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Benzodiazepines Avoid benzodiazepines (any type) for treatment of insom- Minimal effect on weight buy proscar 5mg low price; increases risk of thrombotic events and Short- and intermediate-acting: nia generic 5 mg proscar mastercard, agitation buy discount proscar 5 mg online, or delirium. Glyburide: higher risk of severe prolonged hypoglycemia in older n Triazolam adults. Potential for aspiration and adverse effects; safer alternatives avail- Chloral hydrate* Avoid. Peripheral alpha blockers Not an effective oral analgesic in dosages commonly used; may n Doxazosin Increases risk of orthostatic hypotension or brady- cause neurotoxicity; safer alternatives available. Antipsychotics are associated with an increased risk n Carisoprodol Most muscle relaxants poorly tolerated by older adults, because of of cerebrovascular accident (stroke) and mortality in n Chlorzoxazone anticholinergic adverse effects, sedation, increased risk of fractures; persons with dementia. Chronic Oral antimuscarinics for urinary inconti- Avoid unless no other alternatives. The American Geriatrics Society gratefully acknowledges the support of the John A. Decisions about drug therapy must be based upon the independent judgment of the clinician, changing drug information, and evolving healthcare practices. Analgesics Mild / Moderate Pain Acetaminophen Both acute and chronic doses of acetaminophen are associated with hepatotoxicity. For this reason, this drug has been reformulated so the products are limited to 325 mg per dosage unit. Forms: Liquid, tablet, oral disintegrating tablet, caplet, rectal suppository, injectable Usual oral dosage:1,2 Children <12 years: 10-15 mg/kg/dose every 4-6 hours as needed (maximum90 mg/kg/24 hours,3 but not to exceed 2. Other children may be poor metabolizers of codeine with lower conversion to morphine and, consequently, under-respond to the narcotic. Forms: Liquids: 120 mg acetaminophen and 12 mg codeine/5 mL (Note: Te elixir and solution, but not suspension, contain alcohol. For acute pain, naproxen sodium may be preferred because of increased solubility leading to faster onset, higher peak concentration, and decreased adverse drug events. Forms: Suspension, tablet Usual dosage:2 Children >2 years up to 12 years: 5-7 mg/kg every 8-12 hours as needed Children >12 years: 200 mg every 8-12 hours as needed; may take 400 mg for initial dose (maximum 600 mg/24 hours) Adults: Initial dose of 500 mg, then 250 mg every 6-8 hours as needed (maximum 1250 mg/24 hours) Moderate/Severe Pain Acetaminophen with hydrocodone For pediatric patients, the practitioner should consider prescribing in accordance to body weight (mg/kg) and in 5 mL dosage increments. Forms: Liquids: 300 mg acetaminophen and 10 mg hydrocodone/15 mL 325 mg acetaminophen and 7. May titrate up to 5 mg/dose oxycodone every 4-6 hours (acetaminophen maximum90 mg/kg/24 hours,3 but not to exceed 2. Forms: Suspension, chewable tablet, tablet Usual oral dosage:1,2 (based on amoxicillin component): Children >3 months of age up to 40 kg: 25-45 mg/kg/day in doses divided every 12 hours (prescribe suspension or chewable tablet due to clavulanic acid component) Children >40 kg and adults: 500-875 mg every 12 hours (prescribe tablet) Azithromycin This drug is one of two options for patients with Type I allergy to penicillin and/or cephalosporin antibiotics. Caution: This drug can cause cardiac arrhythmias in patients with pre-existing cardiac conduction defects. Forms: Tablet, capsule, suspension, injectable Usual oral dosage:1,2 (Note: Doses may vary for extended release suspension depending on the reason for prescribing the antibiotic. Forms: Suspension, tablet, capsule Usual oral dosage:1,2 Children >1 year: 25-100 mg/kg/day in divided doses every 6-8 hours (maximum 4g/day) Adults: 250-1000 mg every 6 hours (maximum 4g/day) Endocarditis prophylaxis:2,9 50 mg/kg (maximum 2 g) 30-60 minutes before procedure Clindamycin Note: This is one of two options for patients with Type I allergic reactions to penicillin and/or cephalosporin antibiotics. This antibiotic is effective for infections (eg, abscesses) with gram-positive aerobic bacteria and gram-positive or gram-negative anaerobic bacteria. Due to these and other side efects, women who are pregnant and children <8 years old should not use this drug. Forms: Suspension, tablet, delayed release tablet, capsule, injectable Usual oral dosage for necrotizing ulcerative gingivitis:1,8 Children >8 years who weigh <45 kg: 2. Patients should avoid ingestion of alcohol as a beverage or ingredient in medications while taking metronidazole. Forms: Tablet, tablet extended release, capsule, injectable Usual oral dosage: For anaerobic skin and bone infection:1,3 Children: 30/mg/kg/day in divided doses every 6 hours (maximum 4 g/24 hours) Adolescents and adults: 7. Anaphylactic reactions have been demonstrated in patients receiving penicillin, most notably those with a history of beta-lactam hypersensitivity, sensitivity to multiple allergens, or prior IgE-mediated reactions (eg, angioedema, urticaria, anaphylaxis). Form: Suspension 10 mg/mL, 40 mg/mL; tablet: 50 mg, 100 mg, 150 mg, 200 mg; injectable 200 mg, 400 mg Usual dosage:1,2 Neonates >14 days: Single dose of 6 mg/kg on day 1; then decrease to 3 mg/kg once/day for 7 to 14 days Adolescents and adults: Single dose of 200 mg on day 1; then decrease to 100 mg once/day for 14 days Ketoconazole Form: Tablet, 200 mg Usual oral dosage:1,8 Children >2 years: 3. Miconazole nitrate Forms: Ointment 2%; cream 2% Usual dosage:1 Children >2 years and adults: Apply a thin layer to the corners of the mouth 4 times/day for 14 days or until complete healing. Nystatin Forms: Ointment, cream (100,000 units/g) Usual dosage:1 For all ages: Apply a thin layer to angles of mouth 4 times/day for 14 days or until complete healing. Nystatin, triamcinolone acetonide Forms: Ointment, cream (100,000 units nystatin/g and 0. Topical or transmucosal agents for oral candidiasis Clotrimazole Form: Lozenge 10 mg Usual dosage:1,2 (Note: Not for use in patients < 3 years of age. Miconazole (Oravig ) ® Form: Buccal tablet 50 mg Usual dosage:1,3 Adolescents >16 years and adults: One tablet/day for 14 days; apply to the gum region, just above the upper lateral incisor. Acyclovir Form: Cream 5% Usual dosage:1,3 Children >12 years and adults: Apply a thin layer on the lesion 5 times/day for 4 days. Acyclovir with hydrocortisone (Xerese®) Form: Cream (5% acyclovir with 1% hydrocortisone) Usual dosage:1,3 Children >12 years and adults: Apply a thin layer on the lesion 5 times/day for 5 days. Penciclovir Form: Cream 1% Usual dosage:1,3 Children >12 years and adults: Apply a thin layer on the lesion every 2 hours while awake for 4 days. Tere is a potential for lidocaine toxicity if oral suspension is overused, and there is an increased risk for aspiration if used in children who cannot expectorate.

