Psychiatric

Depression:

Depression + seizure:
Antidepressants used in patient with epilepsy with/without HTN: Paroxetine (SSRIs)
Antidepressants should AVOID in seizure: Bupropion

Depression + weight:
DOC for depression patient who is obese: Bupropion, Venlafaxine
DOC for epileptic patient who loss of appetite: Mirtazapine

# antidepressants act on which area in brain 🧠: Postsynaptic

# anxiolytics with least sedation and withdrawal symptoms: bupropion

Obese: Bupropion
Thin: Mirtazapine
Cardiac ❤: Sertraline
Seizure: Escitalopram
Anxiety 😟: SSRIs
Insomnia 🛌: Mirtazapine, Paroxetine
Pregnant %: Sertraline
Breastfeeding &: Sertraline, Paroxetine

TCA:
Secondary: Protriptyline, Nortriptyline, Desipramine
Tertiary: Doxepin, Amitriptyline, Imipramine, Clomipramine, Trimipramine.
# Amitriptyline cause arrhythmia

MOA-I: # tyramine à cause hypertension crisis

A. Non selective (MAO-A, MAO-B inhibitors): Phenelzine, Tranylcypromine, isocratic #irreversible
B. Selective MAO-A inhibitors: Moclobemide # reversible
C. Selective MAO-B inhibitors: Rasgiline, Selegiline
# Tablet Selegilin for Parkinson disease (PD), Transdermal patch for depression

Drug switching:
- Other anti-depressant à ßMAO-I: 2-weeks washout period
- # EXCEPT fluoxetine it is self-taper 4-5 weeks washout period

Bupropion:
• Not use in seizure, Pregnant
• Used in case of Sexual dysfunction (SD) developed after SSRIs à DOC of SD caused by SSRIs
• Use in obese patient with depression (decrease weight)
Anxiety:

• SSRIs (1st line)

• Buspirone (2nd line) # NOT use with MAO-I
• TCA (2nd line)
• Propranolol (Beta-blocker) # to decrease symptoms, take it before 1 hour of event
• Benzodiazepine (BZDs)

# Bupropion à depression
# Buspirone à Anxiety

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Antipsychotic:

Typical Antipsychotic (1st generation): # Extrapyramidal side effect (EPS), and worse -ve symptoms
Haloperidol, chlorpromazine
# chlorpromazine causes Pigmentary on retina and corneal

Atypical Antipsychotic (2nd generation): # Metabolic side effect

Clozapine, Aripiprazole, olanzapine, Quetiapine
# Clozapine cause agranulocytosis like PTU, monitor ANC, WBC

Antipsychotic for Parkinson patient: Quetiapine, Primavanserin

Patient with Tardive Dyskinesia (TD): Valbenazin # 1st FDA medication approved for TD
Medication for Extrapyramidal effect: Benztropine, Diphenhydramine, BZDs

Most effective in treating +ve symptoms in schizophrenia: 2nd generation

Worsening -ve symptoms and developed EPS : 1st generation
Psychotic patient take olanzapine with high glucose what is alternative: Haloperidol (1st G, less
metabolic changes)

Smoking with Clozapine and Olanzapine 🚬:

Increase metabolism decrease med. Conc. Increase CL of Med.
# Need higher dose of Olanzapine with smoking pt.

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Bipolar:

Acute:
A. Manic: Valproate or Lithium + Antipsychotic
B. Bipolar: Lithium or lamotrigine Also Lurasidone, Olanzapine / fluoxetine
Maintenance:
A. Manic: Lithium +/- 2nd generation of Antipsychotic (SGA)
B. Bipolar: Lamotrigine

Pregnant: Lurasidone, Lamotrigine, Levetiracetam

Lithium: Mood-Stabilizer

SE: Tremor, GI, edema, hypothyroidism

Cause: decrease Crcl, increase BUN à renal impairment
Toxicity: decreasing Na+ like (ACE-I, Diuretic)
Monitoring: 30 min before dose, drawn 8-12 hours post dose,
# Monitor renal and thyroid every 6-12 months

NOTE:
# Be hydrate, Limit sun exposure 🌞
# Take it with food to decrease nausea
# Caution with driving and other heavy activities

Treatment of convulsion due to lithium toxicity: Phenobarbital, propofol, BZDs

Treatment of lithium toxicity (antidote): Sodium polystyrene sulfonate, NaHco3

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 Neurologic:

Parkinson’s disease (PD)

Treatment:
A. Levodopa/Carbidopa:
# Dopa precursor of dopamine, dose depend on carbidopa
# Carbidopa given with levodopa to prevent peripheral metabolism of levodopa
# MOA of l-dopa: inc. DA level in brain 🧠, leading to stimulate DA receptor
# Take it on empty (morning)
B. Dopamine receptor agonist: Pramipexole, Ropinirole, Apomorphine, Rotigotine
C. Catechol-O-Methyltransferase (COMT) inhibitors: Tolcapone # Hepatotoxic
D. Amantadine: Antiviral, Antiparkinsonian, DA agonist # cause Livedo reticularis “pigmentation”
# MOA of Amantadine: interfere with viral M2 protein function, blocking uncoating of the virus particles
E. Anticholinergic: Trihexyphenidyl # cause mydriasis and CAG

Parkinson patient with nausea 🤢:

• if high dose of carbidopa decrease the dose
• Domperidone

Medication for Parkinson cause dizziness: Apomorphine, Pramipexole, Ropinirole, Retigabine

Psychosis in Parkinson patient: Quetiapine, Primavanserin

--------
Alzheimer disease (AD)

Treatment:
A. Cholinesterase inhibitors: Donepezil, Rivastigmine, Glutamine
o Mild - moderate: Donepezil, Rivastigmine, Glutamine
o Advanced: ONLY Donepezil
o Dementia + Alzheimer disease (AD): ONLY Rivastigmine
B. N-methyl-d-aspartate receptor antagonist: Memantine
# MOA of memantine: antagonist effect at 5HT3 receptor, NMDA receptor & block nicotine acetylcholine receptor

BZDs used in Alzheimer (DACL): Diazepam, Alprazolam, Clonazepam, Lorazepam,

Alzheimer patient with urinary urgency: Oxybutynin

All stages: Donepezil

Moderate-sever: Memantine +/- Donepezil

Herbal for Alzheimer disease🌿: Gingko biloba, Caprylidene

Anti-epileptics:

Antiepileptic for pregnant %: Levetiracetam, lamotrigine

Antiepileptic for breastfeeding &: Levetiracetam
Antiepileptic need renal adjustment: Topiramate
Antiepileptic in absence seizures (petit): Ethosuximide
Antiepileptic for older + (AOT): Alprazolam, Oxazepam, Triazolam

Status epilepsy (SE): BZDs

1st BZD: IV Diazepam, Lorazepam, midazolam
2nd: phenytoin, valproic acid, levetiracetam

# Fastest Diazepam (D form Drive)

# Longest Lorazepam (longest from L)
# Strongest Clonazepam

Treat neuropathic pain and depression:

1st: duloxetine, pregabalin
Others: Gabapentin, venlafaxine, CBZs, ..

Phenytoin:
Strong correlation between the plasma level and its effect
Dose: phenytoin sodium 100 mg = 92 mg of phenytoin base
SE of phenytoin: Gingival hyperplasia, nystagmus, hirsutism, acne, Purple glove syndrome

# Topiramate: CI with alcohol, metallic acidosis, metformin

# Carbamazepine, Oxecarbamazapin, Phenytoin, Fosphenytoine: HLA-B 1502

Sodium Channel Blockers (Na+):

- Phenytoin, Fosphenytoine
- Carbamazepine, Oxecarbamazapin
- Lamotrigine

GABA enhancing agent (GABA):

- Barbiturate. # withdrawal symptoms
- Benzodiazepine (BZDs)
- Valproic acid

# Used in trigeminal neuroglia “‫"اﻟﺘﻬﺎب اﻟﻌﺼﺐ اﻟﺴﺎﺑﻊ‬: CBZs

Attention-deficit/hyperactivity disorder (ADHD):

Medication of ADHD and non-stimulant: Atomixifin

ADHD:
• Amphetamine
• Dextro-methamphetamine
• Dextro-methylphenidate
• Methylphenidate

Autism:
Dimethyl glycine (DMG)

# Thimerosal (mercury) containing vaccines may cause: Autism

 Woman !

Labor
Induce labor: Oxytocin
Uterine stimulates: ergot alkaloid (used in migraine)

Induce uterine contraction intravaginal: Dinoprostone

# Dilate cervix: oxytocin, dinoprostone, misoprostol

HIV med. giving during labor: Zidovudine

Premature labor
Stop premature labor 🛑: Ritodrine
Treatment of preterm labor are “Tocolytic”: MgSO4, Indomethacin, Nifedipine

Eclampsia: Mg sulfate

abortion:
Substance that induce abortion: Misoprostol, Mifepristone, Methotrexate
Antiestrogen cause abortion: Anastrozole
Antiprogesterone cause abortion: Mifepristone, Misoprostol

Prevention and treatment of postpartum and post abortion hemorrhage: Ergonovine

—————
Oral birth control ":

For mid age woman want oral birth control to give: Ethinyl estradiol / inestrenol
EXCEPT if she has one of the following will give her: LEVONORGESTREL
§ > 35 + smoker or migraine headache or obese
§ > 50
§ Breastfeeding
§ DM + Vascular disease
§ Risk of DVT or Hx of
§ Hx of uncontrolled HTN or heart problems
§ Breast or endometrial cancer
§ Need to get pregnant

Oral contraceptives suppress GnRH

Oral contraceptives work-on which phase: in ovulation phase
Oral contraceptive used to treat: endometriosis-associate pain “pain in menses and during
intercourses”
Hydroxyurea: Contraceptive require during and after treatment by
§ Female #: 6 months
§ Male $: 12 months
Infertility in women who do not ovulate: Clomiphene citrate
—————

Hormones:

Ovulation phase hormone predominant: LH

Inhibit estrogen synthesis: tamoxifen

Monophase of estrogen: fixed amount of progesterone and estrogen ONLY

Human chorionic gonadotropin is used to: induce ovulation and treatment of infertility

Hormone cause male dysfunction in breastfeeding: androgen

Facial flushing and dry vaginal: estrogen

—————
Medications Should STOP or START with pregnancy:

Start before pregnancy:

§ 1 month: Folic acid (Vit B9):
# To decrease risk of neural tube defect

Stop before pregnancy:

§ 1 month: Isotretinoin (acne)
§ 2 months: Neostigmine (myasthenia gravis), Fingolimod (multiple sclerosis)
§ 6 months: Ribavirin
# Ribavirin: can stay 6 months in body
§ 2 years: Leflunomide (RA treatment)
§ Mycophenolate (immunosuppressant)
o 6 weeks in female
o 12 weeks in male

Medication in pregnancy:
§ Ciprofloxacin # Cause anemia of fetus if taken in the 1st trimester
§ Nicotine # Decrease blood flow to uterine
§ ACE-I # Fetal growth
§ Warfarin # Nasal bone hypoplasia in neonate
§ Finasteride # Genital malformation in the infant
§ Progesterone # Fetal productive abnormalities

—————

Cancer:

Breast cancer
§ Antiestrogen USE in breast cancer: tamoxifen
§ Treatment of breast cancer: Raloxifene, hydrochloride, tamoxifen
§ Prophylaxis of breast cancer: Raloxifene
# Early symptoms of breast cancer: Dimples or nipple discharge

Hysterectomy:
§ hysterectomy (Uterus + ovaries) removed: estrogen
§ Only ovaries removed: estrogen + progesterone # Add progesterone to remove risk

—————
Infection with pregnancy and lactation:

Bacteria:
Pregnant with UTI: Nitrofurantoin
Pregnant with UTI + G6PD: cefuroxime
Prevention recurrence of UTI: TMP/SMX
Prophylaxis UTI: Nitrofurantoin
Pregnant with E.coli and vaginal itching: Nitrofurantoin

Pregnant with pyelonephritis she is been treated with IV ceftriaxone what is the most
appropriate antibiotics: Amoxicillin/ Clavulanate

Pregnant with syphilis: Benzathine penicillin, Amox/Clavul

# PNC allergy: Doxycycline, erythromycin, ceftriaxone

Breastfeeding with mastitis%: dicloxacillin, Cephalexin, Amox / Clavu. # for 10-14 days
# PCN allergy: Clarithromycin

Viral:
Antiviral give pregnant: zidovudine
HIV med. giving during labor: Zidovudine
HIV in pregnant ": NRTI + ritonavir or integrase inhibitors

Fungal:

Pregnant with candida albicans: Clotrimazole

Anti-fungal CI in pregnancy 🛑 " :

Griseofulvin, Ketoconazole, Voriconazole, Flutyisine, Potassium

Anti-fungal SAFE in pregnancy ✅ " :

Amphotericin B, Topical imidazole, Nystatin

Anti-fungal CI in lactation 🛑 %:
Ketoconazole, Itraconazole, Voriconazole

Anti-fungal SAFE in lactation ✅%:

Fluconazole

—————
Psychiatric with pregnancy and lactation:

Pregnant with tonic-clonic seizure": Valproic acid + folic acid

Safest anti-convulsant in pregnancy: Levetiracetam, lamotrigine
Pregnant with mania: levetiracetam, lamotrigine
Pregnant with schizophrenia: Olanzapine, Risperidone, Quetiapine

Antiepileptic in breastfeeding %:
Gabapentin, lamotrigine, OCBZs, Levetiracetam, topiramate, pregabalin, vigabatrin,

Antiepileptic CI in breastfeeding %: Ethosuximide, clonazepam, diazepam

Young girl with rash of Oxcarbamazepine ':

§ Sexual inactive: Ethoxsumide.
§ Sexually active and inconsistent contraceptive use: Topiramate

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Pregnancy with conditions:

GI with pregnancy:
§ Laxative CI in pregnant: senna and castor oil
§ Pregnant with constipation: Psyllium (Bulk forming laxative)
§ Nausea with / without vomiting in pregnant: Vit B6 +/- Doxylamine
§ GERD: Ca++ carbonate antacid
§ Flatulence: Simethicone

Pain: Acetaminophen
Anticoagulant: LMWH
Asthma: Albuterol, Cromolyn

Pregnant with glaucoma 👁 : Brimonidine or Timolol

Thyroid:
§ Hypothyroidism: increase dose by 30% - 50%
§ Hyperthyroidism:
o 1st: PTU
o 2nd & 3rd: Methimazole

Pregnant with DM:

1st: Insulin
2nd: Metformin, Glyburide

Pregnant with HTN: Methyldopa, Labetalol , Nifedipine

# Hydralazine: for emergency and urgency HNT 🚨
Eclampsia: Mg sulfate
—————
Prolactin 🥛:

Responsible for milk production🥛: lactobacillus

1st baby milk named 🍼: Colostrum

# High concentrated with IgA

Medication and prolactin level:

§ Increase Prolactin: Decrease Dopamine (DA)
o Metoclopramide
o Methyldopa
o Estradiol
o Serotonin
o GABA
o Opioid

§ Decrease Prolactin: Increase Dopamine (DA)

o Bromocriptine
o Cabergoline
 Respiratory & Hepatic & Renal:

Respiratory:

Asthma:
A. Quick relief (acute cases)
1. SABA: (Salbutamol or albuterol)
# All asthmatic patient should have SABA for quick relief in acute attack
SE of beta agonist: Tremor, Tachycardia, hypokalemia
2. Systematic Corticosteroid: (Prednisone, Prednisolone, Methylprednisolone)
# Not use for long time
3. Anticholinergics: (Ipratropium) à Short acting
# Approved for COPD, and off-label use for ONLY acute asthma
B. Long term control:
1. Inhaled Corticosteroid: (Beclomethasone, Fluticasone, Mometasone, Budesonide)
# 1st line and DOC in chronic asthma, Consider Ca++ & Vit D supplements
# SE: oropharyngeal candidiasis à Wash mouth after each use
2. LABA: (Formoterol, salmeterol)
# NOT monotherapy in asthma, combined with Corticosteroid
3. Anticholinergic: (Tiotropium) à long acting. # NOT use in acute cases
4. Methylxanthines: (Theophylline)

Monoclonal antibody: Omalizumab

# Omalizumab for allergic asthma, it is anti-IgE

# Medication CI in Asthmatic patient: Beta-blockers, Aspirin, LABA alone

Corticosteroids
Mineral corticosteroids: Fludrocortisone, Deoxy-corticosteroid, Aldosterone
Most potent: dexamethasone
Least potent: hydrocortisone
Max prednisone dose in asthma: 60 mg/kg

Function of alpha-1-antitrypsin in lung:

# Protect the lungs from neutrophils elastase & enhance alveolar exchange

Indapamide used in: Pulmonary Edema, Essential hypertension

Cromolyn for preventing allergic rhinitis:

for the Max. effect take before 1-2 wks before contact with allergen
# MOA of Cromolyn: Mast cell stabilizer
# Cromolyn can be used in chronic asthma in pregnant

Immediate relive allergy after cleaning: Chlorpheniramine

Patient with respiratory depression from anesthesia, what is drug for post anesthesia respiratory
depression: Picrotoxin
# Used as central nervous system stimulate, antidote,
 ---------

Hepatic:

Hepatotoxicity of paracetamol due to: glutathione depletion

Lactulose in Hepatic Encephalopathy (HE): to decrease ammonia level in blood
Hb1 genotype hepatic pt. (HCV) ttt: Interferon, Ribavirin
Fat soluble Vit. Important for liver: Vit (A.D.E.K)

Precursor of bile: cholesterol

Vitamins involved in fatty acid synthesis: B5, B3, B2

# and oxidation reaction

NEVER related on ultrasound if its pancreatic patient

# Pancreatic lipase more specific than amylase

Neuromuscular blocker used in renal or hepatic failure: Atracurim

Liver enzyme:
• High amylase: pancreatitis
• High liver enzymes + normal bilirubin(BUN): cirrhosis
• High liver enzymes + high bilirubin (BUN): stenosis
• Flow of bile Decreased or Blocked: Cholestasis

# Chloramphenicol liver inhibitor: decrease metabolism & increase response

# Hepatotoxic drug should be DC: if LFT > 3 folds than the upper limit

Nucleoside/Reverse transcriptase inhibitors (NRTIs)

# (NRTIs) à Prior to use test ALL patient for HIV
# Boxed warning for ALL NRTIS:
Lactic acidosis, Sever hepatomegaly with stenosis, HBV Exacerbation

Direct antiviral agents (DAA)

# Boxed warning to all (DAA) testing ALL patient for HBV before starting DAA à because
there is a probability to reactivate HBV
# All DAA increase concentration of statin à will increase the risk of rhabdomyolysis

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Renal:

Glomerulus filter:
• Substate wt. < 40,000 can pass the filter
# Mwt > 500 will excreted in biliary
• In healthy kidney protein binding and albumin should not pass the filter

Estimating renal function:

• BUN, Scr, Crcl
# we measure creatinine because it is bound to protein that ONLU excreted by kidney

5 indication for dialysis:

• High Potassium level (K)
• Overload not response
• Acidosis
• Uremia

Kidney failure diuretic DOC: loop diuretic 🔁

Kidney failure + hyperkalemia: Ca gluconate or carbonate
Anticoagulant with dialysis: Heparin
Neuromuscular blocker used in renal or hepatic failure: Atracurim
CI in Kidney failure⛔: Aminoglycosides, Potassium sparing diuretics, Metformin, ACE-I

Vit D that we used in CKD: 1,25-dihydroxycholecalciferol

Anemia with CKD: epoetin

Anemia in CKD with iron deficiency: Darbepoetin
 Vitamins & Minerals:

Vitamins:
Lipid soluble Vitamins (A.D.E.K):
# Lipid vitamins are important for liver
A: Retinol (Deficiency à Night Blindness)
# High dose of Vit A is contraindication in pregnant
D: Cholecalciferol (Deficiency à Rickets, Osteomalacia)
E: Tocopherol (Deficiency à Thalassemia, infertility)
K: Phylloquinone (Deficiency à Bleeding)
# Warfarin Vit K antagonist

Water soluble Vitamins (B.C):

B1: Thiamin (Deficiency à Beri-Beri)
B2: Riboflavin (Deficiency à Ariboflavinosis)
B3: Niacin (Deficiency à Pellagra)
# Niacin (Vit B3) can be used as Antihyperlipidemic agent
B5: Pantothenic (Deficiency à Paresthesia)
B6: Pyridoxin (Deficiency à Neurological symptoms)
# Give Pyridoxin (Vit B6) with Isoniazid (INH), antidote
B7: Biotin (Deficiency à Alopecia, Dermatitis)
B9: Folic acid (Deficiency à Megaloblastic anemia, Neural tube defect)
# Methotrexate is a folic acid antagonist; we should supply folic acid with methotrexate
# Give 1 month before pregnancy à decrease risk of neural tube defect
# Give with Vit b12 in megaloblastic anemia
B12: Cobalamin (Deficiency à Precious anemia, Megaloblastic anemia)
# Higher dose will cause Cyanide toxicity -> we give Hydroxocobalamin
# Schilling test is used to detect Vitamin B12 amount
# Absorbed by intrinsic factor
* if there is a lack of intrinsic factor à lead to decrease Vit B12 absorption à Cause Precious anemia
# Metformin and PPIs and H2RA cause decrease in Vit B12
C: Ascorbic acid (Deficiency à Scurvy, Gingivitis)
# Vit C increase iron absorption
# Vit C use in preparation as preservative agent
# Vit C use in cold ”flu” to reduce the duration

Minerals:

Ca++: (Deficiency à Children: Stunted growth, Adult: OP)

# medication should be separate from Ca++ and Ca containing products “milk, ..etc”
* Tetracycline, Bisphosphonate, Bisacodyl, iron, levothyroxine, quinolone
# Also, Ca++ supplement should be supply to:
* patient with colitis and taking cortisone, Osteoporosis (OP), with SERM
Iodine: (Deficiency à Goiter) # Hyperthyroidism
Iron: (Deficiency à Anemia, weakness)
# Copper is essential for iron absorption in gut
Mg: (Deficiency à Weakness, muscle twitches)
K+: (Deficiency à Muscular weakness, Paralysis, Confusion)
 Dosages:

ADULT PREGNANT BREASTFEEDING GERIATRIC

CA++ 1000 mg 1200 mg --- 1200 mg
VIT D 600 IU 600 IU 600 IU < 70 y: 600 IU
> 70 y: 800 IU
VIT C Men: 90 mg --- --- ---
Women: 75 mg
VIT A Men: 900-1000 mcg 900 mcg 1200 mcg ---
Women: 600-800 mcg
FOLIC ACID Men: 400 mcg 600 mcg 500 mcg ---
(VIT B9) Women: 400 - 800 mcg
IRON 1200 mg/ day --- --- ---
or
325 mg TID
# elemental iron: 65 mg
 Anticoagulant & Antiplatelet:

Anticoagulant:

A. Indirect thrombin Inhibitors: (Heparin)

- UFH: Shorter t1/2, More to cause Heparin inducing thrombocytopenia (HIT)
- LMWH: dose 1 mg/kg/day BID, 1.5 mg/kg/day OD
# Monitor aPTT, Antidote is protamine sulfate
# pregnant we use LMWH, but if she going to labor we use UFH due to shorter ½
# Heparin use in Dialysis patient

B. Direct thrombin inhibitors:

- Oral: dabigatran # GI side effect (take it with food), antidote idarucizumab
- Parenteral: Argatroban # use in case of Heparin inducing thrombocytopenia (HIT)

C. Direct factor Xa inhibitors:

- Oral: Rivaroxaban, Apixaban
- Parenteral: Fondaparinux
# Direct factor Xa inhibitors NOT use in sitting lumber puncture (LP) or spinal surgery

D. Vit K antagonist: (Warfarin). # SE: Hemorrhage, Purple toe syndrome

# Cross BBB, Category X à cause Nasal bone hypoplasia
# Avoid: Tamoxifen, SERM/estrogen à increase bleeding
# Antidote: Vit K
# Vit b12 can be taking with warfarin, warfarin with AL complex in GI & poorly absorption

Antiplatelet:

A. Inhibit prostaglandin synthesis: (Aspirin)

# Inhibits synthesis of thromboxane A2 by irreversibly acetylation of COX enzyme
# NOT give in children and teenagers (< 20 years) à Reyes syndrome “innitus of ear”
# Not use in asthmatic patient, and it is CI with methotrexate

B. P12Y12 receptor inhibitors: (Clopidogrel, Ticlopidine, Ticagrelor)

# Clopidogrel is CYP 2C19, and can NOT take it with omeprazole, use Pantoprazole
A.fib + mechanical valve: warfarin, dabigatran, Rivaroxaban
Valve replacement: warfarin
Anticoagulant with dialysis: Heparin
ED + HTN + PE: Argatropan, Dabigatran
Pulmonary Embolism (PE):
- LMWH (Enoxaparin, Daltaparin)
- UFH (Fondapanux)

