By M. Kaffu. Mount Holyoke College. 2018.
Other adverse impaired platelet function with resultant bleeding 50mg tenormin otc, intracranial effects may include fetal or neonatal jaundice buy 100mg tenormin otc, thrombocytopenia discount 50mg tenormin with amex, bleeding order 50 mg tenormin with visa, renal impairment or failure, oligohydramnios, gastro- hyperbilirubinemia, hemolytic jaundice, fluid and electrolyte im- intestinal (GI) bleeding or perforation, and increased risk of necrotizing enterocolitis, a life-threatening disorder. These drugs are delivery, maternal effects include delayed onset of labor and deliv- not indicated for treatment of dependent edema caused by uterine ery and increased risk of excessive bleeding. They also are inhibitors (eg, celecoxib) have not been studied in pregnant women; not effective in prevention or treatment of pregnancy-induced diclofenac is contraindicated in pregnant women. Thyroid Hormone Loop diuretics (eg, furosemide) are not considered teratogenic, Levothyroxine does not readily cross the placenta and it seems but animal studies indicated fetal toxicity and death. However, it may cause tachycardia in azides, loop diuretics may decrease plasma volume and blood flow the fetus. When given as replacement therapy in hypothyroid to the placenta and fetus. Marijuana impairs formation of DNA and RNA, the Thus far, the main emphasis on drug use during pregnancy basic genetic material of body cells. It also may decrease the has related to actual or potential adverse effects on the fetus. Heroin ingestion in- Despite the general principle that drug use should be avoided creases the risks of pregnancy-induced hypertension, third when possible, pregnant women may require drug therapy trimester bleeding, complications of labor and delivery, and for various illnesses, increased nutritional needs, pregnancy- postpartum morbidity. FETAL THERAPEUTICS Although the major concern about drugs ingested during Herbal and Dietary Supplements pregnancy is adverse effects on the fetus, a few drugs are given to the mother for their therapeutic effects on the fetus. Pregnancy increases nutritional needs and vitamin and min- These include digoxin for fetal tachycardia or heart failure, eral supplements are commonly used. Folic acid supplemen- levothyroxine for hypothyroidism, penicillin for exposure to tation is especially important, to prevent neural tube birth maternal syphilis, and prenatal corticosteroids to promote defects (eg, spina bifida). Such defects occur early in preg- surfactant production to improve lung function and decrease nancy, often before the woman realizes she is pregnant. In addition, pregnancy increases folic Antacids may be used if necessary. Because little systemic acid requirements by 5- to 10-fold and deficiencies are com- absorption occurs, the drugs are unlikely to harm the fetus if mon. A supplement is usually needed to supply adequate used in recommended doses. For deficiency states, 1 mg or more daily may be cralfate may also be used. Herbal supplements are not recommended during preg- Gestational Diabetes nancy. Ginger has been used to relieve nausea and vomit- ing during pregnancy, with a few studies supporting its use. Overall, it has not been proven effective, but is probably This is called gestational diabetes. Most women without risk factors, or Pregnancy-Associated Symptoms whose initial test was normal, should be tested between 24 and and Their Management 28 weeks of gestation. For women with gestational diabetes, initial management Anemias includes nutrition and exercise interventions, calorie restric- tion for obese women, and daily self-monitoring of blood glu- Three types of anemia are common during pregnancy. If these interventions are ineffective, recombinant physiologic anemia, which results from expanded blood vol- human insulin is needed to keep blood sugar levels as nearly ume. A second is iron-deficiency anemia, which is often re- normal as possible. Oral antidiabetic drugs are generally con- lated to long-term nutritional deficiencies. Iron supplements traindicated, although acarbose, metformin, and miglitol seem are usually given for prophylaxis (eg, ferrous sulfate 300 mg to cause minimal fetal risk. Iron prepara- These women may revert to a nondiabetic state when tions should be given with food to decrease gastric irritation.
