Sie sind auf Seite 1von 98

Drug Trade Mechanism Indications Kinetics

Names

Hypothalamic-Anterior
Pituitary Axis

contraception, precocious
long acting GnRH analogs puberty, breast Ca, prostate
leuprolide (essentially antagonists) Ca, endometriosis

contraception, precocious
long acting GnRH analogs puberty, breast Ca, prostate
goserelin (essentially antagonists) Ca, endometriosis

contraception, precocious
long acting GnRH analogs puberty, breast Ca, prostate
nafarelin (essentially antagonists) Ca, endometriosis
diabetic ketoacidosis,
acromegaly, gastinoma,
severe hypoglycemia
long acting somatostatin (insulinoma, B-cell
octreotide analog hyperplasia), VIPoma once/month injections
GH receptor antagonist -
pegvisomant prevents dimerization acromegaly, gigantism

sermorelin Geref synthetic GHRH idiopathic hypopituitarism


typical antipsychotics,
phenothiazines,
metoclopramide,
antihypertensives,
antidepressants dopamine antagonists
bromocriptine dopamine agonist prolactinoma
pergolide dopamine agonist prolactinoma

cabergoline dopamine agonist prolactinoma long 1/2 life

Posterior Pituitary Dz

synthetic oxytocin Pitocin causes uterine contractions accelerates labor

synthetic AVP Pitressin DI short 1/2 life, given IV


vasopressin tannate DI IM injection

DDAVP Desmopressin AVP analog central diabetes insipidus long 1/2 life

chlorpropamide potentiates AVP effect central diabetes insipidus


conivaptan anti-ADH DI iv
tolvaptan anti-ADH DI po

volume contraction decr


HCTZ free water excretion alt tx of DI

prevents Li uptake in distal


amiloride tubule and collecting ducts Li induced DI
prevents prostaglandin
indomethacin antagonism of AVP alt tx of DI

?
cosyntropin synthetic ACTH ACTH stimulation test
cortrosyn synthetic ACTH ACTH stimulation test
dexamethsone dx of Cushings
adrenal insuff - replaces
fludrocortisone aldosterone
prednisone immune suppression
aminoglutethemide
ketoconazole
Synthroid, hypothyroidism, myxedema
levo-thyroxine (L-T4) Levoxyl synthetic T4 coma
cytomel synthetic T3
require several wks before
methimazole Tapazole block production of T3/4 hyperthyroidism effect
require several wks before
propylthiouracil block production of T3/4 hyperthyroidism effect

1st line multinodular goiter,


radioactive iodine 2nd line hyperthyroidism

Osteoporosis
selective estrogen receptor
raloxifene evista modifier osteoperosis
pyrophosphate analog, bind
hydroxyapatite, inhib
bisphosphonates osteoclasts long skeletal retention
alendronate Fosamax
risedronate Actinel
ibandronate Boniva
calcitonin inhaled
PTH analog, incr
osteoblasts and bone
teriparatide formation intermittent

Relative Potencies of Naturally Occurring and Synthetic Corticosteroids

Relative Daily Relative


Compound Glucocorticoid Maintenance Mineralocorticoid

Potency Dose Potency

Hydrocortisone (cortisol) 1 30 mg 1
Prednisone 4 7.5 mg 0.8
Prednisolone 4 7.5 mg 0.8
6a-Methylprednisolone 5 6 mg 0.5
9a-Fluorocortisol 10 0.1 mg 125
(fludrocortisone) (as mineralocorticoid)
11-Desoxycorticosterone 0 NA 20
Cortisone 0.8 37.5 mg 0.8
Corticosterone 0.35 NA 15
Triamcinolone 5 6 mg 0
Paramethasone 10 3 mg 0
Betamethasone 25 1 mg 0
Dexamethasone 25 1 mg 0

Drugs Inhibiting the Synthesis or Actions of Adrenal Corticosteroids

Drug Site of Inhibition Clinical Effects Applications

Ketoconazole Adrenal and Cortisol ¯ Therapy of Cushing's


gonads
Cholesterol Adrenal androgens ¯ syndrome
synthesis and side
chain cleavage

C17-20 lyase Mineralocorticoids ¯ Reduction of adrenal and


gonadal androgens
11-hydroxylation Gonadal steroids ¯
Aminoglutethimide Adrenal cortex Cortisol ¯ Therapy of Cushing's

Cholesterol side Adrenal androgens ¯ syndrome


chain cleavage

Mineralocorticoids ¯ Reduction of adrenal and


gonadal androgens

Mifepristone Peripheral tissues Reduced glucocorticoid and Therapy of Cushing's


progesterone effects syndrome

Glucocorticoid ACTH and cortisol ­ Contraception and induction of


receptor
Progesterone abortion
receptor

Spironolactone Kidney and Reduced mineralocorticoid and Therapy of mineralocorticoid-


peripheral
tissues androgen effects dependent hypertension
Mineralocorticoid Therapy of hirsutism
receptor
Androgen
receptor

Weight Loss
causes early satiety, NE
phentermine Adipex and DA agonist 3-6 mo use

causes early satiety; 5-HT


sibutramine Meridia and NE reuptake inhib up to 3 yrs use

inhib fat absorption from


orlistat Xenical intestines

Diabetes

Glucophage incr insulin sensitivity of


(XR), combo liver; decr hepatic
agents glucose production,
[Glucovance - reduces triglycerides;
glyburide, activates AMPkinase in
Metaglip - liver and muscle; reduces
glipizide, gluconeogenesis and
Avandamet - promotes FA oxidation,
metformin rosiglitazone] decr fat storage in liver 1st line DM2, fatty liver? slow effects (wks)

incr insulin sensitivity in


mscl, adipose; may
preserve beta cell fxn; act
through PPARgamma -->
thiazolidinediones (TZDs) = promote FFA uptake to fat slowest onset of effects (wk-
glitazones cells mos)
pioglitazone Actos
rosiglitazone Avandia
troglitazone Rezulin

incr insulin secretion;


bind SUR1/Kir6.2, close K
channel --> depolarize
beta cell, release of 1-2x / day dosing, rapid
insulin --> stimulate basal response, dose to 1/2
sulfonylureas and postprandial insulin DM2 maximum
Micronase /
glyburide Diabeta renal excretion, 16-24hr
glipizide Glucotrol 12-24 hr
glimepiride Amaryl 24 hr
tolbutamide
chlorpropamide

incr insulin secretion; do shorter duration, shorter 1/2


meglitinides not bind SUR as tightly to be give w/ meals life --> dosed w/ meals
repaglinide Prandin
nateglinide Starlix

delayed absorption of
CHO, inhibit alpha-
glucosidase in intestinal
wall --> slower absorption,
less post-prandial rise of high carb diet, HbA1c <9%,
alpha-glucosidase inhibitors plasma glucose as combo w/ other tx taken w/ meals,
acarbose Precose
miglitol Glyset

inhibits glucagons secr,


stimulates insulin, causes
satiety, decreases gastric
Incretin effects emptying

GLP-1 receptor agonist


(on L-cells of duodenum);
resistant to DDP-4; incr
insulin, decr glucagon,
slow gastric emptying,
exenatide Byetta incr satiety injection, 2x/day

DDP-IV inhib; incr effect


of endogenous incretins
(enhance insulin secr,
decr glucagon release,
slow gastric emptying,
sitaglipin Januvia incr satiety) po, 1x/day

promote satiety, inhib


glucagon secr, slows
amylin modifiers gastric emptying
injection w/ each meal;
DM type 1 and 2 cleared by kidneys, 50min
pramlintide Symlin synthetic amylin analog (longstanding) 1/2-life

injection site (abd > arm >


insulin thigh)
short-acting (6-8 hrs); peak 2-
human / regular 4 hrs
NPH (neutral protamine
Hagedorn) intermediate (12-20hrs)
lente intermediate
ultralente long-acting (18-24 hrs)

aspart monomer insulin analog fast-acting; peak 1 hr

glulisine monomer insulin analog fast-acting; peak 1 hr

lispro monomer insulin analog fast-acting; peak 1 hr


long-acting (24 hrs); inj at
acidic pH --> ppt at
physiologic pH (slow release,
glargine analog maintain basal insulin no peak)
Humalog,
premixed Novolog 2x/day
inhaled regular Exubra inhaled

Lipidemias

HMG-CoA reductase inhib


--> incr LDL receptors, incr typically 12 hrs effective, dose
statins LDL clearance from plasma high LDL at night
Lovastatin Mevacor®,
Altoror®
Simvastatin Zocor®
Pravastatin Pravachol®
Fluvastatin Lescol®
Atorvastatin Lipitor®
Rosuvastatin Crestor®
bile acid binders decr enterohepatic
cholesterol recirc, incr
hepatic bile synth, incr LDL
receptors high LDL tablets or bulk powder
Cholestyramine Questran®
Colestipol Colestid®
Colesevelam WelChol®
fibrates
inhib TG production; decr
synth and release of VLDL
by liver, incr LpL activity
(incr clearance of TG),
incr synth of Apo-A1
(HDLs); activate
PPARalpha high TG, VLDL; low HDL
Gemfibrozil Lopid®
Fenofibrate Tricor®
other
Ezetimibe Zetia®
cholesterol absorption inhib,
(but liver compensates with 10mg tablet once/day, 80%
de novo synth) 2nd line for high LDL enterohepatic recycling
plant sterol esters Benecol, Take displace cholesterol from
Control micelles --> inhib re-uptake
of chol
Fish oil derivatives Super EPA®,
Promega decr synth of VLDL by liver high TGs 3-10 g/day required
nicotinic acid Niacor®, Slo- inhib VLDL synth by inhib
Niacin, Niaspan LpL and direct at liver -->
decr LDL low HDL; also high TG 1-3 g/day
CI/SE Notes

gallstones, d/n/abd pain, hyperglycemia, sinus


bradycardia, HA, alopecia, injections only 60% effective tx of GH tumors

daily injections req'd, incr liver enzymes highly effective

cause increased prolactin secretion --> galactorrhea


also used for acromegaly (poor efficacy ~10%)
also used for acromegaly (poor efficacy ~10%)

very few (low dose), n/v, orthostatic hypotension, HA, 2x/wk dosing, expensive, also used for acromegaly (poor
fatigue, constipation, psychosis, sleep changes efficacy)

coronary spasm, HTN, GI cramps, vasoconstriction,


uterine contractions old, not used
old, not used

no vascular SEs

also used to potentiate AVP: clofibrate, carbamazepine

potassium sparing diuretic

NSAID
monitor thyroid fxn every 6-8 wks -- goal to normalize TSH
MI risk generally not indicated

rash, aches, HA, agranulocytosis

hepatitis crosses placenta better than methimazole

hypothyroidism, may worsen graves ophthalmopathy

poor absorption

prolonged dosing causes bone loss


may incr BP

may incr BP
intestinal cramps, flatus, incontinence, oily spotting;
malabsorption of fat soluble vitamines (take a
multivitamin at a different time of day) improves lipids and blood glucose

diarrhea and nausea, lactic acidosis; Cis of renal,


cardiac (hypoxia --> acidosis), hepatic insuffic, no IV (biguanide) -- requires insulin, lowers HbA1c by 1-2%, no
contrast; mild wt loss, and decr TG, LDL (good SEs) hypoglycemia as monotherapy

may have reduction of cholesterol (cross reactive w/


edema, wt gain (fluids, worse on insulin), anemia PPARalpha [fibrates] ); decr HbA1c 0.5-1.5%; no
(mild), CHF, liver toxicity --> monitor LFTs, some hypoglycemia as monotx; may be cardioprotective and anti-
beneficial endothelial fxn, improved beta cell fxn inflammatory but offset by edema esp in CHF

withdrawn for hepatotoxicity

wt gain, allergy (rare - sulfur), hypoglycemia; effect reduce HbA1c by 1-2%, requires intact beta cells;
potentiated by NSAIDS, sulfas, ASA, antifungals inexpensive

more prone to hypoglycemia


old, not used
old, not used

best for flexible schedules, more expensive than


less risk hypoglycemia sulfonylureas
do not use with gemfibrozil expensive
expensive

flatulence, rare liver enzyme elevation not highly effective (1% reduction of HbA1c)

GLP and GIP, released by intestine after food, stimulate


pancreas; GLP-1 inhibits glucagons secr, stimulates insulin,
causes satiety, decreases gastric emptying --> inactivated by
DDP-4

nausea, wt loss; CI in renal failure low risk hypoglycemia

reduce dose if renal failure no wt loss effects, effects are glucose-dependent

secreted w/ insulin from beta cells; not as abundant as


insulin; promotes satiety, inhib glucagon secretion, slows
gastric emptying; no effect on insulin secretion
endogenous will aggregate in solution -- analogues do not;
reduce dose of insulin by 50% when starting to avoid
nausea, wt loss; hypoglycemia hypoglycemia

wt gain and hypoglycemia are barriers to optimal


control; lipoatrophy with older porcine/bovine absorption variance 10-52% --> daily fluctuations of blood
insulin, lipohypertrophy if same inj site glucose (vol, site, depth, exercise, heat, hydration)

hexamer formation determine kinetics

protamine stabilizes hexamers

high variability

unstable hexamers

unstable hexamers

unstable hexamers

very stable hexamer


70/30 (short/long), require fixed eating schedule (nursing
home pts)
CI for asthma, COPD, smoking, kids, pregnancy

elevations in LFTs, myositis (incr CPK --> baseline and


follow CK), do not use with fibrates ; CI in liver dz;
interactions w/ macrolides, antifungals, protease inhib,
cyclosporine may lower LDL by 40-50%
constipation, flatulence, abd pain, fat-sol vitamin can decr chol by 25-35%; although chol reuptake is inhib,
deficiencies; CI is high TG (>400) overproduction of TG by liver mitigates LDL-lowering effect

skin rash, GI bloating, myalgias, gallstones; potentiates lower total cholesterol by 30-50%, reduces CAD risk, more
warfarin; cholestyramine inhibits absorption, decreases effect if greater initial LDL (>160), no reduction of overall
cyclosporine action; CI renal or hepatic dz mortality;
more effective?
not as effective?

decreased bioavailability if given w/ cholestyramine; decr


back pain, diarrhea, angioedema, incr LFTs when given total chol 12%, LDL 18%, TG 7%; minimal decr fat-sol
w/ statin vitamins, not absorbed systemically

interferes w/ fat-sol vitamins


bloating flatulance, diarrhea, changes in clotting and
glycemic control EPA and DHA; 50% reduction in TG
facial flushing, pruritis, GI irritation, glucose intolerance,
gout; incr LFTs, PUD, asthma, arrhythmias, diabetes,
liver dz; hepatotoxic
Glu
Meta Intra MacC Lact cos
Gram Organism Shape Pattern Enzymes b. cell. onkey ose e H2S

catalase, fac
coagulase, anaer
+ Staphylococcus aureus cocci clusters beta hemolytic obe
fac
catalase, beta anaer
+ Staphylococcus epidermidis cocci clusters hemolytic obe
fac
catalase, beta anaer
+ Staphylococcus saprophyticus cocci clusters hemolytic obe

alpha
+ Streptococcus pneumoniea cocci diplo hemolytic

alpha
+ Viridans streptococci cocci diplo hemolytic

+ Streptococcus pyogenes (GAS) cocci diplo beta hemolytic

+ Streptococcus agalactiae (GBS) cocci diplo beta hemolytic

Enterococcus faecalis, faecium gamma


+ (GDS) cocci diplo hemolytic?
Streptococcus bovis, equinus gamma
+ (GDS) cocci diplo hemolytic?

aerobi
+ Listeria monocytogenes rods c '+ / -

aerobi
+ Bacillus anthracis rods chains c

aerobi
+ Bacillus cereus rods chains c

aerobi
+ Corynebacter diphtheriae rods c

anaer
+ Clostridium tetani rods obic

anaer
+ Clostridium botulinum rods obic
anaer
+ Clostridium perfringens rods obic
anaer
+ Clostridium difficile rods obic

- Neisseria gonorrheae cocci diplo oxidase

- Neisseria meningitides cocci diplo

- Moraxella catarrhalis cocci diplo


- Enterobacter sp. rods + +

- Escherichia coli rods + +

- Klebsiella pneumoneae rods + +

fac
anaer
- Salmonella sp. rods obe '+/- + - + +

- Shigella sp. rods + + - + -

- Proteus sp. rods urease + - +


- Providencia sp. rods + - +
- Serratia sp. rods + - +

- Yersinia sp. rods '+/- + - +

- Yersinia enterocolitica rods '+/- + - +

Yersinia pestis rods '+/- + - +

obligat
e
aerob
- Psuedomonas aeruginosa rods oxidase e + - -
- Acetobacter calcoaceticus rods + - -
- Xanthomonas maltophilia rods + - -
- Burkholderia capecia rods + - -

fac
anaer
- Haemophilus influenzae rods obe -
fac
anaer
- Haemophilus ducreyi rods obe -
fac
anaer
- Gardnerella vaginalis rods obe -

fac
anaer
- Bordatella pertussis rods obe -

fac
anaer
- Legionella pneumophila rods obe '+/- -

fac
anaer
- Brucella sp. rods obe '+/- -
fac
anaer
- Francisella tularensis rods obe '+/- -
fac
anaer
- Pasteurella maltocida rods obe -

microa
erophil
- Campylobacter jejuni rods ic + -

fac
anaer
- Vibrio cholerae rods obe -

- Helicobacter pylori rods -


anaer
- Bacteroides fragilis rods obic -
anaer
- Fusobacterium sp. rods obic -

0 Chlamydia trachomatis +

0 Chlamydia psittaci +

0 Chlamydia pneumoniae +

- Treponema palladium spiral

microa
erophil
- Borrelia burgdorferi spiral ic
- Borrelia recurrentis spiral

aerobi
- Leptospira interrogans spiral c

obligat
e
aerob
0 Mycobacterium tuberculosis rods e '+/-
Mycobacterium avium-
intracellularae (MAI) = avium
0 complex (MAC) rods '+/-

0 Mycobacterium leprae rods '+/-

0 Mycoplasma pneumoniae - pleo


0 Ureaplasma urealyticum - pleo urease

0/- Rickettsia rickettsii +

0/- Rickettsia prowazekii +


0/- Rickettsia typhi +

0/- Rickettsia tsutsugamushi +

0/- Rickettsia akari +

0/- Bartonella quintana '+/-

0/- Bartonella henselae '+/-

0/- Coxiella burnetii '+/-

0/- Ehrlichia canis and chaffeensis '+/-

anaer
obic /
microa
+ Actinomycetes israelii rods branching ero

+ Nocardia asteroides rods


Notes Dx

coagulase pos, protein A (binds Fc prevents opsonization), hemolysins, leukocidins,


penicillinase, novel PBPs, hyaluronidase, staphylokinase, lipase, protease; PVL
gene --> abscess, necrotizing fasciitis; slime layer, DNAse, hyaluronidase,
adhesins, teichoic acid, PDG, superantigen toxins, epidermolytic toxin -->
staphyloccocal scalded skin syndr (SSSS), enterotoxins A-F --> food poisoning,
TSST-1 --> MHC class II superantigen --> Toxic Shock Syndrome Toxin, impetico,
osteomyelitis, septic arthritis, necrotizing pneumonia, acute bacterial endocarditis (IV
drugs, RHvalves), furnicles, carbuncles; one of two bacteria capable of producing GI
Sx <2h after ingestion; can cause abscess w/ pneumonia

skin commensal, infects Foley catheters or central lines or prostheses, coagulase


negative novobiocin-sensitive

UTIs in young women, coagulase negative

90 serotypes, comm acq pneumonia, otits media, pneumococcal meningitis; capsule


polysaccharide is anti-phagocytic, pneumolysin membrane pore forming cytolysin, optochin (Cu disk) sensitive, Quellung
PDG, teichoic acid rxn
S. intermedius, gorgonii, mutans - commensal bacteria of oropharynx, esp S.
mutans causes cavities; subacute bacterial endocarditis; Strep intermedius sepsis
look for lung and brain abscesses optochin resistant

