DRUGS WITH ANTICHOLINERGIC PROPERTIES

MEDICATIONS WITH SIGNIFICANT ANTICHOLINERGIC PROPERTIES
Therapeutic Categories (Drug List*)	Potential Adverse Consequences
Antihistamines  • chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine	Blood pressure, increased  Breathing difficulty, changes  Clumsiness or unsteadiness  Convulsions  Digestive system changes, e.g., • Bloating  • Bowel motility, decreased  • Constipation  • Ileus, paralytic/adynamic  • Nausea or vomiting  • Swallowing difficulty with dry mouth Mental status/behavior changes, e.g., • Distress, excitement, nervousness • Attention, impaired  • Cognitive decline  • Confusion/disorientation  • Hallucinations  • Memory loss  • Restlessness or irritability Delirium  Dizziness or Drowsiness  Fever  Headache  Heart rate, increased  Lethargy, fatigue  Mucous membrane dryness: mouth, nose  Muscle weakness, severe  Speech, slurring  Skin, changes • Dryness  • Sweating, decreased  • Flushing  • Warmth, excessive Vision impairment, changes in acuity • Blurring  • Glaucoma, worsening  • Eye pain  • Light sensitivity Urinary retention or difficulty By Akshaya Srikanth, Pharm.D Intern, India
Antidepressants  • amoxapine, amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, paroxetine
Antipsychotics  • chlorpromazine, clozapine, olanzapine, thioridazine
Antivertigo  • meclizine, scopolamine
Cardiovascular  • furosemide, digoxin, nifedipine, disopyramide
Gastrointestinal  • Antidiarrheal: diphenoxylate atropine  • Antispasmodics: belladonna, clidinium, chlordiazepoxide, dicyclomine, hyoscyamine, propantheline  • Antiulcer: cimetidine, ranitidine
Muscle Relaxants  • cyclobenzaprine, dantrolene, orphenadrine
Parkinsonism  • amantadine, benztropine, biperiden, trihexyphenidyl
Urinary Incontinence  • oxybutynin, propantheline, solifenacin, tolterodine, trospium ©akshaypharmd.blogspot.com

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown.Today, ECT is most often recommended for use as a treatment for severe depression that has not responded to other treatment, and is also used in the treatment of mania and catatonia. 

The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive.

The American Psychiatric Association (APA) 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide).The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence (NICE) guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania.he 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder.

Informed consent is sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all.ECT is usually given on an in-patient basis.Prior to treatment a patient is given a short-acting anesthetic such as thiopental,a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.Both electrodes can be placed one on the same side of the patient's head. This is known as unilateral ECT. Unilateral ECT is used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral ECT.The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains.

