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DRUG GROUPS
Prepared by: Michael Z. Cayabyab, RN, MSNc

Antianginal agents
What are Antianginal agents?

 Antianginal agents is a term used to describe a wide variety of medicines that are used in the
management of angina. Angina is a heart condition characterized by a narrowing of the coronary
arteries (the arteries of the heart). Chest pain is its main symptom.
 Antianginal agents are drugs used to provide immediate relief from angina symptoms and prevent
angina attacks.
 Angina is chest pain or discomfort that happens because of reduced blood flow to the heart.
Angina results from an imbalance in the oxygen supply/demand ratio. Due to the lower oxygen
supply and greater oxygen demand, there is increased pressure on the heart. Constriction of blood
vessels and formation of blood clots may be the major reason for disturbing the oxygen
supply/demand ratio.

Antianginal drugs act by:

 Increasing blood flow to the heart
 Increasing oxygen supply to the heart
 Dilating the blood vessels to reduce the load on the heart
 Preventing clot formation in the blood vessels
 Reducing oxygen demand by decreasing heart rate and contraction

HOW ARE ANTIANGINAL AGENTS USED?

Antianginal agents are used for treating angina pain and preventing an angina attack.

WHAT ARE SIDE EFFECTS OF ANTIANGINAL AGENTS?

Antianginal agents can cause the following side effects:
 Headache
 Low blood pressure
 Increased heart rate
 Lightheadedness
 Blurred vision
 Flushing
 Nausea and vomiting
 Nervousness
 Dry mouth
 Fatigue
 Prolonged bleeding time
 Low platelet count
 Dizziness
 Sleepiness
 Rash
 Itching
 Weakness
 Shortness of breath
 Indigestion
 Cough
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Examples of antianginal agents include:

 Nitrates (eg, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin). These relax smooth muscle
within the blood vessels, widening them and making it easier for blood and oxygen to reach the heart
 Calcium antagonists (eg, diltiazem, nifedipine, nimodipine, verapamil). These inhibit calcium transfer
into cells thereby inhibiting contraction of vascular smooth muscle
 Beta blockers (eg, atenolol, pindolol, propranolol, metoprolol). These slow the heart, reducing how hard it
has to work
 Ranolazine. The exact way it exerts its antianginal effect is not known but may be through inhibition of
ion channels during cardiac repolarization.

WHAT ARE NAMES OF ANTIANGINAL AGENTS?

Generic and brand names of antianginal agents include:
 Aliskiren/amlodipine/hydrochlorothiazide
 Amlodipine
 Amturnide
 Amyl nitrite
 Deponit
 Glyceryl trinitrate transdermal
 Glyceryl trinitrate translingual spray
 Hemangeol
 Inderal
 Inderal la
 Innopran xl
 Katerzia
 Minitran
 Nitrocine
 Nitrodur
 Nitroglycerin transdermal
 Nitroglycerin translingual
 Nitrolingual
 Nitromist
 Norvasc
 Propranolol
 Tekamlo
 Telmisartan/amlodipine
 Transdermal nitroglycerin
 Twynsta
Anticholesterol medication
A healthy lifestyle is the first defense against high cholesterol. But sometimes diet and exercise aren't
enough. You might also need to take cholesterol medications to help:
 Decrease your low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol that increases
the risk of heart disease
 Decrease your triglycerides, a type of fat in the blood that also increases the risk of heart
disease
 Increase your high-density lipoprotein (HDL) cholesterol, the "good" cholesterol that offers
protection from heart disease
Your doctor might suggest a single drug or a combination of cholesterol medications. Here's an overview
of the pros and cons for common classes of cholesterol medications.
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Drug class Benefits Possible side effects

Statins Decrease LDL and Muscle pain, increased blood sugar

Atorvastatin (Lipitor) triglycerides; slightly levels, constipation, nausea,
Fluvastatin (Lescol XL) increase HDL diarrhea, stomach pain, cramps,
Lovastatin (Altoprev) elevation of liver enzymes
Pitavastatin (Livalo)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)

Cholesterol absorption Decreases LDL; Stomach pain, diarrhea, fatigue,

inhibitor slightly decreases muscle soreness; avoid during
Ezetimibe (Zetia) triglycerides; slightly pregnancy and lactation
increases HDL

PCSK9 inhibitors Decrease LDL; Itching, swelling, pain or bruising at

Alirocumab (Praluent) usually reserved for injection site
Evolocumab (Repatha) people who have a
genetic condition that
causes very
high LDL levels or
people with heart
disease who cannot
tolerate statins or
other cholesterol
lowering drugs

Citrate lyase inhibitors Decrease LDL Muscle spasms and joint pain,
Bempedoic acid including acute gout
(Nexletol)
Bempedoic acid-ezetimibe
(Nexlizet)

Bile acid sequestrants Decrease LDL; may Constipation, bloating, nausea, gas,
Cholestyramine slightly heartburn
(Prevalite) increase HDL
Colesevelam (Welchol)
Colestipol (Colestid)

Combination cholesterol Decreases LDL and Stomach pain, fatigue, gas,

absorption inhibitor and triglycerides; constipation, abdominal pain,
statin increases HDL cramps, muscle soreness, pain and
Ezetimibe-simvastatin weakness
(Vytorin)
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Drug class Benefits Possible side effects

Combination calcium The statin component Facial and neck flushing, dizziness,
channel blocker and decreases LDL and heart palpitations, muscle soreness
statin triglycerides; the and pain, increased blood sugar
Amlodipine-atorvastatin calcium channel levels, constipation, nausea,
(Caduet) blocker lowers blood diarrhea, stomach pain, cramps,
pressure elevation of liver enzymes

Fibrates Decrease Nausea, stomach pain, muscle pain

Fenofibrate (Antara, triglycerides;
Lipofen, others) modestly
Gemfibrozil (Lopid) decrease LDL;
increase HDL

Niacin Decreases LDL and Facial and neck flushing, itching,

Prescription niacin triglycerides; stomach upset, increase in blood
(Niacor, Niaspan) increases HDL sugar

Omega-3 fatty acids Decrease Belching, fishy taste, indigestion;

Prescription versions triglycerides; may may increase risk of bleeding
include Lovaza, Omacor increase HDL
and Vascepa

In many people, the muscle pain often associated with statins may not actually be caused by the drug. In
studies where participants don't know if they're getting a statin or a placebo, muscle pain is a common
complaint in both groups. It appears that the expectation of the side effect makes it more likely to occur.
Most cholesterol medications lower cholesterol with few side effects, but effectiveness varies from person
to person. It's also still important to follow a healthy diet and get enough exercise. Cholesterol
medications and lifestyle choices can work together to help reduce your risk of heart attacks and stroke.

Anticoagulants
What are Anticoagulants?
Anticoagulants are medicines that increase the time it takes for blood to clot. They are commonly called
blood thinners.
There are several different types of anticoagulant. Each type works at a different level on the blood
coagulation pathway. Some can be given by mouth; others can only be given by injection.
What are anticoagulants used for?
Anticoagulants may be used to treat blood clots, or in conditions where the risk of blood clots is increased
to reduce the risk. Examples of conditions where anticoagulants may be used include:
 Atrial fibrillation
 Deep vein thrombosis (DVT)
 Hip or knee replacement surgery
 Ischemic stroke
 Myocardial infarction (heart attack)
 Pulmonary embolism
 Unstable angina.
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What are the differences between anticoagulants?

Anticoagulants may be divided into four main groups: coumarins and indandiones; factor Xa inhibitors;
heparins; and direct thrombin inhibitors.
Coumarins and indandiones
Warfarin is a coumarin, and the only coumarin available in the U.S for human use. It works by limiting
the availability of vitamin K, a vitamin that is necessary for the blood coagulation pathway to produce
clotting factors II, VII, IX, and X. This decreases the blood’s ability to clot.
Indandiones have a similar way of working to coumarins but they are mainly used for pest control to
control rat, mice, and rabbit populations. Examples include pindone and diphacinone.
Coumarins and indandiones may also be called vitamin K antagonists.
Generic name Brand name examples

warfarin Coumadin, Jantoven

Factor Xa inhibitors
Factor Xa inhibitors work on factor Xa in the coagulation cascade, which is responsible for converting the
protein prothrombin into thrombin. Factor Xa inhibitors can affect factor Xa within the blood and also
within a pre-existing clot.
Factor Xa inhibitors do not require routine monitoring, unlike some other anticoagulants.
Generic name Brand name examples

apixaban Eliquis

edoxaban Savaysa

fondaparinux Arixtra

rivaroxaban Xarelto
Heparins
The heparins are a group of anticoagulants that consist of unfractionated heparin, low molecular weight
heparins, and heparinoids.
Unfractionated heparin (usually just called heparin) needs to be given directly into the blood by
intravenous (IV) injection, and inhibits thrombin and factor Xa, factors necessary in the final stages of the
blood clotting cascade. Heparin may also be called high molecular weight heparin. Daily monitoring is
required with heparin to check the aPTT. The aPTT is the speed at which clotting occurs.
Low molecular weight heparins (LMWH) also work on thrombin and factor Xa; however, they
preferentially inactivate factor Xa. Because their anticoagulant response is more predictable, they do not
need daily blood monitoring. LMWHs last much longer in the body than heparin and are injected under
the skin (subcutaneously). Some people can learn to inject LMWHs at home by themselves.
Heparinoids have a similar action to heparin and are extracted from specific animal and plant tissues or
made synthetically. They are usually applied topically and are easily absorbed into the skin where they
can reduce small blood clots, reduce inflammation and associated pain and discomfort. Chitin and
chondroitin sulfate are also heparinoids.
Generic name Brand name examples

Unfractionated heparins

heparin Hep-Lock
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Generic name Brand name examples

LMWHs

dalteparin Fragmin

enoxaparin Lovenox

tinzaparin Discontinued

Heparinoids

heparinoid Hirudoid (not available in the U.S.)

