Posts Tagged ‘vomit’

Generic Name
Clotrimazole (kloe-TRIM-uh-zole) 0
Brand Name Mycelex
The information in this profile also applies to the following drug:
Generic Ingredient: Sertaconazole Ertaczo
Type of Drug Antifungal.
Prescribed For
Fungal infections of the mouth, skin, and vaginal tract.
General Information
clotrimazole is useful against a variety of fungal organisms that other drugs do not affect. The exact way in which clotrimazole works is unknown. Sertaconazole is used for athlete’s foot in people age 12 and older with compromised immune systems.
Cautions and Warnings
Do not use this product if you are allergic or sensitive to any of its ingredients.
If clotrimazole causes local itching or irritation, stop using it. Do not use clotrimazole in your eyes.
Proper diagnosis is essential for effective treatment. Do not use this product without first consulting your doctor.
Possible Side Effects
Side effects are infrequent and usually mild.
Cream and Solution
V Most common: redness, stinging, blistering, peeling, itching, and swelling of local areas.
Vaginal Tablets
♦ Most common: mild burning, rash, mild cramps, and frequent urination. Your sexual partner may also experience some burning or itching.
Lozenges
V Most common: stomach cramps or pain, diarrhea, nausea, and vomiting.
Drug Interactions
None known.
Food %%ractions
The oral form of clotrimazole is best taken on an empty stomach, at least 1 hour before or 2 hours after meals. However, you may take it with food as long as you allow the lozenge to dissolve fully in your mouth.
Usual Dose
Topical Cream and Solution
Adult and Child (over age 2): Apply to clean, dry, affected areas morning and night for 7 consecutive days or as needed. For athlete’s foot and ringworm, use daily for 4 weeks. For jock itch, use daily for 2 weeks.
Vaginal Cream
Adult: 1 applicator’s worth at bedtime for 3-7 consecutive days.
Vaginal Tablet
Adult: 1 tablet inserted into the vagina at bedtime for 3 days, or 2 tablets a day for 3-7 consecutive days.
Lozenge
Adult and Child (over age 3): 1 lozenge 5 times a day for 2 weeks or more.
Overdosage
Little is known about the effects of clotrimazole overdose or accidental ingestion. Call your local poison control center for more information. If you seek treatment, ALWAYS bring the prescription bottle or container.
Special Information
If treating a vaginal infection, you should refrain from sexual activity. Call your doctor if burning or itching develops or if the condition does not improve within 7 days.
If you are using the vaginal cream, you may want to wear a sanitary napkin to avoid staining your clothing. Do not use a tampon during treatment.
Dissolve the lozenge slowly in the mouth. This may take up to 30 minutes.
This medicine must be taken on consecutive days. If you forget a dose of oral clotrimazole, take it as soon as you remember. Do not double your dose.
When using clotrimazole for skin infections, do not cover the area with any kind of bandage unless directed to do so by your doctor. For athlete’s foot, wear well-fitting, ventilated shoes, and change your socks at least once a day.
clotrimazole is not effective on scalp or nails.
Special Populations
Pregnancy/Breast-feeding: Women who are or might be pregnant should talk to their doctor about the medication’s risks and benefits. Women who are in the first 3 months of pregnancy should use this drug only if directed to do so by their doctor. If you are pregnant, your doctor may want you to insert vaginal tablets by hand rather than use a vaginal applicator.
It is unknown whether the drug passes into breast milk. Use with caution or use infant formula.
Seniors: Seniors may use this medication without special precaution.

Generic Name
Clozapine (KLOE-zuh-pene) 03
Brand Names
Clozaril    FazaClo Orally Disintegrating Tablets
Type of Drug  Antipsychotic.
Prescribed For  Severe schizophrenia.
General Information
Clozapine is a unique antipsychotic that has the capacity to treat people who do not respond to or cannot tolerate other drugs. It works by a mechanism that differs from those of other antipsychotic drugs.
A very small number of people who take clozapine develop a rapid drop in their white-blood-cell count, known as agranulocytosis. This effect usually reverses itself when the drug is stopped, but the drug must be stopped as soon as it is discovered. An unusually large number of people who have developed clozapine algllaTwlocytosis in the United States are of Eastern European Jewish descent, but the association is not very strong. Most cases of agranulocytosis occur between week 4 and week 10 of treatment. It is essential that blood samples be taken approximately every week and for 4 weeks after the drug is stopped to watch for this effect. Because of the risk of agranulocytosis, clozapine should not be tried until at least 2 other antipsychotic medicines have failed.
Some people taking antipsychotic drugs develop tardive dyskinesia, a potentially irreversible condition marked by uncontrollable movements. Tardive dyskinesia has not been seen in patients taking clozapine, a major advantage of this drug over other antipsychotic medicines. However, there is still a risk that this set of symptoms could occur with clozapine.
Cautions and Warnings
Do not take clozapine if you are allergic or sensitive to any of its ingredients.
Women, seniors, people with serious illnesses, those who are emaciated. those with a history of diseases affecting the white blood cells, or those who are taking other medication that could affect white blood cells may be more susceptible to clozapine agranulocytosis.
Clozapine has been associated with increased mortality in seniors with dementia or Alzheimer’s disease. The specific causes of death related to clozapine and other atypical antipsychotic drugs were either due to a heart-related event or infection, mostly pneumonia. Clozapine should not be taken by those with dementia-related psychosis.
About 5% of people taking the drug experience a seizure in the first year of treatment. Seizure is most likely to occur at higher drug doses.
People with heart disease should be carefully monitored while on clozapine because of possible cardiac risks.
Clozapine may cause low blood pressure, especially at the beginning of therapy.
