Posts Tagged ‘Living with Allergy’

Generic Name
Cromolyn (KROE-inuh-lin) [9
Brand Names
Crolom    Intal
Gastrocrom    Opticrom
The information in this profile also applies to the following drugs:
Nedocromil
Alocril    Tilade
Type of Drug
Allergy preventive and antiastk)m-aft_.
Prescribed For
Prevention of severe allergic reactions, including asthma, runny nose, and mastocytosis; also prescribed for food allergies, eczema, dermatitis, chronic itching, and hay fever. It may be used to treat and prevent chronic inflammatory bowel disease. The eyedrops are used to treat conjunctivitis (pinkeye) and other eye irritations.
General Information
Unlike antihistamines, which work against histamine that has been released into the system, cromolyn sodium prevents allergy, asthma, and other conditions by stabilizing mast cells, a key component in any allergic reaction because they release histamine. Cromolyn prevents the release of histamine and other chemicals from mast cells. The drug works only in the areas to which it is applied; only 7-8% of an inhaled dose and 1 % of a swallowed capsule is absorbed into the blood. Even the oral capsules, which one would normally expect to be absorbed into the blood, treat only gastrointestinal -tract allergies. Cromolyn products must be used on a regular basis to be effective in reducing the frequency and intensity of allergic reactions.
Cautions and Warnings
Do not take cromolyn if you are allergic or sensitive to any of its ingredients. Rarely, people have experienced severe allergic attacks after taking cromolyn.
cromolyn should never be used to treat an acute allergy attack. It is intended only to prevent or reduce the number of allergic attacks and their intensity. Once the proper dosage level has been established for you, reducing that level may result in a recurrence of attacks.
People with kidney or liver disease require reduced dosage.
Cough or bronchial spasm may occasionally occur after the inhalation of a cromolyn dose. Severe bronchospasm is rare.
cromolyn aerosol should be used with caution in people with abnormal heart rhythm or diseased coronary blood vessels because of a possible reaction to the propellants used in the product.
Possible Side Effects
V Most common: rash and itching. Headache and diarrhea (for capsules). Watery, itchy, dry, or puffy eyes; and iztjes (for eyedrops). Most capsule and eyedrop side effects are mkw and may be attributable to the underlying condition; a variety have been reported but cannot be tied conclusively to the drug.
V Less common: local irritation, including nasal stinging, sneezing, tearing, cough, and stuffy nose; urinary difficulty or frequency; dizziness; headache; joint swelling; muscle Possible Side Effects (continued)
pain-, a bad taste in the mouth; sore throat-, nosebleeds’, abdominal pain-, and nausea.
♦ Rare: severe drug reactions, consisting of coughing, difficulty in swallowing, hives, itching, breathing difficulties, or swelling of the eyelids, lips, or face. Contact your doctor if you experience any side effect not listed above.
Drug Interactions None known.
Food Interactions
Inhaled or swallowed cromolyn products should not be mixed with any food, juice, or milk. The nasal and eye products may be taken without regard to food or meals.
Usual Dose
Inhaled Capsules or Solution
Adult and Child (age 2 and over): starting close-20 mg 4 times a day. Children under age 5 may inhale cromolyn powder if their allergies are severe. The solution must be given with a power-operated nebulizer and face mask. Handheld nebulizers are not adequate. To prevent exercise asthma, 20 mg may be inhaled up to 1 hour before exercise.
Aerosol
Adult and Child (age 5 and over): up to 2 sprays 4 times a day, spaced equally throughout the day. To prevent exercise asthma, 2 puffs may be inhaled up to 1 hour before exercise.
Nasal Solution
Adult and Child (age 6 and over): 1 spray in each nostril 3-6 times a day at regular intervals. First blow your nose, and then inhale the spray.
Oral Capsules
MAI and Child (age 12 and over): 2 dissolved capsules 4 times a day taken a half hour before meals and at bedtime.
Child (age 2-12): 1 dissolved capsule (100 mg) 4 times a day a half hour before meals and at bedtime. Dosage may be increased to about 13-18 mg per lb. of body weight in 4 equal doses.
Child (under age 2): about 10 mg per lb, of body weight a day divided into 4 equal doses. This product is recommended in infants
and young children only if absolutely necessary.
Eyedrops
Adult and Child (age 4 and over): 1-2 drops in each eye 4-6 times
a day at regular intervals. Overdosage
No action is necessary other than medical observation. Call your local poison control center or a hospital emergency room for more information. ALWAYS bring the prescription bottle or container.
Special Information
Cromolyn is taken to prevent or minimize severe allergic reactions. It is imperative that you take cromolyn products on a regular basis to provide equal protection throughout the day.
If you are taking cromolyn to prevent seasonal allergies, it is essential that you start taking the medication before you come into contact with the cause of the allergy and that you continue treatment while you are exposed to it.
Cromolyn oral capsules should be opened and their contents mixed with about 4 oz. of hot water. Stir until the powder completely dissolves and the solution is completely clear, then fill the rest of the glass with cold water. Drink the entire contents of the glass. Do not mix the solution with food, juice, or milk.
Do not wear soft contact lenses while using cromolyn eyedrops. The lenses may be replaced a few hours after you stop taking the drug. To prevent contamination, do not touch the applicator tip to any surface including the eyes or fingers.
Call your doctor if you develop wheezing, coughing, a severe drug reaction (see “Possible Side Effects”), rash, or any bothersome or persistent side effect.
Call your doctor if your symptoms do not improve or if they worsen.
If you forget to administer a dose, do so as soon as you remember and sqa(ZRMBmn-maining daily dosage evenly throughout ‘i!M day. Do not take a double dose.
Special Populations
PregnancylBreast-feeding. In animal studies, very large dosages of cromolyn administered by vein have affected the fetus, though no birth defects were reported. When this drug is considered crucial by your doctor, its potential benefits must be carefully weighed
against its risks.
It is not known if cromolyn passes into breast milk. Nursing
mothers who must use cromolyn should use infant formula. Seniors: Older adults with reduced kidney or liver function may require lower dosages.

Generic Name
Cyclobenzaprine (sye-cloe-BEN-zuh-prene) M
Brand Names Amrix
Type of Drug
Skeletal muscle relaxant.
Flexeril
Prescribed For
Serious muscle spasm and acute muscle pain; also used to treat fibrositis (muscular rheumatism).
General Information
Cyclobenzoprine hydrochloride is used to treat severe muscle spasms; it is prescribed as part of a coordinated program of rest, physical therapy, and other measures.
Cautions and Warnings
Do not take cyclobenzaprine if you are allergic or sensitive to any of its ingredients.
This drug should not be taken for several weeks following a heart attack or by people with abnormal heart rhythms, heart failure, heart block (disruption of the electrical impulses that control heart rate), or hyperthyroidism (overactive thyroid gland).
Cyclobenzaprine should be avoided by people with urinary retention, glaucoma, UC 1ntlreased eye pressure.
W)t arug may increase the chances of cavities or gum disease. Cyclobenzaprine is intended only for short-term use of 2-3 weeks.
Cyclobenzaprine is chemically similar to tricyclic antidepressants and may produce some of the more serious side effects associated with those drugs. Abruptly stopping cyclobenzaprine may cause nausea, headache, and feelings of ill health; this is not a sign of addiction.
Drug Interactions
•    The effects of alcohol, sedatives, or other nervous system depressants may be increased by cyclobenzaprine.
•    Cyclobenzaprine may increase some side effects of atropine, ipratropium, and other anticholinergic drugs.
•    The combination of cyclobenzaprine and a monoamine oxidase inhibitor antidepressant may produce very high fever, convulsions, and possibly death. Do not take these drugs within 14 days of each other.
•    Cyclobenzaprine may increase the effects of haloperidol, loxapine, molindone, pimozide, anticoagulant (blood-thinning) drugs, anticonvulsants, thyroid hormones, antithyroid drugs, phenothiazines, thioxanthenes, and nasal decongestants such as naphazoline, oxymetazoline, phenylephrine, and xylometazoline.
•    Barbiturates and carbamazepine may counteract the effects of cyclobenzaprine.
•    Fluoxetine, ranitidine, cimetidine, methylphenidate, estramustine, estrogens, and contraceptive drugs may increase the effects and side effects of cyclobenzaprine.
•    Cyclobenzaprine may counteract the effects of cto(\idine, guanadrel, and guanethidine.
Food Interactions  None known.
Usual Dose
Adult and Child (age 15 and over): 5-10 mg 3 times a day. Child (under age 15): not recommended.
above.    drowsiness, and dizziness.
le weakness. fatigue, nausea, consti-
ch, unpleasant taste, blurred vision,
ess, and confusion.
cts can occur in almost any part of the doctor if you experience any side ef- e.
Possible Side Effects
♦    Most common: dry
♦    Less common: muscl
upset stomach
nervousness, • Rare: Rare side effects
body. Contact your
fect not listed Overdosage
Cyclobenzaprine overdose may cause confusion, loss of con- centration, hallucinations, agitation, overactive reflexes, fever or vomiting, rigid muscles, and other side effects of the drug. It may also cause drowsiness, low body temperature, rapid or irregular heartbeat and other kinds of abnormal heart rhythms, heart failure, dilated pupils, convulsions, very low blood pressure, stupor, coma, and sweating. Overdose victims must be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Cyclobenzaprine causes drowsiness, dizziness, or blurred vision in more than 40% of people who take it, which may interfere with the ability to perform complex tasks like driving or operating equipment. Avoid alcohol, sedatives, and other nervous system depressants because they can enhance sedative effects of cyclobenzaprine.
Call your doctor if you develop rash; hives; itching; urinary difficulties; clumsiness; confusion; depression; convulsions; difficulty breathing; irregular heart rate; chest pain; fever; yellowing of the skin or whites of the eyes; swelling of the face, lips, or tongue; or any other persistent or bothersome side effect.
If you forget a dose of cyclobenzaprine, take it as soon as you remember. If you take cyclobenzaprine once a day and it is almost time for your next dose, skip the one you forgot and continue with your regular schedule. If you take cyclobenzaprine twice a day and it is almost time for your next dose, take 1 dose as soon as you remember, another in 5 or 6 hours, and then go back to your regular schedule. If you take cyclobenzaprine 3 times a day and it is almost time for your next dose, take 1 dose as soon as you remember, another in 3 or 4 hours, and then go back to your regular schedule. Never take a double dose.
Special Populations
Pregnancy/Breast-feeding: -The safety of cyclobenzaprine in ‘jftg)T)1 women has not been established. Cyclobenzaprine should only be used if the potential benefits outweigh the risks.
It is not known if cyclobenzaprine passes into breast milk, but antidepressants with a similar chemical structure do pass into breast milk. Nursing mothers who must take this drug should consider using infant formula.
Seniors: Seniors are more likely to be sensitive to the effects of cyclobenzaprine. Use of Amrix in particular is not recommended
in the elderly.

Generic Name
Cyclosporine (sye-kim-SPQR-in)
Brand Names
Gengraf Neoral
Type of Drug  Immunosuppressant.
Restasis Ophthalmic Emulsion Sandimmune
Prescribed For
Kidney, heart, or liver transplantation; also used for bone-marrow, heart-lung, and pancreas transplants; also prescribed for patchy hair loss, rheumatoid arthritis, aplastic anemia, atopic dermatitis, Beh~et’s disease, cirrhosis of the liver, ulcerative colitis, dermatomyositis, eye symptoms of Graves’ disease, insulin-dependent diabetes, kidney inflammation, multiple sclerosis (MS), severe psoriasis and psoriasis-related arthritis, myasthenia gravis, pemphigus, sarcoidosis of the lung, and pyoderma gangrenosum. Cyclosporine eye emulsion is prescribed for dry eyes.
General Information
Cyclosporine is used to prevent rejection of transplanted organs. It works by blocking the activity of T-cells, which protect the body against invading microorganisms or foreign substances. Cyclosporine also prevents the production of a substance known as interieukin-11 that activates T-cells. In 1995, a new form of Cyclosporine called Neoral, a microemulsion, was introduced by its manufacturer. This form is as safe and effective as the original product but is better absorbed into the bloodstream and requires less medication to achieve the same effect. Cyclosporine eye emulsion treats dry eye caUV ,d by inflammation of the cornea and tissue kWA1 Covers the white part of the eye. It reduces inflammation and allows tears to form and flow.
Cautions and Warnings
Cyclosporine should be prescribed only by doctors experienced in immunosuppressive therapy and the care of organ-transplant patients. Sandimmune is always used with corticosteroid drugs like prednisone. Neoral and Gengraf have been used with a corticosteroid and azathioprine, an immune suppressant. When combined with other immune suppressants, cyclosporine must be used with great care because oversuppression of the immune system may lead to lymphoma or extreme susceptibility to infection.
Sandimmune, the original oral form of cyclosporine, is poorly absorbed into the bloodstream; it must be taken in a dosage that is 3 times greater than the injectable dosage. People taking this drug by mouth for a long period of time should have their blood checked for cyclosporine levels so that the dosage may be adjusted if necessary. Since more of both Gengraf and Neoral is absorbed into the blood you will probably need less of it. Do not substitute Neoral or Gengraf for Sandimmune; they are not equivalent to each other.
cyclosporine causes kidney toxicosis (kidney poisoning)—different from transplant rejection—in 25-35% of people taking it to prevent organ rejection. Mild symptoms usually start after about 2 or 3 months of treatment. Reducing drug dosage may control this effect. In one study, clonidine skin patches used before and after surgery decreased toxic risks to the kidney.
Liver toxicosis is seen in about 5% of transplant patients taking cyclosporine. It usually appears in the first month and may be controlled by reducing dosage.
Convulsions may develop, especially in people also taking high dosages of corticosteroids. Other nervous system side effects are listed below (see “Possible Side Effects”).
In one study, cyclosporine increased cholesterol and other blood-fat levels. It is not known how this affects people who take the drug on a long-term basis.
There is conflicting information on how cyclosporine affects blood sugar. Kidney-transplant patients taking the drug have developed insulin-dependent diabetes, which is related to the dosage of cyclosporine and reverses itself when you stop taking the drug. On the other hand, cyclosporine preserves the function of insuli(Nproducing cells in the pancreas and has allowed many insulin-dependent diabetics t0 11ve Without taking insulin.
UVb vaccines should not be given to people taking cyclosporine.
Do not use cyclosporine eye drops if you have an eye infection.
Small amounts of cyclosporine eye emulsion may be absorbed
into the bloodstream, but the risk of body-wide side effects is small.
Possible Side Effects
V Most common: Cyclosporine is known to be toxic to the kidneys. Your doctor will carefully monitor your kidney function while you are taking it. Other side effects are high blood pressure, increased hair growth, infection, and enlargement of the gums. Lymphoma may develop in people whose immune systems are excessively suppressed.
V Less common: tremors, cramps, acne, brittle hair or fingernails, convulsions, headache, confusion, diarrhea, nausea or vomiting, tingling in the hands or feet, facial flushing, reduced white-blood-cell and platelet counts, sinus inflammation, swollen and painful male breasts, drug allergy (symptoms include rash, itching, hives, and breathing difficulties), conjunctivitis (pinkeye), fluid retention and swelling, ringing or buzzing in the ears, hearing loss, high blood sugar, and muscle pain.
♦    Rare: blood in the urine, heart attack, itching, anxiety. depression, lethargy, weakness, mouth sores, difficulty swallowing, intestinal bleeding, constipation, pancreas inflammation, night sweats, chest pain, joint pain, visual disturbances, and weight loss. Contact your doctor if you experience any side effect not listed above.
Cyclosporine Eye Drops
♦    Most common: burning sensation.
✓    Less common: red-eye, discharge from the eye, overflow of tears, eye pain, a feeling of something in the eye, itching, stinging, and visual disturbances, usually blurring.
Drug Interactions
•    Cyclosporine should be used carefully with other kidney-toxic drugs including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, ac\d s0indac; ciprofloxacin; gentamicinjQtswnydin; vancomycin; trimethoprimsUM,M1~0oxazole; melphalan; amphotericin B; ketoconazole; azapropazon; colchicine; diclofenac; cimetidine; ranitidine; and tacrolimus.
•    Drugs that may increase blood levels of cyclosporine include contraceptive drugs; amiodarone; diltiazem; nicardipine; verapamil; fluconazole; itraconazole; ketoconazole; azithromycin; clarithromycin; erythromycin; quinapristin and dalfopristin; methylprednisolone—this combination also causes convulsions; allopurinol; bromocriptine; colchicine; imatinb-, danazol; and metoclopramide. With ketoconazole, your doctor may use this drug interaction to reduce your cyclosporine
dosage.
•    Drugs that decrease cyclosporine levels and may lead to organ rejection include octreotide, orlistat, sulfinpyrazone, ticlopidine, terbinafine, nafcillin, rifampin, carbamazepine, phenobarbital, phenytoin, and St. John’s wort. Rifabutin may also decrease concentrations of cyclosporine and should be used with caution.
•    Cyclosporine interferes with the body’s ability to clear digoxin, prednisolone, and statin drugs. People taking any of these drugs who start on cyclosporine must have their drug dosage reduced.
•    Combining cyclosporine and nifedipine may lead to gum overgrowth.
•    Cyclosporine increases blood potassium. Excessive blood-potassium levels may be reached if cyclosporine is taken with enalapril, lisinopril, a potassium-sparing diuretic such as spironolactone, salt substitutes, potassium supplements, or high potassium—low sodium—food.
•    Psoriasis patients using other immunosuppressant drugs or receiving radiation therapy should not take cyclosporine due to the danger of infection.
•    Cyclosporine prevents the normal body response to live vaccines. People taking cyclosporine should be vaccinated only after specific discussions with their doctors. You must wait for a period of several months to several years after stopping the medication before vaccination may be considered again.
Food Interactions
Cyclosporine may be taken with fMd 1111 upsets your stomach. For optimal QftlaWr~T)ess, avoid eating a fatty meal within half an hour of taking Neoral.
You may mix Neoral in a glass—not a paper or plastic cup—with room-temperature orange or apple juice or chocolate milk to make it taste better. Do not drink grapefruit juice because it speeds the breakdown of cyclosporine. Drink immediately after mixing, then put more juice or chocolate milk in the glass and drink it to be sure that the entire dose has been taken. Neoral should not be taken with unflavored milk because it may be unpalatable.
Usual Dose
In general, the usual dosage of Neoral is lower than Sandimmune, but dosage must be individualized for you by your doctor. Do not substitute one brand for the other.
Sandimmune
Adult: The usual oral dosage of cyclosporine is 6-8 mg per lb, of body weight a day. The first dose, typically 15 mg per lb., is given 4-12 hours before the transplant operation or immediately after surgery. This dosage is slowly reduced to 11-22 mg per lb. of body weight.
Child: Similar dosages are usually prescribed, but because children tend to release the drug from their bodies faster than adults, larger and more frequent doses may be needed.
Neoral and Gengraf
Adult: In newly transplanted patients, the usual oral dosage of Neoral is 3-4 mg per lb. of body weight a day divided into 2 doses. The initial oral dose of Gengraf is the same as for Sandimmune. The first dose is given 4-12 hours before the transplant operation or immediately after surgery. This dosage is continued after the operation for 1-2 weeks and then slowly reduced to maintain a target amount of cyclosporine in the body. Dosage may vary according to the organ transplanted.
In people being treated for rheumatoid arthritis or psoriasis, the initial dose of Neoral and Gengraf is 1.13 mg per lb. of body weight increased gradually to a maximum of 1.8 mg per lb. of body weight.
Child: Similar dosages are usually prescribed but, because children tend to release the drug from their bodies faster than adults, larger and more frequent doses may be needed.
cyclosporine Eye Emulsion
One drop in the affected eye(s) every Q hours. Before using, rotate and turn the vial Over a few times until you have a uniform, lft8, opaque fluid inside. If you use artificial tears, allow 15 minutes between products. Discard the open vial immediately after use.
Overdosage
Overdose victims may be expected to develop side effects and symptoms of extreme immunosuppression. Induce vomiting with ipecac syrup—available at any pharmacy—which is recommended up to 2 hours after the overdose was taken. Call your doctor or local poison control center before inducing vomiting. If you must go to a hospital emergency room, ALWAYS bring the prescription
bottle or container.
Special Information
Call your doctor at the first sign of fever; sore throat; tiredness’, weakness’, nervousness; unusual bleeding or bruising; tender or swollen gums; convulsions; irregular heartbeat; confusion; numbness or tingling of your hands, feet, or lips; breathing difficulties; severe stomach pain with nausea; or blood in the urine. Other side effects such as shaking or trembling of the hands, increased hair growth, acne, headache, leg cramps, nausea, or vomiting are less serious but should be brought to your doctor’s attention, particularly if they are bothersome or persistent.
Maintain good dental hygiene while taking cyclosporine and use extra care when brushing and flossing because the drug increases your risk of oral infection. cyclosporine may also cause swollen gums. See your dentist regularly.
Continue taking your medication as long as your doctor prescribes it. Do not stop taking it without your doctor’s knowledge. If you cannot take one of the oral forms, cyclosporine can be given by injection.
Do not keep either brand of the oral liquid in the refrigerator. After the bottle is opened, use the medication within 2 months. At temperatures below 68°F, Neoral can form a gel and a light sediment can form in Sandimmune. These do not affect the potency of either product. They can still be used and are effective.
If you forget a dose, take it as soon as you remember if it is within 12 hours of your regular dose. If not, skip the dose you forgot and continue with your regular schedule. Do not take a double dose.
For cyclosporine eye emulsion, each small plastic container is meant to be used once and then thrown away along with any remaining medication. Do not allow the tip of the disposable vial to touch 0Z QyE or any surface, as this may contaminate the emulsion.
Patients with decreased tear production typically should not wear contact lenses. But those that do must remove them before using cyclosporine eye emulsion. Lenses may be reinserted 15 minutes after using the medicine.
Special Populations
Pregnancy/Breast-feeding: In animal studies cyclosporine damages the fetus. Though a small number of pregnant women have taken cyclosporine without major problems, it is recommended that pregnant women avoid cyclosporine. When this drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
cyclosporine passes into breast milk. Nursing mothers who must take cyclosporine should use infant formula.
Seniors: Due to decreased kidney function, seniors are more susceptible to kidney toxicosis.

