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  1. 1. Q1-What is the composition of Migril®?And what is its indication?Why does the value of ergotamine for migraine is limitedMigril:ergotamine tartrate 2 mg, cyclizine hydrochloride 50 mg, caffeine hydrate 100 mgIndicationstreatment of acute migraine attacks and migraine variants unresponsive to analgesicsThe value of ergotamine for migraine is limited by difficulties in absorption and by its side-effects, particularly nausea, vomiting, abdominal pain, and muscular cramps; it is best avoided.The recommended doses of ergotamine preparations should not be exceeded and treatmentshould not be repeated at intervals of less than 4 days.To avoid habituation the frequency of administration of ergotamine should be limited to no morethan twice a month. It should never be prescribed prophylactically but in the management ofcluster headache a low dose (e.g. ergotamine 1 mg at night for 6 nights in 7) is occasionallygiven for 1 to 2 weeks [unlicensed indication].Q2-Give the patient written as well as oral instructions about the oral dose ofMigril?And at what interval he can repeat the dose (if needed)?one tablet at onset, followed after 30 minutes by ½–1 tablet, repeated every 30 minutes ifnecessary; max. 4 tablets per attack and 6 tablets in one weekAlso, see aboveQ3-What warning about peripheral vasospasm should be given to the patient?What advisory label?And what are the contraindications to the use of ergotamine containingproducts?Peripheral vasospasm: Warn patient to stop treatment immediately if numbness or tinglingof extremities develops and to contact doctor.Contra-indications: peripheral vascular disease, coronary heart disease, obliterativevascular disease and Raynauds syndrome, temporal arteritis, hepatic impairment, renalimpairment, sepsis, severe or inadequately controlled hypertension, hyperthyroidism,pregnancy, breast-feeding, porphyria
  2. 2. Q4-Why anti-emetic (like cyclizine in Migril, metoclopromide, or Domperidone)are frequently used in migraine attack?Anti-emetics: such as metoclopramide or domperidone, or phenothiazine and antihistamineanti-emetics, relieve the nausea associated with migraine attacks. Anti-emetics may be given byintramuscular injection or rectally if vomiting is a problem. Metoclopramide and domperidonehave the added advantage of promoting gastric emptying and normal peristalsis; a single doseshould be given at the onset of symptoms. Oral analgesic preparations containingmetoclopramide are a convenient alternativeQ5-If the Rx contains Cafergot® instead of Migril® the:what will be the difference between them regarding the composition and doseQ6-What is Sumatriptan?And what is its indication?And what are the available dosage forms of itSumatriptan is a 5HT1 agonist drugA 5HT1 agonist is of considerable value in the treatment of an acute migraine attack. The 5HT1 agonists(‘triptans’) act on the 5HT (serotonin) 1B/1D receptors and they are therefore sometimes referred to as5HT1B/1D-receptor agonists. A 5HT1 agonist may be used during the established headache phase of anattack and is the preferred treatment in those who fail to respond to conventional analgesics.The available dosage forms are:tablet, injection (S.C.) and nasal sprayQ7-Give the patient written as well as oral instructions about the oral dose ofSumatriptan?What warning and advisory label should be given to the patient about it?50mg (some patients may require 100 mg) as soon as possible after onset ( patient notresponding should not take second dose for same attack );dose may be repeated after not less than 2 hours if migraine recurs;max. 300 mg in 24 hours;child and adolescent under 18 years not recommendedQ8- What are the side effects and contraindications of triptans ?5HT1 agonists are contra-indicated in ischaemic heart disease, previous myocardial infarction,coronary vasospasm (including Prinz----ls angina), and uncontrolled or severe hypertension.
