PHARMACOLOGY JOURNAL

Allergy And Anaphylaxis

Analgesics
Anaesthetic Agents
Anti-Infectives
Cardiovascular Drugs
Blood And Electrolytes
Dermatological Drugs
Ear, Nose and Throat Drugs
Endocrine Drugs
Eye Drugs
Gastrointestinal Drugs
Genitourinary Drugs
Immunomodulators and Antineoplastics
Musculoskeletal Drugs
Neurological Drugs
Obstetric and Gynaecological Drugs
Psychotropic Drugs
Respiratory Drugs
1. Acyclovir 35. Gliclizide 69. Phenobarbitone
2. Adenosine 36. Glucagon 70. Phenytoin
3. Adrenaline 37. Glyceryl trinitrate 71. Potassium chloride
4. Amiodarone 38. Haloperidol 72. Prazosin
5. Amitriptyline 39. Halothane 73. Prednisone
6. Amphetamine/MDMA 40. Heparin 74. Promethazine
7. Aspirin/salicylates 41. Hydralazine 75. Propranolol
8. Atropine 42. Ibuprofen 76. Propofol
9. Azathioprine 43. Insulin 77. Propylthiouracil (PTU)
10. Calcium chloride 44. Iron 78. Quinine
11. Carbamazepine 45. Isoniazid 79. Ranitidine
12. Ceftriaxone 46. Ketamine 80. Rifampicin
13. Charcoal 47. Levo-dopa 81. Salbutamol
14. Chloramphenicol 48. Lignocaine 82. Simvastatin
15. Chloroquine 49. Lithium 83. Sodium bicarbonate
16. Chlorpromazine 50. Magnesium 84. Sotalol
17. Ciprofloxacin 51. Metformin 85. Streptokinase
18. Clonidine 52. Methotrexate 86. Sumatriptan
19. Cocaine 53. Metoclopramide 87. Suxamethonium
20. Codeine 54. Metronidazole 88. Tetracycline
21. Colchicine 55. Midazolam 89. Theophylline
22. Cyclophosphamide 56. Morphine 90. Thiopentone
23. Diazepam 57. N-Acetylcysteine 91. Thyroxine
24. Digoxin 58. Naloxone 92. t-PA
25. Diltiazem 59. Neostigmine 93. Valproic acid
26. Dobutamine 60. Nifedipine 94. Vancomycin
27. Dopamine 61. Nitrous oxide 95. Vasopressin
28. Enalapril 62. Octreotide 96. Vecuronium
29. Ethanol 63. Omeprazole 97. Venlafaxine
30. Fentanyl 64. Ondansetron 98. Verapamil
31. Flumazenil 65. Oxygen 99. Warfarin
32. Fluoxetine 66. Oxytocin 100. Zidovudine
33. Frusemide 67. Paracetamol
34. Gentamicin 68. Penicillin
ALLERGY AND ANAPHYLAXIS

Anaphylaxis
Most anaphylactic reactions are mediated by IgE, they ae typically precipitated by insect stings, foods,
drugs, blood products, latex, food chemicals or additives
Symptoms of Anaphylaxis inc.
 Urticaria
 Angioedema
 Respiratory distress – fatalities most often result from respiratory obstruction due to upper
airway oedema (tongue and laryngeal) or bronchospasm with small airway obstruction
 Vomiting
 Diarrhoea
 Hypotension – which may result in a stroke, MI, arrythmias or death
Rationale for Drug Use
 Prevention of serious complications or death
 Cardiorespiratory support
 Symptom releif
Management of Anaphylaxis
 Sympathomimetics – Adrenaline
 IV fluids – required to expand intravascular volume and restore BP in combination with
adrenaline
 Bronchodilators – to help relieve bronchospasm
 Glucagon – may help persistent hypotension in patients on beta-blockers
 Corticosteroids – used to reduce duration of reaction and prevent relapse
Allergic Reactions
Moderate allergic reactions inc.
 Seasonal and perennial rhinitis
 Allergic conjunctivitis
 Less severe reactions to insect bites and stings
 Urticaria
 Angioedema
Rationale for treatment is symptom relief
 Identify allergen if possible – RAST (specific IgE), skin-prick testing
 Avoid allergen
Management of Allergic Reactions - Antihistamines (H 1 Antagonists)
Sedating Antihistamines
 Cyproheptadine
Dexchlorpheniramine
Pheniramine
Promethazine Hydrochloride
Trimeprazine
Less-Sedating Antihistamines
Cetirizine
Desloratadine
Fexofenadine
Levocetirizine
Loratadine
Drug Name Adrenaline (Epinephrine)

Drug Class Sympathomimetics (Anaphylaxis)

Mode Of Action
Non-selective adrenergic agonist
- Positive inotrope and chronotrope (beta1 receptors)
- Vasodilator at low dose (beta2 receptors)
- Vasoconstrictor at high dose (alpha receptors)
- Bronchial smooth muscle relaxant (beta2 receptors)
- Stabilises mast cells

Indications
Severe allergic reactions inc. anaphylactic shock, life-threatening angioedema
Bronchospasm and croup
Cardiac arrest
Inotropic support in acute heart failure and cardiogenic shock, acute exacerbation of chronic heart
failure, septic shock, positive end expiratory pressure ventilation
Adjunct in local anaesthesia

Precautions
**There are NO contraindications in severe life-threatening allergic reactions.
- IHD and CVD – increased sensitivity to sympathomimetic effects inc. arrhthmias, angina,
myocardial ischaemia
Contraindicated in:
- Phaeochromocytoma
- Tachyarrhythmias