An ingredient in mixtures with trimethoprim (see Combination Agent tenormin 100mg lowest price, below) Sulfasalazine 1 buy tenormin 100 mg online. Ulcerative colitis Ulcerative colitis tenormin 50mg fast delivery, PO 3–4 g PO 40–60 mg/kg/d in (Azulfidine) 2 purchase 50mg tenormin with mastercard. Rheumatoid arthritis daily in divided doses three to six divided bacterial flora in the in- initially; 2 g daily in four doses initially, followed testine. Effectiveness in doses for maintenance; by 30 mg/kg/d in four ulcerative colitis may be maximal daily dose, 8 g divided doses due to antibacterial Rheumatoid arthritis, (sulfapyridine) and anti- PO 2 g daily in divided inflammatory (aminosali- doses cylic acid) metabolites. Urinary tract infections PO 2–4 g initially, then >2 mo: PO 75 mg/kg of excreted: 2. Ocular infections six divided doses then 150 mg/kg/d in likely to cause crystal- Intravaginally, 2. Acute and chronic uri- Urinary tract infections, Urinary tract infections, sulfamethoxazole effectiveness against nary tract infections trimethoprim 160 mg otitis media, and shi- (Bactrim, Septra, many organisms (verify 2. Acute exacerbations and sulfamethoxazole gellosis, PO 8 mg/kg others) susceptibility first), of chronic bronchitis 800 mg PO q12h for trimethoprim and including streptococci 3. Shigellosis (trimethoprim compo- tions, IV 8–10 mg Nocardia: and others. Infection by Pneumo- nent) per kg/d in two to (trimethoprim compo- Most strains of Pseudo- cystis carinii (preven- four divided doses, up nent)/kg in two to four monas are resistant. The combination is less likely to produce resis- tant bacteria than either agent alone. Oral preparations contain different amounts of the two drugs, as follows: a. The oral suspension contains trimethoprim 40 mg and sulfameth- oxazole 200 mg in each 5 mL. The IV preparation con- tains trimethoprim 80 mg and sulfamethoxazole 400 mg in 5 mL. The preparation is con- traindicated if creatinine clearance is less than 15 mL/min. Effective against most Prevention of bacterial Topical application to Same as adults gram-negative and gram- colonization and infec- burned area, once or positive organisms, es- tion of severe burn twice daily, in a thin pecially Pseudomonas wounds layer 2. Usu- Same as mafenide Same as mafenide (Silvadene) Pseudomonas species, ally the preferred drug. Significant amounts may be absorbed systemically with large burned areas and prolonged use. CHAPTER 36 TETRACYCLINES, SULFONAMIDES, AND URINARY AGENTS 541 Drugs at a Glance: Miscellaneous Drugs for Urinary Tract Infections Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Fosfomycin 1. Broad-spectrum, long-acting agent PO 3 g in a single dose, taken with Dosage not established (Monurol) 2. Antibacterial activity only at a urine pH PO 1 g four times daily Age 6–12 y: PO 500 mg four mandelate <5. In acidic urine, the drug forms times daily (Mandelamine) formaldehyde, which is the antibacterial Age <6 y: PO 50 mg/kg/d, in component. Acidification of urine (eg, with 3 divided doses ascorbic acid) is usually needed. Formaldehyde is active against several gram-positive and gram-negative organ- isms, including Escherichia coli. It is most useful for long-term suppression of bacteria in chronic, recurrent infections. Contraindicated in renal failure Methanamine- See methenamine mandelate, above PO 1 g twice daily PO 500 mg–1 g twice daily hippurate (Hiprex) Nalidixic acid 1. Prototype of quinolones PO 4 g daily in four divided doses PO 55 mg/kg/d in four (NegGram) 2.
Because it is a nonprescription drug and is widely oral drops 100 mg tenormin with amex, for use by adults and children purchase 50 mg tenormin otc. It is ef- Acetic acid derivatives include indomethacin (Indocin) buy cheap tenormin 100mg line, fective in pain of low to moderate intensity purchase tenormin 50 mg on-line, especially that sulindac (Clinoril), and tolmetin (Tolectin). These drugs have involving the skin, muscles, joints, and other connective tis- strong anti-inflammatory effects and more severe adverse sue. It is useful in inflammatory disorders, such as arthritis, effects than the propionic acid derivatives. Potentially serious but many people prefer drugs that cause less gastric irritation. These effects are especially associated with in- in 1 to 2 hours, and lasts 4 to 6 hours. Taking aspirin with domethacin; the other drugs were developed in an effort to find food slows absorption, but also decreases gastric irritation. Absorption of enteric-coated aspirin and rectal suppositories Although adverse reactions occur less often with sulindac and is slower and less complete. Aspirin is distributed to all body tissues and