Archive Monthly Archives: December 2017

Female sex hormones

Oestrogens and HRT

Oestrogens are necessary for the development of female secondary sexual characteristics; they also stimulate myometrial hypertrophy with endometrial hyperplasia. In terms of oestrogenic activity natural oestrogens (estradiol (oestradiol), estrone (oestrone), and estriol (oestriol)) have a more appropriate profile for hormone replacement therapy (HRT) than synthetic oestrogens (ethinylestradiol (ethinyloestradiol) and mestranol). Tibolone has oestrogenic, progestogenic and weak androgenic activity.

ESTRADIOL-DYDROGESTERONS:

Indications: Menopausal symptoms and osteoporosis prophylaxis.

Contraindications: pregnancy; oestrogen-dependent cancer, history of breast cancer, active thrombophlebitis, active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction), venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment), liver disease (where liver function tests have failed to return to normal), Dubin-Johnson and Rotor syndromes (or monitor closely), untreated endometrial hyperplasia, undiagnosed vaginal bleeding, breast-feeding.

Dose and Administration: Menopausal symptoms and osteoporosis prophylaxis, in women with a uterus, 1 red tablet daily for 14 days, starting within 5 days of onset of menstruation (or any time if cycles have ceased or are infrequent) then 1 yellow tablet daily for 14 days; subsequent courses repeated without interval; where therapy required for menopausal symptoms alone.

 

ESTRADIOL VALERATE-NORGETREL:

Indications: Menopausal symptoms and osteoporosis prophylaxis.

Contraindications: pregnancy; oestrogen-dependent cancer, history of breast cancer, active thrombophlebitis, active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction), venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment), liver disease (where liver function tests have failed to return to normal), Dubin-Johnson and Rotor syndromes (or monitor closely), untreated endometrial hyperplasia, undiagnosed vaginal bleeding, breast-feeding.

Dose and Administration: Menopausal symptoms and osteoporosis prophylaxis, in women with a uterus, 1 white tablet daily for 11 days, starting on day 5 of menstruation (or at any time if cycles have ceased or are infrequent), then 1 brown tablet daily for 10 days, followed by a 7-day tablet-free interval

 

CONJUGATED OESTROGENS:

Indications: Menopausal symptoms and osteoporosis prophylaxis.

Contraindications: pregnancy; oestrogen-dependent cancer, history of breast cancer, active thrombophlebitis, active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction), venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment), liver disease (where liver function tests have failed to return to normal), Dubin-Johnson and Rotor syndromes (or monitor closely), untreated endometrial hyperplasia, undiagnosed vaginal bleeding, breast-feeding

Dose and Administration: Menopausal symptoms, 0.3–1.25 mg daily continuously; osteoporosis prophylaxis, 0.625–1.25 mg daily continuously; with cyclical progestogen for 12–14 days of each cycle in women with a uterus

 

ESTRADIOL:

Indications: Menopausal symptoms and osteoporosis prophylaxis.

Contraindications: pregnancy; oestrogen-dependent cancer, history of breast cancer, active thrombophlebitis, active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction), venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment), liver disease (where liver function tests have failed to return to normal), Dubin-Johnson and Rotor syndromes (or monitor closely), untreated endometrial hyperplasia, undiagnosed vaginal bleeding, breast-feeding

Dose and Administration: Menopausal symptoms (and osteoporosis prophylaxis, 1 patch to be applied twice weekly continuously, with cyclical progestogen for 12 days of each cycle in women with a uterus; therapy should be initiated with TTS 50 for first month, subsequently adjusted to lowest effective dose. Oral 1–2 mg daily continuously; osteoporosis prophylaxis, 2 mg daily continuously; with cyclical progestogen for 12 days of each cycle in women with a uterus.

TIBOLONE:

Indications: short-term treatment of symptoms of oestrogen deficiency (including women being treated with gonadotrophin releasing hormone analogues); osteoporosis prophylaxis in women at risk of fractures (second-line). Contraindications: hormone-dependent tumours, history of cardiovascular or cerebrovascular disease (e.g. thrombophlebitis, thromboembolism), uninvestigated vaginal bleeding, severe liver disease, pregnancy, breast-feeding. Dose and Administration: 2.5 mg daily. Unsuitable for use in the premenopause (unless being treated with gonadotrophin-releasing hormone analogue) and as (or with) an oral contraceptive; also unsuitable for use within 12 months of last menstrual period (may cause irregular bleeding); induce withdrawal bleed with progestogen if transferring from another form of HRT.

RALOXIFENE HYDROCHLORIDE:

Indications: treatment and prevention of postmenopausal osteoporosis.

Contraindications: history of venous thromboembolism, undiagnosed uterine bleeding, endometrial cancer, hepatic impairment, cholestasis, severe renal impairment; pregnancy and breast-feeding.

Dose and Administration: 60 mg once daily.

 

Progestogens

DYDROGESTERONE:

Indications: Endometriosis, Infertility, irregular cycles, Recurrent miscarriage, Dysfunctional uterine bleeding, Dysmenorrhoea, Amenorrhoea, Premenstrual syndrome, Hormone replacement therapy, with continuous oestrogen therapy.

Contraindications: Progestogens should be avoided in patients with a history of liver tumours, and in severe liver impairment. They are also contra-indicated in those with genital or breast cancer (unless progestogens are being used in the management of these conditions), severe arterial disease, undiagnosed vaginal bleeding and porphyria. Progestogens should not be used if there is a history during pregnancy of idiopathic jaundice, severe pruritus, or pemphigoid gestationis.

Dose and Administration: Endometriosis, 10 mg 2–3 times daily from day 5 to 25 of cycle or continuously. Infertility, irregular cycles, 10 mg twice daily from day 11 to 25 for at least 6 cycles. Recurrent miscarriage, 10 mg twice daily from day 11 to 25 of cycle until conception, then continuously until week 20 of pregnancy and then gradually reduced. Dysfunctional uterine bleeding, 10 mg twice daily (together with an oestrogen) for 5–7 days to arrest bleeding; 10 mg twice daily (together with an oestrogen) from day 11 to 25 of cycle to prevent bleeding. Dysmenorrhoea, 10 mg twice daily from day 5 to 25 of cycle. Amenorrhoea, 10 mg twice daily from day 11 to 25 of cycle with oestrogen therapy from day 1 to 25 of cycle. Premenstrual syndrome, 10 mg twice daily from day 12 to 26 of cycle increased if necessary.

 

MEDROXYPROGESTERONE ACETATE:

Indications: Abnormal Uterine Bleeding due to Hormonal Imbalance, Endometrial Hyperplasia Prevention, Secondary Amenorrhea, Endogenous Estrogen Production Test, Polycystic Ovarian Syndrome, Post-Menopausal Symptoms.

Contraindications: Breast Carcinoma, Cerebrovascular Hemorrhage, Metrorrhagia, Pregnancy, Severe Hepatic Disease, Thromboembolic Disorder, and Thrombophlebitis.

Dose and Administration: By mouth, 2.5–10 mg daily for 5–10 days beginning on day 16 to 21 of cycle, repeated for 2 cycles in dysfunctional uterine bleeding and 3 cycles in secondary amenorrhoea. Mild to moderate endometriosis, 10 mg 3 times daily for 90 consecutive days, beginning on day 1 of cycle. Progestogenic opposition of oestrogen HRT, 10 mg daily for the last 14 days of each 28-day oestrogen HRT cycle.

