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Calorie chart

2009-09-19T10:52:00.000-07:00

The calorie chart below lists calories in food for average adult helpings unless otherwise stated. This type of calorie count should be easier to use than a complicated calorie calculator.

 A diet is when you watch what you eat
and wish you could eat what you watch.
                   (Hermione Gingold)

Being too preoccupied with calculating the exact number of calories absorbed or burned does not make a diet easier to follow or more effective. Changing eating habits is more important - reducing quantities consumed generally as well as calorie burning through some form of exercise, even just walking for at least half an hour per day.

Group	Food	Calories
Dairy foods	Butter, 2 pats Cheese Cream cheese Cream, 1 tablespoon Egg, boiled, poached cooked with fat Scotch Milk, 1 pint Yogurt, 1/4 pint Ice cream, 1/3 pint	100 100 130 80 80 140 300 400 150 205
Bread, cakes, cereal group	Biscuit, plain Bran cereal without milk/sugar Cornflakes without milk/sugar Porridge without milk/sugar Bread Cornbread Cracker, water biscuit Jam tart Plain cake Rich or fruit cake Waffle Sugar, 1 tablespoon Jam, 1 tablespoon	50 90 100 70 80 200 15 150 180 300 250 50 100
Meat and poultry	Bacon, fried (3 slices) Beef, roast (3 slices) Chicken Ham Liver, baked, grilled fried Hamburger	340 300 200 200 100 200 150
Fruits	Apple Apricot Banana Avocado, ½ pear Grapes (12) Grapefruit (half) no sugar) Orange Pear Rhubarb (stewed without sugar) Strawberries, 6 (large)	50 30 100 170 30 25 50 50 4-10 20
Vegetables: Raw	Lettuce Celery Carrot Tomato	10 5 25 25
Vegetables: Cooked	Greens (all) Potato Sweet potato Peas Corn Canned fruits and vegetables (per portion)	30 100 200 65 160 100
Extras	Chocolate sundae Chocolate malted milk Chopsuey Fudge, chocolate fondants (per cubic inch) Pretzel (per 2 in. stick) Tea or coffee: with milk and sugar Cola type drink Squash	340 460 400 100 1 0 20 70 100 30

Is My Child Normal? Early Childhood Physical Development

2009-09-19T10:38:00.000-07:00

This article was written in consultation with
Ziva Schapiro, OTR

From the time of a baby's birth, we eagerly wait for the day when our child will start to roll over, crawl and then walk. Unlike speech and language development, these milestones are at first glance easily determined. Either a child rolls over or he doesn't. Either he crawls or he walks. Yet, what many parents do not know is that within the field of physical development there are separate areas of development and within those areas the manner in which a child is able to accomplish a certain task, can make a big difference in his life.

Once a child learns how to walk, it may be important to examine how that child walks. Does he put one foot in front of the other? What is his gait? Is his pace steady? Once a child learns how to draw with crayons, it may be important to examine the way he draws. How does he hold the crayon? Can he put sufficient pressure on it?

In order to help you answer these questions and better understand the area of physical development, this series will give you basic background information and a developmental checklist to check on your child's development in this area. The area of physical development can be divided into two main areas:

Gross Motor Development
Fine Motor Development

There are also two areas, which can affect a child's ability to learn and may contribute to difficulty with physical tasks. These are:

Attention Skills
Sensory Integration

Here is an explanation of each of these basic terms:

* Gross Motor Development

This is the area of physical development that most parents think of first - the child's general ability to move around and use the various parts of his body. Activities like rolling over; crawling, walking, running and jumping are gross motor skills. These skills usually involve using the entire body or several parts of the body at one time.

Some of the areas that are considered when evaluating the area of gross motor development are:

Muscle Tone: How tightly or loosely a person's body is put together? If a child's body is too tight (high tone) then his movements might be jerky or disconnected. If a child's body is too loose (low tone) then her movements might be slow and lack strength. Some technical terms that are associated with these areas are Hypertonic (someone who has high tone) and Hypotonic (associated with low tone). These are professional terms and do not apply to every child whose tone happens to be either a bit tight or a bit loose. Only a professional can decide if a child's skills fit these criteria.

Muscle strength: How much strength does a child have? How much pressure can she apply with her hands and legs? How much pressure can her body withstand?

Quality of movements: Are a child's movement's smooth or does she seem to jerk her limbs? Does she seem to move either particularly slow or fast? Does it take effort for her to move around?

Range of movement: An important area in physical development is a child's ability to make movements that span the entire length of her body. A significant milestone is the ability to make movements that go from one side of the body to the other, referred to as "crossing the midline." This skill is necessary for a child to do tasks such throwing a ball or passing an object from one hand to another. This concept is also important for the area of fine motor development.

* Fine Motor Development

This term refers to skills that require smaller movements and more intricate capabilities. A generalization that is often made is that fine motor activities are skills that a child does with his hands. While this is not totally accurate, it is true that most fine motor activities involve a child's ability to use his hands properly. Overall, when we say that a child has appropriate fine motor skills, it means that he can use his hands appropriately for a child of his age.

Here are terms that are used to describe specific fine motor skills.

* Visual Motor Skills

These skills require coordination between the child's ability to see (visual skills) and his hands. In early childhood, this includes activities such as putting together puzzles and building with construction toys. (blocks, leggos)

* Grapho-Motor Skills

Any task that involves using a writing tool is considered a grapho-motor skill. These tasks include drawing, coloring, and using a pencil. (Grapho-Motor skills are also visual motor skills.)

An important term related to these areas and fine motor development in general, is eye-hand coordination. This refers to a person's ability to coordinate the information that she sees with her eyes in order to tell her hands what to do.

* Motor Planning

Professionals use the term motor planing to describe a child's ability to interact successfully with his physical environment; which means to plan, organize and carry out unfamiliar motor actions. When a child sees a new puzzle for the first time, it is not enough to have the physical ability to move the pieces around and fit them together. He also needs to know how to organize the activity so that he will be successful. (i.e. start with the ends, put the ones of the same color together, etc…). If a child has difficulty with a task, it is important to consider if he is unable to physically complete the task or if he is unable to figure out how to go about doing so.

While you can evaluate a child's fine motor skills from a very young age, until age two, the line between fine and gross motor skills is often very difficult to ascertain. The skills most closely associated with fine motor skills (drawing, puzzles, building, etc…) generally start to develop in children from ages two and up. Up until age two, a young child is not able to use her hands in a more intricate way. Among infants, babies and toddlers, therefore, physical development difficulties are not always clearly defined as gross motor or fine motor difficulties. By age three, however, the difference between these two areas is more obvious and the tasks that the child has difficulty with are defined as falling into either only one or both of these areas.

Contributing Factors:

When considering a child's motor skills the following factors need to be taken into consideration:

* Attention Skills

Another area that can contribute significantly to a child's ability to perform physical tasks is his attention span. In the last few years, a condition called Attention Deficit Disorder has become very well known and commonly diagnosed among both pre-school and school age children. While this condition can not be properly explained in a few lines, the main point is that a child's attention span can affect his ability to complete activities. It is important to point out that when a child is having difficulty learning to perform physical tasks, it is essential to consider if his abilities are affected by his ability to pay attention to what he is doing. Is he truly unable to build a tower of ten blocks -- Or is he simply too easily distracted by the child next to him who is coloring with markers?

* Sensory Integration

While many parents have heard of attention deficit disorder, few parents are aware of how their child's relationship to his senses, can affect his physical development. All children and adults, in one way or another have sensory sensitivities. There will always be certain smells that make one person feel sick and do not bother someone else, or a certain sound that makes a person's skin crawl while it does not affect someone else. But what many parents and professionals do not realize, is that there are children for whom this sensitivity keeps them from learning in a classroom or at home.

In fact, in addition to the five senses of touch, taste, smell, hearing and sight, there are two more senses that are also essential to a child's development: the movement sense (vestibular) and position in space (propriception).

All seven of these senses need to properly take in information from the environment and organize them in a way that our bodies can use. This is called sensory integration. Sometimes there are imbalances in this system that can lead to over or under sensitivity in one or several of these areas.

Being either over or under sensitive in one or several of these seven areas can affect a child's ability to perform physical tasks.

Here are some examples:

* Touch - A child might be sensitive to the feel of objects against his skin. He might hate activities such as dress up, pretend play with makeup, or arts and craft activities that involve working with playdough or clay. A child who is overly sensitive to touch may overeact when touched even lightly on the shoulder by a teach or a friend. A child who is underly sensitive may have no reaction if he falls or hurts himself.

* Smell - A child might react strongly to unusual or strong smells or not seem to notice even unusual smells such as food burning or gas leaking.

* Taste - Some children are particularly sensitive to the taste of different foods.

* Sight - Strong lights or certain types of colors may bother a child.

* Hearing - A child may be disturbed by sudden or loud noises.

* Position in Space - Some children have difficulty evaluating how much space is needed to reach a certain item. This would include putting a pegboard down on the table without tipping it over, judging if there is room for a child to crawl underneath a jungle gym and sitting down on the center of the chair. A child who seems to eternally "miss the chair" when sitting down may be having difficulty in this area.

* Movement - an overly sensitive child may fear climbing on a jungle gym, and have difficulty with gross motor activities. An underly sensitive child may be fidgety, jump on the couch all afternoon, and have difficulty sitting down to do table activities such as a puzzle.

These are but a few examples of how a child's ability to use the information he receives from his environment is critical to his ability to perform physical tasks.

When a child is having difficulty in the area of physical development, it is essential for parents and professionals that treat a child to consider how his sensory environment affects his development. In this way a parent can determine if a child really "can't" put together that puzzle or if the lights or other sounds in the room are just so disturbing to him that he is unable to do so.

It is also important for parents to understand that sensory integration is a real issue and not just a child being "picky" or "fussy." While to some children a strong smell or bright lights might be annoying, to others, the experience can be unbearable.

Evaluating Contributing Factors:

How can a parent or professional know if a child's problem is a purely physical one or if it is being affected by contributing factors such as sensory integration or attention skills? Often, making this discrimination is the hardest task of all. The first tip off that a contributing factor is affecting a child's development, is if a child can perform a task in some situations, but not in others. If a child can sit and put together 20 piece puzzles at home, but in pre-school he just moves around the pieces, then clearly the problem is not just physical. Instead, a parent and professional should consider if the child's difficulty in school is in the area of attention (too much is going on) or if he has trouble with the sensory stimuli in school (i.e. the lights are too bright, the noise of the children is too loud.)

While it is often easy to determine if a child can or cannot do a particular physical skill it can be difficult to decide if this is an exclusively physical problem or if there are other factors contributing to the child's difficulty. The key for a parent and a professional is to determine how a child's physical skills are developing. Then, if there are any difficulties, it is essential to determine if this is purely a physical difficulty or if other factors may be affecting the child's development.

Here is quick way for you, the parent, to check up on how your child is doing:

Early Childhood Physical Development Checklist:

This checklist was developed by Ziva Schapiro, OTR

Below is a tool to help you check up on how your child is doing. If you don't know which of these tasks your child can complete, just print out the form and keep it handy while working with your child. This tool does not replace consulting with a qualified professional if you are concerned about your child's development.

I will point out which area of physical development the task is connected to by using the following abbreviations:
G= Gross Motor Development
F= Fine Motor Development

If there are tasks that your child has difficulty with, note if they belong primarily to a specific area of physical development. Then also consider if any of the contributing factors that I mentioned about (sensory integration or attention skills) may be affecting his performance in these areas. Try some of the tasks again, in different situations and see if there are things he can do in one situation and not in another. This will help you know what areas to work on with him and may be relevant information to pass on to professionals, if you feel a professional consultation will be necessary.

If your child does not have all of these at the appropriate age - do not worry, children develop at different paces.

If your child has not developed many of these skills or most of the skills in a certain category, then - still do not worry - but you may want to check his development with the relevant professionals.

If after filling out these checklists you are concerned about your child's development go on to read:

Stepping In to Help: What to do if you are concerned about your child's physical development?

Click on your child's age and find out how he is doing:

One Year Old
Two Years Old
Three Years Old
Four Years Old
Five Years Old
Six Years Old

One Year Old:

(Some of the developmental milestones for this list come from What to Expect the First Year.)

Lifts head while lying on stomach (by age 3 months) (G)__
__Grasps a rattle (age 4 months) (F)
__Bring both hands together (age 4 months) )
__Rolls over one way (by age five months) (G
__Keep head level with body when pulled to a sitting position (age six months) (G)
__Rolls over both ways (by age seven months) (G)
__Sit without support (age 8 months) (G)
__Feed herself a cracker (age 8 months) (F)
__Passes an object from one hand to another (age 8 months) (F)
__Get into a sitting position from stomach (8 months) (G)
__Stands holding on to someone or something (10 months) (G)
__Pulls up to standing position from sitting position (age 10 months) (G)
__Can pick up a tiny object. (11 months) (F)
__Can walk holding on to furniture. (12 months) (G)

Back to Article

Two Years Old:

This checklist was developed by Ziva Schapiro, OTR

__Walks and runs on full feet (G)
__Pulls toys with strings (G&F)
__Climbs on furniture to look out the window and can get down (G)
__Climbs stairs holding on with two feet on each stair (G)
__Builds tower of 6 blocks (F)
__Pretends to push a train made out of three blocks after watching an adult do so. (F)
__Strings 1-4 large beads (F)
__One hand starts to be dominant (F)
__Holds crayon with the whole hand (fingers straight) (F)
__Imitates an adult making circular strokes or dots (F)
(The child will make a circle or dots after watching an adult do so.)
__Copies horizontal and vertical lines (F)
__Uses spoon well (F)
__Assists in dressing (G)

Back to Article

Three Years Old:

This checklist was developed by Ziva Schapiro, OTR

__Jumps in place with both feet (G)
__Kicks stationary ball (G)
__Rides tricycle (G)
__Stands on one foot for two seconds (G)
__Swings on swing when stated in motion (G)
__Builds tower of nine blocks (F)
__Snips with scissors (F)
__Completes 5-6 piece puzzle (F)
__Holds crayon with three fingers(F)
__Copies circle (can make a circle when he sees another one on a paper.) (F)
__Imitates cross (can make a cross after watching an adult draw one) (F)
__Draws person with head (F)
__Uses spoon and fork properly (without making a "big" mess) (F)

Back to Article

Four Years Old:

This checklist was developed by Ziva Schapiro, OTR

__Hops on one foot 1-3 times (G)
__Plays catch with large ball (G)
__Good control of tricycle (curves and spins) (G)
__Builds tower with 10 blocks (F)
__Strings small beads (F)
__Holds writing utensil with three fingers (F)
__Copies square (F)
__Draws person wit head feet and body (F)
__30 minute attention span (5-10 minutes per activity)
__Dress/Undress independently (except for closings, i.e. buttons, zippers) (F)
__Crosses midline (F&G) (anchor to this term in the article above)
__Does not switch hands in the middle of an activity (F)
__Clear dominance in right handed children (F)

Back to Article

Five Years Old:

This checklist was developed by Ziva Schapiro, OTR

__Walks on straight line (G)
__Can climb steps holding an object (G)
__Hops on each foot three times (G)
__Stands on one foot 8-10 seconds (G)
__Rides two wheeler with training wheels (G)
__Can swing by himself (G)
__Bounces and catches tennis ball (G&F)
__Builds tower 12 blocks (F)
__Can build three steps out of six blocks (F)
__Draws angled lines and triangle (F)
__Draws a person with head, body, legs and face (F
__Can color in lines (F)
__Cuts on straight lines (F)
__Holds knife in dominant hand (F)

Back to Article

Six Year Old:

This checklist was developed by Ziva Schapiro, OTR

__Stands on one foot with eyes closed for 3 seconds (G)
__Walks on line in heel-toe fashion (G)
__Skips (G)
__Rides bicycle without training wheels (G)
__Jumps rope (G)
__Catches and bounces tennis ball (G)
__Draws diamond (F)
__Cuts with knife (F)
__Holds writing utensil with three fingers with movement in the fingers.
__Ties shoelaces (F)

Calories Burned Per Minute for Various Activities

2009-09-19T10:33:00.000-07:00

Calories Burned Per Minute for Various Activities

Estimated calories burned are based on activities per minute. Actual calories burned vary with your individual body weight, the more you weigh, the more you burn, as indicated by the chart.

Activity

Weight in pounds:

105 - 115

Weight in pounds:

127 - 137

Weight in pounds:

160 - 170

Weight in pounds:

180 - 200

Aerobic Dancing	5.8	6.6	7.8	8.6
Basketball full court	9.8	11.2	13.2	14.5
Bicycling -Stationary 10 mph	5.5	6.3	7.8	8.3
Bicycling -Stationary 20 mph	11.7	13.3	15.6	17.8
Bicycling - 10 mph	5.5	6.3	7.8	14.5
Dancing - Rock & Roll	3.3	3.8	4.4	4.9
Golf - using handcart	3.3	3.8	4.4	4.9
Hiking (with backpack)	5.9	6.7	7.9	8.8
Jogging - 5 mph	8.6	9.2	11.5	12.7
Lawn Mowing (power motor)	3.5	4.0	4.8	5.2
Running - 8 mph	10.4	11.9	14.2	17.3
Sex - active	3.9	4.3	5.6	5.9
Skating - fast	8.1	9.3	10.9	12
Skiing - down hill	7.8	10.4	12.3	13.3
Skiing - cross country	13.1	15	17.8	19.4
Snow shoveling - light	7.9	9.1	10.8	12.5
Snow shoveling - heavy	13.8	15.7	18.5	20.5
Stair Climbing - normal speed	5.9	6.7	7.9	8.8
Swimming - 20 yds. a min.	3.9	4.5	5.3	6.8
Swimming - 60 yds. a min.	11	12.5	14.8	17.9
Tennis (singles)	7.8	8.9	10.5	11.6
Volleyball	7.8	8.9	10.5	11.6
Walking, 2 mph	2.4	2.8	3.3	3.6
Walking 4 mph	4.5	5.2	6.1	6.8
Watching TV	not avail.	145 per hour	not avail	not available

Other Activities - listed by the hour and a half only.

Estimated calories burned are based on one and a half hours of each activity at a body weight of 150 pounds. Actual calories burned vary with your individual body weight, the more you weigh, the more you burn. Yes, you can burn calories while shopping! Probably more when trying on lots of clothes too.

Housecleaning	864 - calories per one and one half hour
Shopping	325 - calories per one and one half hour
Bowling	415 - calories per one and one half hour
Yard Work	555 - calories per one and one half hour
Laundry	150 - calories per one and one half hour
Mowing Lawn	325 - calories per one and one half hour
Driving Car	125 - calories per one and one half hour
Food Shopping w/Cart	150 - calories per one and one half hour
Kissing	150 - calories per one and one half hour
Sitting at Rest	1.6 - calories per hour

May 2006 - Recent studies showed that gardening also burned a lot of calories. Sorry, I don't have the numbers, but was not surprised to read this in a nursing and medical journal. (Maybe that's what "yard work" was considered at the time these numbers were published several years ago.

Ideal Body Weight Chart

2009-09-19T10:28:00.000-07:00

You may be thinking, "What does ideal body weight have to do with a site about flattening your stomach?"

Well, if you've been reading this site, you now know that a flat stomach comes from overall body fitness. So it's important that you get your body as close to your ideal weight as possible.

PLEASE NOTE: This chart is just a guide and may not apply to everyone. It does not take into account different body frames/build, muscle tone, etc. It's important to speak with a physician about your individual weight if you are unsure.

Male		Female
Height	Ideal Weight	Height	Ideal Weight
4' 6"	63 - 77 lbs.	4' 6"	63 - 77 lbs.
4' 7"	68 - 84 lbs.	4' 7"	68 - 83 lbs.
4' 8"	74 - 90 lbs.	4' 8"	72 - 88 lbs.
4' 9"	79 - 97 lbs.	4' 9"	77 - 94 lbs.
4' 10"	85 - 103 lbs.	4' 10"	81 - 99 lbs.
4' 11"	90 - 110 lbs.	4' 11"	86 - 105 lbs.
5' 0"	95 - 117 lbs.	5' 0"	90 - 110 lbs.
5' 1"	101 - 123 lbs.	5' 1"	95 - 116 lbs.
5' 2"	106 - 130 lbs.	5' 2"	99 - 121 lbs.
5' 3"	112 - 136 lbs.	5' 3"	104 - 127 lbs.
5' 4"	117 - 143 lbs.	5' 4"	108 - 132 lbs.
5' 5"	122 - 150 lbs.	5' 5"	113 - 138 lbs.
5' 6"	128 - 156 lbs.	5' 6"	117 - 143 lbs.
5' 7"	133 - 163 lbs.	5' 7"	122 - 149 lbs.
5' 8"	139 - 169 lbs.	5' 8"	126 - 154 lbs.
5' 9"	144 - 176 lbs.	5' 9"	131 - 160 lbs.
5' 10"	149 - 183 lbs.	5' 10"	135 - 165 lbs.
5' 11"	155 - 189 lbs.	5' 11"	140 - 171 lbs.
6' 0"	160 - 196 lbs.	6' 0"	144 - 176 lbs.
6' 1"	166 - 202 lbs.	6' 1"	149 - 182 lbs.
6' 2"	171 - 209 lbs.	6' 2"	153 - 187 lbs.
6' 3"	176 - 216 lbs.	6' 3"	158 - 193 lbs.
6' 4"	182 - 222 lbs.	6' 4"	162 - 198 lbs.
6' 5"	187 - 229 lbs.	6' 5"	167 - 204 lbs.
6' 6"	193 - 235 lbs.	6' 6"	171 - 209 lbs.
6' 7"	198 - 242 lbs.	6' 7"	176 - 215 lbs.
6' 8"	203 - 249 lbs.	6' 8"	180 - 220 lbs.
6' 9"	209 - 255 lbs.	6' 9"	185 - 226 lbs.
6' 10"	214 - 262 lbs.	6' 10"	189 - 231 lbs.
6' 11"	220 - 268 lbs.	6' 11"	194 - 237 lbs.

So before you get too serious about toning your abs and flattening your stomach, you'll have to work on getting your weight down to the ideal number indicated on the chart above.

Check out Burn Fat and Build Muscle for more information on Weight Training to learn more about why body fat percentage is a good measure of weight loss success.

BMI (Body Mass Index)

Another stat you'll want to become familiar with is your BMI - Body Mass Index. This is the measure of your total body fat. It's calculated by dividing your weight (in kilograms) by your height (in meters, squared).

A normal BMI is between 18.5 and 24.9. A person with a BMI under that range is considered to be underweight, and a BMI above that range is considered overweight.

Calculate Your BMI

PLEASE NOTE: The BMI indicator is just a guide and may provide misleading results. It does not take into account different body frames, muscle tone, etc. It's important to speak with a physician about your individual weight if you are unsure.

For example, if you are 5'4, 145 pounds but you have a small frame/build, you may look out of shape even though the BMI caluclator says your weight is "desirable."

Those same stats (5'4 and 145 pounds) may look completely different on someone with an average or larger frame/build.

So even though these two people have the same weight and height, they carry it completely differently. The BMI calculator does not take this into consideration.

That's why it's important you speak to a physician about your individual weight.

Ideal Body Weight Chart

2009-09-19T10:18:00.000-07:00

HAMWI METHOD: IDEAL BODY WEIGHT

Height (inches)

IBW Small Frame (lbs)

IBW Medium Frame (lbs)

IBW Large Frame (lbs)

Hamwi Formula for Men
106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (medium frame)
Small frame (- 10%), Large frame (+ 10%)

Ideal Body Weight Calculator For Women

HAMWI METHOD: IDEAL BODY WEIGHT

IBW Small Frame (lbs)

IBW Medium Frame (lbs)

IBW Large Frame (lbs)

Hamwi Formula for Women
100 lbs for first 5 feet + 5 lbs for each inch over 5 feet (medium frame)
Small frame (- 10%), Large frame (+ 10%)

Ideal Body Weight Chart

How to Approximate Your Frame Size

Bend your forearm up to a 90 degree angle. Your arm should be parallel to your body.
Keep your fingers straight and turn the inside of your wrist towards the body.
Using your other hand, place your thumb and index finger on the two prominent bones (on either side) of the elbow.
Measure the distance between the bones with a tape measure or calipers.
Compare with the tables listing elbow measurements for medium-framed men or women.
Measurements lower than those listed for a medium frame indicate a small frame. Higher measurements indicate a large frame.

Elbow Measurements For Medium Frame

Height in 1" heels	Elbow	Height in 1" heels	Elbow
Men	Breadth	Women	Breadth
5'2"-5'3"	2 1/2"-2 7/8"	4'10"-4'11"	2 1/4"-2 1/2"
5'4"-5'7"	2 5/8"-2 7/8"	5'0"-5'3"	2 1/4"-2 1/2"
5'8"-5'11"	2 3/4"-3"	5'4"-5'7"	2 3/8"-2 5/8"
6'0"-6'3"	2 3/4"-3 1/8"	5'8"-5'11"	2 3/8"-2 5/8"
6'4"	2 7/8"-3 1/4"	6'0"	2 1/2"-2 3/4"

Quick Reference to Find Your Frame Size.

Keep in mind that this is a far less accurate measurement method.

To calculate your frame type place your thumb and index finger around your wrist. If your finger overlaps the thumb, your frame is a "Small Frame". If they touch, your frame is a "Medium Frame". If they do not touch, your frame is a "Large Frame".

Height and Weight Table for Women

Height Feet Inches	Small Frame	Medium Frame	Large Frame
4' 10"	102-111	109-121	118-131
4' 11"	103-113	111-123	120-134
5' 0"	104-115	113-126	122-137
5' 1"	106-118	115-129	125-140
5' 2"	108-121	118-132	128-143
5' 3"	111-124	121-135	131-147
5' 4"	114-127	124-138	134-151
5' 5"	117-130	127-141	137-155
5' 6"	120-133	130-144	140-159
5' 7"	123-136	133-147	143-163
5' 8"	126-139	136-150	146-167
5' 9"	129-142	139-153	149-170
5' 10"	132-145	142-156	152-173
5' 11"	135-148	145-159	155-176
6' 0"	138-151	148-162	158-179

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 3 lbs.; shoes with 1" heels)

Height and Weight Table for Men

Height Feet Inches	Small Frame	Medium Frame	Large Frame
5' 2"	128-134	131-141	138-150
5' 3"	130-136	133-143	140-153
5'' 4"	132-138	135-145	142-156
5' 5"	134-140	137-148	144-160
5' 6"	136-142	139-151	146-164
5' 7"	138-145	142-154	149-168
5' 8"	140-148	145-157	152-172
5' 9"	142-151	148-160	155-176
5' 10"	144-154	151-163	158-180
5' 11"	146-157	154-166	161-184
6' 0"	149-160	157-170	164-188
6' 1"	152-164	160-174	168-192
6' 2"	155-168	164-178	172-197
6' 3"	158-172	167-182	176-202
6' 4"	162-176	171-187	181-207

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 5 lbs.; shoes with 1" heels)

Being underweight or overweight are recognized risk factors for many diseases, namely hypertension, diabetes, hyperlipidemias, and perhaps certain types of cancers.

Remember, these are statistical averages and not absolutes. If you are very muscular, the chart will be inaccurate for you.

