Tag Archives forDisease

Colorectal Cancer

The colon is the last part of the intestines which called the large intestine and it connects the small intestine with the anus with the length of about one meter and 60 CM. It absorbs water and salts which leads to solid stored stool until taken out and the rectum is the path that connects the colon with the anus.

What is colorectal cancer?

It is a cancerous tumor that may affect any part of the colon and rectum; affects men and women alike. Colorectal cancer ranked first in the kingdom of Saudi Arabia in terms of the spread of the disease according to recent statistics and is the second largest type of cancer leading to death, affecting about a third of patients who are infected due to lack of early detection of this type of tumor. Therefore, early detection is very important because most of these tumors grow over long periods and then converts it to be difficult to eradicate and treat; so we recommend the importance of the periodic medical examination after the age of fifty for early detection of these tumors. 

  1.  Early detection of colon and rectum tumors and their discovery at an early stage means treatment and full recovery of them.
  2. Periodic preventive screening for the detection of polyps and eradication may reduce the incidence of colorectal cancer by about 90%
  3. The early detection of cancerous tumors in the colon increases the chance of successful treatment and reduces the mortality rate resulting from this disease.

What are the factors leading to the high incidence of this type of cancer?

There are certain factors that increase the incidence of the disease by two or three times of the normal rate; including:

  • A family history of occurrence of the disease; if a family member has the disease or found that more than one individual in the family is infected with the disease, the percentage of the tumor incidence increases, especially if this member close to first class(father or mother or sister or brother or son)
  • Ulcerative colitis, chronic inflammatory increase the incidence of such tumors.
  • Previous infection with a tumor or polyps may increase the incidence of this tumor again. Especially when the infection at an early age less than 50 years.

There are some factors that may lead to increased incidence of such tumors such as:

  1. Eat meals rich in fat and meat and low in fiber and weight gain.
  2. Lack of physical activity such as sports and others.
  3. Smoking

How can we prevent colorectal cancer?

  1. Eating enough calcium may contribute to reducing the incidence of colorectal cancer.
  2. Continuous physical activity may reduce the incidence of such disease.
  3. Eating foods rich in fiber and reduce fat intake may reduce the incidence of such tumors.
  4. Most people who are at risk of colorectal cancer may require early frequency tests than others.

Symptoms of colorectal cancer:

Most patients do not have any symptoms

Symptoms of colorectal cancer:

Most patients do not have any symptoms of the disease, but there are some indicators; such as:

  1. Severe constipation, especially in the elderly; therefore advised doing a colonoscopy in such cases.
  2. Blood with stool, especially after the age of thirty could mean the presence of tumors or polyps in the colon or rectum.
  3. Severe chronic abdominal pain, especially after the age of forty.
  4. Underweight.

What is the plan for early screening of colorectal cancer?

  • An early screening process for colorectal cancer begins for people aged over 5O years.
  • When there are other factors to increase the incidence of such tumors, such as genetic reasons or inflammatory ulcerative colitis and other, only rely on the colonoscopy and at an early age from 20-year.
  • Early screening options for colorectal tumors.

There are many options for early screening for colon tumors including:

  1. Occult blood test in the stool.
  2. Colonoscopy
  3. Colored colon X-rays.

 

First: Occult blood test in stool: It is known that colon cancer can cause bleeding in the intestines which may be very small quantities and cannot be seen with the naked eye, so the detection of occult blood in the stool helps in the diagnosis process.

How effective is this test?

  • If this test is done every year, it leads to avoid or reduce the number of death resulting from colorectal cancer by about a third.
  • It is not the optimal test to detect polyps.
  • It must be done annually.

Second: colonoscopy (see colonoscopy brochure):

  • Colonoscopy is considered the most accurate examination of reliable early screening for the colon and rectum tumors and it is safe examination if it is conducted by endoscopy specialist.
  • This endoscope is repeated every i0 years.
  • Removes any polyps detected during endoscope, which takes from 2-3 minutes.

Third: Colored colon X-rays:

  • The preparation process for this screening is similar to the colons- copy process to be drinking the same solution as well as put a tube in the rectum to inflate the colon to examine the colon walls accurately.
  • In the case of suspected tumor or the presence of polyps, a colonoscopy must be done, or take a sample or remove these polyps.
  • Most studies indicate the inaccuracy of this type of screening for early detection of colorectal tumors; therefore, it has been replaced in many centers with (CT-Colonography).

Forth: (CT- Colonography):

  • This type of scan is considered as one of the new scans for early detection of colon tumors.
  • Initial studies indicate the effectiveness of this type of scanning for the early detection of colon and rectum tumors, as well as in the detection of polyps larger than 1 cm.
  • In the case of suspected tumor or the presence of polyps, a colonoscopy must be done, or take a sample or remove these polyps.
  • The preparation process for this screening is similar to the colons- copy process to be drinking the same solution as well as put a tube in the rectum to inflate the colon to examine the colon walls accurately.
  • This scanning is repeated every 5 years if there are no tumors or polyps.

Finally, remember, dear reader, the colon and rectum tumors rarely can be avoided and the early detection ensures full recovery of them.

Corticosteroides

Replacement therapy

The adrenal cortex normally secretes hydrocortisone (cortisol) which has glucocorticoid activity and weak mineralocorticoid activity. It also secretes the mineralocorticoid aldosterone. In deficiency states, physiological replacement is best achieved with a combination of hydrocortisone and the mineralocorticoid fludrocortisone; hydrocortisone alone does not usually provide sufficient mineralocorticoid activity for complete replacement.

 

FLUDROCORTISONE ACETATE:

Indications: mineralocorticoid replacement in adrenocortical insufficiency. Adrenogenital Disorder, Primary Adrenocortical Insufficiency, Symptomatic Orthostatic Hypotension.

Contraindications: Chronic Heart Failure, Acute Tuberculosis, Cataracts, Diabetes Mellitus, Disease of Liver, Epilepsy, Glaucoma, Hypercortisolism, Hypertension, Hypokalemia, Hypothyroidism, Inactive Tuberculosis, Myasthenia Gravis, Osteoporosis, Peptic Ulcer, Peripheral Edema, Renal Disease.

