A GUIDE FOR PEOPLE WITH PORPHYRIA - Retina · Web viewA GUIDE FOR PEOPLE WITH PORPHYRIA...

A GUIDE FOR PEOPLE WITH PORPHYRIA

http://www.uq.edu.au/porphyria/PORGUIDE3.htm

Thursday, 10 October 2002

http://www.uq.edu.au/porphyria/PORGUIDE3.htm

This page left intentionally blank

Index

WHAT IS PORPHYRIA ?....................................................................................................................... 1ACUTE INTERMITTENT PORPHYRIA (AIP):....................................................................................2VARIEGATE PORPHYRIA (VP) and HEREDITARY COPROPORPHYRIA (HC):..............................3PLUMBOPORPHYRIA (PP):...............................................................................................................3PORPHYRIA CUTANEA TARDA (PCT):............................................................................................3ERYTHROPOIETIC PROTOPORPHYRIA (EPP):..............................................................................3CONGENITAL PORPHYRIA (CP)......................................................................................................3

THE ACUTE ATTACK............................................................................................................................ 4What is an acute attack?:.................................................................................................................... 4What may bring on an acute attack:?..................................................................................................4What can I do to avoid developing an acute attack?:..........................................................................4THE SKIN IN PORPHYRIA................................................................................................................. 5

Skin care:........................................................................................................................................ 5WHAT ELSE CAN BE DONE FOR PORPHYRIA?.................................................................................6WHAT ABOUT MY CHILDREN?............................................................................................................6THE PORPHYRIAS:............................................................................................................................... 7

A MEDICAL GUIDE............................................................................................................................ 7Features of the Acute Attack...........................................................................................................7Precipitating Factors........................................................................................................................ 8The Drug Lists................................................................................................................................. 8

EVALUATION OF DRUGS FOR PORPHYRIC PATIENTS....................................................................9Drug List........................................................................................................................................... 101. GASTROINTESTINAL SYSTEM..................................................................................................102. CARDIOVASCULAR SYSTEM.....................................................................................................10

Diuretics........................................................................................................................................ 10Anti-hypertensive Agents..............................................................................................................11Calcium Channel Blockers............................................................................................................11Anticoagulants............................................................................................................................... 11

3. RESPIRATORY SYSTEM:............................................................................................................12Antihistamines............................................................................................................................... 12

4. CENTRAL NERVOUS SYSTEM:..................................................................................................13Hypnotics, Sedatives and Anxiolytics:...........................................................................................13Tranquillisers:Anti-Emetics:...........................................................................................................13Psychoanaleptics:......................................................................................................................... 14Anticonvulsants:............................................................................................................................ 14Analgesics: NON-NARCOTIC:......................................................................................................14Analgesics: NARCOTICS:.............................................................................................................15Migraine:....................................................................................................................................... 15Appetite Suppressants:.................................................................................................................15

5. INFECTION:.................................................................................................................................. 166. ENDOCRINE SYSTEM:................................................................................................................16

Hormone Preparations:.................................................................................................................16Anti-Diabetic Agents:.....................................................................................................................17

7. OBSTETRICS, GYNAECOLOGY AND RENAL DISEASE:..........................................................178. MALIGNANT DISEASE: and IMMUNOSUPPRESSION:..............................................................179. NUTRITION AND BLOOD:...........................................................................................................1710. MUSCULO-SKELETAL and JOINT DISEASE:...........................................................................18

(a) Non-Steroidal Anti-Inflammatory Agents:.................................................................................18(b) Corticosteroids:........................................................................................................................18(c) Specific Anti-Rheumatic Agents:..............................................................................................18(d) Anti-Gout Agents:..................................................................................................................... 18(e) Muscle Relaxants and Anti-Spasmodics:.................................................................................19

11. THE EYE:.................................................................................................................................... 1912. THE EAR, NOSE AND OROPHARYNX:....................................................................................1913. THE SKIN:.................................................................................................................................. 1914. VACCINES - NONE PROVEN UNSAFE.....................................................................................1915. ANAESTHESIA:..........................................................................................................................20

ACUTE PORPHYRIA -DIAGNOSIS:....................................................................................................21Screening of Families.......................................................................................................................21A Preliminary Test for the Presence of Porphobilinogen in the Urine...............................................21

MANAGEMENT OF THE ACUTE ATTACK:........................................................................................21Symptomatic Therapy.......................................................................................................................22

Pain:.............................................................................................................................................. 22Nausea, Vomiting and Constipation:.............................................................................................22Tachycardia and Hypertension:.....................................................................................................22Convulsions:.................................................................................................................................. 23Neuropathy:................................................................................................................................... 23Fluid and Electrolyte Balance:.......................................................................................................23

SPECIFIC THERAPY OF THE ACUTE ATTACK: SPECIFIC THERAPY.........................................24Haematin Therapy: ( Haem Arginate )...........................................................................................24

PREVENTION OF ATTACKS:..........................................................................................................24Menstruation:................................................................................................................................. 25Pregnancy and Acute Porphyria:...................................................................................................25Anaesthetics:................................................................................................................................. 25Photosensitivity:............................................................................................................................ 26Prophylaxis and Treatment of Malaria...........................................................................................26

DRUG TREATMENTS IN ACUTE PORPHYRIA..................................................................................28TESTING FOR PORPHYRIA...............................................................................................................30FURTHER READING........................................................................................................................... 30APPENDIX I – ALPHABETICALLY DRUG LISTING............................................................................31

A GUIDE FOR PEOPLE WITH PORPHYRIA

WHAT IS PORPHYRIA ?Porphyria is a fairly uncommon condition. It is not one condition, but a group of several related diseases. Most of these are inherited but some may be acquired. People with porphyria may develop skin problems or a condition known as the acute attack.

In all the porphyria, the basic dilemma is that excessive amounts of porphyrins and their precursors accumulate in the body. It is under-diagnosed. Many sufferers are completely asymptomatic. All living things, including healthy people produce porphyrins. In porphyria, there is an atypical accumulation of porphyrins as the result of enzyme defects; this results in illness.

Our bodies convert two simple substances, 5-aminolaevulinate (ALA) and porphobilinogen (PBG) known as porphyrin precursors, into more complicated substances called porphyrins. These are then converted from one type of porphyrin to the next to form haem, aka heme. Haem is a vital substance in our bodies.

Protoporphyrin together with Iron are the building blocks necessary to make haem. Each step on the pathway is completed by a special protein known as an enzyme. In each type of porphyria, a specific enzyme is deficient, and this is why porphyrins accumulate.

As shown, each of the eight types of porphyria is associated with a deficiency of one of these enzymes.

A GUIDE FOR PEOPLE WITH PORPHYRIA (V1.3) Page 1

ACUTE INTERMITTENT PORPHYRIA (AIP):AIP is an inherited condition. It is passed on from generation to generation. This means that it may be passed on from parents to their children.

This occurs so that half of an affected parent's children are likely to be affected. For example, if you have six children, the chances are that three of them will have porphyria too. Boys and girls stand an equal chance of being affected.

Once the condition has entered a family, there is nothing that anyone can do about it. You cannot be blamed for having porphyria or for passing it on to your children! People with AIP are at risk of developing the acute attack, and you should now read the section The Acute Attack in this booklet.

If you have AIP, your skin will not be affected (unlike the other forms of porphyria) so the section The Skin in Porphyria is not relevant to you.


VARIEGATE PORPHYRIA (VP) and HEREDITARY COPROPORPHYRIA (HC):Like AIP, VP and HC are always inherited conditions. People with VP and HC are prone to skin problems, and to the acute attack. You should now read the following sections in this booklet: The Skin in Porphyria and The Acute Attack.

PLUMBOPORPHYRIA (PP):PP is an extremely rare condition and in the few cases described is similar to AIP.

PORPHYRIA CUTANEA TARDA (PCT):Very rarely, Porphyria Cutanea Tarda (PCT) is inherited from one's parents in the manner described for AIP and VP.

Most people with PCT did not inherit the disorder and will not pass it on to their children. Here, PCT is secondary to another condition. It may arise in some people because of taking too much alcohol.

Commonly, such people have additionally an excess of iron in their bodies. It may also follow the use of some drugs, such as the oestrogen used in the contraceptive pill or for relief of symptoms of the menopause and after exposure to certain chemicals.

It may also develop in people with kidney failure treated with haemodialysis. People with PCT commonly develop skin problems, and should now read the section in this booklet The Skin in Porphyria. They will never suffer an acute attack. Drugs do not hold the same danger for them as they do for people with AIP or VP, (though they should avoid alcohol).

ERYTHROPOIETIC PROTOPORPHYRIA (EPP):This is a less common form of porphyria. Like AIP and VP, it is an inherited disorder that is passed on from parents to their children. People with EPP suffer skin problems, and you should read the section The Skin in Porphyria. As in PCT, people with EPP do not develop acute attacks nor are drugs of concern. However the liver may become involved in later years.

CONGENITAL PORPHYRIA (CP)This is the rarest of the porphyria. It is primarily a skin condition and uniquely is inherited as a recessive condition. Both parents are asymptomatic carriers.


THE ACUTE ATTACKPeople with AIP HC or VP are always at risk of an acute attack of porphyria. This may be very dangerous, and they should read this section carefully and make sure they understand how they can prevent such an attack. Those with PCT, EPP and CP are not at risk, and this section does not apply to them.

What is an acute attack?: The acute attack takes place when the levels of the porphyrin precursors become very much raised for one or other reason. One can think of this as an overloading of the body with porphyrins and their precursors.

During such an attack, the affected person may experience abdominal pain, cramps, constipation, nausea or vomiting. They may also show marked anxiety or disturbed behaviour. Such attacks can be bad enough to require admission to hospital, and the most severe cases may go on to weakness and paralysis.

People have even died of such an attack. Fortunately, a fatal outcome has become rare as modern hospitals now have the facilities to treat such complications. This emphasises the need for people experiencing an acute attack to be admitted to an experienced hospital. It is more common nowadays for people with AIP or VP to develop milder forms of the acute attack with not much more than a feeling of being unwell, some pain in the stomach and, perhaps, nausea.

If you are experiencing such problems, it is important that you immediately stop any medication you may be taking and consult your doctor. Yet everyone has some of these symptoms at one time or another and you cannot blame everything on your porphyria!

What may bring on an acute attack:? Acute attacks may follow the use of many drugs. Porphyric people are unable to handle these drugs in the normal way and their bodies respond to them by overproducing porphyrins. This is the commonest cause of the acute attack.

However, attacks can also be precipitated by alcohol, by an infection and even by dieting. Smoking has been shown to worsen attacks.

What can I do to avoid developing an acute attack?: You must understand that there are many medicines that can aggravate your porphyria, possibly resulting in an acute attack. Therefore, you must never take any medicine or remedy without checking that it is safe for porphyrics. This includes drugs given to you by a doctor, pharmacist or dentist, as well as those you can buy without prescription.

Always consult our list (which you will find in this booklet) before you take the medicine given to you. Note that this includes tonics, herbal remedies and even the contraceptive pill, which has been a major factor in the development of acute attacks.

If you ever need an operation, you must tell the surgeon and anaesthetist that you have porphyria, as some anaesthetic drugs in common use are very dangerous for porphyrics. Safer alternatives can be used. It is desirable to wear a Medic-Alert disc or carry a similar form of identification, so that doctors will know you have porphyria in the event of an accident.

