Pharmacology Revision E6.5 (Medmutant - Xyz)

www.medmutant.
xyz Pharmacology Revision 1 01 1
PHARMACOLOGY REVISION 1 ----- Active space -----
General Pharmacology 00:00:10
Types of drugs :
Types of drugs Description
Orphan drug Used in the treatment of rare diseases.
Essential drugs Satisfying the health care need of majority of the
population.
Features :
a. Single molecule (Not FDC).
b. Safe.
c. Easily available.
d. Affordable.
Prescription drugs Belonging to schedule H class.
Given only after producing prescription.
Spurious drugs Not producing adequate response due to inadequacy in
the drug.
Misbranded drugs Wrongly labelled drug.
Adulterated drugs Drugs with additional unwanted component.
Rational drug use :

• The use of the right drug for the right disease & patient, at the right dose,
duration & route, with the right dispensation and monitoring.
• Right price is not a part of rational drug use.
Pharmacokinetics and Pharmacodynamics :

Pharmacokinetics Pharmacodynamics
1. Drug Absorption
2. Drug Distribution
Drug → Target → Effect
3. Drug Metabolism
4. Drug excretion
Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

2 01 Pharmacology www.medmutant.xyz
----- Active space -----

Pharmacokinetics : Absorption 00:06:57
M/C mechanism : Passive diffusion.

Passive diffusion : Maximum at unionised/non-polar (Lipid soluble) state.
• Acidic drugs → Acidic medium (Stomach : HCl).
• Basic drugs → Alkaline medium (Duodenum : bile).
Maximum absorption of drugs : Small intestine (Duodenum) d/t large surface
area.
Poor oral absorption : Proteins/large-size molecules :
• Peptides (Ends with tide).
• Enzymes (Ends with ase).
• Monoclonal antibodies (Ends with mab).
Types of tablets/capsules :
Plasma concentration
Time
Sustained release &

Enteric coated
Controlled release
↑ duration of action of
Used for :
drugs.
1. Acid labile drugs. Eg. : PPI.
Used in drugs with
2. Prevention of gastric irritation. Eg. : Aspirin.
short t1/2 (< 4h).

www.medmutant.xyz Pharmacology Revision 1 01 3
Extent and rate of absorption : ----- Active space -----
Bioavailability (BA)/ Rate of absorption

Extent of absorption
Fraction of unchanged drug reaching Cmax
Concentration (C)
the systemic circulation.
Ranges from 0-1 (0 = 0% ; 1 = 100%).
Only route with 100% : IV.
Tmax
Time (T)
Depends on : Cmax : Maximum concentration of drug
• First pass metabolism. that can be achieved.
• Absorption. Tmax :
• Time taken for Cmax.
• Marker for rate of absorption.
AUC B C D
Concentration (C)
Oral A
AUC
IV
Time (T)
Rate of absorption : A > B > C > D.
(AUC : Area Under Curve).
BA = AUC oral × 100

AUC IV
AUC denotes : Bioavailability.
P-Glycoprotein (Pgp)/MDR-1 (Multi Drug resistance-1) pump :

Membrane protein on intestinal epithelial cells.
Pgp → Drug efflux → ↓ Absorption → ↓ BA.
• Pgp inducer → Drug failure.
• Pgp inhibitor → Drug toxicity.

----- Active space ----- Pgp substrates Pgp inducers Pgp inhibitors (“VACINE”)
V : Verapamil
Digoxin Enzyme inducers. A : Amiodarone
Protease inhibitors. Eg. : C : Cyclosporine
Loperamide Rifampicin. I : Itraconazole
Bile acid Quinidine N : Nifedipine
E : Erthyromycin/Clarithromycin
Pharmacokinetics : Distribution 00:26:10
Volume of Distribution (VD) :

Apparent VD (aVD) :
Factors affecting :
1. Lipid solubility/pKa (pH at which the drug is 50% ionized).
2. Adipose tissue (More in obese people).
3. Plasma protein binding :
a. Albumin binds to acidic drugs.
b. α-1-acid glycoprotein binds to basic drugs.
Formulae :
D D : Dose of the drug.
aVD =
C0 C0 : Initial plasma concentration.
Loading dose = aVD X Ct. Ct : Target plasma concentration
Loading dose depends on apparent volume of distribution.
Dialysis :
Ineffective against drugs with high VD : “BAD-DOC”.
Drug Antidote
Benzodiazepines Flumazenil
Beta blockers Glucagon
Amphetamine Ammonium chloride
Digoxin Digibind
- -
Opioids Naloxone
Organophosphates Atropine
Calcium channel blockers Calcium gluconate

Pharmacokinetics : Metabolism 00:25:18 ----- Active space -----
Phase I reactions Phase II reaction

Drug inactivation. Make the drug water soluble.
Exception : Prodrugs → Activation.
M/C reaction : Oxidation. M/C reaction : Glucuronidation
Enzymes : M/C enzyme : Glucuronyl transferase.
• CYP450 enzymes (Cytochrome pig- Deficiency
ment). ↓
• M/C : CYP3A4. Criggler Najjar syndrome
3 → Family. ↓
A → Subfamily. ↑ Toxicity of :
4 → Gene locus. • Atazanavir.
• Irinotecan.
Enzyme Inducers Enzyme Inhibitors

Effect Drug failure Drug toxicity
Erythromycin → Theophylline toxicity.
Examples Rifampicin → OCP failure
Clarithromycin → Statin toxicity.
“GRAB Priyanka Chopra” “QuICK VEG Dish”
G : Griseofulvin Q : Quinidine
I : Isoniazid.
R : Rifampicin
Inhibitors of protease.
A : Alcohol C : Cimetidine,
Chloramphenicol,
B : Benzopyrene
Ciprofloxacin
P : Phenytoin. K : Ketoconazole.
Drugs
Primidone. Itraconazole.
Phenobarbital. Fluconazole.
V : Valproate
E : Erythromycin/clarithromycin
C : Carbamazepine. G : Grape juice
Cigarette smoking. D : DEC.
Delavirdine.
Disulfiram.


Drugs metabolised by plasma esterase :
“Plasma Esterase Can Readily Metabolise Short Acting drugs”.
Procaine, Cocaine
Esmolol
Clevidipine
Remifentanil, Remimazolam
Mivacurium
Succinylcholine
Acetylcholine
Pharmacokinetics : Excretion 00:41:34
M/C organ for excretion : Kidney.

For excretion :
• Best state of drug : Water soluble/Ionised/Polar.
• pH of medium (urine) and drug must be different.
Drug toxicity Antidote

Aspirin Bicarbonate
Amphetamine Ammonium chloride
Mechanism of excretion :
Filtration Tubular secretion
20% of excretion 80% of excretion
Excretes only free drugs (Not plasma Excretes both free and plasma protein
protein bound) bound drugs.
Formulae :
Rate of drug elimination (mg/h) = PC × CL.
PC : Plasma concentration.
Infusion/Dosing rate (To acheive steady
CL : Clearance.
state) = PC × CL.
t : Time.
Maintenance dose = PC × CL× t. VD : Volume of Distribution.
t1/2 = 0.693 × VD/CL Ke (Elimination constant) = VD/CL.
t1/2 = 0.693/Ke.

Zero order Vs. First order kinetics : ----- Active space -----
Zero order kinetics First order kinetics

Constant amount of drug Constant proportion of
Mechanism is eliminated per unit time. drug is eliminated per unit
time.
Zero order kinetics First order kinetics
Clearance ↓ Constant
Half life ↑ Constant
↑ Dose
Plasma ↑ Disproportionately ↑ Proportionately
concentration
Alcohol Most of the drugs follow
Theophylline first order kinetics.
Tolbutamide
Examples Phenytoin
Heparin
Methanol
Warfarin

----- Active space ----- PHARMACOLOGY REVISION 2
Pharmacodynamics 00:00:09
Drug Target Effect.
Affinity Efficacy
Terms Definition
• Tendency of a drug to bind to a target.
Affinity
• Dose required to bind to target.
• Maximum clinical effect produced by a drug.
Efficacy
• Effect produced (Most important clinically).
• Relative dose of a drug required to produce a particular effect.
Potency • Potency a 1/Dose.
Dose Response Curve (DRC) 00:04:13
Quantal DRC Graded DRC

Response : Binary (Yes/ No). Response : Graded.
Eg. : Sedation, Pregnancy.
DRC in a population. DRC in an individual.
Response Response
100 A-Enalapril B-Captopril

% of Effect Toxicity Lethality
population
50 C-Nifedipine
0
Log dose
ED50 TD50 LD50 Log Dose
ED50 : Dose required to produce effect in Efficacy : B > A > C. Taller graph Higher
50% population. Marker of potency. Efficacy.
TD50 : Dose required to produce toxicity in Potency : A > B > C. Lesser dose More
50% population. marker of toxicity. potent.
LD50 : only in animals. Dose required to kill Affinity : A > B (Affinity can be compared
50% animals. marker of toxicity. only if the drugs act on same
target Only if DRCs are parallel).

Therapeutic index (T.I) : ----- Active space -----

• Humans = TD50 , Animals = LD50
ED50 ED50
• Measure of drug safety range.
Therapeutic window/range :
MTC
Plasma Therapeutic
Concentration window
MEC
Time
• MEC (Minimum effective concentration) : Effect seen only beyond MEC.
• MTC (Minimum toxic concentration) : Toxicity begins beyond MTC.
• Therapeutic range = between MEC & MTC.
Drug receptor interaction 00:16:24
A : Full agonist
• Full agonist : Maximal effect (+1).
B : Partial agonist
• Partial agonist : Submaximal effect (+1 to 0).
• Antagonist (m/c) : No effect (0). C : Antagonist
• Inverse agonist : Opposite effect (0 to -1). D : Inverse agonist_~ Antagonist
Types of antagonism :
Types Examples
1. Physical/pharmacokinetic Alcohol : Charcoal.
2. Chemical Heparin : Protamine sulphate.
Iron : Desferrioxamine.
3. Physiological Histamine (H1) → Bronchoconstriction.
Adrenaline (β2) → Bronchodilation.
Pharmacology • v4.5 • Marrow 6.5 • 2023

----- Active space ----- 4. Competitive (Pharmacological) 5. Non-competitive

Response Response Response
Drug Drug + Antagonist Drug

Drug + Antagonist
Log dose Log dose Log dose
Right shift of DRC. Decrease in height of DRC.

Efficacy → Same, Vmax → Same. Efficacy , Vmax .
Potency , KM . Potency → Same, KM → Same.
Vmax a Efficacy, KM a 1 /Potency.
Receptors :
1. Ligand gated ion channel 3. Enzymatic
• GABAA. Tyrosine kinase receptors :
• Glutamate. • EGFR (Epithelial growth factor receptor).
• Nicotinic. • VEGFR(Vasculo Endothelial growth factor receptor).
• 5HT3. • Her-2.
• Insulin, IGF-1.
2. Nuclear • Toll like receptors.
Located in cytoplasm : Janus Kinase Receptors(JAK) :
• Vitamin D receptors. • Leptin.
• Androgen receptors. • Growth hormone receptor.
• Mineralocorticoid receptors. • Prolactin receptor.
• Glucocorticoid receptors. Guanylate cyclase receptors :
Located in nucleus : • Atrial natriuretic peptide (ANP).
• Thyroid receptors. • Brain natriuretic peptide (BNP).
• Estrogen receptors.
• Progesterone receptors.
4. G-Protein Coupled Receptors (GPCRs) :

Gs :
• Gs → Stimulates Adenylate cyclase → cAMP → Smooth muscle relaxation
(bronchodilation), cardiac & skeletal muscle contraction.
• E.g : β1 receptors → Dobutamine used in Congestive Heart failure (CHF).
β2 receptors → Salbutamol.
• cAMP is metabolised by
-
a. PDE 3/4 in bronchi Theophylline (Used in asthma).
b. PDE 3 in heart - Milrinone (Used in CHF).
Gq : ----- Active space -----

• Gq → Stimulates Phospholipase C → PIP2 → IP3 → Ca2+ → Smooth
muscle Contraction.
• Eg. : α1 receptor, Angiotensin Receptor, Oxytocin, M1, M3 receptors.
Gi/o :
• Gi/o → cAMP & Ca2+→ Relaxation.
• Eg. : M2 receptors in heart.
G12/13 :
• G12/13 → Stimulates Rho kinase.
• Rho kinase blockers :
a. Fasudil → Vasodilator in stable angina.
b. Netarsudil → Glaucoma.
c. Belumosudil → Graft v/s host reaction.
Trials 00:33:39
Preclinical Trials : Animals.

Clinical Trials : Human → Drug under trial is called as investigational new drug.
Phases Features (mnemonic : TEL)

Human Pharmacology and Toxicity Study
Pharmacokinetics. Toxicity. 20-100 normal healthy volunteers.
1-2 years.
Pharmacodynamics. Safety. Open label trial.
1 Maximum tolerable dose.
Exception for normal healthy volunteers in Phase 1 : Trial for anti-cancer &
anti- HIV drugs.
Therapeutic Exploratory Trial. 100-500 patients, Unicentric.
II Dose range. 2-3 years.
Safety. Randomized Controlled Trial
Determine Efficacy. (RCT).
Therapeutic Confirmatory Trial. 500-3000 patients, Multicentric.
III Safety. 3-5 years.
Confirm Efficacy. RCT/RUCT.
Drug is approved by CDSCO/FDA & marketed..
Post Marketing Surveillance. Many thousands.

IV No specific duration.
Rare Adverse Drug Reaction (ADR).
Long term ADR. Open label trial.
Phase 0 : Microdosing.
Others Phase V : Pharmacoepidemiology.


Adverse Drug Reactions (ADR) 00:38:14
ADR types Examples

A (Augmented)
Antihypertensive causing hypotension.
Dose Dependent
B (Bizarre)
Drugs causing hypersensitivity.
Dose independent
C (Chronic)
Steroids causing HPA suppression.
Dose and Duration dependent
D (Delayed) Drugs causing teratogenicity.
E (End of use : Withdrawal) Opioid withdrawal.
Clonidine withdrawal hypertension.
F (Failure of drug) Enzyme inducers causing OCP failure.
Pharmacovigilance :
ADR reporting software : Vigiflow.
National coordinating centre : IPC ghaziabad (Forms conclusive report).
CDSCO Delhi : Bans the drug based on the report.
International pharmacovigilance center : Uppsala, Sweden.
Therapeutic drug monitoring 00:41:42
Principle : The plasma concentration of a drug should have a good correlation

with effects or side effects.
Indications :
• Clinical effect of a drug cant be easily quantified. E.g., antiepileptics
If can be quantified, TDM not done. Eg. : β blockers, antidiabetics, Warfarin.
• Low therapeutic index, E.g.
A : Aminoglycosides.
Low : Lithium.
Therapeutic : Theophylline.
Drug : Digoxin.
Causes : Cyclosporine.
Toxicity : Tacrolimus, Tricyclic antidepressant.
• Drugs with variable metabolism. Eg. : Drugs metabolized by acetylation.
• To check compliance. Eg. : Antipsychotic.
Important drugs : ----- Active space -----

Digoxin :
• Therapeutic range : 0.5–0.9 ng/ml.
• Toxicity : >2 ng/ml.
Lithium :
• Therapeutic range :
Mania prophylaxis : 0.6–1.0 mEq/L.
Mania treatment : 1.0–1.5 mEq/L.
• Toxicity : >1.5 mEq/L.
• Dialysis : >4 mEq/L.
Theophylline :
• Therapeutic range : 5–15 mg/L.
• Toxicity : > 15 mg/L.
Pharmacogenetic conditions 00:44:04
A : Acetyl transferase polymorphism (NAT-1 gene – Fast acetylators;

NAT-2 gene – Slow acetylators).
Malignant : Malignant hyperthermia with lignocaine, halothane, Succinylcholine.
Gene : G6PD deficiency associated hemolysis,
Glucunoryl Transferase polymorphism causing irinotecan toxicity.
Causes : CYP 450 enzyme polymorphisms.
Very : VKORC1 gene polymorphism causing variable metabolism of warfarin
Severe : Succinyl choline associated prolonged apnea.
Toxicity : Thiopurine methyl transferase polymorphism causing azathioprine,
6-Mercaptopurine, 6-Thioguanine toxicity.
Drugs causing hemolysis in G6PD deficiency Drugs metabolized by acetylation
Dr → Dapsone. H → Hydralazine.
M → Methylene blue. I → Isoniazid.
A → Antimalarial (Primaquine). P → Procainamide. S/E : SLE.
N → Nalidixic acid, Nitrofurantoin. S → Sulfonamides.
I → Isoniazid. Dance → Dapsone.
S → Sulfonamides.
CYP450 polymorphism :
• CYP2C19 → Effect of clopidogrel.
• CYP2C9 → Variable effect of warfarin.
• CYP2D6 → Toxicity of antidepressants/antipsychotics.