Anticoagulant take with meal 🥘: Rivaroxaban

Anticoagulant CI in TIA: Prasugrel

Oral anticoagulant 💊: Warfarin, Dabigatran, Rivaroxaban, Apixaban

Anticoagulant
Dabigatran: dyspepsia and dyspnea
Rivaroxaban: dyspnea

Anti-platelet:
Ticagrelor, elinogrel and Clopidogrel: dyspnea

Ifosfamide: hemorrhagic
HIT: Argotrabem
PCI: Bivalirudin

# Clopidogrel STOP before surgery 🛑: 5 days

# STOP UFH before surgery: 4-6 hours before surgery
# Oral anticoagulant with high risk of GI bleeding: Dabigatran
# DOAC need parental anticoagulant for 5-10 days before starting oral: Apixaban

Natural products and INR

⁃ Incr INR: cranberry, Chinese angelica, ginger, grapefruit 🍇 , garlic , anise
⁃ Dec INR: soya, st johns wort, co-enzyme Q10, green tea 🍵, vitamin E

Drug and INR:

⁃ Incr. INR: NSAID‘s, Omeprazole, cimetidine, ciprofloxacin
Macrolides, isoniazid, trimethoprim, amiodarone, verapamil, retroviral, flu/Ketoconazole.
⁃ Dec. INR: Alcohol, CBZs, phenytoin, Rifampin, oral contraceptives, griseofulvin
 Antidote and Vaccines

Antidote
Activated charcoal give within 4 hours of ingestion

Acetaminophen: Acetylcysteine
Crotaline snake 🐍 and window spider 🕷: antivenin
Organophosphate, nerve gases: Atropine, pralidoxime

CCB’s: CaCL, Glucagon

Hydrofluoric acid CCB: Calcium gluconate
BB : Glucagon
Na channel blockers: Sodium bicarbonate
Iron: Deferoxamine

Heavy metal: Dimercaprol, DMSA

Lead: Calcium disodium “EDTA”, penicillamine

Digoxin: Digoxin Immune FAB “Digi”

Lipophilic cardiotoxic drugs: IV fat emulsion “Intralipid”
Lithium: Sodium bicarbonate, Polystyrene Sulfonate

Methanol: Folic acid, Fomepizole

Ethylene glycol: Fomepizole, thiamine, pyridoxine
Opioids toxicity: Naloxone
Opioid treatment: Methadone
Cocaine: Amyl nitrate
# take by inhalation
Cyanide poisoning such as Cocaine and MDMA: amyl nitrate*
Cyanide: Cyanide Kit, Hydroxocobalamin, sodium Bicarbonate

Serotonin syndrome: Cyproheptadine, BZDs

Benzodiazepines: Flumazenil
TCA: Alpha agonist
Valproic acid: L-Carnitine

Methotrexate: leucovorin
Methemoglobinemia: methylene blue
Sulfonylureas: octreotide

Warfarin, anticoagulant: phytonadione “Vit K1”

# other names: naphthol, (k2) Menadione,
Heparin: protamine sulfate
Dabigatran: Idarcuizumab
Apixaban, Rivaroxaban, edoxaban: Andexanet alfa (a)
Thrombolytics agent: Aminocaproic Acid, Tranexamic Acid

Neuroleptic malignant syndrome, stimulant induce hyperthermia: Dantrolene

# MOA of dantrolene: postsynaptic muscle relaxant inhibitors Ca ions release

Vaso-excitation: phentolamine
Vasopressin extravasation: phentolamine, methylene blue, nitroglycerin

Ach: Atropine
Anticholinergic: physostigmine
Pilocarpine: atropine

Vinca alkaloid: Hyaluronidase

Bleach toxicity: water or milk

Vaccines
MOH Schedule:
At birth: ONLY Hep B
2-4 mon: DR BHIP
6 mon: DO BHIP, BCG
9 mon: MeasM
12 mon (1 year): MMR MOP
18 mon (year and half): MMR DOV AH
24 mon (2 years): A
School (4-6 years): MMR DOV
11 years: Tdap, HPV
12 years: HPV
18 years: MCV 4

#
Hepatitis B vaccine: 3 doses per a year
Hepatitis A vaccine: 2 doses
# Hep A is the most recommended for travel

DTaP : < 7 years

DT : < 7 who had allergy from pertussis
Recommend age to switch from DTaP to Tdap: 7 years

Influenza vaccine taken Oct - Mar

Emergency staff: should take meningitis vaccine

Routs:
Oral vaccine: OPV, RV
Vaccines can be given IM or SC: IPV, PPSV23

Vaccines with conditions:

DM:
DM pt.: Pneumococcal, HBV, Influenza
Diabetic foot: TD only

Pregnancy:
Pregnancy vaccine: HBV, Tdap, influenza
# one Tdap in third trimester every pregnancy between 27- and 36-weeks gestation
Pregnant with +ve Hep B: baby should receive Hep B vaccine and Immunoglobulin
Vaccination prevents pregnant: Depo-Provera (DMPA)
Prevention of cervical cancer and reduce the incidence of infertility: HPV
Older pt:
⁃ > 50: shingle
⁃ > 60: pneumococcal disease vaccine
⁃ All pts. > 65: PCV13 then after 1 year give PPSV23 5 years from last dose

Hajj “Pilgrims”: Influenza, meningococcal vaccine (MCV)

Vaccine with Influenza antiviral drugs (IAD)

Influenza vaccine with IAD
⁃ Inactive vaccine can be taken with IAD
live vaccine
• IAD —> wait 48 h —> LAIV
• LAIV —> wait 2 weeks —> IAD

Live vaccine with Corticosteroid:

Pt receiving high dose of corticosteroids less than 14 days: live vaccine gives immediate
Pt receiving high dose of corticosteroids for more than 14 days: delayed at least 1 month
after DC the steroid

Live vaccines:
MMR, BCG , Varicella, RV, LAIV, ZVL, Yellow fever, Plague, Oral Piolo vaccine, Oral Typhoid
# Don’t give live vaccines to pt who have CD4 < 200

CI of Live attenuated Influenza Vaccine (LAIV):

⁃ 0-6 months
⁃ allergy and egg allergy
⁃ 2-17 years taking aspirin
⁃ 2-4 years with asthma or wheezing past 12 mon
⁃ immune compressed

When to take 2 vaccines:

⁃ 2 inactive vaccines: can be taken at same time
⁃ Live and inactive: same time
⁃ 2 Live vaccines: either same time or 28 days apart

Allergy:
Egg: MMR, Yellow fever, Influenza
Gelatin: varicella, MMR, Yellow fever, Zoster
Latex: HPV, RV
Storage:
Majority in refrigerator (2-8 C)
Zostravax, OPV: freezer (- 15 C)

“Vaccine should be kept in button shelf of refrigerator“

Wound:
Deep wound + Unknown Vaccination history = Td + TIG
Deep wound + Patient has vaccinated within 5 years = No need today
# BUT if 10 years we need
Deep wound + Patient hasn’t vaccinated within 5 years = Only Td

Minor wound + Unknown vaccination history = only Td

Minor wound + Patient has vaccinated within 10 years = No vaccine needed
Minor wound + Patient hasn’t vaccinated within 10 years = only Td

Info:

Thimerosal (mercury) containing vaccines may cause: Autism

Vaccine with a Max. age: Pneumococcal

Zoster cause: shingles

Varicella cause: chicken box 🐓 📦

HPV: it causes syncope à let the pt. set for 15 min

LYMErix vaccine use to prevent Lyme disease

# Lyme disease caused by bacterium Borrelia

Airborne virus need vaccine or cause Endemic: MMR

Vaccination prevent immunocompromise: MMR, MMRV

FluMist: inhaled influenza vaccine from (2-49 years)

Bacteria that cause Diphtheria : Corynebacterium

 CVD:

Arrhythmia:

P wave: Atrium depolarization

QRS complex: Ventricular depolarization
T wave: Ventricular Repolarization

Phase 0: Rapid Ventricular depolarization due to influx of Na

Phase 1: Early rapid repolarization due to Na channel close
Phase 2: Plateau phase due to a Ca influx
Phase 3: Rapid Ventricular repolarization due to efflux of K
Phase 4: RMP, Atrial depolarization

Arrhythmia with heart block: phenytoin

# CCBs is CI in arrhythmia with heart block
Ventricular arrhythmia: procainamide
Digitalis arrhythmia:
1st: lidocaine
2nd: phenytoin
3rd: procainamide
4th: propranolol
Reflex tachycardia (RT): propranolol
A.Fib: Verapamil

Classes:
A. Class I: Na+ Channel blockers
- Ia: Quinidine, Procainamide. #SE of Quinidine: Cinchonism/Quinism (blurred vision, tinnitus, ..)
- Ib: Lidocaine, Mexiletine
- Ic: Flecainide, Propafenone
B. Class II: Beta-blockers. # AVOID: with intrinsic sympathetic activity e.g (Pindolol, acebutolol)
C. Class III: K+ channel blockers
- Amiodaron, Dronedarone, Sotalol, Doftilide
# Amiodaron SE: thyroid abnormalities, Blue-gray man syndrome, photosensitive
# Sotalol is the ONLY one who have Beta blocker activity with K+ channel activity
D. Class IV: CCBs. # verapamil inhibits metabolism of digoxin
- Verapamil, Diltiazem

Other classes:
• Digoxin, Adenosine, Mg sulfate
# Digoxin toxicity will be increased by: decrease K+, decrease Mg+, Renal failure
# Adenosine will not give effect if the patient was taking theophylline or coffee
# Digoxin antidote: Digoxin immune fab (Digifab)
Rate control: BBs, CCBs, Digoxin
Rhythm control: Amiodarone, Propafenone, Sotalol, Flecainide

-ve inotropic: decrease contractility, dec cardiac workload “BB’s”

+ve inotropic: increase contractility “Digoxin”

---------------

Heart Failure (HF):

ACE-I and Beta blocker should be given to ALL heart failure patient unless if there is
contraindications to decrease mortality.
Beta blocker in Heart failure (MBC): Metoprolol, Bisoprolol, Carvedilol
# Diuretic in HF patient: Loop Diuretics

HF with EF < 40 which med. AVOID: CCBs

A.Fib + HF: amiodarone

Drug Decrease mortality with HF: BBs, ACE-I, Spironolactone

Drug Increase mortality wit HF: Metformin, CCBs, Pioglitazone, gabapentin

Med, cause edema: amlodipine, NSAIDs, Corticosteroids, Pioglitazone

---------------
Angina:

Nitroglycerin, Isosorbide mononitrate Cause: orthostatic hypotension

# Drug interaction: PDE-5-I

CI in angina: Vasopressin
Prinzmental angina: nitroglycerin & CCBs
# Schedule doses of nitroglycerin cause tolerance

Increase in case of blessing: Reticulocytes-WBC

# so will produce when there is blood loss
Responsible for fibrin lysis: plasma

Minoxidil: Dilate ONLY artery

# Minoxidil cause water and Sodium & water retention

Nitroprusside sodium: Potent vasodilator

 ---------------

Stroke:

Lysis clots: streptokinase

Acute Ischemia: Alteplase
# Alteplase can cause Angioedema
CI of Fibrinolytic: stroke within 2 months, Uncontrolled HTN

Med. may cause hemorrhagic cystitis: ifosamide

Antiplatelet CI in Hx of TIA: Prasugrel
CI in IHD: Celecoxib

Acute ischemic stroke treat it with: hydralazine

# Hydralazine NOT use monotherapy in HTN
Hydralazine: Vasodilation (Artery > Vein)
# metabolism in intestine

Hemorrhagic stroke:
# Anticoagulant should NOT use while patient bleeding
# Use hypertonic slain (Mannitol)

---------------

Shock:

Cardiac shock: Dopamine or Dobutamine

Anaphylactic shock: Epinephrin
Septic shock: fluid à 1st NE à DA à Epi
# if we give NE without sufficient amount of fluid will cause necrosis
Septic shock with kidney injury: DOC DA

---------------

Pain in CAD: Nitrate, morphine

Preventing cardiomyopathy AFTER bariatric surgery: selenium
Urgent Cardiac surgery of PCI required: Bivalirudin
 Dermatology:

Skin conditions:
§ Chronic skin disease:
o Eczema
o Psoriasis
o Scabies
§ NOT chronic skin disease:
o Chicken pox 🐔

Psoriasis
§ Coal tar
§ Calcipotriol (Vit D)

Acne:
§ Topical:
o Benzyl peroxide (Keratolytic)
o Azelaic acid

§ Systemic:
o Erythromycin, doxycycline
o Isotretinoin
# Isotretinoin should be STOP 1 month before getting pregnant

Sun protective factor (SPF):

