Penicillin: instructions for use
Before buying an antibiotic Penicillin, you should carefully read the instructions for use, how to use and dosage, and other useful information about Penicillin. On the site "Encyclopaedia of Diseases" you will find all the necessary information: instructions for proper use, recommended dosage, contraindications, as well as reviews of patients who have already used this medication.
Penicillinum (Penicillinum) is a product of vital activity of various kinds of mold fungus Penicillium notatum, Penicilium chrysogenum, etc.
Several kinds of penicillin compounds are transferred to the culture fluid of these fungi, which are obtained in crystalline form.
Penicillin - Pharmacological properties
Penicillin is an antibiotic, whose chemical structure is based on a dipeptide formed from dimethylcysteine and acetylserine.
The mechanism of action of penicillin is associated with the suppression of amino acid and vitamin metabolism of microorganisms and a violation of the development of their cell walls.
Penicillin is excreted by the kidneys (about 50%); in the urine its significant concentrations are created, exceeding the concentration in the blood 5-10 times. Some part of penicillin is also excreted with bile.
Penicillin - Therapeutic properties
Penicillin is one of the main representatives of a group of antibiotics, the drug has a broad spectrum of bacteriostatic and bactericidal action (penicillin drugs are most active in benzylpenicillin).
Especially sensitive to penicillin are streptococci, pneumococci, gonococci, meningococci, tetanus, gas gangrene, anthrax, diphtheria, individual strains of pathogenic staphylococci and protea.
Penicillin is ineffective against bacteria of the intestinal typhoid-dysenteric group, tuberculosis, pertussis, Pseudomonas aeruginosa and Freludlander sticks, brucellosis, tularemia, cholera, plague, and rickettsia, viruses, fungi and protozoa.
The most effective intramuscular injection of penicillin drugs. With intramuscular injection, penicillin is rapidly absorbed into the blood (the maximum concentration in the blood is created in 30-60 minutes) and quickly passes into the muscles, lungs, wound exudate, joint cavity.
Penicillin penetration from the blood into the cerebrospinal fluid is insignificant, therefore, for meningitis and encephalitis, a combined use of penicillin is recommended - intramuscular and endolumbic.
Intramuscularly introduced penicillin penetrates into the abdominal and pleural cavities, which requires direct local exposure to penicillin.
Penicillin penetrates well through the placenta to the fetus.
Penicillin - Indications for use
The use of penicillin is shown:
- with sepsis (especially streptococcal);
- in all sulfanilamidorezistentnyh cases of the corresponding infections (pneumococcal, gonococcal, meningococcal infection, etc.);
- After wounds with involvement in the process and infection of large musculoskeletal tracts;
- in the postoperative period to prevent purulent complications;
- with infected third and fourth degree burns;
- with wounds of soft tissues, wounds of the chest;
- purulent meningitis, abscesses of the brain, erysipelas, gonorrhea and its sulfanilamidostoychivyh forms, syphilis, heavy furunculosis, sycosis, with various inflammations of the eye and ear.
In the clinic of internal diseases Penicillin is used to treat croupous pneumonia (together with sulfanilamide preparations), focal pneumonia, acute sepsis, cholecystitis and cholangitis, prolonged septic endocarditis, as well as for the prevention and treatment of rheumatism.
Penicillin in children is used : with umbilical sepsis, septicopyemia and septicotoxic diseases of newborns, pneumonias in newborns and infants and young children, otitis of infants and young children, septic form of scarlet fever, septicotoxic form of diphtheria (necessarily in combination with a special serum ), pleuropulmonary processes that are not amenable to the action of sulfanilamide preparations, purulent pleurisy and purulent meningitis, with gonorrhea.
Penicillin - Rules of Use
The antimicrobial effect of penicillin is achieved both with resorptive and local action.
Penicillin preparations can be administered intramuscularly, subcutaneously and intravenously, inside the cavities, into the spinal canal, by inhalation, sublingually (under the tongue), inside; Locally - in the form of eye and nasal drops, rinses, rinses.
With intramuscular injection penicillin is quickly absorbed into the blood, but after 3-4 hours penicillin almost completely disappears from it. For the effectiveness of therapy in 1 ml of blood should be 0.1-0.3 ED penicillin, so to maintain the therapeutic concentration of the drug in the blood, it should be administered every 3-4 hours.
