodium chloride infusion is the initial treatment for the correction of severe hypokalaemia when sufficient potassium cannot be taken by mouth. Repeated measurements of plasma potassium are necessary to determine whether further infusions are required and to avoid the development of hyperkalaemia which is especially likely to occur in renal impairment. Sodium hydrogen carbonate is also used in the emergency management of hyperkalaemia. especially if hypertonic. electrolyte and acid base disturbances Sodium hydrogen carbonate (sodium bicarbonate) is used to control severe metabolic acidosis (as in renal failure). in these circumstances sodium hydrogen carbonate is best given in a small volume of hypertonic solution (for example 50 ml of 8. provided the kidneys are not primarily affected and the degree of acidosis is not so severe as to impair renal function. and given slowly over 2 to 3 hours with specialist advice and ECG monitoring in difficult cases.treatment of hypoglycaemia diabetes mellitus (may require additional insulin) glucose injections. it is reasonable to correct this first by the administration of isotonic sodium chloride intravenous infusion.4% solution intravenously).9% infusion. sodium hydrogen carbonate (1. In these circumstances. may have a low pH and cause venous irritation and thrombophlebitis. a total volume of up to 6 litres (4 litres of sodium chloride and 2 litres of sodium hydrogen carbonate) may be necessary in the adult. isotonic sodium chloride alone is usually effective as it restores the ability of the kidneys to generate bicarbonate. In severe shock due for example to cardiac arrest. Initial potassium replacement therapy should not involve glucose infusions because glucose may cause a further decrease in the plasmapotassium concentration.1. fluid and electrolyte disturbances. thoroughly mixed.4%) may be infused with isotonic sodium chloride when the acidosis remains unresponsive to correction of anoxia or fluid depletion. plasma pH should be monitored. In renal acidosis or in severe metabolic acidosis of any origin.Solutions correcting water. Since this condition is usually attended by sodium depletion. Glucose I: P/C: A/E: fluid replacement without significant electrolyte deficit). metabolic acidosis may develop without sodium depletion. Potassium chloride concentrate may be added to sodium chloride 0.

Dose: Fluid replacement. hyperglycaemia (on prolonged administration of hypertonic solutions) P/A: Injectable solution: 5%. 10% isotonic. adult and child determined on the basis of clinical and.2% in 20-ml ampoule (equivalent to K+ 1. adult and child depending on the deficit or the daily maintenance requirements (see also notes above)dilution and administration. by slow intravenous infusion. 0. 25 ml Glucose with sodium chloride I: fluid and electrolyte replacement P/C: restrict intake in impaired renal function. electrolyte monitoring Potassium chloride I: electrolyte imbalance. specialist advice and ECG monitoring. peripheral and pulmonary oedema.18% sodium chloride (equivalent to Na+30 mmol/l.Parental Solutions oedema or water intoxication (on prolonged administration or rapid infusion of large volumes of isotonic solutions). Cl-30 mmol/l). Must be diluted and thoroughly mixed before use and administered according to manufacturer’s directions 385 . adult.5 mmol/ml). by intravenous infusion. Dose: Electrolyte imbalance. hypertension. by intravenous infusion of 50% glucose solution into a large vein. whenever possible. renal impairment.2 g (43 mmol)/litre. Cl. A/E: cardiac toxicity on rapid infusion P/A: Solution: 11. Dose: Fluid replacement. by intravenous infusion. toxaemia of pregnancy A/E: administration of large doses may give rise to oedema P/A: Injectable solution: 4% glucose. electrolyte monitoring Treatment of hypoglycaemia. cardiac failure. see also oral potassium P/C: for intravenous infusion the concentration of solution should not usually exceed 3.1.5 mmol/ml. 50% hypertonic. adult and child determined on the basis of clinical and. whenever possible.

Cl. especially in renal impairment.4% isotonic (equivalent to Na+ 167 mmol/L. hypertension. electrolyte monitoring (see notes above) Sodium hydrogen carbonate metabolic acidosis metabolic or respiratory alkalosis.4%) or by continuous intravenous infusion.4%). large doses may give rise to sodium accumulation and oedema. Dose: Metabolic acidosis. monitor electrolytes and acid-base status A/E: excessive administration may cause hypokalaemia and metabolic alkalosis. Solution: 8. HCO3. adult and child a strong solution (up to 8. hypocalcaemia. peripheral and pulmonary oedema. compound solution Injectable solution.9% isotonic (equivalent to Na+ 154 mmol/l.cardiac failure. Various solutions can serve as alternatives. an amount appropriate to the body base deficit (see notes above) Sodium lactate. hypochlorhydria P/C: restrict intake in impaired renal function . adult and child determined on the basis of clinical and. whenever possible.167 mmol/L).Solutions correcting water.4% in 10-ml ampoule (equivalent to Na+ 1000 mmol/L.1000 mmol/L). by intravenous infusion.154 mmol/L). P/A : Injectable solution: 1. HCO3. toxaemia of pregnancy. electrolyte and acid base disturbances Sodium chloride I: P/C: A/E: P/A: Dose: electrolyte and fluid replacement restrict intake in impaired renal function . hypertension.cardiac failure. Fluid and electrolyte replacement. toxaemia of pregnancy administration of large doses may give rise to sodium accumulation and oedema Injectable solution: 0.adult and child a weaker solution (usually 1. 386 I: C/I: . peripheral and pulmonary oedema. Compound solution of sodium lactate is a representative intravenous electrolyte solution. by slow intravenous injection.

and less prone to complications. levels 387 . by intravenous infusion. administration of large doses may give rise to oedema Fluid and electrolyte replacement or hypovolaemic shock. Most controversially.Parental Solutions I: C/I: P/C: A/E: Dose: pre.. whenever possible. electrolyte monitoring (see notes above) Miscellaneous Water for injection 2-mL. It has been used for comatose patients. cardiac failure. Uses: in preparations intended for parenteral administration and in other sterile preparations Total parenteral nutrition Total parenteral nutrition (TPN).and perioperative fluid and electrolyte replacement. 10-mL ampoules. TPN has extended the life of a small number of children born with nonexistent or severely deformed guts. Feeding schedules vary. is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired (Kozier et al. The pump infuses a small amount (0. between 500 mL and 4 L is provided. 2004). peripheral and pulmonary oedema. but one common regimen ramps up the nutrition over one hour. The person receives nutritional formulas containing salts.1 to 10 mL/hr) continuously in order to keep the vein open. adult and child determined on the basis of clinical and. hypocalcaemia or hypochlorhydria restrict intake in impaired renal function. 5-mL. and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. hypertension. bypassing the usual process of eating and digestion.The preferred method of delivering TPN is with a medical infusion pump. lipids and added vitamins. although enteral feeding is usually preferable. Total parenteral nutrition (TPN). Short-term TPN may be used if a person’s digestive system has shut down (for instance by Peritonitis). also referred to as Parenteral nutrition (PN). glucose. is the practice of feeding a person intravenously. Long-term TPN is occasionally used to treat people suffering the extended consequences of an accident or surgery. toxaemia of pregnancy excessive administration may cause metabolic alkalosis. hypovolaemic shock metabolic or respiratory alkalosis. amino acids. A sterile bag of nutrient solution.

and then ramps it down over a final hour. Battery-powered ambulatory infusion pumps can be used with chronic TPN patients. Complications The most common complication of TPN use is bacterial infection. Chronic TPN is performed through a central intravenous catheter. Another common practice is to use a PICC line. such as the subclavian with the tip in the superior vena cava. In critical and/or perioperative care Parenteral nutrition is indicated to prevent the adverse effects of malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. which originates in the arm. This should be done over 12 to 14 hours rather than intermittently during the day. or bowel obstruction. usually due to the increased infection risk from having an indwelling central venous catheter. chronic TPN patients can live quite normal lives. and extends to one of the central veins. Other indications are short gut syndrome. in order to simulate a normal metabolic response resembling meal time. as different patients will have differing abilities to tolerate starvation.Solutions correcting water. highoutput fistula. electrolyte and acid base disturbances off the rate for a few hours.Two related complications of TPN are venous thrombosis and rarely priapism. However. which may result in bile stasis in the gallbladder. fungal infections can also occur. The risk of acute cholecystitis is increased accordingly. sometimes the umbilical vein is used.Aside from their dependence on a pump. may sometimes occur. In infants. prolonged ileus. the decision to initiate TPN needs to be made on an individual patient basis. usually through the subclavian or jugular vein with the tip of the catheter at the superior vena cava without entering the right atrium. Liver failure. Usually the pump and a small (100 mL) bag of nutrient (to keep the vein open) are carried in a small bag around the waist or on the shoulder. Patients can receive the majority of their infusions while they sleep and instill heparin in their catheters when they are done to simulate a more “normal” life style off the pump. Outpatient TPN practices are still being refined but have been used for years. Fat infusion during TPN is assumed to contribute to both. often related to Fatty liver.Total parenteral nutrition increases the risk of acute cholecystitis due to complete unusage of gastrointestinal tract. In patients with frequent bacterial infections. The nutrient 388 . This condition is generally due to excess in glucose provided in TPN solutions.

amino acids. the intravenous route is one of the fastest ways to deliver fluids and medications throughout the body. 389 . The complication rate at the time of insertion should be less than 5%. Catheter-related infections may be minimised by appropriate choice of catheter and insertion technique. Catheter complications include pneumothorax. but can be treated with insulin added to the TPN solution. proteins. minerals and trace elements are added or given separately. once the needle is in place. The needle is inserted through the skin into a vein.. Some medications. Intravenous therapy Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous. Severe hepatic dysfunction is a rare complication. INTRAVENOUS ACCESS DEVICES Needle and syringe The simplest form of intravenous access is a syringe with an attached hypodermic needle. and lipids to be administered. patients receiving TPN have a higher rate of infectious complications. can only be given intravenously. Compared with other routes of administration. it is common to draw back slightly on the syringe to aspirate blood. Complications are either related to Catheter insertion.Total Parental Nutritions solution consists of water and electrolytes. Hyperglycemia is common at the start of therapy. Overall. as well as blood transfusions and lethal injections. glucose. especially one of the metacarpal veins. Metabolic complications include the Refeeding Syndrome characterised by hypokalemia. Usually it is necessary to use a tourniquet first to make the vein bulge. This can be related to hyperglycemia. This is most easily done with an arm vein. or Metabolic (including the Refeeding syndrome). continuous administration is called an intravenous drip. Previously lipid emulsions were given separately but it is becoming more common for a “three-in-one” solution of glucose. and lipids. essential vitamins. and catheter-related sepsis. thus verifying that the needle is really in a vein. accidental arterial puncture. then the tourniquet is removed before injecting. hypophosphatemia and hypomagnesemia. Hypoglycaemia is likely to occur with abrupt cessation of TPN. and the contents of the syringe are injected through the needle into the bloodstream. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration (demonstrated by elevated transaminases).

it can be connected to a syringe or an intravenous infusion line.Solutions correcting water. and 22-gauge (allpurpose pediatric line). making any future access extremely difficult or impossible. If a patient needs frequent venous access. Originally. commonly performed by paramedics and emergency physicians. electrolyte and acid base disturbances Peripheral IV lines Peripheral IV in hand This is the most common intravenous access method in both hospitals and pre-hospital services. Blood can be drawn from a peripheral IV if necessary. or capped with a bung between treatments. The most common sizes are 16-gauge (midsize line used for blood donation and transfusion).and 20gauge (all-purpose line for infusions and blood draws). accounting for their popularity in emergency medicine. Arm and hand veins are typically used although leg and foot veins are occasionally used. On infants the scalp veins are sometimes used. Blood draws are typically taken with specialized IV access sets known as phlebotomy kits.” and the person attempting to obtain the access must find a new access site proximal to the “blown” area. and once the draw is complete.and 14-gauge peripheral lines actually deliver equivalent volumes of fluid faster than central lines. A peripheral IV line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein. however. Veins in the arm are the common site in emergency settings. 18. the needle is removed and the site is not used again. The caliber of cannula is commonly indicated in gauge. the veins may scar and narrow. this system is still 390 . The part of the catheter that remains outside the skin is called the connecting hub. this situation is known as a “blown vein. Ported cannulae have an injection port on the top that is often used to administer medicine. The adage “time is tissue” should be paramount during times like these or if the patient is at risk for a cardiac event. a peripheral IV was simply a needle that was taped in place and connected to tubing rather than to a syringe. 12. these lines are frequently called “large bores” or “trauma lines”. There are times. peripheral vascular disease and IV drug abuse. when underlying physiological factors (morbid obesity. but only if it is in a relatively large vein and only if the IV is newly inserted. with 14 being a very large cannula (used in resuscitation settings) and 24-26 the smallest. to name a few) make insertion into any available vein a medical necessity—particularly if the patient is exsanguinating.

usually the superior vena cava or inferior vena cava. which is usually taped in place or secured with a self-adhesive dressing. Today. saline is now the solution of choice for a “vac lock”. The CDC updated their guidelines and now advise the cannula need to be replaced every 96 hours. sets and flushes contain a small amount of the anticoagulant heparin to keep the line from clotting off. There is room for multiple parallel compartments (lumen) within the catheter. the needle is then removed and discarded. In the United Kingdom. because of the risk of insertion-site infection leading to phlebitis. or within the right atrium of the heart. Central IV lines Central IV lines flow through a catheter with its tip within a large vein. cellulitis and sepsis. consists of an inch or so of flexible tubing and a locking hub. The external portion of the catheter. A peripheral IV cannot be left in the vein indefinitely. now include intravenous cannula. 391 . hospitals use a safer system in which the catheter is a flexible plastic tube that originally contains a needle to allow it to pierce the skin. However.[1] This was based on studies organised to identify causes of Methicillin-resistant Staphylococcus aureus MRSA infection in hospitals. and frequently are called “heparin locks” or “hep-locks”. Medications reach the heart immediately. For centrally placed IV lines. This method is a variation of the Seldinger technique. This has several advantages over a peripheral IV: · · · It can deliver fluids and medications that would be overly irritating to peripheral veins because of their concentration or chemical composition. These include some chemotherapy drugs and total parenteral nutrition. central venous catheters and urinary catheters as the main factors increasing the risk of spreading antibiotic resistant strain bacteria in hospitals. so that multiple medications can be delivered at once even if they would not be chemically compatible within a single tube. and are quickly distributed to the rest of the body. heparin is no longer recommended as a locking solution for peripheral IVs. the UK Department of health published their finding about risk factors associated with increased MRSA infection. while the soft catheter stays in the vein.Intravenous access device used for blood donation sets. as the IV access will only be needed for a few minutes and the donor may not move while the needle is in place.

is externally unobtrusive. Central venous lines There are several types of catheters that take a more direct route into central veins. poses a relatively low risk of bleeding. and also somewhat vulnerable to occlusion or damage from movement or squeezing of the arm. A PICC may have two parallel compartments.Solutions correcting water. There are several types of central IVs. Peripherally inserted central catheter PICC lines are used when intravenous access is required over a prolonged period of time. electrolyte and acid base disturbances Caregivers can measure central venous pressure and other physiological variables through the line. depending on the route that the catheter takes from the outside of the body to the vein. except that the tubing is slightly wider. The insertion site must be covered by a larger sterile dressing than would be required for a peripheral IV. In the simplest type of central venous access. a PICC poses less of a systemic infection risk than other central IVs. These are collectively called central venous lines. or total parenteral nutrition. The PICC line is inserted into a peripheral vein using the Seldinger technique under ultrasound guidance. due to the higher risk of infection if bacteria travel up the catheter. because bacteria would have to travel up the entire length of the narrow catheter before spreading through the bloodstream. a catheter is inserted into a subclavian. and then carefully advanced upward until the catheter is in the superior vena cava or the right atrium. a single-lumen PICC resembles a peripheral IV. The chief disadvantage is that it must travel through a relatively small peripheral vein and is therefore limited in diameter. This is usually done by feel and estimation. and can be left in place for months to years for patients who require extended treatment. or (less commonly) a femoral vein and 392 · . each with its own external connector (double-lumen). as in the case of long chemotherapy regimens. However. internal jugular. or a single tube and connector (singlelumen). Triple connectors (triple-lumen) catheters and power-injectable PICCs are now available as well. extended antibiotic therapy. an X-ray then verifies that the tip is in the right place. From the outside. usually in the arm. The chief advantage of a PICC over other types of central lines is that it is easy to insert.

Forms of intravenous therapy Intravenous drip An intravenous drip is the continuous infusion of fluids. however. If it is plugged it becomes a hazard as a thrombus will eventually form with an accompanying risk of embolisation. through an IV access device. Colloids contain larger insoluble molecules. Medication is administered intermittently by placing a small needle through the skin. Removal of a port is usually a simple outpatient procedure. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. it has a small reservoir that is covered with silicone rubber and is implanted under the skin. instead. called a Hickman line or Broviac catheter. blood itself is a colloid. piercing the silicone. Ports cause less inconvenience and have a lower risk of infection than PICCs. these catheters are also made of materials that resist infection and clotting. The cover can accept hundreds of needle sticks during its lifetime. is inserted into the target vein and then “tunneled” under the skin to emerge a short distance away. When the needle is withdrawn the reservoir cover reseals itself. with or without medications. Implantable ports A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does not have an external connector. or for blood transfusion. since bacteria from the skin surface are not able to travel directly into the vein. the port must be accessed monthly and flushed with an anticoagulant.Intravenous access device advanced toward the heart until it reaches the superior vena cava or right atrium. This may be to correct dehydration or an electrolyte imbalance. Because all of these veins are larger than peripheral veins. crystalloids and colloids. such as gelatin. or the patient risks it getting plugged up. central lines can deliver a higher volume of fluid and can have multiple lumens. Another type of central line. if this is done however. to deliver medications. installation is more complex and a good implant is fairly dependent on the skill of the radiologist. This reduces the risk of infection. into the reservoir. 393 . IV fluids There are two types of fluids that are used for intravenous drips. and are therefore commonly used for patients on long-term intermittent treatment. It is possible to leave the ports in the patient’s body for years.

9% NaCl 154 154 0 0 Lactated Ringer 130 109 0 0 Ringer’s lactate also has 28 mmol/L lactate.Solutions correcting water. Another difference is that crystalloids generally are much cheaper than colloids The most commonly used crystalloid fluid is normal saline. 2+ 394 .3% Dextrose / 0. 4 mmol/L K+ and 3 mmol/ L Ca . which is close to the concentration in the blood (isotonic). is often used instead if the patient is at risk for having low blood sugar or high sodium. The choice of fluids may also depend on the chemical properties of the medications being given. However. A solution of 5% dextrose in water.45% NaCl [Na+] [Cl-] [Glucose] [Glucose] (mmol/L) (mmol/L) (mmol/L) (mg/dl) 0 0 278 5000 2/3D & 1/3S 51 51 185 3333 Half-normal saline Normal saline Ringer’s lactate 77 77 0 0 0. 4 mmol/L K+ and 3 mmol/L Ca2+. Ringer’s lactate or Ringer’s acetate is another isotonic solution often used for large-volume fluid replacement. while. there is still controversy to the actual difference in efficacy by this difference. Ringer’s acetate also has 28 mmol/L acetate. sometimes called D5W. this parameter is decreased by chrystalloids due to haemodilution.3% saline 0. on the other hand. electrolyte and acid base disturbances Colloids preserve a high colloid osmotic pressure in the blood.9% concentration. a solution of sodium chloride at 0. Composition of Common Crystalloid Solutions Solution D5 Other Name 5% Dextrose 3.

sterile container (glass bottle. a long sterile tube with a clamp to regulate or stop the flow. and does not require additional fluid. Once a medicine has been injected into the fluid 395 .. e. Some medications are also given by IV push. but in cases where a change in the flow rate would not have serious consequences. making it easy to see the flow rate (and also reducing air bubbles).Forms of Intravenous Therapy Effect of Adding One Litre Solution D5 2/3D & 1/3S Half-normal saline Normal saline Ringer’s lactate Change in ECF 333 mL 556 mL 667 mL 1000 mL 900 mL Change in ICF 667 mL 444 mL 333 mL 0 mL 100 mL Infusion equipment A standard IV infusion set consists of a pre-filled. plastic bottle or plastic bag) of fluids with an attached drip chamber which allows the fluid to flow one drop at a time. a connector to attach to the access device. the drip is often left to flow simply by placing the bag above the level of the patient and using the clamp to regulate the rate. or if pumps are not available. if it might irritate the vein or cause a too-rapid effect). the tubing is disconnected from the IV access device. Intermittent infusion Intermittent infusion is used when a patient requires medications only at certain times. meaning that a syringe is connected to the IV access device and the medication is injected directly (slowly. This is either an inflatable cuff placed around the fluid bag to force the fluid into the patient or a similar electrical device that may also heat the fluid being infused. adding a dose of antibiotics to a continuous fluid drip.g. A rapid infuser can be used if the patient requires a high flow rate and the IV access device is of a large enough diameter to accommodate it. and connectors to allow “piggybacking” of another infusion set onto the same line. An infusion pump allows precise control over the flow rate and total amount delivered. but after the complete dose of medication has been given. this is a gravity drip. It can use the same techniques as an intravenous drip (pump or gravity drip).

An infected central IV poses a higher risk of septicemia. but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given.Solutions correcting water. The IV device must be removed and if necessary re-inserted into another extremity. It is characterized by coolness and pallor to the skin as well as local edema. and of cancer patients undergoing chemotherapy. in which case the incident is known as extravasation 396 . swelling. Risks of intravenous therapy Infection Any break in the skin carries a risk of infection. become hardened and difficult to access over time. following the injection to push the medicine into the bloodstream more quickly. electrolyte and acid base disturbances stream of the IV tubing there must be some means of ensuring that it gets from the tubing to the patient. the peripheral veins of intravenous drug addicts. and redness around the vein. Infiltration is one of the most common adverse effects of IV therapy and is usually not serious unless the infiltrated fluid is a medication damaging to the surronding tissue. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. If bacteria do not remain in one area but spread through the bloodstream. Due to frequent injections and recurring phlebitis. Phlebitis Phlebitis is irritation of a vein that is not caused by infection. redness. Infiltration Infiltration occurs when an IV fluid accidentally enters the surronding tissue rather than the vein. as it can deliver bacteria directly into the central circulation. causing easily visible swelling. a second fluid injection is sometimes used. Infection of IV sites is usually local. a “flush”. Usually this is accomplished by allowing the fluid stream to flow normally and thereby carry the medicine into the bloodstream. Although IV insertion is a sterile procedure. Symptoms are warmth. the infection is called septicemia and can be rapid and life-threatening. It is usually not painful. skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. or bacteria may be accidentally introduced inside the catheter from contaminated equipment. however. pain. and fever.

this is called embolism. magnesium. potassium. can cause life-threatening damage to pulmonary circulation. Air bubbles of less than 30 milliliters are thought to dissolve into the circulation harmlessly. and it is nearly impossible to inject air through a peripheral IV at a dangerous rate.g. Electrolyte imbalance Administering a too-dilute or too-concentrated solution can disrupt the patient’s balance of sodium. Fatality by air embolism is vanishingly rare. One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. This occurs more frequently with chemotherapeutic agents. Embolism A blood clot or other solid mass. A larger amount of air. and pulmonary edema. in part because it is also difficult to diagnose. if extremely large (3-8 milliliters per kilogram of body weight). or directly (e. heart failure. can be delivered into the circulation through an IV and end up blocking a vessel. 397 . A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Extravasation Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue. either by leakage (e. but ongoing studies hypothesize that these “micro-bubbles” may have some adverse effects. can stop the heart. if delivered all at once.Forms of Intravenous Therapy Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. because of brittle veins in very elderly patients). as well as an air bubble. Air bubbles can leave the blood through the lungs.g. The risk is greater with a central IV. and other electrolytes. because the needle has punctured the vein and the infusion goes directly into the arm tissue). Possible consequences include hypertension. since large solid masses cannot travel through a narrow catheter. Small volumes do not result in readily detectable symptoms. Hospital patients usually receive blood tests to monitor these levels. or. Peripheral IVs have a low risk of embolism.

This dietary requirement varies with age and is relatively greater in childhood. in children the recommended intake of iodine is 50 micrograms daily for infants under 1 year. Deficiency causes endemic goitre and results in endemic cretinism (characterized by deaf-mutism. ergocalciferol (vitamin D) and pyridoxine (vitamin B) may have severe adverse effects. Calcium supplements are usually only required where dietary calcium intake is deficient. Iodine and iodides may suppress neonatal thyroid function and in general iodine compounds should be avoided in pregnancy. pregnancy and lactation due to an increased demand. Calcium gluconate is also used in cardiac resuscitation. intellectual deficit. a calcium intake which is double the recommended daily amount reduces the rate of bone loss. It has often been suggested but never convincingly proved. due to impaired absorption. impaired mental function in children and adults and an increased incidence of still-births and perinatal and infant mortality. Minerals Calcium gluconate. Where it is essential to prevent neonatal goitre and cretinism. which have no more than placebo value. The recommended intake of iodine is 150 micrograms daily (200 micrograms daily in pregnant and breastfeeding women). Control of iodine deficiency largely depends upon salt iodization with potassium iodide or potassium iodate and through dietary diversification. iodine should not be witheld from pregnant women. In areas where iodine deficiency disorders are moderate to 398 . that subclinical vitamin deficiencies cause much chronic ill-health and liability to infections. and in old age. In osteoporosis. Most vitamins are comparatively non-toxic but prolonged administration of high doses of retinol (vitamin A). Iodine is among the body’s essential trace elements.SECTION 29 VITAMINS AND MINERALS VITAMINS Vitamins are used for the prevention and treatment of specific deficiency states or when the diet is known to be inadequate. 90 micrograms daily for children aged 2–6 years. In hypocalcaemic tetany calcium gluconate must be given parenterally but plasma calcium must be monitored. This has led to enormous consumption of vitamin preparations. spasticity and sometimes hypothyroidism). and 120 micrograms daily for children aged 7–12 years.

Systemic fluoride supplements should not be prescribed without reference to the fluoride content of the local water supply. daily use of a less concentrated rinse is more effective than weekly use of a more concentrated one. extreme caution is necessary to prevent the child from swallowing any excess. and an increased susceptibility to infections. principally the liver. particularly measles and diarrhoea. In women of child-bearing age there is a need to balance the possible teratogenic effects of vitamin A should they 399 . High-strength gels must be applied on a regular basis under professional supervision. 6 months to 3 years. daily administration of fluoride tablets or drops is a suitable means of supplementation. Doses of vitamin A should be administered orally immediately upon diagnosis of xerophthalmia and thereafter patients with acute corneal lesions should be referred to a hospital on an emergency basis. It is also used in the treatment of active xerophthalmia. infants need not receive fluoride supplements until the age of 6 months at the earliest. Sodium fluoride. iodized oil given either before or at any stage of pregnancy is found to be beneficial.Vitamins and Minerals severe. Since vitamin A is associated with a teratogenic effect it should be given in smaller doses (no more than 10 000 units/day) to women of child-bearing age. Individuals who are either particularly caries prone or medically compromized may be given additional protection by the use of fluoride rinses or by application of fluoride gels. Universal vitamin A distribution involves the periodic administration of supplemental doses to all preschool-age children with priority given to age groups. or regions at greatest risk. Dentifrices which incorporate sodium fluoride are a convenient source of fluoride. Periodic high-dose supplementation is intended to protect against vitamin A deficiency which is associated with ocular defects particularly xerophthalmia (including night blindness which may progress to severe eye lesions and blindness). It is now considered that the topical action of fluoride on enamel and plaque is more important than the systemic effect. Rinses may be used daily or weekly. All mothers in high-risk regions should also receive a high dose of vitamin A within 8 weeks of delivery. For the use of iron preparations in the treatment of anaemia see section on section on drugs affecting blood Retinol (vitamin A) is a fat-soluble substance stored in body organs. Availability of adequate fluoride confers significant resistance to dental caries. Where the fluoride content of the drinking water is less than 700 micrograms per litre.

wet ‘beri-beri’ is characterized by cardiac failure and oedema.Vitamins and Minerals be pregnant with the serious consequences of xerophthalmia. Chronic dry ‘beri-beri’ is characterized by peripheral neuropathy. Severe deficiency may result in ‘beri-beri’. High doses are given in some metabolic disorders. Facilities for resuscitation should be Riboflavin (vitamin B ) deficiency may result from immediately available. When less severe symptoms are present (for example night blindness) a much lower dose is recommended. Vitamin A therapy should also be given during epidemics of measles to reduce complications. Pyridoxine and thiamine also have a role in status epilepticus (see section 5). Nicotinic acid and nicotinamide are used to prevent and treat nicotinic acid deficiency (pellagra). Vitamin B is composed of widely differing substances which are. It may also occur in association with Pyridoxine (vitamin B ) deficiency is other deficiency states such as pellagra. and paralysis. or shortly after parenteral administration. Nicotinic acid inhibits the synthesis of cholesterol and triglyceride and is used in some hyperlipidaemias. muscle wasting and weakness. alcoholism. therefore intravenous injections should be administered slowly (over 10 minutes) and should be used only if parenteral treatment is essential. for convenience. classed as ‘vitamin B complex’. reduced dietary intake or reduced absorption due to liver disease. Folic acid should not be used in undiagnosed megaloblastic anaemia unless vitamin B is administered concurrently. Hydroxocobalamin is the form of vitamin B used to treat vitamin B deficiency due to dietary deficiency or malabsorption Folic acid is essential for the synthesis of DNA and certain proteins. Thiamine is given by intravenous injection in doses of up to 300 mg daily (parenteral preparations may contain several B group vitamins) as initial treatment in severe deficiency states. but deficiency may occur during isoniazid therapy and is characterized by peripheral neuritis. chronic infection or probenecid therapy. Nicotinamide is generally preferred as it does not cause vasodilation. Deficiency of folic acid or vitamin B is associated with megaloblastic anaemia. such as hyperoxaluria and it is also used in sideroblastic anaemia. otherwise neuropathy may 400 . Potentially severe allergic reactions may occur during. Thiamine (vitamin B ) is used orally for deficiency due to to inadequate dietary intake.rare as the vitamin is widely distributed in foods. Where there are severe signs of xerophthalmia high dose treatment as for patients over 1 year should be given. Wernicke-Korsakoff syndrome (demyelination of the CNS) may develop in severe deficiency.

by mouth. Claims that ascorbic acid is of value in the treatment of common colds are unsubstantiated. These two compounds are equipotent and either can be used to prevent and treat rickets. Simple deficiency of vitamin D occurs in those who have an inadequate dietary intake or who fail to produce enough cholecalciferol (vitamin D3) in their skin from the precursor 7-dehydrocholesterol in response to ultraviolet light. Vitamin K is necessary for the production of blood clotting factors Ascorbic acid (Vitamin C ) I: P/A: A/E: Dose: prevention and treatment of scurvy Tablet: 50 mg.Vitamins and Minerals be precipitated. ADULT and CHILD 25– 75 mg daily Treatment of scurvy. gastrointestinal disturbances reported with large doses Prophylaxis of scurvy. Dark skin with a high melanin content must be exposed to daylight longer than light skin in order to obtain the same synthesis of vitamin D is also used in deficiency states caused by intestinal malabsorption or chronic liver disease and for the hypocalcaemia of hypoparathyroidism. ADULT and CHILD not less than 250 mg daily in divided doses Calcium gluconate I: C/I: hypocalcaemic tetany conditions associated with hypercalcaemia and hypercalciuria (for example some forms of malignant disease) 401 . The term vitamin D covers a range of compounds including ergocalciferol (vitamin D2)and cholecalciferol (vitamin D3 ). by mouth. Supplementation with folic acid 400 micrograms daily is recommended for women of child-bearing potential in order to reduce the risk of serious neural tube defects in their offspring Ascorbic acid (vitamin C) is used for the prevention and treatment of scurvy. Children with dark skin must continue vitamin D prophylaxis for up to 24 months because of their inability to produce enough vitamin D in their skin.

25 mg (50 000 IU). According to manufacturer’s directions Ergocalciferol (Vitamin D) Ergocalciferol is a representative vitamin D compound. calcium and ergocalciferol tablets may be used but the calcium is unnecessary I:: prevention of vitamin D deficiency. sarcoidosis. pregnancy and breastfeeding symptoms of overdosage include anorexia. history of nephrolithiasis. lassitude.25 mg (50 000 units) P/C: C/I: P/C: A/E: P/A: Dose: 402 . vitamin D deficiency caused by malabsorption or chronic liver disease. arrhythmia. Oral liquid: 250 micrograms/mL (10 000 IU/mL). renal impairment. thirst. hypocalcaemia of hypoparathyroidism hypercalcaemia. metastatic calcification ensure correct dose in infants. injection-site reactions. monitor plasma calcium at weekly intervals in patients receiving high doses or those with renal impairment. nausea and vomiting. headache.25 mg continued for several months. peripheral vasodilation. weight loss. fall in blood pressure P/A: Injection: 100 mg/mL in 10-mL ampoule. Various vitamin D compounds can serve as alternatives NOTE. Dose: Hypocalcaemic tetany. ADULT and CHILD 10 micrograms (400 units) daily Treatment of vitamin D deficiency. A/E: gastrointestinal disturbances.8 mmol) daily DILUTION AND ADMINISTRATION. and raised concentrations of calcium and phosphate in plasma and urine. bradycardia. diarrhoea.Vitamins and Minerals monitor plasma calcium concentration. by mouth. If there is no plain vitamin D tablet available for the treatment of simple deficiency. sweating.2 mmol) followed by continuous intravenous infusion of about 4 g (8. ADULT 1 g (2. by mouth. by slow intravenous injection. Prevention ofvitamin D deficiency. nausea and vomiting—may indicate overdose and hypercalcaemia. vertigo. Capsule or tablet: 1. ADULT 1. polyuria. tissue calcification may occur if dose of 1.

190 mg.5 mL (240 mg iodine) in ampoule (oral or injectable). INFANT up to 1 year. 0.Vitamins and Minerals CHILD 75–125 micrograms (3000–5000 units) daily for a limited period. by mouth. by intramuscular injection. CHILD and ADULT 380 mg (aged over 45 years or with nodular goitre. single dose of 100 mg. ADULT during pregnancy. 200 mg once a year A/E: P/A: NOTE. ADULT during pregnancy and one year postpartum. pregnancy hypersensitivity reactions. women of child-bearing age. Dose: Nicotinamide Nicotinamide is a representative vitamin B substance. ADULT 2. Iodized oil may also be given by mouth Endemic moderate to severe iodine deficiency. including any stage of pregnancy. CHILD 1–5 years.57 mL (308 mg iodine) in dispenser bottle. by mouth. 400–960 mg once a year or 200–480 mg every 6 months Iodine deficiency. Iodized oil: 1 mL(480 mg iodine). 0. 76 mg but see also Precautions) (provides up to 3 years protection) Iodine deficiency. single dose of 200 mg. by intramuscular injection. 400 mg once a year. daily Hypocalcaemia associated with hypoparathyroidism. 480 mg once each year.5 mg (100 000 units) daily. hyperthyroidism Capsule: 200 mg. may interfere with thyroid-function tests. 300–480 mg once a year or 100– 300 mg every 6 months. ADULT (except during pregnancy) and CHILD above 6 years. Various compounds can serve as alternatives.5 mg (60 000 units) daily Iodine I: C/I: P/C: prevention and treatment of iodine deficiency breastfeeding over 45 years old or with nodular goitre (especially susceptible to hyperthyroidism when given iodine supplements—iodized oil may not be appropriate). goitre and hypothyroidism. CHILD up to 1. 403 . by mouth. ADULT women of child-bearing age. INFANT under 1 year.

Tablet (sugar-coated): 10 000 IU (as palmitate). massive overdose can cause rough skin. sideroblastic anaemia A/E: generally well tolerated. prophylaxis. Oral oily solution: 100 000 IU (as palmitate)/ml in multidose dispenser. isoniazid neuropathy. ADULT up to 500 mg daily in divided doses Pyridoxine Also known as Vitamin B I: treatment of pyridoxine deficiency due to metabolic disorders. transient increased intracranial pressure in adults or a tense and bulging fontanelle in infants (with high dosage). prevention of complications of measles P/C: pregnancy (teratogenic). ADULT 25–50 mg up to 3 times daily Isoniazid neuropathy. by mouth. but chronic administration of high doses may cause peripheral neuropathies P/A: Tablet: 25 mg (hydrochloride). Dose: Deficiency states. 100 000 IU. raised serum calcium and raised serum alkaline phosphatase concentrations. enlarged liver. dry hair. by mouth. ADULT 100–400 mg daily in divided doses Retinol I: prevention and treatment of vitamin A deficiency.Vitamins and Minerals I: P/A: Dose: treatment of pellagra Tablet: 50 mg. by mouth. Water-miscible injection: 100 000 IU (as palmitate) in 2-mL ampoule. ADULT 10 mg daily Isoniazid neuropathy. treatment. 200 000 IU (as palmitate). high intake may cause birth defects. Dose: Prevention of vitamin A deficiency (universal or targeted distribution programmes) 404 . by mouth. Treatment of pellagra. breastfeeding A/E: no serious or irreversible adverse effects in recommended doses. by mouth. ADULT 50 mg 3 times daily Sideroblastic anaemia. raised erythrocyte sedimentation rate. P/A: Capsule: 50 000 IU.

Dose: Treatment of vitamin B2 deficiency. ADULT. preferably at measles vaccination. ADULT (woman of child-bearing age. However. less severe cases (for example. night blindness). Treatment of xerophthalmia. CHILD over 1 year and ADULT (except woman of childbearing age) 200 000 units on diagnosis. . repeated next day and then after 2 weeks. repeated next day and then after 2 weeks. maximum of 10 000 units daily or maximum 25 000 units weekly.Vitamins and Minerals INFANT under 6 months. Oral vitamin A preparations are preferred for the prevention and treatment of vitamin A deficiency. severe signs of xerophthalmia. in situations where patients have severe anorexia or vomiting or are suffering from malabsorption. 200 000 units every 6 months. 5000–10 000 units daily for at least 4 weeks or up to 25 000 units weekly NOTE. repeated next day and then after 2 weeks. 200 000 units at delivery or within 8 weeks of delivery NOTE. 6–12 months. 100 000 units immediately on diagnosis. see notes above). ADULT MOTHERS. by mouth. 6–12 months. 100 000 units every 4–6 months. I: prevention of dental caries 405 . 50 000 units on diagnosis. 50 000 units.INFANT under 6 months. by mouth. a water-miscible injection preparation may be administered intramuscularly Riboflavin Also known as Vitamin B2 I: vitamin B2 deficiency P/A: Tablet: 5 mg. as for other adults. by mouth. ADULT pregnant woman. 200 000 units every 4–6 months. ADULT and CHILD 1–2 mg daily Sodium fluoride In any appropriate topical formulation. An additional dose should be given the next day in hospitalized children with measles infection. ADULT and CHILD up to 30 mg daily in divided doses Prophylaxis of vitamin B2 deficiency. CHILD over 1 year (preschool). by mouth.

Vitamins and Minerals C/I: A/E: Dose: NOTE. rarely yellowish-brown discoloration if recommended doses are exceeded Prevention of dental caries. CHILD over 6 years. occasional white flecks on teeth at recommended doses. as oral rinse.05% solution daily or 10 mL 0. ADULT 10–25 mg daily 406 . by mouth. Mild chronic thiamine deficiency. not for areas where drinking water is fluoridated or where fluorine content is naturally high in recommended doses toxicity unlikely.2% solution weekly Fluoridated toothpastes are also a convenient source of fluoride for prophylaxis of dental caries Thiamine Also known as Vitamin B1 I: P/C: P/A: Dose: prevention and treatment of vitamin B1 deficiency parenteral administration). 10 ml 0. breastfeeding Tablet: 50 mg (hydrochloride).