M types, pharyngitis common --> scarlet fever w/ rash (not on face), impetigo,
cellulitis, erysipelas, necrotizing fasciitis, STSS (toxic shock syndr), rheumatic fever
1-4 wks following strep throat (chorea, erythema marginatum, myocarditis, fever),
acute glomerulonephritis (post-inf), virulence factors: Lancefield Group A type C
carbohydrate, M protein (inhibits complement activation), non-immunogenic
hyaluronic capsule, adhesins, C5a peptidase, PDG, SpeA,B,C (erythrogenic
exotoxins via lysogenic conversion), streptolysin O (ASO titer tests for Abs),
pyrogenic exotoxin = erythrogenic toxin (scarlet fever), streptokinase (activates
plamin) rapid GAS test, ASO titer

gut and vaginal flora, vertical txmission to neonate --> infect lungs, brain, sepsis;
virulence factors antiphagocytic capsule, C5a peptidase, hemolysin; screen
pregnant woman 35-37 wks; neonatal meningitis main causes E coli, GBS, Listeria

commensal bowel flora, UTIs, biliary infections, subacute bacterial endocarditis; high
resistance to ampicillin and vancomycin (VRE have D-ala-lactate) bile-esculin agar

commensal GI; S. bovis linked to colon cancer bile-esculin agar

only Gm pos to have endotoxin, motile, attacks nervous tissue, meningitis in


neonates and immunosuppressed (esp cell-mediated), lives in macros and PMNs;
granulomas in neonate and granulomas; spontaneous abortion epidemics

spore former; only bacterium with protein capsule, contact w/ hides, goat hair, skin
infect., lung infect., gastroenteritis; cutaneous 5 d incubation, inhaled 7 d incubation,
use macros to replicate in lymphatic sys; virulence plasmid for polyglutamyl capsule
pX02, plasmid for exotoxin pX01 w/ edema factor (EF) [calmodulin-dep adenylate
cyclase, incr cAMP, inhib PMNs, causes edema], protective antigen (PA), lethal
factor (L) [zinc metalloprotease inactivates MAPKK], round black lesion = malignant
pustule,
spore former; gastroenteritis, motile, no capsule, penG resistant, heat labile toxin
causes n/diarrhea, preformed heat stable toxin causes n/v (short incubation); one of
two bacteria capable of producing GI Sx <2h after ingestion; think of reheated rice
and Chinese food

yellow, thick psuedomembrane in pharynx, A-B exotoxin, B binds to cell, A blocks culture potassium tellurite agar,
protein synth by inactivating EF2 Loefler's coagulated blood serum

spore former; neurotoxin, cleaves synaptobrevin in inhib neurons (GABAergic) -->


tetany; trismus = lockjaw, risus sardonicus
"boxcar shape", spore former, soil, honey, skin popping drug use, canned foods,
bioterrorism, neurotoxin cleaves SNARE, prevents ACh release at NMJ --> flaccid
paralysis, floppy baby syndrome; DO NOT USE AMINOGLYCOSIDES (potentiates
effect) toxin neutralization bioassay
spore former; gas gangrene, cellulitis w/ crepitus, clostridial myonecrosis; alpha toxin
is a lecithinase
spore former; diarrhea --> pseudomembranous colitis --> toxic megacolon; toxin A
(entertoxin - fluid accumulation), toxin B (cytotoxin, inactivates GTPases), delayed stool culture assay for toxinB, EIA for
toxin production has fast growth, then rapid dz A or B

invade urethral epithelial cells, joints, conjunctivitis in neonate, PID; lots of PMNs,
purulent cervical discharge, epididytitis and orchitis, 50% asymptomatic; virulence
no capsule, pili (high antigenic variation), adhesins, LPS, antigenic variation;
fluoroquinolone resistance, tetracycline resistance; ectopic pregnancy, PID, gm stain urethral swab, culture, rapid
abscesses, peritonitis, Fitz-Hugh-Curtis syndr (capsule of liver infection), septic urine test; Thayer-Martin chocolate
arthritis, bacteremia, ophthalmia neonatorum agar, DNA probe

goupy polysaccharide capsule, 9 serotypes, main cause of meningitis (serotypes


A,B,C), LPS, IgA protease, iron extraction, meningococcemia w/ petechial rash,
purpura, fever, shock --> DIC; neonates 6mo-2yr and army recruits; virulence
capsule, pili, high antigenic variation; late complement defects prone to infection,
also TLR4 defect; meningococcemia, fulminant meningococcemia (shock w/ adrenal
insuffic, DIC); Waterhouse-Friderichsen syndrome (coagulopathy, hypotension, Thayer-Martin VCN media =
adrenal cortical necrosis, sepsis) chocolate agar
commensal respiratory flora, causes otitis media, sinusitis, bronchitis, pneumonia;
pen resistant (beta-lactamase expression)
motile

may have iron binding siderphore; diarrhea, UTIs, neonatal meningitis, sepsis,
pneumonia; ETEC - traveller's diarrhea, secretes exotoxin, heat stable (ST) or heat
labile toxin (LT); EHEC - shiga-like cytoxin, hemorrhagic colitis, HUS [0157:H7 -
does not ferment sorbitol]; EIEC - pus and blood in stool, dysentery; EPEC -
typically infants, binds epithelial BFP, uptake of TIR , intimin to surface --> pedestal
formation

encapsulate (O antigen), non-motile, nosocomial sepsis, UTIs, pneumonia (esp


alcoholics) with bloody sputum, esp upper lobe cavitations red currant jelly sputum

motile, not normal flora, typhoid fever (S. typhi) is human only with abd pain and
occassional rash, undulant fever; lives in macrophages / reticuloendothelial system,
undulent fever, highly virulent, Vi factor, 1-2 wk intracellular growth incubation;
zoonotic w/ animal resevoirs, "two bucket" syndr; enteroinvasive mech attach pili to
M cells, injection of effector proteins --> ruffling --> phagosome --> infection via cell-
cell transport; sickle cell pts get Salmonella osteomyelitis blood, urine, stool cultures

non-motile, not normal flora, humans only, Shiga toxin kills intestinal epithelial cells
by inhib 60S ribosome, painful bloody pus diarrhea, highly infectious, HUS possible,
spread cell-to-cell, similar to EIEC, same toxin as EHEC

enteric, motile, OX-19,-2,-K cross react w/ Rickettsia, nosocomial infections UTIs, alkaline urine

bright red pigment production, UTIs, wounds, pneumonia

motile, animal resevoir, fecal oral (Y. enterocolitica) vs flea bite (Y. pestis = bubonic
plague), invasion of epithelium and lymph nodes, enterotoxin similar to E coli ST stool or blood culture

diarrheal epidemics in pediatrics, pseudoappendicitis, mesenteric lymphadenitis;


reactive arthritis after enteropathologic infection w/ HLA-B27 stool or blood culture

animal (squirrel and prarie dog) resevoirs, F1 capsular antigen (antiphagocytic), V


and W antigens; phagocytosed by macros, mutliply inside and RE system, inguinal
nodes, fever, HA, black hemorrhage under skin bipolar staining

common nosocomial enteric, high Abx resistance, green pigment (fluorescein) and
blue pigment (pyocyanin), sweet grape-like scent, exotoxins and capsule possible;
causes pneumonia (esp in CF pts), osteomyelitis, burns, sepsis, UTIs,
pyelonephritis, endocarditis (IV drugs), malignant external otitis, corneal infections
(contact lenses); can infect skin as ecthyma gangrenosum via alpha toxin that
inhibits protein synth by binding EF-2

req hematin (factor X) and NAD (factor V) to grow, common URT infections, otitis
media, bronchitis, sinusitis, epiglottitis (stridor, wheezing, drool), septic arthritis;
polysaccharide capsule w/ six types, type B (HiB) most invasive for non-ciliated
epithelium, can invade CNS if capsule, endotoxin in meningitis; kids no capsule
immunity 6mo-3yo

causes chancroid (STD) w/ painful ulcers (syphilis is painless), painful swollen lymph
nodes
causes bacterial vaginitis, used to be Haemophilus vaginalis, but does not require
factorX or V

whooping cough, highly contagious, toxin paralyzes cilia --> catarrhal phase w/
cough, runny nose, fever for 2 wks; paroxysmal stage - mucus production and
inflammation w/ wheezing, lymphocytosis; convalescent stage 4-8 wks, adult
infection is mild; pertussis toxin is exotoxin w/ enzymatic subunit and 5 binding PCR , culture, charcoal blood agar,
subunits (A-B toxin) --> inhibits phagocytosis and PMN/macro function by extra "mercury-like" colonies; must NOT
cytoplasmic adenylate cyclase but incr lymphocytosis, histamine sensitization, incr use cotton swab, use calcium alginate
insulin synth; filamentous hemagglutinin (FHA) binds to ciliated epithelial cells; swab of posterior nares --> Bordet-
tracheal cytotoxin kills ciliated epithelial cells; infants <1yo at risk, immunity from Gengou medium; ELISA, fluorescent
vaccine wanes after 15yo; toxin causes fluid loss by ribosylating Gi Ab test
walking = atypical pneumonia; Legionairres dz (high fever pneumonia) and Pantiac
fever (flu-like non-pneumonia), hepatic and renal dysfunction, thin watery secretions,
dry cough; txmission by aerosolized water inhalation; resistant to macrophages --> fastidious on buffered charcoal yeast
cytokine release (TNF-alpha) --> influx of monos and PMNs --> microabscesses and extract agar, 5 d for culture, DFA test,
cavities; urinary antigen detection

direct contact w/ infected animal meat (goats, cows, pigs, dogs), facultative
intracellular growth in macros --> systemic (fever, etc), undulant fever, rarely fatal;
Brucella abortus can cause endocarditis of aortic >> mitral valves culture of blood, Ab titer
tularemia; resembles bubonic plague, handling rabbits, ticks, deerflies;
ulceroglandular tularemia - skin ulcer w/ black base, fever; pneumonic tularemia,
oculoglandular tularemia, typhoidal tularemia; highly virulent PPD-like skin test, Ab titers

commensal in cat mouths, cat or dog bites

curved rods, infects humans, birds, other animals, chickens, potato salad, shiga-like
toxin, increased risk of Guillian-Barre syndr, invades epithelial cells, secretes LT
toxin, bloody diarrhea,

comma shaped, single falgellum, motile, enterotoxin, adherance to epithelium by


toxin co-regulatory pili (TCP), humans only, never causes systemic dz, brachish /
salt water; cholera toxin induces secretion (A-B toxin), antacids or high stomach pH
lowers required innoculum; V. vulnificus - possible infection from seafood, wounds
--> septicemia w/ 50% mortality; like ETEC heat-labile toxin, incr cAMP, secretion of
Na and Cl --> watery diarrhea

1st cause of duodenal ulcers, 2nd cause of gastric ulcers (after NSAIDs)
indigenous GI tract, female GU tract; abscesses w/ capsule virulence factor; beta-
lactamase production, NO ENDOTOXIN,

periodontal dz and aspiration pneumonias, abd and pelvic abscesses, otitis media

energy parasite w/ ATP/ADP translocator; no PDG layer or muramic acid;


elementary body uptaken by columnar epithelial cells --> convert to reticulate body
--> endosome = replication; trachomatis infects eyes, genitals, and lungs; trachoma
is leading cause of blindness, inclusion conjuctivitis in neonates, nongonococcal
urethritis (NGU) most common STD, cervicitis --> PID, epididymitis, Reiter's
syndrome (arthritis of large joints, men 20-40yo, uveitis + conjuctivitis), Fitz-Hugh-
Curtis syndrome (liver capsuel inflammation, also caused by gonococcal infection),
lymphogranuloma venereum (painless ulcer on genitals), atypical pneumonia culture, PCR, urine
parrot fever, flu-like, infects lungs, ask about pets / bird exposure, atypical
pneumonia
assoc w/ heart disease, walking pneumonia, atypical pneumonia (dry cough), TWAR
strain from Taiwan

syphilis; flagella under outer membrane, TROMP but no LPS; primary chancre
(painless) --> dissemination --> 2ndary Sx (rash on palms and soles, condyloma
latum, CNS/eyes/bones/kidneys/joints) --> latent asymptomatic --> tertiary:
neurosyphilis (subacute meningitis, meningovascular, tabes dorsalis, general
paresis), cardiovascular (aortic aneurysm), gummatous dz of skin and bone; Argyll-
Robertson pupil - midbrain lesion, constricts w/ accommodation but no light rxn; rule
of 6's for disease progression; congenital sypnhilis (early is <2yo) like 2ndary darkfield microscopy; RPR, TRUST,
syphilis, late is similar to tertiary syphilis w/ bone and teeth destruction (saber shins, VDRL (1st line) --> TP-PA, FTA,
saddle nose, Hutchinson's teeth, mulberry molars) and eye disease MHATP (2nd confirm)

Lyme dz; Ixodes scapularis and I. persulcatus vectors, white-footed mouse and
white-tailed deer resevoirs, require >24h for tick to infect; bind complement factor H
to prevent opsonization; waxing waning dz, erythema migrans, target lesion --> skin,
CNS, heart (AV block, myocarditis), joints --> chronic arthritis (HLA-DR) PCR of joint, serology ELISA, WB
body louse vector, causes relapsing fever; high veber, HA, muscle aches, +/- rash; Wright or Giemsa stained peripheral
antigenic variation smear, darkfield
urine of animals, abrupt fever, HA, malaise, red conjuctiva, photophobia, relapsing,
meningismus, CSF WBCs; Weil's dz = infectious jaundice - renal failure, hepatitis, culture blood during febrile phase,
hemorrhage, mental status changes shephard's crook appearance

rod-shaped bacillus, lipid wax FA coat (not Gm stain --> acid-fast), mycoside
(mycolic acid + carbo) --> cord factor, sulfatides (inhibit phagosome fusion), waxD
(antigen); lives inside macros, cell-mediated (Tcell) immunity important for
granulomas and caseous necrosis; Ghon focus = calcified tubercle, Ghon focus +
perihilar lymph calcification = Ghon complex, cavitary lesions w/ air-fluid levels, 10%
lifetime risk of TB, 10%/year if HIV; pulmonary Tb, pleural and pericardial infection,
lymph node infection = scrofula, kidney infection, skeletal (Pott's dz), joint arthritis, acid fast, Lowenstein-Jensen slant;
subacute meningitis, brain granulomas, miliary Tb; wt loss, low fever PPD (unless BCG), CXR

only seen in AIDS; liver, spleen, BM, GI --> watery diarrhea

M. leprae - Hansen's Dz = leprosy, only grows in mouse footpads and armadillos,


spread by inhalation --> 5 yr incubation, most cases India; tuberculoid leprosy Th1
response (skin lesions, Schwann cells, macros); Lepromatous leprosy Th2
response (bulbous skin lesions) and defective T8 cells) --> leonine facies, lepromin skin test (like PPD,
saddlenose, blindness, loss of sensation; MOTT ==> Runyan classification scheme prognostic)

no cell wall, modified sterol membrane, 40% comm acq pneumonia (esp young teen cold agglutinin test, complement
or adult), atypical pneumonia, exascerbation of asthma (IL-5 release), H2O2 fixation test, sputum culture, DNA
production paralyzes cilia, P1 adhesin probe, strep MG agglutinins
lower UTIs urease test

energy parasite; arthropod vectors; Rocky Mtn spotted fever, Dermicenter ticks
vector (D. viriabilis, D. anderoni, Rhipecephalus sanguinous, SE an W USA, male 5- DFA skin Bx, serology, latex
9 y.o., Sx vasculitis, petechial rash ankles and wrists, infects endothelial cells, agglutination, Weil-Felix rxn w/
replicates in cytoplasm, overlapping antigens with Proteus vulgaris (OX-2,-19,-K) Proteus antigens

epidemic typhus, , lice vectors, wiped out Napoleon's army in Moscow 1812, flying
squirrel resevoir, abrupt onset fever and HA, pink macules on trunk, delirium,
gangrene of feet or hands, Brill-Zinsser dz = relapse, usually milder
endemic / murine typhus; flea vector, fever HA, maculopapular rash
scrub typhus / tsutsugamushi fever, asia and SW pacific, mite larvae vector
(chiggers), high fever, HA, maculopapular rash

rickettsialpox, txmitted by mites from house mice, fever, red papule to vesicle
trench fever; louse vector from WWI, high fever, rash, HA, back and leg pain,
relapses
cat scratch fever, regional lymphadenopathy, low fever, also causes bacillary
angiomatosis
Q fever, endospore former, tick and cattle resevoirs, inhaled spores cause
pneumonia, fever, sweats (NO rash)

ehrlichiosis, tick vectors, similar to RMSF, high fever and HA, rare rash

sulfur granules, beaded branching


commensal GI and oral; eroding abscesses, can infect IUDs mycelia
similar to TB, NOT commensal; inhaled to lungs --> erosion, abscesses in lungs,
brain, other; immunocompromised pts especially acid fast, beaded branching mycelia
Tx

oxacillin / methacillin resistant, MDR, vanco resist?

penicillin, fluoroquinolones, cephalosporins;


polyvalent capsular vaccines: 7 serotype for kids
<5yo (covalent bound to diphtheria toxoid) and 23
strain polyvalent for >65yo [Pneumovax]

difficult; prophylaxis for dental & other surgery

penicillin, macrolides, clindamycin

penicillin, vancomycin

vancomycin, rifampin, ciprofloxacin,


chloramphenicol, doxycycline, pristinomycins

ampicillin, TMP/SMZ

penicillin + doxy, cipro, levofloxacin

Abx will not help b/c preformed enterotoxin

anti-toxin, pen or erythromycin DPT vaccine

toxoid vaccine w/ 10 yr booster, tx w/


anticonvulsant, antitoxin, penG, metronidazole

antitoxin; NOT aminoglycosides


metronidazole + vancomycin, stool transplant

ceftriaxone, ciprofloxacin, w/ tetracycline for


Chlamydia; erythromycin eye drops

vaccine (not effective strain B), CNS penetrant Abx


(penicillin, ceftriaxone)

oral (live attenuated) vs injected (killed) vaccines w/


limited protection; cipro or ceftriaxone

some attenuated vaccines

tx if sepsis

tx if sepsis

aminoglycoside (gentamycin) + doxycycline

penicillin + aminoglycoside

antibody to type B capsule conjugated vaccine w/


PRP; combined w/ DPT-HiB; give steroids 15min
prior to Abx in meningitis pts; ampicillin or
amoxicillin, cefotaxime or ceftriaxone (3rd gen
cephalos)

erythromycin or TMP/SMZ
metronidazole

acellular / subunit vaccine, combined w/ DPT-HiB;


tx w/ macrolides, azithromycin, clarithromycin

erythromycin (b/c penetrant to monos); resistant to


beta-lactams

aminoglycoside (gentamycin) + doxycycline

aminoglycoside (gentamycin) + doxycycline

penicillin or doxycycline

fluids, doxycyline
bismuth salts, metronidazole, ampicillin,
tetracycline
metronidazole, some cephalosporins, beta lactam
w/ beta lactamase inhibitor

intracell --> doxycycline, azithromycin /


erythromycin
intracell --> doxycycline, azithromycin /
erythromycin
intracell --> doxycycline, azithromycin /
erythromycin

penicillin, screen HIV; erythromycin + doxycycline if


allergic (toxic to fetus)

doxycycline + penicillin
doxy + erythromycin

penicillin or doxycycline

dapsone, rifampin, clofazimine

tetracycline, erythromycin / macrolides, anti-


ribosomal Abx

doxycycline

tetracycline, chloramphenicol
tetracycline, chloramphenicol

doxycycline

doxycycline

doxycycline

doxycycline

doxycycline

doxycycline

penG, surgical drainage


TMP/SMX ; tx is a SNAP -- Sulfa for Nocardia,
Actinomyces give Penicillin
COLOR KEY:
ENTERIC
RESPIRATORY
STDs
SYSTEMIC

Geno Caps Env Transmissio


DNA me id . Rep. Enzy. Virus n Clinical

own viral skin lesions and death; lesions do not blanch when
DNA/RNA pressed; macules --> papules --> vesicles -->
Pox ds c Y D* dep DNA pol smallpox respiratory pustules --> crusts

molluscum small white bumps w/ central dimple similar to


contagiosum warts, often in AIDS pts (immunocompromised)
gingivostomatitis, herpetic keratitis,
encephalitis - most common cause of viral
Herpes ds i Y D HSV-1 encephalitis in USA,
genital dz w/ vesicles painful burning and itching,
HSV-2 neonatal herpes possible

chickenpox (fever malaise, HA, rash - starts on


face and trunk, lesions at different stages) and
shingles, reinfection is usually dermatomal and
unilateral, can cause pneumonia and encephalitis
VZV respiratory in adults
asymptomatic, congenital (TORCHHES),
mononucleosis-like, reactivation (retinitis [in HIV],
blindness, pneumonia, disseminated, gastritis,
hepatitis), 1-6mo post-transplant
CMV immunosuppressed

mononucleosis (fever, pharyngitis, sweats, HA,


EBV splenomegaly) and Burkitt's lymphoma
kids <2y.o.; exanthema subitum = roseola, high
fever, rash 3-5 d, chance of encephalitis,
HHV-6,-7 neutropenia
HHV-8 Kaposi's sarcoma
Adeno ds i N D adenovirus respiratory URT infection

cutaneous wates , epidermodysplasia


verruciformis, cervical cancer, mucosal warts; head
Papilloma ds i N D HPV neck squamous cell carcinoma (HNSCC)
Polyoma ds i N D BK

progressive multifocal leukoencephalopathy (PML)


JC in immunocompromised, infects oligodendrocytes

erythema infectiosum (5th disease) = slapped


cheeks rash; rash on face and trunk, low fever,
1-5 y.o. kids, life threatening if hemolytic dz -->
fatal hydrops fetalis if pregnant, arthritis in
Parvo ss i N D parvovirus B19 adults, aplastic anemia if immunocompromised

highly
infectious, acute, fulminant, and chronic hepatits,
blood-blood and asymptomatic carrier, hepatocellular carcinoma,
Hepadna pds i Y RT ? hepatitis B sexual cirrhosis

Geno Caps Env Transmissio


RNA me id . Rep. Enzy. Virus n Clinical
RT, Rous sarcoma
Retro ss+ i/h Y RT integrase virus
human T-cell
leukemia virus
(HTLV-I)

mono-like illness 1 mo after infection, latency


(~8 yrs); opportunistic infections: CD4 <400
TB, bacterial infections, VZV, Candidiasis,
fungal infections, EBV and oral hairy
leukoplakia --> CD4 <100 PCP, cryptococcal
meningitis, toxoplasmosis, HSV,
cryptosporidium and isospora diarrhea,
coccidioidomycosis, --> CD4<50 CMV retinitis,
esophagitis, disseminated, MAI disseminated;
neurological damage (encephalopathy,
protease, myelopathy, neuropathy, dementia), malignancy
RT, (B cell lymphoma [w/ EBV], Kaposi's sarcoma
integrase HIV-1 sex, blood [w/ HHV-8])

Picorna ss+ i N R hepatitis A fecal-oral flu-like, jaundice… often asymptomatic

mild viral illness (in infants), aseptic meningitis,


paralytic poliomyelitis; central and peripheral motor
fecal-oral and neuron defects, asymmetric muscel paralysis,
polio respiratory atrophy
asymptomatic or mild febrile, respiratory sx, rashes,
echovirus fecal-oral aseptic meningitis

as for echo, + herpangina - fever, sore throat, small


coxsackie A fecal-oral red-based vesicles on back of throat
as for echo, + pleurodynia (fever, HA, pleuritic pain)
coxsackie B fecal-oral + myocarditis / pericarditis
contact
rhinovirus secretions common cold
self-limited epidemics of acute hepatitis, but risk of
fulminant hepatitis; 20% fatality in pregnant
Calici ss+ i N R hepatitis E fecal-oral women;
Norwalk virus fecal-oral affects adults, diarrhea and vomiting
Astro ss+ i N R
fever and rash, prodrome of flu, red maculopapular
rash from forehead --> face --> torso -->
rubivirus extremities; rash lasts 3 days, less severe than
Toga ss+ i Y R (rubella) respiratory measles, arthritis possible

alpha viruses mosquito encephalitis

parenteral (IV chronic hepatitis and cirrhosis, hepatocellular


Flavi ss+ i Y R hepatitis C needles > sex) carcinoma
hepatitis G
yellow fever hepatitis w/ jaundice, fever, backache, nausea,
virus mosquito vomiting
painful fever w/ backache, HA, muscle pain; also
Dengue fever Dengue hemorrhagic fever w/ 10% mortality and
virus mosquito shock

