Thomas K.F. Foo, PhD

• Assistant Professor
• Department of Radiological Sciences
• Uniformed University of the Health Sciences
• Bethesda, Maryland
• Manager, MRI Lab
• GE Global Research
• Niskayuna, New York

Pharmacodynamics/Kinetics Duration of Action Up to 24 hours (Jain 2017) Half-life Elimination Atomoxetine: 5 hours (up to 24 hours in poor metabolizers); Active metabolites: 4hydroxyatomoxetine: 6-8 hours; N-desmethylatomoxetine: 6-8 hours (34-40 hours in poor metabolizers) Time to Peak Plasma: 1-2 hours; delayed 3 hours by high-fat meal Pregnancy Risk Factor C Pregnancy Considerations Adverse events have been observed in animal reproduction studies schedule 8 medications list 200 mg cordarone sale. Information related to atomoxetine use in pregnancy is limited; appropriate contraception is recommended for sexually active women of childbearing potential (Heiligenstein treatment trends purchase cheapest cordarone, 2003) medications 2355 generic 100mg cordarone mastercard. Pregnancy Considerations Atorvastatin is contraindicated in pregnant females or those who may become pregnant symptoms ulcerative colitis effective cordarone 100 mg. The discontinuation of lipid-lowering medications temporarily during pregnancy is not expected to have significant impact on the long-term outcomes of primary hypercholesterolemia treatment treatment 4 letter word cordarone 250 mg fast delivery. Atorvastatin should be discontinued immediately if an unplanned pregnancy occurs during treatment treatment quotes and sayings discount cordarone 100mg free shipping. Consequently, it is difficult to distinguish reactions attributed to atovaquone from those caused by the underlying disease or a combination thereof. Proguanil: the metabolite cycloguanil inhibits dihydrofolate reductase, disrupting deoxythymidylate synthesis. Together, atovaquone/cycloguanil affect the erythrocytic and exoerythrocytic stages of development. Pregnancy Considerations Outcome information following maternal use of atovaquone and proguanil in pregnancy is limited (Andrejko 2019; Mayer 2018; Pasternak 2011). The pharmacokinetics of atovaquone and proguanil may be altered during pregnancy (Burger 2016). Immune-mediated fetal rejection causing increased abortion or stillbirth was observed in animal reproduction studies. Females of reproductive potential should use effective contraception during therapy and for at least 1 month after treatment is complete. If placental transfer were to occur, fetal toxicity, including B-cell lymphocytopenia, may occur. Pregnancy testing is recommended prior to therapy in sexually active women of reproductive potential. Refer to the cyclophosphamide and fludarabine monographs for information related to use of effective contraception in patients using these medications for lymphodepleting chemotherapy. Potential pregnancies (following treatment) should be discussed with the prescriber. Local Anesthetic/Vasoconstrictor Precautions Significant hypertension can occur with the use of this drug; monitor for hypertension prior to using local anesthetic with vasoconstrictor; medical consult if necessary Effects on Dental Treatment Key adverse event(s) related to dental treatment: Oral mucosal inflammation, stomatitis, and taste alteration have been reported Effects on Bleeding Chemotherapy may result in significant myelosuppression, potentially including significant reduction in platelet counts and altered hemostasis. In patients who are under active treatment with axitinib, medical consult is suggested. Females of childbearing potential should have a pregnancy test prior to therapy; effective contraception should be used during axitinib therapy and for 1 week after the final axitinib dose. Males with female partners of reproductive potential should also use effective contraception during axitinib therapy and for 1 week after the final axitinib dose. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Mucositis, gingival bleeding, oral mucosal petechiae, stomatitis, oral hemorrhage, and tongue ulceration. Thrombocytopenia is reported in 66% to 70% of patients receiving azacitidine subcutaneously. Azacitidine also exerts direct toxicity to abnormal hematopoietic cells in the bone marrow. Based on its mechanism of action, azacitidine may cause fetal harm if administered during pregnancy. Women of childbearing potential should be advised to avoid pregnancy during treatment; verify pregnancy status prior to therapy initiation. In addition, males should be advised to avoid fathering a child while on azacitidine therapy and should use effective contraception during therapy. Central nervous system: Malaise Gastrointestinal: Nausea and vomiting (rheumatoid arthritis: 12%), diarrhea Hematologic & oncologic: Leukopenia (renal transplant: >50%; rheumatoid arthritis: 28%), neoplasia (renal transplant 3% [other than lymphoma], 0. Available guidelines suggest that use of azathioprine is acceptable for the treatment of rheumatoid arthritis in pregnant females (Flint 2016), although use for this indication is contraindicated by the manufacturer. Azathioprine may also be used for the adjunctive treatment of lupus nephritis in pregnant females (Hahn 2012). Females with Crohn disease or ulcerative colitis who are on maintenance therapy with azathioprine may continue treatment during pregnancy (Nguyen 2016). Agents other than azathioprine are recommended for the treatment of immune thrombocytopenia in pregnant females (Neunert 2011). The manufacturer recommends that females of reproductive potential should avoid becoming pregnant during treatment. Azathioprine is compatible for use in males with female partners of reproductive potential (Flint 2016). Seasonal allergic rhinitis: Relief of symptoms of seasonal allergic rhinitis in adults and pediatric patients 2 years (Astepro 0. Pharmacodynamics/Kinetics Onset of Action Immune thrombocytopenia (oral): Initial response: 30 to 90 days; Peak response: 30 to 120 days (Neunert 2011) Half-life Elimination Azathioprine and mercaptopurine: Variable: ~2 hours (Taylor 2005) Time to Peak Oral: 1 to 2 hours (including metabolites) Pregnancy Risk Factor D Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Bitter taste, xerostomia (normal salivary flow resumes upon discontinuation), aphthous stomatitis, glossitis, and burning sensation in throat. Chronic use of antihistamines will inhibit salivary flow, particularly in elderly patients. Effects on Bleeding No information