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Monthly Archives: December 2017

Anthelmintics

Drugs for threadworms

Anthelmintics are effective in threadworm infections, but their use needs to be combined with hygienic measures to break the cycle of auto-infection. All members of the family require treatment.

MEBENDAZOLE:

Indications: Ancylostoma Duodenale Infection, Ascariasis, Enterobiasis, Necator Americanus Infection, Trichuriasis (threadworm, roundworm, whipworm, and hookworm infections).

Contraindications: Disease of Liver.

Dose and Administration: Threadworms, adult and child over 2 years, 100 mg as a single dose; if reinfection occurs second dose may be needed after 2 weeks. Whipworms, adult and child over 2 years, 100 mg twice daily for 3 days.

 

Drugs for hookworms

ALBENDAZOLE:

Indications: Echinococcus Granulosus Infection, Echinococcus Granulosus Infection of the Liver, Echinococcus Granulosus Infection of the Lung, and Echinococcus Granulosus Infection of the Peritoneum, Neurocysticercosis.

Contraindications: Disease of Liver, Anemia, and Neutropenic Disorder.

Dose and Administration: 400 mg by oral route as single dose with food.

Schistosomicides

PRAZIQUANTEL:

Indications: Clonorchiasis due to C. Sinensis, Opisthorchiasis, Schistosomiasis, Schistosomiasis due to S. Haematobium, Schistosomiasis due to S. Japonicum, Schistosomiasis due to S. Mansoni, Schistosomiasis due to S. Mekongi. Contraindications: Ocular Cysticercosis.

Dose and Administration: 25 mg/kg by oral route 3 times per day for 1 day doses not being less than 4 hours and not more than 6 hours apart.

Antibacterial drugs

Antibacterial drugs

Before selecting an antibacterial the clinician must first consider two factors—the patient and the known or likely causative organism. Factors related to the patient which must be considered include history of allergy, renal and hepatic function, susceptibility to infection, ability to tolerate drugs by mouth, severity of illness, ethnic origin, age, whether taking other medication and, if female, whether pregnant, breast-feeding or taking an oral contraceptive. The known or likely organism and its antibacterial sensitivity, in association with the above factors, will suggest one or more antibacterial, the final choice depending on the microbiological, pharmacological, and toxicological properties.

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Drugs for dementia

RIVASTIGMINE:

Indications: mild to moderate dementia in Alzheimer’s disease or in Parkinson’s disease.

Contraindications: breast-feeding.

Dose and Administration: Initially 1.5 mg twice daily, increased in steps of 1.5 mg twice daily at intervals of at least 2 weeks according to response and tolerance; usual range 3–6 mg twice daily; max. 6 mg twice daily.

MEMANTINE HYDROCHLORIDE:

Indications: moderate to severe dementia in Alzheimer’s disease.

Contraindications: breast-feeding.

Dose and Administration: Initially 5 mg in the morning, increased in steps of 5 mg at weekly intervals, up to max. 10 mg twice daily; doses over 5 mg given in 2 divided doses.

Drugs used in Parkinsonism and related Disorders

In idiopathic Parkinson’s disease, the progressive degeneration of pigmented neurones in the substantia nigra leads to a deficiency of the neurotransmitter dopamine. The resulting neurochemical imbalance in the basal ganglia causes the characteristic signs and symptoms of the illness. Drug therapy does not prevent disease progression, but it improves most patients’ quality of life. Treatment is usually not started until symptoms cause significant disruption of daily activities.

Dopaminergic drugs used in Parkinsonism

BROMOCRIPTINE:

Indications: Parkinsonism (but not drug-induced extrapyramidal symptoms).

Contraindications: Eclampsia of Pregnancy, Lactating Mother, Mild Pre­Eclampsia, Pregnancy-Induced Hypertension, Severe Pre-Eclampsia, Severe Uncontrolled Hypertension, Cerebrovascular Accident, Coronary Artery Disease, Hypertension, Psychiatric Disturbance.

Dose and Administration: First week 1–1.25 mg at night, second week 2– 2.5 mg at night, third week 2.5 mg twice daily, fourth week 2.5 mg 3 times daily then increasing by 2.5 mg every 3–14 days according to response to a usual range of 10–40 mg daily; taken with food.

PRAMIPEXOLE:

Indications: Parkinson’s disease, used alone or as an adjunct to levodopa with dopa-decarboxylase inhibitor; moderate to severe restless legs syndrome.

Contraindications: breast-feeding it May suppress lactation.

Dose and Administration: Parkinson’s disease, initially 88 micrograms 3 times daily, dose doubled every 5–7 days if tolerated to 350 micrograms 3 times daily; further increased if necessary by 180 micrograms 3 times daily at weekly intervals; max. 3.3 mg daily in 3 divided doses. During pramipexole dose titration and maintenance, levodopa dose may be reduced. Restless legs syndrome, initially 88 micrograms once daily 2–3 hours before bedtime, dose doubled every 4–7 days if necessary to 350 micrograms daily; max. 540 micrograms daily; child under 18 years not recommended.

