Monthly Archives: June 2017

Anal and Rectal Disorders

  • Hemorrhoid:

Lignocaine 2% and Tribenoside 5%:

Indications: hemorrhoids, pruritus and other ano-rectal conditions.

Contraindications: avoid in children and infants.

Dose and Administration: insert one suppository rectally twice daily after defecation. Apply ointment twice daily and after defecation.

 

Herbal Preparation:

Indications: treatment of external and internal hemorrhoids as well as anal fissures.

Dose and Administration: patients are advised not to defecate for at least 4 hours after dose administration other wise the dose should be repeated after defecation. Ointment: 1 application 3 times daily for 3 weeks. Suppository: 1 suppository 3 times daily for 3 weeks.

 

  • Rectal Sclerosants:

Oily Phenol:

Indications: hemorrhoids

Dose and Administration: 2-3 ml into the submucosal layer at the base of pil; several injections may be given at different sites; maximum total injected 10ml at any one time.

  • Anal Fissures:

Nitroglycerin Ointment:

Indications: anal fissure

Contraindications: hypersensitivity to nitrates, marked anaemia, closed angle glaucoma, mitral stenosis.

Dose and Administration: apply 2.5cm of the ointment to anal canal every 12 hours until pain stops; max. Duration of use 8 weeks; child under 18 years not recommended.

 

Positive Inotropic Drugs: Cardiac Glycosides

Cardiac glycosides increase the force of myocardial contraction and reduce conductivity within the atrio-ventricular (AV) node. These are most useful in the treatment of supraventricular tachycardias.

DIGOXIN:

Indications: treatment of all degrees of congestive heart failure and supraventiricular arrhythmias (particularly atrial fibrillation).

Contraindications: ventricular fibrillations، intermittent complete heart block, second degree AV block, supraventiricular arrhythmias caused by wolf – Parkinson white syndrome، hypertrophic obstructive cardiomyopathy toxic effects present from prior administration of any digitalis preparation, ventricular fibrillation.

Dose and Administration: Orally, rapid digitalization, 1 – 1.5 mg in divided doses over 24 hours; less urgent digitalization, 250 – 500 mcgs daily (higher dose divided). Maintenance، 62.5 – 500 mcgs daily (higher dose divided) according to renal function and, in atrial fibrillation, on heart-rate response; usual range 125 – 250 mcgs daily (elderly125 mcgs). Emergency loading dose by intravenous infusion Adult, 250 – 500 mcgs, over 10 – 20 minutes, followed by further fractions at intervals of 4 – 8 hours (depending on the response), to a total loading dose of 0.5 – 1mg. Note: The above doses may need to be reduced if digoxin (or another cardiac glycoside) has been given in the preceding 2 weeks. For plasma concentration monitoring, blood should ideally be taken at least 6 hours after a dose.

Treatment of Diarrhoea

Antidiarrhoeal agents are used as adjuncts in the symptomatic treatment of diarrhea, although the main aim in the management of acute diarrhoea is the correction of fluid and electrolyte depletion with rehydration therapy; this is especially important in infants and young children and antidiarrhoeal agents are not generally recommended for this age group. Their use is also limited in chronic diarrhea for treatment aimed at the underlying disorder will often alleviate the diarrhea. The main groups of antidiarrhoeal agents are the drugs, which reduce Intestinal motility such as Loperamide, and the adsorbents (kaolin which may absorb bacterial toxins and act as mucosal protectants).

Oral Rehydration salt

Powder -each sachet for 1 liter contains

Sodium chloride ……………….  3.5gm

Trisodium citrate Dihydrate ……  2.9gm

Potassium chloride ……………  1.5gm

Glucose …………………….. 20.0gm

Indications: -replacement of fluid and electrolyte loss in diarrhoea.

Contraindications: – anuria, oliguria, severe dehydration with symptoms of shock, severe diarrhoea, glucose malabsorption, inability to drink, severe and sustained vomiting, intestinal obstruction, paralytic ileus, perforated bowl which may be irritated by ORS.

Dose and Administration: – reconstitute one sachet by adding sufficient water to make 1 liter Oral Rehydration Solution. Dose – according to fluid loss, usually 200-400ml solutions after every loose motion، child – 200ml after every loose motion, infant 1 – 11/2 times usual feed volume.

  • Adsorbent Mixtures

Kaolin/Pectin Suspension:

Indications: fast relief of diarrhea.

Contraindications: not recommended for acute diarrhea. Do not use for more

than 2 days or in the presence of high fever.

Dose and Administration: 10-20ml every 4 hours.

  • Antimotility Drugs:

LOPERAMIDE:

Indications: symptomatic treatment of acute diarrhoea; adjunct to rehydration in acute diarrhoea in adults and children over 4 years; chronic diarrhoea in adults only.

