Department of Clinical Pharmacy 4THYEAR

Pharmacy Practice 2
Drug Monograph and Portfolio Submitted to the Department of Clinical
Pharmacy for Hospital pharmacy clerkship

BY Id NO
Birhan Maru……………………..0311/11
Preceptor: Mr. Chalelgn Kassaw (B. Pharm, MSc)

January 25 /2015 EC
ADDIS ABEBA , ETHIOPIA

Acknowledgment
First of all I would like to thank our teachers and our department head for letting us
practice what we have been learning in theory for 4 years practically. I also like to thank
the owner and manager of yikatit 12 hospital medical collage and all staffs (pharmacy
professsionals) for letting us practice during the one month time period to complete our
attachment.Special thanks for showing us how to interact with patients, choose the
appropriate drugs, label, give counseling tip , stock controlling, bin card balance recording
and file organizing.

Table of content
Acknowledgment..................................................................................................................................... II

1. Introduction....................................................................................................................................... 1

1.1 Hospital Pharmacist....................................................................................................................... 1

1.2. Clinical pharmacy services in Hospital pharmacy................................................................ 1

2. Description of attachment area........................................................................................................ 2

3. Observation and Discussion............................................................................................................ 4

4. Summary and Recommendations................................................................................................... 6

5. Counseling tip monograph............................................................................................................... 6

References............................................................................................................................................... 48

Introduction
1.Hospital pharmacy is the health care service, which comprises the art, practice, and
profession of choosing, preparing, storing, compounding, and dispensing medicines and medical
devices. advising healthcare professionals and patients on their safe, effective and efficientis the
department or service in a hospital which is under the direction of a professionally competent,
legally qualified pharmacists, and from which all medications are supplied to the nursing units
and other services, special prescriptions are filled for patients in the hospital, for ambulatory
patients and out-patients, pharmaceuticals are manufactured in bulk, narcotic and other
prescribed medications are dispensed, injectable preparations prepared and sterilized, and
professional supplies are often stocked and dispensed.

Generally pharmaceutical services in hospital can be

 Inpatient service

 Outpatient service

 Emergency service

 Drug information service

 Paedatrics service

 Drug informatio service

 ART service

 Compounding service
. Other units shall also be established depending on the hospital complexity and demand. Each unit
should be directed by a registered pharmacist.
 OPD Pharmacy Service Unit: shall be organized in one primary location that is
accessible to all categories of patients. But, it may also be organized in multiple locations (e.g.
general OPD pharmacy,
 ART pharmacy, chronic care pharmacy, MCH pharmacy, etc.) depending on the
arrangement of the OPD clinics, proximity and complexity of the hospital so as to improve
accessibility and convenience to patients. Patient waiting areas at the OPD pharmacy units
should be fitted with adequate seats and shading to ensure patient safety and convenience.
Patients with chronic illnesses should be followed up at respective OPD pharmacy or separate
Chronic Care Pharmacies. Depending on the hospital’s level and service specialization, one or
more chronic care pharmacies shall be established. All patients who have follow-up in these
pharmacies shall have individual patient medication profile (PMP) records. The PMP should
be updated by the dispensing pharmacist whenever a refill medication or other drugs are
dispensed to the patient. When a patient presents to the pharmacy for a refill, the pharmacist
must assess the patient for signs of compliance/ adherence, effectiveness and safety of the
therapy.

 Inpatient pharmacy services should function under unit dose dispensing system and
work for 24 hours and 7 days a week.

 Emergency Pharmacy Service Unit: should be organized within or near the

emergency department. The dispensing process should be organized such that medicines reach
to the patient as fast as possible. Emergency pharmacies should function for 24 hours and 7
days a week.

1.1 Services rendered in hospital pharmacy

The Hospital pharmacy provides services that are critical to safe, effective, and cost-effective
medication use in a hospital which includes: the procurement, distribution, and control of all
pharmaceuticals used within the facility, Medication-use policy development, the evaluation and
dissemination of comprehensive information about Medications and their use to the institution's
staff and patients, clinical service and patient care , the monitoring, evaluation, and assurance of
the quality of Medication use and education & research.
1.2 Clinical pharmacy services in hospital pharmacy
Clinical pharmacy services offered in 50% or more of Pharm.D.-affiliated hospitals (core
services) were drug-use evaluation, in-service education, pharmacokinetic consultations,
adverse drug reaction management, drug therapy monitoring, protocol management (most
common for aminoglycosides, nutrition, antibiotics, heparin, warfarin, theophylline), nutrition
team, and drug counseling. Comprehensive pharmaceutical care programs were established in
64%, 42%, and 33% of Pharm.D., B.S., and nonteaching hospitals, respectively. Patient-focused
care programs were beginning or established in 77%, 71%, and 60%, respectively. Pharmacists
served as care team leaders in 23% of hospitals affiliated with a college of pharmacy. Most
common ambulatory care clinics were oncology, anticoagulation, diabetes, geriatrics, refill, and
infectious diseases/HIV. For-profit hospitals rarely provided education for pharmacy students.