Direct thrombin inhibitors
Direct thrombin inhibitors bind directly to thrombin, inhibiting its action. Direct thrombin inhibitors that
need to be given by injection include desirudin which binds to both the active enzymatic site and to
exosite 1, and argatroban which binds to the active enzymatic site only. Dabigatran is an oral direct
thrombin inhibitor which binds reversibly to the active enzymatic site.
Generic name Brand name examples

argatroban Acova

bivalirudin Angiomax

dabigatran Pradaxa

desirudin Iprivask

lepirudin Discontinued in 2012

Are anticoagulants safe?
Anticoagulants are considered safe when administered exactly as intended for the recommended duration
of time. However, they have been associated with some serious side effects such as:
 Major or fatal bleeding and haemorrhage: Because of the way they work to prolong bleeding
time, there is always a risk of severe bleeding with anticoagulants, particularly in people with risk
factors such as active ulceration, bleeding disorders, hemorrhagic stroke, following certain types
of surgery, with kidney disease, or in people taking medicines that also increase the risk of
bleeding. Any bleeding that does not stop or other signs such as persistent nosebleeds, blood in
the urine or stools, heavy menstrual bleeding, or coughing up blood should be investigated
further.
 Spinal/epidural hematomas: Risk is higher with LMWHs when administered to people
undergoing neuraxial (spinal or epidural) anesthesia or spinal puncture. These hematomas may
result in permanent paralysis
 Thrombocytopenia (a deficiency of platelets in the blood)
 Necrosis and/or gangrene of the skin: rare, but has been associated with warfarin use
 An increased risk of thrombotic events on premature discontinuation of dabigatran (before
completion of a course of therapy).
Warfarin can also interact with certain foods and many commonly used medicines. Regular blood
monitoring (international normalized ratio-INR) is necessary because there is a fine line between an
effective dose and a toxic one.
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For a complete list of severe side effects, please refer to the individual drug monographs.
What are the side effects of anticoagulants?
The more common side effects that have been associated with anticoagulants include:
 Bleeding
 Gastrointestinal effects such as diarrhea, heartburn, nausea, and loss of appetite
 Irritation and pain around the site of injection (injectable anticoagulants only)
 Elevations in liver enzymes
 Shortness of breath.
For a complete list of side effects, please refer to the individual drug monographs.

Types of Anticoagulants
Please refer to the drug classes listed below for further information.
 coumarins and indandiones
 factor Xa inhibitors
 heparins
 thrombin inhibitors
Iron supplements
 A person with iron deficiency anemia does not have enough iron in their body to produce a
protein called hemoglobin.
 This protein enables red blood cells to transport oxygen throughout the body, which is essential
for the proper functioning of the organs.
 Iron supplements are the most commonTrusted Source treatment for anemia and can help replace
iron levels in the body so that it can produce sufficient hemoglobin.
 A person can typicallyTrusted Source get over-the-counter (OTC) iron supplements in oral pill
form, as part of a multivitamin, or as an iron-only supplement. Types of iron supplements
include:
 ferrous sulfate
 ferric sulfate
 ferrous gluconate
 ferric citrate
Dosage
 A doctor may recommend a specific dosage.
 In cases where anemia is not chronic, a person may require several supplements a day for 3–6
monthsTrusted Source to replenish their iron levels.
 Individuals should take iron supplements exactly as the doctor directs, as too much iron may
cause harmful side effects.
Benefits
Iron supplements can help replenish the body’s iron levels, which can relieve symptoms of anemia such
as:Trusted Source
 fatigue
 weakness
 gastrointestinal problems
 infection
 problems with memory and concentration
If a person does not receive treatment for anemia, they may be at riskTrusted Source of developing severe
complications, such as heart problems.
Side effects
There are various potential side effects of iron supplements, especially if a person takes high doses. These
include:
 constipation
 nausea
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 vomiting
 diarrhea
 inflamed stomach lining
 ulcers
In extremely high doses, iron becomes toxic and may cause severe side effects, such as:
 convulsions
 organ failure
 coma
 death
Iron may also interact with other medications and supplements. A person should disclose any other
medication they are taking with their doctor, including natural or herbal supplements.
To help mitigate the side effects associated with iron, a person may need to take a delayed or enteric-
coated formulation.
Iron therapy
If iron supplements are not adequate to replenish a person’s iron levels, they may require intravenous (IV)
iron.
A doctor may prescribe administering iron into a vein to increase iron levels in the blood, especially for
patients with severe anemia who have a chronic condition, such as celiac disease.
Dosage
The dosage of IV iron can differ depending on the intravenous iron formulation a doctor prescribes.
Dosages may range from 100 milligrams (mg) per dose of INFeD, the brand name for a compound called
low-molecular-weight iron dextran, to 1,000mg of Monofer — the brand name for the compound iron
isomaltoside.
The time it takes to administer the dose can range from 15 minutes to 6 hours.
Benefits
IV iron may deliver iron into the blood more efficiently and in higher doses than iron supplements, which
can result in better management of anemia symptoms.
Side effects
Side effects may include:
 nausea and vomiting
 diarrhea
 constipation
 headache
 dizziness
 allergic reactions in rare cases
Vitamin B12
Some types of anemia, such as pernicious anemia, develop because the body is deficient in vitamin B12,
which it requires to produce healthy blood cells.
A doctor can prescribeTrusted Source vitamin B12 in the form of an injectable shot or a nasal spray. In
less severe cases, a doctor may recommendTrusted Source large doses of vitamin B12 in pill form.
The supplemental vitamin B12 increases levels of the vitamin, which stimulates blood cell production.

Dosage
The dosage may depend on the severity and type of anemia.
Doctors will typicallyTrusted Source prescribe administering a shot into a muscle every day for a week
and once a month after a person’s levels have normalized.

Benefits
Benefits of vitamin B12 includeTrusted Source:
 reduction of vitamin B12-deficiency anemia symptoms
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 reduction of a compound called homocysteine, which scientists have linked to heart attack and
stroke
 possible positive effects on cognitive function and energy, although more research is necessary

Side effects
Research has not foundTrusted Source any harmful effects of vitamin B12, although it may interact with
some medications. These include gastric acid inhibitors, and Metformin, which doctors use to
treat diabetes.
It is very unlikely for a person to overdose on B12. This is becauseTrusted Source it is a water-soluble
vitamin, meaning that any excess that the body does not absorb leaves the body via urine.
Erythropoiesis-stimulating agents (ESA)
ESA is a synthetic form of a hormone the kidneys naturally produce, called erythropoietin (EPO). EPO
helps stimulate the creation of red blood cells.
In people with certain conditions, such as chronic kidney disease, EPO levels are low, which can result
inTrusted Source anemia. Synthetic ESA can stimulate red blood cell production in a similar way to the
natural hormone.
A doctor can prescribe the medication and perform the injections themselves, or a person may be able to
self-administer the injections at home.
Dosage
The dosage depends on the underlying cause of the anemia and other factors.
For a person with chronic kidney disease-associated anemia, the dose may begin at 50–100 units per
kilogramTrusted Source, three times a week. The dosage may differ for other types of anemia.
Benefits
The medication can increase Trusted Source hemoglobin levels, which will reduce symptoms of anemia.
This can also mean that a person with severe anemia may require fewer other types of treatment, such as
blood transfusions.
Side effects
A 2023 articleTrusted Source notes that ESA can thicken the blood, which can increase the risk of blood
clotting. This could lead to ischemic stroke and heart attack.
ESA may also increase the risk of certain cancers, such as cervical, lung, neck, and breast cancer.
In people who also undergo chemotherapy, side effects can include:
 nausea and vomiting
 diarrhea
 insomnia
 fatigue
 abdominal pain
 rashes
 headache
 prickling or burning sensation
 low platelet count
 swelling in the legs or hands
 muscle pain
 stiff joints
Medication for underlying conditions
A doctor may prescribe other medications to treat underlying conditions that may contribute to or cause
anemia. Many conditions may affect the production of red blood cells and cause anemia symptoms.
Medications for these conditions may include:
 corticosteroids and other immunosuppressant drugs
 chemotherapy drugs to treat cancer
 medication such as antibiotics to treat infection
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Frequently asked questions

Below are the answers to some frequently asked questions about medication for anemia.
What is the best medication for anemia?
The best medication for anemia will depend on the type and severity of the condition. Iron supplements
are the most commonTrusted Source treatment for iron deficiency anemia.
What is the newest medication for anemia?
The Food and Drug Administration (FDA)Trusted Source approved Jesduvroq tablets in February 2023.
The medication is the first oral treatment for anemia caused by chronic kidney disease, and doctors may
prescribe it for adults who have received at least 4 months of dialysis.
Summary
There are different types of anemia, each with different causes and levels of severity, that may require
different types of medication.
Common medication types include iron supplements, IV iron therapy, erythropoiesis-stimulating agents
(ESA), and vitamin B12. Doctors may also prescribe medication to treat underlying conditions.
There are potential benefits and side effects of medication for anemia. Common side effects include
nausea, vomiting, and other gastrointestinal upsets.

What are Diuretics?

 Diuretics (also called water pills or fluid pills) are medicines that increase the amount of urine
you produce. Urination is the body’s way of removing excess salt and water. Not only does this
relieve symptoms such as ankle swelling, it also helps to lower blood pressure, and relieve fluid
from around your heart.
 There are several different classes of diuretics, including carbonic anhydrase inhibitors, loop
diuretics, potassium-sparing diuretics, and thiazide diuretics. Each type works in a distinct way
and in different parts of the kidney cell (called a nephron).
 What are diuretics used for?

Diuretics are used to treat conditions that have fluid retention (also called edema) as a symptom, such
as heart failure, kidney failure, and cirrhosis of the liver.
They are also effective at reducing blood pressure and some (such as thiazides and loop diuretics) are
used for the treatment of high blood pressure (hypertension). Carbonic anhydrase inhibitors are mainly
used for the treatment of glaucoma and are sometimes used off-label for altitude sickness.

What are the differences between diuretics?

Each class of diuretic works in a different way to remove salt and water from the kidney, which means
they have different potencies and different side effects. Below, we have grouped the most common
diuretics into their respective classes.

Thiazide diuretics
Thiazide diuretics inhibit the sodium/chloride cotransporter located in the distal convoluted tubule of a
kidney cell. This decreases the amount of sodium reabsorbed back into the body, which results in more
fluid being passed as urine. Thiazides are relatively weak diuretics.
Generic name Brand name examples

bendroflumethiazide Only available in the U.S. in combination with nadolol (Corzide)

chlorothiazide Diuril

chlorthalidone Thalitone
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Generic name Brand name examples

hydrochlorothiazide (HCTZ) Aquazide H, Microzide

indapamide Generic

metolazone Zaroxolyn

Loop diuretics

Loop diuretics work by inhibiting the sodium-potassium-chloride (Na+/K+/2Cl) cotransporter in the thick
ascending loop of Henle, a distinct area in the kidney cell. These are potent diuretics.
Generic name Brand name examples

ethacrynic acid Edecrin

bumetanide Bumex

furosemide Lasix

torsemide Demadex

Potassium-Sparing Diuretics
Potassium-sparing diuretics interfere with the sodium-potassium exchange in the distal convoluted tubule
of a kidney cell. Some block the aldosterone receptor. Aldosterone is a hormone that promotes the
retention of sodium and water. They are relatively weak diuretics; however, they do not
cause hypokalemia (low potassium levels) but may cause hyperkalemia (high potassium levels),
especially if they are used with other agents that also retain potassium, such as ACE inhibitors.
Generic name Brand name examples

amiloride Midamor

eplerenone Inspra

spironolactone Aldactone, CaroSpir

triamterene Dyrenium
Carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors act by increasing the amount of bicarbonate, sodium, potassium, and water
excreted from the kidney. They are relatively weak diuretics. They also reduce fluid levels in the eye and
may be used to treat glaucoma and are sometimes used off-label to treat altitude sickness.
Generic name Brand name examples

acetazolamide Diamox

Are diuretics safe?