LEVODOPA-CARBIDOPA:

Indications: Idiopathic Parkinsonism, Parkinsonism, Postencephalitic Parkinsonism, Restless Legs Syndrome.

Contraindications: Malignant Melanoma, Narrow Angle Glaucoma, Conduction Disorder of the Heart, Depression, Drug-Induced Psychosis, Duodenal Ulcer, Dyskinesia, Gastric Ulcer, Gastrointestinal Hemorrhage, Myocardial Infarction, Peptic Ulcer, Psychotic Disorder, Pulmonary Disease, Renal Disease, Severe Cardiovascular Disease, Suicidal Ideation.

Dose and Administration: Expressed as levodopa, initially 100 mg (with carbidopa 25 mg) 3 times daily, increased by 50–100 mg (with carbidopa 12.5– 25 mg) daily or on alternate days according to response, up to 800 mg (with carbidopa 200 mg) daily in divided doses. Alternatively, initially 50–100 mg (with carbidopa 10–12.5 mg) 3–4 times daily, increased by 50–100 mg daily or on alternate days according to response, up to 800 mg (with carbidopa 80–100 mg) daily in divided doses. Alternatively, initially 125 mg (with carbidopa 12.5 mg, as 1/2 tablet of co-careldopa 25/250) 1–2 times daily, increased by 125 mg (with carbidopa 12.5 mg) daily or on alternate days according to response.

ENTACAPONE:

Indications: adjunct to levodopa with dopa-decarboxylase inhibitor in Parkinson’s disease and ‘end-of-dose’ motor fluctuations.

Contraindications: pregnancy; breast-feeding; hepatic impairment; phaeochromocytoma; history of neuroleptic malignant syndrome or non-traumatic rhabdomyolysis.

Dose and Administration: 200 mg with each dose of levodopa with dopa­decarboxylase inhibitor; max. 2 g daily.

LEVODOPA-CARBIDOPA- ENTACAPONE:

Indications: Idiopathic Parkinsonism.

Contraindications: Malignant Melanoma, Narrow Angle Glaucoma, Conduction Disorder of the Heart, Depression, Drug-Induced Psychosis, Duodenal Ulcer, Dyskinesia, Gastric Ulcer, Gastrointestinal Hemorrhage, Myocardial Infarction, Peptic Ulcer, Psychotic Disorder, Pulmonary Disease, Renal Disease, Severe Cardiovascular Disease, Suicidal Ideation.

Dose and Administration: Only 1 tablet to be taken for each dose; max. 10 tablets daily.

PIRIBEDIL:

Indications: Treatment of Parkinson’s disease (PD), either as monotherapy (without L-DOPA (Levodopa)) or in combination with L-DOPA therapy, in the early stages as well as in the advanced stages of the disease. Treatment of pathological cognitive deficits in the elderly (impaired attention, motivation, memory, etc). Treatment of dizziness in the elderly. Adjuvant treatment in intermittent claudication due to peripheral vascular disease (PVD) of the lower limbs.

Contraindications: Circulatory collapse, acute myocardial infarction.

Dose and Administration: Administration of piribedil should be initiated with one tablet daily during the first week. Dosage should then be gradually increased every week until achieving the optimal therapeutic dose. as monotherapy: three to five tablets in three to five doses daily. in combination with L-dopa therapy: one to three tablets daily.

Antimuscarinic drugs used in parkinsonism

PROCYCLIDINE HYDROCHLORIDE:

Indications: Parkinsonism; drug-induced extrapyramidal symptoms.

Contraindications: Antimuscarinics should be avoided in gastro-intestinal obstruction and myasthenia gravis.

Dose and Administration: By mouth, 2.5 mg 3 times daily, increased gradually in steps of 2.5–5 mg daily every 2–3 days if necessary; usual max. 30 mg daily in 2–4 divided doses (60 mg daily in exceptional circumstances); elderly preferably lower end of range. By intramuscular or intravenous injection, acute dystonia, 5–10 mg (occasionally more than 10 mg), usually effective in 5– 10 minutes but may need 30 minutes for relief; elderly preferably lower end of range.

 

Drugs used in essential tremor, chorea, tics, and related disorders

PIRACETAM:

Indications: adjunctive treatment of cortical myoclonus.

Contraindications: cerebral haemorrhage; hepatic impairment; pregnancy; breast-feeding.

Dose and Administration: Initially 7.2 g daily in 2–3 divided doses, increased according to response by 4.8 g daily every 3–4 days to max. 20 g daily (subsequently, attempts should be made to reduce dose of concurrent therapy); child under 16 years not recommended

Torsion dystonias and other involuntary movements:

BOTULINUM TOXIN TYPE A:

Indications: to treat the abnormal head position and neck pain that happens with cervical dystonia (CD) in adults. To treat certain types of eye muscle problems (strabismus) or abnormal spasm of the eyelids (blepharospasm) in people 12 years and older.

Contraindications: generalised disorders of muscle activity (e.g. myasthenia gravis).

Dose and Administration: 50 Units in each injection site and to not exceed 200 units during the first treatment session.