Normal Laboratory Values

2009-09-19T10:12:00.000-07:00

Important Notes

Each commercial laboratory has its own set of "normal" values, called "Normal Range" or "Reference Range" on your lab report. These values depend on the equipment or method used. Compare your results to the range shown on your lab report. Results that are "out of range" may not represent a problem. Your test results can be affected by several factors, including your age or gender, if you are pregnant, the time of day when the sample was taken, active infectons, stage of HIV disease, and food (some test samples need to be taken after you have fasted -- not eaten anything -- for several hours). Where normal values for men and women are different, they are indicated as W for women and M for men. Discuss "out of range" results with your health care provider.

The table below compares the units used in the United States with the "Système International d'Unités (SI units), a metric system used in many parts of the world. The last column, "To Convert US to SI Units," is the factor to multiply US lab values to convert them to SI units. To convert SI units to US units, divide the SI value by the conversion factor. See below for a terminology list.

Normal Laboratory Values

Laboratory Test	Normal Range in US Units	Normal Range in SI Units	To Convert US to SI Units
ALT (Alanine aminotransferase)	W 7-30 units/liter M 10-55 units/liter	W 0.12-0.50 µkat/liter M 0.17-0.92 µkat/liter	x 0.01667
Albumin	3.1 - 4.3 g/dl	31 - 43 g/liter	x 10
Alkaline Phosphatase	W 30-100 units/liter M 45-115 units/liter	W 0.5-1.67 µkat/liter W 0.75-1.92 µkat/liter	x 0.01667
Amylase (serum)	53-123 units/liter	0.88-2.05 nkat/liter	x 0.01667
AST (Aspartate aminotransferase)	W 9-25 units/liter M 10-40 units/liter	W 0.15-0.42 µkat/liter M 0.17-0.67 µkat/liter	x 0.01667
Basophils	0-3% of lymphocytes	0.0-0.3 fraction of white blood cells	x 0.01
Bilirubin - Direct	0.0-0.4 mg/dl	0-7 µmol/liter	x 17.1
Bilirubin - Total	0.0-1.0 mg/dl	0-17 µmol/liter	x 17.1
Blood pressure	Normal: 120/70 to 120/80 millimeters of mercury (mmHg). The top number is systolic pressure, when the heart is pumping. Bottom number is diastolic pressure then the heart is at rest. Blood pressure can be too low (hypotension) or too high (hypertension).		No conversion
C peptide	0.5-2.0 ng/ml	0.17-0.66 nmol/liter	x 0.33
Calcium, serum	8.5 -10.5 mg/dl	2.1-2.6 mmol/liter	x 0.25
Calcium, urine	0-300 mg/24h	0.0-7.5 mmol/24h	x 0.025
Cholesterol, total Desirable Marginal High	239 mg/dL	6.18 mmol/liter	x 0.02586
Cholesterol, LDL Desirable Marginal High Very High	190 mg/dL	4.91 mmol/liter	x 0.02586
Cholesterol, HDL Desirable Moderate Low (heart risk)	>60 mg/dL 40-60 mg/dL	>1.55 mmol/liter 1.03-1.55 mmol/liter	x 0.02586
Cortisol: serum	0-25 µg/dl (depends on time of day)	0-690 nmol/liter	x 27.59
Cortisol: free (urine)	20-70 µg/dl	55-193 nmol/24h	x 2.759
Creatine kinase	W 40-150 units/liter M 60-400 units/liter	W 0.67-2.50 µkat/liter M 1.00-6.67 µkat/liter	x 0.01667
DHEA	W 130-980 ng/dl M 180-1250 ng/dl	W 4.5-34.0 nmol/liter M 6.24-43.3 nmol/liter	x 0.03467
DHEA Sulfate	W Pre-menopause: 12-535 µg/dl W Post-menopause: 30-260 µg/dl M 10-619 µg/dl	W Pre-menopause: 120-5350 µg/liter W Post-menopause: 300-2600 µg/liter M 100-6190 µg/liter	x 10
Eosinophils	0-8% of white blood cells	0.0-0.8 fraction of white blood cells	x 0.01
Erythrocyte sedimentation rate (Sed Rate)	W<=30 mm/h M<=20 mm/h	W<=30 mm/h M<=20 mm/h	No conversion
Folate	3.1-17.5 ng/ml	7.0-39.7 nmol/liter	x 2.266
Glucose, urine	<0.05>	<0.003>	x 0.05551
Glucose, plasma	70-110 mg/dl	3.9-6.1 mmol/liter	x 0.05551
GGT (Gamma glutamyl transferase)	W <=45U/L M <=65 U/L	W <=45U/L M <=65 U/L	No conversion
Hematocrit	W 36.0% - 46.0% of red blood cells M 37.0% - 49.0% of red blood cells	W 0.36-0.46 fraction of red blood cells M 0.37-0.49 fraction of red blood cells	x 0.01
Hemoglobin	W 12.0-16.0 g/dl M 13.0-18.0 g/dl	W 7.4-9.9 mmol/liter M 8.1-11.2 mmol/liter	x 0.6206
LDH (Lactate dehydrogenase) (total)	<=270 U/L	<=4.5 µkat/liter	x 0.016667
Lactic acid	0.5-2.2 mmol/liter	0.5-2.2 mmol/liter	No conversion
Leukocytes (WBC)	4.5-11.0x10³/mm³	4.5-11.0x10⁹/liter	No conversion
Lymphocytes	16%-46% of white blood cells	0.16-0.46 fraction of white blood cells	x 0.01
Mean corpuscular hemoglobin (MCH)	25.0-35.0 pg/cell	25.0-35.0 pg/cell	No conversion
Mean corpuscular hemoglobin concentration (MCHC)	31.0-37.0 g/dl	310-370 g/liter	x 10
MCV (Mean corpuscular volume)	W 78-102 µm³ M 78-100 µm³	W 78-102 fl M 78-100 fl	No conversion
Monocytes	4-11% of white blood cells	0.04-0.11 fraction of white blood cells	x 0.01
Neutrophils	45%-75% of white blood cells	0.45-0.75 fraction of white blood cells	x 0.01
Phosphorus	2.5 – 4.5 mg/dL	0.81-1.45 mmol/L	x 0.323
Platelets (Thrombocytes)	130 – 400 x 10 ³µL	130 – 400 x 10 ⁹L	No conversion
Potassium	3.4-5.0 mmol/liter	3.4-5.0 mmol/liter	No conversion
RBC (Red blood cell count)	W 3.9 – 5.2 x 10⁶/µL³ M 4.4 – 5.8 x 10 ⁶/µL³	W 3.9 – 5.2 x 10¹²/L M 4.4 – 5.8 x 10 ¹²/L	No conversion
Sodium	135-145 mmol/liter	135-145 mmol/liter	No conversion
Testosterone, total (morning sample)	W 6-86 ng/dl M 270-1070 ng/dl	W 0.21-2.98 nmol/liter M 9.36-37.10 nmol/liter	x 0.03467
Testosterone, free Age 20-40 Age 41-60 Age 61-80	W 0.6-3.1, M 15.0-40.0 pg/ml W 0.4-2.5, M 13.0-35.0 pg/ml W 0.2-2.0, M 12.0-28.0 pg/ml	W 20.8-107.5, M 520-1387 pmol/liter W 13.9-86.7, M 451-1213 pmol/liter W 6.9-69.3, M 416-971 pmol/liter	x 34.67
Triglicerides (fasting) Normal Borderline High Very high	40-150 mg/dl 150-200 mg/dl 200-500 mg/dl >500 mg/dl	0.45-1.69 mmol/liter 1.69-2.26 mmol/liter 2.26-5.65 mmol/liter >5.65 mmol/liter	x 0.01129
Urea, plasma (BUN)	8-25 mg/dl	2.9-8.9 mmol/liter	x 0.357
Urinalysis - pH Specific gravity	5.0-9.0 1.001-1.035	5.0-9.0 1.001-1.035	No conversion
WBC (White blood cells, leukocytes)	4.5-11.0x10 ³ /mm ³	4.5-11.0x10 ⁹ liter	No conversion

Terminology

Units

gram : common measurement of weight. Used in this table: pg (picograms), g (grams), mg (milligrams), etc. per liter
katal (kat) : a unit of catalytic activity, used especially in the chemistry of enzymes. Used in this table: µkat (microkatals), nkat (nanokatals) per liter
micrometer (µm) : a unit of length. Mean Corpuscular Volume is expressed in cubic micrometers
mole : also "gram molecular weight," a quantity based on the atomic weight of the substance. Many test results in the Système Internationale are expressed as the number of moles per liter. In US units, these measurements are usually in grams per liter. Used in this table: mmol (millimoles), µmol, (micromoles), nmol (nanomoles), pmol (picomoles) per liter

Some units of measurement include the following fractions and multipliers:
mega (M) : 10 ⁶ or x1,000,000
kilo (k) : 10 ³ or x1,000
deca or deka : 10 ¹ or x10
deci (d) : 10 ^-1 or ÷10
milli (m) : 10 ^-3 or ÷1,000
micro (µ) : 10 ^-6 or ÷1,000,000
nano (n) : 10 ^-9 or ÷1,000,000,000

Vancomycin

2009-07-26T22:50:00.000-07:00

Pronunciation: (van-koe-MY-sin)

Class: Anti-infective agent

Trade Names:

Lyphocin
- Powder for injection, lyophilized 500 mg
- Powder for injection, lyophilized 1 g
- Powder for injection, lyophilized 5 g
- Powder for injection, lyophilized 10 g

Trade Names:

Vancocin
- Pulvules 125 mg
- Pulvules 250 mg
- Powder for injection 500 mg
- Powder for injection 10 g

Trade Names:

Vancoled
- Powder for injection 500 mg
- Powder for injection 1 g
- Powder for injection 5 g

Trade Names:

Vancomycin Hydrochloride
- Powder for oral solution 1 g

Pharmacology

Inhibits bacterial cell wall synthesis and alters cell-membrane permeability and RNA synthesis.

Pharmacokinetics

Absorption

Poorly absorbed (orally). C max is 63 mcg/mL. T max is 1 h.

Distribution

55% protein bound. Vd is 0.3 to 0.43 L/kg. Distributes to pleural, pericardial, ascitic, and synovial fluids; in urine; in peritoneal dialysis fluid; and atrial appendage tissue.

Metabolism

No apparent metabolism of the drug.

Elimination

Mean t ½ is 4 to 6 h. 75% is excreted in urine by glomerular filtration (in the first 24 h). Mean plasma Cl is 0.058 L/kg/h. Renal Cl is 0.048 L/kg/h.

Special Populations

Renal Function Impairment

Renal function impairment slows excretion of vancomycin in anephric patients, t ½ is 7.5 days.

Elderly

Total systemic and renal Cl may be reduced.

Indications and Usage

Parenteral

Treatment of serious or severe infections due to susceptible bacteria not treatable with other antimicrobials (eg, staphylococcus).

Oral

Treatment of pseudomembranous colitis caused by Clostridium difficile ; treatment of staphylococcal enterocolitis.

Unlabeled Uses

IV prophylaxis against bacterial endocarditis in penicillin-allergic patients.

Contraindications

Standard considerations.

Dosage and Administration

Adults

PO 500 mg to 2 g/day in 3 or 4 divided doses for 7 to 10 days.

Children

PO 40 mg/kg/day (up to 2 g/day) in 3 or 4 divided doses for 7 to 10 days.

Newborns

PO 10 mg/kg/day in divided doses.

Adults

IV 500 mg by IV infusion every 6 h or 1 g every 12 h.

Children

IV 10 mg/kg/dose every 6 h.

Infants & Newborns

IV 15 mg/kg initially, followed by 10 mg/kg every 12 h for newborns in first week of life, and every 8 h for ages up to 1 mo.

General Advice

* Prepare oral solution by adding 115 mL of water to 10 g vial or 20 mL of water to 1 g vial. Further dilute prepared oral solution dose with 30 mL of water or flavoring syrups may be used with oral solution.
* May give oral solution via nasogastric tube as indicated or ordered.
* Reconstitute parenteral form with sterile water for injection.
* Further dilute parenteral medication with compatible solution (eg, dextrose injection 5%, sodium chloride 0.9%, lactated Ringer's).
* Parenteral form may be administered by oral route.
* Reconstituted oral solution may be stored in refrigerator for 2 wk after bottle is opened.
* Dilute to minimum dilution of 2.5 mL and infuse parenteral solution over at least 60 min. Intermittent infusion preferred.
* Pretreat with antihistamine if patient has previously experienced Red Man Syndrome.
* Dosage or dosage interval may be changed based upon vancomycin serum levels.
* Reconstituted powder for injection is stable at room temperature for 2 wk.
* Dilute solutions (sodium chloride or D5W) are stable at room temperature for 24 h.

Drug Interactions

Aminoglycosides increased risk of nephrotoxicity and ototoxicity when vancomycin given with aminoglycosides
Amphotericin possible increased risk of nephrotoxicity when vancomycin given with amphotericin Close monitoring required with concomitant administration of nephrotoxic drugs or cytotoxics
Anaesthetics, General hypersensitivity-like reactions can occur when intravenous vancomycin given with general anaesthetics See also Surgery and Long-term Medication, section 15.1
Capreomycin increased risk of nephrotoxicity and ototoxicity when vancomycin given with capreomycin
Ciclosporin increased risk of nephrotoxicity when vancomycin given with ciclosporin
Cisplatin increased risk of nephrotoxicity and possibly of ototoxicity when vancomycin given with cisplatin
Colestyramine effects of oral vancomycin antagonised by colestyramine Other drugs should be taken at least 1 hour before or 4-6 hours after colestyramine to reduce possible interference with absorption
Colistin increased risk of nephrotoxicity and ototoxicity when vancomycin given with colistin
Diuretics, Loop increased risk of otoxicity when vancomycin given with loop diuretics
Polymyxins increased risk of nephrotoxicity when vancomycin given with polymyxins
Suxamethonium vancomycin enhances effects of suxamethonium
Tacrolimus possible increased risk of nephrotoxicity when vancomycin given with tacrolimus Interactions do not generally apply to tacrolimus used topically; risk of facial flushing and skin irritation with alcohol consumption (see section 13.5.3) does not apply to tacrolimus taken systemically
Vancomycin belongs to Antibacterials and will have the following interactions:

Oestrogens antibacterials that do not induce liver enzymes possibly reduce contraceptive effect of oestrogens (risk probably small, see section 7.3.1) Interactions of combined oral contraceptives may also apply to combined contraceptive patches; in case of hormone replacement therapy low dose unlikely to induce interactions

Adverse Reactions

Cardiovascular

Hypotension.

Dermatologic

Rash; urticaria; pruritus; inflammation at site of injection.

EENT

Hearing loss.

GI

Nausea.

Genitourinary

Increased serum creatinine and BUN; renal failure.

Hematologic

Neutropenia; eosinophilia.

Respiratory

Wheezing; dyspnea.

Miscellaneous

Anaphylaxis; drug fever; chills; Red Man Syndrome (hypotension with or without rash over face, neck, upper chest, and extremities).

Precautions

Pregnancy

Category C .

Lactation

Excreted in breast milk.

Children

Confirming serum levels may be appropriate in newborns. Use of vancomycin with anesthetics may cause erythema and flushing.

Special Risk Patients

Use with caution in patients with preexisting hearing loss, patients receiving ototoxic or nephrotoxic drugs, patients receiving drugs that cause neutropenia; patients with renal function impairment; elderly; newborns.

Hypotension

Too rapid IV infusion or bolus administration may be associated with exaggerated hypotension, including shock and cardiac arrest, with or without maculopapular rash over face, neck, upper chest, and extremities (Red Man or Redneck syndrome). Reaction has been rarely associated with slow infusion or oral or intraperitoneal administration.

Reversible neutropenia

May occur after total dose of 25 g.

Tissue irritation, thrombophlebitis

Give by secure IV route. May minimize thrombophlebitis by giving slowly as dilute infusion.

Overdosage

Symptoms

Increase serum creatinine, increase BUN, hearing loss, ringing in ears, vertigo.

Patient Information

* Explain that IV medication is given at regular intervals to maintain blood levels.
* Tell patient to report hearing loss, ringing in ears, or vertigo to health care provider.
* Explain signs of superinfection (eg, vaginitis).
* Identify symptoms of potential adverse reactions.
* Tell patient to maintain adequate fluid intake.

Albuterol

2009-07-26T22:49:00.000-07:00

Pronunciation: (al-BYOO-ter-ahl)

Class: Sympathomimetic

Trade Names:

Airet

- Solution for inhalation 0.083% (as sulfate)

Trade Names:

Proventil

- Tablets 2 mg (as sulfate)

- Tablets 4 mg (as sulfate)

- Syrup 2 mg (as sulfate) per 5 mL

- Aerosol Each actuation delivers 90 mcg albuterol

- Solution for inhalation 0.083% (as sulfate)

- Solution for inhalation 0.5% (as sulfate)

Trade Names:

Proventil HFA

- Aerosol Each actuation delivers 90 mcg albuterol (as sulfate)

Trade Names:

Ventolin

- Tablets 2 mg (as sulfate)

- Tablets 4 mg (as sulfate)

- Syrup 2 mg (as sulfate) per 5 mL

- Solution for inhalation 0.5% (as sulfate)

Trade Names:

Ventolin Nebules

- Solution for inhalation 0.083% (as sulfate)

Trade Names:

Ventolin Rotacaps

- Capsules for inhalation 200 mcg microfine (as sulfate)

Airomir (Canada)

Apo-Salvent (Canada)

Apo-Salvent CFC Free (Canada)

Gen-Salbutamol Respirator Solution (Canada)

Gen-Salbutamol Sterinebs P.F. (Canada)

ratio-Salbutamol HFA (Canada)

Sandoz Salbutamol (Canada)

Ventolin Diskus (Canada)

Ventolin Oral Liquid (Canada)

Pharmacology

Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation.

Pharmacokinetics

Absorption

Tablets

Rapidly absorbed; T max is 2 h; C max is about 18 ng/mL.

Inhalation

Less than 20% absorbed; T max is 0.5 h; C max is 2.1 ng/mL.

Elimination

T ½ is 5 to 6 h. 76% recovered in urine over 3 days with 60% as metabolites; 4% excreted in feces.

Onset

Oral

Within 30 min.

Inhalation

Within 5 min.

Duration

Oral

4 to 8 h.

Inhalation

3 to 6 h.

Indications and Usage

Prevention and treatment of reversible bronchospasm associated with asthma and other obstructive pulmonary diseases.

Unlabeled Uses

Adjunctive treatment of hyperkalemia in patients undergoing dialysis.

Contraindications

Cardiac tachyarrhythmias.

Dosage and Administration

Inhalation Aerosol

Adults and Children at least 4 yr of age (at least 12 yr for Proventil )

1 to 2 inhalations every 4 to 6 h.

Prevention of exercise-induced bronchospasm

2 inhalations 15 min before exercise.

Inhalation Solution

Adults and children older than 2 yr of age

2.5mg/dose 3 to 4times/day by nebulization.

Children 2 to 12 yr of age ( AccuNeb )

1.25 mg or 0.63 mg 3 to 4 times/day by nebulization.

Oral

Adults and Children older than 12 yr of age

PO 2 to 4 mg/dose 3 to 4 times/day. Do not exceed 32 mg/day.

Children 6 to 12 yr of age

PO 2 mg/dose 3 to 4 times/day. Do not exceed 24 mg/day.

Children 2 to 6 yr of age

PO 0.1 to 0.2 mg/kg/dose 3 times/day. Do not exceed 12 mg/day.

Adults and Children older than 12 yr of age, extended-release ( Proventil Repetabs )

PO 4 to 8 mg every 12 h. May be cautiously increased stepwise to a max of 16 mg twice daily (max, 32 mg/day).

Children 6 to 12 yr of age, extended-release ( Proventil Repetabs )

PO 4 every 12 h. May be cautiously increased stepwise to a max of 12 mg twice daily.

Syrup

Adults and Children alder than 12 yr of age

2 or 4mg (1 to 2 tsp) 3 or 4 times/day. Doses of above 4 mg 4 times/day may be appropriate when patient fails to respond.

Children 6 to 12 yr of age

2 mg (1tsp) 3 or 4 times/day. Doses of 2 mg 4times/day may be cautiously increased. Do not exceed 24 mg/day in divided doses.

Children 2 to 6 yr of age

Initiate at 0.1 mg/kg 3 times/day. Dose may be increased 2 mg 3 times/day. Do not exceed 2 mg 3 times/day. Dose may be increased to 0.2 mg/kg 3 times/day, but not to exceed 4 mg 3 times/day.

Elderly and those sensitive to beta-adrenergic stimulation

Restrict initial dose to 2 mg (1 tsp) 3 or 4times/day. Individualize dosage thereafter.

Storage/Stability

Store at room temperature. Refrigeration of syrup improves palatability.

Drug Interactions

Atomoxetine Increased risk of cardiovascular side-effects when parenteral salbutamol given with atomoxetine
Digoxin salbutamol possibly reduces plasma concentration of digoxin
Methyldopa acute hypotension reported when infusion of salbutamol given with methyldopa
Salbutamol belongs to Sympathomimetics, Beta2 and will have the following interactions:

Acetazolamide increased risk of hypokalaemia when high doses of beta2 sympathomimetics given with acetazolamide —for CSM advice (hypokalaemia) see section 3.1.1.1
Corticosteroids increased risk of hypokalaemia when high doses of beta2 sympathomimetics given with corticosteroids —for CSM advice (hypokalaemia) see section 3.1.1.1 Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified
Diuretics, Loop increased risk of hypokalaemia when high doses of beta2 sympathomimetics given with loop diuretics —for CSM advice (hypokalaemia) see section 3.1.1.1
Diuretics, Thiazide and related increased risk of hypokalaemia when high doses of beta2 sympathomimetics given with thiazides and related diuretics —for CSM advice (hypokalaemia) see section 3.1.1.1
Theophylline increased risk of hypokalaemia when high doses of beta2 sympathomimetics given with theophylline —for CSM advice (hypokalaemia) see section 3.1.1.1

Adverse Reactions

Cardiovascular

Palpitations; tachycardia; elevated BP; chest tightness; angina.

CNS

Tremor; dizziness; hyperactivity; nervousness; headache; insomnia; weakness; drowsiness; restlessness.

EENT

Dry mouth; throat irritation.

GI

Nausea; vomiting; heartburn; diarrhea.

Genitourinary

Urinary retention.

Respiratory

Cough; bronchospasm; wheezing; dyspnea.

Miscellaneous

Flushing; sweating; anorexia; unusual sensory changes.

Precautions

Pregnancy

Category C .

Lactation

Unknown.

Children

Albuterol aerosol and inhalation powder in children younger than 4 yr of age and albuterol solution for inhalation in children younger than 2 yr of age not established.

Labor and Delivery

May inhibit uterine contractions.

CV effects

Toxic symptoms may occur in patients with CV disorders.

CNS effects

CNS stimulation may occur; use cautiously in patients with history of seizures or hyperthyroidism.

Diabetes

Dosage adjustment of insulin or oral hypoglycemic agent may be required.

Excessive use

Paradoxical bronchospasm and cardiac arrest have been associated with excessive inhalant use.

Hypokalemia

Decreases in potassium levels have occurred.

Tolerance

If previously effective dose fails to provide relief, therapy may need to be reassessed.
Overdosage

Symptoms

Tremor, palpitations, tachycardia, elevated BP, seizures.

Patient Information

* Tell patient not to chew or crush capsules.
* Teach patient correct method for using metered-dose inhaler. Have patient demonstrate proper technique, including timing between inhalations.
* Instruct patient in home monitoring of pulse and BP.
* Advise patient to maintain fluid intake of 2,000 mL/day and to rinse mouth after each complete dose.
* Instruct patient not to use OTC inhalers without consulting health care provider.
* Instruct patient to contact health care provider if symptoms are not relieved by normal dose.
* Tell patient to report adverse reactions or side effects.

Prednisolone

2009-07-26T22:48:00.002-07:00

Pronunciation: (pred-NIS-oh-lone)

Class: Corticosteroid, Glucocorticoid Prednisolone

Trade Names:

Millipred

- Tablets 5 mg

ratio-Prednisolone (Canada)

Sandoz Prednisolone (Canada)

Prednisolone Acetate

Trade Names:

Econopred Plus

- Ophthalmic suspension 1%

Trade Names:

Flo-Pred
- Oral suspens
on 5 mg per 5 mL

- Oral suspension 15 mg per 5 mL

Trade Names:

Pred Forte

- Ophthalmic suspension 1%

Trade Names:

Pred Mild

- Ophthalmic suspension 0.12%

Trade Names:

Prelone

- Syrup 15 mg per 5 mL

Prednisolone Sodium Phosphate

Trade Names:

Orapred

- Oral solution 15 mg per 5 mL

- Orally disintegrating tablets 10 mg

- Orally disintegrating tablets 15 mg

- Orally disintegrating tablets 30 mg

Trade Names:

Pediapred

- Oral liquid 5 mg per 5 mL

Trade Names:

Prednisol

- Ophthalmic suspension 1%

Trade Names:

Veripred 20

- Solution 20 mg per 5 mL

Pharmacology

Advertisement

Intermediate-acting glucocorticoid that depresses formation, release, and activity of endogenous mediators of inflammation, including prostaglandins, kinins, histamine, liposomal enzymes, and complement system. Also modifies body's immune response.

Pharmacokinetics

Absorption

Oral

Rapidly absorbed, reaching C max in 1 to 2 h. C max is approximately 336.8 ng•h/mL and AUC 0-t is approximately 1,946.8 ng•h/mL (15 mg).

Distribution

Plasma protein binding 70% to 90%. Vd is 0.22 to 0.7 L/kg.

Metabolism

Primarily hepatic.

Elimination

Excreted in the urine as sulfate and glucuronide conjugates. t ½ is 2 to 4 h.

Special Populations

Elderly

Mean unbound fraction of prednisolone was higher and V ss unbound prednisolone was reduced in elderly patients.

Indications and Usage

Oral

Allergic conditions; collagen diseases (eg, systemic lupus erythematous, acute rheumatic carditis); dermatologic diseases; edematous states; endocrine conditions; GI diseases; hematologic diseases; neoplastic conditions; neoplastic diseases; nervous system conditions (eg, acute exacerbations of multiple sclerosis); ophthalmic conditions; conditions related to organ transplantation; pulmonary disease (eg, asthma); renal condition (eg, nephrotic syndrome); rheumatologic conditions; specific infectious diseases including trichinosis with neurologic or myocardial involvement, tuberculous meningitis with subarachnoid block or impending block when used concomitantly with appropriate antituberculous chemotherapy; tuberculosis with pleural or pericardial effusion.
Ophthalmic Econopred Plus, Prednisol, Pred Forte

Treatment of steroid-responsive inflammation of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe.
Econopred Plus, Prednisol

Treatment of corneal injury from chemical, radiation, or thermal burns, or penetration of foreign bodies.
Pred Mild

Treatment of mild to moderate noninfectious allergic and inflammatory disorders of the lid, conjunctiva, cornea, and sclera (including chemical and thermal burns).

Dosage and Administration

Adults

PO 5 to 60 mg/day. Oral disintegrating tablet: 10 to 60 mg/day.

Children

PO Range of initial dose is 0.14 to 2 mg/kg/day in 3 or 4 divided doses (4 to 60 mg/m 2 /day).

