1. Prescribing in Disease Clive Roberts

2. So what are drugs good at treating (or preventing)? Pain Inflammation Infection Fluid retention Heart problems High blood pressure Epilepsy Parkinsonism Asthma / COPD Peptic ulcer disease Diarrhoea/constipation Depression Anxiety/sleeplessness Psychosis Metabolic /endocrine diseases Malignant disease Degenerative disease Haematological problems Etc

8. What could happen to this man? 1)Massive fluid overload 2)Hepatic encephalopathy 3)Gross electrolyte abnormality 4)Renal Failure 5)GI or other Haemorrhage 6)Metabolic abnormaility 7)Exacerbation of liver disease 8)Infection 9)Drug accumulation

9. And so the risks of drug use in decompensated liver disease Precipitate encephalopathy –CNS effect –Electrolyte effect –GI effect Worsen metabolic effect/features of hepatic failure –Fluid retention –Sodium retention –Electrolyte abnormality –Hypoglycaemia –Clotting abnormalities

10. Continued: Profound pharmacokinetic disturbance leading to drug accumulation and dose related adverse effects –Decreased systemic clearance of lipid soluble drugs –Increased bioavailability of drugs with high extraction ratio –Decreased plasma protein binding –Altered apparent volume of distribution –Associated impairment of renal function –Failure of pro-drugs –Hepatic blood flow reduction Worsened hepatic state –Hepatotoxic drugs

11. Some examples from the BNF table Anticoagulants Antidepressants, anxiolytics and hypnotics Anti-psychotics NSAIDs Diuretics Phenytoin, Carbamazepine Glibenclamide Opioids Rifampicin

12. Co-amoxyclav, clarythromycin, erythromycin, ketoconazole, isoniazid Chloramphenicol Clopidogrel Cyclophosphamide, methotrexate Lignocaine ACE inhibitors Metformin Verapamil and some dihydropyridine Ca blockers

13. Statins Antacids Theophylline

14. Other risk situations Renal disease The Elderly Need for many drugs Allergy Lung disease Heart disease Gastrointestinal disease Inherited diseases Blood diseases Bone disease Skin disease Pregnancy

15. The renal patient Pharmacokinetic disturbance –Mainly affecting drug clearance –Also protein binding Increased sensitivity Poor tolerance of adverse effects Decreased effectiveness of some drugs

16. Drugs in the elderly Multiple indications leads to polypharmacy Pharmacokinetic disturbance of metabolism, excretion, protein binding and drug distribution Increased sensitivity to the actions of drugs on CVS, CNS, GIT Poor tolerance of adverse effect

17. Other risk situations Renal disease The Elderly Need for many drugs Allergy Lung disease Heart disease Gastrointestinal disease Inherited diseases Blood diseases Bone disease Skin disease Pregnancy

18. Remember Every disease represents a potential contra- indication to particular drugs Prescribing any drug should only follow a decision that potential benefit outweighs potential risk