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Doctors should be aware that in most setngs less than half of patents initated on anthypertensive medicine treatment are stll taking it a year later best 50 mg imitrex. Similarly buy imitrex 50mg low price, in epilepsy, where events may occur at long intervals, adherence is notoriously unsatsfactory. The Doctor-Patent Interacton There is considerable evidence that this is crucial to concordance. If they are in doubt or dissatsfed they may turn to alternatve optons, including ‘complementary medicine’. There is no doubt that the medicine ‘doctor’ has a powerful efect to encourage confdence and perhaps contribute directly to the healing process. Prescripton Reasons Many aspects of the prescripton may lead to non-adherence (noncompliance). It may be illegible or inaccurate; it may get lost; it may not be reflled as intended or instructed for a chronic disease. Also, the prescripton may be too complex; it has been shown that the greater the number of medica- tons the poorer the adherence, while multple doses also decrease adherence if more than two doses per day are given. Not surprisingly adverse efects like drowsiness, impotence or nausea reduce adherence and patents may not admit to the problem. Pharmacist Reasons The pharmacist’s behaviour and professionalism, like the doctor’s, may have a positve impact, supportng adherence, or a negatve one, raising suspicions or concerns. This has been reported in relaton to generic drugs when substtuted for brand-name drugs. Pharmacist informaton and advice can be a valuable reinforcement, as long as it agrees with the doctor’s advice. The Healthcare System The healthcare system may be the biggest hindrance to adherence. Long waitng tmes, uncaring staf, uncomfortable environment, exhausted medicine supplies and so on, are all common problems in developing countries, and have a major impact on adherence. An important problem is the distance and accessibility of the clinic from the patent. Some studies have confrmed the obvious, that patents farthest from the clinic are least likely to adhere to treatment in the long term. They difer from accidental to deliberate excessive dosage or medicine maladministraton. Thalidomide marked the frst recognized public health disaster related to the introducton of a new medicine. It is now recognized that clinical trials, however thorough, cannot be guaranteed to detect all adverse efects likely to be caused by a medicine and hence necessitatng post-marketng surveillance. Health workers are thus encour- aged to record and report to the Natonal Pharmacovigilance Centre for any unexpected adverse efects with any medicine to achieve faster recogniton of serious related problems. Major Factors Predisposing to Adverse Efects It is well known that diferent patents ofen respond difer- ently to a given treatment regimen. For example, in a sample of 2422 patents who had been taking combinatons of drugs known to interact, only 7 (0. Drugs which commonly cause problems in the elderly include hypnotcs, diuretcs, non-steroidal ant-infamma- tory drugs, anthypertensives, psychotropics, digoxin etc. All children, and partcularly neonates, difer from adult in their response to drugs. Some drugs are likely to cause problems in neonates (for example morphine ), but are generally toler- ated in children. Other drugs associated with problems in children include chloramphenicol (grey baby syndrome), antarrhythmics (worsening of arrhythmias), acetylsalicylic acid (Reye’s syndrome etc). Drug Interactons Interactons (see Appendix 6) may occur between drugs which compete for the same receptor or act on the same physiolog- ical system. They may also occur indirectly when a medicine- induced disease or a change in fuid or electrolyte balance alters the response to another medicine. Interactons may occur when one medicine alters the absorpton, distributon, metabolism or eliminaton of another medicine, such that the amount which reaches the site of acton is increased or decreased. When two drugs are administered to a patent, they may either act independent of each other, or interact with each other. Interactons may increase or decrease the efects of the drugs concerned and may cause unexpected toxicity. As newer and more potent drugs become available, the number of serious medicine inter- actons is likely to increase. Remember that interactons which modify the efects of a medicine may involve non-prescripton drugs, non-medicinal chemical agents, and social drugs such as alcohol, marijuana, tobacco and traditonal remedies, as well as certain types of food.

