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There may be a period of excitement and emotional Heroin may be taken by IV injection generic amoxil 250mg antimicrobial body soap, smoking order amoxil uk best antibiotics for mild acne, or nasal lability followed by progressively increasing signs of CNS application (snorting) discount 250 mg amoxil antibiotics ointment for acne. IV injection produces intense eupho- depression (eg buy cheap amoxil online bacteria joke, impaired mental function, muscular incoor- ria, which occurs within seconds, lasts a few minutes, and is dination, and sedation). The rate of recovery de- ject several times daily, cycling between desired effects and pends primarily on the amount of drug ingested and its rate symptoms of withdrawal. More severe overdoses cause respiratory de- velops rapidly, leading to dosage escalation and continued pression and coma. Like other opiates, heroin causes se- There is no antidote for barbiturate overdose; treatment is vere respiratory depression with overdose and produces a symptomatic and supportive. Insertion of an artificial airway and Opiate Dependence mechanical ventilation often are necessary. Gastric lavage may help if started within approximately 3 hours of drug in- Opiates produce tolerance and high degrees of psychological gestion. If the person is comatose, a cuffed endotracheal tube and physical dependence. Most other drugs that produce should be inserted and the cuff inflated before lavage to pre- dependence do so with prolonged usage of large doses, but vent aspiration. Diuresis helps to eliminate the drugs and can morphine-like drugs produce dependence with repeated ad- be induced by IV fluids or diuretic drugs. Medical usage of these drugs pro- removes most of these drugs and may be used with high duces physical dependence and tolerance but rarely leads serum drug levels or failure to respond to other treatment to use or abuse for mind-altering effects. Hypotension and shock are usually treated with IV should not be an issue when the drugs are needed for pain man- fluids. These treatments were formerly used for benzodiazepine Acute effects of opiate administration vary according to overdoses and may still be needed in some cases (eg, over- dosage, route of administration, and physical and mental doses involving multiple drugs). They may produce euphoria, se- is now available to reverse sedation, coma, and respiratory de- dation, analgesia, respiratory depression, postural hypo- pression. Flumazenil (Romazicon) competes with benzodi- tension, vasodilation, pupil constriction, and constipation. The drug has a short duration of action, and repeated IV injections are usually Treatment of Opiate Dependence needed. Recipients must be closely observed because symp- toms of overdose may recur when the effects of a dose of Treatment may be needed for overdose or withdrawal syn- flumazenil subside and because the drug may precipitate acute dromes. Overdose may produce severe respiratory depression withdrawal symptoms (eg, agitation, confusion, seizures) in and coma. Insertion of an endotracheal tube and mechanical benzodiazepine abusers. Drug therapy consists of an opi- Treatment of withdrawal may involve administration of a oid antagonist to reverse opioid effects. Giving an opioid an- benzodiazepine or phenobarbital to relieve acute signs and tagonist can precipitate withdrawal symptoms. If there is no symptoms, then tapering the dose until the drug can be dis- response to the opioid antagonist, the symptoms may be continued. Barbiturate and benzodiazepine withdrawal syn- caused by depressant drugs other than opiates. The person may experience profound respiratory depression, pulmonary edema, hypo- cardiovascular collapse, generalized tonic-clonic seizures, glycemia, pneumonia, cellulitis, and other infections often and acute psychotic episodes. These can be prevented by accompany opiate overdose and require specific treatment gradually withdrawing the offending drug. CHAPTER 15 SUBSTANCE ABUSE DISORDERS 243 Signs and symptoms of withdrawal can be reversed im- CENTRAL NERVOUS mediately by giving the drug producing the dependence. SYSTEM STIMULANTS Therapeutic withdrawal, which is more comfortable and safer, can be managed by gradually reducing dosage over Amphetamines and Related Drugs several days. Clonidine, an antihypertensive drug, is some- times used to relieve withdrawal symptoms associated with Amphetamines and related drugs (see Chap. Except for the use of methylphenidate in nence from further opiate usage. Because this goal is rarely treating ADHD, however, the drugs are more important as met, long-term drug therapy may be used to treat heroin de- drugs of abuse than therapeutic agents. One method uses opioid substitutes to prevent with- drawal symptoms and improve a lifestyle that revolves around obtaining, using, and recovering from a drug. Methadone Amphetamine-Type Dependence has long been used for this purpose, usually a single, daily, Amphetamines and related