By Z. Sebastian. William Penn College.
Additional information Common and serious Injection/infusion-related: Local: injection-site reactions on peripheral undesirable effects venous administration order 100 mg labetalol with visa. Other: Nausea generic labetalol 100 mg free shipping, vomiting buy generic labetalol 100mg line, diarrhoea purchase 100 mg labetalol amex, headache cheap 100 mg labetalol mastercard, arthralgia, myalgia, asthenia, rash, pruritus, anaemia, leucopenia, eosinophilia, "urea and creatinine. Action in case of overdose No specific antidote; observe carefully and give supportive treatment. This assessment is based on the full range of preparation and administration options described in the monograph. Dose in renal impairment: adjusted according to creatinine clearance: * CrCl >50mL/minute: dose as in normal renal function. Withdraw the required dose and add to a suitable volume of compatible infusion fluid (e. Ranitidine | 731 Continuous intravenous infusion Preparation and administration 1. Withdraw the required dose and add to a suitable volume of compatible infusion fluid. Technical information Incompatible with Amphotericin, drotrecogin alfa (activated), insulin (soluble). Stability after From a microbiological point of view, should be used immediately; however, preparation prepared infusions may be stored at 2--8 C and infused (at room temperature) within 24 hours. Monitoring Measure Frequency Rationale Renal function Periodically * A decline in renal function may require a dose reduction. Signs of infection Throughout * Use of antisecretory drugs may "risk of infections such as treatment community-acquired pneumonia, Salmonella, Campylobacter and Clostridium difficile-associated disease. This assessment is based on the full range of preparation and administration options described in the monograph. Biochemical and other tests Bodyweight Rasburicase | 733 Dose Standarddose:200micrograms/kg/day for upto7days dependinguponplasmauricacidlevelsand clinical judgement. Withdraw the required dose (more than one vial may be required) and add to 50mL NaCl 0. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Displacement value Negligible Stability after preparation From a microbiological point of view, should be used immediately; however: * Reconstituted vials may be stored at 2--8 C for 24 hours. Monitoring Measure Frequency Rationale Allergic reactions Following * If severe hypersensitivity reactions occur, stop administration treatment immediately. Periodically levels * Collect the blood sample into a pre-chilled tube containing heparin and immerse in ice/water bath. Samples taken for plasma uric acid interactions assessment must be handled in a precise way -- see Monitoring above. This assessment is based on the full range of preparation and administration options described in the monograph. Concomitant therapy with aspirin: 300mg prior to thrombolysis, followed by 75--150mg once daily at least until discharge. Remove the protective flip-cap from the vial and clean the rubber closure with an alcohol wipe. Open the package containing the reconstitution spike; remove both protective caps from this. Connect the syringe to the reconstitution spike and transfer the 10mL of solvent into the vial. With thereconstitution spike and syringestill attached to thevial,swirl thevial gently to dissolve the injection powder. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Displacement value Negligible Stability after preparation From a microbiological point of view, should be used immediately; however, reconstituted vials may be stored at 2--8 C and used within 8 hours. Monitoring in treatment of myocardial infarction Measure Frequency Rationale Heart rate Continuously * #Pulse may result from reperfusion. Additional information Common and serious Immediate: Anaphylaxis and other hypersensitivity reactions have been undesirable effects reported rarely. Significant * The following may "risk of haemorrhage with reteplase: interactions anticoagulants, heparins, antiplatelet agents, e. Stop administration and give supportive therapy as appropriate, includingfresh frozen plasma, fresh blood and tranexamic acid if necessary. This assessment is based on the full range of preparation and administration options described in the monograph. Rifam picin (rifam pin) 600-mg dry powder vials with solvent * Rifampicin belongs to the rifamycin group of antimycobacterials.