Finally, it is wise to eat regular meals and not to go without food for long periods, or to embark on 'crash' diets. Other than this, there is no special diet that needs to be followed. If you wish to lose weight, discuss your diet with your doctor beforehand. It is also best to avoid alcoholic drinks and to stop (or never start) smoking.


THE SKIN IN PORPHYRIAPeople with VP, HC, CP and PCT may have a sensitive skin. They complain that it is easily damaged and that even the slightest knock can cause the skin to break.

Often these damaged areas take a long time to heal. Sunlight is necessary to cause the skin to become fragile and people with porphyria find that the only parts of their bodies that are affected are those that are exposed to light, particularly their hands, faces, necks, legs and feet.

They develop blisters and open sores. In time their skins become thin, dark, scarred and often rather hairy, particularly on the face.

EPP and CP are somewhat different to the other porphyria. Firstly, the skin may already be affected as a very young child or even in infancy, whereas the other porphyria usually only become obvious later in life. Secondly, such people often find that they react to sunlight rapidly, developing a sensation of burning or stinging shortly after going into the sun. This is unlike VP, HC and PCT, where the damage takes much longer to develop. Affected people learn to avoid too much light because of this discomfort.

Skin care: If you have skin problems because of porphyria you should look after your skin as follows:- 1. Avoid sunlight as much as possible. This means remaining indoors during the sunniest part of the

day, and only going out in the early morning or late afternoon. Unfortunately, sunbathing is OUT if you have skin problems. This is definitely the worst thing a porphyric with skin problems can do.

If you have a job that requires you to be in the sun a lot, you may have to consider changing your occupation. Protect sun-exposed areas by wearing long sleeves, gloves and a hat whenever you go out. These should be made of cotton, which screens out the sun better than nylon. No cream or medication is as effective in protecting your skin.

The only sunscreen creams that can help are the opaque zinc or titanium oxide creams, which are unfortunately thick and greasy. Ask your pharmacist for such a cream.

Note that the usual suntan lotions will not protect your skin. Though they prevent sunburn in normal people, they do not keep out the light which damages a porphyric's skin.

2. Protect your skin from injury: Use a silicone barrier cream and rubber gloves to protect your hands

when washing clothes or dishes. Try not to knock your hands; a porphyric's skin is fragile and easily broken. For instance, wear heavy leather workman's gloves when working on your motor car.

When your skin is blistered or broken, avoid scratching and keep it clean with water and a mild soap. Avoid strong antiseptics. You can avoid permanent scarring if you look after such sores properly.


WHAT ELSE CAN BE DONE FOR PORPHYRIA?Unfortunately, there now is no cure for porphyria. Still, there is a lot that you and your doctor can do to make it less severe. With a little care, your symptoms probably will be mild and you can live a normal life, as many porphyrics do.

First, you must get an accurate diagnosis so that you can be absolutely certain you have porphyria and if so, what type. Speak to your doctor in this regard. Patients with PCT can be helped by avoiding alcohol or any other known cause of the condition.

If the skin remains bad, relief can be obtained by venesection. This means having 500 ml. of blood removed at regular intervals - usually fortnightly - for about eight weeks. Your doctor will arrange this if necessary. People with EPP also must ensure that they have regular medical check-ups as their condition can eventually affect the liver. Regular examinations and blood tests will detect this at an early stage.

WHAT ABOUT MY CHILDREN?If you have PCT, your children will almost certainly be free of porphyria. If you have AIP, HC, VP or EPP, each child has a 50:50 chance of being affected. If they are affected, this is not a terrible thing! They will probably not be any more seriously affected than you - they may be milder. In fact, more than 50% of porphyrics do not show signs of the condition at all, though they may be positive on testing - these are known as latent cases.

With sensible precautions, your children can live to a normal age, marry and have children themselves. Young children tend not to show signs of their porphyria till after puberty - that is, till after they reach sexual maturity. Laboratory tests usually do not even pick it up till then.

An acute attack has developed on only very rare occasions in childhood - even before the tests are positive. Therefore, it is wise to make your children take all the same precautions you do, to minimise this risk. DON'T ALLOW THEM TO HAVE ANY MEDICINES THAT ARE NOT SAFE IN PORPHYRIA AND DO WARN THE DOCTORS BEFORE THEY HAVE ANY ANAESTHETICS.

We suggest having your children tested every two years from the age of 12 until they turn 20 years. If the tests are still negative, then they will very likely be free of symptoms of porphyria after that.

Unfortunately, a few people are silent cases - though their tests are negative, they carry the defective gene, and porphyria can be precipitated in them if they are exposed to the 'dangerous' medicines on our list.

Therefore, the wisest suggestion is that no member of a porphyric family should take any such drug unless essential. It must be emphasised that it is essential to have your children adequately tested in a specialist laboratory.


THE PORPHYRIAS:

A MEDICAL GUIDEThe Porphyrias are a heterogeneous group of either inherited or acquired disorders of haem biosynthesis. In these diseases, specific abnormalities of enzymes in the biosynthetic pathway cause generalised clinical abnormalities. They are classified, as shown below, into acute and non-acute porphyria.

ACUTE PORPHYRIA

ACUTE INTERMITTENTPORPHYRIA (Swedish Porphyria) VARIEGATE PORPHYRIA (South African Genetic Porphyria) HEREDITARYCOPROPORPHYRIA (Coproporphyria) PLUMBOPORPHYRIA (ALA Dehydratase deficiency)

NON-ACUTE PORPHYRIA

PORPHYRIA CUTANEA TARDA (Cutaneous Hepatic Porphyria: Symptomatic Porphyria) ERYTHROPOIETICPROTOPORPHYRIA (Erythrohepatic Porphyria) CONGENITAL PORPHYRIA (Gunther's disease: Erythropoietic Porphyria)

The effects of drugs are most important in the acute porphyria, which are examples of 'Toxico-genetic diseases'. Patients with the acute form of these disorders are at risk of developing life-threatening attacks of porphyria on exposure to certain commonly prescribed drugs.

'Toxico-genetic diseases' - are diseases, genetically acquired, which show an idiosyncratic reaction to drugs. All the acute porphyria are inherited as mendelian autosomal dominants, and each may be linked to lowered activity of one of the enzymes of the haem biosynthetic pathway: in Acute Intermittent Porphyria – a decrease in porphobilinogen deaminase: in Variegate Porphyria - a decrease in protoporphyrinogen oxidase, and in Hereditary Coproporphyria – a decrease in coproporphyrinogen oxidase.

Features of the Acute Attack. Attacks of Acute porphyria vary in their clinical presentation. Severe abdominal pain, vomiting and constipation, with tachycardia and hypertension, are the commonest presenting features. Peripheral neuropathy may develop and lead to fatal respiratory paralysis.

Tachycardia and hypertension are usually present, and hypertensive encephalopathy may develop. Besides hypertension, severe postural hypotension, resulting in syncope may occur. Hypertension may persist to some extent between attacks. Other manifestations of autonomic dysfunction, such as profuse sweating, pallor and pyrexia may also occur.

Severe hyponatraemia, due to inappropriate secretion of antidiuretic hormone, complicates some attacks and sometimes presents as convulsions or deterioration in the conscious level. Another feature of involvement of the Central Nervous System is mental disturbance including agitation, mania, depression, auditory and visual hallucinations, and schizophrenic-like behaviour.


Grand-mal convulsions are not uncommon at the height of an attack and may persist between attacks. In Variegate Porphyria, and in Hereditary Coproporphyria, there may also be skin involvement, with development of solar photosensitivity.

Precipitating Factors It should be emphasised that most subjects who have inherited one of these diseases will enjoy normal health and go through life without any knowledge of his or her disorder or ever experiencing an acute attack. Such, is the latent phase of the disease.

All porphyrics, however, are at risk of developing an attack if exposed to various precipitating factors. Drugs are the most common precipitating agents. Other factors that may trigger attacks, include alcohol ingestion, reduced caloric intake, due to fasting or dieting, and infection. We have also noted that smoking can cause more frequent attacks.

Hormones are also important. Attacks are more common in females and, rarely, occur before puberty or after the menopause. Pregnancy and oral contraceptives may also precipitate attacks. Some women experience regular attacks, commencing in the week prior to the onset of menstruation.

Although most of the drugs incriminated as porphyrinogenic are lipophilic and inducers of the hepatic mixed function oxidase system, it is impossible to reliably predict from chemical structure whether a drug will be safe for use in the porphyric patient.

The Drug Lists. Lists in Table 1 (A) and (B) give information, alphabetically, on all drugs about which some information is known.

It should be borne in mind that such Lists are far from encyclopaedic, that new drugs are constantly being introduced to the pharmacopoeia, and that any form of combined preparationmust be viewed with suspicion, since little is known about metabolic interactions in these diseases.

The ultimate aim of investigative programs in the porphyria is to identify as many as possible of the cases latent for these diseases, using sensitive enzyme-screening tests, and by a program ofeducation, especially on drug usage, transform these potentially fatal conditions to mere genetic curiosities.


EVALUATION OF DRUGS FOR PORPHYRIC PATIENTSThis Table is organised under the Therapeutic Headings given in The British National Formulary. The drugs are categorised, as follows:

A. Those in the 'unsafe group' which have been reported by three or more workers in the field to be associated with clinical exacerbations of porphyria or, in the 'safe group', those considered by three or more authorities to be harmless to porphyric patients on the basis of their clinical experience.

B. Those in the 'unsafe group' which have been reported by two or less workers in the field to be associated with clinical exacerbations of porphyria or, in the 'safe group', those considered by two or fewer authorities to be harmless to porphyric patients on the basis of their clinical experience.

In many instances, the clinical experience with drugs in the above two groups will have been corroborated by experimental data. There are two further headings under which the drugs are listed:

C. Those which have been evaluated only in animals, with experimentally-produced porphyria.

D. Those which have been evaluated only in cell culture systems

No clinical experience has been reported with the drugs in these latter two groups. Finally, those drugs for which conflicting data is available have been listed and classified where possible as:

S. Probably safe. U. Probably unsafe.

NB. While very great care has been taken in the compilation of this table and the drug information is

given in the belief that it is correct at the time of publication, all information contained herein and opinions expressed must be taken as information and opinions given for general guidance only.

The authors hereby disclaim for themselves, The Porphyria Charitable Trust, the Porphyrias Service, the University of Queensland and Queensland Health, all responsibility for any mis-statement or for the consequences to any person of any person acting in reliance on any statement or opinion contained herein.

Medical Practitioners and patients must make their own decisions in the circumstances of the particular case about therapy appropriate in any case of acute porphyria.


