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In heart failure, the heart fails to pump enough blood to maintain sufficient blood flow throughout the body. The goal of the heart is to maintain the cardiac output, which is the amount of blood which is pumped by the heart in one minute. Our body tries to compensate by  Increasing the heart rate.  Activating the Renin-Angiotensin-Aldosterone-System (RAAS), which cause an increase in blood volume and vasodilatation.  Sympathetic activation, which causes tachycardia and cardiac remoulding.  The release of BNP, in response to stretch of cardiac muscle which causes natriuresis and inhibition of aldosterone. These compensatory mechanisms increase the load on the failing heart. Our goal is to inhibit these compensatory mechanisms to decrease the further load on the failing heart which these compensatory mechanisms (especially activation of RAAS and sympathetic system) put. The BNP release is not enough in the presence of activated RAAS.  Thus,...

Testosterone is a hormone responsible for secondary sexual characteristics in a male. It promotes muscle size, increases bone mass, increases red cell production, improves mood, behaviour, libido and sexual function. Testosterone is widely used among the bodybuilders for the purpose of muscle growth. Yes, it does help, but you will have to pay a price. Exogenous testosterone in a normal person, who doesn't have testosterone deficiency causes a decrease in the production of FSH and LH by the pituitary gland. FSH in males is required for spermatogenesis and it stimulates natural testosterone production by the testes. Now if you are providing your body with already made testosterone, the receptors present in the pituitary will not produce FSH, as your blood has a high level of testosterone because of exogenous injections. Now due to lack of FSH and LH, the two hormones required for sperm production, the sperm production decreases, testicular size may also decrease, as they beco...

Azithromycin a widely used broad-spectrum antibiotic used to treat community-acquired pneumonia or respiratory tract infections. It is observed that azithromycin if given with statins, may cause severe rhabdomyolysis which may lead to an acute renal shutdown. A case reported by Dr Gaurav Alreja shows a possible interaction of azithromycin with simvastatin, A 73 years old male who was given azithromycin for bronchitis, he was taking simvastatin. He presented in emergency with the acute weakness of all extremities, he was found to have abnormal renal function tests with elevated creatinine. Simvastatin was stopped, and he was started on supportive management, bicarbonate was replaced, his renal function improved, and two months later he was again started on simvastatin without recurrence of symptoms. This gives us an indication that probably the azithromycin was responsible for the acute severe rhabdomyolysis and resultant acute renal failure when was given along with the statin. So...

Sometimes it becomes difficult to choose a drug in those patients who have multiple co-morbidities. That is are suffering from more than one disease and physician needs to choose a few out of many drugs to avoid drug-drug interactions. Anti-epileptic drugs, or the drugs which are used to treat seizures, do interact with other drugs.  Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, topiramate and primidone are enzyme inducers. Enzyme inducers decrease the efficacy of a drug which is metabolized by the induced enzymes because more concentration of the enzyme will be available and the drug will be quickly metabolized and removed from the system.  Valproic acid, felbamate, rufinamide, and stiripentol, on the other hand, are enzyme inhibitors.  Therefore, we can't give these drugs to a patient who is taking a drug for any medical problem which is metabolized by the liver enzymes (eg cytochrome p450 enzyme system).  The anti-epileptic drugs which are not ...

Acetaminophen is an over the counter drug, easily available without a prescription, but if taken especially if more than 12g is taken which is potentially fatal. The cause of death or the complication is usually the liver failure, which likely occurs if more than 250mg/kg of paracetamol is taken. If a patient arrives at the emergency department with paracetamol poisoning and has taken more than 200mg/kg or more than 10g of paracetamol then immediately resuscitate and start acetylcysteine which is the antidote for paracetamol poisoning. The dose of Acetylcysteine and Method of Administration Consider Oral acetylcysteine, if the patient is not confused and can easily tolerate the medicine orally, the injectable acetylcysteine may also be given by oral route. The oral dose is as follows. Oral Administration of Acetylcysteine The loading dose is 140mg/kg, after giving the loading dose, wait for four hours and after four hours give the maintenance dose, which is 70mg/kg. Repeat ...

