Pharmacokinetic and pharmacodynamic considerations are very much important while choosing any antibiotic specially in presence of comorbidities like chronic renal failure as the renal elimination is compromised in those patients and handling of antibiotics which excrete through kidney are altered hence needs judicious antibiotic selection and dose calculation.In this venture calculating eGFR through different online calculators make the physicians more aware of the underlying disease state and improve dose adjustment of the antibiotics. Examples are MDRD or CKD-EPI or Cockroft-Gault formula.
This document summarizes guidelines for managing lupus nephritis from KDIGO 2023. It recommends treating active proliferative lupus nephritis classes III/IV with glucocorticoids plus mycophenolic acid, low-dose intravenous cyclophosphamide, or belimumab added to one of those. It provides guidance on induction therapy duration, preferred maintenance agents, and managing treatment failure or unsatisfactory response. Trial results are presented for therapies involving belimumab, calcineurin inhibitors, voclosporin, and different immunosuppressive regimens.
- Autoimmune liver diseases involve an immunological attack against hepatocytes and/or the biliary epithelium, presenting variably from asymptomatic to acute/chronic. Diagnosis requires interpreting serological and histological markers alongside biliary imaging.
- Treatment aims to prevent end-stage liver disease and complications, but managing autoimmune liver disease can be challenging. For primary biliary cirrhosis (PBC), ursodeoxycholic acid (UDCA) is the first-line treatment and improves biochemistry and transplant-free survival.
- For autoimmune hepatitis (AIH), prednisolone alone or combined with azathioprine improves liver tests, histology, and survival, with combination
Individualisation and optimization of drug dosing regimenJyoti Nautiyal
Drug dosing regimen, dosing frequency, individualisation, Steps Involved in Individualization of Dosage Regimen, optimization, variability, Clinical experience with individualization and optimization based on plasma drug levels.
This document discusses therapeutic drug monitoring (TDM) and provides examples of aminoglycosides (gentamicin and vancomycin), phenytoin, and digoxin. It defines TDM as measuring specific drug concentrations to maintain constant levels. TDM is indicated to monitor compliance, individualize therapy, diagnose under treatment, avoid toxicity, and detect drug interactions. Drugs suitable for TDM have a narrow therapeutic index, pharmacokinetic variability, a relationship between concentrations and effects, and available assays. The document provides dosing and interpretation guidelines for each drug's TDM.
managing diabetes in critically ill hospitalized patientssumitverma88
This document discusses the management of diabetes in critically ill hospitalized patients. It covers stress hyperglycemia, causes of stress-induced hyperglycemia, proposed mechanisms, effects of prolonged hyperglycemia, past approaches, results of intensive insulin therapy trials, inpatient glucose metrics, intravenous insulin protocols, hypoglycemia management, transitioning to outpatient care, and management of diabetic ketoacidosis, hyperglycemic hyperosmolar state, lactic acidosis, and perioperative care.
Ceritinib is an antineoplastic agent approved for the treatment of adults with ALK-positive metastatic non-small cell lung cancer (NSCLC) whose cancer has progressed on crizotinib. The recommended dosage is 750 mg once daily. Dosage reductions may be necessary due to common adverse effects like gastrointestinal toxicity, hepatotoxicity, interstitial lung disease, QT prolongation, hyperglycemia, and bradycardia. Ceritinib carries warnings for severe gastrointestinal toxicity, hepatotoxicity, interstitial lung disease, QT prolongation, hyperglycemia, and bradycardia.
This document summarizes guidelines for managing lupus nephritis from KDIGO 2023. It recommends treating active proliferative lupus nephritis classes III/IV with glucocorticoids plus mycophenolic acid, low-dose intravenous cyclophosphamide, or belimumab added to one of those. It provides guidance on induction therapy duration, preferred maintenance agents, and managing treatment failure or unsatisfactory response. Trial results are presented for therapies involving belimumab, calcineurin inhibitors, voclosporin, and different immunosuppressive regimens.
- Autoimmune liver diseases involve an immunological attack against hepatocytes and/or the biliary epithelium, presenting variably from asymptomatic to acute/chronic. Diagnosis requires interpreting serological and histological markers alongside biliary imaging.
- Treatment aims to prevent end-stage liver disease and complications, but managing autoimmune liver disease can be challenging. For primary biliary cirrhosis (PBC), ursodeoxycholic acid (UDCA) is the first-line treatment and improves biochemistry and transplant-free survival.
- For autoimmune hepatitis (AIH), prednisolone alone or combined with azathioprine improves liver tests, histology, and survival, with combination
Individualisation and optimization of drug dosing regimenJyoti Nautiyal
Drug dosing regimen, dosing frequency, individualisation, Steps Involved in Individualization of Dosage Regimen, optimization, variability, Clinical experience with individualization and optimization based on plasma drug levels.
