Professional Documents
Culture Documents
6-1 PENICILLIN
6-2 NAFCILLIN (Nafcil, Unipen)
6-3 AMPICILLIN
6-4 CLAVULANIC ACID
6-5 CEFAZOLIN
6-6 CEFTAROLINE (Teflaro)
6-7 IMIPENEM (Primaxin)
6-8 VANCOMYCIN (Vancocin)
6-9 POLYMYXIN B
6-10 GENTAMICIN (Garamycin)
6-11 DOXYCYCLINE (Vibramycin)
6-12 ERYTHROMYCIN
6-13 CLINDAMYCIN (Cleocin)
6-14 CHLORAMPHENICOL (Chloromycetin)
6-15 SULFAMETHOXAZOLE (Gantanol)
6-16 TRIMETHOPRIM (TMP)
6-17 CIPROFLOXACIN (Cipro)
6-18 METRONIDAZOLE (Flagyl)
6-19 ISONIAZID (INH)
6-20 PYRAZINAMIDE (PZA)
6-21 ETHAMBUTOL (Myambutol)
6-22 RIFAMPIN (Rimactane)
6-23 DAPSONE
6-24 AMPHOTERICIN B (Fungizone)
6-25 VORICONAZOLE (Vfend)
6-26 MICONAZOLE (Monistat)
6-27 TERBINAFINE (Lamisil)
6-28 CASPOFUNGIN (Cancidas)
6-29 FLUCYTOSINE (Ancobon)
6-30 GRISEOFULVIN (Fulvicin, Grifulvin)
6-31 CHLOROQUINE (Aralen)
6-32 ARTEMETHER
6-33 PRIMAQUINE
6-34 PENTAMIDINE (Pentam 300, NebuPent)
6-35 ABACAVIR (Ziagen)
6-36 TENOFOVIR (Viread)
6-37 EFAVIRENZ (Sustiva)
6-38 RALTEGRAVIR (Isentress)
6-39 DARUNAVIR (Prezista)
6-40 RITONAVIR (Norvir)
6-41 ENFUVIRTIDE (Fuzeon)
6-42 MARAVIROC (Selzentry)
6-43 ACYCLOVIR (Zovirax)
6-44 FOSCARNET (Foscavir)
6-45 ENTECAVIR (Baraclude)
6-46 INTERFERON ALPHA
6-47 LEDIPASVIR
6-48 SOFOSBUVIR (Sovaldi)
6-49 SIMEPREVIR (Olysio)
6-50 OSELTAMIVIR (Tamiflu)
6-51 AMANTADINE (Symmetrel)
Bibliography
Index
Preface
When we were studying for the USMLE Step I (the “Boards”), we found that there was no single adequate source
for the relevant pharmacology. Many review books were too sparse and telegraphic and left many questions
unanswered. On the other hand, major pharmacology texts were too verbose and detailed to use to study for the
Boards. We therefore decided to assemble our own summaries of the important drugs. Our goal was to create a
reference work that emphasized the “high-yield” facts but was also complete enough to provide a conceptual
framework for learning rather than simple memorization.
We opted for an index card format to allow for both an “active” style of flashcard studying and flexible
organization. The widespread use of PharmCards since the first edition was published is gratifying and confirmed
the need for such a study aid.
In this fifth edition, we have redrawn the figures and added full color to enhance their readability. We have
expanded the class cards to provide greater detail on drugs for diabetes, lipids, and hepatitis C. We have
maintained the grouping of drug cards by category (e.g., adrenergic, cholinergic, and so on) and then by class
(e.g., α-agonists, α-antagonists, β-agonists, and so on) as we have received positive feedback that this structure
facilitates comparing and contrasting similar agents. Some drugs defy easy classification; in these cases, we have
positioned them where we thought they would be most helpful for study. Also note that some diseases are treated
with drugs that span drug categories (e.g., asthma and glaucoma). In these cases, we have listed on each card the
name and class of the other relevant drugs to treat that disease.
Since the publication of the fourth edition, there have been major advances in the field of pharmacology. A
deeper understanding of the molecular mechanisms of disease has led to exquisitely tailored pharmacotherapy.