West Nile virus mosquito mild flu-like illness, encephalitis, death


2-10 d incubation, HA, malaise, fever, dry cough,
Corona ss+ h Y R SARS respiratory dyspnea, hypoxia

fatal encephalitis, variable incubation, prodrome


(fever, HA, sore throat, n, fatigue), brainstem
RNA-dep. encephalitis CN dysfunction, hydrophobia,
Rhabdo ss- h Y R RNA pol rabies animal bite "foaming at the mouth", respiratory muscle failure
RNA-dep. URT adsorbtion and replication, pneumonia in kids;
Paramyxo ss- h Y R* RNA pol parainfluenza respiratory croup with stridor in kids
highly
contagious,
respiratory respiratory
syncytial virus droplet URT adsorbtion and replication, pneumonia in kids
URT infection with viremia, parotitis and orchitis,
mumps respiratory encephalitis

highly
contagious,
measles / respiratory
rubeola droplet URT infection with viremia, encephalitis, fever, rash

RNA-dep.
Orthomyxo ss- * h Y R RNA pol influenza (flu) aerosolized viral pneumonia, URT

hantavirus pulmonary syndrome (fever, cough, n/v,


RNA-dep. muscle ache, pulmonary edema); hemorrhagic
Bunya ss- h Y R RNA pol hantavirus fever w/ renal failure (Asia and Europe)
RNA-dep.
Arena ss- h Y R RNA pol
RNA-dep. fever, diarrhea, wkness, dysphagia, hiccups, mucus
Filo ss- h Y R RNA pol ebola virus body fluids membrane bleeding,
RNA-dep.
Delta ss- ? Y R RNA pol hepatitis D parenteral fulminant hepatitis
Reo ds* i N R rotavirus acute infectious diarrhea

Adsorption Childhood Diseases


Uncoating 1st Dz
Replication 2nd Dz
Assembly 3rd Dz
Release 4th Dz
5th Dz HHV-6,-7 = roseola
6th Dz parvovirus B19 = slapped cheeks
Dx Tx

dumbbell forms, darkfield


microscopy, cytoplasmic vaccine of vaccinia virus
inclusions (avirulent pox virus)

trophism for temporal and


frontal lobes

zoster Ig injection, only helps if


given w/in days of exposure
(before rash), IV acyclovir decr
Tzank smear from vesicles severity and duration; viravax
(syncytia and inclusion bodies) (live attenuated) vaccine

RT-PCR, buffy coat culture ganciclovir, foscarnet

atypical lymphocytes,
heterophile Ab, Monospot test acyclovir

ganciclovir, foscarnet (in CNS


cases only)

HPV vaccine of L1 particle,


Pap smear cryotherapy or surgery for warts

eosinophilic inclusions

blood xfusion if aplastic crisis

HBsAg = dz; anti-HBsAg =


immune or prior dz; IgM anti-
HBcAg = new infection; IgG
anti-HBcAg = old infection;
HBeAg = highly infectious, recombinant vaccine using
current dz; anti-HBeAg = low HBsAg; lamivudine (3TC), IFN-
infectivity alpha, adefovir

Dx Tx
ELISA and WB, viral load PCR, HAART

anti-HAV IgM = active dz; anti-


HAV IgG = prior infection pooled Ig vaccine; self-limiting

injected inactivated polio


vaccine (Salk) --> IgG immunity
only, oral polio vaccine (Sabin)
is attenuated poliovirus [causes
normal fecal viral shedding, but
no CNS complications] --> IgG
trophism for anterior horn cells and IgA immunity

supportive

live attenuated vaccine (MMR)

ELISA, RT-PCR INF-alpha, ribavirin

PCR, ELISA

EIA and IFA, RT-PCR, culture isolation, ventilation

Negri bodies in cytoplasm,


"bullet shaped virus" rabies Ig injections

ribavirin, palivizumab
prophylaxis (monoclonal b),
serum RSV Ig
live attenuated vaccine part of
trivalent MMR

live attenuated vaccine part of


trivalent MMR, vitA reduces
IgM, RT-PCR severity of infection

chick embryo vaccines,


amantadine, rimantidine
(prevent uncoating - M2 inhib)
in type A only; sanamavir and
virus culture, rapid protein tests, oseltamivir (NA inhibitors)
PCR, Ab test shorten course in types A + B

ribavirin

oral rehydration

DNA viruses

RNA ss+
RNA ss-
Envelope DNA
Naked RNA
maternal--fetal danger
Notes

biggest DNA virus, only DNA to replicate in cytoplasm; USA eradication in 1971, WHO
eradication in 1977; infects macrophages, replication in spleen and BM; variola major 10-
30% mortality;

often seen as GU bumps, sexually transmitted


latency possible, reactivation in 25%, cytopathic effect in alpha sub-family (VZV, HSV-1,-2) -->
ultinucleated giant syncytial cells w/ intranuclear inclusion bodies; herpetic keratitis common
cause of corneal blindness
death carries TORCHHES to a pregnant mother: TOxoplasmosis, Rubella, Cytomegalovirus,
HIV, HErpes, Syphilis

infects respiratory tract, 2 wk incubation; resides in dorsal root ganglion

swollen cells, multinucleated giant cells; AIDS pts CD4 <50 get viremia, retinitis, and colitis;
post-transplant immunosuppressed get pneumonitis, viremia, colitis (NOT retinitis)

infects squamous epithelial cells and B cells, binds C3d complement receptor --> internalized
--> transformation; replicated as external episome when latent, linear as lytic; type I = benign;
types II and III - more tumorigenic w/ LMP-1 (nasopharyngeal carcinoma [NPC], induced TNF
transcription inhibits p53), up to 9 latency proteins; post-transplant lymphoproliferative dz
(PTLD) in type III; AIDS related Burkitt's lymphoma and oral hairy leukoplakia; assoc
Hodgkin's dz and X-linked lymphoproliferative syndrome

"sixth dz" or "roseola"

infect squamous epithelial cells, risk of cervical cancer esp w/ types 16,18; most common
STD virus; early genes = non-structural regulatory genes, control host cell growth --> E6
binds p53, E7 binds Rb to promote S phase; replicates as episome in papillomas, integrated
in dysplasia and cancer

demyelination of large oligodendrocytes w/ eosinophilic inclusions, white matter lesions, think


about HIV

only infects bone marrow, fetal liver, fetal heart; life-long immunity

coinfection w/ HIV common; liver injury due to cell-mediated immune response; smallest DNA
virus; intact virus = Dane particle; anti-HBsAg = immunity (Australia antigen); HBeAg is a
marker of active dz; virus packages w/ ssRNA+ and RT --> makes DNA(-) and partial(+);
window period means no HBs Ag or HBs Ab in serum; possesses RNA-dep-DNA poly, can
RT; most pts have subclinical dz followed by spontaneous resolution

Notes
replicates in nucleus; has src oncogene in genome --> transformation;

tropical spastic paraparesis

destruction of CD4+ T-helper lymphocytes, multinucleated giant cells b/c fusion @ gp160; 2
ss RNA dimer w/ 2 LTRs that have sticky ends, gag - codes proteins in envelope
(nucleocapsid, capsid [p24], and matrix), pol - codes protease, integrase, and RT, env - codes
for envelope proteins gp120 + gp41 = gp160 that binds to CD4 receptor; protease is required
to activate viral proteins after translation; other genes are tat, rev, nef, vif, vpr, vpu; fusin on
Tcells and CCR5 on macros are required cofactors for viral binding; B-cell dysfunction and
hypergammaglobulinemia, monocytes and macrophages serve as resevoirs of HIV; CDC
categorizes pts on sx and CD4 ct: "A" is asymptomatic -- "B" is minor sx -- >500 is "1" -- 200-
500 is "2" -- and <200 is "3"

may cause acute hepatitis; 1 mo incubation, mostly young children, often w/o jaundice;
secreted in bile; humans are only resevoir

tropism for Peyer's patches and motor neurons, destruction of presynaptic motor neurons in
anterior horn of spinal cord and postsynaptic neurons leaving cord

>100 serotypes

may cause acute hepatitis (flu-like, w/ jaundice, elevated AST, ALT, GGT, ALP)

may cross placenta to cause birth defects, esp. 1st trimester: heart (patent ductus, IV
septum, PA stenosis, etc), eye (cataracts, chorioretinitis, etc), CNS (retardation,
microcephaly, deafness)
arboviruses = toga + flavi + bunya; Western equine encephalitis, Eastern equine
encephalitis, Venezuelan equine encephalitis

no 5’ cap à IRES in 5’ UTR, quasispecies, 40% develop PHC and cirrhosis

Panama canal

Puerto Rico, Virgin Islands

replicates in endothelial cells cytoplasm, vector is Culex pipiens,

slow migration from wound site to nerve axons --> CNS; glycoprotein attaches to AChRs, 3-8
wk incubation; infects hippocampus and cerebellum
replicate in nucleus; fusion (F) protein causes formation of multinucleated giant cells; NA and
HA together as one glycoprotein

multinucleated giant cells = syncytial cells; lacks NA and HA glycoproteins; main cause of
pneumonia in infants <6 mo; winter and spring outbreaks
replicates in mucus membranes and conjuctival membranes, 2 wk incubation before rash; 3-4
d prodrome (conjuctivitis, photophobia, high fever, hacking cough, rhinitis, malaise) --> 1-2 d
before rash Koplik's spots w/ red-based lesions and blue-white centers in mouth --> 6 d
maculopapular rash from forehead to face to neck to torso to feet; viremia may damage eyes,
myocarditis, encephalitis; fetal death 20% if pregnant; subacute sclerosing panencephalitis
(SSPE) - slow form of encephalitis 6 years after infection; post-infectious encephalomyelitis

spherical, 8 RNA segments, hemagglutinin and neuraminidase anchored by M-proteins; M2


needed for acidification of endosome and exit to cytoplasm; HA binds to sialic acid receptors
(on RBCs and URT) --> activate fusion; NA cleaves neuraminic acid and disrupts mucin,
exposes sialic acid binding sites; Type A infects humans, mammals, birds; types B and C only
humans; antigenic drift causes partial immunity, antigenic shift causes pandemics when
recombines (in birds / swine); pandemics from H1N1 (Spanish Flu - 1918), H2N2 (Asian flu -
1957), H3N2 (Hong Kong flu - 1968), H5N1 (Bird flu - 1997); Reyes' syndrome if aspirin in
kids (fatty liver, encephalopathy, cerebral edema)

deer mouse resevoir

requires HBV coinfection (needs HBV envelope and HBsAg, no viral polymerase)
segmented genome; can undergo genetic shift (like influenza)

Mneumonics:
Polly Had A Pretty Pink [Purse] (Hot!)

HHAPPPy
Rumsfeld, Please Credit A Teacher For Caring
Real Parties Only Begin After Finding Drugs (in) Reo
HHPox (envelopes) vs PAP (naked)
aPCR (astro, picorna, calici, reo)
TORCHHES (toxo, rubella, CMV, herpes,…)
URT infections in kids: 1) RSV, 2) parainfluenza, 3) rhinovirus, 4) adenovirus
Phylum Species Common Life Cycle Endemic Region
Name
Protozoa (flagellates) Entamoeba amoeba ingest cysts --> trophozoites form in sm. Int. -->
histolitica ulcerate intestines --> portal vein to liver -->
abscesses and hepatitis

Giardia lamblia cysts and trophozoites mountain streams are


typical

Cryptosporidium ingested as round oocyst w/ 4 motile sporozoites -->


intracellular in intestinal epithelial cells

Isospora and
Microsporidia

Trichomonas sexual transmission


vaginalis

Naegleria fowleri swimming pools and


freshwater lakes

Acanthamoeba swimming pools and


freshwater lakes

Toxoplasmosis sexual division in cat, excreted in feces as oocyst


gondii containing sporozoites (infectious) --> ingestion by
human, intracellular parasite (tachyzoites) -->
immune response stops tachyzoites, but bradyzoites
persist (non-infectious) --> reactivation later when
immunocompromised from bradyzoites (muscle
cytsts)

Plasmodium malaria gametocytes sexual division in Anopheles mosquito tropical - Anopheles


falciparum --> to human as sporozoite --> invades hepatocyte mosquito
(exoerythrocytic cycle) --> trophozoite does asexual
nuclear division --> schizont (cell w/ thousands of
nuclei) --> merozoites (cytoplasm around each
nucleus) rupture hepatocyte --> infects and
reproduces in RBC (trophozoite to schizont to
merozoite)--> RBC burst releasing merozoite and
gametocytes (irregularly) --> gametocytes uptaken by
mosquito or die; exoerythrocytic and erythrocytic
phases

Plasmodium vivax malaria same as falciparum except timing of RBC rupture tropical - Anopheles
(every 48 hr); may have multiple exoerythrocytic mosquito
cycles in liver as dormant hypnozoites

Plasmodium malaria same as falciparum except timing of RBC rupture tropical - Anopheles
malariae (every 72 hr); may have multiple exoerythrocytic mosquito
cycles in liver (hypnozites)
Plasmodium ovale malaria same as falciparum except timing of RBC rupture tropical - Anopheles
(every 48 hr); may have multiple exoerythrocytic mosquito
cycles in liver as dormant hypnozoites

Babesia microti, babesiosis tick bite --> sporozoite invades RBC --> ring-shaped Ixodes scapularis in NE
divergeris trophozoite --> 4 merozoites "Maltese cross" USA, white-footed mouse
resevoir
Trypanosoma African sleeping cattle and wild animal resevoirs; tsetse fly vector --> Western Africa
brucei gambinese sickness trypomastigote (mobile) to lymph and CNS

Trypanosoma African sleeping cattle and wild animal resevoirs; tsetse fly vector Eastern Africa
brucei sickness
rhodesiense
Trypanosoma Chagas rodents, possums, armadillos --> reduviid bug --> South and Central
cruzi defecates after biting --> trypomastigotes invade skin America
--> lose flagellum to form amastigote -->
multiplication --> invade macro, lymph, skin, distant
organs

Leishmania Leishmaniasis sandfly bites rodent / dog / fox --> promastigote Middle East, Africa, S.
donovani invates macros --> (non-motile) amastigote multiplies and Central America
in RE system

Balantidium Coli pig feces ingestion --> cysts mature to ciliated


trophozoites --> to GI tract, eat commensal GI flora

Platyhelminthes Schistosoma Trematode eggs hatch in feshwater --> larvae swim to snail --> tropical, E Asia
(flatworms) japonicum (fluke) mature larvae released --> infect human through skin
--> inrahepatic mature and mate --> migrate to veins
around intestine and lay eggs --> eggs excreted in
feces

Schistosoma Trematode eggs hatch in feshwater --> larvae swim to snail --> tropical S America, Africa,
mansoni (fluke) mature larvae released --> infect human through skin Puerto Rico
--> inrahepatic mature and mate --> migrate to veins
around intestine and lay eggs --> eggs excreted in
feces

Schistosoma Trematode eggs hatch in feshwater --> larvae swim to snail --> tropical Africa
haematobium (fluke) mature larvae released --> infect human through skin
--> inrahepatic mature and mate --> migrate to veins
around bladder and lay eggs --> eggs excreted in
urine

Clonorchis liver fluke


senensis
Opisthorchis oriental liver
sinensis fluke
Fasciola buski liver fluke
Fasciolopsis buski intestinal fluke

Paragonimus lung fluke


westermani
Taenia saginata Beef tapeworm ingestion of beef w/ larvae (cysticerci) --> tapeworm
(cestode) attaches to intestinal mucosa --> grows up to 10
meters --> eggs released in feces --> eaten by cows
--> larvae spread throughout cow --> cysticercus
(fluid + larvae in muscle)

Taenia solium Pork tapeworm ingestion of pork w/ larvae (cysticerci) --> tapeworm Central and South
(cestode) attaches to intestinal mucosa --> grows 2-8 meters America, SE Asia,
--> eggs released in feces --> eaten by pigs --> Philippines
larvae spread throughout pig --> cysticercus (fluid +
larvae in muscle)
Diphyllobothrium Fish tapeworm larvae ingested in raw freshwater fish --> adult
latum (cestode) matures in human intestine --> eggs in water -->
mature to larvae --> ingested by crustacean -->
ingested by fish
Hymenolepis Dwarf tapeworm humans ingest eggs --> mature to adult --> pass southern USA
nana (cestode) eggs

Echinococcus Hydatid disease humans ingest eggs --> hatch in intestine, mature to areas where dogs used to
granulosus and larvae --> disseminate, mostly to liver, lungs, kidney, herd livestock
multilocularis brain --> fluid filled cysts = hydatid --> budding to
form protoscolices and daughter cysts

Nematoda Ascaris roundworm eggs ingested --> mature to larvae in sm intestine --> tropics, mountains of S
(roundworms) lumbricoids penetrate to bloodstream to lungs --> coughed up USA
and swallowed --> mature to adult in sm intestine,
produce 200,000 eggs / day
Enterobius pinworm eggs ingested --> mature in cecum and ascending
vermicularis colon --> female migrates to perianal area at night to
lay eggs (infectious 4-6 hr later) --> autoinfection by
fecal-oral
eggs ingested --> hatch in GI and migrate to cecum,
ascending colon --> mature adult produces eggs for
1 year, eggs must incubate in moist soil before
Trichuris trichuria whipworm infective
Trichinella spiralis ingestion of larval cyst in pork muscle --> sm
intestine, mature to adults --> adult males passed in
feces, females enetrate intestinal mucosa, produce
larvae --> larvae spread to organs and muscle and
encyst
Necator hookworm filiaform larvae penetrates skin of bare foot --> lungs
americanus --> coughed and swallowed --> mature to adult in sm
intestine, attach by mouth and suck blood, release
eggs
Ancylostoma hookworm filiaform larvae penetrates skin of bare foot --> lungs
duodenale --> coughed and swallowed --> mature to adult in sm
intestine, attach by mouth and suck blood, release
eggs
Ancylostoma cutaneous larval
braziliense migrans dog and cat hookworm larvae penetrate skin SE USA
larvae penetrates skin of foot --> lung --> coughed
and swallowed --> sm intestine, mature to adult and
lay eggs --> eggs mature to larvae and may: 1)
autoinfect, 2) pass in feces --> once in feces may
infect human as larvae or mature and mate
Strongyloides
stercoralis
Wuchereria elephantiasis mosquito bite --> microfilariae mature to adults in Pacific islands, Africa
bancrofti lymph of genitals and legs --> adults mate and
microfilariae infect blood
Brugia malayi elephantiasis mosquito bite --> microfilariae mature to adults in Malay Peninsula, SE Asia
lymph of genitals and legs --> adults mate and
microfilariae infect blood
Lao lao / African eye black fly bite --> larvae mature into adults in skin Africa, C. and S. America;
Onchocerca worm, filariasis nodule --> micro-filariae migrate through dermis and black flies need water to
volvulus connective tissue, may migrate to eye mate

frshwater copepods (tiny crustaceans) ingested


containing larvae --> penetrates intestine, deep
subcutaneous --> adults develop and mate --> male
dies, female grows 100 cm --> migrates to skin, loop
Dracunculus penetrates, uterus exposed to water releases motile
medinensis Guinea worm larvae Africa, Asia
Dz / Sx Dx Tx

may be asymptomatic in E. dispar (can pass cysts in stool exam for cysts / trophozoites (w/ RBC in iodoquinol if local to intestines;
stool); GI -- bloody diarrhea, portal infection and liver cytoplasm), 1-4 nuclei; CT or US of liver for metronidazole
abscesses --> spread to lung and pulmonary abscesses; chromotoid bodies (aggregates of
abscesses ribosomes) in precyst; "flask shaped ulcer"

coats small bowel wall, steatorrhea, foul odor, greasy "falling leaves" on Bx; stool exam shows metronidazole
diarrhea, gas, cramps, NO blood oval or elliptical thick-walled cysts;

wateray diarrhea and abd pain, if immunosupressed nitazoxanide


--> severe diarrhea

severe diarrhea in immunocompromised large almond-shaped cysts in stool TMP/SMX for Iso, albendazole for
Microsporidia

