Pharmacology Notes classificaton 2nd proff.pptx

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1. By: H.Misbah ud din PHARMACOLOGY NOTES

2. 13 February 2015 2 RABBE ZIDNI ILMA

3. Rabbe Zidni Ilmaa Qallat Heelati Anta Waseelati Adrikni Ya Rasool Al ALLAH Ass Salatu Wassalamo Alaika Ya Rasool Al ALLAH 13 February 2015 3 RABBE ZIDNI ILMA

4. Drugs Affecting ANS 13 February 2015 4 RABBE ZIDNI ILMA

5. 1. Cholinergic Agonist: Direct Acting: Cholinergic agonists (also known as parasympathomimetics ) mimic the effects of acetylcholine by binding directly to cholinoceptors . Acetylcholine, Pilocarpine , Bethanecol , Carbachol . Indirect Acting: Acetylcholinesterase is an enzyme that specifically cleaves acetylcholine to acetate and choline and, thus, terminates its actions. Inhibitors of acetylcholinesterase indirectly provide a cholinergic action by prolonging the lifetime of acetylcholine. Physostigmine , Neostigmine , Ecothiophate , Rivastigmine , Tacrine . Reactivation of Actylcholine -esterase: Pralidoxime . 2. Cholinergic Antagonist: Antimuscarinic : Commonly known as antimuscarinics , these agents block muscarinic receptors, causing inhibition of all muscarinic functions. Atropine, Scopolamine, Ipratropium . Ganglionic Bolckers : Ganglionic blockers specifically act on the nicotinic receptors of both parasympathetic and sympathetic autonomic ganglia. Except for nicotine, the other drugs mentioned in this category are nondepolarizing , competitive antagonists. Mecylamine , Nicotine. Neuromuscular Bolckers : These neuromuscular blockers are structural analogs of acetylcholine, and they act either as antagonists ( nondepolarizing type) or agonists (depolarizing type) at the receptors on the end plate of the neuromuscular junction. Neuromuscular blockers are clinically useful during surgery for producing complete muscle relaxation Atracurium , Doxacurium , Succinylcholine , Tubocurarine . Cholinergic Drugs 13 February 2015 5 RABBE ZIDNI ILMA

6. 1. Agrenergic Agonist: Direct Acting: These drugs act directly on α or β receptors, producing effects similar to those that occur following stimulation of sympathetic nerves or release of the hormone epinephrine from the adrenal medulla. Dopamine, Epinephrine, Norepinephrine , Phenylephrine , Sameterol , Terbutaline . Indirect Acting: These agents, which include amphetamine, cocaine and tyramine , may block the uptake of norepinephrine (uptake blockers) or are taken up into the presynaptic neuron and cause the release of norepinephrine from the cytoplasmic pools or vesicles of the adrenergic neuron. As with neuronal stimulation, the norepinephrine then traverses the synapse and binds to the α or β receptors. Amphetamine, Cocaine, Tyramine . Mixed: Capacity both to stimulate adrenoceptors directly and to release norepinephrine from the adrenergic neuron. Ephedrine, Pseudoephedrine. 2. Adrenergic Antagonist: α -Blockers: Drugs that block α - adrenoceptors profoundly affect blood pressure. Doxazocin , Prazocin , Terazocin , Tamsulosin . Β - Blockers: All the clinically available B-blockers are competitive antagonists. Nonselective B-blockers act at both B1 and B2 receptors, whereas cardioselective B antagonists primarily block B1 receptors. Atenolol , Esmolol , Labetalol , Pindolol . NT Uptake or Release: Guanethidine , Reserpine . Adrenergic Drugs 13 February 2015 6 RABBE ZIDNI ILMA

7. Anti-Parkinsonism Drugs: The disease is correlated with destruction of dopaminergic neurons in the substantia nigra . Levodopa , Carbidopa , Amantidine , Apomorphine , Benzotropine . Alzheimer Drugs: Major cause is loss of Cholinergic neurons. Memantine , Rivastigmine , Tacrine . Anxiolytic Drugs: a. Benzodiazepenes : Alprazolam , Temazepam , Flurazepam , Lorazepam , Oxazepam . b. Barbiturates: Amobarbital , Phenobarbital, Pentobarbital, Thiopental. c. Other Anxiolytic : Buspirone (mediated by serotonin (5-HT1A) receptors), Hydroxyzine , Anti-depressants. CNS Stimulants: a. Psychomotor Stimulants: Psychomotor stimulants, cause excitement and euphoria, decrease feelings of fatigue, and increase motor activity. Amphetamine, Cocaine, Caffeine, Theobromine . b. Hallucinogens: The hallucinogens, or psychotomimetic drugs, produce profound changes in thought patterns and mood, with little effect on the brainstem and spinal cord. Lysergic Acid Diethylamide, Tetrahydro Cannabinol . CNS Drugs 13 February 2015 7 RABBE ZIDNI ILMA

8. Anti-Depressants: a. SSRIs: Cetalopram , Fluoxetine , Fluvoxamine . b. SNRIs: Duloxetine , Venlafaxine . c. Atypical Ads: Bupropion , Trazodone . d. TCAs (Older SNRIs): Amitryptiline , Imipramine , Trimipramine . e. MAO Inhibitors: The MAO inhibitors may irreversibly or reversibly inactivate the mitochondrial enzyme (gut and liver), permitting neurotransmitter molecules to escape degradation and, therefore, to both accumulate within the presynaptic neuron and leak into the synaptic space. Phenelzine , Selegiline . f. Anti-Mania & Bipolar Disorders: Valproic Acid, Lithium Salts. Anti-Epileptics: By a variety of mechanisms, including blockade of voltage-gated channels (Na + or Ca 2+ ), enhancement of inhibitory GABAergic impulses, or interference with excitatory glutamate transmission. Barbiturates, BZDs, Carbamezepine , Gabapentin , Ethosuximide , Levetiracetam , Felbamate , Phenytoin , Zonisamide . CNS Drugs 13 February 2015 8 RABBE ZIDNI ILMA