drugs (eg, methylphenidate) pro- oral dose given in a methadone clinic. Proponents say that duce stimulation and euphoria, effects often sought by drug methadone blocks euphoria produced by heroin, acts longer, users. The user may increase the amount and frequency of ad- and reduces preoccupation with drug use. This allows a more ministration to reach or continue the state of stimulation. One normal lifestyle for the client and reduces morbidity and of the drugs, methamphetamine, may be chemically treated mortality associated with the use of illegal and injected drugs. Opponents say that methadone fects of amphetamines are similar to those produced by co- maintenance only substitutes one type of drug dependence caine and are largely dose related. In addition, a substantial percentage of those re- mental alertness, wakefulness, and increased energy. Large ceiving methadone maintenance therapy abuse other drugs, amounts may cause psychosis (eg, hallucinations and para- including cocaine. Another drug approved for maintenance therapy is lev- Acute ingestion of these drugs masks underlying fatigue omethadyl acetate hydrochloride, also called LAAM. LAAM or depression; withdrawal allows these conditions to emerge (Orlaam) is a synthetic, Schedule II opioid indicated only for in an exaggerated form. It is metabolized to long- pression reinforce the compulsion to continue using the acting, potent metabolites. Users may take them alone or to counteract the effects occur within 90 minutes, peak in about 4 hours, and last about of other drugs. Its main advantage over methadone is that it can be pattern of polydrug use in which CNS depressants, such as al- given three times weekly rather than daily. However, if given cohol or sedative-type drugs (downers), are alternated with on a Monday/Wednesday/Friday schedule, the Friday dose CNS stimulants, such as amphetamines (uppers). Also, initial dosage needs care- Treatment of Amphetamine-Type Abuse ful titration to prevent withdrawal symptoms but avoid over- dosage when peak effects occur. Patients must be informed Treatment of amphetamine-type abuse is mainly concerned about the delayed effects of the drug and the risks of over- with overdosage because these drugs do not produce physical dosage if they take other opiates. LAAM has proarrhythmic dependence and withdrawal as alcohol, opiates, and sedative- effects and an electrocardiogram should be done prior to start- hypnotic drugs do.

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The patients were divid- ed into two groups trusted amoxil 250mg light antibiotics for acne, a treatment group (42 cases) and a compari- son group (22 cases) order online amoxil antibiotic resistance latest news. Nine cases in the treatment group and 10 cases in the comparison group had a family history of enuresis generic amoxil 500 mg otc antibiotic resistance process. Four cases in the treatment group and two cases in the compari- son group were diagnosed with occult spina bifida discount 500mg amoxil antibiotics for acne pros and cons. In terms of severity, mild enuresis was defined as bed-wetting less than two times per week with a scanty amount of urine and easy to awak- en. In the treatment group, there were three cases of mild enure- sis and no cases in the comparison group. Medium enuresis referred to bed-wetting 1-3 times per week with a moderate amount of urine, and able to awaken after enuresis. In the treat- ment group, there were five cases of medium enuresis and three cases in the comparison group. Severe enuresis was defined as enuresis more than one time per day with a large amount of urine. The child was difficult to awaken, did not wake when called, and had enuresis during their daytime nap and frequent uri- nation during the day. In the treatment group, there were 34 cases of severe enuresis and 19 cases in the comparison group. In terms of pattern discrimination in the treatment group, there were 32 cases of lung-spleen qi vacuity who presented with fre- quent urination that was scanty in amount, a lusterless facial com- plexion, fatigue, lack of strength, devitalized appetite, thin, sloppy stools, and a deep, forceless pulse. This manifest as clear, copious urine, difficulty waking when called, a white facial com- plexion, devitalized essence-spirit, a cold body and chilled limbs, a pale tongue with thin, white fur, and a deep, moderate or slightly slow, and forceless pulse. There were also four cases with non- interaction of the heart and kidneys. This presented as urination while dreaming as if they were urinating during the day, hyperac- tivity during the day, possible increase of psycho-emotional ten- sion at night, poor memory, timidity, easy crying, easily frightened, and, if scared before bed, they wet the bed. The course of dis- ease is long, and the pulse is fine, deep and forceless. Chinese Research on the Treatment of Pediatric Enuresis 73 Treatment method: Members of the treatment group were prescribed Yi Niao Ting (Enuresis Stopper) which was composed