Adverse Drug Reactions

1. Adverse Drug ReactionsAdverse Drug Reactions
(Summary)(Summary)

2. Adverse reactions (ARs) is any undesirable or unintended
consequence of drug administration. They include all kinds
of noxious effects – trivial, serious or even fatal.
All drugs are capable of producing ARs.All drugs are capable of producing ARs. Whenever a drugWhenever a drug
is given a risk is takenis given a risk is taken.. The magnitude of risk has to be
considered along with other therapeutic advantages
in deciding whether or not to use a drug.
ARs may develop promptly or only after prolonged medication or
even after stoppage of the drug. An incidence of 10–25% ARs
has been documented in different clinical studies.
They are more common with multiple drug therapy and
in elderly patients.

3. It is convenient to classify drug ARs under the
following headings:
Type A (Augmented) reactions will occur in
everyone if enough of the drug is given because
they are due to excess of normal, predictable,
dose-related, pharmacodynamic effects. Their
common and skilled management reduces their
incidence, e.g. postural hypotension, hypoglycemia,
hypokalemia. Type A reactions also include
side, secondary, and toxic effects of drugs.

4. Type B (Bizarre) reactions will occur only in
some people. They are not part of the normal
pharmacology of the drug and are not dose-related.
These effects may be predictable when the
mechanism is known (though predictive tests may
be expensive or impracticable), otherwise they can
be unpredictable for the individual. The class
includes unwanted effects due to inherited
abnormalities (idiosyncrasy) and
immunological processes (drug allergy).

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. Type C (Chronic) reactions due to long-term
exposure, e.g. analgesic nephropathy, dyskinesias
with levodopa.
Type D (Delayed) reactions following prolonged
exposure, e.g. carcinogenesis or short-term exposure
at a critical time, e.g. teratogenesis.
Type E (Ending of use) reactions, where
dicontinuation of chronic therapy is too abrupt, e.g.
adrenal steroid causing rebound adrenocortical
insufficiency, opioid causing the withdrawal
syndrome.
F (Failures) – unwanted drug interactions.

7. Causes of drug ARs
(1) The patient may be predisposed by age, genetic constitution,
tendency to allergy, disease, personality, habits.
(2) The drug. Anticancer agents are cytotoxic by nature.
Some drugs, e.g. digoxin, have steep dose-response curves and
small increments of a dose are more likely to induce augmented
(type A) reactions. Other drugs, e.g. antimicrobials, have a ten-
dency to cause allergy and may lead to bizarre (type B) reactions.
Ingredients of a formulation, e.g. coloring, flavoring, sodium
content, rather than the active drug may also cause ARs.
(3) The prescriber. ARs may occur because a drug is used
for an inappropriately long time (type C), at a critical phase
in pregnancy (type D), is abruptly discontinued (type E) or given
with other drugs (type F – unwanted drug interactions).

8. Severity of adverse drug reactions
has been graded as:
Minor: No therapy or antidote required.
Moderate: Requires change in drug therapy, specific
treatment or prolongs hospital stay by at least one day.
Severe: Potentially life threatening, causes permanent
damage or requires intensive medical treatment.
Lethal: Directly or indirectly contributes to death
of the patient.

9. Drug ARs can be minimizedDrug ARs can be minimized (but not altogether
eliminated) by observing the following practices
(by Tripathi, 2008):
• Avoid all inappropriate use of drugs.
• Use appropriate dose, route and frequency of drug administration.
• Elicit and take into consideration previous history of drug ARs.
• Elicit history of allergic diseases and exercise caution (drug
allergy is more common in patients with allergic diseases).
• Rule out possibility of unwanted drug interactions.
• Use correct drug administration technique (e.g. i.v. injection of
aminophylline must be slow).
• Carry out appropriate laboratory monitoring (e.g. prothrombin time
and INR with acenocoumarol and warfarin; serum drug levels with
lithium – 0.4–1 mmol/L).

