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This should be done on the same scale at the same time each day and with the same clothing proscar 5 mg on-line prostate cancer outlook. Editorial comments • For the treatment of essential hypertension 5 mg proscar amex prostate cancer metastasized, potassium-sparing diuretics are usually combined with other diuretics or antihy- pertensive drugs. Adjustment of dosage • Kidney disease: Creatinine clearance >50 mL/min: usual dose; creatinine clearance 26–50 mL/min: reduce dose by 50% and administer q12h; creatinine clearance 10–25 mL/min: reduce dose by 50% and administer q24h. Warnings/precautions • Use with caution in patients with kidney disease, peripheral neuropathy, preexisting bone marrow suppression, folic acid or vitamin B12 deficiency. Adverse reactions • Common: headache, insomnia, depression, nervousness, abdo- minal pain, nausea, vomiting, diaphoresis, rash, myalgia, chills, fever, dyspnea. Clinically important drug interactions: Drugs that increase effects/toxicity of stavudine: chloramphenicol, cisplatin, ethamb- utol, hydra- lazine, lithium, metronidazole, phenytoin, vincristine. Drug may be cautiously reintroduced at 50% of prior maintenance dose if symptoms resolve. Editorial comments • Stavudine is used in combination therapy with zidovudine or other nucleoside antiviral drugs. This stimulates the formation of anticoagulant proteins, resulting in dissolution of clot. Adverse reactions • Common: superficial bleeding • Serious: angioneuritic edema, bronchospasm, severe internal hemorrhage, Guillain–Barré syndrome, hypersensitivity reaction. Editorial comments • Streptokinase is probably the most widely used fibrinolytic therapy in the world. The addition of better antiplatelet therapy is a bur- geoning area of research in acute coronary syndromes. Mechanism of action: Binds to ribosomal units in bacteria, inhi- bits protein synthesis. Susceptible organisms in vivo: Mycobacterium tuberculosis, Yersinia pestis, Francisella tularensis, Brucella; synergism against enterococci and streptococcoi. Warnings/precautions • Use with caution in patients with renal disease, neuromuscular disorders (eg, myasthenia gravis, parkinsonism), hearing dis- orders. Parameters to monitor • Peak and trough serum levels 48 hours after beginning therapy and every 3–4 days thereafter as well as after changing doses. Editorial comments • Streptomycin has the greatest activity of all the aminoglycosides against M. It is a first-line drug for tuberculosis though not as effective as isoniazid and rifampin. Mechanism of action: Depolarizes motor endplate at myoneural junction, preventing stimulation by endogenous acetylcholine. Note: Succinylcholine should be reserved for use in children who require emergency intubation, who do not have an accessi- ble vein, and for whom an airway can be readily secured.


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Gone without a trace All calcium channel blockers are metabolized rapidly and almost completely in the liver buy proscar 5mg low price prostate 8 formula. This causes dilation of the coronary and peripheral arteries 5 mg proscar with amex androgen hormone 1, which decreases the force of the heart’s contractions and reduces Warning! The relaxation response Adverse Also, by preventing arterioles from constricting, calcium channel blockers reduce afterload. Decreasing afterload further decreases reactions to the oxygen demands of the heart. A slower heart rate reduces the heart’s need for additional lar reactions are the oxygen. Calcium channel thostatic hypotension (a blockers are particularly effective for preventing Prinzmetal’s drop in blood pressure angina. Diltiazem Drug interactions and verapamil can • Calcium salts and vitamin D reduce the effectiveness of calcium cause such arrhythmias channel blockers. Know the program Treatment for hypertension typically begins with a thiazide diuret- ic or a calcium channel blocker. Sympatholytic drugs Sympatholytic drugs include several different types of drugs, but all reduce blood pressure by inhibiting or blocking the sympathet- ic nervous system. They’re classified by their site or mechanism of action and include: • central-acting sympathetic nervous system inhibitors (clonidine and methyldopa) • alpha-adrenergic blockers (doxazosin, phentolamine, prazosin, and terazosin) • mixed alpha- and beta-adrenergic blockers (carvedilol and la- betalol) • norepinephrine depletors (guanadrel, guanethidine, and reser- pine—these are rarely used). Pharmacodynamics All sympatholytic drugs inhibit stimulation of the sympathetic ner- vous system, causing dilation of the peripheral blood vessels or decreased cardiac output, thereby reducing blood pressure. Pharmacotherapeutics If blood pressure fails to come under control with beta-adrenergic blockers and diuretics, an alpha-adrenergic blocker, such as pra- zosin, or a mixed alpha- and beta-adrenergic blocker, such as la- betalol, may be used. If the patient fails to achieve the desired blood pressure, the physician may add a drug from a different class, substitute a drug in the same class, or increase the drug dosage. Adverse reactions to sympatholytics Alpha-adrenergic blockers Guanadrel Reserpine • Hypotension • Difficulty breathing • Abdominal cramps, diarrhea • Excessive urination • Angina Central-acting drugs • Fainting • Blurred vision • Depression • Orthostatic hypotension • Bradycardia • Drowsiness • Bronchoconstriction • Edema Guanethidine • Decreased libido • Liver dysfunction • Decreased heart contrac- • Depression • Numbness, tingling tility • Drowsiness • Vertigo • Diarrhea • Weight gain • Fluid retention • Fatigue • Orthostatic hypotension • Hypotension Drug interactions Sympatholytic drugs can create these drug interactions: • Carvedilol taken with antidiabetics may result in increased hy- poglycemic effect. As blood pres- sure falls, the sympa- Pharmacokinetics thetic nervous system is Most of these drugs are absorbed rapidly and well-distributed. Other reactions to The direct vasodilators relax peripheral vascular smooth muscle, sympathetic stimulation causing the blood vessels to dilate. The increased diameter of the blood vessels reduces total peripheral resistance, which lowers include: blood pressure. Drug interactions • The antihypertensive effects of hydralazine and minoxidil are increased when they’re given with other antihypertensive drugs, such as methyldopa or reserpine. Normally, the kidneys maintain And that’s the way, blood pressure by releasing the hormone renin. Renin acts on the uh-huh, uh-huh plasma protein angiotensinogen to form angiotensin I. Aldosterone, in turn, pro- motes the retention of sodium and water, increasing the volume of blood the heart needs to pump. Captopril is also indicated for the long-term treatment of diabetic • transient elevations of neuropathy.