Clozapine has been associated with obesity, high cholesterol, high blood sugar, and diabetes. Diabetics and pre-diabetics (people with elevated blood sugar and a family history of diabetes) should be carefully monitored.
A serious set of side effects, known as neuroleptic malignant syndrome (NMS), includes a high lever and has been associated With clozapine when it is used together with lithium or other drugs. The symptoms that constitute NMS include muscle rigidity, mental changes, irregular pulse or blood pressure, increased sweating, and abnormal heart rhythm. NMS is potentially fatal and requires immediate medical attention.
Use this drug with caution if you have glaucoma, prostate
problems, or liver or kidney disease.
clozapine may interfere with mental or physical abilities because of the sedation it usually causes during the first few weeks
of treatment.
Possible Side Effects
✓    Most common: rapid heartbeat, low blood pressure, dizziness, fainting, drowsiness or sedation, salivation, and constipation.
✓    Less common: headache, tremor, sleep disturbance, restlessness, slow muscle motions, absence of movement, agitation, convulsions, rigidity, restlessness, confusion, sweating, dry mouth, visual disturbances, high blood pressure, nausea, vomiting, heartburn or abdominal discomfort, fever, and weight gain.
♦    Rare: agranulocytosis (symptoms include fever with or without chills, sore throat, and sores or white spots on the lips or mouth), tardive dyskinesia (symptoms include lip smacking or puckering, puffing of the cheeks, rapid or wormlike tongue movement, uncontrolled chewing motions, and uncontrolled arm and leg movements), and NMS (see “Cautions and Warnings”). Other 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
•    Clozapine’s anticholinergic effects—blurred vision, dry mouth, and confusion—may be enhanced by interaction with other anticholinergics, such as tricyclic antidepressants like amitriptyline.
•    Drugs that reduce blood pressure may enhance the bloodpressure-lowering effects of clozapine.
•    Alcohol and other nervous system depressants, including benzQUIQOmrn and other antianxiety drugs, may enhance clozapine’s sedative action. At least 1 person has died as a result of combining diazepam and clozapine.
•    Combination contraceptive drugs may increase blood levels of clozapine leading to toxic side effects. Women starting on a combination contraceptive may need to have their clozapine dose adjusted.
•    Clozapine should not be used with ritonavir.
•    Cimetidine, caffeine, citalopram, ciprofloxacin, erythromycin, and ketoconazole may increase blood levels of clozapine resulting in increased side effects. Caution should be used with combining clozapine with paroxetine, fluvoxamine, or sertraline as similar reactions may occur, although these interactions are less well-defined.
•    Clozapine may increase blood levels of digoxin, warfarin, heparin, and phenytoin.
•    Use of clozapine with phenytoin, carbamazapine, and rifampin may cause decreases in blood levels of clozapine, reducing its effectiveness.
•    The combination of lithium and clozapine may cause seizures, confusion, and NMS (see “Cautions and Warnings”).
•    Cigarette smoking may alter clozapine dosage requirements.
•    Combining selective serotonin receptor inhibitors (SSRls) with clozapine may require a lower clozapine dosage.
Food Interactions None known.
Usual Dose
Tablets
Starting dose: 25 mg in divided doses twice a day; maintenance dose    generally, 300-450 mg a day in divided doses. Dosage may be increased gradually to a daily maximum of 900 mg in divided doses if required.
Orally Disintegrating Tablets
Starting dose: 12.5 mg once or twice a day increasing to 300450 mg a day in divided doses by the end of 2 weeks. Dosage may then be increased up to 900 mg a day in divided doses if required.
Overdosage
Symptoms of overdose are delirium, drowsiness, changes in heart rhythm, unusual excitement, nervousness, restlessness, hallucinations, excessive salivation, dizziness or fainting, slow or irregular breathing, and coma, Overdose victims must be taken to a hospital emergency room immediately. ALWAYS bring the prescription bottle or container.
Special Information
Clozapine may cause a fever during the first few weeks of treatment. Generally, the fever is not important, but it may occasionally be necessary to stop treatment due to a persistent fever.
Regular blood tests are necessary to monitor blood composition for any changes that might be caused by clozapine.
Call your doctor at once if you develop lethargy or weakness, a flu-like infection, sore throat, feelings of ill health, fever, sweating, muscle rigidity, mental changes, irregular pulse or blood pressure, mouth ulcers, or dry mouth that lasts for more than 2 weeks.
Dry mouth, a common side effect of clozapine, may be countered by using gum, candy, ice, or a saliva substitute such as Orex or Moi-Stir.
Do not stop taking clozapine without your doctor’s knowledge and approval, because a gradual dosage reduction may be necessary to prevent side effects.
Avoid alcohol or any other nervous system depressants while taking clozapine.
Some of the side effects of clozapine    drowsiness, blurred vision, and seizures—may interfere with the performance of complex tasks like driving or operating hazardous equipment.
While taking clozapine, rapidly rising from a sitting or lying position may cause you to become dizzy or faint.
If you take clozapine twice a day and forget a dose, take it as soon as you remember. If it is almost time for your next dose, take 1 dose as soon as you remember and another in 5 or 6 hours, then go back to your regular schedule. If you take clozapine 3 times a day and forget a dose, take it as soon as you remember. If it is almost time for your next dose, take 1 dose as soon as you remember and another in 3 or 4 hours, then go back to your regular schedule. Never take a double dose.
Orally disintegrating tablets should be left in the unopened blister until time of use. They should not be pushed through the foil. Just prior to use, peel the foil from the blister and gently remove the orally disintegrating tablet. Immediately place the tablet in the mouth, allow it to disintegrate and then swallow with saliva. No water is needed.
