Immunosuppressants and immunostimulants

Vitamins
Minerals
Vaccines and antisera
Drugs used in Cardio-pulmonary resuscitation
(CPR) & emergency
Drug therapy in scabies & pediculosis
Enzymes in therapy
Alternative systems of medicine

Suppress the immune system (cell mediated or

humoral or both)
Classification:
1. T-Cell inhibitors cyclosporine, tacrolimus
2. Cytotoxic drugs Methotrexate,
cyclophosphamide
3. Glucocorticoids - Prednisolone
4. Antibodies Muromonab, Infliximab

Glucocorticoids:
Immunosuppressant and anti-inflammatory
Treat graft rejections, myasthenia gravis, RA, SLE,

IBD

Azathioprine:
Suppresses cell mediated immunity.
It is anti inflammatory

RA
Bone marrow suppression, hepatotoxicity

Cyclophosphamide
Alkylating agent
MS, Hemolytic anemia
Nephrotoxicity and hepatotoxicity

Cyclosporine
Organ transplantation liver, kidney, bone marrow
Myasthenia gravis, RA, SLE
Nephrotoxicity, hepatotoxicity, gingival hyperplasia

Tacrolimus

Personal hygiene patients and attenders

Sterile techniques (Injection, wound dressing)
Persons with infection prevent patient
contact
Teach patient to report signs of infection like
fever
Monitor renal function, liver function, blood
counts

Enhance immune response.

Drug

Uses

BCG vaccine

Urinary bladder carcinoma

Thalidomide

Multiple myeloma

Interferons

Malignant melanoma, Hepatitis B

and C

Levamisole

Colon cancer

Vitamins are organic substances that are

needed in small quantities for meeting the
metabolic demands of the body
Mostly serve as cofactors for enzymes
involved in metabolism
Classification
1. Fat soluble A,D,E and K
2. Water soluble B-complex, C

Vitamins

Source

Role

Deficiency
symptoms

Uses

A (Retinol)

Carrot
Cabbage
Pumpkin
Mango
Orange
Papaya
Fish
Liver oil

Vision (dark
adaptation)
Bone
development
Maintain the
integrity of
epithelial cells
Cell mediated
immunity

Night blindness
Xerophthalmia

RX: 50000100000 IU PO
for 3 days

Faulty bone
modelling

PX: 4000 IU
PO/day

Produced in
skin by action of
sunlight
Fish
Liver oil

Stimulates Ca,
po4 absorption
from git, kidney
& bone

Rickets in
children
Osteomalacia in
adults

Daily req: 4000

IU

D (Calciferol)
100-200 IU

Dryness of skin
(phrynoderma)
Rx-4000 IU/day
Px-400 IU/day

Vitamins

Source

Role

Deficiency
symptoms

Uses

E (Tocopherol)
5-15 mg

Vegetable seed
oil
Nuts
Cereals
Green leaves

Antioxidant
protection
against cancer,
coronary artery
disease

Peripheral
neuropathy
Abortion
Male sterility
Degenerative
changes in
skeletal muscles

Nocturnal
muscle cramps
Fibrocystic
breast disease

K (K1
Phytonadione)
70-140 mcg

Liver
Synthesis of
Leafy
clotting factors
vegetable(spinac (II,VII,IX,X)
h, cabbage,
tomato)

Bleeding

Bleeding
associated with
vitamin k def.
Warfarin
toxicity

Vitamins

Role

Deficiency symptom & uses

B Complex Meat, milk, cereals, pulses and vegetable products except B12 (only meat, fish,
egg, milk). Occur together in food
B1 (Thiamine)
(1-2 mg)
B2 (Riboflavin)
2-3 mg

Coenzyme in various
redox reactions
involving
carbohydrate and fat
metabolism

Glossitis, stomatitis
Angular cheilitis

Pellagra (diarrhoea, dermatitis, dementia)

Use as a hypolipidaemic agent

B3 (Niacin)
15-20mg

B6 (Pyridoxine)
2 mg

Beri-beri (neuropathy, heart failure)

Require for pt on reg. hemodialysis
In alcoholics

Carbohydrate, fat,
protein metabolism

Peripheral neuritis, anemia, convulsions

With INH
With B1 and B12 treat neuropathy

Vitamins

Role

Deficiency symptom & uses

Folic acid
500-800mcg

THF(active form) DNA,

purines, pyrimidines, amino
acids synthesis

Megaloblastic anaemia
Px in pregnancy
MTX toxicity

Along with folic acid

require for DNA synthesis
(synthesized in the colon by
bacteria. Meat, liver, eggs
fish)

