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Sometimes kinetic characteristics which are clinically of little importance are stressed to promote an expensive drug while many cheaper alternatives are available purchase proscar 5 mg online mens health 40 superfoods. It is estimated that up to 10% of hospital admissions are due to adverse drug reactions buy proscar prostate tea. Not all drug induced injury can be prevented purchase proscar 5mg with visa prostate 79 grams, but much of it is caused by 32 Chapter 4 Guidelines for selecting P-drugs inappropriate selection or dosage of drugs cheap generic proscar canada man health viagra, and you can prevent that. Often these are exactly the groups of patients you should always be very careful with: the elderly, children, pregnant women and those with kidney or liver disease. Cost: Your ideal choice in terms of efficacy and safety may also be the most expensive drug, and in case of limited resources this may not be possible. Sometimes you will have to choose between treating a small number of patients with a very expensive drug, and treating a much larger number of patients with a drug which is less ideal but still acceptable. This is not an easy choice to make, but it is one which most prescribers will face. The conditions of health insurance and reimbursement schemes may also have to be considered. The best drug in terms of efficacy and safety may not (or only partially) be reimbursed; patients may request you to prescribe the reimbursed drug, rather than the best one. Where free distribution or reimbursement schemes do not exist, the patient will have to purchase the drug in a private pharmacy. When too many drugs are prescribed the patient may only buy some of them, or insufficient quantities. In these circumstances you should make sure that you only prescribe drugs that are really necessary, available and affordable. You, the prescriber, should decide which drugs are the most important, not the patient or the pharmacist. Step v: Choose a P-drug There are several steps to the process of choosing a P-drug. Choose an active substance and a dosage form Choosing an active substance is like choosing a drug group, and the information can be listed in a similar way. In practice it is almost impossible to choose an active substance without considering the dosage form as well; so consider them together. Although active substances within one drug group share the same working mechanism, differences may exist in safety and suitability because of differences in kinetics. Large differences may exist in convenience to the patient and these will have a strong influence on adherence to treatment. Different dosage forms will usually lead to different dosage schedules, and this should be taken into account when choosing your P-drug. Price lists may be available from the hospital pharmacy or from a national formulary (see Table 4, Chapter 3 for an example). Keep in mind that drugs sold under generic (nonproprietary) name are usually cheaper than patented brand-name products. If two drugs from the same group appear equal you could consider which drug has been longest on the market (indicating wide experience and probably safety), or which drug is manufactured in your country. This will give you an alternative if one is not suitable for a particular patient. Choose a standard dosage schedule A recommended dosage schedule is based on clinical investigations in a group of patients. However, this statistical average is not necessarily the optimal schedule for your individual patient. If age, metabolism, absorption and excretion in your patient are all average, and if no other diseases or other drugs are involved, the average dosage is probably adequate. The more your patient varies from this average, the more likely the need for an individualized dosage schedule. Recommended dosage schedules for all P-drugs can be found in formularies, desk references or pharmacology textbooks. In most of these references you will find rather vague statements such as ‘2-4 times 30-90 mg per day’. The best solution is to copy the different dosage schedules into your own formulary. Some drugs need an initial loading dose to quickly reach steady state plasma concentration. Others require a slowly rising dosage schedule, usually to let the patient adapt to the side effects. By knowing the pathophysiology and the prognosis of the disease you will usually have a good idea of how long the treatment should be 35 Guide to Good Prescribing continued. The total amount of a drug to be prescribed depends on the dosage schedule and the duration of the treatment. For example, in a patient with bronchitis you may prescribe penicillin for seven days. You will only need to see the patient again if there is no improvement and so you can prescribe the total amount at once. If the duration of treatment is not known, the monitoring interval becomes important. For example, you may request a patient with newly diagnosed hypertension to come back in two weeks so that you can monitor blood pressure and any side effects of the treatment. As you get to know the patient better you could extend the monitoring interval, say, to one month. Three months should be about the maximum monitoring interval for drug treatment of a chronic disease. Summary How to select a P-drug i Define the diagnosis (pathophysiology) ii Specify the therapeutic objective iii Make an inventory of effective groups iv Choose a group according to criteria efficacy safety suitability cost Group 