This particular Internet page presents  the examples of set of   medicaments prescribed simultaneously,   often as a necessary ' therapeutic complex '

     These  patterns are formulated using only rINN. We formulated these patterns according to real practices encountered in UK in NHS hospitals.

1. Crucial set of cardiological diseases ( hypertension, coronary heart disease  and heart

     failure )

    Coronary Heart Disease ( CHD )

(1) Simvastatin    40 mg,      once   daily

(2) Aspirin          75 mg,       twice  daily

(3) Lisinopril        2.5 mg,    once   daily ,   up to   10 - 20 mg  daily

     or

     Perindopril      2.0 mg     once  daily,      up to  4- 8 mg   daily

     Ramipril         1.25 mg    once daily,       up to 2,5 - 5 mg  daily

(4) Atenolol         25  mg       twice daily

     or

     Bisoprolol         5 mg       once daily        up to 10 mg daily

(5) Amlodipine      5 mg        once daily

(6) Isosorbite Mononitrate    20 mg  3 times daily     

   Hypertension  - supplement to drugs for CHD

    +

(1) Bendroflumethazide   2.5 mg   once in the morning

      or

      Indapamide                 2.5  mg   once daily in the morning

   Heart Failure

    +

 (1) Chlortalidone 50 mg daily

       or

       Furosemide  40 mg daily

       or

       Amiloride hydrochloride   10 mg daily

 (2)  Spironolacton  25 - 50 mg  up to 200 mg daily

 (3)  Digoxin 62.5 micrograms ( maintanance )

                                                                              Myocardial infarction

   Introductory text  about the treatment  of  myocardial infarction  compiled  mainly on the basis of   " E - medicine- instant access to the minds of medicine " http://www.emedicine.com/ [ http://www.emedicine.com/med/topic1567.htm  ] 

   Initial therapy for acute MI is directed toward restoration of perfusion in order to salvage as much of the jeopardized myocardium as possible. This may be accomplished through medical or mechanical means, such as angioplasty or coronary artery bypass grafting.

Further treatment is based on (1) restoration of the balance between the oxygen supply and demand to prevent further ischemia, (2) pain relief, and (3) prevention and treatment of any complications that may arise.

• Thrombolytic therapy has been shown to improve survival rates in acute MI if administered in a timely fashion in the appropriate group of patients. The optimal approach is to administer thrombolytics within 12 hours of onset of symptoms in patients with ST-segment elevation greater than 0.1 mV in two or more contiguous ECG leads, new left bundle-branch block (LBBB), or anterior ST depression consistent with posterior infarction. Tissue plasminogen activator (t-PA) is superior to streptokinase in achieving a higher rate of coronary artery patency; however, the key to efficacy lies in the speed of delivery of therapy. Recent trials show an even greater patency rate if a IIb/IIIa receptor antagonist, such as abciximab, is combined with a half dose of a thrombolytic agent as the initial reperfusion strategy. The reduced dose of a thrombolytic agent combined with a potent platelet inhibitor may prove to be the preferred method for medical reperfusion, but larger clinical trials are pending.

• Aspirin and/or antiplatelet therapy

• Aspirin has been shown to decrease mortality and re-infarction rates after MI. Administer aspirin immediately, which the patient should chew if possible upon presentation. Continue aspirin indefinitely unless an obvious contraindication, such as a bleeding tendency or an allergy, is present. Clopidogrel may be used as an alternative to aspirin in cases of aspirin resistance or allergy.

• Administer a platelet glycoprotein (GP) IIb/IIIa-receptor antagonist, in addition to acetylsalicylic acid and unfractionated heparin (UFH), to patients with continuing ischemia or with other high-risk features and to patients in whom a percutaneous coronary intervention (PCI) is planned. Eptifibatide and tirofiban are approved for this use. Abciximab also can be used for 12-24 hours in patients with unstable angina or non–ST-segment elevation MI in whom a PCI is planned within the next 24 hours.

• Beta-blockers reduce the rates of reinfarction and recurrent ischemia and possibly reduce mortality rate if administered within 12 hours after MI. Administer routinely to all patients with MI unless a contraindication is present.

• Heparin (and other anticoagulant agents) has an established role as an adjunctive agent in patients receiving t-PA but not with streptokinase. Heparin also is indicated in patients undergoing primary angioplasty. Little data exist with regard to efficacy in patients not receiving thrombolytic therapy in the setting of acute MI. Low–molecular-weight heparins (LMWHs) have been shown to be superior to UFHs in patients with unstable angina or NQWMI.

• Nitrates have no apparent impact on mortality rate in patients with ischemic syndromes. Their utility is in symptomatic relief and preload reduction. Administer to all patients with acute MI within the first 48 hours of presentation, unless contraindicated (ie, in RV infarction).

• ACE inhibitors reduce mortality rates after MI. Administer ACE inhibitors as soon as possible as long as the patient has no contraindications and remains in stable condition. ACE inhibitors have the greatest benefit in patients with ventricular dysfunction. Continue ACE inhibitors indefinitely after MI. Angiotensin-receptor blockers may be used as an alternative in patients who develop adverse effects, such as a persistent cough, although initial trials need to be confirmed.

Surgical Care:

• Primary angioplasty

• Primary percutaneous transluminal coronary angioplasty (PTCA) is an attractive alternative to thrombolytic therapy. PTCA provides greater coronary patency (>96% thrombolysis in myocardial infarction [TIMI] 3 flow), lower risk of bleeding, and instant knowledge about the extent of the underlying disease. Some studies have shown that primary PTCA has a mortality benefit over thrombolytics; however, the data are limited, and long-term benefit remains in question. The widespread use of stenting and adjunctive IIb/IIIa therapy are improving the results of primary PTCA. A recently published trial showed that, in patients with acute MI, coronary stenting plus abciximab leads to a greater degree of myocardial salvage and a better clinical outcome than does fibrinolysis with a t-PA. Improvement of long- and short-term outcomes, however, depends highly on the speed with which reperfusion is achieved. However, a body of evidence is accumulating in support of primary angioplasty as a more effective therapy than thrombolytics.

