HYPERTHYROIDISM

 Carbimazol cause agranulocytosis and sometimes alopecia

 Propylthiouracil (not MMI) inhibit the peripheral conversion of T4 o T3
 PTU dose is 300-600mg/day and MMI 30-60mg/day in 3-4 divided dose
 Maintenance dose if PTU 50-300mg and MMI is 5-30mg.Continue the therapy
for 12-24 months to induce REMISSION and patient should be monitored
6-12months after remission.ADR are Agranulocytosis,Aplastic anemia
,LES,Hepatotoxicity ,Hypoprothrombinemia and GI Intolerance and
Polymyosistis
 Iodide blocks thyroid hormone release
 Lugol’s solution(KI) CONTAIN 6.3MG PER DROP and typical daily dose
is 3-10 drops in water n juice
 Propranolol an d nadolol inhibits T4 to T3 AND Propranolol dose is 20-40
Q6hrs with max 240-480mg.B-blocker CI in MAOI , TCA , Sinus brady
arrhythmia
 If B-Blocker are CI then we use Clonidine and
Diltiazem
 Photosesitivity by Ciprofloxacin , Phenothiazines
,Diuretics,Sulfonamides,Sulfonylureas,Antihistamines and TCA
 Nifedipine used in angina , HTN and preeclampcia But not in
arrhythmia
 Pat wid superficial wound first question if u took any Tentnus vaccine in last
10 years
 Bacterial vaginosis in pregnant womwn is metronidazole
 Estrogen doesnot cause atrophy rather cause endometrosis , used in post
menopausal osteoprosis
 Hypothalamus release is Gonedorelin(GnrH)

 ACTH=Corticotropin are synonyms

 Growth Hormon=somatotropin

 Haemophilus inf best ABx is Cefuroxime ( if meningitis we use Cefotaxime ,

ceftriaxone , meropenem)( other infections Cefuroxime . azithro,clarithro ,
flouroquinolones)

 Piroxicame given OD
 Safely given with MAO inhibitor cromolyn not pseudoephdrine
 Nasal sprays given once daily is fluticasine

 More potent steroidal drops are dexamethasone???

 Avoid indomethacin with morphine
 Acute gout indomethasone ,or NSAIDs
 Most closely related to aspirin diflusinil and cilazopirin
 Brufen cause leaset GI effects among NSAIDs

 Must be avoided with Mtx is aspirin except in RA

 Gentamycin should be avoided in pat with severly renal compromised along
witd pip
 Nappy rash we use hydrocortisone as a least treatment option only zinc
oxide, titanium dioxide, petrolatum are effective
 That can raise plasma level of potassium by ACEI is Piroxicme
 Must be avoided with lithium is NSAIDs and Diuretics as hyponatremia
increase toxicity of Li
 Oseltimavir is neuroaminidase inhibitor
 Controlled medicines are kept in double lock
 Penicillin cross inflamed menungis
 Theopyline level is monitored with clarithromycin
 Loperamide is OTC not diphenoxilate
 Hydroxyurea cause sickle cell anemia
 NSAIDs CI with ACEI , b-antagonist AND DIURETICS
 Ramipril max dose is 20mg as in HTN and target dose in CHF is 10mg
 Prophylaxis of malaria is CHLORQUIN
 DRY MOUTH CAUSED BY HYSOSINE
 Tinea infection we use itra , fluconazole and terbinafin?????
 Folic acid dose in pregnancy is 4mg or 400mcg
 Mtx used in breast cancer and psoriasis n IBD BUT not in IBS
 Contraindicated in Unstable angina is Losartan
 IV to oral dose should be increased by whose First past effect is greater
 Nitroglyerine cause tachycardia covered by propanolol
 Category 4 antiarrhythmic is verapamil
 Omega 3 in risky patient is 3gm
 Iv anticoagulant like heparin activate antithrombin2
 Bioavailabilty of propranolol is increased 5o% by protein rich food
 Not used in parkinsonism is tofranil
 Penecillamine used in arsenic poisoning , cystinuria , wilson’s
disease and lead poisoning and RA
 Aspirin CI in gouty arthritis less than 2g dose
 Alprazolam is short acting benzodiazipine
 Procyclidine is CDb
  Aspirin avoid with Lithium
 Dopamine is vasodilator
 Neostigmine used in Myasthenia gravis and before atropine in other conditions
 Ergotamine 2mg at onset then 1-2mg every 30mint and total of
6mg/day(6tab /day) or 10mg/week(10tab)and use antiemetic before it
 Drug discontinued in fixed combination because of 1.this will give less
amount of drug 2.response from person to person vary 3. this will correct
diagnosis n dosing
 Diacetylmorphine is more addicting than morphine
 Lmotil contain diphenoxylate and atropine
 VCZ lies in Nervous system
 All are effective in decreasing viral shading and post herpetic neuralgia
Valciclovir Acyclovir and famcilovir
 Breast cancer risk not included is early menopause while genetic factoe n
first kid at old age and late menopause early menorch are risk factors
 Betamethasone is most potent local steroid not prednisolone and
hydrocortisone
 Hypercalcemia we give saline 300ml/hr infusion of NaCl
 Risk factors forbreast cancer are old age (55yrs) family history , personel
history of breast cancer , radition to chest or face before 30years , obesity , if
no full term pregnancy and late age at first child birth , late menopause or
early minorch

 Pregnancy therapeutic consideration
1. For very high blood pressure in
pregnancy, drugs to avoid are magnesium sulfate (except for
eclampsia
prevention), high-dose diazoxide, nimodipine, and
chlorpromazine
2. Commonly used drugs include methyldopa,
labetalol, and
calcium channel blockers
3.DVT and PE we use LMWH and Heparin for 6 weeks

.Constipation

1.Constipation in pregnancy we use supportive like exercise ,

counselling , dietry fiber with or without stool softener like
Docusate sodium
2.Lactulose, sorbitol, bisacodyl , or
senna can be used occasionally.

• 3. Castor oil and mineral oil should be avoided

HEMORRHOIDS
1. Therapy includes lifestyle and dietary modifications such as
small, frequent meals; alcohol, tobacco, and caffeine
avoidance; food avoidance 3 hours

NAUSE AND VOMITING

1.antihistamines (e.g., doxylamine), vitamins (e.g.,

pyridoxine,cyanocobalamin), anticholinergics (e.g.,
dicyclomine, scopolamine), dopamine
antagonists (e.g., metoclopramide). Ondansetron can
be used when other agents have failed, and ginger is
considered safe and effective. Dexamethasone
or prednisolone have been effective for hyperemesis
gravidarum,but the risk of oral clefts is increased

UTI

1. Cephalexin is considered safe and effective.

2. Nitrofurantoin should not beused after week 37 due

to concern for hemolytic anemia in the
newborn.

3. Sulfa-containing drugs may increase risk for

kernicterus in the newborn and should be avoided during
the last weeks of gestation.
4.Folate antagonists, such as trimethoprim, are
relatively contraindicated during the first
trimester because of their association with cardiovascular
malformations.
5.Fluoroquinolones and tetracyclines are
contraindicated.

Neisseria gonorrhoeae
 1. in N.Gonorrhoea treatment of choice is ceftriaxone,
125 mg intramuscularly (IM) as asingle dose or cefixime,
400 mg orally in a single dose.
2. Spectinomycin 2 g IM as a single dose is appropriate
as a second choice

Genital Herpes

1. Acyclovir has been used safely, and most women will receive
oral acyclovir therapy for first episodes or for recurrence. IV
acyclovir can be used for severe infections.

2. For valacyclovir and famciclovir, safety data are morelimited

ASTHMA

1. All pregnant patients with asthma should have access

to a short-acting B-agonist (albuterol is the preferred
agent)

2.Low-dose inhaled corticosteroids are the treatment of

choice for women with mild persistent asthma.
Budesonide is preferred, but other inhaled
corticosteroids
that were used effectively prior to pregnancy can be
continued.
3.Allergic Rhinitis Intranasal corticosteroids are the
most effective treatment for allergic rhinitis during
pregnancy. Beclomethasone and budesonide have
been used most

TOPICALS

1.Topical agents with minimal pregnancy risk include

bacitracin, benzoyl peroxide, ciclopirox,
clindamycin, erythromycin, metronidazole,
mupirocin,
permethrin, and terbinafine.
PARENTERALS
1.Systemic agents that are considered safe in pregnancy
include acyclovir, amoxicillin, azithromycin,
cephalosporins, chlorpheniramine,
cyproheptadine,dicloxacillin, diphenhydramine,
erythromycin (except estolates),
nystatin, and penicillin

EPILEPSY
1. All women with epilepsy should take a folic acid
supplement,0.4 to 5 mg daily

DEPRESSION

1.depression in pregnent selective serotonin reuptake

inhibitors (SSRIs) are widely used by pregnant women.

TOCOLYTICS

1. Drugs most commonly used for acute tocolysis include

magnesium sulfate, -adrenergic
agonists(terbutaline are 250 to 500 mcg
subcutaneously every 3 to 4 hours), NSAIDs, and
calcium channel blockers

STPTOCOCCUS INFECTION

1.rhumetic fever and endocarditis by Group B

streptococcus currently recommended regimen for
group B Streptococcus disease is penicillin G, 5 million
units IV, followed by 2.5 million units IV every 4 hours until
delivery. Alternatives include ampicillin, 2 g IV, followed
by 1g IV every 4 hours; cefazolin 2 g IV, followed by 1 g
every 8 hours;
clindamycin, 900 mg IV every 8 hours; or erythromycin,
500 mg IV every 6 hours. In women who are penicillin-
allergic, and in whom sensitivitytesting shows the
organism to be resistant to clindamycin and erythromycin,
vancomycin 1 g IV every 12 hours until delivery can be
used.
CERVICAL RIPENING

1.Prostaglandin E2 analogs (e.g., dinoprostone [Prepidil

and Cervidil]) are the most commonly used
pharmacologic agents for cervical ripening. Fetal
heart rate monitoring is required when Cervidil is
used.Applied posterior forinex

LABOUR PAIN
1. The IV or IM administration of parenteral narcotics
(meperidine, morphine,fentanyl) is commonly used to
treat the pain associated with labor analgesia

MEDICINE EXCRETED IN BREAST MILK

1. Medications enter breast milk via passive diffusion of

nonionized and non–protein-bound medication. Drugs with
high molecular weights, lower lipid solubility ,
and higher protein binding are less likely to cross
into breast milk or transfer more slowly or in smaller
amounts and choosing medications with shorter
half-lives; selecting those that are more protein
bound, have lower bioavailability,
and have lower lipid solubility

RELACTATION

1. metoclopramide,10 mg three times daily for 7 to 14

days for RELACTATION

2. Women at high risk (e.g., those who take certain

seizure medications
or who have had a previously affected pregnancy) should
take 4 mg/day.
• Assessment and reduction in the use of alcohol, tobacco,
and other substances prior to pregnancy improve
outcomes. For smoking cessation, behavioral interventions
are preferred. Intermittent delivery formulations
of nicotine replacement therapies are preferred over
the patches. If patches are used, 16-hour patches
are preferred over 24-hour patches.

24. Oral cobalamin is initiated at 1 to 2 mg daily for 1 to

2 weeks, followed by 1 mg daily.
25. A popular regimen is cyanocobalamin 1,000 mcg daily
for 1 week, then weekly for 1 month, and then monthly
26. Oral folate 1 mg daily for 4 months is usually
sufficient for treatment of folate-deficiency anemia, unless
the etiology cannot be corrected. If malabsorption is
present, the daily dose should be increased to 5 mg.