HYDROXYPROGETRONE CAPROATE:

Indications: Habitual abortion, Threatened abortion, Infertility due to corpus luteum insufficiency and Primary & secondary amenorrhea.

Contraindications: History of herpes of pregnancy, previous or existing liver tumours.

Dose and Administration: Habitual abortion 250-500 mg IM wkly during the initial mths of pregnancy. Threatened abortion 500 mg 2-3 times wkly until bleeding ceases. Continue treatment w/ 250 mg IM twice wkly until bleeding stops despite mobilisation. Infertility due to corpus luteum insufficiency 250 mg IM about 3 days after the rise in basal body temp. Primary & secondary amenorrhea 1st day.

 

NORETHISTERONE:

Indications: Endometriosis, Dysfunctional uterine bleeding, menorrhagia, Dysmenorrhoea, Premenstrual syndrome and Postponement of menstruation.

Contraindications: Progestogens should be avoided in patients with a history of liver tumours, and in severe liver impairment. They are also contra-indicated in those with genital or breast cancer, undiagnosed vaginal bleeding and porphyria, Progestogens should not be used if there is a history during pregnancy of idiopathic jaundice, severe pruritus, or pemphigoid gestationis.

Dose and Administration: Endometriosis, by mouth, 10–15 mg daily for 4–6 months or longer, starts on day 5 of cycle. Dysfunctional uterine bleeding, menorrhagia, by mouth, 5 mg 3 times daily for 10 days to arrest bleeding; to prevent bleeding 5 mg twice daily from day 19 to 26. Dysmenorrhoea, by mouth, 5 mg 3 times daily from day 5 to 24 for 3–4 cycles. Premenstrual syndrome, by mouth, 5 mg 2–3 times daily from day 19 to 26 for several cycles. Postponement of menstruation, by mouth, 5 mg 3 times daily starting 3 days before expected onset.

 

PROGESTERONE:

Indications: infertility due to inadequate luteal phase, premenstrual syndrome and post-natal depression, dysfunctional uterine bleeding, recurrent miscarriage due to inadequate luteal phase.

Contraindications: Breast Carcinoma, Cerebrovascular Hemorrhage, Metrorrhagia, Pregnancy, Severe Hepatic Disease, Thromboembolic Disorder, and Thrombophlebitis.

Dose and Administration: By vagina (Crinone), infertility due to inadequate luteal phase, insert 1 applicatorful daily starting either after documented ovulation or on day 18–21 of cycle. In vitro fertilisation, daily application continued for 30 days after laboratory evidence of pregnancy.

By vagina or rectum (cyclogest), premenstrual syndrome and post-natal depression, 200 mg daily to 400 mg twice daily; for premenstrual syndrome start on day 12–14 and continue until onset of menstruation, rectally if barrier methods of contraception are used, in patients who have recently given birth or in those who suffer from vaginal infection or recurrent cystitis.

By deep intramuscular injection(Gestone) into buttock, dysfunctional uterine bleeding, 5–10 mg daily for 5–10 days until 2 days before expected onset of menstruation. Recurrent miscarriage due to inadequate luteal phase or following in vitro fertilisation or gamete intra-fallopian transfer, 25–100 mg 2–7 times a week from day 15, or day of embryo or gamete transfer, until 8–16 weeks of pregnancy; max. 200 mg daily.

Downloading and installing the ExQuilla addon – ExQuilla

Current ExQuilla releases

You may download the current revision of ExQuilla from this links.

http://mesquilla.net/exquilla-currentrelease.xpi

To install, download and save this file. Then from Thunderbird, open Tools/Add-ons, click on the Addon tools button  AddonActionsIcon.png and select “Install Add-on From File”. Install the downloaded file, then restart Thunderbird.

Alternatively, just go to the addons manager in Thunderbird, search for ExQuilla, and install it from there.

 

If you are having trouble, make sure that you know the correct internet address to open a web page to see your email, for example “https://yourcompany.com/owa”  Replace the “owa” with “EWS/Exchange.asmx” and enter that as the Exchange URL. So for this example, the Microsoft Exchange URL would be:

https://yourcompany.com/EWS/Exchange.asmx

 

 

Source: Downloading and installing the ExQuilla addon – ExQuilla

EXCEL – Measuring maximums, minimums, and quartiles

To get the minimum value (lowest value of the list)

=min(range)

To get the max value (which would be the biggest value of the list)

=max(range)

To get the values that are in the 25% place

This is called the first quartile value so we can

=quartile(range,1)

To get the values that are in the 50% place

This would be the 2nd quartile and to get it we can use

=quartile(range,2) this would also be the median

To get the values that are in the 75% place

=quartile(range,3)

 

 

 

Calculating mean and median and mode values

To have the average of a certain data you can use the following

=average(range)

This will give you the average data in the range.

To get the median which is the value exactly in the middle.
=median(range)
If the values are even number, then the median would be the average of the 2 values in the middle.

To get the mode; which is the most common value in the range.
=mode(range)

To get multiple most common values
=mode.mult(range) you can use after typing this formula what is called an array function using ctrl+shift+enter … this would be after selecting 2 cells.

 

 

Corticosteroides

Replacement therapy

The adrenal cortex normally secretes hydrocortisone (cortisol) which has glucocorticoid activity and weak mineralocorticoid activity. It also secretes the mineralocorticoid aldosterone. In deficiency states, physiological replacement is best achieved with a combination of hydrocortisone and the mineralocorticoid fludrocortisone; hydrocortisone alone does not usually provide sufficient mineralocorticoid activity for complete replacement.

 

FLUDROCORTISONE ACETATE:

Indications: mineralocorticoid replacement in adrenocortical insufficiency. Adrenogenital Disorder, Primary Adrenocortical Insufficiency, Symptomatic Orthostatic Hypotension.

Contraindications: Chronic Heart Failure, Acute Tuberculosis, Cataracts, Diabetes Mellitus, Disease of Liver, Epilepsy, Glaucoma, Hypercortisolism, Hypertension, Hypokalemia, Hypothyroidism, Inactive Tuberculosis, Myasthenia Gravis, Osteoporosis, Peptic Ulcer, Peripheral Edema, Renal Disease.

Dose and Administration: 50–300 micrograms daily; child 5 micrograms/kg daily.

 

Glucocorticoid therapy

 

BETAMETHASONE:

Indications: suppression of inflammatory and allergic disorders; congenital adrenal hyperplasia. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Congenital Adrenal Hyperplasia, Congenital Hypoplastic Anemia, Contact Dermatitis, Crohn’s Disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, usual range 0.5–5 mg daily.

 

BETAMETHASONE DIPROPIONATE & SODIUM PHOSPHATE:  Indications: suppression of inflammatory and allergic disorders; congenital adrenal hyperplasia. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Congenital Adrenal Hyperplasia, Congenital Hypoplastic Anemia, Contact Dermatitis, Crohn’s Disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: dosing must be individualized on the basis of the specific disease.