10. 1) Side effects are unwanted pharmacodynamic effects
hat occur at therapeutic doses. They can be predicted
rom the pharmacological profile of a drug. Very often reduction
f the dose relieves the symptoms. In many cases a side
ffect may be based on the same action as the therapeutic
ffect, e.g. M-cholinolytics atropine
s used in preanaesthetic medication
or its antisecretory action produces
erostomia (dryness of
mouth) as a side effect.
Side effect may also be based on a different peculiarity of
rug action, e.g. estrogens cause nausea which is
nrelated to their main antiovulatory action.
AtropineAtropine

11. (2) Secondary effects are indirect consequences of
a primary action of the drug, e.g. suppression of bacterial
flora by aminopenicillins, cephalosporins, tetracyclines,
chloramphenicol, fluoroquinolones, or co-trimoxazole
results in the development of endogenous superinfections.
(3) Toxic effects are the result of excessive pharmaco-
logical action of the drug due to overdosage or prolonged
use. Overdosage may be absolute (accidental, homicidal,
suicidal) or relative (e.g. usual dose of aminoglycoside
antibiotics in the presence of renal failure). Toxic effects are
predictable and dose related. They result from functional
alteration (in high dose atropine causes delirium) or drug-
induced tissue damage (hepatic paracetamol necrosis).

12. Acute paracetamol poisoning occurs especially in
small children who have low hepatic glucuronide conjugating ability.
If a large dose (> 150 mg/kg or > 10 g in adult) is taken,
serious toxicity can occur. The letal dose is 250 mg/kg.
N-acetyl-p-benzoquinoneimine (NABQI)N-acetyl-p-benzoquinoneimine (NABQI) is a highly
reactive metabolite of paracetamol which is detoxified by
conjugation with glutathione. When a very large doses of
paracetamol are taken, the glucuroconjugation capacity is
saturated, more NABQINABQI is formed, hepatic glutathione is
depleted and NABQINABQI binds covalently to proteins in liver
cells and renal tubules causing necrosis. In chronic alcoholics
even 5 g/d paracetamol taken for a few days can result in hepatotoxicity
(because ethanol induces CYP2E1&1A2 that metabolize paracetamol,
to NABQI). Treatment needs activated charcoal, given orally or through
the tube to prevent GI absorption, and for an exogenious donor of
–SH groups – acetylcysteine is used (150 mg/g by i.v. infusion).

13. Metabolism of
Paracetamol
(Acetaminophen)
to hepatotoxic
metabolites:
NABQI…,… etc.
(GSH – glutathione)
Daily dose > 7.5 g:
hepatotoxicity
and
nephrotoxicity
NABQI
Acetylcysteine and GSH
contain –SH groups.
Basic & Clinical Pharmacology – 10th
Ed. (2007):

14. Poisoning may result from dosages of drugs. Specific
antidotes (receptor antagonists, chelating agents, or
specific antibodies) are available only for few poisons.
General supportive and symptomatic treatment includes:
•Termination of exposure.
•Prevention of GI absorption of ingested poisons with suspension
of 20–40 g of activated charcoal in 200 ml water.
•Maintenance of patient airway (artificial respiration, if needed).
•Maintenance of blood pressure and heart beat by fluid infusion,
pressor agents, cardiac stimulants, if needed.
•Hastening elimination of poison by inducing diuresis (furosemide,
mannitol), altering urinary pH (alkalinisation for acidic drugs,
acidification for basic drugs), haemodialysis and haemoperfusion
(passage of blood through a column of charcoal or absorbent resin)

15. (4) Intolerance is the appearance of characteristic toxic
effects of a drug in a patient at therapeutic doses, e.g.
only a few doses of carbamazepine may cause ataxia in
some people; one tablet of chloroquine (250 mg) may
cause vomiting and abdominal pain in some individuals.
Intolerance indicates a low threshold of the individual
to the action of drugs.
(5) Allergic reactions occur only in a small part of the
population exposed to the drug. Prior sensitization is
needed and a latent period of at least 1–2 weeks is required
after the first exposure. The drug or its metabolites act as
antigen (AG) or more commonly hapten (incomplete AG –
drug with small molecules which become antigenic only

