Posts Tagged ‘complication’

Generic Name
Clonidine (KLAH-nih-dene)
Brand Names
Catapres-TTS-2
Catapres-TTS-1    Catapres-TTS-3
Type of Drug
Alpha receptor stimulant.
Prescribed For
High blood pressure, including hypertensive emergency (diastolic blood pressure over 120); also used for excess sweating, childhood growth delay, attention-deficit hyperactivity disorder (ADHD), Tourette’s syndrome, restless leg syndrome, schizophrenic psychosis, migraine, ulcerative colitis, painful or difficult menstruation, hot flashes related to menopause, diagnosis of pheochromocytoma (adrenal-gland tumor), kidney poisoning associated with cyclosporine, diabetic diarrhea, smoking cessation, methadone and opiate detoxification, withdrawal from alcohol and benzodiazepines such as Valium, nerve pain following herpes attack, and allergic reactions in the presence of asthma triggered by external sources.
General Information
Clonidine stimulates nerve endings in the brain called alphaadrenergic receptors. It reduces blood pressure by dilating (widening) blood vessels. Clonidine works quickly, decreasing blood pressure within 1 hour. The other uses of clonidine relate to its stimulation of alpha receptors in the body.
Cautions and Warnings
Do not take clonidine if you are allergic or sensitive to any of its ingredients.
People who have had a stroke or recent heart attack or who have cardiac insufficiency or chronic kidney failure should avoid taking clonidine.
Some people develop a tolerance of their clonidine dosage. If this happens, your blood pressure may increase and your doctor may prescribe a higher dose.
Never stop taking clonidine without your doctor’s knowledge. If you abruptly stop taking clonidine, you may experience an unusual increase in blood pressure accompanied by agitation, headache, nervousness, and severe reactions, possibly death. Restarting clonidine therapy or taking another antihypertensive can reverse these effects.
Clonidine may cause degeneration of the    See your eye doctor for regular GheCk Ups lfiyou are taking this drug.
); you require surgery, your doctor will continue your clonidine therapy until about 4 hours before surgery and resume it as soon as possible afterward.
People who develop skin sensitivity (symptoms include rash, itching, and swelling) to Catapres-TTS, the transdermal patch form of clonidine, may experience the same reactions with oral clonidine.
Possible Side Effects
Tablets
♦    Most common: dry mouth, drowsiness, dizziness, constipation, and sedation.
♦    Common: headache and fatigue. These effects tend to diminish within 4-6 weeks.
•    Less common: appetite loss, swelling or pain in the glands of the throat, nausea, vomiting, weight gain, blood-sugar elevation, breast pain or enlargement, worsening of congestive heart failure, heart palpitations, rapid heartbeat, painful blood-vessel spasm, abnormal heart rhythms, electrocardiogram changes, feeling unwell, changes in dream patterns, nightmares, difficulty sleeping, hallucinations, delirium, anxiety, depression, nervousness, restlessness, rash, hives, thinning or loss of scalp hair, difficult or painful urination, nighttime urination, retaining urine, decrease or loss of sex drive, weakness, muscle or joint pain, leg cramps, increased alcohol sensitivity, dryness and burning of the eyes, dry nose, loss of color, and fever.
Transdermal Patch
✓    Most common: dry mouth and drowsiness.
✓    Less common: constipation, nausea, changes in sense of taste, dry throat, fatigue, headache, lethargy, changes in sleep patterns, nervousness, dizziness, impotence, sexual difficulties, and mild skin reactions including itching, swelling, contact dermatitis, discoloration, burning, peeling, throbbing, white patches, and generalized rash. Rashes of the face and tongue have also occurred but cannot be specifically tied to transdermal clonidine.
Drug Interactions
•    Combining clonidine and a beta-adrenergic blocker may increase the severity of a drug-withdrawal reaction and rebound high MW pressure. This reaction may be very serious.
•    Combining verapamil and clonidine may lead to very low blood pressure and atrioventricular (AV) block (abnormality in heartbeat patterns). This reaction may be very serious.
O    Avoid alcohol, barbiturates, and sedatives because they increase the depressive effects of clonidine.
•    Tricyclic and other antidepressants, appetite suppressants, estrogens, stimulants, indomethacin and other nonsteroidal anti-inflammatory drugs (NSAIDs), and prazosin may counteract the effects of clonidine.
•    clonidine may reduce the therapeutic effects of levadopa +
carbidopa.
Food Interactions
The tablets are best taken on an empty stomach but may be taken with food if they upset your stomach.
Usual Dose
Tablets
Adult: high blood pressure-100 mcg twice a day to start; may be raised by 100 mcg a day until maximum control is achieved. Take no more than 2400 mcg a day. Other uses-100-goo mcg a day, or up to 0.8 mcg per lb. of body weight in divided doses. Seniors should start with a lower dose and increase more slowly.
Child: 50-400 mcg orally twice a day.
Transdermal Patch
Adult: 100 mcg delivered daily from a patch applied once every 7 days. Up to two 300-mcg patches may be needed to control blood pressure. Transdermal dosage exceeding 600 mcg a day has not been shown to increase effectiveness.
Child: not recommended.
Overdosage
Symptoms of overdose are slow heartbeat, central- nervous-system depression, very slow breathing, low body temperature, pinpoint pupils, seizures, lethargy, agitation, irritability, nausea, vomiting, abnormal heart rhythms, mild increases in blood pressure followed by a rapid drop in blood pressure, dizziness, weakness, loss of reflexes, and vomiting. Victims should be taken to a hospital emergency room immediately. ALWAYS bring the prescription bottle or container.
Special Information
Gk’3t1161)e causes drowsiness in about 1/3 of people who take it. Be extremely careful while driving or performing any task that requires concentration. This effect is prominent during the first few weeks of clonidine therapy and then tends to decrease.
Do not take over-the-counter cough and cold medications unless directed by your doctor.
Call your doctor it you become depressed or have vivid dreams or nightmares while taking clonidine, or if you develop swelling in your feet or legs, paleness or coldness in your fingertips or toes, or any persistent or bothersome side effect.
Apply the transdermal patch to a hairless area of skin such as the upper arm or torso. Use a different skin site each time. If the patch becomes loose, apply the supplied adhesive directly over it. If the patch falls off before 7 days are up, apply a new one. Do not remove the patch while bathing.
If you forget a dose of oral clonidine, take it as soon as possible and then go back to your regular schedule. If you miss 2 or more consecutive doses, consult your doctor; missed doses may cause blood pressure increases and severe adverse effects. Do not take a double dose.
Special Populations
Pregnancy/Breast-feeding: Clonidine passes into the fetal bloodstream. Animal studies show that clonidine may damage the fetus in doses as low as 1/3 the maximum dose. When this drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
Clonidine passes into breast milk. Nursing mothers who must take this drug should use infant formula.
Seniors: Seniors are more susceptible to the effects of this drug and should begin with lower doses.

