Oral Contraceptives Combination

Combination oral contraceptives contain a combination of a synthetic estrogen and one of several steroids with progestational activity. Most oral contraceptives contain one of two types of estrogen ethinyl estradiol, which is pharmacologically active, or mestranol, which is converted by the liver to ethinyl estradiol. Many different progestins are found in the various oral contraceptives. These include norethindrone, norethindrone acetate, ethynodiol diacetate, norgestrel, levonorgestrel,...

Patient Encounter Part 2 Medical History Physical Exam and Diagnostic Tests PMH Asthma controlled

FH Father living with diabetes mellitus, type 2 (controlled) and chronic obstructive pulmonary disease mother living with hypertension (controlled) SH Second year pharmacy student. Works as a pharmacy intern at a local hospital Allergies Penicillin (patient states she was admitted to a hospital at the age of 7 years with hives and throat swelling after receiving amoxicillin) Meds Albuterol (salbutamol) inhaler as needed ROS (+) dysuria, urinary frequency (-) fever, nausea, vomiting, flank pain...

Patient Encounter 1 CINV

MJ is a 42-year-old woman diagnosed with stage II hormone-receptor positive, HER2-negative breast cancer. She has been treated with lumpectomy and radiation therapy and presents to clinic for cycle 1 day 1 of adjuvant doxorubicin and cyclo-phosphamide (the AC regimen). She appears calm and optimistic about her prognosis with no more than expected mild anxiety about the side effects of chemotherapy. She reports drinking alcohol only on holidays but does report a history of motion sickness. All...

Nonpharmacologic Therapy

Nonpharmacologic treatment of GERD includes patient-specific lifestyle modifications, antireflux surgery, or endoscopic therapies. Although most patients do not respond to lifestyle changes alone, the importance of maintaining these lifestyle changes throughout the course of GERD therapy should be stressed to selected patients on a routine basis. The most common lifestyle changes that a patient should be educated about include (a) losing weight and (b) elevating the head of the bed if symptoms...

Pulmonary Function Tests

Postbronchodilator FEV1 1.70 L (13.3 increase) FEV1 after exercise 1.23 L (23.1 decrease) Given this additional information, what is your assessment of the patient's asthma severity Identify your treatment goals for this patient. What nonpharmacologic and pharmacologic alternatives are feasible for this patient Outline a treatment plan for this patient that includes nonpharmacologic therapy, pharmacologic therapy, and a monitoring plan. Justify your therapeutic selections. Children Up to 4...

Patient Encounter 2 Part 2 Medical History Physical Examination Diagnostic Tests and Creating a Care Plan

All developmental milestones within normal limits. Two episodes of AOM treated with no sequelae. Current on all immunizations ROS (+) nocturnal incontinence 5 nights week or more (-) vaginal itching, UTIs, urgency, frequency, dysuria, lower abdominal fullness VS BP_ _mm Hg, P_bpm, RR min, T 37.0 C (98.6 F) Resp Within normal limits CV Within normal limits Abd Soft, nontender, nondistended (+) bowel sounds bladder not palpable Neuro Within normal limits...

Treatment Goals of Therapy

The introduction of antibiotic therapy and vaccines has reduced dramatically the mortality associated with bacterial meningitis.19 Prior to these advances, bacterial meningitis was almost universally fatal, and those few patients who survived often suffered from debilitating residual neurologic deficits, such as permanent hearing loss. Although significant improvements have been made, the fatality rate of pneumococ-cal meningitis remains above 20 likely due to its occurrence in debilitated...

Patient Care and Monitoring

Assess the patient's signs, symptoms, and risk factors for meningitis. Do these offer any clues to the offending pathogen 2. Determine if the patient can undergo an immediate LP or if the LP should be delayed until a CNS mass lesion can be ruled out. If the LP is delayed, blood cultures should be drawn and appropriate empirical antimicrobial therapy initiated immediately. 3. Based on patient-specific data, local resistance patterns, and other relevant data, design an appropriate empirical...

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder that is often unrecognized, affecting 4 of middle-aged white men and 2 of middle-aged white women.15 In women, the frequency of OSA increases after menopause. OSA is as common or more common in African Americans and less common in Asian populations. The risk of OSA increases with age and obesity. Individuals with OSA experience repetitive upper airway collapse during sleep, which decreases or stops airflow, with subsequent arousal from sleep to...

Restless Legs Syndrome

RLS treatment involves suppression of abnormal sensations and leg movements and consolidation of sleep. Dopaminergic and sedative-hypnotic medications are prescribed commonly. In the last few years, dopamine agonists (DAs) have become the therapy of choice for the treatment of RLS, replacing levodopa carbidopa as first-line agents. The DAs offer many advantages over levodopa carbidopa, including longer half-lives to cover overnight symptoms, flexible dosing, and a reduced incidence of symptom...

Patient Encounter Part 3 Modifying Treatment Plan

CH returns to the clinic 3 months later. The physician previously diagnosed him with OSA and RLS. He received a prescription for CPAPs for OSA and ropinirole 0.5 mg at bedtime for RLS at his last visit. Via phone calls, his ropinirole dose has been increased to 3 mg at bedtime. He has received moderate relief of his RLS symptoms, but on occasion, he still awakens and cannot fall back asleep. His sleepiness and RLS symptoms are improved ESS 13 24. Based on the information presented, recommend...

Acromegaly Patient Care and Monitoring

Assess patient's clinical signs and symptoms to determine severity of acromegaly. 2. Review the biochemical disease markers to assess severity of acromegaly. 3. Review the available diagnostic data to determine pituitary tumor size and location. Determine if the patient has a coexisting prolactin secreting tumor. Determine if the tumor extends toward the optic chiasm or if it is continuous on the optic tracts. 4. Assess presence of acromegaly complications. Identify any significant...