Amount of light that induce redness in sunscreen protected skin

SPF = ----------------------------------------------------------------------------------------
Amount of light that induce redness in unprotected skin

Simply:

Minutes after SPF (with sunscreen)

SPF = ------------------------------------------------------
Minutes before SPF (without sunscreen)

Inflammation:
§ Diaper inflammation: Petrolatum
 Cancer:

Alkylating anti-cancer agent: Cyclophosphamide

Decrease immunity: cyclophosphamide
Immunosuppressant cause hirsutism: cyclosporine

Methotrexate increase liver enzyme: Give folic acid or decrease dose or STOP 🛑
# Avoid with methotrexate: Aspirin
# Penicillin increase methotrexate level
# Dose of methotrexate: 7.5 - 15 mg once weekly

Treatment of peritoneal carcinoma: Bevacizumab

Common gene in cancer: P53, TP53

Tumor suppression protein: P53

Human papilloma vaccine (HPV) for 💉: Cervical cancer

# Prevention of cervical cancer and reduce the incidence of infertility

Breast cancer:
Treatment of breast cancer: Raloxifene, hydrochloride, tamoxifen
Prophylaxis of breast cancer: Raloxifene
# Supplement decrease the risk of breast cancer: Vit D

Medication to mange N&V from anticancer:

§ Serotonin (5HT3) antagonist (Granisetron, Ondansetron, Dolostone)

Plant sources of anticancer:

§ Vinca Alkaloid: Vinblastine, Vincristine, Vindesine, Vinorelbine
# Vincristine Fatal if given intrathecal ONLY IV infusion
§ Texans: Paclitaxel, Docetaxel
§ Plant origin (epipodophyllotoxin): Etoposide

NOTE:
Methotrexate, cytarabine, hydrocortisone and dexamethasone are commonly given by the intrathecal route.
Occasionally rituximab and thiotepa may be given by this route.
 Dyslipidemia:

Statin: HMG-CoA reductase inhibitors (rate-limiting step)

# Not use: in pregnant and lactating woman (Category X)

# SE: Muscle pain (rhabdomyolysis, myopathy), Elevate liver enzyme, exaggerated glucose level
# Monitor: Creatin Kinase, liver enzyme (if increase X 3 fold from upper limit à Hepatotoxic à DC)
# Decrease myopathy with statin co-administration with Co-enzyme Q10
# Statin + Gemfibrozil or Valproic acid à severe Rhabdomyolysis

Administration of Statin:

SRP statins need dose adjustment: Simvastatin, Rosuvastatin, Pravastatin

AF statin NOT need adjustment: Atorvastatin, Fluvastatin

FAR is statin ☀ / 🌙: Fluvastatin, Atorvastatin, Rosuvastatin

SPFL is statin 🌚 : Simvastatin, Pravastatin, Fluvastatin, Lovastatin

FPRP are statin safe when taken with grape fruit juice 🍇 : Fluvastatin, Pitovastatin,
Rosuvastatin, Pravastatin

Equivalent doses of Statin:

Pharmacist Rock At Saving Lives & Preventing Flu.

Pitavastatin 2 mg = Rosuvastatin 5 mg = Atorvastatin 10 mg = Simvastatin 20 mg =

Lovastatin 40 mg = Pravastatin 40 mg = Fluvastatin 80 mg
# Atorva 40mg = Rovista 20mg

Bile acid Sequestrants: (Resins)

Cholestyramine # Not use in pregnant and CI in Hypertriglyceridemia (increase TG)

Fibric acid derivative: (Fibrates)

Fenofibrate, gemfibrozil
# Not use with statin à severe Rhabdomyolysis

Act on triglycerides and cholesterols: Simvastatin

Acts on triglycerides: gemfibrozil

Others:
- Niacin (Vit B3)
- Cholesterol absorption inhibitors (Ezetimibe). # Can use it with statin
- Omega – 3 – fatty acid
 Details (Enzy. & CYP & Hormones & Cell)

Enzyme:

Abacavir: HLA-B*5701
# Class: Nucleoside reverse transcriptase inhibitors (NRTIs)
Allopurinol: HLA-B*5801
CBZ&OCBZ – Phenytoin & Fosphenytoin: HLA-B*1502

Enzy. inducer:
Phenobarbital, Rifampin, Phenytoin, Ethanol, CBZs
# Phenytoin potent enzy. Inducer

Enzy. Inhibitor:
Allopurinol, Chloramphenicol, Corticosteroids, Cimetidine, MOA-I, Erythromycin,
Ciprofloxacin

Trastuzumab & Pertuzumab (breast cancer ♋): HER2 (+ve) use

Cetuximab & Panitumumab (colorectal cancer ♋): KRAS (-ve) use

Azathioprine: Thiopurine Methyltransferase (TPMT)

Capecitabine & fluorouracil: Dihydropyrimidine dehydrogenases (DPD)
Enzy. Effected by anticancer: aromatase

CYP:

Clopidogrel: CYP2C19
Warfarin: CYP2C9, VKORC1
# also 2C9 amiodarone
Codeine: CYP2D6
# tamoxifen, tramadol, Risperidone
Irinotecan: UGU1A1
Rituximab: CD 20 💿
Fluorouracil: DPYD
Inc. risk of rhabdomyolysis with statin: SLCO1B*1*5
Paracetamol: CYP2E1
Atazanavir: CYP3A4

CYP1A2: caffeine, Clozapine, Theophylline

CYP2C9: Carvedilol, Celecoxib, Glipizide, Warfarin
CYP2C19: Omeprazole, Clopidogrel, phenytoin, Phenobarbital
CYP2D6: Codeine, Amitriptyline, Carvedilol, Donepezil, Haloperidol, Paroxetine
CYP3A4&5: Alprazolam, Amlodipine, Atrovastatin, Cyclosporine, Diazepam, Sildenafil,
Verapamil
Metabolism:

Phase 1:
⁃ oxidation
⁃ Reduction
⁃ Hydrolysis
# Med. undergo phase 1 metabolism: Diazepam

Phase 2:
⁃ Conjugation
# Conjugation reaction excretion will lead to inactive substance

Phase which acid secretion decrease: intestinal phase

Phase which acid secretion increase: Cephalic phase and Gastric phase

Metabolism in intestine: hydrolysis

# Amphotericin B eliminated by hydrolysis

Process require CYP450: Oxidation

After med. metabolism become: Polar

Drug store in body as: Fat and protein
Most common diffusion of med. entry the cell: Aqueous diffusion

Metabolism of paracetamol: Glucuronides conjugates

Glucose from glucose: Glycogenesis
Tyrosine to tyrosinase esterase: tyrosine hydroxylase
L-glutamine to D-glutamine: Glutamate synthesis
Codeine to morphine = dealkylation, demethylation, oxidation

Enzy. Metabolize starch: a-amylas

Polysaccharides: starch
Enzy. kinetic law: Michaelis-Menten law

Aspirin bond: covalent bond

# aspirin reduce the flushing of nitrate
Acetaminophen: Hydrogen bond (H)
1st order: linear
# rate direct proportional of the conc., CL NOT change

0 order: Non-linear
# rate is independent of the conc.

# WAATTP, non-linear
Warfarin, Alcohol, Aspirin, Theophylline, Tolbutaminde, Phenytoin

Largest capsule 💊: 3cm (000)

Med. can be crushed: immediate release tablet 💊

Sustain release depend on:

• interaction with body fluid
• Medium PH
• Enzy. activity

Absorption in stomach:
• non-ionized
• non-polar
• Lipid soluble
Cross BBB 🧠:
• Unionized
• Lipophilic
Cross the placenta %:
• Mwt < 500
• Lipophilic
• Non-ionized
# Protein bound NOT cross PlacentaONLY the free unbound

Effect of volume of distribution: solubility, protein binding, Mwt

Obese pt. The effect of lipid soluble drug: will be on volume of distribution
Controlled med. in body depend on: Body fluid interaction
Mwt > 500 will excreted in: biliary
Contributes for two compartments of drug distribution: Adipose

ACE-I to ARBs: No time is needed

ARBs to ACE-I: No time is needed
ACE-I to ARNI: 36 hours 🕰
ARBs to ARNI: No time is needed

T-lymph: intercellular
B-lymphocytes: extracellular
Hormones:

Posterior pituitary gland:

NOT produce any hormones by its own, store and secrete 2 hormones from hypothalamus
(Oxytocin & ADH)

Anterior pituitary gland:

Produce and release many hormones
(GH, Prolactin, TSH, ACTH, FSH, LH)

Hormone release from adrenal cortex adrenocorticotropic: progesterone

Essential Amino acid (a.a)

# Try This VIP MALL

Try: tryptophan
T: threonine
His: Histidine
V: Valine
I: isoleucine
P: phenylalanine
M: methionine
A: Arganine
L: leucine
L: lysine

Histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan

Non-essential a.a:
Alanine, Asparagine, Aspartic acid, Glutamic acid

A.A conjugate in liver: Glycine, taurine

A.A present in hair and nails: Cysteine, Arginine, Lysine, Methiein (CALM)
On DNA: A, G
Component of purine nitrogen: Adenine, Guanine

Stating code: AUG

Stopping code 🛑: UUA UGA UAA
Monosaccharide:
• Glucose
• Fructose
• Galactose

Disaccharides:
• Maltose
• Lactose
• Sucrose

Polysaccharides:
• Starches
• Fibers
• Glycogen

Cell:

Mitochondrial
• ATP -> energy
• Q10 with selenium

DNA is: Deoxyribonucleic

Epitope: “Antigenic determinant”

Part of an antigen that is recognized by the immune system. Specially by antibodies, B cell, T
cell.

Golgi apparatus:
# Membrane bound organelle found in mast cell.
# Responsible for packing proteins into vesicles to secretion and therefor plays a key role in
the secretory pathway

Plasmid:
# Small, extrachromosomal DNA molecule within a cell that is physically separated from
chromosomal DNA and can replicate independently.
# Found as small circular, double standard

Plasmin: responsible for fibrin lysis

Philadelphia chromosome:
Imatinib 9:22
# Nilotinib used to treat Philadelphia chromosome CML

Active enzy. PEPSIN

 Discoloration and Syndromes
* Discoloration in urine, feces, taste
* Pigmentation
* Syndromes
* Eyes and Ears problems

Urine

Red / orange urine:

§ Phenazopyridine
§ Senna laxative
§ Rifampin
§ Doxorubicin
§ phenytoin

Brown / Dark urine:

§ Metronidazole
§ Nitrofurantoin
§ Carbidopa / levodopa

Green / blue urine:

§ Cimetidine
§ Amitriptyline
§ Doxorubicin
§ Indomethacin
§ Propofol
§ Sildenafil
§ B vitamins

Feces:

Discoloration of feces 💩:
§ Phenytoin
§ Iron
§ Rifampine

Dark stool:
§ Iron
§ Bismuth subgallate
Other pigmentation:

Chlorpromazine, Thioridazine: Pigmentary on retina and corneal 👁

Prostaglandin Analogue: (Latanoprost, ..etc) Darkening of the iris 👁
Red-green color blindness: Ethambutol

Amantadine: Livedo Reticularis “Pattern of reddish-blue skin discoloration”

Hydroxychloroquine “anti-malaria”: Chronic use will cause skin pigmentation

Rifampin: Red urine, tears, sweat

Taste:

Metallic taste:
§ Metformin
§ Metronidazole

Loss of taste: Captopril

Black tongue 😛 : bismuth subgallate
Syndromes:

Toxidrome: The syndrome caused by toxin

Prodrome: the signs and symptoms of toxicity syndrome

Gray baby syndrome $: Chloramphenicol

Gray man syndrome: Amiodarone
Red man syndrome: vancomycin

Blue-Gray skin discoloration: amiodarone

Brown-pink skin discoloration: Clofazimine

Purple gloves syndrome 🧤: phenytoin

Hand-foot syndrome &: capecitabine
Purple toe syndrome 👣: warfarin
Yellow nail syndrome 💅: Sodium aurothiomalate

Lupus like syndrome: hydralazine & procainamide & isoniazid

Monday syndrome: Isosorbide

Red-green color blindness: Ethambutol

Reye syndrome: aspirin (children and teenagers)

# Not use bismuth in children and teenagers who recovering from flu, chickenpox, viral infection -> risk of Reye’s
syndrome

Treatment of Raye syndrome:

§ CCBs: Nipedifine
§ VD: Sildenafil
Eye problems 👁

Retinopathy:
§ Quinine
§ Hydroxychloroquine
§ Ethambutol
§ Indomethacin

Eye pigmentation:
§ Latanoprost # Pigmentation + blurred vision
§ Deferoxamine
§ Chlorpromazine, Thioridazine

