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By N. Sanuyem. Barnard College.

T his pat ient has numerous risk fact ors for deep venous t hrombosis and pulmonary embolism discount cialis super active 20mg amex erectile dysfunction exercise video. T h u s order generic cialis super active icd 9 erectile dysfunction nos, the n u m b er of r isk fact ors h elps t o cat egorize t he likelihood of a disease process. A clinician must understand the complications of a disease so that one may moni- tor the patient. Sometimes the student has to make the diagnosis from clinical clu es an d t h en apply h is/ h er kn owled ge of the sequ elae of the pat h ological pr ocess. For example, the st u dent sh ou ld kn ow that ch ron ic h ypert en sion may affect vari- ous end organs, such as the brain (encephalopathy or stroke), the eyes (vascular ch an ges), the kid n eys, an d the h ear t. Un d er st an din g the t ypes of con sequ en ces also helps the clinician to be aware of the dangers to a pat ient. The clinician is acutely aware of the need t o monit or for the end-organ involvement and undert akes the appropriate intervent ion when involvement is present. To answer this quest ion, the clinician needs t o reach the correct diagnosis, assess the severity of the condition, and weigh the situation to reach the appropriate intervent ion. For t he student, knowing exact dosages is not as import ant as under- st anding t he best medicat ion, rout e of delivery, mechanism of act ion, and possible complicat ion s. It is imp or t ant for the st u d ent t o be able t o ver balize the diagn osis and the rat ionale for t he therapy. A common error is for t he student to “jump to a treatment,” like a random guess, and therefore be given “right or wrong” feedback. In fact, the student’s guess may be correct, but for the wrong reason; conversely, the answer may be a very reasonable one, with only one small error in thinking. Instead, the student should verbalize the steps so that feedback may be given at every reasoning point. For example, if the qu est ion is, “W h at is the best t h erapy for a 25-year-old man wh o complains of a nont ender penile ulcer? T herefore, the best treatment for this man with probable syphilis is int ramuscular penicillin (but I would want to confirm the diagnosis). In the scenario above, the man with a nontender penile ulcer is likely to have syph- ilis. Knowing the limit ations of diagnostic tests and the manifest at ions of disease aids in t his area. There are four steps to the clinical approach to the patient: making the diag- nosis, assessing severity, treatment based on severity, and following response. Assessment of pretest probability and knowledge of test characteristics are essent ial in t he applicat ion of t est result s to t he clinical situat ion. There are seven questions that help to bridge the gap between the textbook and the clinical arena. Her fa m ily h ist o ry in clu d e s o n e m a t e rn a l co u sin wit h o va ria n ca n ce r. On e xa m in a t io n, she is found to have blood pressure 120/70 mm Hg, heart rate 70 bpm, and tem- perature 98°F. Pelvic examination shows a normal multiparous cervix, a normal-size uterus, and no adnexal masses. The patient states that she has regular Pa p a n ico la o u (Pa p ) sm e a rs, a n d t h a the la st o n e p e r fo rm e d 1 ye a r a g o wa s normal. Next step: Each of the following should be performed: stool for occult blood or colonoscopy or sigmoidoscopy, pneumococcal vaccine, influenza vaccine, tetanus vaccine (if not within 10 years), cholesterol screening, fasting blood glu cose. Understand which health maintenance studies should be performed for a patient older than 65 years. Understand that preventive maintenance consists of immunizations, cancer screening, and screening for common diseases. Co n s i d e r a t i o n s The approach to health maintenance consists of three parts: (1) screening for cancer, cardiovascular disease or other conditions, (2) immunizations, and (3) behavioral counseling regarding healthy behaviors such as regular