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Antimetabolites
Topically used:
o SULFACETAMIDE
o SILVER SULFADIAZINE
High BA 70-100% (- topical), 70% PPB, distributed well (including CSF), cross placenta,
metabolized in liver, excreted renally
SE – hypersensitivity reactions (SJ syndrome, uticaria, exfoliative dermatitis, eyrthema
multiforme)
Photosentitivity (more with cotrimoxazole) Increase potential for sunburn, stone formation,
opportunistic infection
Contraindication infants: displacement of bilirubin from albumin -> jaundice -> kernicterus
Rapidly absorbed from GIT, 42-46 PPB%, Well distributed in all of body water, Concentrates in
tissues, T1/2 =8-10 hrs, Eliminated renal, Minimal glucoronylation in liver
COTRIMOXAZOLE (sulphamethoxazole and trimethoprim (5:1))
o BENZYLPENICILLIN (PEN G) (NB destroyed in stomach, given with K + and Na+, 0.5hr, R)
IV, IM
45-65% ppb
UTI, meningitis, Peitonitis
MIC 0.01mg/ml for Strep.4-8 mg/ml Salm
o BENZATHINE PENICILLIN
o PROCAINE PENICILLIN
Orally absorbed penicillins resembling PEN G:
o PHENOXYMETHYLPENICILLIN (PEN V)
Cephalosporins (betalactam, higher generations less effective against gram +ve, more against –ve)
Cephalothin (Keflin)
Cefazolin (Ancef) (2hrs, R)
o IV, IM
o 74-86% PPB
o MIC 0.1-0.25 mg/l for Strep.1-2 mg/l Salm
Cephapirin
Cephradine
Cephalexin
Cefadroxil (Duricef)
Second Generation (RTI, otitis media, acute sinusitis, prophylaxis in abdominal surgery; O, P)
Cefamandole
Cefoxitin
Cefuroxime (Zinnat)
Cefaclor (Keflor) (0.6 – 0.9 hrs, R)
o O
o 25% PPB
o MIC 0.25 mg/l for Strep. 0.06-0.25mg/l Salm
Third Generation (meningitis, otitis media, ceftazidimine covers pseudomonas; O, P) accumulates well in
CSF
Cefotaxime
Moxalactam
Cefoperazone
Ceftizoxime
Ceftriaxone (Rocephin) (7-8 hrs, R)
o O, Parenternal
o 20% PPB
o MIC 0.03mg/ml Strep, 0.5-1 mg/ml Salml, MIC 2.0 ug/ml for Staph.
Ceftazidime
Cefsulodin
Cefmenoxime
Cefixime
Fourth Generation
Cefepime
Carbapenems
o Imipenem (Primaxin )
o Meropenems (Merremâ)
Monobacatms
o Aztreonam (Azactam)
o Moxolactam
Notes: sysnthetic compounds, made due to counteract resistance to betalactams, effective against H.