available to require special precautions Adverse Reactions Adverse reactions may be dose-, indication-, or product-dependent: >10%: Central nervous system: Bitter taste (4% to 20%), headache (1% to 15%), drowsiness (12%) Infection: Cold symptoms (children 17%) Respiratory: Rhinitis (exacerbation; 17%), cough (children: 11%; infants and children: 2%) 2% to 10%: Central nervous system: Dysesthesia (8%), dizziness (2%), fatigue (2%) Dermatologic: Contact dermatitis Endocrine & metabolic: Weight gain (2%) Gastrointestinal: Dysgeusia (children: 2% to 4%), nausea (3%), xerostomia (3%), vomiting 180 Pregnancy Considerations Azathioprine crosses the placenta. Product labeling notes congenital anomalies, immunosuppression, hematologic toxicities (lymphopenia, pancytopenia), and intrauterine growth retardation from case reports following use in maternal renal allograft recipients (based on additional data, this may, in part, be dose related [Colla 2018]). Intrauterine growth retardation and preterm delivery are also reported in pregnancies following a kidney transplant. In addition, fetal immunosuppression and hematologic toxicities are decreased when maintaining appropriate maternal leukocyte counts. Stable immunosuppression is required in pregnant females who have had a kidney transplant and an increased risk of fetal malformations has not been observed with azathioprine. However, data related to the use of azelastine in pregnancy is limited; if treatment for rhinitis in a pregnant woman is needed, other agents are preferred (Wallace 2008). The use of drugs which act on the reninangiotensin system are associated with oligohydramnios. These adverse events are generally associated with maternal use in the second and third trimesters. Untreated chronic maternal hypertension is also associated with adverse events in the fetus, infant, and mother. All doses are expressed as immediate-release azithromycin unless otherwise specified. All trials used pulse-dosing regimens; regimens included: 500 mg once daily for 4 consecutive days per month for 3 consecutive months (Babaeinejad 2011; Parsad 2001) or 500 mg once daily for 3 days in the first week, followed by 500 mg once weekly until week 10 (Maleszka 2011) or 500 mg once daily for 3 consecutive days each week in month 1, followed by 500 mg once daily for 2 consecutive days each week in month 2, then 500 mg once daily for 1 day each week in month 3 (Kus 2005). Bronchiectasis (non-cystic fibrosis), prevention of pulmonary exacerbations (off-label use): Oral: 500 mg 3 times weekly (Wong 2012) or 250 mg once daily (Altenburg 2013). Prevention of exacerbations (off-label use): Oral: 250 to 500 mg 3 times weekly (Berkhof 2013; Uzun 2014) or 250 mg once daily (Albert 2011) Cystic fibrosis, anti-inflammatory (off-label use): Oral: 250 mg (<40 kg) or 500 mg (40 kg) 3 times weekly (Saiman 2003) or 250 mg once daily (Wolter 2002). Note: Patients should be screened for nontuberculous mycobacterial infection prior to treatment and azithromycin should not be given if present (Mogayzel 2013; Saiman 2003). If symptoms have not resolved after 24 hours following single-dose therapy, continue with 500 mg once daily for 2 more days. Endocarditis prophylaxis, dental or invasive respiratory tract procedure (alternative agent for penicillin-allergic patients) (off-label use): Oral: 500 mg 30 to 60 minutes prior to procedure. Note: Only recommended for patients with cardiac conditions associated with the highest risk of an adverse outcome from endocarditis and who are undergoing a procedure likely to result in bacteremia with an organism that has the potential to cause endocarditis. Lyme disease (erythema migrans or borrelial lymphocytoma) (alternative agent) (off-label use): Oral: 500 mg once daily for 7 to 10 days. Note: Patients should be under the care of a clinician with expertise in managing mycobacterial infection. Note: Clinical evaluation and presumptive treatment is preferred for sexual partners of patients with chlamydia. Note: Clinical evaluation and presumptive treatment is preferred for sexual partners of patients with gonorrhea. Note: Patients with pharyngeal infection treated with an alternative regimen should have a 14-day test-of-cure performed. Granuloma inguinale (donovanosis) (off-label use): Oral: 1 g once weekly or 500 mg once daily for 3 weeks and until lesions have healed. Note: Limited data support the use of alternatives to penicillin; close serologic and clinical follow-up is warranted. Use with caution due to potential for hepatotoxicity (rare); discontinue immediately for signs or symptoms of hepatitis. Note: Extended-release suspension (Zmax) is not interchangeable with immediate-release formulations. Warnings/Precautions Use with caution in patients with preexisting liver disease; hepatocellular and/or cholestatic hepatitis (with or without jaundice), hepatic necrosis, failure and death have occurred. Discontinue immediately if symptoms of hepatitis occur (malaise, nausea, vomiting, abdominal colic, fever). May mask or delay symptoms of incubating gonorrhea or syphilis, so appropriate culture and susceptibility tests should be performed prior to initiating a treatment regimen. Oral suspensions (immediate release and extended release) are not interchangeable. Azithromycin suspension, not tablet form, has significantly increased absorption (46%) with food. Management: Immediate release suspension and tablet may be taken without regard to food; extended release suspension should be taken on an empty stomach (at least 1 hour before or 2 hours following a meal). Oral suspension, extended release, should be taken on an empty stomach (at least 1 hour before or 2 hours following a meal). The maternal serum half-life of azithromycin is unchanged in early pregnancy and decreased at term; however, high concentrations of azithromycin are sustained in the myometrium and adipose tissue (Fischer 2012; Ramsey 2003). This milk concentration was obtained following maternal administration of oral azithromycin as a 1 g loading dose followed in 48 hours by azithromycin 500 mg for 3 days; milk concentrations increased over time and reached a peak 30 hours after the last oral dose (Kelsey 1994). Decreased appetite, diarrhea, rash, and somnolence have been reported in nursing infants exposed to macrolide antibiotics (Goldstein 2009). In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora. The manufacturer recommends that caution be exercised when administering azithromycin to breastfeeding women. Researchers reviewed a Tennessee Medicaid cohort of patients to evaluate cardiovascular mortality in patients taking azithromycin, amoxicillin, ciprofloxacin, levofloxacin, or no antibiotic. The cohort included patients who took azithromycin (347,795 prescriptions); propensity-scorematched persons who took no antibiotics (1,391,180 control periods); and patients who took amoxicillin (1,348,672 prescriptions), ciprofloxacin (264,626 prescriptions), or levofloxacin (193,906 prescriptions). The risk of cardiovascular death was greater with azithromycin than with ciprofloxacin, but similar to levofloxacin. The estimated risk for azithromycin was 47 additional cardiovascular deaths per million courses of treatment (Ray 2012). Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases), while cell wall assembly is arrested. Mechanism of Action Inhibits bacterial cell wall synthesis by preventing transfer of mucopeptides into the growing cell wall Pregnancy Considerations Although large studies have not been conducted, absorption is limited following topical application; use during pregnancy has not been associated with an increased risk of adverse fetal events (Leachman, 2006; Murase, 2014). Limitations of use: Patients should first respond to a screening dose of intrathecal baclofen prior to consideration for long term infusion via an implantable pump. Patients with spasticity due to traumatic brain injury should wait at least one year after the injury before consideration of long term intrathecal baclofen therapy. Prescribing and Access Restrictions Cayston (aztreonam inhalation solution) is only available through a select group of specialty pharmacies and cannot be obtained through a retail pharmacy. This network of specialty pharmacies ensures proper access to both the drug and device. Maternal plasma concentrations following administration of intrathecal baclofen are significantly less than those with oral doses; exposure to the fetus is expected to be limited and adverse neonatal events have not been noted in available reports (Morton 2009). Limitations of use: Influenza viruses change over time, and factors such as the virus type or subtype, emergence of resistance, or changes in viral virulence may diminish the clinical benefit of antiviral drugs. Consider available information on drug susceptibility patterns for circulating influenza virus strains when deciding whether to use baloxavir marboxil. Baloxavir has demonstrated antiviral activity against influenza A and B viruses, including strains resistant to standard current antiviral agents (Hayden 2018). Pharmacodynamics/Kinetics Onset of Action Intrathecal bolus: 30 minutes to 1 hour; Continuous infusion: 6 to 8 hours after infusion initiation Peak effect: Intrathecal bolus: 4 hours (effects may last 4 to 8 hours); Continuous infusion: 24 to 48 hours Pharmacodynamics/Kinetics Half-life Elimination 79. Half-life Elimination Oral: Pediatric patients with cerebral palsy (age range: 2 to 17 years): 4. Effects on Dental Treatment Key adverse event(s) related to dental treatment: Opportunistic infections are possible; rare occurrence of esophageal candidiasis and fungal infections have been reported. Although there are no specific reports, patients may be at risk for candida albicans infections in the oral cavity. Effects on Bleeding Active therapy with immunosuppressants such as baricitinib may result in myelosuppression; medical consult suggested. Baricitinib labeling reports the occurrence of anemia and lymphocytopenia; rare occurrence of deep vein thrombosis. In response to extracellular cytokine or growth factor signaling, Jaks 192 Pharmacodynamics/Kinetics Half-life Elimination Primary effect is topical (colonic mucosa); therapeutic effect appears not to be influenced by the systemic half-life of balsalazide (1. Administration of basiliximab did not appear to increase the incidence or severity of adverse effects in clinical trials. Dental Health Professional Considerations the actions of baricitinib in treating rheumatoid arthritis is due to its ability to inhibit cytokines, including some in the interleukin family, from attaching to receptors that exacerbate arthritic symptoms. The receptors rely on the Janus kinase family of enzymes for receptor activations.

The pharmacokinetics of emtricitabine are not significantly altered during pregnancy and dosing adjustments are not needed medications to avoid during pregnancy order 250mg cordarone with mastercard. Use caution with hepatitis B coinfection; hepatitis B flare may occur if emtricitabine is discontinued medicine ball slams buy cordarone from india. Females who become pregnant while taking this combination may continue if viral suppression is effective and the regimen is well tolerated symptoms 7 weeks pregnant best buy for cordarone. Females who become pregnant while taking this combination may continue if viral suppression is effective and the regimen is well tolerated; however symptoms yeast infection women cheap cordarone online, more frequent monitoring is recommended medications 1 gram discount cordarone 200mg. Effects on Bleeding No information available to require special precautions Adverse Reactions Note: Frequency ranges include data from hypertension and heart failure trials treatment ulcerative colitis purchase 250mg cordarone fast delivery. Exchange transfusions or dialysis may be required to reverse hypotension or improve renal function, although data related to the effectiveness in neonates is limited. Exchange transfusions or dialysis may be required to reverse hypotension or improve renal function, although data related to the effectiveness in neonates is limited Chronic maternal hypertension itself is also associated with adverse events in the fetus/infant and mother. Effects on Bleeding No information available to require special precautions Adverse Reactions Since enalapril is converted to enalaprilat, adverse reactions associated with enalapril may also occur with enalaprilat (also refer to Enalapril monograph). However, the frequency of adverse effects associated with placebo is also increased in this population. Enalapril crosses the placenta; the active metabolite enalaprilat can be detected in the newborn (Schubiger 1988). Pharmacodynamics/Kinetics Half-life Elimination 137 hours Time to Peak 4 hours Pregnancy Considerations Based on the mechanism of action and data from animal