Generic Name
Clopidogrel (kloe-PID-oe-grel) nQ
Brand Name  Plavix
Type lul Drug Antiplatelet.
Prescribed For
Heart attack and stroke prevention; also used for blood thinning after placement of a vascular stent.
General Information
Artery-clogging blood clots are often the cause of heart attacks and strokes. clopidogrel reduces the risk of both by helping prevent blood-clot formation. This drug thins the blood by making platelets—the cells that aggregate to form clots—less “sticky.” It starts working in as little as 2 hours after taking a single tablet. The drug’s blood-thinning effect lasts until inactivated platelets are replaced by the body. Studies suggest that clopidogrel is more effective than aspirin in preventing heart attack and stroke in people at risk. People taking clopidogrel after scent surgery usually take it for a relatively short period. Those taking it to prevent a heart attack or stroke must take it for life.
Cautions and Warnings
Do not take clopidogrel if you are allergic or sensitive to any of its ingredients or to ticlopidine, a related antiplatelet. These drugs can rarely cause a rapid drop in white-blood-cell count.
People with bleeding ulcers, brain hemorrhages, or other bleeding problems should use clopidogrel with caution.
Thrombotic thrombocytopenic purpura (TTP) is a rare but serious complication of clopidogrel, sometimes reported after less than 2 weeks of treatment. See your doctor right away if you develop a sudden fever, unusual bruising, nosebleeds, bleeding gums, or any other unusual symptoms. TTP reduces your platelet count, interfering with blood clotting, and affects white-blood-cell count.
People with liver problems should use clopidogrel with caution.
Possible Side Effects
✓    Most common: rash and other skin problems.
✓    Common: chest pain, accidents, flu-like symptoms, pain, headache, dizziness, abdominal pain, upset stomach, joint pain, back pain, black-and-blue marks, and respiratory infection.
✓    Less common: tiredness, Swollen arms or legs, high blood pressure, diarrhea, nausea, bleeding, nosebleeds, breathing difficulties, runny nose, coughing, bronchitis, high blood cholesterol, urinary infection, and depression.
✓    Rare: bleeding in the brain and stomach ulcer. Contact your doctor if you experience any side effect not listed above.
Drug Interactions
•    Clopidogrel may interfere with the body’s ability to break down fluvastatin, nonsteroidal anti-inflammatory drugs (NSAIDs), phenytoin, tamoxifen, tolbutamide, torsamide, and
warfann.
•    Combining clopidogrel and NSAIDs may increase blood loss and bleeding in the stomach and intestines.
•    Do not combine clopidogrel and other antiplatelet drugs or
the anticoagulant (blood thinner) warfarin unless you are
under your doctor’s direct supervision. This interaction may
prevent normal blood clotting and lead to severe bleeding
problems.
Food Interactions
Clopidogrel may be taken without regard to food or meals.
Usual Dose
Adult: 75 mg a day.
Overdosage
Little is known about the effects of clopidogrel overdose aside from reduced blood clotting. Overdose victims should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Minor cuts may take longer to stop bleeding during treatment with clopidogrel. If you are having surgery, make sure your doctor knows you are taking clopidogrel. You may have to stop taking the drug I week before surgery.
If you forget a dose, take it as soon as you remember. If it is almost time for your next dose, skip the forgotten dose and continue with your regular schedule.
Special Populations
Pregnancy/Breast-feeding: The safety of using clopidogrel during pregnancy is not known. Other antiplatelet drugs, tike aspirin, are not used during pregnancy due to their possible effects on Mrjlher and fetus. When this drug is considered crucial by your doctor, its benefits must be carefully weighed against its risks.
Clopidogrel may pass into breast milk. Nursing mothers who must take this drug should use infant formula.
Seniors: Seniors may take this drug without special precaution.

Generic Name
Clorazepate (klor-AZ-uh-pate) 99
Brand Names
Gen-Xene    Tranxene-SD
Tranxene    Tranxene T-Tab
Type of Drug
Benzodiazepine sedative.
Prescribed For
Anxiety, tension, fatigue, and agitation; symptoms of acute alcohol withdrawal; partial seizures; also prescribed for irritable bowel syndrome and panic attacks.
General Information
Clorazepate dipotassium is a benzodiazepine. Benzodiazepines directly affect the brain. They can relax you and make you more tranquil or sleepier, or they can slow nervous system transmissions in such a way as to act as an anticonvulsant. Many doctors prefer benzodiazepines to other drugs that can be used to similar effect because they tend to be safer, have fewer side effects, and usually work as well, if not better.
Cautions and Warnings
Do not take clorazepate if you are allergic or sensitive to any of its ingredients or to another benzodiazepine drug, including clonazepam.
Clorazepate can aggravate narrow-angle glaucoma, but you may take it if you have open-angle glaucoma and are receiving therapy for it.
Other conditions in which clorazepate should be avoided are: severe depression, severe lung disease, sleep apnea (intermittent cessation of breathing during sleep), liver disease, drunkenness, and kidney diseaap_, to inOn of these conditions, the qq)NSSvve effects of clorazepate may be enhanced or could be detrimental to your overall condition.
Clorazepate should not be taken by psychotic patients because it is not effective for them and can trigger unusual excitement, stimulation, and rage.
Clorazepate is not intended to be used for more than 3-4 months at a time. Your doctor should reassess your condition before continuing your prescription beyond that time.
Clorazepate may be addictive. It should be used with caution in people with a history of drug dependence.
Drug withdrawal may develop if you stop taking it after as few as 4 weeks of regular use but is more likely after longer use. It may start with anxiety and progress to tingling in the hands or feet, sensitivity to bright light, sleep disturbances, cramps, tremors, muscle tension or twitching, poor concentration, flu-like symptoms, fatigue, appetite loss, sweating, and changes in mental state. Your dosage should always be reduced gradually to prevent drug withdrawal symptoms.
Possible Side Effects
Weakness and confusion may occur, especially in seniors and in those who are more sickly.
✓    Most common: mild drowsiness during the first few days of therapy.
✓    Less common: confusion, depression, lethargy, disorientation, headache, inactivity, slurred speech, stupor, dizziness, tremors, constipation, dry mouth, nausea, inability to control urination, sexual difficulties, irregular menstrual cycle, changes in heart rhythm, low blood pressure, fluid retention, blurred or double vision, itching, rash, hiccups, nervousness, inability to fall asleep, and occasional liver and kidney dysfunction. If you have any of these symptoms, stop taking the medicine and contact your doctor immediately.
✓    Rare: Rare side effects can affect your heart, stomach and intestines, urinary tract, blood, muscles and joints. Contact your doctor if you experience any side effects not listed above.
Drug Interactions
•    Clorazepate is a central-nervous-system depressant. Don’t mix it with alcohol, other sedatives, narcotics, barbiturates, monoamine oxidase inhibitor and other antidepressants, and antihistamines. Taking Clorazepate with these drugs may result in excessive depression, tiredness, sleepiness, breathing difficulties, or related symptoms.
•    Smoking may reduce clorazepate’s effectiveness by in-
creasing the rate at which it is broken down by the body.
•    Clorazepate’s effects may be prolonged when it is mixed with cimetidine, contraceptive drugs, disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, probenecid, propoxyphene, propranolol, rifampin, or valproic acid. Theophylline may reduce clorazepate’s sedative effects.
•    If you take antacids, separate them from your clorazepate dose by at least 1 hour to prevent them from interfering with the absorption of clorazepate into the bloodstream.
•    Clorazepate may increase blood levels of digoxin and the chances of digoxin toxicity.
•    The effect of levodopa + carbidopa may be decreased if it is taken together with clorazepate.
•    Combining clorazepate with phenytoin may increase phenytoin blood concentrations and the chances of phenytoin toxicity.
Food Interactions
Clorazepate is best taken on an empty stomach, but it may be taken with food if it upsets your stomach.
Usual Dose
Immediate-Release
Adult and Child (age 9 and over): 15-60 mg daily. The average dose is 30 mg in divided quantities, but dosage must be adjusted to individual response for maximum effect. Maximum recommended daily dose is 90 mg. For treatment of anxiety, clorazepate may be taken as a single dose at bedtime.
Child (under age 9): not recommended.
Sustained-Release
Adult: The sustained-release form of clorazepate may be given as a single dose, either 11.25 or 22.5 mg, once every 24 hours. Sustained-release tablets are not recommended for the initial dosage.
Child: not recommended.
Overdosage
Symptoms of overdose are confusion, sleepiness, poor coordination, lack of response to pain such as a pin prick, loss of reflexes, shallow breathing, low blood pressure, and coma. The victim should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Clorazepate can cause tiredness, drowsiness, inability to concentrate, or similar symptoms. Be careful if you are driving, operating machinery, or performing other activities that require concentration.
People taking clorazepate for more than 3 or 4 months at a time may develop drug withdrawal reactions if the medication is stopped suddenly (see “Cautions and Warnings”). Do not stop taking clorazepate or increase or decrease your dosage without first consulting your doctor.
If you forget a dose of clorazepate, take it as soon as you remember. If it is almost time for your next dose, skip the dose you forgot and continue with your regular schedule. Do not take a double dose.
Special Populations
Pregnancy/Breast-feeding: Clorazepate may cause birth defects if taken during the first 3 months of pregnancy. Avoid this drug if you are or might be pregnant.
Clorazepate may pass into breast milk. Nursing mothers who must take clorazepate should use infant formula.
Seniors: Seniors, especially those with liver or kidney disease, are more sensitive to the effects of clorazepate and generally require smaller doses to achieve the same effect.