Adults

Ophthalmic Econopred , Prednisol : 2 drops in affected eye(s) 4 times daily. In cases of bacterial infections, concomitant use of anti-infective agents is mandatory. Pred Forte , Pred Mild : Instill 1 to 2 drops into conjunctival sac 2 to 4 times daily. The dose frequency may be increased if necessary during the first 24 to 48 h.

Multiple Sclerosis

Adults

PO 200 mg/day for 1 wk, then 80 mg every other day for 1 mo.

Nephrotic Syndrome

Children

PO 60 mg/m 2 /day in 3 or 4 divided doses for 4 wk, followed by 4 wk of single dose alternate-day therapy at 40 mg/m 2 /day.

Asthma

Children

PO 1 to 2 m/kg/day in single or divided doses. A short course, or burst therapy, should be continued until children achieve a peak expiratory flow rate of 80% of their personal best or symptoms resolve, which usually requires 3 to 10 days of treatment, although it can take longer.

General Advice

* Alternate-day therapy, a corticosteroid dosing regimen in which twice the usual daily dose is administered every other day, is used to provide patients requiring long-term pharmacologic dose treatment with the beneficial effects of prednisolone while minimizing certain adverse reactions (eg, pituitary-adrenal suppression, Cushingoid state, growth suppression in children).
* Do not break or use partial orally disintegrating tablets.
* Ophthalmic suspensions: Shake well before using.
* Ophthalmic use: If signs and symptoms do not improve after 2 days, re-evaluate the patient.
* Ophthalmic use: Care should be taken not to discontinue prematurely.

Storage/Stability

Oral tablets

Store at 68° to 77°F. Protect oral disintegrating tablets from moisture.

Orapred , Veripred 20

Store at 36° to 46°F.

Prelone

Store at 59° to 86°F.

Pediapred

Store at 39° to 77°F. May be refrigerated.

Ophthalmic suspension Econopred , Prednisol

Store at 46° to 75°F in an upright position.

Flo-Pred

Store at 68° to 77°F.

Pred Forte

Store at temperatures up to 75°F in an upright position. Protect from freezing.

Pred Mild

Store at 59° to 86°F in an upright position. Protect from freezing.

Drug Interactions

Ciclosporin plasma concentration of prednisolone increased by ciclosporin
Ritonavir plasma concentration of prednisolone possibly increased by ritonavir
Prednisolone belongs to Corticosteroids and will have the following interactions:
Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified

ACE inhibitors corticosteroids antagonise hypotensive effect of ACE inhibitors
acetazolamide increased risk of hypokalaemia when corticosteroids given with acetazolamide
Adrenergic Neurone blockers corticosteroids antagonise hypotensive effect of adrenergic neurone blockers
Alpha blockers corticosteroids antagonise hypotensive effect of alpha-blockers
Amphotericin increased risk of hypokalaemia when corticosteroids given with amphotericin —avoid concomitant use unless corticosteroids needed to control reactions Close monitoring required with concomitant administration of nephrotoxic drugs or cytotoxics
Angiotensin-II receptor antagonists corticosteroids antagonise hypotensive effect of angiotensin-II receptor antagonists
Antidiabetics corticosteroids antagonise hypoglycaemic effect of antidiabetics
Aspirin increased risk of gastro-intestinal bleeding and ulceration when corticosteroids given with aspirin , also corticosteroids reduce plasma concentration of salicylate
Barbiturates metabolism of corticosteroids accelerated by barbiturates (reduced effect)
Beta-blockers corticosteroids antagonise hypotensive effect of beta-blockers Since systemic absorption may follow topical application of beta-blockers to the eye the possibility of interactions, in particular, with drugs such as verapamil should be borne in mind
Calcium salts corticosteroids reduce absorption of calcium salts see also Antacids
Calcium-channel blockers corticosteroids antagonise hypotensive effect of calcium-channel blockers Dihydropyridine calcium-channel blockers include amlodipine, felodipine, isradipine, lacidipine, lercanidipine, nicardipine, nifedipine, nimodipine, and nisoldipine
Carbamazepine metabolism of corticosteroids accelerated by carbamazepine (reduced effect)
Cardiac glycosides increased risk of hypokalaemia when corticosteroids given with cardiac glycosides
Clonidine corticosteroids antagonise hypotensive effect of clonidine
Coumarins corticosteroids may enhance or reduce anticoagulant effect of coumarins (high-dose corticosteroids enhance anticoagulant effect) Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Diazoxide corticosteroids antagonise hypotensive effect of diazoxide
Diuretics corticosteroids antagonise diuretic effect of diuretics
loop diuretics increased risk of hypokalaemia when corticosteroids given with loop diuretics
Diuretics, Thiazide and related increased risk of hypokalaemia when corticosteroids given with thiazides and related diuretics
Erythromycin metabolism of corticosteroids possibly inhibited by erythromycin Interactions do not apply to small amounts of erythromycin used topically
Hydralazine corticosteroids antagonise hypotensive effect
of hydralazine
Itraconazole metabolism of corticosteroids possibly inhibited by itraconazole
Ketoconazole metabolism of corticosteroids possibly inhibited by ketoconazole
Methotrexate increased risk of haematological toxicity when corticosteroids given with methotrexate
Methyldopa corticosteroids antagonise hypotensive effect of methyldopa
Mifepristone effect of corticosteroids (including inhaled corticosteroids) may be reduced for 3–4 days after mifepristone
Minoxidil corticosteroids antagonise hypotensive effect of minoxidil
Moxonidine corticosteroids antagonise hypotensive effect of moxonidine
Nitrates corticosteroids antagonise hypotensive effect of nitrates
NSAIDs increased risk of gastro-intestinal bleeding and ulceration when corticosteroids given with NSAIDs See also Aspirin. Interactions do not generally apply to topical NSAIDs
Oestrogens plasma concentration of corticosteroids increased by oral contraceptives containing oestrogens Interactions of combined oral contraceptives may also apply to combined contraceptive patches; in case of hormone replacement therapy low dose unlikely to induce interactions
Phenytoin metabolism of corticosteroids accelerated by phenytoin (reduced effect)
Primidone metabolism of corticosteroids accelerated by primidone (reduced effect)
Rifamycins metabolism of corticosteroids accelerated by rifamycins (reduced effect)
Ritonavir plasma concentration of corticosteroids possibly increased by ritonavir
Sodium Benzoate corticosteroids possibly reduce effects of sodium benzoate
Sodium Nitroprusside corticosteroids antagonise hypotensive effect of sodium nitroprusside
Sodium Phenylbutyrate corticosteroids possibly reduce effects of sodium phenylbutyrate
Somatropin corticosteroids may inhibit growth-promoting effect of somatropin
Sympathomimetics. increased risk of hypokalaemia when corticosteroids given with high doses of beta2 sympathomimetics.
Theophylline increased risk of hypokalaemia when corticosteroids given with theophylline
Vaccines. high doses of corticosteroids impair immune response to vaccines , avoid concomitant use with live vaccines.

For a general warning on live vaccines and high doses of corticosteroids or other immunosuppressive drugs.

Contraindications

Oral

Hypersensitivity to corticosteroids or any component of the product; systemic fungal infections; administration of live, or live, attenuated vaccines in patients receiving immunosuppressive doses.

Ophthalmic

Most viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella; mycobacterial infection of the eye and fungal diseases of the ocular structure; acute untreated purulent ocular infections; hypersensitivity to other corticosteroids or any component of the product.

Adverse Reactions

Cardiovascular

Bradycardia; cardiac arrest; cardiac arrhythmias; cardiac enlargement; CHF; circulatory collapse; elevated BP; fat embolism; hypertension; hypertrophic cardiomyopathy in premature infants; myocardial rupture following recent MI; pulmonary edema; syncope; tachycardia; thromboembolism; thrombophlebitis; vasculitis.

CNS

Arachnoiditis; behavioral and mood changes; convulsions; depression; emotional instability; euphoria; headache; increased appetite; increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of therapy; insomnia; malaise; meningitis; mood swings; neuritis; neuropathy; paraparesis/paraplegia; paresthesia; personality changes; sensory disturbances; vertigo.

Dermatologic

Acne; allergic dermatitis; cutaneous and subcutaneous atrophy; dry scalp; edema; facial erythema; hyper- or hypopigmentation; impaired wound healing; increased sweating; petechiae and ecchymosis; rash; sterile abscess; striae; suppressed reactions to skin tests; thin fragile skin; thinning scalp hair; urticaria.

EENT

Exophthalmos; glaucoma; increased IOP; posterior subcapsular cataracts.

Ophthalmic use

Acute anterior uveitis; conjunctival hyperemia; conjunctivitis; corneal ulcers; delayed wound healing; glaucoma; increased IOP; keratitis; loss of accommodation; mydriasis; optic nerve damage; perforation of the globe; posterior subcapsular cataract formation; ptosis; secondary ocular infection (eg, bacterial, viral).

GI

Abdominal distention; elevation in serum liver enzymes levels; hepatomegaly; hiccups; nausea; pancreatitis; peptic ulcer with possible perforation and hemorrhage; ulcerative esophagitis.

Endocrine

Abnormal fat deposits; decreased carbohydrate tolerance; development of Cushingoid state; hirsutism; manifestations of latent diabetes mellitus and increased requirement for insulin and oral hypoglycemic agents in diabetes; menstrual irregularities; moon facies; secondary adrenocortical and pituitary unresponsiveness (particularly during stress, as in trauma, surgery, or illness); suppression of growth in children.

Genitourinary

Alteration in motility and number of spermatozoa.

Hypersensitivity

Anaphylactoid reaction; anaphylaxis; angioedema.

Metabolic-Nutritional

Alterations in blood glucose; fluid retention; hypokalemic alkalosis; negative nitrogen balance due to catabolism; potassium loss; sodium retention; weight gain.

Musculoskeletal

Aseptic necrosis of femoral and humeral heads; charcot-like arthropathy; loss of muscle mass; muscle weakness; osteoporosis; pathologic fracture of long bones; steroid myopathy; tendon rupture; vertebral compression fractures.

Precautions

Monitor

Body weight, BP, routine laboratory studies, including 2-hour postprandial blood glucose and serum potassium, and a chest x-ray, should be obtained at regular intervals during prolonged therapy. Monitor linear growth of infants and children on prolonged therapy. Upper GI x-rays are desirable in patients with known or suspected peptic ulcer disease. If ophthalmic product is used for more than 10 days or oral product more than 6 wk, routinely monitor IOP.

Pregnancy

Category C .

Flo-Pred

Category D .

Lactation

Excreted in breast milk.

Children

Safety and efficacy not established (ophthalmic).

Elderly

Use with caution, usually starting at the low end of the dosage range, because of the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant diseases or other drug therapy.

Hypersensitivity

Reactions may occur, including anaphylaxis.

Renal Function

Use drug with caution.

Adrenal suppression

Prolonged therapy may lead to hypothalamic-pituitary-adrenal suppression.

Bone density

Bone formation may be decreased and bone resorption may be increased. Long-term use in children can have negative effects on growth and development.

Cardiovascular effects

Use drug with great caution in patient who has suffered recent MI.

Cardiovascular/renal function

Prednisolone may cause elevation of BP, salt and water retention, and increased excretion of calcium and potassium.

Cerebral malaria

Do not use.

Fetal effects

Can cause fetal harm when administered to pregnant women. Use during the first trimester of pregnancy has been associated with an increased risk of orofacial clefts, intrauterine growth restriction, and decreased birth weight.

GI disorders

Risk of GI perforation in patients with certain GI disorders may be increased (eg, active or latent peptic ulcers).

Infections

Signs of infection may be masked. Host-defense mechanisms may be decreased, allowing dissemination of infection. Risk of reactivation or exacerbation of latent infection may be increased.

Kaposis sarcoma

Has been reported in patients receiving corticosteroid therapy, usually for chronic conditions.

Long-term ophthalmic local use

Fungal infections of the cornea are particularly prone to develop with chronic use of corticosteroids, and fungal infections should be suspected in any persistent corneal ulceration.

Mood and behavior disturbances

Use may be associated with CNS effects ranging from euphoria, insomnia, mood swings, personality changes, and severe depression to frank psychotic manifestations. Existing emotional instability or psychotic tendencies may be aggravated.

Ocular effects

Use systemic drug with caution in ocular herpes simplex because of possible corneal perforation.

Ophthalmic effects

Prolonged use may produce posterior subcapsular cataracts and glaucoma with possible damage to the optic nerve, and may enhance the establishment of secondary ocular infections due to fungi or viruses. Use with caution in patients with glaucoma. Do not use in the treatment of optic neuritis.

Stress

Increased dosage of rapidly acting corticosteroid may be needed before, during, and after stressful situations.

Surgery

Use after cataract surgery may delay healing and increase the incidence of bleb formation.

Threadworm infestation

Use with great care.

Thyroid status

Changes in thyroid status may necessitate adjustments in prednisolone dosage.

Tuberculosis

Restrict use to those cases of fulminating or disseminated tuberculosis in which prednisolone is used for management of the disease in conjunction with an appropriate antituberculous regimen.

Withdrawal

Abrupt discontinuation may result in adrenal insufficiency.

Overdosage

Symptoms

The effects of ingestion of large quantities over a short period of time have not been reported.

Patient Information

* Advise patient to take single daily or alternate-day doses in morning before 9 am and to take multiple doses at evenly-spaced intervals throughout day.
* Instruct patient to take medication with meals or snacks to avoid GI irritation.
* Caution patient not to take drug with aspirin or other OTC medications containing salicylates unless directed by health care provider.
* Instruct patient to check weight at home daily at same time of day.
* Advise patient on chronic steroid therapy to wear medical identification (eg, card, bracelet) indicating condition and drug regimen.
* Remind patient to wash hands before and after ophthalmic instillation.
* Teach patient correct method for instilling eye drops.
* Instruct patient not to rub eyes or touch dropper into eye.
* Inform patient of increased appetite and counsel patient on appropriate diet management (ie, diet high in protein, calcium, and potassium but low in sodium and carbohydrates).
* Advise family that medication may slow growth in children.
* Inform patient of the possible adverse reactions of moonface, mood swings, and increased emotions.
* Teach patient to monitor for infection, eye burning, or increased bruising.
* Instruct patient not to drive soon after using eye drops because vision may be blurred initially.
* Inform patient that ophthalmic preparation may cause sensitivity to bright light and recommend use of sunglasses to minimize this effect.
* Instruct patient to report the following symptoms to health care provider: black, tarry stools; menstrual irregularities; muscle weakness; prolonged sore throat, fever, cold, or infection; puffing of face; swelling of lower extremities; unusual weight gain; vomiting of blood.
* Tell patient to notify health care provider if the following symptoms occur after dosage reduction or withdrawal of therapy: anorexia, diarrhea, dizziness, fatigue, low blood sugar, nausea, vomiting, weakness, weight loss.

Morphine Sulfate

2009-07-26T22:48:00.001-07:00

Pronunciation: (moRE-feen SULL-fate)

Class: Opioid analgesic

Trade Names:

Astramorph PF

- Injection 0.5 mg/mL

- Injection 1 mg/mL

Trade Names:

Duramorph

- Injection 0.5 mg/mL

- Injection 1 mg/mL

Trade Names:

Infumorph

- Injection 10mg/mL

- Injection 25 mg/mL

Trade Names:

Kadian

- Capsules, sustained-release 20 mg

- Capsules, sustained-release 50 mg

- Capsules, sustained-release 100mg

Trade Names:

MS Contin

- Tablets, controlled-release 15mg

- Tablets, controlled-release 30 mg

- Tablets, controlled-release 60mg

- Tablets, controlled-release 100 mg

- Tablets, controlled-release 200mg

Trade Names:

MSIR

- Solution 10 mg per 5 mL

- Solution 20 mg per 5 mL

- Solution 20 mg/mL

Trade Names:

Oramorph SR

- Tablets, controlled-release 15mg

- Tablets, controlled-release 30 mg

- Tablets, controlled-release 60 mg

- Tablets, controlled-release 100 mg

Trade Names:

OMS Concentrate

- Solution 20 mg/mL

Trade Names:

RMS

- Rectal Suppositories 5 mg

- Rectal Suppositories 10 mg

- Rectal Suppositories 20 mg

- Rectal Suppositories 30 mg

Trade Names:

Roxanol

- Solution 20 mg/mL

Trade Names:

Roxanol Rescudose

- Solution 10 mg per 2.5 mL

Trade Names:

Roxanol 100

- Solution 100 mg per 5 mL

Trade Names:

Roxanol T

- Solution 20 mg/mL

Trade Names:

Roxanol UD

- Solution 10 mg per 2.5 mL

- Solution 20 mg per 5 mL

- Solution 30 mg per 1.5 mL

M.O.S.-Sulfate (Canada)

Morphine HP Injection (Canada)

Morphine LP Epidural (Canada)

PMS-Morphine Sulfate SR (Canada)

ratio-Morphine SR (Canada)

Pharmacology

Relieves pain by stimulating opiate receptors in CNS; also causes respiratory depression, peripheral vasodilation, inhibition of intestinal peristalsis, sphincter of Oddi spasm, stimulation of chemoreceptors that cause vomiting and increased bladder tone.

Pharmacokinetics

Absorption

Mean T max is 3.7 h and mean C max is 9.9 to 27.4 ng/mL (dose dependent) for sustained-release form. Bioavailability is approximately 40%.

Distribution

Morphine distributes to skeletal muscle, kidneys, liver, intestinal tract, lungs, spleen, and brain; crosses the placental membrane and is found in breast milk.

Metabolism

Virtually all converted into glucuronide metabolites; small fraction is demethylated in the liver. Major metabolite is morphine-3-glucuronide (55% to 75%).

Elimination

The t ½ is approximately 2 to 4 h.

Onset

Onset is 15 to 60 min (intrathecal/epidural).

Duration

Duration is 3 to 7 h.

Indications and Usage

Relief of moderate to severe acute and chronic pain; relief of pain in patients who require opioid analgesics for more than a few days (sustained-release only); management of pain not responsive to nonnarcotic analgesics; dyspnea associated with acute left ventricular failure and pulmonary edema; preoperative sedation; adjunct to anesthesia; analgesia during labor.

Contraindications

Hypersensitivity to opiates; upper airway obstruction; acute asthma; diarrhea caused by poisoning or toxins.

Injection

Heart failure secondary to chronic lung disease; cardiac arrhythmias; brain tumor; acute alcoholism; delirium tremens; idiosyncrasy to the drug; convulsive states (eg, status epilepticus, tetanus, strychnine poisoning).

Immediate-release oral solution

Respiratory insufficiency; severe CNS depression; heart failure secondary to chronic lung disease; cardiac arrhythmias; increased intracranial or cerebrospinal pressure; head injuries; brain tumor; acute alcoholism; delirium tremens; convulsive disorders; after biliary tract surgery; suspected surgical abdomen; surgical anastomosis; idiosyncrasy to the drug; concomitantly with MAOIs or within 14 days of such treatment.

Intrathecal/epidural

Infection at injection site; anticoagulation; bleeding condition; parenteral corticosteroids within past 2 wk; any other drug or condition that would contraindicate intrathecal/epidural therapy.

Dosage and Administration

Adults

PO 10 to 30 mg every 4 h as needed. Subcutaneous/IM 5 to 20 mg/70 kg every 4 h as needed. IV 2.5 to 15 mg per 70 kg in water for injection 4 to 5 mL over 5 min as needed. IV (open-heart surgery) 0.5 to 3mg/kg. IV (MI pain) 8 to 15 mg; for very severe pain, additional smaller doses may be given every 3 to 4 h. PR 10 to 20 mg every 4 h as needed. Epidural Initial injection of 5 mg may provide pain relief for up to 24 h; if pain is not controlled within 1 h, give incremental doses of 1 to 2 mg. Do not exceed 10mg per 24h. Intrathecal Usual dose is 10% of epidural dose. Single injection of 0.2 to 1 mg may provide pain relief for 24 h. Do not inject more than 2 mL of 5 mg per 10 mL ampule or 1 mL of 10 mg per 10 mL ampule. Repeat injections not recommended.

Children

Subcutaneous/IM 0.1 to 0.2 mg/kg every 4 h.

Max dose

15 mg.

Storage/Stability

Store at room temperature (59° to 86°F).

Drug Interactions

Morphine has the following interaction information:

Esmolol morphine possibly increases plasma concentration of esmolol
Ritonavir plasma concentration of morphine possibly reduced by ritonavir
Morphine belongs to Opioid Analgesics and will have the following interactions:

Alcohol enhanced hypotensive and sedative effects when opioid analgesics given with alcohol
Antidepressants, Tricyclic sedative effects possibly increased when opioid analgesics given with tricyclics
Antipsychotics enhanced hypotensive and sedative effects when opioid analgesics given with antipsychotics Increased risk of toxicity with myelosuppressive drugs
Anxiolytics and Hypnotics increased sedative effect when opioid analgesics given with anxiolytics and hypnotics
Cimetidine metabolism of opioid analgesics inhibited by cimetidine (increased plasma concentration)
Ciprofloxacin avoidance of premedication with opioid analgesics advised by manufacturer of ciprofloxacin (reduced plasma concentration of ciprofloxacin) when ciprofloxacin used for surgical prophylaxis
Domperidone opioid analgesics antagonise effects of domperidone on gastro-intestinal activity
MAOIs possible CNS excitation or depression (hypertension or hypotension) when opioid analgesics given with MAOIs —avoid concomitant use and for 2 weeks after stopping MAOIs For interactions of reversible MAO-A inhibitors (RIMAs) see Moclobemide, and for interactions of MAO-B inhibitors see Rasagiline and Selegiline; the antibacterial Linezolid is a reversible, non-selective MAO inhibitor
Metoclopramide opioid analgesics antagonise effects of metoclopramide on gastro-intestinal activity
Mexiletine opioid analgesics delay absorption of mexiletine
Moclobemide possible CNS excitation or depression (hypertension or hypotension) when opioid analgesics given with moclobemide
Sodium Oxybate opioid analgesics enhance effects of sodium oxybate (avoid concomitant use)

Adverse Reactions

Cardiovascular

Hypotension; orthostatic hypotension; bradycardia; tachycardia; palpitations.

CNS

Lightheadedness; dizziness; drowsiness; sedation; euphoria; dysphoria; delirium; disorientation; incoordination.

Dermatologic

Sweating; pruritus; urticaria.

EENT

Blurred vision; miosis.

GI

Nausea; vomiting; constipation; abdominal pain.

Genitourinary

Urinary retention or hesitancy.

Respiratory

Respiratory depression; apnea; respiratory arrest; laryngospasm; depression of cough reflex.

Miscellaneous

Tolerance; psychological and physical dependence with chronic use; pain at injection site; local irritation and induration following subcutaneous use.

Precautions

Warnings

Monitor patient for at least 24 h after initial dose because of reports of severe adverse reactions with epidural/intrathecal use. Improper substitution of Infumorph for regular Duramorph may result in serious overdose.

Pregnancy

Category C

Lactation

Excreted in breast milk.

Children

Safety and efficacy not established.

Elderly

Dosage reduction may be necessary.

Labor and Delivery

Therapeutic morphine doses have increased duration of labor.

Renal Function

May need to reduce dose.

Hepatic Function

May need to reduce dose.

Special Risk Patients

Use drug with caution in patients with myxedema, acute alcoholism, acute abdominal conditions, ulcerative colitis, decreased respiratory reserve, head injury or increased intracranial pressure, hypoxia, supraventricular tachycardia, depleted blood volume or circulatory shock.

Asthma and other respiratory conditions

Bisulfites and morphine may potentiate each other, preventing use by cause severe adverse reactions.

Drug dependence

Has abuse potential.

Overdosage

Symptoms

Miosis, respiratory and CNS depression, circulatory collapse, seizures, cardiopulmonary arrest, death.

Patient Information

* Instruct patient to take oral preparations with food or juice if GI upset occurs.
* Tell patient not to crush or chew controlled-release tablets.
* Explain that full effectiveness of drug may not occur for 30 to 60 min after administration. Emphasize that drug is more effective if taken regularly to prevent pain rather than to treat pain after it occurs.
* If patient is to receive patient-controlled analgesia (PCA), instruct on use of PCA pump.
* Explain that physical dependency may occur with long-term therapy and that dosage will be tapered slowly before stopping to prevent withdrawal symptoms (nausea, vomiting, cramps, fever, faintness, anorexia).
* Encourage patient to turn, cough and breathe deeply every 2 h to prevent atelectasis.
* Advise patient to consult with health care provider if excessive sedation occurs or if pain relief is inadequate.
* Inform patient that drug may cause constipation. Stool softener, fiber laxative, increased fluid intake and bulk in diet may help alleviate problem.
* Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
* Instruct patient to avoid intake of alcoholic beverages and other CNS depressants.
* Advise patient that drug may cause drowsiness, dizziness or blurred vision and to use caution while driving or performing other tasks requiring mental alertness.

Imipramine

2009-07-26T22:47:00.001-07:00

Pronunciation: (im-IPP-ruh-meen)

Class: Tricyclic compound Imipramine Hydrochloride

Trade Names:

Tofranil

- Tablets 10 mg

- Tablets 25 mg

- Tablets 50 mg

Apo-Imipramine (Canada)

Imipramine Pamoate

Trade Names:

Tofranil-PM

- Capsules 75mg

- Capsules 100mg

- Capsules 125mg

- Capsules 150mg

Pharmacology

Inhibits reuptake of norepinephrine and, to a lesser degree, serotonin in CNS.

Pharmacokinetics

Absorption

T max is 2 to 4 h. Steady state is reached in 2 to 5 days.

Distribution

More than 90% is protein bound. Lipid soluble.

Metabolism

Significant first pass effect. Metabolism occurs in liver. Active metabolite is desipramine.

Elimination

The t ½ is 11 to 25 h.

Peak

2 to 4 weeks.

Indications and Usage

Relief of symptoms of depression; treatment of enuresis in children 6 yr and older.

Unlabeled Uses

Treatment of chronic pain, panic disorder, eating disorders (bulimia nervosa), and facilitation of cocaine withdrawal.

Contraindications

Hypersensitivity to any tricyclic antidepressant. Generally not to be given in combination with or within 14 days of treatment with MAO inhibitor or during acute recovery phase of MI; cross-sensitivity may occur among the dibenzazepines.

Dosage and Administration

Depression

Use parenterally only in patients who are not able or not willing to take oral medication. Give via IM route. Do not administer IV. Up to 100 mg/day in divided doses may be given IM. Switch to oral as soon as possible.

Adults

PO 100 to 300 mg/day, in divided doses or once daily at bedtime.

Elderly & Adolescents

PO 30 to 40mg/day; may increase up to 100 mg/day.

Children

PO 1.5 mg/kg/day in divided doses; up to maximum of 5 mg/kg/day.

Childhood Enuresis (6 yr)

PO 25 mg/day given 1 h before bedtime; if response unsatisfactory after 1 wk, may increase to 50 mg in children younger than 12 yr of age. Children older than 12 yr of age may receive 75 mg/night. Do not exceed 2.5 mg/kg/day.

