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:: Numwans Short Note ::
HIV
gp41 CCR-S (cell)
RNA virus retrovirus (RNA DNA)
gp120 rec CD4 cell
1. Primary HIV infection (1-6w) , , , , , N/V, ,

anti-HIV negative
2. Asymptomatic 8-10 HIV Ab+
3. Symptomatic
Ab+ 3
>37.8 , , .>10%, >1, ,
4. AIDS , CD4<200,
:
Goal: CD4>200cell, viral load<50 copies/mL
pregnancy, nephropathy
2NRTI + 1NNRTI (or 1 PI+booster)

1. d4T + 3TC
2. AZT + 3TC
CD4
<200
200-350
>350
CD4 3
CD4 6
+ NVP/EFV/IDV+RTV(booster,enz inhibitor)
*EFV NVP . NVP
EFV
( )
d4T + AZT -> antagonism
. dose IDV ..
. dose NRTI CrCl (AZT, d4T, 3TC, ddI, TDF) ..NNRTI and PI
GPO-VirS : 4dT + 3Tc + NVP / GPO-VirZ : AZT + 3Tc + NVP
HIV
TB & HIV :
HIV : Rifampicin()
. Enz CYP450 and g-plycoprotein NNRTI and PI
HIV :
Rifam =
Rifam : EFV
EFV or NVP TB Rifam PI=based regimen
DRAFT Version 2/2011
:: edit by hongyuu :::
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NVP HAART TB rifam
Side Effect
1. NRTIs < neucleoside reverse transcriptase ez.>
. AZT : N/V, myopathy(minor), (), neutropenia,
. d4T : peripheral neuropathy ( ddI), enz , lipoatrophy ( , ),
, TG , hyperlactenemia, lactic acidosis 2
. 3TC :
. ddI : peripheral neuropathy, pancreatic, , lactic acidosis
i. ,
. TDF :
2. NNRTIs <rash, hepatitis>
. NVP : rash, hepatitis
. EFV : rash , , (), Cat D
3. PIs<hyperlipid>
. IDV : N/V, , , , hemophilia, ( TG,LDL , HDL)
Pravastatin ( CYP)
. RTV
i. : GI N/V
ii. PI booster/CYP3A4 inh
iii.
4. Fusion inhibitorenfurirtide (SC)
Oppotunistic Infection
A. Fungi
1.Candidiasis (Orapharyngeal candidiasis) . symptomatic
: Clotrimazol oral troches 10mg vaginal tab , 4-5 times daily x 10-14
2nd:
Nystatin Solution, Fluconazole 100 mg 1x1 (7-14 d)

Itraconazolesusp. 100 mg 1x1
Ampho B
2.PCP( Pneumocytis pneumonia )
1st prophylaxis : Bactrim SS (80/400) 2x1 ( Toxo )

TMP 5mg/kg + SMX 750 mg/../ 2 dose 3d/w
: Dapsone 100 mg 1x1 or 50mg + pyrimethamine 50mg
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Dapsone 50mg OD + pyrimethamine 50 mg 1d/w + Folinic acid(leucoverine) 25 mg

1d/w
Dapsone 200 mg OD + pyrimethamine 75 mg 1d/w + Folinic acid(leucoverine) 25 mg 1d/w
CD4 > 200 cells/mL 3
: Bactrim ( TMX 15-20 mg/kg/d or SMX 75 mg/kg/d) x 21 days

TMX 15 mg/kg/d + Dapsone 100 mg/d x 21days
Clindamycin 600 mg IV q.8h or 300-450 mg q.6h + primaquine 30mg/d x 21days
, Kernicterus
2ndprophylax = 1stprophy
3.Cryptococcus( CD4< 100) /
1st pro : Fluconazole 400 mg 1d/w

CD4 > 100 cells/mL 3
:
Induction :
Ampho-B 0.7-1 mg/kg/d IV x 14 d
Consolidation :
Fluconazole400 mg/d 8-10w
amphoB Fluco, Itra
2nd pro : Fluconazole 200 mg/d or Itraconazole 2-5 mg/kg 1x1
B. Protozoa
Toxoplasmic encephalitis (CD4 < 100) >> , ,
1st pro : BactrimSS 2x1 = DS 1x1
Treatment :
Pyrimethamine 200mg 1x1 50-75mg/d + sulfadiazine 1-1.5g 1x4 + folinic a 10-20

mg/d 6
sulfa Clinda 600mg q 6-8 hr or Azithromycin 800-1200 mg/d
2nd pro: Pyrimethamine 25-50 mg + sulfadiazine 500-1000 mg 1x4 + folinic 10-25 mg/d
C. virus
Cytomegalovirus (CD4<50) ~ retina (CMV retinitis)
1st pro :
Treat : Gancyclovir 5 mg/kg q 12 h IV ( 2-3 w)
2nd : Gancyclovir 5 mg/kg IV q 24 hr or Foscarnet 90-120 mg/kg IV
D. Bacteria
Mycobacterium avium complex (MAC) CD4< 50 GI&RI
: , . , , , WBC
1st pro:
Treatment :
Clarithromycin 500 mg 1x2 or
CD4 > 100
Azithromycin 1200 mg 1 d/w
Clarithromycin 500mg 1x2 + Ethambuthol 15 mg/kg/d
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Azithromycin 500-600 mg/d + Etham 15 mg/kg/d

Azi clarithro Azi DI clarithro CYP3A4(inh)
PI, NNRTI, rifam, ergot ..
nd
st
2 pro : as 1 pro CD4 > 100 or MAC 12 m
MCV ( Mean Corpuscular Volume) RBD

MCV =
RBC normocytic
82-97
Hctx10 mcm3 or fl
Higher
RBC macrocytic
B12, folic, liver dz, alcohol
RBC count (million/mcL)
lower
RBC microcytic
Fe, Thalassemia
MCH ( Mean Corpuscular Hemoglobin) Hb RBC

MCH = Hbx10 / RBC count
pg/cell
* hypocromic and mycrocytic anemia
High (28-33 pg/cell)

Low
Macrocytic anemia
Microcytic&hypocromic (Iron def)
MCHC ( Mean Corpuscular Hemoglobin Conc) 32-36 g/dL: conc Hb RBC 1

MCHC = MCHx100/MCV or Hbx100/Hct
o
MCH hypochromic and microcytic anemia
hypocromic anemia &Thalassemia
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Thalassemia
Hb RBC RBC

RBC O2
(RBC
)
RBC :,
:, , , . , , ,
4-12 wk
..
Folic acid 2-5mg RBC (RBC) 5-10mg
oxidant drug ex. Sulfonamide
Hb 1 0 g/dl 12 g/dl
( 200 ml/kg/ )
Desferoxamine (sc)
Gene therapy

1. Infection ->
RE system
RBC
2. Heart & Pericardium
a. (Hb ) . O2 hyperdynamic
circulation ->
b. Arrhythmia :
Vit B12 & Folic acid : DNA RBC

DOSE : Folic acid : .>1 5 mg OD.
(PRC)
: . Hb
Hb > 7g/dl
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Hb (~ 10g/dl)
PCR protransfusion Hb = 6-7 g/dl
10mg/kg 3 hr.
. Hb < 5 g/dl
PCR 2 Hb ( 5 mg/kg )
< 2mg/kg/hr ( 24-48 hr)
diuretic PCR
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Anticoagulant, Antiplatelet, Thrombolytic drug

clot
1. thromboplastin intrinsic factor(5,8,9,10,11,12) & extrinsic system (Factor 5,7,10)
2. Thromboplastin proteolytic enz prothrombin thrombin
3. ----------------------------------------------------- fibrinogen fibrin

1. Prostacyclin (PGI2) endothelium

2. Protease inhibitor ex. 1-antiprotease, 2-macroglobulin, 2-antiplasmin, antithrombin 3
3. Heparin sulfate proteoglycan endothelium . antithrombin
4. Protein C&S
Cofactor Va & VIIIa

5. Tissue factor pathway inhibitor (TFPI) lipoprotein factor Xa & VIIa
6. Antithrombin (AT) inactive serine protease IIa, IXa, Xa, XIIa
Anticoagulant Drug : ( Heparin, Hirudin, Wafarin )

(clot) & clot

1. Heparin (gen.1) granule mast cell () Mw 750-1000 kDa
Pharmacology : antithrombin & clotting factor (2a,10a,11a) & thrombin
LMWH(Enoxaparin) (gen.2) 1-10 kDa , activated factor X , factor thrombin (2)
Efficacy F F > sc & ( 1-2 /d )
Protein binding
aPPT
PTT .
Enoxaparin clot 50 mg OD 1x2
PK : IV or SC ( IM local bleeding)

SE: bleeding, transient thrombodytopenia, Alopecia, Osteoporosis
DOSE: start bolus 5000-10,000 unit & cont. infusion 900 unit/hr
Antidote : Protamine () heparin () complex
Fundaparinux (gen.3) :
2. Hirudin specific thrombin inhibitor
. thrombocytopenia heparin
3. Wafarin (Coumarin anticoagulant)
VIT.K
S form R-form 4
Oral anticoagulant
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: anticoagulant
o Vit K antagonist
o -carboxylation glutamate clotting factor ( clotting
factor onset = 8-12 hr & 2-3 )
o factor 2,7,9,10
PK: ... cat X
Antidote : VIT.K <phytonadione> 0.5-2 mg IV , Fresh frozen plasma

INR
INR <5
Hold next dose & resume at lower dose when INR
5-9
Hold 1-2 dose
>9
Hold wafarin & give Vit.K , check INR q. 24h
: 3-5 mg OD
20% 1 wk
5-10% INR 0.5
10-20% ------------------------------ 0.5-1
PT ( Prothrombin time) < 11-13 sec >
(stage3) factor V,VII,X
INR = PT / PT control
aPTT (Activated Partial Thromboplastin Time) (20-30 sec)
intrinsic thromboplastin system (stage I )
PT, INR wafarin / aPTT heparin
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Antiplatelet Drugs (Antithrombotic drug)

..
1. platelet membrane receptor ex. Catecholamine, collagen, thrombin, prostacyclin
2. ADP, PGD2, PGE2, Serotonin
3. & cell PG endoperoxides, TXA2, cAMP, cGMP, Calcium ion
: . Phospholipid PG TXA2 .
1. Aspirin ( metabolism PG) TXA2
Irreversible inhibit COX1
Dose : antiplatelet : 75-327 mg/day
2. Dipyridamole (vasodilator)
enz. Phosphodiesterase(PDE) cAMP , PGI2
< Viagra>
3. Ticlopidine(Prodrug) & Clopidogrel