GU infection - itching, dysuria, vaginal secretions motile parasite on wetmount; may show in metronidazole
(thin, watery, frothy, malodorous discharge), urinalysis
asymptomatic in males;
meningoencephalitis - fever, HA, stiff neck, n/v CSF exam - high PMNs and protein, low intrathecal amphotercin B
glucose (just like bacterial, but Gm stain
shows no bacteria), motile amoeba on
microscopic exam but NO cysts

chronic granulomatous meningoencephalitis in CSF exam shows cysts and trophozoites, antifungals with pentamidine;
immunocompromised; HA, fever, seizures, focal corneal scraping antimicrobial eye drops
neuro; may infect cornea (even
immunocompetent) esp if contact lenses

fever, nodes, hepato/splenomegaly, meningitis, CT scan shows contrast-enhancing mass, pregnant women need to avoid
encephalitis (esp in AIDS --> HA, focal neuro, retina retinal inflammation, elevated Ig titers cats; sulfa + pyrimethamine
infection, chorioretinitis --> visual loss), yellow-white
fluggy cotton patches on retina

severe fevers and chills w/ sweating; anemia; thin and thick smears, trophozoites and chloroquine; mefloquine or
trophozoites make RBCs sticky --> plugged schizontes w/in erythrocytes doxycycline prophylaxis if
capillaries in kidney (renal failure), lungs (pulmonary resistant area
edema), brain (coma)

less severe fever and chills thin and thick smears, trophozoites and chloroquine and primaquine
schizontes w/in erythrocytes

less severe fever and chills thin and thick smears, trophozoites and chloroquine
schizontes w/in erythrocytes

less severe fever and chills thin and thick smears, trophozoites and chloroquine and primaquine
schizontes w/in erythrocytes

fever and hemolysis, usually asymptomatic; worse if thick and thin blood smears, "Maltese cross" quinine and clindamycin
asplenic pt

damage lymph, blood, CNS; painful skin ulcer, blood smear - trypomastigotes, suramin, pentamidine,
fever/HA/dizz/nodes, intermittent fevers, drowsiness Winterbottom's sign melarsoprol, elfornithine
in day, difficulty walking, slurred speech, coma;
slowly progressive fevers, wasting, late neuro sx

same as above, but more severe, death w/in weeks blood smear - trypomastigotes, suramin, pentamidine,
to months Winterbottom's sign melarsoprol, elfornithine
acute dz - chagoma at entry site, fever, swollen blood smear - trypomastigotes; nifurtimox benznidaole for acute
nodes, CNS and heart infection (tachycardia, xenodiagnosis - allow reduviid bugs to feed
meningoencephalitis) --> intermediate phase on pt, then see if reduviids contain T. cruzi
(asymptomatic, but pt has Ab in blood) --> chronic dz
- heart arrhythmias, block, v-tachy, dilated
cardiomyopathy; megadisease of colon and
esophagus (regurgitation, odynophagia, dysphagia,
constipation, abd pain)

Simple cutaneous lesions, Diffuse cutaneous lesions skin PPD-like test if cell-mediated immunity stibogluconate, amphotercin B
(nodules -- cell-mediated immunity defect), intact, visualization of protozoans if not
Mucocutaneous leishmaniasis, Visceral
leishmaniasis w/ abdominal pain and distention and
splenomegaly (severity depends on host cell-
mediated immunity)

asymptomatic or diarrhea largest protozoan human GI infection; tetracycline


ciliated trophozoites or cysts in stool

dermatitis, Katayama fever (hives, HA, wt loss, eggs in feces, eosinophilia praziquantel
cough, fever) as adults lay eggs, chronic fibrosis of
intestine, hepatosplenomegaly; eggs in circulation
(lung, liver, brain) causes granulomas, increased
portal hypertension --> hematuria, chronic abd pain
and diarrhea, pulmonary arterial HTN

dermatitis, Katayama fever (hives, HA, wt loss, eggs in feces, eosinophilia praziquantel
cough, fever) as adults lay eggs, chronic fibrosis of
intestine, hepatosplenomegaly; eggs in circulation
(lung, liver, brain) causes granulomas, increased
portal hypertension --> hematuria, chronic abd pain
and diarrhea, pulmonary arterial HTN

dermatitis, Katayama fever (hives, HA, wt loss, eggs in urine, eosinophilia praziquantel
cough, fever) as adults lay eggs, chronic fibrosis of
intestine, hepatosplenomegaly; eggs in circulation
(lung, liver, brain) causes granulomas, increased
portal hypertension --> hematuria, chronic abd pain
and diarrhea, pulmonary arterial HTN

bile obstruction with secondary bacterial cholangitis

bile obstruction and bile stones

abd pain, diarrhea, intestinal mucosal abscesses

cough, bronchiectasis, hemoptysis

NO cysticercosis, benigh, malnutrition, wt loss proglottids and eggs in feces praziquantel or niclosamide

cysticercosis (after ingestion of eggs) --> cysts in proglottids +/- eggs in feces, cysticercosis w/ praziquantel
brain and skeletal muscle, seizures, CT scan or Bx, serologic tests, eosinophilia
hydrocephalus, focal deficits

vitB12 deficiency, megaloblastic anemia eggs in feces praziquantel or niclosamide

abd pain, n/v eggs in feces praziquantel or niclosamide

unilocular cystic lesions in liver, if cyst bursts, may be CT scan and tissue Bx albendazole, surgical
fatal (allergic rxn), compression of organ (lungs, liver,
brain, kidney) gives Sx

mild or asymp, abd cramping, invasion of bile ducts, high eosinophil ct, eggs in feces, larvae in mebendazole, albendazole,
gall bladder, appendix, liver; malnutrition, cough, sputum thiabendazole, pyrantel pamoate
pulmonary infiltrate; LARGE worms
severe perianal itching scotch tape test, NO eosinophilia mebendazole, albendazole,
thiabendazole, pyrantel pamoate

mebendazole, albendazole,
thiabendazole

abd pain, diarrhea eggs in feces, NO eosinophilia


asymp, abd pain, diarrhea, fever; 1 wk later upon serologic tests, muscle biopsy, eosinophilia, mebendazole, albendazole,
larval migration have fever and muscle aches (fatal if high CPK thiabendazole
heart and brain invaded)

diarrhea, abd pain, wt loss, Fe deficiency anemia, eosinophilia, eggs in feces mebendazole, albendazole,
itching and rash on feet, cough, pulmonary infiltrate thiabendazole, pyrantel pamoate

diarrhea, abd pain, wt loss, Fe deficiency anemia, eosinophilia, eggs in feces mebendazole, albendazole,
itching and rash on feet, cough, pulmonary infiltrate thiabendazole

pruritic migratory skin infection Bx of advancing edge of rash


mebendazole, albendazole,
thiabendazole

eosinophilia, larvae in feces, enterotest


vomiting, abd bloating, diarrhea, anemia, wt loss, (swallow string and pull out), larvae on
pruritic rash, cough, pneumonia, ARDS, MOS sputum
lymphatic infection and chronic leg swelling, fever, positive Ab titers by IFA diethylcarbamazine, surgical
HA, swollen inguinal nodes, thick and scaly skin; correction of blocked lymph
nocturnal periodocity
lymphatic infection and chronic leg swelling, fever, positive Ab titers by IFA diethylcarbamazine, surgical
HA, swollen inguinal nodes, thick and scaly skin; correction of blocked lymph
nocturnal periodocity
pruritic skin rash w/ dark pigmentation, papular microfilariae in skin Bx or in eye by slit lamp ivermectin, diethylcarbamiazine
lesions = intraepithelial granulomas, "lizard skin", exam
"river blindness"

allergic sx, n/v, hives, breathlessness excision


Notes

4 flagella, 2 nuclei, resistant to chlorine,


extracellular parasite, 1-2 wk incubation; resevoir
of beavers, rodents, dogs, pigs
2-10 d incubation

non-invasive, so no immunity

95% pts die w/in 1 wk

chronic

can be primary infection in pregnant women and


fetus (transplacental infection -- only in tachyzoite
stage); TORCHH infection

most deaths in kids <5 yo (cerebral malaria);


resistance if nor RBC Duffy a and b antigens;
resistance if sickle cell; Anopheles only female
bites, only bites at night

most common form of malaria, resistance if nor


RBC Duffy a and b antigens;

variable surface glycoproteins (VSG) give


antigenic variation

variable surface glycoproteins (VSG) give


antigenic variation
NO trypomastigote form

molecular mimicry allows adult to evade immune


response; mature (infectious) larvae = cercariae

molecular mimicry allows adult to evade immune


response; mature (infectious) larvae = cercariae

molecular mimicry allows adult to evade immune


response; mature (infectious) larvae = cercariae

scolex, head, proglottid

niclosamide does not kill proglottid ova

can grow to 45 meters

smallest tapeworm (15-50 mm)

human is dead-end host, dogs and sheep normal


hosts
Fungus Dz course / Sx

Malassezia furfur pigmentation changes

Exophiala werneckii dark brown and black pigmentation on soles of feet and hands

Dermatophytes
ring lesion w/ raised border and healing center
red itchy patches in groin
cracking and peeling b/w toes
scaly red lesions on scalp, mostly in children
thickened, discolored, brittle nails

Sporothrix schenckii subcutaneous nodule --> necrotic and ulcerates, lymphatic spread

Phialophora and Cladosporium small violet wart-like lesion --> cauliflower lesions
inhalation of soil / bird droppings / vegetation aerosolized --> lungs
--> bloodstream; pneumonia, meningitis, bone lytic granulomas,
skin granulomas and ulcers, other organ lesions if
Histoplasma capsulatum immunocompromised
inhalation of soil / bird droppings / vegetation aerosolized --> lungs
--> bloodstream; pneumonia, meningitis, bone lytic granulomas,
skin granulomas and ulcers, other organ lesions if
Blastomyces dermatitidis immunocompromised
inhalation of soil / bird droppings / vegetation aerosolized --> lungs
--> bloodstream; pneumonia, meningitis, bone lytic granulomas,
skin granulomas and ulcers, other organ lesions if
Coccidioides immitis immunocompromised

inhalation to lungs (asympomatic) --> meningoencephalitis, HA/n


confusion, staggering gait, CN defects, fever, meningismus; may
Cryptococcus neoformans also cause pneumonia, skin ulcers, bone lesions;
normal host - oral thrush, vaginitis, diaper rash;
immunocompromised - esophagitis, disseminated (retina); fungal
Candida albicans endocarditis
asthma type1 hypersensitivity (IgE) w/ bronchospasm and
eosinophilia, also type4 rxn (cell-mediated); produce mycotoxin =
aflatoxin that causes liver damage / cancer; occurs w/ CF and TB
Aspergillus flavus, terreus, niger and sarcoid

severe interstitial pneumonia in immunocompromised, most


common infection of AIDS pts (15% per year if CD4 <200); fever,
Pneumocystis jiroveci / carinii (PCP) SOB, nonproductive cough; 85% AIDS pts infected in lifetime
fulminant, acute fungal infection; rhinocerebral mucormycosis in
Zygomycetes / Mucormycocetes ketoacidotic DM

VOCABULARY
yeast unicellular, spherical, ellipsoidal, budding, pseudohyphae
hyphae branching cylindrical tubules, longitudinal excision
multicellular colonies, intertwined hyphae, produce spores or
molds longitudinal excision
spores reproductive bodies of molds
dimorphic can grow as yeast or mold
saprophytes use organic matter as energy source
Dx Tx
pityriasis versicolor, skin scraping mix w/ KOH reveals
spherical yeast and hyphae (spaghetti and meatballs) selenium sulfide shampoo or topical antifungal imidazoles

tinea nigra, skin scraping mix w/ KOH reveals spherical


yeast and hyphae (spaghetti and meatballs) selenium sulfide shampoo or topical antifungal imidazoles
skin scraping KOH digestion --> branched hyphae; direct
examination w/ Wood's light (UV 365nm) --> fluoresce
brilliant green topical imidazoles, avoid moisture
tinea corporis = ringworm
tinea cruris = jock itch
tinea pedis = athlete's foot
tinea capitis oral griseofulvin
tinea unguium = onychomycosis oral griseofulvin

sporotrichosis oral potassium iodide or amphoB


Chromoblastomycosis, KOH reveals copper-colored
sclerotic bodies itraconazole and excision

biopsy of affected tissue; small oval yeast; complement


fixation, cross-rxn w/ coccidioides, blastomycosis itraconazole or amphoB for months

biopsy of affected tissue, Broad Based Budding itraconazole or amphoB for months

biopsy of affected tissue itraconazole or amphoB for months

lumbar puncture, India ink stain shows halo yeast (50%


sens), cryptococcal latex agglutination antigen test (more
sens), culture amphoB and flucytosine (long tx - 6 mo)

blood culture always means pt is immunocompromised, KOH imidazole (oral, vaginal, topical); systemic infection use
prep skin scraping; pseudohyphae amphoB or fluconazole (an imidazole)

systemic corticosteroids, surgical removal; systemic req


branching at 45 degrees septate hyphae, rigid, hyaline mold amphoB, itraconazole

CXR, diffuse bilateral interstitial infiltrates, silver stain, flying-


saucer fungi in sputum, BAL, Bx prophylactic TMP/SMX if CD4 < 250; iv pentamidine
white, cotton-like molds, broad non-septate hyphae, ribbon-
like, right-angle branching surgery, amphoB
Notes Images

fungi secrete keratinase

dimorphic (37 - yeast; 25 - branching hyphae), soil and plants


(gardeners)

rotting wood fungi after puncture wound

dimorphic (25 - mycelial w/ spores on Sabouraud's agar; 37 - yeast on


blood agar); Mississippi River valley; no person-person spread; NOT
encapsulated; intracellular in macrophages

dimorphic (25 - mycelial w/ spores on Sabouraud's agar; 37 - yeast on


blood agar); Mississippi River valley; no person-person spread;
rotten wood, rare infection, but severe and disseminated if you get it

dimorphic (25 - mycelial w/ spores on Sabouraud's agar; 37 - yeast on


blood agar); SW USA; no person-person spread;

polysaccharide capsule yeast; pigeon droppings; 10% of AIDS pts get


cryptococcosis

yeast

mold; infects pts w/ lung cavitations (TB or malignancy); on peanuts,


grains, rice

trophozoite form and cyst form, most people exposed by 2yo, non-
inflammatory pneumonia

Rhizopus, Mucor, Absidia spp.; ubiquitous


Drug Trade Names Mechanism Indications

Antibiotics
sulfonamides dirupted pteroate synthase, inhib PABA toxoplasmosis, nocardosis,
conversion in DNA/RNA/protein synth uncomplicated acute UTIs

trimethoprim (w/ Bactrim, Septra inhibits dihydrofolate reductase (DHFR) broad specturm, UTIs, shigella enteritis, PCP;
sulfamethoxazole) bacterial >> mammalian, prevents second choice for RTIs (H. flue, Spneumo),
DNA/RNA/protein synth plasmodium falciparum, Nocardia, gm neg
bacilli (Salmonella, Brucella, Vibrio cholera)

Quinolones / inhibit DNA replication by blocking DNA broad spectrum, oral, esp for Gm- rods;
Fluoroquinolones gyrase ---> selective more than for ineffective against anaerobes; UTIs inc
mammalian topoisomerase II Pseudomonas aeruginosa, Neisseria
gonorrhoeae, Salmonella, Shigella, E. coli,
Campylobacter; chronic osteomyelitis,
intracellular bugs

ciprofloxacin, oxafloxacin,
norfloxacin
levofloxacin, ofloxacin, improved Gm+ coverage and atypicals,
sparfloxacin community acquired pneumonia
trovafloxacin broad spectrum, improved Gm+ and
anaerobic coverage
nalidixic acid urinary tract antiseptic; DNA gyrase uncomplicated UTI w/ Gm-
inhibitor
nitrofurantoin macrobid urinary tract antiseptic; reduced by uncomplicated UTI w/ Gm-
bacterial enzymes, reactive to destroy
DNA
Cell Wall Synthesis
Inhibitors (bacteriocidal)

D-cycloserine covalently inactivates alanine racemase Mycobacterium tuberculosis resistant to 1st


and comp. inhib. of D-ala-D-ala line tx
synthetase
vancomycin binds D-ala-D-ala-COOH to prevent
addition of new MurNAc-Gly5-GlcNAc to Gm+ only, MRSA and Strep pneumo;
cell wall alternative for streptococci,
pseudomembranous colitis in C difficile
bacitracin inhib dephosphorylation of C55-lipid-P-P

Beta-lactams bactericidal in growing bacteria only, Gm+, Gm- if permeable outer membrane
inhibit cell wall synth as an analogue to
D-ala-D-ala that forms a acyl-enzyme
complex inactivating PBPs, prevents
carboxypeptidation and transpeptidation

penicillin G Gm+ cocci (Strep ABCG, pneumo, E


faecalis/faecium) and Staph aureus, Gm- if
permeable outer membrane (Neisseria
meningitis, treponema palladium,
Bicilin actinomycetes israelaii)
penicillin V Pen-Vee K same as above
penicillinase-resistant b-lactamase strains of Staph aureus (not
peniciliins oxacillin (Bactocil, MRSA), Gm+ only; cellulitis, endocarditis,
Prostaphlin), sepsis
nafcillin (Unipen)
ampicillin diffuses across outer membr in Gm- see penG + better Gm- coverage; group D
strep (Gm+ enterococci), Gm- bacilli (Hflue,
Ecoli, Proteus mirabilis, Shigella,
Salmonella), strep pneumo, Listeria, otitis
media, RTIs, difficult Gm- Proteus
Omnipen,
Pseudomonas Serratia Klebsiella
Polycillin, Unasyn
amoxicillin see penG + group D strep, Gm- bacilli (Hflue,
Ecoli, Proteus mirabilis, Shigella,
Salmonella), also Gm+ enterococci;
Amoxyl, Wymox, outpatient bronchitis, sinusitis, UTIs
Augmentin
ticarcillin, carbenicillin Pseudomonas aeruginosa, aerobic Gm-
bacilli (Ecoli, Proteus m… not Klebsiella)
Ticar, Timentin
piperacillin, azlocillin, Klebsiella and Gm- bacilli (Proteus,
mezlocillin Pseudomonas, Serratia, Enterbacter)
Pipracil, Zosyn
clavulanic acid b-lactamase inhibitor (b-lactam w/ no
bactericidal activity)
b-lactamase inhibitor (b-lactam w/ no
sulbactam bactericidal activity)
aztreonam Azactam aerobic Gm- rods (NO activity for Gm+)
carbapenems (imipenem, very broad spectum, serious infections of
meropenem) unknown origin
Primaxim

act identically to b-lactams, but resistant Staph and Enterococci are RESISTANT; 1st
cephalosporins to penicillinases gen covers Gm+, 3rd gen covers Gm-
Gm+ cocci, tx non-threatening surfact
cephalexin (1st gen) Keflox infections

Ceftin, Kefurox, Gm-, esp anaerobes (sinusitis, otitis, LRTIs


cefuroxime (2nd gen) Zinacef by Hflue, N.gono, B.fragillis, Klebsiella)
lots of Gm- (esp Hflue and Ngonor),
pneumonia of Ecoli or Kpneumoniae,
ceftriaxone (3rd gen) Rocephin meningitis by Gm-
ceftoxime (3rd gen) Claforan adult meningitis
Ceptaz, Fortaz,
ceftazidime (3rd gen) Tazidime S. aureus, P aeruginosa
mostly Gm- coverage with slightly better Gm+
cefepime (4th gen) and Pseudomonas coverage
Protein Synthesis
Inhibitors (Bacteriocidal)

aminoglycosides prevent initiation complex 30S, highly mod to severe aerobic Gm neg (exception is
charged, inhibited by divalent cations Gm+ Staphylococci), and aerobic enterococci
(Ca and Mg), require O2 dependent (w/ penicillin); ineffective alone vs GM pos,
active txport ineffective vs anaerobes; mostly used if other
Abx won't work b/c high toxicity
(except
spectinomycin)
spectinomycin blocks translocation of ribosome to next alt tx for Neisseria gonorrhea resistant to
codon, bacteriostatic; not actually an pen / tetracycline / pregnant women
aminoglycoside
gentamicin, tobramycin, systemic infections
netilmicin, amikacin
neomycin topical infections, oral prophylaxis for
colorectal surgery
streptomycin, kanamycin TB

streptogramins bind to 50S subunit and constrict exit vancomycin resistant E. faecium (NOT E
channel to inhibit peptide exit --> cell faecalis), penicillin resistant Strep pneumo,
Dalfopristin + death from loss of free tRNA; MRSA
quinupristin = dalfopristin / quinupristin always
Syndercid combined for greater effect 16x

Protein Synthesis
Inhibitors (Bacteriostatic)

tetracyclines prevent binding of tRNA-aa to A site broad-spectrum, Rickettsia, Vibrio cholerae,


Borrelia, Brucella, Mycoplasma pneumoniae,
Chlamydiae
doxycycline,
minocycline,
chlortetracycline,
etc
chloramphenicol prevent binding of tRNA-aa to A site broad-spectrum, bacterial meningitis in
pts w/ penicillin anaphylaxis (H.influe,
N.meningitiis), Rickettsia if tetracyclines
contraindicated
Chloromycetin
macrolides blocks translocation of ribosome to next broad spectrum, but mostly Gm+ and
codon atypicals; Legionnella, Mycoplasma
pneumoniae, Chlamydia trachomatis,
Bordatella pertussis, Bacillus anthracis;
erythromycin,
erythromycin drug of choice for community-
clarithromycin,
acquired pneumonia
azithromycin
clindamycin prevent binding of tRNA-aa to A site severe anaerobic infections (Bacteroides
fragiliis), alternative for toxoplasmosis (w/
pyrimethamine) and PCP (w/ primaquine),
female GU infections
Cleocin
oxazolidinones prevent initiation complex by binding 50S, drug resistant Gm+; vanco resistant E.
prevents formation of 70S complex faecium and E faecalis, pen-resist Strep
pneumo, MRSA, GAS and GBS

linezolid (Zyvox)
metronidazole taken up by anaerobic bacteria and anaerobes only, pseudomembraneous colitis
parasites --> converted to metabolite that by C difficile, Bacteroides fragilits,
Flagyl, MetroGel, disrupts DNA trichomoniasis, giardia, amebiasis
Noritate PARASITES