Generic Name
Darunavir (dah-ROON-uh-vere)
Brand Name Prezista
Type of Drug  Protease inhibitor.
Prescribed For
Advanced human immunodeficiency virus (HIV) infection that has not responded to other protease inhibitors.
General Information
Part of the multidrug “cocktail” responsible for important gains in the fight against acquired immunodefiency syndrome (AIDS), darunavir is a member of a group of anti-HIV drugs called protease inhibitors. These drugs work at the end of the HIV reproduction process, whet) proteins are “cut” into strands of exactly tht VbYrect size to duplicate HIV. An enzyme known as protease cuts the protein. Protease inhibitors prevent the mature HIV virus from being formed by inhibiting this cutting process. Proteins that are cut to the wrong length or that remain uncut are inactive.
Darunavir must be taken with a low dose of ritonavir, another protease inhibitor, to extend the action of darunavir in the body.
Without ritonavii, darunavir would be eliminated too rapidly to be effective. Darunavir must also be accompanied by at least 2 other AIDS antivirals. Protease inhibitors revolutionized HIV treatment because, when taken in combination, they reduce the amount of HIV virus in the bloodstream to levels that are often undetectable by current methods—CD4 (immune system) cell counts and viral load (amount of virus in the blood) measurements. Multiple-drug therapy has transformed HIV from a fatal disease to a manageable chronic illness.
Cautions and Warnings
Do not take darunavir if you are allergic or sensitive to any of its ingredients, to sulfa drugs, or to ritonavir.
Darunavir can cause a severe or life-threatening rash.
If a serious toxic reaction occurs while taking darunavir, you should stop the drug until your doctor can determine the cause or until the reaction resolves itself. Then treatment can be resumed.
This drug is primarly broken down in the liver. Use caution if you have moderate to severe liver disease.
Darunavir may raise your blood sugar, worsen your diabetes, or bring out latent diabetes. People with diabetes who take darunavir may need the dosage of their antidiabetes medication adjusted.
People with hemophilia may be more likely to bleed while taking a protease inhibitor.
The HIV virus may become resistant to darunavir or other protease inhibitors. For this reason it is essential that you take darunavir exactly according to your doctor’s directions.
Protease inhibitors can cause body fat redistribution, including increased fat deposits in the upper back and neck, breast and around the back, chest, and stomach. Fat may be lost from the legs, arms, and face. Some people with HIV and a history of an opportunistic infection may develop signs and symptoms of the infection soon after anti-HIV treatment is started. This is called immune reconstitution syndrome.
Darunavir is involved in many drug interactions. Check with your doctor before adding angt ng new to your treatment program.
Possible Side Effects
V Most common: diarrhea, nausea, headache, and common cold symptoms.
of constipation.
Drug Interactions
•    Do not take any of the following medicines with darunavir + ritonavir: astemizole, terfenidine, ergot-based drugs for migraine headache, cisapride, pimozide, midazolam, or triazolam. Mixing these drugs with darunavir + ritonavir can result in very high blood levels and serious side effects.
•    Carbamazepine, phenobarbital, phenytoin, rifampin, and St. John’s wort can substantially reduce blood levels of darunavir. Do not mix these medicines.
•    Lopinavir + ritonavir and saquinavir can significantly reduce blood levels of darunavir. Darunavir significantly increases blood levels of lopinavir + ritonavir. Do not mix these drugs.
•    Mixing darunavir with indinavir can increase blood levels of both drugs.
•    Darunavir + ritonavir does not appear to affect blood levels of atazanavir, nor does atazanavir appear to affect blood levels of darunavir + ritonavir. It may be possible to combine these two protease inhibitors.
•    Taking darunavir with tenofovir can increase blood levels of both drugs. These drugs can be combined with no dose adjustments, though it is necessary to watch carefully for kidney damage related to tenofovir.
•    Darunavir can increase blood levels of efavirenz and efavirenz reduces darunavir levels. These medicines should be mixed with caution.
•    Darunavir increases nevirapine blood levels but the raMUNnation can be taken with no dose a-Syoslment.
•    If didanosine (SWpat 01 a darunavir + ritonavir treatment pro~ram, it must be taken on an empty stomach, 1 hour before or 2 hours after darunavir + ritonavir, which should be taken with food.
•    Darunavir increases blood levels of clarithromycin, itraconazole, and ketoconazole. Daily dosage of itraconazole and ketoconazole should not exceed 200 mg. No clarithromycin
Possible Side Effects (continued)
♦    Less common:    abdominalinal pain, and
♦    Rare: Rare side effects can occur in almost any part
body. Contact your doctor if you
ou experience any side ef
fect not listed above.
adjustment is necessary in people with normal kidney function.    the Darunavir + ritonavir may reduce vonconazole levels in t e
blood. Do not mix these medicines.
•    Darunavir + ritonavir can increase rifabutin levels in the blood-
stream. Rifabutin can also reduce darunavir levels in the
bloodstream. If rifabutin is mixed with darunavir + ritonavir,
the rifabutin dose should be 150 mg every other day.
•    Caution should be exercised when combining darunavir + ritonavir with calcium channel blockers such as felodipine, nifedipine, and nicardipine.
•    Darunavir increases blood levels of the heart antiarrhythmic drugs bepridil, lidocaine, and quinidine. These drugs should be used together with caution and only in situations where blood levels of the heart drugs can be monitored regularly.
•    Darunavir + ritonavir can reduce blood levels of warfarin. It is necessary to monitor warfarin levels while taking this combination.
•    Darunavir + ritonavir can raise blood levels of the tricyclic antidepressant desipramine and the tetracyclic antidepressant trazodone. Dosage reduction is recommended.
•    Darunavir + ritonavir may reduce blood levels of the SSRI antidepressants sertraline and paroxetine. SSRI doses may have to be increased to account for this effect.
•    Darunavir + ritonavir can drastically increase the blood levels of some statin-type cholesterol-lowering drugs, substantially increasing the risk of statin side effects. Simvastatin, pravastatin, and lovastatin should not be mixed with darunavir + ritonavir. It is also possible to take darunavir + ritonavir with atorvastatin, although it can increase the level of atorvastatin in the bloodstream. If atorvastatin is prescribed, it is best to begin with 10 mg a day and slowly increase the dose as necessary. Little is known about how darunavir + ritonavir affects rosuvastatin. The safest statin to take with darunavir + ritonavir is fluvastak”.
•    Darunavir + ritonaxk Can increase blood levels of inhaled MT lCosteroids dexamethasone and fluticasone, the anti-rejection drugs cyclosporine, tacrolimus, and sirolimus. The corticosteroids reduce darunavir blood levels, interfering with its effectiveness.
•    Darunavir + ritonavir can reduce methadone levels in the bloodstream. Methadone dose adjustment may be needed.
•    Darunavir + ritonavir reduces the effectiveness of some contraceptive drugs by decreasing the amount of the hormones ethinyl estradiol and norethindrone in the bloodstream. Women mixing these medicines should use additional contraceptive measures (e.g., condoms).
•    Protease inhibitors may drastically increase blood levels of erectile dysfunction drugs sildenafil, vardenafil, and tadalafil, increasing the risk of side effects including low blood pressure, visual changes, and persistent, painful erection.
•    Dexamethasone may reduce blood levels of darunavir.
Food Interactions
Take darunavir with food. The amount of darunavir absorbed into the blood is vastly reduced when it is taken on an empty stomach, thus negating its antiviral effects.
Usual Dose
Adult: 600 mg (2 300-mg tablets) with 1 00 mg ritonavir twice a day. Do not chew these tablets.
Child: not recommended.
Overdosage
Little is known about the effects of darunavir overdose, but 3200 mg of darunavir has been given to study volunteers with no adverse effects. Call your local poison center or hospital emergency room for more information. If you take the victim to a hospital emergency room, ALWAYS bring the prescription bottle or container.
Special Information
Darunavir is not a cure for HIV. It will not prevent you from transmitting the HIV virus to another person; you must still practice safe sex. You may still develop opportunistic infections or other complications associated with advanced HIV disease.
The long-term effects of this drug are not known.
It is imperative for you to take this medication exactly according to your doctor’s instructions. Do not skip any doses. Skipping doses of darunavir increases the risk that you will become resistant k,3 ft drug. If you forget a dose of darunavir or ritonavir and remember within 6 hours, take it as soon as you remember and then continue with your regular schedule. If 6 hours have passed since the time when you should have taken your medicine, skip the forgotten dose and take your next dose at the regular time. Do not take a double dose.
Special populations
Pregnancy/Breast-feeding: Animal studies with darunavir reveal no damage to the fetus, but there are no data on how this drug affects pregnant women. Darunavir should only be used during pregnancy after carefully weighing its potential benefits against its risks.
It is not known if darunavir passes into breast milk. Nursing mothers with HIV should use infant formula, regardless of whether they take this drug, to avoid transmitting the virus.
Seniors: Seniors can take this drug without special precaution.

Generic Name
Clemastine (KLEH-mas-tene) A
Brand Names
DayHist-1    Tavist-1
Tavist    Tavist Allergy
Combination Pr(3dUtj
Generic Ingredients: Acetaminophen + Clemastine + Pseudoephedrine
Tavist Allergy/Sinus/Headache
Type of Drug  Antihistamine.
Prescribed For
Sneezing, stuffy and runny nose, itchy eyes, and scratchy throat caused by seasonal allergies and for other symptoms of allergies such as rash, itching, and hives.
General Information
Antihistamines generally work by blocking the release of naturally occuring histamine (a chemical released by body tissue during an allergic reaction) from cells at the H, histamine receptor site, drying up secretions of the nose, throat, and eyes. Clemastine fumarate is less sedating than most antihistamines, but not less sedating than astemizole, cetirizine, or loratadine.
Cautions and Warnings
Clemastine should not be taken if you are allergic or sensitive to any of its ingredients.
People with asthma or other deep-breathing problems, heart disease, high blood pressure, diabetes, enlarged prostate, glaucoma, stomach ulcers or other stomach problems, and hyperthyroidism should use clemastine with caution because its side effects can aggravate these problems.
Possible Side Effects
✓    Most common: drowsiness; headache; weakness; nervousness; stomach upset; nausea; vomiting; cough; stuffy nose; diarrhea; constipation; sore throat; nosebleeds; and dry mouth, nose, or throat.
✓    Less common: allergic reaction (symptoms include rash, itching, hives, and breathing difficulties), sleeplessness, menstrual irregularities, muscle aches, sweating, tingling in the hands or feet, frequent urination, visual disturbances, and ringing or buzzing in the ears.
Drug Interactions
•    Cbrnbining clemastine with alcohol, sedatives, sleeping pills, or other nervous system depressants may increase the depressant effects of clemastine. Do not combine these drugs.
•    The effects of oral anticoagulant (blood-thinning) drugs may be decreased by clemastine. Do not take this combination without your doctor’s knowledge.
Monoamine oxidase inhibitor antidepressants may increase the drying and other effects of clemastine. This combination can also worsen urinary difficulties.
e When taking antihistamines on a regular basis, notify your doctor if you are taking large amounts of aspirin. Effects of too much aspirin may be masked by the antihistamine.
Food Interactions
Clemastine is best taken on an empty stomach at least 1 hour before or 2 hours after eating; it may be taken with food if it upsets your stomach.
Usual Dose
Adult and Child (age 12 and over): 1.34 mg twice a day up to 8.04 mg of the syrup or 2.68 mg of the tablets in 24 hours.
Child (age 6-12) (syrup only): 0.67 mg twice a day or up to 4.02 mg a day.
Overdosage
Overdose is likely to cause severe side effects. Overdose victims should be given ipecac syrup—available at any pharmacy—to induce vomiting and should then be taken to a hospital emergency room for treatment. ALWAYS bring the prescription bottle or container.
Special Information
Clemastine may make it difficult for you to concentrate or perform complex tasks such as driving a car. Be sure to report any unusual side effects to your doctor
Antihistamines may occasionally produce excitability, particularly in children.
If you forget to take a dose of clemastine, take it as soon as you remember. If it is almost time for your next dose, skip the one you forgot and continue with your regular schedule. Do not take a double dose.
Special Populations
PregnancylBreast-feedj(IV. DO not take any antihistamines without WU ‘Obtlor’s knowledge if you are or might be pregnant—especially during the last 3 months of pregnancy, because newborns may have severe reactions to antihistamines.
Small amounts of clemastine pass into breast milk. Nursing mothers who must take clemastine should use infant formula.
Seniors: Seniors are more sensitive to side effects.

Generic Name
Clindamycin (klin-duh-MYE-sin)
Brand Names
Cleocin    Clindesse
Cleocin T    Clindets
Clinda-Derm    Evoclin Clindagel
Type of Drug  Antibiotic.
Prescribed For
Serious bacterial infections. The vaginal cream is used to treat bacterial vaginosis. Topical clindamycin is used to treat acne and rosacea.
General Information
Clindamycin is one of the few oral drugs that is effective against anaerobic bacteria, which grow only in the absence of oxygen and are often found in infected wounds, lung abscesses, abdominal infections, and infections of the female genital tract. It also works against bacteria usually treated with penicillin or erythromycin, including serious respiratory tract infections. Clindamycin may be useful for treating certain skin or soft tissue infections. It kills the bacteria that frequently cause acne.
Clindamycin is not used to treat vaginal fungus or yeast infections.
Cautions and Warnings
Do not take clindamycin if you are allergic or sensitive to any of its ingredients or to lincomycin, another antibiotic.
People with asthma or a history of allergies should use clindamycin capsules with caution.
Clindamycin can cause a severe intestina(kmkation called colitis, which can be fatal. Signs of colitis are diarrhea, blood in the Stool, and abdominal cramps. Any form of this drug, including products applied to the skin and the vaginal cream, can provoke colitis. Because of this, clindamycin should be reserved for serious infections or those that cannot be treated with other drugs.
Clindamycin should be used with caution if you have gastrointestinal disease or kidney or liver disease.
Possible Side Effects
Capsules
✓    Most common: stomach pain; nausea-, vomiting-, diarrhea,
in up to 20% of people; and pain when swallowing.
♦    Less common: itching; rash; signs of serious drug sensitivity, such as difficulties breathing and yellowing of the skin or the whites of the eyes; colitis, (see “Cautions and Warnings”); effects on blood components; and joint pain.
Topical Lotion
♦    Most common: dry skin, redness, burning, peeling, oily skin, and itching.
♦    Less common: diarrhea, abdominal pain, upset stomach, and colitis (see “Cautions and Warnings”).
Vaginal Cream
♦    Most common: vaginal itching or irritation; thick, white vaginal discharge; and pain during intercourse.
♦    Less common: nausea, vomiting, diarrhea, constipation, abdominal pain, dizziness, headache, vertigo, and colitis (see “Cautions and Warnings”).
Drug Interactions
•    Do not combine clindamycin and erythromycin.
•    The absorption of clindamycin capsules into the bloodstream is delayed by Kaolin-Pectin Suspension (prescribed for diarrhea). Separate these drugs by at least 1 hour.
•    clindamycin should be used with caution by people also using neuromuscular agents.
Food Interactions
Take the oral medication with a full glass of water or with food to prevent irritation of the stomach and intestine.
Usual Dose
Capsules
MUIV ) 50-450 mg every 6 hours.
Child (under age 16): 3.5-11 mg per lb. of body weight a day, in 3-4 doses. For severe infections, at least 37.5 mg 3 times a day, regardless of weight.
Foam: Dispense enough to cover the affected area(s) onto a cool surface (the foam will melt on contact with warm skin). Use fin-gertips to massage small amounts into the affected area(s) until the foam disappears.
Suppositories: Insert 1 suppository a day for 3 consecutive days.
Topical Lotion: Wash the skin and pat dry before application. Apply enough to cover the affected area(s) with a thin coat twice a day.
Vaginal Cream: Insert 1 applicator’s worth at bedtime for 7 consecutive days, except for Clindesse, which requires one applicator’s worth once at any time of day.
Overdosage
clindamycin overdose may lead to severe diarrhea and other drug side effects. Do not treat this diarrhea on your own. Discontinue use of this drug and call your local poison center for information. If you go to an emergency room for treatment, ALWAYS bring the prescription bottle or container.
Special Information
Prolonged or unsupervised use of clindamycin may lead to secondary infections from susceptible organisms. such as fungi. Take this drug for the full course of therapy as indicated by your physician.
If you develop severe diarrhea or abdominal pain, call your doctor at once. Call your doctor immediately if you experience breathing difficulties or jaundice (yellowing of the skin or whites of the eyes).
Women using the vaginal cream should not have vaginal intercourse or use other vaginal products such as tampons or douches until treatment is complete.
Use of latex condoms or diaphragms within 72 hours following treatment with the vaginal creams or suppositories is not recommended. These products may decrease the efficacy of condoms or diaphragms.
The topical lotion is for external use only. Avoid contact with your eyes or mucous membranes.
If you miss a dose of oral clindamycin, take it as soon as you rememlae~. SSW19 almost time for your next dose of clindamycin, double that dose and go back to your regular dosage schedule.
Special Populations
Pregnancy/Breast-feeding: This drug crosses into fetal blood circulation. When the drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
clindamycin passes into breast milk. Nursing mothers who must take oral clindamycin should use infant formula.
Seniors: Seniors with other illnesses may be unable to tolerate diarrhea and other clindamycin side effects.