2. Description of attachment area

A Name and location of the pharmacy
Yekatit 12 Specialized Hospital was established on 1937E.C.Yekatit 12 (Amharic: የካቲት ፲፪,
romanized: Yekatīt 12) is a date in the Ge'ez calendar which refers to the massacre and
imprisonment of Ethiopians by the Italian occupation forces following an attempted
assassination of Marshal Rodolfo Graziani, Marquis of Negele, Viceroy of Italian East Africa, on
February 19, 1937. Graziani had led the Italian forces to victory over the Ethiopians in the
Second Italian invasion of Ethiopia and was supreme governor of Italian East Africa. This has
been described as the worst massacre in Ethiopian history
There are 58 pharmacists working in the hospital. The hospital pharmacy service directorate
comprises of five case teams; Outpatient, inpatient, emergency, oncology, ART, pediatrics , OR,
communituy pharmacy, compounding unit, unite dose ,clinical pharmacy, DIS,medical
store ,supply store.
Outpatient pharmacy: which serves the largest numbers of customers is located on the
ground infront of the caffe. It has about 9 shelves with full of drugs based on their
pharmacotherapuetic category.OPD has 9 pharmacistes and 3 cashers and it has also 9
windows . it has one semiprivate counsiling window.
Inpatient pharmacy: found at 2nd floor and fourth floor , it serves patients which are
admitted from the same floor.it has 3 pharmacistes each and 2 cashers each.
ART pharmacy: found on the on the ground at the right side nexet to huge building in the
hospitol.it has 2 pharmacistes and one data clark.
Emergency adult: located in the first floor next to emergency laboratory or in front of
diabetes mellitus (DM) clinic.

Human resource organization

 OPD pharmacy
It has about 9 shelves with full of drugs based on their pharmacotherapuetic category.OPD has 9
pharmacistes and 3 cashers and it has also 9 windows . it has one semiprivate counsiling
window. This pharmacy gives 24 hours service. Pharmacists are allocated on different windows
conducive to implement APTS. Two pharmacist assigned at the free patients’ registry (for those
who are government sponsored) window and three pharmacist assigned at the Evaluator/billing
window for those who can afford to buy, the remaining group sit in the middle counseling
windows.Pharmacists made prescription evaluation and quantification of each medication and
then patients referred to the dispensing/counseling counter. Finally pharmacists who are working
at dispensing counter dispense and provide counseling for each patients or care givers.
 In patient pharmacy It has 3 permanent pharmacists for each (in patient one and in
patient two)and 2 cashers for each, This pharmacy gives 24 hours service for patients
from OR, NICU, pediatrics and adult patients. Nurses or the care givers bring the
prescription together with patients’ card and the pharmacist working there cross check the
prescription with physician order, quantify and finally dispense all prescribed
medications after getting signature from the recipients in unit dose systeme.
 In emergency pharmacy
It has three permanent pharmacists, one is case team leader, two cashers, and several cleaners.
This pharmacy gives 24 hours service. They also implement APTS and to serve free patients in
one window. Sometimes nurses bring the prescription together with patients’ card and the
pharmacist working there cross check the prescription with physician order, quantify and finally
dispense all prescribed medications after getting signature from the recipients.
 In ART pharmacy
It has two permanent pharmacists, one is case team leader and one data clark. All are free
patients. This pharmacy gives eight hours service. It also gives service on the weekend. There is
no separate room for counseling but pharmacist do counseling for patents on starting or
switching of their medications.

Average number of customers per day

Even though the outpatient pharmacy (OPD) holds or gives services for maximum number of
patient compared to other pharmacy units, there is no accurate data on the number of service
delivered from this unit.
Similarly in emergency pharmacy this information is not reliably kept, although by looking the
registry of the last 4 weeks, on average 35 patients got service daily from this pharmacy.