This document discusses therapeutic drug monitoring (TDM) and provides examples of aminoglycosides (gentamicin and vancomycin), phenytoin, and digoxin. It defines TDM as measuring specific drug concentrations to maintain constant levels. TDM is indicated to monitor compliance, individualize therapy, diagnose under treatment, avoid toxicity, and detect drug interactions. Drugs suitable for TDM have a narrow therapeutic index, pharmacokinetic variability, a relationship between concentrations and effects, and available assays. The document provides dosing and interpretation guidelines for each drug's TDM.
managing diabetes in critically ill hospitalized patientssumitverma88
This document discusses the management of diabetes in critically ill hospitalized patients. It covers stress hyperglycemia, causes of stress-induced hyperglycemia, proposed mechanisms, effects of prolonged hyperglycemia, past approaches, results of intensive insulin therapy trials, inpatient glucose metrics, intravenous insulin protocols, hypoglycemia management, transitioning to outpatient care, and management of diabetic ketoacidosis, hyperglycemic hyperosmolar state, lactic acidosis, and perioperative care.
Ceritinib is an antineoplastic agent approved for the treatment of adults with ALK-positive metastatic non-small cell lung cancer (NSCLC) whose cancer has progressed on crizotinib. The recommended dosage is 750 mg once daily. Dosage reductions may be necessary due to common adverse effects like gastrointestinal toxicity, hepatotoxicity, interstitial lung disease, QT prolongation, hyperglycemia, and bradycardia. Ceritinib carries warnings for severe gastrointestinal toxicity, hepatotoxicity, interstitial lung disease, QT prolongation, hyperglycemia, and bradycardia.
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
This document discusses new insights into treatment strategies for critically ill patients, including optimal antibiotic dosing and the potential benefits of extended infusion of antibiotics. It also reviews evidence on the use of aerosolized colistin, inhalation antibiotics, statins, probiotics, and prophylactic antibiotics in preventing infections like ventilator-associated pneumonia in ICU patients. While some studies found decreased infection rates, ICU stay, or ventilation time with these approaches, larger trials are still needed to determine clear effects on mortality or define best practices. The document emphasizes individualizing care based on pharmacokinetic factors and calls for more research on optimization of antibiotic use in critical illness.
Clinical pharmacokinetics is the application of pharmacokinetic principles to the safe and effective therapeutic management of drugs in an individual patient. Primary goals of clinical pharmacokinetics include enhancing efficacy and decreasing toxicity of a patient's drug therapy.
The success of drug therapy is highly dependent on the choice of the drug, the drug product, and the design of the dosage regimen. The choice of the drug is generally made by the physician after careful patient diagnosis and physical assessment.
This document discusses maintenance immunosuppressive therapy for kidney transplant recipients. It provides details on tacrolimus and cyclosporine, including their mechanisms of action, dosing, therapeutic drug monitoring, and conversion between formulations. Adverse effects and contraindications are also summarized. Monitoring drug levels is important for efficacy and toxicity, with target trough ranges outlined for different time periods post-transplant.
This document discusses tapering glucocorticoid therapy. It provides indications for withdrawing glucocorticoids, such as when maximum benefit is achieved or side effects become serious. It describes assessing risk of HPA axis suppression and recommends a tapering regimen that gradually reduces the dose by 5-10 mg every 1-2 weeks above 40 mg/day, then by smaller amounts as the dose decreases. It notes symptoms to watch for that could indicate disease flare versus withdrawal and adjusting the taper accordingly.
Therapeutic drug monitoring PHARMACY sAA.pptssuser497f37
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in a patient's blood to optimize drug dosing and ensure concentrations are within a therapeutic range. TDM is useful for drugs with a narrow therapeutic index that can be toxic above the upper limit or ineffective below the lower limit. It helps individualize treatment regimens and assess efficacy and safety. Common drugs monitored include antiepileptics, antiarrhythmics, antibiotics, and immunosuppressants. Interpretation of levels considers pharmacokinetic and pharmacodynamic factors as well as clinical information to guide dosing adjustments. TDM provides insights to improve patient outcomes by achieving maximum benefit while minimizing toxicity risks.
REVIEW OF THERAPIES FOR PULMONARY EMBOLISM .pptxNihanth73
This document reviews therapies for pulmonary embolism (PE). It begins by discussing risk stratification of PE into high, intermediate, and low risk. It then covers diagnostic evaluation and various medical therapies including anticoagulation options. Advanced therapies for higher risk PE such as systemic thrombolysis, catheter-directed thrombolysis, surgical embolectomy, and IVC filters are also reviewed. Specific devices for catheter-based thrombus removal including the AngioVac, FlowTriever, Indigo aspiration catheter, and EKOS catheter are described.