Dose and Administration: 50–300 micrograms daily; child 5 micrograms/kg daily.

 

Glucocorticoid therapy

 

BETAMETHASONE:

Indications: suppression of inflammatory and allergic disorders; congenital adrenal hyperplasia. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Congenital Adrenal Hyperplasia, Congenital Hypoplastic Anemia, Contact Dermatitis, Crohn’s Disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, usual range 0.5–5 mg daily.

 

BETAMETHASONE DIPROPIONATE & SODIUM PHOSPHATE:  Indications: suppression of inflammatory and allergic disorders; congenital adrenal hyperplasia. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Congenital Adrenal Hyperplasia, Congenital Hypoplastic Anemia, Contact Dermatitis, Crohn’s Disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: dosing must be individualized on the basis of the specific disease.

 

DEXAMETHASONE:

Indications: suppression of inflammatory and allergic disorders; diagnosis of Cushing’s disease, congenital adrenal hyperplasia; cerebral oedema associated with malignancy; croup; nausea and vomiting with chemotherapy; rheumatic disease

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, usual range 0.5–10 mg daily; child 10– 100 micrograms/kg daily, By intramuscular injection or slow intravenous injection or infusion (as dexamethasone phosphate), initially 0.5–24 mg; child 200– 400 micrograms/kg daily, Cerebral oedema associated with malignancy (as

dexamethasone phosphate), by intravenous injection, 10 mg initially, then 4 mg by intramuscular injection every 6 hours as required for 2–4 days then gradually reduced and stopped over 5–7 days.

 

HYDROCORTISONE:

Indications: adrenocortical insufficiency; shock; hypersensitivity reactions e.g. anaphylactic shock and angioedema; asthma; severe inflammatory bowel disease; haemorrhoids; rheumatic disease

Contraindications: Fungal Infections, Cataracts, Chronic Heart Failure, Duodenal Ulcer, Esophagitis, Gastric Ulcer, Inactive Tuberculosis, Infection, Intestinal Abscess, Intestinal Anastomosis, Measles, Measles Contact, Ocular Infection, Osteoporosis, Peptic Ulcer, Psychotic Disorder, Renal Disease, Varicella Contact, Viral Ocular Infection.

Dose and Administration: By mouth, replacement therapy, 20–30 mg daily in divided doses; child 10–30 mg. By intramuscular injection or slow intravenous injection or infusion, 100–500 mg, 3–4 times in 24 hours or as required; child by slow intravenous injection up to 1 year 25 mg, 1–5 years 50 mg, 6–12 years 100 mg.

 

METHYLPREDNISOLONE SODIUM SUCCINATE:

Indications: suppression of inflammatory and allergic disorders; severe inflammatory bowel disease; cerebral oedema associated with malignancy; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By intramuscular injection or slow intravenous injection or infusion, initially 10–500 mg; graft rejection, up to 1 g daily by

intravenous infusion for up to 3 days.

 

METHYLPREDNISOLONE ACETATE:

Indications: suppression of inflammatory and allergic disorders; severe inflammatory bowel disease; cerebral oedema associated with malignancy; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By deep intramuscular injection into gluteal muscle, 40–120 mg, a second injection may be given after 2–3 weeks if required.

 

PREDNISOLONE:

Indications: suppression of inflammatory and allergic disorders; see also notes above; inflammatory bowel disease; asthma, and; immunosuppression; rheumatic disease.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By mouth, initially, up to 10–20 mg daily (severe disease, up to 60 mg daily), preferably taken in the morning after breakfast; can often be reduced within a few days but may need to be continued for several weeks or months. Maintenance, usual range, 2.5–15 mg daily, but higher doses may be needed; cushingoid side-effects increasingly likely with doses above 7.5 mg daily.

 

TRIAMCINOLONE:

Indications: suppression of inflammatory and allergic disorders and rheumatic disease. Acquired Thrombocytopenia, Acute Lymphoid Leukemia, Adrenocortical Insufficiency, Adrenogenital Disorder, Allergic Rhinitis, Alopecia Areata, Angioedema, Ankylosing Spondylitis, Aspiration Pneumonitis, Atopic Dermatitis, Autoimmune Disease, Autoimmune Hemolytic Anemia, Berylliosis, Bronchial Asthma, Bursitis, Cerebral Edema, Contact Dermatitis, Crohn’s Disease, Cystic Aponeurosis Tumor, Dermatitis Herpetiformis.

Contraindications: Arginase Deficiency, Arginosuccinate Lyase Deficiency, Carbamyl Phosphate Synthetase Deficiency, Cerebral Malaria, Citrullinemia, Fungal Infections, and Ornithine Carbamyltransferase Deficiency.

Dose and Administration: By deep intramuscular injection, into gluteal muscle, 40 mg of acetonide for depot effect, repeated at intervals according to the patient’s response; max. single dose 100 mg.

 

Drugs Used in Nausea and Vertigo

Drugs Used in Nausea and Vertigo

Vomiting during pregnancy

Nausea in the first trimester of pregnancy is generally mild and does not require drug therapy. On rare occasions if vomiting is severe, short-term treatment with an antihistamine, such as promethazine, may be required. Metoclopramide may be considered as second-line treatments. If symptoms do not settle in 24 to 48 hours then specialist opinion should be sought. Hyperemesis gravidarum is a more serious condition, which requires intravenous fluid and electrolyte replacement and sometimes nutritional support. Supplementation with thiamine must be considered in order to reduce the risk of Wernicke’s encephalopathy.

For indication, dosage, contraindications and available brands refer to drugs acting on gastrointestinal tract.