9. Neuroleptic Drugs (Anti-Psychotic or Major Tranquilizers): They inactivate Dopamine receptors. a. Typical but low potency: Chlorpromazine, Prochlorperazine . b. Typical but high potency: Haloperidol, Thiothixene . c. Atypical: Clozapine , Olanzapine , Risperidone . Opoids : Activation of the opoid receptor decreases the Ca2+ influx and increases the K+ efflux. Decrease Ca+ influx decreases the release of excitatory NT and increased K+ efflux decreases the response of post-synaptic neuron to excitatory NT (Glutamate). a. Strong Agonists: Meperadine , Methadone, Heroine, Fentanyl . b. Moderate/Low Agonists: Codeine, Propoxyphene . c. Partial Agonists: Buprenorphine , Pentazocine . d. Antagonists: Naloxone , Naltrexone . e. Others: Tramadol . CNS Drugs 13 February 2015 9 RABBE ZIDNI ILMA

10. Congestive Heart Failure(CHF): a. Renin Angiotensin System Blockers: These drugs block the enzyme that cleaves angiotensin I to form the potent vasoconstrictor angiotensin II. Also diminish the rate of bradykinin inactivation. [Note: Vasodilation occurs as a result of the combined effects of lower vasoconstriction caused by diminished levels of angiotensin II and the potent vasodilating effect of increased bradykinin .] By reducing circulating angiotensin II levels, ACE inhibitors also decrease the secretion of aldosterone , resulting in decreased sodium and water retention. Captopril , Lisinopril , Quinapril , Ramipril , Enalapril (ACE Inhibitors) ARBs are nonpeptide , orally active compounds that are extremely potent competitive antagonists of the angiotensin type 1 receptor. Losartan , Valsartan , Telmisartan (ARBs) b. β -Blockers: Atenolol , Metoprolol , Carvedilol . c. Diuretics: Diuretics decrease plasma volume and, subsequently, decrease venous return to the heart (preload). This decreases the cardiac workload and the oxygen demand. Bumetanide , Furesamide , Metolazone , Hydrochlorthiazide . d. Direct Vasodilators: Hydralazine , Isosorbide dinitrate , Sod nitroprusside . e. Inotropic Agents: Enhance cardiac muscle contractility and, thus, increase cardiac output. Digitoxin , Digoxin , Dobutamine , Amrinone . f. Aldosterone Antagonist: Spironolactone . *Dec. Angiotensin II cause dec . Aldosterone which cause decreased water & sod retention. Plasma vol is decreased and hence preload also decreased & BP lowered. CVS Drugs 13 February 2015 10 RABBE ZIDNI ILMA

11. Anti- Arrythmic Drugs: Arrhythmias arise either from aberrations in impulse generation (abnormal automaticity) or from a defect in impulse conduction. a. Na + Channel Blockers: Quinidine , Procanamide , Propafenone . b. β -Blockers: Inhibits Phase 4 depolarization in SA & AV nodes. Esmolol , Propranolol , Metoprolol . c. K + Channel Blockers: Prolongs Phase 3 repolarization in ventricular muscle fibres . Amiodarone , Sotalol , Dofetilide . d. Ca 2+ Channel Blockers: Inhibits action potential in SA & AV nodes. Diltiazem , Verapamil . e. Others: Adenosine, Digoxin . CVS Drugs 13 February 2015 11 RABBE ZIDNI ILMA

12. Anti- Anginal Drugs: a. Organic Nitrates: Nitrates decrease coronary vasoconstriction or spasm and increase perfusion of the myocardium by relaxing coronary arteries. In addition, they relax veins, decreasing preload and myocardial oxygen consumption. Isosorbide dinitrate & mononitrate , Nitroglycerin. b. β -Blockers: They decrease the oxygen demands of the myocardium by lowering both the rate and the force of contraction of the heart. Acebutolol , Atenolol , Metoprolol , Propranolol . c. Ca Channel Blockers: The calcium-channel blockers protect the tissue by inhibiting the entrance of calcium into cardiac and smooth muscle cells of the coronary and systemic arterial beds. Amlodipine , Diltiazem , Verapamil , Nicardipine , Nifedipine . Anti- Hyperlipidemics : a. HMG CoA Reductase Inhibitors: Analogs of HMG(precursor of Cholesterol). Because of their strong affinity for the enzyme, all compete effectively to inhibit HMG CoA reductase , the rate-limiting step in cholesterol synthesis (de novo synthesis). Atorvastatin , Lovastatin , Provastatin , Simvastatin . b. Fibrates : Gemfibrozil , Fenofibrate . c. Niacin: Niacin strongly inhibits lipolysis in adipose tissue, the primary producer of circulating free fatty acids. d. Bile Acid Sequestrants : Colestipol , Colestyramine , Colesevelam . e. Cholesterol Absorption Inhibitors: It inhibits intestinal absorption of dietary and biliary cholesterol in the small intestine, leading to a decrease in the delivery of intestinal cholesterol to the liver. This causes a reduction of hepatic cholesterol stores and an increase in clearance of cholesterol from the blood. Ezetimibe . CVS Drugs 13 February 2015 12 RABBE ZIDNI ILMA