ADP-induced platelet aggragration / ADP rec
Onset 3-5 ( ) duration ~10
Clopidogrel : thrombocytopenia & leucopenia Ticlopidine
Efficacy = ASA 2nd prevention stroke & angioplasty 1 (synergist effect)
Dose :
Ticlipidine : 250 mg 1x2 with meal (2nd thromboemboli stroke prevention)

Clopidogrel : LD 300 mg , MD 75 mg/day
4. Glycoprotein IIb/IIIa inhibitor

Abciximab percutaneous coronary intervention & acute coronary syn
Eptifibatide & Tirofiban
Thrombolytic Agents ~ clot

thrombus plasmin (proteolytic activity)
1. Streptokinase (non-specific fibrin) plasminogen plasmin
ADR: , allergic, anaphylaxis ( 6-12 )
2. Urokinase : Streptokinase
3. Anistreplase ( Streptokinase : plasminogen )
4. rt-PA ( recombinant human tissue-type plasminogen activator)
pretein . plasminogen plasmin
specific fibrin ( heparin )
Fibrinolytic inhibitor -aminocaproic aicd, transexamic acid
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COPD
Neutrophil
,,

2
1. (Chronic bronchitis) :
3m/1 year ( 2 )
2. (Emphysema) :
( neutrophil & protease )
Air pollution
-1 antityrpsin deficiency (neutrophil elatase elastin)
Airway hyperresponsiveness
:
FEV1/FVC < 70% ( )
Spirometry :
FEV1% (stage)
DLco (Diffusing capacity CO)
Pack-year = x / 20
stage
I (Mild)
II (Moderate)
III (Severe)
FEV1 80
50% FEV1 80%
30% FEV1 50%
IV (Very severe)
FEV1 30%
FEV1 50% + respiratory failure/
SatO2 < 80%
Short acting bronchodilator

One or more bronchodilator
Add inhaled steroid
( )
Add O2

1. (2-agonist, anticholinergic, theophylline)
Short acting anticholinergic short acting 2-agonist
Theophyline SE,DI
2. Glucocorticosteroids : 1st line severe, exacerbation
Short term oral glucocorticosteroid stable COPD

Prednisolone 30-40 mg/day 7-10
Inhaled glucocorticosteroid FEV1 < 50% exacerbation
LABA
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3.
Vaccine : COPD 50%
pneumonia : COPD 65
4. : exacerbation
5. : (acetyl cysteine, ambrozol)
6. Antioxidant : ex. N-acetyl cysteine exacerbation
7. :
*COPD 1-5 / Asthma 2-5
5A
Ask
Advise
Assess
Assist
Arrange
Aerosol
1-5 m =
< 2 m = Alveoli
< 1 m =
5R
Relevant
Risk
Reward
Road block
Repetition
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Asthma
. .
. ()
mast cell( histamine, PG, LT) & eosinophil (COPD=neutrophil)
mast cell . IgE rec
LAB :
reversible airway obstruction (FEV1 )
FEV1 >12%, PEF >20%
PEFR variability > 20%
PD20 < 8 mg/ml (normal > 13)
mild , moderate, severe
Daytime symptoms
Limit of activity
Nocturnal
Need reliever
Lung func (PEF or FEV1)
Exacerbation
GINA guideline
Step 1
Step 2
1. As need
2-agonist
2. Controller
Select one
options
Low dose ICS
Leukotriene
modifier
Control
Twice/wk
None
None
Twice/wk
Normal
None
Partial control
> Twice/wk
Any
any
> Twice/wk
< 80%
One or more /yr
Uncontrol
3 or >3 of partly control
present in anyweek
Any /week
Step 3
Step 4
Step 5
Select one
Low dose ICS + LABA
Med or High ICS
Low dose ICS + LT modifier
Low dose ICS + theophyline
Add one or more

Med or high ICS + LABA
LT modifier
theophyline
Add one or more

Oral steroid (low dose)
Anti-IgE
Step up () , compliance
Step down: 3 , dose
/dose : 1
1. Controller >
ICS : cell ex. Mast cell, eosinophil, T-lymp, neutron ..etc

collagen, airway remodeling, ,
,
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NFKB & AP-1 cytokine (

cystolic rec)
SE: , (systemic effect ) , spacer ( )
clotrimazole vaginal tablet, Nystatin

LABA
, efficacy ICS
B2-rec . - adenyl cyclase
ATP cAMP protein kinase A Ca cell .
, mucocilliary clearance
SE: , HT, glc , hypokalemia
Onset :
Duration
Rapid
short : Fenoterol, Salbutamol(Albuterol), Terbutaline

Long : Formoterol
Slow
Long : Salmeterol
Sustained release theophyline <add on>

cAMP PDE
Dose (5-10mg/L) anti-inflamation
SE: N/V, , , , , hypotension

Leukotriene modifier (Antileukotriene) <not add on/ ICS>

allergic rhinitis, NSAID induced asthma
LT bronchospasm , mucus secretion
:
5-lypoxygenase
ex. Zileuton
LT
ex. Montelukast, Zafirlukast
SE: (
) ,, , , ez liver
Anti-IgE ( Omalizumab)

IgE IgE mast cell . IgE
SE: inj site reaction, viral infection, sinusitis, headache
Systemic glucocorsteroids (>2w )

SE: > ICS
Dose < reliever
2. Reliever : bronchial hyperesponsiveness ( )
SABA :
SE: , , , hypokalemia, hyperglucose, lactic acidosis .. S-isomer BHR
(S BHR .. )
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Systemic glucocorticosteroids high dose 5 days

o (Pred 40-50 mg/d x 5-10 days)
o SE: , PU, hyperglycemia, HT, , cushing syndrome
Anticholinergic <ipratopium>
o SABA acute exacerbation
o SE : , ,
Methylxanthine <Aminophylines : theophyline half life

Combined drugs
Ipratopium + Salbutamol = Combivent
Ipratopium + Fenoterol = Beradual
Salmeterol + Fluticasone = Seretide
Formeterol + Budesonide = Symbicort
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Allergic rhinitis
asthma
IgE-mediated inflammation
: , , precipitating factor( ,,,)
: IgE . IgE mast cell & basophil cell

histamine, LT
Intermittent : 4 d/wk or < 4wk /yr

Persistent : 4d/wk or 4wk/yr
1.
2. :
Intermittent:
mild
oral antihistamine or intranasal antihis
Mod/sever
---------------------------------------------
Oral + decongestant
Intranasal corticosteroid
Persistent :
mild
oral antihis or intranasal antihis

Oral antihis + decongestant
Mod/severe
intranasal steroid
Oral steroid 1-2 wk or decongestant 10
3. Allergen immunotherapy
, 1-2 yr, , SE
. intranasal corticosteroid
: 1st antihis ( 2nd antihis anticholinergic)

oral decongestant
decongestant & corticosteroid doping drug
trimester 1 : CPM, loratadine, ceterizine
SE
1. Antihis :
1st -> , anticholinergic

2nd ->
2. Intranasal corticosteroid :
3. LT-antagonist :

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4. Decongestant : HT, , , , ,
5. Intranasal mast cell stabilizer (cromoglycate, Nedrocromil) .
1. Antihistamine
H1 , , , ., . Parasym , vascular permeability
1st gen : ex. CPM. Diphen, hydroxyzine, ketotifen, cypohep T1/2
2nd gen : cetirizine, loratadine
3rd gen : active metabolite () ex. Fexofenadine, desloratadine, levocetirizine
Intranasal : SE, &
2. Decongestant ex. Phenylephrine, pseudoephedrine
2-rec masal mucosa & 1 2 CNS, heart,
3. INSs : efficacy ( )
T-helper cell 2 cytokines, IgE, Eosinophil
4. LT rec antagonist ex. Montelukast (cat.B)
antihis INS
5. Mast cell stabilizer
Ca mast cell Ag mast cell
6. Anti-IgE ex. Omalizumab
Ag IgE dose steroid
SE: , , .
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Thyroid
: - Thyroxine (T4) & Triiodothyronine (T3)
- Calcitonin ( Ca)
T3 & T4 tyronine I2
<all step thyroid peroxidase>
1. I- I2 (food) I- active transport TSH . (autoregulation)
~ I- <
thiocyanate, perchlorate
2. Oxidation & iodination
peroxidase
I- cell
I+ tyrosine residue thyroglobulin
I2 ( I+)
Iodination
MIT & DIT
3. T4, T3 (Coupling reaction)

MIT + DIT = T3
DIT + DIT = T4
T4 : T3 = 4:1 (T3 > T4 5 )
oxidation .
thyroid peroxidase
4. thyroid hormone
Thyroglobulin-T3
5. T4T3
TSH
proteolytic
T3 or T4 colloid
( )
5-deiodinase ( PTU enz )

1. Hyperthyroidism 1-2 yr
Grave dz = Toxic goiter ~ autoimmune dz ~
Toxic uninodular/multinodular goiter
: , , (hot intorelance) , , metabolism , , , , , , AF
1.1 Antihyperthyroid drug :

o thioureylenes (Thionamides) -> PTU prototype
o : thyroid peroxidase 1.oxidation 2. Iodination 3. Coupling
(PTC deiodination . )
o PK:
PTU ~ T1/2 (76 min) , PB 75%,

MMI ~ T1/2 ( 4-6 hr), PB,
o ,
o radioactive I2
o (euthyroid) ~ 6wk then KI Solution 2wk
( )
o SE: agranulocytosis**, 2-3 m ,,WBC
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1.2 Ionic inhibitor (anion) ex. Thiocyanate, Percholate, Fluoborate

1.3 Iodides ( Wolff-chaikoff effect) negative feedback
o ( 24hr) ~
o
I2
iodotyrosines & iodothyronine
thyroid hormone (proteolysis)
o ( ), ( )
7-10
& propanolol thyrotoxic crisis

o 1-2 w ( rebound)
o Ex.
Lugols solution : 5%I2 + 10%KI

SSKI (38 mg/drop)
1.4 Radioactive iodine ex. I131, I 123 ()

o I131 iodothyronine ~ -particles .
o , ,
o
, .
o 3-7 ( . euthyroid )
1.5 BB (propanolol)
o peripheral conversion (T4T3) PTU & tremor
o Goal : HR < 90 (brady <60)
o asthma, COPD, HF, pregnant (2,3)
o diltiazem
2. Hypothyroidism
Myxedema ~ I2
Hashimotos thyroiditis ~ autoimmune dz
Cretinism ~