When taken at the recommended dosage, diuretics are considered safe. However, they have been
associated with several serious adverse effects including:
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 Stevens-Johnson syndrome, erythema multiforme and other severe reactions in people with
a sulphonamide allergy who have taken a sulphonamide-containing diuretic (includes
acetazolamide, thiazides, or loop diuretics)
 Severe neurological changes have occurred in people with liver disease given loop diuretics who
are already electrolyte depleted
 Tinnitus or hearing impairment have been reported with loop diuretics, mainly after intravenous
administration, or in people with kidney disease, low protein levels, or administered another
medicine that may also affect hearing
 Excessive urination can occur which may cause dehydration with the potential for adverse
cardiovascular events such as a stroke or blood clots.

What are the side effects of diuretics?

Side effects vary depending on the type of diuretic taken: however, the more common side effects of
diuretics include:
 Changes in electrolyte levels (such as potassium, sodium, calcium or magnesium levels),
depending on the type of diuretic
 Constipation
 Dizziness
 Dry mouth
 Gout
 A headache
 An increase in blood sugar levels
 Muscle cramps
 Stomach upset
 Tiredness.
For a complete list of side effects, please refer to the individual drug monographs.

Types of Diuretics
Please refer to the drug classes listed below for further information.
 carbonic anhydrase inhibitors
 loop diuretics
 miscellaneous diuretics
 potassium-sparing diuretics
 thiazide diuretics

Respiratory agents
What are Respiratory agents?
Respiratory agents is a term used to describe a wide variety of medicines used to relieve, treat, or prevent
respiratory diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD),
or pneumonia.
Respiratory agents are available in many different forms, such as oral tablets, oral liquids, injections or
inhalations. Inhalations deliver the required medicine or medicines directly to the lungs, which means the
medicine(s) can act directly on the lung tissues, minimizing systemic side effects.
Some products contain more than one medicine (for example, inhalers that combine a long-acting
bronchodilator with a glucocorticoid).

Antiasthmatic combinations
What are Antiasthmatic combinations?
Antiasthmatic combinations are products with more than one agent that is used in the treatment of asthma.
The agents work differently to make airflow in and out of the lungs easier and improve the symptoms of
asthma.
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What are Antihistamines?

Antihistamines block histamine release from histamine-1 receptors and are mostly used to treat allergies
or cold and flu symptoms, although some first-generation antihistamines (also called sedating
antihistamines) may be used for other conditions, such as nausea or motion sickness.
Histamine-1 receptors are located in your airways (breathing tubes), blood vessels, stomach, and
esophagus (throat area). Allergens, such as pollen or pet fur can stimulate these receptors, causing the
release of histamine, which results in symptoms such as a rash, sneezing, a runny nose, or a narrowing of
the airways (also called bronchoconstriction). Histamine-1 receptors are also found in the brain and spinal
cord and first-generation antihistamines (sedating antihistamines) can cross through the blood/brain
barrier into the brain and act on these receptors, causing sleepiness (sedation), and drowsiness.
What are antihistamines used for?
Antihistamines can help relieve the symptoms of an allergic reaction, such as:
 a rash
 itchiness
 redness (inflammation)
 swelling (edema)
 red and watery eyes
 a runny nose
 sneezing.
This makes antihistamines very effective for the treatment of:
 allergic rhinitis
 colds
 flu
 food allergies
 hay fever
 hives (urticaria)
 hypersensitivity reactions to drugs
 insect bites
 stings.
Sedating antihistamines (see explanation below) also act in the brain and spinal cord, and on other
receptors. This makes some of them also useful for:
 inducing sleep
 preventing or treating motion sickness
 reducing anxiety
 some symptoms of Parkinson’s disease in people unable to tolerate traditional medications for
Parkinson's disease.
What are the differences between antihistamines?
Antihistamines can be classified into two main categories:
 first-generation antihistamines (also known as sedating antihistamines because they all cause
drowsiness)
 second-generation antihistamines (also known as non-sedating antihistamines because they don't
tend to cause drowsiness, although they may do so in some people).
First-generation (sedating) antihistamines were developed more than seventy years ago and are still in
widespread use today. They act on histamine receptors in the brain and spinal cord and in the rest of the
body (called the periphery). They also act on muscarinic, alpha-adrenergic, and serotonin receptors. This
means that first-generation antihistamines are more likely to cause side effects such as sedation, dry
mouth, dizziness, low blood pressure, and a rapid heart-beat. They are also more likely than second-
generation antihistamines to impair a person’s ability to drive or operate machinery. Interactions with
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other drugs are more common with first-generation antihistamines compared with second-generation
antihistamines.
Second generation (non-sedating) antihistamines were developed in the 1980s and are much less sedating
than first-generation antihistamines. They act on histamine-1 receptors in the periphery and are unlikely
to penetrate the brain, so are less likely to cause side effects or interact with drugs. Most second-
generation antihistamines do not cause drowsiness, although some (such as cetirizine and fexofenadine),
may be more likely to do so at higher dosages.
Common antihistamines available in the U.S.
First Generation (Sedating) Antihistamines
Generic name Brand name examples Duration of action

brompheniramine Generic 12h

carbinoxamine maleate Generic 12h

chlorpheniramine Aller-Chlor 24h

clemastine Generic 12h

diphenhydramine Benadryl 12h

hydroxyzine Vistaril 24h

triprolidine Discontinued 12h

Second Generation (Non-sedating) Antihistamines

Generic name Brand name Duration of action

azelastine nasal spray Astelin 12h

cetirizine Zyrtec Allergy, Children’s Zyrtec 24h+

desloratadine Clarinex, Clarinex Reditabs 24h+

fexofenadine Allegra Allergy, Children's Allegra Allergy 12-24h

 Page 15 of 35

Generic name Brand name Duration of action

levocetirizine Xyzal 24h+

loratadine Alavert, Claritin 24h

olopatadine nasal spray Patanase 12h

What are the side effects of antihistamines?

Side effects of first-generation (sedating) antihistamines may include:
 blurred or double vision
 constipation
 dry eyes
 a dry mouth
 drowsiness or sedation
 a headache
 low blood pressure
 mucus thickening in the airways
 a rapid heartbeat
 stomach pain
 urinary problems
Side effects of second-generation (non-sedating) antihistamines may include:
 coughing
 drowsiness (this is uncommon)
 fatigue
 a headache
 nausea
 a sore throat
 stomach pain.

What are Antitussives?

Antitussives are medicines that suppress coughing, also known as cough suppressants. Antitussives are
thought to work by inhibiting a coordinating region for coughing located in the brain stem, disrupting the
cough reflex arc; although the exact mechanism of action is unknown.
However, their use is not without controversy and they should only be considered for dry, irritating
coughs that do not involve mucus production. Suppressing productive or mucus-producing coughs caused
by some respiratory diseases with antitussives may be hazardous. Many viral coughs are best treated by
increasing fluid intake and exposing the airways to humidity.
Many antitussives, including pholcodine, codeine, and dextromethorphan, are derived from opioids.
Pholcodine and codeine may cause drowsiness and constipation and codeine may be addictive.
Dextromethorphan can increase serotonin levels and may interact with other medicines that also increase
serotonin. Benzonatate is an nonnarcotic antitussive that anesthetizes certain receptors located in the
breathing passages, reducing the urge to cough.
Although antitussives have been shown to be effective in adults, their effectiveness in children has not
been established and their use in children should be discouraged.
 Page 16 of 35

What are Bronchodilators?

Bronchodilators are drugs that open up (dilate) the breathing passages by relaxing the bronchial smooth
muscle. They make breathing easier for people with asthma or other lung conditions.
Bronchodilators include short acting beta2-agonists such as albuterol, long-acting beta2-agonists (such as
salmeterol, formoterol), anticholinergic agents (eg, ipratropium) and theophylline.
Short acting bronchodilators are used when needed for quick relief of asthma symptoms and long acting
bronchodilators are used regularly to control the symptoms of asthma.
Types of Bronchodilators
Please refer to the drug classes listed below for further information.
 adrenergic bronchodilators
 anticholinergic bronchodilators
 bronchodilator combinations
 methylxanthines

What are Adrenergic bronchodilators?

Adrenergic bronchodilators (specifically beta2-adrenoreceptor agonists) dilate the bronchi by a direct
action on the beta2-adrenoreceptors on the bronchial smooth muscle and relax the muscle.
There are two categories of beta2-adrenoreceptor agonists used in asthma. The short acting adrenergic
bronchodilators are used on an as needed basis to control symptoms of asthma. The longer acting
bronchodilators are used regularly, twice daily, as adjunct therapy in patients whose asthma is poorly
controlled by inhaled corticosteroids.

What are Anticholinergic bronchodilators?

Anticholinergic bronchodilators (or muscarinic receptor antagonists) block the parasympathetic nerve
reflexes that cause the airways to constrict, so allow the air passages to remain open. Muscarinic receptor
antagonists bind to muscarinic receptors and inhibit acetylcholine mediated bronchospasm.
Anticholinergic bronchodilators are used more to treat chronic obstructive pulmonary disease than to
treat asthma.

What are Bronchodilator combinations?

Bronchodilator combinations are generally inhalers or inhalation devices, which contain more than one
bronchodilator, or a bronchodilator and a steroid. Bronchodilator combinations with more than one
bronchodilator usually consist of a short acting and a long acting bronchodilator. The bronchodilators
may work by different mechanisms to dilate the air passages, and makes air flow easier. Bronchodilator
combinations with a steroid and bronchodilator act more like a preventative. Steroids block the body's
inflammatory response and effectively improve lung function and reduce asthma symptoms. The
bronchodilator in this combination is generally a long acting one and it also acts as a preventer.

What are Methylxanthines?

Methylxanthines are a unique class of drug that are derived from the purine base xanthine. Xanthine is
produced naturally by both plants and animals. The methylxanthines, theophylline, and dyphylline are
used in the treatment of airways obstruction caused by conditions such as asthma, chronic bronchitis,
or emphysema. Caffeine (present in coffee) and theobromine (present in chocolate) are also
methylxanthines.
Theophylline is the most well known and most commonly used methylxanthine. At low dosages, it has an
immunomodulatory, anti-inflammatory and bronchoprotective effect. Higher dosages are needed for its
bronchodilator effect; however, higher dosages are often associated with toxicity.
Experts are not sure exactly how methylxanthines work but research has shown they inhibit the enzyme
phosphodiesterase, antagonize adenosine receptors, and at lower dosages, their effects on histone
deacetylase activity are believed to contribute to their immunomodulatory effects.
 Page 17 of 35

The main role of theophylline and dyphylline is to help maintain good airway control in chronic,
persistent, airways disease.