Generic Name
Clonazepam (klon-A-zeh-pam)
Brand Name  Klonopin
Type of Drug  Anticonvulsant.
Prescribed For
Petit mal and other seizures and panic attacks; also prescribed for periodic leg movements during sleep, speaking difficulty associated with Parkinson’s disease, acute manic episodes, nerve pain, and schizophrenia.
General Information
Clonazepam is a benzodiazepine drug. Clonazepam is not used as a sedative or hypnotic. It is used only for the uses described above in people who have not responded to other drug treatments. Tolerance to the effects of clonazepam commonly develops within about 3 months of use. Your doctor may raise your clonazepam dosage periodically to maintain the drug’s effect.
Cautions and Warnings
Do not take clonazepam if you are allergic or sensitive to any of its ingredients or any other benzodiazepine.
When stopping clonazepam treatments, the drug must be discontinued gradually. Abrupt discontinuance of clonazepam may lead to drug withdrawal symptoms including severe seizures, tremors, abdominal or muscle cramps, vomiting, whet increased sweating.
IJSIF,l OfMazeparn with caution if you have a chronic respiratory illness, since the drug tends to increase salivation and other respiratory secretions and can make breathing more labored.
Avoid using clonazepam if you have severe depression, severe lung disease, sleep apnea (intermittent cessation of breathing during sleep), liver disease, alcoholism, or kidney disease. These conditions may exacerbate the depressive effects of benzodiazepines, and such effects may be detrimental to your overall
condition.
Clonazepam can aggravate narrow-angle glaucoma, but if you have open-angle glaucoma, you may take it.
Possible Side Effects
♦    Most common: drowsiness, poor muscle control, and behavioral changes.
✓    Rare: Rare side effects can occur in almost any part of the body but are most likely to affect mental function, stomach and intestines, urinary function, blood, and liver. Contact your doctor if you experience any side effect not listed above.
Drug Interactions
•    The depressant effects of clonazepam are increased by sedatives, sleeping pills, narcotic pain relievers, antihistamines, alcohol, monoamine oxidase inhibitor antidepressants, tricyclic antidepressants, and other anticonvulsants.
•    Mixing valproic acid and clonazepam may produce severe petit mal seizures.
•    Smoking, phenobarbital, phenytoin, carbamazapine, and rifampin may reduce clonazepam’s effectiveness.
•    Clonazepam may increase the requirement for other anticonvulsant drugs in people who suffer from multiple types of seizures.
•    The effects of clonazepam may be prolonged when it is taken with cimetidine, contraceptive drugs, disulfiram, fluvoxamine, isoniazid, oral antifungal medications (e.g. ketoconazole), metoprolol, probenecid, propoxyphene, or propranolol.
•    Theophylline may reduce clonazepam’s sedative effects.
•    Separate antacids from y<3kwc_%1Dnazepam dose by at least 1 bZldi %prevent them from interfering with clonazepam being absorbed into the bloodstream.
•    Clonazepam may increase blood levels of digoxin and the risk of digoxin toxicity.
•    Clonazepam may decrease the effect of levodopa + carbidopa.
Food Interactions
Clonazepam is best taken on an empty stomach but may be taken with food if it upsets your stomach.
Usual Dose
Clonazepam is available in either tablets or orally disintegrating tablets, called wafers. Wafers should not be opened until immediately before the dose is to be taken. Do not push the wafer through the foil. Use dry hands to remove the wafer. The wafer will disintegrate quickly in saliva.
Seizures
Adult and Child (age 10 and over): starting dose    0.5 mg 3 times a day. The dose is increased by 0.5-1 mg every 3 days until seizures are controlled or side effects develop. The maximum daily dose is 20 mg.
Panic attacks
Adult and Child (age 10 and over): starting dose-0.25 mg twice daily. The dose is increased to 1 mg a day after 3 days. Most people do not require a higher dose.
Child (under age 10 or below 66 Ms.): starting dose-0.0220.066 mg per lb. of body weight a day in divided doses. Dosage can be increased gradually to a daily dose of 0.22-0.44 mg per lb. of body weight.
Other uses for clonazepam involve doses from 0.5-16 mg a day, depending on the condition and its severity. Clonazepam dosage must be reduced in people with impaired kidney function.
Overdosage
Overdose may cause confusion, coma, poor reflexes, sleepiness, low blood pressure, labored breathing, and other depressive effects. If the overdose is discovered within a few minutes and the victim is still conscious, it may be helpful to induce vomiting with ipecac syrup—available at any pharmacy. Overdose victims must be taken to a hospital emergency room. ALWAYS bring the prescription bottle or contai”iaT.
Special Information
Clonazepam may interfere with your ability to drive or perform other complex tasks because it can cause drowsiness and difficulty in concentrating.
Your doctor should perform periodic blood counts and liver function tests while you are taking this drug to check for possible
side effects.
Do not suddenly stop taking clonazepam—severe seizures may result. The dosage must be discontinued gradually by your doctor.
If you miss a dose by 1 hour or less, take it right away. Otherwise, skip the dose you forgot and go back to your regular schedule. Do not take a double dose.
Carry identification or wear a bracelet indicating that you have a seizure disorder for which you take clonazepam.
Special Populations
Pregnancy/Breast-feeding: Clonazepam crosses into the fetal circulation and can affect the fetus. Women who are or might be pregnant should avoid it. When the drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
Some reports suggest a strong link between anticonvulsant drugs and birth defects, though most of the information pertains to phenytoin and phenobarbital, not clonazepam. It is also possible that the epileptic condition itself or genetic factors common to people with seizure disorders may figure in the higher incidence of birth defects.
Clonazepam may pass into breast milk. Nursing mothers who must take this drug should use infant formula.
Seniors: Seniors, especially those with liver or kidney disease, are more sensitive to the effects of this drug—especially dizziness and drowsiness—and may require smaller doses.

Celecoxib (sel-eh-KOX-ib)
Brand Name
Celebrex
Type of Drug
Cyclooxygenase-2 (COX-2) inhibitor nonsteroidal anti-inflammatory
drug (NSAID).
Prescribed For
Osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, acute pain, some colon polyps (FAR), menstrual pain, and arthritis of the spine (ankylosing spondylitis).
General Information
Traditional NSAIDs work primarily by blocking the effects of COX-2, a body enzyme that plays an important role in regulating pain and inflammation. But these NSAIDs also have an unwanted effect: They interfere with cyclooxygenase-1 (COX-1), a related enzyme that helps to maintain the stomach’s protective lining. NSAIDs that block the effects of this enzyme may produce side effects such as stomach irritation, gas, and stomach ulcers.
COX-2 inhibitors such as celecoxib are a class of NSAIDs that work about as well as the older NSAIDs. In fact, both 200 mg a day and 400 mg a day of celecoxib work as well as naproxen 500 mg twice a day. They interfere primarily with COX-2, leaving the stomach-protecting COX-1 relatively unaffected. This means that COX-2 inhibitor NSAIDs can relieve pain and inflammation just like traditional NSAIDs but are less likely to cause gastrointestinal (GI) side effects. Another advantage of celecoxib is that it does not cause thinning of the blood or affect blood platelets as can happen with older NSAIDs. Celecoxib is broken down in the liver.
Black patients absorb about 40% more celecoxib than Caucasians; its importance is unclear. Celecoxib is the first drug proven effective in reducing the number of intestinal polyps in people with the rare genetic disorder FAR
Cautions and Warnings
Do not take celecoxib if you are allergic or sensitive to any of its ingredients or to sulfa drugs. NSAIDs should not be taken by people with asthma or by those who have had a” allergic reaction to aspirin or another NSA13.1hey can develop a group of sympWMS V1Jnny nose with or without nasal polyps and a severe bronchial spasm) known as the aspirin triad.
COX-2 inhibitors, including celecoxib, have been associated with high blood pressure, kidney damage, heart attacks, and stroke. It should not be used to treat pain associated with heart bypass surgery. Two other COX-2 inhibitors were taken off the market because of safety concerns. Rofecoxib was removed because safety issues were noted after people had taken it for 18 months or more. Valdecoxib was taken off the market because of the lack of safety data, severe skin rashes, and concerns raised in people taking the drug after having had heart surgery.
NSAIDs can cause GI bleeding and ulcers and stomach perforation. This can occur at any time, with or without warning, in people who take NSAIDs regularly. Celecoxib should be used with caution by people who have had stomach ulcers or GI bleeding. Minor upper GI problems, such as upset stomach, are common and may occur at any time during NSAID therapy. People who develop bleeding or ulcers and continue NSAID treatment should be aware of the risk of developing more serious side effects. Risk of GI bleeding and ulcers is increased with longer duration of therapy as well as treatment with oral corticosteroids and anticoagulants, smoking, alcoholism, older age, and general poor health.
Children taking celecoxib may be more likely to vomit blood, suffer acute kidney failure, or develop rashes.
Celecoxib has not been studied in people with severe kidney disease. They should not use this drug unless their doctors closely monitor their kidney function.
Celecoxib can cause liver irritation and should be used with caution by people with hepatitis or cirrhosis. People with moderate liver disease can have twice as much celecoxib in their blood and require a reduced dosage. The effect of celecoxib in people with severe liver failure is not known.
Possible Side Effects
Side effects are similar to those of traditional NSAIDs. Stomach and intestinal side effects are about half as common.
♦    Most common: headache.
✓    Common: diarrhea, upset stomach, sinus irritation, and respiratory infection.
♦    Less common: abdominal pain, gas, nausea, back pain, swelling in the legs m arms, accidental injuries, sleeplessness, dizziness, sore throat, runny nose, and rash.
✓    Rare: Rare side effects can occur in almost any part of the body. Contact your doctor if you experience any side effect not listed above.
Drug Interactions
•    Alcohol may increase the risk of serious GI-related side ef-
fects. Avoid alcohol.
•    Combining celecoxib with an aluminum and magnesium antacid slightly reduces the amount of drug absorbed. Separate doses of these antacids and celecoxib by 1-2 hours.
•    Fluconazole and lithium may raise celecoxib blood levels and increase the risk of side effects.
•    While celecoxib may be combined with low dosages of as-
pirin, taking these drugs together can increase the risk of
stomach or intestinal ulcers or other complications. The ulcer
risk associated with this combination is less than that posed
by single-drug therapy with a traditional NSAID.
•    Celecoxib can reduce the blood-pressure-lowering effect of angiotensin-converting enzyme (ACE) inhibitors and diuretic drugs. This combination can also increase the risk of kidney damage after chronic celecoxib use.
•    Celecoxib may affect lithium blood levels.
•    NSAIDS can reduce the effect of furosemide and thiazidetype diuretics.
•    Celecoxib should be used cautiously with warfarin. Concurrent use of these drugs may cause an increased risk of bleeding complications.
Food Interactions
Celecoxib can be taken without regard to Food or meals. For optimal effectiveness, avoid taking this drug with high-fat meals.
Usual Dose
Adult (age 18 and over): arthritis-100-200 mg once or twice a day. FAP-400 mg twice a day.
Child (age 2 and over): juvenile rheumatoid arthritis-22-55 lbs: 50 mg twice a day; over 55 lbs: 100 mg twice a day.
Child (under age 2): not recommended.
Overdosage
Overdosage symptoms include Mnargy, drowsiness, nausea, vomitiR(;, 16M Stomach pain. Stomach or intestinal bleeding or severe allergic reactions can occur. High blood pressure, kidney failure, breathing difficulties, and coma are rare.
The victim should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Call your doctor if you develop rash, itching, unexplained weight gain, nausea, fatigue, jaundice (yellowing of the skin or whites of the eyes), flu-like symptoms, lethargy, swelling, black stools, severe stomach pain, persistent headache, or any bothersome or persistent side effect.
If you forget a dose and remember within 1 or 2 hours of your scheduled time, take it right away. If you do not remember until later, skip the forgotten dose and continue with your regular schedule.
Special Populations
Pregnancy/Breast-feeding: celecoxib has caused birth defects in animal studies. Any NSAID may affect fetal heart development during the second half of pregnancy. Pregnant women should not take celecoxib without their doctor’s approval. When this drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
NSAIDs may pass into breast milk. There is a possibility that a nursing mother taking celecoxib could affect her baby’s heart or cardiovascular system. Nursing mothers who must take this drug should use infant formula.
Seniors: Generally, seniors can take this drug without special precaution. Those who weigh less than 110 lbs. should begin with the lowest possible dosage.

