drug interactions. an interaction is said to occur when the effects of one drug are changed by the...
TRANSCRIPT
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DR. S. PARTHASARATHY MD., DA., DNB, MD (ACU), DIP. DIAB.DCA, DIP. SOFTWARE STATISTICS PHD (PHYSIO)
MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE , PUDUCHERRY – INDIA
Drug interactions
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OBJECT + PRECIPITANT = ???
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An interaction is said to occur when the
effects of one drug are changed by the
presence of another drug
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OBJECT ?? PRECIPITANT ??
Fentanyl and propofol Object precipitant
Fentanyl morphine Object , precipitant
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WHY SHOULD WE KNOW ABOUT THIS
As anaesthesiologists
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COMBINING DANGEROUS DRUGS
Anesthesiologists usually combine drugs to get better action and benefits
Yes -- we combine drugs -- but what’s the problem ??
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TYPES
pharmaceutical interaction pharmacokinetic interaction pharmacodynamic interaction (direction and intensity)
1. antagonistic 1 + 1 = 0 2. additive 1+1 = 2 3. synergic 1+1 = 3
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DEFINITIONS
A pharmaceutical interaction is a chemical or physical interaction that occurs before a drug is administered or absorbed systemically.
A pharmacokinetic interaction occurs when one drug alters the absorption, distribution, metabolism, or elimination of another.
A pharmacodynamic interaction occurs when one drug alters the sensitivity of a target receptor or tissue to the effects of a second drug.
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HISTORY
WTG morton Ether day ether by itself could produce hypnosis,
reasonable levels of analgesia, and muscle relaxation
Guedel’ s stages
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NOW PATIENTS WANT
No mask induction Pain free Quick recovery No delirium No vomiting
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WHAT NOW ??
IV Agents
Narcotics
Muscle relaxants
So what happened to Guedel stages ??
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PROBLEMS CREATED BY DRUG–DRUG INTERACTIONS Agents with low safety margins warfarin, digoxin, and theophylline
Conscious sedation Pethidine and MAOI
Can we think like this ?? If a drugs fails to act - is it due to a
drug interaction ??
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WHY TO COMBINE ??
Combination therapy can reduce toxicity
atenolol and hydralazine
Drugs for Malignancy
Drugs for Seizures
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PHARMACEUTICAL INTERACTION
Thio and scoline in the IV line
Fortwin and taxim
Bupivacaine and sodabicarb
Adrenaline and soda bicarb
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PHARMACEUTICAL INTERACTION
Heparin and hydrocortisone Inactivation of heparin
Gentamicin and hydrocortisone Inactivation of gentamicin
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INHALATIONAL AGENTS
Older anaesthetists
Trilene and sodalime
Younger ones
Sevoflurane and sodalime
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PHARMACOKINETIC INTERACTIONS
Absorption distribution, metabolism, elimination of another drug
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ABSORPTION
Oral tetracycline can be inactivated by chelation if it is given together with antacids containing polyvalent cations such as Mg2+, Ca2+, or Al3+.
Morphine delays gastric emptying Small gut drugs like para ??
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ABSORPTION
Adrenaline and local anaesthetics
Second gas effect
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DISTRIBUTION
Possible depression of cardiac function
Propofol
Agent
VRG
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PLASMA PROTEINS
Thyrotoxicosis
Fever
aspirin
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ENZYME INDUCTION
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METABOLISM
Neostigmine and scoline
Ecothiophate and scoline
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MAO INHIBITORS
sympathetic neurotransmission:
CNS transmission
Separate topic
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HEPATIC BIOTRANSFORMATION
Hepatic blood flow Agents decrease hepatic blood flow
Extraction High Lidocaine and propranolol
Low-extraction drugs such as diazepam, alfentanil, or mepivacaine have ERs of 0.3 or less.
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etomidate, blocks the synthesis of cortisol and aldosterone by inhibiting the P450-dependent mitochondrial enzymes, 17α-hydroxylase and 11β-hydroxylase.
