Basic course in Pharmacology in the third- and forth-year medicine clerkship (in two semesters) Knowledge is evaluated using written tests and a final oral exam.
1st semester
A. Lectures* and practical classes or seminares
Subject:Practical demonstration and/or case reports
Basic principles of pharmacology. Pharmacodynamics and pharmacokinetics
Seminar, written testFactors influencing the response to a drug
a.depending on the drug
b.depending both on the drug and on the body
c.depending on the body
Seminar, written test
Adverse and toxic effects of drugs. Drug interactions. Seminar, written test
Drug development.
Cholinoceptor-activating and inhibiting drugs
Seminar, written test, Adrenonoceptor-activating and inhibiting drugs
Seminar, written test, Cardiac glycosides
Agents used in cardiac arrhythmias
Antihypertensive drugs
Vasodilators, drugs inducing hypotension. Diuretics. Histamin, antihistaminics.
* texts of all lectures are available for students in the written or electronic forms
Practical classes and seminars
1. Basic principles of pharmacology. Pharmacodynamics and pharmacokinetics - the seminar on:
Pharmacodynamics: nature of drug receptors and their types. Well-established second messengers. Dose-response
curve. Potency and efficacy. Agonists and antagonists. Up and down regulations. Variation in drug responsivness.
Pharmacokinetics: Main mechanisms determining pharmacokinetics of a drug (physico-chemical properties,
permeation through biomembranes, binding)
Absorption, distribution, metabolism, excretion. Pharmacokinetic parameters. Pharmacogenetics.
Bioavailability, bioequivalence.
Written test
Practical demonstrations using Simulated pharmacological preparations by I.E.Hughes Isolated ileum stimulation. Drugs available: acetylcholine, atropine, papaverine, physostigmine, carbachol, methacholine. Topics: Agonists and antagonists. Dose- respose curve construction and its modification.
2. Factors influencing the response to a drug:
Seminar, written test
a. depending on the drug:
physico-chemical features, route of administration, drug formulation, food
b. depending both on the drug and on the body:
dose, repeated administration (accumulation, tolerance), coadministration with other drugs (synergism,
antagonism), delayed effects (teratogenesis, cancerogenesis, mutagenesis)
c. depending on the body:
gender, age, genetic information, pathological state.
Practical demonstrations. Pharmacokinetics I using MUPHARM by L.Saunders et al. Students estimate the influence of different factors on the pharmacokinetics (plasma concentrations) of drugs with a narrow therapeutic window the effects of which are closely related to plasma concentrations: importance of enzyme stimulation (theophylline in smokers) for drugsþ biotransformation. Loading dose at the start of a continuous IV infusion in patients with normal liver functions and in those with hepatic disorders. Sustained- release formulations of drugs and etc.)
3. Adverse and toxic effects of drugs. Drug interactions. Drug development Seminar, written test
4. Cholinoceptor-activating and inhibiting drugs
Seminar, written test
Practical demonstrations using Pharmacology teaching aids, PC program Simulated heart rate and blood
pressure (in vivo) by I.E.Hughes. Drugs available: acetylcholine, atropine, neostigmine, hexamethonium) in
reserpinised, pithed and normal preparation.
5. Adrenoceptor-activating and inhibiting drugs
the seminar, written test
Practical demonstrations: using Pharmacology teaching aids, PC program Simulated heart rate and blood
pressure (in vivo) by I.E.Hughes. Drugs available: adrenaline, noradrenaline, isoprenaline, prazosine, propranolol,
atenolol, cocaine, tyramine, in reserpinised, pithed and normal preparation.
6. Histamin, antihistaminics
Seminar, written test
Practical demonstrations: using Pharmacology teaching aids, PC program þSimulated heart rate and blood
pressure (in vivo) by I.E.Hughes. Drugs available: histamine, mepyramine, ranitidine.
