Exam Hints

CVS/Diabetes
Diabetes
• Glycemic target; FPG <7, PPG <10 mmol/L, Hb1Ac ≤7%.
• 6.5 < Hb1Ac <8.5%, start with diet and exercise for 2:3 months. If not effective start with Metformin.
• Hb1Ac ≥8.5%, start with medications (combination therapy) along with diet and exercise. Or initiate
Insulin
• If blood glucose is 180 mg or 10 mol it will appear in urine.
• Hypoglycemia symptoms: Palpitation (1st sign), sweating, shakiness, dizziness, hunger, irritability.
- Non-selective B-blocker is contraindicated with diabetic patient, cause it will mask palpitation if
hypoglycemia happened.
- Insulin overdose cause hypoglycemia and hypokalemia.
• Hyperglycemia symptoms: polyurea, polyphagia (hunger), polydipsia (thirsty), blurred vision.
• Diabetic ketoacidosis: in Diabetic pts, cells start to break fats to get energy that will release ketone
bodies. Symptoms: fruity breath, polyurea, ketonuria, hyperglycemia, nausea, vomiting.
* Ketone bodies are β-hydroxybutyrate and acetoacetate. Acetoacetate breakdown to acetone (fruit
smell)
* Diagnosis: β-hydroxybutyrate in Blood. Ketones in Urine.
• Diabetes is risk factor of Gastroparesis.
• During Hypoglycemia, glucagon and epinephrine are released to increase blood glucose level.
• Oral hypoglycemic:
- Insulin secretagogue: sulfonylureas (glimepiride, glyburide), Meglitinides (Repaglinide, Nateglinide)
- Increase insulin sensitivity and decrease hepatic glucose: Metformin, Thiazolidinediones (pioglitazone)
- Enhance or mimic incretin hormone: DPP4 (sitagliptin, Vildagliptin), Glucagon-like peptide agonist
(Exenatide, Liraglutide).
- Delay digestion and absorption of starch and sucrose: alpha-glucosidase inhibitor (Acarbose, Miglitol)
(don’t stop absorption of glucose)
- Na glucose co-Transporter 2 inhibitor (NGLT2 inhibitor): Canagliflozin, Dapagliflozin.
• Sulfonylureas (glimepiride, gliclazide, glyburide) could cause prolonged hypoglycemia.
• Metformin and Acarbose both with known GIT SE. Therefore, it started with low dose and increased
gradually to minimize GIT side effects.
• Glucagon-like peptide agonist (increase insulin release + suppress glucagon) ex. Exenatide, liraglutide,
dulaglutide – independent of meals. Used to treat obesity, contraindicated in thyroid cancer.
• Na-glucose co-transporter 2 inhibitors (MOA: increase glucose excretion), ex. Canagliflozin,
dapagliflozin, empagliflozin – SE hyperkalemia
• Thiazolidindiones (pioglitazone, rosiglitazone): increase cells sensitivity to insulin though activation of
PPAR-gamma. Pioglitazone affects lipid metabolism through action at PPAR-alpha; thus, it lower free
fatty acid. SE: cause heart failure and edema, skin and eye yellowing . Contraindicated with bladder
cancer. Liver function test required with glitazones. (Cardiac function don’t show hear failure, it’s only
for infarction)
• Metformin could cause lactic acidosis; therefore, it’s contraindicated in renal and hepatic impairment
and patient >80 years old. No need for Self-monitoring of blood glucose unlike insulin and sulfonylurea.

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 Metformin taken with food to avoid stomach and bowel side effects. Start with low dose and increase
gradually to minimize GIT side effects.
• Insulin secretagogue (sulfonylurea and meglitinides), it’s hypoglycemic effect could be potentiated by
ACEI, SSRI, MAOI, NSAIDs.
• In case of hypoglycemia due to sulfonylurea, the patient should take sugar candy.
• Acarbose and miglitol don’t cause hypoglycemia but could increase risk of hypoglycemia if combined
with secretagogue or insulin. Hypoglycemia in pt take Acarbose treated with glucose rather than
sucrose. Because acarbose decrease absorption of sucrose and starch and don’t stop absorption of
glucose.
• If patient is obese = use Bupropion (reduce appetite), liraglutide, or lipase inhibitor (orlistat)
• Insulin:
- Rapid acting: Aspart, glulisine, lispro.
- intermediate acting: NPH (isophane)
- Long acting: detemir, glargine, degludec
* insulin adjusted according to carbohydrate intake.
*Regular insulin and short acting taken immediately after meals. While NPH and long acting could be
taken before meals
• Insulin side effects: hypoglycemia, weight gain, lipodystrophy.
• If type 1 diabetic, take insulin and have hypoglycemia, he should take glucose supplement and retest
after 15 minutes.
• Flexible insulin: ability to adjust insulin dose each time.
• Change insulin injection site to avoid lipodystrophy (lumps and interfere with insulin absorption)
• Insulin receptor (IR) belong to tyrosine kinase receptors. It’s activated by Insulin, then IR phosphorylate
other proteins, eventually promoting downstream process involving blood glucose hemostasis.
• α-lipoic acid: used for treatment of diabetic neuropathy, increase insulin sensitivity, reduce body weight.
• In Pregnancy, diabetic mother should take 5 mg folic acid 3 months before gestation and continues for
12 weeks, then could be reduce dot 0.4-1 mg folic acid throughout pregnancy and for 6 months
postpartum or till breastfeeding complete.
• Type 2 diabetic patient, before surgery and in ICU, they take Insulin to adjust their blood glucose level.
• Diabetes complications:
- Macrovascular Complications: stroke, coronary artery disease, peripheral vascular disease.
- Microvascular Complications: nephropathy, retinopathy, neuropathy.
* Microvascular happens first then Macrovascular.
• Diabetic foot:
Due to neuropathy, patient could develop foot ulcer. Managed by drainage of abscess, debridement,
use saline and dressing.
• Counteracting insulin hormone include: epinephrine, glucagon, levothyroxine, cortisone.

CVS
• BP should be measure on left then right hand with 5 minutes interval.
• BP target should be <140/90. For diabetic pts, BP target <130/80
• If BP >180/100 send to emergency. More than or equal to 140/90, send to physician.
• Orthostatic hypotension = postural hypotension = low BP upon standing up from lying or sitting position.
* Vasodilators mainly cause postural hypotension and syncope.
• HTN affect brain, kidney, eye.

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• Most accurate blood pressure device is “Mercury manometer and stethoscope”
• BP measurement: Electronic device is preferred over auscultation.
• HTN complication: aneurism, LV hypertrophy, stroke, heart attack, heart failure, narrowing blood vessels
in kidney and eyes, dementia, metabolic syndrome.
• Giving anticoagulant depend on CHADS2 score. – [Congestive cardiac failure=1, hypertension=1,
Age>75years=1, Diabetes Mellitus=1 and previous stroke or TIA=2].
• Statins with short T1/2, fluvastatin, lovastatin, pravastatin and simvastatin, taken at bed time.
• Statins with long T1/2, atorvastatin, rosuvastatin, pitavastatin anytime.
• Torsades de pointes: abnormal heart rhythm (ventricular tachycardia with prolonged QT interval) could
lead to death. Etiology: low Mg, low K, some medications (antiarrhythmic class I (quinidine,
procainamide), antiarrhythmic class III (amiodarone, sotalol), lithium, ephedrine, amphetamine,
citalopram, niacin). Mg+2 IV is the DOC
* Hypokalemia cause Torsades de pointes. Hyperkalemia cause ventricular tachyarrhythmia.
• Verapamil cause constipation.
• Amiodarone SE: hepatic, neurologic, thyroid, ophthalmologic abnormalities, pulmonary fibrosis, skin
pigmentation.
• Dopamine: +ve chronotropic and +ve ionotropic and increase blood flow to kidney. Dopamine SE:
anxiety, arrhythmia, vomiting and nausea. Many antipsychotic drugs are dopamine antagonists,
working to block dopamine receptors in the brain. Dopamine antagonists that act on dopamine
receptors in the gastrointestinal tract may be used to treat nausea, or as anti-emetics to stop vomiting
ex. Domperidone, metoclopramide.
• Dobutamine: B agonist, +ve ionotropic, +ve chronotropic. Used for severe heart failure.
• Dopamine used for treatment of cardiogenic shock because it dilates renal and mesenteric vascular
beds.
• Endothelin receptor antagonists (ex. Sitaxentan, ambrisentan and bosentan) used to treat people with
pulmonary hypertension.
• Diuretics SE:
- Thiazides (hydrochlorothiazide, indapamide, metolazone) Hypo K, Na, Mg, HDL - Hyper Ca, Uric acid,
glucose, LDL/vLDL.
- loop diuretics (furosemide, torsemide) same like thiazides but with hypocalcemia and ototoxicity.
- K sparing diuretics: Hyper K, hyper Cl. Spironolactone: gynecomastia. Triamterene/amiloride: leg
cramps.
* Loop diuretics work on Na/K/Cl pump cause hypo Na, K and Cl. While thiazides work on Na/K pump
cause hypo Na, K.
* Spironolactone is DOC in ascites.
• ACEI: inhibit activation of Angiotensin 1 to Angiotensin 2. ARB: inhibit Angiotensin 2 from binding to
angiotensin 2 receptor Type 1; thus, block vasoconstrictor and aldosterone secretion effect of
Angiotensin 2.
• ACEI SE: Hyperkalemia, angioedema, hypotension, can precipitate renal failure in susceptible pts, rash,
cough.
• ARB SE: Hyperkalemia, angioedema, hypotension, can precipitate renal failure in susceptible pts.
• Avoid ARB and ACEI in renal pts
• According to the guidelines: if HTN patient started with Hydrochlorothiazides or Ca channel blocker;
later we can add ACE inhibitor or ARBs

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• Diuretics MOA:
* Thiazides: inhibit Na, Cl reabsorption in distal convoluted tubule.
* Loop diuretics: inhibit Na, Cl reabsorption in loop of Henle.
* K sparing diuretics: Spironolactone: inhibit aldosterone-mediate Na reabsorption and K secretion in
collecting tubule. Amiloride/triamterene: block Na channel in collecting tubule.
* Carbonic anhydrase inhibitor (ex. Acetazolamide): inhibit HCo3 reabsorption in proximal convoluted
tubule. Cause: high Cl (hyperchloremic)

• Thiazides, ACEI, ARB increase risk of gout. While, Ca channel blockers lower risk of gout.
• In Chronic renal patient, DOC is ACEI/ARBs then thiazide or loop diuretics then B blocker then Ca
channel blocker.
• Telangiosis: any disease of capillaries and terminal arterioles.
• Telangiectasia: (spider veins) dilated blood vessels close to skin.
• Heparin activate enzyme antithrombin (AT) that inhibit clotting factor Xa and IIa (thrombin). while,
Warfarin inhibit vitamin K; that needed for synthesis of coagulation factors (II, VII, IX and X).
• OAC inhibit active site of thrombin (Dabigatran), or factor Xa (apixaban, Rivaroxaban, edoxaban)
• Fondaparinux is indirect factor Xa inhibitor. Used with caution with patient with history of Heparin-
induced thrombocytopenia (HIT)
• Protamine used to antagonize heparin bleeding effect.
• Venus Thromboembolism (DVT and Pulmonary embolism):
1- initial treatment: SC Low molecular weight Heparin/unfractioned Heparin + Warfarin.
2- Oral anticoagulant: Dabigatran, Rivaroxaban, Apixaban.
* LMWH (ex. enoxaparin) is DOC in cancer-associated thrombosis, while warfarin is contraindicated.
* in renal patient: avoid oral anticoagulant and LMWH
* Warfarin is mainly metabolized by liver; thus, could be used by renal patients.
* Heparin could cause thrombocytopenia (low platelet count)
* Dalteparin is a low molecular weight heparin used for treatment and prophylaxis of pulmonary
embolism and deep vein thrombosis.
* Active tumor, smoking, obesity, oral contraceptives is a risk factor for DVT.
* Heparin monitoring: measure activated partial thromboplastin time (aPTT).
* Warfarin monitoring: measure INR (normal 2-3).
* Increase INR >3 (blood thinning) indicate: overdose warfarin, heparin, LMWH, ASA/NSAID,
acetaminophen.
* Decrease INR<2 (blood thickening): Vitamin K, oral contraceptives.
• With Warfarin: INR normal value 2-3, but 2.5-3.5 with mechanical heart valve.
If INR < 2: increase warfarin dose by 5-15%
If INR 3 – 5 and no bleeding: lower dose, omit dose and monitor
If INR 5-9 and no bleeding, skip day.
If INR 5 – 9 with bleeding, skip dose + oral vitamin K
If INR > 9, no bleeding, hold warfarin + oral vitamin K
If INR > 9 with bleeding, hold warfarin + IV vitamin K.
• Alcohol drinking increase risk of bleeding while taking Warfarin.
• Drugs that inhibit warfarin metabolism; thus, increase bleeding risk:
Azole Antifungal, cephalosporins, macrolides (erythromycin, Clarithromycin), quinolones (ciprofloxacin),
allopurinol, cimetidine, amiodarone, alcohol drinking

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• Control Heart Rate (used in case of Atrial Fibrillation): ABCD : Amiodarone, B-Blocker, Ca-Channel
blocker, Digoxin. 1st line B and C.
• Atrial fibrillation (AF) with risk of stroke can use ASA, Warfarin or oral anticoagulant (OAC).
- efficacy: OAC (Dabigatran, Apixaban, rivaroxaban) > Warfarin > ASA.
- OAC is preferred over warfarin
- AF patient with stroke or TIA, to prevent recurrent stroke DOC is OAC not warfarin.
- Valvular AF DON’T use OAC. Warfarin is recommended.
- Anticoagulants: Rivaroxaban, edoxaban, Dabigatran contraindicated if CrCl<30. Apixaban
contraindicated if CrCl<15.
*Paroxysmal AF (intermittent AF that last for 7 days): avoid Digoxin. DOC: B-blocker/Amiodarone
• No P wave in ECG
• Atrial Fibrillation increase the risk of stroke.
• CHADS =0, Patient <65 and no risk factors = no antithrombotic
CHADS =0, patient <65 and vascular risk factor = ASA therapy
CHADS= 1 or/and Patient > 65, = OAC / ASA
CHADS= 2, = OAC
* warfarin used in renal and vulvar patients.
• Vit D increase the Digoxin absorption; thus, the dose should be adjusted.
• Digoxin increase force of contraction and decrease AV conduction.
• Amiodarone could lead to Digoxin toxicity; thus, decrease the dose by 50%.
• Angina treatment: Nitrate, B-blocker, Ca-channel blocker, Na Channel blocker (Ronalzine)
- B-Blocker CAN’T be used for rest/variant/prinzmetal and unstable angina; because it vasospasm of
coronary arteries and worsen the case.
- Nifedipine, amlodipine: rest angina. Verapamil, Diltiazem: stable angina
* ensure 10:12 hour Nitrate-free-period to restore cGMP and avoid tolerance (insensitivity). Also
nitroglycerine ointment need nitrate-free period to avoid tolerance, usually at night (least likely period
for angina attack). Nitroglycerin ointment provides more prolonged effect (6-8 h) compared to
sublingual tablet.
• Post MI:
- Dual antiplatelet = ASA + P2Y inhibitor (1st line prasugrel/ticagrelor; 2nd line clopidogrel 150 mg X 1X7
then 75 mg daily) at least for 1 year.
- Statins: atorvastatin.
- B-blocker, especially for pt with arrythmia and LV dysfunction. Used for all MI unless contraindicated.
- ACEI, considered for all post MI, especially if pt has diabetes, LV dysfunction or HTN. Contraindicate in
renal pts and those with hyperkalemia.
* avoid thiazolidinediones (pioglitazone, rosiglitazone)
• Congestive Heart failure: characterized by LV dysfunction and reduced ejection fraction <40%
- ACEI: DOC in Heart failure
- B-Blocker: only carvedilol, Bisoprolol and metoprolol succinate (NOT Tartrate)
- Diuretics (Thiazides, loop diuretic and K sparing diuretics (spironolactone/eplerenone))
- Ca Channel blocker, amlodipine only is safe *.
- Digoxin
* Reduce mortality: ACEI, B-Blocker, Spironolactone/eplerenone, isosorbide dinitrate + hydralazine.
Reduce morbidity: ACEI, B-Blocker, Digoxin.

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 * Amlodipine is safe with heart failure with reduced ejection fraction; Avoid verapamil and Diltiazem.
Nifedipine has not data.
* Patient should decrease fluid retention by < water and salt intake. Pt should take annual influenza and
pneumococcal vaccines.
* Digoxin with verapamil, diltiazem, amiodarone and B blocker increase risk of bradycardia. Also it’s
affected by enzyme inducers and inhibitors.
* Digoxin toxicity due to: Hypokalemia, Hypomagnesemia, Hypercalcemia.
* Hypokalemia cause digoxin toxicity; thus, thiazide, loop diuretics, corticosteroids and amphotericin B
contraindicated with digoxin.
* Amiodarone and Quinidine, Verapamil, Erythromycin, azole (antifungal) and Vitamin D lead to
Digoxin toxicity.
* Digoxin is contraindicated in Ventricular Tachycardia.
* New York Heart Association (NYHA): classifying the extent of heart failure.
• Heart failure with preserved ejection fraction, verapamil and diltiazem could be used
• Coronary artery disease: Antithrombotic management:
- Age > 65 and CHADS ≥ 1: OAC + Clopidogrel for 12 months, then OAC alone. (if there is PCI: ASA + OAC
+ clopidogrel for 3-6 months, then OAC + clopidogrel for 12 months, then OAC alone.)
- Age < 65 and CHADS = 0: ASA + Clopidogrel for 12 months, then ASA alone
• Warfarin is the DOC for LV thrombus.
• ECG: P wave: atrial depolarization. QRS: Ventricular depolarization. T: ventricular repolarization.
* Atrial fibrillation: irregular heart beats, no P-Wave, heart rate about 150 BPM
• Heart Attack: DOC: B blocker, ACE inhibitor/ARBs
• Naproxen is NSAID with the least CVS side effects.
• Portal vein: form intestine to liver
Hepatic artery: From aorta to liver
Hepatic vein: from liver to Vena cava.
• Venous pooling: blood to collect in veins. Etiology: chronic veins insufficiency: veins valves not working
making blood move to heart difficult. Nitroglycerin effect on veins dilation lead to peripheral pooling of
blood and decrease venous return to heart.
• Cardiac output = heart rate * stroke volume
Blood pressure= cardiac output * resistance.
• Ibuprofen shouldn’t used with Low dose aspirin, because it will decrease antiplatelet effect of ASA. As
both work on same receptor COX1 but Ibuprofen is reversible inhibitor but ASA is irreversible.
• Drugs that inhibit warfarin metabolism; thus, increase bleeding risk:
Azole Antifungal, cephalosporins, macrolides (erythromycin, Clarithromycin), quinolones (ciprofloxacin),
allopurinol, cimetidine, amiodarone, alcohol drinking.
• Thiazides including indapamide cause hyperglycemia that need monitoring.
• ACE inhibitor is 1st line treatment in diabetic patients, MI, heart failure, and non-diabetic chronic renal
disease.
- ACE inhibitors are NOT recommended as 1st line treatment in black patients. Also NOT recommended
in bilateral renal stenosis and solitary kidney (one kidney). SE: angioedema
* ACE inhibitor recommended in chronic renal failure but contraindicated in acute renal failure.
• Hematocrit: ratio of RBCs volume to total blood volume. Low means anemia. High means dehydration,
polycythemia, lung or heart disease.

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• Dyslipidemia:
- HMG coA reductase inhibitor, (statins): superior in decreasing LDL. Check: Creatine Kinase (CK) and
Liver function test (LFT) every 3 months. Contraindicated: alcohol intake, pregnancy and liver disease.
SE: Myopathy, myalgia, rhabdomyolysis.
- Fibrates: (fenofibrate, Gemfibrozil): superior in decreasing Triglycerides. Check: CK, LFT and Renal
function test (RFT). SE: atrial fibrillation, Venous Thromboembolism, myopathy, rhabdomyolysis,
hepatitis, pancreatitis.
- Nicotinic acid (Niacin). MOA: Inhibit TG synthesis and raise HDL. Superior in decreasing Triglycerides
(less than fibrates). Check: blood glucose. SE: Arrhythmia (torsade de points). CI: Hyperglycemia, gout,
peptic ulcer disease.
- Resins ex. Cholestyramine. Check: LFT, Electrolytes. Can be used in pregnancy. SE: constipation.
- Ezetimibe.
* HMG coA reductase: catalyze production of mevalonate from HMG coA, which is rate limiting step in
cholesterol synthesis.
* Statin myopathy effect induced by: alcohol abuse, chronic renal insufficiency, women, macrolides.
• Thrombolytic agents ex. Alteplase, should be given:
- within 6-12 hours in MI
- within 3-4.5 hours in Stroke.
• Alteplase is plasminogen activator, a thrombolytic drug. Used immediately after acute ischemic stroke
or acute MI (heart attack). CI: Systolic BP > 185, Diastolic > 110, history intracranial hemorrhage, after
surgery: all of those increase risk of bleeding.
• Clopidogrel is specific inhibitor of ADP binding to platelet receptor P2Y12 receptor, thus inhibit platelet
aggregation.
* Clopidogrel is prodrug that need first activation by CYP 450.
• Enalapril is a prodrug that excreted in renal only. All ACEI are primarily eliminated by renal except
Fosinopril 50% in renal and 50% in liver.
• Fosinopril and Captopril are not prodrugs.
• PPAR agonists:
Thiazolidinediones (rosiglitazone, pioglitazone): PPAR-gamma agonist. Use: increase insulin sensitivity.
Fibrate (fenofibrate, Gemfibrozil, fenofibric acid): PPAR-alpha agonist. Antihyperlipidemic.
* Pioglitazone is PPAR-gamma and PPAR-alpha agonist.
* Fibrate MOA: activation of PPAR-alpha control gene responsible for lipid metabolism, a- increase
lipase; thus, TG breakdown, b- decrease synthesis of cholesterol and TG, c- increase hepatic elimination
of cholesterol in bile.
• Atrial flutter: catheter ablation is 1st line for management.
• HTN during pregnancy:
- Methyldopa, Nifedipine, Labetalol.
- Avoid: Atenolol, thiazide diuretics, Loop diuretics, Spironolactone, ACEI, ARBs,
* Methyldopa SE: fluid retention, edema, weight gain.
• Missing Digoxin dose, take it as soon as possible if remembered within 12 hours of scheduled dose. Call
the doctor if missed for 2 days or more.
• Transient Ischemic Attack (TIA), DOC is ASA.
• Patient who should take ASA and have gastric ulcer, they should screen and eradicate H. Pylori.
• Sleep apnea is risk factor for Stroke.

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• Antiplatelets: inhibit platelet clumps, ex. COX inhibitor (ASA), ADP inhibitor (Clopidogrel), Adenosine
receptor inhibitor (Dipyridamole)
• Anticoagulant: inhibit coagulation cascade: Vitamin K inhibitor (Warfarin), Factor X inhibitor
(Rivaroxaban), Factor II inhibitor (Dabigatran).
• Plaque formation cause: stroke, angina, intermittent claudication, coronary artery disease.
• Stroke Predispose factors: Age, ethnicity, HTN, diabetes, BMI, smoking, low exercise.
• Hypertrophic Cardiomyopathy: heart thickened. DOC: B blocker then Verapamil. These drugs are
contraindicated: ACE inhibitor, nifedipine, nitrate.

CNS
Antipsychotic Drugs:
• 1st Generation antipsychotic is D2 antagonist.
2nd Generation antipsychotic: D2 antagonist, 5-HT2 antagonist, 5-HT1 agonist. (with rapid D2
dissociation).
* Other effect of both 1st and 2nd generation: antagonism of M1, H1, α1 receptors.
• 2nd generation antipsychotic (ex. Quetiapine): inhibit dopamine (D2) receptor in mesolimbic and
serotonin (5-HT2A) receptor. (antagonize D receptor relief positive symptoms, while antagonizing 5-HT
relief negative symptoms)
• Clozapine has affinity to 5-HT, D1, D4, α-adrenergic, muscarinic receptors.
• EPS is due to imbalance between cholinergic and dopaminergic action; thus, anticholinergic action
restore the balance and minimize EPS.
• Dopamine receptor blocking: Treat psychosis, cause EPS, increase prolactin.
• 1st generation (haloperidol) antipsychotic have EPS. 2nd generation has fewer EPS.
1st could treat positive symptoms while 2nd generation could treat both positive and negative symptoms.
2nd generation are the 1st line of treatment except of clozapine (only resistant cases due to risk of
agranulocytosis and need for regular blood monitoring)
• Aripiprazole can be used with hyperglycemic, hyperlipidemic pts.
• From most to the least safe (SE: hyperglycemia, weight gain, sedation and hyperlipidemia): Aripiprazole
> Risperidone > Quetiapine > Olanzapine> Clozapine
• Haloperidol could be used for Pt with constipation (because of it’s low anticholinergic effect).
• Weight gain, hyperglycemia and hyperlipidemia are more associated with 2nd generation compared to
1st generation. Especially with Clozapine and Olanzapine.
• After using antipsychotic for 2:4 weeks with no response, increase the dose or switch to another
antipsychotic. If no response use CLOZAPINE for 8 weeks.
* Clozapine has risk of agranulocytosis and CVS events (especially in 1st month)
* if the case is still resistant to clozapine, you can combine with other antipsychotic drug.
• 1st generation antipsychotic + Risperidone are associated with hyperprolactinemia results is sexual
dysfunction, gynecomastia, menstrual irregularities.
• Paliperidone palmitate is a pro-drug of paliperidone, an active metabolite of risperidone.
• Antipsychotic = neuroleptic drugs
• Dopamine antagonist such as antipsychotic and metoclopramide, cause EPS.
• Tardive dyskinesia: stiff, limb jerks, eye blink. Causes: due to block of dopamine. Treatment:
Valbenazine.
• Long standing paranoid is a symptom of Schizophrenia.

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• Risperidone is associate with increased risk of death.
• Risperidone SE: weight gain, sedation, hyperprolactinemia, hypotension.
• As a general rule, its better to start with 2nd generation.

Dementia:
1nd line: AchE inhibitors (Donepzil, Galantamine, Rivastigmine), SE: asthma, lower seizure threshold.
NMDA antagonist (Memantine).
* Benzodiazepines (Lorazepam, Oxazepam), for severe agitation.
* if psychotic symptoms are evident use antipsychotic (Risperidone, Olanzapine) as 1st line.
* SSRI used for depression cases.
* Rivastigmine and Galantamine for mild/moderate cases. Donepezil for all stages.
* Galantamine is the reversible, competitive AChE inhibitor. Rivastigmine: pseudo-reversible,
noncompetitive inhibitor. Donepezil: reversible, noncompetitive.
* if Rivastigmine caused nausea or vomiting, pt can use Rivastigmine patch.
• Dementia with hallucination and early parkinsonism = Lewy body dementia.
- Rivastigmine is the DOC for Lewy body dementia. Antipsychotic could worse the case, but if it has to
be used, 2nd generation (quetiapine and olanzapine) are better.
• Alzheimer Pts brain has amyloid plaque formed of accumulation of protein called β-amyloid.
• Diphenhydramine antihistamine with anticholinergic effect.

