Arthritis Australia

By Z. Killian. University of Georgia.

This risk is symbo- lised by a square peg in a round hole to indicate something of a non-standard nature order 15mg mobic mastercard. Itispossible thattheriskscoremayvarydependingonthemethodofadministration;for example order 7.5 mg mobic with mastercard, a direct intravenous injection may score lower than an infusion as there is no further dilution involved and therefore one less risk factor. In these scenarios the risk rating at the end of each monograph is always for the highest rated assessment unless otherwise stated. It is vital that a local risk assessment accounts for method of administration in any given clinical area, so the risk score may be moderated to reflect local practice. In all areas, appropriate competence is essential for healthcare professionals working with injectable medicines to give assurance of safety. Local policies and procedures must be adhered to but individuals should also include injectable therapy in their continuing professional development. Hodder Headline’s policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. Yonkers and I dedicated Treatment of Psychiatric Disorders in Pregnancy to our spouses. Accordingly, Drugs and Pregnancy – A Handbook is dedicated to the future generation: Christian Carroll Ian Carroll Lauren DelHomme Leslie DelHomme Luke DelHomme Catherine DelHomme Madeline DelHomme Nicole Hery, Pharm. Raven Little White Savannah White This page intentionally left blank Contents Preface ix Acknowledgements xi 1 Introduction to drugs in pregnancy 1 2 Antimicrobials during pregnancy: bacterial, viral, fungal, and 22 parasitic indications 3 Cardiovascular drugs during pregnancy 51 4 Endocrine disorders, contraception, and hormone therapy during 75 pregnancy: embryotoxic versus fetal effects 5 Antiasthma agents during pregnancy 101 6 Anesthetic agents and surgery during pregnancy 114 7 Antineoplastic drugs during pregnancy 126 8 Analgesics during pregnancy 149 9 Anticonvulsant drugs during pregnancy 165 10 Psychotropic use during pregnancy 181 11 Antihistamines, decongestants, and expectorants during pregnancy 206 12 Nutritional and dietary supplementation during pregnancy 216 13 Use of dermatologics during pregnancy 240 14 Drug overdoses during pregnancy 254 15 Miscellaneous drugs during pregnancy: tocolytics and 279 immunosuppressants 16 Substance abuse during pregnancy 296 Appendix – Drug names 333 Index 352 This page intentionally left blank Preface The purpose of this volume was originally to condense and update Drugs and Pregnancy second edition. The total length of the original typescript was approximately three times the number of pages for which the publisher contracted. First strategy suggested was to eliminate the large number of references, but this was not acceptable. The final compro- mise developed was to post the full bibliography and supporting materials on a website for the book – http://www. It is intended for the content of this book to be updated and corrected – as necessary – approximately four times per year. These additions to the book will be posted to the website above, which will be maintained by the publisher. In addition, a searchable index of proprietary and generic names is provided on the website. Links to other sites that may be of use to readers of this book will also be included on the website. We have developed an automated search agent that will identify new publications (journal articles, books, etc. The main advantage of having a website accompany the published book is currency of information. Books usually take a year or longer to reach the reader after the author has completed the type- script, and may already be out-of-date by the time of release. Eva Malina, PhD also assisted in production of this volume during her summer vacation by reading and marking page proofs. Donna Savage, University Librarian, and her staff have patiently worked with Nona and me to acquire numerous uncommon reference sources. Finally, I wish to thank the Illinois Poison Control Board for allowing reproduction of their comprehensive list of antidotes, and to Saunders/Elsevier Publishing for allow- ing the adaptation of Figure 14. This page intentionally left blank 1 Introduction to drugs in pregnancy Magnitude of the problem 2 Prenatal diagnosis 14 Clinical evaluation 3 Counseling and evaluation of the Human teratology – principles 4 drug-exposed pregnant patient 14 Animal studies in clinical evaluation 6 Food and Drug Administration Human studies 6 classification of drugs and Known human teratogens 8 informed consent 18 Critical time periods 8 Informed consent and Potential adverse effects 9 post-exposure counseling 19 Maternal physiology during Summary 20 pregnancy 12 Key references 21 Pharmacokinetics in pregnancy 13 Birth defects occur among 3. These estimates have not changed over the past decade and a half, perhaps because genomic research eclipses research in clinical teratology, as suggested by a recent review (Polifka and Friedman, 2002). Nonetheless, much research remains to be done because the magnitude of the problem of medication use during pregnancy may be somewhat underestimated because 65–70 percent of birth defects have an unknown etiology. This may include unreported medically prescribed medication with teratogenic potential, use of alcohol and/or drugs of abuse, and other preventable causes of birth defects (i. Knowledge of the effects of prenatal exposure and the window of opportunity for intervention are the key factors in evaluation and prevention of morbidity and mortality due to drug and chemical exposure during pregnancy. Chapters 2–15 summarize infor- mation currently available regarding drug exposure during pregnancy, with detailed 2 Introduction to drugs in pregnancy 3% 4% Cytogenetic 2% 1% Mendelian and 5% mutation Unknown (polygenic, etc. Clinicians find it difficult to use the narrow window of opportunity to intervene in medication use during pregnancy because pregnant women do not present for prenatal care until embryogenesis is complete (i.