What are Decongestants?

Decongestants are medicines that relieve congestion by reducing swelling, inflammation, and mucus
formation within the nasal passages or the eye. They have no other effect on symptoms such as a runny
nose or sneezing.
Decongestants may be taken orally to help relieve congestion that is affecting the nose, sinuses, and eyes
or sprayed directly in the nose or instilled in the eye for a more local effect.
The inside of the nose is lined with small blood vessels. Blood flow is increased to these blood vessels
when our immune system detects the presence of an allergen (such as a virus or pollen). This causes
swelling within the blood vessels which can block the nasal passageway, making nasal inhalation
difficult. In addition, mucous glands within the nose secrete more mucus to trap the allergen which also
contributes to nasal congestion and creates a sensation of “stuffiness”.
Most decongestants work by activating alpha-adrenergic receptors either by binding directly to them or
stimulating the release of norepinephrine, a chemical transmitter. Activation of these receptors causes
vasoconstriction (a narrowing of the blood vessels within that area). This decreases blood flow and helps
to shrink swollen tissue, relieving congestion. They are often used in combination with antihistamines.
Decongestants are available as nose drops or nasal sprays, eye drops, and as tablets, capsules, and syrup.
What are decongestants used for?
Decongestants are typically used for conditions associated with nasal or eye congestion, such as:
 a cold
 allergies
 hay fever
 rhinitis
 sinusitis.
Decongestants only provide short-term relief from congestion and do not cure the underlying cause or
condition.
What are the differences between decongestants?
Decongestants differ by their duration of action, their formulation availability and their propensity for
side effects. Federal regulations require that pseudoephedrine is sold behind the pharmacy or service
counter because it can be used illegally to manufacture methamphetamine.
Nasal decongestants are usually either short-acting (3 to 4 hours), such as levmetamfetamine
or phenylephrine, or long-acting (8 to 12 hours) such as xylometazoline and oxymetazoline.
Topical decongestants (such as xylometazoline or oxymetazoline) have a more rapid onset of action and
stronger effect than oral decongestants. They are less likely to cause side effects although there have been
rare reports of seizures in children.
Oral decongestants do not cause rebound congestion (see “Are decongestants safe?”, below), but they
are not as effective as topical formulations.
Generic name Brand name examples

naphazoline nasal Privine

naphazoline ophthalmic AK-Con

oxymetazoline nasal Afrin Sinus

oxymetazoline ophthalmic Visine Long Lasting

phenylephrine Nasop, Sudafed PE

 Page 18 of 35

Generic name Brand name examples

propylhexedrine Benzedrex Inhaler

pseudoephedrine Contac Cold, Sudafed Congestion

xylometazoline Generic
Are decongestants safe?
There are not many good quality studies that have investigated the effectiveness of decongestants, or
reported on adverse effects. Most studies excluded children, therefore, most experts recommend not
giving decongestants to children under the age of 12 because their effectiveness and risk of side effects is
unknown.
Some decongestants (such as pseudoephedrine) have been associated with heart-related side effects such
as elevated blood pressure, palpitations, tachycardia. Because decongestants act on alpha adrenoreceptors
which are also located in other areas of the body, they may increase intraocular pressure in the eye and
aggravate urinary obstruction.
Using nasal decongestants regularly and for longer than three to five days has been associated with
rebound congestion. This is when nasal congestion recurs almost immediately once you stop using the
decongestant, prompting repeat use of the nasal decongestant. If use continues unabated, a form of rhinitis
called rhinitis medicamentosa will develop, which is very difficult to treat.
In some people, even recommended dosages of decongestants can aggravate already high blood
pressure or cause heart palpitations or a fast heartbeat. Decongestants may also produce side effects such
as CNS stimulation and may not be suitable for people including those with heart disease, high blood
pressure, urinary problems, or taking certain medications (such as monoamine oxidase inhibitors).
If taken in overdose, decongestants can cause kidney failure, psychotic symptoms, strokes, and seizures.
What are the side effects of decongestants?
Insomnia and irritability are the most common side effects of oral decongestants and these side effects
can occur in up to 25% of people taking these medicines. Other side effects may include:
 dizziness
 a headache
 excitability
 nervousness
 tremors.

What are Expectorants?

Expectorants are ingredients that increase airway secretions. They do this by increasing the water content
of secretions which decreases their stickiness, making them easier to cough up.
What are expectorants used for?
Expectorants aim to make coughing up mucus easier, they do not actually stop coughing. This is
important because a productive cough should not be suppressed because it is the body's way of removing
excess mucus, foreign particles, or microorganisms from the airways.
Expectorants also help to relieve chest congestion that occurs because of a cold, the flu, or allergies.
Guaifenesin is mostly used for the treatment of chesty, wet, productive or phlegmy coughs, which
typically occur with a cold. It has also been used off-label to help improve fertility and sperm survival in
women with hostile cervical mucus (see here for more information).
Potassium iodide has been used to increase the water content of secretions and improve breathing in
people with conditions such as asthma, chronic bronchitis, or emphysema.
Research has shown that expectorants are not as effective as mucolytics when used to treat certain
respiratory conditions such as COPD.
Expectorants will not treat an infection.
 Page 19 of 35

What are the differences between expectorants?

Although guaifenesin and potassium iodide both work by increasing respiratory tract secretions, there are
differences in their likelihood of side effects.
Side effects are much more likely with potassium iodide, which is the potassium salt form of iodine.
Iodine is a trace element, which means that it is only needed by the body in very small amounts, and all
trace elements are toxic if consumed at too high a dose for too long a period.
Sometimes people call expectorants mucolytics and vice versa. Although both result in less viscous
(sticky) mucus, mucolytics have a different way of working than expectorants, and that is by breaking
down the bonds within the mucus, thinning it out. Medicines that have a mucolytic action and that are
available in the U.S. include acetylcysteine inhalation and dornase alfa. Bromhexine is a mucolytic
available internationally.
Generic name Brand name examples

guaifenesin Mucinex, Xpect

potassium iodide iOSTAT

Are expectorants safe?
Guaifenesin is generally well tolerated, and no severe side effects have been reported when it has been
taken at recommended dosages. Higher than recommended dosages have resulted in stomach
upset and vomiting. Guaifenesin should not be given to children younger than 4.
Potassium iodide has been associated with thyroid problems, high potassium levels in the blood, and
iodide poisoning. People who develop neck or throat swelling, chest pain, an irregular heart rate, muscle
weakness, tingly in their extremities, a severe headache, an allergic reaction, or other unusual side effects
should seek immediate medical advice.
It is important to note that even though expectorants have been in use for many years, few studies have
been conducted that prove that they work.
For a complete list of severe side effects, please refer to the individual drug monographs.
What are the side effects of expectorants?
Guaifenesin is generally well tolerated at dosages recommended for use as an
expectorant. Nausea and vomiting are the most commonly reported side effects; constipation,
dizziness, headache, and rash are reported rarely.

Side effects that have been associated with potassium iodide use include:
 Confusion
 Excess salivation
 Fatigue
 Gastrointestinal effects (such as acid reflux, diarrhea, nausea, vomiting, and stomach pain)
 Irregular heartbeat
 Numbness, tingling, pain or weakness in the hands or feet
 A severe headache
 Skin sores
 Sore gums
 Taste disturbances (including a brassy or metallic taste in the mouth).

Leukotriene modifiers
Other names: antileukotrienes, leukotriene receptor antagonists, leukotriene synthesis inhibitors
What are Leukotriene modifiers?
Leukotriene modifiers may be used for the treatment of certain conditions that are associated with an
allergic response.
 Page 20 of 35

Leukotriene modifiers prevent the action of leukotrienes in the body. Leukotrienes are substances that are
released from mast cells, basophils and eosinophils. These substances cause airway constriction (a
narrowing of the airways), increased mucus production, swelling and inflammation in the lungs. This
causes symptoms such as wheezing, cough, post nasal drip and shortness of breath.
Leukotriene modifiers include two types of agents:
 Leukotriene-receptor antagonists, such as montelukast and zafirlukast, prevent leukotrienes from
binding to their receptors
 Leukotriene synthesis inhibitors, such as zileuton, block the enzyme, 5-lipoxygenase, which is
necessary for the formation of leukotrienes.
Montelukast, zafirlukast, and zileuton may be considered for the treatment of asthma. Only montelukast is
approved to treat allergic rhinitis, allergic conjunctivitis, and allergies as well.

What are Lung surfactants?

Lung surfactants are made from animal lung extract and contain phospholipids. Natural surfactant is
produced by the alveolar cells in the lungs and line mainly the alveoli and small bronchioles, and prevents
the alveoli from collapsing. Lung surfactant makes it easier for oxygen to penetrate the lung surface lining
and move into the blood. Without the lung surfactant it would be extremely hard to breathe, and transfer
of oxygen through the surface that lines the lungs would be very difficult.
Natural surfactant is produced by the fetus before they are born and their lungs are prepared to breathe
properly by about 37 week gestation. In unexpected circumstances where labor starts early or a pre-term
emergency caesarean is performed, lung surfactant is given intratracheally to the premature infant to
prevent respiratory distress syndrome.

What are Miscellaneous respiratory agents?

Respiratory agents are drugs or a combination of drugs used to prevent, relieve or treat respiratory
diseases. They can be taken as pills or liquid, for the drugs to work systemically. Or they can be available
as inhalers or other forms or inhalation devices, where the medicine is delivered directly into the lungs.
What are Mucolytics?
Mucolytics are medicines that thin mucus, making it less thick and sticky and easier to cough up. They
are used to treat respiratory conditions characterized by excessive or thickened mucus, such as a chesty
(productive) cough.

What are Respiratory inhalant products?

Respiratory inhalant products are a group of products consisting of finely powdered or liquid drugs that
are carried to the respiratory passages by the use of special devices such as low-pressure aerosol
containers.

What are Inhaled anti-infectives?

Inhaled anti-infectives are agents that act locally, in the lungs to treat infection. Inhaled antibiotics are
used to treat bacterial infection and antiviral medicines treat viral infections. These anti-infectives are
inhaled either as dry powder or as a solution via a nebulizer.

What are Inhaled corticosteroids?

Inhaled corticosteroids are medicines containing corticosteroids such as beclomethasone, budesonide,
ciclesonide, flunisolide, fluticasone, or mometasone in a preparation designed to be inhaled through the
mouth. Inhaled corticosteroids act directly in the lungs to inhibit the inflammatory process that
causes asthma. Inhaled corticosteroids help to prevent asthma attacks and improve lung function. They
may also be used in the treatment of certain other lung conditions, such as chronic obstructive pulmonary
disease (COPD).
 Page 21 of 35

Because inhaled corticosteroids deliver the medicine directly into the lungs, much smaller doses of
corticosteroid are needed to effectively control asthma symptoms compared to what would be needed if
the same medication was taken orally. This also reduces the likelihood of side effects.