of: Huang Qi (Radix Astragali) mix-fried Ma Huang (Herba Ephedrae) Jiu Cai Zi (Semen Alli Tuberosi) Wu Wei Zi (Fructus Schisandrae) Sang Piao Xiao (Ootheca Mantidis) uncooked Zhi Zi (Fructus Gardeniae) These medicinals were ground into powder and then loaded into size 1 capsules. If the children had difficulty swallowing the capsules, the contents of the capules were poured into water and taken. Seven days of this treatment equaled one course of treatment and was contin- ued for 2-4 courses. The dosage of this medicine was 25 milligrams per kilogram, and this dosage was divided and taken two times per day. Note: Ditropan® (oxybutynin chloride) is an antispasmodic, anti- cholinergic agent used for the treatment of overactive bladder. Therefore the total amelioration rate was 81% in the treatment group and 50% in the comparison group. The following table shows 74 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Chinese Research on the Treatment of Pediatric Enuresis 75 the treatment group results in relationship to pattern discrimination and severity of enuresis. Discussion: Professor Yu Jin-mao, a teacher of mine in Hangzhou, explains that many children who suffer from enuresis are also deep sleepers. Because the heart governs the spirit brilliance, many doctors add Shi Chang Pu (Rhizoma Acori Tatarinowii) and Yuan Zhi (Radix Polygalae) to their enuresis formulas to open the orifices and arouse the spirit. Yu says these medicinals are not very effective and prefers to use Ma Huang. Professor Yu uses Ma Huang in his enuresis formula because his very famous pediatric teacher, Wang Bo-yu, also used this medicine. Wang was referred to as the King of Children in Beijing due to his renowned ability to heal chil- dren of various ailments. Ma Huang enters the lung and bladder channels, and its flavor and nature are acrid and warm. The function of Ma Huang is to free the flow of yang and transform the qi, dif- fuse and depurate the lung qi and regulate the waterways. However, a side effect of using too much Ma Huang in clinical prac- tice is that it arouses the brain and causes insomnia. For this rea- son, this medicinal is added to the formula to arouse the brain and, therefore, treats the tip or branch of enuresis. Huang Qi, on the other hand, addresses the root of this condition by supplementing the qi and upbearing the clear. This medicinal also strengthens the constitution of the individual by strengthening their ability to resist disease. It is also said, Children easily become vacuous and easily become replete. With the addition of these medicinals, the formula is able to warm without drying, secure without obstructing, and simul- taneously constrict and scatter and warm and clear. Professor Yu also points out that 30% of enuresis sufferers have a history of recurrent upper respiratory tract infections and simul- taneously develop asthma. In clinical practice, he observes that, when the enuresis is cured, these individuals also experience an obvious reduction in respiratory tract infections. In the comparison group who took Western pharmaceuticals, one case developed hives and three cases had facial flushing as if they had been drink- ing. Other common side effects, such as dry mouth and difficulty urinating, were not noted in this study. The patients in the treatment group took Yi Niao Ting between 7- 28 days. If the patient did not improve after two weeks, they were considered difficult to treat. Yu believes that the way a child is toilet trained influences the rate of enuresis. He believes that these rates are higher in the West compared to China where only 5-6% of six year-olds have enuresis because we use diapers. He believes the main TCM pat- terns of enuresis are kidney vacuity and lung-spleen vacuity. He also said that, if there was occult spina bifida, this related to the governing vessel in TCM and medicinals must be added to the formula which specifically enter this vessel. Warm the kidneys with Sang Piao Xiao (Ootheca Mantidis), Wu Wei Zi (Fructus Schisandrae), Jiu Cai Zi (Bulbus Allii Fistulosi), Tu Si Zi (Semen Cuscutae), and Bu Gu Zhi (Fructus Psoralea). Supplement the lungs and spleen with Huang Qi (Radix Astragali) and Dang Shen (Radix Codonopsitis). Strengthen the du mai by adding either 20 grams of Lu Jiao Shuang (Cornu Degelatinum Cervi), 10 grams of Lu Jiao (Cornu Cervi), six grams of Lu Jiao Jiao (Gelatinum Cornu Cervi), or 0. Other medicinals which enter and strengthen the governing vessel include Du Chinese Research on the Treatment of Pediatric Enuresis 77 Zhong (Cortex Eucommiae), Gou Ji (Rhizoma Cibotii), Xiang Ling Pi (Herba Epimedii), Ba Ji Tian (Radix Morindae Officinalis), and Suo Yang (Herba Cynomorii). Arouse the brain with 4-6 grams each of mix-fried Ma Huang (Herba Ephedrae) and Shi Chang Pu (Rhizona Acori Tatarinowii). Prevent side effects from the use of warm medicinals by using cool- or cold-natured medicinals, such as Huang Qin (Radix Scutellariae), Dan Pi (Cortex Moutan), and/or Zhi Zi (Fructus Gardeniae).