Contraindications: conditions where inhibition of peristalsis should be avoided, where abdominal distension develops, or in conditions such as active ulcerative colitis or antibiotic-associated colitis

Dose and Administration: Acute diarrhoea, 4 mg initially followed by 2 mg after each loose stool for up to 5 days; usual dose 6–8 mg daily; max. 16 mg daily; child under 4 years not recommended; 4–8 years, 1 mg 3–4 times daily for up to 3 days only; 8–12 years, 2 mg 4 times daily for up to 5 days. Chronic diarrhoea in adults, initially, 4–8 mg daily in divided doses, subsequently adjusted according to response and given in 2 divided doses for maintenance; max. 16 mg daily.

Ulcer-Healing Drugs

H2 Receptor Antagonists:

H2-Receptor antagonists are medications used to treat a Varity of Gastrointestinal conditions such as duodenal ulcer, gastric ulcer, GERD, erosive esophagitis and zollinger-ellison syndrome.

Ranitidine:

Indications: Duodenal ulcer, benign gastric ulcer, reflux esophagitis, Zollinger­ellison syndrome, NSAID induced lesions and prevention in acid aspiration syndrome (AAS).

Contraindications: Porphyria, Disease of Liver, Gastric Cancer, Renal Disease.

Dose and Administration: By mouth: benign gastric and duodenal ulceration, chronic episodic dyspepsia, adult and child over 12 years, 150 mg twice daily or 300 mg at night for 4–8 weeks in benign gastric and duodenal ulceration, up to 6 weeks in chronic episodic dyspepsia, and up to 8 weeks in NSAID-associated ulceration (in duodenal ulcer 300 mg can be given twice daily for 4 weeks to achieve a higher healing rate); child 3–12 years, (benign gastric and duodenal ulceration) 2–4 mg/kg (max. 150 mg) twice daily for 4–8 weeks. Gastro­oesophageal reflux disease, adult and child over 12 years, 150 mg twice daily or 300 mg at night for up to 8 weeks or if necessary 12 weeks (moderate to severe, 600 mg daily in 2–4 divided doses for up to 12 weeks); long-term treatment of healed gastro-oesophageal reflux disease, 150 mg twice daily; child 3–12 years, 2.5–5 mg/kg (max. 300 mg) twice daily. Zollinger–Ellison syndrome (but see notes above), adult and child over 12 years, 150 mg 3 times daily; doses up to 6 g daily in divided doses have been used. surgical procedures, slow intravenous injection, 50 mg 45–60 minutes before induction of anaesthesia, or by mouth, 150 mg 2 hours before induction of anaesthesia and also when possible on the preceding evening. By slow intravenous: injection, adult and child over 12 years, 50 mg diluted to 20 mL and given over at least 2 minutes; may be repeated every 6–8 hours. By intravenous infusion: 25 mg/hour for 2 hours; may be repeated every 6–8 hours.

Chelates and complexes: Sucralfate:

Indications: Duodenal and non-malignant gastric ulcer, prophylaxis of duodenal ulcer recurrence and prophylaxis of gastric hemorrhage due to stress ulceration. Contraindications: Pregnant women and children. Aluminum Toxicity and Chronic Renal Failure.

Dose and Administration: Benign gastric and duodenal ulceration and chronic gastritis, adult and child over 15 years, 2 g twice daily (on rising and at bedtime) or 1 g 4 times daily 1 hour before meals and at bedtime, taken for 4–6 weeks or in resistant cases up to 12 weeks; max. 8 g daily. Prophylaxis of stress ulceration, adult and child over 15 years, 1 g 6 times daily; max. 8 g daily.

Proton Pump Inhibitors:

Proton pump inhibitors inhibit gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphatase enzyme system (the ‘proton pump’) of the gastric parietal cell. Proton pump inhibitors are effective short-term treatments for gastric and duodenal ulcers; they are also used in combination with antibacterials for the eradication of Helicobacter pylori In patients with peptic ulcer bleeding, treatment with a proton pump inhibitor reduces the risk of rebleeding and the need for surgery. Side effects: The most common side effects of proton pump inhibitors are: Headache, Diarrhea, Constipation, Abdominal pain, Nausea, Rash. Interactions: Proton pump inhibitors interact with few drugs. The absorption into the body of some drugs is affected by the presence of acid in the stomach, and because PPIs reduce acid in the stomach, they may affect the absorption of these drugs. Specifically, PPIs reduce the absorption and concentration in the blood of ketoconazole and increase the absorption and concentration of digoxin. This may lead to reduce effectiveness of ketoconazole and an increase in digoxin toxicity. Proton pump inhibitors can reduce the breakdown of some drugs by the liver and lead to an increase in their concentration in the blood.