influenza, P. auruginosa, Enterobacteria
VANCOMYCIN (Binds to d-alanyl-d-alanyl terminal subunits through hydrogen bonding and therefore
terminates cross-linking to form cell wall layers) - Bacteriocidal
Gram positive only, last resort, poor O, IV, 6hrs, 55% BPB, accumulates in body fluids, R
SE: nephrotoxicity, ototoxicity, macular rash, hypotension, allergic reaction, flushing, pain at site of
injection
Quinolones (inhibits topoisomerase IV [+ve] or DNA gyrase [-ve], Bactericidal at 30 X the MIC)
Notes: effective against enterobacteria, not effective gram +ve, anaerobes, pseudomonas
Aminoglycosides ( Binds to receptor site on 30s ribosomal sub-unit: Prevents translocation of peptidyl-
tRNA from A site to P- site, blocks initiation of protein synthesis, causes misreading of the mRNA codon-
incooperation of incorrect blocks further translation and cause premature termination of protein
synthesis)
STREPTOMYCIN
KANAMYCIN (20 days, R)
o P, IM
o MIC 2.0 mg/l for Staph
AMIKACIN (2 - 2.3hrs, R)
o P, IM
o MIC 16 mg/l for Staph. 1.0 Ecoli
TOBRAMYCIN
GENTAMICIN (2-3 hrs, R)
o P, IM
o 20-30% PPB
o UTI, meningitis, peritonitis
o MIC 0.4 mg/l for Staph
PAROROMYCIN
Entry into cell-active transport process. Then pass into cells via a energy transport process (involving
Ca2+ ions). This transport process can be blocked by Ca2+, Mg2+, acidic pH low redox conditions
SE: low TI, pain at injection site, nephrotoxic, ototoxic, NMJ blockage, allergic reaction
Tetracyclines (: Binds to 30s ribosomal unit of the A site and prevents access of aminoactyl tRNA to the
codon. Entry into bacterial cell is energy dependent.) Bacteriostatic
Chloramphenicol (Bind to site of 50s & prevents the action of peptidyltrasferase: therefore inhibiting
protein synthesis by preventing transpeptidation) – Bacteriostatic
Palminate – O
Succinate – P
Elimination by glucoronylation
Macrolides (Bind to site of 50s & prevents the action of translocation (i.e. ribosomal shift to allow A site
to become P site inhibited), therefore inhibiting protein synthesis . Bacteriostatic (may be bacteriocidal
at high doses)
Metronidazole
Ferredoxin used by anaerobes w/o mitochondria, acts as electron donor to metronidazole which binds
to DNA causing destruction
Antineoplastic Drugs
Non-cycle specific
Alkylating Agents (alkylate DNA within N7 position of guanine, causes miscoding, cleavage, crosslinking)
Alkyl Sulfonates
Platinum analogues (intra strand cross link) (LUNG CANCER, ESOPHANGEAL AND GASTRIC CANCER,
OVARIAN BREAST)
Cisplatin
o Water soluble
o Slow IV
o Nephrotoxic, severe nausea and vomiting, given with ondanserton, tinnitus, anaphylaxis
Carboplatin
o Derivative of cisplatin w/ less SE
Oxaplatin
Antimetabolites
Folate Antagonists (DHF -> THF by DHFR, DHFR inhibited, purine and thymidylate sysnthesis cease)
5-fluorouracil
o Converted to fdUMP inhibits thymidylate
o Colorectal cancer (+ levasimole), breast cancer
o IV
Cytarabine (cytosine arabinoside, ARA-C) (10min, 2hrs?)
o Falsely incorporated in DNA
o IV
o Acute leukemia, non-hodgkins lymphoma (anthracyclines)
o Cerebellar dysfinction
Natural Products
VInca Alkaloids (binds to tubulin, M specific, arrest mitosis)
Vinblastine
o IV weekly
o Hodgkin disease, lymphomas
o Nausea, emesis, marrow depression, alopecia
Vincristine
Vinorelbine
Podophyllytoxin (cytostatic glucosides – blocks cell in late S-G 2 phase, inhibit topoisomerase II, damage
to DNA)
Etoposide
Teniposide
O, IV
R
Monocytic leukemia, testicular cancer, oat cell carcinoma of lung)