16. after binding with an endogenous protein) and induce
production of antibody (AB)/sensitized lymphocytes.
Chemically related drugs often show cross sensitivity.
One drug can produce different types of allergic reactions.
The course of drug allergy is variable. An individual
previously sensitive to a drug may subsequently tolerate it
without a reaction.
There areThere are several types of allergic reactions:several types of allergic reactions:
• humoral (type I–III)humoral (type I–III)
• cell mediated (type IV)cell mediated (type IV)..

18. Type I (anaphylactic) reactions –
immediate hypersensitivity.
Drug-specific antibodies of the IgE type combine via
their Fc moiety with receptors on the surface of mast cells.
On exposure to the drug, AG/AB reaction takes place on
the mast cell surface releasing mediators (histamine,
5-HT, LT-C4, LT-D4, PGs, PAF, etc.) resulting
in urticaria, itching, angioedema, asthma, rhinitis,
or anaphylactic shock.
The manifestations occur quickly after challenge.

19. ACE inhibitors – swelling of lipsACE inhibitors – swelling of lips

20. Type II (cytolytic) reactions
Complexes drug / antibody (IgG) bind to receptors
located on the surface of blood cells. In reexposure
of drug on the surface of these cells develops AG/AB
reaction, complement system (representing circulating
in an inactive form of protein) is activated and this
causes cytolysis:
thrombocytopenia, agranulocytosis, aplastic
anaemia, haemolysishaemolysis, organ damage (liver,
kidney, muscle), systemic lupus erythematosus.

22. Type III (immune complex vasculitis) reactions
are mediated by circulating antibodies (predominantly IgG).
AG/AB complex binds complement and precipitates
on vascular endothelium giving rise to a
destructive inflammatory response.
Manifestations are rashes, serum sickness (fever,
arthralgia, lymphadenopathy), polyarteriitis nodosa,
Stevens–Johnson syndrome (erythema muliforme, arthritis,
nephritis, myocarditis, mental symptoms). These symptoms
usually subsides in 1–2 weeks.

23. Stevens–Johnson syndrome after oral intake of Co-trimoxazole
(Color Atlas and Synopsis of Clinical Dermatology, 1999)

24. Type IV (delayed hypersensitivity) reactions. They are
mediated through production of sensitized T-lymphocytes
carrying receptors for the AG. On contact with AG T-lym-
phocytes produce lymphokines which attract granulocytes
and generate an inflammatory response, e.g. contact der-
matatitis, some rashes, fever, photosensitization. These
types of allergic reactions generally take > 12 h to develop.
Treatment of drug allergy
The offending drug must be immediately stopped. Most
mild ARs (some skin rashesskin rashes) subside without treatment.
Antihistamine (H1-blockers desloratadine, levocetirizine)
are beneficial in type I reactions (urticaria, rhinitis,

25. welling of lips) and some skin rashes. In case of
naphylactic shock or angioedema of the larynx:
) Put the patient in reclining position, administer oxygen
and perform cardiopulmonary resuscitation if required.
) Inject adrenaline 0.5 mg/1 ml i.m. (not i.v.); repeat every
5 to 10 min if the patient does not improve. This is the
only life-saving measure.
) Administer an H1-blocker (e.g. chlorpheniramine 10–20
mg i.m. or slow i.v.). It may have an adjuvant value.
) In severe/recurrent cases inject slow i.v. methylpredni-
solone or betamethasone. It acts slowly but is especially
valuable for prolonged reactions and in asthmatics.

26. Instructional Video for ANAPENInstructional Video for ANAPEN®®
::
http://www.youtube.com/watch?v=ZR5c5VP2rOs
I.M.
Pre-filled syringes: Anapen®
and EpiPen®
: I.M.