Antiepileptics

CARBAMAZEPINE:

Indications: Complex-Partial Epilepsy, Epilepsy, Mixed Epilepsy, Tonic-Clonic Epilepsy, Trigeminal Neuralgia, Attention-Deficit Hyperactivity Disorder, Bipolar Disorder in Remission, Diabetes Insipidus, Manic Bipolar Disorder, Mixed Bipolar I Disorder, Neuralgia, Paroxysmal Choreoathetosis, Prevention of Seizures following Cranial Trauma or Surgery, Restless Legs Syndrome.

Contraindications: Ataxia, Blurred Vision, Diplopia, Dizziness, Drowsy, Impaired Cognition, Nausea, Nystagmus, Vomiting.

Dose and Administration: By mouth, epilepsy, initially, 100–200 mg 1–2 times daily, increased slowly (see notes above) to usual dose of 0.4–1.2 g daily in divided doses; in some cases 1.6–2 g daily may be needed; elderly reduce initial dose; child daily in divided doses, up to 1 year 100–200 mg, 1–5 years 200– 400 mg, 5–10 years 400–600 mg, 10–15 years 0.4–1 g. Trigeminal neuralgia, initially 100 mg 1–2 times daily (but some patients may require higher initial dose), increased gradually according to response; usual dose 200 mg 3–4 times daily, up to 1.6 g daily in some patients. Prophylaxis of bipolar disorder unresponsive to lithium, initially 400 mg daily in divided doses increased until symptoms controlled; usual range 400–600 mg daily; max. 1.6 g daily.

GABAPENTIN:

Indications: monotherapy and adjunctive treatment of partial seizures with or without secondary generalisation; peripheral neuropathic pain, trigeminal neuralgia.

Contraindications: Suicidal Ideation, Depression, And Renal Disease.

Dose and Administration: Epilepsy, 400 mg on day 1, then 400 mg twice daily on day 2, then 400 mg 3 times daily on day 3 or initially 400 mg 3 times daily on day 1; then increased according to response in steps of 400 mg daily (in 3 divided doses) every 2–3 days; usual dose 0.9–3.6 g daily in 3 divided doses; child 6–12 years (adjunctive therapy only) 10–15 mg/kg daily initially, then increased according to response over 3 days to usual maintenance dose 25– 35 mg/kg daily in 3 divided doses; max. 50 mg/kg daily in 3 divided doses. Neuropathic pain, adult over 18 years, 400 mg on day 1, then 400 mg twice daily on day 2, then 400 mg 3 times daily (approx. every 8 hours) on day 3 or initially 400 mg 3 times daily on day 1, then increased according to response in steps of 400 mg daily (in 3 divided doses) every 2–3 days to max. 3.6 g daily.

PREGABALIN:

Indications: peripheral and central neuropathic pain; adjunctive therapy for partial seizures with or without secondary generalisation; generalised anxiety disorder.

Contraindications: Rhabdomyolysis, Acutely Decompensated Chronic Heart Failure, Angioedema, Myopathy with CK Elevation, Renal Disease with Moderate to Severe Function Impairment, Suicidal Ideation.

Dose and Administration: Neuropathic pain, adult over 18 years, initially 150 mg daily in 2–3 divided doses, increased if necessary after 3–7 days to 300 mg daily in 2–3 divided doses, increased further if necessary after 7 days to max. 600 mg daily in 2–3 divided doses. Epilepsy, adult over 18 years, initially 25 mg twice daily, increased at 7-day intervals in steps of 50 mg daily to 300 mg daily in 2–3 divided doses, increased further if necessary after 7 days to max. 600 mg daily in 2–3 divided doses. Generalised anxiety disorder, adult over 18 years, initially 150 mg daily in 2–3 divided doses, increased if necessary at 7-day intervals in steps of 150 mg daily; max. 600 mg daily in 2–3 divided doses.

LAMOTRIGINE:

Indications: monotherapy and adjunctive treatment of partial seizures and primary and secondarily generalised tonic-clonic seizures; seizures associated with Lennox-Gastaut syndrome; trigeminal neuralgia.

Contraindications: Pregnancy and Suicidal Ideation.

Dose and Administration: Monotherapy, adult and child over 12 years, initially 25 mg once daily for 14 days, increased to 50 mg once daily for further 14 days, then increased by max. 50–100 mg daily every 7–14 days; usual maintenance 100–200 mg daily in 1–2 divided doses (up to 500 mg daily has been required). Adjunctive therapy with valproate, initially 25 mg every other day for 14 days then 25 mg once daily for further 14 days, thereafter increased by max. 25– 50 mg daily every 7–14 days; usual maintenance, 100–200 mg daily in 1–2 divided doses; child 2–12 years initially 150 micrograms/kg once daily for 14 days (those weighing under 13 kg may receive 2 mg on alternate days for first 14 days) then 300 micrograms/kg once daily for further 14 days, thereafter increased by max. 300 micrograms/kg daily every 7–14 days; usual maintenance 1–5 mg/kg daily in 1–2 divided doses (max. single dose 100 mg).

