Deputy Director, Western Michigan University Homer Stryker M.D. School of Medicine
After the identity of the infecting microbe is known gastritis diet цензор order florinef cheap, drug selection can be adjusted accordingly gastritis symptoms heart order florinef 0.1mg without a prescription. As discussed earlier gastritis surgery 0.1mg florinef mastercard, samples for culture should be obtained before drug therapy starts gastritis emocional buy 0.1mg florinef visa. Multiple infectious organisms are common in brain abscesses, pelvic infections, and infections resulting from perforation of abdominal organs. When the infectious microbes differ from one another in drug susceptibility, treatment with more than one antibioticisrequired. PreventingResistance Although use of multiple antibiotics is usually associated with promoting drug resistance, there is one infectious disease-tuberculosis-in which drug combinations are employed for the specific purpose of suppressing the emergenceofresistantbacteria. For example, by combining flucytosine with amphotericin B in the treatment of fungal meningitis, the dosage of amphotericin B can be reduced, thereby decreasingtheriskforamphotericin-induceddamagetothekidneys. Thisistrueofthecombineduseofpenicillinplusan aminoglycoside in the treatment of enterococcal endocarditis. Penicillin acts to weaken the bacterial cell wall; the aminoglycoside acts to suppress protein synthesis. The combination has enhanced antibacterial action because, by weakeningthecellwall,penicillinfacilitatespenetrationoftheaminoglycoside toitsintracellularsiteofaction. DisadvantagesofAntibioticCombinations Use of multiple antibiotics has several drawbacks, including (1) increased risk fortoxicandallergicreactions,(2)possibleantagonismofantimicrobialeffects, (3)increasedriskforsuperinfection,(4)selectionofdrug-resistantbacteria,and (5)increasedcost. ProphylacticUseofAntimicrobialDrugs Estimates indicate that between 30% and 50% of the antibiotics used in the UnitedStatesareadministeredforprophylaxis. Thatis,theseagentsaregivento prevent an infection rather than to treat an established infection. However, in certain situations, antimicrobial prophylaxis is both appropriate and effective. Whenever prophylaxis is proposed, the benefits must be weighed against the risks for toxicity, allergic reactions, superinfection, and selection of drug-resistant organisms. Prophylaxis is also beneficial for women undergoing a hysterectomy or an emergency cesarean section. In contaminated surgery (operations performed on perforated abdominal organs, compound fractures,orlacerationsfromanimalbites),theriskforinfectionisnearly100%. Hence, for these operations, use of antibiotics is considered treatment, not prophylaxis. When antibiotics are given for prophylaxis, they should be given before the surgery. BacterialEndocarditis Individuals with congenital or valvular heart disease and those with prosthetic heartvalvesareunusuallysusceptibletobacterialendocarditis. Forthesepeople, endocarditis can develop after certain dental and medical procedures that dislodgebacteriaintothebloodstream. Thusbeforeundergoingsuchprocedures, these patients may need prophylactic antimicrobial medication. However, according to guidelines released by the American Heart Association, antibiotic prophylaxisislessnecessarythanpreviouslybelievedandhenceshouldbedone muchlessoftenthaninthepast. There is some evidence that the incidence of bacterial infection may be reduced through antibioticprophylaxis. However,prophylaxismayincreasetheriskforinfection with fungi: by killing normal flora, whose presence helps suppress fungal growth,antibioticscanencouragefungalinvasion. OtherIndicationsforAntimicrobialProphylaxis For young women with recurrent urinary tract infection, prophylaxis with trimethoprim/sulfamethoxazolemaybehelpful. For individuals who have had severe rheumatic endocarditis, lifelong prophylaxis may be needed. Antimicrobial prophylaxis is indicated after exposure to organisms responsible forsexuallytransmitteddiseases. AttemptedTreatmentofViralInfection Most viral infections-including mumps, chickenpox, and the common cold- donotrespondtocurrentlyavailabledrugs. Acute upper respiratory tract infections, including the common cold, are a particular concern. When these infections are treated with antibiotics, only 1 patient out of 4000 is likely to benefit. However, the risks remain high: 1 in 4 patientswillgetdiarrhea,1in50willgetarash,and1in1000willneedtovisit anemergencydepartment,usuallybecauseofasevereallergicreaction. TreatmentofFeverofUnknownOrigin Although fever can be a sign of infection, it can also signify other diseases, includinghepatitis,arthritis,andcancer. Theonlysituationinwhichfever,byitself,constitutesalegitimateindication for antibiotic use is when fever occurs in the severely immunocompromised host. Becausefevermayindicateinfection,andbecauseinfectioncanbelethalto the immunocompromised patient, these patients should be given antibiotics whenfeveroccurs-eveniffeveristheonlyindicationthataninfectionmaybe present. ImproperDosage Like all other medications, antibiotics must be used in the right dosage. If the dosage is too low, the patient will be exposed to a risk for adverse effects without benefit of antibacterial effects. If the dosage is too high, the risks for superinfectionandadverseeffectsbecomeunnecessarilyhigh. TreatmentintheAbsenceofAdequate BacteriologicInformation As stressed earlier, proper antimicrobial therapy requires information on the identityanddrugsensitivityoftheinfectingorganism. Exceptinlife-threatening situations, therapy should not be undertaken in the absence of bacteriologic information. OmissionofSurgicalDrainage Antibiotics may have limited efficacy in the presence of foreign material, necrotic tissue, or exudate. Hence, when appropriate, surgical drainage and cleansingshouldbeperformedtopromoteantimicrobialeffects.
