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By Z. Vandorn. Morris Brown College. 2018.

Adalimumab generic hytrin 1mg on-line blood pressure ranges pregnancy, infliximab and etanercerpt are all engineered • Bone marrow hypoplasia, thrombocytopenia and proteins which directly or indirectly inhibit tumour necrosis leukopenia can be fatal. They are a major advance in treating various immune proteinuria in 30% of patients. The drug should be diseases (see Chapter 50), including rheumatoid arthritis, but stopped until proteinuria resolves and treatment then have serious adverse effects, including infusion reactions and resumed at a lower dose. They are currently used by rheumatologists • Other symptoms include hypersensitivity reactions with for adults with active disease which has not responded to two urticaria. They are not continued if a response has not gravis-like syndromes can also be involved. Combinations of these proteins with methotrexate are being investigated for refractory disease, Contraindications with encouraging results. Penicillamine is contraindicated in patients with systemic lupus erythematosus, and should be used with caution, if at all, in individuals with renal or hepatic impairment. A number of hepatic metab- and gives rise to problems because of its limited solubility. Adverse effects Xanthine oxidase Adverse effects include the following: Figure 26. The final enzymatic • peripheral neuropathy; reactions in the production of uric acid are shown in Figure 26. It is more soluble in Colchicine is well absorbed from the gastro-intestinal tract. Plasma uric acid concentration is is partly metabolized, and a major portion is excreted via the lowered either by increasing renal excretion or, more often, by bile and undergoes enterohepatic circulation, contributing to inhibiting synthesis. Hyperuricaemia often occurs in the setting of obesity and excessive ethanol consumption. Hyperuricaemia also Allopurinol is used as long-term prophylaxis for patients occurs when excretion is decreased, for example, in renal fail- with recurrent gout, especially tophaceous gout, urate renal ure or when tubular excretion is diminished by diuretics, pyraz- stones, gout with renal failure and acute urate nephropathy, inamide (Chapter 44) or low doses of salicylate (Chapter 25). It The acute attack is treated with anti-inflammatory analgesic must not be commenced till several weeks after an acute agents (e. Allopurinol is a xanthine oxidase inhibitor and decreases the production of uric acid (Figure 26. It is also used in patients with familial Adverse effects Mediterranean fever and Behçet’s disease. A low dose can be used pro- rashes and life-threatening hypersensitivity reactions (includ- phylactically. It is relatively contraindicated in the elderly and ing Stevens Johnson syndrome) can occur. There is a history of essential hypertension, and he has had a similar but less Drug interactions severe attack three months previously which settled sponta- • Allopurinol decreases the breakdown of 6-mercaptopurine neously. Following this, serum urate concentrations were determined and found to be within the normal range. His (the active metabolite of azathioprine) with a potential for toe is now inflamed and exquisitely tender. He therefore prescribes cocodamol for Use the pain and repeated the serum urate measurement. Review Their main effect on the handling of uric acid by the kidney is his medication (is he on a diuretic for his hypertension? Despite his occupation, the patient does not drink alcohol and he was receiving ben- precipitate an acute attack of gout. The patient should period of poor antihypertensive control in this setting is not drink enough water to have a urine output of 2L/day during of great importance. After the pain has settled and ibuprofen the first month of treatment and a sodium bicarbonate or stopped, the patient’s blood pressure decreases further to 140/84mmHg on amlodipine. He did not have any recurrence potassium citrate mixture should be given to keep the urinary of gout.