Adverse Effects
Common
Anxiety, fear
Headache
Palpitations
Tachycardia
Restlessness
Tremor
Dizziness
Dyspnoea
Weakness
Sweating
Pallor
Hyperglycaemia
Infrequent
Excessive increase in BP, ventricular arrhythmias, pulmonary oedema, angina, peripheral ischaemia,
necrosis (at infusion site)
Rare
Allergic reaction
Overdose, or Rapid IV Administration
Arrhythmias, severe hypertension, cerebral haemorrhage, pulmonary oedema

Dosage
Adult - Anaphylaxis
IM 10micrograms/kg up to 500micrograms (EpiPen 300micrograms, 3mL)
IV 5micrograms/kg
Adult – Cardiac Arrest
IV 0.5-1mg (Adrenaline 1:10,000 is 0.1mg/mL, 10mL)
IV Infusion 1-4micrograms/minute
Drug Name Promethazine Hydrochloride

Drug Class Antihistamine

Mode Of Action
Antihistamines are divided into 2 groups: older sedating drugs and newer less sedating drugs.
Sedating antihistamines (like promethazine) antagonise the action of histamine at H 1 receptors,
reducing histamine-related vasodilation and increased capillary permeability. They also have
anticholinergic activity, some alpha-blocking activity and some antiserotonin activity.
Less sedating antihistamines selectively anatagonise the action of histamine at H 1 receptors –
histamine release causes vasodilation and increases capillary permeability.

Indications
Allergic upper respiratory conditions, inc. rhinitis
Allergic skin conditions, inc. urticaria, contact dermatitis
Pruritis
Nausea and vomiting, inc. motion sickness
Sedation

Precautions
Contraindicated in:
- Closed angle glaucoma, increased intraocular pressure, bladder neck obstruction, hyperthyroidism
– may be worsened by the anticholinergic effects of antihistamines
- Epilepsy – promethazine lowers the seizure threshold

Adverse Effects
Common
Sedation
Dizziness
Tinnitus
Blurred vision
Euphoria
Incoordination
Anxiety
Insomnia
Tremor
Nausea and vomiting
Constipation and diarrhoea
Epigastric discomfort
Dry mouth
Cough
Infrequent
Urinary retention, palpitations, hypotension, headache, hallucinations, psychosis, thrombophlebitis
Rare
Leucopenia, agranulocytosis, haemolytic anaemia, allergic reactions, arrhythmias, dyskinesia,
paraesthesia, paralysis, hepatitis, seizures

Dosage
Adult (do NOT give SC, avoid IV because of risk of thrombophlebitis)
Allergy Oral 25-75mg once daily, or 10-25mg 2-3 times daily (Phenergan – 10mg, 25mg tab)
IM 25-50mg single dose
ANALGESICS

Analgesics are used to treat pain, which is clinically classified as:

 Nociceptive Pain due to activation of normal pain fibres in response to a noxious stimulus (ie.
injury, disease, inflammation); it may be somatic (involving superficial structures ie. skin,
muscle) or visceral (involving deeper organs ie. liver, pancreas)
 Neuropathic Pain due to injury, disease or dysfunction affecting the peripheral nervous system
(ie. post-herpatic neuralgia, diabetic neuropathy) or central nervous system (ie. spinal cord
injury, post-stroke)
Types of Analgesics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-Selective NSAIDs (COX-1 and COX-2 Inhibitors)
Aspirin
Diclofenac
Ibuprofen
Indomethacin
Ketoprofen
Ketorolac
Mefanamic Acid
Naproxen
Piroxicam
Sulindac
Tiaprofenic Acid
Selective NSAIDs (COX-2 Inhibitors)
Celecoxib
Meloxicam
Parecoxib
Other Non-Opioid Analgesics
Paracetamol
Opioid Analgesics
Buprenorphine
Dextropropoxyphene
Hydromorphine
Morphine
Pethidine
Codeine
 Fentanyl
Methadone
Oxycodone
Tramadol
The choice of analgesic depends on the type of pain:

Drug Nociceptive Pain Neuropathic Pain

Effective (negligible anti-inflammatory

Paracetamol Less effective
effects)

NSAIDs Effective (useful anti-inflammatory effects) Less effective

Opioids Effective May be effective

TCAs, Parenteral local

anaesthetics, Rarely used May be effective
antiepileptics, clonidine

Route of Administration
Oral, IV, IM, SC, PCA, Transdermal, Inhaled (mainly for NO), Epidural, Intrathecal, Regional Nerve
Blockade
Drug Name Aspirin (Acetylsalicylic Acid)

Drug Class Analgesic, Antipyretic, Anti-Inflammatory, Anti-Platelet

Mode Of Action
Non-selective NSAID, preventing the synthesis of prostaglandins by non-competitively inhibiting
both forms of cyclo-oxygenase (COX), COX-1 and COX-2. It irreversibly inhibits COX-1 and modifies
the enzymatic activity of COX-2.
COX is required for prostaglandin (pro-inflammatory) and thromboxane (promote clotting,
vasoconstrictor) synthesis. Aspirin acts as an acetylating agent where an acetyl group is covalently
attached to a serine residue in the active site of the COX enzyme. Hence the duration of effect
depends on the rate of enzyme resynthesis.
Aspirin irreversibly blocks the formation of thromboxane A 2 in platelets producing an inhibitory
effect on platelet aggregation.

