Drugs

Dr. Mahadev Desai (MD)

Consultant Physician, Ahmedabad
 DRUGS

Before YOU begin, please Remember

• Quick response is most important

• Don’t hesitate to say no, and get next Q

• If YOU don’t remember the dose (in detail), it’s ok

• YOU are not appearing for Pharmacology exam

• Begin with Class of Drug, Uses etc

 Drugs

• Class of Drug • Precautions

• Important Uses • Use in Pregnancy/
• Dose & Route Lactation
• ADR

Ampule, or ampoule, is a Vial or bulb is a flat base,

small single - broad cylindrical or round
dose container that has a (container) bottle sealed
sealed neck. with rubber stopper and
metal cap
 List of Drugs (never complete !!!)

Emergency Drugs Other Drugs

• Adrenaline, Noradrenaline • Analgesics
• Dopamine, Dobutamine • Antibiotics: Bacterial, Viral, Fungal
• Atropine • Anti-parasitic drugs
• Antihistaminic • Anti-diabetes drugs
• Corticosteroids • Anti-hypertensive drugs
• Diuretics • Anti-asthma drugs
• Bronchodilator • Anti-TB drugs
• Antiarrhythmic drugs • Anti-ulcer drugs
• Heparin, LMWH, Aspirin • Anti-anginal drugs
• Clopidogrel • Cholesterol lowering drugs
• IV fluids • Vaccines
• KCL, MgSo4, Glucose
Drugs : Part-1 : Emergency Drugs
 Emergency Drugs: 1. Adrenaline (Epinephrine)

Route : IM, SC, IV, Trans-tracheal, IO Do not Give Intracardiac

Uses Contraindications
• Anaphylaxis • IHD
• Cardiac arrest - ACLS • Narrow-angle glaucoma
• Allergic reactions • Shock
• Bronchial asthma • GA with halothane
• with lignocaine for L.A.
• Do not use with local anesthetic
Side effects in fingers & toes (gangrene or
• Arrhythmias necrosis),
• Use with caution in patients
• Angina receiving Digitalis, TCA
• Hypertension • in elderly patients
• Palpitations • in pt. with hyperthyroidism
• Headache

No True Contraindication in Emergency

 Emergency Drugs: 2. Noradrenaline (Norepinephrine)
Vasopressor, Adrenergic agonist (action purely on alpha receptors)
Route: IV infusion pump
Dose: Initial dosing 8 to 12 mcg/minute intravenously

Uses Side effects

• Cardiogenic shock • Tachycardia, VPCS

• Septic shock (first choice) • Hypertension

• ACLS – post cardiac arrest • Headache

• Refractory Hypotension after fluid • Skin necrosis

replacement If extravasation

Contraindications & Precautions

• Correct hypovolemia first

• Cautious use if (HOCM) IHSS
 Emergency Drugs: 3. Dopamine
Vasopressor, ionotrope (action on alpha & beta receptors)
Route: IV infusion
Dose: Initially 2 to 5 mcg/kg/min, gradually increase to desired levels
At lower dose main actions on beta receptors, at higher dose ( >15 mcg/kg/min
main actions on alpha receptors,

Uses Side effects

• Cardiogenic shock • VPCs, tachycardia
• Advanced HF • Nausea, vomiting
• Sepsis & septic shock • Photosensitivity rash
• Heart block unresponsive to • Glossitis
atropine (off label) • Extravasation  necrosis

Contraindications & Precautions

• Uncorrected hypovolemia
• Tachyarrhythmia
• Vent. Fibrillation
• Pheochromocytoma
 Emergency Drugs : 4. Dobutamine

Ionotrope, Adrenergic agonist (directly acting on beta receptors)

Route: IV infusion pump
Dose: To initiate infusion with 1 – 2 mcg/kg/min, increase the dose up to 2.5 to
10 mcg/kg/min as required

Uses Side effects

• Cardiogenic shock • Tachycardia, VPCs

• Post-MI, Post CABG • Hypertension
• Sepsis & Septic shock • Headache
• Diagnostic: stress echo

Contraindications & Precautions

• Correct hypovolemia first

• Cautious use if HOCM (IHSS)
 Emergency Drugs: 5. Atropine
Anticholinergic
Route: IM, IV, SC, local- eye ointment

Uses Side effects

• Symptomatic bradycardia (ACLS) (Anticholinergic effects)

• Dryness of mouth
• Cardiac asystole
• Blurring of vision
• Anticholinesterase poisoning
• Urinary retention
(organophosphrous)
Use glycopyrrolate to reduce ADR
• Preanesthetic medication for
reducing resp. Secretions
• Antispasmodic in colicky pains Contraindications &
• Parkinson’s disease Precautions
• Local • Acute glaucoma
- Mydriasis for fundus exam • Obstructive uropathy
• Prostatism
- Corneal ulcer
 Emergency Drugs: 6. Corticosteroids

Inject: Dexamethasone, Methyl prednisolone, Hydrocortisone

Oral: Prednisolone/ methyl, Dexa/Betamethasone, Deflazacort
Route: IV, IM, Oral, Inhalers & Nebulizers, Intra-articular….

