TRISULPHUNOR

Indications

• Fluid and electrolyte imbalances
• Hypoglycemia
• Nutritional supplementation
• Diabetic emergencies

Dosage

Children: Refer to the BNF for Children for appropriate paediatric dosing guidelines.

Adults: The dosage varies based on the clinical condition and specific formulation used. For intravenous administration, consult product literature for precise dosing.

Mechanism of action

Glucose supplies energy to tissues by undergoing glycolysis, which begins with its phosphorylation by hexokinase to form glucose 6-phosphate. This activates glucose for breakdown, ultimately generating ATP and NADH. The aerobic metabolism of glucose can yield up to 36 ATP molecules. Glucose also serves as a precursor for other biomolecules and regulates various physiological processes including gene transcription and hormone secretion.

Pharmacodynamics

Glucose is an obligatory energy source for cellular activities and plays a significant role in metabolic signaling. It is oxidized to yield energy through glycolysis, the citric acid cycle, and oxidative phosphorylation. Glucose can be converted into fat for energy storage and is stored as glycogen in the liver and muscles. Its administration increases blood glucose levels and stimulates insulin secretion, particularly through oral routes that activate gut incretin hormones.

Pharmacokinetics

Glucose is rapidly absorbed from the gastrointestinal tract or directly into the bloodstream when administered intravenously. It is distributed widely throughout the body and metabolized primarily in tissues requiring energy. The body maintains glucose homeostasis through regulatory mechanisms involving insulin and glucagon. Excess glucose can be stored as glycogen or converted to triglycerides for long-term energy storage.

Adverse effects

• Hyperglycemia
• Increased osmolarity
• Fluid overload
• Electrolyte imbalances

Interactions

• Insulin - may require dose adjustments

Precautions

• Use with caution in patients with diabetes mellitus
• Monitor blood glucose levels in patients receiving parenteral glucose
• Adjust dosage in renal impairment

Pregnancy

Glucose is generally considered safe in pregnancy; however, monitoring is advised, especially in diabetic patients.

Breast-feeding

Glucose is considered safe during breastfeeding, as it is a natural sugar found in breast milk.

Storage

Store at room temperature, away from light. Avoid freezing.

Formulations

• Glucose 5% solution for infusion
• Glucose 10% solution for infusion
• Glucose 0.9% solution for injection
• Glucose sodium chloride combination solutions

Indications

• Bacterial infections
• Toxoplasmosis in pregnancy (in combination with pyrimethamine and folinic acid)
• Congenital toxoplasmosis (in combination with pyrimethamine and folinic acid)

Dosage

Children: For children aged 12–17 years, the recommended dose is 1 g three times a day until delivery for toxoplasmosis in pregnancy. For other specific conditions, refer to the BNF for Children for detailed dosing guidelines.

Adults: For adults, the typical dosing for bacterial infections can vary, and it is essential to refer to the BNF for specific recommendations based on the condition being treated. Generally, dosage adjustments may be necessary in renal impairment.

Mechanism of action

Sulfadiazine acts as a competitive inhibitor of the bacterial enzyme dihydropteroate synthetase, blocking the conversion of para-aminobenzoic acid (PABA) to folic acid. This inhibition is crucial for bacterial growth and reproduction, as folic acid is vital for nucleic acid synthesis.

Pharmacodynamics

Sulfadiazine is a synthetic bacteriostatic antibiotic effective against many gram-positive and some gram-negative organisms. It inhibits bacterial multiplication by interfering with folic acid metabolism. Resistance to sulfadiazine usually implies resistance to all sulfonamides, as they share similar mechanisms of action.

Pharmacokinetics

Sulfadiazine is well absorbed when administered orally, with high tissue distribution. It achieves significant concentrations in various bodily fluids, including pleural and synovial fluids. While it is effective, its absorption can be affected by the presence of pus, which can inhibit its antibacterial action. Renal function can influence its clearance, necessitating dose adjustments in cases of impaired renal function.

