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FOREWORD TO THE FIRST EDITION
It is common knowledge that books play a major complementary and contributing role in any educational process. While they are envisioned to facilitate self-learning beyond classroom exercises, not all of them promote learning; some, indeed, hinder it.
To be useful and worthwhile, a book has to be so designed as to present an appropriate body of knowledge in a style that suits students in a particular stage of learning: undergraduate, postgraduate, or postdoctoral.
Accordingly, a book in pharmacology for MBBS phase-II students would have a body of knowledge that relates with the study-course objectives and contains ‘must know’ and ‘nice to know’ levels of factual, conceptual and applied aspects of the subject. It has a presentation style that offers an integrated composite picture of the subject interspersed with lucid explanations, cogent reasoning and logical networking of information. Contents will enable students to grasp topics in proper perspective and trigger students’ higher mental skills like critical thinking, logical reasoning, etc. Proficiency so acquired would enable the students to not only clear qualifying tests but also to wisely manage drug issues in future.
Designing such a book is a challenging task, especially if it is to be concise and comprehensive in scope. Such a version demands wise sifting, prudent pruning and meaningful condensing of the enormous and variegated knowledge base of pharmacology.
Commendably, Dr (Mrs) Tara Shanbhag has accomplished this in her very first venture. A fairly large number of charts, diagrams and other forms of illustrations in the text amply demonstrate this. No wonder, she has received ‘Good Teacher’ award time and again.
A well written concise book as this one, serves twice as a preparatory tool: at the start of the study-course it provides a road-map of the subject to be learnt and thus tunes the students for deeper learning; and at the course-end (and examination time) it helps in rapid review and recapitulation of what is learnt.
I am confident that this well thought out and well planned book, Preparatory Manual of Pharmacology for Undergraduates by Dr Tara V Shanbhag will be of tremendous use to the students.
With pleasure, I compliment Dr (Mrs) Tara V Shanbhag, an erstwhile postgraduate student of mine, for such a fine piece of work.
Professor DR Kulkarni
Formerly: Head, Department of Medical Education, BM Patil Medical College, Bijapur; Director of PG Studies, Head, Department of Pharmacology, KMC, Manipal; Principal, Dr. Patil Medical College, Kolhapur; Head, Department of Pharmacology, JNMC, Belgaum; President, Pharmacological Society of India (1995)
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PREFACE TO THE FOURTH EDITION
Pharmacology is a vast subject and one of the fast-growing branches of medical science and requires addition of latest information from time to time. The present fourth edition includes significant expansion and revision of the third edition. Some new topics like drug dosage forms and calculation of dosage of drugs have been included. The cardiovascular drug summary table also have been included for quick revision. The style has been retained in the form of simple diagrams, self-explanatory flowcharts, tables and student-friendly mnemonics. The textual presentation in tabular format helps in quick reading and recall. Definitions and treatment schedules have been incorporated as per various guidelines.
This extensively revised and updated edition will be useful not only for the students of medicine but also for the practicing doctors as well. This book will also help postgraduates of pharmacology and other clinical subjects for quick revision of pharmacology and therapeutics.
We are extremely thankful to our students and colleagues, who had given us valuable feedback for this edition.
We hope this edition will meet the requirements of the undergraduate medical students and serves as a better learning tool. We would sincerely appreciate critical appraisal of this manual and suggestions for further improvement in future.
Tara V Shanbhag Smita Shenoy
PREFACE TO THE FIRST EDITION
Pharmacology is a vast subject with many crucial aspects related to drugs, their composition, uses, effects, interactions, etc. which make the subject complicated and difficult to comprehend.
During the course of interaction with my students as well as those of other universities where I went as an examiner, I realized the difficulties faced by them while preparing for their exams due to vastness of the subject. This motivated me to write a preparatory manual that condenses this vital subject into essential elements and yet covers the undergraduate syllabus.
The present book thus is a concise exam-oriented preparatory manual. The text is presented in a simple, precise and point-wise manner. This style of presentation would not only make it easier for the students to understand the subject in a better manner, but would also help them to quickly review and revise the subject before examination. Further, to make learning simpler and comprehension easier for the students, numerous tables, flowcharts and line diagrams have been included.