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Although the pharmacist does not typically gather this history discount 5 mg proscar with mastercard, some of this information may be pertinent to patient care provided by the pharmacist buy 5 mg proscar amex. For example cheap 5mg proscar with amex, knowledge of an infant’s birth weight can help you deter- mine whether the mother has a risk factor for diabetes, which, in turn, may influence whether you would recommend diabetes screening for the patient. One way to gather this information would be to ask directly, for example, “There are many risk factors for diabetes, including the birth weight of your children. In this situation, you might ask the patient questions such as, “When did the unprotected sex happen? Health Maintenance/Immunizations This part of the medical history includes information on what immunizations the patient has received, such as influenza, pneumococcal, tetanus, and hepatitis B, as well as the dates they were obtained. Based on this information, you can then recommend any new or booster immunizations the patient may need. The dates and results of screening tests, such as mammograms, Pap smears, and tuberculin tests, should also be included. Information on diabetes and cholesterol screenings may also be included in this section, even though these tests are part of the objective data. These screen- ing tests typically occur because of recommendations from guidelines and are meant to allow for preventative treatments and early diagnosis; therefore, asking the patient about this during the past history component of the patient interview enables you to make recommendations based on the information you have gathered. Family History The family history (Fh) is health information about the patient’s immediate rela- tives. These relatives include parents, grandparents, siblings, children, and grandchil- dren. Because many medical conditions have a genetic component, the purpose of the family history is to determine potential risks factors for the patient’s current and future health. Typically, relatives such as cousins, aunts, and uncles are not included in the family history; however, for certain medical conditions that carry a high genetic link questions about the patient’s family history may be appropriate. In addition, if the person is 18 chapter 1 / the patient interview deceased, ascertain the age at death and the cause of death. It is important to include 4 this specific information because it may determine certain risk factors a patient may carry. For example, if a patient’s father died at the age of 45 secondary to a myocardial infarction, the patient then has a risk factor for coronary artery disease. One way to deter- mine the patient’s family history is to ask, “Are your parents and grandparents alive? The basic social history consists of asking the patient about past and present use of tobacco, alcohol, and illicit substances. If these are currently consumed, you should inquire as to how much and how often each is utilized. In addition, if a patient is a former user of any of these substances, it is vital to ask the patient at subsequent visits if he or she remains abstinent or if relapse has occurred. Because many of the these questions can be very personal and some patients may be reluctant to share such information, either out of embarrassment or fear of being judged, you should ask these questions with sensitivity and respect. However, it is important to be direct so that patients realize these questions are important with regard to their care. For both former and current tobacco users, you should ask at what age they started (and quit); what form of tobacco they use or used, including cigarettes, chewing tobacco, and/or cigars; and quantify the amount. For cigarettes smokers, you should ask how many cigarettes or packs they smoke (or smoked) per day. It is necessary to ask specific questions, because although one drink is tech- nically considered to be 12 ounces of beer, 5 ounces of wine, or 1. It will help if you are straightforward and nonjudgmental when asking about illicit substance use. One way to ask this question is, “Do you currently take, or have you taken in the past, any illicit drugs? It includes the presence of any symptom, even one that the patient may not have deemed to be significant or may have forgotten because of his or her focus on the chief complaint. Additionally, pharmacists may also be part of a medical team, and therefore should be aware of all of the components of a patient interview even if they are not the ones ask- ing the questions. Prior to starting this part of the interview, let the patient know that you will be asking several questions to assess any potential symptoms he or she may be experiencing. Oftentimes, some of these systems may be addressed concurrently with another part of the interview. For example, after checking the patient’s blood pressure, you may ask if the patient has had any dizziness or palpitations. They are taught to develop their own systematic approach to ensure a thorough and accurate physical exam. The comprehensive physical exam includes measurement of vital signs such as height, weight, temperature, blood pressure, and pulse, as well as the observation, inspection, and palpation of the patient’s body from head to toe. Although physicians often complete this part of the patient assessment, pharmacists are also skilled at completing parts of the physical exam.

