دليل التدريب الصيفي لطلاب السنة الرابعة - كلية الصيدلة - جامعة كركوك

Ministry of Higher Education and Scientific Research University of Kirkuk College of Pharmacy summer training guide pharmacy student II Content Chapter 6: endocrine System Chapter 7: for Obstetrics, gynecology, and urinary-tract disorders System Chapter 8: Nutrition...

Ministry of Higher Education and Scientific Research University of Kirkuk College of Pharmacy summer training guide pharmacy student II Content Chapter 6: endocrine System Chapter 7: for Obstetrics, gynecology, and urinary-tract disorders System Chapter 8: Nutrition and blood Chapter 9: Musculoskeletal and joint diseases Chapter 10: Eye Chapter 11: Ear, nose, and oropharynx Chapter 12: skin Note: It is very important to know the side effects of the mentioned medications and their interaction with other commonly used medications. This is a personal effort from you as trainee students, only the medications mentioned here.  Chapter Six : endocrine system 6.1-Drugs used in diabetes 6.1.1-Oral Antidiabetics Note: they are given for type II diabetes. 1-Classification and administration with respect to food (1, 2) : Groups Example(s) Administration 1 Sulphonylureas Glibenclamide, With food Gliclazide, Glimepiride 2 Biguanides Metformin Take with or just after food 3 dipeptidylpeptidase Sitagliptin, Saxagliptin, Without regard to meal -4 inhibitors Vildagliptin 4 Thiozolidinediones Pioglitazone Without regard to meal 5 Meglitinides Nateglinide, Within 30 minutes before Repaglinide meals 6 Alpha-glucosidase Acarbose Tablets should be chewed inhibitor with first mouthful of food or swallowed whole with a little liquid immediately before food. 2- Adverse effects: A-The primary side effects of the sulfonylureas are hypoglycemia and weight gain (about 2 kg) (2). B- The primary side effects of metformin GIT disturbances (anorexia, nausea, vomiting, and diarrhea); and there may be weight loss (3). To minimize GI side effects, metformin should be initiated at 500 mg once or twice daily, to be taken with food, followed by weekly or biweekly increases in increments of 500 mg daily )(2). C-Hypoglycaemia is rare with a biguanide given alone, although it may occur if other contributing factors or drugs are present (3). D-The most commonly reported side effects with dipeptidylpeptidase-4 inhibitors is the increased risk of infection (2). 3- Metformin is the first line of therapy for type 2 diabetes (2). Because metformin is not associated with weight gain, it is preferred in obese patients (3). 4- Important: Metformin is used for the symptomatic management of polycystic ovary syndrome [PCOS]. Metformin helps to normalize menstrual cycle (increasing the rate of spontaneous ovulation), and may improve hirsutism (1). 5-Note: there are many products that contain a combination of oral antidiabetic drugs (e.g. Glucovance® which contain a combination of Metformin and Glibenclamide).  Oral Antidiabetics (including combined products) Scientific name Trade names Dosage form 1 Glibenclamide Daonil Tab. 2.5, 5 (called Glyburide in USA) 2 Metformin Glucophage (Merck Serona) Tab.500 ,850 , 1000, 3 Glimepiride Amaryl (Sanofi Aventis) Tab. 1, 2, 3, 4. (Servier) 4 Gliclazide Diamicron Tab. 40 , 80. S.R Tab.30 (Daiichi Sanko) 5 Repaglinide Prandin Tab. 0.5 ,1 , 2. 6 Saxagliptin Onglyza (Bristol-Myeri squilbb) Tab. 2.5 , 5. Glipizide Glvotrol Tab.5. 7 Minodiab (pharmacia) Any extra notes: 6.1.2-Insulins 1- Therapy with insulin is essential for the long-term survival of all patients with type 1 diabetes mellitus (3). It is also needed for type 2 diabetes when other methods have failed to achieve good control, and temporarily in the presence of intercurrent illness or peri-operatively. Pregnant women with type 2 diabetes may be treated with insulin (1). 2-The most frequent complication of insulin therapy is hypo glycaemia. It is usually associated with an excessive dosage of insulin, or the omission of a meal by the patient (3). 3-The various formulations of insulin are classified, according to their duration of action after subcutaneous injection, as short-, intermediate-, or long-acting (3). (Some analogues, such as insulins lispro and aspart, are also short-acting, with a faster onset and shorter duration of action than soluble insulin (Short acting) and are sometimes known as rapid-acting insulins) (3). Type of insulin Appearance Route(S) Rapid-acting insulin Clear S.C, I.V Insulin Lispro, Insulin aspart, and insulin glulisine ‫صافي‬ Short-acting insulin Clear S.C, I.V, (soluble, regular ,neutral) and I.M Intermediate-acting insulin Isophane insulin also called NPH(neutral protamine hagedorn) Cloudy S.C Lente ‫خابط‬ Only long-acting insulin Cloudy S.C Ultrlente (insulin zinc susp., protamine zinc susp.) only Insulin Glargine Clear Insulin Detemir Clear 4-Biphasic insulins are mixtures providing for both immediate and prolonged action (3). 5-Insulin is generally given by subcutaneous injection; the injection site should be rotated to prevent local side effects (1, 3). Short-acting insulins can also be given by I.V route for urgent treatment (1). 6-The primary sites used for injecting insulin are the lateral thigh, abdomen and upper arm. Many practitioners recommend using the abdominal area because absorption from this site is least affected by exercise and is the most predictable (2). 7- Stability and Storage ( see the product's leaflet also) A-Insulin is a fragile molecule that can be damaged by temperature extremes. All commercially available insulins are stable for at least 28 days (e.g., ∼1 month) at room temperature (20◦–30◦C) (2). B-In practice, most patients store vials currently in use at room temperature because injection of cold insulin is uncomfortable (2). C-All unopened, extra vials or pen devices should be stored in the refrigerator (2◦–8◦C) (2). D-Insulin should not be used if it has been frozen or exposed to temperatures >37◦C (2). E- Insulin preparations should be protected from light (3). 8-Adminstarion of insulin S.C with a syringe (called insulin syringe) is still the most common method of insulin administration. 9- Insulin pen devices are also available for injecting insulin. Pen devices are often preferred as they make insulin administration much easier, especially for patients who need to take their insulin doses away from home (2). 10-The dose of insulin is expressed as units. Insulin preparations (if available) Scientific name Trade names Dosage form (Lilly) 1 Insulin lispro Humalog 100 I.U /mL 3mL (Novo Nordisk) 2 Insulin detemir Levemir 100 I.U /mL 3mL 3 Protamine zinc Hypurin Bovine 100 I.U /mL 10mL (wackhardt) insulin Protamine Zinc 4 Bisphasic insulin NovoMix 30 (Novo-Nordisk) 30% insulin aspart aspart 70% insulin aspart prot. Any extra notes: 6.2-Thyroid and antithyroid drugs 6.2.1-Thyroid hormone 1-Thyroid hormone (thyroxine(levothyroxine)) is used in hypothyroidism (1). (Hypothyroidism is readily treated by lifelong replacement therapy with thyroxine) (3). 2-Absorption is optimal on an empty stomach, at least 60 minutes before meals (2). Its best taken on an empty stomach, usually before breakfast (3). 30 minutes before eating breakfast (4) ‫وبعض المصادر تقبل بأخذه‬ Scientific name Trade names Dosage form 1 levothyroxine Levoxyl Tab.25 , 50 , 100 mcg Syrup 25mcg /5mL Any extra notes: 6.2.2-Antithyroid drugs 1-Antithyroid drugs are used for hyperthyroidism either to prepare patients for thyroidectomy or for long-term management. In Iraq carbimazole is the most commonly used drug (1). 2-Rashes and pruritus are common side effects of carbimazole but they can be treated with antihistamines without discontinuing therapy (1) 3- Carbimazole induced-agranulocytosis (3): A-Rarely, agranulocytosis can develop, and is the most serious adverse reaction associated with this class of drugs. B-Patients or their carers should be told how to recognize such toxicity and should be advised to seek immediate medical attention if mouth ulcers or sore throat, fever, bruising, malaise, or nonspecific illness develop. C-Full blood counts should be performed, and treatment should be stopped immediately if there is any clinical or laboratory evidence of neutropenia. 4-Propranolol (β-blocker) is useful for rapid relief of thyrotoxic symptoms (e.g. tachycardia) and may be used in conjunction with antithyroid drugs (1). Scientific name Trade names Dosage form Carbimazole Neo-Mercazole®(Amdipharm) 5mg , 20 mg tablet Any extra notes: 6.3-Corticosteroids 1-The corticosteroids are used in physiological doses for replacement therapy in adrenal insufficiency. Pharmacological doses are used when anti-inflammatory or immunosuppressant effects are required (3) (for so many different diseases). 2-The effects of different corticosteroids vary qualitatively as well as quantitatively, and it may not be possible to substitute one for another in equal therapeutic amounts. Thus, whereas cortisone and hydrocortisone have very appreciable mineralocorticoid (or sodium-retaining) properties relative to their glucocorticoid (or antiinflammatory) properties, prednisolone have considerably less, and others, such as betamethasone and dexamethasone, have none or virtually none (3). 3- As a rough guide, the approximate equivalent doses of the main corticosteroids in terms of their glucocorticoid (or anti-inflammatory) properties alone, are: Betamethasone 0.75 Mg = Cortisone Acetate 25 Mg = Dexamethasone 0.75 Mg = Hydrocortisone 20 Mg = Methylprednisolone 4 Mg = Prednisolone 5 Mg = Prednisone 5 Mg = Triamcinolone 4 Mg (3). 4- Important: A-The use of pharmacological doses of corticosteroids suppresses the endogenous secretion of steroids by the anterior pituitary (3). B-The adrenal suppression is less when the corticosteroid is given as a single dose in the morning, and even less if this morning dose is given on alternate days or less frequently (3). C-Sudden withdrawal or reduction in dosage, may precipitate acute  adrenocortical insufficiency (3). D-Gradual withdrawal of systemic corticosteroids is required for : -Patient who received more than 40 mg prednisolone (or equivalent) daily for more than 1 week (1). -Patient who received more than 3 weeks’ treatment (1). 