 

DEXAMETHASONE:

Indications: suppression of inflammatory and allergic disorders; diagnosis of Cushing’s disease, congenital adrenal hyperplasia; cerebral oedema associated with malignancy; croup; nausea and vomiting with chemotherapy; rheumatic disease

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, usual range 0.5–10 mg daily; child 10– 100 micrograms/kg daily, By intramuscular injection or slow intravenous injection or infusion (as dexamethasone phosphate), initially 0.5–24 mg; child 200– 400 micrograms/kg daily, Cerebral oedema associated with malignancy (as

dexamethasone phosphate), by intravenous injection, 10 mg initially, then 4 mg by intramuscular injection every 6 hours as required for 2–4 days then gradually reduced and stopped over 5–7 days.

 

HYDROCORTISONE:

Indications: adrenocortical insufficiency; shock; hypersensitivity reactions e.g. anaphylactic shock and angioedema; asthma; severe inflammatory bowel disease; haemorrhoids; rheumatic disease

Contraindications: Fungal Infections, Cataracts, Chronic Heart Failure, Duodenal Ulcer, Esophagitis, Gastric Ulcer, Inactive Tuberculosis, Infection, Intestinal Abscess, Intestinal Anastomosis, Measles, Measles Contact, Ocular Infection, Osteoporosis, Peptic Ulcer, Psychotic Disorder, Renal Disease, Varicella Contact, Viral Ocular Infection.

Dose and Administration: By mouth, replacement therapy, 20–30 mg daily in divided doses; child 10–30 mg. By intramuscular injection or slow intravenous injection or infusion, 100–500 mg, 3–4 times in 24 hours or as required; child by slow intravenous injection up to 1 year 25 mg, 1–5 years 50 mg, 6–12 years 100 mg.

 

METHYLPREDNISOLONE SODIUM SUCCINATE:

Indications: suppression of inflammatory and allergic disorders; severe inflammatory bowel disease; cerebral oedema associated with malignancy; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By intramuscular injection or slow intravenous injection or infusion, initially 10–500 mg; graft rejection, up to 1 g daily by

intravenous infusion for up to 3 days.

 

METHYLPREDNISOLONE ACETATE:

Indications: suppression of inflammatory and allergic disorders; severe inflammatory bowel disease; cerebral oedema associated with malignancy; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By deep intramuscular injection into gluteal muscle, 40–120 mg, a second injection may be given after 2–3 weeks if required.

 

PREDNISOLONE:

Indications: suppression of inflammatory and allergic disorders; see also notes above; inflammatory bowel disease; asthma, and; immunosuppression; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, initially, up to 10–20 mg daily (severe disease, up to 60 mg daily), preferably taken in the morning after breakfast; can often be reduced within a few days but may need to be continued for several weeks or months. Maintenance, usual range, 2.5–15 mg daily, but higher doses may be needed; cushingoid side-effects increasingly likely with doses above 7.5 mg daily.

 

TRIAMCINOLONE:

Indications: suppression of inflammatory and allergic disorders and rheumatic disease. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Alopecia Areata, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Cerebral Edema, Contact Dermatitis, Crohn’s Disease, Cystic Aponeurosis Tumor, Dermatitis Herpetiformis.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By deep intramuscular injection, into gluteal muscle, 40 mg of acetonide for depot effect, repeated at intervals according to the patient’s response; max. single dose 100 mg.

 

Thyroid and antithyroid drugs

Thyroid hormones

Thyroid hormones are used in hypothyroidism (myxoedema), and also in diffuse non-toxic goitre, Hashimoto’s thyroiditis (lymphadenoid goitre), and thyroid carcinoma. Neonatal hypothyroidism requires prompt treatment for normal development. Levothyroxine sodium (thyroxine sodium) is the treatment of choice for maintenance therapy. In infants and children with congenital hypothyroidism and juvenile myxoedema, the dose of levothyroxine should be titrated according to clinical response, growth assessment, and measurements of plasma thyroxine and thyroid-stimulating hormone.

 

LEVOTHYROXINE SODIUM (Thyroxine sodium):

Indications: Congenital Hypothyroidism, Goiter, Hashimoto Thyroiditis, Hypothyroidism, Myxedema, and Thyroid Carcinoma.

Contraindications: Myocardial Infarction, Primary Adrenocortical Insufficiency, Thyrotoxicosis Crisis, Hyperthyroidism, And Pituitary Insufficiency.

Dose and Administration: adult, initially 50–100 micrograms once daily, preferably before breakfast, adjusted in steps of 25–50 micrograms every 3–4 weeks according to response (usual maintenance dose 100–200 micrograms once daily); in cardiac disease, severe hypothyroidism, and patients over 50 years, initially 25 micrograms once daily, adjusted in steps of 25 micrograms every 4 weeks according to response; usual maintenance dose 50–200 micrograms once daily.

 

Antithyroid drugs

Antithyroid drugs are used for hyperthyroidism either to prepare patients for thyroidectomy or for long-term management. Iodine has been used as an adjunct to antithyroid drugs for 10 to 14 days before partial thyroidectomy; however, there is little evidence of a beneficial effect. Iodine should not be used for long-term treatment because its antithyroid action tends. Propranolol is useful for rapid relief of thyrotoxic symptoms and may be used in conjunction with

antithyroid drugs or as an adjunct to radioactive iodine. Beta-blockers are also useful in neonatal thyrotoxicosis and in supraventricular arrhythmias due to hyperthyroidism. Propranolol has been used in conjunction with iodine to prepare mildly thyrotoxic patients for surgery but it is preferable to make the patient euthyroid with carbimazole.

 

CARBIMAZOLE:

Indications: hyperthyroidism either to prepare patients for thyroidectomy or for long-term management.

Contraindications: in patients with a previous history of adverse reactions.

Dose and Administration: the initial dose is in the range 20-60mg taken as two to three divided doses. Maintenance regimen the dose is gradually reduced.

 

PROPYLTHIOURACIL:

Indications: Hyperthyroidism, Thyrotoxicosis Crisis.

Contraindications: Agranulocytosis, Drug-Induced Hepatitis, Interstitial

Pneumonitis, Lactating Mother, Pancytopenia, and Pregnancy.

Dose and Administration: 50 mg by oral route 2 times per day.

Drugs Used in Diabetes

Diabetes mellitus occurs because of a lack of insulin or resistance to its action. It is diagnosed by measuring fasting or random blood-glucose concentration (and occasionally by glucose tolerance test). Although there are many subtypes, the two principal classes of diabetes are type 1 diabetes and type 2 diabetes. Type 1 diabetes, also referred to as insulin-dependent diabetes mellitus (IDDM), occurs as a result of a deficiency of insulin following autoimmune destruction of pancreatic beta cells. Patients with type 1 diabetes require administration of insulin. Type 2 diabetes, also referred to as non-insulin-dependent diabetes (NIDDM), is due either to reduced secretion of insulin or to peripheral resistance to the action of insulin. Although patients may be controlled on diet alone, many also require oral antidiabetic drugs or insulin (or both) to maintain satisfactory control.

 

Insulins

The aim of treatment is to achieve the best possible control of blood-glucose concentration without making the patient obsessional and to avoid disabling hypoglycaemia; close co-operation is needed between the patient and the medical team because good control reduces the risk of complications. Mixtures of insulin preparations may be required and appropriate combinations have to be determined for the individual patient. Insulin preparations can be divided into 3 types:

  • those of short duration which have a relatively rapid onset of action, namely soluble insulin, insulin lispro and insulin aspart.
  • those with an intermediate action, e.g. isophane insulin and insulin zinc suspension.
  • those whose action is slower in onset and lasts for long periods, e.g. insulin zinc suspension.