Over-the-Counter Remedies Vitamin E
Vitamin E, once considered a potential super-nutrient, has fallen out of favor as a preventive for heart disease or cancer viagra comercial with vcr . But back when it still looked ever so promising, a group of Italian dermatologists conducted a study to see if vitamin E could improve symptoms of eczema ecstacy lexapro . 295 It was single-blind; that is, the patients did not know who was getting the active treatment, but the doctors did sources side effects zoloft . The patients ranged in age Vita
This fat-soluble vitamin has been disappointing in studies of cancer or heart disease prevention stopped procardia labor . The natural form of vitamin E used in this study (alpha-tocopherol at 400 IU daily) was surprisingly effective in reducing the lesions and itching of eczema ibuprofen urticaria .
Side effects: Minor digestive upset is possible, but unlikely prescription plans that will cover valtrex . Downside: There has been only one study of this therapy for eczema biaxin pack description . Although vitamin E is inexpensive and relatively nontoxic, more studies to substantiate the benefit would be desirable does lipitor cause skin rash .
Cost: Approximately $3 to $8 a month
from 10 to 60 years old, and all had itching that had not been well controlled by their previous therapies how does naproxen sodium work .
The study lasted 8 months, and over the course of that time, the skin of fewer than 10 percent of the people taking vitamin E (400 IU daily) got worse pseudoephedrine hci 60mg . The skin of more than three-fourths of those on placebo had worsened antabuse breath odor . Conversely, almost half of the patients on vitamin E had excellent improvement, compared to only 1 (of 46) of those on placebo baby cannot keep prednisolone down . The investigators noted that the patients who had good results clinically also had marked reduction in the IgE levels that indicate allergic arousal of the immune system wat is lithium . They concluded that vitamin E might prove to be an excellent therapy for atopic dermatitis sie affects of drug diovan . Unfortunately, there are no other studies to confirm or refute these findings de effects of norvasc .
Topical Creams
Over the years, we have learned of a number of surprising remedies for itchy eczema facts and comparison of zyrtec . One is the old-fashioned moisturizing cleanser Noxzema west palm beach lasix center . Many people have written to say they had success easing the itching and even clearing up the rash after applying Noxzema to their eczema cellcept batten disease . Of course, nothing works for eczema all the time separating codeine from promethazine . But Noxzema is relatively low risk remeron tab . We suspect the herbal oils it contains may contribute to its effect clinical trial exelon . According to the manufacturer, camphor, menthol, and eucalyptus have given Noxzema “its redolent signature since 1914 buy accutane online .”
O fosinopril sodiun . I just had to let you know the success I’ve had with your suggestion to use Noxzema for eczema will lasix help with blood test . My 3year-old son has suffered with this skin condition on his legs and feet for 2 years caffeine gum addiction .
We treated it successfully with the prescription drug Elidel, but after learning of safety concerns, we checked with his doctor and stopped using it metronidazole for catas .
I tried many moisturizing creams to soothe his skin, but he cried and said they hurt levothyroxine purchasing . I started using Noxzema the day I read your article, and there were no tears 5 how sildenafil works .
His skin responded quickly and after 3 weeks almost aft traces of eczema are gone viagra vs kamagra . This advice has changed my young son’s life clozapine adverse event reporting post marketing .
A zoloft memory loss . We are certainly pleased to learn of your success toradol breastfeeding side effects . Lore has it that the name Noxzema was given after the product helped an early customer “knock” her eczema wellbutrin anger .
• 0 •
The mainstay of eczema treatment is a topical corticosteroid order tadalafil no prescription . In most cases, the doctor will prescribe a mild cream for
*** Noxzema
The brand now includes a number of different cleansers, but the one you want is the original, in the blue jar viagra paperweight . Apply it to the affected areas like you would a moisturizing cream olmesartan medoxomil . The herbal ingredients, camphor, menthol, and eucalyptus, may be helpful against itch, and the base cream is a good moisturizer allergic reaction to levaquin levaquin medication .
Side effects: Uncommon mucinex with clonidine . Discontinue use if it irritates the skin evista comprimidos .
Downside: There’s no scientific proof that this product will help eczema buy clonidine without prescription .
Cost: Approximately $4 to $6 for 14 ounces
Topical Hydrocortisone I Percent
Topical corticosteroid lotions, creams, and ointments are the mainstay of eczema treatment any difference between methocarbamol flexeril . This is the one that is available without a prescription, because it is less potent than prescription products carisoprodol china production . clozapine vs clozaril . It probably will help mild eczema sertraline hcl 100mg side effects . It may not be strong enough for moderate or severe conditions tetracycline 500mg strength .
The best way to use thislotion or cream is to apply it conscientiously for 3 to 7 days at a time rechargable aa lithium ion . Then take a break for several days amiodarone thyroid australia .
Side effects: Uncommon, but burning, itching, irritation, or dryness could occur where the product is applied does aygestin stop your period . Downside: Long-term use could lead to thinning of the skin novo levofloxacin side effects . This is a small -risk with the over-the-counter creams, but it should be kept in mind ibuprofen slow release r .
Cost: Approximately $3 to for a 1-ounce tube
use on the face and a more potent one for use elsewhere on the body carbatrol versus lamictal . Hydrocortisone 1 percent is available without a prescription and can be used for eczema cis diagnosis lipitor . We don’t suggest longterm use without checking in with the doctor, though lawsuits lithium heart failure valve damage . Even though the nonprescription cream is not very strong, it could still cause some thinning of the skin if it were used for many months flagyl use in cats .
Those who would prefer to avoid hydrocortisone cream may want to check out a product called CamoCare Soothing Cream order ivermectin merck online . It contains extract of chamomile flowers in an emollient base and has been helpful against eczema in one stud y gatifloxacin ophthalmic solution .296 Apparently, it has an effect comparable to low-dose hydrocortisone cream (0 effects side zyrtec .25 to 0 prednisone indications for use .5 percent), although it does not contain any steroid armada 4100 4200 lithium battery .
Another nonprescription ointment that has been put through a clinical trial is a homemade mixture of honey, beeswax, and olive Oil diamox hearing loss .297 This study was not as rigorous as we would like—not by a long shot how much caffeine in go fast . And honey, beeswax, and olive oil might just be too messy to be practical naltrexone and sertraline . But the Dubai dermatologist who ran the trial found that it had benefit for about 80 percent of the patients with eczema soma cruz genya arikado yaoi . That is almost the same as the percentage who respond well to topical steroid creams compazine box . So if you are in the mood for an experiment, get Soothing Cream
CamoCare his cream apparently was developed in Germany and is better known in Europe than in the United States natural sources of penicillin . German chamomile (Matricaria chamomille) contains an lithium grease plastic lubricant .oil called bisabolol that has been shown to have powerfulanti-inflam-matory action, comparable to that of the drug indomethacin imipramine 150 mg . That might explain its improvement of skin irritation drug recall china methotrexate .
Side effects: Some people are allergic to chamomile precose 50mg . Since individuals with atopic dermatitis may be especially susceptible to developing allergies, discontinue use immediately if the rash gets worse common side effects of paxil .
Downside: We know of only one study of CamoCare for eczema prevacid and children . In addition, it is relatively expensive is hydrochlorothiazide .
Cost: Approximately $10 to $14 for a 1-ounce tube lexapro withdrawal migrains .
out the blender and mix together equal amounts of honey, beeswax, and olive oil maximum dose topiramate 1600mg per day . Then see what it does for you psms and spironolactone . It should have no side effects, other than being sticky president ceo tricor systems inc . And it should not be overly expensive what is piroxicam .
Prescription Options
Doctors are most likely to prescribe some form of corticosteroid (cortisone-like) cream or ointment for eczema bipolar zyprexa . That’s because around 80 percent of patients with atopic dermatitis seem to respond well to these prescription creams pseudoephedrine extraction method . Fewer than 40 percent of those patients improve on a placebo cream or ointment 298 That’s why topical corticosteroids are so widely used avapro high blood pressure medicine .
If your doctor has given you a prescription fora corticosteroid, be sure to get the details on how to use it ivax pharm prozac . Using too strong a preparation on the face can have negative consequences zoloft theraputic level . The skin may become thin and tear or bruise easily, and blood vessels may become prominent guidelines for warfarin therapy . In fact, some people with eczema need two different formulations—a fairly strong one for hard-to-treat areas like the hands and a relatively mild one for eczema on the face fentanyl interaction with ultram . Keep in mind, too, that overuse of topical corticosteroids can thin the skin goldline enteric asprin 81mg .
People sometimes worry about steroid side effects from such creams jshua and abilify . It’s not impossible that side effects typically as-
**** Topical Steroids
One or more topical steroid preparations—a cream or an ointment—will probably be the dermatologist’s first choice to control eczema ld50 asprin . It helps significantly in most cases manufacturer information on prednisone .
Follow the directions carefully soma heightened climax . The cream may need to be applied two or three times daily diclofenac sodium 75mg 3ml injection . Do not put a strong steroid on the face, or any steroid cream near the eyes is kamagra illegal uk . Ask your doctor about “pulsing” the use of cream—applying it for 3 to 7 consecutive days and then stopping for several days 17 b estradiol . Adults may be able to use such products for just a few days a week levaquin and colstridium .
Side effects: Stinging, burning, irritation, itching, peeling Downside: Long-term use or application over a large part of the body, especially under a close covering, could thin the skin, lead to marks on the skin, or (most serious) result in side effects similar to those from oral prednisone lithium 450 mg 900 mg .
Cost: Depends upon the specific steroid the doctor selects cephalexin dose for dogs . These drugs can be expensive lamisil and exacerbation of psoriasis . Inquire about a generic version, which may cost much less amoxicillin and indications and uses .
