Drug Information

Drug Interaction:

EVIDENCE BASED MEDICINE (MIMS-April 2003)

2.Generalised Anxiety Disorder (GAD)

Comparative effectiveness of various Interventions

Definition

1. Excessive worry and tension on most days or atleast for six months

2. With increased motor tension - fatiguability, trembling, restlessness, muscle tension

3. With automatic hyperactivity shortness of breath, rapid heart rate, dry mouth, cold hands and dizziness, but not panic attacks

4. With increased vigilance and scanning- feeling keyed up, increased startling, impaired

concentration

Beneficial

1. Cognitive therapy

Likely to be beneficial

1. Buspirone

2. Certain antidepressants ( paroxetine, imipramine,trazodone, venlafaxine )

Trade-off between benefits and harms

1. Benzidiapines

Unknown effectiveness

1. Anti-psychotic drugs

2. Beta-blockers

KEY POINTS

1. A systemic review of randomised clinical trials (RCTs) has found cognitive therapy with

behavoural interventions is more effective than no treatment, anxiety management training alone, or non-directive therapy. No adverse effects were noticed.

2. One systemic review of randomised clinical trials (RCTs) has found that benzodiapines

are clinically effective and rapid treatment for generalised anxiety disorder. One RCT found no significant difference in the effects of slow release alprozolam and bromozepam.

3. RCTs have found that buspirone is effective in GAD. Slower onset compared with benzodiapines is counter balanced by few side effects.

4. RCTs have found that imipramine, trazodone, venlafaxine and paroxetine are effective treatments for GAD. One trial has found that paraxetine was more effective than benzodiapines. There is a significant risk of side effects with these drugs.

5. It was found that beta-blockers had not been adequately evaluated in GAD.

Indication:

3.DISORDERS AND/ OR ADVERSE REACTIONS - CENTRAL NERVOUS SYSTEM - SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

Refer - Other Information

Contents

1.Evidence Based Medicine i. Depression ii. Generalised anxiety Disorder (GAD) iii. Post Herpetic Neuralgia

2. Facts on Finger Tips

3.Disorders and/or Adverse Reactions Items 1 to 20

EVIDENCE BASED MEDICINE (MIMS -April 2003)

1. Depression

Comparitive effectiveness of various interventions

Beneficial

1. Tricyclic and heterocyclic antidepressants

2. Selective serotonin reuptake inhibitors and related drugs

3. Monamine oxidase inhibitors

4. Interpersonal therapy (mild to moderate depression)

Likely to be beneficial

1. St.Johns wort in mild to moderate depression

2. Problem solving therapy in mild to moderate depression

3. Combining drug psychological treatment in severe depression

4. Maintenance drug treatment may prevent recurrence

Unknown efectiveness

1. Excercise

2. Bibliotherapy (advising patients to read material on mood therapy)

3. Non-directive counselling

4. Psychological treatment in severe depression

5. Clinician colloboration and patient education.

KEY POINTS

1. Several treatments are effective in the treatment of mild to moderate depression. These include anti-depression drugs, cognitive therapy and interpersonal therapy. Less robust RCTs have found that problem solving therapy and St Johns wort are also effective. Specific psychological treatments such as cognitive and interpersonal therapy have been shown to be as effective as drugs and there is no significant difference between anti-depressant drugs, although they vary in adverse effects and costs.

2. There is limited evidence that other treatments such as excercise, bibliography and non- directive counselling may be effective, but further research is needed.

3. There is no reliable evidence that one type of treatment (drug or non-drug) is superior to another. Limited evidence suggest that combining drug and psychological treatments may be effective in severe but not in moderate depression.

4. Of the interventions examined, anti-depressants drugs are the only treatment for which there is good evidence of effectivenes in severe psychotic depressive disorders. There are no trials comparing drug and non-drug treatments in severe depressive disorder.

5. Continuing anti-depressants drug treatment for four to five months after recovery reduces the risk of relapse, and maintenace therapy in recurrent depressive disorder reduces the risk of recurrence.

