CLINICAL PHARMACOLOGY 2003 (PART 3)

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Appendix hTheWorld Health Organization model list of essential drugs' We reprint the current list (by permission). Whilst the WHO programme (revised 1999) was instituted particularly to help less developed countries, the list has interest and lessons for all societies facing, as they now are, the problems of delivering economically affordable health care to all. We commend a study of the list to our readers (see also p. 18). The list of essential drugs may be considered against the background of the available marketed medicines worldwide. Any national or local group of health workers wishing to produce a formulary to provide...

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I TOPICS IN DRUG T H E R A P Y Appendix hTheWorld Health Organization model list of essential drugs' We reprint the current list (by permission). Whilst Explanatory notes the WHO programme (revised 1999) was instituted We print the list in full. particularly to help less developed countries, the list Drugs marked* represent an example of a thera- has interest and lessons for all societies facing, as they peutic group, i.e. various other drugs could serve as now are, the problems of delivering economically an alternative say, on cost grounds. affordable health care to all. We commend a study of Complementary drugs are for use where, for any the list to our readers (see also p. 18). reason, drugs in the main list are unavailable, or The list of essential drugs may be considered there are exceptional medical circumstances, e.g. against the background of the available marketed bacterial resistance, rare disorders. medicines worldwide. Any national or local group Spelling of drug names. The World Health Org- of health workers wishing to produce a formulary anization devises recommended International Non- to provide for the needs of their own community proprietary Names (rINN). These are becoming would be well advised to study the current version universal; most do not give rise to any confusion, but in addition to other sources. occasionally we insert an alternative name or spelling. A major standard reference work (Martindale 1996 Not every entry in the list is discussed in this book. The extra pharmacopoeia. 31st edn., Pharmaceutical Conversely, the book may give drug treatments for Press, London), describes 62500 preparations or specific conditions that differ from those listed here. groups of preparations from 17 different countries. 1 WHO Drug Information Vol 13, No 4,1999 1. Anaesthetics chloral hydrate COMPLEMENTARY DRUG * diazepam * pethidine 1.1 General anaesthetics and * morphine oxygen 2.3 Drugs used to treat gout * promethazine ether, anaesthetic allopurinol halothane colchicine ketamine 2. Analgesics, antipyretics, nitrous oxide nonsteroidal anti- 2.4 Disease-modifying agents oxygen inflammatory drugs used in rheumatic disorders * thiopental (NSAIDs), drugs azathioprine used to treat gout and chloroquine 1.2 Local anaesthetics disease-modifying cyclophosphamide * bupivacaine methotrexate agents used in * lidocaine (lignocaine) penicillamine rheumatic disorders COMPLEMENTARY DRUG (DMARDs) sulfasalazine ephedrine (in spinal anaesthesia during 2.1 Non-opioids and NSAIDs delivery to prevent acetylsalicylic acid (aspirin) 3. Antiallergics and drugs hypotension) * ibuprofen used in anaphylaxis paracetamol * chlorphenamine 1.3 Preoperative medication and * dexamethasone sedation for short-term 2.2 Opioid analgesics epinephrine (adrenaline) procedures * codeine hydrocortisone atropine * morphine prednisolone 28