Uses
• Bronchial asthma
• Anaphylaxis
• Adrenocortical insufficiency
• Cerebral edema
• Acute rheumatic carditis
• Auto-immune diseases: ITP, IBD, pemphigous
• Collagen disorders (SLE, wegner’s granulomatosis etc.)
• Nephrotic syndrome
• Pyogenic meningitis  give 1st dose of steroid before 1st dose of abx.
• Leukemia, lymphoma
• Diagnosis of cushing’s syndrome
 Emergency Drugs: 6. Corticosteroids

Side effects
• Edema, Fluid retention
• Cushingoid: moon face, buffalo hump
• Hypertension
• Hypokalemia, Hyperglycemia
• Easy bruising
• AVN (Avascular Necrosis) of head of femur
• Osteoporosis on prolonged use

Contraindications & Precautions

• Systemic fungal infections

• Ocular herpes simplex infections (use with caution)
 Emergency Drugs : 7. Frusemide (Furosemide)
DIURETIC (acts on loop of Henle), Antihypertensive
Route: IV, IM, Oral
Doses: IV 20 to 40 mg over 1-2 min., double the dose after 1 hour if
inadequate response
Oral 20 to 80 mg/day, increase gradually by 20 mg/day, Maximum daily dose
is 100 mg/day
Uses Side effects
• Acute pulmonary edema • Electrolyte disturbances: ↓ Na, K
• Cerebral edema • Deafness, Tinnitus
• Hypertensive encephalopathy
• S-J syndrome
• CCF
• Nephritic syndrome • ↑ Uric acid level, ↑ Glucose level
• Forced diuresis in poisoning
Contraindications &
• Refractory Ascites
• Refractory edema Precautions
• Elderly pts.
• Pts receiving lithium, succinyl
choline
• Hypovolemia states
 Emergency Drugs: 8. Aspirin

ANALGESIC, ANTI-INFLAMMATORY, ANTIPLATELET

Route: Oral, (?) IV
Doses: As Antiplatelet  50 to 325 mg/day
As NSAID 60 to 90 mg/kg (adults) & 100 mg/kg wt (children)

Uses Side effects

• As an Antiplatelet in AMI, ACS, • Nausea, vomiting, GI bleeding

TIA, Stroke, DVT, PE, PIH. • ↑ Bleeding time
• As anti-inflammatory in • Interstitial nephritis
Rheumatic Carditis, Collagen dis.. • Tinnitus & deafness
• As analgesic in Osteoarthritis • Hypersensitivity reactions in pts.
with h/o asthma, nasal polyp
• In children  Reye’s syndrome
 Emergency Drugs:
9. Anti-Arrhythmic Drugs
 Vaughan Williams Classification of Antiarrhythmic Drugs

Class Action Drug

I Na+ Channel Blockade
Quinidine, Procainamide,
IA Prolong repolarization
Disopyramide
Lidocaine, Mexiletine, Tocainide,
IB Shorten repolarization
Phenytoin
Encainide, Flecainide,
IC Little effect on repolarization
Propafenone
II Beta-Adrenergic blockade Propanolol, Esmolol, Acebutolol,
Prolong Repolarization Sotalol
III K+Channel Blockade Amiodarone, Bretylium, Sotalol

IV Ca+ Channel Blockade Verapamil, Diltiazem

V Miscellaneous
Adenosine, Digitalis, MgSO4
Misc. Actions
 Emergency Drugs: 10. Digoxin
CARDIAC GLYCOSIDE: Action: positive ionotropic, negative chronotropic, 
conduction velocity through AV node
Route: Oral, (?) IV
Doses: Loading dose 10-15 mcg/kg IV/PO divided over 12- 24 hrs (e.g. 0.5 mg
initially, then 0.25 mg 6 hrly for 4 doses)
Maintenance dose 0.125 to 0.5 mg/day (as per clinical response)

Uses Side effects

• Low output CCF • Arrhythmias
• Atrial fibrillation • Nausea, vomiting, gynecomastia
• Atrial flutter
• Blurred vision (halos around
• PAT
objects)
• Disturbed color vision (G-Y tinting)
Rx of digoxin toxicity : Correct
hypokalemia, Phenitoin, digoxian-
antibody Fc fragments (digibind). Contraindications & Precautions

• Ventricular fibrillation, II or III degree AV block, IHSS, WPW synd.

• Sick sinus syndrome
• Hypokalemia, Hypomagnesemia & Hypercalcemia may ↑ dig. toxicity
 Emergency Drugs: 11. Aminophylline

Bronchodilator & smooth muscle relaxants

Route: IV, IM, Oral
Narrow toxic: Therapeutic ratio
Uses Side effects
• Bronchial asthma • Palpitations, headache, anxiety
• Reversible • Tachycardia, Arrhythmia
bronchospasm in COPD
• Hypotension (if given rapidly)
• Diuresis
• Extravasation  Skin & soft tissue necrosis

Contraindications & Precautions

• Severe cardiac, hepatic or renal impairment
• In presence of arrhythmias
• In elderly pts.
• Drug drug interactions with erythromycin, ranitidine, ciprofloxacin (↑level of
aminophylline)
Drugs : Part-2 : Anti-TB drugs
 Drugs: Part 2 - Anti-TB drugs

First Line Second Line

• Isoniazide (INH) (H) • Ethionamide
• Rifampicin (RMP) (R) • Prothionamide
• Pyrizinamide (PZ) (Z) • Cycloserine
• Ethambutol (EMB) (E) • Quinilones: M, L
• Streptomycin (SM) (S) • Capreomycin
• Kanamycin
• Clofazimine

Newer Drugs: Bedaquiline (Bdq), Delamanid (Dlm)

 Doses of First-line Drugs*

Recommended Dose (mg/kg)

Anti-TB Drugs
(Abbreviation) Intermittent
Daily
3 times/week

Isoniazide (H) 5 10

Rifampicin (R) 10 10

Ethambutol (E) 15 30

Streptomycin (S) 15 15

Pyrizinamide (Z) 25 35

Thiacetazone (T) 2.5 -

• All drugs are given as single daily dose

• DOT is recommended for all, especially for intermittent therapy
Directly Observed Therapy - Short Course (DOT-S)
 Recommended treatment regimens
TB Alternative treatment regimens
Treatment (if smear + at end of initial phase of Cat I or Cat II, one more
Category month of initial phase is given)