Human data fit well with these ideas since it is very clear that following prolonged drug use the context of the use of the agent has huge importance discount labetalol 100mg visa. Many dependent drug users go through physical withdrawal and then re-use the drug when they return to where they took the drug previously generic labetalol 100 mg without prescription, whereas those who move away can do much better in keeping off the drug buy 100mg labetalol overnight delivery. Some users are heavily dependent (the prototype addict) cheap 100mg labetalol fast delivery, others use the drug in very particular circumstances (recreational users) whereas others are only beginners generic labetalol 100 mg on-line, many of whom will never continue beyond the experimental stage. The physical and psychological effects of the different drugs, individual differences and contextual issues are all interacting to define the nature of drug use and abuse (Fig. The prevalence of serious addiction in areas of social and financial deprivation may be due to the drug being used as a permanent escape from the misery of everyday life with low incomes and housing standards, low job prospects and yet the individual is surrounded by images of affluence. Here drugs are used by an individual to escape from their circumstances, either into oblivion or from modern society into a group of drug users, a society of its own. These types of users are very different from weekend drug users who have strict rules controlling where and when a drug is used and who interact with peers who both use and abstain from drugs. Piomelli, D, Giuffrida, A, Calignano, A and Rodrõguez de Fonseca, F (2000) The endo- cannabinoid system as a target for therapeutic drugs. The results of binding to target proteins, such as ion channels, can change the overall activity of cells, such as neurons, which in turn impinge on other target tissues. These pharmacodynamic interactions are complex and culminate in the symptomology observed in the patient. Any combination of chemicals in the body, endogenous or not, is a fluid game of competitions, synergies, or antagonisms at the metabolic and functional level. The results may go unseen, may be beneficial, may be harmful or, in some cases, lethal to the subject. Due diligence has been taken by the publishers, editors, and authors of this book to ensure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical expe- rience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the respon- sibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any conse- quences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel. Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc. The fee code for users of the Transactional Reporting Service is: [1-58829-211-8/04 $25. Use of multiple drugs (8–12 on average in hospitalized patients) is common in a number of therapeutic regimens. In addition to multiple drug therapy, a patient may have access to several prescribers, and may have predisposing illnesses or age as risk factors for interactions. Drug interactions may occur between prescription drugs, but also between food and drug, and chemical and drug. Whereas some may be adverse, interactions may also be sought to decrease side effects or to improve therapeutic efficacy. Pharmacokinetic mechanisms of interaction include alterations of absorption, distribution, biotransformation, or elimination. Absorption can be altered when drugs that alter pH or motility are co-administered, as seen with certain antiulcer or antidiarrheal medications, or when drugs are chelators or adsorbents (tetracyclines and divalent cations, cholestyramine, and anionic drugs). Distribution variations can result from competition for protein binding (sulfa drugs and bilirubin binding to albumin) or displacement from tissue-binding sites (digitalis and calcium channel blockers or quinidine). Induction of gene expression (slow), activation or inhibition (much quicker) of liver and extrahepatic enzymes such as P450, and conjugating enzymes have long found a place of choice in the literature describing the potential for adverse drug interactions resulting from altered metabolism. For example, induction is well described with the major anticonvulsant medications phenytoin, carbamazepine, and barbiturates, whereas inhibition can occur with antimicrobials from the quinolone, the macrolide, and the azole families. Finally, excretion can also be modified by drugs that change urinary pH, as carbonic anhydrase inhibitors do, or change secretion and reabsorption pathways, as probenecid does. Pharmacokinetic interactions in general result in an altered concentration of active drug or metabolite in the body, modifying the expected therapeutic response. A second form of interaction has received little attention because of its modeling complexity and perhaps the poor understanding of basic physiological, biochemical, and anatomical substrates for drug action. Pharmacodynamic interactions involve additive (1 + 1 = 2), potentiating (0 + 1 = 2), synergistic (1 + 1 = 3), or antagonistic (1 + 1 = 0) v vi Preface effects at the level of receptors. Large families of receptors to drugs involve signal transduction pathways and changes in intracellular second messenger concentrations (autonomic nervous system drugs and α, β, muscarinic receptors, for example).