The use of Penicillin for the treatment of gonorrhea, syphilis, pneumonia, cerebrospinal meningitis is carried out according to a special instruction.
Penicillin - Adverse Events
Treatment with benzylpenicillins, bicillins and other penicillin-containing drugs may be accompanied by side effects, most often allergic.
The occurrence of allergic reactions to penicillin preparations is usually associated with sensitization to the body as a result of previous use of these drugs, as well as as a result of prolonged exposure to them: professional sensitization of nurses, persons working on the production of antibiotics.
Allergic reactions to penicillin from the side of the skin are expressed in erythema , limited or widespread rashes, urticaria and urtikaropodobnyh rashes, macular, vesicular, pustuloznyh rashes, sometimes life-threatening exfoliative dermatitis.
Numerous cases of contact dermatitis have been registered (medical personnel of medical institutions). Contact dermatitis and reactions from the skin and mucous membranes are observed both in general exposure and in the local application of penicillin in the form of ointments, lotions, drops for the nose and eyes.
On the part of the respiratory organs are noted rhinitis, pharyngitis, laryngopharyngitis, asthmatic bronchitis, bronchial asthma.
On the part of the gastrointestinal tract, allergic reactions are expressed in stomatitis, nausea, vomiting, diarrhea.
In a number of cases, the distinction between toxic and allergic genesis of side effects is difficult. The allergic origin of these phenomena is indicated by their combination with skin rashes, under the influence of penicillin, the development of agranulocytosis is also possible.
If allergic reactions occur on the part of the skin, respiratory tract, gastrointestinal tract, stop treatment with penicillin or reduce its dose, prescribe to the patient Diphenhydramine, Pipolphen, Suprastin, calcium chloride, vitamin B1.
It should be remembered about the possibility of sensitization of the body even in the prenatal period when treating pregnant women with penicillin preparations.
Anaphylactic shock with penicillin
The emergence of anaphylactic shock in the use of penicillin is a very serious complication that can develop independently of the dose and ways of penicillin administration and in severe cases for a short time (5-30-60 minutes) result in death, therefore before injection of penicillin and its preparations should be collected anamnestic data on the use of penicillin drugs in the past and reactions to it.
In case of occurrence of the phenomena of anaphylactic shock, 0.2-0.3 ml of 0.1% Adrenaline should be injected intravenously (!) Mixed with the patient's blood. Injections are repeated until the patient is removed from the severe condition.
At the same time, 0.2-0.3 ml of a 0.1% solution of epinephrine is injected into the injection site of penicillin. Effectively drip norepinephrine (1.0 ml 0.1% solution in 500 ml 5% glucose solution) for 3 hours.
Prednisolone 0.02 g intramuscularly or intravenously, atropine sulfate 0.1% solution 0.5-0.8 ml subcutaneously, lobeline hydrochloride 1% solution 0.5-1.0 ml intravenously or subcutaneously.
Instead of adrenaline, you can inject 1 ml of 5% Ephedrine, and also Eufillin - 5-10 ml of a 2.4% solution with 20-40 ml 40% glucose solution intravenously, Diphenhydramine 5% solution intramuscularly 1 ml (or Pipolphen), chloride calcium - 10% solution of 10 ml intravenously.
Oxygen is under pressure.
Hydrocortisone - during shock and mainly to prevent late complications in a single dose of 0.05-0.07 g.
Intramuscular injection of the neurolithic mixture is also used: 2 ml of a 2.5% solution of Aminazine, 2 ml of 2% solutions of Promedol and Dimedrol and 5% solution of vitamin B1 (using anti-shock solution and vasopressor substances).
When exiting a shock state, patients need hospitalization and clinical follow-up, since late complications are possible.
Dysbacteriosis and fungal diseases with Penicillin
In the treatment of Penicillin, as with other antibiotics, the emergence of pathological conditions can be associated with the development of dysbacteriosis.
At the heart of the dysbiosis lies the fact that penicillin, like other antibiotics, has an antimicrobial effect in the body not only on pathogenic microorganisms, but also on conditionally pathogenic and non-pathogenic microbes, as a result of which the organism's antagonism of microbial associations is disrupted, nonpathogenic microorganisms can acquire a pathogenic character - there are so-called superinfections.