sociated with steroid use might occur, but it is very unlikely unless the area treated is large and has been covered with some kind of bandage or “occlusive dressing withdrawel from zoloft .” Be very careful in applying this kind of treatment barringer wc and minocycline . It may indeed help the skin, but it must not be overdone prevacid for oral suspension ingredients .
Atopiclair
In 2005, the FDA approved a nonsteroidal cream for eczema excellent results taking effexor . Atopiclair is a prescription product that contains a number of botanical extracts in an emollient base taylor lithium scale . Like CamoCare, it contains bisabolol, but Atopiclair also contains a vitamin E—like compound, a licorice root derivative, and an extract of grapeseed, along with shea nut butter celecoxib evaluation . A gel containing licorice extract had earlier shown promise for treating atopic dermatitiS testosterone mesterelone .299
Elidel and Protopic
The frustration of trying to control eczema, a condition that may not respond to the usual anti-inflammatory treatments, has led doctors to explore other treatment options cholesterol pravachol . The de-Clair
This nonsteroidal cream is significantly better than a simple moisturizer at alleviating itch and reducing rash gabapentin and erection problems . It should be applied two or three times a day shell shrimp cytoxan .
Side effects: Local irritation
Downside: People allergic to any of the ingredients, including nuts, should avoid Atopiclair does citalopram .
Cost: Approximately $85 to $95 for lMgram tube
velopment of immune-modulating treatments to prevent the rejection of transplants led some dermatologists to think about modulating the immune reaction at the level of the skin carisoprodol 2444 imprint . After all, eczema does seem to be linked to an immune reaction gone a bit haywire, comparable to hay fever allegra versace 2007 . It turns out that there are two compounds that can be applied topically to dampen the immune response allegra of ri . They are Elidel (pimecrolimus) and Protopic (tacrolimus) seroquel xr versus seroquel .
Parents of children with eczema were very pleased to have these effective treatments made available so they would not have to rely so heavily on potent corticosteroid creams to keep their youngsters comfortable meloxicam taken with tylenol . They were alarmed, however, when the FDA issued a warning that these immune-suppressing drugs might increase the risk of children developing cancer, especially lymphoma order tadalafil ups online . Such cancers are rare in kids, so it will probably be years before it is possible to assess how serious this potential risk really is no prescription german pharmacy prednisone . But weighing red, itchy skin against a potentially lethal disease suggests that these drugs should be used only when other treatments have not worked bupropion high .
Another topical cream for treating eczema is called MimyX cream diflucan used to treat tenia capitas . It is available by prescription, but does not contain a steroid homotaurine campral gabapentin . Clinical trials showed that it can reduce the size of areas affected by eczema and extend the period between flare-ups seroquel too sedating for bipolar . Side effects appear to be local, such as irritation or itching viagra lawsuit . The manufacturer, Stiefel Laboratories, suggests that MimyX could be used on a regular basis without danger prednisone for t12 to l2 fracture . Because it was approved relatively recently, however, there are no good long-term safety data hydroxyzine withdrawl .
This immune-suppressing cream is significantly better than a simple moisturizer asprin 110mg . It is approved for use in adults and in children older than age 2 gabapentin and migraine .
Side effects: Local irritation, burning, stinging, itching, infections, seizures
Downside: Long-term use is discouraged because there is a possibility that it increases the risk of cancer cheap no prescription tramadol . When application of the cream is discontinued, however, a high proportion of patients regress to pretreatment condition,
Cost: Approximately $65 to $80 for a 30-gram tube of 0 phytosterol testosterone .03 percent ointment, the only strength approved for use in children
Other Approaches
A number of other possible treatments may have some benefit for people suffering from atopic dermatitis generic ultram tramadol 50 mg . Some of them are pretty straightforward and well accepted, whereas others are on the wacky side find how to use viagra . Here’s a brief summary:
1 terbutaline ol1 inhalation compounding pharmacy . Heliotherapy can you take zoloft with lorpressor . This means: Get some sunshine on your skin tramadol ultram hci . Sunburn is bad, of course, but a couple of weeks of moderate sun exposure seems to make eczema better combivir indications . 300 This almost sounds like a prescription for a tropical vacation! Be forewarned, though, that some of the medicines used to treat eczema could make skin more sensitive to sunburn clomid and ovulating pain twin . This is a worry particularly with Elidel and Pro-topic paxil cr 125 mg .
2 trazodone and insomnia . Ultraviolet light therapy carisoprodol b carisoprodol . This probably explains why sunshine is beneficial jeffery m allegra . Exposure to ultraviolet A in the dermatologist’s office can help alleviate eczema symptoms treatment rheumatoid arthritis sulfasalazine . Stubborn cases may improve with the addition of a psoralen gel or bath before the light exposure generic drugs atorvastatin . This is similar to a standard treatment for psoriasis buy cheap kamagra . The dermatologist will probably recommend it if she thinks it will be helpful caverta side effect . Although it is usually administered in the office or hospital, a portable unit used at home can be equally effective concerta adhd caffeine adhd theadhdspecialist com .- 301
3 dilantin and lasiz . Balneotherapy digoxin and elderly . Immersion in salts derived from the Dead Sea, followed by exposure to ultraviolet B, can be helpful, especially if eczema is chronic and widespread interactions of imitrex and celexa . This effect was first observed in people actually bathing in the Dead Sea, but it is no longer necessary to go there lithium cr123a . Some dermatologists offer this type of therapy in their treatment suites clindamycin doxycycline bordatella . One big drawback is that it takes a lot of time zoloft seroxat side effects .302,303
4 order sumatriptan mail . Hypnotherapy claritin acrylic coffee cup price . Both hypnosis and self-hypnosis can help 3 people cope with eczema, especially with its terrible itch excessive testosterone acne .
5 ditropan $4 . Music bioidentical testosterone cream for women . Listening to Mozart—but, oddly enough, not to Beethoven—reduced the size of a wheal that rose on the skin in response to a specific allergen challenge in people with eczema and latex allergy allegra’s window songs . 305 This is probably the most peculiar of the therapies we have come across, but the study used quite objective measures (IgE production, size of wheal) that presumably are not easily manipulated availability of viagra in new zealand .
Conclusions
Eczema, or more precisely atopic dermatitis, is an itchy skin condition that is often chronic testosterone and vaginal cancer . Besides the itch, skin affected by eczema may develop a rash with liquid-filled bumps cymbalta lower dosages . Skin-fold areas, such as the back of the knees, seem to be especially susceptible to the rash ct angiogram lopressor san antonio . Eczema is often accompanied by generalized dry skin, and the patient may also have asthma or hay fever domperidone in infants .
There’s no cure for eczema, although sometimes it does go away for a period of time levothroid interactions . No treatment works all the time or for everyone, so people are understandably on the lookout for something that might work better than what they have already tried 18 v lithium ion . Eczema is quite common in young children, and parents need to be especially vigilant in weighing the benefits against the risks of various therapies they might use for their kids nexium and polyps .
• Avoid prolonged exposure to water or any irritating chemicals, including soap or detergent caffeine birth defect . After washing hands or bathing, apply a moisturizer within 3 minutes of patting the skin dry acomplia price .
• A person with a documented food allergy that makes eczema worse should avoid that food paxil vs effexor . Eggs may be a culprit for young children what’s anastrozole .
• Probiotics can help in some instances 1967 neonatal exposure to depo provera . Look for a high-quality supplement with viable organisms price cefpodoxime compare . Lactobacillus GG and L pravastatin 20mg . fermentum have done well in studies aleve competitor .
• Fatty acid supplements providing gamma-linolenic acid (such as evening primrose oil, borage oil, or black currant seed oil) help some individuals, but have not performed well in clinical trials insomnia paxil cr . One exception is hemp seed oil, although the data on it are limited to one study topamax and glaucoma . It might be worth a try effect of ibuprofen on blood pressure .
• Cut table sugar and simple starches out of your diet vasotec blood pressure medicine . A low-glycemic-index approach might be worth trying, though will
there is no scientific evidence that it wicontrol eczema female zantac de .
• According to anecdotal reports, eating salsa may ease eczema symptoms increase of depression with zoloft . If you like spicy foods, go for it can lamictal help depression .
• Drinking 4 cups of oolong tea daily was shown in one study to help eczema that wasn’t responding to other treatments albuterol and nebulizer . It is easy and nontoxic, so it would be worth a try woman on viagra .
• Vitamin E capsules did very well in one study of people with atopic dermatitis caffeine levels pop . Check with your doctor first if you are a smoker or at high risk of heart disease; some large studies suggest vitamin E might increase your risk of serious complications claritin dose . For others, there is very little risk in a short-term personal trial to see if it helps your skin tobacco and depakote .
• Apply Noxzema—the original formula in the blue jar—to the affected areas clomid use after laproscopy . The herbal ingredients, camphor, menthol, and eucalyptol, may soothe itching what is citalopram hydrobromide . Be alert for increased irritation, though avandia image .
• Over-the-counter hydrocortisone cream (0 promethazine hcl suppository .5 or 1 percent) may help if the eczema is mild lithium etek .
• CamoCare Soothing Cream is available without a prescription and may ease itching, redness, and inflammation toradol opiod .
• Blend up a batch of honey, beeswax, and olive oil for a homemade salve that may help celexa anxiety depression . It sounds sticky, though yaz spironolactone .
• Use prescription steroid creams according to the physician’s instructions effects of gabapentin and alchohol . Don’t use a potent steroid on the face, or for too long a time health and wellness caffeine health product . “Pulsing” the dose—applying the cream for 3 to 7 days straight, then not using it for a time—may help zyrtec over the counter patenet . Ask your doctor azithromycin pharmacy .
• Drugs such as Protopic (tacrolimus) or Elidel (pimecrolimus) may be helpful as back-up treatment if the steroid creams stop working or don’t work well enough long term use of carisoprodol .