Given that the rare phenomenon of sudden death is real generic 100mg labetalol with visa, the need to minimize the risk of torsades de pointes is necessary buy discount labetalol 100 mg. Attention to combinations of medicines and their relative risk is therefore essential purchase labetalol 100mg fast delivery. Antipsychotics that may introduce risk in patients who are on other medicines that affect cardiac conduction also include dro- peridol (69) order labetalol 100mg on-line. Neuroleptic Malignant Syndrome This very uncommon cheap labetalol 100mg with amex, but emergent condition may spontaneously arise in those who have been prescribed antipsychotics, particularly the traditional variety (71). Sexual Side Effects: Serotonin and Others A number of neurochemicals affected by antipsychotics impact the sexual-response cycle. Stage one of the cycle, libido, is enhanced by dopamine (77) and diminished by prolactin (77). Antipsychotics therefore can potentially diminish libido by dopamine blockade and/or enhancing prolactin release. Serotonin indirectly may reduce arousal, but this effect has been identified only in patients taking antide- pressants (78). Arousal, therefore, can be inhibited by both traditional and atypical anti- psychotics through two mechanisms, anticholinergic and dopamine-blocking activity. However, serotonin diminishes orgasm (79), which may explain orgasm difficulties found in those prescribed atypical antipsychotics. Thus, most traditional and atypical antipsychotics invariably affect the gonadotro- pic hormonal system. Ultimate effects on relationships and marriages, as well as pro- creation, can be profound. Priapism is a rare side effect in which blood is trapped in the erect penis because of circulatory changes (80). This rare effect is associated with those antipsychotics, chlorpromazine and thioridazine in particular, with the greatest a-adrenergic blockade (80). Fortunately, this reaction is very rare, enough that it should not be affecting pre- scribing decisions unless it has happened. An informed patient can recognize that pri- apism is medicine related, and can seek treatment in an emergency room without panic. Many of those who take antipsychotics have very guarded boundaries and have difficulty broaching issues of sexuality. Impotence and sexual disinterest is embarrassing for them, and often feeds into and off of a low self-esteem that becomes the major, chronic illness. This area is an example of the burden facing the psychiatrist to educate patients at the time of informed consent about sexual side effects, and to probe side effects beyond perfunctory general questions or questionnaires. However questionnaires may satisfy standards of care, they do not represent quality care. Seizures Traditional antipsychotics lower the threshold at which someone with a history of seizures will experience a seizure (81). In practice, this risk is primarily pertinent to those with already diagnosed seizure disorders. The atypical antipsychotic clozapine may directly cause seizures at higher dose, even in patients with no previous history (82). If there are no treatment alternatives, that drawback does not outweigh the bene- fits of continuing to prescribe the medicine. However, seizures from medications can be reduced in frequency with antiseizure medicines added to the regimen. Other interactions must then be addressed, specifi- cally those resulting from the tendency of many antiseizure medicines to lower blood concentrations of antipsychotics. Poor physician management of antipsychotic drug treatment is often the reason for intolerable side effects. If patients discontinue treatment because of unacceptable experiences with antipsychotics when medicines might have been helpful had they been competently managed, injury relating to unmanaged illness may establish a viable mal- practice claim. From there, a transformed product, as well as unchanged drug, enter the bloodstream to exert their effects (83). Research in recent years has increasingly delineated which of the isoenzymes systems is responsi- ble for metabolizing which drugs, what drugs inhibit that metabolism, and what drugs 6. The known isoenzymes associated with antipsychotic metabolism are listed in Table 2. Most combinations of medicines with antipsychotics have not yet been studied to the end point of clear impact of medicines on the metabolism of that specific drug, with a few exceptions. Medicines that slow the metabolism of traditional antipsychotics do so by inhib- iting those enzymes in the liver that would otherwise break down the antipsychotics.