This document summarizes current treatment guidelines for lupus nephritis. It defines lupus nephritis based on ACR criteria and recommends an early renal biopsy. For initial treatment of proliferative lupus nephritis (classes III/IV), guidelines differ on whether cyclophosphamide or mycophenolate mofetil is preferred. Maintenance therapy with mycophenolate mofetil or azathioprine with low-dose steroids is recommended, with mycophenolate mofetil showing better outcomes. Immunosuppression should be continued for at least one year after complete remission is achieved.
This document provides an overview of pharmacokinetics and pharmacodynamics. It defines pharmacokinetics as understanding how the body affects a drug and pharmacodynamics as understanding how a drug affects the body. It discusses how pharmacokinetic-pharmacodynamic modeling can help optimize dosage forms, dosing regimens, and individualize treatment based on a patient's characteristics. The document also provides examples of using pharmacokinetic principles to calculate loading and maintenance doses and simulates drug concentration profiles over time. It summarizes a case study on the effects of sitagliptin on blood pressure and another case study using population pharmacokinetic-pharmacodynamic modeling of warfarin.
Contrast Simulation Study material 20150509.pptAIDA BORLAZA
This document provides guidelines for contrast reactions and their management from the American College of Radiology (ACR). It discusses various types of intravenous contrast media and their risks. Adverse reactions can range from mild to severe/life-threatening and include contrast-induced nephrotoxicity and nephrogenic systemic fibrosis. The document outlines Boston Medical Center's premedication regime using steroids and antihistamines to reduce reaction risk. It also provides guidance on assessing and treating acute contrast reactions according to their severity per ACR guidelines.
Clinical Pharmacokinetics of Voriconazole Omar Negm
The presentation discusses the clinical pharmacokinetics of Voriconazole as anti fungal drug, in addition, it illustrates the drug pharmacology, side effects, indications, dose adjustment in special populations, and therapeutic drug monitoring.
This document discusses the management of adult acute lymphoblastic leukemia (ALL). It notes that ALL accounts for 7.3-57.8% of acute leukemia cases in Indian studies. The document outlines pretreatment evaluation, risk stratification, induction chemotherapy regimens, and key considerations for anthracyclines, cyclophosphamide, and asparaginase when treating adult ALL. The goal of induction therapy is to reduce leukemia cells to below 5% while incorporating central nervous system prophylaxis to achieve remission in over 80% of patients.
The document discusses pharmacokinetics of drugs in critically ill patients. It notes that dosages are usually determined from healthy volunteers but critically ill patients have increased cardiac output, leaky capillaries, organ dysfunction and other factors that impact drug distribution and clearance. This can result in low drug concentrations. The document recommends increasing loading doses to account for higher volumes of distribution, increasing dosage frequency to compensate for higher clearances, and being aware of changes to protein binding. It also notes the impact of renal replacement therapy and importance of therapeutic drug monitoring to optimize dosing for critically ill patients.
recent advances in management of inflammatory bowel diseasessubhash nandwani
This document summarizes recent advances in the management of inflammatory bowel diseases. It discusses various drug classes and their efficacy in treating Crohn's disease and ulcerative colitis. Aminosalicylates such as sulfasalazine and mesalamine are effective for inducing remission and maintenance in ulcerative colitis but not Crohn's disease. Glucocorticoids induce remission in both conditions but are not effective for maintenance. Biological therapies targeting TNF-α like infliximab and adalimumab have response rates of 60% for both conditions. Other emerging therapies discussed include anti-adhesion molecules, anti-interleukins, Janus kinase inhibitors, and fecal microbiota transplantation.
The document discusses using genetic testing to guide warfarin therapy. It explains that genetic polymorphisms affect individuals' responses to medications like warfarin. Variants in CYP2C9 and VKORC1 genes influence warfarin dosing, with clinical trials showing genotype-guided dosing results in faster stabilization of anticoagulation and less risk of bleeding events. The author proposes a study at UNC to incorporate pharmacogenomic guidance in initial warfarin dosing to improve outcomes.
The document discusses various methods for designing dosage regimens, including individualized regimens based on pharmacokinetic measurements, population-based regimens, empirical regimens, and regimens based on partial pharmacokinetic data or nomograms. It also covers considerations for converting patients from intravenous to oral drug administration through sequential, switch, or step-down methods based on pharmacokinetic principles and calculations using steady-state drug concentrations and clearance. An example calculation is provided to determine an appropriate oral theophylline dosage based on intravenous aminophylline infusion rates.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)Gamal Agmy
This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
1) Early studies showed steroids improved survival for lupus patients compared to no treatment, and high-dose steroids worked better than low-dose.