6. There is no evidence of a difference in long-term benefits between treatments

Adverse Reaction:

EVIDENCE BASED MEDICINE (MIMS April 2003)

3. Post-herpetic Neuralgia

Comparitive effectiveness of various interventions

Prevention of post-herpetic neuralgia

Beneficial

1.Oral antiviral agents such as acyclovir, famciclovir, valaciclovir, netivudine

2. Tricyclic antidepressants (amitriptyline)

Unknown effectiveness

1. Levodopa

2. Amantadine

3. Isoprinosine

4. Adenosine monophosphate

Unlikely to be beneficial

1. Topical antiviral agents (idoxurine) for relief of acute pain only

2. Cimetidine

Ineffective or harmful

1. Corticosteroids

Relieving established post-herpetic neuralgia

Beneficial

1. Tricyclic antidepressants (amitriptyline)

2. Oxycodone (opiod)

3. Gabapentin (anticonvulasant)

Unknown effectiveness

1. Capsaicin (topical counterirritant)

2. Topical lignocaine

Ineffective or harmful

1. Epidural morphine

2. Dextromethorphan

KEY POINTS

1. Daily acyclovir reduced the relative risk of of post-herpetic pain at six months by about 50 % compared with placebo

2. Famciclovir significantly reduced pain duration after acute herpes zoster.

3. Idoxuridine was associated with short term pain relief in acute herpes zoster but did not prevent post-herpetic neuralgia

4. Conflicting evidence on whether corticosteroids alone prevent post-herpetic neuralgia. Limited evidence that high dose steroids and antiviral agents combined may speed healing of acute zoster. No evidence that it reduces post-herpetic neuralgia

5. Amitriptyline started during the acute episode reduced prevalence of post-herpetic neuralgia at six months.

6. Insufficient evidence on the effect of other drug treatment.

Other Information:

3.DISORDERS AND OR/ ADVERSE REACTIONS - CENTRAL NERVOUS SYSTEM- SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Sleep Apnea ( 1274 )
2. Cerebellar ataxia ( 92 )
3. Stupor ( 115 )
4.Coma ( 115 )
5. Hypesthesia ( 112 )
6. Confusion ( 122 )
7. Peripheral neuropathy ( 388 )
8. Exacerbation of myasthenia ( 2064 )
9. Extrapyramidal effects ( 388 )
10. Seizures ( 131 )
11. Stroke ( 1911 )
12. Pseudotumor cerebri ( or intracranial hypertension ) ( 1955 )
13. Headache ( 388 )
14. Schizophrenic -like or paranoid reactions ( 150 )
15. Depression ( 70 )
16. Hypomania, mania, or excited reactions ( 151 )
17. Hallucinatory states ( 150 )
18. Delirious or confusional states ( 124 )
19. Sleep disturbances ( 399 )
20. Drowsiness ( 399 )

1. Sleep Apnea ( 1274 )

Number of patients have been described in whom breathing periodically stops during sleep as a result of upper airway obstruction. Airway obstruction can be caused by backward movement of the tongue, collapse of pharyngeal walls , or greatly enlarged tonsils or adenoids. Loud snoring is a feature and the patient may wake violently after an apneic episode. There is often sleep deprivation, and the patient may ehibit daytime somnolence

2. Cerebellar ataxia ( 92 )

Intention tremor, irregular slowness in starting and starting and stopping alternating voluntary movements

3. Stupor    ( 115 )

    In stupor mental and physical activity are reduced to a minimum. Although inacessible to many   stimuli, the patient opens the , looks at the examiner, and does not appear to be unconscoius.  Response to spoken commands is either absent or slow and monosyllabic. As a rule tendon or   plantar reflexes are not altered. On the other hand , tremulousness of movement, coarse twitching   of muscles, restlessnes or sterotyped motor activity and grasping and sucking reflexes are not   infrequent, depending upon the way in which disease affects the nervous system.

The stupor means a state in which impressions of external world are normally received but the activity is suspended or marked negativism eg catatonic stupor of schizophrenia and mania

4.Coma ( 115 )

The patient appears to be asleep and is at the same time incapable of sensing ( unreceptive) and rersponding adequately to either external stimuli or inner needs ( unresponsive ) is in a state of coma

5. Hypesthesia ( 112 )

The term hyperesthesia - It implies a heightened receptiveness of the nervous system, careful testing will usually demontrate an underlying sensory defect, or thermal stimuli, once the stimuli is perceived, however, it may have a severely painful or unpleasant quality (hyperpathia )

6. Confusion ( 122 )

Confusion is a general term denoting an incapacity of the patient to think with with customary speed and clarity. This abnormality may depend on any one of several factors. Confusion is related to a dearrangement of intelluctual functions ie. an ability to,leran, remember, calculate make appriopiate deductions from given premises, reason abstractly etc.