Insomnia
DOC: short acting-benzodiazepine (triazolam), use lowest dose for shortest period. Course of treatment
7-day, evaluate, if unimproved repeat for 7-day with maximum dose then refer if no improvement.
- Non-benzodiazepine GABA agonist: Zolpidem, SE: sleepwalking and sleep eating, and Zopiclone SE:
drowsiness, dizziness and metallic/bitter taste.
* Duration of Zopiclone and Zolpidem: 7-10 consecutive days. Shouldn’t exceed 4 weeks.
* Short acting BZD: Triazolam, midazolam, Alprazolam. Intermediate acting: Lorazepam, temazepam.
Long acting BZD: Flurazepam, Diazepam, clonazepam.
* Diphenhydramine, antihistamine with sedative effect could be used but up to 4 times/week and no
longer than 7 consecutive days.
* if someone couldn’t sleep due to grievance, then he don’t need pharmacotherapy only family support
• St. John's wort is a herbal antidepressant. Inducer of CYP3A4 and CYP2D6. With SSRI could lead to
serotonin syndrome. It interferes with tamoxifen metabolism.
• Grapefruit is CYP3A4 inhibitor; thus, induce drugs action.

Antidepressant:
- SSRI: fluoxetine, paroxetine, citalopram, escitalopram (stereoisomer of citalopram, superior efficacy).
SE: weight gain, sexual dysfunction, dry mouth, sleep disturbance, nausea, QT prolongation. Nausea
and vomiting is the most common side effect.
- SNRI: Venlafaxine, duloxetine. SE: nausea, dry mouth, sleep disturbance. Venlafaxine Dose over
225/day cause HTN
- TCA: (2nd line) Amitriptyline, Nortriptyline
- MAOI (2nd and 3rd line) Irreversible: phenelzine, tranylcypromine. Reversible: Moclobemide (MAO-A
inhibitor).
- Antipsychotic (2nd line) Quetiapine, Aripiprazole.

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• Assessment of antidepressants should be after 2-4 weeks, if it’s okay continue for 6-8 weeks, if
symptoms improved, continue minimum use 6-9 months. Treat for at least 2 years in those at risk of
recurrence (frequent episodes, suicidal thoughts, residual symptoms)
• Antidepressant shouldn’t abruptly stopped. taper slowly over 4–6 weeks.
• Switching SSRI to SSRI/SNRI, could be direct from next day or cross-taper
Switching SSRI to TCA, cross-taper over 1-2 weeks.
Switching irreversible MAOI to any antidepressant, taper MAOI then 2 weeks washout before starting
new drug
Switching reversible MAOI to any antidepressant, need 5 days wash out.
Switching from fluoxetine to irreversible MAOI, 5 weeks wash out.
Switching from Bupropion to SSRI. Taper Bupropion over 7 days then start SSRI.
• Citalopram and Escitalopram are optical isomers (enantiomers)
• TCA (ex. Amitriptyline) overdose is toxic and could be fatal, should be avoided with pt of suicidal
thoughts.
• SSRI and other antidepressants are associate with behavior change including: agitation, hostility, suicidal
thoughts.
• SSRI is related to Sexual dysfunction. While: Bupropion, Mirtazapine cause less sexual dysfunction.
• Mirtazapine is tetracyclic antidepressant. SE: sedation and weight gain.
• SSRI need tapering the dose, but Fluoxetine don’t cause of it’s long T1/2, so it will fade out slowly.
Venlafaxine and paroxetine has short T1/2 so they have rapid withdrawal symptoms.
Bupropion don’t have withdrawal symptoms.

Anti-Parkinson Drugs:
- Mild symptoms: MAO-B inhibitor: Selegiline, Rasagiline. SE: hallucination.
- Severe symptoms and age <60 y: Dopamine agonist: Bromocriptine SE: pulmonary fibrosis,
Pramipexole, Ropinirole SE: sudden sleep, compulsive behavior (hypersexuality, pathological gambling)
- Sever symptoms and age >60 y: Levodopa/carbidopa. SE: wearing off (on-off phenomena)
- COMT inhibitor: Entacapone, Tolcapone. SE: urine discoloration, diarrhea.
- NMDA receptor antagonist: Amantadine
- Anticholinergic: Benztropine. Major effect on Tremor, not bradykinesia nor dyskinesia nor motor
fluctuation
* In mild symptoms, we can use amantadine, Benztropine
* MAO inhibitor and COMT inhibitors (entacapone) can be used for patient with Levodopa wearing-off
* Levodopa complication: freezing (sudden inhibition of movement), treated by physiotherapy
(changing medications are not helpful)
• Levodopa wearing off management:
- increase levodopa dose. Use levodopa CR at bedtime.
- add dopamine agonist, add entacapone or MAO inhibitor.
• Parkinsonism could be induced by:
- 1st and 2nd generation antipsychotic
- Central Dopamine antagonist (anti-emetic): metoclopramide, prochlorperazine.
• Parkinson disease could decrease blinking rate.
• Although Donepezil increase acetylcholine it doesn’t worse parkinsonism with cognitive impairment
patient.

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Smoking cessation:
- Nicotine replacement therapy (NRT): patches, gums, lozenges. (recommended for Old Pts.). SE:
headache
- Non-NRT:
* Varenicline: partial agonist for nicotine receptor (inhibit nicotine from binding to its receptor; thus,
block the nicotine euphoria. SE: nausea, mood change, suicidal behavior.
*Bupropion: antidepressant, used to decrease craving and withdrawal symptoms of nicotine. Should be
avoided in seizures, insomnia, anorexia nervosa, bulimia nervosa. Unlike SSRI doesn’t cause weight gain
or sexual dysfunction.
* Cytisine, nortriptyline, clonidine.
- combination therapy: NRT + Varenicline.
- pregnant, breast feeding, CVS pt and children can use NRT if non-pharmacological therapy not effective
• Smoking cause diarrhea and cessation cause constipation.
• Marijuana SEs: increase BP, hallucination, depression, dry mouth, increase appetite, red eyes, sexual
problems, numbness.
• Smoking ingredient: nicotine, tar, CO2, Formaldehyde, ammonia, arsenic, nickel.
• Smoking release polycyclic aromatic hydrocarbons.
•

Alcoholism
• Alcohol dependence (chronic alcoholism) treated with:
- Disulfiram, naltrexone: contraindicated in hepatic pts. Acamprosate: safe in hepatic pts.

Opioids:
• Opioids has 3 receptors Mu (analgesia, euphoria, constipation, respiratory depression), Kappa (spinal
analgesia, dysphoria), delta (unknown)
- Mu: morphine, methadone, fentanyl, meperidine, codeine, tramadol
- Kappa: morphine.
- kappa agonist/Mu antagonist: pentazocine, nalbuphine
- antagonist: naloxone, naltrexone
* Fentanyl predominantly work on Mu receptor.
• Buprenorphine: partial agonist to Mu and inhibitor for Kappa and Delta.
• Heroin = diacetylmorphine = diamorphine = morphine diacetate = acetylated morphine.
• Withdrawal symptoms: methadone or Buprenorphine + naloxone.
• Buprenorphine and naloxone used to treat opioid withdrawal.
• Buprenorphine is the DOC for Opioid use disorder in pregnancy.

ADHD:
- 1st line: psychostimulant: Dextroamphetamine, methylphenidate, amphetamine—SE: abuse
Atomoxetine: not controlled substance but has CVS risk side effects.
- 2nd line: Bupropion, Venlafaxine (antidepressants). Clonidine (α2 agonist)
* Methylphenidate cause weight loss; thus, Weight should be monitored.
• Autism spectrum, Spectrum means range of symptoms and challenges.

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Anti Epileptic Drugs (AED):
- Absence seizure: Ethosuximide (DOC), Valproic acid.
- Status Epilepticus: phenobarbital, Benzodiazepine, phenytoin/fosphenytoin.
- Myoclonic: Valproic acid (DOC).
* Valproic acid, monitor Liver Function Test (LFT)
* CBC and liver function test are required with AED.
*Carbamazepine, SE: neutropenia (common), a plastic anemia. Valproic acid: SE: thrombocytopenia.
* Fosphenytoin is a prodrug for phenytoin
* Epilepsy during pregnancy:
- avoid Valproic acid, avoid switching Anti-Epileptic Drugs (AED), avoid polytherapy.
- pregnancy increase clearance of AED, so AED level could drop.
- Lamotrigine or levetiracetam could be used.
- Enzyme inducing AED (carbamazepine, phenytoin, phenobarbital), increase degradation of fetus
vitamin K, which is overcome by vitamin K given to new born (routinely to prevent hemorrhagic disease)
- Pregnant woman taking AED should take 1 mg folic acid daily, 3 months before gestation and at first 12
weeks of pregnancy. If the patient taking Valproic acid or have history of neural tube defect, 4 mg daily
is recommended. From 12 weeks to as long as breast feeding continue, 0.4:1mg folic daily
recommended.
* The best AED choice with COC is: Lamotrigine.
* Lamotrigine metabolism is markedly affected by:
- Enzyme inducing AED ex. (carbamazepine, phenytoin, phenobarbital, primidone).
- Enzyme inhibitory AED ex. (Valproic acid)
- Lamotrigine serum level drop by 50% with COC, it should be monitored and could be doubled.
• Antiepileptics drugs (AED) have no rules in provoked seizures, such as hypoglycemia, hyponatremia,
alcohol or drugs withdrawal. Brain injury could provoke seizure, AED could help in first 7 days.
• MOA:
1- Block Ion Channel:
* Na channel blocker: Carbamazepine, Phenytoin, Valproic acid, lamotrigine, Topiramate.
* Ca channel blocker: Ethosuximide, Valproic acid
2- enhance GABA inhibitor effect: BDZ, Barbiturate, Valproic acid, Topiramate
3- Inhibit excitatory Glutamate: Topiramate, Felbamate
“enhancing GABA action leads to increase Cl influx and hyperpolarization”

Panic disorder:
- 1st line: SSRI (paroxetine, citalopram, escitalopram), SNRI (Venlafaxine)
- 2nd line: TCA (imipramine, chloropyramine), BZD (Alprazolam, clonazepam)
- 3rd line: MAOI (phenelzine, tranylcypromine), 2nd generation antipsychotic (risperidone)

Social phobia:
- 1st line: SSRI and SNRI
- 2nd line: phenelzine, BDZ (clonazepam, bromazepam)
- 3rd line: 2nd generation antipsychotic, TCA, B-blocker (Atenolol, propranolol) (30 minutes before anxiety
provoking event)

General Anxiety Disorder:

- 1st line: SSRI, SNRI and pregabalin
- 2nd line: TCA, BDZ, buspirone, bupropion.

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 - 3rd line: 2nd generation antipsychotic, Dextromethorphan, meperidine and St. john’s wort with SSRI and
SNRI could lead to serotonin syndrome.
• Bupropion (antidepressant) MOA: inhibit NE and dopamine reuptake.
• TCA (ex. Amitriptyline, imipramine): block serotonergic receptor (5-HT), adrenergic receptor (NE),
Histamine and muscarinic receptors.

Muscle Relaxants:
• Competitive blocker of Acetylcholine: Curare
• Depolarizing agent: Succinylcholine
• GABA agonist: Diazepam, Baclofen
• Direct acting: interfere with Ca release: Dantrolene.

* Succinylcholine: bind to Ach Nicotinic receptor, at neuromuscular junction that leads to persistent
depolarization then desensitization and muscle relaxation. Succinylcholine mimic acetylcholine but it
has longer duration of action.

Restless Leg Syndrome (RLS):

• Symptoms: urge to move legs during rest (lying down) accompanied with tingling.
• Etiology: low dopamine level.
• Medication:
* DOC: Dopamine agonist: ex. Ropinirole, Pramipexole SE: impulse control disorder (compulsive
gambling).
* Gabapentin and pregabalin (block Ca channel)
* Opioids
* Benzodiazepine: help sleep at night but don’t eliminate leg sensation.

Others
• Dextromethorphan is cough suppressant, also it promote serotonin release. It could cause serotonin
syndrome with SSRI/SNRI
• Physostigmine can pass BBB; therefore, it can treat CNS effect of atropine overdose. Also it used to
treat glaucoma.
• Lithium, serum level 1-1.2 mmol/L, SE: tremors, weight gain, Diabetes insipidus (polyuria),
hypothyroidism, renal impairment, vomiting, diarrhea. Renal function and thyroid function should be
checked regularly.
Lithium conc. (toxicity) increased with: NSAIDs, ACEI, ARBs, Thiazide diuretics. Salt diets and Caffeine
increase means lithium decrease and vice versa (so keep salt and caffeine intake about the same)
• Agitation due to brain-injury: DOC: Propranolol.
• Methylxanthines: theophylline and theobromine in tea and caffeine, pentoxifylline; MOA
1- adenosine receptor inhibitor
2- phosphodiesterase inhibitor
• Hypoglycorrhachia (low CSF glucose level) caused by bacterial meningitis.
• Endorphin, enkephalin and dynorphin are natural pain-killer, opioids-like action.
* Enkephalin: act on both spinal cord and brain
* Endorphin: produced in hypothalamus, pituitary, brain stem.
* Dynorphin: stimulate Kappa receptor. Produced in brain and spinal cord.

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• Pseudoephedrine: Regulated under Precursor Control Regulation, maximum quantity is 3 gm per
package.

Anti-infective
Tuberculosis:
• Anti-tubercular agents: Ethambutol, isoniazid, rifampin.
• Isoniazid and rifampin are DOC for tuberculosis
• Isoniazid: side effects: retinopathy, neuropathy (therefore pyridoxin B6 is take with isoniazid) ,
hepatotoxicity, SLE (skin rash, joints/muscle pain, anemia, lung problems, fever).
• Rifampin: side effects: red secretion (saliva, urine, tears, feces)
• Isoniazid: prophylaxis of TB

Onychomycosis (nail infection)

• Onychomycosis (OM) = fungal nail infection, caused by dermatophytes, nondermatophytes, yeast (C.
albicans)
- DOC for OM caused by dermatophytes: terbinafine 250 mg q.d. for 6 W (finger), 12 W (toe)
- DOC for OM caused by nondermatophytes and yeast: Itracanzole 200 bid (1week/month)X2 (finger) or
3 (toe) or 200 mg OD for 6 weeks (finger), 12 weeks (toe)
• Nail fungal infection = 6 weeks. Toe fungal infection = 12 weeks.
• Tinea pedis best treated with terbinafine, clotrimazole.
• Itrancanzole should be administered after full meal but should be 2 hours after using antacids. (antacid
decrease its absorption). SE: GIT events, liver dysfunction, arrhythmia and hear failure.

Tonsillitis/Pharyngitis:
• Tonsillitis antibiotic: DOC is penicillin (penicillin V or amoxicillin), then use cephalosporins. If allergic to
penicillin: use azithromycin, clarithromycin, clindamycin. Treatment for 10 days, except Azithromycin
for 5 days.
• 90% of pharyngitis is Viral not bacterial. Doesn’t require specific treatment.

Sinusitis:
• Caused by Streptococcus pneumonia, H. Influenza.

Community Acquired Pneumonia CAP:

(mainly B-lactam* + macrolides or respiratory Fluoroquinolones*)
- Outpatient: Doxycycline. If there is risk for resistance: Fluoroquinolones or amoxicillin + macrolides
- Hospital (Ward/ICU): Fluoroquinolones or B-lactam + macrolides
ICU (suspected P. Aeruginosa): B-lactam + (ciprofloxacin or ciprofloxacin + aminoglycosides or
aminoglycosides + macrolides)
* Respiratory fluoroquinolones: Levofloxacin, moxifloxacin
* B-lactam: ampicillin-sulbactam, ceftriaxone, cefotaxime, penicillin G.
* Macrolides: Azithromycin, Clarithromycin, Erythromycin
* Don’t use Erythromycin alone due to low efficacy against H. Influenza.
• Community acquired pneumonia caused mainly by influenza virus, human rhinovirus, Streptococcus
pneumoniae, Mycoplasma Pneumonia, H. influenza, Moraxella catarrhalis,
• The most causative organism for Community Acquired Pneumonia (CAP) is Streptococcus Pneumonia
The most causative organism for Hospital Acquired Pneumonia (HAP) is Pseudomonas Aeruginosa.

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• MRSA Pneumonia: DOC: Vancomycin or Linezolid.
• MRSA: DOC: Vancomycin. SE: ototoxicity and nephrotoxicity.
VRSA: DOC: Linezolid
• Recurrent pneumonia within 3 months after treatment with amoxicillin clavulanate, use antibiotic from
another group (Levofloxacin).
• Chest X-ray is usually requested to confirm pneumonia recovery, if X-ray is ambiguous, make CT or MRI.
Sputum and blood sample used to identify pathogen.
• Chlamydophila pneumoniae: intracellular bacteria that resist cell-wall antibiotics.
• Streptococcus pneumoniae: the associated with the highest mortality rate when cause CAP.

Acute Bronchitis:
- analgesic + anti tussive (codeine, dextromethorphan), + bronchodilator (salbutamol)

Hepatitis:
• Acute hepatitis caused by Hepatitis A and E (last less than 6 months)
• Acute hepatitis < 6 months. Chronic Hepatitis > 6 months (only happen with HBV and HCV)
• Acute Hepatitis: treatment:
- Vit K if INR >1.4 + lactulose ( if encephalopathy)
• Peginterferon: antiviral for hepatitis B and C. SE: flu like symptoms. CI: acute HBV.
• Direct Acting Antiviral (DAA) is class of medication used for HCV treatment.

Pseudomonas aeruginosa is sensitive to:

- antipseudomonal penicillin: ticarcillin, piperacillin
- Ceftazidime and Cefepime (3rd and 4th generation cephalosporins)
- Meropenem (carbapenem), Aztreonam
- aminoglycosides (Gentamycin, tobramycin, amikacin)
- Quinolones (norfloxacin, ciprofloxacin, levofloxacin)
• Pseudomonas aeruginosa is resistant to 1st and 2nd generation cephalosporins (ex. Cefazoline).

Conjunctivitis:
• mainly caused by S. aureus
- bacterial: S. aureus, H. influenza, streptococcus pneumonia. In neonate and sexually active adult : N.
meningitis and N. gonorrhea.
- Viral: Herpes Simplex, adenovirus, papillomavirus.

Meningitis
• caused by: Streptococcus Pneumonia, H. Influenza, N. meningitis. The most common cause is
Streptococcus Pneumonia
Treatment: Ceftriaxone + Vancomycin ± ampicillin.
- if pediatric < 6 weeks, Cefotaxime + Ampicillin
* Prophylaxis: rifampin or Ciprofloxacin or Ceftriaxone. In Pregnancy, Ceftriaxone.

Acute otitis media

• mainly caused by bacteria (Strept pneumoniae, H. influenzae and Moraxella catarrhalis) then virus.
Viral respiratory infection could alter the defense mechanism that leads to bacterial infection.
• Acute otitis media (inflammation of middle ear) more common in winter. “watchful waiting”: means no
antibiotics taken for uncomplicated cases with children more than 6 months.

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• DOC: amoxicillin for 5 days (age >2yrs), or 10 days (age 6 weeks: 2 yrs). If resistance use amoxicillin
clavulanic acid for 10 days. If pts has penicillin allergy use clarithromycin or azithromycin.
• Symptoms: ear pain/fullness, irritability, fever
• * Otitis media or otitis externa if there is Fever, Refer to Doctor.

Otitis externa "swimmer's ear"

• (inflammation of external canal), more in summer. swimming and moisture are risk factors. Symptoms:
ear discharge.
DOC: dexamethasone, ciprofloxacin, acetic acid

Antibiotics
• Fluoroquinolones: ciprofloxacin, norfloxacin and levofloxacin: mostly excreted unchanged, mainly used
in UTI, concentrate in urinary tract, so it needs a lot of water to flush the drug out. Unlike, moxifloxacin
that hepatically excreted used to treat (chest infection), don’t need lots of water.
• Post Antibiotic Effect is seen (aminoglycoside, quinolones, tetracycline, carbapenems), it is persistent
suppression of bacterial growth even after stopping the antibiotic or when its level below MIC.
* once daily dosing of aminoglycosides is effective due to post-antimicrobial effect.
• Tetracycline and Doxacycline NOT recommended for children < 8 years.
• Erythromycin has the highest GI SE (increase GI motility) compared to Azithromycin or clarithromycin.
• Streptomycin makes 8th cranial nerve toxicity and not used in case of meningitis
• Clarithromycin, Azithromycin could be stored at room temperature. While cephalexin and amoxiclav
should be refrigerated.
• Linezolid poisoning, caused when recommended dose given to renal failure pt, lead to
thrombocytopenia.
• Aminoglycosides: Amikacin, Gentamicin, neomycin, tobramycin, streptomycin. SE: ototoxicity and
nephrotoxicity.
• Vancomycin mainly for Gm+ve, MRSA. SE: Ototoxicity and Nephrotoxicity. CI: aminoglycosides.
• Extended-spectrum beta-lactamases (ESBL) are enzymes that confer resistance to most beta-lactam
antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam.
- antibiotics for B-lactamase strains infection: Carbapenems, 3rd generation cephalosporin (cefixime),
nitrofurantoin, B-lactamase inhibitor (clavulanic acid, sulbactam, tazobactam),
• Zidovudine is a prodrug that activated by phosphorylation.
• Clindamycin: SE: nausea, vomiting, Clostridium difficile infection (diarrhea)
• Aminoglycosides and penicillin at same syringe lead to inactivation of aminoglycosides.
• Tetracycline during pregnancy cause tooth discoloration. During breastfeeding cause teeth
discoloration and delayed bone growth.

Impetigo
• mainly cause by S. Aureus, also streptococcus pyogenes
• Bacitracin cream, Mupirocin ointment, Fucidic acid cream
• Cephalexin 500 mg q6h for 10 days.

Antiviral:
• Oseltamivir contraindicated in patients with asthma and COPD, renal impairment need dose
adjustment.
• Oseltamivir (Tamiflu) contraindicated in children < 1 Year old

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• Zanamivir administered for patient > 7 Years old.

Others
• Rickettsia pathogens are transmitted by ticks, fleas, lice, mites. Rickettsia cause Rocky Mountain
Spotted Fever. DOC: Doxycycline.
• Toxoplasmosis, DOC: sulfadiazine + pyrimethamine
• Endocarditis causative organisms: S. Aureus accounts for 40%. Streptococci Viridians accounts for 20%
• S. Viridians is a normal flora in mouth, that could cause endocarditis.
• Gm+ve bacteria (S. aureus) is mainly on Skin
• Hand, Foot and Mouth Disease: viral disease, self-recovery within 7-10 days. Could use NSAID for pain
and fever.
• All antibiotic suspension should be refrigerated except Azithromycin, Clindamycin and Clarithromycin.
Don’t have to reconstituted in aseptic conditions
• Wart (growth in outer-layer skin): caused by infection of skin with Human Papillomavirus (HPV).
Treatment: peeling medicine (Salicylic acid or trichloroacetic acid), podophyllin (cytotoxic), Cimetidine.
• Enterococci are resistant to β-lactam based antibiotic (penicillin, cephalosporins, carbapenems).
• Syphilis caused by Treponema pallidum
• Gm -ve anaerobes are mainly in GIT. Gm +ve in skin.
• The main types of bacteria in the colon are obligate anaerobes.
• Colon has 90% anaerobes and 10% aerobes
• Shingles cause difficulty in eye closure that leads to dry eye.
• Chlamydia is sexual transmitted disease caused by Chlamydia Trachomatis.
• Malaria caused by Plasmodium species: P. falciparum, P. malariae, P. ovale and P. vivax.
• Gastroenteritis mainly caused by virus (Rotavirus, norovirus), and bacteria (Campylobacter)
• Food poisoning mainly caused by: E coli, salmonella, Clostridium Perferingens, Campylobacter,
• Candida can be treated with Fluconazole, Ketoconazole, Nystatin, Amphotericin B. Not Metronidazole
• Bacteroides fragilis (B. Fragilis) susceptible to metronidazole, carbapenems, amoxicillin +clavulanic acid,
ampicillin + sulbactam.
• Lyme disease: infection caused by Borelia Burgdoferi, transmitted to human by ticks. Symptoms:
erythema, joint pain, neuropathy. DOC: Doxycycline, Amoxycillin or cefuroxime.
• Opportunistic infection: pathogens take advantage of compromised immune system.
- Viral: Herpes simplex virus, VZV, CMV.
- Bacterial: tuberculosis, mycobacterium, pneumonia.
- Fungal: Candidiasis
- Parasite: Toxoplasmosis.
• Nystatin, amphotericin: MOA: bind to ergosterol (building unit in fungal cell membrane) causing pores in
cell membrane and cell death.
• Azole (ex. Itraconazole) MOA: inhibit synthesis of ergosterol and hence cell membrane compromising,
leads to cell death.
• HIV will lower down CD4 T-cells below 200. (normal range 500-1500).
• Oseltamivir contraindicated in children < 1 Year old
• Herpes Simplex Virus (HSV): is sexually transmitted disease and transmitted by direct contact with
lesions.
• Animal bites/scratches cause infection with: Pasteurella Multocida
Human bites cause infection with: S. aureus

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 * Soft tissue infections caused by human or animal (cats, dogs) bites treated with
amoxicillin/clavulanate.
• Most prevalent infection for people how use syringes regularly is: S. Aureus.
•

Thyroid Gland
Hypothyroidism:
• Symptoms: weight gain, cold sensitivity, goiter, dry skin, fatigue, mood swings, Constipation.
• Hypothyroidism is diagnosed with TSH test, and confirmed with TSH sensitivity.
- low T4 means hypothyroidism. TSH sensitivity to know if it is thyroid gland or pituitary gland defect.
• 1ry Hypothyroidism: High TSH, low T4
2ry Hypothyroidism (pituitary disorder), 3ry Hypothyroidism (Hypothalamic disorder): Low TSH, Low T4
Hashimoto thyroiditis: autoimmune disease, anti-Thyroid Peroxidase (TPO) is high.
Myxedema: sever hypothyroidism
• Treatment:
- Levothyroxine: Dose adjustment every 4-6 weeks, TSH is monitored every 4-6 weeks, it takes 6 weeks
to attain new steady state after dose adjustment. Taken at morning to avoid insomnia. At empty
stomach for better BAV.
- IV Levothyroxine + IV corticosteroids in myxedema.
- In pregnancy: increase the dose of thyroxin by 2 tablets per week.

Hyperthyroidism
• Symptoms: weight loss, tremors, heat intolerance, diarrhea, sweating, mood swings.
• Hyperthyroidism: low TSH, High T4
• Treatment:
- Methimazole (preferred due to low incidence of hepatotoxicity) and DOC in breastfeeding.
- Propylthiouracil: DOC in pregnancy.
- Radioactive Iodine
- B-Blocker (propranolol)

EYE
Glaucoma
• Increase Intra Ocular Pressure (IOP), increase the risk of glaucoma
• Drugs could worsen glaucoma: corticosteroids, antimuscarinic, topiramate, contraceptives.
• Glaucoma Treatment: β-Blocker, Carbonic anhydrase inhibitor, Prostaglandin analogs, α-adrenergic
agonist, cholinergic agonist
- β-Blocker (timolol), Carbonic anhydrase inhibitor (Dorzolamide, Brinzolamide): inhibit formation of
aqueous humor.
- Prostaglandin analogs (Latanoprost, Travoprost, Bimatoprost): increase aqueous humor outflow.
- α-adrenergic agonist (brimonidine): suppress formation of aqueous humor and increase outflow.
- cholinergic agonist (pilocarpine, physostigmine): contract ciliary muscle and increase outflow.
• 1st line treatment: β-Blocker or Prostaglandin analogs or laser. Timolol is twice daily; while Latanoprost
is once daily.

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• 2nd line: adding or substituting with other classes. Surgery is the last option.
• Prostaglandin analogs, used with asthmatic patient unlike B-blockers. SE: increase eyelash length,
irreversible Iris pigmentation for blue or green eyes patients and these patients should be followed up.
Therefore, those are the least potential patient for PGF2α. Prostaglandin eye drops should be
Refrigerated.

Cataract:
• Preventing cataract:
- using anti-oxidants (vitamin A, C, selenium)
- using sun glasses to protect from UVA, UVB light.
- limit alcohol and quit smoking.
• Cataract Surgery Postoperative Care:
- Dilators and cycloplegics: Tropicamide (Mydracil), phenylephrine, cyclopentolate: used for short term.
- B1 adrenergic antagonist (Timolol), α1 adrenergic agonist (Brimonidine): can be used for long term or
permanently.