  3. 3. Q9-What is the main indication for pizotifen?And what warning or advisory label should be given with it?And how we can reduce or avoid the undue drowsiness?Pizotifen is an antihistamine and serotonin antagonist structurally related to the tricyclicantidepressants. It affords good prophylaxis but may cause weight gain.Label:Warning. May cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholicdrinkTo avoid undue drowsiness treatment may be started at 500 micrograms at night and graduallyincreased to 3 mg; it is rarely necessary to exceed this dose.Q10-What other migraine prophylactic drugs available?Prophylaxis of migraine beta-blockers: propranolol, metoprolol, nadolol, and timolol Sodium valproate Topiramate Tricyclic antidepressants (e.g. amitriptyline in a dose of 10 mg at night, increased to a maintenance dose of 50–75 mg at night) Cyproheptadine Clonidine (Dixarit®) is not recommended Methysergide, (it should only be administered under hospital supervisionQ11-what is the problem in this Rx? Why?Contra-indications: previous or active peptic ulceration; children and adolescents under 16 years(unless specifically indicated e.g. for Kawasaki syndrome) and breast-feeding—risk of Reyessyndrome, haemophilia and other bleeding disorders; not for treatment of goutHYPERSENSITIVITY. Aspirin and other NSAIDs contra-indicated in history of hypersensitivityto aspirin or any other NSAID—which includes those in whom attacks of asthma, angioedema,urticaria or rhinitis have been precipitated by aspirin or any other NSAIDsupplement A:A-Hypersensitivity to aspirin occurs in some people, it has been estimated that 4% of asthmatic patient have thisproblem and aspirin should be used with caution in any patient with history of asthma
  4. 4. Q12-if you suggest paracetamol as an alternative what will be the dose?And how often it may be repeated?What are the advisory labels of paracetamol?Paracetamol oral dose 0.5-1 - : post-immunisation pyrexia ( ) jaundice )Advisory LabelsDo not take more than 2 at any one time. Do not take more than 8 in 24 hoursDo not take with any other paracetamol productsQ13-what are the difference between paracetamol and aspirin?Aspirin is effective against mild to moderate dental pain; dispersible tablets provide a rapidlyabsorbed form of aspirin suitable for most purposes.The analgesic effect of paracetamol in mild to moderate dental pain is probably less than that ofaspirin, but it does not affect bleeding time or interact significantly with warfarin. Moreover, it isless irritant to the stomach. Paracetamol is a suitable analgesic for children; sugar-free versionscan be requested by specifying ‘sugar-free’ on the prescription.Q14/ ??Q15:Co-proxamol (dextropropoxyphene in combination with paracetamol) has little more analgesiceffect than paracetamol alone. An important disadvantage of co-proxamol is that overdosage(which may be combined with alcohol) is complicated by respiratory depression and acute heartfailure due to the dextropropoxyphene and by hepatotoxicity due to the paracetamol. Rapidtreatment is essential.Co-proxamol is to be withdrawn from the market and the CSM has advised that co-proxamoltreatment should no longer be prescribed; patients who are already receiving it should have theirtreatment reviewed and another analgesic considered.adolescent and child under 18 years, not recommendedWhen co-proxamol tablets are prescribed and no strength is stated tablets containingdextropropoxyphene hydrochloride 32.5 mg and paracetamol 325 mg should be dispensed.Q16-what counseling and advisory labels should be given to the patient about indomethacin?To be taken with or after foodDizziness may affect performance of skilled tasks, e.g. driving
  5. 5. Q17-After how long we can achieve full analgesic effect?Pain relief starts soon after taking the first dose and a full analgesic effect should normally beobtained within a weekAnd after how long we can achieve full anti-inflammatory effect?Anti-inflammatory effect may not be achieved (or may not be clinically assessable) for up to 3weeksQ18-If appropriate responses are not obtained within the above time, can we try other NSAIDs?Why?About 60% of patients will respond to any NSAID; of the others, those who do not respond toone may well respond to another. If appropriate responses are not obtained within these times,another NSAID should be triedQ19- If the patient has a previous peptic ulceration could he use indomethacin safely?Non-selective NSAIDs are contra-indicated in patients with previous or active peptic ulcerationand that selective inhibitors of cyclo-oxygenase-2 are contra-indicated in active peptic ulcerationIs the use of enteric coated formulation, taking the oral formulation with milk or food, orchanging the route (e.g. use of rectal supp.) will avoid the risk of gastric or duodenal ulceration?Why?taking oral formulations with milk or food, or using enteric-coated formulations, or changing theroute of administration may only partially reduce symptoms such as dyspepsiaWhat do you suggest if the patient need to continue NSAIDs treatment?If NSAID treatment needs to continue, the following options are suitable:Treat ulcer with a proton pump inhibitor and on healing continue the proton pump inhibitor (dosenot normally reduced because asymptomatic ulcer deterioration may occur);Treat ulcer with a proton pump inhibitor and on healing switch to misoprostol for maintenancetherapy (colic and diarrhoea may limit the dose of misoprostol);Treat ulcer with a proton pump inhibitor and switch NSAID to a cyclo-oxygenase-2 selectiveinhibitor