Drug List

1. GASTROINTESTINAL SYSTEM UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAluminium OHHyoscine ButylbromideMebeverine HClSulphasalazine

CADC

AtropineCisaprideDanthronDicyclomine HClDiphenoxylate HClDomperidoneFamotidineLiquoriceLoperamideMagnesium SulphateMetopimazinePirenzepinePropanthelineSennaSorbitolTrimebutine Maleate

ABABBCBBDBDBBAAD

CimetidineMetoclopramideOmeprazoleRanitidine

UUSU

2. CARDIOVASCULAR SYSTEM

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAmiodarone HCl Ethamsylate Oxypentifylline Simvastatin

D C D C

Adrenaline Aminocaproic Acid Atropine Buflomedil HCl Clofibrate Digoxin Dipyridamole Glyceryl Trinitrate Heptaminol HCl Naftidrofuryl oxalate Probucol Procainamide HCl Quinidine Tranexamic Acid Trimetazidine HCl

BBADDADBDDDDCBD

DisopyramideFenofibrate Prazosin

S SDS

Diuretics UNSAFE THOUGHT TO BE SAFE CONTENTIOUSFrusemide Hydrochlorothiazide Spironolactone

ABC

Acetazolamide Amiloride Bumetanide Ethacrynic AcidTienilic Acid

DBBBD

Bendrofluazide Chlorothiazide Cyclopenthiazide Mersalyl Trichlormethiazide

SSUSS


Anti-hypertensive Agents UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAlpha Methyl DOPA Captopril Clonidine Enalapril Hydralazine Lisinopril Phenoxybenzamine

ADDBBBD

Atenolol Diazoxide Guanethidine Guanfacine HCl Labetalol Mecamylamine Metipropanolol Metoprolol TartratePropanolol Reserpine Timolol Maleate Tolazoline

ADADBCBBAADA

Calcium Channel Blockers UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBepridil HCl Nifedipine Prenylamine Verapamil

DBDB

Diltiazem U

Anticoagulants UNSAFE THOUGHT TO BE SAFE CONTENTIOUS

HeparinWarfarin Na

BB


3. RESPIRATORY SYSTEM: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAllyloxy 3-methylbenzamideAstemizole Bemegride Guaiphenesin Nikethamide Pentylenetetrazol Theophylline

CDBCABB

Beclomethasone dipropionate Ketotifen Mequitazine Pseudoephedrine HCl Salbutamol

BD B B B

Antihistamines UNSAFE THOUGHT TO BE SAFE CONTENTIOUSClemastine Dimenhydrinate Diphenhydramine Flunarizine HCl Terfenadine

BBBDB

Chlorpheniramine Trimeprazine tartrateTripelennamine

A D B

Promethazine U


4. CENTRAL NERVOUS SYSTEM:

Hypnotics, Sedatives and Anxiolytics:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAlprazolam Amylobarbitone Apronalide Carbromal Carisoprodol Chlordiazepoxide Chlormezanone Clotiazepam Diazepam DichloralphenazoneEthchlorvynol Ethinamate Flunitrazepam Flurazepam Glutethimide Hexapropymate Loprazolam Loxapine Meprobamate Methyprylone Nitrazepam Prazepam Quinalbarbitone Sulpiride Sultopride Tetrazepam Thioridazine

DABBABBDAABCBAADDDAABDBCDDB

Benzhexol HCl Chloral hydrate Chlorpromazine Droperidol Lofepramine Methylphenidate Pericyazine Piracetam ProchlorperazinePromazine Temazepam Triazolam Trifluoperazine

D A A B B B D D B A B C B

Bromazepam Chlormethiazole Clobazam Clonazepam Clorazepate Estazolam Haloperidol Lorazepam Methotrimeprazine Midazolam Oxazepam Promethazine

S S U U U DS U S S DS U U

Tranquillisers:Anti-Emetics: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBetahistine HCl Cinnarizine Dimenhydrinate Dixyrazine Hydroxyzine Isometheptene-mucate

D C B C B C

Chlorpromazine Cyclizine Domperidone Meclozine Prochlorperazine

ABCAB

MetoclopramidePromethazine

UU


Psychoanaleptics: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAmineptine HCl Dothiepin HCl Flupenthixol Iproniazid Maprotiline HCl Mianserin HCl Pargyline Phenelzine TranylcypromineTrazodone HCl Veralipride Viloxazine HCl Zuclopenthixol

D C C B C C C C C C D C C

Fluoxetine HCl Fluvoxamine maleate Lithium salts Lofepramine MethylphenidateMinaprine HCl Pipothiazine palmitate

B B B B D D D

Amitriptyline Carpipramine Clomipramine HCl Imipramine Metapramine HCl Nortriptyline Trimipramine

U U DU U DU U U

Anticonvulsants: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBarbiturates Carbamazepine Ethosuximide Diazepam Ethotoin Hydantoins Methsuximide Oxazolidinediones Paramethadione Phenobarbitone Phensuximide Phenytoin Primidone Progabide Succinimides Sulthiame Troxidone

A A A A B A A B A A A A A D A B B

Bromides Magnesium-sulphateParaldehyde

ABB

Chlormethiazole Clonazepam Na Valproate Valpromide

S U U DU

Analgesics: NON-NARCOTIC: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAmidopyrineAntipyrine Floctafenine

CCD

Aspirin Co-codamol Codeine Diflunisal Fenoprofen Glafenine Ibuprofen Naproxen Nefopam HCl Paracetamol

A B B B C C B B D A

Indomethacin Mefenamic acid Nicergoline

S U DU


Analgesics: NARCOTICS: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSDextropropoxypheneOxycodone Pentazocine Phenacetin Tilidate

B C A C B

Buprenorphine Diamorphine Droperidol Meptazinol Methadone Morphine Pethidine

BBABAAA

Dextromoramide S

Migraine: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSClonidine HCl Dihydroergotamine-Mesylate Ergotamine Tartrate Isometheptene Mucate Lysuride Maleate Orphenadrine

B A A B C C

Pizotifen Prochlorperazine

BB

Appetite Suppressants: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSFenfluramine Dexfenfluramine Diethylpropion Methamphetamine

CDCB

Methylcellulose B


5. INFECTION:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSColistin Chloramphenicol Co-trimoxazole Cycloserine Dapsone Econazole Nitrate Erythromycin Flucloxacillin Flumequine Griseofulvin Ketoconazole Miconazole Nalidixic acid Natamycin Novobiocin Pipemidic acid Pivampicillin Pyrazinamide Rifampicin Sulphonamides Tinidazole Trimethoprim Vibramycin

B A B B A B A A D A D D B B B D B A B A D B B

Acyclovir Aminoglycosides Amoxycillin Amphotericin D Ampicillin Ciprofloxacin Clavulanic Acid Flucytosine Gentamycin Hexamine Josamycin Mefloquine HCl Minocycline HCl Netilmycin Norfloxacin Ofloxacin Oxolinic acid Pefloxacin Penicillin Primaquine Quinine Sodium Fusidate Streptomycin Talampicillin Ticarcillin Vancomycin Zidovudine

DBBDABDDCCDDDDDDDDABBBABBBB

Cephalosporins Chloroquine Isoniazid Mebendazole Metronidazole Nitrofurantoin Pyrimethamine Tetracyclines

USUSSUSS

6. ENDOCRINE SYSTEM:

Hormone Preparations:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBromocriptine Danazol Dydrogesterone Metyrapone Oral Contraceptives Stanozolol

DBCDAC

Buserelin Carbimazole Clomiphene Citrate Corticotrophin (ACTH) Dexamethasone Follicle Stimulating Hormone Glucagon Goserelin Methyluracil Propylthiouracil Thiouracil Thyroxine

A B B B B B D B B B B B

Androgens Benzylthiouracil Corticosteroids Cyproterone Acetate Ethinyl Oestradiol Nandrolone Prednisolone Progestogens

U DS S S S U S U


Anti-Diabetic Agents: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSSulphonylureasGlipizide

AB

Biguanides Insulin Metformin Phenformin

CACC

7. OBSTETRICS, GYNAECOLOGY AND RENAL DISEASE: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSErgometrine MaleateHyoscine Butyl Bromide Oral Contraceptives

A A A

Dinoprost Oxytocin Propantheline

CBB

Mifepristone Oestrogens

U U

8. MALIGNANT DISEASE: and IMMUNOSUPPRESSION: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAminoglutethimide Busulphan Chlorambucil CyclophosphamideCyclosporin Megestrol Mercaptopurine Methotrexate Tamoxifen

B C C C C C B C B

Actinomycin D Azathioprine Cisplatin Doxorubicin HClEtoposide Zidovudine

CCDCBB

Cyproterone-Acetate Ethinyl Oestradiol Melphalan Vinblastine Vincristine

S S S UD UD

9. NUTRITION AND BLOOD: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSEthanol A Alpha tocopheryl acetate

Ascorbic Acid Vitamins Folic Acid Fructose Glucose Haem Arginate Iron Preparations Pyridoxine HCl Sodium Calcium Edetate (EDTA) Sulbutiamine

A A B B A A A A A A A D


10. MUSCULO-SKELETAL and JOINT DISEASE:

(a) Non-Steroidal Anti-Inflammatory Agents: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAmidopyrine Azapropazone Benoxaprofen Clometacin Dichloralphenazone Diclofenac Na Dipyrone Flufenamic Acid Oxyphenbutazone Pipebuzone Piroxicam Propyphenazone

A C C D A A A B A D D A

Alclofenac Aspitin Codeine PO4 Dihydrocodeine Fenoprofen Flurbiprofen Ibuprofen Ketoprofen Naproxen Na Nifumic Acid Paracetamol Sulindac Tiaprofenic acid

C A A A C B B C C D B C B

Indomethacin Mefenamic acidPhenylbutazone

SUU

(b) Corticosteroids: UNSAFE THOUGHT TO BE SAFE CONTENTIOUS

Dexamethasone B HydrocortisonePrednisolone

SS

(c) Specific Anti-Rheumatic Agents:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAuranofin Gold-(Sodium Aurothiomalate)

B C

Penicillamine B Chloroquine S

(d) Anti-Gout Agents:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBenzbromarone Piroxicam Sulphinpyrazone

DBD

Allopurinol Colchicine

CB

Probenecid U


(e) Muscle Relaxants and Anti-Spasmodics:

UNSAFE THOUGHT TO BE SAFE CONTENTIOUSBaclofen Carisoprodol Chlormezanone Chlorzoxazone Diazepam Dipyrone Drotaverine Hyoscine ButylbromideMephenesin Orphenadrine Oxanamide

D A B B A A AA D B C

Domperidone Neostigmine Parapenzolate BrPropantheline Br Suxamethonium Tubocurarine

CADBAB

Metoclopramide Pancuronium

US

11. THE EYE: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSChloramphenicol Cocaine Hyoscine Butylbromide Mercuric oxide Oxyphenbutazone Sulphacetamide

A B A B B C

Acetazolamide Amethocaine HCl Atropine Dexamethasone Gentamicin Guanethidine Oxybuprocaine Timolol Maleate Zinc sulphate

B C A B A C C D A

Prednisolone ProxymetacaineTetracyclines

SSS

12. THE EAR, NOSE AND OROPHARYNX: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSOxymetazoline B

13. THE SKIN: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSCrystal violet Econazole nitrateGriseofulvin Ketoconazole Miconazole

B B A D D

Canthaxanthin ß Carotene Resorcinol Zinc Preparations (Topical)

A A B B

Hydrocortisone Butyrate

S

Note - in sections 11, 12 and 13, substances that are neither absorbed nor metabolised are unlikely to be harmful.

14. VACCINES - NONE PROVEN UNSAFE UNSAFE THOUGHT TO BE SAFE CONTENTIOUS


15. ANAESTHESIA: UNSAFE THOUGHT TO BE SAFE CONTENTIOUSAlcuronium Alphaxalone -Alphadolone Barbiturates Carticaine HCl Chloroform Cocaine Enflurane Etidocaine Etomidate Fluroxene Isoflurane Lignocaine Mepivacaine Methohexitone Prilocaine Thiopentone Na

C B A D B B C C C B C C D C B A

Amethocaine HCl Bupivacaine Butacaine SO4 Cyclopropane Diethyl ether Droperidol Fentanyl Flumazenil Meptazinol Midazolam Minaxolone Nitrous oxide Propofol Procaine Suxamethonium Tetracaine Tubocurarine

C C D C A C C D B D C A B B C C C

Haloperidol Halothane Ketamine Pancuronum Br Propanidid Proxymetacaine

UUSSUS


ACUTE PORPHYRIA -DIAGNOSIS:

Acute porphyria should be considered in any patient presenting with unexplained abdominal pain, mental dysfunction or peripheral neuropathy. A further clue to the diagnosis is discolouration of the urine.

