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PHARMACOLOGY
for Medical Graduates
This page intentionally left blank
FOURTH EDITION
( R E V I S E D A N D U P D AT E D E D I T I O N )
PHARMACOLOGY
for Medical Graduates
TARA V SHANBHAG MD
Professor and Head, Department of Pharmacology
Srinivas Institute of Medical Sciences and Research Centre
Mukka, Surathkal, Mangalore
Karnataka, India
Formerly, Professor, Department of Pharmacology
Kasturba Medical College, Manipal, Manipal Academy of Higher Education
Manipal, Karnataka, India
SMITA SHENOY MD
Additional Professor, Department of Pharmacology
Kasturba Medical College, Manipal, Manipal Academy of Higher Education
Manipal, Karnataka, India
RELX India Pvt. Ltd.
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Pharmacology for Medical Graduates, 4e, Tara V Shanbhag and Smita Shenoy (Revised and
Updated Edition)
Copyright © 2020 by RELX India Pvt. Ltd.
Previous editions Copyrighted 2019, 2015, 2013, 2008
All rights reserved.
ISBN: 978-81-312-6259-7
eISBN: 978-81-312-6260-3
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances in
the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors in
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FOREWORD TO THE FIRST EDITION
It is common knowledge that books play a major complementary and contributing role
in any educational process. While they are envisioned to facilitate self-learning beyond
classroom exercises, not all of them promote learning; some, indeed, hinder it.
To be useful and worthwhile, a book has to be so designed as to present an appro-
priate body of knowledge in a style that suits students in a particular stage of learning:
undergraduate, postgraduate, or postdoctoral.
Accordingly, a book in pharmacology for MBBS phase-II students would have a
body of knowledge that relates with the study-course objectives and contains ‘must
know’ and ‘nice to know’ levels of factual, conceptual and applied aspects of the subject.
It has a presentation style that offers an integrated composite picture of the subject
interspersed with lucid explanations, cogent reasoning and logical networking of infor-
mation. Contents will enable students to grasp topics in proper perspective and trigger
students’ higher mental skills like critical thinking, logical reasoning, etc. Proficiency so
acquired would enable the students to not only clear qualifying tests but also to wisely
manage drug issues in future.
Designing such a book is a challenging task, especially if it is to be concise and compre-
hensive in scope. Such a version demands wise sifting, prudent pruning and meaningful
condensing of the enormous and variegated knowledge base of pharmacology.
Commendably, Dr (Mrs) Tara Shanbhag has accomplished this in her very first ven-
ture. A fairly large number of charts, diagrams and other forms of illustrations in the
text amply demonstrate this. No wonder, she has received ‘Good Teacher’ award time
and again.
A well written concise book as this one, serves twice as a preparatory tool: at the start
of the study-course it provides a road-map of the subject to be learnt and thus tunes the
students for deeper learning; and at the course-end (and examination time) it helps in
rapid review and recapitulation of what is learnt.
I am confident that this well thought out and well planned book, Preparatory Manual
of Pharmacology for Undergraduates by Dr Tara V Shanbhag will be of tremendous use
to the students.
With pleasure, I compliment Dr (Mrs) Tara V Shanbhag, an erstwhile postgraduate
student of mine, for such a fine piece of work.
Professor DR Kulkarni
Formerly: Head, Department of Medical Education, BM Patil Medical College, Bijapur;
Director of PG Studies, Head, Department of Pharmacology, KMC, Manipal;
Principal, Dr. Patil Medical College, Kolhapur;
Head, Department of Pharmacology, JNMC, Belgaum;
President, Pharmacological Society of India (1995)
v
http://afkebooks.com
PREFACE TO THE FOUR TH EDITION
Pharmacology is a vast subject and one of the fast-growing branches of medical science
and requires addition of latest information from time to time. The present fourth
edition includes significant expansion and revision of the third edition. Some new
topics like drug dosage forms and calculation of dosage of drugs have been included.
The cardiovascular drug summary table also have been included for quick revision.
The style has been retained in the form of simple diagrams, self-explanatory flowcharts,
tables and student-friendly mnemonics. The textual presentation in tabular format
helps in quick reading and recall. Definitions and treatment schedules have been incor-
porated as per various guidelines.
This extensively revised and updated edition will be useful not only for the students
of medicine but also for the practicing doctors as well. This book will also help
postgraduates of pharmacology and other clinical subjects for quick revision of
pharmacology and therapeutics.
We are extremely thankful to our students and colleagues, who had given us valuable
feedback for this edition.
We hope this edition will meet the requirements of the undergraduate medical
students and serves as a better learning tool. We would sincerely appreciate critical
appraisal of this manual and suggestions for further improvement in future.
Tara V Shanbhag
Smita Shenoy
vii
PREFACE TO THE FIRST EDITION
Pharmacology is a vast subject with many crucial aspects related to drugs, their compo-
sition, uses, effects, interactions, etc. which make the subject complicated and difficult
to comprehend.
During the course of interaction with my students as well as those of other universi-
ties where I went as an examiner, I realized the difficulties faced by them while preparing
for their exams due to vastness of the subject. This motivated me to write a preparatory
manual that condenses this vital subject into essential elements and yet covers the
undergraduate syllabus.
The present book thus is a concise exam-oriented preparatory manual. The text is
presented in a simple, precise and point-wise manner. This style of presentation would
not only make it easier for the students to understand the subject in a better manner, but
would also help them to quickly review and revise the subject before examination.
Further, to make learning simpler and comprehension easier for the students, numerous
tables, flowcharts and line diagrams have been included.
A large number of people have helped me make this book possible. For this, I thank
my postgraduate students and colleagues.
I am grateful to Professor DR Kulkarni for his guidance and suggestions and for
writing the Foreword.
I would appreciate critical appraisal of this manual and suggestions for improvement.
Tara V Shanbhag
viii
BRIEF CONTENTS
Foreword to the First Edition v
Preface to the Fourth Edition vii
Preface to the First Edition viii
1 General Pharmacology 1
2 Autonomic Pharmacology 46
3 Drugs Affecting Cardiovascular Function 98
4 Renal Pharmacology 151
5 Drugs Acting on Central Nervous System 164
6 Autacoids and Respiratory System 230
7 Drugs Used in the Treatment of Gastrointestinal Diseases 263
8 Drugs Affecting Coagulation and Blood Formation 285
9 Endocrine Pharmacology 303
10 Drugs Acting on Uterus 362
11 Chemotherapy 367
12 Miscellaneous Drugs 470
Index 505
ix
CONTENTS
Foreword to the First Edition v

Preface to the Fourth Edition vii
Preface to the First Edition viii
1 General Pharmacology 1
Introduction (Definitions and Sources of Drugs) 1
Routes of Drug Administration 3
Pharmacokinetics 8
Pharmacodynamics 23
Rational Use of Medicines 36
Adverse Drug Effects 37
Poison Information Centres 42
Pharmacoeconomics 43
New Drug Development 43
2 Autonomic Pharmacology 46
Introduction to Autonomic Nervous System 46
Cholinergic System 46
Cholinergic Agents (Cholinomimetics, Parasympathomimetics) 50
Anticholinergic Agents 62
Skeletal Muscle Relaxants 69
Adrenergic Agonists (Sympathomimetic Agents) 75
Adrenergic Receptor Blockers 88
!-Adrenergic Blockers 88
"-Adrenergic Blockers 91
3 Drugs Affecting Cardiovascular Function 98

Antihypertensive Drugs 98
Antianginal Drugs 112
Drugs Used in Congestive Cardiac Failure 122
Antiarrhythmic Drugs 131
Hypolipidaemic Drugs 138
Plasma Volume Expanders 142
4 Renal Pharmacology 151

Diuretics 152
Antidiuretics 161
5 Drugs Acting on Central Nervous System 164

Neurotransmitters and Central Nervous System 164
Sedatives and Hypnotics 165
General Anaesthetics 173
Local Anaesthetics 181
Alcohols (Ethanol and Methanol) 189
xi
xii CONTENTS
Antiepileptic Drugs 192

Analgesics 201
Opioid Analgesics 201
Antiparkinsonian Drugs 211
Drugs for Alzheimer Disease 215
Cognitive Enhancers (Nootropics) 216
CNS Stimulants 217
Psychopharmacology 217
6 Autacoids and Respiratory System 230

Histamine and Antihistamines 230
5-Hydroxytryptamine: Agonists and Antagonists 234
Prostaglandins and Leukotrienes (Eicosanoids) 238
Nonsteroidal Anti-Inflammatory Drugs 240
Drugs Used in the Treatment of Gout 249
Drugs Used in the Treatment of Rheumatoid Arthritis 251
Drugs Used in the Treatment of Cough 254
Drugs Used in the Treatment of Bronchial Asthma 256
7 Drugs Used in the Treatment of Gastrointestinal Diseases 263

Emetics and Antiemetics 263
Antidiarrhoeal Agents 270
Pharmacotherapy of Inflammatory Bowel Disease 272
Laxatives (Purgatives, Cathartics) 274
Pharmacotherapy of Peptic Ulcer and Gastroesophageal Reflux Disease 277
8 Drugs Affecting Coagulation and Blood Formation 285

Drugs Affecting Coagulation and Bleeding 285
Haematinics and Haematopoietic Growth Factors 297
9 Endocrine Pharmacology 303

Introduction 303
Hypothalamic and Pituitary Hormones 304
Thyroid and Antithyroid Drugs 309
Sex Hormones and Their Antagonists 316
Corticosteroids 331
Insulin and Oral Antidiabetic Agents 341
Agents Affecting Calcium Balance 354
10 Drugs Acting on Uterus 362

Uterine Stimulants and Relaxants 362
11 Chemotherapy 367
Sulphonamides 375
Quinolones and Fluoroquinolones 378
Penicillins 383
Cephalosporins 390
Carbapenems 393
CONTENTS xiii
Monobactams 394
Aminoglycosides 394
Tetracyclines 398
Chloramphenicol 401
Macrolides 402
Miscellaneous Antibacterial Agents 405
Urinary Antiseptics 409
Drugs Useful in the Treatment of Sexually Transmitted Diseases 410
Antituberculosis Drugs 412
Antileprotic Drugs 419
Antifungal Agents 422
Antiviral Agents 430
Antimalarial Drugs 438
Antiamoebic Drugs 448
Anthelmintics 454
Anticancer Drugs 459
12 Miscellaneous Drugs 470

Chelating Agents 470
Immunosuppressants and Immunostimulants 472
Antiseptics and Disinfectants 476
Vitamins 479
Minerals 483
Vaccines and Antisera 485
Drugs Used in Common Skin Diseases 487
Drug Therapy of Scabies and Pediculosis 490
Topical Drugs used for Common Diseases of Eye, Nose and Ear 491
Enzymes in Therapy 493
Drug Treatment of Medical Emergencies 494
Drug Dosage Forms 495
Calculation of Dosage of Drugs 498
Index 505
COMPETENCY MAP
Core Chapter
Code Competency Y/N No. Page No.
PHARMACOLOGY
Topic: Pharmacology
PH1.1 Define and describe the principles of pharmacology and Y 1 1
pharmacotherapeutics.
PH1.2 Describe the basis of Evidence based medicine and Y 1 21
Therapeutic drug monitoring.
PH1.3 Enumerate and identify drug formulations and drug Y 1, 12 8, 495
delivery systems.
PH1.4 Describe absorption, distribution, metabolism & Y 1 8 – 18
excretion of drugs.
PH1.5 Describe general principles of mechanism of drug action. Y 1 23 – 27
PH1.6 Describe principles of Pharmacovigilance & ADR Y 1 41
reporting systems.
PH1.7 Define, identify and describe the management of Y 1 37 – 41
adverse drug reactions (ADR).
PH1.8 Identify and describe the management of drug Y 1 35
interactions.
PH1.9 Describe nomenclature of drugs i.e. generic, branded Y 1 2
drugs.
PH1.10 Describe parts of a correct, complete and legible generic Y - -
prescription. Identify errors in prescription and correct
appropriately.
PH1.11 Describe various routes of drug administration, eg., oral, Y 1 3–8
SC, IV, IM, SL.
PH1.12 Calculate the dosage of drugs using appropriate Y 12 498 – 503
formulae for an individual patient, including children,
elderly and patient with renal dysfunction.
PH1.13 Describe mechanism of action, types, doses, side Y 2 75 – 97
effects, indications and contraindications of adrenergic
and anti-adrenergic drugs.
effects, indications and contraindications of cholinergic
and anticholinergic drugs.
PH1.15 Describe mechanism/s of action, types, doses, side Y 2 69 – 75
effects, indications and contraindications of skeletal
muscle relaxants.
PH1.16 Describe mechanism/s of action, types, doses, side Y 6 230 – 254
effects, indications and contraindications of the drugs
which act by modulating autacoids, including: anti-
histaminics, 5-HT modulating drugs, NSAIDs, drugs for
gout, anti-rheumatic drugs, drugs for migraine.
PH1.17 Describe the mechanism/s of action, types, doses, side Y 5 181 – 189
effects, indications and contraindications of local
anesthetics.
(Continued)
xv
xvi COMPETENCY MAP
Core Chapter
effects, indications and contraindications of general
anaesthetics, and pre- anesthetic medications.
PH1.19 Describe the mechanism/s of action, types, doses, side Y 5 164 – 173,
effects, indications and contraindications of the drugs 192 – 229
which act on CNS, (including anxiolytics, sedatives &
hypnotics, anti-psychotic, antidepressant drugs, anti-
maniacs, opioid agonists and antagonists, drugs used
for neurodegenerative disorders, anti-epileptics drugs).
PH1.20 Describe the effects of acute and chronic ethanol intake. Y 5 189 – 191
PH1.21 Describe the symptoms and management of methanol Y 5 191
and ethanol poisonings.
PH1.22 Describe drugs of abuse (dependence, addiction, Y 1, 5 39, 217
stimulants, depressants, psychedelics, drugs used for
criminal offences).
PH1.23 Describe the process and mechanism of drug Y 1, 5 39,
deaddiction. 190 – 191,
204 – 205
affecting renal systems including diuretics, antidiuretics-
vasopressin and analogues.
PH1.25 Describe the mechanism/s of action, types, doses, side Y 3, 8 285 – 296,
acting on blood, like anticoagulants, antiplatelets,
fibrinolytics, plasma expanders.
PH1.26 Describe mechanisms of action, types, doses, side Y 3, 4 98 – 104,
modulating the renin- angiotensin and aldosterone
system.
PH1.27 Describe the mechanisms of action, types, doses, side Y 3 98 – 111
effects, indications and contraindications of
antihypertensive drugs and drugs used in shock.
used in ischemic heart disease (stable, unstable angina
and myocardial infarction), peripheral vascular disease.
used in congestive heart failure.
PH1.30 Describe the mechanisms of action, types, doses, side N 3 131 – 138
effects, indications and contraindications of the
antiarrhythmics.
used in the management of dyslipidemias.
effects, indications and contraindications of drugs used
in bronchial asthma and COPD.
PH1.33 Describe the mechanism of action, types, doses, side Y 6 254 – 256
used in cough (antitussives, expectorants/ mucolytics).
COMPETENCY MAP xvii
Core Chapter
effects, indications and contraindications of the drugs 263 – 270,
used as below: 270 – 272,
1. Acid-peptic disease and GERD 274 – 276,
2. Antiemetics and prokinetics 272 – 273
3. Antidiarrhoeals
4. Laxatives
5. Inflammatory Bowel Disease
6. Irritable Bowel Disorders, biliary and pancreatic
diseases.
effects, indications and contraindications of drugs used 302
in hematological disorders like:
1. Drugs used in anemias
2. Colony Stimulating factors.
PH1.36 Describe the mechanism of action, types, doses, side Y 9 341 – 354,
effects, indications and contraindications of drugs used 309 – 315,
in endocrine disorders (diabetes mellitus, thyroid 354 – 361
disorders and osteoporosis).
PH1.37 Describe the mechanisms of action, types, doses, side Y 9 316 – 326,
used as sex hormones, their analogues and anterior
Pituitary hormones.
PH1.38 Describe the mechanism of action, types, doses, side Y 9 331 – 341
corticosteroids.
effects, indications and contraindications the drugs used
for contraception.
PH1.40 Describe mechanism of action, types, doses, side Y 9, 2 322, 91
effects, indications and contraindications of 1. Drugs
used in the treatment of infertility, and 2. Drugs used in
erectile dysfunction.
effects, indications and contraindications of uterine
relaxants and stimulants.
PH1.42 Describe general principles of chemotherapy. Y 11 367–375
PH1.43 Describe and discuss the rational use of antimicrobials Y - -
including antibiotic stewardship program.
PH1.44 Describe the first line antitubercular dugs, their Y 11 412 – 417
mechanisms of action, side effects and doses.
PH1.45 Describe the dugs used in MDR and XDR Tuberculosis. Y 11 418
effects, indications and contraindications of antileprotic
drugs.
effects, indications and contraindications of the drugs 453,
used in malaria, KALA-AZAR, amebiasis and intestinal 448 – 452,
helminthiasis. 454 – 458
used in UTI/ STD and viral diseases including HIV.
(Continued)
xviii COMPETENCY MAP
Core Chapter
PH1.49 Describe mechanism of action, classes, side effects, Y 11 459 – 469
indications and contraindications of anticancer drugs.
PH1.50 Describe mechanisms of action, types, doses, side Y 12 472 – 476
immunomodulators and management of organ
transplant rejection.
PH1.51 Describe occupational and environmental pesticides, Y 2 60 – 61
food adulterants, pollutants and insect repellents.
PH1.52 Describe management of common poisoning, Y 1 41 – 42,
insecticides, common sting and bites. 60 – 61
PH1.53 Describe heavy metal poisoning and chelating agents. N 12 470 – 472
PH1.54 Describe vaccines and their uses. Y 12 485 – 487
PH1.55 Describe and discuss the following National Health Y - -
Programmes including Immunisation, Tuberculosis,
Leprosy, Malaria, HIV, Filaria, Kala Azar, Diarrhoeal
diseases, Anaemia & nutritional disorders, Blindness,
Non-communicable diseases, cancer and Iodine
deficiency.
PH1.56 Describe basic aspects of Geriatric and Pediatric Y - -
pharmacology.
PH1.57 Describe drugs used in skin disorders. Y 12 487 – 491
PH1.58 Describe drugs used in Ocular disorders. Y 12 491 – 492
PH1.59 Describe and discuss the following: Essential medicines, Y 1 1, 21 – 22
Fixed dose combinations, Over the counter drugs,
Herbal medicines.
PH1.60 Describe and discuss Pharmacogenomics and N 1 43
Pharmacoeconomics.
PH1.61 Describe and discuss dietary supplements and N - -
nutraceuticals.
PH1.62 Describe and discuss antiseptics and disinfectants. Y 12 476 – 479
PH1.63 Describe Drug Regulations, acts and other legal aspects. Y - -
PH1.64 Describe overview of drug development, Phases of Y 1 43 – 45
clinical trials and Good Clinical Practice.
Topic: Clinical Pharmacy