What are Mast cell stabilizers?

Mast cell stabilizers are the name given to a group of medicines that prevent the release of histamine and
other powerful chemical mediators from mast cells. Mast cells are a type of white blood cell that are part
of our immune system and play a key role in our body's response to antigens (a toxic or foreign substance
that is perceived as a threat by our body and which induces an immune response).
Mast cells are involved in allergic rhinitis, allergic conjunctivitis, anaphylaxis, asthma, autoimmune
diseases, eczema, itch, and reproductive disorders. The mast cell stabilizers cromolyn and nedocromil
work by blocking a calcium channel that is essential for mast cell degranulation (the release of chemical
mediator-containing secretory granules which occurs after exposure to a specific antigen).
Mast cell stabilizers may be used to prevent asthma and symptoms of seasonal or chronic allergic rhinitis.

What are Selective phosphodiesterase-4 inhibitors?

Selective phosphodiesterase-4 inhibitors increase cyclic adenosine-3′,5′-monophosphate (cAMP) levels,
resulting in a broad spectrum of anti-inflammatory effects in almost all inflammatory cells. Selective
phosphodiesterase-4 inhibitors are used in the treatment of severe Chronic Obstructive Pulmonary
Disease (COPD) to reduce the risk of COPD exacerbations. They are not bronchodilators and therefore
not indicated for the relief of acute bronchospasm.

What are Upper respiratory combinations?

Upper respiratory combinations are products that may contain one or more medicines, which
relieve cough, act as decongestants or relieve allergy or hay fever symptoms.

Gastrointestinal agents
5-aminosalicylates
What are 5-aminosalicylates?
Aminosalicylates are anti-inflammatory agents used to treat inflammatory bowel disease and some forms
of arthritis. They work by inhibiting the production of cyclo-oxygenase and prostaglandin, thromboxane
synthetase, platelet activating factor synthetase, and interleukin-1 by macrophages so reduces the acute
inflammatory response in inflammatory bowel disease.
Production of immunoglobulin by plasma cells is also decreased.
Aminosalicylates are used to treat ulcerative colitis, proctitis and Crohn's disease.

What are Antacids?

Antacids are medicines that neutralize acid in the stomach. They contain ingredients such as aluminum,
calcium, magnesium, or sodium bicarbonate which act as bases (alkalis) to counteract stomach acid and
make its pH more neutral.
pH is a measure of the concentration of hydrogen ions in a solution and this determines how acidic or
how alkaline that solution is. The scale ranges from 1 to 14, where below 7 is acidic, 7 is neutral, and
above 7 is alkaline. Normal gastric acid pH is in the range 1.5-3.5.

What are antacids used for?

Antacids are used to relieve the symptoms of gastroesophageal reflux disease (GERD, also known as acid
reflux), heartburn or indigestion (also called dyspepsia). By neutralizing stomach acid, antacids relieve
symptoms such as burning behind the breast bone or throat area (esophagus) caused by acid reflux, a
bitter taste in the mouth, a persistent dry cough, pain when lying down, or regurgitation.
Some antacids are also used for completely unrelated medical conditions, for example:
 Page 22 of 35

 Aluminum antacids: lower elevated blood phosphate levels and prevent the formation of kidney
stones
 Calcium carbonate antacids: treat calcium deficiency
 Magnesium oxide antacids: treat magnesium deficiency.
What are the differences between antacids?
The two main differences between antacids is the ingredients they contain and their formulation. The
different ingredients - aluminum, calcium, magnesium, or sodium bicarbonate – all have differences in
how long they take to start working, how long they keep working for, what other medications they may
interact with, and who they are suitable for.
Antacids are available as liquids or tablets. Some products combine several antacid ingredients together
or include alginates. Alginates are gum-like substances that float on top of the stomach contents, forming
a raft that acts like a barrier. These may provide more symptom relief in people with reflux.
Some products also contain other ingredients that are not antacids or alginates, such as simethicone which
helps disperse gas in people prone to bloating. Aspirin also features in some products (for example Alka-
Seltzer).
Ingredients Brand name examples

aluminum hydroxide Amphojel

aluminum hydroxide + magnesium carbonate Acid gone, Gaviscon Extra Strength

aluminum hydroxide + magnesium hydroxide Alamag, Maalox

aluminum hydroxide + magnesium hydroxide Almacone, Gelusil, Mintox Plus

+ simethicone

calcium carbonate Calci-Chew, Titralac

calcium carbonate + magnesium hydroxide Mi-Acid Double Strength, Mylanta Supreme

calcium carbonate + magnesium hydroxide + Mylanta Tonight

simethicone

calcium carbonate + simethicone Alka-Seltzer Heartburn + Gas, Gas-X with Maalox

Extra Strength

magnesium hydroxide Ex-Lax Milk of Magnesia, Milk of Magnesia

magnesium oxide Phillips' Cramp-free, Uro-Mag

sodium bicarbonate Neut

sodium bicarbonate + aspirin + citric acid Alka-Seltzer Extra Strength

Are antacids safe?

When taken at the recommended dosage, for short durations of time, by people without contraindications,
antacids are considered safe.
However, antacids only relieve symptoms and will not cure the underlying problem causing the
symptoms. This means they may mask some serious conditions, such as gastric cancer. If you are taking
 Page 23 of 35

antacids more than two to three times a week for longer than two weeks you should talk to your doctor.
Even if your condition is diagnosed as GERD, other medications (such as H2 antagonists, proton pump
inhibitors), that work by reducing or preventing the secretion of stomach acid rather than just neutralizing
it, may be more appropriate.

Some antacids contain sodium bicarbonate which can affect blood pressure and circulation, particularly
those with pre-existing problems. High intakes of sodium are also not recommended for people with liver
or kidney disease. Anybody on a sodium-controlled or low-sodium diet or prone to high blood pressure,
kidney or liver disease should talk with their doctor before taking antacids containing sodium bicarbonate.
Always speak to your doctor if you are having reflux-like symptoms which do not go away with antacid
use. Some symptoms of heart disease (such as angina or a heart attack) are like those of reflux or heart
burn.

Interactions may occur with some ingredients contained in antacid products if they are used with other
medications. For example, calcium can affect the absorption of medicines such
as bisphosphonates, tetracyclines, and ferrous sulfate (iron). Antacids may also alter the absorption or
excretion of some other medicines (such as digoxin, phenytoin, and pseudoephedrine).

In 2016, the FDA issued a safety alert about antacids that contain aspirin, such as Alka-Seltzer because
their use was associated with reports of serious bleeding, particularly in people also taking other
medications that increased the risk of bleeding.
Antacids should not be given to children aged less than six years. They may not be safe in people with
certain medical conditions, such as gastrointestinal bleeding, liver or kidney disease, or heart disease.
Women who are pregnant or breastfeeding should also talk to their pharmacist or doctor before using
antacids.

What are the side effects of antacids?

The side effects of antacids directly relate to the ingredients they contain. Some combination products
have side effects that cancel each other out (for example, aluminium causes constipation and magnesium
causes diarrhea so products containing a combination of these two ingredients are more likely to have a
neutral effect on the bowel).
Most products have few side effects when taken as directed on the label. Side effects are more prevalent
when the product is overused or taken for longer than intended. Side effects associated with common
antacid ingredients include (some are rare):
 Aluminum: constipation, low blood phosphate levels, aluminium toxicity, osteomalacia
 Calcium: nausea, vomiting, kidney stones, high blood calcium levels, alkalosis
 Magnesium: diarrhea, nausea, vomiting, high blood magnesium levels
 Sodium bicarbonate: increased blood pressure, nausea, bloating, gas.
Antacids that are consumed at too high a dose for too long a period can also cause a condition called acid
rebound. This is when the stomach produces even more acid after food and drinks have been consumed.

What are Antidiarrheals?

Antidiarrheals are the name given to certain types of medicines that stop or slow diarrhea. Antidiarrheals
only relieve the symptoms of diarrhea, such as an increased frequency and urgency when passing stools,
they do not eliminate the cause of it. This means that as soon as you stop taking an antidiarrheal, diarrhea
will return unless whatever has caused it has run its course. Some antidiarrheals work by slowing down
intestinal contractions, increasing the time it takes for the contents of the bowel to be excreted. This
allows more water to be absorbed from the bowel back into the body, reducing the water content of the
stool. Others work by bulking up the stool, increasing its volume with fiber-like substances.
Oral rehydration agents may also be termed antidiarrheals; however, these do not stop or slow diarrhea,
rather they ensure excessive fluid lost during diarrhea is replaced. Other agents used to help relieve the
 Page 24 of 35

symptoms of diarrhea include antimotility agents or antispasmodic agents. Antibacterial agents can
occasionally be used to treat diarrhea caused by specific infections, such as campylobacter or giardia;
however, are not routinely recommended or needed.

What are Digestive enzymes?

Digestive enzymes are proteins that speed up the breakdown (hydrolysis) of food molecules into their
separate components (for example, sucrose is split into glucose and fructose). These reactions happen
within the gastrointestinal tract (GI), and most of the digestive enzymes present naturally in our bodies
are secreted by the pancreas into the small intestine via the pancreatic duct. Examples of digestive
enzymes include amylase, gelatinase, lactase, lipase, maltase, peptidase, and protease.
Digestive enzyme products may be given orally at meal times to improve digestion in people who cannot
digest food properly because their pancreas does not produce the required amounts of enzymes (can occur
as a result of cystic fibrosis, surgery, inherited conditions and other reasons).

What are Functional bowel disorder agents?

Functional bowel disorder agents are different classes of drugs that work by different mechanisms to
relieve symptoms of irritable bowel syndrome, chronic bloating, diarrhea and constipation.

What are Anticholinergics/antispasmodics?

Anticholinergics are a broad group of medicines that act on the neurotransmitter, acetylcholine. They are
also called antispasmodics.
By blocking the action of acetylcholine, anticholinergics prevent impulses from the parasympathetic
nervous system from reaching smooth muscle and causing contractions, cramps or spasms.
Anticholinergics are used in the treatment of some gastrointestinal and bladder conditions. They may also
be used in the treatment of some respiratory or movement disorders.

What are Chloride channel activators?

Chloride channel activator agent is a locally acting agent that activates chloride channels in the intestine
and increases secretion of intestinal fluid that helps in passing of the stool. It is used to treat
chronic constipation especially in patients who have little or no benefit from stool softeners or laxatives.

What are Guanylate cyclase-C agonists?

Guanylate cyclase-C agonists are used to treat irritable bowel syndrome with constipation and chronic
constipation of unknown cause (idiopathic constipation). They work by increasing intestinal fluid
secretion, which can soften stools and stimulate bowel movements.

What are NHE3 Inhibitors?