5- Corticosteroids have numerous side effects including nearly all body systems. 6- Important: Corticosteroids (especially dexamerhasone) are frequently abused in Iraq. (Prolonged use glucocorticoids have a dramatic effect on body fat distribution, resulting in the characteristic appearance of moon face) (3). Corticosteroids Scientific name Trade names Dosage form 1 Betamethasone Celestone Amp.4mg/mL Betnesol (UCB Pharma) Tab.0.5mg 2 Dexamethasone Decadron Tab. 0.5 , 2. Amp.4mg/mL , syrup 2mg/5mL 3 Hydrocortisone Efcortesol (Sovereigin) Amp. Or vial 100mg/mL 4 Methylprednisolone Medrol Tab. 2, 4, 16 Medrone (Pfizer) Vial 40 , 80 ,125, 500 5 Prednisolone Orapred Tab. 1, 5, 25. Pediapred 6 Triamcinolone Kenalog (squibb) 40mg /mL  Any extra notes: 6. 4 Sex hormones 6.4.1-Female sex hormones 6.4.1.1-Hormone replacement therapy (HRT) 1-Hormone replacement therapy (HRT) with small doses of an estrogen (together with a progestogen in women with a uterus) is appropriate for alleviating menopausal symptoms such as vaginal atrophy or vasomotor instability (1). (In women with an intact uterus, the addition of a progestogen reduces the additional risk of endometrial cancer) (1). Note: Vasomotor symptoms include hot flashes, night sweats. The hot flash is a sensation of heat that typically begins in the face and chest and quickly spreads. 2-Menopausal atrophic vaginitis may respond to a short course of a topical vaginal oestrogen (chapter 7) preparation used for a few weeks and repeated if necessary (1). HRT  Scientific name Trade names Dosage form 1 Conjugated Premarin® Tablets oestrogens (Pfizer) (300 mcg, 625 mcg, and 1.25 mg) (Bayer) 2 Estradiol valerate Pyognova Any extra notes: 6.4.1.2-Progestogens 1-Progestogens and drugs with progestogenic actions (e.g. dydrogesterone and medroxyprogesterone and norethisterone may be used in menstrual disorders such as dysmenorrhea and menorrhagia associated with dysfunctional uterine bleeding (1, 3). 2-Progestogens may also be used in the management of endometriosis (3). 3- Progestogens may be used as contraceptive. Progestogens sometimes are used with estrogens for HRT (see above) (3). 4- Important: Progestogens have been used for the prevention of spontaneous abortion in women with a history of recurrent miscarriage (habitual abortion) but there is no evidence of benefit and they are not recommended for this purpose (3). ‫وهذا االستعمال يطلق عليه محليا تسمية مثبت وكما تالحظ فانه ال يتوفر أي دليل علمي يؤيد هذا االستعمال‬  Progestogens Scientific name Trade names Dosage form 1 Dydrogesterone Duphaston ®(Bayer) 10 mg tablet 2 Medroxyprogesterone Provera® (Pharmacia) 5 mg and 10 mg tablet 3 Norethisterone Primolut-N® (Bayer) 5mg tablet 4 Lynestrenolum Orgametril (organom) Tab.5mg Any extra notes: 6.4.2- Male sex hormones 1-The primary indication for androgens, such as testosterone or its esters, is as replacement therapy in male hypogonadal disorders caused by either pituitary or testicular disorders (3). 2-Androgens are useless as a treatment of impotence and impaired spermatogenesis unless there is associated hypogonadism (1). 3- The testosterone esters are usually formulated as oily solutions for intramuscular use to give a prolonged duration of action (3). Male sex hormones Scientific name Trade names Dosage form  1 Mesterolone Pro-Viron® (Bayer) 25 mg tablet 2 Testosterone Sustanon® (MSD) Injection amp. 30 ,60 Any extra notes: 6.4.3 Anti-androgens 1-Cyproterone acetate is an anti-androgen. It is used for the control of libido in severe hypersexuality or sexual deviation in men. Cyproterone acetate may be used with ethinyl estradiol in women for the control of acne and hirsutism (3). It is given after food (1). 2-Fatigue and lassitude may be produced by the drug which may impair performance of skilled tasks (e.g. driving) (1). Scientific name Trade names Dosage form Cyproterone Androcur® Tablets 50 mg Cyproterone 2mg +Ethinyl (Bayer) estradiol 0.03 Diane 35 Tab. Any extra notes: 6.4.4-Anabolic steroids 1-Nandrolone is an anabolic steroid with some androgenic. It is usually given in the form of oily intramuscular injections as an anabolic after debilitating illness (3). 2-Important: The protein-building properties of anabolic steroids have not proved beneficial in the clinical setting. Their use as body builders or tonics is unjustified; some athletes abuse them (1). 3-Anabolic steroids have been given for osteoporosis in women but they are no longer advocated for this purpose (1). Scientific name Trade names Dosage form 1 Nandrolone Deca-Durabolin® Injection (MSD) Any extra notes: 6.5 Hypothalamic and anterior pituitary hormones and antioestrogens 6.5.1-Anti-oestrogens 1- Clomifene (clomiphene) :  A-Clomiphene is the most widely used drug in the treatment of female with anovulatory infertility (1, 3). B-The usual oral dose is 50 mg of clomifene citrate daily for 5 days starting within about 5 days of onset of menstruation (preferably on 2nd day). If ovulation does not occur, a course of 100 mg daily for 5 days may be given (1, 3). C-Patients should be warned that there is a risk of multiple pregnancy (rarely more than twins) (1). 2- Tamoxifen (3) : A-Tamoxifen is an oestrogen antagonist with actions similar to those of clomifene citrate. B- It is used in the treatment of breast cancer. C- Tamoxifen is also used to stimulate ovulation in women with anovulatory infertility. Anti-oestrogens Scientific name Trade names Dosage form 1 clomifene Clomid® (Sanofi Aventis) 50 mg Tablet 2 Tamoxifen Tamoxifen 10 mg and 20 mg Tablets Any extra notes: 6.5.2-Gonadotrophins 1-Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) together , follicle-stimulating hormone alone, or chorionic gonadotrophin, are used in the treatment of infertility in women with proven hypopituitarism or who have not responded to clomifene (1). Gonadotrophins Scientific name Trade names Dosage form 1 Human Chorionic Gonadotrophin; Pregnyl® (MSD) 1500-unit and HCG 5000-unit ampules. 2 Follitropin Alfa (Recombinant Gonal-F® 75-unit ampule. (Merck Serona ) human FSH) 3 Any extra notes: 6.6-Posterior pituitary hormones 1-Vasopressin (antidiuretic hormone, ADH) is used in the treatment of pituitary (‘cranial’) diabetes insipidus as is its analogue desmopressin (1). 2-Desmopressin is more potent and has a longer duration of action than vasopressin; unlike vasopressin it has no vasoconstrictor effect (It is given by mouth or intranasally for maintenance therapy) (1). 3- Patients being treated for primary nocturnal enuresis should be warned to limit fluid intake to minimum from 1 hour before dose until 8 hours afterwards; and to stop taking desmopressin during an episode of vomiting or diarrhea (until fluid balance normal) (1). 4-Other uses: A-Desmopressin is also used to boost factor VIII concentration in mild to moderate hemophilia and in von Willebrand’s disease (1). B- Terlipressin, a derivative of vasopressin, is used to control variceal bleeding in portal hypertension in patient with liver cirrhosis (1). Scientific name Trade names Dosage form Desmopressin Minirin® Nasal spray (ferring ) Any extra notes: 6.7-Bisphosphonates 1- Bisphosphonates (either oral e.g.: Alendronate, ibandronate and risedronate or I.V e.g. zoledronic acid) inhibit bone resorption (1, 3). 2- Osteoporosis associated with excessive bone resorption and turnover and occurs most commonly in postmenopausal women and in those taking long-term oral corticosteroids (1, 3). 3-Uses of Bisphosphonates: A-Bisphosphonates have an important role in the prophylaxis and treatment of osteoporosis (e.g. postmenopausal osteoporosis) and corticosteroid- induced osteoporosis (1). B-Because bone resorption increases plasma-calcium concentrations, the bisphosphonates are used as adjuncts to the treatment of severe hypercalcaemia, especially when associated with malignancy (3). C-They are also used in other disorders associated with excessive bone resorption and turnover, such as Paget’s disease of bone, as well as in the management of bone Metastases (3). 4-Some bisphosphonate preparation may be given once daily (e.g. 10 mg alendronate tablet), once weekly (e.g. 70 mg alendronate tablet, risedronate 35 mg tablet), as well as once monthly (ibandronic acid 150 mg tablet) (1). 5- Important: Administration (5): A-Because bioavailability is very poor for bisphosphonates and to minimize GI side effects, each oral dose should be taken with at least 6 ounces of plain tap water (not coffee, juice, mineral water, or milk) at least 30 (60 for ibandronate) minutes before consuming any food, supplements (including calcium and vitamin D), or medications. B-The patient should also remain upright (i.e., either sitting or standing) for at least 30 minutes after alendronate and risedronate and 1 hour after ibandronate administration. C-A patient who misses a weekly dose can take it the next day. If more than 1 day has lapsed, that dose is skipped until the next scheduled ingestion. If a patient misses a monthly dose, it can be taken up to 7 days before the next administration. 6- Esophageal reactions: Severe esophageal reactions reported with all oral bisphosphonates; patients should be advised to stop tablets and seek medical attention for symptoms of esophageal irritation such as dysphagia, pain on swallowing, retrosternal pain, or heartburn (1).  Bisphosphonates Scientific name Trade names Dosage form 1 Aldendronic acid Fosamax (MSD) Tab. 10mg (Novartis ) 2 Disodium Aredia Vial 15mg ( infusion) pamidronate Any extra notes: Disodium etidronate Didronel tab. 200mg 6.8-Other endocrine drugs 6.8.1-Bromocriptine and other dopaminergic drugs 1-Bromocriptine is a stimulant of dopamine receptors in the brain; it also inhibits release of prolactin by the pituitary. Cabergoline has actions and uses similar to those of bromocriptine, but its duration of action is longer (1)(it is usually given once weekly). 