Contra-indications

• Acute porphyrias

Adverse effects

• Agranulocytosis
• Aplastic anaemia
• Haemolytic anaemia
• Decreased appetite
• Ataxia
• Back pain
• Blood disorders
• Cough
• Crystaluria
• Cyanosis
• Depression
• Diarrhoea
• Dizziness
• Drowsiness
• Dyspnoea
• Eosinophilia
• Erythema nodosum
• Fatigue
• Fever
• Haematuria
• Hallucination
• Headache
• Hepatic disorders
• Hypoglycaemia
• Neutropenia
• Oral disorders
• Pancreatitis
• Photosensitivity reaction
• Skin reactions
• Thrombocytopenia
• Tinnitus
• Vertigo
• Vomiting

Interactions

• Sulfadiazine + antiepileptics: Moderate (increases concentration)
• Sulfadiazine + fosphenytoin: Moderate (increases concentration)
• Sulfadiazine + phenytoin: Moderate (increases concentration)

Precautions

• Caution in asthma
• Caution in blood disorders
• Caution in elderly patients
• Monitor blood counts on prolonged treatment
• Plasma concentration monitoring may be required in moderate to severe renal impairment

Pregnancy

Risk of neonatal haemolysis and methaemoglobinaemia in the third trimester; fear of increased risk of kernicterus in neonates appears to be unfounded.

Breast-feeding

Small risk of kernicterus in jaundiced infants and of haemolysis in G6PD-deficient infants.

Storage

Store in a cool, dry place away from light.

Formulations

• Solution for infusion
• Oral suspension

Indications

• Severe infections caused by gram-negative bacteria
• Complicated urinary tract infections
• Bacterial sepsis
• Endocarditis caused by susceptible organisms

Dosage

Children: Dosing in children is also weight-based and varies by indication. Refer to the BNF for Children for specific dosing recommendations.

Adults: Dosage varies significantly based on the infection severity and type, renal function, and the specific bacterial susceptibility. Refer to clinical guidelines or the BNF for precise dosing.

Mechanism of action

Gram works by inhibiting bacterial protein synthesis. It binds to the 30S ribosomal subunit of the bacteria, causing misreading of the mRNA and ultimately preventing the synthesis of essential proteins necessary for bacterial growth and replication.

Pharmacodynamics

The pharmacodynamics of Gram include its bactericidal activity against susceptible bacteria. The drug shows concentration-dependent killing, meaning that higher drug concentrations correlate with greater bactericidal effects. The post-antibiotic effect is noted, where bacterial growth is inhibited even after the drug concentration falls below the minimum inhibitory concentration (MIC).

Pharmacokinetics

Gram is usually administered parenterally (intravenously or intramuscularly), and its absorption can vary based on the route of administration. It is distributed widely in body fluids and tissues, although it does not penetrate well into the central nervous system. The drug is primarily eliminated through the kidneys, and its half-life may be prolonged in patients with renal impairment. Monitoring of drug levels may be necessary to avoid toxicity.

Adverse effects

• Nausea
• Vomiting
• Diarrhea
• Abdominal pain
• Allergic reactions
• Rash
• Renal dysfunction

Precautions

• Use with caution in patients with renal impairment
• Monitor renal function during therapy
• Assess for potential allergic reactions

Pregnancy

Use only if the potential benefit justifies the potential risk to the fetus. Consult with a healthcare provider.

Breast-feeding

Use with caution, as it may be excreted in breast milk. Consult with a healthcare provider.

Storage

Store in a cool, dry place away from direct sunlight. Keep out of reach of children.

Indications

• Bacterial infections
• Urinary tract infections
• Respiratory tract infections
• Gastrointestinal infections
• Skin and soft tissue infections

Dosage

Children: Refer to BNF for Children for specific paediatric dosing recommendations.

Adults: Refer to BNF for specific adult dosing recommendations.

Mechanism of action

Sulfadimidine inhibits the enzymatic conversion of pteridine and p-aminobenzoic acid (PABA) to dihydropteroic acid by competing with PABA for binding to dihydrofolate synthetase. This inhibition affects the synthesis of tetrahydrofolic acid (THF), which is vital for the production of purines and deoxythymidine monophosphate (dTMP), leading to reduced bacterial growth.

Pharmacodynamics

Sulfadimidine is classified as a bacteriostatic agent, which means it inhibits the growth of bacteria rather than killing them outright. By obstructing the synthesis of dihydrofolic acid, sulfadimidine decreases the availability of nucleotides necessary for DNA synthesis, ultimately leading to a reduction in bacterial proliferation.