NHE3 Inhibitors are a class of medicine that works by inhibiting the Sodium-Proton-Exchanger subtype 3
(NHE3) in the gut. They may be used to treat constipation associated with irritable bowel syndrome with
constipation.
NHE3 mediates the exchange of sodium, and sodium is an essential electrolyte in our body that helps
maintain water balance, influences blood pressure, and is important for proper muscle and nerve function.
High intestinal sodium absorption is one cause of high blood pressure (hypertension).
Medicines that inhibit NHE3 have been shown to reduce high blood pressure and increase the excretion
of sodium in the feces, which can soften hard feces, relieving constipation. An improvement is also seen
in the functioning of the left ventricle in the heart, but this does not seem to have an effect on the increase
and growth of muscle cells (hypertrophy) that ultimately lead to heart enlargement.
What are NHE3 Inhibitors used for?
NHE3 inhibitors may be used for the treatment of irritable bowel syndrome with constipation (IBS-C) in
adults.
 Page 25 of 35

What are the Side Effects of NHE3 inhibitors?

Side effects of NHE3 inhibitors include dehydration (which can be serious in the old or the
young), diarrhea, bloating, flatulence, abnormal bowel sounds, low blood pressure, and dizziness.
Are there any Interactions with NHE3 Inhibitors?
There are no known interactions with NHE3 inhibitors.

Peripheral opioid receptor antagonists

What are Peripheral opioid receptor antagonists?
Peripheral opioid receptor antagonists bind to the peripheral opioid receptors, such as those in the
gastrointestinal tract and block unwanted effects caused by opioids.
They are not able to penetrate the blood brain barrier so do not antagonize central nervous system opioid
receptors, therefore the analgesic effects of opioids is not affected.
Peripheral opioid receptor antagonists are given with opioids to prevent opioid-induced constipation.

What are Peripheral opioid receptor mixed agonists/antagonists?

Opioid receptors are distributed in the central nervous system and the digestive tract. Peripheral acting
agonist and antagonist are not able to penetrate the blood brain barrier so only affect the peripheral opioid
receptors. Opioid receptors can be divided into four types including mu, delta, kappa and the nociceptin
receptors, and these can be further divided into subtypes. Agonist and antagonist that act on these
receptors cause a range of effects depending on the subtype of receptor. By selectively combining
peripheral agonists and antagonists that act on particular subtypes of opioid receptor, medications can be
produced to have a specific effect with reduced unwanted effects.

What are Serotoninergic neuroenteric modulators?

Serotoninergic neuroenteric modulators bind to the serotonin receptors in the gastrointestinal tract and
either act as an agonist or antagonist.
One of the agents in this class is a selective serotonin receptor antagonist, so it binds to the serotonin
receptor and blocks the action of serotonin in the gastrointestinal tract. The agent with serotonin receptor
antagonist activity is used to relieve cramping, abdominal discomfort, diarrhea, etc. associated
with irritable bowel syndrome.
The other agents in this category are selective serotonin receptor agonists that act in the gastrointestinal
tract to regulate bowel function. It is used to treat chronic constipation and constipation related to irritable
bowel syndrome.

What are Gallstone solubilizing agents?

Gallstone solubilizing agents are used to dissolve small non-calcified gallstones. They suppress the
amount of cholesterol synthesized by the liver or inhibit the amount of cholesterol absorbed from the
intestines.
They are used to breakdown gallstones in patients, who do not need to have surgery.

What are GI stimulants?

Gastrointestinal stimulants are drugs that increase motility of the gastrointestinal smooth muscle, without
acting as a purgative. These drugs have different mechanisms of action but they all work to move the
contents of the gastrointestinal tract faster.
Gastrointestinal stimulants are used to treat gastroesophageal reflux disease and other gastrointestinal
conditions where gastrointestinal movement is slowed.

What are H. pylori eradication agents?

Agents used in treatment of Helicobacter Pylori are medicines used for stomach acid inhibition, combined
with antibacterial agents. Treatment is for one week with a proton pump inhibitor or an antacid (or
 Page 26 of 35

antisecretory agents), and two appropriate antibacterial agents. This one week triple therapy does give a
good eradication rate.

H2 antagonists
Other names: H2 blockers, histamine-2 receptor antagonists
What are H2 antagonists?
H2 antagonists block histamine-induced gastric acid secretion from the parietal cells of the gastric
mucosa (lining of the stomach).
H2 antagonists are used to treat gastroesophageal reflux disease (GERD), gastrointestinal ulcers and other
gastrointestinal hypersecretory conditions.

What are Laxatives?

Laxatives are medicines that help resolve constipation or empty the bowel of fecal matter before
procedures or surgery involving the lower bowel. There are several different types available (see
differences below) and each type works in a particular way. Some soften or loosen up the stool, while
others increase how frequently the large colon contracts which helps move the stool along the bowel.
Laxatives may also be called cathartics or purgatives.
What are laxatives used for?
Laxatives are used to treat constipation if lifestyle changes have failed to resolve the constipation or if the
person has a medical condition (such as angina) that may be exacerbated by straining.
Before taking a laxative it is important to be sure the person is actually constipated and that the
constipation is not due to an underlying, undiagnosed condition. People's bowel habits vary and it does
not mean that somebody is constipated if they do not pass a bowel motion every day. Constipation is
usually defined as "The passage of hard stools less frequently than the person's normal bowel pattern".
Laxatives should generally not be used long-term unless under medical supervision because they can
cause electrolyte disturbances (such as low potassium levels), dehydration, and contribute to a sluggish
bowel.
Before using a laxative, lifestyle changes, such as drinking more fluid, exercising, and increasing the
amount of vegetables and fiber in the diet should be tried first.
Types of laxatives include:
 Bulk-forming laxatives (such as fiber, psyllium, or polycarbophil). These absorb water in the
bowel and swell to bulk out the stool making it softer and easier to pass
 Emollient stool softeners (such as docusate). These moisten and lubricate the stool making it
easier to pass
 Osmotic laxatives (such as lactulose, and magnesium sulfate/hydroxide) draw fluid into the bowel
and soften stools
 Stimulant laxatives (such as senna or bisacodyl) promote contraction of the intestines, promoting
the movement of stools through the bowel.
Bowel cleansing preparations
Bowel cleansing preparations are not treatments for constipation. They are used before bowel
surgery, colonoscopy, or radiological examinations to ensure that the bowel is free of solid contents.
They should be used with caution in people with fluid and electrolyte disturbances, such as dehydration
and low potassium levels. These should be corrected before administration.
Examples of bowel cleansing preparations include:
 citric acid/magnesium oxide/sodium picosulfate
 magnesium sulfate/potassium sulfate/sodium sulfate
 polyethylene glycol-3350 with or without electrolytes
 sodium biphosphate/sodium phosphate.
 Page 27 of 35

What are Miscellaneous GI agents?

Gastrointestinal (GI) agents include many different classes of drugs that are used to treat gastrointestinal
disorders. They can be classed as: 5-aminosalicylates, antacids, antidiarrheals, digestive enzymes,
functional bowel disorder agents, gallstone solubilizing agents, GI stimulants, H. pylori eradication
agents, H2 antagonists, laxatives and proton pump inhibitors. A gastrointestinal agents that does not fit
into these categories is put in the class of miscellaneous GI agents.

What are Proton Pump Inhibitors (PPIs)?

Proton pump inhibitors (PPIs) reduce the production of acid by the stomach. They work by irreversibly
blocking an enzyme called H+/K+ ATPase which controls acid production. This enzyme is also known as
the proton pump and is found in the parietal cells of the stomach wall.
What are Proton Pump Inhibitors (PPIs) used for?
PPIs treat conditions that are caused by either an overproduction of stomach acid or exacerbated by
stomach acid. Taking a PPI once a day inhibits around 70% of the proton pumps, so a small amount of
acid is still available for food digestion.
PPIs may be used for the treatment of:
 Acid reflux, also called gastroesophageal reflux disease (GERD)
 Conditions characterized by an overproduction of stomach acid (such as Zollinger-Ellison
syndrome)
 Duodenal or stomach ulcers including those caused by NSAIDs
 In combination with certain antibiotics for the eradication of Helicobacter pylori, a bacteria
associated with duodenal ulcer recurrence
 Erosive esophagitis, and to maintain healing of erosive esophagitis.
What are the differences between Proton Pump Inhibitors?
All PPIs work in the same way, by inhibiting the proton pump. However, there are differences in their
likelihood of drug interactions, and in the way they bind to the proton pump. This can affect how long
they last for.
All the PPIs available in the U.S. are metabolized in the liver by certain liver enzymes (mainly CYP2C19
and 3A4). There is a lot of individual variation in the way these liver enzymes work, and experts have
identified three categories of people; extensive metabolizers (homEM), poor metabolizers (PM), and
people that sit somewhere in between (hetM).
Approximately 3% of Caucasians and 15-20% of Asians are PM. PM take longer to excrete the drug and
therefore their response to PPIs is increased several fold. For example, the pH of gastric acid is around 6
in PM after PPIs compared to around 3-4 in extensive metabolizers (where 1 is the most acidic pH).
Metabolism is also affected in people of an older age and in those with liver disease. Esomeprazole is the
only PPI that is well tolerated by people with liver disease. The extent that somebody is able to
metabolize a PPI can also affect their risk of drug interactions.
Generic name Brand name examples

dexlansoprazole Dexilant

esomeprazole Nexium

lansoprazole Prevacid

omeprazole Prilosec

pantoprazole Protonix

rabeprazole Aciphex
 Page 28 of 35

Are Proton Pump Inhibitors safe?

When taken at the recommended dosage for the recommended duration of time, PPIs are considered safe.
However, they have been associated with several serious adverse effects including:
 Acute interstitial nephritis (a type of kidney failure): May occur at any point during PPI treatment
 Clostridium difficile-associated diarrhea: This is a particularly severe and persistent type of
diarrhea
 An increased risk for osteoporosis-related fractures of the hip, wrist, or spine: The risk is higher
in people who received high-dose therapy (typically multiple daily doses), and with PPI treatment
that lasts longer than one year
 Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE)
 An inhibition of the effect of clopidogrel, a medicine used to reduce the ability of platelets to clot
in people with heart disease.

In addition, there is a risk that the use of PPIs may mask the symptoms of gastric cancer. All patients with
a suboptimal response to PPIs or whose symptoms recur following PPI withdrawal should have additional
diagnostic testing, and an endoscopy should be considered in older people before treatment initiation.
Patients should only take PPIs as directed by their doctor or according to the instructions on the packet if
bought over the counter.

What are the side effects of Proton Pump Inhibitors?

PPIs are generally well tolerated. The more common side effects reported with their use include:
 A headache
 Fever
 Gastrointestinal effects (such as abdominal pain, constipation, diarrhea, flatulence, nausea,
or vomiting)
 Light-headedness
 Magnesium or vitamin B12 deficiency (usually only with long-term administration)
 Rash
 Tongue discoloration or taste disturbances.