A large number of people have helped me make this book possible. For this, I thank my postgraduate students and colleagues.
I am grateful to Professor DR Kulkarni for his guidance and suggestions and for writing the Foreword.
I would appreciate critical appraisal of this manual and suggestions for improvement.
Drugs Used in the Treatment of Rheumatoid Arthritis 251
Drugs Used in the Treatment of Cough 254
Drugs Used in the Treatment of Bronchial Asthma 256
7 Drugs Used in the Treatment of Gastrointestinal Diseases 263
Emetics and Antiemetics 263
Antidiarrhoeal Agents 270
Pharmacotherapy of Inflammatory Bowel Disease 272
Laxatives (Purgatives, Cathartics) 274
Pharmacotherapy of Peptic Ulcer and Gastroesophageal Reflux Disease 277
8 Drugs Affecting Coagulation and Blood Formation 285
Drugs Affecting Coagulation and Bleeding 285
Haematinics and Haematopoietic Growth Factors 297
9 Endocrine Pharmacology 303
Introduction 303
Hypothalamic and Pituitary Hormones 304
Thyroid and Antithyroid Drugs 309
Sex Hormones and Their Antagonists 316
Corticosteroids 331
Insulin and Oral Antidiabetic Agents 341
Agents Affecting Calcium Balance 354
10 Drugs Acting on Uterus 362
Uterine Stimulants and Relaxants 362
11 Chemotherapy 367
Sulphonamides 375
Quinolones and Fluoroquinolones 378
Penicillins 383
Cephalosporins 390
Carbapenems 393
Monobactams 394
Aminoglycosides 394
Tetracyclines 398
Chloramphenicol 401
Macrolides 402
Miscellaneous Antibacterial Agents 405
Urinary Antiseptics 409
Drugs Useful in the Treatment of Sexually Transmitted Diseases 410
Antituberculosis Drugs 412
Antileprotic Drugs 419
Antifungal Agents 422
Antiviral Agents 430
Antimalarial Drugs 438
Antiamoebic Drugs 448
Anthelmintics 454
Anticancer Drugs 459
12 Miscellaneous Drugs 470
Chelating Agents 470
Immunosuppressants and Immunostimulants 472
Antiseptics and Disinfectants 476
Vitamins 479
Minerals 483
Vaccines and Antisera 485
Drugs Used in Common Skin Diseases 487
Drug Therapy of Scabies and Pediculosis 490
Topical Drugs used for Common Diseases of Eye, Nose and Ear 491
Enzymes in Therapy 493
Drug Treatment of Medical Emergencies 494
Drug Dosage Forms 495
Calculation of Dosage of Drugs 498
Index 505
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Code Competency
Topic: Pharmacology
PHARMACOLOGY
PH1.1 Define and describe the principles of pharmacology and pharmacotherapeutics.
PH1.2 Describe the basis of Evidence based medicine and Therapeutic drug monitoring.
PH1.3 Enumerate and identify drug formulations and drug delivery systems.
PH1.4 Describe absorption, distribution, metabolism & excretion of drugs.
PH1.5 Describe general principles of mechanism of drug action.
PH1.6 Describe principles of Pharmacovigilance & ADR reporting systems.
PH1.7 Define, identify and describe the management of adverse drug reactions (ADR).
PH1.8 Identify and describe the management of drug interactions.
PH1.9 Describe nomenclature of drugs i.e. generic, branded drugs.
PH1.10
Describe parts of a correct, complete and legible generic prescription. Identify errors in prescription and correct appropriately.
PH1.11 Describe various routes of drug administration, eg., oral, SC, IV, IM, SL.
PH1.12 Calculate the dosage of drugs using appropriate formulae for an individual patient, including children, elderly and patient with renal dysfunction.
PH1.13 Describe mechanism of action, types, doses, side effects, indications and contraindications of adrenergic and anti-adrenergic drugs.
PH1.14 Describe mechanism of action, types, doses, side effects, indications and contraindications of cholinergic and anticholinergic drugs.
PH1.15
Describe mechanism/s of action, types, doses, side effects, indications and contraindications of skeletal muscle relaxants.