: , , , , ., , , , , , .
1. Levothyroxine sodium ( L-T4, Eltoxin (50-100 g) ~ T1/2 OD

2. Liothyronine sodium (L-T3, Tertoxin)
~ T1/2
3. Thyroid extract
4. Mixture T3&T4 (Liotrix)
T4:T3 = 4:1
Amiodarone, Li, Interferon induce thyroid dz

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Acne

1. Non-inflammatory : comedone
open ()
Close ()
2. Inflammatory : 1 micro comedone
1. & (sebum&sebaceous gland) : androgen , circadian rhythm (

)
2. : androgen cell
metabolized testosterone
5-dihydrotestosterone
DHT ~
3. Microorganism ex. Proprionibacterium acnes, P.granulosum, P.andum anaerobe sebum

4. Inflammatory response : WBC comedone
1. Topical :
1. tretionin, adapthalene(comedone), ATB ex. BP, Erythro, Clinda
2.
3.
steroid
Topical retinoids (Comedolytic ) :
epidermal call turnover comedone lesion
blood flow,
(photoaging)
: comedone, ATB, , prophylaxis , control

, catX
: , 2-3
Benzoyl peroxide :
: G+ & yeast normal flora ATB ( O2 oxidize protein

P.acne ), . Hyperkeratosis
* comedolytic, irritating
: mild-moderate papulopustular acne comedonal acne
: , / ,
BP isotet
Topical ATB ex. Clinda, Erythro :
: static & cidal
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Azelaic acid :
: inh. Tyrosinase, P.acne, free FA, comedolytic effect
: mild-moderate acne
2. Systemic oral
Tetracyclin :
bacteria lipase erythro, FFA
cpmedone acne (500-1000 mg/d max=1500mg/day)
: moderate papulopustular acne
Or Doxy 100 mg/d ( tetra )
Isotretionin (13-cis-retinoic acid) :
/ (teratogenic effect)
: , paraben ( gelatin cap preservative)
Pharmacologic effect
Sebum suppression (dose dependent) 2wk
Comedolytic effect ~ oral comedone
Anti-inflammation
bacteriostatic/cidal sebum
Immunomodulator delayed hypersent . T-cell relapse cyto ( Ab)
: cheilitis & vestibulitis , , , cornea , night vision, skin infection, sunburn
Cotrimazole :
Sulfone (DDS,dapsone) :
Estrogen & OC :
16 ,
topical tretionin & ATB (oral)
Ex. Estrogen, Glucocorticoid, CPA, ald antagonist
androgen
SE: menstrual abnormality, breast tenderness, N/V, fluid retention, headache, melasma,
coronary&peripheral thrombosis
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Heart Failure
CO = HR x SV (Stroke volume = )

1.
Preload (venous return) ~ (. .)
2.
Inotropic state ~ . . ~ Symp&NE ,
3.
Afterload ~ LV
Ejection fraction(EF) : LV systole/diastole

EF >60% , CHF < 40%
HF = organ O2
NYHA classification (function)
I: ,
II:
III:
IIII:
Compensatory to increase CO
CO
Stage of Progression (ACC/AHA)

A:
B:
C:
D:
1. HR&Contraction
. Symp
NE & ald
2. Increase Prelod
- vasoconstric organ
- rennin
3. Ventricular hypertrophy & Remodelling

** Pulmonary congestion
:
R -> (venous congestion) , (CO), , JGV ,
,
L -> Pulmonary congestion, dyspnea, orthopnea, , , , ,
1. Non-Pharmaco : Na (<3g/day), ,
2. Pharmacologic therapy
1.
Vasodilators -> preload & afterload

ACEI = &, symp ~ stage
ARB ( ARB+ACEI+Ald antagonist ==> hyperK)
Hydralazine + oral nitrate
2.
Diuretic -> preload

& ( )
3.
BB -> SYMP & RAAS , afterload

(bisoprolol, carvidilol, metroprolol, nebivolol)
acute HF decompensate
4.
Digoxin -> SYMP ( preload)
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ACEI,BB,diuretic

5.
Spironolactone&Eplerenone -> ald antagonist

. Class 3-4
6.
CCB systolic HF &

amlodipine
Diastolic HF diltiazem&verapamil ( HR )
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CAD :
Acute coronary syndrome (ACS)
Chronic = stable : plaque ,
angina pectoris >20
ACS : plaque
Coronary artery disease (CAD) or Ischemic heart disease(IHD) ( )

(LDL)&.
>50% .
: , , , , , acute pulmonary edema
: DLD, smoking, HT, DM, ( 45, 55), , (inflame,infection,homocysteine,obesity,life style)
clinic
stable angina()
Acute coronary syndrome ( 20 )
1. Acute coronary syndrome

(Artherosclerosis) (plaque rupture)
(platelet aggregation)
(thombus formation)
1.1 Partial occlusion : . (unstable angina) .
1.2 Complete occlusion : . (avute myocardial infarction)

ACS
STEMI : ST segment elevation PCI MI
NSTEMI : ST depression & T-wave inversion PCI MI (UA)
Unstable angina : ez.
*STEMI&NSTEMI acute myocardial infarction (>30min) ,
ez. . STEMI

Cardiac biomarker -> myocardial damage/ injury
Troponin -> myocardial cell damage . positive+

( 3-12 .)
UA T
Creatinine kinase (CK) ( .
, /. ,)
CK-MB : . Q-wave, non Q-wave, MI UA CK&CK-MB

Treatment
1. STEMI :
1.
2.
Thrombolytic agent ( 30% 1 hr) (Streptokinase,Alteplase, Tenecteplase)

. 3 . Ex. Streptokinase, t-PA, Reteplase
Antiplatelet agents ( ) (ASA, Ticlopidine, Clopidogrel)
ASA acute myocardial infarce ASA 160-325 mg then 75-160 mg/day
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Ticlopidine 250 mg bid (onset & SE: neutropenia)
Clopidogrel LD 300mg then 75 mg/d (onset )
Gb 2b/3a antagonist ->
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NSTEMI/UA : PCI &

STEMI : PCI
Antithrombin(anticoagulant) ( UFH, LMWH, Gp 2b/3a antagonist)
Unfractional heparin (UFH) thrombin & factor Xa
LMWH
t-PA, UA/NSTEMI, LV
-UFH : Bolus 60-70 u/kg IV --then---> 12-15 u/kg/h (PTT = 1.5-2.5 control
2-5 )
-Enoxaparin : 1mg/kg/dose SC bid 3-7 (LD 30 mg IV)
Beta-blocker -> MI & ACS
. Bradycardia, CHF, depress, Peripheral vascular disease
: HR<50, SBP<90 mmHg, severe HF, shock, asthma, 2nd or 3rd AV block
:
atenolol 25 mg 1x1
- - ->
100 mg OD
Metoprolol 50 mg bid
--->
100 mg bid
Target does
Nitroglycerin & nitrate -> &

angina ( NO . GC cGMP ~ .)
SE : , , , methemoglobinemia
* sidenafil
*nitrate-free interval = 8-12 hr
Statin ( Goal : LDL<100 mg/dL)
ACEI : . . DM, HT, CHF, LVEF<40%)
2. NSTEMI ASA, heparin or LMWH, BB, nitrate, ACEI, statin
3. UA ASA,BB,Nitrate, ACEI,statin (severe +heparin/ LMWH)
* . asthma diltiazem BB. NSTEMI/UA

1. Anti-ischemic drug = nitrate, BB, CCB
2. Antiplatelet = ASA, ticlopidine, clopidogrel
3. Anticoagulant = UFH, LMWH, GP2b/3a antagonist
4. Thrombolytic = streptokinase, alteplase, tenecteplase
Enoxaparin
<75yrs : 30mg IV bolus + 1mg/kg SC q 12 hr

>75 yrs : 0.75 mg/kg SC q 12hr (max 75 mg for first 2 dose) <IV bolus>
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Streptokinase
25
Ab 2 Ag Ab

UA&NSTEMI :
troponin-T
STEMI&NSTEMI :
EKG
NSTEMI / = UA
. MI off statin .
2. Chronic stable angina ( 2 )
: 5 , nitrate
:
MI ex. ASA low dose, statin, ACEI
, ischemia ex. BB, nitrate ( BB CCB )
Life style modification ex. , HT, DM, , .,
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Cerebrovascular disease (Stroke)

2
1. Ischemic stroke (80-85%) :
: artherosclerosis, cardioembolic stroke, small-artery lacunar infarction, /
2. Hemorrhagic stroke :
ischemic stroke /TIA (<24h)
ASA 50-325 mg (initial therapy recurrent stroke)
Dipyridamole + ASA : 200mg dipyridamole + 25mg ASA
Ticlopidine efficacy SE (neutropenia) 250 mg bid
Clopidogrel 75mg OD : efficacy ASA
nd
2 prevention : ASA 81mg

Stroke
1. Warfarin . AF, thrombus, MI
2. ASA gr.1 (75mg)
3. Clopidogrel ASA
4. Dipyridamole Clopidogrel&ASA
5. ASA + Dipyridamole stroke
* ( compensate) >220/120
* manitol, NSS dextrose
* ASA+ Clopidogrel= bleeding =
*Cardioembolic stroke (~20%) BP140/85 mmHg
1. AF wafarin (INR 2-3) -> ASA 325 mg/d

2. acute MI thrombus stroke wafarin (INR 2-3) 3m-1y (add on ASA 160mg/d)
3. rheumatic mitral valve dz (AF) wafarin (INR 2-3) ASA b/c bleeding
recurrent stroke/TIA or embolism ASA 80mg/d
4. aortic valve dz AF antiplatelet / AF wafarin
5. mechanical heart valve wafarin (INR 2.5-3.5) recurrent stroke /TIA
wafarin ASA 75-100mg/d (target INR same)
Heart & stroke = folic, B6, B12 homocysteine ( cholesterol)
artherosclerosis vascular event standard treatment
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Atrial fibrillation
>350 / (400-700)

Paroxysmal AF :
Persistent AF : cardioversion
permanent AF
stroke 5
Wafarin stroke > ASA intracranial haemorrhage
1. Class 1 : Na channel blocker
Prolong repolarization ex. Quinidine, Procainamide, Disopyramide
shorten repolarization ex. Lidocaine, tocainide, phenytoin
little effect on repolarization ex. Encainide, flecainide
2. BB ex. Propanolol, esmolol, sotalol*, acebutolol