2) Later trials added cytotoxic drugs to steroids and found fewer unfavorable outcomes for lupus nephritis patients.
3) A randomized trial found low-dose IV cyclophosphamide as effective as high-dose IV cyclophosphamide for lupus nephritis, with fewer infectious side effects from the lower dose.
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
This document discusses new insights into treatment strategies for critically ill patients, including optimal antibiotic dosing and the potential benefits of extended infusion of antibiotics. It also reviews evidence on the use of aerosolized colistin, inhalation antibiotics, statins, probiotics, and prophylactic antibiotics in preventing infections like ventilator-associated pneumonia in ICU patients. While some studies found decreased infection rates, ICU stay, or ventilation time with these approaches, larger trials are still needed to determine clear effects on mortality or define best practices. The document emphasizes individualizing care based on pharmacokinetic factors and calls for more research on optimization of antibiotic use in critical illness.
Clinical pharmacokinetics is the application of pharmacokinetic principles to the safe and effective therapeutic management of drugs in an individual patient. Primary goals of clinical pharmacokinetics include enhancing efficacy and decreasing toxicity of a patient's drug therapy.
The success of drug therapy is highly dependent on the choice of the drug, the drug product, and the design of the dosage regimen. The choice of the drug is generally made by the physician after careful patient diagnosis and physical assessment.
This document discusses maintenance immunosuppressive therapy for kidney transplant recipients. It provides details on tacrolimus and cyclosporine, including their mechanisms of action, dosing, therapeutic drug monitoring, and conversion between formulations. Adverse effects and contraindications are also summarized. Monitoring drug levels is important for efficacy and toxicity, with target trough ranges outlined for different time periods post-transplant.
This document discusses tapering glucocorticoid therapy. It provides indications for withdrawing glucocorticoids, such as when maximum benefit is achieved or side effects become serious. It describes assessing risk of HPA axis suppression and recommends a tapering regimen that gradually reduces the dose by 5-10 mg every 1-2 weeks above 40 mg/day, then by smaller amounts as the dose decreases. It notes symptoms to watch for that could indicate disease flare versus withdrawal and adjusting the taper accordingly.
Therapeutic drug monitoring PHARMACY sAA.pptssuser497f37
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in a patient's blood to optimize drug dosing and ensure concentrations are within a therapeutic range. TDM is useful for drugs with a narrow therapeutic index that can be toxic above the upper limit or ineffective below the lower limit. It helps individualize treatment regimens and assess efficacy and safety. Common drugs monitored include antiepileptics, antiarrhythmics, antibiotics, and immunosuppressants. Interpretation of levels considers pharmacokinetic and pharmacodynamic factors as well as clinical information to guide dosing adjustments. TDM provides insights to improve patient outcomes by achieving maximum benefit while minimizing toxicity risks.
REVIEW OF THERAPIES FOR PULMONARY EMBOLISM .pptxNihanth73
This document reviews therapies for pulmonary embolism (PE). It begins by discussing risk stratification of PE into high, intermediate, and low risk. It then covers diagnostic evaluation and various medical therapies including anticoagulation options. Advanced therapies for higher risk PE such as systemic thrombolysis, catheter-directed thrombolysis, surgical embolectomy, and IVC filters are also reviewed. Specific devices for catheter-based thrombus removal including the AngioVac, FlowTriever, Indigo aspiration catheter, and EKOS catheter are described.
This document summarizes current treatment guidelines for lupus nephritis. It defines lupus nephritis based on ACR criteria and recommends an early renal biopsy. For initial treatment of proliferative lupus nephritis (classes III/IV), guidelines differ on whether cyclophosphamide or mycophenolate mofetil is preferred. Maintenance therapy with mycophenolate mofetil or azathioprine with low-dose steroids is recommended, with mycophenolate mofetil showing better outcomes. Immunosuppression should be continued for at least one year after complete remission is achieved.
This document provides an overview of pharmacokinetics and pharmacodynamics. It defines pharmacokinetics as understanding how the body affects a drug and pharmacodynamics as understanding how a drug affects the body. It discusses how pharmacokinetic-pharmacodynamic modeling can help optimize dosage forms, dosing regimens, and individualize treatment based on a patient's characteristics. The document also provides examples of using pharmacokinetic principles to calculate loading and maintenance doses and simulates drug concentration profiles over time. It summarizes a case study on the effects of sitagliptin on blood pressure and another case study using population pharmacokinetic-pharmacodynamic modeling of warfarin.