NEUROLOGIC DISRDERS-

7. Peripheral neuropathy ( 388 )

Adverse Reaction - Drugs
   1. Isoniazid
   2. Hydralazine
   3. Nitrofurantoin
   4. Vincristine
   5. Mustine
   6. Streptomycin
   7. Polymixin, colistan
   8. Clioquinol
   9. Phenelzine
   10. Tricyclic antidepressants
   11, Chloramphenicol
   12. Procainamide
   13. Ethambutol
   14. Ethionamide
   15. Glutethimide
   16. Demeclocyline
   17. Nalidixic acid
   18. Tolbutamide
   19. Chlorpropamide
   20. Methysergide
   21. Phenytoin

8. Exacerbation of myasthenia ( 2064 )

Myasthenia gravis is characterstic of muscular diseases . It is characterised by weakness and easy fatigability, it most frequently affects the oculomoter, facial, laryhgeal, pharyngeal, and respiratory muscles. Patial recovery with rest and and after the administration of antichloinestrase drugs is another important attribute

In myasthena gravis and thyrotoxic myopathy or periodic paralysis , some degree of weakness is present at all times but is made worse by activity. exhastion and fatigability with drug intoxification ( orgonophosphates. certin antibiotics, phenothiazines, barbiturates, and bromides ) .

Adverse Reaction - Drugs ( 388 )

1. Aminoglycosides
2. Polymixins

9. Extrapyramidal effects ( 388 )

Adverse Reaction - Drugs
   1. Butyrophenones eg haloperidol
   2. Phenothiazines
   3. Tricyclic antidepressants
   4. Methyldopa
   5. Levodopa
   6. Reserpine
   7. Metoclopromide

10. Seizures ( 131 )

Certain intercurrent medical diseases manifest themselves at one stage by a seizure of or a series of seizures, beginning as immediate loss of consciousness, with stiffening, then clonic rhytmic jerking of the limbs or only the latter.The focality of the initiating lesion may be indicated by tonic or clonic spasm of the muscles of only one part of the body or a turning of eyes and head on one side.Consciousness tends to be reinstated soon after the cessation of th generalized motor activity

Adverse Reaction - Drugs ( 388 )
   1. Amphetamines
   2. Analeptics
   3. Phenothiazines
   4. isoniazid
   5. Lidocaine
   6. Theophylline
   7. Penicillins
   8. Nalidixic acid
   9. Phytostigmine
   10. Tricyclic antidepressants
   11. Vincristine
   12. Lithium

11. Stroke ( 1911 )

The cardinal feature of cerbrovascular disease is the stroke, a term that cannotes the suuden and dramatic development of a focal neurologic defecit. In its severest form the patient falls hemiplegic and even unconsicous, an event so striking as to deserve its own separate designation , namely,apoplexy, stroke, shock. or cerebrovascular accident. In the mildest form it may consist of only a trivial neurologic disorder insufficient to disturb the customary activites of the patient

Adverse Reaction - Drug ( 388 )
1. Oral contraceptives

12. Pseudotumor cerebri ( or intracranial hypertension ) ( 1955 )

In the condition of pseudomotor cerebri ( meningeal hydrops ) the patient, more often than a child or young woman, complains of headaches, of some weeks standing and when first examined if found to have papilledema, or choked disks, with slightly constricted visual fields and enlarged blind spots. Except for vague dizziness diplopia due to slight abducents weakness, or paresthesia of some parts of the body, neurologic signs are conspisously absent and patient appears remarkbly - bright and well.

