N-acetylcysteine (NAC) is an antidote and mucolytic agent with FDA approval for acetaminophen overdose and adjunctive mucolytic therapy. It works by increasing glutathione stores to prevent liver toxicity from acetaminophen or by lowering mucus viscosity. NAC is available as an intravenous or inhaled solution and oral capsules. The intravenous route is preferred for severe overdose or inability to take oral medications. Common side effects include nausea and vomiting. While its efficacy for other off-label uses like contrast-induced nephrotoxicity prevention is unclear, it is generally well-tolerated with minimal drug interactions.
Digoxin & Nitroglycerin by Dr. Sanaullah Aslam (Complete)Sanaullah Aslam
Your Feedback will be highly appreciated. This presentation was made for students at pharmacy institute in a project of clinical pharmacy and use of digoxin and nitroglycerin. This presentation is made so that you can present it in a same session, without any change.
Digoxin & Nitroglycerin by Dr. Sanaullah Aslam (Complete)Sanaullah Aslam
Your Feedback will be highly appreciated. This presentation was made for students at pharmacy institute in a project of clinical pharmacy and use of digoxin and nitroglycerin. This presentation is made so that you can present it in a same session, without any change.
Contents:
Drug Presentation On Lactulose, Naming of the drug, Classification of the drug, Mechanism of action Indications, Precautions, Contraindications, Side effects, Interactions, Use in pregnancy, Use in Brest feeding, Routes of Administration, Preparations Available,Storage Requirements,Schedule, Dosage and Counseling
Contents:
Drug Presentation On Lactulose, Naming of the drug, Classification of the drug, Mechanism of action Indications, Precautions, Contraindications, Side effects, Interactions, Use in pregnancy, Use in Brest feeding, Routes of Administration, Preparations Available,Storage Requirements,Schedule, Dosage and Counseling
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
Contrast Induce Nephropathy
its include information about the nephropathy thats caused by the contrast , like in patients undergo PCI or other method of imaging containing contrast
I will discuss the causes with the risk factors then explain the headline of the pathophysiology and clinical presentaion with the mangment,
Sean Kelly is an Emergency Physician and Intensivist who's the director at Gosford ICU in New South Wales. He's also the medical director at ICCMU. He gave this great talk at Bedside Critical Care 2012 on Daydream Island. He'll be at SMACC. Check out the ICCMU website.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
3. Indications 3 FDA labeled indications Acetaminophen (APAP) overdose Adjunctive mucolytic therapy Diagnostic bronchial studies Off-label use Prevention of contrast-induced nephrotoxicity (CIN) Helicobacter pylori infection
4. Pathophysiology of APAP Overdose 4 APAP primarily metabolized via glucoronidation or sulphation Secondary metabolism by CYP 450 system In OD, primary route saturated -> CYP 450 system -> NAPQI production NAPQI converted to non-toxic form by glutathione In OD, glutathione stores consumed -> excess NAPQI -> covalent binding to hepatocytes
5. Mechanisms of Action 5 APAP overdose NAC -> cysteine-> glutathione (GSH) Prevention of CIN Possibly minimizes vasoconstriction and oxidative stress Mucolysis Lowers mucus viscosity Free sulfhydryl group opens disulfide bonds in mucoproteins H. pylori infection May increase delivery of medications by ↓ mucus viscosity