2-Uses: A-Bromocriptine, inhibits the secretion of prolactin from the anterior pituitary and is used in the treatment of prolactinoma (prolactin-secreting pituitary adenomas) and endocrinological disorders associated with hyperprolactinaemia, including amenorrhoea, galactorrhoea, and infertility in both men and women (3).  B- Growth hormone secretion may be suppressed by bromocriptine in some patients with acromegaly (3). C-Because of its dopaminergic activity bromocriptine is also used in the management of Parkinson’s disease (3). 3-Adverse Effects (3): A-Nausea is the most common adverse effect at the beginning of treatment with bromocriptine, but vomiting, dizziness, and orthostatic hypotension may also occur. Syncope has followed initial doses. B-Adverse effects are generally dose-related and may therefore be more frequent with the higher doses C-Nausea may be reduced by gradual increase of the dose, taking bromocriptine with food; domperidone (chapter 1) may also be given at least 1 hour before bromocriptine, for the first few days of therapy. 4-Important : concerning cabergoline: the BNF stated that it should be dispense in original container (contains desiccant) (1). (A desiccant is a hygroscopic substance that induces or sustains a state of dryness (desiccation) in its vicinity) ‫إن الدواء غالي نوعا ما وأحيانا يضطر المريض إلى شراء الدواء مفردا (أي حبة أو أكثر) مما يضطر الصيدلي إلى إخراج الدواء من‬ ‫العلبة األصلية ووضعه في كيس من الورق أو النايلون وهو ما ال يسمح به المصدر أعاله‬  Bromocriptine and other dopaminergic drugs Scientific name Trade names Dosage form (Meda ) 1 Bromocriptine Paroldel® 2.5 mg tablet (pharmacia) 2 Cabergoline Dostinex ® 0.5 mg tablet Any extra notes: 6.8.2-Drugs affecting gonadotrophins 6.8.2.1-Danazol 1-Danazol inhibits pituitary gonadotrophins (follicle stimulating hormone and luteinizing hormone); it combines androgenic activity with antiestrogenic and anti- progestogenic activity. It is used mainly for the treatment of endometriosis (1). (Endometriosis is a condition affecting women mainly in their reproductive years, and caused by endometrial tissue developing outside the uterine cavity) (1). Scientific name Trade names Dosage form Danazol Danol® (Sanofi Aventis ) Capsules, danazol 100 mg and 200 mg Any extra notes: 6.8.2.2-Gonadorelin analogues 1-Administration of gonadorelin analogues [buserelin, goserelin, leuprorelin, nafarelin, and triptorelin (which are more potent and have a longer duration of action)] produces an initial phase of stimulation; continued administration is followed by down-regulation of gonadotrophin-releasing hormone receptors, thereby reducing the release of gonadotrophins (follicle stimulating hormone and luteinizing hormone) which in turn leads to inhibition of androgen and estrogen production (1, 3). 2-Gonadorelin analogues are used in the treatment of endometriosis, and prostate cancer (1). 3-Other uses include the treatment of precocious puberty, infertility, anemia due to uterine fibroids (together with iron), breast cancer, and before intra-uterine surgery. Use of leuprorelin and triptorelin for 3 to 4 months before surgery reduces the uterine volume, fibroid size and associated bleeding (1).  Scientific name Trade names Dosage form Goserelin Zoladex® Goserelin acetate is available as depot preparations (3.6 mg and 10.8 mg); injected subcutaneously into the anterior abdominal wall.(3.6 mg is given every 28 days ) (10.8 mg is given every 12 weeks) (1). Any extra notes: References 1- BNF 61. 2- Mary Anne koda-kimble (ed.), Applied Therapeutics: The clinical use of drugs, 10th ed.2013. 3- Sean C. Sweetman. Martindale: The Complete Drug Reference, 36th Edition. Pharmaceutical Press 2009. 4-Current Challenges in the Management of Hypothyroidism. Supplement to U.S. Pharmacist January 2012. 5- Joseph T. DiPiro, Robert L. Pharmacotherapy: A Pathophysiologic Approach, 8th Edition. 2011.  Chapter Seven: for Obstetrics, gynecology, and urinary- tract disorders 7.1Drugs used in obstetrics 7.1.1-Tocolytics 1-Tocolytics inhibit uterine contractions and are used in premature labour to delay early delivery (1). 2-β2- agonists (like salbutamol) (chapter 3) and calcium-channel blockers (Nifedipine) (chapter 2) have used for their tocolytic actions (1). 7.1.2-Induction and augmentation of labour 1-Oxytocin is administered by slow intravenous infusion, using an infusion pump, to induce or augment labor (2). 2-Misoprostol is given orally or vaginally for the induction of labour (2) (and the termination of pregnancies) (1). Drugs for Induction and augmentation of labour Scientific name Trade names Dosage form 1 Oxytocin Pitocin ® Injection 2 Misoprostol Cytotec ® 200 mcg tablet  Any extra notes: 7.1.3-Prevention and treatment of hemorrhage 1-If the uterus fails to contract adequately after delivery (uterine atony), or if retained placental remnants prevent retraction of the placental bed, postpartum hemorrhage may occur. These two causes account for about 80% of cases of postpartum hemorrhage (1). 2-Postpartum hemorrhage may be fatal to the mother unless promptly dealt with, and management generally involves: removal of the placenta if it has not been expelled. the use of oxytocic to contract the uterus. transfusion if blood loss is severe. 3-Parenteral oxytocin, or an ergot alkaloid (ergometrine or methylergometrine), is the oxytocic generally used to control bleeding due to uterine atony (1). Scientific name Trade names Dosage form Methylergometrine Metherin Tab. 0.125 , Amp. 0.5mg/ mL  Any extra notes: 7.2-Preparations for vaginal and vulval conditions 7.2.1-Topical Hormone replacement therapy (HRT) for vaginal atrophy A cream containing an estrogen may be applied on a short-term basis to improve the vaginal epithelium in menopausal atrophic vaginitis (2). Scientific name Trade names(if available) Dosage form Estriol 0.1% Ovestin (MSD) Any extra notes: 7.2.2-Vaginal Fungal infections 1-Guideline for applying vaginal products(3):  1-Start treatment at night before going to bed. Lying down will reduce leakage of the product from the vagina. 2-Wash the entire vaginal area with mild soap and water, and dry completely before applying the product. 3-Vaginal cream: (If prefilled applicators are being used, skip to step 4.) Unscrew the cap; place the cap upside down on the end of the tube. Push down firmly until the seal is broken. Attach the applicator to the tube by turning the applicator clockwise. Squeeze the tube from the bottom to force the cream into the applicator. Squeeze until the inside piece of the applicator is pushed out as far as possible and the applicator is completely filled with cream. Remove the applicator from the tube. Vaginal tablets/suppositories: Remove the wrapper and place the product into the end of the applicator barrel. 4-While standing with your feet slightly apart and your knees bent, as shown in drawing A, or while lying on your back with your knees bent, as shown in drawing B, gently insert the applicator into the vagina as far as it will go comfortably. 5-Push the inside piece of the applicator in and place the cream as far back in the vagina as possible. To deposit vaginal tablets/suppositories, insert the applicator into the vagina and press the plunger until it stops. 6-Remove the applicator from the vagina. 7-After use, recap the tube (if using cream). Then clean the applicator by pulling the two pieces apart and washing them with soap and warm water. 8-If desired, wear a sanitary pad to absorb leakage of the vaginal anti- fungal. Do not use a tampon to absorb leakage. 9-Continue using the product for the length of time specified in the product instructions. Use the product every day without skipping any days, even during menstrual flow. 2-Vaginal candidiasis is treated primarily with antifungal pessaries or cream inserted high into the vagina (including during menstruation) (2). 3-Single-dose preparations offer an advantage when compliance is a problem (2). 4-Imidazole drugs (clotrimazole, econazole, and miconazole) are effective against candida in short courses of 1 to 14 days according to the preparation used;  treatment can be repeated if initial course fails to control symptoms or if symptoms recur (2). 5- All internal preparations should be administered at night (this give the drug time to be absorbed, and eliminate the possibility of accidental loss which is more likely to occur if the person is mobile) (4). 6-Oral treatment of vaginal infection (e.g. with fluconazole) is also effective (2). Antifungals for Vaginal Fungal infections Scientific name Trade names Dosage Treatment course form 1 Nystatin Mycostatin Vag.tab. Insert 1 tablet or cream intravaginally at bedtime for 14 consecutive days. ,cream. 2 Clotrimazole Canestan (Bayer ) Cream1% ,2% , Administer 1 applicatorful pessary100 , intravaginally at bedtime for7 200 consecutive days with 1% or 100 , but 2% or 200 for 3 day. 3 Miconazole Gyno Daktarin Cream Administer 1 applicatorful (Janssen) intravaginally at bedtime for7 ,vig.cap. consecutive days with 2% or 100 , but Daktarin (Janssen) 4% or 200 for 3 day. 1200 for 1day. 4 Econazole Gyno Pevaryl (Janssen) Cream , Administer 1 applicatorful intravaginally at bedtime for7 pessary consecutive days with 1% or 100. Any extra notes: 7.3-Contraceptives Note: there are many contraception methods including: A-Hormonal contraception B-Intra-uterine devices (IUD) C-Barrier methods (like condoms) D- Spermicide. 7.3.1-Hormonal contraception 7.3.1.1-Combined oral contraceptives (COCs) 1-COCs are a combination of estrogen (prevent the development of the dominant follicle) and progestin (prevent ovulation) (5). 