DRUG OF CHOICE FOR COMMON DISEASES
Introduction
The concept of the “Drug of Choice” is fundamental in clinical medicine, pharmacology, and therapeutic decision-making. A drug of choice refers to the preferred medication for treating a particular disease or condition based on evidence of efficacy, safety profile, cost-effectiveness, availability, and patient-specific factors. It does not necessarily mean that the drug is the newest or most powerful agent available. Rather, it indicates that the medication has demonstrated consistent superiority or suitability for most patients under typical clinical circumstances.
Selection of a drug of choice requires integration of multiple parameters including mechanism of action, pharmacokinetics, pharmacodynamics, contraindications, adverse effect profile, drug interactions, patient age, comorbidities, pregnancy status, renal and hepatic function, and resistance patterns. Evidence-based guidelines issued by recognized medical organizations assist clinicians in choosing first-line therapy, yet individualized treatment remains crucial.
In this comprehensive article, common diseases encountered in general practice, emergency medicine, internal medicine, pediatrics, and community healthcare will be discussed along with their respective drugs of choice. Each section will provide a detailed explanation of the rationale for selection, mechanism of action, dosage principles, adverse effects, contraindications, and clinical considerations.
Drug Of Choice In Hypertension
Overview Of Hypertension
Hypertension is a chronic medical condition characterized by persistently elevated arterial blood pressure, typically defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg. It is a major risk factor for cardiovascular disease, stroke, chronic kidney disease, and heart failure. Management involves lifestyle modification and pharmacotherapy.
Drug Of Choice
For uncomplicated essential hypertension, Angiotensin Converting Enzyme (ACE) inhibitors, particularly Enalapril or Lisinopril, are considered drugs of choice in many adult patients.
Mechanism Of Action
ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor that increases blood pressure by:
• Constricting arterioles
• Stimulating aldosterone secretion
• Promoting sodium and water retention
• Increasing sympathetic activity
By blocking its formation, ACE inhibitors reduce peripheral vascular resistance and decrease blood volume.
Advantages
• Effective blood pressure reduction
• Renoprotective in diabetic nephropathy
• Reduce mortality in heart failure
• Prevent cardiac remodeling
Adverse Effects
• Dry persistent cough
• Hyperkalemia
• Hypotension
• Angioedema (rare but serious)
Contraindications
• Pregnancy
• Bilateral renal artery stenosis
• History of ACE inhibitor induced angioedema
Special Considerations
In Black patients without chronic kidney disease, calcium channel blockers or thiazide diuretics may be preferred initially due to better response rates.
Drug Of Choice In Diabetes Mellitus Type 2
Overview
Type 2 Diabetes Mellitus is characterized by insulin resistance and relative insulin deficiency. It is strongly associated with obesity and metabolic syndrome.
Drug Of Choice
Metformin is the first-line drug of choice in Type 2 Diabetes Mellitus.
Mechanism Of Action
Metformin primarily:
• Decreases hepatic gluconeogenesis
• Improves insulin sensitivity
• Enhances peripheral glucose uptake
• Decreases intestinal glucose absorption
It does not stimulate insulin secretion, thus it does not usually cause hypoglycemia.
Advantages
• Weight neutral or slight weight loss
• Low risk of hypoglycemia
• Cardiovascular benefits
• Affordable
Adverse Effects
• Gastrointestinal upset
• Metallic taste
• Vitamin B12 deficiency
• Lactic acidosis (rare but serious)
Contraindications
• Severe renal impairment
• Severe hepatic disease
• Conditions predisposing to hypoxia
Drug Of Choice In Asthma
Overview
Asthma is a chronic inflammatory airway disease characterized by reversible bronchoconstriction, airway hyperresponsiveness, and mucus production.
Drug Of Choice
For acute asthma attack: Salbutamol (Albuterol)
For long-term control: Inhaled Corticosteroids (e.g., Budesonide)
Mechanism Of Action
Salbutamol:
• Short-acting beta-2 agonist
• Causes bronchodilation by relaxing bronchial smooth muscle
Inhaled corticosteroids:
• Reduce airway inflammation
• Decrease mucus production
• Reduce airway hyperresponsiveness
Adverse Effects
Salbutamol:
• Tremors
• Tachycardia
• Palpitations
Inhaled corticosteroids:
• Oral candidiasis
• Hoarseness
Drug Of Choice In Peptic Ulcer Disease
Overview
Peptic ulcer disease involves mucosal ulceration due to acid and pepsin, often associated with Helicobacter pylori infection or NSAID use.