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The programme also involved limit setting – subjects persisting in heroin use were discharged imitrex 25mg without a prescription. It is not possible without further research to ascertain whether it was psychosocial support order 50mg imitrex fast delivery, limit setting, or both, that contributed to better outcomes. The evaluation of ‘low-threshhold’ methadone in Amsterdam showed that failure to suppress heroin use did not protect against blood-borne virus transmission. Patients and practitioners reflect community assumptions that drug use is a matter of personal responsibility, rather than a disease, and many heroin users are reluctant to see themselves as ill. Adopting the role of ‘patient’ involves relinquishing their ‘addict identity’, and they may prefer to see participation in treatment as taking advantage of the supports available to them rather than seeking to recover. It is uncommon for doctors to think of it as management of a chronic medical condition. The first is the risk of death of individuals not in treatment, as a result of diversion (see Glossary) of methadone. Experiencing or witnessing an overdose is a common occurrence among users of illicit opioid drugs,84 but prescribed opioid drugs also carry these risks. It is essential that the medical professional understands the process of careful and safe assessment and prescribing, as well as recognising the times when a patient is most at risk. One important strategy is training users of opioid drugs themselves,84 and also healthcare staff and carers,90 in the recognition of opioid (and other drug) overdose in the community and prison setting, and how to respond, including administration of the opioid antagonist naloxone. Alternative methods of treatment for people not responding to methadone, such as slow-release oral morphine, could enhance consumer choice. Little is known about the efficacy of such approaches and research is needed in this area. In order to deliver such care, doctors report that they need not just initial training, but ongoing supervision, support and reflection. Treatment requires structure, support and monitoring, and has been operationalised into clinical guidelines. In a climate of fiscal austerity, re-tendering of drug treatment programmes has become common, with a view to reducing costs in an already squeezed system. Quite apart from the financial pressure to provide minimalist services, re-tendering in itself risks compromising the quality and continuity of treatment. As reported by Ball and Ross,7 more effective programmes are characterised by stable management, and frequent restructuring of services may compromise effectiveness. Clinical leadership, with well- understood, protocol-driven treatment and support and supervision for staff, are important ingredients of treatment. Summary • Medical management of drug dependence is more difficult and challenging than for other chronic disorders. Many users who present for treatment are socially marginalised, lead chaotic lifestyles and have little to motivate them towards recovery. This attenuates the symptoms of withdrawal from heroin and allows the user to gain control over other aspects of their life, thereby creating the necessary preconditions to cease drug seeking and use. There is substantial evidence that good-quality staff interactions are of benefit for recovery. Some people who use drugs report experiencing disapproval and frustration in their interaction with healthcare services,1 and this can be a significant barrier to accessing healthcare. As discussed in Chapter 8, health professionals who adopt a non- judgemental, non-stigmatising empathic stance are most likely to be effective in delivering healthcare for these patients. There is consistent evidence that in primary care settings, in hospitals, and in mental health settings, doctors frequently do not address alcohol and drug use. The medical frame of reference is a useful one in which to approach drug use – non-judgemental, factual, professional, accurate diagnosis and provision of information and referral, monitoring the response. Contrary to pessimism and reluctance to address drug use as a health issue, there is evidence that, in relation to the legal drugs alcohol and tobacco, medical management can have significant impact,6-9 but it is unclear how far this can be extrapolated to illicit drugs. Opportunistic identification of drug use, and provision of brief health advice, may be useful in triggering individuals to reflect on, and sometimes to modify, their use of drugs. The appropriate response may involve provision of information about health risks and harms, or referral for management. Screening and brief advice from physicians can affect the motivation for change among patients, including those with substance dependence. The doctor must also consider the impact the drug use may be having on children and young people. Relevant information will include family risk factors, such as drug and alcohol misuse, or previous instances of abuse or neglect, but you should not usually share complete records. This section looks at strategies to reduce use in those who are already using drugs. McCambridge and Strang tested brief interventions in young people,16 and found that a single session of motivational interviewing (including discussing illicit drug use) led successfully to reduction in use of these drugs among young people.