PH1.16 Describe mechanism/s of action, types, doses, side effects, indications and contraindications of the drugs which act by modulating autacoids, including: antihistaminics, 5-HT modulating drugs, NSAIDs, drugs for gout, anti-rheumatic drugs, drugs for migraine.
PH1.17
Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of local anesthetics.
Code Competency
PH1.18 Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of general anaesthetics, and pre- anesthetic medications. Y 5 173 – 181
PH1.19 Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of the drugs which act on CNS, (including anxiolytics, sedatives & hypnotics, anti-psychotic, anti- depressant drugs, antimaniacs, opioid agonists and antagonists, drugs used for neurodegenerative disorders, anti-epileptics drugs).
Y 5 164 – 173, 192 – 229
PH1.20 Describe the effects of acute and chronic ethanol intake. Y 5 189 – 191
PH1.21 Describe the symptoms and management of methanol and ethanol poisonings. Y 5 191
PH1.22 Describe drugs of abuse (dependence, addiction, stimulants, depressants, psychedelics, drugs used for criminal offences).
PH1.23 Describe the process and mechanism of drug deaddiction.
PH1.24 Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of the drugs affecting renal systems including diuretics, antidiureticsvasopressin and analogues.
Y 1, 5 39, 217
Y 1, 5 39, 190 – 191, 204 – 205
–
PH1.25 Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of the drugs acting on blood, like anticoagulants, antiplatelets, fibrinolytics, plasma expanders. Y 3, 8 285 – 296, 142 – 143
PH1.26 Describe mechanisms of action, types, doses, side effects, indications and contraindications of the drugs modulating the renin- angiotensin and aldosterone system.
PH1.27 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of antihypertensive drugs and drugs used in shock.
PH1.28 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in ischemic heart disease (stable, unstable angina and myocardial infarction), peripheral vascular disease.
PH1.29 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in congestive heart failure.
PH1.30 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the antiarrhythmics.
PH1.31 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in the management of dyslipidemias.
PH1.32 Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of drugs used in bronchial asthma and COPD.
PH1.33 Describe the mechanism of action, types, doses, side effects, indications and contraindications of the drugs used in cough (antitussives, expectorants/ mucolytics).
Code
PH1.34
PH1.35
Competency
Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of the drugs used as below:
1. Acid-peptic disease and GERD
2. Antiemetics and prokinetics
3. Antidiarrhoeals
4. Laxatives
5. Inflammatory Bowel Disease
6. Irritable Bowel Disorders, biliary and pancreatic diseases.
Describe the mechanism/s of action, types, doses, side effects, indications and contraindications of drugs used in hematological disorders like:
1. Drugs used in anemias
2. Colony Stimulating factors.
PH1.36
PH1.37
PH1.38
PH1.39
Describe the mechanism of action, types, doses, side effects, indications and contraindications of drugs used in endocrine disorders (diabetes mellitus, thyroid disorders and osteoporosis).
Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used as sex hormones, their analogues and anterior Pituitary hormones.
Describe the mechanism of action, types, doses, side effects, indications and contraindications of corticosteroids.
Describe mechanism of action, types, doses, side effects, indications and contraindications the drugs used for contraception.
PH1.40 Describe mechanism of action, types, doses, side effects, indications and contraindications of 1. Drugs used in the treatment of infertility, and 2. Drugs used in erectile dysfunction.
PH1.41 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of uterine relaxants and stimulants.
PH1.42 Describe general principles of chemotherapy.
PH1.43 Describe and discuss the rational use of antimicrobials including antibiotic stewardship program.
PH1.44 Describe the first line antitubercular dugs, their mechanisms of action, side effects and doses.
PH1.45 Describe the dugs used in MDR and XDR Tuberculosis. Y 11 418
PH1.46 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of antileprotic drugs.
PH1.47 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in malaria, KALA-AZAR, amebiasis and intestinal helminthiasis.
PH1.48 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in UTI/ STD and viral diseases including HIV.
– 417
– 448, 453, 448 – 452, 454 – 458
– 410, 430 – 438
(Continued)
Code Competency
PH1.49 Describe mechanism of action, classes, side effects, indications and contraindications of anticancer drugs.
PH1.50 Describe mechanisms of action, types, doses, side effects, indications and contraindications of immunomodulators and management of organ transplant rejection.