3. K channel blocker ex. Amiodarine, Ibutilide, sotolol*
4. CCB ex. Verapamil, diltiazem
BP stroke
BP < 220/120 mmHg & no organ damage = anti-HT
SBP 220 & DBP 120-140 ..
Nicardipine
Labetalol
Sodium nitroprusside
Goal : BP 15% 24hr
Digoxin (CHF)
BB/CCB (non-dyhydropyridine and long acting(SR))
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Vulvular heart disease

acute rheumatic fever(strep. Gr.A)
Mitral stenosis (LA&LV)
~ LA -> P -> LA enlargement
Mitral regurgitation ( mitral )
~ LA,LV
Aortic stenosis
~ LV P
1. rheumatic
PenV 250mg bid or benzathine PenG 1.2 u

Erythro 250 bid
2. HF
3. wafarin
digoxin + ACEI + BB + diuretic

AF, mitral (INR 2-3)
miral valve (INR 2.5-3.5)
Thromboembolism
.
LMWH ex. Enoxaparin 1mg/kg SC q.12hr + wafarin enoxa onset
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CVS
1. Antiplatelet > ASA, Clopidogrel, Ticlopidine
2. Anticoagulant > warfarin, heparin
3. Fibrinolytic > streptokinase, t-PA
4. adrenergic blocking
5. adrenergic blocking
6. CCB
7. ACEI&ARBs
8. Diuretics
9. Nitrates
10. Antiarrhythmic drug
adrenergic blocking agent
. & ex. Sympathetic
& > symp . , CO, vasoconstrict - -> peripheral resistant
. > symp . . .
antagonist
- Non-selective
irreversible : phenoxybenzamine
reversible: phentolamine, tolazoline
- selective 1
: prazosin, terazosin, doxazosin, alfuzosin
- selective 2
: yohimbin
1 antagonist rec 1 competition

adrenergic blocking agent
CO, peripheral vascular resistant, RAAS . -rec
: CO, sympathetic activity, venous return, peripheral vascular resistant
-partial agonist (ISA-> intrinsic sympathomimetic activity)

-selectivity
1-agonist HT . DM (2 -> glycogenolysis -> )
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SE: , ( rec up-regulation .. 1 rec . -> tachycardia),

, TG&HDL, ( . propanolol, metoprolol, labetolol),
, HT(block 2 -> ), K ( RAAS rec)
CHF : ..
catecholamine
AF : sotalol
DM type 2 :
MI : atenolol, Metoprolol, propanolol, timolol
CHF : carvediol, metoprolol, bisoprolol, nebivolol
CCB
HT, angina pectoris, AF, subarchinoid hemorrhage, migraine, esophageal spasm, bipolar disorder
. ca ca channel (L-type) cell .

. & : ca &
PK : met CYP3A4, first pass

SE: postural hypotension, N/V, , (nifedipine)
phenylamine
= verapamil
Non-Dihydropyridine = diltiazem
Dihydropyridine
= amlodipine, felodipine, nicardipine =>
ACEI
ACEI Zn2+ active site ACE
1. sulfhydryl : captopril (active drug, short T1/2)
2. dicarboxyl : enalapril, ramipril, lisinopril
3. phosphoryl : fosinopril
:
Ang 2 ( ald, vasoconstriction)

, bradykinin, ald
Pco :
: vasodilate (&), , BP, . .

: HT & reflux tachycardia, CO&afterload, . .
rennin : Ang2 - -> negative feedback --> renin\
.. ald

PK :
prodrug( met 100-1000x) & active metabolite ( captopril&lisinopril)

.
SE:
hypotension, hyperkalemia, rash,dru cough, angioedema
&(angina pectoris, MI, DM, , CHF)
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ARB
block Ang1 rec .affinity > Ang2
active prodrug--> candersartan, cilexetil, olmesartan
ACEI
SE:
ACEI amgioedema , bradykinin
Nitrate (prodrug)
UA, stable angina, MI, CHF ex. Nitroglycerin, ISDN, ISMN ( )
: denitration NO -> GTP -> cGMP -> vasodilate (nitroglycerin

)
preload () , afterload ()
: angina pectoris (SL<NG, ISDN>)

NTG IV ~ HT (hypertension crisis)
: severe anemia, close-glaucoma, postural hypotension, hemorrhage early MI, PDE-inhibitor (sidenafil)
: nitrate-free interval (6-8hr)
SE:
, , , , , hypotension
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Antibiotic
Bacteriostatic >> S T E P T C (Sulfa, tetra, erythro, Pyrimethamine, trimet, chloram)
Bacteriocidal(time-dependent) >> Pen, Cep, Aminogly, Co-trimox, FQ
Penicillin ( prostate, eye, CSF)
WD grp.
A= thiazolidine ring
H
N
S
A
CH3
B= -lactam
CH3
D
O
COOH
C
C= site of penicillinase action

D= site of amidase
steric effect

cell wall ez. Transpeptidase (ez. cross-link peptidoglycan ~
cell wall)
G+
1. Natural pen ex. PenG ( , syphilis), PenV ( , prophylactic Rheumatic fever)

( penicilinase) strep( becteroids fragilis ), Enterococci
2. Penicillinase resistance penicillin ex. Methicillin(prototype), cloxa, dicloxa <skin>
S.aureus, S.epidermis (MRSA ) MSSA only
3. Ampi & Amoxy strep > stap
URI, ,
Extended release ( g- ) ex. H.influenza, E.coli, Proteus mirabilis, Enterobacterioccae*, H.pylori
G - /
-lactamase inh
4. Anti-pseudomonal ex. Carbenicillin, Ticarcillin
5. Extended spectrum ex. Piperacillin
P.seudo auruginosa + Enterobacteriaceae , anaerobe

PK-PD
1. Conc-dependent (prolong persistant effect) ( LD PPE)
a. Ex. Aminoglycosides, fluoroquinolones, daptomycin, ketolides
2. Time-dependent (minimal or no persistent effect) ( >MIC)
a. Ex. Pennicillin, cephalosporins, carbapenems,astreonem
3. Time-dependent (minimal or no prolong persistent effect)
a. Ex. Macrolide, clinda, tetra
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1. Cell wall synthesis > Pen, Cep, vanco, monobactam, carbape, bacitracin
2. Nucleic a synthesis > Quinolone, metronidazole
3. Protein synthesis
>
30s = tetra, amonogly

50s=macrolide, chloram, clinda
tRNA=mupirocin
4. Folic&metabolism >Sulfa&trimethroprim
5. Cell membrane
> polymyxins
* Pen
1. Ring opening nucleophile(-)ex. H2), OH- attack C electric site(+) = beta lactam
2. Neighboring grp. Participant C e- (NH-) R e- withdrawing
Cephalosporin
1st ex. Cefazolin, cephalexin(oral)
2nd ex cefaclor, cefoxitin, cefuroxime(prodrug)
3rd ex cefotaxime, ceftriaxone, ceftazidime(fortum), cefoperazone, cefdinur(omicep)
4th ex cefeprime (. ESBL)
O
R1
Dihydrothiazine ring
H
N
pen

N
R2
O
C
Olefin linkage & atoxy grp. (good LV)
OH
PK : 2 ceftriaxone, cefoperazone
Spectrum : enterococci, listeria, MRSA, acinobacter
1st : PEK : strep, stap ( pen&MRSA ) vancomycin
2nd : HENPEK : g- E.coli, Klepsialla, proteus, H.influenza, M.catarrhalis (
becteroides spp.)
3rd : enterobacteriaceae, N.gonorrhoeae, S.pneumoneae, strep pyrogen, ( BBB )
**
Ceftazidime(fortum), cefoperazone, cefeprime = P.auroginosa

Cefotaxime S.pyrogen & S.aureus 1st gen
Cep () = ceftriaxone, cefperazone
Ceftriaxone biliary pseudolithiasis (reversible) >2g/g
Cefazolin(1st) -> (t1/2)
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4th > like 3rd lactamase

Sulperazone (cefoperazone+salbactam) = NMTT structure (. vit.K ~
vit.K )
vitK 10mg/wk
Cefoperazone = NMTT thrombocytopenia
vitK
Cefoxitin (2nd) anaerobe ,
NMTT = cofamandole, cefotetan, cefmetazole, cefoperazole, moxalactam
Carbapenems ( Imipenem, Meropenem, Ertapenem )
Ring . pen SC & db ring
-lactamase
G+/G-, anaerobe (serious hospital-acquired infection or mix infection)
Imipenem = + cilastatin ( )
DPH1 brushborder mephrotoxic cilastatin enz.
Dehydropeptidase
Ertapenem = , t1/2, . PB=94%
Meropenem =
P.aeroginosa&A.bomb imi&mero ertapenem
*Ertapenem only ESBL
*ESBL = extended spectrum beta-lactamase
Monobactram >> Aztreonam
Only G- G+, anaerobe
cross-reactivity pen
pen

Vancomycin
cell wall synthesis ()
G+
especially MRSA (IV), pseudomembranous colitis (oral) (2nd line metronidazole), clostridium difficile
phlebitis , red man syndrome ( histamine)
ADR: ototoxicity, red man, phlebitis, nephrotoxic (minor)
*enterococcus -> vanco static
Beta-lactamase inh -> irreversible
Ex. Clavulanic a, Sulbactam
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Macrolide ->weak base, Mw .