6. Dosage Forms 6 Injection solution (Rx) Acetadote 20% (30 ml) Inhalation solution (Rx) Mucomyst, generic 10%, 20% (4 ml, 10 ml, 30 ml) Capsules (OTC) Generic 600 mg (60, 120) Extemporaneous compounding Inhalation solution may be used as IV Inhalation solution may also be mixed w/soda to yield 5% oral solution
7. IV vs. PO 7 Both routes are effective, differences minimal IV route preferred if: Vomiting Contraindication to oral administration of medication Hepatic failure Refuses oral administration Pricing: Acetadote = $145.77/vial (30 ml) NAC 10%, 20% inhalation solution = $1.32/vial (4 ml)
9. Warnings/Precautions 9 Inhaled form may cause increased bronchial secretions, bronchospasm Emesis Oral form may aggravate vomiting Encephalopathy If present, consider discontinuing administration of NAC Odor Has slight disagreeable odor
12. Pharmacokinetics 12 Absorption Bioavailability of oral form is low Distribution Vdss = 0.47 L/kg Plasma protein binding = 83% Metabolism Deacetylated in the liver to cysteine Elimination T1/2 = (Adults) 5.5 hours, (Newborns) 11 hours Primarily non-renal (70%), renal (30%)
13. Pharmacokinetics - Special Populations 13 Pregnant women In limited reports, shown to cross placenta Pregnancy risk category: B Hepatic dysfunction May influence pharmacokinetics T1/2 shown to increase by 80% Renal clearance decreased by 30%
14. Dosing 14 APAP toxicity Children and adults (> 40 kg) Loading dose should be given Oral: 140 mg/kg IV: 150 mg/kg infused over 60 minutes Maintenance doses Oral: 70 mg/kg q 4 hours x 17 doses IV: 50 mg/kg infused over 4 hours, then 100 mg/kg infused over 16 hours (Total 300 mg/kg infused over 21 hours) Patients < 40 kg Fluid volume should be reduced Weight-based dilution
15. Dosing cont… Respiratory conditions Diagnostic bronchial studies 1 – 2 ml of 20% or 2 – 4 ml of 10% 2 – 3 times prior to procedure Prevention of CIN 600 – 1200 mg PO BID x 2 days (begin day before procedure) 15
16. Stability 16 IV solution Stable for 24 hours after dilution w/D5W Inhalation solution Vials must be refrigerated after opening Must be used w/in 96 hours Opened vials may change color Does not affect safety or efficacy
18. Therapeutic Efficacy 18 APAP overdose No trials to evaluate efficacy Low incidence of hepatotoxicity when given early Mucolysis Studies suggest small benefit Prevention of CIN Conflicting results in available data There is a trend towards benefit
19. References 19 Acetadote [package insert]. Nashville, TN:Cumberland Pharmaceuticals, Inc.; February 2006. Gurbuz AK, Ozel AM, Ozturk R, Yildirim S, Yazgan Y, Demirturk L. Effect of N-acetyl cysteine on Helicobacter pylori. South Med J. 2005;98:1095-1097 Lacy, CF, Armstrong, LL, Goldman, MP, Lance, LL. Drug information handbook.17th ed. Hudson: Lexi-Comp, Inc.; c2008. Acetylcysteine; p. 32-4. N-Acetylcysteine, a Novel Treatment for Helicobacter pylori Infection. Dig Dis Sci. 2004 Nov-Dec;49(11-12):1853-61. Pombrio JM, Giangreco A, Li L, Wempe MF, Anders MW, Sweet DH, Pritchard JB, Ballatori N. Mercapturic acids (N-acetylcysteine S-conjugates) as endogenous substrates for the renal organic anion transporter-1. Mol Pharmacol. 2001 Nov;60(5):1091-9. Up to date online. Prevention of contrast-induced nephropathy. Rudnick, MR, Tumlin, JA. 2009 Sep. Dribben WH, Porto SM, Jeffords BK. Stability and microbiology of inhalant N-acetylcysteine used as an intravenous solution for the treatment of acetaminophen poisoning. Ann Emerg Med. 2003 Jul;42(1):9-13
Editor's Notes
NAC is a derivative of the amino acid cysteine.It is classified as a mucolytic and an antidote.