Indications
Inhibit platelet aggregation
Mild-Moderate pain
Fever
Rheumatic fever, Rheumatoid arthritis, Kawasaki’s disease

Precautions
Contraindicated in:
- Allergy to aspirin or other NSAIDs
- Haemophilia
- Heart failure, uncontrolled hypertension – may be exacerbated by sodium and fluid retention
caused by aspirin-induced reduction in GFR and renal blood flow
- Peptic ulcer disease- increased risk of GI ulceration
- Renal and hepatic impairment – increased risk of bleeding

Adverse Effects
Common
Nausea
Dyspepsia
Vomiting
GI Ulceration or bleeding
Asymptomatic blood loss
Increased bleeding time
Headache
Dizziness
Rare
Skin reactions, iron-deficiency anaemia, renal impairment, oesophageal ulceration, major
haemorrhage

Dosage
Adult 300-900mg every 4-6hrs when necessary (available in 300mg white tablets)
Drug Name Paracetamol (Acetaminophen)

Drug Class Analgesic; Antipyretic

Mode Of Action (Not fully determined)

Analgesic effec may be due to inhibition of prostaglandin synthesis centrally, and may be involved in
ther mechanisms which peripherally block pain impulses.
Antipyretic effect probably due to reduced prodution of prostaglandins in the hypothalamus

Indications
Mild to moderate pain
Fever

Precautions
- Sodium restriction – soluble paracetamol products may contain large amounts of sodium
- Phenylketonuria – soluble paracetamol products may contain aspartame
Contraindicated in:
- Chronic liver disease – pts may be at increased risk of liver damage
(safe to use in pregnancy and breastfeeding)

Adverse Effects
Common
Increased transaminases (Hepatotoxicity, which can occur following paracetamol overdose)
Rare
Utricarial or erythematous rash, drug fever, mucosal lesions, hypersensitivity reactions, neutropenia,
thrombocytopenia, pancytopenia, acute hepatitis, hypotension

Dosage
Adult
Oral 0.5-1g every 4-6hrs (max 4g daily)
Oral Controlled Release 2 tablets (665mg per tablet) every 6-8hrs swallowed whole (max 6 tablets
daily)
IV Infusion 1g (100mL) every 4-6hrs (max 4g daily) – IV infusion given over 15min
Combination Doses
Paracetamol Codeine Combination (Panamax, Prodeine, Panadeine Forte) 1-2tablets (paracetamol
500mg, codeine 8, 15, 30mg) every 4-6hrs if needed (max 8 tablets daily)
Paracetamol Metoclopramide Combination (Anagraine, Metomax) 1-2 tablets (paracetamol 500mg,
metoclopramide 5mg) at first signs of migraine, repeat every 4hrs if required
Drug Name Ibuprofen

Drug Class Analgesic; Antipyretic; Anti-Inflammatory; Antiplatelet (non-selective)

Mode Of Action
NSAIDs inhibit synthesis of prostaglandins by inhibiting cyclo-oxygenase (COX). COX is present in 2
forms, COX-1 and COX-2. Inhibition of COX-1 is associated with impaired gastric cytoprotection and
anti-platelet effects. Inhibition of COX-2 is associated with anti-inflammatry and analgesic action.
Reduction in GFR and renal blood flow is associated with both COX-1 and COX-2 inhibition

Indications
Rheumatoid arthritis, inc. juvenile RA
Osteoarthrtis
Other inflammatory arthropathies, inc. ankylosing spondyitis, psoriatic arthriti, Reiter’s Sydnrome
Pain, esp. due to inflammation and tissue injury (eg. period pain, metastatic bone pain, renal colic,
headache, migraine, postoperative pain)
Fever

Precautions
Contraindicated in:
- Allergic reaction to NSAIDs
- Asthma – NSAIDs may increase risk of bronchospasm
- Coagulation Disorders – nonselective NSAIDs increase risk of bleeding (antiplatelet effect), while
selective NSAIDs (and ?diclofenac) increase the risk of thrombosis
- Heart failure and hypertension – NSAIDs may ecacerbate sodium and fluid retention by reducing
GFR and renal blood flow
- Active Peptic Ulcer Disease or GI Bleeding
- Renal Impairment – increased risk of NSAID-induced impairment

Adverse Effects
Common
Nausea
Dyspepsia
GI Ulceration or bleeding
Raised liver enzymes
Diarrhoea
Headache
Dizziness
Salt and fluid retention
Hypertension
Infrequent
Oesophageal ulceration, rectal irritation, heart failure, hyperkalaemia, renal impairment, confusion,
bronchospasm, rash
Rare
Blood dyscrasias, interstitial nephritis, cystitis, nephrotic syndrome, acute renal failure, papillary
necrosis, photosensitivity, epidermal necrolysis, hepatitis, aseptic meningitis, blurred vision, tinnitus,
hypersensitivity

Dosage
Adult 200-400mg 3-4 times daily (Max 2400mg daily) (Nurofen is 200mg tablet)
Ibuprofen and Codeine Combination 1-2 tablets (ibuprofen 200mg, codeine 12.8mg) every 4 hrs if
needed (max 6 tablets) (Nurofen Plus)
Drug Name Morphine

Drug Class Analgesic

Mode Of Action
Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and
peripheral nervous systems to produce analgesia, respiratory depression, sedation and constipation.
It predominantly acts as an agonist on μ-opioid receptors which are in high densities in the amygdala,
hypothalamus, thalamus, caudate nucleus, putamen. They reduce transmission of the pain impulse
by acting pre- and post-synaptically in the spinal cord and by modulating the descending inhibitory
pathways from the brain. Cough suppression occurs in the medullary centre of the brain.

