All drugs of abuse are contraindicated during lactation e.g. amphetamine, cocaine, heroin, phecyclidine and marijuana, accumulate in breast milk and cause irritability and poor sleep patterns.
• Antineoplastics: potential for immune suppression
• Bromocriptine: suppresses lactation
• Ergotamine: potential for suppressing lactation, vomiting, diarrhoea and convulsions
• Immunosuppressants: potential for immunosuppression
• Lithium: milk contains 40% of maternal serum concentration
• Misoprostol: produces severe diarrhoea in infants
• Nicotine (smoking): decreased milk production
• Phenindione:massive scrotal haematoma and wound oozing after herniotomy
Drugs requiring temporary cessation of breast-feeding
• Metronidazole: diarrhoea and secondary lactose intolerance.
• Radiopharmaceuticals:Stop breastfeeding temporarily to allow clearing from milk according to the chemical nature of the isotope.
• Quinolones: potential arthropathy in infants.
Wednesday, July 14, 2010
Drugs Contraindicated During Lactation
Reducing risk of Infant Exposure to Drugs in Breast Milk
A drug should be used only if medically necessary and treatment cannot be delayed until the infant is ready to be weaned.
Drug selection
• Consider whether the drug can be safely given directly to the infant
• Select the drug that passes poorly into breast milk with the lowest milk-to-plasma ratio
• Avoid long-acting formulations e.g. sustained release
• Determine length of therapy and if possible avoid long-term usage
Feeding pattern
• Avoid nursing during times of peak drug concentration
• If possible, plan breast-feeding before administration of the next dose
Other considerations
• Always observe the infant for unusual signs or symptoms e.g. sedation, irritability, rash, decreased appetite, failure to thrive
• Discontinue breastfeeding during the course of therapy if the risks to the fetus outweigh the benefit of nursing
• Provide adequate patient education to increase the understanding of risk factors.
Drug Excretion in Human milk
Breast milk is the optimal source of nutrition for infants. The risk to the infant depends on the amount of drug bioavailable to the mother, the amount reaching breast milk and the actual amount of drug ingested and bioavailable to the nursing infant.
Mechanism of transfer from blood to milk
The basic mechanisms are the same as those across other biologic membranes.
• Diffusion of low molecular weight substances through small water- filled pores
• Diffusion of lipid soluble compounds through lipid membranes
• Active transport carrier-mediated
Factors affecting drug excretion in breast milk
The drug dose, route and frequency of administration and metabolism are important factors in determining the amount of drug available for excretion into milk.
Maternal parameters
• Drug dosage and duration of therapy
• Route and frequency of administration
• Drug metabolism and renal clearance
• Blood flow to the breasts
• pH of milk
• Milk composition
Drug parameters
• Oral bioavailability (to mother and infant)
• Molecular weight
• Lipid solubility
• Protein binding
Infant parameters
• Infant age
• Feeding pattern
• Amount of breast milk consumed
• Drug absorption, distribution, metabolism and elimination
Proven Human Teratogens
Numerous drugs are associated with congenital malformation e.g. aminopterin/methotrexate, ACE-Inhibitors, antineoplastics, anti-thyroids, barbiturates, carbamazepine, cocaine, coumarin derivatives, diethylstilbesterol, ethanol (large dose), iodides, radioactive iodine, lithium, methadone, phenytoin, retinoid, vitamin A (>18,000 IU/day), tetracycline and valproic acid.
FDA categories (teratogenic risks of drugs):
Category A
Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester and the fetal harm appears remote.
Category B
Animal reproduction studies have not demonstrated a fetal risk, but there are no controlled studies in pregnant women. Or animal reproduction studies have shown an adverse effect that was not confirmed in controlled studies in women in the first trimester.
Category C
Studies in animals have revealed ad- verse effects on foetus and no controlled studies in women are available. Or, studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the foetus.
Category D
Evidence of human foetal risk is positive, but the benefits from use in pregnant women may be acceptable despite the risk.