Combined angiotensin receptor-neprilysin inhibitors (ARNIs) for heart failure, sodium glucose cotransporter 2
(SGLT2) inhibitors for diabetes, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for
hypercholesterolemia, and checkpoint inhibitors for cancer therapy are a few examples of new or expanded drug
classes that have been incorporated into this fifth edition of PharmCards.
A few words of advice:
1. Don’t be overwhelmed by the large amount of information contained in the cards. Frequently, understanding
the mechanism of a drug and how that relates to the drug’s clinical use and side effects is sufficient.
2. Concentrate on understanding the major drug classes before diving into the sea of drug names. The class
cards are designed to facilitate this approach.
3. Read through PharmCards several times before trying to memorize anything. This will give you perspective
on what to memorize, and you may be surprised by how much you can recall without resorting to rote
memorization.
4. PharmCards are geared toward studying for the Boards, but they also include information that we found
particularly useful on the wards. We hope that their usefulness will extend beyond that one fateful day of
test taking and that these cards may serve as a quick source of information that bridges basic and clinical
pharmacology on the wards.
We also thank the editorial and production staffs at Wolters Kluwer Health, including Tim Rinehart for his help
in bringing this project to completion.
A project of this magnitude requires a tremendous investment of time and energy, and we thank our wives and
families for being so supportive throughout the process.
Best of luck on the Boards!
E.C.J.
M.S.S.
GENERIC NAME (Trade Name—should not be class
memorized!)
Mechanism The most important section when studying for USMLE Step I! The explanation often starts at the molecular level and then
moves on to organ level effects. Some of the molecular detail is unlikely to be tested on the Boards but is included to provide
you with a stronger conceptual foundation.
Resistance Also an important section. Usually seen with antimicrobials, antineoplastics, and so on.
Clinical For the Boards, it is important to understand how the mechanism of action explains the clinical utility. One need not, however,
know the exact spectrum of activity at the species level for antimicrobials, the specific arrhythmias for which antiarrhythmics
are used, the tumors for which antineoplastics are used, and so on. For third-year students, clinical indications take on
increased importance; these cards can serve as a useful bridge from basic to clinical pharmacology.
Side Effects The most common as well as the severe and unique side effects are worth memorizing.
Antidote This section is found on toxin cards and certain drugs when there is a specific treatment for intoxication (beyond supportive
care).
Contraindic. Life-threatening absolute contraindications are important and are usually italicized. In general, this section serves to emphasize
which side effects are severe enough to prompt usage of a different agent.
Metabolism Noted here are atypical routes of administration, particularly short or long half-lives, and routes of metabolism that are subject
to clinically relevant alterations.
Interactions Reserved for notable drug–drug interactions.
Notes Drugs similar to the prototype discussed above are listed here along with their distinguishing features. It is important to know of
their existence and their significant differences from the prototype.
CATEGORY
PROTOTYPICAL
AGENT
In the top right-hand corner, chemical structures are
Related agent
occasionally provided if they help illustrate a point.
Related agent
These structures should not be memorized.
Related agent
Figures and tables are included here to help clarify pathways and compare related
agents.
