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At least 24 hours should elapse between the last dose of sildenafil and giving a nitrate purchase fucidin with american express treatment for uti medscape. P ro t o t y p e D r u g s Drugs for Erectile Dysfunction and Benign Prostatic Hyperplasia Drugs for Erectile Dysfunction Phosphodiesterase Type 5 Inhibitor Sildenafil Nonoral Drugs Papaverine/phentolamine Alprostadil Drugs for Benign Prostatic Hyperplasia 5-Alpha-Reductase Inhibitor Finasteride Alpha-Adrenergic Antagonist Tamsulosin Alpha Blockers purchase fucidin cheap online antibiotics variceal bleed. Alpha-adrenergic antagonists—including doxazosin [Cardura] and other alpha blockers used for prostatic hyperplasia (see later discussion)—dilate arterioles and can thereby lower blood pressure order generic fucidin line bacteria breath test. However purchase generic fucidin online 00g infection, there was a question as to what caused the adverse events: sildenafil or the sexual activity that sildenafil permitted. Accordingly, the drug should be used with caution by men with the following conditions: • Myocardial infarction, stroke, or life-threatening dysrhythmia within the last 6 months • Resting hypotension (blood pressure below 90/50 mm Hg) • Resting hypertension (blood pressure above 170/110 mm Hg) • Heart failure • Unstable angina In addition, sildenafil should not be used at all by men taking nitroglycerin or any other drug in the nitrate family. To reduce the risk for adverse events, candidates for sildenafil therapy should undergo a careful evaluation of cardiovascular function. Those with impaired function should be counseled about the risks posed by sexual activity and all other moderate to intense physical activity. Vardenafil, Tadalafil, and Avanafil Vardenafil, tadalafil, and avanafil are very similar to sildenafil. As with sildenafil, benefits derive from relaxing arterial and trabecular smooth muscle in the penis. There is no evidence that vardenafil works faster, longer, or better than sildenafil. Plasma levels peak about 1 hour after dosing, or after 2 hours if dosing is done with a high-fat meal. Vardenafil is contraindicated for use with alpha-adrenergic blockers and with nitroglycerin and other nitrates. On average, therapeutic levels of the drug are reached by 2 hours after dosing and persist about 36 hours —much longer than with sildenafil or vardenafil. The most common adverse effects are headache, dyspepsia, back pain, myalgia, limb pain, flushing, and nasal congestion. Because tadalafil has a long duration of action, adverse effects may persist for many hours. Tadalafil is contraindicated for use with nitrates or alpha blockers (except tamsulosin [Flomax]). The manufacturer does not identify a minimum time between dosing and sexual activity. However, because blood levels peak more slowly than with sildenafil or vardenafil, allowing at least 1 hour for absorption would seem reasonable. Daily dosing is recommended only for men who anticipate sexual activity at least twice a week. Plasma levels peak about 30 to 45 minutes after dosing in fasting patients, or after 1. It can increase the hypotensive effects of alcohol and antihypertensive drugs, especially alpha-adrenergic antagonists. A starting dose of 50 mg (the lowest strength available) is recommended if prescribed for patients taking antihypertensive drugs. Specifically, they are administered either by injection into the penis or by insertion into the urethra. Administration is accomplished by loading a pellet into a small plastic applicator, which is then inserted an inch and a half into the urethra. Erection develops 5 to 10 minutes after drug insertion and lasts 30 to 60 minutes. Relaxation of smooth muscle1 1 (arterial, venous, and trabecular), causing a rapid inflow of arterial blood. As explained when discussing physiology of erection, the blood fills the vascular sinusoidal spaces of the corpora cavernosa resulting in an erection. Pressure from the engorged penis helps block venous outflow to promote maintenance of the erect state. Adverse Effects The most common adverse effect, dull ache in the penis, occurs in 32% of users. Systemic symptoms are rare when taken as directed and approximate those of placebo use. Intracavernous Alprostadil [Caverject, Caverject Impulse, Edex] is also available in a form for direct injection into the corpus cavernosum. A training video demonstrating how to inject the medication plus a link to access written instructions is available online at http://www. The dosing end point is an erection that is sufficient for intercourse but that does not last for more than 1 hour. Injectable alprostadil should be used no more than 3 times a week and not