How to write prescription ?

For dentists

By

Dr/ Mohamed waheed

n is y las 2010@ r p .fa bo .c

part 1:

As we all know we don’t have enough info about medications to use in our field coz we just take pharma in 2nd year and not take applied info about how to use it

And I hope from this article to help us solving that problem .I will give few guideline about how to use antibiotic and analgesic according to needed plus some trade names for the most widely used medication in dental field (note the following info not from my own search but its is from course that I took few months ago in Alrazy center for science and development on the hand of specialist pharmacology professor

First I will start with antibiotic and its different types acc.to mode of action

1-antibiotic inhibit cell wall synthesis e.g

-penicillins -cephalosporines -monbactam -carbpenem -glycopeptides

2-antibiotic inhibit protein synthesis

-linosamide -tetracyclines -macrolides –aminoglycoside -chlorameficol

3-antibiotic affect nucleic aid

Quinolone

General guideline for using antibiotic

1- antibiotic should be prescriped only when needed to fight infections and as prophylactic only in medically compromised case like patient with heart and valve problem to avoid resistence of bacteria

2-history of allergic reactions should be considered and taken before antibiotic taken spec. for penicillins and cephalosporine

3-course of antibiotic should be continue for 5 to 7 days even if the sign of infection has been resolved with exceptions in cases of macrolides which the course should only be from 3 to 5 days and not ever exceed it

4-dose of antibiotic should be considered acc to the type of antibiotic dose for example

Penicillins can be used up to 2000 mg per day in form of 1000mg/12hrs or 500 mg /6hrs

5-dose should be adjusted in patient with liver disease and renal disease and switch between drugs that not excreated by the diseased organ is much better

6-medication as general not preferred to be used in pregnancy or laction due to its side effects but when there is need for it we should use the antibiotic that has the least effect like penicillins and cephalosporine and avoid tetracycline , quinolone and macrolides

7-antibiotic injection should be used on cases of sever infection as its fase action over oral antibiotic but with an precautions and allaerg test should be done even the injection is IV or IM

8-in cases of severe infections a combinations of antibiotic should be used for examples

Penicillins and metronidazole or clindamycin

9-its preferred to write medications as general in few times daily to ensure patient wil take them for example single dose or twice daily better than 4 times daily and the patient will not miss a dose

10-antibiotics begin to work in 1 to 3 days but after that time pass and no result appear u should switch to another antibiotic

11-antibiotic dose for children should be calculated acc to the equotion by the age or by the weight

And finally to ensure good result u should avoid as long as possible the widely used un prescriped medications that unwisely taken by patient as bacteria may be resistant

We will start with short list of trade name of the 1st generations of cephalosporine that is widely used in dental field

1-ceporex 500mg ,1gm tab and 125,250mg susp

2-duricef 250,500mg cap & 1gm tab and 125,250,500mg susp and 100mg drops

3-biodroxil 500mg cap& 1gm tab and 250,500mg susp

4-velosef 250,500 mg cap &1gm tab and125, 250mg susp and 250,500mg ,1gm vial

5-longicef 500mg cap and 125,250mg susp

6-curisafe 500mg cap and 125,250mg susp and 100mg drops

7-Ibidroxil 500mg cap,1gm tab and 125,250,500mg susp

8-keflex 500mg,1gm tab and 250mg susp

Part 2:

Antibiotic ( penicillin) mode of action by inhibiting cell wall synthesis

It has some effect on g +ve aerobic bacteria ex streptococcus but some bacteria ex staph. aures synthesis Beta-lactamase enzyme and can resist certain types of penicillin

1-penicillin V oral sensitive penicillin and bacteria can resist it so it may be used as prophylactic ex ospen 1000,1500IU and 400IU susp dose 1000IU /8hrs

2-penicillin G injection it is the long acting penicillin used as prophylactic in case of rheumatic fever ex durapen ,retarpen 1200000 IU vial ,

Note patient on long acting penicillin still need antibiotic coverage in cases of infection as penicillin G is weak and bacteria can resist it