Clinical presentation and diagnosis

Any interaction between a patient and a healthcare provider presents an opportunity to evaluate the patient's height and weight. From these parameters, the BMI should be determined as well as waist circumference and the presence of comorbidities or associated risks. BMI, waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. The BMI is calculated using the measured weight in kilograms divided by the height in meters...

General Approach to Treatment

Since the goals for obesity management in the adult population are multifactorial, it should be considered a chronic illness where treatment is maintained for life. Any implemented therapy promoting weight loss should focus on behavior modification directed toward both dietary restriction and increased activity in conjunction with the selective use of pharmacologic or surgical intervention. Before initiating therapy, secondary causes of obesity (e.g., hypothyroidism and Cushing syndrome) must...

Outcome evaluation

Successful management of overweight and obesity is determined by the ability the treatment plan has to (a) prevent weight gain, (b) reduce and maintain a lower body weight, and (c) decrease the risk of obesity-related comorbidities. Since weight is necessary to calculate the BMI, it, as well as waist circumference, should be determined. Obesity management may encompass more than weight loss or maintenance in the presence of other conditions other pertinent parameters should be assessed at...

Pathophysiology Ischemic Stroke

In ischemic stroke, there is an interruption of the blood supply to an area of the brain either due to thrombus formation or an embolism. Loss of cerebral blood flow results in tissue hypoperfusion, tissue hypoxia, and cell death. Tipid deposits in the vessel wall cause turbulent blood flow and lead to vessel injury, exposing vessel collagen to blood. This vessel injury initiates the platelet aggregation process due to the exposed subendothelium. Platelets release adenosine diphosphate (ADP),...

Treatment Of Acute Hemorrhagic Stroke Supportive Measures

Acute hemorrhagic stroke is considered to be an acute medical emergency. Initially, patients experiencing a hemorrhagic stroke should be transported to a neurointensive care unit. There is no proven treatment for ICH. Management is based on neurointensive care treatment and prevention of complications. Treatment should be provided to manage the needs of the critically ill patient including management of increased ICP, seizures, infections, and prevention of rebleeding and delayed cerebral...

Hemorrhagic Stroke

The pathophysiology of hemorrhagic stroke is not as well studied as that of ischemic stroke however, it is more complex than previously thought. Much of the process is related to the presence of blood in the brain tissue and or surrounding spaces resulting in compression. The hematoma that forms may continue to grow and enlarge after the initial bleed and early growth of the hematoma is associated with a poor outcome. Brain tissue swelling and injury is a result of inflammation caused by...

Amyotrophic Lateral Sclerosis Lou Gehrigs Disease

Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative disorder that is characterized by progressive loss of motor neurons. The median survival is approximately 3 years from the onset of symptoms with less than 15 of patients surviving 10 years. Initially symptoms of ALS present as limb weakness, with other symptoms developing in no particular order including cramps, spasticity, pain, dysarthria, sialorrhea, fatigue, insomnia, depression, fear and anxiety, involuntary emotional...

General Signs and Symptoms

Hypoperfusion of skeletal muscles leads to fatigue, weakness, and exercise intolerance. Decreased perfusion of the CNS is related to confusion, hallucinations, insomnia, and lethargy. Peripheral vasoconstriction due to SNS activity causes pallor, cool extremities, and cyanosis of the digits. Tachycardia is also common in these patients and may reflect increased SNS activity. Patients will often exhibit polyuria and nocturia. Polyuria is a result of increased release of natriuretic peptides...

Mghr on for 1214 hours off for 101 hours

Common adverse effects of nitrates include postural hypotension, flushing, and headache secondary to venodilation. Headache often resolves with continued therapy and may be treated with acetaminophen. Hypotension is generally of no serious consequence. However, in patients with hypertrophic obstructive cardiomyopathy or severe aortic valve stenosis, nitroglycerin may cause serious hypotension and syn- cope. Therefore, long-acting nitrates are relatively contraindicated in these conditions....

Gastrointestinal System

GI involvement may present initially as small bowel obstruction shortly after birth due to abnormally thick meconium that cannot be passed (meconium ileus). Older CF patients may develop distal intestinal obstruction syndrome (DIOS), formerly called meconium ileus equivalent, which occurs due to fecal impaction in the terminal ileum and cecum. Maldigestion due to pancreatic enzyme insufficiency is present in about 85 to 90 of CF patients.5 Thick pancreatic secretions and cellular debris...

Upon completion of the chapter the reader will be able to

Identify the causes of constipation. 2. Compare the features of functional constipation with those of irritable bowel syndrome (IBS) with constipation (IBS-C). 3. Recommend general and dietary modifications and therapeutic interventions for the treatment of functional constipation. 4. Distinguish between acute and chronic diarrhea. 5. Compare and contrast diarrhea caused by different infectious agents. 6. Explain how medication use can lead to diarrhea. 7. Discuss nonpharmacologic strategies...

Epidemiology And Etiology

Constipation is a common complaint of patients seeking medical attention, and about one-third of patients with constipation seek medical treatment. Constipation occurs in approximately 20 of the population. Approximately 2.5 million physician visits and 90,000 hospitalizations per year in the United States are due to constipation.4'5 Many medications and some disease states are associated with constipation. Constipation is associated with high socioeconomic costs and has considerable...

Clinical Presentation And Diagnosis Diagnosis

A complete history should be obtained so that the patient's symptoms can be evaluated and the diagnosis of functional constipation confirmed. The diagnosis of functional constipation is suggested by the presence of two or more of the following criteria (a) straining, (b) hard or lumpy stools, (c) sensation of incomplete evacuation, (d) sensation of anorectal blockage obstruction, (e) need for manual maneuvers, or (f) fewer than three defecations per week for at least 25 of defecations. The...