Antifungals if normal immune: coccidioides (SW USA),


histoplasma (eastern USA), cryptococcus
(bird poo) [more if immunosuppressed]

polyene macrolide that binds cell systemic Candida, Cryptococcus,


membrane, complex w/ sterols (esp Histoplasma (all + fluorocytosine);
Amphocin, ergosterol in fungi) --> pore formation --> Coccidioides meningitis (intrathecal, +
amphotercin B (AMB) Fungizone osmotic leakage flucytosine)
Abelcet,
AmBisome,
Amphotec, ABCD,
amphotercin B lipids ABLC Candida, Cryptococcus, Histoplasma
5-FC converted to 5-fluorouracil --> then
5FdUMP (no conversion in mammalian
5-fluorocytosine (5-FC) Ancobon cells to 5FU) Cryptococcal meningitis w/ amphoB

disrupts spindle formation preventing


griseofulvin mitosis, deposits in keratin precursor cells superficial fungal infections
potassium iodide sporotrichosis

blocks cell wall synth by inhib formation of


squalene epoxide from squalene, onychomycosis (tinea unguium), tinea pedis /
terbinafine accumulates in nails capitis / corporis

blastomycosis, histoplasmosis, candidiasis;


inhib ergosterol synth by blocking P450- 2nd line coccidioidal or cryptococcal
azoles dependent C-14 alpha-demthylase meningitis

endemic mycoses (blastomycosis,


histoplasmosis, coccidioidomysosis) and
ketoconazole Nizoral an imidazole chronic mucocutaneous candidiasis
miconazole

the next amphoB!; chromoblastomycosis,


histoplasmosis, coccidioidomycosis,
itraconazole Sporanox triazole blastomycosis, invasive aspergilliosis
2nd line systemic cryptococcal and
coccidioidal meningitis; cutaneous Candida;
fluconazole Diflucan triazole prophylaxis in AIDS pts
voriconazole triazole invasive aspergilliosis (2nd line)

topical antifungals
oral, esophageal, gastric Candidiasis, topical
nystatin binds ergosterol vaginal candidiasis

clotrimazole, miconazole

Antivirals
phosphorylated by viral thymidine kinase
--> inhibits DNA poly as a chain
acyclovir Zovirax terminator HSV, varacella, zoster
valacyclovir prodrug form of above HSV, varacella, zoster
Trifluorothymidine Viroptic framentation of viral DNA herpes keratitis
blocks uncoating of influenza A by
amantadine Symmetrel binding M2 influenza prophylaxis
blocks uncoating of influenza A by
rimantadine binding M2 influenza prophylaxis

oseltamivir Tamiflu neuraminidase inhibitor, decr viral release influenza prophylaxis

zanamivir Relenza neuraminidase inhibitor, decr viral release influenza prophylaxis


retinitis, colitis, esophagitis from CMV,
foscarnet inhibits viral HSV DNA poly acyclovir-resistant HSV

inhib viral DNA synth by incorporating into


ganciclovir viral DNA and stopping DNA poly CMV
purine nucleoside analog, inhibits RNA RSV bronchiolitis and pneumonia in
ribavirin synth hopsitalized children

IFN-alpha hepatitis B, C, and D

AIDS Tx HIV
Nevirapine,
delaviridine,
non-nucleoside RT efavirenz
inhibitors (NNRTIs)

funsion inhibitors - blocks HIV attachment to CD4 cells by


enfuvirtide Fuzeon, T-20 blocking gp41-mediated fusion
RT inhibitors

Retrovir, AZT,
azidothymidine Zidovudine RT inhibitor; thymidine analog decr rate of txmission to newborns

RT inhibitor; converted to 2,3-dideoxyATP


dideoxyinosine ddI, Didanosine chain terminator resistant to AZT

dideoxycytidine ddC, Zalcitabine RT inhibitor; resistant to AZT


3-deoxythymidine-2-ene d4T, Stavudine RT inhibitor; thymidine analog resistant to AZT
2,3-dideoxy-5-fluoro-3- resistant to AZT; used in combo w/ another
thiacytidine FTC, Lamivudine RT inhibitor RT inhib
protease inhibitors
saquinavir Invirase protease inhib in combo w/ Rtinhib and advanced HIV
ritonavir Norvir protease inhib
indinavir Crixivan protease inhib
lopinavir-ritonavir protease inhib resistant HIV

Anti-Parasitics

metronidazole Flagyl inhibits anaerobic metab amoebae, Giardia, Trichomonas


iodoquinol

kills blood schizonts, gametocidal vs all


Plasmosdium except falciparum; starves
parasite of aa's by inhibiting breakdown of
chloroquine Aralen hemoglobin in RBCs malaria / prophylaxis

effective vs exoerythrocytic phase (vivax


and ovale); gametocidal vs all
primaquine Plasmodium, may be anti-mitochondrial malaria
interferes w/ mitochondrial electron
atovaquone / proguanil Malarone txport / DHFR inhibitor drug resistant falciparum

quinine alkaloid from cinchona tree (S.America) drug resistant falciparum / prophylaxis
artemether drug resistant falciparum

mefloquine Lariam drug resistant falciparum / prophylaxis


doxycycline drug resistant falciparum / prophylaxis
suramin unknown Trypanosomiasis (African sleeping sickness)

pentamidine binds kinetoplast DNA of mitochondria Trypanosomiasis (African sleeping sickness)


trivalent arsenic; toxic by reacting w/
melarsoprol sulfhydryl groups CNS penetrant Trypanosomiasis

elfornithine inhibits ornithine decarboxylase Trypanosomiasis (African sleeping sickness)


South American sleeping sickness / Chagas
nifurtimox generation of free radicals in parasite disease
stibogluconate toxic pentavalent antimonial Leishmanias
Fungizone,
Abelcet,
amphotercin B Ambisome Leishmanias

mebendazole Vermox inhibits microtubules? roundworms


albendazole roundworms
pyrantel pamoate depolarizing worms --> paralysis roundworms

increases cell membrane permeability to


praziquantel Biltricide Ca2+ and paralyzes parasite schistosomiasis, Tenia solium
niclosamide Nicloside tapeworms
Kinetics CI/SE

potentiates warfarin by interfering w/ hematopoietic disorders, skin rashes,


CYP450; acetylated in liver; excreted in kernicterus in newborns due to bilirubin
kidneys displacement and accumulation in basal
ganglia
excreted by kidney, accumulates in same as above, but also
prostatic / vaginal secretions megaloblastosis, leukopenia,
thrombocytopenia, esp if folic acid
deficiency; rash fever, and hepatitis in
AIDS pts w/ PCP
oral; interacts to inhib degradation of n/v, CNS (confusion, HA, dizziness),
theophylline and caffeine --> seizures; damages growing cartilage (contra for
enterohepatic circulation (excreted in bile <18 y.o. and pregnancy), Achillies'
and reabsorbed in intestines) tendonitis;

ciprofloxacin can cause renal


insufficiency and seizures
sparfloxacin causes photosensitivity and
long Q-T intervals
liver toxicity

never combine w/ nitrofurantoin;


anorexia, n/v, hypersensitivity, CNS
never combine w/ nalidixic acid;
anorexia, n/v, hypersensitivity, CNS

systemic toxicity

ototoxicity and nephrotoxicity,


oral for GI infections (not absorbed), other hypersensitivity -- "red man syndrome"
iv; 1/2life 6 hr; eliminated in kidneys due to histamine release

topical
excreted by kidney except nafcillin and least toxic of all Abx; hypersensitivity and
cefoperazone (bile); oral probenicid blocks anaphylaxis
renal secretion

IV or IM; distrib all but CNS, eye, prostate; anaphylaxis, hypersensitivity,


minimal metab; kidney excretion neurotoxicity
(probenicid decreases secretion)

oral
nafcillin excreted in bile, oxacillin, methicillin causes interstitial nephritis
cloxacillin, dicloxacillin all acid-stable
for oral or parenteral admin

oral; also given IV combined w/ gentamycin


(aminoglycoside) for broad coverage

oral

iv platelet dysfunction, hypokalemia


parenteral

hydrolyzed by renal dipeptidase -- allergic rxns, seizures


marketed w/ cilistatin to inhib hydrolysis
and increase half-life in vivo

pain upon IM, come cause bleeding


disorders due to side chain interaction w/
prothrombin or disulfram-rxn (n/v) w/
EtOH (cefotetan, cefoperazone,
cefamandole); 10% of penicillin allergic
pts will be allergic to cephalosporines
cephalexin, cephradine, cefadroxil = oral;
cefazolin = parenteral

parenteral (cefamandole, cefoxitin, hypoprothrombinemia, incr risk of


cefuroxime, cefotetan), oral (cefaclor) superinfections

disulfiram rxn w/ alcohol, incr risk of


long 1/2 life 8hrs, penetrates CNS superinfections
crosses bbb inc rist of superinfections
disulfiram rxn w/ alcohol, incr risk of
crosses bbb superinfections

parenteral, poor BBB, poor GI ototoxicity and nephrotoxicity (severe)


absorption; highly charged, so no oral
bioavailability, give IM, no crossing of
bbb, no premixing of beta lactam;
excreted by kidneys; long post-Abx
effect, concentration-dependent; 1/2life
2.5 hrs

IM inj., ecreted kidneys nausea, chills, fever, dizzy, rash

oral or parenteral, bile elimination hypersensitivity, pseudomembraneous


colitis; inhibit CYP450 (incr conc of
cyclosporine, CCBs,

oral or iv, no bbb, bioavailability inhib by GI irritation, phototoxicity, hepatic and


milk / antacids; removed by liver renal toxicity, deposition in bones and
teeth (yellowing; no children < 8 or
pregnant women), Fanconi syndrome
(n/v/polyuria/proteinuria)

crosses bbb; metab by glucuronyl aplastic anemia (rare, fatal), BM


transferase, 3hr 1/2life suppression, grey-baby syndrome,
CYP450 inhib, no pregnant women or
kids
oral, excreted bile / liver very safe; GI distress, cholestatic
hepatitis; erythromycin and
clarithromycin (not azithromycin)
inhibit CYP450s (corticosteriods,
warfarin, digoxin, cyclosporine)

oral or parenteral, metab liver, secreted in GI distress, skin rashes, hepatotoxicity;


bile high prob of superinfection by Clostridium
difficile and pseudomembranous colitis

oral, iv; synthetic incr bradycardia w/ b-blockers,


thrombocytopenia, superinfections;
reversible MAO-I (must avoid food w/
tyramine), not combine w/ MAOis,
tricyclics, SSRIs, St. John's wort
iv, oral; metab in liver n/HA/dry mouth, disulfiram-like rxn w/
EtOH (antabuse), not given to pregnant
women

nephrotoxicity (glom and dist tubule),


fever w/ rigors, anemia, phlebitis,
slow iv, binds to blood, does not cross cardiotoxic, neurotoxic
bbb but can be given intrathecally, (ha/fever/v/chills/hypotension),
excreted urine 5%/day, persists in hypokalemia, hypomagnesemia,
tissues for weeks hypersensitivity (tx w/ NSAIDS, etc)

reduced toxicity b/c combined w/


cholesteryl sulfate'

BM suppression, allopecia, GI (n/v/d),


oral, crosses BBB, excreted kidneys hepatotoxicity

uncommon: HA/n/v, confusion,


oral, very slow cure photosensitivity, BM suppression

low risk of drug-drug interactions, not


oral metab cyp-450
interfere w/ P450 synth of adrenal and
gonadal steroids; GI Sx, hepatotoxicity,
skin rashes, changes in libido,
gynecomastia; interactions w/ CYP450
food + effect, antacids - effect; v/d/rash system and other drugs

n/v/anorexia, hepatotoxicity, inhib


testosterone synth (gynecomastia,
oral, protein bound impotence), adrenal suppression
topical

oral, protein bound (poor absorption) -->


take w/ acid drink (like o.j.) fewer steroidal / hormonal side effects

penetrates all tissues (even BBB),


excreted urine fewer steroidal / hormonal side effects

topical
topical skin / mucus membranes; not
absorbed orally too toxic for iv,

topical too toxic for systemic use

topical, oral, iv; kidney excretion; 3 hr 1/2life n/ha, carcinogenic, teratogenic


higher 3-5x serum concentrations
eye drops hypersensitivity, stinging, edema
insomnia, nervousness, dizzy, ataxia,
oral, 50% daily renal excretion vision, depression, paranoia
insomnia, nervousness, dizzy, ataxia,
oral, metabolism vision, depression, paranoia

oral

inhaled

decr kidney fxn, n/v/hypocalcemia

teratogenic, carcinogenic, mutagenic,


granulocytopenia, thrombocytopenia

aerosolized teratogenic and embryotoxic, pregnancy


flu sx, BM suppression, fatigue,
depression, anxiety

2x/day sub cut injections pneumonia, skin rxns, allergic rxns

anemia, neutropenia, n/v/ha, fatingue,


confusion, malaise, myopathy
abd cramps, diarrhea, peripheral
neuropathy, acute pancreatitis, liver
failure
rash, stomatitis, fever, peripheral
neuropathy, pancreatitis
peripheral neuropathy, same as ddI

less toxic
lipodystrophy, hyperlipidemia

n/HA/dry mouth, parasthesias w/ EtOH,


oral; 1/2life 8.5 hrs, metab by oxidation and teratogenic and mutagenic so no
glucuronide; excreted by kidneys pregnant women

GI upset, HA, vision blurring, ocular


muscle paralysis and retinal damage ;
oral, degraded by liver, excreted in urine; G6PD defic --> hemolysis

leukocytosis, BM suppression,
leucopenia, anorexia, abd pain, n/v,
oral, slowly absorbed, rapidly excreted hemolysis; G6PD defic --> hemolysis

HA, Gi upset
cinchonism: ear ringing, HA, nausea,
visual changes; G6PD defic -->
IM hemolysis

dizziness, HA, vivid dreams, psychotic


events
CNS: parasthesias, hyperesthesias,
photophobia, urticaria, pruritis,
slow IV infusion, nephrotoxicity
hypotension, n/v, blood dyscrasia, renal
IM; slow excretion in kidneys and hepatic damage
myocardial damage, hypertension,
IV peripheral neuropathy

less toxic

oral, excreted and degraded by kidneys nausea, rash, HA, anorexia

mutagenic and teratogenic = no


oral, poor bioavailability, pregnancy
less toxicity?
n/v/d

sedation, abd pain, fever, sweating, n/HA,


oral, dizziness, eosinophilia
oral, not absorbed
Notes

resistance by synth of altered dihydropteroate synthase, inc prod of PABA,


reduced uptake of sulfonamide; Tree -- respiratory, Mouth -- GI tract, Pee -- GU
tract, Syndrome -- AIDS and PCP

two drugs are synergistic b/c block 2 pts in same folate pathway; resistance by
overproduction of DHFR, expression of altered DHFR

fluoroquinolones added to chicken feed; resistance by mutations in DNA gyrase,


decr permeability

only used in life- or limb- threatening situations

older quinolone

Resistance in Enterococcus faecalis and E. faecium by plasmid expression


of VanH (D-lactate), VanX (D-ala-D-ala hydolytic enzymes), VanY (UDP-
NAcMur-5peptide) --> prod D-ala-D-lactate depsipeptide resistant to vanco

penicillin isolated by Foley 1941, discovered by Fleming 1929; Resistance by 1)


beta-lactamase expression (Staph aur., H.flue, Neisseria) -- circumvented by
giving b-lactamase inhib at same time [clavulanic acid, sulbactam] 2) decr
permeability Gm- 3) overexpression of efflux pump (Neisseria, Pseudomonas,
Salmonella) 4) no autolysis of cell wall (Listeria, staphylococci, streptococci), 5)
mutations in PBPs (Staph aur, Neisseria, Hflue, Strep pneumo)

methicilin rarely used b/c assoc w/ interstitial nephritis

usually combined w/ sublactam (Unasyn)

usually combined w/ clavulonic acid (Augmentin)

usually combined w/ clavulonic acid (Timentin), and gentamycin (aminoglycoside)


for syndergy
usually combined w/ aminoglycoside; piperacillin + tazobactam (b-lactamase
inhib) = Zosyn

Augmentin = amoxicillin + clavulanate;

Unasyn = ampacillin + sulbactam


OK to give to pts w/ hypersensitivity to other penicillins
b-lactamase resistant, imipenem marketed w/ cilastin (renal dipeptidase inhib),
"big guns", Pseudomonas resistance by porin

do not give a cephalosporine to a pt w/ penicillin anaphylaxis

1st generation ceph uses 'PH', except for cefazolin and cefadroxil

"met a fox for tea"

3rd generation names have a 'T'

usually b-lactamase resistant

TA (30S) vs MCL (50S) [tetracyclines & aminoglycosides VS macrolides,


chloramphenicol, Clindamycin, linezolid)

often combined w/ beta-lactam antibiotic w/ Gm+ and Gm- (synergism), high


activity even after conc falls below MIC (postantiobiotic effect), once daily dosing;
do not give casually; resistance by degradative enzymes (mostly, plasmid-
mediated) and alteration of ribosome binding site (less)

big dog; resistance by rRNA mutations

resistance by efflux pump (major), TetM protein protects ribosome (minor); cannot
take with milk

modifying enzyme (chloramphenicol acetyl transferase) by plasmid MDR; serious


infections only; antagonistic w/ erythromycin and clindamycin
antagonistic w/ clindamycin and chloramphenicol; resistance by decr permeability,
efflux pump, target site modification, hydrolysis by esterase; MDR plasmid-
mediated

more aggressive C. difficile (NAP1/027) recently; resistance by methylase (major),


inactivation, decr membrane permeability; antagonistic w/ erythromycin and
clindamycin

mutations in rRNA to decr affinity

decr or loss of enzymes that activate antibiotic

potential interactions w/ other nephrotoxic drugs (aminoglycosides, cysplatin,


cyclosporine); used in combo w/ flucytosine; given w/ aspirin or acetaminophen to
prevent fever, monitor BUN and creatinine

see above

rapid resistance when alone (cytosine permase, cytosine deaminase), used w/


AMB

resitance by efflux pump or altered enzyme 14-alpha-demethylase

candicin, nystatin, natamycin, clotrimazole, miconzole, econazole, tioconazole,


tolnaftate (athlete's foot and ringworm)
resistance w/ continued tx

HAART = protease inhibitor + 2 RT inhibitors; tx of choice is 2 RT inhibitors


w/ efavirenz (NNRTI)

efavirenz only requires 1/day dosing

used in combo w/ other drugs, $20,000/year wholesale

least potent

DOES NOT TX EXOERYTHROCYTIC PHASE (Plasmodium vivax and ovale), if


resistant P. falciparum use quinine, quinidine, artemether,
pyrimethamine/sulfadoxine, fefloquine

primaquine sensitivity in 10-15% -- due to glucose-6-phosphate dehydrogenase


deficiency in RBC

quinine + doxycycline OR mefloquine

from chinese herb


Drug Mechanism Indications Kinetics
Anti-Arrhythmic inhibit heart arrhythmias
Class I
Quinidine block Na channels; decr. SA node SV arrhythmias (A- hepatic metabolism; binds plasma
conduction; decr. contraction (cardiac fib/flutter) proteins
depression); decr. automaticity;
vasodilation (decr. BP)

Procainamide block Na channels SV arrhythmias (A- oral


fib/flutter)
Disopyramide block Na channels V-arrh (serious )

Lidocaine block Na channels; normalizes V arrh (V-tach or V-fib -> #1 1st pass hepatic metabolism;
conduction by blocking damaged cells drug)

Class IC drugs block Na channels orig: life-threatening V-arrh; oral


now: A-fib pts (no
cardiomyopathy, good
ejection fraction, oral)
Class II
Propranolol β−αδρενεργιχ βλοχκερ sinus tachycardia (due to
sympathetic stim.)
Class III
Amiodarone block K channels SV arrhythmias (A-fib) very long T1/2 (50 days)

Dofetilide block K channels SV arrhythmias (A-fib or A- oral; interact w/ drugs that inhib cation
flutter) transport
Bretylium block K channels V-fib (last-line) IV
Class IV
Verapamil block Ca channels; prolong PR
Miscellaneous
Adenosine incr. outward K current -> hyper- SV arrhythmias extremely rapid metabolism -> IV
polarization; slows conduction in AV node bolus only

Digoxin inhib conduction thru AV node SV arrhythmias (A-fib)


Atropine anti-muscarinic sinus bradycardia
Isoproterenol β−αδρενεργιχ αγονιστ sinus bradycardia
Magnesium sulfate
Anti-anginal decrease myocardial O2 demand (usu.
no Tx can incr. O2 supply)
Organic Nitrates
Nitroglycerine (NTG) induce NO & EDRF release from sublingual for acute NTG degrades over time
endothelial cells -> vasodilation of angina; oral, topical,
peripheral vessels -> decr. O2 demand transdermal for
prophylaxis

long-acting nitrates angina prophylaxis less frequent dosing; slow onset (not
for acute angina)
β−βλοχκερσ decr. HR & contractility -> decr. O2 angina, HTN, tachycardia,
demand; (also, decr. renin) prior MI, hyperthyroidism,
migraines

Ca-channel blockers
Verapamil non-dihydropyridine; decr. HR, angina prophylaxis; decr. slow onset
contractility, afterload -> decr. O2 vasospasm (Prinzmetal's),
demand; decr. vasoconstriction -> HTN
vasodilation
Diltiazem non-dihydropyridine; decr. HR, angina prophylaxis; decr. slow onset
contractility, afterload -> decr. O2 vasospasm (Prinzmetal's),
demand; decr. vasoconstriction -> HTN
vasodilation
dihydropyridine; vasodilation (no angina prophylaxis, HTN
direct heart depression)

Anti-hypertension monotherapy preferred

STEP I
Diuretics renal Na excretion, fluid loss (diuresis); HTN drug inter: severe hypotension w/
reduces vascular responsiveness to NE ACE inhibitor

β−βλοχκερσ decr. contractility; decr. renin release HTN, non-vasospastic never stop abruptly -> high rebound
angina, tachycardia, prior tachycardia upon re-exposure to NE
MI, hyperthyroidism,
migraines

Ca-channel blockers HTN, angina


ACE inhibitors inhib. angiotensin II synth -> decr. HTN (w/ CHF, diabetes) drug inter: severe hypotension w/
vasoconstriction, decr. aldosterone, incr. diuretics
renal Na excretion; inhib. bradykinin
breakdown -> vasodilation

AII receptor blocker only blocks AII receptors -> decr. HTN, CHF
vasoconstriction, decr. aldosterone
STEP II sympathetic inhibitors

α1−βλοχκερσ block vasoconstriction; no effect on a-2 HTN w/ hyperlipidemias or


receptors benign prostatic hypertrophy

Central a-agonist stim. a-2 receptors -> decr. sympathetic HTN never stop abruptly -> high rebound
effect -> decr. vasoconstriction, decr. tachycardia
contractility, decr. BP

