Posts Tagged ‘paget s disease’

Bisphosphonates (bis-FOS-fun-ates)
Brand Names
Alendronate Sodium Fosamax
Alendronate Sodium  Cholecalciferol Fosamax Plus D
Etidronate Disodium (9 Didronel
lbandronate Sodium Boniva
Risedronate Sodium 91 Ar.Wm~
Risedronate Sodium  Calcium Carbonate Actonel with Calcium
Tiludronate Disodium Skelid
Prescribed For
Prevention and treatment of osteoporosis (a condition characterized by loss of bone mass due to calcium depletion) in postmenopausal women and in older men; Paget’s disease of bone; and high blood calcium associated with high dosages of corticosteroid treatments and cancer.
General Information
Bisphosphonates have been used for many years to treat a variety of conditions associated with low bone mass caused by calcium depletion. They work on cells called osteoclasts that normally break down bone tissue, making bones stronger by preventing loss of bone mass. In osteoporosis, bones become weak and brittle, increasing the risk of spine, hip, and other bone fractures that are a major cause of death and disability in older women. Etidronate has been used occasionally in children, but these drugs generally are not considered safe for use in children.
Cautions and Warnings
Do not use any bisphosphonate if you are allergic or sensitive to any of its ingredients.
Do not use bisphosphonates if you have severe kidney disease or active stomach or intestinal disease such as difficulty swallowing, ulcers, or stomach irritation. Notify your doctor if you experience any gastrointestinal problems while taking bisphosphonates.
Osteonecrosis of the jaw (ONJ), a condition in which bones of the jaw lose their blood supply and eventually collapse, has been reported in people treated with bisphosphonates. Most cases of ONJ have been in cancer patients having dental procedures such as tooth extractions. People at risk may be those with cancer and those taking corticosteroids or those with poor oral hygiene.
Do not use ibandronate, alendronate, or risedronate it you cannot stand or sit upright for 30 minutes (see “Special Information”).
Bisphosphonates can cause low blood calcium and should not be used by people whose blood calcium is already low.
Bisphosphonates can cause severe and sometimes incapaciating bone,    muscle pain.
Possible Side Effects
Side effects are generally mild and similar to those reported by people taking an inactive placebo (sugar pill).
Possible Side Effects (continued)
Alendronate
♦    Most common: pain.
✓    Common: abdominal pain and discomfort, gas, stomach ulcers, and back pain.
✓    Less common: upset stomach, constipation, diarrhea, nausea, difficulty swallowing, muscle pain, headache, flu-like symptoms, accidents, and swelling in the arms or legs.
♦    Rare: vomiting and changes in taste. Contact your doctor it you experience any side effect not listed above.
Etidronate
✓    Most common: fever.
✓    Common: nausea, excess fluids, and flu-like symptoms.
♦    Less common: convulsions, constipation, inflammation of the lining of the mouth, changes in liver function, low blood levels of magnesium or phosphate, breathing difficulties, and changes in sense of taste.
✓    Rare: allergic reactions. Contact your doctor if you experience any side effect not listed above.
lbandronate
✓    Most common: upper respiratory infection, back pain, bronchitis, and upset stomach.
♦    Common: arm or leg pain, muscle pain, headache, pneumonia, and urinary infections.
✓    Less common: dizziness, fainting, pain due to nerve lesions, weakness, allergic reactions, diarrhea, vomiting, dental problems, stomach pain, low blood cholesterol, joint problems, arthritis, and sore throat.
✓    Rare: eye problems have occurred with other drugs in this group but not with ibandronate. Contact your doctor if you experience any side effect not listed above.
Risedronate
✓    Most common:    qlaftea, abdominal pain, rash, and severe joint pain.
✓    Common: chest pain, dizziness, swelling in the arms or legs, constipation, nausea, sinus irritation, and bone pain.
✓    Less common: leg cramps, weakness, bronchitis, poor vision in one eye, dry eyes, ringing or buzzing in the ears, Possible Side Effects (continued)
parathyroid gland problems, infection, rash and other skin problems, tooth problems, and vitamin D deficiency.
♦    Rare: fatigue and drug reactions, including swelling of the
tongue and throat with difficulty breathing, generalized rash,
and some blisters. Contact your doctor if you experience
any side effect not listed above.
Tiludronate
♦    Most common: diarrhea and nausea.
✓    Common: headache, upset stomach, respiratory infection, runny nose, fluid in the lungs, and sinus irritation.
✓    Less common: vomiting, dizziness, tingling in the hands or feet, coughing, sore throat, gas, aches and pains, cataracts, eye redness, glaucoma, rash, skin disorders, tooth problems, swelling, infection, vitamin D deficiency, and muscle aches.
♦    Rare: tiredness, high blood pressure, fainting, appetite loss, constipation, abdominal pain, and sleeplessness. Contact your doctor if you experience any side effect not listed above.
Drug Interactions
•    Antacids, calcium, and iron-containing supplements and foods can interfere with the absorption of bisphosphonates. Separate doses of these drugs and foods and a bisphosphonate by at least 30 minutes.
•    Separate doses of tiludronate and aluminum-containing antacids by 1 hour.
•    Aspirin can interfere with the absorption of tiludronate.
•    Indomethacin can increase the amount of tiludronate absorbed into the blood by 2-4 times.
•    Bisphosphonates may increase the gastrointestinal-irritating effects of aspirin, ibuprofen, and other NSAWDs.
•    Drugs that reduce the amount of stomach acid, including ranitidine, cimetidine, and omeprazole, may increase the amount of ibandronate in the blood, but the degree of increase is not clinically important.
•    Etidronate may affect the action of warfarin.
•    Bisphosphonates reduce the ability of teriparatide to build new bone.

