Transcript Methylprednisolone

Prescription-Only Medicines
now Accessible to Podiatrists
The Science Behind Them
Dr Jean Mooney
PhD, FChS, FCPodS, FCPodMed, FHEA
Pods and POMs: History
 ~1980

4 injectable plain local anaesthetic solutions
 ~1996




Statutory Instrument gave access to
Further SI gave access to
2 adrenalinised local anaesthetics
Topical anti-fungal agents
Topical 1% corticosteroid
3-day course Ibuprofen, 200mg tds
Patient Group Directions


Legal framework (August 2000)
Allowed Podiatrists to supply and administer specified
medicines to patients who are designated as within a
group as defined by the PGD


e.g: Diabetics with soft tissue or bone infections
POMs supplied directly to a patient without the need for
a separate prescription from a prescriber.



PGD allows access to POMs for specific types of patient
presenting with a specific need: it is NOT a form of prescribing
PGD does not require the podiatrist to have any additional
qualification
Employing organisation must ensure that only fully competent,
trained health care professionals use PGDs.
Supplementary Prescribing (2005)



Voluntary prescribing partnership between
IP and SP
Implements an agreed patient-specific
clinical management plan (CMP)
CMP agreed between




Podiatrist must undergo training (~6/12) to
become SPs


IP: doctor
SP: podiatrist
Patient
HPC-Register annotated
Allows them to prescribe or adapt dosage of
POMs specified within the CMP without
recourse back to IP
Pods and POMs: 17.11.2006

SI extended access to the list of POMs that
can be administered, sold and supplied to
patients by Podiatrists


Schedule 5, Articles 4(2) and 4(4) amended Part
I and III of Schedule 5 to the Prescription Only
Medicines (Human Use) Order 1997
Also regularised access to some Pharmacy
medicines (P) for topical application e.g.:


1% Griseofulvin
1% Terbinafine
2006
Additional POMs from 17.11.06


Adrenaline
2 more plain LA solutions



4 Anti-microbial agents





Levobupivacaine
Ropivacaine
Amoxicillin
Erythromycin
Flucloxacillin
Silver Sulfadiazine
Anti-inflammatory

Methylprednisolone
Further amendments allowed additional
access to other medicines from 10.03.2011
 Ibuprofen
(400mg)
 Codeine phosphate


Co-codamol
Co-dydramol (10/500)
 Pre-mix

injectable solutions
E.g.: Depomedrone (Pre-mixed Lidocaine and
Methylprednisolone)
Recommendations
 Continue
to use all means of access to
POMs

e.g.: PGDs
 Train

Not easy for those in private practice
 Gain


as a Supplementary Prescriber
HPC annotation
POMs
LA
College of Podiatrists Recommendations
Codeine, Co-codamol and Co-dydramol

Indicated for short term treatment of acute /
moderate pain unrelieved by paracetamol,
ibuprofen or aspirin
 Limited to a maximum of 3 days prior to direct
patient review


even though the pack size may exceed that dose level
Essential that all Medicines are correctly labelled
and supplied with an explanatory leaflet that
clearly states



Dosage
Side effects (e.g.: constipation)
Possibility of addiction or habituation
Pharmacodynamics
Adverse Drug Reactions
Pharmacodynamics
 The

effects of the drug on the body
desired and undesired effects of the drug on
body systems
 Intended


effects
Modes of action / drug-receptor interaction
Doses and maximum safe doses
 Undesired
/ unwanted / unexpected effects
= Adverse drug reactions (ADRs)
Classes of Adverse Drug Reaction (1)
 Type A:




Addative effects
Dose related
Predictable effect
Not usually severe
 Management:

Dose modification
Classes of Adverse Drug Reaction (2)
 Type




B
Bizarre, unexpected effect
Unpredictable
Immunological basis
Rare: can be life threatening
 Management:



Immediate withdrawal of drug
Counter treatment, where possible
Avoid all future exposure to the
drug
Comparison: Type A and Type B ADRS
Other Types of Adverse Drug Reaction

Type C



Type D



Delayed effects
Drug does not ‘kick in’ when expected
Type E



Chronic administration
Habituation; tolerance; dependence
Exclusion
Effects of drug withdrawal
Type F


Failure of therapy
Often due to drug interactions
Frequency of ADR, by Class of Drug
ADR-Risk Patients
 Elderly
 Very
young
 Renal disease
 Liver disease
 Genetic
predisposition
ADRs attributed to Celecoxib
(COX2 inhibitor) in 6/12 period
ADR avoidance