Key to Abbreviations
5-HT 5-hydroxytryptamine (serotonin)
AC adenylate cyclase
ACE angiotensin converting enzyme
ACEI angiotensin converting enzyme inhibitor
ACS acute coronary syndrome
ACh acetylcholine
AChR acetylcholine receptor
ADH antidiuretic hormone
ADP adenosine diphosphate
AF atrial fibrillation
AFL atrial flutter
AIDS acquired immune deficiency syndrome
ALL acute lymphocytic leukemia
AML acute myelogenous leukemia
AMP adenosine monophosphate
ANA antinuclear antibody
aPTT activated partial thromboplastin time
ARB angiotensin receptor blocker
ARNI angiotensin blocker-neprilysin inhibitor
ATI angiotensin I
ATII angiotensin II
ATIII antithrombin III
ATP adenosine triphosphate
AV atrioventricular
BBB blood–brain barrier
BNP B-type natriuretic peptide
BP blood pressure
CAD coronary artery disease
cAMP cyclic adenosine monophosphate
CCB calcium channel blocker
CDC Centers for Disease Control and Prevention
CHF congestive heart failure
CMV cytomegalovirus
CNS central nervous system
CO cardiac output
COMT catechol O-methyl transferase
COPD chronic obstructive pulmonary disease
COX cyclooxygenase
CSF cerebrospinal fluid
CV cardiovascular
CVA cerebrovascular accident
CYP450 cytochrome P450
DA dopamine
DAG diacyl glycerol
DBP diastolic blood pressure
DCT distal convoluted tubule
DHF dihydrofolate
DHFR dihydrofolate reductase
DVT deep vein thrombosis
EBV Epstein-Barr virus
FAD flavin adenine dinucleotide
FMN flavin mononucleotide
FSH follicle-stimulating hormone
Gi inhibitory G protein
Gs stimulatory G protein
IV intravenous
LDL low-density lipoprotein
LFT liver function test
LH luteinizing hormone
LMWH low-molecular-weight heparin
LO lipoxygenase
MAC Mycobacterium avium–intracellulare complex
MAO monoamine oxidase
MI myocardial infarction
NAD nicotinamide adenine dinucleotide
NADP nicotinamide adenine dinucleotide phosphate
NE norepinephrine
NM neuromuscular
NSAID nonsteroidal anti-inflammatory drug
OTC over-the-counter
PABA para-aminobenzoic acid
PCSK9 proprotein proprotein convertase subtilisin/kexin type 9
PCT proximal convoluted tubule
PDE phosphodiesterase
PGX prostaglandins (X = A, B, C, etc.)
PIP2 phosphatidyl inositol 4,5-bisphosphate
PLA2 phospholipase A2
Output Drug output is the other major determinant of serum drug concentration.
Renal excretion is the primary route of elimination for most water-soluble compounds. Its efficiency is influenced not only
by GFR, but by acidification or alkalinization of the urine, which will enhance excretion of weak bases or acids,
respectively.
Hepatic clearance plays a prominent role in the elimination of lipophilic compounds. Metabolism proceeds in the liver by a
two-step process: phase I reactions add oxygen moieties via the P450 enzyme system (q.v.). Subsequent phase II
reactions conjugate large, hydrophilic groups to these oxygen moieties. The resulting metabolites are more hydrophilic
than the parent compounds and can be excreted in the bile, urine, or both. Frequently, these metabolites are
pharmacologically inactive, although many important exceptions occur. In fact, some “parent compounds” are inactive
pharmacologically and require the generation of active metabolites in the liver to produce an effect; this may not occur in
the setting of liver failure.
Other drugs are eliminated by a plethora of mechanisms. Examples include P-glycoprotein (q.v.)–mediated excretion,
degradation of catecholamines by COMT and MAO, heparin metabolism by the reticuloendothelial system, and
exhalation of anesthetic gases.
Regardless of the means of drug elimination, it is useful to estimate the rate of output. The great majority of drugs follow so-
called first-order kinetics, in which the rate of elimination is directly proportional to the serum drug concentration.
Clearance (CL) is a frequently used constant for describing this proportionality. It is defined as the ratio of the rate of
elimination (or output) to the drug’s concentration (C); conceptually, it corresponds to the volume of plasma that the body
could clear completely of drug per unit time.
The body’s capacity to handle some drugs is so constrained that these drugs are eliminated at a fixed rate, regardless of drug
concentration. This is referred to as zero-order kinetics.
PHARMACOKINETICS II fundamentals
Half-life Half-life (t½) is the time required to change the amount of drug in the body by one-half during elimination or a constant infusion.
For drugs that follow first-order kinetics, t½ is independent of drug concentration. After starting a new drug, 4 half-lives (50%
→ 75% → 87.5% → 93.75%) are required to achieve >90% of the steady state concentration.
Maintenance To maintain a therapeutic concentration, one must administer a drug at the same rate that it is eliminated from the body (i.e.,
Dose input = output). Thus, at steady state, the administration of 1,200 mg of a given drug daily will result in the elimination of
1,200 mg of the same drug regardless of whether it is given in one dose, 600 mg every 12 hours, 300 mg every 6 hours, or as a
continuous infusion at 50 mg/hour. For drugs that follow first-order kinetics, output is proportional to concentration.
Therefore, administration of any of the preceding maintenance dose (MD) schedules will yield the same average drug
concentration, although peaks and troughs will be greatest for the once-daily dosing schedule. This concentration can be
calculated by solving for CT using the equation at left (CT = 50 mg/hour ÷ CL).
