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Cephalosporins are generally classified into first order promethazine mastercard allergy shots chicago, second order discount promethazine line allergy medicine nighttime, and third generation (Box 2 order 25mg promethazine with visa allergy testing valdosta ga. Cefoxitin, a second-generation cephalosporin, does not contain this side chain and at least theoretically would appear to be a better choice when a broad-spec- trum cephalosporin is indicated during pregnancy (Martens, 1989). Cephalosporins may also cause adverse effects in the mother, such as hypersensitivity reactions, hematologic toxicity, renal toxicity, hepatic toxicity, diarrhea, and pseudomembranous colitis (Box 2. They cross the placenta readily and, when utilized in the latter half of pregnancy, may cause yellow- brown discoloration of the deciduous teeth (Kline et al. Tetracyclines may also be deposited in the long bones of the devel- oping fetus, although there is no scientific evidence that they inhibit fetal or neonatal growth. Whalley and col- leagues (1964) reported an association between tetracycline use during pregnancy and liver toxicity manifested by azotemia, jaundice and acute fatty degeneration. As with erythromycin, tetracycline may cause significant gastrointestinal disturbances manifested by severe nausea and vomit- ing. Because of potential adverse fetal effects, the tetracyclines are rarely indicated during pregnancy, except for penicillin-allergic patients who need treatment for syphilis and for whom desensitization is not available. Aminoglycosides The aminoglycosides interfere with protein synthesis but, unlike erythromycin and tetra- cycline, they are bactericidal. Yoshioka and associates (1972), as well as Weinstein and coworkers (1976) reported cord levels of gentamicin of 33 and 42 per- cent, respectively, of maternal levels. Gilstrap and colleagues (1988a) reported a mean concentration ratio between cord blood and maternal blood for gentamicin of 0. It is important to note that serum levels of various aminoglycosides may be subtherapeu- tic in the fetus and mother. Streptomycin was one of the first members of this group and for many years was the primary drug for the treatment of tuberculosis. It has been reported to result in eighth- nerve damage of the fetus with protracted maternal therapy (Conway and Birt, 1965; Donald and Sellars, 1981). Excluding possible eighth cranial nerve damage, there is no scientific evidence to date that the aminoglycosides as a group are teratogenic. Aminoglycosides may cause significant adverse effects in the mother, such as neuro- muscular blockade, renal toxicity and ototoxicity (Box 2. Again, it should be noted that it may be very difficult to maintain therapeutic levels of aminoglycosides in the mother (or fetus) with usual or standard doses. Clindamycin Clindamycin is a derivative of lincomycin, and interferes with protein synthesis. It is a bacteriostatic antibiotic and is used primarily for serious anaerobic infections. Clindamycin crosses the placenta readily, with detectable levels in the fetus (Gilstrap et al. In one study, the mean concentration ratios of clindamycin for cord blood versus maternal blood was 0. In other reports, the serum levels of this antibiotic approached 50 percent of maternal serum levels (Philipson et al. Although clindamycin crosses the placenta readily, it causes no known adverse fetal effects. There are no adequate studies in humans, but clindamycin was not shown to be teratogenic in laboratory animals (Gray et al. However, clindamycin may be associated with adverse maternal effects, the most serious of which is pseudomembra- nous colitis (Box 2. This latter complication is associated with a toxin produced by Clostridium difficile (George et al. Lincomycin Lincomycin is rarely used today in obstetrics and has been mostly replaced by clin- damycin, at least in obstetrics and gynecology. However, it has been used in the past on large numbers of pregnant women without apparent adverse fetal effects (Mickal and Panzer, 1975). Metronidazole Metronidazole is a nitroimidazole that was first introduced as an antiparasitic and utilized primarily for the treatment of trichomoniasis. Its usage in pregnancy has been limited primarily to the treatment of trichomonal vaginitis. It is a relatively small molecule and crosses the placenta readily, with levels in cord blood reaching significant concen- trations (Heisterberg, 1984). Although this drug crosses the placenta readily, there is no evidence that it is teratogenic in humans. In one study reported by Rosa and colleagues (1987a) of over 1000 women with first-trimester exposure to this drug, the frequency of fetal anomalies was not increased. In addition, the frequency of congenital anomalies has been shown not to be increased in animal reproduction studies in which metronida- zole was given in doses five times the human dose (Hammill, 1989). However, metronidazole has been reported to be carcinogenic in mice and rats (Hammill, 1989) and to be mutagenic in certain bacteria. Because of the