 

LEVETIRACETAM:

Indications: Complex-Partial Epilepsy, Myoclonic Epilepsy Adjunct Treatment, Simple-Partial Epilepsy, And Tonic-Clonic Epilepsy Treatment Adjunct.

Contraindications: Aggressive Behavior, Anxiety, Ataxia, Depersonalization, Depression, Drowsy, Fatigue, Feeling Agitated, Gait Abnormality, Hallucinations, Hostility, Indifference, Irritability, Mood Changes, Psychotic Disorder, Suicidal Ideation.

Dose and Administration: Monotherapy of partial seizures with or without secondary generalisation, by mouth, adult and child over 16 years, initially 250 mg twice daily increased according to response in steps of 250 mg twice daily every 2 weeks; max. 1.5 g twice daily. Adjunctive therapy of partial seizures with or without secondary generalisation, myoclonic seizures, and primarily generalised tonic-clonic seizures, by mouth, adult and child over 12 years, body-weight over 50 kg, initially 500 mg twice daily, adjusted in steps of 500 mg twice daily every 2 to 4 weeks; max. 1.5 g twice daily; child 4–18 years (12–18 years for myoclonic and tonic-clonic seizures), body-weight under 50 kg, initially 10 mg/kg twice daily, adjusted in steps not exceeding 10 mg/kg twice daily every 2 weeks; max. 30 mg/kg twice daily.

PHENOBARBITAL:

Indications: Epilepsy, Insomnia, Seizure Disorder, Simple-Partial Epilepsy, Status Epilepticus, And Tonic-Clonic Epilepsy.

Contraindications: Alcoholism, Lactating Mother, Phenobarbital Toxicity, Porphyria, Pregnancy, Severe Dyspnea, Severe Pain, Sleep Apnea, Chronic Pain, Depression, Hepatic Coma, Hepatic Encephalopathy, Hyperammonemia, Substance Abuse, Suicidal Ideation.

Dose and Administration: By mouth, 60–180 mg at night; child 5–8 mg/kg daily. Status epilepticus, by intravenous injection (dilute injection 1 in 10 with water for injections), 10 mg/kg at a rate of not more than 100 mg/min; max. 1 g.

PHENYTOIN:

Indications: Complex-Partial Epilepsy, Epilepsy, Prevention of Seizures following Cranial Trauma or Surgery, Seizures in Neurosurgery, Simple-Partial Epilepsy, Tonic-Clonic Epilepsy.

Contraindications: Pregnancy, Disease of Liver, Porphyria, And Suicidal Ideation.

Dose and Administration: By mouth, initially 3–4 mg/kg daily or 150–300 mg daily (as a single dose or in 2 divided doses) increased gradually as necessary (with plasma-phenytoin concentration monitoring); usual dose 200–500 mg daily (exceptionally, higher doses may be used); child initially 5 mg/kg daily in 2 divided doses, usual dose range 4–8 mg/kg daily (max. 300 mg daily).

TOPIRAMATE:

Indications: Complex-Partial Epilepsy, Lennox-Gastaut Epilepsy, Migraine Prevention, Simple-Partial Epilepsy, And Tonic-Clonic Epilepsy.

Contraindications: Concentration Difficulty, Decreased Sweating, Drowsy, Fatigue, Impaired Cognition, Memory Impairment, Metabolic Acidosis, Mood Changes, Narrow Angle Glaucoma, Renal Disease with Moderate to Severe Function Impairment, Suicidal Ideation.

Dose and Administration: Monotherapy, initially 25 mg at night for 1 week then increased in steps of 25–50 mg daily at intervals of 1–2 weeks taken in 2 divided doses; usual dose 100 mg daily in 2 divided doses; max. 400 mg daily; child 6–16 years, initially 0.5–1 mg/kg at night for 1 week then increased in steps of 0.5–1 mg/kg daily at intervals of 1–2 weeks taken in 2 divided doses; usual dose 3–6 mg/kg daily in 2 divided doses; max. 15 mg/kg daily. Adjunctive therapy, initially 25 mg at night for 1 week then increased in steps of 25–50 mg daily at intervals of 1–2 weeks taken in 2 divided doses; usual dose 200–400 mg daily in 2 divided doses; max. 800 mg daily; child 2–16 years, initially 25 mg at night for one week then increased in steps of 1–3 mg/kg daily at intervals of 1–2 weeks taken in 2 divided doses; recommended dose range 5–9 mg/kg daily in 2 divided doses; max. 15 mg/kg daily.

VALPROATE SODIUM:

Indications: all forms of epilepsy.

Contraindications: Acute Pancreatitis, Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Chronic Pancreatitis, Citrullinemia, Disease of Liver, Ornithine Carbamyltransferase Deficiency, Pregnancy, Valproic Acid Toxicity.

Dose and Administration: By mouth, initially 600 mg daily in 2 divided doses, preferably after food, increased by 200 mg daily every 3 days to max. 2.5 g daily, usual maintenance dose 1–2 g daily (20–30 mg/kg daily); child body-weight up to 20 kg, initially 20 mg/kg daily in divided doses, may be increased provided plasma concentration monitored (dose above 40 mg/kg daily also monitor clinical chemistry and haematological parameters); child under 12 years body-weight over 20 kg, initially 400 mg daily in divided doses increased according to response (usual range 20–30 mg/kg daily); max. 35 mg/kg daily.