Initial phase Continuation Phase

2 HRZE (2 HRZS) 6 HE
I
2 H3 R3 Z3 E3 (2 H3 R3 Z3 S3) 4 HR

2 SHRZE/1 HRZE 5 HRE

II
2 S3 H3 R3 Z3 E3/ 1 H3 R3 Z3 E3 5 H3 R3 E3

6 HE
2HRZ
III 4 HR
2 H3 R3 Z3
4 H3 R3
Direct observation is recommended for all patients and is
particularly essential when intermittent regimens are used
 Adverse effects of Drugs

Drug Adverse reactions

INH Peripheral neuropathy
Hepatitis

Rifampicin Hepatitis
GI upset: nausea, vomiting, abdominal pain
Reduced effectiveness of o.c. pill

Ethambutol Optic neuritis

Pyrizinamide Hepatitis
Joint pain

Streptomycin Vestibulo-cochlear nerve damage

Nephrotoxicity
 Drug resistance in Treatment of TB

Multidrug-resistant tuberculosis (MDR-TB) is caused by bacteria that do not

respond to, at least, Isoniazid and Rifampicin

Extensively drug-resistant TB (XDR-TB) is a form of multidrug-resistant

tuberculosis that responds to even fewer available medicines, including the most
effective second-line anti-TB medicines
Drugs : Part-3: Antibiotics
 Classification of Antibiotics: Molecular structure

Beta Lactams (BL) Penicillins, Cephalosporin, Carbapenem,

Monobactams
Beta Lactamase Inhibitors Clavulanic acid, Tazobactum…
(BLI)
Macrolides Azithromycin, Clarithromycin, Erythromycin…

Aminoglycosides Gentamycin, Streptomycin, Amikacin,

Kanamycin…

Quinolones Ciprofloxacin, Ofloxacin, Levofloxacin,

Moxifloxacin..

Oxazolidinone Linezolid
Tetracyclines Tetracycline, Doxycycline

Sulfonamides Sulfadiazine, Sulfadoxine+ pyrimethamine

Miscellaneous Chloramphenicol, Clindamycin, Polymixin…
 Dose of Antibiotics depend on Pk/Pd

Concentration-dependant killing Antibiotics:

Give High, Single daily dose: OD dose
- Azithromycin
- Levofloxacin
- Aminoglycosides

Azithromycin or Levofloxacin should not be given in BD dose

Time-dependant killing Antibiotics:

Give in divided doses: BD, TDS or QDS doses

- Amoxicillin
- Cephalosporin when given IV, give infusion
Over 2 to 4 hours x 6 to 8 hrly
- Carbapenem
 Selecting initial Antibiotic

Gram positive infection Gram negative infection Anaerobic infection

• Penicillin • Aminoglycosides • Metronidazole

• Cephalosporines 1st / • Quinolones • Clindamycin

2nd gen. • Carbapenem

• Extended spectrum
• Macrolides Penicillin • Chloramphenicol

• Tetracycline • Cephalosporines 2nd /

3rd / 4th gen.
• Newer quinolone
• Carbapenem
• Linezolid
• Chloramphenicol
• Vancomycin
Drugs : Part-4 : Anti-diabetes
Drugs & Insulin
 Available Antidiabetes Drugs in India

• Biguanides • Alpha Glucosidase • GLP 1 RAs*

• Metformin Inhibitors • Exenatide
• Acarbose • Liraglutide
• Voglibose • Dulaglutide
• Insulin
• Miglitol
Secretagogues
• Sulfonylure SGLT2 Inhibitors
- Glibenclamide • Insulin • Dapaglifozin
- Glypizide • Canaglifozin
- Glimepiride • Empaglifozin
• DPP-4 Inhibitors
- Gliclazide • Sitagliptin
• Non-SU • Saxagliptin
- Repaglinide • Centrally acting
• Vildagliptin agent
- Nateglinide • Linagliptin • Bromocriptine
• Teneligliptin
• Thiazonindione
• Pioglitazone
• Rosiglitazone
* injectable
 DPP-IV Inhibitors

• Primarily works on postprandial excursions

• Reduces HbA1C by 0.75% to 1.5 %

Sitagliptin (50 & 100 mg tab) : 50-100 mg/day, single dose

Vildagliptin (50 mg tab) : 50 mg twice a day
Saxagliptin (2.5 & 5 mg tab) : 2.5-5 mg/day, single dose
Linagliptin (5 mg tab) : 5 mg/day, single dose
Teneligliptin (20 mg tab) : 20 mg /day, single dose

• Doses of all DPP-IV Inhibitors need to be adjusted in renal

insufficiency except Linagliptin and Teneligliptin
SGLT2 inhibitors
 SGLT2 Inhibitors

Available molecules

• Empagliflozin • Average decrease in HbA1c ~ 1%

• Canagliflozin • Weight loss ~ 5 to 10 pounds

• Dapagliflozin • Decrease in Systolic BP

Insulin independent action • Increase in HDL

• Increase in LDL
Adverse effects: • Low risk of hypoglycemia

• Vaginal yeast infections

• Recurrent urinary tract
infections
 Insulin Indications

• Pregnancy – GDM or pre-existing DM

• During major surgery
• Acutely Stressful States
- Septicemia
- Myocardial infarction
- Hepatic or renal dysfunction
• Presence of ketosis
• Very High FPG > 250 mg
 Choosing The Right Insulin

• Species
• Storage
• Route
• Site
• Timing
• Pharmocodynamics
 Injection sites

• Absorption :
Faster in Abdomen  Arms  Thighs  Buttocks
• Rotate the injection site within the same area

