NAUSEA AND VERTIGO

Nausea and vomiting (also called emesis)

Nausea is an uneasy or unsettled feeling in the stomach together with an urge to vomit. Nausea and vomiting, or throwing up, are not diseases. They can be symptoms of many different conditions. 

Many common problems may cause nausea and vomiting, including:

-food allergies

-infections of the stomach or bowels, such as the "stomach flu" or food poisoning

-leaking of stomach contents (food or liquid) upwards (also called gastro-oesophageal reflux or GORD)

-medicines or medical treatments, such as cancer chemotherapy or radiation treatment

-migraine headaches

-morning sickness during pregnancy

-seasickness or motion sickness

-severe pain, such as with kidney stones

Nausea and vomiting may also be early warning signs of more serious medical problems, such as appendicitis, blockage in the intestines, cancer or a tumor, ingesting a drug or poison (especially by children) or ulcers in the lining of the stomach or small intestine.

Nausea and vomiting are common. Usually, they are not serious. Medical advice should be sought immediately if :

-vomited for longer than 24 hours

-blood in the vomit

-severe abdominal pain

-headache and stiff neck

-signs of dehydration, such as dry mouth, infrequent urination or dark urine.

Vertigo

The most common symptoms of vertigo include a feeling of spinning (you or the room around you), tilting or swaying and feeling off balance. These feelings come and go, and may last seconds, hours, or days. You may feel worse when you move your head, change positions (stand up, roll over), cough, or sneeze. Along with vertigo, you may vomit or feel nauseous, have a headache or be sensitive to light and noise, see double, have trouble speaking or swallowing, feel weak or short of breath or sweaty and have a racing heart beat.

The most common causes of vertigo include:

• Inner ear problems: collections of calcium, inflammation, and certain infections can cause problems in the vestibular system. The vestibular system includes parts of the inner ear and nervous system, which controls balance.
• Benign paroxysmal positional vertigo (BPPV): sometimes called benign positional vertigo, positional vertigo, postural vertigo, or simply vertigo, is a type of vertigo that develops due to collections of calcium in the inner ear. These collections are called canaliths. Moving the canaliths (called canalith repositioning) is a common treatment for BPPV. Vertigo is typically brief in people with BPPV, lasting seconds to minutes. Vertigo can be triggered by moving the head in certain ways.
• Meniere disease:  is a condition that causes repeated spells of vertigo, hearing loss, and ringing in the ears. Spells can last several minutes or hours. It is probably caused by a buildup of fluid in the inner ear. 
• Vestibular neuritis: vestibular neuritis, also known as labyrinthitis, is probably caused by a virus that causes swelling around the balance nerve. People with vestibular neuritis develop sudden, severe vertigo, nausea, vomiting, and difficulty walking or standing up; these problems can last several days. 

• Head injury: head injuries can affect the vestibular system in a variety of ways, and lead to vertigo.
• Medications: rarely, medications can actually damage or affect the function of the inner ear or brain and lead to vertigo.
• Migraines: in a condition called vestibular migraine or migrainous vertigo, vertigo can be caused by a migraine. This type of vertigo usually happens along with a headache.
• Brain problems, such as a stroke or TIA (transient ischemic attack), bleeding in the brain, or multiple sclerosis can also cause vertigo. 

-Drugs used in nausea and vertigo:

• Antihistamines:                                                                         

           -cinnarizine (Stugeron, Arievert)                                                        -cyclizine (Valoid)                                                                    

           -promethazine hydrochloride                                                              -promethiazine teoclate (Avomine).                                                              

• Phenothiazines and related drugs: 

            -chlorpromazine hydrochloride

            -perphenazine

            -prochlorperazine (Stemetil, Buccastem)

            -trifluoperazine.

• Domperidone and metoclopramide:

           -domperidone (Motillium)                                      

           -metoclopramide hydrochloride (Maxolon)

• 5HT3 antagonists:

           -dolasetron mesilate (Anzemet)

           -granisetron (Kytril)

           -ondansetron (Zofran)

           -palonosetron (Aloxi)

• Neurikinin receptor antagonist:

          -aprepitant (Emend)

          -fosaprepitant (Ivemend)

• Cannabinoid: nabilone

• Hyoscine: hyoscine hydrobromide (Joy Rides, Kwells, Scopoderm TTS patches)

• Other drugs for Meniere's disease: betahistine dihydrochloride (Serc).  

Sources:

-https://medlineplus.gov/nauseaandvomiting.html

-http://www.medscape.org/

-https://medlineplus.gov/dizzinessandvertigo.html

-http://www.uptodate.com/contents/dizziness-and-vertigo-beyond-the-basics?view=print

-http://backinmotionfl.com/stop-suffering-vertigo/

-http://www.manxhealthcare.com/products/betahistine.html

-https://www.theindependentpharmacy.co.uk/onlinedoctor/treatment/cyclizine-50mg-tablets100/

CONTROLLED DRUGS

The Misuse of Drugs Regulations 2001 (and subsequent amendments) define the classes of person who are authorised to supply and possess controlled drugs while acting in their professional capacities and lay down the conditions under which these activities may be carried out. In the regulations drugs are divided into five schedules each specifying the requirements governing such activities as import, export, production, supply, possession, prescribing, and record keeping which apply to them.

• Schedule 1: includes drugs such as lysergide which is not used medicinally. Possession and supply are prohibited except in accordance with Home Office authority.

• Schedule 2: includes drugs such as diamorphine (heroin), morphine, nabilone, remifentanil, pethidine, secobarbital, glutethimide, the amfetamines, sodium oxybate, and cocaine and are subject to the full controlled drug requirements relating to prescriptions, safe custody (except for secobarbital), the need to keep registers, etc. (unless exempted in Schedule 5). 