more than once in 24 hours. Papaverine Plus Phentolamine The combination of papaverine (a vasodilator) plus phentolamine (an alpha- adrenergic blocking agent) can provide tumescence when injected directly into the corpus cavernosum. Arterial inflow is augmented by alpha-adrenergic blockade (causing arterial dilation) and by the direct relaxant action of papaverine on arterial smooth muscle. Adverse Effects Priapism (persistent erection lasting more than 6 hours) occurs in about 10% of patients. Other adverse effects include orthostatic hypotension with dizziness, transient paresthesias, ecchymosis (extravasation of blood into subcutaneous tissue), and difficulty in achieving orgasm or ejaculation. In 2015 the Canadian Urologic Association developed and published updated clinical guidelines for treatment of erectile dysfunction. Pathophysiology and Overview of Treatment Pathophysiology The prostate is a heart-shaped gland that surrounds the male urethra. Overgrowth of epithelial cells causes mechanical obstruction of the urethra, whereas overgrowth of smooth muscle causes dynamic obstruction of the urethra. Therefore some men with only moderate enlargement may be highly symptomatic, whereas others with substantial enlargement may have no symptoms. These procedures are most appropriate for men with severe symptoms or complications. Watchful waiting, which consists of annual reevaluation with reconsideration of management based on results, is appropriate for men with minimal symptoms. The 5-alpha- reductase inhibitors are most appropriate for men with very large prostates (mechanical obstruction), whereas alpha blockers are preferred for men with relatively small prostates (dynamic obstruction). Teratogenic to the Finasteride Proscar which reduces mechanical obstruction of male fetus. Swallow [Avodart] capsules whole Finasteride Tablets: 5 mg 5 mg once a day May take with or without food. Both drugs can reduce prostate size, although several months are required for a noticeable effect. Because the percentage of epithelial tissue is highest in very large prostates, finasteride is most effective in men whose prostates are highly enlarged. In fact, when given to healthy men to prevent prostate cancer, finasteride actually increased the likelihood of a high-grade tumor. In addition, because finasteride can be absorbed through the skin, pregnant women should not handle tablets that have been broken or crushed. Men are also advised not to donate blood if taking finasteride or until at least 1 month after stopping the drug to avoid the risk of having a pregnant woman as the blood recipient.
The drug is indicated for the rapid conversion of 6 months during amiodarone treatment cheap 10gm fucidin amex antibiotics for uti metronidazole. These actions serve to terminate supraventricular to convert atrial fbrillation and for long-term suppression tachycardia by preventing the retrograde conduction of reen- of the arrhythmia generic 10gm fucidin otc virus like chicken pox. The drug is primarily elimi- including the type associated with W olff-Parkinson-W hite nated by renal excretion purchase cheap fucidin line antibiotic powder, and doses must be reduced in syndrome order fucidin overnight delivery antibiotic resistance hypothesis. Dipyridamole, a vasodilator used to facilitate angiographic studies, inhibits the cellular uptake of Sotalol adenosine and markedly increases its cardiac effects. Adenosine can cause val by blocking the delayed potassium rectifer current bronchospasm and should be used cautiously in persons during phase 3 of the ventricular action potential (see Fig. Digoxin has been used to slow the ven- arrhythmias and is also effective in the management of tricular rate in patients with atrial fbrillation, although atrial arrhythmias, including atrial fbrillation. In fact, digoxin has a Diltiazem and verapamil are calcium channel blockers positive inotropic effect and is also used to treat heart that have signifcant effects on cardiac tissue. As lular cation, has a number of roles in normal cardiac func- shown in Table 14-1, they have little effect on the ventricular tion. Magnesium defciency can be caused by use of drugs conduction velocity and refractory period. Ivabradine is a novel heart rate–lowering drug available in many countries but not yet in the United States for the Miscellaneous Drugs treatment of angina, heart failure, and inappropriate sinus Adenosine tachycardia. When administered as a rapid intrave- which is a mixed Na+-K+ inward current that is activated by nous bolus, it has an extremely short half-life of 10 seconds hyperpolarization, modulated by the autonomic nervous or less. In the body, adenosine is derived from adenosine system, and