7. Cardiac glycosides Agents used in cardiac arrhythmias
Seminar, written test
Practical demonstrations: Pharmacokinetics in medical practice: Pharmacokinetics II using: Pharmacology
teaching aids, PC program PKSIMS by I.E.Hughes. This package enables students to learn about basic
pharmacokinetic parameters, the importance of the route of administration, biovailability, loading doses, toxic and
therapeutic plasma concentrations. Effects of kidney /liver failure and the relationship between steady state plasma
concentrations and dose for drugs with either normal or saturation kinetics.
Pharmacokinetics of digoxin and lidocaine in patients with impaired renal and hepatic functions.
8. Antihypertensive drugs
Seminar, written test
Practical demonstrations: Handling the electronic form of the Czech Drug Formulary
via the selection of information about various antihypertensive drugs the goal of which is to: make a choice of
drugs with different trade names with the identical generic name; consider adverse effects (for treatment of a
diabetic patient or patient with impaired cardiac or renal functions); calculate the cost of therapy; consider an
overview of manufacturers product.
9. Vasodilators.
Seminar, written test
Practical demonstrations: using Pharmacology teaching aids, PC program Simulated isolated vascular
preparations. Arterial and venous ring in vitro. Arterial ring with intact endothelium and denuded of endotheliumþ
by I.E.Hughes. Drugs available: adrenaline, noradrenaline, isoprenaline, phenylephrine, BAY K 8644,
acetylcholine, angiotenzine II, prazosine, atropine, nifedipine, nitroprusside .
10. Skeletal muscle relaxants
Seminar, written test
Practical demonstrations: using Pharmacology teaching aid,s PC program Isolated phrenic nerve-diaphragm
by I.E.Hughes. Drugs available: acetylcholine, tubocurarine, pancuronium, atracurium, neostigmine,
decamethonium, succinylcholine.
2nd semester:::: The topic of this part of the curriculum is mainly basic pharmacology and its exercise but also
to introduce a clinical approach.
Lectures*
Subject:Practical demonstration and/or case reports
Antiasthmatics
Drugs influencing the central nervous system
CNS (neuroleptics, antidepressant agents)
Narcotics, analgesics
Chemotherapy
Antibiotics
Prescription I, II.
*texts of all lectures are available for students in the written or electronic forms
Practical classes and seminars
1. Antiasthmatics (basic pharmacology). Approach to clinical pharmacology: Managing asthma.
Practical demonstrations: Measures of peak expiratory flow rate. Handling different types of inhallers.
2. Drugs used in altered states of hemostasis (bleeding and thrombosis). Anemia.
A. Basic pharmacology. Practical demonstrations:
Experiment No 1: evidence of heparins action in vitro (vs.Warfarin)
Experiment No 2: evidence of heparins action in vivo (in animals)
Experiment No 3: interaction of heparin + protamine sulfate in vivo (in animals)
B. Clinical pharmacology. Case reports:
a.Therapy of thrombosis. Thrombosis with pulmonary emboli is treated using an oral anticoagulant in a
women after general surgery. INR- International normalized ratio, its values and importance are discussed.
b. Monitoring of therapy with oral anticoagulants (Pelentan). Monitoring of drug therapy according to the
clinical response. Various tests for anticoagulantsþ effects are considered. Compliance of a patient is taken into
consideration as well.
3. Drugs influencing the CNS
Neuroleptic and antidepressant agents.
Video recording: Extrapyramidal syndrome due to neuroleptics. Various forms of extrapyramidal symptoms
are presented due to neuroleptics. Their treatment is discussed and its practical outcomes demonstrated.
4. Drugs influencing the CNS
Sedative-hypnotic drugs. Anxiolytics. Antiemetics. (Lecture). Video recording: Benzodiazepinesþ receptors -
angonists and antagonists
5. Control of pain
Basic and clinical pharmacology of narcotics and analgesics (including antiinflammatory drugs), written test.
Case report: Postoperative pain in children.
6. Drugs acting on the musculoskeletal system
Basic pharmacology of: Antiparkinsonics. Anticonvulsants. Muscle relaxants
with central and peripheral mechanisms of action.