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How- mocysteine to a nontoxic substance order amoxil canada infection 4 weeks after wisdom teeth removal, and an increased blood ever amoxil 250mg line bacteria characteristics, deficiencies are common in older adults purchase amoxil 250mg with amex antibiotics for uti shot, especially of vi- level of homocysteine occurs with folic acid deficiency order amoxil 500 mg mastercard infection nursing care plan. With vitamin B12, for example, it is estimated that arteries and leads to plaque formation, arteriosclerosis, and older adults absorb only 10% to 30% of the amount found in thrombosis. Other factors may also contribute to deficiencies, includ- effects by lowering blood levels of homocysteine. Although ing limited income, anorexia, lack of teeth or ill-fitting den- the FDA requirement that folic acid be added to cereal grain tures, drugs that decrease absorption of dietary nutrients, and foods may be helpful, the folic acid intake that helps prevent disease processes that interfere with the ability to obtain, pre- cardiovascular disease is thought to be higher. Vitamin C is thought to help prevent cardiovascular disease Every older adult should be assessed regarding vitamin in- by its antioxidant effects. The atherogenic effects of blood take (from foods and supplements) and use of drugs that in- lipids, especially low-density lipoprotein (LDL) cholesterol teract with dietary nutrients. Vitamin C may help to prevent oxidation of LDL healthy and able to eat a varied, well-balanced diet. Overall, however, the effects of vitamin C on pre- tion, requirements may be increased during illnesses, espe- vention of coronary artery disease (CAD) are unclear. Overdoses, especially of studies indicate an increased risk for CAD only with a severe the fat-soluble vitamins A and D, may cause toxicity and vitamin C deficiency and that vitamin C has little effect on should be avoided. Tolerable ULs for older adults have ischemic heart disease and stroke after adjustment for other been established for some vitamins (D, 50 mg; E, 1000 mg; risk factors. More research is needed before vitamin C supple- C, 2000 mg; folate, 1000 mcg; niacin, 35 mg; pyridoxine, ments are recommended for cardioprotective effects. For a number of years, vitamin E was thought to have an- Use in Preventing Cancer tioxidant, cardioprotective effects similar to those of vitamin C. Vitamin A, its precursor beta carotene, and vitamin C are the main vitamins associated with prevention of cancer. Vitamin Use in Renal Impairment A and beta carotene may reduce cancers of the lung, breast, oral mucosa, esophagus, and bladder. Although vitamin A Patients with renal impairment usually have special needs in supplements are not recommended, increasing dietary intake relation to vitamin intake because of difficulties in ingesting of fruits and vegetables is desirable. Considerations include: anticancer effects stem from beta carotene or other compo- • In patients with acute renal failure who are unable to eat nents of fruits and vegetables. Large doses of vitamin C should be 200 mg or more from fruits and vegetables (five or more serv- avoided because urinary excretion is impaired. In addi- ings daily) are associated with reduced cancer risk, especially tion, oxalate (a product of vitamin C catabolism) may for cancers of the GI tract (eg, oral cavity, esophagus, stom- precipitate in renal tubules or form calcium oxalate ach, and colon) and lung. However, in other studies, vitamin stones, obstruct urine flow, and worsen renal function. C supplements did not decrease the occurrence of stomach or • In patients with chronic renal failure (CRF), deficiencies colorectal cancer. Thus, the cancer-preventing effects of fruits of water-soluble vitamins are common because many 466 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES foods that contain these vitamins are restricted because Use in Critical Illness of their potassium content. In addition, vitamin C is re- absorbed from renal tubules by a specific transport pro- Patients with critical illnesses often experience vitamin defi- tein. When the transport