APPENDIX I 4. Antidotes and other COMPLEMENTARY DRUG 6.4 Antiviral drugs substances used in oxamniquine 6.4.2 Antiherpes drug poisonings aciclovir 4.1 Nonspecific 6.2 Antibacterials 6.4.2 Antiretroviral drugs * charcoal, activated 6.2.1 Beta-lactam drugs nevirapine ipecacuanha * amoxicillin zidovudine 4.2 Specific ampicillin acetylcysteine benzathine benzylpenicillin benzylpenicillin 6.5 Antiprotozoal drugs atropine calcium gluconate * cloxacillin 6.5.1 Antiamoebic and antigiardiasis deferoxamine phenoxymethylpenicillin drugs (desferrioxamine) procaine benzylpenicillin * diloxanide dimercaprol RESTRICTED INDICATIONS * metronidazole * DL-methionine. * amoxycillin + *clavulanic acid ceftazidime 6.5.2 Antileishmaniasis drugs methylthioninium chloride * ceftriaxone * meglumine antimoniate (methylene blue) imipenem + cilastatin pentamidine naloxone COMPLEMENTARY DRUG penicillamine 6.2.2 Other antibacterials potassium ferric amphotericin B * chloramphenicol hexacyanoferrate(II). 2H2 O * ciprofloxacin 6.5.3 Antimalarial drugs (Prussian blue) * doxycycline (a) For curative treatment sodium calcium edetate * erythromycin * chloroquine primaquine sodium nitrite * gentamicin * quinine sodium thiosulfate * metronidazole COMPLEMENTARY DRUGS nalidixic acid * doxycycline (for use only 5. Anticonvulsants/ nitrofurantoin in combination with spectinomycin quinine) antiepileptics * sulfadiazine mefloquine carbamazepine * diazepam * sulfamethoxazole + * sulfadoxine + trimethoprim pyrimethamine ethosuxirnide magnesium sulfate trimethoprim RESTRICTED INDICATIONS phenobarbital (phenobarbitone) COMPLEMENTARY DRUGS artemether phenytoin chloramphenicol artesunate clindamycin (b) For prophylaxis valproic acid COMPLEMENTARY DRUG RESTRICTED INDICATIONS chloroquine * clonazepam vancomycin doxycycline 6.2.3 Antileprosy drugs mefloquine clofazimine proguanil (for use only in 6. Anti-infective drugs combination with dapsone 6.1 Anthelminthics rifampicin chloroquine) 6.3.1 Intestinal anthelminthics 6.5.4 Antipneumocystosis and 6.2.4 Antituberculosis drugs albendazole antitoxoplasmosis drugs ethambutol levamisole pentamidine isoniazid * mebendazole pyrimethamine pyrazinamide niclosamide sulfamethoxazole + rifampicin praziquantel trimethoprim streptomycin pyrantel COMPLEMENTARY DRUG 6.5.5 Antitrypanosomal drugs 6.1.2 Antifilarials thioacetazone (a) African trypanosomiasis diethylcarbamazine 6.3 Antifungal drugs melarsoprol ivermectin amphotericin B pentamidine COMPLEMENTARY DRUG * fluconazole suramin sodium suramin sodium griseofulvin COMPLEMENTARY DRUG 6.1.3 Antischistosomals and other nystatin eflorni thine antitrematode drugs COMPLEMENTARY DRUGS (b) American trypanosomiasis praziquantel flucytosine benznidazole triclabendazone potassium iodide nifurtimox 29
I TOPICS IN DRUG T H E R A P Y 6.5 Insect repellent 10. Drugs affecting the blood * reserpine diethyltoluamide COMPLEMENTARY DRUGS 10.1 Antianaemia drugs prazosin ferrous salt * sodium nitroprusside 7. Antimigraine drugs ferrous salt + folic acid (nutritional supplement for use 12.4 Drugs used in heart failure 7.1 For treatment of acute attack during pregnancy) * captopil acetylsalicylic acid (aspirin) folic acid digoxin ergotamine hydroxocobalamin dopamine paracetamol COMPLEMENTARY DRUG * hydrochlorothiazide 7.2 For prophylaxis * iron dextran 12.5 Antithrombotic drugs * propranolol 10.2 Drugs affecting coagulation acetylsalicylic acid (aspirin) desmopressin COMPLEMENTARY DRUG 8. Antineoplastic and heparin sodium streptokinase immunosuppressant drugs phytomenadione and drugs used in palliative protamine sulfate 12.6 Lipid-lowering agents care * warfarin HMG Co-A reductase inhibitors (statins) have been 8.1 Immunosuppressant drugs shown to reduce the incidence * azathioprine II. Blood products and plasma of fatal and non-fatal * ciclosporin (for organ substitutes myocardial