The organism is influenced by penicillin-resistant microbes (proteus, enterococcus, Pseudomonas aeruginosa, resistant to penicillin strains of staphylococci).
Complications associated with the activation and reproduction of yeast-like (especially in weakened patients) fungi-saprophytes, present in the microbial flora of the mucous membranes of the oral cavity and genitals, trachea, and intestines are noted.
Penicillin, suppressing bacterium-antagonists of fungi, can create favorable conditions for the development of yeast-like flora. Clinically candidiasis can occur in acute and chronic form with pathological manifestations from the skin and mucous membranes (thrush of the mouth, genitals, etc.); from the internal organs (visceral candidiasis) in the form of lesions of the lungs and upper respiratory tract; in the form of a septic syndrome.
The appearance of candidiasis can be prevented by the rational choice of an antibiotic, the correct dosage, the regimen of use, the use of appropriate vaccines and serums, and the sensitivity of the patient's organism to the antibiotic (by conducting special tests).
For the treatment of candidiasis in such cases, iodine preparations (1-3-5% solutions of potassium iodide) are prescribed in combination with intravenous administration of 40% solution of hexamethylenetetramine, gentianviolate 0,05-0,10 g 2-3 times a day, nicotinamide and others preparations of vitamins of group B.
For the prevention and treatment of candidiasis use special antifungal antibiotics, taken internally - Nystatin in tablets of 500 000 units, 6-10 tablets a day and Levorin 500 000 units 2-3 times a day in tablets or capsules, as well as ointments with nystatin sodium and levorin.
Penicillin - Contraindications
The use of penicillin is contraindicated in the presence of hypersensitivity to penicillin, bronchial asthma, urticaria, hay fever and other allergic diseases, with increased sensitivity of patients to antibiotics, sulfonamides and other medicines.
Penicillin during pregnancy and lactation
Possible sensitization of the body to penicillin during intrauterine development in the treatment of pregnant women with antibiotic-drugs penicillin.
Interaction with alcohol
To drink alcohol during treatment with penicillin preparations is categorically contraindicated.
Before applying penicillin and its drugs, it is necessary to conduct samples for sensitivity to them.
Amoxicillin in capsules 0.25 g
Sodium amoxicillin is sterile
Amoxicillin-ratiofarm 250 TC)
Amoxicillin trihydrate (Purimox)
Sodium ampicillin is sterile
Ampicillin sodium salt
Ampicillin sodium salt is sterile
Ampicillin sodium salt-Vial
Ampicillin trihydrate in capsules 0.25 g
Ampicillin trihydrate tablets 0.25 g
Benzathine benzylpenicillin is sterile
Benzathinbenzylpenicillin is sterile
Benzylpenicillin sodium salt crystalline
Benzylpenicillin sodium salt is sterile
Benzylpenicillin sodium salt-Vial
Benzylpenicillin novocaine salt
Carbenicillin disodium salt 1 g
Oxacillin sodium salt
Oxacillin sodium sterile
Oxacillin sodium salt tablets
Penicillin G sodium salt
Penicillin G sodium sterile
Procaine penicillin G 3 mega
Procaine benzylpenicillin is sterile
Phenoxymethylpenicillin (for suspension)
I. Preparations of penicillins obtained by biological synthesis (biosynthetic penicillins):
I.1. For parenteral administration (destroyed in an acidic environment of the stomach):
- short-term action:
benzylpenicillin (sodium salt),
benzylpenicillin (potassium salt);
- continuous action:
Benzylpenicillin (novocaine salt),
I.2. For enteral administration (acid-fast):
phenoxymethylpenicillin (penicillin V).
II. Semisynthetic penicillins
II.1. For parenteral and enteral administration (acid-fast):
- penicillinase resistant to action:
oxacillin (sodium salt),
- a broad spectrum of action:
II.2. For parenteral administration (destroyed in the acidic environment of the stomach)
- a broad spectrum of action, including Pseudomonas aeruginosa:
carbenicillin (disodium salt),
II.3. For enteral administration (acid-fast):
carbenicillin (indanyl sodium),
According to the classification of penicillins, given IB. Mikhailov (2001), penicillins can be divided into 6 groups:
1. Natural penicillins (benzylpenicillins, bicillins, phenoxymethylpenicillin).
2. Isoxazole penicillins (oxacillin, cloxacillin, flucloxacillin).
3. Amidipenicillin (amdinotsillin, pivamdinocillin, bakamdinotsillin, atsidotsillin).
4. Aminopenicillins (ampicillin, amoxicillin, talammpicillin, bacampicillin, pivampticillin).
5. Carboxypenicillins (carbenicillin, carfecillin, carindacillin, ticarcillin).
6. Ureidopenicillins (azlocillin, mezlocillin, piperacillin).
The source of the preparation, the spectrum of action, as well as the combination with beta-lactamases, were taken into account when creating the classification given in the Federal Manual (Formulary System), Issue VIII.