responsible for diastolic depolarization and triphosphate and activates specifc G protein–coupled ade- cardiac impulse initiation. Surgical catheter ablation of arrhythmo- Atrial Fibrillation and Flutter genic tissue is a treatment option for some patients and is Atrial fbrillation is thought to be caused by a disorganized often considered for patients with persistent or paroxysmal form of reentry in atrial tissue, a form in which atrial cells arrhythmias that do not respond to drug therapy. Atrial futter is usually treated in the same manner as There are two general approaches to pharmacologic atrial fbrillation, including the consideration of surgical therapy of atrial fbrillation: rate control and rhythm catheter ablation of the arrhythmogenic tissue. Esmolol is a short-acting drug whose use is underlying atrial fbrillation (Box 14-3). Long-term sup- After the ventricular rate has been controlled, atrial fbril- pression is usually accomplished by use of a calcium channel lation can be converted to normal sinus rhythm by the use blocker, β-blocker, or digitalis glycoside. Surgical ablation of of direct current cardioversion (provided the arrhythmia is the arrhythmogenic tissue can also be effective. The A 76-year-old man arrives in the emergency department with arrhythmia typically causes dyspnea and palpitations and may shortness of breath and chest palpitations for a duration of lead to clot formation on fbrillating atrial leafets; hence most 3 hours while at rest. He has a history of hypertension con- patients receive anticoagulants to prevent thromboembolism trolled with hydrochlorothiazide and type 2 diabetes con- and stroke. There are shows atrial fbrillation with a rapid and irregular ventricular two approaches to the long-term management of atrial fbril- rate averaging 120 beats/min. In the rate control nously, and his ventricular rate becomes more regular with a method, a β-blocker or calcium antagonist is administered to rate of 85 beats/min, and his symptoms subside. Angiotensin inhibitors appear to lower call his physician if symptoms of atrial fbrillation resume, and the relapse rate after cardioversion. A number of new thera- he is scheduled for follow-up evaluations and electrophysio- pies are under development that may overcome some of the logic studies to determine the most appropriate long-term limitations of currently available drugs. Long-term treatment may the intravenous administration of sodium bicarbonate, consist of surgical ablation of arrhythmogenic tissue or use which increases dissociation of the antidepressant from of a sodium or potassium channel blocker to suppress the sodium channels. Patients with a by decremental conduction and reentry in ventricular tissue drug-induced arrhythmia can be treated by withdrawal of (see earlier). Because of their proar- darone are administered, followed by continued attempts at rhythmic effects, their use has declined in favor of defbrillation. They also reduce the incidence of fatal ventricular defbrillator to reduce the number of shocks required to arrhythmias in patients with myocardial infarction. Sotalol is used for both Chapter 14 y Antiarrhythmic Drugs 143 acute and chronic treatment of supraventricular and 5. Amiodarone is a thyroxine analogue that can cause hypothyroidism and, less com- 1. None of the other options is tachycardia, a man reports cold intolerance and of being associated with this adverse effect. Sinus bradycardia (E) results from sociates very slowly from ventricular sodium channels. The woman diographic change should guide dosage adjustments with most likely has supraventricular tachycardia, which may this drug? A woman reports a racing heart that began while she was antiarrhythmic activity, sotalol is a β-adrenoceptor antag- playing softball 2 hours ago. It may cause bronchospasm in sensitive persons by regular heart rate, and she is given an intravenous bolus blocking β2-adrenoceptors in bronchial smooth muscle. Hence, the drug should be avoided in persons with Which drug mechanism may lead to termination of the asthma and chronic obstructive lung disease. Diabetes mellitus and clinical mani- a • Simvastatin (Zocor) festations of noncoronary forms of atherosclerotic disease Bile Acid–Binding Resins (e. Fibric Acid Derivatives Women have a lower risk of heart disease until after • Fenofbrate (Tricor) menopause, and this lower risk may be partly a result of the • Gemfbrozil (Lopid) favorable effect of estrogens on serum lipoprotein levels. Other Drugs Estrogens may also have benefcial effects on the microcir- • Niacin (vitamin B3, nicotinic acid) culation and energy metabolism. After discussing lipoproteins, lipid transport, and the aAlso lovastatin (Mevacor), fuvastatin (Lescol), and pitavastatin (Livalo). Cholesterol, which is an essential component of cell membranes, is the Lipoproteins and Lipid Transport precursor to the sterol and steroid compounds that are syn- Because lipids are insoluble in plasma water, they are trans- thesized in the body. Triglycerides, composed of three fatty ported in the blood in the form of lipoproteins. These sub- acids and glycerol, are the main storage form of fuel used to stances have a core of hydrophobic (water-evading) lipids generate high-energy compounds, such as adenosine tri- surrounded by a shell of hydrophilic (water-attracting) pro- phosphate, that provide the energy for muscle contraction teins and portions of phospholipids. The various types are distinguished in terms Whereas hyperlipidemia and hyperlipoproteinemia are of their buoyant density, lipid and protein composition, and general terms for elevated concentrations of lipids and lipo- role in lipid transport. Moreover, each type is associated with proteins in the blood, hypercholesterolemia and hypertri- a unique group of apoproteins. Some of the apoproteins are glyceridemia refer specifcally to high concentrations of exchanged between different types of lipoproteins as they cholesterol and triglycerides, respectively. The composition and emia contributes to the pathogenesis of atherosclerosis and metabolism of lipoproteins is depicted in Box 15-1. Chylomicrons Hypertriglyceridemia is a risk factor for pancreatitis, but its Chylomicrons are involved primarily in the transport of role in the development of atherosclerosis and heart disease dietary lipids from the gut to the adipose tissue and liver. Clinical trials of drugs that reduce serum When cholesterol and triglycerides are ingested, they are triglycerides have not consistently reduced cardiovascular emulsifed in the intestines by the bile acids and other bile events and have not reduced mortality. After chylo- of premature death in industrialized countries, it is impor- microns are secreted into the circulation, they deliver tant to detect and eliminate modifable risk factors asso- triglycerides to adipose tissue via the action of a lipoprotein ciated with it. In addition to hyperlipidemia, these risk lipase located in the vascular endothelial cells. By this factors include hypertension, cigarette smoking, and a low process, chylomicrons are converted to a cholesterol-rich 144 Chapter 15 y Drugs for Hyperlipidemia 145 chylomicron remnant, which transports cholesterol to Normal arterial wall Tunica the liver. In atheromas, cholesterol is Macrophage phagocytosed by macrophages, which are transformed into foam cells as they become flled with oxidized cholesterol.
The abdomen is inspected cheap fucidin master card infection control training, auscultated for bowel sounds cost of fucidin antibiotic resistance evolution, followed by gentle palpation for the area of maximal tenderness and rigidity buy generic fucidin 10 gm antibiotic 939. Gentle finger percussion is the best method to assess for peritoneal irritation (“rebound tenderness”) order discount fucidin online antibiotic pink eye. The utility of a rectal examination for children with suspected appendicitis is debatable so it is not routinely performed; it can, however, be helpful for localizing the pain source in a female adolescent. Thereafter, it would be expected to be greater than 10,000/mm3 and in cases of perforation, it may be greater than 20,000/mm3. Urinalysis is important to evaluate for glucose and large ketones or pyuria with nitrites and bacteria because these findings sug- gest diabetic ketoacidosis or urinary tract infection respectively. Mild hematuria or pyuria can occur with acute appendicitis because of irritation of the bladder or ure- teral wall. Psoas shadow obliteration, right lower quadrant intestinal dilation, scoliosis toward the affected region, and an appendicolith (seen in 10% of cases) support appendicitis. In a facil- ity experienced in using ultrasonography in children, ultrasound is the preferred imag- ing modality for a child suspected of having appendicitis. Its main limitation is that the appendix cannot always be visualized, which can occur if the appendix has already perforated, the patient is obese, or if there is a lot of bowel distention. If pelvic views are included, it can evaluate for ovarian pathology as the cause of the abdominal pain. Its disad- vantages are the amount of radiation exposure generated, increased cost, and it may give limited information without the use of contrast. Electrolyte abnormalities and volume depletion should be corrected preopera- tively as surgery within 48 hours from diagnosis does not influence perforation rate but reduces the risk of surgical