DRUGS USED IN DISORDERS OF EAR, NOSE, THROAT AND EYE teaming Objectives oie ee trschopter is designed fo enable the learner to anderstond: 4 Usoge of fopical preparations for various ophthalmic conditions 3. Usage of topical preparations for various ear and nose infections Chapter Outline 3. Drug Application for Ocular Diseases a. Pharmacokinetic Principles of Ocular Medicines 5 Various Infective Conditions of Eye (Bacterial, Viral, Fungal and Protozoal) 0 Antiglaucoma Agents 9. Drugs used in Various Ear and Nose Infections j DRUG APPLICATION FOR OCULAR DISEASES er The eyeis a unique sensory organ. has secluded from systemic access by the blood-retinal, Yood-aqueous, and blood-vitreous barriers; due to this, t exhibits some different pharmacodynamic and Pharmacokinetic properties Ocular structure can be divided into two types: |. Extraocular structures: ‘They are protective structures of the eye such as the orbit, eyelids, muscles, and vessels. * Ocular structures: The eye is divided into anterior and Posterior segments, * Anterior segment structures include the cornea, limbus, anterior and posterior chambers, trabecular meshwork, canal of Schlemm (Schlemmis canal), iris, lens, ciliary zonule, and ciliary body. ‘The posterior segment includes the vitreous, retina, choroid, sclera, and optic nerve, PHARMACOKINETIC PRINCIPLES OF OCULAR MEDICINES * Many different routes and formulations are available that are unique to the eye. Some formulations, such as ointments, soft contact lenses, solid inserts, gels, and collagen shields, prolong the duration of action of a drug by increasing the drug absorption beneath the eyelid by prolongation of time in the cul-de-sac, Examples include: Ophthalmic gels: They increase the duration of action by releasing the drugs via diffusion following erosion of soluble polymers. Ointments: They are used to deliver cycloplegic drugs, antibiotics or miotics as they commonly contain petrolatum base and/or mineral oil as a vehicle, Solid inserts, such as intravitreal implant, release a constant amount of drug over a period of time. © Nanoparticles: Some drug formulations use nanoparticles for controlled release of an active substance on an ocular surface. Figure 9.1 shows various routes of systemic absorption of ocular administration of drug. ® The ADME profile of ophthalmic medications is dependent upon the route of administration, flow of ocular fluids, and architecture of the eye. Ma,A majority of opt “Topical application to surface of the eye topical appli In special scenarios, the ophthalmic me Dissolution in tears be administered through injection by subconj intracameral, intracameral, retrobulbar, sub ‘Pathways of absorption and distribution intracorneal routes. Conia sch ra —_— ale VARIOUS INFECTIVE CONDITIONS |cmaly boty -—+ te OF EYE (BACTERIAL, VIRAL, FUNGAL | AND PROTOZOAL) Delivery into the systemic circulation comea tion are given in Table 9.1. Nasolacrimal It is not uncommon to get an eye infection involvin conjunctiva, eyelids, lacrimal glands and even in the peri Fig. 9:1: Verious routes of systemic absorption of ocular area. Some common ocular infectious conditions are gi administration of drug ‘Table 9.2 and treatment is given in Table 9.3. __| Pattern of absorption | Useas Limitations and precautions caieciel sub-tenon, | Sustained, dependingon | * Anterior segment Local toxicity, tissue injury, el and retrobulbar injections _| formulation infections perforation, optic nerve traum: ‘* Posterior uveitis prolonged drug effect * cystoid macular edema Topical Prompt, dependingonthe |* Convenient Compliance, corneal and 4 formulation © Economical conjunctival toxicity, nasal mu © Relatively safe toxicity, systemic side effects nasolacrimal absorption Intravitreal injection or device | Absorption circumvented, * Endophthalmitis Retinal toxicity 7 immediate local effect, © Retinitis qi potential sustained effect | © Age-related macular degeneration j Intraocular (intracameral) —_| Prompt © Anterior segment surgery | Corneal toxicity, intraocular toxi injections © Infections relatively short duration of actio Management _ Dacryoadenitis (lacrimal gland) ‘Staphylococcus aureus, Streptococcus spp., herpes ‘Systemic antibiotics Zoster, mumps, influenza and infectious mononucleosis. Dacryocystitis (lacrimal sac) ‘5. aureus, diphtheroids, Streptococcus spp. Systemic anti Actinomyces israeli and Candida, Hordeolum (stye) S. aureus Topical antibiotic with warm compresses Blepharitis Staphylococcus sp. ‘© Local hygiene © Topical antibiotics (minocyc! tetracycline, azithromycin, doxycycline, and erythromyt(Causative organism TS Of Ear, Nose, Throat ai csuste ore=rior and chemicals, Enterovirus, measles virus, zoster virus, Streptococcus pneumoniae, Neisseria 4pp., Haemophilus spp., chlamydial spp., Mi lacunata and s. aureus. vee orca * Allergies, environmental irritants, contact lenses, Management coxsackievirus, varicella | Broad-spectrum topical antibiotic Bacteria, viruses, fungi, spirochetes, and parasites, Broad-spectrum topical antibiotic erat eopnthalitis spirochetes (rarely). Immunocompromised individuals bacterial or fungus or Parenteral/systemic antibiotics ainfections Varicella zoster, herpes simplex type |and Il, adenovirus ial keratitis e Topical antiviral agents such as Cytomegalovirus and Epstein-Barr virus, trifluridine and ganciclovir pes roster ophthalmicus Varicella zoster ‘Systemic antiviral agents (acyclovir valacyclovir, and famciclovir) atretinitis, Cytomegalovirus, herpes simplex, varicella zoster, and _ | intravenous or Intravitreal antiviral such as ganciclovir Preparation and dose Indications salecetamide | Eye drops: 10, 20, 30% ‘Trachoma blepharits, conjunctivitis, ophthalmia neonatorum, for prophy 1-2 drops to be applied QID of ocular infection after burn and injury, before and after ocular surgery Gloramphenicol | Ointment and eye drops: 1%, 0.5% w/v | Corneal leer, bacterial conjunctivitis, trachoma, ocular infections 1-2 drops to be applied 70S-a1D | Gentamicin Eye drops: 0.3% w/v External bacterial infection of the eye and lid, pre or postoperative oc 1-2 drops to be applied TDS-aID surgery Tobramycin | Eye drops and ointment: 0.3% w/v | Ocular bacterial infection 1-2 drops to be applied QI Neomycin Eye drops: 0.196 w/v Ocular bacterial infecti 1-2 drops to be applied QID Gprofloxacin | Eye drops and ointment: 0.3% w/v _| Bacterial conjunctivitis, keratitis, corneal ulcer and pre or postoperativ 1-2 drops to be applied TDS-QID cular surgery Ofloxacin Eye drops: 0.396 w/v Bacterial conjunctivitis, blepharitis, bacterial corneal ulcer and pre or 1-2 drops to be applied TOS-QID postoperative ocular surgery Moxiloxacin | Eye drops and ointment: 0.5% w/v _| Bacterial conjunctivitis, keratitis, corneal ulcer and pre or postoperative 41 drops to be applied TOS-QID ocular surgery Polymyxin-8 ‘Ointment: 5000 1U ‘Superficial ocular infection Bye drops: 5000/1000 1U 1-2 drops to be applied T0S-QID Sodlovir Eye drops and ointment: 0.3% w/v Herpes simplex keratitis 1-2 drops to be applied 5 times a day ‘iluridine “Topical (196 solution) eratoconjunctivitis and Herpes simplex keratitis 4-2 drops to be applied 5 times a day iancilovir Topical (0.15% gel) Cytomegalovirus retinitis and Herpes simplex keratitis 1-2 drops to be applied 5 times a day "wconazole | Eye drops: 0.3% w/v Fungal infection of eye 1-2 drops 4 times daily ContiTextbook of Pharmacology for BSc Nursing Students ‘Amphotericin B Prepat 0.1-0.5% topical solution (1-2 drops 4 times daily) 0.81 mg subconjunctival instillation 2-10 ug intracameral and intrastromal corneal i 5-10 ug intravitreal injection tion and ¢ stillation indications Seb Nean TCT ES Endophthalmitis, fungal and yeast keratitis — Natamycin '59 topical