reproduction studies, the use of enasidenib in pregnancy may cause fetal harm. Women of reproductive potential should have a pregnancy test prior to treatment initiation; effective contraception should be used during therapy and for at least 1 month after the last dose. Male patients with female partners of reproductive potential should also use effective contraception during therapy and for at least 1 month after the last dose. Based on animal data, treatment with enasidenib may impair fertility in females and males. Prescribing and Access Restrictions Enasidenib is available through select specialty pharmacies and authorized distributors. Effects on Dental Treatment Key adverse event(s) related to dental treatment: Facial paresis has been reported Effects on Bleeding Hemorrhage has been reported; none involving the oral cavity Adverse Reactions Incidences of adverse reactions include those defined during combination therapy with binimetinib. Encorafenib when used as a single agent is associated with an increased risk of certain adverse reactions. Verify pregnancy status in females of reproductive potential prior to initiating encorafenib therapy. Females of reproductive potential should use a highly effective nonhormonal contraceptive during therapy and for at least 2 weeks after the last encorafenib dose; hormonal contraceptives may not be effective. Prescribing and Access Restrictions Encorafenib is available through a network of select specialty pharmacies. Females who become pregnant while taking enfuvirtide may continue if viral suppression is effective and the regimen is well tolerated. Low molecular weight heparins have a small effect on the activated partial thromboplastin time and strongly inhibit factor Xa. Enoxaparin is derived from porcine heparin that undergoes benzylation followed by alkaline depolymerization. The average molecular weight of enoxaparin is 4500 daltons which is distributed as (20%) 2000 daltons (68%) 2000 to 8000 daltons, and (18%) >8000 daltons. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Bleeding is the major adverse effect of enoxaparin. Effects on Bleeding As with all anticoagulants, bleeding is the major adverse effect of enoxaparin. Adverse Reactions As with all anticoagulants, bleeding is the major adverse effect of enoxaparin. Multiple-dose vials contain benzyl alcohol (avoid in pregnant women due to association with gasping syndrome in premature infants); use of preservative-free formulations is recommended. The incidence of Parkinson disease in pregnancy is relatively rare and information related to the use of entacapone in pregnant women is very limited (Kranick, 2010). Note: In adults, indication is based on data in patients with compensated and decompensated liver disease; in children, indication is based on data in patients with compensated liver disease. Entacapone enhances levodopa bioavailability and may increase the occurrence of hypotension/syncope in the dental patient. When entacapone is taken with levodopa, the pharmacokinetics are altered, resulting in more sustained levodopa serum levels compared to levodopa taken alone. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment No significant effects or complications reported Effects on Bleeding No information available to require special precautions related to hemostasis. Pregnant women taking entecavir should enroll in the pregnancy registry by calling 1-800-258-4263. Based on animal reproduction studies and on the mechanism of action, fetal harm and loss of pregnancy would be expected. Male patients with female partners of reproductive potential should use effective contraception during treatment and for 3 months after the last enzalutamide dose. Adverse Reactions >10%: Cardiovascular: Peripheral edema (12% to 15%), hypertension (6% to 14%) Central nervous system: Fatigue (51%), falling (5% to 13%), dizziness (10% to 12%), headache (9% to 12%) Endocrine & metabolic: Hypoglycemia (78%), hypomagnesemia (26%), hot flash (13% to 20%), hyponatremia (16%), weight loss (6% to 12%) Gastrointestinal: Constipation (9% to 23%), diarrhea (12% to 22%), decreased appetite (10% to 19%), nausea (11% to 14%) Hematologic & oncologic: Neutropenia (8% to 15%; grades 3/4: 1%) Neuromuscular & skeletal: Asthenia (51%), back pain (19% to 29%), arthralgia (21%), musculoskeletal pain (15% to 16%) Respiratory: Upper respiratory tract infection (11% to 16%), dyspnea (11%) 1% to 10%: Cardiovascular: Ischemic heart disease (3%) Central nervous system: Myasthenia (10%), insomnia (8% to 9%), paresthesia (7%), cauda equina syndrome (7%), spinal cord compression (7%), anxiety (3% to 7%), altered mental status (4% to 6%), cognitive dysfunction (5%), hypoesthesia (4%), restless leg syndrome (2%) Dermatologic: Pruritus (4%), xeroderma (4%) Endocrine & metabolic: Gynecomastia (3%) Gastrointestinal: Dysgeusia (8%) Genitourinary: Hematuria (7% to 9%), pollakiuria (5%) Neuromuscular & skeletal: Bone fracture (4% to 10%), stiffness (3%) Respiratory: Lower respiratory tract infection (8% to 9%), epistaxis (3%) <1%, postmarketing, and/or case reports: Hypersensitivity reaction, reversible posterior leukoencephalopathy syndrome, seizure, skin rash, vomiting Mechanism of Action Enzalutamide is a pure androgen receptor signaling inhibitor; unlike other antiandrogen therapies, it has no known agonistic properties. It 494 Local Anesthetic/Vasoconstrictor Precautions Use vasoconstrictor with caution since ephedrine may enhance cardiostimulation and vasopressor effects of sympathomimetics such as epinephrine Effects on Dental Treatment Key adverse event(s) related to dental treatment: Xerostomia (normal salivary flow resumes upon discontinuation) Effects on Bleeding No information available to require special precautions Adverse Reactions Frequency not defined. Duration of Action Pressor/cardiac effects: SubQ: 1 hour Half-life Elimination Dependent upon urinary pH; Urine pH 5: ~3 hours; Urine pH 6. Serious postpartum hypertension and possibly stroke may occur if administered with oxytocic medications. Metabolic acidosis has been reported in neonates following maternal use of ephedrine; monitor. Mydriasis during intraocular surgery (product specific): Induction and maintenance of mydriasis during intraocular surgery. Note: Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information. More than 2 sequential doses should only be administered under direct medical supervision. Hypotension/shock: Treatment of