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.

co-fluampicil -tablets of flucloxacillin and ampicillin
co-flumactone Tablets of spironolactone and hydrochlorothiazide.
colchicine The alkaloid obtained from meadow saffron. It is used in acute gout. Dose: 500mg every 2 hours until relief is obtained. A total dose of 10mg should not be exceeded, but relief of pain or the onset of vomiting or diarrhoea usually renders full doses unnecessary. It is also used prophylactically in doses ol’500pg 2 or 3 times a day during early treatment with allopurinol, probericcid and sulphiripyrazone. Gire is necessary in the elderly, and in renal impairment. See page 140 and’I'able 17.
corticotrophin The adrenocorticotrophic hormone of the anterior pituitary gland. It stimulates the production of corticosteroid hormones by the adrenal cortex. It is now used mainly as a test of adrenocortical function. See tetracosactrin.
Hydrocortisone.
cortisone one of the corticosteroids secreted by the adrenal cortex. Although it is rapidly absorbed orally, it is inactive until converted in the liver to hydrocortisone. It therefore has the actions, uses and side-effects of hydrocortisone, which is often the preferred corticosteroid. It should be noted that cortisone is of no value for topical application. See hydrocortisone, page 250 and Table 36.
colestipol An exchange resin used in hyperlipidaemia that acts by binding with bile salts in the gut and preventing their reabsorption, and so indirectly lowers the plasma level of cholesterol.
Dose: 10-30g daily. May interfere with the absorption of many drugs. (Colostid). See page 146 and Table 20.
colfoseeril A pulmonary surfactant used in the respiratory distress syndrome of the new-born. (Exosurf). See beractant.
colistin An antibiotic used mainly for bowel sterilization.
Dose: 4.5-9 mega-units daily. In systemic gram-negative infections 2 mega-units 8-hourly by injection have been used, but less toxic antibiotics are now preferred. Colonlycin).
collodion When applied to the skin, it dries to form a flexible film, and is used as a vehicle for the extended local application of drugs such as salicylic acid.
co-phenotrope tablets of diphenoxylate
and atropine. (Lomotil; Tropergen).
co-prenozide Tablets of oxprenolol and cyclopenthiazide. (Trasidex).
co-proxamol Tablets  and paracetamol. (Distalgesic).
corticosteroids Hormones secreted by the cortex of the suprarenal gland. The principal hormone is hydrocortisone but more potent synthetic derivatives such as dexamethasone are also in use.
co-tenidone Tablets of atenolol and chlorthaliclone. (Tenoretic).
co-triamterzide Tablets of hydrochlorothiazide and triannerine. (Diazide).
co-trimoxazole A mixture of trimethoprini and sulpliaiiietlioxazole. Trimethoprim, like the sulphonamides, interferes with the folic acid cycle of bacterial metabolism, but at a different point, and the mixture has an increased antibacterial action. It was once widely used, but is now advised only for Prieunjocystis carinii pneumonia. Occasionally given in acute bronchitis and urinary infections when no other drug is acceptable.
Dose: 120 nig/kf; daily lot- 14 days; 960 ing 12-hourly by i.v. infusion. (Bactrin); Septrin).
coumarins Compounds that depress the formation in the liver of prothrombin and other blood coagulation factors. See warfarin and phenindione.
counter-irritants Substances, also referred to as rubifacients, that, when applied to the skin, produce a mild, local irritation and inflammation, and give symptomatic relief in painful conditions of the muscles and joints. Creams and liniments containing methyl salicylate, turpentine, capsicum resin and menthol are examples of rubifacients.
crisantaspase Asparagine is an aminoacid essential for the development of some malignant cells. Crisantaspase is an enzyme, also known as asparaginase, that breaks down asparagine, and so has an indirect cytotoxic action. It is used to induce remission in acute lymphoblastic leukaemia in children.
Dose: (after pre-treatment with other drugs): 1000 units/kg by slow i.v. injection daily for 10 days. Side-effects include anaphylactic reactions, and skin tests to detect hypersensitivity
are essential before initial and re-treatment. (Erwinase).
crotamiton An ascaricide and antipruritiL. Used by local application as cream or lotion (10%) in the treatment of scabies and itching conditions. (Eurax).
crystal violet A dyestuffwith a selective action against Gram-positive organisms and yeasts. Used as a 0.5% solution for infected skin conditions, and for skin
preparation.
cyanocobalamin The anti-anaemic factor present III liver. It is specific in the treatment of pernicious anaemia and its neurological complications, and of value in some other anaernias due to nutritional deficiencies.
Dose: in pernicious anaemia, I Ing by i.m. injection at monthly intervals. It has been largely replaced by hydroxocobalamin, which has a more prolonged action. (Cytanien). See page 112 and’I'able 3.
cyclizine An antihistamine, used mainly in I ravel sickness and nausea generally. Also useful in vertigo.
Dose: 100-150 mg daily. Side-effects include dryness of the mouth, headache and drowsiness. (%Ialoid).
cyclopenthiazide A thiazide diuretic with the actions, uses and side-effects of bend roll tiazide.
Dose: I mg initially, 250-500mg daily or on alternate days, in the morning, according to need. (Navidrex). See page 148 and Table 21.
cyclopentolate An anticholinergic agent use(] to produce cycloplegia and mydriasis. The action is more rapid and less prolonged than atropine, particularly in children. (Mydrilate).
cyclophosphamide A widely used alkylating
cytotoxic agent, active orally and by injec-
tion. Used in I lodgkin’s disease, chronic
lymphocytic leukaemia and lymphomas. Dose: 100-300 Ing daily, orally or i.v., or 300 mg-1 g weekly. A high fluid intake is necessary, as a metabolite may cause hacm- ( )rrhagic cystitis, and it is sometimes used with mesna to reduce the risk of such cystitis. Nausea and vomiting are common side-effects, as is epilation with high doses. (Endoxana). See page 122 and Table 8.
cyclopropane An inhalation anaesthetic of high potency with which induction and recovery are rapid. It causes some respiratory depression and cardiac irregularities, and its administration requires care. It is used with closed-circuit apparatus as it forms an explosive mixture with air and oxygen. Supplied in orange-coloured cylinders.
cycloserine An antibiotic used in
pulmonary tuberculosis when standard drugs are ineffective. Occasionally used in urinary infections.
Dose: 250-750 mg daily. Side-effects include drowsiness, vertigo and rash. See page 170 and Table 31.
cyclosporin An antibiotic with a powerful inuininosuppressant action. It is used under expert control to prevent graft rejection in organ and bone marrow transplantation, and in the prevention of graft-versus-host disease (GVI-ID). Prolonged therapy over some months may be required. Side-effects may include tremor, gastrointestinal disturbance, hypertrichosis and nephrotoxicity (Neural; Sandinimun).
cyproheptadine A compound with antihistamine and antiserotonin properties. Sonic allergic reactions are due not only to histamine, but also to serotonin, and cyproheptadine is useful in conditions not responding completely to an antihistamine. Dose: 4-20 ing daily. It has been used as an appetile stimulant in doses of 12 mg daily and in refractory migraine. (11criactin). See page 110 and Table 2.
cyproterone An anti-androgen used to reduce libido in sexual deviants. Dose: 50-100 nig daily. It is also used in the palliative treatment of prostatic carcinoma, particularly in advanced cases that have become resistant to other therapy. Dose: 300 mg daily.