• Cardiac catheterization and angioplasty are indicated in patients who do not fit the above-mentioned criteria for thrombolytic therapy or have persistent ischemia. Primary angioplasty also is the treatment of choice in patients with cardiogenic shock, patients in whom thrombolysis failed, and those with high risk of bleeding or contraindications to thrombolytic therapy.

• Only an experienced operator should perform primary PTCA, and PTCA should be performed only where the appropriate facilities are available. Operators should have at least 75 cases per year, while the center should perform at least 200 cases per year as per the recommendations of the ACC.

• Emergent or urgent coronary artery graft bypass surgery is indicated in patients in whom angioplasty fails and in patients who develop mechanical complications such as a VSD, LV rupture, or a papillary muscle rupture.

Elements of treatment - medicaments with doses.:

Oxygen

Pain and anxiety manamement

    Diamorphine  by slow  intravenous injection 5 mg repeated every 4 hours

    Morphine sulfate for narcotic analgesia due to its reliable and predictable effects, safety

         profile, and ease of reversibility with naloxone. Administered IV, may be dosed in

         a number of ways and commonly is titrated until desired effect. Dose : 2 mg IV q5-

         15min, titrate to symptomatic relief or adverse effects (eg, lethargy, hypotension,

          respiratory depression)

Aspirin

Gliceryl Trinitrate  400 mcg SL or spray q5min, repeat up to 3 times; if symptoms persist,

       5-10 mcg/min IV infusion; titrate to 10% reduction in MAP or symptom relief,

       limiting adverse effects of hypotension.

Thrombolytic drugs

    Alteplase, t-PA (Activase) -- Fibrin-specific agent with brief half-life of 5 min. Adjunctive

       therapy with IV heparin necessary to maintain patency of arteries recanalized by t-PA,

       especially during first 24-48 h. 15 mg IV initial bolus, followed by 50 mg IV over next 30

       min, and then 35 mg IV over next h; total dose not to exceed 100 mg.

    Streptokinase ( Streptase) -- Acts with plasminogen to convert plasminogen

        to plasmin. Plasmin degrades fibrin clots, as well as fibrinogen and other plasma

        proteins. Increase in fibrinolytic activity that degrades fibrinogen levels for 24-36 h

        occurs with IV infusion of streptokinase. Adjunctive therapy with heparin not needed.

        1.5 million IU in 50 cc D5W IV over 60 min

    Reteplase ( Rapilisin ) -- Recombinant plasminogen activator that forms plasmin after

         facilitating cleavage of endogenous plasminogen. In clinical trials, has been comparable

         to alteplase in achieving TIMI 2 or 3 patency at 90 min. Heparin and aspirin usually

         administered concomitantly and after reteplase. 10 IU IV over 2 min, followed by

         second 10-IU IV dose after 30 min

    Anistreplase ( Eminase ) -- Non–fibrin-specific agent that activates conversion of

         plasminogen to plasmin and has half-life of 90 min. However, does not have any benefit

        over streptokinase, although has higher rate of allergic and bleeding complications.

        Easier to administer than t-PA, has lower cost , and does not require heparinization. 30

        IU over 2-5 min. 5 mg IV slow infusion q5min; not to exceed 15 mg or desired heart rate

        25 mg PO bid usual initial dose, up to 100 mg bid; titrate to desired effect

   Tenecteplase  ( Metalyse )

Heparin

Betablockers

  Atenolol  by  i.v. injection at a dose pf 5 mg over 5 minutes, and the dose repeated once

         after 10 - 15 minutes

  Metoprolol  -- Selective beta1-adrenergic receptor blocker that decreases

        automaticity and contractions. Goals of treatment are reduction in heart rate to 60-80

        bpm. During IV administration, carefully monitor BP, heart rate, and ECG.

        Dose .: 5 mg IV slow infusion q5min; not to exceed 15 mg or desired heart rate

        25 mg PO bid usual initial dose, up to 100 mg bid; titrate to desired effect

ACE inhibitors

Treatment  in the situation of   shock

Sympathomimetics

2.71.  Inotropic sympathomimetics

              Dobutamine  - 2.5 - 10 micrograms/kg/minute                          

                  Dobutrex  - strong sterile solution 12.5 mg/ml 

                ( Indications : inotropic support in infarction, cardiac surgery, cardiomyopathies, septic shock and cardiogenic shock )

              Dopamine hydrochloride - 2 - 5 micrograms/kg/minute

                  Dopamine  - sterile concentrate 40 mg/mL or

                                        intravenous infusion - - 1.6 mg/mL in glucose %                 

                ( Indications :  cardiogenic shock in infarction or cardiac surgery  )

              Dopexamine hydrohloride 500 nanograms/kg/minute

2.7.2  Vasoconstrictor sympathomimetics

               Ephedrine hydrochloride
               Metaraminol
               Noradrenaline acid tartarate
               Phenylephrine hydrochloride

2.7.3   Cardiopulmonary resuscitation

              Adrenaline ( epinephrine )
              Amiodarone
              Atropine

***  Plasma and plasma substitutes

               Albumine solution
               Dextran 40
               Dextran 70
               Gelatin
               Etherified starch  

                     Voluven
                     eloHAES
                     HAES-steril
                     Hemohes