Indications
Acute or chronic pain
Opioid adjunct during general anaesthesia

Precautions
Contraindicated in:
- Comatosed patients
- Epilepsy or a recognised risk for seizure (inc. head injury, metabolic disorders, alcohol and drug
withdrawal, CNS infections) – increases risk of seizure
- Raised intracranial pressure – respiratory depression due to opioids may be poorly tlerated and
may further increase intracranial pressure (avoid if possible)
- Biliary Colic – opioids may cause spasm of sphincter of Oddi
- Renal impairment – risk of accumulation of active/toxic metabolites

Adverse Effects – Adverse effects may limit achievement of adequate pain control, the options then
inc. controlling symptoms, reducing opioid dose and ?adding adjuvant analgesic, switching to an
alternate opioid
Common
Nausea and vomiing – may occur initially, an antiemetic may be given prophylactically
Dyspepsia
Drowsiness
Dizziness
Headache
Orthostatic hypotension
Itch
Dry mouth
Miosis
Urinary retention
Constipation – tolerance develops slowly, attention to fluid intake, diet and mobility plus regular
laxative use is essential when chronic opioid treatment is started
Infrequent
Dose-related respiratory depression – judged by degree of sedation, respiratory rate reduction is late
and an unreliable marker
Bronchospasm, confusion, hallucinations, delirium, agitation, mood changes, tremor, visual
disturbances, urticaria, hypothermia, brady or tachycardia, hypertension, ureteric or biliary spasm,
muscle rigidity, myoclonus, flushing due to histamine release
Rare
SIADH, anaphylaxis, seizure

Dosage
Adult
IV Initially 0.5-2mg repeated every 3-5min
SC/IM 7.5-12.5mg (20-39yo), 5-10mg (40-59yo), 2.5-7.5mg (60-69yo), 2.5-5mg (70-85yo), 2-3mg
(>85yo) every 2 hrs as required
(Seredol (10, 20mg tab), Anamorph (30mg tab), MS Contin (5,10,15,30,60,100,200mg tab))
Drug Name Codeine

Drug Class Analgesic

Mode Of Action
Codeine is a pro-drug, it is metabolised in vivo to the primary active compounds morphine and
codeine-6-glucuronide. Because it needs to be metabolised to an active form there is a ceiling effect
around 400-450mg, making it less addictive.
Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and
peripheral nervous systems to produce analgesia, respiratory depression, sedation and constipation.
They reduce transmission of the pain impulse by acting pre- and post-synaptically in the spinal cord
and by modulating the descending inhibitory pathways from the brain. Cough suppression occurs in
the medullary centre of the brain.

Indications
Mild to moderate acute or chronic pain
Cough suppression
Diarrhoea

Precautions
Contraindicated in:
- Comatosed patients
- Epilepsy or a recognised risk for seizure (inc. head injury, metabolic disorders, alcohol and drug
withdrawal, CNS infections) – increases risk of seizure
- Raised intracranial pressure – respiratory depression due to opioids may be poorly tlerated and
may further increase intracranial pressure (avoid if possible)
- Biliary Colic – opioids may cause spasm of sphincter of Oddi
- Renal impairment – risk of accumulation of active/toxic metabolites

Adverse Effects – Adverse effects may limit achievement of adequate pain control, the options then
inc. controlling symptoms, reducing opioid dose and ?adding adjuvant analgesic, switching to an
alternate opioid
Common
Nausea and vomiing – may occur initially, an antiemetic may be given prophylactically
Dyspepsia
Drowsiness
Dizziness
Headache
Orthostatic hypotension
Itch
Dry mouth
Miosis
Urinary retention
Constipation – tolerance develops slowly, attention to fluid intake, diet and mobility plus regular
laxative use is essential when chronic opioid treatment is started
Infrequent
Dose-related respiratory depression – judged by degree of sedation, respiratory rate reduction is late
and an unreliable marker
Bronchospasm, confusion, hallucinations, delirium, agitation, mood changes, tremor, visual
disturbances, urticaria, hypothermia, brady or tachycardia, hypertension, ureteric or biliary spasm,
muscle rigidity, myoclonus, flushing due to histamine release
Rare
SIADH, anaphylaxis, seizure

Dosage
Adult 30-60mg every 4 hours (Oral/SC/IM), max 240mg per 24hrs (Codeine phosphate - 30mg tab,
50mg/mL inj)
Drug Name Fentanyl

Drug Class Analgesic

Mode Of Action
Opioid analgesics mimic endogenous opioids by activating opioid receptors in the central and
peripheral nervous systems to produce analgesia, respiratory depression, sedation and constipation.
They reduce transmission of the pain impulse by acting pre- and post-synaptically in the spinal cord
and by modulating the descending inhibitory pathways from the brain. Cough suppression occurs in
the medullary centre of the brain.

Indications
Acute pain
Opioid adjunct during general anaesthesia
Chronic pain (for patients intolerant of morphine) – first choice for use in cancer patients
Breakthrough pain

Precautions
Contraindicated in:
- Bradyarrhythmias may be exacerbated
- Comatosed patients
- Epilepsy or a recognised risk for seizure (inc. head injury, metabolic disorders, alcohol and drug
withdrawal, CNS infections) – increases risk of seizure
- Raised intracranial pressure – respiratory depression due to opioids may be poorly tlerated and
may further increase intracranial pressure (avoid if possible)
- Biliary Colic – opioids may cause spasm of sphincter of Oddi
- Renal impairment – risk of accumulation of active/toxic metabolites