complications. Analgesia should be given because it has been shown that it does not interfere with identifying the correct diagnosis. For perforated appendicitis, initial management consists of intravenous antibiotics and fluid replacement. Percutaneous catheters can be used to drain any abscess and then appendectomy is performed at a later time. Sickle cell disease (Case 13) may present as an abdominal pain crisis or with gall bladder disease. Pneumonia (Case 14) of the lower lobes is classically described as possibly causing abdominal pain similar to appendicitis. In the smaller child with significant lead poisoning (Case 25), abdominal pain along with achy joints, change in behavior, and encephalopathy can be seen. Bacterial enteritis (Case 28), especially when caused by Campylobacter or Yersinia sp. While malrotation (Case 34) typically occurs in smaller children, the presentation with abdominal pain may be similar; as part of the surgical procedure to correct a malrotation, an appendectomy typically is performed. Diabetic ketoacidosis (Case 42) presents in a vari- ety of ways, among which is abdominal pain; measurement of a serum sugar typically is performed as part of the evaluation of a patient with possible appendicitis. The patient with severe sore throat, abdominal pain, and fever may have streptococcal pharyngitis; the later complication of this condition is poststreptococcal glomerulonephritis (Case 52). Her mother says that she has also had poor appetite and two loose stools the day prior. Because of the pain, she is unable to sit up for lung auscultation or percussion of the costovertebral angles. For which of the following condi- tions would exclude appendicitis from the differential diagnosis? A urine dipstick on a clean-catch specimen shows 1+ leukocytes, trace blood, and trace ketones, but no nitrites and no bacteria. Send the patient immediately to the pediatric hospital for an abdominal ultrasound. Give him a prescription for trimethoprim-sulfamethoxazole; schedule a follow-up visit in 2 days to reevaluate the urine. Admit him to the hospital for intravenous antibiotics to treat presumed pyelonephritis. This child’s presentation is concerning for appendicitis, and she may have already perforated. Abdominal radiographs can be included in the evaluation of abdominal pain but is not the appropriate imaging tool when appendicitis is strongly suspected. It is not uncommon for appendicitis to cause stool changes, either obsti- pation or ileus from the inflammation. Diarrhea can occur by the same mechanism or may be part of the initial illness that created the appendici- tis. A negative pregnancy test only excludes ruptured ectopic pregnancy as her diagnosis. Scleral icterus and tender posterior cervical lymph nodes are not features of appendicitis. This boy’s symptoms and signs can be caused by appendicitis so prompt imaging to further confirm the diagnosis is indicated. His urinalysis is not consistent with a urinary tract infection, especially because he has peripheral leukocytosis; the urine abnormalities are most likely the result of bladder wall or ureter irritation caused by an inflamed appendix. Waiting to perform diagnostic imaging another 24 hours would increase the risk of perforation to 65% or more. Children with abdominal pain require a comprehensive examination but rectal examination is rarely indicated. Inspection of the oropharynx will show pharyngitis or tonsillitis and her age may prevent her from disclosing that she has pain in her throat. Auscultation and percussion of the abdomen should always be done when pain is reported. If you encounter the child supine on the examination table, it is important to watch the child go through changes in position, such as sitting up for the lung examination, transferring off the table, and then her gait. She first started feeling ill 10 days ago with general malaise, headache, and nau- sea. She has worsening sore throat and difficulty swallowing solid foods; she is drinking well. She takes an oral contraceptive daily and took two doses of ampicillin yesterday (left over from a prior illness). She has mild supraorbital edema, bilaterally enlarged tonsils that are coated with a shaggy gray exudate, a few petechiae on the palate and uvula, bilateral posterior cervical lymphadenopathy, and a spleen that is palpable 3 cm below the costal margin. Her examination reveals a fever, rash, tonsillar hypertrophy with exudate, posterior cer- vical lymphadenopathy, and splenomegaly. Differential diagnosis includes group A β-hemolytic streptococcal pharyngitis, but streptococcal infection typi- cally does not have a prodrome similar to this case or cause splenomegaly. Fever, posterior cervical adenopathy, and sore throat are seen in more than 80% of cases. The virus is excreted in saliva; infection results from mucosal contact with an infected individual or from contact with a contami- nated fomite.