Food Interactions
Take these medicines with plain water. Food and drink—even mineral water, orange juice, or coffee—interfere with the absorption of these drugs. Take alendronate or risedronate every morning at least 30 minutes before eating, drinking, or taking other medications. Etidronate should be taken on an empty stomach 2 hours before a meal. lbandronate should be taken as soon as you wake up and 1 hour before you eat or take any other medications, vitamins, or supplements. Tiludronate should be taken when you first wake up; wait 4 hours before eating breakfast.
Usual Dose
Alendronate
10-40 mg a day; or 35-75 mg once weekly. not recommended.
Alendronate + Calcium
70 mg/2800 IU once weekly. not recommended.
Etidronate
up to 4.5 mg per lb. a day to start, gradually increasing to no more than 9 mg per lb. per day.
not recommended.
lbandronate
2.5 mg.once a day: or one 150 mg tablet once a month. not recommended.
Risedronate
5-30 mg a day; or 35 mg once weekly. not recommended.
Tiludronate
400 mg a day.
not recommended.
Overdosage
Little is known about the effeckS,zA USP*nosphonate overdose.
Other symptoms include upset stomach, heartburn, ulcer, and irritation of the esophagus. Milk or antacids may reverse these effects. These drugs can irritate the esophagus. Do not let the victim lie down or vomit. Overdose victims should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Food interferes with the effectiveness of these drugs. Carefully follow the directions in “Food Interactions” above.
Do not suck on any of these tablets or allow them to dissolve in your mouth because they can cause mouth sores.
To reduce the risk of stomach and throat irritation, do not lie down for at least 30 minutes after taking alendronate or risedronate. Do not lie down for 60 minutes after taking ibandronate.
Separate doses of calcium, iron, and vitamin D supplements from those of a bisphosphonate by at least 2 hours. If you forget a dose, take it as soon as you remember. If it is almost time for your next dose, skip the dose you forgot and continue with your regular schedule. If you forget a morning dose and take it later in the day, you must still follow the instructions in “Food Interactions” about avoiding food.
Special Populations
Pregnancy/Breast-feeding: Bisphosphonates cause abnormal bone development in animal fetuses and are toxic to pregnant animals. When any of these drugs is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
It is not known if bisphosphonates pass into breast milk. Since these drugs affect bone formation, nursing mothers who must take a bisphosphonate should use infant formula.
Seniors: Seniors may use these drugs without special restriction.

salbutamol A selective beta,- adrenoceptor  It is widely used to relieve bronchospasm in airway obstruction, including bronchial asthma and status astliniaticus, with the advantage of being largely free from cardiac side-effects. Dose: up to 16 ing orally daily; by aerosol inhalation (in which patients should be carefully instructed) 100-200 pg ( 1-2 puffs) Lip to 4 times a day; by s.c. or i.m. injection 500 pg as required; 250 pg by i.v. injection. Salbutamol also, relaxes uterine muscle, and is given in premature labour in doses of 10 pg/inin initially by i.v. infusion, increased to 45 pg/min until contractions have ceased, when oral therapy may be given. Side-effects include tremor, headache, peripheral vasodilation and tachycardia. Care is necessary in ischacinic heart disease, hypertension pertension and hyperthyroidism. (Ventolin). See page 118 and Table 6.
salcatonin A synthetic form of calcitonin, preferred for extended use, as it is less likely to provoke allergic reactions. Dose: in hypercalcaemia, 5-10 units/kg ,fail), 1)), s.c. or Lin. injection according to need; in Paget’s disease 60 units 3 times a week up to 100 units daily. It is also used in post - menopausal osteoporosis and for the bone pain of malignancy. (C.alcynar; Miacalcic).
salicylic acid Etas useful keratolytic and fungicidal properties. Used as ointment (2%) for skin conditions, and as ointments and plasters (up to 40%) for corns and warts.
salmeterol A beta,-adrenoceptor stimulant of the salbutamol type, but with a longer action. It is used for the extended prophylaxis of asthma, bronchitis and other forms of obstructive airway disease, and together with corticosteroid therapy if required. It is not indicated in acute conditions.
Dose: 50 pg twice daily, either from a metered dose aerosol or by a ‘Disklialer’. salmeterol is well tolerated, but headache, tremor and tachycardia may occur with doses above 200 pg daily. (Serovent). See page 118 and,rable 6.
saquinavirV An antiviral agent that inhibits the enzyme HIV-protease, and prevents the development of immature virus particles into the infective virus. Used in HIV
infection together with it nucleoside analogue that has a different action.
Dose: 1.8g (laity. (Invirase). See page 1+1 ;111,1 TAIle 19.
scopolamine See hyoscine.
selective serotonin re-uptake inhibitors (SSRIS) A small group of drugs that inhibit the re-uptake ofserotonin in the central nervous system, and are used in the treatment of depression. They differ from the tricyclic antidepressants in being less likely to cause sedation or cardiac disturbances, or have anticholinergic side-effects. Care remains necessary with machine-related activities, and before and after monoamine oxidase inhibitors (MAOI) therapy. See page 128 and Table 11.
selegiline A selective enzyme inhibitor that prevents the inactivation of dopamine in the brain. It is used to supplement the action of levodopa in the treatment of parkinsonism, and combined use may give a smoother response, and permit a reduction in the dose of levodopa.
Dose: 5-10111g daily. It may cause nausea and hypotension, and may possibly increase the side-effects of levodopa. (Eldepryl). See page 160 and Table 26.
selenium sulphide Used as a shampoo in the treatment ofdandrull’. Prolonged use may cause alopecia. (Selsun).
senna The leaves and pods of Cassia sp., used as a purgative. Standardized preparations such as Senokot are now preferred.
sermorelinV A synthetic analogue of soniatorelin, the growth hormone releasing factor (GHRH). It is used in the diagnosis of growth hormone deficiency as a single i.v. dose of I pg/kg. (Geref 50).
sertindoleV An antipsychotic agent with a selective action on the limbic system, and used in acute and chronic schizophrenia. Dose: 4 nig once (laity initially, increased alter 2-4 days up to 20 mg daily according to need. Blood pressure should he monitored initially as hypotension may occur.  Contraindicated in patients receiving itraconazole, ketoconazole,  terfanidine, or any drug known to affect the QT interval. (Serdolect). See page 168 and Table 30.