Adverse Effects – Adverse effects may limit achievement of adequate pain control, the options then
inc. controlling symptoms, reducing opioid dose and ?adding adjuvant analgesic, switching to an
alternate opioid
Common
Nausea and vomiing – may occur initially, an antiemetic may be given prophylactically
Dyspepsia
Drowsiness
Dizziness
Headache
Orthostatic hypotension
Itch
Dry mouth
Miosis
Urinary retention
Constipation – tolerance develops slowly, attention to fluid intake, diet and mobility plus regular
laxative use is essential when chronic opioid treatment is started
Infrequent
Dose-related respiratory depression – judged by degree of sedation, respiratory rate reduction is late
and an unreliable marker
Bronchospasm, confusion, hallucinations, delirium, agitation, mood changes, tremor, visual
disturbances, urticaria, hypothermia, brady or tachycardia, hypertension, ureteric or biliary spasm,
muscle rigidity, myoclonus, flushing due to histamine release
Rare
SIADH, anaphylaxis, seizure

Dosage
Adult
Spontaneous Ventilation UV 50-100micrograms, then 25-50micrograms s required
Assisted Ventilation IV 50micrograms-3.5mg, then 50-200micrograms or more as required
Usually given in combination with a benzodiazepine such as midazolam
There are also transdermal patches which release fentanyl into body fats which slowly release into
the blood stream over 48-72hrs
ANAESTHETICS

General Anaestheisa involves:

 Preoperative assessment with or without premedication, to ensure that the process of
anaesthesia is as safe as possible
 Induction, to render the patient unconscious and unreactive to surgical stimuli (using IV or
inhaled drugs)
 Maintenance, to keep the patient anaesthetised for as long as the operation lasts (using IV
and/or inhaled drugs with muscle relaxants and analgesics as necessary)
 Reversal, if non-depolarising muscle relaxants are used, reversal with neostigmine (and an
anticholinergic to prevent undesirable muscarinic effects, esp. bradycardia) is usually required
when the operation is completed
 Recovery, which begins when the anaesthetic is stopped and lasts until the patient is fully
conscious, has stable cardiovascular status, is able to maintain own airway and is comfortable
IV General Anaesthetics
In appropriate doses IV general anaesthetic drugs produce rapid, reversible loss of consciousness and
insensibility to surgical stimuli
Types of IV General Anaesthetis
Ketamine
Propofol
Midazolam
Thiopentone
Inhaled Anaesthetics
Their anaesthetic effect is directly proportional to the partial pressure of the drug in the brain, factors
which shorten the induction time inc.
 High inspired concentration
 Increased alveolar ventilation
 Reduced cardiac output
 Low blood:gas solubility
 Increased alveolar-to-capillary partial pressure difference
Potency is measured by minimum alveolar concentration (MAC) to which it is inverely related - MAC
is the alveolar concentration that prevents movement in response to a skin incision in 50% of
patients, it decreases as age increases
Types of Inhaled Anaesthetics
Volatile Anaesthetics (liquid at room temperature)
Desflurane
Isoflurane
Methoxyflurane
 Sevoflurane
Other Inhaled Anaesthetics
Nitrous Oxide
Nuromuscular Blockers
Types of Neuromuscular Blockers
Neuromuscular blocking drugs produce skeletal (inc. respiratory) muscle relaxation which is used
during general anaesthesia.
Non-Depolarising Neuromuscular Blockers
Atracurium
Cisatracurium
Mivacurium
Pancuronium
Rocuronium
Vecuronium
Depolarising Neuromuscular Blockers
Suxamethonium

Other Anaesthetic Agents

Alpha2 and Imidazoline Agonists
Clonidine
Dexmedetomide
Opioids (anaesthesia)
Alfentanil
Remifentanil
Anticholinergics (anaesthesia)
Glycopyrrolate
Drugs for Local Anaesthesia
Amethocaine (skin)
Bupivacaine
Cocaine
Levobupivacaine
Lidnocaine
Prilocaine
Procaine
Ropivacaine
Drug Name Ketamine

Drug Class Anaesthetic (General)

Mode Of Action
Antagonises NMDA receptors, also interacts with muscarinic receptors, descending monoaminergic
pain pathways, voltage-sensitive calcium channels and opioid receptors in the brain and spinal cord
Is a potent analgesic at subanaesthetic concentrations. It can cause cardiovascular and respiratory
stimulation at recommended doses, it maintains pharyngeal and laryngeal reflexes compared with
other IV anaesthetic agents.

Indications
Induction and maintenance of anaesthesia
Pain relief

Precautions
Contraindicated in:
- Conditions which may be worsened by an increase in BP and/or heart rate, inc. poorly controlled
hypertension, stroke, intracerebral haemorrhage, angina, recent MI, stenotic valvular heart disease,
tachyarrhythmias, chronic heart failure – ketamine increases BP and heart rate
- Psychiatric disorders – hallucinations, irrational behaviour may occur
- Raised intracranial or intraocular pressure – may be further raised
- Addisions Disease, severe anaemia, myxoedema – hypnotic effect may be prolonged or potentiated
- Debilitated patients – more sensitive to adverse and anaesthetic effects
- IV anaesthetics may worsen symptoms of cardiovascular compromise (hypotension,
hypovolaemia)

Adverse Effects
Common
Raised BP and HR
Increased muscle tone (sometimes tonic-clonic and resembling seizures)
Lacrimation
Hypersalivation
Raised intracranial pressure
Raised intraocular pressure
Emergence reactions – inc. vivid dreams, restlessness, confusion, hallucinations and irrational
behaviour
Infrequent
Diplopia, nystagmus, postoperative nausea and vomiting, hypotension and bradycardia, pain on
injection, erythema, morbilliform rash
Rare
Apnoea, laryngospasm, arrhythmias, anaphylaxis

Dosage
Adult
IV 1-4.5mg/kg (usually 2mg/kg over 60s provides anaesthesia within 30s lasting for 5-10min)
IM 6.5-13mg/kg (usually 10mg/kg provides anaesthesia within 3-4min lasting 12-25min)
Drug Name Propofol

Drug Class Anaesthetic (General)

Mode Of Action (uncertain)

Its main CNS depressant action is thought to be via the GABA receptor at a site different to that of
barbiturates and benzodiazepines. May also shorten channel opening times at nicotinic acetylcholine
receptors and sodium channels in the cerebral cortex.
Is most effective at suppressing pharyngeal and laryngeal reflexes allowing rapid control of the
airway, inc. insertion of laryngeal mask and endotracheal intubation. Has some antiemetic effect,
causing less post-operative nausea and vomiting when used alone.