• Schedule 3: includes the barbiturates (except secobarbital, now Schedule 2), buprenorphine, mazindol, meprobamate, midazolam, pentazocine, phentermine, temazepam, and tramadol. They are subject to the special prescription requirements. Safe custody requirements do apply, except for any 5,5 disubstituted barbituric acid (e.g. phenobarbital), mazindol, meprobamate, midazolam, pentazocine, phentermine, tramadol, or any stereoisomeric form or salts of the above. Records in registers do not need to be kept (although there are requirements for the retention of invoices for 2 years).

• Schedule 4: includes in Part I benzodiazepines (except temazepam and midazolam, which are in Schedule 3), zaleplon, zolpidem, and zopiclone which are subject to minimal control. Part II includes androgenic and anabolic steroids, clenbuterol, chorionic gonadotrophin (HCG), non-human chorionic gonadotrophin, somatotropin, somatrem, and somatropin. Controlled drug prescription requirements do not apply and Schedule 4 Controlled Drugs are not subject to safe custody requirements.

• Schedule 5: includes those preparations which, because of their strength, are exempt from virtually all Controlled Drug requirements other than retention of invoices for two years

Standards and safety checks

NMC(standards for medicine management)

-Controlled drugs are kept in a locked cabinet and the keys are carried by the nurse in charge (access to the keys and the CD cabinet is restricted to authorised registrants). CD stationery which is used to order, return or distribute controlled drugs should be kept in the locked cabinet. No other medicines or items to be stored in the controlled drug cupboard.

-There should be a list of the CDs to be held in each ward as stock items, only the CDs listed may be routinely requisitioned or topped-up.

-A copy of the signature of each authorised signatory should be available in the pharmacy department for validation.

-When CDs are delivered to a ward they should be handed to a designated person, under no circumstances should they be left unattended. After the delivery, the registrant in charge and a witness (another registrant) should check the CDs against the requisition, place the CDs in the CD cupboard, enter the CDs into the ward controlled drug record book, update the running balance and check that the balance tallies with the quantity that is physically present.

-All entries in the controlled drug record book must be signed by two registrants.

-Checking the balance in the controlled drugs register against current stock should be done twice a day, recording stock checks along with the date and signature of both health professionals carrying out the check. 

-The registrants should record the amount given and the amount wasted (if there is any) when administering a CD.

-Audits should be carried out to ensure that the record keeping is up to date and correct.

Sources:

-http://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/controlled-drugs-and-drug-dependence

-Controlled drugs: safe use and management(2016) NICE guideline NG46

-https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicines-management.pdf

Images: kwizoo.com, www.officestationerywarehouse.co.uk, www.davidwolfe.com, www.opiates.com.

OBESITY

Obesity means having too much body fat. It is not the same as being overweight, which means weighing too much. A person may be overweight from extra muscle or water, as well as from having too much fat. Both terms mean that a person's weight is higher than what is thought to be healthy for his or her height.

Causes

Taking in more calories than you burn can lead to obesity. This is because the body stores unused calories as fat. Obesity can be caused by: 

-Eating more food than your body can use 

-Drinking too much alcohol 

-Not getting enough exercise. 

Many obese people who lose large amounts of weight and gain it back think it is their fault. They blame themselves for not having the willpower to keep the weight off. Many people regain more weight than they lost.

Today, we know that biology is a big reason why some people cannot keep the weight off. Some people who live in the same place and eat the same foods become obese, while others do not. Our bodies have a complex system to keep our weight at a healthy level. In some people, this system does not work normally.

The way we eat when we are children can affect the way we eat as adults.

The term eating disorder means a group of medical conditions that have an unhealthy focus on eating, dieting, losing or gaining weight, and body image. A person may be obese, follow an unhealthy diet, and have an eating disorder all at the same time.

See more about imbalanced nutrition: http://enfermeriastgo.blogspot.co.uk/2014/03/imbalanced-nutrition-care-plan-and-must.html

Sometimes, medical problems or treatments cause weight gain, including: 

-Underactive thyroid (hypothyroidism) 

-Medicines such as birth control pills, antidepressants and antipsychotics. 

Other things that can cause weight gain are: 

-Quitting smoking: many people who quit smoking gain 4 to 10 pounds in the first 6 months after quitting 

-Stress, anxiety, feeling sad, or not sleeping well 

-Menopause: women may gain 12 to 15 pounds during menopause 

-Pregnancy: women may not lose the weight they gained during pregnancy.

DRUGS USED IN THE TREATMENT OF OBESITY

Obesity should be managed in an appropriate setting by staff who have been trained in the management of obesity; the individual should receive advice on diet and lifestyle modification and be monitored for changes in weight as well as in blood pressure, blood lipids and other associated conditions.

An anti-obesity drug should be considered only for those with a body mass index of 30kg/m or greater in whom at least 3 months of managed care involving supervised diet, exercise and behaviour modification fails to achieve a realistic reduction in weight.

Drugs should never be used as the sole element of treatment. The individual should be monitored on a regular basis; drug treatment should be discontinued if the individual regains weight at any time whilst receiving drug treatment. 

1. Anti-obesity drugs acting on the gastro-intestinal tract:
-Orlistat (Xenical).

2. Centrally acting appetite suppressants:
-Rimonabant (Acomplia)
-Sibutramine Hydrochloride (Reductil).

In July 2012, the FDA approved two new medicines for chronic (ongoing) weight management. Lorcaserin hydrochloride (Belviq®) and Qsymia™ are approved for adults who have a BMI of 30 or greater. 

SURGERY

Weight-loss surgery might be an option for people who have extreme obesity (BMI of 40 or more) when other treatments have failed. It is also an option for people who have a BMI of 35 or more and life-threatening conditions, such as:

-Severe sleep apnea 

-Obesity-related cardiomyopathy

-Severe type 2 diabetes

Two common weight-loss surgeries include banded gastroplasty and Roux-en-Y gastric bypass. For gastroplasty, a band or staples are used to create a small pouch at the top of your stomach. This surgery limits the amount of food and liquids the stomach can hold. 