Contrast Simulation Study material 20150509.pptAIDA BORLAZA
This document provides guidelines for contrast reactions and their management from the American College of Radiology (ACR). It discusses various types of intravenous contrast media and their risks. Adverse reactions can range from mild to severe/life-threatening and include contrast-induced nephrotoxicity and nephrogenic systemic fibrosis. The document outlines Boston Medical Center's premedication regime using steroids and antihistamines to reduce reaction risk. It also provides guidance on assessing and treating acute contrast reactions according to their severity per ACR guidelines.
Clinical Pharmacokinetics of Voriconazole Omar Negm
The presentation discusses the clinical pharmacokinetics of Voriconazole as anti fungal drug, in addition, it illustrates the drug pharmacology, side effects, indications, dose adjustment in special populations, and therapeutic drug monitoring.
This document discusses the management of adult acute lymphoblastic leukemia (ALL). It notes that ALL accounts for 7.3-57.8% of acute leukemia cases in Indian studies. The document outlines pretreatment evaluation, risk stratification, induction chemotherapy regimens, and key considerations for anthracyclines, cyclophosphamide, and asparaginase when treating adult ALL. The goal of induction therapy is to reduce leukemia cells to below 5% while incorporating central nervous system prophylaxis to achieve remission in over 80% of patients.
The document discusses pharmacokinetics of drugs in critically ill patients. It notes that dosages are usually determined from healthy volunteers but critically ill patients have increased cardiac output, leaky capillaries, organ dysfunction and other factors that impact drug distribution and clearance. This can result in low drug concentrations. The document recommends increasing loading doses to account for higher volumes of distribution, increasing dosage frequency to compensate for higher clearances, and being aware of changes to protein binding. It also notes the impact of renal replacement therapy and importance of therapeutic drug monitoring to optimize dosing for critically ill patients.
recent advances in management of inflammatory bowel diseasessubhash nandwani
This document summarizes recent advances in the management of inflammatory bowel diseases. It discusses various drug classes and their efficacy in treating Crohn's disease and ulcerative colitis. Aminosalicylates such as sulfasalazine and mesalamine are effective for inducing remission and maintenance in ulcerative colitis but not Crohn's disease. Glucocorticoids induce remission in both conditions but are not effective for maintenance. Biological therapies targeting TNF-α like infliximab and adalimumab have response rates of 60% for both conditions. Other emerging therapies discussed include anti-adhesion molecules, anti-interleukins, Janus kinase inhibitors, and fecal microbiota transplantation.
The document discusses using genetic testing to guide warfarin therapy. It explains that genetic polymorphisms affect individuals' responses to medications like warfarin. Variants in CYP2C9 and VKORC1 genes influence warfarin dosing, with clinical trials showing genotype-guided dosing results in faster stabilization of anticoagulation and less risk of bleeding events. The author proposes a study at UNC to incorporate pharmacogenomic guidance in initial warfarin dosing to improve outcomes.
The document discusses various methods for designing dosage regimens, including individualized regimens based on pharmacokinetic measurements, population-based regimens, empirical regimens, and regimens based on partial pharmacokinetic data or nomograms. It also covers considerations for converting patients from intravenous to oral drug administration through sequential, switch, or step-down methods based on pharmacokinetic principles and calculations using steady-state drug concentrations and clearance. An example calculation is provided to determine an appropriate oral theophylline dosage based on intravenous aminophylline infusion rates.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)Gamal Agmy
This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
1) Early studies showed steroids improved survival for lupus patients compared to no treatment, and high-dose steroids worked better than low-dose.
2) Later trials added cytotoxic drugs to steroids and found fewer unfavorable outcomes for lupus nephritis patients.
3) A randomized trial found low-dose IV cyclophosphamide as effective as high-dose IV cyclophosphamide for lupus nephritis, with fewer infectious side effects from the lower dose.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
1. Use of Antimicrobials in CKD
patients: Critical Issues
Dr Chiranjib Bagchi
DGO.MD(Pharmacology). DM(Clinical Pharmacology)
Associate Professor
Clinical and Experimental Pharmacology
School of Tropical Medicine, Kolkata
6. Pharmacotherapy principle
“Start low, go slow,”
- Jerry Gurwitz, Gerontopharmacology
- “Go fast, start high”
- German, “Sofort und hoch dosieren,” as
stated by Paul Ehrlich
In Nephropharmacology
8. Drug dosing in Renal disease
A common approach is “start low and go slow” when
there is uncertainty in its dosage or pharmacokinetics -
a conservative approach
But antiinfectives are prescribed to maximize the effect
of the initial dose
Antibiotics also need to target a concentration–time
profile related to the markers of bacterial susceptibility
such as MIC
9. PD issues- Sigmoid effect-
concentration curve
Antibiotics whose effect depends on their concentration have a low Hill coefficient (H<1.5),
while antibiotics whose effect is time-dependent have a high Hill coefficient (H>1.5). The
therapeutically effective range of a drug thus depends on its Hill coefficient: the higher the
Hill coefficient, the narrower the desired range is, and the more closely it centers on CE50.