Loss of vision (Myopia):

§ Topiramate
§ Hydrochlorothiazide
§ Latanoprost (Blurred vision)
§ Itraconazole (vision distribution)
§ Antimuscarinic (Blurred vision)
§ PDE-5 inhibitors (abnormal vision)

Glaucoma ( inc. IOP)

§ topiramate
§ Corticosteroids
§ Tetracycline

Chloramphenicol: cause optic neuritis

Hydroxychloroquine: Ocular toxicity
Tamsulosin: Floppy iris syndrome (during cataract surgery)
Heroin and morphine: miosis “pointed pupil” # Pupillary construction
Cocaine: mydriasis

Ear problems "

Ototoxicity:
§ Aminoglycoside (Irreversible)
§ Vancomycin
§ Macrolides

Quinine: Deafness
Cisplatin: Hearing loss
Aspirin in children: tinnitus of the ear
# For tinnitus treatment: Betahistine
 MIX- NOTE

Medication should stop before IV contrast

§ NSAID: Don’t take then for 2 days before and after the test
§ Metformin: Don’t take it the fay of the test and 2 days after.
§ Diuretics: Avoid for 24h before test
§ ACE-I & ARBs: Stop at least 48 hours
# IV Radiological substance: May cause acute renal failure

-----

Travel ✈:

Hep A: the most recommended for travel

Travel diarrhea prophylactic ✈ : hygiene and bismuth, rifaximin

Travel diarrhea caused by: E.coli
Travel diarrhea treatment:
§ Ciprofloxacin, azithromycin, Quinolones
§ loperamide (opioid with anti-diarrhea effect)

Travel insomnia: Melatonin (Ramelteon)

Jet lag 🛩:
§ Melatonin
§ Zolpidem

Zolpidem
§ MOA of Zolpidem: BZDs like action
§ Uses: Jet lag, insomnia & geriatric “hypo hypnotic”
# NOT cause addiction & withdrawal

§ The patient who using zolpidem will be: drowsiness, Dizziness, Weakness,
lightheadedness
§ Dose:
o Man: 3.5 mg Max.: 10 mg
o Woman: 1.75 mg Max.: 5 mg

-----
G6PD
# G6P Enzy. Activate when there is high insulin level

G6PD deficiency will cause which type of anemia: hemolytic anemia

Medication CI in G6PD deficiency:
§ Hydroxychloroquine (RA treatment)
§ Sulfasalazine (RA treatment)
§ SMX/TMP (Antibiotic)
§ Primaquine (Anti-malaria)

Caution in pt. ē G6PD deficiency: Nitrofurantoin

Pregnant with UTI + G6PD: cefuroxime

-----

Smoking:

Smoking associated with CYP induction 🚬

§ Clozapine and Olanzapine with smoking 🚬:

o Smoking will Increase metabolism à which lead to decrease Conc. & Increase
Clearance
# Need higher dose of Olanzapine with smoking pt.

§ Theophylline + smoking 🚬 : decrease theophylline plasma level

# Require higher dose

Antidepressants used in stop smoking 🚬: Bupropion

-----

Diet:
§ Plate diet: DM
§ Dash diet: HTN
§ Gluten free diet: Celiac disease
§ BRAT diet: Diarrhea
§ Ketogenic diet: epilepsy

-----
Sulfa allergy

§ Celecoxib
§ Sulfasalazine
§ Captopril # The ONLY ACE-I containing sulfa

Sulfonamide allergy CI: Thiazide, Loop diuretics

 Genitourinary (Men)

Erectile dysfunction (ED):

Decrease blood flow to penis

Treatment:
A. Non-pharmacological:
§ Lifestyle (decrease weight, stop smoking & alcohol)
§ Manage the underline causes (HTN, Atherosclerosis)
B. Pharmacological:
§ Phosphodiesterase – 5 inhibitors (PED-5): (1st line)
{Sildenafil, Tadalafil, Vardenafil, Avanafil}. # Tadalafil if the ONLY approved for BPH
# MOA: local release of nitric oxide which will inhibit Phosphodiesterase enzyme à increase cGMP à smooth
muscle relaxes à increase blood flow à erection
# SE: Hypotension, Nasal congestion, headache, dizziness, abnormal vision (STOP once this happen)
# CI: nitrate (will cause sever hypotension)

Benning Prostate Hyperplasia (BPH):

Pathophysiology: Prostate depend on testosterone for development and maintained the

size and function

Testosterone 5 -a reductase > Dihydrotestosterone (DHT) # responsible for normal & hyper growth
# too many conversion it will lead to enlargement of the prostate
# So 5-a reductases inhibitors will ONLY be used in case of prostate enlargement > 40 g

BPH worse by: Anticholinergic (atropine, benztropine, ..etc.)

BPH induce by: Chloramphenicol

Treatment:
1. a1- receptor antagonist: {Prazosin, Terazosin, Tamsulosin}
# SE: orthostatic hypotension, nasal congestion, headache, floppy iris syndrome (with tamsulosin)
2. 5 - a - reductase inhibitors: {Finasteride, Dutasteride}
# used ONLY in prostate enlargement > 40 g
3. Combination therapy: {tamsulosin + Finasteride or Dutasteride}
# Symptoms of BPH with enlargement prostate > 40 g
4. Phosphodiesterase – 5 inhibitors (PED-5): {ONLY tadalafil approved for BPH}
5. Antimuscarinic: {Oxybutynin}

Plant used in BP: Saw palmetto

Urinary incontinence (UI):

Treatment:
§ Anticholinergic: {Oxybutynin, Tolterodine, Darifenacin}. # most common used
§ Anti-diuretic (ADH): desmopressin
# Desmopressin also used in: Diabetic insipidus, nocturnal enuresis, UI

NOTE:

ED: PDE-5 (Sildenafil)

BPH: a1- receptor antagonist (Tamsulosin, Prazosin)

BPH with prostate enlargement score > 40: Combination therapy {tamsulosin + Finasteride
or Dutasteride}

BPH + ED: ONLY Tadalafil

Prostate cancer: Flutamide, Androcur

Prostatitis: Finasteride
# Inflammation of prostate gland

Premature ejaculation: duloxetine

# Terazosin treatment of BPH by relaxation of bladder neck

Treatment of Urine incontinence (urgency and frequency): darifenacin

Treatment of Urine retention: Neostigmine, Carbachol, Pilocarpine

Med. induce impotence: Thiazide, Cimetidine, Propranolol, Azoles

 GIT:

Antacid:

NaHco3 antacid makes an out elimination: Pka = 1.2 -> weak acid
PH stomach gastric: 1.5-3.5

Antacid used in heartburn: Neutralize acidity

Neutralize acidity and treat gastritis: PPIs
Neutralize stomach acidity and prevent PU: Antacid

When use Omeprazole as a single therapy: gastritis

Esomeprazole for esophageal injury: 30 days
PPIs used in GI bleeding: Pantoprazole
PPIs used in case with Clopidogrel: Pantoprazole
Medication make complex with antacid: Fluoroquinolone, Tetracycline, Doxycycline

Mesalazine treat and maintenance of: Ulcerative colitis

Fistulas ulcerative colitis: infliximab
Sulfasalazine used for: IBW (Ulcerative colitis, crohn’s disease)
# Colitis & cortisone: better ca + vit b12, Ca
# Only Colitis: vit B12
Melena treatment: Sulfasalazine
# it is a dark black, bloody faces

Antacids give Cathartic effect as SE: Mg hydroxide

Glycoside of senna cathartic effect: anthraquinone
Pt with catheter jitter should take: ciprofloxacin

H2RA SE: decrease Vit B12

# H2RA in GERD NOT use in case with erosive
PPIs SE: decrease Vit b12 and mg and decrease Ca++ absorption which lead to bone fracture
# PPIs is block H/K irreversibly

# Urea Breath test to detect Pylori infection: we should STOP antibiotics, PPIs, Bismuth and antacid
before 2 weeks

# 20 mg of Omeprazole = 300 mg of Cimetidine

# Clove oil USED in dark box 📦
# Med. incr. absorption with ranitidine: Naproxen

-------------
Constipation:

Classification:
A. Stimulant laxative:
Senna, Bisacodyl, Sodium Picosulfate, Castor oil
# Anthraquinone Glycoside of senna responsible for catheter effect
# Castor oil CI in pregnant
B. Bulk forming laxative:
Psyllium, Methylcellulose, Polycarbophile, wheat bran, inulin
# Safe in pregnancy and old patients
C. Osmatic laxative:
Glycerin, Lactulose
# Glycerin use in pediatric "
# Lactulose use in Hepatic Encephalopathy (HE) to decrease ammonia level
D. Stool Softener: (emollient)
Docusate
# Require water intake, NOT take it with mineral oil
E. Lubricant laxative:
Mineral oil
# Take it in upright position to avoid aspiration & potential sever lipid pneumonitis

-------------

Diarrhea:

Adsorbent antidiarrheal med.:

• •Kaolin
# Bind to bacteria toxin

Antimotility to Control diarrhea:

• •Diphenoxylate
• •Loperamide
# Opioids and have antidiarrheal effect
# Avoid in case of infection and bloody stool

DOC of giardiasis: metronidazole

# infection cause diarrhea

Travel diarrhea:
• Prophylaxis: SMT/TMP, Doxycycline, Bismuth
• Treatment: Ciprofloxacin, Levofloxacin
# Pregnant and Pediatric: Azithromycin

Colitis caused diarrhea: Vancomycin

 -------------

Nausea & Vomiting:

Dopamine (D2) antagonist:

Metoclopramide. # Cross BBB & cause EPS
Domperidone # Not cross BBB butit cause QT prolongation

Pregnant with N&V:

- Meclizine + Pyridoxine (Vit B6)
- Cyclizine + Pyridoxine (Vit B6)
- Doxylamine + Pyridoxine (Vit B6)

Induce vomiting 🤮:
• Ipecac
• Emetic

Emesis NOT use in toxicity of:

• Pt. Ingested caustic substance
• Pt. Ingested volatile hydrocarbon
• Pt. Has CNS depression

Antiemetic use in ER 🆘:
Metoclopramide, Chlorpromazine, Promethazine, Dimenhydrinate

# Metoclopramide work in: Chemo-trigger-zone

-------------

Administration:
- Mineral oil (for constipation) à Upright position
- Bisphosphonate (for OP) à Upright position + empty stomach (morning)
- Levothyroxine (for hypothyroidism) à on empty stomach (morning)
- Levodopa/Carbidopa (for PD) à on empty stomach (morning)

Medications make complex with antacid:

Iron, Bisacodyl, tetracycline, Fluroquinolone, Bisphosphonate
# Digoxin decreases with antacid
# Warfarin with AL poorly absorbed
Medications with Ca++ and products contacting Ca++ (milk, ..etc):
• Dec absorption:
Iron, Bisacodyl, tetracycline, Fluroquinolone, Bisphosphonate
• Change effect:
Increase effect of digoxin
Decrease effect of CCBs

# Decrease gastric emptying rate: Atropine & hypothyroidism

# Complex with dietary products: Ciprofloxacin

# Ibuprofen can take it with milk

# Increase acetaminophen absorption with coffee
# Increase iron absorption with Vit C

# Metformin & lithium takes it with meal to decrease GI side effect

# PPIs take it 30 mins before the meal
 Migraine & Glaucoma:

Migraine

A. Acute attack:
§ Triptan (Sumatriptan):
o Can combine with NSAIDs
o Max. 2 doses/day, 2-3 day/wk.
o Not take Ergot Alkaloids in the same day
o CI: CAD, Stroke, uncontrolled HTN, pregnancy
o Warning: serotonin syndrome

§ Ergot Alkaloids: (Ergotamine, Dihydroergotamine): The same CI with triptan, Category X

§ Analgesic:
o NSAIDs, Paracetamol:
# ONLY moderate attach without vomiting or sever nausea, either NSAID alone or in combination with paracetamol

§ Antiemetic:
o IV metoclopramide, IV/IM chlorpromazine, Prochlorperazine:
# Can be use as Monotherapy
o Oral antiemetic:
# Can’t use as monotherapy, should be combined with metoclopramide and NSAIDs

B. Migraine prophylaxis:

1. Antihypertensive:
§ BBs: (Propranolol, Timolol)
§ CCBs: (Verapamil, Flunarizine)
2. Antiepileptics: Valproate, topiramate, Lamotrigine
3. Antidepressants:
§ TCAs: (Amitriptyline, Nortriptyline, Protriptyline, Doxepin)
4. Serotonin antagonist: Methysergide, Pizotifen, Cyproheptadine
# Cyproheptadine have a antihistaminic activity and 5- hydroxy-tryptamine (5-HT) antagonist “Serotonin antagonist”
5. Botulinum Toxin: Clostridium botulinum toxin type A (Botox)
6. Devices: TENS (Transcutaneous Electrical Nerve Stimulation) device