PH1.51 Describe occupational and environmental pesticides, food adulterants, pollutants and insect repellents.
PH1.52 Describe management of common poisoning, insecticides, common sting and bites.
PH1.53 Describe heavy metal poisoning and chelating agents.
PH1.54 Describe vaccines and their uses.
PH1.55 Describe and discuss the following National Health Programmes including Immunisation, Tuberculosis, Leprosy, Malaria, HIV, Filaria, Kala Azar, Diarrhoeal diseases, Anaemia & nutritional disorders, Blindness, Non-communicable diseases, cancer and Iodine deficiency.
PH1.56 Describe basic aspects of Geriatric and Pediatric pharmacology.
PH1.57 Describe drugs used in skin disorders.
PH1.58 Describe drugs used in Ocular disorders.
PH1.59 Describe and discuss the following: Essential medicines, Fixed dose combinations, Over the counter drugs, Herbal medicines.
PH1.60 Describe and discuss Pharmacogenomics and Pharmacoeconomics.
PH1.61 Describe and discuss dietary supplements and nutraceuticals.
PH1.62 Describe and discuss antiseptics and disinfectants.
PH1.63 Describe Drug Regulations, acts and other legal aspects.
PH1.64 Describe overview of drug development, Phases of clinical trials and Good Clinical Practice.
Topic: Clinical Pharmacy
PH2.1 Demonstrate understanding of the use of various dosage forms (oral/local/parenteral; solid/liquid).
PH2.2 Prepare oral rehydration solution from ORS packet and explain its use.
PH2.3 Demonstrate the appropriate setting up of an intravenous drip in a simulated environment.
PH2.4 Demonstrate the correct method of calculation of drug dosage in patients including those used in special situations.
12 476 – 479
General Pharmacology
Introduction (Definitions and Sources of Drugs)
PH1.1, PH1.59
■ Pharmacology: It is the science that deals with the effects of drugs on living systems.
■ Drug: World Health Organization (WHO) defines drug as ‘ any substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient’.
■ Pharmacokinetics: It means the movement of drug within the body; it includes the processes of absorption (A), distribution (D), metabolism (M) and excretion (E). It means ‘what the body does to the drug’.
■ Pharmacodynamics: It is the study of drugs – their mechanism of action, pharmacological actions and their adverse effects. It covers all the aspects relating to ‘what the drug does to the body’.
■ Pharmacy: It is the branch of science that deals with the preparation, preservation, standardization, compounding, dispensing and proper utilization of drugs.
■ Therapeutics: It is the aspect of medicine concerned with the treatment of diseases.
■ Chemotherapy: It deals with treatment of infectious diseases/cancer with chemical compounds that cause relatively selective damage to the infecting organism/ cancer cells.
■ Toxicology: It is the study of poisons, their actions, detection, prevention and treatment of poisoning.
■ Clinical pharmacology: It is the systematic study of a drug in man, both in healthy volunteers and in patients. It includes the evaluation of pharmacokinetic and pharmacodynamic data, safety, efficacy and adverse effects of a drug by comparative clinical trials.
■ Essential medicines: According to WHO, essential medicines are ‘those that satisfy the healthcare needs of majority of the population’. They should be of assured quality, available at all times, in adequate quantities and in appropriate dosage forms. They should be selected with regard to disease prevalence in a country, evidence on safety and efficacy, and comparative cost-effectiveness. The examples are iron and folic acid preparations for anaemia of pregnancy, antitubercular drugs like isoniazid, rifampicin, pyrazinamide, ethambutol, etc.
■ Orphan drugs: Drugs that are used for diagnosis, treatment or prevention of rare diseases. The expenses incurred during the development, manufacture and marketing of drug cannot be recovered by the pharmaceutical company from selling the drug, e.g. digoxin antibody (for digoxin toxicity), fomepizole (for methyl alcohol poisoning), etc.
■ Over-the-counter drugs (OTC drugs, nonprescription drugs): These drugs can be sold to a patient without the need for a doctor’s prescription, e.g. paracetamol, antacids, etc.