Loading Dose Attainment of therapeutic drug concentration can be substantially delayed while a drug accumulates in the body. As noted above,
a drug must be administered for 4 half-lives in order to attain >90% of its CT. For drugs with long half-lives or in urgent
situations, it may be desirable to give a large initial or loading dose (LD) to rapidly bring drug levels into the therapeutic
range.
PHARMACODYNAMICS fundamentals
Overview Pharmacodynamics refers to the effect and mode of the action of the drug on the body, that is, what the drug does to the body.
Pharmacodynamic information can be found in the mechanism, clinical, and side effects sections of a PharmCard.
Agonists & Agonists bind to and activate receptors. In contrast, antagonists bind to receptors but do not activate them. Therefore,
Antagonists antagonists typically bring about clinical effects by preventing agonists (either endogenous or administered drugs) from
activating their receptors. Whereas competitive antagonists can be overcome by increasing the concentration of the agonist,
irreversible antagonists produce a degree of blockade that is independent of the concentration of the agonist. At full receptor
occupancy, partial agonists elicit a lesser response than do full agonists. Weak partial agonists may be clinical antagonists if
they lessen the effect of endogenous agonists.
Dose– Predicting the effect of a drug in relation to serum concentration is a central concept. At low doses, efficacy, or drug effect,
Response increases in proportion to concentration. At higher doses, efficacy is partially limited by the body’s ability to respond. For
example, a kidney can only produce so much urine, regardless of the amount of diuretic to which it is exposed. Emax is the
maximum attainable efficacy of the drug. By definition, a full agonist has a higher Emax than a partial agonist.
The effect at a given concentration (C) depends on both Emax and the drug concentration required to produce 50% of the Emax
(EC50). Potency is reflected in the EC50. Thus, high-potency drugs achieve their effects at lower concentrations than do low-
potency drugs. Note that whereas the clinical utility of a drug mainly depends on its efficacy, the dose required to achieve a
given effect depends on both potency and efficacy.
Therapeutic Clearly, some drugs are more toxic than others. In clinical practice, it is useful to know how likely a drug is to produce dose-
Index related toxicity. Clinical drug trials and animal studies are conducted to determine the median dose of a drug required to
produce a desired clinical effect in 50% of patients (the ED50) as well as the median dose required to produce toxicity (TD50
or LD50 if the toxic effect is lethal). The therapeutic index (TI) is the ratio of these two doses. Drugs with a low TI require
more precise dose selection and serum monitoring than those with a high TI.
PROTEIN BINDING fundamentals
Overview Competition for and displacement from serum protein binding sites is a frequently touted reason for drug–drug interactions.
Although this mechanism seems intuitively obvious, there are no clinically relevant examples of this phenomenon; most
interactions ascribed to protein-binding competition have proven to be caused by alteration in drug clearance. In clinical
practice, protein binding is only relevant for the interpretation of serum drug levels.
Carrier Albumin is the major serum-binding protein, especially for acidic drugs. α1-Acid glycoprotein is the predominant binding
Proteins protein for basic drugs; as an acute phase reactant, its concentration can be greatly elevated in inflammatory states. β-
Lipoproteins are also important binding proteins for some basic drugs.
Free Drug When drugs are bound to serum proteins, they are pharmacologically inactive. Only the unbound, or free, drug is available to
Concentration interact with receptors and exert its effect. The observation that some drugs could be displaced from their binding sites on
serum proteins, thus increasing the concentration of free drug, led to the theory that this increase in free drug concentration
could explain many drug–drug interactions. In the body, however, this increase in concentration is only transient because any
increase in free drug concentration also increases output (output = clearance × concentration).
Serum Drug An appreciation of fraction of drug bound to serum proteins is critical in the interpretation of serum drug levels. Because
Levels measurement of free drug levels is technically difficult, measurement of the total concentration of drug in the serum (i.e., free
+ protein bound) is generally used. In the example above, after a transient increase, the concentration of free drug eventually
returned to the same level, but paradoxically, the total drug concentration decreases when such a displacement interaction
occurs. Interpretation of this decrease in total concentration as a decrease in the free drug concentration could lead to
unnecessary increases in drug dosing and potential toxicity.