Pharmacokinetics

Sulfadimidine is absorbed well from the gastrointestinal tract, and its bioavailability is influenced by factors such as pH and the presence of food. The drug is distributed widely throughout body tissues and fluids, including the central nervous system. It undergoes hepatic metabolism and is primarily excreted unchanged in the urine, with a half-life that can vary based on the individual's renal function.

Contra-indications

• Hypersensitivity to sulfonamides
• Severe liver or kidney impairment
• Porphyria

Adverse effects

• Rash
• Nausea
• Vomiting
• Diarrhea
• Hematological reactions such as agranulocytosis or aplastic anemia
• Hypersensitivity reactions including Stevens-Johnson syndrome
• Renal impairment

Interactions

• May enhance the effects of anticoagulants such as warfarin
• May interact with oral hypoglycemic agents
• Interactions with other drugs that affect renal function

Precautions

• Use with caution in patients with renal or hepatic impairment
• Monitor for signs of blood dyscrasias
• Ensure adequate hydration to avoid crystalluria

Pregnancy

Not recommended during pregnancy, especially in the third trimester due to the risk of kernicterus in the newborn.

Breast-feeding

Use with caution, as it may be excreted in breast milk and could affect the nursing infant.

Storage

Store in a cool, dry place, away from light. Keep out of reach of children.

Formulations

• Tablets
• Oral suspension

Indications

• Bacterial infections in veterinary medicine
• Coccidiosis in poultry
• Treatment of certain protozoal infections

Dosage

Children: Refer to the relevant prescribing information for specific dosing guidelines as per clinical condition.

Adults: Refer to the relevant prescribing information for specific dosing guidelines as per clinical condition.

Mechanism of action

Sulfaquinoxaline acts as a competitive antagonist of para-aminobenzoic acid (PABA), a key substrate in the bacterial synthesis of folic acid. By inhibiting the enzyme dihydropteroate synthase, sulfaquinoxaline prevents the incorporation of PABA into dihydropteroic acid, which is the precursor of folic acid. This inhibition disrupts the formation of folic acid necessary for DNA synthesis, thus hindering bacterial cell multiplication. Mammalian cells, which utilize preformed folic acid, are not affected by this mechanism.

Pharmacodynamics

The pharmacodynamics of sulfaquinoxaline are characterized by its ability to inhibit bacterial growth through the blockade of folic acid synthesis. It demonstrates a bacteriostatic effect, meaning it stops bacteria from multiplying rather than killing them directly. The efficacy of sulfaquinoxaline depends on the susceptibility of the bacteria involved and is influenced by the presence of PABA in the environment, which can compete with the drug.

Pharmacokinetics

Sulfaquinoxaline is well absorbed from the gastrointestinal tract and achieves therapeutic levels in the serum. It has a distribution that allows it to penetrate tissues and body fluids. The drug is metabolized in the liver and excreted primarily through the kidneys. The pharmacokinetic profile can be influenced by factors such as the presence of other substances that may compete for absorption or metabolism.

Contra-indications

• Hypersensitivity to sulfonamides
• Severe hepatic or renal impairment
• Porphyria

Adverse effects

• Allergic reactions including rash, itching, and fever
• Gastrointestinal disturbances such as nausea and vomiting
• Hematological effects including leukopenia, thrombocytopenia, and aplastic anemia
• Kernicterus in newborns
• Crystalluria

Interactions

• May enhance the effects of anticoagulants such as warfarin
• Potentially decreases the effectiveness of oral contraceptives
• Can increase the toxicity of methotrexate
• May interact with other drugs that affect renal function

Precautions

• Use with caution in patients with renal impairment
• Monitor for signs of blood dyscrasias
• Adequate hydration is important to prevent crystalluria
• Caution in patients with a history of asthma or allergic reactions

Pregnancy

Use during pregnancy only if clearly needed, as sulfonamides can cross the placenta and may cause harm to the fetus.

Breast-feeding

Breastfeeding is not recommended while taking sulfaquinoxaline due to potential adverse effects on the infant.

Storage

Store at room temperature, away from moisture and heat.

Formulations

• Tablets
• Suspensions
• Injectable forms

Indications

• Vitamin deficiency syndromes (e.g., scurvy for vitamin C deficiency, rickets for vitamin D deficiency)
• Support for immune function
• Antioxidant support
• Bone health maintenance
• Vision health
• Energy metabolism support

Dosage

Children: Refer to the BNF for Children for specific vitamin dosing guidelines, which depend on age and nutritional requirements.