During pregnancy and breast-feeding, insulin requirements may alter and doses should be assessed frequently by an experienced diabetes physician. The dose of insulin generally needs to be increased in the second and third trimesters of pregnancy. Hypoglycaemia is a potential problem with insulin therapy. All patients must be carefully instructed on how to avoid it.

 

Short-acting insulins

Soluble insulin is a short-acting form of insulin. For maintenance regimens it is usual to inject it 15 to 30 minutes before meals. Soluble insulin is the most appropriate form of insulin for use in diabetic emergencies e.g. diabetic ketoacidosis and at the time of surgery. It can be given intravenously and intramuscularly, as well as subcutaneously. Insulin aspart and insulin lispro can be administered intravenously and can be used as alternatives to soluble insulin for diabetic emergencies and at the time of surgery.

 

INSULIN (Insulin Injection; Neutral Insulin; Soluble Insulin):

Indications: diabetes mellitus; diabetic ketoacidosis.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous, intramuscular or intravenous injection or intravenous infusion, according to requirements.

 

INSULIN ASPART (Recombinant human insulin analogue): 

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, immediately before meals or when necessary shortly after meals, according to requirements.

 

INSULIN GLULISINE (Recombinant human insulin analogue): 

Indications: Diabetes Mellitus, Type 1 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, immediately before meals or when necessary shortly after meals, according to requirements. child and adolescent under 17 years not recommended.

 

INSULIN LISPRO (Recombinant human insulin analogue): 

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, immediately before meals or when necessary shortly after meals, according to requirements.

 

 

Intermediate- and long-acting insulins

When given by subcutaneous injection, intermediate- and long-acting insulins have an onset of action of approximately 1–2 hours, a maximal effect at 4–12 hours, and a duration of 16–35 hours. Some are given twice daily in conjunction with short-acting (soluble) insulin, and others are given once daily, particularly in elderly patients. Soluble insulin can be mixed with intermediate and long-acting insulins (except insulin detemir and insulin glargine) in the syringe, essentially retaining the properties of the two components.

 

INSULIN DETEMIR (Recomb. human insulin analogue —long acting): 

Indications: Diabetes Mellitus, Type 1 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, adult and child over 6 years, according to requirements.

 

INSULIN GLARGIN (Recomb. human insulin analogue —long acting): 

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, adult and child over 6 years, according to requirements. It is not recommended for routine use in patients with type 2 diabetes unless they suffer from recurrent episodes of hypoglycemia or require assistance with their insulin injections.

 

ISOPHANE INSULIN (Isophane Insulin Injection; Isophane Protamine  Insulin Injection; Isophane Insulin (NPH)—intermediate acting): 

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, according to requirements.

 

BIPHASIC INSULIN ASPART (Intermediate-acting insulin):

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus, Type 2

Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, up to 10 minutes before

or soon after a meal, according to requirements

 

BIPHASIC ISOPHANE INSULIN (Biphasic Isophane Insulin Injection—  intermediate acting):

Indications: Diabetes Mellitus, Hyperglycemia, Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus.

Contraindications: Hypoglycemic Disorder.

Dose and Administration: By subcutaneous injection, according to requirements.

 

Antidiabetic drugs

Oral antidiabetic drugs are used for the treatment of type 2 (non-insulin­dependent) diabetes mellitus. They should be prescribed only if the patient fails to respond adequately to at least 3 months’ restriction of energy and carbohydrate intake and an increase in physical activity. They should be used to augment the effect of diet and exercise, and not to replace them. For patients not adequately controlled by diet and oral hypoglycaemic drugs, insulin may be added to the treatment regimen or substituted for oral therapy. When insulin is added to oral therapy, it is generally given at bedtime as isophane insulin, and when insulin replaces an oral regimen it is generally given as twice-daily injections of a biphasic insulin (or isophane insulin mixed with soluble insulin). Weight gain and hypoglycaemia may be complications of insulin therapy but weight gain may be reduced if the insulin is given in combination with metformin.

 

Sulphonylureas

The sulphonylureas act mainly by augmenting insulin secretion and consequently are effective only when some residual pancreatic beta-cell activity is present; during long-term administration they also have an extrapancreatic action. All may cause hypoglycaemia but this is uncommon and usually indicates excessive dosage. Sulphonylurea-induced hypoglycaemia may persist for many hours and must always be treated in hospital. Sulphonylureas are considered for patients who are not overweight, or in whom metformin is contra-indicated or not tolerated.

 

GLIBENCLAMIDE:

Indications: type 2 diabetes mellitus.

Contraindications: Ketoacidosis, Severe Renal Disease, Debilitation, Hepatic Porphyria, High Fever >101 Degree, Hypoglycemic Disorder, Severe Hepatic Disease, Severe Infection, Surgical Procedure, Trauma.

Dose and Administration: Initially 5 mg daily with or immediately after breakfast, dose adjusted according to response; max. 15 mg daily.

 

GLICLAZIDE:

Indications: type 2 diabetes mellitus.

Contraindications: severe hepatic impairment and in severe renal impairment and in porphyria. They should not be used while breast-feeding, and insulin therapy should be substituted during pregnancy. Sulphonylureas are contra­indicated in the presence of ketoacidosis.

Dose and Administration: Initially, 40–80 mg daily, adjusted according to response; up to 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. For the modified release Dose Initially 30 mg daily with breakfast, adjusted according to response every 4 weeks (after 2 weeks if no decrease in blood glucose); max. 120 mg daily.

 

GLIMEPIRIDE:

Indications: type 2 diabetes mellitus.

Contraindications: severe hepatic impairment and in severe renal impairment and in porphyria. They should not be used while breast-feeding, and insulin therapy should be substituted during pregnancy. Sulphonylureas are contra­indicated in the presence of ketoacidosis.

Dose and Administration: Initially 1 mg daily, adjusted according to response in 1-mg steps at 1–2 week intervals; usual max. 4 mg daily (exceptionally, up to 6 mg daily may be used); taken shortly before or with first main meal.

 

GLIPIZIDE:

Indications: type 2 diabetes mellitus.

Contraindications: severe hepatic impairment and in severe renal impairment and in porphyria. They should not be used while breast-feeding, and insulin therapy should be substituted during pregnancy. Sulphonylureas are contra­indicated in the presence of ketoacidosis.

Dose and Administration: Initially 2.5–5 mg daily shortly before breakfast or lunch, adjusted according to response; max. 20 mg daily; up to 15 mg may be given as a single dose; higher doses divided.

 

Biguanides

Metformin, the only available biguanide, It exerts its effect mainly by decreasing gluconeogenesis and by increasing peripheral utilisation of glucose; since it acts only in the presence of endogenous insulin it is effective only if there are some residual functioning pancreatic islet cells. Metformin is the drug of first choice in overweight patients in whom strict dieting has failed to control diabetes, if appropriate it may also be considered as an option in patients who are not overweight. It is also used when diabetes is inadequately controlled with sulphonylurea treatment.

 

METFORMIN HYDROCHLORIDE:

Indications: diabetes mellitus and polycystic ovary syndrome.