         ***  Allergic emergencies  

      **   Antihistamines, hyposensitisation, and allergic emergencies

             *  Non - sedating antihistamines

              Acrivastine
             Cetrizine hydrochloride
             Desloratadine
             Fexofenadine hydrohloride
             Levocetirizine dihydrochloride
             Loratadine
             Mizolastine 
             Terfenadine

        * Sedating antihistamines

             Alimemazine tartarete
             Brompheniramine maleate
             Chorphenamine maleate   ( Chorpheniramine maleate )  -  tablets .. 4 mg
             Piriton ( GSK Consumer Healthcare )   - tablets .. 4 mg
             Clemastine  - 1 mg twice daily 
                    Tavegil  ( Novartis ) - tablets  .. 1 mg
             Cyproheptadine hydrochloride
             Diphenhydramine hydrochloride

                  Proprietary names -.. on sale  to the public to aid relief of temporary sleep disturbances  in adults include.:

                       Dreemon
                       Medinex
                       Night - calm
                       Nyton
                       Panadol Night

                 Diphenylpyraline hydrochloride
                 Doxylamine
                 Hydroxyzine hydrochloride
                 Promethazine hydrochloride
                Triplolidine hydrochloride

        * Hyposensitisation

                  Bee and wasp allergen extracts
                  Grass and tree pollen extracts

***  Allergic emergencies - Anaphylaxis - Angioedema

        Intramuscular adrenaline ( epinephrine )
        Intravenous adtrenaline ( epinephrine )
        Self- administration of adrenaline ( epinephrine ) 

       Asthma/Chronic obstructive pulmonary disease ( C.O.P.D)

Drug  used in the management of asthma.:

1. Beta₂ agonists

2. Antimuscarinic bronchodilatators

3. Corticosteroids

4. Cromoglicate

5. Nedocromil

6. Leucotriene receptor antagonists

7. Theophylline

The Example  Pattern.:

Inhaled short - acting beta₂  agonists

(1) Salbutamol ( Ventolin,  Volmax, Ventmax )

        [ dose: by inh.100- 200 micrograms ( 1-2 puffs ); by mouth 4 mg - 3 - 4 times daily

                    possible also by:  subcutaneous, intramuscular injection, by slow intavenous

                    injection,  or infusion, by aerosol inhaltion, by inhalation of powder,

                    by nebulised solution ]

      or

     Terbutaline sulphate (  Bricanyl )

       [ dose:  by inh.500 micrograms ( 1-2 puffs ); by mouth  initially 2.5 mg - 3  times

                   daily for 1 - 2 weeks, ,then up to 5 mg 3 times daily

                    possible also by:  subcutaneous, intramuscular injection, by slow intavenous

                    injection,  or infusion, by aerosol inhaltion, by inhalation of powder,

                    by nebulised solution ]

     Fenoterol  hydrobromide( Berotec )

     Babuterol Hydrochloride ( Babmbec )

Inhaled long - acting beta₂  agonists

(2) Salmeterol ( Serevent  - Accuhaler - dry powder for inh, aerosol inh.,
                            Diskhaler - dry powder )

         [ dose: by inh.50 micrograms ( 1-2 puffs or 1 blister )- twice daily ]

      or

     Formeterol ( Oxis, Foradil )

        [ dose: by inhalation of powder  6 - 12  micrograms twice daily - can be increased

           to 24  micrograms daily  ] 

Inhaled corticosteroids

(3) Beclometasone  dipropionate   ( Becotide, AeroBec, Asmabec, Becodisks, Qvar )

         [  dose: by aerosol inhalation -  200 micrograms twice daily   ( 0.2 - 0.8 mg daily )

                 by inhalation powder - 100 micrograms twice daily ]

     or

     Budesonide  ( Pulmicort, Symbicort )  by inhal. of powder 100 -  400 micrograms

                twice daily , also aeosol inhalation 

     Fluticasone proprioniate   ( Flixotide, Seretide  )  by inhal. of powder  50 - 200

                micrograms twice daily ( 0.1 - 0.4 mg daily ),  also aeosol inhalation 

If little response

Antimuscarinc bronchodilatators

Ipratropium bromide ( Atrovent )  by inhalation powder, aerosol

         inhalation 20 - 40 - 80- micrograms - 3-4 times daily, by inhal. of nebulised

         solution  100 - 500 micrograms 3 - 4 times  daily 

or

Oxitropium bromide ( Oxivent )

Tiotropium ( Spiriva )

Theophylline

  Theophylline  by mouth -   tablets - 125 mg -  3 - 4 times daily

  Aminophylline  by mouth - tablets -  100 - 300 mg 3 - 4 times daily

 Cromoglicate

Sodium Cromoglicate  ( Intal )

      [   dose: by aerosol inhalation 10 mg ( 2 puffs ) 4  times daily

                    by inhalation of powder  20 mg 4 times daily 

                   by inhalation of nebulised solution  20 mg 4 times daily ]      

Nedocromil

Nedocromil Sodium  ( Tilade )

    [ dose.:  by aerosol inhalation   4 mg - 4 times daily ]

Leucotriene receptor antagonists

Montelukast ( Singulair ) , 10 mg daily

Zafirlukast  ( Accolate ) , 20 mg twice daily

Steps in management of chronic asthma in adults and children

Step I Occasional relief bronchodilatators

Inhaled -  short acting beta₂ agonist

Step I -  if this kind of inhalation is necessary only  once daily, if more move to step 2.