Make Sure There Is No Syringe - Vial

Mismatch U-40 v.U-100
 Insulin Delivery System

1. Injection – SC / IM / IV
2. Insulin pen
3. Insulin pump – closed loop open loop
4. Inhaler insulin
5. Oral insulin
6. Pancreatic transplantation
 Types of Insulin

• Short-acting

• Intermediate-acting

• Long-acting

Know Onset / Peak / Duration for each

 Insulin Analogues

1. Insulin Lispro • By modification in amino-acid

2. Insulin Glargine sequences

3. Insulin Aspart • Longer acting

4. Insulin Detemir • Not requiring waiting time between

injection & meals
5. Insulin Delgudac
• More expensive
6. Insulin Glulisine
 Profile of Insulin

Effective Maximal
Insulin Type Onset Hrs Peak Hrs
Durations Hrs Duration Hrs

Regular 0.5-1.0 2 to 3 3 to 6 6

Lispro
<15 mim 1 3 4
Aspart

NPH 2 to 4 4 to 10 10 to 16 18

Lente 3 to 4 4 to 12 12 to 18 20

Glargine
Detemir 1 to 2 Flat 24 ?
Degludac
 Basal Insulin Supplementations

• Basal Insulin : Bedtime NPH / Long acting analogue

• Suppresses basal hepatic production
• Reduces Fasting plasma glucose
• Generally used in combination with OHA
• Helps initiate the patient on insulin therapy
 Guidelines for Initiating Insulin

• Alone or in combination with an OHA

• 0.2 units/kg body wt./day of intermediate acting insulin e.g. 8 to 10 units of
NPH Insulin / Long acting analogues
• Increase dose by 2 - 4 u every 3 - 4 days after checking pre & post-prandial
glucose levels

• If requirement exceeds 30 - 40 U, split the dose into two inj. daily : 2/3 before
breakfast, 1/3 before dinner
• If post prandial glucose levels are high introduce short acting insulin in 30:70
or 50:50 ratio
 Adverse effects of Insulins

1. Hypoglycemia

2. Local reactions – swelling, erythema, lipodystrophy

3. Allergy

4. Edema

5. Weight gain
 Hypoglycemia

Symptoms Headache, giddiness, intense hunger, palpitation,

perspiration, tremors, altered sensorium, convulsion, coma

Diagnosis High index of suspicion,

H/o missing meals, more insulin/drug….

Glucometer reading

Therapeutic trial

Management Give glucose in any form: sugar, candy, jaggery,

Glucose tablets (4.0 gm/tab, 4 tab stat)

IV 25% glucose 50 mL

Inj. Glucagon 1 mg
 Uses of Insulin

1. Diabetes mellitus
2. Rx of Hyperkalemia

3. Acute myocardial infarction

4. To test adequacy of vagotomy surgery

Drugs: Part-5 : Drugs for Hypertension
 Technique of BP measurement

Cuff size — proper-sized cuff is essential . If too small a cuff is used, it can lead
to overestimation of SBP by as much as 10 to 50 mmHg in obese pts.
The length of BP cuff bladder should be 80 %, and width at least 40 % , of the
circumference of the upper arm

American Heart Association recommendations:

Arm circumference Pt. Frame Cuff (W x L)

22 to 26 cm Small adult 12 x 22 cm

27 to 34 cm Adult 16 x 30 cm

35 to 44 cm Large adult 16 x 36 cm

45 to 52 cm Adult thigh 16 x 42 cm
 Classification of Blood Pressure
(WHO / ESH guidelines)

Category Systolic Diastolic

Optimal 120 80

Normal >120-129 >80-84

High normal 130-139 85-89

Grade 1 hypertension (mild) 140-159 90-99

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) >180 >110

Isolated systolic hypertension >140 <90

 Hypertension Classification - JNC 7

BP Classification SBP mmHg DBP mmHg

Normal <120 <80

Pre-hypertension 120-139 >80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension >160 >100

 Antihypertensive Drugs

1. Diuretics

2. Beta blockers

3. Calcium channel blockers (CCB)

4. ACE inhibitors

5. Angiotensin Receptor Blocker (ARB)

6. Alpha receptor blockers

7. Miscellaneous - Clonidine, Methyldopa, Hydralazine, Minoxidil

 Antihypertensive Drugs

There is no uniform agreement as to which antihypertensive drugs should be

given for initial therapy.
The major options are:
• Thiazide-type Diuretics
• ACE inhibitors/Angiotensin II receptor blockers (ARBs)
• Calcium channel blockers
• Beta blockers, which are now used less often for initial
therapy in the absence of a specific indication for their use

A or B in Young Combination
C or D in Elderly A/B+C/D
 JNC -7 for Rx of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 ) (SBP >160 or DBP >100 mmHg) indications Other antihypertensive
Thiazide-type diuretics for most. 2-drug combination for most drugs (diuretics, ACEI, ARB, BB, CCB)
May consider ACEI,ARB, BB, CCB, or (usually thiazide-type diuretic and as needed.
combination. ACEI, or ARB, or BB, or CCB)

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
 JNC-7 : Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling Indications

Target <140 mmHg

Lifestyle modification
therapy

Thiazide Long-acting
ARB
diuretic DHP CCB
 JNC-8 (released after 10 years)

• A set of recommendations and Not New Algorithm

• Relaxed approach than aggressive for initiation of Rx in Elderly and pts >60 yrs
with DM & CKD
• Most pts should be initiated ē ACEI / ARB / CCB /Thiazide-type Diuretic (See
no beta blockers!!)
• Pts >60 yrs start Rx if SBP ≥ 150 or DBP ≥ 90
• Pts.<60 yrs start Rx if SBP ≥ 140 or DBP ≥ 90
• Pts. with DM or CKD goal of Rx SBP <140 or DBP <90
• In general Non-black population start with Thiazide-type diuretic or CCB or
ACEI or ARB
• In Black population start with Thiazide-type diuretic or CCB
• Try to attain & maintain goal BP by increasing dose or adding second drug
(then third drug) from other class every month
• Do not use ACEI & ARB in same pt.
 Hypertensive Urgency & Emergency

