UNIT -1 Sources of drugs Drugs are obtained from different sources Most of the drugs that are currently used are manufactured synthetically Recently drugs are synthesized by genetic technologies like human recombinant gene technology Ex Erythropoietin Source Specific source and drugs Category Plants Belladonna- Atropine Digitalis- Digitoxin Opium - Morphine Ant cholinergic Cardio tonic Narcotic analgesics Animals Pork, Beef – Insulin Horse – Tetanus anti toxin Various animals - Heparin Anti-diabetic Ant tetanus Anti- coagulant Minerals Charcoal Magnesium sulfate Aluminum hydroxide Antidote Purgative Antacid Microbes Penicillium Notatum – Penicillin Actinomycetes – Streptomycin E. Coli - L- asparaginase Antibiotic Antibiotic Anti-cancer 1
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UNIT -1Sources of drugs
Drugs are obtained from different sources
Most of the drugs that are currently used are manufactured synthetically
Recently drugs are synthesized by genetic technologies like human recombinant gene technologyEx Erythropoietin
Source Specific source and drugs Category
Plants
Belladonna- Atropine
Digitalis- Digitoxin
Opium - Morphine
Ant cholinergic
Cardio tonic
Narcotic analgesics
Animals
Pork, Beef – Insulin
Horse – Tetanus anti toxin
Various animals - Heparin
Anti-diabetic
Ant tetanus
Anti- coagulant
Minerals
Charcoal
Magnesium sulfate
Aluminum hydroxide
Antidote
Purgative
Antacid
Microbes
Penicillium Notatum – Penicillin
Actinomycetes – Streptomycin
E. Coli - L- asparaginase
Antibiotic
Antibiotic
Anti-cancer
Synthetic
Aspirin
Cimetidine
Paracetamol
Phenitoin
Phenobarbitone
Analgesics
Antacid
Anti-pyretic
Anti-epileptic
Hypnotic
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Dosage forms
Pharmaceutical companies dispense a drug in a variety of formulations suitable for a single or multiple routes of administration
Some antibiotics are available in tablet, capsules or suspension form for oral administration
So doctor can choose the formulation suitable for the patient
It is important because it influences the bioavailability of drug
For ex
Digoxin when injected intravenously, the bioavailability of that drug is 1.00
But when the same amount of the drug is administered into the body by oral route in tablet form, the bioavailability is about is 0.62
On the other hand, the bioavailability of digoxin elixir administered orally is 0.80
When a tablet form of drug is swallowed, it is necessary to disintegrate as well as to dissolve before absorption
But in case of capsule, there is no question of disintegration , only dissolution is necessary
In case of suspension, there is no disintegration or dissolution
So, the rate of absorption is greater in suspension than capsule or tablet
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Route of administration
To produce a pharmacological effect it is very important for the drug to reach the site of action
This depends on the transfer of drugs across one or more membrane barriers
Drugs after reaching the blood circulation builds up a therapeutic concentration
The concentration depends on the volume of distribution, biotransformation and excretion
There are some drugs which are not absorbable from one site but get into the circulation from another
Benzyl penicillin is inactivated in the stomach at gastric PH and is not administered orally
Some drugs absorbed from the gastrointestinal tract pass the intestinal mucosa and the small intestine but metabolized by the gut wall (such as chlorpromazine , dopamine) orby the liver ( such as lignocaine, pethidine, propranolol) In order to select the route for administration this first-pass biotransformation is considered and on occasions is avoided
Slowly absorbed drug may have delayed onset of effect and may even fail to achieve effective concentration
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Mechanism of drug action
Many drugs produce their effects by binding to specific target proteins like receptors, enzymes and ion channels .
Drugs may act on the cell membrane, inside or outside the cell to produce their effect
Drugs may act by one or more complex mechanisms of action
The fundamental mechanism of drug action may be
1.Through receptor
2. Through enzymes and pumps
3. Through ion channels
4. By physical action
5. By chemical interaction
6. By altering metabolic process
1. Through the receptors
Drugs may act by interacting with specific receptors in the body
Receptor
It is a macromolecular site on the cell with which an agonist binds to bring about a change
Affinity
Its the ability of a drug to bind to a receptor
Efficacy
Its the ability of a dung to elicit a response after binding to the receptor
Agonist
An agonist is a substance that binds to the receptor and produces a responseIt has affinity and intrinsic activity
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Antagonist An antagonist is a substance that binds to the receptor and prevents the Action of agonist on the receptorIt has affinity but no intrinsic activity
Partial agonist It binds to the receptor but has low intrinsic activity
Inverse agonist
Some drugs , after binding to the receptors produce opposite to those produced by a pure agonist
Eg
Diazepam acting on benzodiazepine receptors produces sedation, anxiolyses, muscle relaxation and controls convulsions, while beta – carbolines bind to the same receptors to cause arousal , anxiety, increased muscle tone and convulsions
Ligand is a molecule which binds selectively to a specific receptor
Various receptor are have been identified, isolated and extensively studiedSite
The receptors may be present in the cell membrane, in the cytoplasm or on the nucleusNature receptors
Receptor are proteins
Synthesis and life – span
Receptor proteins are synthesized by the cellsThey have a definite life span after which the receptors are degraded by the cell and new receptors are synthesized
Function of Receptors
Recognition and binding o the ligand
Propagation of the message
For the above e function , the receptor has two functional domains (areas)
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A ligand binding domain - The site to bind the drug molecule
An effecter domain – which undergoes a change to propagate the message
The drug – receptor interaction has been considered to be similar to lock and key relationship where the drug specifically fits into the particular receptor ( lock) like a key.
Interaction of the agonist with the receptor brings about changes in the receptor which in turn conveys the signal to the effectors system
The final response is brought about by the effecter system through second messengers.The agonist itself is the first messenger
The entire process involves a chain of events triggered by drug receptor interaction
2. Through enzymes and pumps
Drugs may act by inhibition of various enzymes, thus altering the enzyme- mediated reactions
Ex
Allopurinol inhibits the enzyme xanthene oxidizes ,Acetazolamide inhibits carbonic anhydrase
Membrane pumps like H-K ATPase may be inhibited by drugs
Ex
Omeprazole, digoxin
3. Through ion channels
Drugs may interfere with the movement of ions across specific channels ExCalcium channel blockers and potassium channel blockers
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4. Physical action. The action of a drug could result from its physical properties like
Adsorption - Activated charcoal in poisoning
Mass of the drug - Bulk laxatives like psyllium, branOsmotic property - Osmotic diuretics- Mannitol ,
Osmotic purgatives – Magnesium sulphate
Radioactivity - I 131
Radio- opacity - Barium sulphate contrast media
5. Chemical interaction
Drugs may act by chemical reaction
Antacids - Neutralize Gastric Acids
Oxidizing agents - Like potassium permanganate – germicidal
Chelating agents - Bind heavy metals making them nontoxic
6. Altering metabolic processes
Drugs like antimicrobials alter the metabolic pathway in the micro- organisms resulting in destruction of the micro-organisms Ex
Sulfonamides interfere with bacterial folic acid synthesis
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ANERGIC RECEPTOR
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Cholinergic receptor
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GABA Receptor
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Opium receptor
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Receptor effectors coupling
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Neurotransmitter
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Secondary messengers
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Ligand gated ion channels
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G protein coupled receptor
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TRK RECEPTOR
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Nuclear receptor
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Regulation of receptor
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NEUROTRANSMITTERS
Def The chemical substance that acts as the mediator for the transmission of nerve impulse from one neuron to another neuron through a synapse is called the neurotransmitter Presynaptic neuron Dendrite ---- axon----- break down into minute branches that terminate in small swellings called synaptic knobs or terminal boutons These are in close proximity to the dendrite & the cell body of the post- synaptic neuron The space between them is the synaptic clept In the end of the synaptic knobs are spherical synaptic vesicles The synaptic vesicles containing a chemical known as neurotransmitter The transmitter is released into the synaptic clept the gap between two neurons The neurotransmitter are synthesized by nerve cells & transported along the axons & stored in the synaptic vesicles They are released in response to the action potential & diffuse across the synaptic clepts They act on specific receptor sites on the post-synaptic membranes Their action is short lived Neurotransmitter are either inactivated by enzymes or taken back into the synaptic knobs PROPERTIES The substance must be found in a neuron It must be produced by a neuron It must be released by a neuron After release it must act on a target area & produce some biological effect After the action it must be inactivated
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CLASSIFICATION
1. Depending on chemical nature
A. Amino acids
The neurotransmitters of this group are involved in fast synaptic transmission & are inhibitory and excitatory in actionExGABA, Glycine, glutamate (glutamic acid) and aspirate(aspartic acid)
B. Amines
These are modified amino acidsThese have slow synaptic transmissionThese have inhibitory or excitatory in action
Ex
Adrenaline , nor-adrenaline, dopamine, serotonin and histamine
C. Others
Some neurotransmitters do not fit into any of there categories
2. Depending on function
A. Expiatory neurotransmitter
B. Inhibitory neurotransmitter
A .Expiatory neurotransmitter
It is responsible for the conduction of impulse from the presynaptic neuron to the post-
Neurotransmitter + Receptor--- Opening of Na channels – influx of sodium
ExAcetyl choline, adrenaline
B. Inhibitory neurotransmitters
The inhibitory neurotransmitter inhibits the conduction of impulse from the presynaptic neuron to the post-synaptic neuron
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Inhibitory neurotransmitter is released from the presynaptic axon terminal due to the arrival of action potential
It causes opening of K channels in post-synaptic membrane and efflux of potassium ions
This leads to hyper-polarization which is called inhibitory post-synaptic potential ( IPSP)
When IPSP is developed, the action potential is not generated in the post-synaptic neuron
These are of two subtypes N1 & N2 also referred to as Nm and Nn receptors
The nicotinic receptors are located on postganglionic cell bodies in the autonomic ganglia at neuromuscular junctions of skeletal muscle and on neurons of CNS
2. Muscarinic receptors These are of five types M1, M2, M3, M4 and M5 of which the first three are well definedThe muscarinic receptors are located on smooth h muscle, cardiac muscle, gland cell and some neurons of CNS
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FunctionExcitatory function It is synthesized in axon terminals and stored inside the vesicles
Excitatory functionOpening of legand gated Na channelsAch has very quick and potent action It also destroyed immediately after executing the actionIt is destroyed by the enzyme acetyl-cholinesteraseThis enzyme is present in basal lamina of the synaptic cleft
2. Nor-adrenaline
It is the neurotransmitter in adrenergic nerve fibers
Site of secretion
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Post gang ionic sympathetic nerve endingsCerebral cortexHypothalamusBasal gangliaBrainstemSpinal cord
In many places, it is the excitatory chemical mediator and in very few places, it causesInhibitionIt is believed to be involved in dreams, arousal and elevation of moods
Synthesis
It is synthesized from the amino acid tyrosine in the chromaffin cells of adrenal medulla
These hormones are formed from phenylalanine, but phenylalanine has to be converted into tyrosine
Formation of tyrosine from phenylalanine in the presence of enzyme phenylalanine Hydroxylase
Uptake of tyrosine from blood into the chromaffin cells of adrenal medulla by active Transport
Conversion of tyrosine into dihydroxyphenylalanine (DOPA) by hydroxylation in thepresence of tyrosine hydroxylase
Decarboxylation of DOPA into dopamine by DOPA decarboxylase
Entry of dopamine into granules of chromaffin cells
Hydroxylation of dopamine into nor-adrenaline by the enzyme dopamine betaHydroxylase
Release of nor-adrenaline from granules into the cytoplasm
RECEPTOR
The action of nor-adrenaline are executed by binding with receptors called adrenergicReceptors
They are two types of receptors
A. Alpha- adrenergic receptor
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B. Beta – adrenergic receptor
A. Alpha- adrenergic receptor
It is subdivided into Alpha1 and Alpha2Alpha-adrenergic receptors mediate more of nor-adrenaline action than the adrenalineAction
1. Alpha1 receptor
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Mode of action
It exert their actions by activating the secondary messenger IP3 through phospholipase C
2.Alpha 2 receptor
It exert their effects by inhibiting adenyl cyclase and reducing intracellular CAMP
B. Beta- adrenergic receptor
1. Beta1- receptor
These mediate the actions of both adrenaline and nor-adrenaline almost equally
2. Beta2 receptor
These receptors are larger than B2
These receptors mediate more of adrenaline actions than nor-adrenaline actions
Both B1 and B2 receptors produced their actions by activating adenyl cyclase through G protein and increasing intracellular cyclic AMP
3. SEROTONINE
It also known as 5- hydroxyl-tryptamine
It is synthesized from tryptophan by hydroxylation and decarboxylation
Large amount of serotonin (90%) is found in intero-chromatin cells of GIT
Small amount is found in platelets and nervous system
It is also called Enteramine as GIT contains 80-90% of all the 5 HT in the body
Platelets contain 5HT while passing through the GIT
There are 4 families of 5 HT receptors—5HT1 – 5HT4
It comprising of 14 receptors subtypes
It is contained mainly in the brainstem neurons that innervate practically all other areas of the CNSIn general 5 HT hasAn excitatory effect on motor pathways
An inhibitory effect on the sensory pathways
It plays important role in the neural pathways controlling moods
The presence of descending serotonergic neurons in the brainstem and spinal cord is essential for the analgesic action of morphine
4. GABA
It is an inhibitory neurotransmitter in synapses particularly in CNS
It is responsible for presynaptic inhibition
It is secreted by nerve endings in the following structuresCerebral cortexCerebellumBasal gangliaSpinal cord
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Retina
Mechanism of actionPresynaptic inhibition
It is also known as indirect inhibition and it occurs because of the failure of presynapticaxon terminal to release the excitatory neurotransmitter substance
Post synaptic inhibition
It also called direct inhibition
It occurs due to the release of an inhibitory neurotransmitter from presynaptic terminalinstead of excitatory neurotransmitter substance
The most important inhibitory neurotransmitter is gamma amino butyric acid (GABA) and Glycine
The GABA acts on post-synaptic membrane by binding with receptor
The transmitter receptor complex opens the ligand gated potassium channels instead of sodium channels
The K channels which are more in the cell body of post-synaptic neurons more to ECF
Simultaneously Cl channels also open and Cl ions which are more in ECF move inside the cell body of post-synaptic neurons
The exit of K ions and influx of Cl ions cause more negativity inside, leading to hyperpolarization
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Receptors
1. GABA A ( Intrinsic ion channel receptor)
Opening of ion channels known as chloride channels and conduction of chlorine influx of Cl ions2. GABA B ( G- protein coupled receptor)
Hyper polarization
K conduction
Altering of Ca influx3. GABA C
5. DOPAMINE
It is secreted by nerve endings in the following areas
Basal ganglia
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Hypothalamus
Limbic system
Retina
Sympathetic ganglia
Receptor
Dopamine acts on 5 types of dopamine receptors (D1-D5) - G proteins mediated
The brain contains more of D2 receptors
Synthesis
Dopamine is secreted by adrenal cortex
Dopamine also secreted by dopaminergic neurons in some areas of brain particularly , basal ganglia
In brain this acts as a neurotransmitter
The other physiological functions of circulating dopamine are not understood clearly
Functions
Vaso-constriction by releasing nor-adrenaline
Vasodilatation in mesentery
Increases in heart rate via beta receptorIncreasing in systolic blood pressure
Dopamine dies not affect diastolic blood pressure
Deficiency of dopamine in basal ganglia produces nervous dies-order called Parkinsonism
6. HISTAMINE
It is formed by decarboxylation of the amino acid known as Histidine
It is exciter neurotransmitter
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It is secreted by nerve endings of
Hypothalamus
Limbic cortex
Other parts of cerebral cortex
Gastric mucosa
Mast cells
Spinal cord
Mechanism of action
It is believed to play an important role in arousal mechanism
Functions
Intra-cerebroventricular administration produces
Rise in BP
Cardiac stimulation
Behavioral arousal
Hypothermia
Vomiting
ADH release
Sensation of itching
7. GLUTAMATE (ASPARATE)
It is the most abundant amino acid in the brain and is concentrated in dorsal sensory nerve terminals
It is an important excitatory neurotransmitter in dorsal root afferent and at other sits in CNS
It depolarizes spinal motor neurons and cortical neurons by increasing Na permeability of the membrane
Receptor
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1. Metabotropic receptor
Protein coupled receptor
Mainly involved in production of synaptic plasticity
2. Inotropic receptorLegend gated ion channels
There are 3 subtypes of receptors
In this NMDA ( N- methyl-d-aspirate) are important
This receptors play important role in memory and learning
3. m – GLU8. GLYCINE
It is inhibitory neurotransmitter
It is formed and released by inhibitory inter-neurons which act on motor neurons in the brain and spinal cord
In the spinal cord it is responsible for direct inhibition
It acts by increasing Cl permeability
Site of secretion
Fore brain, brain stem, spinal cord and retina
Gyycine concentration in the ventral grey matter of the spinal cord is higher than any other amino acids
9. SUBSTANCE – P
It is a neuropeptide that acts as a neurotransmitter
It is a polypeptide with 11 amino acid residues
It belongs to a family called neurokinins
The substance p is secreted by the nerve endings of pain pathway in spinal cord
It also found in hypothalamus retina and intestine
It mediates pain sensation
It is a potent vasodilator in CNS
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It is also responsible for regulations of anxiety, stress, mood disorders, neurotexicity, nausea and vomiting
10. NO
It is a neurotransmitter in the CNS
It is produced by non- neuronal cells like the endothelial cells of blood vessels
From the site of production it diffuses into the neuronal and non-neuronal cells where itexerts its action
It also produced in the brain and is responsible for long term protestation LTP and long term depression (opposite of LTP)
NO is synthesized from arginine by action of enzyme NO synthetics
It activates guanyl cyclase in cells, producing c GMP which brings about relaxation of vascular smooth muscle
NO acts as a mediator for the dilator effect Ach on small arteries
It indirectly causes dilatation of arterioles
NO is inactivated by haemoglobulin
NO is released by variety of agents such as Ach, sudden increase in tissue blood flow and products of platelet aggregation
NO deficiency produces hypertension , atherosclerosis and impotency
Drug dependence
Drug dependence means a state of physical or psychic or some times both , characterized by a compulsion to take the drug continuously or periodically in order to experience the psychic effects of well being or to avoid the discomfort of its absence.