Category X
Studies in animals or humans have demonstrated foetal anomalies or there is evidence of foetal risk based on human experience or both and the risk of the drug in pregnant women
clearly outweighs any possible benefits. The drug is contraindicated in women who are or may become pregnant.
Fetal Development and Drug Effects
Early in the embryonic period (conception to 56 days), during the preimplantation and presomite stage (0 to
14 days), exposure to a teratogenic agent usually produces an “all or none” effect on the ovum. The ovum either dies from a lethal dose of a teratogenic drug or it regenerates completely after exposure to a sub- lethal dose. During organogenesis, insult with the same teratogen may produce major morphologic changes.
Causes of malformation
These are classified into …
• Genetic defects: monogenic origin and chromosomal abnormalities (25%) e.g. Down syndrome.
• Interaction between hereditary tendencies and non-genetic environ- mental factors (20% of all defects) e.g. congenital hip dislocation
• Environmental factors: e.g. maternal infections, chemicals and drugs (10% of all defects). Only 2 viruses and a protozoan have been proven to induce malformation. Bacteria tend to release toxins that cause extensive tissue damage and fetal death rather than structural anomalies. The viruses are rubella (cataract, heart disease and deafness) and cytomegalovirus (CMV) infection (deafness, mental retardation, microcephaly, chorioretinitis, seizures, blindness and optic atrophy). The protozoan Toxoplasma gondii (hepatosplenomegaly, jaundice, rash, chorioretinitis, cerebral calcifications and hydrocephalus or microcephalus.
• Maternal infections account for 2% and maternal diseases e.g. diabetes and hyperthermia account for 1-2%.
• Unknown causes: account for 60-65% of cases.
Placental Transfer
Most medications cross the placenta to the foetus. During gestation, the surface area of the placenta increases, while the placental thickness decreases to 1/5 at term. Both processes tend to favour the transfer of chemicals to the fetus.
Mechanism of placental transfer
Drugs, nutrients and other substances cross the placenta by …
• Simple diffusion e.g. most drugs
• Facilitated diffusion e.g. glucose
• Active transfer e.g. vitamins, amino acids
• Pinocytosis e.g. immune antibodies
• Breaks between cells e.g. erythrocytes
The last two are of no practical importance in drugs transfer
Factors influencing rate of transfer
• Molecular weight
• Lipid solubility
• Uterine and umbilical blood flow(major factor)
• Maternal diseases e.g. hypertension, diabetes
Drugs in Pregnancy
Teratogenicity and Breast Feeding
The use of drugs during pregnancy and lactation is controversial and pre- sents great challenge to clinicians. The use of drugs during pregnancy is of special concern because of medi- cal, social, and legal implications. Congenital anomalies or birth defects are among the leading causes of infant morbidity and mortality.
Drugs in Pregnancy
Congenital malformation is defined as structural abnormalities of prenatal origin that are present at birth that seriously interfere with viability or physical well being.
Some drug induced defects relate to changes in functions or conditions that are not structural abnormalities e.g. mental or physical growth retardation, CNS depression, deafness, tumours or biochemical changes. Congenital anomalies i.e. birth defects, include both these toxicities and structural changes.
The prevalence of major malfor- mations is 3% and similar rate is dis- covered in months or years following birth. Anomalies of internal organs e.g. heart, kidneys, reproductive system and GIT may go unrecognized for years or discovered only at autopsy.
Minor malformations are not included in this percentage e.g. umbilical and inguinal hernias, phimosis, external ear, cryptorchidism, hydrocele, and
angiomas. The malformations of little medical significance are not included in incidence data even if they have emotional cosmetic effects. Approximately 6 newborn infants in every
100 will be with a major malformation, but only 3 of these will be identified at birth or in the neonatal period.
To these, one can add an unknown number of infants with mental and
physical growth retardation and those of minor structural anomalies.
Drug consumption during pregnancy
Many drugs are regularly consumed during gestation including some that are potential teratogens. Women consume an average of 5 to 9 medications. Vitamins and iron supplements are the most commonly used followed by anti-infective and analgesic antipyretic anti-inflammatory agents.