: reversibly binding 50s ribosome (P.site) ( protein translocation) so
Erythromycin(ac): estolate (jaundice,, irritate) ADR =
Roxi (ac) : T1/2
Clarithro(pc/ac) : met , 1st line H.pyroli
Azithro (ac) : DI , UTI .. 2gOD, 1g OD
* lactone ring .
form ketal -> GI cramping

Acid labile : enteric coat or ester form
Indication: URI,LRI penicillin, MAC,
Lincosamide : macrolide
Ex. Lincomycin (prototype), clindamycin (semi-synthesis)
: macrolide
aerobe&anaerobe( , metronidazole)( MRSA)
ADR : , pseudomembranous colitis
Indication : pen (strep/stap), anaerobe, PCP( sulfa), toxo
Chloramphenical
Palmitate ( )
carcinogen
Hemisuccinate(inj) .
: inh peptidyl transferase peptide
DOC : Typhoid fever, Brain abcess (severe anaerobe)
PK : , ,
ADR : Gray baby syndrome
Tetracyclin -> derivatives polycyclic nepththacenecarboxamide
: block Aminoacyl-tRNA receptor site on mRNA ribosome complex

, ( doxy)
Isoelectric points =5 divalent ion
membrane active transport
ADR : , ( <18 , ), photosense, hepatitis, vestibular toxic,
Fanconi syndrome (renal toxic )
complex , ,
aerobe & anaerobe G+. G- (broad spectrum)
1st : Chlamydia, Rickettsia, Mycoplasma
2nd : Acne, Syphilis, Lepto, URI/LRI, Malaria
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Doxy, minocyclin lipophilicity = passive

Aminoglycoside -- > gentamycin, treptomycin, amikacin, netilmycin
: 30s ribosome
G-
-Enterobacteriaceae
-P.aeroginosa (genta & amikacin)
-Empirical therapy Endocarditis, meningitis

O2
anaerobe ,
ADR : nephrotoxic (reversible), ototoxic (irreversible), NMJ block-respiratory paralysis (reverse Ca gluconate),
neostygma
PAE (conc dependent)
Fluoroquinolones ( = nalixidic acid-> thyphoid)
aerobe G- (
G+ )
: enzyme gyrase (topoisomerase 2(G-) & 4(G+)) DNA replication &
transcription cell
divalent cation
serum ( CSF, bone, prostate fluid )
O
F
N
HN
COOH
N
X
Modify
1st : Nalixidic ( G- E.coli, Klebsiella, Proteus ), only UTI

2nd : Oflox, Norflox, Levoflox, Ciproflox .. G- UTI , Pyelonephritis, STD, Prostatitis
* Ciproflox pseudomonas
*Norflox 30-40%
pc
rd
3 : gatifloxacin, moxifloxacin streph

4th : Trovafloxacin ~
ADR : cartilage toxicity (arthropathy), Photosense
DI : CYP1A2 ( Ciproflox theophyline )
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Trimethoprim/ Sulfamethoxazole (5:1)
37
SS : 800/160
DS : 400/80
folinic acid
PCU, UTI
ADR : rash, SJS, Cystalluria, BM suppression, Kernicterus( PB~biliribun), Hemolitic
anemia, (metabolite )
Para-aminobenzenesulfonamide (sulfonamide)
Para-amino benzoic
sulfonamide
Dihydropteroate synthase
Dihydrofolic acid
Trimethoprim
Dihydrofolate reductase
Tetrahydrofolic
DNA
Purines
* sulfa G6PD & hemolytic anemia
Polymyxins, Gramicidin
permeability cell membrane bac
Bacteriocidal low selectivity topical form
Polymyxin B = Superficial skin (+)
Gramicidin = Gram
(new ATB)
Fosfomycin = cell wall
state
MRSA , .
Linezolid = oxazolidinone
MRSA
F = 100%, Dose oral = IV
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Psychiatry
Anxiety disorder : sym catecholamine(NE) 5-HT GABA REM
: Trembling, Muscle tension, Shortness of breath, fatigability, autonomic hyperactivity, parenthesis
: , , insomnia
Type : Panic, agoraphobia, generalized anxiety disorder, specific phobia, social phobia, obsessivecompulsive, posttraumatic
Treatment :
Benzodiazepine = alprazolam, chlorazepate, diazepam, lorazepam . onset .... T1/2
Non-BZD : barbiturate
Phenobarbital, sedative anticonvulsion
Beta-block : propanolol
Antidepressant, antipsycotics, 5-HT agonist/partial (onset ) ex. buspirone
BZD-site on GABA receptor GABAA ()
GABA rec
A: Cl- channel hyperpolarization

B: Ca channel Neurotransmitter presynaptic
PK :
A: (lipid solubility faster onset)

D: protein binding (, )
M : CYP450
BZD antagonist = Flumazenil

Therapeutic effect : anxiolytic, sedative, anticonvulsant, amnestic, muscle relaxant, antistress, hypnotic
BZD : ,
BZD , Antidepressant**
Ex. Alprazolam : short half life (12hr) -> panic/anxiety disorder
Diazepam : long half life (100hr) -> seizure, muscle strain, alc withdrawal
Lorazeoam : short half life (15 hr.) > insomnia, anxiety, alc withdrawal
ADR : CNS = , , , , , (..., , tremor
psychosis)/ DI alc, digoxin
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Sleep disorder 1 m (Chronic = >3m)
NREMS :
stage I ( )
Stage II ( )
Stage III-IV ( relax BP,HR )

REMS :
stage IV : ( 1 = 4-6 cycle)
Neurotransmitter
Serotonin : ( REM sleep)
Dopamine: . (.)
NE:
REM
Ach:
. REM
GABA: ,

, , CNS stimulants
1. Nonpharmacological therapy : ,
2. Pharmacological therapy
a. BZD DOC
b. Barbiturate
c. Non-BZD & non-barbiturate : Chloral hydrate, Zolpidem, Zaleplon
d. Antihistamine : Diphenhydramine, hydroxyzine
e. Antidepressant
f. Melatonin (chronobiotic) : circadian rhythms or reset biological clock
*BZD :
Met DI Temazepam, lorazepam, oxazepam
Short acting : triazolam, temazepam (onset duration )
Long acting : flurazepam ( active metabolite T1/2 )

ADR: daytime sedative, tolerance , hangover, rebound-insomnia, anterograde amnesia(
triazolam, midazolam)
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Barbiturate : ex. Amobarbital, Phenobarbital, thiopental

.. rec GABA rec (barbiturate binding site) Cl- ionophore complex
.. ,
overdose, ez inducer
Thus.. antidepressant - b/c
1.
T1/2 ,
...
2. ..
a. ..
onset ex midazolam, triazolam, zopidem
b. ..
c. ...
temazepam, diazepam
Tamazepam, lormerazepam
3. . ...
T1/2 , flurazeopam
4. ..
phase 1 (temazepam, lormerazepam)
5. ...
(temazepam, lormerazepam)
Schizophrenia : . 5-HT ,D2

Biological factor : DA , 5HT, NE , GABA = schizophrenia

Positive symptom : , , , ,
Negative symptom : ,
D2
5-HT
.. antipsychotic, DA antagonist, 5HT/DA antagonist

: , ,
Antipsychotic
1. Conventional :
Block DA receptor (esp. D2)
positive
S/E EPS
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Phenothiazine : chlorpromazine = , , ,sexual dysfn

Thioxanthines : Flupenthizol, Zuclopenthixol
Heterocyclic cpd: Droperidol, Haloperidol, Pimozide, Molindone
2. Atypical ( ) : block 5-HT DA EPS
Block 5HT2A rec > D2 rec
positive/ negative symptom/ EPS
clozapine (S/E : , agranulocytosis), olanzapine (wt ), risperidone,
ziprasidone(potential QT prolong), aripiprazole
SE
Nigrostriatal tract : EPS ( )
Mesocortical tract : cognitive function neg symp
Mesolimbic tract : . positive symptom
Tuberoinfundibular tract : prolactin
prolactin
*EPS (Extrapyramidal symptom) : akathisia, Parkinson, dystonia, tardive dyskinesia, neuroleptic malignancy
Mood disorder
1. Bipor dis : Panic (NE/DA) + Depress (NE, 5HT)
2. Depressive dis
.. DA NE 5HT cortisol
Amine
1 1R
2 -2R : nortryp, desipramine
3-3R : amitryp, imipramine
MAO/COMT = PKS
MAO = mood disorder
Antidepressant
TCA :
reuptake Ne&5HT (non-selective)
Ex. Nortryp, amitryp, imipramine, clomipramine, desipramine
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MAO inhibitor : MAO ( DA,NE,5HT,histamine)

Nonspecific = phenelzine, specific = selegeline(B), moclobemide(A)
.. cheese like effect : , , , , .,
(tyramine) b/c
NE = hypertensive crysis
SSRI : Fluoxetine (suicidal effect, ), fluvoxamine, sertaline(Zoloft), citalopram,
Triazolam(), Bupropian(SE )
Mood stabilizer
Lithium :
bipolar disorder (acute&maintain)
PK : narrow therapeutic index (0.6-1.2 mcg/L)

onset (4-6 wk)
ADR: N/V, diarrhea, , , , hypothyroid goiter

Lithium toxicity: , , ., ,
Antiepileptic : carbamazepine, valproic ( mania)
Alzheimers dz : Ach
hippocampus and other
Amyloid plaques : beta-amyloid peptide
free radical -> toxic (apoptosis)
Neurofibrillary tangle : phosphorylation form tau protein ..
.. Ach (memory loss)

DA & 5HT (Behavioral disturbances)
Glutamate cell death
.. Ach
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Cholinesterase inhibitor : mild- moderate

Tacrine : SE , CYP1A2 inh,
Donepezil & Galantamine : CYP3A4 substrate
Rivastigmine (Exelon) : CYP DI , ez esterase
Pyridostigmine (Mestenon)
ADR: N/V, syncope, , bradycardia, insomnia, muscle cramp
NMDA rec antagonist :
memantine = moderate-severe
Mg
Ca2+
ADR: N/V, , ,
Parkinsons dz
Progressive neurodegeneration condition
DA at nigrostiatal pathway substatia nigra fine movement .
, , ,
1. DA precursor : L-Dopa (Main)

peripheral Dopa decarboxylase inh L-DOPA . (
peripheral N/V )
Carbidopa <sinemed>, Benserazide<mardopa>
High protein food :
* 65 ( )(honeymoon) DA agonist
+COMT or MAO inh
ADR: hallucination, insomnia, hypotension, inh prolactin
:
On-Off phenomenon = SR form, DA ago
Wearing-Off :
MAO-B, COMT inh/
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2. DA agonist (efficacy < L-dopa)

Ex
ergot : Bromcriptine ( dementia), lisuride, pergolide (

Non-ergot : Pramipexel, Ropinirole, Apomorphine
3. MAOB-Inhibitor ( for end stage)