Adults: Refer to specific vitamin guidelines as dosage varies significantly depending on the type of vitamin and individual needs.

Mechanism of action

Vitamins function primarily as coenzymes or precursors for coenzymes in enzymatic reactions. For instance, B vitamins are involved in energy metabolism, while vitamins A, C, D, E, and K support various physiological functions including vision, antioxidant activity, calcium regulation, and blood clotting. Each vitamin has a unique mechanism of action based on its structure and role in the body.

Pharmacodynamics

Vitamins exert their effects at the cellular level, influencing metabolic pathways, gene expression, and immune responses. For example, vitamin D regulates calcium and phosphate homeostasis, while vitamin A is crucial for vision and immune function. Deficiencies in vitamins can lead to a range of disorders, highlighting their importance in maintaining health.

Pharmacokinetics

The pharmacokinetics of vitamins vary widely. Fat-soluble vitamins (A, D, E, and K) are stored in liver and adipose tissues and can be released into circulation as needed. Water-soluble vitamins (B-complex and C) are not stored and must be consumed regularly, with excess amounts excreted in urine. Absorption rates, half-lives, and distribution can also differ based on the specific vitamin and individual metabolic factors.

Interactions

• tretinoin+vitamin: Severe (increases risk of vitamin toxicity)
• retinoids+vitamin: Severe (increases risk of vitamin toxicity)
• retinoids+vitamin: Moderate (increases risk of toxicity)
• carbamazepine+vitamin: Unknown (decreases effects)
• cobicistat+vitamin: Unknown (increases exposure)
• vitamin D substances+digoxin: Unknown (increases risk of toxicity)
• idelalisib+vitamin: Unknown (increases exposure)
• clarithromycin+vitamin: Unknown (increases exposure)

Pregnancy

Consult healthcare professional before use. Vitamin supplementation during pregnancy should be carefully managed to avoid hypervitaminosis.

Breast-feeding

Consult healthcare professional before use. Some vitamins can pass into breast milk and may affect the infant.

Storage

Store in a cool, dry place, away from direct sunlight. Ensure it is kept out of reach of children.

Formulations

• {'name': 'Vitamin A', 'form': 'Capsule', 'strength': '10000 IU'}
• {'name': 'Vitamin D', 'form': 'Tablet', 'strength': '1000 IU'}
• {'name': 'Vitamin E', 'form': 'Softgel', 'strength': '400 IU'}

Mechanism of action

Glucose supplies most of the energy to all tissues by generating energy molecules ATP and NADH during a series of metabolism reactions called glycolysis. Glycolysis can be divided into two main phases where the preparatory phase is initiated by the phosphorylation of glucose by hexokinase to form glucose 6-phosphate. The addition of the high-energy phosphate group activates glucose for the subsequent breakdown in later steps of glycolysis and is the rate-limiting step. Products end up as substrates for following reactions, to ultimately convert C6 glucose molecule into two C3 sugar molecules. These products enter the energy-releasing phase where the total of 4ATP and 2NADH molecules are generated per one glucose molecule. The total aerobic metabolism of glucose can produce up to 36 ATP molecules. These energy-producing reactions of glucose are limited to D-glucose as L-glucose cannot be phosphorylated by hexokinase. Glucose can act as precursors to generate other biomolecules such as vitamin C. It plays a role as a signaling molecule to control glucose and energy homeostasis. Glucose can regulate gene transcription, enzyme activity, hormone secretion, and the activity of glucoregulatory neurons. The types, number, and kinetics of glucose transporters expressed depends on the tissues and fine-tunes glucose uptake, metabolism, and signal generation to preserve cellular and whole body metabolic integrity. Vascular calcification is a hallmark of type 2 diabetes. Glucose stimulates calcification in culture of vascular smooth muscle cells (VSMCs) but the underlying mechanisms remain obscure. We observed that high glucose levels stimulated mouse and human VSMC trans-differentiation into chondrocytes, with increased levels of Sox9, type II collagen, glycosaminoglycan and Runx2 expression, and increased alkaline phosphatase activity and mineralization. These effects were associated with increased expression of IL-1beta, which stimulated alkaline phosphatase and calcification, suggesting that glucose induces chondrocyte differentiation of VSMCs, possibly through IL-1beta activation.