Drug Of Choice
Proton Pump Inhibitors (PPIs) such as Omeprazole.
Mechanism Of Action
PPIs:
• Irreversibly inhibit H+/K+ ATPase in gastric parietal cells
• Profoundly suppress gastric acid secretion
Advantages
• Superior ulcer healing
• Effective in GERD
• Used in H. pylori eradication therapy
Drug Of Choice In Tuberculosis
Overview
Tuberculosis is caused by Mycobacterium tuberculosis and requires combination therapy.
Drug Of Choice
Initial intensive phase includes:
• Isoniazid
• Rifampicin
• Pyrazinamide
• Ethambutol
Isoniazid is considered the backbone drug.
Mechanism Of Action Of Isoniazid
• Inhibits mycolic acid synthesis
• Bactericidal against actively dividing organisms
Adverse Effects
• Hepatotoxicity
• Peripheral neuropathy
Pyridoxine is given to prevent neuropathy.
Drug Of Choice In Iron Deficiency Anemia
Overview
Iron deficiency anemia is characterized by microcytic hypochromic anemia due to inadequate iron.
Drug Of Choice
Oral Ferrous Sulfate
Mechanism
• Replenishes iron stores
• Supports hemoglobin synthesis
Side Effects
• Constipation
• Dark stools
• Gastric irritation
Drug Of Choice In Community Acquired Pneumonia
Overview
Community acquired pneumonia is an acute infection of the pulmonary parenchyma occurring outside hospital settings. It is commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, atypical organisms such as Mycoplasma pneumoniae, and respiratory viruses. Clinical features include fever, productive cough, dyspnea, pleuritic chest pain, and radiographic infiltrates.
Drug Of Choice
For previously healthy adults without comorbidities: Amoxicillin
For atypical coverage or penicillin allergy: Azithromycin
Mechanism Of Action
Amoxicillin:
• Beta-lactam antibiotic
• Inhibits bacterial cell wall synthesis
• Bactericidal
Azithromycin:
• Macrolide antibiotic
• Inhibits protein synthesis by binding to 50S ribosomal subunit
• Effective against atypical organisms
Rationale For Selection
Amoxicillin has excellent activity against Streptococcus pneumoniae and favorable safety. Azithromycin covers atypical pathogens and has convenient once-daily dosing.
Adverse Effects
• Gastrointestinal upset
• Allergic reactions (beta-lactams)
• QT prolongation (macrolides)
Drug Of Choice In Malaria
Overview
Malaria is caused by Plasmodium species transmitted by the Anopheles mosquito. Clinical manifestations include cyclical fever, chills, anemia, splenomegaly, and in severe cases cerebral involvement.
Drug Of Choice
For uncomplicated Plasmodium falciparum malaria: Artemisinin-based Combination Therapy (ACT) such as Artemether-Lumefantrine.
Mechanism Of Action
Artemisinin derivatives:
• Produce free radicals within parasite
• Damage parasite proteins
• Rapid parasite clearance
Lumefantrine:
• Interferes with heme detoxification
Rationale
Combination therapy prevents resistance and ensures complete parasite eradication.
Adverse Effects
• Headache
• Dizziness
• Gastrointestinal symptoms
Drug Of Choice In Epilepsy
Overview
Epilepsy is a neurological disorder characterized by recurrent unprovoked seizures.
Drug Of Choice
For generalized tonic-clonic seizures: Sodium Valproate
For absence seizures: Ethosuximide
Mechanism Of Action
Valproate:
• Increases GABA levels
• Blocks sodium channels
• Inhibits T-type calcium channels
Ethosuximide:
• Blocks T-type calcium channels in thalamus
Adverse Effects
Valproate:
• Weight gain
• Hepatotoxicity
• Teratogenicity
Ethosuximide:
• Gastrointestinal upset
• Fatigue
Drug Of Choice In Rheumatoid Arthritis
Overview
Rheumatoid arthritis is a chronic autoimmune inflammatory disease affecting synovial joints.
Drug Of Choice
Methotrexate
Mechanism Of Action
• Inhibits dihydrofolate reductase
• Reduces lymphocyte proliferation
• Suppresses inflammation
Advantages
• Slows disease progression
• Reduces joint destruction
Adverse Effects
• Hepatotoxicity
• Bone marrow suppression
• Stomatitis
Folic acid supplementation is recommended.