Ex selegeline ( DA & free rad) , rasagiline ADR :
*Cheese effect (tyramine ) hypertention crisis , serotonin syndrome
4. COMT-inhibitor ( for add-on L-DOPA )
Ex Entacapone, Tolcapone
# Parkinsons : Phenothiazines, Butyrophenones, CCB (flunarizine, cinnarizine), Haloperidol,
Valproic & phenytoin, Metoclopamide, Li, Amiodarone
5. DA
Ex Amantadine block reuptake DA, also inhibit NMDA receptor
6. Anticholinergic drug :
Ex Benztropine, Trihexylphenidyl, Biperdinm Orphenadine
* (autonomic symptom)
SE: confusion hallucination, cognitive impairment
//// Antidote = physostigmine
- L-DOPA + MAO-inh or Anticholinergic LDOPA

psychiative
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Peripheral Neurophaty
(motor, sensory, autonomic)
: / (symmetry)
Ex. Diabetic neurophaty, Drug, Alcohol, Inflamatory, B12
Treatment
1. : Para, NSAID, Opioid, Capsaisin(Topical)
2. Corticosteroid :
3. Anti-seizure : (block presynapthic)
Gabapentin, Carbamazepine
4. Antidepressant :
Ex. TCA ( Amitryp, Nortryp, Imipramine, Doxepin, Clomipramine)
Epilepsy

partial generalized seizures

Excitatory neurotransmitter (Glutamate : NMDA, AMPA, kainate )
Inhibitatory neurotransmitter (GABA)
ILAE
1. Generalized (
)
a. Absence (Petit mal) >
b. Tonic :
c. Clonic :
d. Tonic-Clonic(Grandmal/GTC/ ) ------
e. Myoclonic :
f. Atonic :
2. Partial seizure (Focal)
a. Simple seizure :
b. Complex seizure :
c. Secondary generalized : Partial
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3. Status epilepticus (first line = lorazepam, Diazepam)

5-30
1. synap - - GABA
2. synap - - Glutamate, Aspartate
3. ion channel
Depolarization (Na,Ca)
Repolarization
(K,Cl)

(Std. treatment)
1. Phenytoin - - enz inducer , grandma , PB , sub : 2C9
ADR : ..... gingival hyperplasia, nystagmus, Ataxia
Mechanism : inhibit at Na channel
*IV NSS ( D5W ) - -Phenytoin = weak acid
10-20 mg/ml
S/E - - - 10-20 : Nystagmus
20-30 : Ataxia
20-40 : Coma
2. Phenobarital (barbiturate group) enz inducer, sub : 2c19
ADR : paradoxical, serum sickness
Mechanism : GABA receptor
10-40 mg/ml
3. Carbamazepine enz inducer and autoinducer, subs : 3A4
Met CYP3A4 epoxide - - neutropenia
ADR : N/V, . . . SIADH, aplastic anemia
4. Sodium Valproate - -> ** enz inhibitor (2C9)* * // D drip drip - - Heart block
Block Ca channel
ADR : Thrombocytopenia, PTT, /, hyperammonemia
Absence*, Myoclonic, atonic, clonic etc . . .
*. 1-3 enz inducer
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*status epilepticus : diazepam IV redistribution

lorazepam (Ativan)
( ADR )
1. Topiramate ( . )
2. Gabapentin
3. Lamotrigine (aromatic ring structure) - - safe
4. Levetiracetam ( cat C )
5. Oxcarbazepine
6. Vigabetin
7. Ethosuximide -- first line Absence seizure

Antiepileptic
drugs
Blockage of
Na+ channels
Enhancement of
GABA-mediated
excitation
Phenytoin
Carbamazepine
Phenobarbital
Valproate
Benzodiazepines
Ethosuximide
Blockage of
Ca2+
channels
Gabapentin
Felbamate
Lamotrigine
Topiramate
Tiagabine
Vigabatrin
AMPA
antagonist
Diazepam
Zonisamide
NMDA
antagonist
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Blood
Hematopoitic stem cell
Lymphoid
Myeloid
B-cell, T-cell, NK cell
Erythoid
N,E,B,Mast cell,Macrophage
RBC,platelet

1. Erythropoitin ( from kidney 90%) > erythroblast
2. Iron ( Fe3+ (Ferric) - - GI - > Ferrous (Fe2+ ) > . Hb transferin ferritin
( )
Hb - - > Iron + Hgb
globulin recycle
Heme billirubin
Anemia (Hb < 13.5 g/dl, < 12 g/dl )

1. Iron-deficiency anemia (IDA)
RBC : /
LAB : ferritin , MCV
Cause: Malnutrition, GI bleed, Hook worm
Treatment: Fe 200 mg/day ( Fe fumarate = Fe 33% )
Ps. / .... , milk product,
, tetracycline
2. Vit B12 deficiency anemia
RBC :
LAB: MCV
: , .. .
: 12 cyanocobalamine IM
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3. Folic acid deficiency anemia

RBC :
LAB: MCV
.. B12
: Alcoholism, 3rd trimester, hemodialysis
Treatment : Folic acid 1-5 mg/day 4
4. Anemia of chronic disease
RBC : normal
Cause: RBC ,
EPO , , CA, , ,
: EPO, rhEPO ( + Fe ferritin < 100 ng/ml)
( ) IV or SC /// ADR = HT (DBP),
5. Drug induced hemolytic anemia
RBC : Normal
Cause : . Oxidant ex. Ascorbic acid, quinolone, chloroquine, sulfa, dapsone,
nitrofurantoin, chloram, primaquine, ASA, vit K
6. Aplastic anemia > Bone marrow RBC - - - Pancytopenia
Treatment: BM, immunosuppressant, Hematopoietic growth factor ( G-CSF, GM-CSF)
7. G6PD deficiency
- G6PD RBC
Genetic ( sex-linked) , X-chromosome
acute hymolutic : drug induction, infection, DKA
Congenital :

Favism : ( Fava bean)
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Bleeding disorder
Intrinsic pathway - . , kaolin, celite
Extrinsic pathway - .
Vit K - prothrombin factor (factor 2,7,9,10)
Bleeding
Coagulation disease - - > APCD, Hemophilia

Platelet disease - - > ITP, APDE
1. Acquired prothrombin complex deficiency (APCD)

(factor vit K) vit k
: vit K
2. Hemophilia
factor 8(A), 9(B), 11(C) <sex-linked recessive>

: , fresh frozen plasma (FFP), cryoprecipitate ( FFP factor 8 ), cryoremoved plasma(factor 11), fresh dry plasma ( ), factor concentrate (8,9)
3. Acquired Platelet Dysfunction with Eosinophilia (APDE)
Purpura eosinophil -
:
4. Idiopathic thrombocytopenic purpura (ITP)
platelet Ab
: Pred 1-2 mg/kg/day, ( > 4 )
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Immune
Allergic reaction & Pseudoallergic
Drug allergy
1. Allergic ADR : pharmaco 4 type
Type 1 : Immediate type hypersensitivity reaction (anaphylactic)
IgE IgE Mast cell .
mast cell histamine
: , , bronchospasm, hypoteni=sion
72 .
Type 2 : Cytotoxic type ( Complement-mediate Ab)
+ Ab drug-Ab complex cell & cell (platelet, WBC)
, , , ,
Type 3. : Immune complex type (Serum sickness type/ Arthus reaction)
IgG & IgM + Immune complex complement
inflame
: , , , ,
Type 4. Delayed type (allergic contact dermatitis)
Ag . Lymphocyte Sensitized-T cell (sensitization phase) then +
sensitized lymp lymphokines - -
2. Pseudoallergic ADR

(1) immune ( mast cell )
Anaphylactoid reaction ( rate )
vancomycin, opoid, amphotericin
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Immunization - 3 Natural, Passive, Active

Vaccine :
: Ag, Adjuvants ( immune), Haptens
Toxoid ex.
Inactives/killed : DTP, IPV, , JE, heap/B,
Live attenuated : OPV, BCG , MMR
**
SLE - autoimmune disease ( > )

, , RA (), butterfly rash. Nephritic,
pericarditis, , anemia, cotton wod spots etc.

1. NSAID
2. Antimalarial drugs ex. Chloroquine, hydroxychloroquine
3. Corticosteroids ex. Prednisolone, methylprednisolone
4. Cytotoxic drugs Azathioprine, cyclophosphamide, MTX
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Dermatology
Bacterial infection
1. Impetigo :
( stratum corneum)
:
stap aureus - -> Bullous Impetigo ( )

Strep gr.A - - > Impetigo Contagiosa ( )
Treat : Local =
NSS bid ( ATB)

Or 2% mupirocin 3 /week
Systemic =
ATB ex. Dicloxa, Erythro, Cefalexin, Bactrim
2. Ecthyma : 1
(Dermis)
1 systemic treatment > topical
3. Folliculitis :

- - S.aureus & Other
Symptom : Superficial folliculitis, Deep folliculitis
Sycosisbarbae :
Furunculosis :
Carbuncle :
Tx : , ATB : cloxa 2-4 g/d 7-10 days or Erythro 1-2 g/d 7-10 days
4. Erysipalas >

strep. Gr. A ( )
Pen V 500 mg or Erythro 500 mg 1 x 4
5. Cellulitis >

strep. Gr. A, S.aureus, H.influenza, G ve

** Erysipalas
systemic ATB (same as erysipelas
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Virus infection
1. (Herpes Simplex) . , ,,
HSV-1 (,), HSV-2 ()
Primary =
facial-oral herpes simplex

Genital herpes simplex ( 2 wk)
Recurrent :
-- , , ,
Oral = 1-4 times/years,
genital = 3-4 times/year
Symptom :
2-3 . , /,
wet dressing = 3-4

. - -
.
Acyclovir
Primary:
200 mg 1x5
400 mg 1x3
Recurrent :
Famcyclovir
250 mg 1x3
Valacyclovir
1000 mg 1x2
Acyclovir
200 mg 1x5
400 mg 1x3
Famcyclovir
125 mg 1x3
Valacyclovir
500 mg 1x2
7-10 days
5 days
Acyclovir 5% cream q 4 hr (1x5) 5-7 days

** = , glycerin borax or gencienviolet 3-4
** steroid
2. Wart () - - > human papiloma virus (HPV)

salicylin 10-15% 2-3

Podophylline

N2 (-186C)
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Fungi infection (Superficial infection)

1. Dermatophytosis ()/ ringworm
Genus Dermatophytes ex. Trichophyton SP., Microsporum SP., Epidermpphyton SP.
Factor :
, ,
KOH
macule ( , = annular lesion)

** . Tinea capititis(Head), Tinea corporis (body), Tinea cruris(
),Tinea pedis(foot), Tinea ulgium(nail)
Treatment:
:
Griseofulvin 500 mg OD (only ) - - photosense

Or
Ketokonazole 200 mg OD 15 days

Itraconazole 100 mg OD 15 days
Fluconazole 150 mg 1time/week (2-4 weeks)
Tonaftate cream (only ) :

Imidazole & triazole (Board)
Terbinafine Hcl (
cell wall)
Ciclopirox ( pregnant & <16 )
2. Pityriasis versicolor (Tinea versicolor)

(stratum corneum) - - Malassezia furfur ()