FENUGREEK
Fenugreek is a seed used to spice Indian food compare diovan and cozaar . It has also been used in traditional medicine to treat symptoms that indicate diabetes saturday delivery tramadol . Studies done in humans suggest that it can be used in
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type 1 as as type 2 diabetes in addition to,prescribed medi-
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G atenolol personality changes . I found a spice in my spice rack that I had never heard of, and I had no instructions on how to use it lack of response to furosemide . I looked up fenugreek as a spice and found that it is a medicinal herb celebrex chemotherapy colon cancer .
It is used to lower cholesterol and control blood sugar provera for bodybuilders . The only side effect I found is nausea if you take too much specific heat lithium . What do you know about this herb? -
A adderall and selegiline together . Studies in animals and humans show that fenugreek can lower cholesterol and blood sugar methyl prednisone acetate . If diabetics take fenugreek, they should monitor their blood sugar to make sure it doesn’t fall too much xeno lithium .
Fenugreek seeds are rich in soluble fiber and can be used to treat constipation paroxetine heart rate . At high doses, this herb can cause digestive distress evista floaters in eyes .
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GYMNEMA SYLVESTRE
This herb comes from India and has been used in traditional Ayurvedic medicine for centuries ms avoiding caffeine . Animal studies have demonstrated that it is capable of lowering blood sugar viagra lasting .”‘ No serious side effects have been reported, but perhaps the scarcity of well-controlled clinical trials explains that to some extent canadian pharmacy bupropion .
NOPAL (Opuntia sp caffeine in tea bags .)
One interesting botanical treatment has only a little bit of research to support it, but it is becoming increasingly popu-far viagra photo woman . We heard several years ago from a physician who said one of his diabetic patients had improved his blood sugar control with prickly pear tea side effects of stopping tamoxifen . This cactus, called nopal in Mexico, has been studied primarily in animals beta celexa citalopram interferon lyrica pregabalin . That research indicates that the cactus can help lower blood sugar fosinopril solium . 252,253 Research in humans is preliminary, but it suggests that nopal may also be useful in helping to control blood sugar in type 2 diabetes united states wellbutrin bupropion hcl . 254 Close monitoring and medical supervision are advised zithromax ear book .
lama family practitioner and want to share an herbal remedy with you allopurinol and blood pressure . A 60-year-old male Hispanic diabetic patient has had trouble controlling his blood sugar ovulation pain with clomid . Despite intensive diet changes and a prescription for Glucovance, his blood sugar still ran around 160 to 100-plus testosterone treatment and prostate cancer .
One day he came in with his diary showing consistent blood sugars of 90 to 100 fexofenadine solubility in isopropylalcohol . I asked what he was doing differently and he said in a low voice, “I’ve got a new girlfriend from Mexico online fexofenadine . She makes me tea from nopalito [prickly pear> cactus and has me drink it three times a day advil motrin recalls . Now my sugars are doing better buy celecoxib low cost . -
Finding fresh nopal cactus outside of Mexico or the desert of the southwestern United States could be tricky loratadine 180 . When we shared the story about nopalito tea (nopalito is a young stem segment from the cactus), we were inundated with questions from readers who wanted to know how they could get some nopal cactus leaves does prednisone cause sterility . Short of moving, you might try looking for this natural plant product in your local health-food store (or on the Web) voltaren info . Although it is unlikely you will find fresh leaves, you will be able to locate capsules labeled prickly pear cactus (Opuntia) or nopal cactus avandia zantac .
Careful blood sugar monitoring is essential age testosterone . One reader who blended cactus with apple juice kept careful track of his cholesterol levels, triglycerides, and glucose bladder infection ibuprofen . In 6 months, his triglycerides dropped from 191 to 139 and his total cholesterol went from 202 to 169 web md doxepin . More interesting, his blood glucose drifted down as well seafood allergies and atrovent . Here is his account:
I read your article about nopalito tea, so I started using cactus in April and had good results what’s the main resources of caffeine . My doctor knows about it zithromax for oral suspension . I blend one bag of cactus and 3 112 cups of apple juice into a drinkable liquid effexor memory . I drink 4 ounces three times a day mens viagra . Here are my results why is caffeine bad in pregnancy .
Blood Glucose (average)
Jan 147 no cactus
Feb 143 no cactus
Mar 158 no cactus
Apr 142 with cactus
May 132 with cactus
Jun 126 with cactus
Jul 135 with cactus
Aug 128 with cactus
I write down every food I eat every day and take my test every morning and keep a record of it natural alternative to caffeine . I can see which food does what, and I take my medicine as always and my doctor has been kept informed battery lithium watch .
This gentleman is the poster child for responsible blood sugar control doxycycline burns treatment . Not only is he tracking his sugar levels carefully, he is also working closely with his physician to make sure what he does is safe and effective amsterdam nederlands sildenafil .
STEVIA
Stevia (Stevia rebaudiana) is a nonsugar sweetener derived from the leaves of a South American shrub phenytoin effects lab values . It is not approved as a sugar substitute in the United States but is frequently used in Japan didanosine causing lipoatrophy . Some preliminary research suggests that using stevia instead of sugar might have a benefit beyond simply not consuming sugar on levoxyl but still having symtoms . A small study in Brazil found that stevia tea could improve glucose tolerance in nondiabetic individuals simvastatin 80mg tablet . 255 The plant can also lower blood pressure celexa twice normal dose . No significant toxicity has been reported do cardiologists order toradol .
Stevia is a natural sugar substitute fosinopril side effects . In addition to sweetening food and drinks without raising blood sugar, stevia may be capable of improving glucose tolerance 1 2 aa lithium 3.6v battery . Be sure to monitor your blood sugar when adding this sweetener to a medication regimen automobile lithium ion battery .
Downside: In laboratory tests, high doses of stevia interfered with animals’ reproduction ketorolac pediatric .
Cost: Approximately 10 or 20 per serving Easing Stress
There is a direct connection between your level of stress and your blood sugar paroxetine and . For someone without diabetes, this is probably no big deal, unless you are always under stress warfarin metallic taste . But for a diabetic, anxiety, fear, depression, and emotional pressure will boost blood sugar and make the condition harder to control lyrics for lithium .211,2″ Giving a speech, having a fight with your partner, or going in for your annual performance review at work can all affect your stress level and your blood sugar singulair and weight loss . Doctors often look at diet, exercise, and other physical factors ibuprofen crush . They are less likely to consider emotions, even though they have such a profound impact on a diabetic’s health novartis v pfizer zithromax .
How can a diabetic learn how to manage stress successfully? There is no cookie-cutter answer to this question is cipro sulfa based . Everyone handles stress differently phenergan sudaphed contraindication . For some, the only effective strategy might be to quit a highly demanding job and move to a cave decadron for oral surgery . Doing that would stress others out even more preparation of ethinyl estradiol . Finding the right approach may take trial and error xenical caps orlistat roche .
Avoiding people who make your hands cold is a good place to start hartford zyprexa attorneys . Buy a mood ring (a relic of the 1970s) aluminum lithium etchant . It reacts to skin temperature viagra side effects diarrhea . Whenever your hands get cold as a response to stress, you should do something different from your current activity to warm them up decadron contain only t4 . Relaxation tapes can be helpful if you can carve out time to listen lithium arizona . Our favorites are by Emmett Miller, MD chemical composition of neuronal soma . Dr felodipine reaction . Miller has been in this business a long time and has a soothing voice 7 day doxycycline symptoms disappear . We guarantee that if you listen to his Letting Go of Stress, you will be more relaxed afterward viagra levitra cialis comparison .
Some people may benefit from individual psychological counseling or biofeedback training to learn to cope with stress prednisolone hot flashes . But others may be able to find a group that is learning stress management techniques accutane colitis . 251 If you need a guide to doing it yourself, we suggest you look for a copy of Richard Surwit’s book, The Mind-Body Diabetes Revolution requip and compulsive gambling . It has some good
DR what does bactrim treat . MILLER’S SOOTHING SOUNDS
To purchase Dr metformin 500 571 . Miller’s CDs or tapes, you can visit his Web site, www topical oinment chloramphenicol .DrMiller methotrexate how long .com, or call 800-52-TAPES omnicef stomach . Letting Go of Stress or the Ten-Minute Stress Manager is a good starting place celebrex docing information .
tips on learning to relax and overcome stress as well as background on the importance of psychological issues in diabetes citalopram hydrobromide capsules .
When all else fails, an antianxiety agent can be surprisingly effective at controlling blood sugar in the short term remeron childrens studies . If, for example, you know that traveling makes you anxious and throws your blood sugar out of kilter, you may want to ask your doctor whether a short course of diazepam (Valium), alprazolam (Xanax), or some similar medicine might help you deal with the hassle of travel no prescription claritin .259 Such drugs can be habit-forming, however, so relying on them for long periods of time is not desirable veetids expire .
Depression also has a major impact on diabetes and messes up efforts to keep blood sugar where it should’be information about nexium . Everything feels much harder to manage when you’re down in the dumps, and your attention to exercise, diet, medication, and self-care may well suffer viagra doseages effects . Changes in brain biochemistry associated with depression might also contribute directly to a higher risk of diabetes complications lithium battery explosions . MO Blood clots leading to heart attacks or strokes are more likely when diabetics are depressed; so are irregular heart rhythms and inflammation methotrexate factoids . It’s just as crucial for a diabetic to be evaluated regularly for depression, and to get treatment when it is needed, as it is for her to get regular eye exams and foot care prostatitis and flomax .
Pills to Lower Blood Sugar
Quite often, diet and exercise alone are not enough to control blood sugar glyburide 2 mg . There is a bewildering array of medicine the doctor may prescribe: metformin, which also is dispensed under the brand name Glucophage; medicine with “glitazone” in the generic name, like pioglitazone (Actor); and old-fashioned blood sugar—lowering drugs similar to chlorpropamide or tolazamide, or their newer cousins glyburide (Micronase), glimepiride (Amaryl), or glipizide (Glucotrol) zoloft causing cardiac arrythmias . Newer drugs that stimulate insulin secretion, called nateglinide (Starlix) and repaglinide (Prandin), might be used instead of one of the older blood sugar—lowering drugs levaquin diflucan interactions . Eventually, if blood sugar and glycosylated hemoglobin can’t be brought down to acceptable levels, even type 2 diabetics may end up using insulin bacterial vaginosis flagyl did not work . But it usually makes sense to try oral medicines first metaloproteinase cipro .
It is difficult to tell which of these pills would work best for any given patient hold dose metoprolol . As with everything else pertaining to diabetes, people vary in their responses salbutamol and hyperstimulation . Some do well on a single drug, while others need a complicated regimen class action lawsuits against provera . Only you and your doctor can determine which medication(s) are likely to be safest and most effective for you amoxicillin dental work .
To try to sort out the patterns and give doctors some guidance, scientists at Kaiser Permanents, an enormous HMO in northern California, reviewed the organization’s vast database efficacit gel testosterone 50mg j . First they created a registry of the diabetic patients, and then they examined the data to see which drugs were most effective over time male devo provera . Even though most patients are started on one of the medicines like chlorpropamide or glyburide, this was the least effective treatment for getting HbAl down to
target personal experiences of people on wellbutrin .261
The most effective treatment was triple therapy: a
“glitazone”-type drug in combination with metformin and a drug like glyburide onset action lamictal days . Next best after that was metformin together with insulin pepcid indication gi protect .
One of the most interesting features of the Kaiser Permanents study was that patient behavior could be used to predict success, aside from the drug used hydroxyzine helps withdrawls of opium . Patients who monitored their blood sugar frequently and those who kept all or nearly all of their appointments were significantly more likely to get their blood sugar under control and keep it there clomipramine hcl tablets and alcohol . 262 Making sure that you are on top of your diabetes treatment, taking your medication, monitoring your blood sugar, keeping track of HbA, following a sensible diet and exercise regimen, and controlling your weight as much as possible may be nearly as important as which drugs your doctor prescribes atomoxetine medication diaes .
Metformin (Glucophage)
A review by the Cochrane Collaboration of most of the world’s diabetes literature shows that metformin (Glucophage) alone, if used to keep blood glucose under tight control, is an excellent treatment inderal la medicine .263 Metformin improves blood sugar control by improving the cells’ response to insulin and reducing the amount of sugar that the liver makes risperidone weight gain . Unlike some other oral diabetes drugs, it doesn’t lead to weight gain and may even help people get their weight under control amitriptyline mylan .
It can be dangerous, however, for people with kidney disease testosterone replacement therapy cycles . They should not take the drug, and everyone on metformin should have their kidney function monitored regularly (at least once a year) altace absorption . People with congestive heart failure should not take metformin, either sulfamethoxazole ds tabitp .
SYMPTOMS OF LACTIC ACIDOSIS
• Muscle aches or weakness
• Shortness of breath
• Stomachache, nausea, or vomiting
• Lethargy or drowsiness
• Irregular heartbeat
• Feeling generally awful
Metformin has two nasty side effects that patients must know about drugs and norvasc . One, lactic acidosis, is rare, but it is a medical emergency if it occurs villa allegra . Lactic acidosis can be lethal estrace homrmone . People with kidney disease or congestive heart failure are more susceptible to this problem, which is why they must not take metformin hormone replacement therapy weight premarin . Otherwise healthy diabetics might also develop lactic acidosis on metformin, especially if they drink alcohol watermellon viagra .
What makes metformin so tricky is that patients frequently experience digestive tract distress when they first start taking this medicine tramadol ships next day apo . Side effects can include diarrhea, nausea, vomiting, indigestion, and stomachache accutane atlanta attorney . After several weeks, however, these side effects should fade away strattera testimonies . If digestive symptoms
*** Metformin (Glucophage)
Metformin improves insulin sensitivity caffeine and hunger . It may control blood sugar alone or be combined with other diabetes drugs to improve blood sugar control attack heart ibuprofen . Common side effects include diarrhea, nausea and vomiting, flatulence, fatigue, indigestion, and headache intas strattera for sale online .
Avoid guar gum in low-fat foods (salad dressing, frozen desserts, etc depo provera transexual drug .), because it reduces metformin’s absorption and effectiveness is prevacid an nsaid .
Downside: Lactic acidosis, a rare reaction, requires emergency medical attention and can be fatal nifedipine ointment preparation .
Cost: Approximately $90 to $120 per month; generic $65 to $100
recur, they must be brought to the doctor’s attention immediately since they might be symptoms of lactic acidosis ct scan heart and lopressor .
The other side effect is depletion of vitamin B12 snorting bupropion . Because this vitamin is stored in the body, the depletion is gradual and the symptoms either may not be noticed or may be attributed to some other cause can lovastatin subscriptions cause cough . The physician should test for methylinaIonic acid (MMA) as well as for vitamin B,2 levels compare kytril and zofran . Fortunately, it is easy to treat vitamin B12 deficiency with supplements birth defect imuran . The vitamin does not need to be injected in such cases; oral supplements of around 1 milligram daily (a large dose of vitamin B12) will work prednisone before surgery . Do check with your doctor to find out if this is appropriate for you sten testosterone .
I am a retired physician with type 2 diabetes metoclopramide and dialysis . Metformin has kept my blood sugar in the normal range for 10 years malassezia ketoconazole dog . Despite good control of my blood glucose and glycosylated hemoglobin, my foot numbness was getting worse warfarin back pain . I was also a tilde unsteady on my feet though it was very subtle flomax pseudoephedrine .
I reviewed the medical literature and discovered that metformin interferes with vitamin B1, absorption fertility insemination estrace uterine lining . I suspected I might be deficient in this vitamin, and I started taking oral vitamin B,
Within a week, I noticed that my mental capacity was sharper combivir and other antivirals . I had not realized before this that I was having any cognitive problems new england journal of medicine lipitor . I stopped having any trouble walking, and my foot numbness has decreased effects effexor alcohol .
Many older diabetics take metformin doxycycline cellulitis . ff they developed subtle neurological and mental deficits as a result of lack of vitamin B,, these problems could be treated but may well be overlooked zoloft vs xanax .
Pioglitazone (Actos)
Pioglitazone (Actos) is a newer diabetes medicine that increases insulin sensitivity and decreases insulin resistance aldactone for treating acne . These actions reduce the amount of insulin in the bloodstream and should lower HbAl rash from paxil . Not only can this medication bring fasting blood sugar down, it can also help control blood sugar levels after meals 1 4 propecia .” In the Kaiser Permanents study mentioned above, drugs in this class were the medications most likely to get HbA,, down to normal range by themselves lithium ion battery car fire .
Actos has received a lot of attention from doctors who specialize in treating diabetes es because it has a favorable im- pact on some blood lipids vytorin side effects muscle pain . It doesn’t seem to do much for Pioglitazone (Actos)
Pioglitazone improves insulin sensitivity’and decreases insulin resistance reference range estradiol . It lowers triglycerides and raises HDL, which might result in a lower risk of cardiovascular problems viagra and reduced ammunity . It is taken once a day escitalopram with titration .
Downside: May interact with oral contraceptives to make them less effective
Cost: Approximately $100 to $115 per month
bad LDL cholesterol, but it raises good HDL cholesterol (no mean feat) and lowers triglycerides atrovent peanut . 265
No one knows if these improvements in blood fats will result in a lower risk of heart attack or other cardiovascular complications in the long run gabapentin gaba . That, after all, is the really important issue, since diabetics are at such high risk of cardiovascular catastrophes ibuprofen versus rofecoxib . But Actos is fairly effective in preventing the closing up of a cardiac stent after it is put into a coronary artery study volunteers for topamax and alcohol .266 And a head-to-head study of Actos and Avandia (a similar medication) showed that Actos has a better effect on several measures of cholesterol and blood lipids ibuprofen liquid mg per ml . 261 If this translates down the road into reducing the likelihood of a heart attack or stroke, it would certainly be worthwhile allopurinol lab hahnemann .
Pioglitazone can cause fluid retention and as a result is not appropriate for use by patients with congestive heart failure lotrel azor . Side effects include a greater susceptibility to sore throats, colds, bronchitis, and the like; headaches; toothaches; sinusitis; and muscle pain allegra beach resort . A competing drug, rosiglitazone (Avandia, Avandamet), has also been linked to fluid retention celexa cs zoloft . More worrisome, though, is the possibility that this drug may contribute to fluid accumulation in the back of the eye purpose of flagyl .This macular edema could lead to blurred vision and eye damage claritin and cold medicine .
Repaglinide (Prandin)
The goal of treating diabetes is to keep blood sugar within the normal range, because that reduces the likelihood of serious complications prozac overdose nuerological damage . If you can’t achieve this with metformin or one of the “glitazones,” the doctor may add a medicine to stimulate the secretion of insulin lamictal and sunburn . Two drugs, nateglinide (Starlix) Repaglinide (Prandin?
Repaglinide lowers blood sugar by stimulating insulin release and is especially effective for reducing blood sugar following a meal cellcept indications . Repaglinide is taken before meals, usually within 15 minutes before beginning to eat can zovirax treat epstein barr virus .
Downside: Blood sugar may fall too much (hypoglycemia) brompheniramine and pseudoephedrine extended release . Repaglinide may contribute to weight gain caffeine memory .
Cost: Approximately $130 to $140 per month
and repaglinide (Prandin), make beta cells in the pancreas pump out more insulin at mealtime edward drummond m d and cymbalta . 268 This helps keep blood glucose levels from going too high after eating effexor ejaculation .
Some studies have compared these two medicines alone or in various combinations scarring accutane . The results aren’t definitive, but comparing nateglinide alone to repaglinide alone suggests that there is an advantage to repaglinide whats stronger than ultram .269 Prandin lowered HbA, signifi- cantly more than Starlix did; it brought down fasting blood sugar better; and more than half (54 percent) of the patients on Prandin were able to get their HbA below 7 percent, whereas fewer than half (42 percent) of those or Starlix managed that osteoporosis lamotrigine . Of course, there’s a price amitza or zelnorm . Patients on Prandin were more likely to suffer from hypoglycemia (low blood sugar) rimonabant effect on abdominal fat . They also gained more weight (almost 4 pounds in 4 months), a discouraging side effect patient assistance program for accutane . -
These drugs are more effective in combination with metformin than they are on their own memory loss zoloft . 270 tricor cholesterol statin .27L272 Side effects of repaglinide include headache, joint or back pain, and tipper respiratory infection no prescription needed glyburide . Drugs such as ketoconazole (Nizoral) and clarithromycin (Biaxin) boost blood levels of repaglinide, and that could increase the likelihood of unpleasant reactions 2cialis compare levitra . Grapefruit affects the same enzyme (CYP3A4) and might have a similar effect side effects of mircette .
Exenatide (Byetta)
Exenatide (Byetta) is another treatment option for type 2 diabetics prograf pronounced . It has an interesting history zoloft user review . because it got started with research into the saliva of a poisonous Southwestern lizard called a Gila monster what is lexapro medicine . Byetta is injected and is used in combination with metformin or a blood sugar–lowering drug like glyburide claritin d warnings . Byetta reduces the bump in blood sugar after meals and can help diabetics lose weight kidney infection cipro .
The most common side effect is nausea, but the most serious is hypoglycemia sustiva drug . Adding Byetta to a medicine like glyburide increases the risk of a dangerous drop in blood glucose level difference between prilosec and zantac . Patients using Byetta must learn what to do if blood sugar drops too low zoloft causing excessive sweating . Other side effects include vomiting, diarrhea, dizziness, jitters, headache, and indigestion michael soma . Byetta should not be given to people with kidney problems or serious digestive disease prozac vs cymbalta . 273
Conclusions
By now, we hope you appreciate the importance of controlling blood sugar asacol delayed release tablet . Diabetes is common (some diabetologists believe it will soon affect nearly half the population), and its complications are devastating pfizer class action involving zoloft . We have tried to give you a variety of strategies to prevent or control this disease viagra and generic . Remember, though, that whatever tactics you adopt, you must work in close collaboration with your health-care providers prednisone and tracleer .
Below you will find an overview of our recommendations in this chapter rechargable aa lithium ion .
• Preventing diabetes is possible nolvadex steroids . Keep your weight under control, emphasize nonstarchy vegetables over pasta or bread, and avoid soft drinks, fruit juice, and processed meats you made everything possible again viagra .
• Get plenty of exercise, preferably including some time outdoors so you have 10 to 15 minutes of sunshine on your face and hands several days a week celexa proper dosage . If you don’t get outside, take 800 to 1,200 IU of vitamin D3 daily quetiapine and sustained release and dissolution .
• If you are diagnosed with diabetes, learn to monitor your blood sugar can toprol cause chronic abdominal distress . Keep track of how exercise and food affect it prozac and nerve receptors . Consider cinnamon or vinegar to help smooth out blood sugar in reaction to a carbohydrate meal nexium and indications .
• If you’re considering using herbs or dietary supplements such as chromium, bitter melon, fenugreek, Gymnema sylvestre, or nopal, check with your health-care providers before taking them zofran wafer . Monitor your blood sugar carefully ultram nopain .
• If medication becomes necessary, make sure that you and your physician find the safest and most effective option for you viagra nils . You shouldn’t have to suffer with dreadful side effects to keep your blood sugar under control iv ampicillin .

sodium picosulphate A synthetic laxative similar to bisacodyl, but with a slower action.
Dose: 5-15 rug at night.
sodium stibogluconate An organic antimony drug use([ in the treatment of visceral leishmaniasis or kala-azar.
Dose: 20 ruglkg daily by i.m. or i.v. injection for 30 days. Side-effects include anorexia, vomiting, cough and sub-sternal pain. (Pentostain).
I sta
given by i.v. injection as a 50% solution to promote diuresis and to reduce cerebral oedema.
sotalol A beta-adrenergic blocking agent used ill the treatment of hypertension, angina, cardiac arrhythmias and thyrotoxicosis. Dose: 120 nig initially, increased as required; maintenance, 160-600 ing daily. For prophylaxis after infarction, 320 mg daily. In acute cardiac arrhythmias, 20-60 mg by slow i.v. injection under ECG control. Care is necessary in heart block, asthma, hepatic and renal impairment. (BetaCardone; Sotacor). See pages 114 & 148, and Tables 4 & 2 1.
sodium tetradecyl sulphate A venous-occluding agent used in the injection sclerotherapy of varicose veins.
Dose: 0.5-1 nil at any one site, followed by compression bandaging for sonic weeks. The local irritant action of the drug brings about an occlusive venous fibrosis at the injection site. Extra-vascular injection may cause necrosis. Care is necessary in allergic subjects.
sodium thisulphate A 50% solution is given by i.v. injection in cyanide poisoning. See sodium nitrite and kelocyanor.
sodium valproate An anticonvulsant
effective in most forms of epilepsy.
Dose: 600 mg daily in adults initially, increased if required up to a maximum of 2.5 g daily. It may also be given by slow i.v. injection in doses of,100-800ing, followed by similar doses given by i.v. infusion. Liver function tests before and during treatment are essential. Severe side-effects such as vomiting, drowsiness or jaundice require withdrawal of the drug, as does spontaneous bleeding or bruising.
(Epilim). See page 136 and Table 15.
somatropin A form of human growth hormone obtained by biosynthesis. It is used to stimulate growth in hormone-deficient young patients whilst the epiphyses are still open.
Dose: 0.07 units/kg daily by i.m. or s.c. injection. Subcutaneous injection sites should be varied. (Genotropin; Hurrialrope; Norditropin; Salzen).
spectinomycin An antibiotic used in the treatment of penicillin-resistant gonorrhoea.
Dose: 2-4g by deep Lin. injection. Side-effects include nausea, dizziness and tirlicaria. (Trobicin).
spironolactone An aldosterone antagonist which potentiates the action of thiazide and loop diuretics in sonic resistant conditions. It is of value in the oedema of liver cirrhosis, as well as in the nephrotic syndrome and congestive heart failure. Dose: 100 ing daily up to a maximum dose of 400 mg daily. Side-effects include drowsiness, gastrointestinal disturbances, gynacconiastia and an increased sensitivity to warfarin. The combined use of potassium-sparing diuretics or potassium supplements is contraindicated.
(Aldacione; Spiroctan).
SSRls See selective serotonin re-uptake inhibitors.
stanozolol An anabolic steroid with actions and uses similar to those of nandrolone. Dose: 5 ing daily. It also has fibrinolytic properties, and is used in lipoderinatosclerosis (a complication of deep-vein sclerosis), and in some forms of vasculitis. It may also be of sonic value in hereditary angioneurotic oedema and in the relief of itching due to biliary obstruction. Also used in some aplastic anaemias, 2.5-10 ing daily. Sonic androgenic side-effects may Occur, bill are usually mild and reversible Oil stopping treatment. (Stroniba).
93
sorbitol A saccharide that after absorption is converted in the liver almost entirely to laevulose. It has been used as a sugar-substitute in diabetes, and it is sometimes
starch Carbohydrate granules obtained from maize, rice, wheat or potato. Widely used as absorbent dusting powder.

stavudineV An antiviral agent that inhibits the enzyme reverse transcriptase, and so indirectly blocks the synthesis of viral DNA. It is used in HIV infections resistant to or not responding to zidovudine. Dose: 00 ing daily, I hour before food. Side-effects include malaise, peripheral neuropathy and pancreatitis. (Zerit). See page 144 and *['able 19.
sterculia A natural gum that swells in water to a gelatinous mass. It is used as a bulk laxative as when taken with plenty of water it increases faecal volume and promotes peristalsis. It is also used in diverticulitis and irritable bowel syndrome, and as an appetite suppressant. Dose: 5-10g daily but not at night. (Normacol).
Sul
Dose-. I g daily by deep i.m. injection. Its use requires care. as it k both ntotnxir and nephro(oxic, especially in full doses and in renal impairment. Measurement of the plasma concentration QfbErCplU1llV0ll P. advisable during treatment. Cutaneous sensitization has followed contact of the drug trill the skin.
sucralfate An aluminium sucrose sulphate use,] in the treatment ofpeptic ulcer. It is not an antacid, but forms a barrier over the ulcer that is resistant to peptic attack and so promotes healing.
Dose: 4g daily for at least 4 weeks. Antacids should not be taken immediately before or after sucralfate. (Antepsin). See page 162.
94
stilboestrol A synthetic oestrogen with the actions and uses of oestradiol.
Dose: 0.1-0.5 mg daily for menopausal symptoms, but it is now prescribed less frequently. Dose in breast cancer, 10-20 mg daily; in prostatic carcinoma, 3 mg daily or more, although fosfestrol is often preferred. Side-effects include nausea, fluid retention, thrombosis, impotence and gynacconlastia.
streptokinase Ali enzyme preparation obtained from cultures of haemolytic streptococci. It has fibrinolytic properties, and is of value in deep vein thrombosis, pulmonary embolism, myocardial infarction and other conditions requiring fibrinolytic therapy.
Dose: by i.v. infusion, 250000 units or more initially, followed by maintenance doses of 100000 units hourly for up to 72 hours. For myocardial infarction
1 5(10000 units over l hour. Side-effects are fever, rash, haemorrhage and allergic reactions. (Kabikinaw; Streptase).
sulconazole A synthetic antifungal agent similar in actions and uses to miconazole. Applied as a 1% cream twice daily. (Exelderin).
sulfadoxine A long-acting sulphonamide, with the general antibacterial action of the group. It has been used in the treatment of leprosy.
Dose: I-1.3f; weekly. In association with pyrimethainine, it is used in the treatment of malaria, but the use of such mixed products requires great care, as severe, sometimes fatal side-effects have occurred. It is no longer used for malaria prophylaxis. (Fansidar).
sulfametopyrazine A very long-acting sulphonamide used mainly in chronic bronchitis and urinary tract infections. Dose: 2 g once it week. Side-effects and toxic reactions, although mainly those of the sulphonamides generally, may be linked with the slow excretion of the drug. (Kelfizine).
streptokinase- streptodornase A mixture of enzymes obtained from cultures of haemolytic streptococci. It brings about the dissolution of blood clots and the liquefaction of purulent exudates, anti is used as a solution to clean foul wounds, pressure sores and ulcers. (Varidase).
streptomycin The first of the amino-glycoside antibiotics, but now used mainly as part of the multi-drug treatment of tuberculosis.
sulindaC A non-steroidal anti-inflammatory analgesic agent (NSAID) with actions, uses and side-effects similar to naproxen. It is of value in the pain and inflammation of rheumatoid disease and acute gout. Dose: 200-400 ing daily with food. It may cause gastrointestinal disturbance and occasional bleeding. (Clinoril). See
page 165 and Table 29.
sulphadiazine one of the more active and less toxic sulphonamides. It is used mainly in the treatment of severe conditions such as meningococcal meningitis.