Amiodarone has high iodine content, because of the high iodine content it may affect the thyroid gland. It can either cause hypothyroidism or thyrotoxicosis. Approximately 1 out of every 6 patients who are using amiodarone develops thyroid dysfunction. 1. Amiodarone-induced hypothyroidism (AIH).  If a patient's TSH is high and Free T4 is low, it means the patient has developed hypothyroidism. In this situation, start thyroxine and if possible amiodarone should be stopped, but it is not necessary, if the patient still has symptoms such as ventricular tachycardia or arrhythmias then you may continue amiodarone, just add thyroxine and monitor thyroid function every 6 weeks first then maybe after 3 months or 6 months, depending on the clinical scenario. 2. Amiodarone-induced thyrotoxicosis (Hyperthyroidism).  If the patient has developed hyperthyroidism, then it is advised to stop amiodarone and start an anti-thyroid drug such as carbimazole, if it is type 1 amiodarone-indu...

Carbimazole (Neo-Mercazole), an antithyroid drug, which is used as a first line agent to treat hyperthyroidism, has a half-life of 5.3 hours. It can be given as a single daily dose or in divided doses. Some physicians, recommend divided dose to minimize the gastrointestinal side effects, while the other physicians, recommend a single daily dose for better compliance. Research studies showed that the efficacy of carbimazole (Neomercazole) when taken as a single dose per day or in divided doses, is similar or comparable. The single daily dose of Neomercazole is found to be superior to "Divided-dose" method as it is associated with better compliance. It may be difficult for patients to remember taking the divided doses. Sometimes, the patient may forget to take the evening dose. So a single daily dose is especially effective for those patients who find it difficult to remember the timings of divided dose. Conclusion : A single daily dose of Carbimazole is superior to a di...

Brilinta contains Ticagrelor as an active ingredient. It is an antiplatelet drug and works by inhibiting the platelet activation. Inhibition of platelet activation decreases the risk of blood clot formation and thus, cardiovascular problems. Indications of Brilinta (Ticagrelor) Ticagrelor is indicated in ACS (Acute coronary syndrome) that is unstable angina, ST elevation or non ST-elevation myocardial infarction . It has been compared with clopidogrel and it has been observed that Brilinta (Ticagrelor) is more effective in preventing cardiovascular deaths and ischemic stroke . It also prevents stent thrombosis in post-angioplasty patients. Warning and Side effects of Brilinta. Brilinta (Ticagrelor) Shouldn’t be used if a patient has Recently undergone major surgery or had serious trauma or accident. History of intracranial bleed Active bleed (e.g. active peptic ulcer bleed) Severe hepatic impairment Allergy or hypersensitivity to any of its ingredients. Warnings and Side effe...

Drug of choice is that drug which is known to be most effective in order to cure an infection or disease. A drug of choice should be accessible, cost-effective, easily tolerable, safe, and most importantly effective against the disease-causing pathogen. Following is the list of few of drugs that are used in the common infections. Pathogen Disease Drug of Choice Actinomyces Actinomycosis Penicillin G Bacillus anthracis Anthrax Ciprofloxacin, Tetracyclines Bordetella pertussis Whooping cough Erythromycin Borrelia burgdorferi Lyme disease Tetracycline Campylobacter Acute inflammatory diarrhea Ciprofloxacin Candida Vaginal candidiasis Systemic candidiasis Miconazole Fluconazole Chlamydia trachomatis Pelvic inflammatory disease Doxycycline Chlamydia pneumonia Pneumonia Tetracycline H. influenza Pneumonia, Meningitis 3 rd Gen Cephalosporin H. pylori Gastric ulce...

Dr Tayyab Saeed Akhtar, the registrar of medical unit 2 Holy Family Hospital Rawalpindi Pakistan, delivered a comprehensive lecture on “Judicious use of antibiotics in dentistry” at Armed Forces Institute of Dentistry Rawalpindi. Dr Tayyab Saeed Akhtar, who is also a member of the editorial board of medicotips.com comprehensively explained to his audience, the meaning of the term “judicious use of antibiotics” and also “why is this judicious of antibiotics important?”. He started his speech from the discovery of antibiotics. In 1929 when the first antibiotic was discovered, it wasn’t widely available. In the beginning, It was only used by the victims of World War II. Later, It became available in the market. Since the discovery and widespread use of antibiotics the life expectancy of human has been increased significantly. For example, the life expectancy of Americans has been increased from 47 years to 78 years now and the major reason of this phenomenal achievement is the ability t...