Benzylpenicillin (penicillin G),
phenoxymethylpenicillin (penicillin V),
3. Expanded spectrum (aminopenicillins):
4. Active against Pseudomonas aeruginosa:
5. Combined with inhibitors of beta-lactamases (inhibitor-protected):
amoxicillin / clavulanate,
ampicillin / sulbactam,
ticarcillin / clavulanate.
Natural (natural) penicillins are narrow-spectrum antibiotics that affect gram-positive bacteria and cocci. Biosynthetic penicillins are obtained from a culture medium on which certain strains of mold fungi are grown (Penicillium). There are several varieties of natural penicillins, one of the most active and persistent of them is benzylpenicillin. In medical practice, benzylpenicillin is used in the form of various salts - sodium, potassium and novocaine.
All natural penicillins have similar antimicrobial activity. Natural penicillins are destroyed by beta-lactamases, therefore they are ineffective for the therapy of staphylococcal infections, in most cases, staphylococci produce beta-lactamase. They are effective mainly against Gram-positive microorganisms (including Streptococcus spp., Including Streptococcus pneumoniae, Enterococcus spp.), Bacillus spp., Listeria monocytogenes, Erysipelothrix rhusiopathiae, Gram-negative cocci (Neisseria meningitidis, Neisseria gonorrhoeae), some anaerobes (Peptostreptococcus spp., Fusobacterium spp.), spirochete (Treponema spp., Borrelia spp., Leptospira spp.). Gram-negative microorganisms are usually resistant, with the exception of Haemophilus ducreyi and Pasteurella multocida. With regard to viruses (pathogens of influenza, poliomyelitis, smallpox, etc.), mycobacteria tuberculosis, causative agent amoebiasis, rickettsia, fungi penicillins - ineffective.
Benzylpenicillin is active mainly against gram-positive cocci. Spectra of antibacterial action of benzylpenicillin and phenoxymethylpenicillin are almost identical. However, benzylpenicillin is 5-10 times more active than phenoxymethylpenicillin against sensitive Neisseria spp. and some anaerobes. Phenoxymethylpenicillin is prescribed for infections of moderate severity. The activity of penicillin preparations is determined biologically by antibacterial action on a specific strain of Staphylococcus aureus. For unit of action (1 ED), 0.5988 μg of chemically pure crystalline sodium salt of benzylpenicillin is taken.
Significant deficiencies of benzylpenicillin are its instability to beta-lactamases (in the enzymatic cleavage of the beta-lactam ring with beta-lactamases (penicillinases) to form penicillanic acid, the antibiotic loses its antimicrobial activity), insignificant absorption in the stomach (necessitates injection routes) and relatively low activity for most gram-negative microorganisms.
Under normal conditions, benzylpenicillin preparations do not penetrate well into the cerebrospinal fluid, however, when the meninges get inflamed, the permeability through the BBB increases.
Benzylpenicillin, used in the form of highly soluble sodium and potassium salts, acts for a short time - 3-4 hours, t. It is rapidly excreted from the body, and this requires frequent injections. In connection with this, poorly soluble salts of benzylpenicillin (including novocaine salt) and benzathine benzylpenicillin were proposed for use in medical practice.
Prolonged forms of benzylpenicillin, or depot penicillins: Bicillin-1 (benzathine benzylpenicillin), as well as combined drugs based on them - Bicillin-3 (benzathine benzylpenicillin + benzylpenicillin sodium + benzylpenicillin novocaine salt), Bicillin-5 (benzathine benzylpenicillin + benzylpenicillin novocaine salt ), are suspensions that can only be administered intramuscularly. They are slowly absorbed from the injection site, creating a depot in the muscle tissue. This allows maintaining the concentration of antibiotic in the blood for a considerable time and thus reducing the frequency of administration of the drug.