2-The COCs are available in a variety of cycle lengths. The most common is the 28- day pack that contains 21 days of active pills (pills that contain estrogen and progestin) followed by 7 days of placebo pills (to minimize confusion) the patient takes one pill daily. After taking the last pill of a 28-day pack, the patient should begin a new pack the next day (5). ‫ حبة‬21( ‫ يوم‬28 ‫إن تناول المرأة لحبوب منع الحمل يوميا لمدة‬ ) ‫ حبات بالسيبو (تحتوي على الحديد عادة‬7‫تحتوي الدواء و‬ ‫(الحبوب الغامقة في الشريط المجاور) يكون أسهل واقل احتماال‬ ‫ حبة ثم التوقف لمدة‬21 ‫لحدوث االلتباس من تناول المرأة لـ‬.‫أسبوع ومن ثم استئناف تناول الحبوب ثانية‬ 4- COCs have benefits aside from pregnancy prevention that include treatment of acne, hirsutism, premenstrual syndrome (PMS), menstrual cycle regulation…(5). 7.3.1.2-Progestogen-only contraceptives 7.3.1.2.1- Oral progestogen-only contraceptives Advantages 1-Oral progestogen-only preparations may offer a suitable alternative when estrogens are contra-indicated (including those patients with venous thrombosis or a past history of venous thrombosis) (2). 2- Confusion with pill taking is minimized because there is no placebo week and all 28 pills in each pack are the same (5). Disadvantages 1-Important: They must be taken even more regularly than COCs, they are taken as One tablet daily, on a continuous basis, starting on day 1 of cycle and taken at the same time each day (if delayed by longer than 3 hours contraceptive protection may be lost) (3, 5). 2- They may have a higher failure rate than combined preparations(1) (0.3% - 8%) (5). Note (important) use of oral contraceptives during breast-feeding 1-The American College of Gynecology (ACOG) recommends waiting at least 6weeks before starting any estrogen-containing contraceptive regardless of breast-feeding status (By this time, the increased risk of thrombosis that occurs during pregnancy should be reduced to baseline). However, COCs have been reported to decrease milk quantity and quality. Therefore, many providers suggest avoiding COCs in women who are exclusively breastfeeding (5). 2-For non–breast-feeding women, a progestin-only contraceptive may be used immediately postpartum and 6 weeks postpartum if solely breast-feeding and in some cases 3 weeks postpartum if partially breast-feeding (5). Oral contraceptives: COCs and progestin-only contraceptive Scientific name Trade names Dosage form 1 Ethinylestradiol 0.03 , Microgynon® (Bayer) Tab. Or pill Levonorgestrel 0.15 Ethinylestradiol 0.03 (Bayer) 2 Yasmin Pill Drospirenone 0.3 Any extra notes: ‫ إن فعالية حبوب منع الحمل قد تتأثر بكثير من الحاالت ولكل حالة توصية خاصة بها يذكرها‬: ‫مالحظة‬ : ‫ وليس هذا محل ذكرها ومن هذه الحاالت‬BNF ‫كتاب‬ 1- Missed pill 2- Diarrhea and vomiting 3- Interactions with other drugs. 7.3.1.2.2-Parenteral progestogen-only contraceptives 1-Injectable Medroxyprogesterone acetate is given as a 150-mg intramuscular injection (5) repeated every 12 weeks (2). Scientific name Trade names Dosage form 1 Medroxyprogesterone Depo-Provera® (Pfizer) 150 mg injection acetate 7.3.2-Spermicidal contraceptives (nonoxynol ‘9’) 1- Vaginal spermicides (a chemical that kills sperm such as nonoxynol 9) may be used as foam, creams, gels or pessaries - dissolvable tablets, inserted into the vagina. 2-The vaginal pessaries - dissolvable tablets required about 15 minute to produce its effect (onset of action) and has a duration of action of about 1 hour (5). Spermicidal contraceptives (if available) Scientific name Trade names Dosage form 1 Nonoxinol 9 Supp. (Marlborough) Gygel Gel 2% 7.4-Drugs for Genito-urinary disorders 7.4.1-Drugs for benign prostatic hyperplasia (BPH): 1- The alpha1-selective alpha blockers (like: alfuzosin, doxazosin, tamsulosin and terazosin) relax smooth muscle in BPH producing an increase in urinary flow-rate and an improvement in obstructive symptoms (2). 2-The 5α-reductase inhibitors (finasteride and dutasteride) (decreases the conversion of testosterone to the more active form) (reduce prostate volume, although this takes a number of months) (1). So: α1-blokers can produce rapid symptomatic relief only (not affect the prostate volume) while 5α-reductase inhibitors reduce prostate volume but this effect is delayed. Therefore, both drugs may be used together. 3- Tamsulosin, may be used also for expulsion of lower ureteral stones (for both male and female) (1). 4- α1-blokers can cause orthostatic hypotension which may be severe and produce syncope after the initial dose. This reaction can be avoided by starting treatment with a low dose, preferably at night) (1). Patient should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying down until they abate completely (2). Note: Tamsulosin is selective for prostatic α1Areceptors. Therefore, it unlikely to cause orthostatic hypotension. 5-Important: Finasteride could produce feminisation of a male fetus if used in pregnant women; therefore, it recommended that women who are or may become pregnant should not handle crushed or broken finasteride tablets. Finasteride has been detected in semen, therefore use of a condom is recommended if the patient’s sexual partner is, or may become, pregnant (2). 6- In the treatment alopecia in men, finasteride is given orally in a low dose (1 mg daily) while the dose used for BPH is 5 mg daily. 5α-reductase inhibitors Scientific name Trade names Dosage form 1 Finasteride Prostacare Tab.5. Proscar (MSD) α1-blokers Scientific name Trade names Dosage form 1 Alfuzosin Xatral (Sanofi Aventis ) Tab. 2.5. (Pfizer ) 2 Doxazosin Cardura Tab. 1 ,2. 3 Tamsulosin Tadin or Omnic M.R cap 0.4 Combodart M.R tab. 0.4 4 Terazosin Hytrin (Amdipharm) Any extra notes: 7.4.2-Drugs for urinary frequency, enuresis, and incontinence. 7.4.2.1-Urinary incontinence (UI) Note : UI occurs as a result of overfunctioning or underfunctioning of the urethra, bladder, or both. Urethral underactivity is known as stress UI. Bladder overactivity is known as Urge UI (bladder muscle is overactive and contracts inappropriately). 1- The antimuscarinic oxybutynin also has direct smooth muscle relaxant properties and has been most widely used for Urge UI , but adverse effects are common. Tricyclic antidepressants have also been used in urge incontinence because of their antimuscarinic activity (1). 2-Stress incontinence is generally managed by non-drug methods (specific type of exercise). Duloxetine (chapter 4) can be added and is licensed for the treatment of moderate to severe stress incontinence in women (2). Scientific name Trade names Dosage form Oxybutynin Ditropan (Sanofi Aventis ) Tab. 2.5 , 5. syrup 5mg / 5mL  Any extra notes: 7.4.2.2-Nocturnal enuresis 1-Treatment is not appropriate in children under 5 years and it is usually not needed in those aged under 7 years and in cases where the child and parents are not anxious about the bedwetting; however, children over 10 years usually require prompt treatment (2). 2-An enuresis alarm should be first-line treatment for well-motivated, well- supported children aged over 7 years because alarms have a lower relapse rate than drug treatment when discontinued (2). Note: The alarm sounds when the first drop of urine contacts the probe. 3-Drug therapy is not usually appropriate for children under 7 years of age; it can be used when alternative measures have failed, preferably on a short-term basis, for example to cover periods away from home, or if the child and family are anxious about the condition (2). 4-Desmopressin (chapter 6), an analogue of vasopressin, is used for nocturnal enuresis; it is given by oral or by sublingual administration. Particular care is needed to avoid fluid overload. Treatment should not be continued for longer than 3 months without interrupting treatment for 1 week for full re-assessment (2). 5-Important: Desmopressin should not be given intranasally for nocturnal enuresis due to an increased incidence of side-effects (2). ‫ومع األسف فان هذا االستعمال هو الشائع في العراق حاليا‬ 6-Tricyclic antidepressants (see chapter 4 ) such as imipramine, are used but relapse is common after withdrawal. Treatment should not normally exceed 3 months unless a full physical examination is made and the child is fully re-assessed (2). 7.4.3-Drugs for erectile dysfunction 1-Phosphodiesterase type-5 inhibitors: Sildenafil, tadalafil and vardenafil are licensed for the treatment of erectile dysfunction (ED)(2). 2-They have no effect on the penis in the absence of sexual stimulation (1). (Adequate sexual stimulation is needed to trigger the events leading to erection) (5). 3- Adverse effects most commonly reported are related vasodilatation and include Headache and flushing. Also common are visual disturbances such as blurred vision (1). 4-Phosphodiesterase type-5 inhibitors may potentiate the hypotensive effects of nitrates, and are therefore contra-indicated in patients receiving such drugs (1). 5-In erectile dysfunction the usual dose is equivalent to sildenafil 50 mg about one hour before sexual intercourse. The dose may be increased or decreased depending on response. The maximum recommended dose is 100 mg, and sildenafil should not be taken more than once in 24 hours (1). 6-Onset of effect of sildenafil (but not tadalafil or vardenafil) may be delayed if taken with food (2). 7-Important: Sildenafil, and tadalafil are licensed for the treatment of pulmonary arterial hypertension (for both male and female) (2). Phosphodiesterase type-5 inhibitors Scientific name Trade names Dosage form 1 Sildenafil Viagra (Pfizer ) Tab. 25 , 50 , 100. (Lilly ) 2 Tadalafil Cialis Tab. 2.5 , 5 , 10 , 20. (Bayer ) 3 Vardenafil Levitra Tab. 5 , 10 , 20. Any extra notes: 7.5-Other preparations for urinary disorders 7.5.1-Alkalinisation of urine 1-The alkalinizing action may relieve the discomfort of cystitis caused by lower urinary tract infections (2). 2-Prevention of uric acid stones are also an indication for alkalinization of urine (1). 