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They are therefore ideal medications to stop the vi- is unknown or not sure discount 75mg sildenafil overnight delivery erectile dysfunction and premature ejaculation, a biopsy is recommended of the cious circle of bone metastasing and damaging buy 75 mg sildenafil with mastercard erectile dysfunction hand pump. The suspected vertebra either by a posterolateral percutaneous most successful medication is pamidronate (second-gen- approach or by the pedicle of the patient with a Yamshidi eration bisphosphonate) which is successful mostly in bony needle of sufficient diameter (≥3 mm), usually in local metastases of breast cancer and in osteolysis in multiple anesthesia and by image guidance to obtain a proper tis- myeloma. Zoledronic acid is one of the most recently sue sample allowing a histological diagnosis. This can be developed agents and is characterized by an imidazol a simple hand-guided biopsy under image intensifier or a ring. In animal experiments the effect was 100–850 times computer-assisted one. There is no radiotherapeutic regimen showing consis- The objective clinical success of the bisphosphonate tent superiority in the treatment of spinal metastases, al- depends significantly on the reduction and delay of skele- though multiple treatment protocols have been carried out. It can be anticipated today that the bisphos- single fraction and 40 Gy in 20 fractions over 4 weeks. Bisphos- phonate treatment has the goal of diminishing the inci- Pharmacological options dence of bony complications, vertebral body fractures, pain, and osteoporosis. The outcome should be determined by Here we may consider chemotherapy, bisphosphonates, and the survival time – once a spinal metastasis is detected – in some specific tumors hormonal therapy (breast, prostate, in an ambulatory, independent status, where pain is con- thyroid cancer) and as a general medication steroids such as trolled, and the patient is not hospitalized. In our own only a historical value since significant side effects have material of 67 fully documented cases between 1996 and been associated with its use. It should be administered only 2001 the mean survival after surgery was 14. This dosage is well tolerated, and it is the local tumor recurrence, and the survival time in patients regimen of choice in symptomatic patients. They based their sur- that bony metastases in general and of the spine in partic- gical decision making on a new prognostic scoring sys- ular increase treatment costs and may significantly pro- tem. Bisphosphonates tases of the spine and with a survival of 5 years and more have stood the test of time in the treatment of bony com- in 18% of their cases. They found the greatest improvement in the domain of pain reduction, but there was also improvement in other domains of quality of life. The clinical results of nonsur- gical treatment for spinal metastases has been presented in a prospective analysis of 101 patients who were treated with radiation therapy and/or chemotherapy. Of these, 66% remained neurologically stable or improved after treatment; 67% had pain relief, and 64% improved func- tionally, which was more related to the general debility than local tumor recurrence. Unfortunately no prospective study has compared nonsurgical and surgical treatment of spinal metastases with clearly defined condi- tions and parameters to allow a differentiated decision about the best solution for the patient. This leaves us with the necessity to assess every pa- These results also suggest a concept of differentiated tient individually and to weigh the different elements in surgery with more radical options than just palliative sur- shared decision making of an interdisciplinary team to- gery. The neurological outcome is crucial and depends on gether with the patient. It is a complex algorithm tailored the initial neurological deficit before surgery. It cannot be emphasized enough that a gain the ability to walk, but only fewer than 5% of pa- decision for a conservative treatment, specifically with ir- tients, who are paraplegic regain ambulation. Postop- radiation, should not be taken unless there is a clear un- erative complications are frequent and are found in 15 – derstanding that a later surgical option is very improbable. Coman DR, DeLong RP (1951) The mary and metastatic tumors of the cer- Prabhu V, Boland PJ (2002) Diagnosis role of the vertebral venous system in vical spine. Spine 23:2767–2776 and management of a metastatic tumor the metastasis of cancer into the spinal 2. Spine 27: cord: experiments with tumor cell sus- strategies in the management of spinal 1062–1069 pensions in rats and rabbits. Batson OV (1940) The function of the Biagini R, Campanacci L, De Iure F, 12. DeLaney TF, Suit HD (2000) Treat- vertebral veins and their role in the Piccill P (1996) Chordoma of the spine ment of spine tumors: radiation ther- spread of metastases.