When asked what they do when they feel stressed generic 100mg labetalol otc, here’s what they replied (some gave more than one response): 39 percent overeat; 29 percent skip meals; 44 percent lie awake at night cheap labetalol 100 mg without a prescription. Mark Hyman buy labetalol 100mg amex, family physician and five-time New York Times best-selling author generic labetalol 100mg visa, notes labetalol 100mg generic, “Ninety-five percent of disease is either caused by or worsened by stress. The Science of High Cortisol Jump ahead to “Part A: The Gottfried Protocol for High Cortisol” (page 100) if you are not interested in the scientific background. Stress enters your body via certain parts of your brain, including the hypothalamus, amygdala, hippocampus, plus a few other structures that modulate emotion and behavior. Indeed, it’s a bit of a shocker to learn that such an old-school method regulates such crucial tasks as digestion, immune function, sex drive, energy use, and storage, and how you cope with emotions and moods— both your own and that of others. This leads to high blood pressure, high blood sugar, and a poorly working immune system. These changes are temporary if the stressors subside and you perceive that you are free from imminent danger. However, over time, if these temporary conditions persist, they may lead to hypertension, diabetes, perhaps even cancer and stroke. Researchers call this phenomenon a blunted response: you can’t deal appropriately with stress anymore because your feel- good neurotransmitters, such as serotonin, norepinephrine, and dopamine, are depleted. Many of us are so accustomed to unremitting stress—whether from long work hours, or a difficult marriage, or demanding children—that we’ve actually rewired our brains to perceive danger when it’s no longer a threat, or when it’s relatively minor. There’s a significant cost to unskillfully managing stress, which is a problem for at least 75 percent of the adults in the United States. You can see how this could lead to exhaustion, a greater susceptibility to contagious illness, decreased sex drive, low blood pressure, and orthostatic hypotension (you can’t keep your blood pressure normal when you stand up, and feel like lying down again, literally and figuratively). Cortisol and Aging Women in their twenties are the hormonal gold standard, and under normal conditions, produce a tidy 15 to 25 mg of cortisol per day. In a survey of more than 300,000 Americans, those with the worst mental health scores were between ages thirty-five and fifty. High cortisol generates the long list of maladies associated with too much of this hormone. When we age, however, we don’t absorb cortisol into the cells the way we used to in our twenties and thirties (not to mention that high cortisol itself accelerates aging). These two imbalances—in the blood and in the cells— means that we feel tired (low cortisol) and wired (high cortisol). How High Cortisol Accelerates Aging Recall that cortisol’s main job is to normalize your blood- sugar levels. This may lead to prediabetes (as measured by a fasting glucose level between 100 and 125 mg/dL) or diabetes (fasting glucose > 125). The marathon runner has far higher cortisol levels from running, gets more injuries, and ages faster. Not only that, prolonged elevation of cortisol causes a domino effect: when your adrenals are monomaniacally producing cortisol, the rest of the hormone cascade falls into neglect. Here’s what concerns me most: extensive research demonstrates that prolonged exposure to high cortisol constricts blood flow to the brain. That adversely affects brain function, decreases your emotional intelligence, and accelerates age-related cognitive function. Yes, Alzheimer’s disease becomes established more than thirty years prior to symptoms. Ideally we make a lot in the morning, less during the day, very little at bedtime, and a minimal amount while we sleep. Referred to as diurnal variation —diurnal simply means a recognizable daily cycle, similar to how a flower opens and closes during a twenty- four-hour cycle—the process can be documented in a “diurnal cortisol” measurement at four points between about six a. It also sets up one of your most important circadian rhythms, another crucial aspect of hormonal control. Operating on a twenty- four-hour cycle, circadian rhythms establish your biochemical and physiological peaks and valleys, almost like a tide within the body. When the cortisol tide is out, around midnight, and your cortisol is at its lowest, your cells perform their greatest repair and healing. If your cortisol is still high at night, your body can’t do the repair work it needs. That’s no good: when you are most in need of rest, the high cortisol makes you feel you don’t need it—which only depletes your adrenals further, because your adrenals heal at night. Furthermore, depleting your adrenals will cause you to start running low on important feel-good neurotransmitters, including serotonin, dopamine, norepinephrine, and epinephrine. In addition, nighttime is when your hormones get a chance to harmonize and resync with one another. Melatonin and growth hormone, for instance, which help you fall asleep and stay asleep, are mainly secreted at night.