Postoperative nausea and vomiting

The incidence of postoperative nausea and vomiting depends on many factors including the anaesthetic used, the type and duration of surgery, and the patient’s sex. The aim is to prevent postoperative nausea and vomiting from occurring. Drugs used include some phenothiazines (e.g. prochlorperazine), metoclopramide (but 10-mg dose has limited efficacy and higher parenteral doses associated with greater side-effects), 5HT3 antagonists, antihistamines (such as cyclizine), and dexamethasone. A combination of two antiemetic drugs acting at different sites may be needed in resistant postoperative nausea and vomiting. For indication, dosage, contraindications and available brands refer to drugs acting on gastrointestinal tract.

Motion sickness

Antiemetics should be given to prevent motion sickness rather than after nausea or vomiting develop. The most effective drug for the prevention of motion sickness is hyoscine. A transdermal hyoscine patch provides prolonged activity but it needs to be applied several hours before travelling. The sedating antihistamines are slightly less effective against motion sickness, but are generally better tolerated than hyoscine. If a sedative effect is desired promethazine is useful, but generally a slightly less sedating antihistamine such as cyclizine or cinnarizine is preferred. The 5HT3 antagonists, domperidone, metoclopramide, and the phenothiazines (except the antihistamine phenothiazine promethazine) are ineffective in motion sickness. For indication, dosage, contraindications and available brands refer to drugs acting on gastrointestinal tract.

Other vestibular disorders

Management of vestibular diseases is aimed at treating the underlying cause as well as treating symptoms of the balance disturbance and associated nausea and vomiting. Vertigo and nausea associated with Ménière’s disease and middle-ear surgery can be difficult to treat.Betahistine is an analogue of histamine and is claimed to reduce endolymphatic pressure by improving the microcirculation. Betahistine is licensed for vertigo, tinnitus, and hearing loss associated with Ménière’s disease.

Antihistamines

CINNARIZINE:

Indications: vestibular disorders, such as vertigo, tinnitus, nausea, and vomiting in Ménière’s disease; motion sickness.

Contraindications: prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, and pyloroduodenal obstruction. Antihistamines should be used with caution in hepatic disease.

Dose and Administration: Vestibular disorders, 30 mg 3 times daily; child 5– 12 years 15 mg 3 times daily. Motion sickness, 30 mg 2 hours before travel then 15 mg every 8 hours during journey if necessary; child 5–12 years, 15 mg 2 hours before travel then 7.5 mg every 8 hours during journey if necessary.

PROMETHAZINE HYDROCHLORIDE:

Indications: nausea, vomiting, vertigo, labyrinthine disorders, and motion sickness.

Contraindications: prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, and pyloroduodenal obstruction. Antihistamines should be used with caution in hepatic disease.

Dose and Administration: Motion sickness prevention, 20–25 mg at bedtime on night before travel, repeat following morning if necessary; child under 2 years not recommended, 2–5 years 5 mg at night and following morning if necessary, 5–10 years 10 mg at night and following morning if necessary.

Phenothiazines and related drugs

CHLORPROMAZINE HYDROCHLORIDE:

Indications: nausea and vomiting of terminal illness (where other drugs have failed or are not available).

Contraindications: Coma, Lactating Mother, Neuroleptic Malignant Syndrome, Severe Cardiovascular Disease, and Stupor.

Dose and Administration: By mouth, 10–25 mg every 4–6 hours; child 500 micrograms/kg every 4–6 hours (1–5 years max. 40 mg daily, 6–12 years max. 75 mg daily). By deep intramuscular injection initially 25 mg then 25– 50 mg every 3–4 hours until vomiting stops; child 500 micrograms/kg every 6–8 hours (1–5 years max. 40 mg daily, 6–12 years max. 75 mg daily).

Domperidone and metoclopramide

DOMPERIDONE:

Indications: nausea and vomiting, dyspepsia, gastro-oesophageal reflux. Contraindications: prolactinoma, hepatic impairment; where increased gastro­intestinal motility harmful; pregnancy.

Dose and Administration: By mouth, adult and child body-weight over 35 kg, 10–20 mg 3–4 times daily; max. 80 mg daily; child body-weight up to 35 kg (nausea and vomiting only), 250–500 micrograms/kg 3–4 times daily; max. 2.4 mg/kg daily. By rectum in suppositories, adult and child body-weight over 35 kg, 60 mg twice daily; child 15–35 kg (nausea and vomiting only), 30 mg twice daily; child body-weight under 15 kg, not recommended.

METOCLOPRAMIDE HYDROCHLORIDE:

Indications: adults, nausea and vomiting, particularly in gastro-intestinal disorders and treatment with cytotoxics or radiotherapy; migraine. Contraindications: gastro-intestinal obstruction, perforation or haemorrhage; 3–4 days after gastro-intestinal surgery; phaeochromocytoma; breast-feeding. Dose and Administration: By mouth or by intramuscular injection or by intravenous injection over 1–2 minutes, nausea and vomiting, 10 mg (5 mg in young adults 15–19 years under 60 kg) 3 times daily; child up to 1 year (up to 10 kg) 1 mg twice daily, 1–3 years (10–14 kg) 1 mg 2–3 times daily, 3–5 years (15–19 kg) 2 mg 2–3 times daily, 5–9 years (20–29 kg) 2.5 mg 3 times daily, 9–14 years (30 kg and over) 5 mg 3 times daily.

5HT antagonists

ONDANSETRON:

Indications: Prevention of Cancer Chemotherapy-Induced Nausea and Vomiting, Prevention of Post-Operative Nausea and Vomiting, Prevention of Radiation-Induced Nausea and Vomiting.

Contraindications: Severe Hepatic Disease, Extrapyramidal Disease.