Pregnancy drug categories 00:47:02
Classified into 5 categories based on safety in pregnancy :

1. Cat A.
2. Cat B. Safe in pregnancy.
3. Cat C.
4. Cat D : Can be used in pregnancy because of benefits greater
than risk might be acceptable.
Eg. : Valproate in juvenile myoclonic epilepsy. Unsafe in
5. Cat X : Absolutely contraindicated in pregnancy because of risk pregnancy.
greater than benefits.
Eg. : Thalidomide.

Autonomic Nervous System 00:02:47
ANS is divided into sympathetic and parasympathetic systems.

Type of NS Receptors Neurotrans- Rate Limiting Drugs
mitters Step
Para Muscarinic Acetylcholine Choline • Aminoglycosides : Block pre-
sympathetic (G-protein (ACh) reuptake. synaptic voltage gated Ca2+
coupled) channels → release of ACh.
& Nicotinic • Botulinum toxin : Blocks the
(ionic) release of ACh.
Sympathetic α1, α2 , β1 , Nor Tyrosine to • Metyrosine : Blocks tyrosine
β2 & β3 epinephrine. dopa (using hydroxylase (Rx of pheochro-
Exceptions : tyrosine mocytoma).
β3 : +nt on • Renal hydroxylase). • Blocker of VMAT 2 (vesicle
adiopocytes blood monoamine transmitter) :
vessels : Tetrabenazine : Huntington’s
Dopamine chorea (DOC), Tourette
(diuresis). syndrome (DOC for ticks).
• Adrenals Deutetrabenazine &
& sweat Valbenazine : DOC for tardive
glands : dyskinesia.
ACh.
Sys- Parasym- Parasympatholytic Sympathomimetic Sympatholytic

tem pathomimetic
↑ Cognition ↓ Cognition - S/E of Beta
Donepezil Scopolamine (truth se- blockers (lipid
soluble, crosses
CNS
(DOC for rum in narcoanalysis).

Alzheimer’s Thiopental sodium : DOC- BBB) : Depres-
disease). narcoanalysis sion, Insomnia,
Nightmares
Active Miosis Passive Mydriasis (m3 Active Mydriasis Passive Miosis
(M3 receptor receptor block) + (α1astimulation) (α1a block )
stimulation). Cycloplegia (block M3). Drugs : Drugs :
Drugs : Drugs : • Phenylephrine • Phenoxyben-
• Pilocarpine • Tropicamide • Ephedrine zamine
Pupil
• Physostog- • Atropine • Prazosin

mine • Homatropine
• Cyclopentolate
Pharmacology revision • v1.0 • Marrow 6.5 • 2023

----- Active space ----- Sys- Parasym- Parasympatholytic Sympathomimetic Sympatholytic

tem pathomimetic
Uses : Uses : -
Closed angle • Ocular fundus exam
glaucoma : • Prevention of synechiae formation in uveitis.
Pilocarpine • Adjuvant in fungal -
(DOC). corneal ulcer
• pain in iridocyclitis.
• Refractive error test
↑ Secretions. ↓ Secretions. - -
Oropharynx
Used in Preanesthetic drug

Xerostomia Glycopyrrolate (qua-
(Pilocarpine, ternary amine, no BBB
Cevimeline). crossing) > Atropine.
Constriction Dilation Dilation Constriction
C/I in asthma Inhalational - PMDI : • SABA : Salbutamol, Beta blockers
& COPD. • LAMA (OD) : Tiotropium Terbutaline, Pirbu- C/I in asthma
(DOC in COPD), Ume- terol (COPD & BA). & COPD.
Brocnhi
clidinum , Revefenacin. • LABA : Formoterol, (Cardioselective

• IAMA (BD) : Aclidinium Salmeterol beta blockers
• SAMA (QID) : Ipratro- • VLABA : Olodaterol, can be used
pium. Vilanterol, Carmo- with caution).
M/C S/e : Dry mouth terol
↓ HR & ↑ HR & AV conduction. ↑ HR, AV conduction ↓ HR &
AV conduction. Atropine. & ↑ Contractions.AV conduction.
Edrophonium. Used in : Epinephrine. ↓ Contractions
Used in PSVT • Bradycardia (DOC, at Used in : DOC for :
Heart
/ SVT. dose > 0.5mg). • Bradycardia (Chil-

1. A. fibrillation/
• AV block (digoxin tox- dren) flutter : Rate
icity) • Cardiac arrest control
2. HOCM
3. Aortic
dissection
LAMA : Long acting muscarinic agent ; IAMA : Intermediate acting muscarinic agent,
SAMA : short acting muscarinic agent.
OD : once daily, BD : twice daily, QID : Four times a day.
PMDI : Pressurized Metered dose inhaler
SABA : short acting Beta Agonists, LABA : Long acting Beta Agonists,
VLABA : Very Long acting Beta-Agonists.
PSVT : Paroxysmal supraventricular tachycardia.
HOCM : Hypertrophic obstructive cardiomyopathy.
Note :
• Salbutamol, Terbutaline, Pirbuterol, Formoterol : Long acting → Can be used
as reliever in intermittent asthma (<2 attacks/ week).
• Formoterol/salbutamol + ICS (inhaled corticosteroids) : Used in persistent
asthma. ----- Active space -----

• Olodaterol, Vilanterol, Carmoterol : Not used in asthma, only used in COPD.
• S/E of β2 agonist : Palpitations & tremor d/t hyperglycemia & hypokalemia.
System Sympathomimetic Sympatholytic
Vasoconstriction Vasodilation
Uses : Uses :
• Spinal anesthesia induced hypotension: • Preoperative HTN in pheo : Phenoxy-
• Normal/ ↑ HR : Phenylephrine benzamine (DOC)
Blood • ↓ HR : Ephedrine • Cheese reaction, Clonidine withdraw-
vessels • Postural hypotension : Midodrine (DOC) al HTN , Intraoperative HTN in pheo :
• Cardiogenic, septic, neurogenic shock : Phentolamine (DOC)
IV Norepinephrine (DOC). • Scorpion bite induced HTN or
• Anaphylactic shock : Epinephrine (DOC) pulmonary edema : Prazosin (DOC)
• decreases NE release (exception) : • HTN + BPH : Terazosin , Doxazosin
Clonidine (α2 agonist). • HTN (young age) : Beta blockers
Note :
• Epinephrine acts on beta 2 receptor (0.5 mg IM at 1: 1000 dilution).
• S/E of clonidine : withdrawal HTN d/t α2 down regulation (Rx : Phentolamine).
• Rx of pheochromocytoma : Alpha blockade → Beta blockade.
GIT Parasympathomimetic Parasympatholytic

HCl &
contractions ↑ ↓
Uses Gastroparesis & Postop ileus : • Antispasmodics : Glycopyrrolate, Dicyclomine,

Bethanechol, Neostigmine Scopolamine.
• Peptic ulcer disease (rarely used) :
Pirenzepine, Telenzepine.
Note :
• DOC for motion sickness : Scopolamine (transdermal patch at least before 4
to 5 hours of travel, to achieve steady state concentration).
Bladder :
Parasympathomimetic Parasympatholytic Sympathomimetic
MOA Detrussor contraction Detrussor Relaxation Detrussor Relaxation
(M3 agonism) (M3 blockade) (M3 blockade)
Bladder atony/ Overflow Overactive bladder/Urge Overactive bladder/Urge
Uses incontinence. incontinence incontinence :
Post operative urine re- Mirabegron,Vibagron
tention. (β3 agonists).

----- Active space ----- Parasympathomimetic Parasympatholytic Sympathomimetic

eg : Bethanechol eg : Friend DOST : Stress incontinence :
Neostigmine Fesoterodine, Darifenacin, Duloxetine (SNRI) by ↑ NE
Oxybutynin, Solifenacin, stimulating α1 (Bladder
Tolterodine, Trospium sphincter).
Note :
• “-fenacin” drugs : Selective M3 blockers.
• Trospium : Quaternary amine, no BBB crossing.
Skeletal Parasympathomimetic Parasympatholytic Sympathomimetic Sympatholytic

muscles
MOA Contraction Relaxation Contraction Relaxation
• Myasthenia Gravis (MG): Non-depolarizing β2 agonist : β-:
Pyridostigmine (DOC). Muscle relaxants (Clenbuterol) exercise
• Differentiating between (NDMR) during Performance tolerance (not
myasthenic crisis from anesthesia. enhancer by prescribed in
Uses cholinergic crisis & di- athletes (banned athletes).
agnosis of MG (Tensilon in Olympics)
test) : Edrophonium.
• Cobra bite rever-
sal & NDMR reversal : Side effects :
Neostigmine. Tremors.
Note : Always add Atropine while using Neostigmine & Edrophonium.
Side effects of ANS drugs 00:40:50
Cholinergic Anticholinergic Beta blockers Alpha blockers

poisoning (ie, OP (Atropine/Datu-
poisoning) ra/Belladona)
poisoning
C/f • Miosis. • Mydriasis • Bronchospasm. • Postural hypotension
• Salivation, • Dry mouth • Bradycardia/Conduction • Ejaculation abnor-
Sweating • Urine reten- block. mality
• Involuntary uri- tion • Insomnia, Nightmares, • Floppy iris
nation & def- • Constipation Depression.
ecation • Tachycardia • Block symptoms of hy-
• Bradycardia • Hyperthermia, poglycemia (exception
Dry skin of sweating).
• Exercise intolerance .
Rx Atropine (DOC) → Physostigmine Glucagon (DOC)
↑ Pupil size (DOC)
+ ↓ respiratory
secretions.

Most specific drug for OP poisoning : Pralidoximes (Acetyl Esterase reactivator). ----- Active space -----
Most specific sign of Atropinisation : Decreased respiratory secretions.
Beta blockers :
Cardioselective beta blockers (Mr. BEAN Cardiologist) :

• Mr. – Metoprolol • A – Atenolol, Acebutolol
• B – Bisoprolol, betaxolol • N – Nebivolol (most cardioselective BB)
• E – Esmolol • Cardiologist – Celiprolol
3rd generation beta blockers : Betaxolol, nebivolol & celiprolol.

Beta blockers with :
• Alpha blocking functions : Carvedilol, Labetalol.

• NO release : Nebivolol.
• Antioxidant functions : Carvedilol, Nebivolol.
Effect of catecholamines on HR :
All ↑ contraction of heart.

HR
Isoprenaline (Max ↑ in HR)
+ve Epinephrine (↑ in HR).
Dobutamine (maintains HR).

O
-ve
Norepinephrine (↓ HR ).
• Norepinephrine ↑ HR in a transplanted heart / pt on atropine (exception).

• Ivabradine : Normal contraction of heart + ↓ HR.
Dopamine :
Continuous IV infusion.
Dose dependent action (mcg/kg/min) :
• 0-2 : D1 → Renal vasodilation → Diuresis.
• 2 to 10 : β1 → increases cardiac contraction.
• >10 : α1 → vasoconstriction.
Uses : similar to Epinephrine


Epinephrine dilution :
• S/c, I/M, endotracheal - 1:1000.

• IV, intraosseous , Intracardiac - 1:10,000.
• For local vasoconstriction - 1:100,000.
• Epinephrine along with local anaesthetic (Lignocaine) - 1:100,000 or 1:200,000.
Dale’s phenomenon :
BP changes when epinephrine is administered.

Biphasic pattern changes in BP d/t :
1. Initial high epinephrine concentration (as it is administered from outside) →
activates α1 → ↑ BP
2. Epinephrine reaches a lower concentration → β2 stimulated → ↓ BP.
(α1)
BP
(β2) Time
Administration of
drug
- Dale : Biphasic pattern
Epi + β blocker (Re-reversal of Dale)
Epi + α blocker (Vasomotor reversal of Dale)

Antiglaucoma Drugs 00:55:57 ----- Active space -----
Class Drugs MOA Use Side-effects

DOC in • Iris pigmentation
open angle • Trichomegaly
Prostaglandin
Latanoprost, glaucoma • Dry/ Sandy eyes

analogs
↑ uveoscleral
Bimatoprost (latanoprost). • Cystoid macular edema
outflow
No response • C/I : Uveitis/ Herpetic keratitis
→ add beta (prostaglandins ↑ inflammation)
blockers
Timolol, • Timolol : NLD obstruction d/t
Metipranolol, 2nd line in stenosis
Beta blockers
Levobunolol, open angle • Metipranolol : Granulomatous

Carteolol, glaucoma. anterior uveitis
Betaxolol ↓ aqueous • C/I : Systemic beta blockers
Epinephrine, production • Ocular allergy
Dipivefrine (sympathetic • Black pigmentation of conjunctiva
nervous (Epinephrine → Melanin)
system) Open angle • Apraclonidine (also on α1 Gq →
Alpha-2 agonists
glaucoma (3rd ↑calcium ) → Lid retraction,

Apraclonidine line) Mydriasis, conjunctival blanching.
Brimonidine • Brimonidine (can cross BBB →
central sympatholytic) : Apnea in
neonates, drowsiness/somnolence,
hypotension.
Pilocarpine, Pilocarpine is • Pi-Lo at BAR (brow ache,
Miotic agents
Physostig- DOC in closed accommodation spasm, retinal

↑ trabecular
mine, angle glau- detachment, corneal edema.
outflow
Echothio- coma (3rd line • Echothiophate : Iris cysts
phate, in open angle • Echothiophate/Physostigmine :
Carbachol glaucoma) Cataract
Acetazol-
Carbonic anhydrase inhibitors
Oral/IV : amide : Acute

Acetazol- congestive
amide glaucoma
↓ aqueous (DOC : man-
Topical : production nitol) -
Brinzolamide Brinzolamide/
Dorzolamide Dorzolamide
: Open angle
glaucoma (3rd
line)
Open angle • Conjunctival hyperemia
Rho-kinase
↑ trabecular • Corneal verticillata

Netarsudil glaucoma (3rd
inhibitor
outflow
line)
No two beta blockers should be given together (even if it is topically adminis-

tered ) as AV conduction is decreased.