CLONAZEPAM:

Indications: Absence Epilepsy, Atonic Seizures, Lennox-Gastaut Epilepsy, Myoclonic Epilepsy, and Panic Disorder.

Contraindications: respiratory depression; acute pulmonary insufficiency; sleep apnoea syndrome; marked neuromuscular respiratory weakness including unstable myasthenia gravis.

Dose and Administration: mg (elderly 500 micrograms) initially at night for 4 nights, increased according to response over 2–4 weeks to usual maintenance dose of 4–8 mg usually at night (may be given in 3–4 divided doses if necessary); child up to 1 year, initially 250 micrograms increased as above to usual maintenance dose of 0.5–1 mg, 1–5 years, initially 250 micrograms increased as above to 1–3 mg, 5–12 years, initially 500 micrograms increased as above to 3– 6 mg.

VIGABATRIN:

Indications: adjunctive treatment of partial seizures with or without secondary generalisation not satisfactorily controlled with other antiepileptics; monotherapy for management of infantile spasms (West’s syndrome).

Contraindications: Lactating Mother, Pregnancy, Reduced Visual Acuity, Renal Disease, Suicidal Ideation, and Visual Field Defect.

Dose and Administration: With current antiepileptic therapy, initially 1 g daily in single or 2 divided doses then increased according to response in steps of 500 mg at weekly intervals; usual range 2–3 g daily (max. 3 g daily); child initially 40 mg/kg daily in single or 2 divided doses then adjusted according to body-weight 10–15 kg, 0.5–1 g daily; body-weight 15–30 kg, 1–1.5 g daily; body-weight 30–50 kg, 1.5–3 g daily; body-weight over 50 kg, 2–3 g daily. Infantile spasms (West’s syndrome), monotherapy, 50 mg/kg daily, adjusted according to response over 7 days; up to 150 mg/kg daily used with good tolerability.

Analgesics

Non-opioid analgesics

ASPIRIN:

Indications: mild to moderate pain, pyrexia; antiplatelet.

Contraindications: children under 16 years and in breast-feeding (Reye’s syndrome); previous or active peptic ulceration, haemophilia; not for treatment

of gout.

Dose and Administration: By mouth, 300–900 mg every 4–6 hours when necessary; max. 4 g daily; child under 16 years not recommended.

PARACETAMOL (Acetaminophen):

Indications: Arthritic Pain, Back Pain, Dysmenorrhea, Fever, Headache Disorder, Myalgia, Pain, and Toothache.

Contraindications: Acetaminophen Toxicity, Alcoholism, and Disease of Liver.

Dose and Administration: By mouth, 0.5–1 g every 4–6 hours to a max. of 4 g daily; child 2 months 60 mg for post-immunisation pyrexia, repeated once after 6 hours if necessary; 3 months–1 year 60–120 mg, 1–5 years 120–250 mg, 6–12 years 250–500 mg; these doses may be repeated every 4–6 hours when necessary (max. of 4 doses in 24 hours). By intravenous infusion over 15 minutes, adult and child over 50 kg, 1 g every 4–6 hours, max. 4 g daily; adult and child 10–50 kg, 15 mg/kg every 4–6 hours, max. 60 mg/kg daily; neonate and child less than 10 kg, 7.5 mg/kg every 4–6 hours, max. 30 mg/kg daily. By rectum adult and children over 12 years 0.5-1gm every 4-6 hours to a max. of 4gm daily. Children 3 months to 1 year 60-125mg. 1-5 years 125-250mg. 5-12 years 250-500mg. These doses may be repeated every 4-6 hours as necessary ( max. 4 doses in 24 hours).

PARACETAMOL-CAFFEINE:

Indications: Fever, Mild Arthritic Pain, Pain.

Contraindications: Acetaminophen Toxicity, Recovery Phase Following Myocardial Infarct, Alcoholism, Conduction Disorder of the Heart, Disease of Liver, Insomnia, Myocardial Ischemia, Necrotizing Enterocolitis, Peptic Ulcer.

Dose and Administration: Adults and children over 12 years of age 2 tablets (each tablet contain 500mg paracetamol & 65mg caffeine) up to 4 times daily not exceeding 8 tablets per 24 hours.

PARACETAMOL-CAFFEINE-CODEINE:

Indications: relief mild to moderate pain and fever.

Contraindications: Acetaminophen Toxicity, Recovery Phase Following Myocardial Infarct, Alcoholism, Conduction Disorder of the Heart, Disease of Liver, Insomnia, Myocardial Ischemia, Necrotizing Enterocolitis, Peptic Ulcer and in those patients with G6PD deficiency.

Dose and Administration: Adults and children over 12 years of age 2 tablets/capsules (each tablet contain 500mg paracetamol, 30mg caffeine & 8mg codeine phosphate) up to 4 times daily not exceeding 8 tablets per 24 hours.