Conjunctivitis
• Mainly caused by S. aureus
- bacterial: S. aureus, H. influenza, streptococcus pneumonia. In neonate and sexually active adult : N.
meningitis and N. gonorrhea.
- Viral: Herpes Simplex, adenovirus, papillomavirus.

Red eye/pain and Referral:

• - Red eye + watery + itching = probably allergic conjunctivitis (self-care, refer if it last >72 h), if no itching
that mean viral conjunctivitis and need refer.
- Red eye + purulent (pus) = self care, unless children or sever symptoms.
- Red eye + burning + foreign body sensation = self care
- Eye pain or blurred vision = refer
- Eyelid swollen with nodule = self care, refer after 48 H
- Eyelid itchy + red + lice = self care.
• Nystagmus: involuntary repetitive oscillatory eye movement
• The three main layers of the eye include: the cornea (outer layer), the uveal tract (middle layer) and the
retina (inner layer).
• Retina has 2 photoreceptors
- Rods: Responsible for vision at low light level. (night vision), has Rhodopsin (a pigment in rods)
- Cones: Responsible for vision at high light level, for Color vision, has Iodopsin (pigment in cones)
* Horizontal cells: neurons regulate photoreceptors cells.
* Optic nerve composed of retinal ganglion cell axons and glial cells.

Medications cause eye problems:

• Bisphosphonate, Ethambutol, cyclosporine, tacrolimus, Minocycline, Amiodarone, Topiramate,
hydroxychloroquine, Isotretinoin.

Age Related Macular Degeneration (AMD)

•

Page 19 of 83
Others
• Nasolacrimal occlusion technique is used to prevent the eye drops from flowing into drainage duct and
keep more medicine in eye and decrease absorption into blood and systemic side effects.
• Allow 5 minutes between different eyedrops. Don’t put contact lenses for 15 minutes after eyedrops.
• Benzalkonium chloride is the most common preservative used in eyedrops.
• Ocular suspension need to be agitated for uniformity.
• Optic Disc = blind spot (because there is no rods and cons)
• Miosis: caused by opiates and acetylcholine agonist (anticholinesterase)
• Mydriasis: caused by anticholinergic, sympathomimetics.

GIT
• Gastrin: Secreted by Pyloric gland. Secreted when pH increase; thus, parietal cells secrete HCl to
decrease PH again. Also stimulate chief cells to release pepsinogen that converted to pepsin by HCl.
- Secretin: inhibit gastrin action and stimulate the production of bicarbonate from the pancreas.
- Pepsin: enzyme that digest protein.
- Amylase: hydrolysis of starch.

Constipation
• Constipation caused by: Anticonvulsant (phenytoin), Ca-Channel blocker (verapamil), opioid (morphine,
codeine), TCA (amitriptyline), antiparkinson’s drugs (levodopa), Diuretics (furosemide), minerals (iron,
Ca, Al), antipsychotic (clozapine), NSAIDS (ibuprofen), oral contraceptives, Cholestyramine (anti-
hyperlipidemia), Gabapentin, loperamide and anticholinergic (atropine).
• Constipation Treatment in infants: use Glycerin suppository, sorbitol, corn syrup, barely malt extract.
• Constipation treatment in children more than 1 year: 1st line: PEG, lactulose, sorbitol. 2nd line:
Magnesium hydroxide.
• Constipation treatment in pregnancy and breast feeding: Psyllium, dietary bran or wheat fiber.
* Patient on opioids can take more than 1 laxative (docusate is not effective as a laxative)
• Psyllium: is bulk forming laxative, safest agent.

Diarrhea
• Diarrhea caused by: Antibiotics, Mg+2, misoprostol, smoking, laxatives.
• Oral Rehydration Solution to prevent dehydration.
• Clostridium Difficile Diarrhea = antibiotic associated diarrhea: Diarrhea after taking antibiotics or
hospitalization.
* Treatment: mild-moderate case: Vancomycin, then Fidaxomicin, metronidazole oral 500mgX3X10
Sever case: Vancomycin oral 125mgX4X10 or Fidaxomicin 200mgX2X10
severe and complicated (hypotension, shock, megacolon): metronidazole IV + Vancomycin oral
• Diarrhea during pregnancy and breastfeeding:
- Loperamide

• Gastric protective strategies: Misoprostol 200 µg X4X1, PPI, Avoid NSAID (celecoxib can be used but not
with CVS cases) SE. Diarrhea (resolve within 1 week, diarrhea could be minimized by using low dose then
titrate up, or divide the doses to be after meals and before bed time)
• Children who had a antibiotic associated diarrhea, should have a yogurt containing probiotics.

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GERD
• Symptoms include: heartburn, regurgitation, excess salivation, lump in throat, cough, laryngitis,
Dysphagia (difficult swallowing). Refer if there is Dysphagia, it needs endoscopic evaluation.
• GERD risk factors: obesity, connective tissue disorder (scleroderma), smoking, age, Crohn’s disease,
asthma.
• Misoprostol used for prophylaxis of NSAID induced ulcer.
• H2 antagonists, ex. Ranitidine, famotidine, taken on empty stomach (before meals) as it needs acid
media to be effective.
• Naproxen + Esomeprazole combination should be taken at least 30 minute before meals.
• Sucralfate used to treat stomach ulcer, GERD. Taken on empty stomach
• Antacid work by neutralizing acid and it is faster than H2 blocker.
• PPI is DOC in severe GERD

Peptic Ulcer Disease (PUD)

• Risk factors: age >65, NSAIDs, corticosteroids, antiplatelets, anticoagulants, history of PUD.
• Gastroprotective strategies: PPI once daily or misoprostol 800 ug (in 4 divided dose).
• Eradication of H. Pylori prior initiation of ASA or NSAIDs to reduce risk of ulcer.

H pylori
• 1st line: Quadrable therapy
Amoxicillin 1gm + Clarithromycin 500mg + PPI 20mg + Metronidazole 500 mg (BID)
* if allergic to penicillin: Tetracycline 250mg QID + Bismuth 2tb QID + PPI 20gm BID + metronidazole
500mg TID.
2nd line: Triple therapy:
PPI + Amoxicillin + Clarithromycin/Metronidazole/Levofloxacin
• Bismuth used to relieve diarrhea and heartburn. SE: black tongue and stool

Irritable Bowel syndrome (IBS):

• abdominal pain, changing bowel habit (diarrhea, constipation or mixed)
if Diarrhea: use Loperamide, Diphenoxylate + atropine
If Constipation: LinaClotide (improve multiple symptoms), Laxative: PEG, Lactulose, MgOH, Bisacodyl,
senna
Abdominal pain: amitriptyline

Inflammatory Bowel syndrome:

- Ulcerative colitis: continuous inflammation in colon. Symptoms: bloody diarrhea, abdominal pain.
* Remission Induction: Sulfasalazine, 5-ASA for induction. Also, corticosteroids.
* Maintenance: Azathioprine, 6-mercaptopurine.
- Crohn’s disease: discontinuous inflammation of GIT (from anus to esophagus). Symptoms: diarrhea,
abdominal pain.
* Induction: corticosteroids (prednisone 40-60 mg for 12-16 Weeks)
* Maintenance: Azathioprine, 6-mercaptopurine, methotrexate.

Biological treatment: anti-TNF α (Infliximab, Adalimumab) effective in induction remission and

maintenance for both Ulcerative colitis, Crohn’s disease.

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Nausea and vomiting
• Promethazine: antihistamine, used for vomiting after surgery and with chemotherapy.
Doxylamine: antihistamine, used with Pyridoxine as 1st line to treat vomiting in pregnancy.
(Diclectin is Doxylamine + Pyridoxine)
• Chemotherapy induced vomiting treatment:
- Serotonin antagonist: 5HT3 receptor antagonist, ondansetron, granisetron
- Neurokinin receptor antagonist: aprepitant, netupitant, fosaprepitant.
- Corticosteroids: Dexamethasone.
• Motion sickness: related to histamine and acetylcholine.
Treatment: Antihistamine: Dimenhydrinate, Diphenhydramine. Anticholinergic: Scopolamine.
• Ginger has anti-nausea effect

Hemorrhoid treatment:
• anesthetic (lidocaine, dibucaine), Hydrocortisone, vasoconstrictor (phenylephrine), protectant (glycerin,
white petroleum), astringents (zinc sulfate, hamamelis)

Aphthous Ulcer: (mouth ulcer)

• DOC: acetaminophen, montelukast, pentoxifylline, colchicine, Dapsone.
• Avoid: NSAIDs
• Drugs increase the risk of Aphthous Ulcer: NSAID, ACE inhibitor, Anti-arrhythmia, Opioid.

Others
• Cholecystokinin: hormone secreted from duodenum in small intestine. Its stimulate pancreas to release
digestive enzymes and gallbladder to contract and release bile acid into intestine.
• PPI required acidic medium for dissolution and absorption.
• NSAID associate ulcer, use Omeprazole o.d.
• Celiac disease is immune disease, people can’t eat gluten foods because gluten will provoke the immune
system to damage small intestine. Gluten is present in wheat, rye, oats and barley. While rice, corn
(maize), soy are gluten free.
• Lactose intolerance is due to deficiency of Lactase enzyme that needed to digest lactose.
• Domperidone antagonist: (anti-emetic) Domperidone: peripheral dopamine receptor antagonist.
Metoclopramide: peripheral and centrally receptor dopamine antagonist.

Miscellaneous
Anemia
• Microcytic anemia (low MCV) treated with iron
* Microcytic anemia: low: MCV, hemoglobin conc., serum iron, serum ferritin, transferrin. High: Total
Iron Binding Capacity (TIBC)
• Macrocytic anemia (High MCV) either megaloblastic anemia or pernicious anemia treated with Vit B12 +
folic acid and Vit B12 only respectively.
• Hemolytic anemia is a breakdown of RBCs and treated with blood transfusion or stem cell transplant
• Pregnancy anemia is mainly due to iron deficiency or folic acid deficiency.
• Vit B12 deficiency anemia causes: vegans, alcohol, gastric bypass surgery, Crohn’s disease, intrinsic
factor deficiency, metformin.

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• Folic acid deficiency anemia causes: alcohol, pregnancy, malignancy, hemolytic anemia, Phenytoin,
methotrexate (folate antagonist)
• In the diagnosis: first we start with measure Hemoglobin or hematocrit level, then MCV then Ferritin.

Minerals/Vitamins:
• The source of Ca+ that leads to contraction is sarcoplasmic reticulum where it stored.
• Intrinsic factor (produced by parietal cells) needed for Vit B12 absorption.
• Basic amino acids: Arginine (most basic), lysine, histidine. Acidic amino acid: aspartate, glutamate
• Vit B1(thiamine): produce energy from food. Deficiency in neuropathy
• Vit B2 (riboflavin): for metabolism of fats, carbohydrates and proteins.
• Vit B3 (niacin, nicotinic acid): produce hemoglobin and it’s oxygen capacity, maintain blood glucose
level. Reduce TG and Increase HDL. Toxicity lead to hepatoxicity.
• Vit B5 (pantothenic acid): to synthesize coenzyme-A and produce energy from food.
• Vit B6 (pyridoxine): production of many enzymes. Deficiency cause microcytic anemia and neuropathy.
• Vit B7 (Biotin): required for carboxylase enzyme.
• Vit B12: RBC, DNA and neurological function. Deficiency cause pernicious anemia, neuropathy. It’s
presented mainly in meat; therefore, vegetarians needs to have Vit B12
• Folic acid: for new cells formation. Deficiency cause megaloblastic anemia, neural tube defect. Toxicity
increase seizure frequency, increase risk of CV and colon cancer.
• Vitamin A, is teratogenic in high dose. Toxicity cause osteoporosis
* Beta carotene, is a precursor of Vitamin A (retinol)
• Beta-carotene: toxicity cause lung cancer. With Vit A increase risk of CV mortality.
• Ascorbic acid (vitamin C) toxicity: kidney stones
• Vitamin D: help absorbing Ca and support muscles needed to avoid fall. toxicity cause hypercalcemia
and hypercalciuria and renal impairment.
*recommended for Breastfeeding.
• Vitamin E: toxicity increase risk of prostate cancer.
• Vitamin K toxicity: jaundice, hyperbilirubinemia, hemolytic anemia and block anticoagulant effect.
Vitamin K source: Vegetables (Vitamin K1 (Phylloquinone)), Intestinal bacteria (vitamin K2
(Menaquinone), Synthetic (vitamin K3). It’s used in liver for bioactivation of clotting factors.
* Intestinal bacteria synthesis 50% of daily requirement of Vitamin K.
* Newborns should receive IM vitamin K1 (phytonadione) after birth to prevent brain damage and
death.
• Choline toxicity lead to fishy odor + hypotension + cholinergic signs.
• Calcium: toxicity cause CV event + prostate cancer
• Iron: the most abundant metal in body. CAN’T be taken with tetracycline. toxicity lead to cirrhosis +
heart failure.
• Mg: toxicity cause diarrhea, arrhythmia
• Potassium: toxicity lead to renal failure. Hyperkalemia caused by: K sparing diuretics, ACEI, ARBs,
Sulfamethoxazole/Trimethoprim.
• Vit B12 (cyanocobalamin), Ca and Iron are absorbed in acidic medium. Therefore, achlorhdyric patient
(low HCl) decrease Ca, Fe and Vit B12 absorption.
* Vit D recommended for Breastfeeding mothers. Vit K recommended for all neonates.

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Transport/Diffusion:
• Active transport: energy dependent movement of molecules against conc. gradient.
• Passive diffusion: doesn’t need energy, through lipid membrane with conc. gradient (from high to low
conc.). ex. Across placenta, BBB or from blood to milk
* The drug to pass placenta or enter breastmilk, increase when:
- Lipophilic (fat solubility), low molecular weight, Non-ionized, low plasma protein binding.
• Facilitated diffusion: don’t need energy but require carrier. Ex. Glucose uptake by muscles facilitated by
insulin.

Laboratory tests/Investigations
• Fecal Occult Blood detects presence of blood in stool, that often ordered to indicate colorectal cancer.
• Chest X-ray is usually requested to confirm pneumonia recovery, if X-ray is ambiguous, make CT or MRI.
Sputum and blood sample used to identify pathogen.
• Bilirubin test: most sensitive for liver cirrhosis
- ALP test most sensitive for biliary duct obstruction (cholestasis)
- AST, ALT: sensitive for Hepatotoxicity.

Acidosis/Alkalosis
• Alkalosis: due to high bicarbonate in blood or loss of acid or decrease CO2.
• Metabolic alkalosis: due to vomiting, loss of potassium.
• Respiratory Alkalosis: hyperventilation, panic attack, Aspirin poisoning.
• Metabolic acidosis: alcohol, aspirin toxicity, Diabetic ketoacidosis.
• Respiratory acidosis: hypoventilation, sever asthma, pneumonia.
• Metabolic acidosis: due to
- Increase bicarbonate loss: diarrhoea, carbonic anhydrase inhibitors
- Increase acid load: salicylate intoxication, HCL administration, diabetic ketoacidosis.
- decrease acid excretion: Renal failure
• Salicylate (ASA overdose) intoxication:
- first 12 hours: Respiratory alkalosis + alkaluria
- 12-24 hours: Respiratory alkalosis + Aciduria.
- 24 hours or 4-6 hours in children: dehydration + hypokalemia + metabolic acidosis
•

Sunscreens:
- Broad spectrum (against UVA and UVB)
- SPF >15 , recommended 30. If ≥15 can be labelled with “decrease risk of skin cancer and skin aging”. If
<15, “protect against sunburn” label can be used.
- Hypoallergenic, noncomedogenic (don’t block skin pores), non-perfumed.
- SPF number indicate protection against UVB.

Equivalent/Alternate:
• Bioequivalent: 2 drugs with similar bioavailability.
• Pharmaceutical equivalent: same active ingredient, dose, route of administration and bioequivalent.
Could be with different color, pack, flavor, shape, preservative, expiration time. Ex. Lipitor vs Ator
• Pharmaceutical alternate: 2 drugs share the same therapeutic moiety. Ex. Pantoprazole Na vs
Pantoprazole Mg or Quinidine sulfate tablet Vs Quinidine sulfate Capsule.

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• Therapeutic equivalent: 2 chemical equivalent have same therapeutic effect (efficacy and side effects).
Ex. Ramipril vs Lisinopril
• Therapeutic alternate: different active ingredient have same therapeutic effect. Ex. Antihistamines.
Diclofenac Vs ibuprofen.

Metabolism
• Drug metabolism have 2 phases:
- phase 1: oxidation, reduction, hydrolysis. Mostly has “oxidase, reductase, dehydrogenase, hydrolase”.
- phase 2: Glutathione conjugation, acetylation, sulfation, glucuronidation. The enzymes mostly have
“Transferase” moiety in its name. ex. Methyltransferase, acetyltransferase, glutathione transferase.
* Amines group (NH) undergo Phase 2 metabolism: glucuronidation, methylation, acetylation
* OH undergo: glucuronidation, methylation, sulfa
* COOH undergo: glucuronidation, glycine or glutamate conjugation. (Glycine is common in human)
* SH undergo: glucuronidation, methylation
• Ester (R-CO-OR’) is converted to acid and alcohol by hydrolysis (breakdown of compound by interaction
with H2O).
Hydroxylation is adding OH group to the compound
• Acetaminophen undergo phase I, glucuronidation, sulfate conjugation and glutathione conjugation.
* Phase I (oxidation) give toxic metabolite (that is hepatotoxic), which catalyzed by glutathione
conjugation to give cysteine and mercapturic acid.

Onset of actions:
• Clopidogrel has slow onset of action about 2 hours.
• ASA onset of action: 5-30 minutes
• B blocker: 30 minutes
•

Bedsores (pressure ulcers):

• Treatment include: reducing pressure on affected skins, clean with water and saline, debridement
(removing dead, damaged, infected tissue), NSAIDS, Antibiotics.

Elastic compression stockings/Hose

• Prescribe in: varicose veins, compromised venous return, edema, DVT, non-ambulatory patient to
prevent emboli due to inactivity, edema.
• NOT used for elder and patient with ACS, cardiac failure, ambulatory patient with emboli.
• Anything related to artery (ex. Coronary artery disease) is contraindicated.

Weight Loss
• Drugs cause weight loss: Liraglutide, Orlistat.
• Metformin, Bupropion, Topiramate cause weight loss as a side effect.

Earwax
• Remove earwax with: mineral oil, baby oil, triethanolamine, glycerin.
• Earbuds and headphones could increase earwax.
• Earwax accumulation could lead to hear loss

Cushing syndrome
• Due to hyperfunction of adrenal cortex and increase cortisol production.

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• Diagnosis: Urine test, Salivary cortisol test, Low-dose Dexamethasone suppression test (LDDST)
* LDDST: low dose Dexamethasone is given, normal cortisol level should drop but in Cushing syndrome
the cortisol level don’t drop.

Insect Bites and stings:

• Insect repellents: for mosquitoes, black flies and ticks but NOT for stinging insects (ex. Bees). 1st choice
DEET and Icardin.
* DEET: Effective against Mosquitoes, ticks, fleas. NOT recommended for children <6 months.
Sunscreen applied first and allowed to penetrate before applying DEET.
* Icardin: 1st choice for children 6 months – 1year.
* Oil of Citronella: NOT recommended for children <2 years. Short Duration 20 min-2 hours.
* Soybean oil: no age restrictions.

Abbreviations:
Po = orally
qd= once daily
qid/qds= 4 times daily
qhs= at bedtime
Stat= immediately
d.t.d= number of units
ad 90 ml = up to 90 ml
mittee = prepare or make
aa= equal amounts (in prescriptions)
ac = before meals
Pc = after meals
cc= with food
O.D= in the right eyes
O.S/A.l= in the left eyes
O.U= in both eyes
A.D= right ear
A.S/A.l= left ear
A.U = both ears
Ex aq = Ex aqua = in water
sig= label, write
gtt = drops

Others
• Renal function, creatinine clearance, bone mass, total body water, Hair; decrease with age.
• Serum creatinine and Parathyroid hormone (cause bones to release Ca in blood that lead to
osteoporosis) increase with age .
* lead body mass (which is source of creatinine) decrease with age; but renal function also decline,
resulting in less creatinine clearance. Thus, with aging serum creatinine will not increase till 50% of
nephrons are no longer function
• Rhabdomyolysis symptoms: muscle pain and dark urine

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• Urine change in color with: Rifampin (red), nitrofurantoin (brown), Ferrous (black), rhabdomyolysis
• Gingival hyperplasia is an overgrowth of gum tissue
•
• Glycoprotein = protein + carbohydrate.
• Glutathione Composted of three amino acids - cysteine, glycine, and glutamate.
• Polymer: a molecule made from many repeated subunits. Ex. Proteins (polypeptide) made from many
amino acids. Nucleic acids is a polymer made from many nucleotide units.
• Starch is composed of large number of glucose units.
• Starch is not a fiber. Fiber example: pectin, cellulose, chitin, lignin.
•
• Nuclease: breakdown/digest nucleic acids.
• Cystic Fibrosis: genetic disease mainly affect lungs and digestive system. Blocking the airway, inability to
digest food. Treatment: antibiotics, mucus-thinning drugs, bronchodilator, pancreatic enzymes.
• Cold sore is triggered by UV light, viral infection, fever, immune system, stress, fatigue, hormonal
change.
• Classic osmotic pump, follow zero-order kinetics that is independent on drug concentration.
• Validity: extent that instrument measures what it was designed to measure.
Reliability: extent that instrument give the same results over multiple trials.
• Apoenzyme: is an inactive protein portion of the enzyme
- Cofactor: could be inorganic (metals) or organic (vitamins)
- when apoenzyme bind to cofactor = holoenzyme (active enzyme)
- prosthetic group: cofactor bind tightly to protein or enzyme.
• Nutraceutical is regulated as food additive or dietary supplement. Ex. Amino acids, vitamins.
•
• Sulfa drugs (should be avoided with sulfa-allergy pts):
- sulfamethoxazole, erythromycin, celecoxib, dapsone, sulfasalazine, furosemide, chlorothiazide,
Glimepiride, glyburide.
• Pinworm and scabies infection need all the household to be treated
• IV solution should be isotonic; otherwise, Hypotonic solution: lead to swelling and rupture of RBCs
(hemolysis) and swelling and rupture of cells and electrolyte imbalance (hyponatremia). Hypertonic
solution: lead to shrunk of RBCs and destroyed and develop hypernatremia.
• Possible optical isomers = 2n. n= number of chiral centers (carbon atom attached to 4 different groups)
• Prednisolone should be taken with meals to avoid GIT upset. Should be taken at morning to avoid
insomnia and night sweats.
• Medication that increase risk of fall: ACEI, α blocker, anticoagulant, anticonvulsant, antidepressant,
antihistamines, antipsychotic, corticosteroids, PPI, muscle relaxants, NSAID, Nitrates, opiates/narcotics,
BDZ (including Zopiclone, Zolpidem), Thiazolidinediones, metoclopramide, eye drops, alcohol, digoxin,
natural products (for sleep aids and sexual enhancement)
• Co A is acetylated to Acetyl Co A, its main function is deliver acetyl group to citric acid in Krebs’s cycle
• Sleep apnea is a risk factor for stroke, heart attack and abnormal heart beats.
• Bariatric Clinic: clinic for obese patients.
• Drug Clearance depend on: age, protein binding, blood flow, renal, hepatic and CVS function, urine PH,
drug-interactions.
• Depolarization: more +ve charge inside the cell
- Repolarization: more +ve charge outside the cell

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• Occlusive dressing: soften skin by preventing dehydration of skin. Also it provide barrier against bacteria
and reduce shearing force.
• Cell Cycle:
G1 phase: cell growth and Enzyme synthesis.
S Phase: DNA duplication
G2 phase: cell growth continue, repair any errors
M Phase: Mitosis, division the cell into 2 daughter cells.
• Deiodination is a process of activation of T4 to T3. Also, deiodination is a mechanism of degradation of
T4 and T3 to inactive compounds.
• Partition coefficient affects the passage of the drug through stratum corneum (skin). The higher
partition coefficient, the higher the membrane permeability to the drug.
* partition coefficient: ratio of solubility of drug in lipid to water.
• Drink a lot of water with the following medications:
- antibiotics, expectorants, theophylline
- Sulfonamides (Drugs cause crystalluria)
- HTN drugs to avoid dehydration especially ACEI and ARB
• Taken on Empty Stomach: for better absorption and BAV:
- Tetracycline, ampicillin, Cloxacillin, quinolones (norfloxacin, ciprofloxacin), Azithromycin, Isoniazid,
sucralfate, levothyroxine, Alendronate, iron supplement.
• Taken with food: Valproic acid, NSAID, nitrofurantoin, erythromycin.
• Avoid Traveler’s diarrhea: advice (Boil it, Cook it, Peel it or Forget it)
- avoid salad and raw vegetables
- avoid non-sealed water.
- eat fruits if it is peeled or washed by safe water
- Cooked meat or fish
- use waterless alcohol-based hand sanitizers.
* mainly caused by E-coli.
• Potassium Chloride safety:
- use oral KCl rather than IV when possible.
- proper mixing,
- Access to KCl in critical care unit should be safeguarded and restricted.
- Consider purchasing 20 ml size rather than 10 ml, to avoid mix up with 10 ml water or 10 ml saline.
- Add fluorescent label and warning label on KCl once received.
- when non-standard conc. of KCl is ordered, the pharmacist have to intervene. Always premixed KCl is
first.
- use specific area to store concentrated KCl.
• The blister pack used to enhance medication adherence, but it has 4 slots for maximum 4 doses per
medication. Any medication more than 4 doses/day or PRN can’t use blister pack.
• Hyperkalemia caused by: Renal failure, ACEI, ARBs, K sparing diuretics (Spironolactone, Triamterene,
Amiloride), adrenal insufficiency, metabolic acidosis, cardiac arrest, sulfamethoxazole/Trimethoprim.
• Hypokalemia: Thiazides, loop diuretics, adrenal cancer (increase aldosterone that increase K secretion),
vomiting.
• Kinase ex. Creatine kinase: transfer phosphate group from ATP to other substrate converting (ATP to
ADP)
• Inverse agonist: induce pharmacological response opposite to the agonist.