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India

ASTHMA/COPD CLINICAL PHARMACOLOGY

Asthma is a chronic inflammatory disorder of the airways. All patients need a short-acting inhaled β2-agonist to use as needed for symptoms. Patients with mild, moderate, or severe persistent asthma need daily long-term control medication. Start treatment at a higher "step" to achieve rapid control and then "step down" to the minimum therapy needed to maintain control, or start treatment at the "step" that is appropriate to the severity of the patient's asthma and then gradually "step up" therapy until control is achieved and maintained (see chart in this section). The "step-down" approach is preferred. Increases or decreases in medication(s) may be needed over time. 
LONG-TERM CONTROL MEDICATIONS are taken daily to achieve and maintain control of persistent asthma.
Inhaled corticosteroids (eg, beclomethasone, budesonide, flunisolide, fluticasone, triamcinolone) are used in the long-term control of asthma. Systemic corticosteroids are used in long-term therapy to gain prompt control of the disease and also to manage severe persistent asthma. It is possible to prevent disease progression with their early use. Low doses are used for mild persistent asthma; medium doses are used for moderate persistent asthma; high doses are reserved for the most severe cases. To reduce the potential for adverse effects with inhalers: Use a spacer or holding chamber; rinse mouth and spit after inhalation; consider adding a long-acting inhaled β2-agonist to a low-to-medium dose of inhaled steroid rather than using a higher dose of inhaled steroid (especially for nocturnal symptoms); monitor linear growth in children; when inhaled corticosteroid doses exceed 1000mcg per day, consider supplements of calcium (1g-1.5g/day), Vitamin D (400Units/day) and estrogen replacement therapy for postmenopausal women; may reduce doses of inhaled steroids by about 25% every 2–3 months until the lowest dose required to maintain control is reached.
Cromolyn sodium and nedocromil are mild-to-moderate antiinflammatory medications. They may be used as an initial choice in addition to a bronchodilator for long-term control in children. They can also be used as preventative treatment before unavoidable exposure to known allergens and in some cases of exercise-induced asthma. They should not be used to treat acute symptoms or exacerbations.
Long-acting β2-agonists (eg, salmeterol, formoterol, sustained-release albuterol) are used with inhaled corticosteroids for long-term control of symptoms (especially nocturnal symptoms). They may also be used to prevent exercise-induced bronchospasm. They should not be used to treat acute symptoms or exacerbations.
Leukotriene antagonists (eg, zafirlukast, montelukast) may be considered alternative therapy or adjunctive therapy to low doses of inhaled corticosteroids, or cromolyn or nedocromil in mild persistent asthma. Zafirlukast may be used in children ≥5 years of age; montelukast in patients ≥12 months of age.
Theophylline, a methylxanthine, is a mild-to-moderate bronchodilator. Blood levels must be maintained within a safe but effective range.
QUICK-RELIEF MEDICATIONS are used to provide prompt treatment of acute airflow obstruction and accompanying symptoms.
Short-acting β2-agonists (eg, albuterol, levalbuterol, bitolterol, pirbuterol, terbutaline) are preferred for the relief of acute symptoms. Increase in use or use of more than one canister in one month indicates inadequate control of asthma and the need for initiating or intensifying antiinflammatory therapy. Regularly scheduled, daily use of a short-acting β2-agonist is generally not recommended; they may be considered first for preventing exercise-induced asthma.
Systemic corticosteroids (eg, methylprednisolone, prednisolone, prednisone) are used for moderate-to-severe exacerbations to speed recovery and prevent recurrence of exacerbations. The addition of a 3- to 10-day course of oral corticosteroids may be needed to reestablish control during periods of gradual deterioration or for a moderate-to-severe exacerbation. 
Anticholinergic agents (eg, ipratropium) may provide additive benefit to inhaled β2-agonists in severe exacerbations. They may also be used as an alternative bronchodilator for patients who cannot tolerate an inhaled β2-agonist.
by
Akshaya Srikanth
Pharm.D Intern
Hyderabad, India

NEVER JUDGE ANYONE EASILY: A TRUE DOCTOR STORY

A HEART Touching Story: 

A doctor entered the hospital in hurry after being called in for an urgent surgery.

He answered the call asap, changed his clothes & went directly to the surgery block.He found the boy’s father pacing in the hall waiting for the doctor. 

On seeing him, the dad yelled: “Why did U take all this time to come?

Don’t U know that my son’s life is in danger?

Don’t U have any sense of responsibility?”

The doctor smiled & said: “I am sorry, I wasn’t in the hospital & I came as fast as I

could after receiving the call. And now, I wish you’d calm down so that I can do my work”

“Calm down?! What if your son was in this room right now, would U calm down?

If your own son dies now what will U do??” said the father angrily

The doctor smiled again & replied: “I will say what Job said in the Holy Book “From dust we came & to dust we return, blessed be the name of God”.

Doctors cannot prolong lives. Go & intercede for your son, we will do our best by God’s grace” “Giving advises when we’re not concerned is so easy” Murmured the father.

The surgery took some hours after which the doctor went out happy,

“Thank goodness!, your son is saved!” And without waiting for the father’s reply he carried on his way running. “If U have any question, ask the nurse!!” “Why is he so arrogant? 

He couldn’t wait some minutes so that I ask about my son’s state” Commented the

father when seeing the nurse minutes after the doctor left. The nurse answered, tears coming down her face: “His son died yesterday in a road accident, he was in the burial when we called him for your son’s surgery. And now that he saved your son’s life, he left running to finish his son’s burial.”

Moral: Never judge anyone…..

Because U never know how their life is &

what they’re going

 by

Akshaya Srikanth,

Pharm.D Internee

Hyderabad, India

CHF AND ARRHYTHMIAS PHARMACOLOGY

ANTIARRHYTHMICS

Due to the lack of evidence of improved survival for any antiarrhythmic drug in patients without life-threatening arrhythmias, and the proarrhythmic properties of many antiarrhythmic agents, including those in Class IA, the use of antiarrhythmic drugs should be reserved for patients with life-threatening ventricular arrhythmias.