GENERAL CONCIDERATION
 Iron sucrose is 20mg iron/ml and max dose is 1000Mg ADR are Hypotension
n leg crams
 Iron dose in infants is 3mg/kg and 6mg/kg for older than 4 weeks
In iron-deficiency anemia, iron therapy should cause
reticulocytosis in 5-7 days and Hb 2-4g/dl every 3weeks
Epoitin alpha is used in anemia

Patients with SCD should receive routine immunizations plus influenza,

meningococcal, and pneumococcal vaccinations.

Hydroxyurea causes SCD(Sickel cell disease) Hydration and analgesics are

the mainstays of treatment for vasoocclusive
(painful) crisis.Mepridine is avoided

Acne vulgaris is a common, usually self-limiting, multifactorial

disease involving
inflammation of the sebaceous follicles of the face and upper trunk.
The four primary factors involved in the formation of acne lesions
are
The four primary factors involved in the formation of acne lesions
are
increased sebum production, sloughing of keratinocytes, bacterial
growth,
and inflammationsloughing of keratinocytes, bacterial growth,
and inflammation

open comedo, or “blackhead” (because

of melanin accumulation)
Inflammation or trauma to the follicle may lead
to formation of a closed comedo, or “whitehead
Acne lesions typically occur on the face, back, upper chest, and
shoulders.

Lesions may take months to heal completely, and fibrosis associated

with
healing may lead to permanent scarring

The goals of treatment are to prevent the formation of new acne

lesions,
heal existing lesions, and prevent or minimize scarring.

Mild acne usually is managed with topical retinoids alone or with

topical
antimicrobials, salicylic acid, or azelaic acid

Moderate acne can be managed with topical retinoids in

combination
with oral antibiotics and, if indicated, benzoyl peroxide

Severe acne is often managed with oral isotretinoin.

Antibiotics such as tetracyclines and macrolides are the agents of

choice for
papulopustular acne.

Oral isotretinoin is the treatment of choice in severe papulopustular

acne
and nodulocystic/conglobate acne. Hormonal therapy may be an
effective
alternative in female patients.

Benzoyl peroxide may be used to treat superficial inflammatory

acne. It is a
nonantibiotic antibacterial that is bacteriostatic against P. acnes.

It is decomposed on the skin by cysteine, liberating free oxygen

radicals that oxidize proteins of bacteria.

The 10% concentration is not significantly more effective but

may be more irritating.

Gel formulations are usually most potent. whereas

lotions, creams, and soaps have weaker potency. Alcohol-based gel
preparations
generally cause more dryness and irritation.

To limit irritation and increase tolerability, begin with a low-potency

formulation (2.5%)
and increase either the strength (5% to 10%) or
application frequency (every other day, each day, then twice daily).

Patients should be advised to apply the formulation chosen to cool,

clean,
dry skin no more often than twice daily to minimize irritation.

Fair or moist skin is more sensitive; patients should apply the

medication to dry
skin at least 30 minutes after washing.

Side effects include dryness, irritation, and allergic contact

dermatitis. It
may bleach or discolor some fabrics (e.g., clothing, bed linen,
towels).

Tretinoin (a retinoid; topical vitamin A acid) is a comedolytic agent

that
increases cell turnover in the follicular wall and decreases
cohesiveness of
cells, leading to extrusion of comedones and inhibition of new
comedo
formation.

It also decreases the number of cell layers in the stratum

corneum from about 14 to about five.

Tretinoin is available as 0.05% solution (most irritating),

0.01% and 0.025% gels,

and 0.025%, 0.05%, and 0.1% creams (least irritating).

Treatment initiation with 0.025% cream is recommended for mild

acne in
people with sensitive and nonoily skin,

0.01% gel for moderate acne on

easily irritated skin in people with oily complexions,

and 0.025% gel formoderate acne in those with nonsensitive and

oily skin.

Side effects include skin irritation, erythema, peeling, allergic

contact dermatitis
(rare), and increased sensitivity to sun exposure, wind, cold, and
other irritants
A regimen of benzoyl peroxide each morning and tretinoin at
bedtime may enhanceefficacy and be less irritating than either
agent used alone.
Adapalene (Differin) is a third-generation retinoid with comedolytic,
keratolytic,
and antiinflammatory activity.(0.1%-0.3%)

Adapalene is indicated for mild to moderate acne vulgaris. The 0.1%

gel
can be used as an alternative to tretinoin 0.025% gel to achieve
better
tolerability in some patients.

Tazarotene (Tazorac) is a synthetic acetylenic retinoid that is

converted to
its active form, tazarotenic acid, after topical application.
It is used in the treatment of mild to moderate acne vulgaris and
has
comedolytic, keratolytic, and antiinflammatory action.
• The product is available as a 0.05% and 0.1% gel or cream.
• Dose-related adverse effects include erythema, pruritus, stinging,
and burning.

Erythromycin
• Erythromycin in concentrations of 1% to 4% with or without zinc
is
effective against inflammatory acne.

Zinc combination products may enhance penetration of

erythromycin into the pilosebaceous unit.

Topical erythromycin formulations include a gel, lotion, solution, and

disposable pads that are usually applied twice daily.

Development of P. acnes resistance to erythromycin may be

reduced by
combination therapy with benzoyl peroxide

Clindamycin
• Clindamycin inhibits P. acnes and provides comedolytic and
antiinflammatory
activity.
• It is available as 1% or 2% concentrations in gel, lotion, solution,
foam,
and disposable pad formulations and is usually applied twice daily.
Combination with benzoyl peroxide increases efficacy.

Azelaic acid (Azelex) has antibacterial, antiinflammatory, and

comedolytic
activity. Azelaic acid is useful for mild to moderate acne in patients
who do not
tolerate benzoyl peroxide.

It is available in 20% cream and 15% gel formulations, which are

usually
applied twice daily on clean, dry skin.
mild transient burning, pruritus, stinging, and
tingling may occur.

Salicylic acid, sulfur, and resorcinol are second-line topical

therapies. They are keratolytic and mildly antibacterial agents.
Salicylic acid has comedolytic and antiinflammatory action.
Keratolytics may be less irritating than benzoyl peroxide and
tretinoin, but
they are not as effective comedolytic agents.

Disadvantages odor created by hydrogen sulfide on reaction of

sulfur with skin, the brown scale from resorcinol, and (rarely)
salicylism.

Isotretinoin
• Isotretinoin (Accutane) decreases sebum production, changes
sebum composition,
inhibits P. acnes growth within follicles, inhibits inflammation, and
alters patterns of keratinization within follicles.
Dosing guidelines range from 0.5 to 1 mg/kg/day.
Optimal results are usually attained with cumulative doses of
120 to 150 mg/kg.
A 5-month course is sufficient for most patients. Alternatively, an
initial dose of
1 mg/kg/day for 3 months, then reduced to 0.5 mg/kg/day and, if
possible, to
0.2 mg/kg/day for 3 to 9 more months may optimize the therapeutic
outcome

Because of teratogenicity, contraception is required in female

patients
beginning 1 month before therapy, continuing throughout
treatment, and
for up to 3 months after discontinuation of therapy.

Oral Antibacterial Agents

Erythromycin
The usual dose is 1 g/day with
meals to minimize GI intolerance.
• Azithromycin is a safe and effective alternative for moderate to
severe
inflammatory acne. Its long half-life permits intermittent
dosing three
times a week.

Tetracyclines inhibit P. acnes, reduce the amount of keratin in

sebaceous
follicles, and have antiinflammatory properties (inhibiting
chemotaxis,
phagocytosis, complement activation, and cell-mediated immunity).

Drawbacks
to tetracyclines include hepatotoxicity and predisposition to
infections
(e.g., vaginal candidiasis)

Tetracyclines must not be combined with

systemic retinoids because of an increased risk of intracranial
hypertension.

Tetracycline is the least expensive agent in this class for moderate

to severe acne vulgaris.
initial dose is 500 mg twice daily given 1 hour before meals;

after 1 or 2 months when marked improvement is observed, the

dose
may be reduced to 500 mg daily for another 1 or 2 months.

Doxycycline is more effective and produces less resistance than

tetracycline.

Initial dose is 100 or 200 mg daily, followed by 50 mg daily as a

maintenance dose after improvement is seen.

Doxycycline may be given

with food, but it is more effective when taken 30 minutes before
meals.

Minocycline has the most reported adverse

effects of the tetracyclines, some of which may be serious.

Trimethoprim-sulfamethoxazole (or trimethoprim alone) is a

second-line
oral agents.

May be used for patients who do not tolerate tetracyclines and

erythromycin or in cases of resistance to these antibiotics.

The adult dose is usually 800 mg sulfamethoxazole and 160 mg

trimethoprim twice daily.
Clindamycin use is limited by diarrhea and the risk of
pseudomembranous
colitis.

Oral contraceptives containing both an estrogen and progestin are

used as
an alternate treatment for moderate acne in women.

Contraceptive agents currently FDA approved for this indication

include norgestimate with
ethinyl estradiol and norethindrone acetate with ethinyl
estradiol.

Patients should understand that effectiveness of any therapeutic

regimen
may require 6 to 8 weeks and that they may also notice an
exacerbation of
acne after initiation of topical comedolytic therapy.

Psoriasis is a common chronic inflammatory disease characterized

by recurrent
exacerbations and remissions of thickened, erythematous, and
scaling
plaques. There is a significant genetic component in psoriasis.
Climate, stress, alcohol, smoking, infection, trauma, and drugs may
aggravate psoriasis.

Warm seasons and sunlight improve psoriasis in 80%

of patients, whereas 90% of patients worsen in cold weather.

Lithium carbonate,
-adrenergic blockers, some antimalarials, nonsteroidal
antiinflammatory
drugs, and tetracyclines have been reported to exacerbate
psoriasis.

Psoriatic lesions are relatively asymptomatic, but about 25% of

patients
complain of pruritus.

Lesions are characterized by sharply demarcated, erythematous

papules
and plaques often covered with silver-white fine scales. Auspitz sign.

Emollients (moisturizers) hydrate the stratum corneum and

minimize
water evaporation. enhance desquamation, eliminate scaling,
and decrease pruritus.
The lotions, creams, or ointments often need to be
applied up to four times a day to achieve a beneficial response.

Balneotherapy (and climatotherapy) involves bathing in waters

containing
certain salts, often combined with natural sun exposure. The salts in
certain waters (e.g., the Dead Sea) reduce activated T cells in skin
and may
be remittive for psoriasis.

FIRST-LINE TOPICAL PHARMACOTHERAPY:

Keratolytics
• Salicylic acid is one of the most commonly used keratolytics.

Corticosteroids
• Topical corticosteroids (Table 16-1) may halt synthesis and
mitosis of
DNA in epidermal cells and appear to inhibit phospholipase A,
lowering
the amounts of arachidonic acid, prostaglandins, and leukotrienes in
the
skin. These effects, coupled with local vasoconstriction, reduce
erythema,
pruritus, and scaling.

Low-potency products (e.g., hydrocortisone 1%) have a weak

antiinflammatory
effect and are safest for long-term application.

for use on the face

and intertriginous areas, for use with occlusion, and for use in
infants and
young children.
High-potency preparations are used primarily as alternatives to
systemic
corticosteroids when local therapy is feasible.