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• The most prescribed drugs is Antidepressant. Most refilled drugs: CVS drugs.
• Pancreatitis Diagnosis:
- Blood level of pancreatic enzymes (lipase and amylase) are elevated
- CT and ultrasound to detect gallstones and pancreas inflammation.
- Stool test to measure level of fats.
• The main goal of treating alopecia to block immune system attack and/or stimulate hair regrowth and
increase hair density.
• Cystine is a dimer of 2 molecule of Cysteine (amino acid).
• Gastric emptying increase with hunger, cold meals, mild exercise, lying of right side.
• HIV:
- use Pre-exposure prophylaxis: used for risk patient (couples with only one is HIV +ve), people share
needles.
- Post-exposure prophylaxis: within 72 hours after encounter.
• Breast milk is the best option in 1st 6 months. The 2nd options is Iron-Fortified Formula.
• Newtonian fluid: viscosity is constant, regardless to force applied. Ex. Water, oil
• Non-Newtonian fluid: it’s viscosity change with change of force applied.
- Dilatant= shear thickening: viscosity increase if the force applied increase. Ex. Cornstarch suspension.
- Pseudoplastic = Shear thinning: viscosity decrease if force applied increase. Ex. Ketchup
- Rheopexy: time-dependent dilatant. Viscosity increase with force as long the force applied.
- Thixotropy: time-dependent pseudoplastic. Viscosity decrease with force as long the force applied.
• Ca for muscle contraction present extracellular (blood + interstitial)
• Antidiuretic hormone (ADH) deficiency:
- Caused by: compulsive water drinking, diabetes insipidus.
- Symptoms: polyuria, polydipsia.
• Colligative properties: properties that depend on conc. of particles in solution, such as: freezing point,
boiling point, osmotic pressure, vapor pressure.
• Water for Injection: is not sterile and not a final dosage form.
• Sterile Water for Injection is hypotonic, if given IV will lead to hemolysis. Thus, it’s osmolarity and
tonicity should be adjusted before administration.
• Water for irrigation: wound cleaning
• Sterile water for injection: parenteral preparation
• Water for injection: parenteral manufacturing
• Purified water: Reconstitution of oral suspension.
• High Alert Medication, include: Insulin, Antidiabetic, Anticoagulant, Chemotherapy.
• Angle of Repose: Measure glidant properties. Glidant: improve flowability.
• Cyclosporin: immunosuppressant used in rheumatoid arthritis, organ’s transplant, psoriasis. Affected by
CYP 3A4 inhibitors: verapamil, diltiazem, itraconazole, clarithromycin, grapefruit. CYP 3A4 inducers:
carbamazepine, phenytoin, phenobarbital, St john’s wort, rifampin.
• Ibuprofen has 2 isomers: S (+) form which is has the anti-inflammatory effect, while R(-)form has no anti-
inflammatory effect.
• If the drug is completely metabolized by liver and patient has a kidney failure, the active metabolites
could accumulate causing toxicity.
• Teeth: Incisors (four in each jaw), Canines (1 in each quadrant), pre-molar (2 in each quadrant), molar (3
in each quadrant)

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• Tachyphylaxis: sudden decrease in drug response after its administration, it’s rapid short-term of drug
tolerance. Etiology: downregulation of receptor due to repeated drug use.
Anaphylaxis: life threatening allergic reaction.
Chemotaxis: movement of cells or organisms according to chemical stimulus.
• Elevated ESR: inflammation, infection, pregnancy, anemia
Elevated WBC: infection, inflammation.
• Drug transporters: examples: Organic Anionic Transporter (OAT), Organic Cationic Transporter (OCT)
• Essential Amino acids: Try This VIP Mall : Tryptophan, Threonine, Histidine, Valine, Isoleucine,
Phenylalanine, Methionine, Leucine, Lysine.
• ACE Inhibitors and ARBs used in chronic renal patient and contraindicated in acute renal patients.
Cortisone is used in acute renal patient.
• Acidic drug in acidic medium, will be unionized; thus, will be more absorbed. Acidic drug in alkaline
medium will be eliminate.
• Cholesterol undergo hydroxylation (hydroxylase) to form bile acids (cholic acid), that undergo
conjugation with glycine, taurine to form bile salts.
• Management of drug overdose:
- Narrow therapeutic index drugs ex. Digoxin, Warfarin = refer to Emergency
- Safe drugs ex. Amoxicillin = refer to Doctor.
• Barbiturate toxicity, managed by:
- activated charcoal to decrease absorption
- Aminophylline to antagonize it’s respiratory depression action.
- Alkalinization of urine to increase its excretion.
• Decrease PO2 lead to vasodilation and increase blood flow, and vice versa
* Decrease PCO2 lead to vasoconstriction and decrease blood flow, and vice versa.
• Carbonic anhydrase an enzyme in RBCs, convert Co2 to carbonic acid. Play a role in transport of Co2 in
RBCs.
• Pharmacodynamics: the effect of the drug on body.
Pharmacokinetics: the effect of body on the drug (absorption, distribution, metabolism and
elimination). The way the drug move through the body.
• Zero order kinetics (ex. Phenytoin), is due to saturation of renal clearance.
• Competitive Inhibitor: don’t alter the rate of reaction.
• Treatment of Volume depletion: isotonic saline.
• Hand Sanitizer contain at least 60% alcohol.
• If the pt is poor (slow) metabolizer for CYP2D6 and vice versa for rapid (fast) metabolizer:
- if the drug itself is active: that means less drug deactivated; thus, we should lower the dose.
- if it’s a prodrug that activated by CYP: that means less of the drug activated; thus, we should increase
the dose.
• Raynaud syndrome: decrease blood flow to finger due to arterial spasm.
• Hyperkalemia treated with Furosemide and Na polystyrene sulfonate.
• If patient unconscious: protect pt airways and ensure stable vital signs.
• Rhabdomyolysis: muscle death and release its content, due to high waste lead to Renal failure.
• Gauge in syringe: outer diameter of syringe needle. Smaller number means greater diameter
• Osmotic blood pressure of the blood: 300 mOsm/L
• Hyperphosphatemia treated with Ca carbonate.
• Chlorhexidine used for dental caries.

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 Inflammatory/Migraine/ Pain
Migraine:
• Migraine prophylaxis includes: (ABC-T) AED (topiramate), B-Blockers, Ca channel blocker (verapamil),
TCA (e.g., amitriptyline, nortriptyline), candesartan, lisinopril, gabapentin, NSAIDs
* B-Blockers for migraine: Atenolol, Metoprolol, Propranolol, Nadolol, Timolol
• Migraine attacks:
- Not severe: NSAID
- Severe: Triptans (sumatriptan) to abort migraine, could use another dose (if migraine is treated and it
came again) after 2 hours. Don’t use again within 24 hours to avoid vasoconstriction. Then you could
use Triptans + NSAID. Avoid using Triptan with Ergotamine to avoid (Vasoconstriction and serotonin
syndrome). Sumatriptan has similar structure to Serotonin (5-HT).
• Symptoms: pulsing pain usually one side of head, vomiting, sensitivity to light or sound or smell.

Headache
• Cluster headache (attack occur at regular times): prophylaxis: Ca Channel blocker (verapamil), Lithium
• Tension headache (attack bilateral): prophylaxis: TCA (Amitriptyline)

Opioids
• We shift between 2 opioids to prevent tolerance.
• When changing opioids, we start with low dose to avoid tolerance and to account for underestimated
potency.
• The analgesic effect of codeine due to it’s metabolization (O-Demethylation) to morphine.
• Codeine is metabolized by CYP 2D6 to morphine. Ultra-rapid metabolizers (as mothers) in risk of high
morphine level in breast milk.
• Morphine: 30 mg. Oral = 10 mg SC/IV
• Immediate Release opioids are more potential for abuse versus Extended Release.
• Opioids according to potency:
Meperidine > Tramadol > Codeine > Pentazocine > Hydrocodone = Morphine > Oxycodone > Methadone
> Hydromorphone > Fentanyl.
* Morphine and Hydromorphone don’t require metabolic activation.
* Meperidine and Pentazocine could be accumulated and cause serious toxicity.
* Codeine: is a prodrug that should be converted to morphine.
* Fentanyl Patch-for-Patch: patient return the used patch to the pharmacist to take a new patch, to
minimise abuse. If the pt was unable to return the used patch and it’s not pt first prescription, the
pharmacist use his professional judgement to dispense appropriate number of patches but the
pharmacist notify the physician the used patches not returned and the number of new dispensed
patches. If fentanyl patch is loose: fix it with tape. If Fentanyl patch fall down: throw it and use another
one.

Opioids overdose:
• Symptoms: respiratory depression, bradycardia, miosis (pinpoint pupils), sedation, coma, hypotension.
• Naloxone: antidote, full opioid antagonist. Reverse respiratory depression
• Methadone: partial Mu receptor agonist, treat withdrawal symptoms.
• Buprenorphine also give for withdrawal symptoms.

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• Naltrexone: treat alcohol withdrawal symptoms. It works by inhibiting dopamine.
* methadone is given in the pharmacy to be monitored, after dilution with juice (so that the addict can’t
take it IV). It can be given as carry on doses for weekends, after you are sure the addict is serious to
quit.

NSAIDS:
• Non-selective COX2 inhibitor: has GI side effects
Selective Cox2 inhibitor: less GI effect but increase risk of CVS events.
• Rheumatoid Arthritis, to relieve pain use NSAIDs. Opioids should be avoided if possible.
• PG1: protect gastric mucosa
PG2: for cervical opening and uterus contraction.
• PGI2 (prostacyclin): vasodilator and inhibit platelet aggregation
- TXA2 (thromboxane): vasoconstrictor and stimulate platelet aggregation
- PGE2, PGF2α: inflammation, uterine contraction.
- LT2 (leukotrienes): bronchoconstriction.
• COX 1: responsible for TXA2 (platelet aggregation) and gastric protection. COX2: inflammation.
• Paracetamol/acetaminophen (unlike NSAID), pass BBB and inhibit CNS COX2 and COX3. While NSAID
inhibit COX 1 and COX2; COX1 is critical to maintain integrity of platelets, renal function, gastric mucosa.
Thus, paracetamol has least GIT SE. Safe for children, unlike aspirin that cause Reye’s syndrome.
Overdose lead to hepatotoxicity.
* Acetaminophen + alcohol could lead to hepatotoxicity. Consuming more than 3 alcohol drinks/day,
then avoid acetaminophen as analgesic.

Pregnancy pain:
• - 1st choice: acetaminophen. NSAID restricted to 1st and 2nd trimester.
- Opioids in severe pain and new born monitored for respiratory depression.
• Breast feeding pain:
- 1st choice: acetaminophen and NSAID
- Immediate release opioids could be taken. Codeine (serious side effect lead to death) and Meperidine
(has neurotoxic metabolite) are not recommended.

Others
• Fever, sponging with alcohol is NOT recommended, it’s related to intoxication, coma and hypoglycemia.
ASA is not recommended for children < 18 Years.
• Leflunomide (immunosuppressant) used in RA, but could cause hepatotoxicity.
• Aspirin + viral infection = Reye’s syndrome.
• Aspirin + children = metabolic acidosis
• Tapering corticosteroids (ex. Prednisone): taper over more than 2 months, decrease the dose by 2.5:5
mg every 3-7 days till the dose of 5 mg reached.
• Duloxetine is the only antidepressant (SNRI) approved for chronic low back pain.
• Patient Control Analgesia (PCA): a method that allow pt to administer their own pain killer. It’s
programmed by the prescriber so the machine won’t deliver overdose of medication.
• Bradykinin is pro-inflammatory mediator that cause Vasodilation. ACE inactive Bradykinin; therefore,
ACE Inhibitor will increase bradykinin by inhibiting its degradation.
• Anaphylactic shock cause airway edema is treated with adrenaline or epinephrine.
• Black Box warning on NSAIDs include CVS events (stroke, thrombus, MI) and GI effects.

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• Maximum adult dose of acetaminophen is 4 gm daily.
• Cannabis as medication used not before 25 years old (because it could lead to psychosis at lesser age),
not for lactating and pregnant, don’t drive for 6 hours after taking cannabis.
• Neuropathic pain: due to damage of nerve (touch sensitive)
Nociceptive pain: due to tissue damage, symptoms: aching, throbbing. ex. Osteoarthritis, sport injury.

Kidney/Urine:
BPH
• BPH symptoms: nocturia, dribbling after urination, leakage of urine (overflow incontinence), frequent
urination, weak urine stream.
• Management of Low Urinary Tract Symptoms and BPH:
- α1 adrenergic receptor antagonist: Terazosin, doxazosin, silodosin, tamsulosin and alfuzosin
- 5-Alpha-reductase Inhibitors: Finasteride, dutasteride (inhibit the conversion of testosterone to
dihydrotestosterone; thus, decrease the prostatic volume)
- combination of α1 adrenergic receptor antagonist and 5-Alpha-reductase Inhibitors is effective.
- Phosphodiesterase Inhibitors: Tadalafil the only PDE5 for ED, BPH
* Decongestants (phenylephrine, pseudoephedrine, oxymetazoline) shouldn’t be used with BPH as it has
α adrenergic activity.
* α1 adrenergic receptor antagonist takes from days to weeks to appear.
* Terazosin and Doxazocin are non-selective; thus, the dose should be titrated to avoid syncope.
* Silodosin, alfuzosin, tamsulosin are selective to α receptor in prostate and urethra.
* Tamsulosin is associated with SE: intraoperative floppy iris syndrome (IFIS)
* Finasteride dose is 5 mg daily in BPH and 1 mg daily for Alopecia.
* Finasteride has no Cyp interaction unlike Dutasteride which is affected by Cyp 3A4 inducers and
inhibitors.
* If patient is suffering form Sexual dysfunction, its better to avoid alpha reductase inhibitors.
• Tamsulosin is metabolized by CYP 3A4 and 2D6. While Silodosin and Alfuzosin metabolized by CYP 3A4
• It may take 4 to 6 weeks or longer before you feel the full benefit of terazosin for BPH
• Both sympathomimetics (pseudoephedrine) and anticholinergic (diphenhydramine) could worsen BPH.
* Decongestant is more problematic than antimuscarinic drugs with BPH
• - Anticholinergic agents: oxybutynin, solifenacin to manage overactive bladder.
- antidiuretic drug: Desmopressin to manage nocturia. SE. hyponatremia.

Urinary incontinence:
- Stress incontinence: poor closure of the bladder. Small amount of urine with abdominal pressure
(sneezing) due to relaxed pelvic floor. Not related to psychological stress.
* Treatment: SNRI (Duloxetine), estrogen cream for postmenopausal urogenital atrophy.
- Urge/overactive incontinence: Overactive bladder, increased need to void. Due to diabetes, neurological
disease, infection
* Treatment: Anticholinergic (1st line)(darifenacin, oxybutynin, solifenacin, tolterodine), Mirabegron (B3
adrenergic agonist). Vaginal estrogen cream for postmenopausal urogenital atrophy.
- Overflow incontinence: blockage of urethra. Could be due to BPH

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 * Treatment: Discontinue drugs that aggravate retention (anticholinergic, antidepressant, antihistamine,
antipsychotics, alpha agonists)
- functional incontinence: inability to go to toilets due to mobility constraints.
• Drug should be avoided with UI: Diuretics, anticholinergic (urine retention), opioids (urine retention), α-
agonist (ephedrine: urine retention), antihistamines, Ca channel blocker, B agonist/antagonist.

Kidney stones / Gout / Hyperuricemia:

• Calcium oxalate is the most common kidney stone. Treatment should not include decreasing calcium
intake, because eating Calcium will bind to oxalate in stomach and will leave the body without moving
to kidney. But decreasing phosphate intake, leaving enough free calcium to bind to oxalate in intestine.
• Gout is due to increase of blood uric acid, at it appears in joints and ears and could cause kidney stones.
• Gout complication: gouty arthritis, tophi (deposit of uric acid on joint, cartilage), nephrolithiasis (calculi
in urinary system).
• Uric acid is break down of purines (found in beans, liver, mushroom, mackerel). While urea is
breakdown of protein.
• Hyperuricemia caused by: low-dose Aspirin, Cytotoxic drugs, niacin (nicotinic acid), thiazide diuretics
(could aggravate gout)
• GOUT
- Acute attack:
1- 1st line: NSAID; indomethacin or Naproxen 500mgX2X5 days (both have equally efficacy) NOT
Acetaminophen.
2- Colchicine (1st line if NSAID is contraindicated)
3- Steroids injections
n.b. Don’t use urate lowering drugs in acute attacks, it could exacerbate the symptoms.

* Naproxen and Indomethacin or any NSAID should be avoided with severe renal impairment (Cr
clearance <30)
- Chronic gout.
1- Xanthine oxidase inhibitors:
- Allopurinol (SE: rash) or Febuxostat (superior to allopurinol and recommended for renal patients.)
2- uricosuric agent: (not effective in renal pts), potentiate uric acid excretion.
- probenecid or benzbromarone, sulfinpyrazone, losartan, Fenofibrate .
3- Rasburicase: Only for hyperuricemia due to tumor lysis due to cancer chemotherapy
4- Colchicine. SE: Nausea, vomiting, diarrhea and cramps.
5- Indomethacin/Naproxen
6- Vitamin C
• Probenecid decrease secretion of penicillin.

Urinary Tract Infection:

• Acute uncomplicated UTI (Cystitis)
- 1st line: Sulfamethoxazole + Trimethoprim X 3d or Trimethoprim X 3d (if sulfa allergic) or Nitrofurantoin
X 5 d or Fosfomycin.
- 2nd line: Quinolones (Ciprofloxacin, levofloxacin, norfloxacin) X 3d or cefalexin X 7d
- pregnancy: Cephalexin or amoxicillin + clavulanic acid or nitrofurantoin.
* Nitrofurantoin SE: pulmonary toxicity, hepatotoxicity, neuropathy
* Nitrofurantoin contraindicated near delivery.

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 * SFX/TMP contraindicated in 1st trimester and last 6 weeks.
* Fluoroquinolones and tetracyclines contraindicated in pregnancy.
• Mild/Moderate Pyelonephritis treatment duration (10-14 day)
- 1st line: quinolones x 7-14 d
- 2nd line: Amoxicillin + clavulanic acid or Sulfamethoxazole + trimethoprim
• Severe Pyelonephritis: treatment duration (10-14 day)
- 1st line: IV aminoglycosides + IV ampicillin
- 2nd line: quinolones or 3rd generation cephalosporins + aminoglycosides or carbapenem x 7-14 d.
• Mild/moderate complicated UTI treatment duration (7-10 day)
- 1st line: quinolones or sulfamethoxazole + trimethoprim or nitrofurantoin.
- 2nd line: Amoxicillin + clavulanic acid or cephalexin.
• Severe complicated UTI treatment duration (10-14 day)
- 1st line: IV Aminoglycosides + ampicillin
- 2nd line: Quinolones or 3rd generation cephalosporines + aminoglycosides or carbapenem x 7-10 d
• Acute bacterial prostatitis: treatment duration 4 weeks
- 1st line: IV aminoglycosides + IV cloxacillin + IV ampicillin
- 2nd line: Quinolones or trimethoprim + sulfamethoxazole
• Chronic bacterial prostatitis: treatment duration 4-6 weeks
- 1st line: quinolones
- 2nd line: sulfamethoxazole + trimethoprim
• Pregnancy with UTI, 1st choice nitrofurantoin or the Cephalexin. But After week 36, only cephalexin
used, cause nitrofurantoin cause hemolytic anemia.
• Pseudomonas aeruginosa cause complicated UTI and prostatitis and mainly treated by Norfloxacin.
Meropenem is active against P. aeruginosa
• Uncomplicated UTI mainly occur in females + normal genitourinary tract,
Complicated UTI that happen in both males and females + abnormal tract + fever.
* Nitrofurantoin side effects: urine discoloration, pulmonary and hepatic toxicity. Antacid decrease it’s
absorption. Should be taken with food.

Others
• Acute renal failure = decrease filtration = increase water retention = HTN, swelling, edema
• Pre-renal failure: reduction in blood flow to the kidney.
- Causes: dehydration, blood loss (hemorrhage), sepsis, hypotension, cirrhosis, pancreatitis, ACEI,
NSAIDs.
• Chronic kidney disease could be associated with NSAID, volume depletion, aminoglycosides,
radiographic contrast media.
• Glomerular filtration: inulin clearance is the better than creatinine clearance (cause small amount of
creatinine is reabsorbed by kidney)
• Glomerulonephritis: symptoms: proteinuria, hematuria, Azotemia (high level nitrogen-containing
compounds such as creatinine, urea in blood), HTN, edema.
• Adjusting the dose after renal dysfunction
New dose = (non renal % + renal %* kidney function %) * dose
• Renal failure leads to edema, hypertension,
• In renal impairment, usually we do not change the drug dose unless there is active or toxic metabolite.
In late stage renal failure, its better to avoid drug with renal elimination.

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• Kidney Failure complication: Anemia, Hyperphosphatemia, hyperkalemia, hyperuricemia,
hypocalcemia.
* Kidney Failure means GFR <15, Treatment: Dialysis.
• Chronic Kidney Disease (CKD), leads to hyperphosphatemia that treated with:
- 1st line: Ca carbonate/acetate
- 3rd line: Aluminum. Don’t use more than 4 weeks.
• Hemorrhage is risk of acute kidney failure. HTN and Diabetes are risk of chronic kidney failure.
• If < 50% of drug excreted unchanged and patient has a renal failure: no need to adjust the dose.
if >50% of drug excreted renally and patient with renal dysfunction: dose and interval should be
adjusted.

Sexual and Women disease

Vaginal infection
• Bacterial vaginosis: fishy odor, thin creamy discharge, itching, pH=5:6. DOC: Metronidazole 2 gm once
or 500 mg BID X 7. Clindamycin 300 mg BID X 7 (used in pregnancy)
• Trichomoniasis caused by Trichomonas Vaginalis, frothy, wet discharge. DOC: Metronidazole 2 gm once
or 500 BID X 7
• Candidiasis (Yeast infection): thick, odorless discharge. DOC: Fluconazole 150 mg, Clotrimazole vaginal
tablet, Nystatin vaginal cream.
• Bacterial Vaginosis: need no treatment for sex partner.
• Vulvovaginal candidiasis: no treatment for sex partner; but consider treatment for sex partners in
women.
• Cats could transfer Toxoplasmosis to pregnant women.

Contraception
• OCP SE: thromboembolism, hyperkalemia.
• Taking contraceptive required K+ monitoring to avoid hyperkalaemia.
• Estrogen: Ethinyl Estradiol (EE). Progestin: Norethindrone, Levonorgestrel, Depot Medroxyprogesterone
acetate (DMPA), include Levonorgestrel Intrauterine System (LNG-IUS)
• Contraception emergency (Plan B): A single dose of levonorgestrel 1.5 mg within 1:5 days of intercourse.
It’s efficacy decrease with increased body weight/BMI. In-effective in woman > 80 Kg. Should be taken
before Ovulation; therefore, woman with irregular menstrual cycle we cannot know the ovulation time
and shouldn’t take the emergency pills.
* Hormonal contraception to be taken 24 hours of emergency contraception, backup contraception
needed for the first 7 days of hormonal contraception.
• Plan B contraceptive, 95% effective within 24 hours, effective up to 72 hours and can be taken till 5 days
• Plan B is a high dose of progestin that cause vomiting, so it’s better to add Dimenhydrinate (treat
vomiting)
• Contraception Postpartum:
- progestin-based methods immediately after delivery (Norethindrone).
- levonorgestrel intrauterine system (LNG-IUS), intrauterine devices (IUD) immediately.
- Avoid use of combined oral contraceptives (COCs) in the first 6 weeks postpartum due to an increased
risk of thrombosis.
- Depot medroxyprogesterone acetate (DMPA) can be given 6 weeks postpartum if breastfeeding.

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• Contraception breastfeeding:
- progestin-only methods
- COCs shouldn’t be used 6 weeks postpartum
- DMPA can be used 6 weeks postpartum
- LNG-IUS can be used immediately after delivery.
- In emergency: levonorgestrel 1.5 mg can be used within 24–72 hours of unprotected intercourse.
• Breakthrough bleeding related to progestin-only could be managed by giving estrogen or COCs.
• Breakthrough bleeding related to COC, managed by changing the type of progestin in COC or increasing
the dose of ethinylestradiol.
• Breakthrough bleeding (spotting) associated of OCP:
- it’s transient at first 3 months due to progesterone effect on thinning the endometrial lining cause
bleeding.
- If not transient, at first 10 days increase estrogen. After 10 days increase progesterone. If it bleeds
regardless of days increase estrogen. We do anemia assessment.
• Combined Oral Contraceptives, contraindicated in: breast cancer, pulmonary/venous embolism, Vulvar
heart disease, MI, HTN (SBP>160 or DBP>100), migraine with aura, less than 6 weeks postpartum,
breast feeding, smoker, liver cirrhosis/tumor, DM with microvascular complications.
• Estrogen used for hot flashes, vaginal atrophy, and risk of osteoporosis.
• Estrogen is contraindicated in breast cancer. Chemotherapy of breast cancer will lower estrogen level
with SE. hot flashes. Hot flashes management, SSRI/SNRI (Venlafaxine), BP drug (Clonidine),
Gabapentin.
• Contraceptive Vaginal ring will avoid 1st pass and GIT metabolism; thus, provide uniform dose.
Contraceptive patch will be not effective in pt > 90 Kg
• Venous Thromboembolism (VTE) risk increase with age and COC use. VTE risk increase with higher
Estrogen doses and progesterone and cyproterone.
• Estrogen SE: MI, VTE, stroke, breast and endometrial cancer.
• Oral estrogen could lower libido, unlike vaginal estrogen has no effect on libido.
• Estrogen receptor modulators: Raloxifene, Tamoxifen. (Treat and prophylaxis of postmenopausal
osteoporosis and decrease risk of breast cancer), MOA: it block estrogen effect of breast cancer, but
enhance estrogen effect on bones. SE: Hot flashes, cramps and venous Thromboembolism.
• Hot Flashes management:
- Non-pharmacological: use fans, avoid spicy food, alcohol, caffeine, yoga, weight loss.
- Hormonal Therapy: considered for women < 60 years old or < 10 years past menopause. Estrogen: oral
or transdermal. transdermal for women at high risk of VTE, hypertriglyceridemia, obese with metabolic
syndrome.
- Non hormonal: SSRI/SNRI (venlafaxine), Gabapentin, Clonidine.
• Contraceptive missed dose
- missed 1 pill: take it ASAP then continue with usual dose; that mean 2 pills taken on same day.
- missed 2 pills (first 2 weeks): take 2 pills the day u remember + 2 pills the next day, then continue as
usual. Backup method (condom) needed for 7 days from missed day.
- missed 2 pills (third week): take 1 pill till finishing of active pills, then discard the pack and start new
one. Backup method for 7 days.
- Missing 3 pills (any week): same as above, 1 daily without hormone-free interval + 7 days backup.
* missing 2 pills in first 2 weeks: other guidelines say take only the most recent missed pill and discard
any other missed pill, then continue as usual.

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• CYP 3A4 inducers AED (Carbamazepine, Phenobarbital, St. John’s Wort, Phenytoin, barbiturates,
Rifampicin) decrease serum conc. of Oral contraceptives. A solution could be using progestin depot
injection or use intrauterine device.
• Some antibiotics could interfere with oral contraceptives: Rifampin (for sure), Penicillin, amoxicillin,
tetracycline, nitrofurantoin, SFX/TMP, metronidazole
• There’s a debate about antibiotics with OCP, but Rifampin is the confirmed antibiotic that decrease OCP
OCP + Rifampin = need backup
OCP + other antibiotic = no need for backup
OCP + other antibiotics that cause Nausea or Vomiting = need backup
• Antacids could decrease absorption of OCP
• The best AED choice with COC is: Lamotrigine. Lamotrigine level could drop when used with COC
(combined oral contraceptive); therefore, lamotrigine level should be measured before and after COC
and consider doubling Lamotrigine dose after starting COC.
• Progestin only contraceptive: used in women >35 who smoke, who can’t tolerate estrogen,
breastfeeding women and who experience COC side effects (migraine with neurologic symptoms)

Breast Milk
• Breast milk could be store:
- room temperature for 4 hours. If thawed 2 hours
- refrigerator for 4 days. If thawed 1 day.
- freezer for 6 months and could be 1 year. Never freeze thawed breast milk.
- left over from the baby is valid for only 2 hours.