serotonin A substance present in many body cells, which also acts as a neurotransmitter in the central nervous system. A reduction in the brain serotonin levels may be associated with depression and the cranial
vasodilation associated with migraine. (See page 154). Some allergic reactions may also be linked with the action of serotonin on sensitized cells (see cyproheptadine).
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colic and vomiting, but death from adder bite is very rare. If the reaction to an adder bite is severe, European viper anti-venom, if available, should be given by i.v. infu-
sion within 4 hours of the bite.
soda-lime A mixture of calcium and sodium hydroxides, used in closed-circuit anaesthetic apparatus to remove carbon dioxide.
sertraline A selective serotonin-re-uptake inhibitor (SSRI) antidepressant used both for the treatment oftlepression and the prevention of relapse.
Dose: 50 rig daily initially with food, increased at weekly intervals tip to a maximum of 2(0 mg daily. Not to be given with nionoanlilic oxidase inhibitors (MAOls). Side-effects are tremor and a dry mouth. (usual). See page 128 and Table 11.
silicones Synthetic water-repellent substances present in barrier creams and other skin protective products. Dimethicone is a silicone used as an anti-foaming agent in some antacid preparations.
silver nitrate Used mainly as silver nitrate sticks (caustic points) for cauterizing warts. It has also been used as a 0.5% lotion for suppurating lesions. It was once used prophylactically as eye drops (0.1%0) in the newborn, and is still used for that purpose in the USA.
silver sulphadiazine Sulphadiazine combined with silver. It is used topically as a I% cream for its wide-range antibacterial properties in burns and infected skin conditions, especially when an extended action is required. It is active against Pseudornonas aertiginosta and other Cram- negative organisms. (Flamazine).
simvastatin A selective inhibitor of a specific enzyme (I-IMGCOA reductase) concerned with the synthesis of cholesterol in the liver. It is used in the treatment of primary hypercholesterolaernia in patients not responding to other drugs. Dose: 10-40 mg at night. Liver function tests should be carried out regularly. Side effects include gastrointestinal disturbances. (Zocor). See page Wand Table 20.
snake-bite antivenom A bite from an adder, the only poisonous snake indigenous to the UK, can cause local pain and swelling as well as systemic effects such as
sodium acetrizoate An iodine compound used as a contrast agent in i.v. pyelography.
sodium aurothiomalate A gold compound used in the treatment of active rheumatoid arthritis. It is no value in other forms of the disease, or where bone change has already occurred.
Dose: 10 mg by deep Lin. injection weekly initially, slowly increased to 50 mg weekly. and continued until a remission occurs, or until a total dose of I g has been given.
Blood and urine tests are essential after each injection. After remission, 20-50 mg may be given every 2-1 weeks for many months. Side-effects are common, and include blood disorders, skin reactions, mouth ulcers and oedenia, anti may require withdrawal of the drug. It is contraindicated in renal and hepatic disease, blood dyscrasias and hypertension. (Myocrisin). See auranoran,
page 165 and Table 29.
sodium bicarbonate A soluble antacid, often used in association with less soluble antacids such as magnesium carbonate or trisilicate.
Dose: 1-4 g. In severe metabolic acidosis it is given by slow i.v. injection as an 8.4% solution. For alkalization of the urine, up to 3 g orally 2-hourly with further 10 g
doses daily as required.
sodium calcium edetate A chelating or binding agent used in poisoning by lead and other heavy metals.
Dose: 80 mg/kg daily by i.v. infusion in glucose/saline solution. Nausea and cramp are side-effects, and care is necessary in renal impairment. Medclair).
sodium cellulose phosphate An ion-exchange compound that binds with calcium in the intestines, and so reduces calcium absorption. Used in the oral treatment of hypercalcaemia and renal stones, and as an adjunct to low-calcium diets. Dose: 15 g daily. Diarrhoea is an occasional side-effect. (Calcisorb)•

sodium chloride An important constituent of blood and tissues. It is widely used by i.v. infusion as normal saline solution (0.9%), or as glucose-saline in the treatment of dehydration, shock and other conditions of sodium depletion. It is also useful when given orally as Sodium Chloride with Glucose Oral Powder (BNF) (after solution in water), for children with diarrhoea to offset any loss of salt. Its use as an emetic in the treatment of poisoning is no longer recommended. It is used externally as saline solution when a simple cleansing lotion is required.
sodium citrate An alkaline diuretic similar to potassium citrate and given for similar purposes.
Dose: 1-4 g. For citrating milk, 100 mg to each feed may be used. A 3% solution is used by bladder irrigation for the dissolution of blood clots.
sodium clodronate See clodronate, editronate and pamidronate.
sodium cromoglycate An antiallergic agent with a specific action and used for the prophylactic treatment of asthma by inhalation. It stabilizes mast cells and inhibits the release of histamine and other spasmogens that cause bronchospasm. Dose: by powder inhalation from a `Spinhaler* 20 mg up to 9 times a day; by aerosol inhalation, 10 mg (2 puffs) up to 8 times a day. Dose in the treatment for food allergy associated with local inflammation, 800 mg daily orally. It is also of value as eye drops (2%) and eye ointment (40/4) in allergic conjunctivitis, and as nasal drops or spray (2%) in the prophylaxis of allergic rhinitis. (Intal, Rvilacrom). See page I I O and Table 2.
sodium fluoride The fluoride present in dentifrices used to reduce dental caries. It may also be given orally when more intensive treatment is required.