exercise and tobacco cessation. For a 66-year-old woman, this in cludes mammograph y for breast can cer screen in g, colon can cer scr een in g, t et anu s boost er ever y 10 year s, pn eu mococcal vaccin e, an d year ly in flu en z a im m u n iz at ion. S cr een in g for h yp er ch olest er olem ia ever y 5 year s up to age 75 and fasting blood glucose levels every 3 years also are recommended. The most common cause of mortality in men or women over 65 is cardiovascular disease. Cervical cancer screening can be stopped at age 65 if all previous Pap smears have been normal. An optimal screening test has high sensitivity and specificity, is inexpensive, and is easy to perform. Immunizations: Aside from childhood immunizations, routine adult immu- nizations include influenza, pneumococcal, diphtheria, tetanus, and acellular pertussis (Td/ Tdap), zoster, as well as others in certain situations such as hepatitis A or B vaccines. Behavioral counseling: I n q u ir y a n d co u n s elin g r ega r d in g r egu la r exer cis e, avo id - ance or cessat ion of tobacco, moderate alcohol use, or screening for depression. Chemoprevention: Use of medication to prevent disease, such as use of folate during pregnancy to prevent neural tube defects, or low-dose aspirin to prevent car diovascu lar event s. Screening: Ident ificat ion of disease or risk fact ors in an asympt omat ic pat ient. Of these preventive measures, screening requires firm medical evidence that it may offer benefit, and thoughtful consideration from the practitioner before he or she initiates screening, and recommends to an asymptomatic patient that he/ she undergoes a medical intervention with potential harms (such as cost, radiation exposure, anxiet y regarding false-posit ive t est s, biopsies, or ot her follow-up examinat ions). Facilities for diagnosis and treatment of the condition should be available to the patient. There needs to be a latent or preclinical stage of the disease in which it can be detected. The natural history of the disease should be understood to guide intervention or treatment. The cost of case-finding should be balanced within the context of overall medical expenditures. Using these criteria, one may deduce that it would not be useful to screen for Alzheimer dementia since there is no curative treatment and no evidence that early int ervent ion alters t he course of t he disease, or t o perform cancer screening in developing count ries where t reat ment facilit ies may not be available or acces- sible to large port ions of the populat ion. Among Americans bet ween ages 15 and 45, accident s and homicide are t he leading causes of deat h, so prevent ive care may include counseling regarding behavioral risk reduction, such as seatbelt use, avoiding alcohol or texting while driving, or substance abuse. After age 45, the leading causes of death are malig- nancy and cardiovascular disease, so screening is focused on risk factor reduction for t h ose diseases (such as t obacco cessat ion, or cont rol of blood pressure and hyperlipidemia), or early detection of cancers. Regarding cancer screening tests, the American Cancer Society and various subspecialty organizations publish var io u s r ecom m en d at ion s, wh ich are oft en n o t in agr eem en t. Rout ine immunizat ions include annual influenza vaccine (especially import ant in the geriat ric populat ion, since > 90% of influenza-related deat hs occur in pat ient s over 60 years), pneumo- coccal vaccin es (23-valent polysacch ar ide vaccin e an d 13-valent pn eumococcal con - jugat e vaccin e sh ou ld be given sequ ent ially), an d H er pes zost er vaccin e for pat ient s over age 60. O ffering cancer screening to older patients should consider estimated life expect ancy (t ypically at least 10 years), comorbid condit ions, and abilit y or will- ingness to undergo cancer t reat ment if a cancer is detected (eg, to tolerate a hemi- colectomy if a colon cancer is found). The physician orders a fasting glucose level, lipid panel, mammogram, colonos- copy, an d a Pap sm ear of the vagin al cu ff.