3-Potassium Citrate and sodium bicarbonate are used for this purpose. Drugs for Alkalinisation of urine Scientific name Trade names Dosage form 1 Sodium citrate , citric acid , sodium Citrogran® Granules bicarbonate , tartaric acid. 2 Potassium , Sodium , Hydrogen , citrate Uralyt-U® Powder (MADAUS) 3 Khellin , Cymbogon proximus Kellagon® Powder Any extra notes: 7.5.2-Phenazopyridine A-Phenazopyridine exerts an analgesic effect on the mucosa of the urinary tract and is used to provide symptomatic relief of pain and irritability in conditions such as cystitis and prostatitis, and urethritis. It is given after food (1). It causes discoloration of urine. B-Important: If given with an antibacterial for the treatment of urinary-tract infections, treatment should usually not exceed 2 days (1). (Urinary analgesics also may mask signs and symptoms of UTIs not responding to antimicrobial therapy) (6). 7.5.3- Rowatinex® A-A terpene mixture (Rowatinex®) is claimed to be of benefit in urolithiasis (stone) for the expulsion of calculi (2). B-It is given before food (2). Scientific name Trade names Dosage form terpene mixture Rowatinex® Soft gelatin capsule (Rowa) Phenazopyridine Urisept® Tablet Any extra notes: References 1- Sean C. Sweetman. Martindale: The Complete Drug Reference, 36th Edition. Pharmaceutical Press 2009. 2- BNF 61. 3- Rosemary R Berardi. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 16th Edition. 2009. 4-Community Pharmacy. Symptoms, Diagnosis and Treatment. By Paul Rutter.2004. 5- Mary Anne koda-kimble (ed.), Applied Therapeutics: The clinical use of drugs, 10th ed.2013 6-Joseph T. DiPiro, Robert L. Pharmacotherapy: A Pathophysiologic Approach, 8th Edition. Copyright 2011.  Chapter Eight: Nutrition and blood 8.1-Anaemias and some other blood disorders 8.1.1-Oral iron 1-The oral dose of elemental iron for iron- deficiency anemia should be 100 to 200 mg daily (1). 2- The iron content of various iron salts is tabulated in the table (1). 3- Oral iron preferably taken on an empty stomach because food, especially dairy products, decreases the absorption by 40% to 50% (3). (However, many patients must take iron with food because they experience gastrointestinal upset when iron is administered on an empty stomach.) (4) 4-The patient should be told that oral iron therapy produces dark stools (3). 5-Oral iron preparations sometimes produce gastrointestinal irritation and abdominal pain with nausea and vomiting. Adverse effects can be reduced by giving it with or after food (rather than on an empty stomach) or by beginning therapy with a small dose and increasing gradually (2). 6-Important: Oral Liquid preparations containing iron salts should be well diluted with water and swallowed through a straw to prevent discoloration of the teeth (2). 7- Iron should be stored in a safe place, inaccessible to her young children. Accidental ingestion of even small amounts (three to four tablets) of oral iron can cause serious consequences in small children1 (3). 8-Preparations containing iron and folic acid are used during pregnancy in women who are at high risk of developing iron and folic acid deficiency (1). Oral iron (including combination products) Scientific name Trade names Dosage form 1 Ferrous fumarate 200mg. Ferrosam® Tablet 2 Ferrous hydroxide 50mg/5mL. Ferrosam® Syrup 3 Vit. B1,B2,B6,B12, Nicotinamide , MgCl , Ferro-B® Syrup Fe Al citrate , Na-glycerophosph ate. dried ferrous sulphate 150 mg (47 mg 4 iron), folic acid 0.5 mg. Fefol® Capsule 5 Vit. B1,B2,B6,B12, Nicotinamide , Ca – B – Plex Syrup , cap pantothenate Any extra notes: 8.1.2-Parenteral iron 1-Iron can be administered parenterally. Iron dextran, and iron sucrose are currently available in Iraq. Parenteral iron is generally reserved for use when oral therapy is unsuccessful. 2-With the exception of patients with severe renal failure receiving hemodialysis, parenteral iron does not produce a faster hemoglobin response than oral iron provided that the oral iron preparation is taken reliably and is absorbed adequately (1). 3-Anaphylactoid reactions occur in less than 1% of patients treated with parenteral iron therapy and are more commonly associated with iron dextran than with iron sucrose (3). 4- Test dose: A-It is suggested that all patients considered for iron dextran injection receive a test dose. Patient should be observed for more than 1 hour for untoward (chest pain, hypotension …). if no reaction occurs, the remainder of the dose can be given. If an anaphylactic – like reaction occurs, it generally responds to i.v epinephrine, diphenhydramine, and corticosteroids (4).  B- A Test dose of 0.2 mL (10 mg) has been suggested for children weighing less than 10 kg, 0.3 mL (15 mg) for those weighing 10 to 20 kg, and 0.5 mL (25 mg) for adults (2). 5- In Iraq, iron dextran is given most commonly by IM route. In these cases, undiluted drug should be administered using a Z-track technique to avoid staining the skin. (The skin should be pulled laterally before injection; then the drug is injected and the skin is released to avoid leakage of dextran into the subcutaneous tissue) (3). 6- Iron sucrose (i.v only) can be administered undiluted as a slow IV injection (rate not to exceed 20 mg/minute) or as an IV infusion (dilute in a maximum of 100 mL of 0.9% NaCl and infuse at a rate of 100 mg for 15 minutes). A test dose is not indicated for this agent because of the lower incidence of serious anaphylactoid reactions (3). Parenteral iron Scientific name Trade names Dosage form 1 Iron dextran Inferno Amp. 50mg/mL Comofer (pharmacosmos) 2 Iron sucrose Venofer (vifer) Vial 20mg/ mL Any extra notes: 8.1.3-Folic acid 1-Prevention of neural tube defects (NTD) A-Folic acid supplements taken before and during pregnancy can reduce the occurrence of neural tube defects (2). B-For women of child-bearing potential at high risk of having a pregnancy affected by NTD (e.g. if they have had a previous pregnancy affected by a neural tube defect), the dose of folic acid is 4 or 5 mg daily starting before pregnancy (in the USA the recommendation is 4 weeks before) and continued through the first trimester (until week 12 of pregnancy) (2). C-For women at a low risk of having a child with a NTD the dose is 400 micrograms daily and continued through the first trimester (until week 12 of pregnancy) (2). 2-Other indications for folic acid include (1):  A- Folate-deficient megaloblastic anemia. B- Prevention of methotrexate-induced side-effects. C- Prophylaxis of folate deficiency in dialysis. Scientific name Trade names Dosage form Folic acid Folacin Tab. 0.4 , 1, 5. Any extra notes: 8.1.4-Glucose 6-phosphate dehydrogenase (G6PD) deficiency 1-Individuals with G6PD deficiency are susceptible to developing acute hemolytic anemia when they take a number of common drugs (1). 8.2-Intravenous fluids 1-Intravenous sodium: Sodium chloride in isotonic solution (0.9%) provides the most important extracellular ions in near physiological concentrations and is indicated in sodium depletion, which can arise from such conditions as gastro- enteritis (1). 2- Intravenous glucose (dextrose): Intravenous glucose (5%) is used mainly to replace water deficit and should not be given alone except when there is no significant loss of electrolytes. Glucose solutions are also used to correct and prevent hypo glycaemia and to provide a source of energy in those too ill to be fed adequately by mouth (1). 3- Sodium chloride and glucose solutions are indicated when there is combined water and sodium depletion (1). Intravenous fluids Scientific name Trade names Dosage form 1 Dextrose monohydrate Glucose Water 500—1000mL 5% , 10% , 20%. 2 Sodium Chloride Normal saline 500—1000 mL 0.9% 3 Dextrose 5% + Glucose saline 500—1000mL Sodium Chloride 0.9% 4 Na+ , Ca++ , K +, Cl- Ringer 500—1000 mL Any extra notes: 8.3-Minerals and Electrolyte 8.3.1-Calcium supplements 1- Calcium salts are used in the management of hypocalcemia and calcium deficiency states resulting from dietary deficiency or ageing (2). 2- Intravenous calcium (calcium gluconate) salts are also used to reverse the toxic cardiac effects of potassium in the emergency treatment of severe hyperkaliemia (calcium act to protect the heart from hyperkaliemia) (2). 3-Calcium carbonate or acetate are effective phosphate binders and are given orally (with food) to reduce phosphate absorption from the gut in patients with hyperphosphatasemia; this is particularly relevant to patients with chronic renal failure (2). 4-Oral calcium supplements can also be used as an adjunct in the management of osteoporosis (2). 8.3.2-Phosphate-binding agents 1-Calcium-containing preparations are used as phosphate-binding agents in the management of hyperphosphatasemia complicating renal failure (1).  2-Sevelamer hydrochloride and sevelamer carbonate are both licensed for the treatment of hyperphosphatasemia in patients on hemodialysis or peritoneal dialysis (2). 8.3.3-Potassium 1-Potassium salts are used for the prevention and treatment of hypokalemia (2). 2-An intravenous potassium salt (KCL) may be required in severe acute hypokalemia (2). 8.3.4-Zinc 1- Zinc supplement is used for zinc deficiency. 2-Important: Zinc supplements have been shown to reduce the incidence, intensity, or duration of acute diarrhea in children in developing countries. The WHO/UNICEF recommend that children with acute diarrhea also receive zinc (10 mg of elemental zinc/day for infants younger than 6 months; 20 mg of elemental zinc/day for older infants and children) for 10 to 14 days. 3- Zinc prevents the absorption of copper in Wilson’s disease. Minerals and Electrolyte Scientific name Trade names Dosage form 1 Calcium carbonate Calcium Efferv.tab. , syrup , tab.  Calcium gluconate 2 Magnesium sulfate Magnesium Syrup , tab. , Efferv.tab. , amp. (Galen ) 3 Zinc sulfate Selvazinc Efferv.tab. ,tab. , syrup 4 Selenium Selenase Tab. , syrup Any extra notes: 8.4-Vitamins 8.4.1-Vitamin A: 1-Vitamin A, a fat-soluble vitamin, is essential for growth, for the development and maintenance of epithelial tissue, and for vision (2). 2-Vitamin A is used in the treatment and prevention of vitamin A deficiency. Vitamin A has also been used to treat various skin disorders including acne and psoriasis (2). 