tumorigenic effects in ani- mals, however, metronidazole is not recommended for use in the first trimester. Unfortunately, this nitroimidazole provides the only effective treatment for trichomo- niasis. Most pregnant women with this infection can be treated with betadine solution or other similar agents until they are past the first trimester, and then started on metron- idazole as necessary. In a recent meta-analysis on the use of metronidazole in pregnant women, no increase in malformations was found (Burtin et al. Metronidazole does concentrate in the breast milk and results in concentrations close to those found in maternal serum (Simms-Cendan, 1996). Chloramphenicol Chloramphenicol interferes with protein synthesis and is bacteriostatic. It is rarely used today and generally is not recommended for use in pregnant women, although there is 32 Antimicrobials during pregnancy little or no scientific evidence to suggest that it is teratogenic. In a review from the Collaborative Perinatal Project of approximately 100 infants exposed to chlorampheni- col in the first trimester, there was no evidence of an increased frequency of congenital malformations (Heinonen et al. It has been associated with the ‘gray baby syn- drome’ (cyanosis, vascular collapse, and death) in the premature neonate given large doses of this drug. Although chloramphenicol does cross the placenta readily (Scott and Warner, 1950), transplacental passage of the drug rarely, if ever, causes gray baby syn- drome in the fetus or newborn (Landers et al. The most significant potential adverse maternal effect is aplastic anemia, which has been reported in approximately one of 100 000 cases. Sulfonamides The sulfonamides inhibit folate synthesis and are analogs of para-aminobenzoic acid, which is necessary for production of folic acid by bacteria (Landers et al. There are no scientific reports of an association between congenital malformations and the use of sulfonamides during pregnancy. Although the sulfonamides are not terato- genic, they do compete for bilirubin binding sites and, if used near delivery, may cause hyperbilirubinemia, especially in the premature infant (Landers et al. Maternal side effects include hypersensitivity, photosensitivity, blood dyscrasias, and gastrointesti- nal intolerance.
This assessment is based on the full range of preparation and administration options described in the monograph order promethazine in united states online allergy shots types. Exenatide 5 micrograms/dose and 10 micrograms/dose solution in pre-filled pen * Exenatide is a synthetic form of exendin-4 order genuine promethazine on line allergy report houston, a 39-amino-acid peptide isolated from the venom of the Gila monster lizard order promethazine 25 mg visa allergy weeds. It is an incretin mimetic that "insulin secretion, #glucagon secretion, and slows gastric emptying. Pre-treatment checks * Do not use in type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. The dose can then be increased to 10 micrograms twice daily to further improve glycae- mic control. The solution should be clear and colourless, do not use if cloudy or discoloured or if particles are present. Although not specifically recommended by the manufacturer, it would be wise to vary the site of the injection. Technical information Incompatible with Not relevant Compatible with Not relevant pH Not relevant Sodium content Negligible Excipients Contains metacresol which may cause hypersensitivity reactions. Monitoring Measure Frequency Rationale Hypersensitivity At the start of * May very rarely cause hypersensitivity reactions reactions treatment including anaphylaxis. Capillary blood As clinically * Has caused hypoglycaemia with concomitant glucose appropriate sulfonylurea therapy. Action in case of Symptoms to watch for: Severe nausea, severe vomiting and rapidly declining overdose blood glucose concentrations. Counselling Use and storage of pens, disposal of pen and needles, discard pens that have been frozen. Warn about the "risk of hypoglycaemia at the start of therapy in patients being treated with a sulfonylurea. Warn about timing of concomitant antibiotic therapy and other medication if appropriate. This assessment is based on the full range of preparation and administration options described in the monograph. Fentanyl | 335 Fentanyl 50 micrograms/mL solution in 2-mL and 10-mL ampoules * Fentanyl citrate is a potent opioid analgesic chemically related to pethidine. Pre-treatment checks * Avoid in patients with respiratory depression or obstructive airways disease. Assisted respiration: initially 300--3500 micrograms followed by further doses of 100--200 micro- grams adjusted according to response. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Withdraw the required dose and add to a suitable volume of compatible infusion solution. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving initial dose, especially elderly patients or those of low bodyweight. Stability after preparation From a microbiological point of view, should be used immediately; however, prepared infusions may be stored at 2--8 C and infused (at room temperature) within 24 hours. Monitoring Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving initial dose, especially elderly patients or those of low bodyweight. Measure Frequency Rationale Pain or dyspnoea At regular intervals * To ensure therapeutic response. Monitor for side- * May cause side-effects such as nausea and effects and toxicity constipation, which may need treating. Fentanyl | Filgrastim | 337 Additional information Common and serious Common: Nausea and vomiting, constipation, dry mouth, urticaria, pruritus, undesirable effects biliary spasm, " or #pulse, hallucinations, euphoria, drowsiness. This assessment is based on the full range of preparation and administration options described in the monograph. The first dose should be given a minimum of 24 hours after cytotoxic therapy and is usually continued until neutrophil count is within the normal range. The first dose should be given a minimum of 24 hours after cytotoxic therapy and is further titrated according to patient response (see product literature). Maintenance dose should be the minimum required to maintain neutrophil count (see product literature). Maintenancedoseshouldbe the minimum required to maintain neutrophil count (see product literature). Maintenance dose should be the minimum required to maintain neutrophil count (see product literature). Subcutaneous infusion Preparation and administration Filgrastim is incompatible with NaCl 0. Withdraw the required dose and add to a suitable volume of Gluc 5%, ensuring that the final concentration is 15 micrograms/mL or more. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Intermittent intravenous infusion Preparation and administration Filgrastim is incompatible with NaCl 0. Withdraw the required dose and add to a suitable volume of Gluc 5%, ensuring that the final concentration is 15 micrograms/mL or more. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Continuous intravenous infusion Preparation and administration Filgrastim is incompatible with NaCl 0. Withdraw the required dose and add to a suitable volume of Gluc 5%, ensuring that the final concentration is 15 micrograms/mL or more. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Amphotericin, cefotaxime, ceftriaxone, cefuroxime, clindamycin phosphate, furosemide, gentamicin, heparin sodium, imipenem with cilastatin, methylprednisolone sodium succinate, metronidazole. Compatible with Flush: Gluc 5% Solutions: Gluc 5% (concentration dependent) Y-site: Aciclovir, amikacin, aminophylline, ampicillin, aztreonam, bumetanide, calcium folinate, calcium gluconate, ceftazidime, co-trimoxazole, dexamethasone sodium phosphate, fluconazole, ganciclovir, granisetron, hydrocortisone sodium succinate, mesna, metoclopramide, ondansetron, potassium chloride, ranitidine, sodium bicarbonate, ticarcillin with clavulanate, tobramycin, vancomycin, zidovudine (continued) 340 | Filgrastim Technical information (continued) pH 4 Sodium content Negligible Storage Store at 2--8 C (accidental freezing does not adversely affect stability). Vials and pre-filled syringe are for single use only: discard any unused solution. 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. Serum lactate * "Levels have been reported (reversible and dose- dehydrogenase and dependent). Physical examination Periodically, and * Splenomegaly is a direct effect of filgrastim of spleen size (and urgently if patient therapy, but splenic rupture may occur. Bone density Consider if treatment * Long-term therapy maypromote osteoporotic bone >6 months disease. Morphological and Regularly every 12 * Accurate diagnosis is required before cytogenetic bone months in long-term commencing treatment with filgrastim.
When initiating treatment with risperidone depot injection buy promethazine 25mg cheap allergy treatment dog dander, oral risperidone (or the patient’s previous antipsychotic if not risperidone) should also be provided for the first 3 weeks after the first injection buy promethazine 25mg fast delivery allergy testing rocky mount nc. Patients stabilised more than 4mg oral risperidone daily for at least 2 weeks: initiate therapy at 37 discount promethazine 25mg line allergy symptoms in infants. Maintenance therapy: increase the dose if necessary at intervals of at least 4 weeks in steps of 12. Risperidone long-acting injection | 741 Intramuscular injection Preparation and administration 1. The pack should be removed from the refrigerator and allowed to come to room temperature before reconstitution. Follow the manufacturer’s instructions to reconstitute the vial with the diluent provided to give a thick,milkysuspensioncontaining25mg/2mL,37. For gluteal administration use a 50-mm needle and alternate injections between the buttocks; for deltoid administration use a 25-mm needle and alternate between the arms Technical information Incompatible with Not relevant Compatible with Not relevant pH 6. If refrigeration is not available the product may be stored below 25 C for up to 7 days prior to administration. Stability after From a microbiological point of view, should be used immediately; however, preparation