For gastric bypass, a small stomach pouch is created with a bypass around part of the small intestine where most of the calories you eat are absorbed. This surgery limits food intake and reduces the calories your body absorbs.

Like any surgery, there are risks associated to this interventions, side effects and lifelong medical followup is needed after both surgeries.

Sources:
-https://medlineplus.gov/obesity.html
-BNF 57 March 2009
-https://www.nhlbi.nih.gov/health/health-topics/topics/obe/treatment
-http://mhadegree.org/obesity-and-your-healthcare-career/
-http://lifescienceevents.com/2016-obesity-summit-12th-14th-april-2016/

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Attention deficit hyperactivity disorder (ADHD) is a problem of not being able to focus, being overactive, not being able control behavior, or a combination of these. For these problems to be diagnosed as ADHD, they must be out of the normal range for a person's age and development.

Causes:

ADHD usually begins in childhood, but may continue into the adult years. It is the most commonly diagnosed behavioral disorder in children. ADHD is diagnosed much more often in boys than in girls.

It is not clear what causes ADHD. A combination of genes and environmental factors likely plays a role in the development of the condition. Imaging studies suggest that the brains of children with ADHD are different from those of children without ADHD.

Symptoms of ADHD fall into three groups:
-Not being able to focus (inattentiveness)
-Being extremely active (hyperactivity)
-Not being able to control behavior (impulsivity).

Some people with ADHD have mainly inattentive symptoms. Some have mainly hyperactive and impulsive symptoms. Others have a combination of different symptom types. Those with mostly inattentive symptoms are sometimes said to have attention deficit disorder (ADD). They tend to be less disruptive and are more likely not to be diagnosed with ADHD.

Inattentive Symptoms
-Fails to give close attention to details or makes careless mistakes in schoolwork
-Has difficulty keeping attention during tasks or play
-Does not seem to listen when spoken to directly
-Does not follow through on instructions and fails to finish schoolwork or chores and tasks
-Has problems organizing tasks and activities
-Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)
-Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
-Is easily distracted
-Is often forgetful in daily activities.

Hyperactivity Symptoms
-Fidgets with hands or feet or squirms in seat
-Leaves seat when remaining seated is expected
-Runs about or climbs in inappropriate situations
-Has problems playing or working quietly
-Is often "on the go," acts as if "driven by a motor"
-Talks excessively.

Impulsivity Symptoms
-Blurts out answers before questions have been completed
-Has difficulty awaiting turn
-Interrupts or intrudes on others (butts into conversations or games).

PHARMACOLOGY
CNS stimulants and drugs used for ADHD:

-Atomoxetine (Strattera).

-Dexamfetamine sulphate (Dexedrine).

-Methylphenidate hydrochloride (Ritalin, Concerta XL, Equasym XL, Medikinet XL).
-Modafinil (Provigil).

Source:
-http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
-BNF 57

ANTIDEPRESSANT DRUGS

DEPRESSION

Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods.

Clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for a longer period of time.

Symptoms of depression include:
-Low or irritable mood most of the time
-A loss of pleasure in usual activities
-Trouble sleeping or sleeping too much
-A big change in appetite, often with weight gain or loss
-Tiredness and lack of energy
-Feelings of worthlessness, self-hate, and guilt
-Difficulty concentrating
-Slow or fast movements
-Lack of activity and avoiding usual activities
-Feeling hopeless or helpless
-Repeated thoughts of death or suicide.
Low self-esteem is common with depression. It is also common to have sudden bursts of anger and a lack of pleasure from activities that normally make you happy, including sex.

The main types of depression include:

-Major depression: to be diagnosed with major depression, you must have five or more of the symptoms listed above for at least 2 weeks. Major depression tends to continue for at least 6 months if not treated. (You are said to have minor depression if you have less than five depression symptoms for at least 2 weeks. Minor depression is similar to major depression except it only has two to four symptoms.)

-Atypical depression: occurs in about a third of patients with depression. Symptoms include overeating and oversleeping. You may feel like you are weighed down and get very upset by rejection.

-Dysthymia: a milder form of depression that can last for years, if not treated.

Other common forms of depression include:

Postpartum depression: many women feel down after having a baby, but true postpartum depression is more severe and includes the symptoms of major depression.

Premenstrual dysphoric disorder: symptoms of depression occur 1 week before your menstrual period and disappear after you menstruate.

Seasonal affective disorder (SAD): occurs most often during the fall-winter season and disappears during the spring-summer season. It is most likely due to a lack of sunlight.

Depression may also alternate with mania (known as manic depression or bipolar disorder).

PHARMACOLOGY

1. Tricyclic and related antidepressant drugs:

-Amitriptyline hydrochloride (Triptafen).

-Clomipramine Hydrochloride (Anafranil).

-Dosulepin Hydrochloride (Prothiaden).

-Doxepin (Sinepin).

-Imipramine Hydrochloride.

-Lofepramine.

-Nortriptyline (Allegron).

-Trimipramine (Surmontil).

Related antidepressant drugs: Mianserin Hydrochloride and Trazodone Hydrochloride (Molipaxin).

2. Monoamine-oxidase inhibitors (MAOIs):

-Phenelzine (Nardil).

-Isocarboxazid.

-Tranylcypromine.

-Reversible MAOIs: Moclobemide (Manerix).

3. Selective serotonin re-uptake inhibitors: 

-Citalopram (Cipramil).

-Escitalopram (Cipralex).

-Fluoxetine (Prozac).

-Fluvoxamine maleate (Faverin).

-Paroxetine (Seroxat).

-Sertraline (Lustral).

4. Other antidepressant drugs:

-Duloxetine (Cymbalta, Yentreve).

-Flupentixol (Fluanxol).

-Mirtazapine (Zispin SolTab).

-Reboxetine (Edronax).

-Tryptophan (Optimax).

-Venlafaxine (Efexor).