• Hypertensive urgency
• Severe hypertension (DBP > 120 mmhg) in asymptomatic pts (a generally
accepted definition)
• No proven benefit from rapid reduction in BP in asymptomatic pts who have
no evidence of acute end-organ damage and are at little short-term risk

• Hypertensive emergency
• Severe hypertension (>200/120 mm hg) with end organ damage requiring
immediate lowering of BP to reduce further end organ damage
• E.G. Acute LVF, MI, hypertensive encephalopathy

It is generally unwise to lower bp too quickly or too much

For most hypertensive emergencies, mean arterial pressure should
be reduced gradually by about 10 to 20 % in the first hour and by a
further 5 to 15 % over the next 23 hours
 Hypertensive Emergency Management

Initial goal: is not to achieve normal BP, but rather to gradually reduce BP
Cerebral hypoperfusion may occur if BP is lowered >40% in the initial 24 hours

1. Sodium Nitroprusside: dose 0.25 –10 mcg/kg/min as IV infusion, immediate

onset of action, duration of action: 1-2 min.
ADR: N/V/muscle twitching/ thiocyanate & cyanide toxicity. Infusion bottle
has to be covered with dark cloth to avoid effects of light on its efficacy

2. Nitroglycerine: 5-100 mcg/min as IV infusion, onset: 2-5 min., duration: 3-5

min.
ADR: headache, vomiting, methemoglobulinemia, tolerance with prolonged
use
Especially indicated in associated coronary ischemia
 Hypertensive Emergency Management (2)

3. Enalaprilat: 1.25 – 5 mg. every 6 hrly IV, onset: 2-5 min., duration: 6 hrs

ADR: precipitous fall in BP in high renin states, variable response

Useful in associated acute LVF

4. Esmolol (rapidly acting parenteral beta blocker): 250-500 mcg/kg/min for

1min,then 50-100 mcg/kg/min for 4min, may repeat sequence, onset of
action: 1-2 min., duration: 10-20 min.

ADR: hypotension, nausea, Indicated in associated aortic dissection,

Perioperative high BP

5. Diazoxide: 50-100mg IV bolus, repeated or 15-30 mg./min. infusion, onset: 2-

4 min., Duration: 6-12 hrs.

ADR: nausea, tachycardia, flushing, chest pain, Rarely used now as it requires
intensive monitoring
 Hypertensive Emergency Management (3)

6. Hydralazine HCl : 10-20mg IV, onset: 10-20 min,

10-50 mg IM, onset: 20-30 min,
Duration : 3-8 hrs,
ADR: tachycardia, flushing, headache, vomiting,  in anginal pain
Especially used in Eclampsia of pregnancy

7. Labetolol : 20-80 mg IV bolus, every 10min, or 0.5 – 2.0 mg/min IV infusion,

Onset: 5-10 min, duration: 3-6 hrs,
ADR: vomiting, scalp tingling, burning in throat, heart block

8. Phentolamine: 5-15 mg IV, onset: 1-2 min,

Duration: 3-10 min,
ADR: tachycardia, flushing,Headache,
Especially used in hypertensive crisis of, & perioperative period in
pheochromocytoma
Drugs : Part-6 : Drugs for Asthma
 Asthma Medications

Relievers Controllers

• Short acting b-agonist (SABA) • Anti-inflammatory

- Salbutamol, terbutaline - Inhaled steroids
• Long acting b- agonist (LABA) - Oral steroids
- Salmeterol, formoterol - Leukotriene receptor
• Anticholinergic antagonist
- Ipratropium, triotropium - Cromoglycate & nedocromil
- Methotrexate
• Bronchodilators
- Theophylline
- LABA
 Drug delivery options in Asthma

Routes
• Oral
• Injectable
• Inhaler
• Nebulizer

Inhaler
• MDI
• DPI
• MDI with Spacer
 Other treatment of Bronchial Asthma

• Methotrexate

• Rx of GERD

• Omalizumab : IgE blocker, expensive, only injectable

 Treatment of acute severe asthma (Status Asthamaticus)

1. Back rest, Oxymetry, O2 – 60%FiO2 / 5 litres /min. by nasal canula or mask

2. Nebulizer – Salbutamol or Terbutaline (2.5 - 5mg) x 20 min. Add Ipratropium

500 mcg; Observe the response
3. IV line for saline infusion for hydration & collect blood for CBC, ABG,
Electrolytes
4. IV Hydrocortisone 100 to 200 mg. X 6 to 8 hrly or Methyl prednisolone 40 to
125 mg IV 6 to 8 hrly
5. Inj. Aminophylline 500 mcg/Kg/hr in infusion
6. Magnesium Sulfate, 2 g. infused IV over 20 minutes, once
7. Inj. Adrenaline 0.5 ml dil. In 1:1000 SC/IM if no Contraindication
8. Antibiotics only if bacterial infection is the trigger
9. Ventilation : Non-invasive or Invasive

If Dyspnoea persists – take ECG & X-ray chest to

rule out LVF & Pneumothorax
 Drugs : Part-7 : Drugs in
Coronary Artery Disease (CAD)
 Stable Angina : Treatment Options

Angina Treatment
Options

Medicine Percutaneous CABG

 Drug Therapy for Stable Angina Pectoris

1. Nitrates
2. Beta-blockers
3. Calcium channel blockers
4. Potassium channel openers
5. Metabolic drugs
6. Antiplatelet / Anticoagulant agents
7. Statins
 1. Nitrates : dilates peripheral & coronary vessels