Indications
Induction and maintenance of anaesthesia
Conscious sedation (midazolam, propofol)
Sedation during ventilation (midazolam, propofol)

Precautions
Contraindicated in:
- Addisions Disease, severe anaemia, myxoedema – hypnotic effect may be prolonged or potentiated
- Debilitated patients – more sensitive to adverse and anaesthetic effects
- IV anaesthetics may worsen symptoms of cardiovascular compromise (hypotension,
hypovolaemia)
- Severe respiratory compromise – further respiratory depression occurs

Adverse Effects
Common
Pain on injection
Bradycardia
Hypotension
Apnoea
Flushed skin or rash
Cough
Excitation at induction (involuntary movements inc. twitches, tremors, hypertonus and hiccup)
Infrequent
Arrhythmias, thrombosis, phlebitis at injection site
Rare
Anaphylactic reactions, seizure, fever, pancreatitis

Dosage
Adult (1% preparation – 10mg/mL available as 20, 50, 100mL preparations)
IV 2-2.5mg/kg (9-55yo), 1-1.5mg/kg (>55yo or debilitated)
Drug Name Midazolam

Drug Class Anaesthetic (General); Benzodiazepine

Mode Of Action
Potentiates the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative,
hypnotic, anterograde amnesic, muscle relaxant and antiepileptic effects
Is the least effective IV agent for induction of anaesthesia, but is anterograde amnesic effect may be
useful.

Indications
Induction and maintenance of anaesthesia
Conscious sedation (midazolam, propofol)
Sedation during ventilation (midazolam, propofol)
Premedication
Status epilepticus

Precautions
Contraindicated in:
- Addisions Disease, severe anaemia, myxoedema – hypnotic effect may be prolonged or potentiated
- Debilitated patients – more sensitive to adverse and anaesthetic effects
- IV anaesthetics may worsen symptoms of cardiovascular compromise (hypotension,
hypovolaemia)
- Respiratory disease, sleep apnoea – compromised respiratory drive may result in hypoventilation
and hypoxaemia

Adverse Effects
Common
Hypotension
Hiccup
Cough
Infrequent
Pain on injection, erythema, rash, bronchospasm, nasuea, vomiting, headache, confusion, restlessness
Rare
Arrhythmias, cardiorespiratory arrest, anaphylactic reactions

Dosage
Adult (1mg/mL 5mL; 5mg/mL 1, 3, 10mL preparations)
Conscious Sedation IV 2-2.5mg, give further 1mg as needed
Induction of anaesthesia IV 0.15-0.35mg/kg, rate2.5mg per 10s
Drug Name Thiopentone

Drug Class Anaesthetic (General); Barbiturate

Mode Of Action
Potentiates action of the inhibitory neurotransmitter GABA at multiple sites in the CNS resulting in
sedative, hypnotic, anaesthetic and anticonvulsant effects. It also depressesthe actions of excitatory
neurotransmitters in the CNS. Redistribution of cerebral blood flow to injured areas may also be
involved in its neuroprotective effect.
Produces the most rapid onset of anaesthesia, but recovery is slower than with propofol.

Indications
Induction and maintenance of anaesthesia
Short surgical procedures, sole agent
Seizures, short term control
Cerebral protection
Raised intracranial pressure

Precautions
Contraindicated in:
- Addisions Disease, severe anaemia, myxoedema – hypnotic effect may be prolonged or potentiated
- Debilitated patients – more sensitive to adverse and anaesthetic effects
- IV anaesthetics may worsen symptoms of cardiovascular compromise (hypotension,
hypovolaemia)
- Allergy to barbiturates
- Porphyria
- Asthma – bronchospasm may occur
- Severe respiratory compromise – further respiratory depression occurs

Adverse Effects
Common
Transient erythema noted as lushing
Hypotension
Respiratory and myocardial depression
Prolonged somnolence with repeated doses
Infrequent
Laryngospasm, pain at injection site
Rare
Anaphylaxis, bronchospasm

Dosage
Adult (administered as a 2.5% solution (25mg/mL))
IV Bolus 3-5mg/kg according to response; additional injections of 25-50mg when needed
Drug Name Nitrous Oxide

Drug Class Anaesthetic (Inhaled)

Mode Of Action
Enhance the inhibitory ion channel activity and inhibit excitatory activity in the brain to induce
hypnosis and amnesia, and in the spinal cord to cause immobility in response to painful stimuli

Indications
Induction and maintenance of general anaesthesia
Analgesia (in subanaesthetic concentrations)

Precautions
Contraindicated in:
- Myasthenia gravis – muscle weakness may increase
- Susceptibility to malignant hypethermia
- Vitamin B12 deficiency – increased risk of neurological dysfunction, inc. subacute combined
degeneration of the spinal cord with prolonged exposure

Adverse Effects
Common
Shivering (independent of temperature)
Nausea and vomiting
Infrequent
Arrhythmias
Rare
Megaloblastic anaemia, leucopeia, agranulocytosis, neuropathy, myeloneuropathy (with prolonged or
repeated use)