Sources:

-http://www.nlm.nih.gov/medlineplus/ency/article/003213.htm\

-BNF57

ANTIPSYCHOTIC DRUGS

SCHIZOPHRENIA

Schizophrenia is a serious brain illness. People who have it may hear voices that aren't there. They may think other people are trying to hurt them. Sometimes they don't make sense when they talk. The disorder makes it hard for them to keep a job or take care of themselves.

Symptoms of schizophrenia usually start between ages 16 and 30. Men often develop symptoms at a younger age than women. People usually do not get schizophrenia after age 45. There are three types of symptoms:

-Psychotic symptoms distort a person's thinking. These include hallucinations (hearing or seeing things that are not there), delusions (beliefs that are not true), trouble organizing thoughts, and strange movements.

-"Negative" symptoms make it difficult to show emotions and to function normally. A person may seem depressed and withdrawn.

Cognitive symptoms affect the thought process. These include trouble using information, making decisions, and paying attention.

No one is sure what causes schizophrenia. Your genes, environment, and brain chemistry may play a role.

There is no cure. Medicine can help control many of the symptoms. Additional treatments can help you deal with your illness from day to day. These include therapy, family education, rehabilitation, and skills training.

MANIA

Bipolar disorder is a serious mental illness. People who have it go through unusual mood changes. They go from very happy, "up," and active to very sad and hopeless, "down," and inactive, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

The causes of bipolar disorder aren't always clear. It runs in families. Abnormal brain structure and function may also play a role.

Bipolar disorder often starts in a person's late teen or early adult years. But children and adults can have bipolar disorder too. The illness usually lasts a lifetime.

If not treated, bipolar disorder can lead to damaged relationships, poor job or school performance, and even suicide. However, there are effective treatments to control symptoms: medicine and talk therapy. A combination usually works best.

PHARMACOLOGY

ANTIPSYCHOTICS DRUGS
-Benperidol (Anquil).
-Chlorpromazine Hydrochloride (Largactil).
-Flupentixol (Depixol).
-Haloperidol (Dozic, Haldol, Serenace).
-Levomepromazine (Nozinan).
-Pericyazine (Neulactil).
-Perphenazine (Fentazin).
-Pimozide (Orap).
-Prochlorperazine.
-Promazine Hydrochloride.
-Sulpiride (Dolmatil, Sulpor).
-Trifluoperazine (Stelazine).
-Zuclopenthixol acetate (Clopixol Acuphase).
-Zuclopenthixol (Clopixol).

Atypical antipsychotic drugs:
-Amisulpride (Solian).
-Aripiprazole (Abilify).
-Clozapine (Clozaril, Denzapine, Zaponex).
-Olanzapine (Zyprexa).
-Paliperidone (Invega).
-Quetiapine (Seroquel).
-Risperidone (Risperdal).
-Sertindole (Serdolect).
-Zotepine (Zoleptil).

ANTIPSYCHOTIC DEPOT INJECTIONS
-Flupentixol Decanoate (Depixol).
-Fluphenazine Decanoate (Modecate).
-Haloperidol (Haldol Decanoate).
-Pipotiazine Palmitate (Piportil Depot).
-Risperidone (Risperdal Consta).
-Zuclopenthixol Decanoate (Clopixol).

ANTIMANIC DRUGS
-Benzodiazepines
-Antipsychotic drugs.
-Carbamazepine.
-Valproic acid (Depakote, Convulex).
-Lithium Carbonate (Camcolit, Liskonum, Priadel).
-Lithium Citrate (Li-liquid, Priadel).

Source:
-www.nlm.nih.gov/medlineplus/bipolardisorder.html
-BNF 57 March 2009

HYPNOTICS AND ANXIOLYTICS

INSOMNIA

Insomnia is trouble falling asleep, staying asleep through the night, or waking up too early in the morning. Episodes of insomnia may come and go or be long-lasting.

The quality of your sleep is as important as how much sleep you get.

Causes

Sleep habits we learned as children may affect our sleep behaviors as adults. Poor sleep or lifestyle habits that may cause insomnia or make it worse include:

-Going to bed at different times each night

-Daytime napping

-Poor sleeping environment, such as too much noise or light

-Spending too much time in bed while awake

-Working evenings or night shifts

-Not getting enough exercise

-Using the television, computer, or a mobile device in bed

The use of some medications and drugs may also affect sleep, including:

-Alcohol or other drugs

-Heavy smoking

-Too much caffeine throughout the day or drinking caffeine late in the day

-Getting used to certain types of sleep medicines

-Some cold medicines and diet pills

-Other over-the-counter or prescription medicines, herbs, or supplements

Physical, social, and mental health issues can affect sleep patterns, including:

-Bipolar disorder.

-Overactive thyroid gland.

-Waking up at night to use the bathroom.

-Feeling sad or depressed. (Often, insomnia is the symptom that causes people with depression to seek medical help.)

-Physical pain or discomfort.

-Stress and anxiety, whether it is short-term or long-term. For some people, the stress caused by insomnia makes it even harder to fall asleep.

With age, sleep patterns tend to change. Many people find that aging causes them to have a harder time falling asleep, and that they wake up more often.

Symptoms

The most common complaints or symptoms in people with insomnia are:

-Trouble falling asleep on most nights

-Feeling tired during the day or falling asleep during the day

-Not feeling refreshed when you wake up

-Waking up several times during sleep.

People who have insomnia are sometimes consumed by the thought of getting enough sleep. But the more they try to sleep, the more frustrated and upset they get, and the harder sleep becomes.

Lack of restful sleep can:

-Make you tired and unfocused, so it is hard to do daily activities.

-Put you at risk for auto accidents. If you are driving and feel sleepy, pull over and take a break.

ANXIETY

Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. In some people. the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. Types include:

-Panic disorder.

-Obsessive-compulsive disorder.

-Post-traumatic stress disorder.

-Phobias.

-Generalized anxiety disorder.

Treatment can involve medicines, therapy or both.