13. Anti- Hypertensives : a. Diuretics: They cause increased water and sodium excretion leading to decreased extracellular volume & decreased cardiac output. Bumetanide , Furosamide , Spironolactone , Hydrochlorthiazide . b. β -Blockers: Decrease Cardiac Output. Atenolol , Carvedilol , Labetalol , Metoprolol . c. ACE-Inhibitors: ACE inhibitors decrease conversion into angiotensin II and increase bradykinin levels. Vasodilation occurs as a result of the combined effects of lower vasoconstriction caused by diminished levels of angiotensin II and the potent vasodilating effect of increased bradykinin . Captopril , Enalapril,Fosinopril , Lisinopril , Ramipril . d. ARBs: Same As ACEIs but no Cough or Angiodema . Candesartan , Losartan , Telmisartan , Valsartan . e. Ca Channel Blockers: Verapamil , Nifedipine , Nicardipine , Diltiazem , Amlodipine . f. α -Blockers: They decrease peripheral vascular resistance and lower arterial blood pressure by causing relaxation of both arterial and venous smooth muscle. Doxazocin , Prazocin , Terazocin . g. Others: Clonidine , Hydralazine , Sod. nitroprusside , Minoxidil , α -Methyldopa. CVS Drugs 13 February 2015 13 RABBE ZIDNI ILMA

14. Diuretics: a. Thiazides : These drugs increase the concentration of Na + and Cl - in the tubular fluid by decreasing the reabsorption of Na in the distal convulated tubule. Chlorothiazide , Chlorthalidone , Indapamide , Hydrochlorthiazide . b. Loop Diuretics: Loop diuretics inhibit the cotransport of Na + /K + /2Cl - in the luminal membrane in the ascending limb of the loop of Henle . Therefore, reabsorption of these ions is decreased. Most efficacious. Bumetanide , Furosamide , Torsemide . c. Potassium Sparing Diuretics: Amiloride , Spironolactone , Triamterene . d. Carbonic Anhydrase Inhibitors: Acetazolamide . e. Osmotic Diuretics: Mannitol , Urea. CVS Drugs 13 February 2015 14 RABBE ZIDNI ILMA

15. Respiratory System: a. Asthma: β 2 -Adrenergic Agonists, Corticosteroids, Montelukast ( Cysteinyl leukotriene antagonist), Theophylline , Omalizumab . b. Allergic Rhinitis: α-Adrenergic Agonists, Antihistamines, Corticosteroids, Cromolyn . c. COPD: β -Adrenergic Agonists, Corticosteroids, Ipratropium . d. Cough: Dextromethorphan , Opiates. GI Drugs: Parietal cell is acted upon by Acetylcholine, Gastrin , Histamine & Prostaglandin. PG has inhibitory effect while others increase acid release. a. Anti- Microbials : Amoxycillin , Clarithromycin , Tetracycline, Metronidazole . b. H2-Receptor Antagonist: They are competitive antagonists of histamine and are fully reversible. These agents completely inhibit gastric acid secretion induced by histamine or gastrin . Cimetidine , Ranitidine, Famotidine . c. PPIs: They bind to the H+/K+- ATPase enzyme system (proton pump) of the parietal cell, thereby suppressing secretion of hydrogen ions into the gastric lumen. The membrane-bound proton pump is the final step in the secretion of gastric acid Esomeprazole , Omeprazole , Lansoprazole . d. Prostaglandins: Prostaglandin E2, produced by the gastric mucosa, inhibits secretion of HCl and stimulates secretion of mucus and bicarbonate. Misoprostol (Prostaglandin E2 analog). e. Antacids: Aluminium Hydroxide, Magnesium Hydroxide. f. Mucosal Protective Agents: Sucralfate . Drugs Affecting Other Organs 13 February 2015 15 RABBE ZIDNI ILMA

16. Anti-Emetics: a. Phenothiazines : Prochlorperazine (Block dopamine receptors) b. 5-HT 3 receptor blocker: They selectively block 5-HT 3 receptors in the periphery (visceral vagal afferent fibers) and in the brain. Ondansetron , Granisetron , Dolasetron . c. Butyrophenones : Droperidol , Haloperidol (Block Dopamine receptors). d, Substance P/ Neurokinin -I Blocker: Aprepitant (It targets the neurokinin receptor in the brain and blocks the actions of the natural substance) Anti- diarrheals : a. Anti-motility agents: Both are analogs of meperidine and have opioid -like actions on the gut, activating presynaptic opioid receptors in the enteric nervous system to inhibit acetylcholine release and decrease peristalsis. At the usual doses, they lack analgesic effects. Diphenoxylate , Loperamide . b. Adsorbents: Bismuth subsalicylate, Methylcellulose, Aluminum hydroxide. c. Agents that modify fluid and electrolyte transport: Bismuth subsalicylate. ( Traveller’s diarrhea) Drugs Affecting Other Organs 13 February 2015 16 RABBE ZIDNI ILMA

17. Laxatives: a. Irritants & Stimulants: Senna , Bisacodyl . b. Bulk Laxatives: They form gels in the large intestine, causing water retention and intestinal distension, thereby increasing peristaltic activity. Methylcellulose, Psyllium seeds, Bran. c. Stool softeners: (Emollient laxatives/Surfactants) Docusate sodium, Docusate calcium, Docusate potassium. d. Lubricant Laxatives: Mineral oil & Glycerin suppositories. (Facilitate the passage of hard stools) Drugs Affecting Other Organs 13 February 2015 17 RABBE ZIDNI ILMA

18. Erectile Dysfunction (PDE-5 Inhibitors): Sildenafil , Vardenafil . Osteoporosis: Alendronate , Ibandronate , Calcitonin , Zoledronic Acid. Obesity: Orlistat (lipase inhibitor), Sibutramine ( anorexiant ), Phentermine ( anorexiant ). Other Therapies 13 February 2015 18 RABBE ZIDNI ILMA