Theregimenofchoiceforpatientstakinghighlyemetogenic drugs consists of aprepitant [Emend] gastritis diet xyngular purchase florinef 0.1mg, dexamethasone gastritis generic 0.1 mg florinef amex, and a serotonin antagonist gastritis symptoms nih buy 0.1 mg florinef otc, such as ondansetron [Zofran] gastritis inflammation order genuine florinef on line. In fact, for many cancer patients, alopecia is second only to vomiting as their greatest treatment-relatedfear. Forpatientswhochoosetowearahairpieceorwig,oneshould be selected before hair loss occurs. Hairpieces are tax deductible as medical expensesandarecoveredbysomeinsuranceplans. To some degree, hair loss can be prevented by cooling the scalp while chemotherapy is being administered. Cooling causes vasoconstriction and thereby reduces drug delivery to hair follicles. Unfortunately, scalp cooling is uncomfortable,causes headache,andcreatesa smallriskfor cancer recurrence inthescalp(becausedrugdeliveryisreduced). As a result, both are highly susceptible to injury by cytotoxic drugs, especiallythealkylatingagents. However,after18weeksofgestation,riskappearsto be very low: according to a 2012 report in Lancet, exposure during this time doesnotcauseneurologic,cardiac,oranyotherfetalabnormalities. Hyperuricemia Hyperuricemia is defined as an excessive level of uric acid in the blood. Hyperuricemia is especially common after treatment for leukemias andlymphomas(becausetherapyresultsinmassivecellkill). In patients with leukemias and lymphomas, in whom hyperuricemiaislikely,prophylaxiswithallopurinolisthestandardofcare. LocalInjuryFromExtravasationofVesicants Certain anticancer drugs, known as vesicants, are highly chemically reactive. These drugs can cause severe local injury if they make direct contact with tissues. Vesicants are administered intravenously, usually into a central line (becauserapiddilutioninvenousbloodminimizestheriskforinjury). Extremecaremustbeexercised topreventextravasationbecauseleakagecanproducehighlocalconcentrations, resulting in prolonged pain, infection, and loss of mobility. UniqueToxicities In addition to the toxicities discussed previously, which generally apply to the cytotoxicdrugsasagroup,someagentsproduceuniquetoxicities. Forexample, a number of drugs can cause peripheral sensory neuropathy, manifesting as numbness or tingling in the fingers and toes and around the mouth and throat. Neuropathy may impede activities of daily living, such as buttoning clothing, writing, or just holding things. Carcinogenesis Along with their other adverse actions, anticancer drugs have one final and ironictoxicity:thesedrugs,whichareusedtotreatcancer,havecausedcancerin some patients. Giventheknowndangersofthesedrugs,wemust ask why such toxic substances are given to sick people at all. The answer lies withtheprimaryruleoftherapeutics,whichstatesthatthebenefitsoftreatment must outweigh the risks. Thatis,althoughthetoxicitiesoftheanticancer drugs can be significant, the potential benefits (cure, prolonged life, palliation) justify the risks. There are patients whose chances of being helped by chemotherapyareremote,whereastheriskforserioustoxicityishigh. Because the potential benefits for some patients are small and the risks are large, the decisiontoinstitutechemotherapymustbemadewithcare. For treatment to be justified, there should be reason to believe that at least one of these benefits will be forthcoming. If a patient cannot be offered some reasonable hope of cure, prolongedlife,orpalliation,itwouldbedifficulttojustifytreatment. The most important factors for predicting the outcome of chemotherapy are (1) the general health of the patient and (2) the responsiveness of the type of cancer the patient has. General health status is assessed by measuring performance status, frequently using the Karnofsky Performance Scale (Table 82. Accordingly,patients with a low Karnofsky rating should not receive anticancer drugs-unless their cancerisknowntobeespeciallyresponsive. If a positive outcome is deemed likely, the patient