During an attack, the urine is a dark reddish brown and this becomes more pronounced if it is left standing. A simple bedside test can confirm the diagnosis. Quantitative studies of the different porphyrins and precursors in the urine and faeces should be performed later by a specialist laboratory to identify the particular type of acute porphyria.

Successful treatment of an acute attack of Porphyria depends largely on, early diagnosis, removal of precipitating factors, and provision of intensive supportive therapy. On first diagnosing an attack, a careful search should be made for any precipitating factors, and if possible, these should be removed.

The patient's current drug therapy should be scrutinised and a search made for any underlying infection. When appropriate, a pregnancy test should be performed.

Screening of Families Latent cases in affected families may be diagnosed, either by measurement of porphyrins and their precursors in urine, faeces and blood, or by measurement of the activities of the enzymes of the Haem biosynthetic pathway.

Where such screening is required, most Analytical Laboratories, such as our own, prefer to receive samples of urine, stool and heparinized blood. Prophylaxis is extremely important. In particular, Drugs listed in the 'Unsafe Groupings' in Tables 1 and 2, should be avoided.

Patients should also be counselled on the dangers of alcohol, smoking and dieting.

A Preliminary Test for the Presence of Porphobilinogen in the Urine Equal volumes of Urine and Ehrlich's reagent (An acidic solution of p-dimethyl aminobenzaldehyde) are mixed in a tube. If the solution takes a pink colouration, this indicates the presence of porphobilinogen or urobilinogen.

The presence of porphobilinogen may be confirmed by the addition of about 2 volumes of chloroform to the solution and shaking thoroughly. When the mixture is allowed to stand and separate the pink colouration should have remained in the upper aqueous layer.

If it moves to the lower chloroform layer the colouration is due to urobilinogen and not porphobilinogen. When urobilinogen concentrations are high it may be necessary to repeat the extraction.

MANAGEMENT OF THE ACUTE ATTACK:Specific therapies are few: these include the use of high carbohydrate intake and haematin infusion. Initially, steps should be taken to ensure an adequate carbohydrate intake. Most patients suffer from nausea and vomiting during an attack and their poor carbohydrate intake aggravates the disease process.

This cycle must be broken. In mild attacks, this is achieved by ensuring an adequate oral intake of Glucose Polymer drinks, such as Caloreen (Roussel) or Hycal (Beecham Products). In patients experiencing more severe attacks, the constant slow infusion of Carbohydrate solution via a fine bore Teflon nasogastric tube, is helpful.


If the symptoms are not controlled, an infusion of Haem Arginate should be considered.(See below). This treatment is still on trial and may be obtained from the appropriate drug company on a named patient basis.

Symptomatic Therapy

Pain: This is a feature of most attacks. When mild, it may be adequately controlled with aspirin, paracetamol or dihydrocodeine. For more severe pain, pethidine (meperidine), morphine or diamorphine may be required.

Buprenorphine, which may be administered either sublingually or intramuscularly, is also useful. More constant pain relief may be achieved by the continuous intravenous infusion of analgesics.

There is a danger of addiction in patients experiencing frequent attacks, who require large amounts of narcotic analgesics, and every attempt should be made to withdraw all narcotic drugs between attacks.

In a few unfortunate patients, the pain is refractory to even very large doses of narcotic analgesics, and signs of respiratory and cardiovascular system depression appear before pain relief is obtained.

Many of our patients report that the only time the pain goes away is when they are asleep. This observation may be used to advantage by encouraging sleep for several hours by combining chlorpromazine or promazine with the analgesics and leaving the patient undisturbed in a darkened room.

Some patients continue to complain of chronic abdominal pain, unaccompanied by any other symptoms between attacks. This can be very difficult to manage, and the risk of narcotic addiction in these patients is high. Although, sometimes, a psychological overlay may be a factor - in others, the pain is clearly genuine and presumably a manifestation of residual neurological damage.

Nausea, Vomiting and Constipation: These are frequent symptoms and may be controlled with chlorpromazine, promazine or prochlorperazine. As the narcotic analgesics used in controlling the pain often aggravate the nausea and vomiting, it is usually helpful to administer antiemetics with or shortly before the analgesics.

Besides their antiemetic effects, chlorpromazine and promazine control the agitation and other psychiatric manifestations of the attack. In our experience, some porphyria patients develop extrapyramidal side-effects with phenothiazines, necessitating substitution with cyclizine hydrochloride. Constipation, where it occurs, may be severe - to the point of obstipation - and Neostigmine is beneficial in these circumstances.

Tachycardia and Hypertension: These are present in most attacks. They are thought to be the result of sympathetic overactivity and should be controlled with propranolol. The dose can be titrated against its effect on the Cardiovascular System. Frequently very large doses are required.

The pulse and blood pressure should be closely monitored, as they tend to be labile and hypertensive encephalopathy may develop. Postural hypotension, leading to syncope, may occur when a patient sits upright, even when the patient has been hypertensive in the supine position.

When postural hypotension does occur, the supine blood pressure should still be adequately controlled with propranolol, taking care when moving the patient. Paroxysmal cardiac arrhythmias, sometimes leading to collapse, may also occur. These may be precipitated by the patient suddenly


sitting upright. Whenever there is evidence of cardiovascular instability, continual ECG monitoring should be performed and full resuscitative facilities kept at hand.

Convulsions: Convulsions are not infrequent at the peak of an attack. Their onset may be a sign of hyponatraemia, due to inappropriate antidiuretic hormone secretion, and plasma osmolality, and electrolyte values should be checked. If hyponatraemia is the underlying cause, it should be corrected by restricting fluid intake to not more than 700 ml.

The onset of convulsions may also be a sign of hypertensive encephalopathy, and the blood pressure should be checked. Convulsions, occurring during the attack, usually disappear as the attack resolves and, therefore, therapy should be aimed at treating the underlying disease process.

Some patients continue to experience convulsions while in remission. This presents a therapeutic dilemma. Phenobarbitone, primidone, phenytoin and carbamazepine all increase cellular haem utilisation by inducing the synthesis of hepatic monoxygenases, and are contraindicated.

The benzodiazepines and sodium valproate are not inducers of the monoxygenases and, although they are porphyrinogenic in experimental models of porphyria, there is limited evidence that they are porphyrinogenic in man. Status epilepticus, in our own experience, has been treated successfully with intravenous diazepam.

Seizure prophylaxis can be undertaken as a calculated risk with clonazepam or sodium valproate if this is essential, although sporadic clinical reports of porphyr- inogenicity do exist. Sodium bromide and magnesium sulphate are safe, but generally outmoded anticonvulsants.

Neuropathy: All patients should be examined for evidence of developing peripheral neuropathy. This may progress rapidly, leading to quadriplegia and bulbar and ventilatory paralysis. The latter is heralded by weakening of the voice.

When signs of peripheral neuropathy are present, the expiratory peak flow-rate should be monitored. If there is any reduction in this rate, the blood gases should be checked, and the patient nursed in an Intensive Care Unit with facilities for assisted ventilation.

Even in patients in whom there is widespread paralysis requiring assisted ventilation for many months, good functional recovery can still be expected. Attention should be given to splinting of the joints and appropriate physiotherapy in the paralysed patient.

Fluid and Electrolyte Balance: Various disturbances of fluid and electrolyte balance are seen during the acute attack. Dehydration may occur, owing to persistent vomiting. Hyponatraemia, secondary to inappropriate antidiuretic hormone secretion, may also occur, sometimes first becoming apparent after commencingintravenous fluids.

The hyponatraemia can usually be controlled by restricting fluid intake. To maintain adequate carbohydrate intake while restricting fluid intake, it may be necessary to use higher concentrations of glucose, administered via a central venous line.


SPECIFIC THERAPY OF THE ACUTE ATTACK: SPECIFIC THERAPY

Haematin Therapy: ( Haem Arginate ) So far we have concentrated on treating the acute attack by correcting any factors that may have precipitated it, and providing adequate supportive therapy while the attack spontaneously resolves. It is also possible to treat the underlying disease process more directly by administering the endproduct of the deranged pathway as intravenous haematin.

In the liver, it is thought to supplement the depleted intracellular 'free haem pool', thus repressing the activity of the initial and rate-controlling enzyme of haem biosynthesis, ALA synthase, and reducing the overproduction of porphyrins and precursors formed prior to the enzyme block.

In an acute attack of porphyria, the intravenous administration of haematin consistently reduces both the plasma concentration and the urinary excretion of porphyrin precursors. Its effect may be supplemented with inhibitors of the haem degradative enzyme, Haem oxygenase, such as Tin protoporphyrin. The clinical response to the therapy is more difficult to assess.

In a disease characterised by spontaneous relapses and remissions, it is difficult to be sure whether improvement is the result of therapy or just the natural course of the disease. Our current impression is that haematin does curtail the clinical attack, and we frequently employ it.

No major side-effects have been reported with haematin when used in the standard doses. Phlebitis, around the injection site, occurs in a few patients. This can be prevented by injecting the solution into a large peripheral vein or via a central venous line, or by administering the haematin, with human albumin solution, to which it will bind. During haematin therapy, there is a mild disturbance of coagulation, with prolongation of the prothrombin and partial thromboplastin times, and a slight reduction in the platelet count.

This reverts to normal on completion of the haematin course, and has only very rarely resulted in haemorrhagic complications. As mentioned above coagulation indices and the platelet count should be monitored during therapy and haematin should not be used with anticoagulant therapy.

Transient acute renal failure has been reported in one patient who received a bolus intravenous injection of 1000 mg of haematin. Yet, no renal complications have occurred with the standard recommended dosages, and even patients with renal insufficiency appear to tolerate haematin well, although it is probably wise to reduce the dosage slightly as an added precaution.

A commercially available haematin preparations is: NORMOSANG ( Haem Arginate - Leiras)

PREVENTION OF ATTACKS:Patients, who have experienced a clinical attack of porphyria, should be carefully counselled concerning the avoidance of precipitating factors. They should be encouraged to maintain a regular diet and to abstain completely from alcohol and to stop smoking.

In addition, they should be warned about the dangers of certain drugs and given a Reference Booklet, showing which drugs are safe and which are unsafe to take (see Tables 1 and 2).

It is also important to ensure that the patient's General Practitioner is fully informed about the disease and given advice about management. Patients should be reminded to tell any Medical Attendant that they suffer from porphyria.

As an added precaution, they should wear a bracelet or necklace, indicating that they have porphyria, to prevent the administration of dangerous drugs or anaesthetics if an accident or other emergency.


Menstruation: Some women experience regular attacks in the week prior to the onset of menstruation. These are assumed to be initiated by the hormonal fluctuations, and various attempts have been made to prevent them.

Sometimes, merely increasing the carbohydrate intake at the appropriate time ofthe month is found to be helpful. Interfering with the hormonal fluctuations has produced varying results.

Some patients have been reported to benefit from the suppression of ovulation, using various oral contraceptive hormone preparations. However, in our own experience, also that of several otherCentres, the contraceptive pill has usually precipitated attacks.

Attacks have been successfully prevented by administering haematin, prophylactically, just prior to the time in the month when the attack usually starts and through the long term use of synthetic LHRH analogues.

