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For example acne face map order 20 mg oratane with amex, when imipramine is prescribed skin care jakarta barat cheap 10 mg oratane fast delivery, the patient should understand that theobjective is to relieveneuropathic pain and not depression skin care for swimmers oratane 20mg cheap, thedisorderforwhichthisdrugwasoriginallydeveloped skin care gift packs generic oratane 40mg on line. Under the standards, accountability for pain management is shifted from individualpractitionerstotheinstitutionasawhole. Complianceismandatory: health care organizations that fail to meet the standards will lose accreditation. Loss of accreditation would mean loss of insurance reimbursement and would disqualifyteachinghospitalsfromofferingtrainingprograms. Rather,theyfocuson(1)therightsofpatientsto receive appropriate assessment and management of pain and (2) ways for institutions to establish a formalized, systematic approach to pain management that involves interdisciplinary teams whose members have clearly identified responsibilities. Manyofthedrugsconsideredhere are discussed in other chapters, so discussion in this chapter is limited to ophthalmologicapplications. Themostcommonformsofglaucoma are primary open-angle glaucoma and acute angle-closure glaucoma. Of the 120,000 Americans blinded each year by glaucoma, 90% could have saved their sight with timely treatment. Management is usually initiated by specialists; however, primary care providers often play a role in ongoing monitoring and follow-upofpatientstakingthesemedications. All of the antiglaucoma drugs are available for topical administration, which is the preferred route. Becauseallofthese drugs are applied topically, systemic effects are relatively uncommon. Angle-ClosureGlaucoma Angle-closure glaucoma is precipitated by displacement of the iris such that it coversthetrabecularmeshwork,therebypreventingexitofaqueoushumorfrom theanteriorchamber. Treatmentconsistsof drugtherapy (to control the acute attack) followed by correctivesurgery. Acombinationofdrugs(osmoticagents,short-actingmiotics, carbonic anhydrase inhibitors, topical beta-adrenergic blocking agents) is employed to suppress symptoms. DrugsUsedtoTreatGlaucoma Beta-AdrenergicBlockingAgents ActionsandUseinGlaucoma Fivebetablockers-betaxolol,carteolol,levobunolol,metipranolol,andtimolol -are approved for use in glaucoma. Local effects are generally minimal, although patients commonly complain of transientocularstinging. Constriction of the bronchi can occur with beta1-selective antagonists as well as with "nonselective" beta-adrenergic blockers-although the risk is greatest with the nonselective agents. PrototypeDrugs DrugsfortheEye BetaBlockers Betaxolol(beta1selective) Timolol(blocksbeta1andbeta2receptors) Alpha-AdrenergicAgonists Brimonidine ProstaglandinAnalogs Latanoprost AngiogenesisInhibitors Ranibizumab Latanoprost is generally well tolerated, and systemic reactions are rare. Topicallatanoprostmay alsoincreasepigmentationoftheeyelidandmayincreasethelength,thickness, and pigmentation of the eyelashes. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. OtherProstaglandinAnalogs In addition to latanoprost, three other topical prostaglandins are approved for topical therapy of glaucoma. Inclinicaltrials,theseagentswereatleastas effective as timolol, a representative beta blocker. Interestingly, one drug- travoprost-was more effective in blacks than in nonblacks. Like latanoprost, theseprostaglandinscancauseagradualincreaseinbrownpigmentationofthe iris, which may be irreversible. In addition, these drugs can increase pigmentation of the eyelid and growth of the eyelashes. In fact, bimatoprost, marketedasLatisse,isusedforthespecificpurposeofincreasingeyelashlength, darkness, and thickness. With prostaglandins used to treat glaucoma, the most common adverse effect is ocular hyperemia (engorgement of ocular blood vessels). Less commonly, these drugs cause blurred vision, eye discomfort, ocularpruritus,conjunctivitis,dryeye,lightintolerance,andtearing. Themostcommonadverseeffectsare dry mouth, ocular hyperemia, local burning and stinging, headache, blurred vision, foreign body sensation, and ocular itching. In contrast to apraclonidine (see later), brimonidine can cross the blood-brain barrier and hence can cause drowsiness,fatigue,andhypotension. Accordingly, at least 15 minutes should elapse between drug administrationandlensinstallation. Side effects include headache, dry mouth, dry nose, altered taste, conjunctivitis,lidreactions,pruritus,tearing,andblurredvision. EffectsontheEye Bystimulatingcholinergicreceptorsintheeye,pilocarpineproducestwodirect effects:(1)miosis(constrictionofthepupilsecondarytocontractionoftheiris sphincter) and (2) contraction of the ciliary muscle (an action that focuses the lens for near vision). In angle-closure glaucoma, contraction of the iris sphincter pulls the iris away from the pores of the trabecular meshwork, thereby removing the impediment to aqueous humor outflow. TherapeuticUses Although used widely in the past, pilocarpine is now considered a second-line drug for open-angle glaucoma. Contractionoftheciliary muscle focuses the lens for near vision; corrective lenses can provide partial compensationforthisproblem. Constriction of the pupil, caused by contraction of the iris sphincter, may decrease visual acuity. Stimulationofmuscarinicreceptorsthroughoutthebodycanproduceavariety of responses, including bradycardia, bronchospasm, hypotension, urinary urgency,diarrhea,hypersalivation,andsweating. Pilocarpine solutions have a relatively short duration of action and must be administered morefrequentlythanthegel. The basic pharmacology of echothiophate and other cholinesterase inhibitors is discussed inChapter12.