OMEPRAZOLE:

Indications: Omeprazole is used for treating acid-induced inflammation and ulcers of the stomach and duodenum; gastroesophageal reflux disease (GERD); erosive esophagitis, heartburn; prevention of upper gastrointestinal bleeding in critically ill patients; and Zollinger-Ellison Syndrome. It also is used in combination with antibiotics for eradicating H. pylori infection of the stomach. Contraindications: Severe Hepatic Disease.

Dose and Administration: For ulcers, GERD, erosive esophagitis and eradication of H. pylori the recommended dose for adults is 20-40 mg daily. Ulcer healing usually occurs within 4-8 weeks. H. Pylori infections are treated for 10-28 days. The usual dose for prevention of upper gastrointestinal bleeding in critically ill patients is 40 mg daily for 14 days. Omeprazole OTC is used for treating heartburn for up to two weeks, and the usual dose is 20 mg daily. For the management of Zollinger-Ellison Syndrome the starting dose for adults is 60 mg daily, and the dose is adjusted based on either the response of symptoms or the actual measurement of acid production. Doses greater than 80 mg should be divided. Doses up to 120 mg three a day in divided doses have been used in the treatment of Zollinger-Ellison Syndrome. For maximal efficacy, Omeprazole tablets should be taken before meals, swallowed whole and should not be crushed, chewed or opened.

ESOMEPRAZOLE:

Indications: Esomeprazole is approved for the treatment of gastroesophageal reflux disease (GERD) and in combination with amoxicillin and clarithromycin for the treatment of patients with ulcers and H. pylori infection. Since it is very similar to omeprazole, it also is likely that it will be used for the treatment of Zollinger-Ellison syndrome. Esomeprazole also is approved for short-term use in children ages 1-11 for GERD.

Contraindications: Atrophic Gastritis, Severe Hepatic Disease.

Dose and Administration: For GERD, 20 or 40 mg of esomeprazole is given once daily for 4-8 weeks. In children ages 1-11, the dose is 10 or 20 mg daily. For the treatment of H. pylori, 40 mg is administered once daily in combination with amoxicillin and clarithromycin for 10 days.

Esomeprazole capsules should be administered one hour before meals, swallowed whole and should not be crushed or chewed. Patients with difficulty swallowing can open the capsule and mix the pellets with applesauce. The applesauce should not be hot and the pellets should not be chewed or crushed.

PANTOPRAZOLE:

Indications: Although pantoprazole is approved for the treatment of gastroesophageal reflux disease (GERD), like other PPI’s it also is used for treating ulcers of the stomach and duodenum, and the Zollinger-Ellison Syndrome.

Contraindications: Pernicious Anemia.

Dose and Administration: For GERD the recommended dose for adults is 40 mg daily for 4-8 weeks. It generally is recommended that tablets be taken approximately 30 minutes prior to meals for maximal effectiveness. Tablets should be swallowed whole and should not be crushed, split or chewed. IV injection over at least 2 minutes or by IV infusion, duodenal ulcer, gastric ulcer and GERD, 40mg daily until oral administration can be resumed.

LANSOPRAZOLE:

Indications: Lansoprazole is used for treating ulcers of the stomach and duodenum, gastroesophageal reflux disease (GERD) and Zollinger-Ellison Syndrome.

Contraindications: Severe Hepatic Disease.

Dose and Administration: For initial treatment of duodenal ulcers the recommended dose for adults is 15 mg daily for 4 weeks. For the treatment of GERD, the recommended initial treatment is 15 mg for up to 8 weeks. For maintaining healing (long-term) in duodenal ulcer and GERD the recommended treatment is 15 mg daily. For initial treatment of severe (erosive) esophagitis and gastric ulcer, the recommended dose for adults is 30 mg daily for 4-8 weeks. For the management of Zollinger-Ellison Syndrome, the starting dose for adults is 60 mg daily, and the dose is adjusted based on response. Doses up to 180 mg have been used in some patients with Zollinger-Ellison syndrome. It is recommended that capsules be taken before meals for maximum effect. Capsules should be swallowed whole and should not be crushed, split or chewed.

 

RABERAZOLE:

Indications: Rabeprazole is used for treating ulcers of the stomach and duodenum, erosive or ulcerative gastroesophageal reflux disease (GERD) and Zollinger-Ellison Syndrome (in which there is overproduction of acid caused by tumors). It also is used with antibiotics for eradicating Helicobacter pylori infections of the stomach that, along with acid, are responsible for many ulcers. Contraindications: Severe Hepatic Disease.