Sex hormones:
• - FSH: stimulate ovarian follicle (causing egg to grow) and stimulate estrogen production.
- Estrogen: tell the pituitary to stop FSH production and start making LH.
- LH: cause the egg to be released from ovary (ovulation) and stimulate progesterone production.
- Progesterone: secreted after ovulation to maintain uterus ready to receive the embryo. And inhibit
further release of FSH and LH from pituitary. Help implementation of fertilized ovule and stabilize
corpus luteum after ovulation. It increase the body temperature.
* mood swings, hot flashes due to drop in estrogen level.
* placenta secrete Human Chorionic Gonadotropin to make Corpus luteum secrete progesterone
• 1ry hypogonadism: originate from testicles problems.
2ry hypogonadism: testes are normal. Originate from hypothalamus or pituitary gland.
• Anterior pituitary hormones: FSH, LH, TSH, adrenocorticotropic hormone, growth hormone and
prolactin.
• Posterior pituitary hormone: oxytocin, antidiuretic hormone (vasopressin)
• Oxytocin formed in Hypothalamus and stored in Posterior Pituitary gland.
• Androgen deficiency could be:
- 1ry: from testes
-2ry: from anterior pituitary.
- 3ry: from hypothalamus.
• Testosterone changed to estriol by aromatase
Testosterone is changed to DHT by 5 alpha reductase

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• Semen = seminal fluid + sperm. Seminal fluid produced by seminal vesicle and prostate. Sperm
produced from germ cells in testicles. Seminiferous tubules is lined with germ cells where sperm is
produced.
• Estrogen protect the bone from osteoporosis. But cause thrombosis, cancer,

Teratogenic drugs
Phenytoin Lithium Tetracycline Corticosteroids Misoprostol
Topiramate Antifolic acid Thalidomide Coumarin Diethylstilbestrol
(warfarin) (estrogen)
Carbamazepine Retinoids* Anticancer Ethanol ACEI
Valproic acid cocaine Mofetil/Mycophenolate Diazepam Fluconazole
Methimazole Statins Penicillamine SMX/TMP **

*Retinoid: isotretinoin, vitamin A, acitretin.

** Sulfamethoxazole + trimethoprim

• Teratogenic viruses: cytomegalovirus, rubella, herpes simplex, Venezuelan equine encephalitis, and
varicella viruses
• Rubella cause: deafness, eye defect (ex. Cataract), CVS and CNS abnormalities.
• Warfarin associated with abortion, fetal mortality, growth retardation, low birth weight.
• Warfarin is contraindicated in pregnancy
Low dose ASA should be stopped at 36 week
high dose ASA and NSAIDs contraindicate in the 3rd trimester, decrease PGs and lead to closure of
ductus arterioles

Pregnancy
• Preeclampsia: a condition during pregnancy and characterized by high blood pressure, proteinuria,
edema. It could lead to Eclampsia (seizures in mother)
• Pregnancy anemia is mainly due to iron deficiency or folic acid deficiency.
• OTC drugs that should be avoided during pregnancy:
Bismuth subsalicylate (antacid), Aspirin, ibuprofen, Naproxen, decongestant (pseudoephedrine),
guaifenesin.
• Ovulation happen at Day 14, bleeding happen after 14 days of ovulation. Most fertile days are day 12,
13, 14.

ED:
- Sildenafil: onset after 30 min. last for 4 hours. Absorption decrease with fat meals.
- Tadalafil: onset after 30 min. last for 36 hours
- Vardenafil: Onset after 60 min. last for 4 hours. Used for hard-to-treat cases as diabetic pts
* Grape fruit inhibit CYP3A4; thus inhibit the metabolism of PDE-5 inhibitors so increase their blood level
and side effects.
* Sildenafil and Vardenafil absorption affected by fatty meal.
• Sildenafil: SE: headache, low BP, blue vision, flushing, nasal congestion, ringing in ears. CI: nitrate,
hypotension, pre-priapism.

Other
• Sexually transmitted disease: Trichomoniasis, Herpes simplex, Gonorrhea, Chlamydia.
•

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 Lung disease
• Asthma, family history and smoking are risk factors. Pneumococcal vaccine is recommended for
asthmatic pt.
• Leukotrienes (LTs) inhibitors for asthma treatment:
- Zileuton: inhibit lipoxygenase; thus LTs synthesis.
- Montelukast: inhibit LTs receptors.
• Increased oxidative stress in airways cause some diseases, such as Asthma, COPD, Cystic fibrosis. COPD
mainly caused by smoking or fumes or genetic (α-trypsin deficiency)

Asthma: (Reversible airflow obstruction)

- Step 1: Short acting B2 agonist (SABA) (terbutaline, Albuterol, Salbutamol) PRN
- Step 2: Inhaled Corticosteroids (ICS) “budesonide, beclomethasone”
- Step 3: ICS + long acting B2 agonist (LABA) “formoterol, salmeterol” then could increase the dose of
ICS.
- Step 4: add anticholinergic (ipratropium, tiotropium)
(consider adding Leukotrienes receptor antagonist (Montelukast) or theophylline or oral corticosteroids
or mast cell stabilizer (nedocromil)
• In Emergency
- Oxygenation: maintain oxygen saturation 93% - 95%
- SABA, every 20 minutes for up to 4 hours.
- Ipratropium
- oral corticosteroids.
• B-agonist side effects: tremors, restlessness, tachycardia, hypokalemia.
• Montelukast not for acute attacks.
• Prevention of Exercise induced asthma: use SABA (1st choice) or LABA).

COPD: (progressive and partially reversible/irreversible airway obstruction)

- Step 1: short acting B2 agonist or short acting muscarinic antagonist (ipratropium)
- Step 2: SABA + long acting muscarinic antagonist (LAMA)”Tiotropium”
- Step 3: LABA + LAMA combination
- Step 4:LABA + ICS + LAMA
• Emphysema (destruction of lungs) a type of COPD. Emphysema: shortness of breath due to damage of
alveoli. Treatment: bronchodilator, ICS
• SABA and LABA contraindicated with diabetic pts cause it could cause hyperglycemia.
• Epinephrine and isoproterenol are not recommended for asthma due to non B2 selectivity and excessive
cardiac stimulation.
• If COPD flares up (runny nose, increase mucus, more yellow/green mucus, fever) contact the doctor.
• COPD patients are recommended to have Influenza vaccine (every year) and Pneumococcal vaccine
(every 5 years).
• If purulent sputum, use antibiotics: 1st choice: Amoxicillin, amoxicillin/clavulanic acid, Doxycycline,
SFX/TMP,
also u can use: levofloxacin, Clarithromycin, Cefuroxime.
• Empirical treatment in pneumonia is Levofloxacin.
• SABA always PRN.

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• Always SABA is used first to control symptoms, SAMA is added to reduce the hospitalization time.
Moreover, SAMA could be used instead of salbutamol in case of high risk of tremors.
• Salbutamol dose 100 mcg PRN, Tiotropium 18 mcg OD.
• Corticosteroids inhalers SE: Headache, oral thrush (stomatitis), dysphonia (hoarseness and voice change)
• Alpha Antitrypsin (AAT): produced in liver and protect lungs from neutrophil elastase (neutrophil
enzyme that break harmful bacteria in lungs). Liver cirrhosis lead to AAT deficiency; thus, elastase could
damage lung cells (COPD)
• Acute exacerbation of COPD: SABA and Ipratropium + short course of systemic corticosteroids.
• Symptoms: dyspnea, cough, sputum. Spirometer used to diagnose COPD, FEV1 <80% means mild COPD
• COPD and Pneumonia give azithromycin.

Croup
• Airway obstruction in children mainly due to Parainfluenza virus, influenza A and B.
- main goal: relieve symptoms, minimize anxiety, decrease intubation and hospitalization.
- Management: keep calm, warm and AVOID mist therapy.
- Treatment: Dexamethasone, oral – consider budesonide inhaler if can’t take PO (vomiting).
- Obstructive symptoms resolve on it’s own in 2-6 days.
* severe cases: add nebulized L-epinephrine.

Hyperventilation
• Result in decrease Co2 concentration and increase PH of blood (respiratory alkalosis), then it will
progress to metabolic acidosis.
Hyperventilation is due to high Co2 and low PH

Anti-tussive:
• Dextromethorphan can be used for children >6 years.
Codeine, >18 years (Health Canada), >18 years (FDA)
• Dextromethorphan: cough suppressant. Guaifenesin: Expectorant.
•
• Peak Flow meter: measure the maximum speed to blow air out.
Spirometer: measure Forced Expiratory Volume (FEV) and Forced Vital Capacity (FVC), most important
for lung function.

Inhalers
• Inhalers types:
1- MDI: need priming
2- Diskus: spacer is recommended.
3- Respimat: need priming
4- Turbuhaler: need priming, doesn’t need spacer.
• Dry Powder Inhaler (DPI) has lactose as a filler to carry fine particles.
• Spacer/aero-chamber with inhaler used to make it easier for medication to reach the lungs, and also
mean less medication gets deposited in the mouth and throat, where it could lead to infection and
irritation. Hearing a whistle means fast breathing in; therefore slowly breath in. You should either
breath slowly for 5 seconds through the aero-chamber then hold for 10 seconds after. Or you could
breath 3 times in and out. Only 1 puff per time. Rinse the spacer with water and soap only, never use
alcohol or boiling water.
* Turbuhaler: is a type of inhaler that don’t need spacer. Unlike Diskus or Breezhaler (Spacer could be

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 used with evohaler). With Turbuhaler, breath deeply and quickly. Unlike with spacer it should be slowly
* with metered dose inhaler, we use spacer.
* Dry powder inhaler include: turbuhaler and Diskus: need quick inhaling and don’t need spacer.
* Metered Dose Inhaler (MDI)/pressurized inhaler: need spacer and require slow inhaling.

Allergic Rhinitis
• Symptoms: congestion, itching
• Avoid dust, Close doors and windows, Air conditioning (reduce pollen exposure), remove pets from
home, use allergen-proof casing for mattress and pillows.
• Treatment:
- Nasal saline
- Nasal steroids: Beclomethasone, fluticasone.
- Antihistaminic: loratadine, cetirizine, Fexofenadine
- Decongestant: Pseudoephedrine.
* pregnant use only Beclomethasone.
• Prolonged use of topical decongestants (phenylephrine, xylometazoline) cause Rhinitis Medicamentosa
(rebound congestion).
•

Others
• Dysphonia: (hoarseness/breathy voice) could be cause by inhaled corticosteroids.
• Alveoli produce surfactant.

Bone
Osteoporosis treatment:
- Ca 1200 mg/D and vitamin D 800:2000 IU/D
- Bisphosphonate (Alendronate), MOA: inhibit resorption of bone by osteoclast. Taken on empty
stomach for better absorption, consider 1-3 years drug holiday. Administration shouldn’t be followed by
lying down as it could cause esophagitis. Alendronate and Risedronate (1st line option) are more
effective than Etidronate (only if pt intolerant to 1st line)
- RANK ligand inhibitor: Denosumab. (MOA: inhibit osteoclast formation; thus, bone resorption)
- Selective Estrogen Receptor Modulator: Raloxifen,
- Teriparatide: recombinant parathyroid hormone, used for treatment of osteoporosis. MOA: stimulate
growth of new bones (activate osteoblast).
- Calcitriol: active vitamin D, increase intestinal absorption of Ca+.
* Bisphosphonate: inhibit bone thinning (Ca release form bone) so used for osteoporosis, paget’s
disease, bone cancer and hypercalcemia. Ex. Pamidronate, alendronate
* Bisphosphonate dose could be daily, weekly, monthly, yearly.
Weight bearing exercises (ex. Walking), smoking cessation, Ca supplementation, Vit D supplementation
are recommended. Swimming (non-weight bearing exercise) is NOT recommended. (swimming is the
worst exercise of osteoporosis patients)
• Bisphosphonate ex. Alendronate, Actonel (Risedronate). should be taken at early morning, don’t eat,
drink or lying down for 30 minutes after taking the medication. Should be taken with plenty of water
(not mineral water as it could decrease its absorption)

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• Osteoporosis risk factors: age, hyperparathyroidism, hypogonadism, glucocorticoids,
• Bisphosphonate and Denosumab inhibit osteoclast (bond resorption). While, Teriparatide activate
osteoblast (bone formation).
• Parathyroid: hormone increase blood Ca by moving Ca from bone to blood. Calcitonin: hormone
decrease blood Ca by inhibiting osteoclast (bone resorption)
* Calcitonin approved for treatment of hypercalcemia and Paget’s disease.
• Patient at risk of osteoporosis: use Vitamin D. Ca could be supplemented in food.
• Bisphosphonate could be used for hypercalcemia of malignancy.

Osteoarthritis:
• Osteoarthritis: Acetaminophen is 1st choice.
• Osteoarthritis risk factor: age, obesity, weakness, joint injury and overuse, gender (female).
• Rheumatoid Arthritis: morning stiffness > 30 min + systemic symptoms (fatigue, anorexia)
Osteoarthritis: morning stiffness < 30 min
•

Rheumatoid arthritis
- DOC Methotrexate (MTX) 7.5 to 25 mg per week for at least 3 months, use folic acid 5 mg/week to
counteract GI SE and Liver dysfunction
- If MTX contraindicated: Sulfasalazine, leflunomide (SE: diarrhea, severe liver injury), antimalarial
(hydroxychloroquine)
- Combination: MTX + Sulfasalazine + Hydroxychloroquine, if MTX alone has weak response
- Biologics: TNF-α inhibitor: Infliximab, Adalimumab
* NSAID used to relief pain. Corticosteroids reduce inflammation but can’t be used routinely.
* Folic acid = Folinic acid = leucovorin.

Others:
• Using corticosteroids injection in sports injury (tendinitis: tennis elbow) restricted to 3 times per year.
• Vit D deficiency: Treatment, Vit D 5000 u/D or 50,000 unit/week for 8 weeks
•

Dermatology
Scabies/Lice
- treatment with DOC: permethrin 5%, except with head lice permethrin 1%. Dimeticone can be used for
head lice and is not neurotoxic drug, can’t be used for children <2 years.
* Permethrin is 1st line in Canada, used in pregnancy and breastfeeding
* Permethrin should be repeated after 7:9 days.
* Treatment for the whole body not only infection body parts.
* For scabies and pinworms all household members should be treated, even if they don’t have any
symptoms.
* For lice, only affected persons should be treated.
* other treatments: benzoyl alcohol, lindane (neurotoxic)
*

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Acne:
- Mild (only comedone): Topical retinoid: tretinoin, adapalene. SE: photosensitivity.
- Moderate (Mild inflammation with/out comedone) : topical retinoid + benzoyl peroxide ± topical
antibiotic (Erythromycin, clindamycin)
- Sever case: topical therapy + oral antibiotic (Doxycycline, tetracycline, erythromycin, trimethoprim) ±
oral isotretinoin (SE: photosensitivity, myalgia, dry mucous membrane, mucositis, dry eyes, keratitis,
teratogenic) ± antiandrogenic therapy for females (oral contraceptive pills or Spironolactone)
* in pregnancy: Consider benzoyl peroxide, erythromycin. Avoid: oral contraceptives, retinoids,
Tetracycline, doxycycline, trimethoprim
* Wait 8 weeks before considering second course of treatment.
* isotretinoin: contraindicated with tetracyclines (Tetracycline, Doxycycline, Minocycline) it cause
intracranial HTN (pseudotumor cerebri) (allow 7 days washout). Monthly pregnancy test is required.
Use 2 reliable contraception methods 1 month before isotretinoin and 1 month after isotretinoin.
* Benzyl peroxide: has antibacterial activity, its combination with retinoids or antibiotics to decrease
resistance to antibiotics and decrease the antibiotics dose. It’s also used in bleaching clothes. it should
be alcohol free, start with concentration 2.5% (it’s less irritating)
* Tretinoin: Cis form in Oral products; while Trans form in Topical products.

Rosacea:
- flushing on face associate with telangiectasia (dilated blood vessels), associated with eye disorder
(irritation, conjunctivitis).
• Acne: Comedones (blackheads and white heads), no telangiectasia
Rosacea: No Comedones. Telangiectasia and erythema are major features.
- Topical: metronidazole, Ivermectin, azelaic acid
Ocular treatment: Eye ointment fusidic acid + oral Doxycycline
- Oral: isotretinoin, erythromycin, doxycycline
*Avoid steroids, could aggravate the condition.
* Risk factors (SHESHAA): S- spicy food, H- heat, E- emotional stress, S- sunlight, H- hot beverage, A-
alcohol, A- application of corticosteroids

Diaper rash/dermatitis, treatment sequence:

1- zinc oxide 15:20%
2- zinc oxide 25:40%
3- add antifungal agents: Nystatin, clotrimazole, miconazole
4- topical Hydrocortisone 0.5:1 % TID up to 1 week.
* Diaper dermatitis must be assessed by caregiver if, rash extended outside diaper area, blisters or pus,
persist longer than 7 days, UTI, penile infection, systemic symptoms, deep ulceration

Psoriasis treatment:
- topical corticosteroids alone or with tar, anthralin, salicylic acid, vit D, retinoid (Tazarotene), calcineurin
inhibitors (tacrolimus, pimecrolimus)
- Phototherapy (ultraviolet B) with/without Tar
- Systemic therapy is used in moderate to severe cases and if topical and phototherapy are ineffective.
Ex. Retinoid (Acitretin), methotrexate, cyclosporine.
- Biologic response modifiers: infliximab, Etanercept, ustekinumab, adalimumab, secukinumab. SE:
increase risk of infection.

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• Tacrolimus is immunosuppressive agent that inhibit calcineurin, that inhibit IL-2; thus, inhibit further T-
cell activation and production of inflammatory cytokines.
• Psoriasis plaque (patches) appear in scalp, knees, hands, feet, nails, elbows, lower back.
• Risk factors (ASS TOP GIC): A- alcohol, S – smoking, S- stress, T- trauma, O- obesity, P- pregnancy, G-
genetics, I- infection, C - cold weather
• Low-dose methotrexate used for RA and psoriasis. SE: mucositis.
* mouth ulcer caused by Methotrexate could be prevented by administration of folic acid.
Management mouth ulcers: rinse by salt-water, mouthwash contain lidocaine.

Dandruff and scalp Seborrheic Dermatitis: follow the following sequence

- antifungal shampoo (ketoconazole + selenium sulfide + Zine pyrithione) 2-4 times/week
- add keratolytic agent (sulfur ± salicylic acid) ± coal tar ± hydrocortisone
- alternative antifungal (ciclopirox), Calcineurin inhibitors, stronger topical corticosteroids.
* selenium sulfide: also is a bleaching agent.
• Seborrheic dermatitis could mimic psoriasis; however, in psoriasis: scales are more adherent and thick,
present on knees, elbow, sacral area, nail and scalp. Psoriasis associate with other risk conditions such
as arthritis, depression, CVS diseases)
• Spironolactone (antiandrogenic) can be used for acne, alopecia, seborrheic dermatitis or dandruff.

Non-Scalp seborrheic dermatitis:

- Ketoconazole + topical corticosteroids (hydrocortisone)
- calcineurin inhibitors (tacrolimus, Pimecrolimus)
- then use different antifungal and potent corticosteroid.
* Seborrhea: red, itchy and white scales in head, nose, behind the ears, eyebrows, eyelids.

Atopic dermatitis (Eczema)

- Symptoms: lesions in (infants: face and extensors), (children: flexor), (adults: face and hand)
- Treatment: 1st line: moisturizer (petroleum), topical corticosteroids. Calcineurin inhibitors.

Alopecia treatment:
- α reductase inhibitor: Finasteride 1 mg daily. SE: Erectile dysfunction, decrease libido, suicidal thoughts.
- Minoxidil 2%: 2 ml BID. Minoxidil 5%, 1 gm foam BID for men, 1 gm foam QD for women. MOA: stimulate
hair follicle for hair growth. It’s poorly absorbed by skin.
- antifungal shampoo: Ketoconazole.

• Finasteride in BPH 5 mg daily, in alopecia 1 mg daily.

Hirsutism (excessive Hair growth in women)

- 1st line is COC
- If not responding to COC, u can add antiandrogen: spironolactone, cyproterone, flutamide.
- 2nd line is Finasteride.

Stevens-Johnson syndrome
• A skin disease cause rash, blisters. Triggered by medications or infections. Medications (SASPAN) such
as Sulfonamides (SMX, thiazides, sulfonylurea), Allopurinol, Penicillin, Antiepileptics, NSAIDS. Infections:
HIV, HSV, Hepatitis.

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• Steven Johnson syndrome and Toxic Epidermal Necrolysis mainly caused by drugs: sulfa drugs, AED,
piroxicam, Allopurinol.

Others:
• Antihistamine:
- Sedating: Chlorpheniramine, Diphenhydramine.
- Less sedating: Cetirizine, Loratadine, Fexofenadine.
• Diphenhydramine has anticholinergic activity.
• Decongestant: Xylometazoline, Pseudoephedrine. Has sympathomimetic effect so increase BP
• Pinworm and scabies infection need all the household to be treated
• If Skin allergy is severe and bothersome during day and night, refer to Dermatologist.
• Cold sores caused by herpes simplex virus (HSV). HSV-1 transmitted via oral saliva and cause cold sores.
HSV-2 transmitted via genital secretions. Preventive measures are: avoid UV exposure by using SPF 30
sunscreen, avoid stress (eat well, exercise, relaxation), use antiviral drugs before dental procedures.
• Petechiae: Dark patches on skin due to bleeding due to infection, medication (phenytoin, penicillin).

Cancer
• Chemotherapy induce secretion of serotonin that stimulate 5-HT3 receptor in GIT leads to nausea and
vomiting. Ondansetron is selective 5-HT3 antagonist.
• Cancer treatment that lower down estrogen could lead to osteoporosis:
- Aromatase inhibitor (ex. Anastrozole, Letrozole, Exemestane)
SE: arthritis, hot flushes, myalgia, alopecia,
*Tamoxifen reduce bone density with small amount
• Tamoxifen Structure:

- tamoxifen is metabolized by CYP 2D6, 3A4 into active metabolites endoxifen and afimoxifen.
• Estrogen receptor modulators: Raloxifene, Tamoxifen. (Treat postmenopausal osteoporosis and
decrease risk of breast cancer), MOA: it block estrogen effect of breast cancer, but enhance estrogen
effect on bones.
• Tamoxifen is a prodrug that need to be activated by CYP 2D6 and CYP 3A4. SSRI (especially paroxetine)
are CYP 2D6 inhibitors; thus, should be avoided with Tamoxifen.
• Methotrexate: MOA: is antimetabolite (antifolate), dihydrofolate reductase inhibitor, inhibit the
metabolism of folate to tetrahydrofolate that required for DNA synthesis.
• Capecitabine is metabolized to 5-FluoroUracil that inhibit Thymidylate synthase that needed for DNA
synthesis.
• Fluorouracil: MOA: inhibit thymidylate synthase so inhibit synthesis of pyrimidine thymidine that disrupt
DNA synthesis. Metabolized primarily in liver by Dihydropyrimidine Dehydrogenase (DPD)

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• Cisplatin MOA: bind to DNA, inhibit it’s repair and eventually lead to cell death. Cisplatin is more
emetogenic than cyclophosphamide. SE: Nephrotoxicity (hyperuricemia, electrolyte abnormalities),
ototoxicity (hearing loss), neuropathy.
• Imatinib: used for leukemia. MOA: tyrosine kinase inhibitor; thus, inhibit proliferation of tumor cells.
• Colorectal cancer screening: colonoscopy, sigmoidoscopy, CT scan, Fecal Occult Blood Test (FOBT).
• Cell cycles phase inhibition (anticancer)
- G1 phase: Prednisone, L-Asparaginase.
- S Phase: 5-FU, Cytarabine, 6-Thioguanine.
- G2 phase: Bleomycin, Etoposide
- M Phase: vincristine, vinblastine.
• DOC in:
- Breast cancer: Breast surgery, Tamoxifen
- Cervical Cancer: Radiation + Cisplatin
- Multiple myeloma: melphalan + prednisone
- Acute myeloid leukemia: Cytarabine + daunorubicin/idarubicin
- Skin Cancer: 5-FU
- Prostate cancer: Docetaxel, Cabazitaxel, mitoxantrone, estramustine, doxorubin.
• Drugs cause Alopecia, vincristine, doxorubicin, daunorubicin, cyclophosphamide, paclitaxel. Hair
regrow after 1-2 months of stopping chemotherapy.
• Tumor Lysis Syndrome: metabolic abnormalities occur during cancer treatment. Tumor cells are killed
and releasing its content. Characterized by Hyperkalemia, Hyperuricemia, Hyperphosphatemia,
Azotemia (high nitrogen compounds), Hypocalcemia. Could result in nausea, vomiting, acute renal
failure, seizure, arrhythmia.
- Rasburicase or Allopurinol used to manage hyperuricemia.
• Cervical Cancer risk factors: smoking, HIV, oral contraceptive, high number of sexual partners, younger
age at first sexual intercourse, history of STD.

Chemotherapy side effects:

• Nausea and vomiting: during infusion and within days
• Neutropenia: within days to weeks
• Nephrotoxicity: days to weeks
• Thrombocytopenia: weeks to months.
• HTN: weeks to months
• Alopecia: weeks to months
• Neurotoxicity: weeks to months
• Heart failure: months to years
• Gonadal toxicity: months to years

Chemotherapy Emetogenicity:
• Highest emetogenic: Cisplatin, Cyclophosphamide (with high concentration)
• Lowest emetogenic: Bleomycin, vincristine, vinblastine
• Tamoxifen is the least emetogenic.

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 Auto Immune disease/ Immunology
• Auto immune disease: RA, inflammatory bowel syndrome (crohn’s disease, ulcerative colitis), lupus,
multiple sclerosis)

Rheumatoid arthritis
• - DOC Methotrexate (MTX) 7.5 to 25 mg per week for at least 3 months, use folic acid 5 mg/week to
counteract GI SE and Liver dysfunction
- If MTX contraindicated: Sulfasalazine, leflunomide (SE: diarrhea, severe liver injury), antimalarial
(hydroxychloroquine)
- Combination: MTX + Sulfasalazine + Hydroxychloroquine, if MTX alone has weak response
- Biologics: TNF-α inhibitor: Infliximab, Adalimumab
* NSAID used to relief pain. Corticosteroids reduce inflammation but can’t be used routinely.

Psoriasis treatment:
- topical corticosteroids alone or with tar, anthralin, salicylic acid, vit D, retinoid (Tazarotene), calcineurin
inhibitors (tacrolimus, pimecrolimus)
- Phototherapy (ultraviolet B) with/without Tar
- Systemic therapy is used in moderate to severe cases and if topical and phototherapy are ineffective.
Ex. Retinoid (Acitretin), methotrexate, cyclosporine.
- Biologic response modifiers: infliximab, ustekinumab, adalimumab, secukinumab. SE: increase risk of
infection.
• Tacrolimus is immunosuppressive agent that inhibit calcineurin, that inhibit IL-2; thus, inhibit further T-
cell activation and production of inflammatory cytokines.
• Psoriasis plaque (patches) appear in scalp, knees, hands, feet, nails, elbows, lower back.
• Risk factors (ASS TOP GIC): A- alcohol, S – smoking, S- stress, T- trauma, O- obesity, P- pregnancy, G-
genetics, I- infection, C - cold weather
• Low-dose methotrexate used for RA and psoriasis. SE: mucositis.
* mouth ulcer caused by Methotrexate could be prevented by administration of folic acid.
Management mouth ulcers: rinse by salt-water, mouthwash contain lidocaine.

Multiple Sclerosis:
• The immune system attack and destruct CNS myelin that lead to neural damage.

SLE:
• Drug induced Lupus: HIPPP MCQ”? (Hydralazine (vasodilator), INH (isoniazid), Phenytoin, procainamide,
penicillamine, methyldopa, chlorpromazine and quinidine. Resolve after discontinuation.
• Symptoms: rash, alopecia, synovitis, cytopenia (leukopenia, thrombocytopenia, lymphopenia).
• Should avoid sun exposure: use sun screen SPF >30. Use inactivated vaccine (influenza and
pneumococcal)
• Avoid risk of Osteoporosis by taking Ca 1200 mg/day + Vit D 1000 u/day
• should avoid: sulfamethoxazole/trimethoprim, oral contraceptives (except progesterone only).
• Treatment: 1st line antimalarial: Antimalarials (Hydroxychloroquine), SE: eye toxicity. and low-dose
glucocorticoids.
* Immunosuppressants: Mycophenolate, MTX, Azathioprine, Calcineurin inhibitors could be used.
* B cells inhibitors: Rituximab, Belimumab
* For rash: topical corticosteroids and calcineurin inhibitors (tacrolimus)

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Celiac disease
• Immune disease, people can’t eat gluten foods because gluten will provoke the immune system to
damage small intestine. Gluten is present in wheat, rye and barley.