PH2.1 Demonstrate understanding of the use of various dosage Y 12 495 – 498
forms (oral/local/parenteral; solid/liquid).
PH2.2 Prepare oral rehydration solution from ORS packet and Y
explain its use.
PH2.3 Demonstrate the appropriate setting up of an Y
intravenous drip in a simulated environment.
PH2.4 Demonstrate the correct method of calculation of drug Y 12 498 – 503
dosage in patients including those used in special
situations.
C H A P T E R 1
General Pharmacology
Introduction (Definitions and Sources of Drugs) PH1.1, PH1.59
■ Pharmacology: It is the science that deals with the effects of drugs on living systems.
■ Drug: World Health Organization (WHO) defines drug as ‘any substance or
product that is used or intended to be used to modify or explore physiological systems
or pathological states for the benefit of the recipient’.
■ Pharmacokinetics: It means the movement of drug within the body; it includes
the processes of absorption (A), distribution (D), metabolism (M) and excretion
(E). It means ‘what the body does to the drug’.
■ Pharmacodynamics: It is the study of drugs – their mechanism of action, phar-
macological actions and their adverse effects. It covers all the aspects relating to
‘what the drug does to the body’.
■ Pharmacy: It is the branch of science that deals with the preparation, preserva-
tion, standardization, compounding, dispensing and proper utilization of drugs.
■ Therapeutics: It is the aspect of medicine concerned with the treatment of diseases.
■ Chemotherapy: It deals with treatment of infectious diseases/cancer with chemi-
cal compounds that cause relatively selective damage to the infecting organism/
cancer cells.
■ Toxicology: It is the study of poisons, their actions, detection, prevention and
treatment of poisoning.
■ Clinical pharmacology: It is the systematic study of a drug in man, both in
healthy volunteers and in patients. It includes the evaluation of pharmacokinetic
and pharmacodynamic data, safety, efficacy and adverse effects of a drug by com-
parative clinical trials.
■ Essential medicines: According to WHO, essential medicines are ‘those that sat-
isfy the healthcare needs of majority of the population’. They should be of assured
quality, available at all times, in adequate quantities and in appropriate dosage
forms. They should be selected with regard to disease prevalence in a country,
evidence on safety and efficacy, and comparative cost-effectiveness. The examples
are iron and folic acid preparations for anaemia of pregnancy, antitubercular
drugs like isoniazid, rifampicin, pyrazinamide, ethambutol, etc.
■ Orphan drugs: Drugs that are used for diagnosis, treatment or prevention of rare
diseases. The expenses incurred during the development, manufacture and marketing
of drug cannot be recovered by the pharmaceutical company from selling the drug, e.g.
digoxin antibody (for digoxin toxicity), fomepizole (for methyl alcohol poisoning), etc.
■ Over-the-counter drugs (OTC drugs, nonprescription drugs): These drugs can
be sold to a patient without the need for a doctor’s prescription, e.g. paracetamol,
antacids, etc.
■ Prescription drugs: These are drugs which can be obtained only upon producing the
prescription of a registered medical practitioner, e.g. antibiotics, antipsychotics, etc.
1
2 PHARMACOLOGY FOR MEDICAL GRADUATES
SOURCES OF DRUG INFORMATION

Pharmacopoeia: It is a book which contains a list of established and officially approved drugs
with description of their physical and chemical characteristics and tests for their identifica-
tion, purity, methods of storage, etc. Some of the pharmacopoeias are the Indian Pharmaco-
poeia (IP), the British Pharmacopoeia (BP), and the United States Pharmacopoeia (USP).
Other sources of drug information are National Formulary (NF), Martindale – the
Extra Pharmacopoeia, Physician’s Desk Reference (PDR), American Medical Associa-
tion Drug Evaluation, textbooks and journals of pharmacology and therapeutics, drug
bulletins, databases like Micromedex, Medline, Cochrane Library, etc. Information can
also be obtained from pharmaceutical companies through their medical representa-
tives, meetings and drug advertisements in journals.
Formulary: It provides information about the available drugs in a country – their use,
dose, dosage forms, adverse effects, contraindications, precautions, warnings and guid-
ance on selecting the right drug for a range of conditions.
DRUG NOMENCLATURE PH1.9

Drugs usually have three types of names, which are as follows:
1. Chemical name: It denotes the chemical structure of a drug, e.g. acetylsalicylic
acid is the chemical name of aspirin and N-acetyl-p-aminophenol is of paracetamol.
It is not suitable for use in a prescription.
2. Nonproprietary name: It is assigned by a competent scientific body/authority,
e.g. the United States Adopted Name (USAN) council. WHO* along with its
member countries select and recommend the International Nonproprietary
Name (INN) for a drug. So, it is uniform throughout the world and denotes the
active pharmaceutical ingredient. Few older drugs have more than one nonpro-
prietary name, e.g. the opioid, pethidine and meperidine. The INN is commonly
used as generic name. Ideally, generic names should be used in prescriptions be-
cause it is economical and generally uniform all over the world than the branded
counterparts. Examples are aspirin and paracetamol are generic names.
3. Proprietary name (brand name): It is given by the drug manufacturers. Brand names
are short and easy to recall. Drugs sold under brand name are expensive as compared
to their generic version. A drug usually has many brand names – it may have different
names within a country and in different countries. Brand names can also be used in
prescriptions. Disprin is a brand name of aspirin; Crocin for paracetamol.
Chemical name Nonproprietary name Proprietary name/brand name

Acetylsalicylic acid Aspirin • Disprin
• Ecosprin
N-acetyl-p- Paracetamol • Crocin
aminophenol • Metacin
(Acetaminophen) • Tylenol
*S Kopp-Kubel. International Nonproprietary Names (INN) for pharmaceutical substances. Bull World Health
Organ 1995;73(3):275–279.
1—GENERAL PHARMACOLOGY 3
SOURCES OF DRUGS
They are natural, semisynthetic and synthetic. Natural sources are plants, animals, min-
erals, microorganisms, etc. Semisynthetic drugs are obtained from natural sources and
are later chemically modified. Synthetic drugs are produced artificially.
The different sources of drugs:
1. Plants:
a. Alkaloids are nitrogen containing compounds, e.g. morphine, atropine, quinine,
reserpine, ephedrine.
b. Glycosides contain sugar group in combination with nonsugar through ether
linkage, e.g. digoxin, digitoxin.
c. Volatile oils have aroma. They are useful for relieving pain (clove oil), as carmi-
native (eucalyptus oil), flavouring agent (peppermint oil), etc.
d. Resins are sticky organic compounds obtained from plants as exudate, e.g. tincture
benzoin (antiseptic).
2. Animals: Insulin, heparin, antisera.
3. Minerals: Ferrous sulphate, magnesium sulphate.
4. Microorganisms: Penicillin G, streptomycin, griseofulvin (antimicrobial agents),
streptokinase (fibrinolytic).
5. Semisynthetic: Hydromorphone, hydrocodone.
6. Synthetic: Most of the drugs used today are synthetic, e.g. aspirin, paracetamol.
Drugs are also produced by genetic engineering (DNA recombinant technology), e.g.
human insulin, human growth hormone and hepatitis B vaccine.
Routes of Drug Administration PH1.11
Most of the drugs can be administered by different routes. Drug- and patient-related
factors determine the selection of routes for drug administration. These factors are
1. Characteristics of the drug.
2. Emergency/routine use.
3. Condition of the patient (unconscious, vomiting and diarrhoea).
4. Age of the patient.
5. Associated diseases.
6. Patient’s/doctor’s choice (sometimes).
Routes
Local Systemic
Enteral Parenteral
– Oral – Injection
– Sublingual – Inhalation
– Rectal – Transdermal
Routes of drug administration
LOCAL ROUTES
It is the simplest mode of administration of a drug at the site where the desired action
is required. Systemic side effects are minimal.
1. Topical: Drug is applied to the skin or mucous membrane at various sites for
localized action.
a. Oral cavity: As suspension, e.g. nystatin; as a troche, e.g. clotrimazole (for oral
candidiasis); as a cream, e.g. acyclovir (for herpes labialis); as ointment, e.g. 5%
lignocaine hydrochloride (for topical anaesthesia); as a spray, e.g. 10% ligno-
caine hydrochloride (for topical anaesthesia).
b. GI tract: As tablet which is not absorbed, e.g. neomycin (for sterilization of gut
before surgery).
c. Rectum and anal canal:
1) As an enema (administration of drug into the rectum in liquid form):
■ Evacuant enema (for evacuation of bowel): For example, soap water
enema – soap acts as a lubricant and water stimulates rectum.

■ Retention enema: For example, methylprednisolone in ulcerative
colitis.
2) As a suppository (administration of the drug in a solid form into the
rectum), e.g. bisacodyl suppository for evacuation of bowel.
d. Eye, ear and nose: As drops, ointment and spray (for infection, allergic condi-
tions, etc.), e.g. gentamicin – eye and ear drops.
e. Bronchi: As inhalation, e.g. salbutamol, ipratropium bromide, etc. (for bronchial
asthma and chronic obstructive pulmonary disease).
f. Vagina: As tablet, cream, pessary, etc. (for vaginal candidiasis).
g. Urethra: As jelly, e.g. lignocaine.
h. Skin: As ointment, cream, lotion, powder, e.g. clotrimazole (antifungal) for
cutaneous candidiasis.
2. Intra-arterial route: This route is rarely employed. It is mainly used during diag-
nostic studies, such as coronary angiography and for the administration of some
anticancer drugs, e.g. for treatment of malignancy involving limbs.
3. Administration of the drug into deep tissues by injection, e.g. administration of
triamcinolone directly into the joint space in rheumatoid arthritis.
SYSTEMIC ROUTES
Drugs administered by this route enter the blood and produce systemic effects.
Enteral Routes
They include oral, sublingual and rectal routes.
Oral Route. It is the most common and acceptable route for drug administration.
Dosage forms are tablet, capsule, powder, syrup, linctus, mixture, suspension, etc., e.g.
paracetamol tablet for fever, omeprazole capsule for peptic ulcer are given orally. Tablets
could be coated (covered with a thin film of another substance) or uncoated. They are
also available as chewable (albendazole), dispersible (aspirin), mouth dissolving
(ondansetron) and sustained release forms. Capsules have a soft or hard shell.
Advantages
■ Safer.
■ Cheaper.
■ Painless.
■ Convenient for repeated and prolonged use.