Initially starts as macules purchase cialis super active 20 mg erectile dysfunction and injections, then erythematous patches buy generic cialis super active on line impotence hernia, followed by wart-like nodular lesions on the face, ear lobules and limbs. Following treatment, visceral infection disappears, but organisms may remain in skin. In India, it occurs in a small minority of patients, 6 months to 3 years or more after the initial infection, creating a persistent human reservoir. The patient usually presents with macules, papules, nodules (most common) and plaques on the face, mainly around the chin. Hypopigmented macules can occur over all parts of the body and are highly variable in extent and location. A: In early case, depigmented macules, erythematous, well-circumscribed lesions may be seen. Later, wart like nodules, or only multiple nodules of variable sizes and shapes are seen involving nose, cheek and ear lobule. A: As follows: First line treatment: Usually miltefosine should be given: • Adult: 50 mg twice daily for 12 weeks. A: Because: • The mass is in the right hypochondrium and in the epigastrium (left lobe). A: Yes, if it is pushed downward by any pathology in the right side of chest, such as emphysema, pleural effusion or pneumothorax. A: Investigations should be done according to the history and suspicion of cause: 1. A: 4 methods: • Percutaneous (by Vim–Silverman needle, Menghini needle or Tru-cut needle). If bilirubin is high, liver biopsy should not be done, as liver tissue does not take the stain. A: By percussion, upper border of liver dullness is in the sixth intercostal space or rib in right midcla- vicular line and the distance between this upper border and lower border is called liver span. It is character- ized by fever, pain in the right hypochondrium with radiation to right shoulder, tender hepatomegaly, hepatic rub and small right pleural effusion. Treatment: Tetracycline or doxycycline or erythromycin or azithromycin are used for Chlamydia infection. A: Because, the liver is hard, irregular, nodular, non-tender and there is hepatic bruit. Q:How to differentiate between primary carcinoma (hepatoma) and secondary carcinoma? Metabolic abnormalities are polycythaemia, hypercalcaemia, hypoglycaemia and porphyria cutanea tarda. A:Rarely, fbrolamellar hepatocellular carcinoma, common in young adults, affecting equally in male and female, in the absence of hepatitis B and cirrhosis. Other (rare) primary tumours are haemangioendothelial sarcoma, cholangiocarcinoma, hepatoblastoma, leiomyosarcoma, fbrosarcoma. Surgical resection, if pressure symptoms, also if pregnancy is desired (as size is increased in pregnancy). A: Because liver has dual blood supply causing relatively more blood fow (by portal vein and hepatic artery). A: It is a normal component of plasma protein, produced by the foetal liver older than 6 weeks and reaches maximum concentration at 12 to 16 weeks of foetal life. My diagnosis is tender hepatomegaly, which may be due to: • Acute viral hepatitis. Remember the following points: • Clinical features and pathological features are same by all viruses. But in cholestatic hepatitis or obstructive jaundice, alkaline phosphatase may be very high). A: As follows: • Acute fulminating hepatic failure (by B and sometimes E in pregnancy. It is seen in anxious patient who complains of malaise, anorexia, nausea, vomiting, right hypochondrial pain or discomfort in the absence of clinical or biochemical evidence of liver disease. In many cases, there is no active liver disease, normal or slightly raised transaminase and the patient is not highly infective, do not develop progressive liver disease although some patients develop reactive hepatitis. Decompensated cirrhosis can also be treated with oral antiviral agents, but liver transplantation may be required. Organism and animal hosts of different types of Leptospirosis: • Leptospira icterohaemorrhagiae of rat (rodent). The organism is excreted in the urine and may survive in the soil for several weeks. Entry into the human host is through cuts and abrasions on the skin, or through intact mucous membranes or contaminated water. Pathology: Replication occurs in the blood, tissue and multisystem involvement may occur. Initial or septicaemic phase—Persists for 4 to 7 days, characterized by high fever, headache, myalgia, abdominal pain, anorexia, nausea, vomiting, skin rash (macular, maculopapular or haemorrhagic), conjunctival ingestion (blood-shot eyes). Liver failure, myocarditis, cardiac failure, encepha- litis, aseptic meningitis, meningism, may occur. Haemolytic anaemia, thrombocytopenia, uveitis, haemolytic uremic syndrome may occur. Second or immune phase—There is development of antibody and leptospira disappears from blood. Features are usually mild, but meningism or aseptic meningitis and iridocyclitis may occur. Any case with high fever and combination of hepatitis, renal failure, bleeding manifestations and carditis is highly suggestive of Weil’s disease. Antibiotic should be started as early as possible in suspected case: • Doxycycline (100 mg 12 hourly for 1 week). In renal failure and jaundice: • Fluid and electrolyte balance must be maintained. Add—Local oedema and fullness of intercostal space in right lower chest with local intercostal tenderness in right lower chest called punch tenderness. My diagnosis is tender hepatomegaly, which may be due to: • Acute viral hepatitis. A: As follows: • Local oedema and fullness of intercostal space in right lower chest. A: As follows: • Ascending cholangitis in biliary obstruction (common bile duct) by stone, stricture and neoplasm or spreads from empyema of gall bladder. A: Features of pyogenic liver abscess: • Pyogenic abscess are usually multiple and small.