Protease inhibitors such as saquinavir and ritonavir can inhibit the metabolism of midazolam and fentanyl,
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ENZYME INDUCTION
propofol competitively inhibits CYP3A4, and it
can reduce the clearance of midazolam by 37%
Co administration of cimetidine and diazepam
causes clinically significant elevations in
diazepam
Alfentanil and erythromycin are both
metabolized by CYP3A4, and the antibiotic
greatly prolongs the effect of the opioid.
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DRUG ELIMINATION
Probenecid and penicillin
Quinidine and digoxin
The cation system handles the elimination of atropine, isoproterenol, neostigmine, and meperidine
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ACIDIC AND ALKALINE URINE
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PHARMACODYNAMIC INTERACTIONS-
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PHARMACODYNAMIC INTERACTIONS-
Direction and intensity
1. antagonistic 1 + 1 = 0 2. additive 1+1 = 2 3. synergic 1+1 = 3
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ADDITIVE (1 +1 = 2)
Rocuronium and vecuronium Nitrous oxide with volatile anesthetics
is additive Two benzodiazepines
likely to occur when drugs with identical mechanisms are combined
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SYNERGY
potentiation of opioids by NSAIDs potentiation of nondepolarizing
relaxants by the various volatile anesthetics
supra-additive interaction occurs between aminosteroid and benzylisoquinolines
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ANTAGONISTIC DRUG INTERACTIONS neostigmine, naloxone, or flumazenil. An antagonistic interaction occurs between
succinylcholine and the nondepolarizing relaxants.
drug combination may simultaneously be synergistic and antagonistic for different effects.
When butorphanol is combined with midazolam, the mixture increases sedation but has less anterograde amnestic effect than midazolam alone
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CLINICAL SCENARIO
Pharmacodynamic
Interactions Affecting
Hemodynamics
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PATIENTS WITH BRONCHOSPASM
Rapid-acting β2 agonists (albuterol, terbutaline),
anticholinergics (ipratropium)
phosphodiesterase inhibitors (theophylline).
increased risk for tachydysrhythmias and ectopic
rhythms.
Similar considerations apply to the patient receiving the
IV β2 agonist, ritodrine, for premature labor.
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TCADS
minimize the use of pancuronium, halothane, ketamine
Prone for arrhythmias
TCADs induced hypotension ???
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COCAINE
Patients with chronic cocaine intoxication are less of a
problem, (THAN ACUTE) but they are still at risk for
dysrhythmias (avoiding halothane, pancuronium,
atropine, and sympathomimetics)
Increase MAC – halothane
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Pharmacodynamic Interactions Affecting
Analgesia or Hypnosis
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THIOPENTONE – FENTANYL – THEN THIPENTONE
fentanyl and midazolam are combined for conscious sedation, the opioid is producing sleep as well as analgesia.
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Thiopental–midazolam interaction has been studied in humans, and the combination was found to have 1.8 times the expected potency of the individual agents
PROPOFOL AND MIDAZ
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DECREASE MAC OF AGENTS
IV lignocaine Clonidine. Midaz
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Α2-AGONIST INTERACTIONS
Opioid
Benzodiazepines
Agents
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BUPRENORPHINE AND MORPHINE
Agonist and antagonist
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Three-Way Interactions
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PHARMACODYNAMIC INTERACTIONS-
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SEPARATE TOPIC
Herbal Agents Opioids
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SOME EXAMPLES
Adrenaline and local anaesthetics
Prevent absorption----- pharmacokinetic
Alpha 2 agonist action --- pharmacodynamic
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Sodabicarb and local anaethetics
Precipitation = pharmacoceutical
Increased absorption – pharmacokinetic
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PETHIDINE AND PROMETHAZINE
Sedation
Antanalgesic effect
Pharmacodynamic
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THE DESIRABLE BUT UN??WANTED INTERACTION
Thank you all