IU = international unit

3-ampicillin

it must be used on empty stomach as it is affected by food so it should be used one hour before eating or two hours after eating to be effective

staph.bacteria can resist it & adult dose 500mg/6-8hrs

examples

epicocillin 250,500mg caps&125,250mg susp&250,500mg,1gm vial

ampicillin 250,500mg caps&125,250mgsusp&500mg,1gm vial (widely used )

4-amoxicillin

Not affected by food & adult dose 500mg/8hrs

staph.bacteria can resist it

examples

hiconcil 250,500mg caps&125,250mg susp&100mg drops

amoxil 500mgcaps&125,250mg susp&250,500mg,1gm vial

E-mox 500mgcaps&125,250mg susp&250,500mg,1gm vial

Amoxicillin 500mg caps

Biomox 250,500mgcaps&125,250mg susp

Ibiamox 250,500mgcap&125,200,250,400mg susp & 250,500mg,1gm vial

Ospamox 750mg,1gm tab

Alemox 750mg,1gm tab

Note due to resistant of bacteria to ampicillin and amoxicillin its used become mainly as prophylactic before extraction in patient with heart problem to avoid bacterial endocartditis

5-compination penicillin

Consist of more one type of penicillin to avoid resist of staph bacteria

a-(amoxicillin+flucloxacillin) ex

flumox 250,500mgcaps& 250mg susp &500mg,1gm vial

amflux 500mg,1gm vial

floxamo 1gm tab

amofluxine 250mg caps &500mg vial

amoflux 125mg susp

b- (ampicillin+cloxacillin ) ex

ampiclox 500mg caps&500mg vial &250mg susp

c-(ampicillin+dicloxacillin)ex

dipenacid 500mgcaps &250mgsusp &100mgdrops &250,500mg,1gm vial

adult dose for combined penicillin l

1gm/12hrs or 500mg/8hrs but in cases of staph infection which can resist ampicillin and amoxicillin we can use the combined penicillin in modified dose of 1gm/8hrs to avoid the destruction of half of combined penicillin by the staph bacteria

6-penicillin + beta lactamase inhibitor (clavulanic acid or sulbactam )

Beta lactamase inhibitor ensure complete effect against bacterial resistance (staph) also increase effect on anaerobic bacteria

that inhibitor used by percent of 7:1 or 14:1 penicillin: inhibitor

this type have very potent effect and also its expensive

a-( amoxicillin+clavulanic acid )

augmentin 375,625mg,1gm tab & 156,312,457,600mg susp&600,1200mg vial

curam 625mg,1gm tab & 156,312,457mg susp

klavox 375,625mg,1gm tab & 156,312, 457 mg susp

E-mox clav 375,625mg,1gm tab & 156,312 susp

Hibiotic 375,625mg,1gm tab &156,230,312,460mg susp

Delta clav 228.5,457mg susp

Magna-biotic 375,625mg,1gm tab & 600,1200mg vial & 156,312 mg susp

Augmacillin 228,457 mg susp

Adult dose 625mg/8hrs or 1gm/12hrs

b-(ampicillin + sulbactam )

unictam 375mg tab & 250mg susp & 375,750,1500mg vial

unasyn 375mg tab & 250mg susp & 375,750,1500,3000mg vial

ampictam 375mg tab & 250mg susp & 750,1500mg vial

sulbin 375,750,1500mg vial

ultracillin 375,750,1500mg vial

sigmacyn 375mg tab& 250,375mg susp

adult dose 750mg/8hrs or 1500mg/12hrs

Notes

all penicillin excreated from kidnay except flucloxacillin

augmentin and its group is know to produce cholestasis ( jaundice – nausea –itching ) in healthy patient after 2 weeks of use so it is completely contraindicated in patient with liver disease and used in caution with pregnant after consulting with physician

penicillin is as general safe to use with pregnant ,lactating women and children

penicillin allergy is very common and must be taken in consideration before prescriping injection also more than 10% of patient allerg to penicillin is also show allergy to cephalosporine so it may be better to swith to clindamycin or macrloides antibiotic

part 3 :