 Layout of the pharmacy

 OPD pharmacy in dispensing unit there are 9 shelves, all are for medication.
Medications are placed in therapeutic order assigned as cardiovascular (CVS), respiratory,
ant diabetics, anti-infective, central nervous system (CNS), dermatological, gastrointestinal
(GI), ear nose and throat (ENT), vitamins and minerals. Each product has specific bin card
sited on the corresponding shelves. Medication transaction has taken place between the
store, dispensing unit and external suppliers based on current a requirement and needs after
the head pharmacist fill out and send IFRR forms.
 Emergency pharmacy has 3 shelves one is for supplies the rest twos are for
medication, five chairs,1 desk, no have refrigerator and pill counting trays.it has its own
drug store .
Emergency medications, CNS drugs, antibiotics,CVD,ART, Respiratory,antiprotozoal
drugs ,fluids and some medical supplies are found in this pharmacy. Attendants are served
through entery of the pharmacy.it has no any separet window.
In inpatient pharmacy: this contains three shelves, one refrigerator, two computers, one desk,
attendants sitting chair and a couple of chairs. On this pharmacy particularly, antibiotics,
analgesics, CVD, fluids, syringes and other miscellaneous medications are found.
On ART pharmacy three shelves two for ART and other for OI drugs, two computers, and four
chairs are found.it has also pill count. Medications are those
NRTS,NNRTS,protaseinhibitors,integraseinhibitors,cotrimoxazole,INH ,rifampitin,pyridoxine
are found.it has one druge store.
In this unite balace is there used to measure patient’s weight.
Medical store; there are two pharmacistes. It is found on the ground next to community
pharmacy.
Supply store ; it has two pharmacistes. It is found underground of the hiuge building.

3. Observation and Discussion

Analysis of strength and weakness of the pharmacy and the service

Strengths

 It has good working environment and use current technology the so called DAGU.
 IT has fast communication with their colleges (pharmacists who works in different
dispensing units, EPSA and physicians) by the help of DAGU.
 Pharmacists are good communicator and alert when giving survise.
 The areas are well clean and thidy.
 OPD has both entry and exit doors, semiprivate counselling section
 The hospital has internal technology called EMR it is function only the hospital itself.it a
means of internal communication purpose.
 There is full of professionals in each pharmacy unites.
 Counselling practices are some very good
 In the OPD there is guarded to keep clients queue

Weakness

 Controlled drugs are not well locked in the cabinet

 No private counselling area so patient confidentiality is not secured.
 Lack of checking by pharmacists whether there is drug interactions or not
 There is scarcity of different items like doltagravire , atrovastatin, et c
 There is also a gap on labelling of medication, even most drugs are placed in therapeutic
order there are also shelves which require labelling,
 In this pharmacy there is no place for preparing medication (extemporaneous
preparation),
 Written instructions are given rarly for patients.
Comparison of attachment site with available standards
As compared to the national standard the hospital layout can not fullfill the standared, The
dispensing area have separated payment and counseling, and waiting area is available outside of
OPD pharmacy, prescriptions are usually signed by evaluators in OPD pharmacy but counselors
are not performing their duties in this regard. Drug therapy problems are neither identified nor
documented in OPD pharmacy. APTS is implemented in these hospital pharmacies.

Lesson learned and Contribution during your stay

Lesson learned during attachment period are how to interact with customers, different brands of
medication, different dosage forms, about different fixed dose combinations, about available
doses of medication, and how medication are documented. My contribution in those pharmacies
was participating in dispensing practice, documenting prescriptions, identifying DTPS and
working/helping on the system.

4. Summary and Recommendations

Based on the gaps identified during attachment period the following recommendations are
forwarded. The pharmacy needs to fulfill or avail essential medications, regarding to labeling
both medication as well as shelves should be labeled properly, a separate locked cabinet is
required for psychotropic and narcotics, the hospital pharmacy has limited number of stuffs
compare to patients who seek service so extra stuffs should be hired, the stuffs working there
needs to improve their competency and participate in drug therapy problem solving process.
In summary, most of the gaps identified in this pharmacy are not only specific to this one, its
common problem throughout the country. Therefore all stakeholders should work together to
improve the quality of care provided from hospital pharmacy in general.