Step II Regular inhaled prevention therapy

Inhaled -  short acting beta₂ agonist  - as   required

+

Regular standard dose of inhaled corticosteroid

( or alternatives  - less effective )

Step III    Inhaled corticosteroids + long acting inhaled beta ₂ agonists

Inhaled -  short acting beta₂ agonist  - as   required

+

Regular standard dose of inhaled corticosteroid

( or alternatives  - less effective )

+

Regular  inhaled long - acting beta₂  agonist

Step IV High dose  inhaled  corticosteroids + regular bronchodilatators 

Inhaled -  short acting beta₂ agonist  - as   required

+

Regular standard dose of inhaled corticosteroid

( or alternatives  - less effective )

+

Regular  inhaled long - acting beta₂  agonist 

+

Sequential, 6 weeks trials  of one or more of

     Leukotriene receptor antagonist

     Slow Release oral theophylline

     Slow release oral  beta₂  agonist

Step V  Regular corticosteroid tablets

Inhaled -  short acting beta₂ agonist  - as   required

+

Regular high  dose  inhaled corticosteroid

+

Inhaled long - acting beta₂  agonist

₊

Regular prednisolone tablets 

Inhalation

  Inhaler devices

   Pressurised metered - dose inhalers

    Breath-actuated inhalers

    Powder inhalers

  Spacer devices

   Nebulisers 

Oral

   Prednisolone 40 - 50 mg daily for 5 days

    Salbutamol, tablets - by mouth 4 mg - 3 - 4 times daily

    Montelukast ( Singulair ) , 10 mg daily

    Zafirlukast  ( Accolate ) , 20 mg twice daily

    Theophylline  by mouth -   tablets - 125 mg -  3 - 4 times daily

    Aminophylline  by mouth - tablets -  100 - 300 mg 3 - 4 times daily

Parenteral

   Hydrocortisone  400 mg daily

    Ephedrine hydrochloride  - by slow intravenous injection       

 Anticoagulants

   *  Prevention  of  thrombus formation  in veins

        **  Prevention of deep - vein thrombosis ( DVT )  in the legs.

   *  Prevention  of thrombi forming on prosthetic valves 

   *  Prevention in patients  undergoing general surgery to prevent

       postoperative deep - vein thrombosis and pulmonary

       embolism in ' high risk '  patients  ( obesity, malignant

       diseases, formerly DVT or PE over 40 years old, patients

       with thrombophilic disorder )

  *   Extracorporeal circuits like cardiopulmonary bypass and

       haemodialysis

*     Treatment of DVT

*     Treatment of Pulmonary Embolism ( PE )

*      in regiments for ...  myocardial infarction ( MI  )

*      in regiments for .. unstable angina

*      in regiments for .. acute peripheral arterial occlusion  

#     HEPARIN ( standard , unfractionated )

          + first intravenous loading dose

                        [ dose .:  5000 units ( 10 000 units in severe pulmonary embolism )

                                        amp. 100 units/mL ]

          + followed by continuous intravenous infusion

                 - using an infusion pump

                        [ dose.:  15 - 25  units/kg/hour ]

                 - intermittent i.v. injection ..no longer recommended

          + intermittent subcutaneous injections

                        [ 15 000 units every 12 hours ] 

          & an oral anicoagulant ( warfarin...) .. at the same time ..

          & heparin ..continued ..at least 5 days until INR ..

              in   therapeutic range  during 2 days

          @ laboratory monitoring .. daily .. determination of

              Activated Partial Thromboplastin time ( APTT )

#  Low molecular weight heparine

       Endoxaparin  ( Clexane )

                  injection 100 mg /mL,

                  syringe 20 mg, ( 2000 units )  , 40 mg, 60 mg, 80 mg , 120 mg, 150 mg

           [ Dose .:  Prophylaxis of deep - vein thrombosis, subcut. injection  20 -40 mg daily

                            Treatment of deep - vein thrombosis subcut.  injection 120 mg daily  ] 

        Certoparin

        Dalteparin sodium

        Reviparin sodium

        Tinzaparin sodium

# Heparinoids

       Danaparoid

# Hirudins

       Lepirudin by slow intravenous  injection 400 micrograms /kg

# Oral anticoagulants

      The main  indication  for an oral anticoagulant is DVT. Patient with PE  and AF who are at risk of embolisation, as well patients with prosthetic heart valves  should also be treated. 

     Warfarin sodium  - Tablets .: 0.5 mg, 1mg,  3 mg, 5 mg

       [ Dose.: the usual adult loading dose is 10 mg an days 1 and 2. Reduce this to 5mg

         on days 1 and 2 if the patients is in some particular conditions.: 

            * has a prologed base- line prothrombine time

            * is elderly and frail

            * has cardiac failure

            * has liver disease

            * yet some other.

         The dose in 3 and 4 day depends from the result of INR ] 

      Acenocoumarol

      Phenindione

##  Antiplatelets drugs

        Aspirin

        Clopidegrol ( Plavix ) 75 mg once daily

        Dipyridamol ( Persantin )  300 - 600 mg daily

        Glycoprotein  IIb/IIIa inhibitors

         Abciximab ( ReoPRo )

           Eptifibatide ( Integrilin )

           Tirofiban ( Aggrastat )

                                                    Gastro - intestinal system

                  Dyspepsia and gastro - oesophageal reflux disease  

&  Antacids and dimeticone

   #  Aluminium and magnesium containing antacids

       Aluminium hydroxide (  Maalox, Mucogel, Alu-Cap - tablets,  oral suspension )

          [ Dose .: 20mL -   20- 60 min after meals and at bedtime or when required ]

       Magnesium carbonate ( Aromatic Magnesium Carbonate Mixture - oral suspension )

       Magnesium trisilicate  - tablets, oral suspension

   #  Aluminium-magnesium complexes

        Hydrotalcite - oral suspension

    #  Aluminium and magnesium containing   dimeticone         

             Activated dimeticone  ( simethicone) is added to an antacid as an antifoaming agent

         to relieve flatulence. These preparations may be useful for the relief of hiccup in

         palliative care.