Special Populations
Pregnancy/Breast-feeding: This drug Should be used during PM Only if your doctor determines that it is absolutely necessary.
clozapine may pass into breast milk. Nursing mothers who must take this drug should use infant formula.
Seniors: Seniors may be more sensitive to the side effects of clozapine, such as dizziness on rapidly rising from a sitting or lying po-sition, confusion, and excitability. Older men are also more likely to have prostate problems, a reason to be cautious with clozapine. Seniors with psychosis due to dementia who take clozapine are more likely to die from heart disorders and infections than those not taking it.

Generic Name
Codeine (KOE-deep) 0
Brand Name
Only available in generic form.
The information in this profile also applies to the following drugs: Generic Ingredient: Fentanyl
Actiq Lozenge on a Stick    Fentora Buccal Tablet
Duragesic (Patch)    lonsys (Patch)
Generic Ingredient: Morphine Sulfate 10
Avinza    Oramorph SR
Kadian    RMS Suppositories
MS Contin    Roxanol MSIR
Generic Ingredient: Oxycodone Hydrochloride RE
Combunox    OxyFAST
Endocodone    OxylR
M-Oxy    Percolone
OxyContin    Roxicodone Oxydose
Generic Ingredient: Oxymorphone Opana
Type Q( UTUg  Narcotic.
Prescribed For
Mild to severe pain, breakthrough cancer pain, and cough. Long-acting narcotics are meant only for people with chronic pain. Also prescribed for pain and anxiety in pediatric burn patients.
General Information
Codeine relieves pain and suppresses cough. The pain-relieving effect of 30-60 mg of codeine is equal to approximately 650 mg, or 2 tablets, of aspirin. Codeine may be less effective than aspirin for pain associated with inflammation because aspirin reduces inflammation and codeine does not. Codeine suppresses the cough reflex but does not cure the underlying cause of the cough. Other narcotic cough suppressants are stronger pain relievers, but codeine remains the best cough medication available.
Morphine sulfate is a pure narcotic that has been in use for many years. In addition to pain relief, morphine’s effects include drowsiness, mood changes, breathing difficulty, slowed movement of the gastrointestinal tract, nausea, vomiting, and changes in the endocrine and autonomic nervous systems. Morphine sulfate liquid, immediate-release tablets, and suppositories must be taken several times a day. The medication they contain is released immediately for absorption into the bloodstream. Extended- and controlled-release morphine products are designed to release some of the narcotic right away and the rest over a 24-hour period, allowing for less-frequent dosage.
Fentanyl is a potent pain reliever that can be substituted for other narcotic drugs. The patch form, which must be replaced about every 3 days, delivers fentanyl to the bloodstream at a steady rate. The lozenge has a shorter length of action than any other narcotic pain reliever, which makes it useful when given to children before surgery because it provides doctors with the flexibility to obtain maximum benefit with minimal side effects. The lozenge on a stick is used for breakthrough cancer pain as a booster for people already taking narcotic pain relievers. These forms should only be used under controlled circumstances because of the risk of side effects or overdose. Low dosages of fentanyl relieve pain—larger amounts cause loss of consciousness and breathing difficulties.
Oxycodone is a narcotic used to control moderate to severe pain. Most people take it together with aspirin (Percodan) or acetaminophen (Percocet), but it can be used by itself. This is a potent pain reliever that carries a risk (31 addiction with continued use.
Cautions and Warnings
Do not take narcotics if you are allergic or sensitive to any of their ingredients.
Long-term use of narcotics may cause drug dependence or addiction.
Use narcotics with extreme caution if you suffer from asthma or other breathing problems.
Narcotics may make it difficult to monitor the progress of people who have suffered head injuries and acute abdominal conditions.
Actiq contains fentanyl in an amount that can be fatal to children. Keep used and unused lozenges and lozenges on a stick out of reach of children.
Possible Side Effects
♦    Most common: lightheadedness, dizziness, sleepiness, nausea, vomiting, appetite loss, and sweating. If these occur, ask your doctor about lowering your dosage. Most of these side effects disappear if you lie down.
♦    Less common: euphoria (feeling “high”), headache, agitation, uncoordinated muscle movement, minor hallucinations, disorientation and visual disturbances, dry mouth. constipation, flushing of the face, rapid heartbeat, palpitations, faintness, urinary difficulties or hesitancy, reduced sex drive or impotence, itching, rash, anemia, lowered or raised blood sugar, and yellowing of the skin or whites of the eyes. Narcotic analgesics may aggravate convulsions in those who have had them.
More serious side effects of codeine are shallow breathing or breathing difficulties.
Drug Interactions
•    Avoid combining narcotics with alcohol, sleeping medications, sedatives, other depressant drugs, or non-prescription drugs that have alcohol as an ingredient. Alcohol speeds the release of morphine from Avinza. The mixture can result in a deadly narcotic overdose.
•    Narcotic analgesics should not be used at the same time as monoamine oxidase inhibitor antidepressants. Separate usage by at least 14 days.
•    Combining a narcotic pain reliever with an anticholinergic medication may result in severe constipation.
•    Combining a narcotic pain reliever with any other medication that lowers blood pressure can lead to excessive blood-pressure lowering. Avoid this combination.
•    Combining cimetidine with a narcotic pain reliever may cause confusion, disorientation, breathing difficulties, and seizure.
•    Reserpine, rifampin, and remifentanil may decrease the pain-relieving effects of morphine.
•    Fentanyl should be used with caution with azole antifungals (e.g. ketoconazole).
Food Interactions
Codeine may be taken with food to reduce upset stomach. Morphine capsules and the fentanyl patch may be used without regard to food.
