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Combination therapy can prevent or delay bacterial resistance to antitubercular drugs chloromycetin 250 mg low cost treatment 001 - b. Today’s lesson includes information Immune and inflammatory responses protect the body from invad- about drug classes ing foreign substances discount chloromycetin 250 mg overnight delivery treatment stye. These responses can be modified by cer- that can modify tain classes of drugs: responses order chloromycetin without a prescription symptoms you are pregnant. Histamine-1 receptor antagonists The term antihistamine refers to drugs that act as histamine-1 (H1) receptor antagonists; that is discount chloromycetin 250mg on line medicine just for cough, they compete with histamine for binding to H1-receptor sites throughout the body. It’s all about chemistry Based on chemical structure, antihistamines are categorized into five major classes: • Ethanolamines include clemastine fumarate, dimenhydrinate, and diphenhydramine hydrochloride. Pharmacokinetics (how drugs circulate) H1-receptor antagonists are well absorbed after oral or parenteral administration. Pharmacodynamics (how drugs act) H1-receptor antagonists compete with histamine for H1 receptors on effector cells (the cells that cause allergic symptoms), blocking histamine from producing its effects. These drugs include diphenhydramine, dimenhydrinate, promethazine, and various piperidine derivatives. No stomach for this H1-receptor antagonists don’t affect parietal cell secretion in the stomach because their receptors are H2 receptors, not H1. The first one there wins Release the mediators Chlorpheniramine competes with histamine for H1-receptor When sensitized to an antigen, a mast cell reacts to repeated sites on the effector cells. By attaching to these sites first, the antigen exposure by releasing chemical mediators. Not just for allergies Antihistamines can have other therapeutic uses: Adverse • Many are used primarily as antiemetics (to control nausea and vomiting). The most common ad- • Diphenhydramine can help treat Parkinson’s disease and drug- verse reaction to anti- induced extrapyramidal reactions (abnormal involuntary move- ments). They can get the heart racing Corticosteroids Cardiovascular reac- tions may include: Corticosteroids suppress immune responses and reduce inflam- • hypotension mation. Natural and synthetic corticosteroids are classified ac- Sensitivity reactions can cording to their biological activities: also occur. Glucocorticoids Most glucocorticoids are synthetic analogues of hormones secret- ed by the adrenal cortex. Drugs in this class include: • beclomethasone • betamethasone • cortisone • dexamethasone • hydrocortisone • methylprednisolone • prednisolone • prednisone • triamcinolone. Distribution Glucocorticoids are bound to plasma proteins and distributed through the blood. Unfortunately, Metabolism and excretion when glucocorticoids inhibit the immune Glucocorticoids are metabolized in the liver and excreted by the response they may kidneys. Glucocorticoids suppress hypersensitivity and immune responses through a process that isn’t entirely understood. Researchers be- lieve that glucocorticoids inhibit immune responses by: • suppressing or preventing cell-mediated immune reactions • reducing levels of leukocytes, monocytes, and eosinophils • decreasing the binding of immunoglobulins to cell surface re- ceptors • inhibiting interleukin synthesis. Taking the red (and more) out Glucocorticoids suppress the redness, edema, heat, and tender- ness associated with the inflammatory response. How methylprednisolone works Tissue trauma normally leads to tissue irritation, edema, inflammation, and production of scar tissue. Methylprednisolone counter- acts the initial effects of tissue trauma, promoting healing. No leaks, no drips As corticosteroids, glucocorticoids prevent the leakage of plasma from capillaries, suppress the migration of polymorphonuclear leukocytes (cells that kill and digest microorganisms), and inhibit phagocytosis (ingestion and destruction). To ensure a job well done, glucocorticoids decrease antibody formation in injured or infected tissues and disrupt histamine syn- thesis, fibroblast development, collagen deposition, capillary dila- tion, and capillary permeability. Adverse reactions to corticosteroids Corticosteroids affect almost • suppressed immune and in- • diabetes mellitus all body systems. Their wide- flammatory responses • hyperlipidemia spread adverse effects in- • osteoporosis • adrenal atrophy clude: • intestinal perforation • hypothalamic-pituitary axis • insomnia • peptic ulcers suppression • increased sodium and wa- • impaired wound healing. Drug interactions Many drugs interact with corticosteroids: • Aminoglutethimide, barbiturates, phenytoin, and rifampin may reduce the effects of corticosteroids. These drugs include: • fludrocortisone acetate, a synthetic analogue of hormones se- creted by the adrenal cortex • aldosterone, a natural mineralocorticoid (the use of which has been curtailed by high cost and limited availability). Pharmacokinetics Fludrocortisone acetate is absorbed well and distributed to all parts of the body. Metabolism and excretion Fludrocortisone acetate is metabolized in the liver to inactive metabolites. Pharmacodynamics Fludrocortisone Fludrocortisone acetate affects fluid and electrolyte balance by acetate gets me acting on the distal renal tubule to increase sodium reabsorption working harder to and potassium and hydrogen secretion. Fludrocortisone acetate is used as replacement therapy for pa- tients with adrenocortical insufficiency (reduced secretion of glu- cocorticoids, mineralocorticoids, and androgens). Seasoning reasoning Fludrocortisone acetate may also be used to treat salt-losing con- genital adrenogenital syndrome (characterized by a lack of corti- sol and deficient aldosterone production) after the patient’s elec- trolyte balance has been restored. Drug interactions As is the case with adverse reactions, the drug interactions associ- ated with mineralocorticoids are similar to those associated with glucocorticoids. Also these Cyclophosphamide, classified as an alkylating drug, is also used as an immunosuppressant; however, it’s primarily used to treat can- cer. Anakinra is an immunosuppressant used to treat adults with moderate to severe active rheumatoid arthritis who haven’t re- sponded to at least one disease-modifying antirheumatic drug. Distribution The distribution of azathioprine, basiliximab, and daclizumab isn’t fully understood. Distribution of tacrolimus depends on several factors; 75% to 99% is protein-bound. Metabolism and excretion Azathioprine and cyclosporine are metabolized in the liver. Mycophenolate is metabolized in the liver to mycophenolate acid, an active metabolite, and then further metabolized to an in- active metabolite, which is excreted in urine and bile. Concentra- tions of mycophenolate and acyclovir may increase in the pres- ence of nephrotoxicity. Tacrolimus is extensively metabolized and excreted primarily in bile; less than 1% is excreted unchanged in urine. Pharmacodynamics How certain immunosuppressants achieve their desired effects has yet to be determined. They do know this much… In patients receiving kidney allografts, azathioprine suppresses cell-mediated hypersensitivity reactions and produces various al- terations in antibody production. Howev- to become cancerous and perhaps even grow er, cyclosporine, an immunosuppressant used aggressively. This research has raised con- to reduce the risk of organ rejection, may also cern about the use of cyclosporine in organ cause cancer. However, this concern needs to be balanced It has long been believed that when the im- against the life-threatening risk of organ rejec- mune system is weakened by immunosuppres- tion. Scientists are now looking for ways to sants, it loses its ability to fight and kill cancer- block this tumor-promoting effect of cyclo- ous cells. Sirolimus is an immunosuppressant that inhibits T-lymphocyte activation and proliferation that occur in response to antigenic and cytokine stimulation; it also inhibits antibody formation.
Precautons Older people (risk of keratts); if used in angle-closure glaucoma order discount chloromycetin online medicine hat horse, use with a miotc buy chloromycetin 250 mg treatment diarrhea, and not alone; interactons (Appendix 6c); pregnancy (Appendix 7c) buy chloromycetin 500 mg free shipping medicine 027 pill. Adverse Efects Stnging purchase chloromycetin 500 mg with amex symptoms of diabetes, burning, pain, itching, erythema, transient dryness, allergic blepharits, transient conjunctvits, keratts, decreased corneal sensitvity, diplopia, ptosis; systemic efects; partcularly on the pulmonary, cardiovascular and central nervous systems, may follow absorpton; blurred vision; headache. However, in some cases, for example, in gonococcal conjunctvits, both topical and systemic ant-infectve treatment may be neces- sary. Blepharits and conjunctvits are ofen caused by staphy- lococcus, while keratts and endophthalmits may be bacte- rial, viral or fungal. Although most cases of acute bacterial conjunctvits may resolve spontaneously, ant-infec- tve treatment shortens