Drug Interactions

Cimetidine metabolism of imipramine inhibited by cimetidine (increased plasma concentration)
Diltiazem plasma concentration of imipramine increased by diltiazem
Labetalol plasma concentration of imipramine increased by labetalol
Propranolol plasma concentration of imipramine increased by propranolol
Terbinafine plasma concentration of imipramine possibly increased by terbinafine
Thyroid Hormones effects of imipramine enhanced by thyroid hormones
Verapamil plasma concentration of imipramine increased by verapamil
Imipramine belongs to Antidepressants, Tricyclic and will have the following interactions:

Adrenaline (epinephrine) increased risk of hypertension and arrhythmias when tricyclics given with adrenaline (epinephrine) (but local anaesthetics with adrenaline appear to be safe)
Adrenergic Neurone Blockers tricyclics antagonise hypotensive effect of adrenergic neurone blockers
Alcohol increased sedative effect when tricyclics given with alcohol
Amiodarone increased risk of ventricular arrhythmias when tricyclics given with amiodarone —avoid concomitant use Amiodarone has a long half-life; there is a potential for drug interactions to occur for several weeks (or even months) after treatment with it has been stopped
Amprenavir side-effects of tricyclics possibly increased by amprenavir
Anaesthetics, General increased risk of arrhythmias and hypotension when tricyclics given with general anaesthetics See also Surgery and Long-term Medication, section 15.1
Antidepressants, SSRI plasma concentration of some tricyclics increased by SSRIs
Antiepileptics tricyclics antagonise anticonvulsant effect of antiepileptics (convulsive threshold lowered)
Antihistamines increased antimuscarinic and sedative effects when tricyclics given with antihistamines Sedative interactions apply to a lesser extent to the non-sedating antihistamines. Interactions do not generally apply to antihistamines used for topical action (including inhalation)
Antimuscarinics increased risk of antimuscarinic side-effects when tricyclics given with antimuscarinics Many drugs have antimuscarinic effects; concomitant use of two or more such drugs can increase side-effects such as dry mouth, urine retention, and constipation; concomitant use can also lead to confusion in the elderly. Interactions do not generally apply to antimuscarinics used by inhalation
Antipsychotics plasma concentration of tricyclics increased by antipsychotics —possibly increased risk of ventricular arrhythmias Increased risk of toxicity with myelosuppressive drugs
Anxiolytics and Hypnotics increased sedative effect when tricyclics given with anxiolytics and hypnotics
Apraclonidine avoidance of tricyclics advised by manufacturer of apraclonidine
Atomoxetine increased risk of ventricular arrhythmias when tricyclics given with atomoxetine
Baclofen tricyclics enhance muscle relaxant effect of baclofen
Barbiturates tricyclics antagonises anticonvulsant effect of barbiturates (convulsive threshold lowered), also metabolism of tricyclics possibly accelerated (reduced plasma concentration)
Brimonidine avoidance of tricyclics advised by manufacturer of brimonidine
Carbamazepine metabolism of tricyclics accelerated by carbamazepine (reduced plasma concentration and reduced effect)
Cimetidine plasma concentration of tricyclics possibly increased by cimetidine
Clonidine tricyclics antagonise hypotensive effect of clonidine , also increased risk of hypertension on clonidine withdrawal
Clozapine possibly increased antimuscarinic side-effects when tricyclics given with clozapine Avoid concomitant use of clozapine with drugs that have a substantial potential for causing agranulocytosis
Coumarins tricyclics may enhance or reduce anticoagulant effect of coumarins Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Diltiazem plasma concentration of tricyclics possibly increased by diltiazem
Disopyramide increased risk of ventricular arrhythmias when tricyclics given with disopyramide
Disulfiram metabolism of tricyclics inhibited by disulfiram (increased plasma concentration)
Diuretics increased risk of postural hypotension when tricyclics given with diuretics
Entacapone caution with tricyclics advised by manufacturer of entacapone
Flecainide increased risk of ventricular arrhythmias when tricyclics given with flecainide
Lithium risk of toxicity when tricyclics given with lithium
MAOIs increased risk of hypertension and CNS excitation when tricyclics given with MAOIs , tricyclics should not be started until 2 weeks after stopping MAOIs (3 weeks if starting clomipramine or imipramine), also MAOIs should not be started for at least 1–2 weeks after stopping tricyclics (3 weeks in the case of clomipramine or imipramine) For interactions of reversible MAO-A inhibitors (RIMAs) see Moclobemide, and for interactions of MAO-B inhibitors see Rasagiline and Selegiline; the antibacterial Linezolid is a reversible, non-selective MAO inhibitor
Methylphenidate metabolism of tricyclics possibly inhibited by methylphenidate
Moclobemide after stopping tricyclics do not start moclobemide for at least 1 week
Moxifloxacin increased risk of ventricular arrhythmias when tricyclics given with moxifloxacin —avoid concomitant use
Nefopam side-effects possibly increased when tricyclics given with nefopam
Nicorandil tricyclics possibly enhance hypotensive effect of nicorandil
Nitrates tricyclics reduce effects of sublingual tablets of nitrates (failure to dissolve under tongue owing to dry mouth)
Noradrenaline (norepinephrine) increased risk of hypertension and arrhythmias when tricyclics given with noradrenaline (norepinephrine)
Oestrogens antidepressant effect of tricyclics antagonised by oestrogens (but side-effects of tricyclics possibly increased due to increased plasma concentration) Interactions of combined oral contraceptives may also apply to combined contraceptive patches; in case of hormone replacement therapy low dose unlikely to induce interactions
Opioid Analgesics sedative effects possibly increased when tricyclics given with opioid analgesics
Pentamidine Isetionate increased risk of ventricular arrhythmias when tricyclics given with pentamidine isetionate
Phenothiazines increased risk of antimuscarinic side-effects when tricyclics given with phenothiazines
Phenytoin plasma concentration of tricyclics possibly reduced by phenytoin
Pimozide increased risk of ventricular arrhythmias when tricyclics given with pimozide —avoid concomitant use
Primidone tricyclics antagonises anticonvulsant effect of primidone (convulsive threshold lowered), also metabolism of tricyclics possibly accelerated (reduced plasma concentration)
Procainamide increased risk of ventricular arrhythmias when tricyclics given with procainamide
Propafenone increased risk of arrhythmias when tricyclics given with propafenone
Rasagiline increased risk of CNS toxicity when tricyclics given with rasagiline Rasagiline is a MAO-B inhibitor
Rifampicin plasma concentration of tricyclics possibly reduced by rifampicin
Ritonavir plasma concentration of tricyclics possibly increased by ritonavir
Selegiline CNS toxicity reported when tricyclics given with selegiline Selegiline is a MAO-B inhibitor
Sibutramine increased risk of CNS toxicity when tricyclics given with sibutramine (manufacturer of sibutramine advises avoid concomitant use)
Sodium Oxybate increased risk of side-effects when tricyclics given with sodium oxybate
Sotalol increased risk of ventricular arrhythmias when tricyclics given with sotalol
Thyroid Hormones effects of tricyclics possibly enhanced by thyroid hormones
Tramadol increased risk of CNS toxicity when tricyclics given with tramadol
Verapamil plasma concentration of tricyclics possibly increased by verapamil
Imipramine belongs to Antidepressants and will have the following interactions:

Artemether with Lumefantrine avoidance of antidepressants advised by manufacturer of artemether/lumefantrine
Atomoxetine possible increased risk of convulsions when antidepressants given with atomoxetine

Adverse Reactions

Cardiovascular

Orthostatic hypotension; hypertension; tachycardia; palpitations; arrhythmias; ECG changes; stroke; heartblock; CHF.

CNS

Confusion; hallucinations; delusions; nervousness; restlessness; agitation; panic; insomnia; nightmares; mania; exacerbation of psychosis; drowsiness; dizziness; weakness; numbness; extrapyramidal symptoms; emotional lability; seizures; tremors.

Dermatologic

Rash; pruritus; photosensitivity reaction; dry skin; acne; itching.

EENT

Nasal congestion; tinnitus; conjunctivitis; mydriasis; blurred vision; increased IOP.

GI

Nausea; vomiting; anorexia; GI distress; diarrhea; flatulence; peculiar taste in mouth; dry mouth; constipation.

Genitourinary

Impotence; sexual dysfunction; nocturia; urinary frequency; UTI; vaginitis; cystitis; dysmenorrhea; amenorrhea; urinary retention and hesitancy.

Hematologic

Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia; leukopenia.

Hepatic

Hepatitis; jaundice.

Metabolic

Elevation or depression of blood sugar.

Respiratory

Pharyngitis; rhinitis; sinusitis; laryngitis; coughing.

Miscellaneous

Breast enlargement.

Precautions

Pregnancy

Category D .

Lactation

Excreted in breast milk.

Children

Safety and efficacy of imipramine as temporary adjunctive therapy for nocturnal enuresis in pediatric patients younger than 6 yr have not been established; chronic use in patients 6yr and older has not been established. Do not exceed 2.5 mg/kg/day.

Special Risk Patients

Use with caution in patients with history of seizures, urinary retention, ureteral spasm, angle-closure glaucoma or increased IOP, conduction disorders, with hyperthyroid or those receiving thyroid medication, hepatic or renal impairment, schizophrenia or paranoia.

Hazardous Tasks

Patients should use caution while performing tasks requiring alertness.

Cardiovascular disorders

Use with extreme caution in patients with cardiovascular disorders. These patients require cardiac surveillance at all dose levels of the drug.
Overdosage

Symptoms

Confusion, agitation, hallucinations, seizures, status epilepticus, clonus, choreoathetosis, hyperactive reflexes, positive Babinski sign, coma, cardiac arrhythmias, renal failure, flushing, dry mouth, dilated pupils, hyperpyrexia.

Patient Information

* Warn patient of risk of seizure.
* Tell female patient to inform health care provider if becoming or intending to become pregnant.
* Explain that it may be several weeks before a response is noticed.
* Instruct patient to avoid intake of alcoholic beverages or other CNS depressants.
* Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.
* Caution patient to avoid exposure to sunlight and to use sunscreen or wear protective clothing to avoid photosensitivity reaction.
* Teach patient to avoid sudden position changes to prevent orthostatic hypertension.
* Inform patient that dizziness, dry mouth (suggest taking frequent sips of water, sucking on ice chips, or sugarless hard candy or chewing sugarless gum), drowsiness, or constipation may occur, but that these side effects often subside with time.
* Instruct patient to report all problems to health care provider, including dizziness, drowsiness, dry mouth, constipation, or weight gain.

Furosemide

2009-07-26T22:44:00.000-07:00

Pronunciation: (fyu-ROH-se-mide)

Class: Loop diuretic

Trade Names:
Lasix
- Tablets 20 mg
- Tablets 40 mg
- Tablets 80 mg
- Oral solution 8 mg/mL
- Oral solution 10 mg/mL
- Injection 10 mg/mL
Apo-Furosemide (Canada)
Furosemide Special (Canada)
Lasix Special (Canada)
Pharmacology
Inhibits reabsorption of sodium and chloride in proximal and distal tubules and loop of Henle.

Pharmacokinetics

Absorption

Mean bioavailability is 64% with the tablet and 60% with the oral solution.

Distribution

Protein binding is 91% to 99% (albumin).

Metabolism

The major metabolite is furosemide glucuronide.

Elimination

The t 1/ 2 is about 2 h; furosemide is excreted in urine.

Onset

PO 1 h, IV 5 min.
Peak

PO 1 to 2 h, IV 30 min.
Duration

PO 6 to 8 h, IV 2 h.
Indications and Usage

Adjunctive therapy in acute pulmonary edema, edema associated with CHF, hepatic cirrhosis, and renal disease ( IV only); hypertension ( PO only)
.
Contraindications

Hypersensitivity to any component of the product; anuria.

Dosage and Administration

Acute Pulmonary Edema

Adults

IV 40 mg (over 1 to 2 min). If response not satisfactory within 1 h, increase to 80 mg.

Infants and Children

IV/IM Usual initial dose: 1 mg/kg. If response not satisfactory, may increase by 1 mg/kg not sooner than 2 h after previous dose. Max dose: 6 mg/kg. Premature infant's max dose: 1 mg/kg/day.
Edema

Adults

PO Usual initial dose: 20 to 80 mg/day as a single dose may repeat 6 to 8 h later if needed; may titrate up to 600 mg/day. Maintenance: Give determined single dose once or twice daily (8 AM and 2 PM). IV/IM 20 to 40 mg over 1 to 2 min. Repeat 2 h later if needed.
Children

PO Usual initial dose: 2 mg/kg as a single dose. May increase by 1 or 2 mg/kg 6 to 8 h later if needed. Max dose: 6 mg/kg.
Hypertension

Adults

PO 40 mg twice daily.

General Advice

* Tablets and oral solution
* Administer without regard to meals. Administer with food if GI upset occurs.
* Do not use tablets that are discolored.
* Measure and administer prescribed dose of oral solution using supplied dosing cup, calibrated dosing syringe, or calibrated dosing spoon.

* Injection
* For IM or IV administration only. Not for intradermal, subcutaneous, or intra-arterial administration.
* Administer IV injection of usual doses (eg, 20 to 80 mg) over 1 to 2 min.
* For high-dose IV therapy, dilute prescribed dose of furosemide in sodium chloride 0.9% injection, Ringers lactate injection, or dextrose 5% injection (after adjusting pH to more than 5.5) and administer at controlled infusion rate not more than 4 mg/min.
* Furosemide injection precipitates at pH values less than 7. Ensure that pH of prepared infusion solution is in neutral to weakly alkaline range. Do not administer furosemide through infusion line containing acidic solution or acidic drugs.
* Do not administer if particulate matter, cloudiness, or discoloration is noted.

Storage/Stability

Store tablets, oral solution, and injection at controlled room temperature (59° to 86°F). Protect from light. Protect tablets from moisture. Protect injection from freezing.

Drug Interactions

Furosemide (frusemide) has the following interaction information:

Chloral administration of parenteral furosemide (frusemide) with chloral may displace thyroid hormone from binding sites
Metolazone profound diuresis possible when furosemide (frusemide) given with metolazone
Phenytoin effects of furosemide (frusemide) antagonised by phenytoin
Triclofos administration of parenteral furosemide (frusemide) with triclofos may displace thyroid hormone from binding sites
Furosemide (frusemide) belongs to Diuretics, Loop and will have the following interactions:

Acetazolamide increased risk of hypokalaemia when loop diuretics given with acetazolamide
Aminoglycosides increased risk of otoxicity when loop diuretics given with aminoglycosides
Amiodarone hypokalaemia caused by loop diuretics increases cardiac toxicity with amiodarone Amiodarone has a long half-life; there is a potential for drug interactions to occur for several weeks (or even months) after treatment with it has been stopped
Amphotericin increased risk of hypokalaemia when loop diuretics given with amphotericin Close monitoring required with concomitant administration of nephrotoxic drugs or cytotoxics
Antidiabetics loop diuretics antagonise hypoglycaemic effect of antidiabetics
Cardiac Glycosides hypokalaemia caused by loop diuretics increases cardiac toxicity with cardiac glycosides
Corticosteroids increased risk of hypokalaemia when loop diuretics given with corticosteroids Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified
Disopyramide hypokalaemia caused by loop diuretics increases cardiac toxicity with disopyramide
Diuretics, Thiazide and related increased risk of hypokalaemia when loop diuretics given with thiazides and related diuretics
Flecainide hypokalaemia caused by loop diuretics increases cardiac toxicity with flecainide
Lidocaine (lignocaine) hypokalaemia caused by loop diuretics antagonises action of lidocaine (lignocaine) Interactions less likely when lidocaine used topically
Lithium loop diuretics reduce excretion of lithium (increased plasma concentration and risk of toxicity)—loop diuretics safer than thiazides
Mexiletine hypokalaemia caused by loop diuretics antagonises action of mexiletine
Polymyxins increased risk of otoxicity when loop diuretics given with polymyxins
Reboxetine possible increased risk of hypokalaemia when loop diuretics given with reboxetine
Sotalol hypokalaemia caused by loop diuretics increases risk of ventricular arrhythmias with sotalol
Sympathomimetics, Beta2 increased risk of hypokalaemia when loop diuretics given with high doses of beta2 sympathomimetics —for CSM advice (hypokalaemia) see section 3.1.1.1
Theophylline increased risk of hypokalaemia when loop diuretics given with theophylline
Vancomycin increased risk of otoxicity when loop diuretics given with vancomycin
Furosemide (frusemide) belongs to Diuretics and will have the following interactions:

ACE Inhibitors enhanced hypotensive effect when diuretics given with ACE inhibitors
Adrenergic Neurone Blockers enhanced hypotensive effect when diuretics given with adrenergic neurone blockers
Alcohol enhanced hypotensive effect when diuretics given with alcohol
Aldesleukin enhanced hypotensive effect when diuretics given with aldesleukin
Alpha-blockers enhanced hypotensive effect when diuretics given with alpha-blockers , also increased risk of first-dose hypotension with post-synaptic alpha-blockers such as prazosin
Alprostadil enhanced hypotensive effect when diuretics given with alprostadil
Amisulpride hypokalaemia caused by diuretics increases risk of ventricular arrhythmias with amisulpride
Anaesthetics, General enhanced hypotensive effect when diuretics given with general anaesthetics See also Surgery and Long-term Medication, section 15.1
Angiotensin-II Receptor Antagonists enhanced hypotensive effect when diuretics given with angiotensin-II receptor antagonists
Antidepressants, Tricyclic increased risk of postural hypotension when diuretics given with tricyclics
Anxiolytics and Hypnotics enhanced hypotensive effect when diuretics given with anxiolytics and hypnotics
Atomoxetine hypokalaemia caused by diuretics increases risk of ventricular arrhythmias with atomoxetine
Baclofen enhanced hypotensive effect when diuretics given with baclofen
Beta-blockers enhanced hypotensive effect when diuretics given with beta-blockers Since systemic absorption may follow topical application of beta-blockers to the eye the possibility of interactions, in particular, with drugs such as verapamil should be borne in mind
Calcium-channel Blockers enhanced hypotensive effect when diuretics given with calcium-channel blockers Dihydropyridine calcium-channel blockers include amlodipine, felodipine, isradipine, lacidipine, lercanidipine, nicardipine, nifedipine, nimodipine, and nisoldipine
Carbamazepine increased risk of hyponatraemia when diuretics given with carbamazepine
Clonidine enhanced hypotensive effect when diuretics given with clonidine
Corticosteroids diuretic effect of diuretics antagonised by corticosteroids Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified
Diazoxide enhanced hypotensive effect when diuretics given with diazoxide
Hydralazine enhanced hypotensive effect when diuretics given with hydralazine
Indometacin effects of diuretics antagonised by indometacin
Ketorolac effects of diuretics antagonised by ketorolac
Levodopa enhanced hypotensive effect when diuretics given with levodopa
Lymecycline avoidance of diuretics advised by manufacturer of lymecycline
MAOIs enhanced hypotensive effect when diuretics given with MAOIs For interactions of reversible MAO-A inhibitors (RIMAs) see Moclobemide, and for interactions of MAO-B inhibitors see Rasagiline and Selegiline; the antibacterial Linezolid is a reversible, non-selective MAO inhibitor
Methyldopa enhanced hypotensive effect when diuretics given with methyldopa
Minoxidil enhanced hypotensive effect when diuretics given with minoxidil
Moxisylyte (thymoxamine) enhanced hypotensive effect when diuretics given with moxisylyte
Moxonidine enhanced hypotensive effect when diuretics given with moxonidine
Nitrates enhanced hypotensive effect when diuretics given with nitrates
NSAIDs diuretics increase risk of nephrotoxicity of NSAIDs , also antagonism of diuretic effect See also Aspirin. Interactions do not generally apply to topical NSAIDs
Oestrogens diuretic effect of diuretics antagonised by oestrogens Interactions of combined oral contraceptives may also apply to combined contraceptive patches; in case of hormone replacement therapy low dose unlikely to induce interactions
Phenothiazines enhanced hypotensive effect when diuretics given with phenothiazines
Pimozide hypokalaemia caused by diuretics increases risk of ventricular arrhythmias with pimozide (avoid concomitant use)
Platinum Compounds increased risk of nephrotoxicity and ototoxicity when diuretics given with platinum compounds
Sertindole hypokalaemia caused by diuretics increases risk of ventricular arrhythmias with sertindole
Sodium Nitroprusside enhanced hypotensive effect when diuretics given with sodium nitroprusside
Tizanidine enhanced hypotensive effect when diuretics given with tizanidine

Adverse Reactions

Cardiovascular

Chronic aortitis; orthostatic hypotension; thrombophlebitis.
CNS

Dizziness; fever; headache; paresthesia; restlessness; vertigo.
Dermatologic

Erythema multiforme; exfoliative dermatitis; local irritation and pain with parenteral use; necrotizing angiitis; photosensitivity; pruritus; purpura; rash; systemic vasculitis; urticaria.
EENT

Blurred vision; hearing impairment; tinnitus; xanthopsia (yellow vision).
GI

Anorexia; constipation; cramping; diarrhea; nausea; oral and gastric irritation; pancreatitis; vomiting.
Genitourinary

Glycosuria; interstitial nephritis; urinary bladder spasm.
Hematologic

Anemia, hemolytic anemia, leukopenia, thrombocytopenia; aplastic anemia, agranulocytosis (rare).
Hepatic

Jaundice.
Metabolic

Hyperglycemia; hyperuricemia; hypokalemia; metabolic alkalosis.
Miscellaneous

Muscle spasm; weakness.
Precautions
Monitor

Monitor for possible occurrence of blood dyscrasia and liver damage. Monitor urine and blood glucose in diabetes. Frequently monitor serum electrolytes, magnesium, calcium, CO 2 , uric acid, and renal function early in therapy and periodically thereafter during active diuresis. Assess patients for signs or symptoms of fluid or electrolyte imbalance.

Pregnancy

Category C .
Lactation

Excreted in breast milk.
Children

May increase incidence of patent ductus arteriosus in premature infants with respiratory distress syndrome, especially in first few weeks of life.
Hypersensitivity

Patients with known sulfonamide sensitivity may show allergic reactions to furosemide.
Renal Function

Discontinue if increasing azotemia and oliguria occur during treatment of severe progressive renal disease.
Photosensitivity

May occur.
Dehydration

Excessive diuresis may cause dehydration and decreased blood volume with circulatory collapse and possible vascular thrombosis and embolism, especially in elderly cardiac patients.
Diarrhea

Furosemide solution vehicle contains sorbitol and may induce diarrhea, especially in children.
Glucose intolerance

May increase blood glucose; precipitation of diabetes mellitus has been reported rarely.
Hepatic cirrhosis

Sudden alterations of electrolyte balance may precipitate hepatic and coma; monitor carefully.
Hyperuricemia/gout

Asymptomatic hyperuricemia can occur; gout may rarely be precipitated.
Ototoxicity (deafness, tinnitus, vertigo)

Associated with rapid injection, severe renal impairment, very large doses, or concurrent use of other ototoxic drugs. Usually reversible within 1 to 24 h, but may be permanent in some patients. Infusion rates not exceeding 4 mg/min may reduce risk.
Systemic lupus erythematosus

May be exacerbated or activated.

Overdosage

Symptoms

Dehydration, electrolyte imbalance, hypochloremic alkalosis, hypokalemia, hypotension, reduction of blood volume.

Patient Information

* Injection
* Advise patient or caregiver that injection is used when a rapid onset of diuresis is needed, when GI absorption is impaired, or when taking oral medications is not practical, and that conversion to oral therapy will be made as soon as possible.

* Tablets and oral solution
* Advise patient to take prescribed dose without regard to meals but to take with food if stomach upset occurs.
* Advise patient or caregiver using oral solution to measure and administer prescribed dose using supplied dosing cup, calibrated dosing syringe, or calibrated dosing spoon.
* Advise patient that medication will increase urination and not to take before bedtime or before activities in which increased urination would be a problem. Instruct patient that if dose is delayed to take the dose later in the day to prevent interference with activities. Caution patient not to skip doses.
* Caution patient not to change the dose or stop taking unless advised by health care provider.
* Ensure patient understands how to implement fluid and salt restriction if prescribed as part of therapeutic regimen.
* Instruct patient to lie or sit down if they experience dizziness or lightheadedness when standing.
* Caution patient that inadequate fluid intake, excessive perspiration, diarrhea, or vomiting can lead to excessive fall in BP resulting in lightheadedness or fainting.
* Instruct diabetic patient to monitor blood glucose more frequently when drug is started or dose is changed and to inform health care provider of significant changes in readings.
* Caution patient to avoid unnecessary exposure to UV light (sunlight, tanning booths) and to use sunscreen and wear protective clothing when exposed to UV light until tolerance is determined.
* Advise women to notify health care provider if pregnant, planning to become pregnant, or breastfeeding.
* Instruct patient to inform health care provider if any of the following occur: muscle pain, weakness, or cramps; persistent nausea or vomiting; diarrhea; excessive thirst; unexplained tiredness; drowsiness; dizziness or feeling of the room spinning; ringing in the ears or decreased hearing; confusion or changes in thinking; increased heart rate; unexplained joint pain; abnormal skin sensations.

Digoxin

2009-07-26T22:43:00.000-07:00

Pronunciation: (dih-JOX-in)

Class: Cardiac glycoside

Trade Names:

Digoxin

- Elixir, pediatric 0.05 mg/mL

Trade Names:
Lanoxicaps

- Capsules 0.1 mg

Trade Names:

Lanoxin

- Tablets 0.125 mg

- Tablets 0.25 mg

- Injection 0.25 mg/mL

- Injection, pediatric 0.1 mg/mL

Apo-Digoxin (Canada)

Digoxin Injection C.S.D. (Canada)

Digoxin Pediatric Injection C.S.D. (Canada)

PMS-Digoxin (Canada)

Pharmacology

Increases force and velocity of myocardial systolic contraction (positive inotropic action), slows heart rate, and decreases conduction through atrioventricular node.
Pharmacokinetics

Absorption

Bioavailability

100% (IV), 90% to 100% (capsules), 70% to 85% (elixir), 60% to 80% (tablets). T max is 1 to 3 h (oral). Food slows the rate of absorption after oral administration.

Distribution

6 to 8 h tissue distribution phase. Large apparent Vd. Crosses blood-brain barrier and placenta. Excreted in breast milk. Approximately 25% protein bound.

Metabolism

Approximately 16% metabolized; metabolites formed by hydrolysis, oxidation, and conjugation.

Elimination

Elimination follows first-order kinetics. 50% to 70% excreted unchanged in the urine (after IV administration). t ½ is 1.5 to 2 days.

Onset

0.5 to 2 h (oral), 5 to 30 min (IV).

Peak

2 to 6 h (oral), 1 to 4 h (IV).

Special Populations

Renal Function Impairment

Cl correlates with CrCl. Dosage adjustment recommended.

Indications and Usage

Treatment of CHF, atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia, cardiogenic shock.

Contraindications

Ventricular fibrillation; ventricular tachycardia except in certain cases; digitalis toxicity; beriberi heart disease; hypersensitivity to digoxin; some cases of hypersensitive carotid sinus syndrome.

Dosage and Administration

Rapid digitalization with loading dose

Adults

IV 0.4 to 0.6 mg or PO tablets 0.5 to 0.75 mg or capsules 0.4 to 0.6 mg in previously undigitalized patients; additional doses may be given cautiously at 6 to 8 h intervals ( IV 0.1 to 0.3 mg or PO tablets 0.125 to 0.375 mg or capsules 0.1 to 0.3 mg) until clinical response is achieved; thereafter adjust dosage based on levels (usual range 0.125 to 0.5 mg/day as single daily dose). In previously digitalized patients, adjust dosage in proportion to ratio of desired vs current serum levels.

Infants and children

Individualize dosage. Usual doses in children are listed at end of section.