Dose and Administration: Moderately emetogenic chemotherapy or radiotherapy, by mouth, 8 mg 1–2 hours before treatment or by rectum, 16 mg 1–2 hours before treatment or by intramuscular injection or slow intravenous injection, 8 mg immediately before treatment then by mouth, 8 mg every 12 hours for up to 5 days or by rectum, 16 mg daily for up to 5 days; child, by slow intravenous injection or by intravenous infusion over 15 minutes, 5 mg/m2 immediately before chemotherapy then 4 mg by mouth every 12 hours for up to 5 days. Severely emetogenic chemotherapy, by intramuscular injection or slow intravenous injection, 8 mg immediately before treatment, where necessary followed by 2 further doses of 8 mg at intervals of 2–4 hours (or followed by 1 mg/hour by continuous intravenous infusion for up to 24 hours) then by mouth, 8 mg every 12 hours for up to 5 days or by rectum, 16 mg daily for up to 5 days; alternatively, by intravenous infusion over at least 15 minutes, 32 mg immediately before treatment or by rectum, 16 mg 1–2 hours before treatment then by mouth, 8 mg every 12 hours for up to 5 days or by rectum, 16 mg daily for up to 5 days; child, by slow intravenous injection, 5 mg/m2 immediately before chemotherapy then 4 mg by mouth every 12 hours for up to 5 days.

Other drugs for Ménière’s disease

BETAHISTINE DIHYDROCHLORIDE:

Indications: vertigo, tinnitus and hearing loss associated with Ménière’s disease.

Contraindications: phaeochromocytoma.

Dose and Administration: Initially 16 mg 3 times daily, preferably with food; maintenance 24–48 mg daily; child not recommended.

Other Antidepressant Drugs

Mirtazapine, a presynaptic alpha2-adrenoreceptor antagonist, increases central noradrenergic and serotonergic neurotransmission. It has few antimuscarinic effects, but causes sedation during initial treatment. Venlafaxine is a serotonin and noradrenaline re-uptake inhibitor (SNRI); it lacks the sedative and antimuscarinic effects of the tricyclic antidepressants. Tianeptine is an antidepressant agent with a novel neurochemical profile. It increases serotonin (5-hydroxytryptamine; 5-HT) uptake in the brain (in contrast with most antidepressant agents) and reduces stress-induced atrophy of neuronal dendrites. Like the selective serotonin reuptake inhibitors (SSRIs) and in contrast with most tricyclic antidepressant agents, tianeptine does not appear to be associated with adverse cognitive, psychomotor, sleep, cardiovascular or bodyweight effects and has a low propensity for abuse.

MIRTAZAPINE:

Indications: major depression.

Contraindications: Manic Bipolar Disorder, Severe Chronic Neutropenia, And Suicidal Ideation.

Dose and Administration: Initially 15 mg daily at bedtime increased within 2–4 weeks according to response; max. 45 mg daily as a single dose at bedtime or in 2 divided doses; child and adolescent under 18 years not recommended.

VENLAFAXINE:

Indications: Depression, Generalized Anxiety Disorder, Neuropathic Pain, And Post Traumatic Stress Disorder, Social Phobia, Vasomotor Symptoms associated with Menopause.

Contraindications: Hypertension, Narrow Angle Glaucoma, Ocular Hypertension, Prolonged QT Interval, Recovery Phase Following Myocardial Infarct, Severe Uncontrolled Hypertension, Suicidal Ideation, Upper GI Bleed.

Dose and Administration: Depression, adult over 18 years, 75 mg daily as a single dose, increased if necessary after at least 2 weeks to 150 mg once daily; max. 225 mg once daily; child under 18 years not recommended. Generalised anxiety disorder, adult over 18 years, 75 mg daily as a single dose; discontinue if no response after 8 weeks. Social anxiety disorder, adult over 18 years, 75 mg daily as a single dose; discontinue if no response after 12 weeks.

TIANEPTINE:

Indications: Indicated for depressive states of mild, moderate and sever intensity.

Contraindications: Children under 15 years age, pregnancy, breast-feeding or not to be used in combination with other drugs for depression such as non­selective MAOI.

Dose and Administration: The mean dosage is 3 tablets per day (37.5mg per day) to be taken just before the three meals.

Drugs used in Psychosis and related disorders

When prescribing an antipsychotic for administration on an emergency basis, the intramuscular dose should be lower than the corresponding oral dose (owing to absence of first-pass effect), particularly if the patient is very active (increased blood flow to muscle considerably increases the rate of absorption). The prescription should specify the dose for each route and should not imply that the same dose can be given by mouth or by intramuscular injection. The dose of antipsychotic for emergency use should be reviewed at least daily.

Antipsychotic drugs

Antipsychotic drugs generally tranquillise without impairing consciousness and without causing paradoxical excitement but they should not be regarded merely as tranquillisers. For conditions such as schizophrenia the tranquillising effect is of secondary importance. In the short term they are used to quieten disturbed patients whatever the underlying psychopathology, which may be schizophrenia, brain damage, mania, toxic delirium, or agitated depression. Antipsychotic drugs are used to alleviate severe anxiety but this too should be a short-term measure. Selection is influenced by the degree of sedation required and the patient’s susceptibility to extrapyramidal side-effects. However, the differences between antipsychotic drugs are less important than the great variability in patient response; moreover, tolerance to secondary effects such as sedation usually develops. The atypical antipsychotics may be appropriate if extrapyramidal side-effects are a particular concern. Prescribing of more than one antipsychotic at the same time is not recommended; it may constitute a hazard and there is no significant evidence that side-effects are minimised.

CHLORPROMAZINE HYDROCHLORIDE:

Indications: Acute Intermittent Porphyria, Intractable Hiccups, Manic Bipolar Disorder, Nausea and Vomiting, Pre-Op Apprehension, Schizophrenia.