Much can be done by appropriate first aid measures such as clearing the airway. Referral to the appropriate health care facility also helps to reduce the delay in proper management. splinting a fractured limb. Uncontrolled hyperpyrexia is fatal due to damage to vital structures. Still it is the duty of the available medical team to attend to all sorts of emergencies. GENERAL TOPICS Hyperpyrexia The term hyperpyrexia denotes rise of temperature > 41. drugs and specialists may not be available. pneumonia. Temperatures > 390C ( 1020F) themselves make the patient very uncomfortable and the relatives anxious and disturbed. especially infections. giving pain relief. Hyperpyrexia can be due a variety of clinical conditions such as– malaria. Since Kerala Government is also preparing a consensus book for treatment of the common diseases in the State. viral fevers. applying a tourniquet to prevent bleeding. which is crucial for the successful outcome. Particularly in children high temperatures may be associated with convulsions (febrile seizures) which make the situation even more 407 .PART II GUIDELINES FOR FIRST LINE MANAGEMENT OF CLINICAL EMERGENCIES ENCOUNTERED IN PERIPHERAL HOSPITALS INTRODUCTION: Severe emergencies may crop up at dispensaries and small hospitals where the optimum number of health care personnel. stopping a seizure etc.50C (1070F). equipment. septicemia. Once the temperature rises > 410C the body behaves as a poikilothermic organism. pontine haemorrhage and several others. when called upon to do. the section on guidelines for clinical management which was included in Kerala State Drug Formulary. heat stroke. With this purpose in mind. Number1 (Published in 1999) has been modified to include only the emergencies and their management possible at the peripheral hospitals. such diseases which do not require emergency management at the periphery have been deleted from this section. This section is written primarily with the view to provide ready reference for the doctor for immediate action.

angioedema and the others.Anaphylaxis is an immunoglobulin E(IgE) mediated rapidly developing systemic allergic reaction.Guidelines alarming.The physical measures have to be continued till the medication brings in sustained benefit. dizziness.loss of consciousness. cardio 408 .If needed paracetamol can be given IM in dose of 300 mg to be repeated later . vomiting. abdominal pain and others Severe. Paracetamol given in a dose of 1 g orally for an adult (Proportional dose for children see section 26)promptly brings down the temperature within 15 – 30 minutes. Since physical measures alone are inadequate to maintain the benefit.depending on the condition. urticaria. manifesting as generalised erythema. confusion . gastrointestinal or other system may be involved. hypotension. autonomic failure. They are classified as mild. antipyretics have to be administered along with tepid sponging and cooling by breeze. Clinical features .Reactions usually occur within minutes of exposure to antigen.Though febrile seizures are self terminating in the majority of cases and generally do not lead to more adverse sequelae their occurrence leads to panic among the relatives and this has to be deliberately managed by the attending doctor.Main symptoms include dyspnoea. Cyanosis (PaO2 <92%). stridor or wheeze.Hypoxia. cardiovascular. application of cold compresses to the forehead will help to bring down the temperature and provide relief. Febrile fits also respond promptly to the reduction of body temperature. Specific treatment for the cause should be instituted at the earliest on getting the proper diagnosis. moderate and severe. chest or throat tightness. Moderate –Respiratory. systolic BP < 90mmHg. Differential diagnosis 1. Anaphylactic shock has to be differentiated from other causes of shock such as sudden hypotension due to internal bleeding. Physical measures such as tepid sponging and exposure to breeze (by a fan). but occasionally may be delayed for hours. periorbital edema. diaphoresis. nausea. based on the severity of clinical manifestations Mild ~ Skin and subcutaneous tissue only are affected. Definition.Febrile seizures has to be managed on their own merits. Anaphylaxis This acute medical emergency can be precipitated by oral or parenteral administration of drugs or food or by inoculation of toxins brought about by insect or animal bites.

Volume expansion . 5. snake bite etc 2.can prevent relapse of severe reaction. In case of laryngeal edema not responding to epinephrine.000 solution via central line 3-5 mL of 1 in 10. Glucagon-1 mg bolus followed by an infusion up to 1 mg/h can be given in patients on beta blockers for inotropic support. Inhaled salbutamol. MI. cricothyroidotomy or tracheostomy may be required. 3. 6 mg given in slow IV injection or IV drip 6. 0. common preparation is the combination etophylline 169.5 ml of 1 in 1000 solution in case of major airway compromise or hypotension 3-5 mL of 1 in 10..General Topics pulmonary emergencies for eg. Intravenous infusion of epinephrine can be given to maintain B.5 mL of 1 in 1000 solution IM repeated at 10 to 15 minutes intervals if necessary. Methylprednisolone 125 mg IV or hydrocortisone 500 mg. IV can be given. Other rare conditions include Non-IgE mediated anaphylactoid reactions like radiocontrast sensitivity reactions.3 to 0. 2. Epinephrine should be administered immediately 0.4 mg + theophylline 50.2. Antihistamine such as chorpheniramine maleate given in dose of 4 mg 3 or 4 times a day orally relieves skin symptoms and decrease the duration of therapy. (equivalent betamethasone or dexamethasone 8mg) 4. systemic mastocytosis. Establishment of airway Ventilation by mouth to mouth breathing or by Ambu bag Endotracheal intubation should be done if airway remains obstructed. 409 .5 mg can be used to treat resistant bronchospasm. flushing syndrome and others. Methyl Xanthines give relief of bronchspasm. Treatment 1.P >90 mmHg in case of protracted symptoms. 7.000 solution diluted with 10 mL of normal saline via endotracheal tube. certain drug reactions like opiate and fluoroquinolone induced reactions. acute laryngeal obstruction. poisoning .IV normal saline 500 to 1000 ml by rapid infusion followed by maintenance dose based on BP and urine output. Glucocorticoids.panic reactions.

Evaluation of the poisoned patient History: Ascertain the nature. Patients with past history of anaphylaxis or allergy should undergo detailed allergy tests and desensitization if indicated. carbamate insecticides. prolonged fluid replacement etc. paracetamol and others . Patients with past history of anaphylaxis to food or hymenoptra sting should be taught self administration of epinephrine Though many cases of primary anaphylactic reactions can be managed in peripheral hospitals. Suicidal poisoning is most common and next in frequency is accidental poisoning. plant products such as cerbera odollum. barbiturates.Accidental poisoning is often due to organophosphorus insecticides or drugs used by psychiatric patients. are indication for referral to higher medical facilities TOXICOLOGY The common poisons used for suicidal attempt found in Kerala include organophosphorus insecticides. zinc phosphide. General management of the poisoned patient Acute poisoning is a dire emergency. quantity of the poison and the vehicle in which the same was consumed and the time elapsed before patient reaches the hospital. 2. necessity for tracheal intubation. Recurrence of hypotension. Prevention 1. other drugs acting on the CNS. angioedema and mild bronchospasm Patients with moderate to severe reaction should be admitted and observed for a minimum period of 24 hours. lf possible the specimen of the poison left over should be procured for confirmation 410 . Despite this general statement it should be remembered that any type of poison may be involved and the physician should have an open mind. nerium oleandis. Monitoring of patient -Observation for a minimum of 6 hours should be made for patients with mild reaction limited to urticaria.Guidelines Note-glucagon and other more specialized drugs are generally available only in secondary or tertiary care centres. formic acid. diazepam. some complicated cases require more specialized intervention.

Some of the salient features of the commonly ingested poisons Finding 1. CO. Bradycardia Digoxin.General Topics If the patient is shocked or unconscious: 1. Barbiturates. CNS stimulants. Hepatic failure 8. Hyperthermia 10. theophylline. stimulant. If the patient is unconscious. solvents used for paints. beta blockers. Hypothermia 11 . anticholinergics. 4. anticholenergics. Behavioural disturbances Anticholinergics. ethanol. INH. CNS salicylate. Simultaneously maintain the airway by clearing the mouth and throat of foreign materials. methanol. anticholenergic. 3. 2. Narcotic analgesics. calcium channel blockers. cardiovascular drugs. dentures or vomitus and keep the patient with head lowered and neck held in extension. diazepam. alcohol. carbon tetrachloride. 411 . hallucinogens. Aspiration Common cause Organophosphates. Coma 6. Antihistamines. organo phosphates. nerium oleandis. CNS depressants. antidepressant. Intestinal ileus Paracetamol. nerium oleandis. antidepressant. an airway is inserted. cerbera odollum. cerebra odollum. mushroom. hallucinogens. 2. phenothiazines. Cardiac dysrrhythmia 5. CNS depressants. Hallucinations 7. Start an IV line with normal saline through a large bore needle (18G) or cannula through which fluids and drugs can be administered rapidly. CNS stimulant. kerosene. CNS stimulants. Phenothiazine. CNS stimulants. Hypercapnea 9.

Early administration of antidote before referring the patient to a higher centre. Facility for emergency determination of toxic substance is available at the College of Pharmaceutical Sciences. Nystagmus 14. 412 . Theophylline 1. other corrosive acids.e. Pulmonary oedema 15. Cardio respiratory support. Note :AlI doctors who see the patients first should undertake the first aid measures. Thiruvananthapuram round the clock. Definitive care which limits the severity or duration of toxicity through the use of antidotes and by enhanced elimination of the toxin by forced alkaline diuresis and haemodialysis procedures. Anti convulsants. remove all contaminated clothing and remove as much of the toxic agent from the oral cavity. 3. Medical college. Organophosphates. formic acid. Tachycardia Laboratory tests Alcohol. salicylate. C. theophylline. and ECG. Decontamination of the poison which limits the absorption and minimises the extent of toxicity: Clean up the body. B. pharynx and skin. CNS stimulants. Induction of vomiting.Guidelines 12. Seizures 16. the specimen has to be sent by the physician with clinical details 2. Treatment: Emergency Management of poisoned patient includes A. anticholinergics. 4. Supportive care which limits the effects of serious complications of poisoning on the organ systems at risk. CNS depressants. 2. Qualitative and quantitative analysis are available for a number of poisons and are useful in confirming that a particular drug has been ingested and are of value in screening for unknown drugs. Additional tests that may be of use include arterial blood gas analysis. salicylates. i. chest radiograph. 1. Metabolic acidosis 13. Organophosphates. Removal of unabsorbed poison from the surface.

Activated charcoal. 1. Gastric lavage. Acids 4. Aspirin 5. • Patients in Trendelenburg position and left lateral position. Amphetamine 2. Malathion 3. • This acts by adsorbing molecules of chemicals on its surface. • 2 or 3 doses of charcoal given at 4 hourly intervals may be of more use than a single administration. • Decrease risk of aspiration by using cuffed endotracheal tube if available. • Using large bore (36 . Alcohol 6. • Indicated in comatose patients as well as alert patients. aliquots of water at room temperature(50 -250 mL) should be administered and aspirated until the return is clear. Alkalis 5. thereby inhibiting their absorption • Dose is 1 g/kg suspended in water and introduced through the orogastric tube. Quinine 413 1. he can be induced to vomit by tickling the pharynx or administration of gastric irritants such as concentrated common salt solutions 200 -400 mL. 2.General Topics DECONTAMINATION The vast majority of serious poisonings are due to ingestion of toxic substances and gastrointestinal decontamination should be done without delay. • After contents of the stomach are aspirated. Drugs adsorbed by charcoal Drugs not adsorbed by charcoal 1. Chlorpheniramine 3.40 F) orogastric tube. Phenytoin 4. Ferrous sulphate 2. Induction of vomiting is contraindicated in case of corrosive poisons and if the patient is comatose. • Contraindicated in patients who have ingested corrosives or petroleum distillate hydrocarbons. 3. Chlorpromazine 7. If the patient is fully conscious and the general condition is satisfactory. Cyclic antidepressants 6. Lithium .

If phenytoin is given. which is complicated by pulmonary oedema. Brady arrhythmias are best treated with atropine. 4. Maintain the airway appropriately . Aspiration in to the respiratory tract should be prevented. Management of neurological complications Coma and altered level of consciousness require special care for maintenance of fluid and electrolyte levels. cardiac ischemia or encephalopathy should be controlled by direct arterial vasodilators like nitroglycerine or nitroprusside.Guidelines For better efficacy charcoal should be given before and after gastric lavage. Management of respiratory complications. Hypotension usually reflects decreased peripheral vascular resistance and should be treated with fluid administration. Cathartics ( purgatives) • Include sorbitol. thereby shortening the absorption time. Seizures can be safely controlled with short acting benzodiazepines (diazepam 5 . SUPPORTIVE CARE is directed towards the prevention or limitation of respiratory. positive pressure ventilation and PEEP . Hypertension.arrhythmic drugs. cardiovascular and neurological complications. 1. gastric lavage and colonic wash out should be procured for chemical analysis if a definitive clue regarding poisons has not been obtained. Tachyarrhythmias usually requires only monitoring.20 mg IV) or phenobarbitone (20 mg/ kg IV at 50 . If it has occured. 2. Samples of materials obtained by vomiting. 3. only rarely are vasopressors like dopamine required. electrocardiogram 414 . Unabsorbed toxin from the colon can be removed by a large enema (soap and water) or colonic wash out using flatus tube. but may need anti. Management of cardiovascular complications. requiring treatment with high flow oxygen.100 mg/ min). Non cardiogenic pulmonary oedema may be seen early. magnesium citrate • Speed up gastrointestinal motility. but may require temporary transvenous pacing.Ventilatory support may be needed in selected cases. magnesium sulphate. gentle tapping on the chest and suction of the tracheo bronchial tree. try conservative measures such as head low position. lf bronchospasm is present use salbutamol nebulisation or an IV injection of aminophylline 250 mg diluted in 10% glucose slowly.

4. Arsenic. Paracetam ol N-acetylcysteine Initial dose 140m g/ kg Most effective if give n within16h orally. Total dose of 5075m g/kg/day in 2 divided doses up to 5 days 5mg/kg deep intra muscu lar 5. Lead salt e. Cyanide Amylnitrite. Antidotes .g. Behavioral abnormalities including combativeness and agitation are better controlled by physical restraints rather than chemical restraints . 2. Lead acetate Calcium di sodium ede tate 7. Atropine 3. the n70mg/kg4h Initial dose 0.5·2mgi IV 100%by face mask or Hyperbaric oxygen if available. thiosolphate ove r 10min Desferrroxamine Hypote nsive patients – 10mg/kg/h for 4 hours IV. 5mg/kg/h for 8 hours the n 25mg/kg/h Norm oten sive patients 40mg/kg IM 200m g/m l in am p of 5ml to be dilu ted in 5% glucose infu sed IV. sodium Am ylnitrite in halation nitrite eve ry2so dium thiosulph ate 3min. Carbonm onoxide Physostigm ine Oxyge n 4. then 10mL of 3%sodium nitrite I.General Topics should be monitored. Next to the general emergency measures.Diazepam enables rapid control of unmanageable patients while haloperidol is very effective for long term control. Mercu ry. BAL (Dim ercaprol) Gold 415 . DEFINITIVE CARE POISON ANITDOTE ADULT DOSAGE COMMENT 1.V o ver5min the n 50m L25% Sod. Can produ ce convulsions Early treatment is successfu l This helps to re move the poison load but action is slow. antidotes form the mainstay of successful management of poisonings as early as possible and during the course of treatment blood and urine samples should be sent for drug level monitoring. Iron salts 6.

5g/L or total quantity ingested>30mL.this drug is devoid of CNS side effects of atropine 416 .Guidelines 8. ethanol should be given orally in a dose of 30-50 mL in 2-4 h.7g/kg IV diluted or oral.Opiates 11. 1 g IV over 15-30 min 8 h Administration has to be continuous drip to maintain pupil size normal.Peritoneal dialysis only 1/8 th effective as haemodialysis.45 mg per kg body wt IM or IV to be repeated till symptoms are relieved.Organophosphates Methylene blue solution IV Naloxone Atropine Pralidoxime May need exchange 12.very large doses of 250 -750 ampoules may be required for saving serious cases Early management may be successful 9. if blood level of methanol exceeds 20mg/dl Hemodialysis to remove methyl alcohol if blood level >0. Methyl alcohol Ethyl alcohol Correction of metabolic acidosis by sodium bicarbonate 0. Carbamates Atropine Glycopyrrolate 2-3 mg parenterally and repeat until signs of atropine intoxication appears It is an effective antidote It is available as ampoules containing 2mg of the drug to be given in a dose of 0.6-0. 1-2mg/kg of 1% solution 0-4-2mg IV 15mg IV every 15 min till drying of secretions. Nitrites 10.

Ethylene Glycol Anti digoxin –fab fraction Fomipezole 16. Diazepam. Digoxin. Digoxin 15. Drugs effectively eliminated by haemodialysis include: Barbiturates . Useful in Carbamazepine. Sodium valproate. Methanol. Bromides. Hypnotic sedatives Phenytoin Peritoneal dialysis and exchange transfusion are less effective but may be used when other procedures are not available.2mg IV over 30 sec followed by 0.5 .4 h. Chloral hydrate. • Close monitoring of fluid and electrolytes and pH are required for ideal results • Adequate amounts of sodium bicarbonate (1 . Forced alkaline diuresis • Especially useful in phenobarbitone and salicylate over dosages. Examples include Chloramphenicol Procainamide. Disopyramide. cerebral oedema b. Warfarin Vitamin k1 Increasing the Drug Excretion a. Dapsone . (eg. Lithium salts. c.5.infusion) needed to maintain urine pH between 7. small volume distribution and low protein binding. C/I : Congestive cardiac failure. in infants). Salicylates. Ethylene glycol. renal failure. Phenobarbitone. Activated charcoal This is given repeatedly in a dose of 1 g/ kg bw every 2 . lipid solubility and protein binding. Salicylates. Theophylline. are contraindicated or are technically difficult. Theophylline. Ethanol.General Topics 13.8. Phenytoin . Dialysis and haemoperfusion Dialysis is most effective with drugs of low molecular weights. Procainamide. Benzodiazepines Flumazenil 0.3mg at 1 min interval to a total dose of 3mg Dose (vials)=[injested dose (mg)x0. Isopropyl alcohol Haemoperfusion is more effective than dialysis in removing drugs with high molecular weight.8]x1/2 15mg/kg IV followed by 10mg/kg IV 12 hrly for 4 doses 10mg IM. Theophylline 417 .SC or IV 14.2 mg/kg/h IV.

APTT and PT are prolonged. tongue. Prolongation of the clotting time beyond 10 minutes should suggest systemic envenomation. proteinuria. faint bite marks or oozing from the wound. ENVENOMATION Snake envenomation Diagnosis and management of snake envenomation Clinical features Fear. neuropathy.Generally higher clotting times indicate more severe disease. toxicity of venom and side effects of treatment contribute to the symptoms and signs in those bitten by snakes. Fibrinogen is often reduced. Respiratory muscle paralysis can follow. and muscles of deglutition and neck muscles. 418 . hepatic damage and others. Thrombocytopenia is common in viper bite. swelling. haematuria and red blood cell casts may be seen in those with renal involvement. Vomiting is one of the early symptoms of systemic envenomation. haemorrhagic oedema and oozing from bite mark. Suicidal patients should have proper psychiatric management to avoid recurrence. ECG abnormalities may be seen in those with cardiac involvement. Paralysis is first noticed as ptosis and external opthalmoplegia followed by involvement of face. Bite by viperidae (vipers) This produces severe local effects with more prominent bite marks. Bite by elapidae (cobra and krait mainly) Local effects include severe pain. jaws. Hemostatic abnormalities are characterized by persistent bleeding manifestations. Renal failure is the leading cause of death and clinically it manifests with acute oliguric renal failure developing 18 to 36 hours after the bite. Systemic effects are dominated by neuroparalytic symptoms. vocal cords. Laboratory diagnosis Estimation of the clotting time helps to determine the need for antivenom therapy and also for monitoring progress.Guidelines Once the emergency is over these patients should be observed for long term complications such as pneumonia. Oliguria. palate. Sometimes local reaction may be absent or only minimal. mild oedema. intense pain. Direct myocardial involvement is suggested by abnormal ECG and arrhythmias and refractory hypotension.

Carry the victim to the hospital as early as possible. 2. Make an IV line and start normal saline 5. Immobilise the limb with a sling or splint. Clinical examination. 5. 10.General Topics FIRST AID 1. oozing. krait. 7. Reassure the victim that there is treatment. 3. 6. Presence of systemic manifestations such as bleeding tendencies shock neuroparalytic manifestations. Presence of multiple teeth indicate non poisonous nature of bite 3.Only 15-20% of snake bites are by poisonous snakes which include cobras. 4. Management in the ward 1. bleeding. All patients with features of systemic envenomation should have at least 2 IV lines 419 . Check whether tourniquet is applied correctly if not reapply it correctly. viperidae. 3. Apply a tourniquet or a compressive bandage which would occlude lymphatic return from the periphery on an area of single bone in a limb.5 ml IM. Wash the bitten area with soap and water. Injection tetanus toxoid 0. Fang marks 2 or 1 2. 11.. 1. 9. necrosis etc. 5. Blood sample for clotting time. 2. Local reactions like oedema.Tourniquet is preferably loosened only after administration of antivenom. Extreme pain at the site of bite 4. Tab paracetamol 500 mg stat. discoloration. oral or injection tramadol 50 mg IV for pain.Poisonous bites show following features . Indentification of poisonous snake bite. Modify the treatment as per situation.occasionally sea snakes and possibly other varieties as well. Admit all snake bite victims or suspected cases of snake bites. Reassure the patient. 8. Management at casualty 1. 4. Injection metoclopramide 10 mg IV sos to prevent nausea and vomiting.

Note: Before going to the full dose of ASV a sensitivity test should be done as follows: 0.1 mL intradermal. active against cobra krait and viper. and Serum Institute of India. • Haemostatic abnormalities • Cardiovascular signs.6 h.6 vials of ASV after test dose as an infusion in 20 min and observe for other signs of envenomation When systemic envenomation is present. Blood samples for investigation. Complete clinical examination 3. (Storage:Antivenom should be stored at 2-8°C. to test for reaction and if there is no reaction full dose of ASV is given. should be observed for upto 24 hours. • Impaired consciousness. ECG.5 mL diluted in saline given IV. ASV should be given as early as possible for the best results and the dose may have to be repeated often. Dose of antisnake venom When only local reaction is present.Guidelines 2. Pune.Give 3 . test.10 vials of ASV as an infusion in 20 . • Severe local reaction even in the absence of systemic signs. The available preparation is polyvalent ie. it should not be allowed to freeze and the shelf life is 4 years after manufacture). Hospital Management Essentials of hospital treatment consist of rapid assessment of the bite and its complications and early administration of antivenom when indicated . • General rhabdomyolysis. CXR.30 min and simultaneously start 6 vials of ASV in 5% glucose as drip to be run in 4 . Even patients with mild or inapparent symptoms. since delayed envenomation is not rare Indications for Anti-snake venom (ASV) This is prepared by the Haffkine Institute Bombay. • Recurrent vomiting. Hypersensitivity is uncommon and can be managed with IV hydrocortisone. depending on the clinical status. Indications (evidence of systemic envenomation) • Neurotoxic signs. 420 . no reaction occurs 0.

Antivenom has to be stocked in all the primary health centres at all times. plasma expanders and blood should be used judiciously as indicated. 6 h) or cloxacillin (250 – 500 mg 6 h) are reasonably good choices.6 h and ASV administration repeated if necessary. not readily relieved by ASV. Antibiotics active against multiple infections has to be started. 1. attention to the local site is also necessary. Neostigmine given in a dose of 0. 421 . As snake venom is not dialysable there is no role for prophylactic dialysis. Ampicillin (0.5 g IV/IM. Normal saline. Coagulation disturbances are to be treated with fresh blood or blood components if ASV does not correct the abnormality. Special problems in viper bites Prevention of acute renal failure( ARF) in viper bite is by prompt administration of ASV and maintenance of fluid volume. This should include cleaning. If the respiratory failure is not relieved promptly. wound toilet. They may present as acute respiratory paralysis.5 mg IV repeated at short intervals is dramatically effective and life saving. Better late than never is to be the policy with ASV. If patient is oliguric. Need for immobilizing the bitten limb immediately after the bite and avoidance of panic.In the vast majority. Dialysis is indicated once acute renal failure is established. It is atleast partially useful in patients with signs of systemic envenomation who come even a few days after the bite. ventilatory support is required and the patient has to be rushed to a proper centre Prevention of snake bite and health education of public Public should be instructed regarding the do’s and dont’s of snake bite management through the media.General Topics When to repeat ASV ASV is to be given if severe signs of envenomation persist after 1 . Clotting time is to be repeated every 4 . absorbent dressings and partial immobilisation of the limb. Volume replenishment should be stressed as patients can have severe hypovolemia due to several factors.2 h or if the clotting time is not restored within 6 h. Anaerobic infection demands the use of IV metronidazole 500 mg tds Tetanus prophylaxis has to be given to nonimmunized persons. conservative measures for treating ARF should be instituted. Special problems in elapidae bites These may cause acute myasthenic crisis due to neuromuscular blocking action of the toxin.

Availability of effective medicines . Principles of application of tourniquet or broad bandage. If the local reaction is moderate or severe. Persons who are sensitised by previous exposure are at higher risk of angioneurotic oedema of the face. 4. cooling of the bitten part. 3. suction. To avoid incision. Stingers embedded in skin should be scraped or brushed off with a nail or finger nail but not removed with forceps.ASV and other measures in hospitals practicing modern medicine. Using a stick which is tapped on the ground while walking will scare away the snakes. 6. Bee and wasp stings These are common. 5. angioneurotic oedema. it should be taken with the patient for identification. Snake bite can be avoided by carrying a torch while walking at night. anaphylaxis and death. Pursuing and killing the snake is not recommended. which may squeeze more venom out of the venom sac. • Anaphylactic shock and respiratory obstruction demand emergency management. but if the snake is already killed.Guidelines 2. Administration of analgesics such as paracetamol 600mg orally and antihistamines such as chlorpheniramine(4 mg) and diphenhydramine (25 mg) provide symptomatic relief. these should be watched for. Persons allergic to these • • 422 . • The site should be cleansed with soap and water • Ice packs applied locally slow the spread of the venom. For further management refer to Anaphylaxis. wearing shoes and protective clothings. oral prednisolone (20 mg) or injection betamethasone or dexamethasone (4 mg) should be given.Emergency management in the presence of anaphylactic shock is to give 1 mL of adrenaline (epinephrine)1 in 1000 solution IM repeated if necessary. • Elevation of affected site. Since delayed complications such as coagulopathy and renal failure may occur. Multiple stings and especially on the face and head may give rise to severe local reactions. respiratory obstruction and death. Need for immediate transportation to the hospital. Most of the cases are mild and they clear up spontaneously. but must not be handled because even a severed head can inflict lethal injury.

General Topics stings should be warned to avoid further exposure. leading to hemodilution and hemolysis with release of potassium from the red blood cells. In fresh water drowning. Two types of drowning have been recognized . Management First aid: (1) clear the airway of water and foreign bodies by putting the patient head low and by suction (2) institute mouth-to-mouth breathing as early as possible (3) closed chest cardiac massage should be instituted if heart sounds are absent and (4) all cases must be hospitalized to prevent death from secondary drowning. It absorbs more fluid into the alveoli causing pulmonary edema and respiratory failure. but not in Kerala. which may prove fatal.Hypernatremia follows later when the salt is absorbed into the circulation. Secondary Drowning or near-drowning occurs a few hours or few days after the initial resuscitation due to the secondary changes in the lungs such as pulmonary edema. pneumonia. Hospital treatment: This aims at 1) maintenance of adequate oxygenation (2) correction of metabolic and electrolyte imbalance 423 . which proves fatal in 20% of the subjects. electrolyte disturbances and metabolic or respiratory acidosis. pneumothorax.In wet drowning water enters the lungs. ln this. ln dry drowning death is due to laryngeal spasm. In salt water drowning the fluid in the lung is hyperosmotic. The consequences differ between fresh water and sea water drowning. Immersion syndrome. water is quickly absorbed from the lungs. Drowning Drowning is the pathological state leading to death resulting from the aspiration of water into the respiratory tract or due to asphyxia on immersion.dry drowning and wet drowning. sudden death occurs due to cardiac arrest caused by vagal stimulation brought about by sudden immersion into cold water. Specific antisera are available in some countries.hyperkalemia precipitates ventricular arrhythmias. This also prevents the entry of water into the lungs. In addition to hypoxia and ventilatory failure.

In severe dehydration there will be obtundation. low volume pulse and oliguria. Common causes of diarrhoea include1. Viruses like rotavirus.(Dysentery) Laboratory investigations 1. 424 .Prompt correction of dehydration and electrolyte imbalance helps to restore normalcy and prevent death. Watery diarrhoea is characteristic of enteritis where as colitis is characterized by presence of blood and mucous in stools.Norwalk virus. restlessness.the deterioration of general condition may be so rapid that occurs within hours . shigella. Adequate oxygenation is achieved by the use of controlled ventilation with 100% oxygen. ulcerative colitis .intubation and application of positive end expiratory pressure (PEEP) respiration should be resorted to. campylobacter. Bacteria such as various strains of E. In mild diarrhoea child has none of the signs described above and the main goal of treatment is to replace ongoing losses using homemade fluids like salted kanji water or ORAL REHYDRATION SOLUTION (ORS). microscopy of the faeces reveals protozoal or helminthic parasites 2. Other less common causes include antibiotic associated diarrhoea. vibrio cholera.so very prompt measures should be undertaken early enough. dry tongue and decreased skin turgor. 4.diverticulitis and others.In acute diarrhoea . Food poisoning may lead to severe gastroenteritis characterized by vomiting and watery dirrhoea. floppy limbs.coli. 3. Protozoa such as giardia . PAEDIATRICS DIARRHOEA AND DEHYDRATION Diarrhoeal illness is common in childhood and untreated severe diarrhea can be rapidly fatal. culture of the fresh stools directly into culture medium and further microbiological tests help to identify the invading bacterium. Common signs of dehydration are increased thirst. later to be reduced to 40%.entaamoeba and others.Guidelines (3) prevention of secondary effects.corona virus and others 2. If these measures fail to respond.

The IV fluid can then be changed to maintenance fluid if required eg. Dextrose saline may be used instead to prevent hypoglycaemia.Add KCl 20mEq/L as soon as child passes urine. 2 mL/ kg diluted with equal amount of distilled water or 5% dextrose IVslowly in severe acidosis. Breast feeding should be continued in small frequent feeds. Holliday and Segar Formula is generally used to calculate maintenance requirement as given below. Use cup and spoon to give ORS.Shock. l0—20 kg -1000 + 50 mL/additional kg over 10 kg. After each motion give ORS 50mL (1/4 glass) for infants <6months. Dose: First 10 kg . Breast feeding to be continued. coconut water or buttermilk can be used. In cholera much more fluid will be required and constant monitoring of hydration is essential. In moderate dehydration: ORS/IV fluids will be required. In Severe Dehydration: always use IV fluids with wide bore needle . ORS and feeding can be started at the end of 6h as the signs of dehydration disappears by this time.Paediatrics Dose: 1 packet of ORS dissolved in 1 L (5glasses) of potable water (boiled and cooled). acidosis and marked oliguria by themselves are indicative of severe dehydration. 425 . isolyte P. For older children 100mL/kg should be given in 4 h . Use 7. Above 20 kg -1500 + 20 mL/kg for additional kg over 20 kg. Ongoing losses also should be replaced.100 mL/kg/24 h. 1/2 glass for children upto 2 years and 1 glass for older children.5% soda bicarb. Offer plain boiled water in between ORS in those who are not breast fed. IV fluids are used in similar lines for the treatment of severe dehydration (see below) except the initial emergency phase can be omitted. Ringer lactate or Normal saline is used initially Dose: 30mL/kg in first 1h followed by 70mL/kg over next 5 h. Homemade fluids like salted rice water. About 100 mL/kg ORS is given in 4 h. (100mL/ kg in 6 h).

600800mL (3 to 4 glasses of ORS) IV Fluid required 1st 6 hour 100mL/kg (Ringer lactate / N saline) 1st hr 30 mL/kg Next 5 h 70mL/ kg thereafter maintenance fluid if required Severe >1000 mL Antibiotics may be required in many cases though their value is being debated. Once the acute condition is over the child should be referred for active immunization. respiratory rate over 40/min together with use of accessory muscles chest retraction. 4. Signs indicative of acute severe asthma: 1. ciprofloxacin. 2. ACUTE SEVERE ASTHMA (in children) ln acute severe asthma early detection of severity of attack and prompt treatment is essential to prevent mortality.12 kg 500 mL 500 -1000mL Fluid replacement as ORS 1/2 glass=100mL after each stool In first 4 h. 426 too breathless to feed or talk. 3.and erythromycin. Occurence of cholera and gastroenteritis should be notified to the health authority for taking preventive measures. azithromycin.Guidelines An illustrative case eg.The commonly given antibiotics include doxycyline . 2 year old weighing 12 kg Symptoms & signs Mild Moderate None Restless Thirst increased Skin turgor reduced Dry mouth Lethargic Floppy Cold extremities rapid thready pulse Fluid deficit eg.Antibiotic associated diarrhoea responds to metronidazole 400 mg tid for 10 days or vancomycin 250 mg qid for 10 days. Nalidixic acid 55mg/kg in divided dose for 5 days is effective in cholera. tachycardia over 140/ min . Note 1.2 yr old Wt. 2.

f) Aminophylline.A volumatic spacer or a plastic cup can be used for administering the drug in small children. 7. infusion at a rate of 0. silent chest on auscultation.1 g/kg/minute of terbutaline. reduced level of consciousness. sudden onset of bradycardia and poor respiratory effort are all indicative of life threatening asthma. fatigue and exhaustion. preferably using a Nebuliser. cyanosis. 6. b) In small children the dose is calculated as 150 mcg/ kg/dose of salbutamol respirator solution diluted with 10 times volume of normal saline and then nebulised.9 mg/kg/h. bolus dose of 6 mg/kg/diluted IV very slowly followed by an infusion of 0.Dilute 0.Inhaled beta2 agonist is the drug of choice. c) lf a nebulizer is not available a metered dose inhaler can be used in a dose of 2 puffs of salbutamol every 4 to 6 hour or earlier.7-0. a) Beta2 agonists-salbutamol/ terbutaline. g) Hydrocortisone 5 to 10 mg/kg/dose. d) Parenteral dose is 5mcg/kg of terbutaline/dose every 6th hrly SC or it can be given as a bolus dose diluted followed by an IV. Give only 3 mg/kg as bolus if child is already on theophylline or omit the bolus dose. 8. increasing 0. Repeat nebulisation 4-6 hrly or earlier as needed.5mg) salbutamol respirator solution with 4 mL normal saline and place it in the nebulization chamber. 427 .Paediatrics 5. e) Anticholinergic drug like Ipratropium bromide 0.5 mL (2. Repeat 4 to 6 hrly or earlier in severe cases. Using pressurised air or oxygen the solution can be nebulized into fine particles which the child inhales using a mask or mouth piece.5ml1mL(125-250mcg) can be added to salbutamol nebulizer solution and the nebulized every 4-6 hrly in severe cases.1 mcg/kg every 15 minutes to a maximum of 4 mcg/kg/minute.

If needed add systemic needed for symptom steroids 2 mg/kg/day Step 3 Moderate persistent Medium dose inhaled steroid with spacer OR medium dose inhaled steroid with cromolyn OR medium dose inhaled steroid with long acting theophylline Step 2 Mild persistent Daily anti-inflammatory medication “ cromolyn “ or low either inhaled dose inhaled steroids Step1 Mild intermittent No daily medication needed Bronchodilator as needed for symptom relief-either inhaled short acting beta 2 agonist with spacer or oral beta 2 agonists 428 “ “ relief upto three times a day Long term control Quick Relief h) .Guidelines Oxygen inhalation and other treatment modes like antibiotics.V fluid if indicated. Very few cases may need artificial ventilation to save life ASTHMA IN CHILDREN < 5 YEARS OF AGE Step Step 4 Severe Persistent High dose inhaled steroid with Bronchodilator as spacer. alkali therapy. but monitor carefully. and I. No sedation.

one of the most accepted objective method to initate recuscitative procedure is to determine the Apgar score which is given below Score Respiratory effort Heart rate/ min Colour of the baby Muscle tone Reflex stimulation (catheter in the nose) 0 None Absent Blue or pale Flaccid No response 1 Slow irregular <100 Body pink. then initiate external cardiac massage by chest compression 120 times a minute. • Most newborn babies cry immediately at birth. place the baby on a flat resuscitation table under a warmer with head slightly extended by 30 degrees. Clean the airway by oropharyngeal suction.coughs or sneezes Normal babies have an apgar score of more than 8 at 1 & 5 min. Provide tactile stimulus by flicking the soles. Use of oxygen reservoir will enable 100% oxygen administration. If heart rate is less than 60 or fails to rise above 80 after 30 seconds of assisted ventilation. crying >100 Pink Actively moving the extremities Cries. then nose. mouth first. extremities blue Some flexion Grimace 2 Good. Do not slap the baby or hang him upside down. For every 2 chest compression one ventilatory breath is given. Dry the baby in a clean warm towel. If baby is still gasping/apnoeic immediately initiate assisted ventilation with a bag and mask using oxygen at 2-4 L/min. Count heart rate with a stethoscope for 6 seconds and multiply by 10 to get heart rate in 1 minute. 429 • ° • • • • . Apgar score between 4-8 is moderately low while that less than 4 is very low 5 min apgar score is more important that 1 min apgar score • If baby has not cried within 15-20 seconds after birth or if baby is apnoeic or gasping. heart rate and colour.Paediatrics RECUSCITATION OF NEWBORN • Evaluate the neonate at birth for adequacy of respiration.

• Dopamine infusion 2-20 mcg / kg/ min may be used if shock does not improve.Guidelines If there is no reponse to bag and mask ventilation and chest compression then endotracheal intubation and positive pressure ventilation is given using oxygen.V N. • If after 8-10 min of adequate resuscitation baby does not show signs of improvement and acidosis is severe. other solvents .cleaning solutions and a variety of drugs. insecticides and vegetable poisons. abdominal pain. • Hypoglycaemia should be anticipated and corrected. • Endotracheal intubation is indicated if meconium aspiration or diaphragmatic hernia is suspected. But it should be suspected in any healthy toddler with acute onset of unexplained symptoms like vomiting.and cardiopulmonary and 430 • .1 mg/kg IV or IM. 2 mL / kg / diluted with equal amount of distilled water is given slowly over 2-3 min. • If mother had received a narcotic within 4 hours prior to delivery then give naloxone 5-10 mg/kg or nalorphine 0. • If heart rate remains less than 80 / min despite adequate resuscitation. • If the baby is in shock with poor peripheral pulse and circulation give I.5%). Do not use bag and mask ventilation in these circumstances. Note-neonatology and initial care of the newborn have assumed great importance since mishaps occurring in the first hours of life may lead to permanent disabilities in the child. Give 25% glucose 1 mL / kg over 4 min initially and then continue with 10% dextrose infusion 60-90 mL / kg / day.Inadvertently kept drugs used by members of the household may be ingested by the child. chemicals. Physical examination should focus on vital signs. give 1/10000 adrenaline 0. drowsiness or delerium.saline or Ringer lactate or plasma at the rate of 10 mL/kg. Most of the poisoning in children is accidental.detergents.With modern well equipped dedicated units even babies with birth weight of 600g (even lower birth weight in advanced centres) can be kept alive and made to thrive normally. Common poisons include kerosene oil. Therefore it is preferable to send complicated pregnancies to tertiay care centres well before delivery.1 mL/ kg IV or via endotracheal tube or rarely intracardiac. POISONING IN CHILDREN Diagnosis of poisoning in children is easy when history is forthcoming. then NaHCO3 (7.

vomiting should be induced. drooling No emetics/lavage. renal failure 2 Alkali Pain. correction of acidosis and fluid-electrolyte balance and infections . At the time of discharge parents should be advised on prevention of poisoning Some Common Poisoning in Children and their Management . Pain. IVfluid antibiotic + steroid surgical consultation Treatment 3. Desferrioxamine for Iron poisoning. swelling. Lavage/emetics Fluid electrolyte therapy. Sl. Aspirin Vomiting. Cold Water milk IV. Poison Clinical features 1. acidotic breathing seizure.Paediatrics neurological status.by tricking the throat after giving 1 glass of water or fruit juice. Symptomatic and supportive treatment will be required in all cases.K. and phenobarbitone can be hastened by forced alkaline diuresis. Specific antidote if available should be given immediately eg. If induction of emesis is not successful gastric lavage should be done carefully using a ryles tube. Acids Severe pain. abdominal. hypoglycaemia. Vit.Urinary excretion of poisons like salicylate. 30 -50 mL water or 1/2 N. Close observation and masterly inactivity is all that is required in most cases. coma. No. anticonvulsants. flushing. erythema and swelling/ulceration of mouth Laryngeal oedema-watch for shock.Haemodialysis may be required at times. Severe cases with organ dysfunction should be managed in secondary care units Therapeutic interventions include treatment of shock. Gl bleed. forced alkaline diuresis.. tinnitus. antibiotic surgical consultation No emetic/lavage cold water/milk. Glucose. saline is introduced each time and then aspirated until returning fluid is clear. salicylate level >l00mg/dl. fluid. If the child is seen soon after ingestion. white plaques in the mouth Dysphagia. Dialysis in severe poisoning 431 . Correct acidosis.

bradycardia hypotension. hepatic failure Stage 5. Then 50mg/ kg in 5% dextrose over 4-8 h x 3 doses Doses above 100mg/kg body wt. coma.small pupil. After 12 h. or IV. haemodialysis may be useful 8. cough. breathless. 17 such doses IV 50 mg/kg as loading dose. Hepatic failure usually on 3 day. vomiting abdominal. cyanotic. shock encephalopathy. Continue till urine is clear. seizure.of apparent recovery For few hrs stage 3. pulmonary oedema. Kerosene oil Vomiting. acidosis Stage 4. 432 . mottled appearance 5. With higher doses toxicity.05mg/ kg IV at 5-10 min interval as needed Pralidoxine 25-50mg/kg/ IV as a 5% solution after atropinisation. Atropine 0.Guidelines 4.can be toxic. chelation as early as possible desferrioxamine IM. Lacrimation. 2-4 weeks gastric scarring and intestinal obstruction. salbutamol and steroid in case of wheezing Stage 2.chest X-ray. Vin rose colour if serum Iron is high.pain. ventricular-arrhythmia. Emetic / lavage. Nypoglycaemia. risk of hepatic damage and death steadily increase. Oxygen. twitching. coma. symptomatic and coma. smell of kerosene. vomiting. Paracetamol Nausea. Choline esterase activity in RBC/serum <20% in severe cases. crystalline penicillin in case of aspiration. Emetics/lavage. Within hours. Organophosphorous Sweating. No emetic or lavage. Renal failure. Emetic/lavage N-acetyl cysteine initially oral 140mg/ kg. 2-4 days.clean up contaminated skin. then 70mg/ kg every 4 h. 6. Iron 5 stages stage 1.salivation. Gl bleed. supportive.

pleuritis. The major causes are myocardial ischemia (coronary artery disease).Chest pain is often a symptom brought about by anxiety and hypochondriasis Clinical evaluation of chest pain Angina is usually retrosternal in location. The most important cause of acute chest pain is acute coronary syndrome either unstable angina or myocardial infarction. though people below thirty years and women in their reproductive period are rarely only affected. Common causes of chest pain A wide variety of diseases can cause chest pain. The pain is a felt as a constricting sensation or sensation of heaviness or pressure or choking feeling.CARDIOLOGY Evaluation of chest pain One of the most challenging areas in clinical medicine is the evaluation of chest pain. It may be associated with breathlessness or sweating. The pain may radiate to the throat or jaw or arms or rarely epigastrium and interscapular areas. Proper history elicitation and interpretation is the cornerstone in the evaluation of chest pain especially acute coronary syndromes. gastritis and cholecystitis. pericarditis. Atypical pain. It strikes not only the elderly but also the middle aged earning members of the family and even the young.No age is totally immune. Rarely pain is felt only at these sites. Such atypical presentations are common in diabetic patients. They may have an atypical presentation like dyspnoea or pain at sites other than chest (jaw/ throat/arm). Early identification of angina and coronary artery disease is important since it is the main killer. Most of the organs in the chest and some in the abdomen can cause chest pain. Rarely patients may not experience chest pain. demented patients and in the elderly. Other rare causes are herpes zoster involving the thoracic dermatomes and breast inflammation and cancer. 433 . Myalgia and costochondritis are also common causes of chest pain. aortic dissection. Some patients have syncope or extreme fatigue or sweating or nausea and vomiting. Physical findings are few in acute coronary syndromes. esophagitis. The symptoms occur suddenly and a worse turn can occur at any time. acid peptic disease.