Description Nexplanon consists of a single 4-cm rod that contains 68 mg of etonogestrel order cialis super active once a day statistics on erectile dysfunction, a synthetic progestin cheap cialis super active online visa erectile dysfunction video. The rod is implanted subdermally in the groove between the biceps and triceps in the nondominant arm. Etonogestrel then diffuses slowly and continuously, providing blood levels sufficient for contraception for 3 years, after which the rod is removed. Mechanism of Action Etonogestrel suppresses ovulation and thickens cervical mucus. In addition, it causes the endometrium to become involuted and hence hostile to implantation. Pharmacokinetics Daily release of etonogestrel is 60 to 70 mcg initially and gradually declines to 25 to 30 mcg over 3 years. Adverse Effect: Irregular Bleeding In women using Nexplanon, bleeding episodes are irregular and unpredictable. In clinical trials, amenorrhea occurred in 22% of women; infrequent bleeding (less than three bleeding or spotting episodes in 90 days) occurred in 34% of women; frequent bleeding (more than five bleeding or spotting episodes in 90 days) occurred in 7% of women, and prolonged bleeding (more than 14 days of bleeding in 90 days) occurred in 18% of women. The general pattern of irregular and unpredictable bleeding does not change while using Nexplanon. Use During Breastfeeding Nexplanon is safe to use during breastfeeding after the 21st postpartum day. In a controlled clinical trial, there were no significant effects on the physical or psychomotor development of infants. Also, Nexplanon had no effect on the production or quality of milk, even when implanted just a few days postpartum. The drug thereby (1) inhibits follicular maturation and ovulation, (2) thickens the cervical mucus, and (3) causes thinning of the endometrium, making implantation unlikely. When injections are discontinued, return of fertility is delayed (by an average of 9 months). To ensure that the recipient is not pregnant, the first dose should be given either (1) during the first 5 days of a normal menstrual period, (2) within the first 5 days postpartum (if not breastfeeding), or (3) at the sixth week postpartum (if exclusively breastfeeding). Most adverse effects are like those seen with other progestin-only contraceptives. Menstrual disturbances are common; menstruation may be irregular at first and then, after 6 to 12 months, may cease entirely. Women may also experience abdominal bloating, headache, depression, and decreased libido. ParaGard can remain in place for 10 years, Mirena for 5 years, and Liletta and Skyla for 3 years. These devices prevent conception by producing a harmless local inflammatory response that is spermicidal. Mirena, whose active ingredient is levonorgestrel, also causes endometrial involution and thickening of the cervical mucus. Spermicides Spermicides are chemical surfactants that kill sperm by destroying their cell membrane. These drugs are available in the form of a foam, gel, jelly, suppository, vaginal film, and contraceptive sponge. The spermicide must be applied before intercourse, but no more than 1 hour in advance (when used alone). Containers for foam preparations must be shaken thoroughly before each use to ensure dispersal of the spermicide. Suppositories should be inserted at least 10 to 15 minutes before intercourse to allow time for dissolution. The contraceptive sponge [Today Sponge] is a soft, porous, polyurethane disk impregnated with 1000 mg of nonoxynol 9. When inserted to cover the cervix, it protects against conception by (1) releasing spermicide, (2) absorbing seminal fluid, and (3) blocking penetration of sperm. Unlike other spermicide products, which must be reapplied before each act of intercourse, a single sponge is effective for 24 hours, regardless of how often coitus takes place. The rates of unintended pregnancy with the sponge are high: 16% among typical nulliparous users, and 32% among parous users. In the United States nearly 50% of women aged 15 to 44 years report having had at least one unintended pregnancy. Progestin-Only Emergency Contraception Pills Three progestin-only products are available: Plan B One-Step, Next Choice One Dose, and Next Choice. These products are packaged and marketed specifically for emergency contraception. Plan B One-Step and Next Choice One Dose Plan B One-Step and Next Choice One Dose consist of a single, high-dose (1. The package insert calls for taking the tablet within 72 hours of unprotected intercourse. Plan B One-Step reduces the odds of pregnancy by 89% and Next Choice One Dose prevented 84% of expected pregnancies, which is better than it may seem. In the absence of these two medications, the pregnancy rate from a single act of unprotected intercourse is about 8% (i. Plan B