Alosetron Lotronex11 5HT4 Raptor Agonist

0-t50 mg po daily 10-t 50 mg po daily Trig po then 2 mg po after each loose stool daily maximum 16 mg Withdrawn from general use available only under special circumstances. Bulk producers may improve stool passage in IBS-C but are unlikely to have a fa- vorable effect on pain or global IBS symptoms. Psyllium may increase flatulence, which may worsen discomfort in some patients. Methylcellulose products are less likely to increase gas production. Although fiber-based supplements are more likely...

Patient Encounter Part 2

CN begins to improve after 2 days of methylprednisolone 1 g IV daily. The treatment team wants to begin a disease-modifying treatment. Do you agree that she should be on a disease-modifying treatment Why If so, which treatment would you choose Recommend a dosing regimen. How should the patient be counseled on the chosen treatment MS patients usually have upper motor neuron spasticity this type of spasticity cannot be treated with muscle relaxants (i.e., carisoprodol). MS patients must be...

Autonomic and Other Problems

Drooling may be accompanied by speech problems and dysphagia. Anticholinergics, botulinum toxin injections, and sublingual atropine can decrease drooling. Speech therapists perform swallowing studies to assess the risk of aspiration, and nutritionists optimize diet. Patients at high risk of aspiration or poor nutrition may require placement of a percutaneous endoscopic gastrostomy tube. Nausea improves if patients take their PD medications with meals or pharmacologic therapy (domperidone in...

NSAIDs nonsteroidal antiinflammatory drugs SNRIs serotonlnnorepinephrine reuptake inhibitors SSRls selective serotonin

AX, a 27-year-old African American woman, presents to your clinic with GI complaints (e.g., constipation, bloating, and cramping) and fatigue. She is a single mother of three (ages 2, 3, and 6 years) and is a full-time college student. She states that she worries about everything her grades, finances, the 6-year-old riding the school bus, etc. She states that even if it's not important, I still worry. She has difficulty sleeping and says that she often feels like she might jump out of her skin....

Patient Encounter 1 Part 1

HT, a 34-year-old woman, comes to the clinic complaining of fatigue, lethargy, and having a fuzzy head for the past 6 months. She thought it was because she was working too hard, but the symptoms have not improved despite a better work schedule. She has noticed a 2.3-kg (5-lb) weight gain over the past 6 months, her menses have become heavier, she feels cold all the time, and her skin is drier. She takes no medications other than occasional acetaminophen for headache and milk of magnesia for...

Relative Contraindications

Smoking (less than 15 cigarettes per day) at any age History of migraine headache disorder Women stop their oral contraceptives owing to side effects such as headaches, nausea, vomiting, or weight gain that occur during oral contraceptive use. Package labeling reports a higher incidence of these side effects, although it cannot be determined if they occurred because of the pill or just happened when the women were on the pill.1 One double-blind trial compared women taking oral contraceptives...

Patient Care and Monitoring UI

Assess the patient's symptoms to determine if patient-directed therapy is appropriate or whether or not the patient should be evaluated by a physician. Assessment includes the types and severities of symptoms and the presence or absence of exacerbating factors. Does the patient have any UI-related complications 2. Review any available diagnostic data to determine disease status. 3. Obtain a thorough medication history, including use of prescription, nonprescription, and complementary and...

Patient Encounter 1 Part

The patient is diagnosed with IDA and is started on ferrous sulfate 325 mg orally three times daily to be taken on an empty stomach. Follow-up CBC 1 month later reveals a Hgb of 10 g dL (100 g L or 6.2 mmol L), previously 9.3 g dL (93 g L or 5.77 mmol L). The patient complains of shortness of breath on exertion and constipation. She also admits to taking only one tablet a day because of nausea. What Hgb level would constitute a therapeutic response in this patient How can nausea secondary to...

Patient Encounter 2

A 36-year-old female who has been in good health presents to your clinic complaining of constipation and abdominal pain. She explains to you that she has been feeling stressed lately because her 40-year-old sister is undergoing chemotherapy for breast cancer and they just lost their mother to ovarian cancer a few years ago. Does she have a hereditary risk factor What screening tools could be used to monitor this patient Identify the treatment options for prevention of ovarian cancer available...

Clinical Presentation And Diagnosis Cancer

Palliative care is most commonly associated with patients who have cancer. Regardless of whether or not the cancer is curable, most patients have various degrees of physical, psychological, social, and spiritual symptoms which arise once a diagnosis is confirmed. The primary site of solid tumor and hematologic cancers associated with limited life include, but are not limited to, lung, bronchus, breast, colon, rectum, pancreas, prostate, ovaries, uterus, brain, esophagus, liver, kidneys,...

Nonsmall Cell Lung Cancer

The first step in treatment of NSCLC involves confirmation of the clinical stage and determination of resectability of the tumor. This decision should always be made by a thoracic surgeon who routinely performs lung cancer surgery. Treatment options depend on the advancement of disease (i.e., local, locally advanced, or metastatic), PS, and eligibility for resection. Local Disease (Stages 1A, 1B, and II A) Local disease encompasses stages IA through IIA and is associated with a favorable...

Colorectal Cancer Prevention

Strategies to prevent colorectal cancer can be done with pharmacologic or surgical interventions and involve either preventing the initial development of colorectal cancer (primary prevention) or preventing cancer in patients that demonstrate early signs of colorectal cancer (secondary prevention). The most widely studied agents for the chemoprevention of colorectal cancer are agents that inhibit COX-2 (aspirin, NSAIDs, and selective COX-2 inhibitors) and calcium supplementation.19 COX-2...