Drug Of Choice In Major Depressive Disorder
Overview
Major depressive disorder is characterized by persistent low mood, anhedonia, sleep disturbances, appetite changes, and cognitive impairment.
Drug Of Choice
Selective Serotonin Reuptake Inhibitors (SSRIs) such as Fluoxetine or Sertraline.
Mechanism Of Action
• Inhibit serotonin reuptake
• Increase synaptic serotonin levels
Advantages
• Safer in overdose
• Fewer anticholinergic effects
• Well tolerated
Adverse Effects
• Sexual dysfunction
• Nausea
• Insomnia
Drug Of Choice In Hypothyroidism
Overview
Hypothyroidism results from deficiency of thyroid hormone, leading to weight gain, fatigue, cold intolerance, bradycardia, and constipation.
Drug Of Choice
Levothyroxine
Mechanism Of Action
• Synthetic T4
• Converted to active T3 in peripheral tissues
Rationale
Provides stable, predictable hormone replacement.
Monitoring
• TSH levels
• Dose adjustment every 6–8 weeks
Drug Of Choice In Hyperthyroidism
Overview
Hyperthyroidism is characterized by excess thyroid hormone production, commonly due to Graves disease.
Drug Of Choice
Methimazole
Mechanism Of Action
• Inhibits thyroid peroxidase
• Reduces thyroid hormone synthesis
Adverse Effects
• Agranulocytosis
• Hepatotoxicity
• Rash
Propylthiouracil is preferred in first trimester of pregnancy.
Drug Of Choice In Urinary Tract Infection
Overview
Urinary tract infection commonly involves Escherichia coli and presents with dysuria, frequency, urgency, and suprapubic pain.
Drug Of Choice
Nitrofurantoin for uncomplicated cystitis.
Mechanism Of Action
• Damages bacterial DNA
• Concentrates in urine
Advantages
• Minimal resistance
• Effective against common pathogens
Contraindications
• Severe renal impairment
Drug Of Choice In Migraine
Overview
Migraine is a neurovascular disorder characterized by unilateral throbbing headache, nausea, photophobia, and aura in some patients.
Drug Of Choice
For acute attack: Sumatriptan
Mechanism Of Action
• 5-HT1B/1D receptor agonist
• Causes cranial vasoconstriction
• Inhibits neuropeptide release
Adverse Effects
• Chest tightness
• Flushing
• Dizziness
Drug Of Choice In Anaphylaxis
Overview
Anaphylaxis is a life-threatening systemic hypersensitivity reaction characterized by hypotension, bronchospasm, and airway edema.
Drug Of Choice
Epinephrine (Adrenaline)
Mechanism Of Action
• Alpha-1 stimulation: vasoconstriction
• Beta-1 stimulation: increased cardiac output
• Beta-2 stimulation: bronchodilation
Administration
• Intramuscular injection into lateral thigh
Importance
Immediate administration saves life and prevents progression.
Drug Of Choice In Heart Failure
Overview
Heart failure is a clinical syndrome characterized by the inability of the heart to pump sufficient blood to meet the metabolic demands of the body. It may result from ischemic heart disease, hypertension, valvular disorders, cardiomyopathy, or congenital abnormalities. Symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, fatigue, and reduced exercise tolerance.
Heart failure is broadly classified into heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Pharmacologic therapy primarily improves survival in HFrEF.
Drug Of Choice
For chronic HFrEF, ACE inhibitors such as Enalapril remain foundational therapy.
Mechanism Of Action
• Decrease angiotensin II production
• Reduce afterload and preload
• Decrease aldosterone secretion
• Limit cardiac remodeling
Clinical Benefits
• Reduce mortality
• Improve symptoms
• Prevent disease progression
• Decrease hospitalizations
Additional Agents
• Beta blockers (e.g., Metoprolol)
• Mineralocorticoid receptor antagonists (Spironolactone)
• Diuretics (Furosemide) for symptomatic relief
Adverse Effects
• Hypotension
• Hyperkalemia
• Renal dysfunction
• Persistent cough
ACE inhibitors form the cornerstone of heart failure management unless contraindicated.
Drug Of Choice In Stable Angina
Overview
Stable angina is chest discomfort caused by transient myocardial ischemia due to fixed atherosclerotic narrowing of coronary arteries. Pain is typically exertional and relieved by rest.