Very high potency products may be used for thick, chronic

psoriatic lesions
but for only short periods of time and on relatively small surface
areas.

Ointments are the most effective formulations for psoriasis.

occlusive oily phase that conveys a hydrating effect and enhances
penetration of the corticosteroid into the dermis.
They are not suited for use in the axilla, groin, or other
intertriginous areas where maceration and folliculitis may
develop secondary to the occlusive effect.

Creams are more cosmetically desirable for some patient

Topical corticosteroids are applied two to four times daily during

longterm
Therapy. Adverse effects include local tissue atrophy, skin
degeneration, and striae.

If detected early, these effects may be reversible with

discontinuation.Thining of epidermis may result in telangiectasias)
and purpura.

Acneiform eruptions and masking of symptoms of

bacterial or fungal skin infections have been reported.

Tachyphylaxis and rebound flare of psoriasis after abrupt

cessation of therapy can also occur.
Vitamin D Analogs: Vitamin D and its analogs inhibit keratinocyte
differentiation and proliferation and have antiinflammatory effects
by reducing IL-8, IL-2, and
other cytokines.
Use of vitamin D itself is limited by its propensity to cause
hypercalcemia.

Calcipotriene
(Dovonex) is a synthetic vitamin D analog used for mild to
moderate plaque psoriasis. Improvement is usually seen within 2
weeks of
treatment, and approximately 70% of patients demonstrate marked
improvement after 8 weeks. lesional and perilesional burning and
stinging .

Calcipotriene 0.005% cream, ointment, or solution is applied one or

two times a day (no
more than 100 g/wk).

Calcitriol and tacalcitol are other vitamin D derivatives that have

been
studied for treatment of psoriasis.

Tazarotene
(Tazorac) is a synthetic retinoid that is hydrolyzed to its active
metabolite, tazarotenic acid, which modulates keratinocyte
proliferation
and differentiation.
It is available as a 0.05% or 0.1% gel and cream and is
applied once daily (usually in the evening) for mild to moderate
plaque
psoriasis. Adverse effects are dose- and frequency related and
include mild
to moderate pruritus, burning, stinging, and erythema. Application
of the
gel to eczematous skin or to more than 20% of body surface area is
not
recommended.
Tazarotene is often used with topical corticosteroids to decrease
local
adverse effects and increase efficacy.

SECOND-LINE TOPICAL PHARMACOTHERAPY:

Coal tar contains numerous hydrocarbon compounds formed from

distillation
of bituminous coal.
Ultraviolet B (UVB) light–activated coal tar
photoadducts with epidermal DNA and inhibits DNA
synthesis.
This normalized epidermal replication rate reduces plaque
elevation.

Coal tar preparations of 2% to 5% tar are available in lotions,

creams,
shampoos, ointments, gels, and solution.

It is usually applied directly to

lesions in the evening and allowed to remain in skin contact
through the
night. It may also be used in bath water.

Coal tar is an effective treatment, but it is time-consuming, causes

local
irritation, has an unpleasant odor, stains skin and clothing, and
increases
sensitivity to UV light (including the sun).

The risk of carcinogenicity is low, but there may be a higher rate of

nonmyeloma skin cancers in patients chronically exposed to coal tar
and
UV light.

Anthralin possesses antiproliferative activity on keratinocytes,

inhibiting
DNA synthesis by intercalation between DNA strands.
Because anthralin exerts its clinical effects at low cellular
concentrations,
therapy usually starts with low concentrations (0.1% to 0.25%) with
gradual
increases to higher concentrations (0.5% to 1%).

Cream and ointment formulations

are usually applied in the evening and allowed to remain
overnight.

Alternatively, short-contact anthralin therapy (SCAT) with application

for
10 to 20 minutes of higher concentrations (1% to 5%) in
water-soluble
vehicles is effective with decreased local adverse effects.

Anthralin products must be applied only to affected areas

because contact
with uninvolved skin may result in excessive irritation and
staining, which
usually disappear within 1 to 2 weeks of discontinuation.

FIRST-LINE SYSTEMIC PHARMACOTHERAPY:

Infliximab (Remicade) is a chimeric monoclonal antibody directed

against
TNF-
Recently, its indications have been expanded to include psoriatic
arthritis and treatment of adults with chronic severe plaque
psoriasis.

advantage over other systemic psoriasis treatments is that

infliximab does
not adversely affect blood counts, hepatic enzyme levels, or
kidney function.

The recommended dose is 5 mg/kg as an IV infusion at weeks 0, 2,

and
6, then every 8 weeks thereafter.

For psoriatic arthritis, it may be used with

or without methotrexate.

Adverse effects include headaches, fever, chills,

fatigue, diarrhea, pharyngitis, upper respiratory and urinary
tract infec.
Hypersensitivity reactions (urticaria, dyspnea, hypotension).

Etanercept (Enbrel) is a fusion protein that binds TNF-

, competitively
interfering with its interaction with cell-bound receptors.
Unlike the
chimeric infliximab, etanercept is fully humanized, thereby
minimizing
the risk of immunogenicity.

Etanercept is FDA approved for reducing

signs and symptoms and inhibiting the progression of joint damage
in
patients with psoriatic arthritis.

The recommended dose for psoriatic arthritis is 50 mg

subcutaneously
once per week.

For plaque psoriasis, the dose is 50 mg subcutaneously

twice weekly (administered 3 or 4 days apart) for 3 months
followed by a
maintenance dose of 50 mg per week.
Efalizumab (Raptiva) is a humanized monoclonal antibody that
inhibits
CD11- integrin, which is involved in T-cell activation, migration into
skin, and cytotoxic function.

SECOND-LINE SYSTEMIC PHARMACOTHERAPY:

Acitretin (Soriatane) is a retinoic acid derivative and the active
metabolite
of etretinate. It is indicated for severe psoriasis.
It has shown good results when combined
with other therapies, including UVA combined with oral methoxsalen
(PUVA) and UVB and topical calcipotriol.

The initial recommended

dose is 25 or 50 mg; therapy is continued until lesions have
resolved. It is
better tolerated when taken with meals.
Acitretin is a teratogen and is contraindicated in females who are
pregnant or who plan pregnancy
within 3 years after drug discontinuation.

Cyclosporine demonstrates immunosuppressive activity by

inhibiting the
first phase of T-cell activation. The usual dose is between 2.5 and 5
mg/kg/day given in two divided doses.

Adverse effects include nephrotoxicity, hypertension,

hypomagnesemia,
hyperkalemia, alterations in liver function tests, elevations of serum
lipids, GI
intolerance, paresthesias, hypertrichosis, and gingival hyperplasia.

Cumulative treatment for more than 2 years may increase the risk
of malignancy,
including skin cancers and lymphoproliferative disorders.

Tacrolimus, an immunosuppressant that inhibits T-cell activation, is

a useful
alternative in severe recalcitrant psoriasis.

Methotrexate, an antimetabolite, is indicated for moderate to

severe psoriasis.
It is particularly beneficial for psoriatic arthritis. It is also indicated
for patients
refractory to topical or UV therapy. The starting dose is 7.5 to 15 mg
per
week, increased incrementally by 2.5 mg every 2 to 4 weeks until
response;
maximal doses are approximately 25 mg/wk.

Nausea and macrocytic anemia can

be ameliorated by giving oral folic acid 1 to 5 mg/day. Methotrexate
should be
avoided in patients with active infections and in those with liver
disease.

Mycophenolate mofetil (CellCept) inhibits DNA and RNA synthesis

and has
been shown to have a specific lymphocyte antiproliferative effect.
The usual
dose is 500 mg orally four times a day, up to a maximum of 4 g/day.

Common
adverse effects include GI toxicity (diarrhea, nausea, vomiting),
hematologic
effects (anemia, neutropenia, thrombocytopenia), and viral and
bacterial
infections. Lymphoproliferative disease or lymphoma has been
reported.

Sulfasalazine is an antiinflammatory agent that inhibits 5-

lipoxygenase. It
is used selectively as an alternative treatment, particularly in
patients with
concurrent psoriatic arthritis.
When used alone, it is not as effective as
methotrexate, PUVA, or acitretin.

However, it has a relatively high margin

of safety. The usual oral dose is 3 to 4 g/day for 8 weeks. Its adverse
effects
are similar to other sulfonamide antibiotic.

Hydroxyurea inhibits cell synthesis in the S phase of the DNA

cycle. It is
used selectively in the treatment of psoriasis, especially in those
with liver
disease who would be at risk of adverse effects with other agents.
However,
it is less effective than methotrexate. The typical dose is 1 g/day,
with a
gradual increase to 2 g/day as needed and as tolerated. Adverse
effects
include bone marrow toxicity with leukopenia or thrombocytopenia,
cutaneous reactions, leg ulcers, and megaloblastic anemia.

PHOTOTHERAPY AND PHOTOCHEMOTHERAPY:

UVB light (290 to 320 nm) therapy is an important

phototherapeutic intervention
for psoriasis. The most effective wavelength is 310 to 315 nm, which
led to development of a UVB narrowband light source, in which 83%
of the
UVB emission is at 310 to 313 nm.

Topical and systemic psoriatic therapies

are used adjunctively to hasten and improve the response to UVB
phototherapy.

Emollients enhance efficacy of UVB and can be applied just before

treatments.

Combining short-contact anthralin, calcipotriene, or topical

retinoids to UVB may also improve results.

However, topical application

should be done after or at least 2 hours before UVB therapy because
phototherapy can inactivate the topical product.

UVB phototherapy may

also be more effective when added to systemic treatments such as
methotrexate
and oral retinoids.

PUVA is a photochemotherapeutic approach for selected patients.

Candidates
for PUVA therapy usually have moderate to severe, incapacitating
psoriasis unresponsive to conventional topical and systemic
therapies.

Systemic
PUVA consists of oral ingestion of a potent photosensitizer such as
methoxsalen
(8-methoxypsoralen) at a constant dose (0.6 to 0.8 mg/kg) and
variable
doses of UVA depending on patient skin phototype and history of
previous
response to UV radiation.

Two hours after ingesting psoralen, the patient is

exposed to UVA light.
Photochemotherapy is performed two or three times a
week.
COMBINATIONAL, ROTATIONAL, AND SEQUENTIAL THERAPY

Acitretin + UVB light

Acitretin + photochemotherapy using UVA light (PUVA)
Methotrexate + UVB light
PUVA + UVB light
Methotrexate + cyclosporine.
Medications associated with
photosensitivity reactions include fluoroquinolones,
nonsteroidal antiinflammatory
drugs, phenothiazines, antihistamines, estrogens,
progestins,
sulfonamides, sulfonylureas, thiazide diuretics, and
tricyclic antidepressants.
The skin lesions of dermatitis may or may not be painful
or pruritic.lesions are described as being less than or
greater than 0.5 cm in diameter

Macules are circumscribed, flat lesions of any shape or

size that differ from surrounding skin because of their
color. They may result from hyperpigmentation,
hypopigmentation, vascular abnormalities, capillary
dilatation(erythema), or purpura
Papules are elevated LESS than 1cm

Cradle Cap is a seborrheric dermatitis in children with

scalp involvement

Early eruptions appear

within a few hours to 3 days after drug ingestion,
whereas late eruptions occur up to 9 days after
exposure.