Anti arrhythmic drugs 00:00:15
Arrhythmias arising from atria :

1. Supra ventricular tachycardia (SVT)
2. Paroxysmal ventricular tachycardia (PSVT)
3. Atrial fibrillation.
4. Atrial flutter.
1. Rx of SVT/PSVT :
AV node blockers (Rate control) : ABCD drugs.
Drug Route Uses C/I
DOC for an acute C/I in COPD, asthma
Adenosine I.v attack SVT (Rapid I.V & atrial fibrillation
push). (Induces AF).
C/I in COPD &
Beta blockers I.v & oral
bronchial asthma.
Calcium channel
blockers (CCB) :
I.v & oral DOC for SVT in COPD
• Verapamil
/asthma Pt.
• Diltiazem
Digoxin Oral
In acute attack : Use I.v drugs (Adenosine > Beta blockers > CCB).
In long term Rx : Use oral drugs (Beta blockers > CCB > Digoxin).
2. Rx atrial fibrillation/atrial flutter :

• Acute attack (TOC) : Cardioversion ± Ibutilide
• Long term Rx : Long term Rx
Rate control : To keep Rhythm control :

Ventricle rate <100 bpm K channel blocker >
+
Na+ Channel blocker

DOC : Beta blockers
DOC : Amiodarone
Arrhythmias arising from ventricles : ----- Active space -----

1. Ventricular tachycardia (VT).
2. Ventricular fibrillations (VFib).
Management :
Inhibiting myocardial cells with K+/Na+ channel blockers.
Amiodarone Lidocaine
K+ channel blocker Na+ channel blocker
DOC : VT/VFib d/t MI, angi-
DOC : VT/VFib
na & digoxin toxicity.
Management of long QT syndrome :
Acute attack Long term Rx

(Aka torsades de pointes)
Congenital Acquired
Congenital/Acquired
DOC : MgSO4 DOC : Beta blockers Avoid drugs that prolong
TOC : Cardiac pacemaker QT interval
Management of WPW syndrome :
DOC : TOC : DOC in AF d/t WPW

Oral Flecainide Radiofrequency syndrome :
ablation IV Procainamide
Heart failure drugs: 00:16:05
Acute heart failure Chronic heart failure

DOC to se contraction : Drugs for symptomatic Rx :
Dobutamine • Furosemide (Preferred).
no response • Digoxin
PDE-3 inhibitor : Milrinone Drugs to cardiac remodelling :
(Inodilator). 1. Sacubitril :
• Blocks neprilysin & BNP.
• S/E : Angioedema (C/I with ACE
inhibitors).
• Can be given with valsartan
(ARB).

----- Active space ----- Acute heart failure Chronic heart failure
DOC for pulmonary edema : 2. Omapatrilat : Neprilysin inhibitor +
Furosemide ACE inhibitor.
no response Other drugs : SHIVA Beta
IV Nitroglycerine 3. Spironolactone.
(Reduces preload) 4. SGLT 2 inhibitors.
no response 5. Hydralazine + Isosorbide dinitrate.
BNP analogue 6. Ivabradine.
(IV Nesiritide) 7. Vericiguat.
Nesiritide is metabolized by neutral 8. ACE inhibitors/ARB.
endopeptidase (Neprilysin). 9. Beta-blockers.
Regimen for CHF :

1. Furosemide
2. ACE Inhibitor/ARB or Sacubitril + Valsartan
3. Beta blocker
Anti hypertensive drugs 00:24:42
Management of mild - moderate HTN :

1st line drugs :
• ACE inhibitors/ARB
• CCB
• Thiazides
2nd line drugs : All other drugs.
Approach : Age of the patient (No comorbidities)
Young age ( Renin) Old age ( Renin)

DOC : ACEI/ARB DOC : CCB
2nd line : Beta blockers 2nd line : Thiazides
Resistant hypertension :
Patient does not respond to atleast 3 drugs of which one must be a diuretic.
Rx : Add spironolactone (Aldosterone levels are in resistant HTN).

Rx of hypertension with comorbidities : ----- Active space -----
Hypertension with : DOC

Diabetes mellitus
CKD
ACE inhibitors/ARB
Nephrotic syndrome
Scleroderma
Migraine
Hyperthyroidism
Stable angina Beta blockers
Anxiety disorder
Essential tremor
Osteoporosis
Thiazides
Edema
Raynaud’s disease
CCB
Cyclosporine induced hypertension
BPH Alpha blockers
Hypertensive urgency (BP ≥ 200/125 mmHg Oral Clonidine
with no end organ damage) Other : Captopril & Nifedipine
Hypertensive emergency ( BP + end organ
IV Nicardipine
damage)
Hypertensive emergency in pregnancy IV Labetalol
Anti Anginal drugs 00:31:30
Anti anginal drugs MOA (In stable angina)

CCB • Stable angina : Preload
Nitrates (Sublingual nitroglycerine) : • Variant angina : Coronary vasodila-
DOC for an acute attack of angina tion
Beta blockers Decrease myocardial O2 demand
• Block late inward Na channels (1˚

Ranolazine MOA)
( Risk of AF & HbA1c) • PFOX inhibition/Beta blockade (2˚
MOA)

----- Active space ----- Antianginal drugs MOA (In stable angina)
Ivabradine
risk of AF & luminous phenomena Funny channel inhibition
(seeing colorful halos).
Nicorandil K+ channel opener
Fasudil Rho kinase inhibitor
Trimetazidine PFOX inhibitor
Statins, Aspirin, ACE inhibitors mortality in stable angina.
Side effects of CVS drugs 00:34:41
Amiodarone:
Mnemonic : Potassium channel blocker makes liver, nerve and skin toxic
• Pulmonary fibrosis
• Cornea Verticillata (Whorl like deposits in cornea)
• Blue colored skin (Ceruloderma, on sun exposed areas)
• Myocarditis
• Liver toxicity
• Neurotoxicity
• Alpha receptor block : Causes hypotension
• Photosensitivity (Brown skin : on sun exposed areas)
• Thyroid (Hypothyroidism > Hyperthyroidism)
Anti arrhythmics causing QT prolongation :
Class 1a Class III

Sotalol
Amiodarone
Quinidine
Dronedarone
Procainamide
Dofetilide
Disopyramide
Ibutilide
Vernakalant

Digoxin : ----- Active space -----
Side effects Contraindications

M/c & Earliest : Nausea & vomiting. 1. Conditions that increase risk of
Xanthopsia (Yellow vision). digoxin toxicity : KMC in Manipal
Gynecomastia. Rocks
Hyperkalemia. • K : Hypokalemia
Arrhythmias : • M : Hypomagnesemia
• M/c : Ventricular bigeminy. • C in : Hyercalcemia
• Most characteristic : Atrial tachy- • Manipal : MI
cardia with AV block. • Rocks : Renal failure
2. WPW syndrome
3. HOCM
Rx of digoxin toxicity : Digibind
RAAS inhibitors 2. ARB :
1. ACE inhibitors : Losartan :
All are pro drugs except : • PPAR γ agonist : Insulin resistance.
• Captopril • Uric acid excretion (Can be used in
• Lisinopril HTN + gout).
S/E : • Blocks thromboxane A2 (Anti aggre-
• Dry cough (M/c). grant).
• Angioedema. Telmisartan : Max PPAR γ agonist.
3. Direct renin inhibitors : Aliskiren.
C/I of RAAS inhibitors :

• Pregnancy
• B/L Renal artery stenosis
• Renal failure
S/E of CCB :
• Headache
• Constipation (Only verapamil)
• Ankle edema (Prevented by ACEi/ARB)
• AV block (Only verapamil & diltiazem)
Verapamil & diltiazem should not be given with beta blockers.


Hypolipidemic drugs 00:41:28
Decrease LDL Decrease triglycerides Increase HDL

1. Statins.
2. Bempedoic acid.
3. Ezetimibe. 1. Fibrates.
4. Inclisiran. 2. Icosapent. Niacin
5. PCSK-9 inhibitors. 3. Omega-3 fatty acids.
6. Bile acid binding resins.
7. Lomitapide.
Hypolipidemic drugs MOA Uses S/E

Statins : • Hypolipidemic effect : DOC : Type II Myopathy
Most potent : Pitav- Inhibit HMG CoA hypercholesterolemia. Hepatotoxicity
asatin > Rosuvasta- reductase → LDL, Insulin resistance
tin (Maximum LDL VLDL & triglycerides DOC : Familial hyperli-
among statins). • HDL. poproteinemia. C/I :
Pregnancy
Longest acting : Pleiotropic effects : 1˚/2˚ prophylaxis of MI Children <1o years
Rosuvastatin > Ator- • Anti aggregrant & stroke.
vastatin • Anti coagulant Pravastatin : C/I in
• Anti inflammatory Night time dosing : Not children <8 years
All metabolized • Anti oxidant mandatory with rosu-
by CYP450 except • Increases NO vastatin & atorvastatin.
Pravastatin.
• Plaque stabilization
Pravastatin : DOC in
Protease inhibitor in-
duced dyslipidemia.
Inhibits ATP citrate

Bempedoic acid Add on to statins
lyase, decreases LDL
Hypertriglyceri-
demia
Bile acid binding Hyperchloremic
Inhibit enterohepatic Add on to statins
resins : alkalosis
Cholestyramine circulation of bile acid,
Preferred in pregnan- GI upset & Ab-
Colestipol LDL. cy & children. sorption of other
Colesevelam
drugs (Minimum
with colesevelam)

Hypolipidemic drugs MOA Uses S/E ----- Active space -----
PCSK 9 inhibitors : Prevent degradatiion

Evolocumab of LDL receptors → Add on to statins
Alirocumab Max in LDL.
Si RNA → Breaks
Inclisiran mRNA of PCSK 9 → Add on to statins
LDL.
Blocks angiopoie-
Familial hypercholes-
tin like protein 3
Evinacumab terolemia
→Blocks LPL→
Add on to statins
LDL & triglycerides
Familial hypercholes-
Lomitapide Blocks MTP terolemia
Add on to statins
Fibrates :
Stimulate PPAR α & DOC : Hypertriglycer-
Clofibrate
LPL synthesis idemia Cholethiasis
Fenofibrate
triglycerides, chy- DOC : Chylomi- Myopathy
Bezafibrate
lomicrons & VLDL. cronemia syndrome
Gemfibrozil
Triglyceride rich
Hypertriglyceridemia
VLDL synthesis/se-
Icosapent cretion by liver.
Add on to statins
Inhibits platelet ag-
( CVS mortality).
gregation
Hormone sensi- Hepatotoxicity

Niacin : Dyslipidemia with
tive lipase syn- Insulin resistance
Max in HDL. HDL
thesis. Flushing
High LDL with or without ASCVD (MI, Angina, Stroke) :
Patient without clinical ASCVD Patient with clinical ASCVD or

& LDL < 190 LDL > 190
Moderate intensity statin therapy High intensity statin therapy
Rosuvastatin 5 - 10 mg Rosuvastatin 10 - 20 mg
& &
Atorvastatin 10 - 20 mg Atorvastatin 40 - 80 mg

----- Active space ----- Rx of Familial hypercholesterolemia :

Start high dose statins
No response
Add Ezetemibe or PCSK 9 inhibitor
No response
Add lometapide or Evinacumab
Rx of Hypertriglyceridemia :
Assess the risk of ASCVD
Absent Present
Moderate Moderate-Severe Start Statins

(TGA : 150 - 499 mg/dl) (TGA : 500 - 999mg/dl) No response
Add Icosapent
Lifestyle Fibrates No response
modifications
TGA still > 500
No response
Add Fibrates

Renal pharmacology 00:00:15
1. Diuretics
Drug class MOA Uses
• Acetazolamide : DOC in acute
mountain sickness.
Carbonic anhy- Block carbonic
• Acetazolamide/Dichlorphenamide:
drase inhibitors anhydrase in PCT.
Familial hypokalemic periodic
paralysis.
• Blocks Na/K/2Cl DOC in (renal/cardiac) edema.
pump in thick • Furosemide : DOC in cardiogenic
ascending limb. pulmonary edema.
Loop diuretics • Indirect vasodila- • Torsemide : Longest acting.
tors : • Bumetanide : Most potent.
Prostaglandins. • Ethacrynic acid : Most ototoxic.
NSAIDs → effect. Most effective if GFR< 40.
Uses : First-line in mild/moderate
• Blocks Na/Cl
HTN, add-on drug in edema mx.
cotransporter in
• Chlorthalidone : Longest acting,
DCT.
preferred in HTN mx.
• Direct vasodila-
Thiazides • Chlorothiazide : Shortest acting.
tors :
• Indapamide : Predominantly he-
• Open K channels,
patic excretion.
so they are ef-
All others → Renal excretion.
fective in HTN.
Metolazone : Effective in GFR <40.
K sparing di-
uretics
Aldosterone DOC in cirrhotic edema, resistant
Spironolactone,
antagonist. HTN.
Eplerenone
Blocks ENaC chan-

DOC in Li-induced DI, Liddle
Amiloride nels in collecting
syndrome, cystic fibrosis.
duct.

----- Active space ----- A : Acute congestive glaucoma

(DOC).
B : Braking of diuretics (resistance)
Osmotic diuretics Promotes solute free
C : Cerebral edema (DOC).
(mannitol) water loss
D : Dialysis disequilibrium.
E : Expected renal failure [but C/I
in established renal failure].
Side effects of diuretics : 00:08:41
Carbonic
Loop K sparing Osmotic
anhydrase Thiazides
diuretics diuretics diuretics
inhibitors
Hypo/hyper-
Hypokalemia Hypokalemia Hypokalemia Hyperkalemia
kalemia
Metabolic Metabolic Metabolic Metabolic Hypo/hyper-
acidosis alkalosis alkalosis acidosis natremia
↓ Mg ↓ Mg Gynaecomastia
Renal stones ↑ Glucose ↑ Glucose (d/t spironolac-
↑ Uric acid ↑ Uric acid tone)
Pulmonary
Hyperam-
edema
monemia
↓ Ca2+ ↑ Ca2+ (even though
(C/I in liver
it is used as
cirrhosis)
DOC for cer-
Hypersensi- Cause oto-
ebral edema)
tivity; bone toxicity : C/I Worsens DM,
marrow sup- with amino- gout
pression glycosides
2. Other renal drugs : 00:17:15
Drugs Uses Side effects

Vasopressin antagonists (Vaptans) :
Tolvaptan :
Conivaptan (IV) SIADH Hypokalemia,
Tolvaptan (PO) (IV for emergency, oral for longterm mx) hepatotoxicity
Mozavaptan (PO) (max use dura-
tion : 1 month)

Vasopressin analogues : ----- Active space -----
Terlipressin DOC acute variceal bleeding

• DOC central diabetes insipidus,
Water intoxication,
nocturnal enuresis.
Desmopressin headache.
• Used in Von Willebrand disease type
I, hemophilia A.
Used in :
• Central diabetes insipidus for Facial pallor, nausea,
Vasopressin replacement. vomiting.
• Acute variceal bleeding.
• NE resistant shock.
CNS pharmacology 00:19:30
1. Drugs for epilepsy

Seizure disorders DOC
GTCS
Valproate
Myoclonic seizure (JME), Dravet syndrome
Typical : Ethosuximide.
Absence seizure Atypical (change in muscle tone)
: Valproate.
Partial seizure, Rolandic epilepsy Carbamazepine
Valproate (DOC).
Lennox Gastaut syndrome Topiramate, lamotrigine,
rufinamide.
Seizures in neonates Phenobarbital
Diazepam.
Alcohol withdrawal seizures Lorazepam (safe in liver
dysfunction).
Status epilecticus Lorazepam
Infantile spasm with Tuberous Sclerosis (TS) Vigabatrin
Infantile spasm without TS/West syndrome/
ACTH
Salaam spasm


Epilepsy mx in pregnancy :
Pregnant + JME + on Valproate → Continue valproate while performing TDM.
+
Folic acid supplementation is a must.
+
Usual dose : 400 mcg (If h/o neural tube defects : 4000 mcg).
DOC for epilepsy in pregnancy : Levetiracetam > Lamotrigine.