Usual Dose
Dosing of narcotic pain medications is highly individualized based on patient tolerance and response to medication.
Codeine
Adult: 15-60 mg every 4-6 hours for relief of pain; 10-20 mg every few hours as needed to suppress cough.
Child: 1 mg per lb. of body weight every 4-6 hours for relief of pain; 2.5-10 mg every 4-6 hours to suppress cough.
Fentanyl Lozenge and Lozenge on a Stick
Adult: 200-1600 mcg. Dosage may be repeated up to 4 times daily. Allow the lozenge to dissolve in your mouth. DO NOT CHEW. Child: not recommended.
Fentanyl Patch: Apply to a clean and non-irritated patch of skin as directed, usually once every 3 days.
Morphine Extended-release and Controlled-release
Tablets and Capsules
Adult: 1-3 capsules a day, depending on the specific product and individual need.
Morphine Oral Liquid and Immediate-release Tablets Adult: 5-30 mg every 4 hours.
Morphine Suppositories
Adult: 5-30 mg several times a day.
Oxycodone
Adult: 10-30 mg every 4 hours as needed. OxyContin should be swallowed whole and not broken.
Child: not recommended.
Overdosage
Symptoms include breathing difficulties or slowing of respiration, extreme tiredness progressing to stupor and then coma, pinpointed pupils, no response to pain stimulation, cold and clammy skin, slowing of heartbeat, lowering of blood pressure, convulsions, and cardiac arrest. The victim should be taken to a hospital emergency room immediately. ALWAYS bring the prescription bottle or container.
Special Information
Codeine is a respiratory depressant and affects the central nervous system (CNS), producing sleepiness, tiredness, or inability to concentrate. Be careful when driving or doing any task that requires concentration. Avoid alcohol.
Call your doctor if you develop breathing difficulties, constipation, dry mouth, or any bothersome or persistent side effect.
Apply the fentanyl patch only to non-irritated skin on a flat surface of the upper body. Hair at the application site should be clipped or cut, not shaved, before applying the patch. Do not use oils, soaps, lotions, alcohol, or anything else that might irritate the skin before applying the patch.
If you are taking a controlled-release narcotic product, do not crush, chew, or break the tablet or lozenge. Rapid release may result in a potentially fatal dose of the drug.
If you forget a dose of codeine, 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. Never take a double dose.
Special Populations
Pregnancy/Breast-feeding: Narcotics pass into the fetal circulation. Excessive use of them during pregnancy may cause drug dependence in newborns. Narcotics may also cause breathing difficulties in infants during delivery. Animal studies show that codeine may cause fetal harm. If given to a pregnant woman before cesarean section, fentanyl may cause drowsiness in newborns. When either of these drugs is considered crucial by your doctor, its potemt(a1 bel)elft must be carefully weighed against its risks.
Narcotics pass into breast milk. Nursing mothers who must take codeine should use infant formula.
Seniors: Seniors are more likely to be sensitive to side effects and should be treated with the smallest effective dosage.

Bosentan
Type of Drug     Endothelia receptor antagonist.
Prescribed For
Pulmonary arterial hypertension.
General Information
These drugs lower blood pressure by working on the endothelin system. Endothelia is a hormone that plays an important role in maintaining blood pressure. It is normally found in blood vessels, but endothelin levels are very high in the blood and lungs of people with pulmonary arterial hypertension. People with this condition have high blood pressure, trouble breathing, and get very tired even when walking or doing other moderate exercising. Pulmonary arterial hypertension can be fatal.
Cautions and Warnings
These drugs should not be used by those who are allergic or sensitive to any of their ingredients.
Bosentan can cause liver injury. People taking these drugs should have their liver enzymes checked monthly. Enzyme increases can be a sign of liver injury and may be a reason to stop taking bosentan.
These drugs are broken down in the liver. People with liver damage should take them with caution.
These drugs should not be taken during pregnancy as they are likely to cause birth defects (see “Special Populations”).
These drugs cause a reduction in red blood cells, leading to anemia. Larger doses of bosentan cause a greater loss of red blood cells.
Possible Side Effects
Ambrisentan
Most side effects are mild. Only stuffy nose increases with increased dosage.
V Most common: swelling k%) -aims or legs, stuffy nose, si1)u6fis, flushing, heart palpitations, abdominal pain, constipation, difficulty breathing, and headache.
Bosentan
♦ Most common: headache and sore throat and nose.
Drug Interactions
•    It is possible that bosentan may cause failure of hormonal contraceptives.
•    Cyclosporine, used to prevent transplant rejection, increases blood levels of bosentan and ambrisentan. Do not combine these drugs.
•    Mixing glyburide, an antidiabetes drug, with bosentan increases the risk of elevated liver enzyme levels. Do not combine these drugs.
•    Ketoconazole greatly increases blood levels of bosentan by slowing its breakdown in the liver.
•    Combining bosentan with a statin-type cholesterol - lowering drug such as simvastatin, lovastatin, or atorvastatin reduces the amount of statin drug in the blood. Dose increases may be needed.
•    Bosentan can reduce the amount of warfarin in the blood by
about 1/3. Changes in warfarin dosage may be needed.
•    Combining ambrisentan with atanazavir, clarithromycin, indinavir, itraconazole, ketoconazole, nelfinavir, ritonavir, omeprazole, saquinavir,or telithromycin may increase the amount of ambrisentan in the blood. Caution is advised.
•    Combining ambrisentan with rifampin may reduce the
amount of ambrisentan in the blood. Caution is advised.
Food Interactions
These drugs may be taken with or without food.