Contraindications: Coma, Lactating Mother, Neuroleptic Malignant Syndrome, Severe Cardiovascular Disease, Stupor, Breast Carcinoma, Conduction Disorder of the Heart, Congenital Long QT Syndrome, Disease of Liver, Extrapyramidal Disease, Glaucoma, Metabolic Syndrome X, Myocardial Infarction, Myocardial Ischemia, Obesity, Organophosphate Insecticide Poisoning, Prolonged QT Interval, Senile Dementia, Symptomatic Prostatic Hypertrophy, Tardive Dyskinesia, Torsades de Pointes, Urinary Retention

Dose and Administration: By mouth, schizophrenia and other psychoses, mania, short-term adjunctive management of severe anxiety, psychomotor agitation, excitement, and violent or dangerously  impulsive behaviour initially 25 mg 3 times daily (or 75 mg at night), adjusted according to response, to usual maintenance dose of 75–300 mg daily (but up to 1 g daily may be required in psychoses); elderly (or debilitated) third to half adult dose; child (childhood schizophrenia and autism) 1–5 years 500 micrograms/kg every 4–6 hours (max. 40 mg daily); 6–12 years 10 mg 3 times daily (max. 75 mg daily). By deep intramuscular injection, (for relief of acute symptoms but see also Cautions and Side-effects), 25–50 mg every 6–8 hours; child, 1–5 years 500 micrograms/kg every 6–8 hours (max. 40 mg daily); 6–12 years 500 micrograms/kg every 6–8 hours (max. 75 mg daily). Induction of hypothermia (to prevent shivering), 25– 50 mg every 6–8 hours; child 1–12 years, initially 0.5–1 mg/kg, followed by maintenance 500 micrograms/kg every 4–6 hours.

FLUPENTHIXOL:

Indications: schizophrenia and other psychoses, particularly with apathy and withdrawal but not mania or psychomotor hyperactivity; depression.

Contraindications: hepatic impairment; renal impairment; pregnancy; breast-feeding.

Dose and Administration: Psychosis, initially 3–9 mg twice daily adjusted according to the response; max. 18 mg daily; elderly (or debilitated) initially quarter to half adult dose; child not recommended.

HALOPERIDOL:

Indications: Acute Schizophrenia, Aggressive Behavior, Chronic Schizophrenia, Drug-Induced Psychosis, Gilles De La Tourette Syndrome, Manic Disorder, Organic Psychotic Condition, Psychotic Disorder, Schizophrenia

Contraindications: CNS Depression, Coma, Drug Induced CNS Depression, Lactating Mother, Parkinsonism, Torsades de Pointes, Agranulocytosis, Angina, Congenital Long QT Syndrome, Hypokalemia, Hypomagnesemia, Neuroleptic Malignant Syndrome.

Dose and Administration: schizophrenia and other psychoses, mania, short-term adjunctive management of psychomotor agitation, excitement, and violent or dangerously impulsive behaviour, by mouth, initially 1.5–3 mg 2–3 times daily or 3–5 mg 2–3 times daily in severely affected or resistant patients; in resistant schizophrenia up to 30 mg daily may be needed; adjusted according to response to lowest effective maintenance dose (as low as 5–10 mg daily); elderly (or debilitated) initially half adult dose; child initially 25–50 micrograms/kg daily (in 2 divided doses) to max. 10 mg. By intramuscular or by intravenous injection, initially 2–10 mg, then every 4–8 hours according to response to total max. 18 mg daily; severely disturbed patients may require initial dose of up to 18 mg; elderly (or debilitated) initially half adult dose; child not recommended. Agitation and restlessness in the elderly, by mouth, initially 0.5–1.5 mg once or twice daily.

SULPIRIDE:

Indications: schizophrenia and other psychoses.

Contraindications: hepatic impairment, renal impairment, cardiovascular disease, Parkinson’s disease (may be exacerbated by antipsychotics), epilepsy (and conditions predisposing to epilepsy), depression, myasthenia gravis, prostatic hypertrophy, or a susceptibility to angle-closure glaucoma

Dose and Administration: 200–400 mg twice daily; max. 800 mg daily in predominantly negative symptoms, and 2.4 g daily in mainly positive symptoms; elderly, lower initial dose, increased gradually according to response; child under 14 years not recommended.

TIAPRIDE:

Indications: Treatment of certain beha-vioural disorders and for the treatment of certain types of intense and referactory pains.

Contraindications: prolactin dependent tumor, pheochromocytoma.

Dose and Administration: dosage is variable and has to be adjusted to each individual case. For use in adults and children over the age of 6 years only.

ZUCLOPENTHIXOL ACETATE:

Indications: short-term management of acute psychosis, mania, or exacerbations of chronic psychosis

Contraindications: hepatic impairment; renal impairment; pregnancy; breast-feeding.

Dose and Administration: By deep intramuscular injection into the gluteal muscle or lateral thigh, 50–150 mg (elderly 50–100 mg), if necessary repeated after 2–3 days (1 additional dose may be needed 1–2 days after the first injection); max. cumulative dose 400 mg per course and max. 4 injections; max. duration of treatment 2 weeks—if maintenance treatment necessary change to an oral antipsychotic 2–3 days after last injection, or to a longer acting antipsychotic depot injection given concomitantly with last injection of zuclopenthixol acetate; child not recommended

ZUCLOPENTHIXOL:

Indications: schizophrenia and other psychoses, particularly when associated with agitated, aggressive, or hostile behaviour

Contraindications: hepatic impairment; renal impairment; pregnancy; breast-feeding and apathetic or withdrawn states.

Dose and Administration: By mouth, initially 20–30 mg daily in divided doses, increasing to a max. of 150 mg daily if necessary; usual maintenance dose 20– 50 mg daily; elderly (or debilitated) initially quarter to half adult dose; child not recommended​

Hypnotics and anxiolytics

Most anxiolytics (sedatives) will induce sleep when given at night and most hypnotics will sedate when given during the day. Prescribing of these drugs is widespread but dependence (both physical and psychological) and tolerance occurs. This may lead to difficulty in withdrawing the drug after the patient has been taking it regularly for more than a few weeks. Hypnotics and anxiolytics should, therefore, be reserved for short courses to alleviate acute conditions after causal factors have been established. Benzodiazepines are the most commonly used anxiolytics and hypnotics; they act at benzodiazepine receptors which are associated with gamma-aminobutyric acid (GABA) receptors. Older drugs such as meprobamate and barbiturates are not recommended—they have more side-effects and interactions than benzodiazepines and are much more dangerous in overdosage.

Hypnotics

Before a hypnotic is prescribed the cause of insomnia should be established and, where possible, underlying factors should be treated. However, it should be noted that some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of insomnia.

Chloral Hydrate:

Indications: General Anesthesia Adjunct, Insomnia, and Sedation in Pediatric Patients.