Least teratogenic drugs : Most teratogenic drugs :
• Epilepsy : Levetiracetam. • Epilepsy.
• Bipolar disorder : Lamotrigine. • Bipolar disorder. Valproate
2. Drugs for mood disorders 00:25:55
Mood disorders DOC

Atypical antipsychotics (aripiprazole) >
Acute mania, mania in pregnancy
typical antipsychotics
Mania prophylaxis, bipolar disorder Lithium
Rapid cycling bipolar disorder Valproate
Depression SSRI (DOC) > SNRI
Depression with insomnia Mirtazapine
Depression with Erectile Mirtazapine > bupropion
Dysfunction (ED) (since they don’t cause ED)
Lithium.
Clozapine.
Suicidal tendency
ECT.
[Mnemonic : Life Can End]
Drugs causing ED (d/t ↑ serotonin) : MAO inhibitors, TCAs, SSRIs, SNRIs.

Novel antidepressants :
• Vilazodone : SSRI + 5HT1A agonist.
• Vortioxetine (MSAA drug : Multiple Serotonin Agonist Antagonist).
Reserved for treatment of resistant or major depression.

3. Drugs for parkinsonism 00:31:00

New case of Parkinson’s disease

Effect on lifestyle
Negligible Significant complaints

1. No drug treatment ideally.
2. If needed, Age<65 Age≥65
• DOC : MAO-B inhibitors DOC : D2 agonist DOC : Levodopa +
(Selegiline, Rasagiline). (pramipexole, ropinirole) Carbidopa
• Amantadine. S/E :
S/E : -Fatigue
-Ankle edema -Compulsive gambling/
-Livedo reticularis sexual activity
Side effects of levodopa Rx Considerations

• DOC : Pimavanserin.
Psychosis d/t D2 stimulation
• Psychosis is a C/I for levodopa rx.
Dyskinesia DOC : Amantadine
Mydriasis Can worsen glaucoma
On-off phenomenon DOC : COMT inhibitors (entacapone).
3. Drugs for other neurodegenerative disorders 00:36:50
Disorders DOC
1. DOC : Riluzole.
2. If not responsive, Edaravone.
ALS 3. Newer agents :
• Sodium phenylbutyrate taurursodiol.
• Tofersen.
1. DOC : Cholinergics (Donepezil/rivastigmine/
galantamine).
2. Add memantine (NMDA receptor blocker) in
Alzheimer’s disease
mod-to-severe cases.
3. Newer agents : β amyloid blockers
(aducaNumab, lecaNemab) in mild cases.


4. Drugs for some other disorders 00:40:18
Disorders DOC Other considerations
Trigeminal neuralgia Carbamazepine
MOA : Binding to α2δ1

Restless leg syndrome,
Gabapentin/pregabalin subunit of presynaptic Ca
Postherpetic neuralgia
channels.
Psychosis
Atypical antipsychotics
Resistant psychosis Clozapine

ADHD Drawbacks : Worsen ticks,
Methylphenidate
abuse potential
ADHD with Tourette
Clonidine
syndrome
ADHD with family MOA : Selective NE reuptake
Atomoxetine/Viloxazine
history of drug abuse inhibitors (not SNRI).
Tics associated with
Tetrabenazine
Tourette syndrome
5. Drugs for migraine 00:43:54

CN V nucleus
5HT 1F (Lasmiditan)
Ganglion
RP
5HT 1B/1D (Triptan) CG
CGRP
CGRP receptor
Vasodilation in meningeal
blood vessels
Meningeal edema and compression :

Headache (migraine).

Goal Treatment ----- Active space -----
Migraine treatment DOC : Triptans (5HT 1B/1D agonist).

Oral (fast acting) :
• Rizatriptan
• Sumatriptan Acute attacks
• Eletriptan
Oral (slow acting) :
• Frovatriptan Protracted
• Naratriptan attacks
Migraine prophylaxis Propranolol (DOC).
Topiramate.
Rizatriptan : Fastest oral triptan.

Sumatriptan : Overall fastest (s/c administration).
Triptans are C/I in angina, other ischemic conditions, due to their
vasoconstrictive action.
Ergotamine : Can cause gangrene of organs with end artery supply.
New drugs for migraine :

5HT-1F agonist : Lasmiditan (oral Rx).
CGRP ligand blockers :
• Eptinezumab
• Fremanezumab S/C, prophylaxis
• Galcanezumab
CGRP receptor blockers :
• Erenumab : S/C, prophylaxis.
• Olcegepant
Oral, treatment & prophylaxis
• Rimegepant
• Ubrogepant
6. Narcolepsy & insomnia 00:51:30
Disorders DOC
Narcolepsy Modafinil
Insomnia :
1. DOC : Ramelteon (lesser dependence, less effective).
Sleep induction, jet lag
2. Zolpidem (If non-responsive).
1. DOC : DORA (dual orexin receptor antagonist) :
Sleep maintenance Suvorexant, daridorexant.
2. Zolpidem (If non-responsive).

----- Active space ----- 7. Opioid agents 00:53:40
Disorders DOC
Opioid toxicity DOC : Naloxone
• To ↓ withdrawal symptoms : Methadone,
Opioid dependence :
Buprenorphine
• To prevent relapse : Naltrexone.
Labour analgesia Morphine > Pethidine
Opioid induced constipation Methylnaltrexone
Postoperative ileus Alvimopan
Postanaesthetic chills Pethidine/Tramadol (MOA: α2 agonist)
Characteristics Opioid drug

Partial agonist at mu and antagonist at kappa Buprenorphine.
Partial agonist at mu and full agonist at kappa. Pentazocine.

5HT and NE reuptake inhibition. Tramadol.
MAO inhibitory effect. Pethidine.
C/I in MI Pentazocine d/t HR
Note : Tolerance to constipation, convulsions, and miosis is not seen with opioids.
New agents :
• Rett syndrome : Trofinetide.
• Fredrich’s ataxia : Omaveloxolone.
8. Drugs for alcohol and smoking dependence 00:57:45
Alcohol dependence drugs Considerations

FDA approved :
Blocks aldehyde dehydrogenase → ↑
acetaldehyde → palpitations, tremors,
sweating, chest pain, anxiety, feeling of
Disulfiram : Aversive agent
doom.
Requires 12 hours of abstinence before
administration.

Hepatotoxicity. ----- Active space -----

Naltrexone
Anti-craving agents Depression, suicidal tendency.
Acamprosate Depression, suicidal tendency.
Non-FDA Approved anti-craving agents : Benzodiazepines, clonidine, topira-
mate, baclofen, ondansetron.
Smoking Dependence Drugs Considerations
First line :
Bupropion Anti-depressant
P. A. at α4β2 nicotinic receptor.
Varenicline
Most effective anti-smoking drug.
1. Nasal Spray : Most effective replacement
route
Nicotine replacement 2. Patch.
3. Gums Need to avoid liquids 15 mins
before and after
4. Lozenge
Second line : TCA, clonidine, cytisine.
9. Side effects of anti-epileptics 01:01:25
Valproate Phenytoin Carbamazepine

Mnemonic: T. VALPROIC Acid Mnemonic : HYDANTOIN Mnemonic : HEADS
Tab. Hyponatremia
Tremor, Teratogenic Hirsutism, Hyperpla-
H H [Delayed side-ef-
(Max) sia of gums
fect, M.C in elderly]
V Vomiting, nausea Y LYmphadenopathy E Eosinophilia
Diplopia*, De-
Ataxia*, Aplastic
A Ammonia increased D creased vit D (Hy- A
anemia
pocalcemia)
Ataxia*, Agranulo-
L Liver toxicity A D Diplopia*
cytosis
Stevens-John-
P Pancreatitis N Nystagmus S son syndrome :
HLA-B1502 gene
Teratogenic – Facial Oxcarbazepine, Eslicar-
R Rash T
clefts bazepine : less toxicity,
O Obesity O Osteomalacia but more hyponatremia

----- Active space ----- Increased bleeding in

Infertility in females
I IN Newborns : Vit K should
(PCOS)
be administered
Carnitine used as
* Ataxia and diplopia : Man-
C antidote for liver tox-
aged with therapeutic drug
icity
monitoring and dose adjust-
Acid Alopecia ment
Lamotrigine : Causes SJS, start at low doses as a precaution.

Topiramate : Renal stones, acute closure glaucoma, metabolic acidosis, weight
loss (off-label use in obesity).
10. Side effects of anti-depressants 01:04:20
Anti-depressant Side effects Considerations

SSRIs 5Ht2 : Anxiety/insomnia/vivid • Benzodiazepines given for 1
( 5HT) Brain dreams. month for a pt on SSRI.
5Ht2 : Erectile dysfunction (ED)/ • SSRIs can used in premature
Spinal anorgasmia/ delayed ejaculation (dapoxetine).
cord. ejaculation. • ED : M/c delayed side effect
• Nausea : M/c side effect.
5HT3 Nausea, vomiting.
5HT4 Loose stools.
SNRI Similar to SSRI
Constipation, dry mouth,
M (-) • Avoid in glaucoma, BPH.
mydriasis, urine retention.
• TCA toxicity : High risk of
TCA 5HT (-) Obesity.
mortality d/t arrythmias,
H1 (-) Sedation.
DOC : Bicarbonate.
α1 (-) Postural hypotension.
Noradrenergic and specific se-
Mirtazapine Sedation, Obesity rotonine agonist, 5HT2 and α2
blocker
Trazodone Priapism
Bupropion Seizure, max anxiety
Cheese reaction,
MAO inhibitors Not used frequently anymore
serotonin syndrome

11. Side effects of anti-psychotics 01:08:11 ----- Active space -----
D2 receptor blockade Other receptor blockade

M : Constipation, dry mouth, mydriasis, urine retention
(avoid in glaucoma, BPH).
EPS
H1 : Sedation.
Hyperprolactinemia
H1 & 5HT : Obesity.
Max = Risperidone
α1 : Postural hypotension.
Min = Clozapine
Metabolic side-effects : Dyslipidemia, hyperglycemia.
Zero = Pimavanserin
Max = Clozapine > Olanzapine.
(Pure 5HT2 H1
Min = Risperidone.
(-))
Zero (weight neutral) = Aripiprazole/cariprazole (Partial
agonist at D2 and 5HT1A), ziprasidone.
EPS Treatment
Akathisia (M/C) : Restlessness. 1. DOC : Beta blockers.
2. Add on : Benzodiazepines.
Acute dystonia (earliest) : Abnormal 1. DOC : Anticholinergics : Benzhexol

posturing, facial grimacing. (trihexyphenidyl).
Parkinsonism : Tremor, bradykinesia. 2. Antihistamine : Promethazine
(Also seen with metoclopramide).
Cause : D2 block
• DOC : Dantrolene*
Neuroleptic malignant syndrome (Most
• Bromocriptine (most specific drug)
lethal) :
Muscle rigidity, hyperthermia, auto-
*Also, DOC for malignant
nomic instability (sweating, tachycar-
hyperthermia
dia, tachypnea, labile BP)
Cause : D2 block
Tardive dyskinesia (most delayed). VMAT-2 inhibitors :

Facial dyskinesia (tongue protrusion, Valbenazine, deutetrabenazine
lip smacking), Limb dyskinesia (piano
finger movements, foot tapping).
Cause : D2 upregulation


12. Lithium 01:16:05
Side effects : Mnemonic → HOTHEAD

H : Hypothyroidism.
O : Obesity.
T : Tremor (at normal conc → Fine, at toxic conc → Coarse).
H : Hypercalcemia.
E : Ebstein’s anomaly (C/I in 1st trimester of pregnancy).
A : Acne.
D : Diabetes insipidus – Thirst (DOC : Amiloride).
Food and drug interactions :

Li and Na are similar in structure.
Na deficiency/loss d/t diuretics (thiazides > K sparing > loop), diarrhea/vomiting
& fasting, can lead to Li retention & toxicity.
TDM : Blood sample taken 12 hours after last dose.

• 0.6 - 1.0 mEq/L : Therapeutic range for prophylaxis of mania.
• 1.0 - 1.5 mEq/L : Therapeutic range for acute mania.
• > 1.5 : Indicative of toxicity.
• > 4 : Indication for dialysis.
11. Side effects and withdrawal symptoms of opioids 01:19:48
Side effects
Withdrawal symptoms
(d/t Mu receptors)
M Miosis Symptoms d/t withdraw-
U Urine retention al are opposite those d/t
S Sedation Mu receptor stimulation
C Constipation, Convulsion
A Analgesia
R Respiratory depression
I Increased muscle rigidity
N No bile flow – Contraction of sphincter of Oddi
E Euphoria
Note : Opioids are no longer C/I for pain management in biliary colic.

Antimicrobial drugs : Classification 00:00:18
Class of drug Drugs

1. Beta lactams 2. Vancomycin (Glycopeptide).
Cell wall
• Penicillins. 3. Bacitracin.
synthesis
• Cephalosporins. 4. Cycloserine.
inhibitors
• Carbapenems. 5. Fosfomycin.
(Cidal)
• Monobactams.
1. Tetracyclines.
• MOA : Block A site on mRNA.
• Mechanism of resistance : Drug efflux.
Protein 3. Macrolides.
2. Aminoglycosides (Cidal).
synthesis 4. Linezolid.
• MOA : Misreading of mRNA.
inhibitors 5. Streptogramins.
• Mechanism of resistance : Enzymatic
(Static) 6. Clindamycin.
inactivation (Except amikacin).
• Not effective against anaerobes &
typhoid.
Drugs acting 1. Daptomycin (Lipopeptide) :
on cell MOA → Depolarization of bacterial cell membrane leading to
membrane K+ efflux.
(Cidal) 2. Polymyxins : Colistin.
Antifolate 1. Sulfonamides (Static).
drugs 2. Cotrimoxazole (Cidal).
MOA : Inhibits DNA gyrase.
1. Ciprofloxacin.
2. Ofloxacin.
Fluoroquino- 3. Respiratory quinolones (Rx of pneumonia).
lones (Cidal) • Gemifloxacin.
• Levofloxacin : Maximum oral bioavailability.
• Moxifloxacin : Maximum t1/2, QT prolongation, seizure
potential, hepatic excretion (So never used in UTI).