(A) Sublingual nitroglycerin- for relief of acute anginal pain. It can also be used
prophylactically before activities that may precipitate angina.
Dose: 0.3 to 0.6 mg Glyceryl trinitrite or
5 to 10 mg Isosorbide dinitrate
Action: starts within 2 to 5 minutes
Important side effects: headache, hypotension, dizziness

(B) Oral nitrate: Isosorbide Mononitrate (ISMN) or ISDN for Chronic stable
anginal pain
Dose: ISMN – 20 to 60 mg /day
Action: 6 to 8 hours
(up to 24 hours for Sustained release preparation)
 1. Nitrates (contd.):

C) IV nitroglycerine (NTG) infusion

for unstable angina

Dose : 6 to 10 mcg /min

D) NTG patch (5-20 mg / 24 hrs)

Ointment (6.25 mg x 2-4 times a day)

• Nitrate Tolerance develops within few hours

• Always keep nitrate-free interval (8-10 hrs) to avoid nitrate tolerance

• Always keep asymmetrical dose schedule

• Always inquire about use of Sildenafil before giving nitrates

 2. Beta-blockers

• Used for symptomatic relief of angina

• Prevention of ischemic events.
They work by ↓ myocardial O2 demand and by ↓ heart rate and myocardial
contractility. Beta-blockers reduce the rates of mortality and morbidity following
acute MI

Drug Dose/ day Frequency/day

Propranolol 40 to 120 mg 2 to 3

Atenolol 50 to 200 mg 1 to 2

Metoprolol 25 to 100 mg 1 to 2

Carvedilol 3.125 to 25 mg 1 to 2

Nebivolol 5 to 10 mg 1 to 2
 3. Calcium Channel Blockers

• Drug of choice for Prinzmetal angina

• For all kinds of angina when no relief with nitrite or beta-blockers
• Avoid short-acting calcium channel blockers
• Avoid in CHF or low EF

Drug Dose Frequency/day

Nifedipine 10 to 20 mg 3 to 4
Amlodipine 5 to 10 mg 1 to 2
Verapamil 40 to 80 mg 2 to 3
Diltiazem 30 to 90 mg 2 to 3

Important side effects:

Constipation, bradycardia, gum hypertrophy, oedema
 4. Potassium channel openers

Nikorandil: Selective activation of K+ATP channels at the sarcolemmal and

mitochondrial level  Coronary and peripheral vasodilatation with subsequent
reduction of preload and afterload

Also considered as a cardio-protective drug

Dose: Oral - 5 to 10 mg two times a day

Intra-coronary Inj. In ACS while performing Coronary Angiography

 5. Metabolic drugs

Trimetazidine is an anti-ischemic (anti-anginal) metabolic agent, which improves

myocardial glucose utilization through stopping of fatty acid metabolism.

Dose: 20 to 30 mg 2 to 3 times a day

Ranolazine  effect via altering trans-cellular late Na+ current. It ↓ late Na+
current & thereby ↓ intracellular ca++ overload. No effects on HR or BP

Not for Rx of acute angina

Dose: 500 mg 2 times a day

ADR: watch for QT interval prolongation

Avoid in pts receiving Class I or III antiarrhythmic drugs

 6. Antiplatelet Drugs / Anticoagulant drugs

• Aspirin: 75 to 325 mg / day, First give soluble aspirin, later on enteric coated
aspirin may be given

ADR: gastritis, hemetemesis

P2Y12 inhibitors: Clopidogrel, Prasugrel, Ticagrelor

• Clopidogrel: Loading dose 300mg then 75 mg daily

ADR: gastritis, increased bleeding complications

• Prasugrel: Loading dose 20 mg then 10 mg/d (not in >75 yrs)

• Ticagrelor: Loading dos 180 mg then 90 mg bd

• GP IIb / IIIa inhibitors : Tirofiban, Eptifibatide, Abcicimax

• Heparin: Unfractionated or Low Molecular Weight Heparin
 7. Statins

• All Statins help in plaque stabilization in Acute Coronary Syndrome

• Statins are mainstay of Rx for hyperlipidemia

Statin Dose / day

Simvastatin 20 mg

Atorvastatin 10 mg

Pravastatin 20 mg

Rosuvastatin 5 mg

Pitavastatin 4 mg
 Management of Unstable Angina

1. Aspirin 160 – 325 mg soluble (if enteric coated- ask pt. to chew)
2. Complete bed rest, O2 (if SpO2<90%), ECG monitoring
3. IV access, draw blood for cardiac markers, CBC, electrolytes, blood sugar,
creatinine, lipid profile
4. Analgesics - tramadol / morphine / pethidine
5. Nitroglycerine (NTG) infusion to start with 8-10 mcg/min and to titrate,
maximum 100 mcg/min
6. Heparin 5000-10000 units stat & 800 – 1200 U/hr by infusion pump,
monitor with aPTT or use LMWH
 Management of Unstable Angina (2)

8. Clopidogrel (for pts not planned for PCI) or

9. GPIIb/IIIa inhibitors- Abcicimax / Tirofiban /Eptifibatide (for pts likely to
undergo PCI)
10. High dose Statins for plaque stabilization
11. Beta-blockers- 5 mg metoprolol slowly over 5 min. for 3 doses
12. ACEI – captopril 6.25 mg x according to BP response
13. Supportive Rx- stool softeners, light diet, anxyolytics
14. Coronary angiography PTCA & Stenting or CABG
 Treatment of Acute Myocardial Infarction