10. Aminoglycoside in renal failure
Aminoglycosides: Shifting from Low dose short interval to
High dose extended interval (once-daily aminoglycoside
dosing)
To maximize antibacterial efficacy as well as limit toxicities
In impaired kidney function dose interval extended to 36-
48 hrs for complete drug elimination
Takes advantage of optimum bactericidal activity,
postantibiotic effect, decreased resistance
Caution: in Cr CL< 30-40/ml leading to high
aminoglycoside concentration
Where traditional dosing with close TDM is still
recommended
11. Drug dose calculation in CKD
For patients in CKD stage 3 or above whose GFR is below
60 mL/min, the dose must be adjusted
Traditionally Cockcroft-Gault formula
However, there is a movement toward using
GFR (calculated with either the Modification of Diet in
Renal Disease [MDRD] or Chronic Kidney Disease
Epidemiology Collaboration [CKD-EPI] equation) to dose
24-hour urine CrCl was used in CG whereas iothalamate
clearance in MDRD and CKD-EPI equations – so
difference in estimation is expected
Debate: Majority drug dosing studies used CG vs MDRD
/CKD-API accurately measures renal function in low GFR
12. Dosage regimen- Limitation
Dosage adjustment in patients with kidney disease is
defined by the product label
Considerable variability among recommendations
Initially determined in patients with normal or mildly
impaired kidney function
Then tested in a smaller number of patients with
advanced kidney disease before registration
Data in ESKD treated with dialysis are particularly
limited before registration because of complex
pharmacokinetics
Dose adjustment requires careful consideration of
patient and antibiotic-related factors
13. Dose regimen: adjustment
Administering smaller doses maintains more steady
drug concentrations and is therefore preferred for time
dependent antibiotics
Extending the time between antibiotic doses
maintains high peak and low trough concentrations
and is therefore preferred for concentration-
dependent antibiotics.
15. Antibiotic Dosing-Critically Ill
Critically ill patients are at high risk for development of life-
threatening infection
Adequate antimicrobial therapy is pivotal
Pathophysiological changes in critical illness impact on
pharmacokinetics of antimicrobials
Concentrations of hydrophilic antimicrobials may be increased
because of decreased renal clearance due to acute kidney injury.
Antimicrobial concentrations may be decreased because of
increased volume of distribution and augmented renal clearance
provoked by systemic inflammatory response syndrome,
capillary leak, decreased protein binding and administration of
intravenous fluids
Often multiple other conditions influence pharmacokinetics
In general, conditions leading to underdosing are predominant.
16.
17. A patient Case
KC is a 45yo patient with a history of a renal
transplant in 2007 who presents with respiratory
distress and hypotension. He is emergently intubated
in the ER and fluid resuscitated with 3L of NS.
KC has NKDA, weighs 91kg and his admit SCr=3.2
mg/dl
His SCr at a clinic visit one month prior = 1.3 mg/dl
Cefepime, ciprofloxacin and vancomycin are written
for – What doses should be given?
18. Antibiotics in Critical care
Betalactam and
Carbapenem
Aminoglycoside
Slow concentration-
independent continuous kill
fT>MIC is the PK/PD index
best correlated to efficacy
An improved PD profile vis-
à-vis efficacy is achieved
with a more frequent dosing
or extended or continuous
infusion (for a fixed total
dose)
Conc-dependent kill
characteristics
Prolonged persistent effects
– Cmax/MIC and AUC/MIC
are better than T>MIC.
Optimize peak - Go for
once-a-day regime.
High trough conc not high
peak indicates increased
risk of toxicity – TDM
recommended.
19. Antibiotics in Critical Care
Vancomycin Fluroquinolones
A time dependent (T>MIC)
killing
Protein binding: Moderately
high, in hypoalbuminemia Vd,
CL increased.