Atopic dermatitis is most likely to occur in children.

Menopausal womentend to develop brown hyperpigmentation, or

melasma. Pregnant womenmay develop hyperpigmentation of the
areola and genitalia as well as melasma

Astringents such as aluminum acetate or witch hazel decrease

weeping
from lesions, dry out the skin, and relieve itching. They are applied
as a wet dressing for no longer than 7 days.

If the reaction does not subside within a few days, topical or oral
corticosteroids may be needed in Contact dermatitis

SEBORRHIC DERMATITIS
Scalp involvement can be treated with twice-daily topical
corticosteroids in conjunction with a shampoo containing
selenium sulfide, coal tar, or salicylic acid to help soften and
remove scales.

• Topical calcineurin inhibitors (e.g., tacrolimus

ointment(0.03%-0.1%), pimecrolimus cream) have fungicidal
and antiinflammatory properties and can be used for the scalp or
face

Lukewarm water and mild soap can be used to clean the area
thoroughly,which should then be allowed to dry

•Occlusive agents (e.g., zinc oxide, titanium dioxide,

petrolatum) shouldbe generously applied to the area before the
clean diaper is put on the child.

Antihistamine (hydroxyzine and diphenhydramine)

and Antidepressants ( Doxapine 75mg HS or 75 mg
bid)
CUSHING’S SYNDROME

1.Metyrapone and Aminoglutethimide are

used in thr treatment of CS od ACTH related
2.Cyproheptadine is used CS related to
Pituatry related

HAAD QUESTIONS
1.Dose calculation is done by WEIGHT and
not by BSA and GENDER
2.Berri berri is by Thiamine deficiency
3.vomitting is SE of Digoxin
4.Staph.aureus penicillinese produing is
sensitive to only amoxil . FGC , Septran ,
CINDAMYCIN and oxacillin
5.which one is not used as topically in acne is
topical Estrogen
6.cyanide toxicity by Sodium Nitroprusside
7.Cisapride is prokinetic and 5HT1,4 agonist
use in IBS constipation
8.Cyprheptadine is H1 antihistamine used in
serotonin syndrome
9.Alcohlic is used mostly in preparation
Ophthalmics
10.Otitis media we need systemic antibiotic if
beteria found , we don’t use topical Abx in
Otitis media
11.Gaviscon constituents are Sodium
Alginate
12.Sympathetic ganglia near the spinal cord
13.Clindamycin is topical Abx in Acne
treatment
14.Dizziness , loss of balance , nausea and
Tinnitis by Minocycline as its most toxic
among tetracycline and Monocycline used in
acne and R.arthristis
15.Naloxone is antidote of morphine
16.Promethazine , Hydroxizine and
Diphenhydramine are most sedating
17.Prednisolone is used orally only in Asthma
18.Lidocain has greatest first past effect not
Lorazepam , fluoxetine
19.LOrazepam , tamezepam and Oxpezepam
are used in elderly and hepatic impairment
20.Iodides rlease the TSH hormone release
21.Not used prophylactic in migraine is
Dihydroergotamine
22.Clomefene is reacemic mixture and is
anti-estrogen
23.Scopolamine drived from Belladona
24.GTC drug of choice is valproic acid ,
lamotrigine and topiramate and levetriacetam
25.

GI
ULCERATIVE COLITIS

1. Transdermalnicotine improved symptoms of patients with

mild to
moderate active ulcerative colitis in daily doses of 15 to 25
mg.

2.Prednisoneup to 1 mg/kg/day or 40 to 60 mg daily may be

used for patients who do not have an adequate response to
sulfasalazine or mesalamine.

3.The first line of drug therapy for the patient with mild to moderate
colitis is oralsulfasalazineor an oralmesalamine derivative, or
topical mesalamine or steroids for distal disease.

4.When given orally, usually 4 g/day, up to 8 g/day of sulfasalazine is

required to attain control of active inflammation.

5.Sulfasalazine therapy should be instituted at 500 mg/day and

increased every few days up to 4 g/day or the maximum tolerated.
6.OraL mesalamine derivatives are reasonable alternatives to
sulfasalazine for treatment of ulcerative colitis but they are not more
effective than sulfasalazine.

Crohn disease

7.Sulfasalazine is more effective when Crohn’s disease involves

the colon.

8.Mesalamine derivatives (such as Pentasa or Asacol) that release

mesalamine in the small bowel may be more effective than
sulfasalazine for ileal involvement.

9.Metronidazole (given orally up to 20 mg/kg/day) may be useful

in some patients with Crohn’s disease, particularly in patients with
colonic or ileocolonic involvement or those with perineal disease.

10.Thecombination of metronidazole with ciprofloxacin is efficacious

in some patients.

11.Budesonide is a viable first-line option for patients

with mild to moderate ileal or right-sided disease.

12. Systemic steroids induce remission in up to 70% of patients

and should be reserved for patients with moderate to severe
disease who have failed aminosalicylates or budesonide.

Drug therapy for IBD is not a contraindication for

13.

pregnancy, and most pregnancies are well managed in patients

with these diseases.

14.If
a patient has an initial bout of IBD during
pregnancy, a standard approach to treatment with sulfasalazine
or steroids should be initiated.
15.Folic acid supplementation, 1 mg twice daily, should be
given.

15.Metronidazole or methotrexate should not be used during

pregnancy.Azathioprine and mercaptopurine may be associated
with fetal deformities.

16.Patients
receiving sulfasalazine should receive oral folic acid
supplementation since sulfasalazine inhibits folic acid
absorption.

17.Non–dose-related adverse effects of sulfasalazine include

rash, fever, or hepatotoxicity most commonly, as well as relatively
uncommon but serious reactions such as bone marrow suppression,
thrombocytopenia, pancreatitis, pneumonitis, interstitial nephritis,
and hepatitis.

18.Oral
mesalamine derivatives may impose a lower frequency
of adverse effects compared with sulfasalazine.

19.Up to 90% of patients who are intolerant to sulfasalazine

will tolerate oral mesalamine derivatives.

20.Olsalazine may cause watery diarrhea in up to 25% of

patients

R.ARTHRITIS
1. First-line DMARDs include methotrexate (MTX),
hydroxychloroquine, sulfasalazine, and leflunomide.

2. Leflunomide appears to have long-term efficacy similar to

MTX

3. DMARDs that are less frequently used include azathioprine,

penicillamine, gold salts (including auranofin), minocycline,
cyclosporine, and cyclophosphamide. These agents have either
less efficacy or higher toxicity, or both.

4.Most effective DMARD combinations (1) MTX plus cyclosporine,

and (2) MTX plus sulfasalazine and hydroxychloroquine

4. Nonsteroidal antiinflammatory drugs (NSAIDs) and/or

corticosteroids may be used for symptomatic relief if needed.
They provide relatively rapid improvement compared with
DMARDs, which may take weeks to months before benefit is seen

5. NSAIDs have no impact on disease progression,

 and corticosteroids have the potential for long-term
complications.NASIDs should seldom be used as
monotherapy in RA rather as adjuant to DMARDs

3. Biologic agents with disease-modifying activity include the anti-

TNF agents (etanercept, infliximab, adalimumab), the IL-1
receptor antagonist anakinra, and rituximab, which depletes
peripheral B cells. Biologic agents are effective for patients who fail
treatment with other DMARDs

1. A disease-modifying antirheumatic drug (DMARD) should be

started
within the first 3 months of symptom onset
2. Methotrexate or other DMARD NSAID, Prednisone
within first 3 months
3. Leflunomide causes Hepatitis, GI distress, alopecia
Nausea/vomiting, gastritis, diarrhea, hair loss, jaundice
4.Mtx cause GIT , Pulmonary and Hepatotoxicity , we can use folic
acid as supplement to reduce ADR

5.CI of Mtx is Pregnancy , Thrombocytopenia , CrCl <40ml/min

6. Leflunomide(Arava) inhibits pyrimidine synthesis, which

reduces lymphocyte
proliferation and modulation of inflammation. Its efficacy for RA
is similar to that of MTX. Avoid in Pregnancy

7. Hydroxychloroquine lacks the myelosuppressive,

hepatic, and renal toxicities seen with some other DMARDs

8.Toxicities are GI , Ophthalmologic and dermatologic

9. Antirheumatic effects should be seen in 2 months with

Sulfasalazine

10.ADR of sulfasalazine is GI , Hematologic and Hepatic

11. Azathioprine is a purine analog that is converted to 6-

mercaptopurine and
is thought to interfere with DNA and RNA synthesis.DC it if no
response seen in 12weeks at max doses

12.Cyclosporin Important toxicities at doses of

1 to 10 mg/kg/day include hypertension, hyperglycemia,
nephrotoxicity,
tremor, GI intolerance, hirsutism, and gingival
hyperplasia.
13. the combination of infliximab and MTX
halted progression of joint damage and was superior to
MTX monotherapy.

14. Adalimumab (Humira) is less antigenic than infliximab

15. In RA Rituximab is useful in patients failing MTX or TNF

inhibitors

16. Methylprednisolone 100 mg should be given 30 minutes

prior to rituximab
to reduce the incidence and severity of infusion reactions.
Acetaminophen
and antihistamines may also benefit patients who have a
history of
reactions.

BIPLAR DISORDER
1
1. Quetiapine is the only antipsychotic that is FDA approved for
bipolar depression

2. Lithium, olanzapine, and lamotrigine are approved for

maintenance treatment of bipolar disorder

3. Lithium is the drug of choice for bipolar disorder with

euphoric mania,
whereas valproate has better efficacy for mixed states,
irritable/dysphoric mania, and rapid cycling compared with
lithium..

4. tricyclic antidepressants are associated with an increased

risk of inducing mania in bipolar I disorder and possibly cause rapid
cycling

5. Nimodipine may be more effective than verapamil for rapid-

cycling
bipolar disorder because of its anticonvulsant properties, high lipid
solubility,
and good penetration into the brain.

6.Lithium reduces suicide risk 8-10 folds

7.Lithium side effects

a. Polydipsia and polyuria (so give at bedtime)
b.CNS effects and hand tremors (give propranolo 20-120mg/day)
c.GI effects
 d.Diabetes insipidus , decrease capacity of kidney to conc urine
(give Loop diuretics , thiazides and triamterene) If a thiazide
diuretic is used, lithium doses should be decreased by 50%
and
lithium and potassium levels monitored.
e. Hypothyroidism
f. atrioventricular block, and bradycardia and EKG changes
g. benign reversible leukocytosis,
acne, alopecia, exacerbation of psoriasis, pruritic dermatitis,
maculopapular rash, folliculitis, and weight gain.

• Lithium toxicity can occur with serum levels greater than 1.5
mEq/L, but the elderly may have toxic symptoms at
therapeutic levels. Severe toxic symptoms may occur with
serum concentrations above 2 mEq/L, including vomiting,
diarrhea, incontinence, incoordination, impaired cognition,
arrhythmias, and seizures. Permanent neurologic impairment
and kidney
damage may occur as a result of toxicity.

COLCHICINE

USES.
1.Gout treatment and prophylaxis.