fluids, in- In addition to other uses, intravenous (IV) indomethacin cluding fetal tissues, breast milk, and the central nervous is approved for treatment of patent ductus arteriosus in pre- system (CNS). In plasma, aspirin binds to artery to the aorta in the fetal circulation. Aspirin has a short half-life of 15– close, blood is shunted from the aorta to the pulmonary 20 minutes because it is rapidly converted to salicylic acid, artery, causing severe cardiopulmonary problems. Salicylic acid has a half-life of 2 to Other drugs related to this group are etodolac (Lodine), 3 hours at low doses and 6 to 12 hours at therapeutic anti- ketorolac (Toradol), and nabumetone (Relafen). It undergoes oxidation and conjugation portedly causes less gastric irritation, especially in older in the liver and its metabolites are excreted through the kidneys. Ketorolac is used only for In alkaline urine (eg, pH of 8), renal excretion of salicylate is pain, and although it can be given orally, its unique charac- greatly increased. Parenteral ketoro- Aspirin is a home remedy for headaches, colds, influenza lac reportedly compares with morphine and other opioids in and other respiratory infections, muscular aches, and fever. How- can be purchased in plain, chewable, enteric-coated, and ef- ever, its use is limited to 5 days because it increases the risk fervescent tablets and rectal suppositories. Hematomas and wound bleeding have been re- in liquid form because it is unstable in solution. Diflunisal (Dolobid) is a salicylic acid derivative that dif- Oxicam drugs include meloxicam (Mobic) and piroxicam fers chemically from aspirin. Meloxicam has a serum half-life of 15 to 20 hours rior to aspirin in mild to moderate pain, rheumatoid arthritis, (text continues on page 108) CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 105 Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Acetaminophen Pain PO 325–650 mg q4–6h, PO 10 mg/kg or accord- Warning: Overdoses may (Tylenol, others) Fever or 1000 mg three or ing to age as follows: cause fatal liver dam- four times per day; 0–3 mo, 40 mg; age. Maximum recom- maximum 4 g/d 4–11 mo, 80 mg; mended dose for adults 1–2 y, 120 mg; 2–3 y, is 4 g/d, from all 160 mg; 4–5 y, 240 mg; sources. Parents and 6–8 y, 320 mg; 9–10 y, caregivers should ask 400 mg; 11 y, 480 mg. Rectal suppository 650 mg Rectal suppository: age q4–6h, maximum of under 3 y, consult 6 in 24 h physician; age 3–6 y, 120 mg q4–6h, maxi- mum, 720 mg in 24 h; age 6–12 y, 325 mg q4–6h, maximum 2. RA: PO 150–200 mg/d in two, three or four divided doses (continued) 106 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Ankylosing spondylitis AS: PO 100–125 mg/d in Diclofenac sodium is (AS) four or five divided available in 25-, 50-, Pain, dysmenorrhea doses (eg, 25 mg four and 75-mg delayed- or five times daily) release tablets and a Pain, dysmenorrhea: 100-mg extended- (diclofenac potassium release (XR) tablet. It only) PO 50 mg three is not recommended times daily for acute pain or dys- menorrhea. Diflunisal (Dolobid) Osteoarthritis OA, RA: PO 500– Not recommended for use Rheumatoid arthritis 1000 mg/d, in two in children <12 years of Pain divided doses, in- age creased to a maximum of 1500 mg/d if necessary Pain: PO 500–1000 mg initially, then 250– 500 mg q8–12h Etodolac (Lodine, Osteoarthritis OA, RA: PO 600– Dosage not established Available in immediate- Lodine XL) Rheumatoid arthritis 1200 mg/d in two to release and extended- Pain four divided doses release (XL) tablets of Pain: PO 200–400 mg various strengths. The q6–8h immediate-release Maximum according to forms should be used weight: 1200 mg/d for to treat acute pain. Bursitis to a maximum of three doses Acute painful shoulder 150–200 mg/d, if Acute gout necessary Closure of patent ductus arteriosus (IV only) CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 107 Drugs at a Glance: Analgesic, Antipyretic, Anti-inflammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Acute gouty arthritis, acute painful shoulder, PO 75–150 mg/d in three or four divided doses until pain and inflammation are con- trolled (eg, 3–5 d for gout; 7–14 d for painful shoulder), then discon- tinued Ketoprofen (Orudis, Pain Pain, dysmenorrhea: PO Do not give to children Extended-release cap- Oruvail) Dysmenorrhea 25–50 mg q6–8h PRN <16 years unless di- sules are available as Osteoarthritis OA, RA: PO 150–300 mg/d rected by a physician. Note that the doses names do not contain Sustained-release (Oruvail any letters (eg, SR, XL) SR), 200 mg once daily that indicate long-acting Maximum, 300 mg/d for dosage forms. IM 15 mg q6h to a maximum of 60 mg/d Meloxicam (Mobic) Osteoarthritis PO 7.