CYTOCHROME P450 ENZYME fundamentals
SYSTEM
Mechanism Human cytochrome P450 (also called CYP450) refers to a superfamily of heme-containing enzymes that catalyze the
monooxygenation of xenobiotics (e.g., drugs, toxins) and endogenous compounds (e.g., steroids, prostaglandins).
P450 enzymes are primarily located in the smooth endoplasmic reticulum of the liver and are thought to have evolved to enable
animals to detoxify chemicals in plants.
Metabolism of lipophilic drugs is traditionally divided into two phases. First, the P450 enzyme system incorporates a reactive
oxygen moiety into the drug (phase I). In phase II, other enzyme systems conjugate soluble groups (e.g., acetyl, glucuronate)
to this reactive species. The resulting hydrophilic metabolites can be active or inactive pharmacologically; occasionally, they
are more potent or toxic than the parent compounds (e.g., acetaminophen). Moreover, some compounds are inactive
(prodrugs) until they undergo P450 metabolism.
Side Effects Many xenobiotics induce the expression of specific P450 isoenzymes. This permits the liver to respond to changing
environmental conditions and is responsible clinically for many drug–drug interactions. Some xenobiotics also inhibit
specific P450 isoenzymes (see table).
Nomenclature P450 enzymes are classified based on amino acid similarity. Families are numbered and subfamilies receive letter designations.
For example, CYP2D6 is the sixth member of the D subfamily of family 2. The major families involved in drug metabolism
are CYP1, CYP2, and CYP3.
Notes P450 enzymes are named for their characteristic absorbance at 450 nm when exposed to carbon monoxide.
CYTOCHROME P450 INTERACTIONS
Isoenzyme Inhibitor Inducer Substrate Prodrug Substratea
CYP1A2 Cimetidine Cigarette smoke Theophylline
Ciprofloxacin
CYP2C8 Cimetidine Phenobarbital Diazepam
Rifampin
CYP2C9 Amiodarone Rifampin Phenytoin Losartan
Cimetidine Warfarin
Isoniazid
CYP2C19 Fluconazole Phenytoin Clopidogrel
Omeprazole Rifampin
CYP2D6 Cimetidine β-Blockers Codeine
Fluoxetine Codeine Tamoxifen
Quinidine TCAs
CYP2E1 Disulfiram Ethanol Ethanol
Isoniazid Halothane, isoflurane
CYP3A4 Cimetidine Phenobarbital Carbamazepine
Erythromycin Rifampin Cyclosporine
Fluconazole Midazolam
Ritonavir, Verapamil Terfenadine
TCAs, tricyclic antidepressants.
aNote that generally, the pharmacologic effect of a drug will ↑ with P450 inhibition (because of ↓ metabolic degradation).
However, if the drug requires P450-mediated biotransformation to become an active compound, then the pharmacologic effect will ↓
with P450 inhibition (because of ↓ active metabolite formation).
P-GLYCOPROTEIN fundamentals
Mechanism P-glycoprotein (P-gp) is a multisubstrate transporter that uses ATP hydrolysis to pump xenobiotics (drugs, toxins, etc.) out of
cells against steep concentration gradients. Its primary function is to prevent absorption of toxic compounds by the gut and to
facilitate their excretion into bile and the renal proximal tubules. P-gp expression in brain and testis capillary endothelium
limits the ability of toxins to enter these sensitive tissues.
Cells that normally express P-gp (e.g., colonic epithelium) display intrinsic resistance to many anticancer drugs. Overexpression
of P-gp in tumor cells confers a multidrug resistance (MDR) phenotype. For this reason, P-gp is sometimes referred to as
MDR1.
Metabolism P-gp is responsible for many drug–drug interactions. Inducers and inhibitors of P-gp have been identified (see table on reverse).
Drugs that are subject to P-gp efflux can have poor oral availability and, in the presence of P-gp inducers or inhibitors,
markedly varied oral availability.
CYP3A4 and P-gp have many common substrates, inducers, and inhibitors (compare table on reverse to P450 table). Thus, some
drug–drug interactions are amplified by the combined effects of altered absorption (via P-gp) and metabolism (via CYP3A4).
Notes The “P” in P-glycoprotein derives from the fact that it regulates the apparent permeability of cells to many drugs.