27. (Tripathi, 2008)
Skin testSkin test (intradermal, patch) or intranasal test may
usually forewarn in about 10%10% of cases with Type IType I
hypersensitivityhypersensitivity but not in other types.but not in other types.

29. (6) Idiosyncrasy is genetically determined abnormal
reactivity to a drug and other xenobiotics. Certain ARsCertain ARs
of some drugs are largely restricted to individuals withof some drugs are largely restricted to individuals with
a particular genotypea particular genotype..
AcetylationAcetylation is an important route of metabolism
for many drugs that possess an amine (–(– NHNH22) group.
Most individuals are either rapid or slow acetylators
but the proportion of each varies greatly between
races. Some 90% of Japanese are rapidSome 90% of Japanese are rapid
acetylators whereas in Westernacetylators whereas in Western
populations the proportion is 50%populations the proportion is 50% or
less. IsoniazidIsoniazid may cause peripheralperipheral
neuropathyneuropathy in slow acetylators
on standard doses

30. and pyridoxine is added to the antituberculosis
regimen where there is a special risk, e.g. in diabetes,
alcoholism, renal failure. Acute hepatocellularAcute hepatocellular
necrosis with isoniazid is more common in rapidnecrosis with isoniazid is more common in rapid
acetylatorsacetylators, perhaps because they more readily
form a hepatotoxic metabolite. Sulphasalazine
(used for rheumatoid arthritis) causes ARs
more frequently in slow acetylators, probably
because it forms sulphapyridine, a component which
is inactivated by acetylation.
Bacterial resistance to drugs is geneticallyBacterial resistance to drugs is genetically
determineddetermined and is of great clinical importance.

31. Individuals who are Glucose-6-phosphate
dehydrogenase (G6PD) deficient may suffer
from acute haemolysisacute haemolysis if they are
exposed to certain oxidant substances,
including drugs (dapsone, methylene
blue, nitrofurantoin, primaquine,
fluoroquinolone, some sulphonamides).
Characteristically there is an acute haemolytic episode
2–3 days after starting the drug. The haemolysis is
self-limiting, only older cells with least enzymesonly older cells with least enzymes
being affectedbeing affected. The condition is common in Africa, the
Mediterranean, the Middle East, and South East Asia.

32. Porphyrins represent precursors of haem. But inBut in
people with porphyria the various porphyrins accumulate.people with porphyria the various porphyrins accumulate.
Acute porphyrias are characterized by severe attacks
of neurovisceral dysfunction precipitated principally by
a wide variety of drugs (barbiturates, sulphonamides,
hormonal contraceptives), some mushrooms,
infections, and alcohol too.
Certain peculiarities of an individual (for which no definite
genotype has been described) are included among
idiosyncratic reactions, e.g. phenobarbital causes
excitement and mental confusion in some patients.
The porphyrias comprise a number of rare, genetically
determined enzyme defects in haem biosynthesis.

33. Porphyria cutanea tarda. Periorbital and molar violaceous coloration, hyperpigmentation,
and hypertrichosis on the face; bullae, crusts, and scars on the dorsa of the hands.

34. Amanita phalloides can causeAmanita phalloides can cause porphyriaporphyria..

35. (7) Drug dependence is a state arising from repeated,
periodic or continuous administration of a drug, that
results in harm to the individual and sometimes to society
(Bennett ad Brown, 2003).The subject feels a desire, need,
or compulsion to continue using the drug and feels ill if ab-
ruptly deprived of it (abstinence or withdrawal syndrome).
Drug dependence is characterized by:
• Psychological dependence: there is emotional distress
if the drug is withdrawn.
• Physical dependence:
there is a physical illness if the
drug is withdrawn.
• Tolerance.