Extraintestinal Manifestations and Complications of IBD

Patients may manifest signs and symptoms of disease in areas outside the GI tract. These extraintestinal manifestations may occur in various body regions.5,13 Painful joint complications associated with IBD include sacroiliitis and ankylosing spondylitis. Ocular involvement with episcleritis, uveitis, or iritis may manifest as blurred vision, eye pain, and photophobia. Associated skin findings include pyoderma gan-grenosum (involving papules and vesicles that develop into painful ulcerations)...

Treatment Desired Outcomes

O The primary goals of management of TLS are (a) prevention of renal failure (b) prevention of electrolyte imbalances. Thus, the best treatment for TLS is prophylaxis to enable delivery of cytotoxic therapy for the underlying malignancy. For patients that present with or develop TLS despite prophylaxis, treatment goals include (a) decreasing uric acid levels (b) correcting electrolyte imbalances (c) preventing compromised renal function. These goals should be achieved in a cost-effective...

Insulin

Insulin is one of a very few medications which is itself a whole protein, and can induce IgE sensitivity directly. This can result in anaphylaxis. Adverse reactions to insulin also include erythema, pruritis, and indurations, which are usually transient and may be injection site-related. For the sensitivity reactions, treatment options include dexa-methasone or desensitization. If the reaction is injection site-related, a change in delivery system (i.e., insulin pump or inhaled insulin) may be...

Patient Encounter Part

BB is now 3 days old and presents with body temperature fluctuations and hypotension. A workup to rule out sepsis was initiated with collection of blood cultures. He was empirically started on ampicillin 50 mg (50 mg kg dose) IV every 8 hours and gentamicin 4 mg (4 mg kg dose) IV daily. (1 0.2 x IOVL Bands 0 Segs41 Lymphs 49 Monocytes 6 SO 0.4 mg dL (35.4 pmol L) Less than or equal to 0.6 rng dL 53 imol L) Using the most appropriate method, calculate a creatinine clearance for BB. The mg kg...

Common Errors in Pediatric Drug Therapy

Prevention of errors in pediatric drug therapy begins with identification of possible sources. Reports have shown that nearly 50 of medication errors in the United States in neonatal and pediatric critical care units are attributable to prescribing and transcribing errors.2 Up to 69.5 of overall calculation errors affect pediatric patients.29 As pediatric drug therapy is based on weight, body surface area, and age, it is crucial to verify accurate weight, height, and age for dosing calculations...

Other Contributing Processes and Factors

Many other processes are proposed to contribute to the development of hypertension, including obesity, physical inactivity, insulin resistance, potassium and magnesium depletion, chronic moderate alcohol consumption, and transient effects of cigarette smoking and caffeine intake.9 The assessment of global cardiovascular risk in all hypertensive patients should be part of the management plan while also pursuing target BPs through nonpharmacologic and pharmacologic means. Regardless of the...

Angiotensin Receptor Blockers

ARBs are another key class of agents whose role in managing patients with hypertension has been further defined by recently completed studies. ARBs are inhibitors of the angiotensin-1 (ATI) receptors (Fig. 5-3). ATI receptor stimulation evokes a pressor response via a host of accompanying effects on catecholamines, aldosterone, and thirst. Consequently, inhibition of ATI receptors directly prevents this pressor response and results in up-regulation of the RAAS. Up-regulation of the RAAS results...

Epidemiology And Etiology Epidemiology

HF is a major public health concern affecting approximately 5 million people in the United States. An additional 550,000 new cases are diagnosed each year. HF manifests most commonly in adults over the age of 60. The growing prevalence of HF corresponds to (a) better treatment of patients with acute myocardial infarctions (MIs) who will survive to develop HF later in life, and (b) the increasing proportion of older adults due to the aging Baby Boomer population. The relative incidence of HF is...

Patient Encounter Part 1

BE is a 62-year-old female with a history of known CAD and type 2 diabetes mellitus who presents for a belated follow-up clinic visit (her last visit was 2 years ago). She states that she used to be able to walk over one-half mile (0.8 km) and two flights of stairs before experiencing chest pain and becoming short of breath. Since her last visit, she has had increasing symptoms and has now progressed to shortness of breath (SOB) with walking only half a block and doing chores around the house....

Unique Oral Contraceptives

Along with varying doses of ethinyl estradiol and different progestins, there are also formulation modifications that may benefit various patient situations. In the United States, these formulations include products such as Loestrin-24 Fe, Seasonale, Seaso-nique, Ortho Tri-Cyclen, Estrostep Fe, Yasmin, Yaz, Mircette, Ovcon 35, and Lybrel. Each of these products may show benefit in certain women owing to their unique characteristics. Loestrin-24 Fe (norethindrone ethinyl estradiol) is an...

Abbreviatons Introduced in This Chapter

AML Acute myeloid leukemia ANC Absolute neutrophil count American Society of Clinical Oncology B ll sul fa n- ey cloph osph a m id e Chemotherapy-induced nausea and vomiting Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

ABlockers

Generally, ai-blockers are considered as inferior agents and should not be used as monotherapy. The ALLHAT trial had an ai-blocker arm that was discontinued early as terazosin was associated with an increase in cardiovascular events. aiBlockers may be considered as add-on therapy to other agents (i.e., 3rd or 4th line) when hypertension is not adequately controlled. In addition, they may have a specific role in the antihypertensive regimen for elderly males with prostatism however, their use is...

About The Editors

Chisholm-Burns, BPharm, PharmD, MPH, FCCP, FASHP, is professor and head of the Department of Pharmacy Practice and Science at The University of Arizona College of Pharmacy. She received her BS and PharmD degrees from The University of Georgia and completed a residency at Mercer University Southern School of Pharmacy and at Piedmont Hospital in Atlanta, Georgia. She is the founder and executive director of the Medication Access Program. She has also served in elected positions in...