Dose and Administration: For healing ulcerative or erosive GERD, the recommended dose for adults is 20 mg daily for 4-8 weeks. If healing does not occur after 8 weeks, another 8-week course may be considered. The recommended maintenance dose is 20 mg daily. Heartburn due to GERD is treated with 20 mg daily for 4 weeks and an additional 4 weeks if symptoms do not resolve. Ulcers are treated with 20 mg daily for 4 weeks. For the management of Zollinger-Ellison Syndrome, the starting dose for adults is 60 mg daily, and the dose is adjusted based on improvement in symptoms, healing of ulcers, or the effectiveness of acid suppression. Doses of 100 mg per day and 60 mg twice daily have been used in some patients with Zollinger-Ellison Syndrome. The regimen for eradication of Helicobacter pylori is Rabeprazole 20 mg, clarithromycin 500 mg, amoxicillin 1000 mg all given twice daily (morning and evening) for 7 days. Tablets should be swallowed whole and should not be crushed, split or chewed. Rabeprazole can be taken with or without meals since food has little effect on its absorption.

Antispasmodics & Other Drugs Altering Gut Motility: Antimuscarinics

Antispasmodics & Other Drugs Altering Gut Motility: Antimuscarinics

  • Antimuscarinics:

Antimuscarinics that are used for gastro-intestinal smooth muscle spasm include Atropine sulphate and Hyoscine (Scopolamine) Butylbromide. The side effects frequently associated with the use of antimuscarinics include xerostoma (dry mouth), blurred vission, cycloplegia, mydriasis, photophobia، anhidrosis, urinary hesitancy and retention, tachycardia, palpitation، and constipation. Side effects that occur occasionally include confusion (particularly in elderly), nausea, vomiting and giddiness. Antimuscarinics may interact with antacids or antidiarrheals (reduce absorption of anticholinergics.

Atropine Sulphate:

Indications: – dyspepsia, irritable bowel syndrome, diverticular disease; premeditation; mydriasis and cycloplegia; poisoning see also notes above Contraindications: Antimuscarinics are contra-indicated in myasthenia gravis, paralytic ileus, pyloric stenosis and prostatic enlargement.

Dose and Administration: Adults – IM, S.C., I.V. – 0.4 – 0.6 mg. Every four to six hours. Children – SC – 0.01 mg/kg of body weight, not to exceed 0.4 mg, every for to six hours.

 

Hyoscine (Scopolamine) Butyl bromide:

Indications: – symptomatic relief of visceral spasms of the gastro- intestinal tract, painful spasm of the biliary and genito-urinary system.

Contraindications: Antimuscarinics are contra-indicated in myasthenia gravis, paralytic ileus, pyloric stenosis and prostatic enlargement.

Dose and Administrations: By mouth, smooth muscle spasm, 20 mg 4 times daily; child 6–12 years, 10 mg 3 times daily. Irritable bowel syndrome, 10 mg 3 times daily, increased if required up to 20 mg 4 times daily. By intramuscular or slow intravenous injection, acute spasm and spasm in diagnostic procedures, 20 mg repeated after 30 minutes if necessary (may be repeated more frequently in endoscopy), max. 100 mg daily.

  • Other Antispasmodics: 

Mebeverine Hydrochloride;

Indications: adjunct in gastro-intestinal disorders characterized by smooth muscle spasm, irritable bowel syndrome.

Contraindications: paralytic ileus.

Dose and Administration: adults and child over 10 years 1 tablet 3 times daily preferably 20 minutes before meals or 1 capsule twice daily preferably 20 minutes before meals.

 

Pinaverium Bromide:

Indications: pain of gastrointestinal or biliary disease, also for preparation for barium enema.

Contraindications: during pregnancy and breast-feeding also in case of galactosemia.

Dose and Administration: 3-4 tablets/day within meals, dose can be increased to 6 tablets/day

 

Prifinium Bromide:

Indications: pain of gastritis, gastro-duodenal ulcer, enteritis, colitis, post gastrectomy syndrome and irritable colon.

Contraindications: patients with prostatic hypertrophy and patients with glaucoma.

Dose and Administration: Adults: 30-60mg 3 times daily. Children: 6-12 years old may take 15-30mg 3 times daily.

 

Alverine Citrate:

Indications: adjunct in gastro-intestinal disorders characterised by smooth muscle spasm; dysmenorrhoea.

Contraindications: children under 12 years old, pregnancy, and breast-feeding and paralytic ileus; when combined with sterculia, intestinal obstruction, faecal impaction, and colonic atony.

Dose and Administration: 60–120 mg 1–3 times daily; child under 12 years not recommended.

 

Anti-Flatulents

Vegetable Charcoal:

Indications: Flatulence, indigestion and intestinal distention.

Dose and Administration: One to three soft gelatins capsules three times daily after meals. Food poisoning and sever diarrhea 3-5 capsules 3 times daily. Children (above 2 years) one capsule once daily.

Simethicone:

Indications: symptomatic treatment of all types of excessive gas accumulation in GIT also to prepare for radiological investigations.

Contraindications: obstructive gastrointestinal disorders.

Dose and Administration:

Adults: one to two chewable tablets 3 times after meals and bedtime. 25-50 drops with little fluid after meals and bedtime. Children: one tablet 3 times after meals and bedtime. 15-20 drops with little fluid after meals and bedtime. Infants: 10-15 drops 3 times daily.