         Altacite Plus

         Asilone

         Maalox Plus - oral suspension

            [ Dose 10 ml 4 times daily after meals and at bedtime or when required ]

     #    Dimeticone alone

         Dentinox ( drops, emulsion )

         Infacol

    #   Compound alginates and proprietary indigestion preparations

         Algicon ( tablets, suspension  ..)

            [ Dose.: 2 tablets 4 times daily ..]

         Gastrocote

         Gaviscon

         Gaviscone Advance

         Peptac

         Rennie Duo

         Topal 

                       Antispasmodics and other drugs altering gut motility

   # Antimuscarinics

     Atropine sulphate , tablets 600 micrograms , dose 0.6 - 1.2 mg at night 

     Dicycloverine hydrochloride - Dicyclomine hydrochloride ( Merbentyl, tablets-10 mg )

            The drug decreases fecal urgency and pain. It is useful with diarrhea-predominant

             symptoms.

          [ Dose:  10 -20 mg 3 times daily ]

     Hyoscine butylbromide  ( Buscopan, tablets - 10 mg , injections 20mg/mL )

         [ PL -  Scopolan ] 

         [ Dose: by mouth 20 mg  4 times daily ]

     Propantheline bromide ( Pro - Banthine, tablets -  15 mg )    

         [ Dose:  15 mg 3 times daily ]

# Other spasmodics

    Alverine citrate ( Spasmonal, capsules -  60 mg 

        [ Dose 60 - 120 mg 1- 3 times daily ]

    Mebeverine hydrochloride, tablets 135 mg  (  Colofac, tablets 135 mg )

        [ PL - Duspatalin ]

        [ Dose:  135 - 150 mg 3 times daily ]

    Peppermint Oil ( Colpermin, Mintec capsules - pepermint oil 0.2 mL )

# Antimotility drugs

    Loperamide hydrochloride - capsules - 2mg ( Imodium - capsules - 2 mg )

       [ Dose.: acute diarrhoea  4 mg initially followed by 2 mg after each loose stool

         for up to 5 days, usual dose 6 - 8 mg daily ] 

    Codeine phosphate  - tablets 15 mg

       [ Dose.: acute diarrhoea, 30 mg  3 - 4 mg daily ]

    Co - phenotrope  ( Lomotil )

       [ A mixture of Diphenoxylate hydrochloride 2.5 mg  with atropine sulfate 0.025 mg ]

       [ Dose.: Initially  4 tablets, followed by 2 tablets  every 6 hours  until  diarrhoea

            controlled  ]  

    Morphine  - oral suspension 

# Motility stimulants

   Metoclopramide hydrochloride

      [ Dose: by mouth, by intramuscular  or  intravenous injection, 10 mg 3 times daily ]

   Domperidone  - tablets - 10 mg ( Motilium - tablets - 10 mg )    

      [ Dose: by mouth acute -  nausea and vomiting 10 - 20 mg every 4 - 8 hours,

         functional dyspepsia 10 - 20 mg 3 times daily  ous injection, 10 mg 3 times daily ]

***

    In Poland are available also

Trimebutinum ( Debridat )

Oksyfenonium ( Spasmophen )

Papaverinum hydrochloricum ( injections )

Drotaverinum (  NOSPA )

Silicons ( Espumisan, Esputicon, Ceolat, Bobotic )

                                             Laxatives

# Bulk - forming laxatives

       Ispoghula Husk ( Fybogel, Isogel, Ispagel,  Konsyl, Regulan )

       Methylcellulose ( Celevac )

       Sterculia ( Normacol )

# Stimulant laxatives

       Bisacodyl

       Dantron ( Co-danthrusate, Co -danthramer )

       Docusate sodium

       Glycerol

       Senna ( tablets , dose 2-4 tablets, usually at night , Manevac, Senokot )

       Sodium picosulfate ( Dulco-lax )

# Fecal softeners

       Liquid Paraffin ( oral emulsion )

       Arachis Oil ( for enema )

# Osmotic laxatives

       Lactulose

       Macrogols ( Polyethylene glicols, Idrolax, Movicol, oral powder 10g/sachet  )

       Magnesium Salts ( Magnesium Hydroxide Mixture , Liqid Paraffin and

              Magnesium Hydroxide Oral Emulsion, Magnesium sulphate  - oral emulsion )

       Phosphates - rectal

       Sodium citrate - rectal       

                                                Ulcer healing drugs

#  H₂ - recepto antagonists

      Cimetidine ( Tagamet, PL- Altramet )

          [ Dose by mouth 400 mg twice daily or 800 mg at night, also by intramuscular

            injection, by slow  intravenous injection, by  intravenous   infusion ]

      Famotidine ( Pepcid, Pl - Ulfamid )

      Nizatidine ( Axid )

      Ranitidine ( Zantac, Pl - Ranigast )

          [ Dose by mouth 150 mg twice daily or 300 mg at night, also by intramuscular

            injection, by slow  intravenous injection, by  intravenous   infusion ]

      Ranitidine Bismuth Citrate

#  Chelates and complexes

     Tripotassium Dicitratobismuthate

     Sucralfate

#  Prostoglandin analogues

    Misoprostol ( Cytotec )

# Proton pump inhibitors

    Omeprazole ( capsules - 10 mg ) ( Losec )

         [ Dose.: by mouth 20 mg once daily for 4 - 8 weeks, by intravenous

            injection 40 mg once daily ]

    Esomeprazole ( Nexium )

    Lansoprazole ( PL- Lanzul )

         [ Dose.: by mouth 30 mg once daily, in the morning  for 4 - 8 weeks,

            maintenance 15 mg daily]  

    Pantoprasole ( PL - Controloc )