■ Can be self-administered.
Disadvantages
■ It is not suitable for/in:
■ unpalatable and highly irritant drugs
■ unabsorbable drugs (e.g. aminoglycosides)
■ drugs that are destroyed by digestive juices (e.g. insulin)
■ drugs with extensive first-pass metabolism (e.g. lignocaine)
■ unconscious patients
■ uncooperative and unreliable patients
■ patients with severe vomiting and diarrhoea
■ emergency as onset of action of orally administrated drugs is slow
Sublingual Route. The preparation is kept under the tongue. The drug is absorbed
through the buccal mucous membrane and enters systemic circulation directly, e.g.
nitroglycerin(for acute attack of angina) and buprenorphine.
Advantages
■ Quick onset of action of the drug.
■ Action can be terminated by spitting out the tablet.
■ Bypasses the first-pass metabolism.
■ Self-administration is possible.
Disadvantages
■ It is not suitable for:
■ irritant and lipid-insoluble drugs
■ drugs with bad taste
Rectal Route. Drugs can be given in the form of solid or liquid.

1. Suppository: It can be used for local (topical) effect (see p. 4) as well as systemic
effect, e.g. indomethacin for rheumatoid arthritis.
2. Enema: Retention enema can be used for local effect (see p. 4) as well as systemic
effect. The drug is absorbed through rectal mucous membrane and produces sys-
temic effect, e.g. diazepam for status epilepticus in children methylprednisolone
enema in ulcerative colitis.
Parenteral Routes
Routes of administration other than enteral route are called parenteral routes.
Advantages
■ Onset of action of drugs is faster, hence suitable for emergency.
■ Useful in:
■ unconscious patient
■ uncooperative and unreliable patient
■ patients with vomiting and diarrhoea
■ Suitable for:
■ irritant drugs
■ drugs with high first-pass metabolism
■ drugs not absorbed orally
■ drugs destroyed by digestive juices

Disadvantages
■ Require aseptic conditions.
■ Preparation should be sterile, and is expensive.
■ Require invasive techniques, which are painful.
■ Cannot be usually self-administered.
■ Can cause local tissue injury to nerves, vessels, etc.
Inhalation. Volatile liquids and gases are given by inhalation for systemic effects, e.g.
general anaesthetics.
Advantages
■ Quick onset of action.
■ Dose required is very less, so systemic toxicity is minimized.
■ Amount of drug administered can be regulated.
Disadvantages
■ Local irritation may cause increased respiratory secretion and bronchospasm.
Injections (Fig. 1.1)

Intradermal Route. The drug is injected into the layers of skin, e.g. BCG vaccination
and drug sensitivity tests. It is painful and a small amount of the drug can be administered.
Subcutaneous (s.c.) Route. The drug is injected into the subcutaneous tissue of the
thigh, abdomen, arm, e.g. adrenaline, insulin, etc.
Advantages
■ Self-administration of drug is possible, e.g. insulin.
■ Depot preparations can be inserted into the subcutaneous tissue, e.g. norplant for
contraception.
Disadvantages
■ It is suitable only for nonirritant drugs.
■ Drug absorption is slow, hence not suitable for emergency.
Intradermal
Subcutaneous
Intravenous
Intra-arterial
Intramuscular
Intra-articular
Fig. 1.1 Injectable routes of drug administration.

Intramuscular (i.m.) Route. Drugs are injected into large muscles, such as deltoid, glu-
teus maximus and vastus lateralis, e.g. paracetamol, diclofenac, etc. A volume of 5–10 mL
can be given at a time.
Advantages
■ Absorption is more rapid as compared to oral route.
■ Mild irritants, depot injections, soluble substances and suspensions can be given
by this route.
Disadvantages
■ Aseptic conditions are needed.
■ Intramuscular (i.m.) injections are painful and may cause abscess.
■ Self-administration is not possible.
■ There may be injury to nerves.
Intravenous (i.v.) Route. Drugs are injected directly into the blood stream through
a vein. Drugs are administered as
1. Bolus: Single, relatively large dose of a drug injected rapidly or slowly into a vein,
e.g. i.v. ranitidine in bleeding peptic ulcer.
2. Slow intravenous injection: For example, i.v. morphine in myocardial infarction.
3. Intravenous infusion: For example, dopamine infusion in cardiogenic shock;
mannitol infusion in cerebral oedema; fluids infused intravenously in dehydration.
Advantages
■ Bioavailability is 100%.
■ Quick onset of action, so it is the route of choice in emergency, e.g. intravenous
diazepam to control convulsions in status epilepticus.

■ Large volume of fluid can be administered, e.g. intravenous fluids in patients with
severe dehydration.
■ Highly irritant drugs, e.g. anticancer drugs can be given because they get diluted in blood.
■ Hypertonic solution can be infused by intravenous route, e.g. 20% mannitol in
cerebral oedema.
■ By i.v. infusion, a constant plasma level of the drug can be maintained, e.g. dopamine
infusion in cardiogenic shock.
Disadvantages
■ Local irritation may cause phlebitis.
■ Self-administration is usually not possible.
■ Strict aseptic conditions are needed.
■ Extravasation of some drugs (e.g. noradrenaline) can cause injury, necrosis and
sloughing of tissues.
■ Depot preparations cannot be given by i.v. route.
Precautions
■ Drug should usually be injected slowly.
■ Before injecting, make sure that the tip of the needle is in the vein.
Intrathecal Route. Drug is injected into the subarachnoid space, e.g. lignocaine
(spinal anaesthesia), antibiotics (amphotericin B), etc.
Transdermal Route (Transdermal Therapeutic System). The drug is administered in

the form of a patch or ointment that delivers the drug into the circulation for systemic
effect (Fig. 1.2), e.g. scopolamine patch for sialorrhoea and motion sickness, nitroglycerin
Backing layer
D D D D
D D D Drug reservoir
D D D D
D D D D D Rate controlling
membrane
Adhesive layer
Outer layer, which is

peeled off before
application to skin
Fig. 1.2 Transdermal drug delivery system.
patch/ointment for prophylaxis of angina, oestrogen patch for hormone replacement

therapy (HRT), clonidine patch for hypertension, fentanyl patch for terminal stages of
cancer pain and chronic pain, nicotine patch for tobacco deaddiction, etc.
Advantages
■ Self-administration is possible.
■ Patient compliance is better.
■ Duration of action is prolonged.
■ Systemic side effects are reduced.
■ Provides a constant plasma concentration of the drug.
■ First-pass metabolism is bypassed.
Disadvantages
■ Expensive.
■ Local irritation may cause dermatitis and itching.
■ Patch may fall off unnoticed.
SPECIAL DRUG DELIVERY SYSTEMS PH1.3

They have been developed to prolong duration of drug action, for targeted delivery of
drugs or to improve patient compliance.
1. Ocusert: It is kept beneath the lower eyelid in glaucoma. It releases the drug slowly
for a week following a single application, e.g. pilocarpine ocusert.
2. Progestasert: It is an intrauterine contraceptive device that releases progesterone
slowly for a period of one year.
3. Liposomes: They are minute vesicles made of phospholipids into which the drug
is incorporated. They help in targeted delivery of drugs, e.g. liposomal formula-
tion of amphotericin B for fungal infections.
4. Monoclonal antibodies: They are immunoglobulins, produced by cell culture,
selected to react with a specific antigen. They are useful for targeted delivery of
drugs, e.g. delivery of anticancer drugs using monoclonal antibodies.
5. Drug-eluting stents: e.g. paclitaxel releasing stents used in coronary angioplasty.
6. Computerized, miniature pumps, e.g. insulin pump for continuous subcutaneous
delivery of insulin
Pharmacokinetics PH1.4
Pharmacokinetics is derived from two words: Pharmacon meaning drug and kinesis
meaning movement. In short, it is ‘what the body does to the drug’. It includes
absorption (A), distribution (D), metabolism (M) and excretion (E). All these pro-
cesses involve movement of the drug molecule through various biological membranes.
All biological membranes are made up of a lipid bilayer. Drugs cross various bio-
logical membranes by the following mechanisms:
1. Passive diffusion: It is a bidirectional process. The drug molecules move from a
region of higher to lower concentration until equilibrium is attained. The rate
of diffusion is directly proportional to the concentration gradient across the
membrane. Lipid-soluble drugs are transported across the membrane by passive
diffusion. It does not require energy and is the process by which majority of the
drugs are absorbed.
2. Active transport: Drug molecules move from a region of lower to higher concen-
tration against the concentration gradient. It requires energy, e.g. transport of
sympathomimetic amines into neural tissue, transport of choline into cholinergic
neurons and absorption of levodopa from the intestine. In primary active trans-
port, energy is obtained by hydrolysis of ATP. In secondary active transport, energy
is derived from transport of another substrate (either symport or antiport).
3. Facilitated diffusion: This is a type of carrier-mediated transport and does not
require energy. The drug attaches to a carrier in the membrane, which facilitates
its diffusion across the membrane. The transport of molecules is from the region
of higher to lower concentration, e.g. transport of glucose across muscle cell mem-
brane by a transporter GLUT 4.
4. Filtration: Filtration depends on the molecular size and weight of the drug.
If drug molecules are smaller than the pores, they are filtered easily through the
membrane.
5. Endocytosis: The drug is taken up by the cell through vesicle formation. Absorp-
tion of vitamin B12–intrinsic factor complex in the gut is by endocytosis.
DRUG ABSORPTION PH1.4

Movement of a drug from the site of administration into the blood stream is known as
absorption.
Factors Influencing Drug Absorption

1. Physicochemical properties of the drug:
a. Physical state: Liquid form of the drug is better absorbed than solid formulations.
b. Lipid-soluble and unionized form of the drug is better absorbed than water-
soluble and ionized form.
c. Particle size: Drugs with smaller particle size are absorbed better than larger
ones, e.g. microfine aspirin, digoxin and griseofulvin are well absorbed from
the gut and produce better effects. Some of the anthelmintics have larger par-
ticle size. They are poorly absorbed through gastrointestinal (GI) tract, hence
they produce better effect on gut helminths.
d. Disintegration time: It is the time taken for the formulation (tablet or capsule)
to break up into small particles and its variation may affect the bioavailability.
e. Dissolution time: It is the time taken for the particles to go into solution. Shorter
the time, better is the absorption.
f. Formulations: Pharmacologically inert substances like lactose, starch, calcium
sulphate, gum, etc. are added to formulations as binding agents. These are not
totally inert and may affect the absorption of drugs, e.g. calcium reduces the
absorption of tetracyclines.
Weakly acidic drugs

(barbiturates)
Unionized form in Acidic

pH Weakly basic drugs
(morphine, amphetamine)
Better absorbed
from the stomach
Alkaline pH in Unionized form
Better absorbed from

the intestine
Fig. 1.3 Effect of pH and ionization on drug absorption.
2. Route of drug administration: A drug administered by intravenous route bypasses

the process of absorption as it directly enters the circulation. Some drugs are highly
polar compounds, ionize in solution and are not absorbed through GI tract, hence
are given parenterally, e.g. gentamicin. Drugs like insulin are administered paren-
terally because they are degraded in the GI tract on oral administration.
3. pH and ionization: Strongly acidic (heparin) and strongly basic (aminoglycosides)
drugs usually remain ionized at all pH, hence they are poorly absorbed (Fig. 1.3).
4. Food: Presence of food in the stomach can affect the absorption of some drugs.
Food decreases the absorption of rifampicin, levodopa, etc., hence they should be
taken on an empty stomach for better effect. Milk and milk products decrease the
absorption of tetracyclines. Fatty meal increases the absorption of griseofulvin.
5. Presence of other drugs: Concurrent administration of two or more drugs may
affect their absorption, e.g. ascorbic acid increases the absorption of oral iron.
Antacids reduce the absorption of tetracyclines.
6. Area of the absorbing surface: Normally, drugs are better absorbed in small in-
testine because of a larger surface area. Resection of the gut decreases absorption
of drugs due to a reduced surface area.
7. Gastrointestinal and other diseases: In gastroenteritis, there is increased peristal-
tic movement that decreases drug absorption. In achlorhydria, absorption of iron
from the gut is reduced. In congestive cardiac failure, there is GI mucosal oedema
that reduces absorption of drugs.
BIOAVAILABILITY
It is the fraction of a drug that reaches systemic circulation from a given dose. Intrave-
nous route of drug administration gives 100% bioavailability as it directly enters the
circulation. The term bioavailability is used commonly for drugs given by oral route.
If two formulations of the same drug produce equal bioavailability, they are said
to be bioequivalent. If formulations differ in their bioavailability, they are said to be
bioinequivalent.
Factors Affecting Bioavailability. The factors which affect drug absorption (physico-
chemical properties of the drug, route of drug administration, pH and ionization, food,
Fig. 1.4 First-pass metabolism.
presence of other drugs, area of absorbing surface, GI and other diseases) also affect bio-
availability of a drug. Other factors that affect the bioavailability of a drug are discussed
as follows:
1. First-pass metabolism (First-pass effect, presystemic elimination): When drugs
are administered orally, they have to pass via gut wall n portal vein n liver n
systemic circulation (Fig. 1.4). During this passage, certain drugs get metabolized
and are removed or inactivated before they reach the systemic circulation. This
process is known as first-pass metabolism. The net result is a decreased bioavail-
ability of the drug and diminished therapeutic response, e.g. drugs like lignocaine
(liver), isoprenaline (gut wall), etc.
Consequences of high first-pass metabolism:
1) Drugs which undergo extensive first-pass metabolism are administered
parenterally, e.g. lignocaine is administered intravenously in ventricular
arrhythmias.
2) Dose of a drug required for oral administration is more than that given by
other systemic routes, e.g. nitroglycerin.
2. Hepatic diseases: They result in a decrease in drug metabolism, thus increasing
the bioavailability of drugs that undergo high first-pass metabolism, e.g. pro-
pranolol and lignocaine.
3. Enterohepatic cycling: Some drugs are excreted via bile but after reaching the in-
testine they are reabsorbed n liver n bile n intestine and the cycle is repeated –
such recycling is called enterohepatic circulation and it increases bioavailability
as well as the duration of action of the drug, e.g. morphine and doxycycline.
DRUG DISTRIBUTION PH1.4

Distribution is defined as the reversible transfer of drugs between body-fluid compart-
ments. After absorption, a drug enters the systemic circulation and is distributed in the
body fluids. Various body-fluid compartments for a 70-kg person can be depicted as
follows:
TBW (42 L)
ECF (14 L) ICF (28 L)
Plasma Interstitial fluid Transcellular fluid

(3 L) compartment compartment
(10.5 L) (0.5 L)
ECF, extracellular fluid; ICF, intracellular fluid; TBW, total body water.
Apparent Volume of Distribution