Pregnancy and Acute Porphyria: Pregnancy may precipitate acute porphyria, with attacks being most common in early pregnancy and during the puerperium. The first attack often occurs during pregnancy. In patients with the genetic trait, who have normal porphyrin excretion, who have never experienced a clinical attack, pregnancy is, usually, uneventful.

If vomiting is a problem in early pregnancy, the patient should be admitted to the hospital at an early stage and dextrose administered, intravenously, to prevent the reduced dietary intake from inducing an attack. Dextrose should also be administered, intravenously, during labour. Patients who have had clinical attacks of porphyria, and have increased urinary excretion of porphyrins and precursors are likely to experience attacks during pregnancy.

We advise such patients not to consider pregnancy until they have been free of symptomatic attacks for at least 18 months.

When attacks do occur during pregnancy, they should be treated as already described. But, as there is insufficient information about the effect of Haematin on the foetus, this therapy should be avoided unless the condition of the mother demands it. Most attacks of porphyria during pregnancy settle with adequate supportive therapy, resulting in a successful outcome for both mother and child. We only, rarely, consider therapeutic termination of pregnancy in patients with acute porphyria and then, only in very severe attacks, occurring in early pregnancy.

Besides the possible risks of pregnancy, many patients question the advisability of bearing children likely to inherit a genetic disorder. It should be explained to the patient that, although each child will have a 50 per cent chance of inheriting the trait, the majority of porphyrics remain clinically latent throughout life.

When affected individuals decide to delay or avoid pregnancy, they should be warned about the dangers of oral contraceptives, and advised about other forms of contraception.

Anaesthetics: Provided appropriate precautions are taken, most patients with acute porphyria can tolerate surgery and general anaesthesia. However, patients experiencing frequent attacks of porphyria will be at risk of developing complications, and the indications for surgery should be carefully examined. Care must always be taken in selecting safe anaesthetic agents.

Atropine and morphine may be used as premedication. Intravenous propofol and ketamine have been found to be safe alternatives to thiopentone as anaesthetic-inducing agents. Cyclopropane and ether


are safe inhalation agents with respect to the porphyrias, but they suffer the disadvantages of being potentially explosive and inducing post-operative vomiting.

Nitrous oxide, used with intravenous narcotics, and muscle relaxants, may be a more acceptable alternative. Suxamethonium and D-tubocurarine can be used as muscle relaxants and diamorphine, morphine, pethidine or fentanyl are suitable narcotics for controlling post-operative pain.

In some situations, epidural anaesthesia may be preferable to general anaesthesia, in which case bupivacaine is the local anaesthetic of choice. To prevent an attack being induced by fasting, an intravenous infusion of dextrose should be commenced prior to surgery, and continued until the patient can eat properly.

Photosensitivity: Photosensitivity may be found in Variegate porphyria and Hereditary Coproporphyria. The occurrence of skin lesions depends on the degree of porphyrin overproduction and the amount of exposure to sunlight.

Skin lesions should be treated by removing any inducing factors, such as drugs, alcohol, or inadequate diet, that may increase the porphyrin overproduction. There is no specific treatment for the skin photosensitivity occurring in Variegate porphyria and Hereditary coproporphyria, although Beta-carotene treatment has been suggested of benefit.

Barrier creams may be used. Avoidance of excess sunlight is advised. The dermatological features often subside after the acute attack, as the amount of circulating porphyrin is reduced.

Prophylaxis and Treatment of Malaria. The steady encroachment of chloroquine-resistant malaria and increased travel to malarious regions has resulted in a pressing need to re-evaluate the prophylactic strategy for people visiting or residing in areas known to harbour the disease. Many commonly used antimalarials are known to be porphyrinogenic.

Chloroquine has been the most widely used prophylactic and therapeutic agentfor decades, however most authorities describe its use in porphyrics as 'contentious'. Added to this is the problem of widespread chloroquine resistance, so that chloroquine per se should not be regarded as adequately protective against malaria.

The other agents commonly prescribed for prophylaxis, dapsone and sulphadoxine, are definitely contraindicated in porphyrics. Combined preparations as 'Maloprim' and 'Fansidar' should not be used, as they contain one or other of these agents.

Pyrimethamine is probably safe, but it should have little place in the prophylaxis of malaria because of relative inefficiency. 'Daraclor', contains both chloroquine and pyrimethamine which are suspect not only for safety in porphyrics, but also for their efficacy in resistant malaria.

Finally, there are three remaining drugs primaquine, mefloquine and proguanil. These are thought to be safe, mefloquine and proguanil on cell culture tests and primaquine on human experience. What then, should the porphyric person contemplating a visit to a malarial area be advised to do? An alternative to the use of chloroquine is to consider the prophylactic use of quinine, which is of proven safety in porphyrics.

Though widely used as a prophylactic in the past it has the disadvantages of requiring a twice daily administration (compared with once weekly for chloroquine) and of hazardous side-effects, when taken long-term. Yet, it retains efficacy against chloroquine-resistant Falciparum malaria.


A third strategy, the one that is probably safest to suggest now, is to avoid chemoprophylaxis altogether and adopt the following steps:-

1. Direct prophylactic measures against the vector instead of the parasite, thus reducing the risk of an infected bite. This has been shown to reduce the risk of contracting malaria considerably and entails:

i) visiting malarial areas in the dry rather than the wet season; ii) staying in towns rather than the bush; iii) covering up with long sleeves and trousers at sundown; iv) liberal use of insect repellents, both on the person and in the environment; v) the use of mosquito coils; (vi) proper use of mosquito netting.

2. The visitor should be advised to carry a course of quinine sulphate tablets at all times and be instructed on the possible symptoms of malaria, particularly pyrexia, backache, nausea and headache. A course of quinine should be commenced at the first sign of an illness and medical support sought as quickly as possible.

Such an approach is favoured by some authorities as a general strategy against chloroquine resistant malaria and hence, if applied to porphyrics, as outlined, does not represent a major departure from current thinking.

What of treatment of established malaria in porphyric patients? The course here is clear: They should receive quinine sulphate alone; this will be efficacious against chloroquine resistant malaria and is of proven safety in porphyria.

Finally, where malaria, other than Falciparum, is suspected, primaquine may safely be employed to eradicate the exo-erythrocytic cycle of these parasites.


TABLE 3:

DRUG TREATMENTS IN ACUTE PORPHYRIA CONDITION DRUG CATEGORY DRUG

SPECIFICTREATMENTS

HAEM ARGINATE GLUCOSE

ABDOMINAL PAIN Analgesics ASPIRIN BUPRENORPHINEDIAMORPHINEDIHYDROCODEINEMORPHINE PARACETAMOL PETHIDINE

VOMITING Anti-Emetics CHLORPROMAZINE CYCLIZINEPROCHLORPERAZINEPROMAZINE

HYPERTENSION ANDTACHYCARDIA

Anti-Hypertensives ATENOLOL GUANETHIDINE LABETALOL MECAMYLAMINEPROPRANOLOL

NEUROSIS,PSYCHOSIS ANDSEIZURES

Sedatives,Tranquillisers and Anticonvulsants

CHLORPROMAZINE CLONAZEPAM LORAZEPAMPROCHLORPERAZINEPROMAZINETRIFLUOPERAZINE

CONSTIPATION Laxatives and Anti-Cholinesterases

DANTHRON NEOSTIGMINE SENNA

Other Clinical Features:

CONDITION DRUG CATEGORY DRUG

ALLERGIC REACTIONS

Anti-histamines CHLORPHENIRAMINETRIPELENNAMINE

ANAESTHESIA Anaesthetics ATROPINE BUPIVACAINECYCLOPROPANE DROPERIDOL ETHER FENTANYL KETAMINE NITROUS OXIDE


CONDITION DRUG CATEGORY DRUG

PRILOCAINE PROCAINE PROPOFOL SUXAMETHONIUMTUBOCURARINE

ARTHRITIC AND RHEUMATICCONDITIONS

Anti-Inflammatories ALLOPURINOL ASPIRIN COLCHICINE FLURBIPROFEN INDOMETHACIN NAPROXEN PENICILLAMINE

CANCER ChemotherapeuticAgents

ACTINOMYCIN D CISPLATIN CYPROTERONE-ACETATEDOXORUBICIN MELPHALAN VINCRISTINE SO4

CARDIOVASCULAR Anti-ArrhythmicDrugsand Diuretics

CONDITIONS AMILORIDE ATROPINE BUMETANIDECYCLOPENTHIAZIDE DIGOXIN DISOPYRAMIDE

DIABETES Hypoglycaemics INSULIN

INFECTION Antibiotics AMOXYCILLINGENTAMICIN HEXAMINE PENICILLINS

MALARIA Anti-Malarials PRIMAQUINEPYRIMETHAMINE QUININE

ORGAN TRANSPLANT Immunosuppressives AZATHIOPRINEPREDNISOLONE

THYROID DISEASE Anti-Thyroid Drugs METHYL URACILPROPYLTHIOURACIL


TESTING FOR PORPHYRIASAMPLES:

1. URINE

200 ml. ALIQUOT FROM 24-HOUR URINE COLLECTION (with no added preservative) OR SPOT SAMPLE OF AT LEAST 100 ml. URINE

2. BLOOD:

10 ml. WHOLE BLOOD IN LITHIUM HEPARIN CONTAINER 3. FAECES:

5g FAECAL SAMPLE (in sealed container) TO BE SENT (with a short case history) TO THE:-

PORPHYRIAS SERVICE NRCET PO Box 594 Archerfield 4108 Queensland, AUSTRALIA

FURTHER READING Should the reader require further information on this subject, the undernoted books will provide a valuable addition to the information in this booklet 1. DISORDERS OF PORPHYRIN METABOLISM

Michael R. Moore, Kenneth E.L. McColl, Claude Rimington and Abraham Goldberg PLENUM PRESS, NEW YORK (1987).

2. PORPHYRIA - CLINICS IN DERMATOLOGY 3

Eds. P.B. Disler and M.R. Moore LIPPINCOTT, PHILADELPHIA (1985).

3. CLINICS IN HAEMATOLOGY 9. THE PORPHYRIAS

Eds. A. Goldberg and M.R. Moore SAUNDERS, LONDON (1980).