General Advice

* For IV administration, digoxin injection may be diluted (up to 4-fold) with normal saline, D5W, or sterile water for injection. Infuse slowly, over 5 min or longer.
* Do not mix digoxin solution with other drugs.

Drug Interactions

Acarbose plasma concentration of digoxin possibly reduced by acarbose
Alprazolam plasma concentration of digoxin increased by alprazolam (increased risk of toxicity)
Amiodarone plasma concentration of digoxin increased by amiodarone (halve dose of digoxin) Amiodarone has a long half-life; there is a potential for drug interactions to occur for several weeks (or even months) after treatment with it has been stopped
Antacids absorption of digoxin possibly reduced by antacids Antacids should preferably not be taken at the same time as other drugs since they may impair absorption
Atorvastatin plasma concentration of digoxin possibly increased by atorvastatin
Captopril plasma concentration of digoxin possibly increased by captopril
Chloroquine and Hydroxychloroquine plasma concentration of digoxin possibly increased by chloroquine and hydroxychloroquine
Ciclosporin plasma concentration of digoxin increased by ciclosporin (increased risk of toxicity)
Cytotoxics absorption of digoxin tablets reduced by cytotoxics
Darifenacin plasma concentration of digoxin possibly increased by darifenacin
Diltiazem plasma concentration of digoxin increased by diltiazem
Gentamicin plasma concentration of digoxin possibly increased by gentamicin
Itraconazole plasma concentration of digoxin increased by itraconazole
Lercanidipine plasma concentration of digoxin increased by lercanidipine
Macrolides plasma concentration of digoxin increased by macrolides (increased risk of toxicity) See also Telithromycin
Mefloquine possible increased risk of bradycardia when digoxin given with mefloquine
Neomycin absorption of digoxin reduced by neomycin
Nicardipine plasma concentration of digoxin increased by nicardipine
Nifedipine plasma concentration of digoxin possibly increased by nifedipine
Penicillamine plasma concentration of digoxin possibly reduced by penicillamine
Phenytoin plasma concentration of digoxin possibly reduced by phenytoin
Prazosin plasma concentration of digoxin increased by prazosin
Propafenone plasma concentration of digoxin increased by propafenone (halve dose of digoxin)
Proton Pump Inhibitors plasma concentration of digoxin possibly slightly increased by proton pump inhibitors
Quinine plasma concentration of digoxin increased by quinine
Rifampicin plasma concentration of digoxin possibly reduced by rifampicin
Ritonavir plasma concentration of digoxin possibly increased by ritonavir
Salbutamol plasma concentration of digoxin possibly reduced by salbutamol
Sitagliptin plasma concentration of digoxin increased by sitagliptin
Spironolactone plasma concentration of digoxin increased by spironolactone
St John's Wort plasma concentration of digoxin reduced by St John's wort —avoid concomitant use
Sulfasalazine absorption of digoxin possibly reduced by sulfasalazine
Telithromycin plasma concentration of digoxin possibly increased by telithromycin
Telmisartan plasma concentration of digoxin increased by telmisartan
Trimethoprim plasma concentration of digoxin possibly increased by trimethoprim
Verapamil plasma concentration of digoxin increased by verapamil , also increased risk of AV block and bradycardia
Digoxin belongs to Cardiac Glycosides and will have the following interactions:

Acetazolamide increased cardiac toxicity with cardiac glycosides if hypokalaemia occurs with acetazolamide
Amphotericin increased cardiac toxicity with cardiac glycosides if hypokalaemia occurs with amphotericin Close monitoring required with concomitant administration of nephrotoxic drugs or cytotoxics
Beta-blockers increased risk of AV block and bradycardia when cardiac glycosides given with beta-blockers Since systemic absorption may follow topical application of beta-blockers to the eye the possibility of interactions, in particular, with drugs such as verapamil should be borne in mind
Calcium Salts arrhythmias can be precipitated when cardiac glycosides given with large intravenous doses of calcium salts see also Antacids
Colestipol absorption of cardiac glycosides possibly reduced by colestipol Other drugs should be taken at least 1 hour before or 4-6 hours after colestipol to reduce possible interference with absorption
Colestyramine absorption of cardiac glycosides possibly reduced by colestyramine Other drugs should be taken at least 1 hour before or 4-6 hours after colestyramine to reduce possible interference with absorption
Corticosteroids increased risk of hypokalaemia when cardiac glycosides given with corticosteroids Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified
Diuretics, Loop increased cardiac toxicity with cardiac glycosides if hypokalaemia occurs with loop diuretics
Diuretics, Thiazide and related increased cardiac toxicity with cardiac glycosides if hypokalaemia occurs with thiazides and related diuretics
NSAIDs plasma concentration of cardiac glycosides possibly increased by NSAIDs , also possible exacerbation of heart failure and reduction of renal function See also Aspirin. Interactions do not generally apply to topical NSAIDs
Sucralfate absorption of cardiac glycosides possibly reduced by sucralfate
Suxamethonium risk of ventricular arrhythmias when cardiac glycosides given with suxamethonium
Tizanidine possible increased risk of bradycardia when cardiac glycosides given with tizanidine

Adverse Reactions

Cardiovascular

Arrhythmias (supraventricular arrhythmias are more common in infants and children), including ventricular tachycardia and premature ventricular contractions.

CNS

Headache; weakness; apathy; drowsiness; mental depression; confusion; disorientation.

EENT

Visual disturbances (eg, blurred vision, halo effect).

GI

Anorexia; nausea; vomiting; diarrhea.

Precautions

Monitor

Monitor apical pulse for 1 full min before administering. Withhold dose and notify health care provider if pulse rate is less than 60 bpm in adult, less than 70 bpm in child, or less than 90 bpm in infant. Note signs of toxicity occur (eg, abdominal pain, anorexia, nausea, vomiting, visual disturbance, bradycardia, ECG changes, arrhythmias, headache, seizure). Be prepared to administer digoxin antibodies (digoxin-immune Fab) for severe overdose toxicity.

Pregnancy

Category C .

Lactation

Excreted in breast milk.

Children

Newborns show varying tolerance. Premature and immature infants are particularly sensitive; reduce and individualize dose as needed.

Elderly

Use with caution; renal Cl likely to be reduced.

Renal Function

Excretion may be decreased, leading to digoxin accumulation and toxicity; adjust dosage.

CV disease

Electrical conversion of arrhythmias may require dose reduction.

Digitalis toxicity

Anorexia, nausea, and vomiting may be associated with toxicity or CHF. Arrhythmias for which digoxin is indicated may also be a reflection of toxicity.

Electrolyte imbalance

Maintain normal serum potassium, calcium, and magnesium levels.

Lanoxicaps

Lanoxicaps have greater bioavailability than standard tablets. The 0.2 mg capsule is equivalent to 0.25 mg tablet; the 0.1 mg capsule to 0.125 mg tablet; the 0.05 mg capsule to 0.0625 mg tablet.
Usual Pediatric Digitalizing and Maintenance Dosages With Normal Renal Function Based on Lean Body Weight Age Digitalizing Dose (mcg/kg) Daily Maintenance Dose as % of Loading Dose (mcg/kg in 2 to 3 divided doses) PO IV Premature 20 to 30 15 to 25 20% to 30% Term 25 to 35 20 to 30 25% to 35% 1 to 24 mo 35 to 60 30 to 50 25% to 35% 2 to 5 yr 30 to 40 25 to 35 25% to 35% 5 to 10 yr 20 to 35 15 to 30 25% to 35% > 10 yr 10 to 15 8 to 12 25% to 35%

Overdosage

Symptoms

GI tract (eg, anorexia, nausea, vomiting, diarrhea); nervous system (eg, headache, weakness, apathy, drowsiness, visual disturbances such as blurred, yellow or green vision, halo effect), depression, confusion, restlessness, disorientation, seizures, EEG abnormalities, delirium, hallucinations, neuralgia and psychosis; cardiovascular system (eg, ventricular tachycardia, PVCs, paroxysmal and nonparoxysmal nodal rhythms, AV dissociation, accelerated nodal rhythm and premature atrial contraction with block, atrial fibrillation, ECG changes, all alterations in cardiac rate and rhythm). Conduction disturbances are common manifestations of toxicity in children.

Patient Information

* Instruct patient to take digoxin at same time each day to ensure steady-state dosing and to contact health care provider for instructions if dose is missed.
* Teach patient and family name, action, administration, adverse reactions, and toxic effects of particular digoxin preparation.
* Emphasize importance of regular follow-up exams to determine effectiveness and to monitor for toxicity.
* Caution patient to avoid taking otc medications without consulting health care provider. Antacids and antidiarrheals, for example, slow absorption of digoxin.
* Teach patient and family to take pulse and to seek health care provider's advice for rates less than 60 bpm or more than 100 bpm (adults).
* If patient is directed by health care provider, help identify ways to supplement potassium intake.

Cimetidine

2009-07-26T22:42:00.000-07:00

Pronunciation: (sigh-MET-ih-deen)

Class: Histamine H 2 antagonist

Trade Names:

Cimetidine
- Tablets 300 mg
- Tablets 400 mg
- Tablets 800 mg
- Liquid 300 mg (as hydrochloride) per 5 mL
- Injection 150 mg (as hydrochloride) per mL

Trade Names:

Cimetidine in 0.9% Sodium Chloride
- Injection, premixed 6 mg (as hydrochloride) per mL

Trade Names:

Tagamet HB
- Tablets 200 mg
Apo-Cimetidine (Canada)
Gen-Cimetidine (Canada)
Nu-Cimet (Canada)

Pharmacology

Pharmacokinetics

Absorption

Oral

Rapidly absorbed. T max is 45 to 90 min. 60% to 70% bioavailable.

Distribution

13% to 25% protein bound. Vd is 0.8 to 1.2 L/kg. Crosses the placenta and is excreted in breast milk.

Metabolism

Following oral administration, cimetidine is extensively metabolized with the sulfoxide being the major metabolite.

Elimination

The t ½ is about 2 h.

Oral

48% is excreted unchanged in the urine.

IV/IM

About 75% is excreted unchanged in the urine.

Special Populations

Renal Function Impairment

Drug accumulation may occur in those with severe renal failure. Dosage adjustment may be necessary.

Indications and Usage

Management of duodenal ulcer; treatment of gastroesophageal reflux disease (GERD), including erosive esophagitis; therapy for benign gastric ulcer; treatment of pathologic hypersecretory conditions; prevention of upper GI bleeding.

Unlabeled Uses

Prevention of aspiration pneumonia and stress ulcers; herpes virus infection; chronic idiopathic urticaria; anaphylaxis (relieves dermatologic symptoms only); dyspepsia; used before anesthesia to prevent aspiration pneumonitis; treatment of hyperparathyroidism and control of secondary hyperparathyroidism in chronic hemodialysis patient; treatment of chronic viral warts in children.
Contraindications

Hypersensitivity to cimetidine or other H 2 antagonists.

Drug Interactions

Amiodarone cimetidine increases plasma concentration of amiodarone Amiodarone has a long half-life; there is a potential for drug interactions to occur for several weeks (or even months) after treatment with it has been stopped
Amitriptyline cimetidine inhibits metabolism of amitriptyline (increased plasma concentration)
Amprenavir plasma concentration of cimetidine possibly increased by amprenavir
Antidepressants, Tricyclic cimetidine possibly increases plasma concentration of tricyclics
Antipsychotics cimetidine possibly enhances effects of antipsychotics Increased risk of toxicity with myelosuppressive drugs
Artemether with Lumefantrine avoidance of cimetidine advised by manufacturer of artemether/lumefantrine
Azapropazone cimetidine possibly increases plasma concentration of azapropazone
Benzodiazepines cimetidine inhibits metabolism of benzodiazepines (increased plasma concentration)
Calcium-channel Blockers cimetidine possibly inhibits metabolism of calcium-channel blockers (increased plasma concentration) Dihydropyridine calcium-channel blockers include amlodipine, felodipine, isradipine, lacidipine, lercanidipine, nicardipine, nifedipine, nimodipine, and nisoldipine
Carbamazepine cimetidine inhibits metabolism of carbamazepine (increased plasma concentration)
Chloroquine and Hydroxychloroquine cimetidine inhibits metabolism of chloroquine and hydroxychloroquine (increased plasma concentration)
Chlorpromazine cimetidine possibly enhances effects of chlorpromazine
Ciclosporin cimetidine possibly increases plasma concentration of ciclosporin
Cilostazol cimetidine possibly increases plasma concentration of cilostazol —avoid concomitant use
Citalopram cimetidine increases plasma concentration of citalopram
Clomethiazole cimetidine inhibits metabolism of clomethiazole (increased plasma concentration)
Clozapine cimetidine possibly enhances effects of clozapine Avoid concomitant use of clozapine with drugs that have a substantial potential for causing agranulocytosis
Coumarins cimetidine inhibits metabolism of coumarins (enhanced anticoagulant effect) Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Doxepin cimetidine inhibits metabolism of doxepin (increased plasma concentration)
Epirubicin cimetidine increases plasma concentration of epirubicin
Ergotamine and Methysergide increased risk of ergotism when cimetidine given with ergotamine and methysergide —avoid concomitant use
Erythromycin cimetidine increases plasma concentration of erythromycin (increased risk of toxicity, including deafness) Interactions do not apply to small amounts of erythromycin used topically
Escitalopram cimetidine increases plasma concentration of escitalopram
Flecainide cimetidine inhibits metabolism of flecainide (increased plasma concentration)
Fluorouracil cimetidine inhibits metabolism of fluorouracil (increased plasma concentration)
Imipramine cimetidine inhibits metabolism of imipramine (increased plasma concentration)
Labetalol cimetidine increases plasma concentration of labetalol
Levothyroxine (thyroxine) cimetidine reduces absorption of levothyroxine (thyroxine)
Lidocaine (lignocaine) cimetidine increases plasma concentration of lidocaine (lignocaine) (increased risk of toxicity) Interactions less likely when lidocaine used topically
Loratadine manufacturer of loratadine advises cimetidine possibly increases plasma concentration of loratadine
Mebendazole cimetidine possibly inhibits metabolism of mebendazole (increased plasma concentration)
Metformin cimetidine reduces excretion of metformin (increased plasma concentration)
Metoprolol cimetidine increases plasma concentration of metoprolol
Metronidazole cimetidine inhibits metabolism of metronidazole (increased plasma concentration) Interactions do not apply to topical metronidazole preparations
Mirtazapine cimetidine increases plasma concentration of mirtazapine
Moclobemide cimetidine increases plasma concentration of moclobemide (halve dose of moclobemide)
Nortriptyline cimetidine inhibits metabolism of nortriptyline (increased plasma concentration)
Octreotide absorption of cimetidine possibly delayed by octreotide
Opioid Analgesics cimetidine inhibits metabolism of opioid analgesics (increased plasma concentration)
Phenytoin cimetidine inhibits metabolism of phenytoin (increased plasma concentration)
Posaconazole cimetidine reduces plasma concentration of posaconazole
Pramipexole cimetidine reduces excretion of pramipexole (increased plasma concentration)
Procainamide cimetidine increases plasma concentration of procainamide
Propafenone cimetidine increases plasma concentration of propafenone
Propranolol cimetidine increases plasma concentration of propranolol
Quinine cimetidine inhibits metabolism of quinine (increased plasma concentration)
Rifampicin metabolism of cimetidine accelerated by rifampicin (reduced plasma concentration)
Sertindole increased risk of ventricular arrhythmias when cimetidine given with sertindole —avoid concomitant use
Sertraline cimetidine increases plasma concentration of sertraline
Sildenafil cimetidine increases plasma concentration of sildenafil (reduce initial dose of sildenafil)
Sulphonylureas cimetidine enhances hypoglycaemic effect of sulphonylureas
Terbinafine cimetidine increases plasma concentration of terbinafine
Theophylline cimetidine inhibits metabolism of theophylline (increased plasma concentration)
Tolazoline cimetidine antagonises effects of tolazoline
Valproate cimetidine inhibits metabolism of valproate (increased plasma concentration)
Zaleplon cimetidine inhibits metabolism of zaleplon (increased plasma concentration)
Zolmitriptan cimetidine inhibits metabolism of zolmitriptan (reduce dose of zolmitriptan)
Cimetidine belongs to Histamine H2-antagonists and will have the following interactions:

Atazanavir histamine H2-antagonists possibly reduce plasma concentration of atazanavir
Cefpodoxime histamine H2-antagonists reduce absorption of cefpodoxime
Itraconazole histamine H2-antagonists reduce absorption of itraconazole
Ketoconazole histamine H2-antagonists reduce absorption of ketoconazole

Dosage and Administration

Duodenal Ulcer (Active)

Adults

PO 800 mg at bedtime for 4 to 6 wk.

Alternate regimens

PO 300 mg 4 times daily with meals and at bedtime or 400 mg twice daily.

Maintenance Therapy

PO 400 mg at bedtime.

Active Benign Gastric Ulcer

Adults

PO 800 mg at bedtime.

GERD

Adults

PO 1600 mg daily in divided doses (800 mg or 400 mg) for 12 wk, although some patients may require chronic therapy.
Pathologic Hypersecretory Conditions

Adults

PO 300 mg 4 times daily w/meals and at bedtime. If needed, 300 mg doses may be given more often (max, 2400 mg/day).
Prevention of Upper GI Bleeding

Adults

Continuous IV infusion of 50 mg/h. For hospitalized patients with pathologic hypersecretory conditions or intractable ulcers, or patients unable to take PO medication.

Usual dose

IM/IV 300 mg every 6 h to 8 h (max 2400 mg/day).

General Advice

* Dilute IV dose (300 mg) in 0.9% normal saline, D5W, or other compatible solution to a total of 20 mL. Inject slowly over at least 5 min.
* For intermittent IV infusion, dilute 300 mg in at least 50 mL of compatible solution; infuse over at least 20 min (continuous IV infusion is usually preceded by a loading dose).
* Do not add drugs or additives to mixture. Stop other inline drugs while administering, and flush lines before and after administration.
* Product may be added to standard TPN solutions.

Storage/Stability

Store premixed products at room temperature. Discard any unused mixed solutions after 48 h. Store oral doseform between 15° to 30°C (59° to 86°F).
Adverse Reactions

Cardiovascular

Cardiac arrhythmias.

CNS

Headache; somnolence; fatigue; dizziness; confusional states; hallucinations

GI

Diarrhea.

Genitourinary

Impotence; loss of libido.

Respiratory

Bronchospasm.

Miscellaneous

Gynecomastia; hypersensitivity reactions; transient pain at injection site; reversible exacerbation of joint symptoms with pre-existing arthritis, including gouty arthritis.

Precautions

Pregnancy

Category B .

Lactation

Excreted in breast milk.

Children

Safety and efficacy not established.

Elderly

May have reduced renal function; decreased Cl may occur.

Hypersensitivity

Rare cases of anaphylaxis have occurred as well as rare episodes of hypersensitivity.

Renal Function

Decreased Cl may occur; reduced dosage may be needed.

Hepatic Function

Use caution; decreased Cl may occur.

Gastric malignancy

Symptomatic relief with cimetidine does not preclude gastric malignancy.

Antiandrogenic effect

Gynecomastia may occur, especially in patients treated for pathologic hypersecretory states.

Rapid IV administration

Has been followed by rare instances of cardiac arrhythmias and hypotension.

Reversible CNS effects

Mental confusion, agitation, psychosis, depression, anxiety, hallucinations, and disorientation have occurred, predominantly in severely ill patients. Advanced age and pre-existing liver or renal disease appear to be contributing factors.
Patient Information

* Counsel patients to stop smoking, since smoking reduces ulcer-healing efficacy of cimetidine.
* Instruct patients to keep appointments for laboratory testing and health care provider follow-up.
* Instruct patients to report to health care provider immediately any black tarry stools, coffee-ground emesis, abdominal pain or confusion.
* Counsel patients regarding need for lifestyle changes, stress reduction programs and dietary modifications (eg, avoid spicy foods and alcohol).

Chlorpheniramine Maleate

2009-07-26T22:41:00.002-07:00

Pronunciation: (klor-fen-AIR-uh-meen MAL-ee-ate)\

Class: Alkylamine, nonselective

Trade Names:

Aller-Chlor
- Tablets 4 mg
- Syrup 2 mg per 5 mL

Trade Names:

Allergy
- Tablets 4 mg

Trade Names:
Allergy Relief
- Tablets 4 mg

Trade Names:

Chlor-Trimeton
- Tablets 4 mg

Trade Names:

Chlor-Trimeton Allergy 8 Hour
- Tablets, extended-release 8 mg

Trade Names:

Chlor-Trimeton Allergy 12 Hour
- Tablets, extended-release 12 mg

Trade Names:

Chlorpheniramine Maleate
- Capsules, sustained-release 8 mg
- Capsules, sustained-release 12 mg

Trade Names:

Chlorpheniramine Maleate
- Tablets 4 mg
Chlor-Tripolon (Canada)

Pharmacology

Competitively antagonizes histamine at H 1 receptor sites.

Pharmacokinetics

Absorption

Readily absorbed.

Distribution

72% protein bound.

Metabolism

Metabolized predominantly in the liver, but also in the lung and kidneys.

Elimination

Renally eliminated, mostly as metabolites within 24 h.

Indications and Usage

Temporary relief of sneezing, itchy, watery eyes, itchy nose or throat, and runny nose caused by hay fever (allergic rhinitis), or other respiratory allergies.

Contraindications

Hypersensitivity to antihistamines; narrow-angle glaucoma; stenosing peptic ulcer; symptomatic prostatic hypertrophy; asthmatic attack; bladder neck obstruction; pyloroduodenal obstruction; MAO therapy; use in newborn or premature infants and in breast-feeding mothers.

Dosage and Administration

Immediate-release tablet or syrup

Adults and children 12 yr of age and older

PO 4 mg every 4 to 6 h (max, 24 mg/day).

Children 6 to younger than 12 yr of age

PO 2 mg every 4 to 6 h (max, 12 mg/day).

Children younger than 5 yr of age

PO As recommended by health care provider.

Extended-release tablets

Adults and children 12 yr of age and older

PO 8 mg every 8 to 12 h or 12 mg every 12 h (max, 24 mg/day).

Extended-release capsules

Adults and children 12 yr of age and older

PO 8 or 12 mg in the morning and evening (max, 24 mg/day).

General Advice

* Administer without regard to meals. Administer with food if GI upset occurs.
* Measure and administer prescribed dose of oral syrup using dosing syringe, dosing spoon, or dosing cup.
* Advise patient receiving extended-release tablets or sustained-release capsules to swallow tablets or capsules whole and not to crush, chew, break, or open.

Storage/Stability

Store all dose forms at controlled room temperature (59° to 86°F).

Drug Interactions

Lopinavir plasma concentration of chlorphenamine (chlorpheniramine) possibly increased by lopinavir In combination with ritonavir as Kaletra® (ritonavir is present to inhibit lopinavir metabolism and increase plasma-lopinavir concentration)—see also Ritonavir
Chlorphenamine (chlorpheniramine) belongs to Antihistamines, Sedating but Antihistamines, Sedating has no interactions information.
Chlorphenamine (chlorpheniramine) belongs to Antihistamines and will have the following interactions:
Sedative interactions apply to a lesser extent to the non-sedating antihistamines. Interactions do not generally apply to antihistamines used for topical action (including inhalation)

Alcohol increased sedative effect when antihistamines given with alcohol (possibly less effect with non-sedating antihistamines)
Antidepressants, Tricyclic increased antimuscarinic and sedative effects when antihistamines given with tricyclics
Antidepressants, Tricyclic (related) possible increased antimuscarinic and sedative effects when antihistamines given with tricyclic-related antidepressants
Antimuscarinics increased risk of antimuscarinic side-effects when antihistamines given with antimuscarinics Many drugs have antimuscarinic effects; concomitant use of two or more such drugs can increase side-effects such as dry mouth, urine retention, and constipation; concomitant use can also lead to confusion in the elderly. Interactions do not generally apply to antimuscarinics used by inhalation
Anxiolytics and Hypnotics increased sedative effect when antihistamines given with anxiolytics and hypnotics
Betahistine antihistamines theoretically antagonise effect of betahistine
MAOIs increased antimuscarinic and sedative effects when antihistamines given with MAOIs For interactions of reversible MAO-A inhibitors (RIMAs) see Moclobemide, and for interactions of MAO-B inhibitors see Rasagiline and Selegiline; the antibacterial Linezolid is a reversible, non-selective MAO inhibitor

Adverse Reactions

Cardiovascular

Bradycardia; extrasystoles; orthostatic hypotension; palpitations; reflex tachycardia; tachycardia.

CNS

Confusion; convulsions; disturbed coordination; dizziness; drowsiness; euphoria; excitation; faintness; fatigue; headache; hysteria; insomnia; irritability; nervousness; neuritis; paresthesias; restlessness; sedation; tremor; vertigo.

EENT

Acute labyrinthitis; blurred vision; diplopia; dry nose and throat; nasal stuffiness; sore throat; tinnitus.

GI

Anorexia; constipation; diarrhea; dry mouth; epigastric distress; nausea; vomiting.

Genitourinary

Difficult urination; dysuria; early menses; urinary frequency or retention.

Hematologic

Agranulocytosis; hemolytic anemia; thrombocytopenia.

Metabolic

Increased appetite; weight gain.

Respiratory

Chest tightness; respiratory depression; thickening of bronchial secretions; wheezing.

Miscellaneous

Chills; excessive perspiration; hypersensitivity reactions; photosensitivity.

Precautions

Monitor

Allergy symptoms

Assess allergy symptoms (eg, cough, rhinitis, nasal congestion, sneezing, watery eyes, or itching nose, throat, or eyes) before starting therapy and periodically during therapy. Notify health care provider if symptoms are not improving or are getting worse.

Dizziness/Drowsiness

Monitor patient for dizziness and excessive drowsiness. If noted, hold therapy and notify health care provider.

Review therapy

Ensure therapy periodically is reviewed to determine if it needs to be continued without change or if a dose change (eg, increase, decrease, discontinuation) is indicated.

Pregnancy

Category C . Do not use during third trimester.

Lactation

Contraindicated in breast-feeding mothers.

Children

Overdosage may cause hallucinations, convulsions, and death. Antihistamines may diminish mental alertness. In young children, they may produce paradoxical excitation. Contraindicated in newborn or premature infants. Sustained-release form not recommended in children younger than 12 yr of age.

Elderly

Use with caution, usually starting at the low end of the dosage range because of the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant diseases or other drug therapy.

Hypersensitivity

May occur. Have epinephrine 1:1,000 immediately available.

Hepatic Function

Use drug with caution in patients with cirrhosis or other liver disease.

Special Risk Patients

Use drug with caution in patients with predisposition to urinary retention, history of bronchial asthma, increased IOP, hyperthyroidism, CV disease, or hypertension. Avoid in patients with sleep apnea.

RESP disease

Generally not recommended to treat lower respiratory tract symptoms, including asthma.

Overdosage

Symptoms

CNS depression (including sedation, apnea, CV collapse), CNS stimulation (including insomnia, hallucination, tremors, convulsions), tinnitus, blurred vision, dizziness, ataxia, hypotension. Stimulation and atropine-like signs and symptoms (including dry mouth, fixed dilated pupils, flushing, hyperthermia, GI symptoms) are more likely in children.