Figure 7 Streptomyces fervens produces melanin cheap labetalol 100 mg with visa, and its melanin synthesis was inhib- ited by kojic acid at dose response order 100mg labetalol free shipping, when the concentration of kojic acid increased from left to right buy 100mg labetalol with mastercard. Table 4 In Vitro and Animal Assays for Depigmentation Agents Assays with which melanogenesis inhibition was conﬁrmed Depigmentation agents Kojic acid 1 purchase labetalol 100 mg mastercard. Melanin reduction of B-16 melanoma cells 4n-butylresorcinol Ascorbic acid Liquiritin 3 order 100 mg labetalol mastercard. Depigmentation Agents 133 Table 5 Chemical Structures of Main Depigmentation Agents melanin, turning the color of the medium to black again. Various assays to detect depigmentation agents (9–12) are listed in Table 4, and the chemical structures of main depigmentation agents are shown in Table 5. Cultured B-16 melanoma cells are also excellent material for visually con- ﬁrming the melanogenesis inhibition in vitro. After 5 days of the culture, the cells are ﬁxed by formalin and stained by ammonical silver nitrate, then premelanosome can be visually stained in black. Right side shows inhibition effect of kojic acid put into the culture medium at 2. Figure 9 Black gold ﬁsh (upper and bottom as controls) changed color form black to brown, when kojic acid was added in the water at 0. Depigmentation Agents 135 cells are alive, and such premelanosome stain is negative with the presence of depigmentation agents, melanogenesis is recognized as having been successfully inhibited (Fig. More dramatic effects of melanogenesis inhibition can be recognized when a depigmentation agent is added to the water in which black goldﬁsh are kept. The addition of kojic acid required a month or two for the black goldﬁsh to turn to yellowish brown; since they were alive and vivid, this demonstrated that only melanogenesis was inhibited, not systemic metabolism (Fig. When there is no clinical effect of depigmentation, they are of course useless, even though they showed excellent results in vivo trials. Laser is not effective to melasma, and is very effective to solar lentigo and to nevus of Ota to which depigmentation agents are less effective or ineffective. First, for that purpose, depigmentation agents should be mixed in vehicles, normally creams or lotions, without any alteration of the color or the effective- ness. They should pass acute, subacute, and chronic toxicity tests, skin and eye irritation tests, skin sensitization tests (maximization and similar tests), oncogenicity tests (Ames test, micronuclei tests, carcinogenicity tests), teratogenicity tests, and sta- bility tests. These tests are all required to develop new drugs and likewise with depigmentation agents. It is because depigmentation agents require several months to exhibit their effects and consumers may use them for several months or even several years. Double-blind clinical tests for melasma usually are not appropriate because as it takes more than 3 months for the effect to be recognized. Actually, depig- mentation agents like kojic acid, hydroquinone, and arbutin can improve the brown hyperpigmentation of melasma by continual usage for 3–12 months. Theo- retically it is possible to give active depigmentation agents to one group while a second group is given a placebo cream for 3 to 12 months (13,14); there should be no signiﬁcant differences between the backgrounds of the melasma patients as to age, severity, and sun exposure. It is ethically acceptable to use a placebo when another, effective treatment is given. However, when melasma patients are involved in the clinical trial, they have the right to see improvement in a short period of time. Double-blind tests are alright when the test ends in a week or so (as with corticosteroid oint- ments or antibiotics), especially when some another reliable basic treatment is given or the placebo is a competing drug having a deﬁnite effect. Hydroquinone cream is not suitable as an active placebo because the brown color change after a few months indicate that it is hydroquinone: this is an open test (6), not a blind test. With cosmeceuticals, double-blind tests have not always been demanded, presumably because they were not as strong as drugs and had mild effects not detectable in a short period. When some medical effects are exhibited after long- time usage, double-blind tests are difﬁcult and, in some instances, not ethical when the patients are to be given a placebo with no effect for months. Therefore, double-blind tests should be introduced with care with cosmeceuticals with mild and slow effects. With melasma, the brown pigmentation fades so slowly that patients often do not recognize the effects of depigmentation agents after 6 months of continual, twice-a-day application. The best way to evaluate is to take color photographs of the faces of melasma patients from three angles—front, 45° right, and 45° left. When the same camera, ﬂashlight, and color ﬁlm are used, the effect of depigmentation agents can surely be recognized (7,13,14). First the color of the melasma turns from brown to yellowish brown or normal skin color, and second, the contrast at the border of the melasma becomes obscure. When colorimetry is used, it is possible to recognize the change of tint, but when the place of measurement differs at times of measurement, correct change of color is difﬁcult to be obtained. Mapping the human cheeks and forehead to determine the same spots at each time of measurement is usually difﬁcult. On the other hand, pattern recognition using color photographs from the same three angles of the face is much easier (13,14).