Friday, April 30, 2010
Pharmaceutical Care Extras
Pharmaceutical Care
Page 15
After the first paragraph
The practice, therefore didn't stop at practicing clinical pharmacy & in fact clinical pharmacy is single component in the practice
The term pharmaceutical care was introduced during 1990 to describe health care provided to the patient by the pharmacist at any practice sitting ( Hosp, community clinics)
The term pharmacy practice was introduced to described the describe the discipline of pharmacy that is responsible for developing the professional role of the pharmacist as health care provider
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Page 26
Mortality May be death if take drug by overdose
Morbidity May be death by small dose
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Page 27
The pharmacist is the best member of the health care team to see the patient
Only member of the team that is available for the patient to seek advices & information
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Page 46
Listening skills
God gave us one tongue & two ears so we could hear twice as much as we speak
Empathy = Active listening
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Page 49
Types of commu. Language
We communicate and build relationship through
Verbal language
Speech
Writing
Listening
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Page 51
Facial expression
Include
Your smile
Tilt your head ; eg if your head tilted to one side , it usually indicate you are interested in what some one is saying
Eye Contact
Lack of eye contact make you appear weak or not trustworthy
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Page 52
Body posture
Also your clothes and accessories what message are you sending if you are dressed casually at an important meeting
OTC DRUGS
Page 117
Dr abdel hamid said
ممكن نكون دوله متقدمة لو بقى عندنا ولو براند نيم واحد بدليل ان
Cimetidine
انقد انجلترا اقتصاديا والان كعلاج فى مزبلة ال
H2 Blockers
Page 121
Some drugs has two doses one for prescribing and other for non-prescribing
Innovator : the first brand produced for Generic Name
ADHERENCE
Page 128
Potent drug has :
Narrow therapeutic index
Wide individual variation clearance
In kidney transplantation if poor adherence with immunosuppressant lead to rejection or death so dose should be individualized acc. To patient
الأصرار على التفائل قد يصنع الذى كان مستحيلا
Tuesday, January 5, 2010
Heart Sounds and Murmers
article source
http://www.texasheart.org/education/cme/explore/events/eventdetail_5469.cfm
| Heart Sound and Murmur Recordings This collection of mp3 recordings is available for personal use to listen to online or download onto a personal player device. Use headphones for best audio quality. All materials copyright Texas Heart Institute. Inquiries for commercial use may be directed to the webmaster. | |
| Heart Sounds | Heart Murmurs |
| Physiologic Split S2 (normal) | Mitral Regurgitation Case1a Mitral Regurgitation Case1b Mitral Regurgitation Case1c Mitral Regurgitation Case2 Mitral Regurgitation Case3 Mitral Stenosis Case1 Mitral Stenosis Case2 |
Interpreting ECG
An ECG is printed on paper covered with a grid of squares. Notice that five small squares on the paper form a larger square. The width of a single small square on ECG paper represents 0.04 seconds. To successfully interpret ECGs, you must have this value committed to memory. Do this now. If each small square represents 0.04 seconds, then a second will be 25 small squares across. If you print out a minute's worth of your heart's electrical activity, the paper would be 1500 small squares wide. If something on an ECG is, let's say, 12 small squares in width, that means that it lasted 12 x 0.04, or almost half a second. A common length of an ECG printout is 6 seconds; this is known as a "six second strip."
 | The first little hump is known as the P wave. It occurs when the atria depolarize (i.e. trigger). The next three waves constitute the QRS complex. They represent the ventricles depolarizing. These three are lumped together because a normal rhythm may not have all three. Many times, you'll only see a R and an S. This is not abnormal. If there are less than three, how do we know which one is which? Well, the R wave is the first wave ABOVE the isoelectric line. You then name the waves in relation to the R wave. If it falls before the R wave, it is called the Q wave; after the R wave is the S wave. |
ANALYZE ECG's
Each one of the figures represents an ECG pattern displaying three types of abnormal rhythms: Tachycardia, Bradycardia, and Arrhymthmia. Identify each.