One-Step and Next Choice One Dose work primarily by delaying or stopping ovulation. The major side effects of Plan B One-Step are heavier menstrual bleeding, nausea, abdominal pain, headache, and dizziness. Importantly, if pregnancy does occur, having used levonorgestrel will not increase the risk for major congenital malformations, pregnancy complications, or any other adverse pregnancy outcomes. These drugs will not terminate an existing pregnancy and will not harm a fetus if present. Because Plan B One-Step and Next Choice One Dose act before fertilization and implantation, they cannot be considered abortifacients. For women aged 15 years and older, Plan B One-Step and Next Choice One Dose are now available over the counter. For women who are not yet 15 years old, Plan B One-Step is still available, but a prescription is required. Prescriptions can be obtained from private physicians, clinics run by Planned Parenthood, and student health departments at colleges and universities. According to the package insert, women should take 1 tablet within 72 hours of intercourse and a second tablet 12 hours later. Like Plan B One-Step, Next Choice can be obtained without a prescription (by women 15 years and older) or with a prescription (by women younger than 15 years). Ulipristal Acetate Emergency Contraception Pill Ulipristal acetate [ella] is a drug that acts as an agonist-antagonist at receptors for progestin. Like levonorgestrel, ulipristal acetate prevents conception primarily by suppressing ovulation.

When aggressive factors outweigh mucosal defenses purchase 20mg cialis super active fast delivery best herbal erectile dysfunction pills, gastritis and peptic ulcers result quality 20 mg cialis super active erectile dysfunction treatment aids. Defensive Factors Defensive factors serve the physiologic role of protecting the stomach and duodenum from self-digestion. Conversely, when defenses are compromised, aggressive factors are able to cause injury. Bicarbonate Bicarbonate is secreted by epithelial cells of the stomach and duodenum. Most bicarbonate remains trapped in the mucus layer, where it serves to neutralize any hydrogen ions that penetrate the mucus. Bicarbonate produced by the pancreas is secreted into the lumen of the duodenum, where it neutralizes acid delivered from the stomach. If submucosal blood flow is reduced, the resultant local ischemia can lead to cell injury, thereby increasing vulnerability to attack by acid and pepsin. These compounds stimulate secretion of mucus and bicarbonate, and they promote vasodilation, which helps maintain submucosal blood flow. By taking up residence in the space between epithelial cells and the mucus barrier that protects these cells, the bacterium manages to escape destruction by acid and pepsin. In fact, the bacterium has been declared a type 1 carcinogen by the International Agency for Research on Cancer. By doing so, they can decrease submucosal blood flow, suppress secretion of mucus and bicarbonate, and promote secretion of gastric acid. Gastric Acid Gastric acid is an absolute requirement for peptic ulcer generation: in the absence of acid, no ulcer will form. In fact, in most patients with gastric ulcers, acid secretion is normal or reduced, and among patients with duodenal ulcers, only one third produce excessive amounts of acid. From these observations, we can conclude that, in most patients with peptic ulcers, factors in addition to acid must be involved. Zollinger-Ellison syndrome is the primary disorder in which hypersecretion of acid alone causes ulcers. The syndrome is caused by a tumor that secretes gastrin, a hormone that stimulates gastric acid production. Like gastric acid, pepsin can injure unprotected cells of the gastric and duodenal mucosa. Possible mechanisms include reduction of the beneficial effects of antiulcer medications, reduced secretion of bicarbonate, and accelerated gastric emptying, which would deliver more acid to the duodenum. Overview of Treatment Drug Therapy The goals of drug therapy are to (1) alleviate symptoms, (2) promote healing, (3) prevent complications (hemorrhage, perforation, obstruction), and (4) prevent recurrence. With the exception of antibiotics, the drugs employed do not alter the disease process. Because nonantibiotic therapies do not cure ulcers, the relapse rate after their discontinuation is high. Drug Selection Helicobacter pylori–Associated Ulcers In 1997, a National Institutes of Health Consensus Development Conference recommended that all patients with gastric or duodenal ulcers and documented H. To hasten healing and relieve symptoms, an antisecretory agent should be given along with the antibiotics. Evaluation We can evaluate ulcer healing by monitoring for relief of pain and by radiologic or endoscopic examination of the ulcer