All salts of benzylpenicillin are used parenterally. they are destroyed in the acidic environment of the stomach. Of natural penicillins, acid-stable properties, although to a weak degree, are only phenoxymethylpenicillin (penicillin V). Phenoxymethylpenicillin differs chemically from benzylpenicillin by the presence of a phenoxymethyl group in the molecule instead of benzyl.
Benzylpenicillin is used for infections caused by streptococci, including Streptococcus pneumoniae (community-acquired pneumonia, meningitis), Streptococcus pyogenes (streptococcal tonsillitis, impetigo, erysipelas, scarlet fever, endocarditis), with meningococcal infections. Benzylpenicillin is the antibiotic of choice in the treatment of diphtheria , gas gangrene, leptospirosis , Lyme disease .
Bicillins are shown, first of all, if it is necessary to maintain effective concentrations in the body for a long time. They are used for syphilis and other diseases caused by pale treponema (yaws), streptococcal infections (excluding infections caused by Group B Streptococcus) - acute tonsillitis, scarlet fever, wound infections, erysipelas, rheumatism, leishmaniasis .
In 1957, 6-aminopenicillanic acid was isolated from natural penicillins and based on it, development of semi-synthetic drugs was started.
6-Aminopenicillan acid is the basis of the molecule of all penicillins ("penicillin core") - a complex heterocyclic compound consisting of two rings: thiazolidine and beta-lactam. A lateral radical is associated with the beta-lactam ring, which determines the essential pharmacological properties of the drug molecule formed in this process. In natural penicillins, the structure of the radical depends on the composition of the medium on which Penicillium spp. Grows.
Semisynthetic penicillins are obtained by chemical modification, attaching various radicals to the 6-aminopenicillanic acid molecule. Thus, penicillins with certain properties were obtained:
- resistant to action of penicillinases (beta-lactamases);
- acid-fast, effective at appointment inside;
- have a wide range of activities.
Isoxazolpenicillins (isoxazolyl penicillins, penicillin-resistant, antistaphylococcal penicillins). Most staphylococci produce a specific enzyme beta-lactamase (penicillinase) and are resistant to benzylpenicillin (penicillinase-forming 80-90% strains of Staphylococcus aureus).
The main antistaphylococcal drug is oxacillin. The group of penicillin-resistant drugs also includes cloxacillin, flucloxacillin, methicillin, nafcillin and dicloxacillin, which, because of their high toxicity and / or low efficacy, have not been clinically applied.
The spectrum of antibacterial action of oxacillin is similar to that of benzylpenicillin, but due to the stability of oxacillin to penicillinase it is active against penicillinase-forming staphylococci resistant to benzylpenicillin and phenoxymethylpenicillin, and resistant to other antibiotics.
By activity against Gram-positive cocci (including staphylococci, not producing beta-lactamase) isoxazole penicillins, incl. oxacillin, are much inferior to natural penicillins, therefore, in diseases caused by microorganisms sensitive to benzylpenicillin, they are less effective than the latter. Oxacillin does not show activity against gram-negative bacteria (except Neisseria spp.), Anaerobes. In this regard, drugs of this group are shown only in cases when it is known that the infection is caused by penicillin-forming staphylococcal strains.
The main pharmacokinetic differences of isoxazole penicillins from benzylpenicillin:
- Fast, but not complete (30-50%) absorption from the digestive tract. You can apply these antibiotics as parenterally (in / m, in / in), and inside, but for 1-1.5 h before meals, tk. they have low resistance to hydrochloric acid;
- a high degree of binding to albumin plasma (90-95%) and the inability to remove isoxazole penicillins from the body during hemodialysis;
- Not only renal, but also hepatic excretion, no need to correct the dosing regimen for mild renal failure.
The main clinical significance of oxacillin is the treatment of staphylococcal infections caused by penicillin-resistant strains of Staphylococcus aureus (except for infections caused by methicillin-resistant Staphylococcus aureus, MRSA). It should be taken into account that Staphylococcus aureus strains resistant to oxacillin and methicillin (methicillin - the first penicillin-resistant penicillin, are discontinued) are located in hospitals. Nosocomial and community-acquired strains of Staphylococcus aureus resistant to oxacillin / methicillin are usually multidrug-resistant - they are resistant to all other beta-lactams, and also often to macrolides, aminoglycosides, fluoroquinolones. Drugs of choice for infections caused by MRSA are vancomycin or linezolid.