Drug Of Choice
For acute relief: Sublingual Nitroglycerin
Mechanism Of Action
• Releases nitric oxide
• Causes venodilation
• Reduces preload
• Decreases myocardial oxygen demand
Clinical Use
• Rapid symptom relief within minutes
• Used before anticipated exertion
Adverse Effects
• Headache
• Hypotension
• Reflex tachycardia
Long-term management includes beta blockers and antiplatelet agents.
Drug Of Choice In Acute Myocardial Infarction
Overview
Acute myocardial infarction results from sudden occlusion of a coronary artery due to thrombus formation over a ruptured atherosclerotic plaque. It presents with severe chest pain, diaphoresis, nausea, and ECG changes.
Drug Of Choice
Immediate administration of Aspirin is critical.
Mechanism Of Action
• Irreversibly inhibits cyclooxygenase-1
• Decreases thromboxane A2 synthesis
• Inhibits platelet aggregation
Importance
• Reduces mortality
• Prevents further thrombus formation
• Must be given as early as possible
Additional Management
• P2Y12 inhibitors
• Anticoagulants
• Thrombolytics or primary angioplasty
• Beta blockers
• ACE inhibitors
Drug Of Choice In Ischemic Stroke
Overview
Ischemic stroke occurs due to obstruction of cerebral blood flow, leading to neuronal injury.
Drug Of Choice
Within therapeutic window: Alteplase (tPA)
Mechanism Of Action
• Converts plasminogen to plasmin
• Dissolves fibrin clots
Indications
• Administered within 4.5 hours of symptom onset
• After exclusion of hemorrhage
Risks
• Intracranial bleeding
• Systemic hemorrhage
Rapid evaluation is essential for eligibility.
Drug Of Choice In Gout
Overview
Gout is an inflammatory arthritis caused by deposition of monosodium urate crystals due to hyperuricemia.
Drug Of Choice
For acute attack: Indomethacin
For chronic management: Allopurinol
Mechanism
Indomethacin:
• NSAID
• Reduces inflammation
Allopurinol:
• Inhibits xanthine oxidase
• Decreases uric acid production
Considerations
Allopurinol should not be initiated during acute attack.
Drug Of Choice In Osteoporosis
Overview
Osteoporosis is characterized by reduced bone mass and microarchitectural deterioration, increasing fracture risk.
Drug Of Choice
Bisphosphonates such as Alendronate.
Mechanism Of Action
• Inhibit osteoclast-mediated bone resorption
• Increase bone mineral density
Administration Advice
• Take on empty stomach
• Remain upright for 30 minutes
Adverse Effects
• Esophagitis
• Osteonecrosis of jaw (rare)
Drug Of Choice In Gastroesophageal Reflux Disease
Overview
GERD is caused by reflux of gastric contents into esophagus, leading to heartburn and regurgitation.
Drug Of Choice
Proton Pump Inhibitors such as Pantoprazole.
Mechanism
• Inhibit gastric acid secretion
• Promote mucosal healing
Duration
• Typically 4–8 weeks
Drug Of Choice In Acute Diarrhea
Overview
Acute diarrhea is characterized by frequent loose stools due to infection, toxins, or dietary causes.
Drug Of Choice
Primary treatment: Oral Rehydration Solution (ORS)
Importance
• Prevents dehydration
• Restores electrolytes
Antibiotics are reserved for specific bacterial infections.
Drug Of Choice In Constipation
Overview
Constipation involves infrequent bowel movements or difficult stool passage.
Drug Of Choice
Bulk forming agents such as Psyllium.
Mechanism
• Absorb water
• Increase stool bulk
• Promote peristalsis
Advantages
• Safe for long-term use
Drug Of Choice In Bacterial Meningitis
Overview
Bacterial meningitis is inflammation of meninges caused by bacterial infection, presenting with fever, neck stiffness, headache, and altered consciousness.
Drug Of Choice
Empirical therapy: Ceftriaxone plus Vancomycin
Mechanism
Ceftriaxone:
• Inhibits cell wall synthesis
Vancomycin:
• Inhibits cell wall formation in resistant organisms
Importance
Immediate treatment reduces mortality and neurological complications.
Drug Of Choice In Chronic Obstructive Pulmonary Disease
Overview
Chronic obstructive pulmonary disease is a progressive inflammatory airway disorder characterized by airflow limitation that is not fully reversible. It includes chronic bronchitis and emphysema. The disease is strongly associated with cigarette smoking, environmental pollutants, and occupational exposures. Patients present with chronic cough, sputum production, dyspnea, and reduced exercise tolerance. Exacerbations significantly worsen prognosis.