should almost always be treated, even if his or her Karnofsky score is low. In contrast, if a positive outcome is deemed highly unlikely, the patient shouldbetreatedonlyaftercarefulconsideration,soastoavoidthediscomforts ofacourseoftreatmentthathaslittletooffer. An important requirement for deciding in favor of chemotherapy is that the effectoftreatmentbemeasurable. For solid tumors, we should be abletomeasureadecreaseintumorsize(oratleastinhibitionoffurthergrowth). Ifwe cannot determine that drugs are doing something beneficial, there is little justificationforgivingthem. Patients should be informed as accurately as possible about the potential risks and benefits of the proposed therapy. When the decision to treat is made, it should be the result of collaboration between the patient, family, and physician and should reflect a conviction on the part of the patient that, within his or her set of values, the potentialbenefitsoutweightheinherentrisks. SharedProperties MechanismofAction the alkylating agents are highly reactive compounds that can transfer an alkyl group tovarious cellconstituents. Toxicities Alkylating agents are toxic to tissues that have a high growth fraction. Blood dyscrasias-neutropenia, thrombocytopenia, and anemia-caused by bone marrow suppression are of greatest concern. Unlike many anticancer drugs, the nitrosoureas are highly lipophilic and hence can readilypenetratetheblood-brainbarrier. PlatinumCompounds the platinum-containing anticancer drugs-cisplatin, carboplatin, and oxaliplatin-aresimilartothealkylatingagentsandareoftenclassifiedassuch.
AdverseEffects Tigecycline is a tetracycline analog and hence may have adverse effects like those of the tetracyclines extreme gastritis diet order florinef online now. Like the tetracyclines diet gastritis erosif buy 0.1mg florinef mastercard, tigecycline may pose a risk for pseudotumor cerebri (a benign elevation of intracranial pressure) and may increase sensitivity to ultraviolet light gastritis diet cheese purchase florinef line, thereby increasing the risk for sunburn gastritis symptoms and prevention buy generic florinef on-line. Acute pancreatitis, including fatal cases, has occurredduringtigecyclinetreatment. BlackBoxWarning:Tigecycline Among patients treated for severe infections, mortality is higher for those receiving tigecycline than for those receiving other antibiotics. Tigecycline does not affect the cytochrome P450systemandhencewillnotalterthekineticsofdrugsmetabolizedbyP450. Treatmentconsistsofa100-mginitial dose followed by 50mg every 12 hours for 5 to 14 days. No adjustment in dosage is needed for patients with renal impairment or with mild to moderate hepaticimpairment. Forpatientswithseverehepaticimpairment,theinitialdose is unchanged, but maintenance dosing should be reduced to 25mg every 12 hours. For impetigo therapy, retapamulin is more convenient than mupirocin, but generic mupirocinischeaper. Thedrugbinds to the 50S bacterial ribosomal subunit and thereby inhibits protein synthesis. However, the 50S binding site is different from that of other antibiotics, and hence cross-resistance with other antibiotics is not expected. Mupirocin Mupirocin [Bactroban, Bactroban Nasal] is a topical antibiotic with two indications: (1) impetigo caused by S. Of note, bactericidal activity persists for several hours after serum levels have droppedbelowtheminimalbactericidalconcentration,aphenomenonknownas thepostantibioticeffect. Bacterial kill appears to result from production of abnormal proteins rather thanfromsimpleinhibitionofproteinsynthesis. Inhibitionofproteinsynthesisperse doesnotseemthelikelycauseofbacterialdeathbecausecompleteblockadeof protein synthesis by other antibiotics. MicrobialResistance the principal cause for bacterial resistance is production of enzymes that can inactivate aminoglycosides. Among gram-negative bacteria, the genetic informationneededtosynthesizetheseenzymesisacquiredthroughtransferof Rfactors. Of all the aminoglycosides, amikacin is least susceptible to inactivation