, ,
macule patch(/ )
*** ( )
ketoconazole(Nizorol)
200mg OD 10-14 days (same as )
Itraconazole(Sporal)
200 mg OD 7 days
Selenium sulfide (Selsun)
15-30 1 w
Sodium Thiosulfate Solution 25% 2-4 w

Kelatolytic agent ex. Whitfield ointment ( Salicylic + benzoic )
Imidazoe derivaive
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3. Candidiasis ( Candida albican)

( **)
: , , , , ATB broad spectrum &
steroid
ketconazole 200 mg bid
5 days
Itraconazole 100 mg OD
15 days
Fluconazole 150 mg/week
2-4 wk
- Nystatin (Candida only**) --

- nystatin syrup, clotrimazole
Acne
Cause:
1. Hypercornification ( ) linoleic

2. Testosterone hormone () - - > dihydrotestosterone( )

3. FFA, squlaene - - > .
4. Bac ( Propionibacterium acnes) - - - - > FFA & enz (preteus,
hyaluronidase)

1.
2. (steroid, OC, INH, I2, phenytoin)
3. , ,
4.
5. progesterone 1
1. Non-inflamatory acne // Comedone

open/black head comedone
Closewhite head comedone - -
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2. Inflammatory acne
Acne vulgaris -- > Hormone . bac
Treatment : sebum, keratin /
(gel cream )

1. Tretionin (Trans-retinoic acid; vit A) (Retin A) - - >
comedolytic agent stratum corneum - - >
(comedo acne)
Benzoyl peroxide & ATB
- - ( )
Photosense
3
ATB (BP&ATB)
** (BP & Tretinoin) BP reactive oxidant

BP Tret
2. Adaptalene (Differin) > synthetic retinoid
Tret stable
oxidize BP
Photosense
3. Salicylic acid
microcomedone , keratolytic&comedolytic ,
ATB
1. Benzoyl peroxide (BP, Panoxyl,Benzac)
P.acne FFA ( cystein freeO2 oxidize
Bac - - > )

5-10 30
2. Azelaic acid
Bacteriostatic P.acne FFA & 5 reductase dihydrotestosterone - -
keratin
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3. clinda, Erythro, Tetra

P.acne FFA

Tret + BP : BP Tret
BP + ATB : BP Erythro P.acne ps. Erythro
ATB
1. Oral ATB : 6
. P.acne FFA ,
Tetracycline = 1-2g/day (2-4 ac) : 3-4 wk
Erythromycin = --------------------- pc
Co-trimoxazole 2x2 ( )
Doxycycline 1000 mg OD
Minocycline 100 mg OD - - sebaceous follicle
Clindamycin 300-450 mg/day - -
2. Retinoid
-isotretinoin :
( 3-6 months : )
C.corneum FFA
FFA P.acne
: 0.5-1 mg/kg/day ( 3-4 )

SE : , , teratogenic (cat X) - - > 1-3 months, TG ,
(epiphyseal plate )
3. Hormone
ex.
Estrogen >
CPA, spironolactone : androgen rec
Pred, Dexa :
androgen
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Melasma ()
. melanin (.)
(symmetry)
melanocyte melanin , (),
,
PABA, micronized titanium dioxide, oxybenzene

Ex. Hydroquinone : enz tyrosinase melanin ( FDA
cosmetic ), Retinoic acid, Topical steroid,
Natural extract (licorice, vitC, vitE)
Psoriasis ( )
: (Li, malaria, BB), ( ),
: .
:
(Auspits sign) , , etc
**..

1.
Tar ( DNA) ,
Corticosteroid
.. steroid + salicylic acid

.. steroid low potency
Dithranol (Anthalin) - - DNA ()

Calcipotriol - - keratinocyte, cytokine
2.
MTX 2.5-25 mg/w
Retinoid :
Colchicine*()
Tetracycline (Pustular psorosis)
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Steroid - - Pred rebound effect

Antihistamine - - itching
Biological agent
3.
Ex. Immunosuppressant, Phototherapy, rational therapy, combinatory therapy
. . , antralin, Vit D3
Eczema or Dermatitis

IgE (mitogenic response) or leukocyte
Eczema
Endogeneous > Atopic/Seborrhic dermatitis : : /

Exogenous > contact dermatitis (irritant, Allergic, Photo)
:
1. Acute eczema :
wet dressing - - > steroid ( + ATB)
2. Subacute >>
steroid( ) - - > emollient
3. Chronic : (lichen fraction)
wet dressing
Steroid + keratolytic ( oral steroid 5-7 days )
**Wet dressing : : NSS 0.9%, Burow solution 5% (Al acetate), K permanganate,

Ag nitrate, acetic acid ( Boric acid)
Atopic dermatitis :
: steroid, emollient (oilatum ~ mineral oil)
Topical calcineurin inhibitors (Tacrolimus, Pimecrolimus)
Seborrheic dermatitis
Tar shampoo, selenium sulfide 2%, ketoconazole, steroid
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Topical corticosteroid

liposome
Hydrocortisone acetate (0.1%) , Prednisolone (0.5%)
Triamcinolone acetonide (0.02%) ~ Aristocort
Triamcinolone acetonide (0.1%), Betamethasone valerate (0.1%)

Momethasone furoate (0.1%) - - Elomet
Amcinonide (0.1%), Desoximetasone (0.25%), Betamethasone dipropionate(0.05%)
Betametasone dipropionate (0.5%)

Clobetasol propionate (0.05%) - - Dermovate
Parasite infection
- - >
- - benzyl benzoate ( BB)
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Oncology
: overexpression, hypoxia ( ), , .flux transport,
enz reductase metabolize (. Reduction)
Staging :
Tumor
(T1-T4,N0-N3,M0-M1) CA
lymp
metastasis
cytotoxic drug:
vertical laminar air flow biological safety carbinet (Biohazard)
BSA (m2) = wt(kg)0.425 x ht(cm)0.725 x 0.007184
Or
BSA(m2) =
* BSA body surface area * *

Aseptic technique
Milking technique :
Chemotherapy
Neoadjucant : /
Adjuvant: /
Pallitative : .

Chemotherapy -specific :
-Non-specific:
Antimetabolite(S-phase), vinca alkaloid(M-phase)

alkylating agent, ATB type
Purine synthesis
Pyrimidine synthesis
Ribonucleotides
Deoxyribonucleotides
DNA
mRNA
Protein
Enzyme
Microtubules
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Alkylating agents
alkyl(-) DNA(+) = inh DNA synthesis
Nitrogenmustard ( NS ) cycophosphamide, Ifosfamide ( dose SE
)
ADR: Hemorhaggic cystitis (from acrolein)
1. Mesna ( SH gr. acrolein -> inactive . ): 15 min ac/4 hr pc/8 hr pc
2. hydration
Platinum ex. Cisplatin( ) , carboplatin
ADR: N/V *****, nephrotoxicity(Mg,K), ototoxicity
1. Antimetabolite > inhibit DNA/RNA synthesis ( false substrate) [S-phase]
Folate antagonist
ex. MTX ( dihydrofolic acid dihydrofolate
reductase(DHFR)
folic->folate)
Antidote= leucovorin rescue ( MTX )
ADR: Mucositis, severe N/V(high dose), nephrotoxic, hepatotoxic
Purine analogue(2 ring)
Ex 6-MP, 6-TG
6-MP Allopurinol oxidize XO

dose 6-MP 50%
Pyrimidine analogue(1rings)
Ex 5-FU + leucoverin 5dUMP
Thymidase enz
ADR:
IV drip : 5-f dump (DNA) -> mucositis (Gi toxicity)

IV bolus (5 FUTP)(RNA) -> BM suppression
Cytarabine (ARA-C) - - > Chain terminator

ADR: ** ( steroid ), neurotoxic
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2. Antitumor ATB : streptomycin

Topoisomerase 2 inh. (Anthracyclin)
ex. Doxorubicin, Daunorubicin
: free rad CA (DNA) ( )
Mitoxantrone(synthesis) : -> SE - - free rad eff
ADR: Radiation recall, Cardiotoxicity**, Extravasation( )
Antibiotic
Ex. Bleomycin, Mitomycin
form alkylating & superoxide free radical
ADR: vesicant, pulmonary toxicity, fever
3. Antimicrotubule (M-phase arrest) >
depomerization microtubule DNA
Vinca alkaloid ex. Vincristine, vinblastine - - - (catharanthus rosea)

ADR:
vinblastin = BM suppress, extravasation

Vincrist = . Neuro ( CNS), extravasation
** extravasation :
Taxanes ex. Palcitaxel, Docetaxel (semi-synthesis)

: lock mitotic spindle
ADR:
Palcitaxel cremophor Pacific Yew
- - - hypersensitivity give Premed
Docetaxel , Edema**
4. Topoisomerase inhibitors
I : Irinotecan, Topotecan : Diarrhea**, cholinergic effect
II : Etoposide, Tenoposide : hypotension, myelosuppression
5. Miscellaneous
a. Asparagease (enz bac L-asparagine-> aspartic acid)
+PEG = T1/2
b. Hydroxyurea (HU) (S-phase) - - inh ribonucleotide reductase enz
c. Hormone ex.
Antiestrogen (Tamoxifen)
Aromatase inh (Anastrozole)
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Cancer Pain Management

1. Nociceptive pain : .
Somatic pain : .
Visceral pain : .
2. Neuropathic pain :
(hyperexcitability etc). opoid adjuvant
Severe pain
Strong opioid
Adjuvant
Moderate pain
Weak opioid
Mild pain
Non opioid
Non opioid
Adjuvant
Adjuvant
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Drug
1. Opioid analgesics
Mild
Codeine (CYP2D6 substrate)
Tramadol (max 400 mg/d_ - - inh. 5HT & NE reuptake :::.
Strong
Morphine (mu agonist)
MST(tab)
Controlled release
Kapanol (pellet in capsule)