When the secretion of the skin and mucous membrane is restored by aconite buy mobic 15 mg, a full dose of quinine will sometimes accomplish the desired result cheap mobic 7.5 mg, when it would accomplish nothing without this agent. Aconite is so assuredly a specific in febrile conditions that its influence in chronic diseases is almost entirely overlooked. It is in certain chronic and non-febrile conditions a very reliable remedy because of its certain action upon the nervous system. John King advised its use in treatment of non-febrile spinal irritation in young women, and the writer has followed his suggestions in this condition for years with superior results in many cases. Its direct influence upon the cerebro-spinal system is recognized by homeopathists, Deschere says: “Aconite is useful in mental diseases and hysteria when there is particular aversion to excitement; the patients show an intolerance of music; they can bear no sounds. The symptoms indicating it in these cases are numerous and important, and necessarily so, since aconite restrains the blood flow and also exerts a special action on the heart and its nerves. There are congestions of both heart and lungs, palpitation with anxiety, cardiac oppression and even syncope. The palpitation is worse when walking, lancinating stitches occur and prevent the patient from assuming an erect posture or taking a deep inspiration. Attacks of intense pain at times extend down the left arm from the heart and are associated with numbness and tingling in the fingers. The agent is advised by many in angina pectoris when there are strong contractions or pure hypertrophy, but not in enfeebled heart or where there is much valvular insufficiency. The aconitine, in granules, is the best form for its internal administration in neuralgia. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 11 Webster has used aconite externally for pruritus, with excellent results. Occasionally the condition returns but in most cases the cure has remained permanent. The remedy is diluted and applied according to the discretion and knowledge of the physician. Aconite is of common use in local pain, to relieve congestion, irritation and distress. Perhaps the most immediate influence obtainable in acute pain is to pour ten drops each of chloroform and aconite into the palm of the hand and hold it over the seat of the pain for two or three minutes. It may be used in this manner in acute stomach or bowel pains until the cause of the pain is removed by other measures, or in acute pleurisy, and especially in angina pectoris. The pain ends with the application, and measures can be adopted to prevent its recurrence. Any local pain or neuralgia will yield, for a time at least, and in some cases it will not return. Sciatica treated two or three times per week with this simple formula will sometimes cease to return. We have observed that aconite intensifies, modifies and otherwise improves the action of several other agents with which it may be combined or alternated. The characteristic effects of Cimicifuga racemosa will occur in much less time with this remedy than when given alone. The influence of belladonna upon all local congestions and in equalizing general circulation is intensified in a characteristic manner when the remedy is given with, or alternated with aconite. Given with gelsemium in nervous excitement, cerebral fullness, nervous twitchings and fevers which result from irritation of the nerves and nerve centers, the effects of both are heightened. Given with asclepias tuberosa, with proper external means, hardly any other agent will be needed in acute pleuritis. Veterinarians find aconite immensely beneficial in the treatment of the inflammatory diseases of anitnals; but objections arise in the treatment of disease in horses, from the fact that horses are much more susceptible to Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 12 its action than man. An overdose produces in the mouth and throat a tingling sensation, followed by symptoms of strangulation from paralysis of the nerve endings. The patient becomes too weak to stand, the respiration is greatly depressed and insufficient, the heart beats more feebly and the pulse may vary every few minutes in its character, but it is always weak. Aconite depresses the heat centers, and, by dilating the capillaries of the skin, permits rapid heat radiation, thus at the same time, acting in a two-fold manner upon the temper-ature. Consequently the temperature of the surface of the body is a fairly correct criterion by which to judge of the internal temperature. There may be vomiting, failure of the special senses from the general paralyzing effect of the agent, syncope or mild delirum and convulsions. Antidotes—If a full toxic dose be taken, the above symptoms advance most rapidly, and no time whatever should be lost in combating the influence of the agent. If there is any reason for believing that the stomach contains any of the agent, large quantities of warm water should be swallowed and immediately evacuated. It may be vomited or siphoned out with a long stomach tube, or pumped out, but extreme nauseating emetics are contra-indicated. A mild infusion of oak bark, drunk freely, serves the double purpose of diluting the aconite and antidoting it by the tannin it contains.