Contraindications: renal impairment, ketoacidosis, withdraw if tissue hypoxia likely (e.g. sepsis, respiratory failure, recent myocardial infarction, hepatic impairment), use of iodine-containing X-ray contrast media (do not restart metformin until renal function returns to normal) and use of general anaesthesia (suspend metformin on the morning of surgery and restart when renal function returns to normal), pregnancy and breast-feeding.

Dose and Administration: Diabetes mellitus, adult and child over 10 years initially 500 mg with breakfast for at least 1 week then 500 mg with breakfast and evening meal for at least 1 week then 500 mg with breakfast, lunch and evening meal; usual max. 2 g daily in divided doses.

 

METFORMIN HYDROCHLORIDE- GLIBENCLAMIDE:

Indications: diabetes mellitus type 2 in adults and as replacment for previous treatment with metformin and glibenclamide in patients whose glycaemia is stable and well controlled.

Contraindications: renal impairment, ketoacidosis, withdraw if tissue hypoxia likely (e.g. sepsis, respiratory failure, recent myocardial infarction, hepatic impairment), use of iodine-containing X-ray contrast media (do not restart metformin until renal function returns to normal) and use of general anaesthesia (suspend metformin on the morning of surgery and restart when renal function returns to normal), pregnancy and breast-feeding.

Dose and Administration: the starting dose should not exceed the daily dose of glibenclamide and metformin already being taken. The daily dose may be titrated every two weeks to the minimum effective dose.

 

Other antidiabetics

 

ACARBOSE:

Indications: diabetes mellitus inadequately controlled by diet or by diet with oral antidiabetic drugs.

Contraindications: inflammatory bowel disease, predisposition to partial intestinal obstruction; hernia, previous abdominal surgery; hepatic impairment; renal impairment; pregnancy; breast-feeding.

Dose and Administration: Initially 50 mg daily increased to 50 mg 3 times daily, then increased if necessary after 6–8 weeks to 100 mg 3 times daily; max. 200 mg 3 times daily; child and adolescent under 18 years not recommended.

 

REPAGLINIDE:

Indications: type 2 diabetes mellitus (as monotherapy or in combination with metformin when metformin alone inadequate).

Contraindications: ketoacidosis; severe hepatic impairment; pregnancy and breast-feeding.

 

Dose and Administration: Initially 500 micrograms within 30 minutes before main meals (1 mg if transferring from another oral hypoglycaemic), adjusted according to response at intervals of 1–2 weeks; up to 4 mg may be given as a single dose, max. 16 mg daily; child and adolescent under 18 years and elderly over 75 years, not recommended.

 

PIOGLITAZONE:

Indications: type 2 diabetes mellitus (alone or combined with metformin or a

sulphonylurea, or with both).

Contraindications: hepatic impairment, history of heart failure, pregnancy,

breast-feeding.

Dose and Administration: Initially 15–30 mg once daily increased to 45 mg

once daily according to response.

 

ROSIGLITAZONE:

Indications: type 2 diabetes mellitus (alone or combined with metformin or a sulphonylurea, or with both).

Contraindications: hepatic impairment, history of heart failure, pregnancy, breast-feeding.

Dose and Administration: Initially 4 mg daily; may be increased after 8 weeks to 8 mg daily (in 1–2 divided doses) according to response; child and adolescent under 18 years not recommended.

 

ROSIGLITAZONE-METFORMIN:

Indications: type 2 diabetes mellitus.

Contraindications: hepatic impairment, history of heart failure, pregnancy, breast-feeding, Acutely Decompensated Chronic Heart Failure, Alcohol Intoxication, Alcoholism, Bacterial Septicemia, Cardiogenic Shock, Dehydration, Disease of Liver, Drug-Induced Hepatitis, Hypoxia, Ketoacidosis, Lactic Acidosis, Metabolic Acidosis, Myocardial Infarction, Radiography with IV Iodinated Contrast Agent, Renal Disease, Respiratory Depression, Severe Chronic Heart Failure, Shock, Surgical Procedure, Trauma.

Dose and Administration: Type 2 diabetes mellitus not controlled by metformin alone, initially one-tablet 2mg/500 mg twice daily increased after 8 weeks according to response, max. 8 mg rosiglitazone and 2 g metformin hydrochloride daily; child and adolescent under 18 years not recommended

 

ROSIGLITAZONE-GLIPIZIDE:

Indications: type 2 diabetes mellitus.

Contraindications: Acutely Decompensated Chronic Heart Failure, Drug-Induced Hepatitis, Lactating Mother, Severe Chronic Heart Failure, Angina, Body Fluid Retention, Chronic Heart Failure, Coronary Artery Disease, Disease of Liver, Edema, Hepatic Porphyria, Hypoglycemic Disorder, Myocardial Infarction, Myocardial Ischemia, Osteopenia, Osteoporosis, Pulmonary Edema, Type 1 Diabetes Mellitus.

Dose and Administration: therapy should be individualized for each patient and should be given once daily with the first meal of the day.

 

DPP-4 INHIBITORS

 

SITAGLIPTIN:

Indications: type 2 diabetes mellitus (in combination with metformin or a

thiazolidinedione, when metformin or thiazolidinedione is inadequate).

Contraindications: ketoacidosis; pregnancy and breast-feeding.

Dose and Administration: adult over 18 years, 100 mg once daily.

 

VILDAGLIPTIN:

Indications: type 2 diabetes mellitus (in combination with metformin or a thiazolidinedione, when metformin or thiazolidinedione is inadequate).

Contraindications: Hypersensitivity to the active substance or to any of the excipients.

Dose and Administration: When used in dual combination with metformin or a thiazolidinedione, the recommended daily dose of vildagliptin is 100mg, administered as one dose of 50 mg in the morning and one dose of 50 mg in the evening. Doses higher than 100mg are not recommended.

 

 

Treatment of hypoglycaemia

Hypoglycaemia which causes unconsciousness is an emergency. Glucagon, a polypeptide hormone produced by the alpha cells of the islets of Langerhans, increases plasma-glucose concentration by mobilising glycogen stored in the liver. In hypoglycaemia, if sugar cannot be given by mouth, glucagon can be given by injection. Carbohydrates should be given as soon as possible to restore liver glycogen; glucagon is not appropriate for chronic hypoglycaemia.

 

GLUCAGON:

Indications: Hypoglycemic Disorder.

Contraindications: Diabetes Mellitus, Glucagonoma, Insulinoma, and Pheochromocytoma.

Dose and Administration: Insulin-induced hypoglycaemia, by subcutaneous, intramuscular, or intravenous injection, adult and child over 8 years (or body-weight over 25 kg), 1 mg; child under 8 years (or body-weight under 25 kg), 500 micrograms; if no response within 10 minutes intravenous glucose must be given.

 

Antifungal Drugs

 

AMPHOTERICIN (Amphotericin B):

Indications: Aspergillosis, Blastomycosis, Candidal Endocarditis, Candidal Meningitis, Candidal Septicemia, Candida Peritonitis, Candidemia, Candidiasis, Coccidioidomycosis, Cryptococcal Septicemia, Cryptococcosis, Disseminated Candidiasis, Disseminated Sporotrichosis, Esophageal Candidiasis, Fungal Endocarditis, Fungal Infection of Lung, Fungal Meningitis, Fungal Septicemia, Fungal Urinary Tract Infection, Histoplasmosis, Infectious Disease of Abdomen, Leishmaniasis, Mucormycosis, Pulmonary Cryptococcosis, Rhinocerebral Phycomycosis.