Apparent volume of distribution (aVd) is defined as the hypothetical volume of body
fluid into which a drug is uniformly distributed at a concentration equal to that in
plasma, assuming the body to be a single compartment.
Total administered amount of drug

aVd !
Concentration of the drug in plasma
■ Drugs with high molecular weight (e.g. heparin) or extensively bound to plasma
protein (e.g. warfarin) are largely restricted to the vascular compartment, hence their
aVd is low.
■ If aVd of a drug is about 14–16 L (0.25 mL/kg in a person weighing 70 kg), it indi-
cates that the drug is distributed in the ECF, e.g. gentamicin, streptomycin, etc.
■ Small water-soluble molecules like ethanol are distributed in total body water –
aVd is approximately 42 L.
■ Drugs which accumulate in tissues have a volume of distribution which exceeds
total body water, e.g. chloroquine (13,000 L) and digoxin (500 L). Haemodialysis
is not useful for removal of drugs with large aVd in case of overdosage.
■ In congestive cardiac failure, Vd of some drugs can increase due to an increase in
ECF volume (e.g. alcohol) or decrease because of reduced perfusion of tissues.
■ In uraemia, the total body water can increase which increases Vd of small water-
soluble drugs. Toxins which accumulate can displace drugs from plasma protein
binding sites resulting in increased concentration of free form of drug which can
leave the vascular compartment leading to an increase in Vd.
■ Fat:lean body mass ratio – highly lipid-soluble drugs get distributed to the adipose
tissue. If the ratio is high, the volume of distribution for such a drug will be higher;
fat acts as a reservoir for such drugs.
Redistribution (see p. 178)
Highly lipid-soluble drug, such as thiopentone, on intravenous administration, immedi-
ately gets distributed to the areas of high blood flow, such as brain, and causes general an-
aesthesia. Immediately within few minutes, it diffuses across the blood–brain barrier (BBB)
into blood and then to the less perfused tissues, such as muscle and adipose tissue. This is
called redistribution, which results in termination of drug action. Thiopentone has a very
short duration of action (5–10 minutes) and is used for induction of general anaesthesia.
Drug Reservoirs or Tissue Storage
Some drugs are concentrated or accumulated in tissues or some organs of the body,
which can lead to toxicity on chronic use, e.g. tetracyclines – bones and teeth; thiopen-
tone and DDT – adipose tissue; chloroquine – liver and retina; digoxin – heart, etc.
Blood–Brain Barrier
The capillary boundary that is present between blood and brain is called blood—brain
barrier (BBB). In the brain capillaries, the endothelial cells are joined by tight junctions.
Only the lipid-soluble and unionized form of drugs can pass through BBB and reach the
brain, e.g. barbiturates, diazepam, volatile anaesthetics, amphetamine, etc. Lipid-insol-
uble and ionized particles do not cross the BBB, e.g. dopamine and aminoglycosides.
Pathological states like meningitis and encephalitis increase the permeability of the
BBB and allow the normally impermeable substances to enter the brain, e.g. penicillin
G in normal conditions has poor penetration through BBB, but its penetrability in-
creases during meningitis and encephalitis.
Placental Barrier
Drugs administered to a pregnant woman can cross placenta and reach the fetus. Passage
across placenta is affected by lipid solubility, degree of plasma protein binding, presence
of transporters, etc. Quaternary ammonium compounds, e.g. d-tubocurarine (d-TC)
and substances with high molecular weight like insulin cannot cross the placental barrier.
PLASMA PROTEIN BINDING PH1.4

Many drugs bind to plasma proteins like albumin, "1 acid glycoprotein, etc.
Clinical importance of plasma protein binding
Absorption
1. Drug Enters circulation
Binds to plasma protein (acidic drugs to

albumin, basic drugs to α1 acid glycoprotein)
Free form (pharma- Bound form (cannot exert pharmacological

cologically active) action, acts as a ‘temporary store’ of the drug)
2. Drugs that are highly bound to plasma proteins have a low volume of
distribution.
3. Plasma protein binding delays the metabolism of drugs.
4. Bound form is not available for filtration at the glomeruli. Hence, excretion of
highly plasma protein bound drugs by filtration is delayed.
5. Highly protein bound drugs have a longer duration of action, e.g. sulphadiazine is
less plasma protein bound and has a duration of action of 6 hours, whereas
sulphadoxine is highly plasma protein bound and has a duration of action of
1 week.
6. In case of poisoning, highly plasma protein bound drugs are difficult to be
removed by haemodialysis.
7. In disease states like anaemia, renal failure, chronic liver diseases, etc. plasma
albumin levels are low (hypoalbuminaemia). So, there will be a decrease in bound
form and an increase in free form of the drug, which can lead to drug toxicity.
8. Plasma protein binding can cause displacement interactions. More than one drug
can bind to the same site on plasma protein. The drug with higher affinity will
displace the one having lower affinity and may result in a sudden increase in the
free concentration of the drug with lower affinity.
BIOTRANSFORMATION (Drug Metabolism) PH1.4

Chemical alteration of the drug in a living organism is called biotransformation. The
metabolism of a drug usually converts lipid-soluble and unionized compounds into
water-soluble and ionized compounds, hence not reabsorbed in the renal tubules and
are excreted. If the parent drug is highly polar (ionized), then it may not get metabo-
lized and is excreted as such.
Sites: Liver is the main site for drug metabolism; other sites are GI tract, kidney, lungs,
blood, skin and placenta.
The end result of drug metabolism is inactivation, but sometimes a compound with
pharmacological activity may be formed as shown below:
1. Active drug to inactive metabolite: This is the most common type of metabolic
transformation.
Phenobarbitone Hydroxyphenobarbitone
Phenytoin p-Hydroxyphenytoin
2. Active drug to active metabolite
Codeine Morphine
Diazepam Oxazepam
3. Inactive drug (prodrug) to active metabolite
Levodopa Dopamine
Prednisone Prednisolone
Prodrug
It is an inactive form of a drug, which is converted to an active form after metabolism.
Uses of Prodrugs (Advantages)

1. To improve bioavailability: Parkinsonism is due to deficiency of dopamine. Dopa-
mine itself cannot be used since it does not cross BBB. So, it is given in the form of a
prodrug, levodopa. Levodopa crosses the BBB and is then converted into dopamine.
Dopa decarboxylase
Levodopa Levodopa Dopamine
BBB
2. To prolong the duration of action: Phenothiazines have a short duration of

action, whereas esters of phenothiazine (fluphenazine) have a longer duration
of action.
3. To improve taste: Clindamycin has a bitter taste, so clindamycin palmitate sus-
pension has been developed for paediatric use to improve the taste.
4. To provide site-specific drug delivery:
acidic pH of urine
Methenamine Formaldehyde (acts as urinary antiseptic)
Pathways of Drug Metabolism. Drug metabolic reactions are grouped into two
phases. They are Phase I or nonsynthetic reactions and Phase II or synthetic reactions.
Phase I Reactions (Table 1.1). Oxidation: Addition of oxygen or removal of hydrogen

is called oxidation. It is the most important and common metabolic reaction.
■ Oxidation reactions are mainly carried out by cytochrome P450, cytochrome P450
reductase, molecular O2 and NADPH.

■ There are several cytochrome P450 isoenzymes.
Table 1.1 Phase I reactions

Oxidation Addition of oxygen/removal of Phenytoin, phenobarbitone, pento-
hydrogen barbitone, propranolol
Reduction Removal of oxygen/addition of Chloramphenicol, methadone
hydrogen
Hydrolysis Break down of compound by Esters – procaine, succinylcholine
addition of water Amides – lignocaine, procainamide
Cyclization Conversion of straight chain Proguanil
compound into ring structure
Decyclization Breaking up of the ring structure Phenobarbitone, phenytoin
of the drug
■ They are numbered as 1,2,3,4… (to denote families) and each as A, B, C, D

(subfamilies).
■ More than 50% of drugs undergo biotransformation reactions by CYP3A4/5.
Other enzymes include CYP2D6, CYP2C9, CYP2E1, CYP2C19, etc.

Reduction: Removal of oxygen or addition of hydrogen is known as reduction.
Hydrolysis: Breakdown of the compound by addition of water is called hydrolysis.
This is common among esters and amides.
Cyclization: Conversion of a straight chain compound into ring structure.
Decyclization: Breaking up of the ring structure of the drug.
At the end of phase I, the metabolite may be active or inactive.
Phase II Reactions (Table 1.2). Phase II consists of conjugation reactions. If the phase
I metabolite is polar, it is excreted in urine or bile. However, many metabolites are lipo-
philic and undergo subsequent conjugation with an endogenous substrate, such as
glucuronic acid, sulphuric acid, acetic acid or amino acid. These conjugates are polar,
usually water-soluble and inactive.
Not all drugs undergo phase I and phase II reactions in that order. In case of isoniazid
(INH), phase II reaction precedes phase I reaction (Fig. 1.5).
Table 1.2 Phase II reactions

Conjugation reaction Enzyme Examples
Glucuronidation UDP glucuronosyl transferase • Aspirin
• Morphine
Acetylation N-acetyltransferase • Isoniazid
• Dapsone
Sulphation Sulphotransferase • Paracetamol
• Methyldopa
Methylation Transmethylase • Adrenaline
• Dopamine
Glutathione conjugation Glutathione transferase • Paracetamol
Glycine conjugation Acyl CoA glycine transferase • Salicylates
Drug Drug Drug Drug Drug

(INH)
Phase I Phase I
Unchanged
Phase II form
Phase II Phase II Phase I
Metabolite excreted
Fig. 1.5 Phases of biotransformation.
Table 1.3 Microsomal and nonmicrosomal enzymes

Microsomal enzymes Nonmicrosomal enzymes
Location
Smooth endoplasmic reticulum of Cytoplasm, mitochondria, plasma, e.g. conjugases,
cells, liver, kidney, lungs, e.g. esterases, amidases, flavoprotein oxidases
cytochrome P450, monooxygen-
ase, glucuronyl transferase
Reactions
Most of the phase I reactions, Oxidation, reduction (few), hydrolysis.
Glucuronide conjugation All conjugations except glucuronide conjugation
Inducible Not inducible – may show genetic polymorphism
Drug-Metabolizing Enzymes
They are broadly divided into two groups – microsomal and nonmicrosomal enzyme
systems (Table 1.3).
Hofmann Elimination
Drugs can be inactivated without the need of enzymes – this is known as Hofmann elimi-
nation. Atracurium, a skeletal muscle relaxant, undergoes Hofmann elimination.
Factors Affecting Drug Metabolism
1. Age: Neonates and elderly metabolize some drugs to a lesser extent than adults. In
these cases, it is due to diminished amount/activity of hepatic microsomal enzymes.
Neonates conjugate chloramphenicol more slowly, hence develop toxicity – grey
baby syndrome. Increased incidence of toxicity with propranolol and lignocaine
in elderly is due to their decreased hepatic metabolism.
2. Diet: Poor nutrition can decrease enzyme function.
3. Diseases: Chronic diseases of liver may affect hepatic metabolism of some drugs,
e.g. increased duration of action of diazepam, in patients with cirrhosis, due to its
impaired metabolism.
4. Genetic factors (pharmacogenetics): These factors also influence drug metabo-

lism. The study of genetically determined variation in drug response is called
pharmacogenetics
a. Slow and fast acetylators of isoniazid: There is an increased incidence of pe-
ripheral neuritis with isoniazid in slow acetylators. The fast acetylators require
a larger dose of the drug to produce therapeutic effect.
b. Succinylcholine apnoea: Succinylcholine, a neuromuscular blocker, is metabolized
by plasma pseudocholinesterase enzyme. The duration of action of succinylcholine
is 3–6 minutes. However, some individuals have atypical pseudocholinesterase that
metabolizes the drug very slowly. This results in prolonged succinylcholine apnoea
due to paralysis of respiratory muscles, which is dangerous.
c. Glucose-6-phosphate dehydrogenase (G6PD) deficiency and haemolytic
anaemia: G6PD activity is important to maintain the integrity of the RBCs. A
person with G6PD deficiency may develop haemolysis when exposed to certain
drugs like sulphonamides, primaquine, salicylates, dapsone, etc.
5. Simultaneous administration of drugs: This can result in increased or decreased
metabolism of drugs (see enzyme induction or inhibition).
Enzyme Induction. Repeated administration of certain drugs increases the synthesis of

microsomal enzymes. This is known as enzyme induction. The drug is referred to as an
enzyme inducer, e.g. rifampicin, phenytoin, barbiturates, carbamazepine, griseofulvin, etc.
Clinical Importance of Microsomal Enzyme Induction

1. Enzyme induction may accelerate the metabolism of drugs, thus reducing the du-
ration and intensity of drug action leading to therapeutic failure, e.g. rifampicin
and oral contraceptives. Rifampicin induces the drug metabolizing enzyme of oral
contraceptives, thus enhancing its metabolism and leading to contraceptive failure.
2. Autoinduction may lead to development of drug tolerance, e.g. carbamazepine
enhances its own metabolism.
3. Enzyme induction can lead to drug toxicity, e.g. increased incidence of hepatotox-
icity with paracetamol in alcoholics is due to overproduction of toxic metabolite
of paracetamol.
4. Prolonged phenytoin therapy may produce osteomalacia due to enhanced me-
tabolism of vitamin D3.
5. Enzyme inducers, e.g. barbiturates, can precipitate porphyria due to overproduc-
tion of porphobilinogen.
6. Enzyme induction can also be beneficial, e.g. phenobarbitone in neonatal jaundice
– phenobarbitone induces glucuronyl transferase enzyme, hence bilirubin is
conjugated and jaundice is resolved.
Enzyme Inhibition. Certain drugs, e.g. chloramphenicol, ciprofloxacin, erythromycin,

etc. inhibit the activity of drug metabolizing enzymes and are known as enzyme in-
hibitors. Inhibition of metabolism of one drug by another can occur when both are
metabolized by the same enzyme. Enzyme inhibition is a rapid process as compared to
enzyme induction.
Clinical Relevance of Enzyme Inhibition. Enzyme inhibition can result in drug toxicity,
e.g. increased incidence of bleeding with warfarin, due to concomitant administration of
erythromycin or chloramphenicol, etc. These drugs inhibit drug metabolizing enzyme of
warfarin resulting in increased plasma concentration of warfarin and enhanced anticoagu-
lant effect (bleeding). Toxicity following inhibition of metabolism is significant for those
drugs which have saturation kinetics of metabolism. Enzyme inhibition can be beneficial,
e.g. boosted protease inhibitor regimen used for treatment of HIV infection (see p. 436).
DRUG EXCRETION PH1.4