Methyldopa decr. vasoconstriction HTN w/ pregnancy

Catecholamine depletor depletes peripheral NE -> decr. HTN; use w/ diuretic


vasoconstriction, decr. contractility

STEP III
Hydralazine direct-acting vasodilator (like NTG -> HTN (last line), CHF (w/ rapid response
EDRF-NO) nitrates)

HTN Emergencies
Nitroprusside organic nitrate (like NTG); direct-acting 1st choice for HTN metabolized to cyanide; IV infusion
vasodilator emergencies; intraop only -> immediate onset -- must
surgery monitor closely
Diazoxide direct-acting vasodilator HTN urgency IV push -> usu. works in 1 dose
Trimethaphan autonomic ganglionic blocker -> HTN urgency
vasodilation
Dyslipidemias
Statins inhib. HMG-CoA reductase -> decr. lower cholesterol; drug inter: incr. SE risk w/ niacin,
cholesterol; incr. LDL receptor, decr. hyperlipidemia (1st line) gemfibrozil, cyclosporin, or
VLDL production erythromycin
Fibrates incr. lipolysis of TG -> incr. VLDL TG lower triglycerides; drug inter: displace plasma protein-
clearance hypercholesterolemia (w/ bound drugs (warfarin,
statin) hypoglycemics), incr. statin myopathy

Niacin decr. chol. by decr. hepatic secretion of w/ statin for hyperchol +/- drug inter: incr. statin myopathy;
VLDL; decr. TG by decr. lipolysis, incr. hyperTG antagonizes all anti-diabetic drugs
VLDL clearance

Bile acid sequestrants decr. intestinal absorption of bile acids -> lower cholesterol drug inter: interferes w/ absorption of
incr. excretion -> incr. conversion of many oral drugs & fat-sol vitamins
cholesterol to bile acids (A,D,E,K)

Anti-platelet interfere w/ platelet function

COX inhibitors
Aspirin (ASA) irrev. acetylates & inhib. COX -> inhib. acute MI, after MI, unstable oral (chewed faster); affects platelet
TXA2 production angina, post-CABG, for 10-day lifespan
angioplasty

NSAIDs reversible platelet inhibition


ADP receptor inhibitors
Ticlopidine irrev. noncompetitive ADP (P2) reduce thrombosis after require activation; platelet inhibition
receptor inhibitor stent delayed 1-2 days
Clopidogrel irrev. noncompetitive ADP (P2) reduce thrombosis after require activation; platelet inhibition
receptor inhibitor stent delayed 1-2 days
GPIIb/IIIa inhibitors PCI or high risk

Abciximab (ReoPro) chimeric Ab vs. GPIIaIIIb; steric percutaneous coronary short T1/2, but extensively bound
hindrance of fibrinogen binding artery interventions to plasma proteins
Eptifibatide (Integrilin) analog of C-term fibrinogen (mimicry), percutaneous coronary
blocks GPIIaIIIb artery interventions
Tirofiban (Aggrestat) non-peptide, small molecule; inhib. percutaneous coronary
GPIIaIIIb artery interventions
Dipyridamole inhib. phosphodiesterase -> incr. cAMP
-> decr. ADP
(Aggrenox) dipyridamole + aspirin stroke prevention
Anti-Coagulant prevent clot formation & extension DVT
Heparin (UFH) accel. ATIII inhibition of FXa & FIIa parenteral only (IV bolus (1 hr T1/2)
(thrombin) or SC bid (few hr T1/2)); does not
cross placenta - OK pregnant
low MW heparin (LMWH) accel. ATIII inhibition of FXa only better bioavailability (less binding) &
longer T1/2 than UFH

Hirudin direct IIa (thrombin) inhibitor vs. clot- HITTS


bound thrombin
Danaparoid Sodium indirect IIa (thrombin) inhibitor HITTS
Warfarin (Coumadin) inhibits VitK epoxide reductase -> always start w/ heparin + warfarin,
interferes w/ VitK metabolism -> decr. continue heparin for 4-5 days until
VitK-dep. coag. factor production (II, INR in desired range; many drug
VII, IX, X, PC, PS) inter.; bound plasma proteins

Thrombolytic activate fibrinolysis -> plasmin dissolves acute MI; stroke, pulm. tPA inhib. by PAI-1; plasmin inhib. by
thrombi (also restore flow, reduce infarct) emboli, DVT a2-antiplasmin

Tissue Plasminogen serine-protease from endothelial cells acute MI (treat quickly) slightly better than streptokinase (but
Activator (t-PA) activates plasminogen at site of clotted more $$); no systemic effects w/ MI
fibrin (specific)

Streptokinase (SK) not an enzyme; binds free blood acute MI (treat quickly) systemic effects (binds plasminogen
plasminogen, exposes active site -> in blood); cheaper than tPA
activates other free plasminogen to
plasmin
Other
spironolactone aldosterone receptor antagonist; CHF
potassium sparing diuretic
CI/SE Notes
Singh - Vaughn Williams classification

incr. AV node conduction (incr. class IA; digoxin pre-treatment slows AV


ventricular rate in pts. w/ A- conduction; quinidine decr. digoxin excretion ->
fib/flutter); cinchonism = GI upset, very high digoxin levels -> may be fatal
tinnitus, diplopia, dizziness; CI:
digoxin-induced arrhythmias
lupus-like Sx in slow acetylators class IA; no cinchonism

intense atropine-like SE; CI: glaucoma, class IA


enlarged prostate
CNS sedation -> seizures are major class IB; minimal effects on AV node conduction
cause of death; hypotension or contractility

can cause arrhythmias & AV block include flecainide, moricizine, propafenone; only
(sudden death) used in pt. w/ serious heart problems

also include sotalol, esmolol

pulmonary fibrosis, neuropathy, epith


pigmentation, vision impaired,
"hypothyoidism"
prolonged AP & QT -> torsades

transient AV block; pressor, then diagnostic (affects AV nodal only)


depressor -> reflex tachycardia, angina;
bronchoconstriction
adjunct to quinidine

reflex tachycardia; headache, flushing, prototype; pts at risk for acute angina -> always
dizziness -> SE decrease over time carry sublingual (SL) NTG tablets; overdose ->
(tolerance); CI: EtOH, anti- hypotension, decr. LAD/RCA flow, tachycardia ->
hypertensives, sildenafil (excess underperfusion -> acute MI or stroke; 3 dose, dial
hypotension), sympathomimetics 911 rule
(counteract NTG effects)

tolerance -> decr. action of SL NTG isosorbide dinitrate, pentaerythritol tetranitrate,


(prevent by drug-free intervals) erythrityl tetranitrate
CI: vasospastic Prinzmental's angina, used alone (antianginal) or w/ nitrates (reduce
severe CHF, COPD, asthma, diabetes, nitrate-induced reflex tachycardia)
2nd deg heart block

decr. AV conduction, no reflex used alone (antianginal) or w/ nitrates (reduce


tachycardia; CI: cardiac depressants nitrate-induced reflex tachycardia); act on heart &
(b-blockers, anti-HTN, quinidine, vasculature
EtOH)
decr. AV conduction, no reflex used alone (antianginal) or w/ nitrates (reduce
tachycardia; CI: cardiac depressants nitrate-induced reflex tachycardia); act on heart &
(b-blockers, anti-HTN, quinidine, vasculature
EtOH)
reflex tachycardia; never give act only on vasculature (no cardiac depression)
sublingually -> severe decr. BP -> fatal
incr. HR
stepped-care approach; MAO inhibitors &
guanedithine also anti-HTN
hypokalemia, hyperuricemia, gout, ex) Hydrochlorothiazide
hyperlipidemia, hyperglycemia;
hypotension (when w/ ACE inhib); CI:
gout, diabetes
CI: asthma, diabetes, AV block, cardioselective = atenolol, metoprolol; ISA =
vasospastic Prinzmetal's angina, pindolol; weak a-blockers = labetolol (HTN
severe CHF, arterial disease urgency), carvedilol; pheochromocytoma: b-
blocker causes incr. BP

CI: 1st degree AV-block ex) verapamil, diltiazam; nifedipine


SE: cough, angioedema, hypotension ex) Captopril
(when w/ diuretics); hyperkalemia
(EKG=tall T); CI: pregnancy
(teratogenic), renal disease,
hyperkalemia, hyponatremia

CI: pregnancy (same as above except ex) Losartan


no cough or angioedema
SE: orthostatic hypotension, activate R-
A-S, CNS probs, impaired sexual
performance
SE: first-dose faint orthostatic ex) Prazosin; terazosin, doxazosin
hypotension; reflex tachycardia, renal
Na & H2O retention (may need diuretic)

rebound incr. BP & incr. HR ex) Clonidine

hepatotoxic; autoimmune Coombs(+) ->


hemolytic anemia
orthostatic hypotension, bradycardia, ex) Reserpine; related: guanadrel
CHF, parasymp predomination

use when other options have failed


reflex tachycardia (may need Ca- or b- related: Minoxidil (Rogaine hair topical cream)
blocker); Na/H2O retention (may need
diuretic); lupus-like syndrome (like
procaine amide); peripheral neuritis

cyanide poisoning when if BP increases (refractory) -> DO NOT give more


overwhelmed endogenous nitroprusside (CN- accum); prevent by IV
thiosulfate (skin cherry red) thiosulfate
use when nitroprusside not available

CI: pregnant
myopathy, rhabdomyolysis, SE manifest 1st as muscle ache; ex)
myoglobinuria, renal failure, Atorvastatin, etc.
hepatotoxicity
cholelithiasis ex) Gemfibrozil (prototype)

significant flushing & pruritis; GI upset; aka VitB3 (nicotinic acid)


CI: peptic ulcer disease, hyperuricemia,
gout, liver disease, diabetes mellitus

ex) Cholestyramine, Colestipol; act in GI, not


bloodstream

PCI = percutaneous coronary artery interventions


= angioplasty or stent

GI upset (b/c PGE2 decr.); hemorrhagic COX aka PG-H2 synthase; inhib COX-1 more
stroke; decr. renal fxn; impaired ACE than COX-2; also minor inhib. PGI2 (prostacyclin)
inhibitor efficacy by endothelial cells; primary prevention: no
reduced mortality, decr. nonfatal MI, incr. stroke

transient effect
GI upset, bleeding, TTP, neutropenia block platelet activation; more expensive than
ASA -> used less
GI upset, bleeding, TTP block platelet activation; used more often b/c less
neutropenia
high risk = failed ASA, ST depression, troponin
elevation, angioplasty
bleeding, thrombocytopenia plasma levels fall quickly, but see effect up to 15
days
bleeding, thrombocytopenia

bleeding, thrombocytopenia

uncommonly used alone; also antianginal:


potentiates adenosine -> vasodilation

bleeding, HITTS, osteoporosis monitor by APTT, TCT, ACT; if bleeding, rapid


reversal by protamine

minimal effect on APTT; outpatient: no need to


monitor b/c predictable biol. response

coumadin skin necrosis (if warfarin monitor carefully & regularly by PT (FVII T1/2
alone 1st -> APC inhibited rapidly); OD -> PT incr. first) -> varies by thromboplastin
-> prolonged INR -> bleeding -> Tx by source -> use INR correction factor (pt. range
VitK + FFP (coag Fx); embryopathy = 2-3); reversible by VitK
(teratogenic wks 6-12) -> CI: pregnant;
blue-toe syndrome

hemorrhagic stroke, minor bleeding treat acute MI within 6 hrs (best 1 hr); tPA also for
vascular patency, cell migration; also,
staphylokinase, urokinase, reteplase (r-PA),
lanoteplase (n-PA), tenecteplase (TNK)

"kringle" domain

bacterial origin -> immunogenic -> avoid


readministration (pt. may have pre-existing anti-
SK Abs)

low GFR, high creatinine, high serum


[K] >5, high dose ACEi ==> all give
hyperkalemia…. NSAIDs may give
hypernatremia
Drug Trade Names Mechanism Indications

Bronchodilator open airways COPD, asthma


isoproterenol non-selective beta agonist Not used
epinephrine non-selective adrenergic agonist severe acute asthma attacks
beta2 agonists Galpha-s inc. cAMP, promote SMC relaxation;
inhib. mast cell degranulation, inhib function of
other immune/inflammatory cells; inc
brochodilation, inc glycolysis, dilate blood
vessels

albuterol Proventil, Ventolin acute asthma attack

levalbuterol Xopenex
metaproterenol Alupent
terbutaline Brethaire
pirbuterol Maxair
salmeterol Serevent partial B2 agonists (less desensitization), inhibit exercise-induced asthma, nocturnal asthma
mast cell degranulation, edema, inc mucus
clearance

fomoterol Foradil partial B2 agonists (less desensitization), inhibit exercise-induced asthma, nocturnal asthma
mast cell degranulation, edema, inc mucus
clearance

phosphodiesterase elevation of cAMP inhibits mast cell


inhibitors degranulation, increases SMC relaxation

theophylline inhibits cAMP PDE, inc cAMP; antagonizes exercise-induced asthma, nocturnal asthma
adenosine mediated bronchoconstriction

muscarinic antagonists

ipratropium Atrovent bronchodilation by dec parasymp tone to SMC, COPD


dec mucus secretion
tiotropium Spiriva selective for M1 and M3 receptors COPD
oxitropium
atropine

Anti-inflammatory

diphenhydramine Benadryl anti-histamine; inhibits binding of histamine to allergic conditions


H1 receptors
fexofenadine, loratadine Claratin anti-histamines, non-sedating allergic conditions

dextromethorphan opiod agonist in cough syrups; anti-tussive


agent suppresses cough center in medulla

inhaled corticosteroids dec mucus production, inc B2 receptors, dec


vascular permeability, dec inflammatory cells
(limit chemotaxis); inhibit action of PG,
proteases, O2… block IL1,2 action on Tcells

beclomethazone Beclovent
triamcinolone Azmacort
flunisolide Aerobid
fluticasone Flovent
budesonide Pulmicort
fluticasone + salmeterol Advair

leukotriene modifiers inihib action of esp leukotriene D4 effective in pts who suffer asthma attacks after
NSAID use
zafirlukast Accolate leukotriene receptor antagonist
montelukast Singulair leukotriene receptor antagonist
zileuton Zyflo 5-lipoxygenase inhibitor
mast cell modifiers
cromolyn sodium Intal aerosolized NSAID; inhib mast cell maint. Tx for asthma
degranulation
nedocromil Tilade aerosolized NSAID; inhib mast cell maint. Tx for asthma
degranulation
Omalizumab Xolair injected anti-IgE antibody binds free IgE to severe asthma
prevent membrane-bound IgE's available on
mast cells --> recuded atopy of mast cells and
basophils

Nicotine (et al.) ligand-gated ion channels (Na and K),


pentamer (alpha7 or alpha4beta2)
addiction

DA mediated?, atypical catechol/5HT reuptake


buproprion Zyban inhib
clonidine alpha2 adrenergic receptor agonist
partial agonist of alpha4beta2, blocks full
varenicline Chantix agonist effect of nicotine
cannabinoid receptor antagonist (CB-1
rimonabant receptor, Gprotein coupled) marijuana, nicotine addiction

Pulmonary Arterial PAH causes: decr prostacyclin synthase, incr


endothelin-1, decr NOsynthase, incr PDE5
Hypertension

prostacyclin agonists
(epoprostenol, treprostenil, prostacyclin synth by endothelial cells, stim
iloprost) SMC Gs to incr cAMP --> vasodilation PAH
epoprostenol
treprostinil
ilioprost

prevent endothelin-1 ET-A receptor mediated


endothelin receptor effects (vasoconstriction and proliferation of
antagonists SMC) ; ET-B receptors (NO, vasodilation) PAH
bosantan non-selective endothelin receptor antag
sitaxsentan and
ambrisentan selective ET-A antagonist
inhibits PDE5 --> incr cGMP duration after NO
Revatio (PAH), release --> vasodilation, anti-proliferative for
sildinafil Viagra (ED) SMCs PAH, ED

Tuberculosis / combination Tx 95% effective TB, MAC (ethambutol + clarithromycin /


azithromycin)
Mycobacterial Tx

bacteriocidal, inhib of mycolic acid synth (cell


isoniazid INH, Nydrazid wall) mycobacteria

mycobacteria, prophylactic rifabutin if AIDS w/o


MAC to prevent N meningitidis and H. influe;
bacteriocidal, inhib bacterial DNA-dep RNA rifabutin for MAI; rifampin also used for leprosy
rifampin, rifabutin Rifadin, Rimactane polymerase w/ dapsone and clofazimine

requires actively dividing cells; inhib synth of mycobacteria, MAC (w/ azithromycin /
ethambutol Myambutol arabinogalactan (cell wall) clarithromycin)

pyrazinamide PZA bactericidal, nicotinamide analog mech unknwn mycobacteria

2nd line tx: streptomycin,


amikacin, capreomycin,
ethionamide, D-cycloserine,
ofloxacin, ciprofloxacin see aminoglycosides for streptomycin
Kinetics CI/SE

inc BP, HR

chronic use leads to desensitization of B2


receptors

short acting (1-5 min onset, 2-6 hr duration),


inhaled
short acting, inhaled
short acting, inhaled
short acting, inhaled
short acting, inhaled
long acting 12hrs (more lipophilic), slow onset, harmful if used chronically if not combined
inhaled with corticosteroid

long acting 12hrs (more lipophilic), slow onset,


inhaled

oral low therapeutic index (n/v, insomnia,


irritability)

MDI or nebulized dry mouth

MDI or nebulized
MDI or nebulized

many

anti-cholinergic effects --> sedative

large first pass effect metab to prevent systemic oropharyngeal candidaisis, hoarseness,
side effects throat irritation, decr bone density

longer lasting
longer lasting

CYP450 metabolism rxns (warfarin,


theophylline)
oral
oral
oral liver toxicity
one injection / 2-4 weeks

absorbed buccal, skin, lungs --> direct to brain EPI release, tachycardia / bradycardia,
(7sec), 1/2-life 2hrs, metab in liver C-oxidation NMJ wkness, analgesia, tremors,
by CYP2A6 convulsions, vomiting, release of DA (nuc
accumbens, VTA)

iv, 1/2 life 3 min


sub cut, 1/2 life 2 hr
oral

oral, 1/2life 5 hrs liver toxicity

liver toxicity

n/v/d, neurotoxicity (psychosis, seizures,


conf, peripheral neuritis [pyridoxine
oral, crosses BBB, inactivated by acetylation in deficiency = vit B6]), hepatotoxicity (20%)
liver (N-acetyl transferase) [slow (Whites) vs (incr liver enzymes, hepatitis with EtOH),
rapid (A-As) acetylators is genetic] decr metab of phenytoin, CYP450

mostly safe; hypersensitivity rxn, n/v/d,


hepatotoxicity, autoimmune, incr metab
oral, 1/2life 3hrs, crosses BBB, excreted urine P450 = shorter 1/2 lives for ... (digitalis,
and bile, deacetylated in liver OCT, cyclosporine, warfarin)

mostly safe, optical neuritis, retrobulbar


neuritis (in renal failure pts), peripheral
oral, excreted kidney unchanged, 1/2life 4hrs neuritis, nephrotoxicity

oral, excreted kidney, 1/2life 4hrs hepatotoxicity (<5%), gout-like Sx, n/v/fever

ototoxic, nephrotoxic, no pregnant women


= streptomycin
Notes

mainstay of asthma tx until 1960s

use as prophylaxis controversial; small number of B2 receptors in heart can inc HR;
may increase inflammation in asthma if used chronically

prototypical selective B2 agonist

combined w/ corticosteroid (fluticasone; Advair); corticosteroid may inc B2adrenergic


receptors

PDE4 is the major enzyme in inflammatory and immune cells

non-selective inhib of PDE; inexpensive

no blockade of M2 prevents drug-induced ACh release

ASTHMA: CD1d-restricted NK Tcells linked w/ Th2 response stimulated by IL-4 (also


inhibits Th1 response); missing T-bet transcription factor for IFN-gamma to drive to
Th1 response and inhibit Th2

no abuse potential like other opiods

inc production of lipocortin --> inhibits PLPA2 synth of leukotrienes, prostaglandins,


and PAF; compliance is problematic

requires 4 doses/day
expensive ($12,000 / year)

alpha4 and beta2 subunits important for addiction, self-medication observed in


Parkinson's Alzheimer's schizophrenia Tourette's

doubles quit rates


reduced severity of withdrawal symptoms

improves 2yr survival, exercise capacity

INH, rifampin, pyrazinamide 2mo --> INH and rifampin 4mo; OR INH, rifampin,
ethambutol, pyrazinamide 6mo; fluoroquinolones if resistant

resistance 1 in 10^6, overproduction of inhA gene give resistance to ethionamide also;


katG encodes catylase (high level risistance)

resistance 1 in 10^7, via mutations in RNA poly; will turn body secretions orange-red

discontinued once determined TB infection is not drug resistant


Drug Trade Names Mechanism Indications
Antivirals
IFN-alpha 2b activates T cells and NK cells to kill HCV, HBV
infected cells; inhibits viral replication;
cytostatic effect on replicating cells

pegylated IFN added polyethylene glycol HCV

ribavirin Copegus, Rebetol, purine nucleotide analog, inhibits HCV, viral pneumonia in infants
Virazole replication by inhib inosine-5-phosphate and young children
dehydrogenase inhibiting GTP -->
blocked mRNA synth and 5'-capping;
decr GTPase cycling and signaling

lamivudine 3TC, Epivir pyrimidine nucleoside analog of cytosine; HBV, HIV


RT inhibitor
adefovir Hepsera prodrug RT inhibitor lamivudine-resistant HBV

entecavir Baraclude inhib priming of HBV polymerase and RT lamivudine-resistant HBV


inhib

Portal HTN
propranolol non-selective beta blocker; decr portal
pressure and decr risk of bleeding from
varices; splanchnic vasodilation?