P-GLYCOPROTEIN INTERACTIONS
Inhibitora Inducer Substrate
Verapamil Rifampin Digoxin
Cyclosporin A St. John’s wort Doxorubicin, daunorubicin
Quinidine Vincristine, vinblastine
Ritonavir Etoposide, teniposide
Erythromycin, clarithromycin Paclitaxel
Ketoconazole, itraconazole Cyclosporin A, tacrolimus
Midazolam Saquinavir, amprenavir, ritonavir
Tamoxifen Methotrexate
Hydrocortisone, dexamethasone
Terfenadine
aP-glycoprotein inhibition may increase serum levels of a substrate by decreasing its excretion and by increasing its absorption.
Furthermore, in tissues expressing high levels of P-gp (e.g., MDR tumors), P-gp inhibition can increase intracellular concentrations of
drugs by preventing their export.
Classification Schema
1. ADRENERGIC AGENTS
Direct Sympathomimetic
Epinephrine
Dopamine
Dobutamine
Indirect Sympathomimetic
Amphetamine
Ephedrine
Cocaine
Sympathoplegic
Methyldopa
α-Adrenoceptor Agonists and Antagonists
Phenylephrine
Clonidine
Dexmedetomidine
Phentolamine
Prazosin
β-Adrenoceptor Agonists and Antagonists
Isoproterenol
Albuterol
Mirabegron
Metoprolol
Carvedilol
Timolol
D1-Agonist
Fenoldopam
2. CHOLINERGIC AGENTS
Nicotinic Agonist
Nicotine
Succinylcholine
Antinicotinic
Pancuronium
Muscarinic Agonist
Bethanechol
Pilocarpine
Antimuscarinic
Tertiary Amine
Atropine
Benztropine
Quaternary Amine
Ipratropium
Oxybutynin
Cholinesterase Inhibitor
Therapeutic
Neostigmine
Donepezil
Toxin
Sarin
3. CARDIOVASCULAR & RENAL AGENTS
Direct Vasodilators
Nitroglycerin
Nitroprusside
Nesiritide
Hydralazine
ACEI, ARBs, ARNI, & Renin Inhibitors
Captopril
Losartan
Sacubitril/Valsartan
Aliskiren
Calcium Channel Blockers
Nifedipine
Verapamil
Other Antianginals
Ranolazine
Inotropes & Pulmonary Arterial Vasodilators
Digoxin
Milrinone
Sildenafil
Epoprostenol
Bosentan
Diuretics
Furosemide
Hydrochlorothiazide
Spironolactone
Acetazolamide
Mannitol
Antiarrhythmics
Procainamide
Lidocaine
Flecainide
Amiodarone
Ibutilide
Ivabradine
Adenosine
4. HEMATOLOGIC AGENTS
Antiplatelet
Acetylsalicylic acid
Clopidogrel
Vorapaxar
Eptifibatide
Dipyridamole
Anticoagulant
Heparin
Enoxaparin
Bivalirudin
Warfarin
Rivaroxaban
Fibrinolytic
Alteplase
Procoagulant
Tranexamic acid
Hematopoietic
Erythropoietin
Filgrastim
Eltrombopag
5. ENDOCRINE AGENTS
Glucocorticoids
Prednisone
Beclomethasone
Estrogens, SERMs, & Progestins
Estradiol
Clomiphene
Tamoxifen
Anastrozole
Progesterone
Androgens & Antiandrogens
Testosterone
Flutamide
Finasteride
Hormones
Leuprolide
Octreotide
Oxytocin
Vasopressin
Thyroid Hormone & Antithyroids
Levothyroxine
Methimazole
Glucose-Lowering Drugs
Insulin
Metformin
Rosiglitazone
Glyburide
Nateglinide
Liraglutide
Sitagliptin
Empagliflozin
Acarbose
Hypolipidemics
Atorvastatin
Evolocumab
Ezetimibe
Fenofibrate
Niacin
Cholestyramine
Bisphosphonates & Other Bone Mineral Homeostatic Drugs
Alendronate
Teriparatide
Cinacalcet
6. ANTIMICROBIAL AGENTS
Antibacterials
β-Lactams and Other Cell Wall Agents
Penicillin