It is of a catching nature and it increases on deep inspiration. Aortic dissection The pain of aortic dissection is usually of a tearing quality often referred to the lower limbs as well. Pulmonary embolism Patients have sudden onset of dyspnoea and chest pain. This is the single most important source of data. The patient will have shallow respiration and pleural rub is usually present.05 mv ) is significant. The main ECG changes that can occur with angina are ST segment changes (ST segment depression or ST segment elevation) and T wave inversion. The predominant symptom is dyspnoea. immobilization. ST segment elevation is usually indicative of acute myocardial infarction. It is usually accompanied by pericardial rub. ST segment depression of 0. It may vary with posture and respiration. A new onset left bundle branch block is indicative of myocardial infarction. The lower limb pulses may be weak or absent.Guidelines Pericardial pain Pericardial pain is of a catching nature. It should be obtained as early as possible preferably within 10 minutes of presentation. T wave changes like tall peaked T waves and T inversion are also suggestive of myocardial ischemia.5 mm or more ( 0. Esophageal pain It is retrosternal burning type of pain usually persistent. The pain may radiate to the interscapular area. ST segment elevation is significant if there is 1 mm or more elevation. prothrombotic conditions or post surgical state. Pleuritic pain It is usually felt on one side of the chest. Electrocardiogram The electrocardiogram (ECG) is one of the most important investigations that should be done in a patient with chest pain. Chest pain is usually unilateral. It is usually seen in a setting of a cause for deep vein thrombosis such as obesity. 434 . There will be severe pain on coughing. It is usually seen in hypertensive patients. A transient ST segment elevation can occur in unstable angina especially in those with coronary spasm. Pericardial pain usually radiates to the shoulder.use of oral contraceptives. It may be associated with dysphagia.

Indications In acute MI with angina. cardiac Imaging like ECHO. 435 . congestive heart failure. Minor degrees of ST segment depression are sometimes seen in females especially in those with mitral valve prolapse. Nitrates: These are used for relief of anginal pain. CT angiogram. determination of cardiac markers like troponins . Minor T inversions (<0. as well as prevention of its recurrence.creatine kinase CK and CK-MB.Cardiology ST segment elevation can also occur in pericarditis. Maintenance dose is continued in patients with recurrence of angina and persistent pulmonary venous congestion. left bundle branch block. The disadvantage of ECG is that it is a brief sample and confounding baseline ST segment deviations are common. Patient’s who shows any abnormality of ECGor any sign of haemodynamic instability such as rapid pulse. The vasodilatory effect is immediate and action is of short duration.If facilities exist presence of ST elevation along with typical chest pain is an indication for administering thrombolytic drugs such as streptokinase IVin a dose of 250.000 U diluted in 100 ml normal saline and infused over 1 hour or as a slow IVinjection. tread mill test and coronary angiography. persistent angina or hypertension. Availability of a old ECG improves diagnostic accuracy. ST segment depression can also occur with left ventricular hypertrophy. For maintenance therapy other preparations are used which have more prolonged actions. ANGINA PECTORIS MANAGEMENT 1.When the clinical suspicion of myocardial ischaemia is strong repeat ECGs done at 2 hourly intervals may demonstrate the evolving lesion. nitrates are given for the first 24-48 hours.P . Further investigations include the following.development of triple heart sounds should all be indications for referral to higher centres.The sensitivity and specificity are not fully reliable so that both false positive and false negatives may occur. For immediate action glyceryl trinitrate is used IV or sublingually. Serial ECG changes are most important and suggestive.02 mv) may rarely be seen in normal people. left ventricular hypertrophy and early repolarization syndrome.falling B. Computerized chest pain protocols are available for triaging the patient and proceeding further.

2. 50 and 60 mg are available. Hypotension and hypovolemia are managed by elevation of the foot-end of the bed and intravenous fluids. If there are no contraindications. oral metoprolol 50 mg is given 6 hourly for two days and then changed to 100 mg bid. 2% skin ointment and transdermal patches containing 2. In general. 10 mg and 20 mg sustained release tablets. Sublingual Dose: Glyceryl trinitrate is available as tablets containing 0. or 1.3 mg may be repeated every 5 minutes to a maximum of 1. 8 am and 2 pm.V dose. but generally it is delayed.4 mg. Methemoglobinemia may develop after large doses.5.5. 5. Additional doses of 0.3-0. reduction or withdrawal of the dose helps to relieve the side effects. Transdermal preparation of nitrates should not be used continuously for more than 12 hours.2 mg in 15 minutes. 436 . released over 24 hours. Side Effects of Glyceryl Trinitrate: Headache and flushing. These are used for maintenance therapy and prevention of angina after the emergency is tided over. This includes relief of angina. e. One vial is diluted in 500 mL normal saline prior to infusion and run at a rate of 5-10 mcg/minute to start with. metoprolol is given IV in three boluses of 5 mg each at intervals of 2-5 minutes if the heart rate is >60/minute. It is increased by 5 to 10 mcg/minute until clinical effect is manifest. fall of blood pressure by 10% in normotensive. Isosorbide mononitrate Short acting tablets of 10 and 20 mg and long acting tablets of 40. hypovolemia and ventilation-perfusion imbalance in the lungs. If hemodynamic stability continues for 15 minutes after the last I. and up to 30% in hypertensive patients. hypotension.0 and 15 mg. Tolerance to all forms of nitrates develops after continuous administration even within 12-24 hours. Beta Adrenergic Blockers If angina is severe and non-responsive to nitrates intravenous metoprolol is the drug of choice. Other preparations are buccal spray containing 400 mcg metered doses.6mg. It is given initially at doses of 0. Tolerance to nitrates is prevented by giving the drugs at eccentric intervals allowing 10-12 hours of nitrate free intervals in between. lsosorbide dinitrate: This is available as 5 mg.6 and 6.g.25 mg metered dose buccal spray.Guidelines Glyceryl trinitrate is available in vials of 5 and 25 mg at concentrations of 1 or 5 mg/mL.

Prompt institution of specific treatment reduces mortality. absolute or relative hypovolemia is usually not present in cardiogenic shock. The majority of cases end up fatally.e. 437 . Treatment General measures: Shock should be diagnosed early. given orally. The patient is put to bed with foot-end of the bed elevated to increase the venous return to the heart. Survival is inversely related to the duration of the shock before starting treatment. Alteration in the consciousness such as agitation. Cardiogenic Shock This form of shock is caused by failure of the heart to act as an effective pump. third degree heart block. In contrast to other forms of shock. if left untreated.The shock syndrome is characterized by rapid thready pulse and cold clammy skin. The urinary output falls below 20 mL/h with the urinary sodium falling below 30 mmol/liter. and bisoprolol 5 mg daily. if needed. prolonged PR interval > 0. bradycardia (heart rate< 60/minute). The ultra short acting drug Esmolol can be used in an emergency in a dose of 500 mcg/kg/minute for 4 minutes I V. hypotension (BP < 90). somnolence. Vital signs like pulse. diminished peripheral perfusion pulmonary congestion. and elevation of systemic vascular resistance and pulmonary vascular pressures.24 second or. SHOCK Clinically shock is usually accompanied by hypotension i. every 10-15 minutes to reach a total dose of 15-20 mg. It occurs most commonly as a complication of acute myocardial infarction. a mean arterial pressure < 60 mmHg in a previously normotensive person.Cardiogenic shock is characterized by low cardiac output. Other commonly used beta blockers include atenolol 50-100 mg daily. morphine 5 mg is given intravenously and repeated. The onset is usually sudden.confusion or coma is a common feature. Patency of the airway is established by removing foreign bodies from the mouth and throat and by keeping the neck extended backwards to prevent the tongue from falling back. If there is pain. Metabolic acidosis manifests with tachypnea and Kussmaul’s respiration.Cardiology Contraindications for beta blockers include cardiac failure evidenced by the presence of rales heard over the lower parts of the chest 10 cm above the the level of the diaphragm.

depending upon the response of blood pressure and urine output. isotonic. Blood.Further maintenance depends on rate of fluid loss. depending on the response. Vasodilator drugs: Commonly used vasodilator drugs include: 1. Metabolic acidosis is corrected by administration of 50-100 mmols of sodium bicarbonate given as a 7. blood pressure and urine flow are monitored. if prolonged treatment becomes necessary.Combination of vasodilators with inotropic agents gives better results.) and dobutamine (3-15 mcg/kg/min). infusion of 7.15 mcg/ kg/min. but cardiac arrhythmias may be precipitated.14 cm of water. Vasopressor drugs: Sympathomimetic drugs are used to improve vascular tone. The rate of infusion should match the rate of fluid loss. Hypovolemic shock: Rapid replacement of the blood volume by administration of the appropriate fluid (depending on the fluid lost) is lifesaving and this should be undertaken without delay.5 mcg/min. Dopamine is given intravenously at a rate of 3.Guidelines respiration.5% solution. thrombolytic therapy and surgical revascularisation for acute myocardial infarction. antibiotics for septic shock and dialysis procedures for poisoning. A venous cannula introduced into the jugular vein helps to monitor the central venous pressure and also to administer fluids. Apart from these general measures each type of shock demands appropriate specific management. Fluid infusion is continued until the systolic blood pressure comes up to 100 mm Hg. Phentolamine given IV at a dose of 0. 2. 438 .saline or plasma volume expanders such as 6% dextran or other colloidal solutions should be used. These drugs cause improvement in cardiac output and blood pressure. Other drugs in this group are isoprenaline (4-8 mcg/min. For example. 3. Vasodilators should be started in small dosage and the dose should be worked up. It is ideal to keep the central venous pressure at 10.5% saline (100-400 mL) may help to restore the blood pressure. If the shock is unresponsive to replacement of conventional fluids. Sodium nitroprusside given IV at a dose of 10-20 mcg/ min Nitroglycerine given IV at a dose of 10-20 mcg/ min. In severe cases of gastroenteritis up to 3-4 litres of fluid may have to be infused in the first 1-2 hours.

The picture is one of an apparently healthy or ailing person falling unconscious.Cardiology Cardiac arrest and its management: Cardiac arrest is a most dramatic medical emergency which may happen in all unexpected situations from time-to-time. One person starts the procedure. Cessation of breathing or gasping respiration. full consciousness is not regained. Put the patient on a firm non-resilient surface and clear the airway. with total loss of consciousness and cessation of heart beat and pulse. If cardiac standstill is not corrected within 3-4 minutes. irreversible damage occurs to the brain and vital centers. 4. 1. 2. Other supportive evidences are. If the maneuver is properly done. Loss of consciousness. Remove dentures and foreign bodies from the mouth and throat. 3. at the rate of 50-60/min. Resuscitative measures should be instituted if the main pulses are not palpable and heart sounds are not heard. The ECG will fibrillation. 2. It is mandatory to distinguish between the ventricular asystole and the ventricular fibrillation for Specific management Steps to be followed: 1. Dilation of the pupils. loosen clothing. Such a patient may continue to live a vegetative existence without regaining consciousness and other cerebral functions. Start external cardiac massage by pressing firmly over the sternum (so as to compress the precordium) and releasing it. The most common causes are ventricular fibrillation and ventricular asystole. the carotid pulse will be felt. 439 . Management of cardiac arrest is a team work. Resuscitation becomes futile thereafter or even if the cardiac rhythm is restored. the others soon join him for assistance. Cyanosis or pallor. confirm whether the heart is in asystole or ventricular A planned line of management is absolutely essential to avoid these catastrophies. and remove secretions from the air passages by proper positioning and suction. if available. Introduce an airway. pull the chin up so that the tongue does not fall back to obstruct the throat.

5. 9. lf the heart returns to activity.scouts and so on. 20 mL of 5% solution of calcium chloride can be given after repeating sodium bicarbonate and adrenaline. or using an Ambu bag. lf facilities are available. Start an intravenous line with 5% glucose to act as a route of medication.5 mL of 1/1000 solution into the cavity of the right ventricle using a lumbar puncture needle inserted through the third or fourth left intercostal space. lf ECG shows ventricular fibrillation. ln many centres adrenaline is given by the intravenous route. The DC shock can be repeated if conversion is not achieved with single shock. porters. Periodically guidelines are published to simplify 440 .steps are taken to transport the patient to the hospital in a suitably equipped ambulance. lf ventricular asystole is detected adrenaline 0. dopamine may be started as an intravenous drip at the rate of 2-3 mcg/kg/min. 4. 8. Other drugs: Sodium bicarbonate is given l. 6.V in a dose of 100 mmol ( 100 mL of 7. This is adequate if external cardiac massage is performed effectively. apply the electrodes and give a DC shock of 200 joules (100—400joules). Emergency first aid management of cardiac arrest is taught to several groups such as ambulance personnel.to-mouth respiration. Often this converts asystolc into ventricular fibrillation and this can be converted by DC shock. Start artificial ventilation simultaneously by mouth. paramedical staff.Guidelines 3. 7.4 % solution )for an adult rapidly to counteract metabolic acidosis. continue massage till the systolic blood pressure is maintained at 70-80 mm Hg. lf the heart is beating but BP is low. As soon as the emergency team starts to give first aid. the trachea is intubated with a cuffed endotracheal tube and positive pressure respiration given with oxygen-enriched air at the rate of 10-12 L/min without interference to the external cardiac massage. Often the fibrillation disappears and heart resumes normal beat. lf the heart continues in asystole after adrenaline and massage. External cardiac massage and resuscitatory measures are stopped if the heart fails to recover within one hour and the pupils remain dilated and fixed despite adequate massage.5 mg is given intravenously or intracardiac (0.

Diuretic: Frusemide 40 mg should be given intravenously. in the position of maximum comfort. The venous return from three limbs is obstructed at a time and the tourniquets are rotated at 15 min. lf the effect is not evident in 30 min the dose may be repeated. at 15 min. Patient is hospitalized and put to rest with a back rest or cardiac table. ventilators and oxygen delivery systems are available in public places and in several aircraft. Morphine sulfate 3-5 mg is given intravenously over three minutes and repeated to a total dose of 15-20 mg. 2. 4. bronchodilation and diuresis. Once the emergency is managed successfully. depresses the respiratory center. allays dyspnea. Emergency resuscitation helps to prevent death and permanent morbidity. Aminophylline has different actions such as improvement of cardiac output. This method of physiological venesection is very effective. 8. Aminophylline in a dose of 5 mg/kg given intravenously slowly is very effective in increasing the cardiac output and relieving bronchospasm. 5. 7.5-1 mg digoxin when there is clear indication. further elective management depends upon the underlying condition. ACUTE CARDIOGENIC PULMONARY EDEMA(ACUTE LEFT HEART FAILURE) 1. The patient is given oxygen immediately at a flow rate of 7-10 L / minute. and reduces the adrenergic vasoconstrictor stimuli. 6. Vasodilators such as nitroprusside given intravenously may be required in intractable cases. 441 . Digitalisation: Rapid digitalisation is done by intravenous injection of 0. Reduction of preloads :Tourniquets are applied to the extremities proximally to reduce venous return and thus reduce preload. Venesection should not be done on hypotensive patients. In many cases the effect of aminophylline is dramatic.Cardiology the procedure so that more persons can practice emergency resuscitation. stimulation of the respiratory center. Morphine abolishes anxiety. ln less acute cases the drug can be given intramuscularly in doses of 15-20 mg. intervals. Rarely open venesection to remove 300—500 mL blood rapidly may be required. intervals. Hypotension and anaphylaxis are potential adverse effects of aminophylline. Life saving equipment such as defibrillators. 3.

MANAGEMENT OF HYPERTENSIVE EMERGENCIES Introduction Hypertension related emergencies account for nearly 25% of all acute medical emergencies. whereas in cases of chronic effusions large quantity of fluid may accumulate before tamponade develops. Volume expansion should be done with blood. cause obstruction to inflow of blood into the ventricles.particularly the right ventricle. Since cardiac care centers are available in many towns in Kerala. which involves the surgical opening of a communication between the pericardial space and the intrapleural space is sometimes required in recurrent effusions. 442 . A 16 or 18 gauge needle is inserted at an angle of 30-45° to the skin.Guidelines Cardiac tamponade When sufficient amount of pericardial fluid accumulates. Removal of pericardial fluid is the definitive therapy for tamponade. Management In pericardial effusions without tamponade aim is to establish the etiology by a careful history including medication review and radiation therapy. aiming towards the left shoulder. Drainage of pericardial effusion is usually unnecessary unless purulent pericarditis is suspected or cardiac tamponade supervenes. In cases of trauma rapid accumulation of even small quantities of blood can cause tamponade. Depending on the circumstances. near the left xiphocostal angle. plasma. or isotonic sodium chloride solution. Surgical creation of a pericardial window. pericardiocentesis is required. it can increase the intrapericardial pressure. Most commonly employed method for closed pericardiocentesis is the subxiphoid approach. If a definite etiology is not evident by non-invasive testing. dextran. Removal of small amounts of pericardial fluid (50 mL) produces considerable symptomatic and hemodynamic improvement. Pericardial Aspiration Those patients with tamponade should be considered as having a medical emergency. general physical examination and investigations. it is better to refer cases needing pericardial aspiration to such centers. the investigations should include.and fall in cardiac output. This is cardiac tamponade. skin testing for tuberculosis. as necessary to maintain adequate intravascular volume. infections and hypothyroidism. screening for neoplastic and autoimmune diseases.

but short term risks are significant. Common hypertensive emergencies Hypertensive encephalopathy: clinical features. Cardiovascular complications: Aortic dissection.P has to be reduced within hours. Hypertensive emergencies may require parenteral drug therapy. The level of blood pressure may vary and atleast in some it may be only below 180 mm Hg systolic. The term hypertensive emergency refers to the condition where the immediate risks of target organ damage are high and B. When immediate risks are not high. The level of blood pressure and the risks of target organ damage determine hypertensive crisis. cerebral hemorrhage.Cardiology Approach to treatment depends not only on the level of BP. whereas a BP of 200 / 120 in a chronic hypertensive with no end organ damage would just need routine blood pressure control. whereas urgencies can be controlled by oral medications. Headaches. Often hospitilisation is necessary.P has to be brought down within 24 hours this is termed hypertensive urgency. and the B. progressive target organ damage and demanding immediate reduction of blood pressure within one hour usually by using parenteral drugs. clouding of consciousness. acute pulmonary oedema Cerebrovascular complications: Acute cerebral infarction. but also on the rate of rise of the blood pressure and the severity of associated co-morbidity. petechial hemorrhages in the retina are all associated with blood pressure often above 180/110 mm Hg.subarachnoid haemorrhage and hypertensive encephalopathy 443 . Definitions Hypertensive crisis is a term to describe both hypertensive emergencies and hypertensive urgencies. Hypertensive emergency is the situation with severe elevation of blood pressure. associated with severe symptoms. seizures. focal or general neurological deficits. visual disturbances. acute myocardial infarction or unstable angina. A blood pressure of 140 / 90 mm Hg in a patient with aortic dissection would constitute an emergency. Hypertensive crisis is a term that encompasses both hypertensive emergencies and hypertensive urgencies.

bilateral renovascular disease and a few others. flushing. which is quite effective to reduce BP .0mcg/kg/min as IV infusion. The effects start within 1-5 min and last for upto 60 minutes after cessation 444 . Titrate infusion every 5.30 minutes and it lasts for 12.Guidelines Management General principles It is safer to reduce the BP gradually but promptly. lasts for 1-2 h. vomiting and precipitation of angina.25 mg Q6h IV. followed by infusions 3 – 25 mg /h. vomiting.Initial reduction of mean arterial BP[diastolic+1/3rd (systolic-diastolic)] of 25% over minutes to 1-2 hrs.10 minutes for optimal BP control. followed by gradual reduction to about 160 / 100 mm Hg over the next 2-6 hours is safe in most cases. headache.5 minutes. The onset of action occurs in 15. If the patient remains stable it is ideal to reduce the BP to < 140 / 90 mmHg over the next 12-24 hours. Very useful in hypertensive crisis associated with acute coronary syndromes. onset of action occurs in 2. Dose is 5 – 200 mcg /min as infusion. Specific therapy Vasodilators Sodium nitroprusside: For immediate reduction of BP the drug of choice is sodium nitroprusside in a dose of 0. This brings down the BP instantaneously but the effect is transient Nitroglycerine: Dominantly a venous dilator. Hydralazine: Dominantly an arterial dilator. heart blocks and bradycardia.25 – 10. This drug is mostly of use in preeclampsia and eclampsia and it is contraindicated in the setting of acute coronary syndromes. repeat every 4-6 hrs. dose is 10-20 mg IV bolus. The dose is 5 -10 mg IV as bolus . Verapamil: This is a calcium channel blocker.and the action lasts for 5 -10 minutes after infusion stopped.24 hours after last dose. can be given IM also. tachycardia. Enalaprilat should be used with caution in patients with renal failure. The response is unpredictable . Enalaprilat: This is an arterial dilator (ACE Inhibitor) Given in a dose of 0. onset in 10-20 minutes. Side effects are headache.625 – 1.Side effects are tachycardia. It should be used with caution in the presence of heart failure.

The bolus can be repeated after 5 minutes. The onset of action is within 2.The dose is either 500mcg /kg bolus injection or 25 -100 mcg / kg/min infusion. heart blocks. heart blocks. Esmolol : This is an ultrashort acting betablocker.5-10 mg od Metoprolol:50-100 mg daily Diuretics: Frusemide 40-80 mg daily ACE Inhibitors: Enalapril:10-20 mg od Lisinopril:5-10 mg daily Perindopril:2-8 mg daily ARBs : losartan 50-100 mg daily 445 . hypotension .5 minutes and the action lasts for 2 – 6h after the drug is withdrawn. heart failure .Cardiology Adrenergic inhibitors Labetolol: Usual dose is 20 -80 mg as IV bolus every 10 minutes. Onset of action is within 15 minutes and it last for 15 -30 minutes. so too the rate of infusion can be increased upto 300 mcg/kg/min. heart failure and others Oral drugs for hypertensive urgencies z z z z z z Adrenergic Drugs Clonidine:50-100 mcg tid Labetolol:200-400 mg repeated every 2-3 h Calcium channel blockers: Verapamil:240 mg daily in 2-3 divided doses Diltiazem:60-120 mg bd Amlodipine :5-10 mg od Beta adrenergic blockers: Propranolol:40-80 mg bd Atenolol:25-100 mg od Bisoprolol:2.Labetalol is often used in pregnancy related hypertension.Adverse effects include asthma. or upto 2 mg/ min as IV infusion. Side effects include bronchoconstriction.

Patient should be adequately hydrated. 0. salt restriction and specialized obstetric management are essential for successful outcome.Guidelines Specific hypertensive emergencies Hypertension in pregnancy: Gestational hypertension is more common in primigravida.5 mg intramuscularly.gentle tapping on the chest. ANTIBIOTICS.If the patient can co-operate removal of secretion should be aided by postural coughing .This usually resolves after delivery. There is increased susceptibility to hypertensive encephalopathy.Mucolytic agents can be administered as aerosols eg acetyl cysteine. Diuretics and ACE inhibitors are contraindicated.Bed rest.If the patient cannot expectorate freely secretion should be aspirated. In preeclampsia the BP is elevated after the 20th week of pregnancy and it is associated with proteinuria The traditional drugs for the management of gestational hypertension are alpha methyl dopa. In recumbent comatose patient chin should be pulled up to prevent the tongue from falling back and obstructing the pharynx. Assessment of the infecting agent can be made by gram staining and culture of the sputum and suitable antibiotic can be started. Tracheostomy may be required in some cases where the tidal volume is low.The normal levels of blood pressure during pregnancy are lower than in the non-pregnant state(110/75 mm Hg). and in those with multiple pregnancies.Salbutamol and beclomethasone can also be given as metered aerosols. hydrallazine and labetolol. Parenteral betamethasone 4 mg may have to given if bronchospasm is not relieved by simple measures.Sustained rise in BP of 30 mm Hg or more in systolic and 15 mm Hg or more in diastolic should be taken as hypertension.If bronchospasm is present it can be relieved by drugs like salbutamol given 2 to 4 mg orally. RESPIRATORY SYSTEM ACUTE RESPIRATORY FAILURE (ARF) Maintanence of the airway Irrespective of the cause all cases of respiratory failure the upper air passages should be fully inspected and foreign bodies and secretions should be removed. In the acute 446 .steam inhalation and administration of drugs like bromhexine hydrochloride in a dose of 8mg tds.

30 min. lnhaled beta agonist . Bronchodilator treatment Preparations : 1.assisted ventilation and so on. the rate is 2 to 3 litres per minute and the catheter tip should be located 15 cm from the nostril.Respiratory System case crystalline penicillin and in the chronic case a broad spectrum antibiotic such as ampicillin or amoxicillin may be required. Antibiotic therapy may have to be reviewed when microbiological results are obtained. 1 mL + 3 mL saline every 20 . Supportive measure If the respiratory failure does not clear up patient may require more advanced supportive measures such as fluid and electrolyte administration with monitoring of central venous pressure. If FEV1and PEFR remain less than 40% of the predicted value after one intense treatment hospitalization is required. In chronic respiratory failure administration of oxygen should be closely supervised to avoid the development of carbon dioxide narcosis. ACUTE SEVERE ASTHMA Acute exacerbation of asthma can progress on to life threatening severity if not treated early. The clinical clues are use of accessary muscles of inspiration.The concentration of oxygen can be adjusted at 24. It is desirable to bring the PaO2 level above 50mm Hg and pH above 7. Intensification of bronchodilator regimen or a short course of corticosteroid can abort a life threatening asthma attack.10 min time repeated 6 h. 3.salbutamol / terbutaline 100 mcg 2 puffs every half an hour 2.25. In most situation patient’s respiratory distress itself is an indicator of severe asthma attack.V. If given by nasal catheter.Once the emergency has been tided over.inability to speak continuously pulsus paradoxus and refusal to recline. Correction of hypoxia: Oxygen is administered with nasal catheter.This have to be arranged in appropriate centres. 28 or 35% by giving oxygen at rates ranging from 4 to 8 L/ min. Nebulizer device (wet aerosol) respirator solution salbutamol 5 mg / mL. 447 . The venturi mask which delivers oxygen at a preset low concentration is ideal if available. I. the patient is weaned off from oxygen gradually. aminophylline 250 mg mixed in 25 mL of 25% glucose bolus given in 7 . or by more effective methods such as masks or tents.

When obstruction due to large bolus of food occurs at the table. 5.3 weeks to prevent relapse. If FEV1 / PEFR remains less than 40 % of predicted that is acute severe asthma and the patient should be referred to a specialised centre for blood gas analysis and ventilator assistant management.and peaked expiratory flow rate (PEFR) is mandatory. Ipratropium respirator solution is given by inhaler / nebulizer or metered dose inhaler I.V. and cyanosed. Anticholinergic drugs. large chunks of meat or other matter. Acute obstruction in children leads to cyanosis and inspiratory indrawing of the trachea. corrosives or insect stings) 448 . restless. intensive monitoring is essential as it can worsen to a life threatening attack. FOREIGN BODY ASPIRATION Acute laryngeal obstruction may present as a life threatening emergency. If after 60 . Foreign bodies include dentures. In those already on oral theophylline the loading dose is best avoided. but the voice is lost.hydrocortisone 2 mg/ kg bw IV bolus then 0. If the obstruction is not relieved immediately. and dyspnea are the hallmarks of laryngeal obstruction. This is called Café Coronary . the victim becomes anxious. irritant fumes. It is difficult to assess by clinical presentation alone. The movement of a foreign body within the larynx may be palpable during respiratory effort. After the acute attack is over therapy with corticosteroids should be maintained for 1. Foreign body 2. Inflammatory or allergic edema (including angio-neurotic edema due to food. Clinical features: Stridor. He tries to cry. corticosteroid .Guidelines (6 mg/kg bw) the maximum dose should not exceed 6mg / kg bw in 24 h. Obstruction by bolus of food is more common under alcohol intoxication.5 mg/ kg bw IV line. Or hydrocortisone 200 mg stat may be given and repeated as required.Measurement of forced expiratory volume in 1 second( FEV1). 4.90 min of treatment with the above drugs symptoms are not alleviated. Methyl prednisolone 125 mg IV 6 h.Foreign bodies may get impacted in the larynx. aphonia. Causes of laryngeal obstruction 1. he falls unconscious and death may occur within minutes.

2. Heimlich maneuver: This effective method is to be learnt by all first aid teams. Management: First aid consists of the removal of the foreign body manually or with a pair of tongs. pulmonary tuberculosis. The patient is hugged from behind with the rescuer’s hands crossing each other.Migration of soil transmitted nematodes through the lungs used to be a frequent cause of mild haemoptysis . bronchiectasis 3. the airway should be made patent by tracheostomy or by inserting a few large-bore hypodermic needles into the trachea. pulmonary embolism and rarely haemorrhagic diseases. This helps in dislodging the obstruction. 6. 449 3.If the above attempt fails. 7.Respiratory System Acute Iaryngitis and epiglottitis (especially in infants) Exudates Laryngeal muscle spasm Inhaled blood clot/vomitus in the unconscious Tumors: Chronic progressive obstruction – especially carcinoma Bilateral vocal cord paralysis Diagnosis: Acute laryngeal obstruction should be suspected when an otherwise healthy individual suddenly becomes choked and cyanotic with loss of voice. Heimlich maneuver: Application of sudden pressure over the abdomino-thoracic region may dislodge the laryngeal foreign body HAEMOPTYSIS It is defined as expectoration of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial haemorrhage. over the patient’s epigastrium and the chest is compressed suddenly. 5.With the reduction of helminthic infection this condition has subsided .If the quantity of expectorated blood is more than 600 mL in 24 h or 300 mL in 12 h it is termed as massive haemoptysis and it is life threatening. 8. bronchogenic carcinoma. 6. 4. 4. Common causes include-1. The impacted foreign body can be dislodged by a sudden forcible thud on the chest with the head lowered. mitral stenosis. 5. . lung abscess. The patient is transported to hospital for further management.

Maintenance of airway. Cough suppressant. . 5.contralateral lung also.Emergency treatment is to institute thoracostomy with a wide bore needle or a suitable catheter and connected to under water seal through a tube. Antibiotics . The condition is fatal if severe.codeine phosophate / sulphate 30 mg 6 h.lung abscess and trauma.broad spectrum. Common causes include rupture of sub pleural bullae. 4. After releasing the tension the patient should be transported to the nearest tertiary care centre. Bed rest and proper positioning. Sedation . If the patient is in distress and thoracostomy tube is not readily available. with normal chest X-ray and having recurrent haemoptysis.Bronchoscopy is indicated if 1. Once the emergency is tackled. 3. Patient is a smoker 2. ENT sources of bleed and pulmonary thromboembolism.tuberculous cavities. Non smoker having an abnormal X-ray.cystic lung. which can be managed at small hospitals. Non smoker aged > 35 years 4. Management : Immediate release of tension is necessary. 8 h 6. Blood transfusion has to be arranged if there is profuse bleeding.This leads to compression of ipsilateral lung and later. use a 20 guage needle connected to a 20 mL syringe containing 10 mL of sterile water and aspirate the air for immediate relief. identify the underlying cause for management 450 . 2. Recurrent haemoptysis is a definite indication for full investigation TENSION PNEUMOTHORAX This is the condition in which air collects in the pleural cavity under pressure.bronchoscopy and detailed sputum examination for proper diagnosis and management. Non smoker aged < 35 yrs.Guidelines Treatment 1. Exclude hemetemesis. ampicillin 500 IV. 3.Patient present with severe dyspnoea and chest pain with progressing distress. HRCT. Patient has to be referred to higher centres for X-ray studies.required to relieve restlessness and anxiety 5 mg diazepam stat-oral or IV. BP and pulse to be recorded every half an hour and the quantity of blood expectorated should be recorded. X-ray chest is confirmatory. Note:Even though haemoptysis is alarming to the patient and the relatives majority of cases are mild and self limiting.

bleeding into the pleural cavity. pneumonias. Sufficient fluid is removed to relieve the distress.Common causes include pulmonary tuberculosis . parenteral steroids and intravenous fluids. it should be send for diagnostic investigations. producing respiratory distress.In mild cases the air is automatically absorbed. Sometimes aspiration of the pleural cavity may give rise to complications. lt is generally advisable to restrict the volume of fluid removed at one sitting to 1 litre or less in order to avoid pulmonary edema. When bleeding is evident it is advisable to stop the procedure Entry of air inadvertently during aspiration converts a simple pleural effusion into hydropneumothorax.(2) to relieve distress. Indication for aspiration (1) to make the diagnosis. Inadequate local anesthesia may be a predisposing factor. Pleural shock : The patient develops vasomotor collapse on puncturing the pleura. The fluid is aspirated by thoracocentesis done in the eigth or ninth intercostal space in the posterior axillary line after anesthetising the part. pulmonary edema. Two or three aspirations will be adequate in most of the cases of tuberculous effusion. Elective aspiration:Medical therapy is instituted depending on clinical features and pleural fluid analysis. It may present as an emergency with respiratory embarrassment.In bilateral effusion aspiration is done on the side of greater fluid collection. and accidental introduction of air into the pleura. It is ideal to aspirate the fluid after instituting specific drug therapy for 3-4 days. Whenever pleural fluid is aspirated.Bleeding should be suspected when the aspirated fluid becomes progressively blood stained. Pleural shock may be fatal if not recognized in time. pleural or pulmonary malignancy and generalized edema. 451 . infection. anaphylactic shock due to anaesthetic. Aspiration has to be repeated at times. These include pleural shock.Emergency aspiration is done if the fluid is massive or bilateral. Urgent resuscitatory measures include the injection of adrenaline.Respiratory System PLEURAL EFFUSION Collection of free fluid in the pleural cavity is called the pleural effusion. and (3) to remove the exudate so as to hasten full recovery of the pleura and avoid complications.

Guidelines Pulmonary edema occurs in some cases of chronic effusion when the lung expands on removal of the fluid.30% Step 1 Mild intermittent PEFR > 80% predicted Variability < 20% “ “ “ PULMONARY EMBOLISM Clinical features of pulmonary thromboembolism will be non specific and vague in many cases. hemoptysis and circulatory collapse in a patient who is apparently well and progressing from other underlying disorders. The patient becomes cyanosed.Slow aspiration and limiting the volume of fluid aspirated at one sitting to 1 litre help to reduce these complications CHRONIC ASTHMA IN ADULTS Classification Step 4 Severe persistent PEFR < 60% Var : > 30% Long term High dose inhaled steroid +long acting bronchodilator like long acting inhaled beta agonist or sustained release theophylline or long acting beta agonist tablets. convulsive and 452 . Oral steroids 2 mg/ kg/ day High dose inhaled steroid or low dose inhaled steroid + long acting beta agonist Inhaled low dose steroids cromolyn or nedocromyl Sustained release theophylline Montelukast (10 mg at bed time daily) or Zileuton Symptomatic treatment as and when required “ “ Quick relief Inhaled beta 2 agonist as needed Step 3 Moderate persistent PEFR 60 .In some cases low grade fever may be caused by venous thrombosis. angina pain.80% Var : > 30% Step 2 Mild persistent PEFR > 80% Var 20 . Acute massive pulmonary embolism: ln this condition more than 50% of the cross-sectional area of the pulmonary arterial tree is occluded. lt manifests with sudden dyspnea.

Patient should be transported rapidly to a centre where thrombolysis can be undertaken. there may be no local signs to suggest venous thrombosis. Emergency management Patient is put to bed. The latter though alarming is not generally dangerous.If shock ensues. Proper examination of the nasal cavities.arises from around the stems of celiac trunk and superior mesenteric artery and inserts into 3rd or 4th portion of duodenum or more frequently into duodeno-jejunal flexure). Some cases present with signs of acute right ventricular failure with raised jugular venous pressure and hepatomegaly.Oxygen is administered and closed chest cardiac massage is started. Clinically acute massive pulmonary embolism may mimic acute myocardial infarction or dissecting aneurysm of the aorta. in addition to restoring cardiac output.In many cases. Common causes of haematemesis include-acid peptic 453 .An effective closed chest cardiac massage. ln many. this should receive prompt attention. The blood that is vomited out will be fresh blood if the bleeding is active and massive whereas in slow oozing the vomitus contains altered blood-(coffee ground). Submassive pulmonary embolism: This presents with the triad of symptoms consisting of cough. ALIMENTARY SYSTEM HAEMATEMESIS (ACUTE GASTROINTESTINAL BLEEDING) Haematemesis results from bleeding proximal to the ligament of Treitz(tissue that connects duodenum to diaphragm. sudden development of right ventricular strain should raise the possibility of massive pulmonary embolism.. Physical examination reveals the presence of pleural rub and signs of consolidation. pleuritic pain and hemoptysis.All cases should be accessed for thrombolytic therapy early in the disease.Alimentary System comatose. pharynx and throat should be made to distinguish true haematemesis from vomitus containing swallowed blood. Examination of the limb may show edema or tenderness along the veins in some cases.may help in fragmenting the thrombus and driving it into the peripheral branches. lf not relieved in time massive pulmonary embolus is rapidly fatal within minutes. this is life saving measure. Electrocardiogram shows evidence of right ventricular strain and in a patient who had normal ECG. Homan’s sign may be elicitable in a few . Cardiac auscultation reveals loud pulmonary second sound. It may occur from any part below the upper end of the esophagus up to the duodenum.