HYPNOTICS AND ANXIOLYTICS

1. HYPNOTICS:

-Benzodiazepines: Nitrazepam, Flurazepam (Dalmane), Loprazolam, Lormetazepam and Temazepam.

-Zaleplon (Sonata), Zolpidem Tartrate (Stilnoct) and Zoplicone (Zimovane) are non-benzodiazepine hypnotics, but they act at the benzodiazepine receptor.

-Chloral and derivatives: Cholral Hydrate (Chloral mixture/elixir, Welldorm) and Triclofos sodium.

-Clomethiazole (Heminevrin).

-Antihistamines (on sale to the public for occasional insomnia): Promethazine hydrochloride, Sodium oxybate (Xyrem) and Melatonin (Circadin).

2. ANXIOLYTICS:

-Benzodiazepines: Diazepam, Alprazolam, Chlordiazepoxide Hydrochloride, Lorazepam and Oxazepam.

-Buspirone hydrochloride (Buspar).

-Meprobamate.

3. BARBITURATES:

-Barbiturates (Sodium Amytal, Soneryl, Seconal sodium, Tuinal).

Sources:

-http://www.nlm.nih.gov/medlineplus/

-BNF 57 March 2009

RESPIRATORY STIMULANTS, OXYGEN, MUCOLYTICS, COUGH PREPARATIONS AND DECONGESTANTS

RESPIRATORY STIMULANTS

Their use has been replaced by ventilatory support.

1. Doxapram hydrochloride (Dopram).

PULMONARY SURFACTANTS

Used in the management of respiratory distress syndrome in neonates and preterm neonates.

1. Beractant (Survanta).

2. Poractant Alfa (Curosurf).

OXYGEN

-High concentration oxygen therapy: for uncomplicated cases of conditions such as pneumonia, pulmonary thromboembolism, fibrosing alveolitis, shock, severe trauma, sepsis or anaphylaxis.

-Low concentration oxygen therapy: reserved for patients at risk of hypercapnic respiratory failure, which is more likely in patients with: COPD, cystic fibrosis, non-cystic fibrosis bronchiectasis, severe kyphoscoliosis or severe ankylosing apondylitis, severe lung scarring caused by tuberculosis, musculoskeletal disorders with respiratory weakness and overdose of opioids, benzodiazepines or other drugs causing respiratory depression.

MUCOLYTICS

-Carbocisteine

-Erdosteine (Erdotin)

-Mecysteine Hydrochloride (Visclair)

-Dornase Alfa (Pulmozyme)

-Hypertonic sodium chloride (MucoClear).

COUGH PREPARATIONS

1. Codeine Phosphate (Codeine Linctus).

2. Pholcodine (Pholcodine Linctus, Galenphol)

-Cough preparations used in palliative care: Methadone hydrochloride and Morphine hydrochloride.

SYSTEMIC NASAL DECONGESTANTS

-Pseudoephedrine hydrochloride (Galpseud, Sudafed).

Source:

-BNF 57 March 2009

Cortocosteroids, cromoglicate, leukotriene, antihistamines and hyposensitisation

CORTICOSTEROIDS
-Beclometasone Dipropionate (Clenil, Asmabec, Beclazone, Becodisks, Qvar, Fostair).
-Budesonide (Novolizer, Pulmicort, Symbicort).
-Ciclesonide (Alvesco).
-Fluticasone Propionate (Flixotide, Seretide).
-Mometasone Furoate (Asmanex).

CROMOGLICATE AND RELATED THERAPY AND LEUKOTRIENE RECEPTOR ANTAGONISTS

1. Cromoglicate and related therapy:
-Sodium cromoglicate (Intal).
-Nedrocromil sodium (Tilade).

2. Leukotriene receptor antagonists:
-Montelukast (Singulair).
-Zafirlukast (Accolate).

ANTIHISTAMINES, HYPOSENSITISATION AND ALLERGIC EMERGENCIES

1. Antihistamines:
-Cetirizine Hydrochloride
-Desloratadine (Neoclarityn).
-Fexofenadine Hydrochloride (Telfast).
-Levocetirizine Hydrochloride (Xyzal).
-Loratadine.
-Mizolastine (Mizollen).
-Alememazine Tartrate (Vallergan).
-Chlorphenamine Maleate (Piriton).
-Clemastine (Tavegil).
-Cyproheptadine Hydrochloride (Periactin).
-Hydroxyzine Hydrochloride (Atarax, Ucerax).
-Ketotifen (Zatiden).
-Promethazine Hydrochloride (Phenergan).

2. Allergen Inmunotherapy:
-Bee and wasp allergen extracts: Pharmaigen.
-Grass and tree pollen extracts: Pollinex, Grazax.
-Omalizumab: for prophylaxis of severe persistent allergic asthma (Xolair).

3. Allergic emergencies:

-Adrenaline (epinephrine) provides physiological reversal of the inmediate symptoms associated with hypersensitivity reactions such as anaphylaxis and angioedema (Anapen, EpiPen, Minijet Adrenaline)
-Icatibant: for acute attacks of hereditary angioedema in patients with C1 esterase inhibitor deficiency (Firazyr).

Source:
-BNF 57 March 2009

BRONCHODILATORS

ASTHMA

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air.

Symptoms of asthma include:

-Wheezing

-Coughing, especially early in the morning or at night

-Chest tightness

-Shortness of breath

Not all people who have asthma have these symptoms. Having these symptoms doesn't always mean that you have asthma. Your doctor will diagnose asthma based on lung function tests, your medical history, and a physical exam. You may also have allergy tests.

When your asthma symptoms become worse than usual, it's called an asthma attack. Severe asthma attacks may require emergency care, and they can be fatal.

COPD
COPD (chronic obstructive pulmonary disease) makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it.

At first, COPD may cause no symptoms or only mild symptoms. As the disease gets worse, symptoms usually become more severe. They include:
-A cough that produces a lot of mucus
-Shortness of breath, especially with physical activity
-Wheezing
-Chest tightness

Doctors use lung function tests, imaging tests, and blood tests to diagnose COPD. There is no cure. Treatments may relieve symptoms. They include medicines, oxygen therapy, surgery, or a lung transplant. Quitting smoking is the most important step you can take to treat COPD.