Familial Mediterranean fever (FMF): Oral: 1.2-2.4 mg/day in 1-2 divided doses. Titration:
Increase or decrease dose in 0.3 mg/day increments based on efficacy or adverse
effects; maximum: 2.4 mg/day

Gout: Oral:

U.S. labeling:

Flare treatment: Initial: 1.2 mg at the first sign of flare, followed in 1 hour with a
single dose of 0.6 mg (maximum: 1.8 mg within 1 hour). Patients receiving
prophylaxis therapy may receive treatment dosing; wait 12 hours before
resuming prophylaxis dose. Note: Current FDA-approved dose for gout flare
is substantially lower than what has been historically used clinically. Doses
larger than the currently recommended dosage for gout flare have not been
proven to be more effective.

Prophylaxis: 0.6 mg once or twice daily; maximum: 1.2 mg/day

 Canadian labeling:

Flare treatment: Initial: 1-1.2 mg at the first sign of flare, followed by 0.5-0.6 mg
dose every 2 hours until pain relief; maximum: 3 mg/24 hours

Prophylaxis: 0.5-0.6 mg 1-4 times/week (mild-moderate cases) or 0.5-0.6 mg once

or twice daily (severe cases); maximum: 1.2 mg/24 hours

Pericarditis post-STEMI (unlabeled use): Oral: 0.6 mg twice daily (Antman, 2004)

Recurrent pericarditis due to previous autoimmune or idiopathic cause (unlabeled

use): Note: Dosage strength not available in the U.S.: Oral: 0.5-1 mg every 12 hours for
1 day, followed by 0.25-0.5 mg every 12 hours for 6 months (in combination with high-
dose aspirin or ibuprofen) (Imazio, 2011)

Patients <70 kg or unable to tolerate higher dosing regimen: 0.5 mg every 12 hours for 1
day followed by 0.5 mg once daily.

Primary biliary cirrhosis (unlabeled use): Oral: 0.6 mg twice daily (Kaplan, 2005); Note:
Use reserved for patients refractory to ursodiol..

ANTIARRYTHMICS
CLASS 1 (Na channel blocker)
1A (QDP QUINIDINE , DISOPYRAMIDE AND PROCAINAMIDE)
1B(LM LIDOCAINE AND MEXILITINE)
1C(FMP FLECAINIDE MORCIZINE PROPAFENONE)

CLASS2(B-Blocker)
Esmolol
Metoprolol
Propanolol
Intermediate- or short-acting BZs are preferred for chronic use in the
elderly and those with liver disorders because of minimal
accumulation
and achievement of steady state within 1 to 3 days
 Coadministration of moderate CYP3A4 inhibitor (eg, aprepitant, diltiazem, erythromycin,
fluconazole, fosamprenavir, grapefruit juice, verapamil):

FMF: Maximum dose: 1.2 mg/day (0.6 mg twice daily)

Gout prophylaxis:

If original dose is 0.6 mg twice daily, adjust dose to 0.3 mg twice daily or 0.6
mg once daily

If original dose is 0.6 mg once daily, adjust dose to 0.3 mg once daily

Gout flare treatment: 1.2 mg as a single dose; do not repeat for at least 3 days

Coadministration of P-gp inhibitor (eg, cyclosporine, ranolazine):

FMF: Maximum dose: 0.6 mg/day (0.3 mg twice daily)

Contraindications
Concomitant use of a P-glycoprotein (P-gp) or strong CYP3A4 inhibitor in presence of renal or
hepatic impairment

Canadian labeling: Additional contraindications (not in U.S. labeling): Hypersensitivity to

colchicine; serious gastrointestinal, hepatic, renal, and cardiac disease
Buspirone is a 5-HT1A partial agonist that lacks anticonvulsant, muscle
relaxant, sedative-hypnotic, motor impairment, and dependence-producing
properties.

It is considered a second-line agent for GAD because of inconsistent reports

of efficacy, delayed onset of effect, and lack of efficacy for comorbid
depressive and anxiety disorders (e.g., panic disorder or SAD). It is the agent
of choice in patients who fail other anxiolytic therapies or in patients with a
history of alcohol or substance abuse.

It is not useful for situations requiring

rapid antianxiety effects or as-needed therapy.
It has a mean t1/2 of 2.5 hours, and it is dosed two to three times daily.
• Side effects include dizziness, nausea, and headaches
Buspirone doses can be titrated in increments of 5 mg/day every 2 or 3 days
as needed.

Buspirone may increase haloperidol levels and elevate blood pressure in

patients taking a monoamine oxidase inhibitor (MAOI).
• Verapamil, itraconazole, and fluvoxamine can increase buspirone levels,
and rifampin reduces buspirone blood levels by 10-fold.

Drug interactions with the BZs are generally pharmacodynamic or pharmacokinetic

(Table 68-11). The combination of BZs with alcohol or other
CNS depressants may be fatal.
• Alprazolam dose should be reduced by 50% if nefazodone (Serzone) or
fluvoxamine is added.

Acute Anxiety treatment:

Treatment of acute anxiety generally should not exceed 4 weeks. BZs can
be given as needed, and if several acute courses are necessary, a BZ-free
period of 2 to 4 weeks should be implemented between courses. Persistent
symptoms should be managed with antidepressants.
• BZs with a long t1/2 may be dosed once daily at bedtime and may provide
nighttime hypnotic and anxiolytic effects the next day.

In the elderly, doses should be low, and short-elimination half-life agents

prescribed.

PANIC DISORDER:
Alprazolam, clonazepam, sertraline, paroxetine, and venlafaxine are
FDA approved for this indication.

CBT alone is indicated, as it is associated with improvement in 80% to

90% of patients short-term and 75% of patients at 6-month follow-up.

Patients must be educated to avoid caffeine, drugs of abuse, and stimulants.

Bipolar disorder :

Lithium:

Lithium
Lithium is rapidly absorbed; it is not protein bound, not
metabolized, and
is excreted unchanged in the urine and other body fluids.
• Lithium is effective for acute mania, but it may require 6 to
8 weeks to show antidepressant efficacy.
Current estimates of the rate of occurrence of Epstein anomaly in infants
exposed to lithium during the first trimester is between 1:1,000 and 1:2,000.
• When lithium is to be used during pregnancy, it should be used at the
lowest effective dose in order to avoid “floppy” infant syndrome, hypothyroidism,
and nontoxic goiter in the infant.

Serum concentrations in the nursing infant are 10% to 50% of the

mother’s serum concentration, thus breast-feeding is usually discouraged
for women taking lithium.

Combining lithium with typical antipsychotics may cause neurotoxicity

(e.g., delirium, cerebellar dysfunction, extrapyramidal symptoms).

Lithium
should be withdrawn and discontinued at least 2 days before electroconvulsive
therapy.

Side effects:

Initial side effects are often dose related and are worse at peak serum
concentrations (1 to 2 hours postdose).

Lowering the dose, taking smaller

doses with food,
using extended-release products,
and once-daily dosing at
bedtime may help.

GI distress may be minimized by standard approaches or by adding

antacids or antidiarrheals.

Muscle weakness and transient lethargy occur in about 30%

of patients.
Polydipsia with polyuria and nocturia occurs in up to 70% of
patients and is managed by changing to once-daily dosing at
bedtime.

Fine hand tremor may occur in up to 50% of patients. Hand tremor may be
treated with propranolol 20 to 120 mg/day.

Lithium reduces the kidney’s ability to concentrate urine and may cause a
nephrogenic diabetes insipidus with low urine specific gravity and low
osmolality polyuria (urine volume greater than 3 L/day).

This may be treated with loop diuretics, thiazide diuretics, or triamterene.

If a thiazide diuretic is used, lithium doses should be

decreased by 50% and lithium and potassium levels monitored.

Long-term lithium therapy is associated with a 10% to 20% risk of

morphologic renal changes (e.g., glomerular sclerosis, tubular atrophy,
and interstitial nephritis).

Lithium-induced nephrotoxicity is rare if patients are maintained on the

lowest effective dose, if once-daily dosing is used, if good hydration is
maintained, and if toxicity is avoided.

Up to 30% of patients on maintenance lithium therapy develop transiently

elevated serum concentrations of thyroid-stimulating hormone, and 5% to
35% of patients develop a goiter and/or hypothyroidism, which is doserelated
and more likely to occur in women. This is managed by adding
levothyroxine to the regimen.

Several factors predispose to lithium toxicity, including :

sodium restriction,
dehydration,
vomiting, diarrhea, drug interactions that decrease
lithium clearance, heavy exercise, sauna baths, hot weather, and fever.

Patients should be told to maintain adequate sodium and fluid intake and
to avoid excessive coffee, tea, cola, and other caffeine-containing beverages
and alcohol.

HAAD First Aid:

Poison on the Skin  Remove contaminated clothing.

 Flood skin with water for 10 minutes.

 Wash with soap and water.

 Rinse well.

Poison  Flood BOTH eyes with warm water (not hot).

in the
Eye  This can be done in the shower by directing the shower
stream to the forehead area and letting the water run into
BOTH eyes.
 Repeat for 15 minutes.
 Have the person blink as much as possible while flooding
the eyes.

 Do not force the eyelid open.

Poison  If the person is not breathing, start  Some products can

Swallowed artificial respiration. much medicine can
especially to children
 If the person is conscious, check to
see if the person can swallow.  The poison specialis
 Do not make the person vomit until treatment is needed
you have checked with the poison
center.

 In some cases vomiting can cause

more damage.
Venomous  Remove any jewelry. Do not cut
Snake Bite and try to extract the venom.  The poison specialis
treatment is needed
 Do not use ice or a tourniquet.
 Do not try to capture the snake.
 Then Call 800-424
 Drugs in Lactation

Breastfeeding mothers and medicines

 A drug commonly prescribed for infants is usually a good choice for a breastfeed
 A drug that has a history of use by breastfeeding mothers is a better choice th
drug.
 The duration of the drug therapy can affect its compatibility with breastfee
compatible with breastfeeding when taken for a few days might not be compat
period of time.
 A short-acting form of the drug may be a better choice for a breastfeeding m
form that stays in the mother's system for a longer per
 A drug given by injection or by mouth is less concentrated than one given intra
may be given intravenously because it is inactivated or not absorbed by the dig
digestive system would also inactivate or not absorb the
 Some drugs accumulate in a baby's system and can potentially build to toxic le
eliminated by the baby is more compatible with breastfee
 Some drugs should be avoided by breastfeeding mothers because they affect b
down or milk supply).

Always consult your doctor before taking any medications incuding over
meications if your are breast feeding.
 MEDICATION IN PREGNANCY

Frequnet Q&A

Is it safe to use medicine while I am pregnant?

There is no clear-cut answer to this question. Before you start or stop any
medicine, it is always best to speak with the doctor who is caring for you while
you are pregnant. Read on to learn about deciding to use medicine while
pregnant.

How should I decide whether to use a medicine while I am pregnant?

When deciding whether or not to use a medicine in pregnancy, you and your
doctor need to talk about the medicine's benefits and risks.

• Benefits: what are the good things the medicine can do for me and my baby
(fetus)?
• Risks: what are the ways the medicine might harm me or my baby (fetus)?

There may be times during pregnancy when using medicine is a choice. Some of
the medicine choices you and your doctor make while you are pregnant may
differ from the choices you make when you are not pregnant. For example, if you
get a cold, you may decide to "live with" your stuffy nose instead of using the
"stuffy nose" medicine you use when you are not pregnant.

Other times, using medicine is not a choice—it is needed. Some women need to
use medicines while they are pregnant. Sometimes, women need medicine for a
few days or a couple of weeks to treat a problem like a bladder infection or strep
throat. Other women need to use medicine every day to control long-term health
problems like asthma, diabetes, depression, or seizures. Also, some women have
a pregnancy problem that needs medicine treatment. These problems include
severe nausea and vomiting, earlier pregnancy losses, or preterm labor.