Sinus cavities are something that most people just don’t know they have. It’s only when they start to

hurt that you find out where they are. ‘There is this terrible throbbing pain above and around my eyes,

and in my cheeks. It’s the most unpleasant feeling, but it’s hard to describe to anyone who hasn’t felt

it,’ says Gina, who suffers from chronic sinusitis (long-term inflammation of the sinus cavities).

There are no figures, but chronic sinusitis seems to be increasingly common.
A sinus cavity has no function, it is just empty space without which our skulls would be much heavier.

In other words, these airy spaces seem to have evolved simply to help us feel more ‘light-headed’. If

you have sinusitis, unfortunately, you feel just the opposite. ‘I had sinusitis for years,’ says Dr

Wellington S. Tichenor, a New York allergist who now specialises in treating chronic sinusitis. ‘I kept

working but felt like I wanted to die.’
Sinus cavities are lined with a membrane which is essentially similar to that lining the nose. It

contains immune cells and can produce mucus when necessary. Most of the time it doesn’t need to produce

much, because relatively few microbes or foreign particles get into the sinus cavities.
Any mucus that is produced should escape from the sinus cavities through narrow drainage channels,

called Ostia, leading to the nose. Unfortunately, the Ostia are very narrow – the diameter of a

pin-head – and U-shaped, making them prone to blockage. And that is not the only problem. These

drainage channels are situated at the top rather than the bottom of the main sinus cavities – this

arrangement was fine for our ancestors who walked on all fours, and therefore did not have to fight

gravity when clearing their sinuses. Sadly for
us, natural selection has not got around to reorganising things yet. It would be a completely hopeless

arrangement if not for the tiny hairs known as cilia, which lie like a carpet across the membranes

lining the sinus cavities. The cilia beat rhythmically. 18 times a second, to waft the mucus upwards to

the top of the sinus cavity.
This is a far-from-perfect system, and it is hardly surprising that it sometimes goes wrong. Chronic

sinusitis can begin in at least three different ways:
• The sinus membranes become inflamed due to an allergic reaction – 28 for likely airborne

allergens.
• The drainage channels from the sinus cavities become blocked due to events in the nose

(infection or allergy) or due to the growth of polyps (non-cancerous jelly-like lumps that can block

the drainage channels). When mucus cannot drain away, it stagnates in the sinus cavities encouraging

infection by bacteria or fungi. These infections cause inflammation.
• A bout of acute sinusitis (see box on p. 31), due to bacterial infection, never really goes

away and the persistent infection causes longterm inflammation. Note that this is unlikely: it is rare

for acute sinusitis not to clear up.
Whether the problem begins through allergy or blockage or infection, once it has begun a vicious circle

can be set up all too easily. Mucus output increases when there is inflammation, blocking the drainage

channels even more, so the sinus cavities become clogged up and increasingly uncomfortable. More mucus

pooling in the sinus cavities perpetuates any existing infections and fosters new ones.
All this infection results in more severe inflammation, causing the membranes which line the sinus

cavities to swell up. Inflammation also makes polyp growth more likely. The cilia may be lost or

severely depleted, and the mucus gets thicker. All this means yet more blockage. To cap it all, there

can be allergic reactions to some of the microbes involved (see right), fuelling the inflammation

further.
The body’s own attempts to clear the sinuses are defeated, and the problem is also very resistant to

medical treatment. This may make depressing reading, if you have chronic sinusitis, but don’t despair.

Understanding the complexities of the problem is a large part of the battle. Chronic sinusitis is not

invincible, if you have a good doctor to help you - that means a doctor who also understands these

complexities.
The symptoms of sinusitis are:
• pain and a sense of swelling or unpleasant fullness around the cheeks, or over and between the

eyes
• earache or headache; pain around the teeth
• reduction in the senses of smell and taste
• sore throat
• coughing, particularly at night
• post-nasal drip (mucus from the back of the nose running into the throat and airways)
• bad-smelling breath
• feverishness
• for some people, severe fatigue, poor concentration and even (but very rarely) psychiatric

symptoms
• irritability, especially in children.
Note that any of these symptoms can be caused in other ways, and even if you have several of them, you

may not necessarily have sinusitis. On the other hand, sinusitis can go unrecognised - to some people

it may seem like nothing more than a lingering cold.
Acute or chronic?
In medical terms, ‘acute’ means short-lived, while ‘chronic’ means long-lasting.
Acute sinusitis — a short, sharp dose of it, lasting less than 3-4 weeks - usually follows on from a

cold. Colds are caused by viruses, but a bacterial infection can follow, and it is the bacteria that

move into the sinus cavities and cause trouble. Some people are far more susceptible than others and

have an attack of sinusitis after every cold.
Chronic sinusitis means symptoms lasting more than three months, according to some authorities, but the

time point is a little arbitrary. This article deals with chronic sinusitis.
If your sinusitis has been going on for between four weeks and three months you will obviously be

asking ‘Is this acute or chronic?’ At this point, no one can say, but you would certainly be wise to

seek some expert medical treatment now, on the basis that it could be the start of chronic sinusitis.