5. drug monograph
Table of contents.
1. Metformin
2. Tramadol
3. Dexametazone
4. Hydrochlorothiazide
5. prazilquatel

1. Generic name Metformin 500mg, 850mg, 1000mg

1.1 Brand name met-denk-100birrperstrip
.Metformin.is the treatment of type 2 diabetes, particularly in overweight patients, whan
dietary management and exercise alone does not result in adequate glacaemic control.
.may be used as mono therapy or in combination with other oral anti-diabetic agents, or with
insulin
1.2 Classification
Therapeutic:anti-diabetics
Pharmacologic:biguanides
Pregnancy Category B
1.3 MECHANISM OF ACTION
Decreases hepatic glucose production. Decreases intestinal glucose absorption. Increases
sensitivity to insulin. Therapeutic Effects: Maintenance of blood glucose.
1.4 INDICATIONS
Management of type2 diabetes mellitus; maybeusedwithdiet, insulin, or sulfonylurea or
hypoglycemic.
Metabolism and Excretion :Eliminated almost entirely unchanged by the kidneys.
Half-life:17.6hr.
1.5 CONTRAINDICATIONS AND PRECAUTIONS
Contraindicated n: Hypersensitivity; Metabolic acidosis ;Dehydration ,sepsis ,hypoxaemia,
hepatic impairment, excessive alcohol use(acuteor chronic); Renal dysfunction
(SCr>1.5mg/dLinmenor>1.4mg/dLinwomen); Radiographic studies requiring IV iodinated
contrast media (withholdmetformin); HF.

1.6 PRECAUTIONS: Concurrent renal disease; Geri: Geriatric /debilitatedpatients

(decrease doses may be required; avoid inpatients >80yr unless renal function is
normal) ;Chronic alcohole use /abuse ;Serious medical conditions (MI,stroke) ;Patients under
going stress (infection, surgical procedures) ; Hypoxia; Pituitary deficiency or hyperthyroidism;
OB: Lactation: Pediyatric: Pregnancy, lactation, or children <10yr (safety note stablished;
extended release for use inpatients >17yr only).

1.7 ADVERSE REACTIONS AND SIDEFFECTS

GI : abdominal bloating, diarrhea, nausea, vomiting, unpleasant
metallictaste. :hypoglycemia. :decreased vitamin B12 levels.

1.8 INTERACTIONS
Drug-Drug: Acute or chronic alcohol ingestion or iodinated contrast media increase risk of lactic
acidosis .Amiloride ,digoxin, morphine, procainamide ,quinidine, ranitidine, triamterene,
trimethoprim, calcium channel blockers, and vancomycin may compete for elimination
pathways with metformin. Altered responses may occur. Cimetidine and furosemide may
increase effects of metformin. Nifedipine increase absorption and effects.
Drug-Natural Product: Glucose amine may worsen blood glucose control. Chromium, and
coenzyme Q-10 may produce increase hypoglycemic effects.

1.9 ROUTE/DOSAGE
PO: (Adults and children >17yr): 500mg twice daily; may increased by 500mg at weekly intervals
up to 2000mg/day. If doses >2000mg/day are required givein three divided doses (not to
exceed 2500mg/day) or 850mg once daily; may increase by 850mg at 2-week intervals (in
divided doses) up to 2550mg/day in divided doses (up to 850mg three times daily); Extended-
release tablets—500–1000mg once daily with evening meal, may increase by 500mg at weekly
intervals up to 2500mg once daily. If 2000mg once daily is in adequate ,1000mg twice daily may
be used.
PO: (Children >10yr): 500mg twice daily, may be increase by 500mg/day at 1-week intervals ,up
to 2000mg /day in 2divideddoses.

2. Generic name; tramadol

2.1, Brand name ASPrin 50mg
 Price 1 strip 25birr

2.2,Classification
Therapeutic:analgesics,(centrallyacting)
Pregnancy Category C
2.3 MECHANISM OF ACTION
Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the
CNS.Therapeutic Effects: Decreased pain.
2.4 INDICATIONS
Moderate to moderately severe pain (extended-release formulations indicated for patients who
require around-the-clock pain management).
2.5, Distribution:Crosses the placenta; enters breast milk.
Metabolism and Excretion: Mostly metabolized by the liver ;one metabolite has analgesic
activity; 30% is excreted unchanged in urine.
Half-life: Tramadol—6–8hr,ER—7.9hr; active metabolite—7–9hr; both are increase in renal or
hepatic impairment.