Practical demonstrations: Therapeutic drug monitoring (TDM) in antiepileptic therapy
7. Drugs and alcohol abuse.
Case reports (made according to Bismuth CH and Dally S: Cas clinique en toxicology. M‚dicine-Sciences
, Flammarion, 1994):
a. Coma in a 2year-old child.
Mother found her small daughter in coma. The doctor who was sent for considered the history and symptoms
and decided the child to be admitted to the hospital. Laboratory data and clinical features are typical for
intoxication with alcohol.
b. If two people are using the same, the results may be the same.
Two foreigners came to Paris. After 2 days they were found unconsciousness in the flat of a friend. They are
admitted to the hospital. Definitive diagnosis is: withdrawal syndrome due to heroin abuse. Treatment is
discussed.
c. Pulmonary edema heroin lung.
A consequence of heroin abuse and its clinical symptoms.
d. Confused old women as a result of benzodiazepine withdrawal.
8. Drugs acting on the gastrointestinal tract. Hypolipidemic drugs.
9. Pharmacology of drugs acting on the endocrine system
Seminar,written test
10. Antibiotics
Seminar, written test
Case reports:
Nephrotoxicity of aminoglycosides
Antibiotics in meningitis (choice of antibiotics according to pathogens).
Practical demonstrations:
TDM of antibiotics (aminoglycosides, vancomycin). Aminoglycosides OD.
11. Cytostatics and immunopharmacology
12. Toxicology
Introduction to toxicology. Chelators and heavy metal intoxication. Management of the poisoned patient
Students become familiar with the techniques: of centrifugation, spectrophotometry and fluorometry important
for the preparation of microsomes and the measurement of cytochromes P450 and selected mixed-function oxidase
activities (see Drug development), and with chromatographic methods used for in vivo and in vitro measurement
of the parent drugs and its metabolites (except for toxicology see also TDM).
13. Prescription writing I:
Students are asked to learn of the main features of common drug formulations that are important for drug
action.
14. Prescription writing II
According to guidelines (given by a textbook including some prototypes of prescription) students are to
prescribe various drug formulations using a simulated formulary.
II. Elective course in Clinical pharmacology incorporated in to the fifth-year medicine clerkship (for
senior students).
An integrated approach using problem-based learning as our main teaching method is used to deliver a
multiprofessional course to students. The course is oriented towards clinical pharmacology, internal medicine and
pediatrics.
At our school the 30-hour course is organized on the classroom basis. It is devoted both to lectures on
core principles and PC- assisted programs (demonstrating our case reports) where students are asked to analyze
a patients history, physical examination and laboratory data. They are working using a system of multiple choice
question with an explanation or commentary at the end of each answer (whether it is right or wrong). In using
such an interprofessional case report, students are led to make rational therapeutic decisions and to individualize
drug therapy as necessary. All case reports appear in the Remedia- journal (Prague) so they can undergo the
criticism of both clinicians and practitioners. By using the students recently acquired clinical knowledge, this
course amplifies material from the core course in pharmacology. and helps students to practice their knowledge
of drug therapy necessary for final exams and medical practice.
Subject:Practical demonstration and/or case reports
1. Effects of disease on drug disposition. Drugs in pregnancy/lactating women and at extremes of age.
Pharmacogenetics
2. Safety of drug therapy
3. Therapeutic drug monitoring (TDM)
4. Clinical pharmacology of cardiac glycosides, antiarrhytmics and antihypertensive drugs
5. Clinical pharmacology of antihypertensive drugs
6. Clinical pharmacology of antibiotics
7. Clinical pharmacology of cytostatics
8. Managing diabetes mellitus
9. Drug development. Clinical trial. Drug regulations.Good clinical and good laboratory practices
10 .Managing drug selection. Rational drug prescribing. Pharmacoeconomy+
* texts of all lectures are available for students in their written or electronic forms
1. Effects of disease on drug disposition:
Several common disorders influence the way the body handles drugs. Individualization of therapy is needed
in patients with disorders as follows:
Gastrointestinal disease that alters absorption of orally administered drugs, prescribers should keep in mind
that therapeutic failure may be a consequence of this mechanism.