infarction, transplantation) 11.1 Plasma substitutes stroke and mortality (all 8.2 Cytotoxic drugs * dextran 70 causes), as well as the need asparaginase * polygeline for coronary artery bypass bleomycin surgery. Since no single drug 11.2 Plasma fractions for specific calcium folinate has been shown to be uses chlorambucil significantly more effective or albumin, human chlormethine less expensive than others in COMPLEMENTARY DRUGS cisplatin the group, none is included in * factor VIII concentrate, cyclophosphamide the model list; the choice of * factor IX complex cytarabine drug for use in patients at (coagulation factors II, VII, IX, dacarbazine highest risk should be decided X) concentrate daunorubicin at national level. dactinomycin * doxorubicin 12. Cardiovascular drugs etoposide 13. Dermatological drugs 12.1 Antianginal drugs (topical) fluorouracil * atenolol levamisole glyceryl trinitrate 13.1 Antifungal drugs mercaptopurine * isosorbide dinitrate benzoic acid + salicylic acid methotrexate * verapamil * miconazole procarbazine sodium thiosulphate vinblastine 12.2 Antiarrhythmic drugs COMPLEMENTARY DRUG vincristine * atenolol selenium sulfide digoxin 8.3 Hormones and lidocaine 13.2 Anti-infective drugs antihormones verapamil * methylrosanilinium chloride * prednisolone COMPLEMENTARY DRUGS (gentian violet) tamoxifen epinephrine (adrenaline) * neomycin + *bacitracin 8.4 Drugs used in palliative care isoprenaline potassium permanganate The drugs are included in the * procainamide silver sulfadiazine relevant sections of the model * quinidine list, according to their 13.3 Anti-inflammatory and 12.3 Antihypertensive drugs antipruritic drugs therapeutic use, e.g. * atenolol analgesics * betamethasone * captopril * calamine lotion * hydralazine * hydrocortisone 9. Antiparkinsonism drugs * hydrochlorothiazide * biperiden methyldopa 13.4 Astringent drugs levodopa + *carbidopa * nifedipine aluminium diacetate 30
APPENDIX I 13.5 Drugs affecting skin 17. Gastrointestinal drugs 18.3.3 Barrier methods differentiation and condoms with or without 17.1 Antacids and other antiulcer proliferation spermicide (nonoxinol) drugs benzoyl peroxide diaphragms with spermicide aluminium hydroxide coal tar (nonoxinol) cimetidine dithranol magnesium hydroxide 18.4 Estrogens fluorouracil * ethinylestradiol * podophyllum resin 17.2 Antiemetic drugs salicylic acid metoclopramide 18.5 Insulins and other antidiabetic urea * promethazine agents * glibenclamide 13.6 Scabicides and pediculicides 17.3 Antihaemorrhoidal drugs insulin injection (soluble) * benzyl benzoate local anaesthetic, astringent and intermediate-acting insulin permethrin anti-inflammatory drug metformin 13.7 Ultraviolet-blocking agents 17.4 Anti-inflammatory drugs 18.6 Ovulation inducers COMPLEMENTARY DRUGS hydrocortisone * clomifene * sulfasalazine topical sun protection agent with activity against UVA 18.7 Progestogens 17.5 Antispasmodic drugs norethisterone and UVB cream, lotion atropine COMPLEMENTARY DRUG or gel 17.6 Laxatives medroxyprogesterone acetate * senna 18.8 Thyroid hormones and 14. Diagnostic agents 17.7 Drugs used in diarrhoea antithyroid drugs 14.1 Ophthalmic drugs levothyroxine fluorescein 17.7.1 Oral rehy drat ion potassium iodide * tropicamide oral rehydration salts (for propylthiouracil glucose-electrolyte solution) 14.2 Radiocontrast media 17.7.2 Antidiarrhoeal (symptomatic) drugs Immunologicals * amidotrizoate 19. codeine barium sulfate 19.1 Diagnostic agents * iohexol tuberculin, purified protein * iopanoic acid 18. Hormones, other endocrine derivative (PPD) * propyliodone (for drugs and contraceptives administration only into the 19.2 Sera and immunoglobulins 18.1 Adrenal hormones and bronchial tree) anti-D immunoglobulin (human) synthetic substitutes * antitetanus immunoglobulin COMPLEMENTARY DRUG * dexamethasone * meglumine iotroxate (human) hydrocortisone antivenom serum prednisolone diphtheria antitoxin 15. Disinfectants and COMPLEMENTARY DRUG immunoglobulin, human antiseptics fludrocortisone normal 15.1 Antiseptics 18.2 Androgens rabies immunoglobulin * chlorhexidine COMPLEMENTARY DRUG 19.3 Vaccines * ethanol testosterone * polyvidone iodine 19.3.2 For universal immunisation 18.3 Contraceptives BCG 15.2 Disinfectants 18.3.1 Hormonal contraceptives diphtheria * chlorine base compound * ethinylestradiol + pertussis chloroxyenol * levonorgestrel tetanus glutaral * ethinylestradiol + hepatitis B * norethisterone measles levonorgestrel poliomyelitis 16. Diuretics COMPLEMENTARY DRUGS * amiloride * levonorgestrel 19.3.2 For specific groups of individuals * furosemide (frusemide) influenza medroxyprogesterone acetate * hydrochlorothiazide meningitis norethisterone enantate spironolactone mumps COMPLEMENTARY DRUG 28.3.2 Intrauterine devices rabies * mannitol copper-containing device rubella 31
I TOPICS IN DRUG T H E R A P Y typhoid 22.2 Antioxytocics theophylline yellow fever salbutamol COMPLEMENTARY DRUG * cromoglicic acid (sodium cromoglycate) 20. Muscle relaxants 23. Peritoneal dialysis (peripherally acting) and solution 25.2 Antitussives cholinesterase inhibitors intraperitoneal dialysis * dextromethorphan * alcuronium chloride solution (of appropriate * neostigmine composition) 26. Solutions correcting water, pyridostigmine bromide electrolyte and acid-base suxamethonium chloride 24. Psychotherapeutic drugs disturbances COMPLEMENTARY DRUG vecuronium bromide 24.1 Drugs used in psychotic 26.1 Oral rehydration disorders oral rehydration salts (glucose- chlorpromazine electrolyte solution) 21. Ophthalmological * fluphenazine potassium chloride preparations * haloperidol 26.2 Parenteral 21.1 Anti-infective agents 24.2 Drugs used in mood disorders glucose * gentamicin glucose with sodium chloride * idoxuridine 24.2.1 Drugs used in depressive potassium chloride silver nitrate disorders sodium chloride * amitryptiline * tetracycline sodium hydrogen carbonate 21.2 Anti-inflammatory agents 24.2.2 Drugs used in bipolar disorders * compound solution of sodium * prednisolone carbamazepine lactate lithium carbonate 26.3 Miscellaneous 21.3 Local anaesthetics valproic acid water for injection * tetracaine (amethocaine) 24.3 Drugs used in generalised 21.4 Miotics and antiglaucoma anxiety and sleep disorders 27. Vitamins and minerals drugs diazepam ascorbic acid acetazolamide 24.4 Drugs used in obsessive- * ergocalciferol * pilocarpine compulsive disorders and iodine * timolol panic attacks * nicotinamide 21.5 Mydriatics clomipramine pyridoxine atropine * retinol COMPLEMENTARY DRUG riboflavin epinephrine (adrenaline) 25. Drugs acting on the * sodium fluoride respiratory tract thiamine 25.1 Antiasthmatic drugs COMPLEMENTARY DRUG 22. Oxytocics and * aminophylline calcium gluconate antioxytocics beclometasone 22.1 Oxytocics epinephrine (adrenaline) * ergometrine ipratropium bromide oxytocin * salbutamol Appendix 2:The prescription The prescription is the means by which medicines and efficacy and to prevent fraudulent misuse; full that are not considered safe for sale directly to the details will be found in national formularies and public are delivered to patients. Its format is officially prescribers have a responsibility to comply with regulated to ensure precision in the interests of safety these. 32