Antacids

Antacids are basic compounds, which neutralize hydrochloric acid in the gastric secretions. They are used to prevent and relieve pain in the symptomatic management of gastro-intestinal disorders associated with gastric hyperacidity such as dyspepsia, gastro-oesphageal reflux disease, and peptic ulcer.

Aluminum Hydroxide/Magnesium Hydroxide:

Indications: symptomatic relief of indigestion, non-ulcer dyspepsia, epigastric pain in peptic ulcer disease (PUD) or heartburn in gastroesophageal reflux disease (GERD).

Contraindications: Hypophosphataemia, renal impairment and bowel obstruction.

Dose and Administration: Suspension: 10-20ml 20-60 min after meals and at bed time or when required, Pediatric, below 12 years 5-15ml up to every 1 hour. Tab: chew 1-2 tablets 4 times per day as needed. Child under 12 years not recommended.

 

Aluminum Hydroxide/Magnesium Hydroxide & Simethicone

Indications: Relief heartburn, acid indigestion and sour stomach especially if those symptoms accompanied with gaseous distension. Relief hyperacidity associated with peptic ulcer. Relief symptoms of (GERD)

Contraindications: Hypophosphataemia, renal impairment and bowel obstruction.

Dose: 1-4 Tablets or 10ml of the suspension to be taken 4 times daily after meals and at bedtime.

GENERAL ADVICE TO PRESCRIBERS

 

RATIONAL APPROACH TO THERAPEUTICS

Drugs should only be prescribed when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risks involved. Bad prescribing habits lead to ineffective and unsafe treatment, exacerbation or prolongation of illness, distress and harm to the patient, and higher cost. The following steps will help to remind prescribers of the rational approach to therapeutics.

  1. Define the patient’s problem
  2. Specify the therapeutic objective
  3. Selecting therapeutic strategies
  • Non–pharmacological treatment
  • Pharmacological treatment

– Selecting the correct group of drugs

– Selecting the drug from the chosen group

– Verifying the suitability of the chosen pharmaceutical treatment for each patient

– Prescription writing

– Giving information, instructions and warnings – Monitoring treatment

VARIATION IN DOSE RESPONSE

Success in drug treatment depends not only on the correct choice of drug but also on the correct dose regimen. Unfortunately drug treatment frequently fails because the dose is too small or produces adverse effects because it is too large. This is because most texts, teachers and other drug information sources continue to recommend standard doses. The concept of a standard or ‘average’ adult dose for every medicine is firmly rooted in the mind of most prescribers. After the initial ‘dose ranging’ studies on new drugs, manufacturers recommend a dosage that appears to produce the desired response in the majority of subjects. These studies are usually done on healthy, young male Caucasian volunteers, rather than on older men and women with illnesses and of different ethnic and environmental backgrounds. The use of standard doses in the marketing literature suggests that standard responses are the rule, but in reality there is considerable variation in drug response. As a result many prescribed doses are far too low or too high, leading to treatment failure or toxicity. There are many reasons for this variation, which include adherence (see below), drug formulation, body weight and age, composition, variation in absorption, distribution, metabolism and excretion, variation in pharmacodynamics, disease variables, and genetic and environmental variables.

Drug formulation

Poorly formulated drugs may fail to disintegrate or to dissolve. Enteric-coated drugs are particularly problematic, and have been known to pass through the gastrointestinal tract intact. Some drugs like digoxin or phenytoin have a track record of formulation problems, and dissolution profiles can vary not only from manufacturer to manufacturer but from batch to batch of the same company. The problem is worse if there is a narrow therapeutic to toxic ratio, as changes in absorption can produce sudden changes in drug concentration. For such drugs quality control surveillance should be carried out.

Body weight and age

Although the concept of varying the dose with the body weight or age of children has a long tradition, adult doses have been assumed to be the same irrespective of size or shape. Yet adult weights vary two to threefold, while a large fat mass can store large excesses of highly lipid soluble drugs compared to lean patients of the same weight.

Physiological and pharmacokinetic variables

Drug absorption rates may vary widely between individuals and within the same individual at different times and in different physiological states. Drugs taken after a meal are delivered to the small intestine much more slowly than in the fasting state, leading to much lower drug concentrations. In the case of drugs like paracetamol with a high rate of metabolism on ‘first pass’ through the liver, this may render a standard dose completely ineffective. In pregnancy gastric emptying is also delayed, while some drugs may increase or decrease gastric emptying and affect absorption of other drugs.

Drug distribution

Drug distribution varies widely: fat-soluble drugs are stored in adipose tissue, water-soluble drugs are distributed chiefly in the extra cellular space, acidic drugs bind strongly to plasma albumin and basic drugs to muscle cells. Hence variation in plasma albumin levels, fat content or muscle mass may all contribute to dose variation. With very highly albumin bound drugs like warfarin; a small change of albumin concentration can produce a big change in free drug and a dramatic change in drug effect.