U’Suk Dose
Ambrisentan
Adult (age 18 and over): 5-10 mg once a day. Do not crush, split, or chew these tablets.
Child: not recommended.
Possible Side Effects (continued)
♦    Common: flushing, abnormal liver blood pressure, and heart
♦    Less common: upset stomach, tiredness.
ver function, leg swelling, palpitations.
, swelling, itching, anemia,
Bosentan
Adult (age 18 and over): 62.5 mg twice a day for 4 weeks, then
125 mg twice a day.
Child: not recommended.
Overdosage
Massive overdose may result in severe lowering of blood pressure, requiring emergency attention. The most common effects associated with overdosage are headache, low blood pressure, increased heart rate, and nausea and vomiting. Overdose victims should be taken to a hospital emergency room for treatment. ALWAYS bring the prescription bottle or container.
Special Information
Do not stop taking these drugs without gradually reducing the dosage as instructed by your doctor.
If you forget to take a dose, 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.
Contact your doctor at once if you develop severe itching, yellowing of the skin or eyes, tiredness, swelling in the arms or legs, nausea, vomiting, fever, or abdominal pain.
Doctors must enroll in special restricted distribution programs before they can prescribe these medicines, because of the risks of liver injury and birth defects associated with them. These medicines are not available in regular pharmacies but are mailed to you from a central pharmacy only after the testing and other program requirements have been met by your doctor.
Special Populations
Pregnancy/Breast-feeding: These medicines are very likely to cause major birth defects and should not be taken by pregnant women. Women must be sure they are not pregnant before beginning these treatments.
Women should also use non-hormone contraceptives while on these drugs. Hormone-based contraceptives such as birth control pills, injections, and implants may not work in women taking Wst m or ambrisentan.
It is not known if either of these medicines passes into breast milk. Nursing mothers should use infant formula.
Seniors: The greater chance of kidney, liver, and cardiac function side effects in seniors may affect drug dosage. Seniors may also experience more swelling in the arms or legs.

Bisoprolol (bye-SOPE-roe-lol) 91
Brand Name
Zebeta
Combination Product
Generic Ingredients: Bisoproldl + Hydrochlorothiazide (0 Ziac
Type of Drug
Beta-adrenergic blocking agent.
Prescribed For
High blood pressure; may also be used for angina pectoris, and stable congestive heart failure.
General Information
Bisoprolol fumarate is one of many beta-adrenergic blocking drugs, or beta blockers, which interfere with the action of a specific part of the nervous system. Beta receptors are found all over the body and affect many body functions. Each beta blocker has particular characteristics that make it more suitable for certain conditions or people. Hydrochlorothiazide is a diuretic that lowers blood pressure.
Cautions and Warnings
Do not use bisoprolol if you are allergic or sensitive to it or other beta blockers.
Beta blockers should not be used by people with a slow heart rate, a condition called heart block (a disorder of the heart’s conduction system), or those in cardiac shock or overt heart failure_
Peoplewith angina who take bisoprolol for high blood pressure risk aggravating their angina if they suddenly stop taking the drug. These people should have their dosage reduced gradually over 1-2 weeks.
Bisoprolol should be used with caution if you have liver or kidney disease, because your ability to eliminate the drug from your body may be impaired.
People with chronic bronchitis or emphysema should use bisoprolol with caution.
Bisoprolol reduces the amount of blood pumped by the heart with each beat. This blood flow reduction may aggravate the condition of people with poor circulation or circulatory disease.
If you are undergoing major surgery, your doctor may want you to stop taking bisoprolol at least 2 days before surgery.
People with a history of severe anaphylactic reaction to allergens may be unresponsive to usual doses of epinephrine while taking beta blockers.
Possible Side Effects
Side effects are relatively uncommon and usually mild. T Mrnk common: impotence.
V Less common: unusual tiredness or weakness, slow heartbeat, heart failure, dizziness, breathing difficulties, bronchospasm, depression, confusion, anxiety, nervousness, sleeplessness, disorientation, short-term memory loss, Possible Side Effects (continued)
emotional instability, cold hands and feet, constipation, diarrhea, nausea, vomiting, upset stomach, increased sweating, urinary difficulties, cramps, blurred vision, rash, hair loss, stuffy nose, facial swelling, aggravation of lupus erythematosus, itching, chest pain, back or joint pain, colitis, drug allergy (symptoms include fever and sore throat), and liver toxicity.
Drug Interactions
•    Bisoprolol may interact with surgical anesthetics to increase the risk of heart problems during surgery. Some anesthesiologists recommend gradually stopping the drug by 2 days before surgery.
•    Bisoprolol may interfere with the normal signs of low blood sugar and with the action of oral antidiabetes drugs.
•    Bisoprolol increases the blood-pressure-lowering effects of other blood-pressure-reducing agents, including clonidine, guanabenz, and reserpine, and calcium channel blockers, such as nifedipine.
•    Aspirin-containing drugs, indomethacin, sulfinpyrazone, and estrogen drugs may interfere with the blood-pressurelowering effect of bisoprolol.
•    Cocaine may reduce the effectiveness of all beta blockers.
•    Bisoprolol may worsen the problem of cold hands and feet associated with taking ergot alkaloids, used to treat migraine. Gangrene is possible in people taking both an ergot and bisoprolol.
•    Calcium channel blockers, diphenhydramine, flecainide, contraceptive drugs, quinolone antibacterials, and quinidine may increase the amount of bisoprolol in the bloodstream and lead to increased bisoprolol effects.
•    Bisoprolol may increase the effects of ephedrine. Initially, high blood pressure wvd they a slow heart rate may result.