2.6, CONTRAINDICATIONS AND PRECAUTIONS

Contraindicated in :Hyper sensitivity; Cross-sensitivity with opioids may occur ;Patients who are
acutely intoxicated with alcohol, sedatives /hypnotics ,centrally acting analgesics ,opioid
analgesics, or psychotropic agents; Patients who are physically dependent on opioid analgesics
(may precipitate withdrawal); Ryzolt only—Acute or severe bronchial asthma or hypercapnia in
un monitored settings or in absence of resuscitative equipment; :Lactation: Pregnancy or
lactation; only—CCr<30mL/min or hepatic impairment.
2.7, PRECAUTIONS; Geri:Immediate-release—Not to exceed 300mg/day in patients
>75yr ;ER—Use with extreme caution in patients >75yr ;Patients with ahistory of epilepsy or risk
factors for seizures ;Renal impairment (increase dosing interval recommended if
CCr<30mL/min) ;Hepatic impairment (increase dosing interval recommended inpatients with
cirrhosis) ;Patients receiving MAO inhibitors, neuroleptics, SSRIs, or TCAs ,or other CNS
depressants; Patients who are suicidal or prone to addiction (increase risk of suicide); Excessive
use of alcohol (increase risk of suicide); increase intra cranial pressure or head trauma; Patients
with a history of opioid dependence or who have recently received large doses of opioid; Pedi:
Children<16yr (safety not established).
2.8 ADVERSE REACTIONS AND SIDEFFECTS
CNS: SEIZURES, dizziness, headache , somnolence, anxiety, CNS
stimulation ,confusion ,coordination disturbance ,euphoria, malaise, nervousness, sleep
disorder, weakness. EENT :visual disturbances. CV: vasodilation. GI :constipation,
nausea ,abdominal pain ,anorexia, diarrhoea , dry mouth, dyspepsia, flatulence, vomiting .GU:
menopausal symptoms, urinary retention/frequency .Derm: pruritus, sweating .Neuro:
hypertonia .Misc :SEROTONIN SYNDROME,physical dependence, psychological
dependence ,tolerance.

2.9 INTERACTIONS
Drug-Drug: increase risk of CNS depression when used concurrently with other CNS
depressants, including alcohol,antihistamines,sedative/hypnotics,opioid
analgesics,anaesthetics,or psychotropic agents. Increase risk of seizures with high doses of
penicillins, cephalosporins, phenothiazines, opioid analgesics, or antidepressants.
Carbamazepine increase metabolism and dcreases effectiveness of tramadol (increased doses
may be required). Use cautiously inpatients who are receiving MAO inhibitors (increase risk of
adverse reactions). Quinidine, fluoxetine, paroxetine, amitriptyline, ketoconazole, and
erythromycin mayincrease levels. Increase risk of serotonin syndrome when used with SSRI and
SNRI antidepressants, TCAs, MAO inhibitors ,5HT1 agonists, CYP2D6 inhibitors, and CYP3A4
inhibitors.
Drug- Natural Product: Concomitant use of kava-kava, valerian, or chamomilecan increase CNS
depression. Increase risk of serotonin syndrome when used with St.Johns' wort.
2.10 ROUTE/DOSAGE
Immediate-release (including orally- disintegrating tablets)
PO: (Adults ≥18yr): Rapid titration—50–100mgq4–6hr (not to exceed 400mg/day [300mg
inpatients >75yr]). Gradual titration—25mg/day initially, increase by 25mg/day q3 days to
reach dose of 25mg 4times daily, then increase by 50mg/day q3 days to reach dose of 50mg
4times daily; may then use 50–100mgq 4–6hr (maximum dose=400mg/day).
Renal Impairment
PO: (Adults): CCr<30mL/min— increase dosing interval to q12hr (not to exceed 200mg/day).
Hepatic Impairment
PO: (Adults) :50mg q12hr.
Extended-release
PO: (Adults):Ultra mER (not currently receiving immediate-release)—100mg once daily
initially ,may then titrate q5days up to 300mg/day; Ultra mER (currently receiving immediate-
release)—calculate24- hr total dose of immediate-release product and gives adose (rounded
down to next lowest 100-mgincrement) of ER once daily (maximum dose= 300mg/day); Ryzolt
(not currently receiving immediate- release )—100mg once daily initially, may then titrate by
100mg/day q2–3days up to 300mg/day; Ryzolt (currently receiving immediate- release)—
Calculate 24- hr total dose of immediate-release product and gives adose (rounded down to
next lowest 100-mg increment) of Ryzol to once daily (maximum dose= 300mg/day).