CROUP
Croup is breathing difficulty and a "barking" cough. Croup is due to swelling around the vocal cords. It is common in infants and children.

PHARMACOLOGY
BRONCHODILATORS

1. Adrenoceptor agonists:

-Selective beta agonists: Bambuterol Hydrochloride (Bambec), Fenoterol Hydrobromide, Formoterol Fumarate (Atimos, Foradil, Oxis), Salbutamol (Ventolin, Ventmax, Airomir, Asmasal, Salbulin), Salmeterol (Serevent) and Terbutaline Sulphate (Bricanyl). 

-Other adrenoceptor agonists: Ephedrine Hydrochloride and Orciprenaline Sulphate (Alupent).

2. Antimuscarinic bronchodilators:

-Ipratropium Bromide (Atrovent, Respontin).

-Tiotropium (Spiriva).

3. Theophylline:

-Theophylline (Nuelin, Slo-Phyllin).

-Aminophylline (Phyllocontin Continus).

4. Compound bronchodilator preparations:

-Combivent (ipratropium bromide + salbutamol).

-Duovent (fenotrol hydrobromide + ipratropium bromide).

5. Peak flow meters, inhaler devices and nebulisers:

-Peak flow meters: standard range (MicroPeak, Mini-Wright, Personal Best, Piko-1, Pocketpeak and Vitalograph) and low range (Mini-Wright and Pocketpeak).

-Drug delivery devices: inhaler devices (pressurised metered dose inhalers, breath-actuated inhalers and dry powder inhalers) and spacer devices (Able Spacer, AeroChamber, Babyhaler, Haleraid, Nebuchamber, Nebuhaler, Optichamber, Volumatic, Pocket Chamber and PARI Vortex Spacer).

-Nebulisers: e.g: Medix Lifecare Nebuliser:

Source:
-http://www.nlm.nih.gov/medlineplus/
-BNF 57 March 2009

LIPID-REGULATING DRUGS AND LOCAL SCLEROSANTS

Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It is mainly made by the liver but can also be found in some foods.

Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your health. High cholesterol itself does not cause any symptoms, but it increases your risk of serious health conditions.

Cholesterol is carried in your blood by proteins, and when the two combine they are called lipoproteins. There are harmful and protective lipoproteins known as LDL and HDL, or 'bad' and 'good' cholesterol:

-Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells that need it. If there is too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is known as "bad cholesterol".

-High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and back to the liver, where it is either broken down or passed out of the body as a waste product. For this reason, it is referred to as "good cholesterol" and higher levels are better.

LIPID-REGULATING DRUGS

-Statins:

They are more effective than other lipid-regulating drugs at lowering LDL-cholesterol concentration but they are less effective than the fibrates in reducing triglyceride concentration. However, statins reduce cardiovascular disease events and total mortality irrespective of the initial cholesterol concentration.

-Atorvastatin (Lipitor).

-Fluvastatin (Lescol).
-Pravastatin sodium (Lipostat).
-Rosuvastatin (Crestor).
-Simvastatin (Zocor, Inegy).
-Bile acid sequestrants: used in the management of hypercholesterolaemia.
-Colesevelam hydrochloride (Cholestagel).
-Colestyramine (Questran).
-Colestipol hydrochloride (Colestid).
-Ezetimibe: inhibits the intestinal absorption of cholesterol (Ezetrol).

-Fibrates: act mainly by decreasing serum triglycerides, they have variable effects on LDL-cholesterol.

-Bezafibrate (Bezalip).

-Ciprofibrate (Modalim).

-Fenofibrate (Lipantil, Supralip).

-Gemfibrozil (Lopid).

-Nicotinic acid group:

-Acipimox: indicated for hyperlipidaemias of types IIb and IV (Olbetam).

-Nicotinic Acid: adjunt to statin in dyslipidaemia or used alone if statin not tolerated (Niaspan).

-Omega-3- fatty acid compounds:

-Omega-3-Acid Ethyl Esters: indicated for hypertriglyceridaemia (Omacor).

-Omega-3-Marine Triglycerides: adjunt in the reduction of plasma triglycerides in severe hypertriglyceridaemia (Maxepa).

LOCAL SCLEROSANTS

-Ethanolamine oleate: indicated for sclerotherapy of varicose veins.
-Sodium Tetradecyl Sulphate: indicated for sclerotherapy of varicose veins (Fibro-vein).

Source:
-http://www.nlm.nih.gov/medlineplus/cholesterol.html
-BNF 57 March 2009

MYOCARDIAL INFARCTION, FIBRINOLYSIS, ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS

MYOCARDIAL INFACTION

Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart is starved of oxygen and heart cells die.

The medical term for this is myocardial infarction.

Causes

A substance called plaque can build up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells.

A heart attack may occur when:

-A tear in the plaque occurs. This triggers blood platelets and other substances to form a blood a clot at the site that blocks blood from flowing to the heart. This is the most common cause of heart attack.

-A slow buildup of plaque may narrow one of the coronary arteries so that it is almost blocked.

The cause of heart attack is not always known.

Heart attack may occur:

-when you are resting or asleep

-after a sudden increase in physical activity

-when you are active outside in cold weather

-after sudden, severe emotional or physical stress, including an illness.

Symptoms

Chest pain is the most common symptom of a heart attack.

You may feel the pain in only one part of your body OR pain may move from your chest to your arms, shoulder, neck, teeth, jaw, belly area, or back.

The pain can be severe or mild. It can feel like:

-a tight band around the chest

-bad indigestion

-something heavy sitting on your chest

-squeezing or heavy pressure.

The pain most often lasts longer than 20 minutes. Rest and a medicine to relax the blood vessels (called nitroglycerin) may not completely relieve the pain of a heart attack. Symptoms may also go away and come back.