protein becomes saturated, ciencies unless they are prevented by early supplementation. Vitamin C is Patients receiving enteral nutrition should usually be given removed by dialysis, and, therefore, patients receiving DRI-equivalent amounts of all vitamins. The optimal re- resections (short bowel syndrome) may be able to take most placement dose is unknown but probably should not ex- vitamins orally or by GI tube. However, they usually need in- ceed 200 mg/day (to avoid increased oxalate and possible jections of vitamin B12 because they are unable to absorb it stones). Those with fat malabsorption syndromes A multivitamin product with essential vitamins, in- need supplements of the fat-soluble vitamins A, D, E, and K. Be- daily vitamin supplementation have been developed by the cause patients with CRF often have increased vitamin A Nutrition Advisory Group of the American Medical Associ- concentrations, vitamin A should be omitted or reduced ation (NAG-AMA). These guidelines are based on the DRIs in dosage for those requiring parenteral nutrition. Several parenteral multivitamin formulations meet the Use in Hepatic Impairment NAG-AMA guidelines for adults and children. Those for adults do not contain vitamin K, which is usually injected Vitamin deficiencies commonly occur in patients with chronic weekly. The usual dose is 2 to 4 mg, but some clinicians give liver disease because of poor intake and malabsorption. Vitamin K is included in pediatric parenteral nu- hepatic failure, hepatic stores of vitamin A, pyridoxine, folic trition solutions. Therapeutic doses of vitamins should be given for documented deficiency states. The home care nurse needs to assess household members and Niacin is contraindicated in liver disease because it may the home setting for indications of vitamin deficiencies or use increase liver enzymes (alanine and aspartate aminotrans- of supplements, especially megadoses. If actual or potential ferase, alkaline phosphatase) and bilirubin and cause further difficulties are found, the nurse may need to counsel house- liver damage. Long-acting dosage forms may be more hepa- hold members about dietary sources of vitamins and adverse totoxic than the fast-acting forms. To increase therapeutic effects and avoid adverse reactions (2) Do not give oral preparations at the same time as mineral Mineral oil absorbs the vitamins and thus prevents their systemic oil. Thus, any injection may cause trauma tion, apply gentle pressure to the injection site, and inspect and bleeding at the injection site. For intravenous injection, vitamin K may be given by direct injection or diluted in intravenous fluids (eg, 5% dextrose in water or saline). With B-complex vitamins: (1) Give parenteral cyanocobalamin (vitamin B12) intra- muscularly or deep subcutaneously. Have the Niacin causes vasodilation, which may result in dizziness, hypo- client sit or lie down for about 1⁄ hour after administration. Observe for therapeutic effects (mainly decreased signs and symptoms of deficiency) a. With vitamin A, observe for improved vision, especially Night blindness is usually relieved within a few days. Skin lesions in dim light or at night, less dryness in eyes and conjunctiva may not completely disappear for several weeks. With vitamin K, observe for decreased bleeding and more Blood coagulation tests usually improve within 4 to 12 hours. With B-complex vitamins, observe for decreased or absent Deficiencies of B-complex vitamins commonly occur together and stomatitis, glossitis, cheilosis, seborrheic dermatitis, neuro- produce many similar manifestations. With vitamin B12 and folic acid, observe for increased Therapeutic effects may be quite rapid and dramatic. The client appetite, strength and feeling of well-being, increased reticu- usually feels better within 24 to 48 hours, and normal red blood locyte counts, and increased numbers of normal red blood cells begin to appear. Anemia is decreased within approximately cells, hemoglobin, and hematocrit. With vitamin C, observe for decreased or absent malaise, irritability, and bleeding tendencies (easy bruising of skin, bleeding gums, nosebleeds, and so on).