by bacterial enzymes. To minimize emergence of resistant bacteria, amikacin should be reserved for infectionsthatareunresponsivetootheraminoglycosides. AntimicrobialSpectrum Bactericidal effects of the aminoglycosides are limited almost exclusively to aerobic gram-negative bacilli. Sensitive organisms include Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, Proteus mirabilis, and Pseudomonas aeruginosa. To produce antibacterial effects, aminoglycosides must be transported across the bacterial cell membrane, a process that is oxygen dependent. Because, by definition, anaerobic organisms live in the absence of oxygen, these microbes cannot take up aminoglycosides and hence are resistant. For the same reason, aminoglycosides are inactive against facultative bacteria when these organisms are living under anaerobic conditions. TherapeuticUse ParenteralTherapy the principal use for parenteral aminoglycosides is treatment of serious infectionsduetoaerobicgram-negativebacilli. One aminoglycoside-gentamicin-is now commonly used in combination witheithervancomycinorabeta-lactamantibiotictotreatseriousinfectionswith certain gram-positive cocci, specifically Enterococcus species, some streptococci,andStaphylococcusaureus. The aminoglycosides used most commonly for parenteral therapy are gentamicin, tobramycin, and amikacin. Selection among the three depends in largepartonpatternsofresistanceinagivencommunityorhospital. Insettings where resistance to aminoglycosides is uncommon, either gentamicin or tobramycin is usually preferred. Organisms resistant to both gentamicin and tobramycin are usually sensitive to amikacin. In patients anticipating elective colorectal surgery, oral aminoglycosides have been given prophylactically to suppressbacterialgrowthinthebowel. Topical preparations of gentamicin and tobramycin are used to treat conjunctivitiscausedbysusceptiblegram-negativebacilli. Pharmacokinetics All of the aminoglycosides have similar pharmacokinetic profiles. However, when used for wound irrigation, aminoglycosides may be absorbed in amounts sufficient to produce systemic toxicity. Distribution Distribution of aminoglycosides is limited largely to extracellular fluid. Aminoglycosidesbindtightlytorenaltissue,achievinglevelsinthekidneysup to 50 times higher than levels in serum. Aminoglycosides penetrate readily to the perilymph and endolymph of the inner ears and can thereby cause ototoxicity (see later). In patients with normal renal function, half-lives of the aminoglycosides range from 2 to 3 hours.
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Thedrugshouldbeavoidedbywomenwhoare pregnant or breastfeeding and by patients who may be allergic to human albumin gastritis symptoms nz safe 0.1mg florinef,aproteininBotoxpreparations gastritis zwieback generic florinef 0.1 mg online. Inaddition gastritis symptoms and diet safe florinef 0.1mg,Botoxshouldbeavoided by people using aminoglycoside antibiotics or any other agent that has neuromuscular blocking properties gastritis acid reflux diet order florinef 0.1 mg visa. The drug should be used with caution in patients with myasthenia gravis and other neuromuscular disorders that can intensifymuscleparalysis. If antibodies do develop, patients may still respond to a product known as Myobloc,whichconsistsofbotulinumtoxintypeB(insteadofbotulinumtoxin typeA). AntiperspirantsandDeodorants Perspiration is produced by two types of sweat glands: eccrine glands and apocrine glands. The unpleasant odor associated with sweating results from chemical and bacterial degradation of the compounds in apocrine sweat. Perspiration odor can be reduced with antiperspirants (agents that decrease flow of eccrine sweat) and deodorants (antiseptics that suppress growth of skin-dwelling bacteria). Antiperspirants the principal compounds employed as antiperspirants are aluminum chlorohydrate,aluminumchloride,andbufferedaluminumsulfate. Reduced flow appears to result from inhibition of sweat production and from partial occlusion of sweat glands. Severe