Hyperthyroidism is a condition in which thyroid gland starts to secrete an increased amount of thyroxine in the blood. This, in turn, produces several effects in the body, including, palpitations, weight loss, increased appetite, heat intolerance, sleeplessness, generalized weakness and abortions. There are various causes that are responsible for this increased production of thyroxine by the thyroid gland. We will not go into this detail in this article but have explained it in a separate article, the link of which is stated below. Thyroid Diseases, an overview Hyperthyroidism in pregnancy should be treated, because it may result in fetal abnormalities. The thyroid hormone T3 and T4 crosses the placenta in small amounts. The amount of diffusion across the placenta decreases with the age of the pregnancy. But still, it may cross in significant amounts. The thyrotropin-releasing hormone and thyroid stimulating immunoglobulins (which are responsible for maternal hyperthyroidism) and be...

Beta blockers include, atenolol (Tenormin), propranolol (Inderal ) and metoprolol (Lopressor) and are used to treat high blood pressure, certain cardiac problems, migraine and few other conditions. People usually take atenolol, propranolol or metoprolol for many years as a treatment of high blood pressure or after having an episode of heart attack . Sometimes, it becomes necessary to withdraw these beta blockers due to their potential side effects that trouble the patients or sometimes doctor wants to change the drug and shift the patient to some other anti-hypertensive medicine. No matter whatever the cause is, whenever, a patient who has been using a beta blocker for a long period of time, and he needs to be stopped from further usage of that beta blocker, must not stop taking it. One should taper off the dose of a beta blocker. Now a question arises how to wean off or taper off a beta blocker? The method of tapering off beta blocker varies from individual to individual. Allow you...

Alprazolam is available in the market with the trade names of Xanax, Alp and many others. It belongs to a class of drugs called benzodiazepines. Xanax is generally used to manage anxiety, stress and panic attacks. It shouldn’t be used to treat psychosis. Xanax (alprazolam) should be sold under prescription only. In developed countries, it is strictly sold under prescription but unfortunately, in many developing countries, it is being sold as an over-the-counter drug. A person can get Xanax by asking the medical storekeeper to give him some sleeping pills. He takes them, uses them according to his own wishes and when after some time, one tablet doesn’t work he adds one more. This is a very wrong practice. Alprazolam (Xanax) is not Paracetamol (acetaminophen) that can be used anywhere anytime. Many individuals do not know the proper usage of Xanax (alprazolam). Especially in developing countries where there is a lack of education and also due to the heavy flow of the patients to governme...

Insulin is the final choice of therapy for a type 2 diabetic patients. Usually, a type two diabetic patient is shifted to insulin therapy when oral hypoglycemic drugs fail to control the Diabetes . There are various types of insulin that can be used. Each type has its own time on the onset of action, the Peak time of action and duration of action. These types are named after, onset and duration of action. According to this, insulin has the following 4 types. Rapid-acting Insulin Short-acting insulin Intermediate-acting insulin Long-acting insulin There is a 5th type of insulin which is called “ Premixed insulin ”. In this type a short acting and intermediate acting insulin is mixed in different proportion (eg. 70:30, 50:50, 75:25). Usually Regular insulin and NPH are mixed. 1. Rapid-acting insulin. This is called rapid acting because it’s action starts within 10-30 minutes of injection. Insulin lispro, aspart and glulisine are included in this category. Their peak action starts...

Oral contraceptives prevent conception/pregnancy due to their following effects on a woman’s body. 1. Oral contraceptive pills contain Estrogen and a Progestogen. The most commonly used Estrogen in oral contraceptive pills is  Ethinyl Estradiol while the commonly use Progestogens are Norethindrone, Levonorgestrel, Desogestrel and Norgestimate. You can see their names written in the leaflet that is supplied along with the pill pack.  2. Oral contraceptives inhibit ovulation. they inhibit the release of the egg from the ovaries and without the egg, the male sperm can’t produce a baby. Oral contraceptives inhibit ovulation by manipulating the normal hormonal responses and blood level of a female. Hypothalamus secretes a hormone called Gonadotropin-releasing hormone (GnRH). This acts on the anterior pituitary and causes the release of FSH and LH. FSH reaches the ovaries via blood where it causes follicle maturation and development. It also signals the release of Estrogen from...