Increased Vd and CL requiring
high maintanance dose
TDM in the form of trough conc
monitoring is recommended
Continuous infusion improves
the PD and minimizes the risk
of toxicity
Dose reduction in renal
impairment,
Lipophilic; fluid shifts have
minimal effect on Vd; Cmax is
decreased
Conc-dependent kill
characteristic with time-
dependent effects
AUC/MIC>125 in gm – ve
pathogens
Suboptimal drug
exposure(AUC/MIC<100)
selection of antimicrobial
resistance
20. Antibiotics in Critical Care
Tigecycline Colistin
Broad spectrum glycycline
antimicrobial – active against
gm +ve, gm –ve, and
anaerobic
Lipophilic, large Vd, biliary
excretion, long t1/2
Prolonged PAE – the
AUC/MIC ratio is the PK/PD
index correlated with efficacy
No dosing adjustment in
renal dysfunction or mild to
moderate hepatic
dysfunction
Current dosage regimens are
sub-optimal in the critically-ill.
The ƒAUC/MIC of colistin is the
PK/PD index most predictive
Attainment of steady-state
colistin conc is significantly
delayed.
Renal function is crucial
determinant of maintenance
dosing
A large colistin exposure during
the first ~12 h may be beneficial
and immune system will tackle
the rest
21. PK issues in nutshell
Absorption
Decreased gastric absorption due edema but rather increased due to
loss of barrier – Bioavailability increased
Volume of distribution (Vd)
Change of Vd during intradialytic wt gain is low
Effect of severe edema on Vd is inconsistent may double or unchanged
Vd often increase in AKI
Hydrophilic medications generally stay in the plasma volume (Vd < 0.7
L/kg)
Influenced by fluid administration and capillary leak
Lipophilic medications distribute into intracellular and adipose tissue
(Vd > 1 L/kg)
Not generally affected by fluid administration and third spacing
22. Loading Doses
Goal is to achieve therapeutic concentrations rapidly so
loading doses are usually recommended
Recommend giving high end of normal loading dose (or even
higher dose)
Example: Vancomycin (normal patient Vd ~0.7 L/kg)
100kg septic shock patient
Recommended loading dose for complicated infections in
seriously ill patients is 25-30 mg/kg based on actual body weight
Am J Health-Syst Pharm 2009;66:82-98
23. What dose to give?
Lack of information in patients with sepsis/shock and acute kidney
injury
Since SCr is not at steady state -> not a reliable estimate of CrCl
Concern for underdosing and treatment failure
Recommendations from “A clinical update from Kidney Disease:
Improving Global Outcomes (KDIGO)”
Loading dose: Volume of distribution is usually significantly increased in acute
kidney injury for hydrophilic medications
Recommend: Aggressive loading doses (25-50% greater than normal)
Maintenance dose: Need to estimate degree and rate of change in kidney status
Need to also take into account nonrenal clearance
Recommend: Initiate at normal or near-normal dosage regimens
Therapeutic drug monitoring: Most concern for drugs with narrow therapeutic
window
Recommend: Check serum concentrations if possible
Recommend: If no serum concentrations: watch for excessive pharmacologic effect or
toxicity
Concern with cefepime use in renal dysfunction (Hosp Pharm 2009;44:557-61)
24. Intravenous Dosing of Antibiotics
Loading dose followed by maintenance
Intermittent infusion : 30-60 mins
Extended infusion : 3-4 hrs
Continuous infusion : 24 hrs
25. Extended and Continuous Infusion
for Time Dependent Antibiotics
For time-dependent antibiotics, e.g., beta-lactams and
vancomycin, the CI obviously has certain theoretical
advantages toward efficacy but not in all.
For vancomycin, CI can be chosen, not always for better
clinical efficacy, but because it is practical, cheaper,
associated with less AUC24h (area under the curve >24 h)
variability, and easier to monitor.
26. Meropenem – 30 min vs 3 hr
Infusion
Optimal meropenem extended infusion dosing in
critically ill elderly patients with reduced renal
function(Usman and colleagues)
PTA(Probabilty of Target Attainment) was
analyzed for PD target of 40%, 60%, and 80% of T
>MIC at MIC ranges of 0.25 to 128 mg/L at various
levels of renal function.