sweating can be reduced with botulinum toxin type A [Botox], the same drug used to smooth facial wrinkles. Botulinum toxin inhibits release of acetylcholinefromsympatheticneuronsthatinnervatesweatglandsandthereby reduces sweat volume. To treat axillary hyperhidrosis (severe underarm sweating), 10 to 15 intradermal injections (0. Deodorants Deodorants inhibit growth of the surface bacteria that degrade components of apocrine sweat into malodorous products; deodorants do not suppress sweat formation. DrugsforSeborrheicDermatitisandDandruff Seborrheic dermatitis is a chronic, relapsing condition characterized by inflammationandscalingofthescalpandface. Symptoms respond rapidly to topical treatment with ketoconazole, an antifungal drug with activity against yeast (see Chapter 77). For treatment of seborrhea, ketoconazole is available in a 2% cream [Ketoderm], 2% foam [Extina],2%gel[Xolegel],and1%and2%shampoos[Nizoral]. Aftertheyeastinfection hasbeencontrolled,remissioncanbemaintainedbyperiodicuseofashampoo that contains a yeast-suppressing drug, such as ketoconazole (in Nizoral), pyrithionezinc(inHead&Shoulders),orseleniumsulfide(inSelsunBlueand Head&ShouldersIntensiveTreatment). DrugsforHairLoss Two drugs are available to promote hair growth: minoxidil and finasteride. TopicalMinoxidil Minoxidil is a direct-acting vasodilator used primarily to treat severe hypertension. Consideration here is limited to its use against patterned hair loss in men and women. Improved cutaneous blood flow secondary to vasodilation does not seem to be involved. Unfortunately, response rates are somewhat disappointing:onlyaboutone-thirdofpatientsexperiencesignificantrestoration of hair to regions of baldness. Hair regrowth is most likely when baldness has developedrecentlyandhasbeenlimitedtoasmallarea. When minoxidil is discontinued, newly gained hair is lost in 3 to 4 months, and the natural progression of hair loss resumes. About 4% of men experience reduced libido, erectile dysfunction, impaired ejaculation,andreducedejaculatevolume. Finasterideisateratogenthatcancausegenitourinaryabnormalities in males exposed to the drug in utero. Accordingly, women who are or may becomepregnantshouldnottakefinasteride,norshouldtheyhandletabletsthat arecrushedorbroken. Substantial hair reduction occurred in 40% of treated women in one study and 20% of treated women in another, compared with a 10% response in women receiving the vehicle alone. Among the women who did respond, benefits developed slowly-over4to8weeksormore-andthenfadedentirelywithin8weeksof stopping treatment. Rather,itslowshairgrowth,causeshairtobefinerandlighter,and decreases (but does not eliminate) the need forshaving andother hair-removal procedures. Eflornithine cream is generally well tolerated-although there is some concern about possible fetal harm. The most common reactions are transient stinging,burning,tingling,orrashattheapplicationsite. Althougheflornithine absorption is minimal, it may still be sufficient to cause fetal injury. In animal studies, there was no evidence that topical eflornithine is teratogenic or fetotoxic. However, of the 19 pregnancies that occurred during clinical trials, therewere4spontaneousabortionsand1birthdefect(Downsyndrome). Most cases are seen in children 2 to 5 years old, although all age groups are susceptible. Thisinfectiontypicallymanifestsasa single small macule or papule that evolves into a vesicle that oozes a yellowbrownexudate,whichthendriesintoahoney-coloredcrust. Selectionof a topicalanesthetic is based on durationof action,desiredvehicle (cream, ointment,solution,gel), and prior history of hypersensitivityreactions. AnatomyoftheEar the ear has three major divisions: the external ear, middle ear, and inner ear. The condition affects more than 75% of childrenbyage3yearsandabout95%byage12years. The middle ear is filled with purulent fluid, whichcancausethetympanicmembranetobulgeoutward. This results in negative pressure in the middle ear that, in turn, leads to fluid accumulation in the middle ear.
