Adverse Drug Effects Bds
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Dr.U.P.Rathnakar MD.DIH.PGDHM
Adverse Drug Effects Any undesirable or unintended consequence of drug administration “Any response to a drug that is noxious and unintended and that occurs at doses used in man for the prophylaxis, diagnosis, or therapy of disease or for modification of physiological function” – WHO Adverse event: Any untoward event that occurs during treatment not necessarily with causal relation ship to treatment
ADE: Predictable and Unpredictable Predictable: Type A : Augmented Augmented pharmacological properties Side effects, toxic effects, Drug withdrawal effects Common, dose related, Reversible Unpredictable: Type B: Bizarre Reactions Not known action of drug Idiosyncracy, Allergy Less common, Non dose related
ADE: Severity Minor: No tt required Moderate: Requires change in tt, change of drug Severe: Potentially life threatening,
permanent damage Lethal: Directly or indirectly contributes to death
ADE 1. Side effects: Unwanted ,unavoidable pharmacodynamic effects at therapeutic doses Eg. Antihistaminics cause sedation 2. Secondary effects: Indirect consequence of primary action of a drug Eg. Tetracyclines cause superinfection 3. Toxic effects: Due to overdose or prolonged use Eg. Respiratory failure by morphine Coma by barbiturates
ADE 4. Intolerance:
5.
Low threshold to the action of drug Eg. EPS with single dose of Metoclopromide Idiosyncrasy: A genetically determined reaction An unusual individual reaction to food or a drug Eg. Barbiturates cause excitement and mental confusion Chloramphenicol causes aplastic anemia
6. ADE:Drug allergy (drug hypersensitivity)
Immunologically mediated reaction Types of drug allergy 1. Anaphylactic-
-Type I 2. Cytolytic -Type II 3. Immune complex mediated[Arthus]: -Type III 4. Delayed hypersensitivity -Type IV
Type 1
Drug allergy-Type I [Anaphylaxis] Exposure to drug Eg.Penicillin
IgE AB Fixed to mast cells
Reexposure
Treatment: •Medical emergency •Inj.Adrenaline[1:1000] .3 to .5 ml i.m. •Inj.Hydrocortisone 100 mgi.v. •Inj.Diphenhydramine 25mg i.v. •Oxygen •i.v. fluids
AG+AB
Release of mediators: Histamine, 5-HT, PGs, LTs, PAF Anaphylactic shock: Hypotension, Bronchospasm, Urticaria Etc.
Type 2
Drug allergy-Type II [Cytolytic] Exposure to drug Eg.Quinine
Drug+Tissue= AG IgG, IgM- AB
Re exposure
Eg. Hemolysis by Quinine, Quinidine
Tissue+AB
Complement Cell destruction
Type 3
Drug allergy-Type III[Immune mediated] AG+AB IgG
Complement fixation
Deposited on vascular endothelium Destructive inflammatory response
Eg. • Serum sicknes [Fever, urticaria, joint pain, lymphadenopathy] •Penicillin, Sulfa •NSAIDs
Type 4
Drug allergy-Type IV [Delayed]
•Inflammatory respone •Delayed by 2-3 days •Contact dermatitis with LA creams •Not AB related •Cell mediated
7. Photosensitivity Sensitization of the skin by drugs UV radiation Cutaneous reaction-Photosensitivity 8. Carcinogenicity & mutagenicity: Ability of the drug to cause cancer and genetic defects respectively Eg. Tobacco, anticancer drugs 9. Iatrogenic diseases: iatros = physician (physician induced diseases): Parkinsonism – Phenothiazines Peptic ulcer – Aspirin,corticosteroids Hepatitis Isoniazid
Drugs frequently cause allergic reactions Penicillins
Carbamazapine
Cephalosporins
ACE inhibitors
Sulfonamides
Local anesthetics
Tetracyclines Quinolones Antitubercular drugs Salicylates
Teratogenicity: terataos = monster Capacity of the drug to cause fetal abnormalities when administered to pregnant mother
10.