A person may be dependent on one or more drugs
Drug dependence is of two types namely
1. Physical dependence
2. Psychic dependence
1. Physical dependence
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It is an adoptive state which causes intense physical disturbance when the administration of the drug is stopped
These disturbances , that is withdrawal produce specific symptoms characteristic for each drug type
It may produce tolerance
2. Psychic dependence
Here there is a feeling of satisfaction and a psychic drive that requires periodic or continuous use of the drug to produce a sense of well being or to avoid discomfort
Psychic dependence is specific and it varies with the individuals and with the drug
The following drugs are produce drug dependence
1. Opium drugs
2. Morphine , Heroin , codeine, synthetic drugs like pethidine and methadone
6. Volatile solvents like toluene, acetone and carbon tetrachloride
7. Caffeine, tobacco, betel leaves and nutmegs
Problems of drug dependence
Mere dependence on drugs itself is a problem as it necessitates the use of drugs continuously even though they are not required therapeutically
Dependence on caffeine is condonable.
Dependence on tobacco is avoidable dependence
Where as dependence on alcohol has to be condemned and legally prevented
The problems associated with drug dependence are of three types
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1. The individual problems are that the drugs may adversely affect the physical and mental health of the addict
2. Socio-cultural problems are that the drug dependence may cause loss of earning capacity of the drug user
3. Socio-legal problem is prohibiting and controlling the traffic in such dangerous drugs. Further the smuggling of dangerous drugs is to be considered as criminal activity
Tolerance
Def
Tolerance is the requirement of more amount of drug to produce specific response
Concept of can be explained in easiest possible way with the example of effect of alcohol
Specific quantity of alcohol produces a certain effect in CNS
After periodic consumption of alcohol the same quantity of alcohol the same can not produce the same effect, this effect is reduced
To get the same effect, one has to consume more amount of alcohol.
This is development tolerance for alcohol
Drugs also follow the same rules
Some times tolerance is observed even when drug is administered for the first time
Tolerance can be classified into
1. Natural tolerance2. Acquired tolerance
1. Natural tolerance
It is the presence of tolerance without prior exposure to the drugThe effect of drug in a few individuals or few species are less in magnitude from the very first exposure to drug
Ex
Some individuals require more amount of anticoagulants as compared to normal therapeutic doses. The reasons are usually genetic
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2. Acquired tolerance
It is the development of tolerance after a prolonged or rapid or excessive use of drugs
Mechanism for development of acquired tolerance
1.Down regulation of receptors
It is the decrease in number and sensitivity of receptors for an agonist after prolonged exposure to it
2. Internalization of receptor
After prolonged exposure to agonists some receptors are taken inside the cell and they remain unavailable for action
3. Enzyme induction
Alcohol induces hepatic microsomal enzymes that are required for its own metabolism
So long term use of alcohol results in faster metabolism and elimination and reduced action of alcohol. Tachyphylaxis
It is the development of tolerance after repeated administrations of a drug
Ex
Ephedrine stimulates release of stored nor adrenaline from the nerve endings
After repeated administrations of ephedrine, the store of nor adrenaline is exhausted and effect of ephedrine is reduced
Clinical implications of tolerance
Previous prolonged exposure to drug can produce clinical effects that are less than what are expected
Development of tolerance when demands increase in doses, decision is not very easy. Because tolerance for effect may not be associated with tolerance for side effects
Cross tolerance
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If prolonged use of one drug results in development of tolerance for another drug, it is cross tolerance for another drug
Such two drugs are usually similar in either structure or in function
Ex
Prolonged exposure to barbiturates results in development of tolerance for hypnotic agents
Pseudo tolerance
From the prehistoric period, poisons are consumed regularly and in small quantities to develop tolerance against them . This type of logic is not scientifically proved
DISTRIBUTION
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METABOLISM
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UNIT – 2
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NEURO-HUMARAL TRANSMISSION
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Synaptic transmission involves many steps
Synapse
It is a region including the axon terminal of a presynaptic neuron, the plasma membrane of the postsynaptic cell
In presynaptic neurons
Ex
Neurotransmitter synthesis and storage in vesicles
Synaptic cleft
physical space between the cells is known as synaptic cleft
Postsynaptic cells can be neurons or other cells( effecter cell in the muscle) At synapse, electrical transmissions –action potentials along presynaptic neurons are translated into chemical signals which lead to postsynaptic cell responses, increases or excitation , decrease or inhibition or modulation of neuron activity or biochemistry
On postsynaptic membranes
Ex
Binding to receptors, change in ion channel function
In postsynaptic neurons
Ex
Effect on second messenger transduction
Stimulations of enzymes
Physiological action
Communication (transmission of information) across synapses occurs via chemical
messengers – neurotransmitters- stored in vesicles in presynaptic neurons
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Action potentials at presynaptic axon terminals initiate steps that release neurotransmitter
molecules into a synapse which cross the synaptic cleft and bind reversibly to
postsynaptic receptors
Receptor activators (ex drugs) are agonists and antagonists are drugs that combine with
but do but activate receptors
Transmitters are removed form synapses by enzymatic destruction m diffusion, and
active reuptake into presynaptic neurons
Major peripheral neurotransmitters are acetylcholine ,catecholamine(ephedrine and
dopamine)
In brain and spinal cord , major excitatory neurotransmitters are glutamate and aspirate
Major inhibitory neurotransmitters are GABA and glycine
5 –HT, or serotonin and neuropeptides are other neurotransmitters
Neurohumoral transmission implies that nerves transmit their message across synapses
and neuroeffector junctions by the release of humeral messengers
Neurohumoral transmitters substance must fulfill the following criteria
1. It should be present in the presynaptic neurons ( usually along with enzymes
synthesizing it)
2. It should be released in the medium following nerve stimulation
3. Its application should produce response identical to those produced by nerve
stimulation
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4. Its effects should be antagonized or potentated by other substances which
similarly alter effects of nerve stimulation
Steps in Neurohumoral transmission
1. Impulse conduction
2. Transmitter release
3. Transmitter action on postjunctional membrane
4. Postjuctional activity
5. Termination of transmitter act ion
1. Impulse conduction
The resting Tran membrane potential (70 mV negative inside) is established by high K
permeability of axonal membrane and high axoplasmic concentration of this ion coupled
with low Na permeability and its active extrusion
Stimulation or arrival of an electrical impulse causes a sudden increase in Na
conductance—depolarization and overshoot ( reverse polarization – 20 mV positive)
K ions then move ort in the direction of their concentration gradient and repolarization
occurs
Ionic distribution is normalized during the refractory period by the activation of Na-K
pump
The action potential generated sets up local circuit currents which activate ionic channel
at the next excitable part of the membrane ( next node of Ranvier in myelinated fiber )
and the AP is propagated without decrement
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Transmitter release
The transmitter (excitatory or inhibitory) is stored in prejunctional nerve endings within
synaptic vesicles
Nerve impulse promotes fusion of vesicular and axonal membranes, through Ca entry
which fluidizes membranes
All contents of the vesicle ( transmitter, enzymes and other proteins)are extruded in the
functional cleft
3. Transmitter action on postjunctional membrane
The released transmitter combines with specific receptors on the postjunctional
membrane and depending on its mature induces an excitatory postsynaptic potential
(EPSP) or (IPSP) an inhibitory postsynaptic potential
EPSP
It increase in permeability to all cations –Na or Ca influx ( through fast or slow channels)
causes depolarization followed by K efflux
These ionic movements are passive as the flow is down the concentration gradients
IPSP
It increase in permeability to smaller ions
That is K and Cl ( hydrated K ion is smaller than hydrated Na ion) only, so that K
moves out and CL moves in (in the direction of their concentration gradients ) resulting
in hyper polarization
4. Postjunctional activity
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A suprathreshold EPSP generates a propagated postjunctional AP which results in nerve
impulse ( in neuron), contraction ( in muscle ) or secretion ( in gland)
IPSP stabilizes the postjunctional membrane and resists depolarizing stimuli
5. Termination of transmitter action
Following its combination with the receptor ,the transmitter is either locally degraded (ex
Ach) or is taken back into the prejunctional neuron by active uptake or diffuses away (ex
NA, GABA)
Rate of termination of transmitter action governs the rate at which responded can bet
Acetyl choline (Ach) an ester of choline, is an important neurotransmitter of the ANSThe nerves that synthesize, store and release Ach are called cholinergic
The site of release of Ach is
Cholinergic receptors
There are two classes of cholinergic receptors
They are nicotinic and muscarinic receptors
Muscarinic receptors are present in the heart, smooth muscles, glands , eyes and CNS
Five subtypes of muscarinic receptors – M1 to M5 are recognized
Nicotinic receptors are present in the neuromuscular junction, autonomic ganglia and adrenal medulla
Two subtypes of nicotinic receptors are identified
Nm receptors are present at the skeletal muscle end plate and Nn receptors at the autonomic ganglia and adrenal medulla
1. Ganglia - All the preganglionce fibers of ANS I.e. both the sympathetic and parasympathetic ganglia
2. The postganglionic nerve fibers of parasympathetic nerve endings
3. Sweet glands – The sympathetic postganglionic nerve endings supplying the sweet Glands
They act on every type of nerve fiber and can cause both sensory and motor paralysis in the innervated area
They act on axons, cell body , dendrites, synapse and other excitable membranes that utilize sodium channels as the primary means of action potential generation
Cocaine was the first agent to be isolated by Niemann in 1860 and used for 30 years
Procaine was synthesized in 1905 and it rules the field for the next 50 years
In 1943 , Lignocaine was synthesized and it continues to dominate the field till today
Chemistry
Local anesthetics are bases and consist of a hydrophilic amino groups on one side and a lopophilic aromatic residue on the other side , joined by an intermediate chain through an ester or amide linkage
Local anesthetics are weak bases and the infected tissues have a low extra cellular PH
Local anesthetics ionize in such medium bases and the infected tissues have a low extra cellular PH
Local anesthetics ionize in such medium and a very low fraction of non-ionized LAs available for diffusion into the cell
So LA are much less effective in infected tissues
Action potential
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If enough Na channels are opened, then the rate of Na entry into the axon exceeds the rate of K exit
Threshold potential
At the point where the rate of Na entry into the axon exceeds the rate of K exit that point is called threshold point or threshold point
At the this point, the entry of Na ions further depolarizes the membrane
This opens more Na channels, resulting in further depolarization that opens more Na channels and so on.