One of the major problems associated with this neoplasm is determining the stage of the lesion and the treatment plan mobic 7.5 mg sale. The extent of the tumor in the pregnant patient tends to be underestimated (Pentheroudakis and Pavlidis cheap mobic 7.5mg mastercard, 2006; Yazigi and Cunningham, 1990). The treatment depends upon the stage of the cancer and gestational age of the preg- nancy. In the first half of pregnancy, treatment consists basically of radical hysterectomy and lymphadenectomy for small lesions and radiotherapy for more extensive lesions (Yazigi and Cunningham, 1990). Radiotherapy will generally result in spontaneous abortion, and therapeutic abortion should be offered as an option. Chemotherapy is generally utilized for advanced or metastatic disease, and the best prognosis for the infant is probably associated with treatment initiated after the first trimester if possible. Patients with microinvasion or preinvasive lesions can generally be treated with cone biopsy or conservative therapy until after pregnancy (Pentheroudakis and Pavlidis, 2006). Ovarian cancer Approximately 6 percent of adnexal masses in pregnancy are malignant compared to 15–20 percent in the nonpregnant patient, and the incidence of ovarian cancer during pregnancy is approximately one in 18 000–25 000 deliveries (Beischer et al. The most recent estimate for ovarian cancer is 1:10 000 to 1:100 000 (Pavlidis, 2002). Epithelial cell, germ cell, gonadal stromal cell, and endodermal sinus tumors have all been reported during pregnancy. Therapy depends on the stage of the disease and gesta- tional age of the pregnancy. Depending on the stage of pregnancy, more advanced disease may require hysterec- tomy or radical surgery. Chemotherapy may be indicated as adjuvant therapy, and the same principle applies as with other cancers (with the exception of acute leukemia); i. In a recent survey of 23 cases of ovarian carcinoma during pregnancy, Dgani and col- leagues (1989) reported that 35 percent were borderline grade and that overall survival was much better than expected for ovarian cancer because more of the cases in preg- nancy are of an earlier stage. The overall 5-year survival for women in this series was 61 percent and 92 per- cent for stage I lesions. The conflict arises because the predominant cellular event that occurs during in utero devel- opment is replication. Cell differentiation and replication dominate embryonic develop- ment; increases in cell number (hyperplastic growth) are the major occurrences during fetal growth and development. Hence, the greatest risk of antineoplastic agents during the first trimester is for birth defects, and the greatest risk during the fetal period is for intrauterine/fetal growth retardation. The safety of 6- mercaptopurine for childbearing patients with inflammatory bowel disease. Many nonnarcotic analgesics are commercially available (many of them over-the-counter medications) and fortunately, with few exceptions, can be utilized safely for the treatment of minor pain during pregnancy. Limited data are available on the pharmacokinetics of analgesics during pregnancy, and the findings are not entirely consistent. For example, acetaminophen has a decreased half- life and increased clearance in one study, but it is unchanged in another at about the same gestational age (Table 8. The pharmacokinetics of meperidine in pregnancy are unchanged compared to nonpregnant controls, and the same is true of the kinetics of mep- tazinol. In contrast, morphine has a decreased half-life and increased clearance, implying the need for increased frequency or dose regimen to maintain adequate analgesia. Low- dose aspirin does not appear to significantly affect umbilical artery circulation (Owen et al. Notably, the half-life for aspirin increases during pregnancy, implying that a dose decrease in amount and/or frequency may be needed (Table 8. Salicylates have been used clinically use for over 100 years and are one of the most commonly used nonnarcotic analgesics. Aspirin is one of the drugs most used by pregnant women (Corby, 1978; Sibai and Amon, 1988; Streissguth et al. In one prospective study of 1529 pregnant women in 1974 and 1975 (Streissguth et al. Prostacyclin, a potent vasodilator, also inhibits platelet aggrega- tion, while thromboxane A , a potent vasoconstrictor, stimulates platelet aggregation2 (Bhagwat et al. High or normal doses (>325 mg) block production of prostacyclin and thromboxane, and low-dose aspirin (60–83 mg) results in selective block of thromboxane production, and favors the prostacyclin (vasodilation) pathway (Beaufils et al. This provides the basis for the use of low-dose aspirin to fore- stall or prevent pregnancy-induced hypertension (Gant and Gilstrap, 1990) (see Special considerations). Importantly, low-dose aspirin does not completely inhibit thromboxane and does not completely ‘spare’ prostacyclin. One group of investigators found that 81 mg of aspirin inhibited thromboxane by 75 percent, but also inhibited prostacyclin by approximately 20 percent (Spitz et al.