Pallor of mucous membrane . First priority is to replace fluid losses and restore hemodynamic stability by giving i. 2. 4. Hypotension-systolic B.haemorrhagic disorders and the gastro esophageal tear occurring in Mallory Weiss syndrome. Pulse rate >100/min and steadily going up. Such patients require further specialist management such as endoscopic procedures . gastric erosions caused by drugs such as NSAIDs. 4.P<100 mm Hg 3. Absence of blood in the aspirate is not a guarantee that bleeding has stopped.Ranitidine 50 mg I. Procedure: 1.increase of>20 beats /min or fall of systolic BP >20mm Hg on standing. If the patient is to be managed at the periphery start pantoprazole 40 mg IV as bolus followed by continuous infusion at the rate of 8 mg/hour for 24-72 hours .Guidelines disease. malignancies in the stomach or the oesophagus.Hence they have to be referred to higher medical centers without delay. 2. If the tachycardia or hypotension persists or if the hemoglobin level is below 10 g/dl especially in older patients with coexisting cardiovascular diseases . emptiness of neck veins and reduction in urine output<60mL/h all indicate fall in intravascular volume.Administration of antacids 454 . In most cases of haematemesis . 3.V 6 hourly or cimetidine 200mg IV 6 hourly may be given to reduce the bleeding but they are less effective than proton pump inhibitors.diverticula. Insertion of Ryle’s tube and periodic aspiration will help to identify continuing bleeding.malaena accompanies. 6. The following clinical features indicate substantial loss of intravascular volume-(more than 1L in adults) 1.v. definitive treatment in specialized units. Postural changes in pulse rate. oesophago-gastric varices in portal hypertension. use of inhaled oxygen and transfusion of plasma expanders with fresh blood or packed erythrocytes should be considered in order to maintain adequate oxygen carrying capacity of the blood. infusion of crystalloid fluid-normal saline using 1 or 2 large bore hypodermic needles 16-18 gauge or a central catheter if peripheral access is not available. Elderly persons above 60 years do worse when large blood loss occurs. Haematemesis which is the medical emergency requires urgent treatment. supportive first aid measures and later.

2-22mg/dl) 8.5 -7.9 g/dl <10 g/dl Hemoglobin for women 10-11.7 mg/dl) >25 mmol / L (>70 mg/dl) Hemoglobin for men 12-12.If bleeding persists .9 g/dl <10 g/dl Other variables at presentation Pulse >100 Melena Syncope Hepatic disease Cardiac failure 1 1 2 2 2 1 6 1 3 6 1 2 3 2 3 4 6 Points Higher scores indicate higher risk . the patient has to be referred for endoscopic management .9 mmol / L (22. Any score > 8 will be an indication of immediate referral. At presentation Systolic BP 100-109 mm Hg 90-99 mm Hg <90 mmHg Blood urea nitrogen 6. Risk stratification can be done by Blatchford score which is given below.9 mmol / L (28-69.Alimentary System such as aluminium hydroxide gel 30 to 50 mg orally may act synergistically. 455 .9 g/dl 10-11.9 mmol / L (18.0-9.4-27.7mg/dl) 10-24.

In some cases at least. On examination:¾ Dehydration : reduced skin turgor 456 .This syndrome consists of the triad of hyperglycemia. atypical anti-psychotics (clozapine.ENDOCRINOLOGY DIABETIC KETOACIDOSIS (DKA) Diabetic ketoacidosisis an acute metabolic complication of diabetes mellitus. the criteria for DKA are Arterial pH <7. Polydipsia. the diabetes may be presenting for the first time with ketoacidosis. thiazides.coma. olanzapine) ¾ Alcohol abuse Psychological problems accompanied by eating disorders may account for 20% of recurrent ketoacidosis in young individuals ¾ Unknown causes Diagnosis Although the symptoms of poorly controlled diabetes may be present for several days.blurring of vision. Polyphagia. abdominal pain. As per the recommendations of American Diabetes Association. the metabolic alterations in DKA evolve within a short time frame (<24hrs).terbutaline). ketosis and acidosis.clouding of sensorium. cocaine.3 Bicarbonate level < 18 mEq/L Blood Glucose > 250 mg/dL Moderate degree of ketonemia and ketonuria(presence of ketone bodies in the urine).weakness.Nausea. vomiting. muscle cramps.respiratory distress. ¾ ¾ ¾ ¾ History ¾ Polyuria. Factors which precipitate DKA ¾ Inadequate insulin administration ¾ Recent onset Type 1 DM ¾ Infections – pneumonia/urinary tract infection( UTI)/ gastroenteritis/ sepsis ¾ Infarction – myocardial/ cerebral/ mesenteric/ peripheral ¾ Drugs – Steroids. sympathomimetic drugs (dopamine.

Once the patient is having urinary output.00-7. blood urea and arterial blood gases are necessary and therefore the patient may be referred to a higher centre. all patients must be started on IV normal saline. stupor. ¾ Abdominal tenderness. the first 500 mL should be given within 2 hrs and then 500 mL in 4 h. Suspect hypoglycemia in a diabetic on antidiabetic drug treatment who missed a meal or was unable to take the food because of illness.15U/kg (10 -15U) followed by continous infusion at the rate of 0.fluid must be changed to glucose saline once the random blood sugar (RBS) comes below 250 mg% or urine sugar becomes less than 1%.30 15-18 Positive >10 Alert Moderate >250 7. Blood glucose should fall by 50-75mg/dL/hour.mimicking acute pancreatitis or a surgical abdomen Classification of DKA: ¾ ¾ ¾ ¾ Mild 1 2 3 4 5 6 Plasma glucose (mg/dL) pH Serum bicarbonate Urine and serum ketones Anion gap Alteration in sensorium >250 7.1 ampoule of potassium chloride 10 mL must be added to every bottle of IV fluids.If serum glucose does not fall by 50-75 mg/dL in first hour.double the dose of insulin infusion hourly until glucose falls by 50-70mg/dL . Un 457 . depending on the state of hydration. The IV. electrolytes.00 <10 Positive >12 Stupor/coma On diagnosis. HYPOGLYCEMIA This is a very common medical emergency which demands prompt action.Endocrinology Tachycardia Hypotension / shock Hypothermia Altered level of consciousness – confusion.25-7. For proper management. frequent monitoring of blood sugar. coma ¾ Kussmaul’s breathing(deep sighing respiration) :. drowsiness . All patients must be started on IV bolus of regular insulin 0.1U/kg/h(5-7unit/h).develops as a result of metabolic acidosis ¾ Smell of acetone in breath may be present in some cases.24 10 to <15 Positive >12 Alert/drowsy Severe >250 <7.

cold extremities.M dose of 1 mg of glucagon will be helpful. In children in whom hypoglycemia. Even when facilities for blood glucose estimation exist. If the patient is drowsy or comatose give I. Thyroid crisis is more frequent if surgery is undertaken during active thyrotoxicosis.quinine .mental confusion .Hypoglycemia may occur less commonly in non –diabetic subjects especially those with Addison’s disease.An alternative is to administer glucose solution 20% through a ryles’s tube. where intravenous injection may be difficult an I.In the ordinary cases blood glucose levels of 60mg/dL or less may be taken as to be diagnostic.Guidelines accustomed exertion. 458 .even lowering of blood glucose to normal or near normal may precipitate symptoms. Invariably the patient regains conciousness at the end of the injection.diarrhoea and vomiting precipitate hypoglycemia. feeling of emptiness in the epigastrium.It is unusual for the blood glucose levels to go low (below 30mg/dL or even less) especially in patients receiving antidiabetic drug therapy.V glucose 100 mL of 25 % solution rapidly within 2 min.pancreatic islet cell tumours and disseminated malignancies. profuse sweating. spontaneously or immediately after surgery.Several drugs may precipitate hypoglycaemia eg. emergency treatment should be started on clinical suspicion since there is no absolute diagnostic level for the development of symptoms in individual cases.prediabetic state. hypopitutarism. THYROID STORM(Thyroid crisis) This is a medical emergency caused by sudden release of thyroid hormones from the gland.In those patients who are exposed to high blood glucose levels for long period.tremor. convulsion and coma. or any sweets (3-4 ordinary biscuits) if the patient is able to swallow. Once the patient is conscious give oral carbohydrates so that hypoglycaemia may not occur.gatifloxacin and others.Though determination of blood glucose level is essential for proper diagnosis . Clinical features include anxiety . later confirmed by the prompt response to glucose or sugar administration. Treatment : If the patient is concious give either 25 g glucose dissolved in 200mL water orally. raised blood pressure.disorientation. exaggerated reflexes. The condition improves within 10 minutes.often this may not be available at hand and in many situations diagnosis has to be presumptive. Alternatively sucrose 25 g in 200 mL of any drink. if the drug is available .In elderly patients disturbances of higher functions may predominate (neuroglycopenia) .

The 459 . hypothermia. l. peripheral vascular collapse or psychotic behaviour. 5. severe tachycardia.Iodine containing radio-contrast dyes such as sodium iopodate 500 mg orally daily will restore the serum T3 to normal in 2-3 days. Propranolol and sodium iopodate can be withdrawn after 14 days.4 hours.heart failure. Diazepam is given in doses of 5-10 mg IV to allay the agitation and quieten the patient.The patient should be hospitalized. after which it is to be repeated.hourly along with potassium iodide 50-100 mg orally.V glucose saline drip is started and hydrocortisone 100 mg is given at 4-6 hour intervals to combat shock. 2. If IV sodium iodide is not available. an effective antithyroid regimen is to give propylthiouracil 100 mg 6. Propranolol given IV in doses of 1-4 mg stat over a period of 5 minutes is very effective and the effect lasts for 3. Coma is the result of a combination of factors such as heart failure. cold environment and sedatives. 3. 4. hypotension. Beta-adrenergic blockers are very effective in reducing tachycardia and adrenergic symptoms. surgery. Treatment of myxoedema coma: Treatment of myxedema coma is a medical emergency. The core temperature measured by rectal thermometer will be less than 35°C. in doses ranging from 120-240 mg in 24 hours.rectally or through a Ryle’s tube as the case may be. Cerebral ischemia.even upto 600-1200 mg. In less severe cases propranolol can be given orally. hypoventilation and coma It is more common in colder climates where exposure precipitates coma.Endocrinology Thyroid crisis can be precipitated by stress or infections. Thyroid crisis should be suspected if they develop high fever. In addition to frank overt myxoedema .even secondary hypothyroidism can give rise to coma when exposed to stress. Coma is usually precipitated by sepsis. Sodium iodide is given IV in a dose of 300-600 mg 8 hourly till the metabolic crisis is controlled. Treatment 1. Tepid sponging helps to keep the temperature down from rising to hyperpyrexia levels. Carbimazole can also be given 15-20 mg 6 h through a Ryle’s tube MYXOEDEMA COMA This condition should be suspected when a patient with hypothyroidism slips into hypothermia. and hypothyroidism. restlessness.

Hydrocortisone should he given along with thyroxine replacement in order to prevent hypoadrenal crisis and to help recovery from shock. lethargy and hypotension. Management The emergency management includes starting an IV line with 5 % glucose saline and a bolus injection of 100 mg hydrocortisone.diuretics and hypoglycaemic agents may precipitate hypoadrenal crisis. If parenteral preparations of thyroxine are not available. Other measures to correct the precipitating factors should be undertaken along with.Guidelines drug of choice is tri-iodothyronine (T3) given lV in a dose of‘20mcg stat and repeated 4 hours later. It has to be suspected in any known patient with hypoadrenalism who gets infection. he may be put on his usual maintenance dose of oral corticosteroids and investigations and long term management should be arranged in a specialized clinic. ADRENAL CRISIS The secretions of the adrenal glands especially mineralocorticoids and less so glucocorticoids are vital and absence of these hormones are fatal. 3-4 times a day Dexamethasone 2 mg IV 6 hourly is a suitable alternative. After this. Emergency treatment is needed to save life. and thereafter the dose is modified suitably. Myxoedema coma is associated with high mortality and therefore best results are obtained if treatment is undertaken in well-equipped centers.Hypoadrenal crisis may occur in patients with primary hypoadrenal states or in those with hypopitutarism with secondary hypoadrenal state. At present parenteral preparation of levothyroxine sodium is also available for use. The best strategy is to prevent it by detecting it early and prevent it by increasing the dose of corticosteroids. The dose is 500 mcg IV stat and repeated 4 hours later.and normal or elevated serum potassium levels. hydrocortisone may be given in doses of 100 mg 6 h or as a continuous infusion at the rate of 10 mg/h. 460 .and thereafter 100mcg per day .dehydration. illness or stressful states.Laboratory investigations reveal hypoglycaemia . The dose is 100 mg IV. Intravenous glucose drips.1 mg three times or four times a day is advised till the coma clears. weakness.It is clinically characterised by nausea. Once the patient is stabilised and the precipitating factor treated. maintenance of proper ventilation and the treatment of coexisting infections. administration of thyroxine through a nasogastric tube in doses of 0. Supportive measures include gradual warming up of the patient with hot water bottles or other warming equipment.hyponatremia.Drugs such as morphine. vomiting.

catatonia and others Elderly persons Cerebrovascular accidents.NEUROLOGY COMA Coma is one of the most serious medical emergencies in practice. Verbal response(V) 461 . In evaluating a comatose patient a common clinical parameter which is used is the Glasgow coma scale which is useful both for initial assessment and monitoring of progress.poisoining. hysterical coma.There are several causes for coma.raised intracranial tension.encephalitis .Depending upon the age the common causes are – Children Intracranial infections –meningitis . metabolic abnormalities.Eye opening(E) Spontaneous To sound To pain Nil Obeys commands Localises pain Normal flexion withdrawal Abnormal flexion(decorticate rigidity) Extension (decerebrate rigidity) No response Well-oriented Disoriented and converses Confusedly Inappropriate words Incomprehensible sound None 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 2. trauma.Motor movements(M) 3.cerebrovascular accidents. increased intracranial tension. cardiovascular disease and others.raised intracranial tension.brain abscess. Glasgow Coma Scale It is an objective method of evaluating the depth of coma.systemic infections such as cerebral malaria. Glasgow Coma Scale(GCS) TEST SCORING 1.seizures. seizures.cerebral tumours. Young adults Intracranial infections. subdural or extradural haematomas.

e.1 mg/kg at 2 mg/minute is preferable to diazepam as it has longer duration of action (> 4 hrs)and lesser respiratory depression. as status epilepticus Management Time is a critical factor in the management of status epilepticus. This dose serves to achieve optimum therapeutic blood level and maintains the antiseizure effect. or more than one seizure within 30 minutes even if consciousness is not lost. for a longer period. Its action lasts for 20-30 minutes. If necessary a patent airway should be introduced. It is the current consensus to consider any seizure (both clinical or electrical) lasting for more than 30 minutes.5-1g (18 mg/kg) is given intravenously over 20 minutes at a rate of 50 mg/min in those who are not already on this drug. midazolam and clonazepam are all potent fast-acting antiepileptic drugs. 10 mg diazepam (0. The neck has to be kept extended to prevent falling back of the tongue. preferred for terminating the attack immediately. STATUS EPILEPTICUS When recurrent seizures occur at a frequency which does not allow consciousness to be regained in between seizures. Secretions have to be removed by postural drainage and suction. when patient is first seen. The fallacy of Glasgow coma scale is that even a dead person will have a score of 3. This has not in any way reduced the importance of the Glasgow coma scale. Simultaneously a loading dose of phenytoin. lorazepam. Lorazepam in doses of 0.Guidelines A conscious individual will have a score of 15. MANAGEMENT OF COMATOSE PATIENT Comatose patients are very susceptible to develop several complications as a result of loss of protective reflexes and these have to be prevented.0. Tracheostomy may be required in some cases.Maintenance of the airway is of utmost importance. The 462 . it is called status epilepticus. In cases with respiratory depression assisted ventilation has to be instituted early.3-0.5 mg/kg/bw) should be given slowly intravenously over a period of 2-5 minutes. Severe and permanent brain damage may result from status epilepticus persisting for more than an hour. Benzodiazepines such diazepam. There are many therapeutic regimes but none of them is totally satisfactorily. Initially. The scores progressively diminish as the coma becomes deeper. i.

MR angiography. If status epilepticus still persists. Maintenance of the airway.It is ideal to maintain the blood pressure around 140/90 mmHg in those who are hypertensive. proper positioning of the neck and control of hypertension by oral or parenteral antihypertensive drugs. Once the patient is seizure free. In the absence of such a facility phenytoin should be given as IV bolus in doses of 200 mg. phenytoin is to be repeated at a dose of 5 mg/kg IV till a maximal total dose of 30 mg/kg is reached. the infusion lasting for 12 hours.digital subtraction angiography.oxygen administration. phenytoin or other antiepileptic drugs are introduced by the oral route.6 g of the drug and this is very effective.the management of stroke. Treatment in this units give better results as regards mortality. and therefore the patient should be closely monitored clinically and with ECG. Phenobarbitone given intravenously in doses upto 0. hence wherever possible patients with stroke should be referred to higher centers after initial first aid.8-1 g in 24 hours (20 mg/kg at 100 mg/min) is an effective anticonvulsant and this should be added if seizures are not controlled by diazepam and phenytoin. Phenytoin is incompatable with glucose containing solutions and hence it should not be mixed with them. but with less of local irritant property. Assisted ventilation is mandatory when phenobarbitone or thiopentone is given. 150 mg fosphenytoin is equivalent to 100 mg phenytoin. 463 . and is able to take oral medication.PET studies and others have revolutionalised . Phenytoin levels can be maintained by giving it as an IV drip containing 100 mg in 500 mL of normal saline or distilled water. and therefore this route should not be relied upon. Fosphenytoin is a water soluble prodrug of phenytoin which is similar in action and dosage. Phenytoin is not absorbed properly after IM injection. Initial management at the periphery includes1. several dedicated stroke units have come up. run at the rate of 40 mL per hour. CEREBROVASCULAR OCCLUSIVE DISEASE Since modern investigations such as CT scan .Neurology anticonvulsant action of intravenous phenytoin is manifest within 10-20 minutes. especially after diazepam administration. In intractable cases thiopental anesthesia is induced with IV injection of 0. Now thrombolytic agents are gaining acceptance in thrombotic occlusions.3-0. Large doses of IV phenytoin may lead to hypotension and cardiac arrhythmias. morbidity and functional recovery.

by appropriate fluid therapy. Monitor for life threatening complications 5. 4. 464 . Maintenance of nutritional status. ARF occurs due to a various etiological factors.NEPHROLOGY ACUTE RENAL FAILURE It is potentially reversible rapid decline in the excretory function of the kidney which develops over hours to days leading to retention of nitrogenous waste products and the consequent clinical complications. Specific therapy of the underlying cause of obstruction such as prostatic enlargement ensures recovery. For example ARF complicating sepsis in the ICU setting has a mortality of up to 70%. Management of ARF Principles of management of ARF 1. Maintenance of fluid and electrolyte balance 3. The most important factor determining the outcome is the severity of the underlying disease. The condition should be diagnosed when the urine output goes below 400mL in 24 hours and there are signs of retention of the waste products. relief of obstruction is the crucial factor influencing recovery of renal function. Renal replacement therapy when indicated Treatment of the Underlying Cause The cornerstone in the management of ARF is the treatment of the underlying cause. ARF following snake envenomation and leptospirosis have a mortality of only around 30 to 40 % though they are severe and they need dialysis support Prerenal ARF improves with restoration of renal perfusion. On the other hand. The use of vasodilators and ionotropes help to restore renal perfusion in congestive heart failure In postrenal ARF. Treatment of the underlying cause 2.

BP reaches normal levels . the patient will be pale and in shock b) Urine highly sensitive pregnancy test (like card test) is usually positive.When ectopic pregnancy is suspected the patient should be 465 . 4. Once the patient tolerates oral feeds she must be advised to have sips of fluids. Confirm the diagnosis of pregnancy by clinical examination.2mg tablets hs may be continued. Exclude vesicular mole by ultrasonography in all cases of hyperemesis.with or without bleeding per vaginum (PV) 2. start IV fluids (5% or 10% dextrose. 5. Instantly Oral Rehydration Solution ( ORS) is preferable. If the ectopic pregnancy has ruptured. Diagnosis: a) Clinical examination : Movement of cervix is painful. dextrose saline and Ringer lactate) until the dehydration is corrected. 6. gastritis. When patient presents with abdominal pain with missed periods. c) Ultra sound examination (transvaginal ) will help in excluding intra uterine pregnancy.OBSTETRICS AND GYNECOLOGY HYPEREMESIS GRAVIDARUM 1. Exclude other causes for vomiting like. After making a diagnosis of hyperemesis. ECTOPIC GESTATION Ectopic pregnancy should be suspected 1. or metoclopramide 10mg IM can be given. anti-emetics like promethazine 25 mg IM. Check urine for sugar and acetone. When products of conception are scanty during abortion or evacuation . If vomiting is not controlled . 3. 2. 7.the size of the uterus is less than what is expected for the period of amenorrhoea.skin turgor is restored and urine flow normalizes. 3. Adnexal tenderness or mass may be palpable. Oral antiemetics like doxylamine succinate(doxinate. jaundice and diabetic ketoacidosis.

pulse.Guidelines transfered to a referral centre with facilities for blood transfusions and surgery.5 mg IM depending on the weight of the patient. Transfer the patient as quickly as possible to a centre where facilities for blood tranfusions and caesarean section are available. 9. Sedate the patient by injection of pethidine 50-75 mg IM or morphine 5-7. Magnesium sulphate: 10 mL of 50% magnesium sulphate deep IM in each buttock as a loading dose using 20 guage needle Maintenance dose: 5 g every 4 h deep IM in the buttock.haemodynamic changes occurs.P. Start an IV line with a wide bore needle preferably a cannula (18G) 2. 4. 8. ANTEPARTUM HAEMORRHAGE Bleeding per vaginum after 28 completed weeks of gestation is called antepartum haemorrhage. Management 1. 6. 7. Phenytoin 400 mg IV should be given very slowly watching the pulse and respiration. patient should be transfered as early as possible to the referral centre. with IV line running.respiratory rate record the rate of blood loss. Assess the general conditions of the patient . If placenta previa is suspected avoid doing vaginal examination for confirmation. 10. 2. keep the foot end of the bed elevated.high blood pressure and oedema). In ruptured ectopic. 3. 3. Take blood for grouping.. Diazepam 10 – 20 mg IV 466 . Give anticonvulsants (any of the following. give nasal oxygen if available. cross matching and clotting time. Make a quick examination to form a provisional diagnosis regarding the causes of antepartum haemorrhage.) 1. Depending on the degree of hypotension and anoxia. Take a quick history and do a quick examination to form a diagnosis (Tonic clonic convulsions . The relatives should be informed about the seriousness of the disease and the need for blood transfusion.Depending on the duration and amount of blood loss . 5. 2. ECLAMPSIA 1. Keep an IV line running. Put in an indwelling catheter to record the urine output. B.

Metronidazole 500mg IV 8 h may be added if anaerobic infection is suspected or if pre-labour rupture of membrane is more than 24 hours duration.ampicillin 500 mg IM 6 h with Inj. 4. 3. 2. PRETERM LABOUR 1. Transfer the patient as quickly as to a centre with good facilities for managing preterm babies. If the patient cannot be monitored properly. 2. Instead. Give glucocorticoids IM a.5 to 5 units of oxytocin is given in 5% dextrose or normal saline infusion . 3. patient should be transferred to a tertiary care centre. 467 . Make sure whether the liquor is clear. If the gestational period is 37 weeks or more. This may have to be supplemented with oxytocin. 2. by speculum examination. 8 h is satisfactory.LABOUR RUPTURE OF MEMBRAN ES 1. Confirm that the patient is in labour by recording the regular intermittent and painful uterine contractions. PGE2 gel is applied to the cervical canal under aseptic precautions. If the patient is in advanced labour. If pregnancy is less than 34 weeks. after giving glucocorticoids. tocolytics should not be given in the peripheral hospitals. PRE. looking at the liquor or if needed. If pregnancy is more than 34 weeks the patient should be transferred to the nearest First Referal Unit (FRU).gentamicin 80 mg IM. give tocolytics . Confirm diagnosis by giving a sterile pad. induction of labour can be done by giving oxytocin drip or PGE2 gel.Obstetrics and Gynecology Transfer the patient to a referral centre with facilities for anaesthesia and caesarean section and intensive care unit facilities as quickly as possible. Terbutaline sulphate 250 mcg subcutaneous hourly till contraction subsides and thereafter 5 mg oral 4th hourly. Keep the baby as warm as possible and transfer immediately to a referal hospital. conduct the delivery. Dexamethasone 6 mg IM 6 h and 4 more doses may be given further. mature blood-stained or meconium stained. Betamethasone 12mg IM 12 h 2 doses or b. Give parenteral antibiotics:A combination of Inj.drugs which inhibit uterine contractions.

the patient should be transferred to a tertiary care centre with facilities for blood . Ergometrine 0. In traumatic postpartum haemorrhage.It is desirable to have a hospital staff accompanying the patient. After giving the first aid care. anaesthesia and surgical intervention as quickly as possible. Treatment consists of applying nasal packs dipped in adrenaline solution.It can be arterial or venous. if there are no facilities for suturing and blood transfusions. 2.5 mg IM and oxygen inhalation.2 mg IV 3. If the pregnancy less than 37 weeks duration.Hypertension which is a common cause of epistaxis 468 . No time should be wasted. a pressure pack should be kept in the vagina to arrest the bleeding temporarily. are the ones usually given . Other measures include cauterization and ligation of bleeding spot in intractable cases. This should be suspected in instrumental deliveries . Take blood for grouping and cross matching and clotting time.Guidelines 5. 3.NOSE AND THROAT EMERGENCIES EPISTAXIS Epistaxis is bleeding from the nasal cavity. dextrose saline and blood volume expanders such as polygeline. If atonic.V. Keep the foot end of the bed raised by 9 inches(22 cm) if there is hypotension. Start IV line with a wide bore canula (18G) 2. Then give 1.transfusion. PGF2 alpha 250 mcg IM if bleeding persists 4. fluids for volume replacement Normal saline. the uterus will be flabby. EAR. Oxytocin 10-20 units in normal saline as I. (vaccum extraction or forceps delivery). POSTPARTUM HAEMORRHAGE MANAGEMENT 1. 4. give antibiotics and transfer to the referal centre where preterm babies can be looked after.V drip. Differentiate between atonic and traumatic haemorrhage. Give sedation with pethidine 50-75 mg IM or morphine 5-7. PGE1 800 mcg per rectum Traumatic postpartum haemorrhage is suspected when there is bleeding with a well contracted uterus. The patient should be transferred with IV fluid running. Start I.

Start antibiotic drops. drip set and wash continuously with the upper eye lid everted. 469 . Parenteral steroids-Inj betamethasone 4. Treatment: Wash the eye with distilled water or boiled cooled water loaded in a 5 cc syringe (without needle) with upper eye lid everted. Apply antibiotic ointment. viral infections or others. Alkali burns are more dangerous than acid burns. In selected cases sedatives may be required.Ophthalmology does not warrant any specific treatment except local measures.Identify the location of the foreign body by proper examination of the eye by everting the eyelids and with a proper source of light. assurance and antihypertensive drugs. insect bite. Ask for any history of food allergy. Adrenaline-1/1000 solution IM. Management : Keep the airway patent . Connect the drip bottle to IV. CHEMICAL BURNS These are common in persons who handle corrosive acids or alkalies during their occupation. drug allergy. lips or choking sensation. Wash the eye with normal saline or Ringer lactate solution. ACUTE LARYNGEAL OEDEMA DUE TO ALLERGIC ANGIOEDEMA Patient presents with oedema of eyelids.If foreign body does not dislodge refer to an ophthalmologist. close monitoring.8 mg IV. OPHTHALMOLOGY FOREIGN BODY IN THE EYE On examination: Localized congestion over the bulbar conjunctiva with severe irritation. Antihistamines Oxygen inhalation If there is progressing airway obstruction tracheostomy or tracheal intubation and ventilation.

Disinterestedness in studies. use cotton swab to clean the lid.Avoid combination preparations or exclusive preparations containing corticosteroids if corneal ulcer is suspected. congestion +++ more in fornices Treatment: frequent washing.Guidelines CONJUNCTIVITIS On examination: Excessive discharge .Broad spectrum antibiotic drugs should be instilled into the eye hourly. RECOGNITION OF REFRACTIVE ERROR IN CHILD History of child with clumpsy handwriting. Antibiotic drops to be used 2 hourly and refer to an ophthalmologist if there is no improvement within three days. Refer to opthalmologist if no improvement occurs in two days. The condition can be easily recognized by testing each eye separately with the other eye covered. Early referral to ophthalmologist to make proper diagnosis and prescribing glasses is absolutely necessary to ensure proper learning facilities for the child. matting of eye lashes . 470 . CORNEAL ULCER Any white spot in the eye with redness .pain and watering should be diagnosed as corneal ulcer. mistakes in copying written matter from board . .School medical examination programmes are available at present.Avoid topical steroids and topical steroid combination with the antibiotics.strong family history of short sight.

COTRIMOXAZOLE TAB IP 8. NAME OF THE DRUG STRENGTH PACKING 1.PARACETAMOL TAB IP 4. ERYTHROMYCIN STEARATE TABLET IP 15.IP 10.PARACETAMOL SYRUP IP 5. ANTIPYRETICS ANTINFLAMMATORY & ANTI ARTHRITICS 1.NORFLOXACIN TAB IP 80mg+400mg 160mg+800mg 125mg 250mg 500mg 100mg 250mg 400mg 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 471 300mg 75mg 500mg 250mg/5ml 50mg 400mg 10x14 10X14 10x10 60ml Bottle 10x10 10x10 40mg+200mg/5ml 150ml. LIST OF ESSENTIAL DRUGS TO BE STOCKED IN GOVERNMENT HOSPITALS z z z z Primary care hospitals ( Dispensaries and mini PHCs) Secondary care hospitals ( Block PHCs and CHCs) Taluk hospitals Tertiary hospitals ( District / General hospitals and Medical college Hospitals) ESSENTIAL DRUGS LIST FOR PRIMARY CARE HOSPITALS (DISPENSARIES AND MINI PHCS) Sl.No.susp . ANTIBIOTICS&ANTIBACTERIALS 7.PART III A.IBUPROFEN TAB (FILM COATED) IP 2. ANALGESICS.COTRIMOXAZOLE TAB IP 9.AMOXYCILLIN CAP IP 13.AMOXYCILLIN DISPERSIBLE TAB IP 11.COTRIMOXAZOLE ORAL SUSP.AMOXYCILLIN CAP IP 12.ACETYL SALICYLIC ACID TAB IP 2.DICLOFENAC SODIUM TAB IP 6.ACETYL SALICYLIC ACID TAB IP 3.DOXYCYCLINE CAP IP 14.

SALBUTAMOL NEBULISER SOLUTION 5mg/ml 32.ETHAMBUTOL TAB IP 23. ANTIALLERGIC AND DRUGS USED IN ANAPHYLAXIS 35. PREDNISOLONE TAB IP 10mg 472 2mL amp 10x10 10mlAmp 10x10 10ml 500ml Bottle 30ml vial 1 ml amp vial 1 ml Amp 10x10 1ml amp 2ml amp 10x10 .6mg/ml 6. DRUGS ACTING ON THE RESPIRATORY TRACT 27. THEOPHYLLINE & 169.PYRAZINAMIDE TAB 24. ANAESTHETICS & ALLIED DRUGS 33.Essential Drugs 16.RIFAMPICIN ORAL SUS BP 200mg 400mg 1g 150mg 100mg 300mg 400mg 500mg 450mg 100mg /5ml 10x10 10x10 vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10 26.STREPTOMYCIN INJ IP 19. SALBUTAMOL SULPHATE TAB IP 4mg 31.ETHAMBUTOL TAB IP 600mg 4. CONCENTRATED 5.INH TAB IP 22.INH TAB IP 21. ADRENALINE INJ IP 1mg/ml 37. ANTITUBERCULAR DRUGS 18. CHLORPHENERAMINE MALEATE TAB IP 4mg 38.METRONIDAZOLE TAB IP 3.ATROPINE INJ IP 0.6mg 28.LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 34.METRONIDAZOLE TAB IP 17. AMINOPHYLLINE INJ IP 25mg/ml 30. CHLORPHENIRAMINE MALEATE INJ IP 10mg/ml 39. EXPECTORANT MIXTURE. PROMETHAZINE INJ IP 25mg/ml 40. THEOPHYLLINE & ETOPHYLLINE TAB 23mg.4 mg ETOPHYLLINE INJ 50. HYDROCORTISONE SODIUM SUCCINATE INJ 100 mg 36.RIFAMPICIN CAP IP 25.77mg 29.RIFAMPICIN CAP IP 20.

ANTIMALARIAL DRUGS 51. CARBAMAZEPINE TAB IP 8. FOLIC ACID TAB IP 14. DIGOXIN TAB IP 15. ANTHELMINTICS 45. ISOSORBIDE DINITRATE TAB IP 57. ANTIFILARIAL DRUGS 47. LIQUID PARAFFIN IP 66. POVIDONE IODINE SOLUTION IP 70. ISOSORBIDE DINITRATE TAB IP 58. PHENOBARBITONE TAB IP 43. FRAMYCETIN SKIN CREAM 30mg 60mg 100mg 200mg 100mg 750mg/5ml 100mg 2% w/w 200mg 10x10 10x10 10x10 10x10 6x1 450mL 10x10 20g tube 3 tab 15 g tube 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 100g Bottle Drum Can 500g Bottle 500ml Bottle 500g Bottle 500mlBottle 20g tube 473 25mg 400mg 50mg 50mg 5mg 5mg 10mg 50mg 100mg 2. AMLODIPINE TAB 61. GLYCERINE MAGSULPH PASTE BPC 69. DIETHYLCARBAMAZINE CITRATE TAB IP 10. ATENOLOL TAB IP 60.DERMATOLOGICAL DRUGS 63.5mg 5mg 0.ANTIFUNGAL DRUGS 48. SILVER SULFADIAZINE CREAM IP 64. ANTIEPILEPTIC DRUGS 41.CLOFAZIMINE CAP IP 13.RIFAMPICIN CAP IP 53.ANTILEPROTIC DRUGS 52. CLOTRIMAZOLE CREAM IP 49.PIPERAZINE CITRATE ELIXIR IP 9. BENZYL BENZOATE APPLICATION IP 68.CARDIOVASCULAR DRUGS 56. CLOTRIMAZOLE VAG TAB IP 50. ATENOLOL TAB IP 59.DAPSONE TAB IP 54. PHENYTOIN SODIUM TAB IP 44. PHENOBARBITONE TAB IP 42.Primary Care Hospitals 7.25mg 1%w/w 25kg 5 Litre 10% w/w 25% w/v 5% w/v 1% w/v . MEBENDAZOLE TAB IP 46. WHITFILED’S OINTMENT IP 11. GLYCERINE IP 65. SALICYLIC ACID OINTMENT 67.DRUGS AFFECTING THE BLOOD 55. CHLOROQUINE PHOSPHATE TAB IP 12. AMLODIPINE TAB 62.

RAPID ACTING IP 97 INSULIN BOVINE. WITH CITRATE SALT 92 BISACODYL TAB IP 93 CARMINATIVE MIXTURE 22. SODIUM CHLORIDE 0. CALMINE LOTION IP 16.5%15% w/v 5% w/v 40mg 10mg/ml 50mg/2ml 150mg 500mg 10mg 10mg 10mg/ml 5 ml Bottle 5 ml Bottle 10ml Bottle 10x10 500mlBottle 500ml Bottle 25mL Amp 10mL Amp 1 L Bottle 1 L Bottle 10x10 2ml Amp 2ml Amp 10x10 10x10 10x10 10x10 2ml Amp 27.5g packet 5mg 10x10 (CPC FORMULA) 500ml Bottle 5mg 500mg 40IU/ml 40IU/ml 40IU/ml 40IU/ml 10x10 10x10 vial vial vial vial . TURPENTINE LINIMENT IP 72.Essential Drugs 71. DIAZEPAM TAB IP 18.FRAMYCETIN EYE DROPS 74.3% w/v 0.DIURETICS 83 FRUSEMIDE TAB IP 84 FRUSEMIDE INJ IP 21. RAPID ACTING 99 INSULIN HUMAN.I.SALINE NASAL DROPS 17.G.5%w/v 0.V FLUIDS AND ELECTROLYTES 77.T.HORMONES &ENDOCRINE DRUGS 94 GLIBENCLAMIDE TAB IP 95 METFORMIN TAB IP 96 INSULIN BOVINE. LONG ACTING 474 500ml Bottle 500ml Bottle 0.DRUGS 85 RANITIDINE HCL INJ IP 86 RANITIDINE HCL TAB IP 87 ALUMINIUM HYDROXIDE TAB IP 88 DOMPERIDONE TAB 89 DICYCLOMINE HCL TAB IP 90 DICYCLOMINE HCL INJ IP 91 ORS POWDER WHO.9% & DEXTROSE 78 DEXTROSE INJ IP 79 DEXTROSE INJ IP 80 STERILE WATER FOR INJECTION IP 19.PSYCHOTROPIC DRUGS 76.9 % w/v 5mg 5% w/v IP 5%w/v 25%w/v 10ml 7.DISINFECTANTS & ANTISEPTICS 81 CHLORHEXIDINE CETRIMIDE SOLUTION 82 CHLOROXYLENOL SOLUTION IP 20.I.CIPROFLOXACIN EYE/EAR DROPS 75. LONG ACTING IP 98 INSULIN HUMAN.OPHTHALMIC DRUGS/ENT DRUGS 73.

ANTI BIOTICS & ANTI BACTERIALS 12 COTRIMOXAZOLE TAB 13 COTRIMOXAZOLE TAB 14 COTRIMOXAZOLE ORAL SUSP.Secondary Care Hospitals 23.VITAMINS & MINERALS 102. PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP 300mg 75mg 500mg 250mg/ml 50mg 25mg/ml 10x14 10x14 10x10 60ml bottle 10x10 3ml Amp 10x10 2ml Amp 2ml Amp 1ml Amp 10x10 10x10 10x10 10x10 475 6.ASCORBIC ACID TAB IP 100mg 105.VITAMINA & D CAP (HARD/SOFT) 6000/1000 IU 107.MULTI. ANTIPYRETICS. ANALGESICS.FERROUS SULPHATE TAB IP 200mg 5mL vial 10mLvial 10x10 10x10 10x10 10x10 10x10 10X10 ESSENTIAL DRUGS LIST FOR SECONDARY CARE HOSPITALS (Blocks PHCs and CHCs) SlNo NAME OF THE DRUG STRENGTH PACKING 1. TRAMADOL TAB 2.CALCIUM LACTATE TAB IP 300mg 103.IMMUNOLOGICALS 100TETANUS TOXOID INJ IP/BP 10 dose 101 ANTISNAKE VENOM FREEZE DRIED. VITAMIN TAB NFI 106. PARACETAMOL INJ 10. ANTI INFLAMMATORY ANTI ARTHRITIC 1. 5. ACETYL SALICYLIC ACID TAB IP 3.IP 80mg+400mg 160mg+800mg 150mg/2ml 50mg/ml 100mg 40mg+200mg/5ml 50ml susp 15 AMOXYCILLIN DISPERSIBLE TAB IP 125mg . IBUPROFEN TAB (FILM COATED) IP 400mg 8.VITAMIN B COMPLEX TAB NFI (STRONG) 104. PARACETAMOL TAB IP 4. POLYVALENT 24. DICLOFENAC SODIUM INJ IP 7. ACETYL SALICYLIC ACID TAB IP 2. TRAMADOL INJ 11. PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml 9.

IP 38 ETHAMBUTOL TAB IP 39 THEOPHYLLINE & ETOPHYLLINE INJ 41 AMINOPHYLLINE INJ IP 42 SALBUTAMOL SULPHATE TAB IP 43 SALBUTAMOL NEBULISER SOLUTION 476 250mg 250mg 500mg 500mg 10Lakhs Units 2mg/ml 80mg/2ml 100mg 400mg 500mg 200mg 400mg 5mg/ml 1g 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg 10x10 10x10 10x10 Vial Vial 100ml I.Essential Drugs 16 CLOXACILLIN CAP IP 17 AMOXYCILLIN CAP IP 18 AMOXYCILLIN CAP IP 19 AMPICILLIN INJ IP 20 BENZYL PENICILLIN INJ IP 21 CIPROFLOXACIN INJ IP 22 GENTAMICIN INJ IP 23 DOXYCYCLINE CAP IP 25 NORFLOXACIN TAB IP 26 CIPROFLOXACIN TAB IP 27 METRONIDAZOLE TAB IP 28 METRONIDAZOLE TAB IP 29 METRONIDAZOLE I.V INJ IP 3.4mg 2ml Amp 10x10 10ml Amp 10x10 10mAmp 25mg/ml 4mg 5mg/ml 40 THEOPHYLLINE ETOPHYLLINE TAB 23mg 77 mg . DRUGS ACTING THE RESPIRATORY TRACT 50. ANTITUBERCULAR DRUGS 30 STREPTOMYCIN INJ IP 31 RIFAMPICIN CAP IP 32 INH TAB IP 33 INH TAB IP 34 ETHAMBUTOL TAB IP 35 PYRAZINAMIDE TAB 36 RIFAMPICIN CAP IP 37 RIFAMPICIN ORAL SUSP.V Amp 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle Vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10 24 ERYTHROMYCIN STEARATE TAB IP 250mg 4.6mg 169.