The fast inward Na current quickly depolarizes the membrane towards the Na equilibrium potential around + 70 m V
Then, Inactivation of the Na channels and the continuing efflux of K ion cause the repolarization of the membrane
Finally, the Na channels regain their normal excitable state and the Na pump restores the lost K and removes the gained Na ions
Mechanism of action
Local anesthetics prevent the generation and the conduction of nerve impulses
The primary mechanism of action is blockade of voltage – gated sodium channels
Local anesthetics directly interact with specific site or receptor on voltage – sensitive Na channels and gradually raise the threshold for excitation
With increasing concentration, impulse conduction slows, rate of rise of AP declines, AP amplitude decreases and finally the ability to generate an AP is abolished
These result from binding of LA to more and more Na channels
So it prevents the generation of an AP and its conduction
The small fibers are blocked first
That is autonomic fibers are blocked first followed by sensory fibers conducting pain, temperature sense, then touch, pressure and vibration sensations in the same order
Sensory and motor fibers are equally sensitive
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Non – myelinated fibers are blocked more readily than the myelinated
Pharmacological actions
1. Effect on sensation
They cause the reversible loss of sensory perception
The order of blockade is pain- temperature- touch
They produce blockade of smaller nerve fibers initially followed by large nerve fibersRecovery occurs in the reverse order
Applied to the tongue, bitter taste is lost firs followed by sweet and sour and salty taste
If it is given with adrenaline through injection route, the adrenaline reduces the systemic toxicity of local anesthetics because it reduces the rate of absorption and metabolismkeeps the plasma concentration lower and increase the activity when exactly the action is required
2. CNS
They produce sequence of stimulation followed by depression cocaine is a powerful CNS stimulant causing in sequence
Euphoria – excitement - mental confusion - restlessness - tremor and twitching of muscles - convulsions - unconsciousness - respiratory depression - death in a dose dependent manner
Procaine and lignocaine are synthetic compounds and much less potent in this regard
3. CVS
All local anesthetic except cocaine produce vasodilatation and hypotension
But cocaine produces vasoconstriction and so a hypertensive effect
All LA produces depressant effect on the myocardium, they increase the effective refractory periods similar effect of the quinidine so used in the arrhythmias 4. Other effects
They produce relaxant effect on smooth muscles and neuromuscular blockade
They relax the vascular and brachial smooth muscles
Pharmacokinetics
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These are rapidly absorbed from the mucous membranes and abraded skin
Rate of absorption is dependent on the vascularity of the area
The vasoconstriction decreases the absorption
Toxicity depends on the balance between absorption and metabolism That is if it gets metabolized as it gets absorbed, then toxicity is less
They are usually administered through the subcutaneous route
They are metabolized in the liver and excreted in the kidney
Adverse effects
Hypersensitive reactions like skin rashes, dermatitis , angioedema, asthma and rarely anaphylaxis
CVS Effects
Like light headedness, dizziness, auditory and visual disturbances , mental confusion, disorientation, shivering, twitching, tremors, finally convulsions and reparatory arrest
CVS Effects
The effects like bradycardia, hypotension, cardiac arrhythmias and vascular collapseRarely cardiac arrest is seen
USES
Surface anesthesia or pain due to burns, fissures and ulcers
Infiltration anesthesia to anaesthetize nerve endings by subcutaneous infiltration
Nerve block anesthesia where I t is injected close to specific nerve
Spinal anesthesia where it is injected close to specific nerve
Systemic use for anti- arrhythmic affect
Some of the important drugs which possess this action are cocaine, procaine.lignocaine, benzocaine and amethocaine
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Cocaine
It is an alkaloid obtained from the leaves of coca plant
It is insoluble in water but its salts are soluble in water
It is poorly absorbed in the intestines but well absorbed by the mucous membrane and it can be given as surface anesthetic
Actions
Local anesthetic action
CNS stimulants
Dilates pupil
Raise the body temperature
Rise the BP
Produces euphoria
Toxic effects
Mental excitement
Confusion
Tremors
Convulsions
Respiratory paralysis
Dose
8 – 16 mg by injection
Adrenaline has to be given along with cocaine which produces local vasoconstriction and prolong the local anesthetic effect
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Procaine
It is synthetic product having local anesthetic effect
Administration – It I snot absorbed by mucous membrane and hence has to be given by injection
It rapidly diffuses from the site of injection and vasoconstrictors like adrenaline as to given , to prolong the effect of procaine
Dose0.25 - 2% solution is injected subcutaneously
For spinal anesthesia it is still popular
It is injected into the spinal theca to block spinal nerves and to produce spinal anesthesia
Lignocaine ( Lidocaine or xylocaine)
It is an active surface anesthetic and also efficient on injection
This is more powerful and more stable and longer acting than procaine
ToxicityToxicity is very low
It is injected as a 0.5% to 2% solution
Duration of action is about 15- 45 min
I fit is combined with adrenaline the effect will last for about two hours
It can also be used in the treatment of status epilepticus and acute ventricular arrhythmia
BenzocaineThis is a local apathetic employed as an application to various mucous surfaces
It is incorporated in throat lozenges to relieve the local soreness and is used in rectal suppositories
Amethocaine
This is a more powerful anesthetic than procaineIt is well absorbed form mucous membrane and is often used in t he form of spray or lozenges to anaesthetize the throat before various manipulationsBut toxic effects are same as procaine
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UNIT - 4
General anesthetics
DefGeneral anesthetics are drugs which produce reversible loss of all sensation and consciousness
Conditional feature of General anesthetics are
Loss of all sensation. Specially pain
Sleep ( unconsciousness) and amnesia
Immobility and muscle relaxation
Abolition of reflexes
1. Inhalation anesthetics
A. Gas
Nitrous oxideCyclopropaneEthylene
B. Liquids
EtherChloroformHalothaneEthyl chlorideVinyl ether
11. Intravenous anesthetics
ThiopentoneMethohexitoneKetamineParaldehyde
Ether ( Di-ethyl ether )
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Properties
It is one of the oldest anesthetic agents in use It is a colorless and volatile liquid with a pungent odorIt is highly inflammable and explosiveIt is quickly absorbed and eliminated through lungs
Actions
5-10% of ether is required in the inspired air to induce anesthetic and at least 3-5% to maintain it
It irritates respiratory tract leading to efflux secretion of saliva and mucous from the mouth and respiratory tract
So atropine should be given at least half an hour before to paralyses secretion
The initial stages are more prolonged with ether in the absence of premeditation
Other actions
Ether does little damage to the heart
It increases cardiac output and coronary blood flow
The rate and depth of respiration may be increased
It does not cause any damage to liver
Advantages
It is safest agent . It can be used even by a nurseIt produces analgesiaIt produces skeletal muscle relaxationIt produces less inhibition of respiratory centre than other unaesthetic agents It does not effect the blood pressureIt dies not interfere with liver or kidney functionsIt can be given by all techniques
Dis-advantages
It catches fireInduction of anesthesia as well as Recovery are slowVomiting is likely to occur postoperativelyGeneralized convulsions are produced specially in children
Chloroform
It is a volatile liquid having a powerful anesthetic property
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It is a colorless non-inflammable volatile liquid with a sweetish smell
It produces server toxic effects on the liver and heart
It is not used at present
Actions
Anesthesia is induced by the open drop method or by closed circuit method 2% of chloroform is required in the inspired air to induce anesthesia and about 0.5% for maintenance of anesthesia
Other action
In addition to general an aesthesia, externally it is used as a rubefacint
Internally it is used as a carminative
It is used as a vehicle in mixtures
Advantages
It does not irritate respiratory tractMuscular relaxation is goodRecovery is accompanied by less nausea and vomiting than with etherIt is non inflammableInduction is rapid and pleasant
Disadvantages
Chloroform depresses myocardium resulting in slowing down of the heart and even cardiac arrest
It depresses the respiratory centre
Liver function is affected leading to necrosis and hepatic failure and deathIntestinal motility is diminished
Margin of safety is very less
Blood concentration of about 15 mg% is required to maintain anesthesia but about 20-25 mg% is fatal
Halothane
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Physical properties
It is heavy, colorless liquid, anesthetic agent
It is non inflammable, non toxic fluorinated hydrocarbon
It has sweet , fruity odor and boils
It affects most of metals including stainless steel ,,copper, rubber
Advantages
Induction is very smooth as it has sweet , fruity odor
Recovery is also fast , smooth with low incidences of nausea and vomiting It is not inflammable and hence does not irritate respiratory passage inhibits salivary secretion hence endotracheal intunotion is much easier
It does not produce bronchospasm, and can be used in patients with bronchial asthma
Dis advantages
Muscular relaxation is inadequate
It causes respiratory, cardiovascular depression
Mental recovery is delayed
Shivering during recovery is very common
It is poor analgesic
It is expensive, needs special apparatus for administration
Nitrous oxide
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Properties
It is also called as laughing gas
It induces laughing in the patient under the anesthesia
It is colorless gas with sweet odor and taste
It is non inflammable
Advantages
Induction and recovery are quick
Irritation is less
Does not produce vomiting and cardiovascular collapse
It is not toxic to liver and kidney
Disadvantages
It dies not produce muscular relaxation
It is not potent, means it requires 90% concentration to produce complete anesthesiaCauses cyanosis
It produces excitation and euphoria
Uses
It is used for short duration operations such as tooth extraction or setting right a fracture
It is used along with the oxygen for producing partial anesthesia following basal anesthetics
Halothane
Physical properties
I t is heavy , colorless liquid, anesthetic agent
It is non inflammable , non toxic fluorinated hydrocarbon
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It has sweet, fruity odor and boils at 50 C
It effects most of metals including stainless steel, brass, cupper and rubber
Advantages
Induction is very smooth as it has sweet ,fruity odor
Recovery is also fast, smooth with low incidences of nausea , vomiting
It is not inflammable and hence does irritate respiratory passage inhibits salivary secretion hence end tracheal intubations is much easier
It does not produce branch spasm, larygospasm, hence can be used in patients with bronchial asthma
Disadvantage
Muscular relaxation is inadequate
It causes respiratory, cardiovascular depression
Mental recovery is delayed
Shivering during recovery is very common
It is poor analgesic
It is expensive ,needs, special apparatus for administration
Intravenous anesthetics
Barbiturates are generally used as intravenous general anesthetics for short term operations
Of these Thiopentone and hex baritone are the drugs of choice being given by the slow route to avoid respiratory arrest
Advantages
Easy to administer
Induction is rapid and smooth
Past anesthetic complications are rare
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Recovery is very fast
Respiratory and myocardial functions remains unaffected
General anesthetics are the drugs which are used to produce complete loss of sensation to allow the surgical operations to be performed without the sensation of pain to the patient
General anesthetics depress the sensory as well as motor nerves and produce loss of sensation which is reversible
The common method of inducing anesthesia is by inhalation, intravenous , spinal and rectal anesthesia are also used
Requirement of an ideal anesthetic
Administration should be easy without requiring complicated apparatus
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Anesthesia must be induced rapidly, smoothly and easily controllable
BP should remain normal
When discontinued the anesthetic should be eliminated quickly without harming the tissues
It should produce adequate muscular relaxation with complete motor and sensory paralysis
Stages of anesthesia
Induction of general anesthesia is divided into four stages according to the deapth of CNS depression
All these stages are continuous but described separately for the sake of clarity
Four stage of anesthesia are
1. Stage of induction
2. Stage of excitement
3. Stage of surgical anesthesia
4. Stage of modularly depression or respiratory paralysis
1. Stages of induction
There is a sensation of warmth and suffocation , reflex secretion of mucous and saliva with coughing and sneezing are noticed
Muscle are stiff, pupils are dialate and pulse rate is quick
2. Stage of excitement
Blunting of consciousness occurs
There will be loss of self control and motor excitement
Pulse rate is rapid
Respiration becomes irregular and fast
Pupils are dilated and active
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Sensory nerves cells are paralyzed first but motor reflexes are still present
There is a gradual unconsciousness
3. Stages of surgical anesthesia
Here complete paralysis of the enters of cerebral cortex and Spinal reflexes commencesThis is reversible
Muscles are relaxed , pulse is slow and regular, respiration becomes slow
Pupils are contracted
Eye balls are fixed, there will be a fall in body temperature
This stage is suitable for surgical operations to be performed as all the motor reflexes are abolished and the muscles are relaxed fully 4. Stage of modularly depression
The modularly centers are gradually depressed
There is deep unconsciousness
Respiration becomes slower and slower
Pupil are dilated and inactive , pulse becomes weak and blood pressure falls.
Finally respiration stops leading to the arrest of the heart and death
Recovery from the anesthesia
Soon after the removal of the anesthetic the respiration becomes quieter and less strenuous
The eye lid and deglutition movements reappear
Pupils dilate, coughing, acute vomiting may occur just before returning to consciousness
This is commonly succeed by natural sleep lasting for several hours
Mechanism of action
Reticular activating system
This is a complex polysynaptic pathway in the brainstem reticular formation that projects diffusely to the cortex
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Activity in the RAS is concerned with maintaining consciousness and because it is sensitive to the depressant action of anesthetics, it is thought to be their primary site of action
The general anesthetics increase the sensitivity of the gamma- amonobutyric acid (GABA A) receptors to the neurotransmitter, GABA, at clinically effective concentration of the drug
This causes a prolongation of the inhibitory chloride ion current after a pulse of GABA release.
Postsynaptic neuronal excitability is thus diminished
Others receptors are also affected by volatile anesthetics
Ex
The activity of the inhibitory glycine receptors in the spinal motor neurons is increased
The inhalation anesthetics block the excitatory postsynaptic current of the nicotinic receptors
Pre-unaesthetic medication
The pharmacological agent when administered externally with an important objective to make anesthetic more smooth and agreeable for patient , the phenomenon is termed as preanaesthetic medication
Aim
To induce sedationTo decrease gastric secretion
To minimize pre and post operative complications
To facilitate smooth and rapid induction
To overcome secretary effects of general anesthetics
To decrease vagal stimulation and secretions
Supplement analgesic actions to potentate anesthetics so less anesthetic is needed
Drugs used in preanaesthetic medication are
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1.Opiods
Ex
Morphine
To produce analgesia
2. Sedatives
Ex
Diazepam or lorazepam
Ant anxiety drugs –for smooth induction
3. Anti-cholinergic
ExAtropine
To reduce salivary and bronchial secretions
4. Neuroleptics
ExChlorpromazine
To smooth induction and anti-emetic action
5. H2 Blockers
ExRanitidine
To prevent the ulcer formation
6. Anti-emeticsExMetaclopramideTo reduce post operative vomiting
S No Type Drug Dose
1 Opoid analgesic Morphine, pethidine 15,30 mg
2 Barbiturates Phenobarbitone, secobarbitone 30mg
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3 Anxiolytic Diazepam 5mg
4 Anti- emetic Promethazine 30mg
5 Anti-secretary Atropine 0.6mg
6 Skeletal muscle relaxants D-tuocurarine 10mg
Alcohols
Alcohols are aliphatic hydrocarbons
They contain one or more hydroxyl groups
Classification
1. Mono-hydroxy alcohols
Methyl, ethyl and propyl alcohols
2. Dihydroxy alcohols
Ethylene glycols, propylene glycol
3. Tri-hydroxy alcohols
Glycerol or glycerine
4. Poly-hydroxy alcohols
Mannitol, sorbitol
Ethyl alcohol
Ethyl alcohol is commonly used alcohol
It is the main constituent of all kinds of alcoholic beverages
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It is generally obtained by fermentation of sugars by yeast
The alcohol is separated by simple distillation
It is a colorless, volatile and inflammable liquid
The alcohol content of various beverages varies between 4-55% by volume
Wines containing more than 16% of alcohol
Beer contains 4-6 % (v/v) of alcohol
Stronger preparation are called Spirit
Mechanism of action
Alcohol produce CNS depression by a generalized membrane action by altering the state of membrane lipids
Alcohol promotes GABAA receptor mediated synaptic inhibition (through chloride channel opening ) as well as inhibits NMDA and type of excitatory amino acid receptors (operating thorough captions channels)
Alcohol can indirectly reduce neurotransmitter release by inhibiting voltage sensitive neuronal calcium channels
Blockade of adenosine uptake by alcohol could also contribute to synaptic depressionThe activity of membrane bound enzymes like Na – K ATPase and adenyl cyclase is also altered
The activity and translocation of channel or enzyme proteins in the membrane could be affected by alcohol through protein kinase C and protein kinase A mediated alteration in the state of their phosphorlation
Pharmacological actions
1. Externally
It evaporates quickly and producing cooling effect and is used for reducing the temperature in fevers
It is used in shaving lotion for producing cooling effect on the skin
In concentration of 40- 50, it act as rubifacient and mild irritant action
In concentration of 70% , it acts as antiseptic , the action is seen only against vegetative forms of organism and spores are resistant
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Concentrated alcohol , if injected , produces tissue destruction
Higher concentration denature proteins by partial precipitation and dehydration In such concentration , it acts as an astringent, a germicidal and an irritant 2. GIT
If taken orally , it increases salivary secretion by reflex action
It has an irritant action on the gastric mucous membrane and act as appetizer50 ml of 7-10% alcohol increases the gastric secretion ,by releasing histamine and gasstrin from the antrum of the stomach Concentration above 15% inhibit both motility and secretion and effect may persist for many hours
Concentration above 20% reduce the enzymatic activity of the gastric and the intestinal juices
Concentration above 40% and over have a direct toxic effect on gastric mucosa and may precipitate gastritis, giving rise to pain, nausea, vomiting and other symptoms
Many alcoholics suffer from gastritis and chronic achlorhydria
Many alcoholics suffer from chronic diarrhea as a result of malabsorption from chronic mucosal damage
3. CNS
It is primarily a CNS depressant and acts by enhancing the inhibitory GABA receptor activity or inhibiting NMDA receptors
Proteins are the primary site of its actions
It produces initial excitation due to depression of higher inhibitory centers
This is followed by progressive depression, drowsiness, sleep and unconsciousness as the dose is increased
Sudden withdrawal of alcohol causes excitation and hyperactivity of the CNS
4. CVS
Small dose produce only cutaneous and gastric vasodilatation B.P is not affected
Moderate doses cause tachycardia and a mild rise in BP due to increased muscular activity and sympathetic stimulation
Large doses cause direct myocardial as well as vasomotor centre depression and there is fall in BPChronic alcoholism may contribute to hypertension and lead to cardiomyopathy
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Atrial fibrillation and other cardiac arrhythmias may occur due to conduction defects and Q-T prolongation
5. On respiration
Moderate doses produce slight stimulation whereas large doses produce respiratory depression which may be fatal
6. Kidney
Diuresis is often notified after alcohol intake
It is due to depression of ADH production
It does not impair renal function
7. Sax
Alcohol is reputed as an aphrodisiac.