Use prescribed medications only when
necessary



Patients should be warned of the possibility of
ADR occurring


In the lowest dose, to achieve required effect
For the shortest time, to maintain the required effect
Package advice leaflet
BNF Yellow card system

Report all suspected ADRs
Pharmacokinetics
Drug Interactions
Pharmacokinetics
 The


effects of the body on the drug
How the body deals with the drug
What the body does to the drug
• Absorption
• Metabolism
• Excretion
 Drug
interactions
Drug Interactions (DIs)

Effect or action occurring in the body



Due to taking two or more drugs, or one
drug+






Beneficial / desired
Adverse / unwanted
OTC medicines
Vitamin and mineral supplements
Medicinal herbs
Foods
Does not occur when taking either alone
DIs usually inadvertent, e.g.:




POM + OTC
Drugs supplied by more than one prescriber
The more drugs that are taken, the more
likely that DI will occur
Often under-reported as they mimic
exaggerated action of drug
Drug Interactions

Desired effects: potentiating effect of drugs used in combination


Undesired effects: one drug mitigates the effect of another




absorption by small intestine
metabolism to non-active substances by liver
(non-active substances excreted via the kidney: may still carry some
drug effect)
DIs also occur when drug constituents interact with e.g.: foods,
antacids, vitamin, mineral or herbal supplements


e.g.: Erythromycin reduces the effectiveness of oral contraceptives
Most DIs arise due to effects on Cytochrome P450 enzyme system


e.g.: codeine combined with paracetamol gives greater pain relief
e.g.: Antacids can bind with antibiotics preventing blood uptake
It is essential that the name and dosage of all medications
(including OTCs) are identified before supplying a POM to a
patient

Full medical history
Antibiotics
Antibiotics (ABx)

Substances that kill or inhibit a range of MOs


Dose: usually minimum 5-7 days




Any MO-derived substance that antagonizes growth of another MO
in high dilution
to ensure full MO kill
wound swab BEFORE starting ABx
review patient after 3 days to check response to AB treatment
Classified

By manufacture
• natural, semi-synthetic or synthetic analogues of natural
compounds

Spectrum of biological effect
• Bactericidal / Bacteriostatic

Susceptibility of a range of MOs to ABx effect
• Broad / Medium / Narrow spectrum
Amoxicillin
Flucloxacillin
Erythromycin
Silver Sulfadiazine
Available to HPC POM-annotated Podiatrists since Nov 2006
Amoxicillin

Beta-lactam penicillin-type antibiotic with moderatespectrum of activity


Bacteriolytic
Inhibits synthesis of G+ve and G-ve bacterial cell walls

Good absorption with oral administration
 MO resistance is common


MOs produce beta-lactamase and degrade amoxicillin
Often formulated in combination with clavulanic acid (Coamoxiclav / Augmentin) to overcome MO resistance
Amoxicillin Contd:

Dose:


Uses



250mg / 500mg tds
Skin infections
(No longer recommended for prevention of
bacterial endocarditis)
Side effects (ADRs)


D+V
Non allergic rashes
• Affects 3-10% of children

Anaphylaxis
Flucloxacillin
 Beta-lactam
penicillin-type antibiotic with
narrow spectrum of activity

Inhibits synthesis of bacterial cell walls
 Used
to treat infections caused by
susceptible G+ve bacteria




Active against beta-lactamase MOs, such as
Staph aureus
Not effective against G-ve organisms or non-beta
lactamase producing G+ves
Ineffective against MRSA
MO Resistance
Flucloxacillin Contd.

Dose


250-500mg qds
Uses



Skin infections
Surgical prophylaxis
Cellulitis
• May be combined with ampicillin (Co-fluampicil) if Strep
pyogenes suspected

ADRs include


D+V, superinfection (candidiasis), allergy
Avoid use in patients with renal or hepatic impairment
Erythromycin

Bactericidal macrolide antibiotic
 Slightly wider antimicrobial spectrum than
penicillins



Often used in subjects with penicillin allergy


Unknown mechanism of activity
Taken up by macrophages so concentrates in area of
infection
Indicated for skin infections
Metabolised in the liver
Erythromycin Contd.