Dose: 250-5001igdaily.
daily by i.v. infusion. Side-effects include nausea, rash and jaundice. Liver function tests should be carried out during treatment. (Fucidiu).
sodium hypochlorite A weak solution of sodium hypochlorite containing 0.25% of available chlorine is used as eusol, for the cleansing of wounds and ulcers. The
Solution is unstable and should be freshly prepared. Its value has recently been questioned. Stronger, stabilized solutions are used for the general disinfection of surfaces contaminated with blood and other body fluids. Their use reduces the risk of transmission of hepatitis and other viral infections.
sodium ironedetate (sodium feredetate) A soluble iron complex available as a solution containing 27.5 mg of iron per 5 nil. It is used in the oral treatment of iron-deficiency anaemias, and is of value when other iron preparations are not tolerated. Dose: 15-30 nil daily. (Sytron). See page 112 and Table 3.
sodium lactate Has been used as M/6 solution, or as Hartmann’s solution, by i.v. infusion for metabolic acidosis, but sodium bicarbonate is now preferred.
sodium nitrite A cyanide antidote.
Dose: as it 30/b solution by i.v. injection of 10 nil, followed by the slow injection of 25 nil of sodium thiosulphate solution (50%). Early treatment is essential. See kelocyanor.
sodium nitroprusside A short-acting arteriovenous vasodilator used in hypertensive crisis and for controlled hypotension during anaesthesia.
Dose: by i.v. infusion, 0.3-1 pg1kg/juin, the lower doses being used to obtain hy
, poten-
sion during surgery. It is also used in acute heart failure in doses of 10-1 5 pg/niin, increased as required to 2001ighnin.
sodium fusidate An antibiotic used mainly in penicillin- resistant staphylococcal infections, although a secondary anti-staphylococcal antibiotic is often given to increase the response and inhibit drug-resistance. It is useful in osteomyelitis and similar conditions as it penetrates into bone tissues.
Dose: 2 g daily. In severe infections, 1.5 g
sodium perborate White powder soluble in water, with antiseptic and deodorant properties similar to hydrogen peroxide. A 2% solution is used as a mouthwash.
sodium phosphate A solution of sodium phosphate with sodium acid phosphate is sometimes used by enema as a laxative.

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ethinyloestradiol A synthetic oestrogen formerly used to control menopausal symptoms and other conditions where oestrogen therapy is indicated.
Dose: 10-50 pg daily. It is present with a pi ugestogen in many oral contraceptive products. See page 264 and Table 40.
othosuximide An anticonvulsant for the treatment of petit trial epilepsy (absence seizures). May be used alone, or combined with other anticonvulsants, and it is often of value in patients not responding to other drugs.
Dose: 500 nig daily initially, gradually increased if required, to a maximum of 2 g daily. Care is necessary in renal or hepatic disease. Drowsiness, headache and gastrointestinal disorders are sonic side-effects. (F meside; Zaronlin). See page 136 and Table 15.
etidronate disodium A bisphosphonate used in Paget’s disease of bone, as it slows down the rapid turnover of bone and relieves the pain of that disease.
Dose: 5 nig/kg as a single daily dose between meals for 6 months or more. Side-effects are nausea and diarrhoea; high (loses may increase bone pain and the risks of fracture. (Didronel). Didronel PMO also contains calcium carbonate, and is used in the extended treatment of vertebral osteoporosis. See clodronate and pamidronate.
include nausea, alopecia and myelosuppression. (Vespid). See page 122 and Table 8.
eusol A chlorine antiseptic solution used as lotion, or as compress. The solution should be freshly prepared. Now less popular, thought to be irritant.
evening primrose oil See gamolenic acid.
eye drops Weak solutions of drugs for the treatment of ocular conditions. They may be antibacterial, antifungal or antiviral in action, or maybe used for non-infective conditions such as glaucoma, or for diagnosis. For routine use they are supplied sterile in multiple-application containers, but are intended for individual use only. They contain preservatives, and for home use may be used for up to one month after the container has been opened. In eye Surgery, single application products should be used. Occasionally, enough of a drug may be absorbed from eye drops to have systemic effects, and corticosteroids, if used as eye drops over a prolonged period, may cause’steroid glaucoma’. Care should be taken with contact lenses, and ideally they Should not be worn during eye drop treatment. Soft contact lenses can absorb the preservatives, which may cause irritation.
etodolac A non-steroidal anti-inflammatory agent (NSAID) of the naproxen type, with similar actions, uses and side-effects. Dose: in rheumatoid conditions, 400 mg daily. (Lodine). See page 169 and
Table 29.
etomidate A short-acting i.v. hypnotic used lor the induction of anaesthesia. It causes little cardiac disturbance or hypertension, but muscle movement and pain may
occur during injection.
Dose: 300 pg/kg by i.v. injection.
f Ilypnomidate).
etoposide A cytotoxic agent used in small-cell lung cancer and resistant testicular cancers. It is given in daily doses based on skin area for 5 days, repeated after 21 days according to response.
Dose: 120-240 nighn’ daily orally; by i.v. infusion 60-120 mghn’, and care must be taken to avoid extravasation. Side-effect-,
Factor Vila A recombinant and active form of the blood coagulation Factor VII. The treatment of haemophilia with Factors Vill and IX is complicated by the development of antibodies to those factors. Factor Vila acts as a late stage in the conversion of fibrinogen to fibrin, can function independently of Factors Vill and IX, and does not induce the formation of antibodies. It is used to control serious bleeding in haemophiliac patients and during surgery, under specialist supervision.