Drug metabolism and excretion

Drug metabolic rates are determined both by genetic and environmental factors. Drug acetylation shows genetic polymorphism, whereby individuals fall clearly into either fast or slow acetylator types. Drug oxidation, however, is polygenic, and although a small proportion of the population can be classified as very slow oxidizers of some drugs, for most drugs and most subjects there is a normal distribution of drug metabolizing capacity, and much of the variation is under environmental control. The kidneys eliminate many drugs without being metabolized. Renal disease or toxicity of other drugs on the kidney can therefore slow excretion of some drugs.

Pharmacodynamic variables

There is significant variation in receptor response to some drugs, especially central nervous system responses, for example pain and sedation. Some of this is genetic, some due to tolerance, some due to interaction with other drugs and some due to addiction, for example, morphine and alcohol.

Disease variables

Both liver disease and kidney disease can have major effects on drug response, chiefly by the effect on metabolism and elimination respectively (increasing toxicity), but also by their effect on plasma albumin (increased free drug also increasing toxicity). Heart failure can also affect metabolism of drugs with rapid hepatic clearance (for example lidocaine, propranolol). Respiratory disease and hypothyroidism can both impair drug oxidation.

Environmental variables

Many drugs and environmental toxins can induce the hepatic microsomal enzyme oxidizing system (MEOS) or cytochrome P450 oxygenases, leading to more rapid metabolism and elimination and ineffective treatment. Environmental pollutants, anesthetic drugs and other compounds such as pesticides can also induce metabolism. Diet and nutritional status also impact on pharmacokinetics. For example in infantile malnutrition and in malnourished elderly populations drug oxidation rates are decreased, while high protein diets, charcoal cooked foods and certain other foods act as metabolizing enzyme inducers. Chronic alcohol use induces oxidation of other drugs, but in the presence of high circulating alcohol concentrations drug metabolism may be inhibited.

ADHERENCE (COMPLIANCE) WITH DRUG TREATMENT

It is often assumed that once the appropriate drug is chosen, the prescription correctly written and the medication correctly dispensed, that it will be taken correctly and treatment will be successful. Unfortunately this is very often not the case, and physicians overlook one of the most important reasons for treatment failure—poor adherence (compliance) with the treatment plan. There are sometimes valid reasons for poor adherence—the drug may be poorly tolerated، may cause obvious adverse effects or may be prescribed in a toxic dose.

Failure to adhere

With such a prescription has been described as ‘intelligent noncompliance’. Bad prescribing or a dispensing error may also create a problem, which patients may have neither the insight nor the courage to question. Even with rational prescribing, failure to adhere to treatment is common. Factors may be related to the patient, the disease, the doctor, the prescription, the pharmacist or the health system and can often be avoided. The Following points are recommended to increase patient compliance

– Review the prescription to be sure it is correct.

– Spend time explaining the problem and the reason for the drug.

– Establish a good relationship with the patient, rather than a hurried or brusque manner with little eye contact.

– Explore problems, for example reading the label, getting the prescription filled.

– Insist that patients bring their medication to the clinic ‘for checking’, so that tablet counts can be made unobtrusively.

– Insist that patients learn the names of their tablets, and review their regimen with them. Write notes for them.

– Keep treatment regimens simple.

– Communicate with the pharmacist, to develop teamwork and collaboration in helping and advising the patient.

– Involve the partner or another family member, – Listen to the patient.

ADVERSE EFFECTS AND INTERACTIONS

Adverse drug reactions

An adverse drug reaction (ADR) may be defined as ‘any response to a drug which is noxious, unintended and occurs at doses normally used for prophylaxis, diagnosis, or therapy. ADRs are therefore unwanted or unintended effects of a medicine, including idiosyncratic effects, which occur during its proper use. They differ from accidental or deliberate excessive dosage or drug maladministration. Any drug may produce unwanted or unexpected adverse reactions. Detection and recording of these is of vital importance. Doctors and pharmacists are urged to the pharmacy and therapeutic committee.

Major factors predisposing to adverse effects

It is well known that different patients often respond differently to a given treatment regimen. For example, in a sample of 2422 patients who had been taking combinations of drugs known to interact, only 7 (0.3%) showed any clinical evidence of interactions. In addition to the pharmaceutical properties of the drug therefore، there are characteristics of the patient, which predispose to ADRs.

Extremes Of Age.