Probiotics and Barrett Esophagus Probiotics are supplements that contain useful or good bacteria. The gastrointestinal tract of the human body is full of natural bacteria, especially the large intestine and the last part of the small intestine. These bacteria are not harmful to the human body, instead, they are useful. They perform some good function including, production of vitamin K and suppressing the growth of harmful bacteria that can produce disease. There are 400 types of good bacteria in the human gastrointestinal tract. The most important of these 400 types is lactobacillus acidophilus or lactic acid bacillus (LAB). These good bacteria suppress the growth of harmful bacteria. They do so by competing for space and food. The good bacteria occupy space and consume food, and don’t allow harmful bacteria to take their place. The harmful bacteria don’t get enough space and food for their growth and hence their growth is suppressed. Probiotics are used in a number of disorders. The...

Author: Dr. Adil Ramzan Khyber Medical University, Peshawar, Pakistan Bannu Medical College, Bannu, Pakistan Typhoid fever also known as enteric fever is one of the world’s most common diseases. Typhoid fever affects More than 20 million people each year of which 0.7 million people die. In the 1980s the treatment of typhoid fever was started with chloramphenicol, ampicillin and TMP/SMX. But today, most of the bacterial strains that cause typhoid fever are resistant to both ampicillin and TMP/SMX. Resistant strains to chloramphenicol are now emerging. Nowadays third-generation cephalosporin and Floroquinolones are considered first-line agents for the treatment of typhoid fever. In a study, conducted by Department of Paediatrics and Child Health and Faculty of Medicine of the University of Natal (situated in Durban, Republic of South Africa) compared the efficacy of chloramphenicol and ceftriaxone for the treatment of typhoid fever. They included 59 children in the study. All ch...

Q: Hello I have a question. My son has been on Suboxone (buprenorphine and naloxone) for approx 8 months. 1 8mg film daily. Finally, he has smartened up and wants to be rid of this lifestyle forever. So on December 17, 2012, he took his last half. He had a prescription of tramadol from a previous injury so in order to eliminate the withdrawal from the suboxone he has been taking the tramadol. If it has been 13 days without any suboxone will he still go through the physical withdrawals from it? If so how long do they typically last? If he were going to suffer any withdrawals wouldn't they have already kicked in? Thank you so much for taking the time to help me. A: Ok tell me for how long had he took opioids? and ( which drug he was addicted to). Suboxone is used to treat opioid addiction. Was he addicted to other stronger opioids? Has he encountered any withdrawal symptom?  What kind of symptoms did he have? and is he absolutely fine now? Q: If I were to have to guess I would ...

Dietary or pharmacological reduction of elevated plasma cholesterol levels can reduce the risk of atherosclerosis and subsequent cardiovascular disease. the association between elevated plasma triglyceride levels is less dramatic, but it is becoming more recognized. In addition, elevated plasma Triglycerides can produce life-threatening pancreatitis. Drugs useful in treating hyperlipidemias ( Increased conc. of lipids in the blood) 1. Inhibitors of Cholesterol Biosynthesis. following drugs inhibit cholesterol synthesis: Lovastatin (mevinolin, Mevacor)  Simvastatin (Zocor) Pravastatin (Pravachol) Fluvastatin (Lescol) Atorvastatin (Lipitor) Rosuvastatin (Crestor) Drugs that inhibit cholesterol synthesis are effective at lowering plasma LDL cholesterol and total cholesterol 2. Nicotinic acid ( Niacin ) (brand names: Nicobid, Nicolar) Nicotinic acid Fibric Acid Analogues. Finofibrate ( Antara, Triglide, Lofibra) Gemfibrozil (Lopid) Bi...

Colesevelam (WelChol) Mechanism of action: colesevelam (WelChol)  bind with bile acids and impair their absorption and reduce enterohepatic circulation and re-utilization of bile acids. colesevelam (WelChol) also decreases the absorption of dietary cholesterol. In this way, colesevelam (WelChol) decrease the absorption of cholesterol and blood level of cholesterol is decreased. Therapeutic Uses: colesevelam (WelChol) is effective in reducing plasma cholesterol level (to about 10 - 20 % ) in patients with some normal LDL receptors. colesevelam (WelChol) is ineffective in the treatment of patients who completely lack LDL receptors due to a genetic defect ( homozygous familial hypercholesterolemia). Adverse Effects: colesevelam (WelChol) is generally safe because are not absorbed in the small intestine. common side effects are; colesevelam (WelChol) has lesser GI side effects (constipation, nausea and diarrhoea) than other drugs like Colest...