To prevent liver damage acne cyst removal 40 mg oratane mastercard, the hepatic function of patients should be monitored when they begin therapy with valproate skin care line reviews discount oratane 30mg line. Valproate has been associated with an increased incidence of spina bifida and other birth defects in the offspring of women treated with the drug during pregnancy skin care vietnam generic 10 mg oratane with amex. In addition acne extraction order discount oratane on-line, recent epidemiologic studies showed impaired cognitive development in the offspring of women who took valproate during pregnancy compared with those who took another antiepileptic medication. Valproate inhibits the metabolism of other drugs and can increase the serum levels of lamotrigine, phenobarbital, and primidone. It is poorly soluble in water, and different pharmaceutical formulations of it may have different bioavailability. A new formulation, called fosphenytoin, has become available for parenteral administration. Fosphenytoin is more soluble in water, and this prevents precipitation of the drug after intramuscular or intravenous administration. Phenytoin is converted to an inactive hydroxylated metabolite by cytochrome P450 enzymes. The drug exhibits dose-dependent kinetics, whereby lower concentrations are eliminated by a first-order process, but higher concentrations saturate biotransformation enzymes and exhibit zeroorder kinetics. These factors are responsible for the considerable patient variation in the plasma drug concentrations produced by a given dose. Because of this variation, serum drug levels should be monitored at the start of therapy and whenever toxicity or therapeutic failure occurs. As with carbamazepine, phenytoin blocks voltage-sensitive sodium channels by prolonging the inactivation state of these channels. This enables phenytoin to inhibit the repetitive firing of neurons in a seizure focus. The drug interferes with folate metabolism, and this can lead to megaloblastic anemia. Folate antagonism can also contribute to birth defects such as those seen in fetal hydantoin syndrome. This syndrome is characterized by cardiac defects; malformation of ears, lips, palate, mouth, and nasal bridge; mental retardation; and microcephaly. By impairing cerebellar function, phenytoin can cause ataxia, diplopia, nystagmus, and slurred speech. By interfering with vitamin D metabolism and decreasing calcium absorption from the gut, phenytoin sometimes causes osteomalacia. Phenytoin adversely affects collagen metabolism and thereby contributes to gingival hyperplasia, a condition in which the gums can extend down over the teeth if good dental hygiene is not practiced. Because of these adverse effects, phenytoin use in children should generally be avoided. Serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrosis have been observed in Asian patients administered phenytoin or fosphenytoin. In patients who are being treated with phenytoin, vitamin K supplements are given to prevent hypoprothrombinemia and bleeding. Carbamazepine induces the metabolism of phenytoin and decreases its serum levels, whereas cimetidine and other drugs inhibit the metabolism of phenytoin and increase its serum levels. Despite its many adverse effects and drug interactions, phenytoin is widely used in the treatment of Chapter 20 y Antiepileptic Drugs the levels of carbamazepine and phenytoin, whereas these drugs decrease the levels of valproate. Because of these interactions, serum levels should always be monitored when another drug is added to or removed from the treatment regimen of a patient with seizure disorders. Patients should be warned that salicylates can increase the serum levels of valproate. Of the various antiepileptic drugs, valproate has the broadest spectrum of activity. It is effective in the treatment of partial seizures and all forms of generalized seizures, and it can be given in combination with other drugs when a single drug does not adequately control seizures (see later). Valproate is also used as an alternative to lithium to treat the manic phase of bipolar disorder (see Chapter 22) and for the prophylaxis of migraines (see Chapter 29). Lamotrigine Lamotrigine blocks voltage-sensitive sodium channels and thereby interferes with neuronal membrane conduction and the release of excitatory neurotransmitters such as glutamate. It is one of the more effective adjunct drugs for treating partial seizures in adults and children. Lamotrigine is also indicated for the treatment of the manic phase of bipolar disorder. It is mostly conjugated with glucuronate in the liver and excreted by the kidneys. Serum levels of lamotrigine are decreased by carbamazepine and phenytoin and are increased by valproate. The primary side effects of lamotrigine include cerebellar dysfunction, drowsiness, and rash. Patients should be advised to report early signs of skin changes, because the rash can progress to Stevens-Johnson syndrome. This potentially fatal syndrome, a severe form of erythema multiforme, is characterized by mucocutaneous and systemic lesions. The syndrome is more common in patients who are being treated with the combination of lamotrigine and valproate, possibly because valproate increases the serum level of lamotrigine. If children are treated with both drugs, the dosage of lamotrigine should be lower than that used in other patients.
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