Other symptoms of a heart attack can include: anxiety, cough, fainting, light-headedness, dizziness, nause or vomiting, palpitations, shortness of breath ans sweating.

Some people (the elderly, people with diabetes, and women) may have little or no chest pain. Or, they may have unusual symptoms such as shortness of breath, fatigue, and weakness. A "silent heart attack" is a heart attack with no symptoms.

FIBRINOLYTIC DRUGS
Fibrinolytic drugs act as thrombolytics by activating plasminogento form plasmin, which degrades fibrin and so breaks up thrombi.
-Alteplase (Actilyse).
-Reteplase (Rapilysin).
-Streptokinase (Streptase).
-Tenecteplase (Metalyse).
-Urokinase.

ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS
-Etamsylate: blood loss in menorrhagia (Dicynene).
-Tranexamic acid: it can be used to prevent bleeding or to treat bleeding associated withexcessive fibrinolysis (Cyklokapron).

Blood products:
-Antithrombin III concentrate: indicated for congenital deficiency of antithrombin III.
-Dried prothrombin complex.
-Drotrecogin alfa (activated).
-Factor VIIa (recombinant).
-Factor VIII fraction, dried.
-Factor VIII inhibitor bypassing fraction.
-Factor IX fraction, dried.
-Factor XIII fraction, dried.
-Fresh frozen plasma.
-Protein C concentrate.

Source:
-http://www.nlm.nih.gov/medlineplus/ency/article/000195.htm
-BNF 57 March 2009

SYMPATHOMIMETICS, ANTICOAGULANTS, PROTAMINE AND ANTIPLATELET DRUGS.

SYMPATHOMIMETICS

They act increasing both heart rate and contractility, it can cause peripheral vasodilation or vasoconstriction.

1. Inotropic sympathomimetics: 

-Dobutamine (Indications: inotropic support in infarction, cardiac surgery, cardiomyopathies, septic shock and cardiogenic shock).

-Dopamine Hydrochloride (Indications: cardiogenic shock in infarction or cardiac surgery).

-Dopexamine Hydrochloride (Indications: inotropic support and vasodilator in exacerbations of chronic heart failure and in heart failure associated with cardiac surgery).

2. Vasoconstrictor sympathomimetics (raise blood pressure transiently):

-Ephedrine Hydrochloride.

-Metaraminol.

-Noradrenaline Acid Tartrate/ Norepinephrine Bitartrate.

-Phenylephrine Hydrochloride.

3. Cardiopulmonary resuscitation:

-Adrenaline/Epinephrine.

ANTICOAGULANTS AND PROTAMINE

Mainly used to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation, prevention and treatment of deep-vein thrombosis in the legs. They are used to prevent thrombi forming on prosthetic heart valves.

1. Parenteral anticoagulants:

-Heparin.

-Bemiparin Sodium (Zibor).

-Dalteparin Sodium (Fragmin).

-Enoxaparin Sodium (Clexane).

-Tinzaparin Sodium (Innohep).

-Danaparoid Sodium (Orgaran).

-Bivalirudin (Angiox).

-Lepirudin (Refludan).

-Epoprostenol (Flolan).

-Fondaparinux Sodium (Arixtra).

2. Oral anticoagulants:

-Warfarin Sodium.

-Acenocoumarol (Sinthrome).

-Phenindione.

-Dabigatran Etexilate (Pradaxa).

-Rivaroxaban (Xarelto).

3. Protamine sulphate (Prosulf).

ANTIPLATELET DRUGS

-Abciximab.

-Aspirin (Angettes 75, Caprin).

-Clopidogrel (Plavix).

-Dipyridamole (Persantin).

-Eptifibatide (Integrilín).

-Tirofiban (Aggrastal)

Sources:

-http://www.evidence.nhs.uk

-BNF 57 March 2009

ANGINA

ANGINA

Angina is chest pain or discomfort you feel when there is not enough blood flow to your heart muscle. Your heart muscle needs the oxygen that the blood carries. Angina may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw, or back.

Angina is a symptom of coronary artery disease(CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow.

There are three types of angina:

-Stable angina is the most common type. It happens when the heart is working harder than usual. Stable angina has a regular pattern. Rest and medicines usually help.

-Unstable angina is the most dangerous. It does not follow a pattern and can happen without physical exertion. It does not go away with rest or medicine. It is a sign that you could have a heart attack soon.

-Variant angina is rare. It happens when you are resting. Medicines can help.

Nitrates, calcium-channel blockers and other antianginal drugs.
1. Nitrates:
-Glyceryl Trinitrate (GTN, Coro-Nitro Pump Spray, Glytrin Spray, Nitromin, Suscard, Nitrocine, Nitronal, Deponit, Minitran, Percutol, Nitro-Dur, Transiderm-Nitro, Trintek).
-Isosorbide Dinitrate (Angitak, Cedocard Retard, Isoket Retard).
-Isosorbide Mononitrate (Elantan, Ismo, Chemydur, Imdur, Isodur, Isotard. Isib, Modisal, Monomax, Monomil, Monosorb, Zemon).
2. Calcium-channel blockers:
-Amlodipine (Istin, Exforge).
-Diltiazem Hydrochloride (Tildiem, Adizem, Angitil, Calcicard, Dilcardia, Dilzem, Slozem, Tildiem, Viazem, Zemtard).
-Felodipine (Plendil).
-Isradipine (Prescal).
-Lacidipine (Motens).
-Lercanidipine Hydrochloride (Zanidip).
-Nicardipine Hydrochloride (Cardene).
-Nifedipine (Adalat, Adipine, Coracten, Fortipine, Hypolar Retard, Nifedipress, Tensipine, Vaini).
-Nimodipine (Nimotop).
-Verapamil Hydrochloride (Cordilox, Securon, Univer, Verapress, Vertab).
3. Other antianginal drugs:
-Ivabradine (Procoralan).
-Nicorandil (Ikorel).
4. Peripheral vasodilators and related drugs:
-Cilostazol (Pletal).
-Inositol Nicotinate (Hexopal).
-Moxisylyte (Opilon).
-Naftidrofuryl Oxalate (Praxilene).
-Pentoxifylline (Trental).