It is FDA approved as an antidote for APAP overdose, as adjunctive therapy for respiratory conditions, and as a mucolytic for diagnostic bronchial studies.The off-label uses are for the prevention of contrast-induced nephropathy and asAn adjunct in the treatment of H. pylori infections
Before I go over the mechanism of action, I thought I should explain the reason why NAC is useful as an antidote.APAP has 2 routes of metabolism, the primary route is through glucoronidation or sulphation which would make APAP more water soluble so that it may then be excreted in the urine. The secondary route involves the CYP 450 system which converts APAP to a highly reactive oxide called NAPQI. From there, NAPQI is quickly converted to mercapturic acid by glutathione and is excreted in the urine. However, in an overdose situation, the amount of APAP is high enough to overwhelm the primary route and its metabolism is shunted to the CYP system which increases the production of NAPQI, however because of the sharp increase, our glutathione stores also become overwhelmed and the end result is excess NAPQI that may covalently bind to hepatocytes and cause hepatic necrosis.
It is useful in an overdose because essentially what we are doing when we administer NAC is giving exogenous glutathione. In our cells, NAC is converted to cysteine which is a precursor of glutathione.The exact mechanism of how NAC prevents CIN has not been fully elucidated, however the theory is that it minimizes vasoconstriction and oxidative stress.In addition to antioxidant benefits, It may also be used as a mucolytic.NAC contains a free sulfhydryl group that may open disulfide bonds in mucoproteins. Disulfide bonds increase the rigidity of proteins and support its secondary structure. Therefore, by breaking the structure of the protein, the mucus becomes less “bulky” or viscous. And for this same reason it has been thought to be beneficial in the treatment H. pylori infection because it may increase delivery of medications to the gut by decreasing mucus viscosity, however there is not a lot of strong evidence to support this.
The only available injectable form of NAC is Acetadote 20% which is not generically available.The inhalation solution is available generically and as brand Mucomyst in concentrations of 10% and 20%.There are also capsules available over the counter, however these are considered dietary supplements and are not regulated by the FDA. If Acetadote is not available, the inhalation solution may be used intravenously however, each dose must be infused through a filter and the dosing is different. To make NAC more palatable, it may be mixed with juice or soda and taken orally.
Both routes are effective in the treatment of APAP overdose, however, if the patient is vomiting, has a condition that makes giving oral medications not feasible, has hepatic failure, or refuses oral meds, then IV is the preferred route.Some of the benefits of oral therapy include:Minimal anaphylactoid reactionsThe oral form undergoes the first pass effect which allows it to achieve high concentrations in the liverMay be an alternative for patients with previous anaphylactoid reactions to IV formLess dosing errors Less expensive than IV formSome benefits of IV therapy include:Less N/VMay result in shorter hospital stay More stable than oral form. Once compounded, the oral form is only stable for 1 hour.Cost is another aspect we should consider when determining which route is best. 1 vial of acetadote is 145.77 and 1 vial of the inhalation is 1.32.
The only contraindication for the use of NAC is hypersensitivity to it or any component of the formulation.
When NAC is inhaled, it may cause bronchospasm which may be mitigated by giving a bronchodilator such as albuterol or ipratropium 10 – 15 minutes prior to administration.The oral form may cause nausea and vomiting and so giving to someone who is actively vomiting may not be the best thing to do. Hepatic failure may result in encephalopathy which can be exacerbated by NAC because it is nitrogenous substance and may lead to uremic encephalopathy. There have been no reports of this, the risk is theoretical but should still be considered. The oral formulation has a slight disagreeable odor that may affect palatability and may cause patients to refuse it. We use the Rumack-Matthew nomogram to predict the liklihood of a patient developing hepatotoxicity after an acute APAP overdose. This nomogram does not apply to all situations. If the time of ingestion is unknown, or the patient has been chronically overdosing, the nomogram does not apply. The nomogram may be used in cases of extended-release APAP overdose, however, multiple levels should be obtained and then plotted on the nomogram.Treatment with NAC is most effective when administered within 8 hours of ingestion. If APAP levels are not available or if ingestion time is unknown, NAC should be given immediately, however after 8 hours post-ingestion treatment efficacy declines.