2-cephalosporine mode of action by inhibiting cell wall synthesis

there is 4 types of cephalosporine generation but the most widely used in dental field is the 1st and 3rd generation

a-first generation has same effect like penicillin and widely used

examples of 1st generation antibiotic are previously mention in part 1 of this topic

b-third generation has great effect against -ve bacteria and some effect against +ve bacteria , there is main four subtypes of 3rd generation

most of it is in injection form

examples of third generation

1-cefotaxime ex :

Cefotax 250,500mg,1,2gm vial

Ceforan 500mg,1gm vial

Claforan 500mg,1gm vial

Cefaxim 500mg,1gm vial

Xorin 500mg,1gm vial

Rametax 500mg,1gm vial

Sigmataxim 500mg,1gm vial

2-cefoperazone

Cefobid 500mg,1gm vial

Cefazone 500mg,1,2gm vial

Cefrone 500mg,1gm vial

3-ceftazidime

Fortum 250,500mg,1gm vial ( IM vial form contain L.A , IV vial form without L.A )

Cefzim 250, 500mg,1gm vial

Kefadim 500mg,1gm vial

4-ceftriaxone

Ceftriaxone 250,500mg,1gm vial ( IM vial form contain L.A , IV vial form without L.A )

Cefaxone 250,500mg,1gm vial

Rocephin 500mg,1gm vial

Adult dose up to 1gm/12hrs

Cephalosporine is generally safe to use even with neonate, also safe in pregnancy and lactation (put in mind previous precaution concerning pregnancy) ,most safe cefadroxil

All cephalospoine is excreated from kidnay except cefoperazone and ceftriaxone which both excreated from liver

3-lincosamide mode of action by inhibiting protein synthesis

It has effect on + ve and many anaerobic bacteria

the main side effect is Mild diarrhea; nausea; vomiting

a-clindamycin

clindam 150,300mg caps

dalacin c 150,300mg caps & 150,300,600 mg amp

clinacyn 150,300mg caps

clindacine 150mg caps

mepaclind 150,300mg caps

b-lincomycin

lincocin 300,600mg amp

clindamycin safe and not known to be harmful during pregnancy

adult dose 300mg/8hrs

note clindamycin can be used as prophylactit antibiotic in dose of 600 mg one hour before treatment for adult

lincosamide is excreated through liver and so it can be used in cases of reanal failure also can be used in case of patient is allergic to penicillin and cephalosporine

also clindamycin not known to be harmful during pregnancy

4-tetracyclines mode of action by inhibiting protein synthesis

Not more widely used because its side effect specially concerning teeth discoloration if taken during pregnancy and in children up to age of 8 to 12yrs and so it is contraindicated in those previous cases

a-doxycycline used mainly in treatment of periodontitis with dose of 100mg/12hrs

doxymycin 100mg

vibramycin 100mg

doxy MR 100mg used once daily

b-oxytetracycline used as mouth bath in cases of aphthous ulcer also some dentist use it as topical antibiotic in irrigation solution in RCT

ex: oxytetracid 250mg

c-tetracycline used as mouth bath in cases of aphthous ulcer also some dentist use it as topical antibiotic in irrigation solution in RCT

ex: tetracid 250mg

5-macrolides mode of action by inhibiting protein synthesis

Has some effect on + ve bacteria ( streptococcus bacteria )

May cause GIT disturbance

a-azithromycin ex:

zithromax 250mg caps,500mg vial ,600,900,1200mg susp

xithrone 250mg caps ,500 tab ,200mg susp

zithrokan 100,200mg susp&500mg caps

zithrocin 100mg susp& 500mg caps

azomycin 250mg susp& 250mg caps

note azithromycin can be used as prophylactic antibiotic in dose of 500mg one hour before treatment for adult

adult dose 500mg /24hr (once daily) one hour before eating or 2hours after eating as it is affected by food for 3 to 5 days not more than that

note It can be used for 7 days for severe infection in some cases that not related to

dental field ex in STD

b-erythromycin ex: there is some resistance to it shown from +ve bacteria

erythromycin 200mg susp,500mg caps

adult dose 500mg/12hrs for 3 to 5 days not more than that

c-clarithromycin ex:

klarimix 250,500mg & 125mg susp

adult dose 500mg/12hrs for 3 to 5 days not more than that

d-spiramycin has some effect against –ve bacteria ex:

rovamycin 1.5,3 MIU tabs (MIU=million international unit)

spiramycin 1.5,3 MIU tabs

-both of azithromycin ,erythromycin and spiramycin are excreated from liver but clarithromycin is excreated from kidnay