reconstituted suspension may be stored at 25 C for up to 6 hours. Shake the syringe vigorously to re-suspend the microspheres before administration. Monitoring Measure Frequency Rationale Therapeutic effect During dose adjustment * To ensure reduction/elimination of and periodically psychotic symptoms. Additional information Common and serious Weight gain, depression, fatigue and extrapyramidal symptoms. If the patient is in shock, treatment with metaraminol or noradrenaline may be appropriate. Counselling Advise patients not to drink alcohol especially at the beginning of treatment. May impair alertness so do not drive or operate machinery until susceptibility is known. This assessment is based on the full range of preparation and administration options described in the monograph. ClinicalGuideline82:Coreinterventionsinthetreatmentand management ofschizophreniain primary and secondary care (update). Pre-treatment checks * Caution in patients with a history of cardiovascular disease because exacerbation of angina, arrhythmia, and heart failure have been reported. Administer only in an environment where full resuscitation facilities are immediately available. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Observe for mild infusion-related * #Infusion rate usually resolves reactions: fevers, chills rigors these symptoms. Respiratory function * In patients with pre-existing pulmonary conditions or in whom adverse pulmonary events have occurred at previous infusions. Infusion-related: Occur predominantly during the first infusion and include cytokinereleasesyndrome(see Monitoringabove),feverandchills,nausea and vomiting, allergic reactions (such as rash, pruritus, angioedema, bronchospasm and dyspnoea), flushing and tumour pain. Actionincaseof overdose There is no specific antidote and treatment should be symptomatic. Counselling Any vaccination schedule should be completed at least 4 weeks prior to the first treatment. This assessment is based on the full range of preparation and administration options described in the monograph. Premature labour: glucose is the preferred diluent and use of a syringe pump is the preferred means of administration ("risk of maternal pulmonary oedema if saline or large volumes of fluid are used). However, this use is controversial as it is reportedly no more effective than 10--20mg nebulised salbutamol and may be more likely to cause cardiac arrhythmias. If effective, #K levels are seen in 30 minutes and the effect may last for up to 2 hours. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Continuous intravenous infusion (large volume infusion) Preparation of a 20 micrograms/mL solution 1. Using the 5mg/5mL strength of salbutamol, withdraw 10mg (10mL) and add to the prepared infusion bag to give a solution containing 20 micrograms/mL. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Stability after From a microbiological point of view, should be used immediately; however, it preparation may be stored at 2--8 C and infused (at room temperature) within 24 hours. Monitoring Measure Frequency Rationale Respiratory function Frequently * For signs of clinical improvement. Significant * Beta-blockers (including eye drops) may #salbutamol levels or effect. This assessment is based on the full range of preparation and administration options described in the monograph. Selenium 50 micrograms/mL solution in 2-mL and 10-mL ampoules * Selenium is an essential trace element that acts as a co-factor in various enzymes in the human body. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Technical information Incompatible with A precipitate forms if the pH falls below 7 and if the solution is mixed with reducing substances, e. Monitoring Measure Frequency Rationale Selenium level Periodically * For signs of clinical improvement. Additional information Common and serious None known undesirable effects Pharmacokinetics Elimination is dependent on the selenium status of the body. Chronic overdose can affect growth of nails and hair and may lead to peripheral polyneuropathy. Antidote: Forced diuresis or the administration of high doses of ascorbic acid may be of use. In the case of an extreme overdose (1000--10000 times the normal dose) dialysis may help. This assessment is based on the full range of preparation and administration options described in the monograph. Pre-treatment checks Do not use in pregnancy, or severe renal or hepatic disease, a history of blood disorders, exfoliative dermatitis, systemic lupus erythematosus, necrotising enterocolitis, pulmonary fibrosis or porphyria. The dose frequency may then be reduced to every 2 weeks until full remission occurs and then further reduced on specialist advice. If thereisno evidenceof improvement after atotaldose of1g has beengiven, andifthere arenosigns of gold toxicity,then100mg may be giveneveryweekfor 6weeks. Technical information Incompatible with Not relevant Compatible with Not relevant pH Not relevant (continued) 752 | Sodium aurothiomalate Technical information (continued) Sodium content Negligible Storage Store below 25 C in original packaging.