Others
• MHC I: expressed on all nucleated cells. Present antigen to CD8 (cytotoxic) T cells. Used for Infected
cells and tumor cells mainly.
• MHC II: expressed on APC (dendritic cells, B cells, macrophages). Present antigen to CD4 T cells. Used
for bacterial antigens (which endocytosed then presented)
• Passive immunity: transfer of antibody form one person to another. Could be natural: antibody transfer
from placenta to fetus, from breast milk to neonate. Vaccines contain antibodies or lymphocytes made
by animal or human confers passive immunity.
• Natural Killer cells (NK): Part of innate immune system. Recognize cells that don’t express MHC-I and
destroy it. Destroy infected cells and tumor cells.
• Neutrophil is the most abundant cell and 1st cell reach site of infection and inflammation.
•

Vaccination
• Live Attenuated Vaccine is more effective than Inactivated Vaccine, but should be avoided in specific
groups ( < 2yrs , >59 yrs, pregnant, immunodeficiency, children using ASA, asthma)

•
• Live attenuated vaccine ex. MMR (Measles, Mumps, Rubella), Polio, chicken pox, shingles, yellow fever.
• Inactivated Vaccine ex. Hepatitis, Plague, Cholera, Typhoid, Rabies, Meningitis, influenza.
• Toxoid: Tetanus and Diphtheria.
• MMR Vaccine is given at age of 1 year then booster at age of 5:6 years.
• Vaccines should be placed in middle shelves of refrigerator. When dispensing vaccine, it should be
labelled with “refrigerate and don’t freeze”

Flu vaccine
• Flu immunization season is October – mid November. Flu season is October to April. High risk pt, >65,
COPD, Asthma, Diabetic, children >6 months <5 years, Healthcare workers and pregnancy.
- Contraindication to Flu Vaccine: children <6 months, egg allergy (can be given in dr. supervision, no
skin test needed), with flu symptoms.
• Flu vaccines are killed vaccines except Flu intranasal mist.
* Influenza vaccine either:
- Live attenuated: intranasally administration. From 2 years.
- Inactivated: IM administration. From 6 months.

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• Live Attenuated Influenza Vaccine (LAIV): not for children < 2 years and adults >59 years, used only if
Inactivated vaccine is not available. Safe in egg-allergic pt.
* Contraindicated with pregnancy and pt taking immunosuppressive or patient <18 old taking ASA or
patient suffer form sever asthma or wheezing in the last 7 days.
• Influenza and pneumococcal vaccine recommended for pt > 60 Y old
• Influenza vaccine is highly recommended for high risk group: children (6 months – 5 years), pregnant,
seniors >65, residents of nursing home (long-term care facility), adult/children with anemia, cancer,
respiratory disorder, renal disease, obese, household contacts (family member of high risk groups),
those providing service to high risk groups.

Chicken pox and Shingles

• Chicken pox vaccine (varicella-zoster):
- for children < 13 y old and for people >13 years who didn’t get chickenpox or chickenpox vaccine
before.
- Get the vaccine within 3-5 days of being exposed to someone with chickenpox.
• Shingles vaccine (Herpes Zoster):
- recommended for adults > 50 Y old.
- Whether or not the pt had herpes zoster before. (but should be at least 1 year after shingles, not given
for patients who currently have shingles)
- No need to screen history of Varicella (chicken pox) or conduct laboratory test for serological evidence
of prior varicella infection.

Others
• Pharmacist MUST document post-immunization adverse effect in patient record.

Pharmacy management/ Law/ Ethics

• Dealing with transgender: use the new name, ask about the preferred pronoun.
• Academic Detailing: giving academic information to improve the prescription practice.
• Advancing prescription: like using pre-printed prescription or computerize the process.
• Barrier of collaboration: lack of compensation and time, need for multiple pharmacist/physicians
collaboration.
• Podiatrist: foot specialist. Chiropractor: assessment of spinal problems.
• Drs shouldn’t prescribe additive drugs to themselves or their families. Prescribing to family is unethical
but not illegal. Pharmacists can refuse prescription if they think abuse is coming.
• Clinical Trial Phases:
- Phase 0 : pharmacokinetics; half-life and BAV
- Phase I: Safety; 20:100 healthy volunteer
- Phase II: efficacy and SEs; 100:300 patients.
- Phase III: efficacy, effectiveness and safety. 300:3000 patients
- Phase IV: post marketing surveillance.
* you submit new drug submission after Clinical trials. Notice of Compliance (NOC) issued, by Health
Canada under Food & Drug Act and Regulation, following satisfactory review of submission. After NOC,
the product get Drug Identification Number (DIN)

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• In hospital, there is “Stop Policy” stop the medication after 5-7 days unless doctor order to continue, ex.
Antibiotic, narcotics, anti-diarrhea, ketorolac. “Step Down” from IV to oral (cost effective and more
available)
• If the drug in not available in hospital formulary, he fill non-formulary drug request form. Then the
pharmacist check substitutions and try to give the option to physician.
• Delegation should be clinically appropriate and for patient’s interest. Both delegator and delegate are
responsible if anything gone wrong.
• Adverse Drug Reaction (ADR) = side effects
Adverse Drug Events = ADR + medication errors (prescribing and dispensing errors, patient adherence)

Pharmacist/ Technician/ Assistant

• 3 tasks, only pharmacist is responsible for:
- check appropriateness: drug-drug interaction, drugs are compatible with the indication.
- counselling.
- anything related to narcotics: verbal order, buying.
• Regulated technician: can’t do counselling, verbal narcotic. Can: recommend sugar free cough syrup,
OTC device demonstration, Verbal Rx order from prescriber, package and labeling. can take verbal order
for drugs except narcotics. They could verify the prescription (the name of the pt, prescription validity
but not the therapeutic appropriateness), they check any prescription including narcotics technically not
clinically. Final check to check that the dispensed drug same as in the Rx could be done by technician.
technician can do all the compounding steps. The pharmacist can check the final product.
• Assistant: can only: Data entry, package and labeling, monitor storage condition. Can only deliver the
prescription. He can’t weigh, mix, calculate, making label.
• Accounting manager: responsible for capital equity.
• Pharmacy director: responsible for all activity and departments but have to collaborate with all
departments managers to provide good service.
• Public health (Federal) insurance cover: cash transfer to cover medically necessary service (hospitals),
direct fund of: natives (inuits), inmates (prisoners), RCMP (royal police), refugees (sponsored by the
country), veterans (military).
• Federal government responsible for: health protection and regulation, pharmaceutical regulation,
consumer safety, disease surveillance and protection, support health promotion and health research,
health related tax measures.
• Federal government don’t cover pharmaceutical drugs and cosmetic surgeries.
• Health Canada is primarily funded by Government.
• Service is provided by provinces and territories except in remote areas by Health Canada.
• Provinces cover seniors above 65 years old and who needs social welfare.
• Province provide the medical service for hospitalized patients that paid by Federal.

References:
• 1ry literature: original materials on which other research is based. Pros: most recent research, excellent
for continuing education. Cons: could be not accurate. Ex.(clinical trials published in medical journals)
• 2ry literature: They are interpretations and evaluations of primary sources. Pros: easy and quick way for
screening 1ry literature. Cons: each service provider may provide specific list of journals (Medline,
PubMed, research summaries). Review is 2ry while Research/report are 1ry.
• 3ry sources: text books and compendia. Pros: easy and one textbook contain comprehensive topics.
Cons: no recent info. Ex. Martindale, Compendium of pharmaceutical Specialist (CPS)

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• References

Compendium of Pharmaceutical Specialists (CPS)
Compendium of Therapeutic choices (CTC)
RxTx: electronic version of CTC
Medline (PubMed)
Martindale
Compendium of therapeutic minor aliments
(CTMA)
US Pharmacopeia DI-Vol 1 (USP)
USPDI Vol 2
Cochrane data base
Health Canada Drug Product Database (DPD)
Health care professional use
Professional product Monograph
American Hospital Formulary Society (AHFS)
Remington (science and practice of pharmacy)
Merck manuals (several books)
Merck Index
Merck manual of diagnosis and therapy
Clin-Alert
Pediatric Dosage Handbook/ Sick Kids Guide
Drugs in Canada (on-label uses) Monographs, SE,
clinical uses, CI, Doses, storage, package inserts
Treatment options (1st line treatment)
Off label use
Foreign drugs
Selfcare and OTC
FDA approved drugs in USA
Advice for patients.
Evidence based medicine database
New drugs approved
Public use/ patient information
Consumer product monograph
Drug information, Drug-lab test interaction,
pharmacokinetics
Cover pharmacy practice (Compounding), ethics,
industrial pharmacy.
Done by Merck company.
Chemical properties, Formulas for compounding
Pathophysiology and diagnosis
Adverse drug reaction reported, Drug-drug
interaction.
Therapy info. In pediatric population

* CPS DOESN’T contain all drugs in Canada. Full list of Canadian drugs are found in DPD.

• Checking the therapeutic choice for any disease follow the sequence:
1- guidelines ex. (cancer association, hypertension guidelines)
2- CTC or RxTx (electronic version of CTC)
• Micromedex: identify tablets with its shape and markings.
• Package insert has a lot of info (such as side effects, kinetics), but don’t have drug-drug interaction.
• Inventory turnover measures the efficiency of your business overall, with a higher turnover generally
meaning greater efficiency. Turnover should be from 4 to 6. Turnover 4 = in a year, 4 times inventory
bought and sold. Turnover = cost of good sold / ((opening stock + closing stock)/2)
• Trans-theoretical model of change: precontemplation-Contemplation-Preparation-action-Maintenance-
termination.
• Quitting stages: (5 stages) precontemplation-Contemplation (receive information about quitting and
identifying the barriers for quitting)-Preparation (set date to quit)-action-Maintenance
• Surrogate endpoint = is a measure of the effect of a specific treatment. Ex. Blood glucose level, tumor
size, biomarker level, cholesterol level, IOP, Hb1Ac
• The highest prescribed drugs by units = antidepressants. The highest refill = CVS.
• Biopharmaceutical manufacturing order: upstream, downstream then production.
Upstream: cell processing (cell culture, harvesting), downstream: filtration, centrifugation.
it could be Upstream (feedback), then production, then downstream (sales)

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Errors
• Medication incidents (errors) reported to: (through a CMIRPS program)
- Institute of Safe Medication Practice (ISMP)
- Canadian Institute of Health Information (CIHI)
• MedEffect: a platform for patients and health professionals to report or obtain drug’s side effects. It’s
responsible for advisories, warning and recalls. While Medical incidents (errors) reported to Canada
Medication Incident Reporting and Prevention System (CMIRPS) (it’s a collaborative program between
ISMP, Health Canada and CIHI)
• Canada Vigilance Program (part of MedEffect): Canada post marketing surveillance program that collect
and assess reports of adverse reaction.
• Withdrawal of drug initiated by Canada Vigilance and executed by Manufacturer.
• ISMP (Institute of Safe Medication Practice): developed and recommend to use Best Possible Medication
History (BPMH)
• ISMP work for error prevention by fixing the system rather than blaming individuals.
• Medication incident in community pharmacy reported to ISMP.
• Medication incident in hospital pharmacy reported to Canadian Institute of Health Information (CIHI)
• Error in community pharmacy:
- ask the pt if he took the medication. If yes, apologize then ask him to return the medication back to
the pharmacy and call the doctor. If no, ask the pt to return the medication back to exchange. Last step
is to report the error.
• Error in hospital: first contact patient care team (nurse or physician)
• Dispensing error:
- Inform patient, inform manager and inform doctor (if pt have taken the medication).
- Document the mistake and discuss it with all staff
• If anyone in the pharmacy, misconduct or incompetent professionally, you should report directly to the
province; not the pharmacy manager nor the owner.
• TALLman letter used to avoid sound alike name drugs to avoid medication errors.
• To avoid any pills count error: double count all narcotics and BDZ and document on Rx hard-copy.
• If you have noticed an error in another pharmacy, you notify the pharmacy (pharmacy manager of the
second pharmacy) and they should report the incident; cause could gather great information about
factor lead to the error.

CADTH, CDR, MAC, P&T:

• Canadian Agency for Drugs and Technologies in Health (CADTH): provides report on cost effectiveness,
safety, clinical effectiveness of new drugs.
• COMMON DRUG REVIEW (CDR): assess new drugs for potential coverage by participating federal,
provincial and territorial drug benefit plans. Done by CADTH
• Canadian Expert Drug Advisory Committee (CEDAC): use CDR and CADTH reports to decide what drugs
to include in the formularies of the participating drug plans.
• Medical Advisory Committee (MAC): appoint medical staff to other standing or special committees.
Receive reports from other committees such as P&T committee.
• Pharmacy and Therapeutic committee (P&T): evaluate, set standards of drug use, develop drug
substitution police. Recommend drugs to be added to formulary and report to MAC that decide.
* Pharmacy and Drug committee (P&T committee): establish and maintain drug formulary (drug list and
alternatives).

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• Therapeutic Products Directorate: Pre-marketing of products, it review safety, efficacy of drugs.
• Patented Medicine Prices Review Board (PMPRB): set the prices of prescription drugs. Only regulate
patented drugs not generic drugs. Report to Parliament of Canada.
• Patented medicine pricing controlled by Federal through PMPRB
* Generic drugs pricing is controlled by Provinces and territories
• Health Canada: determine the manufacturing conditions of drugs (GMP)
• Public Health Agency (PHA): health promotion and disease prevention.
• Canadian Institute of Health Research (CIHR): gather information for federal and provincial agencies.
• Patented Medicine Price Review Board (PMPRB): Determine the price of brand and patented drugs.
• Canadian Food Inspection Agency (CFIA): Monitor food safety across Canada.

Pharmacy formats:
- Franchise pharmacy: pharmacist own the business but not the physical assets. Company support all
operations.
- Banner pharmacy: Pharmacist own business and physical assets. Group of independent pharmacies
have joint advertising, same banner name. have NO central distribution, inventory and supply.
- Food-stores & Mass Merchandisers: departments within a supermarket or mass merchandise outlet.
Pharmacy manager follow the direction of head office for all marketing, merchandising, buying,
professional activities.

• Patient’s medical information should be always confidential except with:

1- a consent from the patient
2- Court order
3- patient unable to make a decision (incapacity)

Studies
• Case control: Start from diseased cases and compare the exposure to risk factors between diseased
cases and not diseased cases. Results depend on Odd Ratio (OR) compare the proportion of exposed
persons in 2 groups. (Retrospective). Useful of adverse effects and Rare disease studies.
- Cohort: start from exposure towards disease incidence. Results depend on Risk-Ratio (RR) the
incidence of disease in exposed group vs unexposed group. (prospective study). Useful for common
disease, harmful exposure, ethically safe.
- Cross sectional: determine the prevalence. Track changes of different subjects at same time point.
- Case serious: same as case control but it lack the control group. A serious of Pts who all have the same
disease and trying to look retrospective to find an association.
* Cohort study, Case-Control and Cross Sectional studies are Observational Study.
• The order of studies in regard to confidence, robustness, power of study:
Cochrane study > Systematic Review > Meta analysis > Randomized Clinical Trial (RCT) > Cohort > Case
control > Cross-Sectional > Case studies > Case report.
• Bias could be avoided by: control selection, blinding, source of information from hospital files.
• Delphi method: Questionnaire filled by group of experts for future forecast.
- Longitudinal study: track change of same subject (people, organization) over time. Could be done by
interviewing, questionnaire.
• Short Form 36 (SF 36): survey that measure quality of life.

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• Calculating Relative Risk (RR) and Relative Risk Reduction (RRR)
- AR (absolute risk) = the number of events (good or bad) in treated or control groups, divided by the
number of people in that group
- ARC = the AR of events in the control group
- ART = the AR of events in the treatment group
- ARR (absolute risk reduction) = ARC – ART
- RR (relative risk) = ART / ARC
- RRR (relative risk reduction) = (ARC – ART) / ARC = 1 - RR
- NNT (number needed to treat) = 1 / ARR
- additional cost: NNT X price , the lower the price the better.
* Control Event Rate (CER): the effect of the control in the experiment.
• Odd Ratio (OR): Odd that case was exposed / odd that control was exposed
OR = A/C / B/D
•
• ISMP prohibited the following abbreviations: q.d., ug, hs, HS, qhs, iu, in, o.d., qn, qhs, sc, sq, sub q, SSRI,
SSI, U, UD, TIW, IJ, q6pm
- don’t use zero after decimal point (use 1 instead of 1.0), use Zero before decimal point (0.5 instead of
.5), put space between dose and units (100 mg and not 100mg).
- use complete drug name rather than abbreviations (use methotrexate instead of MTX).
• Ethics principle:
- Beneficence: doing good.
- nonmaleficence: prevent harm. Ex. Refuse to fill Rx that could harm the Pt.
- autonomy: patient right to choose. The opposite is Paternalism (to have the authority to choose for Pt)
- Veracity: telling the truth without deception.
- justice: to be fair, first come first serve.
- Fidelity: loyal and sincere to your job.
• Sexually abused adult; the pharmacist should report or give the number of support group/agencies to
the patient.
• Sexually abused child; the pharmacist should contact Child Associate Society (CAS)
• NAPRA put the guidelines for pharmacy practice regulations and put the schedule of prescription.
• Pharmacy Colleges: the authority that regulate the pharmacy practice and implement the guidelines.
• Upon receiving medication stock, keep it a stock room at a controlled room temperature.
• Who Can Prescribe Narcotics?
Doctors, Dentist, Veterinary, Midwife, Nurse practitioner (not registered nurse), Podiatrist (chiropodist).
• Any drug in Canada even if it’s newly approved is listed in Drug Product Database (DPD).
• Drug ads, shouldn’t have its indication or price.
• Pharmacist Associations: advocate pharmacists, provide continuous education and publish new books.
• Pharmacy colleges: regulate the pharmacy profession.
• Hospital funding comes from: province taxes, Federal cash transfer, charities.
• Written instruction is more favored than verbal instructions
• The barrier between health care professionals: attitude, timing and skills/knowledge.
• The barrier between pharmacist vs patients: environmental (pharmacy design, noise), personal (shying
persons), administrative (high workload).
• The pharmacist can refuse prescribing a drug against his ethics, but have to provide a second choice.
Unless there is no alternative (no other pharmacists in the pharmacy or the next pharmacy is so far)

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• The doctor can prescribe to himself or to his relatives in emergency cases or when there no prescriber
available. If there is no emergency and still prescribed, it’s unethical. Exception, narcotic and controlled
drugs must not be prescribed (it’s illegal) by the doctor to himself or to his relatives.
• Pharmaceutical gifts or donation is not accepted if it is more than 100 $. Patient and physician
information are not shared to pharmaceutical companies.
• - Fill: give the full dose.
- Refill: to repeat the fill
- Part Fill: give part of the whole dose every interval. 10 tablets every 10 days.

• Food and Drug Act (F&DA): Control manufacturing conditions and advertising
• Controlled Drug and Substance Act (CDSA): control narcotics, controlled drugs and BDZ.
• Straight Narcotics: 1 or 1+1. Rx written only. No refills, no transfer. Sales report. Ex. Tylenol 4
Narcotic preparation: 1+2. Rx written and verbal. No refills, no transfer. Ex. Tylenol 3 & 2
Controlled Part 1: Rx written and verbal. Refill only written (with specified interval). No transfer.
Sales report. Ex. Amphetamines, methylphenidate.
Controlled Part 2: Rx written and verbal. Refill written and verbal. No transfer. Ex. Barbiturates
Controlled Part 3: Rx written and verbal. Refill written and verbal. No transfer. Ex. Anabolic (any
testosterone formulation)
BDZ= Targeted Substance: Rx written and verbal. Refill written and verbal. One transfer allowed.
Expire in a year.

* Exempted narcotics (BTC narcotics under pharmacy supervision) 8 mg opioid + 2 non narcotics
drugs or codeine 19.6 mg /30ml : no Rx needed, dispensed by pharmacist only ex. (Tylenol 1=
codeine 8mg+ caffeine+ acetaminophen)
*Part-fill is permitted for all verbal and written. But in Straight narcotics it must be written
* Purchase record is required for all. Sales record required only for Straight Narcotics and
controlled part 1.
* Written Rx = Faxed Rx
* all records and document should be kept for 2 years (On hand), 10 years (electronically)

* Straight Narcotics (any preparations contain those): diacetyl morphine (heroin), oxycodone,
hydrocodone, methadone, pentazocine.
* all Narcotics, BDZ are dispensed by pharmacist or student/intern under pharmacist direct
supervision (physical presence), not technician
* opioid: morphine, codeine, ketamine.
* Controlled drug CAN’T refill earlier than interval stated.
* Contact “Office of Controlled Substance” is there is any theft, missing or damage of narcotic or
controlled drugs within 10 days of discovery. Expired drugs shouldn’t be destroyed unless receiving
a letter back from the Office, unless its BDZ it could destroyed you have send out letter but don’t
need to wait for a letter back.
* any theft of forgery, legally the police should be contacted and Office of Controlled Substance.
But the Office of Controlled Substance within 10 days, so it is not urgent. Calling the pharmacist
and pharmacy manager is not legally required.

• Unscheduled drugs (schedule U): present in corner stores. Ex. Ibuprofen 400mg, Acetaminophen 650
mg.

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• While destroying expired narcotics, there should be a witness (pharmacy technician). Students can’t
be witnesses. All controlled drugs need witness for destruction.
•
• The pharmacist should show empathy to patients.
• Job analysis: determine all necessary requirement and aspects of the job. It’s study of pharmacy staffing
needs. It comprised of job description and specification.
- Position description (job Ad): describe the main component of each position. Nature of job,
responsibilities, qualification, experiences.
- Job description: include job title, location, summary, duties, working condition, hazards and reporting.
- Job specification: Experiences, qualification, skills, training, emotional characteristics, responsibilities.
• Dispensing error: inform the Nurse immediately (to stop administration)
• Wrong drug already administered: inform the doctor, write report to P&T Committee.
• Cold chain: store insulin and vaccines.
• Pharmacy administrative tasks:
- Salary administration, scheduling, liability, human rights, appraisal, orientation and training, HR
planning (include hiring)
• Financial tasks: Benchmark (compare Workload to other organizations), Rx/shift, salary costs/Rx,
overhead costs/Rx, obtain additional resources, justify service provided, relate Rx income to service
provided and expenses.

Forgery
• If Suspecting forgery:
- Verify physician signature, ask for pt photo ID, check pt profile, review prescription spelling errors,
contact prescriber to confirm prescription.
• If forgery confirmed: Retain the original prescription but if patient demands it, make a copy, stamp the
original, report to police, fill Health Canada Forgery Report. (don’t compromise your safety or staff
safety)
•
• Prescription label Should Not have expiry dates.
• Canadian Health Act (CHA) has 5 principles (PUPAC):
- Universality: all insured pts have same service
- Public administration: audited by public authority
- Portability: any resident have an access anywhere in Canada.
- Accessibility: access of insured hospital without barriers.
- Comprehensiveness: insurance cover essential services, hospitalization, medical practitioners
• CHA doesn’t cover services delivered by health care professionals other than doctors in the hospitals,
pharmaceutical, home care, rehabilitation outside hospital.
• Provincial Drug benefit program cover people over 65 year old, social assistance, disabilities and long-
term illness.
• Federal Drug benefit program cover: natives (aboriginals), refugees, inmates, veterans, RCMP and
military (Canadian forces).
• Mental Capacity: ability to make a decision.
• Contingency Management: management of perishable medication.
• NAPRA:
- categorized drugs in schedules 1, 2 and 3 and unscheduled drugs.

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 - Provide information and guidance on pharmacy profession regulation.
- Set standard of professional qualification and competencies.
• Insurance:
- Deductible: amount of money paid by the patient every year.
- Co-Payment: fixed amount of money paid by the patient for every prescription.
- Co-insurance: patient pay specific percentage of the prescription.
- Total Yearly cap: maximum value covered by insurance company per year, pt pay exceeding amount.
- Professional fee cap: max. professional fee paid by insurance company, pt pay exceeding amount.
• Loss Leader: sell product below its market price to attract customer to buy other products.
• Cold Chain: system of transporting and storing vaccine at 2-80 C
• Medication Reconciliation: Gather patient medication history, obtain all patient’s medication, including
name, dosage, frequency and route = Best Possible Medication History (BPMH). Preformed by
pharmacy technician. Objective: Avoid adverse drug events. It’s done in admission, transfer and
discharge.
• Highest expenditure (most expensive health services): Hospitals > Drugs (Prescribed + OTC) > physicians.
• If there is a damage, theft or loss of narcotic or controlled substance, you must contact Office of
Controlled Substance within 10 days of discovery.
• Call the prescriber if: life-threatening case, contraindication medicine, Major drug interaction. After
calling, no apology and go direct to the point and Give alternatives.
• If the pt don’t have a prescription or refill, and it’s emergency case you can: advancing drug (give it in
advance), provide emergency refills.
• If one the pharmacy staff abusing sick-leave privilege, ask for medical evidence.
• - NAPRA: put the guidelines of pharmacy profession regulation.
- Colleges: Regulate and audit the pharmacy profession.
• Management:
- Triangle structure (manager at the top): in stress and crisis time. Leaders steps up and delegate roles.
- Flat structure: steady work time, equilibrium, not a lot of change.
• “interchangeable drugs”, the pharmacist can change the medicine with another generic as long it has
same active ingredient, same amount, same route of administration, same kinetics; without contacting
the prescriber.
- If the prescriber wrote “No sub” or “No substitution” it should be in doctor’s hand writing, the
pharmacist has to give the written brand only.
• The pharmacy need license for following actions:
- sell oversized products with more than 3 g pseudoephedrine per package.
- selling to another pharmacy or retailer (considered wholesaling)
- importing/exporting require license.
• .

Drug shortage:
• Causes:
- Supply issues: ex. Contamination of active ingredients or raw materials. The main reason is lack of raw
material
- Manufacturing issues: contamination of manufacturing stages, multiple products using same
equipment, changes in manufacturing procedures, recall due to potential problem with the product.
- Contracting issues: the company could rely on only one supplier. Hospital rely on only one company.