Specifically buy discount fucidin line antibiotic resistance data, we need to ensure sufficient intake of calcium and vitamin D generic 10gm fucidin visa antibiotics for uti not sulfa, and we need to adopt a lifestyle that promotes bone health buy cheap fucidin line bacteria 2 kingdoms. Calcium is needed to maximize bone growth early in life and to maintain bone integrity later in life generic 10gm fucidin with visa human antibiotics for dogs. Note that calcium requirements are greatest for adolescents and teens (1300 mg/day), then drop for younger adults (1000 mg/day), and then rise for older adults (1200 mg/day). Other important predictors include a family history of hip fractures, a personal history of fractures, low body mass index, and use of oral glucocorticoids. Individual risk is calculated after entering the following data: • Age • Gender • Weight • Height • Previous fracture • Hip fracture in a parent • Secondary osteoporosis (i. In 2016, The American Association of Clinical Endocrinologists and the American College of Endocrinology released joint clinical practice guidelines for diagnosis and treatment of postmenopausal osteoporosis. Treating Osteoporosis in Women The objective of osteoporosis treatment is to reduce the occurrence of fractures by maintaining or increasing bone strength. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2016. Antiresorptive drugs—estrogen, raloxifene, bisphosphonates, calcitonin, and denosumab—are used most often. These agents do a good job of preventing bone loss by reducing osteoclast activity, but are largely unable to reverse bone mass that has already occurred. Accordingly, antiresorptive drugs are most beneficial when used early—before substantial loss has occurred. With all antiresorptive drugs, success requires a sufficiency of calcium and vitamin D. At this time, teriparatide [Forteo] is the only drug that effectively promotes bone formation. Of the drugs employed for osteoporosis, three agents—teriparatide, denosumab, and zoledronate (a bisphosphonate)—are most likely to reduce fractures. Treating Osteoporosis in Men In the United States about 2 million men have aging-related osteoporosis, and another 3 million are at risk. Hip fractures occur in 80,000 American men annually, compared with 269,000 American women. Although rates of osteoporosis and fractures in men are significant, they are still much lower than in women. As discussed, bone mass in men peaks in the third decade and begins progressive decline at about age 50 years. The rate of decline in men is about equal to that in women—except that in men, there is no counterpart to the accelerated phase of bone loss that occurs after menopause. If men and women lose bone mass at similar rates, why do men experience less osteoporosis? The main reason is that bones in men, at their peak, are larger and stronger than bones in women. Hence, after decline begins, male bones can tolerate more loss before fractures are likely. Factors that contribute to the risk for osteoporosis in men include low testosterone, prolonged use of glucocorticoids, white race, calcium deficiency, vitamin D deficiency, smoking, excessive alcohol consumption, and insufficient exercise. For alendronate, zoledronate, and teriparatide, dosages are the same as those used in women. If testosterone deficiency underlies osteoporosis, testosterone replacement therapy is indicated, unless the patient has testicular cancer or some other disorder that contraindicates testosterone use. Prescribing and Monitoring Considerations Vitamin D Assessment Therapeutic Goals Goals include treatment of rickets, osteomalacia, and hypoparathyroidism, and prevention of vitamin D deficiency. Baseline Data The prescriber may order serum levels of vitamin D, calcium, phosphorus, and alkaline phosphatase as well as a 24-hour urinary calcium determination. Ongoing Monitoring and Interventions Monitoring Summary Monitor serum calcium, serum phosphorus, and urinary calcium. Vitamin D–induced hypercalcemia can cause dysrhythmias in patients taking digoxin. Large therapeutic doses may cause hypervitaminosis D, a syndrome characterized by hypercalcemia, hypercalciuria, decalcification of bone, and deposition of calcium in soft tissues. If vitamin D toxicity develops, instruct the patient to discontinue vitamin D immediately, increase fluid intake, and institute a low-calcium diet. Oral Calcium Salts Assessment Therapeutic Goals Goals include treatment of mild hypocalcemia and supplementation of dietary calcium. Identifying