, in
Clinical
Pharmacology,
Therapeutics
and Prescribing
in
Clinical
Pharmacology,
Therapeutics
and Prescribing
, Kerry Layne MBBS, BSc (Hons), PhD, MRCP
Specialist Registrar in Clinical Pharmacology
and Therapeutics/General Medicine, Guy’s and St Thomas’ NHS
Foundation Trust, London, UK
Albert Ferro PhD, FRCP, FBPhS, FBIHS, FESC
Professor of Cardiovascular Clinical Pharmacology, King’s
College London, and Honorary Consultant Physician, Guy’s
and St Thomas’ NHS Foundation Trust, London, UK
100 Cases Series Editor:
Janice Rymer MBBS, FRACP
Professor of Obstetrics & Gynaecology and Dean of Student Affairs,
King’s College London School of Medicine, London, UK
CRC Press
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CONTENTS
Preface ix
Authors xi
Abbreviations xiii
Reference Ranges for Common Investigations xv
Section 1: Basic Principles
Case 1: The Cytochrome P450 System 3
Case 2: Therapeutic Levels 7
Case 3: Renal Excretion 9
Case 4: Drug Interactions 11
Case 5: Monoclonal Antibody Therapy 13
Case 6: Ligand-Gated Ion Channels 15
Case 7: Acetylation 19
Case 8: Metabolism 21
Case 9: Distribution 23
Case 10: Absorption 27
Case 11: Renin-Angiotensin-Aldosterone Axis 29
Case 12: COX Inhibition 33
Case 13: 5-HT Receptors 37
Case 14: Dose-Response Curves 41
Case 15: G-Protein-Coupled Receptors 43
Section 2: Therapeutics
Case 16: Toxicology 49
Case 17: Ecstasy 51
,Case 18: Managing Nausea and Vomiting 53
Case 19: Managing Pain 55
Case 20: Managing Delirium 57
Case 21: Acetylcysteine 59
Case 22: End of Life Care 63
Case 23: De-Prescribing 65
Case 24: Anti-Epileptics in Pregnancy 67
Case 25: Treating Macrocytic Anaemias 69
Section 3: Prescribing Cases
Case 26: Prescribing 1 73
Case 27: Adverse Drug Reactions 1 75
Contents
Case 28: Prescribing 2 77
Case 29: Prescribing 3 81
Case 30: Planning Management 1 83
Case 31: Calculation Skills 1 85
Case 32: Adverse Drug Reactions 2 87
Case 33: Prescribing 4 89
Case 34: Prescribing 5 91
Case 35: Planning Management 2 93
Case 36: Prescribing 6 95
Case 37: Calculation Skills 2 97
Case 38: Prescribing 7 99
Case 39: Prescribing 8 101
Case 40: Prescribing 9 104
Case 41: Prescription Review 1 107
Case 42: Prescribing 10 109
Case 43: Planning Management 3 111
Case 44: Prescription Review 2 113
Case 45: Planning Management 4 115
Case 46: Planning Management 5 117
Case 47: Providing Information 1 119
Case 48: Calculation Skills 3 121
Case 49: Calculation Skills 4 123
Case 50: Adverse Drug Reactions 3 125
Case 51: Data Interpretation 1 127
Case 52: Planning Management 6 129
Case 53: Drug Monitoring 1 131
Case 54: Prescribing 11 133
, Case 55: Prescription Review 3 135
Case 56: Prescription Review 4 137
Case 57: Planning Management 7 139
Case 58: Drug Monitoring 2 141
Case 59: Data Interpretation 2 143
Case 60: Planning Management 8 145
Case 61: Calculation Skills 5 147
Case 62: Providing Information 2 149
Case 63: Prescribing 12 151
Case 64: Prescription Review 5 153
Case 65: Prescribing 13 155
Case 66: Drug Monitoring 3 157
Case 67: Data Interpretation 3 159
vi
Contents
Case 68: Adverse Drug Reactions 4 161
Case 69: Calculation Skills 6 163
Case 70: Providing Information 3 165
Case 71: Prescription Review 6 167
Case 72: Drug Monitoring 4 169
Case 73: Drug Monitoring 5 171
Case 74: Data Interpretation 4 173
Case 75: Adverse Drug Reactions 5 175
Case 76: Prescribing 14 177
Case 77: Providing Information 4 179
Case 78: Prescription Review 7 181
Case 79: Prescribing 15 184
Case 80: Drug Monitoring 6 187
Case 81: Data Interpretation 5 189
Case 82: Adverse Drug Reactions 6 191
Case 83: Calculation Skills 7 193
Case 84: Providing Information 5 195
Case 85: Prescribing 16 197
Case 86: Drug Monitoring 7 199
Case 87: Data Interpretation 6 201
Case 88: Planning Management 9 203
Case 89: Calculation Skills 8 205
Case 90: Planning Management 10 207
Case 91: Prescribing 17 209
,Case 92: Data Interpretation 7 211
Case 93: Adverse Drug Reactions 7 213
Case 94: Providing Information 6 215
Case 95: Providing Information 7 217
Case 96: Drug Monitoring 8 219
Case 97: Prescription Review 8 221
Case 98: Adverse Drug Reactions 8 223
Case 99: Planning Management 11 225
Case 100: Prescription Review 9 227
Index 229
Clinical pharmacology is the study of drug use in humans. It is closely linked to thera- peutics,
which is the study of how diseases are treated. A good understanding of both sub- jects is
essential for safe and effective prescribing, either by doctors or by the more recent (and rapidly
increasing) generation of non-medical prescribers.