somatostatin / octreotide reduce portal venous pressure by acute variceal bleeding


vasoconstriction

Hepatic serum ammonia is causative --> astrocyte


metab to glutamine (osmol) --> swelling,
Encephalopathy NT unbalance

lactulose non-absorbable disaccharide; acidifies


gut lumen to decr ammonia uptake -->
traps NH4+ in lumen; incr fecal nitrogen
and laxative

neomycin decr ammonia production by reducing


bacterial load of gut

ursodiol bile acid that solubolizes cholesterol to delay progression of PBC


improve bile flow; tx in PBC

GI Functional
Control

H. pylori ABX
proton pump inhibitors inhib H/K-ATPase; prodrug, req GERD, Zollinger-Ellison Syndrome
activation in acidic environment

omeprazole Prilosec

lansoprazole Prevacid
rabeprazole Aciphex
pantoprazole Protonix
esomeprazole Nexium

block H2 receptors; blocks histamine-


mediated stim of H+ release (fundus
distention, gastrin, food, fasting, nocturnal reflux, esp duodenal ulcers, GERD,
H2 blockers secretion, muscarinic agonists) stress ulcers

cimetidine Tagamet
ranitidine Zantac
famotidine Pepcid
nizatidine Axid
stimulate mucin secretion and HCO3
Prostaglandin analogs secretion, "cytoprotective" prevent NSAID injury
binds to PGE2R, EP3, --> decr cAMP
levels in parietal cell to inhibit H+
secretion; also protects from NSAID
injury by stimulating bicarb and mucus
misoprostol Cytotec secretion
NaHCO3, CaCO3, Mg(OH) buffering
antacids agents
lines epithelial cells, inhibits acid
sucralfate hydrolysis of proteins
anticholinergics
cytoprotective agents
carbenoxolone (licorice
root) alters mucin
Rebamipide increase prostaglandins (Asia)
Ecabet increase prostaglandins (Japan)
binds to peptic ulcers, promotes HCO3
Bismuth and mucin production ulcers, H pylori

Nasuea Control
emetics poisoning or drug OD
ipecac syrup acts on CTZ
apomorphine acts on CTZ
anti-emetics
chemotherapy anti-emesis,
irradiation anti-nausea, tx of
ondansetron Zofran 5HT3 receptor antagonist hyperemesis in pregnancy
chemotherapy anti-emesis,
irradiation anti-nausea, tx of
granisetron Kytril 5-HT receptor blocker hyperemesis in pregnancy
chemotherapy anti-emesis,
irradiation anti-nausea, tx of
dolasetron Anzemet 5-HT receptor blocker hyperemesis in pregnancy
phenothiazines:
prochlorperazine,
thiethyperazine,
chlorpromazine, dopamine receptor antagonists (antag of
metaclopramide D2 in CTZ) anti-nausea, anti-emetics

H1 Receptor antagonist (antihistamine),


cyclizine act on vestibular afferents in brain stem motion sickness, post-op emesis

H1 Receptor antagonist (antihistamine),


hydroxyzine act on vestibular afferents in brain stem motion sickness, post-op emesis

H1 Receptor antagonist (antihistamine),


promethazine act on vestibular afferents in brain stem motion sickness, post-op emesis

H1 Receptor antagonist (antihistamine),


diphenhydramine Benadryl act on vestibular afferents in brain stem motion sickness, post-op emesis
scopolamine muscarinic receptor antagonist motion sickness

prophylactic cancer chemo,


dronabinol cannabinoid, CB1 agonist stimulates appetite, AIDS

GI Function
Miscellaneous

5HT3 receptor antagonist, inhibits


alosetron Lotronex vasomotor response to rectal dilation IBS diarrhea

IBS constipation (decr abd pain,


# BMs, stool consistency,
tegaserod Zelnorm 5HT4 receptor agonist bloating, constipation)

motilin Motilin receptor agonist


electrolytes (Na, K, Cl,
citrate, glucose) diarrhea
psyllium Metamucil osmotic (absorb water) diarrhea
polycarbophil Fibercon, Fiberall osmotic (absorb water) diarrhea
Carboxymethylcellulose osmotic (absorb water) diarrhea
Kaolin and pectin Kaopectate osmotic (absorb water) diarrhea
attapulgite Diabsorb osmotic (absorb water) diarrhea
salt-induced diarrhea, s/p
cholestyramine Questran anion resin that binds bile acids cholecystectomy
bismuth subsalicylate w/ Mg diarrhea, H pylori, abd cramps and
/ Al silicate Pepto-Bismol nausea
act at peripheral mu opiod receptor to incr
small bowel transit time (antikinetic) and
loperamide Imodium decr secretion diarrhea
act at peripheral mu opiod receptor to incr
small bowel transit time (antikinetic) and
diphenoxylate, difenoxin Lomotil, Mofofen decr secretion diarrhea

severe secretory diarrhea from GI


octreotide Sandostatin analog of somatostatin tumor, portal HTN (see above)

polyethylene glycol (PEG) osmotic (retains water in GI lumen) constipation


phenolphthalein Modane stimulant laxative incr secretion constipation
rheum rhubarb stimulant laxative incr secretion constipation
castor oil, docusates stool softening agent constipation
prokinetics
bethanechol, carbachol cholinergic muscarinic agonist
colonic pseudo-obstruction,
neostigmine AChE inhibitor paralytic ileus
prokinetic, incr LES tone, incr
Dopamine D2 receptor antagonist (and gastric emptying, anti-nausea, anti-
metoclopramide 5HT4 agonist) emetic

domperidone dopamine receptor antagonist (selective) anti-nausea, anti-emetics,

cisapride

IBD treatment

sulfasalazine Azulfidine 5-aminosalicylic acid mild-mod ulcerative colitis


5-aminosalicylic acid , inhibits COX and
lipoxygenase to decr LTB4 and 5-HETE,
mesalamine may scavenge O2 radicals mild-mod ulcerative colitis
5-aminosalicylic acid , inhibits COX and
lipoxygenase to decr LTB4 and 5-HETE,
balsalazide Colazal may scavenge O2 radicals UC
glucocorticoids anti-inflammatory
thioguanine derivatives (6-
MP, AZA) immunosuppressive, anti-inflamatory
inhibits DHFR, immunosuppressive and
methotrexate anti-inflammatory

inhibits calcineurin, immunosupressant


cyclosporine Sandimmune, Neoral and anti-inflammatory acute severe UC

monoclonal Ab vs TNFalpha, decr Crohn's disease, fistulas, UC, RA,


infliximab Remacade inflammation ankylosing spondylitis, psoriasis
Kinetics CI/SE Notes

sub cut.; clearance by kidney, flu-like, neuropsych depression, hemato Sx 10-20% response rate
dose every 24-48 hrs (BM suppression --> cytopenia tx w/ EPO);
cirrhosis (IFN can cause hepatocyte lysis)

increased 1/2-life and as above


absorption; sub cut inj every
week
oral, 2x daily? anemia, fatigue, irritability, rash, sinusitis, 48 wk tx w/ pegylated IFN + ribavirin --> 55%
etc response rate; follow dz progression by serum RNA
load

oral pancreatitis high resistance

oral genotoxic, renal tubular nephropathy,


hepatotoxicity
oral expensive better than lamivudine; resistance less common?

iv or sub cut.

protein restriction helpful, but pos N balance


needed for liver regeneration; must also tx inciting
events (dehydration, electrolyte imbalance,
constipation, infection)

toxicity and bacterial resistance

pp-Inhib / bismuth + amoxicillin / clarithromycin /


metronidazole OR pp-Inhib + tetracycline +
bismuth + metronidazole
oral, dissolve in blood --> incr risk of pneumonia take before meal; do not take with H2 blocker b/c
enter parietal cells; 1/2 life need acid secretion to activate drug
few hours, effect longer b/c
req. resyth of new ATPase;
liver metab CYP450

n/d/constip/gas, abd colic; subacute over the counter now


myopathy, skin rash, HA

oral, peak plasma conc in hrs, preferred over PPI for initial Tx; take between
metab in liver, excreted in d/HA, fatigue, drowsiness, muscle pain, supper and bedtime to prevent nocturnal H+
kidney constip secretion
gynecomastia (binding to androgen
receptors), impotence, prolactin secretion;
inhibits CYP450
rapid absorption and metab, diarrhea, cramps; worsens IBS Sx; can
excreted in kidneys cause abortions / contractions in pregnant
systemic alkalinazation, acid rebound,
constip, diarrhea
take on empty stomach,
activated by acid constipation

respiratory suppression

not useful for motion sickness

also antihistamine and anticholinergic, act at NTS


and CTZ

patch

central sympathomimetic (tachycardia,


conjuctival injection), risk of abuse

ischemic colitis, severe constipation

diarrhea
erythromycin has motilin receptor activity -->
prokinetic

oral rehydration
decr bioavailability of any pos charged drug

constipation, anticholinergic

constipation, anticholinergic

systemic SE, not effective no coordinated peristalsis

oral

no CNS side effects not used in USA

blocks IRK channels --> severe arrhythmias no longer available in USA

fever, malaise, n/v/HA, diarrhea, allergic


oral rxns

oral or enema well tolerated

enema 20% 12wk response rate

slow onset (months for effect) BM suppression

cytotoxic

cytotoxic

increased risk of infection (esp TB),


respiratory infections, HA, rash, couging,
stomach pain, lymphoma, HBV activation, DO NOT take with Anakinara (IL-1 receptor
IV, liver injury, CNS, CHF antagonist)
Drug Trade Names Mechanism Indications
Diuretics
Loop diuretics sulfa drugs, inhib Na/K/2Cl CFH, edema (pulmonary,
co-transporter in thick hepatic, nephotic syndr), ARF,
ascending loop of Henle, hypercalcemia
incr urinary Na, decr tonicitiy
of medullary interstitium

furosemide loop diuretic


bumetanide loop diuretic
torsemide loop diuretic
ethacrynic acid similar to loop diuretics, but
not a sulfa drug
osmotic diuretics acute renal failure, maintenance
of urine flow, glaucoma;
hydrocephalus, increased ICP,
hemolysis, rhabdomyolysis

mannitol osmotic diuretic


urea osmotic diuretic
carbonic anhydrase inhibitors proximal tubule, inhibits
luminal and cytoplasmic
carbonic anhydrase
acetazolamide edema, glaucoma (topical),
acute mountain sickness,
metabolic alkalosis,
alkalinization of urine in aspirin
CA inhibitor toxicity
dorzolamide incr intraocular pressure
CA inhibitor (glaucoma)
brinzolamide incr intraocular pressure
CA inhibitor (glaucoma)
thiazide diuretics act at distal tubule to inhibit HTN, CFH, edema, diabetes
Na/Cl cotransporter --> incr insipidus, renal stones
excretion of Na, Cl, H2O

hydrochlorothiazide thiazide diuretic


metolazone thiazide diuretic
K sparing collecting tubule block of Na offset K wasting effect of other
channel, decr lumen diuretics, improved clearance in
electronegativity, decr K CF, Li+ induced nephrogenic
secretion diabetes insipidus

amiloride K sparing diuretic,


stimulates Na+ excretion,
inhibit SMC Ca release -->
vasodilation

triamterene K sparing diuretic


aldosterone antagonists competitively inhibit combination tx w/ other
aldosterone binding to diuretics, CHF, aldosteronism
aldosterone receptor --> (1 or 2ary)
prevent uptake of Na in late
DT and CD
spironolactone aldosterone antagonist primary and secondary
aldosteronism

indapamide results in Na loss and dirctly


vasodilatory

Antihypertensives
sympathoplegics
methyldopa bind to alpha adrenergic
receptors in medulla to
inhibit sympathetic NS
clonidine bind to alpha adrenergic
receptors in medulla to
inhibit sympathetic NS
ganglion blocking agents inhibit symp NS
guanethidine uptaken into NE vesicals
presynaptically replacing
NE and decr symp NS
vasoconstriction; also
blocks Na channels

reserpine blocks NE storage vesicle


transporter --> depletion of
NE from symp terminals

beta blockers
alpha-1 blockers decrease IP3 levels in
arterioles and venules -->
vasodilation
prazosin alpha blocker
terazosin alpha blocker
doxazocin alpha blocker

vasodilators
hydralazine dilates arterioles only long term outpatient HTN
dilates arterioles only;
opens K+ channels to
minoxidil hyperpolarize SMC long term outpatient HTN

dilates arterioles and


veinules; stimulates incr
nitroprusside cGMP --> SMC relaxation HTN emergencies
diazoxide HTN emergencies
fenoldopam HTN emergencies
calcium channel blockers HTN
virapamil

dihydropyridines

anti-angiotensin drugs
ARBs blockade of AT1 receptor antihypertensive
--> inhib Ca release in
SMCs --> vasodilation; pre-
synaptic inhib NE release
and dis-inhibited NE uptake
(clearance) from synapse;
inhib aldosterone release
from adrenal cortex

losartan
valsartan
candesartan
iprosartan
irbesartan
telmisartan
ACE inhibitors inhibit angiotensin I
converting enzyme; inhib
AngII and incr bradykinin
1/2 life --> vasodilation
captopril decr TPR w/o incr HR,
promote Na excretion and
H2O loss
enalapril
benazapril

Transplant
Immunosuppresives
azathioprine cell cycle inhibitors
mycophenolate mofetil cell cycle inhibitors
cdk : cyclin balance --> inhib
sirolimus (rapamycin) cell cycle
cyclosporine calcineurin inhib --> block
signal 1
calcineurin inhib --> block
tacrolimus signal 1
binds CD3 to prevent APC--
OKT3 TCR binding

glucocorticoids
daclizumab IL2 receptor inhibitor
basiliximab IL2 receptor inhibitor

Transplant
Immunosuppresives
secondary hyperparathyroidism
sevelamer phosphate binder in CKD
secondary hyperparathyroidism
vitD analogues in CKD
calcimemetic, sensitizes
parathyroid to [Ca] to
cinacalcet decrease PTH ESRD
erythropoietin anemia of CKD
darbopoietin anemia of CKD

Urological
alpha blockers (prazosin,
doxazosin) Cardura BPH, HTN
tamsulosin alpha blocker kidney stones
5alpha reductase inhib Proscar BPH
(finasteride)
sildinafil Viagra ED
tadalafil Cialis ED
vardenafil Levitra ED
LHRH agonist / GHRH
agonsit, inhibiting
gonadotropin hormone
lupron Leuprolide release prostate cancer, infertility
LHRH agonist / GHRH
agonsit, inhibiting
gonadotropin hormone
goserelin release prostate cancer, infertility

synthetic PGE1,
intracavernosal injection to
alprostadil increase SMC relaxation ED
prevention of kidney stones
acetohydroxamic acid urease inhibitor (struvite)
citrate kidney stone prevention
antimuscarinics overactive bladder
Kinetics CI/SE Notes

hyponatremia, low ECFV, hypoCa, K+ backleak drives reabsorption of Ca and Mg; large increase in urine
hypoMg, hypoK, hypoH (alkalosis), volume, U-Na and U-Cl and U-Ca and U-Mg
ototoxic, hyperuricemia, hyperglycemia,
sulfonamide hypersensiticity

iv contra in CHF, pulmonary edema; neg lumen potential b/c more Na delivery and uptake in CT -->
excessive loss of H2O and electrolytes, promotes K+ secretion
hypokalemia

hypokalemia not very effective, alkaline urine, small incr urine volume

metabolic acidosis (loss of bicarb), renal


stones (Ca salts less soluble in alkaline
urine), sulfonamide hypersensitivity /
photosensitivity, hypokalemia drugs absorb UV radiation --> ROS irritation
topical no systemic effects

topical no systemic effects

hypoK, hypoH, gout, hyperglycemia, enhance PTH-regulated Ca reabsorption in DT


hyperlipidemia, sulfonamide
hypersensitivity

hyperkalemic metabolic acidosis

used in combo w/ other diuretics

used in combo w/ other diuretics


hyperkalemia

incr CYP450 activity; gynecomastia,


antiandrogenic

no longer used b/c extensive side effects


oral resistance common used in combo w/ other drugs

oral reflex tachycardia, hirsutism Rogaine is topical minoxidil


cyanide poisoning if prolonged infusion;
postural hypotension

i.v.
i.v.
i.v.

teratogenic, hypotension, renal failure no cough, more complete blockade of angII effects than ACEi's

cough, teratogenic, hypotension, renal


failure, angioedema

post-transplant hyperlipidemia
post-xplant DM, HTN, hyperlipidemia

post-xplant DM, HTN, hyperlipidemia

post-xplant DM, HTN, hyperlipidemia

slow effects increase serum Ca, inhibit PTH synth

rapid effect decrease serum Ca, inhibit PTH synth and secretion

dizziness, retrograde ejaculation


<7mm passable, give w/ HCTZ, hydrate
gynecomastia, decr libido, ED

nitroprusside
long half life nitroprusside
quick onset nitroprusside, virapamil

continual admin will turn off body's endogenous LHRH

continual admin will turn off body's endogenous LHRH

injection or intraurethral pill priapism, fibrosis


Drug Trade Mechanism Indications Kinetics
Names
Local
Anesthetics
ester; blockade of NE metabolized by plasma
cocaine uptake pseudo-ChE
metabolized by plasma
procaine Novocaine ester pseudo-ChE
benzocaine Americaine ester
tetracaine Pontocaine ester
metab by liver microsomal
lidocaine Xylocaine amide esterase
etidocaine Duranest amide
mepivacaine Carbocaine amide
bupivacaine Marcaine amide
ropivacaine Naropin amide

General
Anesthetics disruption of lipid bilayer
(Gasses) voltage gated ion channels
dantrolene neuroleptic malignant
syndrome (NMS),
malignant hyperthermia

desflurane rapid induction


enflurane
halothane

modulation of GABA-gated low B:G ratio; hepatic


Cl channels? metabolism (40%)
isoflurane
methoxyfurane highly soluble; high B:G ratio
(slow onset); 70% kidney
metabolism
nitrous oxide
very poorly soluble, low B:G
ratio (rapid effect); cannot
dental and obstetrics achieve 1.0 MAC alone
sevoflurane rxn with CO2 soda lime -->
pediatric induction compound A gives renal
anesthesia damage

General
Anesthetics
(Injected)
thiopental barbiturate; potentiate
GABAa actions ultra short-acting
methohexital barbiturate ultra short-acting
thiamylal barbiturate ultra short-acting
propofol
tolerance of ICU ventilation rapid recovery
dexmedetomidine
tolerance of ICU ventilation rapid recovery
etomidate rapid anesthesia in
cardiovascular dz pts rapid
midazolam
benzodiazepine; potentiate short dental procedures for
GABAa channel anterograde amnesia
diazepam Valium benzodiazepine
lorazepam benzodiazepine
ketamine
to produce dissociative
anesthesia, tx hypovolemic
NMDA receptor blockade shock
morphine
mu-receptor opiod agonist
meperidine
mu-receptor opiod agonist
remifentanil
mu-receptor opiod agonist short surgical procedures
alfentanil
mu-receptor opiod agonist short surgical procedures
fentanyl '+ droperidol --> neuroleptic
analgesia; + droperidol +
N2O --> neuroleptic
mu-receptor opiod agonist anesthesia
sufentanil
mu-receptor opiod agonist

Antipsychotic
inapsine delirium 3rd line im or iv, rapid onset
benzodiazepine
alcohol withdrawal delirium,
akathisia
benztropine
Parkinsonism SE of typical
Cogentin anticholinergic antipsychotics, akathisia
trihexylphenidine Parkinsonism SE of typical
Artane anticholinergic antipsychotics

typical,
1st generation neuroleptic,
antipsychotics tranquilizer D2 blockers
chlorpromazine Thorazine agitation in schizo low potency
thioridizine
Mellaril low potency
haloperidol
Haldol delirium 1st line, schizo high potency
fluphenazine high potency
loxapine mid potency
perphenazine Trilafon mid potency
2nd generation positive sx; 1st line
antipsychotics psychosis, bipolar disorder
atypical 5-HT2a / D2 antagonists (acute care)
clozapine

tx-resistant schizo; anti-


Clozaril suicide; tardive dyskinesia
risperidone
Risperdal delirium 2nd line, schizo
olanzapine
Zyprexa
quetiapine Seroquel
ziprasidone Geodon
aripiprazole Abilify
paliperidone

Movement Dz

converted by aromatic
amino acid decarboxylase much broken down in liver (no
levodopa to form DA Parkinson's brain access)
carbidopa inhibits peripheral
Sinemet breakdown of L-DOPA Parkinson's
entacapone
COMT inhibitor -- prevents
Stelevo breakdown of DA Parkinson's
ropinirole Parkinson's, restless leg
Requip DA2/3 agonist syndrome
pramipexole Mirapex DA2/3 agonist Parkinson's
pergolide Permax D2 agonist Parkinson's
bromocriptine Parkinson's, neuroleptic
Parlodel D2 agonist malignant syndrome
amantidine Mirapex NMDA antagonist, flu Parkinson's
rimantidine NMDA antagonist, flu Parkinson's
benzotropine akathisia, drug induced
Cogentin anticholinergic (muscarinic) Parkinson's, dystonia im or iv
trihexylphenidine drug induced Parkinson's,
Artane anticholinergic (muscarinic) dystonia im or iv
diphenhydramine antihistamine and
Benadryl anticholinergic dystonia im or iv
selegiline deprenyl MAO-B inhibitor Parkinson's
carbergoline Dostinex D2 agonist Parkinson's
MPTP

Cognition

tacrine Cognex ChE inhibitor mild to mod AD, dementia

donepezil Aricept ChE inhibitor mild to mod AD, dementia once/day dosing

rivastigmine Exelon ChE inhibitor mild to mod AD, dementia

galantamine Reminyl ChE inhibitor mild to mod AD, dementia

glutamate NMDA inhibitor,


blocks overactivation
memantine Namenda excitotoxicity cognitive impairment
vitaminE
diclofenac,
ibuprofen,
NDAIDs naproxen
estrogen
physical activity