High-Risk Patients Calcium salts are contraindicated for patients with hypercalcemia, renal calculi, and hypophosphatemia. Administration Considerations Individual calcium salts differ with respect to percentage of elemental calcium. As a result, the dose required to provide a specific amount of calcium differs among the salts. Ongoing Monitoring and Interventions Minimizing Adverse Effects Prolonged therapy can cause hypercalcemia. Calcitonin-Salmon Assessment Therapeutic Goals Goals include treatment of postmenopausal osteoporosis, Paget disease of bone, and hypercalcemia. Baseline Data The prescriber may order measurements of serum alkaline phosphatase, calcium, and phosphorus, as well as a 24-hour urinary hydroxyproline. Identifying High-Risk Patients Salmon calcitonin is contraindicated for patients allergic to this preparation. Ongoing Monitoring and Interventions Evaluating Therapeutic Effects Postmenopausal Osteoporosis. Monitor for reductions in bone pain, serum alkaline phosphatase levels, and 24- hour urinary hydroxyproline value. Bisphosphonates Used for Osteoporosis Assessment Therapeutic Goals Goals include prevention and treatment of osteoporosis. For patients receiving zoledronate, obtain a baseline value for creatinine clearance and assess for adequate hydration. Identifying High-Risk Patients Oral bisphosphonates are contraindicated for patients with esophageal disorders that can impede swallowing and for patients who cannot sit or stand for at least 30 minutes (60 minutes with ibandronate). Administration Considerations Proper administration is needed to maximize absorption and minimize the risk for esophagitis. Patients must be able to sit upright for at least 30 minutes (60 minutes with ibandronate) after taking bisphosphonates. To ensure absorption, bisphosphonates must be taken on an empty stomach; no food should be ingested for at least 30 minutes (60 minutes with ibandronate) after administration. Oral bisphosphonates can cause severe esophagitis, sometimes resulting in ulceration. Avoid these drugs in patients with esophageal disorders that could impede swallowing and in patients who are unable to sit or stand for 30 minutes (60 minutes with ibandronate).
The dosing objective is to produce plasma theophylline levels in the therapeutic range buy generic fucidin 10 gm virus informaticos, which for most patients is 5 to 15 mcg/mL order discount fucidin on line virus 007. Ongoing Monitoring and Interventions Evaluating Therapeutic Effects Monitor theophylline levels to ensure that they are in the therapeutic range (5– 15 mcg/mL for most patients) buy 10 gm fucidin otc antimicrobial therapy definition. Severe effects (convulsions buy fucidin online yeast infection 8 weeks pregnant, ventricular fibrillation) can occur at drug levels above 30 mcg/mL. Tobacco and marijuana smoking can increase clearance to 50% in adults and 80% in older adults. Accordingly, it is important to inquire regarding smoking habits in order to optimize dosing. Phenobarbital, phenytoin, rifampin, and other drugs can lower theophylline levels. In the presence of these drugs, the dosage of theophylline may need to be increased. Cimetidine, fluoroquinolone antibiotics, and other drugs can elevate theophylline levels. Manage toxicity by (1) discontinuing theophylline and (2) administering activated charcoal (to decrease theophylline absorption) plus a cathartic (to accelerate fecal excretion). Drugs for Allergic Rhinitis Allergic rhinitis is an inflammatory disorder that affects the upper airway. Major symptoms are sneezing, rhinorrhea, pruritus, and nasal congestion caused by dilation and increased permeability of nasal blood vessels. In addition, some patients experience associated conjunctivitis, sinusitis, and even asthma. Symptoms are triggered by airborne allergens, which bind to immunoglobulin E (IgE) antibodies on mast cells, and thereby cause release of inflammatory mediators, including histamine, leukotrienes, and prostaglandins. Allergic rhinitis is the most common allergic disorder, affecting almost one out of every six people living in the United States. Seasonal rhinitis, also known as hay fever, occurs in the spring and fall in reaction to outdoor allergens such as fungi and pollens from weeds, grasses, and trees. Perennial (nonseasonal) rhinitis is triggered by indoor allergens, especially the house dust mite and pet dander. Principal among these are (1) glucocorticoids (intranasal), (2) antihistamines (oral and intranasal), and (3) sympathomimetics (oral and intranasal). Sympathomimetics Oral/nasal Activate vascular alpha receptors and thereby cause1 Oral: Restlessness, vasoconstriction, which reduces nasal congestion; insomnia, increased do not decrease