Dose




ADRS include



D+V, nausea and abdo cramps
Cardiac arrhythmias and deafness
Allergies


250mg qds
Non acid-stable (give after meals)
Clarythromycin is acid-stable
To be avoided in infancy, pregnancy and lactation
Not used in conjunction with many drugs

e.g.: Warfarin, OCs, corticosteroids, simvastatin, antimigraine drugs, verapamil, terfenadine, theophilline,
clindamycin
Silver Sulfadiazine

Topical agent



Antibacterial: broad-spectrum activity in chronic wounds




G+ve and G-ve bacteria (including Pseudomonas aeruginosa)
Some yeasts and fungi
Poor penetration on normal skin
Up to 1% show hypersensitivity reaction, e.g.:





1% cream
Sulfonamide and Silver
Rashes; erythema multiforme
Skin discolouration (argyria)
Avoid in late pregnancy / infancy
Avoid in patients with G6PD deficiency
May increase wound healing times

Not recommended by Cochrane review
LET’S
See you again in 15 mins
Pain control
Analgesia
Anaesthesia
Analgesics

Analgesic = painkiller




Act at PNS and / or CNS membrane receptors
Include




Paracetamol (acetaminophen in US),
NSAIDs, e.g.: Salicylates (aspirin), Ibuprofen
Opioids, including Morphine and Codeine
CoP advice:


an = without; algos = pain
NB: Anaesthetics = without sensation
Max administration = 3 days, then direct patient review
Analgesic choice is determined by


Severity of pain
Pain type, e.g.: neuropathic pain is more responsive to tricyclic
antidepressants and anticonvulsants (e.g.: gaba-pentin)
Codeine phosphate

Opiate drug




Actions


Weak to mid-range opioid
Makes up 3% of opium
CSN and PNS action
Analgesic, anti-tussive, anti-diarrhoeal
Side effects (especially in overdose)




Gut immobility
Respiratory suppression
Tolerance, habituation, addiction, coma, death
Codeine is metabolised to morphine
• 5% show rapid metabolism to morphine  ‘High’
• Avoid use during lactation
Codeine contd.

Unwanted side effects include




Euphoria, itching, nausea, vomiting, drowsiness,
orthostatic hypotension, urinary retention, depression,
constipation, and paradoxical coughing
Hives and rashes due to allergic reaction
Long-term administration causes erectile dysfunction
and hypogonadism (especially in white males)
Sugar cravings
• Induces hypoglycaemia (the ‘munchies’)
• Was once used to control diabetes, as was morphine
Co-dydramol

Compound analgesic


Dihydro-codeine tartrate 7.5 / 10 / 20 / 30mg
+ Paracetamol 500mg

Used to relieve moderate pain
 Side effects




Allergic reactions - urticaria, breathing difficulty, increased
sweating, facial flushing, mouth ulcers.
Abdominal pain
GIT upsets: abdominal pain, nausea, heartburn,
constipation, loss of appetite, dry mouth,
Blood problems - anaemia, nose bleeds, increased risk of
infection, bruising.
Co-dydramol Side Effects Contd





UT upsets - pain or difficulty in passing urine.
Nervous system - confusion, drowsiness, dizziness,
mood changes, depression, hallucinations,
restlessness, excitation, fits, painful eyes, headache,
sleeping problems,
Tolerance or dependence.
Eyes - blurred or double vision, extremely small
pupils.
Other - trembling, tiredness. weakness, malaise, low
body temperature, muscle stiffness, changes in libido.
Co-Codamol
 Compound


Codeine phosphate 8 / 12.8 / 15 / 30mg
+ Paracetamol 500 / 1000mg
 For

analgesic
the relief of mild – moderate pain,
where paracetamol alone, or NSAIDS
(aspirin, ibuprofen, naproxen) does not control
the pain
Co-codamol Contd.

Side effects include





Allergic reactions: Shortness of breath
Hypersensitivity, pruritis, Rashes,
CNS effects: Confusion, Loss of short
term memory, Dizziness, Fainting,
Drowsiness, Sedation, Euphoria,
dysphoria, addiction.
Blood changes: bleeding gums, easy
bruising
GIT effects: Abdominal pain, Nausea /
vomiting, Constipation
Others: Dry mouth;
Paracetamol (Acetaminophen)

OTC analgesic and antipyretic

Relief of minor aches and pains
• COX2 inhibitor

COX + arachidonic acid  prostaglandin
• Reduces Prostaglandin E2  lowers temperature
• Modulates endogenous canabinoid system

 pain awareness reduced
• Inhibits sodium channels in pain fibres




Constituent of many cold and ‘flu relief remedies
Does not cause gastric irritation
Does not have marked anti-platelet effect
Used in combination with opioid analgesics to
control more severe pain, e.g.: post surgery
Paracetamol contd.