Antiepileptics
phenytoin Dilantin block Na channels partial, tonic-clonic
carbamazepine Tegretol block Na channels partial, tonic-clonic
oxcarbazepine Trileptal block Na, modulate K partial, tonic-clonic

lamotrigine Lamictal block Na, prevent glutamate partial, mixed


zonisamide Zonegran block Na and T-type Ca partial, tonic-clonic

block Na, open GABA,


antagonize AMPA/kainate,
topiramate Topamax inhib carbonic anhydrase partial, tonic-clonic

prolong GABA opening for partial, tonic-clonic, status


phenobarbital Cl-, some blockade of Na epilepticus
block Na channels, partial, tonic-clonic,
valproate Depakote enhance GABA absence, mixed
incr GABA conc and partial, tonic-clonic;
gabapentin Neurontin inhibition trigeminal neuralgia
tiagabine Gabitril inhib GABA reuptake partial
irreversibly inhib GABA-
vigabatrin Sabril transaminase partial
clorazepate Tranxene partial

ethosuximide Zarontin blocks T-type Ca channels absence


clonazepam Klonopin absence

diazepam Valium incr freq of GABA opening status epilepticus


lorazepam Ativan status epilepticus
fosphenytoin Cerebryx status epilepticus

Anti-
inflammatory
leukotrienes

thromboxanes
prostaglandins

PGE

prostacycline
PGI
leukotriene effective in pts who suffer CYP450 metabolism rxns
modifiers asthma attacks after NSAID (warfarin, theophylline)
use
zafirlukast Accolate LTD4 receptor antagonist chronic asthma oral

montelukast Singulair LTD4 receptor antagonist chronic asthma oral

zileuton Zyflo 5-lipoxygenase inhibitor chronic asthma oral

mast cell
modifiers
cromolyn sodium Intal aerosolized NSAID; inhib maint. Tx for asthma
mast cell degranulation

nedocromil Tilade aerosolized NSAID; inhib maint. Tx for asthma


mast cell degranulation

Omalizumab Xolair injected anti-IgE antibody severe asthma one injection / 2-4 weeks
binds free IgE to prevent
membrane-bound IgE's
available on mast cells -->
recuded atopy of mast cells
and basophils

NSAIDs

fever, pain, inflammation

acetominophen Tylenol blocks CNS isoform COXs fever, pain

bound to protein in blood,


metab in liver --> glycine and
glucuronide conjugates ==>
covalent (permanent) inflammation, prophylaxis all excreted by urine, 1/2life =
acetylsalicylic acid Aspirin binding to COX 1 and 2 colon cancer, MI 4hrs
Motrin, Advil, protein bound, metab in liver,
ibuprofen Nuprin inhib COX 1 and 2 excreted in urine
naproxen Aleve
indomethacin severe inflammation
piroxicam Feldene anti-inflammatory long 1/2-life
entodolac Lodine some COX2 selectivity long 1/2-life
nabumetone Relafen partially COX2 selective
protect from GI effects of
misoprostol PGE analog chronic NSAID use
celecoxib Celebrex COX2 inhib
rofecoxib Vioxx COX2 inhib

valdecoxib Bextra COX2 inhib


DMARDs RA
gold salts
(aurothiomalate,
aurothioglucose) rheumatoid arthritis parental

chloroquine,
hydroxychloroquine RA, malaria
penicillamine RA
methotrexate RA

Etanercept decoy TNF-alpha receptor RA


infliximab,
adalimumab anti-TNF-alpha Ab RA

Anakinra anti-IL1R RA, inflammation


anti-Gout

anti-microtubule agent,
blocks leukocyte migration
cholchicine and phagocytosis limit inflammation from gout

allopurinol inhib xanthine oxidase prevention of gout

probenecid, weak acids limid uric acid


sulfinpyrazone resorbtion from urine prevention of gout
Anti-Histamines rhinitis, urticaria,
conjunctivitis, hayfever,
dermititis, insect stings;
competitive antagonist of motion sickness, oral, metab liver, excreted
H1 receptor antiemesis, sedation kidney;
diphenhydramine Benadryl 1st generation
dimenhydrinate Dramamine 1st generation
promethazine HCl Phenergan 1st generation
fexofenadine Allegra 2nd gen
loratadine Claritin 2nd gen
cetirizine Zyrtec 2nd gen

Addiction potentiates GABAa, inhib


NMDA-glutamate, etc

naltrexone ReVia anti-opiate; blocks GABA blocks relapse to heavy


firing drinking
acamprosate helps prevent relapse

disulfiram Antabuse blocks metab of alcohol prevents drinking


(blocks breakdown of
acetaldehyde by aldehyde
dehydrogenase)

Hypnotics
barbiturates
banzodiazepines
Other Agents
zolpidem Ambien act at BZD site on GABAa trouble sleeping through metab liver, CYP450
channels (alpha1 subunit) night oxidation; rapid onset, short
duration
zaleplon Sonata act at BZD site on GABAa rapid onset sleep metab liver, CYP450
channels (alpha1 subunit) oxidation; rapid onset, short
duration
eszopiclone Lunesta act at BZD site on GABAa metab liver, CYP450
channels (alpha1 subunit) oxidation; rapid onset, short
duration
chloral hydrate CNS depressant

anti-histamines
(diphenhydramine, 1st generation H1
doxylamine, Nytol, Sominex, antagonist -- anticholinergic
chlorpheniramine) Unisom effect
antidepressants sedating antidepressants,
(nefazodone, but have other receptor
trazodone) effects
kava kava CNS depressant

valerian root metab to desmethyldiazepine


5-HT derivative, released must consume many hours
melatonin prior to sleep prior to sleep
melatonin MT1 and MT2
receptor agonist in
ramelteon Rozerem suprachiasmatic nuc insomnia
non-ergot D2 receptor
agonist, acts via
ropinirole nigrostriatal pathway restless leg syndrome; PD?

Migraine
triptans

Opiods mu, delta, kappa receptors


on pre- and post-synaptic;
inhib pain NT release (Gi -
Ca2+ channels inhib),
hyperpolarize neurons (Gi -
K channels open) [mu only]

enkephalin endogenous
dynophrin endogenous
endorphins endogenous
morphine full agonist 4-6 hrs duration
meperidine Demerol full agonist
fentanyl full agonist general anesthesia highly potent
codeine weak agonist crosses BBB
methadone long acting substitute for opiate addiction crosses BBB
opiates
oxycodone Percocet
(hydrocodone)
tramadol Ultram
propoxyphene Darvocet
dextromethorphan antitussive
heroin, full agonist fast acting, crosses BBB
acetylmorphine
buprenorphine partial agonist / antagonist

naloxone Narcan antagonist heroine overdose reversal short acting (1-2 hrs) IV only

naltrexone ReVia antagonist maintenance of opiod long acting (10-48 hrs), ~40%
abuse tx, EtOH abuse oral bioavailability
pentazocine k-agonist, u partial agonist

salvinorim A kappa ONLY

Anxiolytics / prior to surgery, severe


emotional crisis, withdrawal,
Antidepressan anxiety disorders, psych
ts disorders, anesthesia

Buspirone Buspar 5-HT 1A agonist generalized anxiety slow acting (~2 wks)
disorder
Lithium carbonate / bipolar disorder (esp 2-3 wks to reach steady state,
citrate manic) excreted only (not
metabolized); monitor serum
electrolytes to maintain
therapeutic dose

valproate Depakote acute mania


lamotrigine prevention of bipolar
episodes (type I)
flumazenil BZD receptor antagonist OD or revese BZD effects
(sedation)
barbiturates increased duration of Cl short term sleep aid to
channel opening (GABAa) sustain sleep

pentobarbital
secobarbital
amobarbital
benzodiazepines GABAa -- increased anxiolytics, high lipid solubility --> rapid
frequency of Cl- opening sedative/hypnotic (faster onset, completely absorbed
sleep initiation, longer PO; metab in liver; mostly
duration), EtOH detox, Phase I transformation to
muscle relaxer, desmethyldiazepam (active
anticonvulsant metabolite) --> increased 1/2
life up to 1 wk

chlordiazepoxide Librium 1st line for EtOH withdrawal long acting

clonazepam Klonopin BZD withdrawal, trigeminal long acting


neuralgia
flurazepam Dalmane long acting, rapid onset
diazepam Valium long acting

carbamazepine trigeminal neuralgia, manic


episodes
alprazolam Xanax panic disorder hydroxylated prior to phase II;
short acting
estazolam short-lived b/c bypasses
desmethylation
quazepam short-lived b/c bypasses
desmethylation
triazolam Halcion very short acting, bypasses
phase I (desmethylation)

midazolam Versed sedation (surgery) injection only


oxazepam Serax phase II metab, short acting

temazepam Restoril phase II metab, short acting

lorazepam Ativan EtOH withdrawal IM possible; phase II metab,


short acting (bypasses
desmethylation)

antidepressants also for comorbid


depression
amoxapine Asendin depression w/ psychotic
features
buproprion Wellbutrin, inhibits uptake of DA and insomnia, swizures,
Zyban NE sweating, smoking
cessation
mirtazepine Remeron blockade at alpha2 --> depression w/ wt loss
increased 5-HT and NE
release; 5HT2 and 3
antagonist, incr 5HT1A
function; H1 antagonist

nefazodone Serzone like trazodone (see below)

trazodone Desyrel weak 5HT reuptake inhib / sleep aid, used short term
partial agonist; alpha1 for pts starting SSRI
antag; H1 antag;
TCAs block reuptake of 5-HT and panic disorder tertiary broken down to
NE 2ndary --> both have effect

amitriptyline Elavil tertiary amine


desipramine Norpramin, secondary amine
Pertofrane
doxepin Adapin,
Sinequan
imipramine Tofranil enuresis tertiary amine
nortryptiline Aventyl, secondary amine
Pamelor
clomipramine Anafranil OCD
SSRIs inihbit reuptake of 5-HT (not 1st line panic disorder,
NE) OCD, social anxiety,
PTSD, GAD

sertraline Zoloft OCD, panic disorder, social


anxiety, PTSD
fluoxetine Prozac OCD, panic disorder
paroxetine Paxil OCD, panic disorder, social
anxiety, GAD, PTSD

fluvoxamine Luvox OCD, panic disorder


escitalopram Lexapro

citalopram Celexa GAD


SNRIs block reuptake of NE > 5- panic disorder, PTSD, GAD
HT
venlafaxine Effexor XR social anxiety
duloxetine Cymbalta neuropathic pain
MAOIs decreased breakdown of panic disorder, social
NE and 5-HT; irreversible anxiety disorder, atypical
inhibition of monoamine depression
oxidase

isocarboxazid, Marplan, Nardil, non-selective


phenelzine, Parnate
tranylcypromine
deprenyl (selegiline) MAO-B specific

moclobemide reversible
CI/SE Notes

PABA metabolite --> allergy; vasoconstriction, HTN,


tachycardia, euphoria

PABA metabolite --> allergy prototypical ester

toluidine metabolite --> methemoglobinemia prototypical amide

S enantiomer

lipid solubility = potency; may be functioning by GABAa


receptor potentiation?

lung irritant (not given in COPD)

severe cardiovascular depression; halothane-mediated


myocardial sensitization, depressed myocardial
contraction, baroreceptor reflex --> bradycardia, relaxed
peripheral vascular smooth muscle; hypotension and
hypoperfusion; sensitization to catecholamine
dysrhythmias (pressor agents like EPI); post-anesthesia
hepatitis; malignant hyperthermia (autosomal doinant halothane metab to chlorotrifluoroethyl free radical or
genetic dz --> tx with dantrolene to inhib Ca release from autoimmune hepatotoxicity; do not give with epinephrine
muscle) (risk of arrhythmias); lower risk of hepatotoxicity in kids

nephrotoxic, releases fluoride ions in metabolism

minimal cardiovascular SE; vitB12 megaloblastic anemia


due to decr methionine synthase production; -->
peripheral neuropathies "laughing gas"

kidney damage non-pungent, pediatric anesthesia

combined with gasses

hypotension

hypotension similar to propofol


similar to PCP; given with benzodiazepine (midazolam) to
emergence delirium, incr BP, incr CO blunt emergence delirium

long QT with droperidol extremely potent! Fatally mixed w/ heroin

torsades des pointes, long QT (>450ms); HTN


may worsen confusion and delirium, behavioral
disinhibition, amnesia, ataxia, respiratory suppression;
hepatic encephalopathy

can also use diphenhydramine (antihistamine) to tx EPS side


effects of antipsychotics

EPS (extrapyramidal SE) including Parkinsonism,


akathisia, tardive dyskinesia [involuntary
movements], hyperprolactinemia, anticholinergic
SEs, sedation, wt gain, orthostatic hypotension,
dystonia, neuroleptic malignant syndrome (NMS) Parkinsonism (rigidity, tremor, bradykinesia), only 30%
[fever, rigidity, cognitive change] treatment response
introduced 1953, initially a sedative
lower potency agenst have lower TD and EPS side effects,
torsades des pointes, long QTc (>450ms) but more autonomic side effects

low anti-cholinergic SEs, and very little alpha1-blockade most potent D2 blocker

most cost effective


low risk EPS, cause fewer secondary negative sx, may
improve cognition, less dysforic mood; wt gain,
hyperglycemia, DM; very expensive

agranulocytosis (monitor WBC), seizures, mycarditis, doctors resistant to prescribing; only clozapine is proven to
wt gain, sedation, orthostasis, tachycardia, be better than typicals; 30% tx rate in tx-resistant pts; more
constipation, sialorrhea, no prolactin SE, no EPS effective tx of negative sx

marginally small benefit over other drugs, but more wt gain


and metabolic Ses

torsades des pointes


no prolactin SE

freezing, dyskinesias -- too much DA release requires existing DA neurons, wears off
valvular heart disease (5-HT mediated)

neuraminidase inhibitors
neuraminidase inhibitors
D2 receptors on ACh interneurons in striatum (block to treat)
innervate GABAergic

valvular heart disease (5-HT mediated)


locked-in syndrome was trying to synth meperidine (opiate)

GI (n/v/d), muscle cramps, fatigue, insomnia, syncope


25% response at 10mg dose, drug benefits mostly in first
GI (n/v/d), muscle cramps, fatigue, insomnia, syncope year of dosing (slows cognitive decline)

GI (n/v/d), muscle cramps, fatigue, insomnia, syncope

GI (n/v/d), muscle cramps, fatigue, insomnia, syncope

constipation, insomnia, dizziness, HA, hallucinations slows rate of decline and improves cognition
high cardiovascular disease risk

hemorrhage, stroke reduces AD risk


no effect on AD

neuro and psych (most common), GI (n/heartburn),


hyponatremia, ALT/AST incr, leukopenia,
thrombocytopenia, wt changes, long term… neuropathy,
cerebellar syndrome, osteomalacia, osteoperosis,
anemia, teratogenesis, facial coarsening, hirsutism,
gigival hyperplasia, rash, Stevens-Johnson syndrome,
aplasia, agranulocytosis start with monotherapy, next try another drug alone…
CYP450 inducer
CYP450 inducer selective CYP3A

CYP450 inhib

CYP450 inducer

CYP450 inhib
monocyte and granulocyte chemotaxis, constrict airways

activate platelets
stimulate mucus and HCO3 production, increase kidney
perfusion, regulate temperature at hypothalamus

vasodilation, edema, potentiate pain stimuli, relax airways

inhibit platelets
vasodilation

asthma tx: inhaled corticosteroids, short acting b2 agonist,


long acting b2 agonist, cromolyn, nedocromyl

liver toxicity requires 4 doses/day

expensive ($12,000 / year)

GI irritation >> hypersensitivity rxn >> nephrotoxicity >>


hepatotoxicity, clotting dz, BM suppression, MI, stroke
long term use --> nephrotoxic; acute liver toxicity if 2-3x >
recommended dose does not treat inflammation

(salycism) chronic high doses --> tinnitus, dzzy, conf,


n; compensated respiratory alkylosis, even acidosis
(respiratory suppression), coma, death if overdose;
Reyes syndrome (encephalitis) in children with VZV restore acid-base balance if overdose and gastric lavage,
and influenza, causes demyelination infuse bicarb to incr pH of urine

less GI toxicity than ASA

potent, but high incidence of GI effects


moderate GI toxicity
low GI toxicity
mild GI toxicity

induces abortion
cardiovascular events,
removed from market

severe necrotizing skin rxns, cardiovascular effects


dermatitis, BM suppression, renal toxicity

highly toxic
chemotherapeutic

re-emergence Tb, autoimmune rxns "molecular sponge" concept

re-emergence Tb, autoimmune rxns, lymphomas

increased emergence of TB, opportunistic pathogens


tx acute attack w/ NSAIDs or cholchicine;

GI, esp diarrhea

GI toxicity

GI irritation

sedation, GI effects, n/v/d/constipation, dry mouth, second generation drugs do not penetrate CNS --> less
urinary retention, hypersensitivity, photosensitivity sedation and anti-muscarinic effects
sedation
sedation
sedation

EtOH withdrawal -- tx w/ benzodiazepines; fetal alcohol


syndrome (short palpebral fissures, flat midface, short
nose, flat philtrum, thin upper lip)

improves from 10 to 20% maintaining abstainance, less


withdrawal sx
nausea with drinking high placebo effect obscures drug effect

see Anxiolytics
see Anxiolytics

do not mix with EtOH, preserve sleep architecture, less next day effect, minimal
REM rebound, low risk tolerance, dependence

do not mix with EtOH, preserve sleep architecture, less next day effect, minimal
REM rebound, low risk tolerance, dependence

do not mix with EtOH, preserve sleep architecture, less next day effect, minimal
REM rebound, low risk tolerance, dependence

cheap
NOT schedule IV agents
do not mix w/ EtOH --> coma; liver toxicity

only NON scheduled agent for insomnia

analgesia, euphoria, sedation, cough suppression; withdrawal has low mortality, altough physical effects are
hypotension, bradycardia, constipation (no tolerance), severe
decreased GI motility, urinary retention, mast cell
histamine release, prolonged labor, decreased uterine
contractions, respiratory suppression, miosis (no
tolerance); potentiation of effects w/ BZD, EtOH,
tricyclics, antipsychotics, MAO-Is

cough suppressant

lower abuse potential


does not produce "high"

schedule II

tolerance and addiction possible

withdrawal

withdrawal

can ppt withdrawal NOT used clinically

very few ADEs, but slow kinetics

renal dysfunction, arrhythmias, GI distress, tremor, anticonvulsants (carbamazepine or valproic acid) may also
cognitive impairment, hypothyroidism, 1st semester be used to tx bipolar disorder; mechanism unknown, may
congenital abnormalities (heart defects); edema, inhib inositol production or inhib cAMP synth?; very low
polydypsia, polyuria, mental status changes, ataxia; therapeutic index… toxic > 1.5 mEq/L
interactions with diuretics, NSAIDs
do not give if mixed OD with EtOH or TCA, can ppt no effect on other CNS depressants
withdrawal if pt is dependent
narrow margin of safety; respiratory depression, CYP rarely used
induction, tolerance/dependence, withdrawal; incr
porphyrin synth

tolerance/dependence if long term, potential OD decreased sleep latency, decreased stage 4 and REM,
when combined w/ other sedating drugs --> increased stage 2, increased total sleep time; toxicity can
(respiratory suppression, coma, seizures, death), take 7-10 days to occur, steady state can take 1-2 wks;
drowsiness, ataxia, disinhibited, paradoxical cross-tolerance to barbiturates, severe alcoholics; schedule
aggression (rare), allergic (rare), anterograde IV drugs, reduce dose w/ elderly, rapid tolerance in 1-2 wks;
amnesia (esp short-acting agents), morning wider safety margin than barbiturates
drowsiness; discontinuation can cause rebound
anxiety, incr REM sleep (less physically restful),
withdrawal if abrupt; CIs: liver damage, age, COPD,
sleep apnea; tobacco decreases BDZ levels via
induction; crosses placenta and breast milk; do not
mix with EtOH

original BZD, NOT used for sleep

often used with mood stabilizers

daytime psychomotor impairment, NOT used for sleep

Fast acting: requires frequent dosing, earlier w/d sx, rebound


anxiety, anterograde amnesia

useful if impaired liver function

pseudoparkinsonism dangerous if OD

low risk seizures (0.01%), CI if head injury, seizure hx, no sexual side effects, no serotonin effects
eating disorder

wt gain, sedation no sexual side effects

liver failure no sexual side effects, no longer on market

sedation, priapism, orthostatic hypotension no overdose possible

also blocks ACh (alpha1 and muscarinic) and three ring structure
antihistamine (sedating): dry mouth, constipation, dizzy,
tachycardia, urinary retention, decr libido, orthostatic
hypotension, wt gain; cardiotoxicity (arrhythmias),
delerium, respiratory depression, potentiation of sedating
drugs; high risk suicide b/c low therapeutic index
stimulates appetite

only TCA to have serotonin reuptake inhibition


very low toxicity, can worsen anxiety initially (initial can use BZDs short term until titrated up; cognitive
neurovegetative improvement before mood behavioral therapy (CBT) also; panic disorder tx requires
improvement); nausea, sexual dysfunction (delayed slow titration and low dose
ejaculation, anorgasmia), insomnia, anxiety;

most likely to cause GI Ses

the most specific SSRI

SEs are similar to SSRIs

idiopathic HTN at high dose


no hypertensive effect
hypertensive crisis with the consumption of tyramine MAO-A in DA and NE neurons, also in intestinal tyramine
(or other pressor agents / sympathomimetics) --> breakdown; MAO-B in 5-HT neurons, not in intestines;
dietary restrictions (red wine, smoked meats, serotonin syndrome = hyperthermia, muscle rigidity,
cheeze), drug interactions (stimulants, meperidine, myoclonus, mental status changes
levodopa, cold medicines); n/v chills, sweating; risk
if combined with other 5-HT inhibitors --> serotonin
syndrome (must wait 2 wks for washout before
switching drugs);

not FDA approved yet

Das könnte Ihnen auch gefallen