NOTE:
Migraine:
§ Mild - moderate: acetaminophen, Ibuprofen
§ Sever: triptans (Sumatriptan) +/- NSAID
Glaucoma:
Most common cause is increase Interocular pressure (IOP) due to increase fluid

Treatment:

A. Decrease fluid production: (beta-blockers)

§ Selective B1-blocker: Betaxolol
§ Non-selective B-blocker: Timolol
# Non-selective do NOT used in asthmatic patient

B. Increase fluid outflow: (Prostaglandin analogue)

§ Latanoprost, Travoprost
# warning: it causes darkling of the iris
# SE: Blurred vision, increase pigmentation

C. Decrease fluid production & Increase fluid outflow: (Adrenergic a-2 agonist)
§ Brimonidine
# warning: Caution with heavy activity (e.g driving) until you know the effect on your body
# SE (adrenergic SE): sedation, burning, itching eye, dry mouth

NOTE:

§ Glaucoma in pregnant: Brimonidine or Timolol

§ Glaucoma in asthmatic patient: Betaxolol or Latanoprost

# Non-selective do NOT used in asthmatic patient

§ Open angle glaucoma (OAG): Pilocarpine

# Pilocarpine is a cholinergic agonist used to reduce pressure inside the eye
 HTN:

Diuretics:
A. Thiazide: Hydrochlorothiazide, Chlorthalidone
# SE: hypo K, Mg, Na/ Hyper Ca, glucose, uric acid. “Bone protective”
# CI: DM, gout, renal failure
# Indapamide which is used in essential HTN & Pulmonary edema “thiazide like diuretic”

B. Loop Diuretics: Furosemide, torsemide, ethacrynic acid # diuretic in kidney failure

# SE: hypo K, Mg, Na, Ca/ Hyper glucose, uric acid / Ototoxicity
# CI: DM, gout, Aminoglycoside
# Furosemide infusion rate: 4 mg/min

C. K-sparing diuretics: Spironolactone, Eplerenone, amiloride

# SE: Hyper K, Gynecomastia, impotence
# CI: BBs, ACE-I, K supplements, Renal failure
# Spironolactone with cimetidine have anti-androgenic effect
Furosemide : Spironolactone (40 : 100)

CCBs:
A. Nifedipine: (can use in pregnant)
B. Verapamil / Diltiazem:
# SE: Gingival hyperplasia, Ankle edema, constipation, 1st degree atrioventricular block (verapamil)
# Avoid: with digoxin, beta-blockers, Heart block

Renin-Angiotensin-Aldosterone-System-Inhibitors (RAAs-I) :
A. ACE-I:
# SE: Hyper K, cough, Angioedema, hypotension
# Cause of cough: increase the of bradykinin
# CI: in kidney failure and pregnant woman (fetal growth)
# ACE-I it is used: to convert Macroalbuminuria to Microalbuminuria
# ACE-I should be taken to ALL patient with HF to decrease mortality except if there is CI
B. ARBs & Renin-I (aliskiren):
# aliskiren CI in kidney and pregnant
# Both are less cough and angioedema

Beta-Blockers:
Propranolol it is used in: Thyroid storm, HTN, Anxiety, Migraine
Labetalol: use in pregnant with HTN
# ALL beta blockers are CI in: asthma, DM
Centrally Acting Sympathetic Inhibitors:
- Clonidine: cause hypertension crisis if withdraw suddenly
- Methyldopa: use in pregnant woman

Vasodilator:
- Hydralazine: NOT use monotherapy in HTN

HTN in pregnant:
1st: Methyldopa
2nd: labetalol or Nifedipine
# Hydralazine can be use in HTN crisis in pregnancy

HTN Urgency:
BP > 180/120 without organ dysfunction

HTN emergency:
BP > 180/120 with organ dysfunction

Black people: CCBs, Thiazide

Albuminuria (regardless to race and CKD): ACE-I or ARBs
Cause hypotension due to blocking efferent limb: Beryllium
Indomethacin use in: essential Hypertension
# Also used in Pulmonary edema
 Hematology:

Anemia:

Types of anemia:
A. Iron deficiency anemia: (Decrease iron)
§ Oral iron: {ferrous sulfate, ferrous fumarate}.
# SE: GI, constipation, dark stool.
# Copper: essential for iron absorption in gut.
# DI: decrees levothyroxine, levodopa, methyldopa / PPIs: decrease iron / Vit C: increase absorption
# Dose: 325 mg TID {elemental iron = 65 mg}.
# Antidote: deferoxamine {non-receptor mechanism, because it is bind to free iron}
§ Parenteral iron: {iron dextran, iron sucrose}
# Parenteral iron is restricted to: unable to tolerate oral iron, extensive CKD
# Black box warning: anaphylactic shock # test the dose before

# Iron store in the body: Hemosiderin

B. Megaloblastic anemia, Macrocytic anemia: {Decrease both Folic acid (Vit B9), Vit B12}
§ Vitamin B12: Cyanocobalamine
# High dose will cause cyanide toxicity à give Hydroxocobalamin
§ Folic acid (Vit B9):
# Give it before 1 month of pregnancy à decrease risk of neural tube defect

C. Pernicious anemia: {Decrease Vit B12}

# Using Schilling test to detect amount of Vit B12
# Absorbed by intrinsic factor {* if there is a lack of intrinsic factor à lead to decrease Vit B12 absorption à
Cause Precious anemia}
# Common medication decreases Vit B12 {Metformin, PPIs, H2RA}

D. Normocytic anemia: {Decrease Erythropoietin (EPO)}

§ Erythropoiesis stimulating agent (ESA): Epoetin alfa, Epoetin beta, Darbepoetin
# iron is important for ESA to be effective

E. Aplastic anemia: {bone marrow fail to make RBCs}

§ Immunosuppressant, blood transfusion, bone marrow transplantation

F. Hemolytic anemia: {RBCs destroyed and removed before their lifespan}

Acute lymphoid anemia:
• Doxorubicin, vincristine
• 6-mercaptupurine methotrexate
• Etoposide L-asparaginase

Non lymphocytic anemia:

• Thioguanine
• Cytarabine

NOTE:

Iron deficiency anemia: iron

Megaloblastic anemia: folic acid & Vit b12
Pernicious anemia: Vit b12
# Lack of intrinsic factor
Hemolytic anemia: Cortisone
# Decrease G6D cause hemolytic anemia

Anemia of chronic renal failure: epoetin

# If there is a iron deficiency: darbepoetin

Medication Cause anemia: Nitrous oxide

Medication cause aplastic anemia: Chloramphenicol
Medication cause megaloblastic anemia: Trimethoprim

----------

Sickle Cell disease (SCD):

Treatment:
A. Non-pharmacological:
§ Blood transfusion # The ONLY cure for SCD if bone marrow transplantation
B. Pharmacological:
§ Immunization
§ Analgesics: acetaminophen, NSAIDs, Opioid (sever cases)
§ Hydroxyurea:
# Black box warning: myelosuppression
# Avoid: live vaccines
# warning: Embryo-fetal toxicity
# NOTE: contraceptive required during and after DC of therapy by 6 months in women and 12
months in men

SCA with pain crisis: hydroxyurea

 Musculoskeletal:

Osteoporosis (OP): Lower bone density

Gold Slandered test: Dual energy X-ray absorptiometry (DEXA)

Treatment:
• Non-pharmacological:
- Supplement (Ca++, Vit D)
- Lifestyle modification (Exercise, avoid smoking and alcohol, fall prevention)
• Pharmacological:
- Bisphosphonate. (1st line in OP)
- Selective estrogen receptor modulator (SERM) # High risk of VTE
§ Raloxifen. # Need Ca++ & Vit D supplement

Bisphosphonate:
Oral
• Alendronate: daily, weekly
• Ibandronate: daily, monthly
• Risedronate: daily, weekly, monthly
IV
• Ibandronate: 4 times per a year
• Zoledronic acid: once per a year

Alendronate OP dose:
§ Prevention: 5 mg/day or 35 mg/wk
§ Treatment: 10 mg/day or 70 mg/day

Bisphosphonate associated with gastric ulcer: oral alendronate and risedronate

Need renal adjustment: Zoledronic acid

Side effect of Bisphosphonate:

§ Esophageal irritation (upright position)
§ Osteonecrosis of the jaw (ONJ) -> Avoid with dental procedure
§ Atypical femoral fracture
§ Hypophosphatemia

NOTE of bisphosphonate:
§ Should evaluate Ca++ & vit D before start therapy
§ Take it on empty stomach (morning)
§ Remain upright position for 30-60 minutes
§ NOT use in active upper GI disease
§ Delay therapy if the patient will undergo any dental procedure
# because it may cause Osteonecrosis of the jaw (ONJ)
§ Separate Ca++, antacid, Iron, Mg at least 2 hours
Osteoarthritis (OA): Most common joint disease
Breakdown of cartilage, bony changes, deterioration of tendons & ligament

Treatment:
A. Pain management: Topical, paracetamol, NSAIDs, opioid (Not responded)
B. Other treatment
o Glucosamine & Chondroitin # NOT recommended
o Hydronic acid, Hydronated sodium (tissue lubricant). # lip pigmentation

Q: what Glucosamine and chondroitin used for: OA

Rheumatoid Arthritis (RA):

Treatment:
Disease modifying antirheumatic drugs (DMARDs)
A. Non-biologic DMARDs:
1. Methotrexate: ( 1st line) # Folic acid antagonist
Uses: Cancer, RA, abortion (category X)
AVOID: aspirin with methotrexate
# the patient should have a folic acid supplement even if it decreases the methotrexate effect but to reduce
the adverse effect
2. Leflunomide:
# female should DC 2 years before getting pregnant or administered cholestyramine
B. Biological DMARDs:
1. TNF-a inhibitors: Etanercept, infliximab, adalimumab
2. T-cell activation blockade: Abatacept
3. B-cell depletion: Rituximab
4. IL-6 inhibitors: Tocilizumab
# Most medication increase the risk of TB infection
# Live vaccine should be avoided to avoid the risk of infection

Metal use in treatment of RA: Gold 💎

--------

Osteoporosis (OP): Alendronate (Bisphosphonate)

Osteoporosis + Methotrexate: Leflunomide (Non-biological DMARDs)

Osteoarthritis (OA): Etanercept (Biological DMARDs)

Osteoarthritis + Methotrexate:
1st choice Etanercept
2nd choice Leflunomide
Gout

Treatment:

A. Acute gout attack:

§ 1st line in acute is NSAIDs:
o Indomethacin (DOC)
o Naproxen, Sulindac
§ 2nd line:
o Colchicine: Plant Alkaloid # Also used in Bechet’s disease
§ 3rd line:
o Corticosteroids

B. Chronic gout:
§ Allopurinol { Xanthine oxidase inhibitors (XOI) }
§ Probenecid
# When Allopurinol is CI or NOT tolerated
§ Lesinurad
# Combination with XOI, NOT use alone

Uricosuric:
Increase uric acid excretion which lead to decrease the uric acid Conc. In blood.
Ex.: Probenecid

Allopurinol:
Decrease uric acid synthesis Xanthine oxidase inhibitors (XOI)
# Cause sever cutaneous ( red skin rash ).