Hence in any given segment order labetalol 100mg mastercard, there is a definite laterality (ipsilateral/ contralateral) and a three-dimensional organisation (rostrocaudal buy labetalol 100mg otc, mediolateral generic 100mg labetalol free shipping, dorsoventral) of the afferent terminations 100 mg labetalol otc. The grey matter can be organised into ten different laminae order labetalol 100 mg line, which run continuously along the entire length of the spinal cord. Within a given section of a spinal cord, each lamina can be seen as a layer of functionally distinct cells. Lamina V plays an important role in nociception since it receives both Ad- and C-fibre inputs. Some cells in lamina V also respond to cutaneous low- and high-threshold mechanical stimuli and receive nociceptive inputs from the viscerae. Many of these neurons also project onto mono- neurons and so act as interneurons in the polysynaptic withdrawal reflex to noxious stimuli. The spinal cord is an important site at which the various incoming nociceptive signalling systems undergo convergence and modulation and is under ongoing control by peripheral inputs, interneurons and descending controls. One consequence of this modulation is that the relationship between stimulus and response to pain is not always straightforward. The response of output cells could be greatly altered via the interaction of various neurotransmitter systems in the spinal cord, all of which are subject to plasticity and alterations during pathological conditions. The arrival of action potentials in the dorsal horn of the spinal cord, carrying the sensory information either from nociceptors in inflammation or generated both from nociceptors and intrinsically after nerve damage, produces a complex response to pain. In addition, presynaptic kainate receptors for glutamate have been described in the spinal cord. However, if a repetitive and high-frequency stimulation of C-fibres occurs there is then an amplifica- tion and prolongation of the response of spinal dorsal horn neurons, so-called wind-up (Fig. The reason is that under normal physiological conditions the ion channel of this receptor is blocked by the normal levels of Mg2 found in nervous tissues. The lack of peptides in large Ab afferent fibres explains the lack of wind-up after low-threshold stimuli. These drugs have been shown to be antinociceptive in a number of animal models of inflammation and nerve damage and there are also data from volunteer and clinical studies to support this. This is partly because adequate dosing is prevented by the narrow therapeutic window of the existing drugs. As neurons become more active, then ion channels, other than sodium channels, open in their membranes. There are a number of voltage-operated calcium channels (see Chapter 3) that are critical for both transmitter release and neuronal excitability. Successful results in animals with agents that block neuronal voltage-sensitive calcium channels would also suggest that there is an increase in central neuronal excitability after both inflammation and nerve damage. N-type channels, blocked by o-conotoxin, a marine snail toxin, have been shown to play a key role in behavioural allodynia and the neuronal responses to low- and high-threshold natural stimuli after nerve damage, and in the C-fibre-evoked central hyperexcitability that follows inflammation. Unfortunately, since calcium channels are extensively distributed in all excitable tissue it is necessary to give blockers used for analgesia by the spinal route. Gabepentin is an antiepileptic drug that has analgesic activity in neuropathic pain states from varying origins. It has also been reported that gabapentin is effective in pain due to peripheral nerve injury and central lesions, with particular effectiveness on paroxysmal pain and allodynia. How gabapentin works is not clearly established but it is thought the drug may interact with calcium channels in that it becomes attached to the so-called gabapentin-binding protein, itself associated with a subunit of the calcium channel. This action would fit with the evidence that N-type calcium channel blockers are more effective in reducing behavioural and electrophysiological responses to sensory stimuli after both nerve injury and tissue damage, conditions where it appears that N-type calcium channels are upregulated. Rises in internal calcium in neurons is a key means by which genes can be activated. The protooncogene markers c-fos and c-jun can be observed in dorsal horn neurons only minutes after the application of noxious stimulation, either mechanical or thermal or from tissue damage. It is now recognised that in addition to the well-documented production of prostaglandins in peripheral tissues there can be central neuronal synthesis, again with calcium being the trigger. There are important inhibitory systems built into the control of events following C- fibre stimulation. Several studies have demonstrated Bzs to be analgesic, whereas others have found no antinociceptive properties. In addition, there are contradictory reports of Bzs both potentiating and antagonising morphine analgesia. This diversity of results, however, is the product of many different experimental protocols, models of nociception and routes of administration. Baclofen modulation of nociceptive transmission is seen under inflammatory conditions in animals but in humans the drug appears to lack any analgesic effect. The assessment of the analgesic effectiveness of opioids in both animals and in patients is complicated by the fact that the type of neuropathy and the extent, duration and intensity of the symptoms will vary. There is no real consensus from clinical studies on the efficacy of morphine in neuropathic pain states.