Contraindications: Esophagitis, Gastritis, Peptic Ulcer, Severe Hepatic Disease, Severe Renal Disease, Acute Intermittent Porphyria, Severe Cardiovascular Disease, Substance Abuse

Dose and Administration: chloral hydrate 200 mg/5mL (4%) in a suitable vehicle with a black currant flavor. Child 1 month–1 year 30–50 mg/kg, taken well diluted with water at bedtime. 1–12 years 30–50 mg/kg (max. 1 g), taken well diluted with water at bedtime.

Anxiolytics

Benzodiazepine anxiolytics can be effective in alleviating anxiety states. Although these drugs are often prescribed to almost anyone with stress-related symptoms, unhappiness, or minor physical disease, their use in many situations is unjustified. In particular, they are not appropriate for treating depression or chronic psychosis. In bereavement, the psychological adjustment may be inhibited

by benzodiazepines. In children, anxiolytic treatment should be used only to relieve acute anxiety (and related insomnia) caused by fear (e.g. before surgery). Anxiolytic treatment should be limited to the lowest possible dose for the shortest possible time. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.

Benzodiazepines

Benzodiazepines are indicated for the short-term relief of severe anxiety but long-term use should be avoided. In panic disorders (with or without agoraphobia) resistant to antidepressant therapy may be used; alternatively, a benzodiazepine may be used as short-term adjunctive therapy at the start of antidepressant treatment to prevent the initial worsening of symptoms.

DIAZEPAM:

Indications: short-term use of anxiety or insomnia, the adjunct to acute alcohol withdrawal; status epilepticus, febrile convulsions, muscle spasm, peri-operative use.

Contraindications: Lactating Mother, Myasthenia Gravis, Narrow Angle Glaucoma, Pregnancy, Respiratory Depression, Severe Hepatic Disease, Sleep Apnea, Alcohol Intoxication, Depression, Pulmonary Disease, Severe Chronic Obstructive Pulmonary Disease.

Dose and Administration: By mouth, anxiety, 2 mg 3 time’s daily increased if necessary to 15–30 mg daily in divided doses; elderly (or debilitated) half adult dose. Insomnia associated with anxiety, 5–15 mg at bedtime. By intramuscular injection or slow intravenous injection (into a large vein, at a rate of not more than 5 mg/minute), for severe acute anxiety, control of acute panic attacks, and acute alcohol withdrawal, 10 mg, repeated if necessary after not less than 4 hours

ALPRAZOLAM:

Indications: Anxiety, Anxiety with Depression, Generalized Anxiety Disorder, Panic Disorder and Insomnia.

Contraindications: Lactating Mother, Narrow Angle Glaucoma, Pregnancy, Alcohol Intoxication, CNS Depression, Depression, Fainting, Seizure Disorder, Sleep Apnea, Substance Abuse, Suicidal Ideation.

Dose and Administration: 250–500 micrograms 3 times daily (elderly or debilitated 250 micrograms 2–3 times daily), increased if necessary to a total of 3 mg daily; child not recommended.

LORAZEPAM:

Indications: short-term use of anxiety or insomnia, status epilepticus, and peri­operative

Contraindications: Alcohol Intoxication, Narrow Angle Glaucoma, Pregnancy, Respiratory Depression, Sleep Apnea, Depression, Fainting, Hepatic Encephalopathy, Severe Chronic Obstructive Pulmonary Disease, Severe Hepatic Disease.

Dose and Administration: By mouth, anxiety, 1–4 mg daily in divided doses; elderly (or debilitated) half adult dose.

BROMAZEPAM:

Indications:  used to relieve anxiety, nervousness, and tension.

Contraindications: Lactating Mother, Narrow Angle Glaucoma, Pregnancy, Alcohol Intoxication, CNS Depression, Depression, Fainting, Seizure Disorder, Sleep Apnea, Substance Abuse, Suicidal Ideation.

Dose and Administration: By mouth, anxiety, 6-18 mg daily in divided doses; elderly (or debilitated) half adult dose.

 

Cough Preparations

Expectorant and demulcent cough preparations

Expectorants are claimed to promote expulsion of bronchial secretions but there is no evidence that any drug can specifically facilitate expectoration. The assumption that sub-emetic doses of expectorants, such as ammonium chloride, ipecacuanha, and squill promote expectoration is a myth. However, a simple expectorant mixture may serve a useful placebo function and has the advantage of being inexpensive.

Demulcent cough preparations contain soothing substances such as syrup or glycerol and some patients believe that such preparations relieve a dry irritating cough. Preparations such as simple linctus have the advantage of being harmless and inexpensive; pediatric simple linctus is particularly useful in children. Compound preparations are on sale to the public for the treatment of cough and colds; the rationale for some is dubious.

GUAIFENESIN:

Indications: Guaifenesin is used to help coughs caused by colds or similar illnesses clear mucus or phlegm (pronounced flem) from the chest. It works by thinning the mucus or phlegm in the lungs. Guaifenesin is used to reduce chest congestion caused by the common cold, infections, or allergies.

Contraindications: There are no adequate studies

Dose and Administration: Adults—200 to 400 milligrams (mg) every four hours. Children 6 to 12 years of age—100 to 200 mg every four hours. Children 4 to 6 years of age—300 mg every twelve hours. Children and infants up to 4 years of age—Use is not recommended.

Guaifenesin and Dextromethorphan:

Indications: The combination of dextromethorphan and guaifenesin is used to treat cough and chest congestion caused by the common cold, infections, or allergies.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults 10ml every four hours.

Guaifenesin and Theophylline:

Indications: Preventing and treating symptoms and blockage of airway due to asthma or other lung diseases such as emphysema or bronchitis.

Guaifenesin/Theophylline are a combination xanthine derivative and expectorant. The xanthine derivative works by relaxing the smooth muscle surrounding the bronchial tubes (air passages) of the lungs, allowing the tubes to widen, and making breathing easier

Contraindications: if allergic to any ingredient in Guaifenesin/Theophylline.