3.Generic name, Dexamethasone (injection)

Brand name Dexa 1vial-120bir
3.1 Classification
Therapeutic: corticosteroids
Pregnancy Category C
3.2 MECHANISM OF ACTION
In Pharmacologic doses, suppresses inflammation and then or malimmune response. Has
numerous in tense metabolic effects (see Adverse Reactions and Side Effects). Suppresses
adrenal function at chronic doses of 0.75mg/day. Has negligible mineral cortical alctivity.
Therapeutic Effects: Suppression of inflammation and modification of then or malimmune
response.

3.3 Lesson learned and Contribution during your stay

INDICATIONS
Used systemically and locally in awide variety of chronic diseases including: Inflammatory,
Allergic, Hematologic, Endocrine, Neoplastic, Dermatologic, Auto immune disorders,
Management of cerebral edema, Diagnostic agent in adrenal disorders. Unlabeled Uses :Short-
term administration to high-risk mothers before delivery to prevent respiratory distress
syndrome in the new born. Adjunctive management of nausea and vomiting from
chemotherapy. Treatment of air way edema prior to extubation. Used in neonates with
broncho pulmonary dysplasia to facilitate even til at or weaning.
Distribution: Widely distributed, crosses the placenta, and appears to enter breast milk.
Metabolism and Excretion: Mostly metabolized by the liver.
Half-life ; Low birth weight infants with BPD :9.3hr ;Children 3mo–16yr: 4.3hr; Adults: 3–4.5hr
(plasma), 36–54hr (tissue); adrenal suppress ion lasts 2.75days.
3.4 CONTRAINDICATIONS AND PRECAUTIONS
Contraindicated in: Active untreated infections (may be used in patients being treated for tube
rculous meningitis) ;Known alcohol or bisulfate hypersensitivity or intolerance (some products
contain these and should be avoided in susceptible patients) ;Lactation :Avoid chronic use.
3.5 PRECAUTIONS: Chronic treatment (will lead to adrenal suppression; use lowest possible
dose for shortest period of time) ;Stress (surgery, infections); supplemental doses may be
needed; Potential infections (may mask signs); OB :Safety note stablished; Pedi: Early post natal
administration of high doses can cause significant and persistent reductions inneuro motor and
cognitive functioning; results in decrease growth; use lowest possible dose for shortest period
of time.
3.6 ADVERSE REACTIONS AND SIDEEFFECTS
Adverse reactions/side effects are much more common with high- dose/long-term therapy
CNS: depression, euphoria, hallucinations, headache, increase intracranial pressure
(childrenonly), insomnia, personality changes, psychoses, restlessness. EENT: cataracts, increase
intra ocular pressure. CV: hypertension, edema. GI: PEPTICULCERATION, anorexia, nausea,
increase appetite, vomiting. Derm: acne, decrease wound healing ,ecchymoses, hirsutism,
petechiae. Endo: adrenal suppression, hyperglycemia. FandE: amenorrhea, hypokalemia,
alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain. MS: muscle
wasting, osteoporosis, avascular necrosis of joints, muscle pain. Misc: cushing oid appearance
(moon face,buffal hump),increase susceptibility to infection.
3.7 INTERACTIONS
Drug-Drug: increase risk of hypokalemia with thiazide and loop diuretics, amphoteric in
B,piperacillin, orticarcillin. Hypokalemia may increase risk of digoxin toxicity. May increase
requirement for insulin or oral hypoglycemic agents. May decrease levels of phenytoin and
isoniazid. Levels may be increase with oral contraceptives. Increase risk of adverse GI effects
with NSAIDs (including aspirin), alcohol and caffeine. At chronic doses that suppress adrenal
function, may increase the antibody response to and increase risk of adverse reactions from
live-virus vaccines. May increase or decrease the effects of warfarin. Levels may be decrease
when used with phenytoin, phenobarbital, or rifampin. May increase risk often donr upture
when used with fluoroquinolones.
3.8 ROUTE/DOSAGE
IV: (Adults): Anti-inflammatory—0.75–9mg daily in divided doses q6–12hr. Air way edema or
extubation —0.5–2mg/kg/day divided q6hr; begin 24hr prior to extubation and continue for
24hr post-extubation.Cerebral edema—10mgIV, then 4mg IM or IV q6hr until maximal response