ANTI EPILEPTIC DRUGS 58 PHENOBARBITONE TAB IP 59 PHENOBARBITONE TAB IP 60 PHENYTOIN SODIUM TAB IP 61 CARBAMAZEPINE TAB IP 62 SODIUM VALPROATE TAB IP 63 DIAZEPAM INJ IP 64 SODIUM VALPROATE TAB 8.Secondary Care Hospitals 44 TERBUTALINE INJ IP 45 EXPECTORANT MIXTURE CONCENTRATED 5. ANAESTHETICS & ALLIED DRUGS 46 LIGNOCAINE HYDROCHLORIDE GEL IP 47 LIGNOCAINE HYDROCHLORIDE INJ 48 ATROPINE INJ IP 0.5mg/ml 1ml Amp 500 bottle 2%w/v 2%w/v 0. ANTI ALLERGICS AND DRUGS USED IN ANAPHYLAXIS 49 DEXAMETHASONE SODIUM INJ IP 4mg/ml 50 HYDROCORTISONE SODIUM SUCCINATE INJ 51 DEXAMETHASONE TAB IP 52 ADRENALINE INJ IP 53 CHLORPHENIRAMINE MALETE TAB IP 54 CHLORPHENIRAMINE MALEATE INJ IP 55 PROMETHAZINE INJ IP 56 CETIRIZINE TAB 57 PREDNISOLONE TAB IP 7. ANTHELMINTICS 65 MEBENDAZOLE TAB IP 66 PIPERAZINE CITRATE ELIXIR IP 100mg 750mg/5ml 30mg 60mg 100mg 200mg 200mg 5mg/ml 500mg 100mg 0.5mg 1mg/ml 4mg 10mg/ml 25mg/ml 10mg 10mg .6mg/ml 30ml vial 30ml vial 1ml Amp 2ml vial Vial 10x10 1ml Amp 10x10 1ml Amp 2ml amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x2ml 10x10 6x1 450ml 477 6.

ANTIPARKINSONIAN DRUGS 75 TRIHEXYPHENIDYL TAB IP 14.5mg 5mg 0. DRUGS AFFECTING THE BLOOD 76 FOLIC ACID TAB IP 15.25mg 25mg 10x10 10x10 10x10 10x14 10x10 10x10 10x10 10x10 5mg 10x10 2mg 10x10 400mg 50mg 50mg 10x10 10x10 10x10 25mg 10x10 2%w/v 200mg 20g tube 3tab 15g tube 100mg 10x10 .Essential Drugs 9.CARDIOVASCULAR DRUGS 77 ISOSORBIDE DINTIRATE TAB IP 78 ISOSORBIDE DINTRATE TAB IP 79 NIFEDIPINE TAB IP 80 ATENOLOL TAB IP 81 ENALAPRIL MALEATE TAB 82 AMLODIPINE TAB 83 DIGOXIN TAB IP 84 HYDROCHLOROTHIAZIDE TAB IP 16.ANTIFUNGAL DRUGS 68 CLOTRIMAZOLE CREAM IP 69 CLOTRIMAZOLE VAG TAB IP 70 WHITFIELD’S OINTMENT IP 11.ANTILEPROTIC DRUGES 72 RIFAMPICIN CAP IP 73 CLOFAZIMINE CAP IP 74 DAPSONE TAB IP 13.ANTIMALARIAL DRUGS 71 CHLOROQUINE PHOSPHATE TAB IP 12. ANTIFILARIAL DRUGS 67 DIETHYLCARBAMAZINE TAB IP 10.DERMATOLOGICAL DRUGS 85 SILVER SULFADIAZINE CREAM IP 86 GLYCERINE IP 87 LIQUID PARAFFIN IP 88 SALICYLIC ACID OINTMENT 89 BENZYL BENZOATE APPLICATION IP 478 1%w/v 25kg 5L 10% w/w 25%w/v 100g bottle drum can 500g bottle 500ml bottle 5mg 10mg 10mg 50mg 2.

1%w/v 0.OBSTETRIC & GYNAECOLOGY DRUGS 100 OXYTOCIN INJ IP 101 METHYLERGOMETRIN MALEATE INJ 102 CARBOPROST INJ 19.5ml 0.25mg 0.3%w/v 5% w/v 1% w/w 500g bottle 5g tube 500ml bottle 20g tube 500ml bottle 5ml bottle 5ml bottle 10ml bottle 10ml bottle 10ml bottle 1ml Amp 1ml Amp 0.Secondary Care Hospitals 90 GLYCERINE MAGSULPH BPC 91 BETAMETHASONE VALERATE CREAM1% w/w 92 POVIDONE IODINE SOLUTION 93 FRAMYCETIN SKIN CREAM 94 TURPENTINE LINIMENT IP 17.PSYCHOTROPIC DRUGS 103DIAZEPAM TAB IP 104 CHLORPROMAZINE TAB IP 105 CHLORPROMAZINE TAB IP 106 IMIPRAMINE TAB IP 107 AMITRIPTYLINE TAB IP 108 NITRAZEPAM TAB IP 109 ALPRAZOLAM TAB 110 ALPRAZOLAM TAB 111 HALOPERIDOL TAB 112 CHLORDIAZEPOXIDE TAB 20.I.5mg 5mg 10mg 5 IU/ml 200mcg/ml 125 mcg/0.9%w/v 5% w/v 5mg 50mg 100mg 25mg 25mg 5mg 0.OPHTHALMIC DRUGS/EAR DROPS 95 FRAMYCETIN EYE DROPS 96 CIPROFLOXACIN EYE/EAR DROPS 97 SODIUM BICARBONATE EAR DROPS BPC 98 SALINE NASAL DROPS 99 XYLOMETAZOLINE NASAL DROPS 18.9%w/v 0.5ml Amp 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 10 x 10 500ml bottle 500ml bottle 479 .V FLUIDS AND ELECTROLYTES 113 SODIUM CHLORIDE INJ IP 114 SODIUM CHLORIDE 0.5%w/v 0.9% & DEXTROSE 0.

/ml 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 10mg/ml 27.5mg 500mg 40 IU/ml 1L bottle 500ml bottle 1L bottle 1L bottle 10 x 10 2mL Amp 2mL Amp 10 x 10 10 x 10 10 x 10 2mL Amp 10 x 10 2mL Amp Packet 10 x 10 500mL bottle 10 x 10 10 x 10 10 x 10 10 x 10 vial .DRUGS 125 RANITIDINE HCL INJ IP 126 RANITIDINE HCL TAB IP 127 ALUMINIUM HYDROXIDE TAB IP 128 OMEPRAZOLE CAP 129 METOCLOPRAMIDE INJ 130 DICYCLOMINE HCL TAB IP 131 DICYCLOMINE HCL INJ IP 132 ORS POWDER WHO WITH CITRATE SALT 133 BISACODYL TAB IP 134 CARMINATIVE MIXTURE 135 DOMPERIDONE TAB IP 24.5% 15% w/v 70% v/v 20%w/v 5%w/v 40mg 10mg.DISINFECTANTS & ANTISEPTICS 119CHLORHEXIDINE/ CETRIMIDE SOLUTION 120SURGICAL SPIRIT 121HYDROGEN PEROXIDE SOLUTION IP 122CHLOROXYLENOL SOLUTION IP 22. HORMONES & ENDOCRINE DRUGS 136 GLIBENCLAMIDE TAB IP 137 GLIBENCLAMIDE TAB IP 138 METFORMIN TAB 139 INSULIN BOVINE.5g 5mg CPC Formula 10mg 5mg 2.Essential Drugs 115 DEXTROSE INJ IP 116 DEXROSE INJ IP 117 RINGER LACTATE INJ IP 118 STERILE WATER FOR INJECTION IP 21.G.I T. RAPID ACTING IP 480 5% w/v 25% w/v 500ml bottle 25ml Amp 500ml 10ml Amp 7.DIURETICS 123 FRUSEMIDE TAB IP 124 FRUSEMIDE INJ IP 23.

VITAMINS & MINERALS 150 CALCIUM LACTATE TAB IP 151 VITAMIN B COMPLEX TAB NF1 (STRONG) 152 VITAMIN B COMPLEX INJ NF1 153 ASCORBIC ACID TAB IP 154 CALCIUM GLUCONATE INJ IP 155 MULTI VITAMIN TAB NFI 40 IU/ml 40 IU/ml 40 IU/ml 0.IMMUNOLOGICALS 144 TETANUS TOXOID INJ IP/BP 145 TETANUS IMMUNOGLOBULIN USP 146 ANTI SNAKE VENOM FREEZE DRIED. LONG ACTING IP 141 INSULIN HUMAN.No. RAPID ACTING 142 INSULIN HUMAN. CELL CULTURE IP 148 TRIPLE ANTIGEN IP 149 POLIO VACCINE. POLYVALENT IP 147 RABIES VACCINE HUMAN. ANTIPYRETICS.5ml /dose 20 doses 300mg vial vial vial 10 x 10 5mL vial vial vial vial 0. LONG ACTING 143 THYROXINE SODIUM TAB IP 25.5 mL Amp vial 10 x 10 10 x 10 10ml 100mg 10% w/v vial 10 x 10 10 mL Amp 10 x 10 10 x 10 10 x 10 156 VITAMIN A & D CAP (HARD/SOFT) 6000IU/1000IU 157 FERROUS SULPHATE TAB IP 200mg ESSENTIAL DRUG LIST FOR TALUK HOSPITAL SI.Taluk Hospitals 140 INSULIN BOVINE. ANALGESICS. ANTIARTHRITIC 1 2 ACETYL SALCYLIC ACID TAB IP ACETYL SALICYLIC ACID TAB IP1 300mg 75mg 10x14 10x14 481 .1mg 10 dose 250 IU/vial 10ml 2. ORAL 26. NAME OF THE DRUG STRENGTH PACKING 1.5 IU 0. ANTINFLAMMATORY.

Essential Drugs 3 4 5 6 7 8 9 PARACETAMOL TAB IP PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP DICLOFENAC SODIUM INJ IP 500mg 250mg/ml 50mg 25mg/ml 10x10 60mlBottle 10x10 3ml Amp 10x10 2ml Amp 1ml Amp 2ml Amp 1ml amp 1ml Amp 10x10 10x10 10x10 50ml susp 10x10 10x10 10x10 10x10 Vial Vial vial 100ml IV Amp 10x10 10x10 10x10 10x10 30ml bottle 10x10 10x10 IBUPROFEN TAB (FILM COATED ) IP 400mg PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml PENTAZOCINE LACTATE INJ IP 30mg/ml 150mg/2ml 15mg/ml 50mg/ml 100mg 80mg+400mg 160mg +800mg 40mg+200mg/ 5 mL 250mg 250mg 250mg 500mg 10 Lakhs units 250 mg 2mg/ml 80mg/2ml 100mg 400mg 500mg 125mg/5ml 200mg 400mg 10 PARACETAMOL INJ 11 MORPHINE SULPHATE INJ IP 12 TRAMADOL INJ 13 TRAMADOL TAB 2. ANTIBIOTICS & ANTIBACTERIALS 14 COTRIMOXAZOLE TAB IP 15 COTRIMOXAZOLE TAB IP 16 COTRIMOXAZOLE ORAL SUSP.IP 17 AMOXYCILLIN DISPERSIBLE TAB IP 125mg 18 AMOXYCILLIN CAP IP 19 CLOXACILLIN CAP IP 20 AMPICILLIN CAP IP 21 AMPICILLIN INJ IP 22 BENZYL PENICILLIN INJ IP 23 CEFOTAXIME SODIUM INJ IP 24 CIPROFLOXACIN INJ IP 25 GENTAMICIN INJ IP 26 DOXYCYCLINE CAP IP 28 NORFLOXACIN TAB IP 29 CIPROFLOXACIN TAB IP 30 CEPHALEXIN ORAL SUS (DRY) IP 31 METRONIDAZOLE TAB IP 32 METRONIDAZOLE TAB IP 482 27 ERYTHROMYCIN STEARATE TAB IP 250mg .

Taluk Hospitals 33 METRONIDAZOLE INJ IP 34 CEFOTAXIME INJ IP 35 CEPHALEXIN CAP IP 3.5mg/ml 100mcg/mdi 100mL bottle Vial 10x10 vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml Bottle 10x10 4.6mg 1669.4mg 23mg. ANTITUBERCULAR DRUGS 36 STREPTOMYCIN INJ IP 37 RIFAMPICIN CAP IP 38 INH TAB IP 39 INH TAB IP 40 ETHAMBUTOL TAB IP 41 PYRAZINAMIDE TAB 42 RIFAMPICIN CAP IP 43 RIFAMPICIN ORAL SUSP BP 44 ETHAMBUTOL TAB IP 45 THEOPHYLLINE & ETOPHYLLINE INJ 46 THEOPHYLLINE & ETOPHYLLINE tab 47 AMINOPHYLLINE 48 SALBUTAMOL SULPHATE TAB IP 49 SALBUTAMOL NEBULISER SOLUTION 50 Terbutaline Inj IP 51 BUDESONIDE RESPIRATORY SOLUTION 52 EXPECTORANT MIXTURE CONCENTRATED 5. DRUGS ACTING ON RESPIRATORY TRACT 2ml amp 10 x 10 10ml amp 10x10 10mL 1ml amp 200mdi 500ml bottle 50mg/ml 200ml 2% 10ml vial bottle tube 30g 483 . ANAESTHETICS & ALLIED DRUGS 53 KETAMINE INJ IP 54 HALOTHANE USP LIQUID 55 LIGNOCAINE HYDROCHLORIDE GEL IP 5mg/ml 1g 250mg 1gm 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg 50.77mg 25mg/ml 4mg 5mg/mL 0.

6mg/ml 0. ANTIALLERGICS & DRUGS USED IN ANAPHYLAXIS 69 HYDROCORTISONE SUCCINATE INJ 100mg 70 DEXAMETHASONE TAB IP 71 BETAMETHAZONE SODIUM INJ IP 72 ADRENALINE INJ IP 73 CHLORPHENIRAMINE MALEATE TAB IP 74 CHLORPHENIRAMINE MALEATE TAB IP 75 CHLORPHENIRAMINE MALEATE INJ IP 76 PROMETHAZINE INJ IP 77 CETIRIZINE TAB 78 PREDNISOLONE TAB IP 79 METHYL PREDNISOLONE ACETATE INJ IP 484 0.5mg 4 mg/mL 1mg/ml 4mg 2mg 10mg/ml 25mg/ml 10mg 10mg 40mg/ml 50mg & 75mg 0.5g 30 ml 2ml amp 4ml amp 1ml amp 1ml amp 2ml amp 20ml Amp 50ml amp 10ml Amp 10ml vial vial 10x10 10x10 1mL amp 1ml amp 10x10 10x10 1ml amp 2ml amp 10x10 10x10 1ml amp .Essential Drugs 56 LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 57 LIGNOCAINE HCL & DEXTROSE INJ IP 58 BUPIVACAINE inj IP 59 ATROPINE INJ IP 60 NEOSTIGMINE METHYL SULPHATE INJ IP 61 PANCURONIUM BROMIDE INJ BP 62 PROPOFOL INJ 63 PROPOFOL INJ 64 SODIUM BICARBONATE INJ IP 65 SUCCINYL CHOLINE CHLORIDE INJ IP 66 THIOPENTONE SODIUM INJ IP 67 OXYGEN IP 68 NITROUS OXIDE IP 6.5% w/v 50mg/ml 0.5 mg/ml 2mg/ml 1% w/v 1%w/v 7.5% 0.

ANTIMALARIAL DRUGS 100 CHLOROQUINE PHOSPHATE TAB IP 101 QUININE INJ 102 PRIMAQUINE TAB IP 25mg 300mg/ml 7.6mg/ml 500mg 400mg/ml 1g 100ml 10x10 1mlamp vial .ANTIFILARIAL DRUGS 94 DIETHYLCARBAMAZINE CITRATE TAB IP 11. ANTHELMINTICS 92 MEBENDAZOLE TAB IP 93 PIPERAZINE CITRATE ELIXIR IP 10.5mg 10x10 2ml Amp 10x10 485 125mg 200mg 2%w/w 200mg 15g 10x10 10x10 5gm 3tab tube 100mg 10x10 100mg 750mg/5ml 6x1 450ml Bottle 30mg 60mg 100mg 200mg 200mg 5mg/ml 50mg/ml 500mg 10x10 10x10 10x10 10x10 10x10 2ml amp 2ml amp 10x10 0.Taluk Hospitals 7.ANTIFUNGAL DRUGS 95 GRISEOFULVIN TAB IP 96 KETOCONAZOLE TAB IP 97 CLOTRIMAZOLE CREAM IP 98 CLOTRIMAZOLE VAG TAB IP 99 WHITFIELD’S OINTMENT IP 12. ANTIEPILEPTIC DRUGS 84 PHENOBARBITONE TAB IP 85 PHENOBARBITONE TAB IP 86 PHENYTOIN SODIUM TAB IP 87 CARBAMAZEPINE TAB IP 88 SODIUM VALPROATE TAB 89 DIAZEPAM INJ IP 90 PHENYTOIN SODIUM INJ IP 91 SODIUM VALPROATE TAB 9. ANTIDOTES AND OTHER SUBSTANCES IN POISONING 80 ATROPINE SULPHATE INJ IP 81 ACTIVATED CHARCOAL TAB 82 NALOXONE INJ 83 PRALIDOXIME INJ IP 8.

Essential Drugs

103 SULFADOXINE & PYRIMETHAMINE TAB IP 104 ARTEMETHER INJ 13.ANTIVIRALDRUGS/ ANTIAIDS 105 ACYCLOVIR TAB 14.ANTILEPROTIC DRUGS 106 107 CLOFAZIMINE CAP IP DAPSONE TAB IP

500mg+25mg 80mg/ml 200mg 50mg 50mg 2mg 10mg/100mg 100mcg/ml 5mg 10mg/ml

10x10 1ml Amp 10x10 10x10 10x10 10x10 10x10 2ml Amp 10x10 1ml Amp 500ml Bottle

15.ANTIPARKINSONISM DRUGS 108 TRIHEXYPHENIDYL TAB IP 109 CARBIDOPA 10mg+ LEVODOPA 100mg TAB IP 16. DRUGS AFFECTING THE BLOOD 110 CYANOCOBALAMIN INJ IP 111 FOLIC ACID TAB IP 112 PHYTOMENADIONE (VITK1) INJ 113 DEXTRAN 40 WITH SODIUM CHLORIDE 0.9% INFUSION 17.CARDIOVASCULAR DRUGS 114 ISOSORBIDE DINITRATE TAB IP 115 ISOSORBIDE DINITRATE TAB IP 117 ISOSORBIDE -5MONONITRATE TAB 118 DILTIAZEM TAB IP 119 ATENOLOL TAB IP 120 ATENOLOL TAB IP 121 ENALAPRIL MALEATE TAB 122 METHYL DOPA TAB IP 123 ENALAPRIL MALEATE TAB 124 AMLODIPINE TAB 125 AMLODIPINE TAB 486 5mg 10mg 10x10 11x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 10x10 10x10

116 ISOSORBIDE 5 MONONIRATE TAB 10mg 20mg 30mg 50mg 100mg 2.5mg 250mg 5mg 2.5mg 5mg

Taluk Hospitals

126 DIGOXIN TAB IP 127 DOPAMINE HCL INJ USP 128 DOBUTAMINE HCL INJ 129 130 METOPROLOL INJ 131 METOPROLOL TAB IP 132 METOPROLOL TAB IP 18.DERMATOLOGICAL DRUGS 133 SILVER SULFADIAZINE CREAM IP 134 GLYCERINE IP 135 LIQUID PARAFFIN IP 136 SALICYLIC ACID OINTMENT 137 BENZYL BENZOATE APPLICATION IP 138 GLYCERINE MAGSULPH BPC

0.25mg 40mg/ml 50mg/ml 5mg/ml 25mg 50mg 1% w/w 25kg 5 Litre 10% w/w 25%w/v

10x10 5ml 5ml amp 10x10 1ml amp 10x10 10x10 100g/bottle Drum Can 500g bottle 500ml bottle 500g bottle 25gm tub 5gm ube 100mlBottle 500ml bottle 20 g tube 500ml bottle

HYDROCHLOROTHIAZIDE TAB IP 25mg

139 POVIDONE IODINE OINTMENT IP 5%w/w 140 BETAMETHASONE VALERATE CREAM 141 GAMMA BENZENE HEXACHLORIDE SOLUTION 142 POVIDONE IODINE SOLUTION 143 FRAMYCETIN SKIN CREAM 144 TURPENTINE LINIMENT IP 19.OPHTHALMIC DRUGS/EAR/NASAL DROPS 145 FRAMY CETIN EYE DROPS 147 148 150 0.5%w/v 1%w/w 1%w/v 5%w/v 1%w/w

5ml Bottle 5ml bottle 5g tube 5ml bottle 5ml bottle 5ml bottle 5ml bottle 487

146 CIPROFLOXACIN EYE/EAR DROPS 0.3%w/v CIPROFLOXACIN EYE OINTMENT 0.3%w/w PILOCARPINE EYE DROPS TROPICAMIDE EYE DROPS 0.5w/v 0.5%w/v 1%w/v 0.1%w/v

149 TIMOLOL MALEATE DYE DROPS 151 BETAMETHASONE EYE DROPS

Essential Drugs

152 SODIUM BICARBONATE EAR DROPS BPC 153 XYLOMETAXOLINE NASAL DROPS IP 0.1%w/v

10ml bottle 10ml bottle

154 CHLORAMPHENICOL APPLICAPS 155 OXYTOCIN INJ IP 156 157 158 159 PROSTAGLANDIN INJ METHYLERGOMETRINE MALEATE TAB IP

1%w/v (250mg/cap) 50/bottle 5 IU/ml 250mcg/ml 0.125mg 1ml Amp 1ml Amp 10x10 1ml Amp 10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 1ml Amp 1mlAmp 10x10 10x10 500ml bottle 500ml Bottle

20.OBSTETRIC AND GYNAECOLOGY DRUGS

METHYLERGOMETRINEMALEATE INJ 200mcg/ml POVIDONE IODINE VAGINAL PESSARIES DIAZEPAM TAB IP CHLORPROMAZINE TAB IP AMITRIPTYLINE TAB IP NITRAZEPAM TAB IP ALPRAZOLAM TAB ALPRAZOLAM TAB FLUOXETINE CAP FLUOXETINE CAP HALOPERIDOL TAB CHLORDIAXEPOXIDE TAB HALOPERIDOL INJ CLOZAPINE TAB CLOZAPINE TAB SODIUM CHLORIDE INJ IP SODIUM CHLORIDE 0.9 % DEXTROSE 5% w/v INJ IP 200mg 5mg 50mg 25mg 5mg 0.25mg 0.5mg 10mg 20mg 5mg 10mg 5mg/ml 25mg 100mg 0.9%w/v 0.9%, 5%w/v

21. PSYCHOTROPIC DRUGS 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 488

FLUFENAZINE DECANOATE INJ IP 25mg/ml

22. IV FLUIDS & ELECTROLYTES

Taluk Hospitals

176 177 178 179 180 181 182

DEXTROSE INJ IP DEXTROSE INJ IP DEXTROSE INJ IP DEXTROSE INJ IP RINGER LACTATE INJ IP MANNITOL INJECTION IP STERILE WATER FOR IN JECTION IP CHLORHEXIDINE & CETRIMIDE SOLUTION

5%w/v 10%w/v 50%w/v 25%w/v 500ml 20%w/v 10ml

500mll bottle 500ml bottle 25mlAmp 25ml Amp Bottle 250ml bottle Amp

23. DISINFECTANTS & ANTISEPTICS 183 7.5% /15% w/v 70% w/v 20% w/v 7.5%w/v 1 L bottle 500ml bottle 1Lbottle 500ml Bottle 1Lbottle 1L bottle 10x10 2ml Amp 10x10 10x10 2ml Amp 10x10 10x10 10x10 2ml amp 10x10 10mlvial 10x10 10x10 489

184 SURGICAL SPIRIT 185 HYDROGEN PEROXIDE SOLUTION IP 186 187 188 189 190 191 192 POVIDONE IODINE SCRUB

CHLOROXYLENOL SOLUTION IP 5%w/v CHLOROXYLENOL SOLUTION IP 5%w/v FRUSEMIDE TAB IP FRUSEMIDE INJ IP SPIRONOLACTONE TAB IP SPIRONOLACTONE TAB IP 40mg 10mg/ml 25mg 100mg 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 5mg/ml 10mg 10mg

24.DIURETICS

25.G.I.T. DRUGS 193 RANITIDINE HCL INJ IP 194 RANITIDINE HCL TAB IP 195 196 197 198 199 200 201 ALUMINIUM HYDROXIDE TAB IP OMEPRAZOLE CAP METOCLOPRAMIDE INJ METOCLOPRAMIDE TAB METOCLOPRAMIDE INJ DOMPERIDONE TAB DICYCLOMINE HCL TAB IP

Essential Drugs

202 203 204 205 206

DICYCLOMINE HCL INJ IP ORS POWDER WHO WITHCITRATE SALT BISACODYL TAB IP CARMINATIVE MIXTURE (CPC FORMULA) SYRUP LACTULOSE

10mg/mL 27.5g 5mg

2ml amp Packet 10x10 500ml Bottle

667mg/ml 5mg 2.5mg 500mg 5mg

100ml Bottle 10x10 10x10 10x10 10x10 40 IU/ml 40 IU/ml Vial Vial 10x10 5ml vial Vial Vial 10 mlVial Vial Vial

26.HORMONES & ENDOCRINE DRUGS 207 GLIBENCLAMIDE TAB IP 208 GLIBENCLAMIDE TAB IP 209 METFORMIN TAB 210 GLIPIZIDE TAB 212 213 214 215 216 217 218 219 220 221 222 223 225 490

211 INSULIN BOVINE, RAPID ACTING IP INSULIN BOVINE LONG ACTING IP INSULIN HUMAN, RAPID ACTING 40 IU/ml INSULIN HUMAN, LONG ACTING 40 IU/ml THYROXINE SODIUM TAB IP TETANUS TOXOID INJ IP/BP TETANUS IMMUNOGLOBULIN USP HUMAN ANTID IMMUNOGLOBULIN USP ANTISNAKE VENOM FREEZE DRIED POLYVALENT RABIES VACCINE HUMAN, CELL CULTURE HEPATITIS B VACCINE IP HEPATITIS B VACCINE IP POLIO VACCINE, ORAL 250 IU 10 mcg/ml 20 mcg/ml 20 doses 0.5ml dose 0.1mg 10 dose 250 IU 250 mcg

27.IMMUNOLOGICALS

Vial 0.5ml amp 1ml amp 10ml 0.5ml Amp 2ml Amp

224 TRIPLE ANTIGEN IP

ANTIRABIES IMMUNOGLOBULIN HUMAN 150IU/ml

Tertiary Hospitals

28.VITAMINS & MINERALS 226 CALCIUM LACTATE TAB IP 227 VITMINE B COMPLEX TAB NFI (STRONG) 228 230 231 232 233 234 VITAMIN B COMPLEX INJ NFI 100mg 10%w/v CALCIUM GLUCONATE INJ IP MULTIVITAMIN TAB NFI FERROUS SULPHATE TAB IP THIAMINE HCL INJ IP 200mg 100mg/ml 229 ASCORBIC ACID TAB IP 300mg 10x10 10x10 10ml Amp 10x10 10ml amp 10x10 10x10 1ml Amp

VITAMIN A & D CAP (HARD/SOFT) 6000 IU/1000 IU 10x10

ESSENTIAL DRUGS LIST FOR TERTIARY HOSPITAL (DISTRICT /GENERAL HOSPITALS & MEDICAL COLLEGE HOSPITALS) Sl No NAME OF THE DRUG STRENGTH PACKING

1. ANALGESICS, ANTI PYRETICS,ANTI INFLAMMATORY & ANTI ARTHRITICS 1. ACETYL SALICYLIC ACID TAB IP 2 3 4 5 6 7 8 9 ACETYL SALICYLIC ACID TAB IP PARACETAMOL TAB IP PARACETAMOL SYRUP IP DICLOFENAC SODIUM TAB IP DICLOFENAC SODIUM INJ IP 300mg 75mg 500mg 250mg/ml 50mg 25mg/ml 10X14 10X14 10X10 60mL Bottle 10x10 3ml Amp 10x10 2ml amp 1ml Amp 2ml Amp 1ml Amp 1ml Amp 10x10 10x10 10x10 491

IBUPROFEN TAB (FILM COATED) IP 400mg PETHIDINE HYDROCHLORIDE INJ IP 50mg/ml PENTAZOCINE LACTATE INJ IP 30mg/ml 150mg/2ml 15mg/ml 50mg/ml 100mg 100mg 500mg

10 PARACETAMOL INJ 11 MORPHINE SULPHATE INJ IP 12 TRAMADOL INJ 13 TRAMADOL TAB 14 ALLOPURINOL TAB IP 15 SULFASALAZINE TAB

Essential Drugs

2. ANTIBACTERIALS 16 COTRIMOXAZOLE TAB IP 17 COTRIMOXAZOLE TAB IP 18 COTRIMOXAZOLE ORAL SUSP IP 20 AMOXYCILLIN CAP IP 21 CLOXACILLIN CAP IP 22 AMPICILLIN CAP IP 23 AMPLICILLIN INJ IP 24 BENZYL PENICILLIN INJ IP 25 BENZATHINE PENICILLIN INJ IP 26 CEFOTAXIME SODIUM INJ IP 27 CIPROFLOXACIN INJ IP 28 GENTAMICIN INJ IP 29 FORTIFIED PROCAINE PENICILLIN IP 30 DOXYCYCLINE CAP IP 32 NORFLOXACIN TAB IP 33 OFLOXACIN TAB 34 OFLOXACIN INJ 35 CEFUROXIME INJ IP 36 CEFUROXIME INJ IP 37 AMIKACIN SULPHATE INJ IP 38 CIPROFLOXACIN TAB IP 39 CEPHALEXIN ORAL SUS (DRY)IP 40 METRONIDAZOLE TAB IP 41 METRONIDAZOLEL TAB IP 42 METRONIDAZOLE INJ IP 43 TETRACYCLINE CAP IP 44 CEFOTAXIME INJ IP 45 VANCOMYCIN INJ 492 80mg+400mg 160mg+800mg 10x10 10x10 10x10 10x10 10x10 10x10 Vial Vial Vial Vial 100ml vial Amp Vial 10x10 10x10 10x10 10x10 100ml bottle Vial Vial 2ml Vial 10x10 30ml bottle 10x10 10x10 100ml bottle 10x10 Vial Vial

40mg+200mg/5mL 50ml susp 250mg 250mg 250mg 500mg 10lakhs units 12 Lakhs Units 250mg 2mg/ml 80mg/2ml 500000IU 100mg 400mg 200mg 2mg/ml 250mg 750mg 250mg/ml 500mg 125mg/5ml 200mg 400mg 5mg/ml 250mg 1g 500mg

19 AMOXYCILLIN DISPERSIBLE TAB IP 125mg

31 ERYTHROMYCIN STEARATE TAB IP 250mg

Tertiary Hospitals

46 AZITHROMYCIN TAB 47 CEPHALEXINE CAP IP 48 CEFPIROME INJ 49 CLINDAMYCIN INJ 3. ANTI TUBERCULAR DRUGS 50 STREPTOMYCIN INJ IP 51 RIFAMPICIN CAP IP 52 INH TAB IP 53 INH TAB IP 54 ETHAMBUTOL TAB IP 55 PYRAZINAMIDE TAB 56 RIFAMPICIN CAP IP 57 RIFAMPICIN ORAL SUS BP 58 ETHAMBUTOL TAB IP 59 THEOPHYLLINE & ETOPHYLLINE INJ 60 THEOPHYLLINE & ETOPHYLLINE TAB 61 AMINOPYLLINE INJ IP 62 ALBUTAMOL SULPHATE TAB IP 63 SALBUTAMOL NEBULISER SOLUTION 64 TERBUTALINE INJ IP 65 BUDESONIDE RESPIRATORY SOLUTION 5. ANAESTHETICS & ALLIED DRUGS 67 KETAMINE INJ IP 68 HALOTHANE USP LIQUID 69 LIGNOCAINE HYDROCHLORIDE GEL IP

250mg 250mg 1g 300mg 1gm 150mg 100mg 300mg 400mg 500mg 450mg 100mg/5ml 600mg

10x10 10x10 Vial 2ml Amp Vial 10x10 10x10 10x10 10x10 10x10 10x10 100ml bottle 10x10

4. DRUGS ACTING ON THE RESPIRATORY TRACT 50.6mg,169mg-2ml 23mg,77mg 25mg/ml 4mg 5mg/ml 0.5mg/ml 100mcg/mdi 2ml Amp

10x10 10mlAmp 10x10 10ml 1ml Amp 200mdi 500ml bottle 10ml vial Bottle Tube 30gm 493

66 EXPECTORANT MIXTURE CONCENTRATED 50mg/ml 200ml 2%

Essential Drugs

70 LIGNOCAINE HYDROCHLORIDE INJ 2% w/v 71 LIGNOCAINE HCL & DEXTROSE INJ IP 72 BUPIVACAINE INJ IP 73 ATROPINE INJ IP 74 NEOSTIGMINE METHYL SULPHATE INJ IP 75 PANCURONIUM BROMIDE INJ BP 76 PROPOFOL INJ 77 PROPOFOL INJ 78 SODIUM BICARBONATE INJ IP 79 SUCCINYL CHOLINE CHLORIDE INJ IP 80 THIOPENTONE SODIUM INJ IP 81 NITROUS OXIDE IP 82 OXYGEN IP 6.ANTIALLERGIC AND DRUGS USED IN ANAPHYLAXIS 83 DEXAMETHASONE SODIUM INJ IP 84 HYDROCORTISONE SODIUM SUCCINATE INJ 85 DEXAMETHASONE TAB IP 86 BETAMETHASONE SODIUM INJ IP 87 ADRENALINE INJ IP 88 CHLORPHENIRAMINE MALEATE TAB IP 89 CHLORPHENIRAMINE MALEATE INJ IP 90 PROMETHAZINE INJ IP 91 CETIRIZINE TAB 92 PREDNISOLONE TAB IP 93 METHYL PREDNISOLONE SODIUM SUCCINATE INJ 94 METHYL PREDNISOLONE ACETATE INJ IP 494 4mg/ml 100mg 0.5mg 4mg/ml 1mg/ml 4mg 10mg/ml 25mg/ml 10mg 10mg 500mg 40mg/ml 50mg &75mg 0.5% 0.6mg/ml 0.5mg/ml 2mg/ml 1% w/v 1% w/v 7.5gm% w/v 50mg/ml 0.5g

30ml vial 2ml Amp 4ml Amp 1ml Amp 1ml Amp 2ml Amp 20ml Amp 50ml vial 10ml Amp 10ml vial vial

2ml vial Vial 10x10 1ml amp 1m amp 10x10 1ml amp 2ml amp 10x10 10x10 Vial 1ml amp

Tertiary Hospitals

7. ANTIDOTES AND OTHER SUBSTANCES IN POISONING 95 ATROPINE SULPHATE INJ IP 0.6mg/ml 96 ACTIVATED CHARCOAL POWDER IP 50g 97 NALOXONE INJ 400mcg/ml 98 PRALIDOXIME INJ IP 1g 99 PENICILLAMINE CAP IP 250mg 100 DESFERRIOXAMINE INJ 500mg 101 N-ACETYL CYSTEINE INJ 200mg/ml 102 DISULFIRAM TAB 250mg 103 DIMERCAPROL INJ IP 50mg/ml 104 SODIUM CALCIUM EDETATE INJ 200mg/ml 105 SODIUM NITRITE INJ 30mg/ml 106 SODIUM THIOSULPHATE INJ 250mg/ml 107 METHYLENE BLUE INJ 10mg/ml 8. ANTIEPILEPTIC DRUGS 108 PHENOBARBITONE TAB IP 109 PHENOBARBITONE TAB IP 110 PHENOBARBITONE SODIUM INJ 111 PHENYTOIN SODIUM TAB IP 112 CARBAMAZEPINE TAB IP 113 SODIUM VALPROATE TAB IP 114 DIAZEPAM INJ IP 115 PHENYTOIN SODIUM INJ IP 116 CLOBAZAM TAB 117 SODIUM VALPRDATE TAB 9. ANTHELMINTHICS 118 MEBENDAZOLE TAB IP 119 PIPERAZINE CITRATE ELIXIR IP 10. ANTI FILARIAL DRUGS 120 DIETHYLCARBAMAZINE CITRATE TAB IP 121 DIETHYLCARBAMZINE CITRATE SUSP 30mg 60mg 200mg/ml 100mg 200mg 200mg 5mg/ml 50mg/ml 5mg 500mg 100mg 750mg/5ml

100ml Packet 1ml amp Vial 10x10 Vial 2ml amp 10x10 2ml amp 5ml amp 10ml amp 50ml amp 10ml amp 10x10 10x10 1ml amp 10x10 10x10 10x10 2ml amp 2ml amp 10x10 10x10 6x10 450ml bottle

100mg 100mg/5ml

10x10 50ml bottle 495

Essential Drugs

11. ANTI FUNGAL DRUGS 122 GRISEOFULVIN TAB IP 123 KETOCONAZOLE TAB IP 124 CLOTRIMAZOLE CREAM IP 125 CLOTRIMAZOLE VAG TAB IP 126 WHITFIELD’S OINTMENT IP 12 ANTIMALARIAL DRUGS 127 CHLOROQUINE PHOSPHATE TAB IP 128 QUININE INJ 129 PRIMAQUINE TAB IP 130 SULFADOXINE & PYRIMETHAMINE TAB IP 131ARTEMETHER INJ 132 ACYCLOVIR INJ 133 ACYCLOVIR TAB 134 ACYCLOVIR CREAM 135 ZIDOVUDINE CAPS 136 LAMIVUDINE TAB 137 INDINAVIR TAB 14. ANTI LEPROTIC DRUGS 138 RIFAMPICIN CAP IP 139 CLOFAZIMINE CAP IP 140 DAPSONE TAB IP 15. ANTI PARKINSONIAN DRUGS 141TRIHEXYPHENIDYL TAB IP 142 CARBIDOPA 10mg LEVODOPA 100mg TAB IP 16. DRUGS AFFECTING THE BLOOD 143 CYANOCOBALAMIN INJ IP 144 FOLIC ACID TAB IP 496 100mcg/ml 5mg 2ml amp 10x10 2mg 10mg/100mg 10x10 10x10 400mg 50mg 50mg 10x10 10x10 10x10 25mg 300mg/ml 7.5mg 500mg+25mg 80mg/ml 250mg 200mg 5%w/w 300mg 150mg 400mg/800mg 10x10 2ml amp 10x10 10x10 1ml amp Vial 10x10 5g tube 10x10 10x10 10x10 125mg 200mg 2%w/w 200mg 15gm 10x10 10x10 5g 3tab tube

13. ANTI VIRAL DRUGS/ANTI RETROVIRALS

Tertiary Hospitals

145 HEPARIN SODIUM INJ IP 146 PHYTOMENADIONE (VIT K1) INJ 147 HYDROXY ETHYL STARCH IV INFUSION 148 HYDROXY ETHYL STARCH 1.V 6% 130000 DALTONS /0.4m 149 DEXTRAN 40 WITH DEXTROSE 5% INFUSION 150 DEXTRAN 40 WITH SODIUM CHLORIDE 0.9% INFUSION 151 GELATIN POLYMER ELECTROLYTE INJ 152 FAT EMULSION I.V 153 AMINOACID+ ELECTROLYTE+ DEXTROSE 154 PROTAMINE SULPHATE INJ 155 WARFARIN SODIUM TAB IP 17. CARDIOVASCULAR DRUGS 156 ISOSORBIDE DINITRATE TAB IP 157 ISOSORBIDE DINITRATE TAB IP

5000 IU/ml 10mg/ml 6% 6%

5ml vial 1 ml amp 500ml 500ml Flexibag 500ml bottle 500ml bottle

0.63 g 30% 500ml 10mg/ml 2mg 5mg 10mg

500ml bottle 300ml bottle Bottle 5ml amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x14 10x14 10x10 10x10 10x10 10x10 497

158 ISOSORBIDE-5-MONONITRATE TAB 10mg 159 ISOSORBIDE -5-MONONITRATE TAB 20mg 160 DILTIAZEM TAB IP 161 NIFEDIPINE TAB IP 162 NIFEDIPINE TAB IP 163 NIFEDIPINE SOFT GELATIN CAP 164 VERAPAMIL TAB IP 165 ATENOLOL TAB IP 166 ATENOLOL TAB IP 167 ENALAPRIL MALEATE TAB 168 METHYL DOPA TAB IP 169 ENALAPRIL MALEATE TAB 170 AMLODIPINE TAB 30mg 20mg 10mg 5mg 40mg 50mg 100mg 2.5mg 250mg 5mg 2.5mg

5mg/2ml 40mg/ml 50mg/ml 25mg 5mg/ml 25mg 50mg 75mg 50mg 100mg 750000 IU 1500000 IU 50mg 1%w/w 25kg 5L 10%w/w 25%w/v 5%w/w 1%w/w 1%w/v 5%w/v 1%w/w 500ml 10x10 10x10 2ml 5ml 5ml Amp 10x10 1ml Amp 10x10 10x10 10x10 10x10 10x10 Vial Vial Vial 100g bottle Drum Can 500gbottle 500ml bottle 500g bottle 25g tab 5g/tube 100mL bottle 500ml bottle 20g tube Bottle .25mg 0. DERMATOLOGICAL DRUGS 186 SILVER SULFADIAZINE CREAM IP 187 GLYCERINE IP 188 LIQUID PARAFFIN IP 189 SALICYLIC ACID OINTMENT 190 BENZYL BENZOATE APPLICATION IP 191 GLYCERINE MAGSULPH BPC 192 POVIDONE IODINE OINTMENT IP 193 BETAMETHASONE VALERATE CREAM 194 GAMMA BENZENE HEXACHLORIDE SOLUTION 195 POVIDONE IODINE SOLUTION 196 FRAMYCETIN SKIN CREAM 197 TURPENTINE LINIMENT IP 498 5mg 0.Essential Drugs 171 AMLODIPINE TAB 172 DIGOXIN TAB IP 173 DIGOXIN INJ IP 174 DOPAMINE HCL INJ USP 175 DOBUTAMINE HCL INJ 176 HYDROCHLOROTHIAZIDE TAB IP 177 METOPROLOL INJ 178 METOPROLOL TAB IP 179 METOPROLOL TAB IP 180 CLOPIDOGREL TAB 181 NICOTINIC ACID TAB IP 182 NICOTINIC ACID TAB IP 183 STREPTOKINASE INJ 184 STREPTOKINASE INJ 185 SODIUM NITROPRUSIDE INJ 18.