Is it safe to take medicine while you are pregnant?

It can be hard to plan exactly when you will get pregnant, in order to avoid taking
any medicine. Most of the time, medicine a pregnant woman is taking does not
enter the foetus. But sometimes it can, causing damage or birth defects. The risk
of damage being done to a foetus is the greatest in the first few weeks of
pregnancy, when major organs are developing. But researchers also do not know
if taking medicines during pregnancy also will have negative effects on the baby
later.
Many drugs that you can buy over-the-counter (OTC) in drug and discount stores,
and drugs your health care provider prescribes are thought to be safe to take
during pregnancy, although there are no medicines that are proven to be
absolutely safe when you are pregnant. Many of these products tell you on the
label if they are thought to be safe during pregnancy. If you are not sure you can
take an OTC product, ask your health care provider.

Some drugs are not safe to take during pregnancy. Even drugs prescribed to you
by your health care provider before you became pregnant might be harmful to
both you and the growing foetus during pregnancy. Make sure all of your health
care providers know you are pregnant, and never take any drugs during
pregnancy unless they tell you to.
Also, keep in mind that other things like caffeine, vitamins, and herbal teas and
remedies can affect the growing foetus. Talk with your health care provider about
cutting down on caffeine and the type of vitamins you need to take. Never use
any herbal product without talking to your health care provider first.

What over-the-counter and prescription drugs are not safe to take during
pregnancy?

The Food and Drug Administration (FDA) has a system to rate drugs in terms of
their safety during pregnancy. This system rates both over-the-counter (OTC)
drugs you can buy in a drug or discount store, and drugs your health care
provider prescribes. But most medicines have not been studied in pregnant
women to see if they cause damage to the growing foetus. Always talk with your
health care provider if you have questions or concerns.

The FDA system ranks drugs as:

• Category A - drugs that have been tested for safety during pregnancy and have
been found to be safe. This includes drugs such as folic acid, vitamin B6, and
thyroid medicine in moderation, or in prescribed doses.

• Category B - drugs that have been used a lot during pregnancy and do not
appear to cause major birth defects or other problems. This includes drugs such
as some antibiotics, acetaminophen (Tylenol), aspartame (artificial sweetener),
famotidine (Pepcid), prednisone (cortisone), insulin (for diabetes), and ibuprofin
(Advil, Motrin) before the third trimester. Pregnant women should not take
ibuprofen during the last three months of pregnancy.

• Category C - drugs that are more likely to cause problems for the mother or
foetus. Also includes drugs for which safety studies have not been finished. The
majority of these drugs do not have safety studies in progress. These drugs often
come with a warning that they should be used only if the benefits of taking them
outweigh the risks. This is something a woman would need to carefully discuss
with her doctor. These drugs include prochlorperzaine (Compazine), Sudafed,
fluconazole (Diflucan), and ciprofloxacin (Cipro). Some antidepressants are also
included in this group.

• Category D - drugs that have clear health risks for the foetus and include
alcohol, lithium (used to treat manic depression), phenytoin (Dilantin), and most
chemotherapy drugs to treat cancer. In some cases, chemotherapy drugs are
given during pregnancy.

• Category X - drugs that have been shown to cause birth defects and should
never be taken during pregnancy. This includes drugs to treat skin conditions like
cystic acne (Accutane) and psoriasis (Tegison or Soriatane); a sedative
(thalidomide); and a drug to prevent miscarriage used up until 1971 in the U.S.
and 1983 in Europe (diethylstilbestrol or DES).

Here are some examples:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil®),

naproxen, and aspirin (acetylsalicylate), can cause serious blood flow problems in
the baby if used during the last third of pregnancy (after 28 weeks). Also, aspirin
may increase the chance for bleeding problems in the mother and the baby
during pregnancy or at delivery.

• The labels for nicotine therapy drugs, like the nicotine patch and lozenge,
remind women that smoking can harm an unborn child. While the medicine is
thought to be safer than smoking, the risks of the medicine are not fully known.
Pregnant smokers are told to try quitting without the medicine first.

• In rare cases, a woman's health care provider may want her to use these type
of drugs under close watch.

I have a health problem. Should I stop using my medicine while I am

pregnant?
If you are pregnant or thinking about becoming pregnant, you should talk to your
doctor about your medicines. Do not stop or change them on your own. This
includes medicines for depression, asthma, diabetes, seizures (epilepsy), and
other health problems. Not using medicine that you need may be more harmful to
you and your baby than using the medicine.

Are vitamins safe for me while I am pregnant?

Regular multivitamins and prenatal vitamins are safe to take during pregnancy
and can be helpful. Women who are pregnant or trying to get pregnant should
take a daily multivitamin or prenatal vitamin that contains at least 400
micrograms (µg) of folic acid. It is best to start taking these vitamins before you
become pregnant or if you could become pregnant. Folic acid reduces the chance
of a baby having a neural tube defect, like spina bifida, where the spine or brain
does not form the right way. See our information on Folic Acid. Iron can help
prevent a low blood count (anemia). It's important to take the vitamin dose
prescribed by your doctor. Too many vitamins can harm your baby. For example,
very high levels of vitamin A have been linked with severe birth defects.

What about taking natural medications, or herbal remedies, when you

are pregnant?
While some herbal remedies say they will help with pregnancy, there have been
no studies to figure out if these claims are true. Likewise, there have been very
few studies to look at how safe and effective herbal remedies are. Echinacea,
Gingko biloba, and St. John's Wort have been popular herbs, to name a few. Do
not take any herbal products without talking to your health care provider first.
These products may contain agents that could harm you and the growing foetus,
and cause problems with your pregnancy.

If you are pregnant or thinking about getting pregnant….

• Do not stop any prescribed medicines without first talking to your

doctor.
• Talk to your doctor before using any over-the-counter medicine

Food
Poisoning
Food poisoning is a common, usually mild, but sometimes
deadly illness. Typical symptoms include nausea, vomiting,
abdominal cramping, and diarrhea that occur suddenly (within
48 hours) after consuming a contaminated food or drink.
Depending on the contaminant, fever and chills, bloody stools,
dehydration, and nervous system damage may follow. These
symptoms may affect one person or a group of people who ate
the same thing.
Worldwide, diarrheal illnesses are among the leading causes of
death. Travelers to developing countries often encounter food
poisoning in the form of traveler's diarrhea.

Safe food preparation and cooking

  Keep everything clean!
 Wash your hands, utensils, cutting boards and counters with warm, soapy
water before and after handling raw foods. .
 Sanitize cutting boards often in a solution of one teaspoon chlorine bleach
in one quart of water.
 Use a plastic cutting board. Wood cutting boards are hard to clean. Germs
can hide in the cracks.
 Do not cross-contaminate. Keep raw meat, poultry, fish, and their juices
away from other food. After cutting raw meats, wash hands, cutting board,
knife, and counter tops with hot, soapy water.
 Wash all fruits and vegetables before eating.
 Cook ground meats to 160°F; ground poultry to 165°F. Beef, veal, and
lamb steaks, roasts and chops may be cooked to 145°F; all cuts of fresh
pork, 160°F. Whole poultry should reach 180°F in the thigh; breasts
170°F.
 Thaw meat, poultry and seafood in the refrigerator or microwave oven. Do
not leave on the counter at room temperature. Promptly cook thawed
foods.
 Thoroughly cook ground meat and poultry so that no redness remains and
juices run clear
 Avoid eating raw clams and oysters and undercooked meats and poultry
 Thoroughly reheat previously prepared food

keep everything clean!

Food
Storage
Guidelines
 Storing Foods Safely
 Take your groceries directly home after shopping –
promptly store all cold items.
 Periodically check temperatures in the refrigerator and
freezer to be sure they are correct: Refrigerator 40o F
(5 C) Freezer 0o F (-18 C).
 Store eggs in the original container in the main section
(not in the door) of the refrigerator.
 Avoid consuming raw or undercooked eggs. Cook eggs
until both the white and yolk are firm and not runny.
Pasteurized eggs or egg substitutes are acceptable
alternatives for fresh eggs.
 Promptly refrigerate leftover foods in sealed
containers.
 Maintain proper temperatures for all food while
serving, especially during the warmer months.
 As a rule, “keep hot foods hot and cold foods cold” and
do not allow either to be out longer than two hours.
 Do not eat any food that has been unrefrigerated for
more than two hours.
 If any food looks or smells unusual, do not eat it or
give it.
 If any food has been “around” for more than a few
days, discard it. Contamination may be present and
may not yet be detectable by just looking at it or
smelling it.

Keep it cool!
TUBERCULOSIS
What is tuberculosis (TB)?
Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air.
TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the
kidneys, or the spine. In most cases, TB is treatable; however, persons with TB can die if they do not
get proper treatment.

What is multidrug-resistant tuberculosis (MDR TB)?

Multidrug-resistant TB (MDR TB) is TB that is resistant to at least two of the best anti-TB drugs,
isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons
with TB disease.

What is extensively drug resistant tuberculosis (XDR TB)?

 Extensively drug resistant TB (XDR TB) is a relatively rare type of MDR TB.
 XDR TB is defined as TB which is resistant to isoniazid and rifampicin, plus resistant to any
fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin,
kanamycin, or capreomycin).

What is the importance of XDR TB?

XDR TB is of special concern for persons with HIV infection or other conditions that can weaken the
immune system. These persons are more likely to develop TB disease once they are infected, and also
have a higher risk of death once they develop TB.

How is MDR TB spread?

Drug-susceptible TB and MDR TB are spread by the same way.

How does drug resistance happen?

Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged. Examples include

 When patients do not complete their full course of treatment;

 When health-care providers prescribe the wrong treatment, the wrong dose, or length of time
for taking the drugs;
 When the supply of drugs is not always available; or
 When the drugs are of poor quality.

Who is at risk for getting MDR TB?

Drug resistance is more common in people who:

 do not take their TB medicine regularly

 do not take all of their TB medicine as told by their doctor or nurse
 develop active TB disease again, after having taken TB medicine in the past
 come from areas of the world where drug-resistant TB is common
 have spent time with someone known to have drug-resistant TB disease

How can MDR TB be prevented?

The most important thing a person can do to prevent the spread of MDR TB are the following:

1. To take all of their medications exactly as prescribed by their health care provider.
2. No doses should be missed and treatment should not be stopped early.
3. Patients should tell their health care provider if they are having trouble taking the
medications.
4. If patients plan to travel, they should talk to their health care providers and make sure they
have enough medicine to last while away.
5. Another way to prevent getting MDR TB is to avoid exposure to known MDR TB patients in
closed or crowded places such as hospitals, prisons, or homeless shelters. If you work in
hospitals or health-care settings where TB patients are likely to be seen, you should consult
infection control or occupational health experts. Ask about administrative and environmental
procedures for preventing exposure to TB. Once those procedures are implemented,
 additional measures could include using personal respiratory protective devices.

What should I do if I think I have been exposed to someone with TB disease?

If you think you have been exposed to someone with TB disease, you should contact your doctor or
local health department about getting a TB skin test or special TB blood test. And tell the doctor or
nurse when you spent time with this person, after that you have to get the required medical care.

HIV AIDWhat is Influenza (Also Called Flu)?