Opioid analgesics

Opioid analgesics are usually used to relieve moderate to severe pain particularly of visceral origin. Repeated administration may cause dependence and tolerance, but this is no deterrent in the control of pain in terminal illness. Regular use of a potent opioid may be appropriate for certain cases of chronic non-malignant pain; treatment should be supervised by a specialist and the patient should be assessed at regular intervals. Opioids should be used with caution in patients with impaired respiratory function (avoid in chronic obstructive pulmonary disease) and asthma (avoid during an acute attack), hypotension, shock, prostatic hypertrophy, obstructive or inflammatory bowel disorders, diseases of the biliary tract, and convulsive disorders.

MORPHINE SULPHATE:

Indications: General Anesthesia Adjunct, Local Anesthesia Adjunct, Neonatal Abstinence Syndrome, Pain.

Contraindications: Acute Asthma Attack, Head Injury, Intracranial Hypertension, Paralytic Ileus, Status Epilepticus, Chronic Disease of Respiratory System, CNS Depression, Cor Pulmonale, Gastrointestinal Obstruction, Hypotension, Pancreatitis, Respiratory Depression.

Dose and Administration: Acute pain, by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection, initially 10 mg (elderly or frail 5 mg) every 4 hours (or more frequently during titration), adjusted according to response; neonate initially 100 micrograms/kg every 6 hours, adjusted according to response; child 1–6 months initially 100– 200 micrograms/kg every 6 hours, adjusted according to response; child 6 months–2 years initially 100–200 micrograms/kg every 4 hours, adjusted according to response; child 2–12 years initially 200 micrograms/kg every 4 hours, adjusted according to response; child 12–18 years initially 2.5–10 mg every 4 hours, adjusted according to response. By slow intravenous injection, initially 2.5 mg (reduce dose in elderly or frail) every 4 hours (or more frequently during titration), adjusted according to response; neonate initially 40– 100 micrograms/kg every 6 hours, adjusted according to response; child 1–6 months initially 100–200 micrograms/kg every 6 hours, adjusted according to response; child 6 months–12 years initially 100–200 micrograms/kg every 4 hours, adjusted according to response.

PETHIDINE HYDROCHLORIDE:

Indications: moderate to severe pain, obstetric analgesia; peri-operative analgesia.

Contraindications: Acute Asthma Attack, Head Injury, Intracranial Hypertension, Paralytic Ileus, Status Epilepticus, Chronic Disease of Respiratory System, CNS Depression, Cor Pulmonale, Gastrointestinal Obstruction, Hypotension, Pancreatitis, Respiratory Depression.

Dose and Administration: Acute pain, by subcutaneous or intramuscular injection, 25–100 mg, repeated after 4 hours; child, by intramuscular injection, 0.5–2 mg/kg. By slow intravenous injection, 25–50 mg, repeated after 4 hours. Premedication, by intramuscular injection, 25–100 mg 1 hour before operation; child 0.5–2 mg/kg. Postoperative pain, by subcutaneous or intramuscular injection, 25–100 mg, every 2–3 hours if necessary; child, by intramuscular injection, 0.5–2 mg/kg.

FENTANYL CITRATE:

Indications: Administration of General Anesthesia, General Anesthesia Adjunct, Postoperative Pain, Regional Anesthesia for Postoperative Pain, Regional Anesthesia for Surgery.

Contraindications: Acute Asthma Attack, Paralytic Ileus, Toxin-Mediated Diarrhea, Chronic Disease of Respiratory System, Cor Pulmonale, Inflammatory Bowel Disease, Respiratory Depression.

Dose and Administration: By slow intravenous injection, with spontaneous respiration, 50–100 micrograms (max. 200 micrograms on specialist advice), then 50 micrograms as required; child 1–5 micrograms/kg, then 1 microgram/kg as required. With assisted ventilation, 0.3–3.5 mg, then 100–200 micrograms as required; child 5–10 micrograms/kg, then 1–3 micrograms/kg as required. By intravenous infusion, with spontaneous respiration, adult and child, 50– 80 nanograms/kg/minute adjusted according to response. With assisted ventilation, adult and child, initially 10 micrograms/kg over 10 minutes then 100 nanograms/kg/minute adjusted according to response; adults may require up to 3 micrograms/kg/minute during cardiac surgery.

TRAMADOL HYDROCHLORIDE:

Indications: moderate to severe pain.

Contraindications: Alcohol Intoxication, Benzodiazepine Toxicity, Opioid Toxicity, Pregnancy, Respiratory Depression, Alcohol Withdrawal Syndrome, Central Nervous System Infection, CNS Depression, Epilepsy, Head Injury, Hypoglycemic Disorder, Hyponatremia, Intracranial Hypertension, Lower Seizure Threshold, Serotonin Syndrome, Severe Renal Disease, Substance Abuse, Suicidal.

Dose and Administration: adult and child over 12 years, by mouth, 50– 100 mg not more often than every 4 hours; total of more than 400 mg daily not usually required. adult and child over 12 years, by intramuscular injection or by intravenous injection (over 2–3 minutes) or by intravenous infusion, 50–100 mg every 4–6 hours. Postoperative pain, 100 mg initially then 50 mg every 10–20 minutes if necessary during first hour to total max. 250 mg (including initial dose) in first hour, then 50–100 mg every 4–6 hours; max. 600 mg daily.