36. Psychological dependence develops when an
individual believes that the optimal state of wellbeing is
achieved only through the action of drugs. It may start as
liking for the drug effects and may progress to
compulsive drug use in some individuals. The intensity
of psychological dependence may vary from desire
to craving.
Reinforcement is the ability of a drug to produce effects
that make the user wish to take it again. Opioids,Opioids,
cocaine, and amphetamine are strong reinforcers,cocaine, and amphetamine are strong reinforcers,
while benzodiazepines are week reinforcers.while benzodiazepines are week reinforcers.

37. Physical dependence is an altered physiological state
produced by repeated administration of a drug which
necessitates the continued presence of the drug to
maintain physiological equilibrium.
Discontinuation of the drug results in a characteristic
withdrawal (abstinence) syndrome.
Drugs producing physical dependence are depressants
of CNS: opioids (morphinomimetics), barbiturates,
benzodiazepines, alcohol.
Central nervous stimulants such as amphetamines andCentral nervous stimulants such as amphetamines and
cocaine produce little or no physical dependence.cocaine produce little or no physical dependence.

38. Physical dependencePhysical dependence

40. Drug abuseDrug abuse means the use of psychotropic substancesmeans the use of psychotropic substances
in a way that would “constitute a public health and socialin a way that would “constitute a public health and social
problemproblem”.”. For a regulatory agency “drug abuse” refers to
any use of an illicit drug.
Drug addiction is a pattern of compulsive drug use
characterized by overwhelming involvement with the
use of a drug. Amphetamines, cocaine, cannabis, LSD
are drugs which produce addiction but little or no physical
dependence.
Drug habituation is less intensive involvement with the
drug, so that its withdrawal produces only mild discomfort
without physical dependence (e.g. tea, coffee, tobacco).

41. Types of drug dependenceTypes of drug dependence (Bennett, Brown, 2003)(Bennett, Brown, 2003)
 Morphine or Heroin type:
— psychological dependence severe
— physical dependence severe; develops quickly
— tolerance marked
— cross-tolerance with related drugs
— naloxone induces abstinence syndrome.
 Barbiturate-type:
— psychological dependence severe
— physical dependence very severe; develops
slowly at high doses
— tolerance less marked than with morphine
— cross-tolerance with alcohol and benzodiazepines

42. Cocaine

44.  Amphetamine-type:
— psychological dependence severe
— physical dependence slight:
psychoses occur during use
— tolerance occurs.
 Cannabis-type:Cannabis-type:
— psychological dependence
— physical dependence dubious (no characteristic
abstinence syndrome)
— tolerance occurs.
 Cocaine-type:
— psychological dependence severe
— physical dependence slight
— tolerance slight (to some actions).

45.  Alcohol-type:
— psychological dependence severe
— physical dependence with prolonged heavy use
— cross-tolerance with other sedatives.
 Tobacco-type:
— psychological dependence
— physical dependence.
 Drug mixtures: Barbiturate-amphetamine mixtures
induce a characteristic alteration of mood that does
not occur with either drug alone
— psychological dependence strong
— physical dependence occurs
— tolerance occurs.
 Heroin-cocaine mixtures: similar characteristics.

49. Nicotine is anNicotine is an
enzyme inducer.enzyme inducer.

53. karoshi
ModernModern
obsessionsobsessions

57. (8) Drug withdrawal syndrome – sudden interruption
of therapy with certain drugs (glucocorticoids, antiepileptic
drugs, CV drugs, etc.) usually results in ARs, mostly in the
form of worsening of the clinical condition for which the
drug was being used. Examples:
• Frequency of seizures may increase on
sudden withdrawal of an antiepileptic drugantiepileptic drug.
• Worsening of angina pectoris or acute myocardial infarction
may result from stoppage of beta-blockers or nitrovasodilators.
• Severe hypertension and sympathetic overactivity may occur
shortly after discontinuing clonidine.
In all these cases, it is very important to keep patient’s
compliance and/or to stop the drug gradually.