the infectous process and prevents complicatons. Acute infectve conjunctvits is treated with antbacterial eye drops by day and eye ointment applied at night. Gentamicin is a broad-spectrum bactericidal aminoglycoside antbiotc with partcular actvity against Pseudomonas aeru- ginosa, Neisseria gonorrhoea and other bacteria that may be implicated in blepharits or conjunctvits. Its antbacterial actvity is atributed to precipitaton of bacterial proteins by silver ions. It is available in 1% ophthalmic solutons and is used for prophylaxis of gonococcal ophthalmia neonatorum. Tetracycline is a broad spectrum antbiotc with actvity against many Gram-positve and Gram-negatve bacteria including N. Ophthalmic tetracycline is used in blepharits, conjunctvits, and keratts produced by susceptble bacteria. Tetracycline is also used in the treatment of trachoma caused by Chlamydia trachomats and in the prophylaxis of neonatal conjunctvits (ophthalmia neonatorum) caused by N. Precautons Maintain adequate hydraton (especially with infusion or high doses); monitor neutrophil count at least twice weekly in neonates; renal impairment (Appendix 7d); lactaton (Appendix 7b); pregnancy (Appendix 7c); not to be applied on mucous membrane. Adverse Efects Nausea, vomitng, abdominal pain, diarrhoea, headache, fatgue, rash, urtcaria, pruritus, photosensitvity; very rarely, hepatts, jaundice; dyspnoea; neurological reactons (including dizziness, confusion, hallucinatons, convulsions and drowsiness); acute renal failure; anaemia, thrombocytopenia and leucopenia; on intravenous infusion; severe local infammaton (sometmes leading to ulceraton), and very rarely, agitaton, tremors; psychosis and fever; increase in blood urea and creatnine, encephalopathy; seizures; anorexia, tremors. Contraindicatons Pregnancy (Appendix 7c), lactaton (Appendix 7b), porphyria; hypersensitvity. Precautons Avoid repeated courses and prolonged treatment; reduce doses in hepatc impair- ment (Appendix 7a); renal impairment; blood counts required before and peri- odically during treatment; monitor plasma- chloramphenicol concentraton in neonates; interactons: (Appendix 6c). Adverse Efects Blood disorders including reversible and irreversible aplastc anaemia (with reports of resultng leukaemia); peripheral neurits, optc neurits; headache; depression; urtcar- ia, erythema multforme; nausea, vomitng, diarrhoea; stomatts, glossits, dry mouth; nocturnal haemoglobinuria; grey syndrome (abdominal distension, pallid cyanosis, circu- latory collapse) may follow excessive doses in neonates with immature hepatc metabolism. Dose Adult and child above 12 years- Instll 2 to 3 drops in afected eye 3 to 4 tmes daily to start with thereafer reduce slowly as infecton subsides. Exposure to excessive sunlight should be avoided (discontnue if photosensitvity occurs). Avoid excessive alkalinity of urine and ensure adequate fuid intake (risk of crystalluria); interactons (Appendix 6c); paediatric use. Adverse Efects Nausea, vomitng, dyspepsia, abdominal pain, diarrhoea (rarely, antbiotc-associated colits); headache; dizziness; sleep disorders; rash (rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis) and pruritus. Less frequent side-efects include anorexia, increase in blood urea and creatnine; drowsiness,restlessness,asthenia,depression, confusion, hallucinatons, convulsions, tremor, paraesthesia, hypoaesthesia; photosensitvity, hypersensitvity reactons including fever, urtcaria, angioedema, arthralgia, myalgia, and anaphylaxis; blood disorders (including eosinophilia, leucopenia, thrombocytopenia); disturbances in vision, taste, hearing and smell. Other side-efects that have been reported include haemolytc anaemia, renal failure, intersttal nephrits, and hepatc dysfuncton (including hepatts and cholestatc jaundice). The drug should be discontnued if psychiatric, neurological or hypersensitvity reactons (including severe rash) occur. Ophthalmic soluton:local burning, discomfort, corneal ulcers, lid oedema, corneal infltraton. Ointment: discomfort, keratopathy, blurred vision, corneal staining, epitheliopathy, photophobia. Dose Instllaton into the eye Adult- Mild to moderate infectons: 1 drop every 2 h, reducing frequency as infecton is controlled, then contnue for 48 h afer healing is complete. Precautons Prolonged use may lead to skin sensitzaton and emergence of resistant organisms including fungi; discontnue if purulent discharge, infammaton or exacerbaton of pain; ophthalmic ointment may retard corneal healing, renal impairment (Appendix 7d), interactons (Appendix 6c), pregnancy (Appendix 7c). Adverse Efects Burning; stnging; itching; dermatts; conjuctval