Aggressive sexual behavior is due to loss of inhibitory control
It also provokes the sensation but takes away the performance
Chronic alcoholism can produce impotence, gynaecomastia and infertility
8. Body temperature
Alcohol produces a sense of warmth due to cutaneous and gastric vasodilatation , but heat loss is increased in cold surroundings
High intake of alcohol produces depress temperature regulating centre
9. Liver
It produces fatty liver on chronic administration
It mobilize peripheral fat and increases fat synthesis in liver
Proteins may also accumulate in liver because their secretion is decreased
Acetaldehyde produced during metabolism of alcohol appears to damage the hepatocytes on chronic ingestion of large amounts
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Increased lipid peroxidation and glutathione depletion occurs
Regular alcohol intake induces microtonal enzymes
10. Skeletal muscle
Alcohol produces little direct effect. Fatigue is produced by small doses, but muscle work is increases or decreased
Weakness and myopathy occurs in chronic alcoholism
11. Blood
Regular intake of small to moderate amounts has been found to raise HDL levels and decrease LDL oxidation Megaloblastic anemia has been seen in chronic alcoholism due to interference with folate metabolism
Absorption , fate and excretion
Alcohol is absorbed in the stomach (25%) and 75% in small intestine
hypoglycemiaCollapse, respiratory depression Coma and death
Treatment
Gastric lavage maintain patent airway and take steps to prevent aspiration of vomit us
Positive pressure respiration may be needed if it is markedly depressed
Most patients will recover with supportive treatment, maintenance of fluid and electrolyte balance and correction of hypoglycemia by glucose infusion till alcohol is metabolized
Recovery can be hastened by haemodialysis
Insulin + fructose drip has been found to accelerate alcohol metabolism
Chronic alcoholism
On chronic intake, tolerance develops to subjective and behavioral effects of alcohol
It is both pharmacokinetic and cellular tolerance
Psychic dependence often occurs even with moderate drinking
Physical dependence occurs only on heavy and round the clock drinking
Heavy drinking is often associated with nutritional deficiencies, because food is neglected and malabsorption may occur
Alcoholic cirrhosis of liver, hypertension, cardiomyopathy , CHF, arrhythmias, stroke and skeletal myopathy are complications
Treatment
Psychological and medical supportive measures are needed during withdrawal
Many CNS depressants like barbiturates , phenothiazines, chloral hydrate have been used as substitution therapy in the past to suppress withdrawal syndrome but benzodiazepines like chordiazepoxide, diazepam are the preferred drugs now
These have a long duration of action and can be gradually withdrawn later
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Disulfiram
It is a drug for the treatment of chronic alcoholism
It is a inhibits the enzyme aldehyde dehydrogenaase
So acetaldehyde is not converted into Acetyl CoA
This leads to accumulation of acetaldehyde which produces nausea and vomiting
It is administered at a dose of 500 mg once daily for a week and alter 250 mg daily as maintenance dose
When alcohol is ingested after taking disulfiram, the concentration of acetaldehyde in tissues and blood rises and a number of distressing symptoms (aldehyde syndrome ) are produced These are
Flushing Burning sensation Throbbing headache PerspirationUneasinessTightness in chest Dizziness Vomiting Visual disturbances Mental confusion and circulatory collapse
Duration of the syndrome (1-4 hours ) depends on the amount of alcohol consumed
Disulfiram is used in chronic alcoholics who are motivated and sincerely desire to leave the habit
Sensitization to alcohol develops after 2-3 hours of first dose and lasts for 7-14 days after stopping it ,because inhibition of aldehyde dehydrogenase with disulfiram is irreversibleSynthesis of fresh enzyme is required for return of activity
It should not be used in patients who are physically dependent on alcoholSide effect of disulfiram are DrowsinessHeadacheCramps RashesMetallic tasteNervousnessAbdominal upset
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Unit - 5Hypnotics and sedatives
Hypnotics are drugs which produce sleep resembling natural sleep
Sedatives are drugs which reduce excitement without producing sleep
Qualitatively hypnotics and sedatives produce depression of CNS and the difference between them is mainly quantitative
1. Barbiturate derivatives2. Non – barbiturate derivatives
Barbiturates o derivatives of barbituric acid which is obtained by condensation of urea and malonic acid
Barbituric acid itself does not possess hypnotic activity but hypnotic activity is produced, if the hydrogen atoms at position 5 are replaced by alkyl or aryl groups
The barbiturates were formerly the mainstay of treatment used to sedate the patient or to induce and maintain sleep
Today , they have been largely replaced by the benzodiazepines, primarily because barbiturates induce tolerance, drug metabolizing enzymes, physical dependence and severe withdrawal symptoms
The barbiturates in severe doses produces coma
Mechanism action of barbiturates
The sedative – hypnotic action of the barbiturates is due to their interaction with GABA A
receptors which enhances GABA nergic transmission
The binding site of distinct from that of the benzodiazepines
Barbiturates potentate GABA Acton on chloride entry into the neuron by prolonging the duration of the chloride channel openings
In addition , barbiturates can block excitatory glutamate receptors
Anesthetic concentration of pentobarbital also block high frequency sodium channels
All of these molecular action lead to decreased neuronal activity
Pharmacological actions
On CNS
Barbiturates produce all degrees of CNS depression like mild sedation, hypnosis and general anesthesia
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Sleep
Barbiturate induced sleep resembles natural sleep
But it decreases the time spent on rapid-eye movement sleep, also there is hangover effect after awakening
Analgesic effect
Barbiturates do not relieve pain without producing unconsciousness
They enhance the analgesic effect of salicylates and para-amino phenol derivatives
Anesthetic effect
Thionarbiturates and some ultra short acting oxybarbriturates produce anesthesia on intravenous administration
Anti- consultant effect
Barbiturates like phenobarbitone which have a phenyl group at the 5 th carbon atom have anticonvulsant effect
Respiration
Respiration is not affected at sedative or hypnotic dose
Large dose administered intravenously may produce death due to central respiratory paralysis
GIT
Intestinal motility is not affected at a normal dose, but gastric secretion may be depressed
Uterus
Force and frequency of uterine contractions are depressed at toxic dose
Kidney
No effect at normal dose but anesthetic dose decreases urinary output due to decrease in glomerular filtration and release of Ach
Liver
No effect at normal dose but anesthetic dose may produce hepatic dysfunction
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Enzyme induction
Barbiturates induce P450 microsomal enzymes in the liver
Chronic barbiturate administration diminishes the action of many drugs that a re dependent on P450 metabolism to reduce their concentration
ADME
Barbiturates can be administered by oral and parenteral routes
They are distributed in all tissues and body fluids
They cross placental barrier and also are excreted in milk They are chiefly metabolized in the liver and to a small extent in kidney and brain
Excretion is through urine both in free form and as glucuronic acid conjugate
Adverse reaction
Intolerance like nausea, headache and diarrhea
Fetal respiratory depression if administered during labor
Drug automatism due to repeatedly taking the drug owing to forgetfulness
Tolerance because of increased inactivation in the liver
Dependence and withdrawal symptoms
Therapeutic uses
Sedation in case of anxiety or tension
Hypnosis to relieve insomnia
Anticonvulsant effect in case of tetanus or status epilepticus
Pre anesthetic medication and to produce basal anesthesia
Potentiation of analgesics like salicylates
In psychiatric practice and in neonatal jaundice
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Benzodiazepines
These are very important class of hypnotics and sedatives because of their high therapeutic index
The important Benzodiazepines are
DiazepamFlurazepamNitrazepamLorazepamOxazepam
Mechanism of action
The GABA (Gamma amino butyric acid ) is acts as an inhibitory neurotransmitter in the body
It acts on GABA receptors
But the benzodiazepine receptor are associated with GABA receptors
These benzodiazepines acts on GABA and stimulate the GABA receptors , leading to increase in the GABA activity
GABA activating the chloride channels leading to increase in the Cl conductance and hence decrease firing of the regions
Benzodiazepines produce increase in pre-synaptic inhibition , decrease in turnover of 5HT, nor adrenaline and dopamine
These also posses GABA agonistic activity Therapeutic uses
In anxiety and insomnia
As a pre-anesthetic medication
Treatment of epilepsy and seizure states or muscular relaxation in spastic conditions
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In control of ethanol and sedative- hypnotic withdrawal symptoms
As diagnostic aid for treatment in psychiatry
Adverse effectsDrowsiness, confusion, impaired motor in co-ordination, tolerance and dependence to the less extent and reparatory depression
Chloral hydrate
Chloral hydrate is a trichlorinated derivative of acetaldehyde .
It is converted to the active metabolite , trichloroethanol, in the body
The drug is an effective sedative and hypnotic that induces sleep in about thirty minutes and lasts about six hours
Chloral hydrate is irritating to the gastrointestinal tract and causes epigastric distress
It also produces an unusual, unpleasant taste sensation
It synergizes with ethanol
It does not have the analgesic activity but may produce excitement and delirium in presence of pain
Adverse effectsNausea, vomiting, gastric irritation, respiratory and vasomotor depression , myocardial depression and arrhythmia
Paraldehyde
It is nauseating and volatile, liquid hypnotic which is harmless and quick in Acton
It is more potent than the chloral hydrate and polymer of acetaldehyde
During labor it causes analgesic effect but it can cross placenta and may delay respiration in new born
Higher doses may cause hypotension, respiratory depression and coma
It can be used as anticonvulsant , hypnotic and basal anesthetic
It is absorbed thorough the oral and parental administration
It is excreted through the lungs with offensive smell
It reacts with plastic materials so cannot administer with the plastic syringes
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Rectal administration cause irritation to mucosa of rectum an may cause ulceration
Ethyl alcohol
It has antianxiety and sedative effects , but its toxic potential outweighs its benfits
Alcoholism is a serious medical and social problem
Ethanol is a CNS depressant producing sedation and ultimately hypnosis with increasing dosage
It is readily absorbed orally and has a volume of distrinution close to that of total body water
It is metabolized primarily in the liver, first to acetaldehyde by alcohol dehydrogenate and then to acetate by aldehyde dehydrogenate
Elimination is mostly through the kidney, but a fraction is excreted through the lungs
Ethanol synergizes wit h many other sedative agents and can produce severe CNS depression with antihistamines or barbiturates
Chronic consumption can lead to severe liver disease, gastritis and nutritional deficiencies
Cardiomyopathy is also a consequence of heavy drinking
The treatment of choice for alcohol withdrawal are the benzodiazepines
Carbamzepine is effective in treating convulsive episodes during withdrawal
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Antianxiety drugs
DefAntianxiety drugs (anxiolytics) are CNS depressants which control symptom of anxietyThey produce a calming effect in anxiety states
1. BenzodiazepinesDiazepam
Oxazepam
Lorazepam
Alprazolam
2. Azapirones
Buspirone
Gipirone
Benzodiazepines
These are the commonly used antianxiety drugs
They have anxiolytic, hypnotic, muscle relaxant and anticonvulsant actions
They are less toxic and addiction liability is very low
Mechanism of action
It is believed that these agents facilitate the effects of GABA receptor activation in the CNS
Like all other benzodiazepines, it has a hypnotic, anxiolytic, muscle relaxant and anticonvulsant actions
It is quickly absorbed on oral administration
Uses
Acute panic states
Anxiety associated with organic disease
Status epileptic us
Dose 2- 5 mg twice a day Oxazepam
It is active metabolites of diazepam
This benzodiazepine is slowly absorbed on oral administration also
It also penetration slow
It has a short duration of action
So it is used mainly in short lasting anxiety states
Dis-advantages
It is short acting
It is not well absorbed
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Dose
10 mg
Lorazepam
This benzodiazepine is slowly absorbed on oral administration
It also penetration in brain is slow
It has a short duration of action
So it is used mainly in short lasting anxiety states
Dose
1-4mg
Alprazolam
It is a recently introduce antianxiety drug
In addition to anxiolytic effect
It has a mood elevating action
It also produces less drowsiness
USE
Anxiety states associated with depression
Dose
0.25-1 mg three times daily
Meprobamate
The drug produces calmness In as individual
It reduces tension and hostility
Reactions of the patient to his environment become – congenial
Unlike phenothiazines it dies not abolish conditioned reflexes
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Adverse reaction
DrowsinessAngioneurotic edema and other r allergic manifestationsBlood dyscrasias
Disadvantages
Tolerance develops
IT produces drug
Dependence
USES
Anxiety
Neurosis
Chlordiazapoxide
Though it is a benzodiazepine, its actions resemble barbiturates
It produces calmness
It also produces sedation
It produces skeletal muscle relaxation
It stimulates appetite
Adverse reaction
Drowsiness, lethargy and ataxia
Hypotension is produce in few
Disadvantages
Tolerance develops
It induces physical dependence , withdrawal symptoms are produced on its stoppage
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Use
Anxiety and neurosis
It is used to suppress withdrawal symptoms of alcohol
As preanaesthestic medication
Buspirones
It is new antianxiety drug
It does not have sedative, hypnotic, muscle relaxant and anticonvulsant effects as produced by benzodiazepines
It has a slow action and the effect is delayed for even two weeks
Mechanism of action
It acts by stimulating presynaptic 5-HT 1A auto receptors
USE
Mild to moderate anxiety
Dose
10-30 mg daily is divided doses
Flumazinil
It is a benzodiazepine antagonist
It binds competitively with benzodiazepine receptors and blocks many of the pharmacological actions of benzodiazepines
USE
To reverse benzodiazepine anesthesia
In Benzodiazepine overdose
Hepatic coma and alcohol intoxication
Centrally acting muscle relaxants
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Skeletal muscle relaxation without altering consciousness or normal voluntary movement is necessary during unwanted muscular spasms and rigidity and during operative procedures
The classes of drugs which can be used fro skeletal muscle relaxation are centrally acting drugs and drugs acting peripherally at neuromuscular junction
It is the first centrally acting muscle relaxant which was introduced in 1946 still being widely used today
It relaxes normal and spastic skeletal muscles without interfering within neuro-muscular transmission
In moderate dose it reduces muscle tone and motor activities
But large doses produce hypotension, respiratory paralyses and death
The drug is will absorbed orally and parent rally ,but duration of action is short
It is used to treat acute spasm of skeletal muscle in tetanus and status epileptic us
It is used to produce muscular relaxation during operative procedures
Use to reduce agitation in chronic alcoholism an to relieve muscular rigidity and tremors in parkinsonism
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Dose
orally 1 gram to 3 grams
Parentally 100mg to 1 gram
Mephenesin carbamate an ester of mephanesin has a longer duration of action and hence is preferred
Dose – 1 to 1.2 gram per day orally
Methocarbamol
This chemically elated to mephenesin carbamate
It acts both as muscle relaxant and sedative
It is orally active with a longer duration of action and milder side effects
Uses - Same as mephenesin
Dose – 0.5 grams per day orally
It can also be given by I.M or I.V route
Carisoprodol
It is chemically related to meprobamate
It produces muscle relaxation and sedative effects
It is used in cerebral palsy to produce muscular relaxation
Unwanted side effects are drowsiness, vertigo, weakness and allergic reactions on skin
Dose - 350 mg oral
Metaxalone
Dose - 0 3.2 rams per day in divided doses
Serious side effects are leucopenia and jaundice
Muscle relaxants are contra-indicated in pregnant women , in the presence of renal damage and myasthenia gravis
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Muscle relaxants acting at neuromuscular junction
The contraction of skeletal muscle is initiated by acetyl choline at the neuromuscular junction
Acetyl choline acts on the receptor of the muscle producing contraction
But there are drugs which block the action f acetyl choline on skeletal muscle receptors thereby producing muscle relaxation
They are of two types namely
1. Competitive blockers
2. Depolarization blockers
1. Competitive Blockers
The drugs which act by this mechanism are d-tubocurarine and gallamine
They compete with the acetylcholine to reach the muscle receptors
D-TubocurarineThis is the dextro rotatory alkaloid obtained from the strychnos species
Curare was mainly used as an arrow poison in South America
It competes with acetyl choline to reach the receptors and thus blocks the action of acetylcholine at the neuromuscular junction and produces muscle relaxation
It is inactive orally, but is active parent rally
The drug is given intravenously for muscle relaxation during operative procedures
Dose -- 6 to 10 mg given with general anesthetic
Disadvantage - It is that it causes release of histamines from the tissues