6 Combining beta blockers with lidocaine can increase lidocaine levels, possibly leading to toxicity.
•    Beta blockers taken with prazosin may increase the side effect of lightheadedness upon standing up that prazosin can produce.
•    Beta blockers may block the effects of epinephrine.
Smoking makes the liver break this drug down more quickly. If you stop smoking while taking bisoprolol, your daily dose
may have to be reduced.
Food Interactions
This drug may be taken without regard to food or meals.
Usual Dose
Adult: starting dose-5 mg once daily. The daily dose may be gradually increased up to 20 mg. Maintenance dose-5-10 mg once daily. People with kidney or liver disease may need only 2.5 mg a day to start. Seniors should be treated cautiously; they may respond to lower doses.
Child: not recommended.
Overdosage
Symptoms of overdose include changes in heartbeat—unusually slow, unusually fast, or irregular—severe dizziness or fainting, breathing difficulties, bluish fingernails or palms, low blood pressure, heart failure, shock, and seizures. The victim should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Do not stop taking bisoprolol unless directed to do so by your doctor. It is meant for continuous use. Abrupt withdrawal may cause chest pain, breathing difficulties, increased sweating, and unusually fast or irregular heartbeat. Dosage should be reduced gradually over a period of about 2 weeks when bisoprolol treatment is stopped.
Call your doctor at once if you develop back or joint pain, breathing difficulties, cold hands or feet, depression, rash, or changes in heartbeat. Bisoprolol may produce an undesirable lowering of blood pressure, leading to dizziness or fainting: call your doctor if this happens to you. Also call your doctor if you experiem:.epeisistent or bothersome anxiety, diarrhea, constipation, impotence, headache, itching, nausea or vomiting, nightmares or vivid dreams, upset stomach, trouble sleeping, stuffed nose, frequent urination, unusual tiredness, or weakness.
Bisoprolol may cause drowsiness, dizziness, blurred vision, or lightheadedness. Be careful when driving or performing complex It is best to take bisoprolol at the same time every day. If you forget a dose, take it as soon as you remember. If it is within 8 hours of 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: Infants born to women who took a beta blocker while pregnant had lower birth weights, low blood pressure, and reduced heart rates. Bisoprolol should be avoided by pregnant women and women who might become pregnant while taking it.
It is not known if bisoprolol passes into breast milk. Nursing mothers taking bisoprolol should use infant formula.
Seniors: Seniors taking bisoprolol may be more likely to suffer from cold hands and feet, reduced body temperature, chest pain, general feelings of ill health, sudden breathing difficulties, increased sweating, or changes in heartbeat.

Let’s hope it never happens - but if it does, knowing what to do could make the difference between surviving and not surviving. The sensible thing is to read these pages - or whichever parts are relevant to you or your child - before you encounter an emergency. It is often helpful to rehearse the procedure in your mind and actually imagine yourself going through the actions described here.
Find out in advance what the local ambulance service is like, and ask your GP for advice about who to contact in an emergency. (If you have latex allergy, check in advance that all local ambulances carry a latex-free kit.) These are the options:
• Call your GP.If the doctor is nearby and the hospital or ambulance station a long way off, this may be the best decision. Doctors in rural areas may have supplies of adrenaline for emergency treatment, and oxygen for those suffering a severe asthma attack.
• Call an ambulance. Where the local ambulance service is dependable, this is always the best option. The ambulance crew will have adrenaline and oxygen.
• Go by car or taxi to the nearest hospital
emergency department. This is not usually a
good plan, because your condition may quick-
ly get worse, and you have no emergency
treatment available. But there may be situa-
tions where it is a sensible decision. Emergencies can occur when you are away on holiday or business. Never stay anywhere without a phone – check that it is working as soon as you arrive. Make sure you have the number of a local doctor and know where the nearest hospital is. A remote holiday cottage can be a dangerous place to suffer an asthma attack or anaphylactic shock.
Anaphylactic shock
This is an extremely serious emergency, requiring immediate medical help. The signs of anaphylactic shock are listed on p.58. In the case of food allergy, there are additional signs in the mouth, lips and throat (see p. 62). Use adrenaline (epinephrine) straight away if you have it – but get emergency medical help as well. With injectable adrenaline (an EpiPen or Anapen – see p. 150), remove the cap and jab firmly into the outer thigh, going straight through any clothing. Never inject into any other part of the body – this can be dangerous.
If you have an adrenaline inhaler (see pp. 155-6) you can use this first to treat symptoms in the mouth, throat and airways, and then use the injector if you still have symptoms. (Improvise a spacer – see p. 100 – if there is difficulty in inhaling the adrenaline.) Anyone whose reactions tend to be severe should use the injector first and follow up with the inhaler if necessary. Overdosing with adrenaline is possible, and can be fatal, but using the inhaler as well as the injector is safe as long as you don’t have a heart condition (see pp. 155-6).
If you do not improve after using the injector, a second one can be used, 10-15 minutes later.
In situations where medical help is not yet available and the symptoms are not abating, another shot of adrenaline can be given every 15-20 minutes. But the maximum number of shots recommended by your doctor should never be exceeded. Keep count of how many you’ve had, and tell medical staff.
An asthmatic who does not have an adrenaline inhaler can use a beta-2 reliever inhaler such as Ventolin (see p. 152) as well as the adrenaline injection, although it probably won’t help very much.
Suppose you know for sure that you have encountered your allergen, but you don’t have any symptoms yet? In Britain, the usual advice is to wait for symptoms, but doctors in the United States say go ahead and use the adrenaline injector if you have reacted very badly in the past. In general, for people with no other health problems, it is better to give an adrenaline injection which isn’t needed than to delay giving one that is needed. Delaying the use of the injector may mean that the reaction gets out of control. Some people put off using the injector because they think it should be saved for when they ‘really need it’. In fact the adrenaline works just as well if you have used it on previous occasions.