SUFENTANYL CITRATE:

Indications: Administration of General Anesthesia, General Anesthesia Adjunct.

Contraindications: Bradycardia, Decreased Cardiac Function, Head Injury, Hypothyroidism, Intracranial Hypertension, Intracranial Lesion, Renal Disease.

Dose and Administration: Adult Dosage,In minor but painful general surgical procedures (anticipated duration of anesthesia of 1–2 hours) requiring endotracheal intubation and assisted or controlled respiration in adults, a total sufentanil dosage of 1–2 mcg/kg is administered IV in conjunction with nitrous oxide and oxygen; approximately 75% or more of the total dosage (titrated to patient response) may be administered by slow IV injection or infusion prior to intubation. Pediatric Dosage, The manufacturers state that when sufentanil is used to provide induction and maintenance of anesthesia without additional anesthetic agents in children younger than 12 years of age undergoing cardiovascular surgery, an initial anesthetic dose of 10–25 mcg/kg is administered IV in conjunction with 100% oxygen and a skeletal muscle relaxant; additional IV doses of up to 25–50 mcg each (or, alternatively, 1–2 mcg/kg each) are recommended as necessary based on response to the initial dose and as determined by changes in vital signs that indicate surgical stress or lightening of anesthesia.

TRAMADOL-PARACETAMOL:

Indications: moderate to severe pain.

Contraindications: Acetaminophen Toxicity, Alcohol Intoxication, Benzodiazepine Toxicity, Opioid Toxicity, Pregnancy, Respiratory Depression, Alcoholism, Alcohol Withdrawal Syndrome, Central Nervous System Infection, CNS Depression, Disease of Liver, Epilepsy, Head Injury, Hypoglycemic Disorder, Hyponatremia, Intracranial Hypertension, Lower Seizure Threshold, Serotonin Syndrome, Severe Renal Disease, Substance Abuse, Suicidal.

Dose and Administration: 2 tablets (tramadol hydrochloride 37.5 mg, paracetamol 325 mg) not more than every 6 hours; max. 8 tablets daily; child under 12 years not recommended.

 

Antimigraine Drugs

ERGOTAMINE TARTRATE:

Indications: treatment of acute migraine

Contraindications: Bacterial Septicemia, Buerger’s Disease, Coronary Angioplasty, Coronary Artery Disease, Disease of Liver, Induction of Labor, Intermittent Claudication, Lactating Mother, Nutritional Disorder, Occlusive Peripheral Vascular Disease, Phlebitis, Pregnancy, Premature Labor, Raynaud’s Phenomenon, Renal Disease, Severe Arteriosclerotic Vascular Disease, Severe Pruritus, Severe Uncontrolled Hypertension, Vascular Surgery.

Dose and Administration: adult and child over 12 years, 1–2 tablets (each contain ergotamine tartrate 1 mg, caffeine 100 mg) at onset; max. 4 tablets in 24 hours, not to be repeated at intervals of less than 4 days; max. 8 tablets in one week.

SUMATRIPTAN:

Indications: treatment of acute migraine.

Contraindications: Angina, Basilar Migraine, Cerebral Ischemia, Cerebrovascular Accident, Coronary Artery Disease, Hemiplegic Migraine, Ischemic Bowel Disease, Myocardial Infarction, Myocardial Ischemia, Ophthalmoplegic Migraine, Peripheral Vascular Disease, Prinzmetal Angina, Severe Hepatic Disease, Severe Uncontrolled Hypertension, Transient Cerebral Ischemia.

Dose and Administration: By mouth, 50 mg (some patients may require 100 mg); dose may be repeated after at least 2 hours if migraine recurs; max. 300 mg in 24 hours; Intranasally, 10–20 mg (adolescent 12–17 years 10 mg) into one nostril; dose may be repeated once after at least 2 hours if migraine recurs; max. 40 mg (adolescent 12–17 years 20 mg) in 24 hours.

RIZATRIPTAN:

Indications: treatment of acute migraine.

Contraindications: Angina, Basilar Migraine, Hemiplegic Migraine, Myocardial Infarction, Myocardial Ischemia, Prinzmetal Angina, Severe Uncontrolled Hypertension, Disease of Liver, Peripheral Vascular Disease, Renal Disease.

Dose and Administration: one tablet (5 mg) by oral route once, may repeat at 2-hour intervals; do not exceed 30 mg in 24 hours.

Selective Serotonin Re-uptake Inhibitors (SSRIs)

SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression. In patients with unstable angina or who have had a recent myocardial infarction, sertraline has been shown to be safe.

 

CITALOPRAM:

Indications: Depression, Depression associated with Manic Depressive Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Post Traumatic Stress Disorder, Vasomotor Symptoms associated with Menopause.