Onset of analgesia is approximately 11 minutes after oral
administration



Half-life = 1–4 hours.
Metabolised by liver
Recommend dose = 1g tds

3g daily
• 2g daily maximum for heavy drinkers
• 325mg tds in USA

Acute overdose causes potentially fatal liver damage
• First aid = activated charcoal
• Paracetamol toxicity is foremost cause acute liver failure
• Rare individuals develop irreversible liver damage at normal
dose

Risk of overdose increased by alcohol consumption
Local Anaesthetics

Lidocaine hydrochloride (Xylocaine)


Bupivacaine hydrochloride (Marcain)


Lidocaine hydrochloride + 1:200,000 adrenaline
Bupivacaine hydrochloride + 1:200,000 adrenaline
Mepivacaine (Scandonest)
 Prilocaine (Citanest)
 Levo-Bupivacaine (Chirocaine)
 Ropivacaine (Naropin)
LAs prevent generation of nerve
impulses (action potentials) in pain fibres

Injected LA diffuses into nerve fibre


LA molecule blocks Na+channels in nerve fibre
membrane
Nerve impulse cannot be generated

LA gradually diffuses out of the nerve fibre
 Nerve function returns to normal


Impulse can be generated and propagated
LA taken up from site of injection into general
circulation
 LA metabolised in liver and excreted via kidney
Onset of Action
 Lidocaine
hydrochloride = 5 mins
 Bupivacaine hydrochloride = 20 mins
 Mepivacaine = 10 mins
 Prilocaine = 10 mins
 Levo-Bupivacaine = 20 mins
 Ropivacaine = 10-30 mins
Duration of Action

Lidocaine = 1-2 hours


Bupivacaine = 6-8 hours




Bupivacaine + 1:200,000 adrenaline = 12-16 hours
Mepivacaine = 2-4 hours
Prilocaine = 2-4 hours
Levo-Bupivacaine = 5-15 hours


Lidocaine + 1:200,000 adrenaline = 2-4 hours
Up to 30 hours post-op analgesia
Ropivacaine = 4-8 hours

Up to 24 hours post-op analgesia
Cautions

Do not inject adrenalinised solutions into the
distal foot




Causes ischaemia
‘Chemical tourniquet’
Ischaemic effect persists for duration of anaesthesia
Avoid adrenalinised solutions in patients taking



Beta-blockers
MAOIs
Tri-cyclic anti-depressants
Calculation (in mg) of total LA dose administered
from drug labelled as % solution
 Percentage



Mass
1% solution = 10mg of drug in 1ml
2% solution = 20 mg of drug in 1ml
3% solution = 30mg of drug in 1ml
 THUS



3.5ml of 1% soln delivers 35mg of drug
8.3ml of 2% soln delivers 166mg of drug
5.6ml of 3% soln delivers 168mg of drug
Maximum safe doses
70Kg or >70Kg person

Lidocaine



Bupivacaine / Levobupivacaine



150mg (2mg / Kg)
30ml of 0.5% OR 60ml of 0.25% soln
Mepivacaine OR Prilocaine



200mg (3mg / Kg)
20ml of 1% OR 10ml of 2% soln
400mg (6mg /Kg)
13ml of 3% soln
Ropivacaine


~250mg (4mg/Kg)
50ml of 0.5% OR 33ml of 0.75% soln
Maximum Safe Dose for patient <70kg

MSD of 1% Lidocaine for 68kg person?




MSD of 3% Mepivacaine for 61kg person?




MSD for 70kg = 200mg
MSD for 68kg in mg = 68/70*200 = 195mg
MSD of 1% Lidocaine soln for 68kg, in ml = 195/10 = 19.5ml
MSD for 70kg = 400mg
MSD for 61kg in mg = 61/70*400 = 349mg
MSD of 3% Mepivacaine soln for 61kg, in ml = 349/30 = 11.6ml
MSD of 0.5% Bupivacaine for 58kg person?