I. Preimplantation:conception to 17 days-Abortion ii.Organogenesis:18-55 days-Deformities iii.Growth and development:56 days onwards Thalidomide –Phocomelia Corticosteroids – Cleft lip TC-Discolouration of teeth, retarded bone growth
17 D
17-55 D
Implantation Organogen Death Fetus
Malform
>56D Growth&Dev Growth retard
Human teratogenic drugs
Cleft Palate Hydrocephalus Anticancer drugs
Hand defects Warfarin
Fetal alcohol syndrome Alcohol
Phocomelia Thalidomide
Neural tube Defects Valproate
Hydantoin syndrome Phenytoin
Tetracycline
Staining
After Tt
11.Organ toxicity Hepatotoxicity: INH, Rifampicin Nephrotoxicity: Aminoglycosides Ototoxicity: Aminoglycosides,
Frusemide Ocular toxicity: Ethambutol, Chloroquine
12. Drug dependence A state Psychological or physical Due to interaction - living organism+Drug Characterised by behavioral and other responses Always includes a compulsion to take the drug continuously or periodically Psychological: Intense desire to take drug and immense satisfaction later Physical: Physiological equilibrium is maintained by drug
Poisoning “Poisons in small doses are the best medicines; and useful medicines in too large doses are poisonous” William Withering 1789
Poisoning Large enough dose of a drug Sub.which endagers life Accidental or suicidal Treatment Hospitalization Gastric lavage Airway-Suction, Endotracheal tube Breathing-Mechanical ventilation Circulation-i.v.Fluids Diuretics or Dialysis Antidote-OP poisoning-Atropine
Poisoning Resuscitation and maintainance of vital functions Airway, BP, Body temp., Blood sugar 2. Termination of exposure Fresh air, remove wet clothes, wash, 3. Prevention of absorption Gastric lavage, Activated charcoal, 4. Hastening elimination Diuresis, Altering urine pH, Hemodialysis 1.
Prevention of adverse effects Right dose, route, frequency Previous history drug allergy and
allergic diseases Rule out drug interactions Correct technique of administration TDM if appropriate
Pharmacovigilance Actively look for adverse drug effects “Activities relating to detection, assessment,
understanding and prevention of adverse effects or any other drug related problem” Information collected by Regional centers to Zonal centers to National centers to Uppsala monitoring center (Sweden) Uses Educating doctors about ADE Assessing safety of drugs
Adverse Drug Effects Any undesirable or unintended consequence of drug administration “Any response to a drug that is noxious and unintended and that occurs at doses used in man for the prophylaxis, diagnosis, or therapy of disease or for modification of physiological function” – WHO Adverse event: Any untoward event that occurs during treatment not necessarily with causal relation ship to treatment
ADE: Predictable and Unpredictable Predictable: Type A : Augmented Augmented pharmacological properties Side effects, toxic effects, Drug withdrawal effects Common, dose related, Reversible Unpredictable: Type B: Bizarre Reactions Not known action of drug Idiosyncracy, Allergy Less common, Non dose related
ADE: Severity Minor: No tt required Moderate: Requires change in tt, change of drug Severe: Potentially life threatening,
permanent damage Lethal: Directly or indirectly contributes to death
ADE 1. Side effects: Unwanted ,unavoidable pharmacodynamic effects at therapeutic doses Eg. Antihistaminics cause sedation 2. Secondary effects: Indirect consequence of primary action of a drug Eg. Tetracyclines cause superinfection 3. Toxic effects: Due to overdose or prolonged use Eg. Respiratory failure by morphine Coma by barbiturates
ADE 4. Intolerance:
5.
Low threshold to the action of drug Eg. EPS with single dose of Metoclopromide Idiosyncrasy: A genetically determined reaction An unusual individual reaction to food or a drug Eg. Barbiturates cause excitement and mental confusion Chloramphenicol causes aplastic anemia
6. ADE:Drug allergy (drug hypersensitivity)
Immunologically mediated reaction Types of drug allergy 1. Anaphylactic-
-Type I 2. Cytolytic -Type II 3. Immune complex mediated[Arthus]: -Type III 4. Delayed hypersensitivity -Type IV
Type 1
Drug allergy-Type I [Anaphylaxis] Exposure to drug Eg.Penicillin
IgE AB Fixed to mast cells
Reexposure
Treatment: •Medical emergency •Inj.Adrenaline[1:1000] .3 to .5 ml i.m. •Inj.Hydrocortisone 100 mgi.v. •Inj.Diphenhydramine 25mg i.v. •Oxygen •i.v. fluids
AG+AB
Release of mediators: Histamine, 5-HT, PGs, LTs, PAF Anaphylactic shock: Hypotension, Bronchospasm, Urticaria Etc.