- data present are not enough to be sure if it is completely safe during pregnancy and lactation so it is wisely to avoid it as possible at least in infection related to dental field

- macrolides can be used in case of allergic to penicillin and cephalosporine

When you prescribe macrolide you should put in your mind the following interaction with other medications

-macrolides + antidiabetic lead to hypoglycemia

-macrolides + anticoagulant lead to increase effect of anticoagulant and increasing bleeding tendency

6- quinolone mode of action by affecting nucleic acid (DNA&RNA)

It effect on +ve bacteria increase from 1st to 4th generation

Not widely used in dental field ,most of it use in renal and pulmonary infection

It shouldn’t be used under age of 18 yrs old as it may cause cartilage defects also shouldn’t be used beyond age of 60yrs old

Also contraindicated during pregnancy and lactation

Dose of quinolone and duration of administration is adjusted according to type of infection ( it may be used from 7 to 10 days )

1- Second generaion

adult dose from 250mg up to 750mg per day used twice daily ex:

Bactiflox 250,500mg tab

Ciprofloxacin 250,500mg tab&200mg vial

Ciproxil 1gm tab

Neofloxin 400mg tab

Ofloxin 200mg tab

Ciprofar 250,500,750 mg tab

2-third generation

Adult dose from 400 to 500mg per day used once daily ex:

Gatiflox 400mg tab

Unibiotic 250,500 mg tab

They previous mentioned types of quinolone are manily excreated from kidnay

Put in mind interaction between quinolone + anti diabetic which lead to hypoglycemia

7-rifampicin mode of action by affecting nucleic acid (DNA&RNA)

It use limited only in treatment of TB infection also it have some antiviral effect

Ex rimactane 300 mg cap & 100mg susp

Rifampicin 150,300mg caps

It is always called drug of tuberculosis and also can be used as moth bath in cases of herps simplex due to its antiviral effect but as second choice as it is preferred to limit its use to TB infection only

part 4 : (last part of antibiotic)

8-nitromidazole (ex: metronidazole ( mode of action by reduction of nitro group of DNA bacteria and protozoal to unstable compound

Is an antibiotic for anaerobic bacteria , and antiprotozoal

nitromidazole group contain 3 subtypes

1-metronidazole most widely used

2-tinidazole

3-secnidazole

1-metronidazole very potent against anaerobic bacteria(widely used in dental field)

Ex : -flagyl 250,500mg tab&125mg susp &500mg IV infusion which used in hospital )note some dentist use (flagyl IV infusion) as follow ---> 0 .5cm of flagyl IV infusion inject it in canal on RCT as topical anaerobic antibiotic it give good result but this not scientifically proven

-Amirzole 250,500mg tab&125mg susp

Adult dose 250 to 500 mg /8hrs for 3 to 5days

Metronidazole mainly excreated from liver 85% so it is contraindicated in cases of liver disease and if it is must to use it the dose is reduced to one third(1/3) only of healthy patient dose

Metronidazole should be used in caution in patient with blood disorder or even it may be contraindicated as in case of G6PD deficiency

Metronidazole is contraindicated in pregnancy and lactation

Disadvantage metallic taste and GIT disturbance

2-tinidazole (not widely used in dental field )

-protozole 500mg tab

-fasigyn 500mg tab

adult dose 1gm/12hrs for 3 days or 2gm/24hrs (once daily )

3-secnidazole most safe and less metallic taste (not widely used in dental field )

-Secnidazole 500mg tab

-Cipazoleforte 1gm tab

Adult dose 2gm /24hrs (once daily )

9-compination of more than one type of antibiotic in one drug

Ex spirozole tab (125mg spiramycin +125mg metronidazole) adult dose 3times daily

Spirozole forte tab (250mg spiramycin+250mg metronidazole ) adult dose two or three times daily

should be taken on empty stomach

Contraindicated in patient with blood disorder&patient with active nervous system disease