3-In view of evidence suggesting that high levels of vitamin A may cause birth defects (teratogenic), women who are (or may become) pregnant are advised not to take vitamin A supplements ( except on the advice of a doctor ); nor should they eat liver (1).  (The American College of Obstetricians and Gynecologists has recommended that women who are pregnant or planning pregnancy should ensure that any vitamin supplements they take contain a daily dose of vitamin A of no more than 5000 units. The Australian Adverse Drug Reactions Advisory Committee has advised women in this category to avoid vitamin A supplements and to not exceed the recommended daily allowance of 2500 units from all sources) (2). 8.4.2-Vitamin B Substances Vitamin B Scientific name Uses B1 Thiamine Thiamine is used in the treatment and prevention of thiamine deficiency (2). B2 Riboflavin Riboflavin is used in the treatment and prevention of riboflavin deficiency (2). B6 Pyridoxine -Pyridoxine is used in the treatment and prevention of pyridoxine deficiency states (2). - Prevention of isoniazid-induced neuropathy (2). - Treatment of premenstrual syndrome (2). B12 Cobalamins -Vitamin B12 is used in the treatment and prevention of vitamin B12 deficiency (2). - Treatment of B12- deficient megaloblastic anaemias (2). 8.4.3-Vitamin C (Ascorbic acid) Claims that vitamin C ameliorates colds or promotes wound healing have not been proved (1). 8.4.4-Vitamin D 1-The term Vitamin D is used for a range of compounds which possess the property of preventing or curing rickets. They include ergocalciferol (calciferol, vitamin D2 ), colecalciferol (vitamin D3 ), alfacalcidol (1-α hydroxycholecalciferol), and calcitriol (1,25-dihydroxycholecalciferol) (1). 2-Vitamin D requires hydroxylation by the kidney to its active form, therefore the hydroxylated derivatives alfacalcidol or calcitriol should be prescribed if patients with severe renal impairment require vitamin D therapy (1). 3-Preparations containing calcium with Vitamin D are available for the management of combined calcium and vitamin D deficiency (1). 8.4.5-Vitamin E 1-Vitamin E is used in the treatment and prevention of vitamin E deficiency (2). 2- Vitamin E has been tried for various other conditions but there is little scientific evidence of its value (1). 8.4.6-Vitamin K 1-Vitamin K is necessary for the production of blood clotting factors (1).  2-Vitamin K compounds are used in the treatment and prevention of hemorrhage associated with vitamin K deficiency (2). 3-Because vitamin K is fat soluble, patients with fat malabsorption, especially in biliary obstruction or hepatic disease, may become deficient. Menadiol sodium phosphate is a water-soluble synthetic vitamin K derivative that can be given orally to prevent vitamin K deficiency in malabsorption syndromes (1). Vitamins Scientific name Trade names Dosage form 1 Retinol Vit. A Tab., cap. 400 I.U syrup 200 I.U /mL 2 Thiamine Vit. B1 In oral & injection vit. B complex 3 Riboflavin Vit. B2 In oral & injection vit. B complex Pyridoxine Vit. B6 Tab. 60mg, Amp. 10, 20 4 ,50 /mL. 5 Ascorbic acid Vit. C Efferv,.tab. , Tab.50,100, 200,500 6 Ergocalciferol Vit. D2 Tab. ,efferv.tab. , syrup, Coecalcilerol Vit. D3 , Dibase (Abiogen) Amp. 100000 I.U/ 2mL. 7 a-Tocopherol Vit.E Cap.400 I.U acetate 8 Menadiol Vit.K Tab. 10. Phytomenadione Vit.K 1 Cap.1 , Amp.10mcg/mL 9 Mthylcobalamin Vit.B12 Amp. 1mg/2mL. Tab. 1mg.  Any extra notes: 8.4.7-Multivitamin preparations 1-It is generally considered that healthy persons eating a normal balanced diet should have no need for vitamin supplementation (2). 2-Supplementation should concentrate on groups of people at risk of deficiency such as pregnant and lactating women, who need calcium, folic acid, and iron; and certain groups who need vitamin D. A multivitamin supplement might be considered for some groups such as the elderly and those with reduced calorie intake (2). Multivitamin preparations Scientific name Trade names Dosage form 1 Fe, folic acid , vit. B12,B1,B2, C Ironorm Gelatin cap. Nicotinamide 2 Fe ,folic acid , vit. B6 , B12 Feroglobin (vitabiotic) Gelatin cap. 3 Vit.B1,B2,B6,B12 Vit. B complex Cap. , Amp. Ca-pantothenate 4 Vit. A, B1,B2,B6,B12,C,D3,E ,folic acid, Zn , Multi-vitamin Gelatin cap. Selenium , Fe Any extra notes: 8.5-Drugs used in metabolic disorders Wilson’s disease 1-Penicillamine is used in Wilson’s disease to aid the elimination of copper ions (1). 2-Zinc prevents the absorption of copper in Wilson’s disease (1). Scientific name Trade names Dosage form (if available) Penicillamine Cuprimine Tab. 125 , 250. Distamine (Alliance ) Any extra notes: References 1- BNF 61 2- Sean C. Sweetman. Martindale: The Complete Drug Reference, 36th Edition. Pharmaceutical Press 2009. 3- Mary Anne koda-kimble (ed.), Applied Therapeutics: The clinical use of drugs, 10th ed.2013. 4- Joseph T. DiPiro, Robert L. Pharmacotherapy: A Pathophysiologic Approach, 8th Edition. 2011. Chapter Nine: Musculoskeletal and joint diseases 9.1-Non-steroidal anti-inflammatory drugs (NSAIDs) 1-NSAIDs have analgesic, anti-inflammatory, and antipyretic properties. NSAIDs are used for the relief of mild to moderate pain, minor febrile conditions, and for acute and chronic inflammatory disorders such as osteoarthritis, and rheumatoid arthritis (1). 2-Some NSAIDs are applied topically for the relief of muscular and rheumatic pain, and some (like diclofenac) are used in ophthalmic preparations for ocular inflammatory disorders (1). 3-The commonest adverse effects of NSAIDs are generally gastrointestinal disturbances, such as gastrointestinal discomfort. These are usually mild and reversible but, in some patients, peptic ulceration and severe gastrointestinal bleeding may occur (1). 4- NSAIDs are contra-indicated in patients with peptic ulceration. 5- To reduce the risk of gastrointestinal effects: A- NSAIDs may be taken with or after food or milk. B- Taking histamine H2-antagonists, or proton pump inhibitors such as omeprazole. C- Using enteric-coated formulations (1, 2). D- Using some NSAIDs like celecoxib (called selective COX-2 inhibitors) where the risk of serious upper gastro-intestinal side effects is lower with selective inhibitors compared to non-selective NSAIDs (1, 2). 6- NSAIDs should be used with caution in patients with asthma , and hypertension (it cause sodium and water retention) (1). 7-Important : Use of more than one NSAID together should be avoided because of the increased risk of adverse effects (1). 8-Owing to an association with Reye’s syndrome, aspirin should not be given to children under 16 years, unless specifically indicated (2). NSAIDs Scientific name Trade names Dosage form 1 Celecoxib Celebrex Cap.100 ,200. (Pharmacia) 2 Diclofenac Voltorol (Novertis) Tablet (immediate and sustained release), capsule (enclosing enteric coated or modified Voltarene , release granules), gel, injection, patch, Olfen. suppository, eye drop. 3 I buprofen Brufen (Abbott Tab. 200, 400 , 600, susp. 100/5mL healthcare)  4 Indomethacin Indocin Cap.25 , supp. 50 , 100. 5 Mefenamic Acid Ponstan (Chemidex) Cap.250 ,tab. 500 , susp. 50/ 5mL 6 Meloxicam Mobic Tab. 7.5 , 15 , Amp. 15mg/1.5mL 7 Naproxen Naprosyn (Roche) Tab. 250 , 500, susp. 125/ 5mL Anaprox 8 Piroxicam Feldene (Pfizer) Cap. 10 , 20 , tab. 20 , supp. 20 , Brexixol (Chiesi) Amp. 20mg/2mL 9 Aspirin Aspegic Powder 500 , 1000 , tab. 100, 300. 10 Tenoxicam Mobiflex (Meda) Tab. 20 Any extra notes: 11 Ketorolac Rolac , Toradol tab. 10 , Amp. 30/ 2mL (Sanofi-Aventis) 12 Ketoprofen Orudis cap. 50 , 100 , supp.100 9.2- Glucosamine and Chondroitin 1-The glucosamine sulfate and chondroitin sulfate are dietary supplements. Both compounds are found naturally in the body and are essential to the formation of cartilage (The combination is believed to have a synergistic effect by stimulating cartilage production(glucosamine) and inhibiting its destruction (chondroitin). 2- It is used for mild to moderate osteoarthritis of the knee. Therapy should continue For several months. Glucosamine and Chondroitin Scientific name Trade names Dosage form  1 D-glucosamine + Dorofen Cap. 500+50 Ginkgo Biloba D-glucosamine sulfate 750, (Bioactive ) 2 Bioflox Efferv. Tab. , cap. Chondroitin sulfate 60 , MSM 300, Ginger extracte 20. Any extra notes: 3 Glucosamine sulfate Fancital powder 1.5 g 9.3-Rubefacients, topical NSAIDs, and capsaicin 1-They may provide some relief of pain in musculoskeletal conditions. Rubefacients, topical NSAIDs, and capsaicin Content(s) Trade names Dosage form 1 Oleoresin of capsicum , Rheumalgin® Ointment camphor , turpentine oil , peppermint oil , methylsalicylate , menthol. 2 Diethylamine salicylate Algesin ® Cream +menthol 3 turpentine oil , menthol , Smicks ® Ointment camphor , naiauh oil , eucalyptus oil , thymol. Moov® Gel 4 Diclofenac Voltaren®, olfen® Gel diethylamine 5 Diclofenac , menthol , Divon® Gel methylsalicylate , oleum lini.  6 Ketoprofen Fastium® Gel 2.5% 9.4-Drugs for gout 1- Acute attacks of gout Acute attacks of gout are usually treated with high doses of NSAIDs. Colchicine is an alternative in patients in whom NSAIDs are contra-indicated. 2- Prophylactic therapy of gout: e.g. Allopurinol which decrease serum uric acid concentration. 3-Note: Allopurinol is also used as a prophylaxis against uric acid stone. Drugs for gout Scientific name Trade names Dosage form Allopurinol Zyloric (GSK) Tab. 100 , 300. Colchicine Colchicine Tab. 0.5 mg. 9.5-Local corticosteroid injections 1- Intra-articular corticosteroid injections (e.g. Methylprednisolone or Triamcinolone) may be useful when only a few joints are affected in case of osteoarthritis and rheumatoid arthritis. They are also injected locally in some other conditions. Local corticosteroid injections Scientific name Trade names Dosage form 1 Methylprednisolone Depo-medrol® Amp. 40 , 80 , tab.4 2 Triamcinolone acetonide Kenacort ® (squibb) Amp. 40mg/mL Any extra notes: 9.6-Skeletal muscle relaxants 1-These drugs are used for the relief of muscle spasm or spasticity. 