Dose: (, 9 g daily by deep i.m. injection or i.v. infusion for 2 days, followed by 2 g or more orally daily. Dose in the prevention of rheumatic fever I g daily. Side-
effects are nausea, rash and blood dyscrasias.
sulphadimidine One of the least toxic of the sulphonamides, now used mainly in urinary infections.
Dose: 2 g initially, with maintenance of 1. - 4 g daily orally. Side-effects include nausea, drug fever, rash and leucopenia.
sulphamethoxazole A sulphonamide present with trimethaprim in co-trinioxazole.
sulphasalazine A sulphonamide derivative that is taken up selectively by the connective tissues of the intestines. It is used in the treatment and maintenance of remission in ulcerative colitis and Crohn’s disease.
Dose: 4-8g daily initially; maintenance, 1.5-2 g daily. 11 is also given as a 3 g enema and as 500 mg suppositories. Occasionally given in rheumatoid arthritis in doses of 03-3 g daily. Side-effects include nausea, rash, drug fever and blood dyscrasia. If blood dyscrasia is suspected, a blood count should be done and the drug withdrawn. (Salazopyrin). See niesalazine, olsalazine, page 172 and’I'able 32.
sulphathiazole One of the early sulphonamides, and survives in a few mixed products.
sulphinpyrazone. A uricosuric agent with the selective action of increasing the excretion of uric acid, hence used in the treatment of chronic gout and hyperuricaemia. Dose: 100-200 mginitially with food, increased according to the plasma uric acid levels up to 60(1-800 nag daily, with tower maintenance doses according to need and response. Side-effects are nausea, abdominal pain and rash. Care is necessary in peptic ulcer and renal impairment, and blood counts are necessary during, treatment. Salicylates antagonize the action of the drug. (Anturan). See
page 1.10 and Table 17.
sulphonamides A group of drugs that have an antibacterial action by preventing the uptake and use of folic acid. They are thus bacteriostatic and not bactericidal in action. The use of the sulphonamides ides has
declined, and they are now used mainly in urinary tract infections due to sulphonamide-sensitive bacteria. The side-effects of the sulphonamides include nausea, dyspepsia, diarrhoea and allergic reactions. Bone marrow depression may occur if treatment is prolonged. The uncommon Stevens-Johnson syndrome is a very serious reaction. See sulphadiazine ind co-trinioxazole.
sulphonylureas A group of orally active drugs represented by chlorpropamide that promote the release of insulin from the beta-cells of the pancreas. They are used in mild diabetes not controlled by diet, and in the late-onset diabetes of middle age, but they are not suitable for the treatment of juvenile diabetes. The presence of some still-functioning beta-cells is essential for sulphonylurea activity. Side-effects include weight gain, rash, fever and jaundice. During illness and pregnancy, insulin treatment should replace sulphonylurea therapy. See page 131 and Table 13.
sulphide An antipsychotic drug with a central action on dopaminereceptors. It is used in the treatment of acute and chronic schizophrenia, as in low doses it increases awareness in apathetic and withdrawn patients, and in larger doses controls the active forms of the illness.
Dose: 400-800 mg daily: in severe conditions up to 2.4 g daily. The side-effects are similar to those of chlorpromazine. (Dolmatil; Sulparex; Sulpitil). See
page 168 and Table 30.
sumatriptan A serotonin agonist used in
i lie treatment of acute migraine. (It is not suitable for prophylaxis.)
Dose: 50-100 mg orally as soon as possible after onset of an attack, but a second dose should not be given for the same attack, but may be repeated once if migraine symptoms recur. In severe migraine an(] cluster headache 6 mg by S.C. injection, but not more than 12 nig in 24 hours. (Pre-filled syringes and an auto-injector are available.) If should not be given until 24 hours after other antimigraine treatment, or any other drug that influences the re-uptake of serotonin. Side-effects include tingling and tightness in any part of the body, and an angina-like chest pain that may be severe. (I migran). See page 154 and Table 23.

salbutamol A selective beta,- adrenoceptor  It is widely used to relieve bronchospasm in airway obstruction, including bronchial asthma and status astliniaticus, with the advantage of being largely free from cardiac side-effects. Dose: up to 16 ing orally daily; by aerosol inhalation (in which patients should be carefully instructed) 100-200 pg ( 1-2 puffs) Lip to 4 times a day; by s.c. or i.m. injection 500 pg as required; 250 pg by i.v. injection. Salbutamol also, relaxes uterine muscle, and is given in premature labour in doses of 10 pg/inin initially by i.v. infusion, increased to 45 pg/min until contractions have ceased, when oral therapy may be given. Side-effects include tremor, headache, peripheral vasodilation and tachycardia. Care is necessary in ischacinic heart disease, hypertension pertension and hyperthyroidism. (Ventolin). See page 118 and Table 6.
salcatonin A synthetic form of calcitonin, preferred for extended use, as it is less likely to provoke allergic reactions. Dose: in hypercalcaemia, 5-10 units/kg ,fail), 1)), s.c. or Lin. injection according to need; in Paget’s disease 60 units 3 times a week up to 100 units daily. It is also used in post - menopausal osteoporosis and for the bone pain of malignancy. (C.alcynar; Miacalcic).
salicylic acid Etas useful keratolytic and fungicidal properties. Used as ointment (2%) for skin conditions, and as ointments and plasters (up to 40%) for corns and warts.
salmeterol A beta,-adrenoceptor stimulant of the salbutamol type, but with a longer action. It is used for the extended prophylaxis of asthma, bronchitis and other forms of obstructive airway disease, and together with corticosteroid therapy if required. It is not indicated in acute conditions.
Dose: 50 pg twice daily, either from a metered dose aerosol or by a ‘Disklialer’. salmeterol is well tolerated, but headache, tremor and tachycardia may occur with doses above 200 pg daily. (Serovent). See page 118 and,rable 6.
saquinavirV An antiviral agent that inhibits the enzyme HIV-protease, and prevents the development of immature virus particles into the infective virus. Used in HIV
infection together with it nucleoside analogue that has a different action.
Dose: 1.8g (laity. (Invirase). See page 1+1 ;111,1 TAIle 19.
scopolamine See hyoscine.
selective serotonin re-uptake inhibitors (SSRIS) A small group of drugs that inhibit the re-uptake ofserotonin in the central nervous system, and are used in the treatment of depression. They differ from the tricyclic antidepressants in being less likely to cause sedation or cardiac disturbances, or have anticholinergic side-effects. Care remains necessary with machine-related activities, and before and after monoamine oxidase inhibitors (MAOI) therapy. See page 128 and Table 11.
selegiline A selective enzyme inhibitor that prevents the inactivation of dopamine in the brain. It is used to supplement the action of levodopa in the treatment of parkinsonism, and combined use may give a smoother response, and permit a reduction in the dose of levodopa.
Dose: 5-10111g daily. It may cause nausea and hypotension, and may possibly increase the side-effects of levodopa. (Eldepryl). See page 160 and Table 26.
selenium sulphide Used as a shampoo in the treatment ofdandrull’. Prolonged use may cause alopecia. (Selsun).
senna The leaves and pods of Cassia sp., used as a purgative. Standardized preparations such as Senokot are now preferred.
sermorelinV A synthetic analogue of soniatorelin, the growth hormone releasing factor (GHRH). It is used in the diagnosis of growth hormone deficiency as a single i.v. dose of I pg/kg. (Geref 50).
sertindoleV An antipsychotic agent with a selective action on the limbic system, and used in acute and chronic schizophrenia. Dose: 4 nig once (laity initially, increased alter 2-4 days up to 20 mg daily according to need. Blood pressure should he monitored initially as hypotension may occur.  Contraindicated in patients receiving itraconazole, ketoconazole,  terfanidine, or any drug known to affect the QT interval. (Serdolect). See page 168 and Table 30.

serotonin A substance present in many body cells, which also acts as a neurotransmitter in the central nervous system. A reduction in the brain serotonin levels may be associated with depression and the cranial
vasodilation associated with migraine. (See page 154). Some allergic reactions may also be linked with the action of serotonin on sensitized cells (see cyproheptadine).
I Sod
colic and vomiting, but death from adder bite is very rare. If the reaction to an adder bite is severe, European viper anti-venom, if available, should be given by i.v. infu-
sion within 4 hours of the bite.
soda-lime A mixture of calcium and sodium hydroxides, used in closed-circuit anaesthetic apparatus to remove carbon dioxide.
sertraline A selective serotonin-re-uptake inhibitor (SSRI) antidepressant used both for the treatment oftlepression and the prevention of relapse.
Dose: 50 rig daily initially with food, increased at weekly intervals tip to a maximum of 2(0 mg daily. Not to be given with nionoanlilic oxidase inhibitors (MAOls). Side-effects are tremor and a dry mouth. (usual). See page 128 and Table 11.
silicones Synthetic water-repellent substances present in barrier creams and other skin protective products. Dimethicone is a silicone used as an anti-foaming agent in some antacid preparations.
silver nitrate Used mainly as silver nitrate sticks (caustic points) for cauterizing warts. It has also been used as a 0.5% lotion for suppurating lesions. It was once used prophylactically as eye drops (0.1%0) in the newborn, and is still used for that purpose in the USA.
silver sulphadiazine Sulphadiazine combined with silver. It is used topically as a I% cream for its wide-range antibacterial properties in burns and infected skin conditions, especially when an extended action is required. It is active against Pseudornonas aertiginosta and other Cram- negative organisms. (Flamazine).
simvastatin A selective inhibitor of a specific enzyme (I-IMGCOA reductase) concerned with the synthesis of cholesterol in the liver. It is used in the treatment of primary hypercholesterolaernia in patients not responding to other drugs. Dose: 10-40 mg at night. Liver function tests should be carried out regularly. Side effects include gastrointestinal disturbances. (Zocor). See page Wand Table 20.
snake-bite antivenom A bite from an adder, the only poisonous snake indigenous to the UK, can cause local pain and swelling as well as systemic effects such as
sodium acetrizoate An iodine compound used as a contrast agent in i.v. pyelography.
sodium aurothiomalate A gold compound used in the treatment of active rheumatoid arthritis. It is no value in other forms of the disease, or where bone change has already occurred.
Dose: 10 mg by deep Lin. injection weekly initially, slowly increased to 50 mg weekly. and continued until a remission occurs, or until a total dose of I g has been given.
Blood and urine tests are essential after each injection. After remission, 20-50 mg may be given every 2-1 weeks for many months. Side-effects are common, and include blood disorders, skin reactions, mouth ulcers and oedenia, anti may require withdrawal of the drug. It is contraindicated in renal and hepatic disease, blood dyscrasias and hypertension. (Myocrisin). See auranoran,
page 165 and Table 29.
sodium bicarbonate A soluble antacid, often used in association with less soluble antacids such as magnesium carbonate or trisilicate.
Dose: 1-4 g. In severe metabolic acidosis it is given by slow i.v. injection as an 8.4% solution. For alkalization of the urine, up to 3 g orally 2-hourly with further 10 g
doses daily as required.
sodium calcium edetate A chelating or binding agent used in poisoning by lead and other heavy metals.
Dose: 80 mg/kg daily by i.v. infusion in glucose/saline solution. Nausea and cramp are side-effects, and care is necessary in renal impairment. Medclair).
sodium cellulose phosphate An ion-exchange compound that binds with calcium in the intestines, and so reduces calcium absorption. Used in the oral treatment of hypercalcaemia and renal stones, and as an adjunct to low-calcium diets. Dose: 15 g daily. Diarrhoea is an occasional side-effect. (Calcisorb)•

sodium chloride An important constituent of blood and tissues. It is widely used by i.v. infusion as normal saline solution (0.9%), or as glucose-saline in the treatment of dehydration, shock and other conditions of sodium depletion. It is also useful when given orally as Sodium Chloride with Glucose Oral Powder (BNF) (after solution in water), for children with diarrhoea to offset any loss of salt. Its use as an emetic in the treatment of poisoning is no longer recommended. It is used externally as saline solution when a simple cleansing lotion is required.
sodium citrate An alkaline diuretic similar to potassium citrate and given for similar purposes.
Dose: 1-4 g. For citrating milk, 100 mg to each feed may be used. A 3% solution is used by bladder irrigation for the dissolution of blood clots.
sodium clodronate See clodronate, editronate and pamidronate.
sodium cromoglycate An antiallergic agent with a specific action and used for the prophylactic treatment of asthma by inhalation. It stabilizes mast cells and inhibits the release of histamine and other spasmogens that cause bronchospasm. Dose: by powder inhalation from a `Spinhaler* 20 mg up to 9 times a day; by aerosol inhalation, 10 mg (2 puffs) up to 8 times a day. Dose in the treatment for food allergy associated with local inflammation, 800 mg daily orally. It is also of value as eye drops (2%) and eye ointment (40/4) in allergic conjunctivitis, and as nasal drops or spray (2%) in the prophylaxis of allergic rhinitis. (Intal, Rvilacrom). See page I I O and Table 2.
sodium fluoride The fluoride present in dentifrices used to reduce dental caries. It may also be given orally when more intensive treatment is required.
Dose: 250-5001igdaily.
daily by i.v. infusion. Side-effects include nausea, rash and jaundice. Liver function tests should be carried out during treatment. (Fucidiu).
sodium hypochlorite A weak solution of sodium hypochlorite containing 0.25% of available chlorine is used as eusol, for the cleansing of wounds and ulcers. The
Solution is unstable and should be freshly prepared. Its value has recently been questioned. Stronger, stabilized solutions are used for the general disinfection of surfaces contaminated with blood and other body fluids. Their use reduces the risk of transmission of hepatitis and other viral infections.
sodium ironedetate (sodium feredetate) A soluble iron complex available as a solution containing 27.5 mg of iron per 5 nil. It is used in the oral treatment of iron-deficiency anaemias, and is of value when other iron preparations are not tolerated. Dose: 15-30 nil daily. (Sytron). See page 112 and Table 3.
sodium lactate Has been used as M/6 solution, or as Hartmann’s solution, by i.v. infusion for metabolic acidosis, but sodium bicarbonate is now preferred.
sodium nitrite A cyanide antidote.
Dose: as it 30/b solution by i.v. injection of 10 nil, followed by the slow injection of 25 nil of sodium thiosulphate solution (50%). Early treatment is essential. See kelocyanor.
sodium nitroprusside A short-acting arteriovenous vasodilator used in hypertensive crisis and for controlled hypotension during anaesthesia.
Dose: by i.v. infusion, 0.3-1 pg1kg/juin, the lower doses being used to obtain hy
, poten-
sion during surgery. It is also used in acute heart failure in doses of 10-1 5 pg/niin, increased as required to 2001ighnin.
sodium fusidate An antibiotic used mainly in penicillin- resistant staphylococcal infections, although a secondary anti-staphylococcal antibiotic is often given to increase the response and inhibit drug-resistance. It is useful in osteomyelitis and similar conditions as it penetrates into bone tissues.
Dose: 2 g daily. In severe infections, 1.5 g
sodium perborate White powder soluble in water, with antiseptic and deodorant properties similar to hydrogen peroxide. A 2% solution is used as a mouthwash.
sodium phosphate A solution of sodium phosphate with sodium acid phosphate is sometimes used by enema as a laxative.

jt34vef7mn

ethinyloestradiol A synthetic oestrogen formerly used to control menopausal symptoms and other conditions where oestrogen therapy is indicated.
Dose: 10-50 pg daily. It is present with a pi ugestogen in many oral contraceptive products. See page 264 and Table 40.
othosuximide An anticonvulsant for the treatment of petit trial epilepsy (absence seizures). May be used alone, or combined with other anticonvulsants, and it is often of value in patients not responding to other drugs.
Dose: 500 nig daily initially, gradually increased if required, to a maximum of 2 g daily. Care is necessary in renal or hepatic disease. Drowsiness, headache and gastrointestinal disorders are sonic side-effects. (F meside; Zaronlin). See page 136 and Table 15.
etidronate disodium A bisphosphonate used in Paget’s disease of bone, as it slows down the rapid turnover of bone and relieves the pain of that disease.
Dose: 5 nig/kg as a single daily dose between meals for 6 months or more. Side-effects are nausea and diarrhoea; high (loses may increase bone pain and the risks of fracture. (Didronel). Didronel PMO also contains calcium carbonate, and is used in the extended treatment of vertebral osteoporosis. See clodronate and pamidronate.
include nausea, alopecia and myelosuppression. (Vespid). See page 122 and Table 8.
eusol A chlorine antiseptic solution used as lotion, or as compress. The solution should be freshly prepared. Now less popular, thought to be irritant.
evening primrose oil See gamolenic acid.
eye drops Weak solutions of drugs for the treatment of ocular conditions. They may be antibacterial, antifungal or antiviral in action, or maybe used for non-infective conditions such as glaucoma, or for diagnosis. For routine use they are supplied sterile in multiple-application containers, but are intended for individual use only. They contain preservatives, and for home use may be used for up to one month after the container has been opened. In eye Surgery, single application products should be used. Occasionally, enough of a drug may be absorbed from eye drops to have systemic effects, and corticosteroids, if used as eye drops over a prolonged period, may cause’steroid glaucoma’. Care should be taken with contact lenses, and ideally they Should not be worn during eye drop treatment. Soft contact lenses can absorb the preservatives, which may cause irritation.
etodolac A non-steroidal anti-inflammatory agent (NSAID) of the naproxen type, with similar actions, uses and side-effects. Dose: in rheumatoid conditions, 400 mg daily. (Lodine). See page 169 and
Table 29.
etomidate A short-acting i.v. hypnotic used lor the induction of anaesthesia. It causes little cardiac disturbance or hypertension, but muscle movement and pain may
occur during injection.
Dose: 300 pg/kg by i.v. injection.
f Ilypnomidate).
etoposide A cytotoxic agent used in small-cell lung cancer and resistant testicular cancers. It is given in daily doses based on skin area for 5 days, repeated after 21 days according to response.
Dose: 120-240 nighn’ daily orally; by i.v. infusion 60-120 mghn’, and care must be taken to avoid extravasation. Side-effect-,
Factor Vila A recombinant and active form of the blood coagulation Factor VII. The treatment of haemophilia with Factors Vill and IX is complicated by the development of antibodies to those factors. Factor Vila acts as a late stage in the conversion of fibrinogen to fibrin, can function independently of Factors Vill and IX, and does not induce the formation of antibodies. It is used to control serious bleeding in haemophiliac patients and during surgery, under specialist supervision.
Dose: 60-120pg initially by i.v. injection, followed by a second dose after 2-3 hours, then 4-12-hourly as required for
2-3 weeks or more. (NovoSeven).
Factor Vill Haemophilia A is caused by a deficiency of the blood clotting agent Factor Vill, and highly purified preparations of human Factor VIII as well as recombinant forms are used as replacement therapy in doses based on the degree of deficiency of that factor. (Kogenate; Monoclate P; Recombinate).
Factor IX Haemophilia B is due to a deficiency of Factor IX, and preparations of that factor, obtained by monoclonal antibody techniques, are given i.v. in doses based on the degree of efficiency of the factor. (Monomine; Replenine).
famiclovir An antiviral agent similar to acyclovir, and used in herpes zoster (shingles) and genital herpes infections. Dose: 75 mg daily for 7 days. (Panivir). See page 144 and “fable 19.
famotidine An H,-receptor antagonist with the uses and side-effects of cinictidine, but a longer action.
Dose: in benign peptic ulcer, 40 ing at night lor,1-8 weeks; 20 mg at night for the prevention of recurrence, also used in reflex oesophagitis. In Zollinger-Ellison
syndrome, doses of 20 mg 6-hourly are given. ( Pepcid). See page 162 and] *able 27.
pain and inflammation in rheumatoid arthritis and similar conditions.
Dose: 600-900 nig daily. Like other
NSAIDs, it may cause gastrointestinal disturbance and dizziness, but the incidence of rash requires withdrawal of the drug. (Leclet-fen). See page 165;uidfable 29.
fencifibrate A plasma-lipid regulating agent of the clofibrate type, with similar uses and side-effects.
Dose: 300 ing initial]),, with food, later 200-400 mg daily according to need. (Lipantil). See page 146 and Table 20.
fenoprofen A non-steroidal anti-inflammatory and anti-rheumatic agent. It is also used as a mild analgesic in a variety of painful conditions.
Dose: 900 mg-3 g daily. Side-effects include nausea, dizziness, vertigo and rash. (Fenoprofen; Progesic). See page 165 and Table 29.
fenoterol A sympathomimetic agent with the actions, uses and side-effects of salbutamol. Dose: by oral inhalation, 100-200 [Ig (1-2 puffs) up to 4 times a day. (Berotec). See page 118 and Table 6.
Fansidar Pyriniethamine, 25 mg with sulfadoxine 500 mg. Both these antimalarial drugs block the formation of folinic acid in the malarial parasite, but the combination is more effective. Mainly used with quinine in resistant filciparum malaria. (Fansidar is no longer recommended for prophylaxis, as fatalities have followed such use.)
felodipine A calcium antagonist used in the treatment of hypertension generally (see calcium channel blocking agents). Dose: 5 nig daily initially, adjusted to maintenance doses up to to mg daily. ‘I abiets should be taken in the morning, and swallowed whole with water. No adjustment of dose necessary for elderly patients, but care is required in marked hepatic impairment. Hypotension with tachycardia may occur with susceptible patients. (Plendil). See page 148 and Table 21.
felypressin A vasopressin derivative, used as a vasoconstrictor in local anaesthetic solutions for dental use, when sympathetic pressor drugs are contraindicated.
fenbufen A non-steroidal anti-inflammatory agent (NSAID) used for the relief of
fentanyl A narcotic analgesic, used mainly in thiopentone anaesthesia to increase the response and permit a reduction in dose of thiopentone, especially in poor-risk patients. It is also used with droperidol to produce a state of neuroleptanalgesia. Dose: 50-200 pg by i.v. injection.
(Subli niaze). Also used as a patch for the relief of chronic pain. (Durogesic).
fenticonazole An antifungal used in vaginal candidiasis as pessaries of 200 mg. (Lonlexin).
ferrous sulphate, fumarate, gluconate & succinate These iron salts are used in the prophylaxis and treatment of iron-deficiency anaemias. Ferrous sulphate is the standard drug, given in doses of 600 mg daily, but it may cause gastric disturbance in some patients, and ferrous fumarate, gluconate and succinate are better tolerated alternatives. Sonic better tolerated slow-release products are available, but may be less well absorbed. Ferrous sulphate tablets are potentially dangerous for small children, and death has occurred after accidental administration. See desferrioxamine.