Megaloblastic anaemia
Peripheral neuritis
Pernicious anaemia

Formation of haemoglobin
and maturation of RBCs

Scurvy (fatigue,
Used in common
swollen spongy
cold and viral
bleeding gums, loose infection
teeth, conjunctival
and subperiosteal
hemorrhages,

B12
1mcg

C (Ascorbic
acid)
30-50 mg
Citrus fruit

Formation of collagen, bone,

teeth

Uses:
Scurvy Rx 500-1500 mg/day
Px 50-100 mg/day
To acidify urine in alkaline drug poisoning
Help in healing of wound
Use in common cold
cancer

Vitamin A avoided in pregnancy

Vitamin A,D, E, K can cause hypervitaminosis
Niacin itching, flushing on oral
administration can be prevented by aspirin

Elements essential for normal body functions

Needed in large quantities:

Calcium, sodium, potassium, magnesium,

phosphorus, chloride, sulphur

Needed in small quantities:

Iron, zinc, manganese, copper, iodine, fluoride,

cobalt

Widely distributed in ECF (130-145 mEq/L)

Daily requirement 5-10 g/day
Common salt
Lost through sweat and urine
Hyponatremia cramps, hypotension,
tachycardia. 0.9% NS or salt
supplementation
Hypernatremia CCF, renal failure. Oedema,
altered mentation, rise in BP. Loop diuretics,
salt restriction

ICF important constituent

Normal level 3.5 to 5 mEq/L
Maintenance of muscular and neuronal activity
Source - Tender coconut, banana, orange, nuts
<3mEq/L sweating, vomiting, diarrhea, DKA,
diuretics
Oral potassium salt diluted in tumbler full of
water. I.V slow
>5mEq/L NSAIDs, ACEs, renal failure, burns
10% calcium gluconate, salbutamol, insulin with
glucose

Bone and teeth

0.3 0.35 g/day
Fish, green leafy vegetables, coconut.
Actions:
i.m and i.v CNS, Cardiac depressant, Uterine

relaxant
Oral Antacid and osmotic purgative
Rectal reduce intracranial tension
Topical oedema

Hypermagnesaemia 10% Calcium

gluconate

Cofactor CA, LDH, ALK

Sources Egg, meat, cereals, fruits, nuts
Deficiency dermatitis, delayed wound healing,
alopecia, growth retardation
Zinc Oxide Astringent and antiseptic. Eczema,
haemorrhoids, skin infection
Zinc Sulphate Helps in healing of ulcers. To
treat diarrhea
Zinc Carbonate in calamine lotion. In eczema,
sunburns, skin rashes.

Sources egg, meat, fish, pulses, cereals

Daily requirement 0.8 to 1 g/day
Hypophosphataemia Chronic antacid use,
hyperparathyroidism, vit D def, DKA.
Hyperphosphataemia renal failure. Calcium
carbonate and aluminium hydroxide to
decrease absorption of phosphorus from
intestine

Monitor patient being treated for electrolyte disturbances

Oral potassium salts should be mixed with sufficient water

and then administered to prevent intestinal ulceration

I.V. KCl is administered after mixing with i.v fluids

I.V. potassium should be administered slowly and patient be

monitored

Calcium should not be administered in fluids containing

bicarbonates as it will be precipitated

Vaccines are biological products which

increase the immunity of the body. They are
antigenic materials.
Types

Constituent

Killed (Inactivated)

Micro-organisms killed by heat, chemicals

Live attenuated

Live micro-organisms rendered avirulent

Toxoid

Modified bacterial exotoxins so that toxicity

is lost but antigenicity is retained

Active immunization administration of

antigen to host in order to induce antibody
production
eg:- Vaccines

Passive immunization providing immunity to

a host passively by transfer of antibodies.
eg:- antisera, immunoglobulins(Ig)

KILLED VACCINES
CHOLERA

TYPHOID- PARATYPHOID
WHOOPING COUGH( PERTUSSIS)
MENINGOCOCCAL

HAEMOPHILUS INFLUENZAE TYPE b

PLAGUE

LIVE VACCINES
BCG
(Bacilli Calmette Guerin )
TYPHORAL- Ty 21 a

KILLED VACCINES

LIVE VACCINES

POLIOMYELITIS, INACTIVATED
(IPV, Salk)

POLIOMYELITIS, LIVE ORAL

( OPV, Sabin)