PSYCHOTROPIC DRUGS 215 DIAZEPAM TAB IP 216 CHLORPROMAZINE TAB IP 217 CHLORPROMAZINE TAB IP 218 IMIPRAMINE TAB IP 219 AMITRIPTYLINE TAB IP 220 NITRAZEPAM TAB IP 221 ALPRAZOLAM TAB 222 ALPRAZOLAM TAB 250mcg/ml 0.Tertiary Hospitals 19.25mg 0.5%w/v 1%w/v 0.5mg . OPHTHALMIC DRUGS/EAR/NASAL DROPS 198 FRAMYCETIN EYE DROPS 0. OBSETETRICS AND GYNAECOLOGY DRUGS 208 OXYTOCIN INJ IP 5 IU/ml 209 PROSTAGLANDIN INJ 210 METHYLERGOMETRINE MALEATE TAB IP 211 METHYLERGOMETRINE MALEATE INJ 212 NYSTATIN VAGINAL PESSARIES 213 POVIDONE IODINE VAGINAL PESSARIES 214 MAGNESIUM SULPHATE INJ 21.5%w/v 0.1%w/v 1%w/v(250mg/cap) 50/bottle 1ml Amp 1ml Amp 10x10 1ml Amp 10 10 2ml Amp 10x10 10x10 10x10 10x10 10x10 10x10 10x10 10x10 499 20.3%w/w 0.3%w/v 200 CIPROFLOXACIN EYE OINTMENT 201 PILOCARPINE EYE DROPS 202 TIMOLOL MALEATE EYE DROPS 203 TROPICAMIDE EYE DROPS 204 BETAMETHASONE EYE DROPS 206 XYLOMETAZOLINE NASAL DROPS IP 207 CHLORAMPHENICOL APPLICAPS 0.5%w/v 199 CIPROFLOXACIN EYE/ EAR DROPS 0.1%w/v 5ml bottle 5ml bottle 5g tube 5ml bottle 5ml bottle 5ml bottle 5ml bottle 10ml bottle 10ml bottle 205 SODIUM BICARBONATE EAR DROPS BPC 0.125mg 200mcg/ml 100000IU 200mg 500mg/ml 5mg 50mg 100mg 25mg 25mg 5mg 0.

9 % & DEXTROSE 5% w/vINJ IP 237 DEXTROSE INJ IP 238 DEXTROSE INJ IP 239 DEXTROSE INJ IP 240 DEXTROSE INJ IP 241 ELECTROLYTEP INJECTION (PAEDIATRIC) 242 ELECTROLYTE M INJ IP (MAINTENANCE) 243 RINGER LACTATE INJ IP 244 MANNITOL INJECTION IP 246 POTASSIUM CHLORIDE INJ IP 23.9%/5%w/v 5%w/v 10%w/v 50%w/v 25%w/v 500ml 500ml 500ml 20%w/v 10% w/v 245 STERILE WATER FOR INJECTION IP 10ml 7.9% w/v 236 SODIUM CHLORIDE 0.V FLUIDS AND ELECTROLYTES 235 SODIUM CHLORIDE INJ IP 0. DISINFECTANTS & ANTISEPTICS 247 CHLORHEXIDINE/ CETRIMIDE SOLUTION 248 SURGICAL SPIRIT 500 0. I.Essential Drugs 223 FLUOXETINE CAP 224 FLUOXETINE CAP 225 HALOPERIDOL TAB 226 CHLORDIAZEPOXIDE TAB 227 HALOPERIDOL LIQUID 228 HALOPERIDOL INJ 229 FLUFENAZINE DECANOATE INJ IP 230 CLOZAPINE TAB 231 CLOZAPINE TAB 232 CITALOPRAM TAB 233 LITHIUM CARBONATE TAB 234 SERTRALINE TAB 10mg 20mg 5mg 10mg 2mg/ml 5mg/ml 25mg/ml 25mg 100mg 20mg 150mg 50mg 10x10 10x10 10x10 10x10 30ml bottle 1ml Amp 1ml amp 10x10 10x10 10x10 10x10 10x10 500ml bottle 500ml bottle 500ml bottle 500ml bottle 25ml Amp 25ml amp Bottle Bottle Bottle 250ml bottle Amp 10ml Amp 22.5%/15%w/v 70%v/v 1L bottle 500ml bottle .

T DRUGS 257 RANITIDINE HCL INJ IP 258 RANITIDINE HCL TAB IP 259 ALUMINIUM HYDROXIDE TAB IP 260 OMEPRAZOLE CAP 261 METOCLOPRAMIDE INJ 262 METOCLOPRAMIDE TAB 263 METOCLOPRAMIDE INJ 264 DOMPERIDONE TAB 265 DICYCLOMINE HCL TAB IP 266 DICYCLOMINE HCL INJ IP 267 DICYCLOMINE ORAL SOLUTION 268 ORS POWDER WHO. DIURETICS 253 FRUSEMIDE TAB IP 254 FRUSEMIDE INJ IP 255 SPIRONOLACTONE TAB IP 256 SPIRONOLACTONE TAB IP 25.5g 5mg 2mg/ml 667mg/ml 1L bottle 500ml bottle 1L bottle 5L bottle 10x10 2ml Amp 10x10 10x10 2ml amp 10x10 10x10 10x10 2ml amp 10x10 10ml vial 10x10 10x10 2ml Amp 30ml bottle Packet 10x10 500ml bottle 2ml Amp 100ml bottle 10x10 10x10 10x10 501 270 CARMINATIVE MIXTURE (CPC FORMULA) 26.Tertiary Hospitals 249 HYDROGEN PEROXIDE SOLUTION IP 250 POVIDONE IODINE SCRUB 251 CHLOROXYLENOL SOLUTION IP 252 CHLOROXYLENOL SOLUTION IP 24. WITH CITRATE SALT 269 BISACODYL TAB IP 271 ONDANSETRON INJ 272 SYRUP LACTULOSE 20%w/v 7.I.5mg 500mg . HORMONES AND ENDOCRINE DRUGS 273 GLIBENCLAMIDE TAB IP 5mg 274 GLIBENCLAMIDE TAB IP 275 METFORMIN TAB 2.5%w/v 5%w/v 5%w/v 40mg 10ml/ml 25mg 100mg 50mg/2ml 150mg 500mg 20mg 5mg/ml 10mg 5mg/ml 10mg 10mg 10mg/ml 10mg/ml 27.G.

ORAL 20 doses 291 TRIPLE ANTIGEN IP 0. RAPID ACTING IP 40 IU/ml 278 INSULIN BOVINE. HUMAN 150 IU/ ml 293 I. 28. LONG ACTING IP 40 IU/ml 279 INSULIN HUMAN.5 ml / dose 292 ANTIRABIES IMMUNOGLOBULIN.V. 10 x 10 302 VITAMIN A & D CAP (HARD/SOFT) 6000 IU/ 1000 IU 10 x 10 . NFI 299 ASCORBIC ACID TAB IP 300 CALCIUM GLUCONATE INJ.5 ml.5 ml Amp 2 ml Amp. 100 mg.1mg 50mg IMMUNOLOGICALS TETANUS TOXOID INJ IP/BP 10 dose TETANUS IMMUNOGLOBULIN USP 250 IU HUMAN ANTI D IMMUNOGLOBULIN USP 250 mcg 286 ANTI SNAKE VENOM FREEZE DRIED POLYVALENT 10 ml 287 RABIES VACCINE HUMAN. CELL CULTURE 250 IU 288 HEPATITIS B VACCINE IP 10 mcg / ml 289 HEPATITIS B VACCINE IP 20 mcg / ml 290 POLIO VACCINE. 10 ml 0.Essential Drugs 276 GLIPIZIDE TAB 5mg 10x10 Vial Vial Vial Vial 10x10 10x10 5 ml Vial Vial Vial vial vial 0. Amp. RAPID ACTINE 280 INSULIN HUMAN LONG ACTING 281 THYROXINE SODIUM TAB IP 282 PROPYLTHIOURACIL TAB 27 283 284 285 40 IU/ml 40 IU/ml 0. vial vial vial 10 x 10 10x 10 277 INSULIN BOVINE. 1 ml Amp. IP 301 MULTIVITAMIN TAB NFI 502 10 ml.5 ml Amp. 10 % w / v 10 x 10 10 ml. 294 BCG VACCINE IP 295 MMR VACCINE 0. 297 VITAMIN B COMPLEX TAB NFI (STRONG) 298 VITAMIN B COMPLEX INJ.GAMMA GLOBULIN 2. Amp. VITAMINES & MINERALS 296 CALCIUM LACTATE TAB IP 300 mg.5 g.

67 ml vial 260 mg/43. 50 mg. 100 mg/16. 326 AMIFOSTINE INJ. bottle vial vial vial vial 10 x 10 50 caps 10 x 10 10 x 10 vial 2 ml. 307 IOHEXOL INJ.Tertiary Hospitals 303 FERROUS SULPHATE TAB IP 304 THIAMINE HCL INJ. 500 mg. 5 x20 ml. 5x20 ml. ANTICANCER DRUGS & IMMUNO SUPPRESSIVES 311 MITOMYCIN C INJ. 322 CISPLATIN INJ IP 323 CISPLATIN INJ IP 324 ETOPOSIDE INJ 325 LEUCOVORIN CALCIUM INJ. 50 mg. IP 29./10 ml. 50 mg./50 ml. 327 PACLITAXEL INJ 328 PACLITAXEL INJ 1 mg. 308 SODIUM& MEGLUMINE DIATRIZOATE INJ 309 SOD & MEGLUMINE DIATRIZOATE INJ 310 BARIUM SULPHATE SUSPENSION IP 200 mg./ml 240 mg. 10 mg./ml 300 mg. 306 IOHEXOL INJ. 20 ml. 350 mg /ml 60% 76% 10 x 10 1 ml/Amp. 50 ml. USE) 200 mg. 100 mg/5 ml.5 mg 15 mg. IP 313 CYCLOPHOSPHOMIDE INJ IP 314 CYCLOPHOSPHOMIDE INJ IP 315 BUSULPHAN TAB IP 316 CYCLOSPORIN CAP 317 AZATHIOPRINE TAB IP 318 METHOTREXATE TAB IP 319 BLEOMYCIN INJ 320 METHOTREXATE INJ IP 321 L-ASPARAGINASE INJ. 20 ml. Amp. 312 VINCRISTINE SULPHATE INJ. 100 mg. 2./ml./ 1 ml (I./2 ml 10000 KU 50 mg./5ml 500 mg.V. vial vial vial vial vial vial 30. USP 10 mg. 2mg 25 mg. 500 ml.34 ml vial 503 . DIAGNOSTIC AGENTS 305 IOHEXOL INJ.

RTI + STI treatment + control 7. Urban Health 8./5ml 100 mg 500 mg. 3 MIU 5 MIU 10 mg. 504 . 500 mg 50 mg. Child Health 5. Condoms iii. Maternal Health 3. Adolescent Health 6. POPULATION STABILIZATION 5 modern contraceptive options i. IUDs iv . REPRODUCTIVE CHILD HEALTH (RCH) 1952-1956 Family Planning Programme 1977 National Family Welfare Programme 1992 CSSM 1997-2002 RCH – 1 (CSSM + STI + RTI Component) 2004-2009 RCH – II Components of RCH – II 1. OCP ii. Tribal Health I. vial vial vial vial 10 x10 vial vial vial 10 x 10 330 DAUNORUBICIN(LYOPHILISED) INJ 20 mg B NATIONAL HEALTH PROGRAMMES OF INDIA 1. Emergency Contraception : 2 types. Sterlization v . New born care 4. Population stabilization 2.Essential Drugs 329 PACLITAXEL INJ 331 CYTOSINE ARABINOSIDE INJ 332 CYTOSINE ARABINOSIDE INJ 333 HYDROXY UREA TAB 334 DOXORUBICIN HCL INJ 335 INTERFERON ALPHA – 2 A INJ 336 INTERFERON ALPHA – 2 B INJ 337 TAMOXIFEN TAB 30 mg.

persistent vomiting Assess main symptoms Cough/difficult breathing. ear problems. CHILD HEALTH 1.75 mg levonorgestrel (2 tab) 1st tab within 72 hours of unprotected intercourse 2nd tab 12 hours after 1st tab. IUD within 5 days of unprotected intercourse.convulsions. fever. Check for danger signs . unconsciousness. inability to drink/breast feeding.Child Health 1. ↓ ↓ ↓ ↓ ↓ ↓ ↓ Assess Nutrition and immunisation status and potential feeding problem Check for other problem Classify conditions and identify Treatment Action according to colour coding PINK Urgent Referral ↓ YELLOW Treatment of OPD Treat local infection GREEN Home management ↓ Flow chart for line of action of a health worker on observing a sick child 505 . II. lethargy. Progesterone only pill 0. IMNCI / Integrated management of neonatal and childhood illness OPD HEALTH FACILITY. 2. diarrheoa.

In Severe Dehydration: always use i. Common signs of dehydration are increased thirst. In severe dehydration there will be obtundation. fluids. New: Low osmolarity ORS Management of diarrhoeas according to Diarrhoea control Programme. drytongue and decreased skin turgor. 1/2 glass for children upto 2 years and 1 glass for older children. coconut water or buttermilk can be used.In mild diarrhoea child has none of the signs described above and the main goal of treatment is to replace ongoing losses using homemade Fuids like salted kanji water or ORAL REHYDRATION SOLUTION (ORS).National Health Programme 2) Diarrhoea control Programme and ORS programme. In moderate dehydration: ORS/IV fluids will be required. floppy limbs.v. restlessness. Breast feeding to be continued. In cholera much more fluid will be required and constant monitoring of hydration is essential. Shock. Use cup and spoon to give ORS. acidosis and marked oliguria by themselves are indicative of severe dehydration. Dose: 1 packet of ORS dissolved in 1 L (5glass) of potable water (boiled and cooled).For older children 100mL/kg should be given in 4 h . Breast feeding should be continued in small frequent feeds. About100 mL/kg ORS is given in 4 h.ORS and feeding can be started at the 506 . IV fluids are used in similar lines for the treatment of severe dehydration (see below) except the initial emergency phase can be omitted.(100mL/ kg in 6 h). Best treatment for dehydration is Oral Rehydration Therapy by Oral Rehydration Salt solution. Offer plain boiled water in between ORS in those who are not breast fed.Add KCL 20mEq/L as soon as child passes urine. low volume pulse and oliguria. Dextrose saline may be used instead to prevent hypoglycaemia. After each motion give ORS 50mL (¼ glass) for infants <6months. Home made fluids like salted rice water. Ringer lactate or Normal saline is used initially Dose: 30mL/kg in first 1h followed by 70mL/kg over next 5 h.

Cotrimoxazole or Erythromycin. Dose: First 10 kg .v. slowly in severe acidosis. DIARRHOEA AND DEHYDRATION eg. Use 7.100 mL/kg/24 h.12 kg Mild Moderate None 500 mL Fluid replacement as ORS 1/2 glass=100mL after each stool In first 4 h. Lethargic >1000 mL Floppy Cold extremities Rapid thready pulse Severe IV Fluid required 1st 6 hour 100mL/kg Ringer lactate / N saline 1st hr 30 mL/kg Next 5hr 70mL/ kg thereafter maintenance fluid if required. 1 year old weighing 10 kg Symptoms & signs Fluid deficit eg. Ongoing losses also should be replaced. The i. 507 . fluid can then be changed to maintenance fluid if required eg. 2 mL/ kg diluted with equal amount of distilled water or 5% dextrose i. drug given is Ciprofloxacin.In Shigella infection. Zinc supplementation decreases episode.20 mg Zinc for children >6 months of age. l0—20 kg Above 20 kg -1000 + 50 mL/additional kg over 10 kg. -1500 + 20 mL/kg for additional kg over 20 kg.v.In Cholera drugs given are Doxycycline. Antidiarrhoeals are contra indicated.Dose is 10 mg Zinc for infants less than 6 months of age. Antibiotics are not necessary except in invasive diarrhoea characterised by blood in stools due to Shigella infection or in cases of Typhoid or Cholera.5% soda bicarb.duration and severity. Tetracycline.2 yr old Wt. 600-800mL (3 to 4 glasses of ORS) Restless 500-1000mL Thirst increased Skin turgor Dry mouth. Isolyte P Holiday and Segar Formula is generally used to calculate maintenance requirement as given below.Diarrhoea Control Programme end of 6h as the signs of dehydration disappears by this time.

5 mg/Dose x 8 hourly Very Severe Pneumonia • Inability to drink.National Health Programme 3. Classification No Pneumonia Pneumonia Therapy Symptomatic / home remedy Cotrimoxazole oral (sulphmethoxazole 100 mg and Trimethoprim 20 mg) for 5 days Respiratory Rate/minute > 60 > 50 > 40 One Tablet BD Two Tablets BD Three Tablets BD Patient should be hospitalized Where to treat At Home At Home or Health facility Age in month <2 2 -12 12 – 60 Severe Pneumonia Antibiotics IM 50000 IU/kg/Dose 6 hourly OR Inj: Ampicillin 50 mg /kg/Dose Chest in-drawing Injection Benzyl Pencillin + Inj: Gentamicin 2. • Excessive drowsiness h/o of apnoea Chloromphenical cyanosis/ orally or IM convulsions 25 mg/kg/dose 6 hourly Must always be admitted and treated at health facility with provision of oxygen • • Stridor in calm child Hypothermia Respiratory severe Grunting malnutrition 4. Acute Respiratory Infection control Programme. National Programme for prophylaxis against Blindness in children caused due to vit A deficiency Starting at 9 months with measles as a first dose (1Lac1U) then at 15 months a second dose (2 Lac 1U) then every 6 months (2 Lac 1U) till the age of 5 years. Total doses = 9 508 . Management of ARI.

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

4 & 7 months _ 2 + II Sputum smear +ve Relapse Sputum smear +ve Failure Sputum smear +ve Treatment after default 2(HRZES)3 _ Start continuation phase test sputum at 5 & 6 months Continue intensive phase for 1 more month.test Sputum at 3. test sputum at 6 months + 4(HR)3 Re-register the patient and begin category II treatment H : ISONIAZID 600 mg Z: PYRAZINAMIDE 1500 mg S: STREPTOMYCIN 750 mg Patient weight > 60 kg Patient > 50 years old 510 R: RIFAMPICIN ( 450 mg) E: ETHAMBUTOL (1200 mg) Receive additional Rifampicin 150 mg Receive Streptomycin 500 mg . 6 months Continue intensive phase 1 more month + 2 + Seriously ill Sputum Smear –ve Seriously ill Extra pulmonary 4 (HR)3 _ Start continuation phase test sputum at 6 months Continue intensive phase for 1 month.6 & 9 months 1(HRZE)3 + 3 + 5 (HRE)3 III New Sputum Smear –ve not seriously ill New Extra pulmonary Not seriously ill _ 2(HRZ)3 _ 2 Start Continuation phase. test sputum at 4.test sputum again at 4.National Health Programme Treatment categories and sputum examination schedule in DOTS TREATMENT REGIMEN SPUTUMEXAMINATIONSFORPULMONARYTB PreTreatment Sputum Category of Treatment I Type of Patient New Sputum Smear Positive Regimen If Month result is _ Then 2(HRZE)3 Start continuation Phase.

Microscopically positive PV cases (plasmodium Vivax) should be treated with chloroquine in full therapeutic dose of 25 mg/kg body weight over 3 days.75 mg / kg body weight on the 1st day. 4. Kala-azar.25 mg / kg 511 . Filarial. Para aminosalicylic acid (PAS) is included in the regimen as a substitute drug if any bactericidal drug (K. Microscopically positive PF cases (Plasmodium Falciparam) should be treated with chloroquine in therapeutic dose of 25 mg / kg body weight over 3 days and single dose of primaquine 0.Ofl. Malaria. ethambutol and cycloserine) during 6 -9 months of Intensive phase and 4 Drugs (ofloxacin. Japanese Encephalitis. pyrazinamide. Primaquine can be given in dose of 0. ethionamide. 3. Resistant to these formulation and severe and complicated malaria Quinine will be the drug of choice. ethionamide. All fever cases should preferably be investigated for malaria by Microscopy or Rapid Diagnotic kit (RDK) 2. Z and Eto) or any 2 bacteriostatic (E and Cs) drugs are not tolerated.National TB Control Programme DOTS PLUS STRATEGY: Treatment of Multi Drug resistant TB Standardised treatment regimen (STR) comprising of 6 drugs – kanamycin. ofloxacin. Dengue fever and Dengue haemorrhagic fever and Chikungunya fever. ethambutol and cycloserine) during 18 months of the continuation phase. Malaria Drug Policy 2007 1. The first line of treatment is chloroquine and the 2nd line is ACT (Artesunate + sulpha pyrimethamine) combination. Drugs < 45 kg > 45 kg Kanamycin 500 mg 750 mg Ofloxacin 600 mg 800 mg Ethionamide 500 mg 750 mg Ethambutol 800 mg 1000 mg Pyrazinamide 1250 mg 1500 mg Cycloserine 500 mg 750 mg PAS 10 mg 12 g All drugs should be given in a single daily dosage under directly observed treatment (DOT) by a DOT Provider NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME 2004 This Programme for control of 6 diseases namely.

Chemoprophylaxis for selected cases: Given for (1) Pregnant woman in high risk areas (2) Travellers In Chloroquine sensitive areas. 512 . This is to continue till one month after delivery in case of pregnancy and in travellers till one month after return from endemic area. 6.Vivax ie: 25 mg/ kg bw over 3 days alone with 0.25 mg / kg bw of primaquine for 14 days under medical supervision. Start with loading dose of 10 mg/kg bw and followed by a weekly dose of 5 mg/kg bw.25 mg per kg bw of pyrimethamine on the 1st day. Quinine salt:10 mg/kg bw 8 hourly in 5% Dextrose saline. In chloroquine resistant areas: Chloroqine 5 mg/kg bw weekly + Proguanil 200 mg daily. 5. Oral dose10 mg/kg bw 8 hourly not exceeding 2 gm in a day in any case. The terminating dose should be radical treatment for P. Chemoprophyl axis is to be started a week before arriving to malarious area for visitors and for pregnant women prophylaxis should be initiated from 2nd trimester. Patients should be switched over to oral quinine as early as possible. weekly dose of chloroquine will be given but in chloroquine resistant areas it should be supplemented by daily dose of proguanil. 7. Total duration of a quinine therapy 7 days including both parenteral and oral doses. Primaquine may not be given with ACT combination as Artesunate reduces gametocyte carriage. Chemoprophylaxis should not exceed 3 years due to the cumulative toxic effects of chloroquine.National Health Programme body weight daily for 14 days under medical supervision only to prevent relapse. Severe and complicated malaria cases In severe and complicated malaria of PF (clinically / microscopically/ confirmed) parenteral artemisinin or quinine is the drug of choice. irrespective of chloroquine resistance status of area. Treatment of PF in chloroquine resistant areas: DOC : ACT 4 mg/kg bw of artesunate daily for 3 days + 25 mg/kg bw of sulphadoxine/ sulphalene + 1.

IV Benzyl Penicillin is given initially and then switched to oral Phenoxymethyl Penicillin. Albendazole – 400 mg 1 Tab It is administered once a year for a total of 5 years.6 mg/kg bw IM followed by 1. may be used for the management of severe and complicated malaria (for adults and non pregnant only) Dose: Artesunate 2. Chemoprophylaxis should be started immediately or within 4 hours Chemoprophylaxis should be monitored on 1.National Filaria Control Programme Injectable form of artemisinin derivative. 6 – 14 years – 100 mg – 2 Tabs 15 years and above – 100 mg – 3 Tabs. Pregnancy.4 mg/kg bw IM/IV followed by 1. 3. NATIONAL AIDS CONTROL PROGRAMME Post Exposure Prophylaxis: Recommended steps following HIV exposure: 1.2 mg/kg bw once daily for total duration of 5 days. CI -< 2 years. Rapid HIV testing facilities should be available.2 mg/kg bw after 12 hours then 1. 2.36. Disability management: Analgesic like Paracetamol.48 and 60 hours.Antifilarial drugs are not given in acute stage.6 mg/kg bw IM injection twice daily for 3 days a total of 6 injection.If allergic to Penicillin Erythromycin is given.If allergic to penicillin Erythromycin is given.Antibiotics like Amoxicillin are given.3 and 6 months interval 513 . 100 mg 2-5 years – 100 mg – 1 Tab.Antifungal creams are given for topical application.In severe cases. Exposure with HIV should be considered as a medical emergency. Artemisinin 10 mg/kg bw at 0 and 4 hours followed by 7 mg/kg bw at 24.6 mg/kg bw daily for total of 6 injections or 1. NATIONAL FILARIA CONTROL PROGRAMME Mass Drug Administration (MDA) Drugs Administered are DEC (Diethyl Carbamazine) and Albendazole Dose: DEC Adult Dose – 6 mg/kg single dose DEC Preparations available Tab 50 mg. Artemether 1. Arteether 150 mg daily IM for 3 days in adults only. 3. seriously ill persons and elderly.

of blood and blood with Offer . ZDV + 3 Lamivudine .. J.Kishore. of blood but may be having low titres or blood with high titres only but may not exposed to large vol. Increased Risk large vol. ZDV + 3 Lamivudine+ Indinavir/Saquinavir ZDV + 3 Lamivudine Recommended . Ref: National Health Programme of India 5th Edition. ZDV + 3 Lamivudine + Indinavir/ Saquinavir ZDV + 3 Lamivudine both large Vol. ZIDUVUDINE (ZDV) : 300 mg BD X 4 weeks LAMIVUDINE : INDINAVIR : SAQUINAVIR : 150 mg BD X 4 weeks 800 mg Thrice Daily 600 mg Thrice Daily.National Health Programme Drugs recommended in different types of exposures: EXPOSURE PROPHYLAXIS ANTIRETROVIRAL REGIMEN Percutaneous Blood Highest risk Increased risk Body fluid Mucous Membrane Blood Body fluid Skin Blood Body fluid Blood with highest Risk high titres of HIV Offer . Community Medicine Park and Park 514 . Offer Offer ZDV + 3 Lamivudine+Indinavir/ Saquinavir .....

it isimportant to treat the mother whenever needed while protecting the unborn to the greatest possible extent. and may also affect the unborn child. Consequently. Such approaches may impose risk to maternal well-being.Folic acid supplements should be given during pregnancy planning because periconceptual use of folic acid reduces neural tube defects 515 . During the first trimester drugs may produce congenital malformations (teratogenesis). Major congenital malformations occur in 2-4% of all live births. Prescribing in pregnancy lf possible counselling of women before a planned pregnancy should be carried out including discussion of risks associated with specific therapeutic agents. Up to 15% of all diagnosed pregnancies will result in fetal loss. It is important to know the “background risk’ in the context of the prevalence of drug-induced adverse pregnancy outcomes. Few drugs have been shown conclusively to be teratogenic in man but no drug is safe beyond all doubt in early pregnancy. lt is important to remember this when prescribing for a woman of childbearing age or for men trying to father a child. Drugs can have harmful effects on the fetus at any time during pregnancy. Drugs given shortly before term or during labour may have adverse effects on labour or on the neonate after delivery. traditional medicines and abuse of substances such as nicotine and alcohol. Maternal well being is an absolute prerequisite for the optimal functioning and development of both parts of this unit. and the greater risk is from third to the eleventh week of pregnancy. suboptimal treatment and treatment failures. However. impaired maternal compliance.APPENDIX 1 PREGNANCY During pregnancy the mother and the fetus form a non-separable functional unit. This includes untreated illness. ’The cause of these adverse pregnancy outcomes is understood in only a minority of the incidents. irrational fear of using drugs during pregnancy can also result in harm. During the second and third trimester drugs may affect the growth and functional development of the fetus or have toxic effects on fetal tissues. Screening procedures are available where there is a known risk of certain defects.

The following list includes drugs which may have harmful effects in pregnancy and indicates the trimester of risk lt is based on human data but information on animal studies has been included for some drugs when its omission might be misleading. delayed onset and increased duration of labour with increased blood loss. All drugs should be avoided if possible during the first trimester. occasional single drinks are probably safe Aciclovir Albendazole Alcohol 516 . with high doses.Drugs should be prescribed in pregnancy only if the expected benefits to the mother are thought to be greater than the risk to the fetus. avoid analgesic doses ifpossible in last few weeks (low doses probably not harmful). Table of drugs to be avoided or used with caution in pregnancy Medicine Comment Acetylsalicylic acid Third trimester: Impaired platelet function and risk of haemorrhage. Well known single component drugs should usually be preferred to multi-component drugs. closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of newborn. second trimesters: Regular daily drinking is teratogenic (fetal alcohol syndrome) and may cause growth retardation. kernicterus in jaundiced neonates Not known to be harmful. Absence of a medicine from the list does not imply safety. limited absorption from topical preparations Contraindicated in cestode infections First trimester: avoid in nematode infections First. Drugs which have been used extensively in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs and the smallest effective dose should be used.

outweighs risk Not known to be harmful Third trimester: With large doses. use only if potential benefit outweighs risk Manufacturer advises . neonatal respiratory depression. for example in asthma.avoid unless essential. hypotonia. and bradycardia after 517 Amitriptyline Amoxyillin Arnoxycillin + Clavulanic acid Amphotericin B Ampicillin Artcmether Artcmether + Lumefantrine Artesunate Atenolol Atropine Azithromycin Beclomethasone Betamethasone Benzathine Benzylpenicillin Bupivacaine . neonatal hypoglycaemia. risk geater in severe hypertension Not known to be harmful Limited information available—use only if adequate altematives not available Benefit of treatment. and bradycardia. particularly during first and third trimesters Not known to be harmful Not known to be harmful Not known to be harmful but use only if potential benefit outweighs risk Not known to be harmful First trimester: Avoid First trimester: Avoid First trimester: Avoid May cause intrauterine growth restriction.Third trimester: Withdrawal may occur in babies of alcoholic mothers Alcuronium Does not cross placenta in significant amounts.

risk of intrauterine growth retardation on prolonged or repeated systemic treatment. withdrawal effects in neonates of dependent mothers. outweighs risk.paracervical or epidural block. third trimesters: Benefit of prophylaxis and treatment in malaria outweighs risk Third trimester: Extrapyramidal effects in neonate All trimesters: Avoid—arthropathy in animal studies. use only if clear Cefazolin Cefixime Ceftazidime Ceftriaxone Chlorarnphenicol Chloroquine Chlorpromazine Ciprofloxacin Clomifene Cloxacillin Codeine Dapsone Dexamethasone Diazepam 518 . Possible effects on fetal development Not known to be harmful Third trimester: Depresses neonatal respiration. lower doses of bupivicaine for intrathecal use during late pregnancy Carbamazepine First trimester: Risk of teratogenesis including increased risk of neural tube defects Not known to be harmful Not known to be harmful Not known to be harmful Not known to be harmful Third trimester: Neonatal ‘grey baby’ syndrome First. for example in asthma. gastric stasis and risk of inhalation pneumonia in mother during labour Third trimester: Neonatal haemolysis and methaemoglobinaemia. Benefit of treatment. Avoid regular use (risk of neonatal withdrawal symptoms).

risk of neonatal withdrawal Third trimester: Extrapyramidal effects Second. also possible skull defects and oligohydramnios. maternal hepatotoxicity Avoid (potential teratogenic effects) All trimesters: Avoid. third trimesters: Dental discoloration. Manufacturer advises use only if potential benefit outweighs risk. may adversely affect fetal and neonatal blood pressure control and renal function. increased risk of lactic acidosis and hepatic steatosis Avoid First trimester: Effects on skeletal development Second. Third trimester: Extrapyramidal effects in neonate Third trimester: Depresses neonatal respiration 519 Efavirenz Enalapril Erythromycin Ethambutol Ethinylestradiol Fluconazole Flucytosine Fluoxetine Fluphenazine Gentamicin Glibenclamide Griseofulvin Haloperidol Halothane . third trimesters: Auditory or vestibular nerve damage. Avoid (fetotoxicity and teratogenicity in animals). Not known to be harmful Not known to be harmful no harmful effects on fetus Avoid (multiple congenital abnormalities reported with long-term high doses) Teratogenic in animal studies. Third trimester: Neonatal hypoglycaemia.indication such as seizure control (high doses during late pregnancy or labour may cause neonatal hypothermia. hypotonia and respiratory depression) Didanosine Diethylcarbamazine Doxycycline Avoid in first trimester.

third trimesters: Neonatal goitre and Hypothyroidism Not known to be harmful Not known to be harmful Monitor maternal serum-thyrotrophin concentration—levothyroxine may cross the placenta and excessive dosage can be detrimental to fetus. outweighs risk. no reports of serious harm following use in third trimester Not used to treat hypertension in pregnancy Third trimester: May cause neonatal thrombocytopenia Benefit of treatment. hypotonia. risk of intrauterine growth retardation on prolonged or repeated systemic treatment. theoretical risk of hyperbilirubinaemia and renal stones in neonate if used at term. Second. corticosteroid cover required by mother during labour. Avoid unless potential benefit outweighs risk Third trimester: With regular use closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of the newborn. Avoid during first and second trimesters.Heparin Hydralazine Hydrochlorothiazide Hydrocortisone Ibuprofen Indinavir All trimesters: Maternal osteoporosis has been reported after prolonged use. neonatal respiratory depression. and bradycardia alter paracervical or epidural block Iodine Ipratropium Isoniazid Levothyroxine Lidocaine 520 . Third trimester: With large doses. for example in asthma. Delayed onset and increased duration of labour Avoid if possible in first trimester.