Absorption

Oral absorption may be reduced in premature infants and neonates due to differences in gastric acid secretion and pancreatic and biliary function. Full-term neonates have a gastric pH of 6 to 8 at birth and pH 1 to 3 by 48 hours of age. Gastric acid output per kilogram is lower in premature infants and increases with age to adult levels by 6 11 12 months of age. Low gastric acid secretion can result in increased serum concentrations of weak bases and acid-labile medications, such as penicillin,...

Acetaminophen

Acetaminophen is a centrally acting analgesic that produces analgesia by inhibiting prostaglandin production in the brain and spinal cord. It is an effective and inexpensive analgesic with a favorable risk-benefit profile.12 For treatment of mild to moderate pain, acetaminophen should be tried initially at an adequate dose and dur- ation before considering an NSAID J Acetaminophen is generally considered to be as effective as NSAIDs for mild to moderate joint pain with a superior safety...

Acid Base Disturbances

Acid-base disturbances associated with PN usually are related to the patient's underlying condition(s). However, acid-base abnormalities may develop as a result of changes in chloride or acetate concentrations in PN admixtures. Because acetate is converted to bicarbonate in the body, excessive acetate salts in PN can lead to metabolic alkalosis excessive chloride salts in PN can lead to metabolic acidosis. PN should not be used to treat or correct acute underlying disorders. However, adjusting...

Acute Adrenal Insufficiency

During an acute adrenal crisis, the immediate treatment goals are to correct volume depletion, manage hypoglycemia, and provide glucocorticoid replacement. V lume depletion and hypoglycemia can be corrected by giving2large volumes (approximately 2-3 L) of IV normal saline and 5 dextrose solution. Glucocorticoid replacement can be accomplished by administering IV hydrocortisone, starting at a dose of 100 mg every 6 to 8 hours for 24 hours, increasing to 200 mg to 400 mg day if complications...

Adapted from

Lopinavir ritonavir (dosed once or twice daily) c. Atazanavir ritonavir (dosed once daily) d. Fosamprenavir ritonavir (dosed twice daily) e. Darunavir ritonavir (dosed once daily) The decision to choose a NNRTI- or Pi-based regimen as initial therapy is based on many patient- and clinician-specific factors. Drug resistance testing should be performed at diagnosis, and again prior to initiating treatment, if time has elapsed between diagnosis and treatment (see Pharmacologic Treatment for...

Adapted from Ref 5

An additional consideration when stopping or changing therapy is a staggered discontinuation of antiretrovirals with different half-lives. For example, in patients taking Atripla (tenofovir, emtricitabine, and efavirenz) tenofovir and emtricitabine should be continued for at least 4 days after discontinuation of efavirenz due to the much prolonged half-life of efavirenz as compared to tenofovir and emtricitabine. Otherwise, the potential for monotherapy with efavirenz exists. If new...

Adult Outpatient With Comorbid Conditions

The comorbid conditions that can impact therapy and outcomes in patients with CAP include diabetes mellitus, COPD, chronic heart, liver, or renal disease, alcoholism, malignancy, asplenia, and immunosuppressive condition or use of immunosuppress-ive drugs. 8 If the patient did not receive antibiotics in the last 3 months then either a respiratory fluoroquinolone alone or a combination of an oral -lactam agent plus a macrolide or azalide is recommended. If the patient received an antibiotic in...

Advantages

More hemodynamic stability (blood pressure) due to slow ultrafiltration rate 2. Increased clearance of larger solutes, which may explain good clinical status in spite of lower urea clearance 3. Better preservation of residual renal function 4. Convenient intraperitoneal route of administration of drugs such as antibiotics and insulin 5. Suitable for elderly and very young patients who may not tolerate hemo-dialysis well 6. Freedom from the machine gives the patient a sense of independence (for...

AF atrial fibrillation

These studies have found no significant differences in mortality in patients who received rhythm control therapy versus those who received rate control therapy.29-32 Howevei patients assigned to the rhythm control strategy were more likely to be hospitalized -31-32 and were more likely to experience adverse effects associated with drug therapy. Therefore, drug therapy for the purpose of maintaining sinus rhythm or reducing the frequency of episodes of AF should be initiated only in those...

Agerelated Changes

In basic terms, pharmacokinetics is what the body does to the drug, whereas pharmacodynamics is what the drug does to the body. All four components of pharmacokinetics absorption, distribution, metabolism, and excretion are affected by aging, the most clinically important and consistent being the reduction of renal elimination of drugs12 As people age, they become frailer and are more likely to experience altered and variable drug pharmacokinetics and pharmacodynamics than younger patients....

Airway Obstruction

Symptoms of airway obstruction include chest tightness, cough, and wheezing. Airway obstruction can be caused by multiple factors including airway smooth muscle constriction, airway edema, mucus hypersecretion, and airway remodeling. Airway smooth muscle tone is maintained by an interaction between sympathetic, parasym-pathetic, and nonadrenergic mechanisms. Acute bronchoconstriction usually results from mediators such as histamine, cysteinyl leukotrienes, prostaglandins, and tryptase released...

ALL in Infants

Infants account for approximately 5 of all children with ALL, and they experience the worst prognosis of any group of children with the disease. These patients have several poor prognostic features at diagnosis, including hyperleukocytosis, hepatomegaly, splenomegaly, and CNS leukemia.6 The bone marrow of infants at day 14 usually shows poor response to therapy. Infants with ALL have increased frequencies of cytogenetic abnormalities 60 to 70 have a translocation that involves the MLL gene...

ALL in the Elderly

The proportion of ALL in patients older than age 60 years constitutes between 16 and 31 of all adult leukemias. Treatment of adults largely has followed the conventional chemotherapeutic regimes used in childhood ALL. However, the intensification regimens common in childhood are not suitable for this population because of their associated toxicities in older patients. The adverse prognostic factor, the Ph+, occurs in 15 to 30 of adults and thus is more common in the over 60 age group.21 Based...