----- Active space ----- Cell Wall Synthesis Inhibitors : Site of action 00:06:30
1. Fosfomycin.
2. Cycloserine.
3. Bacitracin.
4. Vancomycin (inhibit
transglycosylation).
5. β lactams.
Antibiotics : Uses 00:08:25
Antibiotic DOC in
• Atypical pneumonia : Chlamydia, mycoplasma, legionella.
• Campylobacter.
Azithromycin
• Cholera in children.
• Cholera and chlamydia in pregnancy.
• Listeria meningitis.
Ampicillin • Enterococcus faecalis endocarditis (Along with
gentamicin).
• Gonorrhea.
• Typhoid (Note : Oral DOC in typhoid → Cefixime).
Ceftriaxone (IV) • Haemophilus influenzae meningitis.
• Empirical treatment of meningitis.
• Infections of E. coli, Klebsiella & Providencia.
Ceftazidime Pseudomonas (Gentamicin is added in severe infections).
• Extended spectrum β lactamase producing organisms.
• Serratia.
• Acinetobacter.
Carbapenems • Enterobacter.
Note : Imipenem is metabolized by renal dehydropeptidase
and is combined with cilastatin, a renal dehydropeptidase
inhibitor.

Cefazolin Surgical prophylaxis. ----- Active space -----
• Toxic shock syndrome.

• Supradiaphragmatic anaerobic infections.
Clindamycin
Note : Metronidazole is preferred in infradiaphragmatic
anaerobic infections.
• Contacts of meningococcal meningitis.
• Pyelonephritis.
Ciprofloxacin • Typhoid carriers.
• Shigella.
• Travelers diarrhea.
• Burkholderia cepacia.
Cotrimoxazole • Cyclospora.
(Combination of • Pneumocystis pneumonia.
trimethoprim & • Isospora.
sulfamethoxazole • Nocardia.
in the ratio 1:5) • Sarcocyst.
• Stenotrophomonas (Along with piperacillin).
Daptomycin
VRSA
S/E : Myopathy.
(Vancomycin Resistant Staphylococcus Aureus).
C/I : Pneumonia.
• Mycoplasma pneumonia.
• Plague prophylaxis.
• Rickettsia.
Doxycycline • Borrelia.
• Brucella.
• Cholera.
• Chlamydia.
• Pertussis.
• Diphtheria.
Erythromycin
Note : Erythromycin can be used in gastroparesis as a
prokinetic drug due to motilin receptor stimulation.
• Plague.
Gentamicin
• Tularemia.
Mupirocin Staphylococcal nasal carrier
(Topical) Note : Bacitracin is also used.

----- Active space ----- • Syphilis.

• Streptococcus.
• Leptospira.
• Yaws.
Benzathine
• Gas gangrene.
penicillin G (IM)
• Rat bite fever.
• Actinomycosis.
• Meningococcus.
Note : DOC in neurosyphilis → IV aqueous penicillin G.
Silver
Burns patients.
sulfadiazine
IV :
• Methicillin resistant S. aureus.
• Enterococcus faecium endocarditis (Along with
Vancomycin gentamicin).
Oral : Pseudomembranous enterocolitis.
Note : The latest drug used as DOC in pseudomembranous
enterocolitis is oral fidaxomicin.
Linezolid Vancomycin resistant enterococcus.
Antibiotics : Side Effects 00:24:12
Antibiotic Side effects

• Photosensitivity.
• Acute renal failure (Except doxycycline).
• Blocks bone growth due to calcium binding.
• Diabetes insipidus.
• Esophagitis.
Tetracyclines • Yellowing of teeth.
• Vestibular toxicity : Minocycline.
C/I :
• Pregnancy.
• Children.
• Along with antacids.

• Nephrotoxicity. ----- Active space -----
• Ototoxicity (Irreversible).
Auditory : Amikacin.
Aminoglycosides
Vestibular : Streptomycin.
• Neuromuscular toxicity.
C/I : Pregnancy.
• Motilin receptor stimulation :
Hypertrophic pyloric stenosis.
Diarrhea.
Erythromycin
• Skeletal muscle weakness.
• QT prolongation.
• Cholestatic jaundice.
• Photosensitivity.
• QT prolongation.
• Rash.
Fluoroquinolones
• Seizure.
• Tendinitis, tendon rupture (Increased risk is seen in
elderly, renal failure and steroid use).
• Bone marrow suppression.
• MAO inhibition.
Linezolid • Mitochondrial toxicity :
Optic neuritis.
Lactic acidosis.
• Pseudomembranous enterocolitis (3rd generation
Beta lactams cephalosporins > amoxicillin).
• Hypersensitivity.
Cefoperazone,
moxalactam, • Disulfiram like reaction.
cefamandole, • Hypoprothrombinemia.
cefotetan
Imipenem • Seizures.
• Kernicterus after birth.
• Acute intermittent porphyria.
• Methemoglobinemia.
Sulphonamides
• Rash.
• Bone marrow suppression.
• Crystalluria.

----- Active space ----- Antiviral drugs 00:28:48
Anti herpes drugs DOC in S/E
Oral valacyclovir > oral

HSV/VZV
acyclovir/topical acyclovir Crystalluria.
IV Acyclovir HSV encephalitis.
Oral valganciclovir > oral
CMV.
ganciclovir Bone marrow
CMV with high risk of suppression.
IV ganciclovir
blindness.
Foscarnet Resistant herpes. Electrolyte abnormalities.
• Recurrent laryngeal
papillomatosis.
Cidofovir
• BK virus.
• Adenovirus.
Anti influenza drugs Used in

Oral oseltamivir. Influenza A & B, bird flu.
Neuraminidase inhibitors
Oseltamivir resistant
(Block viral release) Inhalational zanamavir.
cases.
RNA polymerase inhibitors : Baloxavir.
Anti hepatitis B drugs Anti hepatitis C drugs

Specific : • Interferon α.
• Entecavir. • Oral ribavirin.
• Adefovir. • Direct-acting antivirals (DOC) :
Non specific (Anti HIV drugs used for Paritaprevir (Protease
hep B) : blockers).
• Tenofovir. Sofosbuvir (NS5B blockers).
• Lamivudine. Velpatasvir (NS5A blockers).
• Emtricitabine : Derivative of
lamivudine (Not to be given in
combination with it).
• Clevudine.
• Telbivudine.
Miscellaneous drugs :
• Interferon α : Used for short
duration treatment (Max for 48 w).
Note : DOC in ----- Active space -----

• RSV Rx : Inhalational ribavirin.
• RSV prophylaxis : Palivizumab.
Anti retroviral drugs

Nucleoside reverse transcriptase inhibitors :
• Zidovudine : Anemia d/t bone marrow suppression.
• Lamivudine.
• Emtricitabine : Pigmentation of palms & soles.
• Tenofovir : Nephrotoxic, safety unknown in age < 10 years & weight < 30 kg
(Abacavir is used).
• Abacavir : Steven Johnson syndrome.
Lamivudine, Emtricitabine and Tenofovir : Least toxic and preferred drugs.
Non nucleoside reverse transcriptase inhibitors :
DOC to prevent perinatal HIV transmission (Syrup zidovudine is also
Nevirapine used).
S/E : Hepatotoxicity.
Entry inhibitors
CD4 inhibitor GP 120 inhibitor CCR5 inhibitor GP 41 inhibitor
Ibalizumab (IV). Fostemsavir. Maraviroc. Enfuvirtide (S/c).
Active against HIV-1. Active against HIV-1. Active against Fusion inhibitor.
HIV-1 & 2.
Note : All antiretroviral drugs are given by oral route except ibalizumab and
enfuvirtide.
Protease inhibitors
Metabolized by CYP3A4 (Except Nelfinavir → metabolized by CYP2C19).
Enzyme inhibitors of CYP3A4.
Common S/E :
• Dyslipidemia.
• Hyperglycemia.
• Lipodystrophy.
• Lopinavir (LPV).
• Ritonavir :
Most potent enzyme inhibitor.
Used as a booster drug (E.g : LPV/r).
• Atazanavir : Does not cause dyslipidemia.
• Indinavir : S/E → Renal stones.
----- Active space ----- Note :

Cobicistat is a CYP3A4 inhibitor given in combination with :
• Atazanavir.
• Darunavir.
• Elvitegravir.
Integrase inhibitors
• Raltegravir.
• Dolutegravir.
Post-exposure prophylaxis
2 NRTIs + I miscellaneous drug used in combination.
Preferred regimen in India : Tenofovir + Lamivudine + Dolutegravir (TLD).
Antifungal drugs 00:50:00
Antifungal drugs DOC in

Amphotericin B : • Kala azar.
• MOA : Sequesters ergosterol in the cell membrane. • Mucormycosis.
• Given via IV route with 5% dextrose as the carrier. • Cryptococcal
• S/E : meningitis.
a. Hypokalemia : Prevented by administering KCl.
b. Nephrotoxicity : Prevented by
Preloading with NaCl.
Combining with liposomes (Liposomal
Amphotericin B).
Azoles :
MOA : Inhibit ergosterol synthesis by blocking 14-α sterol demethylase.
• Candida albicans.
Fluconazole • Mucocutaneous
candidiasis.
Clotrimazole (Lozenge) Oral candidiasis.
• Endemic mycoses.
• Sporotrichosis.
• Allergic
Itraconazole
bronchopulmonary
asperigillosis
(Steroids also DOC).

Ketoconazole : ----- Active space -----

Cushing disease
S/E : Gynecomastia, impotence.
Voriconazole Invasive aspergillosis.
• Mucormycosis.
Posaconazole • Used in graft vs host
disease.
• Mucormycosis.
Isavuconazole
• Invasive aspergillosis.
Griseofulvin :
Tinea capitis.
Taken along with fatty food to increase absorption.
Natamycin Fungal corneal ulcer.
Antihelminthic drugs 00:57:36
Nematodes DOC
Roundworm.
Whipworm.
Hookworm. Albendazole.
Enterobius vermicularis.
Trichinella spiralis.
Ivermectin :
Strongyloides. MOA : Produces tonic paralysis by
Onchocerca volvulus. stimulating glutamate sensitive
chloride channels.
Diethylcarbamazine (DEC).
Loa loa.
Note : Ivermectin + DEC + Albendazole
Filariasis.
regimen is used to treat filariasis.
Drancunculiasis. Metronidazole.
Cestodes DOC
Neurocysticercosis.
Albendazole.
Echinococcus.
Intestinal Taenia solium.
Praziquantel
Taenia saginata.
MOA : Produces spastic paralysis by
Hymenolepis nana.
stimulating calcium channels.
Diphyllobothrium latum.
----- Active space ----- Trematodes DOC

Fasciola hepatica. Triclabendazole.
All other liver flukes.
Lung flukes. Praziquantel.
Schistosoma.
Anti Protozoal drugs 01:02:28
Protozoal disease DOC

Amoebiasis
Intestinal (Symptomatic) Metronidazole.
Luminal amebicidal drugs :
Intestinal (Asymptomatic) • Paramomycin (DOC).
• Diloxanide furoate.
Metronidazole.
Note : For radical cure of amoebiasis,
Extra intestinal
metronidazole is given in combination
with a luminal amoebicidal drug.
Leishmaniasis
IV Liposomal amphotericin B.
Visceral (Kala azar)
Oral DOC : Miltefosine.
Cutaneous Sodium stibogluconate.
Post kala azar dermal leishmaniasis Miltefosine.
Trypanosomiasis
East African Early stage IV Suramin.
sleeping sickness Late stage IV Melarsoprol.
West African Early stage IV Pentamidine.
sleeping sickness Late stage IV Eflornithine.
Note : Fexinidazole is a recently approved oral drug for African sleeping
sickness.
American Chagas disease Benznidazole.
Cryptosporidiosis Nitazoxanide : S/E → Green urine.
Babesiosis Atovaquone + Azithromycin.
Toxoplasmosis Sulfadiazine + Pyrimethamine.

Giardiasis ----- Active space -----

Metronidazole
Amoebiasis
S/E : Disulfiram-like reaction
Trichomoniasis
(Avoided with alcohol).
Bacterial vaginosis
Malaria
Chloroquine (S/E : Bull’s eye maculopathy, corneal deposits).
Uncomplicated
(+)
vivax malaria
Radical cure with : Primaquine for 14 days (Or) Tafenoquine
once.
Uncomplicated
falciparum • Artemisinin combination therapy (ACT).
malara and • Artesunate + Sulfadoxine + Pyrimethamine.
chloroquine • Artemether + Lumefantrine (Preferred in North
resistant vivax Eastern Indian states).
malaria
Severe
IV Artesunate : Most potent and fastest acting
falciparum
schizontocidal drug.
malaria
Malaria Doxycycline 100mg OD started 2 days

< 6 weeks
prophylaxis before travel.
(Based on
duration of travel Mefloquine 250mg/week started 2
≥ 6 weeks
to endemic weeks before travel.
areas)
Note : Malaria prophylaxis is continued for 2 weeks after return from travel.
Vivax Chloroquine.
Chloroquine • 1st trimester : Quinine + Clindamycin.
Malaria in resistant vivax • 2nd and 3rd trimesters : ACT.
pregnancy malaria and
falciparum
malaria.

----- Active space ----- Anti Tubercular drugs 01:16:18
First line anti-tubercular drugs :

Isoniazid Rifampicin Pyrazinamide Ethambutol
Gets activated by
catalase-peroxidase Blocks RNA
MOA
& blocks mycolic acid polymerase.
synthesis.
• Kat-G gene
mutation.
Mechanism
• InhA gene overex- RPO-b gene
of
pression : Produces mutation.
resistance
cross-resistance to
ethionamide.
• Cidal. • Cidal • Cidal. • Static.
• Intracellular + (maximum). • Intracellular. • Extracel-
Activity extracellular. • Intracellular + • Non lular.
against • Replicating bacteria. extracellular. replicating • Replicating
mycobac- • Non replicat- bacteria. bacteria.
terium ing bacteria
aka persistors
(maximum).
Liver.
Organ of
Liver. (Safest drug in Liver. Kidney.
excretion
renal failure).
D/t ↓ vit B6 : • Red/orange • Hepato- • Optic

1. Pyridoxine dependent urine. toxicity neuritis.
anemia. • Flu-like (maximum). • Red-
2. Reduced GABA levels : symptoms. • Hyperurice- green
• Neuropathy. • Thrombo- mia. color
S/E • Psychosis. cytopenic • Gout. blindness
Toxicity : Seizures. purpura. • Arthralgia. (Green >
Treatment : Vitamin B6. • Pulmonary Red).
syndrome.
Note :
• Purpura and pulmonary syndrome are indications to discontinue rifampicin
forever.
• Order of hepatotoxicity : Pyrazinamde > Isoniazid > Rifampicin.