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Enteric coated: PO Dissolve in small intestine rather than stomach; Do not crush; instruct clients not to chew or crush discount sildenafil 50mg free shipping erectile dysfunction for young males. Solutions Oral: PO buy sildenafil 75 mg fast delivery impotence quotes the sun also rises, GI tube • Absorbed rapidly because they do not need to be Use of appropriate measuring devices and accurate dissolved measurement are extremely important. Parenteral: IV, IM SC, • Medications and all administration devices must Use of appropriate equipment (eg, needles, syringes, intradermal be sterile IV administration sets) and accurate measurement • IV produces rapid effects; SC is used mainly for in- are extremely important. Insulin syringes should sulin and heparin; IM is used for only a few drugs; always be used for insulin and tuberculin syringes intradermal is used mainly to inject skin test ma- are recommended for measuring small amounts of terial rather than therapeutic drugs. Suspensions PO, SC (NPH and • These are particles of active drug suspended in Drug particles settle to the bottom on standing. If Lente insulins) a liquid; the liquid must be rotated or shaken not remixed, the liquid vehicle is given rather than before measuring a dose. Dermatologic Creams, Lotions, Ointments Topically to skin • Most are formulated for minimal absorption Formulations vary with intended uses and are not through skin and local effects at the site of appli- interchangeable. Solutions and Powders for • Oral inhalations are used mainly for asthma; nasal Several research studies indicate that patients often Oral or Nasal Inhalation, sprays for nasal allergies (allergic rhinitis) do not use MDIs correctly and sometimes are in- Including Metered Dose • Effective with less systemic effect than oral drugs correctly taught by health care providers. Correct Inhalers (MDIs) • Deliver a specified dose per inhalation use is essential to obtaining therapeutic effects and avoiding adverse effects. Eye Solutions and Ointments • Should be sterile Can be systemically absorbed and cause systemic • Most are packaged in small amounts, to be used adverse effects by a single patient Throat Lozenges • Used for cough and sore throat Ear Solutions • Used mainly for ear infections (continued) 34 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 3–2 Drug Dosage Forms (continued) Dosage Forms and Their Routes of Administration Characteristics Considerations/Precautions Vaginal Creams and • Formulated for insertion into the vagina Suppositories • Commonly used to treat vaginal infections Rectal Suppositories • Formulated for insertion into the rectum Effects somewhat unpredictable because absorption and Enemas • Suppositories may be used to administer seda- is erratic tives, analgesics, laxatives • Medicated enemas are used to treat inflammatory bowel diseases (eg, ulcerative colitis) PO, oral; GI, gastrointestinal; IV, intravenous; IM, intramuscular; SC, subcutaneous. CALCULATING DRUG DOSAGES animal tests (ie, the amount of drug required to produce a particular response). For ex- When calculating drug doses, the importance of accuracy ample, concentrations of insulin and heparin are both ex- cannot be overemphasized. Accuracy requires basic skills in pressed in units, but there is no relation between a unit of mathematics, knowledge of common units of measurement, insulin and a unit of heparin. These drugs are usually ordered and methods of using data in performing calculations. Milliequivalents express the ionic ac- The most commonly used system of measurement is the met- tivity of a drug. Drugs such as potassium chloride are ordered ric system, in which the meter is used for linear measure, the and labeled in the number of milliequivalents per dose, tablet, gram for weight, and the liter for volume. The apothecary system, now obsolete and rarely used, has units called grains, minims, drams, ounces, pounds, pints, Mathematical Calculations and quarts. The household system, with units of drops, tea- spoons, tablespoons, and cups, is infrequently used in health Most drug orders and labels are expressed in metric units of care agencies but may be used at home. If the amount specified in the order is the same alent measurements within and among these systems. Equiv- as that on the drug label, no calculations are required, and alents are approximate. For example, if A few drugs are ordered and measured in terms of units the order reads ibuprofen 400 mg PO and the drug label or milliequivalents (mEq). Units express biologic activity in reads ibuprofen 400 mg per tablet, it is clear that one tablet is to be given. What happens if the order calls for a 400-mg dose and 200-mg tablets are available? The question is, How many TABLE 3–3 Equivalents 200-mg tablets are needed to give a dose of 400 mg? This is a simple example that also can be 1 mL = 1 cc = 15 or 16 minims = 15 or 16 drops used to illustrate mathematical calculations. This problem 4 or 5 mL = 1 fluid dram = 1 tsp can be solved by several acceptable methods; the following 60 or 65 mg = 1 gr 30 or 32 mg = 1/2 gr formula is presented because of its relative simplicity for stu- 30 g = 30 mL = 1 oz = 2 tbsp dents lacking a more familiar method. V = unit (one tablet, here) CHAPTER 3 ADMINISTERING MEDICATIONS 35 400 mg X ablett 3. Order: 4 mg IV = Label: 10 mg/mL 200 mg 1 tablet Cross multiply: 4 mg X mL = 200X = 400 10 mg 1 mL 10X = 4 400 X = = 2 tablets 200 4 X = = 04. The desired or ordered dose and the available or label dose 10,000X = 5000 must be in the same units of measurement.