EMERGENCY DRUGS IN HYPERTENSIVE EMERGENSIES

Systolic Blood Pressure More Than 220 mmHg or diastolic Blood Pressure More Than 120 mmHg with
evidence of active end organ damage. Following Emergency drugs are used in hypertensive crisis.

 SODIUM NITROPRUSSIDE Dose : 20-300 microgram/ min i.v Because of predictable,

instantaneous, titrable and balanced arteriovenous vasodilatory action it is preferred.
Toxic in higher dose.And That’s The Reason Proper Monitoring Should Be Done.
 LABETALOL for pregnancy induced hypertension.
 ESMOLOL can also be used. If injection is not available Use Capsule Nifedipine S/L
 PHENTOLAMINE OR LABETALOL for hypertensive episode in pheochromocytoma,
cheese reaction or clonidine withdrawal
EMERGENCY DRUGS FOR CARDIOVASCULAR SYSTEM EMERGENCIES
Following Emergency drugs are used in cardiovascular emergencies

CORONARY PAIN SYNDROMES :

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It is a group of conditions due to decreased blood flow in the coronary arteries such that part of the heart
muscle is unable to function properly or dies.It refers to a spectrum of clinical manifestations associated
with myocardial infarction and angina.

STABLE ANGINA
Angina pectoris is a throbbing pain, usually felt in the central chest, which may spread to the neck, both
arms and occasionally, the back that occurs during exercise or emotional stress and is rapidly relieved by
rest.

 GLYCERYL TRINITRATE (GTN, NITROGLYCERIN) ) A potent vasodilator, nitro-

glycerine relaxes vascular smooth-muscle beds. It works well on coronary arteries,
improving blood flow to ischemic areas.Dose : 0.5 mg Tablet is given sublingually every
5 min (max 3 dose)
UNSTABLE ANGINA:
This coronary syndrome is characterised by anginal pain which is severe, of recent onset, or which has
recently become abruptly worse. Angina occurring at rest or following recent myocardial infarction is
also classified as unstable angina If pain is not relieved by GLYCERYL TRINITRATE GTN then
infusion of NTG MORPHINE SULPHATE – Visceral Pain Dose Of 10-15 mg i.m or s.c or 2-3 mg i.v is
given. Or TRAMADOL Injected i.v 100 mg tramadol is equianalgesic to 10 mg i.m morphine.

 ASPIRIN : It is given for chewing or diluted before administration as soon as MI is

suspected. Aspirin slows platelet aggregation, reducing the risk of further occlusion or
reclusion of the coronary artery or recurrent ischemic event. Dose: 162-325 mg
tablet .Aspirin if diluted in a glass of water before given the disintegration time will be
saved and faster action will be obtained.
MYOCARDIAL INFARCTION:
Complete occlusion of a coronary artery leads to the death of the cardiac muscle it supplies. For pain
relieve GTN or Morphine is given. Aspirin to limit the infarct size. Thrombolytic Therapy to dissolve the
thrombi or emboli and recanalize an occluded vessel. Tenecteplase and Alteplase are preferred as their
administration doesn’t require prolonged i.v infusion. Following Emergency drugs are used in MI,

 STREPTOKINASE : 1.5 million units i.v over 60 minutes.

 UROKINASE :2.5 lac unit i.v over 10 minutes
 ALTEPLASE :15 mg bolus i.v followed by 50 mg within half an hour.
 TENECTEPLASE :i.v bolus of 0.53 mg/kg over 10 seconds
 NITROGLYCERIN) Dose : It Is A potent vasodilator, nitro-glycerine relaxes vascular
smooth-muscle beds. It works well on coronary arteries, improving blood flow to
ischemic areas.
Dose:0.5 mg Tablet is given sublingually every 5 min (max 3 dose)

CARDIOGENIC SHOCK:
It is defined as a state where the cardiac output is inadequate to maintain tissue perfusion. Following
Emergency drugs are used in cardiogenic shock
 Page 30 of 35

 DOBUTAMINE : It is a beta1 agonist with prominent inotropic action.Dose: 2-20

microgram/kg/min by i.v infusion. Dobutamine is preferred as it increases force of
contraction without significant increase in HR.
 DOPAMINE :Dose: 2-20 microgram/kg/min by i.v infusion. Preferred in patients with
hypotension. Improve cardiac contractility.
CARDIAC ARRYTHMIAS:
ARRYTHMIA DRUG Paroxysmal supraventricular tachycardia Atrial tachycardia (150-200/min) with
1:1 A-V conduction.Following Emergency drugs are used in Cardiac Arrythmias,

 ADENOSINE 6-12 mg rapid i.v injection. Causes membrane hyperpolarisation. Atrial

Flutter Atria beat at rate of 200-350/min and there is 2:1 or 4:1 AV block.
 VERAPAMIL ± DIGOXIN OR AMIODARONE Control ventricular rate Atrial
fibrillation Atrial fibres are activated asynchronously at rate of 350-500/min associated
with grossly irregular and often fast ventricular response.
 AMIODARONE (I.V) 100-300 mg over 30-60 minutes. Above mentioned drugs for vent.
rate control
 WARFARIN 2-5 mg oral or i.v Ventricular Tachycardia 4 or more consecutive ventricular
exrasystoles
 LIGNOCAINE i.v 50-100 mg bolus. Suppress VT and prevent VF Torsades de pointes
Life threatening form of polymorphic ventricular tachycardia with rapid asynchronous
complex and an undulation ECG baseline.
 MAGNESIUM SULPHATE 50% 2 gm i.v over 5-10 min. Ventricular fibrillation
Irregular, rapid and fractionalized activation of ventricles resulting in uncoordinated
contraction of its fibres.
 Defibrillation ± i.v AMIODARONE 100-300 mg over 30-60 minutes. AV Block
Depression of impulse conduction through AV node and bundle of His. ATROPINE 0.6-
1.2 mg i.m if due to vagal over activity. ADREANLINE/ ISOPRENALINE in partial AV
block
CARDIAC ARREST:
Cardiac arrest is a sudden stop in effective blood flow due to the failure of the heart to contract
effectively.

 Defibrillation is the most prompt treatment.

 ADRENALINE : Adrenaline concentrates the blood around the vital organs, specifically
the brain and the heart, by peripheral vasoconstriction. Adrenaline also strengthens
cardiac contractions as it stimulates the cardiac muscle. Amiodarone and Lidocaine
are given to control arrhythmias.
 Dose: 1 mg i.v bolus (1 ml of 1:1000)

EMERGENCY DRUGS FOR RESPIRATORY EMERGENCIES

ASTHMA :
Asthma is chronic inflammatory disease of the airways of the lungs And Status Asthmatics is an
emergency condition where asthma attack is not relieved by relievers ( Bronchodilators). Following
Emergency drugs are used in Asthmatics emergency
 Page 31 of 35

 SALBUTAMOL :It is beta-2 agonist and causes bronchial smooth muscle relaxation.
Dose Of 100 – 200 microgram/puff. Such 2 puffs are inhaled through meter dose inhaler
in case of breathlessness with the help of spacer.
 In case of acute asthma- 2.5 mg SALBUTAMOL+ 500 microgram IPRATROPIUM
BROMIDE repulse. Aerosolize respule solution by nebulizer and inhale through nose and
mouth by face mask.
 IPRATROPIUM BROMIDE is anticholinergic and cause bronchodilation by blocking
M3 receptor.
 HYDROCORTISON HEMISUCCINATE : Steroids improve airway, reduce asthma
exacerbation. They also improve response of airway smooth muscle to beta2
agonist and reduce refractoriness to them.Dose: 200 mg given i.v immediately.
 AMINOPHYLLINE :250mg/10ml ampoule to be dissolved in 20 ml of 5% glucose and
is given i.v slowly. It causes smooth muscle relaxation.
EXACERBATION OF CHRONIC OBSTRUCTIVE AIRWAY DISORDER :
 SALBUTAMOL to relieve breathlessness. Ipratropium bromide HYDROCORTISONE
and AMINOPHYLINE given i.v for immediate effect.
EPIGLOTTITIS .Epiglottitis is a medical emergency and failure to provide prompt treatment may be
fatal. It is due to infection of the epiglottis with Haemophilus influenzae bacteria.
 CEFTRIOXONE :Dose: 100mg/kg i.v immediately
PULMONARY OEDEMA:Acute pulmonary oedema is a medical emergency that requires prompt
treatment. Oxygen, morphine, vasodilators and diuretics should be used.
 FUROSEMIDE :Dose: 40 mg i.v is given immediately. Intravenous furosemide has a
beneficial vasodilatory action as well as being a powerful diuretic.
 NITROGLYCERINE (INJ) 25 mg in 50 ml normal saline slowly i.v if systolic BP > 100
mm Hg.
 DOPAMINE or DOBUTAMINE in case of cardiogenic shock.
 MORPHINE :- 2 mg i.v to reduce anxiety and dyspnea.
NEUROLOGIC EMERGENCIES
Most seizures are self-limited and brief. Emergency drug treatment is only necessary if the seizures are
prolonged (>5 minutes) or recurrent. Initial treatment is to stop convulsions and maintain ABC
SEIZURES

 ANTICONVULSANTS: MEDAZOLAM: Injection (solution for injection): 1 mg/ml; 5

mg/ml (administered into the buccal cavity between the gum and cheeks by syringe)
 DIAZEPAM : 5 mg intravenous bolus and repeat every 2 minutes to a maximum dose of
20 mg And 0.5 mg/kg per rectum (Intravenous solution can be used , if i.v. line is not
assesed ). PLUS for seizures – Injection phenytoin 15 mg/kg via intravenous infusion
over 20 minutes followed by maintenance dose.
 Thiopentone infusion – For status epilepticus :Thiopentone :5 mg/kg intravenous bolus
 Lorazepam:4 mg injected i.v. at the rate of 2mg/min
 Fosphenytoin:100-150 mg/min i.v. infusion to a maximum of 1000 mg
 Phenytoin sodium:Injected at the rate of 25- 50mg/min.
 Phenobarbitone sodium:50-100mg/min i.v. injection to a maximum of 10mg/kg Injection
Valproate :5 mg/kg intravenous bolus
TETANUS a) Tetanus immune globulin :This substance neutralizes circulating toxin. Give tetanus
immune globulin 4000 units intravenously over 30 minute.
 Antimicrobials :Give benzylpenicillin 100,000 units/kg (maximum dose 2.4 million
units) intravenously every 4 hours. OR if penicillin sensitive give metronidazole 7.5
 Page 32 of 35

mg/kg (maximum dose 500 mg) intravenously every 8 hours c) Morphine and diazepam
 used to control muscle spasms.
MENINGITIS: Bacterial meningitis is a medical emergency and antibiotic therapy should not be delayed
if there is difficulty in obtaining a CSF sample. In such cases, empirical therapy should be started
immediately.
 Empirical therapy Penicillin G intravenously 4-hourly for 10 days plus chloramphenicol
750 mg – 1 g intravenously 6-hourly for 10 days In patients hypersensitive to penicillin:
Chloramphenicol alone OR Ceftriaxone 4 g intravenously daily in one or two divided
doses
ENDOCRINE EMERGENCIES
HYPOGLYCAEMIA :
If the patient is conscious and able to swallow, give a sugary food or drink. And If the patient is unable to
swallow or unconscious at home, give sugar paste or honey into the mouth and transfer immediately to
the nearest health care facility for intravenous glucose therapy.