Remarkably generic tenormin 50 mg with visa, almost every of 100 electrodes was inplanted into M1 of neuron within a microelectrode array con- monkeys to record from 7 to 30 neurons trusted 100mg tenormin. The tributes some aspect of the intended movement buy 100 mg tenormin with mastercard, investigators created a filter method that suggestive of a locally distributed network within weighted the sum of neural firing to mathe- a single map of the workspace of the hand matically translate the output to accurately re- around the body tenormin 100mg for sale. The neuronal firing data were built normal arm movements and maintain this con- into a model for movement with decoding fil- trol. Thus, by using control algorithms for ters based on 1–2 minutes of recordings from changes in what neurons are tuned to during M1. Several adjustments corrected the alo- mental practice, a neuroprosthesis or other gorithm. Little training was required before brain-machine interface ought to serve robust the monkey was facile in being able to use its functions for a paralyzed person who can learn own neural activity-based signal to carry out with modest effort. Thus, Strategies for the cortical control of a neu- rapid learning and sensory feedback were roprosthesis or robotic device will take advan- Figure 4–1. General design for a neuroprosthesis that takes neuronal signals associated with the thought of a movement, processes this electrical activity to generate a control signal, and moves the plegic arm using a system of functional neu- romuscular electrical stimulation. Neurostimulators and Neuroprostheses 203 tage of the distributed network for motor con- been offered, depending on the location of the trol, allowing perhaps just one or two sites to cause of blindness. Representational plasticity for make use of the selective survival of inner layer movements that results from practice at a task retinal cells for people with macular degener- will also strengthen the control of the recorded ation or retinitis pigmentosa by directly stimu- assembly for that movement over time. Other lating them, bypassing damaged photorecep- regions of the brain, such as those with mirror tors. With complete retinal or optic nerve neurons that are active during both the obser- damage, the stimulation must include the oc- vation and imitation of a movement, may rap- cipital visual cortex. One approach captures idly acquire firing patterns that the prosthesis images with a camera and a stimulating device uses to control new movements. The density then, the neuroprosthesis will be self-learning, of the array and just what properties it signals rewarded by behavioral success, and poten- determines the size of the visualized pixels. As technical limitations lessen and math- matrix of pixels that is approximately eight by ematical encoding of neural signals improves, eight, visual acuity improves enough to make the activity of assemblies of cells may be used out coarse features. Although comes available for people with longstanding still far from a reality, multichip modules that or congenital blindness, the prior experience of incorporate the nonlinear dynamics and adap- visual cortex may alter its effectiveness. For ex- tive properties of neurons and neural net- ample, new visual inputs to visual and visual as- works48 are being designed to communicate sociation cortices may have to compete with with uninjured surrounding cortical tissue by auditory or finger sensory inputs (from reading conforming to the cytoarchitecture of the en- Braille). The brain and silicon module may adapt tems may be evaluated with fMRI or PET ac- to each other for tasks represented by this in- tivation paradigms. The cochlear specific actions, such as delivering items from implant has restored speech discrimination to one place to another or assisting mobility. At least seven commer- Available machines programmed to travel cial varieties are available. A microphone by the down a corridor by sensing the location of the external ear picks up acoustic signals, converts walls are too crude to help patients with neu- sound into electric signals, and delivers them rologic impairments. Signals are however, suggest that robotic technology will transmitted to an electrode array implanted lead to more complex capabilities induced by into the scala tympani of the cochlea, into the autonomous learning during real-world inter- auditory nerve, or near target neurons. Electronic command neurons, the robotic received a total of 25 hours of ac- coordinating neurons, central pattern genera- tivity for the affected arm. Those assigned to tors, and sensory feedback allow software to the control group had considerably less specific manage a remarkably modest number of cir- proximal arm therapy of any kind, so an inten- cuits to mimic all locomotor activities. Such sity of practice effect, rather than a motor neurocreations may extend the reach of the dis- learning paradigm, may have accounted for the abled. The investigators aim Intelligent wheelchairs and lightweight exo- to develop an additional robotic component skeletons with sensors and tiny actuators worn that incorporates arm motion with 3° of free- under clothes and powered without leaden bat- dom and robotic manipulation of wrist and tery packs could also serve a robotic function. An ankle-foot orthosis, for example, is a pas- The Mirror Image Motion Enabler (MIME) sive device that is not as compliant as an an- is an upper extremity robotic device offering kle, does not adapt over time to the changing 6° of freedom. Hemi- their greatest benefit in helping the mobility paretic subjects can practice preprogramed and self-care activities of the disabled. For re- reaching movements in multiple planes with an habilitation at present, the most successful ro- assist from the robotic arm or can carry out botic efforts have been simple devices de- bilateral shoulder and elbow movements with signed to enhance the retraining of movement. A 6-axis sensor measures the tion Robotics (ICORR) presents biannual up- forces and torques between the robot and dates on robotic devices that replace or aug- the hemiparetic arm.