4. A CENTURY OF PORPHYRIA

Ed. M.R. Moore Molecular Aspects of Medicine 2 (1990)

5. BIOSYNTHESIS OF HEME AND CHLOROPHYLLS

Ed. H.A. Dailey McGRAW-HILL, NEW YORK (1990)


APPENDIX I – ALPHABETICALLY DRUG LISTING

System/Area Sub Area Drug Useability Test CommentsNUTRITION AND BLOOD (Edta) Safe A THE EYE Acetazolamide Safe B CARDIOVASCULAR SYSTEM Diuretics Acetazolamide Safe D

Acetylcholine SafeMALIGNANT DISEASE: and IMMUNOSUPPRESSION Actinomycin D Safe CINFECTION Acyclovir Safe D

Adenosine Monophosphate SafeCARDIOVASCULAR SYSTEM Adrenaline Safe BMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Alclofenac Safe C ANAESTHESIA Alcuronium Unsafe CMUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Allopurinol Safe BRESPIRATORY SYSTEM Allyloxy 3-Methylbenzamide Unsafe CCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Alpha Methyl Dopa Unsafe ANUTRITION AND BLOOD Alpha Tocopherylacetate Safe A ANAESTHESIA Alphaxalone - Alphadolone Unsafe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Alprazolam Unsafe DGASTROINTESTINAL SYSTEM Aluminium OH Unsafe C

Aluminium Preparations UnsafeANAESTHESIA Amethocaine HCL Safe C THE EYE Amethocaine HCL Safe C CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Amidopyrine Unsafe CMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Amidopyrine Unsafe A CARDIOVASCULAR SYSTEM Diuretics Amiloride Safe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Amineptine HCL Unsafe D CARDIOVASCULAR SYSTEM Aminocaproic Acid Safe BMALIGNANT DISEASE: and IMMUNOSUPPRESSION Aminoglutethimide Unsafe B INFECTION Aminoglycosides Safe B

Aminophylline UnsafeCARDIOVASCULAR SYSTEM Amiodarone HCL Unsafe D CENTRAL NERVOUS SYSTEM Psychoanaleptics Amitriptyline Contentious UINFECTION Amoxycillin Safe B

Amphetamines Unsafe Note 2INFECTION Amphotericin D Safe DINFECTION Ampicillin Safe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Amylobarbitone Unsafe AENDOCRINE SYSTEM Hormone Preparations Androgens Contentious UCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Antipyrine Unsafe CCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Apronalide Unsafe BNUTRITION AND BLOOD Ascorbic Acid Safe A CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Aspirin Safe A MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Aspitin Safe A

A GUIDE FOR PEOPLE WITH PORPHYRIA Page 31

System/Area Sub Area Drug Useability Test CommentsRESPIRATORY SYSTEM Astemizole Unsafe DCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Atenolol Safe ACARDIOVASCULAR SYSTEM Atropine Safe AGASTROINTESTINAL SYSTEM Atropine Safe ATHE EYE Atropine Safe A MUSCULO-SKELETAL and JOINT DISEASE Specific Anti-Rheumatic Agents Auranofin Unsafe B

Aurothiomalate Unsafe Associated with acute attacks of porphyria.

MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Azapropazone Unsafe C MALIGNANT DISEASE: and IMMUNOSUPPRESSION Azathioprine Safe CMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Baclofen Unsafe D ANAESTHESIA Barbiturates Unsafe ACENTRAL NERVOUS SYSTEM Anticonvulsants Barbiturates Unsafe A RESPIRATORY SYSTEM Beclomethasone Dipropionate Safe B RESPIRATORY SYSTEM Bemegride Unsafe BCARDIOVASCULAR SYSTEM Diuretics Bendrofluazide Contentious SMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Benoxaprofen Unsafe C MUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Benzbromarone Unsafe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Benzhexol HCL Safe D ENDOCRINE SYSTEM Hormone Preparations Benzylthiouracil Contentious DS CARDIOVASCULAR SYSTEM Calcium Channel Blockers Bepridil HCL Unsafe D

Beta-Carotene SafeCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Betahistine HCL Unsafe D ENDOCRINE SYSTEM Anti-Diabetic Agents Biguanides Safe CCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Bromazepam Contentious SCENTRAL NERVOUS SYSTEM Anticonvulsants Bromides Safe AENDOCRINE SYSTEM Hormone Preparations Bromocriptine Unsafe DCARDIOVASCULAR SYSTEM Buflomedil HCL Safe DCARDIOVASCULAR SYSTEM Diuretics Bumetanide Safe BANAESTHESIA Bupivacaine Safe C CENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Buprenorphine Safe BENDOCRINE SYSTEM Hormone Preparations Buserelin Safe A MALIGNANT DISEASE: and IMMUNOSUPPRESSION Busulphan Unsafe C ANAESTHESIA Butacaine SO4 Safe D

Butylscopolamine Unsafe Associated with acute attacks of porphyria.

THE SKIN Canthaxanthin Safe A CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Captopril Unsafe DCENTRAL NERVOUS SYSTEM Anticonvulsants Carbamazepine Unsafe A ENDOCRINE SYSTEM Hormone Preparations Carbimazole Safe B CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Carbromal Unsafe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Carisoprodol Unsafe AMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Carisoprodol Unsafe ACENTRAL NERVOUS SYSTEM Psychoanaleptics Carpipramine Contentious U

Carpipramine HCL Safe Note 1


System/Area Sub Area Drug Useability Test CommentsANAESTHESIA Carticaine HCL Unsafe D

Cefuroxime Unsafe Note 2Cephalexin Unsafe Note 2

INFECTION Cephalosporins Contentious UCephradine Unsafe Note 2

CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Chloral Hydrate Safe A MALIGNANT DISEASE: and IMMUNOSUPPRESSION Chlorambucil Unsafe C INFECTION Chloramphenicol Unsafe ATHE EYE Chloramphenicol Unsafe A CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Chlordiazepoxide Unsafe BCENTRAL NERVOUS SYSTEM Anticonvulsants Chlormethiazole Contentious SCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Chlormethiazole Contentious SCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Chlormezanone Unsafe BMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Chlormezanone Unsafe BANAESTHESIA Chloroform Unsafe BINFECTION Chloroquine Contentious SMUSCULO-SKELETAL and JOINT DISEASE Specific Anti-Rheumatic Agents Chloroquine Contentious SCARDIOVASCULAR SYSTEM Diuretics Chlorothiazide Contentious SRESPIRATORY SYSTEM Antihistamines Chlorpheniramine Safe A CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Chlorpromazine Safe A CENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Chlorpromazine Safe A

Chlorpropamide Unsafe Associated with acute attacks of porphyria.

MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Chlorzoxazone Unsafe BGASTROINTESTINAL SYSTEM Cimetidine Contentious UCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Cinnarizine Unsafe C INFECTION Ciprofloxacin Safe BGASTROINTESTINAL SYSTEM Cisapride Safe BMALIGNANT DISEASE: and IMMUNOSUPPRESSION Cisplatin Safe DINFECTION Clavulanic Acid Safe DRESPIRATORY SYSTEM Antihistamines Clemastine Unsafe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Clobazam Contentious UCARDIOVASCULAR SYSTEM Clofibrate Safe DMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Clometacin Unsafe D

Clomiphene SafeENDOCRINE SYSTEM Hormone Preparations Clomiphene Citrate Safe B CENTRAL NERVOUS SYSTEM Psychoanaleptics Clomipramine HCL Contentious DU CENTRAL NERVOUS SYSTEM Anticonvulsants Clonazepam Contentious UCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Clonazepam Contentious UCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Clonidine Unsafe DCENTRAL NERVOUS SYSTEM Migraine Clonidine HCL Unsafe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Clorazepate Contentious UCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Clotiazepam Unsafe D

Cloxacillin SafeANAESTHESIA Cocaine Unsafe B


System/Area Sub Area Drug Useability Test CommentsTHE EYE Cocaine Unsafe B CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Co-Codamol Safe B CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Codeine Safe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Codeine PO4 Safe A MUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Colchicine Safe DCENTRAL NERVOUS SYSTEM Colistin Unsafe BENDOCRINE SYSTEM Hormone Preparations Corticosteroids Contentious SENDOCRINE SYSTEM Hormone Preparations Corticotrophin (ACTH) Safe B INFECTION Co-Trimoxazole Unsafe B

Coumarins SafeTHE SKIN Crystal Violet Unsafe B CENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Cyclizine Safe BCARDIOVASCULAR SYSTEM Diuretics Cyclopenthiazide Contentious UMALIGNANT DISEASE: and IMMUNOSUPPRESSION Cyclophosphamide Unsafe C ANAESTHESIA Cyclopropane Safe C INFECTION Cycloserine Unsafe BMALIGNANT DISEASE: and IMMUNOSUPPRESSION Cyclosporin Unsafe C ENDOCRINE SYSTEM Hormone Preparations Cyproterone Acetate Contentious SMALIGNANT DISEASE: and IMMUNOSUPPRESSION Cyproterone-Acetate Contentious SENDOCRINE SYSTEM Hormone Preparations Danazol Unsafe BGASTROINTESTINAL SYSTEM Danthron Safe AINFECTION Dapsone Unsafe A

Desferrioxamine SafeTHE EYE Dexamethasone Safe B MUSCULO-SKELETAL and JOINT DISEASE Corticosteroids Dexamethasone Safe B ENDOCRINE SYSTEM Hormone Preparations Dexamethasone Safe B CENTRAL NERVOUS SYSTEM Appetite Suppressants Dexfenfluramine Unsafe DCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Dextromoramide Contentious SCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Dextropropoxyphene Unsafe B

Dextrose SafeCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Diamorphine Safe BCENTRAL NERVOUS SYSTEM Anticonvulsants Diazepam Unsafe A CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Diazepam Unsafe AMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Diazepam Unsafe ACARDIOVASCULAR SYSTEM Anti-hypertensive Agents Diazoxide Safe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Dichloralphenazone Unsafe AMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Dichloralphenazone Unsafe A MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Diclofenac Na Unsafe A GASTROINTESTINAL SYSTEM Dicyclomine HCL Safe B

Dienoestrol UnsafeANAESTHESIA Diethyl Ether Safe ACENTRAL NERVOUS SYSTEM Appetite Suppressants Diethylpropion Unsafe CCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Diflunisal Safe B CARDIOVASCULAR SYSTEM Digoxin Safe A

Dihydralazine Unsafe


System/Area Sub Area Drug Useability Test CommentsMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Dihydrocodeine Safe A

Dihydroergotamine Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Migraine Dihydroergotamine-Mesylate Unsafe ACARDIOVASCULAR SYSTEM Calcium Channel Blockers Diltiazem Contentious U RESPIRATORY SYSTEM Antihistamines Dimenhydrinate Unsafe BCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Dimenhydrinate Unsafe B

Dimercaprol SafeDimethicone Safe

OBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Dinoprost Safe CRESPIRATORY SYSTEM Antihistamines Diphenhydramine Unsafe BGASTROINTESTINAL SYSTEM Diphenoxylate HCL Safe BCARDIOVASCULAR SYSTEM Dipyridamole Safe DMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Dipyrone Unsafe AMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Dipyrone Unsafe A CARDIOVASCULAR SYSTEM Disopyramide Contentious SCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Dixyrazine Unsafe C GASTROINTESTINAL SYSTEM Domperidone Safe CMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Domperidone Safe CCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Domperidone Safe CCENTRAL NERVOUS SYSTEM Psychoanaleptics Dothiepin HCL Unsafe C MALIGNANT DISEASE: and IMMUNOSUPPRESSION Doxorubicin HCL Safe C

Doxycycline Unsafe ANAESTHESIA Droperidol Safe C CENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Droperidol Safe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Droperidol Safe B MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Drotaverine Unsafe AENDOCRINE SYSTEM Hormone Preparations Dydrogesterone Unsafe CINFECTION Econazole Nitrate Unsafe BTHE SKIN Econazole Nitrate Unsafe B CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Enalapril Unsafe BANAESTHESIA Enflurane Unsafe COBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Ergometrine Maleate Unsafe A

Ergot Compounds Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Migraine Ergotamine Tartrate Unsafe AINFECTION Erythromycin Unsafe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Estazolam Contentious DS

Estramustine Unsafe Associated with acute attacks of porphyria.