Dose and Administration: adults 15-30ml 2-3 times daily. Children over 45kg the same dose as adults. Over 8 years old 15ml 2-3 times daily. Under 8 years old 2.5ml per each 4.5kg body weight 2-3 times daily.

Guaifenesin/Dextromethorphan/Pseudoephedrine:

Indications: Relieving congestion, cough, and throat and airway irritation due to colds, flu, or hay fever.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin 30mg Pseudoephedrine and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults’ 10ml every four hours.

Diphenhydramine/Menthol:

Indications: control of cough and allergy and hay fever and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: children 1 to 6 years 5ml every 6 hours. From 6 to 12 years 10ml every 6 hours.

Diphenhydramine/Ammonium Chloride/Menthol:

Indications: for controlling cough due to colds and allergy and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: each 5ml syrup contains 14mg Diphenhydramine, 135mg Ammonium chloride, and 1.1mg Menthol. Children 1 to 6 years 2.5ml every 6 hours, 6 to 12 years 5ml every 6 hours and for adults 5 to 10ml every 6 hours.

Cough Suppressants

Dextromethorphane:

Indications: Dextromethorphan is a cough suppressant. It works by loosening mucus and lung secretions in the chest and making coughs more productive. Temporarily relieving cough due to the common cold, upper respiratory tract infections, sinus inflammation, sore throat, or bronchitis.

Contraindications: if allergic to any ingredient in Dextromethorphan or taking or have taken a monoamine oxidase (MAO) inhibitor within the last 14 days.

Dose and Administration: each 5ml contains 15mg of Dextromethorphane. Children above 2 years 2.5ml to 5ml up to 4 times daily. Adult’s 5ml to 10ml 4 times daily.

Thyme fluid extract and primula root fluid extract:

Indications: used in cough, bronchitis, bronchial catarrh and mucous obstruction of the bronchi.

Contraindications: in case of allergy to thyme, primula root extract or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is one spoon every 2-3 hours up to 6 times per day. Children half of the adult dose.

Thyme fluid extract:

Indications: used in whooping cough, bronchitis, and bronchial catarrh Contraindications: in case of allergy to thyme or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is two spoons 3 times per day. Children half of the adult dose.

Fentanyl Patch Overdose – Case Scenario

Source: Fentanyl Patch Overdose – Case Scenario – Med Ed 101

 

An elderly female was on a maintenance opioid regimen of Morphine ER 15 mg BID, with breakthrough Norco 10/325mg QID PRN. Needless to say, I was fairly shocked to see a prescription come in for her calling for Fentanyl 100 mcg/hr patches W 72 hours and breakthrough Dilaudid 2 mg Q 2 hours. This is an increase from approximately 70 mg morphine equivalent to 450 mg morphine equivalent. I called the prescriber and they informed me that the patient was on the 100 mcg patch in the hospital with them along with a PCA pump for 2 days and that she had tolerated it fine. “The doctor is not worried about this dose at all” the nurse said to me on the phone. I then spoke with the patients husband when he came to pick up the prescription for fentanyl and I inquired about how she was doing. He then informed me that she had been home for three days, used none of her breakthrough medication and was still very sedated with limited ability to communicate.

Treatment of Influenza

Less than 50% of the U.S. population obtains the seasonal influenza vaccine, and the vaccine does not confer perfect immunity. There are three types of influenza, plus numerous variations. Practitioners should be confident in the use of antiviral agents in patients with influenza. The most recent guidelines recommend the use of nonpharmacologic management and neuraminidase inhibitors to either prevent the transmission of influenza or treat the infection. Pharmacotherapy is based on an understanding of which

Source: Antiviral Therapy in Patients With Influenza

Treatment of Influenza

Nonpharmacologic Treatment: Nonpharmacologic recommendations for influenza are bed rest, avoidance of other persons, and hydration. Fluids should be consumed throughout the illness to prevent complications from dehydration. Acetaminophen or ibuprofen may be used to relieve fever, headache, and muscle aches. However, some patients may benefit from antiviral treatment (see Pharmacotherapy Considerations section).17-19

Pharmacologic Agents: Antiviral medications with activity against influenza viruses are an important adjunct to vaccination for control of the influenza virus. Oseltamivir (Tamiflu), inhaled zanamivir (Relenza), and IV peramivir (Rapivab) are the currently recommended agents for influenza.20-22 These drugs, which are neuraminidase inhibitors with activity against both influenza A and influenza B, work by selectively inhibiting the neuraminidase enzyme, thereby preventing the release of viral particles from infected cells. These medications may be used for treatment, but only oseltamivir and zanamivir may be used for treatment and chemoprophylaxis. The chemoprophylaxis dosages for these drugs are lower than the treatment dosages; however, the therapy duration is longer (TABLE 1).20-23 Oseltamivir and zanamivir are indicated for use in adults and children; peramivir has not been FDA-approved for use in children.19,23

Summary of currently available antiviral agents

Summary of currently available antiviral agents

Besides the neuraminidase inhibitors, two other products are available: amantadine (Symmetrel) and rimantadine (Flumadine), both of which are adamantane antiviral agents with activity against influenza A viruses. These agents exert an inhibitory effect on influenza A subtypes (H1N1, H2N2, and H3N2) early in the viral replicative cycle. However, they are no longer recommended for treatment and prevention of influenza because of the increased rates of resistance (>99%) in influenza A types H3N2 and H1N1.19,23

Pharmacotherapy Considerations

Early treatment with the previously mentioned antivirals can shorten the duration of influenza symptoms by 1/2 day to 3 days and may reduce the risk of complications.24 The greatest clinical benefit is seen when antiviral treatment is initiated within 48 hours of illness onset. It is also important to correctly identify patients who meet parameters for either chemoprophylaxis or treatment so that they receive the correct dosage and duration of therapy.19