Topotecan
o Prodrug -> SN-38
o Metastatic ovarian cancer (cisplatin resistant)
o Neutropenia, thrombocytopenia, anemia
Irinotecan
o Colon/rectal cancer
o Severe diarrhea, myelosuppression
Paclitaxel (Taxol)
o Ovarian and advanced breast cancer
Docetaxel (Taxotere)
o Advanced breast cancer
Hormones
Estrogens
Oestradiol
o Gynecomastia
o Prostate, testicular cancer
Antiestrogens
Tamoxifen
o Binds to estrogen receptors
o G1 phase, highly protein bound, active metabolite
o SE: hot flashes, fluid retention, nausea, amenorrhoea
o Primary therapy for metastatic breast cancer (men and postmenopausal women)
Reloxifene
Faslodex
Androgens
Testosterone
o Masculinisation
o Breast cancer
Antiandrogen
Flutamide
o Antagonizes androgenic effect
o Prostate cancer
GnRH agonist (paradoxic effect on pituitary, stimulate release of FSH and LH, then inhibits these
hormones, results in reduced testicular androgen synthesis)
Leuprolide
Goserelin
Gynecomastia, edema, thromboembolism
Metastatic carcinoma of prostate, hormone receptor-positive breast cancer
Aromatase Inhibitors
Aminogluthethimide
o Inhibit aderenal steroid synthesis
o Inhibits enzyme aromatase
o Dizziness, lethargy, visual blurring, rash
o Positive metastatic breast cancer
Anastrozole
Glucocorticoids
Prednisone
o Cushings’s syndrome
o Lymphoma
Progestins
Megestrol
o Fluid rentention
o Endometrial cancer
Finasteride (Proscar®)
Procarbazine: forms active metabolites which cause DNA breaks, DI with alcohol
Radioactive isotopes: Iodine-131, Cobalt-60
AVASTIN
ABVD
MOPP
Antiviral
Viral Uncoating Inhibitors (inhibits influenza A, inhibit M2 protein -> viral envelope -> enables H+ to
enter -> facilitates uncoating)
Amantadine (18hrs, R)
o O (slow), peak 3-4hrs
o Low PPB
o Insomnia, dizziness, dry, mouth, teratogneic
Rimantadine
Given in combination
IV, SC – 100mg/bid
BA by SC = 84%
92% PPB
Nebirapine (1hr, H)
o Good O, 93%
o 60% PPB
o Low SE, SJ syndrome
Delaviridine (5hrs, R)
o 85% BA
o 98% PPB
o Low SE, allergic reaction
Interferons-antiviral state promoters (cytokines -> increase antiviral state in cells, triggered by
abnormal amounts of dsRNA) -> binds to cell -> causes synthesis of protein kinases that prevent
translation + synthesis of endonucleases which destroy viral mRNA
Alpha – produced by WBC
Beta – produced by connective tissue fibroblasts
Gamma – produced by T-lymphocytes
Broad spectrum: DNA (HSV1/2, HPV, VZV, HBV), RNA (influenza, HCV)
Parenternal only: IM, SC
Also Topical in nasal spray
SE: flu-like symptoms, fatigue, depression, muscle weakness, change in thyroid finction, bone
marrow suppression with high doses
Protease Inhibitors (inhibition of late protein assembling, used in combination) (< 1hr, H cyp450)
Saquinavir
o Variable O
o 98% PPB
o Distributes well in tissue
o SE: nausea, diarrhea, hyperglycemia, hepatotoxic
Ritonavir
Indinavir
Darunavir
Antifungals
Amphotericin B (bind to ergosterol causing pore formation in membrane) (very slow R [up to
2mnths], 1-2 days and 15 days
o Streptomyces nodosus
o Topical, poor O, slow IV (lipophillic)
o Colloidal suspension e.g. sodium deoxycholate susp – C-AMB
o Lipid formulations (less toxic) e.g. cholerteryl sulphate
o SE: cytokine release (fever, shaking chills) with 1 st dose preventable by giving aspirin or
glucocortocoid, pain, seizures, phlebitis (prevented by heparin), hypokalemia,
nephrotoxicity (80%)
o >90% PPB
o SE: hypotension, emesis, headache, labored breathing (1-3 hours after start of IV, rare)