Dose: 60-120pg initially by i.v. injection, followed by a second dose after 2-3 hours, then 4-12-hourly as required for
2-3 weeks or more. (NovoSeven).
Factor Vill Haemophilia A is caused by a deficiency of the blood clotting agent Factor Vill, and highly purified preparations of human Factor VIII as well as recombinant forms are used as replacement therapy in doses based on the degree of deficiency of that factor. (Kogenate; Monoclate P; Recombinate).
Factor IX Haemophilia B is due to a deficiency of Factor IX, and preparations of that factor, obtained by monoclonal antibody techniques, are given i.v. in doses based on the degree of efficiency of the factor. (Monomine; Replenine).
famiclovir An antiviral agent similar to acyclovir, and used in herpes zoster (shingles) and genital herpes infections. Dose: 75 mg daily for 7 days. (Panivir). See page 144 and “fable 19.
famotidine An H,-receptor antagonist with the uses and side-effects of cinictidine, but a longer action.
Dose: in benign peptic ulcer, 40 ing at night lor,1-8 weeks; 20 mg at night for the prevention of recurrence, also used in reflex oesophagitis. In Zollinger-Ellison
syndrome, doses of 20 mg 6-hourly are given. ( Pepcid). See page 162 and] *able 27.
pain and inflammation in rheumatoid arthritis and similar conditions.
Dose: 600-900 nig daily. Like other
NSAIDs, it may cause gastrointestinal disturbance and dizziness, but the incidence of rash requires withdrawal of the drug. (Leclet-fen). See page 165;uidfable 29.
fencifibrate A plasma-lipid regulating agent of the clofibrate type, with similar uses and side-effects.
Dose: 300 ing initial]),, with food, later 200-400 mg daily according to need. (Lipantil). See page 146 and Table 20.
fenoprofen A non-steroidal anti-inflammatory and anti-rheumatic agent. It is also used as a mild analgesic in a variety of painful conditions.
Dose: 900 mg-3 g daily. Side-effects include nausea, dizziness, vertigo and rash. (Fenoprofen; Progesic). See page 165 and Table 29.
fenoterol A sympathomimetic agent with the actions, uses and side-effects of salbutamol. Dose: by oral inhalation, 100-200 [Ig (1-2 puffs) up to 4 times a day. (Berotec). See page 118 and Table 6.
Fansidar Pyriniethamine, 25 mg with sulfadoxine 500 mg. Both these antimalarial drugs block the formation of folinic acid in the malarial parasite, but the combination is more effective. Mainly used with quinine in resistant filciparum malaria. (Fansidar is no longer recommended for prophylaxis, as fatalities have followed such use.)
felodipine A calcium antagonist used in the treatment of hypertension generally (see calcium channel blocking agents). Dose: 5 nig daily initially, adjusted to maintenance doses up to to mg daily. ‘I abiets should be taken in the morning, and swallowed whole with water. No adjustment of dose necessary for elderly patients, but care is required in marked hepatic impairment. Hypotension with tachycardia may occur with susceptible patients. (Plendil). See page 148 and Table 21.
felypressin A vasopressin derivative, used as a vasoconstrictor in local anaesthetic solutions for dental use, when sympathetic pressor drugs are contraindicated.
fenbufen A non-steroidal anti-inflammatory agent (NSAID) used for the relief of
fentanyl A narcotic analgesic, used mainly in thiopentone anaesthesia to increase the response and permit a reduction in dose of thiopentone, especially in poor-risk patients. It is also used with droperidol to produce a state of neuroleptanalgesia. Dose: 50-200 pg by i.v. injection.
(Subli niaze). Also used as a patch for the relief of chronic pain. (Durogesic).
fenticonazole An antifungal used in vaginal candidiasis as pessaries of 200 mg. (Lonlexin).
ferrous sulphate, fumarate, gluconate & succinate These iron salts are used in the prophylaxis and treatment of iron-deficiency anaemias. Ferrous sulphate is the standard drug, given in doses of 600 mg daily, but it may cause gastric disturbance in some patients, and ferrous fumarate, gluconate and succinate are better tolerated alternatives. Sonic better tolerated slow-release products are available, but may be less well absorbed. Ferrous sulphate tablets are potentially dangerous for small children, and death has occurred after accidental administration. See desferrioxamine.

fexofenadine An antihistamine with the general properties of that group of drugs. It is less likely to affect the ability to drive. Dose: 120 mg once daily. See
page 110 and Table 2.
fibrinolytic agents Drugs used to break up blood clots, and so are of value in thrombosis. See alteplase, anistreplase, streptokinase and urokinase.
filgrastim A recombinant form of human granulocyte colony stimulating factor (G-CSF), one of a group of natural growth factors concerned with bone marrow activity. It stimulates the development of neutrophils, the production of which is depressed during cytotoxic therapy. The neutropenia thus caused increases the risks of infection, but the neutrophil count can be restored by filgrastim. It is used mainly in the neutropenia associated with the cytotoxic treatment of non-myeloid malignancy. Dose: 500 000 units/kg daily by s.c. injection or i.v. infusion for 14 days, or until the neutrophil count return, to normal. Double doses are given after bone marrow transplanlation.The main side-effects are musculoskeletal pain and dysuria.  See lenograstini and molgrastirn.
His, and is of value in serious ventricular tachycardia and extrasystoles.
Dose: 200-400 mg daily. May he given by slow i.v. injection in doses of 2 iiig/kg in acute conditions resistant to other therapy, and under hospital control. Care is necessary in patients with pacemakers, and in renal impairment. Dizziness and visual disturbances are side-effects. (Tainhocor). See page 141 and Table 18.
flucloxacillin A derivative of cloxacillin, that is absorbed more readily when given orally. It is used mainly in infections due to penicillinase-producing penicillin-resistant staphylococci.