CARDIOVASCULAR SYSTEM Diuretics Ethacrynic Acid Safe BEthambutol Safe

CARDIOVASCULAR SYSTEM Ethamsylate Unsafe C NUTRITION AND BLOOD Ethanol Unsafe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Ethchlorvynol Unsafe B


System/Area Sub Area Drug Useability Test CommentsCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Ethinamate Unsafe CMALIGNANT DISEASE: and IMMUNOSUPPRESSION Ethinyl Oestradiol Contentious SENDOCRINE SYSTEM Hormone Preparations Ethinyl Oestradiol Contentious S

Ethionamide UnsafeEthoheptazine Citrate Safe

CENTRAL NERVOUS SYSTEM Anticonvulsants Ethosuximide Unsafe A CENTRAL NERVOUS SYSTEM Anticonvulsants Ethotoin Unsafe B ANAESTHESIA Etidocaine Unsafe CANAESTHESIA Etomidate Unsafe CMALIGNANT DISEASE: and IMMUNOSUPPRESSION Etoposide Safe B

F.S.H. SafeGASTROINTESTINAL SYSTEM Famotidine Safe B

Fenbrufen SafeCENTRAL NERVOUS SYSTEM Appetite Suppressants Fenfluramine Unsafe CCARDIOVASCULAR SYSTEM Fenofibrate Contentious SDCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Fenoprofen Safe C MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Fenoprofen Safe C ANAESTHESIA Fentanyl Safe C CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Floctafenine Unsafe DINFECTION Flucloxacillin Unsafe AINFECTION Flucytosine Safe DMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Flufenamic Acid Unsafe B ANAESTHESIA Flumazenil Safe D INFECTION Flumequine Unsafe DRESPIRATORY SYSTEM Antihistamines Flunarizine HCL Unsafe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Flunitrazepam Unsafe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Fluoxetine HCL Safe B CENTRAL NERVOUS SYSTEM Psychoanaleptics Flupenthixol Unsafe C CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Flurazepam Unsafe AMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Flurbiprofen Safe B ANAESTHESIA Fluroxene Unsafe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Fluvoxamine Maleate Safe B NUTRITION AND BLOOD Folic Acid Safe B ENDOCRINE SYSTEM Hormone Preparations Follicle Stimulating Hormone Safe B NUTRITION AND BLOOD Fructose Safe A CARDIOVASCULAR SYSTEM Diuretics Frusemide Unsafe A

Fusidic Acid SafeTHE EYE Gentamicin Safe A INFECTION Gentamycin Safe CCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Glafenine Safe C

Glibenclamide Unsafe Associated with acute attacks of porphyria.

ENDOCRINE SYSTEM Anti-Diabetic Agents Glipizide Unsafe BENDOCRINE SYSTEM Hormone Preparations Glucagon Safe D NUTRITION AND BLOOD Glucose Safe A


System/Area Sub Area Drug Useability Test CommentsCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Glutethimide Unsafe ACARDIOVASCULAR SYSTEM Glyceryl Trinitrate Safe BMUSCULO-SKELETAL and JOINT DISEASE Specific Anti-Rheumatic Agents Gold-(Sodium Aurothiomalate) Unsafe CENDOCRINE SYSTEM Hormone Preparations Goserelin Safe B

Gramicidin UnsafeINFECTION Griseofulvin Unsafe ATHE SKIN Griseofulvin Unsafe A RESPIRATORY SYSTEM Guaiphenesin Unsafe CTHE EYE Guanethidine Safe C CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Guanethidine Safe ACARDIOVASCULAR SYSTEM Anti-hypertensive Agents Guanfacine HCL Safe DNUTRITION AND BLOOD Haem Arginate Safe A ANAESTHESIA Haloperidol Contentious UCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Haloperidol Contentious UANAESTHESIA Halothane Contentious UCARDIOVASCULAR SYSTEM Anticoagulants Heparin Safe BCARDIOVASCULAR SYSTEM Heptaminol HCL Safe DINFECTION Hexamine Safe CCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Hexapropymate Unsafe DCENTRAL NERVOUS SYSTEM Anticonvulsants Hydantoins Unsafe A CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Hydralazine Unsafe BCARDIOVASCULAR SYSTEM Diuretics Hydrochlorothiazide Unsafe BMUSCULO-SKELETAL and JOINT DISEASE Corticosteroids Hydrocortisone Contentious STHE SKIN Hydrocortisone Butyrate Contentious SCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Hydroxyzine Unsafe B

Hyoscine Unsafe OBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Hyoscine Butylbromide Unsafe A GASTROINTESTINAL SYSTEM Hyoscine Butylbromide Unsafe ATHE EYE Hyoscine Butylbromide Unsafe A MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Hyoscine Butylbromide Unsafe ACENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Ibuprofen Safe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Ibuprofen Safe B CENTRAL NERVOUS SYSTEM Psychoanaleptics Imipramine Contentious UCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Indomethacin Contentious SMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Indomethacin Contentious SENDOCRINE SYSTEM Anti-Diabetic Agents Insulin Safe ACENTRAL NERVOUS SYSTEM Psychoanaleptics Iproniazid Unsafe B

Iron SafeNUTRITION AND BLOOD Iron Preparations Safe A ANAESTHESIA Isoflurane Unsafe CCENTRAL NERVOUS SYSTEM Migraine Isometheptenemucate Unsafe BCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Isometheptene-Mucate Unsafe CINFECTION Isoniazid Contentious UINFECTION Josamycin Safe D

Kebuzone Unsafe


System/Area Sub Area Drug Useability Test CommentsANAESTHESIA Ketamine Contentious SINFECTION Ketoconazole Unsafe DTHE SKIN Ketoconazole Unsafe D MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Ketoprofen Safe C RESPIRATORY SYSTEM Ketotifen Safe D

L.H.R.H. SafeCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Labetalol Safe B

Levonorgestrol Unsafe Associated with acute attacks of porphyria.

ANAESTHESIA Lignocaine Unsafe CGASTROINTESTINAL SYSTEM Liquorice Safe BCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Lisinopril Unsafe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Lithium Salts Safe B CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Lofepramine Safe B CENTRAL NERVOUS SYSTEM Psychoanaleptics Lofepramine Safe B GASTROINTESTINAL SYSTEM Loperamide Safe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Loprazolam Unsafe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Lorazepam Contentious SCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Loxapine Unsafe D

Lynestrenol Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Migraine Lysuride Maleate Unsafe C GASTROINTESTINAL SYSTEM Magnesium Sulphate Safe BCENTRAL NERVOUS SYSTEM Anticonvulsants Magnesium-Sulphate Safe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Maprotiline HCL Unsafe C INFECTION Mebendazole Contentious SGASTROINTESTINAL SYSTEM Mebeverine HCL Unsafe DCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Mecamylamine Safe C

Mecillinam Unsafe Associated with acute attacks of porphyria.

Meclofenoxate HCL SafeCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Meclozine Safe A

Medroxyprogesterone Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Mefenamic Acid Contentious UMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Mefenamic Acid Contentious UINFECTION Mefloquine HCL Safe DMALIGNANT DISEASE: and IMMUNOSUPPRESSION Megestrol Unsafe C MALIGNANT DISEASE: and IMMUNOSUPPRESSION Melphalan Contentious SMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Mephenesin Unsafe D

Mephenytoin Unsafe Associated with acute attacks of porphyria.

ANAESTHESIA Mepivacaine Unsafe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Meprobamate Unsafe AANAESTHESIA Meptazinol Safe B


System/Area Sub Area Drug Useability Test CommentsCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Meptazinol Safe BRESPIRATORY SYSTEM Mequitazine Safe B MALIGNANT DISEASE: and IMMUNOSUPPRESSION Mercaptopurine Unsafe B THE EYE Mercuric Oxide Unsafe B

Mercury Compounds UnsafeCARDIOVASCULAR SYSTEM Diuretics Mersalyl Contentious S

Mestranol UnsafeCENTRAL NERVOUS SYSTEM Psychoanaleptics Metapramine HCL Contentious DU ENDOCRINE SYSTEM Anti-Diabetic Agents Metformin Safe CCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Methadone Safe ACENTRAL NERVOUS SYSTEM Appetite Suppressants Methamphetamine Unsafe BANAESTHESIA Methohexitone Unsafe CMALIGNANT DISEASE: and IMMUNOSUPPRESSION Methotrexate Unsafe C CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Methotrimeprazine Contentious S

Methoxyflurane UnsafeCENTRAL NERVOUS SYSTEM Anticonvulsants Methsuximide Unsafe A

Methyl Dopa Unsafe Associated with acute attacks of porphyria.

Methyl Sulphonal Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Appetite Suppressants Methylcellulose Safe B CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Methylphenidate Safe B CENTRAL NERVOUS SYSTEM Psychoanaleptics Methylphenidate Safe D ENDOCRINE SYSTEM Hormone Preparations Methyluracil Safe B CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Methyprylone Unsafe A

Methysergide UnsafeCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Metipropanolol Safe BGASTROINTESTINAL SYSTEM Metoclopramide Contentious UMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Metoclopramide Contentious UCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Metoclopramide Contentious UGASTROINTESTINAL SYSTEM Metopimazine Safe D

Metoprolol SafeCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Metoprolol Tartrate Safe BINFECTION Metronidazole Contentious SENDOCRINE SYSTEM Hormone Preparations Metyrapone Unsafe DCENTRAL NERVOUS SYSTEM Psychoanaleptics Mianserin HCL Unsafe C INFECTION Miconazole Unsafe DTHE SKIN Miconazole Unsafe DANAESTHESIA Midazolam Safe D CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Midazolam Contentious DSOBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Mifepristone Contentious U CENTRAL NERVOUS SYSTEM Psychoanaleptics Minaprine HCL Safe D ANAESTHESIA Minaxolone Safe C INFECTION Minocycline HCL Safe D

Minoxidil Unsafe


System/Area Sub Area Drug Useability Test CommentsCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Morphine Safe A

Nadolol SafeNadrolone Unsafe Associated with acute

attacks of porphyria.CARDIOVASCULAR SYSTEM Naftidrofuryloxalate Safe DINFECTION Nalidixic Acid Unsafe BENDOCRINE SYSTEM Hormone Preparations Nandrolone Contentious UCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Naproxen Safe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Naproxen Na Safe C INFECTION Natamycin Unsafe BCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Nefopam HCL Safe D MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Neostigmine Safe AINFECTION Netilmycin Safe DCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Nicergoline Contentious DU CARDIOVASCULAR SYSTEM Calcium Channel Blockers Nifedipine Unsafe BMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Nifumic Acid Safe D RESPIRATORY SYSTEM Nikethamide Unsafe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Nitrazepam Unsafe BINFECTION Nitrofurantoin Contentious UANAESTHESIA Nitrous Oxide Safe A

Nordazepam UnsafeNorethisterone Unsafe Associated with acute

attacks of porphyria.Norethynodrel Unsafe

INFECTION Norfloxacin Safe DCENTRAL NERVOUS SYSTEM Psychoanaleptics Nortriptyline Contentious UINFECTION Novobiocin Unsafe BOBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Oestrogens Contentious U INFECTION Ofloxacin Safe DGASTROINTESTINAL SYSTEM Omeprazole Contentious SOBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Oral Contraceptives Unsafe AENDOCRINE SYSTEM Hormone Preparations Oral Contraceptives Unsafe ACENTRAL NERVOUS SYSTEM Migraine Orphenadrine Unsafe CMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Orphenadrine Unsafe BMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Oxanamide Unsafe CCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Oxazepam Contentious UCENTRAL NERVOUS SYSTEM Anticonvulsants Oxazolidinediones Unsafe B INFECTION Oxolinic Acid Safe DTHE EYE Oxybuprocaine Safe C