suspension 1-2 drops 4 times daily Conjunctivitis, keratitis, fungal and yeast blepharitis, nazole 1% topical solution 1-2 drops 4 times daily Fungal and yeast keratitis, Fungal Infections © Fungal ocular infection is usually seen in immuno- compromised patients. Itinvolves sclera, cornea, orbit and intraocular structures. Antifungal agents, such as natamycin, are available topically, while other agents are available in many forms (intravitreal, corneal intracameral, topical). Antifungal agent should be used after sensitivity testing. Protozoal Infections * The common Topi intrastromal, subconjunctival, and parasitic infections are caused by ° Acanthamoeba and Toxoplasma gondii. fal anti-inflammatory agents In person wearing contact lens with poor hypig chances of getting protozoal infection (Acanthay are high. Maintenance of proper hygiene and topical anny agents are usually advised for the treatment ofr ocular infection, cal preparation of anti-inflammatory, anti-alergy various agents indicated for mydriatic and cy action are given in Tables 9.4 to 9.6, respectively. [RJANTIGLAUCOMA AGENTS Glaucoma is associated with progressive loss of field and damage to the optic nerve. [indications 1-2 drops 4-6 times daily Dexamethasone Eye drops: 0.1% w/v Noninfected steroid responsive inflammatory 1-2 drops 4-6 times daily conditions such as uveitis, marginal keratitis ale conjunctivitis and scleritis Betamethasone Eye drops: 0.5% w/v Same as above 1-2 drops 4-6 times daily Hydrocortisone Eye drops: 0.25% w/v Same as above Prednisolone Eye drops: 0.1% w/v 1-2 drops 4-6 times daily Same as above Fluorometholone Eye drops: 0.1% and 0.25% w/v Instill one drop in to the conjunctival sac ip. During the intial 1240 hours, the dosage may be increased to one application every 4 hours Steroid responsive inflammation of the palpebyl2? bulbar conjunctiva, cornea and anterior segment eye Triamcinolone Eye drops: 0.1% w/v 1 drop 2-3 times daily Ocular inflammation Loteprednol Eye drops: 0.05% w/v 1 drop 4 times daily Seasonal allergic conjunctivitisinflammatory agents [nici se sees Eye drops: 0.03%, 0.3% wiv Post laser and postoperative anterior segment ‘ripe 1-2 drops every % hourly, 2-3 hours before ocular _| inflammation of eye if surgery to prevent intraoperative miosis | Eye drops: 0.5% wiv Seasonal allergic conjunctivitis, (iad 1 drop to the affected eye | Eye drops: 0.1%, 0.2% w/v Postoperative inflammation after cataract surgery. Al test 1 drop every % hour, 2-3 houts before and 3 hours | used to prevent miosis and other inflammatory condit after ocular surgery of eye ye drops: 0.1% w/v Postoperative pain and inflammation after cataract. patente 41 drop 3 times a day for 3 weeks surgery emt e@pmunens 2 [Preparation anddose =| ween [REED et a ener 1-2 drops 2-3 times a day “eaum eromogiyeate | Eye drops: 2% w/v Keratoconjunctivitis, allergic vernal keratoconjunctivitis and hay fever ; 1-2 drops 4 times a day reaestne ye drops: 0.05% w/v Ocular allergy 1-2 drops 4 times a day (opataine Eye drops: 0.1% w/v Seasonal allergic conjunctivitis 1-2 drops twice daily rete Eye drops: 0.025% w/v Ocular allergy foe eens | Preparation and dose fi) | lincications eee ae TASER Eye drops: 1% w/v Allergic conjunctivitis, corneal burn, uveitis, refraction in children, keratit suppression amblyopia, pre- and postoperative use after surgery Homatropine Eye drops: 2% w/v Corneal burn, uveitis, refraction, postoperative use after surgery Toicamide Eye drops: 0.8, 1% w/v Pre- and postoperatively, for mydriasis in diagnostic procedure 1- Drops 6-8 times a day Gdopentolate Eye drops: 0.5, 1% w/v Refraction, retinal examination and used in postoperatively Phenylephrine Eye drops: 5%, 10% w/v Ocular examination, vasoconstriction in uveitis, pupil dilation, surgery, ptosis-Horner’s or Raeder’s syndrome 'n glaucoma, there is an increase in intraocular pressure ‘more than 21 mm Hg. ° Thete ae four types of glaucoma: Open-angle glaucoma Angle-closure glaucoma Normal-tension glaucoma a Glaucoma in children Pigmentary glaucoma ‘is usually presented with pain in the eye, tubular Vis fe i Sion, headache, nausea, vomiting, blurred vision, eye redness, etc, ‘The management of glaucoma is given in Table 9.7, Vitreous substitutes and tear substitutes are giver Tables 9.8 and 9.9, respectively. DRUGS USED IN VARIOUS EAR AND NOs INFECTIONS Preparations for topical use in ear and nose (Tables 9 and 9.11) Preparations for topical use in buccal cavity (Table 9.12) A1-2 drops once daily | Preparation and dose ication: OTe Pilocarpine Eye drops: 0.5, 1%, 2%, 4% w/v Glaucoma 1-2 drops instill in to conjunctival sac Carbachol Eye drops: 1.5% w/v Glaucoma 1-2 drops instillin to conjunctiva sac Dipivetrine Eye drops: 0.1% w/v Chronic open-angle glaucoma 1-2 drops instill n to conjunctival sac Timolol Eye drops: 0.25%, 0.55% w/v Chronic open-angle glaucoma, aphatic {drops twice daily slaucoma, secondary glaucoma Betaxolol Eye drops: 0.25%, 0.55% w/v Chronic open-angle glaucoma drops twice daily Levobunolol Eye drops: 0.5% w/v Chronic open-angle glaucoma, ocular hypertension Acetazolamide 1-4 tablets daily in divided dosage Chronic open-angle glaucoma Dorzolamide Eye drops: 2% w/v 1 drops thrice daly or twice daily with other adjunctive therapy ‘Ocular hypertension, open-angle glaucon Brimonidine Eye drops: 0.15%, 0.2% w/v I drops twice daily ‘Ocular hypertension, open-angle glaucon Apraclonidine Eye drops: 0.5%, 1% w/v ‘One drop of solution should be starting instilled in the schedule operative eye one hour before anterior segment laser surgery and second drop to the same eye instilled immediately after surgery For control of intraocular tension followi anterior segment laser surgery Latanoprost Eye drops: 0.005% w/v drop once daily in the evening Ocular hypertension, open-angle glaucon Travoprost Eye drops: 0.004% w/v 1 drop once daily in the evening Ocular hypertension, chronic open-angle glaucoma Leet qs [Preparation anddose | Indleations CR aE Polydimethy! siloxane Injection: 10 mt. Complex retinal detachment, severe diabetic tractional retinal detachn| giant tear and traumatic retinal detachment Leena o Preparation and dose Hydroxyl propyl methyl cellulose Eye drops: 0.7% w/v 1-2 drops thrice daily Anterior segment surgical procedure (cataract and IOL implantation) Also use in gonioscopy for ‘glaucoma and artificial tear Carboxy methyl Eye drops: 1% w/v. Anterior segment surgical procedure (cataract and IOL implantation) cellulose 1-2 drops thrice daily Also use in gonioscopy for glaucoma and artificial tearPreparation and dose Ear drops and Solution: 5% w/v Indications eae Otitis externa, chronic otitis media, | campnentcol gee Adult: 2-3 drops 34 times a day Children: 1-2 drops 3 times a day post aural or mastoid surgery 6 yea! Children <6 years: instill 2-3 drops int 0 still 2-3 drops into each nostril BD or TDS ‘Nasal congestion each nostril BD or TDS, duration not to exceed >7 days Nasal drops: 0.01, 0.025, ‘Adult and children >6 years: instil Children <6 years: instill 2-3 drops int not to exceed >7 days Onymetazoline to 0.05, 0.1% w/v 112-3 drops into eac! ‘Nasal congestion fh nostril BD or TDS ‘each nostril BD or TDS, dur Nasal congestion dium chloride | Nasal drops: 0.6596 w/V ‘Tos Instill 2~3 drops into each nostril BD or Nasal drops: 0.25% w/v. Instill 45 drops into each nos Phenylephrine stril every ‘Nasal congestion 4-6 hours Nasal congestion Ne ephazoline | Nasal drops: 0.01% w/¥ 4-6 hours instill 2-3 drops into each nostril every Nasal drops: 296 w/v. instil 2-3 drops Inhaler: 2 mg/MDI, BD/TOS Sodium omoglycate into e: ‘ach nostrilevery 8/12 hours | Allergic chinitis Spray: 2.8 mg/dose, BD/TDS. ‘Nasal drops: 0.075, 0.5% W/V il 2-3 drops into each nostril every Phedrine