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Benzphetamine cheap sildenafil 50 mg on-line erectile dysfunction patient.co.uk doctor, diethylpropion order sildenafil 50mg on line impotence pumps, Pancreatin PO 1 or 2 capsules PO 1 or 2 capsules phendimetrazine, and phentermine are adrenergic drugs (see (Creon, others) or tablets with or tablets with Chap. This action in nerve terminals of the increased in amount or fre- hypothalamic feeding center suppresses appetite. Other drug quency if neces- actions that may contribute to decreased appetite and weight sary and if adverse loss include increasing energy and decreasing gastric secretion. His meal times are breakfast 8:00 AM, lunch 12:00, with meals or and dinner 6:00 PM. CHAPTER 30 NUTRITIONAL SUPPORT PRODUCTS AND DRUGS FOR OBESITY 439 commonly prescribed antiobesity drug. This drug inhibits the Heights and Weights Indicating TABLE 30–5 reuptake of serotonin and norepinephrine in the brain, thereby Overweight and Obesity increasing the amounts of these neurotransmitters. Clinical Weight (lbs) Indicating Weight (lbs) Indicating effects include increased satiety, decreased food intake, and a Height (ft/in) Overweight (BMI 25) Obesity (BMI 30) faster metabolism rate. Sibutramine is approved by the FDA 5′2″ (62 in) 135 165 for long-term use, but its effects are mostly unknown beyond 5′3″ 140 170 one year. The drug increases blood pressure and heart rate and 5′4″ 145 175 is contraindicated in cardiovascular disorders (eg, hyperten- 5′5″ 150 180 sion, dysrhythmias). It should be used cautiously in clients 5′6″ 155 185 5′7″ 160 190 who take other medications that increase blood pressure and 5′8″ 165 195 pulse rate. It should also be used cautiously in clients with im- 5′9″ 170 200 paired hepatic function, narrow-angle glaucoma (may cause 5′10″ 175 205 mydriasis), or a history of substance abuse or dependency. Peak plasma levels of the active metabolites occur within 3 to 4 hours and drug half-life is 14 to 16 hours. The drug is highly bound to plasma proteins and rapidly distributed to most body tissues, with the highest con- These drugs are central nervous system (CNS) and cardio- centrations in the liver and kidneys. It is metabolized in the vascular stimulants and are contraindicated in cardiovascular liver, mainly by the cytochrome P4503A4 enzymes. In active metabolites produced by first-pass metabolism are addition, they are promoted for short-term use (8 to 12 weeks), further metabolized to inactive metabolites, which are then weight is usually rapidly regained when the drugs are stopped, excreted in urine and feces. Overall, their use as ap- Common adverse effects include dry mouth, headache, in- petite suppressants is not recommended. Its use should be limited to pa- serious drug interactions may occur if sibutramine is taken tients with a BMI >30 kg/m2, or >27 kg/m2 if the client also has with other cardiovascular stimulants (increased risk of hyper- risk factors or other health problems that are aggravated by ex- tension and dysrhythmias), CNS stimulants (increased anxiety cessive weight. Its use is contraindicated in clients with hyper- and insomnia), and serotonergic drugs (serotonin syndrome). Phentermine is pharmacologically and tonin reuptake inhibitors (eg, fluoxetine [Prozac] and re- chemically similar to amphetamines; physical and psycholog- lated drugs), the triptan antimigraine drugs (eg, sumatriptan ical dependence may occur. The drug should also be used cau- [Imitrex]), dextromethorphan (a common ingredient in cough tiously in clients with anxiety or agitation because of CNS syrups), and lithium. The most commonly reported adverse effects any of these drugs may cause serotonin syndrome, a condition are nervousness, dry mouth, constipation, and hypertension. Drugs at a Glance: Drugs for Obesity Generic/Trade Name Route and Dosage Range (Adults) Controlled Substance Status Appetite Suppressants Benzphetamine (Didrex) PO 25–50 mg once daily initially, increased up to 3 times daily if indicated Schedule III Diethylpropion (Tenuate) Immediate release tablets, PO 25 mg 3 times daily Schedule IV Controlled release tablets, PO 75 mg once daily in midmorning Phendimetrazine (Bontril) Immediate release tablets, PO 35 mg 2 or 3 times daily, 1 h before meals Schedule III Sustained-release capsules, PO 105 mg once daily, 30–60 min before the first morning meal Phentermine hydrochloride (Adipex) PO 8 mg 3 times daily or 15–37. Although echinacea, It was unknown whether the deaths were related to the use of ginseng, and St. The majority of the deaths (16) were related to 27 students took weight loss products. The manufacturer reported knowledge of BMI in the acceptable range, and 11 of the 19 participants who 32 deaths of people taking sibutramine but stated there was reported an adverse reaction continued to take the products. In general, many consumers do not appreciate the benefits Orlistat (Xenical) differs from other antiobesity drugs be- of proven weight management techniques (ie, appropriate diet cause it decreases absorption of dietary fat from the intestine and exercise) or the potential risks of taking weight loss prod- (by inhibiting gastric and pancreatic lipase enzymes that nor- ucts. The drug Ephedra (ma huang) is an herb in many weight loss products blocks absorption of approximately 30% of the fat ingested (eg, Metabolife, Herbalife, others). Decreased fat absorption leads to decreased caloric use by anyone because it is a strong cardiovascular and CNS intake, resulting in weight loss and improved serum choles- stimulant that increases risks of heart attack, seizure, stroke, terol values (eg, decreases total and LDL cholesterol levels). Many ephedra-containing products also The improvement in cholesterol is believed to be independent contain caffeine, which can further increase cardiovascular of weight loss effects. Orlistat is not absorbed systemically, and its action occurs Glucomannan expands on contact with body fluids. Consequently, it does not cause systemic ad- cluded in weight loss regimens because of its supposed ability verse effects or drug interactions as do phentermine and sibu- to produce feelings of stomach fullness, causing a person to tramine. There is little evidence (3 times daily) and GI symptoms (abdominal pain, oily spot- to support its use as a weight loss aid.

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