Drugs of one sort or another have been used by physicians since very ancient times, but not
always on the basis of sound science. The first known writings of the use of medicines date
back 4000 years or so, to the ancient Egyptians, who used a mixture of minerals and plant-
derived concoctions and magic spells to treat disease. Independently, the ancient Indians and
Chinese developed their own methods of using of plant- and herb-derived extracts for treating
ailments of different kinds, with somewhat variable (and usually not well documented) results.
None of these systems for the use of therapeutic substances, collectively often termed ‘materia
medica’, were based on an understanding of the underlying basis of disease (pathology) or of
the modes of action of these substances (pharmacology).
In more recent times, our understanding of both pathology and pharmacology, coupled with the
use of rigorous clinical trials for the testing of new medicines, has meant that we have a vast
and ever-expanding armamentarium of effective medicines available for the treatment of
diseases, and for the clinician who is treating patients it is important to understand how they
work and why they might often give rise to unwanted side effects.
This is why we have put together this book. Our aim is to give the reader a good understand-
ing of the principles of effective and safe use of medicines in the clinic. We also wish to illus-
,trate how the non-clinical use of pharmacologically active substances, or ‘recreational drugs’,
can present to the clinician.
The most useful way to transmit such knowledge is by the use of real cases, and we hope that
the 100 cases we present here will serve this purpose. The first 15 cases cover some important
basic principles of clinical pharmacology. The next 75 cases are based on the types of ques-
tions that appear in the Prescribing Safety Assessment exam, and will form a good prepa- ration
for candidates sitting this exam. The final 10 cases cover other clinically important therapeutic
scenarios.
We hope that the reader will find these cases both instructive and interesting.
Kerry Layne and Albert Ferro
Albert Ferro studied Medicine at King’s College London (1978–1984), obtaining a First Class
Honours intercalated BSc degree in Biochemistry in 1981 along the way. After qualifying, and
following training as a junior doctor in medicine, he completed his PhD in Clinical
Pharmacology at Cambridge University. He has been a consultant physician and hyperten- sion
specialist at Guy’s and St Thomas’ Hospitals in London since 1996, and was appointed
professor of Clinical Pharmacology at King’s College London in 2009. He has published over
150 papers in peer-reviewed journals.
Professor Ferro is ex-vice-president of the British Pharmacological Society (Clinical Section),
and previously chaired the Royal College of Physicians Joint Specialty Committee on Clinical
Pharmacology & Therapeutics. He served as chair of the London Cardiovascular Society
between 2005 and 2009, of which he remains a committee member. He is a fellow of a num-
ber of professional societies, including the British Pharmacological Society, British & Irish
Hypertension Society, European Society of Cardiology and the Association of Physicians of
Great Britain and Ireland. He is editor-in-chief of JRSM Cardiovascular Disease and also
serves on the editorial boards of several other medical and cardiovascular scientific journals.
He currently also chairs the MRCP(UK) Part 1 Board.
Kerry Layne studied medicine at King’s College London (2002–2008) and also obtained a
First Class Honours intercalated BSc degree in Pharmacology in 2005. She began her junior
doctor training at Guy’s and St Thomas’ NHS Foundation Trust and subsequently spe- cialised
in ‘General Internal Medicine’ and ‘Clinical Pharmacology and Therapeutics’. She undertook
a PhD in Cardiovascular Medicine during this time. She has recently completed her training
,and is due to commence a consultant post.
ABG arterial blood gas
ACE angiotensin converting enzyme
ADP adenosine diphosphate
ALP alkaline phosphatase
ALT alanine aminotransferase
ARB angiotensin II type 1 receptor blocker
ATP adenosine triphosphate
BD twice daily
Bili bilirubin
BP blood pressure
Creat creatinine
CRP C-reactive protein
CT computed tomography
DKA diabetic ketoacidosis
ECG electrocardiogram
GGT gamma glutamyl transferase
GTN glyceryl trinitrate
Hb haemoglobin
HbA1c glycated haemoglobin
HCG human chorionic gonadotropin
HDL high-density lipoprotein
HIV human immunodeficiency virus
HR heart rate
JVP jugular venous pressure
K potassium
LDL low-density lipoprotein
LMWH low molecular weight heparin
Na sodium
NIV non-invasive ventilation
NSAID non-steroidal anti-inflammatory drug
NT pro-BNP N-terminal pro-hormone brain natriuretic protein
OD once daily
Plt platelet count
, QDS four times daily
RR respiratory rate
SBP systolic blood pressure
SpO2 peripheral capillary oxygen saturations
TDS three times daily
VBG venous blood gas
VTE venous thromboembolism
WCC white cell count
REFERENCE RANGES FOR COMMON
INVESTIGATIONS
Reference range Units
Full blood count
White cell count 4.0–11.0 ×109/L
Neutrophil count 2.0–7.0 ×109/L
Lymphocyte count 1.0–4.0 ×109/L
Eosinophil count 0.1–0.4 ×109/L
Haemoglobin level 120–160 g/L
Platelet count 150–400 ×109/L
Mean corpuscular volume 80–100 fL
Renal profile
Sodium 135–145 mmol/L
Potassium 3.5–5.0 mmol/L
Urea 2.5–7.8 mmol/L
Creatinine 60–100 μmol/L
Liver function tests
Bilirubin 05–21 μmol/L
Alanine aminotransferase 05–40 IU/L
Alkaline phosphatase 30–130 IU/L
Gamma glutamyl transferase 7–40 IU/L