Contraindications: Hyponatremia, SIADH Syndrome, Suicidal Ideation, Upper GI Bleed

Dose and Administration: Depressive illness, 20 mg once daily increased if necessary in steps of 20 mg daily at intervals of 3–4 weeks; max. 60 mg daily (elderly over 65 years, max. 40 mg daily). Panic disorder, initially 10 mg daily increased gradually if necessary in steps of 10 mg daily, usual dose 20–30 mg daily; max. 60 mg daily (elderly over 65 years, max. 40 mg daily).

ESCITALOPRAM:

Indications: Generalized Anxiety Disorder, Major Depressive Disorder, Depression associated with Manic Depressive Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Post Traumatic Stress Disorder, Vasomotor Symptoms associated with Menopause

Contraindications: Hyponatremia, SIADH Syndrome, Suicidal Ideation, Upper GI Bleed.

Dose and Administration: adult over 18 years, depressive illness, generalised anxiety disorder, and obsessive-compulsive disorder, 10 mg once daily increased if necessary to max. 20 mg daily; elderly initially half adult dose, lower maintenance dose may be sufficient; child not recommended. adult over 18 years, panic disorder, initially 5 mg once daily increased to 10 mg daily after 7 days; max. 20 mg daily; elderly initially half adult dose, lower maintenance dose may be sufficient. adult over 18 years, social anxiety disorder, initially 10 mg once daily adjusted after 2–4 weeks; usual dose 5–20 mg daily.

 

FLUOXETINE:

Indications: Bulimia Nervosa, Depression, Obsessive-Compulsive Disorder, Panic Disorder, And Premenstrual Dysphoric Disorder.

Contraindications: Abnormal Sexual Function, Anorexia, Bipolar Disorder, and Disease of Liver, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Suicidal Ideation, Upper GI Bleed.

Dose and Administration: Major depression, 20 mg once daily increased after 3–4 weeks if necessary, and at appropriate intervals thereafter; max. 60 mg once daily (elderly usual max. 40 mg once daily but 60 mg can be used). Bulimia nervosa, 60 mg once daily; child and adolescent under 18 years not recommended. Obsessive-compulsive disorder, 20 mg once daily; if inadequate response after 2 weeks increase gradually to max. 60 mg once daily (elderly usual max. 40 mg once daily but 60 mg can be used).

 

FLUVOXAMINE MALEATE:

Indications: depressive illness, obsessive-compulsive disorder.

Contraindications: Lactating Mother, Bipolar Disorder, Hypomania, Manic Disorder, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Suicidal Ideation, And Upper GI Bleed.

Dose and Administration: Depression, initially 50–100 mg daily in the evening, increased gradually if necessary to max. 300 mg daily (over 150 mg in divided doses); usual maintenance dose 100 mg daily; child and adolescent under 18 years not recommended. Obsessive-compulsive disorder, initially 50 mg in the evening increased gradually if necessary after some weeks to max. 300 mg daily (over 150 mg in divided doses); usual maintenance dose 100– 300 mg daily; child over 8 years initially 25 mg daily increased if necessary in steps of 25 mg every 4–7 days to max. 200 mg daily (over 50 mg in 2 divided doses).

 

PAROXETINE:

Indications: major depression, obsessive-compulsive disorder, panic disorder; social anxiety disorder; post-traumatic stress disorder; generalised anxiety disorder.

Contraindications: Pregnancy, Bipolar Disorder, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Suicidal Ideation, And Upper GI Bleed.

Dose and Administration: Major depression, social anxiety disorder, post-traumatic stress disorder, generalised anxiety disorder, usually 20 mg each morning, higher doses on specialist advice only (see also CSM advice, below); max. 50 mg daily (elderly 40 mg daily); child and adolescent under 18 years not recommended. Obsessive-compulsive disorder, initially 20 mg each morning, increased gradually in steps of 10 mg to usual dose of 40 mg daily, higher doses on specialist advice only (see also CSM advice, below); max. 60 mg daily (elderly 40 mg daily); child and adolescent under 18 years not recommended. Panic disorder, initially 10 mg each morning, increased gradually in steps of 10 mg to usual dose of 40 mg daily, higher doses on specialist advice only (see also CSM advice, below); max. 60 mg daily (elderly 40 mg daily); child and adolescent under 18 years not recommended.

SERTRALINE:

Indications: depressive illness, obsessive-compulsive disorder (under supervision in children), and post-traumatic stress disorder in women.

Contraindications: Bipolar Disorder, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Suicidal Ideation, And Upper GI Bleed.

Dose and Administration: Depressive illness, initially 50 mg daily, increased if necessary by increments of 50 mg over several weeks to max. 200 mg daily; usual maintenance dose 50 mg daily. Obsessive-compulsive disorder, adult and child over 12 years initially 50 mg daily, increased if necessary in steps of 50 mg over several weeks; usual dose range 50–200 mg daily; child 6–12 years initially 25 mg daily, increased to 50 mg daily after 1 week, further increased if necessary in steps of 50 mg at intervals of at least 1 week (max. 200 mg daily). Post-traumatic stress disorder, initially 25 mg daily, increased after 1 week to 50 mg daily; if response is partial and if drug tolerated, dose increased in steps of 50 mg over several weeks to max. 200 mg daily; child and adolescent under 18 years not recommended.

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