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Beta-blockers slow the heart and may induce myocardial depres- sion generic proscar 5 mg on-line prostate cancer 6 of 10, rarely purchase cheapest proscar prostate cancer exam, precipitatng heart failure. They should not be given to patents who have incipient ventricular failure, second-or third- degree atrioventricular block, or peripheral vascular disease. Beta-blockers should be used with cauton in diabetes since they may mask the symptoms of hypoglycaemia, such as rapid heart rate. Beta-blockers enhance the hypoglycaemic efect of insulin and may precipitate hypoglycaemia. Calcium-Channel Blockers: A calcium-channel blocker, such as verapamil, is used as an alternatve to a beta-blocker to treat stable angina. Calcium- channel blockers interfere with the inward movement of calcium ions through the slow channels in heart and vascular smooth muscle cell membranes, leading to relaxaton of vascular smooth muscle. Myocardial contractlity may be reduced, the formaton and propagaton of electrical impulses within the heart may be depressed and coronary or systemic vascular tone may be diminished. Calcium-channel blockers are used to improve exercise tolerance in patents with chronic stable angina due to coronary atherosclerosis or with abnor- mally small coronary arteries and limited vasodilator reserve. Calcium-channel blockers can also be used in patents with unstable angina with a vasospastc origin, such as Prinzmetal’s angina and in patents in whom alteratons in cardiac tone may infuence the angina threshold. Unstable Angina: Unstable angina requires prompt aggressive treatment to prevent progression to myocardial infarcton. Inital treatment is with acetylsalicylic acid to inhibit platelet aggregaton, followed by heparin. Prinzmetal’s Angina: Treatment is similar to that for unstable angina, except that a calcium-channel blocker is used instead of a beta-blocker. Atenolol* Pregnancy Category-D Schedule H Indicatons Angina and myocardial infarcton; arrhythmias; hypertension; migraine prophylaxis. Dose Oral Adult- 50 mg once daily, increased if neces- sary to 50 mg twice daily or 100 mg once dai- ly. Angina: 50 mg daily administered alone or with a diuretc, dose can be increased to 100 mg (over 100 mg has no added advantage). Contraindicatons Asthma or history of obstructve airways disease (unless no alternatve, then with extreme cauton and under specialist supervision); uncontrolled heart failure, Prinzmetal angina, marked bradycardia, hypotension, sick sinus syndrome, second- and third-degree atrioventricular block, cardiogenic shock; metabolic acidosis; severe peripheral arterial disease; pheochromocytoma (unless used with alpha- blocker). Adverse Efects Gastrointestnal disturbances (nausea, vomitng, diarrhoea, constpaton, abdominal cramp); fatgue; cold hands and feet; exacerbaton of intermitent claudicaton and Raynaud phenomenon; bronchospasm; bradycardia, heart failure, conducton disorders, hypotension; sleep disturbances, including nightmares; depression, confusion; hypoglycaemia or hyperglycaemia; exacerbaton of psoriasis; rare reports of rashes and dry eyes (oculomucocutaneous syndrome-reversible on withdrawal). Diltazem Pregnancy Category-C Schedule H Indicatons Angina pectoris due to coronary artery spasm; chronic stable angina; cardiac arrhythmia. Dose Oral Adult-30 mg 2 to 5 tmes a day before food and at night (bed tme), increase gradually to 240 mg in 3 to 4 divided doses daily. They should therefore be dispensed in glass or stainless steel containers and closed with a foil-lined cap which contains no wadding. No more than 100 tablets should be dispensed at one tme and any unused tablets should be discarded 8 weeks afer opening the container.


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