Removal of the drug and its metabolite from the body is known as drug excretion. The
main channel of excretion of drugs is the kidney; others include lungs, bile, faeces, sweat,
saliva, tears, milk, etc.
1. Kidney: The processes involved in the excretion of drugs via kidney are glo-
merular filtration, passive tubular reabsorption and active tubular secretion.
Glomerular filtration and active tubular secretion facilitate drug excretion,
whereas tubular reabsorption decreases drug excretion.
Rate of renal excretion ! (Rate of filtration # Rate of secretion) – Rate of reabsorption
1) Glomerular filtration: Drugs with small molecular size are more readily
filtered. The extent of filtration is directly proportional to the glomerular
filtration rate (GFR) and to the fraction of the unbound drug in plasma.
2) Passive tubular reabsorption: The main factor affecting passive reabsorption
is the pH of renal tubular fluid and the degree of ionization. Strongly acidic
and strongly basic drugs remain in ionized form at any pH of urine, hence
are excreted in urine.
a) Weakly acidic drugs (e.g. salicylates, barbiturates) in acidic urine remain
mainly in ‘unionized’ form, so they are reabsorbed into the circulation. If
the pH of urine is made alkaline by sodium bicarbonate, the weakly
acidic drugs get ‘ionized’ and are excreted easily.
b) Similarly, weakly basic drugs (e.g. morphine, amphetamine, etc.) in alka-
line urine remain in ‘unionized’ form, hence are reabsorbed. If the pH of
urine is made acidic by vitamin C (ascorbic acid), these weakly basic
drugs get ‘ionized’ and are excreted easily.
3) Active tubular secretion: It is a carrier-mediated active transport which re-
quires energy. Active secretion is unaffected by changes in the pH of urine
and protein binding. Most of the acidic drugs (e.g. penicillin, diuretics, pro-
benecid, sulphonamides, etc.) and basic drugs (e.g. quinine, procaine, mor-
phine, etc.) are secreted by the renal tubular cells. The carrier system is rela-
tively nonselective and therefore drugs having similar physicochemical
properties compete for the same carrier system, e.g. probenecid competi-
tively inhibits the tubular secretion of penicillins, thereby increasing the
duration of action as well as the plasma half-life and effectiveness of penicil-
lins in the treatment of diseases, such as gonococcal infections.
2. Lungs: Alcohol and volatile general anaesthetics, such as ether, halothane, isoflu-
rane, sevoflurane and ether are excreted via lungs.
3. Faeces: Drugs like purgatives, e.g. senna, cascara, etc. are excreted in faeces
4. Bile: Some drugs are secreted in bile. They are reabsorbed in the gut while a small
portion is excreted in faeces, e.g. tetracyclines.
5. Skin: Metals like arsenic and mercury are excreted through skin.
6. Saliva: Certain drugs like potassium iodide, phenytoin, metronidazole and lith-
ium are excreted in saliva. Salivary estimation of lithium may be used for nonin-
vasive monitoring of lithium therapy.
7. Milk: Drugs taken by lactating women may appear in milk. They may or may not
adversely affect the breast fed infant. Drugs like penicillins, erythromycin, etc. are
safe for use but amiodarone is to be avoided in mothers during breast feeding.
PHARMACOKINETIC PARAMETERS
The important pharmacokinetic parameters are bioavailability, volume of distribution,
plasma half-life (t1/2) and clearance.
Plasma Half-Life (t1/2)
It is the time required for the plasma concentration of a drug to decrease by 50% of
its original value (Fig. 1.6A). Plasma half-life of lignocaine is 1 hour and for aspirin it is
4 hours.
Clinical Importance of Plasma Half-Life. It helps to
■ determine the duration of drug action.
■ determine the frequency of drug administration.
■ estimate the time required to reach the steady state. At steady state, the amount of
drug administered is equal to the amount of drug eliminated in the dose interval.
It takes approximately four to five half-lives to reach the steady state during re-
peated administration of the drug. A drug is almost completely eliminated in four
to five half-lives after single administration.
Clearance
Clearance (CL) of a drug is defined as that volume of plasma from which the drug is
removed in unit time.
Rate of elimination
Clearance !
Plasma concentration of the drug
1. First-order kinetics: A constant fraction of the drug in the body is eliminated per
unit time.
For example, assume drug ‘A’ with plasma t1/2 of 1 hour following first-order kinet-
ics of elimination and having an initial plasma concentration of 100 mcg/mL.
1 hour 1 hour
100 mcg/mL 50 mcg/mL 25 mcg/mL
½ ½
If its concentration is increased to 200 mcg/mL, a constant fraction (1/2) gets
eliminated in unit time, i.e. after 1 hour, concentration is 100 mcg/mL.
The rate of drug elimination is directly proportional to its plasma concentration.
The t1/2 of the drugs following first-order kinetics will always remain con-
stant. The drug will be almost completely eliminated in four to five plasma
half-lives if administered at a constant rate at each half-life. Most of the drugs
follow first-order kinetics.
2. Zero-order kinetics: A constant amount of a drug in the body is eliminated per
unit time. For example, ethanol is eliminated from the body at the rate of about
10 mL/h.
Assume a drug ‘B’ with an initial plasma concentration of 200 mcg/mL and
eliminated at a constant amount of 10 mcg per unit time. The concentration
will be 190 mcg/mL after 1 hour and 100 mcg/mL after 10 hours. So, half-life
is 10 hours.
1 hour 1 hour
200 mcg/mL 190 mcg/mL 180 mcg/mL
10 mcg 10 mcg
If its concentration is increased to 300 mcg/mL, concentration will be 290 mcg/mL

after 1 hour (as constant amount 10 mcg per unit time is eliminated) and
150 mcg/mL after 15 hours. The half-life increases to 15 hours. Thus, the t1/2
of the drug following zero-order kinetics is never constant. The rate of elimina-
tion is independent of plasma drug concentration
Drugs like phenytoin and aspirin
At low doses, follow first-order kinetics

As the plasma concentration increases
Elimination processes get saturated
Kinetics changes over to zero order (saturation kinetics)
Note: Phenytoin exhibits saturation kinetics and its plasma concentration has to be care-
fully monitored (therapeutic drug monitoring, TDM) when used in the treatment of
epilepsy. Once the kinetics changes to zero order, an increase in dose will result in a
marked increase in plasma concentration leading to drug toxicity.
Steady-State Concentration
If constant dose of a drug is given at constant intervals at its t1/2, plasma concentration
of the drug increases due to its absorption and falls due to elimination in each dosing
interval. Finally, the amount of drug eliminated will equal the amount of drug admin-
istered in the dosing interval. The drug is said to have reached steady-state or plateau
level (Fig. 1.6B). It is attained after approximately four to five half-lives.
Target Level Strategy
The dosage of drug is calculated to achieve the desired plasma steady state concentration
of the drug which produces therapeutic effect with minimal side effects.
Loading dose: Initially, a large dose or series of doses of a drug is given with the aim
of rapidly attaining the target level in plasma. This is known as loading dose. A
loading dose is administered if the time taken to reach steady state is relatively more as
100 Steady state

Plasma concentration
Plasma concentration
50
0 1 2 3 4 5 6 7 8 9
Half-life Time
Time
(A) (B)
Fig. 1.6 (A) Plasma half-life of a drug after single intravenous injection. (B) Steady state: achieved
after approximately four to five half-lives during repeated administration at a constant rate.
compared to the patient’s condition, e.g. the half-life of lignocaine is more than 1 hour,
so it takes more than 4–6 hours to reach the target concentration at steady state. When a
patient has life-threatening ventricular arrhythmias after myocardial infarction, initially
a large dose of lignocaine has to be given to achieve desired plasma concentration quickly.
Once it is achieved, it is maintained by giving the drug as an intravenous infusion.
Maintenance dose: The dose of a drug which is repeated at fixed intervals or given as a
continuous infusion to maintain target level in plasma or steady-state concentration is
known as maintenance dose. The dose administered is equal to dose eliminated in a
dosing interval.
Therapeutic Drug Monitoring PH1.2

Monitoring drug therapy by measuring plasma concentration of a drug is known as
therapeutic drug monitoring (TDM).
Indications of TDM
1. Drugs with narrow therapeutic index, e.g. lithium, digoxin, phenytoin, aminogly-
cosides, etc.
2. Drugs showing wide interindividual variations, e.g. tricyclic antidepressants.
3. To ascertain patient compliance.
4. For drugs whose toxicity is increased in the presence of renal failure, e.g.
aminoglycosides.
5. In patients who do not respond to therapy without any known reason.
In drug poisoning, estimation of plasma drug concentration is done.
TDM is not required in the following situations:

1. When clinical and biochemical parameters are available to assess response:
a. Blood pressure measurement for antihypertensives.
b. Blood sugar estimation for antidiabetic agents.
c. Prothrombin time, aPTT and International Normalized Ratio (INR) for anti-
coagulants.
2. Drugs producing tolerance, e.g. opioids.
3. Drugs whose effect persists longer than the drug itself, e.g. omeprazole.
Fixed-Dose Combinations (FDCs; Fixed-Dose Ratio Combinations) PH1.59

It is the combination of two or more drugs in a fixed-dose ratio in a single formulation.
Some of the examples of WHO approved FDCs are
■ Levodopa # carbidopa for parkinsonism
■ Isoniazid # rifampicin # pyrazinamide # ethambutol for tuberculosis.
■ Ferrous sulphate # folic acid for anaemia of pregnancy
■ Sulphamethoxazole # trimethoprim in cotrimoxazole (antimicrobial agent)
■ Amoxicillin # clavulanic acid (antimicrobial agent)
■ Oestrogen # progesterone (oral contraceptive)
Advantages and disadvantages of FDCs are explained in Table 1.4, p. 22.
Methods to Prolong the Duration of Drug Action

Prolongation of action of a drug helps
■ to reduce the frequency of drug administration.
■ to improve patient compliance.
■ to minimize fluctuations in plasma concentration.

Table 1.4 Advantages and disadvantages of FDCs

Advantages Disadvantages
1. Increased patient compliance 1. Inflexible fixed-dose ratio
2. Prevents development of mi- 2. Incompatible pharmacokinetics can interfere with
crobial resistance in diseases action of the drug
like TB, AIDS, etc. as missing 3. Increased toxicity due to inappropriate combina-
of single drug is prevented tions. If adverse effect occurs, difficult to identify
3. Increased efficacy the component of FDC causing it
4. Reduced side effects 4. The preparation cannot be used if there is a
5. Reduced cost contraindication for use of one component
6. Synergistic effect 5. Physician and pharmacist’s ignorance of the
contents
Various methods to prolong the duration of drug action are

1. By retarding drug absorption:
a. For orally administered drugs:
■ Using sustained release/controlled release preparations: Sustained release prep-
arations consist of drug particles, which have different coatings that dissolve
at different intervals of time. It prolongs the duration of action of the drug,
reduces the frequency of administration and improves patient compliance,
e.g. tab. diclofenac has a duration of action of 12 hours, whereas diclofenac
sustained release preparation has a duration of action of 24 hours.
b. For parenterally administered drugs:
■ By decreasing the vascularity of the absorbing surface: This is achieved by
adding a vasoconstrictor to the drug, e.g. adrenaline with local anaesthet-

ics. When adrenaline is added to a local anaesthetic, the vasoconstriction
produced by adrenaline will delay the removal of the local anaesthetic
from the site of administration and prolongs the duration of its action. It
also reduces the systemic toxicity of the local anaesthetic and minimizes
bleeding in the operative field.
■ By decreasing the solubility of the drug: by combining it with a water-insoluble
compound, e.g. combining procaine/benzathine with penicillin G.

■ Injection penicillin G has a duration of action of 4–6 hours.
■ Injection procaine penicillin G: It has a duration of action of 12–24 hours.
■ Injection benzathine penicillin G: It has a duration of action of 3–4 weeks.
■ By combining the drug with a protein, e.g. protamine zinc insulin – the
complexed insulin is released slowly from the site of administration, thus

prolonging its action.
■ By esterification: Esters of testosterone, e.g. testosterone propionate and
testosterone enanthate are slowly absorbed following intramuscular admin-

istration resulting in prolonged action.
■ Injecting the drug in oily solution, e.g. depot progestins (depot medroxypro-
gesterone acetate).
■ Pellet implantation: e.g. norplant for contraception.
■ Transdermal patch (see p. 7)
2. By increasing the plasma protein binding of the drug, e.g. sulphadiazine is less
bound to plasma proteins and has duration of action of 6 hours. Sulphadoxine is
highly protein bound and so has duration of action of 1 week.
3. By inhibiting drug metabolism: For example, allopurinol # 6-mercaptopurine

(6-MP). 6-MP is metabolized by xanthine oxidase. Allopurinol (xanthine oxidase
inhibitor) n inhibits metabolism of 6-MP n prolongs action of 6-MP.
4. By delaying renal excretion of the drug, e.g. penicillin/cephalosporins with pro-
benecid (see p. 36).
Pharmacodynamics
Pharmacodynamics (Greek pharmacon: drug; dynamis: power). It covers all aspects re-
lating to ‘what the drug does to the body’. It is the study of drugs – their mechanism of
action, pharmacological actions and adverse effects.
TYPES OF EFFECTS OF A DRUG

1. Stimulation: Some drugs act by increasing the activity of specific organ/system,
e.g. adrenaline stimulates the heart resulting in an increase in heart rate and force
of contraction.
2. Depression: Some drugs act by decreasing the activity of specific organ/system, e.g.
alcohol, barbiturates, general anaesthetics, etc. depress the central nervous system.
3. Irritation: Certain agents on topical application can cause irritation of the skin
and adjacent tissues. When an agent on application to the skin relieves deep seated
pain, it is known as counterirritant, e.g. eucalyptus oil, methyl salicylate, etc. They
are useful in sprain, joint pain and myalgia. They exert their action by
■ reflexly increasing local circulation in deeper structures.
■ blocking impulse conduction in the spinal cord.
4. Cytotoxic: Drugs are selectively toxic for the infecting organism/cancer cells, e.g.
antibiotics/anticancer drugs.
5. Replacement: When there is a deficiency of endogenous substances, they can be
replaced by drugs, e.g. insulin in diabetes mellitus, thyroxine in cretinism and
myxoedema, etc.
MECHANISM OF DRUG ACTION PH1.5

Mechanism of action of drugs
Nonreceptor mediated Receptor mediated
Nonreceptor-Mediated Mechanism of Action of Drugs