o Accumulates in tissue, low CSF, increases with inflammation
Nystatin (bind to ergosterol causing pore formation in membrane)
o Streptomyces moursei
o Broad spectrum, superficial only, fungicidal
o Only topical (insoluble in water and plasma
o Only oral, vaginal and intestinal
o SE: nausea, diarrhoea
Azoles (competitive inhibition of lanosterol demthylase, inhibits ergosterol, cell membrane
integrity)
o Fluconazole (27-37 hrs, R)
O, IV
Fluoride triazole
Drug of choice for cryptococcal meningitis
11% PPB, accumulates in tissue high CSF
SE: GIT upset, nausea, rare hepatitis and SJ syndrome
Negligible inhibition of p450
Nail infection (tinea unguium) 150mg
o Itraconazole
o Ketoconazole (1-4hrs and 6-10hrs, M P450 -> B)
Good O in stomach, IM
Broad spectrum, fungistatic
90% PPB, poor CSF
SE: inhibit steroids (used in prostate cancer), inhibits p450, rashes, pruritus
o Clotrimazole
Topical only, 1% creams, 100-500mg vaginal tablets, lozenges
Vaginal candida, dermatophytes
SE edema, pruritus, urticaria
Terbinafine (reversible non-competitive inhibition of ergosterol synthesis (squalene epoxidase)
(200-400hrs, R)
o O
o 250mg for 6 weeks, toenail and fingernail
o Low BA = 40%, >99% PPB, accumulate in skin, nail, fat
o Dermatophytes (alternative to griseofluvin)
o SE: inhibit cyp450, neutrapenia, lymphocytopenia, hepatic failure (contraindication
hepatic failure patients
o Tines unguium nail infections, 250mg, qid 6-12 weeks
Flucytosine (prodrug, pyrimidine analog, cytosine deaminase coverts to 5-fluorouracil, enzyme low in
host cell -> 5-FdUMP -> inhibit thymidylate synthase and disrupts DNA, RNA, protein synthesis) (2.5-
6hrs, R)
O, slow absorption
Systemic infection + AMPHOTERICIN B or AZOLES (reduces resistance)
SE: nausea, emesis, bone marrow suppression)
Griseofulvin (from penicillium, specific for dermatophytes, accumulates in newly synthesized keratinized
tissue -> when fungus enters tissue it binds to microtubules, inhibits mitosis -> no effect on mature
infected cells)
O, slow absorption, peak plasma conc 5 hr, give with fatty meal
Dermatophytes only, 1st line
Fungistatic, CROSSES PLACENTA
Induces cytp450
SE: leucopenia, granulocytopenia, photosensitivity, hepatic failure
Antiprotozoal
Quinoline compounds (increase pH in plasmodium food vacule, prevent digestion of haemoglobin,
blood schizonticidal drugs)
Primaquine (inhibiting electron transport in plasmodium -> generates reactive species) (6 hrs, M)
Gametocidal (P falciparum)
Tissue schizonticidal (relapse due to vivax and ovale)
Good O, 1-2 hrs
No IV, causes hypotension
Concentrates in tissues, not in RBC
Haemolysis in G6PD
Abdominal cramps
Folate Inhibitors
Tissue trophozites (mucosal cells -> intestinal amoeabiasis, liver -> liver abscesses)
Combinations
Benzimidazoles (bind to b-tubulin, inhibit microtubule polymerization -> reduced glucose uptake
reduced oxidative phosphorolation, also inhibit mitochondrial fumarate reductase) –
vermicidal, larvicidal, ovicidal
o Thiabendazole (Mintezol)
o Mebendazole (Vermox) (2-6 hrs, F + M (high first pass)
Poor O (10%)
90% PPB
SE: nausea, emesis, diarrhea (rare)
Contraindication: pregnancy, infants
o Albendazole (Zentel) (8-12 hrs, F + M)
Poor O (< 5%), increased with fat meal
SE: nausea, diarrhea, insomnia, hypotension, hypersensitivity
Contraindication – pregnancy (teratogenic)
Piperazine (GABA receptor agonist – flaccid paralysis) (R)
o Citrate salt (Vermizine)
o Good O absorption
o Contraindication: epilepsy
o SE: dizziness, ataxia, visual disturbances