Following anaphylactic shock, you should be kept in hospital for 6-12 hours even when everything seems fine. Attacks have recurred as much as eight hours later. Corticosteroids reduce the chance of this happening – ask if these have been given. If you are discharged early and it is a long journey home, consider waiting in the hospital, or nearby, until eight hours after the original reaction.
First aid for anaphylactic shock
A badly swollen tongue or throat can cause suffocation. If there is visible swelling and the person is unconscious or turning blue, try to keep the top of the trachea (the main airway leading from the throat) open. Use the handle of a spoon – one that has very smooth edges. Slide it carefully over the top of the tongue and into the throat. Press down gently but firmly to open the airway.
Someone who is feeling faint or dizzy, or losing consciousness, or (in the case of a child) becoming very pale and floppy, may be suffering from a dangerous drop in blood pressure. He or she is more at risk of a fatal collapse if in an upright position, because not enough blood is reaching the heart. The worst thing is to stand up suddenly, or to move (or be moved) quickly from a lying to a sitting position –death can follow within seconds. The best thing is to lie down, preferably with the legs resting on cushions or a stool so that they are above the torso, and with the arms raised above the chest. Adrenaline can be given while in this position. A stretcher should be used to get the patient to an ambulance.
Latex allergy and emergency treatment
If you have anaphylaxis due to latex allergy, going to hospital can be alarming, as you may suffer further reactions to latex gloves or equipment. Some patients with latex allergy have had such bad experiences in ambulances and hospitals that they become fearful of using their adrenaline injector, since this means they must go to the hospital afterwards. They delay using the injector, which makes the situation worse. Some doctors are now giving such patients all the medicines and training they need to manage their anaphylactic shock themselves, so that they don’t need to attend hospital.
A person who has lost consciousness should be lying down on their side in case they are sick (this reduces the chance of them inhaling their vomit). The same goes for anyone who feels nauseous.
On the other hand, if the major problem at the outset is difficulty in breathing (as it generally is in children) a sitting position is better.
It is unusual for both faintness and severe breathing problems to be present at once. If this occurs, the patient should lie down, and if there is swelling in the throat, a spoon should be used (see left) to keep the airways open.
Insect-sting allergy
If you don’t have an adrenaline injector, get medical help immediately.
If you’ve had a cutaneous systemic reaction (see p. 60) in the past, use the adrenaline injector if there is any difficulty in breathing, hoarseness, stomach cramps, diarrhoea, nausea, faintness, dizziness or confusion. If you are unsure, remember that, unless you have a heart condition, it is usually better to overreact (i.e. use the adrenaline unnecessarily) than under-react.
If you’ve had a severe systemic reaction (i.e. anaphylactic shock) in the past, use an adrenaline injector at the first sign of any reaction other than immediately around the sting.
If there is a honeybee stinger left in the skin, scrape or flick it out sideways using a fingernail, knife blade or credit card – the venom sac is attached and will go on injecting venom for up to 10 minutes if you leave it there.
Don’t try to pull the stinger out – this squeezes the venom sac and pumps more venom into the skin.
Get emergency medical help, and follow the other measures for dealing with anaphylactic shock (see left).
Don’t go alone
If you suffer vomiting or diarrhoea during anaphylaxis, and have to go to the toilet, tell someone to call an ambulance and take someone else with youto the toilet. Do not go in alone and lock the door, in case you collapse.
Asthma attacks
Even those with mild asthma, who have never had a serious attack before, can quite suddenly get into difficulties and require emergency treatment. Don’t be over-anxious about this, because it is unlikely to happen – but do be prepared. Not having your reliever inhaler with you when a severe attack starts is a recipe for disaster – always take it, wherever you go.
Deal with an attack promptly. The sooner you act, the fewer drugs you’ll need in the long run to control the attack. Most asthmatics wait too long and then under-treat their asthma.
The important thing is recognising an asthma attack, and knowing when it is getting out of control. Not all attacks are the same – some come on fast, some come on slowly.
Rapid asthma attacks come on in a matter of hours. You may have been fine all day, but then start to feel very breathless and wheezy, or begin coughing badly. Less than an hour later, despite using the reliever, the breathlessness is worse and it is a struggle to speak or walk across the room. This is a severe attack: don’t delay in getting medical help.
Slow asthma attacks come on over a period of days. At first you are more breathless and wheezy than usual, and your reliever inhaler is not helping much. Asthma wakes you up at night, and you are far more breathless than usual in the morning. This could be the beginning of a severe attack, so don’t delay in getting medical help. If you get to the point where your asthma is disturbing your sleep every night, and in the morning you have difficulty in speaking or walking about, this is a very serious situation – you must see your doctor or go to the hospital now.
A few asthmatics have great difficulty recognising when they are increasingly breathless, and for them, using a peak-flow meter (see p. 97) every day is essential. Indeed, most asthmatics find
Recognising an asthma attack in a very young child
With a young child, these signs indicate a severe asthma attack:
• the nostrils are flared
• the shoulders are unusually high
• the child can say only one or two words between breaths
• the ribs are pushed out, and the spaces between the ribs, and below the chest cage, are sucked in during breathing
• you can hear wheezing (a whistling noise)
• the lips, tongue or fingernails are blue.
If wheezing stops, without any other apparent improvement, this is a very bad sign — it may mean that the airways are now so narrow that no air is passing through them. This is called a ’silent chest’, and indicates an urgent need for medical attention.
that monitoring peak flow is a valuable way of spotting attacks in advance. However, if your peak flow seems normal, and yet you feel breathless and have a tight feeling in your chest, pay attention to your symptoms and get medical help.