Because of the differences in pharmacological activity of the various antiarrhythmic drugs, they are classified according to the mechanisms that they target.

CLASS I ANTIARRHYTHMICS 

-Block the transmembrane influx of sodium (Na+)

-Subdivided into three classes:

1) Class 1A (eg, quinidine, procainamide, disopyramide):

-Broad-spectrum antiarrhythmics

-Intermediate in binding kinetics to Na+ channel receptors

-Slow conduction velocity, prolong the refractory period, and decrease automaticity

-Indicated to treat ventricular and supraventricular arrhythmias

2) Class 1B (eg, mexiletine):

-Bind to and dissociate quickly from Na+ channel receptors

-Have little effect on conduction velocity

-Decrease refractory period and automatocity 

-More effective in treating ventricular arrhythmias

3) Class 1C (eg, flecainide, propafenone):

-Bind to and dissociate slowly from Na+ channel receptors

-Potent effects on slowing ventricular conduction

-Refractory period left unchanged

-Used to treat both ventricular and supraventricular arrhythmias

-Limited by the risk of proarrhythmias

CLASS II ANTIARRHYTHMICS 

-Composed of β-blockers (eg, acebutolol, propranolol)

-Inhibit β-adrenergic receptors in the heart

-Slow conduction velocity, prolong the refractory period, and decrease automaticity

-Useful in treating re-entrant arrhythmias involving the atrioventricular (AV) node and in controlling ventricular rates in atrial fibrillation or flutter

CLASS III ANTIARRHYTHMICS (eg, dofetilide, amiodarone, sotalol)

-Block potassium channels in the heart causing an increase in action potential duration (increased QT interval) and a reduction in normal automaticity 

-Increase in refractoriness makes them effective in treating re-entry

-Amiodarone and sotalol also have β-blocking properties that contribute to efficacy

-Used to treat ventricular arrhythmias (particularly life-threatening arrhythmias resistant to other treatments)

CLASS IV ANTIARRHYTHMICS 

-Composed of calcium channel blockers (eg, diltiazem, verapamil)

-Block calcium channels in slow response tissue of the sinus and AV nodes 

-Slow conduction velocity, prolong the refractory period, and decrease automaticity 

-Used to treat automatic or re-entrant tachycardias that arise from sinoatrial and AV nodes

CONGESTIVE HEART FAILURE (CHF)

CHF is a condition in which the heart fails to pump blood at a rate proportionate to the metabolic needs of the body. 

Goals of therapy:

-Improve patient's quality of life

-Reduce symptoms

-Reduce hospitalizations

-Slow the progression of the disease

-Prolong survival

RENIN-ANGIOTENSIN SYSTEM ANTAGONISTS

-Cause arterial vasodilation resulting in decreased afterload and increased stroke volume and cardiac output

-Prevent Na+ and water retention, potentiating the effect of diuretics 

-Decrease sympathetic nervous system activity

1) ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs) (eg, ramipril, lisinopril)

-Block angiotensin II and aldosterone production

-More potent arterial than venous dilators

-Reduce bradykinin degradation thereby increasing production of vasodilator substances (nitric oxide, prostaglandin I2)

-"ACE escape" (an increase in circulating angiotensin II) can result with chronic therapy

-Start with low dose to avoid abrupt drop in blood pressure

-Bradykinin-mediated side effects: cough, angioedema

2) ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) (eg, candesartan, valsartan)

-Block angiotensin II receptor subtype AT1

-May provide more potent reduction of the effects of angiotensin II than ACEIs

-Does not appear to affect bradykinin (however, angioedema has been reported with ARBs)

-Preferred alternative in patients who cannot tolerate ACEIs

DIURETICS (For more information on diuretics see the Edema section)

-Recommended for all patients with evidence of fluid retention

-Reduce extracellular fluid volume and ventricular filling pressure

-Response often impaired in patients with CHF

-The use of spironolactone, an aldosterone antagonist, has been beneficial in patients with moderate to severe heart failure

CARDIAC GLYCOSIDES (eg, digoxin)

-Positive inotropic effect due to inhibition of Na+,K+-ATPase

-Control ventricular rate response to atrial fibrillation

-Neurohumoral effects: block sympathetic activation and reduce renin release

-Narrow therapeutic index (monitor for toxicity)

-No longer considered first-line treatment 

β-BLOCKERS (eg, metoprolol, carvedilol)