1 Group 2 Group 3 v Choose a P-drug efficacy safety suitability cost Drug 1 Drug 2 Drug 3 Conclusion: Active substance, dosage form: Standard dosage schedule: Standard duration: 36 Chapter 5 P-drug versus P-treatment C hapter 5 P-drug and P-treatment Not all health problems need treatment with drugs. As explained in Chapter l, the treatment can consist of advice and information, non-drug therapy, drug treatments, referral for treatment, or combinations of these. Making an inventory of effective treatment alternatives is especially important in order not to forget that non-drug treatment is often possible and desirable. As with selecting your P-drugs, the criteria of efficacy, safety, suitability and cost should be used when comparing treatment alternatives. Exercise Make a list of possible effective and safe treatments for the following common patient problems: constipation, acute diarrhoea with mild dehydration in a child, and a superficial open wound. Constipation Constipation is usually defined as a failure to pass stools for at least a week. Because of tolerance, laxatives are only effective for a short period and may then lead to abuse and eventually even to electrolyte disturbances. The first treatment plan, your P-treatment, should therefore be advice; not drugs! Acute watery diarrhoea with mild dehydration in a child 37 Guide to Good Prescribing In acute diarrhoea with mild dehydration in a child, the main objective of the treatment is to prevent further dehydration and to rehydrate; the goal is not to cure the infection! The inventory of possible effective treatments is therefore: Advice and information: Continue breast feeding and other regular feeding; careful observation. Non-drug treatment: Additional fluids (rice water, fruit juice, homemade sugar/salt solution).
Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures generic proscar 5mg overnight delivery mens health yogurt. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment buy proscar 5 mg without a prescription prostate cancer cure rate. Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia purchase 5mg proscar fast delivery androgen hormone qui. The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair discount proscar 5mg online prostate cancer bone scan. Contralateral tendon rupture risk is increased in individuals with a previous Achilles tendon rupture. Outcome of skin graft versus flap surgery in the salvage of the exposed achilles tendon in diabetics versus nondiabetics. Venous thromboembolism in patients undergoing laparoscopic and arthroscopic surgery and in leg casts. Minimally-invasive surgical repair of ruptured Achilles tendon as a day case procedure with early full weight bearing. Repair of the Achilles tendon sleeve avulsion: quantitative and functional evaluation of a transcalcaneal suture technique. Treatment of chronic Achilles tendon rupture with triple bundle suturing technique and early rehabilitation: Early results. Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Reliability of isokinetic dynamometry in assessing plantarflexion torque following Achilles tendon rupture. Prospective trial of conservative and surgical treatment of Achilles tendon rupture [abstract]. Immediate full-weight bearing mobilisation for repaired Achilles tendon ruptures: a pilot study. Gait abnormalities following rupture of the tendo Achillis: a pedobarographic assessment. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Conservative, open or percutaneous repair for acute rupture of the Achilles tendon. The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon rupture. Pedicled tendon transfer in the repair of subcutaneous rupture of the Achilles tendon. Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Musculoskeletal disorders of the lower limb - Ultrasound and magnetic resonance imaging correlation. Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures. Changes in plantar pressure distribution after Achilles tendon augmentation with flexor hallucis longus transfer. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture. Isokinetic strength and strength endurance of the lower limb musculature ten years after achilles tendon repair. Long-term results after functional nonoperative treatment of achilles tendon rupture. Surgical repair followed by functional rehabilitation for acute and chronic achilles tendon injuries: excellent functional results, patient satisfaction and no reruptures. Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external splintage. Immediate, full weightbearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study. Acute achilles tendon rupture postoperative treatment with a below knee cast the ankle in neutral position compared to early restricted motion of the ankle. Elongation of the Achilles tendon after rupture repair occurred slightly less with postoperative early motion than with postoperative immobilization. Comparison of surgical and no surgical treatment of Achilles tendon rupture in athletes. Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical study about early functional treatment vs. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Scripta Medica Facultatis Medicae Universitatis Brunensis Masarykianae 2006;79(2):75-84. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs. Reconstruction for neglected Achilles tendon rupture: the modified Bosworth technique. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. Early mobilisation of operatively treated achilles tendon ruptures: 1 to 2 years follow-up [abstract].