sneezing, itching, or rhinorrhea. Antileukotrienes Oral Block leukotriene receptors and thereby reduce nasal Rare neuropsychiatric effects congestion. Approaches to rhinitis management are based in large part on The Diagnosis and Management of Rhinitis: An Updated Practice Parameter (2008), an evidence-based guideline developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. Actions and Uses Intranasal glucocorticoids are the most effective drugs for prevention and treatment of seasonal and perennial rhinitis. Because of their antiinflammatory actions, these drugs can prevent or suppress the major symptoms of allergic rhinitis: congestion, rhinorrhea, sneezing, nasal itching, and erythema in 90% of patients who use them properly. Three of these—budesonide [Rhinocort Aqua], fluticasone propionate [Flonase], and triamcinolone [Nasacort Allergy 24 hours]−are available in the United States without a prescription. The most common are drying of the nasal mucosa and a burning or itching sensation. Of greatest concern are adrenal suppression and slowing of linear growth in children (whether final adult height is reduced is unknown). Systemic effects are least likely with ciclesonide, fluticasone, and mometasone, which have very low bioavailability (see Table 61. Preparations, Dosage, and Administration Intranasal glucocorticoids are administered using a metered-dose spray device. After symptoms are under control, the dosage should be reduced to the lowest effective amount. For patients with seasonal allergic rhinitis, maximal effects may require a week or more to develop. For patients with perennial rhinitis, maximal responses may take 2 to 3 weeks to develop. If nasal passages are blocked because of nasal congestion, they should be cleared with a topical decongestant before glucocorticoid administration. Oral Antihistamines Oral antihistamines (histamine-1 [H ] receptor antagonists) are first-line drugs1 for mild to moderate allergic rhinitis. For therapy of allergic rhinitis, antihistamines are most effective when taken prophylactically and less helpful when taken after symptoms appear. Actions and Uses These drugs can relieve sneezing, rhinorrhea, and nasal itching; however, they do not reduce nasal congestion. Because histamine is only one of several mediators of allergic rhinitis, antihistamines are less effective than glucocorticoids. Antihistamines should be administered on a regular basis throughout the allergy season, even when symptoms are absent, to prevent an initial histamine receptor activation. Because histamine does not contribute to symptoms of infectious rhinitis, antihistamines are of no value against the common cold. Some patients take first-generation antihistamines for their drying effect; however, this may complicate treatment of colds by increasing the viscosity of secretions. The most common complaint is sedation, which occurs frequently with the first-generation antihistamines (e. Accordingly, second-generation agents are clearly preferred for students who need to remain alert in class and for patients who do work that requires alertness. Preparations, Dosage, and Administration Dosages for some popular H antagonists are presented in 1 Table 61. Intranasal Antihistamines Two antihistamines—azelastine [Astelin, Astepro] and olopatadine [Patanase]— are available for intranasal administration. Both drugs are indicated for allergic rhinitis in adults and children older than 12 years. Additionally, some patients experience nosebleeds and headaches with both azelastine and olopatadine. P ro t o t y p e D r u g s f o r A l l e r g i c R h i n i t i s, C o u g h, a n d C o l d s Intranasal Glucocorticoid Beclomethasone Antihistamines Azelastine (intranasal, nonsedating) Loratadine (oral, nonsedating) Intranasal Sympathomimetics (Decongestants) Phenylephrine (short acting) Oxymetazoline (long acting) Opioid Hydrocodone Nonopioid Dextromethorphan Intranasal Cromolyn Sodium The basic pharmacology of cromolyn sodium is discussed in Chapter 60. Actions and Uses For treatment of allergic rhinitis, intranasal cromolyn [NasalCrom] is extremely safe but only moderately effective. Cromolyn reduces symptoms by suppressing release of histamine and other inflammatory mediators from mast cells. Accordingly, the drug is best suited for prophylaxis and hence should be given before symptoms start. Responses may take a week or two to develop; patients should be informed of this delay. Adverse reactions are minimum—less than with any other drug for allergic rhinitis. Preparations, Dosage, and Administration For treatment of allergic rhinitis, cromolyn sodium is available in a metered-dose spray device that delivers 5.
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