-Improve left ventricular structure and function, decrease chamber size, and increase ejection fraction

-Reduce the incidence of sudden death

-Recommended therapy in patients with ejection fraction <35% in conjunction with ACEIs or ARBs, and diuretics

-Should be initiated at low doses and increased slowly because of the potential to worsen symptoms and ventricular function

-May be necessary to adjust diuretic regimen because of increased fluid retention

-Increase in exercise tolerance seen with metoprolol

NITRATES & HYDRALAZINE 

-Nitrates are venodilators that produce reductions in preload

-Hydralazine is a direct-acting vasodilator that reduces afterload and increases stroke volume and cardiac output

-Combination therapy (nitrate + hydralazine) should be considered in patients with renal dysfunction who cannot tolerate ACEIs

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India

NON-NEOPLASTIC BONE AND JOINT LESIONS

It includes: Osteoporosis, Osteomalacia and Rickets, Hyperparathyroidism
Osteoporosis

• Metabolic disease characterized by diffuse skeletal lesions due to a decreased mass of normally mineralized bone
• Post-menopausal females
• Increased bone resorption (osteoblastic activity is normal)
• Estrogen may lead to increased secretion of IL-1, IL-6, TNF and MCSF by stromal cells which will stimulate osteoclasts 

Primary osteoporosis

• Some genetic basis
• Dependent upon levels of Ca++ and vitamin D
• Exercise

Secondary osteoporosis

• Corticosteroid excess (endogenous or exogenous)
• Hyperthyroidism
• Hypogonadism
• Multiple myeloma
• PTH-secreting tumors
• Malabsorption
• Alcoholism

Osteomalacia and Rickets
Accumulation of unmineralized bone matrix resulting from a diminished rate of mineralization
Causes:

• Dietary deficiency in vitamin D
• Defective bone mineralization
• Congenital or acquired defects in vitamin D or phosphate metabolism
• Malabsorption (most common cause in US)
• Crohn’s disease
• Celiac disease
• Cholestatic liver disease
• Biliary obstruction
• Chronic pancreatitis

Hyperparathyroidism

• Increased bone resorption secondary to increased PTH
• Classic pathologic change referred to as osteitis fibrosa cystica
• Replacement of marrow by fibrous tissue
• Numerous microfractures
• Hemosiderin-laden macrophages
• Eventually cystic degeneration and classic gross appearance referred to as “brown tumor”

Osteopetrosis (marble bone disease, Albers-Schönberg disease)

• Inherited lysosomal defect
• Most severe form (autosomal recessive) is severe and often lethal
• Death secondary to anemia, cranial nerve entrapment, hydrocephalus and infection
• Dense bones weighing 2-3 times normal
• TX with BMTx and IFN

by
Akshaya Srikanth
Pharm.D Intern
Hyderabad, India

Food and Drug Interactions: An Inside Story

That fruit juice you're drinking can gang up with your morning meds. It can cause a chemical reaction that you and your doctor were not counting on. One that can be unpredictable and dangerous.

The food you eat while taking certain medications can affect the way your body uses those medicines. Some foods can lower the amount of a drug that your body absorbs, making it less effective. Other foods may interfere with your body's process of breaking down and using medications. This can cause drug levels to be dangerously high.

Older adults often take more than one medication at a time, so the risk of drug reactions increases with age.

Some common examples of how certain foods can affect the way your body uses medicine are listed below:

Grapefruit juice

Many medicines are affected by grapefruit or grapefruit juice. A chemical in the fruit can cause medication to build up in the body. It is not known exactly how much grapefruit causes this effect, but as a pharmacists I recommend that you simply avoid this fruit if you take the following medications.

Some cholesterol-lowering drugs called statins, including: atorvastatin, simvastatin and lovastatin

Some drugs given for high blood pressure, irregular heartbeat, and other heart conditions, including: felodipine, nifedipine, nimodipine, nisoldipine, amiordarone and disopyramide.

Some immunosuppressive medications. including: cyclosporine, tacrolimus, 

A medication for HIV, saquinavir

Bottom line: If you take any prescription medications, ask your pharmacist if it is safe to enjoy grapefruit. If you don't want to give it up, ask your doctor if there are any alternatives for the any medications that interact.

Milk, yogurt and other dairy products

Some antibiotics, especially some used for skin infections or acne, should not be mixed with milk or milk products. These drugs include tetracycline and doxycycline. Eating milk or milk products with these antibiotics can lower their effectiveness.