Gallamine
It is a synthetics quaternary ammonium compound with curare like action
It also acts as a skeletal muscle relaxant by competitive blockade of acetylcholine
But is less potent than d – tubocurarine It does not release histamineIt is not active orallyHence given parent rally
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It is also used to produce muscular relaxation during operative procedures
Dose - 100 mg by I.V injection
Depolarization blockers
Here the drugs act by depolarizing the receptor motor end plate of the muscle which becomes resistance to further stimulation
The drug which stimulation
The drug which acts by this process and relaxing skeletal muscles is succinyl chloride
It has very short duration of action
Its action can be enhanced by anti-choline esterasis like neostigmine
It does not release histamine
It is used in anesthesiology to produce muscle relaxation by continuous I. V infusion
Other drugs which act this process is decamethonoum
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Unit - 6
Anti-psychotic drugs
These are the drugs which used in treatment of major psychosis
They are also called a major tranquilizers, since they reduce agitation and disturbed behavior seen in schizophrenia
These are the most widely used compounds in the treatment of major psychosesPhenothiazines are three ringed structures
In which two benzene rings are linked by a sulphur and a nitrogen atom
Chlorpromazine is the important phenothiazine and was synthesized in 1950
According to the chemical structure , phenothiazines could be predominantly antipsychotic c, ant cholinergic or antihistaminic
Mechanism of actionPhenothiazines and other antipsychotic drugs produce beneficial effects probably by affecting three of the major integrating systems in the brain
Mesolimbic system
Mesocortical system
Hypothalamus
Cause blockage mainly of postsynaptic dopaminergic (D2) receptors and to smaller extent 5-HT receptors
Modify the function of the mesolimbic system Reduce the incoming sensory stimuli by acting on the brainstem reticular formation
Pharmacological actionsOn CNSWhen chlorpromazine is given to patients with psychosis , it produces
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Psychomotor slowing
Emotional quietening
Decreased initiative
Decreased anxiety
Phenothiazines do not have as analgesic effect
But they potentate the analgesic effect of morphine
They dontot have anticonvulsant effect
Behavioral effects
In normal subjects CPZ reduces motor activity, produces drowsiness and indifference to surroundings
In psychotic agitated patients, it reduce aggression , initiative and motor activity, relieves anxiety and brings about emotional quietening and drowsiness
It normalizes the sleep disturbances characteristic of psychoses
Other CNS actions
Cortex
CPZ lowers seizure threshold and can precipitate convulsions in untreated epileptics
Hypothalamus
CPZ decreases gonadotrophin secretion and may result in amenorrhea in women It increases the secretion of prolactin resulting ins galactorrhiea and gynaecomastia
Basal ganglia
CPZ acts as a dopamine antagonist and therefore results in extra-pyramidal motor symptoms ( drug induced parkinsonism)
Brainstem
Vasomotor reflexes are depressed leading to a fall in BP
Anti-emetic action
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CPZ has a powerful anti emetic effect
These block the dopamine (DA) receptors in the CTZ
This effect is produced by depress the chemoreceptor trigger zone
On ANS
The actions on the ANS are complexCPZ is an alpha adrenergic blocker
The alpha blocking potency varies with each neuroleptic
CPZ also has ant cholinergic properties which leads to side effects like dryness of mouth, blurred vision, reduced sweating, decreased gastric motility, constipation and urinary retention
The degree of anti cholinergic activity also varies with each drug
CVS
CPZ produce hypotension due to alpha blockade action and reflex tachycardia
It also has a direct myocardiac depressant effect like guanidine
It also has anti- fibrillatory effect
Local anesthetic effect
These has local anesthetic properties but is not used for the purpose since in is an irritant
Kidney
CPZ depresses ADH secretion and has weak diuretic effects
Tolerance develops to the sedative and hypertensive actions while no tolerance is seen to the anti psychotic actions
On endocrine glands
These produces inhibition of ovulation, amamenorrhea and lactation in females
In males, it produces loss of libido
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These effect are produced by blocking the action of dopamine on hypothalamus and pituitary
Other actions
Inhibition of hiccough
Skeletal muscle relaxant effectPharmacokinetics
It is well absorbed after oral and parenteral administration
It is highly protein bound
High concentration is found in the lungs, liver and adrenal glands
It is subjected to enterohepatic circulation
This increases its duration of action
The half life period is 20 to 24 hours and is therefore given once a day
It is metabolized in the liver and the metabolic products are excreted in urine s
Adverse reaction
CNS effects
Drowsiness, excitement, psychotic reactions, confusion and parkinsonism
ANS effects
Blurred vision, constipation, nasal stuffiness and urinary retentionThese occur due to the ant cholinergic effects
CVS effects
Hypotension, palpitation and tachycardia
Hemopoietic effects
Agranulocytosis, thrombocytopenia and aplastic anemia
Endocrine effects
Gymaecomastia, lactation and menstrual disturbances
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Hypersensinitivity reactions
Jaundice, agranulocytosis and skin rashes
Drug interactions
CPZ enhance the sedative effects of CNS depressants, alpha blockers and of ant cholinergic drugs
When combined with these groups of drugs , the effects may be additive
These inhibit the actions of dopamine agonists and Levo dopa
Dose
Chlorpromazine tablets and syrup- 25 to 1000mg by mouth
Chlorpromazine injection-25 to 50 mg by intramuscular injection
Uses
These are given orally ( chlorpromazine 100 – 800mg)
In acute psychosis they may be given intramuscularly and response is seen in 24 hrs
While in chronic psychosis it takes 2-3 weeks of treatment to demonstrate the beginning of obvious response
It is used in the treatment of major psychosis
It is used to control aggressiveness in children
It is used as ant emetic
CPZ can control intractable hic- cough
It is used in pre- anesthetic medication
It used in neuropsychiatry disorders such as Huntington’s disease
Drug dependence
They are useful in the management of psychosis associated with chronic alcoholism tbu are contraindicated in acute withdrawal syndromes for fear of precipitating seizures
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Haloperidol
This is a very potent drug, belonging go the class of butyrophenones but with similar clinical effects as piperzine phenothiazines
It is more effective in highly agitated or manic patients and has less prominent sedative and autonomic effects than chlorpromazine
It is given orally in the dose of 1.5 to 7.5mg , there times day
It can also be given IM in the dose of 2-10 mg, repeated every hour up to a total of 30 mg, in agitated and violent patients
Depot injection preparation of haloperidol are also available
The incidence of EPS with this drug is high and it dies not seem to be superior to phenothiazines in the routine treatment of schizophrenia
The irreversible toxic encephalopathy has been reported in patients on lithium if they are given high doses of haloperidol
The other drugs of this series are trifluperidol and droperidol which are used in combination with fentamyl for neuroleptanalgesia
Rauwolfia alkaloids
It is alkaloid obtained from a plant called Rauwolfia serpentine
In ancient Ayurvedic medicine, the extract of this plant has been claimed to be useful in cases of insomnia , insanity and snake bite
It is called serpentine because of the resemblances of the root to a snake
Mechanism of action
Reserpine is of great pharmacological interest because it produces depletion of endogenous catecholamine and 5-HTfron the brain and peripheral sites by interfering with amine storage
Such depletion can last for day or weeks
A single dose of 5 mg / kg body weight is sufficient to cause 90% reduction in brain nor adrenaline and 5-HT over a period of 10 days
This depletion of cerebral monoamines is believed to be responsible for its central actionsPharmacological actions of reserpine
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CNSIt has central antipsychotic action resembling those of phenothiazines
It differs from the latter compounds in that it has no antihistaminic, cholinergic blocking or direct adrenergic blocking effects
In man , it produces a similar calming effect as well as extra pyramidal action as those observed flowing chlorpromazine
It does not produce clouding of consciousness
Reserpine is less effective than phenothiazines in t he treatment of schizophrenia
It may cause mental depression precipitating suicidal tendencies , hence it is no more used as an antipsychotic drug
CVSIt is used as antihypertensive drug
Reserpine is less effective tam phenothiazines in the treatment of schizophrenia But is commonly used as an antihypertensive drug
Clozapine
This antipsychotic drug, related to heterotricyclic compounds like imipramine , was synthesized in 1960
It was found to cause agranulocytosis and its use was abandonedIt has selective effects in the limbic, dopaminergic systems, its other actions include antiadrenergic , anti5-HT and ant cholinergic actionsIt differs from phemothiazines in that it causes fewer EPRs and does not cause hyperprolactinemia
It given orally, it produces antipsychotic effects similar to other standard neuroleptics
Its major advantage is that the drug improves not only the positive symptoms but also the negative symptoms such as emotional withdrawal, bunted affect, retardation and social withdrawal
It is started in the dose of 12.5 mg once daily and gradually increased to 200- 450 mg / day in divided doses
Adverse reactionsThese includes nausea, vomiting , sedation , hypotension , severe tachycardia , and confusion
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Anti-depressant drugs
These are the drugs used for the treatment of mental depression
They are also called as psycho analeptics or mood elevators
IV. Serotonin or nor epinephrine re-uptake inhibitors
Phenelzine
Tranylcypromine
1. Mono-amine oxidase inhibitors (MAOI)
Monoamine oxidase (MAO) is a mitochondrial enzyme found in nerve , liver and gutIn the neuron, MAO functions is to deaminate and inactivate any excess neurotransmitter molecules (nor epinephrine, dopamine and serotonin) that may leak out of synaptic vesicles when the neuron is at test
The MAO inhibitors may irreversibly or reversibly inactivate the enzyme, permitting neurotransmitter molecules to escape degradation and therefore to both accumulate within the presysaptic neuron and leak into the synaptic space
This causes activation of nor- epinephrine and serotonin receptors and it may be responsible for the antidepressant action of these drugs
Two MAO inhibitors are currently available for treatment of depression- Phenelzine and tranylcypromine
The use of MAO inhibitors is now limited due to the complicated dietary restrictions required of patients taking MAO inhibitors
Mechanism of action
MAO inhibitors such as phenelzine form stable complex with enzyme, causing irreversible inactivation
These results in increased stores of nor epinephrine, serotonin and dopamine within the neuron and subsequent diffusion of excess neurotransmitter into the synaptic space
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These drugs inhibit the MAO in brain and as well as in t he peripheral
Pharmacological actions
1.BehaviorIn case o f mental depression, these compounds elevate the moodThe patient feels more energetic and fresh
2. On CVSNo effect on heart or circulation at normal dose
3. Potentiation of sympathomimetic aminesThese compounds potentiate the action of symathomimitic amines like amphetamine and tyramineThese have a mild, amphetamine like stimulant effect
Pharmacokinetics
These drugs are will absorbed on oral administration
Antidepressant effects require two to four week of treatment
MAO inhibitors are metabolized and excreted rapidly in the urine
Uses
MAO inhibitors are indicated for depressed patients who are un- responsive or allergic to TCA or who experience strong anxiety
These drugs are also useful in the treatment of phobic statesMAO inhibitors also used in the treatment of a special subcategory of depression called atypical depression
Atypical depression is characterized by labile mood , rejection sensitivity and appetite disorders
Adverse effects
Behavioral effects
Headache, excitement and disturbed sleep
CNS effects
Twitching, ataxia and tremors
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ANS effects
Dry mouth, constipation and blurred vision
HypertensionTyramine is met abolished by the enzyme MAO
In presence of MAOI , tyramine is not metabolized
These leads to accumulation of tyramine
Tyramine produces rise in blood pressure by releasing nor adrenaline
11. Tricyclic antidepressants
These blocks nor epinephrine and serotonin uptake into the neuron
These drugs are voluble alternative for patients who do not respond to SSRIs
Mechanism of action
These are potent inhibitors of the neuronal re-uptake of nor epinephrine and serotonin into presynaptic nerve terminals
This produces increase in its concentration at the receptor sites
These contributes for the antidepressant action
TCAs also block serotonergic, alpha adrenergic ,histamine and muscarinic receptors
Pharmacological actions
1. Behavior
These elevate mood, improve mental alertness ,increase physical activity
The onset of the mood elevation is slow , requiring two weeks or longer
These drugs do not produce CNS stimulation or mood elevation in normal individuals
Physical and psychological dependence have been reported
The drugs can be used for prolonged treatment of depression without loss of effectiveness
2. CVS
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No effect at normal dose
But toxic doses may produce cardiac arrhythmias
3. ANS
Imipramine produces anti cholinergic effects like dry mouth, constipation , palpitation and blurred vision
ADME
Imipramine is well absorbed on oral administration
Because of their lipophilic nature ,they are widely distributed and readily penetrate into the CNS
This lipid solubility also causes these drugs to have long half lives – 4 – 17 hours for imipramine
These drugs are metabolized by the hepatic microsomal system and conjugated with glucuronic acid
The TCA are excreted as inactive metabolites via the kidney
It actions are mediated through desmethyl-imipramine which is a metabolite product
Adverse reactions
CNS effects
Lethargy, headache and drowsiness
ANS effects
Dry mouth, constipation and tachycardia
CVS effects
Cardiac arrhythmias and hypotension
Allergic reactions
Skin rashes and photosensitivity
Uses
These are very effective in treating severe major depression
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Some panic disorders also respond to TCA
Imipramine has been used to control bed- wetting in children by causing contraction of the internal sphincter of the bladder
TCAs , particularly amitriptyline , have been used to treat chronic pain
Drugs which belongs to these groups areFluoxetineCitalopramEscitalopramParoxetineSertaline
These drugs do not produce CNS stimulation or mood elevation in normal individuals They selectively inhibit 5 – HT reuptake
They have less antimuscarinic effects and also sell sedation
They are safer than tricyclic antidepressants
These have little ability to block the dopamine transporter
Pharmacological actions
SSRIs block the re-uptake of serotonin , leading to increased concentrations of the neurotransmitter in the synaptic clefts and to greater postsynaptic neuronal activity
Anti-depressants including SSRIs typically take two weeks to produce improvement in mood and maximum benefit may require twelve weeks or more
The patients that do not responds to one antidepressant may respond to another and approximately eithy percent or more will respond to at least one antidepressants drug
Pharmacokinetics
These are well absorbed on oral administration
Peak levels are seen in five hours on average
Food has little effect on absorption
Only sertraline undergoes significant first –pass metabolism
All these agents are well distributed
The half life of SSRIs are in-between 16 -36 hours
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These are metabolized by the P-450 – dependent microsomal enzymes
These produced the conjugation of glucuronide or sulfate conjugationBoth citlopram and fluoxetin are racemic mixtures
Escitalopram is the pure S- enatiomer of citalopram
Fluoxetine and paroxetine are potent inhibitors of a hepatic cytochrome P-450 iso enzymes responsible for elimination of tricyclic antidepressant drugs
Excretion of the SSRIs is primarily through the kidneys except for paroxetine and sertraline which also undergo fecal excretion
USESThe primary indication for SSRIs is depression, for which they are as effective as the tricyclic antidepressants
A number of other psychiatric disorders also respond favorably to SSRIs m including obsessive compulsive disorder, panic disorder, generalized anxiety
Adverse reactionSSRIs have fewer and less severe adverse effects than the tricyclic antidepressant and MAOI
1. Sleep disturbances
Paroxetine and fluvoxamine are sedating and may useful in patients who have difficulty sleeping
2. Sexual dysfunction
Loss of libido, delayed ejaculation and anorgasmia are underreported side effects often noted by clinicians but not prominently featured in list of standard side effects
3. Use in children and teenagers
Anti depressants should be used cautiously in children and teenagers , because about one out of fifty children become more suicidal as result of SSRI treatment
Pediatric patients should be observed for worsening depression and suicidal thinking whenever one of these drugs is started or their dose is increased or decreased
4. Overdoses
Large intakes of SSRIs do not cause cardiac arrhythmias, but fluoxetine may cause seizuresAll SSRIs have the potential to cause a serotonin syndrome characterized by hyperthermia , muscle rigidity , clonic muscle twitching and changes in mental status and vital signs when used in the presence of a monoamine oxidase inhibitor