fexofenadine An antihistamine with the general properties of that group of drugs. It is less likely to affect the ability to drive. Dose: 120 mg once daily. See
page 110 and Table 2.
fibrinolytic agents Drugs used to break up blood clots, and so are of value in thrombosis. See alteplase, anistreplase, streptokinase and urokinase.
filgrastim A recombinant form of human granulocyte colony stimulating factor (G-CSF), one of a group of natural growth factors concerned with bone marrow activity. It stimulates the development of neutrophils, the production of which is depressed during cytotoxic therapy. The neutropenia thus caused increases the risks of infection, but the neutrophil count can be restored by filgrastim. It is used mainly in the neutropenia associated with the cytotoxic treatment of non-myeloid malignancy. Dose: 500 000 units/kg daily by s.c. injection or i.v. infusion for 14 days, or until the neutrophil count return, to normal. Double doses are given after bone marrow transplanlation.The main side-effects are musculoskeletal pain and dysuria.  See lenograstini and molgrastirn.
His, and is of value in serious ventricular tachycardia and extrasystoles.
Dose: 200-400 mg daily. May he given by slow i.v. injection in doses of 2 iiig/kg in acute conditions resistant to other therapy, and under hospital control. Care is necessary in patients with pacemakers, and in renal impairment. Dizziness and visual disturbances are side-effects. (Tainhocor). See page 141 and Table 18.
flucloxacillin A derivative of cloxacillin, that is absorbed more readily when given orally. It is used mainly in infections due to penicillinase-producing penicillin-resistant staphylococci.
Dose: I g daily before food; by injection 1 -4 g daily, but larger doses arc given in very severe infections. Side-effects are those of the penicillins generally. (Floxapen). See co-fluanipicil.
fluconazole A systemically acting synthetic antifungal agent.
Dose: in oral candidiasis, 50 ing daily for 7-14 days: in vaginal candidiasis, a single dose of 1.50 mg. Dose in systemic candidiasis and cryptococcosis, 200-400 mg daily orally or by i.v. infusion. Side-effects include nausea and abdominal discomfort. Combined treatment with
asternizole, cisapride or terfenadine should be avoided. (Dillucan).
finasteride An inhibitor of the enzyme 5-alpha reductase, and so prevents the conversion of testosterone to dihydrotestosterone, the biologically active form of the male hormone. It is used for the symptomatic relief of benign prostatic hyperplasia, as prolonged therapy promotes a reduction in the size of the prostate gland.
Dose: 5 nig daily for 6 months or more. Side-elfects are reduced libido and impotence. (Proscar). See page 164 and Table 28.
flavoxate An antispasmodic of value in urinary disorders such as dysuria, frequency and related conditions. Dose: 600 mg daily. Side-effects include dry mouth and blurred vision. Contraindicated in glaucoma and bladder obstruction. (Urispas).
flecainicle An orally active anti-arrhythmic
agent of the lignocaine type. It chiefly
influences conduction in the bundle of
flucytosine An antifungal agent used in systemic yeast infections such as candidiasis and cryptococcosis.
Dose: 100-200 mg/kg daily i.v. It may Cause sonic bone marrow depression, and sensitivity tests should be carried out before and during treatment, as resistance to the drug may limit its value. Care is necessary in renal and hepatic inipairmclit. Side-effects include nausea, diarrhoea and rash. (Alcobon).
fludarabine A fluorinated cytotoxic agent used in chronic lymphocytic leukaemia (CI.L) after other treatment has failed. Dose by i.v. infusion 25 mg/in’ for 5 days a nionth. It is generally well tolerated, but myclosuppression may occur as with related drugs. (Fludara).

Few drugs create quite so much alarm as corticosteroids. To some extent, this alarm is justified — if

over-used, they have dangerous side effects. But rejecting them entirely is a great mistake, because

they are safe at the right dose, and immensely useful for a variety of allergic symptoms. With the

information given here, you can use steroids as safely and effectively as possible.
Although their proper name is corticosteroids, these drugs are commonly — and rather inaccurately —

called steroids. This name adds to their doubtful reputation by confusing them with the notorious

anabolic steroids (see box on p. 142). However, the term ’steroids’ is used for corticosteroids in this

book, simply because that is the name most people recognise.
Steroids do not deal with the allergic reaction itself, unlike antihistamines (see p. 138) or

cromoglycate (see p. 148). Instead, they tackle the consequences of the allergic reaction,

inflammation.
What exactly is inflammation? The visible features of this phenomenon – for example, if it occurs in

the skin, around a scratch or cut – are redness and slight swelling. There is also soreness, and some

warmth. All these effects are produced by an influx of immune cells, intent on protecting the broken

skin from infection. These immune cells generate messenger chemicals (see box on p. 10) which boost the

inflammation, as well as attracting yet more immune cells to the area. When inflammation affects

delicate membranes, as when you suffer a sore throat for example, there can be a great deal more

swelling and discomfort.
The inflammation that follows allergic reactions is very similar to that provoked by infection,

although the balance of immune cells and messenger chemicals is slightly different. Eosinophils (see p.

19) play a particularly important role in sustaining the inflammation produced by allergies.
This influx of eosinophils and other immune cells, which lights the fires of inflammation, occurs some

hours after the allergic response itself. It is known as the Late Phase Reaction (see p. 13). Steroids

work well for allergies because they curtail the Late Phase Reaction and have a calming effect on

various immune cells, especially the eosinophils.
Steroid phobia
So many patients have a profound objection to taking steroids that doctors call it, half-jokingly,

’steroid phobia’. One of the hazards of giving information about potential side effects – as in this

book – is that it may encourage ’steroid phobia’. That would be a tragedy, because steroids really are

useful drugs that can do you a lot of good and very little harm, if used correctly. The risks are very

small when the steroids are used at low to medium doses, and targeted directly onto the inflammation.

Even with high doses, the serious side effects can generally be avoided. Please don’t use the

information here to scare yourself – instead, use it to protect yourself while getting the most from

steroid treatment.
A few effects on other body processes remain, even with the new steroids:
•    Raised blood pressure – this can occur even with short-term use of steroids.
•    Children may stop growing, or grow more slowly. Usually they make up for this later.
•    Quite commonly, there is increased hunger (though you don’t actually need more food, and will

put on weight if you eat more than usual). Insomnia and an agitated, edgy feeling during the day may

occur. These are minor side effects, and no cause for concern.
•    Side effects in the eye can occur: there is an increased risk of glaucoma and, with prolonged

use, cataracts.
•    Long-term use can also result in loss of minerals from the bones, leading to thinning and

fragility (osteoporosis).
•    Psychological changes may occur. Some people experi- ece euphoria or greatly increased energy

levels – with the opposite effects occurring when the course of steroids ends. At worst, steroids can

trigger paranoia or severe depression and suicidal feelings. (These effects are more likely to occur in

those with a history of mental illness. If you are concerned about this aspect, discuss the possible

risks with your doctor before taking steroid tablets.)
•    Epileptics may suffer more frequent or more severe seizures.
•    Very rarely, stomach ulcers develop, or other side effects in the digestive system.
•    The skin may become thin, and the small blood vessels beneath it more fragile, leading to easy

bruising and stretch marks (striae). This is also a potential problem with steroid creams (see p. 146).

Elderly patients are much more susceptible to this side effect.
•    Some diabetics need more insulin. in addition, anyone with the potential to develop diabetes is

more likely to do so, but only if taking steroid tablets long term. The diabetes usually goes when the

steroids are stopped.
•    A few men suffer impotence, but only with long-term use of tablets. This can be treated, so see

your doctor. Women may have irregular periods.
•    Damage to the hip bones may rarely occur, usually with excessive doses of steroid tablets. This

is called avascular necrosis and may require hip replacement.
In addition to these effects on other body processes, there are also some side effects that arise from

the steroids’ suppression of the inflammation. These can occur even with short courses. Again, however,

these problems can almost always be prevented, or treated, or reversed if detected at an early stage.
•    Skin wounds may be slow to heal, and are more likely to become infected because of reduced

immunity. This is not a serious problem – just keep all cuts as clean as possible.
•    Infections by viruses and fungi (e.g. Candida – see box on p. 83), may occur more readily.
•    Some infections may be masked initially because fever is suppressed by the steroids.
•    Chickenpox and measles can be far more serious – even fatal – if steroid tablets are being

taken, or have been taken for more than three weeks within the last three months. This is something to

be very careful about (see item 15 on p. 143).
•    Prolonged use can increase the risk of chest infections.
•    Vaccination with live vaccines can cause problems.
•    Older people who once suffered from tuberculosis (TB) may find it comes back.
•    Steroids can lead to pregnancy if using an IUD, because IUDs work by inducing mild inflammation

in the womb.
The most insidious effect of steroids – and remember again that this is only a hazard of prolonged

high-dose treatment – is adrenal suppression. When steroid tablets are taken for more than three weeks,

the adrenal glands’ own ability to produce cortisol (see p. 141) starts to be slightly suppressed. The

longer the course of steroids, the greater the effect. Stopping the steroids abruptly leaves the body

without enough cortisol to protect itself, which, in the very worst cases, can lead to collapse. Less

obviously, there may be greater vulnerability to the effects of accidents, serious illnesses, surgery

or childbirth – demanding events that would normally stimulate a rise in cortisol production to help

the body cope with the stress.
If you take a short course of steroid tablets during this period, there is more risk of side effects

than normal. Adrenal suppression can last for 6-12 months after steroid treatment ends. It may be two

years before the body can cope with surgery unaided and you will need low doses of steroids to get you

through stress of this kind.
Will I look like a weight-lifter?
Absolutely not. The steroids taken by unscrupulous athletes to pump up their muscles artificially are

anabolic steroids. They are entirely different from the corticosteroids used to treat allergies.
Mimicking nature
All corticosteroids are chemically very similar to a substance known as cortisol that is produced

naturally by the body. Cortisol – which is a hormone made in the adrenal glands, located near the

kidneys – has a great number of different effects, apart from damping down inflammation. It regulates

the action of the kidneys, moves proteins out of the muscles and bones, and alters the pattern of fat

distribution.
Like other hormones and chemical messengers that the body produces, cortisol achieves its effects by

binding to receptors on target cells (e.g. immune cells, muscle cells and the cells that make up the

kidneys). These receptors vary a little, which gives researchers scope for making a synthetic version

of the hormone, cunningly modified so that it binds well to one kind of receptor (the one on the immune

cells, for example) but not so well to another (the one on the kidneys).
Hydrocortisone, the original steroid drug, is identical to cortisol, but the newer steroids have been

modified chemically to have the maximum effect on inflammation and minimal effects on other body

processes. While hydrocortisone can only be used for allergies at very low doses (as in

non-prescription hydrocortisone cream), the modified steroids can be used at higher doses.
The side effects of steroid drugs are of two basic kinds:
•    those due to suppression of inflammation (the desired effect of the drugs) because this

partially reduces immunity to disease
•    those due to the effects of steroids on other body processes – undesirable effects which have,

as far as possible, been designed out of the modern drugs.
These different side effects are discussed in more detail on p. 142. First, it is important to look at

the crucial difference between taking steroids in tablet form and applying them directly to the

affected area. Much unnecessary anxiety can be avoided by understanding this difference.
Targeting steroids
The risks of steroids fall dramatically if, instead of taking them in tablet form, you put them exactly

where they are needed: that means drops for the nose or eyes, inhalers to get the drug into the

airways, or creams and ointments to target the skin.
The medical term for this is topical application, and it is infinitely preferable to taking steroid

tablets. When a drug is swallowed, it does its job by being absorbed through the stomach lining into

the bloodstream, and then being carried around the body in the blood. This is called systemic treatment

because it reaches the whole body-system via the blood.
The areas that need the drug – the itchy skin or inflamed airways – get their dose, but so does every

other part of the body. In order to get a useful amount to the afflicted parts, a fairly large total

dose has to be taken which inevitably affects the rest of the body, making the drug far more hazardous.
When a drug is targeted precisely, in sprays, drops, creams or inhalers, the dose used can be very much

smaller. Some of the drug does get into the bloodstream, by penetrating the skin or the membranes of

the nose or airways, and entering the tiny blood vessels that lie just below. But the amount reaching

the bloodstream is usually minuscule compared with the amount in the blood when you take steroid

tablets. Systemic side effects –those due to the drug going round in the blood (see below) – are

usually avoided, although there may be some local side effects, where the drug is applied.
Only with very powerful doses – as in the steroid inhalers used for severe asthma, or high-potency

creams for eczema – do topical steroids reach the bloodstream in sufficient amounts to cause systemic

side effects. You have to be on these treatments for a long time, or be overdoing the dose (a possible

hazard with creams for eczema), to run the risk of systemic side effects.
Steroid tablets
Short courses of steroid tablets – which means three weeks or less – are pretty safe. They are usually

sufficient to get the inflammation under control, and can be taken three or four times a year without

creating any problems.
Even if you have no choice but to take steroid tablets on a long-term basis, remember that the serious

side effects can usually be avoided, or reversed if caught early (see p. 143).
Side effects
Apart from changes that may (rarely) occur in the stomach lining, the side effects of steroid tablets

are all systemic side effects.
In the early days of steroid use, a set of side effects that resemble a disease known as Cushing’s

Syndrome were frequently seen. The side effects included deposits of fat on the shoulders and abdomen,

and around the face, producing a ,moon face’, water retention resulting in puffiness, weakening of the

bones, easy bruising, acne and muscle wasting. All these changes are due to the unwanted effects of

steroids on other body processes, not to any effect on inflammation.
With the new and improved steroids (see left), plus a much more watchful approach by doctors, these

severe side effects have become very rare, but they can still occur in those on high-dose steroid

tablets. As long as they are noticed in good time (see p. 143) the problem can be reversed.
Using steroid tablets safely
Those taking steroid tablets for more than three weeks, or taking a lot of short courses, can protect

themselves from serious side effects in the following ways:
1. Weigh yourself every day. Should your weight suddenly start to rise, despite eating normally,

consult your doctor: this may be a sign of water retention.
2. If you develop hip pain, swollen ankles, muscle weakness or acne tell your doctor.
3. Get your blood pressure checked regularly by the doctor.
4. Get your eyes checked regularly by an optician, who can detect any problems before there is

irreversible damage.
5. In the case of children, make sure the child’s growth is being monitored carefully by the doctor.
6. Stay as active as possible, with plenty of vigorous exercise, to protect against osteoporosis. Avoid

getting too thin, as this is also a risk factor for osteoporosis. Reduce your salt intake and don’t

drink too much alcohol. Ask your doctor to order a bone-density measurement periodically. Following the

menopause, women on steroid tablets should consider taking hormone replacement therapy (HRT) as this

protects against osteoporosis.
7. Persistent unexplained back pain must be reported to your doctor: this can be a sign of

osteoporosis. If you fracture your wrist in a fall (a Colles’ fracture) make sure your doctor knows

about this, and prescribes urgent drug treatment for osteoporosis.
8. See your doctor if you are over-tired, thirsty, or need to pass urine much more frequently – these

can sometimes be signs of diabetes.
9. Take your tablets after food to protect the stomach. See your doctor if you have persistent

indigestion: coated forms of the tablets may help.
10. If you ever produce black, tarry stools, call your doctor immediately. This is generally a sign of

bleeding from the digestive tract.
11. With your doctor’s permission, take all your daily steroids as a single dose in the morning. The

long gap between one dose and the next stimulates the body to maintain its own steroid-making abilities

and so reduces the risk of adrenal suppression. It can also protect against growth problems in

children. Even greater protection comes from taking steroids on alternate days – one day on, one day

off – although not everyone can keep their symptoms under control with this regime. Obviously, you must

consult your doctor before you try. Your dose may need adjusting.
12. Adrenal suppression puts you at risk during any medical procedure. Tell your doctor, dentist, and

anyone treating you in an emergency – even if you stopped taking steroids up to two years earlier. You

should also carry a Steroid Card at all times, in case you are unconscious. These cards are available

from your doctor.
13. Ask the doctor what you should do if you develop any kind of infection or suffer an accident. It is

often necessary to increase the dose of steroid tablets.
14. Tell your doctor if you have ever had tuberculosis, as this can recur.
15. If you or your child have not had measles or chickenpox, avoid contact with anyone suffering from

these diseases – or from shingles (herpes zoster) which is caused by the chickenpox virus. See your

doctor promptly if there is any contact with someone infected. Emergency treatment to combat the virus

must be started promptly.
16. When being vaccinated, remind the doctor or nurse that you are taking steroid tablets.
17. Never stop taking steroid tablets abruptly if you have been taking them for more than three weeks,

as some degree of adrenal suppression may already have begun. Your body needs time to recover its

natural level of activity, so reduce the dosage gradually. Get precise instructions from your doctor

about how to do this.
18. If you are asthmatic, at the end of any course of steroid tablets lasting more than three weeks, be

extra careful about exposure to allergens and asthma triggers. You may be more vulnerable to severe

asthma attacks for as much as a year after long-term steroid tablets are stopped, or the dosage

reduced.
Watch out for adrenal suppression
If you develop any of the following symptoms after stopping steroids,
or while reducing the dose, call your doctor as soon as possible:
•    muscle weakness; muscle and joint pain
•    feeling ‘under the weather’
•    mental changes
•    scaly or flaking skin
•    breathlessness
•    lack of appetite; or nausea and vomiting
•    fever and weight loss
•    painful itchy lumps on the skin.
Note that, very rarely, withdrawal of steroid tablets, or lowering the dose, can unmask a disease

called Churg-Strauss Syndrome (see p. 160).
Steroid nose drops and sprays
Most steroid nose drops and nasal sprays contain very low doses of the drug, and produce no significant

side effects when used for short periods of time. The safety of these preparations is such that several

are available without prescription.
Steroid drops and sprays for the nose are a very effective way of treating hayfever and perennial

allergic rhinitis. They can be used after the symptoms have begun, or in advance of encountering the

allergen.
Steroid nose drops are also useful in reducing the size of nasal polyps (see p. 30) but only if the

drops are inserted correctly. Kneel down and, bending your neck forward as much as possible, put the

crown of your head on the floor. Now put the drops in and stay in this position for several minutes

while the drops reach their target. Once the polyps have shrunk, the drops can be replaced by a steroid

spray which will keep them under control.
Always stick to the stated dose, as with any drugs – don’t use the drops or spray more often than you

should. If you have a cold or other infection in the nose, stop using steroid drops and sprays until it

is better. Following surgical operations on the nose, ask your doctor’s advice before using steroid

drops or sprays.
Side effects
Minor short-term side effects may include dryness and irritation in the nose and throat, and

disturbances of smell and taste. Nosebleeds might occur and should be reported to your doctor. When

inserting the drops, try to keep them away from the central partition of the nose (the septum), as this

is
the part most vulnerable to bleeding. If you are a long-term user of steroid nose drops, your doctor

should check the membranes in your nose regularly, to be sure that they are not becoming thinned. Eye

checks may also be advisable with long-term use, as glaucoma can occur.
Allergic reactions to the steroid are possible, and they can cause bronchospasm (contraction of the

airway muscles) though this is unusual. You should obviously stop using the drops and see your doctor

if this occurs.
With very high doses of steroids in the nose, or prolonged treatment, some systemic side effects might

occur. The main cause for concern is children’s growth (see box on p. 145) – their height should be

checked regularly.
Steroid eye drops
Steroid eye drops are sometimes given for severe inflammation of the eye during the hayfever season.