Nasal congestion aday |e ee twice/thC Textbook of Pharmacology tor Nasal spray: 0.05% w/v Use 1-2 sprays in each nostril Fluticasone nasal Allergie/inflammatory nasaico cong spray Budesonide nasal | Nasal spray: 100 ye Allergic/inflammatory nas) spray Use 1-2 sprays in each nostril ‘Mometasone | Nasal spray: 50 ug Allergc/inflamamatorynaticey nasal spray Use 1-2 sprays in each nostril ‘Nasal spray and solution: 0.1% Use 1-2 sprays in each nostril ‘Azelastine nasal Allergic nasal congestion spray fescue) reparation anddose Indication Chlorhexidine Mouthwash: 0.12, 0.2, 0.259% v/v ‘Stomatitis, tonsilltis, gingivitis and oral bacterial infection of mo Povidone-iodine | Mouthwash: 1% w/v ‘Stomatitis, tonsilltis, gingivitis and oral candidal or bacterial infs of mouth Triameinolone ‘Mouthwash: 0.1% w/v is and oral candidal or bacterialinfe Benzocaine Mouthwash: 2.7% w/v is and oral candidal or bacterial nfs, Stomatitis, tonsillts, gingi of mouth, Benzydamine Mouthwash: 0.15% w/v ‘Stomatitis, tonsilltis, gingivitis and oral candidal or bacterial inf of mouth, Sodium fluoride | Mouthwash: 0.2% w/v ‘Stomatitis, tonsilltis, gingivitis and oral candidal or bacterial inf of mouth Mandl’s paint lodine+potassium iodide + glycerin, Stomatitis, tonsilltis, gingivitis and oral candidal or bacterial infec of mouth ‘Acomponent of gum paint available as 2-20% wiv Tannic acid is and oral candidal or bacterial inet Stomatitis, tonsil of mouth, ingi Potassium nitrate | Tooth paste: 5% w/w Oral solution/rinse: 3% w/v ‘Stomatitis, tonsilltis, gingivitis and oral candidal or bacterial inet of mouth, Nursing Implications Baseline Assessment “ Obtain complete medical and personal. history ophthalmologic, eye traumas, cerebrovascular, cardiovascular, respiratory, metabolic disease, drug history, drug/food allergy, (OTC/herbal drugs, alcohol use, smoking and present prescription. ‘Assess contraindications or cautions: known allergies to these drugs to avoid hypersensitivity reactions. Veda dene Xe MLC concn RUiSieeracss Visual difficulties Lacrimation Pain Blindness Poor hygiene Poor knowledge of medicines Drug-related side effects including Coceece Obtain any history of visual difficulties such as eye pain, blurred Vision, color halos, loss of peripheral vision, diminished vision and night blindness. is able to understand the given instruction, Obtain baseline vital signs and assess whether patient or caregivererapeutic effect of drugs such as reduced signs and ‘oor vision, normalization of |OP (below 20 mm Hg), tin visual acuity and field. ios importance to observe ay side effects suchas hyper Fs eee. ain, exophthalmia, xerophthalmia (dry eye), ap, cedness, pruritus, photophobia during drug administration ir ould be reported promptly. ror the th snd improvernen Nursing diagnosis and shoul epee ee ous ~The patients: (below 20 mm Hg), improvement in visual acuity and field. + Can have negligible drug-induced side effects. + Can elf-administer drug in prescribed dose and timing, (nce culicles To Ensure Drug Therapeutic Effect: Monitor the effect of appropriate drug for obtaining desirable result as reduction in signs and symptoms of diminished vision, normalization of IOP (below 20 mm Hg), improvement in visual acuity and field, © Every nurse should be well aware of the proper technique of topical applications of drugs on the eye and should not hesitate to learn the procedures from their seniors. ™ Follow and teach appropriate techniques of routes of administration. Minimize Side Effects: % Nurse should avoid extraocular drug instillation by applying appropriate technique; after instillation of drug into the conjunctival sac, press the lacrimal duct gently for 1 minute to avoid nasolacrimal excretion, ~ Nurse should aware in patient who are using contact lens; the Contact lens should be removed before instillation of eye drop. ~ Nurse should check the expiry date of all the medicines, ~ Always monitor the vital signs while treating patient; beta blockers and cholinergic agents are used to cause bradycardia or hypotension. ~ Nurse should provide eye comfort room in patient with glaucoma; fi beta-blockers can cause miosis, Monitor rugs that induce ADRs like hyper lacrimation, eye pain, Srophthalmia, xerophthalmia (dry eye), iritation, redness, pruritus, Photophobia, ‘will observe the therapeutic outcome of given drugs like reduced signs and symptoms of poor vi yn, normalization of |OP Can express the indications, side effects and precautions of given drugs. GeCiis suse ke “Nurse should educate the patients that if any irritation occurs on application of eye drop; they should immediately discontinue the drugs and report to the physician. © Provide thorough patient teaching, including drug name, prescribed dose, measures for avoidance of adverse effects, and warning signs that may indicate possible problems. \ Educate patient and their relative/caregivers how to take BP by sphygmomanometer, pulse and make sure that all equipment is well functioning and calibrated. “ Advise patient to remove contact lens before drug instillation and remain without at least for 15-20 minutes for better absorption of drug. ‘ Educate parents/guardians to take extra precautions while giving drugs to children. \ Educate patient and their caregiver to report any unwanted side effect such as hyper lacrimation, eye pain, exophthalmia, xerophthalmia (dry eye), irritation, redness, pruritus, photophobia, hypotension and bradycardia,earring Objectives oe ihis chapter is designed fo enable the learner to understand: a Prophylaxis of iron, folic acid and tetanus toxoid 3 Drugs used during labor 0 Specific drugs for uterine contraction to manage PPH. Chapter Outline Introduction Iron Supplements Folic Acid/Calcium Gluconate Tetanus Prophylaxis in Pregnancy (Adopted From WHO) Vitamin K Supplementation Ortocin Ergometrine and Methylergometrine Prostaglandins (Prostaglandins PGF, and Misoprostol) Misoprostol Magnesium Sulfate gooaa aaaa oa unrropuction * Medications used during antenatal, labor and even Postnatal period have shown immense impact on the Outcome of both maternal and fetus. Administration of drugs in various stages of pregnancy has different consequences; as in first trimester; there igs advocated in antenatal) labon/and) postn: (sete) Characteristics __| Recommended drugs Antenatal period | Iron and folic acid supplements, tetanus prophylaxis, calcium labor Vitamin-k (if required), oxytocin, misoprostol, magnesium sulfate (if required). Postpartum Ergometrine and Methylergometrine (if required), will be chances of congenital malformation and in t trimester; fetal growth and development could be affec © To prevent this hazardous effect of drug; many drugs categorized and are contraindicated in pregnancy na as Category-X drugs. The drugs shown in Table 13.1 are advocated in antenatal, labor and even postnatal period. [D)IRON SUPPLEMENTS (Described in Chapter 5) © Ironis essential for the production of hemoglobin, wh is the oxygen-carrying component of RBCs. © It is an important constituent of hemoglobin, ferrit myoglobin, cytochromes and other enzymes. © The total body iron content is about 3.5~4 g in adult m: and about 2.5 g in adult females, out of which 70% iron present in hemoglobin. 