hypotension associated with septic shock in adults (increase mean arterial blood pressure). Note: As of May 1, 2016, ratio expressions of epinephrine concentrations are prohibited on drug labels. Therefore, the ratio expression of 1:1,000 is equivalent to 1 mg/mL and 1:10,000 is equivalent to 0. Hypersensitivity reaction (eg, anaphylaxis): Note: SubQ administration results in slower absorption and is less reliable. Pediatric Note: As of May 1, 2016, ratio expressions of epinephrine concentrations are prohibited on drug labels. Ampules, vials, and syringes of epinephrine with ratio expressions may, however, remain in inventory until replaced by products with revised labeling. Note: Recent clinical studies suggest that lower epinephrine concentrations delivered by endotracheal administration may produce transient beta 2-adrenergic effects which may be detrimental (eg, hypotension, lower coronary artery perfusion pressure). Note: Suggested concentration of initial solution is more dilute than those typically utilized in other clinical conditions; evaluate infusion concentration with continued therapy and patient fluid status. Infants, Children, and Adolescents: Intraocular: Must dilute 1 mL of a 1 mg/mL preservative-/sulfitefree, single-use solution to a concentration of 1 mcg/ mL to 10 mcg/mL prior to intraocular use: May use as an irrigation solution as needed during the procedure or may administer intracamerally (ie, directly into the anterior chamber of the eye) with a bolus dose of 0. Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. Accidental injection into digits, hands, or feet may result in local reactions, including injection-site pallor, coldness, and hypoesthesia or injury, resulting in bruising, bleeding, discoloration, erythema, or skeletal injury; patient should seek immediate medical attention if this occurs. Intraocular administration: Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information prior to selecting a product. Prior to intraocular use of an appropriate product, must dilute single-use 1 mg/mL (1 mL) solution to a concentration of 1 mcg/mL to 10 mcg/mL. Corneal endothelial damage has occurred when products containing sodium bisulfite have been used undiluted; therefore, dilution is advised prior to any intraocular use. In addition, products containing chlorobutanol must also not be used intraocularly (may be harmful to corneal endothelium). Contraindications There are no absolute contraindications to the use of injectable epinephrine (including Adrenaclick, Auvi-Q, EpiPen, EpiPen Jr, Symjepi, Allerject [Canadian product], and Twinject [Canadian product]) in a life-threatening situation. Some products include the following contraindications: Hypersensitivity to sympathomimetic amines; general anesthesia with halogenated hydrocarbons (eg, halothane) or cyclopropane; narrow angle glaucoma; nonanaphylactic shock; in combination with local anesthesia of certain areas such as fingers, toes, and ears; use in situations where vasopressors may be contraindicated (eg, thyrotoxicosis, diabetes, in obstetrics when maternal blood pressure is in excess of 130/80 mm Hg and in hypertension and other cardiovascular disorders). Warnings/Precautions Use with caution in elderly patients, patients with diabetes mellitus, cardiovascular diseases (eg, coronary artery disease, arrhythmias, cerebrovascular disease, heart disease hypertension), thyroid disease, pheochromocytoma, or Parkinson disease. May precipitate or aggravate angina pectoris or induce cardiac arrhythmias; use with caution especially in patients with cardiac disease or those receiving drugs that sensitize the myocardium. Due to peripheral constriction and cardiac stimulation, pulmonary edema may occur. In hypovolemic patients, correct blood volume depletion before administering any vasopressor. Some products contain sulfites as preservatives; the presence of sulfites in some products should not deter administration during a serious allergic or other emergency situation even if the patient is sulfite-sensitive. Hypersensitivity reactions: Do not inject into the buttock; may not effectively treat anaphylaxis and has been associated with Clostridial infections (gas gangrene). Serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), have been reported rarely at the injection site. Cleansing skin with alcohol may reduce bacteria at the injection site, but alcohol cleansing does not kill Clostridium spores. Do not administer repeated injections at the same site (tissue necrosis may occur). Lacerations, bent needles, and embedded needles have been reported in young children who are uncooperative during injection for hypersensitivity reaction. Although the manufacturers of auto-injectors recommend varying lengths of time for holding the device in the thigh (range: 2 to 10 seconds), longer times have occasionally resulted in injury. For all devices, the needle should remain in the thigh for the least amount of time as possible (~3 seconds) (Brown 2016). Specific dosing is not available; use with caution and monitor hemodynamic response (Hepner 2013). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Breastfeeding Considerations It is not known if epinephrine is present in breast milk. Nebulization solution: Children 4 years and Adolescents: Handheld bulb nebulizer: Add 0. Metered-dose inhaler: Children 12 years and Adolescents: Oral inhalation: 1 inhalation once; if symptoms not relieved after 1 minute, may repeat 1 inhalation; wait 4 hours between additional doses; maximum daily dose: 8 inhalations/24 hours Croup (laryngotracheobronchitis), airway edema; moderate to severe: Limited data available: Infants, Children, and Adolescents: Note: Typically relief of symptoms occurs within 10 to 30 minutes and lasts 2 to 3 hours; patients should be observed for rapid symptom recurrence and possible repeat treatment. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Xerostomia (normal salivary flow resumes upon discontinuation) and dry throat. Warnings/Precautions Use with caution in patients with diabetes mellitus, heart disease and/or hypertension, increased intraocular pressure or glaucoma, thyroid disease, cerebrovascular disease, prostatic hyperplasia and/or urinary retention, psychiatric or emotional conditions, or in patients with seizure disorders. Discontinue use and notify health care provider if your asthma is getting worse, or if difficulty sleeping, rapid heartbeat, tremors, nervousness, or seizure occur. The product should not be used more frequently or at higher doses than recommended. Effects on Bleeding No information available to require special precautions Adverse Reactions No data reported. Dental Usual Dosage Gingival retraction: Adults: Pass the impregnated cord around the neck of the tooth and place into gingival sulcus; normal tissue moisture, water, or gingival retraction solutions activate impregnated cord. Limit use to one quadrant of the mouth at a time; recommended use is for 3-8 minutes in the mouth. Pharmacodynamics/Kinetics Onset of Action Bronchodilation: Inhalation: ~1 minute Pregnancy Considerations Epinephrine crosses the placenta following injection (Sandler 1964). Pharmacodynamics/Kinetics Half-life Elimination Triphasic; Mean terminal: 33 hours Pregnancy Risk Factor D Pregnancy Considerations Adverse events were observed in animal reproduction studies. Women of reproductive potential should be advised to use effective contraception and avoid becoming pregnant during treatment. Limited information is available from a retrospective study of women who received epirubicin (in combination with cyclophosphamide or weekly as a singleagent) during the second or third (prior to week 35) trimester for the treatment of pregnancy-associated breast cancer (Ring 2005) and from a study of women who received epirubicin (weekly as a single-agent) at gestational weeks 16 through 30 for the treatment of pregnancy-associated breast cancer (Peccatori 2009). Some pharmacokinetic properties of epirubicin may be altered in pregnant women (van Hasselt 2014). There should be a 3-week time period between the last chemotherapy dose and anticipated delivery, and chemotherapy should not be administered beyond week 33 of gestation. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Mucositis Effects on Bleeding Causes severe myelosuppression, including severe thrombocytopenia (grades 3/4: <5%) and anemia. Epoetin alfa is not indicated for patients who are willing to donate autologous blood preoperatively. Limitations of use: Epoetin alfa has not been shown to improve quality of life, fatigue, or patient well-being. Overexpression of aldosterone is thought to contribute to myocardial fibrosis (especially following myocardial infarction) and vascular fibrosis. Mineralocorticoid receptors are located in the kidney, heart, blood vessels, and brain. Eplerenone selectively blocks mineralocorticoid receptors reducing blood pressure in a dose-dependent manner and appears to prevent myocardial and vascular fibrosis. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment No significant effects or complications reported Pharmacodynamics/Kinetics Half-life Elimination ~3 to 6 hours Time to Peak Plasma: ~1. Pregnancy Considerations Information related to eplerenone use in pregnancy is limited to case reports (Cabassi 2012; Gunganah 2015; Hutter 2006; Morton 2011). Untreated hypertension and heart failure are both associated with adverse pregnancy outcomes.

Oral mucosal inflammation (off-label use): Topical: Cream: Apply twice daily for up to 2 weeks (maximum dose: 50 g/week); discontinue application when control is achieved; if no improvement is seen medicine 5852 cheap generic cordarone uk, reassessment of diagnosis may be necessary medicine 75 yellow order cordarone 100mg fast delivery. Mild to moderate plaque-type psoriasis of nonscalp areas: Topical: Foam: Apply twice daily for up to 2 weeks (maximum dose: 50 g/week) medicine quizlet buy discount cordarone 100mg on line. Treatment with lotion beyond 2 weeks should be limited to localized lesions (<10% body surface area) that have not improved sufficiently medicine 7 years nigeria order 100mg cordarone otc. Spray: Apply by spraying directly onto affected area twice daily and gently rub into skin treatment juvenile rheumatoid arthritis buy cordarone line. Limit treatment to 4 consecutive weeks; treatment beyond 2 weeks should be limited to localized lesions that have not improved sufficiently treatment authorization request buy cordarone 250 mg cheap. Scalp psoriasis, moderate to severe: Topical: Foam: Apply twice daily for up to 2 weeks (maximum dose: 50 g/week). Shampoo: Apply thin film to dry scalp once daily (maximum dose: 50 g/week or 50 mL/week); leave in place for 15 minutes, then add water, lather, and rinse thoroughly. Due to the high incidence of adrenal suppression noted in clinical studies, clobetasol lotion, shampoo, and spray are not recommended for use in patients <18 years of age. Dermatoses (steroid-responsive): Children 12 years and Adolescents: Topical: Cream, emollient cream, gel, ointment: Apply sparingly twice daily for up to 2 weeks; maximum weekly dose: 50 g/week Solution: Apply sparingly to affected area of scalp twice daily for up to 2 weeks; maximum weekly dose: 50 mL/week Plaque-type psoriasis of nonscalp areas; mild to moderate: Children 12 years and Adolescents: Topical: Foam: Apply sparingly to affected area twice daily for up to 2 weeks; maximum weekly dose: 50 g/week or 21 capfuls/week Plaque-type psoriasis; moderate to severe: Emollient cream: Adolescents 16 years: Topical: Apply sparingly twice daily for up to 2 weeks; if response is not adequate, may be used for up to 2 more weeks if application is <10% of body surface area; use with caution; maximum weekly dose: 50 g/week Lotion: Adolescents 18 years: Topical: Apply twice daily for up to 2 weeks; maximum weekly dose: 50 g/week or 50 mL/week) Spray: Adolescents 18 years: Apply by spraying directly onto affected area twice daily and gently rub into skin. Limit treatment to 4 consecutive weeks; treatment beyond 2 weeks should be limited to localized lesions which have not improved sufficiently. Scalp psoriasis, moderate to severe: Foam: Children 12 years and Adolescents: Topical: Apply twice daily for up to 2 weeks; maximum weekly dose: 50 g/week or 21 capfuls/week) 335 Shampoo: Adolescents 18 years: Topical: Apply thin film to dry scalp once daily; leave in place for 15 minutes, then add water, lather, and rinse thoroughly; maximum weekly dose: 50 g/week or 50 mL/week. Allergic contact dermatitis may occur; it is usually diagnosed by failure to heal rather than clinical exacerbation. Local effects may occur, including folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary infection, striae, miliaria, skin atrophy and telangiectasia; may be irreversible. Topical corticosteroids, including clobetasol, may increase the risk