However, the eye is vulnerable to infections if treated with steroid drops, and such treatment requires

close medical supervision.
Side effects
Be extremely careful about infections – don’t rub your eyes with your fingers, for example, or dry

around your eyes with a towel unless it is absolutely clean. Follow your doctor’s instructions very

carefully, and go back immediately if your eyes become more uncomfortable, if redness increases, or if

you have any other cause for concern.
Steroid eye drops are rarely used for more than a few weeks. With prolonged use, there is a risk of two

serious side effects, glaucoma and cataract.
Using two lots of steroid
Allergy sufferers who need steroid nose drops or a nasal spray, as well as a steroid inhaler, often

worry that they are getting too much steroid overall.
In fact there is no cause for concern, unless you are taking very high doses of inhaled steroid, in

which case talk the matter over with your doctor. The amount in most nose drops and sprays is quite

small and the same is true of steroid eye drops. In all cases, relatively little gets into the

bloodstream.
If you have allergies in the nose, this may well be making your asthma worse, and using steroid nose

drops can be very helpful for the asthma symptoms (see p. 39).
Inhaled steroids and children’s growth
If an asthmatic child inhales relatively high doses of steroids for many years, his or her growth can

be stunted. However, only a small number of children need these high doses, and with low to moderate

doses most children’s growth is unaffected. They may experience a short-term slow-down in growth, but

their eventual height should be normal.
Unfortunately, there are a few children whose growth is stunted even by relatively low doses of inhaled

steroids - and it is impossible to predict which children will respond in this way. However, if it is

noticed in good time, and if the steroids can be withdrawn safely, the child’s growth rate will almost

certainly recover.
Your GP or paediatrician should be monitoring your child’s growth. You can also measure this yourself,

and go back to the doctor if you are concerned. Keep the risks in perspective - uncontrolled severe

asthma also stunts children’s growth, as well as endangering the child in far more serious ways, so

don’t stop using the steroid inhaler.
Steroid inhalers
Inhaled steroids are a key part of the modern treatment of asthma (see p. 157). As with other topical

treatments, inhaled steroids are a great deal safer than steroid tablets. However, some of the drug

does get into the bloodstream, and with high-dose inhaled steroids taken for several years, the levels

can be high enough to cause systemic side effects such as osteoporosis (see p. 142).
The dose is the crucial factor here. The packaging or information leaflet that comes with your inhaler

will tell you how much of the drug is delivered with each inhalation. To interpret the information

about side effects correctly, you need to know your total daily consumption of inhaled steroid, and

whether this corresponds to a low, medium or high dose:
•    For budesonide or beclomethasone, two of the more common steroids, less than 400mcg

(micrograms) per day counts as a low dose for adults and children over the age of five. A moderate dose

is 500-800mcg per day, and more than 800mcg a day is a high dose.
•    For fluticasone (Flixotide), halve these figures (i.e. more than 400mcg a day is a high dose).
•    In the case of children under five, all these figures should be halved (e.g. a high dose of

beclomethasone is more than 400mcg a day).
•    For other steroids, check with your pharmacist.
Anyone taking a low or moderate dose has very little to worry about as regards systemic side effects.

Only those inhaling high-dose steroids for many years need feel concerned.
If you may be at risk of systemic side effects, follow the protective measures described for steroid

tablets on p. 143. Apart from growth suppression in children (see box above) the most likely effects

are osteoporosis, adrenal suppression, and a recurrence of tuberculosis.
You can minimise the risk of systemic side effects from
steroid inhalers by swallowing as little as possible of the steroid. Always rinse out your mouth,

gargle, and spit out the water after using your inhaler. Using your steroid inhaler morning and

evening, just before brushing your teeth, will make it much easier to remember to do this.
Bear in mind that inhaling steroids regularly will help you avoid the need for steroid tablets.

Asthmatics who are worried about side effects sometimes skip doses of their inhaled steroids, then find

their asthma is much worse and that they need a course of steroid tablets. Frequent courses of tablets

increase the risk of serious side effects.
Minor local side effects of inhaled steroids include hoarseness and short-lived coughing due to direct

irritation of the throat. These are no cause for concern.
If you are regularly inhaling steroids from a nebuliser, make sure the mask fits really well (see p.

163).
Because steroids reduce the immune defences a little, one common side effect of inhaling them is a

throat infection by Candida (see upper box on p. 83). Oesophageal infections with Candida can also

happen but these are rare; the symptoms are heartburn and indigestion. Gargling with warm water after

each inhalation will help prevent Candida infections. There are also anti-fungal lozenges, if you are

still having trouble.
Keep inhaled steroids away from your lips if you suffer from cold sores (herpes infections around the

mouth). These can be made worse with steroids.
Fortunately, other infections are no more common when using inhaled steroids. This includes chest

infections.
Recent research has found other side effects in children using high doses of inhaled steroids. Cough

and thirst are common, while hoarseness and loss of voice affect quite a few. Behavioural problems also

occur, including hyperactivity, mood swings, excitability, sleep disturbances, depression, and even

hallucinations.
Steroid creams and ointments
Steroid creams and ointments are used for both atopic eczema and contact dermatitis. By delivering the

drug to the place where it is needed, they reduce the dose required to an absolute minimum and, if used

correctly, are very safe. Dr Ernst Epstein, a dermatologist at the University of California, observes

‘All too often I encounter children who are miserable with uncontrolled atopic dermatitis because of

their parents’ unjustified fears of steroid side effects. It is cruel to the child and the family to

forgo topical medication.’
It is very important to use a steroid cream of the right strength. For example, applying a 1%

hydrocortisone cream (available without prescription) to severe atopic eczema will be of no value.

Similarly, only applying a prescribed cream occasionally, or only once a day when the doctor said three

times a day, will mean that the rash never really succumbs to the treatment.
Keeping old tubes of steroid cream in the bathroom cabinet, and using these rather than the newly

prescribed cream, is another frequent mistake. If the earlier prescription was for a weaker steroid

cream, that is not quite up to the job, you won’t get the symptoms under control.
Inadequate treatment means that the rash goes on longer, so you probably apply more steroid in the long

run – which exposes you to a greater risk of local side effects. It is far better to use a moderately

strong steroid cream for a short period of time and get the inflammation fully under control.
Remember that steroid creams are absorbed far more effectively immediately after a bath or shower, so

this is a good time to apply them (see p. 48).
Don’t stop using steroid creams too soon. The skin looks healthy and happy long before it is completely

healed underneath. You must continue until the ‘hidden healing’ has occurred. As a rough guide, the

point when the skin looks good is just the halfway point: so the steroid creams should be continued for

the same length of time again. If it took three weeks to get to the point where the skin looks fine,

then you should go on applying the steroid creams for another three weeks after that.
Generally speaking, it is a good idea to phase out steroid creams slowly, especially after using them

for a long period of time. Stopping abruptly may cause the rash to flare up again –this is called a

rebound effect.
Once you have atopic eczema under good control, you will still need some steroid cream at home for

dealing with relapses. As soon as you notice any rough, itchy skin, apply the cream twice daily for

three days, then once daily for another three days. This should be enough to curb the outbreak of

eczema before it really gets going.
Side effects
To assess the risk of side effects from your steroid cream or oirtment, you need to know how strong it

is. Four grades are recognised: mild (corresponding to non-prescription hydrocortisone cream),

moderately potent, potent and very potent. Ask your doctor or pharmacist which grade corresponds to

your cream, so that you can make sense of the information given below.
Unfortunately, if steroid creams are not used correctly, there are some quite serious local side

effects. Any steroid cream that is strong enough to work is also strong enough to produce side effects

if over-used, so this is a delicate balancing act. The main local side effects are thinning of the skin

and striae (stretch marks). Teenagers and pregnant women are particularly susceptible to stretch marks

if using steroid creams.
It is important to take care because these side effects can be irreversible. The stretch marks, for

example, may fade in time but never entirely disappear. Sustained over-use of steroid creams can

produce permanent thinning of the skin. Thinning of the ski on the face may produce redness, with small

blood vessels shoving through. The fingertips may develop painful cracks.
Note that these side effects can come on very gradually.. Some may be mistaken for symptoms of the

disease itself.
Other local side effects may include an outbreak of spots that look rather like acne. Increased

hairiness or change in skin colour are also possible. Fortunately these effects are reversible.
To avoid side effects, follow the instructions for using steroid creams carefully, and don’t apply too

much or too often. If you have not been given clear instructions by your doctor on the quantity to use,

go back and ask for more information. Ideally, you should actually be shown the correct amount of the

cream to use each time. Remember to wash your fingers after applying steroid creams
If potent or very potent steroid creams are slapped on W& abandon, enough is absorbed into the

bloodstream to produce systemic side effects, comparable to those that can occur with steroid tablets

(see p. 142).
With very potent steroid creams, used for a long period of time, there is some risk of slight systemic

side effects even though the instructions for use are carefully followed. Young children more

susceptible. Bear in mind that covering the skin with cages after applying the cream increases the

amount absorbed into the bloodstream. The degree of adrenal suppression caused by using the cream (see

p. 142) is probably going to remain unnoticed in everyday life, but a major illness, accident,

childbirth or a surgical operation might reveal the problem – so tell medical what you have been using.
Different areas of the body respond differently to steroids creams. The skin of the face, and within

skin folds.
sensitive and generally requires a lower-strength cream, while the palms of the hands and the soles of

the feet require a higher strength. The genitals and the area around the anus are particularly

sensitive, and can become permanently damaged (and then a source of intense discomfort) by strong

steroid creams: some dermatologists recommend using nothing stronger than 1 % hydrocortisone.
Make sure you see your doctor regularly when using steroid creams continuously, especially if:
•    you are using very potent steroid cream
•    you are applying potent or moderately potent steroid cream over more than 20% of your body for

more than a month
•    you are applying potent steroid cream to a baby or young child.
The vehicle – the cream or ointment base in which the steroid is carried – is important because

sensitivity reactions can occur to certain of its ingredients (see p. 45). Eczema sufferers can even

become sensitised to the steroid itself, and this problem is difficult to diagnose because patch tests

with steroids often give false negatives (see box on p. 91). If you are not getting better, ask the

doctor if this could be the explanation. (If a rash gets worse and starts to spread when you begin

using steroid creams, go back and see the doctor very promptly – you may have an infection called

tinea, or ringworm, which flourishes all the more when steroid creams are applied.)
Tacrolimus and pimecrolimus
These are new treatments for atopic eczema. They are not steroids, but are covered here because they

are an alternative to steroid creams and ointments, and if you are comparing the two treatments it may

help to have the information on them side-by-side.
Tacrolimus ointment (brand name Protopic) is for the treatment of moderate to severe atopic eczema, and

pimecrolimus ointment (brand name Elidel) is for milder atopic eczema, especially in children.
These drugs are immunomodulatory rather than immune-suppressive – they adjust the balance of immune

reactions in the
skin. Unlike with steroid creams, there is no risk of thinning the skin, so they can be used on

delicate areas like the face and eyelids.
These treatments are generally used for patients who are not getting better with moisturisers and

steroid creams. Because they cost so much more (about ten times as much as topical steroid treatment),

and since much of the fear of steroid creams is unfounded, doctors are reluctant to prescribe

tacrolimus ointment ,on demand’. With time, the cost of these treatments may fall.
One important advantage of tacrolimus and pimecrolimus ointments is that they may have good effects

that persist after you have stopped using them. And the benefits are cumulative: in one trial where

babies with atopic eczema were treated with pimecrolimus ointment on an as-needed basis, most had fewer

and fewer flare-ups as the months went by. This was not true of babies being treated with steroid

cream.
As with topical steroids, the effect of tacrolimus and pimecrolimus on infections such as

Staphylococcus aureus is surprisingly beneficial: the enormous improvement in the surface structure of

the skin keeps bacteria out. But heavily infected skin should be thoroughly treated with antibiotics

before you start. While using the ointment, watch out for any signs of infection, especially herpes

(see p. 44), and see your doctor immediately.
Minimise your exposure to UV light – in sunlight and sunlamps – because of the tendency of UV to

provoke skin cancers. With the dampening effect that tacrolimus has on the immune system, the risk of

skin cancers may be a little higher.
Don’t apply anything else to the skin (not even moisturisers) within two hours of putting on the

tacrolimus ointment – they dilute the treatment too much. And don’t apply tacrolimus ointment

underneath bandages or other dressings.
Side effects
A few patients find that, while using tacrolimus ointment, skin in areas not being treated actually

gets worse. Talk to your doctor if this happens. Other possible side effects include stinging and

burning when applied, or redness. These are nothing to worry about, and usually lessen with time.
Some common brand names
Common brand names of steroids include:
nose drops – Betnesol, Vista-Methasone
nasal sprays – Beclometasone, Beconase, Flixonase, Nasacort, Nasonex, Rhinocort Aqua, Syntaris eye

drops – Betnesol, Cloburate, Maxidex, Predsol, Vista-Methasone
inhalers – Aerobec, Becloforte, Beclometasone, Becotide, Flixotide, Pulmicort
tablets – Betnesol, Cortisyl, Dexamethasone, Medrone, Prednesol, Prednisolone,
creams – Adcortyl, Betnovate, Dermovate, Fucibet, Synalar

Asthma.
Tom works for the Post Office, sorting mail on a night shift. ‘After work, I come out of the sorting office - it’s about five or six in the morning, and really cold - and when I suddenly hit the cold air, I feel as if I just can’t breathe. My chest clamps up like anything, so much that it hurts. Then, when I get in the car and put the heater on, it’s fine again.’
What Tom is describing is bronchospasm, the key event in asthma – a sudden, but reversible, tightening of the bands of muscle that surround the airways. The narrowed airways stop air from leaving the lungs at the normal speed, which means the lungs are still half-full when it’s time for the next in-breath.
Taking more air into half-full lungs produces pain and tightness in the chest, as the lungs become over-inflated. (This can be alarming, because it can seem like pain from the heart, but it is just the rib joints and chest muscles hurting as they become stretched.)
Insufficient oxygen reaches the bloodstream because there is so much stale air in the lungs, so the asthmatic also feels breathless. Meanwhile, the air being forced through the narrowed airways makes a whistling sound called wheezing.
Those are the common symptoms of asthma, but there are others:
• Coughing, rather than wheezing, is the main symptom for some people (see box on p. 40).
• Sometimes there is vomiting during an asthma attack, especially in children, because the
overexpanded lungs put a great deal of pressure on the stomach.
• A few asthmatics suffer narrowing in the trachea (the upper part of the windpipe) rather than
in the airways lower down, and therefore feel as if they are being strangled.
Bronchospasm is just the endpoint of the disease process in asthma, a process which begins with inflammation of the lining of the airways. Although the airway muscles relax when an asthma attack is over, and you therefore feel much better, the underlying inflammation of the airways remains.
Airway inflammation may be caused, or partially caused, by allergy. Among asthmatic children, allergies are detected in 80-90%.
Inflammation makes the lining of the airways swell up, which itself narrows the airways a little. The inflamed airway lining often makes more mucus than usual, in an effort to protect itself (this is basically a healthy response – mucus works like a sponge mopping up irritating dust particles so that they can be ejected by coughing – but it’s excessive in asthma). This mucus can clog up the airways even more. Finally, the inflamed airways send nerve impulses direct to the airway muscles telling them to contract.
Mucus alert
Asthmatic mucus is white or clear, and sometimes frothy. Greenish or yellowish mucus suggests an infection and should be reported to your doctor.
In severe cases of asthma, a lump of mucus can completely block an airway, leading part of the lung to collapse. It is vital to clear mucus from the lungs, and a physiotherapist can help with this.
What causes asthma?
This question can be answered at three different levels:
1 What makes someone predisposed to asthma?
2 What starts asthma off – in other words, what starts the inflammation process in the airways?
3 What triggers asthma attacks (episodes of bronchospasm)?
What makes someone predisposed to asthma?
The predisposition to asthma is partly inherited (see p. and partly a matter of lifestyle: a poor
diet makes asthma more likely (see p. 206), as does too much cleanliness (see p. 21), obesity and lack of exercise.
What starts off the inflammation?
The predisposition to asthma sets the stage, but it does not, in itself, start the inflammation of the airways. That is often begun by an allergic reaction to something in the air – such as house-dust mite or pet allergens.
Alternatively, the initiating factor could be a viral infection, especially a kind known as Respiratory

Syncytial Virus or RSV – there are epidemics of RSV every two or three years. Those predisposed to

asthma may make an abnormal kind of immune response to chest infections caused by viruses, a response

that shifts the balance of the immune system towards Th2 cells (see p. 11) and allergy-type reactions.

Although the infection is defeated by the immune system, some inflammation of the airway lining

remains.
A heavy dose of certain irritants, such as chlorine, or the substances used in spray-painting cars, can

also initiate asthma; this mainly occurs in a workplace setting, causing occupational asthma (see box

on p. 133).
What triggers asthma attacks?
Once the inflammation of the airways has begun, the airways are ‘twitchy’ –oversensitive – and the

airway muscles contract (i.e. bronchospasm occurs) at the smallest provocation. This contraction of the

muscles – an asthma attack –can be caused by irritants in the air, such as tobacco smoke, or a great

variety of other things. The possible triggers range from cold air or the scent of hyacinths, to

thunderstorms, laughter or anxiety – see p. 39 for a full list. Exposure to the allergens that started

the inflammation will also trigger an asthma attack, as will a virus (viral) infection such as a cold

or flu.
For many asthmatics, the breathing pattern is disturbed by the asthma attacks, and may remain abnormal

between attacks. Hyperventilation or ‘over-breathing’ can begin quite easily for asthmatics, and then

adds to the overall problems. It may be difficult to tell if you hyperventilate or not, because your

habitual pattern of breathing will seem normal to you, but there may be tell-tale symptoms such as

dizziness, tingling of the hands and feet, numbness and muscle cramps. For a full list of symptoms see

p. 227.
Mind power
The muscle of the airways is the kind of muscle over which we have no conscious control, like that of

the heart. It is known as involuntary muscle, whereas muscles in the arms and legs, which contract or

relax when we tell them to, are called voluntary muscles. Studies with biofeedback have shown that

asthmatics may, with training, gain some degree of control over these involuntary muscles. Experienced

yoga practitioners are able to influence certain involuntary muscles, including those in the airways.
There are also various ways in which the mind, or a person’s social and emotional situation, can make

asthma worse (see p. 234) but the damaging idea that it is an entirely ‘psychological’ disease is now

discounted.
Allergens and irritants
Understanding the difference between allergens and irritants is important for asthmatics. Allergens are

specific — either pollen is an allergen for you or it isn’t, depending on how your immune system reacts

to it. They are also a basic cause of asthma — they start it off.
Irritants, on the other hand, are non-specific: they affect every asthmatic if sufficiently

concentrated, causing bronchospasm by aggravating the airway lining. And, at the levels usually

encountered, they only cause trouble because the inflammation of the airways has already occurred.