58. (9) Effects of prolonged administration:
Chronic organ toxicity (types C and D reactions)
Eye. Toxic cataractToxic cataract can be due to chloroquine
and related drugs, adrenal steroids (topical and
systemic), phenothiazines and alkylating agents.
Corneal opacities occur with phenothiazines,
amiodarone, and chloroquine. Retinal injuryRetinal injury
occurs with thioridazine (particularly of the
antipsychotics), chloroquine, and indometacin.
Nervous system. Tardive dyskinesiasTardive dyskinesias occur with
neuroleptics; polyneuritispolyneuritis with isoniazid, metronidazole,
or zalcitabine; optic neuritis with ethambutol.

61. PolyneuritisPolyneuritis
TardiveTardive
dyskinesiadyskinesia

62. Pulmotoxicity. Amiodarone may cause pulmonary fibrosis.
Sulphasalazine is associated with fibrosing alveolitis.
Nephrotoxicity: Aminoglycosides, polymyxines, gold salts.
Hepatotoxicity: Methotrexate, paracetamol, halothane.
Thyreotoxicity: Amiodarone
Carcinogenesis. The principal mechanisms are:
•Alteration of DNA (genotoxicity, mutagenicity).
•Immunosuppression. A wide range of cancers
develop in immunosuppressed patients, e.g. after
organ transplantation and cancer chemotherapy.
•Hormonal. Long-term use of estrogen replacement in
postmenopausal women induces endometrial cancer.

63. Тhe biggest medical tragedy of modern times
(10) Teratogenisity represents the the fetal abnormalities
of a drug, administered to the pregnant mother (by Tripathi, 2008).
The placenta does not strictly constitute a barrier and any
drug can cross to a greater or lesser extent. The embryo is
one of the most dynamic biological systems and in contrast
to adults, drug effects
very often are irreversible.
The thalidomide disasterthalidomide disaster
(1958–1962) resulting in
10 000 of babies born with
phocomeliaphocomelia and other defects
focused attention to these
types of drug adverse effects.

64. The Australian obstetrician
William McBride and the German
pediatrician Widukind Lenz suspected
a link between birth defects andbirth defects and
thalidomidethalidomide, and this was proved
by Lenz in 1961. McBride was later
awarded a number of honours
including a medal and prize money by
the L'Institut de la Vie in Paris.

65. Phocomelia
– seal-like limbsseal-like limbs
(W. Lenz, K. Knapp.
Thalidomide embryopathy.
Dtsch Med Wochenschr.
1962 Jun 15; 87:1232–42).
Germany:
2500 babies

66. UK: 456
babies

67. - Absence of the auricles with deafness.
- Defects of the muscles of the eye
and of the face.
- Absence or hypoplasia of arms,
preferentially affecting the
radius and the thumb.
- Thumbs with three joints.
- Defects of the femur and of the tibia.
- Malformations of the heart, the bowel,
the uterus, and the gallbladder.
W. Lenz

68. In 1962,
the United States Congress
enacted laws requiring tests
for safety during pregnancy
before a drug can receive
approval for sale in the U.S.
USA: 17
babies

71. Thalidomide is racemic: it contains both left- and right-handed
isomers. The (R) enantiomer is effective against morning sickness.
The (S) is teratogenic and causes birth defects. The enantiomers
can interconvert in vivo. The (S) enantiomer intercalates (inserts)
into the DNA in G–C (guanine – cytosine) rich regions.
(S)-thalidomide (R)-thalidomide

72. Drugs can affect the fetus at the following stages:
•Fertilization and implantation – from conception to 14–17
days: failure of pregnancy (which often goes unnoticed).
•Embryogenesis (organogenesis) – between 15–18 to 55
days of gestation: most vulnerable period, major
morphologic deformities are produced.
•Fetogenesis (growth and development) – from 56 days of
gestation to birth: developmental and functional abnormali-
ties can occur, e.g. aminoglycosides can cause ototoxicitiy,
ACE inhibitors – hypoplasia of cranium, lungs, and kidneys;
NSAIDs may induce premature closure of d. arteriosus.
The type of malformation depends on the drug
as well as the stage of exposure to the teratogen.