Oxybutynin HCL UnsafeCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Oxycodone Unsafe CTHE EAR, NOSE AND OROPHARYNX Oxymetazoline Unsafe BCARDIOVASCULAR SYSTEM Oxypentifylline Unsafe DTHE EYE Oxyphenbutazone Unsafe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Oxyphenbutazone Unsafe A


System/Area Sub Area Drug Useability Test CommentsOxytetracycline Unsafe

OBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Oxytocin Safe BMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Pancuronium Contentious S

Pancuronium Bromide Safe Note 1ANAESTHESIA Pancuronum Br Contentious SCENTRAL NERVOUS SYSTEM Analgesics: NON-NARCOTIC Paracetamol Safe AMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Paracetamol Safe B CENTRAL NERVOUS SYSTEM Anticonvulsants Paraldehyde Safe BCENTRAL NERVOUS SYSTEM Anticonvulsants Paramethadione Unsafe A MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Parapenzolate Br Safe DCENTRAL NERVOUS SYSTEM Psychoanaleptics Pargyline Unsafe C INFECTION Pefloxacin Safe DMUSCULO-SKELETAL and JOINT DISEASE Specific Anti-Rheumatic Agents Penicillamine Safe BINFECTION Penicillin Safe ACENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Pentazocine Unsafe A

Pentolinium SafeRESPIRATORY SYSTEM Pentylenetetrazol Unsafe B

Perhexiline UnsafeCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Pericyazine Safe D CENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Pethidine Safe ACENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Phenacetin Unsafe CCENTRAL NERVOUS SYSTEM Psychoanaleptics Phenelzine Unsafe C ENDOCRINE SYSTEM Anti-Diabetic Agents Phenformin Safe C CENTRAL NERVOUS SYSTEM Anticonvulsants Phenobarbitone Unsafe A

Phenoperidine SafeCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Phenoxybenzamine Unsafe DCENTRAL NERVOUS SYSTEM Anticonvulsants Phensuximide Unsafe A

Phentolamine Mesylate SafeMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Phenylbutazone Contentious U

Phenylhydrazine UnsafeCENTRAL NERVOUS SYSTEM Anticonvulsants Phenytoin Unsafe A MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Pipebuzone Unsafe D INFECTION Pipemidic Acid Unsafe DCENTRAL NERVOUS SYSTEM Psychoanaleptics Pipothiazine Palmitate Safe DCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Piracetam Safe D

Pirbuterol SafeGASTROINTESTINAL SYSTEM Pirenzepine Safe B

Piritramide UnsafeMUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Piroxicam Unsafe CMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Piroxicam Unsafe D INFECTION Pivampicillin Unsafe B

Pivmecillinam Unsafe Associated with acute attacks of porphyria.

CENTRAL NERVOUS SYSTEM Migraine Pizotifen Safe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Prazepam Unsafe D


System/Area Sub Area Drug Useability Test CommentsCARDIOVASCULAR SYSTEM Prazosin Contentious S THE EYE Prednisolone Contentious SMUSCULO-SKELETAL and JOINT DISEASE Corticosteroids Prednisolone Contentious SENDOCRINE SYSTEM Hormone Preparations Prednisolone Contentious SCARDIOVASCULAR SYSTEM Calcium Channel Blockers Prenylamine Unsafe DANAESTHESIA Prilocaine Unsafe BINFECTION Primaquine Safe BCENTRAL NERVOUS SYSTEM Anticonvulsants Primidone Unsafe A MUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Probenecid Contentious B CARDIOVASCULAR SYSTEM Probucol Safe DCARDIOVASCULAR SYSTEM Procainamide HCL Safe DANAESTHESIA Procaine Safe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Prochlorperazine Safe B CENTRAL NERVOUS SYSTEM Migraine Prochlorperazine Safe BCENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Prochlorperazine Safe B CENTRAL NERVOUS SYSTEM Anticonvulsants Progabide Unsafe D

Progesterone Unsafe Associated with acute attacks of porphyria.

ENDOCRINE SYSTEM Hormone Preparations Progestogens Contentious U Proguanil HCL Safe

CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Promazine Safe A RESPIRATORY SYSTEM Antihistamines Promethazine Contentious U CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Promethazine Contentious U CENTRAL NERVOUS SYSTEM Tranquillisers:Anti-Emetics Promethazine Contentious U ANAESTHESIA Propanidid Contentious UCARDIOVASCULAR SYSTEM Anti-hypertensive Agents Propanolol Safe AGASTROINTESTINAL SYSTEM Propantheline Safe BOBSTETRICS, GYNAECOLOGY AND RENAL DISEASE Propantheline Safe BMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Propantheline Br Safe BANAESTHESIA Propofol Safe B

Propranolol SafeENDOCRINE SYSTEM Hormone Preparations Propylthiouracil Safe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Propyphenazone Unsafe AANAESTHESIA Proxymetacaine Contentious STHE EYE Proxymetacaine Contentious SRESPIRATORY SYSTEM Pseudoephedrine HCL Safe B INFECTION Pyrazinamide Unsafe ANUTRITION AND BLOOD Pyridoxine HCL Safe A INFECTION Pyrimethamine Contentious S

Pyrrocaine UnsafeCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Quinalbarbitone Unsafe BCARDIOVASCULAR SYSTEM Quinidine Safe CINFECTION Quinine Safe BGASTROINTESTINAL SYSTEM Ranitidine Contentious U CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Reserpine Safe A


System/Area Sub Area Drug Useability Test CommentsTHE SKIN Resorcinol Safe B INFECTION Rifampicin Unsafe BRESPIRATORY SYSTEM Salbutamol Safe B GASTROINTESTINAL SYSTEM Senna Safe ACARDIOVASCULAR SYSTEM Simvastatin Unsafe C

Sodium Aurothiomalate UnsafeSodium Bromide Safe

NUTRITION AND BLOOD Sodium Calcium Edetate Safe A INFECTION Sodium Fusidate Safe B

Sodium Oxybate UnsafeCENTRAL NERVOUS SYSTEM Anticonvulsants Sodium Valproate Unsafe U Note 2GASTROINTESTINAL SYSTEM Sorbitol Safe ACARDIOVASCULAR SYSTEM Diuretics Spironolactone Unsafe C THE SKIN ß Carotene Safe A ENDOCRINE SYSTEM Hormone Preparations Stanozolol Unsafe C INFECTION Streptomycin Safe ACENTRAL NERVOUS SYSTEM Anticonvulsants Succinimides Unsafe A NUTRITION AND BLOOD Sulbutiamine Safe D

Sulfadoxine SafeMUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Sulindac Safe C THE EYE Sulphacetamide Unsafe C

Sulphadiazine Unsafe Associated with acute attacks of porphyria.

Sulphadimidine Unsafe Associated with acute attacks of porphyria.

Sulphadoxine Unsafe Associated with acute attacks of porphyria.

Sulphamethoxazole Unsafe Associated with acute attacks of porphyria.

GASTROINTESTINAL SYSTEM Sulphasalazine Unsafe C MUSCULO-SKELETAL and JOINT DISEASE Anti-Gout Agents Sulphinpyrazone Unsafe UINFECTION Sulphonamides Unsafe AENDOCRINE SYSTEM Anti-Diabetic Agents Sulphonylureas Unsafe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Sulpiride Unsafe CCENTRAL NERVOUS SYSTEM Anticonvulsants Sulthiame Unsafe B CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Sultopride Unsafe DANAESTHESIA Suxamethonium Safe C MUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Suxamethonium Safe AINFECTION Talampicillin Safe BMALIGNANT DISEASE: and IMMUNOSUPPRESSION Tamoxifen Unsafe BCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Temazepam Safe B RESPIRATORY SYSTEM Antihistamines Terfenadine Unsafe BANAESTHESIA Tetracaine Safe C INFECTION Tetracyclines Contentious S THE EYE Tetracyclines Contentious S


System/Area Sub Area Drug Useability Test CommentsCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Tetrazepam Unsafe DRESPIRATORY SYSTEM Theophylline Unsafe BANAESTHESIA Thiopentone Na Unsafe ACENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Thioridazine Unsafe B ENDOCRINE SYSTEM Hormone Preparations Thiouracil Safe B ENDOCRINE SYSTEM Hormone Preparations Thyroxine Safe B MUSCULO-SKELETAL and JOINT DISEASE Non-Steroidal Anti-Inflammatory Agents Tiaprofenic Acid Safe BINFECTION Ticarcillin Safe BCARDIOVASCULAR SYSTEM Diuretics Tienilic Acid Safe DCENTRAL NERVOUS SYSTEM Analgesics: NARCOTICS Tilidate Unsafe BTHE EYE Timolol Maleate Safe D CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Timolol Maleate Safe DINFECTION Tinidazole Unsafe D

Tolazamide Unsafe Associated with acute attacks of porphyria.

CARDIOVASCULAR SYSTEM Anti-hypertensive Agents Tolazoline Safe ATolbutamide Unsafe Associated with acute

attacks of porphyria.CARDIOVASCULAR SYSTEM Tranexamic Acid Safe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Tranylcypromine Unsafe C CENTRAL NERVOUS SYSTEM Psychoanaleptics Trazodone HCL Unsafe C

Triacetyloleandomycin SafeTriamterene Safe

CENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Triazolam Safe C CARDIOVASCULAR SYSTEM Diuretics Trichlormethiazide Contentious SCENTRAL NERVOUS SYSTEM Hypnotics, Sedatives and Anxiolytics Trifluoperazine Safe B GASTROINTESTINAL SYSTEM Trimebutine Maleate Safe D RESPIRATORY SYSTEM Antihistamines Trimeprazine Tartrate Safe D CARDIOVASCULAR SYSTEM Trimetazidine HCL Safe DINFECTION Trimethoprim Unsafe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Trimipramine Contentious U RESPIRATORY SYSTEM Antihistamines Tripelennamine Safe B CENTRAL NERVOUS SYSTEM Anticonvulsants Troxidone Unsafe B ANAESTHESIA Tubocurarine Safe CMUSCULO-SKELETAL and JOINT DISEASE Muscle Relaxants and Anti-Spasmodics Tubocurarine Safe B

Valproate UnsafeCENTRAL NERVOUS SYSTEM Anticonvulsants Valpromide Contentious DUINFECTION Vancomycin Safe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Veralipride Unsafe D CARDIOVASCULAR SYSTEM Calcium Channel Blockers Verapamil Unsafe BINFECTION Vibramycin Unsafe BCENTRAL NERVOUS SYSTEM Psychoanaleptics Viloxazine HCL Unsafe C MALIGNANT DISEASE: and IMMUNOSUPPRESSION Vinblastine Contentious UD MALIGNANT DISEASE: and IMMUNOSUPPRESSION Vincristine Contentious UDNUTRITION AND BLOOD Vitamins Safe B


System/Area Sub Area Drug Useability Test CommentsCARDIOVASCULAR SYSTEM Anticoagulants Warfarin Na Safe B INFECTION Zidovudine Safe BMALIGNANT DISEASE: and IMMUNOSUPPRESSION Zidovudine Safe BTHE SKIN Zinc Preparations (Topical) Safe BTHE EYE Zinc Sulphate Safe ACENTRAL NERVOUS SYSTEM Psychoanaleptics Zuclopenthixol Unsafe C


A GUIDE FOR PEOPLE WITH PORPHYRIA - Retina · Web viewA GUIDE FOR PEOPLE WITH PORPHYRIA...

Documents

Transcript of A GUIDE FOR PEOPLE WITH PORPHYRIA - Retina · Web viewA GUIDE FOR PEOPLE WITH PORPHYRIA...