Isotretinoin may pose a risk for depression and suicide gastritis from ibuprofen buy 0.1 mg florinef fast delivery, although proof of a causal relationship is lacking gastritis diet 7 up coupon purchase florinef 0.1mg. Nonetheless gastritis rash 0.1mg florinef with mastercard, because the potential consequences of depression are severe gastritis operation cheap florinef 0.1 mg without prescription, steps should be taken to minimize risk. Vitamin A, a close relative of isotretinoin, can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity,tetracyclinesandvitaminAsupplementsshouldbediscontinuedbefore isotretinointherapy. Major fetal abnormalities that have occurred include hydrocephalus, microcephaly, facial malformation, cleft palate, cardiovascular defects, and abnormalformationoftheouterear. The program has rules that apply to the prescriber, patient, pharmacist, and wholesaler. Pregnancy must be ruled out before the initial prescription and again before eachmonthlyrefill. Beforetheinitialprescription,thepatientmustundergotwo pregnancy tests, both of which must be negative. Birth control measures must be implemented at least 1 month before starting isotretinoin and must continue at least 1 month after stopping. Birth control is not required after hysterectomy or for women who commit to total abstinence from sexual intercourse. Each patient must sign a Patient Information/Informed Consent document, designedtoreinforcethebenefitsandrisksofisotretinoinuse. At each contact, the patient must answer questions on program requirements and mustindicatehertwochosenmethodsofbirthcontrol. Isotretinoin is available in standard capsules (10, 20, 30, and 40mg) sold as Amnesteem and Claravis. Ifneeded,asecond course may be given, but no sooner than 2 months after completing the first course. Inbothcases, benefits derive from decreasing androgen activity, leading to decreased productionofsebum. Treatmentislimitedtofemalesatleast 15 years old who want contraception, have reached menarche, and have not responded to topical drugs. Spironolactone Spironolactone[Aldactone]blocksavarietyofsteroidreceptors,includingthose for aldosterone and sex hormones. This sequence makes sense because spironolactone is teratogenic, andhencecontraceptionshouldbeimplementedbeforetakingthedrug. In 2016, the American Academy of Dermatology published Guidelines of Care for the Management of Acne Vulgaris. Inadditiontopromotingtanning,solar radiation can cause burns, premature aging of the skin, skin cancer, and immunosuppression. Asa result, sunscreens can protect against sunburn, photoaging of the skin, and photosensitivity reactions to certain drugs. Sunscreens can also decrease the risk for actinic keratoses, squamous cell carcinoma, and melanoma. CompoundsEmployedasSunscreens Therearetwocategoriesofsunscreens:organicscreens(alsoknownaschemical screens) and inorganic screens (also known as physical screens). Hence, rather than absorbing solar radiation, they reflect and scatter sunlight, thereby preventing penetration to the skin. Only two agents are employed as physical screens: titanium dioxide and zinc oxide. In fact, these products must carry a warningthattheydonotprotectagainstskincancerorphotoaging. UsingaSunscreenEffectively Sunscreens must be used properly to achieve maximal benefit. Protection is greatest when a sunscreen has been allowed to penetrate the skin in advance of exposure to the sun. That is, if treated skin can be expected to burn when sun exposure exceeds 2 hours, no amountofreapplicationcanpreventburningifthedurationofexposureexceeds thelimit. Theconditionischaracterizedbydry,scalyskinandintensepruritusthatoften leadstoscratchingandrubbing,whichinturncanleadtoerythema,abrasions, rash, erosions with an exudate, and increased susceptibility to skin infection. Unfortunately,theglucocorticoidscancause skin atrophy, hypopigmentation, telangiectasis (permanent focal red lesions), and, in high doses, possible systemic effects, including adrenal suppression. If topical glucocorticoids are insufficient, patients may be treated with a topical immunosuppressant(seelater). Although effective against atopic dermatitis, both drugs may pose a risk for skin cancer and lymphoma. Because of this potential for serious harm, tacrolimus and pimecrolimusareconsideredsecond-linedrugsforatopicdermatitisandshould bereservedforpatientswhohavenotrespondedtoglucocorticoids. Adverse effects associated with systemic tacrolimus (nephrotoxicity, neurotoxicity, hypertension, diarrhea, nausea) have not occurred with topical therapy. There have been reportsofskincancerandlymphomainhumans,althoughacausalrelationship has not been established. To reduce any risk for skin cancer, patients should protecttreatedareasfromdirectsunlightandshouldavoidsunlampsandtanning beds. PimecrolimusCream Pimecrolimus 1% cream [Elidel] is a topical immunosuppressant approved for mildtomoderateatopicdermatitis. Thedrugisverysimilartotacrolimuswith regard to mechanism, therapeutic effects, and adverse effects.