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Pharmaceutical Substance Drying Conditions Drying Time Prescribed Limit (°C) (Hrs) (%) Inorganic Salt Hydrates : l cheap 50mg imitrex with mastercard. The chromatographic procedure may be carried out by employing : (a) A stainless-steel column (1 m × 2 mm) packed with porous polymer beads e buy imitrex 50mg with amex. From the chromatograms obtained and taking into account any water detectable in solution (1), calculate the percentage w/w of water taking 0. Limits of Non-Volatile Matter Pharmaceutical chemicals belonging to the domain of inorganic as well as organic substances containing readily volatile matter for which the various official compendia prescribe limits of non-volatile matter. It is pertinent to mention here that the Pharmacopoeia usually makes a clear distinction between substances that are readily volatile and substances that are volatile upon strong ignition, for instance : (a) Readily Volatile : e. Limits of Residue on Ignition In fact, the limits of residue on ignition are basically applicable to the following two categories of pharmaceutical substances, namely : (a) Those which are completely volatile when ignited e. Limits of Loss on Ignition Official compendia include the limits of ‘loss on ignition’ which is generally applied to relatively stable pharmaceutical substances that are likely to contain thermolabile impurities. Limits on Ash Value The ash values usually represent the inorganic residue present in official herbal drugs and pharmaceuti- cal substances. These values are categorized into four heads, namely : (a) Ash Value (Total Ash), (b) Acid-Insoluble Ash, (c) Sulphated Ash, and (d) Water-Soluble Ash. These values would be explained with the help of some typical examples stated below : 1. Ash Value (Total Ash) Ash value normally designates the presence of inorganic salts e. The official ash values are of prime importance in examination of the purity of powdered drugs as enumerated below : (i) To detect and check adulteration with exhausted drugs e. The most common procedure recommended for crude drugs is described below : Procedure : Incinerate 2 to 3 g of the ground drug in a tared platinum or silica dish at a temperature not exceeding 450°C until free from carbon. Acid-Insoluble Ash The method described above for ‘total ash’ present in crude drugs containing calcium oxalate has certain serious anomalies, namely : • Offers variable results upon ashing based on the conditions of ignition. Hence, the treatment of the ‘total ash’ with acid virtually leaves silica exclusively and thus comparatively forms a better test to detect and limit excess of soil in the drug than does the ash. Repeat until the difference between two successive weighings is not more than l mg. Calculate the percentage of acid-insoluble ash with reference to the air-dried drug. Sulphated Ash The estimation of ‘sulphated ash’ is broadly employed in the case of : (a) Unorganized drugs e. The general method for the determination of ‘sulphated ash’ is enumerated below : Procedure : Heat a silica or platimum crucible to redness for 30 minutes, allow to cool in a desiccator and weigh. Place a suitable quantity of the substance being examined, accurately weighed in the crucible, add 2 ml of 1 M sulphuric acid and heat, first on a waterbath and then cautiously over a flame to about 600°C. Continue heating until all black particles have disappeared and then allow to cool. Add a few drops of 1 M sulphuric acid, heat to ignition as before and allow to cool. Add a few drops of a 16% solution of ammonium carbonate, evaporate to dryness and cautiously ignite. Following are the examples to depict the ‘sulphated ash’ present in various official pharmaceutical chemicals : S. Water-Soluble Ash Water-soluble ash is specifically useful in detecting such samples which have been extracted with water. Now, calculate the percentage of water-soluble ash with reference to the air-dried drug. A typical example of an official drug is that of ‘Ginger’, the water-soluble ash of which is found to be not more than 6. These impurities very often creep into the final product through a number of means stated below, namely : (a) Through atmospheric pollution. In short, all prescribed tests for impurities in the Pharmacopoeia usually fix certain limits of tolerance. For lead, arsenic and iron general quantitative or limit tests are precisely laid down which, with necessary variations and modification are rigidly applicable to pharmaceutical substances. Limit Tests for Lead Theory : The offcial test is based on the conversion of traces of lead salts present in the pharmaceutical substances to lead sulphide, which is obtained in colloidal form by the addition of sodium sulphide in an alkaline medium achieved by a fairly high concentration of ammonium acetate. The reaction may be expressed as follows : PbCl2 + Na2S → PbS B + 2NaCl The brown colour, caused due to colloidal lead sulphide in the test solution is compared with that produced from a known amount of lead. Equipment : Nessler Cylinders (or Nessler Glasses) : According to the British Standard Specifica- tion No : 612, 966—a pair of cylinders made of the same glass and having the same diameter with a graduation mark at the same height from the base in both cylinders (Figure 1).

