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By M. Hatlod. California Institute of Integral Studies. 2019.

Circulate freely Heparin can be used to prevent clotting whenever the patient’s blood must circulate outside the body through a machine buy 50mg losartan mastercard, such as the cardiopulmonary bypass machine or hemodialysis machine discount 25mg losartan fast delivery, and during blood transfusions generic losartan 25mg amex. Adverse reactions to heparin One advantage of heparin is that it produces relatively few adverse re- actions cheap 50 mg losartan overnight delivery. Even so discount losartan 50 mg online, these reactions can usually be prevented if the pa- tient’s partial thromboplastin time is maintained within the therapeutic Heparin increases range. If a ly by administering protamine sulfate, which binds to heparin to form a patient is also taking stable salt. Other adverse reactions include bruising, hematoma formation, necrosis of skin or other tissue, and thrombocytopenia. Drug interactions • Because heparin acts synergistically with all oral anticoagu- lants, the risk of bleeding increases when the patient takes both drugs together. Another reason to quit • Drugs that antagonize or inactivate heparin include antihista- mines, cephalosporins, digoxin, neomycin, nicotine, nitroglycerin, penicillins, phenothiazines, quinidine, and tetracycline. It binds extensively to plasma albumin and is metabo- absorbed quickly, it lized in the liver and excreted in urine. Although warfarin is ab- can take a couple of sorbed quickly, its effects don’t occur for about 48 hours, with the days for their full full effect taking 3 to 4 days. Because warfarin is highly plasma-protein-bound and is metab- olized by the liver, administration of warfarin with other medica- tions may alter the amount of warfarin in the body. This may in- crease the risk of bleeding or clotting, depending upon the med- ications administered. However, clotting factors already in the blood- stream continue to coagulate blood until they become depleted, so anticoagulation doesn’t begin immediately. Patients with this disorder begin taking the medication while still receiving heparin. However, outpatients at high risk for thromboembolism may begin oral anticoagulants without first re- ceiving heparin. To decrease the risk of arterial clotting, oral anticoagulants warfarin levels are sometimes combined with an antiplatelet drug, such as as- pirin, clopidogrel, or dipyridamole. Patients taking warfarin need close monitoring of Drug interactions prothrombin time and In- ternational Normalized Many patients who take oral anticoagulants also receive other Ratios to make sure they drugs, placing them at risk for serious drug interactions. Examples include acetaminophen, allopurinol, amiodarone, If laboratory results fall cephalosporins, cimetidine, ciprofloxacin, clofibrate, danazol, dia- outside the accepted zoxide, disulfiram, erythromycin, fluoroquinolones, glucagon, he- range, warfarin dosage parin, ibuprofen, isoniazid, ketoprofen, methylthiouracil, metron- should be adjusted. Examples include barbiturates, carba- Adverse mazepine, corticosteroids, corticotropin, mercaptopurine, naf- cillin, hormonal contraceptives containing estrogen, rifampin, reactions spironolactone, sucralfate, and trazodone. The primary adverse re- Other interactions include the following: action to oral anticoagu- • A diet high in vitamin K reduces the effectiveness of warfarin. Acute alcohol intoxication increases the ing can occur, however, risk of bleeding. Necrosis or Aspirin, clopidogrel, dipyridamole, sulfinpyrazone, and ticlopi- gangrene of the skin and dine are examples of oral antiplatelet drugs. Quick fix The effects of oral anti- Pharmacokinetics coagulants can be re- When taken orally, antiplatelet drugs are absorbed very quickly versed with phytona- and reach peak concentration in 1 to 2 hours. Sulfinpyra- zone may require several days of administration before its anti- platelet effects occur. The effects of these drugs occur within 15 to 20 minutes of administration and last about 6 to 8 hours. Elderly patients and patients with renal failure may have de- creased clearance of antiplatelet drugs, which would prolong the antiplatelet effect. It lengthens platelet survival and prolongs the patency of arteriovenous shunts used for hemodialysis. Salve for surgery Dipyridamole is used with a coumarin compound to prevent thrombus formation after cardiac valve replacement. Adverse reactions to antiplatelet drugs Hypersensitivity reactions, particularly anaphylaxis, can occur. Tales of toxicity • Aspirin increases the risk of toxicity of methotrexate and val- proic acid. You just don’t know Because guidelines haven’t been established for administrating ticlopidine with heparin, oral anticoagulants, aspirin, or fibrinolyt- ic drugs, these drugs should be discontinued before ticlopidine therapy begins. Pharmacokinetics Direct thrombin inhibitors are typically administered by continu- ous I. They may also be given as an intra-coronary bo- lus during cardiac catheterization. In that case, the drug begins acting in 2 minutes, with a peak response of 15 minutes and a du- ration of 2 hours. In patients with heparin-induced thrombocytopenia, platelet count recovery becomes apparent within 3 days.