Dose: I g daily before food; by injection 1 -4 g daily, but larger doses arc given in very severe infections. Side-effects are those of the penicillins generally. (Floxapen). See co-fluanipicil.
fluconazole A systemically acting synthetic antifungal agent.
Dose: in oral candidiasis, 50 ing daily for 7-14 days: in vaginal candidiasis, a single dose of 1.50 mg. Dose in systemic candidiasis and cryptococcosis, 200-400 mg daily orally or by i.v. infusion. Side-effects include nausea and abdominal discomfort. Combined treatment with
asternizole, cisapride or terfenadine should be avoided. (Dillucan).
finasteride An inhibitor of the enzyme 5-alpha reductase, and so prevents the conversion of testosterone to dihydrotestosterone, the biologically active form of the male hormone. It is used for the symptomatic relief of benign prostatic hyperplasia, as prolonged therapy promotes a reduction in the size of the prostate gland.
Dose: 5 nig daily for 6 months or more. Side-elfects are reduced libido and impotence. (Proscar). See page 164 and Table 28.
flavoxate An antispasmodic of value in urinary disorders such as dysuria, frequency and related conditions. Dose: 600 mg daily. Side-effects include dry mouth and blurred vision. Contraindicated in glaucoma and bladder obstruction. (Urispas).
flecainicle An orally active anti-arrhythmic
agent of the lignocaine type. It chiefly
influences conduction in the bundle of
flucytosine An antifungal agent used in systemic yeast infections such as candidiasis and cryptococcosis.
Dose: 100-200 mg/kg daily i.v. It may Cause sonic bone marrow depression, and sensitivity tests should be carried out before and during treatment, as resistance to the drug may limit its value. Care is necessary in renal and hepatic inipairmclit. Side-effects include nausea, diarrhoea and rash. (Alcobon).
fludarabine A fluorinated cytotoxic agent used in chronic lymphocytic leukaemia (CI.L) after other treatment has failed. Dose by i.v. infusion 25 mg/in’ for 5 days a nionth. It is generally well tolerated, but myclosuppression may occur as with related drugs. (Fludara).

butobarbitone A barbiturate of medium clisityand rapidity of onset.
Dose: 60-200 mg. (Soneryl).
cabergoline A dopamine similar to bromocriptine, but with a longer .1, 1 ioli.
Dose: for suppression of lactation I mg, followed by doses of 0.25 ing for 2 days. Nausea, dizziness and breast pain are side effects. (Cabaser; Dostinex).
cadexomer iodine A modified starch powder containing 0.9% of iodine in a slow release form. It is used as an antiseptic application for venous ulcers and pressure sores. It should not be used during prenancy or lactation, during thyroid investigations or in patients sensitive to iodine. (lodosorb).
caffeine The central nervous system stimulant present in tea and coffee. It is used with paracetamol and other mild analgesics.
calamine Zinc carbonate. It has a mild astringent and soothing action and is widely used as Calamine Lotion for skin irritation and as Oily Calamine Lotion in eczema.
calciferol (vitamin D 2) form of vitamin 1) used in the prophylaxis and treatment of deficiency states such as rickets in children and osteomalacia in adults, and in other bone disorders. Dose: prophylactic 800 units daily; therapeutic 5000-50 000 units daily. In resistant rickets and parathyroid deficiency, higher doses may be required, but such therapy requires care, as hypercalcaemia percalcaernia and irreversible renal damage may occur. See ako alfacalcidol and calcitriol.
calcipotriol An analogue of vitamin D with a selective inhibitory action on the proliferation of keratinocytes. Used in the treatment of psoriasis as a 0.005% cream or ointment twice a day. Not more than 100 g/week. (Dovonex).
calcitonin Pork-derived calcitonin is a hormone that has an action similar to that
of the parathyroid gland in regulating blood calcium levels. It is used in the hypercalcaemia associated with malignancy, and in osteoporosis. It is also of value in Paget’s disease of bone, in which it relieves bone pain and reduces the neurological symptoms.
Dose: 10-160 units daily by s.c. or i.m. injection according to need and response. In Paget’s disease, prolonged treatment for some months may he required. Side-effects are nausea, flushing and paraesthesia, and local reactions may also occur. (Calcynar; Calcitare; Miacalcic). See salcatonin.
calcitrol The metabolite formed in the kidney from calciferol. It is the most powerful and rapidly acting metabolite with vitamin L) activity. It is of value in chronic renal deficiency states when the normal metabolism of calcium and phosphorus is impaired, as in renal osteodystrophy. Dose: 1-2 pg daily under biochemical control. Side-effects, such as hypercal-
caemia and hypercalciuria, are usually , P
reversible on withdrawing the drug. (Rocaltrol).
calcium channel blocking agents The movement of calcium ions through the calcium channels of the myocardium plays an essential role in cardiac activity. The inhibition of such movement by channel blocking agents reduces myocardial contractility and lowers the tone of the cardiovascular system. Such a reduction is of value in angina, hypertension and cardiac arrhythmias, and can be obtained by the use of calcium channel blocking agents such as diltiazem, felodipine, isradipine, nicardipine, nifedipine, nimidopine and verapamil. These compounds exhibit certain differences in action and in therapeutic applications, and their use requires care. Nifedipine and veraparail have been used in the prophylactic treatment of migraine. Their side-effects include nausea, oedema, rash and bradycardia. See pages 114 & 148, and Tables 4 & 21.
calcium carbonate A time honoured antacid now used less frequently. It also acts as a phosphate binder, and is used in hyperphosphatacinia.
calcium chloride The calcium salt present In various intravenous electrolyte solutions.