APPENDIX I Prescriptions of pure drugs or of formulations abbreviations or invent your own; it is not safe from the British National Formulary (BNF)1 are to do so. satisfactory for almost all purposes. The composition Quantities (after BNF) of many of the preparations in the BNF is laid down — 1 gram or more: write 1 g etc. in official pharmacopoeias, e.g. British Pharmaco- — Less than 1 g: write as milligrams: 500 mg, poeia (BP). There are also many national and not 0.5 g. international pharmacopoeias. — Less than 1 mg: write as micrograms, e.g. 100 Traditional extemporaneous prescription-writing micrograms, not 0.1 mg. art, defining drug, base, adjuvant, corrective, flav- — For decimals a zero should precede the ouring and vehicle is obsolete, as is the use of the decimal point where there is no other figure, Latin language. Certain convenient Latin abbrevia- e.g. 0.5 mL, not .5 mL, or for a range, 0.5 to 1 g. tions do survive for lack of convenient English — Do not abbreviate microgram, nanogram or substitutes (chiefly in hospitals where instructions unit. are given to nurses and not to patients). They are — Use millilitre, ml or mL, not cubic listed below, without approval or disapproval. centimetre, cc. — Home/domestic measures, see below. The elementary requirements of a prescription are that it State dose and dose frequency; for 'as should state what is to be given to whom and by whom required', specify minimum dose interval or prescribed, and give instructions on how much should be taken how often, by what route and for how long or total maximum dose per day. quantity to be supplied, as below. 6. Directions to the pharmacist, if any: 'mix', 'make a solution'. Write the total quantity to be dispensed (if this is not stated in 5 above); or 1. Date. duration of supply. 2. Address of doctor. 7. Instruction for the patient, to be written on container by the pharmacist. Here brevity, 3. Name and address of patient: age is also clarity and accuracy are especially important. It desirable for safety reasons; in the UK it is a legal is dangerous to rely on the patient remembering requirement for children under age 12 years. oral instructions. The BNF provides a list of recommended 'cautionary and advisory labels 4. R for dispensed medicines' representing a balance This is a traditional esoteric symbol2 for the between 'the unintelligibly short and the word 'Recipe' — 'take thou', which is addressed inconveniently long', e.g. 'Do not stop taking to the pharmacist. It is pointless; but since many this medicine except on your doctor's advice'. doctors gain a harmless pleasure from writing Pharmacists nowadays use their own it with a flourish before the name of a initiative in giving advice to patients. proprietary preparation of whose exact nature they are ignorant, it is likely to survive as a 8. Signature of doctor. sentimental link with the past. Example of a prescription for a patient with an annoying unproductive cough. 5. The name and dose of the medicine. 1,2,3, as above Abbreviations. Only abbreviate where there is 4.9 an official abbreviation. Never use unofficial 5. Codeine Linctus, BNF, 5 ml 6. Send 60 ml 1 Supplied free to all doctors practising in the UK National 7. Label: Codeine Linctus [or NP]. Take 5 ml Health Service. twice a day and on retiring. 2 Derived from the eye of Horus, ancient Egyptian sun god. 8. Signature of doctor. 33
I TOPICS IN DRUG T H E R A P Y Computer-issued prescriptions must conform q.d.s.: quater die 4 times a day (qid is also to recommendations of professional bodies. If sumendus used) altered by hand (undesirable), the alteration must q. or q.q.: quaque every, e.g. qq6 h = every 6 h be signed. q.q.h.: quarta every 4 hours quaque hora Medicine containers. Reclosable child-resistant q.s.: quantum a sufficiency, enough containers and blister packs are increasingly used, sufficiat as is dispensing in manufacturers' original sealed rep: repetatur let it be repeated, as