Bottom line: Don't take tetracycline or doxycycline 1 hour before or 2 hours after consuming milk or milk products. Also, ask your pharmacist about over-the-counter medications that can decrease the effectiveness of these drugs.

Leafy greens and other foods high in vitamin K

Vitamin K plays a role in the complex process of blood clotting. Because of this, it's important to watch how much vitamin K you get in your diet when you are taking the blood thinner warfarin (Coumadin). Some foods with lots of vitamin K include spinach and other leafy greens, kale, collards, and parsley. But don't stop eating these foods altogether. It's best to maintain a consistent intake of vitamin K in your diet.

Bottom line: The goal is to try to take in about the same amount of vitamin K every day. If you change your eating patterns, you may need a medication adjustment, so always check with your doctor about the right foods for you.

Coffee, colas, tea, energy drinks and other foods with caffeine

Caffeine is a stimulant. That means it causes your heart to beat faster and makes you more alert. Certain asthma medications also have stimulant affects. These medications include:

Albuterol

Theophylline

Bottom line: Limit or cut out caffeine when you are taking these medications. This will help you avoid nausea, vomiting and abnormal heartbeat and other symptoms of too many stimulants.

Bananas and other potassium-rich foods

Foods high in potassium are almost always good for you. They include bananas, oranges and many green leafy vegetables. People who take certain types of water pills, also called diuretics, are encouraged to eat plenty of them. These diuretics include:

Chlorothiazide

Bumetanide

Ethacrynic acid

Furosemide

But some other medicines, including some diuretics that are used to treat high blood pressure or heart failure, can cause potassium overload. Depending on your potassium levels, your doctor may ask you to limit your intake of potassium-rich foods when you take them. These medications include:

Eplerenone

Spironolactone

Triamterene, which is also found in Dyazide and Maxzide

Bottom line: If you take a water pill, ask your pharmacist about potassium.

My Comment:

Many foods interact with medications, both prescription and over-the-counter. 

To cut your risk for interactions:

Be sure to read the prescription label on every container.

Talk to your doctor and pharmacist about everything you're taking, including supplements.

by

Akshaya Srikanth

Pharm.D Internee

Hyderabad, India

BMI and YOUR WEIGHT LOOSING TIPS

BMI, which stands for Body Mass Index, isn't exactly a household word, but you should know that it's an important measure of overweight and obesity.
If your BMI is too high (25 or above), you're at an increased risk for chronic health problems. These include high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis and respiratory problems. Your risks for endometrial, breast, prostrate and colon cancers also increase. Conditions associated with being overweight are the second-leading cause of preventable death in the United States. Smoking is the first.
Making sense of the numbers
Underweight: below 18.5 
Normal: 18.5 to 24.9
Overweight: 25 to 29.9
Obese: 30 and above
Be a weight-loss winner
Although it is possible to be overweight and have very little fat, few people (except body builders, for example) actually fall into this category. Most people who are overweight have too much body fat rather than muscle weight, and need to be conscious of the need to lose weight.
Once you're overweight, it can be hard to lose weight permanently. The most successful weight-loss strategies involve reducing calories, increasing physical activity and having behavior modification therapy to improve your eating and exercise habits.
Here are some suggestions on what you and your family can do to lose weight and keep it off:

• Seek your doctor's advice before launching into an exercise or any weight-loss program, especially if you have a chronic health condition.  
• Get active. Over time, you should aim to meet the guidelines established by experts. The guidelines recommend healthy adults get 150 minutes per week of moderate-intensity activity (such as walking fast or running). They also advise doing strength-training exercises at least twice a week.
• Be wary of fad diets and rapid weight-loss programs. They may provide dramatic short-term results, but can be hazardous to your long-term health.
• Set realistic weight-loss goals, such as 1 to 2 pounds a week.
• Stick with it. Don't give up just because you reached a plateau or binged on potato salad, hot dogs and hamburgers at yesterday's barbecue.

Know what you're eating.

1. Reduce fats: Consume less than 10 percent of calories from saturated fats. Consume less than 10 percent of calories from saturated fats. Instead of junk food, keep fruit, a bowl of washed carrots or celery front and center in your refrigerator.
2. Avoid oversized portions: Read labels to determine serving size. Fill half your plate with fruits and vegetables.
3. Eat whole grains: Make sure at least half of all the grains you eat are whole grains.
4. Pack protein: Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds.