19. Cell Wall Inhibitors: These drugs interfere with the last step of bacterial cell wall synthesis ( transpeptidation or cross-linkage), resulting in exposure of the osmotically less stable membrane. Cell lysis can then occur, either through osmotic pressure or through the activation of autolysins. These drugs are thus bactericidal. a. B- lactams : i - Penicillins : Amoxicillin, Ampicillin , Piperacillin , Oxacillin , Methicillin , Nafcillin . ii- Cephalosporins : 1 st Generation ( Cefadroxil , Cefalexin ) 2 nd Generation ( Cefaclor , Cefoxitin , Cefprozil ) 3 rd Generation ( Cefixime , Cefotaxime , Cefibuten , Ceftriaxone ) 4 th Generation ( Cefepime ) iii- Carbapenems : Meropenem , Imipenem . Iv- Monobactam : Aztreonam . b. Other Antibiotics: Bacitracin , Vancomycin , Daptomycin . Antibiotics (Antimicrobials) 13 February 2015 19 RABBE ZIDNI ILMA

20. Protein Synthesis Inhibitors: a. Tetracyclines : The drug binds reversibly to the 30S subunit of the bacterial ribosome, thereby blocking access of the amino acyl-tRNA to the mRNA-ribosome complex at the acceptor site. By this mechanism, bacterial protein synthesis is inhibited. Doxycycline , Minocycline , Tetracycline. b. Glycylcyclines : Also binds reversibly to the 30S of the ribosomal unit. Tigecycline . c. Aminoglycosides (derived from Streptomyces have - mycin suffixes, whereas those derived from Micromonospora end in – micin ): Also binds reversibly to the 30S ribosomal subunit & inhibiting protein translation. All aminoglycosides should be given parenterally except neomycin. Amikacin , Gentamicin , Neomycin, Tobramycin , Streptomycin. d. Macrolides / Ketolides : The macrolides bind irreversibly to a site on the 50S subunit of the bacterial ribosome, thus inhibiting the translocation steps of protein synthesis. Azithromycin , Clarithromycin , Erythromycin, Telithromycin . e. Chloramphenicol (50S subunit) f. Clindamycin g. Dalfopristin / Quinupristin (50S subunit) h. Linezolid (binds to a site on the 50S subunit near the interface with the 30S subunit) Antibiotics (Antimicrobials) 13 February 2015 20 RABBE ZIDNI ILMA

21. Fluoroquinolones : These drugs enter the bacterium by passive diffusion through water-filled protein channels ( porins ) in the outer membrane and then inhibit the replication of bacterial DNA by interfering with the action of DNA gyrase ( topoisomerase II) and topoisomerase IV during bacterial growth and reproduction. Nalidixic Acid, (Ciprofloxacin, Ofloxacin , Norfloxacin ), Levofloxacin , Moxifloxacin . Folate Synthesis Inhibitors: Silver Sulfadiazene , Sulfamethoxazole , Sulfasalazine , Sulfisoxazole . Folate Reduction Inhibitors: Pyrimethamine , Trimethoprim . Combination of Above two: Co- trimoxazole . UTI Antiseptics: Methenamine , Nitrofurantoin (urine discoloration). Where Sulfonamides and Trimethoprim act ?? Pteridine + p-ABA + Glutamate Dihydrofolic Acid (Sulfonamide) (microbes) Dihydrofolic Acid Tetra hydro folic Acid ( Trimethoprim ) (humans) Tetrahydrofolic Acid Amino Acid Synthesis + Purine Synthesis + Thymidine Synthesis Antibiotics (Antimicrobials) reduction 13 February 2015 21 RABBE ZIDNI ILMA Dihydropteroate synthetase

22. Anti-TB drugs: Isoniazid ( altering cell membrane function), Ethambutol (inhibit normal arabinogalactin cell wall), Rifampicin (inhibits synthesis of mRNA), Pyrazinamide (unknown). (1 st line drugs) Aminoglycosides , Macrolides , Cycloserine , Ethionamide ,. (2 nd line drugs) Anti-Leprosy Drugs: Clofazimine , Dapsone , Rifampin . Subcutaneous and Systemic Mycoses: Amphitericin B, Fluconazole , Ketoconazole , Micafungin , Capsofungin . Cutaneous Mycoses: Butoconazole , Griseofulvin , Nystatin , Terbinafine . Antimycobacterials And Antifungals 13 February 2015 22 RABBE ZIDNI ILMA

23. Amebiasis : Chloroquine , Emetine, Dehydroemetine , Metronidazole , Paramomycin . Malaria: Artemisinin , Primaquine , Pyrimethamine , Mefloquine , Quinine/ Quinidine . Trypanosomiasis : Benznidazole,Suramin , Nifurtimox , Melarsoprol . Leishmaniasis : Sodium stibogluconate . Toxoplasmosis: Pyrimethamine . Giardiasis : Metronidazole , Nitazoxanide , Tinidazole . Anti-Nematodes ( Ascaris , Hookworms, Filarias . Enterobius , Trichinella ): Ivermectin , Pyrantel pamoate , Diethylcarbamazine . Anti- Trematodes ( Schistosomes ): Praziquantel . Anti- Cestodes (Tapeworms): Niclosamide , Albendazole . Antiprotozoals & Antihelminthics 13 February 2015 23 RABBE ZIDNI ILMA

24. Respiratory Virus Infections: Amantadine , Rimantadine , Ribavirin , Zanamivir . Hepatic Viral Infections: Interferon, Adefovir , Entecavir . HIV Infections: Abacavir , Didanosine , Etravirine , Fosamprenavir , Tenofovir . Anti- Virals 13 February 2015 24 RABBE ZIDNI ILMA

25. Antimetabolites : Methotrexate , Gemcitabine , 6-Mercaptopurine, Cytarabine . Antibiotics: Bleomycin , Doxorubicin, Daunorubicin . Alkylating Agents: Cyclophosphamide , Busulfan , Ifosfamide , Mechlorethamine , Streptozocin . Microtubule Inhibitors: Docetaxel , Vincristine , Vinblastine , Vinorelbine . Steroids, Hormones and their Antagonists: Prednisone, Tamoxifen , Estrogens, Goserelin , Letrozole . Monoclonal Antibodies: Cetuximab , Rituximab . Others: Asparaginase , Interferons , Cisplatin , Etoposide , Imanitib , Topotecan , Oxaliplatin . Anti-Cancers 13 February 2015 25 RABBE ZIDNI ILMA