Chemoprophylaxis should be considered in adults and children aged 1 year and older who are at high risk for developing influenza complications and for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness (e.g., significantly immunocompromised persons).18,19 Chemoprophylaxis should also be considered in this population when the vaccination has not yet been administered and influenza has been detected within the community. Unvaccinated adults—including healthcare workers—and children aged ≥1 year who are in close contact with persons at high risk for developing influenza complications during periods of influenza activity should be considered for chemoprophylaxis, as should all vaccinated and unvaccinated persons in institutions experiencing influenza outbreaks.19

Antiviral treatment should be initiated in all persons with laboratory-confirmed or highly suspected influenza virus infection, including those at high risk for developing complications (TABLE 2).19 Patients who require hospitalization for influenza regardless of vaccination status or underlying illness should also receive treatment. Outpatients at high risk for complications whose illness is not improving and who have a positive influenza test result may be candidates for influenza treatment. The same is true for outpatients who are not at increased risk, but wish to shorten the duration of illness or are in close contact with someone at high risk for complications secondary to influenza infection.19

high rist for Influenza complications

high rist for Influenza complications

When the appropriate drug for chemoprophylaxis or treatment is being selected, local patterns of influenza circulation in the community throughout the influenza season should be considered. Oseltamivir (Tamiflu), zanamivir (Relenza), and peramivir (Rapivab) were the antivirals recommended for the 2016–2017 influenza season.19 A generic oseltamivir was approved by the FDA in August 2016, giving patients a less expensive option.25

In patients who are mechanically ventilated or critically ill, oseltamivir may be administered via nasogastric or orogastric (NG/OG) tube. The powder from capsules should be dissolved in 20 mL of Sterile Water and injected down the NG/OG tube, followed by a 10-mL Sterile Water flush.20

– See more at: https://www.uspharmacist.com/article/antiviral-therapy-in-patients-with-influenza#sthash.5hPEtMHF.dpuf

Conclusion

Despite advances in preventive care, infection with the influenza virus sometimes occurs. In such cases, practitioners must be able to quickly identify patients at high risk for developing complications in order to lessen the morbidity and mortality associated with the influenza virus. Some patients may require chemoprophylaxis to prevent infection. The agents for treatment and chemoprophylaxis are the same, and pharmacists should play an active role in ensuring that the correct dosage is used for the correct indication.

REFERENCES

1. Taubenberger JK, Morens DM. The pathology of influenza virus infections. Annu Rev Pathol. 2008;3:499-522.
2. CDC. CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States. www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm. Accessed December 29, 2016.
3. CDC. Weekly US influenza surveillance report: 2016-2017 season, week 51 ending December 24, 2016. www.cdc.gov/flu/weekly/weeklyarchives2016-2017/Week51.htm. Accessed March 8, 2017.
4. Santibanez TA, Kahn KE, Zhai Y, et al. Flu vaccination coverage, United States, 2015–2016 influenza season. www.cdc.gov/flu/fluvaxview/coverage-1516estimates.htm. Accessed March 3, 2017.
5. Luo M. Influenza virus entry. Adv Exp Med Biol. 2012;726:201-221.
6. Lakadamyali M, Rust MJ, Zhuang X. Endocytosis of influenza viruses. Microbes Infect. 2004;6:929-936.
7. CDC. Influenza (flu): information for schools. www.cdc.gov/flu/school/qa.htm. Accessed December 30, 2016.
8. CDC. Types of influenza viruses. www.cdc.gov/flu/about/viruses/types.htm. Accessed January 14, 2017.
9. CDC. How the flu virus can change: “drift” and “shift.” www.cdc.gov/flu/about/viruses/change.htm. Accessed December 30, 2016.
10. Hunt R. Vaccines: past successes and future prospects. Virology. www.microbiologybook.org/lecture/vaccines.htm. Accessed January 14, 2017.
11. Sedova ES, Shcherbinin DN, Migunov AI, et al. Recombinant influenza vaccines. Acta Naturae. 2012;4:17-27.
12. CDC. Selecting viruses for the seasonal influenza vaccine. www.cdc.gov/flu/about/season/vaccine-selection.htm. Accessed January 14, 2017.
13. Thompson WW, Comanor L, Shay DK. Epidemiology of seasonal influenza: use of surveillance data and statistical models to estimate the burden of disease. J Infect Dis. 2006;194(suppl 2):S82-S91.
14. Montalto NJ. An office-based approach to influenza: clinical diagnosis and laboratory testing. Am Fam Physician. 2003;67:111-118.
15. CDC. Influenza signs and symptoms and the role of laboratory diagnostics. www.cdc.gov/flu/professionals/diagnosis/labrolesprocedures.htm. Accessed January 14, 2017.
16. Vemula SV, Zhao J, Liu J, et al. Current approaches for diagnosis of influenza virus infections in humans. Viruses. 2016;8:96.
17. CDC. Influenza (flu) treatment. www.cdc.gov/flu/consumer/treatment.htm. Accessed December 22, 2016.
18. Fiore AE, Fry A, Shay D, et al. Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60:1-24.
19. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children—diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:1003-1032.
20. Oseltamivir. Lexi-Comp Online. Hudson, OH: Lexi-Comp, Inc; 2016. https://online.lexi.com. Accessed December 9, 2016.
21. Zanamivir. Lexi-Comp Online. Hudson, OH: Lexi-Comp, Inc; 2016. https://online.lexi.com. Accessed December 9, 2016.
22. Peramivir. Lexi-Comp Online. Hudson, OH: Lexi-Comp, Inc; 2016. https://online.lexi.com. Accessed December 9, 2016.
23. CDC. Influenza antiviral medications: summary for clinicians. www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Accessed March 8, 2017.
24. Cooper NJ, Sutton AJ, Abrams KR, et al. Effectiveness of neuraminidase inhibitors in treatment and prevention of influenza A and B: systematic review and meta-analyses of randomized controlled trials. BMJ. 2003;326:1235.
25. The FDA approves first generic version of widely used influenza drug, Tamiflu. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm514854.htm. Accessed January 13, 2017.
26. CDC. Antiviral emergency use authorization. www.cdc.gov/flu/professionals/antivirals/antiviral-emergency-use.htm. Accessed December 17, 2016.

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