    Rabeprazole sodium

#  Other ulcer - healing drugs

    Carbenoxolone sodium

                                                Chronic bowel disorders

                                                      Irritable Bowel Syndrome

*   Merbentyl ( Dicycloverine hydrochloride )  3 times daily 10 mg

        [ The drug decreases fecal urgency and pain. It is useful with diarrhea-predominant

          symptoms ]

      or

*  Lomotil ( Co - phenotrope  )

       [ Inhibits excessive GI propulsion and motility. It may exacerbate constipation ] 

     or

*  Buscopan ( Hyoscine butylbromide )    

      [ Antispasmodic. Decreases fecal urgency and pain. Useful with diarrhea-predominant

         symptoms ]

     or

* Loperamide hydrochloride ( Imodium )

                                                  Inflammatory bowel disease

# Aminosalicylates

    Balsalazide Sodium (  Colazide )

    Mesalazine ( Salofak, Asacol, Ipocol, Pentasa )

    Olsalazine Sodium ( Dipentum )

    Sulfosalazine  ( Salazopyrin ) 

# Corticosteroids

    Budesonide ( Budenofalk, capsules - 3mg , 3 mg 3 times daily )

    Hydrocortisone - rectal ( Colifoam )

    Prednisolone ( oraly or rectal, Predenema,  Predfoam, Predsol - enema  )              

Diabetic ketoacidosis (DKA)

1.  Etiology. Infection, trauma, myocardial infarction or other severe stress, and patient noncompliance are common precipitating factors.

2. Diagnosis.  Hyperglycemia with ketonuria may occur with a normal serum bicarbonate and is managed by increasing the insulin dose and fluid intake. DKA occurs when ketone formation is proceeding at a rapid rate  and the fluid, electrolyte, and pH balance of the body are upset.  DKA with coma should provoke a search for other causes of obtundation, (meningitis, head trauma, stroke, drug overdose, hypoxia, hypotension, infection).   

3. Emergency measures.   Once the diagnosis of DKA is established by clinical assessment and documentation of hyperglycemia, metabolic acidosis, and ketonemia, these emergency measures should be initiated immediately. Coexisting lactic acidosis due to  overwhelming infection, sepsis, hypoxia, or hypotension should be considered and the underlying condition(s) treated:

a. Fluid replacement. Administer IV normal saline initially at a rate  of 1000 ml/hour  for 1-2 hours to correct hypovolemia while reducing hyperosmolarity. If severe hypotension is present, more rapid IV administration of fluids or use of plasma expanders may be required. Catheterize the bladder if the patient is stuporous or comatose to allow accurate urine output, glucose, and ketone measurements. A careful record of fluid intake and output as well as hourly measurements of blood pressure and pulse rate should be tabulated on a flow sheet.

IV fluids should be changed to 0.45 % normal saline after 2-3 liters of normal saline but not before blood volume appears clinically to be repleted.

b.  Blood chemistry. Draw baseline levels for arterial pH, serum sodium, potassium, bicarbonate, chloride, BUN and creatinine, as well as plasma glucose. Qualitative acetone determinations with crushed Acetest tablets on undiluted and diluted plasma are helpful in following ketonemia. Quantitative assessment is unreliable because these tablets detect acetoacetate but not 3-hydroxybutyrate, which is usually present in greater amounts. These chemistries should be repeated q2h for at least the first 6-8 hours of treatment and tabulated on the therapeutic flow sheet

C. Insulin therapy. Administer 0.15 units/kg ( about 10 units )  regular insulin IV as a bolus. Follow immediately by a continuous insulin infusion of 6 units/hour ( 0.l unit/kg/hour )  using 50 units of insulin in 500 ml of normal saline piggybacked to the patient's IV hydration line. To minimize absorption of insulin to the infusion system, discard the initial 50 ml of outflow. If continuous IV infusion of in­sulin is not possible, patients may be effectively treated with intermittent in­sulin given IV (approximately 5 units/hour) or IM (0.1 units/kg/hour).

d. Sodium bicarbonate therapy. If the arterial pH is < 7.0, administer l or 2  50-ml ampules of sodium bicarbonate (44 mEq/ampule) in l liter of hypotonic (0.45%) saline.

4. Follow-up care

a Plasma glucose. Hyperglycemia should respond to treatment with a minimum fall of about 50-100 mg/dl/hour. With lesser decrements in plasma glucose, the rate of insulin infusion should be increased by 50-100%. Once the plasma glucose declines to 250-300 mg/dl,

5% glucose  in saline (with 20-30 mEq/liter of potassium chloride) should be administered to cushion the decline in hyperosmolarity and to avoid hypo­glycemia. As ketonemia clears, insulin dosage can be reduced and SQ injections of regular insulin can replace the continuous infusion. The patient must be given SQ insulin immediately after discontinuing IV insulin to assure adequate insulin replacement.

b. Potassium replacement. After 1-2 hours of IV fluids, follow the patient's serum potassium level carefully; if it is < 4 mEq/liter, infuse solutions containing potassium, preferably as potassium chloride (40 mEq) over a period of 2-3 hours, as indicated. It may be advisable to begin admin­istration of potassium soon after treatment is begun if serum potassium is initially <5 mEq/liter despite acidemia. When the patient is able to swallow, change to supplementary potassium salts by mouth.

c.  Oral feedings and fluid. If ketonuria is disappearing or is rapidly improving (usually in 24-48 hours) and the patient not anorexic, give small  frequent feedings of liquid and semiliquid foods containing 50-75 gm glucose (or equivalent sugar) and protein (e.g., as milk) q3-4h while awake and cover with a sliding scale  of regular insulin SQ q4h (see Table )

depending on blood glucose values. Fluids should be forced by mouth, and urine should be examined for glucose and ketone bodies q3-4h. After 24 hours, if the patient shows steady improvement, place on a regular diabetic diet with appropriate insulin replacement.