epithelial defects;conjuctval hyperemia; thrombocytopenic purpurea; hallucinaton. Dose Adult and child-Fungal infecton of eye: instll 2 to 3 drops 3 to 4 tmes a day in infected eye or as required. Precautons Contact with eyes and mucous membranes should be avoided, pregnancy (Appendix 7c). Adverse Efects Occasional local irritaton and hypersensitvity reactons include mild burning sensaton, erythema; pruritus and itching. Oxytetracycline Pregnancy Category-D Schedule H Indicatons Infectons caused by susceptble pathogens, uncomplicated gonorrhoea, external bacterial infectons of the eye, acne vulgaris. Dose Oral Infectons caused by susceptble pathogens: Adult-250-500 mg 4 tmes daily. Therapy should be contnued for at least 24–48 hours afer symptoms and fever have subsided. Ophthalmic External bacterial infectons of the eye: Adult- Apply the ointment 2-3 tmes daily. Contraindicatons Hypersensitvity to tetracyclines, children below 8 years, renal impairment, pregnancy (Appendix 7c), lactaton. Precautons Hepatc impairment, myasthenia gravis, porphyria, elderly, interactons (Appendix 6b, 6c). Adverse Efects Corneal plaques, erythema multforme, blurred vision, stnging on applicaton. Dose Applicaton to the eye Adult- Superfcial bacterial infecton: 1 applicaton of ointment, 3 to 4 tmes daily. Trachoma, intermitent treatment: 1 applicaton of ointment into each eye either twice daily for 5 days or once daily for 10 days, every month for 6 consecutve months each year, repeated as necessary. Trachoma, contnuous intensive treatment: 1 applicaton of ointment into each eye twice daily for at least 6 weeks. Child (over 8 years)- Superfcial bacterial infecton: 1 applicaton of ointment 3 to 4 tmes daily. Trachoma, intermitent treatment: 1 applicaton of ointment into each eye either twice daily for 5 days or once daily for 10 days, every month for 6 consecutve months each year, repeated as necessary. Trachoma, contnuous intensive treatment: 1 applicaton of ointment into each eye twice daily for at least 6 weeks. Precautons Prolonged use may lead to overgrowth of non- susceptble organisms; lactaton (Appendix 7b); interactons (Appendix 6d); pregnancy (Appendix 7c). Dangers include the development of open-angle glau- coma (chronic simple glaucoma) and cataracts, and the aggrava- ton of a simple herpes simplex epithelial lesion into an exten- sive corneal ulcer and subsequent permanent corneal scarring, with possible damage to vision and even loss of the eye. Cortcosteroids such as prednisolone are useful in the treat- ment of infammatory conditons including uveits and scle- rits. Before administraton of an ophthalmic cort- costeroid, the possibility of bacterial, viral or fungal infecton should be excluded. Treatment should be the lowest efectve dose for the shortest possible tme; if long-term therapy (more than 6 weeks) is unavoidable, withdrawal of an ophthalmic cortcosteroid should be gradual to avoid relapse. Contraindicatons Undiagnosed ‘red eye’ caused by herpetc keratts; glaucoma; viral diseases of cornea and conjunctva. Precautons Cataract, corneal thinning, corneal or conjunctval infecton; discontnue treatment if no improvement within 7 days; risk of adrenal suppression afer prolonged use in infants; hepatc impairment (Appendix 7a); lactaton (Appendix 7b); interactons (Appendix 6c, 6d); pregnancy (Appendix 7c).
A lock purchase chloromycetin now medicine just for cough, or a notice from man- agitating retorts—(1) Indicating mercury- agement posted at or near the record- in-glass thermometer buy cheap chloromycetin online treatment narcolepsy. Each retort shall ing device that provides a warning that be equipped with at least one mercury- only authorized persons are permitted in-glass thermometer whose divisions to make adjustments purchase chloromycetin 500 mg without prescription symptoms testicular cancer, is a satisfactory are easily readable to 1 °F and whose means of preventing unauthorized temperature range does not exceed 17 changes order 500mg chloromycetin visa treatment depression. Ther- bined with the steam controller and mometers shall be tested for accuracy may be a recording-controlling instru- against a known accurate standard ment. The temperature-recorder bulb thermometer upon installation and at shall be installed either within the re- least once a year thereafter, or more tort shell or in a well attached to the frequently if necessary, to ensure their shell. Records of thermometer ac- well shall have a 1⁄16-inch or larger curacy checks which specify date, bleeder opening emitting steam con- standard used, method used, and person tinuously during