Cardiac failure that affects pharmacokinetics in several ways. In practice the most important thing is for
prescribers to be alert to the possibility that therapeutic failure is due to malabsorption, and to appreciate that the
risk of toxicity is increased by reduced clearance.
Renal impairment that decreases elimination of a drug having a narrow pharmacotherapeutic window and
excreted predominantly by the kidneys. Prescribing for patients with renal disease. Liver disease that causes
unpredictable effects on drug handling and rules for prescribing for patients with liver disease. Thyroid disease
that affects drug disposition partly via drug metabolism and partly via renal elimination.
Drugs in pregnant/lactating women and at extremes of age
Practical demonstration using PC-assisted exercises:
calculation of individual pharmacokinetic parameters and plasma concentrations prediction in various patients
using Human kinetics PC and MV PHARM program.
2. Safety of drug therapy:
A. Adverse effects.
B. Intoxication (acute and chronic form) and its management.
C. Drug interactions (food-drug and drug-drug type)
Case reports:
a. Adverse effects of penicillin: Hoign‚ syndrome
b. Extensive cutaneous necrosis in women on warfarin
c. Analgesic nephropathy
d. Adverse effects due to antiepileptic therapy
e. Intoxication due to digoxin. Diagnosis, mechanisms, and treatment.
e. Interaction of methotrexate with antiinflammatory drugs. Diagnosis, mechanisms.
f. Interaction of oral anticoagulants (Pelentan) with salicylates. Diagnosis, mechanisms.
Practical demonstration:
Adverse drug reaction monitoring/surveillance (Pharmacovigilance)
3. Role of drug monitoring in therapeutics (TDM). Pharmacodynamic and kinetic measures of clinical responses.
The objectives of measurement of drug concentrations in plasma. Methods of TDM. Dose schedule prediction
and its evaluation.
The impact is devoted to: digoxin, lithium, aminoglycoside antibiotics, antiepileptics, methotrexate,
theophylline, cyclosporin and some antiarrhythmic drugs.
Case reports:
Nephrotoxicity of aminoglycosides. Aminoglycosides once daily.
TDM of theophylline in asthma. After an increase in the dose, high plasma concentrations appear probably
due to saturation in drug elimination.
Convulsions in an asthmatic patient. What may be the cause? How to prevent it?
4. Clinical pharmacology of cardiac glycosides, and antiarrhytmics
Seminar.
Practical demonstration and case reports:
a. Intoxication due to cardial glycosides.
b. Acquired QT syndrome. Combination of prolonged QT interval and torsades de pointes due to quinidine.
Clinical consequences (syncopes) and treatment.
c. Heart failure treatment in the patient with chronic renal insufficiency and hypertension. Diagnosis and
treatment.
d. Heart failure and myocardial infarction. Diagnosis and treatment.
e. Arrhythmias in a hypertensive patient with acute myocardial infarction. Diagnosis and treatment.
f. Unwanted effects of antiarrhythmics. Unwanted effects of therapy with amiodarone.
5. Clinical pharmacology of antihypertensives.
Case reports:
Antihypertensive agents and their adverse effects.
Antihypertensive agents in the elderly. Diuretics and their adverse effects.
6. Clinical pharmacology of antibiotics
Seminar.
Principles of the antibiotic rationale prescription. Aminoglycosides OD.
Practical demonstration and case reports:
a. Streptococcal nasopharyngitis and treatment.. The first-choice of antibiotics
b. Aminoglycosides in preterm newborns with a low body weight during the first week of the postnatal age.
c. Pulmonary candidosis in a child with acute lymphoblastic leukemia (ALL). Review of the antimycotic
choice in febrile neutropenia.
d. Systemic candidosis in a preterm newborn. Review of the antimycotic choice.
e. Catheter bacteriemia in child with ALL. Antibiotic treatment in febrile neutropenia.
7. Clinical pharmacology of cytostatics
Seminar.
