Die Struktur von Tadalafil erlaubt eine selektive Bindung an die Bindungsstelle der PDE5 und minimiert gleichzeitig die Interaktion mit PDE6, was visuelle Nebenwirkungen einschränkt. Seine Verteilung im Organismus erfolgt breit, wobei das Verteilungsvolumen etwa 63 Liter beträgt. Über 90 % des Wirkstoffs sind an Plasmaproteine gebunden. Die Wirkung bleibt unabhängig von der Nahrungsaufnahme konstant. Der Abbauweg über CYP3A4 kann durch Hemmer wie Ritonavir oder Ketoconazol verlangsamt werden, was die Plasmakonzentrationen deutlich erhöht. In diesem Kontext wird cialis 20mg preis häufig in Bezug auf pharmakokinetische Wechselwirkungen erwähnt.
Serotonİn
SEROTONIN Biosynthesis and Metabolism L-Tryptophan
Tryptophan-5-hydroxylase X p-chlorophenilalanine p-chloroamphetamine 5-Hydroxy tryptophan (5-HTP)
Dopa decarboxylase 5-Hydroxytryptamine (5-HT) 5-HT N-acetylase MAOA-B N-acethyl-5-HT Hydroxyindol O-methyltransferase 5-hydroxyindole acetaldehyde Melatonin Aldehyde dehydrogenase Aldehyde reductase 5-HIAA 5-Hydroxytryptophol Kidney Distribution and Storage
• Found in plant (eg. bananas), animal tissues,
• Enterochromaffin cells in the gastrointestinal tract
• Serotonergic neurons in the enteric nervous system
• Raphe nuclei of the brain stem, brain serotonergic
neurons (involved in deppression, anxiety, migraine, mood, sleep, appetite, temperature regulation, pain, blood pressure and vomiting)
• Pineal gland (Serotonin → Melatonin) • Carcinoid tumor
Pharmacological Effects
Cardiovascular System • A powerful vasoconstrictor except in skeletal muscle
• Dimetoxyiodophenylaminopropan → 5-HT ↑→
• Sumatriptan → 5-HT1D → vasoconstraction
• Ergot alkaloids → 5-HT1 → vasoconstraction
• Serotonin → Angiotensin II, norepinephrine, PGF2α↑→
1. Bezold-Jarich reflex → blood pressure ↓ 2. Vasoconstraction → blood pressure ↑ 3. Vasodilation in vessels in skeletal muscle, NO ↑→
Airways
bronchial sensory nerve ending → hyperventilation
• Bronchospasm in asthmatic patients Gastrointestinal tract • The stimulatory response → direct effects of 5-HT in smooth muscle cells (5-
in intestine and 5-HT2B in stomach fundus)
→ stimulation of enteric ganglia (5-HT ↑
→ stimulation of nevre endings on longitudinal and
• Relaxation or contraction in esophagus (5-HT ↑
• Enteric 5-HT → intraluminal pressure↑, pH ↓,
intraluminal pressure↑, pH ↓, peristaltic contraction ↑ (5-HT ↑
Nervous System • present in raphe nuclei of the brain stem, brain
in vomiting center and GI tract → vomiting
reflex X Ondansetron, granisetron.
• A potent stimulant pain and itch sensory nerve ending
chemoreceptor reflex (Bezold-Jarich reflex) → bradycardia and hypotention
Pathophysiologic effects Carcinoid tumors
Enterochromaffin cell tumors → secretion of 5-HT↑→ serotonin crysis X octreotide Migrain • Plasma and platelet 5-HT concentrations vary with the
• Urinary concentrasions of 5-HT and its metabolites↑ Dumping sendrome Postgastrectomy sendrome (flushing, dizziness, weakness, vasomotor collapse, pain and headache) Pulmonary embolism Thromboemboli → Serotonin ve TXA ↑→
(5-HT2 X Ketanserin) Anxiety and depression Serotonin→5-HT →
(Buspirone)
Serotonin Agonists
• Acute treatment of migraine attacks with or without
• Cont: Ischemic heart disease, peripheral and cerebral
vascular syndromes, uncontrolled hypertension, use within 24 hours of ergotamine derivatives, another 5-HT1 agonists; use within 72 hrs CYP3A4 inhibitors, hemiplegic or basilar migraine, prophylactic treatment of migraine, severe hepatic impairment, in patients <18 years of age
• Adverse reactions: Chest pain, palpitation, dizziness,
headache, chills, pain, vertigo, nausea, vomiting,
dyspepsia, abdominal pain/discomfort, weakness, paresthesia, back pain, hypertonia, pharyngitis
• Pregnancy Risk Factor C Eletriptan (Relpax) • It is the latest addition to this group
• Ketoconazole, erytromycin, fluconazole & verapamik
Naratriptan (Naramig) • Is the one of the most potent 5-HT agonist
• The active metabolite, N-desmethyl rizatriptan has
Rizatriptan (Maxalt RPD) • Absorption and elimination are rapid
• Metabolise by MAO-A to inactive metabolites
• Competitive inhibitor of CYP2D6 Sumatriptan (Imigran, Sumatran) • 5-HT1B and 5-HT1D ↑→ Acute migraine and Cluster
• Contraindicated in coronary artery disease and angina
• Naratriptan is contraindicated in severe hepatic or
renal impairment, peripheral vascular syndromes
Zolmitriptan (Zomig) • The dose should be reduced in moderate to severe Ergotamine (Avmigran, Cafergot, Ergafein), dihydroergotamine (Neomigran) • Some of their properties are similar to those of
Additional effects: adrenergic receptors block, vasoconstriction directly
Buspirone (Buspon), gepirone, ipsapirone • 5-HT ↑
Methysergide (5-HT1 and 5-HT2 block)
strong competitive serotonin antagonist, partial serotonin agonist (vasoconstrictor)
• used in the prophylaxis of migraine and Horton
• antidiaretic in carcinoid syndrome and Dumping
• contraindicates in peripheral vascular diseases and
Cyproheptadine (5-HT2A ve H1 block)
• Antidiaretic in carcinoid syndrome and Dumping
• side effects: weight gain, drowsiness and increased
Ketanserin (5-HT1C, 5-HT2 and α1 block)
• used in the treatment of hypertension,
vasospastic conditions and Raynaud syndrome
Ritanserin (5-HT2 block)
• platelet agregation ↓, vasoconstriction↓,
Granisetron >Ondansetron (5-HT3 block)
• used in the prevention of nausea and vomiting Tropisetron (5-HT3 block)
• used in the prevention of nausea and vomiting Pizotifen (Antiserotonerjik, antihistaminik) • used in the prophylaxis of migraine
Summary of prescribing guidance for thetreatment and prophylaxis of influenza-likeillness: TREATMENT PHASEThis guidance is intended to enable health protection units (HPUs) to address local queries aboutthe treatment and prophylaxis of influenza A(H1N1). It is not a substitute for the Summary ofProduct Characteristics (SPC) and the Patient Information Leaflet (PIL) which must accompany theFurt