the processing period. Each thermometer should have should have adequate filter systems to a tag, seal, or other means of identity ensure a supply of clean, dry air. A thermom- be equipped with a pressure gage that eter that has a divided mercury column should be graduated in divisions of 2 or that cannot be adjusted to the pounds or less. Ther- be equipped with an automatic steam mometers shall be installed where they controller to maintain the retort tem- can be accurately and easily read. This may be a recording-con- Bulbs in indicating thermometers shall trolling instrument when combined be installed either within the retort with a recording thermometer. I (4–1–10 Edition) steam controller activated by the provide a continuous record of the steam pressure of the retort is accept- speed. A means of preventing unau- able if it is carefully maintained me- thorized speed changes on retorts shall chanically so that it operates satisfac- be provided. Bleeders, except those for speed adjustment device that provides thermometer wells, shall be one-eight a warning that only authorized persons inch or larger and shall be wide open are permitted to make adjustments, is during the entire process, including the a satisfactory means of preventing un- come-up-time. If a retort jams the outermost location of containers at or breaks down during processing oper- each end along the top of the retort; ations, necessitating cooling the retort additional bleeders shall be located not for repairs, the retort shall be operated more than 8 feet apart along the top of in such a way that ensures that the the retort. All bleeders shall be ar- product is commercially sterile, or the ranged so that the operator can ob- retort is to be cooled promptly and all serve that they are functioning prop- containers either reprocessed, repacked erly. When op- checked with sufficient frequency to erated as a still retort, all containers ensure adequate removal of condensate shall be given a full still retort process or shall be equipped with an automatic before the retort is cooled. If, in such alarm system(s) that would serve as a an emergency, a scheduled still process continuous monitor of condensate- or another process established to en- bleeder functioning. Visual checks sure commercial sterility is to be used, should be done at intervals of not more it shall be made readily available to than 15 minutes. Heat distribution data or (ii) Both the time at which the reel documentary proof from the manufac- stopped and the time the retort was turer or from a competent processing used for a still retort process, if so authority, demonstrating that ade- used, shall be marked on the recording quate venting is achieved, shall be kept chart and entered on the other produc- on file. If the drain should be opened for a time the alternative procedure of prompt sufficient to remove steam condensate cooling is followed, the subsequent from the retort, and provision shall be handling methods used for the con- made for continuing drainage of con- tainers in the retort at the time of densate during the retort operation. The rotational below the temperature specified in the speed of the retort shall be specified in scheduled process while containers are the scheduled process. The speed shall in the retort, the retort reel shall be be adjusted and recorded when the re- stopped promptly. An automatic device tort is started, at any time a speed should be used to stop the reel when change is made, and at intervals of suf- the temperature drops below the speci- ficient frequency to ensure that the re- fied process temperature. Before the tort speed is maintained as specified in reel is restarted, all containers in the the scheduled process. These adjust- retort shall be given a complete sched- ments and recordings should be made uled still retort process if the tempera- every 4 hours or less. The discharged containers and recorded at intervals of sufficient shall be either reprocessed, repacked frequency to ensure that the consist- and reprocessed, or discarded. Both the ency is as specified in the scheduled time at which the reel stopped and the process. Minimum closing machine time the retort was used for a still re- vacuum in vacuum-packed products, tort process, if so used, shall be marked maximum fill-in or drained weight, on the recording chart and entered on minimum net weight, and percent sol- the other production records required ids shall be as specified in the sched- in this chapter. If the alternative pro- uled process for all products when devi- cedure of emptying the retort is fol- ations from such specifications