1. Aspirin (Soluble) 325 mg. To be chewed + Clopidogrel* (300 mg)

2. Bed rest (Complete) and O2 (60%) for 36 hours, Betablockers
3. Continuous ECG monitoring, Clopidogrel 300 mg stat
4. Insert IV line – collect blood for cardiac enzymes, glucose, urea, electrolytes,
CBC, lipids
5. Pain relief – Morphine (2-4 mg. IV) / IM Pethidine (50-100 mg)
– Buprenorphin / NTG infusion
6. Anxiety Relief – Diazepam 5 mg. / Alprazolam 0.5 mg
7. Thrombolytic – SK 1.5 million units in 100 ml 0.9% saline over 1 hr. by IV
infusion pump
8. Before SK - Inj. Hydrocortisone 100 mg.
- Inj. Chlorpheniramine maleate IV
9. Other agents : Urokinase, tPA: tissue plasminogen activator
 Treatment of Acute Myocardial Infarction (2)

10. High dose Statins: e.g. A (80 mg), R (40 mg)

11. ACEI (ACE-inhibitors)

12. PAMI (Primary Angioplasty in Acute MI)

13. Emergency CABG

14. Supportive Rx & Treatment of complications

Drugs : Part-8 : Acute Rheumatic Fever
 Management of Acute Rheumatic Fever

Aims: 1) To limit cardiac damage

2) To relieve pain
3) To eliminate streptococcal infection

1) Primary prevention of rheumatic fever from GAS infection

2) Treatment of Arthritis
3) Treatment of Carditis
4) Treatment of complications
5) Treatment of chorea
6) Secondary prophylaxis to prevent recurrent strept. infection
 1. Primary Prevention of Rheumatic Fever
(Treatment of Strept. Tonsillo-pharyngitis)
Agent Dose Mode Duration

Benzathine 6 lacs U for pt. ≤ 27 kg. IM Once

penicillin G 12 lacs U for pt. > 27 Kg.
or
Penicillin V Children: 250 mg 2-3 times/day Oral 10 d
(phenoxy - Adolescents & adults: 500 mg
methyl penicillin) 2-3 times daily

For individuals allergic to penicillin

Erythromycin: 20-40 mg/kg/d 2-4 times daily Oral 10 d
Estolate (maximum 1 g/d)
or
Ethyl succinate 40 mg/kg/d 2-4 times daily Oral 10 d
(maximum 1 g/d)

Recommendations of American Heart Association

 Primary prevention of GAS infection causing ARF

Alternative treatment suggested by IDSA

• Amoxicillin 500 mg bd for 10 days
• Cephalexin 500 mg bd for 10 days

Patients allergic to Penicillin/Cephalosporins

• Azithromycin 500 mg daily for 5 days
• Clarithromycin 250 mg bd for 10 days
• Clindamycin 600 mg tds for 10 days (<70 Kg wt 7 mg/kg)
 2. Treatment of Arthritis

(A) Bed rest

(B) Aspirin: relieves pain promptly (within 24 hours), start with a dose of 60
mg/kg/day in 6 divided doses, increase up to 100 mg/kg/day;

Common side effects- nausea, tinnitus, deafness, vomiting, metabolic acidosis

Continue till all symptoms resolved & inflammatory markers like ESR or CRP
normalized

(C) Steroids: indicated in severe arthritis (not controlled with aspirin)

Start with 1-2 mg/kg/day of Prednisolone, continue until ESR/CRP is normal,
gradually taper it
 3. Treatment of Carditis

(A) Bed rest

(B) Steroids: There is no evidence that anti-inflammatory treatment improved
cardiac outcomes. Usually steroids preferred to aspirin Start with 1-2 mg/kg/day
of Prednisolone, continue until ESR is normal, then gradually taper it. Add
aspirin while tapering the dose of steroid to prevent rebound symptoms

C) Aspirin:
4. Treatment of complications

• Treatment of CCF with SRD, digoxin (at lower dose), diuretics

5. Treatment of chorea
• Self limiting
• Tranquilizer – diazepam or chlorpromazine for short period
• Carbamazepine or Sodium Valproate
 6. Secondary Prevention of Rheumatic Fever
(Prevention of Recurrent Attacks)
Agent Dose Mode
Benzathine penicillin G 12 lacs U every 4 weeks* IM
or
Penicillin V 250 mg twice daily Oral

or
Sulfadiazine 0.5 g once daily for pt. ≤ 27 kg Oral
1.0 g once daily for pt. > 27 kg

For individuals allergic to penicillin and sulfadiazine

Erythromycin 250 mg twice daily Oral

*In high-risk situations, administration every 3 weeks is justified

and recommended

Recommendations of American Heart Association

 Duration of Secondary prophylaxis

Rh. Fever without carditis  For 5 yrs after last attack or

up to 21 yrs age
(whichever is longer)

Rh. Fever with carditis  For 10 yrs after last attack or

but without valve damage 21 yrs age (whichever is longer)

Rh. Fever with  For 10 yrs after the last attack or

persistent valve damage 40 yrs age (whichever is longer)
sometimes lifelong
Drugs : Part-9 : Infective Endocarditis
 Management of Infective Endocarditis

Antibiotics for prolonged period

Streptococcal viridans: Inj. Benzyl penicillin 4 MU /6 hrly +

Inj. Gentamicin 3 mg/kg/day for 2 weeks; then
Inj. Penicillin 4 MU/6 hrly for further 2 to 4 weeks
For patients allergic to penicillin
Inj. Vancomycin 15 mg/kg x 12 hrly for 4 weeks or
Inj. Ceftriaxone 2 gm once daily for 4 weeks

Enterococcus fecalis: Inj. Ampicillin 2 gm/ 4 hrly or Penicillin 4 MUx4hrly

+ Inj. Gentamicin 3 mg/kg / day for 4-6 weeks or
In case of penicillin allergy : Inj. Vancomycin 15 mg/kg / 12 hrly
+ Inj. Gentamicin 3mg/kg/day for 4-6 weeks
Staph. aureus : Vancomycin (15 mg/kg/ 12 hrly) or
Cefazolin 2 gm/ 8 hrly for 4- 6 weeks
 Management of Infective Endocarditis (2)