1. By physical action:
a. Osmosis: Some drugs act by exerting an osmotic effect, e.g. 20% mannitol in
cerebral oedema and acute congestive glaucoma.
b. Adsorption: Activated charcoal adsorbs toxins; hence, it is used in the treatment
of drug poisoning.
c. Demulcent: Cough syrup produces a soothing effect in pharyngitis by coating
the inflamed mucosa.
d. Radioactivity: Radioactive isotopes emit rays and destroy the tissues, e.g. 131I in
hyperthyroidism.
2. By chemical action:
a. Antacids are weak bases – they neutralize gastric acid – useful in peptic ulcer.
b. Metals like iron, copper, mercury, etc. are eliminated from the body with the
help of chelating agents. These agents trap metals and form water-soluble com-
plexes, which are rapidly excreted from the body, e.g. dimercaprol (BAL) in
arsenic poisoning, desferrioxamine in iron poisoning and d-penicillamine in
copper poisoning.
3. Through enzymes: Some drugs act by inhibiting the enzyme activity.
a. Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, enala-
pril, etc. act by inhibiting ACE. They are used in the treatment of hyperten-
sion, congestive heart failure, etc.
b. Xanthine and hypoxanthine are oxidized to uric acid by the enzyme xanthine
oxidase, which is inhibited by allopurinol. Allopurinol (competitive inhibitor)
is used in the treatment of chronic gout to reduce the synthesis of uric acid.
Xanthine Hypoxanthine Uric acid
Xanthine oxidase
!
Allopurinol
4. Through ion channels: Some drugs directly bind to ion channels and alter the
flow of ions, e.g. local anaesthetics block sodium channels in neuronal membrane
to produce local anaesthesia.
5. Through antibody production: Vaccines produce their effect by stimulating
the formation of antibodies, e.g. vaccine against tuberculosis (BCG), oral polio
vaccine, etc.
6. Transporters: Some drugs produce their effect by binding to transporters. Selec-
tive serotonin reuptake inhibitors (SSRIs) n bind to 5-HT transporter n block
5-HT reuptake into neurons n antidepressant effect.
7. Others: Drugs, like colchicine, bind to tubulin and prevent migration of neutro-
phils (hence useful in acute gout).
Receptor-Mediated Mechanism of Action of Drugs
Receptors are macromolecules, present either on the cell surface, cytoplasm or in the
nucleus with which the drug binds and interacts to produce cellular changes.
!!
Drug (D) # Receptor (R) #!"
! Drug-receptor complex 
→ Response
For example, adrenergic receptors (" and $), cholinergic receptors (muscarinic and
nicotinic), opioid receptors, etc.
Affinity: The ability of the drug to get bound to receptor is known as affinity.
Intrinsic activity: The ability of the drug to produce pharmacological action after
combining with the receptor is known as intrinsic activity of the drug.
Agonist: A drug that is capable of producing pharmacological action after binding to
the receptor is called an agonist.
Agonist has high affinity # high intrinsic activity (e.g. morphine and adrenaline).
Antagonist: A drug that prevents binding of agonist to its receptor or blocks its
effect/s is called an antagonist. It does not by itself produce any effect.
Competitive antagonist has high affinity without intrinsic activity (e.g. naloxone and
atropine). It produces receptor blockade.
Partial agonist: A drug that binds to the receptor but produces an effect less than that
of an agonist is called partial agonist. It inhibits the effect of agonist.
Partial agonist has affinity # less intrinsic activity (e.g. pindolol and buprenorphine).
Inverse agonist: It has full affinity towards the receptor but produces effect opposite
to that of an agonist, e.g. benzodiazepines (BZDs) produce antianxiety and anticonvul-
sant effects by interacting with BZD receptors, but $-carbolines act as inverse agonist at
BZD receptor and produce anxiety and convulsions.
Inverse agonist has affinity # intrinsic activity between 0 and –1 (e.g. $-carboline).
RECEPTOR FAMILIES (Table 1.5) PH1.5

1. Ligand-gated ion channels (inotropic receptors)
2. G protein-coupled receptors (GPCRs; metabotropic receptors)
3. Enzymatic receptors
4. Receptor-regulating gene expression (transcription factors) or the nuclear receptor
Ligand-Gated Ion Channels (Inotropic Receptors). Examples are nicotinic (NM)
acetylcholine receptors at neuromuscular junction, GABA (gamma amino butyric
acid) and glutamate receptors in the CNS.
Binding of agonist to Opens the ion channels Flow of ions
inotropic receptors (Na+, K+, Ca2+, Cl–) through channels
Tissue Hyperpolarization/
response Depolarization
The onset of action of a drug is fastest through this receptor.

G Protein-Coupled Receptors (GPCRs, Metabotropic Receptors). GPCRs are trans-
membrane receptors which control cell function via adenylyl cyclase, phospholipase C, ion
channels, etc. They are coupled to intracellular effectors through G proteins. G proteins are
membrane proteins and have three subunits (", $, %) with GDP bound to " subunit.
Table 1.5 Characteristics of various receptor families

G protein-
Ligand-gated coupled Enzymatic Nuclear
ion channels receptors receptors receptors
Location Membrane Membrane Membrane Intracellular
Effector Ion channel Channel or Enzyme Gene transcrip-
enzyme tion
Examples Nicotinic, Muscarinic, Insulin epider- Steroid, thyroid
GABAA adrenergic mal growth hormone
receptors receptors factor receptors
receptors
Time required Milliseconds Seconds Minutes to Hours
for response hours
The agonist that binds to the receptor is the first messenger. It results in the formation
or recruitment of molecules (second messengers) that initiate the signalling mechanism
in a cell. Examples of second messengers are cAMP (generated by adenylyl cyclase),
cGMP (generated by guanylyl cyclase), Ca2#, IP3-DAG (generated by phospholipase C),
nitric oxide, etc.
Binding of Coupling of G protein GDP bound to α subunit

agonist to receptors to the receptors exchanges with GTP
Dissociation of G protein
subunits from occupied
receptor; α-GTP also
dissociates from βγ subunit
α-GTP and βγ subunits

are released
Stimulation of GTPase Bind to target enzyme/ion

associated with α subunit channel
GTP GDP Effects produced depends on the

type of G protein (Gs, Gi, Gq and
Go), which associates with agonist
α subunit associates with βγ subunit occupied receptor (see below)
Gs Gi Gq !"
! " ! !/"
Adenylyl cyclase Adenylyl cyclase Phospholipase C Enzymes and ion channels,

e.g. all GPCRs
↑cAMP, ↓cAMP, ↑IP3 and ↑DAG,

e.g. β-adrenergic e.g. α2-adrenergic e.g. muscarinic (M1)
receptors receptors in smooth muscle receptors
Transmembrane Enzyme-Linked Receptors. Transmembrane enzyme-linked

receptors have enzymatic activity in their intracellular portion. The enzyme is
mainly tyrosine kinase, e.g. receptor tyrosine kinases for insulin, epidermal growth
factor, etc.).
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fancy that the explanation of the miracle lies in the hypothesis I have
suggested, the long wall on which the minarets are built having
probably settled, and so, having no communication with the side
walls, being no miracle, but merely bad building. We saw the
miracle, expressed our wonder, thanked “the hereditary functionary,”
and went home sadder and wiser than we came.
Vaccination is now happily appreciated in Persia. On my first
arrival it was unknown, and inoculation was regularly practised.
Another plan, too, was common, and the future native pastor of the
Protestant Armenians lost a child by its practice. He put his own child
in bed with a child having small-pox, that it might take the disease in
a benign form; confluent small-pox of the most virulent type resulted,
and the poor child died, to the great grief of the parent, a most
deserving and honest fellow.
This man and one other are the only teetotalers of Julfa, which
may dispute the palm with any Scotch town for capability of
swallowing liquor on a Sunday.
So common is drunkenness here, that an old cook of mine, an
English-speaking Armenian, used to say to me on Sunday night—
“Dinner finished, sir; if you no orders, I go get drunk with my
priest.” Needless to add, that they both did get drunk, and that it was
at the cook’s expense. Happily, there are some few exceptions
among the Julfa priests, for all India, Persia, and Batavia are
supplied with priests for their Armenian communities from Julfa.
Spirits are supposed to deaden pain, and a Yezdi, a guebre (fire-
worshipper), who had lodged some slugs and iron in his hand, prior
to my removing them, swallowed a quart of strong spirit without my
knowledge. I supposed him to become suddenly delirious, but he
was only suddenly drunk.
Our first care was to make a road for our little dog-cart. The gates
separating the parishes were mostly too narrow to let it pass, and we
finally made one six feet wide at the narrowest, having three bridges
without parapets (which we widened), and one was at a sharp angle,
and a deep ditch the whole way on one side, and a wall on the other.
This was capital for a small two-wheel thing, as long as the horse
didn’t jib or shy, or we didn’t meet any one. Happily, it did not in our
time, but when we got a bigger trap, a park phaeton, with a pair of
horses, the pleasure of our drive was somewhat damped by the
possibility of a capsize at night in the dark! But the cherub that
always keeps a watch over poor Jack must have been on duty, for
we never did have an accident. It was Hobson’s choice, that road or
none.
Crossing the river at Marnūn became our favourite ride, and here
one could canter for miles on a good road, the greater part of which
was shaded by the gardens and orchards on either side. A great
deal of firewood, too, is grown in this neighbourhood, water is
plentiful, and so firewood is a staple crop. Getting out beyond the
gardens, on a small mountain standing by itself on the plain, was the
ruin of an ancient fire-temple. It was merely built of mud bricks, but
here at Ispahan these remain for centuries, and it was only on
climbing up to it that one perceived that it was not all quite modern,
and a small portion built of very large bricks on an ancient wall. A
grand view was got from it, as it commanded the entire plain.
Several large plane-trees are to be seen in the villages, many with
platforms built round them, where the villagers sit and smoke in the
evenings. A sort of semi-sacred character is attached to some of
them, particularly to one which is called the “plane of Mortaza Ali.”
A striking feature at Julfa is the so-called racecourse at Ferhabad.
A couple of walls enclose a straight run of over a mile. These walls,
which are in ruins, and of mud, have at intervals various pavilions,
some of the rooms of which are still almost perfect. At the end is a
large square, having many rooms round it in a still better state. The
road turned at a right angle towards the village of Julfa; but as this is
intersected by wells and watercourses, it is not used as a cantering
ground. The place is supposed to have been the summer palace of
the Afghan conquerors.
Ruins and ancient buildings, when built of burnt bricks, rapidly
disappear in Persia. It is for a very simple reason. It is cheaper to
demolish an old building, and carry off the good seasoned bricks by
donkey-loads, than to make and burn new ones, which often
crumble.
In my own time a large and handsome college near the Char Bagh
of Ispahan has utterly disappeared, the prince having given an order
for its demolition, and that the material be used in making the new
one he has now completed. The very foundations were grubbed up.
In Ispahan itself every third house is a ruin, and in Julfa the walls of
gardens and orchards often contain the bare inner walls of ancient
houses, which retain the brightness of their painting and gilding in
the dry and pure air.
Donkeys, as beasts of burden, are much employed in a country
where there are no carts or wheeled vehicles; save in the capital, the
donkeys do all the ordinary work of vehicles. Earth, manure,
produce, firewood, charcoal, grain, are all carried on these beasts or
on mules. Each animal has his pack-saddle, in which he lives and
sleeps. It is only removed when the donkey gets a rare and very
occasional curry-combing from a very primitive sort of instrument,
having jangling rings, which produce a music supposed to be
soothing to a donkey’s soul. Every villager has his donkey; if more
than one he is well-to-do. The ordinary wage of a man is one keran,
a man and donkey one keran and a half, and each additional donkey
half a keran. They work from sunrise to sunset, with an hour’s
interval for feeding.
Julfa is a particularly healthy place, for the cesspools are
constantly kept clean by the market-gardeners, who pay for the
privilege of removing the manure. By mixing the contents of the
cesspools with ashes, a dry and portable manure is produced of the
highest efficacy, and odourless. It is removed on donkeys, and
stored in the fields until required.
In the very depth of the winter, when snow and ice had rendered
the ride to the town highly dangerous for horses, I was summoned in
haste to see my old patient the Zil-es-Sultan, now the most important
man in the kingdom next to the king. I went, though risking my
horse’s knees, and was rather disgusted to find that I was sent for to
see if he was ill or not, as he was not sure. I found him in a hot room,
temperature eighty (by the thermometer), wrapped in furs, being
shampooed by three attendants, while a fourth was reading poetry to
him. He was, I told him, in a fair way to get ill, and that air and
exercise were all he needed. He took my advice, and returned to his
usual very active life.
He showed me an armoury of some eight hundred rifles, with a
proportionate amount of fowling-pieces and pistols. I expressed the
desired amount of admiration. I suppose the time will come when his
Royal Highness will make an effort for the throne, probably on the
present Shah’s death. It will be a lucky day for Persia if he succeeds,
as he is clever, tolerant, and a good governor. His personal
popularity is very great, and his luck as a governor proverbial. He
has a dislike to deeds of blood, but is a severe governor, like his
uncle, the late Hissam-u-Sultaneh, whose virtues he emulates.
The Valliāt, or heir-apparent, on the contrary, is physically weak,
and mentally imbecile, being a bigot in the hands of a few holy men,
and as impracticable as he is obstinate. No doubt if he ever does
reign a black time will set in for the country, for religious persecution
on a gigantic scale will commence, and the future of Iran be very
sad.
The Zil-es-Sultan had just got two bull-terriers from England. He
was convinced of their ferocity; and certainly the dog, very short-
faced, and almost a bull-dog, was of terrific appearance. His Royal
Highness caused them to be let into the courtyard, cautioning me to
be very still, as not knowing me they might attack me, and providing
me with a lump of sugar to appease them. Of course nothing of the
sort took place, but the dogs ran about and smelt the various
grandees, to their great disgust. The prince made great pets of them,
feeding them with sugar. I was surprised to find that though these
dogs had not seen an Englishman for months, yet on my speaking to
them in English they followed me about, fawning on me, and
neglecting the prince, and the dog-man who was their valet.
Since this time the prince has procured two huge half-bred Dutch
mastiffs, in which he greatly rejoices, and these animals, though not
fierce, are certainly very powerful dogs. Strange that the love of
animals in a man like the Zil-es-Sultan should so overcome the
Mussulman dislike of the unclean beast. The dogs were in the habit
of licking the prince’s hand.
This particular winter was an unusually severe one. There was
much snow, and it was impossible to get out for rides for a fortnight;
and two store-rooms of my huge house fell in, from the heavy mud
roofs being soaked with water, and breaking their supports by the
enormous increase of weight.
On one occasion in the early spring we had ridden out to the
garden palace of Haft Dust, and were preparing to take tea, when
with great noise the Zil-es-Sultan rode into the place with some fifty
horsemen. No sooner did he see and recognise my servants than he
asked if I was alone. On hearing that my wife (“my house,” as my
man put it) was with me, he rode out, taking all his followers with
him, and sending me a message to “go on with my tea, that he
trusted I should enjoy my visit, that the place was mine as long as I
pleased,” etc.
Europeans avoid the Persians when with ladies, as very ridiculous
scenes are at times the result. One gentleman, whose wife was not
in her first youth, on meeting the prince when riding with her, instead
of avoiding him, stopped to speak.
It was one of his rude days, for he calmly asked, in defiance of the
rules of Persian politeness, which demand the ignoring of the
existence of any female:
“Is that your wife?”
“Yes, my wife.”
“Well, I wouldn’t have a wife so old and ugly as that. Get a young
one.”
The situation for both lady and gentleman was embarrassing.
CHAPTER XXXIV.
JOURNEY TO AND FROM TEHERAN.
Proceed to Teheran—Takhtrowan—Duties—Gulhaek—Lawn-tennis—Guebre
gardener—A good road—The Shah—Custom of the Kūrūk—M. Gersteiger—
Cossack regiments—Austrian officers—New coinage—Count Monteforte—
New police—Boulevard des Ambassadeurs—English Embassy—Tile gates—
Summer palaces—Bazaars—Russian goods—Demarvend—Drive to Ispahan
—Difficulties of the journey—Accidents—Danger of sunstroke—Turkeys—
Keeping peacocks—Armenian tribute of poultry—Burmese and Japanese
embassies—Entertainment and fireworks—Cruel treatment of Jews—Oil
paintings—Bahram and his queen—Practice makes perfect—Pharaoh and the
Red Sea—Pharaoh and the magicians.
After an eighteen months’ stay in Julfa (Ispahan) I received orders