73. Embryogenesi
Dorland’s Illustrated Medical Dictionary (2003, 2004)Dorland’s Illustrated Medical Dictionary (2003, 2004)

75. (By Moore KL: The Developing Human: Clinically Oriented Embryology, 4th
ed. Saunders, 1988.)(By Moore KL: The Developing Human: Clinically Oriented Embryology, 4th
ed. Saunders, 1988.)
Schematic diagram of critical periods of human developmentSchematic diagram of critical periods of human development

76. A
B
C
D
X
Pregnancy and
Lactation Risk
Categories
(PRCs and LRCs
The FDA (USA) has established 5 categories
to indicate the potential of systematically
absorbed drugs for causing birth defects.
The key differentiation among the categories
rests upon the reliability of documentation
and the risk:benefit ratio (Lacy et al., 1998).

77. PRC A: Controlled studies in pregnant women fail to
demonstrate a risk to the fetus in the first trimester with
no evidence of risk in later trimesters.
Examples: Folic acid, T4, Magnesium sulfate (inj.!)
PRC B: The animal-reproduction studies have not
demonstrated a fetal risk but there are no controlled
studies in pregnant women.
Examples: penicillins, erythromycin, paracetamol,
lidocaine.

78. PRC C: The studies in animals have revealed ARs
on the fetus (teratogenic, embryocidal, or other effects)
and there are no controlled studies in women, or studies
in women are not available. The drug should be given only
if the potential benefits justify the potential risk to the fetus.
Examples: atropine, adrenaline, thiopental, bisoprolol.
PRC D: There is positive evidence of human fetal risk,
but the benefits from use in pregnant women may be
acceptable despite the risk (e.g. if the drug is needed in
a life-threatening situation or for a serious disease for
which safer drugs that can be used are ineffective).
Examples: phenytoin, valproate, diazepam, lorazepam.

79. СPhenytoin syndrome

80. PRC X: Studies in animals or human beings have
demonstrated fetal abnormalities and
the risk of the use of the drug in pregnant women clearly
outweighs any possible benefit. The drug is contraindi-
cated in women who are or may become pregnant.
Examples: thalidomide, estrogens, isotretinoin,
ergometrine.

81. (Tripathi, 2008)

82. EythroxylonEythroxylon
coca L.coca L.
•CocaineCocaine

84. Lactation Risk Categories – LRC)Lactation Risk Categories – LRC)

85. PRCs LRCs
A: controlled studies
show no risk (Vit. B9)
B: no evidence of risk in
humans (Penicillins)
C: risk cannot be ruled
out (Bisoprolol)
D: positive evidence of
risk (Diazepam)
X: contraindicated in
pregnancy (Estrogens)
L1: safest (Ibuprofen,
Paracetamol)
L2: safer (Cephalosporins,
Omeprazole)
L3: moderately safe
(Acarbose, Aspirin)
L4: possibly hazardous
(Diazepam, Lithium)
L5: contraindicated
(ACE inhibitors)

86. (11) Drug-induced diseases(11) Drug-induced diseases are also calledare also called
iatrogeniciatrogenic (physician induced) diseases(physician induced) diseases.. They represent
functional disturbances (diseases) caused by drugs which
persist even after the offending remedy has been
withdrawn and largely eliminated. Examples:
•Parkinsonism by phenothiazine and other neuroleptics.
•Hepatitis by isoniazid.
•Peptic ulcer by salicylates, glucocorticoids, or reserpine
•Aplastic anaemia
by chloramphenicol etc.

87. PolypragmasyPolypragmasy

88. ParkinsonismParkinsonism

93. www.medpharm-sofia.euwww.medpharm-sofia.eu