Pyrantel Pamoate (Antiminth) (increase Ach accumulation – spastic paralysis)
o Poor oral absorption
o SE: nausea, dizziness, headaches
Ivermectin (opens CL- ion channels -> hyperpolarization -> flaccid paralysis) (16 hrs, H -CYP450)
o Slow oral, peak plasma 4-5 hrs
o Distributes in tissue, does not criss BBB
o 93% PPB
o SE (rare) – nausea, emesis, diarrhea
Diethylcarbamazine (Hetrazan) (Renders larva more susceptible to host destruction) (2-13hrs
depending on urine pH, R 50%, M 50%)
o Good oral, peak plasma conc 1-2 hrs
o SE (rare): nausea, emesis, diarrhea
Trematodes
Praziquantel (Biltricide)
Cestodes
Praziquantel (increase membrane permeability to Ca -> spastic paralysis) (1-3 hrs, high first pass
M, R and B)
o Good oral
o Peak Plasma 1-2hrs
o 80% PPB
o SE: headaches, dizziness, nausea, drowsiness
Niclosamide (inhibit oxidative phosphorlation, scolex becomes susceptible to gut enzymes, rapid
vermicidal action only) F
o Poor oral (empty GIT, chewable tablet)
o Laxative for full expulsion
o SE: nausea, emesis, diarrhea
[Cysticercosis – pork tapeworm, larva invade CNS, eye -> praziquantel (prolonged high dose),
albendazole (1st line), infection of eye - prednisolone]
Contracts ileum
Increase mucous secretion -> diarrhea
Antagonist – epinephrine
Vasodilation
Bronchioconstriction -> asthma
Contraction of uterus -> abortion
Allergy triple response
Antagonists
o Ethanolamines
Diphenhydramine (may inhibit muscarinic receptors)
Sedative, local anesthetic, antimuscarinic, antemetic
Dimenhyrinate
o Ethylenediamines
Mepyramine (weak everything, fail)
o Alkylamines
Chlorphenamine – daytime use
o Piperazines (long duration, low sedation, good antimuscarinic, very good antiemetic)
Cyclizine
Meclizine
Chlrocyclizine
Cetirizine (anaphylaxis, adjunct with epinephrine)
Phenothiazine-mequitazine
o Phenothiazines
Promethazine (may inhibit α1-adrenoceptors) -> epic win at everything
o Piperidines
Terfenadine Astemizole
Loratadine
SE: dry mouth, blurred vision, constipatiom, urinary retention, tinnitus, dizziness, fatigue,
excessive produce convulsions excitation in children, topical can cause allergic dermatitis
Bradykinin
B1
B2
5HT Agonists
5HT4 agonists
o Cisapride – reflux oesophagitis, disorders of gastric emptying, can cause diarrhea
o Metoclopramide – same as above
o tegaserood – irritable bowel syndrome
5HT1
o Sumatriptan – migraine treatment
5HT2
o Ketanserin, cyproheptadine, pizotifen, ergot alkaloids (methysegide,
dihydroergotamine) – prophylactically in migraine
o Pizotifen, Ketotifen – extrinsic asthma
Eicosanoids
Prostanoids
o Prostaglandins
o Thromboxanes
Leukotrienes
Synthesized from AA (phospholipase A2), released by cellular injury, c5a, thrombin on platelets,
bradtkinin, antigen-antibody reaction, epinephrine
AA + cox = prostanoids
AA + lipoxygenase = leukotrienes
Cox1 – found in most cells, physiological function
Cox2 – inducible during inflammation, macrophages + mast cells etc (target for inflammatory
drugs eg rofecoxib)
Prostanoids
PGI2: IP
Vasodilation
Inhibit platelet aggregation
Stimulates rennin release and natriuresis
Inhibits gastric secretion
Hyperalgesia
Vasodilation
Inhibits platelet aggregation
Relax GIT smooth muscle
Relax uterine muscles
Bronchioconstriction (TP receptors – low affinity)
Modifies release of pituitary hormone
TXA2: TP
Vasoconstriction
Bronchioconstriction
Platelet aggregation – might precipitate thrombosis
Calor: PGE2
PGE1 analogue
PGE2 analogue
PGF2 α analogue
PGI2
LTB4: BLT
CysteinylLTs: CysLT