may af- lowed, the subsequent handing methods fect the scheduled process. All meas- used for the containers in the retort at urements and recordings of critical fac- the time of the temperature drop shall tors should be made at intervals not to be entered on the production records. Each retort shall thermal processing requirements may be equipped with at least one mercury- be used before restarting the retort in-glass thermometer whose divisions reel. Alternatively, container entry to are easily readable to 1 °F and whose the retort shall be stopped and an au- thorized emergency agitating process temperature range does not exceed 17 may be used before container entry to °F per inch of graduated scale. When emer- mometers shall be tested for accuracy gency procedures are used, no con- against a known accurate standard tainers may enter the retort and the thermometer upon installation and at process and procedures used shall be least once a year thereafter, or more noted on the production records. Records of thermometer ac- specified in the scheduled process shall curacy checks which specify date, be measured and recorded on the proc- standard used, method used, and person essing record at intervals of sufficient performing the test should be main- frequency to ensure that the factors tained. Each thermometer should have are within the limits specified in the a tag, seal, or other means of identity scheduled process. The minimum that includes the date on which it was headspace of containers, if specified in last tested for accuracy. A thermom- the scheduled process, shall be meas- eter that has a divided mercury column ured and recorded at intervals of suffi- or that cannot be adjusted to the cient frequency to ensure that the standard shall be repaired or replaced headspace is as specified in the sched- before further use of the retort. The headspace of solder- mometers shall be installed where they tipped, lapseam (vent hole) cans may can be accurately and easily read. The headspace of double seamed be installed either within the retort cans may also be measured by net shell or in external wells attached to weight determinations for homogenous the retort. External wells or pipes shall liquids, taking into account the spe- be connected to the retort through at cific can end profile and other factors least a 3⁄4-inch-diameter opening, and which affect the headspace, if proof of equipped with a 1⁄16-inch or larger the accuracy of such measurements is bleeder opening so located as to pro- maintained and the procedure and re- vide a full flow of steam past the sultant headspace is in accordance length of the thermometer bulb. When the bleeder for external wells shall emit product consistency is specified in the steam continuously during the entire scheduled process, the consistency of processing period. I (4–1–10 Edition) shall be the reference instrument for additional bleeders shall be located not indicating the processing temperature. Each Bleeders may be installed at positions retort shall have an accurate tempera- other than those specified above, as ture-recording device. Graduations on long as there is evidence in the form of the temperature-recording devices heat distribution data that they ac- shall not exceed 2 °F within a range of complish adequate removal of air and 10 °F of the processing temperature. Each chart shall have a working scale In retorts having top steam inlet and of not more than 55 °F per inch within bottom venting, a bleeder shall be in- a range of 20 °F of the processing tem- stalled in the bottom of the retort to perature. All bleeders shall be adjusted to agree as nearly as pos- be arranged in a way that enables the sible with, but to be in no event higher operator to observe that they are func- than, the known accurate mercury-in- tioning properly. A means of preventing unauthor- The air in each retort shall be removed ized changes in adjustment shall be before processing is started. A lock, or a notice from man- tribution data or documentary proof agement posted at or near the record- from the manufacturer or from a com- ing device that provides a warning that petent processing authority, dem- only authorized persons are permitted onstrating that adequate venting is to make adjustments, is a satisfactory achieved, shall be kept on file. At the means for preventing unauthorized time steam is turned on, the drain changes. The recorder may be com- should be opened for a time sufficient bined with the steam controller and to remove steam condensate from the may be a recording-controlling instru- retort and provision should be made for ment.