Sources:
-http://www.nlm.nih.gov/bsd/pmresources.html
-BNF 57 March 2009

HYPERTENSION AND HEART FAILURE

Hypertension

Blood pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body. Hypertension is another term used to describe high blood pressure.

Blood pressure readings are given as two numbers. The top number is called the systolic blood pressure. The bottom number is called the diastolic blood pressure. For example, 120 over 80 (written as 120/80 mmHg).

One or both of these numbers can be too high.

-Normal blood pressure is when your blood pressure is lower than 120/80 mmHg most of the time.

-High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.

-If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.

If you have heart or kidney problems, or you had a stroke, your doctor may want your blood pressure to be even lower than that of people who do not have these conditions.

Causes

Many factors can affect blood pressure, including:

-The amount of water and salt you have in your body

T-he condition of your kidneys, nervous system, or blood vessels

-Your hormone levels

You are more likely to be told your blood pressure is too high as you get older. This is because your blood vessels become stiffer as you age. When that happens, your blood pressure goes up. High blood pressure increases your chance of having a stroke, heart attack, heart failure, kidney disease, or early death.

You have a higher risk of high blood pressure if:

-You are African American

-You are obese

-You are often stressed or anxious

-You drink too much alcohol (more than 1 drink per day for women and more than 2 drinks per day for men)

-You eat too much salt

-You have a family history of high blood pressure

-You have diabetes

-You smoke.

Most of the time, no cause of high blood pressure is found. This is called essential hypertension.

High blood pressure that is caused by another medical condition or medicine you are taking is called secondary hypertension. Secondary hypertension may be due to:

-Chronic kidney disease

-Disorders of the adrenal gland

-Hyperparathyroidism

-Pregnancy or preeclamsia 

-Medications such as birth control pills, diet pills, some cold medicines, and migraine medicines

-Narrowed artery that supplies blood to the kidney (renal artery stenosis).

Symptoms

Most of the time, there are no symptoms. For most patients, high blood pressure is found when they visit their doctors or have it checked elsewhere.

Because there are no symptoms, people can develop heart disease and kidney problems without knowing they have high blood pressure.

Malignant hypertension is a dangerous form of very high blood pressure. Symptoms include:

-Severe headache

-Nausea or vomiting

-Confusion

-Vision changes

-Nosebleed.

Heart failure

Heart failure is a complex syndrome characterised by reduced heart efficiency and resultant haemodynamic and neurohormal responses (Poole-Wilson 1985).

Heart failure is caused by a number of pathological conditions. Some causes are reversible, but others are not.

Causes of heart failure:

-Ischaemic heart disease.

-Hypertension.

-Arrythmias.

-Valve disorders.

-Myocarditis.

-Alcohol-induced cardiomyopathy (heart muscle abnormalities).

-Chemotherapy-induced cardiomyopathy.

-Genetic cardiomyopathies.

-Amyloidosis.

-Sarcoidosis.

-Metabolic disorders.

(*This is a shortened list).

Patients can have acute heart failure without underlying chronic heart failure but more commonly acute presentations are due to destabilisation of chronic disease.

Patients who are well managed can have a good quality of life and extend their prognosis, but heart failure is unpredictable and difficult to prognosticate for individual patients.

Diagnosis

Heart failure should be diagnosed using the pathway in the European Society of Cardiology (ESC) guidelines (McMurray et al 2012).

Once diagnosis is confirmed the severity of the symptoms can be expressed using the New York Heart Association (NYHA) classification.

DRUGS USED IN HYPERTENSION AND HEART FAILURE

Angiotensin-converting enzyme inhibitors:

1. Vasodilator antihypertensive drugs:

-Ambrisentan (Volibris).

-Bosentan (Tracleer).

-Diazoxide (Eudemine).

-Hydralazine Hydrochloride (Apresoline).

-Iloprost (Ventavis).

-Minoxidil (Loniten).

-Sildenafil (Revatio, Viagra).

-Sitaxentan sodium (Thelin).

-Sodium Nitroprusside.

2. Centrally acting antihypertensive drugs:

-Clonindine Hydrochloride (Catapres, Dixarit).

-Methyldopa (Aldomet).

-Moxonidine (Physiotens).

3. Adrenergic neurone blocking drugs:

-Guanethidine Monosulphate (Ismelin).

4. Alpha-adrenoceptor blocking drugs:

-Doxazosin (Cardura).

-Indoramin (Baratol, Doralese).

-Prazosin (Hypovase).

-Terazosin (Hytrin).

-Phenoxybenzamine Hydrochloride (Dibenyline).

-Phentolamine Mesilate (Rogitine).

5. Drugs affecting the renin-angiotensin system:
The main indications of ACE inhibitors are heart failure and hypertension among others.
-Captopril (Capoten).
-Cilazapril (Vascace).
-Enalapril Maleate (Innovace).
-Fosinopril Sodium (Staril).
-Imidapril Hydrochloride (Tanatril).
-Lisinopril (Carace, Zestril).
-Moexipril Hydrochloride (Perdix).
-Perindopril Erbumine.
-Quinapril.
-Ramipril.
-Trandolapril.

Angiotensin-II receptor antagonists
-Candesartan Cilexetil (Amias).
-Eprosartan (Teveten).
-Irbesartan (Aprovel).
-Losartan Potassium (Cozaar).
-Olmesartan Medoxomil (Olmetec).
-Telmisartan (Micardis).
-Valsartan (Diovan).

Renin inhibitors
-Aliskiren (Rasilez).


Sources:
-http://www.nlm.nih.gov/medlineplus/
-BNF 57 March 2009
-nop.rcnpublishing.com/ September 2014/ Volume 26/ Number 7.