Nafcillin
Ampicillin
Clavulanic acid
Cefazolin
Ceftaroline
Imipenem
Vancomycin
Polymyxin B
Protein Synthesis Inhibitors
Gentamicin
Doxycycline
Erythromycin
Clindamycin
Chloramphenicol
Antimetabolites
Sulfamethoxazole
Trimethoprim
Others
Ciprofloxacin
Metronidazole
Antimycobacterials
Cell Wall Agents
Isoniazid
Pyrazinamide
Ethambutol
Other Agents
Rifampin
Dapsone
Antifungals
Cell Wall Agents
Amphotericin B
Voriconazole
Miconazole
Terbinafine
Caspofungin
Other Agents
Flucytosine
Griseofulvin
Antimalarials
Chloroquine
Artemether
Primaquine
Antiparasitic
Pentamidine
Antiretrovirals
RT Inhibitors
Abacavir
Tenofovir
Efavirenz
Integrase Inhibitor
Raltegravir
Protease Inhibitor
Darunavir
CYP450 inhibitor
Ritonavir
Entry Inhibitors
Enfuvirtide
Maraviroc
Antivirals
Antiherpesviral
Acyclovir
Foscarnet
Hepatitis Antivirals
Entecavir
Interferon alpha
Ledipasvir
Sofosbuvir
Simeprevir
Influenza Antivirals
Oseltamivir
Amantadine
7. CNS AGENTS
Antiepileptics
Phenytoin
Carbamazepine
Topiramate
Perampanel
Valproic acid
Ethosuximide
Gabapentin
Tiagabine
Phenobarbital
Sedative-hypnotics
Propofol
Diazepam
Zolpidem
Antispasmodic
Baclofen
General Anesthetic
Halothane
Local Anesthetic
Procaine
Glutamate Antagonists
Memantine
Riluzole
Serotonin Agonists & Antagonists
Sumatriptan
Ergotamine
Buspirone
Lorcaserin
Ondansetron
Alosetron
Antidepressants
Fluoxetine
Venlafaxine
Nefazodone
Amitriptyline
Phenelzine
Dopamine Agonists & Antagonists
Levodopa/Carbidopa
Pramipexole
Prochlorperazine
Antipsychotics
Chlorpromazine
Haloperidol
Olanzapine
Aripiprazole
Lithium
NK1 (Substance P) Inhibitor
Aprepitant
Opioids & Opioid Antagonists
Morphine
Codeine
Pentazocine
Diphenoxylate
Methadone
Naloxone
8. ANTI-INFLAMMATORY AGENTS
COX Inhibitors
Ibuprofen
Celecoxib
Acetaminophen
Leukotriene Antagonist
Zafirlukast
Immunosuppressants
Cyclosporine
Sirolimus
Antithymocyte globulin
Etanercept
Anakinra
Secukinumab
Natalizumab
Mycophenolate mofetil
Methotrexate
Immunomodulators
Interferon beta
Hydroxychloroquine
Sulfasalazine
Cromolyn
Antihistamines
Diphenhydramine
Fexofenadine
Antigout
Allopurinol
Colchicine
Probenecid
9. ANTINEOPLASTIC AGENTS
DNA Damaging Agents
Alkylating agents
Cisplatin
Bleomycin
Doxorubicin
Etoposide
Transcription Inhibitor
Dactinomycin
PARP Inhibitor
Olaparib
Antimetabolite
Cytarabine
Fludarabine
5-Fluorouracil
Hydroxyurea
Mercaptopurine
Antimicrotubule
Vincristine
Paclitaxel
Gene Expression Modifiers
All-trans retinoic acid
Azacitidine
Kinase Inhibitors
Tyrosine kinase inhibitors
Imatinib
Crizotinib
Ibrutinib
Trastuzumab
Bevacizumab
Other kinase inhibitors
Vemurafenib
Ruxolitinib
Palbociclib
Antitumor Monoclonals
Rituximab
Proteosome Inhibitor
Bortezomib
Immune Checkpoint Inhibitor
Nivolumab
Immunomodulator
Lenalidomide
BCL-2 Inhibitor
Venetoclax
10. MISCELLANEOUS AGENTS
H2 Blocker
Cimetidine
Proton Pump Inhibitor
Omeprazole
Prostaglandins
Misoprostol
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.