The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe
illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccine
each year.

Symptoms of Flu
People who have the flu often feel some or all of these symptoms:

 fever* or feeling feverish/chills

 cough
 sore throat
 runny or stuffy nose
 muscle or body aches
 headaches
 fatigue (very tired)
 Some people may have vomiting and diarrhea, though this is more common in children than
adults.

*It’s important to note that not everyone with flu will have a fever.

How Flu Spreads

Most experts believe that flu viruses spread mainly by droplets made when people with flu cough,
sneeze or talk. These droplets can land in the mouths or noses of people who are nearby. Less often,
a person might also get flu by touching a surface or object that has flu virus on it and then touching
their own mouth, eyes or nose.

Period of Contagiousness
You may be able to pass on the flu to someone else before you know you are sick, as well as while you
are sick. Most healthy adults may be able to infect others beginning 1 day before symptoms develop
and up to 5-7 days after becoming sick. Some people, especially children and people with weakened
immune systems, might be able to infect others for an even longer time.

How serious is the Flu?

Flu is unpredictable and how severe it is can vary widely from one season to the next depending on
many things, including:

 what flu viruses are spreading,

 how much flu vaccine is available
 when vaccine is available
 how many people get vaccinated, and
 how well the flu vaccine is matched to flu viruses that are causing illness.

Certain people are at greater risk for serious complications if they get the flu. This includes older
people, young children, pregnant women and people with certain health conditions (such as asthma,
diabetes, or heart disease).

During 2009-2010, a new and very different flu virus (called 2009 H1N1) spread worldwide causing the
first flu pandemic in more than 40 years. In contrast to seasonal flu, nearly 90 percent of the deaths
occurred among people younger than 65 years of age.

Complications of Flu
Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration,
and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.
Preventing Seasonal Flu: Get Vaccinated
The single best way to prevent the flu is to get a flu vaccine each season. There are two types of flu
vaccines:

 The "flu shot"–an inactivated vaccine (containing killed virus) that is given with a needle.
The seasonal flu shot is approved for use in people 6 months of age and older, including
healthy people, people with chronic medical conditions and pregnant women.
 The nasal–spray flu vaccine –a vaccine made with live, weakened flu viruses that do not
cause the flu (sometimes called LAIV for "Live Attenuated Influenza Vaccine"). LAIV is
approved for use in healthy* people 2-49 years of age who are not pregnant.

About two weeks after vaccination, antibodies develop that protect against influenza virus infection.
Flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses.
The seasonal flu vaccine protects against the three influenza viruses that research suggests will be
most common. The 2010-2011 flu vaccine will protect against 2009 H1N1, and two other influenza
viruses (an H3N2 virus and an influenza B virus).

When to Get Vaccinated Against Seasonal Flu

Yearly flu vaccination should begin in September, or as soon as vaccine is available, and continue
throughout the flu season. While flu season can begin early as October, most of the time seasonal flu
activity peaks in January or later.

Who Should Get Vaccinated?

While everyone should get a flu vaccine each flu season, it’s especially important that certain people
get vaccinated either because they are at high risk of having serious flu-related complications or
because they live with or care for people at high risk for developing flu-related complications.

Who is at Higher Risk for Developing Flu-Related Complications?

 Children younger than 5, but especially children younger than 2 years old,
 Adults 65 years of age and older
 Pregnant women, and,
 People who have medical conditions including:

 Asthma (even if it’s controlled or mild)

 Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and
cystic fibrosis)
 Heart disease (such as congenital heart disease, congestive heart failure and
coronary artery disease)
 Blood disorders (such as sickle cell disease)
 Endocrine disorders (such as diabetes mellitus)
 Kidney disorders
 Liver disorders
 Weakened immune system due to disease or medication (such as people with HIV or
AIDS, or cancer, or those on chronic steroids)
 People who are morbidly obese (Body Mass Index (BMI) of 30 or greater)

Who else should get vaccinated?

Other people for whom vaccination is especially important are:

 People who live in nursing homes and other long-term care facilities
 People who live with or care for those at high risk for complications from flu, including:

 Health care workers

 Household contacts and caregivers of children younger than 5 years of age with
particular emphasis on vaccinating contacts of children younger than 6 months of
age (children younger than 6 months are at highest risk of flu-related complications
but are too young to get vaccinated)
Who Should Not Be Vaccinated Against Seasonal Flu
Some people should not be vaccinated without first consulting a physician. They include:

 People who have a severe allergy to chicken eggs.

 People who have had a severe reaction to an influenza vaccination in the past.
 People who developed Guillian-Barré syndrome (GBS) within 6 weeks of getting an influenza
vaccine previously.
 Children younger than 6 months of age (influenza vaccine is not approved for use in this age
group).
 People who have a moderate or severe illness with a fever should wait to get vaccinated
until their symptoms lessen.

What is important about HIV/AIDS?

HIV/AIDS is one of the world's most serious health problems. It is the leading infectious killer
worldwide, accounting for about 2 million deaths in 2008 alone, and killed more than 25 million
people since the time it was first appeared in 1981.
Moreover, the epidemic of AIDS continues to grow inspite of the international efforts to prevent the
spread of the virus.
At the end of 2008, about 33.4 million people in the world were living with HIV, and in the same year
close to 2.7 million were newly infected. About two thirds of all people infected with HIV are living in
Sub-Saharan Africa.
In our region (the Eastern Mediterranean Region), the estimated number people living with HIV
reached 530,000 by the end of 2007, and about 55,000 new HIV infections occurred in that year. Even
though the number of people infected with the virus is lesser than in many other areas, the high
increase in rates of infection makes it a real concern to the health care systems in this region, and
forces them to work harder to control the spread of the virus.

Basic facts to understand:

Human Immunodeficiency Virus "HIV" is the name of the virus that causes AIDS. AIDS is the name of
the resultant disease, and it stand for Acquired Immune Deficiency Syndrome.

 When the virus enters your body, it infects specific cells in your immune system, which are
important to fight infection and disease. These cells are called CD4 cells or helper T cells.
 The virus destroys or impairs the function of the infected immune cells, leading to
progressive deterioration of the immune system
 When your CD4 cells are not working well, you are more likely to get extremely sick by even
the simplest illnesses.
 When your immune system is healthy, you will usually have between 500 and 1800 CD4 cell
count per cubic millimeter of blood.
 AIDS as a disease is diagnosed when the CD4 count goes below 200.

How a person gets infected?

Below are the main routes by which a person can get infected:

 Vaginal or anal sex with an infected person (without using condom).

 Oral sex (especially if a person has ulcers or gum problems).
 Transfusion of blood or its components from an infected person.
 Sharing needles for injecting drugs or tattooing.
 Sharing sharp instruments like nail cutters or scissors.
 Mother to baby transmission during pregnancy or childbirth.
 Breast feeding by HIV positive mother.

Why infection happens through those ways?

Infection usually happens through one or more of the above mentioned ways, because the virus exists
at high concentration in can pass on through the following body fluids:

 Blood
 Semen
 Vaginal secretions
 Anal secretions
  Breast milk

Even though the HIV can also be found in other body fluids, like saliva, sweat, tears, and urine, but
they cannot pass through these fluids.

HIV is NOT passed on by:

 Hugging, kissing, or holding hands

 Sharing a bath or a swimming pool
 Sharing toilet seats or towels
 Sharing food or utensils
 Insects bits

What happens after a person gets infected with the virus?

A person can be infected with the HIV for many years before AIDS develops:

 After infection, the body needs 1-3 months (up to 6 months) to develop antibodies against
the HIV.
 Detection of these antibodies in the blood will show that the person is infected with HIV.
Therefore, doing the blood test in the first three months of infection, i.e. before antibodies
are formed will give a negative result even though the person is already infected with the
virus and can infect others.
 Generally, after three months the blood test would be positive and this leads to the
diagnosis of an infection with HIV.
 If left untreated, the majority of people infected with HIV will develop the disease (AIDS)
within 5-10 years, and up to 15 years in some cases.

What to do if you got exposed to any of the possible routes of infection?

 Go to your health care provider, and get the necessary counseling.

 Do blood test to detect the HIV antibodies. If the test result was negative, repeat the test
after 3months of the risky exposure.
 According to standards of screening for HIV by the Health Authority-Abu Dhabi (HAAD), a
blood sample is tested first with a sensitive test called ELISA. Only the sample that tests
repeatedly positive for the second time will be tested by a confirmatory test called Western
Blot.

What if the test was confirmed to be positive?

Although HIV is a very serious infection and cannot be cured yet, many people with HIV and AIDS are
living longer and healthier lives today because of the new and effective treatments that are available
now.

Knowing the HIV status can therefore help a person in two ways:

 He can get the necessary health care and support that will enable him to live for a longer
time.
 It will let him take the necessary precautions to prevent spread of HIV to others.

Advices to people living with HIV:

 Follow your doctor’s instructions. Keep your appointments.

 If your doctor prescribed you a medicine, take it exactly as prescribed.
 Inform your doctor on time of any complaints.
 Do not stop any medication without consulting your doctor (taking some of your medicines
and not taking others gives HIV infection more chance to grow).
 Take specific immunizations as would be advised by your doctor.
 Stop smoking, and stop using any medication not prescribed by your doctor.
 Eat healthy foods. This will keep you strong, keep your weight up, and help your body
protect itself.
 Exercise regularly to stay strong and fit.
  Get enough sleep and rest.

What are the common presentation of AIDS ?

Due to destruction of the immune system, the patient may suffer from symptoms related to many
different opportunistic infections. These include:

 High fever
 Profuse sweating
 Diarrhea
 Weight loss
 Enlarged lymph nodes
 Skin rashes or itching
 Changes in vision
 Mouth thrush and sores
 Trouble swallowing
 Breathing problems.

AIDS patients can present with some cancers that further deteriorate their health status.

What is the most common life-threatening opportunistic infection affecting people living with
HIV/AIDS?
Tuberculosis (TB) is by far the most common killing infection among AIDS patients. It kills nearly a
quarter of a million people living with HIV each year. It is the leading cause of death among these
people.
Other infections include: Pneumonia, Hepatitis C, Cytomegalovirus, Toxoplasmosis,
Cryptosporidiosis, and others.

What is the treatment for HIV or AIDS?

Medicines: The drugs used to treat HIV or AIDS are called antiretroviral medicines because HIV is a
certain type of virus c known as retrovirus. These medicines are very powerful in controlling the virus
and slowing progression of the infection, but they do not cure it.
Treatment Regimen: The recommended treatment for HIV is a combination of three or more
medicines, and this regimen is called Highly Active Antiretroviral Therapy (HAART).

When HIV patient will start getting this treatment?

It is only the doctor who will decide when to start the antiretroviral medications for HIV patients. The
decision is usually taken based on the CD4 cells count, viral load, and clinical assessment. Generally,
antiretroviral treatment (ART) in HAAD facilities is started when the CD4 count drops below 300 per
cubic mm of blood.

How to protect yourself of getting the infection?

It is always true that prevention is better than treatment, especially when it comes to a serious killing
preventable infection like HIV/AIDS. Below are the best ways to minimize the risk of getting infected:

 Keep a faithful relationship with a single uninfected partner.

 Use male or female condoms correctly each time you have sex.
 Don’t share needles or syringes used by others.
 Don’t share equipments to prepare drugs for injection.
 Don’t share razors or toothbrushes with others.
 Don’t share any sex instruments.