Ex:conaz tab , norfloxacin TZ tab both consist of (400mg norfloxacin + 600mg tinidazole ) may be used in dental field

adult dose twice daily for 5 days with or after meals

contraindicated in children under age of 15 ,also in pregnancy and lactation ,patient with convulsions ,liver diseases , blood disorders ,

disavdangets nausia,vomting,rashes, anemia ,acute hepatitis,

also shouldnt be taken with anti-acid as it may affect its absorption from GIT

How to write the prescription ?

a-First u have to know the following abbreviation

tablets = tabs.

syrup= syrp.

suspention = susp.

capsules = caps.

suppositories = sup.

ampules = amp.

vial = vial

ointment = oint.

gel = gel

drops=dp.

Mouth wash =M/W.

Gargle=gargle

sachets =sach.

effervescent =eff.

the following abbrevation (latin)

ac... Take medication before meals.

bid …Take medication twice a day.

hs... Take medication at bedtime.

po... Take medication by mouth.

pc... Take medication after meals.

prn ... Take medication as needed.

q3h ...Take medication every three hours.

qd…Take medication every day.

qid... Take medication four times a day.

tid ... Take medication three times a day

b- form of any prescription

1-name of drug (trade name)

2-concentration of drug ex125,250,500mg ,…etc

3-form of drug ex caps,tab,susp,…etc

4-dose of drug which can be written in more than one way

Ex –by write the dose :-three time daily or cap every 8hrs (most known )

Ex – by numbers 1x3 mean three time daily

Ex –by abbreviation mention qid or tid or bid

5-duration of course 3,5, 7 days or may be as needed

Ex

Rx:Floxamo 1gm tab

Tab every 12hrs for 7 days or twice daily Or 1x2 or bid

6-in case of prescriping injection s we should write the No. of inject and also you should ask for sensitivity test specially before IV injection

Ex

Rx: Unictam 1.5gm vial NO:6

IM injection every 12hrs for 3 days

Note : the all four parts of this topic contain most of the widely used antibiotic in dental field , and so there are plenty of antibiotic that not mention here (not related to dental field )

All the previously mention drugs are in the market but some concentration is not widely handed so you better check the present form of drugs in the nearest pharmacy

You can also search for the different concentration of drugs from the website

www.arabrxlist.com which contain most of drug index in the Arabic countries

part 5 :

-Anti-edematous drugs

Used in cases of swelling either from infection or after minor surgery to decrease swelling also have anti-inflammatory effect and also increase effect of antibiotics

Ex

α – chymotrypsin amp (IM) dose once daily

sensitivity against this drug has been reported in some patient so it is better to ask for sensitivity test if you prescribe it

alphintern tab dose 3 times daily on empty stomach (1hr before meal )

ambezim-g tab dose 3 times daily on empty stomach

maxilase syrup dose 3 times daily on empty stomach

reparil tab dose 3 times daily after meals

reparil gel –N gel topical use not widely used in dental field

-Anti-viral drugs ( mode of action by inhibiting viral replication ex acyclovir)

Dose of anti-viral drugs differ according to type of disease

Ex

acyclovir 200,400,800mg tab & 100,250,500mg amp & skin cream &eye cream

lovir dipersable tab for children ( dispered in a quarter of glass of water )

zovirax 200,400mg tab & syrup for children & vial & skin cream &eye cream

(it is very expensive and mainly the only form prescriped is the syrup form for children )

-Anti-fungal drugs

1-Nystatin mode of action by interfering with ergosterol (fungicidal )

Ex nystatin oral-drops , cream

Fungistatin oral-drops

Mycostatin oral-drops, ointment

dose 4 times daily for about 7 to 10days

2-amphotericin B mode of action by interfering with ergosterol (fungicidal )