of posterior subcapsular cataracts and glaucoma. Clobex lotion, Clobex shampoo, Clobex spray, and Clodan shampoo are not recommended for use in pediatric patients 17 years. Do not use on the face, axillae, or groin or for the treatment of acne vulgaris, rosacea or perioral dermatitis. It is not known if topical application of clobetasol will result in detectable quantities in breast milk. Information related to the use of clobetasol and breastfeeding is limited (Carrillo Dde 2006). Low to moderate potency topical corticosteroids are preferred for initial treatment of psoriasis in breastfeeding females (Bae 2012). Do not apply topical corticosteroids to breast until breastfeeding ceases (Leachman 2006); hypertension was noted in a breastfed infant when a high potency topical corticosteroid was applied to the nipple (Butler 2014; Leachman 2006). Avoid Concomitant Use Avoid concomitant use of Clobetasol with any of the following: Aldesleukin Increased Effect/Toxicity Clobetasol may increase the levels/effects of: Deferasirox; Ritodrine Decreased Effect Clobetasol may decrease the levels/effects of: Aldesleukin; Corticorelin; Hyaluronidase Pregnancy Considerations Information related to the use of clobetasol in pregnancy is limited (Westermann 2012). However, there may be an increased risk of low birth weight infants following maternal use of potent or very potent topical products, especially in high doses. Use of mild to moderate potency topical corticosteroids is preferred in pregnant females and the use of large amounts or use for prolonged periods of time should be avoided (Chi 2016; Chi 2017; Murase 2014). The treatment of psoriasis in pregnancy is initiated with conservative treatment as in nonpregnant females. However, some have occurred in patients with postmenopausal osteoporosis taking oral bisphosphonates. Effects on Bleeding No information available to require special precautions hypocalcemia after birth (Djokanovic 2008; Stathopoulos 2011). Intravenous therapy (primarily zoledronic acid) was received by 88% of the patients and 12% received oral treatment (primarily alendronate). Available data have not shown that exposure to bisphosphonates during pregnancy significantly increases the risk of adverse fetal events (Djokanovic 2008; Levy 2009; Stathopoulos 2011). However until additional data is available, most sources recommend discontinuing bisphosphonate therapy in women of reproductive potential as early as possible prior to a planned pregnancy; use in premenopausal women should be reserved for special circumstances when rapid bone loss is occurring (Bhalla 2010; Pereira 2012; Stathopoulos 2011). Pharmacodynamics/Kinetics Half-life Elimination Children and Adolescents 2 to 19 years: 5. All patients should use effective contraception to prevent pregnancy during treatment. The incidence of adverse fetal effects following maternal use of clomiphene for ovulation induction is similar to those seen in the general population. Effects on Bleeding No information available to require special precautions Adverse Reactions Data shown for children reflects both children and adolescents studied in clinical trials. Seizure disorders: Mono- or adjunctive therapy in the treatment of the Lennox-Gastaut syndrome (petit mal variant), akinetic, and myoclonic seizures; absence seizures (petit mal) unresponsive to succinimides. Clomipramine and its metabolite desmethylclomipramine cross the placenta and can be detected in cord blood and neonatal serum at birth (Loughhead 2006; ter Horst 2012). Serum concentrations were not found to correlate to withdrawal symptoms (ter Horst 2012). Withdrawal symptoms (including jitteriness, tremor, and seizures) have been observed in neonates whose mothers took clomipramine up to delivery. Data collection to monitor pregnancy and infant outcomes following exposure to clomipramine is ongoing. Dental Health Professional Considerations See Local Anesthetic/Vasoconstrictor Precautions Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Xerostomia and changes in salivation (normal salivary flow resumes upon discontinuation), gum soreness, and coated tongue. Effects on Bleeding No information available to require special precautions Adverse Reactions Reactions reported in patients with seizure disorder, unless otherwise noted. Note: Patient should be instructed to suck on the tablet, retain saliva in mouth near the pain sites without swallowing for 3 minutes, and then expectorate saliva (GremeauRichard 2004). Note: Use with caution in patients with dementia, gait disorders, or obstructive sleep apnea (Aurora 2010). Restless leg syndrome (off-label use): Oral: Initial: 1 mg 30 minutes prior to bedtime; increase dose by 0. Doses up to 2 mg once daily have been used in clinical trials (Montagna 1984; Peled 1987; Saletu 2001). Additional data may be necessary to further define the role of clonazepam in the treatment of this condition. Tardive dyskinesia (off-label use): Oral: Initial: 1 mg/day; adjust dosage based on response and tolerability by 1 mg/day every 3 to 4 days up to a maximum dose of 4. Dosing range in clinical studies was 1 to 12 mg/day (Merikangas 1985; Troung 1988). Pediatric Note: If necessary to discontinue clonazepam therapy, drug should be withdrawn gradually. Neuroirritability, agitation (palliative care): Limited data available: Infants, Children, and Adolescents: Oral: Patient weight: <30 kg: Initial: 0. Discontinuation of treatment: To discontinue, treatment should be withdrawn gradually. Usual maintenance dose: 2 to 8 mg daily in 1 to 2 divided doses (Brodie 1997); do not exceed 20 mg/day. Clonazepam may cause respiratory depression and may produce an increase in salivation; use with caution in patients with compromised respiratory function (eg, chronic obstructive pulmonary disease, sleep apnea) and in patients who have difficulty handling secretions. May be used in patients with open angle glaucoma who are receiving appropriate therapy; contraindicated in acute narrow angle glaucoma. Use with caution in patients with hepatic impairment; accumulation likely to occur. Use with caution in patients with renal impairment; clonazepam metabolites are renally eliminated. Worsening of seizures may occur when added to patients with multiple seizure types. Loss of anticonvulsant activity may occur (typically within 3 months of initiation); dose adjustment may be necessary. Periodically reevaluate the long-term usefulness of clonazepam