Inj (sc, iv ,im)
Morphine sulphate syrup - - - breakthrough pain
ADR: + CNS , , , delirium, ( tolerance), N/V
Fentanyl ( > Morphine 100 ) - - - . (transdermal)
Pethidine . ( met CNS=)
**Opioid Rotation : , route
2. Adjuvant drugs
a. Anticonvulsant ex. Carbamazepine, phynytoin, gabapentin
b. Antidepressant ex. TCA (amitryp)
c. Steroid
d. Anxiolytic ex. BZP (diazepam)
3. Non-opioid analgesics
Ex. Para, aspirin, NSAID ( tolerance ceiling dose)
GI toxic management
Nausea - -> Retching( ) - - > Vomiting,Emesis()
1. Acute (withing 24 hr) - - 5HT, D2, NK1
(5HT + steroid)
2. Delay (>24hr)
(D2 antagonist + steroid)
3. Anticipatory
Ondansetron + Dexa/lora
Metroclopramide + Dexa
4. Breakthrough
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Anti-emetic drugs
5HT3 antagonist (Ondansetron: met CYP2D6) - - > 5HT in GI ::: Acute
D2 antagonist (Metroclopamide)
- - > block D2( Delay) CTZ & GI motility(prokinetic)
Corticosteroid (Dexa, methypred) - -> PGs( Delay) & 5HT

BZP (diazepam, lorazepam) - - > anticipatory
*** 5-30 & around the clock (prn if breakthrough)
Mucositis
Drug induced = Anthracycline, 5-FU, MTX, .etc
Stomatitis cocktails : lidocaine(5cc) + diphenhydramine(5cc) + antacid(5cc)
5-15
Cryotherapy = 30 30
Etc . . .
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Hypertension
SBP
<120 and
120-139 or
140-159 or
160 or
>180
Normal
Pre-HT
Stage 1
Stage 2
HTN crisis
DBP
<80
80-89
90-99
100
>120
Life
Yes
Yes
Yes
Yes
Drug
No
No
Single
Combine
Goal : cardiovascular risk (CV risk)

<140/90 , DM/CKD < 130/80 ( or 85), Proteinuria > 1g - - > <125/75
CKD = GFR<60ml/min, SCr > 1.3-1.5 or albuminurea > 300 mg/day
CO () x
BP =
TPR ( )
Cardiac factor
Circulating volume
BB
ACEI/ARB
CCB
Diuretic
Adrenegic
Aldosterone antagonist
(once-daily drug) - - BP
1. Diuretic
Thiazide :
Na+Cl- cotransport (distal)
Ex.
HCTZ: start 12.5 25 mg OD MAX dose = 50 mg/day; max effective dose : 25 mg/day
Indapamide( + Perindopril : previous stroke)
CrCl > 30
ADR : metabolic effect ( uric, blood sugar, lipid )

Loop diuretic > inh Na/K/Cl ATPase
Ex. Furosemide ( When CrCl < 30 or resistance to HCTZ)
K-sparing > Na+ absorption at collecting duct
Ex.
Spironolactone : Ald antagonist compelling HF 1st line --> ACEI/diuretic

amirolide ( + HCTZ = moduretic)
2. Beta-blocker
Negative chronotropic & inotropic , rennin **
1st line in ischemic heart, MI, HF
COPD, asthma, bronchitis,DM ( inh insulin secretion),peripheral arterial disease
ADR : bradycardia ( monitor HR, FBS), metabolic SE (HDL , TG, suger b/c insulin )
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**
ISA ( agonist & antagonist) : Pindololm Carteolol, Acebutalol
High lipid soluble : C,P,M <met CYP2D6(SSRI)>
Vasodilate BB : atenolol, metoprolol, bisoprolol (MBA)
HF : B,C,M,N selective trial
3. ACEI
Ang 1 -- > Ang 2

(Rennin Juxtaglomerulus apparatus)
efferent arteriole - - > glomerulus pressure - - > Protein urea
compelling indication : DM, CHF, Post-MI, CKD, Previous stroke
PK :
Captopril (active drug)

Enalapril, Perindopril, Fosinopril, Ramipril (Prodrug)
ADR :
HyperK, BUN&Scr, , Angioedema

. SCr < 3 or K > 5.5 or >30%base
. bilateral stenosis
**Lisinopril Metabolize
4. ARB :: same same as ACEI
5. CCB : 3rd line in CHF(non-hydro)
Block Ca channel (smooth muscle cell) BP
Slow-rating CCBs : block AV conduction
1.Dihydropyridine
nifedipine
CYP3A4 substrate
2.Non-dihydropyridine
Verapamil, diltiazem
CYP3A4 inh
CCB protein urea Diltiazem
ADR :
Verapamil(constipation) & Diltiazem = bradycardia, heartblock
Dihydropyridine : : Ankle edema ( ), headache, flushing

6. Alpha-blocker : BPH ( syncope = first dose hypotension) peripheral
Doxazosin, Prazosin, Terazosin
7. Renin inhibitor ex. Aliskeren
ADR : hypotension, angioedema (efficacy ACEI & SE )
8. Nitrate : MI
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Hypertensive crisis - - BP > 180/120 () 2

1. Hypertensive urgency : BP dose & monitor BP
2. Hypertensive emergency : involve organ , BP Na nitroprusside (SE) or
Nitroglycerin()
MAP 25% 1 .
Goal -
Stable; BP 160/100-110 in 2-6 hr
Std. goal BP within 24-48 hr
DM
Metabolic
DPP-4 . GLP-1 GI insulin + glucagon
Post-Pandial glucose : in DM type2 (200 mg/dl) > type 1 (150 mg/dl)
: Polyuria, Polydipsia, ., polyphagia, , , ,
1 2 - - - - severe hyperglycemia ( insulin)
TG ketone body = = => ketoacidosis
Ketoacidosis : , , ., , dehydration, hypotension, tachycardia, hyperventilation,
hyperthermia, N/V, .
DM = insulin

IFG; FPG
-IGT;
-2-h PG
75mgsugar 2 .
Goal
Pre-diabetic
100-125
140-199
DM
> 126 mg/dl
> 200 mg/dl
A1C < 7%
Prepandial 90-130 mg/dl
Peak postpandial PG <180 mg/dl
BP : 130/80
LDL < 100, TG < 150, HDL >40, >50
DM
Insulin secretagogue : insulin,
1. SU :
1st =
nd
2 =
chlorpropamide (long T1/2)

short acting : Glipizide, Glicazide
Long acting : Gliben (Gliburide), Glimepiride
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: . insulin SU receptor cell adenosine

triphosphate-dependent K channels membrane depolarization - - > Ca influx - - > insulin
ADR: weight gain, hypoglycemia ( BB sweating*), Chlopropamide -> Na ( ADH),
disulfuram-like effect
2. Non-SU : ( skip dose ) Post pandrial
Ex. Rapaglinide ( CYP3A4), Nateglinide ( CYP2C9)
: SU / ( SU )
SE : SU
Insulin sensitizer : creatine protein microvascular
3. Biguanide : Metformin ( DM type 2 . BMI > 25)
: insulin . insulin-stimulated uptake
,
HDL, TG
microvascular**

ADR : metallic taste, lactic acidosis, N/V, HF, dehydration, alc abuse
4. Thiazolidinediones ex. Rosiglitazone, pioglitazone
: . Nuclear transcription factor (PPAR-gamma) carbohydrate&
insulin insulin

. - - ***
ADR:
+, , . hepato toxic
. CHF stage 3&4
Alpha-glucosidase inhibitor ex. Acarbose, voglibose

glucosidase brush boarder
monosaccharide
ADR:
dipeptidylpeptidase-4 (DPP-4)
DPP-4 ez. incretin GLP-1 & GIP ( insulin )
Ex. Sitagliptin (Januvia)
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:: Numwans Short Note ::

gp41 CCR-S (cell)

RNA virus retrovirus (RNA DNA)

gp120 rec CD4 cell

1. Primary HIV infection (1-6w) , , , , , N/V, ,

2NRTI + 1NNRTI (or 1 PI+booster)

*EFV NVP . NVP

d4T + AZT -> antagonism

GPO-VirS : 4dT + 3Tc + NVP / GPO-VirZ : AZT + 3Tc + NVP

EFV or NVP TB Rifam PI=based regimen

DRAFT Version 2/2011

:: edit by hongyuu :::

:: Numwans Short Note ::

NVP HAART TB rifam

Nystatin Solution, Fluconazole 100 mg 1x1 (7-14 d)

2.PCP( Pneumocytis pneumonia )

1st prophylaxis : Bactrim SS (80/400) 2x1 ( Toxo )

DRAFT Version 2/2011

:: edit by hongyuu :::

:: Numwans Short Note ::

Dapsone 50mg OD + pyrimethamine 50 mg 1d/w + Folinic acid(leucoverine) 25 mg

: Bactrim ( TMX 15-20 mg/kg/d or SMX 75 mg/kg/d) x 21 days

3.Cryptococcus( CD4< 100) /

1st pro : Fluconazole 400 mg 1d/w

Ampho-B 0.7-1 mg/kg/d IV x 14 d

Fluconazole400 mg/d 8-10w

amphoB Fluco, Itra

2nd pro : Fluconazole 200 mg/d or Itraconazole 2-5 mg/kg 1x1

1st pro : BactrimSS 2x1 = DS 1x1

Pyrimethamine 200mg 1x1 50-75mg/d + sulfadiazine 1-1.5g 1x4 + folinic a 10-20

Treat : Gancyclovir 5 mg/kg q 12 h IV ( 2-3 w)

2nd : Gancyclovir 5 mg/kg IV q 24 hr or Foscarnet 90-120 mg/kg IV

Clarithromycin 500 mg 1x2 or

CD4 > 100

Azithromycin 1200 mg 1 d/w

Clarithromycin 500mg 1x2 + Ethambuthol 15 mg/kg/d

:: edit by hongyuu :::

:: Numwans Short Note ::

Azithromycin 500-600 mg/d + Etham 15 mg/kg/d

2 pro : as 1 pro CD4 > 100 or MAC 12 m

MCV ( Mean Corpuscular Volume) RBD

B12, folic, liver dz, alcohol

RBC count (million/mcL)

MCH ( Mean Corpuscular Hemoglobin) Hb RBC

* hypocromic and mycrocytic anemia

High (28-33 pg/cell)

MCHC ( Mean Corpuscular Hemoglobin Conc) 32-36 g/dL: conc Hb RBC 1

MCH hypochromic and microcytic anemia

hypocromic anemia &Thalassemia

DRAFT Version 2/2011

:: edit by hongyuu :::

:: Numwans Short Note ::

Folic acid 2-5mg RBC (RBC) 5-10mg

oxidant drug ex. Sulfonamide

Vit B12 & Folic acid : DNA RBC

DRAFT Version 2/2011

:: edit by hongyuu :::

:: Numwans Short Note ::

PCR protransfusion Hb = 6-7 g/dl

< 2mg/kg/hr ( 24-48 hr)

DRAFT Version 2/2011

:: edit by hongyuu :::

:: Numwans Short Note ::