Allopurinol dose depend on Crcl:

o Crcl 3-9: 100 mg /day
o Crcl 10-20: 200 mg / day

CI (hyperuricemia)
§ Diuretics (Thiazide, Loop diuretics)
§ Pyrazinamide, Ethambutol (TB antibiotics)
# Both of them increasing the uric acid level

Indomethacin: Cause water retention

# Also minoxidil

--------
Multiple Sclerosis (MS):

Multiple sclerosis: Fingolimod (1st line oral)

# DC 2 months before getting pregnant & during pregnancy
# CI: MI, unstable angina, stroke, TIA , HF with block

Relapsing form of Multiple sclerosis: natalizumab

Refractory MS: Teriflunomide, natalizumab

Symptomatic therapy: TCA, Anticonvulsant

Walking impairment: Dalfampridine # ONLY approved for improve walking in MS patient

Routs of MS medications:
Injections (S.c) 💉: interferons, Glatiramer acetate
oral 💊: Fingolimod, Dimethyl fumarate, Teriflunomide
IV 💉: Natalizumab, Alemtuzumab, Ocrelizumab

--------

Myasthenia Gravies: OP‫اﻟﻮﻫﻦ اﻟﻌﻀ‬

Treatment:
§ Cholinergic: Neostigmine, Physostigmine
# MOA: block the action of Acetylcholinesterase à increasing Acetylcholine level
 Natural products:
Use of cranberry juice: UTI
Saw palmetto: BPH
#Saw palmetto SE: dizziness, headache, N/V/C/D.
Painful menstruation: Black cohosh

Grapefruit NOT: with amiodarone

Herbal safe with warfare: fish oil 🐠

Dry cough: Thyme😷

Plant used for cough relief 😷:
Oil form eucalyptus tree 🌳

Stress: Chamomile, lavender, lemon 🍋

Herbal for mental disease🌿: Gingko biloba
# use in Alzheimer
Herbal for sedative: Valerian
Plant used to increase physical activity ⛹: Ginger

Flavor used in: fruits 🍎

Natural products of burning 🔥: cool water, Aloe over, honey 🍯, coconut oil 🥥 , vinegar
# Sliver sulfadiazine FDA approved for wound infection and burn
Plant used to treat vomiting 🤮:
Citrus lemon 🍋, berberis vulgaris, malus domestica, mentha piperita, valeriana officinalis,
zingiber officinalis
Natural products for hyperlipidemia:
Garlic , red yeast rice 🍚, Fish oil 🐟
Plant with adaptogenic effect:
Ginger, Chinese Schisandra

Plant source use for acute gout🍀: colchicine

Derived of belladonna 🍃: Atropine
Anti-malaria from natural source: Cinchona “quinine”
Plant sources of anticancer:

Vinca Alkaloid: Vinblastine, Vincristine, Vindesine, Vinorelbine

# Vincristine Fatal if given intrathecal ONLY IV infusion

Texans: Paclitaxel, Docetaxel

Plant origin (epipodophyllotoxin): Etoposide

Natural estrogen:
Estrone, Estriol, Estradiol

Sources of insulin:
⁃ Human insulin ——> E.coli by DNA technology
⁃ Cows 🐄
⁃ Pigs 🐖
⁃ Human

Natural emulsifying agent: Acacia

Decoction: Extraction active material from plant by boiling 🔥 🌱

 Pediatric & Children !

Ages:
§ Premature neonate: birth before < 37 week of pregnancy
§ Term neonate: birth after > 37 week of pregnancy
§ Neonate: 0 – 28 day (< 1 month)
§ Infant: 1 – 12 months (1 year)
§ Toddler: 1 -3 years
§ Children: 4 – 12 years
§ Adolescent (teenagers): 13 – 18 years

Medication Contraindication (CI):

§ 1 - 28 days: Ceftriaxone. # Cause hyperbilirubin
§ 0 - 6 months: Live attenuated Influenza Vaccine (LAIV)
§ Neonate: SMX / TMP
§ < 6 months: Ibuprofen
§ < 2 years: Promethazine # Cause fetal respiratory depression
§ < 4 years: Dextromethorphan
§ < 12 years: Codeine & Tramadol #Consider lethal dose
§ Pediatric: Tetracycline (tooth discoloration), Fluroquinolone (QT prolongation)
§ Pediatric: Antihistamine # Cause liver toxicity
§ Children & Teenagers: Bismuth
# Who recovering from flu chickenpox, viral infection because there is a risk of Reye’s syndrome
§ Children & Teenagers: Aspirin
# Cause Reye’s syndrome

Conditions:
Teething gel for children ! : Antiseptic
Gonococcal conjunctivitis in newborn 👁 !: Oral erythromycin # Topical alone NOT effective
Neonate with bronchiolitis: Ventilation + supportive IV nutrition
Neonate with ductus arteries: Indomethacin
Respiratory syncytial virus (RSV) in neonate: Palivizumab
Pediatric with diabetic mellitus: Metformin
Constipation in neonate & infant: Glycerin suppository
Diaper inflammation: Petrolatum
Kernicterus:
Type of brain 🧠 damage that can result from high levels of bilirubin in baby’s ! body.
# Treatment of kernicterus is sulfonamide

Route:
Morphine in neonate: IV
Vit K in neonate: IM

# Theophylline in children: increase metabolism à we need higher dose

 Potassium (K)

Medication increase K level (Hyperkalemia):

§ ACE-I
§ K-Sparing diuretic
§ Trimethoprim
§ Aldosterone Antagonist
§ Long use of heparin
§ Ringer lactate # CI in hyperkalemia and lactic acidosis
§ NSAIDs
§ Beta Blockers (BB) # Potentially cause hyperkalemia
§ Isoniazid # Hyperkalemia one of manifest of isoniazid toxicity

Medication decrease K level (Hypokalemia):

§ Thiazide diuretic
§ Loop diuretic
§ Insulin
§ Beta-agonist
§ Corticosteroid
§ Amphotericin B, Itraconazole ،Posaconazole
§ Na HCO3
§ Dialysis
§ Laxative
§ Salicylates
# Salicylates cause respiratory alkalosis à and one of the important results in respiratory alkalosis is
hypokalemia

Digoxin:
§ Digoxin side effect (SE): hyperkalemia
§ Digoxin toxicity: Hypokalemia
# If there is hypokalemia à will induce the toxicity of digoxin (which the effect of digoxin increase) à then will
lead to increase the K level as a side effect
 Preparation

Prepare emulsion: continental, dry gum method, wet gum method

Preparation can be use externally as optic waxes remover !:

Glycerin + 5% sodium bicarbonate

NOT prepared in horizontal laminar flow: large volume fluid

Not consider formation of suspension: use chelating agent

Boric acid in preparation: puffer

Agents:

Gums used in tableting as: Binding agent

Aspartame added to preparation as: sweeting agent
Bentonite used as: suspending agent and Rheological agent
Vit C in preparation: preservative
Used to prepare suppository: Cocoa butter
Oleaginous base: white petroleum
Which preparation have more moisture: ointment

Water:

Which type of water use in cold cream: Distilled water

Which type of water use in large amount of parental: sterile water for injection

Normal water used for preparation of: External preparation

# Pka for normal water in room temp: 14

Sterilization:

Method sterilization our society: Autoclave

Method used in sterilization: moist heat, dry heat

Methods:

Decoction: Extraction active material from plant by boiling 🔥 🌱

Liquid dissolved in liquid: Miscibility
Levigation: grinding an insoluble substance to fine powder (dec. size)
Tablet to powder: Disintegration
Freeze drying is done by: Sublimation
Big fragments into small fragments: Reduction

From more lipid to less lipid: Biotransformation

Grinding powder before adding it: Trituration

The most common disintegrator in compressed tablet is: Starch

Parameter describing dissociation in solution: Pka

Ophthalmic preparation should have 👁 : Sterile, Purified, Isotonic

PH of eye preparation 👁: 6-8

Surfactant use orally: Tween & Span

Surfactant NOT use orally: Na lauryl sulphate
 Pain management and anesthetics:

Pain management:

A. Non-opioid:
1. Acetaminophen: {analgesic & antipyretic}
# Caffeine increase absorption & enhance effect
# CI in sever hepatic impairment
# Hepatotoxicity of acetaminophen is due to: Decrease glutathione “NAPQI” à lead to direct live cell
damage
# Antidote: N-acetylcysteine (mucolytic agent)

2. NSAIDs: {analgesic & antipyretic & anti-inflammatory}.

§ COX-1: in gastric mucosa, platelets, kidney
§ COX-2: Macrophages, Monocytes —> inflammation
§
By blocking COX-1 {Selective COX-1 inhibitors}: High GI risk, CV protective, Decrease renal blood flow
By blocking COX-2 {Selective COX-2 inhibitors}: Less GI risk, CV risk Less effect on renal

• Aspirin: The ONLY NSAIDs Irreversibly block

# CI: in asthmatic patient, with methotrexate, patient less than < 20 years (Reye’s syndrome)
# SE: tinnitus, bleeding

• Indomethacin: {one of the most NSAIDs potent}

# Uses: acute gout, Rheumatoid arthritis (RA), Closing patent ducts arteriosus
# High GI risk & CNS risk

§ Ketorolac: {MOST potent}. # NOT use > 5 days

§ Piroxicam: High GI risk
• Celecoxib: Selective COX-2 inhibitors, CYP2C9, CI: sulfa allergy

Risk ⚠:
• GI risk:
o Lowest risk: Ibuprofen, Celecoxib
o High risk: Indomethacin, Piroxicam, Ketorolac
• CV risk ♥:
o Lowest risk: Naproxen
o High risk: Diclofenac
• CNS risk 🧠 : Indomethacin
• Nephrotoxic risk:
o Lowest risk: Aspirin, ibuprofen
Uses:
§ Gout: Indomethacin
§ Ductus arteries: ibuprofen, Indomethacin
§ Pain with renal stone: Diclofenac
§ Primary dysmenorrhea: Mefenamic acid
§ Menstrual migraines prophylaxis: Naproxen
§ Migraine and severe headache 🤕: Tolfenamic acid
§ Patient with GI risk: ibuprofen or Celecoxib + Misoprostol or PPIs
§ Pediatric: ibuprofen

“Use NSAIDS with LOWEST effective dose for SHORTEST possible duration”
 B. Opioids:

Heroin and morphine: miosis “pointed pupil”

Cocaine: mydriasis

Narcotic addiction: methadone (treatment)

Narcotic toxicity or overdose: naloxone (antidote)

Codeine to morphine (CYP2D6) = dealkylation or demethylation or oxidation

Analgesic and consider narcotic but dispense normally: methadone, Ketorolac

Enkephalins are small peptides: similar to morphine action

Morphine in neonate%: IV 💉

Fentanyl:
IV: adjunct to anesthetic
Patch: chronic pain # AVOID heat


CYP of analgesic:
§ Paracetamol: CYP2E1
§ Codeine, Tramadol: CYP2D6

Anesthetics:

Inhaled anesthesia:
§ Halothane
§ Nitrous oxide (laughing gas)
§ isoflurane, desflurane (pungent odor)

Interventions anesthesia:
§ Propofol (1st choice). # Milk like appearance
# CI: in patient with allergy of egg & soy products
§ Ketamine: # Benefit in hypovolemic patient
# increase Bp, CO, CSF pressure, bronchodilator

Local anesthesia:
§ Lidocaine # Systematic: antiarrhythmic / Locally: anesthetic
§ Articaine (Best choice)
§ Ropivacaine (Popular choice)

DOC of Neuromuscular block in Spinal Anesthesia: Tetracaine

Which place produce spinal fluid: choroid plexus

Neuromuscular blocker used in renal or hepatic failure: Atracurim

Neuromuscular blocker has the lowest half-life: Succinylcholine

Age related muscular degeneration: Bevacizumab (anti-cancer)

# Bevacizumab used for peritoneal carcinoma
Medication used in age related muscular degeneration: Pegaptanib

Malignant hypothermia complication of: General anesthesia

Patient with respiratory depression from anesthesia, what is drug for post anesthesia respiratory
depression: Picrotoxin
# Used as central nervous system stimulate, antidote

Intrathecal: spinal cord

Intraosseous: bone marrow

Lumber puncher (LP): CI in seizure and intercranial pressure (ICP)

 Endocrania:

DM:

Type 1:
Destruction of B-cell in pancreases that produce insulin
# C-peptide test to determine if there still insulin production or not
# if there is no sufficient amount of insulin to take glucose inside the cell to produce energy à the body will break the fat to
produce ketone body as an alternative source of energy
Type 2:
Insulin resistant and deficiency, decrease insulin sensitivity in body cells

Diagnosed of DM:
• A1C > 6.5
• FBG > 126

Medication:
A. Oral:
1. Biguanide (metformin):
# SE: lactic acidosis, Metallic taste, decrease Vit B2, GI upset (take it with food)
# Avoid: with Iodinated contrast 48 hours. # Drug interaction: topiramate
# off label use: gestational DM, decrease weight, Poly cystic ovarian syndrome (PCOS)
# CI: lactic acidosis, renal failure. > 80 y: metformin consider CI, bc. Kidney function will decrease
2. Meglitinides: (repaglinide, Nateglinide). # CI: T1DM, DKA, cause hypoglycemia
3. Sulfonylurea: (Glipizide, Glimepiride, Glyburide) # CI: T1DM, DKA, Sulfa allergy, cause hypoglycemia
4. Thiazolidinediones: (pioglitazone, Rosiglitazone) # CI: HF, Hepatic failure, edema
5. SGLT-2I: (canagliflozin, Dapagliflozin, Empagliflozin) # Monitor: renal
6. DPP-4I: (Sitagliptin, Sexagliptin, Linagliptin) # Cause: Pancreatitis