MSD for 70kg = 150mg
MSD for 58kg in mg = 58/70*150 = 120mg
MSD of 0.5% Bupivacaine soln for 58kg, in ml = 120/5 = 24.25ml
ADRs of LA
 Toxicity

(Type A ADR)
High plasma concentration
• Actual overdose
• Relative overdose
 Faint

Vasovagal attack
• Psychosomatic effect
 Hypersensitivity

reactions
Rare with amide-type LAs
Toxic Effect of LAs

CNS effects






Inebriation, Lightheaded-ness, Drowsiness
Numbness of tongue / peri-oral tissues, Paraestheiae
Restlessness, Nausea + vomiting, Blurred vision
Muscle twitching, Tremors, Convulsions
Respiratory failure, Coma
Cardiovascular effects




Myocardial depression
Peripheral vasodilatation
Hypotension and Bradycardia
Arrhythmias and Cardiac arrest
Be cautious in using LAs on these patients
 Children,
elderly or debilitated patients
 Impaired cardiac conduction
 Cardiovascular disease
 Hypovolaemia
 Shock
 Impaired respiratory function
 Epilepsy
 Myaesthenia gravis
Contra-Indications to LA

Inflamed / infected tissues


Reduced anaesthetic effect
Increased rate of absorption predisposes to toxicity

Patients with heart block

Adrenalinised LA solutions

Never into a digit
• Risk of ischaemic necrosis



Not with severe hypotension
Not with unstable cardiac rhythm (e.g.: uncontrolled
AF)
Not with MAOIs and tricyclic antidepressants
Drug Interactions and Local Anaesthetics

Lidocaine + Cimetidine


Lidocaine / Bupivacaine / Levo-bupivacaine /
Prilocaine / Ropivacaine + Propanolol /
Amiodarone


Increased plasma concentration of lidocaine
Lidocaine + Loop and Thiazide Diuretics


Increased myocardial depression
Lidocaine + antivirals


Lidocaine metabolism reduced / plasma concentration
increased
Lidocaine effectiveness reduced
Mepivacaine + opioid sedatives

Increased risk of LA toxicity
Drug Interactions and Local Anaesthetics,
Contd

Lidocaine + bupivacaine



Prilocaine + dapsone


Methaemoglobinaemia
Ropivacaine + Fluvoxamine (Anti-depressant)


Increased risk of LA toxicity
Total dose should not exceed combined MSDs
Ropivaciane metabolism inhibited
Levo-bupivacaine + TCAs or MAOIs

Increased risk of LA toxicity
Anaphylaxis (Type B ADR)

Drugs: Antibiotics (LAs = rare)



Angio-oedema




Breathing difficulties (stridor)
Hives
D+V; abdominal cramps
Severe hypotension



Immunologically mediated response
Tends to increase with repeat exposure
Loss of consciousness
Death
Management

Administer adrenaline
• 0.5ml (0.5mg) 1:1000 adrenaline,
• Repeated after 5 mins as necessary
• 999
Anti-Inflammatory
Agents
NSAIDs
Corticosteroids
Ibuprofen


Iso-butyl-propanoic-phenolic acid
OTC Non-steroidal anti-inflammatory agent (NSAID)




Common adverse side effects include:





Used to control pain that has an inflammatory component
Mild, short-lasting anti-platelet effect (cf aspirin)
Vasodilatory action
GIT: Nausea, Indigestion, GIT ulceration/bleeding, Raised liver
enzymes, Diarrhoea, Constipation,
Cardiovascular effects: Epistaxis, Hypertension, Increased risk of
myocardial infarction, Priapism
Neurological: Dizziness, Hearing loss, Tinnitus
Others: Skin rashes, Fluid retention, Spontaneous abortion
All SEs minimised by low-dose administration
Ibuprofen Contd.

Action:

Non-selective inhibition of
• COX-2 (prevents degradation of arachidonic acid to
prostaglandin)
• COX-1 (prevents platelet aggregation)

Off label
• Treatment of acne
• Prophylaxis of Alzheimer's disease and Parkinson’s diseases
(low dose, long term)

Dose-dependent duration of action (4-8 hrs)



Self-medication: Max 1200mg (400mg tds) daily
Prescribed: Max 3200mg (800mg qds) daily
Stable in solution: topical gel
Corticosteroids
Anti-inflammatory effects of
corticosteroid

Modifies gene transcription



‘Switches off’ pro-inflammatory genes
OR: ‘Switches on’ anti-inflammatory genes
Reduces formation of pro-inflammatory mediator
chemicals, e.g.: cytokines



Local pain reduction
Reduction of local swelling
Reduction of local erythema and tissue irritation
Anti-inflammatory Effects of Glucocorticoid
‘Dermatitis’ and Skin Inflammation