Table -  Sample Regular Insulin (SQ) Sliding Scale

Plasma glucose (mg/dl)      Regular Insulin (SQ, units q4h)

<180                                None

180-240                           4

240-300                           6

300-400                           8

>400_________________10 (monitor frequently)

B. Hyperosmolar nonketotic syndrome

1.  Diagnosis. This is characterized by severe hyperglycemia, hyper-osmolarity, and dehydration in the absence of ketoacidosis. It is an infrequent but not rare cause of coma. It most often occurs in the elderly type II diabetic patient who is being managed with oral hypoglycemic agents, but half of the patients so afflicted are not known to have had diabetes. Cortico-steroids, thiazide diuretics, phenytoin, propranolol, and calcium channel blockers may be precipitating factors. Underlying renal disease, hypertension, and congestive heart failure are common.

2. Treatment is similar to that of diabetic ketoacidosis except that the amount of insulin needed may be less and the amount of fluid greater. Because of the severe dehydration, many liters of fluid may be required in the first 12 hours. Initial fluids are  normal saline given IV to replete intravascular blood volume and stabilize blood pressure; 0.45% saline solution is then used to replace remaining total body free water deficits until severe hyperosmolarity improves. Overly vigorous fluid replacement, especially with nor­mal saline solution, may lead to pulmonary edema if the cardiac reserve is compromised. Potassium replacement should be started early since initial hyperkalemia is less common than with diabetic ketoacidosis. The prognosis is usually poor because of the elderly state of many of the patients and the associated severe disorder,  which often precipitates this condition.

C. Hypoglycemia is the most common complication of insulin or oral  hypoglycemic therapy, and occurs when the diabetic fails to eat, ingests excessive alcohol, engages in too strenuous exercise, or takes more insulin or oral hypoglycemic medication than is needed. It is manifested by weakness, confusion, localized numbness and tingling, hunger, sweating,

irritability, faintness, and tremors or convulsions, all of which are relieved promptly by the administration of glucose. Patients taking intermediate- or long- acting insulin preparations should be carefully observed for the possibility of relapse.

a.  Prevention

1) Glucose lozenges or sucrose should be carried at all times by diabetic patients because of the danger of hypoglycemia. It is advisable for every diabetic to carry a glucagon ampule, to be injected IM by a trained member of the family if found unconscious.)

(2) A medical identification bracelet or pendant should be worn and a card should be carried by every diabetic patient.

b.  Treatment. If the patient is conscious and able to swallow, sugar, glucose, candy, or juice may be given. If the patient is unconscious, one of the methods listed below may be used. Do not attempt to feed a patient who is unconscious.

(1)  IV Glucose is the treatment of choice. If the patient is unconscious, give 50 ml of Glucose 50 % slowly. As soon as consciousness is restored, oral feedings may begin. Alternatively, an infusion of  Glucose 5% or  Glucose 10% can be started after IV  Glucose 50 % has been given.

(2) Glucagon (outside hospital, no IV glucose available): l mg Glucagon given IM will restore blood glucose to normal within 10 minutes if the hepatic glycogen reserve is adequate.

  Diabetes mellitus - examples of recommended Insulin regimens

C. Pattern nr 1  - conventional therapy

     ( 1 ) Before  breakfast  :

             Insulin Mixtard  30  Penfill * ( or Novolet **)           8 - 24 units 

     ( 2 ) Before the evening meal :

             Insulin Mixtard  30 Penfill *( or Novolet)                  8 - 12 units

                                             ............................................................................

                                    Sum                                                       16 -  36 units 

     Patter nr 2  - conventional therapy  

     ( 1 ) Before  breakfast  :

             Insulin Mixtard  30  Penfill * ( or Novolet )                     16 units

    ( 2 )  Before  evening meal

             Insulin Acrapid  HM                                                            6  units   

    ( 3 )  At   bedtime

             Insulin Mixtard  30   Penfill * ( or Novolet )                   12 units

                                               ..........................................................................

                                            Sum                                                        34  units 

   Pattern 3  - Divided dosing          

     ( 1 ) Before  breakfast  :

             Insulin Acrapid  HM                                                            12   units 

    ( 2 ) Before  lunch  :

             Insulin Acrapid  HM                                                             8  units

    ( 3 )  Before the evening meal :

             Insulin Actrapid  HM                                                            6    units

    ( 4 )   At bedtime 

             Insulin Mixtard 30  Penfill * ( or Novolet )                        12   units

                                             .................................................................................

                              Sum                                                                       38    units 

     ................................................................................

 * Penfill cartrige can be used by means of

      ' injection devices ' .; Autopen, Innovo, NovoPen

 ** Novolet it is a preffiled disposable injection device

Oral antidiabetic drugs

Sulphonylureas

   Chlorpropamide

   Glibenclamide  ( Daonil, Euglucon ) 5 mg daily, max. 15 mg daily, in elderly 2.5 mg

   Gliclazide ( Diamicron ) 40 -80 mg daily,up to 160 mg as a single dose, max 320 mg daily    

   Glimepiride ( Amaryl )  1 mg , max. 4 mg

Biguanides

    Metformin hydrochloride ( Glucophage ) tabl. 500 mg  -with breakfast, max 3 g

Other antidiabetics

    Acarbose ( Glucobay ) 50 mg daily, increasing  to 3 times daily

    Nateglinide

    Repaglinide

    Pioglitazone

    Rosiglitazone  

                                        Drugs used in nausea and vertigo

#  Antihistamines

        Cinnarizine ( Stugeron )  tablets - 15 mg

             [ Dose .:   Vestibular disorders, 30 mg 3 times daily ] 

        Ciclizine ( Valoid )