Drug Of Choice
For maintenance therapy, Long Acting Beta Two Agonists (LABA) such as Salmeterol or Formoterol are considered foundational bronchodilators. Long acting muscarinic antagonists like Tiotropium are also widely used.
Mechanism Of Action
LABA:
• Stimulate beta two receptors
• Relax bronchial smooth muscle
• Improve airflow
Tiotropium:
• Blocks muscarinic receptors
• Prevents bronchoconstriction
Clinical Benefits
• Improve symptoms
• Reduce exacerbations
• Enhance quality of life
Adverse Effects
• Dry mouth
• Tremors
• Palpitations
Combination inhalers containing LABA and inhaled corticosteroids are used in advanced disease.
Drug Of Choice In Acute Otitis Media
Overview
Acute otitis media is common in children and involves infection of the middle ear. It presents with ear pain, fever, irritability, and sometimes hearing impairment.
Drug Of Choice
Amoxicillin remains first line therapy.
Mechanism Of Action
• Inhibits bacterial cell wall synthesis
• Effective against Streptococcus pneumoniae and Haemophilus influenzae
Duration
• Typically five to ten days depending on age and severity
Adverse Effects
• Diarrhea
• Allergic reactions
Drug Of Choice In Typhoid Fever
Overview
Typhoid fever is caused by Salmonella typhi and transmitted through contaminated food and water. It presents with prolonged fever, abdominal discomfort, and systemic toxicity.
Drug Of Choice
Ceftriaxone or Azithromycin depending on resistance pattern.
Mechanism
Ceftriaxone:
• Bactericidal beta lactam antibiotic
Azithromycin:
• Inhibits bacterial protein synthesis
Early treatment prevents complications such as intestinal perforation.
Drug Of Choice In Schizophrenia
Overview
Schizophrenia is a chronic psychiatric disorder characterized by hallucinations, delusions, disorganized speech, and social withdrawal.
Drug Of Choice
Second generation antipsychotics such as Risperidone or Olanzapine.
Mechanism Of Action
• Dopamine D2 receptor antagonism
• Serotonin receptor modulation
Advantages
• Lower risk of extrapyramidal symptoms compared to first generation agents
Adverse Effects
• Weight gain
• Metabolic syndrome
• Sedation
Drug Of Choice In Attention Deficit Hyperactivity Disorder
Overview
ADHD is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity.
Drug Of Choice
Methylphenidate
Mechanism Of Action
• Blocks reuptake of dopamine and norepinephrine
• Increases synaptic concentration
Benefits
• Improves attention
• Enhances academic performance
• Reduces impulsivity
Adverse Effects
• Insomnia
• Reduced appetite
• Increased heart rate
Drug Of Choice In Allergic Rhinitis
Overview
Allergic rhinitis is an IgE mediated hypersensitivity reaction causing sneezing, nasal congestion, and watery discharge.
Drug Of Choice
Intranasal Corticosteroids such as Fluticasone.
Mechanism Of Action
• Reduce nasal inflammation
• Suppress immune response
• Decrease mucosal edema
Advantages
• Highly effective
• Minimal systemic absorption
Drug Of Choice In Acne Vulgaris
Overview
Acne vulgaris is a chronic inflammatory condition of pilosebaceous units involving increased sebum production and bacterial colonization.
Drug Of Choice
For moderate to severe acne: Isotretinoin
Mechanism Of Action
• Reduces sebaceous gland size
• Decreases sebum production
• Anti inflammatory effects
Precautions
• Highly teratogenic
• Requires pregnancy prevention measures
Drug Of Choice In Parkinson Disease
Overview
Parkinson disease is a neurodegenerative disorder caused by dopamine deficiency in substantia nigra, presenting with tremor, rigidity, bradykinesia, and postural instability.
Drug Of Choice
Levodopa combined with Carbidopa
Mechanism Of Action
Levodopa:
• Converted to dopamine in brain
Carbidopa:
• Prevents peripheral breakdown
• Increases central availability
Adverse Effects
• Dyskinesias
• Nausea
• Orthostatic hypotension
Drug Of Choice In Chronic Kidney Disease With Proteinuria
Overview
Chronic kidney disease is progressive loss of renal function. Proteinuria accelerates damage.