to proceed to Teheran “to act” (for my chief).
We started, my wife travelling in a “takhtrowan” (moving bed). This
consists of a box with doors and windows, six feet long, three feet
wide, and four feet high. A thick mattress is placed in it, and plenty of
pillows. Where the road is fairly level, as from Ispahan to Teheran, it
is not a bad way of travelling for a lady. The great cause of
satisfaction to her was that she had her baby with her. Water was
kept out of the machine by a waterproof sheet being tacked to the
top, and a thick carpet was lashed over the roof when travelling in
strong sun. At each end of the box are shafts, and between each
pair a mule. The movement is at first rather sickening, but this is
soon got over, and the traveller sleeps the greater portion of the
stage.
Although we travelled as lightly as possible, we were forced to
take twenty-four mules, and were heartily glad when our journey,
which was twelve long stages, and without incident of any kind, was
over. I hired a little house at Gulhaek, the village where are situated
the summer quarters of the English Embassy, and where lives the
chief of my Department, in the summer.
In addition to my own work I was in charge of the staff of the Indo-
European Telegraph Company’s line who lived in Teheran. Our own
signalling staff too lived in the town. As however we had an
exceptionally healthy summer, the duties were very light.
I was also placed in medical charge of the Russian Embassy by
the Russian Ambassador, M. Zenoview, for the greater part of my six
months’ stay, their own physician having gone to Russia for a time
on private business.
Gulhaek is one of the villages at the foot of the mountains
bounding the Teheran valley, and by prescriptive right the English
Legation go to Gulhaek, the Russians to the next village, Zergendeh,
and the French to another a couple of miles higher, called Tejreesh.
These places are delightfully cool, and if the signallers of the
Department and of the Company could be moved to them, it would
be a great boon to the men, for it is terribly hot and unhealthy in the
town, and the expense would not be great: in fact it ought to be
done.
Lawn-tennis, when we arrived, was in high vogue, and was played
every afternoon on a level ground (a lawn in Persia is nearly
impossible) mudded over with what is termed “kah gil,” a mixture of
“kah” (cut straw) and “gil” (mud). This forms a sort of sheet of smooth
and springy ground, which gives a good foothold, and dries rapidly.
The tennis was justly popular, and was the most pleasant means of
obtaining exercise, and consequently health.
Our own comfort was increased by the arrival of an English nurse,
whom we had engaged to come out for a certain three years.
I was enabled to buy a small park-phaeton and a pair of well-
broken horses from a German, the master of the Shah’s mint, who
was leaving because he declined to debase the coinage, which was
contrary to the terms of his agreement.
In the garden next to ours lived a Guebre. A few of these men
have been under the protection of the English Embassy time out of
mind. He kept us supplied with strawberries at tenpence a plateful;
and as we had not tasted them since leaving England, they were a
great luxury, particularly in a warm climate.
The greater part of the road from Gulhaek to Teheran, being the
way to the Shah’s favourite summer residences, is planted on both
sides with trees and shrubs. These give a grateful shade; and as the
road is in good order, it is pleasant driving; but, when thronged, the
dust rises and covers everything, so that it is like a very dusty return
from the Derby, but with no excitement, and hotter. Still, a good road
in nearly roadless Persia was a thing to be taken advantage of.
Several times when out driving we met the Shah, and invariably
drew on one side to allow him to pass. His Majesty was always very
polite, and returned our salutes. On our passing the first time he sent
a man to inquire who we were. The Prime minister, too, was
particular in behaving in a civilised manner, but the ragamuffin
attendants on the royal ladies always used to shout “Begone,” “Be
off,” and their postilions would always drive as close as possible, and
pass one as if they wished a collision, or to take a wheel off.
The custom of the kūrūk is dying out. It used to be death for any
man to be in the neighbourhood of the royal wives when on their
numerous outings. The people always fled, or stood with faces to the
wall; and Europeans, when they saw the eunuchs’ procession
approaching, and heard the cry of “Gitchen” (Turkish “Begone”), to
avoid unpleasantness and possible rows, used to turn down the first
street. A very eccentric Austrian, the Baron Gersteiger Khan (the
latter title being, of course, a Persian dignity; for many years
instructor to the Persian army, and at last general; principal officer of
engineers, and constructor of roads, in which latter work he has
really left some striking marks of his success), on meeting the ladies
when he was on foot, turned his face to the wall like a native, and as
each carriage passed, deliberately saluted from the back of his head.
This delighted the ladies, and they informed the Shah. The Shah
sent for Gersteiger, and made him repeat his salutes, and after
laughing a good deal, gave him a handsome present.
The king generally travelled in a carriage very like a sheriff’s, with
eight pairs of horses harnessed to it, with postilions. They went at a
fair pace, were always preceded by the royal runners (“shatirs”), clad
in their ancient Persian dress of red, with the curious turreted hat,
like a fool’s cap and bells, and each bearing a gold baton. These
men were all good runners, and some six or eight ran in front, while
one or two always kept at his Majesty’s side.
When we were in Teheran a number of Russian officers were
engaged in forming some so-called Cossack regiments. They
engaged horsemen, whom they regularly paid, and seemed to be
teaching these men their drill successfully. These so-called
Cossacks were the Shah’s favourite toy of the moment, and he was
never tired of reviewing them. They were well but plainly dressed,
well horsed and well armed, and the Russian officers were very
popular both with Shah and soldiers.
A large contingent of Austrian officers had also arrived to instruct
the infantry and artillery; but though these gentlemen were well paid,
they did not find Persia the El Dorado they expected. Some of them
resigned while I was there. They also fought among themselves; and
all have now, I fancy, left the country. The capital was ever rather a
rowdy place; murders and burglaries were common; and, as in other
towns of Persia, the “darogas,” or police-masters, and their
dependants were so mercenary, that the townspeople preferred
being robbed to complaining to them, on the principle of two evils to
choose the less.
The manufacture of false money had become a national evil, and
forgeries of the royal seals were frequent. The first evil was sought to
be got over by calling in the old rough coinage, which was hammer-
struck, and substituting a handsome series of medals in gold and
silver, having milled edges. These were introduced with great
success, and the new coinage was handsome and popular. But it
was soon counterfeited, and when the nuisance had attained its
height the Count Monteforte arrived with special credentials from the
Emperor of Austria, and was installed as head of police. This
gentleman seemed to be exactly the right man in the right place. He
got on with the natives, in a few weeks established a character for
honesty and shrewdness, detected many offenders, recovered much
stolen property, and established a regiment of policemen, well
drilled, well dressed, honest, polite, and who refused bribes. As
bribes are to the Persian what beef is to the Englishman, these
phenomena have probably ere this been either shelved or corrupted;
but when we were in Teheran in 1880, they were in full swing, and
the wonder and admiration of foreigners and natives.
Just one street in Teheran is very much Europeanised; it is fairly
paved, and lighted by lamp-posts containing candles. It is called the
Boulevard des Ambassadeurs, and as it is a wide street, the view
from the bottom is somewhat striking, ending as it does in the green
hills and black mountains covered on their tops with snow.
At the top, approached by an ornamental gate of great size, is the
palace of the English Ambassador. This has been recently erected at
enormous cost, partly from designs by the late Major Pierson, R.E. It
is surrounded by trees, and the edifice meets the requirements of the
country, and is very original in appearance. It stands in a magnificent
garden of great size, in which are placed the houses of the
secretaries, built like English villas of the better class. The interior of
the Embassy is furnished with great splendour with English furniture,
and our ambassador to the Court of Persia is lodged as he should
be, en prince.
The rest of the town is wholly Oriental. Dead walls of mud and
brick are seen in every direction. The streets are mud in winter and
dust in summer.
The principal feature in Teheran is the numerous tiled gates.
These structures, covered with floridly-coloured tiles in elaborate
patterns, mostly geometrical, having centre-pieces of
representations of scenes from the mythology of Persia, were
certainly novel and curious. As a rule, the modern tile-work is in
striking contrast to the ancient, which is much chaster, and in better
taste.
Of the many palaces none were worth description, of those that I
visited, which were all mere summer retreats. They were gaudy,
much painted and gilt, and the white plaster-work, decorated with
mirrors, was the only kind of ornamentation having the slightest
pretence to be artistic. The dry climate, however, enables this
effective style of decoration to be used for exteriors, and it retains its
pristine whiteness in the clear air for many years. Many large
buildings seen from a distance in Teheran have a great appearance
of magnificence, and it does not strike the beholder at first that they
are merely plaster-of-Paris over mud bricks. To them the term
“whitened sepulchre” is particularly appropriate; but the insecurity of
property must be considered, and a man would be unwise to build an
expensive edifice which would expose him to jealousy.
The bazaars are good, and sufficiently curious; of course much
inferior in size and richness to those of Stamboul (Constantinople).
Most of the goods exposed, not of native manufacture, are Russian.
[36]
The Russian goods are liked in the Eastern market. They are very
cheap, and very strong; in fact, are suited to the country; they are
also, alas! very ugly. The tremendous land journey from Trebizonde,
or that from the Persian Gulf, or the alternative from Baghdad viâ
Kermanshah, closes the Persian market at Teheran to the English.
Fortunes, however, are made there, an importer of French goods
(which are particularly appreciated by the Persians) having retired
with a large one. About four hundred per cent. is generally charged,
which covers the heavy freight and the duty, and leaves about cent.
per cent. profit.
We found a great deal of gaiety at Teheran. A weekly dinner at the
Embassy, generally a daily drive, and the society of many Europeans
of different nationalities, was of course a great break in the
monotony of our life in Persia. But our pleasures after four months
were interrupted by the serious illness of my wife. Our second little
boy was born, and we were lucky in having a reliable nurse.
The view of Teheran is made very unique by the great semi-extinct
volcano, Demarvend, in the distance, which gives it great grandeur,
towering, as it does, over the valley, with its top covered in eternal
snows, and taking innumerable lovely tints at the rising and setting of
the sun.
We came to Teheran by the longer way of Natanz, thus avoiding
the great Kohrūd pass, a particularly unpleasant stage when there is
much snow; and as my wife was really an invalid, we determined to
return to Ispahan driving—a thing no one has done before, and I
fancy no one will do again. I had a new set of wheels made specially
strong and heavy, and with very strong tyres. I succeeded in buying
a second pair of half-broken horses, in case my own pair came to
grief, and we left in the autumn for Ispahan, the nurse and babies
occupying the takhtrowan, while my wife and I went in the trap.
We drove through the town with some trouble, and as soon as we
were clear of the fortifications the road became broad and level, and
we reached Hadjiabad, a garden, where we stopped the night.
The next day we crossed a rocky mountain, having to drag the
phaeton by hand some miles, and then, locking the wheels with
ropes, we got it down a very steep place. The rest was plain sailing;
the roads were generally fairly good. My wife had to get out only
some four times on a fifteen days’ journey, and it was only on getting
into or out of villages, where there were at times deep ditches, but
plenty of willing helpers, that we had any difficulty.
On our last stage but three we mistook the road, and came forty-
eight miles instead of twenty-four. We, however, only used our
second pair once, as they were very unsafe; and our horses, strange
to say, did the whole journey well, and arrived in fair condition.
At the last stage but two a ridiculous accident occurred. We had
frequently snapped the heads of bolts, and even the bolts
themselves, by going over very rough places, the jolt breaking the
heads off, as they were steel. These we generally detected and
replaced by others, which we had caused to be made in Teheran.
But Mūrchicah is a big village, with numerous twists and turns
between dead walls ere one gets to the post-house. We had come a
long stage, were very tired, and very anxious to get in, and, instead
of going over a deep dry ditch which we had to pass, and which was
very narrow, in a careful way, I was foolish enough to try to pass it
quickly. The result was a snap of all three bolts that fixed the trap to
what is, I fancy, technically termed the fore-carriage. The thing hung
together till we had got the hind wheels out of the ditch, and then the
horses, pole, and two front wheels went on, the carriage itself
remaining behind and falling forward; and, had not the apron been
up, we should have been shot out. Fortunately the reins were long,
and the horses easily pulled up. They were probably unaware of the
accident. Though we were in the village there was no one about. The
servants were either in front with the bedding, or behind with the
loads, yet in five minutes the bolts were replaced by fresh ones, and
we were proceeding on our way.
At this stage our little boy was taken very ill, and we both felt that
another march in the sun in the “kajawehs,” with his man-nurse,
might be fatal to him. So next morning we started very early, and
taking him in the trap, which had a hood and an opening with a cut
leather curtain behind, that made it very cool: we hurried over the
twenty-two miles, and did it in two hours and twenty minutes through
deep sand.
The next day’s stage was a very bad one, as, though short, we
had to pass through the town, and had to take the horses out twice,
and I dreaded our own very narrow and dangerous road to the
house. However, we got in without accident, by starting at dawn,
before ten; and the child, by rest and nursing, was soon himself
again.
The sun in Persia is a very insidious enemy. Many cases of sun-
apoplexy each year are seen, and I had a fixed rule that, except for
evening rides, my wife and I always wore an Elwood’s sun-helmet,
and this is the only real way to preserve oneself. All other things but
the topi are valueless, unless one uses the hideous pith hat, or
resorts to the turban. Of course in India these precautions are still
more necessary. I don’t know if these sun hats are made for children.
They are very necessary if children are allowed to go at all in the
sun, and they will go, and natives will let them. But really good-
looking riding-hats are turned out for ladies. My wife had a solar
riding-hat à la Gainsborough, that was almost becoming; so that
ladies at least have no excuse. I was constantly warning those under
my care of the danger of little caps, billycocks, etc., but in many
cases I was looked on as a “Molly,” though I felt it my duty to press
my warnings. Of another thing I am convinced, that the powerful
effect of the sun is much lost sight of in Europe, and I look on a
bright helmet of metal, unless air-chambered, as an invention of the
devil, and pity the poor Life Guards, etc.; the horsehair, however,
happily saves them a little.
On our journey down, at a place called Sinsin, we saw a big
turkey, and succeeded in buying a pair for fifty kerans, supposing
them to be the only pair. We found afterwards that the head-man of
the neighbouring village had a hundred birds, and the price
afterwards fell to eight shillings a bird.
We were very successful in the rearing of the young turkeys, the
hens sitting on their own eggs, and proving good mothers. So many
poults did we have, that, when we left Ispahan eighteen months
afterwards, we ate two a week for nearly six months. The turkeys
were of two varieties, the ordinary black ones, as seen in Europe,
and of large size, and a smaller bird, of lighter colour, and more
delicate, some of which latter were almost pure white.
Peacocks are much valued in Persia, and supposed only to be
kept by royalty: the English Minister has several fine birds, and the
privilege of keeping them is jealously guarded.
We brought a quantity of tame ducks down from Teheran; these
increased and multiplied amazingly, and bred with some wild ducks
of the common kind. We brought also three geese. Geese, ducks,
and turkeys were common long ago in Julfa when Ispahan was the
capital, but the Armenians, finding that they had to pay a yearly
tribute of fat birds, allowed them to die out, and so escaped the
exaction. However, when we left Julfa, all the Europeans had turkeys
and ducks, and there were plenty of geese at Soh, three stages off:
so, doubtless, by now (two years) they are plentiful.
We were glad to get back to our own home, for though Teheran
gave us most of the joys of civilisation, still we felt that our home was
in our big house at Julfa. And how we did enjoy not having to start as
usual the next morning!
Our stay in Ispahan was not chequered by any very exciting
events, save those personal to ourselves.
During our sojourn, two ambassadors passed through it. One, the
Burmese, an old and cheery man with huge ears, accompanied by a
staff of attachés, one of whom spoke English well, and had been
educated at King’s College. He was supposed to be carrying rubies
for disposal through Europe. He had a ring with him as a present
from the King of Burmah to the Shah. Hoop, collet, and all, were cut
out of one solid and perfect ruby of the first water—a truly barbarous
present. These Burmese all wore the national apology for
unmentionables—a handsome sheet of silk, termed a “langouti.” This
is wrapped around the waist, and depends nearly to the feet; their
heads were bound with fillets of muslin. The Zil-es-Sultan gave an
entertainment in their honour, to which we were all invited. A fair
dinner was followed by fireworks; these in Persia are always fairly
good, the only thing being that Persians do not understand coloured
fireworks, otherwise their displays are very good. One very good
feature is, that the public are always freely admitted. All the walls are
marked out with clay oil-lamps, and festoons of the same hang from
wires affixed to high poles: these are lighted after sunset, as soon as
it is dark. Music of a promiscuous character is played, all the
musicians and singers joining in to different airs. The military bands
strike up, each man playing his loudest at his own sweet will. A gun
is fired, and the huge golden rains from earthen cones light up the
whole scene, disclosing the shouting throng of good-tempered
Persians of the lower orders; all people of condition having been
provided with rooms and seats. All the roofs are thronged with
crowds of veiled women, flights of rockets are continually let off, and
the set-pieces soon commence. These are supplied in great
profusion, and, save for the want of colour, they are quite equal to
any effort of European pyrotechny.
A row of wretched Jews are now pushed into the tank—a
proceeding which always accompanies any official display of
fireworks. I know not why, unless it is to let the poor Jews feel, even
in times of rejoicing, the wretchedness of their position. Dancing
boys dressed as girls twirl and tumble, buffoons dance and pose
grotesquely, the noise of music and singing is at its loudest.
“Kūrbāghah” (frogs), a kind of water firework, are thrown in the tanks
in every direction, and, as the set-pieces are fading, the whole
concludes with a tremendous bouquet of fire as in Europe.
The Japanese ambassador, or rather commissioner, was received
with less ceremony, as he was proceeding incog. on his way to
Europe, having a mission to introduce Japanese goods to the notice
of Europeans generally. His attachés, too, spoke French and
English, and were funny little fellows; but, as the Persians put it, “too
ugly to have any value, even as slaves!”
We patronised art in Ispahan by having oil-paintings, executed by
native artists, of incidents in Persian life; some of these were
sufficiently curious. Among the subjects illustrated were “The Sticks,”
a very tragic picture indeed, where the expressions of pain, terror,
supplication, and ferocity were well shown.
Another amusing series were five pictures representing the history
of Bahram and his queen. The monarch is shown as pinning, with a
master-shot from his bow, the foot of an antelope to its side while it
was scratching itself.
“What do you think of that?” says the exulting king.
“Oh, practice makes perfect,” coolly remarked the lady.
They naturally separate; for it is a dangerous thing for a wife to
disparage her husband’s shooting. And here a curious parody of an
ancient classical legend occurs. Bahram hears of a lady of great
strength, who is in the habit of carrying a full-sized bull to the top of a
tower!
He goes to see the prodigy, and sees a lovely woman perform the
feat (scene depicted); his astonishment is manifested by his placing
his finger to his mouth—the typical gesture for this sensation in
Eastern art.
“Oh, that is nothing,” says the triumphant queen, “practice makes
perfect.” She then explains that she had commenced her feat when
the bull was a little calf. The king smiled, and took her back.
Many of the subjects illustrated were the histories from the Koran.
Thus the passage of the Egyptians, and their subsequent fate in the
Red Sea, is shown; Pharaoh and his host drowning, while a green-
winged angel exhibits to the sinking monarch a divine scroll, on
which his sentence is written. The expiring Egyptians are good, and
the look of horror on the face of Pharaoh is well done. But a small
steamer is seen in the distance! Another picture was “The staff of
Aaron changed to a serpent, having devoured the serpents of the
magicians of Egypt.” Here the winged dragon (or serpent) of Aaron is
so tremendous, that Wagner would have been glad of him at
Bayreuth: he is vomiting fire, and is a bogey of the first water.
Pharaoh, his eyes starting from his head, is depicted in horror, while
Moses has the satisfied expression of a conjurer after a successful
tour de force. Another represents Iskender (Alexander the Great),
who, having conquered the world, proceeds to the regions of eternal
night, as according to Persian legend he did in fact. The conqueror
and his warriors are well and carefully drawn, many of the figures
carrying torches and cressets; but the eternal night is shown by
painting the whole of the figures, trees, etc., on a black ground, and
a curious effect is thus produced.
Solomon in all his glory (see Frontispiece) is a favourite subject.
Solomon, who had the power of speaking the languages of animals
and all created things, and who could command the spirits of the
earth and air, is seen seated on his throne. Above his head is the
fabulous bird, the simūrgh; to his right, on a perch, is his favourite
the hoopöe, below this are two tiny efreet. The Queen of Sheba is
seated in a chair of state, behind her are her female servants and
slaves, and two gigantic jinns (genii). To the king’s left, are his Vizier
Asaph (the author of the Psalms of Asaph, or possibly the person to
whom they were dedicated), and Rūstam, the Persian Hercules,
armed with his bull-headed mace. Behind them are four jinns of
terrible aspect. The air is full of birds; and the foreground of beasts,
reptiles, and insects. The tiny figures with crowns are angels,
servants of Solomon; the turbaned figures are courtiers and
servants.
CHAPTER XXXV.
WE RETURN VIÂ THE CASPIAN.
New Year’s presents—Shiraz custom—Our cook’s weaknesses—He takes the