calcium folinate See folinic acid.
calcium gluconate A soluble and well-tolerated calcium salt used in many condi- tions associated with calcium deficiency such &i rickets, coeliac disease and parathyroid deficiency; also during pregnancy and lactation often in association with vitamin D. Calcium gluconate is also given in chilblains, urticaria and allergic reactions. Dose: usually given in (loses of 0.5-2g, but ill hypocalcaemic tetany it is given by slow i.v. injection in doses of 10 ml of a 100% solution, with laboratory control of the blood calcium levels. Calcium gluconate is also given i.v. in the early
treatment of toxic hyperkalaemia.
calcium lactate The calcium salt most commonly given orally in mild deficiency states.
Dose: 1-5 g.
Calcium Resonium An ion-exchange resin that take, up potassium in exchange for calcium. Used in hyperkailatentia associated with anuria and haernodialysis. Should be used only when potassium and calcium serum levels are under biochemical control. Dose: 15- 30g 3 or 4 times a day. In children, 0.5-1 g/kg daily. It is sometimes given as a retention enema.
are given in heart failure. Side-effects include proteinuria, neutropenia, agranulocytosis, rash and loss of taste. (Acepril; Capotin). See ACE inhibitors, page 148 and Table 21.
carbachol A parasympathomimetic agent used orally and by injection in the treatment of postoperative atony and retention of urine, and occasionally as eye drops (3%) in i the treatment ofglaucoma. Dose: 2-4 ing orally, 250 pg by s.c. injection. Side-effects include nausea, bradycardia and colic.
carbamazepine An anticonvulsant effective in all types of epilepsy except petit mat (absence seizures). It is also of value in trigeminal neuralgia and is given prophylactically in manic-depressive states. Dose: 200-400 ing daily initially, slowly increased up to 1.8 g daily if required. Suppositories of 125-250 mg are available. Carbamazepine has some antidiuretic properties, and has been used in diabetes insipidus in doses of 100-2M mg daily. Side-effects include dizziness, gastrointestinal disturbances and all erythematous rash. (Tegretol). See page 136 andTable 15.
carbaryl An insecticide used as it lotion and shampoo in pediculosis.
canrenoate A steroid-derived aldosterone antagonist with the actions and uses of spironolactone.
Dose: given in oedema by slow i.v, inject ion or infusion in doses of 200-400 mg daily. Nausea and vomiting are high-dose side-effects. (Spiroctan-M).
capreomycin An antibiotic of value in resistant i uberculosis or when other drugs are not tolerated.
Dose: I g daily by i.m. injection. It may cause tinnitus, deafness, renal damage and allergic reactions. (Capastat).
captopril An inhibitor of the angiownsin converting enzyme. It is used in the treatment of hypertension, including that resistant to other therapy, but care is necessary as the initial dose may cause marked hypotension, and so is best taken ill bed. It is often given with a thiazide diuretic to improve the response, and with a beta-blacker to maintain the effect. Dose: 25 mg initially, slowly increased, as required, up to 450 mg daily. Similar doses
carbenoxcilone A cytoprotectant derived front liquorice, used for mouth ulcers. (Bioplex; Bioral). See Table 27.
carbidopa An enzyme inhibitor used with ievodopa in parkinsonism. It prevents the breakdown of levodopa, thus permitting a larger amount to reach the brain. See
page 160.
carbimazole An antithyroid drug. It inhibits the formation of thyroxine and is valuable in the treatment of thyrotoxicosis and in preparation for thyroidectomy. Dose: 30-60 mg, daily initially; maintenance dose, 5-20 ing daily. It is sometimes given together with thyroxine it) the’blockage replacement’ treatment of hyperthyroidism. Side-effects are nausea, rash and pruritus; alopecia and agranulcytosis have been reported. (Neo-Mercazole).
carbocisteine A mucolytic agent used to reduce the production and viscosity of sputum in respiratory disorders.
Dose: 1.5 g daily. (Mucodyne).

bezafibrate A plasma-lipid regulating agent with an action similar to clofibrate, and used in the treatment of hyperlipidaemia not responding to diet.
Dose:daily with food. Contraindicated in renal or hepatic dysfunction. May potentiate oral anticoagulants. Side-effects are nausea, pruritus and urticaria. (Bezalip). See page 146 and Table 20.
Dose: It is given in hypertension and angina in doses of 5-20 nig daily. (Enicor; Monocor). See pages 114 & 148, and fables 4 & 21.
bisphosphonates Substances used in Paget’s disease of bone and hypercalcaemia of malignancy. See alendronate, disodium etidronate, disodium pamidronate and sodium clodronate.
bicalutamide A nonsteroidal anti-androgen that binds, selectively with androgen receptors. It is used with an LH-111-1 analogue such as goserelin in advanced prostatic cancer in doses of 50 mg daily. (Casodex). See page 122 and Table 8.
bipetiden An antispasmodic and parasympatholytic drug used chiefly to control the rigidity and excessive salivation of parkinsonism. It has less effect on tremor.
Dose: 2 ing daily initially, increased, as required, up to 0 mg or more daily. If necessary it may be given by i.m. or slow i.v. injection in doses of 5-20 mg daily. Side-effects include dizziness, blurred vision and drowsiness. (Akineton). See page 160 and Table 26.
BIPP A mixture of bismuth subnitrate, iodoform and liquid paraffin, used occasionally as an antiseptic dressing.
bisacodyl A synthetic laxative that exerts its action by a direct stimulating effect on Ilse nerve endings of the colon.
Dose: 10 mg orally, or as a suppository. Abdominal cramp is an occasional side-effect. It should not be used in intestinal obstruction.
bismuth chelate A potassium-bismuthcitrate complex used to promote the healing of peptic ulcers, mainly by a protective action.