15-20% of iron is stored in liver, spleen and bo: marrow.xtbook of Pharmacology for BSc Nursing Students Ieean be obtained from liver, egg yolk, meat, fish, chicken, spinach, jaggery, dry fruits, wheat germ, apple, banana, pulses, root vegetables, etc, Milk and milk produets are poor sources of iron, Daily Requirement of iron is hit compare to adults, In pregn requiremtent rose up to 3-5 mg. ‘Wo types of iron preparations are available: oral and parenteral, yer among the children wey and lactation, the Oral preparation includes: Ferrous. sulfate, ferrous sluconate, ferrous fumarate, colloidal ferric hydroxide, ferrous succinate, carbonyl iron, iron choline citrate and {ferric hynaxy polymaltose, Parenteral preparation includes: Iron-dextran, Iron sorbitol citrie acid, ferrous sucrose, ferric carboxymaltose, 1000 and iron sorbitex (Jectofer) Tron therapy isindicated for the treatment and prophylaxis, of anemia in pregnancy, lactation, chronic illnesses and blood loss. ‘The total iron requirement is calculated by; Iron requirement (mg) = dal x body weight (kg) x Hb deficit (g/dL). Oral iron therapy may cause epigastric pain, nausea, vomiting, metallic taste in mouth, abdominal colic, constipation or diarrhea and staining of teeth with liquid preparations, iron isomalto [FOLIC ACID/CALCIUM GLUCONATE ae errno Described in Chapter 14: Miscellaneous) Calcium is used as health supplements during pregnancy and lactation. Itis available as 10% injection in 5 mL ampoules. Itis the most preferred IV preparation of calcium salt, It can be given safely by slow IV route, as it is non- irritating to the vascular endothelium, Extravasation should be avoided. + It is most commonly used in management of, hypocalcemia, + Itproduces a sensation of warmth on IV injection TETANUS PROPHYLAXIS IN PREGNANc (ADOPTED FROM WHO) © Tetanus is available in three form such as tetanus to (TT), tetanus with diphtheria (Ta) and combinatig Tetanus toxoid, reduced diphtheria toxoid and acel pertussis (Tdap). * Women with unknown status of previous tet immunization will have two dose of TT or TD onem apart before delivery. * Ifthe woman has had 1-4 doses of tetanus toxoid in past, give one dose of TT/Ti before delivery with at dose of five will have protection for childbearing year © Two types of tetanus were manufactured. These are: © Tetanus immunoglobulin: It ted patients who are not immunized and having hig contaminated wound with a risk of develop tetanus. * Prophylactic dose: 250-500 IU, intramuscul: * Therapeutic dose:3000-60001U intramuscul, and/or 250-500 IU. intrathecally = Tetanus antitoxin (ATS) * Prophylactic dose: 1500-3000 IU, intran scularly/subcutaneously © Therapeutic dose: 50,000-100,000 IU pa intravenously and rest by intramuscularly. ‘Tetanus toxoid immunization schedule, eg. for wor with unknown history of i isin munization is given The tetanus toxoid immunization schedule for women history of previous immunization during infancy, childho and adolescent is depicted in Table 13.3 AAs soon as pregnancy is confirmed At least one month after 1" dose of TT None 1-3 years At least six months after TT2 or during subsequent pregnancy Atleast § years At least one year after TT3 or during subsequent pregnancy At least 10 years At least one year after TTA or during subsequent pregnancy For all childbearing age yeasTetanus toxoid immunization schedule for womien with history of previous immunization durin infancy, chidheed and Sd rm Eee 301? 2 doses of T1/Td (minimum 4 weeks | 1 dose of T1/T interval between doses) ‘4pTP 1 dose of TT/Td A dose of T1/Td 3DTP +1 01/Td 1 dose of T/Td 1 dose of TI/Td aDTP +1 D1/Td 1 dose of TT/Td None 4DIP+1DTat4a-6yrs+1T/Tdat — | None None 14-16 yrs VITAMIN K SUPPLEMENTATION inscribed in Chapter 14) | Vitamin K (Koagulation vitamin) is essential for the coagulation process. It is not directly involved in the clotting process but required for the synthesis of four clotting factors in the liver cell: Factor Il, VII, IX and X, | Itoccurs naturally in two forms: Phylloquinone (K,) from plant source and menaquinone (K,) which is synthesized bycolonic bacteria (E. coli) in the colon. K, is the synthetic form and is available as Fat-soluble forms (menadione, acetomenaphthone) and water-soluble forms (menadione sod, bisulphate and menadione sod. diphosphate). Green leafy vegetables, such as cabbage, spinach and liver, cheese, cereals, nuts, and egg yolk, etc. Wheat germ oil is the richest source. Vitamin K is essential for formation of clotting factor-I, VII, IX, X, protein-C and S. ‘The deficiency of vitamin K occurs due to liver disease, obstructive jaundice, malabsorption, long-term antimicrobial therapy which alters intestinal flora ‘The most important manifestation is bleeding tendency due to lowering of the levels of prothrombin and other dlotting factors in blood. Hematuria is usually first to occur; other common sites of bleeding are gastrointestinal tract, nose and under the skin where it presents in the form of hemorrhagic spots. Some of the conditions where vitamin K is useful are: jc disease of the new- ly premature infants and other clotting = For prevention of hemorrhagi born: All new-borns, especial have low levels of prothrombin factors, Vitamin K I mg IM soon after birth has best recommended routinely. Alternatively, 5-10 m8 0% to the mother 4-12 hours before delivery can De given, Hemorrhagic disease of the newborn can be effectively prevented/treated by such medication. = Patients with obstructive jaundice or malabsorption syndromes (sprue, regional ileitis, steatorrhea, etc). ‘The therapy given is vitamin K 10 mg IM/day, or orally along with bile salts for better absorption. = Asan antidote in overdose of oral anticoagulants. oxytocin (Described in Chapter 12) © Oxytocin is a peptide hormone secreted by the posterior pituitary, It is released by stimuli, such as parturition, suckling and coitus and their secretion depends upon the nature of the stimulus. ‘© Oxytocin plays an essential role in labor, milk ejection reflex and formation of love bonding between mother and infant. © In uterus, oxytocin increases the force and frequency of uterine contractions. This effect is seen more vividly in pregnant uterus after >24 weeks’ pregnancy as estrogens sensitize the uterus to oxytocin. Secondly, it acts through oxytocin receptors and the number of these receptors is increased by estrogens. Thirdly; the level of oxytocin is owestin non-pregnant uterusand during early pregnancy. Oxytocin facilitates milk ejection by contraction of the mammary glands. Suckling (nipple and areolar region) stimulates the release of oxytocin. Oxytocinisinesfectiveorallyhence,givenby intramuscular or intravenous in infusion only. ‘Therapeutic uses are as follows: = Induction of labor: following s {500 mL of glucose or saline soluti For induction of labor, the schedule is employed: 5 TU is diluted in jon (10 milli [U/mL)and the intravenous infusion is started at 2 low rate of 02-20 ml/min and progressively accelerated according to response. Usually 2 total of 2-4 IU is needed before starting infusion; obstetric contraindications should be evaluated thoroughly. = Postpartum hemorrhage (PPH): Oxytocin cen be used as an alternative to ergometrine when it is contraindicated. For this purpose, 5 IU of oxytocin may be injected intramuscularly or may be administered by intravenous infusion for immediate control of PPH. = Breast engorgement: Intranasal oxytocin spray is useful when milk ejection is impaired in nursing mothers. "Uterine inertia: If uterine contractionsare feebleand there is no cephalopelvic disproportion, oxytocin can beused. ERGOMETRINE AND METHYLERGOMETRINE Described in Chapter 14) + Ergometrineisan alkaloid and its semisynthetic derivative is called methylergometrine but has more potent action than ergometrine. + These agents increase force, frequency and duration of uterine contractions. They act both upper and lower Uterine segments and uterus passes into a state of sustained tonic contractions + The uterotonic action of | ergometrine and methylergometrine is due to partial agonistic action on 5-HT2 and a adrenergic receptors. © Exgometrine can be given by oral, IM or IV and onset of uterine action can be seen + Therapeutic uses: = Postpartum haemorrhage (PPH): 0.2-0.3 mg of ergometrine is given by IM route at delivery of anterior shoulder. It reduces the blood loss and chances of PPH. In active PPH: 0.5 mg ergometrine by IV route or a combination of 0.5 mg ergometrine with oxytocin 5 IU IM or IV may be used. To prevent uterine atony after caesarean section or instrumental delivery. * To hasten uterine involution: 0.123 mg of, ergometrine or methylergometrine is given thrice daily orally for 7 days. fextbook of Pharmacology for BSc Nursing Students PROSTAGLANDINS (PROSTAGLANI PGF2a AND MISOPROSTOL) (Described in Chapter 6) ‘© Prostaglandins are synthesized by the uterus. PGE2, PGF2a and 15-methyl PGF2a contraction of both pregnant and non-p: (sensitivity is higher in the later part of p © They also cause ripening of cervix amniotically. i and misoprostol by intravaginal route. Prostaglandins PGF2a uterine contraction. 