Type 2
Drug allergy-Type II [Cytolytic] Exposure to drug Eg.Quinine
Drug+Tissue= AG IgG, IgM- AB
Re exposure
Eg. Hemolysis by Quinine, Quinidine
Tissue+AB
Complement Cell destruction
Type 3
Drug allergy-Type III[Immune mediated] AG+AB IgG
Complement fixation
Deposited on vascular endothelium Destructive inflammatory response
Eg. • Serum sicknes [Fever, urticaria, joint pain, lymphadenopathy] •Penicillin, Sulfa •NSAIDs
Type 4
Drug allergy-Type IV [Delayed]
•Inflammatory respone •Delayed by 2-3 days •Contact dermatitis with LA creams •Not AB related •Cell mediated
7. Photosensitivity Sensitization of the skin by drugs UV radiation Cutaneous reaction-Photosensitivity 8. Carcinogenicity & mutagenicity: Ability of the drug to cause cancer and genetic defects respectively Eg. Tobacco, anticancer drugs 9. Iatrogenic diseases: iatros = physician (physician induced diseases): Parkinsonism – Phenothiazines Peptic ulcer – Aspirin,corticosteroids Hepatitis Isoniazid
Drugs frequently cause allergic reactions Penicillins
Carbamazapine
Cephalosporins
ACE inhibitors
Sulfonamides
Local anesthetics
Tetracyclines Quinolones Antitubercular drugs Salicylates
Teratogenicity: terataos = monster Capacity of the drug to cause fetal abnormalities when administered to pregnant mother
10.
I. Preimplantation:conception to 17 days-Abortion ii.Organogenesis:18-55 days-Deformities iii.Growth and development:56 days onwards Thalidomide –Phocomelia Corticosteroids – Cleft lip TC-Discolouration of teeth, retarded bone growth
17 D
17-55 D
Implantation Organogen Death Fetus
Malform
>56D Growth&Dev Growth retard
Human teratogenic drugs
Cleft Palate Hydrocephalus Anticancer drugs
Hand defects Warfarin
Fetal alcohol syndrome Alcohol
Phocomelia Thalidomide
Neural tube Defects Valproate
Hydantoin syndrome Phenytoin
Tetracycline
Staining
After Tt
11.Organ toxicity Hepatotoxicity: INH, Rifampicin Nephrotoxicity: Aminoglycosides Ototoxicity: Aminoglycosides,
Frusemide Ocular toxicity: Ethambutol, Chloroquine
12. Drug dependence A state Psychological or physical Due to interaction - living organism+Drug Characterised by behavioral and other responses Always includes a compulsion to take the drug continuously or periodically Psychological: Intense desire to take drug and immense satisfaction later Physical: Physiological equilibrium is maintained by drug
Poisoning “Poisons in small doses are the best medicines; and useful medicines in too large doses are poisonous” William Withering 1789
Poisoning Large enough dose of a drug Sub.which endagers life Accidental or suicidal Treatment Hospitalization Gastric lavage Airway-Suction, Endotracheal tube Breathing-Mechanical ventilation Circulation-i.v.Fluids Diuretics or Dialysis Antidote-OP poisoning-Atropine
Poisoning Resuscitation and maintainance of vital functions Airway, BP, Body temp., Blood sugar 2. Termination of exposure Fresh air, remove wet clothes, wash, 3. Prevention of absorption Gastric lavage, Activated charcoal, 4. Hastening elimination Diuresis, Altering urine pH, Hemodialysis 1.
Prevention of adverse effects Right dose, route, frequency Previous history drug allergy and
allergic diseases Rule out drug interactions Correct technique of administration TDM if appropriate
Pharmacovigilance Actively look for adverse drug effects “Activities relating to detection, assessment,
understanding and prevention of adverse effects or any other drug related problem” Information collected by Regional centers to Zonal centers to National centers to Uppsala monitoring center (Sweden) Uses Educating doctors about ADE Assessing safety of drugs
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