Tackling chronic sinusitis before the problem becomes
entrenched and complex is a good plan.
Allergy and chronic sinusitis
Chronic sinusitis is not necessarily an allergic disease, but it can be connected with allergies (or

other forms of immune sensitivity) in various ways:
• Allergic reactions can occur in the sinuses, usually in conjunction with allergic reactions in

the nose.
• Even if the allergic reaction does not affect the sinuses directly, allergic reactions in the

nose can block the drainage channels from the sinuses, causing an accumulation of mucus there. This may

lead to sinus infections.
• Once sinusitis has begun, infectious fungi (moulds) in the sinuses may provoke allergic

reactions, or other forms of immune sensitivity. This allergy to ‘the enemy within’ fuels more

inflammation and more mucus production. Right now, allergic fungal sinusitis (as it is known) is a

source of heated debate - 32. Allergic reactions to some of the bacteria that are present may also

occur.
• Chronic sinusitis - however caused - can contribute to asthma. Research on children with both

sinusitis and asthma found that 80% no longer needed asthma drugs once their sinusitis had been

treated, and 85% no longer wheezed. The link may be due to post-nasal drip, increased mouth-breathing,

or to a nerve-connection between the sinuses and the airways (the sinobronchial reflex) which can

stimulate airway inflammation. Alternatively, the sinusitis may simply fire up the immune system with

messenger chemicals in the bloodstream, resulting in more powerful responses throughout the body.
• Chronic sinusitis can also be the root cause of long-standing nettle rash (chronic urticaria),

and treating the sinusitis can result in a prompt and remarkable clearance of the skin symptoms.
• Some people who have chronic sinusitis are sensitive to aspirin (see box on p. 28) - a

sensitivity which is also linked with asthma, nasal polyps, rhinitis and chronic urticaria. Avoiding

aspirin and all other aspirin-like drugs (151) may substantially improve the sinusitis.
Diagnosis
Because so many different factors can play a part in chronic sinusitis, diagnosis should, ideally,

consider the problem from several different angles:
• The sinuses are viewed using X-rays and CT scans (computed tomographic scans - they use X-rays

but give a much more precise picture). These reveal how badly swollen the sinus membranes are, which

sinus cavities are blocked, and how much mucus has collected in the sinuses.
• Endoscopy (92) may be used to look inside the sinus cavities. Polyps are best located by this

method.
• Where allergies seem to be part of the picture, the doctor may employ skin-prick tests (91) to

identify allergies to airborne allergens (from house-dust mites, moulds, pets, pollen, cockroaches,

etc.)
• Laboratory tests on samples taken from your sinus cavities will be used to show which bacteria

and/or fungi have set up home there. There may also be a hunt for the immune cells known as eosinophils

(19) or the typical debris which they generate. The presence of large numbers of eosinophils is one

indication of allergic fungal sinusitis (see below).
• Skin testing with fungi (moulds) found growing in the sinus cavities may also be tried if

allergic fungal sinusitis is suspected.
• In severe cases, there may be tests of immune function, to see whether this is depressed in any

way.
• Children may be tested for an inherited disorder affecting the cilia, or for cystic fibrosis -

mild forms may escape detection, and can produce both chronic sinusitis and wheezing.
The enemy within
The biggest controversy in sinusitis research at the moment concerns allergic fungal sinusitis. The

orthodox view of this condition is that:
• It affects a small minority of chronic sinusitis patients -fewer than 10%.
• There is a true IgE-mediated allergic reaction to the fungus (mould) growing in the sinus

cavities. This allergic reaction is detectable with a skin-prick test (91). Immune cells known as

eosinophils (19) are also key players in the inflammatory reaction to the fungus, but it is an

IgE-response to the fungus that draws the eosinophils into the sinuses.
• There is clear evidence of fungal infection in the mem- banes of the sinus cavities.
• There may also be ‘fungus balls’ - a solid mass of fungus inside the sinus cavity. Or there may

be ‘allergic mucin’, a dark sticky mucus containing fragments of the fungus.
A rare complication
In rare cases, the fungi involved in allergic fungal sinusitis can be invasive, spreading from the

sinuses to the surrounding bone. This problem needs prompt and thorough treatment with anti-fungal

drugs.
In 1996, researchers at the Mayo Clinic in Rochester, Minnesota, USA, caused a rumpus by claiming to

have identified a different form of allergic fungal sinusitis which is overlooked by standard

diagnostic techniques, and which affects 96% of patients with chronic sinusitis.
This is a staggering figure - 96% means, in effect, that they are claiming to have found the

fundamental cause of virtually all chronic sinusitis. ‘Up to now, the cause of chronic sinusitis has

not been known. Our studies indicate that, in fact, fungus is the likely cause of nearly all of these

problems,’ states Dr David Sherris, one of the researchers.
According to the Mayo Clinic team:
• The fungi (moulds) are growing in the mucus of the sinus cavities, not generally in the

membrane itself. They are not detected by normal diagnostic methods which tend to ignore the mucus. A

special method of collecting the mucus is required to detect the fungi.
• The immune reaction to the fungi is not usually an IgEmediated reaction, so skin-prick tests

are often negative.
• Finding evidence of unusual numbers of eosinophils is adequate for diagnosis of allergic fungal

sinusitis because the eosinophils are the prime movers in this sensitivity reaction to the fungi, as in

several other diseases (19).
‘We can now begin to treat the cause of the problem instead of the symptoms,’ says Dr Eugene Kern, head

of the research team. There is a lot of scepticism about these claims among other sinusitis

specialists, and so far no new treatment for chronic sinusitis has emerged.
The Mayo Clinic researchers say that they are in the process of developing a drug treatment, but that

it will take several more years before it is generally available. Existing anti-fungal drugs (taken in

capsule form) could not work on this particular form of allergic fungal sinusitis (if it exists)

because the drug does not get into the mucus. Any new treatment would probably involve inserting an

anti-fungal drug directly into the sinus cavities, which is far from easy.
All we can do for now is wait and see what emerges from the ongoing research. The current treatment for

allergic fungal sinusitis involves all the usual methods (see right) with special emphasis on steroids

to calm the inflammation, plus anti-fungal drugs where fungal infection is detectable in the membrane.

In some countries, immunotherapy is also used to reduce the immune reaction to the fungus, but this is

difficult to obtain in Britain (164).
Clearing moulds from your home may help (34). So may reducing the humidity in the house (119), as humid

conditions seem to be linked with allergic fungal sinusitis.
Treatment
Sinusitis can be very hard to treat, particularly if it has been going on for a long time. You need a

really committed attitude if treatment is to be successful.
All these treatments should be given at the same time:
1 Antibiotics for 2-3 weeks minimum (it takes this long because the antibiotic has such trouble getting

into the sinus cavities – if you are offered a shorter course, this suggests that the doctor does not

have enough expertise with chronic sinusitis, so you might be better off with someone else). It must be

the right antibiotic – commonly used ones such as penicillin, tetracycline and erythromycin are

unlikely to work because the bacteria are usually resistant to them.
2 Steroid drops in the nose to combat the inflammation. It is important to put these in correctly, so

that they have maximum effect (144) especially if you have polyps.
3 Irrigating the nose and sinus cavities daily with sterile salt water (saline). Your doctor will show

you how to do this.
4 Tablets that reduce the congestion in the nose.
5 Nose drops that reduce congestion, but for three days only (29).
6 Steam inhalations to loosen the mucus. There are special steam vaporisers on sale (ask at a

pharmacy), but you can just inhale steam from a bowl of boiling water, with a towel over your head to

keep the steam in. Adding eucalyptus oil to the water may help. For a quick-and-easy version, warm up a

damp flannel in the microwave and place it over your nose. Some doctors recommend having a steam

vaporiser beside the bed at night, when nasal blockage is most likely to occur, but if you have

allergies to house-dust mite or moulds this is not a good idea in the long term, as a damp bedroom will

favour both (and could encourage allergic fungal sinusitis).
7 A drug called guaifenesin which thins the mucus is used in some countries but rarely in Britain.