site. Unfortunately, evaluation is seldom straightforward because cessation of pain and disappearance of the ulcer rarely coincide: in most cases, pain subsides before complete healing. However, the converse may also be true: pain may persist even though endoscopic or radiologic examination reveals healing is complete. A Note About the Effects of Drugs on Pepsin Pepsin is a proteolytic enzyme that can contribute to ulcer formation. For example, treatment that produces a 99% reduction in gastric acidity will cause pH to rise from a base level of 1. To avoid activation of pepsin, drugs that reduce acidity should be administered in doses sufficient to raise gastric pH above 5. Nondrug Therapy Optimal antiulcer therapy requires implementation of nondrug measures in addition to drug therapy. The traditional “ulcer diet,” consisting of bland foods together with milk or cream, does not accelerate healing. Furthermore, there is no convincing evidence that caffeine-containing beverages (coffee, tea, colas) promote ulcer formation or interfere with recovery. A change in eating pattern may be beneficial: consumption of five or six small meals a day, rather than three larger ones, can reduce fluctuations in intragastric pH and may thereby facilitate recovery. Other Nondrug Measures Smoking is associated with an increased incidence of ulcers and also delays recovery. However, if the patient notes a temporal relationship between alcohol consumption and exacerbation of symptoms, then alcohol use should stop. Many people feel that reduction of stress and anxiety may encourage ulcer healing; however, there is no good evidence that this is true. Antibacterial Drugs Antibacterial drugs should be given to all patients with gastric or duodenal ulcers and confirmed infection with H. Antibiotics are not recommended for asymptomatic individuals who test positive for H. Antibiotics Employed The antibiotics employed most often are clarithromycin, amoxicillin, bismuth, metronidazole, and tetracycline. Furthermore, if these drugs are used alone, the risk for developing resistance is increased. Antibacterial activity is highest at neutral pH and hence can be enhanced by reducing gastric acidity with an antisecretory agent (e. Bismuth Bismuth compounds—bismuth subsalicylate and bismuth subcitrate—act topically to disrupt the cell wall of H. Tetracycline Tetracycline, an inhibitor of bacterial protein synthesis, is highly active against H. Because tetracycline can stain developing teeth, it should not be used by pregnant women or young children. Metronidazole Metronidazole [Flagyl] is very effective against sensitive strains of H. A disulfiram-like reaction can occur if metronidazole is used with alcohol, and hence alcohol must be avoided. Like metronidazole, tinidazole can cause a disulfiram-like reaction and hence must not be combined with alcohol. To minimize emergence of resistance, the guidelines recommend using at least two antibiotics, and preferably three. Eradication rates are good with a 10-day2 course and slightly better with a 14-day course.

Paradoxical Effects When employed to treat anxiety purchase 20mg cialis super active fast delivery erectile dysfunction pump rings, benzodiazepines sometimes cause paradoxical responses discount cialis super active 20mg amex causes of erectile dysfunction in 20 year olds, including insomnia, excitation, euphoria, heightened anxiety, and rage. Hence, in contrast to the barbiturates, benzodiazepines present little risk as vehicles for suicide. It must be emphasized, however, that although respiratory depression with oral therapy is rare, benzodiazepines can cause severe respiratory depression when administered intravenously. The behavior pattern that constitutes “addiction” is uncommon among people who take benzodiazepines for therapeutic purposes. When asked about their drug use, individuals who regularly abuse drugs rarely express a preference for benzodiazepines over barbiturates. Use in Pregnancy and Lactation Benzodiazepines are highly lipid soluble and can readily cross the placental barrier. Use of benzodiazepines during the first trimester of pregnancy is associated with an increased risk for congenital malformations, such as cleft lip, inguinal hernia, and cardiac anomalies. Because they may represent a risk to the fetus, most benzodiazepines are classified in U. Four of these drugs—estazolam, flurazepam, temazepam, and triazolam—are in Category X. Women of childbearing age should be warned about the potential for fetal harm and instructed to discontinue benzodiazepines if pregnancy occurs. Benzodiazepines enter breast milk with ease and may accumulate to toxic levels in the breastfed infant. Other Adverse Effects Occasional reactions include weakness, headache, blurred vision, vertigo, nausea, vomiting, epigastric