7 It is also believed that PGF 2c is also associated inhibition of production of progesterone and corpus luteum degradation. + PGE 2c derivatives are carboprost, Dinoprostone ts various gynecological conditions. © Carboprost used in a dose of 5 mg/mL intra injection for induction and facilitation of labomla trimester abortion. * Dinoprostone is available in a dose of 05 mg vag vaginal tab, extra-amniotic solution used for in and facilitation of labor, mid-trimester abortion, [ MisoprosToL « Itisa PGEI derivative, Single oral dose of misoprostol 400 yg is given after mifepristone (antiprogestin) 600 mg for abortion up to 49 days of pregnancy. Intravaginal misoprostol can also be given as effects are less with this route. [MAGNESIUM SULFATE + Itisa CNS depressant, inhibits peripheral neuromust ‘transmission and reduces ACh release in the my junction. * It stabilizes the neuromuscular junction by effid calcium, potassium, and sodium ions.sisindicatedforthe controloflifethreateningconvulsions 11 contol of BP in preeclampsia and eclampsia, jis also used for the management of acute nephritis in + (laren, tetany due to hypomagnesemia and as tocolytic. tris vailable in IV/IM formulation for treatment of the following conditions: Preeclampsia and eclampsi: 250 mL NS/D5W). " 4-5 g (diluted in RSS eats tong Answer Question 1, Define the use of tetanus and their immunization schedule. short Answer Question 1. Write short notes on: a. Vitamin K b. Iron supplement Magnesium sulfate d. Drug for PPH Multiple Choice Questions 1. Vitamin beneficial in osteoporosis in combination with vitamin D i a. VitaminE © Vitamin K a. sul of the following are characteristic features Of eavner! of iron deficiency anemia with oral iron supplements; Except: a. If 200-300 mg elemental iron is consumed, about 50 mgis b. Vitamin A d. Vitamin B sorbed ne crerpreportion of ron absorbed reauces 3S hemoglobin me et sunt should begin to increase in two c. The reticulocyte © Se weeks and peak in 4 ent : to treatrpent should be aiscontin d. The treatment 3 hemoglobin normalizes 0 Pre weeks—this SUBBEStS £O* ued immediately once vont side effects of iron. ugs used for Pret 7 Drug: ghant Women during Antenatal, Labor and Postnatal Period 1 Tocolytic: 4-6 g IV over 20 minutes (loading dose); maintenance: 2-4 g/hr IV for 12-24 hours as tolerated. + Nowadays, magnesium sulphate is not preferred agents due to availability of better alternative drugs. 3, Misoprostol is a: a. Prostaglandin €1 analogue b. Prostaglandin €2 analogue cc. Prostaglandin antagonist d. Antiprogestin 4. Which one of the following is not an antacid? a. Magnesium sulfate b. Magaldrate c. Magnesium carbonate d. Magnesium phosphate 5, The following drugs are used in the management of postpartum hemorrhage, except: a. Oxytocin b. Methyl ergometrine c. Mifepristone d. CarboprostMISCELLANEOUS TOPICS pn I SS Sa Learning Objectives This chapter is designed to enable the learner to understand: The drugs used in de-addiction, emergency + Various stages of resuscitation Drugs used in the vitamin and minerals di Management of poisoning Immunization 3 Immunosuppression leficiency Chapter Outline 0 Drugs for Deaddiction Treatment of Substance use Disorders 0 Drugs used in Deaddiction Drugs used in Cardiopulmonary Resuscitation and Emergency Drugs Required for the Management of Various Emergencies Vitamins Minerals Immunosuppressants Antidotes Antivenom Vaccine and Sera Immunity Vaccines Antisera and Immunoglobulins Food Poisoning a 9a9aqaaqqga0aqaq [By] DRUGS FOR DEADDICTION Addiction means excessive, recurrent and compulsive use drug/drugs to obtain pleasurable effects, The addicted individ become so obsessed to these drugs that it becomes their prim aim to procure and use these drugs. This behavioral cha disrupts their ability to adjust in the family, workplace and soci Addiction involves the following features © There is always intense craving for the drugs. Crav ‘means intense desire to take the drug by any means. © There is a need to increase the dose of drugs to get same level of pleasure due to development of tolerance ® Appearance of life-threatening withdrawal sympto if the dose of addictive drug is missed or ceased, wh forces the individual to take the drug again and again. © ‘The detrimental effects of the drug harm the individu family and society as well There are v; us terms, which are used in relation to excessive and compulsive use of the drugs such as habituati drug dependence and drug addiction. * Habituation means that a person is in the habit of taki the substance without any detrimental effects on his bo or society and there is no craving, tolerance and withdraw symptoms. Examples: tea, coffee, etc. * Drug dependence means the state of a person arisi after repeated and continuous use of a substance in whi alldetrimental effects and craving appear. There is psychological and physical need to continue the drug f the fear of getting the withdrawal symptoms, * Psychological dependence means the behavior involved procurement of the drug. * Physical dependence means body demands the presence substance in the blood to continue the various physiologic processes, hence also called Physiological dependenc Withdrawal symptoms appear on discontinuance of the drtThe Diagnostic and Statistical Manual of Mental disorders (DSM-5) have included all the above terms in a single term substance use disorder, ranging from mild to severe. This was done to remove the confusion of using above mentioned different and various terms. ‘The different substances which can produce addiction or substance use disorders are as follows: * Tea,coffee, tobacco in various forms such as bidi, cigarette, sgutka, Khaini, etc. These cause mild form of substance used disorders. © Marijuana (sulfa), amphetamine, cocaine, nicotine due to excessive use of >20 cigarettes/day. © Opioids, benzodiazepines, alcohol, etc. TREATMENT OF SUBSTANCE USE DISORDERS Goal of Treatment * The ultimate goal of treatment program is to achieve a drug-free status as early as possible and to prevent relapse. © The drug-free status is achieved with the help of pharmacotherapy. © The prevention of relapse is achieved by a combination of behavioral treatment, rehabilitation program, psychosocial interventions and pharmacotherapy. DRUGS USED IN DEADDICTION Opioi Deaddiction Drugs Methadone * Methadone is a long-acting synthetic opioid agonist medication that can prevent and reduce the craving and withdrawal symptoms in opioid-addicted individuals. Itis a type of substitution therapy. © Italso blocks the effects of illicit opioids. © Itisused in the treatment of opioid dependence in adults, © Methadone maintenance is more effective when it is combined with behavioral treatment. © Itis given orally in a dose of 10 mg OD, Buprenorphine e It is also a synthetic opioid medication