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Anti- manic drugs
The following drug are used in the treatment of manic disorder
Lithium saltsCarbamazepine Valproic acid
Lithium carbonates
It is a small monovalent cation
In 1949 it was found to be sedative in animals and to exert beneficial effects in manic patients
Mechanism of action
The mechanism of antimanic and mood stabilizing action of LI is not knownIt has been proposed that
Lithium partly replaces body Na and is nearly equally distributed in and outside the cells ( contrast Na and K ) , this may affect ionic fluxes across brain cells or modify the property of cellular membranes
Lithium has been found to decrease the release of Na and DA in t he brain of treated animals without affecting 5 –HT release
This may correct imbalance in the turnover of brain monoamines
Pharmacological actions
On CNS
Lithium has practically no acute effects in normal individuals as well as in MDI patients
It is neither sedative nor euphorient, but on prolonged administration, It acts as a mood stabilser in bipolar disease
Given to patients in acute mania, it gradually suppresses the episode taking 1-2 weeks
The markedly reduced sleep time in manic patients is normalized
Other actions
Lithium inhibits action of ADH on distal tubules and causes a diabetes like state
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It has some insulin like action on glucose metabolism
Leukocyte count is increased by lithium therapy
Lithium reduces thyroxin synthesis by interfering with iodination of tyrosine
Pharmacokinetics
Lithium is given orally and the ion is excreted by the kidney
It is neither protein bound nor metabolized
It first distributes in the extra cellular water and then gradually enters cells and slowly penetrates into the CNS , ultimately attaining a rather uniform distribution in total body water , apparent volume of distribution at steady- state averages 0.8 L/kg
The lithium is handled by the kidney in much the same way as Na ,
Most of the filtered Lithium is reabsorbed in the proximal convoluted tubule
When N a is restricted, a larger fraction of filtered Na is reabsorbed , so is Li
After a single dose of li urinary excretion of rapid for 10- 12 hours followed by a much slower phase is 16- 30 hours
Renal clearance of lithium is 1/5 of creatinine clearance
On repeated medication steady-state plasma concentrations achieved in 5-7 days
Levels are higher in older patients and in those with renal insufficiency
Peaks in plasma lithium level over and above the steady-state level occur after every dose and produce episodes of toxicity if steady-state level if high or the dose is large
Divided daily dosing in 2-4 portions is needed to avoid high peaks
Lithium is excreted in sweat and saliva also salivary concentration is proportionate to serum concentration and may be used for noninvasive monitoring
Lithium is secreted in breast milk
Mothers on lithium should not breastfeed
Adverse reaction
Side effects are common but are mostly tolerable
Toxicity occurs at levels only marginally higher than therapeutic levels
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Nausea, vomiting and mild diarrhea occur initially, can be minimized by starting at lower doses
Thirst and polyuria are experienced by most, some fluid retention may occur initially but clears later
Fine tremors and rarely seizures are seen even at therapeutic concentrations
CNS toxicity – coarse tremors, giddiness, ataxia, motor in coordination, mental confusion, slurred speech,
On long term use some patients develop renal diabetes and goiter has been reported in about 4 %
Interactions
Diuretics ( thiazide, furosemide0 by causing ) Na loss promote proximal tubular reabsorption of Na as well as lithium – plasma levels of lithium rise
Tetracycline’s , indomethacin and ACE inhibitors can also cause lithium retention
Lithium reduces presser response to NA
Lithium tends to enhance insulin / sulfonylurea induced hypoglycemiaSuccinyl-choline and pancuronium have produced prolonged paralysis in lithium treated patients
Haloperidol have been frequently used along with lithium without problem , sometimes , the combination of haloperidol and lithium produces marked tremor and rigidity
Dose
Lithium used as its carbonate salt because this is less hygroscopic and less gastric irritant than lithium chloride or other salts
It converted into chlorides in the stomach
It is generally stared at 600 mg/day and gradually increased to yields therapeutic plasma levels, mostly 600-1200 mg /day is required
Hallucinogens
These are drugs which alter mood, behavior, thought and perception in a manner similar to that seen in psychosis
In appropriate doses these produce changes in visual, auditory perception, in smell and taste , broadly illusions and hallucinations
There will be alteration of the sense of time and space with personality changes
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Memory is not affected The drugs which possess their actions are cannabis, mescaline, LSE -25 , psilocybin , bufotenine and harmoline
Cannabis
It is obtained from cannabis indica or Indian hemp
Flowering tops (ganja), the leaves (bhang) , the resinous exudation (Charas) or the whole drug ( Hashish)
In U.S.A. it is called as marihuana
Cannabinal (chemically an alcohol) a red syrapy oil is said to be the active principle
It produces hallucinations of time , space, euphoria ( sense of well being), imagination, mental exaltation, impulsive behavior, delirium ( confusion and excitement), mania ( mental disorder)
Cannabis is not useful therapeutically
Mescaline
It is an alkaloid obtained from a cactus
When given orally the drug produces sympathomimetic effects and visual hallucinations and a sense of floating in space
It also produces excitement , restlessness, change of mood and intelligenceIt is used only for experimental purposes to produce psychotic states
LSD – 25 ( Lysergic acid diethylamide)
This is a derivative of ergot alkaloid, now being used in psychiatric research
It induces psychotic states in which repressed memories form the subconscious mind are brought of light
It stimulates emotional activity producing the sense of lightness and withdrawal from reality
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It brings about personality change
It may be used in obsessional thoughts and anxiety conditions accompanied by mental tension
It is orally active in a dose of 25 micro gram
But it is widely misused for its hallucinogenic effects
The person become disoriented and his activities disorganized
It is noticed that it can induce chromosomal abnormalities and fetal malformation and possibly leukemia and hence it I withdrawn even form research
Other minor hallucinogens like bufetinine, psilocybin and harmolin produce similar psychic effects but not used therapeutically
Unit - 7
Anti- Epileptic drugs
It is a collective term applied for a group of convulsive disorders
The common features of epilepsy areLoss or disturbance of consciousnessesCharacteristic body movements (usually, but not always) CLASSIFICATION
Phenytoin was synthesized in 1908, but its anticonvulsant property was discovered only in 1938
It is effective in suppressing tonic-clinic and partial seizures and is a drug of choice for initial therapy, particularly in treating adults
Mechanism of action
Phenytoin blocks voltage-gated sodium channels by selectively binding to the channel in the inactive state and stabilizes the neuronal membraneIt inhibits the generation of repetitive action potentialsAt much higher concentrations , phenytoin can block voltage-dependent calcium channels and interfere with the release of monoaminergic neurotransmitters
Pharmacological action
Phenytoin exerts antiseizure activity without causing general depression of the CNS
It is one of the most effective drugs against generalized tonic-clonic seizures and partial seizures
Phenytoin reduces the propagation of abnormal impulses in the brain
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Pharmacokinetics
Phenytoin is poorly water soluble hence absorption is slow
It is 90% bound to plasma proteins
It is metabolized in liver
Phenytoin is enzyme inducer
Therapeutic uses
Phenytoin is highly effective for all partial seizures ( simple and complex), for tonic-chronic seizures and in the treatment of status epileptics
Phenytoin is not effective for absence seizures, which often may worsen if treated with this drug
Adverse effects
It depend dose , duration and route
Nausea, vomiting, epigasric pain, anorexia
Nystagmus, diplopia, ataxia are common
Gingival hyperplasia is more common in children on prolonged use
Peripheral neuropathy
Phenytoin inhibits insulin release and produces hyperglycemia
Decreases the release of ADH
Osteomalacia , hypocalcaemia due to altered metabolism of vitamin D and inhibition of intestinal absorption of Ca
Hypersensitivity - Rashes , SLE, hepatic necrosis , and neutropenia
Megaloblastic anemia – Phenytoin decreases absorption and increases excretion of folates
Teratogenicity
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When taken by the pregnant lady, phenytion produces fetal hydantion syndrome characterized by hypo plastic phalanges, cleft palate, and harelip
Drug interactions
Phenytoin is an enzyme inducer
Phenytoin given with phenobarbitone , both increases each other metabolism
Phenytoin and carbamazepine enhance each others metabolism
Valproate displaces protein bound phenytoin
Cimetidine and chloramphenicol inhibit the metabolism of phenytioin resulting in toxicity
Antacids decreases the absorption of phenytoin
Phenobarbitone
Phenobartitone was the first effective antiepileptic drug to be introduced in 1912. It still remains one of the widely used drugs
It has antiepileptic activity and raises the seizure threshold
Mechanism of action
Barbiturates enhances the inhibitory neurotransmission in the CNS by enhancing the activation of GABA receptors and facilitating the GABA mediated opening of chloride ion channels
Pharmacokinetics
It is well absorbed orally
The drug freely penetrates the brain
Approximately 75 % of the drug is inactivated by the hepatic mocrosomal system, whereas the examining drug is excreted unchanged by the kidney
It is a potent inducer of the cytochrome P450 system and when given chronically, it enhances the metabolism of their agents
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Therapeutic uses
It provides favorable response for simple partial seizures, but it is not very effective for complex partial seizures
The drug had been regarded as the first choice in treating recurrent seizures in children, including febrile seizures
It also used to treat recurrent tonic-clonic seizures, especially in patients who donot respond to diazepam plus phenytoin
It also used as a mild sedative to relieve anxiety, nervous tension and insomnia
Adverse effects
Sedation, ataxia, vertigo , nausea and vomiting
Agitation and confusion occur at high doses Rebound seizures can occur on discontinuance of Phenobarbital
Primdone
It structurally related to Phenobarbital and it resembles Phenobarbital in its anticonvulsant activity
It is an alternative choice in partial seizures and tonic – clonic seizures
It has more efficacy due to the its metabolites Phenobarbital and phenyl-ethyl-malonamide which have longer half- lives than the parent drug
It is effective against tonic-clinic and simple partial seizures and phenyl-ethy-lmalonamide is effective against complex partial seizures
Primidone is often used with carbamazepine and phenytoin
It is well absorbed orally
It exhibits poor protein binding
These drug has the same adverse effects as those seen with Phenobarbital
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Benzodiazepines
Several of the benzodiazepines show antiepileptic activityDiazepam and lorazepam are the drugs of choice in the acute treatment whereas Clonazepam and clorazepate and clorazepate are used for chronic treatment of status epilepticus
Clonazepam
It suppresses seizure spread from the epileptogenic focus and is effective in absence and myoclonic seizures , but tolerance develops
Clonazepate
Clorazepate is effective in partitial seizures when used in conjunction with other drugs
Diazepam
It is effective against
Pedestal epilepsyMylclonic seizuresStatus epilepsyIt is drug of choice for status epilepticus
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Lorazepam
Lorazepam and diazepam are both effective in interrupting the repetitive seizures of status epilepticus.
Lorazepam has a longer duration of action and is preferred by some clinicians
All of the antiepileptics, the benzodiazepines are the safest and most free from severe side effects
All benzodiazepines have sedative properties
Side effectsDrowsiness,Somnolence, Fatigue,Ataxia, Dizziness and behavioral changes
Respiratory depression and cardiac depression may occur when given intravenously in acute situations
Ethosuximide
It reduces propagation of abnormal electrical activity in the brain, most likely by inhibiting t- type calcium channels in a manner similar to the action of phenytoin on sodium channels
It is the first choice in absence seizures
It is well absorbed orally and is not bound to plasma proteins
About 25% of the drug is excreted unchanged in the urine and 75% is converted to inactive metabolites in the liver by the microsomal cytochrome P450 system
It does not induce P450 enzyme synthesis
The drug is irritating to the stomach and nausea and vomiting may occur on chronic administration
Drowsiness, lethargy, dizziness , restlessness , agitation , anxiety and the inability to concentrate are often observed
Valproic Acid
It is a broad spectrum anticonvulsant
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It has multiple actions , including sodium channel blockade and enhancement of GABAergic transmission
It is the most effective agent available for treatment of myoclinec seizures
It also diminishes absence seizures, but because of its hepatotixic potential, it is a second choice
It also reduces the incidence and severity of tonic-clonic seizures
The drug is effective orally and is rapidly absorbed
About 90% is bound to the plasma proteins ,only 3% of the drug is excreted unchanged, the rest is converted into active metabolites by the liver
It is metabolized by cytochrome P450 enzymes
Metabolites are excreted by kidney
It can cause nausea, vomiting ,sedation, ataxia and tremor are common
It inhibits the metabolism of a number of antiepileptic drugs , including Phenobarbital, carbamazepine and ethosuximide
Carbamaepines
Actions
It reduces the propagation of abnormal impulses in the brain by blocking sodium channels, thereby inhibiting the generation of repetitive action potential in the epileptic focus and preventing their spread
ADME
It is absorbed slowly following oral administration
It enters the brain rapidly because of its high lipid solubility
It induces the drug metabolizing enzymes in the liver
The enhanced hepatic cytochrome p450 system activity also increases the metabolism of many drugs including other antiepileptic drugs
It is an inducer of the cytochromep450 isozyme cyp3a4, which decrease the effects of drugs that are metabolized by his enzyme
Therapeutic uses
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It is effective in Temporal lobe epilepsy
Trigeminal neuralgia
Used in post hepatic pain
Adverse effects
Chronic administration of carbamazepine can cause stupor, coma and respiratory depression
It also produces drowsiness, vertigo, ataxia, and blurred vision
The drug is irritating to the stomach and nausea and vomiting may occur
Drug interaction
The hepatic metabolism of carbamazepine is inhibited by several drugs
Toxic symptoms may arise if the dose is not adjusted
Anti - parkinsonism
It was described b James Parkinson in 1817 and is therefore named after him
Parkinsonism is a chronic , progressive, motor disorder
Characterized by
Akinesia
Muscular rigidity
Tremors
Other symptoms
Excessive salivation
Abnormalities of posture and gait
Seborrhea
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Mood changes
The incidence is about 1% of population above 65 years of age
It is usually idiopathic in origin but can also be drug induced
In idiopathic parkinsonism, there is degeneration of nigrostriatal neurons in the basal ganglia resulting in dopamine deficiency
The balance between inhibitory dopaminergic neurons and excitatory cholinergic neurons is disturbed
Antiparkinsonian drugsIt can only help to alleviate the symptoms and improve the quality of life The two strategies in the treatment are
1. To enhance dopamine activity
2. To depress cholinergic over- activity
Classification of Anti parkinsonism drugs
1. Drugs that increase dopamine levels
A. Dopamine precursor
Levodo[a
B. Drugs that release the dopamine
Amantidine
C. Dopaminergic agonists
Bromocryptine
Lisuride
D. Inhibit dopamine metabolism
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MAO inhibitors - Selegiline
11. Drug influencing cholinergic system
A. Central anticholinergics
Bintropine
Benzhexol
Biperidine
B. Antihistamines
Diphenhydramine
Promethazine
Levodopa
Acetylcholin and dopamine are excitatory and inhibitory neurotransmitters in the corpus striatum
The dopaminergic system is impaired in parkinsonism, so the balance is disturbed
Levodopa acts by getting converted to dopamine and restoring the balance
Parkinsonism is due to dopamine deficiency
Levodopa improves all the manifestations of parkinsonism
But it is not effective in drug induced parkinsonism
Decarboxylase inhibitors like carbidopa are administered with levodopa
They decrease the peripheral decarboxylation of levodopa
Dopamine is of no therapeutic value because it dies not cross the blood- brain barrier
Levodopa is a prodrug which is converted to dopamine in the body
It crosses the Blood- Brain-Barrier and is taken up by the surviving nigrostriatal neurons
The arachidonic acid is liberated from damaged cells during an inflammatory reaction
Prostaglandins and other mediators of inflammation are formed from Arachidonic acid with the help of an enzyme Cyclo-oxygemase
The prostaglandin formed are responsible for many of the features of inflammation I.e. – swelling, redness and pain )
These prostaglandins produce hyperalgesia -- They sensitize the nerve endings to pain and other mediators of inflammation like bradykinin and histamine
The NSAID block the action of enzyme cyclo-oxygenase and thus prevent or reduces the production of prostaglandins and other mediators of inflammation