 Give dextrose 50% 50 ml intravenously followed by continuous intravenous infusion of

5% dextrose for up to 24 hours.
DIABETIC KETOACIDOSIS :
It is characterized by hyperglycaemia, ketosis and acidosis. All patients should be given oxygen via a face
mask. Nasogastric tube is recommended to limit regurgitation and aspiration.

Intravenous Fluids :
Initially fluid resuscitation should be with large volumes of normal saline.When the blood glucose falls to
below ( 300 mg %) i.e. 15mmol/l then the fluid should be changed to 5% dextrose or dextrose-saline.
( Reason – To clear ketone from blood) c) Insulin

 Intravenous bolus dose of 10 units short-acting regular insulin followed insulin

intravenous infusion @4 units/hour.
 Electrolytes :Potassium : intravenous potassium at a rate of 10-20 mmol/hour .
 Bicarbonate : It is only given when the blood pH is less than 7.0. Treatment of
underlying cause Hyperosmolar hyperglycaemic state (Non Ketotic)
MYXEDEMA COMA (HYPOTHYROID CRISIS)
 Intravenous fluids :Despite their oedematous appearance, most patients have
intravascular fluid depletion. This should be corrected by careful administration of 0.9%
saline intravenously. Monitoring of central venous pressure and urine output is essential.
b) Corticosteroids .Give hydrocortisone 200 mg intravenously stat then 100 mg
intravenously 6-hourly.
 Thyroid hormone :Give thyroxine 5 microgram/kg via nasogastric tube as a single dose
then 50 microgram per day rising to 100 microgram daily after 7 days. Injection T3 – 20-
mg loading dose to be infused over 30 min (Take caution of Arrhythmia)
PHAEOCHROMOCYTOMA .Give labetalol 0.2 mg/kg intravenously and repeat every
10 minutes OR infuse labetalol until the paroxysm ends or the blood pressure is stable.
ADRENAL INSUFFICIENCY
Following Emergency drugs are used in adrenal insufficiency
 Page 33 of 35

 Intravenous fluids :Use normal saline to correct hyponatraemia and dehydration: • Give
0.9% saline 1000 ml intravenously over 1 hour THEN • Give 0.9% saline 1000 ml
intravenously over 2 hours. b) Corticosteroids Give hydrocortisone 200 mg intravenous
bolus then give 100 mg every 6 hours
THYROID STORM
 Intravenous fluids: Dehydrated or shocked patients should be resuscitated with 0.9%
saline. b) Beta-adrenergic antagonists Give propranolol 0.5 mg intravenous bolus every 2
minutes to a maximum of 10 mg using control of tachycardia (pulse <100 beats/minute)
as an endpoint. (Cardiac monitoring is desirable.) c) Antithyroid drugs .Give carbimazole
100 mg via nasogastric tube then 20 mg every 8 hours.
EMERGENCY DRUGS FOR TREATMENT OF SPECIFIC POISON
Following Emergency drugs are used in the treatment of specific poison

 OPIATES Example ;codeine, heroin, pethidine, morphine, methadone.These drugs cause

depression of conscious state and hypoventilation. Particular attention should be paid to
the maintenance of the airway and adequate ventilation.
 SPECIAL ANTIDOTE • Give naloxone 0.4 mg intravenously or intramuscularly and
repeat in 5 minutes if necessary to a maximum of 2 mg.
 PARACETAMOL :- minimum toxic dose is 150 mg/kg and almost all patients who
ingest more than 350 mg/kg will develop hepatic failure. SPEACIALANTIDOTE • Give
acetylcysteine 150 mg/kg intravenously over 15minutes THEN • Give acetylcysteine 50
mg/kg intravenously over 4 hours
 ORGANOPHOSPHATE
 SPECIALANTIDOTE • Give atropine 2 mg intravenously every 10 minutes till dryness
of mouth or other signs of atropinazation apear ( max. 200 mg in administred in a day ) •
Pralidoxime 1 g intravenously over 30 minutes and repeat every 12 hours if symptoms
persist. ( 500 mg / hour ) ( Muscle power – Neck muscle )
 ORAL ANTICOAGULANTS For Example WARFARIN , RAT POISON
Overdose of these substances causes prolongation of the prothrombin time and increased risk of bleeding.

 SPECIFIC ANTIDOTE :Give vitamin K 10 mg intramuscularly daily PLUS if

necessary (i.e. active bleeding or at high risk because of for example known active peptic
ulcer).
Give fresh frozen plasma 2 units intravenously and repeat as necessary to a maximum of 8 units using
repeated measurement of the prothrombin time as a guide to therapy

 BETA-ADRENERGIC ANTAGONISTS e.g PROPRANOLOL , ATENOLOL

 SPECIAL ANTIDOTE : Give adrenaline infusion 10 micrograms/minute and increase
by 5 micrograms/minute . Every 2 minutes until the systolic blood pressure is >90
mmHg, to a maximum of 100 micrograms/minute
 IRON :Overdose of iron initially causes vomiting, diarrhoea, abdominal pain and
sometimes haematemesis. After a variable quiescent period during which these gastro-
intestinal symptoms resolve, the patient may develop shock and hypoglycaemia plus
cardiac, hepatic and renal failure.
 SPECIAL ANTIDOTE :The specific antidote is desferrioxamine but supportive care
including intravenous fluid and glucose (if necessary) is important as well. Give
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desferrioxamine 15 mg/kg per hour by intravenous infusion continued until the patient is
asymptomatic (usually 12 to 24 hours)
 ASPIRIN :This commonly used drug can be highly toxic in overdose. The toxic dose is
greater than 150 mg/kg. Give 0.9% saline (or 0.3% saline with 3% dextrose in children)
intravenously at a rate necessary to maintain a urine output greater than 2 ml/kg per hour
PLUS .Give sodium bicarbonate 1 mmol/kg intravenously every 4 hours to maintain a
urine pH greater than 7.5 PLUS .Give potassium chloride 0.25 mmol/kg intravenously
over at least one hour, every 4 hours to maintain serum potassium levels > 4 mmol/l
 DIGOXIN Digoxin toxicity causes following condition.
Following Emergency drugs are used in specific emergency conditions

 VENTRICULAR TACHYCARDIA Rx – phenytoin 15 mg/kg intravenously –

magnesium sulphate 50 mg/kg intravenously (maximum dose 5 g) over 5 minutes
 BRADIARRYTHMIAS Rx – atropine 10 microgram/kg intravenous
 HYPERKALEMIA Rx – short-acting insulin 10 units intravenous bolus – Give 50 ml of
50% glucose intravenously over five minutes -sodium bicarbonate 100 mmol
intravenously over five minutes
 TRICYCLIC ANTIDEPRESSANTS (e.g. amitriptyline, doxepin, imipramine) Rx – (a)
for seizure • Give diazepam 0.1 mg/kg intravenous bolus and repeat in 5 minutes if
necessary
 For hypotension – Give 0.9% saline 10 ml/kg intravenous bolus THEN if hypotension
persists •Give sodium bicarbonate 1 mmol/kg intravenous .For Ventricular tachycardia •
Give sodium bicarbonate 1 mmol/kg intravenous bolus THEN if arrhythmia persists •
Give Lignocaine 1 mg/kg intravenous bolus
 METHANOL POISONING A blood level of >50mg/dl methanol is associated with
sever poisoning. FATAL DOSE :- 75-100 ml SPECIALANTIDOTE  Administer
ETHANOL ( 10% water ) through a nasogastric tube; loading dose of 0.7 ml/kg is
followed by 0.15 ml/kg/hour.
ANTIDOTES
 AMYL NITRITE INDICATION:- Cyanide poisoning
 BENZATROPINE (MESILATE ) INDICATION :- Dystonic reaction cause by
antipsychotic drug or metoclopromide.
 CALCIUM DISODIUM EDETATE INDICATION :- Poisoning with metals , especially
lead
 CALCIUM GLUCONATE INDICATION :- (1) Hydrofluoric acid skin burn (2)
Poisoning with CCB
 DIMERCAPROL INDICATION :- Poisoning with arsenic mercury lead
 FOMEPIZOLE INDICATION :- Poisoning with ethylene glycol or methanol
 FOLINATE –Calcium Leucoverin INDICATION :- methotrexate rescue
 FLUMAZENIL INDICATION :- Reversal of benzodiazepine sedation in anasthetic ,
intesive care and diagnostic procedure
 GLUCAGON INDICATION : Poisoning with beta- adrenoreceptor blocking drugs.
 PENICILLAMINE INDICATION:- Poisoning wth lead , copper , arsenic .
 ISOPRENALINE INDICATION :Hypotension or low cardiac output due to cardiotoxic
drugs ( beta- adrenoreceptor drugs and CCB drugs )
 PHENTOLAMINE INDICATION : Severe hypertension caused by amphetamines ,
MAOIs , clonidine . 13. PHYTOMENADIONE ( vit.- k1 )INDICATION ;- poisoning
with caumarin anticoagulants .
 SODIUM NITRITE INDICATION : Cyanide poisoning
 Page 35 of 35

 PYRIDOXIME INDICATION:Poisoning with isoniazid,Gyromeria species.

 SODIUM BICARBONATE INDICATION :- Poisoning with salicylates , chlorophenoxy
herbicides .
 SODIUM 2,3-DMPS INDICATION :- Poisoning with metals especially mercury , arsenic
, bismuth , copper .
 SODIUM NITROPRUSSIDE INDICATION : Severe hypertension due to ergotamine ,
amphetamine , MAOIs.
 SODIUM THIOSULPHATE INDICATION :- Cyanide poisoning
 ATROPINE ( SULPHATE ) INDICATION :- Organophosphate or carbamate insectiside
poisoning .
OXYGEN
 In emergency condition O2 is required for severe physiological stress.Shock ,Traumatic
injury , Acute myocardial infarction, Cardiac arrest.Without O2 brain death occurs within
6 minutes
 O2 is delivered using nasal mask or intranasal catheter.It is delivered through nasal
cannula at the rate of 1- 4 litre/ min ( 24 % ) Through face mask the rate is 5-10 L/min
And The oxygen is titrated according to SPO2. (when below 90 %. Caution in cases of
COPD patients as they may lose their hypoxic respiratory drive.
For more information about various Drugs and medicines visit Drugs/Medicines sections.

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