that acts as a partial agonist at opioid receptors. © It does not produce the euphoria and sedation caused by heroin or other opioids but is able to reduce or eliminate withdrawal symptoms associated with opioid depen, and carries a low risk of overdose. = Buprenorphine maintenance therapy is current in India as a part of opioids deaddiction regim © Buprenorphine is available in two formulations taken sublingually: = Buprenorphine tablet alone (8 mg). i ® Combination of buprenorphine (8 mg) with nal (2 mg), an antagonist (or blocker) at opioid rece LAAM © Itislevo-alfa-acetyl-methadol. © Itisa long-acting analogue of methadone. © Itis given thrice weekly in a dose of 20-40 mg in patients who had not been initiated with methadon up to 120 mg to methadone receiving patients, | © Ithas minimum abuse potential. © It may cause arrhythmia and QT prolongation, needs regular monitoring. © Ithas been banned in few countries, Naloxone © It isa synthetic pure opioid antagonist. E © _ Itis competitive antagonist to all opioids receptors, © It also blocks the action of endogenous opioids su endorphins and encephalins. © Itimmediately antagonizes all the action of opioids, © It is given in a dose of 0.1-0.4 mg IV until the des effects are achieved. q Naltrexone * Naltrexone is a synthetic opioid antagonist. * It blocks opioids from binding to their receptor: thereby prevents their euphoric and other effects, © The de-addiction treatment with naltrexone ideally begin in a residential setting in order to pr withdrawal symptoms. But it can be prescribe outpatient medical settings also. * Before initiation of therapy, the patient should be o free for at least 7-10 days. The therapy is started’ with 25 mg initially under supervision, then 50 mg till the patient stabilizes and then, 100 mg three | week, A © Recently, a long-acting injectable version of nalt has been approved to treat opioid addiction. It only) to be delivered once in a month to improve complia!y ttl adal isa synthetic opioid agonist. tromoctaas and reduces the eraving and withdrawal Pris in opioid-addicted individuals, sre ype of substitution therapy. may ts given in a dose of 50 mg BD, then 50 mg As then tapering to 50 mg BD and 50 mg OD fora few Joys Ten, it is withdrawn in a tapering fshion, sqhacco Deaddiction Drugs nicotine Replacement Therapy (NRT) rarety of formulations of nicotine replacement therapies (NST) now exist, incuding the transdermal nicotine patch, sictine spray, nicotine gum, and nicotine lozenges. Because sicotine is the main addictive ingredient in tobacco, the rationale for NRT lies in providing the stable low levels of sitine to prevent withdrawal symptoms. It helps to keep pape motivated to quit. Research shows that combining the uth with another replacement therapy is more effective than the single therapy alone. Bupropion + Itisan antidepressant drug, produces mild stimulant effects by blocking the reuptake of certain neurotransmitters, especially norepinephrine and dopamine, lis quite effective in suppressing tobacco craving, helping them quit smoking without weight gain, tis given orally in a dose of 150 mg OD for three days, then 150 mg BD for at least 7 weeks. Varenicline * Wis the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors in the brain thought tobe involved in the rewarding effects of nicotine, Ttalso blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing cravings and supporting abstinence from smoking, ‘This s given initially 0.5 mg once daily for one week, then 1 mg BD for 6 months. Each of the above pharmacotherapy is recommended for use in combination with behavioral interventions, including group and individual therapies, as well as telephone Quitline’s. Alcohol Deaddiction Drugs Naltrexone It blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. Ithas been shown to reduce relapses. It is given three times a week in a dose of 100-150 mg or 50 mg OD or in the form of depot injection on monthly basis. Acamprosate * It acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to Teduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria, Itis given for maintenance therapy of alcohol abstinence. Itis given in a dose of 666 mg two to three times in a day. Itcan be given for several weeks to months, and it may be more effective in patients with severe dependence. Disulfiram (Aversion Therapy) * It interferes with degradation of alcohol by inhibiting aldehyde dehydrogenase enzyme which is required for ‘metabolism of alcohol as given in Figure 14.1. [Alcohot Aldehyde Ethyl alcohol +[Acetaldehyde| +[Acetic acid +{Acetyl CoA] +{Co,+H.O+ ATP) [Dehydrogenase Dehydrogenase | Disulfram Fie. 14.1: Mechanism of action of disuilfiram‘This results in accumulation of acetaldehyde, which in turn, produces a very unpleasant reaction, known as aldehyde syndrome, ‘Ihis reaction may be seen in mild to severe form depending upon the amount of alcohol ng disulfiram therapy. Patients with this jon may need to be hospitalized reactions, Therefore, this drug is alwa supervision to well-motivated patients Itis given in a dose of 500 mg/day for a we 250 mg daly Another regimen is 1000 mg on Ist day, 750 mg on 2nd day, 500 mg 3rd day and 250 mg subsequently. Sensitization to alcohol develops after 2-3 hours of Ist dose and lasts for several days after stopping the drug. consumed dui ease of severe WS Bi ter counseling, followed by under piramate Tecan be used for the treatment of alcohol dependence on OPD basis. Tt modulates the gamma aminobutyric Anergic transmission in the cent nter implicated in the regulat alcohol intake. Itis given in a dose of 150-300 mg/day. id (GABA) 1 amygdala, a brain n of emotions and DRUGS USED IN CARDIOPULMONARY RESUSCITATION AND EMERGENCY ardiopulmonary resuscitation (CPR) is a technique of basic © support (BLS) for the purpose to restore the normal rdiopulmonary function. ‘The CPR is an emergency procedure that combines chest impression often with artificial ventilation in a manual effort preserve oxygenation to the heart, lungs and brain, until ther measures are taken to restore spontaneous blood reulation and breathing in a person who is Resuscitation is a continuous process from Basic Life apport (BLS) to Advanced Cardiac Life Support (ACLS). erebral resuscitation is the most important goal of advanced cardiac arrest. ardiac life support. BLS initiates the process of resuscitation ad ACLS restores and maintains the spontaneous respiration nd circulation. istory of CPR ‘+ $000 BC: First artificial mouth-to-mouth respiration, * 3000 BCL: Ventilation, + 1780: First attempt of newborn resuscitation by blowing, took of Pharmacology for BSc Nursing Stud! lents #874; First expertmey #1901: First siccossful direct cardiac massyp 1946: First experimental indivect defibrillation, diac maser a and #1960: indirect cardiac m + 1980; Development of eadiopulmonary resus to works of Peter Safar, lon dg Stages of Resuscitation (ABCDE) + Airway: Ensure open airway by preventing the fay back of tongue and tracheal intubation, if possible. + Breathing: Start artificial ventilation of hung mouth to mouth of mouth to nose technique, + Cire mmpressio + Drugsand defibrillatio or electric de by ely lation: By external eardiac massager manual hey Y use of different mediator lation in case of ventricular fibration © Establish the components of advanced life support tablish oxygen administration to correct hypoxia tablish an IV fine to administer drugs + Electrocardiogram (ECG) monitoring Endotracheal intubation, if required Know ‘According to the latest CPR guidelines, 2015 by American Hear Association, the sequence employed for CPR is C-A-, Le, is perform Chest compression to maintain circulation, fllone! by Airway patency checking followed by