ALL RABIES VACCINES

MEASLES

INFLUENZA

RUBELLA

HEPATITIS B

VARICELLA

HEPATITIS A

TOXOIDS

TETANUS TOXOID
(FLUID/ADSORBED)
DIPTHERIA
(ADSORBED)

COMBINED VACCINES
TYPHOIDPARATYPHOIDCHOLERA (TABC)

MEASLES- MUMPS
RUBELLA (MMR)

Live attenuated vaccine

Killed vaccine

Single dose is sufficient

Repeated doses

Long lasting immunity

Short lasting immunity

More efficacious

Less efficacious

Less stable at room temp

Require proper storage

More stable at room temp

e.g. : BGC, Oral polio, MMR, chicken

pox

e.g. : typhoid, cholera, pertussis,

rabies, polio, hepatitis B

BCG (Bacilli Calmette Guerin Vaccine)

Live attenuated
Single dose i.m at upper arm at birth or within 6

weeks of age.
It may cause ulceration and lymphadenitis

Polio vaccine
Oral Polio Vaccine (Sabin): live attenuated virus
Injectable Polio Vaccine (Salk): inactivated virus

Oral polio

Injectable polio

Live attenuated

Killed virus

orally

s.c. or i.m. route

Less expensive

expensive

Require storage in freezer

Not require storage

Suitable for controlling

epidemics

Not suitable for epidemics

Diphtheria Pertussis Tetanus Toxoid Triple

Antigen
Mixed vaccine.
Vial not to be frozen
Given deep i.m at lateral aspect of thigh in infants

Redness, irritability, fever etc

Paracetamol to control fever

Measles Mumps Rubella (MMR) Vaccine

Mixed vaccine
i.m at age 15 months and 4-5 years.

Pain, swelling, redness. Irritability, fever etc.

Antisera are purified and concentrated

preparations of serum of horses actively
immunized against a specific antigen.
Cause allergic reactions.

Tetanus antitoxin (ATS)

Diphtheria antitoxin (ADS)
Gas gangrene antitoxin (AGS)
Antirabies serum (ARS)
Antisnake venom polyvalent (ASV)

Reassure
Symptomatic treatment = clean site
- PCM for pain
- tetanus toxoids
- Immobilize the limb or splinting
Monitor BP, HR, urine output and respiration
Establish IV line polyvalent anti snake venom
(20 ml/kg/hour in NS slowed later) after test dose
Inj hydrocortisone 200mg & pheniramine maleate
100 mg prior to anti snake venom

Antibiotics prophylactically
Blood transfusion and packed cell if
necessary
IV neostigmine - in cobra bite
- to reverse neuromuscular blockade

Do not administer if patient has signs of acute infection,

because vaccines exacerbate infections

History: allergy to any vaccines or immunoglobulins, recent

blood transfusion, use of immunoglobulins, rule out
pregnancy in females

Supportive care injection discomfort (local heat

application, resting arm). Flu like symptoms (rest,
paracetamol)

Patient teaching immunization card, explain warning signs

of adverse events, need for booster doses

All nurses should be immunized with hepatitis B

vaccine
Live vaccine not given in pregnant women
Storage proper and protected from sunlight
Once vaccine vials are opened used within 1 hour
Check expiry date
Adrenaline, diphenhydramine, hydrocortisone
should be kept ready before injecting the antisera
Vaccines can cause local reactions like pain,
redness, swelling and fever

BASIC LIFE SUPPORT

Call for help
Airway

Breathing
Circulation

Oxygen to correct hypoxia

Endotracheal intubation if necessary

Establish i.v line if necessary

ECG monitoring

Condition

Drug Treatment

Anaphylactic Shock Inj. Adrenaline (1:1000) 0.3 to 0.5 ml i.m

Inj. Hydrocortisone 200mg i.v
Inj. Diphenhydramine 25-50 mg i.v/i.m
Hypoglycemia

Oral glucose or fruit juice or

50ml of 50% glucose i.v

Adrenal crisis

Inj.hydrocortisone 200mg i.v

I.V normal saline with 5% glucose
Fluid and electrolyte imbalance

Acute Angina / MI

Tab. Nitroglycerine 0.5mg sublingually

Not more than 3 tablets in 15 mins
If not relieved Aspirin 300mg and refer to
cardiologist

Condition

Drug Treatment

Status
Asthmaticus

Humidified Oxygen
Salbutamol 5-10mg + ipratropium bromide
0.5mg continuous nebulization
Inj. Hydrocortisone hemisuccinate 200mg iv
stat and every 6th hourly till attack subsides
Cap.Amoxicillin 500mg PO TDS