Drug Of Choice
ACE inhibitors or Angiotensin Receptor Blockers
Mechanism
• Reduce intraglomerular pressure
• Decrease proteinuria
• Slow disease progression
Drug Of Choice In Helicobacter Pylori Infection
Overview
Helicobacter pylori infection contributes to peptic ulcer disease and gastric malignancy.
Drug Of Choice
Triple therapy including:
• Proton pump inhibitor
• Clarithromycin
• Amoxicillin
Duration
• Fourteen days
Drug Of Choice In Candidiasis
Overview
Candidiasis is fungal infection caused by Candida species.
Drug Of Choice
For oral or vaginal candidiasis: Fluconazole
Mechanism Of Action
• Inhibits fungal ergosterol synthesis
• Disrupts cell membrane
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Drug Of Choice In Sepsis
Overview
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It represents a spectrum ranging from systemic inflammatory response syndrome to septic shock with profound circulatory and metabolic abnormalities. Early recognition and immediate intervention significantly reduce mortality.
Drug Of Choice
Empirical broad-spectrum intravenous antibiotics are the drug of choice. A common initial regimen includes:
• Piperacillin-Tazobactam
• Meropenem (in severe or resistant cases)
• Vancomycin (if MRSA suspected)
Mechanism Of Action
Piperacillin-Tazobactam:
• Inhibits bacterial cell wall synthesis
• Beta-lactamase inhibitor extends spectrum
Meropenem:
• Broad-spectrum carbapenem
• Bactericidal against gram-positive, gram-negative, and anaerobes
Vancomycin:
• Inhibits cell wall synthesis in resistant gram-positive organisms
Clinical Principle
Antibiotics must be administered within one hour of diagnosis. Therapy is later adjusted based on culture results.
Drug Of Choice In Deep Vein Thrombosis
Overview
Deep vein thrombosis is the formation of a clot in deep veins, usually in the lower limbs. It may lead to pulmonary embolism, which can be fatal.
Drug Of Choice
Low Molecular Weight Heparin such as Enoxaparin is first-line initial therapy.
Mechanism Of Action
• Activates antithrombin III
• Inhibits factor Xa
• Prevents clot propagation
Long-Term Management
• Direct oral anticoagulants such as Apixaban
• Warfarin in selected patients
Monitoring
• Renal function
• Signs of bleeding
Drug Of Choice In Pulmonary Embolism
Overview
Pulmonary embolism is obstruction of pulmonary arteries by thrombus. Symptoms include sudden dyspnea, chest pain, tachycardia, and hypoxia.
Drug Of Choice
Immediate anticoagulation with Heparin.
In massive PE with hemodynamic instability: Alteplase (thrombolytic).
Mechanism
Heparin:
• Prevents clot extension
Alteplase:
• Dissolves existing clot
Prompt treatment reduces mortality.
Drug Of Choice In Hyperlipidemia
Overview
Hyperlipidemia is elevated cholesterol or triglycerides increasing cardiovascular risk.
Drug Of Choice
Statins such as Atorvastatin.
Mechanism Of Action
• Inhibit HMG-CoA reductase
• Decrease cholesterol synthesis
• Increase LDL receptor expression
Benefits
• Reduce LDL cholesterol
• Decrease cardiovascular events
• Stabilize atherosclerotic plaques
Adverse Effects
• Myopathy
• Elevated liver enzymes
Drug Of Choice In Anxiety Disorders
Overview
Anxiety disorders include generalized anxiety disorder, panic disorder, and social anxiety disorder. Symptoms include excessive worry, palpitations, restlessness, and sleep disturbance.
Drug Of Choice
Selective Serotonin Reuptake Inhibitors such as Escitalopram.
Mechanism
• Increase synaptic serotonin
• Modulate mood and anxiety circuits
Short-Term Relief
Benzodiazepines may be used briefly but carry risk of dependence.
Drug Of Choice In Bipolar Disorder
Overview
Bipolar disorder is characterized by episodes of mania and depression.
Drug Of Choice
Lithium for mood stabilization.
Mechanism Of Action
• Modulates neurotransmitter signaling
• Stabilizes neuronal excitability
Monitoring
• Serum lithium levels
• Renal and thyroid function
Toxicity Signs
• Tremors
• Confusion
• Arrhythmias
Drug Of Choice In Glaucoma
Overview
Glaucoma is optic neuropathy commonly associated with elevated intraocular pressure.
Drug Of Choice
Prostaglandin analogues such as Latanoprost.