Third trimester: Neonatal haemolysis and methaemoglobinaemia. neonate should be monitored closely for signs of bleeding First. insulin is normally substituted Not known to be harmful Not known to be harmful Avoid high-dose regimens Third trimester: Depresses neonatal respiration.Magnesium sulfate Third trimester: not known to be harmful for short-term intravenous administration in eclampsia but excessive doses may cause neonatal respiratory depression Avoid (genital malformations and cardiac defects reported in male and female fetuses). gastric stasis and risk of inhalation pneumonia in mother during labour Not known to be harmful First. risk of teratogenicity greater if more than one antiepileptic used. May possibly cause vitamin K deficiency and risk of neonatal bleeding. third trimesters: Congenital malformations (screening advised). risk of teratogenicity greater if more than one antiepileptic used. if vitamin K not given at birth. (withdrawal effects in neonates of dependent mothers. risk of neonatal bleeding. inadvertent use of depotmedroxyprogesterone acetate contraceptive injection in pregnancy unlikely to harm fetus All trimesters: Avoid. 521 Medroxyprogesterone Metformin Methyldopa Metoclopramide Metronidazole Morphine Paracetamol Phenobarbital Phenytoin Primaquine . third trimesters: Congenital malformations.

and bradycardia. risk greater in severe hypertension Second. high doses should be given by inhalation only. third trimesters: Neonatal goitre and hypothyroidism Use only if potential benefit outweighs risk Third trimester: Neonatal myasthenia with large doses First trimester: teratogenic High doses are Propylthiouracil Pyrazinamide Pyridostigmine Quinine Ranitidine Retinol Rifampicin Salbutamol Not known to be harmful First trimester: Excessive doses may be teratogenic. decreased synthesis of cholesterol possibly affects fetal development All trimesters: Possibility of premature separation of placenta in first 18 weeks. theoretical possibility of fetal haemorrhage throughout pregnancy. parenteral use can affect the myometrium and possibly cause cardiac problems Avoid — congenital anomalies reported. third trimesters: Auditory or vestibular nerve damage First trimester: Teratogenic risk Third trimester: Neonatal haemolysis and Simvastatin Streptokinase Streptomycin Sulfamethoxazole + Trimethoprim 522 . risk of maternal haemorrhage on postpartum use Second.Propranolol May cause intrauterine growth restriction. First trimester: Very high doses teratogenic in animal studies Appropriate to use for asthma. neonatal hypoglycaemia.

fetal and neonatal haemorrhage Avoid if possible in first trimester. fear of increased risk of kernicterus in neonates Suxamethonium Tamoxifen Testosterone Tetracycline Mildly prolonged maternal paralysis may occur Avoid—possible development. benefit of treatment considered to outweigh risk in second and third trimesters Avoid . Measles Vaccine.teratogenic Thiopental Trimethoprim Vaccine. MMR Vaccine. Influenza Vaccine. third trimesters: Dental discoloration Third trimester: Depresses neonatal respiration. Rubella Vaccine. may inhibit labour All trimesters: Congenital malformations. effects on fetal All trimesters: Masculinization of female fetus First trimester: Effects on skeletal development Second. Varicella Verapamil Warfarin Zidovudine All anti malignant drugs 523 . dose should not exceed 250 mg First trimester: Teratogenic risk (folate antagonist) Not known to be harmful First trimester: Theoretical risk of congenital malformations Avoid. pregnancy should be avoided for l month after immunization Avoid. pregnancy should be avoided for 3 months after immunization May reduce uterine blood flow with fetal hypoxia.methaemoglobinaemia. pregnancy should be avoided lor l month after immunization Avoid.

iodides) may exceed the concentration in the maternal plasma so that therapeutic doses in the mother may cause toxicity to the infant. may be given to the mother during breastfeeding. Some drugs inhibit lactation (for example. cause hypersensitivity in the infant even when the concentration is too low for a pharmacological effect.Toxicity to the infant can occur if the drug enters the milk in pharmacologically significant quantities.APPENDIX 2 BREAST FEEDING Administration of some drugs (for example. at least theoretically. phenobarbital). Infants should be exclusively breastfed for the first 6 months of life. absence from the table does not imply safety.Because of the inadequacy of information on drugs in breast milk the following table should be used only as a guide. The concentration in milk of some drugs (for example. The following table lists drugs: • • which should be used with caution or which are contraindicated in breastfeeding for the reasons given above which. because they appear in milk in amounts which are too small to be harmful to the infant. whereas administration of others (for example digoxin) has little effect. estrogens). WHO POLICY. ergotamine) to nursing mothers may harm the infant. on present evidence. thereafter they should receive appropriate complementary food and continue to be breastfed up to 2 years of age or beyond.Some drugs inhibit the infant’s sucking reflex (for example. • For many drugs insufficient evidence is available to provide guidance and it is advisable to administer only drugs essential to a mother during breastfeeding.Drugs in breast milk may. which are not known to be harmful to the infant although they are present in milk in significant amounts. 524 .

safe in usual dosage. possible risk of Rey syndrome Significant amount in milk after systemic administration. monitor infant Continue breastfeeding. use altemative drug if possible. regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infant if neonatal vitamin K stores low. adverse effects possible . monitor infant. amount probably too small to be harmful. Trace amounts in milk. but considered safe to use A Large amounts may affect infant and reduce milk consumption Detectable in breast milk.Table of medicines present in breast milk Medicine Comment Acetylsalicylic acid Short course safe in usual dosage. Continue breast -feeding. continue breastfeeding. inadequate for 525 Acyclovir Alcohol Amitriptyline Artemether + Lumefantrine Beclomethasone Betamethasone Benzylpenicillin Carbamazepine Cefazolin Cefixime.monitor infant for drowsiness Excreted in low concentrations. Ceftazidime Ceitriaxone Safe in usual dosage Chloramphenieol Chloroquine . may cause bone-marrow toxicity in infant. safe in usual dosage.adverse effects possible. Systemic effects in infant unlikely with matemal dose of less than equivalent of prednisolone 40 mg daily. monitor infant for drowsiness Discontinue breastfeeding during and for 1 week after stopping treatment.concentration in milk usually insufficient to cause ‘grey syndrome For malaria prophylaxis.

use altemative drug if possible (absorption and therefore discoloration of teeth in infant probably usually prevented by chelation with calcium in milk) Caution with high doses. continue breastfeeding. may cause hypercalcaemia in infant Only small amounts in milk . continue breastfeeding. may inhibit lactation Significant amount in milk. monitor infant for drowsiness Continue breastfeeding. use altemative drug if possible Limited information available. avoid breastfeeding when used for rheumatic disease Chlorpromazine Ciprofloxacin Clofazimine Continue breastfeeding. monitor infant for jaundice Continue breastfeeding.reliable protection against malaria. monitor infant Clomifene Oral contraceptives Dapsone Diazepam Doxycycline Ergocalciferol Erythromycin Ethambutol Ethinylestradiol Ethosuximide Fluconazole 526 . adverse effects possible. monitor infant for drowsiness safe in usual dosage. adverse effects possible. can cause reversible skin discoloration in nursing infant May inhibit lactation May inhibit lactation Although significant amount in milk risk toinfant very small. monitor infant for drowsiness Continue breastfeeding. adverse effects possible.not known to be harmful Amount too small to be harmful Use alternative method of contraception.

avoid breastfeeding during toxoplasmosis treatment Breastfeeding contraindicated 527 Isoniazid Ivermectin Levamisole Levodopa + carbidopa Metronidazole Mifepristone Praziquantel Primaquine Pyrazinamide Pyridostigmine Pyrimethamine Ribavirin . Continue breastfeeding. prophylactic pyridoxine advisable in mother and infant Avoid treating mother until infant is l week old Breastfeeding contraindicated Present in milk-levodopa may inhibit lactation Significant amount in milk. appears to be concentrated in milk Monitor infant for possible toxicity. use alternative drug if possible Avoid breastfeeding for 14 days after administration Avoid breastfeeding during and for 72 hours after treatment.Gentamicin Hydrochlorothiazide Insulin Iodine Amount probably too small to be harmful. avoid large doses. danger of neonatal hypothyroidism or goitre. lactation may inhibit Amount too small to be harmful Stop breastfeeding. considered safe to continue breastfeeding in treatment of schistosomiasis risk of haemolysis in G6PD-deficient infants Amount too small to be harmful Amount probably too small to be harmful avoid administration of other folate antagonists to infant. theoretical risk of convulsions and neuropathy. monitor infant for thrush and diarrhoea Continue breastfeeding.

increased by vitamin K deficiency. all patients with renal impaimrent are given a loading dose which is the same as the usual dose for a patient with normal renal function. 4. monitor infant for diarrhoea Suppresses lactation. high doses suppress lactation Risk of haemorrhage. The maintenance dose of a drug can be reduced either by reducing the individual 528 . The dosage of many drugs must be adjusted in patients with renal impairment to avoid adverse reactions and to ensure efficacy. may cause masculinization in the female infant or precocious development in the male infant. The failure to excrete a drug or its metabolites may produce toxicity. In general. The tolerance to adverse effects may be impaired. 3. The level of renal function below which the dose of a drug must be reduced depends on how toxic it is and whether it is eliminated entirely by renal excretion or is partly metabolized to inactive metabolites. avoid unless potential benefit outweighs risk Avoid. 2. Breast feeding recommended during first 6 months if no safe alternative to breastmilk Warfarin Zidovudine APPENDIX 3: RENAL IMPAIRMENT Reduced renal function may cause problems with drug therapy for the following reasons: l. The sensitivity to some drugs is increased even if the renal elimination is unimpaired.Senna Tamoxifen Testosterone Continue breastfeeding. The efficacy of some drugs may diminish.Maintenance doses are adjusted to the clinical situation.

Renal function (GFR. assume at least a mild degree of renal impairment. The table includes only drugs for which specific information is available. The recommendations are given for various levels of renal function as estimated by the glomemlar filtration rate (GFR). sex and weight by special nomograms. ln the following table drugs are listed in alphabetical order. The interval extension method may provide the benefits of convenience and decreased cost.dose leaving the normal interval between doses unchanged or by increasing the interval between doses without changing the dose. Nephrotoxic drugs should. it is therefore important to also refer to the individual drug entries. Many drugs should be used with caution in renal impairment but no specific advice on dose adjustment is available. When prescribing for the elderly. if possible. while the dose reduction method provides more constant plasma concentration. It is advisable to determine renal function not only before but also during the period of treatment and adjust the maintenance dose as necessary. be avoided in all patients with renal disease because the nephrotoxicity is more likely to be serious. creatinine clearance) declines with age so that by the age oi‘80 it is half that in healthy young subjects. Renal impairment is usually divided into three grades: mild-GFR 20-50 ml/minute or approximate serum creatinine 150-300 micromol/litre moderate-GFR l0-20 ml/minute or serum creatinine 300-700 micromol/ litre severe—GFR <l0 ml/minute or serum creatinine >700 micromol/litre When using the dosage guidelines the following must be considered: • • • • Drug prescribing should be kept to a minimum. 529 . usually measured by the creatinine clearance (best calculated from a 24-hour urine collection)The serum—creatinine concentration is sometimes used instead as a measure of renal function but it is only a rough guide even when corrected for age.

50 mg daily if creatinine clearance 15-35mL/minute May reduce renal blood flow and adversely affect renal function. protein binding or metabolism. or liver function. Table of medicines to be avoided or used with caution in renal impairment Medicine Abacavir Acetazolamide Acetylsalicylic acid Degree of Impairment Severe Mild Severe Comment Avoid Avoid. reduce dose to max. and other drug therapy precludes use of fixed drug dosage and an individualized approach is required. sodium and water retention.• Uraemic patients should be observed carefully for unexpected drug toxicity. rashes Risk of crystalluria Atenolol Mild to Moderate Severe Reduce dose to max. metabolic acidosis Avoid. ln these patients the complexity of clinical status as well as other variables for example altered absorption. 25 mg daily if creatinine clearance less than 15 mL/minute Amoxycillin Mild to moderate Severe 530 . increased risk of gastrointestinal bleeding Risk of crystalluria with high doses Reduce dose. deterioration in renal function.

Benzathine penicillin Benzylpenicillin Severe Severe Neurotoxicity. monitor plasma Concentrations Avoid Reduce dose 531 Gentamicin Glibenclamide Imipenem + Cilastatin Mild Severe Mild . avoid in rheumatic disease Avoid if possible. toxicity increased by electrolyte disturbances clearance less than 30 ml/rninute. neurotoxicity—high doses may cause convulsions Reduce dose Reduce dose Reduce dose Maximum 2 g daily. deafness may follow rapid IV injection Reduce dose. high doses may cause convulsions Maximum 6 g daily. also monitor plasma concentration Reduce dose in rheumatic disease Reduce dose for malaria prophylaxis. Hyperkalaemia and other adverse effects Cefazolin Cefixime Ceftazidime Ceftriaxone Moderate Moderate Mild Severe Chloroquine Mild to moderate Severe Cisplatin Mild Digoxin Mild Enalapril Mild Furosemide Moderate May need high doses. nephrotoxic and Neurotoxic Reduce dose.

high risk of Hyperkalaemia in renal impairment Avoid Reduce dose . The ability to eliminate a specific drug may or may not correlate with liver’s synthetic capacity for substances such as albumin or clotting factors. accumulates. high risk of Hyperkalaemia Neurotoxicity: high doses may cause Convulsions Monitor plasma K . which tends to decrease as hepatic function declines. increased risk of extrapyramidal reactions reduce dose or avoid Avoid routine use. monitor plasma-vancomycin concentration and renal function regularly Avoid Severe Mild Vancomycin Moderate Mild Warfarin Severe APPENDIX: 4 HEPATIC IMPAIRMENT Liver disease may alter the response to drugs. nephrotoxic Avoid Avoid or use small dose. where estimates of renal function based on creatinine clearance correlate with parameters of drug 532 . the hepatic reserve appears to be large and liver disease has to be severe before important changes in drug metabolism take place. Unlike renal disease.Metformin Methotrexate Mild Mild Metoclopramide Moderate Severe Morphine Potassium chloride Procaine Benzylpenicillin Spironolactone Moderate to Severe Moderate Avoid. increased risk of lactic acidosis Reduce dose. However.

• Decreased bioavailability due to malabsorption of fats in cholestatic liver disease. However.. ln severe liver disease increased sensitivity to the effects of some drugs can further impair cerebral function and may precipitate hepatic encephalopathy (for example morphine). • Decreased protein binding and increased toxicity of drugs highly bound to proteins (for example phenytoin) due to impaired albumin production. The table contains only those drugs that need dose adjustment. ibuprofen. prednisolone. most hepatotoxic reactions to drugs occur only in rare persons and are unpredictable. Both should be avoided.dexamethasone). Information to help prescribing in hepatic impairment is included in the following table. • Altered volume of distribution of drugs due to increased extracellular fluid (ascites. The altered response to drugs in liver disease can include all or some of the following changes: Impaired intrinsic hepatic eliminating (metabolizing) capacity due to lack of or impaired function of hepatocytes. • Impaired hepatic blood flow due to surgical shunting. A few drugs cause dose-related hepatotoxicity. • Increased bioavailability through decreased first-pass metabolism.elimination such as clearance and half life. In patients with impaired liver function the dose·related hepatotoxic reaction may occur at lower doses whereas unpredictable reactions seem to occur more frequently. 533 • . Usually drugs are metabolized without injury to the liver. oedema) and decreased muscle mass. routine liver function tests do not reflect actual liver function but are rather markers of liver cellular damage. absence from the table does not automatically imply safety as for many drugs data about safety are absent. However. collateral circulation or poor perfusion with cirrhosis and portal hypertension. it is therefore important to also refer to the individual drug entries. Oedema and ascites in chronic liver disease may be exacerbated by drugs that cause fluid retention (for example acetylsalicylic acid. • Impaired biliary elimination due to biliary obstruction or transport abnormalities (for example rifampicin is excreted in the bile unchanged and may accumulate in patients with intrahepatic or extrahepatic obstructive jaundice).

hepatotoxic Avoid in severe liver disease Sedative effects increased Avoid or reduce dose—may precipitate coma Avoid in active liver disease and if history of pruritus or cholestasis during pregnancy Can precipitate coma Avoid in severe liver disease May cause idiosyncratic hepatotoxicity Reduce dose or administer on altemate days Can precipitate coma. avoid or use small dose. hepatotoxic Hypokalaemia may precipitate coma increased risk of hypomagnesaemia in alcoholic cirrhosis Increased risk of hypoglycaemia in severe liver disease. Can precipitate coma. oral Diazepam Ergometrine Erythromycin Fluoxetine Fluphenazine Furosemide Glibenclamide 534 .5 mg Avoid (or reduce dose) in severe liver disease Metabolism impaired in advanced liver disease. consider initial dose of 2.may need dose reduction.Table of medicines to be avoided or used with caution in liver disease Medicine Comment Acetylsalicylic acid Avoid in severe hepatic impairment increased risk of gastrointestinal bleeding Sedative effects increased Half life prolonged . can produce jaundice Amitriptyline Amlodipine Bupivacaine Carbamazepine Chlorpromazine Clomifene Clomipramine Codeine Contraceptives.

hypokalaemia may precipitate coma Increased risk of gastrointestinal bleeding and can cause fluid retention. avoid or do not exceed 8 mg/ kg daily Avoid in active liver disease or unexplained persistent elevations in serum transaminases Prolonged apnoea may occur in severe liver disease due to reduced hepatic synthesis of plasma cholinesterase Avoid if possible hepatotoxicity and hepatic failure Avoid in severe liver disease. reduce dose in severe liver disease Dose related toxicity—avoid large doses Avoid—may precipitate coma in severe liver disease. Hepatotoxic Monitor hepatic function—idiosyncratic hepatotoxicity more common. avoid in severe liver disease ln severe liver disease. avoid in severe hepatic impairment Impaired elimination.Heparin Hydralazine Hydrochlorothiazide lbuprofen Reduce dose in severe liver disease Reduce dose Avoid in severe liver disease. monitor liver function. especially if prothrombin time already prolonged. Metronidazole Morphine Ofloxacin Paracetamol Promethazine Pyrazinamide Rifarnpicin Simvastatin Suxarnethonium Valproate Warfarin 535 . reduce: total daily dose to one-third and give once daily Avoid or reduce dose-may precipitate coma Hepatic dysfimction reported.

APPENDIX: 5 DRUG SCHEDULES AND ACTS There are various drug schedules and acts in India. import and manufacturing of new drugs Schedule H : Schedule I : Schedule Q : Schedule R : Schedule W : Schedule X : Schedule Y : 536 . The important ones are as per Drugs and Cosmetics Act (l940) as amended in 2001 are: Schedule A : Schedule B : Schedule C : Schedule D : Schedule F : Schedule G : gives specimen of prescribed form gives fees for test and analysis of drugs gives details with biological and other special products is concerned with exemption regarding drug import gives details of standard ophthalmic solutions deals with details of drugs to be labeled ‘CAUTlON — it is dangerous to take this medicine except under medical supervision’ deals with drugs and medicine to be sold on prescription — only lists all ailments for which no cure can be claimed eg AIDS deals with cosmetics deals with standards for contraception gives details of drugs which should be marketed under generic name only deals with psychotropic drugs which require special licence for manufacturing and sale (new addition): specifies the requirements and guidelines on conduct of clinical trials.

5 mg/mI (5m1 amp) Injection Dextran-70 Injection Diazepam 5mg/ml Injection Dicyclomine hydrochloride I0mg/ml Injection Diphenhydramine Injection Diltiazem Injection Diphtheria Antitoxin Injection Dobutamine 50mg/ml (5 ml amp) Injection Dopamine hydrochloride 40 mg/ml (5ml amp) injection Epinephrine hydrochloride lmg /ml Injection Flumazenil Injection Fresh Frozen Plasma Injection Frusemide 10mg/mI Injection Glucose with sodium chloride Injection Glyceryl trinitrate 5mg/ml Injection Dextrose 50% Injection Haloperidol Injection Heparin sodium 50001U/ml Injection Hydrocortisone sodium succinate I00mg/ml Injection Insulin soluble (bovine + porcine or porcine) 401U/ml injection Lignocaine IV 2% Injection Lidocaine 2% Injection Magnesium sulphate Injection Mannitol 10%.6mg/ml Inject ion Calcium chloride Injection Chloroquine phosphate 64.APPENDIX : 6 LIST OF EMERGENCY MEDICINES / LIFE SAVING DRUGS Adenosine Injection Adrenaline Bitartrate Injection Aminophylline Injection Amiodarone Injection Antisnake venom polyvalent Injection Antitetanus Human Immunoglobulin Injection Atropine sulphate O. 20% Injection Metoclopramide 5mg/ml 537 .

Metoprolol 1mg/ml Injection Morphine sulphate Injection N/2 saline Injection N/5 saline Injection Naloxonc 0.Primary health care S . APPENDIX : 7 ESSENTIAL DRUG LIST (INDIA) 2003 The names of drugs are followed by the following letters to indicate their need at various levels of medical care.4mg/mI Injection Neostigmine 0. P .Secondary health care T .Universal. 2.5 mg/ml lnjection Oxygen Inhalation Oxytocin Injection Pancuronium 2mg/ml Injection Phenobarbitone 200mg/ml Injection Phenytoin 50 mg/ml Injection Potassium Chloride Injection Pralidoxime chloride (2-PAM) 25mg/ml Injection Protamine sulphate Injection Rabies vaccine Injection Ringer lactate Injection Salbutamol sulphate Inhalation Sodium bicarbonate Injection Succinyl choline 50mg/ml Injection Streptokinase Injection Tetanus toxoid Injection Vit K 10 mg/ml Injection. The information is given as: Name of the Drug Category Medicine Category Route of Administration/ Strengths Dosage Form · · · · 538 .5.Tertiary health care U .

T U T Tablets 5 mg.3 Preoperative medication and sedation for short term procedures Atropine Sulphate U Injection 0. T S. 400mg 539 . ANTIPYRETICS. Local Anaesthetics Bupivacaine HCL Ethyl Chloride Lignocaine HCI Injection 1-2% Spinal 5%+7.5% Glucose Lignocaine HCl+Adrenaline U Injection 1% .1 Non –opioid analgesics.5%.5%+7. 2.T Inhalation Inhalation Inhalation Injection 10mg/ml 50mg/ml Inhalation Inhalation Injection 0.6 mg/ml Diazepam Midazolam Morphine sulphate Promethazine Doxapram U U S.2.T S.1.5% Glucose 1. Injection 5 mg/ml Injection 1mg/ml.25g% 1. ANALGESICS.5g. NSAIDS. General anesthetics and Oxygen Ether S. Injection 25 mg/ml Tablets 200mg.1. T Halothane Isoflurane* Ketamine HCI Nitrous Oxide Oxygen Thiopentone Na 0.100mg. T U U U S.000in vial. MEDICINES IN GOUT AND RHEUMATOID DISORDERS. 0. 1g powder Injection 0. antipyretics and nonsteroidal antiinflammatory medicines Acetyl Salicylic Acid U Tablets 300-350 mg Diclofenac Ibuprofen * Complementary T U Tablets 50 mg. 5 mg/ml Injection 10 mg/ml Syrup 5 mg/5 ml Inj 4mg/ml 2. ANAESTHETICS 1. U U Spray 1% Topical Forms 2-5% S.2% + Adrenaline 1:200.

Medicines used to treat Gout Allopurinol S.T S. Nonspecific Activate Charcoal U Powder Atropine Sulphate 540 U Injection 0.T U U U Tablets 150mg Tablets 2.T 2. ANTIALLERGICS AND MEDICINES USED IN ANAPHYLAXIS Dexchlorpheniramine Maleate Hydrocortisone sodium Succinate U Pheniramine Maleate Prednisolone Promethazine U S U 4. Injection 10 mg/ml Tablets10mg Tablets25 mg Injection 30 mg/ml Injection 50mg/ml Tablets 100mg Tablets 0.4 Disease modifying agents used in rheumatoid disorders Azathioprine S.T Tablets 50mg Choroquine Phosphate Methotrexate Sulfasalazine Adrenaline Bitartrate Chlorpheniramine Maleate Dexamethasone S.T S.3. 3.T S.Paracetamol U Injection 150 mg/ml Syrup 125 mg/5ml Tablets 500mg.75 mg/ml Tablets 5 mg Tablets 10 mg.5 mg Tablets 500mg Injection 1 mg/ml Tablets 4 mg Syrup 0. Opioid Anaglesics Morphine Sulphate Pentazocine Pethidine HCL S.T 2.5 mg 2.2.5 mg/5ml Tablets 0.1. ANTIDOTES AND OTHER SUBSTANCES USED IN POISONING 4. 25 mg Syrup 5 mg/5ml.T S.6 mg/ml .T Colchicine S.5 mg Injection 4 mg/ml Injection 100mg Injection 22.

1.T T Injection Polyvalent Injection 100mg/ml Injection 500mg Injection in oil 50 mg/ml Injection 0. ANTIINFECTIVES U 6.1. Anthelmintics 6.4.T S. ANTIEPILEPTICS Carbamazepine Diazepam Magnesium Sulphate Phenobarbitone Phenytoin Sodium U U T U S.4 mg/ml Tablets or Capsules 250 mg Injection 25 mg/ml Injection 30 mg/ml Injection 250mg/ml Pralidoxime Chloride (2-PAM) S.T S.T S.T Injection 0.500 mg Syrup 200mg/5ml S.100mg.1.200mg Syrup 20 mg/ml Injection 5 mg/ml Injection 500mg/ml Tablets 30 mg. Intestinal anthelmintics Albendazole Mebendazole Niclosamide * Complementary U U U Tablets 400 mg Suspension 200mg/5ml Tablets 100 mg Suspension 100 mg/ 5ml Chewable Tablets 500 mg 541 .2. Specific Antisnake Venom Calcium Gluconate Desferrioxamine Mesylate Dimercaprol Flumazenil* U S.T Injection 10 mg/ml Naloxone Penicillamine Sodium Nitrite Sodium thiosulphate 5. Syrup 25 mg/ml Injection 50 mg/ml Tablets 200mg.T S.T Sodium Valprote 6.T S.1 mg/ml Solution/ Lyophilyzed Polyvalent serum Methylthioninium Chloride (Methylene blue) S.T U Tablets 100mg. 60 mg Injection 200 mg/ml Capsules or Tablets 50mg.

T S. 10 lacs units Injection 125. Capsules 250 mg. 250mg. 500 mg Powder for suspension 125 mg/5ml Injection 500 mg Injection 6 lacs. 500 mg Capsules 250 mg.Pyrantel Pamoate U Tablets 250 mg Suspension 250 mg/ml 6.500mg Suspension 100 mg/5ml Injection 500mg Syrup 125 mg/5ml Capsules 250mg.2.2 Antibacterials Powder for suspension 125 mg/5ml.1 Beta lactam medicines Amoxicillin U Ampicillin U Benzathine Benzylpenicillin Benzylpenicillin Cefotaxime* Ceftazidime* Cetriaxone* Cefuroxime* Cloxacillin U U S. 1g Injection 250 mg.T S.T Azithromycin* S.1.500mg Injection 250 mg. 12 lacs.2 Antifilarials Diethylcarbamazine Citrate U Tablets 50 mg 6.2 Other antibacterials Amikacin* S.3 Antischistosomals and Antitrematode Praziquantel S.T Tablets 600 mg 6.T S. 24 lacs units Injection 5 lacs.2. 1g Injection 250 mg.T U Injection Crystalline penicillin U Injection 250 mg/2ml Capsules or Tablets 100 mg. 250.500mg 6. Liquid 125mg/5ml 6. 750 mg Capsules 250 mg.T Cephalexin* 542 U .1.500 mg Injection 250 mg.

T S. 100mg Tablets 50 mg.T S.T U T S.4 Antituberculosis medicines Ethambutol U Isoniazid Ofloxacin* Pyrazinamide * Complementary U S.400mg.Tablets 250 mg.T S.100mg Capsules or Tablets 150.750mg.Clarithromycin* Chloramphenicol S.500 mg Tablets 40+200 mg Suspension 40+200 mg/5ml Ciprofloxacin Co-trimoxazole HCI U U (Trimethoprim 80+400mg sulphamethoxazole) Doxycycline Erythromycin Estolate Gentamicin Metronidazole Nalidixic Acid Nitrofurantoin Norfloxacin Roxithromycin* Sulphadiazine* Tetracycline Vancomycin HCL* 6. 500 mg Tablets 100 mg Tablets 400 mg Tablets 50 mg.300mg Tab 200mg.500mg Injection 200 mg/100 ml Tablets 250 mg.500 mg Injection 10mg/ml.1000mg.400 mg Injection 500 mg/100 ml Tablets 250 mg. 40 mg/ml Tablets 200 mg.2.3 Antileprosy Clofazimine Dapsone Rifampicin U U U U U U U S.100 mg.1500 mg 543 6.600mg.T S.2.1 g Capsules 50 mg.200 mg Syrup 50mg/5ml Tab 500 mg.T U .150 mg Tablets 500 mg Tablets or Capsules 250 mg Injection 500 mg.T U U Capsules 100 mg Syrup 125 mg/5ml Tablets 250 mg.800mg Tablets 50 mg.300mg Tablets 100 mg.T Capsules 500 mg Injection 1 g Suspesnion 125mg/5ml Capsules.

300mg.600mg Nevirapine* S.400 mg Lamivudine* S.4.2.400mg Injection 250 mg.T Tablets 150 mg Tablets 150 mg+200 mg+30 mg Tablets 150 mg+300 mg Capsules 15mg.T U S.T 6.2 Antiretroviral medicines* 6.T P.150mg.000 IU Pessaries 100.4 Antiviral medicines Tablets 200mg.300 mg Lamivudine+Nevirapine+Stavudine* S.T S.000 IU Streptomycin Sulphate Thiacetazone + Isoniazid U S.2 Non-nucleoside reverse transcriptase inhibitors Efavirenz* S.500 mg Suspension 400mg/5ml 6.4. 100 mg. 450 mg Syrup 100mg/5ml Injection 0.T S. 150mg.T Lamivudine+Zidovudine* Stavudine* Zidovudine* S.4.T Tablets 250 mg.2. 200mg Capsules 250 mg Capsules or Tablets 125.1 Nucleoside reverse transcriptase inhibitors Didnosine* S.30mg.T Capsules 200mg Suspension 50mg/5ml 544 .75g.250 mg Tablets 200 mg Tablets 500.4.T U S.T S.1 Antiherpes medicines Acyclovir* S.Rifampicin U Capusles/Tab50mg .T U 6.S.40mg Tablets 100 mg.200mg Gel 2% Capsules or Tablets 50 mg.1g Tablets 150mg+300mg Injection 50mg Pessaries 100 mg.T 6.T Capsules 200mg.3 Antifungal medicines Amphotericin Clotrimazole Fluconazole Flucytosine Griseofulvin Ketoconazole Nystatin 6.

T U U Tablets 150 mg Syrup 50mg/5ml * Complementary 545 .4.6.1 For curative treatment Artesunate T Chloroquine Phosphate base U Injection 60 mg Tablets 150 mg Injection 40 mg/ml.T S.T S.5 Antiprotozoal Tablets 500 mg Tablets 200 mg.3 Protease inhibitors Indinavir* S.400mg Injection 500 mg/100ml Tablets 500 mg Injection 50 mg Injection 200 mg Injection 100 mg/ml 6.5 mg.2 Antileshmaniasis Amphotericin Pentamidine Isothionate Sodium Stibogluconate U P.5.T S.3.T Capsules 200mg.1 Antiamoebic and antigiardiasis Diloxanide Furoate U Metronidazole U Tinidazole 6.S.5.3 Antimalarial medicines 6. syrup 50mg/5ml Tablets 2.2 For Prophylaxis Choloroquine Phosphate base U U U S.T 6.5mg Tablets 25 mg Tablets 300 mg Injection 300mg/ml Tablets 500 mg+25 mg Primaquine Pyrimethamine Quinine Sulphate Sulfadoxine+Pyrimethamine 6.T Nelfinavir Ritonavir* Saquinavir* S.3.400mg Capsules 250mg Capsules 100mg Syrup 400 mg/ml Capsules 200mg 6.5.T S.5.5.7.2.

1 For Treatment of acute attack U S. 25mg. IMMUNOSUPPRESSIVES AND MEDICINES IN PALLIAIVE CARE 8. 50mg.80mg+400mg Suspension 40+200 mg/5ml Inj 200mg Tablets 100mg 7. 1000 mg/vial Capsules 50mg.4. 100mg Injection 10 mg.1 Immunosuppressive medicines T T Tablets 50mg Capsules 10mg. ANTINEOPLASTIC. T U U Tablets 300 – 350 mg Tablets 1 mg Tablets 500mg Tablets 10mg. 50mg Actinomycin D* Alpha Interferon Bleomycin* Busulphan* Cisplatin* Cyclophosphamide* Cytosine Arabinoside* Danazol* Doxorubicin* 546 . Antipneumocystosis and Antitoxoplasmosis Co-Trimoxazole (Trimethroprim+Sulphamethoxazole) U Pentamidine Isothionate Trimethoprim S.5.5 mg Injection 3 million IU Injection 15 mg Tablets 2mg Injection 10mg/vial 50mg/ vial Tablets 50mg Injection 200 mg. 40 mg Acetyl Salicylic Acid Dihydroergotamine Paracetamol 7.6.2 Cytotoxic medicines T T T T T T T T T Injection 0.100mg Concentrate for Injection 100 mg/ml Azathioprine* Cyclosporine 8.T U Tablets 40 +200mg. 500mg Injection 100 mg/ vial 500 mg/vial.2 For prophylaxis Propranolol HCl 8. ANTIMIGRAINE MEDICINES 7.

Injection 100mg/ml Tablets 2.5mg Tablets 100 mg+10 mg 250mg+25mg. 1g Injection 10000 KU Tablets 2 mg. ANTIPARKINSONISM MEDICINES Bromocriptine Mesylate S.8mg Injection 2mg/ml Syrup2mg/5ml Tablets 1.Etoposide* Flutamide* 5-Fluorouracil* Folinic Acid Gemcitabine HCl* L-Asparaginase* Melphalan* Mercaptopurine* Methotrexate* Mitomycin-C* Paclitaxel* Procarbazine* Vinblastine Sulphate* Vincristine T T T T T T T T T T T T T T S.25 mg.5 mg Injection 50mg/ml Injection 10 mg Injection 30mg/5ml Capsules 50 mg Injection 10 mg Injection1 mg/ml Tablets 5 mg Injection 20 mg 25 mg (as sodium phosphate or succinate) 8.3 Hormones and antihormones Prednisolone* Raloxifene* Tamoxifen Citrate T T T S.100mg+25mg Tablets 2 mg 547 8.20mg Tablets 10 mg Tablets 4 mg.T Tablets 60 mg Tablets 10mg.T Capsules 100mg Injection 100 mg/ 5ml Tablet 250 mg Injection 250mg/5ml Injection 3 mg/ml Injection 200mg.4 Medicnes used in palliative care Morphine Sulphate* Ondansetron* 9.T Levodopa+ Carbidopa Trihexyphenidyl HCl * Complementary U U .2. 5 mg Tablets 50 mg.

X) . MEDICINES AFFECTING BLOOD 10.5mg Injection 50 mg iron/ml Tablets 5 mg 10.2.10.T S.T S.T *S.1. Albumin Cryoprecipitate Factor VIII Concentrate* Plasma fractions for specific use Factor IX Complex (Coagulation Factors II.1 Antianemia medicines Cyanocobalamin Ferrous Salt U U Injection 1 mg/ml Tablets Equivalent to 60mg elemental iron Oral solution25 mg elemental iron (as sulphate)/ml Folic Acid Iron Dextran Pyridoxine Acenocoumarol 4 mg Heparin Sodium Protamine sulphate Phytomenadione Warfarin Sodium S.5% Injection 5%.T S.T S.2 Medicines affecting coagulation 11.T Platelet Rich Plasma 548 S.T Injection 1000 IU/ml. VII.T U S.T Injection 10% Injection 6% Injection Injection 6% Injection 3.T S. BLOOD PRODUCTS AND PLASMA SUBSTITUTES 11.20% Injection Injection Dried Injection Dried Injection 11. Plasma Substitutes Dextran-40 Dextran-70 Fresh Frozen Plasma Hydroxyethyl Starch (Hetastrach) Polygeline U U T S. IX. 5000IU/ml Tablets 10mg Injection 10mg/ml Injection 10mg/ml Tablets 5 mg Menadione sodium Sulphite S.T S.T S.T U Tablets 1 mg.

T T T S.200mg Injection 150 mg Injection1mg. 100 mg Tablets 25mg.2. CARDIOVASCULAR MEDICINES 12.60mg Sublingual Tablets 0.T 12.T T S.60mg Injection 5mg/ml Injection 10mg/ml Injection 2mg/ml Injection 1%.1.50mg Injection 1 mg/ml Tablets 10 mg.50 mg 549 12.80 mg Injection 2.T U Tablets 75 mg.100mg.5mg/ml Tablets 2.12. 50mg.3.5 mg. Antianginal medicines Acetyl Salicyclic Acid* Diltiazem Glyceryl Trinitrate Isosorbide 5 Mononitrate/ Dinitrate Metoprolol* Propranolol U S. 40mg Injection 1mg/ml Injection 3mg/ml Tablets 100mg.T S. 2mg. Injection 5mg/ml U U U Tablets 10 mg.2% Capsules.20mg Tablets 25 mg.T T T T S. Antiarrhythmic medicines Adenosine* Amiodarone Bretylium Tosylate* Diltiazem Diltiazem Esmolol* Isoprenaline HCl* Lignocaine HCl Mexiletine HCl Procainamide HCl Quinidine Verapamil S.T S. 350mg Tablets 30 mg.5 mg. 4mg/ml Tablets 30mg.10mg Tablets 50mg.5 mg.150mg Injection 25mg/ml Tablets 250 mg Injection 100mg/ml* Tablets 100 mg Tablets 40mg. Antihypertensive medicines Amlodipine Atenolol Chlorthalidone* U U U .

2.T Tablets 100mg.100mg Injection 1000.2.4 Medicines used in heart failure Dobutamine* Dopamine HCl Acetyl Salicylic Acid Herparin sodium* Streptokinase Urokinase S. Sustained release capsules 10mg.000 IU Injection 500. 20 mg.50 mg Tablets 250 mg Capsules 5.5. Antiinfective medicines Methylrosanilinium Chloride (Gentian Violet) .00.5000 IU/ml Injection 750. Antithrombotic medicines 13.T U U Neomycin+ Bacitracin 550 U Ointment or Cream 6%+3% Ointment or Cream 2% Cream 5% Cream 0.150 mg Tablets 2.T S.5% Ointment 5mg+500 IU 13.T U S.T T Injection 50mg/ml Injection 40 mg/ml Tablets 75. Antifungal medicines Benzoic Acid+Salicyclic Acid U Miconazole Acyclovir Framycetin sulphate U S.25 mg/ml Elixir 0.5. 12.1.00.40 mg Injection 50mg/5ml Tablets 1.5% Aqueous solution 0.000. 15.Clonidine HCl* Enalalpril maleate Losartan Potassium* Methyldopa Nifedipine Propranolol Sodium Nitroprusside* Terazosin* Digoxin S.5.T U S. DERMATOLOGICAL MEDICINES (TOPICAL) 13.25 mg Injection 0.T U S.T S.10 mg Tablets 10mg.10 mg Injection 1.25 mg/ml Tablets 25.T S.05 mg/ml Tablets 10 mg.000 IU/ml 10. or tablets 20 mg.T U T S.000 IU/ml 12.5 mg Tablets 0.

T S.T S.1 Opthalmic medicines Fluorescein Lignocaine Tropicamide S. DIGNOSTIC AGENTS U T U U U U 13.5 Medicines affecting skill differentiation and proliferation 13.3 Antiinflammatory and antipruritic Betamethasone Dipropionate U Calamine U 13.T S.2 Radiocontast media Barium Sulphate Calcium Ipodate Iopanoic Acid Meglumine Iothalamate .T Eye drops 1% Eye drops 4% Eye drops 1% Suspension 100%w/v 250%w/v Injection 3 g Tablets 500 mg Injection 60% w/v (iodine= 280 mg/ml) Meglumine Iotroxate Propyliodone Sodium Iothalamate Solution 5-8 g (Iodine in 100-250 ml) Oily.T S.suspension 500-600 mg/ml Injection 70% w/v (iodine = 420 mg/ml) 551 14.1-2% Solution Solution 5% Lotion 25% Lotion 1% 13.05% Lotion Dusting powder Solution 5% Ointment 0.T S.4 Astringent medicines Zinc Oxide U Coal Tar Dithranol* Glycerin Salicylic Acid Benzyl Benzoate Gamma Benzene Hexachloride 14.T S.Provide Iodine Silver Nitrate Silver Sulphadiazine U U U Solution or Ointment 5% Lotion 10% Cream 1% Cream/Ointment 0.6 Scabicides and pediculicides 14.T S.T S.T S.

Sodium Melgumine Diatrizoate S.1. 50 mg Injection 10%.=292 mg/ml)76%w/v (Iodine conc. 10mg/ml Tablets 40 mg Tablets 25 mg.T Injection 60% w/v (Iodine conc.1. Antiseptics Acriflavin+Glycerin Benzion Compound Cetrimide Chlorhexidine Ethyl Alcohol 70% Gentian Violent Hydrgoen Peroxide Povidone Iodine 15.10% 17. Aluminium Hydroxide+ Magnesium Hydroxide Omeprazole Ranitidine HCl U U 552 . 300mg Injection 25 mg/ml. Antacids and other antiulcer medicines U Tablet Suspension Capsules 10. DISINFECTANTS AND ANTISEPTICS 15.5%.20% Tablets 25 mg U U U U U U U U Solution Tincture Solution 20% (conc.2 Disinfectants Bleaching Powder Formaldehyde IP Glutaraldehyde Potassium Permanganate 16. for dilution ) Solution 5% (conc. DIURETICS Furosemide Hydrochlorothiazide Mannitol* Spironolactone U U S.T U U U U U Powder Solution Solution 2% Crystals for solution Injection.40 mg Tablets 150. For dilution) Solution Paint 0. 370mg/ml) 15.20.1% Solution 6% Solution 5%. GASTROINTESTINAL MEDICINES 17.

T Loperamide* S.7 Medicines used in diarrhoea 17.4 Antiinflammatory medicines Sulfasalazine Dicyclomine HCl Hyoscine Butyl Bromide T U U Tablets 500mg Tablets 10 mg Injection 10 mg/ml Tablets 10 mg Injection 20mg/ml Tablets/ suppository 5 mg Granules Powder for solution As per IP Tablets 100 mg Syrup 25 mg/5 ml Capsules 2mg 17.7. Adrenal hormones and synthetic substitutes Dexamethasone Hydrocortisone Sodium Succinate S.2 Antiemetics Domperidone Metoclopramide U U Tablet 10mg Syrup 1mg / ml Tablet 10mg Syrup 5mg/ml Injection 5mg / ml Tablet 5mg.1.T Tablets 0.7. Astringent and Antiinflammatory medicines U Ointment/ suppository 17.3 Antihaemorrhoidal medicines Local anaesthetic.25mg Tablet 10mg.T (Contraindicated for pediatric use) 18.2 Antidiarrhoeal medicines Furazolidone S.1 Oral rehydration salts U 17. OTHER ENDOCRINE MEDICINES AND CONTRACEPTIVES 18.5 mg Injection 4 mg/ml Injection 100 mg/ml 553 U .5 Antispasmodic medicines 17. 25mg Elixir or Syrup 5 mg/5ml Injection 25mg/ml Prochlorperazine Promethazine U U 17. HORMONES.6 Laxatives Bisacodyl Isphaghula U U 17.17.

3.05mg 18.3 Condoms Barrier Methods U 18. Androgens Testosterone 18.1 .03+0.2 Intrauterine devices IUD containing Copper U 18.1 Hormonal contraceptives Enthinylestradiol+ Levonorgesterol U Enthinylestradiol+ Norethisterone Hormone Releasing IUD U T Tablets 0.3 Contraceptives 18.4 Estrogens Ethinylestradiol U Tablets 0.2 Hyperglycaemics Glucagon* U U U T T Injection 40 IU/ml Injection 40 IU/ml Tablets 500 mg Injection 1mg/ml Tablets 25.100mg 18.2.5.5 Antidiabetics and hyperglycaemics 18.T U T T Injection 40 mg/ml Injection 5 mg 10 mg Capsules 40 mg (as undecanoate) Injection 25 mg/ml (as propionate) 18.01.035mg+1mg Levonorgesterol Releasing IUD 18. 5mg Insulin Injection (Soluble) Internediate Acting Insulin (Lente/NPH Insulin) Metformin 18.3.10 mg .5.5mg.0.Methylprednisolone Prednisolone S.3.3.6 Ovulation inducers Clomiphene Citrate* 18.7 Progestogens Medroxy Progresterone Acetate 554 U Tablets 5 .Insulins and other antidiabetic Agents Glibenclamide U Tablets 2.15 mg Tablet 0.4 Non hormonal contraceptives Centchroman U Tablets 30 mg 18.50.