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Pharmacodynamics Stimulant laxatives promote peristalsis and produce a bowel movement by irritating the intestinal mucosa or stimulating nerve endings of the intestinal smooth muscle generic imitrex 50 mg amex. Adverse They’re also used to treat constipation caused by prolonged reactions to bed rest discount 50mg imitrex with amex, neurologic dysfunction of the colon, and constipating stimulant drugs such as opioids. However, because these laxatives produce increased intesti- clude: nal motility, they reduce the absorption of other oral drugs admin- • weakness istered at the same time, especially sustained-release forms. Pharmacokinetics In its nonemulsified form, mineral oil is minimally absorbed; the emulsified form is about half absorbed. Absorbed mineral oil is distributed to the mesenteric lymph nodes, intestinal mucosa, liv- er, and spleen. Metabolism and excretion Mineral oil is metabolized by the liver and excreted in stool. Pharmacodynamics Mineral oil lubricates stool and the intestinal mucosa and prevents water reabsorption from the bowel lumen. Adverse reactions to mineral oil Adverse reactions to mineral oil include: • nausea and vomiting • diarrhea • abdominal cramping. Mineral oil can impair the Impacting impaction absorption of some oral Administered orally or by enema, this lubricant laxative is also drugs. To minimize drug interactions, adminis- ter mineral oil at least 2 hours before these medications. Top of the charts Ondansetron is currently the antiemetic of choice in the United States. Pharmacodynamics Some antiemetics block the vomiting The action of antiemetics may vary. The mechanism of action that produces the antiemetic effect of antihistamines is unclear. Phenothiazines produce their antiemetic effect by blocking the dopaminergic receptors in the chemoreceptor trigger zone in the brain. Lend me your ear Antihistamines are specifically used for nausea and vomiting caused by inner ear stimulation. Scopolamine prevents motion sickness, but its use is limited because of its sedative and anti- Dronabinol cholinergic effects. It has also been used to motility disorders including gastroparesis in di- stimulate appetite in the patient with acquired abetic patients. However, its use is limit- tive when given before activities that produce motion sickness and are much less effective when nausea or vomiting has already begun. They’re used when vomiting becomes severe and potentially haz- ardous, such as postsurgical or viral nausea and vomiting. Both types of drugs are also prescribed to control the nausea and vom- iting resulting from chemotherapy and radiotherapy. Adverse reactions to antiemetics Use of these antiemetic drugs may lead to ad- • The anticholinergic effect of antiemetics may verse reactions: cause constipation, dry mouth and throat, • Antihistamine and phenothiazine antiemetics painful or difficult urination, urine retention, im- produce drowsiness and sometimes paradoxi- potence, and visual and auditory disturbances. Ipecac syrup is used to induce vomiting in early management of oral poinsoning or drug overdose. The use of ipecac syrup has become controversial, however, be- cause it delays the use of activated charcoal. The American Academy of Pediatrics no longer recommends the routine use of ipecac syrup. The first action parents or caregivers should take if a child has ingested a poisonous substance is to call the poison control center and emergency medical services. Pharmacokinetics Little information exists concerning the absorption, distribution, and excretion of ipecac syrup. Adverse Pharmacodynamics reactions to Ipecac syrup induces vomiting by stimulating the vomiting center located in the brain’s medulla. It shouldn’t be used after ingestion of petroleum prod- ever, prolonged vomiting ucts, volatile oils, or caustic substances, such as lye, because of (for more than 1 hour) or the risk of additional esophageal injury or aspiration. If poisoning results from ingestion of a phe- Some people are very nothiazine, the phenothiazine’s antiemetic effect may decrease the sensitive to ipecac emetic effect of ipecac syrup. The antiemetic drug that would probably be best for a patient who experiences motion sickness on an airplane is: A. An antihistamine, such as dimenhydrinate, is the most effective antiemetic for a patient who experiences motion sickness during air travel. To prevent a postsurgical patient from straining during a bowel movement, the practitioner is most likely to prescribe: A. Docusate is commonly prescribed to prevent strain- ing during a bowel movement after surgery. Multitalented The kidneys perform several vital tasks, including: • disposing of wastes and excess ions in the form of urine • filtering blood, which regulates its volume and chemical make- up • helping to maintain fluid, electrolyte, and acid-base balances • producing several hormones and enzymes • converting vitamin D to a more active form • helping to regulate blood pressure and volume by secreting renin. Thiazide and thiazide-like diuretics Derived from sulfonamides, thiazide and thiazide-like diuretics are used to treat edema and to prevent the development and recur- rence of renal calculi. They’re also used for such cardiovascular diseases as hypertension and heart failure.

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