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 - Economic decisions: product without demand and lack financial return. Manufacturers consolidating,
limiting or eliminating production.
•
• Business Ownership:
1- Sole: sole owner, low startup cost, with unlimited liabilities. Creditors can take your personal assets.
2- Partnership: skills and knowledge could be shared, but with rate of conflicts.
3- Corporation and limited liability companies: limited liability, several directors, legal entity but high
government involvement. Here, creditors will not affect your personal assets.
* Simplest = Sole
Easiest = Franchise.
• When putting pharmacy schedule, it should consider: Fair for all employees, predictable so the
employees would be committed, not template every month.
• Pharmacist can initiate, adapt and renew prescriptions
- Initiating: pharmacist can initiate smoking cessation prescription such as Varenicline and Bupropion.
- Adaptation: change the dose, dosage form, route of administration.
- Renewing: for continuity, but not more than 6 months or more than quantity prescribed.
* No adaptation or renewing in narcotics and controlled drugs.
* refill use the original prescription number, unused refills should be cancelled
* renewing: use a new prescription number, + reference to the original prescription.
• If manager suspect one of the staff involved in narcotic theft, limit his access to narcotics. Regarding
the incidence, report about it, but don’t not accuse him (unless u r sure).
• If an OTC product could be abused or misused (restricted to certain age), you can move it to Behind The
Counter.
• You can call the police first for any forgery prescription )‫(مزورة‬to prevent further harm to other
pharmacies.
• If there is a prescription form out of Canada, it’s unethical for the pharmacist to enter in agreement with
physician to co-sign or rewrite it.
• Health Care System in Canada is funded by federal and provincial funding and their taxation.
• Failure Mode and Effects Analysis (FMEA): a prospective approach, proactive to prevent potential failure
from happening.
• Precision: absence of random error
Reliability: could be repeated and give same results
Validity: absence of bias or all errors
Accuracy: lack of error
• Health Canada send fund to provinces to cover medical necessary services. Provinces share from
taxation and charities. Provinces are the main provider of the services. Except in remote areas, Health
Canada is the service provider.
• Incidents (errors) : dispensing errors, medication errors
Near missed incidents: error did not reach to patient.
• Pharmacoeconomics: analysis of the cost of the drugs to healthcare system and society.
- Cost Benefit Analysis (CBA): cost and outcome measured in dollars.
- Cost Effectiveness Analysis (CEA): cost of the drugs/clinical effect (blood pressure)
- Cost minimizing Analysis (CMA): when outcome is equal, only costs are compared.
- Cost Utility Analysis (CUA): cost of drug compared to quantity and quality of life = Quality Adjusted Life
Year (QALY)

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 - Cost of illness Analysis (CIA, COI): measure the economic burden of illness to society.
* Perspective: refer to stakeholder whose interest is most represented in study’s conclusion
• Hospital are covered by Federal, provincial taxes and some users pay
• “X” sign in prescription means refill.
• Autocracy: absolute power concentrated in the hand of one person. The leader dictate what’s done and
how to be done. Needed when immediate decision needs to be done.
• Insurance cover vacation supply up to 6 months.
• SOAP format:
Subjective: patient info (age, gender, symptoms, complain), past medical history, past surgical history.
Objective: lab tests, vital signs,
Assessment: symptoms, risk factors
Plan: therapeutic plan, medication needed, patient counseling.
• Inventory shrinkage could be due to: internal theft, external theft, paper work error, fraud. Policies
need to be applied such as: employee bag check, external visitor sign-in and sign-out policies.
• Polypharmacy: simultaneous use of multiple drugs for 1 condition.
• EpiPen: epinephrine injection to treat sever allergy. Should be stored in Room temperature, Don’t
refrigerate.
• Non-formulary drug could be requested in hospital if:
- new drug released in market with superior efficacy.
- new pt admitted that use non-formulary drug
- patient condition is resistant to formulary drug.
• Inventory management include:
- Save money
- less stock outs
- check expiry so near expired drugs placed in front.
• Quality assurance program ensure that pharmacist and pharmacy technician competent regarding
skills and knowledge:
- Continuing education, self-assessment (every 5 years), practice assessment (every 4-6 years)
- Document near-miss errors used to assess the competency pharmacist.
• Sharing patient information only for the Patient Care Circle (his physician) according to the required.
• In case if a colleague pharmacist doing something wrong, report to provincial authority.
• Nurse errors should be reported first to Doctor.
• If Refrigerator power off:
- Isolate the vaccine and pack them in insulated bags. As long the refrigerator doors were closed, the
efficacy has not compromised.
• Mailing medications to USA:
- For temporarily stay (vacation) in USA.
- The package should have a letter form the prescriber about their condition.
- Narcotics is not allowed to be mailed.
• If a natural product is not approved in Canada, the contents can’t be verified.
• Need book: ‫كراسة النواقص‬
• Refrigerator should be checked twice per day.
• We don’t return back any dispensed drug; the patient can only return the drug for safe disposal.
• Medicare: Canada publicly funded Health insurance program (Canada Healthcare system)

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• Public Health expenditure mainly used by Hospitals, then drugs, then physicians. While for private
insurance company highest expenditure is Dental.
• Pharmacist and not technician, can do prescription adaptation: change dosage form, strength,
therapeutic equivalent.
• Merchandising: visual selling, visual display of products in store.
• Ambulatory care = (outpatient care) or (same day emergency care) = patient assessed, diagnosed,
treated and discharged on same day without admission into hospital bed.
• Collaborative care = interprofessional cooperation, aim to improve patient outcome and its most recent
issue these days in Canada.
• Hospital monitoring and quality done by provincial authority or hospital management.
• Health Related Quality of Life (HRQOL): focus on nonclinical information; such as well being, return to
work. It’s a questionnaire divided into General Health Statues Instrument: measure global health status
and Disease Specific Instrument: target disease specific issues.
• If pt come to pharmacy complain about wrong dispensed medication, first I should establish if the pt
took any of incorrect medication.
• Confounding: inability to determine the true effect on the outcome.
• Pharmacotherapy ultimate goal based on patient decision.
• Root cause analysis don’t blame individuals but blame the system.
• Privacy Act: protect privacy of individuals held by governmental institutions
• Personal Information Protection And Electronic Documents Act (PIPEDA): applies to all private sector
companies (including healthcare corporations such as pharmacies)
• Conscience Clause: Health providers can refuse to apply service against their personal beliefs.
• Call emergency if any patient exceeded the daily dose of any drug.
• Delay tactic: if patient come with a forgery Rx, u can tell him u don’t have the medication and to come
tomorrow, then u could call the police.
• Disclosure of patient information in specific cases:
consent provided, communicable diseases (HIV), patient consent, guardian consent (if pt incapacitated),
medical professional within patient’s circle of care, patient of risk with self harm or harming others,
court orders, gunshot wounds.
• To minimize dispensing error: we use 2 identifiers: first patient’s name then birthdate or telephone
number.
• If there’s shortage in staff, we could use automation of the pharmacy.

Natural products:
• Examples: vitamins, minerals, probiotics, fatty acids, homeopathic medicines, minerals, Chinese and
herbal medicines.
• Don’t require prescription for sale.
• Identified by: DIN-HM or NPN
• Regulated by: Natural and Non-prescription Health Product Directorate (NNHPD)

Advertising prescription drugs:

• Direct to consumer advertising is prohibited except for the name, price and quantity. It’s use and/or
benefits shouldn’t be referenced.
• It’s prohibited to advertise unauthorized dugs.

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Off label use /Extended use
• Manufacturers can’t promote any off-label uses of their products, if they did they will be fined heavily.
They can only market their drugs for indications approved by Health Canada.
• Off-label use may or may not be supported by strong scientific evidence
• Physicians can prescribe drugs for its off-label use.

Drug recall
• Class 1: if drug has severe side effects or cause death
• Class 2: if the drug cause temporary reversible side effect or little side effect
• Class 3: product not cause adverse effect.

Recall is initiated by manufacturer.

Compounded Sterile Preparations (CSPs) Immediate-use preparations

• The perpetrations shouldn’t exceed 3 sterile units.

Beyond Use Date (PUD)

• It is similar concept of Expiration date but for non-sterile compounded products.
- non-aqueous formulations (non-water contained - ointment, suppository, troches): no later than
expiration date of any API or 6 months, whichever earlier.
- Water-containing oral formulation: 14 days in controlled cold temperature.
- Water-containing topical/dermal, semi-solid, mucosal-liquid formulations (ointment, cream): 30 days.
* Shouldn’t be the same as expiration date given by manufacturer.

Hazardous drugs:
• Should be labeled to avoid misuse. Should be dispensed in unit dose packaging, all equipment used for
preparation of hazardous drugs should be labelled. Gloves and mask should be worn during its
handling. Blue pad should be placed in counter before any work.

Pharmaceutical Care
• Pharmacist main goal to improve pt’s quality of life. And assist pts to achieve the desired outcome
(cure/eliminate/slowing/preventing a disease or symptoms)
• Pharmaceutical care process (plan): identify, resolve, prevent drug-related problems.

Special Access Program

• Special access program (SAP): not proved drugs and withdrawn drugs could be obtained by SAP
• If the pharmacist received a Rx of drug not approved in Canada, first contact the physician to inform him
to prescribe another drug, otherwise the doctor could order it through Special Access Program (SAP)
• If receive a Rx of not approved drug, should inform the doctor. Unless, it is necessary and no
substitution, then should inform the doctor to order it from (Special Access Program) SAP
• SAP must be submitted by practitioners and for life-threating, serious conditions and when conventional
treatments have failed. For chronic conditions 6 months supply could be considered.
• The manufacturer has the final word on whether the drug will be supplied.
• The drug could be supplied free by the manufacturer. Otherwise, it could be covered by hospitals,
public or private insurance plans, patient himself of his family.

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Others
• If the patient is illiterate, u could explain the risks and benefits to him.
• Incompetent = ‫غير كفء‬
Incapable= ‫غير قادرجسديا و عقليا علي ممارسة المهنة‬
• Each drug in the prescription has a dispensing fee. If one Rx, contain 3 drugs and the dispensing fee is
10$, then the total dispensing fees were 10$*3= 30$
• Unit-dose system: safest and decrease waste and errors but costy.
• The best one to ask for a concern related to medicine is Pharmacist.
• In multicultural society, you could hire multilingual staff.
• Floor stock system: drugs in stock in each floor (used in emergency for any patient)
• Nonverbal skills during phone conversation:
Do: smile (be sure friendly voice). Don’t: put patient on hold.
•

bCalculations and statistics:

• If significance level (α)is 0.05, the corresponding confidence level is 95%. The data is significant
when:
- P value is less than α-value (p< 0.05).
- If the P value is less than alpha, the confidence interval will not contain the null hypothesis value.
- If the confidence interval does not contain the null hypothesis value, the results are statistically
significant.
- Confidence interval usually is 95% but can be as wide as 99% (with smaller sample size) or as
narrow as 90% (with larger sample size). The width % is reciprocal to sample size.
• P Value > α value : null hypothesis is true.
P value < α value : null hypothesis is false.
• 95% confidence interval is narrower than a 99% confidence interval which is wider. The 99%
confidence interval is more accurate than the 95%
• If P value is less than α value, the data is significantly different.
• Type I error (False positive error) due to change. When Null hypothesis is true but test reject it.
Type II error (False negative error) due to sample size. When Null hypothesis is false, but the test
accepts it. ex. When investigating drugs that cause Side effect (liver failure), null hypothesis say
liver failure not related to drug, the study accept it so the drug don’t do liver failure, if it’s wrong;
thus it’s False Negative.
• Children dose:
- (age in month / 150) x adult dose
- (weight in lb / 150) x adult dose
- (Age (in years) / (Age (in years) + 12) ) X adult dose
- (BSA in m2 / 1.73) x adult dose
• Drug metabolism:

Zero Order 1st order

Constant amount of drug eliminated /unit time Constant % of drug eliminated / unit time
Metabolism Rate doesn’t increase with plasma Metabolism Rate increase with plasma drug
drug conc. conc.

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 T1/2 depend on drug conc. T1/2 is constant
Linear plot: Conc vs Time graph = linear graph * Linear Plot: Conc. Vs time = Curve (Exponential)
* Semi-log plot: logarithmic conc Vs time = linear
graph
After saturation. Some drugs: aspirin, phenytoin, Most drugs at most doses
ethanol, Cisplatin, fluoxetine, Omeprazole
•
• Half-life (T1/2)
- 1st order: T1/2= 0.693/K
- zero order: T1/2= 0.5* A/K
• Shelf life (T90) = measure at room temp (250 C) when 90% of drug is still stable
- 1st order: T90= 0.105/K
- zero order: T90= 0.1* A/K
• Slope:
- Zero order = - K
𝐾
- 1st order = - 2.303
• Log C = log C0 – kt/2.303
• Trough level: Ctrough is the lowest concentration reached by a drug before the next dose is
administered.
• Bioequivalent: pharmaceutical equivalent drugs with similar bioavailability. Ex. Generic and brand
• Biosimilar: almost an identical copy of an original product. Just small change over the original
product.
• IF accuracy 95% = 5% Error
Sensitivity requirement = min. weighable weight X error
• Linear pharmacokinetics: (dose independent) pharmacokinetics parameters (Vd, Cl, K, T1/2) are
constant and wouldn’t change with dose. ADME follow 1st order kinetics. Conc. Vs time for
different doses are superimposable.
• Non-linear pharmacokinetics (dose dependent) pharmacokinetics parameters (Vd, Cl, K, T1/2) are
dose-dependent. Conc. vs Time for different doses are not superimposable. Ex. Phenytoin,
carbamazepine, salicylate, lidocaine, propranolol, prednisolone,
• Steady state Conc. (Css) is reached after 3:5 T1/2. 50% Css = 1 T1/2 . 75% Css = 2 T1/2 .
90% Css = 3.3 T1/2 . 95% Css = 4.4 T1/2 .
• Drug accumulation depend on drug frequency and T1/2 and not the Dose.
• Ex. 13, 13, 13, 13, 14, 14, 16, 18, 21
Mean = sum up all values / no. of values (15)
Median= the middle value (14)
Mode= most repeated number (13)
Range= largest number – smallest number (21-13 = 8)
• Coefficient of Variation = 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐷𝑒𝑣𝑖𝑎𝑡𝑖𝑜𝑛 / 𝑀𝑒𝑎𝑛
• Epinephrine 1:1000 means 1 gm per 1000 ml = 1 mg/ml
• Total clearance: the sum of all processes by which drug is removed from the body, renal excretion
and metabolism. Cl= Vd * Kel
• Sensitivity requirement = weight * error %
𝑐𝑜𝑠𝑡 𝑜𝑓 𝑔𝑜𝑜𝑑 𝑠𝑜𝑙𝑑 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑔𝑜𝑜𝑑 𝑠𝑜𝑙𝑑
• Turnover rate = 𝑜𝑝𝑒𝑛𝑖𝑛𝑔 𝑠𝑡𝑜𝑐𝑘 + 𝑐𝑙𝑜𝑠𝑖𝑛𝑔 𝑠𝑡𝑜𝑐𝑘 = 𝑎𝑣𝑒𝑟𝑎𝑔𝑒 𝑖𝑛𝑣𝑒𝑛𝑡𝑜𝑟𝑦 𝑐𝑎𝑝𝑖𝑡𝑎𝑙
2

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 • Gross Profit = Sales - Cost
• Gross margin = (Sales – Cost / Sales) * 100
• Markup = (Sales – Cost / Cost) * 100
• Sales price = Cost + (Cost * markup %)
• Cost price = Sales price/ (1+markup%)
𝐷𝑟𝑢𝑔 𝑎𝑚𝑜𝑢𝑛𝑡 𝑇𝑜𝑡𝑎𝑙 𝐶𝑙
• Vd= 𝐷𝑟𝑢𝑔 𝑐𝑜𝑛𝑐.𝑎𝑡 𝑡𝑖𝑚𝑒 0 = 𝐾𝑒𝑙
0.693
• Rate of infusion = Css * CL = Css * Vd * Kel = Css * Vd * 𝑇1
2
• Loading dose = Css * Vd
• AUC: concentration of drug over time interval ( mass*time/volume)
• Css= AUC/T(dosing interval)
• Amount available for absorption = F * D
• Total clearance = amount absorbed/AUC = 𝐹 ∗ 𝐷/𝐴𝑈𝐶. F: BAV, D: amount of drug
𝑊 (𝐾𝑔) ∗ 𝐻 (𝑐𝑚)
• Body Surface Area (BSA) = √ = m2
3600
𝑊(𝐾𝑔)
• Body Mass Index (BMI) = 𝐻 2 (𝑚2 )
𝐴𝑈𝐶𝑜𝑟𝑎𝑙
• Bioavailability =
𝐴𝑈𝐶𝐼𝑉
𝐴𝑈𝐶𝑑𝑟𝑢𝑔 ∗𝐷𝑜𝑠𝑒𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑
- Relative Bioavailability = 𝐴𝑈𝐶
𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 ∗ 𝐷𝑜𝑠𝑒𝐷𝑟𝑢𝑔

• Displacement Value: the volume of drug that displaces 1 gram of suppository base. Ex.
Displacement value of tannic acid 0.9, means 0.9 gm of tannic acid = 1 gm of coca butter
• When bioavailability (F) of 100 mg tablet is 0.6. Then 100 X 0.6 = 60 mg is available for absorption.
• Right drug distribution achieved by providing Right drug in Right dosage form in Right strength for
Right pt at Right time.
𝐺𝑚
• Part per million (PPM) = ∗ 1000,000
𝑚𝑙
𝐺𝑚
Part per Billion (PPB) = 𝑚𝑙
∗ 1000,000,000
𝑔𝑎𝑖𝑛−𝑖𝑛𝑣𝑒𝑠𝑡𝑒𝑚𝑒𝑛𝑡
• ROI = 𝐼𝑛𝑣𝑒𝑠𝑡𝑒𝑚𝑒𝑛𝑡
* 100
• The Kaplan–Meier estimator (Product limit estimator), use to measure the faction of patient living
for certain amount of time after treatment.
•
• Dependent variable (outcome variable): ex. Blood pressure.
- Independent Variable (Predictor variable) ex. Lifestyle, ACEI, Salt
• Wilcoxon test: when same group has been tested or asked twice. Ex. Asking same group of people to
rank how hungry they are before and after meal.
- Chi Square Test: compare 2 or more dependent variables within 2 or more groups, useful for
multigroup comparison.
• Data could be:
1- Continuous (infinite options, on scale and has fraction) usually numbers: Age, weight, blood pressure.
a) Interval: zero has a value, there is minus: Temperature
b) Ratio: Zero has no value, start with zero: BP, Time, pule, distance.
* permissible statistics: mean, SD, T test/ANOVA
* Compare 2 groups = T-test. More than 2 groups ANOVA.

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 2- Categorical (Discrete) (finite options, don’t have fraction): number of children, number of pts,
number of asthma attack per week, could be words not numbers.
a) Ordinal (ordered categories): pain severity, grade of breast cancer
b) Nominal (no ordered categories): Blood groups, eye color.
c) Binary (only 2 options): Yes/No, Pass/Fail
* Permissible statistics: Mode, Median, Chi Square, Z test, Cochrane, fisher
* Nominal: 2 groups = fisher. Chi Square test: more than 2 samples. If the groups related then use
Cochrane. Z test: 1 or 2 samples.
* Ordinal: 2 groups = Wilcoxon. More than 2 groups Friedman
• Intention-to-treat analysis: to avoid bias for patient who are non adherent/complaint to medication in
clinical trial. (To include all the patient assigned for the study regardless of their adherence or
withdrawal from treatment)
• Cmax and Tmax depend on the rate and extent of drug absorption.
• Concentration:
W/V % = 100 * gm/ml
V/V % = 100 * ml/ml
W/W %= 100 * gm/gm
• Fluid ounce (fl oz) = 30 ml
Kg = 2.2 Pound
16 ounce (OZ) = 1 pound
• Gram = specific gravity * ml

•
• BMI = weight (Kg)/Height (m2)
• 5% Dextrose in Water = D5W
10% Dextrose in water = D10W
5% Dextrose in normal saline = D5NS
• Allegation:
- Ex. How many grams of hydrocortisone powder should be added to 32 g of 5% hydrocortisone
ointment to prepare an ointment containing 20% of hydrocortisone?
Hydrocortisone powder concentration = 100%

X= 32*15/80 = 6 gm. So we add 6 gm of 100% hydrocortisone to 32 gm of 5% hydrocortisone to get 20%

hydrocortisone.

- Ex. You have 3 preparations of betamethasone 50%, 20%, 5%. In what proportions should they mixed
to prepare 10%.

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 the proportion should be 5:5:50 (1:1:10) of 50%, 20% and 5% respectively.

• Gram of substance to be added in 1000 g water to get isotonic solution = Molecular weight * 0.28
- ex. Non electrolyte substance with molecular weight 90.3 g/mol. How much is required to make 100 g
of water solution isotonic?
ans. Grams = MWT * 0.28 = 90.3 * 0.28 = 25.28 (but this for 1000 g water)
for 100 g we will use 2.528 g
• NaCl Equivalent (E) = 0.23, it means 1 gm of the drug = 0.23 gm NaCl
- Ex. Determine the volume of purified water and 0.9% w/v of NaCl solution needed to prepare 30 ml of
a 1% w/v solution of hydromorphone hydrochloride (E= 0.22)
Ans. 30 ml has = 1 gm *30/100 = 0.3 gm
0.3 gm X 0.22 (E value) = 0.066 g NaCl equivalent
Isotonic solution of 30 ml should have 0.9% NaCl that means = (0.9/100) X 30 = 0.27 g NaCl
0.27 gm – 0.066 gm = 0.204 gm NaCl needed
as long we have stock of 0.9% so we need to add = 0.204 X 100 /0.9 = 22.67 ml of 0.9% NaCl should be
added, then we can add water by 30 – 22.67= 7.33 ml water
• mEq = mg * valence / MW
• mg = mEq* Molecular weight /valence, if you have mEq and MW, it’s easy to calculate mg
• Ex. Doctor prescribed 20 mEq K, how many mg of K should be taken (M.W of K = 39)
Ans. Mg = mEq * mw /valence = 20 * 39 /1= 780
• Mmol = mEq/Valence = weight /MW
• Osmol/L = Weight (g/L)*no of species / MW (gm)
• Milli-Osmol/L= (gm/L) X species X 1000 / MW
• Abbreviations:
qd= once daily
qid/qds= 4 times daily
qhs= at bedtime
Stat= immediately
d.t.d= number of units
ad 90 ml = up to 90 ml
mittee = prepare or make
aa= equal amounts (in prescriptions)
• For weak acids: pH = pKa + log (ionized/non ionized). Ionized at high pH
- pH - pKa = 0 , ionized 50%
- pH - pKa = 1, ionized 90% pH - pKa = -1, ionized 10%
- pH - pKa = 2, Ionized 99% pH - pKa = -2, ionized 1%
• For weak base: (the opposite of acid) pH = pKa + log (non ionized/ ionized). Ionized at low pH
- pH - pKa = 0 , ionized 50%
- pH - pKa = 1,non-ionized 90% pH - pKa = -1, non-ionized 10%
- pH - pKa = 2, non-Ionized 99% pH - pKa = -2, non-ionized 1%
•

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• Non-ionized = lipid soluble = cross BBB, membrane = high absorption
Ionized = water soluble = poor absorption and excrete faster.
• Confidence Interval (CI), if CI 95%, then significance level (α) 0.05. if P value < α value (0.05) then data is
statistically significant.
- The significance of CI depend on the parameter being evaluated:
1- if it’s a difference (mean difference, difference in T1/2, Relative Risk Reduction RRR, Absolute Risk
Reduction ARR). If CI include Zero (ex. CI 2 - 5), then results Not Statistically Significant.
2- If it’s ratio (Relative Risk RR, Odd Ration OR, Hazard Ration HR). If CI include 1 (ex. CI 0.5 - 1.1), then
results Not Statistically Significant.
• What is the final concentration if you add 10 gm 2.5% hydrocortisone to 2 gm 5% hydrocortisone to 14
gm base ointment?
answer: C1V1 + C2V2 + C3V3 = Cf Vf
2.5 * 10 + 5 *2 + 0 * 14 = Cf * 26
Cf = 35/26 = 1.35%
• Arrhenius equation: describe the effect of temperature on drug degradation.
• Noyes-whitney: determine rate of dissolution.
• Ficks law: determine rate of absorption
• Hasselback: Factors affect rate of absorption: pH effect and ionization/unionization.
* Henderson Hasselbalch equation: estimate pH of a buffer solution based on acid and conjugate base.
it describe the relation between ionized and non-ionized electrolytes.
• At renal function, 44% of the drug excreted unchanged with half life of 8 hours. What will be the half life
for the dose of the drug with 50% renal function?
Answer: New T1/2= old T/2 + (%renal excreted portion *% renal function*old T1/2) = 8 + (44%*50%*8)
= 8 + 1.76= 9.76
• Sensitivity: measure the true positive rate. Ex. Percentage of sick people who truly have the condition.
Specificity: measure the true negative rate. Ex. Percentage of health people who truly not have the
condition.
Incidence: rate of future occurrence.
Prevalence: widespread of the disease.
• Ex. Drug X, 1 tablet BID for 1 month, Refill 3.
- Total quantity= 2*30*4= 240 tablets
- Quantity authorized = 2*30 = 60 tablets
- Quantity remaining = 180 tablets.
- Quantity on hand = quantity in pharmacy after dispensing.
• Tmax: independent of dose, but dependent on rate of absorption and elimination.
Cmax: rate of drug absorbed = rate of drug eliminated.
* Sustained release form: have same Cmax, AUC, but longer Tmax.
• Michaelis-Menten: V=Vmax*(S)/(Km+(S))
V=reaction rate, Vmax=maximum reaction rate, (S)= substrate conc., Km= Michaels-Menten constant.
Zero order: (S) = Km, Vmax = Km, substrate conc. doesn’t affect reaction rate.
1st order: (S) << Km, Km < Vmax, rate of reaction depend on substrate conc.
• Calculate Dissociation factor, if HCl undergoes 60% dissociation ?
Ans. HCl = H + Cl. 60% ionized means 40% unionized.
Dissociation factor = H + Cl + HCL = 60% + 60% + 40% = 1.6

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Financial statements:
• Income Statement (Profit & Loss Statement): indicator of sales, cost of goods sold, gross profit, net
profit.
• Sales = units * unit price
Cost of goods sold = units * unit cost
Gross margin/profit = Sales – cost of goods sold
Gross margin % = (sales – cost of goods sold)/sales *100
Net profit = Gross margin – expenses.
• Balance sheet: indicator for assets and liabilities. Assets = cash + current inventory + prepaid expenses +
furniture. Liability = account payable (debts)+ long-term liabilities
• Net worth (owner equity) = assets – liabilities
Total current assets = cash + inventory + prepaid expenses
Total assets = current assets + fixed assets
Liability = account payable (supplier money) + note payable (bank loans)
• Retained Earning Statement: represent net income after paying off dividend to shareholders.
• Patient give 1gm Vancomycin IV, after 3 days T1/2 the blood conc. 15 mmol/L, he received 1 gm
vancomycin. What peak and trough conc. of vancomycin
Ans. After 3 days (T1/2) the conc. was 15. So at time of administration was 30; thus, each 1 gm
vancomycin give 30 mmol/L. We calculate the concentration after 5 T1/2
Steady state conc. reach after 3-5 T1/2. So the steady state trough conc. = 29
• Closing Inventory equal to Opening Inventory for the next year.
• Zwitter ion formation = (pka+pkb)/2
•

Physiology
Nerve:
• Radial nerve in upper arm, supply triceps; responsible for extending the elbow, wrist and fingers and its
injury result in Wrist drop.
• Radial nerve: pass through forearm, write and fingertips. It supply muscles in forearm.
•
• Auxiliary nerve supplies shoulder joint
• PNS:
-Schwan cells: surround axons. provide the myelin sheath for peripheral axons.
- Satellite cells: surround and nourish cell bodies.
• CNS:
- Astrocytes: support neurons (as Satellite cells), maintain Blood brain barrier.
- Oligodedrocytes: produce myelin sheath in CNS. (as Schwan cells)
- microglia: remove debris and foreign material.
- Ependymal cells: produce and circulate CSF

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• Parasympathetic originate from Carnial and Scaral
* Sympathetic originate from Thoracic and Lumbar.
• Vagal nerve is a parasympathetic nerve control pulmonary, digestive and urinary system and heart
beats.
• Cranial nerves: Olfactory (smell), Trigeminal (chewing, face and mouth touch, pain), oculomotor (eyelid
and eyeball movement), trochlear and abducens (eye movement), facial (face expression, secretion of
tears, saliva, taste), hypoglossal (tongue movement), Glossopharyngeal (sense carotid BP, taste), Vagal
(aortic BP, heart rate, digestive organs, taste), vestibulocochlear (hearing and equilibrium)
• Parasympathetic cranial nerves: oculomotor, Glossopharyngeal, Facial, Vagus nerve.
• Sciatic nerve: run through buttock, thighs till foot. It innervates whole foot. Divided into tibia and
common fibular nerve which supply muscle of posterior thighs, all legs and foot. Injury lead: difficulty
flexion of the knee, bending the foot inward.
• All organs are innervated with both Sympathetic and Parasympathetic system, except exocrine gland
only innervated with Parasympathetic (except only salivary gland which is innervated by the two). In
Salivary gland, parasympathetic produce thick saliva while sympathetic produce light saliva.
•

Glands
• Mucus is produced by Goblet cells
• Posterior pituitary gland: Vasopressin (ADH) and Oxytocin.
- Anterior pituitary: FSH, LH, TSH, ACTH, GH, prolactin.
- Pineal: melatonin.
- Thymus: Thymosin (development of T cells).
• Thymus gland is active till puberty then it start to shrink till replaced by adipose tissue
• Lymphatic system function: removal of interstitial fluid, absorb fatty acids from digestive system,
transport WBCs.
* Lymphatic vessels (Lacteal) in small intestine absorb digest fats. It connects to small veins.
• Salivary gland: comprise of parotid gland, submandibular, sublingual gland.
• Parotid gland: salivary gland present in side of mouth and front of ears.
• Sebaceous gland: skin gland that secret sebum (oil) to lubricate hair and skin.
• Ceruminous glands: sweat gland present in external auditory canal in ears, produce cerumen and
earwax
• Pancreas secrete enzymes such as peptidase, dipeptidase, nucleotidase, nucleosidase, and
enterokinase.
• Ciliary body produce aqueous humor
• Lacrimal gland produces tears
• Ceruminous gland produces earwax, cerumen

Brain
• Brain function:
- Medulla Oblongata: center of respiration and circulation, regulate breathing, swallowing.
- Cerebellum: coordinate muscle movements, posture and equilibrium. Dyskinesia is associate with it.
- Cerebrum: controls voluntary functions, speech (vision, hearing, learning, emotions and reasoning).
Dementia is associate with it.
• Cerebrum is composed of cerebral cortex (grey matter) and underlying white matter.
Cerebral cortex composed of:

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 1- Occipital lobe: vision
2- Parietal lobe: intelligence, reasoning, sensation, reading
3- Temporal lobe: speech, behavior, memory
4- Frontal lobe: (has Motor cortex) movement, intelligence, personality

others
• Gastrointestinal absorption could be affected by:
PH alteration, flora alteration, motility alteration.
• Blood consist of: 55% plasma, 44% RBCs, (1% WBC + Platelets.)
Plasma: 91% water, Proteins 6-8%, vitamins +glucose +salt.
Plasma protein: 60% albumin, 36% globulin, 4% Fibrinogen.
• Cruciate ligament present in Knee.
• Respiration rate: 12-20 breath/min
• Centrosome organize microtubules, pull chromatids apart during cell division.
• Adrenal cortex secret: cortisol (increase glucose), aldosterone (Na retention), androgen (develop early
male sex organs and female sex drive and puberty)
• Adrenal medulla: secrete epinephrine (adrenaline).
• Blood flow: deoxygenated blood enter heart through superior and inferior vena cava to right atrium ----
then through tricuspid valve to Right ventricle ---- pulmonary artery to lungs ----- pulmonary veins carry
oxygenated blood to left atrium ---- left ventricle through mitral valve ---- Aorta.
• CSF role: protect brain and spinal cord from trauma, supply nutrients to nervous system, remove waste
products from cerebral metabolism.
• GIT Layers from innermost to outermost:
Mucosa – Submucosa – Muscularis – Adventitia/Serosa
• RBCs half-life 100:120 days. Platelets half life 8:9 days.
• Platelets originate from megakaryocytes.
• Pressure in veins is lower than arteries. The widest vein is vena cava, that mean lowest BP
• Left ventricular failure cause pulmonary edema. Right ventricular failure cause peripheral edema.
• Antidiuretic hormone ADH (vasopressin): When plasma osmolarity increase, it stimulate Posterior
pituitary to release ADH, leading to decrease plasma osmolarity and increase urine osmolarity.
• Dysphagia: difficult swallowing. Odynophagia: difficult swallowing with pain.