Asprin
It is a acetyl salicylic acid
It is one of the oldest analgesic-anti-inflammatory drugs and is still widely used
It is rapidly converted in the body to salicylic acid which is responsible for most of the actions
Other actions are the result of acetylation of certain macromolecules including COX
Mechanism of action
It inhibits cycloxygenase which is responsible for the synthesis of prostaglandin and thromboxane
It also inhibits platelet aggregation
Pharmacological actions
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1. Analgesic action
Asprin is a weaker analgesic than morphine
These are effective only in dull- aching pain of low intensity
They do not relieve severe pain like visceral pain
They act by preventing the integration of pain sensation in the thalamus
But they do not alter the emotional reaction to pain2. Anti-pyretic effect
Salycylates do not lower normal body temperature
Only the elevated temperature is lowered
Mechanism
A. The hypothalamic heat regulating center ( thermostat of the body) is set for a higher temperature in fever This is reset for a lower temperature by salicylates
B. The salicylates produce sweating which also lowers body temperature
3. Anti- inflammatory action
Asprin exert the anti-inflammatory action at high doses 3- 6 grams /day
Signs of inflammation like pain, tenderness, swelling , vasodilatation and leukocyte infiltration are suppressed
Asprin inhibits cyclo-oxygenase activity, it diminishes the formation of prostaglandins and modulates those aspects of inflammation in which prostaglandins act as mediators
Asprin inhibits inflammation in arthritis
4. On respiration
Salycylates stimulate respiration
The stimulation is depend on the dose
Salicylates stimulates respiration directly by stimulating the respiratory centre
Stimulate the respiration indirectly by through CO2
At anti –inflammatory respiration is stimulated by peripheral( increased CO2 production)and central ( increased sensitivity of respiratory centre to CO2 ) actions
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Hyperventilation is prominent in salicylate poisoning
Further rise in salicylate level causes respiratory depression
Death is due to respiratory failure
5. Cardiovascular system
No effect at normal dose
Large doses increase cardiac output to meet increased peripheral O2 demand and cause direct vasodilatation
Toxic doses produce paralysis of vasomotor centre and BP may fall
6. GI TractSalicylates produce nausea and vomiting due toDirect stimulationStimulation of chemoreceptor trigger zone Salicylates can also cause gastric ulceration and hemorrhage
7. Anti- rheumatic effect
Salicylates have powerful anti-rheumatic effect
T his effect is produced by reducing pain and inflammation of the joints
8. Blood
Salicylates lower the erythrocyte sedimentation rate (ESR) which is high in rheumatic fever
They also decrease prothrombin level of plasma
Uricosuric effect
Slicylates promote the excretion of uric acid
This effect is produced by inhibiting the reabsorption of uric acid in the proximal tubule
Immunological effect
Salicylates inhibit antigen- antibody reaction and so prevent the release of histamine
9. Metabolic effects
Salicylates produce uncoupling of oxidative phosphorylation
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They produce hyperglycemia and glycosuria
They inhibit the synthesis but enhance the breakdown of fatty acids
10. Hormones
Salycylates stimulate the release of adrenaline from adrenal medulla
They also stimulate the release of adreno-corticotrophic hormone (ACTH)
They interfere with the binding of thyroxin with plasma proteins
This free thyroxin depresses the secretion of thyroid stimulating hormone (TSH)
11. Local actions
Salicylates , especially salicylic acid and methyl salicylate have antiseptic, fungi staticand keratolytic effects
ADME
Salicylates are absorbed from the stomach and small intestine
They are bound to plasma proteins
They are mainly concentrated in the liver, heart, muscle, and brain
They are metabolized in liver by conjugation with glycine and glucuronic acid
The metabolic products are mainly excreted through urine
Adverse reactions
Gi tracts disturbances like nausea, vomiting , diarrhea , ulceration perforation and hemorrhage
Intolerance leading to skin rashes of various types
Bone marrow depression leading to agranulocytosis , thrombocytopenia and a plastic anemia
Fatty infiltration of liver and kidney
Salicylism characterized by headache, difficulty in hearing, drowsiness, lethargy and confusion
Sodium salicylate as mixture - 0.6 g - 2 gram oral
Methyl salicylate - Ointment
Salicylic acid - Ointment
UsesIt is used as analgesic for light and moderate pain
Used as anti-pyretic in fever
It is used as anti-rheumaticIt also used as antiseptic , anti-fungal and keratolytic
Pracetamol
It is a Para-amino phenol derivative
It has analgesic and antipyretic effects like salicylates
Parcetamol , a metabolite of phenacetin is found to be safer and effective
It has analgesic , good antipyretic and weak anti- inflammatory properties
Due to weak PG inhibitory activity in the periphery, it has poor anti-inflammatory actions
Paracetamol is active on cyclo-oxygenase in the brain which accounts for its antipyretic action
In presence of peroxides present at the site of inflammation , it has poor ability too inhibit cyclo-oxygenase
It does not stimulate respiration
It has no action on acid- base balance , cellular metabolism , cardiovascular system and platelet function
It does not produce gastrointestinal irritation and uricosuric effect
Mechanism of action
Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation
It produces antipyresis by inhibiting the hypothalamic heat- regulating centre
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Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS
ADME
It well absorbed orally
30% protein binding
It is metabolized by the hepatic microtonal enzymes by glucuronide conjugation (60% )And glutathione conjugation (20% )
Treatment
Stomach wash is given
Activated charcoal prevents further absorption
Antidote is N-acetylcysteine more effective when given early
(150 mg/kg IV infusion over 15 min followed by 70 mg/kg every 4 hours -17 doses)
N- cetylcysteine partly replenishes the glutathione stores of the liver and prevents binding of toxic metabolites to the cellular constituents
Adverse effects
In antipyretic doses , paracetamol is safe and well – tolerated
Nausea and rashes may occur
But when large doses are taken, acute paracetamol poisoning results
Children are more susceptible due to their ability to conjugate by glucuronidation to poor
10 – 15 grams in adults cause serious toxicity
Symptoms
Nausea
Vomiting
anorexia
Abdominal pain
Parecetamol is hepatotoxic and causes severe hepatic damage
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Hepatic lesions are reversible when promptly treated
UsesParacetamol is used as an analgesic in painful conditions like toothache, headache and myalgiaAs an antipyretic
Chronic pulpitis, periodontal abscess, post- extraction – parcetamol is used with IbuprofenIbuprofen
It is propionic acid derivatives
It is a better tolerated than aspirin
It exhibits anti- inflammatory, analgesic and antipyretic activities
Analgesic, antipyretic and anti-inflammatory efficacy is slightly lower than aspirinIt is 99% bound to plasma proteins
Its analgesic activity is independent of anti- inflammatory activity and has both central and peripheral effect
Temperature is reduced in febrile patients
It is a potent inhibitor of the enzyme cycloxygenase resulting in t he blockage of prostaglandin synthesis
It also prevents formation of thromboxane A2 by platelet aggregation
Adverse effects
Nausea
Vomiting
Gastric discomfort
CNS effects
Hypersensitivity reactions
Dose 400- 800 mg TDS
Uses
1. It has analgesic and antipyretic activity
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2. It is used in the treatment of gout
3. Surgical removal of impacted tooth – a combination of ibuprofen with a skeletal muscle relaxant like chlorzoxaxone is recommended
4. Chronic pulpits, periodontal abscess, gingival abscess – a combination of ibuprofen with paracetamol is preferred
Indomethacin
It has anti-inflammatory, analgesic, antipyretic and antigout actions
It is a portent inhibitor of cycloxygenase thus reducing prostaglandin synthesis
It relieves pain and reduces temperature in febrile patients reduces pain and joint swelling in rheumatoid arthritis but does not modify progress
It is well absorbed, 90% bound to plasma proteins & half life is 4 – 6 hours
Dose
25 -30 mg BD-TDS
Adverse effects
Adverse effects are high .
Gastrointestinal irritation with nausea, GI bleeding , vomiting , diarrhea and peptic ulcers can occur
CNS effects include headache, dizziness, ataxia, confusion, hallucinations, depression and psychosis
Hypersensitivity reactions like skin rashes, leucopenia and asthma in aspirin sensitive individuals
Drug interactions
Indomethacin blunts the diuretic action of furosemide and the anti-hypertensive action of thiazides, furosemide, beta blockers and ACE inhibitors by causing salt and water retention
Uses
Rheumatoid arthritis
Gout
Ankylosing sodalities
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For closure of patent ductus arteriosus
Nimesulide
It is a sulfonamide compound is a weak inhibitor of prostaglandin synthesis with a higher affinity for COX-2 then COX-1
The action of nimesulide is somewhat different form that of classic NSAD
It inhibits leukocyte function, prevents the release of mediators and in addition has antihistaminic and ant allergic properties
It has analgesic, antipyretic and anti-inflammatory actions like other ASAID
May also inhibit release of tumor necrosis factor alpha and thus reduce the formation of cytokines
Relief of mild to moderate pain and fever, inflammatory
It is well absorbed orally, extensively bound to plasma proteins and has a half life is 3 hours
It is excreted by kidney
Dose 50 -100 mg BD
Adverse reactionNausea
Diarrhea,
Vomiting
Rash
Dizziness
Somnolence
Headache
Long term use can cause hepatotoxicity
UsesIt is used as an analgesic, antipyretic and anti- inflammatory agent for short periods as in headache, toothache, myalgia, dysmenorrheal, sinusitis, post-operative pain and arthritis
It is beneficial in patients who develop bronchospasm with other NSAID
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Phenyl- butazone
It has good anti- inflammatory activity, is more potent but has poorer analgesic and antipyretic effects
I is an urocosuric agent
It causes retention of Na and water. Thus after 1-2 weeks of use edema results It can also precipitate CHF
PharmacokineticsIt is completely absorbed from orally
IM injection is not recommended because its absorption is slow as it binds to local tissue proteins and also causes local tissue damage
It is 98% bound to plasma proteins . Half life is 60 hrs
Dose100 – 200 mg , BD
Small doses may be given 3-4 times a day to avoid gastric irritation
Adverse effects
Phenyl butazone is more toxic than aspirin and is poorly tolerated – dyspepsia, epigastric distress nausea and vomiting . Peptic ulceration and diarrhea may occur
Hypersensitivity reactions like rashes, serum sickness stomatitis hepatitis, nephritis, dermatitis and jaundice can occur
It may inhibit iodine uptake by thyroid resulting in hypothyroidism and goiter on lojg term use
CNS effects like insomnia vertigo, optic neuritis, blurring of vision and convulsions may be encountered
UsesRheumatoid arthritis
Ankylosing sodalities
Osteoarthritis
Gout Other musculoskeletal disorders
Oxyphenbutazone
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It is a major metabolite of phenylbutazone, similar in pharmacodynamic, pharmacokinetic, toxic and drug interaction profile
Dose
100 – 200 mg BD
Diclofenac sodium
Diclofenac is an analgesic, antipyretic and anti-inflammatory agent
It is tissue penetrability is good and attains good concentration n synovial fluid which is maintained for a long time
Mechanism if action
Inhibition of the enzyme cycloxygenase in prostaglandin synthesis
Prostaglandins are known to be associated with inflammation
Diclofenac is available as the sodium or potassium salt
The potassium salts are absorbed rapidly and action sets in much earlier
Adverse effects are mild
Dose
50 mg BD- TDS
Gel is available for topical application
Ophthalmic preparation is available for use in postoperative pain
UsesTreatment of chromic inflammatory conditions like rheumatoid arthritis and osteoarthritis
Acute musculo-skeletal pain
Post- operatively for relief of pain and inflammation
Severely painful conditions live acute pulpits and acute periapical abscess
Mephenamic acidAn analgesic, antipyretic and anti-inflammatory drug which inhibits COX as will as antagonists certain actions of PGS
Mephenamic acid exerts peripheral as will as central analgesic action
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PharmacokineticsOral absorption is slow but almost complete
It is highly bound to plasma proteins- displacement interactions can occur
Plasma half life is 2 – 4 hrs
Adverse effectsDiarrhea is the most important dose related side effect
Epigastria distress is complained, but bleeding is not significant
Skin rashes, dizziness and other CNS manifestations have occurred
Hemolytic anemia is rare but serious complication
Dose 250 – 500 mg TDS
UsesMephenamic acid is indicated primarily as analgesic in muscle, joint and soft tissue pain where strong anti-inflammatory action is not needed
It may be useful in some cases of rheumatoid and osteoarthritis but has mo distinct advantage
Opioid analgesics
AnalgesicsThese are drugs which relieve pain without causing loss of consciousness
Opioid analgesicsThese are the natural accruing, semi-synthetic and synthetic drugs which have morphine like action i.e. relief of pain and depression of CNS
1. According to ring structure
A . Phenanthrene derivatives
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MorphineCodeineThebaine
B . Benzo-isoquinoline derivatives
PapaverineNoscapine
11. According to synthesis
A. Natural opium alkaloids
MorphineCodeine
B. Semi synthetic opium alkaloids
HeroinePholcodeine
C. Synthetic opiods
PethidineMethadineTramadol
Morphine
Morphine is a natural opium alkaloid
It is a dried extract obtained from the capsules of the poppy plant known as papaver somniferum
Mechanism of action
Opioids exert their major effects by interacting with opioid receptors in the CNS
Opioids causes hyper polarization of nerve eells , inhibition of nerve firing and presynaptic inhibition of transmitter release
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Morphine acts at kappa receptors in lamina 1 and 11 of the substantia gelatinosa of the spinal cord and decreases the release of substance p, which is modulates pain perception in the spinal cord
Pharmacological actions
1. Analgesia
Morphine causes analgesiaMorphine relieves severe pain like visceral pain and pain of trauma
Mechanisms
Opioids relieve pain both by raising the pain threshold at the spinal cord level and more importantly by altering the brains perception of pain
It alters the emotional reaction to pain
It produces sleep which also elevates the threshold
2.CNS
Morphine produces euphoria in presence of pain
But in the absence of pain , it produces dysphoria
With an increased dose, it produces sleep
3. RespirationAt normal doses morphine causes respiratory depression by reduction of the sensitivity of respiratory center neurons to CO2
At higher doses it produces respiratory ceases
Respiratory depression is the most common cause of death in acute overdose
4. Anti-tussive property
Morphine has anti-tussive property
Morphine suppress cough by depressing the cough center
5. Emesis
In small doses, morphine directly stimulates the chemoreceptor trigger zone in the area postrema that causes vomiting
Tolerance develops to vomiting on prolonged use
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But a large dose of morphine inhibits vomiting
6. Pupil
The pinpoint pupil, characteristic of morphine use, results from stimulation of u and k receptors
It produces spasm of intestinal smooth muscles and sphincters
It also increases absorption of water
So the feces get dried
All these effects lead t o constipation
8. Billary tract
Morphine increase billiary tract pressure due to contraction of the gallbladder and
constrictor of the biliary sphincter
This produces increase in intrabiliary pressure
Atropine antagonizes t his effect
9. Cardiovascular system
Normal dose of morphine produces no effect on heart rate , blood pressure or circulation
But hypo tension and bradycardia may be produced at toxic dose
Because of respiratory depression and carbon dioxide retention, cerebral vessels dilate and increase the cerebrospinal fluid pressure
Morphine is usually contraindicated in individuals with severe brain injury
10. Histamine release
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Morphine releases histamine from mast cells, causing urticaria, seating and vasodilatation
Morphine can cause the bronco-constriction , asthmatics should not receive the drug
11. Hormonal actions
Morphine inhibits release of GRH and corticotrophic releasing hormone and it decreases the concentration of luteinizing hormone, FSH, ACTH
It increases prolactin and growth h hormone release by diminishing dopaminergicinhibit ion
It increases antidiuretic hormone and leads to urinary retention ADME
Absorption of morphine from GI T is slow and incompleteQuick effect is produced on subcutaneous injectionIt is partly bound to plasma proteins It is metabolized by conjugation with glucuronic acidIt is almost completely excreted in urine within 24 hours
Dose
Morphine sulphate orMorphine hydrochloride
Adverse reactions
GIT Symptoms – Nausea, vomiting and constipation
Acute morphine poisoning characterized by respiratory depression, pin point pupil cyanosis, reduced body temperature, hypotension , shock and coma
Tolerance and drug dependence
Central effects like dysphoria and mental clouding
Intolerance like tremor, delirium and skin rashes
Depression of fetal respiration
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Drug interactions
The depressant actions of morphine are enhanced by phenothiazines, monoamine oxidase inhibitors and tricycle antidepressants
Tolerance and dependence
Repeated use produces tolerance to the respiratory depressant, analgesic, euphoric ,and sedative effects of morphine