  6. 6. Q20- If the patient has Cardiovascular disease?Could he take selective cyclo-oxygenase-2 (Cox -2) (like celecoxib) inhibitor safely?Why?Cyclo-oxygenase-2 inhibitors and cardiovascular eventsIn the light of emerging concerns about cardiovascular safety, cyclo-oxygenase-2 selectiveinhibitors should be used in preference to non-selective NSAIDs only when specificallyindicated (i.e. for patients who are at a particularly high risk of developing gastroduodenal ulcer,perforation, or bleeding) and after an assessment of cardiovascular risk. Furthermore, the CSMhas advised (August 2005) that patients who have ischaemic heart disease or cerebrovasculardisease should not receive a cyclo-oxygenase-2 selective inhibitorQ21-Are these doses considered appropriate doses?? Would the use of more than oral NSAIDs considerappropriate option (see CSM advice boxthese doses are not appropriateDiclofenac Na:Dose: 1 tablet daily preferably with foodMeloxicam:Rheumatoid arthritis, ankylosing spondylitis, 15 mg once daily with food, may be reduced to 7.5mg daily; elderly 7.5 mg dailyQ22-If the patient is breast feeding mother?Then which of the following NSAIDs are compatible with breast feeding:Ibuprofen, celecoxib, diclofenac, indo----cin, mefenamic acid, meloxicam,naproxen, and piroxicam?Celecoxib: Manufacturer advises avoid—no information availableDiclofenac: Amount too small to be harmfulIndo----cin:Amount probably too small to be harmful but convulsions reported in one infant—manufacturers advise avoidMefenamic acid: Amount too small to be harmful but manufacturer advises avoidMeloxicam: No information available—manufacturer advises avoid
  7. 7. Naproxen: Amount too small to be harmful but manufacturer advises avoidPiroxicam: Amount too small to be harmfulQ23-Would the use of topical NSAIDs (like diclofenac, piroxicam, ketoprofen, oribuprofen) provide great or slight relief of pain in musculoskeletal conditions?Topical NSAIDs (e.g. felbinac, ibuprofen, ketoprofen and piroxicam) may provide some slightrelief of pain in musculoskeletal conditions.Q24-what is Alendronic acid?And What are its indications?Alendronic acid is a drug from Bisphosphonate group.Bisphosphonates are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate ofgrowth and dissolution, and therefore reducing the rate of bone turnover. Bisphosphonates havean important role in the prophylaxis and treatment of osteoporosis and corticosteroid-inducedosteoporosisIndication:Treatment of postmenopausal osteoporosis and osteoporosis in menpostmenopausal osteoporosisPrevention of postmenopausal osteoporosisPrevention and treatment of corticosteroid-induced osteoporosisQ25-What counseling should be given to the patient about the administration ofAlendronic acid? Why?Counselling Tablets should be swallowed whole with plenty of water while sitting or standing; tobe taken on an empty stomach at least 30 minutes before breakfast (or another oral medicine);patient should stand or sit upright for at least 30 minutes after taking tabletQ26-The patient told you that he is a hypertensive patient and he was heard thatibuprofen increase blood pressure? What you will tell him?See supplement B
  8. 8. Q27-Can we use it safely if the patient is allergic to aspirin?NSAIDs are contra-indicated in patients with a history of hypersensitivity to aspirin or any otherNSAID—which includes those in whom attacks of asthma, angioedema, urticaria or rhinitis havebeen precipitated by aspirin or any other NSAIDQ28-which ibuprofen formulation (enteric coated or the ordinary tablet) aremore suitable for single analgesic use ?Gastric irritation may be a problem; it is minimised by taking the dose after food. Enteric-coatedpreparations are available, but have a slow onset of action and are therefore unsuitable for single-dose analgesic use (though their prolonged action may be useful for night painQ 29/ used with causionQ30-How often we can use voltaren injection for ureteric pain?Ureteric colic, 75 mg then a further 75 mg after 30 minutes if necessaryQ31-What is tramadol and what is its advantage over other opioid analgesics?It has fewer of the typical opioid side-effects - notably, less respiratory depression, lessconstipation and less addiction potentialQ32-Are Diclofenac and sodium cromoglicate eye drops indicated for the aboveophthalmic condition?yesSodium cromoglicate eye drops may be useful for vernal keratoconjunctivitis and other allergicforms of conjunctivitis.Diclofenac eye drops are also licensed for seasonal allergic conjunctivitis