achieved, then switch to PO regimen and taper over 5–7days.
IM: IV: (Children): Airway edema or extubation —0.5–2mg/kg/day divided q6hr; begin 24hr
prior to extubation and continue for 24hr post -extubation. Anti-inflammatory
—0.08–0.3mg/kg/day or 2.5–10mg/m2/day divided q6–12hr. Physiologic replacement —0.03–
0.15mg/kg/day or 0.6–0.75mg/m2/day divided q6–12hr.
IV: (Children): Chemotherapy induce demesis—5–20mg given 15–30min be fore treatment.
Cerebral edema— Loading dose 1–2mg/kg followed by1–1.5mg/kg/day divided q4–6hr for
5days (not to exceed 16mg/day); then taper over 1–6wk. Bacterial meningitis—0.6mg/kg/day
divided q6hr x4days (start at time of first antibiotic dose).
Intras in ovial(Adults):0.4–6mg/day.
4. Generic name Hydrochlorothiazide
(25mg, 50mg, 100mg)
Brand name –HCT –SSP (25mg, 50mg, 100mg )15birr
 Microzide,
 Oretic,
 Urozide
4.1 Classification
Therapeutic: anti hypertensives, diuretics
Pharmacologic: thiazide diuretics
Pregnancy Category B
4.2 MECHANISM OF ACTION
Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule.
Promotes excretion of chloride, potassium, hydrogen ,magnesium, phosphate ,calcium and
bicarbonate. May produce arteriolar dilation. Therapeutic Effects: Lowering of BP in
hypertensive patients and dieresis with mobilization of edema.
4.3 INDICATIONS
Management of mild to moderate hypertension. Treatment of edema associated with: HF,
Renal dysfunction, Cirrhosis, Glucocorticoid therapy, Estrogen therapy.
4.4 Distribution:Distributed in to extracellular space; crosses the placenta and enters breast
milk.
4.5 Metabolism and Excretion: Excreted mainly unchanged by the kidneys.
Half- life: 6–15hr.
4.6 CONTRAINDICATIONS AND PRECAUTIONS
Contraindicated in: Hypersensitivity (cross-sensitivity with other thiazides or sulphonamides
may exist); Some products contain tartrazine and should be avoided in patients with known
intolerance; Anuria;Lactation.
4.7 PRECAUTIONS: Renal or hepatic impairment; OB: Jaundice or thrombocytopenia may be
seen in the new born.
4.8 ADVERSE REACTIONS AND SIDEEFFECTS
CNS :dizziness, drowsiness ,lethargy ,weakness. CV: hypotension. GI: anorexia, cramping,
hepatitis, nausea ,vomiting. Derm: STEVENS JOHNSON SYNDROME, photosensitivity, rash.
EENT: acute angle-closure glaucoma, acutemyopia. Endo: hyperglycemia. FandE: hypokalemia,
dehydration, hypercalcemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia,
hypophosphatemia, hypovolemia. Hemat: blood dyscrasias. Metab: hyperuricemia, hyper
cholesterolemia. MS: musclecramps. Misc: pancreatitis.
4.9 INTERACTIONS
Drug-Drug :Additive hypotension with other antihypertensives, acute ingestion of alcohol, or
nitrates. Additive hypokalemia with corticosteroids, amphotericinB, piperacillin, orticarcillin.
Decrease the excretion of lithium. Cholestyramine or colestipol decrease absorption.
Hypokalemia increase risk of digoxin toxicity. NSAIDs may decrease effectiveness.
4.10 ROUTE/DOSAGE
When used as adiuretic in adults, generally given daily, but may be given every other day or 2–3
days/week
PO: (Adults): 12.5–100mg/day in 1–2 doses (up to 200mg/day; not to exceed 50mg/day for
hypertension; doses above 25mg are associated with greater like lihood of electrolyte
abnormalities).
PO: (Children >6mo): 2 mg/kg in 2 divided doses (not to exceed 200mg/day).
PO : (Children <6mo ): Up to 2–4mg/kg /day in 2 divided doses (not to exceed 37.5mg/day).
5. Generic name Praziquantel 600mg
5.1 Classification
Therapeutic Antihelmitics
Pregnancy categoryB
5.2 MECHANISM OF ACTION
Praziquantel works by causing severe spasms and paralysis of the worms muscles this paralysis
is accompanied and probably caused by a rapid Ca+2 in fluxin side the schistosome
morphologica lalterations are another early effects of praziquantel
5.3 Indications
Praziquantel is indicated for the treatment of infections due to :all species of schistosoma (for
example,Schistosomamekongi, Schistosomajaponicum,Schistosomamansoni and
Schistosomahematobium), and infections due to the liver flukes, Clonorchissinensis
/Opisthorchis viverrini (approval of this indication was based on studies in which the two
species were not differentiated).