Contraindications: Hypokalemia, Hypomagnesemia, Renal Disease.

Dose and Administration: By intravenous infusion, systemic fungal infections, initial test dose of 1 mg over 20–30 minutes then 250 micrograms/kg daily, gradually increased over 2–4 days, if tolerated, to 1 mg/kg daily; max. (severe infection) 1.5 mg/kg daily or on alternate days. Prolonged treatment usually necessary; if interrupted for longer than 7 days recommence at 250 micrograms/kg daily and increase gradually.

 

 

AMPHOTERICIN B LIPID COMPLEX:

Indications: Cryptococcosis, Disseminated Candidiasis, Mucormycosis, And Refractory Aspergillosis.

Contraindications: Hypokalemia, Hypomagnesemia, Renal Disease.

Dose and Administration: By intravenous infusion, severe invasive candidiasis; severe systemic fungal infections in patients not responding to conventional amphotericin or to other antifungal drugs or where toxicity or renal impairment precludes conventional amphotericin, including invasive aspergillosis, cryptococcal meningitis and disseminated cryptococcosis in HIV patients, adult and child, initial test dose 1 mg over 15 minutes then 5 mg/kg once daily for at least 14 days.

 

FLUCONAZOLE:

Indications: Candidal Urinary Tract Infection, Cryptococcal Meningitis, Disseminated Candidiasis, Esophageal Candidiasis, Mucocutaneous Candidiasis, Oral Candidiasis, Oropharyngeal Candidiasis, Prevention of Disseminated

Candidiasis,                                     Vulvovaginal                                   Candidiasis
Contraindications: Disease of Liver, Prolonged QT Interval, Renal Disease.

Dose and Administration: Vaginal candidiasis and candidal balanitis, by mouth, a single dose of 150 mg. Mucosal candidiasis (except genital), by mouth, 50 mg daily (100 mg daily in unusually difficult infections) given for 7–14 days in oropharyngeal candidiasis (max. 14 days except in severely immunocompromised patients); for 14 days in atrophic oral candidiasis associated with dentures; for 14–30 days in other mucosal infections (e.g. oesophagitis, candiduria, non­invasive bronchopulmonary infections); child by mouth or by intravenous infusion, 3–6 mg/kg on first day then 3 mg/kg daily (every 72 hours in neonate up to 2 weeks old, every 48 hours in neonate 2–4 weeks old). Prevention of fungal infections in immunocompromised patients, by mouth or by intravenous infusion, 50–400 mg daily adjusted according to risk; 400 mg daily if high risk of systemic infections e.g. following bone-marrow transplantation; commence treatment before anticipated onset of neutropenia and continue for 7 days after neutrophil count in desirable range; child according to extent and duration of neutropenia, 3–12 mg/kg daily (every 72 hours in neonate up to 2 weeks old, every 48 hours in neonate 2–4 weeks old); max. 400 mg daily.

 

ITRACONAZOLE:

Indications: Aspergillosis, Blastomycosis, Histoplasmosis, and Onychomycosis due to Dermatophyte.

Contraindications: Chronic Heart Failure, Congenital Long QT Syndrome, Heart Failure, Lactating Mother, Pregnancy, Presumed Infection in Febrile Neutropenic Patient, Torsades de Pointes, Ventricular Arrhythmias.

Dose and Administration: By mouth, oropharyngeal candidiasis, 100 mg once daily (200 mg once daily in AIDS or neutropenia) for 15 days. Vulvovaginal candidiasis, 200 mg twice daily for 1 day. Tinea corporis and tinea cruris, either 100 mg once daily for 15 days or 200 mg once daily for 7 days. Tinea pedis and tinea manuum, either 100 mg once daily for 30 days or 200 mg twice daily for 7 days. Onychomycosis, either 200 mg once daily for 3 months or course (‘pulse’) of 200 mg twice daily for 7 days, subsequent courses repeated after 21-day interval; fingernails 2 courses, toenails 3 courses. Histoplasmosis, 200 mg 1–2 times daily. Systemic aspergillosis, candidiasis and cryptococcosis including cryptococcal meningitis where other antifungal drugs inappropriate or ineffective, 200 mg once daily (candidiasis 100–200 mg once daily) increased in invasive or disseminated disease and in cryptococcal meningitis to 200 mg twice daily.

 

KETOCONAZOLE:

Indications: Blastomycosis, Chromomycosis, Coccidioidomycosis, Disseminated Candidiasis, Histoplasmosis, Oral Candidiasis, Paracoccidioidomycosis, Tinea Corporis, Tinea Cruris, Tinea Pedis, and Tinea Versicolor.

Contraindications: Achlorhydria, Congenital Long QT Syndrome, Disease of Liver, Prolonged QT Interval, Torsades de Pointes.

 

Dose and Administration: 200 mg once daily, increased if response inadequate to 400 mg once daily; continued until symptoms have cleared and cultures negative (usually for 4 weeks in dermatophytoses, 2–3 weeks for oral and cutaneous candidiasis, 1–2 months for hair infections); child body-weight 15–30 kg, 100 mg once daily; body-weight over 30 kg, adult dose. Chronic, recurrent vaginal candidiasis, 400 mg once daily for 5 days.

 

TERBINAFINE:

Indications: Fingernail Onychomycosis, Onychomycosis due to Dermatophyte, Tinea Capitis, Toenail Onychomycosis.

Contraindications: Disease of Liver, Lactating Mother, Alcoholism, Renal Disease, and Systemic Lupus Erythematosus.

Dose and Administration: By mouth, 250 mg daily usually for 2–6 weeks in tinea pedis, 2–4 weeks in tinea cruris, 4 weeks in tinea corporis, 6 weeks–3 months in nail infections. Child usually for 4 weeks, tinea capitis, over 1 year, body-weight 10–20 kg, 62.5 mg once daily; body-weight 20–40 kg, 125 mg once daily; body-weight over 40 kg, 250 mg once daily.

 

NYSTATIN:

Indications: Gastrointestinal Candidiasis, Mucocutaneous Candidiasis, And Oral Candidiasis.

Contraindications: Abdominal Pain with Cramps, Diarrhea, Nausea, and Vomiting.

Dose and Administration: By mouth, intestinal candidiasis 500 000 units every 6 hours, doubled in severe infection; neonate 100 000 units 4 times daily; child 1 month–12 years, 100 000 units 4 times daily; immunocompromised children may require higher doses.

 

Antiviral drugs

Antiviral drugs

The majority of virus infections resolve spontaneously in immunocompetent subjects. A number of specific treatments for viral infections are available, particularly for the immunocompromised.

Herpesvirus infections

The two most important herpesvirus pathogens are herpes simplex virus (herpesvirus hominis) and varicella–zoster virus.

ACICLOVIR:

Indications: Chickenpox, Herpes Genitalis, Herpes Labialis, Herpes Simplex Encephalitis, Herpes Simplex Infection, Herpes Zoster, Mucocutaneous Herpes Simplex, Recurrent Herpes Genitalis, Recurrent Mucocutaneous Herpes Simplex, Suppression of Recurrent Herpes Simplex Infection.

Contraindications: Dehydration, Renal Disease.