Mechanism
• Increase aqueous humor outflow
• Reduce intraocular pressure
Advantages
• Once daily dosing
• Highly effective
Drug Of Choice In Erectile Dysfunction
Overview
Erectile dysfunction is inability to maintain erection sufficient for intercourse.
Drug Of Choice
Sildenafil.
Mechanism
• Inhibits phosphodiesterase type 5
• Increases nitric oxide mediated vasodilation
Contraindication
• Concurrent nitrate therapy
Drug Of Choice In Influenza
Overview
Influenza is a viral respiratory infection causing fever, myalgia, cough, and fatigue.
Drug Of Choice
Oseltamivir when started within forty-eight hours.
Mechanism
• Neuraminidase inhibitor
• Prevents viral release
Drug Of Choice In COVID 19 (Severe Cases)
Overview
Severe COVID 19 involves inflammatory lung injury and hypoxia.
Drug Of Choice
Dexamethasone in hospitalized patients requiring oxygen.
Mechanism
• Suppresses inflammatory response
• Reduces cytokine mediated lung damage
Drug Of Choice In Epistaxis (Severe)
Overview
Severe nasal bleeding may require pharmacologic support.
Drug Of Choice
Tranexamic acid.
Mechanism
• Inhibits fibrinolysis
• Stabilizes clot formation
Drug Of Choice In Vitamin D Deficiency
Overview
Vitamin D deficiency leads to bone pain, weakness, and increased fracture risk.
Drug Of Choice
Cholecalciferol supplementation.
Mechanism
• Enhances calcium absorption
• Promotes bone mineralization
Advanced Clinical Considerations In Drug Selection
Choosing a drug of choice is not static. It evolves with:
• Emerging resistance patterns
• Pharmacogenomic discoveries
• Updated clinical trials
• Regional availability
• Patient affordability
Personalized medicine is increasingly important. Genetic variations affect metabolism of drugs such as warfarin and clopidogrel. Renal and hepatic impairment require dose adjustment. Polypharmacy increases interaction risks in elderly patients.
Ethical prescribing also demands avoiding unnecessary antibiotics to prevent resistance. Stewardship programs guide rational antimicrobial use.
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Drug Of Choice In Acute Bacterial Sinusitis
Overview
Acute bacterial sinusitis is inflammation of the paranasal sinuses usually following a viral upper respiratory tract infection. It presents with facial pain, nasal obstruction, purulent nasal discharge, fever, and headache. The most common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Drug Of Choice
Amoxicillin-Clavulanate
Mechanism Of Action
• Amoxicillin inhibits bacterial cell wall synthesis
• Clavulanate inhibits beta-lactamase enzymes
• Extends antimicrobial spectrum
Rationale
Increasing beta-lactamase resistance makes combination therapy more effective than amoxicillin alone.
Adverse Effects
• Gastrointestinal upset
• Diarrhea
• Allergic reactions
Drug Of Choice In Infective Endocarditis
Overview
Infective endocarditis is microbial infection of heart valves. It presents with fever, new murmur, embolic phenomena, and systemic manifestations. It is life threatening and requires prolonged intravenous therapy.
Drug Of Choice
Empirical therapy often includes:
• Vancomycin
• Ceftriaxone
Mechanism
Vancomycin:
• Inhibits cell wall synthesis in resistant gram-positive bacteria
Ceftriaxone:
• Broad spectrum cephalosporin
• Effective against streptococci
Duration
• Typically four to six weeks of intravenous therapy
Drug Of Choice In Helicobacter Associated Gastritis (Resistant Cases)
Overview
Resistance to clarithromycin is increasing globally.
Drug Of Choice
Bismuth-based quadruple therapy:
• Proton pump inhibitor
• Bismuth
• Tetracycline
• Metronidazole
Rationale
Improves eradication rates in resistant strains.
Drug Of Choice In Acute Pancreatitis (Supportive Management)
Overview
Acute pancreatitis is inflammation of pancreas commonly caused by gallstones or alcohol. It presents with severe epigastric pain radiating to back.
Drug Of Choice
Primary treatment is supportive:
• Intravenous fluids (Ringer lactate)
• Analgesics such as Fentanyl
Antibiotics are not routine unless infection is suspected.
Drug Of Choice In Psoriasis
Overview
Psoriasis is chronic immune mediated inflammatory skin disorder characterized by erythematous plaques with silvery scales.