The most important adverse reactions to the inhalation are bronchospasm and n/v. Asthmatic patients are at higher risk of developingbronchospasm. Approximately 10 – 20 % of patients receiving NAC will have an anaphylactoid reaction to the IV form and patients with asthma are at a higher risk. These reactions are most commonly seen w/in 30 – 60 minutes of starting the infusion.If the reaction is just flushing, the infusion should continue, however if other symptoms are present such as rash, hypotension, or shortness of breath, the NAC infusion may be interrupted until the symptoms are adequately treated. [If they return or progress, stop NAC and consider calling the poison control center’s APAP over dose line for health care providers 1-800-525-6115]Treatment of anaphylactoid reactions:Diphenhydramine 1mg/kg IV up to 50 mgCimetidine 5 mg/kg up to 300 mg Oral ephedrine 0.5 mg/kg up to 25 mg
There are no significant drug interactions, however NAC is adsorbed to activated charcoal.
NAC is a protein so it’s oral bioavailability is low due to catabolism in the gut.The volume of distribution at steady state is 0.47 L/kg and it is approximately 83% protein bound in plasma.NAC is metabolized to other substances such as cysteine and other conjugates.Elimination of total acetylcysteine is primarily through extrarenal sources, however 30% of it’s elimination is though the kidneys. The elimination half-live is about 5.5 hours in adults and 11 hours in newborns. **Elimination is 3% fecal**
IN pregnant women, NAC has been shown to cross the placenta.And The pharmacokinetics of NAC are different in patients with hepatic dysfunction. The half-life is increases by 80% and the renal clearance decreases by 30%. Although we know this, there are no data to support a dosage adjustment in these patients or patients with renal dysfunction.
The dosing of NAC can be somewhat complicated which may lend itself to dosing errors.Patients that weigh more than 40 kg should receive a loading of 140 mg/kg by mouth or 150 mg/kg IV [in 200 ml D5W] infused over 60 minutes. The oral maintenance dose is 70 mg/kg for 17 additional doses. The IV maintenance dose is 50 mg/kg [in 500 ml D5W] infused over 4 hours, then 100 mg/kg [in 1 L D5W] infused over 16 hours for a total of 300 mg/kg infused over 21 hours)Patients that weigh less than 40 kg should receive the same dose of NAC, however the volume of D5W used to dilute the drug is less to avoid fluid overload which may lead to hyponatremia, seizure, and death.
The dosing for respiratory conditions is straight forward, for infants, the dose is 200 – 400 mg inhaled via nebulizer 3 – 4 times a day.For children and adults, the dose is 600 mg – 1 g inhaled via nebulizer 3 – 4 times a day. Either the 10% or 20% solution may be used, however, you must note the difference in volume needed.For diagnostic pulmonary procedures the dose is 200 – 400 mg (using either the 10% or 20% solution) inhaled via nebulizer 2 – 3 time before the procedure.To prevent CIN, the inhalation solution may be given by mouth mixed in soda or juice twice a day for 2 days beginning the day before the procedure.**When mixed w/juice or soda, final concentration must be 5%**
Once the IV solution has been diluted, it is only stable for 24 hours. The inhalation solution is stable for 96 hours once the vial has been opened as long as it is kept in the refrigerator.When NAC is exposed to air, the solution may change to a light purple color. This has no effect on its stability or efficacy and should not be cause for alarm. The recommended diluent is D5W, however, NS, ½ NS, or SWFI may also be used.
While patients are on NAC, we should monitor them for signs and symptoms of anaphylaxis.Specifically for patients with APAP overdose, we should monitor their APAP levels and renal and liver function tests as well as their INR.
There have been no placebo-controlled trials conducted to evaluate the efficacy of NAC in APAP overdose because that would be unethical but, the trials that have been conducted show that there is a low incidence of hepatotoxicity when it is given early.Trials to evaluate NAC effectiveness as a mucolytic demonstrate that NAC does provide small benefit in the treatment of respiratory conditions such as COPD.While NAC is used to prevent CIN, there are conflicting results in numerous trials. In the largest meta-analysis conducted, NAC was shown to significantly lower the risk of renal dysfunction.