Dose and Administration: By mouth, herpes simplex, treatment, 200 mg (400 mg in the immunocompromised or if absorption impaired) 5 times daily, usually for 5 days (longer if new lesions appear during treatment or if healing incomplete; increase dose to 800 mg 5 times daily for genital herpes in the immunocompromised); child under 2 years, half adult dose, over 2 years, adult dose. Herpes simplex, prevention of recurrence, 200 mg 4 times daily or 400 mg twice daily possibly reduced to 200 mg 2 or 3 times daily and interrupted every 6–12 months. Herpes simplex, prophylaxis in the immunocompromised, 200– 400 mg 4 times daily; child under 2 years, half adult dose, over 2 years, adult dose. Varicella and herpes zoster, treatment, 800 mg 5 times daily for 7 days; child, varicella, 20 mg/kg (max. 800 mg) 4 times daily for 5 days or under 2 years 200 mg 4 times daily, 2–5 years 400 mg 4 times daily, over 6 years 800 mg 4 times daily.

 

FAMCICLOVIR:

Indications: Herpes Genitalis, Herpes Labialis, Herpes Zoster, Recurrent Herpes Genitalis, Recurrent Herpes Simplex, Recurrent Mucocutaneous Herpes Simplex in Human Immunodeficiency Virus Infected Patients, Suppression of Recurrent Herpes Simplex Infection.

Contraindications: Renal Disease

Dose and Administration: Herpes zoster, 250 mg 3 times daily for 7 days or 750 mg once daily for 7 days (in immunocompromised, 500 mg 3 times daily for 10 days). Genital herpes, first episode, 250 mg 3 times daily for 5 days (longer if new lesions appear during treatment or if healing incomplete); recurrent infection, 125 mg twice daily for 5 days (in immunocompromised, all episodes, 500 mg twice daily for 7 days). Genital herpes, suppression, 250 mg twice daily (in HIV patients, 500 mg twice daily) interrupted every 6–12 months. child not recommended.

 

VALACICLOVIR:

Indications: Chickenpox, Herpes Genitalis, Herpes Labialis, Herpes Zoster, Recurrent Herpes Genitalis, and Suppression of Recurrent Herpes Simplex Infection.

Contraindications: Bone Marrow Transplant, Renal Transplant.

Dose and Administration: Herpes zoster, 1 g 3 times daily for 7 days. Herpes simplex, first episode, 500 mg twice daily for 5 days (longer if new lesions appear during treatment or if healing incomplete); recurrent infection, 500 mg twice daily for 5 days. Herpes simplex, suppression, 500 mg daily in 1–2 divided doses. Reduction of transmission of genital herpes, seek specialist advice, 500 mg once daily to be taken by the infected partner. Prevention of cytomegalovirus disease following renal transplantation (preferably starting within 72 hours of transplantation), 2 g 4 times daily usually for 90 days. child not recommended.

 

Cytomegalovirus infection

GANCICLOVIR:

Indications: CMV (cytomegalovirus) Retinitis in AIDS Patients, CMV Retinitis in Immunocompromised Patients, and Prevention of CMV Disease After Organ Transplant.

Contraindications: Lactating Mother, Severe Neutropenic Disorder, Severe Thrombocytopenia, Neutropenic Disorder, Renal Disease, Severe Anemia, And Thrombocytopenic Disorder.

Dose and Administration: By intravenous infusion, initially (induction) 5 mg/kg every 12 hours for 14–21 days for treatment or for 7–14 days for prevention; maintenance (for patients at risk of relapse of retinitis) 6 mg/kg daily on 5 days per week or 5 mg/kg daily until adequate recovery of immunity; if retinitis progresses initial induction treatment may be repeated.

 

VALGANCICLOVIR:

Indications: CMV Retinitis in AIDS Patients, Prevention of CMV Disease After Cardiac Transplantation, Prevention of CMV Disease After Kidney-Pancreas Transplantation, Prevention of CMV Disease After Kidney Transplantation. Contraindications: Aplastic Anemia, Lactating Mother, Severe Anemia, Severe Bone Marrow Depression, Severe Neutropenic Disorder, Severe Thrombocytopenia, Anemia, Neutropenic Disorder, Renal Disease, Thrombocytopenic Disorder.

Dose and Administration: CMV retinitis, induction, 900 mg twice daily for 21 days then 900 mg once daily; induction regimen may be repeated if retinitis progresses. Prevention of cytomegalovirus disease following solid organ transplantation (starting within 10 days of transplantation), 900 mg once daily for 100 days. child under 18 years not recommended.

 

Viral hepatitis

The management of uncomplicated acute viral hepatitis is largely symptomatic. Early treatment of acute hepatitis C with interferon alfa may reduce the risk of chronic infection. Hepatitis B and hepatitis C viruses are major causes of chronic hepatitis. For details on immunisation against hepatitis A and B infections.

 

ADEFOVIR DIPIVOXIL:

Indications: chronic hepatitis B infection with either compensated liver disease with evidence of viral replication, and histologically documented active liver inflammation and fibrosis or decompensated liver disease.

Contraindications: Lactating Mother, Lactic Acidosis, and Steatosis of Liver.

Dose and Administration: adult over 18 years, 10 mg once daily.

 

LAMIVUDINE:

Indications: Chronic Type B Viral Hepatitis, HIV Infection.

Contraindications: Acute Pancreatitis, Chronic Pancreatitis, Lactating Mother, Lactic Acidosis, and Steatosis of Liver.

Dose and Administration: Chronic hepatitis B infection with either compensated liver disease (with evidence of viral replication and histology of active liver inflammation or fibrosis), or decompensated liver disease, 100 mg daily; child 2–11 years, 3 mg/kg once daily (max. 100 mg daily); 12–17 years, adult dose.

 

ENTECAVIR:

Indications: chronic hepatitis B infection with compensated liver disease, evidence of viral replication, and histologically documented active liver inflammation or fibrosis.

Contraindications: Abnormal Hepatic Function Tests, Lactic Acidosis, Steatosis of Liver and breast-feeding.

Dose and Administration: adult over 18 years, not previously treated with nucleoside analogues, 500 micrograms once daily. adult over 18 years with lamivudine-resistant chronic hepatitis B, 1 mg once daily.

 

Influenza

Oseltamivir and zanamivir reduce replication of influenza A and B viruses by inhibiting viral neuraminidase. They are most effective for the treatment of influenza if started within a few hours of the onset of symptoms; they are licensed for use within 48 hours of the first symptoms.

OSELTAMIVIR:

Indications: Oseltamivir licensed for post-exposure prophylaxis of influenza when influenza is circulating in the community. Oseltamivir should be given within 48 hours of exposure to influenza. Oseltamivir also licensed for use in exceptional circumstances (e.g. when vaccination does not cover the infecting strain) to prevent influenza in an epidemic.

Contraindications: Severe Renal Disease, Delirium, Impaired Cognition, Suicidal Ideation.

Dose and Administration: Prevention of influenza, adult and adolescent over 13 years, 75 mg once daily for 10 days for post-exposure prophylaxis; for up to 6 weeks during an epidemic; child 1–13 years, body-weight under 15 kg, 30 mg once daily, body-weight 15–23 kg, 45 mg once daily, body-weight 23–40 kg, 60 mg once daily, body-weight over 40 kg, adult dose. Treatment of influenza, adult and adolescent over 13 years, 75 mg every 12 hours for 5 days; child 1–13 years, body-weight under 15 kg, 30 mg every 12 hours, body-weight 15–23 kg, 45 mg every 12 hours, body-weight 23–40 kg, 60 mg every 12 hours, body-weight over 40 kg, adult dose.