■ Prescription drugs: These are drugs which can be obtained only upon producing the prescription of a registered medical practitioner, e.g. antibiotics, antipsychotics, etc.
SOURCES OF DRUG INFORMATION
Pharmacopoeia: It is a book which contains a list of established and officially approved drugs with description of their physical and chemical characteristics and tests for their identification, purity, methods of storage, etc. Some of the pharmacopoeias are the Indian Pharmacopoeia (IP), the British Pharmacopoeia (BP), and the United States Pharmacopoeia (USP). Other sources of drug information are National Formulary (NF), Martindale – the Extra Pharmacopoeia, Physician’s Desk Reference (PDR), American Medical Association Drug Evaluation, textbooks and journals of pharmacology and therapeutics, drug bulletins, databases like Micromedex, Medline, Cochrane Library, etc. Information can also be obtained from pharmaceutical companies through their medical representatives, meetings and drug advertisements in journals.
Formulary: It provides information about the available drugs in a country – their use, dose, dosage forms, adverse effects, contraindications, precautions, warnings and guidance on selecting the right drug for a range of conditions.
DRUG NOMENCLATURE
Drugs usually have three types of names, which are as follows:
PH1.9
1. Chemical name: It denotes the chemical structure of a drug, e.g. acetylsalicylic acid is the chemical name of aspirin and N-acetyl-p-aminophenol is of paracetamol. It is not suitable for use in a prescription.
2. Nonproprietary name: It is assigned by a competent scientific body/authority, e.g. the United States Adopted Name (USAN) council. WHO* along with its member countries select and recommend the International Nonproprietary Name (INN) for a drug. So, it is uniform throughout the world and denotes the active pharmaceutical ingredient. Few older drugs have more than one nonproprietary name, e.g. the opioid, pethidine and meperidine. The INN is commonly used as generic name. Ideally, generic names should be used in prescriptions because it is economical and generally uniform all over the world than the branded counterparts. Examples are aspirin and paracetamol are generic names.
3. Proprietary name (brand name): It is given by the drug manufacturers. Brand names are short and easy to recall. Drugs sold under brand name are expensive as compared to their generic version. A drug usually has many brand names – it may have different names within a country and in different countries. Brand names can also be used in prescriptions. Disprin is a brand name of aspirin; Crocin for paracetamol.
Chemical name
Nonproprietary name
Acetylsalicylic acid Aspirin
N-acetyl-paminophenol (Acetaminophen)
Paracetamol
Proprietary name/brand name
• Disprin
• Ecosprin
• Crocin
• Metacin
• Tylenol
*S Kopp-Kubel. International Nonproprietary Names (INN) for pharmaceutical substances. Bull World Health Organ 1995;73(3):275–279.
SOURCES OF DRUGS
They are natural, semisynthetic and synthetic. Natural sources are plants, animals, minerals, microorganisms, etc. Semisynthetic drugs are obtained from natural sources and are later chemically modified. Synthetic drugs are produced artificially.
The different sources of drugs:
1. Plants:
a. Alkaloids are nitrogen containing compounds, e.g. morphine, atropine, quinine, reserpine, ephedrine.
b. Glycosides contain sugar group in combination with nonsugar through ether linkage, e.g. digoxin, digitoxin.
c. Volatile oils have aroma. They are useful for relieving pain (clove oil), as carminative (eucalyptus oil), flavouring agent (peppermint oil), etc.
d. Resins are sticky organic compounds obtained from plants as exudate, e.g. tincture benzoin (antiseptic).
6. Synthetic: Most of the drugs used today are synthetic, e.g. aspirin, paracetamol.
Drugs are also produced by genetic engineering (DNA recombinant technology), e.g. human insulin, human growth hormone and hepatitis B vaccine.
Most of the drugs can be administered by different routes. Drug- and patient-related factors determine the selection of routes for drug administration. These factors are
1. Characteristics of the drug.
2. Emergency/routine use.
3. Condition of the patient (unconscious, vomiting and diarrhoea).
4. Age of the patient.
5. Associated diseases.
6. Patient’s/doctor’s choice (sometimes).
LOCAL ROUTES
It is the simplest mode of administration of a drug at the site where the desired action is required. Systemic side effects are minimal.