Patient Information

* Caution patient using OTC chlorpheniramine that each product has specific dosing instructions and to read package label before using and not to exceed dose or frequency of administration instructions.
* Advise patient to take each dose without regard to meals, but to take with food if stomach upset occurs.
* Advise patient or caregiver using oral syrup to measure and administer prescribed dose using dosing syringe, dosing spoon, or dosing cup.
* Advise patient that if a dose is missed, to take it as soon as possible unless it is nearing time for the next scheduled dose. If it is nearing time for next scheduled dose, advise patient to skip the missed dose and take the next dose at the regularly scheduled time. Caution patient not to double the dose to catch up.
* Advise patient that if allergy symptoms are not controlled, not to increase the dose of medication or frequency of use but to inform health care provider. Caution patient that larger doses or more frequent dosing does not increase efficacy and may cause excessive drowsiness or other adverse reactions.
* Instruct patient to stop taking drug and immediately report any of these symptoms to health care provider: persistent dizziness; excessive drowsiness; severe dry mouth, nose, or throat; flushing; unexplained shortness of breath or difficulty breathing; unusual tiredness or weakness; sore throat, fever, or other signs of infection; bleeding or unusual bruising; fast or irregular heartbeat; excitability, confusion, or changes in thinking or behavior; chest tightness; difficulty with urination.
* Advise patient medication may cause drowsiness or dizziness and not to drive or perform other activities requiring mental alertness until tolerance is determined.
* Advise patient to take sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum if dry mouth occurs.
* Caution patient alcohol and other CNS depressants (eg, sedatives) will have additional sedative effects if taken with chlorpheniramine.
* Caution patient not to take any other OTC antihistamines while taking this medication unless advised by health care provider.
* Caution patient that medication may cause sensitivity to sunlight and to avoid excessive exposure to the sun or UV light (eg, tanning booths) and to wear protective clothing and use sunscreens until tolerance is determined.
* If patient is to have allergy skin testing, advise patient not to take the medication for at least 4 days before the skin testing.

Ceftriaxone Sodium

2009-07-26T22:41:00.001-07:00

Pronunciation: (SEF-trye-AX-one SO-dee-um)

Class: Antibiotic, Cephalosporin

Trade Names:

Rocephin

- Injection, powder for solution 250 mg (3.6 mEq of sodium/g)

- Injection, powder for solution 500 mg (3.6 mEq of sodium/g)

- Injection, powder for solution 1 g (3.6 mEq of sodium/g)

- Injection, powder for solution 2 g (3.6 mEq of sodium/g)

- Injection, powder for solution 10 g (3.6 mEq of sodium/g)

Trade Names:

CefTRIaxONE

- Injection 1 g (3.6 mEq of sodium/g)

- Injection 2 g (3.6 mEq of sodium/g)

Pharmacology

Inhibits mucopeptide synthesis in bacterial cell wall.

Pharmacokinetics

IM
Ceftriaxone is completely absorbed. T max is 2 to 3 h.

Distribution

Vd is 5.78 to 13.5 L. Ceftriaxone is 85% to 95% protein bound.

Elimination

33% to 67% is excreted in urine as unchanged drug and the remainder in feces; half-life is 5.8 to 8.7 h. Plasma Cl is 0.58 to 1.45 L/h. Renal Cl is 0.32 to 0.73 L/h.

Special Populations

Renal Function Impairment

No dosage adjustment needed.

Hepatic Function Impairment

No dosage adjustment needed.

Indications and Usage

Acute bacterial otitis media ( Rocephin ); treatment of infections of lower respiratory tract, skin and skin structures, bone and joint, and urinary tract; treatment of pelvic inflammatory disease, intra-abdominal infections, gonorrhea ( Rocephin ), meningitis, and septicemia caused by susceptible microorganisms; preoperative prophylaxis.

Unlabeled Uses

Neurologic complications, arthritis, and carditis associated with Lyme disease in patients refractory to penicillin G.

Contraindications

Hypersensitivity to cephalosporins; neonates (28 days of age or younger); calcium-containing IV solutions.

Dosage and Administration

Ceftriaxone for injection and dextrose injection ( CefTRIaxONE ) is intended for IV administration only. Ceftriaxone sodium ( Rocephin ) may be administered IV or IM.

Acute Otitis Media

Children

IM A single dose of 50 mg/kg (max, 1 g) is recommended.

Pediatric Meningitis

Children

IV CefTRIaxONE or IV/IM Rocephin : Recommended initial dose is 100 mg/kg (max, 4 g) followed by 100 mg/kg/day (max, 4 g/day) for 7 to 14 days.

Skin or Skin Structure Infections

Children

IV/IM CefTRIaxONE IV or Rocephin IV/IM : Recommended daily dosage is 50 to 75 mg/kg once a day or in equally divided doses twice daily (max, 2 g/day).

Surgical Prophylaxis

Adults

IV CefTRIaxONE or IV/IM Rocephin : 1 g as a single dose 30 min to 2 h before surgery.

Uncomplicated Gonococcal Infections

Adults

IM 250 mg as single dose.

Miscellaneous Infections

Adults

IV CefTRIaxONE or IV/IM Rocephin : Usual adult daily dosage is 1 to 2 g once a day or in equally divided doses twice daily, depending on the type and severity of infection (max, 4 g/day).

Children

IV CefTRIaxONE : Recommended daily dose is 50 to 75 mg/kg IV once a day or in divided doses every 12 h (max, 2 g/day). IV/IM Rocephin : Recommended daily dose is 50 to 75 mg/kg IV/IM in divided doses every 12 h (max, 2 g/day).

General Advice

* Reconstituted solution should be light yellow to amber. Do not administer if solution is cloudy or precipitate is present.
* When giving IM, inject deeply into large muscle (eg, upper outer quadrant of gluteus muscle, lateral thigh); massage well.
* For piggyback infusion, reconstituted solution may be diluted with dextrose 5% in water or sodium chloride 0.9% infused over 30 to 60 min.
* Because of the possibility of precipitation of ceftriaxone calcium, do not administer IV ceftriaxone and a calcium-containing IV solution within 48 h of each other.
* Ceftriaxone is physically incompatible with fluconazole and vancomycin in admixture. When either drug is coadministered with ceftriaxone, it is recommended that they be given sequentially with thorough flushing of the IV line.
* Generally, therapy should be continued for at least 2 days after signs and symptoms of infection have disappeared. The usual duration of therapy is 4 to 14 days. In complicated infections, therapy may be longer.
* Streptococcus pyogenes treatment should continue for at least 10 days.
* Ceftriaxone for injection and dextrose injection ( CefTRIaxONE ) is intended for IV administration only. Ceftriaxone sodium ( Rocephin ) may be administered IV or IM.

Storage/Stability

Ceftriaxone

Store unactivated unit at 59° to 86°F. Following reconstitution, product must be used within 24 h if stored at room temperature or within 7 days if stored under refrigeration.

Rocephin

Store sterile powder at temperatures not exceeding 77°F. Protect from light. After reconstitution, protection from normal light is not necessary. Depending on the diluent, product must be used within 1 to 2 days if stored at room temperature or within 3 to 10 days if stored under refrigeration.

Drug Interactions

Coumarins cephalosporins possibly enhance anticoagulant effect of coumarins Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Probenecid excretion of cephalosporins reduced by probenecid (increased plasma concentration)
Ceftriaxone belongs to Antibacterials and will have the following interactions:

Oestrogens antibacterials that do not induce liver enzymes possibly reduce contraceptive effect of oestrogens (risk probably small, see section 7.3.1) Interactions of combined oral contraceptives may also apply to combined contraceptive patches; in case of hormone replacement therapy low dose unlikely to induce interactions

Adverse Reactions

GI

Diarrhea (2%).

Hematologic-Lymphatic

Eosinophilia (6%); thrombocytosis (5%); leukopenia (2%).

Lab Tests

Elevated ALT and AST (3%); elevated BUN (1%).

Local

Induration/tightness/warmth (17%); induration/pain/tenderness (1%).

Miscellaneous

Fatal ceftriaxone-calcium precipitates in lung and kidneys of neonates.

Precautions

Monitor

Periodically measure plasma levels of the drug in patients with impaired renal function. If evidence of drug accumulation is present, adjust the dose accordingly. In patients with both hepatic function impairment and renal disease, closely monitor ceftriaxone plasma concentrations. Monitor PT in patients with impaired vitamin K synthesis or low vitamin K stores.

Adverse reactions

Monitor patient for GI, skin, and general body adverse reactions, and signs of superinfection. Instruct patient to inform health care provider if noted and significant, and to immediately report severe diarrhea, diarrhea containing blood or pus, or severe abdominal cramping.

Response to therapy

Monitor patient's response to therapy.

Pregnancy

Category B.

Lactation

Excreted in breast milk.

Children

Cephalosporins may accumulate in newborns.

Hypersensitivity

Reactions range from mild to life-threatening. Administer drug with caution to penicillin-sensitive patients because of possible cross-reactivity.

Renal Function

No dosage adjustment is needed in patients with renal failure who are receiving usual doses of ceftriaxone.

Hepatic Function

No dosage adjustment is needed in patients with hepatic function impairment; however, in patients with both hepatic function impairment and renal disease, the dosage should not exceed 2 g daily without close monitoring of serum concentrations.

Superinfection

May result in bacterial or fungal overgrowth of nonsusceptible microorganisms.

Calcium-containing products

Because of the possibility of precipitation of ceftriaxone calcium, do not administer ceftriaxone and a calcium-containing IV solution within 48 h of each other.

Prothrombin times

Alterations in PT may occur.

Pseudomembranous colitis

Consider in patients in whom diarrhea develops.

Sonographic abnormalities

Sonographic abnormalities in the gallbladder, with symptoms of gallbladder disease, have been reported.

Overdosage

Symptoms

May include the adverse reactions listed, but of a more severe nature.

Patient Information

* Remind patient to check body temperature daily. If fever persists for more than a few days or if high fever (higher than 102°F) or shaking chills are noted, notify health care provider immediately.
* Advise patient to maintain normal fluid intake while using this medication.
* Instruct diabetic patient to use enzyme-based tests (eg, Clinistix , Testape ) for monitoring urine glucose because drug may give false results with other tests.
* Instruct patient to report these symptoms to health care provider: bleeding, bruising, diarrhea, hives, muscle or joint pain, nausea, skin rash, sore throat, vomiting.
* Advise patient to report signs of superinfection: black, “furry” tongue; white patches in mouth; foul-smelling stools; vaginal itching or discharge.
* Warn patient that diarrhea that contains blood or pus may be a sign of serious disorders. Tell patient to seek medical care and not to treat at home.
* Instruct patient to seek emergency care immediately if wheezing or difficulty in breathing occurs.
* Instruct patient to notify health care provider if infection does not improve or appears to worsen.

Aspirin

2009-07-26T22:39:00.000-07:00

( Acetylsalicylic Acid ; ASA )

Pronunciation: (ASS-pihr-in)

Class: Salicylate

Trade Names:

Arthritis Foundation Pain Reliever
- Tablets 500 mg

Trade Names:

Bayer Children's Aspirin
- Tablets, chewable 81 mg

Trade Names:

Bayer Low Adult Strength
- Tablets, delayed-release 81 mg

Trade Names:

Easprin
- Tablets, enteric-coated 975 mg

Trade Names:

Ecotrin
- Tablets, enteric-coated 325 mg

Trade Names:

Ecotrin Adult Low Strength
- Tablets, enteric-coated 81 mg

Trade Names:

Ecotrin Maximum Strength
- Tablets, enteric-coated 500 mg

Trade Names:

Empirin
- Tablets 325 mg

Trade Names:

Extended Release Bayer 8-Hour
- Tablets, extended-release 650 mg

Trade Names:

Extra Strength Bayer Enteric 500 Aspirin
- Tablets, enteric-coated 500 mg

Trade Names:

Genprin
- Tablets 325 mg

Trade Names:

Genuine Bayer
- Tablets 325 mg

Trade Names:

½ Halfprin
- Tablets, enteric-coated 165 mg

Trade Names:

Halfprin 81
- Tablets, enteric-coated 81 mg

Trade Names:

Heartline
- Tablets, enteric-coated 81 mg

Trade Names:

Maximum Bayer
- Tablets 500 mg

Trade Names:

Norwich Extra-Strength
- Tablets 500 mg

Trade Names:

Regular Strength Bayer Enteric Coated Caplets
- Tablets, enteric-coated 325 mg

Trade Names:

St. Joseph Adult Chewable Aspirin
- Tablets, chewable 81 mg

Trade Names:

ZORprin
- Tablets, controlled-release 800 mg
Asaphen (Canada)
Asaphen E.C. (Canada)
Asatab (Canada)
Coated Aspirin (Canada)
Entrophen (Canada)

Pharmacology

Advertisement

Inhibits prostaglandin synthesis, resulting in analgesia, anti-inflammatory activity and platelet aggregation inhibition; reduces fever by acting on the brain's heat-regulating center to promote vasodilation and sweating.
Pharmacokinetics

Absorption

Rapidly and completely absorbed. T max is 1 to 2 h (salicylic acid).

Distribution

Widely distributed to all tissues and fluids including CNS, breast milk, and fetal tissues. Approximately 90% of salicylate is protein bound at concentrations of less than 100 mcg/mL and approximately 75% is bound at concentrations of more than 400 mcg/mL.

Metabolism

Rapidly hydrolyzed to salicylic acid (active). Salicylic acid is conjugated in the liver to the metabolites.

Elimination

Salicylic acid plasma t ½ is approximately 6 h but may exceed 20 h in higher doses. The t ½ is approximately 15 to 20 min for aspirin. Elimination follows zero order kinetics. Renal elimination of unchanged drug depends on urine pH. A pH of more than 6.5 increases renal Cl of free salicylate from less than 5% to more than 80%.

Indications and Usage

Treatment of mild to moderate pain; fever; various inflammatory conditions; reduction of risk of death or MI in patients with previous infarction or unstable angina pectoris or recurrent transient ischemia attacks or stroke in men who have had transient brain ischemia caused by platelet emboli.

Unlabeled Uses

Prevention of cataract formation; prevention of toxemia of pregnancy; improvement of inadequate uteroplacental blood flow in pregnancy.

Contraindications

Hypersensitivity to salicylates or NSAIDs; hemophilia, bleeding ulcers, or hemorrhagic states.

Dosage and Administration

Analgesic/Antipyretic

Adults

PO 325 to 650 mg every 4 h as needed; 500 mg every 3 h as needed; 1,000 mg every 6 h as needed.

Children (2 to 12 yr of age)

PO 10 to 15 mg/kg/dose every 4 h as needed (up to 80 mg/kg/day).

Arthritis and Other Rheumatic Conditions

Adults

PO 3.2 to 6 g/day in divided doses.

Juvenile Rheumatoid Arthritis

Children

PO 60 to 110 mg/kg/day in divided doses every 6 to 8 h.

Acute Rheumatic Fever

Adults

PO 5 to 8 g/day, initially, for up to 2 wk. Subsequent doses are based on patient response.

Children

PO 75 to 100 mg/kg/day.

Transient Ischemic Attacks in Men

Adults

PO 1300 mg/day in 2 to 4 doses.

MI Prophylaxis

Adults

PO 160 to 325 mg/day.

Kawasaki Disease

Children

PO 80 to 180 mg/kg/day during acute febrile period; 10 mg/kg/day after fever resolves.

Storage/Stability

Store oral forms at room temperature in tightly closed container.

Drug Interactions

Inhibitors risk of renal impairment when aspirin (in doses over 300 mg daily) given with ACE inhibitors , also hypotensive effect antagonised
Angiotensin-II Receptor Antagonists risk of renal impairment when aspirin (in doses over 300 mg daily) given with angiotensin-II receptor antagonists , also hypotensive effect antagonised
Antacids excretion of aspirin increased by alkaline urine due to some antacids Antacids should preferably not be taken at the same time as other drugs since they may impair absorption
Antidepressants, SSRI increased risk of bleeding when aspirin given with SSRIs
Carbonic Anhydrase Inhibitors increased risk of toxicity when high-dose aspirin given with carbonic anhydrase inhibitors
Cilostazol manufacturer of cilostazol recommends dose of aspirin should not exceed 80 mg daily when given with cilostazol
Clopidogrel increased risk of bleeding when aspirin given with clopidogrel
Corticosteroids increased risk of gastro-intestinal bleeding and ulceration when aspirin given with corticosteroids , also corticosteroids reduce plasma concentration of salicylate Interactions do not generally apply to corticosteroids used for topical action (including inhalation) unless specified
Coumarins increased risk of bleeding when aspirin given with coumarins (due to antiplatelet effect) Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Heparins aspirin enhances anticoagulant effect of heparins
Ibuprofen antiplatelet effect of aspirin possibly reduced by ibuprofen
Iloprost increased risk of bleeding when aspirin given with iloprost
Kaolin absorption of aspirin possibly reduced by kaolin
Methotrexate aspirin reduces excretion of methotrexate (increased risk of toxicity)—but for concomitant use in rheumatic disease see Methotrexate, section 10.1.3
Metoclopramide rate of absorption of aspirin increased by metoclopramide (enhanced effect)
Mifepristone avoidance of aspirin advised by manufacturer of mifepristone
NSAIDs avoid concomitant use of aspirin with NSAIDs (increased side-effects) See also Aspirin. Interactions do not generally apply to topical NSAIDs
Phenindione increased risk of bleeding when aspirin given with phenindione (due to antiplatelet effect) Change in patient's clinical condition particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Phenytoin aspirin enhances effects of phenytoin
Probenecid aspirin antagonises effects of probenecid
Sibutramine increased risk of bleeding when aspirin given with sibutramine
Spironolactone aspirin antagonises diuretic effect of spironolactone
Sulfinpyrazone aspirin antagonises effects of sulfinpyrazone
Valproate aspirin enhances effects of valproate
Venlafaxine increased risk of bleeding when aspirin given with venlafaxine
Zafirlukast aspirin increases plasma concentration of zafirlukast
Aspirin belongs to Analgesics but Analgesics has no interactions information.

Laboratory Test Interactions

May increase levels of serum uric acid, cause false-positive readings of urine glucose by copper reduction method ( Clinitest ) and false-negative readings by glucose oxidase method ( Clinistix ); may interfere with urine tests of 5-hydroxyindoleacetic acid, ketone, phenolsulfonphthalein, vanillylmandelic acid.

Adverse Reactions

EENT

Dizziness; tinnitus.

GI

Nausea; dyspepsia; heartburn; bleeding.

Hematologic

Increased bleeding times; anemia; decreased iron concentration.

Miscellaneous

Hypersensitivity reactions may include urticaria, hives, rashes, angioedema and anaphylactic shock.

Precautions

Pregnancy

Category D

Lactation

Excreted in breast milk.

Children

Reye syndrome has been associated with aspirin administration to children (including teenagers) with acute febrile illness. Do not use without consulting health care provider.

Hypersensitivity

Reaction may include bronchospasm and generalized urticaria or angioedema; patients with asthma or nasal polyps have greatest risk.

Renal Function

May decrease renal function or aggravate kidney diseases.

Hepatic Function

May cause hepatotoxicity in patients with impaired liver function.

GI disorders

Can cause gastric irritation and bleeding.

Surgical patients

Aspirin may increase risk of postoperative bleeding. If possible, avoid use 1 wk before surgery.

Overdosage

Symptoms

Nausea, vomiting, tinnitus, dizziness, respiratory alkalosis, metabolic acidosis, hemorrhage, convulsions.

Patient Information

* Instruct patient to take drug with food or after meals and with full glass of water. Explain that antacids should be avoided within 1 to 2 h after ingestion of enteric-coated tablets.
* Tell patient to discard any aspirin that has a vinegar-like odor.
* Instruct patient to report ringing in ears or unusual bleeding, bruising, or persistent GI pain.
* Advise patient on long-term therapy to inform health care provider or dentist before seeking surgery or dental care.
* Tell patient on sodium-restricted diet to limit use of effervescent or buffered aspirin preparations.
* Caution parents to avoid giving aspirin to children or teenagers with flu-like symptoms or chickenpox without first consulting health care provider.
* Instruct patient to avoid intake of alcoholic beverages or other CNS depressants.

Allopurinol

2009-07-26T22:36:00.000-07:00

Pronunciation: (AL-oh-PURE-ee-nahl)

Class: Agent for gout, Antimetabolite

Trade Names:

Aloprim

- Powder for injection, lyophilized 500 mg

Trade Names:

Zyloprim

- Tablets 100 mg

- Tablets 300 mg

Apo-Allopurinol (Canada)

Pharmacology

Inhibits xanthine oxidase, the enzyme responsible for conversion of hypoxanthine to xanthine and then to uric acid.

Pharmacokinetics

Absorption

About 90% absorbed from GI tract. T max is 1.5 h (allopurinol) and 4.5 h (oxipurinol). C max is 3 mcg/mL (allopurinol 300 mg) and 6.5 mcg/mL (oxipurinol).

Metabolism

Rapidly oxidized to oxipurinol.

Elimination

About 20% is excreted in the feces. Allopurinol is essentially cleared by glomerular filtration, whereas oxipurinol is reabsorbed in the kidney tubules. T 1/2 , plasma is about 1 to 2 h (allopurinol) and about 15 h (oxipurinol).

Onset

Uric acid decreases in about 2 to 3 days.

Peak

May require a week or more of treatment.

Duration

Xanthine oxidase inhibition is maintained over 24 h; however, uric acid levels may not return to pretreatment levels until 7 to 10 days following cessation of therapy.

Indications and Usage

Tablets

Treatment of primary or secondary gout, hyperuricemia resulting from chemotherapy for malignancies, recurrent calcium oxalate renal calculi.

Tablets and injections

Management of patients with leukemia, lymphoma, and solid tumor malignancies when concurrently receiving cancer therapy that causes elevations of serum and urinary uric acid levels. Use injection in patients who cannot tolerate oral therapy.

Unlabeled Uses

Prevention of fluorouracil-induced stomatitis and fluorouracil-induced granulocyte suppression.

Contraindications

Standard considerations.

Dosage and Administration

Control of Gout/Hyperuricemia

Adults

PO 100 to 800 mg/day. For amounts over 300 mg, give divided doses.

Secondary Hyperuricemia Associated with Malignancies

Children 6 to 10 yr of age

PO 300 mg/day.

Children under 6 yr of age

PO 150 mg/day.

Prevention of Uric Acid Nephropathy in Vigorous Chemotherapy of Neoplastic Disease

Adults

PO 600 to 800 mg/day for 2 to 3 days.

Reduction of Risk of Acute Gouty Attacks

Adults (initial dose)

PO 100 mg/day, increased by 100 mg at weekly intervals until adequate response is achieved or max recommended dose (800 mg/day) is reached.

Leukemia, Lymphoma, Solid Tumor Malignancies

Adults

IV 200 to 400 mg/m 2 /day (max 600 mg/day).

Children

IV Starting dose 200 mg/m 2 /day.

Storage/Stability

Reconstituted solution

Store reconstituted solution at 20° to 25°C; do not refrigerate or dilute product.

Tablets

Store tablets in tightly closed container in cool location.

Unreconstituted solution

Store unreconstituted powder at room temperature.

Drug Interactions

Amoxicillin increased risk of rash when allopurinol given with amoxicillin
Ampicillin increased risk of rash when allopurinol given with ampicillin
Azathioprine allopurinol enhances effects and increases toxicity of azathioprine (reduce dose of azathioprine to one quarter of usual dose)
Capecitabine avoidance of allopurinol advised by manufacturer of capecitabine Capecitabine is a prodrug of fluorouracil
Captopril increased risk of toxicity when allopurinol given with captopril especially in renal impairment
Ciclosporin allopurinol possibly increases plasma concentration of ciclosporin (risk of nephrotoxicity)
Coumarins allopurinol possibly enhances anticoagulant effect of coumarins Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Didanosine allopurinol possibly increases plasma concentration of didanosine Antacids in tablet formulation may affect absorption of other drugs
Diuretics, Thiazide and related increased risk of hypersensitivity when allopurinol given with thiazides and related diuretics especially in renal impairment
Mercaptopurine allopurinol enhances effects and increases toxicity of mercaptopurine (reduce dose of mercaptopurine to one quarter of usual dose)
Theophylline allopurinol possibly increases plasma concentration of theophylline

Adverse Reactions

CNS

Drowsiness; generalized seizure (injectable); headache; neuritis; paresthesias; peripheral neuropathy.

Dermatologic

Allergic vasculitis; alopecia; ecchymosis; skin rash. Allergic reactions may be severe and sometimes fatal.

EENT

Epistaxis; myopathy; taste disturbance.

GI

Abdominal pain; diarrhea; dyspepsia; gastritis; granulomatous changes; nausea; vomiting.

Genitourinary

Renal failure; uremia.

Hematologic

Bone marrow depression; eosinophilia; leukocytosis; leukopenia; thrombocytopenia.

Hepatic

Cholestatic jaundice; elevated liver enzymes; hepatic necrosis; hepatitis; reversible hepatomegaly.

Other

Acute gouty attacks; arthralgia; fever; myopathy; necrotizing angiitis.

Precautions

Pregnancy

Category C .

Lactation

Excreted in breast milk.

Children

Allopurinol is rarely indicated for use in children, except for hyperuricemia resulting from malignancy or with certain rare inborn errors of purine metabolism.

Hypersensitivity

Discontinue drug at first appearance of skin rash or other signs of allergic reaction. Rash may be followed by more severe hypersensitivity reactions and, rarely, death.

Renal Function

Reduced dose is given in patients with this condition. Drug may exacerbate renal failure in certain patients.

Acute gouty attacks

May occur during initial stages of therapy.

Bone marrow depression

Reported in patients given allopurinol.

Patient Information

* Encourage patient to focus on weight loss or control.

* Tell patient to avoid purine-rich foods (eg, organ meats).

* Caution patient to avoid excessive intake of alcohol.

* Explain that gouty attacks may not end for 2 to 6 wk after beginning therapy.

* Instruct patient to stop taking medication and notify health care provider if rash or flu-like symptoms develop.

* Advise patient that drug may cause drowsiness, and to use caution while driving or performing other tasks requiring mental alertness.