Prosthetic Valve Endocarditis (PVE): Vancomycin (15 mg/kg)x 12 hrly for 6-8
weeks + Gentamicin (1 mg/kg x 8 hrly for 2 weeks) + Rifampicin (300 mg x 8 hrly
for 6-8 weeks)
Gram negative infection: Inj. Ampicillin 2 gm/ 4 hrly + Inj. Gentamicin 3 mg/kg/
day for 4-6 weeks

Fungal infection: Rare, when occurs poor results

Amphotericin B + surgical removal of valve ideal
Flucytosine 3 gm/6 hrly IV 30 min followed by
Fluconazole 50 mg /24 hrs. If resistant to flucytosine or
Aspergillus as the cause
Miconazole if poor renal function

Surgical Treatment : Removal native valve & insertion / replacement of

prosthetic valve
Indications : 1. Heart failure not responding to medical treatment
2. Valve ring abscess
3. Repeated major emboli
4. Unstable prosthesis
 Antibiotic Prophylaxis Regimens for Infective Endocarditis

Patients at high risk undergoing procedure or surgery likely to cause

bacteraemia

Single dose  Oral 1 hour or IV 30-60 min before procedure

• Amoxicillin 2 gram oral or Ampicillin 2 gram IV or

• Cephalexin (or Cefuroxime) 2 gram oral or 1 gram IV
• Pts. Allergic to Penicillin:
- Azithromycin or Clarithromycin 500 mg oral or IV or
- Clindamycin : 600 mg oral or IV
Drugs : Part-10 : Analgesics & NSAIDs
 Analgesics & Anti-inflammatory Drugs

Mechanism of action: Central & Peripheral Nervous System

• Paracetamol

• NSAIDs

• Partial agonist Narcotic analgesics: Codeine, Tramadol, Buprenorphine

• Narcotic analgesics : Morphine, Pethidine, Fentanyl

 Paracetamol (Acetaminophen)

• Simple analgesic, little anti-inflammatory action

• Act on nitric oxide pathways; NMDA & substance P receptors
• No peripheral action
• Moderate relief in pain and pyrexia

Route: Oral, IV
Dose: 650 to 1000 mg 1 to 4 times a day in adult

Not > 6 grams/day

Not > 2 grams / day in alcoholics (CLD)

Major ADR: liver damage

Antidote: N Acetyl Cysteine (NAC)
 Classification of NSAIDs

Non-selective COX Inhibitors

Salicylates: Aspirin
Arylalkanoic acids: Diclofenac , indomethacin
2-Arylpropionic acids: Ibuprofen, ketoprofen, naproxen
(profens):
Pyrroles: Ketorolac
Enolic acids (oxicams): Piroxicam, meloxicam
Sulphonanilides: Nimesulide

Selective COX-2 Inhibitors

Coxibs: celecoxib, rofecoxib, valdecoxib, etoricoxib
 Adverse Side Effects Of The NSAIDs

GI Tract Kidneys
- Abdominal pain - Hematuria
- Bleeding - Cystitis
- Diarrhea - Renal necrosis
- Nausea, vomiting
Misc
- Ulcerations
- Perforations of the gut - Bronchospasm

- Hepatotoxicity - Anemia
CNS
- Thrombocytopenia
- Headaches
- Skin rashes
- Tinnitus
- Vertigo - Reye’s syndrome
- Depression
 Average adult daily dose of NSAIDs

Drug Daily Dose (mg) Frequency

1. Aspirin 900 - 1800 3-4

2. Ibuprofen 1200 - 1800 3-4

3. Diclofenac 75 - 150 2-3

4. Indomethacin 50 - 150 2-3

5. Naproxen 250 - 500 2-3

6. Piroxicam 20 - 40 1-2

7. Etoricoxib 90 - 180 2-3

8. Nimesulide 100 - 300 2-3

9. Meloxicam 7.5 - 15 1-2

 Narcotic Analgesics : morphine, pethidine

• Analgesic action via μ receptors

• All pain states, moderate – severe
Routes : IV, IM, S.C., Intrathecal, Oral

Dose: Morphine: 2 – 10 mg

Pethidine: 50 – 100 mg

Major ADR
• Respiratory depression
• Constipation
• Drowsiness
 Tramadol

• Centrally acting analgesic with a multimode of action

• Acts on serotonergic & noradrenergic nociception
• Its metabolite acts on the µ-opioid receptor.

A weak opioid agonist (1/10 of morphine)

Route : Oral, IV, IM

Dose: 25 to 100 mg / day, titrate dose gradually

Major ADR:
• Nausea vomiting
• Dizziness
• Sweating
• Serotonin sydrome
Drugs : Part-11 : Vaccines
 Vaccines in Adults

CDC Recommendations 2018 (For all adults >19 yrs)

• Influenza (IIV): Single dose, 0.5 mL IM, Annually

• Pneumonia: * Single dose: 0.5 mL, IM, All >65 yrs

PCV13 * Any age for high risk*

PPSV23 * Second dose after 5 yrs of first dose

• Hepatitis B: 3 doses of 1.0 mL IM, to All at 0, 1, 6 months

Booster dose: 21 yrs after first dose

” ” ” : earlier if antibodies titre fall

• Typhoid: Typhim Vi : single dose 0.5 mL IM every 3 yrs

(Tetanus, reduced diphtheria toxoid, acellular pertussis)
• Tdap: 0.5 mL IM; Any time if not received in childhood
Booster after 10 years
Thank You