pledge—And becomes an opium-eater—Decide to go home—Dispose of kit—
Start for Europe—Our own arrangements—Diary of our journey home—
Arrival.
A severe winter, diversified with occasional fine weather, when the

days were even hot in the sun, brought the No Rūz (or Persian New
Year) and the commencement of spring. Our servants brought their
plates of sweetmeats to mark the day, and duly received a month’s
pay, or clothes to that amount. The woman-servant Bēbē brought her
mistress an earthen water-bottle, around the ledge of which was
sown barley, the grains being held on by a bandage, and the porous
jar keeping them constantly wet; the result was a number of rings of
bright grass, the whole forming a very pretty and original, if useless,
present. It is a common custom to do this in Shiraz at the New Year,
and even the poorest has his water-pot covered with brilliant green.
Our cook is giving some trouble just now; for though a capital chef,
and though he has been with me fourteen years—having begun at
eight shillings a month, and arrived for the last five years at forty and
the spending of all the money—yet he has his vices. When he was
first with me as a youth of nineteen, he was perpetually getting
married, and as frequently getting divorced; then he took to getting
continually arrested for debt; next drink became his foible, and this
endured for about four years; dismissal, the bastinado (by the
authorities), fining, were all tried without avail: at length, in despair, I
sent him to the head of religion in Ispahan, with a note to the Sheikh,
in which I apologised for troubling him, but stated that the man was a
very old servant in whom I had a great interest, and would he make
him take the pledge? The cook, who took the note himself, had no
idea of the contents. He told me that the Sheikh read it and told him
to wait; when the large assembly that always throngs the Sheikh’s
house had disappeared, the old gentleman produced a Koran, and
proposed that the cook should take the pledge. He dared not refuse.
After swearing to take no wine or spirits, a formal document was
drawn up, to which the cook attached his seal. The Sheikh wrote me
a very polite note, and assured me that the man would keep the
pledge.
It appeared that he exhibited a tremendous “taziana,” or cat-o’-
nine-tails, to my man, as what pledge-breakers are punished with.
The cook now was for weeks as sober as a judge, but he was
becoming a fool; the dinners were spoiled, or incongruous, or both:
in fact, as he must do something, he had become an opium-eater.
Opium, though habitually used by the aged of both sexes, is seldom
taken to excess, save by “lutis,” or confirmed debauchees.
At last, finding it impossible to cure this determined offender, I
gave my reluctant consent to his proceeding to Kermanshah, his
native place, where he wished to stay at least a year. I never saw
him again.
I don’t know if the last straw was the loss of our cook, or if we had
come to the conclusion that definitely Persia was not the place for a
lady, but we decided to go home on two years’ leave, to which I was
now entitled; and as we felt that it was very probable we should
never return, we determined to sell off our entire kit. We accordingly
drew out a catalogue of our worldly goods in Persia, and distributed
it among the telegraph officials. By a couple of months everything
was disposed of but the rubbish. This was sold by auction, and
produced a keen competition among the Armenians.
I was enabled to get rid of our phaeton without loss, for a Persian
of wealth, the “Mūllavi,” gave me within forty pounds of what I gave
for it and the horses; and the severe work we had had out of trap
and horses for two years was well worth the difference.
Captain W⸺, who was expecting his sisters out, viâ Russia, took
all our road kit and saddlery, and my wife’s mare and the
“takhtrowan,” all to be given over at Resht, on the Caspian, so we
were quite free to start.
OUR JOURNEY HOME.

March 28th, 1881.—Ispahan Julfa.—At last I hear that a muleteer
is found who will go direct to Resht, by way of Kūm, Hajeeb, and
Kasvin, avoiding the capital. I go to the house of a Baghdad
merchant in Julfa, and find the muleteer, who is being regaled with
pipes; he is the head-man of the neighbouring village of Se Deh
(three villages), and the proprietor of a hundred mules. I am told that
his son-in-law will go with the mules, and am introduced to a young
fellow some six feet high and thickly built, who is a Tabrizi, and
speaks good Turkish and bad Persian. He is wearing the large heavy
sheepskin cap of Tabriz, with the wool long. The merchant informs
me that he thinks the hire should be sixty kerans per mule. This is
said in English, and he then turns to the elder man and says:
“You will, of course, give this sahib mules at forty kerans per
mule?”
The old man replies: “I have, after much persuasion, got Jaffer
Kūli, my son-in-law, to agree to eighty.”
The young man, with many vows, raises his hands to heaven and
demands eighty-five. “Why do you throw words into air, Jaffer Kūli?
as I am this merchant’s friend let us say eighty, and the sahib will
have had mules for nothing. Of course we get a present?”
I here get up, saying, “These fellows are quite mad; let us talk to
men.”
They in turn rise and say, “Our last word is seventy-five.”
So we talk for an hour. Then, and not till then, the ceremony of
agreement is gone through, and the articles strictly drawn up by the
merchant, after much chaffering. At last he begins to read in a sing-
song drawl, for our mutual edification, the following:

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Pharmacology for Medical Graduates

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MCQs for Student Paramedics Covering anatomy physiology

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Foreword to the First Edition v

Preface to the Fourth Edition vii

Preface to the First Edition viii

3 Drugs Affecting Cardiovascular Function 98

4 Renal Pharmacology 151

5 Drugs Acting on Central Nervous System 164

6 Autacoids and Respiratory System 230

7 Drugs Used in the Treatment of Gastrointestinal Diseases 263

8 Drugs Affecting Coagulation and Blood Formation 285

9 Endocrine Pharmacology 303

10 Drugs Acting on Uterus 362

12 Miscellaneous Drugs 470

Foreword to the First Edition v

3 Drugs Affecting Cardiovascular Function 98

4 Renal Pharmacology 151

5 Drugs Acting on Central Nervous System 164

Antiepileptic Drugs 192

6 Autacoids and Respiratory System 230

7 Drugs Used in the Treatment of Gastrointestinal Diseases 263

8 Drugs Affecting Coagulation and Blood Formation 285

9 Endocrine Pharmacology 303

10 Drugs Acting on Uterus 362

12 Miscellaneous Drugs 470

Topic: Clinical Pharmacy

Introduction (Definitions and Sources of Drugs) PH1.1, PH1.59

SOURCES OF DRUG INFORMATION

DRUG NOMENCLATURE PH1.9

Chemical name Nonproprietary name Proprietary name/brand name

Routes of Drug Administration PH1.11

enema – soap acts as a lubricant and water stimulates rectum.

■ Convenient for repeated and prolonged use.

■ unpalatable and highly irritant drugs

■ unabsorbable drugs (e.g. aminoglycosides)

■ drugs that are destroyed by digestive juices (e.g. insulin)

■ drugs with extensive first-pass metabolism (e.g. lignocaine)

■ uncooperative and unreliable patients

■ patients with severe vomiting and diarrhoea

■ emergency as onset of action of orally administrated drugs is slow

■ Action can be terminated by spitting out the tablet.

■ Bypasses the first-pass metabolism.

■ irritant and lipid-insoluble drugs

■ drugs with bad taste

Rectal Route. Drugs can be given in the form of solid or liquid.

■ uncooperative and unreliable patient

■ patients with vomiting and diarrhoea

■ drugs with high first-pass metabolism

■ drugs not absorbed orally

■ drugs destroyed by digestive juices

■ Preparation should be sterile, and is expensive.

■ Require invasive techniques, which are painful.

■ Cannot be usually self-administered.

■ Can cause local tissue injury to nerves, vessels, etc.