2-Examples are: Baclofen, diazepam, orphenadrine and carisoprodol. 3-Some of these drugs (like carisoprodol) may be abused by some individual (addicts). Skeletal muscle relaxants Scientific name Trade names Dosage form  1 Paracetamol + Norgesic®, myogesic®, Tablet Orphenadrine kanagesic® 2 Carisoprodol Somadril compound® Tablet Caffeine , para. 3 Baclofen Lioresal® (Novertis) Tablet 5, 10 , 25 amp.0.5/mL , syrup5mg/5mL 4 Diazepam Valium Tab. 2, 5, 10. syr.2/5mL Amp. 1mg/1mL Any extra notes: 9.7-Disease-modifying anti-rheumatic drugs (DMARDs) 1-These drugs affect the immune response and can suppress the disease process in rheumatoid arthritis which is the main indication of them. Examples are penicillamine, hydroxychloroquine, chloroquine, Methotrexate and sulfasalazine (2). 2- Hydroxychloroquine, and chloroquine can cause ocular (eye) toxicity, therefore the patient should be asked about visual symptoms and monitor visual acuity annually using the standard reading chart (2). 3- Methotrexate is usually given once weekly. DMARDs Scientific name Trade names Dosage form 1 Penicillamine Cuprimine Tab. 125, 250. Distamine (Alliance ) 2 Hydroxychloroquine Plaquenil (Sanofi Aventis) Tab. 150 , 200. 3 Chloroquine Avalen or Medacoin Tab. 150 , 200. 4 Methotrexate Maxtrex Tab. 2.5 , 10 , Metaject (Medoc) Amp. 50mg/mL 5 Sulfasalazine Sulazine Tab.500. Salazopyrin (pharmacia) Any extra notes: References 1- Sean C. Sweetman. Martindale: The Complete Drug Reference, 36th Edition. Pharmaceutical Press 2009. 2-BNF 61.  Chapter Ten: Eye 10.1-Administration of drugs to the eye 1-Administration guideline for eye drops and ointments are shown in the tables below (1):  ‫ من طريقة استعمال القطرة أعاله على‬8 ‫ تنص نقطة رقم‬: ‫مالحظة‬ ‫قيام المريض مباشرة (بعد وضع القطرة وغلق العين) بتسليط ضغط‬ ‫بواسطة اإلصبع ولمدة دقيقة على األقل على الزاوية الداخلية للعين‬ ‫(الشكل المجاور) وذلك للتقليل من تسرب الدواء إلى األنف بواسطة‬.‫القناة الموجودة هناك‬ 2-Important: When two different eye-drop preparations are used at the same time of day, dilution and overflow may occur when one immediately follows the other. The patient should therefore leave an interval of at least 5 minutes between the two (2). 3- Very important: If using a suspension, shake well before instilling. If using the suspension with another dosage form, place the suspension drop last, because it has prolonged retention time in the tear film (1). Note: most steroid eye drops present as a suspension. 4- Important: If both drop and ointment therapy are indicated, instill the drops at least 10 minutes before the ointment so that the ointment does not become a barrier to the drops' penetrating the tear film or cornea (1). 5- Important: Discard or replace eye drop bottles 30 days after the sterility safety seal is opened (unless stated otherwise by manufacturer). The manufacturer's expiration date does not apply once the seal is broken (1). 6- Important: Some eye drops (like latanoprost (Xalatan®) need to be stored at refrigerator. 7-Patients should be warned not to drive or perform other skilled tasks until vision is clear after using eye drops or eye ointments (2). 8- It is common to use drops during the day and then use eye ointment in the evening or at night upon retiring when the blurring of vision will be less inconvenient (3). 9-Contact lenses and drug treatment: In general, patients should be counseled not to place any ophthalmic solution, suspension, gel, or ointment into the eye when contact lenses are in place (1). The lenses should be removed before drop instillation and not worn during the period of treatment (2). 10.2-Antibacterials eye preparations 1-Bacterial eye infections are generally treated topically with eye drops and eye ointments (2). 2- Common antibacterials available as an eye preparation include (2):  A- Chloramphenicol. B- Quinolones: ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin. C- Aminoglycosides: gentamicin, neomycin, and tobramycin D- Polymyxin B. E- Fusidic acid. 3- Many antibacterial preparations are also combined with a corticosteroid (see corticosteroid below) (2). 4- Frequency of application depends on the severity of the infection (sometimes they are applied as frequent as 1 drop every 2 hours) (2). Antibacterials alone Scientific name Trade names Dosage form 1 Fusidic acid Fusithalmic (LEO) Eye drop , ointment 2 Gentamicin Genedin Eye drop , ointment (Alcon ) 3 Tobramicin Tobravisc Eye drop 4 Tetracycline Sumycin or Tetra. Eye ointment (Allergan ) 5 Ciprofloxacin Ciloxan Eye drop (Allergan ) Oflaxacin Oflex 6- Choramphenicol Chloromycetin (mercury) Eye drop , ointment Any extra notes: 10.3-Antivirals 1- Commonly used antivirals are aciclovir (acyclovir) or ganciclovir for hrpes simplex infections. Antivirals Scientific name Trade names Dosage form (GSK) acyclovir Zovirax Eye ointment 10.4-Corticosteroids and other anti-inflammatory preparations 1-Commonly used corticosteroids are : Betamethasone, Dexamethasone, Fluorometholone, Hydrocortisone, and Prednisolone (2). 2- They are used to treat inflammatory eye conditions (2). 3-They may be combined with anti-infective (2). 4- Other anti-inflammatory preparations used for the topical treatment of inflammation and allergic conjunctivitis include Sodium cromoglicate (sodium cromoglycate), and nedocromil sodium (2). 5-Diclofenac (which is one of the NSAIDs) eye drops may be used for seasonal allergic conjunctivitis. It is also indicated for the treatment of eye inflammation after eye surgery (2). corticosteroids  Scientific name Trade names Dosage form 1 Prednisolone acetate Pred-mild® Eye drop 0.12% , And 1% Pred-forte® 2 Fluorometholone FML® (Allergan) Eye drop 3 Betamethasone 0.1% Methadin® Eye drop (Alcon) Olopatadine Opatanol® Eye drop 4 (spectrum thea ) 5 Ketotifen fumarate Zalidin ® Eye drop 6 Fluriprpfen Flurptic ® (Cooper) Eye drop Antibacterials with corticosteroids Scientific name Trade names Dosage form 1 Betamethasone 0.1% Methadin-N® Eye drop Neomycin sulfate 0.5% 2 Dexamethasone 0.1% Tobradex®|(Alcon) Eye drop tobramycin 0.3% 3 Polymyxin B. Neomycin PND® Eye drop and Dexamethasone. 4 Neomycin , polymyxin B , Maxitrol® (Alcon) Eye drop Dexamethasone 5 Dexamethasone o.1% Maxidex (Alcon) Eye drop Other anti-inflammatory preparations Scientific name Trade names Dosage form 1 Diclofenac Valtarene Eye drop Diclogesic 2 Sodium cromoglicate Allergotin or Crom Eye drop (moorfield ) Catacrom  Any extra notes: 10.5-Drugs for dry eye (tear deficiency) (artificial tear preparations). 1-They act by stabilizing the tear film (by increasing the viscosity of tear decrease evaporation) (1). 2-Examples are: Hypromellose (hydroxypropyl methylcellulose), Polyvinyl alcohol and Carbomers. 3- Some of these products may be available as pack that contain single dose eye drops (e.g. 28 or 30 single dose eye drops that contain small volume usually 0.4 mL and each drop is intended for single use only). 4- Some of these products may be available as preservative free eye drops. If a patient is likely to be using artificial tears for a long time, a preservative-free preparation should be considered because the prolonged exposure of the eye to the preservative (mostly it is benzalkonium chloride) can produce damage to the cornea. Artificial tear preparations Scientific name Trade names Dosage form (Alcon) 1 Dextran Tear naruale Eye drop hypromellose 2 Sod. Hyaluronate Hyfresh Eye drop  (scope ophthalmics) Hylo- tear Any extra notes: 10.6-Antiglaucoma Drugs 1- Drugs that reduce intra-ocular pressure by different mechanisms are available for managing glaucoma (2). All are used topically except actazolamide which is available as an oral tablet (and less commonly as an injection). 2- Antiglaucoma drugs include: Pharmacological class Examples 1 Topical beta-blockers Timolol, and betaxolol 2 Prostaglandin Latanoprost, travoprost and bimatoprost analogues and prostamides 3 The carbonic Acetazolamide (systemic administration), anhydrase inhibitors Brinzolamide (Topical), and dorzolamide(Topical) 4 Parasympathomimetic Pilocarpine 5 Sympathomimetics Brimonidine (selective α2- agonists) 3- Sometimes, it may be necessary to combine two or more of these drugs to control intra-ocular pressure (2).  4-Important: eye drops containing beta-blockers should not be used in patients with asthma or a history of obstructive airways disease (unless no alternative treatment is available. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken) (2). 5- Important: Prostaglandin analogues are usually applied once daily, preferably in the evening (2). (may be more effective). 6- Important: Prostaglandin analogues may cause, darkening, thickening and lengthening of eye lashes (2)( reversible upon stopping treatment) (4). Antiglaucoma drugs (single drug preparations) (please try to select drugs from different classes) Scientific name Trade names Dosage form (MSD) 1 Timolol maleate 0.25% , Timoptol Eye drop 0.5% (Pfizer ) 2 Catanoprost Xalatan Eye drop (Allergan) 3 Brimonidine tartarate Alphagan Eye drop (MSD) 4 Dorzolamide HCl Trusept Eye drop (Alcon) 5 Travaprost Travatan Eye drop (Alcon ) 6 Betaxalol HCl Betoptic Antiglaucoma drugs (combined preparations) Scientific name Trade names Dosage form 1 Dorzolamide Xolamol Eye drop (MSD) +timolol Cosopt (pharnacia) 2 Latanoprost + Xolacom Eye drop timolol  Any extra notes: 10.7- Decongestants and decongestants-antihistamine combination (5). 1-Such preparation may be intended for the treatment of allergic conjunctivitis. 2-Common decongestants-antihistamine combination is (Naphazoline- Antazoline). 3- Oxymetazoline (Nasordin® eye/nose drop) is a decongestant used most commonly for nose (less commonly for eye) in Iraq. Decongestants and decongestants-antihistamine combination Scientific name Trade names Dosage form 1 Naphazoline Ophthazolin Eye drop Antazoline 2 Oxymetazoline Nasordin Nasal & eye drop Any extra notes: 3 Naphazoline Naphicon (Alcon) Eye drop. References 1- Rosemary R Berardi. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 16th Edition. 2009. 2- BNF 61. 3- Mary Anne koda-kimble (ed.), Applied Therapeutics: The clinical use of drugs, 10th ed.2013. 4- Sean C. Sweetman. Martindale: The Complete Drug Reference, 36th Edition. Pharmaceutical Press 2009. 5-Iraqi drug guide. First edition.1990.  Chapter Eleven: Ear, nose, and oropharynx 11.1-Drugs acting on the ear 11.1.1-Administration of ear drop (3): Guidelines for administering Ear drop 1-Wash your hands with soap and warm water; then dry them thoroughly. 2-Carefully wash and dry the outside of the ear, taking care not to get water in the ear canal. 3-Warm eardrops to body temperature by holding the container in the palm of your hand for a few minutes. Do not warm the container in hot water. Hot eardrops can cause ear pain, nausea, and dizziness. 4-If the label indicates, shake the container. 5-Tilt your head (or have the patient tilt his or her head) to the side, as shown in drawing A. Or lie down with the affected ear up, as shown in drawing B. Use gentle restraint, if necessary, for an infant or a young child. 6-Open the container carefully. Position the dropper tip near, but not inside, the ear canal opening. Do not allow the dropper to touch the ear, because it could become contaminated or injure the ear. Eardrop bottles must be kept clean. 7-Pull your ear (or the patient's ear) backward and upward to open the ear canal (see drawing A). If the patient is a child younger than 3 years old, pull the ear backward and downward (see drawing B). 8-Place the proper dose or number of drops into the ear canal. Replace the cap on the container. 9-Gently press the small, flat skin flap (tragus) over the ear canal opening to force out air bubbles and push the drops down the ear canal. 10-Stay (or keep the patient) in the same position for the length of time indicated in the product instructions. If the patient is a child who cannot stay still, the primary care provider may tell you to place a clean piece of cotton gently into the child's ear to prevent the medication from draining out. Use a piece large enough to remove easily, and do not leave it in the ear longer than an hour. 11-Repeat the procedure for the other ear, if needed. 12-Gently wipe excess medication off the outside of the ear, using caution to avoid getting moisture in the ear canal. 13-Wash your hands. 11.1.2-Treatment of otitis externa 1-Otitis externa is a general term used to describe inflammation of the skin of the external auditory canal that may be due to infection with bacteria, viruses, or fungi or secondary to skin disorders such as eczema (2). 2- Otitis externa may be acute or chronic. The treatment of both acute and chronic otitis externa includes thorough cleansing and the use of appropriate antibacterial ear drops, with or without a corticosteroid, even though some have doubted the value of topical antibacterials (2). (Topical corticosteroids are used to treat inflammation and eczema in otitis externa. If infection is present, the corticosteroid should be used in combination with a suitable anti-infective ) (3). 3-Ear drops containing aminoglycosides, such as gentamicin, neomycin, or framycetin, or polymyxins should not be used when the ear drum is perforated because of the risk of ototoxicity (2).  Ear products for otitis externa (Corticosteroids, Anti-infective, and combination products) Trade names Scientific name Dosage form 1 Methadin® Betamethasone 0.1% Ear drop 2 Methadin-N® Betamethasone 0.1% Ear drop Neomycin sulfate 0.5% 3 Genedin ® Gentamicin 0.3% Ear drop 4 Otosporin® Hydrocortisone, Ear drop neomycin, polymyxin B 5 Synalar Flucinolone acetonide , Otic drop neomycin , Polymyxin B 6- Sofredex (Sanofi-Aventis) Dexamethasone Ear & eye drop ,framycetin , gramicidin 7- Conestan (Bayer Clotrimazole +PEG Solution , otic drop consumer care) Any extra notes: 11.1.3-Treatment of otitis media 1-Otitis media is a general term used to describe inflammation of the middle ear that usually results from dysfunction of the Eustachian tube after a viral infection of the nasopharynx. It is one of the most frequent childhood illnesses seen in general practice (2). 2-Acute otitis media is the commonest cause of severe ear pain in small children (2). 3-However, it is common practice to prescribe a systemic antibacterial as well as an analgesic, although the need for routine antibacterial treatment is questionable (2). Systemic ‫إي إن المضادات الحيوية في حالة الحاجة إليها ال تعطى موضعيا على شكل قطرة وإنما تعطى‬ 4-The American Academy of Pediatrics has produced guidelines for the diagnosis and management of uncomplicated acute otitis media (AOM) in children from 2 months to 12 years of age. They suggest that these children should be given symptomatic treatment and observed for 48 to 72 hours; if the illness worsens during the observation period or there is no improvement then systemic antibacterials should be considered (2). 5-Pain management is important, and appropriate analgesics should be offered. If antibacterial treatment is given high dose amoxicillin (80 to 90 mg/kg daily) is recommended for most children (2). 11.1.4-Removal of ear wax (cerumen) Nonpharmacologic Therapy  1- The only recommended nonpharmacologic method of removing cerumen is to use a wet, wrung-out washcloth draped over a finger. 2-The common use of cotton-tipped swabs to remove earwax is ineffective and potentially dangerous, increasing the risk of otitis externa and leading to perforation of the eardrum. Pharmacologic Therapy (Cerumenolytics) These agents used to soften ear wax examples are : 1-Sodium bicarbonate (freshly prepared) This product should be instilled two to three times a day for up to 3 days. 2-Docusate ((dioctyl sodium sulpho-succinate) (Dewax ®) The manufacturers of Dewax® recommend that adults and children use enough ear drops to fill the affected ear on not more than two consecutive nights. Cerumenolytics Scientific name Trade names Dosage form 1 dioctyl sodium Dewax® Ear drop sulpho-succinate (Meda) 2 Docusate sodium Waxsol Ear drop 0,5% 11.2-Drugs acting on the nose 11.2.1- Administration of nasal preparations (1). Notes: 1-Nasal sprays are preferable for adults and children aged over 6 years because spray has a faster onset of action and cover a large surface area. 2-Nasal drops are preferable for children aged below 6 years because their nostrils are not sufficiently wide to allow effective use of sprays. 11.2.2-Drugs used in nasal allergy 11.2.2.1-Corticosteroids 1-Nasal preparations containing corticosteroids (beclomethasone, betamethasone, budesonide, fluticasone, mometasone, and triamcinolone) have a useful role in the prophylaxis and treatment of allergic rhinitis (3). 2-Regular use is essential for full benefit and it take several days before full effect is reached. Corticosteroids (nasal preparations) Scientific name Trade names Dosage form 1 Betamethasone Methadin® Nasal drop (A&H) 2 Beclometasone Beconazse® Nasal spray 3 Budesonide Rhinocort® (Astra-Zeneca) Nasal spray 4 Mometasone Nasonex® (MSD) Nasal spray (Sanofi Aventis) 5 Triamcinolone Nasocort acetonide 6 Fluticasone Flixonase (A&H) Nasal spray (A&H) propionate Flixonase Nasule Nasal drop  Any extra notes: 11.2.2.2-Mast-cell stabilizers 1- Mast-cell stabilizers such as nedocromil, and sodium cromoglicate. They are an alternative to corticosteroids in the prophylactic treatment of allergic rhinitis (1) (but may be less effective) (3). Scientific name Trade names Dosage form Sod. Cromoglicate Nasocrom Nasal drop , nasal spray Any extra notes: 11.2.2.3-The topical antihistamine 1-The topical antihistamine azelastine is useful for controlling breakthrough symptoms in allergic rhinitis. Topical antihistamines are considered less effective than topical corticosteroids but probably more effective than cromoglicate (2). The topical antihistamine(if available) Scientific name Trade names Dosage form Azelastine HCl Rhinlast (Meda) Nasal spray  11.2.3Topical nasal decongestants 1- Intranasal sympathomimetics such as phenylephrine, naphazoline, oxymetazoline, and xylometazoline may be useful for short-term treatment to relieve severe nasal congestion (2). (Symptoms of nasal congestion associated with rhinitis and the common cold can be relieved by the short-term use (usually not longer than 7 days) of decongestant nasal drops and sprays) (3). 2- Not to use these products for longer than 7 days because of rebound congestion (with congestion returning after stopping the drug often worse than before). 3-Note: some of these products may present in two concentrations (one for children and one for adults). 4- Nasal drop containing normal saline is preferred for infants (may relieve nasal congestion by helping to liquefy mucous secretions). Topical nasal decongestants Scientific name Trade names Dosage form 1 Naphthazolin Nasophrine ® Nasal drop. 0.025%,phenylephrine ,chlorobutol 2 Oxymetazoline HCl 0.05% Nasordin® Nasal drop. Benzalkonium chloride 3 Xylometazoline Otrivine® Nasal drop. 4 Sodium chloride 0.9% Otrivine saline® Nasal drop. (Novertis) 5 Dimethidene maleate , Vibrocil Nasal drop. Phenylephrine. Nasal spry. 6 7 Any extra notes: 11.3-Drugs acting on the oropharynx 11.3.1- Topical corticosteroid 1-Triamcinolone acetonide in orabase (oral paste) (Kenalog in orabase®) is used for mouth ulcer. 2- It is applied 2-4 times daily after food (after food, as food is likely to rub the paste off). Scientific name Trade names Dosage form  1 Triamcinolone Kenalog in orabase® oral paste 11.3.2-Topical antifungals 1- Topical antifungals for oropharyngeal fungal infections (thrush) include nystatin (as an oral drop (as a suspension)) and miconazole (as an oral gel). 2-Nystatin dose: Adult and child, 100 000 units (1ml of the drop) 4 times daily after food (hold in mouth), usually for 7 days (continued for 48 hours after lesions