Case report: The principles of high-dose methotrexate treatment of ALL in childhood. What is necessary
for safe therapy?
8. Managing Diabetes mellitus
Seminar.
Case reports:
a. Advanced diabetes mellitus in young people. Diagnosis and treatment-
b. Keto-acidotic coma in diabetes mellitus. Diagnosis and treatment. Prophylaxis.
c. Diabetic foot. Diagnosis, protection against and drug therapy.
9. The process of drug development. Clinical trial. Drug regulations. Codes of practice in the research and
development process (Good Pharmaceutical Manufacturing Practice, Good Laboratory Practice -GLP, Good
Clinical Practice-GCP). Czech regulatory system. Preclinical studies. Clinical trials, phase I-IV. Ethics Committee.
Practical demonstration: data needed for the proces of GLP and GCP.
10. Managing drug selection. Rational drug prescribing and rational treatment. Pharmacoeconomy.
Managing drug selection. Selection criteria (WHO), advantages, generic drugs.
Drugs on the world market,. Registered drugs. Standard drugs, me too drugs. Essential drugs. Drug-oriented and
disease-oriented data: a formulary list and a formulary manual (contains summary drug information) and treatment
guidelines (that assist prescribers in deciding on appropriate treatment). The first-choice treatment. A fully
developed formulary system, that usually includes, in addition to the formulary list and formulary manual, regular
newsletter of bulletins, guidelines for the use of nonformulary drugs, and methods for evaluating the need for
changes in the formulary list of the manual.
Practical demonstration and cases:
Students are asked to consider items as follows:
a. the first-choice drugs according to Antibiotic Guidelines, Analgesic Guidelines
b. me too drugs in antibiotic therapy
c. generic drugs in analgesic therapy
B. Rational drug prescribing
Case report:
Acute tonsilopharyngitis and its treatment in an teenager with an allergic reaction to penicillins in his history.
The process of rational treatment is discussed (efficacy-safety-suitability-cost of treatment). P-drugs (according
to the program of WHO). Drugs of first-choice. Other case reports according to the booklet of WHO (Guide to
good prescribing, 1995
C. Pharmacoeconomy (lecture)
II. Innovation and good practice in teaching pharmacology
a. The starting point: Analysis of pharmacokinetics and pharmacodynamics of drugs using PC-assisted
teaching program:
OBJECTIVE: to enable students understand the main pharmacokinetic and dynamic features of drugs. Our
teaching program is focused on essential drugs (according to the concept recommended by WHO).
DETAILS: Within the1 semester students are analysing kinetics and dynamics using PC-assisted program
with simulations (by dr Hughes) as follows:
Smooth muscle pharmacology (in vitro-isolated rat ileum simulation)
PKSIMS- pharmacokinetis simulation)
MUPHARM and MW-PHARM-pharmacokinetic simulation
Cardiovascular pharmacology (in vivo simulated heart rate and blood pressure in rat)
Isolated phrenic nerve-diaphragm (in vitro)
Simulated isolated vascular preparations (arterial and venous rings in vitro)
Students do their experiments according to our textbook: Instructions for practical exercises in pharmacology
for students in 3rd and 4th year, Prague 1999)
b. Decision making how to prevent, diagnose and treat common diseases and injuries.
Within the 2nd semester some simple forms of the integrated approach are included (PC assisted- case
reports) to the understanding of the use of drugs in medical practice. The main interest is in therapeutic and
adverse effects, and toxicity. Every case report consists of short a patient history, examinations (physical exam,
chemistry) and description of the patientþs pathological state. Students are making decisionþs step by step (each
decision is evaluated by a short piece of commentary). For students in 5 year an elective course in clinical
pharmacology is available based on PC-assisted case reports. These reports (with multiple choice questions) are
more complex than those for the previous year.
c. Rational prescribing to inform students about rational use of drugs, national drug policy and therapeutic guidelines.
d. Drug information syst‚m to inform students about sources of valid information (including the Czech electronic database: the Czech National Formulary). Moreover, our homepage on the Internet gives students information about recent material for studying (lectures, textbooks, references).