Immunoglobulin (Human) Antisnake Venom Antitetanus Human Immunoglobin Diphtheria antitoxin Rabies Immunoglobulin U Injection 19.1 Diagnostic agents Tuberculin.300 mg Injection 10ml Injection 250 IU. Purified Protein Derivative Anti-DS.T S.3. 500IU Injection 10.T Injection 10mg/ml Neostigmine Pancuronium Bromide * Complementary S.2 Sera and Immunoglobulins T U U S. IMMUNOLOGICALS U S.000 IU Injection 150 IU/ml 19.Norethisterone Carbimazole Levothryoxine Iodine 19.T S.2 For Specific group of individuals Rabies Vaccine U Injection Tetanus Toxoid U Injection 20 MUSCLE RELAXANTS (PERIPHERALLY ACTING) AND CHOLINESTERASE INHIBITORS Atracurium Besylate* S.1 mg Solution 8mg/5ml 18.5 mg/ml Injection 2mg/ml 555 .T S.T Tablets 15 mg Injection 0.T U Injection 250.1 For universal immunization BCG Vaccine U DPT Vaccine Hepatitis B Vaccine Measles Vaccine U U U U Injection Injection Injection Injection Solution Oral Poliomyelitis Vaccine (Live Attenuated) 19.3.T Tablets 5 mg Tablets 5 mg.8 Thyroid and antithyroid medicines 19. 10 mg Tablets 0.3 Vaccines 19.

3 Local anaesthetics Tetracaine HCI Acetazolamide Betaxolol HCI Physostigmine Salicylate* Pilocarpine Timolol Maleate 21.05%.5% Tablets 250 mg Drops 0.T S.6 Ophthalmic Surgical Aids 22. 1% Drops/Ointment 0.1 Oxytocics 556 . 0.0.5% Drops/Ointment 1% Drops 2% Drops 5% Injection 2% 21. OPTHALMOLOGICAL PREPARATIONS 21.3% Drops 0.4% Drops 0. 0.T S.25%.T Tablet 60 mg Injection 1mg/ml Injection 50 mg/ml 21.2 Antiinflammatory agents 21.3% Drops 1% Drops0.1% Drops 1% Drops 0.T S. OXYTOCICS AND ANTIOXYTOCICS 22.T S.Pyridostigmine Bromide Succinyl Choline Chloride S.25%.T S.4 Miotics and antiglaucoma medicines 21.T U U U T Drops/ Ointment 0.1 Antinfective Agents Chloramphenicol Ciprofloxacin HCI Gentamicin Miconazole Povidone Iodine Sulphacetamide Na Tetracycline HCI Prednisolone Acetate Prednisolone sodium Phosphate Xylometazoline U U U U S.5% Drops 0.30% Ointment 1% Drops 0.4 %.20%.5 Mydriatics Atropine Sulphate Homatropine Phenylephrine Methyl Cellulose* 21.6% Drops 10%.1% Drops 0.25% Drops 2%.T U U U U U U S.

PERITONEAL DIALYSIS SOLUTION Intraperitoneal Dialysis Solution (of approximate composition) 24. 10 IU/ml Tablets 10 mg Injection 5 mg/ml Tablets 2.5 mg Injection 0.2 Medicines used in bipolar disorders Lithium Carbonate T Tablets 150 mg 24. T S.1 Medicines used in psychotic disorders Chlorpromazine U Tablets 25.4 U U Tablets 2. T 24. T Tablets 0.5 mg Diazepam Nitrazepam 24. 10 mg Tablets 5 mg. PSYCHOTHERAPEUTIC MEDICINES 24. 10 mg Haloperidol Trifluoperazine S. 25 mg * Complementary 557 . 10mg Medicines used for obsessive compulsive disorders and panics attacks Clomipramine HCL S.125mg Injection 0.Methyl Ergometrine Mifepristone Oxytocin U T S. 10 mg Injection 5 mg/ml Tablets 5 mg. 50.25.5 mg/ml 22.100 mg Syrup 25 mg/5 ml Injection 25 mg/ml Tablets 1.5. 5.2 mg/ml Tablets 200mg Injection 5. T S. 75 mg 24. T S. 5.2.2 Antioxytocins Isoxsuprine HCL Terbutaline Sulphate 23.2.3 Medicines used for generalized anxiety and sleep disorders Alprazolam U Tablets 0.1 Medicines used in depressive disorders Amitriptyline U Tablets 25 mg Fluoxetine HCL Imipramine U U Capsules 20 mg Tablets 25 mg. 0.2 Medicines used in mood disorders 24. T Tablets 10.

1 Antiasthmatic medicines Aminophylline Beclomethasone Dipropionate Hydrocortisone Sodium Succinate Salbutamol Sulphate U U U U Injection 25 mg/ml Inhalation 50 mg. SOLUTIONS CORRECTING WATER.T U U U U U 26. 10 ml Tablets 100. MEDICINES ACTING ON THE RESPIRATORY TRACT 25. 200.2% Sol.2 Antitussives Codeine Phosphate U U 26.2 Parenteral Glucose Glucose with Sodium chloride Normal Saline N/2 Saline N/5 Saline Potassium Chloride Ringer Lactate Sodium Bicarbonate U U S.1 Oral Oral Rehydration Salts U U Powder for Solution As per IP Injection 5% isotonic 50% hypertonic Injection 5%+ 0.3 Miscellaneous Water for Injection 27. 250 mg/dose Injection 100. Injection Injection Injection 2. ELECTROLYTE AND ACIDBASE DISTURBANCES 26. 5. 4 mg Syrup 2 mg/5 ml Inhalation 100 mg/dose Tablets 100.9% Injection Injection Injection 11. VITAMINS AND MINERALS Ascorbic Acid 558 .T S. 400 mg Tablets 2mg.25.500 mg 26.9% Injection 0. 200mg Tablets 10 mg Syrup 15 mg/5 ml Dextromethorphan U Tablets 30 mg Theophylline Compounds 25.

8.1mg APPENDIX 8 LIST OF DRUGS BANNED IN INDIA LIST OF DRUGS PROHIBITED FOR MANUFACTURE AND SALE THROUGH GAZETTE NOTIFICATIONS UNDER SECTION 26 A OF DRUGS & COSMETICS ACT 1940 BY THE MINISTRY OF HEALTH AND FAMILY WELFARE DRUGS PROHIBITED FROM THE DATE OF NOTIFICATION. Amidopyrine Fixed dose combinations of vitamins with anti-inflammatory agents and tranquillizers.500 mg Tablets Tablets 50 mg Tablets 25 mg Tablets 5 mg Tablets 100 mg Tablets 5000 IU Capsules 10. 2. 7.000 IU 50. 10. 6. 5.Calcium salts Multivitamins Nicotinamide Pyridoxine Riboflavine Thiamine Vitamin A U U U U U U U Tablets 250.000 IU/ml (Having composition as per schedule Y of drugs and cosmetics act. Fixed dose combinations of Atropine in Analgesics and Antipyretics. 1.25 mg. Arsenic and Yohimbine. Fixed dose combinations of Iron with strychnine. Fixed dose combinations of Strychnine and Caffeine in tonics. 9. Fixed dose combinations of Yohimbine and Strychnine with Testosterone and Vitamins. 4.T Capsules 0.000 IU Injection 50. 3.1940) Vitamin D3 (Ergocalciferol) S. Fixed dose combinations of Sodium Bromide/chloral hydrate with other drugs Phenacetin Fixed dose combinations of antihistaminic with antidiarrhoeals Fixed dose combinations of Penicillin with Sulphonamides 559 .

* 28. Fixed dose combinations of Oestrogen and Progestin (other than oral contraceptive) containing per tablet estrogen content of more than 50 mcg (equivalent to Ethinyl Estradiol) and progestin content of more than 3 mg (equivalent to Norethisterone Acetate) and all fixed dose combination injectable preparations containing synthetic Oestrogen and Progesterone.isoniazid and Pyrazinamide. 18. (Subs. 13. Tetracycline Liquid Oral preparations Nialamide Practolol Methapyrilene. Fixed dose combinations of Hydroxyquinoline group of drugs with any other drug except for preparations meant for external use Fixed dose combinations of Corticosteroids with any other drug for internal use.By Noti.743 (E) dated 10-08-1989). 26. Fixed dose combination of Rifampicin. Fixed dose combinations of any other Tetracycline with Vitamin C. Methaqualone Oxytetracycline Liquid Oral preparations Demeclocycline liquid oral preparations Combination of anabolic Steroids with other drugs. 14. antihistamines for the treatment of migraine. Fixed dose combinations of Chloramphenicol with any other drug for internal use Fixed dose combinations of crude Ergot preparations except those containing Ergotamine. 24. Fixed dose combinations of Sedatives/hypnotics/anxiolytics with analgesics. *29. except those which provide daily adult dose given below 17. its salts. 25. 15. 560 . 22.antipyretics. 19. 16. 23. analgesics.No.11. Fixed dose combinations of Vitamins with Analgesics. Caffeine. 12. 21. 27. 20. headaches Fixed dose combinations of Vitamins with anti TB drugs except combination of Isoniazid with pyridoxine Hydrochloride (Vitamin B6) Penicillin skin/eye Ointment.

Fixed dose combination containing Pectin and/or Kaolin with any drug which is systemically absorbed from Gl tract except for 561 *31. The patent and proprietary medicines of fixed dose combinations of essential oils with alcohol having percentage higher than 20% proof except preparations given in the Indian Pharmacopoeia All pharmaceutical preparations containing Chloroform exceeding 0. . **35. **37. **40. Fixed dose Combination containing more than one antihistamine. Preparations claiming to combat cough associated with asthma containing centrally acting antitussive and/or an antihistamine.+ Ethambutol 800mg. Fixed dose combination of any anthelmintic with cathartic/ purgative except for piperazine Fixed dose combination of Salbutamol or any other bronchodilator with centrally acting antitussive and/or antihistamine. **42. Liquid oral tonic preparations containing glycerophosphates and/ or other phosphates and/or central nervous system stimulant and such preparations containing alcohol more than 20% proof. Fixed dose combination of centrally acting. or INH 300mg. antitussive with antihistamine. *32.Drugs Rifampicin Isoniazid Pyrazinamide *30. Fixed dose combination of Ethambutol with INH other than the following: INH200mg +Ethambutol 600mg. Fixed dose combination of laxatives and/or anti-spasmodic drugs in enzyme preparations. **38.5% w/w or v/v whichever is appropriate. India. Minimum 450 mg 300 mg 1000mg Maximum 600 mg 400mg 1500 mg Fixed dose combination of Histamine H-2 receptor antagonists with antacids except for those combinations approved by Drugs Controller. **33. **34. **39. **41. **36. having high atropine like activity in expectorants. Fixed dose combination of Metoclopramide with systemically absorbed drugs except fixed dose combination of metoclopramide with aspirin/paracetamol.

Antidiarrhoeal formulations containing Koalin or Pectin or Attapulgite or Activated Charcoal. Dover’s Powder Tablets I. 51. Chloral Hydrate as a drug. *** 43. 52. Antidiarrhoeal formulations containing Phthalyl Sulphathiazole or Sulphaguanidine or Succinyl Sulphathiazole. 562 . 44. dextrose: sodium molar ratio-not less than1:1 and not more than 3:1 (b) Cereal based ORS on reconstitution to one litre shall contain: total osmolarity not more than2900mOsm. Antidiarrhoeal formulations containing Neomycin or Streptomycin or Dihydrostreptomycin including their respective salts or esters.P. Dovers Powder I.Precooked rice equivalent to not less than 50g and not more than 80g as total replacement of dextrose (c) ORS may contain amino acids in addition to ORS conforming to the parameters specified above and labeled with the indication for “Adult choleratic Diarrhoea” only (d) ORS shall not contain mono or polysaccharides or saccharin sweetening agent 53. 47.P. 45. Liquid Oral antidiarrhoeals or any other dosage form for pediatric use containing Diphenoxylate Lorperamide or Atropine or Belladona including their salts or esters or metabolites Hyoscyamine or their extracts or their alkaloids. 48 49. Fixed dose combination of Oxyphenbutazone or Phenylbutazone with any other drug.combinations of Pectin and/or Kaolin with drugs not systemically absorbed. Liquid Oral antidiarrhoeals or any other dosage form for pediatric use containing halogenated hydroxyquinolines. 50. 46. Fixed dose combination of antidiarrhoeals with electrolytes. Patent and Proprietary Oral Rehydration Salts other than those conforming to the following parameters (a) Oral rehydration salts on reconstitution to one litre shall contain: sodium-50 to 90mM.

55. 99 GSR 814(E) Sep.3.12. 16.54.99 Jan 1. 1. 57. protease And lipase with any other enzyme Fixed dose combination of Nitrofurantoin and trimethoprim.10. 2. Fixed dose combination of Analgin with any other drug.01 563 . 58. Fixed dose combination of Pancreatin or Pancrelipase containing amylase. standards of which are prescribed in the Second Schedule to the said Act with an Ayurvedic. 4.SALE AND DISTRIBUTION FROM SUBSEQUENT DATE Drugs Formulation Effective date Notification 1. 59. Siddha or Unani drug.99 Sep 1. DRUGS PROHIBTED FOR MANUFACTURE. Fixed dose combination of dextropropoxyphene with any other drug other than antispasmodics and/or non-steroidal antiinflammatory drugs (NSAIDS) Fixed dose combination of a drug. Fenfluramine and Dexfenfluramine.92 GSR 93 (E) dt. 25. Fixed dose combination of Diazepam and Diphenhydramine Hydrochloride. 12. Mepacrine Hydrochloride (Quinacrine and its salts) in any dosage form for use for female sterilization or contraception.4.1998 GSR 444 (E) dt.2001 GSR702 (E) dt. 2000 GSR 814(E) dt. Cosmetics Licensed as toothpaste/tooth Powder containing tobacco Parenteral Preparations fixed dose Combination of streptomycin with Penicillin Fixed dose combination of Vitamin B1 Vitamin B6 and Vitamin B12 for human use Fixed dose combination of haemoglobin in any from (natural or synthetic). 2002 GSR 170(E) dt.14. 2000 dt16. 12.30.2.97 Jan 1. 6. 56. 5. 3. With immediate effect Jan 1.

2002 GSR 170 (E) dt. 2004 July 25.01 Jan 1. Valdecoxib and it’s formulation 564 GSR170 (E) dt.5.01 Jan 1.3.07. 1.3.3.1.12.2002 GSR 170 (E) dt.2002 GSR170(E) dt.3.03 GSR 191 (E) dt.2002 GSR170 (E) dt. 12. Fenformin 17. 2003 Dec 13. 12.3.3.3.1.5.12.7. 04 GSR 510(E) Dt25.2003 Apr. 2005 15.05 .3.12. 1. 8.12.2002 Jan 1. Rofecoxib 18.2003 Oct. 12. 13. Terfinadine 16.01 Jan 1.2003 Apr.01 GSR 170 (E) dt.01 Jan 1.2002 GSR 170 (E) dt. 03 GSR 810(E) dt. 13. 14. 9. 10 11.03 GSR 780(E) dt . 10.3. Fixed dose combination of Phenobarbitone with any anti-asthmatic drugs Fixed dose combination of Phenobarbitone with Hyoscine and/ or Hyoscyamine Fixed dose combination of Phenobarbitone with Ergotamine and/ or Belladona Fixed dose combination of Haloperidol with any anti-cholinergic agent including Propantheline Bromide Fixed dose combination of Nalidixic Acid with any anti-amoebic including Metronidazole Fixed dose combination of Loperamide Hydrochloride with Furazolidone Fixed dose combination of Cyproheptadine with Lysine or Peptone Astemizole Jan 1.01 Jan 1. 12.12.01 GSR 191 (E) dt.

APPENDIX 8 ADVERSE DRUG EVENT REPORTING FORM 565 .

..................... 422 Alendronate .............................. 195 Adenosine arabinoside ...............INDEX Abacavir .................................................................................................................................................................. 119 Amikacin ................................................................................................ 190 Acetylcystine ......................................... 116 Amantadine .. 99 Alemtuzumab ..................... 344 Adrenaline .............................. 344 Amidotrizoate .................................................................................................... 137 Alkylating Agents ................................................................................................ 293 Acetretin .................................. 141 Aluminium hydroxide ................................................................................................................................................................. 257 Albendazole .......... 273 Anti D Immunoglobulin ................................................................................... 135 Allopurinol .....................124 Ambroxol ............................. 88 Aceclofenac . 259 Anti Tetanus Immunoglobulin ............................................................................................................................................................................................ 88............................................................ 169 Alprazolam ............................................................. 344 Acetyl salicylic acid ...............................................................................................................103..................... 413 Acyclovir ............ 31.......................................................................... 326 Altepase ............................................................................... 85 Adapalene ............................................................... 35 Acetazolamide ......................................................................... 259 AlphaMethyldopa ................. 105 All Trans Retinoic Acid (ATRA) ...................... 200 Amifostine .. 222 Anastrazole ....................................................................................................................339 Activated charcoal ........................................ 69 566 ...............................

............... 114 Aspirin ...................................................... 254 Antiviral drugs .... 91 Antispasmodic .... 246 Antiandrogens ............. 92 Artesunate ............Amiloride ..................................... 225 Antithyroid drugs .............................................................................................................354 Asparaginase ........................................................................................................................................................ 11 Aminophylline ..... 83 Antihistamines ...............................................213 Aminoacid infusion ............................. 93 Ascorbic acid .................................................................................... 10. 138 Atenolol .............. 220 Antimalarial drugs ... 315 Antifungal drugs ....................................................................................................................................................... 351 Aminoglycosides .............................................................................................................................................. 342.........................161 Atorvastatin . 222 Anti oestrogens ......................345 Amitriptyline ............. 83 Ampicillin ......................... 156 567 ...................................................................187 Amphotericin – B ..................................................................187 Androgens ................................................................................................................................................................................................... 156 Antidepressants .......................................................... 153................................ 64.......... 178........................................................................................................................ 243 Anticoagulants ....................................................................................................................................................................................................................................................................276........................................................315 Amlodipine ............... 166 Amoxapine ......... 63................. 160................................................ 143 Artemether ....................................... 318 Amoxycillin ................................................................... 278..........371 Amiodarone ... 242 Antacids ............... 85 Aprotinin ...........................................

.......................... 173 Botulinum toxin .......................... 130 Bleomycin ............................. 187.................................................................................................................. 77 Baclofen .......................................................................................................................361........................................................................................................... 62 Benzhexol .................................................................................. 234 Barium sulphate ................... 293 Bethanechol ................................................. 231 Bisoprolol ................. 153 Betamethasone .................................................................. 343.......................... 281 Balzalazide ...................340 Azathioprine ............................................. 360 Azithromycin ...............................372 Benzathine penicillin ......................... 11.......................... 261 Beclomethasone Dipropionate ................................................... 74 Aztreonam .................................................. 125 Benzoyl peroxide ......................... 194 Benzylbenzoate .......... 201 BCG vaccine ............................................................................................. 157 Biguanides ............61 Beta blockers ............................................................................... 282 568 ............................................................................................................................................................................................................................ 42 Azelastine ...................................................................................... 275 Bezafibrate ................ 111 Bosentan ............................................................. 284 Atropine sulphate ..............................................................................................................239 Betaxolol ......... 251 Biotin .................................... 68 Bacitracin .................................. 162 Bisphosphonate ............................................................ 353 Bisacodyl ................................................................ 256 Bivalirudin ......................220......................................................................................................................................... 27...................................................................Atracurium .... 191 Benzyl penicillin ..........................

........................................................ 67 Cefoperazone ...................................372 Bupivacaine ............................................................................................................................... 344 Bromocriptine ....................................................................362...............................................................306............................. 219.............................................................................................................................. 65 Cefepime .... 163.................................................. 327 Calamine ... 65 Cephalosporins .... 255.............................................. 121 Budesonide ............. 66 Cefotaxime ........................................................................ 283 Carvedilol . 188 Calcium polycarbophil .... 66 Ceftriaxone .......343............. 66 Cefuroxime ............................................................................... 254 Carboplatin ....................................................................................................................................................... 67 Cefixime .................................................. 67 Ceftazidime ..................................... 65 Cephalexin ......................... 51 Carbimazole ..................................................................................................................................................................... 67 Cefazolin ......................................................... 66 Cefpirome ............... 324 Buspirone .........................Bromhexine .............................................. 170 Carbamazepine ......... 23 Buprenorphine ........................................................................................................................................................ 189 Captopril .................................345 Cefdinir ... 115 Carisoprodol ............................................................................ 65 Cefpodoxime proxetil ...... 64 569 ......... 233 Calcium channel blockers ................................357 Calcipotriol ...................................................................... 163 Calcium gluconate ..... 41 Bupropion ..........................................................................................................................233............................................................................................................................................................................................................................................

............... 188 Carbidopa +Levodopa ..................................... 114 Citalopram ......................................................................................................... 168 Clopidogrel ........................................ 10...............................190 Ciclopiroxolamine ................. 11.............................................................................. 307 Chlorthalidone ............................................................................... 105............................... 71 Chlorhexidine .......... 220 Cetirizine ..................................................................................... 220 Chlorpromazine ........................... 120 Codeine Phosphate ...............................91.............................................................................97................. 304 Clomipramine ...................................... 75.................. 208 Cholestyramine .................. 197 Clomiphene Citrate ...................................... 43... 321 Clarithromycin ......................................220..............198 Clindamycin ......................... 182 Ciprofloxacin ................................... 220.............................................................341 Chenodeoxycholic acid .......... 10......... 10...................................................... 73.............................269 Chloramphenicol ...................................................................................................................................................................................................................................................................................................................................... 235 Chlorambucil ................................. 10............................................................................................................................................ 139 Clotrimazole ............ 41 570 ..................................... 159 Chloroxylenol ..........................303 Clobazam .................................................................. 205 Chloroquine ...... 35 Clofazamine ..................187 Clozapine ..........340 Chlorpheniramine Maleate ...................................302 Cloxacillin .............................................................................. 274 Cyclosporin .................................Ceruminolytics .......................................................... 182.... 312 Coal Tar Ointment ......................... 79 Cisplatin .....................318 Clonidine ............... 63..........

................. 267 Cytarabine (cytosine arabinoside) ........................ 245 Copper .................................................................... 239 Dextran 70 .........................................281.............................................................................. 112 Danazol ......... 293 Cyclophosphamide ..........................................................................................................................................................................................................................................325 Diclofenac Sodium ...........105.................................................196 Daunorubicin .....................................28.... 243 Dapsone ......................................................................................................................................27.................................................. 193................................ 111 Deferiprone ...................................................................................................................... 33 Dicyclomine ..........................................263 Cycloserine ...................................................... 174....................... 132 Dexamethasone .341 Didanosine ................ 97 571 .......................................... 354 Diloxanide furoate ......................................... 225.... 25 dihydroxy Cholecalciferol (Calcitriol) ....................................... 353 Cyclopentolate ............................................................................................................................................................................ 81 Cyanocobalamin ........... 239 Deriphylline ....................... 255 1............................................................................................................. 41 Diazepam ...... 133 Deflazacort ............................... 368 Cyclosporine ............. 146 Dextropropoxyphene ....................................................................... 89 Diethylcarbamazine .................................... 109 Dacarbazine ............................... 10.......... 10................. 101 Digoxin .....Conjugated oestrogen ... 342 Desferrioxamine .......................................................................................344 Dihydrotachysterol .... 107 Dactinomycin ............................................................................................................................................. 358 Co-trimoxazole ...............................

........................... 286 Efavirenz ................................. 178 Dipyridamole ..................................................................................... 175.......................................................... 113 Domperidone ................................................................................................. 176 Disulfiram .................................................. 123 Epinephrine ..............Diltiazem ......341 Donepezil .................................................... 142 Ergocalciferol ................................................................................. 164 Diphenhydramine ................344 Docetaxel ................ 188 Dobutamine ............................................................................................................................................................................ 10..................... 188 Enalapril ....................................... 318 Doxapram ......................................175 Entacapone .............................................................................................344 Dothiepin ............. 180................................................................................................................ 131 Edrophonium ................................................... 10.... 322 Dutasteride ............................................................................................. 255 Erythromycin .............................................. 110 Doxycycline ................................................................................341 Epirubicin .... 261 Duloxetine ..........72 572 ........................... 71 DPT vaccine ....................... 375 Doxepin ...................................... 113 Epsilon amino caproic acid (EACA) ................................. 275 Eculizumab ... 319 Doxorubicin .................................................................................................................................................................................................................... 329 Dithranol ............................................................. 138 Disopyramide .................... 227......................................................................90 Emollients ........................................................................ 287 Dopamine ............................................................................... 171..................... 341 Diphenylhydantoin ............................................................................................. 23..............................................................

372 Fluvoxamine ...................................................................................................................Esmolol .. 50 573 ................................................................................................................................................................................................................................................................ 109 Fluconazole .............................................................................................................................345 Ethambutol ....................................................... 166 Fenofibrate ......... 309 Flurazepam ........... 162.............................................................................. 187 Fludarabine .......................... 276 5 – Fluorouracil ....................................... 224 Felbamate .................................................................. 368 Ethosuximide ............................... 243.............................................. 320 Fondaparinux ........................................ 158 Famotidine ........................................... 310 Fluphenazine .......... 35 Ezetimibe ............ 343............................... 53 Ethanol .................................................................. 206 Etoposide .................................................................................................. 115 Etoricoxib ................................................................................................................................... 84 Fluorescein Sodium .................................................................................................................................................... 365 Ethinyloestradiol ...................................................................................................275 Flavoxate ................................................................................................... 129 Folic acid .................................................... 157 Fexofenadine ....................... 319 Flupenthixol ............................................... 328 Flutamide ..................................................... 221 Finasteride . 244 Fluticasone propionate ........................................................................... 204 Fluoxetine ................................................ 59 Felodipine ................................................... 245 Ethionamide .. 353 Fosphenytoin ..................................................................................... 136 Flucytosine ....................................................................

................................................................................................................................................................................................ 249.. 56 Galantamine ........................................187 Frusemide (furosemide) ........................................ 250 Glucagon ........................... 228..................................................................................... 237 Glutaral ............................................................ 209 Glycerine .......................... 11....... 261 Homatropine .128 Hepatitis B Immunoglobulin ....................... 167 574 ....................................... 85 Gatifloxacin ............................................................... 118 Gemcitabine ........................................... 249 Glipizide .............................250 Gliclazide . 232 Glyceryl Trinitrate ........................................................................................................................................................................................................ 288 Ganciclovir ...................................Framycetin ..............................................................................................................304 Haloperidol ................. 250 Glimipiride .................................. 151 Glycopyrrolate ....................................................................... 185 Glibenclamide ........................................................................................................................ 30 Granisetron ................... 10................................................................................... 186 Griseofulvin ............. 351 Glucocorticoids ..................................................... 157 Gentamicin ........ 69 Gentian Violet ............................................................................................................................................................. 70........................................... 186 Gabapentin ...........................................................................309 Halothane ............. 210 Fusidic Acid ............................................... 252 Glucose ......................................... 18 Heparin ................................................................................ 110 Gemfibrozil ..... 80 Gefitinib ....................................................................................................................................................................... 294 Hydralazine .............................................................

............................................ 18 Isoniazid .............................. 247 Hydroxy Urea . 131 Hydroxyzine ...................................................................................................................188.........................................................................................240........................................................ 372 Injectable contraceptives ...............................................................358 Isoflurane ..317 Indapamide ............................................................ 342....................................................341 Indinavir ..........................................................................117 Immunoglobulins ........................ 33..................................................... 202 Ipratropium Bromide ............. 127..............241............. 11.............................................................. 226.......................... 359 Iohexol ............................... 34................................................... 118.................................... 106 Imatinib . 152 575 ...................................................................... 67 Imipramine ................................................................ 128 Hydroxy pregesterone caproate ........................ 251 Interferon Alpha .................................... 234 Inhaled steroids ..................90 Ibuprofen .............................. 2.......................... 76........370 Iron ............................................... 152 Isosorbide Dinitrate ........... 106.........272 Indomethacin ............128.............. 10.......................................................363 Isoprenaline .................................. 87...................341 Hydroxocobalamine ............................................................ 303 Insulins ............ 181 Isosorbide 5 mononitrate ................ 10........................................340 Infliximab ....................................................159.............Hydrochlorothiazide ....................339 Ifosfamide .................................................... 153 Iodine ......................................................................................210 Hydrocortisone ................... 258 Intravenous nitroglycerine ............................................................................................. 221 Hyoscine butyl bromide ..............137 Imipenem ........................................................................ 159...........................................................

............................................. 171 Lithium Carbonate ........................................................................ 58 Letrozole .......... 78 Liquid paraffin ..................................................177.......Ispaghula husk .............. 55 Lansoprazole ..................................................................................................................................................... 327 Losartan ........................................ 69.. 163 Lactobacillus Acidophilus ......... 89 Lamotrigine .................................. 229 Lactulose ............... 80 Levothyroxine sodium ............................................................................................. 156 Lugols Iodine ................ 26.............................................................................. 172................................................................................................... 19 Ketoconazole ......345 Linezolid ............................. 231 Lamivudine ......................... 253 Lignocaine ...................184 Ketorolac .................345 Lovastatin .................................374 Labetalol ................................................... 185 Ivermectin ............ 183.......................................................................................................................................... 231 Lisinopril ... 229 Loratidine ........................................................................................ 324 Lomefloxacin ...................................................................................................................................................................................................................................................... 255 576 ......................................................................367 Ketamine ............................................................................................................................................. 37 Ketotifen ................................................................................................................................................... 221 Lorazepam ..................................191 Kanamycin .... 23............. 232 Itraconazole ............................................................................................................................. 79 Loperamide ............... 224 Levetiracetam ............................. 362....................... 102............................................................................ 116 Levodopa ............................................. 120 Levofloxacin .........

............................................................................................................................................................................................................................................... 222 Magnesium sulphate ...........................Loxapine ........................................................... 357 Magnesium trisilicate ......................................340 Methyl Ergometrine ........................................................................ 305 Mefenamic Acid ...................................................................................................... 241 Mexiletine ..............................................342 Mannitol ..................................................306.................................................................340 Mefloquine ................................................................................. 213 Measles vaccine ............ 281 Methotrexate ......................................................................................... 299 Methyl Prednisolone .................. 226 Metoprolol ....................................................................................................................................................................... 99 Medroxy progesterone acetate . 108 Meropenem ............... 93 Meglumine ....... 44..................................................................... 68 Mesalazine .......... 119 Metformin ...... 234 Mesna ........................................ 203 Melphalan ............. 21 577 ................................ 161 Metronidazole ............... 35.....................................................................270 Metoclopramide ................190.................................... 238. 311 Macrolides .............................. 60......................................................... 251 Methadone .................................................................................. 222 Magnesium Salts ..305.....................329 Methocarbamol ......................................................................................................... 262 Mebendazole ...................................107............ 182 Midazolam .................................................................................... 95 Metyrapone . 72 Magnesium hydroxide ....................... 10...................................... 177 Miconazole .................................................................................................... 106 Mercaptopurine ............................................................

............................................................... 340 Nedocromil sodium ................. 10..... 91 Nicorandil .......................................................... 186 Neostigmine .................................................................... 403 Minocycline ........................... 373 Neomycin ........................................................................................................................................ 158 Nifedipine .....Milnacipran ..... 343 Morphine ......................................................................... 218 Naproxen ...... 322 Mitomycin ................................ 151 Nitrazepam ................................. 194 Misoprostol .................345 Nimodipine ................................................................ 112 Moclobemide ..........286 Netilmicin ................................................................................................... 155 Nicotinamide ............................................................................................................................................................................ 77 Mycophenolate mofetil .... 328 578 .................... 322 Mifepristone ........ 38 Mosapride .......................................... 228 Moxifloxacin ................................................................................................................................................................................................ 27.................................................................. 269 Naphazoline ...............................................165.................................................................. 70 Neomycin + Bacitracin .............................................................................................................................................................................. 273 Nevirapine .................................. 323 Monteleukast .............. 166 Nitrates ................................................................... 71................................................................................................................................... 301 Mirtazapine ......................................................................................................... 69 Neutral phosphate .............................................................................. 81 Mupirocin ............................. 301 Minerals .......198 Minoxidil ...................................... 403 Nicotinic Acid .........................................................................................................................

.................................................................................................................... 368 Paracetamol ............... 115 Oxazepam ............................................................................. 350 Orphenadrine .................. 32......................................................................339 Parenteral nutrition ..................................... 18... 276 Oxygen therapy ........ 225 Para Aminosalicyclic Acid (PAS) ......... 284 Pantoprazole ................................................................................................................................................................................................... 86 Oxcarbazepine ............................................................................. 21 Norethisterone ................................................................................................. 38 Oral contraceptives ........ 327 Oxybutinin ....................................... 22 Oxymetazoline ........................................................... 10............................ 113 Pancuronium .......................................................................................197 Olanzapine .......................... 274 Oseltamivir ............................................... 313 Omeprazole .................................................................................................................................... 84 Oestrogens .. 78 Nortriptyline ....................................................................................... 298 Paclitaxel ....................................... 387 Papaverine ........... 317 NSAIDs .. 224 Ondansetron ............................................................................................................ 305 Norfloxacin ......... 126 Orthophosphate ......... 79........................ 279 579 ...........................................................................................104............................................................................ 218 Oxytocin ................................. 244 Ofloxacin ..................................... 303 ORS ........................................................................................................................................................................................................................................................ 52 Oxaliplatin ...................................................Nitrous Oxide ................................................. 227 Opioid Analgesics ............. 31 Nystatin .........................................................................

....................................178 Pholcodeine .......................................................................................................................................................... 262 Potassium ............................................................................................................................... 79 Penicillamine ...................................... 64 Piperazine ............................................................................... 63 Penicillins .....................................................................................Broad spectrum ................. 100 Piroxicam ........... 190 Polyene Antibiotics ........ 36 Podophyllum resin .................................. 360 Phenytoin ........................ 39 Pheniramine Maleate ............................................................................................. 98 Pentazocine ............274.......... 77 Polymyxin – B ................................................. 357 Pimozide .... 11 Pentamidine ......................................................................................................................... 272 Potassium permanganate ............................................................................... 40 Perindopril ......................... 172 Permethrin ... 320 Pefloxacin ..................... 49....340 Penicillin G ...................................................................... 61 Penicillin V ............................ 356 Potassium citrate ................................. 46......................................................................... 63 Phenylephrine ...................................... 10................................ 63 Penicillins .......................................................................................................................................................... 49 Phenoxymethyl penicillin ........................................................Paroxetine .......................betalactamase resistant .................................................................................. 311 Piperacillin ............... 192 Pethidine .......................................................................................................................... 184 580 ..... 376 Phosphorus .. 63 Penicillins ......... 77 Poliomyelitis vaccine (oral)IP .......................................................................................................... 10........................................................................................................................... 341 Phenobarbitone .........................................

..................................................................................270 Prednisolone ..................................................... 100 Pyrazinamide .......342 Pregabalin ... 62 Prochlorperazine ................................. 225 Rabies Immunoglobulin .. 101 Prazocin .............................................. 122 Praziquantel .................................................................. 229 Ramipril ..341 Propranolol ... 273 Pyrimethamine ......................... 286 Pyridoxine ........................................ 189 Pyrantel pamoate ................................. 29.............................................................................................................. 299 Psoralen ........... 10................................................... 237.........................134.. 172 Raloxifen ................................................................................ 10............................... 104.............. 365 Pyridostigmine .... 95 Quetiapine ................................ 169 Prednisone ........................................126............................................ 27...................................................... 206 Pramipexol ............................................................................................ 254 Prostaglandin ...................................................... 247 Promethazine ......................................... 246 581 .176 Quinine ...... 260 Racecadotril ............................................. 94 Quinidine . 125 Progesterone .......................................................................................................................................................................................................... 131.............................................160 Propylthiouracil ....................................................................................................................................................... 59 Primaquine .......................................................................................................................................Povidone iodine .................................................................................................................................................................................................................. 309 Procyclidine ..................................................................... 176 Procaine penicillin ......................................................................................................... 314 Rabeprazole ..................... 94 Procainamide ..........................

..................................................... 10 Secnidazole ..................................................................................... 342............................................................. 117 Ropinirole ......197............................................................................................................................................ 319 Sildenafil ............................................... 123 Reboxetine ............................... 355 Sodium cromoglycate .................................................................369 Salicylic acid ................................... 268 Sisomycin ................ 352 Rifampicin ............... 167 Sodium Stibogluconate ...................................................................... 182 Salmeterol ......................... 10 Rituximab .................................................... 97 582 ..................................................................................................... 123 Selenium sulphide ................... 343 Saquinavir ....................... 313 Ritonavir ..................................356 Sodium Chloride ................................................... 97 Selegiline ....................... 223 Ranolazine ....................................................... 183 Sertraline ................................................................361 Sodium Etidronate ............................................................................ 86 Risperidone ............................................................................................................................................. 186 Sodium bicarbonate . 256 Sodium Nitroprusside . 220...................................... 219.......... 155 Rasagiline ... 280 Silver-sulphadiazine .................................................................................... 122 Rosuvastatin ........................................................................................................................................ 74 Salbutamol .........................................................................................................278........................................................................................................................................................Ranitidine ...............................................................364 Rimantidine ........... 156 Roxithromycin ....................... 323 Riboflavin .............................................................................................. 82 Sirolimus .......................................... 11..................................................

.................. 306 Testosterone ................ 170.......................................................................275 Terbinafine ..................................... 117 Theophylline ................... 107 Terazosin ...........................................233 Sulphonamide ......................................................................370 Terfenadine ............ 193 Tacrolimus .366 Sulphacetamide ............. 75 Spironolactone .... 10.................................. 242 Tetracycline ................................ 90 Streptokinase ...........................................................370 Thiamine .............. 285 Synthetic progestins ............................................................................................................................... 81 SulphonylUreas ................................. 70 Thalidomide ............................... 343........................................................................................................ 268 Tadalafil ........... 183 Sodium valproate ............................................ 45....................................................................................185 Terbutaline ................................... 83 Sulphasalazine ............................................................................................................................. 68......................................... 179 Sparfloxacin ........................................................................................................... 183..................... 247 Systemic corticosteroids ......................................................................................................................... 77 Temozolamide ...... 53 Sotalol .............. 352 583 .................. 280 Tamoxifen ..........212 Stavudine ............................................................... 249 Suxamethonium Chloride .................................................................................................................. 140 Streptomycin ................................................................................................................................ 232 Teicoplanin .......Sodium Thiosulphate ........................................................................................................................116 Tegaserod ....................................... 159....... 11........................................................................................................ 80 Spiramycin ................................................................. 10......................................................

............................. 141 Ursodeoxycholic acid .........................Thiazide diuretics .............................................................................................. 57 Tibolone ....................................... 135..................... 186 Topical Steroids ....................................................................................................................................................................................................................................... 141 Tizanidine ...... 253 Thyroxin Sodium (T4) .................................................................................................................... 246 Ticarcillin ............. 210.......................................................................................................... 64 Ticlopidine .. 189 Topiramate .................................................................. 125....................................... 81 Urokinase ............................... 305 Trastuzumab ................................................ 235 584 ............................................................................................................... 282 Tolterodine tartrate ......................................... 253 Tiagabine .........................................................................................................................................272 Thiopentone sodium .... 308 Trihexyphenidyl(benzhexol) ..................253 Trimetazidine ......................... 160 Trifluoperazine ............................................................................................................................................................................................ 97 Tissue Plasminogen Activator (Altepase) ..... 118 Tretinoin .................................................... 40 Tranexamic acid ........................................................................................................................................................................................... 308 Thymoglobulin .......... 57 Torasemide .................................................................................................................................................... 277 Topical antibiotics .............................. 240 Triamterene ...195 Triamcinolone . 20 Thioridazine .............................. 139 Timolol ..... 154 Trimethoprim-Sulfamethoxazole ......................... 10 Tinidazole ............... 271 Thyroid Hormone ............................................................................................ 211 Tramadol ........................

................................................................................... 10............................................................................................................................................................ 56 Vinblastine ............................ 10................ 354 Vitamin E .............163.................. 314 Zopiclone .......................... 315 585 ...................................................... 285 Venlafaxine ............345 Vigabatrin ............................................................................ 261 Valaganciclovir ............................. 355 Warfarin .......................................................... 352 Vitamin B6 ..................................................................Vaccines ............................................................ 352 Vitamin B2 .......................................................................................................... 85 Vancomycin ................ 353 Vitamin D .... 113 Vincristine .................................................. 118 Zuclopenthixol ............................................................. 130 Xipamide ..................... 218 Zafirlukast .. 88 Zinc sulphate .......................................... 76 Vecuronium ................... 328 Zoledronic acid ........................................................................... 355 Vitamin K .................................................. 358 Ziprasidone .................................. 321 Verapamil ......................................................................................................................................................... 159 Xylometazoline .................................................................................................................................................................................................................. 374 Zidovudine .....114 Vitamin A ..........................................................................................................................................................................................................................