Second line antitubercular drugs : ----- Active space -----

Used in :
• MDR TB : TB resistant to Isoniazid + Rifampicin.
• XDR TB : TB resistant to Isoniazid + Rifampicin + Fluoroquinolones + One
injectable drug like aminoglycoside.
Bedaquiline Delamanid Pretomanid

Blocks ATP
MOA Nitroimidazoles : Block mycolic acid synthesis.
synthase.
Route Given by oral route along with food as it increases absorption.
• Seques- • High plasma
tered in protein binding
tissues. of 99%.
Pharmacoki- • Long t 1/2 : • Metabolized by
netics 165 days. albumin (C/I if
serum albumin
< 2.8 mg/dL).
S/E QT prolongation (C/I in arrhythmia).
Safety in
Safe. Safety unknown.
pregnancy
Anti Leprosy drugs 01:30:57
First-line anti-leprosy drugs :

Rifampicin Dapsone Clofazimine
Activity Cidal (maximum) Static Static
S/E Hemolysis in G6PD deficiency Ichthyosis
Second-line anti-leprosy drugs :
Minocycline Clarithromycin Fluoroquinolones (Ofloxacin, moxifloxacin)
Activity Static Static Cidal

Anti cancer drugs 00:00:42
Drugs of choice :
Brain tumor :
TOC refers to treatment regimen.
Temozolomide.
Head and neck
cancer : Cisplatin.
Esophageal : TOC : Cisplatin +
Cisplatin. 5FU.
TOC : Cisplatin
+ 5FU. Lung Cancer :
Cisplatin.
Liver :
Sorafenib. Gastric cancer :
Cisplatin.
TOC : Cisplatin +
Pancreas cancer : 5FU.
Gemcitabine.
Colorectal cancer :
5 Fluorouracil.
Kidney : TOC : FOLFOX/ FOLFERI
Pembrolizumab. 5 FU + Oxaliplatin/
Irinotecan + Folinic
acid ( Leucovorin).
Urogenital cancer (Bladder, ovary,

cervix, testicular) : Cisplatin. Anal cancer :
Treatment regimen : 5 Fluorouracil.
• Bladder : Cisplatin +Gemcitabine. TOC : 5FU + Note : Mitomycin
• Ovary : Cisplatin + Paclitaxel. Mitomycin C. C → Also used to
• Testicular : BEP (Bleomycin + prevent Laryngo-
Etoposide + Cisplatin). tracheal stenosis.

Breast Carcinoma : 00:08:24

Breast Carcinoma
ER +ve Her 2 +ve
Premenopausal Postmenopausal DOC : Trastuzumab

If resistant
DOC : Tamoxifen DOC : Letrozole • Lapatinib Her 2 Tyrosine
(SERM). (Aromatase • Neratinib kinase inhibitor
inhibitor). OR
• Pertuzumab.
Side effects :
• Uterine cancer.
• Thrombosis.
• Hot flashes.
Note : Pregnancy planning :

• After 3 months of stopping SERM (Tamoxifen).
• After 7 months of stopping Trastuzumab.
Hematological causes : 00:12:28
Hematology
Leukemia Lymphoma
Non Hodgkins lymphoma Hodgkins lymphoma
High grade Low grade
• �ituximab. • Fludarabine. • Adriamycin.

• Cyclophoshpamide. • Cyclophosphamide. • Bleomycin.
• Hydroxydaunorubicin. • Rituximab. • Vinblastine.
• Oncovin (Vincristine). • Dacarbazine.
• Prednisolone.


Leukemia
Acute Leukemia Chronic Leukemia
ALL AML CML CLL
Vincristine. TOC : Cytarabine DOC : Imatinib FCR

Prednisolone. + Idarubicin or (1 st gen).
Asparaginase. Daunorubicin.
No response
Daunorubicin.
Dasatinib
Nilotinib (2 nd gen).
Bosutinib
No response
T- 315- I mutation
Ponatinib (3rd gen).
Note : The drugs used in Rx of CML are BCR-ABL Tyrosine kinase inhibitor →
Blocks the enzymatic site.
If CML is still unresponsive to 3 rd gen Tyrosine kinase inhibitor :

• Asciminib is used (blocks BCR-ABL → allosteric site).
• Omacetaxine : Blocks BCR- ABL protein.
• Interferon alpha (rarely used).
Drug of choice in other hematological conditions :

• Hairy cell Leukemia : Cladribine.
• Sickle cell disease
• Polycythemia vera Hydroxyurea.
• Essential Thrombocytosis

Lung carcinoma Rx : 00:42:34 ----- Active space -----
Small Cell Carcinoma :

Cisplatin + Etoposide + Immunotherapy (Atezolizumab or Durvalumab).
Non-Small Cell Carcinoma :

Driver mutation absent :
• PDL1 expression > 50% : Immunotherapy (Pembrolizumab or Atezolizumab).
• PDL1 expression < 50% : Add Chemotherapy.
a. For non-squamous : Cisplatin + Pemetrexed.
b. For squamous : Cisplatin + Paclitaxel.
Driver mutation present :
• EGFR L858 R mutation :
a. 1st gen : Gefitinib, Erlotinib.
b. 2nd gen (more toxic) : Afatinib, Dacomitinib.
c. 3rd gen (T790M mutation) : Osimertinib.
• ALK mutation :
a. 1st gen : Crizotinib.
b. 2nd gen (L1196M mutation) : Alecitinib, Brigatinib, Certinib.
c. 3rd gen (G1202R mutation) : Loratinib.
Note : Some named trials in non small cell lung Carcinoma :

• Keynote 189 trial : Chemotherapy + Pembrolizumab.
• Checkmate 227 trial : Ipilimumab + Nivolumab.

----- Active space ----- Side effects of anticancer drugs. 00:19:24
Complication Drugs responsible Rx & its mechanism

SIADH. Vincristine
• Cisplatin. Rx :
1. Nausea, Vomiting
• Ondansetron.
Ototoxicity, Maximum nausea, 2. Nephrotoxicity
vomiting, Nephrotoxicity. • NaCl (Chloride diuresis).
• Mannitol (Diuretic).
• Amifostine (Radio
protective).
Diarrhoea. •
Irinotecan. Rx : Loperamide.
•
Cisplatin.
Peripheral Neuropathy. •
Vincristine.
•
Paclitaxel.
•
Ifosfamide > Prevention : MESNA.
Hemorrhagic cystitis.
Cyclophosphamide. Cause : Acrolein.
• Trastuzumab.
Cardiotoxicity. • Doxorubicin.
• Daunorubicin.
Pulmonary fibrosis. • Bleomycin > Busulfan.
• 6- Mercaptopurine.
Hepatotoxicity. • 6- Thioguanine.
• Methotrexate.
Note : Methotrexate can cause Liver cirrhosis if used for treatment of psoriasis or
Rheumatoid arthritis. (Long term low dose exposure).
• Capecitabine > Prevention : Vitamin B6.
Hand and Foot syndrome.
5 Fluorouracil.
• Methotrexate. MOA : DHFR blockers.
• Pemetrexed. Prevention :
• Methotrexate → Folinic
Bone marrow suppression. acid (Leucovorin) > Folic
acid.
• Pemetrexed → Folinic
acid + Vitamin B 12.
Flagellate dermatitis : Long • Bleomycin.
streaks of hyperpigmentation.
Note : Side effects of Bleomycin are usually seen in skin and lungs (as the hydrolases
are deficient in these sites).

Miscellaneous anti cancer drugs 00:29:40 ----- Active space -----
Identification of monoclonal antibodies function based on nomenclature.

Nomenclature Use Example.
tu/tum • Tumor (Breast cancer). Trastuzumab.
• Circulation (block Gp IIb/IIIa). Abciximab.
c/ci
• Antidote for Dabigatran. Etaracizumab.
• Toxin (Against Clostridium difficle toxin :
tox toxin B) → Used in Pseudomembranous Bezlotoxumab.
enterocolitis.
• Virus (used in Respiratory syncitial
vi Palivizumab.
virus).
li/lim • Target Lymphocytes (TNF α blocker). Infliximab.
n/ne • Neurology. Erenumab.
bac • Bacteria (against anthrax). Raxibacumab.
Identification of source of Monoclonal antibodies : (before mab)
• Zu : Humanized. • U : Human.
• Xi : Chimeric. • O : Murine.
Kinase inhibitors :
1. Imatinib : BCR ABL Tyrosine kinase inhibitor → Rx of CML, GIST.
2. Gilteritinib : FLT-3 kinase inhibitor → Rx of AML.
3. Dabrafinib : BRAF inhibitor
Rx of Melanoma.
4. Cobimetinib : MEK 1/2 inhibitor
5. Idelalisib : PI-3K inhibitor (Phosphatidyl inositide) Rx of CLL.
6. Ibrutinib : Brutons tyrosine kinase blocker.
Others :
1. Olaparib : PARP blocker (Poly ADP Ribose polymerase) → Rx of Breast Ca.
2. Bortezomib : Proteazome inhibitor → Rx of Multiple Myeloma.
3. Sonidegib : Hedgehog pathway blocker.
4. Retinoic acid : DOC for Promyelocytic leukemia.
5. Aspariginase : Rx of ALL.
Note :
Side effects of Asparaginase :
• Hyperglycemia. • Hypercoagulation. • Hypersensitivity.
• Hyperlipidemia. • Hemorrhage.


Immune check point inhibitors and uses :
Mnemonic : �ew Rising Star Drugs Acting At Immune Check Point.
PD-L1 blocker (Programmed

PD 1 blocker. CTLA-4 blocker.
death cell ligand 1 blocker).
• Nivolumab. • Durvalumab. • Ipilimumab.
• Retifanlimab. • Avelumab.
• Dostarlumab. • Atezolizumab.
• Cemiplimab.
• Pembrolizumab.
1. PD 1 Blockers :
Nivolumab Pembrolizumab
Mnemonic : Nivea CREAM Hydration. Mnemonic : PEMBROLI.
• Non small cell lung Ca. • Primary mediastinal B-cell
• Colorectal Ca. lymphoma.
• RCC, Urothelial cancer. • Endometrial and Cervical Ca.
• Esophageal Ca, Gastric Ca. • Melanoma, Merkel cell cancer.
• Adjuvant Rx. • Breast Ca (triple -ve).
• Melanoma, Mesothelioma. • RCC, Urothelial Ca.
• Head and neck Ca, Hodgkin’s • Oesophageal, Oral and Gastric
disease. carcinoma.
• Liver Ca, Lung Ca, Hodgkin’s
lymphoma.
• Intestinal CA (Colorectal).
2. PD-L1 Blocker :
Durvalumab Avelumab Atezolizumab
Mnemonic : Dura BL Mnemonic : Avail RUM Mnemonic : Ate LAMB
• Biliary tract Ca. • RCC. • Ca Liver, Ca Lung (non
• Liver Ca / Lung • Urothelial cancer. small cell).
Ca (non small cell/ • Merkel cell • Alveolar sarcoma.
small cell). carcinoma. • Melanoma.
• Breast Ca (triple -ve).

3. CTLA-4 Blocker : ----- Active space -----
Ipilimumab
Mnemonic : IP MEN Like Chinese Restaurant.
• Melanoma, Mesothelioma.
• Esophageal Carcinoma.
• Non small cell lung Carcinoma.
• Lung Carcinoma.
• Colorectal carcinoma.
• RCC.
Endocrinology 00:45:04
Antidiabetic drugs :
Note : Drugs which cause Hypoglycaemia → Insulin > drugs which cause in-
crease in insulin release.
Drug. MOA & uses. Side effects & C/I.

1. Insulin.
Inhalational route. • Cough.
Afrezza : Control post prandial hyperglycaemia. • Lung cancer.
a. Shortest and has 3 colors : C/I :
fastest acting. Blue → 4 units. • COPD.
Green → 8 units. • Asthma.
Yellow → 12 units. • Smokers.
Subcutaneous route :
m/c site → Anterior Abdominal wall except
periumbilical region.
• Use 60 min before food : Regular insulin
b. Short acting
(slow acting).
insulin.
• 15 min before food : Glulisine, Aspart, Lispro
(fast acting). Also called monomeric. • Hypoglycemia
Use : control post prandial hyperglycaemia, (m/c).
DKA, Hyperkalemia. • Hypokalemia.
Subcutaneous route. • Lipodystrophy.
c. Intermediate
• NPH ( cloudy white)
acting insulin.
• Lente (30 % Semilente + 70 % Ultralente).
Subcutaneous route.
• Glargine : forms white crystals if com-
d. Long acting insulin.
bined with other insulin.
• Degludec : Longest acting.


Drug. MOA & uses. Side effects & C/I.
2. Insulin release.
a. Sulfonylureas :
• Glyburide.
• Glimepride.
• Gliclazide. • Hypoglycaemia.
Inhibit ATP sensitive K+ channels.
b. Meglitinides : • Weight gain.
• Repaglinide.
• Nateglinide.
• Mitiglinide.
Note : Hypoglycaemia and Weight gain : Sulfonylureas > Meglitinides.
c. DPP-4 inhibitors :
• Sitagliptin. • Weight neutral.
• Saxagliptin. GLP-1 : increase insulin release. • Respiratory
• Alogliptin. infection.
• Linagliptin.
Note : All DPP-4 inhibitors are C/I in Renal failure except Linagliptin (Liver excretion).
• Pancreatitis.
d. GLP-1 agonist :
Subcutaneous route (peptides). • Weight loss :
• Liraglutide
• Release insulin. Semaglutide >
• Dulaglutide
• Delays gastric emptying. Liraglutide (DOC
• Albiglutide
• Type 11 DM for maintanence. in obesity).
• Semaglutide
• Hypoglycaemia.
Note : Semaglutide can also be given via oral route.
3. Hepatic Glucose production.
• Weight loss
• Decrease Vit
B12
• Lactic acidosis
Contraindication :
• Stimulates AMPK : blocks Hepatic glucone-
• Elderly.
Biguanides : ogenesis.
• Renal/ Hepatic
• Metformin • DOC : Type 2 DM, Metabolic Syndrome,
failure.
PCOS. • Chronic alco-
holic.
• CHF, Severe
Respiratory dis-
tress.
Note : Smoking is not a risk factor for use of Biguanides.
4. Insulin resistance :
Edema , CHF, Mac-
Thiazolidenidiones :
• Stimulate PPAR-γ. ular edema, Bone
• Pioglitazone.
• Insulin resistance. fractures in female ,
• Rosiglitazone.
Hepatotoxicity.