LIST of case reports (on the interprofessional approach):
Mart¡nkov J, Chrob k L: Therapy of thrombosis.
Mart¡nkov J, Chrob k L : Monitoring of therapy with oral anticoagulants (Pelentan).
Mart¡nkov J, Kr lov M: Postoperative pain in children.
Mart¡nkov J: Nephrotoxicity of aminoglycosides.
Mart¡nkov J, Kopeck J, Dole~alov K: TDM of theophylline in asthma. After an increase in
the dose high plasma concentrations appear probably due to saturation of drug elimination.
Mart¡nkov J, Chl dkov J: Convulsions in an asthmatic patient. What may be a cause? How to prevent it?
Mart¡nkov J: Adverse effects of penicillin: Hoign‚ syndrome
Chrob k L, Mart¡nkov J: Extensive cutaneous necrosis in a woman on warfarine
Mart¡nkov J: Analgesic nephropathy
Mart¡nkov J: Adverse effects due to antiepileptic therapy
Mart¡nkov J., Kvasnika J: Intoxication due to digoxin. Diagnosis, mechanisms, and
treatment.
Mart¡nkov J: Interaction of methotrexate with antiinflammatory drugs. Diagnosis,
Mechanisms. Treatment .
Mart¡nkov J, Chrob k L : Interaction of oral anticoagulants (Pelentan) with salicylates.
Diagnosis, mechanisms.
Mart¡nkov J., Kvasnika J: Acquired QT syndrome. Combination of the prolonged QT interval and torsades
de pointes to quinidine. Clinical consequences (syncopes). Treatment.
Mart¡nkov J., Kaerovskþ J: Heart failure treatment in the patient with chronic renal
insufficiency and hypertension.
Mart¡nkov J., Kvasnika J: Heart failure and myocardial infarction.
Mart¡nkov J., Kavskþ J, Gregor J: Arrhythmias in a hypertensive patient with acute
myocardial infarction.
Mart¡nkov J., Pleskot J: Unwanted effects of antiarrhythmics.
Mart¡nkov J, Kaerovskþ J: Antihypertensive agents in the elderly.
Chl dkov J., Mart¡nkov J, Chl dek J: Streptococcal nasopharnitis and treatment.
Mart¡nkov J., Tilþer I: Aminoglycosides in preterm newborns with the low body weight during the first
week of the postnatal age.
Mart¡nkov J, Dost l V: Antibiotics in meningitis (choice of antibiotics according to pathogens).
Chl dkov J, Mart¡nkov J: Pulmonary candidosis in a child with acute lymphoblastic
leukemia (ALL). Review of the antimycotics choice in patients with febrile neutropenia.
Chl dkov J, Pokorn E, Orbþ lov S, Buri nkov B, Mart¡nkov J: Systemic candidosis in a preterm
newborn. Review of the antimycotics choice.
Chl dkov J, Mart¡nkov J: Neutropenic fever and its treatment. Empiric antibiotic therapy.
Mart¡nkov J, Chl dkov J: Catheter bacteriemia in a child in immunodeficiency.
Mart¡nkov J, þiþpera L, Slav¡k Z, Hak J: The principles of high-dose methotrexate treatment of ALL in
childhood. What is necessary for the safe therapy?
Mahelov A, Kvasnika J, Mart¡nkov J: Advanced diabetes mellitus in young people.
Diagnosis and treatment.
Mahelov A, Kvasnika J, Mart¡nkov J: Keto-acidotic coma in diabetes mellitus. Diagnosis
and treatment. Prophylaxis.
Mahelov A, , Mart¡nkov J, Kvasnika J: Diabetic foot. Diagnosis, protection and drug therapy.
Rozsypal H: AIDS Alcohol and drug abuse:
Mart¡nkov J: Coma in 2-year old child
Mart¡nkov J: If two people are using the same, the results may the same.
Mart¡nkov J: Pulmonary edema heroin lung.
Mart¡nkov J: Confused old woman.