Dosage
Adult 70% with 30% oxygen (analgesia 25-50% with oxygen)
Drug Name Vecuronium

Drug Class Anaesthetic (Neuromuscular Blocker)

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
Drug Name Suxamethonium

Drug Class Anaesthetic (Neuromuscular Blocker)

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
Drug Name Clonidine

Drug Class Anaesthetic

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
Drug Name Cocaine

Drug Class Local Anaesthetic

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
Drug Name Lidnocaine

Drug Class Local Anaesthetic

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
CARDIOVASCULAR DRUGS

Drugs for Heart Failure

Aldosterone Antagonists
Eplerenone
Spironolactone
Loop Diuretics
Bumetanide
Ethacryic Acid
Frusemide
Sympathomimetics
Adrenaline
Dobutamine
Dopamine
Noradrenaline
Drugs for Angina and Acute Coronary Syndromes
Nitrates
Glyceryl Trinitrate
Isosorbide Dinitrate
Isosorbide Mononitrate
Other Antianginal Drugs
Ivabradine
Nicorandil
Perhexiline
Antihypertensives
Thiazide and Diuretics
Chlorthalidone
Hydrochlorothiazide
Indapamide
Potassium-Sparing Diuretics
Amiloride
Beta-Blockers
Atenolol
Bisoprolol
Carvedilol
 Labetalol
Metoprolol
Oxprenolol
Pindolol
Propranolol
ACE Inhibitors
Catopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
Calcium-Channel Blockers
Amlodipine
Diltiazem
Felodipine
Lercanidipine
Nifedipine
Nimodipine
Verapamil
Vasodilators
Diazoxide
Hydralazine
Minoxidil
Sodium Nitroprusside
Centrally Acting Hypertensives
Clonidine (see Anaesthetic Agents)
Methyldopa
Moxonidine
Non-Selective Alpha-Blockers
Phenoxybenzamine
Phentolamine
Selective Alpha-Blockers
Prazosin
 Terazosin
Antiarrhythmics
Adenosine
Amiodarone
Atropine
Digoxin
Disopyramide
Esmolol
Flecainide
Soprenaline
Lignocaine (see Anaesthetic Agents)
Mexiletine
Sotalol
Statins (Drugs fo Dyslipidaemia)
Atorvastatin
Fluvastatin
Pravastatin
Rosuvastatin
Simvastatin
Drug Name

Drug Class Anaesthetic

Mode Of Action

Indications

Precautions
Contraindicated in:

Adverse Effects
Common
Rare

Dosage
Adult
BLOOD AND ELECTROLYTES

Anticoagulants
Heparins
Dalteparin (LMWH)
Danaparoid
Enoxaparin (LMWH)
Heparin
Vitamin K Antagonists
Phenindione
Warfarin
Antiplatelet Drugs – antiplatelet drugs inhibit platelet aggregation, they are used in the management
of arterial thrombosis (clots initially made of platelets), they are not used in management of VTE
(fibrin clots)
Glycoprotein IIb/IIIa Inhibitors
Abciximab
Eptifibatide
Tirofiban
Other Antiplatelet Drugs
Aspirin
Clopidogrel
Dipyridamole
Ticlopidine
Thrombolytics
Alteplase
Reteplase
Streptokinase
Tenecteplase
Urokinase
Other Drugs Affecting Haemostasis
Vitamin K
Tranexamic Acid
Drugs For Anaemia
Folic Acid
Iron
Vitamin B12
Drug Name Heparin (standard or unfractionated), Dalteparin and Enoxaparin are LMWHs

Drug Class Anticoagulants

Mode Of Action
Inactivate clotting factors IIa (thrombin) and Xa by binding to antithrombin III, LMWHs have a much
greater effect on Factor Xa than on thrombin.

Indications
Prevention of VTE and other thromboses in surgical and high risk medical patients
Treatment of VTE
Treatment of acute coronary syndromes
Treatment of peripheral arterial occlusion
Treatment of DIC

Precautions
Contraindicated in:
- Those with a risk of bleeding inc. thrombocytopenia, bleeding disorders (haemophilia), peptic
ulcer, recent cerebral haemorrhage, severe uncontrolled hypertension, bacterial endocarditis, major
trauma or recent surgery
- Renal impairment (use heparin rather than LMWH)
(safe to use in pregnancy and breastfeeding)

Adverse Effects
Common
Bleeding
Bruising and pain at injection site
Hyperkalaemia
Mild reversible thrombocytopenia
Infrequent
Transient elevation in liver aminotransferases, severe thrombocytopenia
Rare
Skin necrosis (at injection site), osteoporosis and alopecia with long term use, allergic reactions
including urticaria

Dosage
Adult - Prevention (Heparin or Dalteparin)
SC 5000 units 2-3 times daily fr 7-10 days or until mobilised (medical high risk patients)
Drug Name Warfarin (Coumadin, Marevan)

Drug Class Anticoagulants, Vitamin K Antagonists

Mode Of Action
Inhibits synthesis of vitamin K-dependent clotting factors (II, VII, IX, X) and the antithrombotic
factors protein C and protein S

Indications
Prevention and treatment of VTE (DVT, PE)
Prevention of thromboembolism in patients with prosthetic heart valves
Primary prevention of stroke in patients with AF associated with mitral valvulopathy and other risk
factors
Secondary prevention of stroke in patients with AF
Prevention of thromboembolism before and after cardioversion for AF
Prevention of stroke in patients with previous MI and increased embolic risk