Your response to your reliever inhaler is another helpful sign assessing asthma attacks. Things are serious if:
• the reliever inhaler does not seem to be working at all within 10 minutes of taking a puff
• it does not work as well as usual
• it works, but the effect wears off in less than three hours. If you have an asthmatic child, give everyone who normally takes care of the child detailed written instructions for recognising and dealing with an asthma attack. People forget verbal instructions especially in an emergency. A child who is exhausted or upset c. an attack should always be given medical care.
Taking action
If your reliever inhaler is not working well (see above), take another puff to open up your airways – and then take further action. as described below.
If you seem to be in the early stages of a slow asthma attack check your management plan, and if your peak flow has fallen below the recommended level, double the dose of inhaled steroids (twice as many puffs each time) now. Add any other medicines (e.g. steroid tablets) as recommended by the management plan.
Those who don’t have a peak-flow meter or management plan should double the dose of inhaled steroids and make an urgent appointment to see the doctor.
If you are suffering a rapid attack, or a slow attack that has got out of control, you need emergency medical help. Ring for an ambulance, ring your doctor, or go to the hospital – the ideal course of action will vary, depending on where you live (see p. 98).
Use your reliever inhaler until medical help arrives. You can take a puff every 5-10 minutes if needed, but keep a count of how many puffs you’ve had and stop after 30. Some doctors suggest taking up to 30 puffs all at once. (If you have a heart condition, this dose might be dangerous: follow your doctor’s advice.)
If it is difficult to inhale, use a spacer – this can make all the difference, especially for children.
You can improvise a spacer from a plastic cup, a plastic bottle, or a paper bag. Make a hole in the bottom of the cup or bottle, or in one corner of the paper bag, and insert the mouthpiece of the inhaler here. The open end of the cup, bottle or bag goes in or over the mouth – with the bag, you have to bunch it up and hold it around the mouth. Squirt the inhaler repeatedly into the improvised spacer, while breathing steadily in and out.
The six golden rules for asthma attacks
• Breathe as slowly as possible and concentrate on breathing out, not on breathing in. Exhale as fully as you can and your in-breath will follow automatically.
• Never panic – if you do, you may start hyperventilating, and this makes matters much worse (see p. 226). Panicky parents are the worst possible thing for an asthmatic child during an attack.
• Adopt a position that makes breathing as easy as possible. Propping your arms up at about shoulder height can help – for example, sit back-to-front on a dining chair, with your arms folded and resting on the back. Or put pillows on a table, sit in an upright chair, and rest your head and arms on the pillows. Don’t lie down, as this makes matters worse. Open a window, as long as the air outside is not cold, polluted or loaded with pollen.
• Avoid factors that can make an asthma attack worse, for example, vigorous activity, cold air, irritants and allergens.
• Drink plenty of water, fruit juice or other liquids as a lot of water is lost through the surface of the airways during an asthma attack, and you can become dehydrated.
• Don’t take anything to help you sleep, even herbal pills. If your asthma gets worse during the night, you need to wake up so that you can get more air.
After an attack
Asthmatics who have suffered a severe attack are occasionally sent home from hospital before they are completely better. A few people have died as a result of being discharged too soon. So if you feel breathless or otherwise unwell after you leave hospital, don’t hesitate to go back – or seek other medical help.
See your GP or specialist within a few days of any emergency treatment. Don’t be over-confident just after a severe attack – this can be a very vulnerable time. Take more rest than usual and drink plenty of fluids, as you may be dehydrated. Keep taking your preventer inhaler at the increased dose – reducing the dose now could lead to another severe, possibly fatal, attack. Keep taking steroid tablets if you have been given them.
If you produced a lot of mucus during the attack, try to clear it, but without violent coughing. Mucus can sometimes form solid plugs which block small airways. Treatment by a physiotherapist would help, and expectorants – drugs which help loosen mucus –can also be useful (ask your pharmacist about these). Don’t take ordinary cough medicine (see box on p. 163). There are also some breathing exercises which can help to clear mucus (see p. 231).
An asthma attack represents a chance to learn more about preventing asthma – so think about what went wrong. Had you forgotten to take your preventer inhaler regularly? How long is it since you had your medicines reviewed by the doctor or asthma clinic? Have you been using your peak-flow meter daily? Were you exposed to a high dose of allergen or an irritant?
A reaction to aspirin-like drugs
Aspirin sensitivity can begin quite suddenly in someone who has previously taken aspirin without trouble. If you have unexplained chronic urticaria, or polyps in the nose, plus asthma and/or rhinitis, the development of aspirin sensitivity at some time in the future is a distinct possibility (see p. 151).
A sensitivity reaction to aspirin or aspirin-like drugs usually begins between 30 minutes and two hours after the drug is taken. You will have some or all of these symptoms:
• a runny or badly blocked nose, and red eyes
• a feeling of warmth, flushing and sweating
• a general rash
• a sensation of tightness in the chest, a dry cough, increasing breathlessness
• malaise and exhaustion
• vomiting or diarrhoea
• swelling (angioedema) and/or nettle rash (urticaria). If you have such symptoms get emergency medical help immediately because the reaction can quickly develop into severe asthma, shock, collapse and unconsciousness.
If you have asthma, use your reliever inhaler as much as required (up to 30 puffs) until medical help arrives. Anyone who has an adrenaline (epinephrine) auto-injector, or an adrenaline inhaler, can use this as well – up to 30 puffs of the inhaler, or whatever maximum dose is given in the instructions. Tell the ambulance crew and doctors exactly what you have taken.