Manufacturing
Delivery systems
• Iontophoresis: process facilitated transdermal delivery of protein through skin also used to treat
hyperhidrosis (excessive sweating). Ex. Cortisone.
• A drug with low T1/2, should be formulated in SR form, not in tablet or suspension form (cause that will
need many doses per day). It could be formulated in spray if local effect needed.
• Transdermal patch:
Adv: avoid 1st pass metabolism, prolong duration of action, easy to eliminate the drugs; thus, it is useful
with drugs of short half-life (nitroglycerine), narrow therapeutic window.
• Avoid 1st pass metabolism through: IV, IM, inhalation, sublingual, suppository, transdermal.
• Avoid 1st pass metabolism by: increasing the dose and change the route.
• Injections:
- Intra-articular: in joints.

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 - Epidural: in spine.
- Spinal “Intrathecal”: injection reach CSF.
• Sublingual: has rapid onset, used when needed. Patch or ointment: slow absorption, for chronic
therapies, has systemic effects.
• IV injection: the vehicle should be water. Ex. Oil in water emulsion.
• Sustained release is best for drugs with short half life
• Coating could mask the odor, taste, improve appearance, decrease release rate, protect the drug from
stomach. But will not increase its release rate.
• intravenous piggyback mainly used with antibiotics.
•

Tablet problems:
• Capping: separation of top and bottom
• Lamination: separation of tablet into 2 or more layers.
• Picking: removal of surface material by a punch
• Sticking: adhesion to die wall
• Mottling: unequal color distribution

* Evaluation test for tablet:

• Hardness: for to break tablet. Effect its disintegration and dissolution
• Friability: ability to withstand abrasion in packing, handling and shipping. Tumbler method to test
friability
•

Sterilization
• Terminal sterilization: is sterilizing the product in its final container. Methods: moist heat, dry heat,
radiation, gases.
• Sterilization:
- Dry heat: For glassware + metal instruments + thermostable liquid and powder.
- Moist heat: media + reagents. Moist heat (steam sterilization/autoclaving) used in terminal
sterilization of aqueous injection (sealed Vials), ophthalmic preparations and hemodialysis solutions.
- Gas (ethylene oxide): devices
- Radiation: DNA + ointments + plastic syringes
- Filtration: heat sensitive injections and ophthalmic solutions, biological products and air and other
gases for supply to aseptic areas.
• Hormones, proteins are sterilized by filtration and radiation.
• Polymorphism: ability of molecule to be in different crystalline form.
Amorphous: differ from crystals in long-range periodicity (repeat itself periodically). Amorphous form of
compounds are more soluble than crystalline form.
* Crystalline: has distinct melting point. Unlike, amorphous: no distinct melting point.
• Vertical Laminar Flow: recommended for cytotoxic, anticancer antibiotics (ex. Doxorubicin) and
microbial preparations. High Efficiency Particulate Air (HEPA) filter: air filter used in laminar flow.
• Horizontal laminar flow: Lack of protection glass, so can put equipment and instruments inside (ex.
Microscope). Shouldn’t be used with biohazardous materials, toxins.
• Pyrogens is eliminated by distillation.
• Optic and Parental solution should be sterilized.

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Special powders
• Hygroscopic: substance absorb moisture from the air.
• Deliquescence: when hygroscopic material absorb moist form atmosphere till it dissolved in absorbed
water and form solution.
• Efflorescence: crystalline form liberate water and become powder.
• Effervescent: liberate Co2 with water

Others
• PEGylation: attachment of PEG to protein, peptide or antibody, to reduce its immunogenicity and
decrease its renal clearance; thus, prolong its circulation time.
• Blister pack improve adherence for old patients.
• Preservatives should be in multi-dose injection but should NOT be included in Large Volume Parenteral
• - Single dose vial: lack antimicrobial preservative.
- Multi dose vial: contain antimicrobial preservative.
• Micronization: a process of decreasing particles size. It increase its dissolution rate and efficacy.
• Lyophilization: (freeze drying) preserving biological material by removing the water from the sample,
which involves first freezing the sample and then drying it (sublimation), under a vacuum, at very low
temperatures.
• Sublimation: process of removal of water (ice) to vapor without going through liquid.
• Laminal flow hood should be inspected every year. HEPA filter should not be sprayed with alcohol.
• Matrix tablet: controlled drug delivery system, where drug is dispersed in polymer matrix. It could be
either:
- Erodible Matrix tablet: Erosion/degradation of the polymer is the rate limiting step.
- Non-erodible matrix tablet: drug diffusion is the rate limiting step.
• Fillers (for tablets and capsules): starch, lactose, Microcrystalline cellulose.
Binder: ex. Gelatin, cellulose, PEG, Starch.
Lubricant: decrease friction and improve tablet ejection. Ex. PEG, stearic acid salt.
Glidant: improve flowability. Ex. Starch, silica, talc. Angle of Repose: measure Glidant properties.
Anti-adherent: Reduce adhesion. Ex. Talc, starch.
Disintegrants: facilitate dissolution. Starch, corn starch, clay, cellulose.
• Emulsion problems: creaming, cracking, phase inversion.
• Levigating/wetting agent: decrease the surface tension between 2 ingredients. Ex. Glycerin
• Levigation: process of decrease particle size by Triturating it in a mortar, or Spatulating it on an
ointment slab or pad, with a small water to form paste.
* Levigation process:
1- triturate the solid by using pestle and mortar.
2- add levigating agent as lubricating agent.
• Surfactant used as wetting agent, detergent, emulsifier. Ex. Polysorbate 80 (tween 80).
• Emulsifier: agent the help 2 liquids mix. It should be soluble in oil and water. Ex. polysorbate
• Surfactant used in suppository: to improve drug dispersion/spreading in rectal mucosa.
• Adding cholesterol to liposome decrease its permeability and increase its stability.
• PEG 40: used as solubilizer, surfactant, emulsifier
• Pyrogen is removed by: ion-exchange chromatography, ultrafiltration.
• HPLC used for thermostable compounds.
• Pyrogen destruction by: heating, oxidation, hydrolysis, NaOH, double distillation.

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• Propylene glycol used as solvent in Diazepam injection.
• Light and temperature affect drug stability = Physical incompatibility
Drug components interact and precipitate = Chemical incompatibility
• Spray is the fastest dosage form.
• Metabisulfite: used as preservative, disinfectant and antioxidant. In parenteral formulation used as
antioxidant
• Particle size of internal phase affect the physical stability of oil-in-water emulsion.
• Eutectic temperature: lowest melting temperature.
• Benzyl alcohol: used as preservative.
• Surfactant: added to formulation to solubilize lipophilic active ingredients and also they could
solubilized lipids in stratum corneum.
• Any suspension: shake well before use.
• Isotonicicty is measured by depression in freezing point.

Biotechnology/ Recombinant
Colony Stimulating factors
• Pegfilgrastim/Filgrastim: Recombinant Granulocyte colony stimulating factor, stimulate production of
white blood cells. Used to treat neutropenia, chemotherapy induced neutropenia.
• Erythropoietin/Epoetin: (hormone primarily produced by kidney to produce RBCs), used to treat
chemotherapy induced anemia.

Monoclonal antibodies:
• Infliximab: chimeric recombinant (human + murine), TNFα antibody, used for autoimmune diseases. Ex.
Psoriasis, RA. Require monitoring of BP and infection.
• Rituximab: is chimeric monoclonal antibody (human + murine). It attacks B cell and decrease its activity;
hence, used to manage autoimmune diseases such as RA, SLE, myositis, vasculitis.
• Anakinra: recombinant protein of human interleukin 1 receptor antagonist protein. Treat RA
• Bevacizumab: anti-vascular endothelial growth factor (anti-VEGF) monoclonal antibody, prevent
angiogenesis (formation of blood vessels). Thus, prevent metastasis.
• Nomenclature:
- mab = monoclonal antibody
(-mu-mab) Ex. Adalimumab = human monoclonal antibody
(-xi-mab) ex. Infliximab = chimeric monoclonal antibody
• Flu like symptoms occur at start of therapy.

DNA:
• Purine bases: Adenine and Guanine
• Pyrimidine base: Thymine, Cytosine and Uracil.
• Oligonucleotide probe: a small single strand DNA/RNA that detect complementary nucleic acid
sequence.
• Nucleoside = Base (A,T,C,G) + Sugar (Ribose, Deoxyribose)
Nucleotide = Nucleoside + Phosphate group

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• Histone: alkaline (positive charged) proteins
Nucleosome: 8 histones bound to DNA
Chromatin: repeating units of nucleosome.
Chromosome: condense chromatin.
• DNA transcribed to mRNA which is translated to Protein.
• Anti sense DNA strand: is strand that transcribed to mRNA. Therefore, mRNA will be similar to sense
strand, except uracil (U) instead of thymine (T) base.
•
• SDS-Gel electrophoresis: used to separate proteins.
Sodium Dodecyl Sulfate (SDS): denature protein (lose its configuration)
• Gel Electrophoresis: method of separation of proteins, DNA, RNA and protein according to
charge/molecular size.
• Polyacrylamide Gel Electrophoresis (PAGE): small pores. Separate proteins and DNA
• Agarose Gel Electrophoresis (AGE): large pores. Separate DNA.
• Centrifugation: separation of organelles/macromolecules based on size affected by gravity.
• Mass spectrometer: measure mass of charged particles. Use Mass/ion charge ratio.
* Electron ionization: result well established fragmentation pattern that is useful in identification of
unknown.
• Proteomic: large scale study of proteins (protein expression, interaction, discovery,….)
• Southern blot: Detect DNA
Northern blot: Detect RNA
Western blot: Detect Protein.
Eastern blot: Detect protein post translational modification.
* SNOW DROP
• Viral Vectors:
- Adenovirus: infect variety of mammalian cells. Don’t integrate into host genome; thus, suitable for
transient expression
- Retrovirus: only infect dividing cells. Integrate genetic material into host genome; thus, suitable for
stable expression.
- Lentivirus: can infect both proliferating and no proliferating cells. Used for transient and stable
expression.
• Reverse transcriptase: enzyme convert RNA to cDNA. Used by viruses to convert it’s RNA to DNA; thus,
it could integrate in host genome for replication.
• IgG is the most abundant antibody, while IgM is the first antibody to be made.
• Some bacterial don’t have the necessary post-translational modification to produce human proteins.
• Virus can’t grow in growth media (artificial media); unlike, bacteria. Virus must grow in living cells.

Side Effects
• Heparin-induced thrombocytopenia (HIT): low platelet count after administration of heparin, that could
lead to thrombosis, therefore it is called Heparin Induced Thrombocytopenia and Thrombosis (HITT).
• ACEI could cause angioedema. ARBs could also cause angioedema (with unknown mechanism).
Angioedema is not first dose side effect, it could happen after days/weeks of starting the drug.

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• Lupus (SLE) caused by “HIPPP MCQ”? (Hydralazine (vasodilator), INH (isoniazid), Phenytoin,
procainamide, penicillamine, methyldopa, chlorpromazine and quinidine.
* Hydralazine used to treat HTN, SE: fluid retention.
• Steven Johnson Syndrome and Toxic Epidermal Necrolysis caused by medications (SASPAN):
Sulfonamides (sulfa drugs), Allopurinol, Penicillin, AED, NSAID.
•
• Most Serious SE of Oral contraceptives: Thrombotic events.
• Isotretinoin SE: teratogenic, IBS, photosensitivity, depression, suicide thoughts, hypertriglyceridemia,
pseudotumor cerebri.
• Salicylate (ASA overdose) intoxication:
- first 12 hours: respiratory alkalosis + alkaluria
- 12-24 hours: Respiratory alkalosis + Aciduria.
- 24 hours or 4-6 hours in children: dehydration + hypokalemia + metabolic acidosis
• Prolonged use of topical decongestants (phenylephrine, xylometazoline) cause Rhinitis Medicamentosa
(rebound congestion).
• Statins SE: Myopathy, Rhabdomyolysis, neuropathy, Lupus like symptoms
• Methotrexate SE: mucositis.
• Erectile dysfunction is a side effect of Diuretics and B-blockers. ACEI and ARBs are not related to sexual
dysfunction.
• Photosensitive drugs:
- Retinoids (isotretinoin, adapalene)
- Antibiotics: Tetracycline, Doxycycline, Trimethoprim, Ciprofloxacin, Dapsone, Griseofulvin (antifungal),
- Hydroxychloroquine (antimalarial).
- Anti arrhythmic: Amiodarone, Quinidine.
- Diuretics: thiazides, furosemide, triamterene.
- Sulfonylurea: glyburide, glipizide.
- NSAID: Ibuprofen, Naproxen, piroxicam.
- Anti Neoplastic: 5-FU
• Urine change in color with: Rifampin (red), warfarin (pink), ferrous (black), nitrofurantoin (brown),
rhabdomyolysis
• Antimalarial: Hydroxychloroquine and chloroquine cause irreversible retinopathy.
• Ethambutol: cause optic nerve toxicity
• Estrogen receptor modulator (ex. Raloxifene, Tamoxifen) SE: hot flashes, cramps
• Colchicine SE: Nausea, Vomiting, Diarrhea, Cramps. CI: hepatic and renal patient.
• Gabapentin and Pregabalin, SE: double vision, ataxia, sedation, weight gain, respiratory depression.
• Corticosteroids SE: HTN, Hyperglycemia, truncal obesity, muscle atrophy, cataract, infections and
avascular necrosis, osteoporosis, CVS events. It counteract insulin; therefore, increase insulin dose is
required.
• Folic acid deficiency in pregnancy cause neural tube defect, spina bifida.
• Cardiotoxic drugs: Antiviral (Zidovudine/Azidothymidine: against HIV), anticancer (Cisplatin, doxorubicin,
imatinib), oral antidiabetic (Thiazolidinediones)
• Tricyclic antidepressant (TCA) ex. Amitriptyline, Clomipramine. SE: anticholinergic (dry mouth, blurred
vision, constipation), antihistaminic (sedation, weight gain), lower seizure threshold, sexual dysfunction,
orthostatic hypotension.

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• Phenytoin side effect (PHENYTOIN): P- p450 inducer, H- hirsutism, E- enlargement of gums, N-
nystagmus, Y- yellow skin (sjs), T- teratogenic, O- osteomalesia, I- interferes folic absorption, N-
neuropathy
• PPI side effects: diarrhea, hypomagnesemia, decrease vitamin B12, bone fractures.
• NSAIDs increase water and Na retention; thus, increase BP. Aspirin doesn’t increase risk of HTN.
Ibuprofen increase risk of HTN and stroke. Diclofenac increase risk of stroke. Naproxen and Celecoxib
doesn’t increase the risk of HTN or stroke.
• Vancomycin: SE: Red man syndrome (red rash on neck and face)
Chloramphenicol SE: Grey baby syndrome (grey skin, vomiting)
Amiodarone SE: Grey man syndrome (blue-grey pigmentation)
Warfarin SE: purple toe syndrome (purple lesion in toe)
• Acetaminophen can cause acute hepatic failure.
• Toxic nephropathy drugs: penicillin, cephalosporins, Thiazides, furosemide, NSAIDs, Rifampicin, cisplatin,
cyclosporine, penicillamine.
• Macrolides (erythromycin, clarithromycin): SE: hepatitis, QT prolongation, potent CYP inhibitor except
Azithromycin. (not related to nephrotoxicity)

Teratogenic drugs:
• Rubella could cause fetal defect and deafness. CMV could cause deafness.
•
•

Drug interactions/ Contraindication:

Enzyme inducers/inhibitors
• CYP 3A4 inducers AED (Carbamazepine, Phenobarbital, St. John’s Wort, Phenytoin) decrease serum
conc. of Oral contraceptives. A solution could be using progestin depot injection or use intrauterine
device.
• CYP inhibitor: Grape fruit, Azole antifungal, macrolides, Amiodarone, Valproic acid.
• Enzyme Inhibitors: Macrolides (except Azithromycin), Quinolones (except levofloxacin), verapamil,
diltiazem, itraconazole/fluconazole/Miconazole, Grapefruit,
• Enzyme Inducers: Phenytoin, Phenobarbital, Carbamazepine, St john Wart, Rifampin
• Drugs that inhibit warfarin metabolism; thus, increase bleeding risk:
Azole Antifungal, cephalosporins, macrolides (erythromycin), quinolones (ciprofloxacin), allopurinol,
cimetidine, amiodarone.
• Clarithromycin is enzyme inhibitor so inhibit metabolism of SSRI
• Erythromycin is Cyp 3A4 inhibitor; thus, Sildenafil dose should be reduced.
- Azithromycin is not Cyp inhibitor.
• Lamotrigine + Valproic acid = lamotrigine metabolism decrease; thus, the dose should be reduced.
Lamotrigine + Carbamazepine= lamotrigine metabolism increase; thus, the dose should be increased.

• The best AED choice with COC is: Lamotrigine. Lamotrigine level could drop when used with COC
(combined oral contraceptive); therefore, lamotrigine level should be measure before and after COC and
consider doubling Lamotrigine dose after starting COC.
• Parkinson Disease become worse with these medications: first generation antipsychotic drugs
(chlorpromazine, fluphenazine, Haloperidol), metoclopramide (antiemetic, inhibit D2 receptor in CTZ)

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• Peginterferon: Contraindicated with Acute Hepatitis B Virus.
• Avoid antacids with tetracycline, quinolone (ciprofloxacin, levofloxacin, moxifloxacin), Digoxin. Separate
with 2 hours.
• B2 agonist (Salbutamol, Salmeterol) could lead to hyperglycemia, so contraindicated with Diabetic pts.
• Contraindicated in Pregnancy: ASA
• Bismuth (anti diarrheal) decrease the anti-HTN effect of ACEI, ARBs and B-blocker.
• Breastfeeding contraindicated with:
- Codeine: serous side effects and lead to death of children.
- Meperidine: has neurotoxic metabolites.
• Codeine is converted by CYP2D6 to morphine; thus, its effect and toxicity affected by poor metabolizers
and ultra-metabolizer. Therefore, its better to use morphine instead.
• Corticosteroids injection contraindicated in Achilles tendonitis where risk rupture is highest.
• Gabapentin and Pregabalin contraindicated with opioids due to risk of respiratory depression.
• Renal patients:
- With Thrombus: avoid Heparin and OAC (Dabigataran, Apixaban, Rivaraxaban), but can use Warfarin.
• Serotonin syndrome caused when combine MAO with
Dextromethorphan, Tramadol, Triptan, St John Wart, TCA, SSRI, SNRI, ephedrine, pseudoephedrine,
Buspirone, ondansetron.
• Acetylsalicylic acid bind to plasma protein; thus, displace other drugs such as phenytoin, thyroxin,
valproic acid.

Drugs
Warfarin
* Warfarin monitoring: measure INR (normal 2-3).
* Increase INR >3 (blood thinning) indicate: overdose warfarin, heparin, LMWH, ASA/NSAID,
acetaminophen.
* Decrease INR<2 (blood thickening): Vitamin K, oral contraceptives.
• With Warfarin: INR normal value 2-3, but 2.5-3.5 with mechanical heart valve.
If INR < 2: increase warfarin dose by 5-15%
If INR 3 – 5 and no bleeding: lower dose, omit dose and monitor
If INR 5-9 and no bleeding, skip day.
If INR 5 – 9 with bleeding, skip dose + oral vitamin K
If INR > 9, no bleeding, hold warfarin + oral vitamin K
If INR > 9 with bleeding, hold warfarin + IV vitamin K.
• Alcohol drinking increase risk of bleeding while taking Warfarin.
• Drugs that inhibit warfarin metabolism; thus, increase bleeding risk (increase INR):
Azole Antifungal, cephalosporins, macrolides (azithromycin, Clarithromycin), quinolones (ciprofloxacin),
allopurinol, cimetidine, amiodarone, alcohol drinking (binge drinking)
• Drugs that decrease INR
increase warfarin metabolism: phenobarbital, barbiturate, phenytoin, St Johns Wort, Rifampin
Decrease warfarin absorption: Azathioprine, cholestyramine, sucralfate, estrogen.
• Each warfarin concentration has a different tablet color.

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Dextromethorphan
• Cough suppressant and increase serotonin

NSAIDS:
• Generally, Ibuprofen has the lowest risk.

Pyridoxine Vit B6
• Isoniazid cause neurotoxicity, that’s why pyridoxine B6 is good with it.
• It increase Levodopa breakdown; therefore, it increase its peripheral side effect.

Folic acid:
• Diabetic pregnant: 5 mg for 3 months before gestation then continue for 12 weeks. After 12 weeks use
0.4-1 mg throughout pregnancy and 6 months postpartum or till finish breastfeeding.
• Pregnant woman taking AED should take 1 mg folic acid daily, 3 months before gestation and at first 12
weeks of pregnancy. If the patient taking Valproic acid or have history of neural tube defect, 4 mg daily
is recommended. From 12 weeks to as long as breast feeding continue, 0.4:1mg folic daily
recommended.
• Used with Vit B12 in pernicious anemia (high MCV)
• Counteract Methotrexate GIT side effects such as mucositis (mouth ulcers)

Structures

• Xanthine oxidase inhibitor

•

• : both Pyrophosphate and Bisphosphonate are structurally similar.

•

• Benzodiazepine structure:
• Cis: functional group on same side. Trans: functional group on opposite side.
• Homology: the difference between 2 compounds is (CH2) group
Analog: same skeletal structure but different functional group attached.
Bioisosters: functional groups or atoms with similar physical and chemical properties, can be
substituents. Ex. Bromine vs Chlorine, Methyl vs Ethyl

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•
• Warfarin has a coumarin ring.
• Omega 3: double bond located 3 carbons away from the molecule end
- Omega 6: double bond located 6 carbons away from the molecule end
- Omega 9: double bond located 9 carbons away from the molecule end
• Heme is composed of tetra pyrrole.

• Vitamin B12: tetra pyrrole with cobalt in center

• Purine bases: Adenine and Guanine

• Pyrimidine base: Thymine, Cytosine and Uracil.

• Folic acid: has Pteridine nucleus.

•
• Carbonic anhydrase inhibitors (ex. Acetazolamide, Dorzolamide) has sulfonamide group.

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• Sulfhydryl group is the active group in Captopril, while the active group in other ACEI is carboxylic acid.

Isomers
• Isomers: have same molecular formula
• Constitutional isomers (structure isomers): same molecular formula + different connectivity
• Conformational Isomers: isomers are identical by rotation around single bond
• Stereoisomers: same molecular formula + same connectivity + mirror image
• Diastereomers: Same molecular formula + same connectivity + not mirror image (more than 1 chiral
center) subtype is Epimer: only one chiral center is different.
• Geometric isomers: in one isomer two atoms or groups are on the same side of the plane of a double
bond or ring (Cis), whereas in the other isomer they are on opposite sides (Trans).

Herbal:
• Foxgloves planet is the source of Digoxin. SE: blurred vision, small eye pupils, excessive urination,
tremors, convulsions.
• Belladonna used for nausea, vomiting, motion sickness, nocturia, tremors and rigidity caused by
Parkinson disease. SE: blurred vision, dry mouth, enlarged pupils, inability to urinate or sweat.
• FeverFew used for migraine
Prime rose: premenstrual cycle
St. John Wort: antidepressant
Saw palmetto: BPH
Echniacea: common cold
Garlic: Lipid levels.
Ginkgo: increase memory
Vincristine, Vinblastin: anticancer.
•

Lab Tests
• Creatine Kinase: increase after heater attack, muscle injury (myopathy), drinking too much alcohol.
• Creatinine level (blood): increase with impaired kidney function.
• Creatinine Clearance Rate: estimate glomerular filtration rate (GFR) = rate of blood flow through
kidneys.
• Pregnancy test could give false-positive result if patient is taking fertility medicine (contain Human
Chorionic Gonadotropin (hCG)). Most antibiotics and contraceptive pills don’t affect the test results.
• Plasma Viral Load: measure how much HIV is in the blood.
• PSA test used to screen for Prostate Cancer.
•

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Extra
Atrial Fibrillation

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