26. NSAIDs: Aspirin, Diclofenac , Indomethacin , Fenamates , Ibuprofen, Piroxicam , Sulindac . CoX-2 Inhibitors: Celecoxib . Other Analgesics: Acetaminophen. Anti-Arthritis: Adalimumab , Anakinra , Infliximab , Gold salts, D- Penicillamine . Drugs for Gout: Allopurinol , Colchicine , Probenecid , Sufinpyrazone . Anti-Inflammatory 13 February 2015 26 RABBE ZIDNI ILMA

27. Prostaglandins: Misoprostol . H1-Antihistamines : H1 receptors present in exocrine excretion, bronchial smooth muscles, intestinal smooth muscles and sensory nerve endings. H1 & H2 receptors present in CVS & Skin. H2 receptors found only in stomach. First Generation ( Chlorpheniramine , Diphenhydramine , Dimenhydrinate ) Second Generation ( Cetrizine , Fexofenadine , Loratadine ) Migraine Headache : Almotriptan , Naratriptan , Riztriptan , Sumatriptan , Zolmitriptan . Autocoids & Their Antagonists 13 February 2015 27 RABBE ZIDNI ILMA

28. Substance P Blocker: APREPITANT Isoniazid written as INH represents IsoNicotinic acid Hydrazide . Uterus Parts: Fundus ; Body; Corporis ; Cervix. Fallopian tube connects ovary with uterus. Female Reproductive System: Ovary; Fallopian Tube; Uterus; Vagina. Embryo life cycle: 1-8weeks Fetus: After 8weeks Uterus walls: Endometrium Myometrium ; Parametrium . Endo & Myometrial walls involved in the production of Prostaglandins. F2 α : Vasoconstrictor( dysmenorrhia ) E2: Vasodilator ( menorraghia ) I2: Myometrial relaxation; vasodialtion ; anti-platelets. Menarchie : First Periods of a woman (8-16yrs) Avg : 13yrs. Most regularized periods: 20-40yrs. Average cycle: 28days (24-36days) Average Flow: 3-7days; Typical Flow: 5days Starts light then heavy then again light. ACEIs contraindicated in bilateral renal artery stenosi . Desmopressine used in nocturnal enuresis. Facts to Remember 13 February 2015 28 RABBE ZIDNI ILMA

29. Ovulation: Release of ova from the ovary. Range: Day 8 th -20 th (14 th day). A woman has almost 2000days of periods in her life (400cycles) except pregnancy and illness. Menstrual cycle: Menstruation; Proliferation; Ovulation; Secretory . Menstruation: Day 1-5. Proliferation: Day 6-13. Ovulation: Day 14 th . Secretory : Day 15-28. Graffian Follicle before ovulation secrete estrogen and after ovulation is is known as Corpeus Luteum and secretes Progesterone which develops thick wall of uterus ( endometrium ). Cervix: Neck of uterus. Basal Body Temperature (BBT): Temp at relaxed body state. Nociceptives : Nerve Endings that sense pain. Anhedonia : An unprovoked stimuli could result in painful sensation normally not painful. Gestational Diabetes: Diabetes that occurs during pregnancy and soon disappears after child birth. Major Adverse effect of Adenosine { is Dyspnea . Verapamil is contraindicated with CNS Depressants. Daily dose of Folic Acid is 400-500µg. Facts to Remember 13 February 2015 29 RABBE ZIDNI ILMA

30. Types of Pain: Nociceptive : Pain due to sensitization of nociceptive nerve endings due to certain tissue damage. Neuropathic: Any lesion or damage to the nerve fibres , resulting in pain. E.g. Diabetic Peripheral Neuropathy (DPN) Mixed: Low back pain; Ankolysing Spondylitis . Mechanism of Feeling pain: Reception: Stimulation of nociceptives by PGs. Conduction: From Nerve ending to brain. Perception: Cortex & Thallamus receive impulse. Suffering: Reaction. Pain & Inflammation Mediators: Histamine; Bradykinins ; Kinins ; Substace P; PGs. PGs increase blood flow to the injury site and accelerate the transfer of WBCs and Platelets. Inflammation: Natural response to the injury to inactivate causative agent. PGs increase vascular permeability and WBCs migration and sensitization of Nociceptives . PAE: The postantibiotic effect (PAE) is a persistent suppression of microbial growth that occurs after levels of antibiotic have fallen below the MIC. Myasthenia gravis: (Muscle weakness) Autoimmune disorder due to blockade of cholinoceptors by circulating antibodies. Treatment by Neostigmine , physostigmine . Diabetes Type-I: Insulin Dependant; when the body stops making insulin. Also called brittle or labile diabetes. Diabetes Type-II: Non Insulin Dependant; body is making insulin either in insufficient amount or the cells do not respond to body made insulin. Facts to Remember 13 February 2015 30 RABBE ZIDNI ILMA

31. Menorrhagia : Excess Blood flow in frequency, duration or amount; upto 80ml. (20-30ml) PGE2: Inc. vasodilation ; Dec. platelet adhesion & aggregation…… Inc. Blood Flow. PGF2 α : Inc. vasospasm; Inc. uterine contractions…… Painful Menses. Hyperalgesia : Intensed Pain. Articular : Bones & Joints. Non- Articular : Tendons; Ligaments; Bursa. Epicondyl : Bony projections at the end of long bones. Sprains: Injury to the ligament. Stills Disease: Juvenile Idiopathic Arthritis. In enteral route duodenum is the major site for drug absorption. Bioavailability: Fraction of the drug that reaches the blood stream. Total body water in 70kg human=42litres. Intracellular( 28ltrs) + Interstitial(10ltrs) + Plasma(4ltrs)= 42 litres . Volume of Distribution: Hypothetical volume of fluids into which drug is dispersed. Albumin has the strongest affinity with anionic and hydrophobic drugs. Each cell may have 10,000 receptors e.g. heart has B-receptor for norepinephrine and muscarinic receptor for acetylcholine. Potassium is administered as Slow IV infusions. Facts to Remember 13 February 2015 31 RABBE ZIDNI ILMA