             [ Dose .: 50 mg up to 3 times daily, by intramuscular  injection 50 mg  3 times daily ]

        Meclozine hydrochloride  

        Promethzine hydrochloride

             [ Dose .: motion sickness prevention, 20 - 25 mg at badtime on night before travel ] 

        Promethazine teoclate  ( Avomine )

             [ Dose.:  25 - 75 , max 100mg daily ]

#  Phenothiazin and related  drugs

        Chorpromazine hydrochloride

             [ Dose .: by mounth , 10 - 25 mg every 4 - 6 hours, by intramuscular

               injection 25 - 50 every 3 - 4 hours until vomiting stops ]

        Perphenazine  [Dose .: 4 mg 3 times daily ]

        Prochlorperazine  ( Stemetil )

             [ Dose .:  20 mg initially then 10 mg after 2 hours, prevention 5 - 10 mg

                2- 3 times daily  ]

        Trifluoperazine   

            [ 2- 4 mg daily in divided doses ]

#  Metoclopramide and Domperidone

#  5HT₃ antagonists

        Granisetron

             [ by mouth 1 - 2 mg within 1 hour before start of treatment, then 2 mg daily

                in 1 - 2 divided doses during treatment ]

        Ondansetron

             [  Dose.: 8 mg 1 -2 hours before treatment.. by intramuscular injection

                or slow intravenous injection 8 mg immediately before  treatment ]

        Tropisetron

            [  Dose .: by slow intravenous injection  5 mg shortly before chemotherapy,

               then 5 mg by mouth every morning at least 1 hour before food for 5 days ]

# Cannabinoid

        Nabilone

            [ Dose.:  initially 1 mg twice daily, increased if necessary to 2 mg twice daily ]

# Dexamethasone

# Hyosine

       Hyoscine hydrobromide  

Anti - arrhythmic drugs

Anti- arrhythmic drugs classified clinically

1. Those that act on supraventricular arrhythmias

     e.g. Verapamil

2. Those that act on both supraventricular and ventricular arrhythmias

     e.g. Disopyramide

3.  Those that act on ventricular arrhythmias

     e.g. Lidocaine 

Antiarrhythmic medicines classified according to their effects on the electrical activity :

• Class I antiarrhythmic medicines are sodium-channel blockers, which slow electrical conduction in the heart. Quinidine, procainamide, disopyramide, flecainide, propafenone, tocainide, and mexiletine are examples of class I medicines.
   
• Class II antiarrhythmic medicines are beta blockers, which work by blocking the impulses that may cause an irregular heart rhythm and by interfering with hormonal influences (such as adrenaline) on the heart's cells. By doing this, they also reduce blood pressure and heart rate. Propranolol, metoprolol, and atenolol are examples of class II medicines.
   
• Class III antiarrhythmic medicines slow the electrical impulses in the heart by blocking the heart's potassium channels. Amiodarone, sotalol, and dofetilide are examples of class III medicines.
   
• Class IV antiarrhythmic medicines work like class II medicines but act by blocking the calcium channels in the heart. Diltiazem and verapamil are examples of class IV medicines.

Class I A

     Quinidine , 200 mg

     Disopyramide( Rythmodan,  Disocor) , 100mg

     Prajmalina ( Neogilurytmal )  20 mg

      Class  I B

           Lidocainum ( Lignocainum hydrochloride ), 1% , 2 %- 10mg/10ml

          Mexiletine hydrochloride ( Mexitil ), 200 mg

      Class I C 

          Propafenone hydrochloride ( Arythmol, Rytmonor ),150, 300 mg

      Class III

          Amniodarone ( Cordarone X, Opacorden ), 200 mg 

Supraventricular arrhythmias

    Adenosine ( Adenocor )

           [ Dose.:  by rapid intravenous injection  - 3 mg over 2 seconds, if necessary followed

             by 6 mg after 1- 2 minutes, and then by 12 mg after a futher  2 minutes ]

Supraventricular and ventricular arrhythmias

      Amiodarone  hydrochloride

           [ Dose .: by mouth 200 mg 3 times daily,  by intravenous injection 300 mg ]

      Disopyramide ( Rythmodan )

           [ Dose .: by mouth 300 - 800  mg daily in divided doses,  by intravenous

             injection up to 150 mg, by  intravenous infusion 300 mg in first hour and 800 mg

             daily ]   

      Flecainide acetate

           [ Dose .: by mouth 100 mg initially twice  daily, max. 400 daily

              by intravenous injection  max 150 mg over 10 -30 minutes ]

      Procainamide hydrochloride ( Pronestyl )

           [ Dose .:  by  slow intravenous injection  100 mg, by intravenous infusion

              500 - 600 mg over 25 - 30 minutes ]

      Propafenone hydrochloride ( Arythmol ) 

           [ Dose .: by mouth 150 mg initially 3 times  daily, max. 300  twice daily ]  

      Quinidine ( Quinidine Sulphate, Kinidine Durules  ) , tablets - 200 mg

           [ Dose .: by mouth  200 - 400 mg initially 3 times  daily ]

Ventricular arrhythmias

      Bretylium tosilate

           [ Dose.: by slow intravenous injection 5 - 10 mg/kg ..]

      Lidocaine ( Lignocaine )  hydrochloride

           [ Dose . : by intravebnous injection 100 mg as a bolus, followed by infusion ...]

      Mexiletine hydrochloride ( Mexitil )

           [ Dose.: by mouth initially 400 mg, followed by 200 mg 3- 4 times daily ,

               by intravenous injection 100  - 250 mg, then  ...  ]

The content of this Internet page will be developed.

The author of the page:

prof. dr hab. n. med. Andrzej Brodziak

 e- mail.: andrzejbrodziak@wp.pl

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