Irritants include cigarette smoke, other smoke and some industrial fumes, ozone (see p. 130), sulphur

dioxide (given off by some foods and drinks — see box on p. 207), fly spray, air freshener and other

aerosols.
Diagnosis
There are four separate aspects to diagnosis:
1 Is this really asthma or something else entirely?
2 Is it combined with other diseases, and how are they affecting the asthma?
3 What is the basic cause of the inflammation in the airways, and can this be avoided?
4 What sort of factors trigger the asthma attacks?
You may not get this full diagnostic programme, but you can probably help in finding answers to some of

the questions.
Is this really asthma or something else entirely?
There are no tests that can diagnose asthma with complete certainty, but the average case of adult

asthma is pretty easy to spot, and the same is true for children over five. It is also true, however,

that some patients now described as asthmatic would have been given a different diagnosis (e.g. wheezy

bronchitis) thirty years ago. To some extent, this is because asthma was under-diagnosed in the past:

doctors were hesitant about giving a diagnosis of asthma, because of the supposed overtones of

psychosomatic disease. Sweeping away that stigma has been of immense value, but certain patients

(especially young children) may now get diagnosed as asthmatic without sufficient evidence. However,

there are also many instances of asthma being missed.
There are two tests that should be carried out before you are given a diagnosis of asthma:
1 Peak flow is the top speed of the outgoing air from your lungs, usually measured with a simple

portable machine called a peak-flow meter. Because of the narrowed airways, asthmatics have a lower

peak flow than normal.
2 The reversibility test depends on measuring peak flow before and after inhaling a beta-2 reliever

drug which relaxes the airway muscles (see p. 152). If the drug improves peak flow by more than 15%,

this strongly suggests asthma.
Asthma may be difficult to diagnose in certain situations:
• In babies, who often wheeze, especially when they have colds or chest infections. This

generally clears up later and does not automatically develop into asthma. There is great controversy

about whether wheezy babies should be labelled ‘asthmatic’ or not, and how bad the wheezing should be

before they are given asthma drugs. Views on this vary, so you may want to see a different doctor for a

second opinion. For older children who wheeze only when they get chest infections, most doctors feel it

is valuable to use asthma drugs – such treatment does not ‘turn wheezing into asthma’
as is sometimes claimed. (There are several things you can do to minimise the chance of early wheezing

turning into asthma later – see pp. 244-9.)
• When the main symptom is coughing (see box on p. 40).
• When asthma occurs only at night. In some asthmatics, even intensive testing reveals no

abnormality in the airways during the day. The only way to diagnose the condition is to use a peak-flow

meter at home, morning and evening.
• When there is a sudden one-off asthma attack in response to a powerful allergen load. This

sometimes happens to hayfever sufferers at the height of the pollen season (especially during

thunderstorms). Some doctors will want to start asthma drugs immediately, but it may be better to get

the hayfever well controlled with antihistamines and see what happens. Often there are no further

asthma attacks.
Then there are conditions that can be mistaken for asthma:
• In children, an inhaled object – such as a nut or part of a toy – becoming stuck in the

airways. In babies it can also be inhalation of milk droplets; if so, the ‘asthma’ comes on mainly

after feeding.
• Post-nasal drip (see p. 29)
• Heiner’s Syndrome – (see p. 72)
• Bronchiolitis: a viral infection (generally caused by RSV –see p. 37) which affects the small

airways (the bronchioles) of babies and toddlers. Unlike asthma, it usually produces fever.
• Gastro-oesophageal reflux (GER), or the rising of acid from the stomach into the oesophagus.

(This is commonly called heartburn, after its most typical symptom, but you can suffer from GER without

having heartburn.) GER can aggravate existing asthma, and it can also be an asthma mimic. Babies,

children and adults can all suffer from this problem. There will usually be clues such as symptoms that

come on at night after a late supper, or whenever lying down.
• Hyperventilation (see p. 227) in non-asthmatics can be misdiagnosed as asthma if it causes

breathlessness.
• Aspergillosis (see box on p. 18)
• Problems with the vocal cords. Habitually contracting the vocal cords on the in-breath makes a

loud wheezing sound and can cause breathlessness. This problem can mimic asthma, but it also affects

those who really are asthmatic. The cause may be psychological.
• Low-level carbon monoxide poisoning, generally from gas fires, which can cause breathlessness

and fatigue.
• Bronchlectasis: stretching and damage to the airways caused by diseases caught in childhood,

such as pneumonia or whooping cough. This causes lifelong breathlessness.
Is it combined with other diseases, and how are they affecting the asthma?
Any allergic problems in the nose will contribute to asthmatic symptoms in the lungs, because there are

nerve-connections between the two. Long-term sinusitis can also make matters worse. Optimum treatment

for the nasal and sinus symptoms (see pp. 28-35) will help considerably with the asthma.
One unlikely source of asthmatic symptoms has only recently been recognised: allergies can develop to

the fungi causing athlete’s foot, or other diseases (see pp. 16-17).
GER (see p. 38) can contribute substantially to asthma. In some people, the reflux causes no obvious

symptoms, apart from worsening the asthma; medical tests can show that reflux is occurring. Your doctor

can advise on this, and on treatment.
For older people, especially veteran smokers, asthma may be part of a larger picture of inflammation

and damage to the air sacs of the lung (emphysema) and/or to the airways (bronchitis). This mosaic of

problems is known as chronic obstructive pulmonary disease (COPD). It may be difficult to tell if there

is asthma present, or how much it is contributing to the overall problem. Since many patients with COPD

are helped by asthma drugs, and trying out the drugs does no harm, doctors often prescribe them just to

see what happens.
What is the basic cause of airway inflammation? Skin-prick tests are usually needed here, to check for

allergic reactions. It may be difficult to get these in Britain, where there is a shortage of

allergists (see p. 89).
Simple detective work may pinpoint allergens without the need for tests. The likely suspects are all

airborne allergens – see p. 28. Remember that the reaction does not generally start as soon as exposure

to the allergen begins: there is a time-lag. So a new dog or cat, or an allergen encountered at work,

may cause no trouble for the first year or two.
Some irritants can also be a basic cause of asthma, but only if encountered in high doses, which

usually occur in the workplace. These are called asthmagens (see box on p. 133).
In all cases, removing the allergen or irritant from the airways should be a top priority. The sooner

you can end the exposure, the more likely you are to shake off the asthma, rather than have it for

ever. Once the inflammation of the airways is firmly established, it just fuels itself – so act

quickly.
In a minority of cases, food sensitivity is the initiating cause of asthma. The reaction to food is

delayed, so the link will not be obvious. Skin-prick tests for the culprit food are usually negative,

so an elimination diet (see p. 194) is needed to diagnose this problem and identify the food concerned.

Those most likely to benefit are brittle asthmatics (those most severely affected) – as many as 60%

have a food sensitivity. There are various other clues that food could be a factor (see p. 69).
When asthma begins in adulthood, there may be no clear initiating cause – it is just a question of

long-term damage and irritation to the airways. But there can be allergens playing a part, so it is

worth investigating this possibility.
What sort of factors trigger the asthma attacks?
Most asthmatics will recognise one or more of these as triggers:
• cold or dry air
• strong smells including perfume and fragrant flowers
• irritants in the air (such as cigarette smoke and other indoor pollutants, traffic fumes,

industrial pollutants); indoor pollution is often the worst, especially if you have a gas cooker

without adequate ventilation, so there is a lot you can do to improve the air you breathe (see pp.

128-30)
• sulphur dioxide given off by preservatives used in some food and drink (see box on p. 207)
• weather conditions, particularly thunderstorms
• laughing, sighing, yawning, coughing or any other altered breathing pattern
• stress or anxiety
• strong emotions such as fear, anger or excitement
• situations or people that evoke unpleasant memories –including traumatic childhood memories;

sometimes psychotherapy is needed to sort out such problems (see p. 233)
• exercise (because breathing hard dries out the airways)
• the allergens responsible for the asthma, e.g. cat allergen
• colds, flu and chest infections.
Recording your symptoms day-by-day should help to identify the triggers that are most powerful for you.

Generally speaking, such triggers should be avoided, but this is not the case for exercise which does

much more good than harm, in the long run – without exercise, your asthma will get far worse (see p.

41).
Take care with aspirin
Aspirin sensitivity can develop unexpectedly in asthmatics, especially those with allergic rhinitis

and/or nasal polyps (see box on p. 28). It can produce a severe, even fatal, asthma attack in someone

who has previously been able to take aspirin (see p. 151).
Treatment
The first and most important aspect of asthma is environmental control – to try to minimise contact

with allergens and irritants. If you are asthmatic and you smoke, you must stop, because this will only

make matters worse by stoking up the inflammation. Any other smokers in the family should accept that

from now on this is an outdoor activity.
One of the aims of good asthma treatment is to calm the airways down, so that they are less sensitive

and ‘twitchy’. This means tackling the inflammation. You can do this with preventer drugs such as

steroids or cromoglycate (see p. 157), or with the new anti - leu kotriene drugs (see p. 159), or you

can simply remove the basic cause of the trouble, if it is a domestic allergen source, such as a cat, a

dog or house-dust mites.
Treating associated diseases such as sinusitis, hayfever, perennial allergic rhinifis, gastroesophageal

reflux (GER – see p. 38) and athlete’s foot (where this is adding to the symptoms – see p. 16) can also

help in reducing the airway inflammation. Eating a better diet may make a further contribution to

calming the airways down (see p. 206).
The second strand of treatment is to deal with bronchospasm (contraction of the airway muscles) when it

occurs. This is done with reliever drugs such as Ventolin and Atrovent (see p. 152). Note that these

only relieve the symptoms of an asthma attack, and do not address the underlying problem of

inflammation. What is more, if used too frequently (more than once a day) they may increase the risk of

a fatal or near-fatal asthma attack (see p. 153).
At one time, reliever drugs were the mainstay of asthma treatment, and were perceived as entirely safe,

while preventer drugs such as steroids were only given to those with severe asthma. All this has

changed, and most asthmatics, other than those with very infrequent attacks, are now given a

pre-venter. If your drug regime has not been reviewed for some time, make an appointment with your

doctor and check that you are getting the best of the modern treatments.
Drug treatment of asthma is not something you can just hand over to the doctor – it requires a lot of

personal decision - making. If you usually get worse when you have a cold, for example, you need to
Just a cough?
For some, coughing is the main symptom of asthma. Known as cough-variant asthma, this is not always

diagnosed correctly, especially in children. For children with recurrent coughing (two or more episodes

per year of coughing without a cold) it may be a long time before the doctor considers asthma. But

other doctors may diagnose a coughing child as `asthmatic’ all too readily, without doing enough tests.

The important point is that asthma involves episodes of bronchospasm – contraction of the airway

muscles. Without this it is not asthma. Bronchospasm can be detected by medical tests such as peak-flow

readings. Wheezing is one possible symptom of bronchospasm, but coughing is another.
If there is only coughing as a symptom, and never any wheezing, this is probably not asthma. Among

children with this pattern of symptoms, allergies are unlikely to be involved. The cause of such

coughing may be:
• in children, the effects of parental smoking
• in those with perennial allergic rhinitis (see pp. 28-9) mucus from the nose running into the

lungs. This is called post-nasal drip and produces a persistent cough.
• in the middle-aged, eosinophilic bronchitis. This is caused by an influx of eosinophils (see p.

19) into the airway lining, causing inflammation. Allergies do not seem to play a part (it is no more

common in atopics than anyone else) and the airway muscles do not contract abnormally. Treatment is

with inhaled steroids.
• in atopics (those prone to allergies), a condition sometimes called atopic cough. It involves

eosinophils congregating in the trachea (windpipe) and bronchi, but not in the lower airways. There is

inflammation but no airway narrowing. Very little is known about this disease at present; it may or may

not involve allergies. Again, inhaled steroids are effective.
• for a few people, habitual coughing. This is usually an expression of some underlying emotional

difficulty and responds to psychological treatments. The cough often has a honking or barking sound.
Any of these can be misdiagnosed as asthma. For patients with eosinophilic bronchitis or atopic cough,

this is no tragedy as they will probably get the right treatment (inhaled steroids) anyway. But if more

exact diagnostic criteria are being used (e.g. a reversibility test – see p. 38) such patients will not

be classed as asthmatic – this is more of a problem because they may not get appropriate treatment.
increase your dose of preventer as soon as a cold appears, to stop airway inflammation before it

starts. You also need to know when an asthma attack is serious enough to warrant calling an ambulance.

A management plan, worked out with your doctor, is a useful aid (see p. 96). Using a peak-flow meter,

night and morning, to monitor your asthma will also be valuable (see p. 97).
The third strand of asthma treatment is to deal with associated problems:
• Panicky reactions during asthma attacks –which make matters infinitely worse – can be dealt

with by meditation, yoga, relaxation techniques or martial arts training (see p. 222).
• Hyperventilation, which plays a much larger role in asthma than previously suspected, can be

tackled by a variety of methods (see p. 228).
• The distortions of the rib-cage that develop in severe asthma can be treated with osteopathy.
• Losing weight, if you are very heavy, will help ease the burden on your breathing.
Exercise and asthma
Exercise-induced asthma is best tackled, paradoxically, by taking exercise. As your fitness improves,

you don’t pant so hard when exercising, so your airways dry out much less. Countless asthmatics will

tell you that once you overcome the first hurdle – of wheezing the minute you start to exercise –

things get a great deal easier. You will need reliever drugs, and possibly extra preventer, to help you

over this hurdle, but it’s worth it. Warming up with a few sharp sprints, separated by a rest period,

will also help. (If you get an asthma attack while exercising, however, you should always stop –

carrying on regardless can be fatal – literally. Always have your reliever inhaler with you when you

exercise and use it if you get an attack.)
Swimming is an excellent starting point for unfit asthmatics, because the moist air prevents the

airways from drying out. Swim outdoors if you can, since chlorine can be an irritant.
Once you are fitter, regular strenuous exercise makes the breathing muscles stronger, which is of great

benefit – this can also be achieved with special exercises (see p. 231).
Don’t underestimate asthma
Asthma can be fatal, so never take it too lightly. If you often wake up in the night with asthma, you

cannot keep up with most other people your age, or are frequently breathless when climbing stairs or

walking uphill, then your asthma is not under control. The same is true if you need your reliever

inhaler more than once a day, or frequently need steroid tablets. Review your treatment with your

doctor because you probably need more preventive treatment such as inhaled steroids (see p. 157) or

anti-leukotriene drugs (see p. 149).
Recognising an asthma attack and knowing when to call for help, or go to the hospital, is also crucial

(see p. 100). Remember that fatal asthma attacks often come on very quickly – half those who die do so

within two hours of the attack starting, and a quarter die within 30 minutes. Those who die are

generally people who have neglected their preventer medication, or have been exposed to very high

levels of allergens.
There is a major organisation involved in asthma prevention, by the name of Asthma UK. They work together with people with asthma, health professionals and researchers, to develop and share expertise to help people increase their understanding of asthma, and asthma prevention, allowing them to voice their concerns to the people who matter and reduce the effect of it on their lives. They are the only charity dedicated to asthma prevention by improving the health and well-being of people with asthma and are funded by voluntary donations, indeed they are responsible for nearly £3m of asthma research each year for the cause of asthma prevention.

A form of asthma prevention can be in the improvements in environmental quality to benefit everyone in the school building because pollutants have a universally negative effect. For example, for the benefit of the students, schools should undertake extensive building repairs, painting, cleaning, and extermination during long vacations. They should replace plastic furniture and carpeting, which often emit pollutants in the form of noxious gases. For further asthma prevention, they should limit use of cleaning supplies and equipment that emit toxic fumes and strong odours which again are pollutants, and require good ventilation when they are used. They should have the entire building (particularly the heating and ventilation system) cleaned regularly to eliminate dust mites, mildew, animal dander, feathers, cockroaches, and other possible asthma and allergy triggers, and make sure that leaks of water and plaster dust are stopped and quickly cleaned up. Additionally the can help in asthma prevention by regularly monitoring the air quality of schools, especially those in sealed buildings and try to increase the ventilation so that pollutants can escape. All this can help with asthma prevention. So whilst schools may not be able to eliminate other pollutants, such as chalk dust, they can, as an act of asthma prevention, find out which of them are triggers for particular students and try to limit the student’s exposure to them. Further, sensitive scheduling can keep students with specific sensitivities away from certain art supplies and animals, which may enhance the education of some students but sicken students with asthma.

As an asthma prevention in Scandinavia, cross-country skiers sometimes wear breathing masks which store the heat and moisture from the air they breathe out and then return it to the air they breathe in. This is helpful in avoiding exercise-induced asthma. Good control of your asthma, whether by breathing in a ‘preventer’ treatment or by avoiding causes of asthma such as house dust mites and pets can have a tremendously helpful effect on exercise-induced asthma. Reliever inhalers can be tremendously helpful in asthma prevention if you use them just before you exercise. This applies especially to the so-called ‘beta-2 stimulants’ such as salbutamol (albuterol) or terbutaline. The benefit should last for hours. Long-acting reliever inhalers are also very helpful; they just work for longer. If you are a competitive athlete or sportsman, you may be concerned about disqualification because you use drugs. The good news is that all the ordinary asthma medicines, used in the medically recommended way and dosage, are acceptable to sporting bodies provided you use them correctly for asthma. The wise thing is to check with your sports authority or sports doctor. Asthma prevention is good asthma management!
There are oral asthma medications that an individual can take to control their asthma, inhaled at the onset of an asthma attack. People with asthma can carry a peak flow meter; a hand-held tool for measuring their air flow to determine whether an attack is imminent, thus requiring their asthma medications. With help from medical providers and age-appropriate printed materials, children can learn to monitor their asthma and self-medicate with their asthma medications. Taking such control of their asthma medications not only decreases its symptoms, but also promotes the children’s feelings of self-confidence, with the management of their asthma and its medications.

There are dozens of asthma medications available in the UK; the most frequently prescribed of these medications being: Ventolin; Bricanyl; Becodite; Pulmicort; Intal and Tilade. The first 2 asthma medications are essentially relievers, whilst the others are preventers. The preventer drugs are taken by an inhaled route and must be taken regularly to gain maximum effect. They belong to either the steroid or anti-inflammatory groups of asthma medications. The reliever drugs do not need to be taken as often; indeed there is evidence to support that these medications are more effective when they are taken only occasionally. Naturally there will be a concern about side effects, but in the main, asthma medications are safe and free from problems.

One such treatment which can have side effects is a steroid called prednisolone; which is taken by tablet form. These asthma medications dampen down and reduces inflammation, swelling and phlegm. There is a soluble form of these medications called Prednesol, which is useful for children and people who struggle to swallow tablets. If used in short courses there should be no risks at all; it is only when these asthma medications are prescribed over a period of years that certain side effects can occur. These include skin changes, thinning of the bones, increased blood pressure, indigestion, ulcers and the development of diabetes. Once again the emphasis is on serious long term prescriptions of these asthma medications and a brief course has no history of causing any of the above side effects.

Asthma is not an allergy as such, but there are asthma triggers, which can be caused by an allergic reaction to any number of incidents. If you have asthma, your air passages are irritable. This means things which are harmless to other people may be asthma triggers to an asthma sufferer. Various asthma triggers include: (i) Emotional stress - people with asthma often say their asthma gets worse if they are upset. (ii) Cold air - if you move from warm indoor air to cold air outdoors it can affect the air passeges. (iii) Pollution, in particular tobacco smoke - e.g. in a pub, can be one of the more common asthma triggers. (iv) Grass pollen - particularly when exposed to a recently mown lawn. (v) House dust mites - often attracted by central heating. (vii) Pet fur - especially during the malting season can affect the air passeges. (viii) Exercise - can provoke narrowing of the air passages. (ix) Infections of the lining of the breathing passages - e.g. colds and ‘flu. (x) Some drugs - especially medicines called beta blockers used for high blood pressure or heart disease have been known to be asthma triggers. (xi) Indigestion - also called gastro-oesophageal reflux, with stomach acid coming up into your gullet. (xii) Laughing - so don’t laugh! (Only joking, but it can happen). All the above reflect the irritability of the air passages in asthma, even if some of them do so in somewhat different ways, they all can be asthma triggers.

There have been significant changes in air quality over the past few decades. Pollution, from the burning of coal, which resulted in emissions of sulphur dioxide and particulate matter has decreased considerably; however, the frequency of peaks of traffic related pollution and the geographical extent of it have probably increased. Episodes of pollution from secondary pollutants, notably ozone, produced by photochemical oxidation, have also increased and this is one of the chief asthma triggers. Moreover, there have also been changes in people’s diet, lifestyle, and in homes and other indoor environments. For example, homes have tended to become warmer and, in this and other ways, much more appealing to cohabitation by dust mites, a real enemy of asthma sufferers. All these can act as asthma triggers. Cinemas and theatres can also surprisingly act as asthma triggers for some people. Research carried out recently found low levels of bacteria and moulds on carpets and seats, but high concentrations of cat allergens; presumably brought in on the clothes of members of the audience. Maybe get a DVD next time!