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However order losartan 25mg overnight delivery, haloperidol may restore an acutely ill schizophrenic safe 50 mg losartan, who was previously withdrawn generic losartan 25mg with amex, or even mute and akinetc 25 mg losartan amex, to normal actvity and social behaviour buy generic losartan 50 mg line. In the acute phase chlorpromazine may be administered by intramuscular injecton in a dose of 25-50 mg which can be repeated every 6-8 h while observing the patent for possible hypotension. In most cases, however, the intramuscular injecton is not needed and patents can be treated with an oral dose. Maintenance Therapy: Long-term treatment in patents with a defnite diagnosis of schizophrenia may be necessary afer the frst episode to prevent the manifest illness from becoming chronic. The lowest possible dose of antpsychotc drug that will prevent major exacerbatons of forid symptoms is used for long-term management. Intramuscular depot preparatons such as fuphenazine may be used as an alternatve to oral mainte- nance therapy especially when compliance with oral treat- ment is unreliable. Exacerbatons of illness in patents on maintenance drug therapy can be precipitated by stress. Withdrawal of maintenance drug treatment requires careful surveillance since it is not possible to predict the course of the disease and the patent may sufer a relapse if treatment is withdrawn inappropriately. Further, the need for contnuaton of treatment may not be evident on withdrawal of treatment because relapse may be delayed for several weeks. Hypotension and interference with tempera- ture regulaton, neuroleptc malignant syndrome and bone- marrow depression are the most life-threatening. They can result in dangerous falls and hypothermia in the elderly and this must be considered before prescribing these drugs for patents over 70 years of age. Extrapyramidal symptoms are the most troublesome and are caused most frequently by the piperazine phenothiazines such as fuphenazine, the butyrophenones such as haloperidol and the depot preparatons. Although easily recognized, they are not so easy to predict because they depend in part on the dose and patent susceptbility as well as the type of drug. However, there is a general tendency for low-potency drugs to have less extrapyramidal adverse efects, while high-potency drugs such as haloperidol have more extrapyramidal efects but less seda- ton and antcholinergic (more correctly antmuscarinic) efects. Extrapyramidal symptoms consist of parkin- sonian-type symptoms including tremor which may occur gradually; dystonia (abnormal face and body movements) and dyskinesia, which may appear afer only a few doses; akathisia (restlessness), which may occur afer large inital doses and may resemble an exacerbaton of the conditon being treated; and tardive dyskinesia (an orofacial dyskinesia), which usually takes longer to develop but may develop on short-term treat- ment with low doses; short-lived tardive dyskinesia may occur afer withdrawal of the drug. Parkinsonian symptoms are usually reversible on withdrawal of the drug and may be suppressed by antcholinergic (antmuscarinic) drugs but they may unmask or worsen tardive dyskinesia. Tardive dyskinesia is usually associated with long-term treatment and high dosage of an antpsychotc, partcularly in elderly patents. There is no established treatment for tardive dyskinesias, which may be irreversible on withdrawing therapy. However, withdrawal at the earliest signs of tardive dyskinesia may halt its full devel- opment. Treatment of all patents on antpsychotcs must be carefully and regularly reviewed. Neuroleptc malignant syndrome (hypothermia, fuctuatng levels of consciousness, muscular rigidity, and autonomic dysfuncton with pallor, tachycardia, labile blood pressure, sweatng and urinary incontnence) is a rare adverse efect of haloperidol and chlorpromazine. It is managed by discontn- uing the antpsychotc, correctng fuid and electrolyte defects, and giving bromocriptne and sometmes dantrolene. Dose Oral Adult- Schizophrenia and other psychoses, mania, psychomotor agitaton, violent behaviour and severe anxiety (adjuvant): initally 25 mg 3 tmes daily (or 75 mg at night) adjusted to response to usual maintenance dose of 100-300 mg daily (but up to 1. Elderly or debilitated- Schizophrenia and other psychoses, mania, psychomotor agitaton, violent behaviour and severe anxiety (adjunct): one-third to one-half adult dose. Child- Schizophrenia and other psychoses, mania, psychomotor agitaton, violent behaviour and severe anxiety (adjunct); (for childhood schizophrenia and autsm) 1 to 5 years: 500 µg/kg every 4-6 h (max. Deep intramuscular injecton Adult- Relief of acute symptoms: 25 to 50 mg every 6 to 8 h. May impair ability to perform skilled tasks, for example operatng machinery, driving. Fluphenazine Pregnancy Category-C Schedule H Indicatons Maintenance treatment of schizophrenia and other psychoses; mania, postoperatve nausea. Precautons Treatment requires careful monitoring for optmum efect; inital small test dose as adverse efects are prolonged; extrapyramidal symptoms occur frequently; when transferring from oral to depot therapy, dosage by mouth should be reduced gradually; cardiovascular and cerebrovascular disorders; respiratory disease, epilepsy; acute infectons; pregnancy (Appendix 7c), lactaton (Appendix 7b); renal and hepatc impairment (avoid if severe; Appendices 7a), history of jaundice; leukopenia (blood counts if unexplained fever or infecton); hypothyroidism, myasthenia gravis, prostatc hypertrophy, angle-closure glaucoma; elderly (partcularly in very hot or very cold weather); interactons (Appendix 6a, 6c); alcohol withdrawal, extreme heat. May impair ability to perform skilled tasks, for example operatng machinery, driving. Adverse Efects As for Chlorpromazine (see above), but less sedatng and fewer hypotensive and antcholinergic symptoms; higher incidence of extrapyramidal symptoms (most likely to occur a few hours afer injecton and contnue for about 2 days but may be delayed); systemic lupus erythematosus; pain at injecton site, occasionally erythema, swelling, nodules; tardive dyskinesia, neurological disturbances, blood dyscrasias. Dose Oral Adult-Schizophrenia and other psychoses, mania, psychomotor agitaton and violent behaviour and severe anxiety (adjuvant): initally 1. Elderly or debilitated-Schizophrenia and other psychoses, mania, psychomotor agitaton and violent behaviour and severe anxiety (adjuvant): initally half adult dose. Child-Schizophrenia and other psychoses, mania, psychomotor agitaton and violent behaviour and severe anxiety (adjuvant): initally 25 to 50 µg/kg daily in 2 divided doses (max. Intramuscular injecton Adult- Acute psychotc conditons: initally 2 to 10 mg, subsequent doses every 4 to 8 h according to response (up to every h if necessary) to max. May impair ability to perform skilled tasks, for example operatng machinery, driving.

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