Drugs MOA/ Uses Side effects and C/I
5. Blocks glucose absorption :
α Glucosidase in- • Inhibit breakdown of starch
hibitors : and disaccharide.
• Flatulence
• Acarbose. • Use : post prandial
• Diarrhoea.
• Voglibose. hyperglycemia. (drug taken
• miglitol. after few bites of food).
6. Urine glucose excretion : SGLT-2 inhibitor.
7. Miscellaneous drugs :
• Nausea.
• Delays gastric emptying.
Amylin analog : • Vomiting.
• Use : Post prandial
• Pramlintide. • Weight loss (Not FDA ap-
hyperglycemia.
proved).
• Colesevelam.
• Bromocriptine.
GnRH related drugs : 00:56:52
GnRH agonist :
Intermittent dosing Continuous dosing
LH, FSH LH, FSH
• Breast cancer • Infertility : Anovulation,

• Fibroids Estrogen. Oligospermia.
• Endometriosis • Delayed puberty.
• Prostate cancer → Testosterone.
• Precocious puberty.
GnRH agonist :
• Goserelin.
• Buserelin.
• Nafarelin.
• Leuprolide.
Side effects : Multiple gestation

When used as intermittent dosing Carcinoma ovary
Ovarian cyst

----- Active space ----- • Osteoporosis

• Vaginal atrophy d/t Estrogen.
• Hot flushes
When used as continuous dosing
• Osteoporsis
• Impotence d/t Testosterone.
• Gynaecomastia
GnRH Antagonist :
• MOA : LH and FSH
• Action and side effets same as GnRH agonist at continuous dose.
Contraceptive drugs : 00:59:35
Regular contraception Mechanism

Combined OCPs • Inhibit ovulation.
• Increase cervical mucus viscosity.
Mini pills • Decrease sperm penetration.
• Inhibit blastocyst implantation.
Mifepristone • Blastocyte detachment.
Emergency contraceptives Dose
0.75 mg 2 tab 12 hrs apart or 1.5 mg
Levonogestrel (DOC)
single dose within 3 days.
Ulipristal (SPRM) 30 mg 1 tab within 5 days.
Mifepristone 600 mg 1 tab within 3 days.
Note : SPRM → Selective Progesterone Receptor Modulator.
Growth Hormone (GH) related drugs : 01:00:46

GH analogs :
Somatrem/Somatropin.
Use : DOC for treatment of Dwarfism.
Side effects and contraindication : Mnemonic → CHILDREN.
• C : Carpel Tunnel syndrome. Contraindication
• H : Hyperglycemia. • Re : Retinopathy
• I : ICT is raised. • N : Neoplasia
• L : Leukemia.
• D : Diabetes.

Sermorelin ----- Active space -----
GHRH analogs : Macimorelin Diagnosis of dwarfism.

Tesamorelin
Somatostatin analogs Use Side effects
• Octreotide. Drug of choice : • Hypothyroidism
• Lanreotide. • Acromegaly. (can also TSH).
• Pasireotide. • Secretory diarrhoea. • Gall stones.
• Glucagonoma.
• Somatostatinoma.
• VIPoma.
Also used in :
• Thyrotrope adenoma.
• Acute variceal bleeding.
Note : Gall stones are caused by → Somatostatin analogs and Fibrates.
GH receptor antagonist :
Pegvisomant.
Use : Treatment of Resistant Acromegaly.
Osteoporosis related drugs : 01:03:48
Drugs decreasing Bone resorption :
Drugs MOA/uses Side effects

Bisphosphonates :
• Inhibit farnesyl pyrophos-
• Zoledronate/ • Hypocalcemia.
phate synthase.
Pamidronate : • Esophagitis (prevented
• Block ruffled border syn-
Parenteral route. by taking the drug with
thesis by the osteoblast.
• Alendronate/ full glass of H2o on empty
DOC :
Risedronate : stomach and not to lie down
• Pagets disease.
Oral. for 30 min).
• Osteoporosis.
• Osteonecrosis of jaw.
• Hypercalcemia of
Note : Zoledronate • Femoral Chalk stick
malignancy (IV drugs).
→ Longest acting fracture.
and most potent.
Note :
• Prefer to begin with oral drugs for Rx of Osteoporesis (3-5 yrs).
• Hypocalcemia is fastest with Calcitonin and maximum with Bisphosphonates.

----- Active space ----- Drugs MOA/uses Side effects

Blocks RANK ligand.
Use : Post meopausal osteo- • Osteonecrosis of Jaw.
Denosumab. porosis (When bisphosphonate • Femoral fracture.
intolerance (+) with high risk of • Hypocalcemia.
fracture).
Use : In treatment of postmeno-
pausal women with osteoporosis • Hot flashes.
Raloxifene (SERM).
and having a high risk of breast • Thrombosis.
cancer.
MOA : Inhibits resorption.
Use : • Liver cancer.
Calcitonin.
• Pagets disease. • Breast cancer.
• Osteoporosis prophylaxis.
Drugs increasing bone formation :

Drug and Route MOA/ Uses Side effects
of Administration
• Osteosarcoma (max use
Stimulate osteoblast mediated bone
• Teriparatide limited to 2 years).
formation.
(PTH analog). • Hypotension.
Use :
• Abolaparatide
• Post menopausal osteoporosis.
(PTHRP analog). Note : Contraindicated in
• Bisphosphonate intolerance
Pagets disease ( risk factor
with high risk of fractures.
for osteosarcoma).
Note : Teriparatide used for Bisphosphonate induced fracture.
• Stimulate bone formation.
• Blocks sclerostin.
Use :
• Romosozumab.
• Post menopausal osteoporesis.
• Bisphosphonate intolerance
with high risk of fractures.
Drugs decreasing bone resorption and increasing bone formation :

Drug and Route of MOA/ Uses
administration
Strontium ranelate. • Bone resorption.
• Bone formation.

Steroid drugs : 01:09:44 ----- Active space -----
Steroids Half life Uses

Hydrocortisone : (Derived 8- 12 hrs. • Replacement : Addisons disease.
from cortisol).
Prednisone. 12-36 hrs. • Supress Immune system.
Prednisolone. • Supression of inflammation (RA, Vas-
Methylprednisolone. culitis, Gout).
Triamcinolone.
Dexamethasone. 36-72 hrs.
Betamethasone.
Note :
• Least potent and shortest acting steroid : Hydrocortisone.
• Most potent and longest acting steroid : Dexa/Betamethasone.
• Triamcinolone and Dexa/Betamethasone → Also called pure glucocorticoids.
• Cushings disease → Side effect of steroids.
Thyroid related drugs : 01:13:23
Hyperthyroidism :
Drugs MOA /uses Side effects

• Propylthiouracil : (Short
• Hepatotoxic.
acting → Need multiple
• Agranulocytosis.
dosing).
Inhibit Thyroid
peroxidase. • Teratogenic : Choanal and
• Carbimazole, Methimazole
esophageal atresia, cutis
: (Both are Long acting →
aplasia.
OD dosing.) • Agranulocytosis.
Note :
Universal DOC → Carbimazole/ Methimazole.
DOC for Hyperthyroidism in pregnancy.
• 1st Trimester : Propylthiouracil.
• 2nd & 3rd Trimester : Carbimazole / Methimazole.
• Inhibit thiol endo-
peptidase → block
release of T3/ T4.
• Potassium iodide. • Thyroid size and
• Lugols iodine (fastest vasculogenesis.
acting antithyroid drug). (Use in preopertive
preperation : make
thyroid gland firm
and small.

----- Active space ----- Drugs MOA /uses Side effects

• Inhibit thiol endopeptidase
→ block release of T3/ T4.
• Potassium iodide. • Thyroid size and
• Lugols iodine (fastest vasculogenesis. (Use in
acting antithyroid drug). preopertive preperation :
make thyroid gland firm
and small.
• Propranolol.
• Propylthiouracil. Block peripheral conversion
• Amiodarone. of T4 → T3.
• Steroids.
Note :
• Thyroid storm → DOC : Propylthiouracil.
c. 1 st drug to be started → Propranolol.
d. In Bronchial asthma/COPD → DOC : Verapamil/Diltiazem.
Radioactive Iodine : I 131 Destroys Follicular cells by beta • Secondary cancers
and gamma rays. • Permanent
Use : hypothyroidism.
• Thyroid cancer. Contraindicated in
• Recurrent Graves disease. Pregnancy.
• Hyperthyroidism in elderly.
Hypothyroidsim :
Drugs MOA/ Uses Side effects

Levothyroxine : T4 • DOC for replacement : • Osteoporosis
salt (Long acting). Oral route → in empty • Atrial fibrillation : Decrease
stomach. the dose of drug.
• Thyroid cancer.
• Myxedema coma : IV
route.
Liothyronine : T3 salt. • Before Radioactive Io-
dine therapy in thyroid
cancer (oral route) →
Increase I 131 uptake.
• Myxedema coma : IV
route.

Autacoids 00:00:15
Antihistamines:
First generation Second generation
HCross
1
blockers
BBB: (Sedative). Do not cross BBB (Non sedative).
C/I : Elderly, children, drivers & pilots.
Uses :
• Non allergic rhinitis.
• Used as anti muscarinic in :
a. Extra pyramidal symptoms Uses :
b. Motion sickness • DOC for urticaria.
c. Meniere’s disease. • Rx of allergic rhinitis (DOC is
Note : Max muscarinic block seen with Intranasal steroids : Fluticasone).
1. Promethazine
2. Diphenhydramine
3. Dimenhydrinate
Important drugs : Important drugs :
1. Doxylamine + vitamin B6 : DOC for 1. Cetirizine : Most sedating 2nd gen

morning sickess. antihistamine (Since it is derived
from hydroxyzine).
2. Chlorpheniramine :
• Least sedative 1st generation anti- 2. Levocetirizine
histamine. 3. Fexofenadine
• Preferred for day time use. 4. Loratadine
5. Desloratadine
3. Doxepin : Used as TCA. 6. Rupatadine : Blocks Platelet
activating
4. Cyproheptadine : 5-HT2 blocker→ factor (Anti inflammatory).
DOC for Serotonin syndrome.
7. Topical antihistamines (Only) :
5. Hydroxyzine : Used for pruritis. • Olopatadine
• Levocarbastine
• Ketotifen
• Azelastine
• Astemizole
Pharmacology Revision • v1 • Marrow 6.5 • 2023


NSAIDs :
Non selective COX inhibitors :
They cause gastric ulcer, nephrotoxicity.
1. Acetaminophen/paracetamol :
• Good analgesic & antipyretic.
• Poor anti inflammatory .
• M/c cause of drug poisoning.
• M/c cause of drug induced liver failure.
• Liver toxicity :
Caused d/t NAPQI metabolite (Depletes glutathione).
At >150-250 mg/kg or ≥10g (Fatal dose : ≥20g).
M/c in chronic alcoholics & during fasting.
HPE : Centrilobular necrosis with periportal sparing.
To predict toxicity : Rumack Matthew nomogram is used.
Antidote : N-Acetyl Cysteine (Replenish glutathione & blocks NAPQI).
Note : For vancomycin nephrotoxicity, Matzke nomogram is used.
2. Aspirin :
• Different doses have different effects :
Dose Action
Low dose
Antiaggregant
(50-325 mg OD)
Moderate dose
Antipyretic & analgesic
(325-650 mg SOS)
High dose
Anti inflammatory
(3-4g/d, divided doses)
• S/E : Reye’s syndrome.

• C/I :
a. Viral fever in children.
b. Gout.

Non selective COX ----- Active space -----

Important points
inhibitors
• MOA : Blocks
a. COX.
b. Phospholipase A.
3. Indomethacin c. Lymphocyte proliferation and chemotaxis.
• Uses :
a. DOC for acute attack of gout.
b. Closure of PDA.
• DOC for closure of PDA.
4. Ibuprofen
• M/c cause of drug induced aseptic meningitis.
• C/I with aspirin (One drug efficacy of other).
• Long acting drug (Undergo enterohepatic circulation).
5. Piroxicam
• Used in chronic pain.
• Hepatotoxic
6. Nimesulide • C/I for use > 15 days in adults.
• In India, banned in children < 12 years.
Used in :
7. Ketorolac • Post operative pain.
• Eye drops (Ocular pain).
Selective COX inhibitors :

They are cardiotoxic (Can cause MI).
Selective COX-2 inhibitors Important points
Celecoxib Usesd as 3rd line drugs for pain/
Etoricoxib inflammation.
Parecoxib Post operative pain.
Lumiracoxib Banned due to hepatotoxicity.
Valdecoxib
Banned as both cause MI.
Refecoxib


Prostaglandins :
Prostaglandin Analogues Uses
• Abortion.
Misoprostol • NSAID induced gastric ulcer.
Prostaglandin E1 • Maintain patency of DA.
• Maintain patency of DA.
Alprostadil • Erectile dysfunction.
• Abortion.
Prostaglandin E2 Dinoprostone • Cervical ripening.
• PPH.
Prostaglandin F2 • Abortion.
Carboprost
alpha • PPH.
Latanoprost/Bimatoprost Open angle glaucoma.
Synthetic PGI2 : Epoprosterenol

Prostaglandin I2 PGI2 analogs : Iloprost Pulmonary hypertension.
PGI2 receptor agonist : Selexipag
Disease Modifying Anti Rheumatic Drugs (DMARDs) :

Drugs used in rheumatoid arthritis (RA) :
Conventional DMARDs Biological DMARDs Targeted DMARDs
1. Methotrexate (DOC) : 1. TNF-alpha inhibitors : JAK inhibitors :
• Anchor drug. • Downregulate lympho- • Tofacitinib
• MOA in RA : Increases cytes. • Baricitinib
adenosine. • S/E : risk of infections. • Upadacitinib
2. Hydroxychloroquine • C/I : Hep B & CHF.
3. Sulfasalazine • Drugs : S/E : risk of
4. Cyclophosphamide a. In : Infliximab infections.
5. Immunomodulators : b. C : Certolizumab
• Azathioprine c. A : Adalimumab
• Cyclosporine d. G : Golimumab
• Mycophenolate mofetil e. E : Etanercept
• Leflunomide 2. Rituximab : Anti CD 20.
3. Abatacept : Anti CD 80/86.
4. Anakinra : IL 1 antagonist .
5. IL-6 inhibitors :
• Tocilizumab
• Sarilumab

Treatment of Rheumatoid Arthritis (RA): ----- Active space -----

New case of RA
Start Methotrexate
If no response
Add
HCQ (or) Leflunomide (or) Biologicals

+ No response
Sulfasalazine Change to another
biological agent
or
Anti gout drugs : JAK inhibitor
Acute gout :
DOC : Indomethacin > Colchicine.
Colchicine MOA : Blocks microtubules Blocks chemotaxis.
Chronic gout :
New case of chronic gout
Start Allopurinol
If pt develops hypersensitivity If ineffective

(Steven Johnson syndrome)
Stop Allopurinol & Switch to Add

(or)
use Oxypurinol Febuxostat Uricosuric drugs
No response
Use pegloticase (Uricase analogue)
Xanthine oxidase inhibitors : Uricosuric drugs :

Drugs : Increase uric acid excretion.
1. Allopurinol Drugs :
2. Oxypurinol 1. Sulfinpyrazole Not effective in
3. Febuxostat 2. Probenecid renal failure
3. Benzbromarone Effective in
S/E : Xanthine stones. 4. Lesinurad renal failure
SJS (Allopurinol). S/E : Urate stones.