Topical application

1% hydrocortisone acetate
cream, e.g. HC45

Daktacort
Standardized unit of application =
fingertip unit

FTU.
One FTU = amount of topical
steroid squeezed from the tip of
the index finger to dipj

One FTU will treat an area of
skin twice the size of an
adult's hand.
Methylprednisolone acetate

Synthetic corticosteroid



Pharmacological effects by


topical, inhaled, injected, or systemic
delivery
Glucocorticoid action




Reduces normal cellular wall adhesion
Reduces normal collagen production
Hypertensive
Immunosuppressive
Diabetogenic
Anti-inflammatory
Intra-articular Injection
Dose: 40mg / ml
Delivered under U/S guidance
Forms a depot injection
Repeated x3 at monthly intervals
Plantar Fasciitis
P
Beneficial effects may not persist beyond 3/12
Indicated for short term relief of intractable
heel pain
Plantar Digital Neuroma
CS Drug Interactions 1

Systemic effects of corticosteroids are increased (or their
hepatic metabolism is reduced) when administered with




Erythromycin
Clarithromycin
Ketoconazole (Nizoral
Oestrogens, including OCs and HRT

Lower doses of corticosteroids may be indicated in these
cases

The doses of both methylprednisolone and cyclosporin
may need to be reduced to if they are administered
concurrently, to avoid increased side effects of either
drug


Cyclosporin reduces the hepatic metabolism of
methylprednisolone
Methylprednisolone reduces the metabolism of cyclosporin
CS Drug Interactions 2

Increase or decreases the effect of warfarin


Phenobarbital, Phenytoin and Rifampicin may
increase corticosteroid metabolism, reducing
corticosteroid effects.


Anti-coagulated patients on corticosteroids should be
monitored and therapy adjusted to achieve the
appropriate levels of anti-coagulation
Dose of methylprednisolone may need to be
increased
The effects of CS in pregnancy and lactation
have not been fully evaluated
Systemic side effects of
corticosteroid therapy 1
Vary from mild temporary to severe and permanent body wide effects:
 Fluid retention, weight gain and central obesity
 Hypertension
 Potassium depletion
 Headache
 Muscle weakness
 Facial puffiness (moon face)
 Hirsuites
 Thinning of the skin
 Glaucoma
 Cataracts
 Incidence or exacerbation of diabetes
 Irregular menses
 Growth retardation in children
 Convulsions
Systemic side effects of
corticosteroid therapy 2












Psychic disturbances (depression, euphoria, mood swings,
psychoses)
Suppression of adrenal cortex activity, causing Addisonian crisis if the
corticosteroid therapy is stopped abruptly
Masked signs of infection
Impaired immune response to infection
Increased susceptibility to infection
Exacerbations of viral infections
Development of e.g.: small pox if live vaccines administered
Reactivation of dormant TB and malaria
Loss of vaccine-induced immunity
False negative results from the TB (Heaf) test
Impaired calcium absorption causing osteoporosis and fractures
Aseptic necrosis of joints
Adrenaline
Epinephrine (Adrenaline)

Hormone secreted by the adrenal medulla


Sympathetic neurotransmitter


Catecholamine
Nonselective agonist of all (α1, α2, β1, β2, and β3) adrenergic
receptors
Participates in the fight or flight response

Increases blood glucose levels
• α-adrenergic receptors: inhibits pancreatic insulin secretion,
stimulates pancreatic gluconeogenisis, and skeletal glcyolyisis
• β-adrenergic receptors: triggers pancreatic glucagon secretion.
increases pituitary ACTH secretion, and increases adipose lypolysis




Increases heart rate
Constricts blood vessels and increases blood pressure
Dilates bronchi and bronchioles
Increases skeletal muscle contraction
Epinephrine (Adrenaline) Contd.

Adverse reactions to adrenaline include



Drug of choice for treatment of anaphylaxis



Palpitations, tachycardia, arrhythmia, anxiety,
headache, tremor, hypertension and acute pulmonary
oedema
Contraindicated in people on non-selective betablockers
Administered as 1:1000 dilution
0.5mg / ml IM, repeated if necessary 5mins later
Vasoconstrictor action in LA




Pre-mix 1:200,000 dilution
Reduced dose / prolonged action
CI for LA is distal part of the foot
CI for patients on MAOIs
And we are
looking
forward to
Independent
Prescribing!
Thank you for
your kind
attention
[email protected]