Alpha-methyl-cysteine is another drug that breaks up mucus. It is mainly used in chronic bronchitis but

some doctors also find it valuable in chronic sinusitis. If steam inhalations didn’t work – suggesting
that the mucus is too solid to be shifted – these drugs may be worth trying.
8 Anti-fungal drugs (taken by mouth) if allergic fungal sinusfis is suspected. Sometimes these have a

dramatic effect on chronic sinusitis that has previously resisted treatment.
You may also be given other drugs, such as steroid tablets. The new anti-leukotriene drugs (149) are

also being tried, with some success. As well as being taken by mouth, they can be applied directly to

the nose in an irrigation fluid, and may be helpful for those with nasal polyps.
Problems with nose drops
Nasal drops and washes contain preservatives and other non-drug ingredients. Some of these may act as

irritants – or the pH (acidity or alkalinity) of the preparation might cause problems. If you

experience burning or irritation after inserting drops or irrigating the sinuses, ask your doctor or

pharmacist about trying a different preparation.
Antibiotic resistance
Bacteria are becoming resistant to the effects of antibiotics: it is probably the biggest headache

facing modern medicine.
This is emerging as a particular problem in chronic sinusitis because many patients have been dosed

very regularly with antibiotics. Although most of the bacteria have been killed each time, the fact

that the sinus cavity is so clogged up with mucus, and so badly accessed by the bloodstream anyway,

means there is always some nook or cranny where a few bacteria survive because they have not been

exposed to the full lethal dose of the antibiotic. As you might expect, these survivors tend to be the

‘tough ones’ – those bacteria that are not just well hidden but also the least sensitive to the

antibiotic.
Repeat this process many times, with frequent courses of antibiotics (separated by intervals during

which the hard-to-kill bacteria multiply in numbers) and what happens? Eventually you breed a race of

bacteria that are completely resistant to one or more of the antibiotics taken.
If you ever get to this point with your sinusitis, treatment is going to be extremely difficult. That’s

why it is so important to treat infections really thoroughly, and get rid of them completely. Expert

medical help is essential for this treatment campaign.
Too many people with chronic sinusitis are careless about taking their antibiotics regularly, or feel

ambivalent about them and stop the course before it’s complete, or don’t see the doctor again when the

tablets are used up. This is courting disaster.
Don’t start antibiotic treatment for chronic sinusitis until you are sure you can see it through. If

you have doubts about taking antibiotics, try all the other treatments and self-help measures first.

They may be sufficient, especially if you find you have an allergy underlying the chronic sinusitis and

can tackle this successfully.
Should there be no improvement, you could then go on to the antibiotic programme: delaying this

treatment for a few months will do no harm. What is hazardous is starting the antibiotic programme and

then stopping, or not taking the drugs consistently.
Antihistamines may be prescribed to treat any allergic reactions, but some specialists feel that they

can also aggravate the problems. In their experience, antihistamines dry out the mucus so that it

sticks to the walls of the sinus cavities, rather than being ushered out by the cilia. Drying out the

mucus may make you feel better initially, by reducing the pressure inside the sinus cavities, but it

makes matters worse in the long run.
Anti-chollnergic drugs (156) are sometimes prescribed for chronic sinusitis, but they too can dry up

the mucus and should be used cautiously.
After three weeks, if the sinusitis has not improved substantially, a different antibiotic is given. If

there are any bacteria resistant to the first antibiotic infesting your sinus cavities, the new

antibiotic is intended to kill them off.
Should you still have sinusitis after another three weeks, you will be given yet another antibiotic.

Changing the antibiotic, and taking prolonged courses, is the best way of exterminating the bacteria

completely, which prevents the development of antibiotic-resistant bacteria (see box at left).
It is crucial that you always see the doctor promptly at the end of each course, so that there is no

gap between the courses – do not give the bacteria any opportunity to build up their numbers again. The

last antibiotic treatment should continue for at least a week after symptoms clear up.
Dealing with allergic reactions is also important:
• If you cannot get allergy tests, try to work out for yourself if an allergen is playing a part.

Ask yourself if there were any changes in your life before the sinusitis began, such as getting a new

pet, moving house, increased exposure to moulds or house-dust mite, or starting a new job with exposure

to allergens. When thinking about this, remember that allergies to newly encountered allergens do not

develop immediately – it may take up to two years. Try avoiding the allergen concerned and seeing if

you improve.
• Should you discover that an allergen is at the root of the problem, but have difficulty

reducing your exposure to the offending item, try to obtain immunotherapy (164) or another form of

desensitisation treatment (210).
• If you suspect allergic fungal sinusitis (32), it is well worth eliminating any mould growth in

your home (120). One research study showed that the moulds growing in a patient’s sinus cavities were

often the same as those growing in the patient’s house. It is possible that, by inhaling the mould

spores from moulds in their houses, sinusitis sufferers are continually reinfecting their sinuses.
Various other self-help measures can be valuable during this medical treatment:
• Reduce your exposure to cigarette smoke (including other people’s) to an absolute minimum.

Cigarette smoke acts as an irritant to the nose and sinuses, but, more importantly, it paralyses the

cilia, preventing them from shifting mucus out of the sinus cavities.
• Avoid breathing other irritants, especially ozone (130). Think about the chemicals you use both

at work and at home – could any of these be irritants that are aggravating your sinusitis?
• Don’t drink too much alcohol – it dries out the sinus membranes and makes matters worse.
• Drink plenty of water, to keep your mucus from becoming too dry and therefore hard to shift.
• Try to breathe through your nose as much as possible. The amount of oxygen in your sinus

cavities drops drastically if you breathe through your mouth, and the low oxygen level probably fosters

the growth of certain bacteria. Devices, such as nose clips, that help keep the nose open at night may

be worth trying.
• Spicy food can help to clear nasal and sinus congestion, so try eating chilli or hot curry

regularly.
• Some people find that garlic helps – either eaten or sniffed.
• If you suspect that your sinusitis might be related to food sensitivity (68) consider trying an

elimination diet to identify the culprit food.
• Observe your reactions immediately after eating – some foods, such as yeast and red wine, can

cause an immediate swelling of the nasal membranes in certain people. So can sulphite food additives.

Avoid such items if you are affected.
• Treating gastro-oesophageal reflux (acid regurgitation from the stomach after meals) can

improve sinusitis.
• See an osteopath. By gently manipulating parts of your face, a good osteopath may be able to

improve the drainage from the sinus cavities.
• Some patients experience good effects from acupuncture although there are no observable changes

on CT scans. Other alternative therapies, such as homeopathy or Chinese herbal medicines, have not been

investigated scientifically, but some patients report good results.
Prolonged courses of antibiotics destroy many of the beneficial bacteria in the intestine, and may

cause long-term bowel problems. It makes sense to take a bacterial replacer (205).
Surgery for sinusitis
Chronic sinusitis sufferers may be offered surgery to remove polyps, or to correct anatomical problems

such as a deviated septum (the central division of the nose).
These operations can be very useful, but if you have asthma try all other options first, because

surgery to the nose can sometimes make asthma much worse.
Surgery on the sinus cavities themselves is also a possibility, when sinusitis does not respond to

medical treatment. The operation enlarges the natural drainage channels, so that mucus drains away more

easily. This rarely cures chronic sinusitis completely, but it usually makes it much easier to manage.

Once the drainage channels are larger, antibiotics can be put directly into the sinus cavities, for

example, avoiding the need for antibiotic tablets.
Don’t agree to surgery unless other forms of treatment, such as allergen avoidance or immunotherapy,

have been tried to the full. Patients for whom surgery seemed to be the only answer have sometimes

found they did not need an operation once their allergies were treated.
If you decide on having an operation, make sure your surgeon has a proven track-record with this type

of surgery. Don’t be afraid to ask searching questions about how many operations of this kind the

surgeon has done, how many he or she carries out per year, and the complication rates (how often things

go wrong). It’s a delicate job, and you want a real expert.