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Syndromes

  • Nausea and vomiting
  • If the blood clumps together only when B cells are added to your sample, you have type A blood.
  • Forced expiratory volume (FEV)
  • DO NOT use outdated foods, packaged food with a broken seal, or cans that are bulging or have a dent.
  • Get to the hospital emergency room or labor and delivery unit 
  • When was the last time you urinated?
  • Irritability
  • Avoid tasks that require concentration or complicated thinking. These include reading, homework, and preparing reports.
  • Leakage of the bone cement into surrounding area (this can cause pain if it affects the spine or nerves) - this problem is more common with this procedure than kyphoplasty

These products injection may contain valproic acid as the acid discount amoxil 500mg amex antibiotics for acne on bum, as the sodium salt (sodium valproate) buy 250 mg amoxil free shipping antimicrobial textiles, or a combi- nation of the two (dival- proex sodium) order discount amoxil on-line antibiotics for sinus infection dosage. Zonisamide (Zonegran) Partial seizures purchase amoxil 250mg without a prescription antibiotic resistance china, with PO 100–200 mg daily as <16 y: not recommended other AEDs a single dose or as 2–3 divided doses; increase by 100 mg/d every 1–2 wk if neces- sary; maximum dose, 600 mg daily AED, antiepileptric drug; PE, phenytoin equivalent; Crcl, creatinine clearance. It is well absorbed with oral administration MAOIs should be discontinued at least 14 days before car- and reaches peak serum levels in 3 to 7 hours; a steady-state bamazepine is started. It is elimi- Clonazepam (Klonopin), clorazepate (Tranxene), di- nated mainly by hepatic metabolism to inactive metabolites; azepam (Valium), and lorazepam (Ativan) are benzodi- about 20% is excreted unchanged through the kidneys. Clonazepam elimination half-life is approximately 30 hours in children and clorazepate are used in long-term treatment of seizure and 60 hours in adults. Ethosuximide may be used with other disorders, alone or with other AEDs. Clonazepam has a long Gabapentin (Neurontin) is used with other AEDs for half-life and may require weeks of continued administration treatment of partial seizures. As with other benzo- doses, circulates largely in a free state because of minimal diazepines, clonazepam produces physical dependence and binding to plasma proteins, is not appreciably metabolized, withdrawal symptoms. The elim- life, withdrawal symptoms may appear several days after ad- ination half-life is 5 to 7 hours with normal renal function and ministration is stopped. Abrupt withdrawal may precipitate up to 50 hours with impaired renal function, depending on cre- seizure activity or status epilepticus. Diazepam and lorazepam are used to terminate acute con- Adverse effects include dizziness, drowsiness, fatigue, vulsive seizures, especially the life-threatening seizures of sta- loss of muscle coordination, tremor, nausea, vomiting, ab- tus epilepticus. Diazepam has a short duration of action and normal vision, gingivitis, and pruritus. In status epilepticus, it is subside spontaneously or with dosage reduction. Gabapentin followed with a long-acting anticonvulsant, such as phenytoin. Lorazepam has become the drug of choice for status epilepticus Because the drug is eliminated only by the kidneys, dosage because its effects last longer than those of diazepam. CHAPTER 11 ANTISEIZURE DRUGS 189 Lamotrigine (Lamictal) is used with other AEDs for treat- Oxcarbazepine (Trileptal) is a newer drug that is struc- ment of partial seizures. It is thought to reduce the release of turally related to carbamazepine. It is approved for both glutamate, an excitatory neurotransmitter, in the brain. It is monotherapy and adjunctive (with other AEDs) therapy in well absorbed after oral administration, with peak plasma lev- adults with partial seizures and for adjunctive therapy only in els reached in 1. For patients receiving carbamazepine or oxcar- bound to plasma proteins. It is metabolized in the liver to an bazepine, either drug may be substituted for the other with- inactive metabolite and eliminated mainly in the urine. However, the equivalent dose of oxcarbazepine ataxia, blurred or double vision, nausea and vomiting, and is 50% higher than the carbamazepine dosage. Because a serious skin rash may occur, especially the recommended