Allergen avoidance underlies all other treatments of AR

There are several limitations to implementing allergen avoidance Identification of allergens is necessary to successfully employ avoidance strategies Literature support for a clinically significant impact on symptoms from allergen avoidance, especially any single measure, is meager Quality of life may be negatively impacted by forced removal of a pet from the household Outdoor plant pollen and mold fungi parts Limit outdoor exposure, especially during high pollen conditions (warm sunny days...

Allergic conjunctivitis Etiology

Ocular allergy is a broad term that includes several diseases with the hallmark symptom of itching, often accompanied by tearing, conjunctival swelling, and nasal congestion.14 Seasonal ocular allergy is the most common type of allergic conjunctivitis. This is an IgE-mediated hypersensitivity to pollen or other airborne allergens.11 Often, the patient's history is positive for atopic conditions such as allergic rhinitis, asthma, or eczema.14 Perennial allergic conjunctivitis has similar but...

Aloe vera

Lactose intolerance is responsible for many cases of acute diarrhea, especially in patients of African descent, Asians, and Native Americans. Possible food-related causes include fat substitutes, dairy products, and products containing nonabsorbable carbohydrates. The diarrhea of IBS is sudden and perhaps watery but likely loose, usually accompanied by urgency, bloating, and abdominal pain occurring upon arising in the morning or immediately following a meal. Inflammatory bowel disease is...

Amenorrhea in adolescents

Amenorrhea in the adolescent population is of great importance because this is the time in the female life cycle when peak bone mass is achieved. The cause of amenor-rhea and appropriate treatment must be identified promptly in this population because hypoestrogenism contributes negatively to bone development. Estrogen replacement, typically via an OC, is important. In addition, ensuring that the patient is receiving adequate amounts of calcium and vitamin D is imperative. Table 49-2...

Anastasia Rivkin BS PharmD BCPS

Associate Professor and Division Director of Pharmacy Practice Arnold and Marie Schwartz College of Pharmacy and Health Sciences St. Luke's Roosevelt Hospital Center Chapter 67 Coagulation and Platelet Disorders P. David Rogers, PhD, FCCP First Tennessee Chair of Excellence in Clinical Pharmacy Professor and Associate Dean for Transitional Research University of Tennessee College of Pharmacy Chapter 84 Invasive Fungal Infections

Anovulatory bleeding in adolescents

Anovulatory cycles are not unusual in the perimenarchal reproductive years. Ovulation typically is established a year or more following menarche. When anovulatory bleeding occurs in this population, it may be excessive. If the bleeding is excessive, the patient should be evaluated for blood dyscrasias. The prevalence of blood dys-crasias, including von Willebrand's disease and prothrombin deficiency, and the prevalence of idiopathic thrombocytopenia purpura in this population ranges from 5 to...

Anticonvulsants

A life-threatening syndrome can occur following a few weeks of therapy with anticonvulsants, such as phenytoin, phenobarbital, and carbamazepine. Symptoms include fever, a maculopapular rash, generalized lymphadenopathy and varying degrees of internal organ dysfunction. The rash may be mild at first but can progress to exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis. The causative agent should be withdrawn immediately. Valproic acid,...

Antihistamines

Whether due to their antihistaminic activity or their sedative side effects, pruritus caused by contact dermatitis can be relieved with the use of sedating oral antihistam-ines such as diphenhydramine or hydroxyzine. Topical antihistamines are available, but use is limited due to their high-sensitizing potential.26,33 In addition to sedation, many oral antihistamines can cause hypotension, dizziness, Diphenhydramine and hydroxyzine can be safely administered to children older than 2 years and...

Antimicrobial Considerations in Selecting Therapy

Drug-specific considerations in antimicrobial selection include spectrum of activity, effects on nontargeted microbial flora, appropriate dose, pharmacokinetic and pharmacodynamic properties, adverse-effect and drug-interaction profile, and cost (Table 69-2). Spectrum of Activity and Effects on Nontargeted Flora Most initial antimicrobial therapy is empirical because cultures usually have not had sufficient time to identify a pathogen. Empirical therapy should be based on patient-and...

Antimicrobial Prophylaxis in Specific Surgical Procedures

Enteric gram-negative bacilli, anaerobes, group B streptococci, and enterococci are all possible pathogens that may be encountered in gynecologic or obstetric surgeries. For patients undergoing hysterectomy, cefoxitin or cefotetan are appropriate therapies (Table 85-3). Cefazolin or ampicillin sulbactam may be used. In the case of ft-lactam allergy, the following regimens are appropriate clindamycin combined with gentamicin, aztreonam, or ciprofloxacin metronidazole combined with gentamicin or...

Appendix C Common Medical Abbreviations

These are the abbreviations used commonly munication and in the medical record. A A ApUm gmtm a ikoholi n mm j-hhui AAA Ahihimin.il jortii.-jii Liry& m AA vJ Awikr iiiJ OriinUIni Iu lime. jicrtun A PC Atwlutr lund OHinlt ataolult tMwplnt counii apnea, bj jiljt i rd i i. nnd ey t> l gyi ispti ation, biopsy, J i d cytology. jrlilu E tata edil APO Kluud grtup fylttm (A. AH. B, anJ ) At He fori meals (unir t ta ) ACb An iiHuuin-Cvnvtrliilg L'nzyihc ACE- Augiat fliin oiiv n l ug ut yme l...

AR[S Acutc rcspir310ry disticss syndrome MCT Mediumchain triglycerides

Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html. 1. Ros E, Navarro S, Bru C, et al. Occult microlithiasis in idiopathic acute pancreatitis Prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991 101 1701-1709. 2. Bradley EL, III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch...