 

ZANAMIVIR:

Indications: Zanamivir licensed for post-exposure prophylaxis of influenza when influenza is circulating in the community. Zanamivir should be given within 36 hours of exposure to influenza. Zanamivir also licensed for use in exceptional circumstances (e.g. when vaccination does not cover the infecting strain) to prevent influenza in an epidemic.

Contraindications: Bronchospastic Pulmonary Disease, Chronic Obstructive Pulmonary Disease.

Dose and Administration: By inhalation of powder, post-exposure prophylaxis of influenza, adult and child over 5 years, 10 mg once daily for 10 days. Prevention of influenza during an epidemic, adult and child over 12 years, 10 mg once daily for up to 28 days. Treatment of influenza, adult and child over 5 years, 10 mg twice daily for 5 days.

 

 

Respiratory syncytial virus

PALIVIZUMAB:

Indications: monoclonal antibody licensed for preventing serious lower respiratory-tract disease caused by respiratory syncytial virus in children at high risk of the disease; it should be prescribed under specialist supervision and on the basis of the likelihood of hospitalisation.

Contraindications: Severe Coagulation Defects, Thrombocytopenic Disorder.

Dose and Administration: By intramuscular injection (preferably in anterolateral thigh), 15 mg/kg once a month during season of RSV risk (child undergoing cardiac bypass surgery, 15 mg/kg as soon as stable after surgery, then once a month during season of risk); injection volume over 1 mL should be divided between more than one site.

 

RIBAVIRIN:

Indications: in combination with peginterferon alfa or interferon alfa for chronic hepatitis C in patients without liver decompensation.

Contraindications: Autoimmune Hepatitis, Lactating Mother, Pregnancy, Sickle Cell Disease Anemia, and Thalassemia Anemia.

Dose and Administration: Chronic hepatitis C (in combination with interferon alfa or peginterferon alfa), adult over 18 years, body-weight under 75 kg, 400 mg in the morning and 600 mg in the evening; body-weight 75 kg and over, 600 mg twice daily.

 

 

Antiprotozoal drugs

Antiprotozoal drugs

Antimalarials

Chloroquine:

Indications: chemoprophylaxis and treatment of malaria; rheumatoid arthritis and lupus erythematosus

Contraindications: Hemolytic Anemia from Pyruvate Kinase and G6PD Deficiencies, Maculopathy, Retinal Disorder, Visual Field Defect.

Dose and Administration: Prophylaxis of malaria, preferably started 1 week before entering endemic area and continued for 4 weeks after leaving, 300 mg once weekly; infant up to 12 weeks body-weight under 6 kg, 37.5 mg once weekly; 12 weeks–1 year body-weight 6–10 kg, 75 mg once weekly; child 1–4 years body-weight 10–16 kg, 112.5 mg once weekly; 4–8 years body-weight 16– 25 kg, 150 mg once weekly; 8–13 years body-weight 25–45 kg, 225 mg once weekly; over 13 years body-weight over 45 kg, adult dose.

 

Mefloquine:

Indications: Chloroquine Resistant Plasmodium Falciparum Malaria, Chloroquine-Resistant Plasmodium Falciparum Malaria Prevention, Plasmodium Vivax Malaria, and Plasmodium Vivax Malaria Prevention.

Contraindications: Depression, Generalized Anxiety Disorder, Psychiatric Disturbance, Psychotic Disorder, Schizophrenia, and Seizure Disorder.

Dose and Administration: Prophylaxis of malaria, preferably started 21/2 weeks before entering endemic area and continued for 4 weeks after leaving (see notes above), adult and child body-weight over 45 kg, 250 mg once weekly; body-weight 6–16 kg, 62.5 mg once weekly; body-weight 16–25 kg, 125 mg once weekly; body-weight 25–45 kg, 187.5 mg once weekly.

HYDROXYCHLOROQUINE SULPHATE:

Indications: Discoid Lupus Erythematosus, Malaria Prevention, Plasmodium Falciparum Malaria, Plasmodium Falciparum Malaria Prevention, Plasmodium Malariae Malaria, Plasmodium Malariae Malaria Prevention, Plasmodium Ovale Malaria, Plasmodium Ovale Malaria Prevention, Plasmodium Vivax Malaria, Plasmodium Vivax Malaria Prevention, Rheumatoid Arthritis, Systemic Lupus Erythematosus.

Contraindications: Deficiency of Glucose-6-Phosphate Dehydrogenase, Hemolytic Anemia from Pyruvate Kinase and G6PD Deficiencies, Maculopathy, Retinal Disorder, Visual Field Defect.

Dose and Administration: Administered on expert advice, initially 400 mg daily in divided doses; maintenance 200–400 mg daily; max. 6.5 mg/kg daily (but not exceeding 400 mg daily), see recommendations above; child up to 6.5 mg/kg daily (max. 400 mg daily).

 

Amoebicides

METRONIDAZOLE:

Indications: Intestinal amoebiasis, Extra-intestinal amoebiasis (including liver abscess), Urogenital trichomoniasis, Giardiasis.

Contraindications: Lactating Mother, Alcohol Intoxication, Alcoholism, Lower Seizure Threshold, Peripheral Neuropathy, Seizure Disorder, Severe Hepatic Disease.

Dose and Administration: By mouth, invasive intestinal amoebiasis, 800 mg every 8 hours for 5 days; child 1–3 years 200 mg every 8 hours; 3–7 years 200 mg every 6 hours; 7–10 years 400 mg every 8 hours. Extra-intestinal amoebiasis (including liver abscess), 400–800 mg every 8 hours for 5–10 days; child 1–3 years 100–200 mg every 8 hours; 3–7 years 100–200 mg every 6 hours; 7–10 years 200–400 mg every 8 hours. Urogenital trichomoniasis, 200 mg every 8 hours for 7 days or 400–500 mg every 12 hours for 5–7 days, or 2 g as a single dose; child 1–3 years 50 mg every 8 hours for 7 days; 3–7 years 100 mg every 12 hours; 7–10 years 100 mg every 8 hours. Giardiasis, 2 g daily for 3 days or

400 mg 3 times daily for 5 days or 500 mg twice daily for 7–10 days; child 1–3 years 500 mg daily for 3 days; 3–7 years 600–800 mg daily; 7–10 years 1 g daily.

 

TINIDAZOLE:

Indications: Acute Intestinal Amebiasis due to Entamoeba Histolytica, Bacterial Vaginosis, Giardiasis, and Liver Abscess Amebiasis due to Entamoeba Histolytica, Trichomoniasis.

Contraindications: Lactating Mother, Pregnancy, Epilepsy, And Peripheral Neuropathy.

Dose and Administration: Intestinal amoebiasis, 2 g daily for 2–3 days; child 50–60 mg/kg daily for 3 days. Amoebic involvement of liver, 1.5–2 g daily for 3–6 days; child 50–60 mg/kg daily for 5 days. Urogenital trichomoniasis and giardiasis, single 2 g dose; child single dose of 50–75 mg/kg (repeated once if necessary).

 

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