Precautions
Contraindicated in:
- Patients with high risk of bleeding – bleeding disorders, previous GI bleeding, haemorrhagic
retinopathy, intracerebral aneurysm or haemorrhage, severe hypertension, bacterial endocarditis,
frequent falls
- Caution in patients with renal and/or hepatic impairment
Surgery – it is safe to continue warfarin in people with high risk of thromboembolism where there is
a low risk of significant bleeding, otherwise stop warfarin 4-5days before elective surgery to allow
the INR to return to normal (give IV heparin or SC LMWH)

Adverse Effects
Common
Bleeding
Rare
Skin necrosis, purple discolouration of toes, allergic reactions, alopecia, fever, rash, nausea, vomiting,
diarrhoea, hepatic dysfunction

Dosage
Adult usually 5mg daily for 2 days then adjust according to INR, usual maintenance dose 1-10mg
daily
Drug Name Aspirin (acetylsalicyclic acid) (Aspirin, Cardiprin, Cartia, Aspro clear, Solprin,
Astrix)

Drug Class Antiplatelet Agent

Mode Of Action
Inhibits platelet aggregation by irreversibly inhibiting cyclo-oxygenase, reducing the synthesis of
thromboxane A2 (an inducer of platelet aggregation) for the life of the platelet

Indications
Acute MI
Unstable angina
Primary and secondary prevention of stroke and acute MI in patients with risk factors
Secondary prevention in ischaemic heart disease (angina, MI, after CABG)
Prevention of thromboembolism in non-rheumatic AF in low risk patients
Relief of pain, inflammation and fever

Precautions
Contraindicated in:
- Those with a risk of bleeding inc. thrombocytopenia, bleeding disorders (haemophilia), peptic
ulcer, recent cerebral haemorrhage, severe uncontrolled hypertension, bacterial endocarditis, major
trauma or recent surgery
- Renal and/or hepatic impairment

Adverse Effects
Common
GI irritation
Asymptomatic blood loss
Increased bleeding time
Infrequent
Stevens-Johnson syndrome, toxic epidermal necrolysis, iron deficiency anaemia, GI haemorrhage
Rare
Intracranial haemorrhage, GI ulcer

Dosage
Adult
75-150mg daily is effective for long term use
150-300mg daily may be required in acute conditions
Drug Name Clopidogrel (Iscover, Plavix)

Drug Class Antiplatelet Drug

Mode Of Action
Inhibits bindig of adenosine diphosphate (ADP) to its platelet receptor, and the subsequent ADP-
mediated activation of the glycoprotein IIb/IIIa complex, thereby inhibiting platelet aggregation

Indications
Prevention of vascaular ischaemic events in patients with symptomatic atherosclerosis (recent
ischaemic stroke, recent MI, peripheral arterial disease)
Non-ST segment elevation acute coronary syndrome (with aspirin)
Adjuvant to reperfusion therapy for STEMI (with aspirin), unless acute coronary artery bypass
grafting is likely

Precautions
Contraindicated in:
- Those with a risk of bleeding inc. thrombocytopenia, bleeding disorders (haemophilia), peptic
ulcer, recent cerebral haemorrhage, severe uncontrolled hypertension, bacterial endocarditis, major
trauma or recent surgery
- Renal and hepatic impairment

Adverse Effects
Common
Bleeding
Diarrhoea
Rash
Infrequent
Intracranial bleeding, GI ulcer
Rare
Thrombotic thrombocytopenic purpur, aplatic anamia, thrombocytopenia, neutropenia, allergy
including angioedema and Steven-Johnson syndrome

Dosage
Adult
75mg daily (preventive dose)
Drug Name Streptokinase (Streptase)

Drug Class Thrombolytics

Mode Of Action
Convert plasminogen to plasmin, which catalyses the breakdown of fibrin

Indications
Acute STEMI
Acute massive VTE in patients who are haemodynamically unstable
Peripheral arterial thromboembolism
Thrombosed IV cannulae, central venous catheters and haemodialysis shunts
Acute ischaemic stroke within 3 hours of onset of symptoms

Precautions
Contraindicated in:
- Those with a risk of bleeding inc. thrombocytopenia, bleeding disorders (haemophilia), peptic
ulcer, recent cerebral haemorrhage, severe uncontrolled hypertension, bacterial endocarditis, major
trauma or recent surgery
- Hepatic impairment

Adverse Effects
Common
Hypotension
Bleeding (inc. at injection sites)
Intracerebral bleeding
Internal bleeding
Infrequent
Allergic reactions including fever, chills, rash, nausea, headache, bronchospasm, anaphylaxis,
vasculitis, nephritis, hypotension
Rare
Cholesterol embolism

Dosage
Adult - Prevention (Heparin or Dalteparin)
Acute STEMI – 1500000 units over 30-60min (IV infusion)
DVT – 250000 units over 30min, then 100000 units/hr for 24-72 hours (IV infusion)
Drug Name Iron

Drug Class Drugs For Anaemia

Mode Of Action
Essential element required for the formation of haemoglobin and myoglobin

Indications
Prevention and treatment of iron deficiency anaemia
Treatment of iron deficiency anaemia in people on haemodialysis receiving epoetin

Precautions
Contraindicated in:
- Haemochromatosis
- Anaemia not due to iron deficiency
(safe to use in pregnancy and breastfeeding)

Adverse Effects
Common
Abdominal pain
Nausea
Vomiting
Constipation
Diarrhoea
Black discolouration of faeces

Dosage
Adult - (1mg of elemental iron is equivalent to 3mg ferrous fumarate, 3mg ferrous sulfate)
Treatment of iron deficiency – 100-200mg daily (orally)