How to protect others if you have HIV?

 Tell your partner you have HIV.

 The surest way to avoid spreading the infection is to not to have sex.
 Use condom consistently and correctly when doing sex with your partner (condom use does
not guarantee 100% protection).
 Use protection during oral sex. A condom or dental dam (a square piece of latex used by
dentists) can be used. Do not reuse them.
 Do not share sharp instruments with others.
 Do not donate blood, plasma, or organs.
  For a pregnant woman, she has to talk right away to the doctor. Taking treatment will
greatly increase the baby’s chance of not getting HIV.

Where can I find help about HIV/AIDS?

If you are diagnosed with HIV or you develop AIDS:

 Do not hesitate to seek help from your healthcare provider or HAAD Communicable Diseases
Centers in your region for follow up and advice.
 You will be given all information you need with full confidentiality.
 All needed psychological and social support will be provided as required.

You will be updated on this Website once a Helpline/Network gets established

Food
poisoning
self-care at
home
 Self-care at Home
 Short episodes of vomiting and small amounts of
diarrhea lasting less than 24 hours can usually be cared
for at home.
 Do not eat solid food while nauseous or vomiting but
drink plenty of fluids.
 Small, frequent sips of clear liquids (those you can see
through) are the best way to stay hydrated.
 Avoid alcoholic, caffeinated, or sugary drinks. Over-the-
counter rehydration products made for children such as
Pedialyte and Rehydralyte (ORS) are expensive but
good to use if available.
 After successfully tolerating fluids, eating should begin
slowly, when nausea and vomiting have stopped.
 Plain foods that are easy on the stomach should be
started in small amounts. Consider eating rice, wheat,
breads, potatoes, low-sugar cereals, lean meats, and
chicken (not fried) to start. Milk can be given safely,
although some people may experience additional
stomach upset due to lactose intolerance.
 Most food poisonings do not require the use of over-
the-counter medicines to stop diarrhea, but they are
generally safe if used as directed. It is not
recommended that these medications be given to
children. If there is a question or concern, you should
always check with a doctor.

Viral Hepatitis: A through E

What is viral hepatitis?
Viral hepatitis is inflammation of the liver caused by a virus. Several different viruses, named the hepatitis
A, B, C, D, and E viruses, cause viral hepatitis.
All of these viruses cause acute, or short-term, viral hepatitis. The hepatitis B, C, and D viruses can also
cause chronic hepatitis, in which the infection is prolonged, sometimes lifelong. Chronic hepatitis can lead
to cirrhosis, liver failure, and liver cancer.
Researchers are looking for other viruses that may cause hepatitis, but none have been identified with
certainty. Other viruses that less often affect the liver include cytomegalovirus; Epstein-Barr virus, also
called infectious mononucleosis; herpes virus; parvovirus; and adenovirus.

What are the symptoms of viral hepatitis?

 Symptoms include
 jaundice, which causes a yellowing of the skin and eyes
 fatigue
 abdominal pain
 loss of appetite
 nausea
 vomiting
 diarrhea
 low grade fever
 headache

However, some people do not have symptoms.

Hepatitis A

How is hepatitis A spread?

Hepatitis A is spread primarily through food or water contaminated by feces from an infected person.
Rarely, it spreads through contact with infected blood.

Who is at risk for hepatitis A?

People most likely to get hepatitis A are

 international travelers, particularly those traveling to developing countries

 people who live with or have sex with an infected person
 people living in areas where children are not routinely vaccinated against hepatitis A, where
outbreaks are more likely
 day care children and employees, during outbreaks
 men who have sex with men
 users of illicit drugs

How can hepatitis A be prevented?

The hepatitis A vaccine offers immunity to adults and children older than age 1. The Centers for Disease
Control and Prevention recommends routine hepatitis A vaccination for children aged 12 to 23 months and
for adults who are at high risk for infection. Treatment with immune globulin can provide short-term
immunity to hepatitis A when given before exposure or within 2 weeks of exposure to the virus. Avoiding
tap water when traveling internationally and practicing good hygiene and sanitation also help prevent
hepatitis A.

What is the treatment for hepatitis A?

Hepatitis A usually resolves on its own over several weeks.

Hepatitis B

How is hepatitis B spread?

Hepatitis B is spread through contact with infected blood, through sex with an infected person, and from
mother to child during childbirth, whether the delivery is vaginal or via cesarean section.
Who is at risk for hepatitis B?
People most likely to get hepatitis B are

 people who live with or have sexual contact with an infected person
 men who have sex with men
 people who have multiple sex partners
 injection drug users
 immigrants and children of immigrants from areas with high rates of hepatitis B
 infants born to infected mothers
 health care workers
 hemodialysis patients
 people who received a transfusion of blood or blood products before 1987, when better tests to
screen blood donors were developed
 international travelers

How can hepatitis B be prevented?

The hepatitis B vaccine offers the best protection. All infants and unvaccinated children, adolescents, and
at-risk adults should be vaccinated. For people who have not been vaccinated, reducing exposure to the
virus can help prevent hepatitis B. Reducing exposure means using latex condoms, which may lower the
risk of transmission; not sharing drug needles; and not sharing personal items such as toothbrushes, razors,
and nail clippers with an infected person.

What is the treatment for hepatitis B?

Drugs approved for the treatment of chronic hepatitis B include alpha interferon and peginterferon, which
slow the replication of the virus in the body and also boost the immune system, and the antiviral drugs
lamivudine, adefovir dipivoxil, entecavir, and telbivudine. Other drugs are also being evaluated. Infants
born to infected mothers should receive hepatitis B immune globulin and the hepatitis B vaccine within 12
hours of birth to help prevent infection.
People who develop acute hepatitis B are generally not treated with antiviral drugs because, depending on
their age at infection, the disease often resolves on its own. Infected newborns are most likely to progress
to chronic hepatitis B, but by young adulthood, most people with acute infection recover spontaneously.
Severe acute hepatitis B can be treated with an antiviral drug such as lamivudine.

Hepatitis C

How is hepatitis C spread?

Hepatitis C is spread primarily through contact with infected blood. Less commonly, it can spread through
sexual contact and childbirth.

Who is at risk for hepatitis C?

People most likely to be exposed to the hepatitis C virus are

 injection drug users

 people who have sex with an infected person
 people who have multiple sex partners
 health care workers
 infants born to infected women
 hemodialysis patients
 people who received a transfusion of blood or blood products before July 1992, when sensitive
tests to screen blood donors for hepatitis C were introduced
 people who received clotting factors made before 1987, when methods to manufacture these
products were improved

How can hepatitis C be prevented?

There is no vaccine for hepatitis C. The only way to prevent the disease is to reduce the risk of exposure to
the virus. Reducing exposure means avoiding behaviors like sharing drug needles or personal items such as
toothbrushes, razors, and nail clippers with an infected person.

What is the treatment for hepatitis C?

Chronic hepatitis C is treated with peginterferon together with the antiviral drugs.
If acute hepatitis C does not resolve on its own within 2 to 3 months, drug treatment is recommended.

Hepatitis D

How is hepatitis D spread?

Hepatitis D is spread through contact with infected blood. This disease only occurs at the same time as
infection with hepatitis B or in people who are already infected with hepatitis B.

Who is at risk for hepatitis D?

Anyone infected with hepatitis B is at risk for hepatitis D. Injection drug users have the highest risk. Others
at risk include

 people who live with or have sex with a person infected with hepatitis D
 people who received a transfusion of blood or blood products before 1987

How can hepatitis D be prevented?

People not already infected with hepatitis B should receive the hepatitis B vaccine. Other preventive
measures include avoiding exposure to infected blood, contaminated needles, and an infected person’s
personal items such as toothbrushes, razors, and nail clippers.

What is the treatment for hepatitis D?

Chronic hepatitis D is usually treated with pegylated interferon, although other potential treatments are
under study.

Hepatitis E

How is hepatitis E spread?

Hepatitis E is spread through food or water contaminated by feces from an infected person. This disease is
uncommon in the United States.

Who is at risk for hepatitis E?

People most likely to be exposed to the hepatitis E virus are

 international travelers, particularly those traveling to developing countries

 people living in areas where hepatitis E outbreaks are common
 people who live with or have sex with an infected person

How can hepatitis E be prevented?

There is no U.S. Food and Drug Administration (FDA)-approved vaccine for hepatitis E. The only way to
prevent the disease is to reduce the risk of exposure to the virus. Reducing risk of exposure means avoiding
tap water when traveling internationally and practicing good hygiene and sanitation.

What is the treatment for hepatitis E?

Hepatitis E usually resolves on its own over several weeks to months.

Points to Remember

 Viral hepatitis is inflammation of the liver caused by the hepatitis A, B, C, D, or E viruses.

 Depending on the type of virus, viral hepatitis is spread through contaminated food or water,
contact with infected blood, sexual contact with an infected person, or from mother to child
during childbirth.
 Vaccines offer protection from hepatitis A and hepatitis B.
 No vaccines are available for hepatitis C, D, and E. Reducing exposure to the viruses offers the
best protection.
 Hepatitis A and E usually resolve on their own. Hepatitis B, C, and D can be chronic and serious.
Drugs are available to treat chronic hepatitis.

What else causes viral hepatitis?

Some cases of viral hepatitis cannot be attributed to the hepatitis A, B, C, D, or E viruses, or even the less
common viruses that can infect the liver, such as cytomegalovirus, Epstein-Barr virus, herpes virus,
parvovirus, and adenovirus. These cases are called non-A–E hepatitis. Scientists continue to study the
causes of non-A–E hepatitis.
Measles

What is measles disease? and How it is transmitted?

Measles is a highly contagious viral disease, which affects mostly children. It is transmitted via droplets
from the nose, mouth or throat of infected persons. Infected persons are usually contagious from 4
days before onset of signs or symptoms, and until 4 days after the onset of signs or symptoms.

What are the signs and symptom of the disease?

The first sign of measles is usually a high fever, which begins about 10 to 12 days after exposure to
the virus, and lasts four to seven days. A runny nose, a cough, red and watery eyes, and small white
spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually on
the face and upper neck. Over about three days, the rash spreads, eventually reaching the hands and
feet. The rash lasts for five to six days, and then fades. On average, the rash occurs 14 days after
exposure to the virus (within a range of seven to 18 days).
Severe measles is more likely among poorly nourished young children, especially those with
insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.

Who is at risk?
People who have not received the vaccine for measles are much more likely to develop the disease.
People who recover from measles are immune for the rest of their lives.

Is there any treatment for measles disease?

There is no specific treatment for measles and most people recover within 2–3 weeks.

Dose the disease cause any complications?

Yes, particularly in malnourished children and people with reduced immunity; measles can cause
serious complications, including pneumonia, encephalitis, severe diarrhea, ear infection and
blindness.

How it is prevented?
Measles can be prevented by immunization. The measles vaccine has been in use for over 40 years. It
is safe and effective. The measles vaccine is often incorporated with rubella and/or mumps vaccines in
countries where these illnesses are problems. It is equally effective in the single or combined form.
Two doses of the vaccine are recommended to ensure immunity, as about 15% of vaccinated children
fail to develop immunity from the first dose.

When should I consult a doctor?

Call your doctor if you think you or your child may have been exposed to measles, or if you or your
child exhibits symptoms that make you suspect measles. Review your family's immunization records
with your doctor.