Systemic anti-fungal not used in dental field

3- Imdazole group mode of action by inhibiting ergosteral synthesis

a-miconazole

ex: daktarin oral gel

miconaz oral gel orange taste

micazole oral gel strawberry taste

adult dose half of spoon 4 times daily

children dose a quarter of spoon 4 times daily

The gel should be kept in mouth as long as possible and the treatment should be continued for a week after the symptoms have disappeared

note the previous drugs also supplied in cream form which used topically only on skin also may be supplied with hydrocortisone like daktacort and miconaz –H

b-fluconazole (systemic antifungal)

ex : flucoral 150mg caps

diflucan 50,150mg caps & syrup(5mg/ml) & parental infusion

flocazole 50,150mg caps

alkanazole 50,150mg caps

fungican 150mg caps

triconal 50,150mg caps

treflucan 150mg caps

contraindicated in renal failure so we may use itraconazole

c-ketoconazole (systemic antifungal)

ex fungizole 200mg tab

ketozole 200mg tab

kizole 200mg tab

nizoral 200mg tab

ketoconazole 200mg tab

contraindicated in pregnancy and in liver diseases

d- itraconazole (systemic antifungal )

ex itranox 100mg caps

arozole 100mg caps

itracon 100mg caps

itrapex 100mg caps

sporanox 100mg caps

contraindicated in liver disease

systemic antifungal drugs may be used in cases of chronic candidal leukoplakia or in candidal infection in immunosuppressive patient(ex AIDS)

dose of systemic antifungal about one tab once in a week for two weeks or

one tab daily for two days only in a week for two weeks

-Anti-hemorrhagic drugs

Hemorrhage after extraction or after minor surgery is common complication and it may be due to local or systemic causes and there are many ways to avoid that beginning from good medical history to detect condition which affect blood clot , blood vessel ligature and may be medications

1-Vitamin K drugs which used in patient with liver diseases

Ex: amri-k 10mg amp

Konakion 10mg amp , 10mg tab (expensive)

Haemokion 10mg amp ,10mg chewable tab

Phytovit MM 10mg amp

K1apex chewable tab

Alcokion chewable tab

k-viton chewable tab

Adult Dose 10 mg once daily intramuscular injection

Children dose : 2 to 5 mg

Note that it can be given IV but slow infusion but not preferred as it may cause complications

In patient with liver disease it should be taken from about 30 to 60minute before extraction and put in mind that even with vit.K amp patient with liver disease may

still bleeding so you may need to ask the patient to make INR,CBC,bleeing time,clotting time,before extraction

Vitamin K cant be used topically coz some dentist may crush amp in cotton and applied it topically and that is completely unuseful

2-drugs that used to stop bleeding

Ex : A-ethamsylate

a-Haemostop 250mg amp &250,500 mg tab

Dose acc. to case ex:

The ampoule may be crushed in gauze or cotton and applied in the socket after extraction

In minor surgery it may used 500 mg as loading dose and continue 250 mg every 6 hrs till bleeding stop also it may be used as prophylactic 2 amp 2hrs before surgery

b-hemostat 250mg amp ,500mg tab

The ampoule may be crushed in gauze or cotton and applied in the socket after extraction

Dose acc. to case prophylactic 2 amp IM 2hrs before extraction or for treatment of bleeding 2 amp IM them 250to 500 mg every 6hrs

c-dicynone 250mg amp,250,500 mg tab

dose acc. To case

prophylactic 500 mg 1hr before surgery

post surgical 500 mg every 6hrs

it is contraindicated in pregnancy and lactation

B-tranexamic acid (antifibrinolytic drug)

Ex kapron 500mg amp, 500mg tab

Used in cases of prevention of bleeding after surgery or after extraction

Adult dose

Orally :1 gm to 1.5 gm about 2 to 4 times daily or (15to 25 mg/kg) 2 to 4 times

Slow IV .5gm to 1gm 3 times daily

Contraindicated in patient with renal disease

3-drugs that decrease bleeding by V.C of blood vessels

Epinephrine amp (.25mg/ml) adrenaline decrease bleeding by vc effect but it may lead to delayed bleeding due to the V.D effect amp curshed and put above wound also it may lead to hypertension if reach the vessels

We can also use local anaethesia with epi. as v.c on cotton to decrease bleeding from small vessels

4- vitamin C that is capillary stablilizing agent and enhance healing

ex:

Rutin –C caps

Ruta–C 60 tab

Rutalex-C tab