Hyperuricemia in tumor lysis syndrome :
• Solid tumors : DOC Allopurinol
• Leukemia : DOC Rasburicase
Respiratory system 00:29:00
Anti asthmatic drugs :

Beta-2 agonists & Anti cholinergics - -
Adenosine A1 block :
Methyl Xanthines : • Bronchodilatation d/t • Seizures
• Theophylline adenosine A1 antagonism, • Arrhythmias
• Aminophylline PDE 3 > 4 block. • Diuresis
• Anti inflammatory d/t PDE 4
New PDE-4 inhibitor approved for block, histone deacetylase PDE-4 block :
COPD : Roflumilast stimulation, IL-10. • GIT upset
• Headache
Inhaled corticosteroids (ICS) : Fluti-
• Hoarseness of
casone (most potent) • DOC : Persistent asthma
voice (M/c).
Soft steroids : • TOC in acute attack : ICS +
• Oropharynge-
• Ciclesonide Formoterol
al candidiasis.
• Beclomethasone
For Rx acute exacerbation
Systemic steroids
( Beta-2 agonist effect)
LOX inhibitor : Zileuton Persistent bronchial asthma add
Hepatotoxic
LT C4/D4 inhibitors : Montelukast on EIA
Mast cell stabilizers :
Prophylaxis of allergen induced
• Cromolyn sodium Safest drugs
asthma
• Nedocromil
Severe persistent bronchial Not effective in
Anti Ig E : Omalizumab
asthma atopic dermatitis
Anti IL 5 :
• Reslizumab
Severe eosinophilic
• Mepolizumab
asthma
Anti IL 5 receptor : Bendralizumab
Anti IL 4 receptor : Dupilumab

Anti-tussives : ----- Active space -----

Centrally acting drugs :
All drugs are used for dry cough.
Opioids Non opioids
For mild/moderate dry cough : • Dextromethorphan :
• Codeine 1. NMDA antagonist
• Pholcodine 2. S/E : Hallucinations (Has
• Hydrocodone abuse potential).
• Diphenhydramine
For severe cough (eg. bronchial Ca) : • Noscapine
• Methadone • Levopropoxyphene
• Morphine
Expectorants :
Guaifenesin : Cause oscillatory movement of the bronchi leading to expulsion of
products.
Mucolytics :
N-acetyl cysteine : Breaks disulfide bonds in the mucus.
Ambroxol/Bromhexine : Depolymerise mucopolysaccharides.
Management of productive cough :

Syrup : Ambroxol/Bromhexine + Salbutamol + Phenylephrine.
Gastrointestinal system 00:35:00
Peptic ulcer disease :

DOC in :
• GIT upset.
• Peptic ulcer disease (PUD).
Proton pump inhibitors : • Pneumonia.
• GERD.
• Omeprazole • Pseudomembranous
• Zollinger Ellison syn-
• Pantoprazole enterocolitis.
drome.
• Lansoprazole • Osteoporosis.
• H.pylori.
• Rabeprazole • Iron, B12 deficiency.
• Barret’s esophagus (Life
• Hypergastrinemia.
long Rx with PPI).
H2 blockers : Same as PPI, for Rx. Cimetidine :
• Cimetidine DOC for prophylaxis of aspira- • Impotence.
• Ranitidine tion pneumonia in postoperative • Gynecomastia.
• Famotidine patients . • Galactorrhea.

----- Active space ----- Drugs Uses Side effects

Most specific for NSAID induced • Diarrhoea.
Misoprostol
ulcer. • Abdominal cramps.
• Constipation.
Sucralfate • PUD. • Gastric bezoars.
• Rectal ulcer. • C/I with food,
antacids & other drugs.
• Constipation.
Bismuth subsalicylate/sub- • H.pylori.
• Black discoloration of
citrate • Traveler’s diarrhoea.
stool and tongue.
Antacids (Salts of Al3+ and

• PUD. Decrease absorption of oth-
Mg2+)
• Dyspepsia. er drugs.
Al3+ : Causes constipation
• GERD.
Mg2+ : Causes diarrhea.
Note :
• PPI’s sholud be consumed 30 mins before food.
• Antacids should be given 30 min after sucralfate.
• Food should be consumed 1 hr before sucralfate.
• Any other drug should be consumed 2hrs before sucralfate.
Prokinetics :
Classification Drugs /side effects
1. Metoclopramide :
• Crosses BBB.
D2 antagonists • Causes EPS.
• Hyperprolactinemia.
2. Domperidone : No EPS.
1. Mosapride
5-HT4 agonists 2. Itopride
3. Prucalopride
1. Erythromycin
Motilin receptor agonists
2. Mitemcinal
CCK1/A receptor agonist 1. Dexloxiglumide

Antiemetics : ----- Active space -----

5-HT3 antagonists : • DOC : Chemo/radi-
• Ondansetron : Short- ation/postoperative
est acting. nausea or vomiting.
• Palonosetron : Long- • Morning sickness.
est acting, most
potent
NK1R antagonists :
• Aprepitant Chemo induced nausea &
• Rolapitant vomiting
• Netupitant
CB 1R agonists : Chemo induced nausea & • Hypotension (Monitor
• Dronabinol vomiting BP).
• Nabilone (As an add on drug). • Blood shot eyes .
Chemo induced nausea &
Dexamethasone
vomiting
M/c used drugs in chemo induced nausea and vomiting :
Ondansetron + Aprepitant + Dexamethasone.
Laxatives :
Increase water in Increase intestinal contrac- Increase stool Softening of
intestine tion bulk stool
Bisacodyl, Senna, Cascara :
1. Osmotic laxatives :
• Promote low grade
Mannitol :
inflammation of large
• Used as second line in Probiotics :
intestine increase Docusate Na+ :
constipation (Costly). Beneficial micro
contraction. They increase
• Used in hepatic en- organisms
• Taken at night. surface tension
cephalopathy as well. • Lactobacillus
• Used for short term treat- of stool
• Saccharomyces
ment of constipation. Collapses stool.
Polyethylene glycol : • B. clausii
• Senna causes melanosis
DOC for IBS associated
coli and pink/yellow brown
constipation.
discoloration of urine.

----- Active space ----- Increase water in Increase intestinal con-

Increase stool bulk Softening of stool
intestine traction
2. Chloride secretory
agents :
1. Lubiprostone : Prebiotics : Docusate Ca2+ :
Stimulates type II chlo- 5-HT4 agonists : Dietary fibers They increase
ride channels. • Mosapride • Methyl cellulose surface tension
2. Linaclotide : Stimulates • Prucalopride • Psyllium husk of stool
guanylate cyclase, • Bran Collapses stool.
cGMP, which stimu-
lates CFTR.
3. Tenapanor : Inhibitor
of sodium-proton ex-
changer.
Anti diarrheal agents :

Drugs MOA/Uses
5-HT3 antagonist.
Alosetron
IBS associated with diarrhea in females.
Loperamide DOC for non secretory diarrhea
(opioid) (IBS associated diarrhea).
Octreotide DOC for secretory diarrhoea.
Bile acid bending resins Biliary diarrhoea
Hematology 00:47:03
Antiaggregants :
COX-1 inhibitor : Primary prophylaxis of
Bleeding
Aspirin : TXA2 synthesis MI & stroke.
C/I : Cerebrovascular
Primary prophylaxis of
PAR 1 blocker : Vorapaxar disorders (Intracranial
MI.
bleed )
GP IIb/IIIA blockers :
• Abciximab PCI in MI. Bleeding
• Tirofiban Unstable angina. Thrombocytopenia
• Eptifibatide

AD/P2Y12 blockers : ----- Active space -----
Irreversible Reversible
1. Clopidogrel : Primary prophylaxis of 1. Cangrelor :
MI and stroke. • Adenosine analog : IV & short act-
2. Ticlopidine : ing.
S/E : Agranulocytosis, TTP-HUS, • Use : PCI in MI.
thrombocytopenia. 2. Ticagrelor :
3. Prasugrel : • Oral
• Causes intracranial bleed. • Use : Acute coronary syndrome,
• C/I in stroke/TIA. prophylaxis of MI and stroke.
• Use : PCI in MI.
Anticoagulants :
Drugs Uses Comments
Direct acting oral No monitoring required.
• DVT Rx.
anticoagulant (DAOC) : Incase of bleeding (D/t
• DOC DVT prophylaxis.
• Oral DTI : Dabigatran overdose) :
• DOC prophylaxis of
• Oral Xa inhibitors : • Dabigatran :
thrombosis in non val-
4. Apixaban Idarucizumab
vular atrial fibrillation
5. Rivaroxaban • Oral Xa inhibitors :
(Native valve).
6. Edoxaban Andexanet alfa
• Skin necrosis : Due to
rapid in proteins C and
S.
• DVT Rx & prophylaxis. • Purple toe syndrome :
Warfarin :
• DOC for prophylaxis of Cholesterol embolus.
• Blocks VKOR .
thrombosis in • Teratogenic : Mid facial
• Decreases levels of
valvular atrial hypoplasia, stippled epi-
factors II,VII,IX,X &
fibrillation physeal calcification, CNS
proteins C and S.
(Mechanical valve). defects.
Antidote : Vitamin K &
4 factor prothrombin com-
plex > FFP

----- Active space ----- Drugs Uses Comments

Common use : Heparin
induced thrombocytope-
Parenteral DTI (Direct nia (HIT)
thrombin inhibitor) DOC : Argatroban Monitor aPTT
(> Fondaparinux)
Desirudin
Bivalirudin
Does not need monitoring Needs monitoring

D : DOAC
UFH & Parenteral DTI (Argatroban) : aPTT
L : LMWH
Warfarin : PT/INR
F : Fondaparinux
Prophylaxis of thrombosis in atrial fibrillation :
Mechanical valve Native valve
Warfarin Look for :

• Severe MS (Valve SA <1.5 cm2).
• Renal failure.
Yes No
Warfarin DOAC

Direct thrombin inhibitors : ----- Active space -----
Low Molecular Weight

Unfractionated heparin (UFH) Fondaparinux
Heparin (LMWH)
Inhibits Xa = IIa Inhibits Xa > IIa Inhibits only Xa
S.c route : Only for prophylaxis
Both Rx and prophylaxis given by s.c route.
(Poor bioavailability).
(Good bioavailability)
IV route : For Rx.
Short acting (Metabolized by
macrophages) : Need multiple Long acting, can be given as single dose/OD.
doses
Can be used in renal failure. C/I in renal failure.
Protamine sulfate has Protamine sulfate

Protamine sulfate has good
some efficacy as an has no efficacy as
efficacy as an antidote.
antidote. an antidote.
risk of heparin induced
Less risk of HIT No risk of HIT
thrombocytopenia (HIT)
DOC for thrombosis (In MI, DVT, Pulmonary
embolism, cancer induced thrombosis)
S/E of heparin :
• H : Hyperkalemia, Hair loss.
• O : Osteoporosis.
• T : Thrombocytopenia.
Fibrinolytics :
t-PA
Plasminogen Plasmin Breaks fibrin
t-PA analogs :
1. Alteplase
2. Reteplase
3. Tenecteplase (Most clot specific).
Given in IV form.
Use : STEMI
S/E : Bleeding (DOC for bleeding : Tranexemic acid > Epsilon aminocaproic acid).


Hematopoietic agents :
Erythropoiesis Granulopoiesis Thrombopoiesis
Erythropoietin analogs : G-CSF analog : IL-11 analong :
1. Epoietin alfa 4. Lenogastrim Oprelevekin
2. Darbopoetin alfa 5. Filgastrim Use : Thrombocytopenia
(Long acting). 6. Lipefilgastrim (Long due to chemotherapy.
acting, given once
Uses : in a chemotherapy Thrombopoietin agonist :
• Anemia of CRF. cycle, more 1. Eltrombopag.
• Anemia causes by preferred). 2. Romiplostim.
chemotherapy/drug. Use : ITP
• Anemia of dialysis. GM-CSF analog : 1. Lusutrombopag
Sargamostim 2. Avatrombopag
S/E : Use : To decrease
• Pure red cell aplasia. Uses : bleeding in liver cirrhosis
• Hypertension. • Neutropenia planned for procedure.
• Thrombosis. • HIV
• Iron deficiency. • Chemotherapy
S/E :
• Bone pain

Immunosuppressants 01:07:20 ----- Active space -----
Immunomodulators MOA and Uses Side effects

Common : Hepatotoxicity,
Hyperkalemia, Hyperten-
sion, Nephrotoxicity, Neuro-
Calcineurin inhibitors :
toxicity, Hyperglycemia.
Cyclosporine IL-2 transcription.
Cyclosporine :
Tacrolimus
• Hirsutism.
1st line drug for GVHD.
• Gums hyperplasia.
• Hyperlipidemia.
• Hyperuricemia.
Everolimus mTOR inhibitors : Inhibit CD8
Hypokalemia
Sirolimus proliferation at G1-S phase.
Prodrug of Bone marrow suppression &
Azathioprine
6-mercaptopurine . hepatotoxicity
Blocks IL-2 receptor/CD 25.
Basiliximab Used for prophylaxis of
acute graft rejection.
Mycophenolate Blocks IMP dehydrogenase
GIT upset
mofetil Blocks purine synthesis.
Blocks dihydro-orotate
Bone marrow suppression
Leflunomide dehydrogenase Blocks
Hepatotoxicity
pyrimidine synthesis.
Blocks CD 3.
Uses :
Muromonab • Rx of acute graft re- Cytokine release syndrome
jection.
• Rebound rejection.
Belatacept CD 80/86 inhibitor
Alemtuzumab CD 52 inhibitor
Belumosudil Rho kinase inhibitor
Phocomelia mechanism :
Anti inflammatory
Blocks cereblon & tubulins
Anti angiogenic
Thalidomide Blocks vasculogenesis &
Anti neoplastic
free radicals blocks
Immunosuppressant
fetal organ development.

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xyz Pharmacology Revision 1 01 1

PHARMACOLOGY REVISION 1 ----- Active space -----

General Pharmacology 00:00:10

Rational drug use :

Pharmacokinetics and Pharmacodynamics :

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

M/C mechanism : Passive diffusion.

Sustained release &

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

Extent and rate of absorption : ----- Active space -----

Bioavailability (BA)/ Rate of absorption

BA = AUC oral × 100

P-Glycoprotein (Pgp)/MDR-1 (Multi Drug resistance-1) pump :

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

Volume of Distribution (VD) :

Loading dose = aVD X Ct. Ct : Target plasma concentration

Loading dose depends on apparent volume of distribution.

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

Pharmacokinetics : Metabolism 00:25:18 ----- Active space -----

Phase I reactions Phase II reaction

Enzyme Inducers Enzyme Inhibitors

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

----- Active space -----

Pharmacokinetics : Excretion 00:41:34

M/C organ for excretion : Kidney.

Drug toxicity Antidote

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

Zero order kinetics First order kinetics

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

----- Active space ----- PHARMACOLOGY REVISION 2

Drug Target Effect.

Dose Response Curve (DRC) 00:04:13

Quantal DRC Graded DRC

100 A-Enalapril B-Captopril

Pharmacology Revision • v1.0 • Marrow 6.5 • 2023

Therapeutic index (T.I) : ----- Active space -----

Drug receptor interaction 00:16:24

• Inverse agonist : Opposite effect (0 to -1). D : Inverse agonist_~ Antagonist

Pharmacology • v4.5 • Marrow 6.5 • 2023

----- Active space ----- 4. Competitive (Pharmacological) 5. Non-competitive

Drug Drug + Antagonist Drug

Log dose Log dose Log dose

Right shift of DRC. Decrease in height of DRC.

4. G-Protein Coupled Receptors (GPCRs) :

Gq : ----- Active space -----

Preclinical Trials : Animals.

Phases Features (mnemonic : TEL)

Post Marketing Surveillance. Many thousands.

Pharmacology • v4.5 • Marrow 6.5 • 2023

----- Active space -----

ADR types Examples

Therapeutic drug monitoring 00:41:42

Principle : The plasma concentration of a drug should have a good correlation

Important drugs : ----- Active space -----

Pharmacogenetic conditions 00:44:04

A : Acetyl transferase polymorphism (NAT-1 gene – Fast acetylators;