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Adverse effects The adverse effects of saw palmetto involve gastro-intestinal Figure 17 generic 2mg hytrin mastercard blood pressure chart 5 year old. Chondroitin inhibits the enzymes the putative antidepressant effects of St John’s wort, the phar- that degrade cartilage. Drug controlled, double-blind study evaluated the effects of glu- interactions with therapeutic failure of concomitant drugs, cosamine on disease progression and supported the use of e. Adverse effects Drug interactions The adverse effects associated with glucosamine involve Many clinical trials are now reporting significant pharmacoki- gastro-intestinal disturbances, including dyspepsia, nausea, netic interactions with long-term treatment with St John’s constipation and diarrhoea, skin rashes and allergic reactions wort and drugs from a variety of therapeutic classes. More recently, kava kava (hepatotoxicity), aristocholic acid (nephrotoxicity) it was shown that St John’s wort enhanced the activity of tran- and phen phen (pulmonary hypertension) have recently scription factors, including the pregnane X receptor to tran- been communicated to prescribers and the public. Glucosamine is available as a non-prescription dietary supple- • The most commonly used products are garlic, ginkgo ment and in many products is obtained from shellfish. It is one biloba, echinacea, soy, saw palmetto, ginseng and St of several naturally occurring 6-carbon amino sugars found in John’s wort. Amino sugars are essential building blocks for • The efficacy of such products in many cases is not supported by rigorous clinical trials. Some • Patients believe herbals are safe and are unaware of commercial products contain glucosamine in combination documented or potential toxicities. The precise mechanism of action of glu- • Many patients take herbal products in conjunction with cosamine is unknown. In vitro data suggest glucosamine can prescription medications, unknowingly risking stimulate cartilage cells to synthesize glycosaminoglycans and herb–drug interactions. It is more likely that the cell produces smaller, her drug therapy (either therapeutic failure or toxicity) soluble subunits; assembly of these smaller, soluble subunits a careful history concerning the use of herbal products outside of the cell into a soluble form of collagen has been should be obtained. Nutraceutical therapies tacrolimus, mycophenolic acid and relatively low doses of for degenerative joint diseases: a critical review. When seen in follow up at approximately nine months meta-analysis of randomised controlled trials. Current concepts in Current clinical examination revealed some mild subcostal the therapeutic management of osteoarthritis with glucosamine. British Journal of Clinical laboratory investigation revealed no infectious cause. St John’s wort-associated drug interactions: short- pressive regimen that could lead to this clinical situation? Answer 2 It is possible, but should be clarified with the patient, that she has been taking St John’s wort for anxiety and insom- nia. The current public view of St John’s wort is that it is a harmless, herbal therapy that can be used to help patients with anxiety, insomnia and depression. Carefully enquiring about this possibility with the patient would be mandatory in this case. Apart from rifampicin, other drugs that induce 3A4 (but which the patient has not been prescribed) include phenobarbitone, carbamazepine, other rifamycins, pioglitazone, nevirapine (see Chapter 13). In this associated with troubled dreams punctuated by repeated wak- chapter, we discuss the management – both non-pharmacological enings. The result is that both patient and doctor are tempted to restart medication to suppress the withdrawal phenomena, resulting in a vicious cycle. These include: edly occurs in 35% of adults and is most frequent in women • pain (e. Yes No No Yes Treat underlying Treat underlying cause (Physical/ cause (Physical/ Psychological) Psychological) Chronic/ Chronic/ long-term long-term cause? Yes No No Yes Non-pharmacological Non-pharmacological methods/ methods/ behavioural behavioural therapies therapies No No Severe Severe and/or and/or disabling? Yes Yes First line First line Benzodiazepine Benzodiazepine Alternative (elderly) Second line (where sedation Clomethiazole is to be avoided) Buspirone Second line Zopiclone, zolpidem, zaleplon Figure 18. Much chronic insomnia is due to dependence on hypnotic • Drugs of other types may be needed when insomnia drugs. In addition, external factors such as noise, snoring part- complicates psychiatric illness. Shortened sleep time is common in the elderly, and Antipsychotics, such as chlorpromazine, may help to patients with dementia often have a very disturbed sleep pattern. They should be used for short • Hypnotics should not be routinely given to hospital periods (two to four weeks at most) and, if possible, taken patients or in any other situation, except where intermittently. On withdrawal the dose and frequency of specifically indicated and for short-term use only.

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