Aspirin

ASA reduces the risk of death or developing MI by about 50 (compared to no anti- platelet therapy) in patients with NSTE ACS. Therefore, ASA remains the cornerstone of early treatment for all ACS.43 Dosing of ASA for NSTE ACS is the same as that for STE ACS (Table 8-2). ASA is continued indefinitely. For patients with NSTE ACS, clopidogrel added to ASA and started on the first day of hospitalization as a 300 to 600 mg loading dose and followed the next day by 75 mg orally per day is recommended...

Modified Dukes Criteria for the Diagnosis of IE Definite IE

(1) Microorganisms demonstrated by culture or histologic examination of a vegetation that has embolized, or an intracardiac abscess specimen, or (2) Pathologic lesions vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis (2) One major criterion and three minor criteria, or (3) Five minor criteria Possible IE (1) One major criterion and one minor criterion, or (2) Three minor criteria Rejected (1) Firm alternate diagnosis explaining evidence of IE,...

Behavioral considerations

The correlation between risky sexual behavior and STIs is well documented. Inconsistent and incorrect condom use has been recognized to increase the incidence of new STIs. Assuming that patients, especially adolescents, consistently use and understand how to use condoms, spermicides, or diaphragms can be detrimental and may contribute to nonpharmacologic mismanagement. Health care providers who manage persons at risk for STIs should counsel women concerning the option for emergency...

BiPAP Pi level posit i ve airway pressure

BZ DRA Bt1 nzod i aiepiHC reccptO r agon 1st CPA P Cont i nuo us posit ive a i rway pressu re HiitofismpniiN ily leukocyte antigen Stmlonin and norepinephrine reuptake inhibitor Selective serotonin reuptake inhibitor Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Bisphosphonates

Bisphosphonates are first-line therapy for osteoporosis due to established efficacy in preventing hip and vertebralfractures. They are also the most commonly prescribed therapy for osteoporosis. They decrease bone resorption by binding to the bone matrix and inhibiting osteoclast activity. They remain in the bone for a prolonged period and are released very slowly. These effects increase bone mineral density. Although sever- al bisphosphonates are currently available, only alendronate,...

BP blood pressure CO cardiac output HR heart rate PCWP pulmonary capillary wedge pressure SVRf systemic vascular

Table 6-11 Usual Doses and Monitoring of Commonly Used Hemodynamic Medications BP, HR, unnary output and kidney function, ECGr extremity perfusion (higher doses only) BP, Hi urinary output and function, EGG function, ECGh charges in ischemic symptoms e.g., ch' 'St pain), electrolytes function, blood cyanide and or ihiocyariate concentrations if toxicity suspected (nausea, vomi liny, altered mental function) GNP. f -type natriuretic peptide RPr blood pressure MR, heart rate tfln add 11 ion Lo...

Bursitis and Tendonitis

Bursitis is an inflammation of the bursa, the fluid-filled sac near the joint where the tendons and muscles pass over the bone. The bursa assists with movement by reducing friction between joints. Tendonitis (also known as tendinitis) is an inflammation of the tendon or, more specifically, the fibrous sheath that attaches muscle to bone. Tenosynovitis is an inflammation of the tendon sheath. Repetitive overuse of a tendon can cause cellular changes in the tissues. Specifically, collagenous...

CAM and OTC Medication

An estimated 31 to 84 of children with cancer, 74 with autism spectrum disorder, 71 with asthma, and 15 seen in the emergency department utilize CAM or other OTC products. Over 50 of parents caregivers do not disclose this use to the physicians.35 CAM can include mind-body therapy (e.g., imagery, hypnosis), energy field therapies (e.g., acupuncture, acupressure), massage, antioxidants (e.g., vitamins C and E), herbs (e.g., St. John's wort, kava, ginger, valerian), prayer, immune modulators...

Cardiac Output

CO is an important determinant of BP. Factors which elevate CO may, in theory, contribute to the development of primary hypertension. Increases in CO and subsequently BP may arise from factors that increase preload (fluid volume) or myocardi-al contractility. Nonetheless, even if increased CO may be involved in the development of primary hypertension, these increases do not appear to persist over time. As a consequence, elevated CO is not considered a hemodynamic hallmark of established primary...

Causes of Thyrotoxicosis Hyperthyroidism

Thyrotoxicosis is any syndrome caused by excess thyroid hormone. Hyperthyroidism is related to excess thyroid hormone secreted by the thyroid gland. Thyrotoxicosis can be related to the presence or absence of excess hormone production (hyperthyroid-ism). The common causes of thyrotoxicosis are shown in Table 44-6 ' disease is the most common cause of hyperthyroidism. Thyrotoxicosis in the elderly is more likely due to toxic thyroid nodules or multinodular goiter than to Graves' disease....

Cbnidine

Dexmedetomidine Digoxin Diltiazem D'pyridamole Disopyrarnide Donepezil Dronedarone Flecainide Acute treatment of the symptomatic patient consists primarily of administration of the anticholinergic drug atropine, which may be given in doses of 0.5 mg IV every 3 to 5 minutes. The maximum recommended total dose of atropine is 3 mg 14 however, this total dose should not be administered to patients with sinus bradycardia, but rather should be reserved for patients with cardiac arrest due to...

Cellulitis and erysipelas epidemiology and etiology

Cellulitis and erysipelas are bacterial infections involving the skin. OG Cellulitis is an infection of the dermis and subcutaneous tissue, whereas erysipelas is a more superficial infection of the upper dermis and superficial lymphatics. Although both can occur on any part of the body, about 90 of infections involve the leg.12, 3 These infections develop after a break in skin integrity, resulting from trauma, surgery, ulceration, burns, tinea infection, or other skin disorder. However, they...