The exclusion criteria were 6 being physically handicapped as reported by parents buy mobic 7.5mg fast delivery, teachers purchase 7.5mg mobic free shipping, school nurses, or self; suffering from any serious illness such as type 1 diabetes requiring insulin, renal disease, or moderate to severe asthma as reported by parents, teachers, school, nurses, or self; having any major developmental disability as reported by parents. Seventy-five children in the cohort had elevated fasting glucose levels (≥100mg/dL). For each of these “prediabetic” children, three children matched for normal fasting glucose levels (≤100mg/dl), age, sex, and race were randomly selected. Analysis of serum IgG Responses Serum samples were obtained by sterile venipuncture from each participant early in the morning after an overnight fast. The blood samples (10ml) were allowed to clot for 2 hours at room temperature before centrifuging (20 minutes at approximately 2000 x g). Specific IgG responses for periodontal pathogens were measured using an immuno-checkerboard (Sakellari et al. Nitrocellulose membranes were prepared, and the Miniblotter apparatus was pre- chilled for 4 hours at 4°C. Each membrane was loaded with bacterial suspensions (in duplicate) at 125 µl and protein A at 10µg/ml as a positive control (Boehringer, Germany). Membranes were dried at 37°C, blocked, washed, incubated for one hour with 100 ml of a solution containing distilled water (105 ml), 100% methanol (30 ml) and 30% hydrogen peroxide (15 ml), and then washed and blocked again. Miniblotters were mounted and rotated 90°, and channels were loaded with 130 µl of the unknown serum samples (diluted at 1/50, 1/1000 and 1/2000) and standards (IgG at various concentrations). Images were scanned, and the IgG response to each of 18 bacteria, 17 periodontal pathogens (P. In addition to the individual bacteria responses, combinations of detectable bacteria were noted as present or absent for each subject. The combinations considered were: two or more red complex 8 bacteria; two or more of the orange complex bacteria; at least one orange complex bacteria plus A. Statistical Analysis Univariate statistics were used to summarize responses for the demographic and bacteria data. The Chi-square test was used to compare the detectable proportion of each bacteria between males and females and between African-American and Caucasian children. Fisher’s exact test was used to compare the presence of the combinations of bacteria between gender and ethnic subcohorts. Forty-five percent (n=135) were female and 58% (n=176) were African-American (Table 1). Prevalence of serum IgG response to individual bacteria The proportion of children with detectable bacterial threshold levels for all species examined ranged from 2. A higher proportion of girls had a positive IgG response to 14 of the individual pathogens (Table 2). Compared to the boys, girls had elevated proportions of detectable thresholds for all 3 10 red complex bacteria although this did not reach statistical significance. Within the other bacterial complexes statistically significant higher proportions of girls had IgG responses to two of the orange (P. For the red complex bacteria, significantly higher proportions of IgG responses to T. Statistically significant elevations in the proportions of detectable thresholds were also observed for five of the orange complex bacteria (C. Frequencies (n) of subjects with detectable levels of IgG BacteriaBacteria AllAll MalesMales FemalesFemales p-valuep-value CaucasianCaucasian AfricanAfrican p-valuep-value (n=303)(n=303) (n=168)(n=168) (n=135)(n=135) (n=127)(n=127) AmericanAmerican (n=176)(n=176) RedRed complexcomplex Pg 5. A higher proportion of females were IgG positive for 6 of the 7 combinations of bacteria, but girls and boys differed statistically only for all three of the red complex bacteria (p<0. Frequencies (n) of subjects with detectable levels of IgG to different combinations of bacteria Groups of Subject groups Bacteria All Males Females p-value Caucasian African p- (n=303) (n=168) (n=135) (n=127) American value (n=176) Red Complex At least 2 6. Again, a higher proportion of the African American children were positive for all seven of the combinations of bacteria with a statistically significant difference (P<0. This first paper documents the prevalence of positive IgG responses to a number of periodontal pathogens. The rationale is that IgG antibody response represents an estimate of the overall systemic burden induced by periodontal infection. When combined with clinical periodontal measurements, these immune and other inflammatory responses could provide better estimates of the overall systemic burden imposed by an oral infectious challenge in chronic diseases such as diabetes. The major finding of the present exploratory study is that the children in this cohort were exposed to and exhibited detectable immune responses to a broad range of known periodontal pathogens at an early age. This immune response against specific microorganisms can be used as evidence for exposure and impact of the microbial etiology on the pathogenesis of periodontitis (Kinane et al. Significantly more girls 9-11 years of age were likely to have IgG responses to one or more orange complex bacteria and A. In addition, significantly more African Americans had IgG responses to both red and orange complex bacteria as well as A.