Akshaya Srikanth
Pharm.D Intern
Hyderabad, India

Fever During and After Childbirth

Fever During Pregnancy and Labor: Differential Diagnosis Cystitis Acute pyelonephritis Septic abortion Amnionitis Pneumonia Malaria Typhoid Hepatitis

Acute Pyelonephritis Treat, because of risks of  Preterm labor Sepsis Easy to treat Inexpensive

Management of Acute Pyelonephritis: 

If in shock or preterm labor, manage as indicated Check urine culture and sensitivity and give appropriate antibiotic If no culture available, give IV antibiotics until woman is fever-free for 48 hours: Ampicillin every 6 hours PLUS gentamicin daily Ensure adequate hydration by mouth or IV Give paracetamol by mouth for pain and to lower temperature

Acute Pyelonephritis: Subsequent Prophylaxis: 

Recurrence of acute pyelonephritis in the same gestation is reported to be 10–18% Suppressive therapy: 2.7% will get another urinary tract infection No suppressive therapy: 20–30% will get another urinary tract infection To prevent further infections, give antibiotics once daily at bedtime for remainder of pregnancy and 2 weeks postpartum: Trimethoprim/sulfamethoxazole Amoxicillin Sweet and Gibbs 1996; Duff 1996.

Septic Abortion:

Cause of 12.9% of maternal deaths Postabortion care has had tremendous impact on reducing mortality, particularly with use of manual vacuum aspiration

Management of Septic Abortion: 

Begin antibiotics as soon as possible before evacuation: Ampicillin every 6 hours PLUS gentamicin daily PLUS metronidazole every 8 hours Continue until fever-free for 48 hours Manual vacuum aspiration

Amnionitis: Antibiotics: 

Prompt intrapartum initiation (rather than delay until after delivery) of broad spectrum antibiotics results in: Less newborn bacteremia Less newborn pneumonia Reduced maternal febrile morbidity Shorter duration of hospitalization Treatment initiated intrapartum will not mask newborn infection Gibbs RS et al 1988.

Ampicillin and gentamicin Broad coverage for wide variety of organisms Crosses placenta and achieves adequate concentrations in the fetus Excellent activity against group B streptococci and E. coli – major causes of newborn sepsis Anaerobic coverage is not necessary (unless cesarean section performed) Hauth et al 1985.

Management of Amnionitis: 

Give combination of antibiotics until delivery: Ampicillin every 6 hours PLUS gentamicin daily If woman delivers vaginally, discontinue antibiotics postpartum If woman has cesarean section: Continue above antibiotics Add metronidazole every 8 hours Continue until fever-free for 48 hours ACOG 1998.

If cervix is favorable, induce labor with oxytocin If cervix is unfavorable, ripen with prostaglandins and infuse oxytocin or deliver by cesarean section

Aminoglycosides During Pregnancy: 

Objective and Design:

To evaluate teratogenic potential of aminoglycosides Methods: Selected cases of congenital anomalies from Hungarian congenital anomaly registry from 1980–1996 Gleaned exposure data from antenatal care records, medical documents, questionnaire to mother Czeizel et al 2000.

Results:

Fever During and After Childbirth Aminoglycosides During Pregnancy: Results No detectable teratogenesis from parenteral gentamicin, streptomycin, tobramycin or oral neomycin Czeizel et al 2000.

Fever after Childbirth: 

Differential Diagnosis:

Metritis Pelvic abscess Peritonitis Breast engorgement Mastitis Breast abscess Wound abscess, wound seroma or wound hematoma Wound cellulitis Cystitis Acute pyelonephritis Deep vein thrombosis Pneumonia Atelectasis Uncomplicated malaria Severe/complicated malaria Typhoid Hepatitis

Obstetric and Medical Factors Affecting Postpartum Sepsis:

Sepsis Intervention during labor and delivery Dangerous infections following prolonged and obstructed labor Thrombophlebitis, pulmonary embolism, coagulopathy and septic shock may complicate the infection Remember that clostridium infections may be difficult to detect and occur where contamination with earth or cow dung is possible Kwast 1991.

Health Service Factors Affecting Postpartum Sepsis: 

Majority of deaths occur between first and second week of puerperium and are linked to medical and midwifery/nursing staff factors: Inadequate: monitoring of temperature bacteriological investigations treatment with antibiotics or operative intervention Lack of: asepsis and antisepsis blood for transfusion appropriate drugs Kwast 1991.