Physical and psychological dependence readily occur with morphine
Withdrawal produce a series of autonomic , motor and psychological responses that incapacitate the individual and cause serious - unbearable symptoms
Uses
It is an analgesic for the relief of severe pain
Used as pre-anesthetic medication
For producing sleep and sedation
Used as anti-tussive
For the treatment of diarrhea
In the treatment of acute left ventricular failure
Codeine
It is a phenanthrene alkaloid of opium
It is methyl- morphine
Naturally , it appears in opium and is partly converted in the body to morphine
It is less potent than morphine and also less efficacious
It is more selective cough suppressant
Sub-analgesic doses (10 – 30 mg ) suppress cough
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It has a predominant anti-tussive effect
It is a less potent analgesic when compared to morphine
Codeine has very low affinity y for opioid receptors
The other action like spasmogenic effect, nausea and vomiting , miosis and addiction are less with codeine
It rarely produces dependence
Codeine produces less euphoria then morphine
Codeine is often used in combination with aspirin or acetaminophen
In most non – prescription cough preparations , codeine has been replaced by drugs such as dextro- methorphan - a synthetic cough depressant that has mo analgesic action and a low potential for abuse
Codeine has good activity by oral route
Single oral dose acts for 4 – 6 hours
Constipation is a prominent side effect when it is used as analgesic
It has been used to control diarrheas
The abuse liability of codeine is low
Though codeine phosphate is water soluble and can be injected
Parental preparation is not available in India and most other countries
Heroin
It is a diamorphine, or diacetylmorphine
It does not occur naturally
It is produced by di-acetylation of morphine
It is a semi-synthetic derivative of morphine
It is a about 3 times more potent than morphine
It is more lipid soluble
160
Due to its greater lipid solubility allows it to cross the blood- brain barrier more rapidly than morphine
Heroin is converted to morphine in the body
It enters brain more rapidly but duration of action is similar
It is considered to be more euphorient (specially on iv injection) and highly addicting
The sedative, emetic and hypertensive actions are said to be less prominent
It has mo outstanding therapeutic advantage over morphine and has been banned in most countries except U.K
Pethidine
It is a synthetic compound
It is a opioid structurally unrelated to morphine
It is used for acute pain
Mechanism of action
Pethidine binds to opioid receptors, particularly U receptors
It also binds well to k receptors
Pharmacological actions
Respiratory depression
Sedation and euphoria
Analgesic effect
Spasmogenic effect on smooth muscles and sphincters
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It dilates cerebral vessels, increases CSF pressure and contracts smooth muscle
It does not cause pinpoint pupil but rather causes the pupils to dilate because of an atropine like action
It has mo significant cardiovascular action when given orally
On IV administration , it produces a decrease in peripheral resistance and an increase in peripheral blood flow and it may cause an increase in cardiac rate
It does not produces the anti- tussive effects
Pharmacokinetics
It is well absorbed from the GIT when given orally and parental administration
It most often administered IM
It crosses the placental barrier. It also secreted in the milk
T he drug has a duration of action of two to four hours which shorter than that of morphine
It is converted normeperidin the liver and is excreted in the urine DOSE
Pethidine hydrochloride tablets – 25 –100 mg
Pethidine hydrochloride injection – 25 – 100 mg by subcutaneous or intramuscular injection and 25 to 50 mg by iv injection
Adverse reactions
Euphoria, dysphoria, weakness and palpitation
Depression o fetal respiration
Dry mouth, nausea and vomiting
Local irritation on parenteral administration
Respiratory depression, coma and convulsions
Addiction and tolerance
Uses
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It provides analgesia for any type of severe apin
For producing sedation and sleep
As pre-anesthetic medication
Methadone
it is a synthetic, orally effective opioid it has equal potency to morphine
it produce less euphoria and has a somewhat longer duration of action
It has somewhat longer duration of action than morphine
Mechanism of action
The actions of methadone are mediated by the u receptors
Pharmacological actions
It is chemically dis-similar but pharmacologically very similar to morphine
It has analgesic , respiratory depressant , emetic , anti-tussive , constipating and biliary actions similar to morphine
Pharmaco-kinetic actions
It is readily absorbed following oral administration
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It accumulates in tissues, where it remains bound to proteins, from which it is slowly released
The drug is biotransformed in the liver and excreted in the urine
Adverse effects
It can produce physical dependence like that of morphine
Uses
It has been used primarily as substitution therapy opioid dependence
It can also be used as an analgesic for the same conditions as morphine
It is occasionally employed as anti-tussive
Tramadol
It is a centrally acting analgesic that binds to the u – opioid receptor
It weakly inhibits re-uptake of nor-epinephrine and serotonin
It is used to manage moderate to moderately severe pain
Its respiratory-depressant activity is less than that of morphine
Its analgesic action is only partially reversed by opioid antagonist known as naloxone
Tramadol causes less respiratory depression, sedation, constipation, urinary retentionand rise in intrabiliary pressure than morphine
It is well tolerated
Pharmaco-kinetics
Oral bioavailability is good
The half life is 3-5 hrs and effects last 4-6 hrs
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Adverse effects
Dizziness
Nausea
Sleepiness
Dry mouth
Sweating
Drug interaction
Tramadol should also be avoided in patients taking mono amine oxidase inhibitors
Dose
50 mg cap, 100 mg SR tab
50 mg/ml inj in 1 and 2 ml amps
Opioid antagonists
Pure opioid antagonists
1. Naloxone2. Naltrexone3. Nalmefene
1. Naloxone
It is N- alyl-nor- oxy- morphone and a competitive antagonist on all types of opioid receptors
It blocks u receptors at much lower doses than those needed to block k or delta receptors
Naloxone is a competitive antagonist at u, k and delta receptors with a ten- fold higher affinity for u receptors than for k
Naloxone produces no pharmacologic effects in normal individuals , but it precipitates withdrawal symptoms in opioid abusers
Naloxone is used to reverse the coma and respiratory depression of opioid overdose
It rapidly displaces all receptor- bound opioid molecules and is able to reverse the effect of a heroin overdose
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Within 30 sec of iv injection of naloxone, the respiratory depression and come characteristic of high doses of heroin are reversed, causing the patient to be revived and alert
Naloxone has a half-life o f60 – 100 minutes
No physical or psychological dependence has been observed
Injected intravenously (0.4 – 0.8 mg ) , it promptly antagonizes all actions of morphine
It is inactive orally because of high first pass metabolism in liver
Injected iv , it acts in 2 – 3 min
The primary pathway of metabolism is glucuronidation
Plasma half life is 1 hour in adults and 3 hours in new borns
USES
Naloxine is the drug of choice for morphine poisoning ( 0.4 mg iv every 2 -3 min, maximum 10 mg)
It also partially reverses alcohol intoxication
2. Naltrexone
It is chemically related to naloxone and is anther pure opioid antagonist
It is more potent than naloxone
It has actions similar to those of naloxone
Naltrexone differs from naloxone in being orally active and having a long duration of action (1 – 2 days)
It has a longer duration of action than naloxone and a single oral dose of naltrexone blocks the effect of injected heroin for up to 48 hours
Alcohol craving is also reduced by naltrexone , it is being used to prevent relapse of heavy drinking
Naltrexone in combination with clonidine and sometimes with bruprenorphine is employed for rapid opioid detoxification
It may also be beneficial in treating chronic alcoholism by an unknown mechanism , but benzodiazepines and clonidine are preferred
Naltrexone is hepatotoxic
166
Dose
50 mg tab
Side effects
Nausea
Headache
Higher doses can causes hepatotoxicity
3. Nalmefene
This is recently developed pure opioid antagonist lacks
No hepatotoxicity
It has higher oral bioavailability and long duration of action
CNS Stimulants
These are brain stimulants which markedly stimulate the respiration and circulation These in large doses acts as convulsants’The;y are useful in the following conditions
1. Chronic hypoventilation with CO2 retention2. Respiratory failure in newborns3. Respiratory failure due to overdose of CNS depressants4. Post anesthetic respiratory depression
1. Direct CNS stimulants
A. Cortical stimulants 1. Xanthene alkaloids Caffeine Theophylline Theo-bromine Aminophylline
2. Sympathomimetics
167
Amphetamine Methyl phenidate
B. Medularly stimulants
PicrotoxinPentylene-tetrazolNikethamideDoxapram
C. Spinal stimulants
Strychnine
11. Reflex CNS Stimulants
LobelineNicotineVeratrineAmmonia
Xanthene alkaloids
Methyl xanthenes includes theophyline found in tea and Theo bromine found in cocoa
Caffeine , the most widely consumed stimulant in the world, is found in highest concentration in coffee, but is also present in tea, cola drinks , chocolate candy and cocoa
Mechanism of action
Several mechanisms have been proposed for the actions of methylxanthine
All Xanthene alkaloids inhibit phosphodiesterase and blockade of adenosine receptors
Due to above mechanism there is increase in translocation of extra cellular calcium
Increase in cyclic adenosine monophosphare
Increase in cyclic guanosine monophosphate
Which causes various pharmacological actions including increase in force of contraction of heart and relaxation of vascular and non vascular smooth muscles
Pharmacological actions
168
On CNS
The caffeine contained in one to two cups of coffee (100 – 200mg) causes a decrease fatigue and increased mental alertness as a result of stimulating t he cortex and other areas of the brain
Consumption of 1.5 grams of caffeine ( 12 – 15 cups of coffee ) produces anxiety and tremors
The spinal cord is stimulated only by very high doses (2 -5 g) of caffeine
It also produces stimulation or respiratory , vasomotor and vagal centers
Tolerance can rapidly develop to the stimulating properties of caffeine
Withdrawal consists of feelings of fatigue and sedation
On CVS
A high dose of caffeine has positive inotropic and chronotropic effects on the heart
Increased contractivity can be harmful to patients with angina pectoris
Xanthenes produce a direct stimulant effect on the myocardium, also they produces dilatation of coronary and pulmonary blood vessels due to the stimulation of vagal nerve
On bronchioles
Caffeine and its derivatives relax the smooth muscles of the bronchioles Decrease in fatigue of smooth muscles
Diuretic action
Caffeine has a mild diuretic action that increases urinary output of sodium, chloride and potassium
GIT
Methylxanthines stimulates secretion of hydrochloric acid from the gastric mucosaIndividuals with peptic ulcers should avoid beverages containing methylxanthines
Pharmacokinetics
The methylxanthines are well absorbed orally
Caffeine distributes throughout the body , including the brain
The drugs cross the placenta to the fetus and are secreted into the mothers milk
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All the methylxanthines are metabolized in the liver and the metabolites are then excreted in the urine
Adverse effects
Moderate doses of caffeine cause insomnia , anxiety and agitation
High dosage is produced emesis and convulsions
The lethal dose is about 10 grams of caffeine about 100 cups of coffee which induce cardiac arrhythmias
Lethargy, irritability and headache occur in users who have routinely consumed more than 600 mg of caffeine per day roughly six cups of coffee per day and then suddenly stop
Therapeutic uses
Caffeine and its derivatives relax the smooth muscles of the bronchioles
Antidepressants
Coronary vasodilators
Diuretics
Nicotine
It is the active ingredient in tobacco
The drug is not currently used therapeutically except in smoking
It is mostly widely used CNS stimulant
Nicotine represents a serious risk factor for lung and cardiovascular disease and various cancers
Dependency on the drug is not easily overcome
Mechanism of action
In low doses, nicotine causes gang ionic stimulation by depolarization
At high doses, nicotine causes gang ionic blockade
Nicotine receptors exist in the CNS, where similar actions occurs
Pharmacological actions
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On CNS
Nicotine is highly soluble in lipid and readily crosses the blood-brain barrier
Cigarette smoking or administration of doses of nicotine produces some degree of euphoria and arousal as well as relaxation
It improves attention, learning , problem solving and reaction time
High doses of nicotine result in central respiratory paralysis and severe hypotension caused by modularly paralysis
Peripheral effects
The peripheral effects of nicotine are complex
Stimulation of sympathetic ganglia as well as the adrenal medulla increases blood pressure and heart rate
The use of tobacco is particularly harmful in hypertensive patients
Stimulation of parasympathetic ganglia also increases motor activity of the bowel
At higher doses , blood pressure falls and activity ceases in both the GIT and bladder musculature
Pharmacokinetics
Nicotine is highly lipid-soluble
Absorption readily occurs via the oral mucosa, lungs, gastrointestinal mucosa and skin
Nicotine crosses the placental membrane and is secreted in the milk if lactating women
Most cigarettes contain 6-8 mg of nicotine
The acute lethal dose is 60 mg
More than 90% of nicotine inhaled in smoke is absorbed
Clearance if nicotine involves metabolism in the lung and the liver and urinary excretion
Tolerance to the toxic effects of nicotine develops rapidly
Adverse effects
The CNS effects of nicotine include irritability and tremors
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Nicotine may also cause intestinal cramps, diarrhea and increased heart rate and blood pressure
Cigarette smoking increases the rate of metabolism for a number of drugs
Withdrawal syndrome
Nicotine is an addictive substance and physical dependence on nicotine develops rapidly and is severe
Withdrawal is characterized by irritability, anxiety, restlessness, difficulty concentrating , headaches and insomnia
Appetite is affected and gastrointestinal pain often occurs
Cocaine
Cocaine is an inexpensive , widely available and highly addictive drug that is currently abused daily by more than three million people in the USA
It is an alkaloid obtained from the leaves of coca plant
It is insoluble in water but its salts are soluble in water
It is poorly absorbed in the intestines but well absorbed by the mucous membrane and it can be given as surface anesthetic
Mechanism of action
The primary mechanism of action of cocaine is blockade of re-uptake of the monoamines ( nor epinephrine, serotonin and dopamine) into t he presymaptic terminals from which these neurotransmitters are released
Pharmacological actions
On CNSCNS stimulant
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Cocaine acutely increases mental awareness and produces a feeling of well being and euphoria similar to that caused by amphetamine
Cocaine can produces hallucinations and delusions
Cocaine increases motor activity and at high doses m it causes tremors and convulsions, followed by respiratory and vasomotor depression
Sympathetic nervous system
Peripherally, cocaine potentates the action of nor-adrenaline and produces the fight or flight syndrome characteristic of adrenergic stimulation
This is associated with tachycardia, hypertension, papillary dilation and peripheral vasoconstriction
Local anesthetic action
Dilates pupil
Raise the body temperature
Rise the BP
Produces euphoria
Pharmacokinetics
Cocaine is often self-administered by chewing intra-nasal snorting, smoking or intravenous injection
The peak effect occurs at fifteen to twenty minutes after intra-nasal intake of cocaine powder
Rapid but short-lived effects are achieved following iv injection of cocaine
Toxic effects
Mental excitement
Confusion
Tremors
Convulsions
Respiratory paralysis
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Stimulation followed by depression
Cocaine can induce seizures as well as fatal cardiac arrhythmias
IV administration of diazepam and propranolol may be required to control cocaine – induced seizures and cardiac arrhythmias
Dose
8 – 16 mg by injection
Adrenaline has to be given along with cocaine which produces local vasoconstriction and prolong the local anesthetic effect
Uses
Cocaine has a local anesthetic action
Cocaine is applied topically as a local anesthetic during eye, ear ,nose and throat surgery
The anesthetic action of cocaine is due to a block of voltage – activated sodium channels
An interaction with potassium channels may contribute to the ability of cocaine to cause cardiac arrhythmias
Drug Abuse
The use of drugs for non-therapeutic purposes and mainly the drugs acting on CNS is termed as misuse or drug abuse.
They may be misused for the production of dangerous and thrilling effects for escaping from physical discomforts like hunger, fatigue, pain or mental discomforts like boredom ,frustration and anxiety.
Generally the drugs which are abused are – ethanol, diazepam, morphine, heroin, pethidine, methadone, methaqualon, LSD-25 , cannabis and mescaline.
Control of drug dependence and abuse
First it should be identified whether the dependence on a particular drug is addiction or abuse or socially acceptable.
The methods of controlling drug abuse are
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Limitation of availability of specified drugs for the addicted persons. Reduction of interest in and demand for such drugs for non-medical use.
Public must be given drug education on the harmful physical and mental effects of drug dependence and abuse
Legal prohibition of possession and transportation in these drugs which may be abused for non-medical purposes