1. Topical: Drug is applied to the skin or mucous membrane at various sites for localized action.
a. Oral cavity: As suspension, e.g. nystatin; as a troche, e.g. clotrimazole (for oral candidiasis); as a cream, e.g. acyclovir (for herpes labialis); as ointment, e.g. 5% lignocaine hydrochloride (for topical anaesthesia); as a spray, e.g. 10% lignocaine hydrochloride (for topical anaesthesia).
b. GI tract: As tablet which is not absorbed, e.g. neomycin (for sterilization of gut before surgery).
c. Rectum and anal canal:
1) As an enema (administration of drug into the rectum in liquid form):
■ Evacuant enema (for evacuation of bowel): For example, soap water enema – soap acts as a lubricant and water stimulates rectum.
■ Retention enema: For example, methylprednisolone in ulcerative colitis.
2) As a suppository (administration of the drug in a solid form into the rectum), e.g. bisacodyl suppository for evacuation of bowel.
d. Eye, ear and nose: As drops, ointment and spray (for infection, allergic conditions, etc.), e.g. gentamicin – eye and ear drops.
e. Bronchi: As inhalation, e.g. salbutamol, ipratropium bromide, etc. (for bronchial asthma and chronic obstructive pulmonary disease).
f. Vagina: As tablet, cream, pessary, etc. (for vaginal candidiasis).
g. Urethra: As jelly, e.g. lignocaine.
h. Skin: As ointment, cream, lotion, powder, e.g. clotrimazole (antifungal) for cutaneous candidiasis.
2. Intra-arterial route: This route is rarely employed. It is mainly used during diagnostic studies, such as coronary angiography and for the administration of some anticancer drugs, e.g. for treatment of malignancy involving limbs.
3. Administration of the drug into deep tissues by injection, e.g. administration of triamcinolone directly into the joint space in rheumatoid arthritis.
SYSTEMIC ROUTES
Drugs administered by this route enter the blood and produce systemic effects.
Enteral Routes
They include oral, sublingual and rectal routes.
Oral Route. It is the most common and acceptable route for drug administration. Dosage forms are tablet, capsule, powder, syrup, linctus, mixture, suspension, etc., e.g. paracetamol tablet for fever, omeprazole capsule for peptic ulcer are given orally. Tablets could be coated (covered with a thin film of another substance) or uncoated. They are also available as chewable (albendazole), dispersible (aspirin), mouth dissolving (ondansetron) and sustained release forms. Capsules have a soft or hard shell.
Advantages
■ Safer.
■ Cheaper.
■ Painless.
■ Convenient for repeated and prolonged use.
■ Can be self-administered.
Disadvantages
■ It is not suitable for/in:
■ unpalatable and highly irritant drugs
■ unabsorbable drugs (e.g. aminoglycosides)
■ drugs that are destroyed by digestive juices (e.g. insulin)
■ drugs with extensive first-pass metabolism (e.g. lignocaine)
■ unconscious patients
■ uncooperative and unreliable patients
■ patients with severe vomiting and diarrhoea
■ emergency as onset of action of orally administrated drugs is slow
Sublingual Route. The preparation is kept under the tongue. The drug is absorbed through the buccal mucous membrane and enters systemic circulation directly, e.g. nitroglycerin(for acute attack of angina) and buprenorphine.
Advantages
■ Quick onset of action of the drug.
■ Action can be terminated by spitting out the tablet.
■ Bypasses the first-pass metabolism.
■ Self-administration is possible.
Disadvantages
■ It is not suitable for:
■ irritant and lipid-insoluble drugs
■ drugs with bad taste
Rectal Route. Drugs can be given in the form of solid or liquid.
1. Suppository: It can be used for local (topical) effect (see p. 4) as well as systemic effect, e.g. indomethacin for rheumatoid arthritis.
2. Enema: Retention enema can be used for local effect (see p. 4) as well as systemic effect. The drug is absorbed through rectal mucous membrane and produces systemic effect, e.g. diazepam for status epilepticus in children methylprednisolone enema in ulcerative colitis.
Parenteral Routes
Routes of administration other than enteral route are called parenteral routes.
Advantages
■ Onset of action of drugs is faster, hence suitable for emergency.