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A randomized cheap 5mg proscar mastercard, double-blind trial of anidulafungin versus fluconazole for the treatment of esophageal candidiasis generic proscar 5mg line. Exposure to fluconazole and risk of congenital malformations in the offspring: A systematic review and meta-analysis purchase proscar 5mg with visa. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. First-trimester itraconazole exposure and pregnancy outcome: a prospective cohort study of women contacting teratology information services in Italy. Some patients experience encephalopathic symptoms, such as lethargy, altered mentation, personality changes, and memory loss that are usually a result of increased intracranial pressure. Any organ of the body can be involved, and skin lesions may show myriad different manifestations, including umbilicated skin lesions mimicking molluscum contagiosum. Isolated pulmonary infection is also possible; symptoms and signs include cough and dyspnea in association with an abnormal chest radiograph, which typically demonstrates lobar consolidation, although nodular infiltrates have been reported. Pulmonary cryptococcosis may present as acute respiratory distress syndrome and mimic Pneumocystis pneumonia. Serum CrAg is usually positive in both meningeal and non-meningeal infections and may be present weeks to months before symptom onset. Three methods exist for antigen detection: latex agglutination, enzyme immunoassays, and lateral flow assay (a newly developed dipstick test). Limited epidemiological evidence suggests that exposure to aged bird droppings may increase risk of infection. Patients with isolated cryptococcal antigenemia without meningitis can be treated similarly to patients with focal pulmonary cryptococcosis (see below). Treating Disease Treating cryptococcosis consists of three phases: induction, consolidation, and maintenance therapy. Historically, amphotericin B deoxycholate has been the preferred formulation at a dose of 0. However, there is a growing body of evidence that lipid formulations of amphotericin B are effective for disseminated cryptococcosis, particularly in patients who experience clinically significant renal dysfunction during therapy or who are likely to develop it. When using flucytosine, serum levels of flucytosine, if this assay is available, should be obtained 2 hours post-dose after 3 to 5 doses have been administered. The dose of flucytosine should be reduced by 50% for every 50% decline in creatinine clearance. Fluconazole alone, based on early fungicidal activity, is inferior to amphotericin B22 for induction therapy and is recommended only for patients who cannot tolerate or do not respond to standard treatment. Most of the data on use of these extended-spectrum triazole antifungals have been reported for treatment of refractory cases, with success rates of approximately 50%. In contrast to the other African study, this study used deoxycholate amphotericin B (0. All the triazole antifungals have the potential for complex, and possibly bidirectional, interactions with certain antiretroviral agents. Table 5 lists these interactions and recommendations for dosage adjustments, where feasible. Lumbar opening pressure should be measured in all patients with cryptococcal meningitis at the time of diagnosis. Patients treated with amphotericin B formulations should be monitored for dose-dependent nephrotoxicity and electrolyte disturbances. Pre-infusion administration of 500 to 1000 mL of normal saline appears to reduce the risk of nephrotoxicity during amphotericin B treatment. In patients receiving flucytosine, dosage should be adjusted based on changes in creatinine clearance and can be guided by flucytosine levels. Peak serum flucytosine levels should be obtained 2 hours after an oral dose and the therapeutic range is between 25 and 100 mg/L. Patients treated with flucytosine also should be monitored for hepatotoxicity and gastrointestinal toxicities. Isolates collected to evaluate for persistence or relapse should, however, be checked for susceptibility and compared with the original isolate. While clinical data are lacking, strains with minimum inhibitory concentrations against fluconazole ≥16 µg/mL in patients with persistent disease or relapse may be considered resistant. Patients who fail to respond to induction with fluconazole monotherapy should be switched to amphotericin B, with or without flucytosine. Those initially treated with an amphotericin B formulation should remain on it until a clinical response occurs. The newer triazoles—posaconazole and voriconazole—have activity against Cryptococcus spp. Special Considerations During Pregnancy The diagnosis of cryptococcal infections during pregnancy is similar to that in non-pregnant adults. Lipid formulations of amphotericin B are the preferred initial regimen for the treatment of cryptococcal meningoencephalitis, disseminated disease, or severe pulmonary cryptococcosis in pregnant patients.