Adverse Reaction - Drug ( 388 )
   1. Corticosteroids
   2. Oral contraceptives
   3. Tetracyclines
   4. Hypervitaminosis A

13. Headache ( 388 )

Adverse Reaction - Drugs
   1. Hydralazine
   2. Bromides
   3. Glyceryl trinitrate
   4. Ergotamine ( withdrawal )
   5. Indomethicin

PSYCHIATRIC DISORDERS ( 389 )

14. Schizophrenic -like or paranoid reactions ( 150 )

Schizophrenia - this is a hereditary lifelong disease of the nervous system which begins in early life, pursues a recurrent course without full remissions, and is characteized by the above syndrome or variant thereof. This disease is frequent world wide . Prevalent rates are in the order of 0.2 to 0.5% and life expectancy rates ( chance of manifesting scizophrenic symptoms during life time ) are st least 1.0%. world prevalent is about 10 to 20 million cases

Adverse Reaction - Drugs ( 389 )
   1. Amphetamines
   2. Lysergic acid
   3. Levodopa
   4. Tricyclic antidepressants
   5. Monoamine oxidase inhibitors
   6. Bromides
   7. Corticosteroids

15. Depression ( 70 )

There are few persons who do experience periods of discouragement and despair, and these periods in modern society where individual freedom manifestly more frequent in modern society where individual freedom is constrained to ones impulses must be inhibited. As with nervous and anxiety , depression of mood that is approipiate to a given situation in life is natural, healthy reaction and seldom is the basis of medical complaint. The patient tends to seek help only when grief or unhappiness becomes uncontrollable.

Adverse Reaction - Drugs ( 389 )
   1. Centrally acting antihypertensives ( reserpine, methyldopa, clonidine )
   2. propranolo
   3. Corticosteroids
   4. Amphetamine withdrawal
   5. Levodopa

16. Hypomania, mania, or excited reactions ( 151 )

Maniac depressive disease - It it occurs acutely in association with a prominent affective or mood disoder in a previuiosly well- adjusted individual, especially it is preceded by euphoria, hyperactivity, flight of ideas, pressure of speech, grandiosity, hostility, and sleeplessness, ( the usaual signs and symptom of mania ) the diagnosis will usually turn out to be maniac -depressive disease

Adverse Reaction - Drugs ( 389 )
1. Levodopa
2. sympaththomimetics
3. Corticosteroids
4. MAO inhibitors
5. Tricyclic antidepressants

17. Hallucinatory states ( 150 )

The thought of these patients are often interrupted by hallucinucinations ( usually auditory ) and unreal dreamlike experiences. sometimes the hallucinations consist of voices coming from outside the body, but often no clear distintion is drawn between hallucination and an idea that can be planted in the mind. In the struggle to retain sanity, patients try to vainly to separate their own thoughts and perpceptual experiences from those others who ostesibly trying to control them.

Adverse Reaction - Drugs ( 389 )
1. Amantadine
2. Narcotics
3. Pentazocine
4. Propranolol
5. Levodopa
6. Tricyclic antidepressants
7. Mepidrine

18. Delirious or confusional states ( 124 )

The first indications of of the approaching attack are difficulty in concentrating , restless irrotability, tremulousness, insomnia, and poor appetite. One of several generalized convulsions are the initial major symptom in almost 30% of the cases. The patients rest becomes troublesome by unpleasant and terrifying dreams

Adverse Reaction - Drugs (389 )
1. Digitalis
2. Antichlinergics
3. Bromides
4. Sedatives and hypnotics
5. Phenothiazines
6. Antidepressants
7. Corticosteroids
8. Isoniazid
9. Levodopa
10. Amantadine
11. Penicillins
12. Aminophylline
13. Methldopa

19. Sleep disturbances ( 399 )

Adverse Reaction - Drugs
   1. Anorexiants
   2. Levodopa
   3. Monoamine oxidase nhibitors
   4. Sympathomimetics

20. Drowsiness ( 399 )

Adverse Reaction - Drugs
   1. Anxiolytic drugs
   2. Major tranquilizers
   3. Tricylic antidepressants
   4. Antihistamines
   5. Methyldopa
   6. Clonidine
   7. Reserpine

DISORDERS AND/OR ADVERSE REACTIONS- 3. CENTRAL NERVOUS SYSTEM - SUMMARY

Drug Interaction

Indication

Adverse Reaction

Other Information

Drug Interaction:

Indication:

Adverse Reaction:

Other Information:

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