The very old and the very young are more susceptible to ADRs. Drugs, which commonly cause problems in the elderly, include hypnotics, diuretics, non-steroidal anti-inflammatory drugs, antihypertensives, psychotropic and digoxin. All children, and particularly neonates, differ from adults in the way they respond to drugs. Some drugs are likely to cause problems in neonates (for example morphine), but are generally tolerated in children. Other drugs (for example valproic acid) are associated with increased risk of ADRs in children of all ages. Other drugs associated with problems in children include chloramphenicol (gray baby syndrome), antiarrhythmics (worsening of arrhythmias), aspirin (Reye syndrome).

Intercurrent Illness

If besides the condition being treated the patient also suffers from another disease, such as kidney, liver or heart disease, special precautions are necessary to prevent ADRs. Remember also that, as well as the above factors, the genetic make-up of the individual patient may predispose to ADRs.

DRUG INTERACTIONS

Interactions may occur between drugs, which compete for the same receptor or act on the same physiological system. They may also occur indirectly when a drug-induced disease or a change in fluid or electrolyte balance alters the response to another drug. Interactions may occur when one drug alters the absorption, distribution or elimination of another drug, such that the amount, which reaches the site of action, is increased or decreased. Drug-drug interactions are some of the commonest causes of adverse effects. When two drugs are administered to a patient, they may either act independently of each other, or interact with each other. Interaction may increase or decrease the effects of the drugs concerned and may cause unexpected toxicity. As newer and more potent drugs become available, the number of serious drug interactions is likely to increase. Remember that interactions, which modify the effects of a drug, may involve non-prescription drugs, non-medicinal chemical agents, and social drugs such as alcohol, marijuana, and traditional remedies, as well as certain types of food. The physiological changes in individual patients, caused by such factors as age and gender, also influence the predisposition to ADRs resulting from drug interactions.

Incompatibilities between drugs and IV fluids

Drugs should not be added to blood, amino acid solutions or fat emulsions. Certain drugs, when added to IV fluids, may be inactivated by pH changes, by precipitation or by chemical reaction. Benzyl penicillin and ampicillin lose potency after 6– 8 hours if added to dextrose solutions, due to the acidity of these solutions. Some drugs bind to plastic containers and tubing, for example diazepam and insulin. Amino glycosides are incompatible with penicillin’s and heparin. Hydrocortisone is incompatible with heparin, tetracycline, and chloramphenicol.

Adverse effects caused by traditional medicines

Patients who have been or are taking traditional herbal remedies may develop ADRs. It is not always easy to identify the responsible plant or plant constituent. Refer to the drug and toxicology information service if available and/or to suitable literature.

The effect of food on drug absorption

Food delays gastric emptying and reduces the rate of absorption of many drugs; the total amount of drug absorbed may or may not be reduced. However, some drugs are preferably taken with food, either to increase absorption or to decrease the irritant effect on the stomach.

PRESCRIPTION WRITING

A prescription is an instruction from a prescriber to a dispenser. The following guidelines will help to ensure that prescriptions are correctly interpreted and leave no doubt about the intention of the prescriber. The guidelines are relevant for primary care prescribing; they may, however, be adapted for use in hospitals or other specialist units.

Prescription form

The most important requirement is that the prescription be clear. It should be legible and indicate precisely what should be given. The following details should be shown on the form:

– The prescriber’s related data (name, stamp and signature). This will allow either the patient or the dispenser to contact the prescriber for any clarification or potential problem with the prescription.

– Patient bio-data including name, gender, age, file number, encounter number, weight, high, pregnancy, lactation, allergy and diagnosis.

– Medication related data including generic name, dosage form, strength, frequency and duration of treatment.

– Types of prescription forms used are regular prescription, E-prescription, GOSI prescription, controlled drug prescription and narcotic drug prescription.

Directions

Directions specifying the route, dose and frequency should be clear and explicit; use of phrases such as ‘take as directed’ or ‘take as before’ should be avoided. For preparations which are to be taken on an (as required) basis, the minimum dose interval should be stated together with, where relevant, the maximum daily dose.

It is good practice to qualify such prescriptions with the purpose of the medication (for example ‘every ٦ hours as required for pain’, ‘at night as required to sleep’). It is good practice to explain the directions to the patient; the dispenser will then reinforce by the label on the medicinal product and possibly by appropriate counseling these directions. It may be worthwhile giving a written note for complicated regimens although it must be borne in mind that the patient may lose the separate note.

Quantity to be dispensed

The quantity of the medicinal product to be supplied should be stated such that it is not confused with either the strength of the product or the dosage directions. Alternatively, the length of the treatment course may be stated (for example ‘for ٥ days’). For liquid preparations, the quantity should be stated in milliliters (abbreviated as ‘ml’) or liters (preferably not abbreviated since the letter ‘l’ could be confused with the figure ‘1’). For regular prescriptions a maximum of 30 days medication supply could be dispensed with a refill of 1-2 months. For E.R. prescriptions the following should be followed

– 5-7 days supply of antibiotics.

– 5 days supply of chronic medications.