Nafcillin is slightly more active than oxacillin and other penicillinase-resistant penicillins (but less active than benzylpenicillin). Nafcillin penetrates the BBB (its concentration in the cerebrospinal fluid is sufficient for the treatment of staphylococcal meningitis), is excreted primarily with bile (the maximum concentration in bile is much higher than serum), to a lesser extent - by the kidneys. It is possible to use inside and parenterally.
Amidipenicillins are penicillins of a narrow spectrum of action, but with a predominant activity against gram-negative enterobacteria. Preparations amidipenicillinov (amdinotsillin, pivamdinotsillin, bakamdinotsillin, atsidotsillin) are not registered in Russia.
Penicillins with extended activity spectrum
In accordance with the classification presented by D.A. Kharkevich, semisynthetic antibiotics of a wide spectrum of action are divided into the following groups:
I. Preparations that do not affect Pseudomonas aeruginosa:
- Aminopenicillins: ampicillin, amoxicillin.
II. Preparations active against Pseudomonas aeruginosa:
- Carboxypenicillins: carbenicillin, ticarcillin, carfecillin;
- Ureidopenicillins: piperacillin, azlocillin, mezlocillin.
Aminopenicillins are broad-spectrum antibiotics. All of them are destroyed by beta-lactamases of both gram-positive and gram-negative bacteria.
Amoxicillin, ampicillin are widely used in medical practice. Ampicillin is the ancestor of the group of aminopenicillins. For gram-positive bacteria, ampicillin, like all semisynthetic penicillins, is inferior in activity to benzylpenicillin, but superior to oxacillin.
Ampicillin and amoxicillin have similar spectra of action. In comparison with natural penicillins, the antimicrobial spectrum of ampicillin and amoxicillin extends to sensitive strains of enterobacteria, Escherichia coli, Proteus mirabilis, Salmonella spp., Shigella spp., Haemophilus influenzae; better than natural penicillins act on Listeria monocytogenes and sensitive enterococci.
Of all oral beta-lactams, amoxicillin is most active against Streptococcus pneumoniae, resistant to natural penicillins.
Ampicillin is ineffective against penicillinase-forming strains of Staphylococcus spp., All strains of Pseudomonas aeruginosa, most strains of Enterobacter spp., Proteus vulgaris (indole-positive).
Combined preparations are produced, for example Ampiox (ampicillin + oxacillin). The combination of ampicillin or benzylpenicillin with oxacillin is rational, because The spectrum of action with this combination becomes wider.
The difference between amoxicillin (which is one of the leading oral antibiotics) from ampicillin is its pharmacokinetic profile: when ingested, amoxicillin is absorbed more quickly and well in the intestine (75-90%) than ampicillin (35-50%), bioavailability does not depend on food intake . Amoxicillin better penetrates into some tissues, including. in the bronchopulmonary system, where its concentration is 2 times higher than the concentration in the blood.
The most significant differences in pharmacokinetic parameters of aminopenicillins from benzylpenicillin are:
- possibility of appointment inside;
- insignificant binding to plasma proteins - 80% of aminopenicillins remain in the blood in free form - and good penetration into tissues and body fluids (with meningitis concentrations in the cerebrospinal fluid may be 70-95% of the concentrations in the blood);
- multiplicity of prescription of combined preparations - 2-3 times a day.
The main indications for the administration of aminopenicillins are upper respiratory tract infection and ENT, kidney and urinary tract infections, gastrointestinal infections, eradication of Helicobacter pylori (amoxicillin), meningitis.
A special feature of the undesirable action of aminopenicillins is the development of an "ampicillin" rash, which is a non-allergic maculopapular rash that quickly passes when the drug is withdrawn.
One of the contraindications to the appointment of aminopenicillins is infectious mononucleosis .
Shelf life and storage conditions
Store in a cool dry place, protected from light. The expiry date is individual and specified in the instructions of each penicillin group drug.
We want to pay special attention to the fact that the description of the antibiotic Penicillin is presented for informational purposes only! For more accurate and detailed information about the Penicillin drug, please refer exclusively to the manufacturer's annotation! Do not self-medicate! You should definitely consult a doctor before starting the drug!