Cerebral Ischemic Events

'O' There are two main classifications of cerebral ischemic events transient ischemic attack (TIA) and cerebral infarction. A TIA is a temporary reduction in perfusion to a focal region of the brain causing a short-lived disturbance of function. TIAs have a rapid onset (5 minutes) and short duration (2-15 minutes, up to 24 hours). The symptoms vary depending on the area of the brain affected however, no deficit remains after the attack. The classic definition of TIA is based on symptom duration...

Cetuximab and Panitumumab

Cetuximab (Erbitux) and panitumumab (Vectibix) are monoclonal antibodies directed against the EGFR. Cetuximab is a chimeric antibody, whereas panitumumab is a fully human monoclonal antibody. The EGFR receptor is overexpressed in colorectal can- cers and leads to an increase in tumor proliferation and growth. ' ' Cetuximab received FDA approval for use in EGFR-expressing meta-static colorectal cancer in irinotecan relapsed or refractory patients. Cetuximab should be administered in combination...

Chemoprevention

Chemoprevention refers to the use of prophylactic medications to prevent the development of cancer. Many studies of potential chemopreventatives, including nonster- oidal anti-inflammatory drugs, retinoids, inhaled glucocorticoids, vitamin E, selenium, and green tea extracts, have been conducted, but none has been successful. Large randomized clinical trials have evaluated P-carotene and vitamin E as lung cancer che-mopreventative agents in high-risk patients (older smokers). Although vitamin E...

Choice of Contraceptives Important Considerations

When helping a patient decide on a contraceptive, the most important goal is to find an option that the patient is comfortable with and that the clinician feels will be beneficial for the patient. It is imperative to explain the side effects, safety concerns, and noncontraceptive benefits of each alternative to the patient so that she may make an informed decision. Fertility goals vary for each patient. It must be determined if the goal is to postpone contraception, space out the next...

Choosing an Antibiotic

An antimicrobial used in surgical prophylaxis should meet certain criteria. Selecting an antimicrobial with a spectrum that covers expected pathogens is crucial. The antimicrobial should be inexpensive, available in a parenteral formulation, and easy to use. Adverse-event potential should be minimal. Choosing an agent with a longer halflife reduces the likely need to redose unless the surgical procedure is prolonged. Table 85-2 Major Pathogens in Surgical Wound Infections 43Data reported by the...

Chronic medical conditions

Inflammatory conditions of the prostate Coronary and peripheral vascular disease Neurologic disorders (e.g., Parkinson's disease and multiple sclerosis) Endocrine disorders (hypogonadism and pituitary, adrenal, and thyroid disorders) Psychiatric disorders (depression, anxiety, and schizophrenia) Penile disease (Peyronie's disease or anatomic abnormalities) Surgical procedures Perineal surgery Radical prostatectomy Vascular surgery Lifestyle Age Excessive alcohol consumption Obesity Poor overall...

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) has a prolonged and variable course. Patients with COPD have a high number of physician visits and hospital admissions. Palliative care treatment is directed at reducing symptoms, reducing the rate of decline in lung function, preventing and treating exacerbations, and maintaining quality of life. In end-stage COPD, bronchodilators and anti-inflammatory agents become less effective. Symptoms of late-stage disease include wheezing, chronic sputum...

CKCreatine kinase

CK-MB Creatine kinase myocardial band CPR Cardiopulmonary resuscitation rtiplii utahlc cardioverter defibrillator National Cholesterol Education Program Pc rcu la n coui to ro n a ry i n ter vc n t io n Thrombolysis io myocardial infarction Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

Clinical Assessment and Diagnosis

It is important for the clinician to identify the cause(s) of AHF in order to maximize treatment efficacy and reduce future disease exacerbations. Cardiovascular, metabolic, and lifestyle factors can all precipitate AHF. The most common precipitating factors for acute decompensation and how they contribute pathophysiologically are listed in Table 6-3. Routine laboratory testing of patients with AHF includes electrolytes and blood glucose, as well as serum creatinine and blood urea nitrogen to...

Clinical Course

The clinical course of MS has four basic patterns Relapsing remitting, secondary progressive, primary progressive, and progressive relapsing (Fig. 29-3). Relapsing remitting MS develops into secondary progressive MS in 50 of patients within 10 years and in 75 within 25 years of diagnosis.1 Rating scales are used clinically (Table 29-2). MS reduces overall life expectancy 6 to 7 years. Suicide is disproportionately high in MS patients, accounting for about 15 of MS-related deaths. r Desired...

Clinical Course O

Patients with POAG typically have a slow, insidious loss of vision. This is contrasted by the course of acute PACG which can lead to rapid vision loss that develops over hours to days. For POAG, only 4 to 8 of patients may progress to legal blindness. It may take 13 to 16 years for a patient to go blind from glaucoma. A patient's quality of life may not be affected until significant visual field loss is present and the patient can no longer perform the activities of daily living. Vision loss...

Clinical presentation

Fever, night sweats, weight loss, fatigue, and a productive cough are the classic symptoms of tb.1,2,6,19 Onset may be gradual, and the diagnosis is easily missed if the symptoms are muted, such as in the elderly.2,6,19 Progressive pulmonary disease leads to cavitation visible on x-ray. Physical examination is nonspecific but may be consistent with pneumonia. Dullness to chest percussion, rales, and increased vocal fremitus may be observed on examination. Laboratory data often are...

Clinical Presentation and Diagnosis of TTH

Patients experiencing TTH may display the following headache symptoms and characteristics Two or more of the following present 3. Mild or moderate pain intensity Both of the following 1. No nausea or vomiting (anorexia possible) 2. Either photophobia or phonophobia (not both) Duration 30 minutes to 7 days Criteria for diagnosis 10 or more attacks fulfilling above criteria occurring on average less than 1 day per month are necessary for diagnosis