Fever After Childbirth: 

General Management:

Encourage bedrest Ensure adequate hydration by mouth or IV Decrease temperature with fan or tepid sponging If shock suspected, begin treatment immediately

Management of Metritis: 

Start antibiotics: Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours Assess if retained placental fragments All the while: Give fluids Transfuse blood as needed Give pain medication Continue close monitoring Watch for shock Watch for development of abscess

Antibiotics for Metritis: 

IV antibiotics: Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours Continue until fever-free for 48 hours No oral antibiotics after treatment: Not proven to add any benefit Only add to expense

Managing Metritis:

Objective and Design:

To assess the effects of different regimens and their complications in the treatment of endometritis. Methods: 41 randomized controlled trials Outcomes: duration of fever, treatment failure, other complication (infectious), drug reaction, costs French and Smaill 2000.

Results:

More treatment failure with regimens other than clindamycin and an aminoglycoside RR 1.37 (1.10–1.70) Three studies looked at once-daily gentamicin vs. three-times daily: no difference in failure rates, but a trend toward fewer failures with once-daily dosing RR 0.60 (0.30–1.20) No difference in nephrotoxicity, lower cost French and Smaill 2000.

Septic Shock: 

IV antibiotics for sick patients Antibiotics for Gram + (penicillin, ampicillin) Gram - (gentamicin), and Anaerobes (metronidazole) Adequate doses of antibiotics are necessary Aggressive fluid resuscitation (2–3 liters to start) Look for abscess, peritonitis or other condition requiring surgery IV antibiotics may be necessary for longer if bacteremia

Prevention Strategies: 

Infection prevention practices for every delivery: Minimum manipulation High-level disinfected or sterile gloves for examination Avoid unnecessary procedures (e.g., episiotomy) Three Cleans: Clean hands Clean surface Clean blade Plus: Clean tie Clean perineum Clean nails.

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India

HIGH BLOOD PRESSURE

A blood pressure of greater that 140/90 mmHg is said to be high and, at this level, studies have shown that lowering blood pressure has a beneficial effect on reducing the likelihood of developing a stroke or heart attack. 
Underlying Factors in the development of high blood pressure

Evidence suggests that obesity coupled with a lack of exercise are important factors involved in the development of high blood pressure. However, there is much stronger evidence to suggest that salt intake is related to the development of hypertension, and in particular the rise in blood pressure with age, and that potassium intake has the opposite effect and may, in certain circumstances, partially offset the effects of a high salt intake. Excess alcohol intake is epidemiologically related to blood pressure, but the effect appears to be transient and there is debate as to whether excess alcohol intake causes a more sustained increase in blood pressure. Other dietary factors, e.g. calcium, magnesium and fat and protein intake have also been studied but so far the results are inconsistent.

The benefits of reducing blood pressure in the 'normal' range
Epidemiological studies show that the risk of blood pressure is throughout its range, starting at a systolic of 115 mmHg, and more than 80% of the adult population exceeds this level. Indeed, the greatest number of strokes and heart attacks attributable to blood pressure occur in the upper range of normal, although the risk is less than in those with high blood pressure, the numbers exposed are much greater hence the greater number of events. 

Relative risk of stroke in relation to systolic and diastolic blood pressure

A study on the diastolic blood pressure, Approximately three-quarters of all strokes attributable to blood pressure occurred among individuals classified as "normotensive

Any intervention therefore that would lower blood pressure in the general population, even by small amounts, is likely to be of immense benefit in preventing both strokes and heart attacks and over a period of time would have even more benefit if it slowed down the rate of increase in blood pressure with age. Geoffrey Rose pointed out many years ago that even a 2 mmHg reduction in systolic pressure in the whole population would carry more benefit than all of the blood pressure treatment currently being given. In addition, recent studies of individuals at high risk of cardiovascular disease have demonstrated the very large benefits of reducing blood pressure even in the "normal" (average) range. 

Evidence that relates salt to blood pressure 

A large number of studies have been conducted, all of which support the concept that salt intake is the major factor increasing population blood pressure. The diversity and strength of the evidence is much greater than for other lifestyle factors, e.g. weight reduction, lack of fruit and vegetable consumption and lack of exercise. The evidence that links salt to blood pressure is as strong as that linking cigarette smoking to cancer and heart disease. 

by

Akshaya Srikanth

Pharm.D Internee

Hyderabad, India