Pharmacodynamics

Blood glucose is an obligatory energy source for humans involved in various cellular activities, and it also acts as a signaling molecule for diverse glucose-sensing molecules and proteins. Glucose undergoes oxidation into carbon dioxide, water, and yields energy molecules in the process of glycolysis and subsequent citric cycle and oxidative phosphorylation. Glucose is readily converted into fat in the body which can be used as a source of energy as required. Under a similar conversion into storage of energy, glucose is stored in the liver and muscles as glycogen. Glucose stores are mobilized in a regulated manner, depending on the tissues' metabolic demands. Oral glucose tablets or injections serve to increase the supply of glucose and oral glucose administration is more effective in stimulating insulin secretion because it stimulates the incretin hormones from the gut, which promotes insulin secretion.

Mechanism of action

Sulfadiazine is a competitive inhibitor of the bacterial enzyme dihydropteroate synthetase. This enzyme is needed for the proper processing of para-aminobenzoic acid (PABA) which is essential for folic acid synthesis. The inhibited reaction is necessary in these organisms for the synthesis of folic acid.

Pharmacodynamics

Sulfadiazine is a sulfonamide antibiotic. The sulfonamides are synthetic bacteriostatic antibiotics with a wide spectrum against most gram-positive and many gram-negative organisms. However, many strains of an individual species may be resistant. Sulfonamides inhibit multiplication of bacteria by acting as competitive inhibitors of <i>p</i>-aminobenzoic acid in the folic acid metabolism cycle. Bacterial sensitivity is the same for the various sulfonamides, and resistance to one sulfonamide indicates resistance to all. Most sulfonamides are readily absorbed orally. However, parenteral administration is difficult, since the soluble sulfonamide salts are highly alkaline and irritating to the tissues. The sulfonamides are widely distributed throughout all tissues. High levels are achieved in pleural, peritoneal, synovial, and ocular fluids. Although these drugs are no longer used to treat meningitis, CSF levels are high in meningeal infections. Their antibacterial action is inhibited by pus.

Mechanism of action

Sulfonamides inhibit the enzymatic conversion of pteridine and p-aminobenzoic acid (PABA) to dihydropteroic acid by competing with PABA for binding to dihydrofolate synthetase, an intermediate of tetrahydrofolic acid (THF) synthesis. THF is required for the synthesis of purines and dTMP and inhibition of its synthesis inhibits bacterial growth. Pyrimethamine and trimethoprim inhibit dihydrofolate reductase, another step in THF synthesis, and therefore act synergistically with the sulfonamides.

Pharmacodynamics

Sulfamethazine is a sulfonamide drug that inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid (PABA) for binding to dihydropteroate synthetase (dihydrofolate synthetase). Sulfamethazine is bacteriostatic in nature. Inhibition of dihydrofolic acid synthesis decreases the synthesis of bacterial nucleotides and DNA.

Mechanism of action

Bacteriostatic. Sulfonamides interfere with the biosynthesis of folic acid in bacterial cells; they compete with paraaminobenzoic acid (PABA) for incorporation in the folic acid molecule. By replacing the PABA molecule and preventing the folic acid formation required for DNA synthesis, the sulfonamides prevent multiplication of the bacterial cell. Susceptible organisms must synthesize their own folic acid; mammalian cells use preformed folic acid and, therefore, are not susceptible. Cells that produce excess PABA or environments with PABA, such as necrotic tissues, allow for resistance by competition with the sulfonamide. /Sulfonamides/ Sulfonamides are structural analogs and competitive antagonists of para-aminobenzoic acid (PABA) and thus prevent normal bacterial utilization of PABA for the synthesis of folic acid (pteroylglutamic acid). More specifically, sulfonamides are competitive inhibitors of dihydropteroate synthase,the bacterial enzyme responsible for the incorporation of PABA into dihydropteroic acid, the immediate precursor of folic acid. Sensitive microorganisms are those that must synthesize their own folic acid; bacteria that can utilize preformed folate are not affected. Bacteriostasis induced by sulfonamides is counteracted by PABA competitively. Sulfonamides do not affect mammalian cells by this mechanism, since they require preformed folic acid and cannot synthesize it. /Sulfonamides/