– 3 days supply for acute medications.

 

Narcotics and controlled substances

The prescribing of a medicinal product that is liable to abuse requires special attention and may be subject to specific statutory requirements. Practitioners may need to be authorized to prescribe controlled substances; in such cases it might be necessary to indicate details of the authority on the prescription. In particular, the strength, directions and the quantity of the controlled substance to be dispensed should be stated clearly, with all quantities written in words as well as in figures to prevent alteration. Other details such as patient particulars and date should also be filled in carefully to avoid alteration.

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Core Values of Respiratory Therapy Unit

In the daily path of professional activities the Respiratory Therapist shall be bound by the following ethical and professional principles. Respiratory Therapists shall:

  1. Demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in the profession and its professionals.
  2. Promote and practice evidence-based medicine.
  3. Seek continuing education opportunities to improve and maintain their professional competence and document their participation accurately.
  4. Perform only those procedures or functions in which they are individually competent and which are within their scope of accepted and responsible practice.
  5. Respect and protect the legal and personal rights of patients, including the right to privacy, informed consent, and refusal of treatment.
  6. Divulge no protected information regarding any patient or family unless disclosure is required for the responsible performance of duty as authorized by the patient and/or family, or required by law.
  7. Provide care without discrimination on any basis, with respect for the rights and dignity of all individuals.
  8. Promote disease prevention and wellness.
  9. Refuse to participate in illegal or unethical acts.
  10. Refuse to conceal, and will report, the illegal, unethical, fraudulent, or incompetent acts of others.
  11. Avoid any form of conduct that is fraudulent or creates a conflict of interest, and shall follow the principles of ethical business behavior.
  12. Promote health care delivery through improvement of the access, efficacy, and cost of patient care.
  13. Encourage and promote appropriate stewardship of resources.
  14. Work to achieve and maintain respectful, functional, and beneficial relationships with all health professionals.

Scope of Service Respiratory Therapy Unit

TYPES OF PATIENTS SERVED

The department provides a wide range of inpatient services that are therapeutic and diagnostic in nature. The services includes neonates, pediatric and adult patients as well as providing services for elderly patients in long term care.

The Respiratory Therapy Department is organized under the supervision of the Office of Medical Director and Internal Medicine Department and is staffed by qualified Respiratory Therapists. Medical direction is provided by a board certified Internist. All personnel are licensed by the Council for Certification of Health Care Specialties.

The Department of Respiratory Therapy provide an array of services, including patient assessment, therapy / treatment recommendation, medication delivery, diagnostic testing and life support management for newborn, pediatric, adult, and geriatric patients. Services available to inpatients include but are not limited to: aerosol and oxygen therapy, chest physiotherapy, obtaining sputum specimens, airway maintenance, insertion and care of artificial airways, patient education, and make clinical suggestions for the service needs and inject a plan of care for patients supported with mechanical ventilation (invasive or non-invasive).

Scope and complexity

The department cares for all inpatient age groups in all stages of diseases, assist patients with many different types of breathing disorders and problems.

Level of services provided

The respiratory therapy department provides:

  1. Diagnostic services
    Inpatient diagnostics include blood gas sampling and analysis, bedside spirometry / spontaneous mechanics measurement and assists with capnography. Pulmonary Function Testing for Patient.
  2. Treatments
    The department manages all mechanical ventilation supported patients , oxygen therapy, administers aerosol drugs and cardiopulmonary rehabilitation. Routinely move all mechanically ventilated patients in the hospital when they are about to leave the ICU , or when these patients are transferred to a local hospital or their country of origin.
  3. Education
    The department provides vital knwledge to the patients helping them control and manage their disease/ illness and wellness promotion. The focus of patient and family increased education is to engage and increase knowledge and unique understanding of the disease process, medical therapy and self-help.

RANGE OF TREATMENTS OR ACTIVITIES PERFORMED

The practice of respiratory care includes activities in diagnostic evaluation strategies , therapy, and education of the patient and family. These activities are enhanced through education, research, and administration. Diagnostic activities for RT include but are not limited to: obtaining and throughly analyzing the specimens interpreting data, performing tests and studies of the cardiopulmonary system.

Therapy includes but is not limited to the application and critical monitoring of all medical gases (excluding anesthetic gases) and environmental controling systems;  ventilator support; artificial airway bronchopulmonary hygiene; pharmacological agents related to respiratory care procedures; hemodynamic cardiovascular support and pulmonary function testing.

TYPES OF STAFF CARRYING OUT THESE ACTIVITIES

All treatments are carried out by qualified Respiratory Therapists who are licensed by the Council for Certification of Health Care Specialties. A competency-based individual training prog is in place for each personnel administering respiratory related care, to ensure the highest quality of services with proper allocation of resources to standardize care delivery and implement best practice guidelines in support of quality improvement and clinical collaboration.

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