Acute Bronchial
Asthma

Salbutamol MDI 100mcg/puff. 1 to 2 puffs stat

and as and when required (not >8 puffs/day)

Seizures

Inj. Diazepam 5 10mg i.v slowly or

Inj. Lorazepam 0.1 mg/kg i.v slowly

Condition

Drug Treatment

Severe bleeding
after dental
procedures

Pressure + Ice pack

Topical haemocoagulase or
Cotton pad soaked in 0.1% adrenalin sol or
Inj. Tranexaemic acid 500mg slow i.v

Tetany

10ml of 10% calcium gluconate slow i.v

Status
Asthmaticus

Humidified Oxygen
Salbutamol 5-10mg + ipratropium bromide
0.5mg continuous nebulization
Inj. Hydrocortisone hemisuccinate 200mg iv
stat

Scabies
Sarcoptes scabiei
Burrows along the skin and lays eggs

Webs of fingers, hands. Genitalia, trunk

All the members of family has to be treated

simultaneously

Pediculosis
They thrive on head (Pediculosis capitis)
Pubic hair (Pediculosis pubis)

Body (Pediculosis corporis)

Eggs (nits) get attached to hair

Drug
Permethrin

Formulation

Details

Cream, lotion, Most efficacious

gel
Scabies: 5% - applied neck to toe, hot water
bath after 12hrs to wash off drug
Pediculosis: 1% - applied on scalp and pubis
and washed after 10min
Repeated after 1 week
Skin rashes, redness, itching, burning

Drug

Formulation

Details

Gamma
Benzene
Hexachloride
(Lindane)

Emulsion,
Scabies: 1%
lotion, cream, Pediculosis: 1%
ointment,
soap
Contraindicated in children, pregnant,
epileptics

Benzyl
Benzoate

Emulsion,
lotion (25%)

Crotamiton

Lotion, Cream Less efficacious. Antipruritic activity also

Applied after scrub bath. Repeated after 24 hrs.
(10%)
Used in children

Applied twice in a gap of 12 hrs. Scrub bath 12

hrs after second application.

Drug

Formulation

Details

Sulphur

10%
ointment

Bad odour. Rarely used

Less efficacy

DDT
(Dicophane)

Ointment,
lotion (1-2%)

Applied twice in a gap of 12 hrs. Scrub bath 12

hrs after second application.

Ivermectin

Tablet(0.2
mg/kg)

Single dose.
Contraindicated in children, pregnant and
lactating women

Key points
All contacts should be treated
Drugs avoid contact with eyes and mouth

Enzymes proteins secreted by living cells, which

are capable of causing or accelerating biochemical
reactions
Can cause allergic reaction
e.g. hyaluronidase
chymotrypsin
serratiopeptidase
urokinase
t-PA
L- asparaginase

Enzyme

Sources

Availability & Actions

route

Hyaluronidase Mammalia Topical, sc,

n testes
im,
intraarticular
Vial
1500U/mL

Uses

Depolymerize promote the

absorption of
s hyaluronic
drugs &
acid &
fluids
increases the
resorption of
permiability of
extravasated
the tissue
fluid or blood
in hematoma
or edema
diffusion of
local
anaesthetic
in
opthalmolog
y

Enzymes

Sources

Availability & Actions

route

Uses

Chymotrypsin

Ox pancreas

Tablet and
topical

reduces post
operative
oedema

chymotrypsin

Ox pancreas

Injectable and Mucolytic and During

tablet
proteolytic
cataract
activity
surgery to
facilitate
removal of
lens

Proteolytic
enzyme

Serratiopeptid Serratia
ase
species

Tablet

AntiTo relieve
inflammatory pain and
activity
inflammation

Urokinase

IV

Fibrinolytic

Human fetal
kidney cell
culture

Acute MI,
DVT, PE

Enzymes

Sources

Availability
& route
Tissue
Recombina i.v.
Plasminogen nt DNA
Activator
technology

Actions

Uses

Fibrinolytic
(dissolves
clot)

Ac. MI, DVT,

PE

LE. coli
Asparaginase

Asparine
Aspartic
acid

ALL

i.V

Ayurveda
Ayu life and veda science
Vata

Pitta
Kapha
Aims to treat person as a whole and prevent

disease

Homeopathy
Samuel Hahnemann

Minute doses of drug which in large doses

produce same symptoms of disease in healthy

individuals
Dilute drug stimulates immunity

Siddha
Tamil Nadu
Basic concept resembles Ayurveda

Unani
Four humors: Blood, phlegm, yellow bile, black

bile.
Drugs restore humoral balance to retain health