■ Useful in:
■ unconscious patient
■ uncooperative and unreliable patient
■ patients with vomiting and diarrhoea
■ Suitable for:
■ irritant drugs
■ drugs with high first-pass metabolism
■ drugs not absorbed orally
■ drugs destroyed by digestive juices
Disadvantages
■ Require aseptic conditions.
■ Preparation should be sterile, and is expensive.
■ Require invasive techniques, which are painful.
■ Cannot be usually self-administered.
■ Can cause local tissue injury to nerves, vessels, etc.
Inhalation. Volatile liquids and gases are given by inhalation for systemic effects, e.g. general anaesthetics.
Advantages
■ Quick onset of action.
■ Dose required is very less, so systemic toxicity is minimized.
■ Amount of drug administered can be regulated.
Disadvantages
■ Local irritation may cause increased respiratory secretion and bronchospasm.
Injections (Fig. 1.1)
Intradermal Route. The drug is injected into the layers of skin, e.g. BCG vaccination and drug sensitivity tests. It is painful and a small amount of the drug can be administered.
Subcutaneous (s.c.) Route. The drug is injected into the subcutaneous tissue of the thigh, abdomen, arm, e.g. adrenaline, insulin, etc.
Advantages
■ Self-administration of drug is possible, e.g. insulin.
■ Depot preparations can be inserted into the subcutaneous tissue, e.g. norplant for contraception.
Disadvantages
■ It is suitable only for nonirritant drugs.
■ Drug absorption is slow, hence not suitable for emergency.
Intradermal
Subcutaneous
Intravenous
Intra-arterial
Intramuscular
Intra-articular
Fig. 1.1 Injectable routes of drug administration.
Intramuscular (i.m.) Route. Drugs are injected into large muscles, such as deltoid, gluteus maximus and vastus lateralis, e.g. paracetamol, diclofenac, etc. A volume of 5–10 mL can be given at a time.
Advantages
■ Absorption is more rapid as compared to oral route.
■ Mild irritants, depot injections, soluble substances and suspensions can be given by this route.
Disadvantages
■ Aseptic conditions are needed.
■ Intramuscular (i.m.) injections are painful and may cause abscess.
■ Self-administration is not possible.
■ There may be injury to nerves.
Intravenous (i.v.) Route. Drugs are injected directly into the blood stream through a vein. Drugs are administered as
1. Bolus: Single, relatively large dose of a drug injected rapidly or slowly into a vein, e.g. i.v. ranitidine in bleeding peptic ulcer.
2. Slow intravenous injection: For example, i.v. morphine in myocardial infarction.
3. Intravenous infusion: For example, dopamine infusion in cardiogenic shock; mannitol infusion in cerebral oedema; fluids infused intravenously in dehydration.
Advantages
■ Bioavailability is 100%.
■ Quick onset of action, so it is the route of choice in emergency, e.g. intravenous diazepam to control convulsions in status epilepticus.
■ Large volume of fluid can be administered, e.g. intravenous fluids in patients with severe dehydration.
■ Highly irritant drugs, e.g. anticancer drugs can be given because they get diluted in blood.
■ Hypertonic solution can be infused by intravenous route, e.g. 20% mannitol in cerebral oedema.
■ By i.v. infusion, a constant plasma level of the drug can be maintained, e.g. dopamine infusion in cardiogenic shock.
Disadvantages
■ Local irritation may cause phlebitis.
■ Self-administration is usually not possible.
■ Strict aseptic conditions are needed.
■ Extravasation of some drugs (e.g. noradrenaline) can cause injury, necrosis and sloughing of tissues.
■ Depot preparations cannot be given by i.v. route.
Precautions
■ Drug should usually be injected slowly.
■ Before injecting, make sure that the tip of the needle is in the vein.
Intrathecal Route. Drug is injected into the subarachnoid space, e.g. lignocaine (spinal anaesthesia), antibiotics (amphotericin B), etc.
Transdermal Route (Transdermal Therapeutic System). The drug is administered in the form of a patch or ointment that delivers the drug into the circulation for systemic effect (Fig. 1.2), e.g. scopolamine patch for sialorrhoea and motion sickness, nitroglycerin
