1. P Drug Exercises Dr Navneet Kaur

2. P-Drug Concept P-drugs are the drugs you have chosen to prescribe regularly, and with whom you have become familiar. The P-drug concept is more than just the name of a pharmacological substance, it also includes the dosage form, dosage schedule and duration of treatment. PersonalPriorityPreferred

3. Choice of P-drug (STEP Criteria) A P-drug is selected depending upon the following criteria: Safety: possible adverse effects. Tolerability: suitability for a patient. Efficacy: drug profile. Price: always look at the total cost of treatment rather than the cost per unit.

4. Process of Choosing a P Drug Define the Diagnosis Set Therapeutic Objective Make inventory of effective groups of drugs Choose an Effective Group Choose a P drug

5. Exercise 1 A 40 years old man moderately obese is a diagnosed case of hypertension with BP 146/94. ECG shows left ventricular enlargement. Choose the effective P Drug.

6. Example of selecting a P-drug: angina pectoris 1.Define the diagnosis Stage I hypertension 2. Specify therapeutic objective Prolong useful life by preventing cardiovascular problems by reducing BP < 140/90 iii. Make inventory of effective groups ACE inhibitors AT receptor antagonists Diuretics ß-blockers Calcium channel blockers

7. iv. Choose a group according to criteria Efficacy Safety Suitability Cost ACE inhibitors(tablet) + + ++ ++ - B- blockers + + + - Diuretics + + ++ + CCB + + + +

8. Choose a P-drug Efficacy Safety Suitability Cost Captopril(tablet) + ± - + Ramipril(tablet) + ++ ++ + Lisinopril(tablet) + + + ±

9. Conclusion Active substance, dosage form: Ramipril, tablet 5 mg Dosage schedule: 1 tablet OD Duration: length of monitoring interval

10. Exercise 2 A patients is a 60-year old man, with no previous medical history. During the last month he has had several attacks of suffocating chest pain, which began during physical labour and disappeared quickly after he stopped. He has not smoked for four years. Auscultation reveals a murmur over the right carotid artery and the right femoral artery. Physical examination reveals no other abnormalities. Blood pressure is 130/85, pulse 78 regular, and body weight is normal.

11. Example of selecting a P-drug i. Define the diagnosis Stable angina pectoris, caused by a partial occlusion of coronary artery ii. Specify therapeutic objective Stop an attack as soon as possible Reduce myocardial oxygen need by decreasing preload, contractility, heart rate or afterload iii. Make inventory of effective groups Nitrates ß-blockers Calcium channel blockers

12. iv. Choose a group according to criteria Efficacy Safety Suitability Cost Nitrates (tablet) + ± ++ + B-blockers (injection) + ± - - CCB (injection) + ± - -

13. Choose a P-drug efficacy safety suitability cost GTN(tablet) + ± + + (spray) + ± (+) - IDN(tablet) + ± + ± IMN(tablet) + ± + ±

14. Conclusion Active substance, dosage form: glyceryl trinitrate, S/L tablet 1 mg Dosage schedule: 1 tablet as needed; second tablet if pain persists Duration: length of monitoring interval

15. Exercise 3 A 50 year-old male patient complains of bloody, mucoid stools and abdominal pain. There is no history of alcohol abuse. You have diagnosed it as a case of acute amoebic dysentery. Choose an appropriate drug and mention its dosage schedule and duration of treatment.

16. Step 1: Define the diagnosis  Amoebiasis is a protozoal infection caused by the ingestion of amoebic cysts of Entamoeba histolytica Step 2: Specify the therapeutic objective  To treat the signs and symptoms  Eradicate the disease and prevent transmission of the disease  Prevent further complications.

17. Step 3: Make an inventory of effective groups of drugs  Nitroimidazoles [ metronidazole, tinidazole, secnidazole,ornidazole ]  Alkaloids [emetine, dehydroemetine]  Amide [diloxanide furoate]  8-Hydroxyquinolines [iodochlorohydroxyquin, diiodohydroxyquin]  Antibiotics [tetracyclines, paromomycin]

18. Step 4: Choose an effective group according to criteria Inventory of effective groups of drugs Group EfficacySafetySuitabilityCost Total Score Nitroimidazoles +++++ Relatively frequent but nonserious +++++ Alkaloids Amides +/- + --- ( highly toxic) ++ (very well tolerated) - + + Antibiotics 8-Hydroxyquinolines ++++ - - (well tolerable ) ++++

19. EfficacySafetySuitabilityCost MetronidazoleNo difference Rs 6.75 TinidazoleNo difference Rs 12.65 SecnidazoleNo difference Rs 26.40 OrnidazoleNo difference Rs 39 SatranidazoleNo differenceBetter tolerabiity, absence of neurological side effects Can be preferred in patients with susceptible neurological symptoms Rs 40

20. Step 5: Choose a P-drug Choose an active substance and a dosage form Metronidazole 400 mg followed by a diloxanide furoate 500 mg to prevent carrier state Choose a standard dosage schedule 400 mg three times a day Choose a standard duration of treatment Tablet metronidazole 400 mg three times a day for five days followed by Tablet Diloxanide furoate 500 mg three times a day for 10 days.

21. Exercise Verify in each of these cases whether the active substance and dosage form of your P -drug is suitable (effective, safe) for this patient.

22. Man, 45 years. Suffers from asthma. Uses salbutamol inhaler. A few weeks ago you diagnosed essential hypertension (145/100 on various occasions). You advised a low-salt diet, but blood pressure remains high. You decide to add a drug to your treatment. Your P-drug for hypertension in patients under 50  Tab atenolol 50 mg a day

23. Woman, 22 years, 2 months pregnant. Large abscess on her right forearm. You conclude that she will need surgery fast, but in the meantime you want to relieve the pain. Your P-drug for common pain is acetylsalicylic acid (aspirin) tablets Boy, 4 years. Cough and fever of 39.5 C. Diagnosis: pneumonia. One of your P-drugs for pneumonia is tetracycline tablets.

24. Step 3B: Is the standard dosage schedule suitable for this patient?

25. Woman, 43 years. History of insulin dependent diabetes for 26 years. Stable on treatment with two daily doses of neutral insulin, 20 IU and 30 IU. Recently mild hypertension was diagnosed, and diet and general advice have not been sufficiently effective. You would like to treat this condition with a beta-blocker. Your P-drug is atenolol 50 mg once daily. Woman, 50 years. Chronic rheumatic disease, treated with your P-drug, indometacin 50 mg, 3 times daily plus a 50 mg suppository at night. She complains of pain early in the morning

26. Step 3C: Is the standard duration of treatment suitable for this patient Woman, 62 years. Angina pectoris, waiting for referral to a specialist. R/glyceryl trinitrate 5 mg, as necessary 1 tablet sublingual, give 60 tablets. Woman, 24 years. Feels weak and looks a bit anaemic. No Hb result available. R/ferrous sulfate 60 mg tablets, 1 tablet three times daily, give 30 tablets