Dose: 480 nig daily for 28 days, repeated if* necessary at monthly intervals. Not to be given with food. It may blacken the faeces. (Dc-NoltalO.
bismuth subgallate A yellow insoluble powder with astringent properties. Used as dusting powder, and as suppositories for rectal conditions.
bisoprolol A beta-blocking agent with the actions, uses and side-effects of propranolol.
bleomycin A cytotoxic antibiotic, exceptional in causing little or any disturbance of bone marrow activity. Used mainly in skin tumours, lymphomas and mycosis fungoides.
Dose: 15-30 ing twice-weekly by i.m. or i.v. injection up to a total dose of 500 ing. The onset of stomatitis is an indication of the maximum tolerated close. Pigmentation of the skin may occur, but a severe close-related, delayed reaction is
pulmonary fibrosis, requiring immediate withdrawal of the drug. There is a risk of respiratory failure during general anaesthesia associated with a high oxygen intake. See page 122 and ‘rable 8.
botulinum toxin complex Botulinuin toxin causes severe respiratory muscle paralysis, but a modified form has a local action. The complex is used in severe blepharospasm and given by injection into the ocular muscle. Response is slow (1-2 weeks) and treatment may need to be repeated at intervals of 8 weeks. (Botox; Dysport).
bretylium An antihypertensive agent, now used on[), in the control of resistant ventricular arrhythmias.
Dose: i mg/kg, i.m., 6-8-hourly. It may also be given by slow i.v. injection in doses of 5-10 mg/kg, repeated as required. Side-effects include nausea, vomiting and severe hypotension. (Bretylate).
brimonidine A selective alpha,-andrenergic receptor agonist. It is used in the treatment of glaucoma when bcta-blockers are not suitable or not tolerated.
Dose: one drop of a 0.2% solution in the eye or eyes twice daily. Some initial burning and stinging may occur, and an ocular allergic reaction may occur with prolonged therapy. (Alphagan).
bromazepam A benzodiampine used mainly
in the short-term treatment of anxiety.

Dose: 9-18 mg daily. Contraindicated in respiratory depression and phobic states. (I-exotan). See page 117 and fable 5.
bromocriptine An inhibitor of the release of prolactin from the pituitary gland. It is used to prevent or suppress lactation when other measures have failed.
Dose: 1-1.5 mg daily initially for a few days, then twice daily for 14 days. It also stimulates dopamine receptors in the brain and is used in parkinsonism, mainly in patients unable to tolerate levodopa, to stimulate any surviving dopamine receptors. Dose: 1.25 mg at night initially, with food, slowly increased according to response up to 40 mg. The use of the drug requires care, as it has many side-effects, including early hypotensive reactions. Bromocriptine is also used in some condi- tions of pituitary dysfunction such as acromegaly. (Pardolcl). See page 160 an(] Table 26.
brompheniramine An antihistamine similar to promethazine, but with shorter action and reduced side-effects. It also has some antitussive properties.
Dose: 12-32 mg daily. (Dimotane). See pate 110 and Table 2.
budesonide A steroid similar to beclomethasone, and used by oral aerosol inhalation in chronic airway obstruction and other asthmatic conditions.
Dose: 200800 pglkg (1-4 puffs) according it) need. A long-acting form (Entocort) is used in the treatment of Crohn’s disease. Dose: 9 nig daily before breakfast for up to 8 weeks. Also used locally as a cream (0.025%) in eczema, psoriasis and
dermatitis. (Pulmocort; Preferid).
bumetanide A rapidly acting loop diuretic similar to frusemide, with comparable actions, uses and side-effects.
Dose: 1-5 mg daily. Much larger doses may be needed when renal function is impaired. In acute pulmonary and cardiac oedema, 1-2 mg may be given i.v. Morirxx). See page 148 and “fable 21.
bupivacaine A local anaesthetic related to lignocaine but characterized by its increased potency and long duration of action which may be tip to 8 hours when used for nerve blocks. It is also of value in continuous epidural analgesia. It is used as a 0.25% to 0.5% solution in doses
according to requirements with or without adrenaline. The side-effects are those of lignocaine, but it may cause more severe myocardial depression. (Marcain).
bupronorphine A powerful analgesic, related to morphine, but less likely to cause dependence. Valuable in pain of terminal cancer, after operation or myocardial infarction.
Dose: 200-100 Vg 6-8-hourly as sublingual tablets, or 300-600 pg by i. in. or slow i.v. injection at intervals of 6-8 hours according to need. Side-effects include drowsiness, nausea and dizziness. Naxolone is only a partial antagonist. f *1 enigesic).
buserelin A synthetic gonadotrophinreleasing hormone that indirectly depresses androgen and oestrogen synthesis. It is used in the treatment of testosterone-sensitive prostatic carcinoma.
Dose: 500 Vg by s.c. injection 8-hourly for 7 clays, followed of    bv intranasal mainte- nonce dosesdoseso100 pg’6 times a day. Patients should be warned that an
increase in pain may occur initially. Side-effects are hot flushes and loss of libido. (Suprefact). It is also used its a nasal spray in the long-term treatment of endometriosis in doses of 900 pg daily. Side-effects are menstrual-like bleeding and mood changes. (Suprecur). See goserelin, lcuprorelin and nafarelin.
buspirone A drug for the treatment of anxiety. It acts more selectively than the benzod iazepi ties on serotonin receptors in the brain, but the full response may take 1-2 weeks.
Dose: 10-15 mg daily initially, slowly
in, ceased as required up to a maximum of 45 mg daily. Side-effects are nausea, dizziness and drowsiness. Benzod  must be withdrawn slowly before transfer to buspirone. ( Ruspar). See page 117 and “fable 5.
busulphan A cytotoxic compound used in the palliative treatment of chronic myeloid leukaemia. Close haernatological control is essential during treatment as remission of symptoms may not be complete for some weeks and overdose may cause irreversible myelodepression.
Dose: 0.5-4 mg daily. Side-el’16:ts include pigmentation of the skin. (vIvIeran).