Active ingredient: Furosemide - Brands / Synonyms

2009-07-21T22:08:00.001-07:00

Brands / Synonyms

Acetic Acid Potassium Salt; Aisemide; Aldalix; Aldic; Aluzine; Anfuramaide; Apo-Frusemide; Apo-Furosemide; Aquarid; Aquasin; Arasemide; Beronald; Bioretic; Bristab; Bristurin; Cetasix; Depix; Desal; Desdemin; Di-Ademil; Dihydroflumethiazide; Dirine; Disal; Discoid; Disemide; Diucardin; Diumide-K; Diural; Diurapid; Diuretic Salt; Diurin; Diurolasa; Diusemide; Diusil; Diuzol; Dranex; Dryptal; Durafurid; Edemid; Edenol; Eliur; Elodrine; Endural; Errolon; Eutensin; Farsix; Finuret; Fluidrol; Fluss; Franyl; Frumex; Frumide; Frumil; Frusedan; Frusema; Frusemid; Frusemide; Frusemin; Frusenex; Frusetic; Frusid; Fulsix; Fuluvamide; Fuluvamine; Furanthril; Furanthryl; Furantril; Furanturil; Furesis; Furetic; Furex; Furfan; Furix; Furmid; Furo-Basan; Furo-Puren; Furobeta; Furocot; Furodiurol; Furodrix; Furomen; Furomex; Furomide M.D.; Furorese; Furosan; Furose; Furosedon; Furosemid; Furosemida [Inn-Spanish]; Furosemide "Mita"; Furosemide Injection; Furosemide [Usan:Inn:Jan]; Furosemidu; Furosemidu [Polish]; Furosemidum; Furosemidum [Inn-Latin]; Furosemix; Furoside; Furosifar; Furosix; Furoter; Furovite; Fursemid; Fursemida; Fursemide; Fursol; Fusid; Golan; Hissuflux; Hydol; Hydrenox; Hydrex; Hydro; Hydro-Rapid; Hydroflumethiazide; Hydroled; Impugan; Jenafusid; Katlex; Kofuzon; Kolkin; Kutrix; Lasemid; Lasex; Lasiletten; Lasilix; Lasix; Lasix Retard; Lasix Special; Laxur; Lazix; Leodrine; Less Diur; Liside; Logirene; Lowpston; Lowpstron; Luscek; Macasirool; Marsemide; Metflorylthiazidine; Methforylthiazidine; Mirfat; Mita; Moilarorin; Myrosemide; Naclex; Nadis; Nelsix; Neo-Renal; Nephron; Nicorol; Novosemide; Octan Draselny; Odemase; Odemex; Oedemex; Olmagran; Osyrol; Polysquall A; Prefemin; Profemin; Promedes; Promide; Protargen; Puresis; Radisemide; Radonna; Radouna; Retep; Rodiuran; Rontyl; Rosemide; Rosis; Rusyde; Sal Diureticum; Salinex; Salix; Salurex; Salurid; Saluron; Salutensin; Seguril; Selectofur; Sigasalur; Sisuril; Spirofur; Synephron; Transit; Trofurit; Uremide; Uresix; Urex; Urex-M; Urian; Uridon; Uritol; Urosemide; Vergonil; Vesix; Yidoli; Zafimida

Active ingredient: Furosemide - Chemisty and Biological Activity

2009-07-21T22:07:00.001-07:00

Chemisty and Biological Activity

Chemical Formula

C12H11ClN2O5S

Chemical Name

4-chloro-2-(2-furylmethylamino)-5-sulfamoyl-benzoic acid

Chemical Structure

Molecular Weight

330.745 g/mol

Physical State

Solid

Melting Point

206 oC

Water Solubility

0.006 mg/mL

Isoelectric Point

Not Available

Organisms Affected

Humans and other mammals

Phase 1 Metabolising Enzyme (1-st Step of Metabolism)

Not Available

Primary Drug Target
Name Na+/K+/2Cl- co-transporter
Gene Name SLC12A1
Synonyms Solute carrier family 12, member 1; Bumetanide-sensitive sodium-; potassium-chloride cotransporter 2; Kidney-specific Na-K-Cl symporter
Specific Function Electrically silent transporter system. Mediates sodium and chloride reabsorption. Plays a vital role in the regulation of ionic balance and cell volume

Active ingredient: Furosemide - Basic Profile / Key Facts

2009-07-21T22:00:00.000-07:00

Furosemide

Basic Profile / Key Facts Chemisty and Biological Activity Brands / Synonyms

Nutrilib.com
A comprihensive source of nutritional information

Basic Profile / Key Facts

Drug Category

* Diuretics

Dosage Forms

* Tablet

Indications

For the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. Also for the treatment of hypertension alone or in combination with other antihypertensive agents.

Pharmacology

Furosemide, a sulfonamide-type loop diuretic structurally related to bumetanide, is used to manage hypertension and edema associated with congestive heart failure, cirrhosis, and renal disease, including the nephrotic syndrome.

Mechanism of Action

Furosemide, by inhibiting the reabsorption of sodium and chloride in the ascending limb of the loop of Henle, increases the urinary excretion of sodium, chloride, and water. Furosemide also increases the excretion of potassium, hydrogen, calcium, magnesium, ammonium, and phosphate and, as it inhibits carbonic anhydrase, bicarbonate.

Absorption

Not Available

Toxicity

Not Available

Biotrnasformation / Drug Metabolism

Not Available

Contraindications

Furosemide is contraindicated in patients with anuria and in patients with a history of hypersensitivity to furosemide.

Drug Interactions

Furosemide may increase the ototoxic potential of aminoglycoside antibiotics, especially in the presence of impaired renal function. Except in life-threatening situations, avoid this combination.

Furosemide should not be used concomitantly with ethacrynic acid because of the possibility of ototoxicity. Patients receiving high doses of salicylates concomitantly with furosemide, as in rheumatic disease, may experience salicylate toxicity at lower doses because of competitive renal excretory sites.

Furosemide has a tendency to antagonize the skeletal muscle relaxing effect of tubocurarine and may potentiate the action of succinylcholine.

Lithium generally should not be given with diuretics because they reduce lithium's renal clearance and add a high risk of lithium toxicity.

Furosemide may add to or potentiate the therapeutic effect of other antihypertensive drugs. Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs.

Furosemide may decrease arterial responsiveness to norepinephrine. However, norepinephrine may still be used effectively.

Tablets

Simultaneous administration of sucralfate and furosemide tablets may reduce the natriuretic and antihypertensive effects of furosemide. Patients receiving both drugs should be observed closely to determine if the desired diuretic and/or antihypertensive effect of furosemide is achieved. The intake of furosemide and sucralfate should be separated by at least two hours.

Tablets, Injection, and Oral Solution

One study in six subjects demonstrated that the combination of furosemide and acetylsalicylic acid temporarily reduced creatinine clearance in patients with chronic renal insufficiency. There are case reports of patients who developed increased BUN, serum creatinine and serum potassium levels, and weight gain when furosemide was used in conjunction with NSAIDs.

Literature reports indicate that coadministration of indomethacin may reduce the natriuretic and antihypertensive effects of furosemide in some patients by inhibiting prostaglandin synthesis. Indomethacin may also affect plasma renin levels, aldosterone excretion, and renin profile evaluation. Patients receiving both indomethacin and furosemide should be observed closely to determine if the desired diuretic and/or antihypertensive effect of furosemide is achieved.

Lasix (Furosemide) - Drug Interactions, Contraindications, Overdosage

2009-07-21T21:51:00.001-07:00

DRUG INTERACTIONS

Drug Interactions

LASIX may increase the ototoxic potential of aminoglycoside antibiotics, especially in the presence of impaired renal function. Except in life-threatening situations, avoid this combination.

LASIX should not be used concomitantly with ethacrynic acid because of the possibility of ototoxicity. Patients receiving high doses of salicylates concomitantly with LASIX, as in rheumatic disease, may experience salicylate toxicity at lower doses because of competitive renal excretory sites.

LASIX has a tendency to antagonize the skeletal muscle relaxing effect of tubocurarine and may potentiate the action of succinylcholine.

Lithium generally should not be given with diuretics because they reduce lithium's renal clearance and add a high risk of lithium toxicity.

LASIX may add to or potentiate the therapeutic effect of other antihypertensive drugs. Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs.

LASIX may decrease arterial responsiveness to norepinephrine. However, norepinephrine may still be used effectively.

Simultaneous administration of sucralfate and LASIX tablets may reduce the natriuretic and antihypertensive effects of LASIX. Patients receiving both drugs should be observed closely to determine if the desired diuretic and/or antihypertensive effect of LASIX is achieved. The intake of LASIX and sucralfate should be separated by at least two hours.

One study in six subjects demonstrated that the combination of furosemide and acetylsalicylic acid temporarily reduced creatinine clearance in patients with chronic renal insufficiency. There are case reports of patients who developed increased BUN, serum creatinine and serum potassium levels, and weight gain when furosemide was used in conjunction with NSAIDs.

Literature reports indicate that coadministration of indomethacin may reduce the natriuretic and antihypertensive effects of LASIX (furosemide) in some patients by inhibiting prostaglandin synthesis. Indomethacin may also affect plasma renin levels, aldosterone excretion, and renin profile evaluation. Patients receiving both indomethacin and LASIX should be observed closely to determine if the desired diuretic and/or antihypertensive effect of LASIX is achieved.

OVERDOSAGE

The principal signs and symptoms of overdose with LASIX are dehydration, blood volume reduction, hypotension, electrolyte imbalance, hypokalemia and hypochloremic alkalosis, and are extensions of its diuretic action.

The acute toxicity of LASIX has been determined in mice, rats and dogs. In all three, the oral LD50exceeded 1000 mg/kg body weight, while the intravenous LD50ranged from 300 to 680 mg/kg. The acute intragastric toxicity in neonatal rats is 7 to 10 times that of adult rats.

The concentration of LASIX in biological fluids associated with toxicity or death is not known.

Treatment of overdosage is supportive and consists of replacement of excessive fluid and electrolyte losses. Serum electrolytes, carbon dioxide level and blood pressure should be determined frequently. Adequate drainage must be assured in patients with urinary bladder outlet obstruction (such as prostatic hypertrophy).

Hemodialysis does not accelerate furosemide elimination.

CONTRAINDICATIONS

LASIX is contraindicated in patients with anuria and in patients with a history of hypersensitivity to furosemide.

Lasix (Furosemide) - Side Effects and Adverse Reactions

2009-07-21T21:48:00.000-07:00

ADVERSE REACTIONS

Adverse reactions are categorized below by organ system and listed by decreasing severity.

Gastrointestinal System Reactions

1. hepatic encephalopathy in patients with hepatocellular insufficiency
2. pancreatitis
3. jaundice (intrahepatic cholestatic jaundice)
4. anorexia
5. oral and gastric irritation
6. cramping
7. diarrhea
8. constipation
9. nausea
10. vomiting

Systemic Hypersensitivity Reactions

1. systemic vasculitis
2. interstitial nephritis
3. necrotizing angiitis

Central Nervous System Reactions

1. tinnitus and hearing loss
2. paresthesias
3. vertigo
4. dizziness
5. headache
6. blurred vision
7. xanthopsia

Hematologic Reactions

1. aplastic anemia (rare)
2. thrombocytopenia
3. agranulocytosis (rare)
4. hemolytic anemia
5. leukopenia
6. anemia

Dermatologic-Hypersensitivity Reactions

1. exfoliative dermatitis
2. bullous pemphigoid
3. erythema multiforme
4. purpura
5. photosensitivity
6. urticaria
7. rash
8. pruritus

Cardiovascular Reaction

Orthostatic hypotension may occur and be aggravated by alcohol, barbiturates or narcotics.

Other Reactions

1. hyperglycemia
2. glycosuria
3. hyperuricemia
4. muscle spasm
5. weakness
6. restlessness
7. urinary bladder spasm
8. thrombophlebitis
9. fever

Whenever adverse reactions are moderate or severe, LASIX dosage should be reduced or therapy withdrawn.

REPORTS OF SIDE EFFECTS / ADVERSE REACTIONS RELATED TO LASIX

Below is a sample of reports where side effects / adverse reactions may be related to Lasix. The information is not vetted and should not be cosidered as verified clinical evidence.

Possible Lasix side effects / adverse reactions in 79 year old male

Reported by a physician from Japan on 2007-01-12

Patient: 79 year old male weighing 38.0 kg (83.6 pounds)

Reactions: Anorexia, Dehydration, NO Therapeutic Response, Depressed Level of Consciousness, Atrial Fibrillation, Sinus Arrest, Arrhythmia

Adverse event resulted in: death

Suspect drug(s):
Lasix
Administration route: Oral
Indication: Cardiac Failure Chronic
Start date: 2006-11-28
End date: 2006-12-17

Ancaron
Administration route: Oral
Indication: Atrial Fibrillation
Start date: 2006-12-07
End date: 2006-12-12

Ancaron
Administration route: Oral
Start date: 2006-12-13
End date: 2006-12-17

Longes
Administration route: Oral
Indication: Cardiac Failure Chronic
Start date: 2006-11-28
End date: 2006-12-17

Aldactazide-A
Administration route: Oral
Indication: Cardiac Failure Chronic
Start date: 2006-11-28
End date: 2006-12-17

Other drugs received by patient: Warfarin Sodium; Aspirin; Aspirin

Possible Lasix side effects / adverse reactions in 73 year old male

Reported by a health professional (non-physician/pharmacist) from Sweden on 2007-01-12

Patient: 73 year old male

Reactions: Gastrointestinal Haemorrhage, Syncope, Anaemia, Blood Creatinine Increased

Adverse event resulted in: hospitalization

Suspect drug(s):
Atacand HCT
Administration route: Oral
Indication: Essential Hypertension

Lasix
Administration route: Oral

Trombyl 160 MG
Administration route: Oral

Metformin
Administration route: Oral
Indication: Diabetes Mellitus

Glibenklamid Recip 1,75 MG
Administration route: Oral
Indication: Diabetes Mellitus

Diclofenac Sodium
Indication: Gout

Other drugs received by patient: Folacin 5 MG; Behepan 1 MG; Lansoprazole

Possible Lasix side effects / adverse reactions in 84 year old male

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-12

Patient: 84 year old male

Reactions: Subdural Haematoma, International Normalised Ratio Increased, Fall, Haematoma

Adverse event resulted in: hospitalization

Suspect drug(s):
Amlor
Administration route: Oral

Perindopril Erbumine
Administration route: Oral

Previscan
Administration route: Oral
Indication: Atrial Flutter

Glucophage
Administration route: Oral

Lasix
Administration route: Oral

Possible Lasix side effects / adverse reactions in 91 year old female

Reported by a individual with unspecified qualification from France on 2007-01-16

Patient: 91 year old female

Reactions: Right Ventricular Failure, Bedridden, Hyperkalaemia, Lung Infection, Atrioventricular Block Complete, Cachexia, Renal Failure, Decubitus Ulcer, Hypoxia, Hyperthyroidism

Adverse event resulted in: death, hospitalization

Suspect drug(s):
Cordarone
Dosage: 200 mg 1x per 1 day
Administration route: Oral
Indication: Atrial Fibrillation

Cordarone
Dosage: 200 mg 1x per 1 day
Administration route: Oral
Indication: Atrial Flutter

Perindopril Erbumine
Administration route: Oral
Indication: Essential Hypertension
End date: 2006-10-18

Lasix
Dosage: 40 mg 1x per 1 day
Administration route: Oral
End date: 2006-10-18

Voltaren
Dosage: 75 mg 1x per 1 day
Administration route: Oral
Indication: Rheumatoid Arthritis
End date: 2006-10-18

Other drugs received by patient: Stablon (Tianeptine); Depakene; Amlodipine Besylate

Possible Lasix side effects / adverse reactions in 76 year old female

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-16

Patient: 76 year old female weighing 70.0 kg (154.0 pounds)

Reactions: Pruritus, Rash Erythematous, Rash Maculo-Papular

Adverse event resulted in: hospitalization

Suspect drug(s):
Aldactone
Dosage: daily dose:25mg
Administration route: Oral
Start date: 2006-08-31
End date: 2006-09-13

Lasix
Administration route: Oral
Start date: 2006-07-20
End date: 2006-09-16

Triatec
Administration route: Oral
Start date: 2006-07-27
End date: 2006-09-13

Previscan
Administration route: Oral

Cordarone
Administration route: Oral
Start date: 2006-08-24
End date: 2006-09-13

Diffu K
Administration route: Oral
Start date: 2006-08-31
End date: 2006-09-16

Possible Lasix side effects / adverse reactions in 65 year old female

Reported by a health professional (non-physician/pharmacist) from Japan on 2007-01-16

Patient: 65 year old female

Reactions: Pemphigoid, Stevens-Johnson Syndrome

Suspect drug(s):
Lasix
Administration route: Oral
End date: 2006-12-14

BI Sifrol
Start date: 2006-12-08
End date: 2006-12-14

Other drugs received by patient: Gramalil; Luprac

Possible Lasix side effects / adverse reactions in 74 year old female

Reported by a individual with unspecified qualification on 2007-01-16

Patient: 74 year old female

Reactions: Pruritus, Rash Erythematous, Eczema

Adverse event resulted in: hospitalization

Suspect drug(s):
Lasix
Administration route: Oral

Cordarone
Administration route: Oral

Allopurinol TAB
Administration route: Oral
Start date: 2006-06-01
End date: 2006-09-22

Nebcin
Start date: 2006-07-10
End date: 2006-07-12

Previscan /00789001/
Administration route: Oral

Gentamicin
Start date: 2006-07-13
End date: 2006-07-15

Other drugs received by patient: Aldactone; Adancor; Corvasal /00547101/; Imovane; Nexium; Serevent; Mixtard /00634701/

Possible Lasix side effects / adverse reactions in 91 year old female

Reported by a individual with unspecified qualification from France on 2007-01-16

Patient: 91 year old female

Reactions: Escherichia Urinary Tract Infection, Hyperkalaemia, Pain, Failure TO Thrive, C-Reactive Protein Increased, Decubitus Ulcer, Oedema Peripheral, Pulmonary Congestion, Hypoxia, Renal Failure Acute, White Blood Cell Count Increased, Dyspnoea, General Physical Health Deterioration, Physiotherapy Chest, Brain Natriuretic Peptide Increased, Cardiac Failure, Bronchitis, Asthenia

Adverse event resulted in: death, hospitalization

Suspect drug(s):
Voltarene LP
Dosage: 75 mg, qd
Administration route: Oral
Indication: Rheumatoid Arthritis
End date: 2006-10-18

Perindopril Erbumine
Administration route: Oral
Indication: Essential Hypertension
End date: 2006-10-18

Lasix
Dosage: 40 mg, qd
Administration route: Oral
End date: 2006-10-18

Cordarone
Dosage: 200 mg, qd
Administration route: Oral
Indication: Atrial Fibrillation
End date: 2006-10-18

Other drugs received by patient: Depakene; Amlor; Stablon

Possible Lasix side effects / adverse reactions in 72 year old female

Reported by a physician from France on 2007-01-17

Patient: 72 year old female

Reactions: Malaise, Hypoglycaemia, Renal Failure Acute

Adverse event resulted in: hospitalization

Suspect drug(s):
Acarbose
Dosage: total daily dose: 150 mg unit dose: 50 mg
Administration route: Oral
Indication: Diabetes Mellitus
End date: 2006-07-07

Kayexalate
Administration route: Oral
Indication: Unevaluable Event

Glucophage
Dosage: total daily dose: 3000 mg unit dose: 1000 mg
Administration route: Oral
Indication: Diabetes Mellitus

Omeprazole
Dosage: total daily dose: 20 mg unit dose: 20 mg
Administration route: Oral
Indication: Duodenitis

Hemigoxine Nativelle
Dosage: total daily dose: 0.125 mg unit dose: 0.125 mg
Administration route: Oral
Indication: Atrial Fibrillation

Lasix
Dosage: total daily dose: 80 mg unit dose: 40 mg
Administration route: Oral
Indication: Essential Hypertension

Possible Lasix side effects / adverse reactions in 48 year old female

Reported by a individual with unspecified qualification from France on 2007-01-17

Patient: 48 year old female

Reactions: Rhabdomyolysis, Dizziness, Amnesia

Suspect drug(s):
Lasix
Dosage: dose: unknown dosage

Anti-Parathyroid Hormones
Indication: Hyperparathyroidism Secondary
Start date: 2006-07-01
End date: 2006-10-01

Other drugs received by patient: Sevelamer Hydrochloride; Rabeprazole Sodium; Calciprat

Possible Lasix side effects / adverse reactions in 22 year old female

Reported by a consumer/non-health professional from Brazil on 2007-01-17

Patient: 22 year old female weighing 97.0 kg (213.4 pounds)

Reactions: Vomiting, Diarrhoea, Dizziness, Muscular Weakness, Headache

Adverse event resulted in: disablity

Suspect drug(s):
Lasix

Other drugs received by patient: Tandrilax; Plasil /00041901/; Omeprazole; Levonorgestrel and Ethinyl Estradiol; Amlodipine

Possible Lasix side effects / adverse reactions in 60 year old female

Reported by a physician from Japan on 2007-01-18

Patient: 60 year old female weighing 62.8 kg (138.2 pounds)

Reactions: Pleural Effusion

Adverse event resulted in: hospitalization

Suspect drug(s):
Anafranil
Dosage: unk, unk, oral
Administration route: Oral
Indication: Depression

Lasix
Dosage: see image
Administration route: Oral
Indication: Pleural Effusion
Start date: 2006-10-26
End date: 2006-11-05

Lasix
Dosage: see image
Administration route: Oral
Indication: Pleural Effusion
Start date: 2006-11-06

Blinded Therapy (Exemestane VS Anastrazole)()
Dosage: unk, unk, oral
Administration route: Oral
Indication: Breast Cancer
Start date: 2006-11-16

Nitrazepam
Dosage: unk, unk, oral
Administration route: Oral
Indication: Depression

Almarl(arotinolol Hydrochloride)
Dosage: unk, unk, oral
Administration route: Oral
Indication: Hypertension

Loxonin /00890702(loxoprofen Sodium)
Dosage: unk, unk, oral
Administration route: Oral
Indication: Pain

Possible Lasix side effects / adverse reactions in 34 year old male

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-18

Patient: 34 year old male weighing 60.0 kg (132.0 pounds)

Reactions: Dermatitis Bullous, Thrombocytopenia

Adverse event resulted in: hospitalization

Suspect drug(s):
Triflucan
Indication: Fungal Infection
Start date: 2006-09-27
End date: 2006-10-06

Amiklin
Start date: 2006-09-27
End date: 2006-10-02

Cordarone
Administration route: Oral
Start date: 2006-09-27
End date: 2006-10-05

Lasix
Indication: Renal Failure Acute
Start date: 2006-09-27
End date: 2006-09-28

Tienam
Start date: 2006-09-27
End date: 2006-09-28

Vancomycin
Start date: 2006-09-27
End date: 2006-10-14

Possible Lasix side effects / adverse reactions in 58 year old male

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-19

Patient: 58 year old male

Reactions: Drug Interaction, Angiopathy, Renal Failure Acute, Nephropathy

Adverse event resulted in: hospitalization

Suspect drug(s):
Lasix
Dosage: daily dose: 20 milligram(s)
Administration route: Oral
Indication: Ill-Defined Disorder
End date: 2006-05-02

Lasix
Dosage: daily dose: 80 milligram(s)
Administration route: Oral
Start date: 2006-05-03
End date: 2006-05-08

Lasix
Dosage: daily dose: 40 milligram(s)
Administration route: Oral
Start date: 2006-05-09

Other drugs received by patient possibly interacting with the suspect drug:
Perindopril Erbumine
Dosage: daily dose: 4 milligram(s)
Administration route: Oral
Indication: Ill-Defined Disorder
End date: 2006-05-02

Perindopril Erbumine
Dosage: daily dose: 2 milligram(s)
Administration route: Oral
Start date: 2006-05-12

Nexen
Dosage: daily dose: unknown
Administration route: Oral
Indication: Back Pain
Start date: 2005-11-01
End date: 2006-05-02

Other drugs received by patient: Kredex; Fenofibrate

Possible Lasix side effects / adverse reactions in 81 year old female

Reported by a physician from France on 2007-01-22

Patient: 81 year old female

Reactions: Renal Failure Acute

Adverse event resulted in: hospitalization

Suspect drug(s):
Acarbose
Administration route: Oral
Indication: Unevaluable Event
End date: 2006-11-05

Lasix
Administration route: Oral
Indication: Unevaluable Event

Lasix
Administration route: Oral

Levothyroxine Sodium
Administration route: Oral
Indication: Unevaluable Event

Levothyroxine Sodium
Administration route: Oral

Novonorm
Indication: Unevaluable Event
End date: 2006-11-05

Fozitec
Administration route: Oral
Indication: Unevaluable Event
Start date: 2006-09-15
End date: 2006-11-05

Other drugs received by patient: Hydrea; Avlocardyl; Previscan; Inipomp

Possible Lasix side effects / adverse reactions in 92 year old male

Reported by a individual with unspecified qualification from Japan on 2007-01-23

Patient: 92 year old male

Reactions: Bronchopneumonia, Oedema Peripheral, Condition Aggravated, Respiratory Arrest, Respiratory Distress

Adverse event resulted in: death

Suspect drug(s):
Stromectol
Dosage: 6 mg/daily
Administration route: Oral
Indication: Acarodermatitis
Start date: 2006-10-05
End date: 2006-10-05

TAB Epinastine Hydrochloride
Dosage: 20 mg/daily
Administration route: Oral
Indication: Pruritus
Start date: 2006-10-05
End date: 2006-10-07

Lasix
Dosage: 1 tablet/daily
Administration route: Oral
Start date: 2006-10-02
End date: 2006-10-17

Other drugs received by patient: Eurax

Possible Lasix side effects / adverse reactions in 73 year old male

Reported by a health professional (non-physician/pharmacist) from Sweden on 2007-01-23

Patient: 73 year old male

Reactions: Gastrointestinal Haemorrhage, Syncope, Anaemia, Blood Creatinine Increased

Adverse event resulted in: hospitalization

Suspect drug(s):
Atacand HCT
Dosage: 16 mg / 12.5 mg
Administration route: Oral
Indication: Essential Hypertension

Metoprolol Tartrate
Administration route: Oral

Lasix
Administration route: Oral

Aspirin
Administration route: Oral

Diklofenac
Administration route: Oral
Indication: Gout

Metformin HCL
Administration route: Oral

Other drugs received by patient: Folacin; Behepan; Lansoprazole; Glibenklamid

Possible Lasix side effects / adverse reactions in 49 year old female

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-23

Patient: 49 year old female

Reactions: Renal Failure Acute, Stevens-Johnson Syndrome

Adverse event resulted in: life threatening event

Suspect drug(s):
Dalacine
Administration route: Oral
Start date: 2006-10-12
End date: 2006-11-03

Lasix
Dosage: daily dose:1gram
Start date: 2006-10-30
End date: 2006-11-01

Oflocet
Administration route: Oral
Start date: 2006-10-13
End date: 2006-11-03

Gentamicin
Start date: 2006-10-13
End date: 2006-10-24

Possible Lasix side effects / adverse reactions in 84 year old male

Reported by a health professional (non-physician/pharmacist) from France on 2007-01-24

Patient: 84 year old male

Reactions: Hyponatraemia, Orthostatic Hypotension

Adverse event resulted in: hospitalization

Suspect drug(s):
Xatral
Administration route: Oral
Indication: Drug USE FOR Unknown Indication
End date: 2006-10-21

Nisis
Administration route: Oral
Indication: Hypertension
End date: 2006-10-21

Aldalix
Administration route: Oral
Indication: Hypertension
End date: 2006-10-21

Amlor
Administration route: Oral
Indication: Hypertension
End date: 2006-10-21

Temesta
Administration route: Oral
Indication: Anxiety
End date: 2006-10-21

Lasix
Administration route: Oral
Indication: Hypertension
End date: 2006-10-21

Other drugs received by patient: Imodium; Creon; Cordarone; Glimepiride; Minisintrom

Possible Lasix side effects / adverse reactions in 78 year old male

Reported by a individual with unspecified qualification from Japan on 2007-01-25

Patient: 78 year old male

Reactions: Blood Alkaline Phosphatase Increased, Pruritus, Blood Lactate Dehydrogenase Increased, Erythema, Haemoglobin Decreased, RED Blood Cell Count Decreased, Cardiac Failure, Cerebral Artery Embolism, Pemphigoid, Blister

Suspect drug(s):
Lasix
Administration route: Oral
End date: 2005-06-20

Lasix
Administration route: Oral
Start date: 2005-08-03
End date: 2005-08-17

Artist

Other drugs received by patient: Micardis; Adalat; Warfarin Sodium; Luprac

Lasix (Furosemide) - Warnings and Precautions

2009-07-21T21:46:00.000-07:00

WARNING

LASIX®(furosemide) is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. Therefore, careful medical supervision is required and dose and dose schedule must be adjusted to the individual patient's needs. (See DOSAGE AND ADMINISTRATION.)