for the individual patient. Duration of action after a single dose is determined by redistribution rather than metabolism. Flumazenil may cause withdrawal in patients receiving long-term benzodiazepine therapy (Brogden 1988). Monitor all patients for notable changes in behavior that might indicate suicidal thoughts or depression; notify health care provider immediately if symptoms occur. Use caution in patients with depression, particularly if suicidal risk may be present. The mother was taking clonazepam throughout pregnancy (dose not specified); milk sampling began 72 hours after delivery (Fisher 1985). Clonazepam has a long half-life and may accumulate in the breastfed infant, especially preterm infants or those exposed to chronic maternal doses (Davanzo 2013). Infants of females using medications for seizure disorders should be monitored for drowsiness, decreased feeding, and poor weight gain (Veiby 2015). The incidence of premature birth and low birth weights may be increased following maternal use of benzodiazepines; hypoglycemia and respiratory problems in the neonate may occur following exposure late in pregnancy. Neonatal withdrawal symptoms may occur within days to weeks after birth and "floppy infant syndrome" (which also includes withdrawal symptoms) has been reported with some benzodiazepines, including clonazepam (Bergman 1992; Iqbal 2002; Wikner 2007). A combination of factors influences the potential teratogenicity of anticonvulsant therapy. When treating pregnant females with epilepsy, monotherapy with the lowest effective dose and avoidance medications known to have a high incidence of teratogenic effects is recommended (Harden 2009; Wlodarczyk 2012). Pain management (epidural): Continuous epidural administration as adjunctive therapy with opioids for treatment of severe cancer pain in patients tolerant to or unresponsive to opioids alone; epidural clonidine is generally more effective for neuropathic pain and less effective (or possibly ineffective) for somatic or visceral pain. Local Anesthetic/Vasoconstrictor Precautions No information available to require special precautions Effects on Dental Treatment Key adverse event(s) related to dental treatment: Significant xerostomia (normal salivary flow resumes upon discontinuation) and abnormal taste; Patients may experience orthostatic hypotension as they stand up after treatment; especially if lying in dental chair for extended periods of time. Effects on Bleeding No information available to require special precautions Adverse Reactions Frequency not always defined. Oral, Transdermal: Incidence of adverse events may be less with transdermal compared to oral due to the lower peak/trough ratio. Epidurally administered clonidine produces dose-dependent analgesia not antagonized by opiate antagonists. The analgesia is limited to the body regions innervated by the spinal segments where analgesic concentrations of clonidine are present. Clonidine is thought to produce analgesia at presynaptic and postjunctional alpha-2-adrenoceptors in the spinal cord by preventing pain signal transmission to the brain. Pharmacodynamics/Kinetics Onset of Action Antihypertensive effect: Oral: Immediate release: 0. The pharmacokinetics of clonidine may be altered during pregnancy due to an increase in nonrenal clearance (Buchanan 2009; Claessens 2010). However, in a rare obstetrical, or postpartum patient, potential benefits may outweigh the possible risks. Clonidine has been evaluated for use as an adjunctive agent for epidural labor analgesia (Kumari 2018; Landau 2002; Roelants 2015; Zhang 2015) including patients who are opioid dependent (Hoyt 2018). Effects on Bleeding Clopidogrel irreversibly inhibits platelet aggregation which persists for the life of the platelet (7-10 days) and until new platelets are released. Clopidogrel should not be discontinued in patients with cardiac stents that have not completed their full course of dual antiplatelet therapy (eg, aspirin and clopidogrel [prasugrel or ticagrelor]); patient-specific situations need to be discussed with cardiologist. If normal platelet function is desired, clopidogrel should be discontinued for at least 5 days. A medical consult is recommended to determine the benefit:risk of continuing or discontinuing clopidogrel therapy for invasive dental procedures. Adverse Reactions As with all drugs that may affect hemostasis, bleeding is associated with clopidogrel. Risk is dependent on multiple variables, including the concurrent use of multiple agents that alter hemostasis and patient susceptibility. An appropriate regimen for this patient population has not been established in clinical outcome trials. Although a 600 mg loading dose, followed by 150 mg once daily produced greater active metabolite exposure and antiplatelet response compared to the 300 mg/ 75 mg regimen, it does not appear that this dosing strategy improves outcomes for this patient population (Price 2011; Simon 2011). Age 75 years: Loading dose of 300 mg followed by 75 mg once daily for at least 14 days up to 1 year (in the absence of bleeding). Age >75 years: 75 mg once daily (no loading dose) for at least 14 days up to 1 year (in the absence of bleeding). Peripheral artery percutaneous transluminal angioplasty (with or without stenting) or peripheral artery bypass graft surgery, postprocedure (off-label use): Oral: 75 mg once daily. Clopidogrel experienced: Continue clopidogrel 75 mg once daily prior to procedure (Kalich 2018). Post-procedure: Not on anticoagulation post-procedure: 75 mg once daily for 3 to 6 months depending on valve type and patient-specific risks of bleeding or thrombosis plus life-long aspirin (Otto 2017). On anticoagulation post-procedure: Practice varies and local protocols should be established. It may be reasonable to use anticoagulation (warfarin or a non-warfarin oral anticoagulant) plus life-long aspirin or clopidogrel 75 mg once daily for 3 to 6 months followed by life-long aspirin (eg, not dual antiplatelet therapy) (Kalich 2018). Children >2 years and Adolescents: Initial dose: 1 mg/kg once daily; titrate to response; in general, do not exceed adult dose (Finkelstein 2005; Soman 2006). Hepatic Impairment: Pediatric There are no specific recommendations in pediatric patients; in adults, no dosage adjustment is necessary. Mechanism of Action Clopidogrel requires in vivo biotransformation to an active thiol metabolite.

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