in rep. packs containing a patient information leaflet. mist(ura), repeat the These add to immediate cost but may save money mixture in the end (increased efficiency of use, and safety). s.c.: subcutaneous by subcutaneous injection s.o.s.: si opus sit if necessary. It is useful to Unwanted medicines. Patients should be encour- confine sos to prescriptions aged to return these to the original supplier for to be repeated once only disposal. and to use prn where many repetitions are intended Drugs liable to cause dependence or be the subject stat: statim immediately of misuse. Doctors have a particular responsibility t.d.s.: ter (in) die 3 times a day (tid is also to ensure that (1) they do not create dependence, (2) sumendus used). the patient does not increase the dose and create dependence, (3) they are not used as an unwitting source of supply to addicts. To many such drugs special prescribing regulations apply (see BNF). Weights and measures Abbreviations (see also Weights and measures, below) In this book doses are given in the metric system, or a.c.: ante cibum before food in international units (IU) when metric doses are b.d.: bis in die twice a day (bid is also impracticable. used) BNF British National Formulary Equivalents: BP British Pharmacopoeia 1 litre (1 or L) = 1.76 pints BPC British Pharmaceutical 1 kilogram (kg) = 2.2 pounds (Ib) Codex i.m.: intramuscular by intramuscular injection Abbreviations: IU International Unit 1 gram (g) i.v: intravenous by intravenous injection 1 milligram (mg) (1 x 10~3 g) NP: nomen proper name 1 microgram3 (1 x 10-6 g) propnum 1 nanogram3 (1 x 10-9 g) o.d.: omni die every day 1 decilitre (dL) (1 x 10-11) o.m.: omni mane every morning 1 millilitre (mL) (1 x 10-31) o.n.: omni nocte every night p.c.: post cibum after food Home/domestic measures. A standard 5 ml p.o.: per os by mouth spoon and a graduated oral syringe are available. p.r.: per rectum by the anal/rectal route Otherwise the following approximations will serve: p.r.n.: pro re nata as required. It is best to add 1 tablespoonful = 14 ml (or mL) the maximum frequency of 1 dessertspoonful = 7 ml (or mL) repetition, e.g. Aspirin and 1 teaspoonful = 5 ml (or mL) Codeine Tablets, 1 or 2 prn, 4-hourly 3 p.v.: per vagmam by the vaginal route Spell out in full in prescribing. 34
APPENDIX I Percentages, proportions, weight in volume required, especially as any errors are liable to be by a factor of 10 and can be fatal. Doctors who do not Some solutions of drugs (e.g. local anaesthetics, feel confident with such calculations (because they epinephrine/adrenaline) for parenteral use are do not do them frequently) should feel no labelled in a variety of ways: percentage, proportion, embarrassment,4 but should recognise that they or weight in volume (e.g. 0.1%, 1:1000,1 mg per mL). have a responsibility to check their results with Also, dilutions may have to be made by doctors at a competent colleague or pharmacist before the time of use. Such drugs are commonly proceeding. dangerous in overdose and great precision is 4 Called to an emergency tension pneumothorax on an intercontinental flight, two surgeons, who chanced to be passengers, were provided with lignocaine 100 mg in 10 ml (in the aircraft medical kit). They were accustomed to thinking in percentages for this drug and 'in the heat of the moment' neither was able to make the conversion. Chest surgery was conducted successfully with an adapted wire coat-hanger as a trocar ('sterilised' in brandy), using a urinary catheter. The patient survived the flight and recovered in hospital. Wallace W A 1995 Managing in-flight emergencies: A personal account. British Medical Journal 311: 374. 35
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