32. Receptor: Biological molecule to which drug binding produce measurable response. Receptor Types: Ligand gated Ion Channels: GABA (Fastest reception) G-protein Coupled: Sildenafil Enzyme Linked: Insulin Intracellular Receptors: Steroids (Slowest reception) Competitive Antagonism: Same site on same receptor e.g. Prazocin & Norepinephrine . Non-competitive Antagonism/ Allosteric : Different sites on same receptor e.g. Protamine & Heparin. Functional/Physiologic Antagonism: Different receptors involved e.g. Epinephrine & Histamine. Quantal -Dose Response: Study of dose-response on a population that responds. Therapeutic Index: Ratio of toxic dose to effective dose. Drugs with High Therapeutic Index is SAFER to use. Catecholamines have brief duration & rapid onset of action and do not cross BBB. Non- catecholamines have longer duration of action and can be administered orally. Narcolepsy: Narcolepsy is a relatively rare sleep disorder that is characterized by uncontrollable bouts of sleepiness during the day. It is sometimes accompanied by catalepsy, a loss in muscle control, or even paralysis brought on by strong emotions, such as laughter. P450 enzyme INDUCERS: Smoking, Omeprazole , Rifampicin , Carbamazepine , Phenytoin , Phenobarbital. P450 enzyme INHIBITORS: Cimetidine , Fluvoxamine , Isoniazid Quinidine , Macrolides , Chloramphenicol . Facts to Remember 13 February 2015 32 RABBE ZIDNI ILMA

33. INR: A laboratory test to called INTERNATIONAL NORMALISED RATIO measures the time it takes for a blood sample to clot and compares it with average clotting time (5-11min) . Average CT measured by Dale’s method (taking a blood sample in a thin capillary and the end of tube is broken every 30sec until clot formed). Bleeding Time: It is the time until which the blood continues oozing from the injured site (1-5min) . Measured by Duke’s method (pricking a finger and taking the blood sample every 30sec. on a filter paper until blood stops coming). Norepinephrine is ineffective orally. Alpha Methyldopa is the only ani -hypertensive used in pregnancy. Major side effect of Doxorubicin is tissue necrosis. Oxidation is Phase-I reaction. In overdosage of Digoxin we use Antidote FAB fragment. Digitoxin toxicity reflects in ECG as to prolong PR interval. Myxodema (Hypothyroidism) treated by Thyroid sodium. Vit A daily dose is 30,000-50,000 IU. Vit C daily dose is 400mg for both men and women. Floxapen ( flucloxacillin ) is resistant to penicilinnase . Chelators are drugs that form covalent bonds with cationic metals. Antibiotics showing Conc. dependant killing involve aminoglycosides , flouroquinolones , carbapenems . While those showing time dependant killing involve β - lactams , macrolides , clindamycin . Narrow Spectrum: Covering single or limited group of microbes. e.g Isoniazid . Extended Spectrum: Covering gram + ve and also significant gram – ve bacteria. e.g Ampicillin Broad Spectrum: Covering a wie variety of microbes; also the beneficial microbes causing Candida albicans . e.g Tetracyclines , Chloramphenicol . Facts to Remember 13 February 2015 33 RABBE ZIDNI ILMA

34. Angina Pectoris: It is a characteristic sudden, severe, pressing chest pain radiating to the neck, jaw, back, and arms. It is caused by coronary blood flow that is insufficient to meet the oxygen demands of the myocardium, leading to ischemia. Stable Angina(Typical): It is characterized by a burning, heavy, or squeezing feeling in the chest. It is caused by the reduction of coronary perfusion due to a fixed obstruction produced by coronary atherosclerosis. Unstable Angina: In unstable angina, chest pains occur with increased frequency and are precipitated by progressively less effort.(lies b/w Angina and MI) Prinzmetal /Variant/ Vasopastic Angina: It is an uncommon pattern of episodic angina that occurs at rest and is due to coronary artery spasm. Symptoms are caused by decreased blood flow to the heart muscle due to spasm of the coronary artery. Mixed Angina: Patients with advanced coronary artery disease may present with angina episodes during effort as well as at rest, suggesting the presence of a fixed obstruction associated with endothelial dysfunction. Angiodema : Angioedema  or  Quincke's edema is the rapid swelling (edema) of the dermis, subcutaneous tissue, mucosa and submucosal tissues. Also known as angioneurotic oedema . Due to increased bradykinin (vasodilator) levels which occurs in ACEIs treatment. Hydralazine causes Lupus Like Syndrome. Hypothyroidism & Antidepressants causes Weight Gain. Low Density Lipoproteins LPLs act as Carriers of cholesterol in Plasma. HDLs cause atherosclerosis. Sites of Antibiotics: Cell wall synthesis(B- lactams ); metabolism(sulfonamides); protein synthesis( macrolides ); nucleic acid function or synthesis( cipro ); cell membrane function( isoniazid ). Facts to Remember 13 February 2015 34 RABBE ZIDNI ILMA