Inhibitors of Leukotrines
CysLT
o Zafirlukast – adjunct to other antiasthmatic
o Montelukast – prevent acute attack
5-lipoxygenase
o Zileuton – antiinflammatory, antiasthmatic
o Piripost – antiinflammatory, antiasthmatic
Immunoreceptors
Selective immunosuppressive
Cyclosporine (inhibition of release and receptor of IL-2 -> lower T helper and CD8+ cytotoxic T cell, binds
to cyclophilin -> calcineurin) 24hrs, H cp450
O, IV
Acute and chronic suppression of organ rejection (heart, kidney, liver, pancreas)
Given with PREDINOSOLONE
SE: nephro, neuro, hepato toxicity, hypertension/kalemia, hirsutism, NO BONE MARROW
SUPPRESSION
Tacrolimus (macrolide antibiotic, similar to cyclosporine except binds to FKBPs instead) 7hr, H CP450
O, IV
X10-100 Greater than cyclosporine
Used for prophylaxis against liver and kidney
Preferred in liver transplants than cyclosporine
Given with: GLUCOCORTICOID
SE: more toxic than cyclosporine, neuro, nephro hepato toxicity, hypertension/glycemia,
thrombocytopenia, NO HIRSUTISM
Non-selective immunosuppressants
Corticosteroids (H) (decrease IL1-8, binds to GM-CSF, inhibits PGE2 -> reduced cox2, reduce
iNOS, leukotriene synthesis, histamine release from basophils, IgG production, complement
components)
o Prednisolone
O, IV, IM, inhalation
RA, SLE, Myasthenia gravis
Suppress allograft rejection
Infection
Cushing’s syndrome, osteoporosis, hyperglycemia, glaucoma, orapharyngeal
candidasis
Increase osteoclast activity, decrease osteoblast activity, affect phosphorous
and calcium metabolism. Insulin resistance
o Deamethasone
Cushings syndrome – buffalo hump, hypertension, thin skin, thin limbs, muscle wasting, benign
intercranial hypertension, cataracts, moon face, increased abdominal fat, avascular necrosis of femoral
head, easy bruising, poor wound healing
O, IV, IM
Extremely powerful
Ablate lymphoid elements for bone marrow transplant
SLE, hemolytic anemias, Wegeners granulomatosis
Given with PREDNISONE + ANTILYMPHOCYTE GLOBULIN
SE: bone marrow suppression, thrombocytopenia, hemorrhagic cystitis, nausea, emesis)
Methotrexate (folate analogue, dihydrofolate reductase) (8-10hrs, H, conversion to polyglutamates)
O, IM, IV
Given with CYCLOSPORINE for prophylaxis of GvHD, bone marrow transplant, severe RA
Psoriasis refractory to other drugs
SE: bone marrow suppression, hepatic fibrosis, cirrhosis, pneumonitis, GIT epithelial damage
Azathioprine (prodrug to 6MP, S phase specific, inhibits DNA synthesis, inhibits T and B in induction
phase) (10-20mins, 6-MP 50mins in adults, H)
O, IV
Renal transplantation, hemolytic anaemias, acute glomerulonephritis
Amplified by ALLOPURINOL (xanthine oxidase breaks down azathioprine)
SE: bone marrow suppression, hepatotoxicity, nausea, emesis
Mycophenolate Mofetil (synthetic estser from fungus, hydrolyzed in GIT -> mycophenolic acid,
reversible inhibition of monophosphate dehydrogenase -> purine sysnthesis, inhibits T and B cell and
leukocyte recruitment) (18hrs, H)
Good O
Given with CORTICOSTEROIDS + CYCLOSPORINE
Mg(OH)2 and Al(OH)3 impair absorption
Immunosuppressive antibodies
Basiliximab, Daclizumab (monoclonal antibodies against IL-2 receptor)
o IV
o Kidney transplant
o Serious hypersensitivity, abdominal pain
Muromonab-CD3 (monoclonal antibody against CD3 on T cells)
o IV
o Renal, cardiac allograft rejection
o Anaphylactoid reactions, seizures, high fever
Anti-lymphocyte globulin (destroys T cells)
o Given with ANTIMETABOLITES and CORTICOSTEROIDS
o Allograft rejection kidney
o Aplastic anemia