B. Injection:
1. GLP-1: (Exenatide, Liraglutide) # Have adverse effect on thyroid
# Liraglutide it an FDA approved to decrease weight
2. Insulin # High risk medication
- Rapid (lispro, Aspart)
- Short (regular) # use IV in DKA
- Intermediate (NPH) # cloudy and can be mix with other insulin
- Long (detemir, Glargine)

Insulin dose:
T1DM: 0.3-0.6 U/kg/day
T2DM: 0.1-0.2 U/kg/day
Vaccination with Diabetic patient:
Vaccine in diabetic foot: TD ONLY
Vaccine in DM: Pneumonia, HBV, influenza

Diabetic insipidus:
• Vasopressin
• Desmopressin
# desmopressin also used in nocturnal enuresis and urine incontinence (UI)

DM in pregnant:
1st: insulin # NOT cross placenta
2nd: metformin
3rd: Glyburide # NOT cross placenta

DM & weight:
Approved medication: liraglutide
Off-label use: Metformin
Obesity: Orlistat

NOTE on DM:

# Medication can exaggerate blood glucose and cause hyperglycemia: Thiazide diuretic & statin
# Medication can exaggerate insulin effect and cause hypoglycemia: linezolid
# Medication masking the symptoms of hypoglycemic: Beta-Blockers

Oral hypoglycemic agent used in T1DM: empagliflozin

Oral hypoglycemic agent CI in HF: Sulfonylurea, glitazone (ex: pioglitazone)
Diabetes medication need renal adjustment: Sitagliptin
Oral hypoglycemic cause acute pancreatitis: DPP-4 (sitagliptin)
Metformin and sitagliptin: monitoring kidney
Pioglitazone and glipalamide: monitor liver

Meta needed for insulin production: Zinc, Copper, Chromium

# Chromium help to regulate glucose

Hypoglycemia: glucose or dextrose

Dextrose: NOT in DM and ICP

-----------------
Thyroid:

Hypothyroidism:

Diagnosis:
Primary Hypothyroidism: low T4, High TSH
Secondary Hypothyroidism: low T4, Low TSH
Subclinical Hypothyroidism: Normal T4, High TSH

S/sx: Cold intolerance, fatigue, decrease weight

Causes: Hashimotos’s disease, drugs (lithium), conditions

Treatment: Levothyroxine
# t1/2: 7 days
# take on empty stomach (morning)
# Safe for pregnant but we should increase dose by 30%-50% in pregnancy
# you will see the effect on patient energy & lab

Crisis case of hypothyroidism: Myxedema # Life-threating condition

# Treatment: levothyroxine

Hyperthyroidism:

Diagnosis: High T4, Low TSH

S/sx: Heat intolerance, decrease weight, Goiter, Exophthalmos

Causes: Grave’s disease, Thyroiditis, drugs

Treatment:
A. Antithyroid agents: Methimazole, Propylthiouracil (PTU)
# in pregnancy {1st trimester PTU, 2nd & 3rd trimesters use methimazole}
# SE: Agranulocytosis, PTU à Hepatotoxic
B. Iodides: Potassium iodide (KI), Saturated Solution of Potassium iodide (SSKI)

Crisis case of hyperthyroidism: Thyroid storm # Life-threating condition

# Treatment: PTU + SSKI + Dexamethasone + Propranlol (for symptoms) + Acetaminophen (for fever)

Adrenal hormones:

Hyper Cortisone secretion: Cushing syndrome

Hypo Cortisone secretion: Addison’s disease
Hyper Aldosterone secretion: Conn’s syndrome
 Extra info:

Off-label

Anticholinergic (Ipratropium): Acute asthma

Biguanide – (Metformin): Polycyclic Ovarian Syndrome (PCOS), Decrease weight

-----------

Anticholinesterase:

Myasthenia gravis: Pyridostigmine, Neostigmine

Alzheimer disease (AD): Rivastigmine

Antiandrogens:

Spironolactone, cimetidine, Finasteride

-----------

MOA:

MOA Cromolyn: prophylactic anti-inflammatory that inhibit mast cell degranulation and release
histamine
MOA Phentolamine: reversible alpha antagonist & vasodilation
MOA Cholestyramine: bile acid sequestrants
MOA Pancratium: skeletal muscle relaxant
MOA Ribavirin: antiviral decrease RNA
# Rimantadine inhibit viral RNA uncoating

MOA Clomiphene: non-steroidal estrogenic and selective estrogen receptor modulator (SERM)
MOA of Clopidogrel: inhibit ADP -> platelets aggression

MOA TCA: increase NE & serotonin

MOA CBZ: Na channel block
MOA BZDS:
enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA
receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety),
anticonvulsant.
 -----------

Resistance to penicillinase allergy:

Flucloxacillin, Oxacillin, Cloxacillin, Methicillin

-----------

Administration:
- Mineral oil (for constipation) à Upright position
- Bisphosphonate (for OP) à Upright position + empty stomach (morning)
- Levothyroxine (for hypothyroidism) à on empty stomach (morning)
- Levodopa/Carbidopa (for PD) à on empty stomach (morning)

-----------

Photosensitive:
Lithium, tetracycline, Quinolones, Amiodarone

Sensitive to light:
Amphotericin
 Infections:

Worm 🐛:

Pin worm 🐛📌 : mebendazole, pyrantelpamote, elbendazole

Ringworm 💍 “Tinea”
• Clotrimazole, Miconazole, Terbinafine, Ketoconazole (OTC)
• Griseoflulvin, Terbinafine, Itraconazole, Fluconazole

Tape worm: Praziquantel, Neclosamide

Malaria:

# transmission by female anopheles’ mosquito

Treatment of malaria: chloroquine

# chloroquine is a 4-aminoquinolines
Anti-malaria cause anemia: primaquine
Anti-malaria used in KSA:
• 1st line: combination of pyrimthamine/sulfadoxine/artesunate
• 2nd line: lumefantrine/artemether
Anti-malaria AVOIDED in G6PD: primaquine
Anti-malaria from natural source: Cinchona “quinine”

Amphotricin: Antifungal act ONLY parentally 💉

# eliminated by hydrolysis
Grisofulvin: Antifungal act ONLY orally 💊
Micronazole: Antifungal act locally and systemic

UTI:

NON pregnant with UTI: TMP/SMX

Pregnant with UTI &: Nitrofurantoin
Pregnant with UTI + G6PD: cefuroxime
Prevention recurrence of UTI: Nitrofurantoin
Prophylaxis UTI: TMP/SMX

Use of cranberry juice: UTI

Microorganism:

M.O for dental caries: streptococcus mutants

M.O cause Diphtheria infection: Corynebacterium
M.O cause Osteomyelitis: staphylococcus auras
M.O for food poisoning: staphylococcus aureus
M.O Obligate anaerobic: bacteria’s fragilis
Lyme: bacterium Borrelia
Plague: Yersinia Pestis
# transmitted by flea

Cell wall in fungi: N-acetylglucosamine polymers chitin

Membrane wall of fungus: chitin, glucans, glycoproteins
Makeup of cell wall fungi: ergosterol

Most imp. structure in viral: Nucleic acid

Probiotics: live yeast a bacterium

Obligated aerobe: Need O2

Obligated anaerobe: NO need O2
Facultative anaerobe: with or without O2

Chemotaxis: movement of an organism in response to chemical stimulus.

Shape & Type:

G +ve: enterococcus (staph, strep, bacillus, listeria, closeted)

Types of clostridium: +ve, rodes, anaerobic
Skin normal flora: staphylococcus aureus
Actinomyces shape: Rod
Bacterial genome consists of: single circular DNA
Bacteria take cluster shape: staphylococcus
Bacteria cause plague: yersinia pastis
Cryptococcus neoformans: encapsulated yeast
Cause croup: Parainfluenza virus

Release by cell wall of bacteria:

• During infection or growth: Exotoxins
• During phagocytosis: Endotoxins
Treatment of endocarditis:
• Penicillin G
• Ampicillin / sulbactam + aminoglycoside

CAP: Ceftriaxone + Macrolides

MSSA: ceftriaxone, daptomycin, oxacillin
MRSA: Vancomycin, lineside
# Ceftaroline is the ONLY beta-lactams against MRSA

Meningitis: ceftriaxone, cefuroxime

Meningitis in neonate: Ampicillin, Gentamicin, cefotaxime

Clostridium: metronidazole
Chlamydia: Doxycycline, Azithromycin
👁
# Neonate chlamydia infection: erythromycin eye ointment
Leprosy: Dapsone, Rifampin, Clofazinine

Travel diarrhea treatment: Quinolones, ciprofloxacin

Antibiotics cause diarrhea as SE: Amoxil / Clavi, Clindamycin
Treatment of Giardiasis “diarrhea disease”: Metronidazole, Tinidazole, Nitazoxanide
Antibiotics associated with colitis: clindamycin

Used to treat Amoeba:

1. Metronidazole
2. Diloxanide
# if the symptoms still present
3. Tetracycline

GI Amebiasis:
• Nitroimidazole (Metronidazole, Tinidazole)

Ascaris infection 🐛:
• Piperazine
• Mebendazole
• Pyrantel
• Levamisole

Head lice ( 🐛 : Pyrethrin’s, Permethrin lotion

Athletic foot: Terbinafine topical
Others: Clotrimazole, Miconazole, Ciclopirox, Tolnaftate
# analgesic for foot and leg pain Diclofenac or Ketorolac
Ear tinnitus ): betahistine
# Also used to treat the symptoms of Ménière's disease
Child with nail injure 💅+:
⁃ Bacteria: paronychia
⁃ Fungal: onychomycosis
Acute Otitis Media (AOM):
1st: high dose of Amoxicillin
2nd: Azithromycin
Antibiotics CI in pediatric:
Tetracycline, Doxycycline, Minocycline, Tigecycline
# tooth discoloration
Quinolones:
# QT prolongation
Daptomycin:
# Musculoskeletal, Neuromuscular

Rotavirus: supportive therapy

Respiratory synoptical virus (RSV): Palivizumab
To prevent RSV: Palivizumab
Flu 🤧: oseltamivir
Zanamivir: Treat and prevent influenza A & B

Antiviral can be combined with all genotypes: Sofosbuvir, velpatasvir

Antiviral for HIV which nucleotide reverse Transcriptase
🍼 inhibitors: Zidovudine
# prevent passing the HIV virus to the unborn baby .
# Same as Diazocine

Pt. exposed to COW and had symptoms 🐮 “Brucellosis”:

• Doxycycline, tetracycline
• Streptomycin
• Cipro / oflo
• Rifampine
• SMX/TMP
• Azithromycin
# Treatment for 6 weeks
🐮 by direct inoculation, consumption of non-pasteurized dairy,
# Brucellosis transmitted
airborne transmission.

Anthrax transmitted to human by: Cattle 🐫🐑

# Ebola virus highly transmitted by direct contact with infected blood, secretion, tissues,
organs and other body fluid.
Azole
Fluconazole: need renal adjustment
Gaspofungin & Voriconazole: need hepatic adjustment
CI in HF: Itraconazole
Penetrate BBB 🧠 to treat meningitis: Fluconazole, Voriconazole
Treatment for Aspergillus: Voriconazole, Amphotericin

Cytomegalovirus: Ganciclovir, Valganciclovir, foscarnet

# also Foscarnet use for cytomegalovirus
DOC for treatment of all forms of Schistosomiasis: Praziquantel
# Snail fever & bilharziasis

Use as topical ointment: Gentamycin, Tobramycin

Erythromycin also used for: acne

————————
NOTE:

# Ciprofloxacin oral suspension NOT give by NG tube or other tube

# Cause anemia of fetus if taken in the 1st trimester: ciprofloxacin
# Pt with catheter jitter should take: ciprofloxacin

# Penicillin NOT give IV: Cardiorespiratory arrest

# Sensitivity test of penicillin done after 30 days or more
⚠
# Linezolid caution with insulin because it causes hypoglycemia
# Vancomycin use as an IV route EXCEPT C.difficile and enterocolitis
# Max. infusion 10 mg/min = 2 ml/min ( vial 500 mg/100 ml)
☀
🌞
# Doxycycline need sunscreen because it is a photosensitive drug
# Lithium limit sunlight
💉
# Colistin Injection can be use for inhalation
# Argument CI in patient with jaundice

# Tetracycline it is decrease Penicillin

🍺 WHILE Penicillin increase Methotrexate
# Cilastatin give with imipenem to protect imipenem from hydrolyzed by dehydropeptidase
# Metronidazole NOT with alcohol

IPV allergy: neomycin

Spike fever: will be with viral “high reading then low”

Bacterial: high for long time