1000 mg of meropenem every 8 hours as a 3-hour
extended infusion result in optimal PD with CrCl
≤ 50 mL/min in the critical care setting
27. Adverse effects of Antibiotics in CKD
Mostly related to inappropriate dosing, others due to pathologic
changes associated with uremia
Neurologic toxicity, including psychosis, visual and auditory
hallucinations, myoclonus and seizures - penicillin, imipenem,
beta-lactams, acyclovir, amantadine, and quinolones
Aminoglycoside or vancomycin-induced ototoxicity
Sulfonamide-induced hypoglycemia
Platelet aggregation abnormalities induced by high doses of
penicillins add to HIT
Cephalosporins containing the N-methyl-thiotetrazole side
chain - vitamin K deficiency in renal failure, seems to be the
culprit for coagulopathy
Fluoroquinolones with increased risk for spontaneous Achilles
tendon rupture in renal failure
28. Drug dosing in Hemodyalysis
Antibiotic dosing in hemodialysis is considerably different
than in CKD
Considerable drug removal during hemodialysis, supplemental
doses administered at the end
Alternatively, antibiotic doses may be held until after
hemodialysis
If 30% of total drug clearance by HD – clinically relevant an
increased dose adjustments are needed
Drug factors favouring hemodialysis clearance: smaller
molecular weight, smaller volume of distribution and lower
plasma protein binding
29. Drug dosing in Hemodyalysis
The type of dialyzer used also determine drug clearance
Conventional filters vs high-flux dialyzers with a larger
pore size(more common)
It is prudent to consider the type of dialyzer studied while
reviewing references
Increased frequency and time on dialysis on SDHD may
contribute to enhanced antibiotic clearance
Drug dosing recommended for three times weekly HD
may contribute to antibiotic underdosing
There are a number of references available to the clinician
30. Drug dosing in Peritoneal dialysis
Peritonitis and exit-site infections are common
infections
Intraperitoneal administration is the preferred route of
antibiotic delivery
Antibiotics may be administered with every
intraperitoneal dwell (continuous dosing) or with
the long dwell (intermittent dosing)
Intermittent dosing - Concentration dependent
antibiotics and continuous dosing for time-dependent
antibiotics.
CAPD vs APD
31. Conclusion
Knowledge gap related to drug dosing in renal disease and
hemodialysis
In CKD, renal function estimates using available equations may be
inaccurate
Ideally, therapeutic drug monitoring help guide dosing of antibiotics
but few antibiotics are available
Clinicians need to carefully evaluate response to therapy
and monitor for dose-related toxicity
Final decision needs to be informed by an understanding of drug
pharmacokinetics and clearance principles, therapeutic drug
monitoring, and sound clinical judgment
clinical benefit from treatment over months or years (e.g., antihypertensives or oral hypoglycemics) this approach is less useful for drugs requiring a rapid onset of effect, such as anti-infective agents. Antibiotics are inappropriately dosed in patients with decreased GFR, and this may contribute to poorer outcomes in those requiring kidney replacement therapy
The Kunin rule with halving of the starting dose leads to higher trough values and more frequent peak values than the Dettli-2 rule with the same dose given at longer intervals. The Dettli-1 rule, with a reduced dose and a constant interval, results in lower peaks and higher troughs than normal
The higher the Hill coefficient (H>1.5), the closer the threshold concentration (CE05) and the ceiling concentration (CE95) lie to the concentration with half-maximal effect (CE50).
The higher the Hill coefficient (H>1.5), the closer the threshold concentration (CE05) and the ceiling concentration (CE95) lie to the concentration with half-maximal effect (CE50).
Traditionally the aminoglycosides
are dosed by giving lower doses (e.g., gentamicin doses of 3–6
mg/kg per day) (44,45) divided into two or three doses per day,
with serum concentration monitoring to guide dose adjustments
However, a more optimal method of dosing, called “high dose,extended interval,” Because high residualconcentrations are associatedwith nephrotoxicity, the dosinginterval using this method is extended to 36 or 48 hours inpatients with impaired kidney function to allow them to fullyeliminate the drug. That is, they continue to exertantibacterial effects even when drug concentrations fallbelow the bacteria’s MIC for a portion of the dosing interval
Dose adjustment for ciprofloxacin, a drug whose effect is concentration-dependent, according to a mechanistic model (23). If renal failure causes a doubling of the half-life from four to eight hours, the dose should not be halved (upper graph); rather, the interval between doses should be doubled (lower graph). If half the normal dose is given, it will take 168 hours for E. coli to be eliminated (above), but if the interval is doubled, the pathogen will be eliminated in 96 hours, as it is when renal function is normal
In critically ill patients, several factors may increase volume of distribution and enhance renal clearance, promoting the risk of antibiotic underdosing. The duration of infusion of beta-lactams has been shown to influence the fT>minimal inhibitory concentration and an improved beta-lactam pharmacodynamics profile may be obtained by longer exposure with more frequent dosing, extended infusions, or continuous infusions.
In a post-hoc analysis of a prospective multicenter study of critically ill patients from 68 ICUs across 10 countries, patients receiving beta-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P=0.012].
Vancomycin (1449.3 g/mol), daptomycin (1620.7 g/mol), and dalbavancin are not cleared using conventional
low-flux dialyzers but are removed using high-flux dialyzers.