distress, and diarrhea. Rarely, benzodiazepines may cause severe allergic reactions, including angioedema and anaphylaxis. Drug Interactions Benzodiazepines undergo very few important interactions with other drugs. Unlike barbiturates, benzodiazepines do not induce hepatic drug-metabolizing enzymes. Hence, although benzodiazepines are very safe when used alone, they can be extremely hazardous in combination with other depressants. Tolerance and Physical Dependence Tolerance With prolonged use of benzodiazepines, tolerance develops to some effects but not to others. No tolerance develops to anxiolytic effects, and tolerance to hypnotic effects is generally low. Physical Dependence Benzodiazepines can cause physical dependence—but the incidence of substantial dependence is low. When benzodiazepines are discontinued after short-term use at therapeutic doses, the resulting withdrawal syndrome is generally mild and often goes unrecognized. Withdrawal from long-term, high- dose therapy can cause more serious reactions, such as panic, paranoia, delirium, hypertension, muscle twitches, and seizures. Symptoms of withdrawal are usually more intense with benzodiazepines that have a short duration of action. Because the benzodiazepine withdrawal syndrome can resemble an anxiety disorder, it is important to differentiate withdrawal symptoms from the return of the original symptoms of anxiety. The intensity of withdrawal symptoms can be minimized by discontinuing treatment gradually. Substituting a benzodiazepine with a long half-life for one with a short half-life is also helpful. After discontinuation of treatment, patients should be monitored for 3 weeks for indications of withdrawal or recurrence of original symptoms. Acute Toxicity Oral Overdose When administered in excessive dosage by mouth, benzodiazepines rarely cause serious toxicity. If an individual known to have taken an overdose of benzodiazepines does exhibit signs of serious toxicity, it is probable that another drug was taken, too. Preparations, Dosage, and Administration Preparations and dosages for insomnia are presented later in the chapter. Preparations and dosages of benzodiazepines used for other disorders are presented in Chapters 19, 20, and 28. When used for sedation or induction of sleep, benzodiazepines are almost always administered by mouth. Oral Patients should be advised to take oral benzodiazepines with food if gastric upset occurs. Also, they should be instructed to swallow sustained-release formulations intact, without crushing or chewing. Patients should be warned not to increase the dosage or discontinue therapy without consulting the prescriber. For treatment of insomnia, benzodiazepines should be given on an intermittent schedule (e. P ro t o t y p e D r u g s Sedative-Hypnotic Drugs Benzodiazepine Triazolam Benzodiazepine-Like Drugs Zolpidem Zaleplon Barbiturate Secobarbital Melatonin Receptor Agonist Ramelteon Benzodiazepine-Like Drugs Three benzodiazepine-like drugs are available: zolpidem, zaleplon, and eszopiclone. However, although approval is limited to short-term use, many patients have taken the drug long term with no apparent tolerance or increase in adverse effects. All zolpidem formulations have a rapid onset and hence can help people who have difficulty falling asleep. Like the benzodiazepines, zolpidem can reduce sleep latency and awakenings and can prolong sleep duration. Rather, binding is limited to the benzodiazepine-1 subtype of benzodiazepine receptors. Zolpidem is extensively metabolized to inactive compounds that are excreted in the bile, urine, and feces. Daytime drowsiness and dizziness are most common, and these occur in only 1% to 2% of patients. Like the benzodiazepines, zolpidem has been associated with sleep driving and other sleep-related complex behaviors. Short-term treatment is not associated with significant tolerance or physical dependence. Zaleplon Zaleplon [Sonata] is the first representative of a new class of hypnotics, the pyrazolopyrimidines. The drug is approved only for short-term management of insomnia, but prolonged use does not appear to cause tolerance. In contrast to zolpidem, zaleplon has a very rapid onset and short duration of action and hence is good for helping patients fall asleep, but not for maintaining sleep. Plasma levels peak about 1 hour after administration and then rapidly decline, returning to baseline in 4 to 5 hours. Zaleplon is metabolized by hepatic aldehyde oxidase before excretion in the urine. The most common side effects are headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain. Like the benzodiazepines, zaleplon has been associated with rare cases of sleep driving and other complex sleep-related behaviors.

Universidad Tecnológica de Chihuahua
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