35. Structure : Inner part Medulla secreting Epinehprine . Outer part cortex. Cortex is further divided into three parts. Inner most of cortex is Reticularis which secretes Adrenal androgens ; Middle part called Fasciculata secreting Glucocorticoids and outer most is the Glomerulosa which secretes Mineralocorticoids . Physiology: Hypothalamus A Pituitary Adrenal Gland Glucocorticoids & Mineralocorticoids are collectively known as Corticosteroids. Cortisol also acts as a feedback mechanism and inhibits both processes from hypothalamus to anterior pituitary and pituitary to adrenal glands. Glucocorticoids : Short Acting (1-12 hrs): Hydrocortisone, Cortisone. Intermediate Acting (12-36hrs): Prednisone, Prednisolone , Methylprednisolone . Long Acting (36-55hrs): Betamethasone , Dexamethasone . Mineralocorticoids : Deoxycorticosterone , Fludrocortisone . Glucocorticoids act as anti inflammatory by inhibiting PGs and Leukotrienes & also redistribute WBCs to other body sites; also reduce histamine release from mast cells and basophils ; decrease ability of macrophages and leukocytes to antigens and mitogens . Also used in Treatment of Allergies and Diagnosis of Cushing’s disease ( Overproduction of glucocoricoids ) 13 February 2015 RABBE ZIDNI ILMA 35 Adrenal Hormones Corticotropin -releasing Factor Corticotropin ACTH Aldosterone Corisol Androgens

36. Types of Insulin: Lispro , Aspart , Glulisine , Glargine , Detemir , Neutral Protamine Hagedorn (NPH). 13 February 2015 RABBE ZIDNI ILMA 36 Diabetes Mellitus-II Treatment Drug Class Drugs MoA Plasma Insulin Risk of HYPO Sulfonylurea (1st Gen) Tolbutamide Increase Insulin secretion Increased Yes Sulfonylurea (2 nd Gen ) Glipizide ; Glimepiride Increase Insulin secretion Increased Yes Meglitinides Nateglinide ; Repaglinide Increase Insulin secretion Increased Rarely Biguanides Metformin Inhibiting Gluconeogenesis Decreased No Glitazones Pioglitazone ; Rosglitazone Binds to Peroxisome Perforator Activated Receptor & decrease Insulin Resistance Highly decreased No α - Glucosidase Inhibitors Acarbose ; Miglitol Decrease breakdown of starch and oligosaccharides & glucose absorption. Little or no change No DPP-IV Inhibiotrs Sitagliptin ; Vildagliptin Prolongs Incretin thus increase insulin & decrease glucagon production Increased No

37. Poison or Syndrome Antidote Mechanism Acetaminophen N- acetyl cystine Accelerate detoxification of toxic agents Anticholinergic agents ( Muscarine ) Physostigmine Inhibits Acetylcholine-esterase Benzodiazepene Flumazenil Antagonist Cyanide Amyl nitrite pearls or Sodium nitrite then Sod. thiosulfate Provide alternative target Digitalis Digoxin Immune Fab Methanol Ethylene Glycol Fomepizole Reduce metabolic activation Heparin Protamine sulphate Antagonist Lead Dimercaptosuccinic aid Chelators Mercury; Arsenic; Gold Dimercaprol Chelators Methemoglobinemia Methylene Blue Chelators Opiates Naloxone ; Naltrexone Antagonist Organophosphates (pesticides); Carbamates ; Nerve gases Atropine; Pralidoxime Pharmacological antagonist 13 February 2015 RABBE ZIDNI ILMA 37 Toxicology

38. Abbreviations Meanings Latin Origin Abbreviations Meanings Latin Origin a.c before meals ante cibum ad Upto ad a.m Morning ante meridiem a.d Right ear Auris dextra b.i.d Twice a day bis in die admov . apply admove gtt drop gutta agit stir/shake agita h.s at bed time hora somni a.r / a.s left ear auris laeva / sinistra p.c After food post cibum a.u both ears auris utraque p.m Afternoon post meridiem bol . single large dose bolus p.o Orally per oral BUCC in cheek bucca p.r.n as needed pro re nata c.c with food cum cibo q.d Every day / daily quaque die e.m.p as directed ex modo prescripto q.h Every hour quaque hour et and et q.s A sufficient quantity quantum sufficiat ft make fiat Rx Prescription recipe gtt drop gutta sig. / S. Directions signa mist mix mistura stat. Immediately statim m.d.u used as directed more dicto utendus u.d as directed ut dictum mitte send mitte q.o.d Every other day quaque otram diem mane in morning mane noct . at night nocte non rep. no repeats non repetatur 38 Common Latin Abbreviations 13 February 2015 RABBE ZIDNI ILMA

39. Cholinergic Agonists Drugs Therapeutic Uses Bethanecol Treatment of Urinary Retention Carbachol Miosis during Ocular Surgery; Topically to reduce IO pressure. Pilocarpine Reduce intraocular pressure in open angle & narrow angle glaucoma Physostigmine Increase bladder motility; reverse CNS effects of Antidepressants & Atropine. Neostigmine Treat Myasthenia Gravis; Antidote for Tubocurarine . Rivastigmine Alzheimer’s Disease Ecothiphate Open Angle Glaucoma. Facts to Remember 13 February 2015 39 RABBE ZIDNI ILMA

40. Cholinergic Antagonists Drugs Therapeutic Uses Atropine Mydriasis and cycloplegia prior to refraction. Organophosphate poisoning. Suppress respiratory secretions. Scopolamine In obstetrics, to produce amnesia and sedation(with morphine) Motion Sickness. Ipratropium Asthma Nicontine None Mecamylamine Treatment of moderate to severe hypertension. Facts to Remember 13 February 2015 40 RABBE ZIDNI ILMA

