This case study describes a 64-year-old male patient with heart failure who was prescribed digoxin therapy. He experienced side effects from antibiotics prescribed for a lung infection. His digoxin dose was later increased when he reported new symptoms. After being diagnosed with chronic renal failure years later, his digoxin levels became toxic as his kidneys could no longer clear the drug appropriately. His digoxin dose was adjusted and monitored based on his kidney function to safely control his heart condition.
The number of drugs associated with adverse reactions involving the liver is extensive, but in clinical practice is dominated by alcohol, antibiotics, antiepileptic medications and acetaminophen.
Complementary (herbal) medicines contribute to Liver Dysfuntion.
A 65-year-old man with heart failure and DKA is admitted to hospital with a potassium level of 7.1 mmol/L.
HE was started with
Rx
lisinopril 20 mg daily,
spironolactone 25 mg daily.
Insulin Infusion + 5% Dextrose
This presentation gives complete in-depth information about therapeutic drug monitoring of DIGOXIN. Points covered are:
1. Basic pharmacokinetics
2. Target concentration levels
3. Dosage forms available and their bioavailability
4. Procedure to conduct TDM
5. The principle of DIGOXIN estimation
6. Interpretation of TDM results.
7. TDM algorithm
The number of drugs associated with adverse reactions involving the liver is extensive, but in clinical practice is dominated by alcohol, antibiotics, antiepileptic medications and acetaminophen.
Complementary (herbal) medicines contribute to Liver Dysfuntion.
A 65-year-old man with heart failure and DKA is admitted to hospital with a potassium level of 7.1 mmol/L.
HE was started with
Rx
lisinopril 20 mg daily,
spironolactone 25 mg daily.
Insulin Infusion + 5% Dextrose
This presentation gives complete in-depth information about therapeutic drug monitoring of DIGOXIN. Points covered are:
1. Basic pharmacokinetics
2. Target concentration levels
3. Dosage forms available and their bioavailability
4. Procedure to conduct TDM
5. The principle of DIGOXIN estimation
6. Interpretation of TDM results.
7. TDM algorithm
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
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Программа вебинара:
1. Формы подписки в решении задач лидогенерации
2. Возможности нового редактора форм.
3. Практические примеры внедрения.
4. Обзор некоторых других возможностей, вошедших в релиз.
an overall overview in corticosteroids and its application in oral and maxillofacial diagnostic medicine and pathology drawing to the conclusions of the limitations and drawbacks of these medicines. i have also included the precautions to be taken in dental therapeutic procedures fo
2. Case Scenario for Clinical pharmacokinetics
• A 64 yrs old male had heart failure was put on digoxin therapy in tablet
form, formulated by XY pharmaceutical. Initially he was given 0.5 mg 8
hourly for three days followed by 0.125 mg/day. Simultaneously he was
suffering from severe cough, fever and malaise, the physician after
thorough investigations diagnosed as a case of lower respiratory tract
infection and prescribed 100mg/d doxycycline initially for one week
which was further extended to 10 days. The patient suffered from
diarrhea, doxycycline was discontinued, a course of metronidazole was
given and patient got cured.
• After few days patient complaint of fatigue, palpitations and dyspnea.
The dose of digoxin was increased to 0.25mg/ day and he felt better.
• After several years he was diagnosed for chronic renal failure, blood urea
and creatinine is raised. He developed heart sinking and palpitation. ECG
showed pulses bigeminy. Serum digoxin was 2.8ng/ml. Digoxin therapy
was stopped for three days. KCl was administered for few days The
plasma level was now 1ng/ml and the dose of digoxin was adjusted to
0.125mg digoxin/day.
3. Case Scenario for Clinical pharmacokinetics
1. What is form?
2. Why patient was asked to take the digoxin
formulated by XY pharmaceutical only?
3. Why he suffered from diarrhea?
4. Why he was given high doses of digoxin initially?
5. Why the patient complaint of fatigue, palpitations
and dyspnea.
6. Why the physician had to increase the dose of
digoxin?
7. Therapeutic blood monitoring is required, at which time
you will take blood sample?
8. Plasma concentration is found to be 0.35 ng/ml.
How will you calculate the new dose?
4. 8. What is the first symptom of digoxin toxicity leading
to diagnosis?
9. Why patient developed cardiac toxicity?
10. Enumerate the formulas applied for Estimation of
GFR & Creatinin clearance
11.What is the normal range of serum digoxin level?
12. After increasing the dose to 0.25 mg/day how long
it took to improve the patients condition and was
stabilized?
13. What is the mechanism of development of pulses
bigeminy?
14. What will be effect of chronic renal failure on
plasma half life of digoxin?
15. Later, on reducing the dose from 0.25 to 0.125 mg,
how long will it take to reach Css?
5. Clinical Evidences
Doxycycline
• Antibiotics might increase digoxin absorption
by inactivating intestinal bacteria
• John R Horn, Pharmacy times 2004
Azole Derivatives
• Antifungal Agents (Azole Derivatives,
Systemic): May increase the serum
concentration of Cardiac Glycosides.
(UpToDate)
6. Doxycycline
• Unlike many tetracyclines, doxycycline does
not appear to accumulate in patients with
impaired renal function, and aggravation of
impairment may be less likely. Similarly, there
is also no evidence that doxycycline causes
severe hepatitis (BMJ)
7. Metronidazole
• DOSING: RENAL IMPAIRMENT
• To reduce possible accumulation in patients receiving
multiple doses, consider reduction to 50% of dose or
every 12 hours; Note: Dosage reduction is unnecessary in
short courses of therapy. Some references do not
recommend reduction at any level of renal impairment
(Lamp, 1999).
• DOSING: HEPATIC IMPAIRMENT — Unchanged in mild
liver disease; reduce dosage in severe liver disease.
8. 4-variable MDRD," (Modification of Diet in Renal
Disease Study Group) serum creatinine, age
race, & Gender.
CKD-EPI including urinary albumin