5.4 Contraindications and precautions

Praziquantelis contraindicated inpatients who previously have shown hypersensitivity to the
drug or any of the excipients .Since parasite destruction with in the eye may cause irreversible
lesions, ocular cysticercosis must not be treated with this compound. Concomitant
administration with strong Cytochrome P450 (P450) inducers, such as rifampin, is
contraindicateds in therapeutically effective blood levels of praziquantel may not be achieved
Inpatients receiving rifampin who need immediate treatment for schistosomiasis, alternative
agents for schistosomiasis should be considered. However, if treatment with praziquantelis
necessary, rifampin should be discontinued 4 weeks be for administration of praziquantel.
Treatment with rifampin can then be restarted one day after complet ion of praziquantel
treatment.
5.5 Precaution: Approximately 80% of adose of praziquantel is excreted in the kidneys,
almost exclusively (>99%) in the form of metabolites. Excretion might be delayed inpatients
with impaired renal function, but accumulation of unchanged drug would not be expected.
Therefore, dose adjustment for renal impairment Is not considered necessary. Nephrotoxic
effects of praziquantel or its metabolites are not known. Caution should be exercised in the
administration of the usual recommended dose of praziquantel to hepatosplenic schistosomias
is patients with moderate to severe liver impairment (Child- Pugh class B and C).Reduced
metabolis mofpraziquantel by the liver in the sepatients may lead to consider ably higher and
longer lasting plasma concentrations of un metabolized praziquantel Minimal increases in liver
enzymes have been reported in some patients Patients suffering from cardiac irregularities
hould be monitored during treatment.
As praziquantel can exacerbate central nervous system pathology due to schistosomiasis ,as
ageneral rule this drug should not be administered to individuals reporting ahistory of epilepsy
and/ or other signs of potential central nervous systems involvement sach as subcutaneous
nodules suggestive of cysticercosis.
When schistosomiasis or fluke infection is found to be associated with cerebral cysticercosisitis
advised to hospitalize the patient for the duration of treatment. Mutagenesis, Carcinogenesis
Mutageniceffects in Salmonella tests found by one laboratory have not been confirmed in the
same tested train by other laboratories. Long term carcinogenicity studies in rats and golden
hamsters did not reveal any carcinogenic effect.

5.6 Adverse reaction and Side Effects

Ingeneral ,praziquantel is very well tolerated. Side effects are usually mild and transient and do
not require treatment. The following side effects were observed generally in order of severity:
malaise ,headache ,dizziness, abdominal discomfort with or with out nausea, rise in
temperature and, rarely, urticaria. Such symptoms can, however,also result from the infection
it self .Such side effects may be more frequent and/ or serious in patients with aheavy worm
burden.

5.7 Interactions
Concomitant administration of rifampin, astrong P450 inducer ,with praziquantelis
contraindicated and must be avoided. In across over study with a 2-week wash out period, 10
healthy subjects ingested a single 40 mg/kg dose of praziquantel following pre-treatment with
oral rifampin (600mg daily for 5 days ). Plasma praziquantl concentrations were un detectable
in 7 out of 10 subjects .When asingle 40mg/kg dose of praziquantel was administered to these
healthy subjects two weeks after discontinuation of rifampin, the mean praziquantel AUC and
Cmax were 23% and 35% lower, respectively, than when praziquantel was given alone.
Inpatients receiving rifampin, for example, as part of acombination regimen for the treatment
of tuberculosis, alternative agents for schistosomiasis should be considered. However, if
treatment with praziquantel is necessary, treatment with rifampin should be discontinued 4
weeks be fore administration of praziquantel. Treatment with rifampin can be then restart
done day after completion of praziquantel treatment.

5.8 Route/Dosage
The dos age recommended for the treatment of schistosomiasisis: 20mg/kg body weight three
times a day as a one-day treatment, at intervals of not less than 4hours and not more than
6hours. There commended dose for clonorchiasis and opisthorchiasisis: 25mg/kg body weight
three times a day as a one-day treatment ,at intervals of not less than 4 hours and not more
than 6hours. The tablets should be was hed down un chewed with water during meals. Keeping
the tablets or segments there of in the mouth can reveal a bitter taste which can promote
gagging or vomiting.

References
1.Birtish Pharmacopeia.
2 Medscape
3 Pharmacy practice hand out
4 Pharmacists in yikatit 12 hospital
5 Ethiopian Hospital Transformation Guideline, 2017