Breathing by ete ‘mouth to mouth or mouth to nose technique. Specific Drug Therapy It is based upon the underlying cause of cardiac arrest at other associated conditions. ‘The main drugs used in CPR and post resuscitation a follows: Adrenaline [Retieanddowe naan [aioe 1mgiveor ‘Any pulseless | Increases eal (Intracardiac injection is Sere sult “Every 3-5 minutesyoradrenaline Miscellaneous Topid piven Fppetitated to effect Atropine ‘Second and subst ndications =| Ac total dose of 3 mg/kg. Goaeanddose | Indications | zomglV push aS min, | Bradycardia, | Parasympatholytic, Peorenae ‘maximum of 3mg* | asystole eliminates vagal tone 2 sir eo ‘lay be repeated if required. Lignocaine spits YienionsTosions on] [Rome and aon [naans [RT FE st | typctenson Vasopressor LO-LS mg/kg | Ventricular fbi | Class 18 (predominately an IV*push lation, pulseless antiarrhythmic; Q-agonist) ventricular tachy- | suppresses cardia, ventricular | ventricular activ tachycardia witha | and electrical pulse conduction L—_____|pulse_ conduction fequent doses of 0.75 mg/kg every 5 minutes te Dopamine and Dobutamine Route and dose _| Indications Actions 17 mg/kg IV slow bolus at maximum | tachycardia with a Fate of 50 mg/min* | pulse Ventricular Decreases myocar- dial excitability and Routeanddose | Indications [Actions predominantly a action. Soda Bicarbonate p20ys/ielmin® | Hypotension | inotropic agent (B-agonist) “Low doses are predominantly B; high doses become Route and dose indications [Actions SOméq inthe IV fluid* | Metabolic acidosis Corrects metabolic acidosis “To be titrated with the pH Esmolol Routeanddose | Actions | OS me/ke bolus over | Supraventric- Aminute followed by | ular tachy- 0.05-0.02 me/ke/min* | cardia, atrial arrhythmia fibrillation oF | B-Blocker (short flutter acting) Reduces heart rate, blood pressure and “May be given as another bolus if desired Grip 50 ue/kg/min, Metoprolol effect not achieved; start [Route and dose | Indications _| Actions | Smgv*push Supraventric- ular tachycar- dia, myocardi- alinfarction BeBlocker (81 selective) conduction velocity *Continue infusion’ Vasopressin terminated, onset of (4mg/min) until QRS widening >50%, dysrhythm. hypotension; or 17 mg/kg infused. Route and dose | Indications ___~(Actions. 40.u we Ventricular fibrilla- tion, pulseless ven- tricular tachycardia Increases peripheral vascular resistance Adenosine “Single dose, may be followed at 10 minutes by epine; phrine, Routeanddose _| dications [Actions through proximal Peripheral ine: central line dose is one-half up to 12 mg); third Amiodarone mg rapid 1V*push | Supraventricular needed, second dose of 12 m; Endogenous nucle side cousing brief asystole allowing dominant pacemzker to resume function 1 (Pediatric, double initial dose dose of 12-18 mg tachycardia Route and dose [indications] For ventticular fibrillation or pulseless ventricular tachycardia: 300mg IV*push Ventricular fibrila- pulseless ven- tricular tachycardia, ventricular tachy- cardia with a pulse, Supraventricular tachycardia Predominately class antiarrhythmic, buthassodium, — | Potassium channel, | andaand 6 receptor blockade “Repeat twice at S-minute intervals, then give 50 mg oral load “May use second dose of 150 mg for recurrent ventri ventricular tachycard icular fibrillation? ia In children may be repeated in S mg/g.INTRODUCTION TO DRUGS USED IN SYSTEMS OF MEDICIN Learning Objective This chopter is designed to enable the learner fo understand: G Demonstrate awareness of the common drugs used in alternative systems of medicine Chapter Outline Homeopathy Unani Medicine Siddha Medicine agaqaaa [ALTERNATIVE SYSTEM OF MEDICINES ee eEOEemeINES In India, the Central Council of Indian Medicines (CCIM, a Statutory body established in 1971) under Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH), Ministry of Health and Family Welfare, Government of India, monitors higher education in areas of Indian medicine including, Ayurveda, Unani and Siddha, MM AYuRVEDA Ayurveda (Ayur-life, Veda-knowledge) is a system of ‘medicine with historical roots in the Indian subcontinent. Ayurveda is considered as one of the oldest systems a of medicine in the world, Globalized and modernized practices derived from Ayurveda traditions are a type of complementary or alternate medicine. * The oldest record of documents regarding use of plants as ‘medicines in India is found in Rigveda (during 2000 BC). * Atharvaveda (1500-1000 BC) described many more plants for medicinal use and introduced more concepts of Ayurveda, * The original texts of Ayurveda have been documented in Charaka Samhita (1000 BC) and Sushruta Samhita (1000 BC). * The practical knowledge and training of these concepts was imparted to students by Punarvasu Atreya and Dhanvantri. In Hindu mythology, the origin of ayurvedic medicines is credited to Dhanvantri, the physician of the Gods. Ayurvedic Concept of Health * According to Ayurveda, the body is composed of five ‘elements and three doshas. ‘The health is defined as the state of equilibrium of these following elements and doshas: ® Five elements (panch-mahabhoota) denote Earth, ‘Water, Fire, Air and Universe (ether). ‘Three doshas are Vata, Pitta, Kapha, * Ayurvedic concept of health is shown in Figure 15.1. Ayurveda names seven basic tissues (saptadhatu), which ares * Plasma or rasa dhatu © Blood or rakta dhatu © Muscles or mamsa dhatu © Fator meda dhatu © Bone or asthi dhatu (.Fig. 15.1: Ayurvedic concept of health © Marrow or maja dhatu © Semen or shukra dhatu ‘The diseases are caused by abnormal mentioned dhatus. between these above- Three Doshas Vata or Vatha (Airy Element) * _Itis characterized by properties of dry, cold, light, minute, and movement. All movement in the body is due to property of vata. © Pain is the characteristic feature of deranged vata, ® Some of the diseases due to vata are windy humor, flatulence, gout, rheumatism, etc, Pitta It is the fiery element or bile that is secreted between the stomach and bowels and flows through the liver and permeating spleen, heart, eyes, and skin, © It is characterized by hotness, moist, liquid, sharp and sour. © Its main quality is heat. «It is the energy principle, which uses bile to direct digestion and enhance metabolism. «It is primarily characterized by body heat or burning sensation and redness. Kapha + [tis the watery element. ‘* Itis characterized by heaviness, cold, tenderness, soft slowness, lubrication, and the carrier of nutrient, © Itis nourishing element of the body. ° © Allthe soft organs are made by kapha. # It plays an important role in taste perception nourishment and lubrication. The Principle of Ayurveda © The fundamental theory of Ayurveda is thet « ba between panchamahabootha, saptadhatu and three dor necessary for the normal physiological functions of thet “The imbalance between these elements causes disease. © The balance between panchamahabootha, saptad and doshas are maintained by the procedure of trea depicted in Figure 15.2. Drugs in Ayurveda Ayurvedic drugs are of natural origin, including: * Plants: Whole plants or their parts such as Ajwain, Haldi, Banafsa, Mulethi, Safed Musli, Isabgol, etc. © Animals: Animal parts and their products such 2s Milk, Bones, etc. ‘© Minerals: Minerals either alone or in combinations as Sulfur, Copper, Arsenic, Gold, Iron, etc. ©All of the above mentioned ayurvedic drugs mig given alone or in combinations. Panchakarma therapy is an important part of Ayurveda \Upakarma (Treatment) —_ 4h Canghana | Bimhana (Depleting) |_| (ours “Sodhana (Purification) | _t (- Vamana (Emesis) | Virechana (Purgation) = Pachana (Using diges + Deepana (Increasing - Vasti (Enema) digestive fre) | Nasya (Nasal medication) + Kshudha (Hunge!) | Raktamoksha (Blood letting)) | + Trish (Thirst) + Marutha (Wind) + Wyayama (Exercises) Fig. 15.2: Procedure of treatment in ayurvedag HOMEOPATHY prSamuel Hahnemann, a German physic introduced the system of Homeopathy in 1796, Homeopathy is defined as the therapeutic method based onthe law, simula simuilibus curentur, usually translated as sjet likes be cured by likes’, that states that ifany substance causes a symptom in healthy people, it the same symptom in sick people, an be used to treat Dr Hahnemann penned down his experiences and guidelines for practicing the system of medicine in "Organon of Medicine’, which guides how a physician should proceed while treating the patients, principles of Homeopathy + Homeopathy is based on the following three primary principles: 1. Law of Similia, that states that only that substance ta particular disease which has a capability of symptoms in healthy individuals, of Simplex, that states that only one single, simple medicinal substance is to be administered toa patient in a given point of time 3. Law of Minimum, that states that medicine should be administered in minute doses, ‘The quantity is minimum, yet appropriate, for a gentle remedial effect, + Individualization is yet another foundation stone of homeopathy that means the characteristics of the chosen medicine should be as similar as possible to the characteristics of the illness in the patient, + An example will clarify the concept of homeopathy. If coffee Keeps you awake, then according to homeopathy, diluted coffee will put you to sleep, ‘The more dilute, the stronger the effect, Ifyou keep diluting it until there isnt a single molecule of coffee left it will be even stronger, Drug Proving * Apart fromthe primary three principlesstatedabove, Drug proving forms an important principle of homeopathy. find out which remedy does what, they are tested—not by controlled scientific studies but instead by “proving: * Healthy people ingest the substance and report everything that happens to them (for example, “my big toe itched at midnight, I got heartburn after eating a big meal, I felt angry"). ‘There is no attempt to separate the ordinary changes of everyday life from symptoms caused by the substance. * These reports are then compiled as an index, which is called Repertory, where the practitioner can look up 4 patient's symptoms or characteristics to find out the remedies associated with a particular symptom in the provings. Homeopathic Remedies * Homeopathic remedies are prepared from various sources. Anything could be a homeopathic remedy. The primary sources of homeopathic remedies are: * Plants (like digitalis, poison ivy, belladonna, etc.) * Animals (snake venoms, ants, spiders, etc.) "Minerals (silver, gold, phosphorus, common salt, ete.) * Healthy secretions (milk of various mammals) Unhealthy secretions (secretion from cancerous tissue in breast cancer) Various energy sources (magnetic poles, eclipsed moonlight, ete.) ‘© Soluble materials could be diluted in water or alcohol. Nonsoluble materials could be ground into powder (triturated) and diluted with sugar (lactose powder) * Homeopathic remedies are usually labeled with the notation X or C, corresponding to ten and one hundred. 15C would mean that one part of remedy was diluted in 100 parts of water, one part of the resulting solution was again diluted in 100 parts of water, and the process was repeated fifteen times. * Hahnemann typically used 30C remedies. At30C, it would take a container thirty million times the size of Earth to hold enough of the remedy to make it likely that it would contain a single molecule of the original substance. + There are higher potencies available as well and they depend on the amount of dilution done. ‘© ‘The practitioner consults Materia Medica for a list of symptoms that are associated with each remedy. For example, for Lachesis, the remedy made from the venom of bushmaster snake, the book lists symptoms in all the following areas: mind, head, eyes, ears, nose, face, stomach, abdomen, rectum, urine (male/female), respiratory, heart, extremities, sleep, skin, fever, and modalities. + ‘The symptoms are then matched to the most similar remedy and itis then prescribed to the patient. Doctrine of Drug Potentization Potentization is a process, by which the medicinal/curative properties ofa substance are increased and the negative/toxic properties are negated. Thisis done by two methods known as:1. Succussion (the substance is diluted with alcohol with distal water and shaken vigorously). 2. Trituration (the insoluble solid are diluted by grinding them with lactose). Current Scenario of Homeopathy in India © The Central Council of Homeopathy was established in 1973 to monitor higher education in homeopathy, and ‘National Institute of Homeopathy in 1975. © A minimum ofa recognized diploma in homeopathy and registration on a state register or the Central Register ‘of Homoeopathy is required to practice homeopathy in India. © Use of homeopathy is widely accepted nowadays. UNANI MEDICINE Yunani or Unani medicine is the term for Perso-Arabic traditional medicine as practiced in Mughal India during 13th century. © Itisbased on the concept of the four humors: 1. Blood 2. Phlegm 3. Yellow bile 4. Black bile Basis of Disease According to Unani Medicine ‘© Unani medicine has similarities to Ayurveda. Both are based on theory of the presence of the elements in the human body. ‘* According to followers of Unani medicine, these elements are present in different fluids and their balance leads to health and their imbalance leads to illness. The abnormal humor leads to pathological changes in the tissues anatomically and physiologically at the affected site and exhibits the clinical manifestations. Diagnosis of Disease According to Unani Medicine «In the diagnosis, clinical features, ie. signs, symptoms, laboratory features and mizaj (temperament) are important. © Any cause and or factor are countered by Quwwat-e- ‘Mudabbira-e-Badan (the power of body responsible to maintain health), the failing of which may lead to quantitatively or qualitatively derangement of the normal equilibrium of akiilat (humors) of body, which constitute the tissues and organs. Principles of Management After diagnosing the disease, Usool-e-flaj ( management) of disease is determined on etiology in the following pattern: = Taalae Sabab (elimination of cause) = Tadeele Akhlat (normalization of humors) = Tadeele Aza (normalization of tissuesforgans) According to Unani medicine, management of any qi depends upon the diagnosis of disease, as “These medicines help to restore body functio the disease. TINE and cy Principle o the basis Current Scenario of Unani Medicine in India ‘As an alternative form of medicine, Unani has foun favor in India where popular products like Roghan Bai Margh (Egg Oil) and Roghan Badam Shirin (Alm, Oil) are commonly used for hair care. Unani practitioners can practice as qualified doctors India, as the government approves their practice. SIDDHA MEDICINE Basis of Disease According to It isa traditional medicine first developed in Tamilaka in Tamil Nadu, India. According to the Palm: leaf manuscripts, “Siddha syste was first described by Lord Shiva to his wife Parva Parvati explained all this knowledge to her son Le Muruga. He taught this knowledge to his disciple s Agasthya. ‘Agasthya is considered as the first Siddha and the guru all Siddhars. idha Medicine According to Siddha, the normal functioning ofthe b depends upon seven elements, namelys 1. Blood 2. Plasma 3. Fat tissues 4, Bone 5. Brain 6. Muscles 7. Semen Generally, the basic concepts of the Siddha medicine similar to Ayurveda, It is assumed that when the normal equilibrium of three humors; Vaadham, Pittham and Kabam isdist! disease is caused,