equivalent oxcarbazepine dosage is 20% in children, lamotrigine should not be given to children higher than the carbamazepine dosage. Most effects are attrib- to occur with concomitant valproic acid therapy, high lamo- uted to an active metabolite produced during first-pass trigine starting dose, and rapid titration rate. It may resolve if metabolism in the liver; the metabolite is 40% protein lamotrigine is discontinued, but it progresses in some clients bound. The elimination half-life is 2 hours for oxcarbazepine to a more severe form, such as Stevens-Johnson syndrome. Dosage must Phenytoin, carbamazepine, and phenobarbital induce drug- be reduced in patients with severe renal impairment (ie, crea- metabolizing enzymes in the liver and accelerate lamotrig- tinine clearance < 30 mL/min). If lamotrigine is combined with other AEDs plus valproic or with other AEDs. They included cardiac dysrhythmias, acid, dosage must be substantially reduced. To discontinue, drowsiness, dizziness, hypotension, nausea, vomiting, skin dosage should be tapered over at least 2 weeks. Because of the risk of hyponatremia, Levetiracetam (Keppra) is a newer drug approved for oxcarbazepine should be used with caution in clients taking treatment of partial seizures, in combination with other other drugs that decrease serum sodium levels, and serum AEDs. It is chemically unrelated to other AEDs and its sodium levels should be monitored periodically during main- mechanism of action is unknown. Some studies indicate that skin reactions ronal firing but does not affect normal neuronal excitability occur less often with oxcarbazepine than with carbamazepine. Several drug–drug interactions may occur with oxcar- Levetiracetam is well and rapidly absorbed with oral ad- bazepine. The drug inhibits cytochrome P450 2C19 enzymes ministration; peak plasma levels occur in about one hour. This rapid attainment of thera- induce cytochrome P450 enzymes, including phenytoin, peutic effects is especially useful for patients with frequent may reduce plasma levels of the active metabolite by about or severe seizures. Dosage must be reduced with impaired renal oxcarbazepine or its metabolite. The drug is not metabolized by the liver and does Phenobarbital is a long-acting barbiturate that is used not affect the hepatic metabolism of other drugs. It was well tolerated in declined with the advent of other AEDs that cause less seda- clinical trials and the incidence of adverse events was similar tion and cognitive impairment. Common adverse effects include drowsi- verse effects associated with barbiturates may occur, but drug ness, dizziness, and fatigue; others include decreases in red dependence and barbiturate intoxication are unlikely with and white blood cell counts, double vision, amnesia, anxiety, usual antiepileptic doses. Because phenobarbital has a long ataxia, emotional lability, hostility, nervousness, paresthesia, half-life (50 to 140 hours), it takes 2 to 3 weeks to reach ther- pharyngitis, and rhinitis. It is metabolized in the liver; about 25% is elim- acteristics that may make it especially useful in clients who re- inated unchanged in the urine. It induces drug-metabolizing quire combination antiepileptic drug therapy, who take drugs enzymes in the liver and thereby accelerates the metabolism of with increased potential for drug interactions, or who have im- most AEDs when given with them. After oral administration, tiagabine is well ab- Dosages of all formulations are expressed in valproic acid sorbed; peak plasma levels occur in about 45 minutes if taken equivalents. It is Zonisamide (Zonegran) is chemically a sulfonamide (and highly protein bound (96%) and is extensively metabolized contraindicated for use in clients who are allergic to sulfon- in the liver, by the cytochrome P450 3A family of enzymes. It is approved for adjunctive treatment of partial Only 1% of the drug is excreted unchanged in the urine and seizures and may also be effective for monotherapy and gen- the metabolites are excreted in urine and feces. It is thought to act by inhibiting the entry of tion half-life is 4 to 7 hours in clients receiving enzyme- sodium and calcium ions into nerve cells. Clients with Zonisamide is well absorbed with oral administration and impaired liver function may need smaller doses because the produces peak plasma levels in 2 to 6 hours.

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