41. Adrenergic Agonists Drugs Receptor Specificity Therapeutic Uses Epinephrine α 1, α 2, β 1, β 2 Acute Asthma; Anaphylactic Shock; In local anesthetics. Norepinephrine α 1, α 2, β 2 Shock Treatment Isoproterenol β 1, β 2 Cardiac Stimulant Dopamine α 1, β 1, Dopaminergic CHF, Raise BP Dobutamine β 1 CHF Methoxamine α 1 Supraventricular tachycardia Clonidine α 2 Treatment of hypertension Phenylephrine α 1 Nasal decongestant Albuterol ; Terbutaline β 2 Short acting bronchospasm Salmeterol ; Formoterol β 2 Long acting bronchospasm Amphetamine α , β , CNS CNS stimulant in children, ADHD, Narcolepsy. Ephedrine; Pseudo Ephedrine α , β , CNS Asthma, Nasal decongestant Facts to Remember 13 February 2015 41 RABBE ZIDNI ILMA

42. Adrenergic Antagonists Drugs Receptor Specificity Therapeutic Uses Propranolol β 1, β 2 Hypertension, Glaucoma, Migraine, Angina pectoris, MI Nadolol ; Timolol β 1, β 2 Glaucoma, Hypertension Atenolol ; Esmolol ; Metoprolol β 1 Hypertension Pindolol (Partial Agonist) β 1, β 2 Hypertension Carvedilol ; labetalol α 1, β 1, β 2 Hypertension, CHF Facts to Remember * Pindolol and Aebutolol are Partial Agonists 13 February 2015 42 RABBE ZIDNI ILMA

43. Metabolism can happen in two phases. Phase I reactions involve hydrolysis, oxidation and reduction (results in low hydrophilicity ). Phase II reactions involve glucoronidation , sulfonation , acetylation , methylation , conjugation with glutathione or amino acids(cause high hydrophilicity ). Phase I may or may not precede Phase II. Clearance is the volume of plasma cleared off drug per unit time. Its unit is ml/min. Pharmacokinetics involves the movement of drug or its metabolites into or out of the body and also evaluates its metabolism rates. Zero order kinetics is independent of drug concentrations ; usually seen when reaction system is saturated.e.g Metabolism of Phenytoin , Constant rate IV Infusion. In First order kinetics rate of drug elimination at particular time is directly proportional to the amount of drug in the body at that time; Semi Logarithmic plot of Plasma Drug Conc vs time is a straight line. Elimination rate constant, Vd , clearance and half life are independent of the dose of the drug. First order kinetics is also known as monoexponential kinetics ; in which rate of reaction is directly proportional to the drug concentration in the reaction. Mixed Order Kinetics depends on the dose of the drug and are thus known as Dose Dependant or Non-Linear Kinetics. Generally described by Michelis Menten Equation. 13 February 2015 RABBE ZIDNI ILMA 43 Biopharm Concepts

44. Pharmacokinetic Models are imaginary compartments. Central Compartment represents plasma and tissues which rapidly equilibrate with drugs. Peripheral Compartments represents tissues or organs which equilibrate slowly. Number and site of compartments is determined by the blood perfusion capacity and drug physicochemical properties. Michelis Menten Equation: -dc = V max x C dt K m + C Plasma albumin has 4 binding sites . i.e Warfarin , Diazepam, Tamoxifen , Digoxin . Total body tissue comprises 40% of the total body. Pharmaceutical Equivalents: If two drugs contain same amount of active ingredient in same dosage form. They may contain different excipients . Pharmaceutical Alternatives: If two drugs contain same drug molecule but in different chemical form e.g different salt or strength. Bioavailability: Rate and extent to which a drug is absorbed from the site of administration and become available at the site of action. Bioeuivalence : Drugs showing same bioavailability are said to be bioequivalent. Essentially Similar Product: A copy of the research or Innovator Product. (ME 2) 13 February 2015 RABBE ZIDNI ILMA 44 Biopharm Concepts

45. Therapeutic Equivalents: If two drugs provide the same desired therapeutic effect with same safety and efficacy. C max : Maximum Drug Plasma concentration partly depends on the rate of release of drug from the formulation. T max : Time required to reach maximum Plasma drug concentration; also dependant on rate of drug release. T 1/2 : Elimination half life. Mean Residence Time (MRT): Time a drug molecule spends in the body before it gets excreted out. Metabolism reactions are also said to be Bioactivation reactions. Metabolism is basically involved in converting a drug more hydrophilic to facilitate its excretion from the body. 13 February 2015 RABBE ZIDNI ILMA 45 Biopharm Concepts

46. Bacteria Disease Caused Actinomyces Respiratory disease; Cavities Bacillus anthracis Anthrax Clostridium tetani Tetanus Cornyebacterium diphteriae Diphtheria Mycobacterium tuberculosis Tuberculosis Staphylococcus aureus ; S. epidermis Streptococcus pneumonia; S. pyogenes Alpha hemolysis ; Beta hemolysis . Mycoplasma Walking pneumonia Listeria Fetal pathogens; Newborn meningitis Nocardia Respiratory Diseases Common Gram + ve Bacteria 13 February 2015 46 RABBE ZIDNI ILMA

47. Bacteria Disease Caused Borrelia Lymes Disease Campylobacter GI Diseases Chlamydia STD; Trachoma(blindness); Pneumonia Enterobacter UTIs Escherichia coli Normal GI tract Helicobacter Peptic Ulcer Hemophilus influenzae Upper RTIs; Epiglottitis ; Meningitis; Otitis Legionella Pneumonia Neisseria gonorrheae ; N. meningitidis STD; Meningitis Salmonella typhi Typhoid Shigella Dysentry Vibrio cholera Cholera Yersinia Plague Treponema pallidum Syphilis Pseudomonas Nosocomiel Infections(acquired at hospial ). Common Gram - ve Bacteria 13 February 2015 47 RABBE ZIDNI ILMA

48. THE END Best of Luck. To Confuse is the 1 st Step To Lose. Be Confident & Stay Jubilant. Keep Praying to ALLAH as HE only can change what is destined. 13 February 2015 48 RABBE ZIDNI ILMA