WARNINGS

In patients with hepatic cirrhosis and ascites, LASIX therapy is best initiated in the hospital. In hepatic coma and in states of electrolyte depletion, therapy should not be instituted until the basic condition is improved. Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis. Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis.

If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, LASIX should be discontinued.

Cases of tinnitus and reversible or irreversible hearing impairment have been reported. Usually, reports indicate that LASIX ototoxicity is associated with rapid injection, severe renal impairment, doses exceeding several times the usual recommended dose, or concomitant therapy with aminoglycoside antibiotics, ethacrynic acid, or other ototoxic drugs. If the physician elects to use high dose parenteral therapy, controlled intravenous infusion is advisable (for adults, an infusion rate not exceeding 4 mg LASIX per minute has been used).

PRECAUTIONS

General

Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in elderly patients. As with any effective diuretic, electrolyte depletion may occur during LASIX therapy, especially in patients receiving higher doses and a restricted salt intake. Hypokalemia may develop with LASIX, especially with brisk diuresis, inadequate oral electrolyte intake, when cirrhosis is present, or during concomitant use of corticosteroids or ACTH. Digitalis therapy may exaggerate metabolic effects of hypokalemia, especially myocardial effects.

All patients receiving LASIX therapy should be observed for these signs or symptoms of fluid or electrolyte imbalance (hyponatremia, hypochloremic alkalosis, hypokalemia, hypomagnesemia or hypocalcemia): dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps, muscular fatigue, hypotension, oliguria, tachycardia, arrhythmia, or gastrointestinal disturbances such as nausea and vomiting. Increases in blood glucose and alterations in glucose tolerance tests (with abnormalities of the fasting and 2-hour postprandial sugar) have been observed, and rarely, precipitation of diabetes mellitus has been reported.

Asymptomatic hyperuricemia can occur and gout may rarely be precipitated.

Patients allergic to sulfonamides may also be allergic to LASIX. The possibility exists of exacerbation or activation of systemic lupus erythematosus.

As with many other drugs, patients should be observed regularly for the possible occurrence of blood dyscrasias, liver or kidney damage, or other idiosyncratic reactions.

Information for Patients

Patients receiving LASIX should be advised that they may experience symptoms from excessive fluid and/or electrolyte losses. The postural hypotension that sometimes occurs can usually be managed by getting up slowly. Potassium supplements and/or dietary measures may be needed to control or avoid hypokalemia.

Patients with diabetes mellitus should be told that furosemide may increase blood glucose levels and thereby affect urine glucose tests. The skin of some patients may be more sensitive to the effects of sunlight while taking furosemide.

Hypertensive patients should avoid medications that may increase blood pressure, including over-the-counter products for appetite suppression and cold symptoms.

Laboratory Tests

Serum electrolytes (particularly potassium), CO2, creatinine and BUN should be determined frequently during the first few months of LASIX therapy and periodically thereafter. Serum and urine electrolyte determinations are particularly important when the patient is vomiting profusely or receiving parenteral fluids. Abnormalities should be corrected or the drug temporarily withdrawn. Other medications may also influence serum electrolytes.

Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency.

Urine and blood glucose should be checked periodically in diabetics receiving LASIX, even in those suspected of latent diabetes.

LASIX may lower serum levels of calcium (rarely cases of tetany have been reported) and magnesium. Accordingly, serum levels of these electrolytes should be determined periodically.

Drug Interactions

LASIX may increase the ototoxic potential of aminoglycoside antibiotics, especially in the presence of impaired renal function. Except in life-threatening situations, avoid this combination.

LASIX should not be used concomitantly with ethacrynic acid because of the possibility of ototoxicity. Patients receiving high doses of salicylates concomitantly with LASIX, as in rheumatic disease, may experience salicylate toxicity at lower doses because of competitive renal excretory sites.

LASIX has a tendency to antagonize the skeletal muscle relaxing effect of tubocurarine and may potentiate the action of succinylcholine.

Lithium generally should not be given with diuretics because they reduce lithium's renal clearance and add a high risk of lithium toxicity.

LASIX may add to or potentiate the therapeutic effect of other antihypertensive drugs. Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs.

LASIX may decrease arterial responsiveness to norepinephrine. However, norepinephrine may still be used effectively.

Simultaneous administration of sucralfate and LASIX tablets may reduce the natriuretic and antihypertensive effects of LASIX. Patients receiving both drugs should be observed closely to determine if the desired diuretic and/or antihypertensive effect of LASIX is achieved. The intake of LASIX and sucralfate should be separated by at least two hours.

One study in six subjects demonstrated that the combination of furosemide and acetylsalicylic acid temporarily reduced creatinine clearance in patients with chronic renal insufficiency. There are case reports of patients who developed increased BUN, serum creatinine and serum potassium levels, and weight gain when furosemide was used in conjunction with NSAIDs.

Literature reports indicate that coadministration of indomethacin may reduce the natriuretic and antihypertensive effects of LASIX (furosemide) in some patients by inhibiting prostaglandin synthesis. Indomethacin may also affect plasma renin levels, aldosterone excretion, and renin profile evaluation. Patients receiving both indomethacin and LASIX should be observed closely to determine if the desired diuretic and/or antihypertensive effect of LASIX is achieved.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Furosemide was tested for carcinogenicity by oral administration in one strain of mice and one strain of rats. A small but significantly increased incidence of mammary gland carcinomas occurred in female mice at a dose 17.5 times the maximum human dose of 600 mg. There were marginal increases in uncommon tumors in male rats at a dose of 15 mg/kg (slightly greater than the maximum human dose) but not at 30 mg/kg.

Furosemide was devoid of mutagenic activity in various strains of Salmonella typhimurium when tested in the presence or absence of an in vitro metabolic activation system, and questionably positive for gene mutation in mouse lymphoma cells in the presence of rat liver S9 at the highest dose tested. Furosemide did not induce sister chromatid exchange in human cells in vitro, but other studies on chromosomal aberrations in human cells in vitro gave conflicting results. In Chinese hamster cells it induced chromosomal damage but was questionably positive for sister chromatid exchange. Studies on the induction by furosemide of chromosomal aberrations in mice were inconclusive. The urine of rats treated with this drug did not induce gene conversion in Saccharomyces cerevisiae.

LASIX (furosemide) produced no impairment of fertility in male or female rats, at 100 mg/kg/day (the maximum effective diuretic dose in the rat and 8 times the maximal human dose of 600 mg/day).

Pregnancy

PREGNANCY CATEGORY C - Furosemide has been shown to cause unexplained maternal deaths and abortions in rabbits at 2, 4 and 8 times the maximal recommended human dose. There are no adequate and well-controlled studies in pregnant women. LASIX should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

The effects of furosemide on embryonic and fetal development and on pregnant dams were studied in mice, rats and rabbits.

Furosemide caused unexplained maternal deaths and abortions in the rabbit at the lowest dose of 25 mg/kg (2 times the maximal recommended human dose of 600 mg/day). In another study, a dose of 50 mg/kg (4 times the maximal recommended human dose of 600 mg/day) also caused maternal deaths and abortions when administered to rabbits between Days 12 and 17 of gestation. In a third study, none of the pregnant rabbits survived a dose of 100 mg/kg. Data from the above studies indicate fetal lethality that can precede maternal deaths.

The results of the mouse study and one of the three rabbit studies also showed an increased incidence and severity of hydronephrosis (distention of the renal pelvis and, in some cases, of the ureters) in fetuses derived from the treated dams as compared with the incidence in fetuses from the control group.

Nursing Mothers

Because it appears in breast milk, caution should be exercised when LASIX is administered to a nursing mother.

Geriatric Use

Controlled clinical studies of LASIX did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.

This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and it may be useful to monitor renal function. (See PRECAUTIONS: General and DOSAGE AND ADMINISTRATION.)

Lasix (Furosemide) - Indications and Dosage

2009-07-21T21:42:00.000-07:00

INDICATIONS AND USAGE

Edema

LASIX is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. LASIX is particularly useful when an agent with greater diuretic potential is desired.

Hypertension

Oral LASIX may be used in adults for the treatment of hypertension alone or in combination with other antihypertensive agents. Hypertensive patients who cannot be adequately controlled with thiazides will probably also not be adequately controlled with LASIX alone.

DOSAGE AND ADMINISTRATION

Edema

Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response.

Adults

The usual initial dose of LASIX is 20 to 80 mg given as a single dose. Ordinarily a prompt diuresis ensues. If needed, the same dose can be administered 6 to 8 hours later or the dose may be increased. The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained. The individually determined single dose should then be given once or twice daily (eg, at 8 am and 2 pm). The dose of LASIX may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states.

Edema may be most efficiently and safely mobilized by giving LASIX on 2 to 4 consecutive days each week.

When doses exceeding 80 mg/day are given for prolonged periods, careful clinical observation and laboratory monitoring are particularly advisable. (See PRECAUTIONS: Laboratory Tests.)

Geriatric patients

In general, dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range (see PRECAUTIONS: Geriatric Use).

Pediatric patients

The usual initial dose of oral LASIX in pediatric patients is 2 mg/kg body weight, given as a single dose. If the diuretic response is not satisfactory after the initial dose, dosage may be increased by 1 or 2 mg/kg no sooner than 6 to 8 hours after the previous dose. Doses greater than 6 mg/kg body weight are not recommended. For maintenance therapy in pediatric patients, the dose should be adjusted to the minimum effective level.

Hypertension

Therapy should be individualized according to the patient's response to gain maximal therapeutic response and to determine the minimal dose needed to maintain the therapeutic response.

Adults

The usual initial dose of LASIX for hypertension is 80 mg, usually divided into 40 mg twice a day. Dosage should then be adjusted according to response. If response is not satisfactory, add other antihypertensive agents.

Changes in blood pressure must be carefully monitored when LASIX is used with other antihypertensive drugs, especially during initial therapy. To prevent excessive drop in blood pressure, the dosage of other agents should be reduced by at least 50 percent when LASIX is added to the regimen. As the blood pressure falls under the potentiating effect of LASIX, a further reduction in dosage or even discontinuation of other antihypertensive drugs may be necessary.

Geriatric patients

In general, dose selection and dose adjustment for the elderly patient should be cautious, usually starting at the low end of the dosing range (see PRECAUTIONS: Geriatric Use).

HOW SUPPLIED

LASIX (furosemide) Tablets 20 mg are supplied as white, oval, monogrammed tablets in Bottles of 100 (NDC 0039-0067-10), 500 (NDC 0039-0067-50), and 1000 (NDC 0039-0067-70). The 20 mg tablets are imprinted with "Lasix®" on one side and "HOECHST" on the other, or with "Lasix®" on one side.

LASIX Tablets 40 mg are supplied as white, round, monogrammed, scored tablets in Bottles of 100 (NDC 0039-0060-13), 500 (NDC 0039-0060-50), 1000 (NDC 0039-0060-70), and Unit Dose Packs of 100 (NDC 0039-0060-11). The 40 mg tablets are imprinted with "Lasix®40" on one side and the Hoechst logo on the other, or with "Lasix®40" on one side.

LASIX Tablets 80 mg are supplied as white, round, monogrammed, facetted edge tablets in Bottles of 50 (NDC 0039-0066-05) and 500 (NDC 0039-0066-50). The 80 mg tablets are imprinted with "Lasix®80" on one side and the Hoechst logo on the other, or with "Lasix®80" on one side.

Note: Dispense in well-closed, light-resistant containers. Exposure to light might cause a slight discoloration. Discolored tablets should not be dispensed.

Tested by USP Dissolution Test 2

Store at 25 C (77 F); excursions permitted to 15 – 30 C (59 – 86 F). [See USP Controlled Room Temperature.]

Revised April 2008

sanofi-aventis U.S. LLC
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Lasix (Furosemide) - Description and Clinical Pharmacology

2009-07-21T21:27:00.000-07:00

DESCRIPTION

LASIX®is a diuretic which is an anthranilic acid derivative. LASIX tablets for oral administration contain furosemide as the active ingredient and the following inactive ingredients: lactose monohydrate NF, magnesium stearate NF, starch NF, talc USP, and colloidal silicon dioxide NF. Chemically, it is 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid. LASIX is available as white tablets for oral administration in dosage strengths of 20, 40 and 80 mg. Furosemide is a white to off-white odorless crystalline powder. It is practically insoluble in water, sparingly soluble in alcohol, freely soluble in dilute alkali solutions and insoluble in dilute acids.

The CAS Registry Number is 54-31-9.

The structural formula is as follows:

CLINICAL PHARMACOLOGY

Investigations into the mode of action of LASIX have utilized micropuncture studies in rats, stop flow experiments in dogs and various clearance studies in both humans and experimental animals. It has been demonstrated that LASIX inhibits primarily the absorption of sodium and chloride not only in the proximal and distal tubules but also in the loop of Henle. The high degree of efficacy is largely due to the unique site of action. The action on the distal tubule is independent of any inhibitory effect on carbonic anhydrase and aldosterone.

Recent evidence suggests that furosemide glucuronide is the only or at least the major biotransformation product of furosemide in man. Furosemide is extensively bound to plasma proteins, mainly to albumin. Plasma concentrations ranging from 1 to 400 μg/mL are 91 to 99% bound in healthy individuals. The unbound fraction averages 2.3 to 4.1% at therapeutic concentrations.

The onset of diuresis following oral administration is within 1 hour. The peak effect occurs within the first or second hour. The duration of diuretic effect is 6 to 8 hours.

In fasted normal men, the mean bioavailability of furosemide from LASIX Tablets and LASIX Oral Solution is 64% and 60%, respectively, of that from an intravenous injection of the drug. Although furosemide is more rapidly absorbed from the oral solution (50 minutes) than from the tablet (87 minutes), peak plasma levels and area under the plasma concentration-time curves do not differ significantly. Peak plasma concentrations increase with increasing dose but times-to-peak do not differ among doses. The terminal half-life of furosemide is approximately 2 hours.

Significantly more furosemide is excreted in urine following the IV injection than after the tablet or oral solution. There are no significant differences between the two oral formulations in the amount of unchanged drug excreted in urine.

Geriatric Population

Furosemide binding to albumin may be reduced in elderly patients. Furosemide is predominantly excreted unchanged in the urine. The renal clearance of furosemide after intravenous administration in older healthy male subjects (60–70 years of age) is statistically significantly smaller than in younger healthy male subjects (20–35 years of age). The initial diuretic effect of furosemide in older subjects is decreased relative to younger subjects. (See PRECAUTIONS: Geriatric Use.)

Acetaminophen

2009-07-20T22:01:00.000-07:00

( N-Acetyl-p-Aminophenol ; APAP )

Pronunciation: (a-SEET-a-MIN-oh-fen)
Class: Analgesic, Antipyretic

Trade Names:
Acephen
- Suppositories 120 mg
- Suppositories 325 mg
- Suppositories 650 mg

Trade Names:
Acetaminophen Children's
- Tablets, chewable 80 mg

Trade Names:
Acetaminophen Extra Strength Caplets
- Tablets 500 mg

Trade Names:
Aminofen
- Tablets 325 mg

Trade Names:
Aminofen Max Extra Strength
- Tablets 500 mg

Trade Names:
Anacin
- Tablets 500 mg

Trade Names:
Apap
- Tablets 325 mg
- Tablets 500 mg

Trade Names:
Apap 500
- Liquid 500 mg per 5 mL

Trade Names:
Apap Infant's Drops
- Solution, concentrate 100 mg/mL

Trade Names:
Apra Children's
- Elixir 160 mg per 5 mL

Trade Names:
Cetafen
- Tablets 325 mg

Trade Names:
Cetafen Extra
- Tablets 500 mg

Trade Names:
Children's Feverall
- Suppositories 120 mg

Trade Names:
Children's Genapap
- Tablets, chewable 80 mg
- Elixir 160 mg per 5 mL

Trade Names:
Children's Mapap
- Tablets, chewable 80 mg

Trade Names:
Children's Silapap
- Elixir 80 mg per 2.5 mL

Trade Names:
Children's Tylenol Dye-Free
- Liquid 160 mg per 5 mL

Trade Names:
Children's Tylenol Meltaways
- Tablets, chewable, dispersible 80 mg

Trade Names:
Children's Tylenol Suspension Liquid
- Liquid 160 mg per 5 mL

Trade Names:
Children's Tylenol with Flavor Creator
- Suspension, oral 160 mg per 5 mL

Trade Names:
Ed-Apap Children's
- Solution 160 mg per 5 mL

Trade Names:
ElixSure Children's Fever Reducer/Pain Reliever
- Solution 160 mg per 5 mL

Trade Names:
Feverall
- Suppositories 650 mg

Trade Names:
Feverall Infants'
- Suppositories 80 mg

Trade Names:
Feverall Junior Strength
- Suppositories 325 mg

Trade Names:
Genapap
- Tablets 325 mg

Trade Names:
Genapap Extra Strength Gelcaps
- Tablets, rapid release 500 mg

Trade Names:
Genebs
- Tablets 325 mg

Trade Names:
Genebs Extra Strength
- Tablets 500 mg

Trade Names:
Infantaire Drops
- Solution, concentrate 100 mg/mL

Trade Names:
Infants' Silapap
- Solution 100 mg/mL

Trade Names:
Jr. Tylenol Meltaways
- Tablets, chewable, dispersible 160 mg

Trade Names:
Mapap
- Capsules 300 mg

Trade Names:
Mapap Arthritis Pain
- Tablets, extended-release 650 mg

Trade Names:
Mapap Caplets
- Tablets 500 mg

Trade Names:
Mapap Gelcaps
- Tablets, rapid-release 500 mg

Trade Names:
Mapap Infant Drops
- Solution 100 mg/mL

Trade Names:
Mapap Junior Strength
- Tablets, chewable 160 mg

Trade Names:
Mapap Regular Strength
- Tablets 325 mg

Trade Names:
Masophen
- Tablets 325 mg
- Tablets 500 mg

Trade Names:
Masophen Extra Strength
- Capsules 500 mg

Trade Names:
Non-Aspirin Extra Strength Caplets
- Tablets 500 mg

Trade Names:
Nortemp Children's
- Suspension, oral 160 mg per 5 mL

Trade Names:
Pain and Fever
- Tablets 325 mg
- Tablets 500 mg

Trade Names:
Pain and Fever Children's
- Tablets, chewable 80 mg

Trade Names:
Pain and Fever Relief Children's
- Solution 160 mg per 5 mL

Trade Names:
Pain and Fever Relief Children's Drops
- Solution, concentrate 100 mg/mL

Trade Names:
Pain Relief Extra Strength Caplets
- Tablets 500 mg

Trade Names:
Pain Reliever
- Tablets 325 mg

Trade Names:
Pain Reliever Extra Strength
- Tablets 500 mg

Trade Names:
Q-Pap
- Tablets 325 mg
- Tablets 500 mg

Trade Names:
Q-Pap Children's
- Liquid 160 mg per 5 mL
- Suspension, oral 100 mg/mL

Trade Names:
Q-Pap Infants Drops
- Solution, concentrate 160 mg per 5 mL

Trade Names:
Quick Melts Children's Non-Aspirin
- Tablets, disintegrating 80 mg

Trade Names:
Quick Melts Jr. Strength Non-Aspirin
- Tablets, disintegrating 160 mg

Trade Names:
Silapap Children's
- Liquid 160 mg per 5 mL

Trade Names:
Silapap Infants
- Solution, concentrate 100 mg/mL

Trade Names:
Tylenol 8 Hour
- Tablets, extended-release 650 mg
- Geltabs 650 mg

Trade Names:
Tylenol Arthritis Pain
- Tablets, extended-release 650 mg
- Geltabs 650 mg

Trade Names:
Tylenol Extra Strength
- Liquid 166.6 mg per 5 mL

Trade Names:
Tylenol Extra Strength Caplets
- Tablets 500 mg

Trade Names:
Tylenol Extra Strength Cool Caplets
- Tablets 500 mg

Trade Names:
Tylenol Extra Strength EZ TABS
- Tablets 500 mg

Trade Names:
Tylenol Extra Strength GoTabs
- Tablets, chewable 500 mg

Trade Names:
Tylenol Extra Strength Rapid Release Gels
- Tablets, immediate-release 500 mg

Trade Names:
Tylenol Infants' Drops
- Solution, concentrate 100 mg/mL

Trade Names:
Tylenol Regular Strength
- Tablets 325 mg

Trade Names:
Tylenol Sore Throat Daytime
- Liquid 500 mg per 15 mL

Trade Names:
UN-Aspirin Extra Strength
- Tablets 500 mg

Trade Names:
Valorin
- Tablets 325 mg
- Tablets 500 mg
Apo-Acetaminophen (Canada)
Atasol (Canada)
Pediatrix (Canada)
Tempra (Canada)
Tylenol Junior Strength Tablets “Meltaways” (Canada)
Pharmacology

Advertisement

Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects in periphery; reduces fever through direct action on hypothalamic heat-regulating center.

Pharmacokinetics

Absorption

Rapid and complete from the GI tract. T max is 0.5 to 2 h; 4 h after overdosage.

Distribution

Distributed throughout most body fluids. Binding to plasma proteins is variable.

Metabolism

Primarily metabolized by hepatic conjugation (94%), and about 4% is metabolized by CYP-450 oxidase to toxic metabolite.

Elimination

The t ½ is about 2 h. 90% to 100% is recovered in the urine within the first day, primarily as inactive metabolites. 5% is excreted as unchanged drug.

Special Populations

Hepatic Function Impairment

The half-life may increase 2-fold or more in patients with liver disease.

Neonates and cirrhotic patients

The t½ is slightly prolonged.

Indications and Usage

Temporarily relieves minor aches and pains due to common cold or flu, backache, headache, arthritis, menstrual and premenstrual cramps, muscular aches, sore throat, toothache; temporarily reduces fever.

Unlabeled Uses

Pain and fever prophylaxis after vaccination.

Contraindications

Standard considerations.

Dosage and Administration

If possible, use the patient's weight to determine the dose; otherwise, use age.

Adults and Children older than 12 yr of age

PO 325 to 650 mg every 4 to 6 h (immediate-release) or 1,300 mg every 8 h (extended-release). Do not exceed 4 g in 24 h.

Children

PO

12 yr of age or 43.6 kg (96 lb) or more

640 mg every 4 to 6 h (max, 5 doses/day [3.2 g in 24 h]).

11 yr of age or 32.7 to 42.3 kg (72 to 95 lb)

480 mg every 4 to 6 h (max, 5 doses/day [2.4 g in 24 h]).

9 to 10 yr of age or 27.3 to 32.3 kg (60 to 71 lb)

400 mg every 4 to 6 h (max, 5 doses/day [2 g in 24 h]).

6 to 8 yr of age or 21.8 to 26.8 kg (48 to 59 lb)

320 mg every 4 to 6 h (max, 5 doses/day [1.6 g in 24 h]).

4 to 5 yr of age or 16.4 to 21.4 kg (36 to 47 lb)

240 mg every 4 h (max, 5 doses/day [1.2 g in 24 h]).

2 to 3 yr of age or 10.9 to 15.9 kg (24 to 35 lb)

160 mg every 4 h (max, 5 doses/day [800 mg in 24 h])

Adults and Children 12 yr of age and older

PR Two 325 mg or one 650 mg suppositories every 4 to 6 h carefully inserted well up into rectum while symptoms persist (max, 3,900 mg in 24 h).

Children

PR

6 to 12 yr of age

One 325 mg suppository every 4 to 6 h carefully inserted well up into rectum while symptoms last (max, 1,900 mg in 24 h).

3 to 6 yr of age

One 120 mg suppository carefully inserted well up into rectum every 4 to 6 h while symptoms persist (max, 720 mg in 24 h).

12 to 36 months of age

One 80 mg suppository carefully inserted well up into rectum every 4 h (max, 480 mg in 24 h).

3 to 11 months of age

One 80 mg suppository carefully inserted well up into rectum every 6 h.

General Advice

* Adult extra-strength formulation should not be used in children younger than 12 yr of age.
* Shake elixirs, infant drops, and suspensions well before using.
* Chew chewable tablets before swallowing.
* Dissolve disintegrating tablets in mouth before swallowing. Do not chew or swallow whole.
* Dissolve in the mouth or chew dispersible tablets before swallowing.
* Swallow extended-release tablets whole; do not crush, break, or chew.
* Suppositories are for rectal use only.
* Remove suppository wrapper before inserting.

Storage/Stability

Oral dose forms

Store at 59° to 80°F. Avoid high humidity.

Suppositories

Store at 36° to 80°F.

Drug Interactions

Busulfan paracetamol possibly inhibits metabolism of intravenous busulfan (manufacturer of intravenous busulfan advises caution within 72 hours of paracetamol)
Colestyramine absorption of paracetamol reduced by colestyramine Other drugs should be taken at least 1 hour before or 4-6 hours after colestyramine to reduce possible interference with absorption
Coumarins prolonged regular use of paracetamol possibly enhances anticoagulant effect of coumarins Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug administration, necessitates more frequent testing. Major changes in diet (especially involving salads and vegetables) and in alcohol consumption may also affect anticoagulant control
Metoclopramide rate of absorption of paracetamol increased by metoclopramide

Adverse Reactions

Hematologic

Hemolytic anemia, leukopenia, neutropenia, pancytopenia, thrombocytopenia.

Hepatic

Jaundice.

Miscellaneous

Allergic skin eruptions, hypoglycemia, fever.

Precautions

Pregnancy

Category B .

Lactation

Excreted in breast milk.

Hepatic Function

Can cause liver damage, especially when recommended dose is exceeded. Chronic alcoholics should not exceed 2 g/day.

Persistent pain or fever

May indicate serious illness.

Overdosage

Symptoms

Abdominal pain, acute renal failure, anorexia, cardiac arrhythmias, confusion, diaphoresis, diarrhea, jaundice, liver failure, low BP, malaise, nausea, vomiting.

Patient Information

* Instruct family to consult health care provider for use in children younger than 3 yr of age, and not to continue taking drug more than 5 days unless advised by health care provider.
* Instruct adult patients not to continue taking drug more than 10 days for pain or 3 days for fever.
* Instruct patients to contact health care provider if new symptoms occur, redness or swelling is present, pain gets worse or lasts for more than 10 days, or fever gets worse or lasts for more than 3 days.
* Advise patient not to use with other products containing acetaminophen.
* Advise patient that if a measuring cup is provided for oral liquids, to use it to determine children's dose.
* Advise patients to shake suspensions well before using.
* Advise patients that if a sore throat is severe, persists for more than 2 days, or is accompanied or followed by fever, headache, nausea, rash, or vomiting, to consult health care provider promptly.
* Advise patients that if they consume 3 or more alcoholic drinks per day, to ask health care provider whether they should take acetaminophen or another pain reliever or fever reducer.
* Caution patients not to exceed the recommended dose. In case of an overdose, instruct patient or caregiver to contact health care provider or a poison control center immediately. Prompt medical attention is critical even if no signs or symptoms are present.
* Advise diabetic patients to use sugar-free form of drug.