Drug Of Choice
For moderate to severe disease:
• Methotrexate
• Biologic agents such as Adalimumab
Mechanism
Methotrexate:
• Inhibits DNA synthesis
• Suppresses immune activation
Biologics:
• Target tumor necrosis factor alpha or interleukins
Drug Of Choice In Systemic Lupus Erythematosus
Overview
Systemic lupus erythematosus is autoimmune multisystem disease.
Drug Of Choice
Hydroxychloroquine for long-term control.
Mechanism
• Modulates immune activity
• Reduces disease flares
Monitoring
• Regular ophthalmologic examination due to retinal toxicity risk
Drug Of Choice In Acute Rheumatic Fever
Overview
Acute rheumatic fever is immune mediated sequela of streptococcal pharyngitis affecting heart, joints, skin, and brain.
Drug Of Choice
Benzathine Penicillin G for eradication of streptococcal infection.
Additional Therapy
• Aspirin for arthritis
• Corticosteroids for severe carditis
Drug Of Choice In Tetanus
Overview
Tetanus is caused by Clostridium tetani toxin leading to muscle rigidity and spasms.
Drug Of Choice
Human tetanus immunoglobulin plus Metronidazole.
Mechanism
Immunoglobulin:
• Neutralizes circulating toxin
Metronidazole:
• Eliminates bacteria
Drug Of Choice In Rabies Exposure
Overview
Rabies is fatal viral encephalitis transmitted through animal bites.
Drug Of Choice
Post exposure prophylaxis:
• Rabies vaccine
• Rabies immunoglobulin
Immediate wound washing is essential.
Drug Of Choice In Acute Glomerulonephritis (Post Streptococcal)
Overview
Post streptococcal glomerulonephritis presents with hematuria, edema, and hypertension.
Drug Of Choice
Supportive management with:
• Antihypertensives such as ACE inhibitors
• Diuretics for edema
Antibiotics if active infection persists.
Drug Of Choice In Iron Overload (Hemochromatosis)
Overview
Iron overload causes organ damage including liver cirrhosis and cardiomyopathy.
Drug Of Choice
Deferoxamine in cases requiring chelation.
Mechanism
• Binds excess iron
• Promotes excretion
Drug Of Choice In Migraine Prophylaxis
Overview
Frequent migraine attacks require preventive therapy.
Drug Of Choice
Propranolol.
Mechanism
• Beta receptor blockade
• Stabilizes vascular tone
Drug Of Choice In Status Epilepticus
Overview
Status epilepticus is continuous seizure activity lasting more than five minutes.
Drug Of Choice
Intravenous Lorazepam.
Mechanism
• Enhances GABA activity
• Rapid seizure termination
Followed by long acting antiepileptic such as Phenytoin.
Drug Of Choice In Osteoarthritis
Overview
Osteoarthritis is degenerative joint disease.
Drug Of Choice
Paracetamol for mild pain.
NSAIDs for moderate to severe symptoms.
Drug Of Choice In Acute Allergic Reaction (Non Anaphylactic)
Overview
Mild allergic reactions include urticaria and itching.
Drug Of Choice
Antihistamines such as Cetirizine.
Mechanism
• Block H1 receptors
• Reduce histamine mediated symptoms
Drug Of Choice In Chronic Hepatitis B
Overview
Chronic hepatitis B can lead to cirrhosis and hepatocellular carcinoma.
Drug Of Choice
Tenofovir.
Mechanism
• Inhibits viral DNA polymerase
• Suppresses viral replication
Drug Of Choice In Chronic Hepatitis C
Overview
Chronic hepatitis C is treated with direct acting antivirals.
Drug Of Choice
Sofosbuvir based combinations.
Mechanism
• Inhibit viral RNA polymerase
• Achieve high cure rates
Advanced Principles Of Rational Pharmacotherapy
- Evidence based guideline adherence
- Individualized patient assessment
- Minimization of polypharmacy
- Monitoring for adverse drug reactions
- Cost effectiveness consideration
- Antimicrobial stewardship
- Dose adjustment in organ dysfunction
- Patient education and adherence support
Comprehensive Closing Remarks
The determination of a drug of choice reflects integration of pharmacological science with clinical judgment. Although first line therapies are standardized through global guidelines, treatment must always be individualized according to patient specific variables.
Continuous medical education, awareness of evolving resistance, and adoption of precision medicine will shape the future of therapeutic decision making. Mastery of drug selection principles is essential for physicians, pharmacists, and nurses in delivering optimal patient outcomes.
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